Samaritan Choice Formulary 2023

This document includes a list of the drugs (formulary) for our plan which is current as of

8/1/2024.

2024 Formulary

List of Covered Drugs

Samaritan Choice Plans

Note to existing members: This formulary may have changed since last year. Please review this

document to make sure that it still contains the drugs you take.

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

it refers to “plan” or “our plan,” it means Samaritan Choice. You must generally use network

pharmacies to use your prescription drug benefit.

If you have any questions, please call Customer Service at 541-768-4550, toll free 800-832-4580

(TTY 800-735-2900), Monday through Friday, from 8 a.m. to 8 p.m.

Important information about your plan

This document provides highlights of your pharmacy benefits.

To find out how a drug is covered under your plan, you can view the entire formulary and

pharmacy information available online at choice.samhealthplans.org or call our Customer

Service Department.

A list of participating network pharmacies is also online at choice.samhealthplans.org.

Using your prescription drug benefit

Your prescription drug benefit requires that you fill your prescription at a network or

participating pharmacy. Always present your current member identification card at a network or

participating pharmacy. You may purchase up to a 90-day supply of certain maintenance drugs at

either a retail pharmacy or a mail order pharmacy.

Using your prescription drug formulary

The formulary or drug list is a list of brand and generic prescription medications approved by the

Food and Drug Administration (FDA). The drug list is developed by physicians and pharmacists

through a Pharmacy and Therapeutics Committee. It is designed to offer drug treatment options

for covered medical conditions.

The formulary can help you and your provider find covered options that are safe and effective

and less costly to help minimize your out of pocket expense.

Some prescription drugs require a prior authorization or approval to determine the medical

necessity of that specific drug and to determine whether the drugs we have on formulary will

work just as well as the medication you and your provider are requesting.

Prescriptions by mail

You are able to order your maintenance medications using a participating or network mail order

pharmacy. Our online pharmacy directory can help you find a mail order pharmacy in our

network. A list of participating network pharmacies is online at choice.samhealthplans.org. If

you have any questions, please call Customer Service at the number on the cover page of the

document.

This document includes a list of the drugs (formulary) for our plan which is current as of

8/1/2024.

Out of network or non-participating pharmacies

Sometimes due to certain emergencies or reasons, you may need to use a pharmacy that is not in

our network. If this happens, you will need to pay the full price of the medication at the time of

purchase.

You can apply for reimbursement using our reimbursement forms available on our website

choice.samhealthplans.org. Approval of reimbursement requests is always subject to your

plan’s limitations and exclusions. Members will be reimbursed based on the plan’s in-network

contracted rate for prescription drugs minus member co-pay or co-insurance.

What is a formulary (drug list)?

A formulary is a list of covered drugs selected by our plan, in consultation with a team of health

care providers, which represents the prescription therapies believed to be a necessary part of a

quality treatment program. Our plan will generally cover the drugs listed in our formulary as

long as the drug is medically necessary, the prescription is filled at a network pharmacy, and

other plan rules are followed. For more information on how to fill your prescriptions, please

review your member materials.

Can the formulary (drug list) change?

Most changes in drug coverage happen on January 1, but we may add or remove drugs on the

drug list during the year, move them to different cost-sharing tiers, or add new restrictions. We

must follow the plan rules in making these changes.

• New generic drugs. We may immediately remove a brand name drug on our drug list if

we are replacing it with a new generic drug that will appear on the same or lower cost

sharing tier and with the same or fewer restrictions. Also, when adding the new generic

drug, we may decide to keep the brand name drug on our drug list, but immediately move

it to a different cost-sharing tier or add new restrictions. If you are currently taking that

brand name drug, we may not notify you in advance before we make that change, but we

will later provide you with information about the specific change(s) we have made.

o If we make such a change, you or your prescriber can ask us to make an exception

and continue to cover the brand name drug for you. You can find information in

the section below entitled “How do I request an exception to the formulary?”

How do I use the formulary (drug list)?

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

Medical condition

The formulary begins on page 1. The drugs in this formulary are grouped into categories

depending on the type of medical conditions that they are used to treat. If you know what your

This document includes a list of the drugs (formulary) for our plan which is current as of

8/1/2024.

drug is used for, look for the category name in the list that begins on page 1. Then, look under

the category name for your drug.

Alphabetical listing

If you are not sure what category to look under, you should look for your drug in the index at the

end of the formulary. The index provides an alphabetical list of all of the drugs included in this

document. Both brand name drugs and generic drugs are listed in the index. Look in the index

and find your drug. Next to your drug, you will see the page number where you can find

coverage information. Turn to the page listed in the index and find the name of your drug in the

first column of the list.

What are brand-name drugs?

Brand-name drugs are medications approved by the FDA and protected by a drug patent, which

prevents other manufactures from making that specific medication for a number of years. It is

only the pharmaceutical company that holds that patent that has the exclusive rights to make and

sell that drug.

What are generic drugs?

A generic drug is approved by the FDA as having the same active ingredient as the brand name

drug. It is tested by the FDA to be as safe and effective as brand-name drugs. Generally, generic

drugs cost less than brand name drugs.

What are maintenance drugs?

Maintenance drugs are drugs that are usually prescribed to treat conditions that are considered

long-term or chronic. Examples of such conditions are diabetes and high blood pressure.

Are there any restrictions on my coverage?

Some covered drugs may have additional requirements or limits on coverage. These

requirements and limits may include:

• Prior authorization: Our plan requires you (or your provider) to get prior authorization

for certain drugs. This means that you will need to get approval from our plan before you

fill your prescriptions. If you don’t get approval, we may not cover the drug.

• Quantity limits: For certain drugs, our plan limits the amount of the drug that we will

cover during a specific time-frame such as daily or monthly.

• Step therapy: In some cases, our plan requires you to first try certain drugs to treat your

medical condition before we will cover another drug for that condition. For example, if

drug A and drug B both treat your medical condition, we may not cover drug B unless

you try drug A first. If drug A does not work for you, we will then cover drug B.

This document includes a list of the drugs (formulary) for our plan which is current as of

8/1/2024.

• Morphine milligram equivalent (MME): This shows the amount of morphine in

milligrams that is equivalent to the strength of the specific opioid medicine your provider

has prescribed.

You can find out if your drug has any additional requirements or limits by looking in the

formulary that begins on page 1. You may also ask us to send you a copy. Our contact

information, along with the date we last updated the formulary, appears on the front cover page.

Your prescriber can ask us to make an exception to these restrictions or limits or for a list of

other, similar drugs that may treat your health condition. See the section, “How do I request an

exception to the formulary?” for information about how to request an exception.

What if my drug is not on the formulary?

If your drug is not included in this formulary (list of covered drugs), you should first contact

Customer Service and ask if your drug is covered.

If our plan does not cover your drug, you have two options:

• Your prescriber can ask Customer Service for a list of similar drugs that are covered by

our plan. When you receive the list, show it to your provider and ask him or her to

prescribe a similar drug that is covered by our plan.

• Your prescriber can ask us to make an exception and cover your drug. See below for

information about how to request an exception.

How do I request an exception to the formulary?

Your prescriber can ask us to make an exception to our coverage rules by faxing a request to

844-403-1029 or submitting electronically through Surescripts or CoverMyMeds. There are

several types of exceptions that they can ask us to make.

• They can ask us to cover a drug even if it is not on our formulary. If approved, this drug

will be covered at a pre-determined cost-sharing level, and you would not be able to ask

us to provide the drug at a lower cost-sharing level.

• They can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not

on the specialty tier. If approved, this would lower the amount you must pay for your

drug.

• They can ask us to waive coverage restrictions or limits on your drug. For example, for

certain drugs, our plan limits the amount of the drug that we will cover. If your drug has a

quantity limit, they can ask us to waive the limit and cover a greater amount.

Generally, we will only approve the request for an exception if the alternative drugs included on

the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not

This document includes a list of the drugs (formulary) for our plan which is current as of

8/1/2024.

be as effective in treating your condition and/or would cause you to have adverse medical

effects.

We will make a coverage determination within 72 hours of receipt for standard requests and

within 24 hours of receipt for expedited requests. Your provider can request an expedited (fast)

exception if you or your provider believe that your health could be seriously harmed by waiting

up to 72 hours for a decision. If requested, we must give you a decision no later than 24 hours

after receipt of request.

For more information

For more detailed information about your prescription drug coverage, please review your

member materials.

If you have questions about our plan, please contact us. Our contact information, along with the

date we last updated the formulary, appears on the front cover page.

Formulary

The formulary below provides coverage information about the drugs covered by our plan. If you

have trouble finding your drug in the list, turn to the index.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g.,

AMOXIL) and generic drugs are lower-case (e.g. amoxicillin).

The information in the “Notes” column tells you if our plan has any special requirements for

coverage of your drug.

List of abbreviations

EA: Each.

PA: Prior authorization. Our plan requires you (or your provider) to get prior authorization for

certain drugs. This means that you will need to get approval from our plan before you fill your

prescriptions. If you don't get approval, we may not cover the drug.

QL: Quantity limit. For certain drugs, our plan limits the amount of the drug that we will cover.

This may be in addition to a standard one-month or three-month supply.

ST: Step therapy. In some cases, our plan requires you to first try certain drugs to treat your

medical condition before we will cover another drug for that condition. For example, if drug A

and drug B both treat your medical condition, we may not cover drug B unless you try drug A

first. If drug A does not work for you, we will then cover drug B.

This document includes a list of the drugs (formulary) for our plan which is current as of

8/1/2024.

Opioid limits:

Opioid anti-tussive limits:

• Liquids: Maximum of 240ML per

fill.

• Tablets/capsules: Maximum seven-

day supply per fill.

Short-acting opioid limits:

• New to therapy:

o Maximum of 49.99 MME.

o Maximum seven-day supply

per fill.

• Experience with therapy:

o Maximum of 90 MME.

Long-acting opioid limits:

• PA required.

• Maximum of 90 MME.

Table of Contents

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*...................................................................................................................................10

*Allergenic Extracts/Biologicals Misc*.......................................................................................................................................................11

*Aminoglycosides*...................................................................................................................................................................................... 12

*Analgesics - Anti-Inflammatory*...............................................................................................................................................................12

*Analgesics - Nonnarcotic*..........................................................................................................................................................................14

*Analgesics - Opioid*.................................................................................................................................................................................. 16

*Androgens-Anabolic*.................................................................................................................................................................................20

*Anorectal And Related Products*.............................................................................................................................................................. 20

*Anthelmintics*............................................................................................................................................................................................21

*Antianginal Agents*...................................................................................................................................................................................21

*Antianxiety Agents*...................................................................................................................................................................................21

*Antiarrhythmics*........................................................................................................................................................................................22

*Antiasthmatic And Bronchodilator Agents*.............................................................................................................................................. 22

*Anticoagulants*..........................................................................................................................................................................................24

*Anticonvulsants*........................................................................................................................................................................................ 25

*Antidepressants*.........................................................................................................................................................................................27

*Antidiabetics*.............................................................................................................................................................................................28

*Antidiarrheal/Probiotic Agents*.................................................................................................................................................................32

*Antidotes And Specific Antagonists*.........................................................................................................................................................32

*Antiemetics*...............................................................................................................................................................................................33

*Antifungals*............................................................................................................................................................................................... 33

*Antihistamines*..........................................................................................................................................................................................33

*Antihyperlipidemics*................................................................................................................................................................................. 34

*Antihypertensives*..................................................................................................................................................................................... 35

*Anti-Infective Agents - Misc.*...................................................................................................................................................................37

*Antimalarials*.............................................................................................................................................................................................38

*Antimyasthenic/Cholinergic Agents*.........................................................................................................................................................38

*Antimycobacterial Agents*........................................................................................................................................................................ 38

*Antineoplastics And Adjunctive Therapies*..............................................................................................................................................38

*Antiparkinson And Related Therapy Agents*............................................................................................................................................44

*Antipsychotics/Antimanic Agents*............................................................................................................................................................45

*Antivirals*.................................................................................................................................................................................................. 46

*Beta Blockers*............................................................................................................................................................................................49

*Calcium Channel Blockers*....................................................................................................................................................................... 50

*Cardiotonics*..............................................................................................................................................................................................51

*Cardiovascular Agents - Misc.*................................................................................................................................................................. 51

*Cephalosporins*......................................................................................................................................................................................... 52

*Contraceptives*.......................................................................................................................................................................................... 52

*Corticosteroids*..........................................................................................................................................................................................60

*Cough/Cold/Allergy*................................................................................................................................................................................. 61

*Dermatologicals*........................................................................................................................................................................................62

*Diagnostic Products*..................................................................................................................................................................................66

*Dietary Products/Dietary Management Products*..................................................................................................................................... 73

*Digestive Aids*.......................................................................................................................................................................................... 73

*Diuretics*....................................................................................................................................................................................................73

*Endocrine And Metabolic Agents - Misc.*................................................................................................................................................74

*Estrogens*...................................................................................................................................................................................................75

*Fluoroquinolones*......................................................................................................................................................................................76

*Gastrointestinal Agents - Misc.*................................................................................................................................................................ 76

*Genitourinary Agents - Miscellaneous*.....................................................................................................................................................78

*Gout Agents*..............................................................................................................................................................................................78

*Hematological Agents - Misc.*..................................................................................................................................................................78

*Hematopoietic Agents*.............................................................................................................................................................................. 79

*Hemostatics*...............................................................................................................................................................................................80

*Hypnotics/Sedatives/Sleep Disorder Agents*............................................................................................................................................80

*Laxatives*...................................................................................................................................................................................................80

*Macrolides*................................................................................................................................................................................................ 81

*Medical Devices And Supplies*.................................................................................................................................................................81

*Migraine Products*...................................................................................................................................................................................121

*Minerals & Electrolytes*..........................................................................................................................................................................122

*Miscellaneous Therapeutic Classes*........................................................................................................................................................123

*Mouth/Throat/Dental Agents*..................................................................................................................................................................124

*Multivitamins*..........................................................................................................................................................................................124

*Musculoskeletal Therapy Agents*........................................................................................................................................................... 128

*Nasal Agents - Systemic And Topical*....................................................................................................................................................129

*Neuromuscular Agents*........................................................................................................................................................................... 131

*Ophthalmic Agents*.................................................................................................................................................................................131

*Otic Agents*.............................................................................................................................................................................................133

*Oxytocics*................................................................................................................................................................................................133

*Passive Immunizing And Treatment Agents*..........................................................................................................................................133

*Penicillins*............................................................................................................................................................................................... 134

*Pharmaceutical Adjuvants*...................................................................................................................................................................... 134

*Progestins*................................................................................................................................................................................................134

*Psychotherapeutic And Neurological Agents - Misc.*.............................................................................................................................134

*Respiratory Agents - Misc.*.....................................................................................................................................................................138

*Tetracyclines*...........................................................................................................................................................................................138

*Thyroid Agents*.......................................................................................................................................................................................139

*Toxoids*................................................................................................................................................................................................... 140

*Ulcer Drugs/Antispasmodics/Anticholinergics*...................................................................................................................................... 140

*Urinary Antispasmodics*......................................................................................................................................................................... 141

*Vaccines*..................................................................................................................................................................................................141

*Vaginal And Related Products*................................................................................................................................................................143

*Vasopressors*...........................................................................................................................................................................................144

*Vitamins*..................................................................................................................................................................................................144

Drug Name Brand Tier Generic Tier Formulary Notes

*Adhd/Anti-Narcolepsy/Anti-Obesity/Anorexiants*

*Adhd Agent - Selective Alpha Adrenergic Agonists***

CLONIDINE HCL ER ORAL TABLET EXTENDED

RELEASE 12 HOUR 0.1 MG

Tier 3 QL (4 EA per 1 day)

GUANFACINE HCL ER ORAL TABLET EXTENDED

RELEASE 24 HOUR 1 MG, 2 MG, 3 MG, 4 MG

Tier 3 QL (2 EA per 1 day)

*Adhd Agent - Selective Norepinephrine Reuptake

Inhibitor***

ATOMOXETINE HCL ORAL CAPSULE 10 MG, 100

MG, 18 MG, 25 MG, 40 MG, 60 MG, 80 MG

Tier 3 QL (1 EA per 1 day)

*Amphetamine Mixtures***

AMPHETAMINE-DEXTROAMPHET ER ORAL

CAPSULE EXTENDED RELEASE 24 HOUR 10 MG, 15

MG, 20 MG, 25 MG, 30 MG, 5 MG

Tier 3 QL (1 EA per 1 day)

AMPHETAMINE-DEXTROAMPHETAMINE ORAL

TABLET 10 MG, 12.5 MG, 15 MG, 20 MG, 30 MG, 5

MG, 7.5 MG

Tier 3

AMPHET-DEXTROAMPHET 3-BEAD ER ORAL

CAPSULE EXTENDED RELEASE 24 HOUR 12.5 MG,

25 MG, 37.5 MG, 50 MG

Tier 3 QL (1 EA per 1 day)

*Amphetamines***

DEXTROAMPHETAMINE SULFATE ER CAPSULE

EXTENDED RELEASE 24 HOUR 10 MG ORAL

Tier 3 QL (1 EA per 1 day)

DEXTROAMPHETAMINE SULFATE ER CAPSULE

EXTENDED RELEASE 24 HOUR 15 MG ORAL

Tier 3 QL (3 EA per 1 day)

DEXTROAMPHETAMINE SULFATE ER CAPSULE

EXTENDED RELEASE 24 HOUR 5 MG ORAL

Tier 3 QL (1 EA per 1 day)

DEXTROAMPHETAMINE SULFATE ORAL TABLET

10 MG, 15 MG, 2.5 MG, 20 MG, 30 MG, 5 MG, 7.5 MG

Tier 3

LISDEXAMFETAMINE DIMESYLATE ORAL

CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60

MG, 70 MG

Tier 3 PA; QL (1 EA per 1 day)

LISDEXAMFETAMINE DIMESYLATE ORAL TABLET

CHEWABLE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60

Tier 3 PA; QL (1 EA per 1 day)

*Anti-Obesity - Glp-1 Receptor Agonists***

WEGOVY SOLUTION AUTO-INJECTOR 0.25

MG/0.5ML SUBCUTANEOUS

Tier 5 PA; QL (0.072 ML per 1 day)

WEGOVY SOLUTION AUTO-INJECTOR 0.5

MG/0.5ML SUBCUTANEOUS

Tier 5 PA; QL (0.072 ML per 1 day)

WEGOVY SOLUTION AUTO-INJECTOR 1

MG/0.5ML SUBCUTANEOUS

Tier 5 PA; QL (0.072 ML per 1 day)

WEGOVY SOLUTION AUTO-INJECTOR 1.7

MG/0.75ML SUBCUTANEOUS

Tier 5 PA; QL (0.11 ML per 1 day)

WEGOVY SOLUTION AUTO-INJECTOR 2.4

MG/0.75ML SUBCUTANEOUS

Tier 5 PA; QL (0.11 ML per 1 day)

*Stimulants - Misc.***

CONCERTA TABLET EXTENDED RELEASE 18 MG

ORAL (METHYLPHENIDATE HCL ER (OSM))

Tier 3 Tier 3 QL (1 EA per 1 day)

CONCERTA TABLET EXTENDED RELEASE 27 MG

ORAL (METHYLPHENIDATE HCL ER (OSM))

Tier 3 Tier 3 QL (1 EA per 1 day)

Drug Name Brand Tier Generic Tier Formulary Notes

CONCERTA TABLET EXTENDED RELEASE 36 MG

ORAL (METHYLPHENIDATE HCL ER (OSM))

Tier 3 Tier 3 QL (2 EA per 1 day)

CONCERTA TABLET EXTENDED RELEASE 54 MG

ORAL (METHYLPHENIDATE HCL ER (OSM))

Tier 3 Tier 3 QL (1 EA per 1 day)

DEXMETHYLPHENIDATE HCL ER ORAL CAPSULE

EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 20

MG, 25 MG, 30 MG, 35 MG, 40 MG, 5 MG

Tier 3 QL (1 EA per 1 day)

DEXMETHYLPHENIDATE HCL ORAL TABLET 10

MG, 2.5 MG, 5 MG

Tier 3

METHYLPHENIDATE HCL ER (CD) ORAL CAPSULE

EXTENDED RELEASE 10 MG, 20 MG, 30 MG, 40 MG,

50 MG, 60 MG

Tier 3 QL (1 EA per 1 day)

METHYLPHENIDATE HCL ER (LA) CAPSULE

EXTENDED RELEASE 24 HOUR 10 MG ORAL

Tier 3 QL (1 EA per 1 day)

METHYLPHENIDATE HCL ER (LA) CAPSULE

EXTENDED RELEASE 24 HOUR 20 MG ORAL

Tier 3 QL (1 EA per 1 day)

METHYLPHENIDATE HCL ER (LA) CAPSULE

EXTENDED RELEASE 24 HOUR 30 MG ORAL

Tier 3 QL (2 EA per 1 day)

METHYLPHENIDATE HCL ER (LA) CAPSULE

EXTENDED RELEASE 24 HOUR 40 MG ORAL

Tier 3 QL (1 EA per 1 day)

METHYLPHENIDATE HCL ER ORAL TABLET

EXTENDED RELEASE 10 MG, 20 MG

Tier 3 QL (1 EA per 1 day)

METHYLPHENIDATE HCL ER TABLET EXTENDED

RELEASE 24 HOUR 18 MG ORAL

Tier 3 QL (1 EA per 1 day)

METHYLPHENIDATE HCL ER TABLET EXTENDED

RELEASE 24 HOUR 27 MG ORAL

Tier 3 QL (1 EA per 1 day)

METHYLPHENIDATE HCL ER TABLET EXTENDED

RELEASE 24 HOUR 36 MG ORAL

Tier 3 QL (2 EA per 1 day)

METHYLPHENIDATE HCL ER TABLET EXTENDED

RELEASE 24 HOUR 54 MG ORAL

Tier 3 QL (1 EA per 1 day)

METHYLPHENIDATE HCL ORAL SOLUTION 10

MG/5ML, 5 MG/5ML

Tier 3 AGE (Max 10 Years)

METHYLPHENIDATE HCL ORAL TABLET 10 MG, 20

MG, 5 MG

Tier 3

METHYLPHENIDATE HCL ORAL TABLET

CHEWABLE 10 MG, 2.5 MG, 5 MG

Tier 3 AGE (Max 10 Years)

MODAFINIL ORAL TABLET 100 MG, 200 MG Tier 3 QL (30 EA per 30 days)

*Allergenic Extracts/Biologicals Misc*

*Allergenic Extracts***

GRASTEK SUBLINGUAL TABLET SUBLINGUAL

2800 BAU

Tier 5 PA

PALFORZIA (12 MG DAILY DOSE) ORAL 2 X 1 MG

& 10 MG

Tier 6 PA; Specialty

PALFORZIA (120 MG DAILY DOSE) ORAL 20 MG &

100 MG

Tier 6 PA; Specialty

PALFORZIA (160 MG DAILY DOSE) ORAL 3 X 20

MG & 100 MG

Tier 6 PA; Specialty

PALFORZIA (20 MG DAILY DOSE) ORAL Tier 6 PA; Specialty

PALFORZIA (200 MG DAILY DOSE) ORAL 2 X 100

Tier 6 PA; Specialty

Drug Name Brand Tier Generic Tier Formulary Notes

PALFORZIA (240 MG DAILY DOSE) ORAL 2 X 20

MG & 2 X 100 MG

Tier 6 PA; Specialty

PALFORZIA (3 MG DAILY DOSE) ORAL 3 X 1 MG Tier 6 PA; Specialty

PALFORZIA (300 MG MAINTENANCE) ORAL

PACKET

Tier 6 PA; Specialty

PALFORZIA (300 MG TITRATION) ORAL PACKET Tier 6 PA; Specialty

PALFORZIA (40 MG DAILY DOSE) ORAL 2 X 20

Tier 6 PA; Specialty

PALFORZIA (6 MG DAILY DOSE) ORAL 6 X 1 MG Tier 6 PA; Specialty

PALFORZIA (80 MG DAILY DOSE) ORAL 4 X 20

Tier 6 PA; Specialty

PALFORZIA INITIAL ESCALATION ORAL 0.5 & 1

& 1.5 & 3 & 6 MG

Tier 6 PA; Specialty

*Aminoglycosides*

*Aminoglycosides***

NEOMYCIN SULFATE ORAL TABLET 500 MG Tier 3

*Analgesics - Anti-Inflammatory*

*Antirheumatic - Janus Kinase (Jak) Inhibitors***

RINVOQ ORAL TABLET EXTENDED RELEASE 24

HOUR 15 MG, 30 MG, 45 MG

Tier 6 PA; Specialty

XELJANZ ORAL SOLUTION 1 MG/ML Tier 6 PA; Specialty

XELJANZ ORAL TABLET 10 MG, 5 MG Tier 6 PA; Specialty

XELJANZ XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 11 MG, 22 MG

Tier 6 PA; Specialty

*Anti-Tnf-Alpha - Monoclonal Antibodies***

ADALIMUMAB-ADAZ SUBCUTANEOUS SOLUTION

AUTO-INJECTOR 40 MG/0.4ML

Tier 6 PA; Specialty

ADALIMUMAB-ADAZ SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 40 MG/0.4ML

Tier 6 PA; Specialty

ADALIMUMAB-FKJP (2 PEN) SUBCUTANEOUS

AUTO-INJECTOR KIT 40 MG/0.8ML

Tier 6 PA; Specialty

ADALIMUMAB-FKJP (2 SYRINGE) SUBCUTANEOUS

PREFILLED SYRINGE KIT 20 MG/0.4ML, 40

MG/0.8ML

Tier 6 PA; Specialty

ADALIMUMAB-FKJP SUBCUTANEOUS AUTO-

INJECTOR KIT 40 MG/0.8ML

Tier 6 PA; Specialty

ADALIMUMAB-FKJP SUBCUTANEOUS PREFILLED

SYRINGE KIT 20 MG/0.4ML, 40 MG/0.8ML

Tier 6 PA; Specialty

HADLIMA PUSHTOUCH SUBCUTANEOUS

SOLUTION AUTO-INJECTOR 40 MG/0.4ML, 40

MG/0.8ML

Tier 6 PA; Specialty

HADLIMA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 40 MG/0.4ML, 40 MG/0.8ML

Tier 6 PA; Specialty

SIMPONI SUBCUTANEOUS SOLUTION AUTO-

INJECTOR 100 MG/ML, 50 MG/0.5ML

Tier 6 PA; Specialty

SIMPONI SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 100 MG/ML, 50 MG/0.5ML

Tier 6 PA; Specialty

YUSIMRY SUBCUTANEOUS SOLUTION PEN-

INJECTOR 40 MG/0.8ML

Tier 6 PA; Specialty

Drug Name Brand Tier Generic Tier Formulary Notes

*Cyclooxygenase 2 (Cox-2) Inhibitors***

CELECOXIB CAPSULE 100 MG ORAL Tier 2

CELECOXIB CAPSULE 200 MG ORAL Tier 2

CELECOXIB CAPSULE 400 MG ORAL Tier 3

CELECOXIB CAPSULE 50 MG ORAL Tier 2

*Interleukin-6 Receptor Inhibitors***

ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION

AUTO-INJECTOR 162 MG/0.9ML

Tier 6 PA; Specialty

ACTEMRA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 162 MG/0.9ML

Tier 6 PA; Specialty

*Nonsteroidal Anti-Inflammatory Agents (Nsaids)***

DICLOFENAC POTASSIUM ORAL TABLET 50 MG Tier 3

DICLOFENAC SODIUM ER ORAL TABLET

EXTENDED RELEASE 24 HOUR 100 MG

Tier 3

DICLOFENAC SODIUM TABLET DELAYED

RELEASE 25 MG ORAL

Tier 3

DICLOFENAC SODIUM TABLET DELAYED

RELEASE 50 MG ORAL

Tier 2

DICLOFENAC SODIUM TABLET DELAYED

RELEASE 75 MG ORAL

Tier 2

ETODOLAC ER ORAL TABLET EXTENDED RELEASE

24 HOUR 400 MG, 500 MG, 600 MG

Tier 3

ETODOLAC ORAL CAPSULE 200 MG, 300 MG Tier 3

ETODOLAC ORAL TABLET 400 MG, 500 MG Tier 3

FLURBIPROFEN ORAL TABLET 100 MG, 50 MG Tier 3

IBU ORAL TABLET (IBUPROFEN) 400 MG, 600 MG,

800 MG

Tier 2 Tier 2

INDOMETHACIN ER ORAL CAPSULE EXTENDED

RELEASE 75 MG

Tier 3

INDOMETHACIN ORAL CAPSULE 25 MG, 50 MG Tier 3

KETOPROFEN ORAL CAPSULE 50 MG Tier 3

KETOROLAC TROMETHAMINE INJECTION

SOLUTION 15 MG/ML, 30 MG/ML

Tier 3

KETOROLAC TROMETHAMINE ORAL TABLET 10

Tier 3

MELOXICAM ORAL TABLET 15 MG, 7.5 MG Tier 2

NABUMETONE ORAL TABLET 500 MG, 750 MG Tier 2

NAPROXEN ORAL TABLET 250 MG, 375 MG, 500 MG Tier 2

NAPROXEN SODIUM ORAL TABLET 275 MG, 550 MG Tier 3

OXAPROZIN ORAL TABLET 600 MG Tier 2

PIROXICAM CAPSULE 10 MG ORAL Tier 2

PIROXICAM CAPSULE 20 MG ORAL Tier 3

SULINDAC ORAL TABLET 150 MG, 200 MG Tier 2

*Phosphodiesterase 4 (Pde4) Inhibitors***

OTEZLA ORAL TABLET 30 MG Tier 6 PA; Specialty

OTEZLA ORAL TABLET THERAPY PACK 10 & 20

& 30 MG

Tier 6 PA; Specialty

Drug Name Brand Tier Generic Tier Formulary Notes

*Pyrimidine Synthesis Inhibitors***

LEFLUNOMIDE ORAL TABLET 10 MG, 20 MG Tier 3

*Selective Costimulation Modulators***

ORENCIA CLICKJECT SUBCUTANEOUS

SOLUTION AUTO-INJECTOR 125 MG/ML

Tier 6 PA; Specialty

ORENCIA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 125 MG/ML, 50 MG/0.4ML,

87.5 MG/0.7ML

Tier 6 PA; Specialty

*Analgesics - Nonnarcotic*

*Analgesics-Sedatives***

BAC ORAL TABLET (BUTALBITAL-APAP-

CAFFEINE) 50-325-40 MG

Tier 3 Tier 3

BUTALBITAL-ASPIRIN-CAFFEINE ORAL CAPSULE

50-325-40 MG

Tier 3

TENCON ORAL TABLET (BUTALBITAL-

ACETAMINOPHEN) 50-325 MG

Tier 4 Tier 3

*Salicylates***

ADULT ASPIRIN REGIMEN ORAL TABLET

DELAYED RELEASE 81 MG

Tier 1

ASPIRIN 81 ORAL TABLET CHEWABLE 81 MG Tier 1

ASPIRIN 81 ORAL TABLET DELAYED RELEASE 81

Tier 1

ASPIRIN ADULT LOW DOSE ORAL TABLET

DELAYED RELEASE 81 MG

Tier 1

ASPIRIN ADULT LOW STRENGTH ORAL TABLET

DELAYED RELEASE 81 MG

Tier 1

ASPIRIN CHILDRENS ORAL TABLET CHEWABLE 81

Tier 1

ASPIRIN EC ADULT LOW DOSE ORAL TABLET

DELAYED RELEASE 81 MG

Tier 1

ASPIRIN EC ADULT LOW STRENGTH ORAL TABLET

DELAYED RELEASE 81 MG

Tier 1

ASPIRIN EC LOW DOSE ORAL TABLET DELAYED

RELEASE 81 MG

Tier 1

ASPIRIN EC LOW STRENGTH ORAL TABLET

DELAYED RELEASE 81 MG

Tier 1

ASPIRIN LOW DOSE ORAL TABLET CHEWABLE 81

Tier 1

ASPIRIN LOW DOSE ORAL TABLET DELAYED

RELEASE 81 MG

Tier 1

ASPIRIN REGIMEN ORAL TABLET DELAYED

RELEASE 81 MG

Tier 1

BAYER ASPIRIN EC LOW DOSE ORAL TABLET

DELAYED RELEASE (ASPIRIN) 81 MG

Tier 1 Tier 1

BAYER LOW DOSE ORAL TABLET CHEWABLE

(ASPIRIN) 81 MG

Tier 1 Tier 1

BAYER LOW DOSE ORAL TABLET DELAYED

RELEASE (ASPIRIN) 81 MG

Tier 1 Tier 1

CHILDRENS ASPIRIN ORAL TABLET CHEWABLE 81

Tier 1

Drug Name Brand Tier Generic Tier Formulary Notes

CVS ASPIRIN ADULT LOW DOSE ORAL TABLET

CHEWABLE 81 MG

Tier 1

CVS ASPIRIN ADULT LOW STRENGTH ORAL

TABLET DELAYED RELEASE 81 MG

Tier 1

CVS ASPIRIN EC ORAL TABLET DELAYED

RELEASE 81 MG

Tier 1

CVS ASPIRIN LOW DOSE ORAL TABLET DELAYED

RELEASE 81 MG

Tier 1

CVS ASPIRIN LOW STRENGTH ORAL TABLET

DELAYED RELEASE 81 MG

Tier 1

DIFLUNISAL ORAL TABLET 500 MG Tier 3

ECOTRIN LOW STRENGTH ORAL TABLET

DELAYED RELEASE (ASPIRIN) 81 MG

Tier 1 Tier 1

EQ ASPIRIN ADULT LOW DOSE ORAL TABLET

DELAYED RELEASE 81 MG

Tier 1

EQ ASPIRIN LOW DOSE ORAL TABLET CHEWABLE

81 MG

Tier 1

EQL ASPIRIN LOW DOSE ORAL TABLET

CHEWABLE 81 MG

Tier 1

EQL ASPIRIN LOW DOSE ORAL TABLET DELAYED

RELEASE 81 MG

Tier 1

FT ASPIRIN LOW DOSE ORAL TABLET DELAYED

RELEASE 81 MG

Tier 1

FT ASPIRIN ORAL TABLET CHEWABLE 81 MG Tier 1

GNP ADULT ASPIRIN LOW STRENGTH ORAL

TABLET CHEWABLE 81 MG

Tier 1

GNP ASPIRIN LOW DOSE ORAL TABLET DELAYED

RELEASE 81 MG

Tier 1

GNP ASPIRIN ORAL TABLET DELAYED RELEASE 81

Tier 1

GOODSENSE ASPIRIN LOW DOSE ORAL TABLET

DELAYED RELEASE 81 MG

Tier 1

GOODSENSE ASPIRIN ORAL TABLET CHEWABLE 81

Tier 1

H-E-B ASPIRIN ORAL TABLET DELAYED RELEASE

81 MG

Tier 1

HM ASPIRIN EC LOW DOSE ORAL TABLET

DELAYED RELEASE 81 MG

Tier 1

HM ASPIRIN ORAL TABLET CHEWABLE 81 MG Tier 1

KLS ASPIRIN LOW DOSE ORAL TABLET DELAYED

RELEASE 81 MG

Tier 1

KP ASPIRIN ORAL TABLET DELAYED RELEASE 81

Tier 1

MM ASPIRIN ORAL TABLET DELAYED RELEASE 81

Tier 1

PX ASPIRIN ORAL TABLET CHEWABLE 81 MG Tier 1

PX ENTERIC ASPIRIN ORAL TABLET DELAYED

RELEASE 81 MG

Tier 1

QC ASPIRIN LOW DOSE ORAL TABLET CHEWABLE

81 MG

Tier 1

Drug Name Brand Tier Generic Tier Formulary Notes

QC ASPIRIN LOW DOSE ORAL TABLET DELAYED

RELEASE 81 MG

Tier 1

QC CHILDRENS ASPIRIN ORAL TABLET

CHEWABLE 81 MG

Tier 1

RA ASPIRIN ADULT LOW DOSE ORAL TABLET

CHEWABLE 81 MG

Tier 1

RA ASPIRIN ADULT LOW STRENGTH ORAL

TABLET CHEWABLE 81 MG

Tier 1

RA ASPIRIN CHILDRENS ORAL TABLET

CHEWABLE 81 MG

Tier 1

RA ASPIRIN EC ADULT LOW ST ORAL TABLET

DELAYED RELEASE 81 MG

Tier 1

RA ASPIRIN EC ORAL TABLET DELAYED RELEASE

81 MG

Tier 1

SB CHILDRENS ASPIRIN ORAL TABLET CHEWABLE

81 MG

Tier 1

SB LOW DOSE ASA EC ORAL TABLET DELAYED

RELEASE 81 MG

Tier 1

SM ASPIRIN ADULT LOW STRENGTH ORAL

TABLET CHEWABLE 81 MG

Tier 1

SM ASPIRIN ADULT LOW STRENGTH ORAL

TABLET DELAYED RELEASE 81 MG

Tier 1

SM ASPIRIN EC LOW STRENGTH ORAL TABLET

DELAYED RELEASE 81 MG

Tier 1

SM ASPIRIN LOW DOSE ORAL TABLET CHEWABLE

81 MG

Tier 1

SM ASPIRIN LOW DOSE ORAL TABLET DELAYED

RELEASE 81 MG

Tier 1

SM CHILDRENS ASPIRIN ORAL TABLET

CHEWABLE 81 MG

Tier 1

ST JOSEPH ASPIRIN ORAL TABLET DELAYED

RELEASE (ASPIRIN) 81 MG

Tier 1 Tier 1

ST JOSEPH LOW DOSE ORAL TABLET

CHEWABLE (ASPIRIN) 81 MG

Tier 1 Tier 1

ST JOSEPH LOW DOSE ORAL TABLET DELAYED

RELEASE (ASPIRIN) 81 MG

Tier 1 Tier 1

*Analgesics - Opioid*

*Codeine Combinations***

ACETAMINOPHEN-CODEINE ORAL SOLUTION 120-

12 MG/5ML

Tier 3 QL (136 ML per 1 day)

ACETAMINOPHEN-CODEINE TABLET 300-15 MG

ORAL

Tier 3 QL (13 EA per 1 day)

ACETAMINOPHEN-CODEINE TABLET 300-30 MG

ORAL

Tier 3 QL (10 EA per 1 day)

ACETAMINOPHEN-CODEINE TABLET 300-60 MG

ORAL

Tier 3 QL (10 EA per 1 day)

BUTALBITAL-APAP-CAFF-COD ORAL CAPSULE 50-

325-40-30 MG

Tier 3

BUTALBITAL-ASA-CAFF-CODEINE ORAL CAPSULE

50-325-40-30 MG

Tier 3

Drug Name Brand Tier Generic Tier Formulary Notes

*Dihydrocodeine Combinations***

APAP-CAFF-DIHYDROCODEINE ORAL CAPSULE

320.5-30-16 MG

Tier 3 QL (12 EA per 1 day)

*Hydrocodone Combinations***

HYDROCODONE-ACETAMINOPHEN ORAL

SOLUTION 2.5-108 MG/5ML, 5-217 MG/10ML, 7.5-325

MG/15ML

Tier 3 QL (98 ML per 1 day)

HYDROCODONE-ACETAMINOPHEN TABLET 10-300

MG ORAL

Tier 3 QL (4 EA per 1 day)

HYDROCODONE-ACETAMINOPHEN TABLET 10-325

MG ORAL

Tier 3 QL (4 EA per 1 day)

HYDROCODONE-ACETAMINOPHEN TABLET 5-300

MG ORAL

Tier 3 QL (9 EA per 1 day)

HYDROCODONE-ACETAMINOPHEN TABLET 5-325

MG ORAL

Tier 3 QL (9 EA per 1 day)

HYDROCODONE-ACETAMINOPHEN TABLET 7.5-300

MG ORAL

Tier 3 QL (6 EA per 1 day)

HYDROCODONE-ACETAMINOPHEN TABLET 7.5-325

MG ORAL

Tier 3 QL (6 EA per 1 day)

HYDROCODONE-IBUPROFEN TABLET 10-200 MG

ORAL

Tier 3 QL (4 EA per 1 day)

HYDROCODONE-IBUPROFEN TABLET 5-200 MG

ORAL

Tier 3 QL (9 EA per 1 day)

HYDROCODONE-IBUPROFEN TABLET 7.5-200 MG

ORAL

Tier 3 QL (6 EA per 1 day)

LORTAB ORAL ELIXIR 10-300 MG/15ML Tier 5 QL (73.5 ML per 1 day)

*Opioid Agonists***

CODEINE SULFATE TABLET 15 MG ORAL Tier 3 QL (21 EA per 1 day)

CODEINE SULFATE TABLET 30 MG ORAL Tier 3 QL (10 EA per 1 day)

CODEINE SULFATE TABLET 60 MG ORAL Tier 3 QL (5 EA per 1 day)

FENTANYL CITRATE INJECTION SOLUTION

PREFILLED SYRINGE 100 MCG/2ML

Tier 3

FENTANYL TRANSDERMAL PATCH 72 HOUR 100

MCG/HR, 12 MCG/HR, 25 MCG/HR, 37.5 MCG/HR, 50

MCG/HR, 62.5 MCG/HR, 75 MCG/HR, 87.5 MCG/HR

Tier 3 PA; QL (0.34 EA per 1 day)

HYDROCODONE BITARTRATE ER ORAL TABLET

ER 24 HOUR ABUSE-DETERRENT 100 MG, 120 MG,

20 MG, 30 MG, 40 MG, 60 MG, 80 MG

Tier 3 PA; QL (1 EA per 1 day)

HYDROMORPHONE HCL ER ORAL TABLET

EXTENDED RELEASE 24 HOUR 12 MG, 16 MG, 32

MG, 8 MG

Tier 3 PA; QL (2 EA per 1 day)

HYDROMORPHONE HCL INJECTION SOLUTION 0.25

MG/0.5ML

Tier 3

HYDROMORPHONE HCL ORAL LIQUID 1 MG/ML Tier 3 QL (12.25 ML per 1 day)

HYDROMORPHONE HCL PF INJECTION SOLUTION 1

MG/ML

Tier 3

HYDROMORPHONE HCL TABLET 2 MG ORAL Tier 3 QL (6 EA per 1 day)

HYDROMORPHONE HCL TABLET 4 MG ORAL Tier 3 QL (3 EA per 1 day)

HYDROMORPHONE HCL TABLET 8 MG ORAL Tier 3 QL (1 EA per 1 day)

MEPERIDINE HCL ORAL SOLUTION 50 MG/5ML Tier 3 QL (49 ML per 1 day)

Drug Name Brand Tier Generic Tier Formulary Notes

MEPERIDINE HCL ORAL TABLET 50 MG Tier 3 QL (9 EA per 1 day)

METHADONE HCL ORAL TABLET 10 MG, 5 MG Tier 3 PA

MORPHINE SULFATE (CONCENTRATE) ORAL

SOLUTION 100 MG/5ML, 20 MG/ML

Tier 3 QL (2.4 ML per 1 day)

MORPHINE SULFATE ER BEADS CAPSULE

EXTENDED RELEASE 24 HOUR 120 MG ORAL

Tier 3 PA; QL (2 EA per 1 day)

MORPHINE SULFATE ER BEADS CAPSULE

EXTENDED RELEASE 24 HOUR 30 MG ORAL

Tier 3 PA; QL (1 EA per 1 day)

MORPHINE SULFATE ER BEADS CAPSULE

EXTENDED RELEASE 24 HOUR 45 MG ORAL

Tier 3 PA; QL (1 EA per 1 day)

MORPHINE SULFATE ER BEADS CAPSULE

EXTENDED RELEASE 24 HOUR 60 MG ORAL

Tier 3 PA; QL (1 EA per 1 day)

MORPHINE SULFATE ER BEADS CAPSULE

EXTENDED RELEASE 24 HOUR 75 MG ORAL

Tier 3 PA; QL (1 EA per 1 day)

MORPHINE SULFATE ER BEADS CAPSULE

EXTENDED RELEASE 24 HOUR 90 MG ORAL

Tier 3 PA; QL (1 EA per 1 day)

MORPHINE SULFATE ER ORAL CAPSULE

EXTENDED RELEASE 24 HOUR 10 MG, 100 MG, 20

MG, 30 MG, 50 MG, 60 MG, 80 MG

Tier 3 PA; QL (2 EA per 1 day)

MORPHINE SULFATE ER ORAL TABLET EXTENDED

RELEASE 100 MG, 15 MG, 200 MG, 30 MG, 60 MG

Tier 3 PA; QL (3 EA per 1 day)

MORPHINE SULFATE INTRAVENOUS SOLUTION 50

MG/ML

Tier 3

MORPHINE SULFATE SOLUTION 10 MG/5ML ORAL Tier 3 QL (24.5 ML per 1 day)

MORPHINE SULFATE SOLUTION 20 MG/5ML ORAL Tier 3 QL (12.25 ML per 1 day)

MORPHINE SULFATE TABLET 15 MG ORAL Tier 3 QL (3 EA per 1 day)

MORPHINE SULFATE TABLET 30 MG ORAL Tier 3 QL (1 EA per 1 day)

NUCYNTA ER ORAL TABLET EXTENDED

RELEASE 12 HOUR 100 MG, 150 MG, 200 MG, 250

MG, 50 MG

Tier 4 PA; QL (2 EA per 1 day)

NUCYNTA TABLET 100 MG ORAL Tier 4 QL (1 EA per 1 day)

NUCYNTA TABLET 50 MG ORAL Tier 4 QL (2 EA per 1 day)

NUCYNTA TABLET 75 MG ORAL Tier 4 QL (1 EA per 1 day)

OXYCODONE HCL ORAL CAPSULE 5 MG Tier 3 QL (6 EA per 1 day)

OXYCODONE HCL ORAL CONCENTRATE 100

MG/5ML

Tier 3 QL (1.6 ML per 1 day)

OXYCODONE HCL ORAL SOLUTION 5 MG/5ML Tier 3 QL (32.6 ML per 1 day)

OXYCODONE HCL TABLET 10 MG ORAL Tier 3 QL (3 EA per 1 day)

OXYCODONE HCL TABLET 15 MG ORAL Tier 3 QL (2 EA per 1 day)

OXYCODONE HCL TABLET 20 MG ORAL Tier 3 QL (1 EA per 1 day)

OXYCODONE HCL TABLET 30 MG ORAL Tier 3 QL (1 EA per 1 day)

OXYCODONE HCL TABLET 5 MG ORAL Tier 3 QL (6 EA per 1 day)

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-

DETERRENT (OXYCODONE HCL ER) 10 MG, 20 MG,

40 MG, 80 MG

Tier 4 Tier 4 PA; QL (4 EA per 1 day)

OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-

DETERRENT 15 MG, 30 MG, 60 MG

Tier 4 PA; QL (4 EA per 1 day)

Drug Name Brand Tier Generic Tier Formulary Notes

OXYMORPHONE HCL ER ORAL TABLET EXTENDED

RELEASE 12 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40

MG, 5 MG, 7.5 MG

Tier 3 PA; QL (4 EA per 1 day)

OXYMORPHONE HCL TABLET 10 MG ORAL Tier 3 QL (1 EA per 1 day)

OXYMORPHONE HCL TABLET 5 MG ORAL Tier 3 QL (3 EA per 1 day)

ROXYBOND TABLET ABUSE-DETERRENT 15 MG

ORAL

Tier 4 QL (2 EA per 1 day)

ROXYBOND TABLET ABUSE-DETERRENT 30 MG

ORAL

Tier 4 QL (1 EA per 1 day)

TRAMADOL HCL TABLET 100 MG ORAL Tier 3 QL (4 EA per 1 day)

TRAMADOL HCL TABLET 50 MG ORAL Tier 3 QL (8 EA per 1 day)

XTAMPZA ER ORAL CAPSULE ER 12 HOUR

ABUSE-DETERRENT 13.5 MG, 18 MG, 27 MG, 36

MG, 9 MG

Tier 4 PA; QL (4 EA per 1 day)

*Opioid Combinations***

ENDOCET TABLET 10-325 MG ORAL

(OXYCODONE-ACETAMINOPHEN)

Tier 3 Tier 3 QL (3 EA per 1 day)

ENDOCET TABLET 2.5-325 MG ORAL

(OXYCODONE-ACETAMINOPHEN)

Tier 3 Tier 3 QL (12 EA per 1 day)

ENDOCET TABLET 5-325 MG ORAL (OXYCODONE-

ACETAMINOPHEN)

Tier 3 Tier 3 QL (6 EA per 1 day)

ENDOCET TABLET 7.5-325 MG ORAL

(OXYCODONE-ACETAMINOPHEN)

Tier 3 Tier 3 QL (4 EA per 1 day)

OXYCODONE-ACETAMINOPHEN ORAL SOLUTION

5-325 MG/5ML

Tier 4 QL (32.6 ML per 1 day)

*Opioid Partial Agonists***

BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450

MCG, 600 MCG, 75 MCG, 750 MCG, 900 MCG

Tier 5 PA; QL (2 EA per 1 day)

BRIXADI (WEEKLY) SOLUTION PREFILLED

SYRINGE 16 MG/0.32ML SUBCUTANEOUS

Tier 6 Specialty; QL (0.046 ML per 1 day)

BRIXADI (WEEKLY) SOLUTION PREFILLED

SYRINGE 24 MG/0.48ML SUBCUTANEOUS

Tier 6 Specialty; QL (0.069 ML per 1 day)

BRIXADI (WEEKLY) SOLUTION PREFILLED

SYRINGE 32 MG/0.64ML SUBCUTANEOUS

Tier 6 Specialty; QL (0.092 ML per 1 day)

BRIXADI (WEEKLY) SOLUTION PREFILLED

SYRINGE 8 MG/0.16ML SUBCUTANEOUS

Tier 6 Specialty; QL (0.023 ML per 1 day)

BRIXADI SOLUTION PREFILLED SYRINGE 128

MG/0.36ML SUBCUTANEOUS

Tier 6 Specialty; QL (0.013 ML per 1 day)

BRIXADI SOLUTION PREFILLED SYRINGE 64

MG/0.18ML SUBCUTANEOUS

Tier 6 Specialty; QL (0.007 ML per 1 day)

BRIXADI SOLUTION PREFILLED SYRINGE 96

MG/0.27ML SUBCUTANEOUS

Tier 6 Specialty; QL (0.01 ML per 1 day)

BUPRENORPHINE HCL TABLET SUBLINGUAL 2 MG

SUBLINGUAL

Tier 3 QL (3 EA per 1 day)

BUPRENORPHINE HCL TABLET SUBLINGUAL 8 MG

SUBLINGUAL

Tier 3 QL (4 EA per 1 day)

BUPRENORPHINE HCL-NALOXONE HCL FILM 12-3

MG SUBLINGUAL

Tier 3 QL (2 EA per 1 day)

BUPRENORPHINE HCL-NALOXONE HCL FILM 2-0.5

MG SUBLINGUAL

Tier 3 QL (90 EA per 23 days)

Drug Name Brand Tier Generic Tier Formulary Notes

BUPRENORPHINE HCL-NALOXONE HCL FILM 4-1

MG SUBLINGUAL

Tier 3 QL (90 EA per 30 days)

BUPRENORPHINE HCL-NALOXONE HCL FILM 8-2

MG SUBLINGUAL

Tier 3 QL (4 EA per 1 day)

BUPRENORPHINE HCL-NALOXONE HCL TABLET

SUBLINGUAL 2-0.5 MG SUBLINGUAL

Tier 1 QL (3 EA per 1 day)

BUPRENORPHINE HCL-NALOXONE HCL TABLET

SUBLINGUAL 8-2 MG SUBLINGUAL

Tier 1 QL (4 EA per 1 day)

BUPRENORPHINE TRANSDERMAL PATCH WEEKLY

10 MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR, 7.5

MCG/HR

Tier 3 PA; QL (0.15 EA per 1 day)

BUTORPHANOL TARTRATE NASAL SOLUTION 10

MG/ML

Tier 3 QL (2.5 ML per 1 day)

PENTAZOCINE-NALOXONE HCL ORAL TABLET 50-

0.5 MG

Tier 3 QL (5 EA per 1 day)

SUBLOCADE SOLUTION PREFILLED SYRINGE

100 MG/0.5ML SUBCUTANEOUS

Tier 6 Specialty; QL (0.018 ML per 1 day)

SUBLOCADE SOLUTION PREFILLED SYRINGE

300 MG/1.5ML SUBCUTANEOUS

Tier 6 Specialty; QL (0.054 ML per 1 day)

*Tramadol Combinations***

TRAMADOL-ACETAMINOPHEN ORAL TABLET 37.5-

325 MG

Tier 3 QL (8 EA per 1 day)

*Androgens-Anabolic*

*Androgens***

DANAZOL ORAL CAPSULE 200 MG Tier 3

TESTOSTERONE CYPIONATE INTRAMUSCULAR

SOLUTION 100 MG/ML, 200 MG/ML

Tier 3

TESTOSTERONE ENANTHATE INTRAMUSCULAR

SOLUTION 200 MG/ML

Tier 3

TESTOSTERONE TRANSDERMAL GEL 1.62 %, 12.5

MG/ACT (1%), 20.25 MG/1.25GM (1.62%), 20.25

MG/ACT (1.62%), 25 MG/2.5GM (1%), 40.5 MG/2.5GM

(1.62%), 50 MG/5GM (1%)

Tier 3 ST

TESTOSTERONE TRANSDERMAL SOLUTION 30

MG/ACT

Tier 3 ST

*Anorectal And Related Products*

*Intrarectal Steroids***

HYDROCORTISONE RECTAL ENEMA 100 MG/60ML Tier 3

*Rectal Anesthetic/Steroids***

HYDROCORTISONE ACE-PRAMOXINE EXTERNAL

CREAM 1-1 %

Tier 3

*Rectal Steroids***

PROCTO-MED HC EXTERNAL CREAM

(HYDROCORTISONE (PERIANAL)) 2.5 %

Tier 3 Tier 3

PROCTOSOL HC EXTERNAL CREAM

(HYDROCORTISONE (PERIANAL)) 2.5 %

Tier 3 Tier 3

PROCTOZONE-HC EXTERNAL CREAM

(HYDROCORTISONE (PERIANAL)) 2.5 %

Tier 3 Tier 3

Drug Name Brand Tier Generic Tier Formulary Notes

*Anthelmintics*

*Anthelmintics***

EMVERM ORAL TABLET CHEWABLE 100 MG Tier 5

IVERMECTIN ORAL TABLET 3 MG Tier 3 PA

*Antianginal Agents*

*Antianginals-Other***

RANOLAZINE ER ORAL TABLET EXTENDED

RELEASE 12 HOUR 1000 MG, 500 MG

Tier 3 PA

*Nitrates***

ISOSORBIDE DINITRATE ORAL TABLET 10 MG, 20

MG, 30 MG, 5 MG

Tier 3

ISOSORBIDE MONONITRATE ER ORAL TABLET

EXTENDED RELEASE 24 HOUR 120 MG, 30 MG, 60

Tier 1

ISOSORBIDE MONONITRATE ORAL TABLET 10 MG,

20 MG

Tier 3

NITROGLYCERIN SUBLINGUAL TABLET

SUBLINGUAL 0.3 MG, 0.4 MG, 0.6 MG

Tier 3

NITROGLYCERIN TRANSDERMAL PATCH 24 HOUR

0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR

Tier 3

NITROGLYCERIN TRANSLINGUAL SOLUTION 0.4

MG/SPRAY

Tier 3

*Antianxiety Agents*

*Antianxiety Agents - Misc.***

BUSPIRONE HCL ORAL TABLET 10 MG, 15 MG, 30

MG, 5 MG, 7.5 MG

Tier 3

HYDROXYZINE HCL ORAL SYRUP 10 MG/5ML Tier 3

HYDROXYZINE HCL ORAL TABLET 10 MG, 25 MG,

50 MG

Tier 3

HYDROXYZINE PAMOATE ORAL CAPSULE 100 MG,

25 MG, 50 MG

Tier 3

MEPROBAMATE ORAL TABLET 400 MG Tier 3

*Benzodiazepines***

ALPRAZOLAM ER ORAL TABLET EXTENDED

RELEASE 24 HOUR 0.5 MG, 1 MG, 2 MG, 3 MG

Tier 3

ALPRAZOLAM INTENSOL ORAL CONCENTRATE

1 MG/ML

Tier 3

ALPRAZOLAM ORAL TABLET 0.25 MG, 0.5 MG, 1

MG, 2 MG

Tier 3

ALPRAZOLAM XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 0.5 MG, 1 MG, 2 MG, 3 MG

Tier 3

CHLORDIAZEPOXIDE HCL ORAL CAPSULE 10 MG,

25 MG, 5 MG

Tier 3

CLORAZEPATE DIPOTASSIUM ORAL TABLET 15

MG, 3.75 MG, 7.5 MG

Tier 3

DIAZEPAM ORAL SOLUTION 5 MG/5ML Tier 3

DIAZEPAM ORAL TABLET 10 MG, 2 MG, 5 MG Tier 3

LORAZEPAM INTENSOL ORAL CONCENTRATE

(LORAZEPAM) 2 MG/ML

Tier 3 Tier 3

Drug Name Brand Tier Generic Tier Formulary Notes

LORAZEPAM ORAL TABLET 0.5 MG, 1 MG, 2 MG Tier 3

OXAZEPAM ORAL CAPSULE 10 MG, 15 MG, 30 MG Tier 3

*Antiarrhythmics*

*Antiarrhythmics Type I-A***

DISOPYRAMIDE PHOSPHATE ORAL CAPSULE 150

Tier 3

QUINIDINE GLUCONATE ER ORAL TABLET

EXTENDED RELEASE 324 MG

Tier 3

QUINIDINE SULFATE ORAL TABLET 200 MG, 300

Tier 3

*Antiarrhythmics Type I-B***

MEXILETINE HCL ORAL CAPSULE 150 MG, 200 MG Tier 3

*Antiarrhythmics Type I-C***

FLECAINIDE ACETATE ORAL TABLET 100 MG, 150

MG, 50 MG

Tier 1

PROPAFENONE HCL ORAL TABLET 150 MG, 225 MG Tier 3

*Antiarrhythmics Type Iii***

AMIODARONE HCL TABLET 100 MG ORAL Tier 3

AMIODARONE HCL TABLET 200 MG ORAL Tier 1

AMIODARONE HCL TABLET 400 MG ORAL Tier 3

MULTAQ ORAL TABLET 400 MG Tier 4

*Antiasthmatic And Bronchodilator Agents*

*Adrenergic Combinations***

ADVAIR HFA INHALATION AEROSOL 115-21

MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT

Tier 3 QL (0.4 GM per 1 day)

ANORO ELLIPTA INHALATION AEROSOL

POWDER BREATH ACTIVATED 62.5-25 MCG/ACT

Tier 4 QL (1 EA per 30 days)

BREO ELLIPTA INHALATION AEROSOL POWDER

BREATH ACTIVATED 100-25 MCG/ACT, 200-25

MCG/ACT

Tier 4 QL (1 EA per 30 days)

BREYNA INHALATION AEROSOL (BUDESONIDE-

FORMOTEROL FUMARATE) 160-4.5 MCG/ACT, 80-

4.5 MCG/ACT

Tier 3 Tier 3 QL (10.2 GM per 30 days)

COMBIVENT RESPIMAT INHALATION AEROSOL

SOLUTION 20-100 MCG/ACT

Tier 4 QL (4 GM per 30 days)

DULERA AEROSOL 100-5 MCG/ACT INHALATION Tier 4 QL (1 GM per 30 days)

DULERA AEROSOL 200-5 MCG/ACT INHALATION Tier 4 QL (1 GM per 30 days)

DULERA AEROSOL 50-5 MCG/ACT INHALATION Tier 4

IPRATROPIUM-ALBUTEROL INHALATION

SOLUTION 0.5-2.5 (3) MG/3ML

Tier 1 QL (18 ML per 1 day)

TRELEGY ELLIPTA INHALATION AEROSOL

POWDER BREATH ACTIVATED 100-62.5-25

MCG/ACT, 200-62.5-25 MCG/ACT

Tier 4 ST

WIXELA INHUB INHALATION AEROSOL

POWDER BREATH ACTIVATED (FLUTICASONE-

SALMETEROL) 100-50 MCG/ACT, 250-50 MCG/ACT,

500-50 MCG/ACT

Tier 2 Tier 2 QL (1 EA per 30 days)

Drug Name Brand Tier Generic Tier Formulary Notes

*Anti-Ige Monoclonal Antibodies***

XOLAIR SUBCUTANEOUS SOLUTION AUTO-

INJECTOR 150 MG/ML, 300 MG/2ML, 75 MG/0.5ML

Tier 6 PA; Specialty

XOLAIR SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 150 MG/ML, 300 MG/2ML, 75 MG/0.5ML

Tier 6 PA; Specialty

*Beta Adrenergics***

ALBUTEROL SULFATE NEBULIZATION SOLUTION

(2.5 MG/3ML) 0.083% INHALATION

Tier 1 QL (18 ML per 1 day)

ALBUTEROL SULFATE NEBULIZATION SOLUTION

(5 MG/ML) 0.5% INHALATION

Tier 3

ALBUTEROL SULFATE NEBULIZATION SOLUTION

0.63 MG/3ML INHALATION

Tier 3 QL (18 ML per 1 day)

ALBUTEROL SULFATE NEBULIZATION SOLUTION

1.25 MG/3ML INHALATION

Tier 3 QL (18 ML per 1 day)

ALBUTEROL SULFATE NEBULIZATION SOLUTION

2.5 MG/0.5ML INHALATION

Tier 3

SEREVENT DISKUS INHALATION AEROSOL

POWDER BREATH ACTIVATED 50 MCG/ACT

Tier 4 QL (60 EA per 30 days)

TERBUTALINE SULFATE ORAL TABLET 2.5 MG, 5

Tier 3

VENTOLIN HFA AEROSOL SOLUTION 108 (90

BASE) MCG/ACT INHALATION (ALBUTEROL

SULFATE HFA)

Tier 4 Tier 2 QL (0.534 GM per 1 day)

VENTOLIN HFA AEROSOL SOLUTION 108 (90

BASE) MCG/ACT INHALATION (ALBUTEROL

SULFATE HFA)

Tier 4 Tier 2 QL (1.2 GM per 1 day)

XOPENEX HFA INHALATION AEROSOL

(LEVALBUTEROL TARTRATE) 45 MCG/ACT

Tier 4 Tier 4 QL (2 GM per 30 days)

*Bronchodilators - Anticholinergics***

ATROVENT HFA INHALATION AEROSOL

SOLUTION 17 MCG/ACT

Tier 4 QL (2 GM per 30 days)

INCRUSE ELLIPTA INHALATION AEROSOL

POWDER BREATH ACTIVATED 62.5 MCG/ACT

Tier 4 QL (1 EA per 30 days)

TIOTROPIUM BROMIDE MONOHYDRATE

INHALATION CAPSULE 18 MCG

Tier 3 QL (30 EA per 30 days)

*Leukotriene Receptor Antagonists***

MONTELUKAST SODIUM ORAL PACKET 4 MG Tier 3

MONTELUKAST SODIUM ORAL TABLET 10 MG Tier 1

MONTELUKAST SODIUM ORAL TABLET

CHEWABLE 4 MG, 5 MG

Tier 1

*Selective Phosphodiesterase 4 (Pde4) Inhibitors***

ROFLUMILAST ORAL TABLET 250 MCG, 500 MCG Tier 3 PA

*Steroid Inhalants***

ASMANEX (120 METERED DOSES) INHALATION

AEROSOL POWDER BREATH ACTIVATED 220

MCG/ACT

Tier 2 QL (0.067 EA per 1 day)

ASMANEX (14 METERED DOSES) INHALATION

AEROSOL POWDER BREATH ACTIVATED 220

MCG/ACT

Tier 2 QL (0.067 EA per 1 day)

Drug Name Brand Tier Generic Tier Formulary Notes

ASMANEX (30 METERED DOSES) INHALATION

AEROSOL POWDER BREATH ACTIVATED 110

MCG/ACT, 220 MCG/ACT

Tier 2 QL (0.067 EA per 1 day)

ASMANEX (60 METERED DOSES) INHALATION

AEROSOL POWDER BREATH ACTIVATED 220

MCG/ACT

Tier 2 QL (0.067 EA per 1 day)

ASMANEX HFA INHALATION AEROSOL 100

MCG/ACT, 200 MCG/ACT, 50 MCG/ACT

Tier 2 QL (0.867 GM per 1 day)

BUDESONIDE SUSPENSION 0.25 MG/2ML

INHALATION

Tier 2 QL (8 ML per 1 day)

BUDESONIDE SUSPENSION 0.5 MG/2ML

INHALATION

Tier 2 QL (4 ML per 1 day)

BUDESONIDE SUSPENSION 1 MG/2ML INHALATION Tier 2 QL (2 ML per 1 day)

FLUTICASONE PROPIONATE DISKUS INHALATION

AEROSOL POWDER BREATH ACTIVATED 100

MCG/ACT, 250 MCG/ACT, 50 MCG/ACT

Tier 4 QL (4 EA per 1 day)

FLUTICASONE PROPIONATE HFA AEROSOL 110

MCG/ACT INHALATION

Tier 4 QL (0.8 GM per 1 day)

FLUTICASONE PROPIONATE HFA AEROSOL 220

MCG/ACT INHALATION

Tier 4 QL (0.8 GM per 1 day)

FLUTICASONE PROPIONATE HFA AEROSOL 44

MCG/ACT INHALATION

Tier 4 QL (0.707 GM per 1 day)

PULMICORT FLEXHALER INHALATION

AEROSOL POWDER BREATH ACTIVATED 180

MCG/ACT, 90 MCG/ACT

Tier 5 QL (1 EA per 30 days)

QVAR REDIHALER INHALATION AEROSOL

BREATH ACTIVATED 40 MCG/ACT, 80 MCG/ACT

Tier 2 QL (0.71 GM per 1 day)

*Xanthines***

THEOPHYLLINE ER ORAL TABLET EXTENDED

RELEASE 12 HOUR 100 MG, 200 MG, 300 MG, 450 MG

Tier 3

*Anticoagulants*

*Coumarin Anticoagulants***

JANTOVEN ORAL TABLET (WARFARIN SODIUM) 1

MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG,

7.5 MG

Tier 2 Tier 2

*Direct Factor Xa Inhibitors***

ELIQUIS DVT/PE STARTER PACK ORAL TABLET

THERAPY PACK 5 MG

Tier 4 QL (3 EA per 1 day)

ELIQUIS TABLET 2.5 MG ORAL Tier 4 QL (2 EA per 1 day)

ELIQUIS TABLET 5 MG ORAL Tier 4 QL (3 EA per 1 day)

XARELTO TABLET 10 MG ORAL Tier 4 QL (1 EA per 1 day)

XARELTO TABLET 15 MG ORAL Tier 4 QL (2 EA per 1 day)

XARELTO TABLET 2.5 MG ORAL Tier 4 QL (2 EA per 1 day)

XARELTO TABLET 20 MG ORAL Tier 4 QL (1 EA per 1 day)

*Low Molecular Weight Heparins***

ENOXAPARIN SODIUM INJECTION SOLUTION 300

MG/3ML

Tier 3 QL (35 ML per 180 days)

Drug Name Brand Tier Generic Tier Formulary Notes

ENOXAPARIN SODIUM INJECTION SOLUTION

PREFILLED SYRINGE 100 MG/ML, 120 MG/0.8ML, 150

MG/ML, 30 MG/0.3ML, 40 MG/0.4ML, 60 MG/0.6ML, 80

MG/0.8ML

Tier 3 QL (35 ML per 180 days)

FRAGMIN SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 5000 UNIT/0.2ML

Tier 4

*Thrombin Inhibitors - Selective Direct &

Reversible***

PRADAXA ORAL CAPSULE (DABIGATRAN

ETEXILATE MESYLATE) 110 MG

Tier 5 Tier 3

*Anticonvulsants*

*Anticonvulsants - Benzodiazepines***

CLOBAZAM ORAL SUSPENSION 2.5 MG/ML Tier 3 PA

CLOBAZAM ORAL TABLET 10 MG, 20 MG Tier 3 PA

CLONAZEPAM ORAL TABLET 0.5 MG, 1 MG, 2 MG Tier 3

CLONAZEPAM ORAL TABLET DISPERSIBLE 0.125

MG, 0.25 MG, 0.5 MG, 1 MG, 2 MG

Tier 3

DIAZEPAM RECTAL GEL 10 MG, 2.5 MG, 20 MG Tier 3

*Anticonvulsants - Misc.***

CARBAMAZEPINE ER ORAL CAPSULE EXTENDED

RELEASE 12 HOUR 100 MG, 200 MG, 300 MG

Tier 3

CARBAMAZEPINE ER ORAL TABLET EXTENDED

RELEASE 12 HOUR 100 MG, 200 MG, 400 MG

Tier 3

CARBAMAZEPINE ORAL SUSPENSION 100 MG/5ML Tier 3

CARBAMAZEPINE ORAL TABLET CHEWABLE 100

Tier 3

EPITOL ORAL TABLET (CARBAMAZEPINE) 200

Tier 3 Tier 3

GABAPENTIN ORAL CAPSULE 100 MG, 300 MG, 400

Tier 2

GABAPENTIN ORAL TABLET 600 MG, 800 MG Tier 2

LACOSAMIDE ORAL SOLUTION 10 MG/ML, 100

MG/10ML, 50 MG/5ML

Tier 3 PA

LACOSAMIDE ORAL TABLET 100 MG, 150 MG, 200

MG, 50 MG

Tier 3 PA

LAMICTAL STARTER ORAL KIT (LAMOTRIGINE

STARTER KIT-BLUE) 35 X 25 MG

Tier 4 Tier 3

LAMICTAL STARTER ORAL KIT (LAMOTRIGINE

STARTER KIT-ORANGE) 42 X 25 MG & 7 X 100 MG

Tier 4 Tier 3

LAMICTAL STARTER ORAL KIT (LAMOTRIGINE

STARTER KIT-GREEN) 84 X 25 MG & 14X100 MG

Tier 4 Tier 3

LAMOTRIGINE ORAL TABLET CHEWABLE 25 MG, 5

Tier 3

LEVETIRACETAM ORAL SOLUTION 100 MG/ML, 500

MG/5ML

Tier 1

LEVETIRACETAM ORAL TABLET 1000 MG, 250 MG,

750 MG

Tier 1

OXCARBAZEPINE ORAL SUSPENSION 300 MG/5ML Tier 3

OXCARBAZEPINE TABLET 150 MG ORAL Tier 1

OXCARBAZEPINE TABLET 300 MG ORAL Tier 1

Drug Name Brand Tier Generic Tier Formulary Notes

OXCARBAZEPINE TABLET 600 MG ORAL Tier 3

PREGABALIN CAPSULE 100 MG ORAL Tier 2 QL (3 EA per 1 day)

PREGABALIN CAPSULE 150 MG ORAL Tier 2 QL (3 EA per 1 day)

PREGABALIN CAPSULE 200 MG ORAL Tier 2 QL (3 EA per 1 day)

PREGABALIN CAPSULE 225 MG ORAL Tier 2 QL (2 EA per 1 day)

PREGABALIN CAPSULE 25 MG ORAL Tier 2 QL (3 EA per 1 day)

PREGABALIN CAPSULE 300 MG ORAL Tier 2 QL (2 EA per 1 day)

PREGABALIN CAPSULE 50 MG ORAL Tier 2 QL (3 EA per 1 day)

PREGABALIN CAPSULE 75 MG ORAL Tier 2 QL (3 EA per 1 day)

PREGABALIN ORAL SOLUTION 20 MG/ML Tier 2 QL (30 ML per 1 day)

PRIMIDONE TABLET 250 MG ORAL Tier 3

PRIMIDONE TABLET 50 MG ORAL Tier 1

ROWEEPRA ORAL TABLET (LEVETIRACETAM)

500 MG

Tier 1 Tier 1

SUBVENITE ORAL TABLET (LAMOTRIGINE) 100

MG, 150 MG, 200 MG, 25 MG

Tier 3 Tier 3

SUBVENITE STARTER KIT-BLUE ORAL KIT

(LAMOTRIGINE STARTER KIT-BLUE) 35 X 25 MG

Tier 3 Tier 3

SUBVENITE STARTER KIT-GREEN ORAL KIT

(LAMOTRIGINE STARTER KIT-GREEN) 84 X 25 MG

& 14X100 MG

Tier 3 Tier 3

SUBVENITE STARTER KIT-ORANGE ORAL KIT

(LAMOTRIGINE STARTER KIT-ORANGE) 42 X 25 MG

& 7 X 100 MG

Tier 3 Tier 3

TOPIRAMATE ORAL CAPSULE SPRINKLE 15 MG, 25

Tier 3

TOPIRAMATE ORAL TABLET 100 MG, 200 MG, 25

MG, 50 MG

Tier 1

ZONISAMIDE ORAL CAPSULE 100 MG, 25 MG, 50

Tier 1

*Gaba Modulators***

TIAGABINE HCL ORAL TABLET 12 MG, 16 MG, 2

MG, 4 MG

Tier 3

*Hydantoins***

DILANTIN ORAL CAPSULE 30 MG Tier 4

PHENYTEK ORAL CAPSULE (PHENYTOIN SODIUM

EXTENDED) 200 MG, 300 MG

Tier 3 Tier 3

PHENYTOIN INFATABS ORAL TABLET

CHEWABLE (PHENYTOIN) 50 MG

Tier 3 Tier 3

PHENYTOIN ORAL SUSPENSION 100 MG/4ML, 125

MG/5ML

Tier 2

PHENYTOIN SODIUM EXTENDED CAPSULE 100 MG

ORAL

Tier 1

*Succinimides***

ETHOSUXIMIDE ORAL CAPSULE 250 MG Tier 3

*Valproic Acid***

DIVALPROEX SODIUM ER ORAL TABLET

EXTENDED RELEASE 24 HOUR 250 MG, 500 MG

Tier 3

Drug Name Brand Tier Generic Tier Formulary Notes

DIVALPROEX SODIUM ORAL CAPSULE DELAYED

RELEASE SPRINKLE 125 MG

Tier 3

DIVALPROEX SODIUM ORAL TABLET DELAYED

RELEASE 125 MG, 250 MG, 500 MG

Tier 3

VALPROATE SODIUM INTRAVENOUS SOLUTION

100 MG/ML, 500 MG/5ML

Tier 3

VALPROIC ACID ORAL CAPSULE 250 MG Tier 3

VALPROIC ACID ORAL SOLUTION 250 MG/5ML Tier 3

*Antidepressants*

*Alpha-2 Receptor Antagonists (Tetracyclics)***

MIRTAZAPINE ORAL TABLET 15 MG, 30 MG, 45 MG,

7.5 MG

Tier 3

MIRTAZAPINE ORAL TABLET DISPERSIBLE 15 MG,

30 MG, 45 MG

Tier 3

*Antidepressants - Misc.***

BUPROPION HCL ER (SR) ORAL TABLET

EXTENDED RELEASE 12 HOUR 100 MG, 150 MG, 200

Tier 3

BUPROPION HCL ER (XL) TABLET EXTENDED

RELEASE 24 HOUR 150 MG ORAL

Tier 1

BUPROPION HCL ER (XL) TABLET EXTENDED

RELEASE 24 HOUR 300 MG ORAL

Tier 3

BUPROPION HCL ORAL TABLET 100 MG, 75 MG Tier 3

*Gaba Receptor Modulator - Neuroactive Steroid***

ZURZUVAE CAPSULE 20 MG ORAL Tier 6 PA; QL (28 EA per 365 days)

ZURZUVAE CAPSULE 25 MG ORAL Tier 6 PA; QL (28 EA per 365 days)

ZURZUVAE CAPSULE 30 MG ORAL Tier 6 PA; QL (14 EA per 365 days)

*Monoamine Oxidase Inhibitors (Maois)***

EMSAM TRANSDERMAL PATCH 24 HOUR 12

MG/24HR, 6 MG/24HR, 9 MG/24HR

Tier 4

TRANYLCYPROMINE SULFATE ORAL TABLET 10

Tier 3

*Selective Serotonin Reuptake Inhibitors (Ssris)***

CITALOPRAM HYDROBROMIDE ORAL SOLUTION

10 MG/5ML

Tier 3

CITALOPRAM HYDROBROMIDE ORAL TABLET 10

MG, 20 MG, 40 MG

Tier 3

ESCITALOPRAM OXALATE ORAL SOLUTION 5

MG/5ML

Tier 3

ESCITALOPRAM OXALATE ORAL TABLET 10 MG,

20 MG, 5 MG

Tier 3

FLUOXETINE HCL ORAL CAPSULE 10 MG, 20 MG, 40

Tier 3

FLUOXETINE HCL ORAL CAPSULE DELAYED

RELEASE 90 MG

Tier 3

FLUOXETINE HCL ORAL SOLUTION 20 MG/5ML Tier 3

FLUOXETINE HCL ORAL TABLET 10 MG Tier 3

FLUVOXAMINE MALEATE ORAL TABLET 100 MG,

25 MG, 50 MG

Tier 3

Drug Name Brand Tier Generic Tier Formulary Notes

PAROXETINE HCL ORAL TABLET 10 MG, 20 MG, 30

MG, 40 MG

Tier 3

SERTRALINE HCL ORAL CONCENTRATE 20 MG/ML Tier 3

SERTRALINE HCL ORAL TABLET 100 MG, 25 MG, 50

Tier 3

*Serotonin Modulators***

TRAZODONE HCL ORAL TABLET 100 MG, 150 MG,

300 MG, 50 MG

Tier 3

TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG Tier 4 ST

VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG Tier 4 ST

VILAZODONE HCL ORAL TABLET 10 MG, 20 MG, 40

Tier 3 ST

*Serotonin-Norepinephrine Reuptake Inhibitors

(Snris)***

DULOXETINE HCL ORAL CAPSULE DELAYED

RELEASE PARTICLES 20 MG, 30 MG, 40 MG, 60 MG

Tier 3

VENLAFAXINE HCL ER CAPSULE EXTENDED

RELEASE 24 HOUR 150 MG ORAL

Tier 3

VENLAFAXINE HCL ER CAPSULE EXTENDED

RELEASE 24 HOUR 37.5 MG ORAL

Tier 3

VENLAFAXINE HCL ER CAPSULE EXTENDED

RELEASE 24 HOUR 75 MG ORAL

Tier 1

VENLAFAXINE HCL ER ORAL TABLET EXTENDED

RELEASE 24 HOUR 225 MG

Tier 3

VENLAFAXINE HCL ORAL TABLET 100 MG, 25 MG,

37.5 MG, 50 MG, 75 MG

Tier 3

*Tricyclic Agents***

AMITRIPTYLINE HCL ORAL TABLET 10 MG, 100

MG, 150 MG, 25 MG, 50 MG, 75 MG

Tier 3

CLOMIPRAMINE HCL ORAL CAPSULE 25 MG, 50

MG, 75 MG

Tier 3

DESIPRAMINE HCL ORAL TABLET 10 MG, 100 MG,

150 MG, 25 MG, 50 MG, 75 MG

Tier 3

DOXEPIN HCL ORAL CAPSULE 10 MG, 100 MG, 150

MG, 25 MG, 50 MG, 75 MG

Tier 3

DOXEPIN HCL ORAL CONCENTRATE 10 MG/ML Tier 3

IMIPRAMINE HCL ORAL TABLET 10 MG, 25 MG, 50

Tier 3

IMIPRAMINE PAMOATE ORAL CAPSULE 100 MG,

125 MG, 150 MG, 75 MG

Tier 3

NORTRIPTYLINE HCL ORAL CAPSULE 10 MG, 25

MG, 50 MG, 75 MG

Tier 3

NORTRIPTYLINE HCL ORAL SOLUTION 10 MG/5ML Tier 3

*Antidiabetics*

*Alpha-Glucosidase Inhibitors***

ACARBOSE ORAL TABLET 100 MG, 25 MG, 50 MG Tier 1

*Antidiabetic - Amylin Analogs***

SYMLINPEN 120 SUBCUTANEOUS SOLUTION

PEN-INJECTOR 2700 MCG/2.7ML

Tier 4 PA

Drug Name Brand Tier Generic Tier Formulary Notes

SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-

INJECTOR 1500 MCG/1.5ML

Tier 4 PA

*Biguanides***

METFORMIN HCL ER ORAL TABLET EXTENDED

RELEASE 24 HOUR 500 MG, 750 MG

Tier 2

METFORMIN HCL ORAL TABLET 1000 MG, 500 MG,

850 MG

Tier 2

*Diabetic Other***

BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE Tier 4 QL (2 EA per 30 days)

BAQSIMI TWO PACK NASAL POWDER 3

MG/DOSE

Tier 4 QL (2 EA per 30 days)

GLUCAGON EMERGENCY KIT 1 MG INJECTION Tier 1 QL (2 EA per 30 days)

GLUCAGON EMERGENCY KIT 1 MG INJECTION Tier 2 QL (2 EA per 30 days)

*Dipeptidyl Peptidase-4 (Dpp-4) Inhibitors***

JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG Tier 4 ST

SAXAGLIPTIN HCL ORAL TABLET 2.5 MG, 5 MG Tier 3 ST

TRADJENTA ORAL TABLET 5 MG Tier 5 ST

*Dipeptidyl Peptidase-4 Inhibitor-Biguanide

Combinations***

JANUMET ORAL TABLET 50-1000 MG, 50-500 MG Tier 5 ST

JANUMET XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 100-1000 MG, 50-1000 MG, 50-

500 MG

Tier 5 ST

SAXAGLIPTIN-METFORMIN ER ORAL TABLET

EXTENDED RELEASE 24 HOUR 2.5-1000 MG, 5-1000

MG, 5-500 MG

Tier 3 ST

*Human Insulin***

ADMELOG INJECTION SOLUTION (INSULIN

LISPRO) 100 UNIT/ML

Tier 2 Tier 2

ADMELOG SOLOSTAR SUBCUTANEOUS

SOLUTION PEN-INJECTOR (INSULIN LISPRO (1

UNIT DIAL)) 100 UNIT/ML

Tier 2 Tier 2

APIDRA INJECTION SOLUTION 100 UNIT/ML Tier 2

APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION

PEN-INJECTOR 100 UNIT/ML

Tier 2

BASAGLAR KWIKPEN SUBCUTANEOUS

SOLUTION PEN-INJECTOR 100 UNIT/ML

Tier 2

FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION

PEN-INJECTOR 100 UNIT/ML

Tier 2

FIASP INJECTION SOLUTION 100 UNIT/ML Tier 2

HUMALOG INJECTION SOLUTION (INSULIN

LISPRO) 100 UNIT/ML

Tier 2 Tier 2

HUMALOG JUNIOR KWIKPEN SUBCUTANEOUS

SOLUTION PEN-INJECTOR (INSULIN LISPRO

JUNIOR KWIKPEN) 100 UNIT/ML

Tier 2 Tier 2

HUMALOG KWIKPEN SUBCUTANEOUS

SOLUTION PEN-INJECTOR (INSULIN LISPRO (1

UNIT DIAL)) 100 UNIT/ML

Tier 2 Tier 2

HUMALOG KWIKPEN SUBCUTANEOUS

SOLUTION PEN-INJECTOR 200 UNIT/ML

Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS

SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML

Tier 2

HUMALOG MIX 50/50 SUBCUTANEOUS

SUSPENSION (50-50) 100 UNIT/ML

Tier 2

HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS

SUSPENSION PEN-INJECTOR (INSULIN LISPRO

PROT & LISPRO) (75-25) 100 UNIT/ML

Tier 2 Tier 2

HUMALOG MIX 75/25 SUBCUTANEOUS

SUSPENSION (75-25) 100 UNIT/ML

Tier 2

HUMALOG SUBCUTANEOUS SOLUTION

CARTRIDGE 100 UNIT/ML

Tier 2

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS

SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

Tier 2

HUMULIN 70/30 SUBCUTANEOUS SUSPENSION

(70-30) 100 UNIT/ML

Tier 2

HUMULIN N KWIKPEN SUBCUTANEOUS

SUSPENSION PEN-INJECTOR 100 UNIT/ML

Tier 2

HUMULIN N SUBCUTANEOUS SUSPENSION 100

UNIT/ML

Tier 2

HUMULIN R INJECTION SOLUTION 100 UNIT/ML Tier 2

HUMULIN R U-500 (CONCENTRATED)

SUBCUTANEOUS SOLUTION 500 UNIT/ML

Tier 2

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS

SOLUTION PEN-INJECTOR 500 UNIT/ML

Tier 5

INSULIN ASPART PENFILL SUBCUTANEOUS

SOLUTION CARTRIDGE 100 UNIT/ML

Tier 2

INSULIN DEGLUDEC FLEXTOUCH SUBCUTANEOUS

SOLUTION PEN-INJECTOR 100 UNIT/ML, 200

UNIT/ML

Tier 4 PA

LEVEMIR FLEXPEN SUBCUTANEOUS SOLUTION

PEN-INJECTOR 100 UNIT/ML

Tier 2

LEVEMIR FLEXTOUCH SUBCUTANEOUS

SOLUTION PEN-INJECTOR 100 UNIT/ML

Tier 2

LEVEMIR SUBCUTANEOUS SOLUTION 100

UNIT/ML

Tier 2

NOVOLIN 70/30 FLEXPEN RELION

SUBCUTANEOUS SUSPENSION PEN-INJECTOR

(70-30) 100 UNIT/ML

Tier 2

NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS

SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

Tier 2

NOVOLIN 70/30 RELION SUBCUTANEOUS

SUSPENSION (70-30) 100 UNIT/ML

Tier 2

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION

(70-30) 100 UNIT/ML

Tier 2

NOVOLIN N FLEXPEN RELION SUBCUTANEOUS

SUSPENSION PEN-INJECTOR 100 UNIT/ML

Tier 2

NOVOLIN N FLEXPEN SUBCUTANEOUS

SUSPENSION PEN-INJECTOR 100 UNIT/ML

Tier 2

NOVOLIN N RELION SUBCUTANEOUS

SUSPENSION 100 UNIT/ML

Tier 2

NOVOLIN N SUBCUTANEOUS SUSPENSION 100

UNIT/ML

Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

NOVOLIN R FLEXPEN INJECTION SOLUTION

PEN-INJECTOR 100 UNIT/ML

Tier 2

NOVOLIN R FLEXPEN RELION INJECTION

SOLUTION PEN-INJECTOR 100 UNIT/ML

Tier 2

NOVOLIN R INJECTION SOLUTION 100 UNIT/ML Tier 2

NOVOLIN R RELION INJECTION SOLUTION 100

UNIT/ML

Tier 2

NOVOLOG 70/30 FLEXPEN RELION

SUBCUTANEOUS SUSPENSION PEN-INJECTOR

(INSULIN ASP PROT & ASP FLEXPEN) (70-30) 100

UNIT/ML

Tier 2 Tier 2

NOVOLOG FLEXPEN RELION SUBCUTANEOUS

SOLUTION PEN-INJECTOR (INSULIN ASPART

FLEXPEN) 100 UNIT/ML

Tier 2 Tier 2

NOVOLOG MIX 70/30 RELION SUBCUTANEOUS

SUSPENSION (INSULIN ASPART PROT & ASPART)

(70-30) 100 UNIT/ML

Tier 2 Tier 2

NOVOLOG RELION INJECTION SOLUTION

(INSULIN ASPART) 100 UNIT/ML

Tier 2 Tier 2

TOUJEO MAX SOLOSTAR SUBCUTANEOUS

SOLUTION PEN-INJECTOR (INSULIN GLARGINE

MAX SOLOSTAR) 300 UNIT/ML

Tier 5 Tier 5 ST

TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION

PEN-INJECTOR (INSULIN GLARGINE SOLOSTAR)

300 UNIT/ML

Tier 5 Tier 5 ST

*Incretin Mimetic Agents (Glp-1 Receptor Agonists)***

BYDUREON BCISE SUBCUTANEOUS AUTO-

INJECTOR 2 MG/0.85ML

Tier 4 PA; QL (4 ML per 28 days)

BYETTA 10 MCG PEN SUBCUTANEOUS

SOLUTION PEN-INJECTOR 10 MCG/0.04ML

Tier 4 PA; QL (1 ML per 30 days)

BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION

PEN-INJECTOR 5 MCG/0.02ML

Tier 4 PA; QL (1 ML per 30 days)

TRULICITY SUBCUTANEOUS SOLUTION PEN-

INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML, 3

MG/0.5ML, 4.5 MG/0.5ML

Tier 4 PA; QL (0.08 ML per 1 day)

VICTOZA SUBCUTANEOUS SOLUTION PEN-

INJECTOR (LIRAGLUTIDE) 18 MG/3ML

Tier 4 Tier 4 PA; QL (3 ML per 30 days)

*Meglitinide Analogues***

NATEGLINIDE ORAL TABLET 120 MG, 60 MG Tier 3

REPAGLINIDE ORAL TABLET 0.5 MG, 1 MG, 2 MG Tier 3

*Sglt2 Inhibitor - Dpp-4 Inhibitor - Biguanide Comb***

TRIJARDY XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 10-5-1000 MG, 12.5-2.5-1000 MG,

25-5-1000 MG, 5-2.5-1000 MG

Tier 4 ST

*Sglt2 Inhibitor - Dpp-4 Inhibitor Combinations***

GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG Tier 4 ST

*Sodium-Glucose Co-Transporter 2 (Sglt2)

Inhibitors***

FARXIGA ORAL TABLET 10 MG, 5 MG Tier 4 ST; QL (1 EA per 1 day)

JARDIANCE ORAL TABLET 10 MG, 25 MG Tier 4 ST; QL (1 EA per 1 day)

Drug Name Brand Tier Generic Tier Formulary Notes

*Sodium-Glucose Co-Transporter 2 Inhibitor-Biguanide

Comb***

SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500

MG, 5-1000 MG, 5-500 MG

Tier 4 ST

SYNJARDY XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 10-1000 MG, 12.5-1000 MG, 25-

1000 MG, 5-1000 MG

Tier 4 ST

XIGDUO XR ORAL TABLET EXTENDED RELEASE

24 HOUR 10-1000 MG, 10-500 MG, 2.5-1000 MG, 5-

1000 MG, 5-500 MG

Tier 4 ST

*Sulfonylurea-Biguanide Combinations***

GLIPIZIDE-METFORMIN HCL ORAL TABLET 2.5-250

MG, 2.5-500 MG, 5-500 MG

Tier 2

GLYBURIDE-METFORMIN ORAL TABLET 1.25-250

MG, 2.5-500 MG, 5-500 MG

Tier 2

*Sulfonylureas***

GLIMEPIRIDE ORAL TABLET 1 MG, 2 MG, 4 MG Tier 1

GLIPIZIDE ER ORAL TABLET EXTENDED RELEASE

24 HOUR 10 MG, 2.5 MG, 5 MG

Tier 2

GLIPIZIDE ORAL TABLET 10 MG, 5 MG Tier 2

GLIPIZIDE XL ORAL TABLET EXTENDED RELEASE

24 HOUR 10 MG, 2.5 MG, 5 MG

Tier 2

GLYBURIDE MICRONIZED ORAL TABLET 1.5 MG, 3

MG, 6 MG

Tier 2

GLYBURIDE ORAL TABLET 1.25 MG, 2.5 MG, 5 MG Tier 2

*Thiazolidinedione-Biguanide Combinations***

PIOGLITAZONE HCL-METFORMIN HCL ORAL

TABLET 15-500 MG, 15-850 MG

Tier 3

*Thiazolidinediones***

PIOGLITAZONE HCL ORAL TABLET 15 MG, 30 MG,

45 MG

Tier 1

*Antidiarrheal/Probiotic Agents*

*Antiperistaltic Agents***

DIPHENOXYLATE-ATROPINE ORAL LIQUID 2.5-

0.025 MG/5ML

Tier 3

DIPHENOXYLATE-ATROPINE ORAL TABLET 2.5-

0.025 MG

Tier 3

*Antidotes And Specific Antagonists*

*Antidotes - Chelating Agents***

DEFERASIROX ORAL TABLET SOLUBLE 125 MG,

250 MG, 500 MG

Tier 6

FERRIPROX ORAL SOLUTION 100 MG/ML Tier 5

*Opioid Antagonists***

NALOXONE HCL INJECTION SOLUTION PREFILLED

SYRINGE 2 MG/2ML

Tier 3

NALTREXONE HCL ORAL TABLET 50 MG Tier 3

NARCAN NASAL LIQUID (NALOXONE HCL) 4

MG/0.1ML

Tier 3 Tier 3 QL (4 EA per 180 days)

Drug Name Brand Tier Generic Tier Formulary Notes

VIVITROL INTRAMUSCULAR SUSPENSION

RECONSTITUTED 380 MG

Tier 6 PA; Specialty; QL (0.04 EA per 1 day)

*Antiemetics*

*5-Ht3 Receptor Antagonists***

ONDANSETRON HCL ORAL SOLUTION 4 MG/5ML Tier 3 QL (600 ML per 30 days)

ONDANSETRON HCL TABLET 4 MG ORAL Tier 3 QL (180 EA per 30 days)

ONDANSETRON HCL TABLET 8 MG ORAL Tier 3 QL (90 EA per 30 days)

ONDANSETRON TABLET DISPERSIBLE 16 MG ORAL Tier 3

ONDANSETRON TABLET DISPERSIBLE 4 MG ORAL Tier 3 QL (180 EA per 30 days)

ONDANSETRON TABLET DISPERSIBLE 8 MG ORAL Tier 3 QL (90 EA per 30 days)

*Antiemetic Combinations***

DOXYLAMINE-PYRIDOXINE ORAL TABLET

DELAYED RELEASE 10-10 MG

Tier 3

*Antiemetics - Anticholinergic***

SCOPOLAMINE TRANSDERMAL PATCH 72 HOUR 1

MG/3DAYS

Tier 3

TRIMETHOBENZAMIDE HCL ORAL CAPSULE 300

Tier 3

*Antifungals*

*Antifungals***

GRISEOFULVIN MICROSIZE ORAL SUSPENSION 125

MG/5ML

Tier 3

GRISEOFULVIN ULTRAMICROSIZE ORAL TABLET

125 MG, 250 MG

Tier 3

NYSTATIN ORAL TABLET 500000 UNIT Tier 3

TERBINAFINE HCL ORAL TABLET 250 MG Tier 3 QL (90 EA per 365 days)

*Imidazoles***

KETOCONAZOLE ORAL TABLET 200 MG Tier 3

*Triazoles***

FLUCONAZOLE ORAL SUSPENSION

RECONSTITUTED 10 MG/ML, 40 MG/ML

Tier 3

FLUCONAZOLE ORAL TABLET 100 MG, 150 MG, 200

MG, 50 MG

Tier 3

ITRACONAZOLE ORAL CAPSULE 100 MG Tier 3

VORICONAZOLE ORAL SUSPENSION

RECONSTITUTED 40 MG/ML

Tier 3

VORICONAZOLE ORAL TABLET 200 MG, 50 MG Tier 3

*Antihistamines*

*Antihistamines - Phenothiazines***

PROMETHAZINE HCL ORAL SOLUTION 6.25

MG/5ML

Tier 3

PROMETHAZINE HCL ORAL TABLET 12.5 MG, 25

MG, 50 MG

Tier 2

PROMETHEGAN RECTAL SUPPOSITORY

(PROMETHAZINE HCL) 12.5 MG, 25 MG

Tier 3 Tier 3

PROMETHEGAN RECTAL SUPPOSITORY 50 MG Tier 3

Drug Name Brand Tier Generic Tier Formulary Notes

*Antihistamines - Piperidines***

CYPROHEPTADINE HCL ORAL SYRUP 2 MG/5ML Tier 2

CYPROHEPTADINE HCL ORAL TABLET 4 MG Tier 2

*Antihyperlipidemics*

*Antihyperlipidemics - Misc.***

ICOSAPENT ETHYL ORAL CAPSULE 0.5 GM Tier 3

OMEGA-3-ACID ETHYL ESTERS ORAL CAPSULE 1

Tier 1

*Bile Acid Sequestrants***

CHOLESTYRAMINE LIGHT ORAL PACKET 4 GM Tier 3

CHOLESTYRAMINE LIGHT ORAL POWDER 4

GM/DOSE

Tier 3

CHOLESTYRAMINE ORAL POWDER 4 GM/DOSE Tier 3

COLESEVELAM HCL ORAL TABLET 625 MG Tier 3

COLESTIPOL HCL ORAL GRANULES 5 GM Tier 3

COLESTIPOL HCL ORAL PACKET 5 GM Tier 3

COLESTIPOL HCL ORAL TABLET 1 GM Tier 3

*Fibric Acid Derivatives***

FENOFIBRATE MICRONIZED CAPSULE 134 MG

ORAL

Tier 1

FENOFIBRATE MICRONIZED CAPSULE 200 MG

ORAL

Tier 1

FENOFIBRATE MICRONIZED CAPSULE 43 MG ORAL Tier 3

FENOFIBRATE MICRONIZED CAPSULE 67 MG ORAL Tier 1

FENOFIBRATE ORAL CAPSULE 134 MG, 200 MG, 67

Tier 1

FENOFIBRATE ORAL TABLET 145 MG, 160 MG, 48

MG, 54 MG

Tier 1

GEMFIBROZIL ORAL TABLET 600 MG Tier 1

*Hmg Coa Reductase Inhibitors***

ATORVASTATIN CALCIUM ORAL TABLET 10 MG,

20 MG, 40 MG, 80 MG

Tier 1

LOVASTATIN ORAL TABLET 10 MG, 20 MG, 40 MG Tier 1

PRAVASTATIN SODIUM ORAL TABLET 10 MG, 20

MG, 40 MG, 80 MG

Tier 1

ROSUVASTATIN CALCIUM ORAL TABLET 10 MG, 20

MG, 40 MG, 5 MG

Tier 1

SIMVASTATIN ORAL TABLET 10 MG, 20 MG, 40 MG,

5 MG, 80 MG

Tier 1

*Intest Cholest Absorp Inhib-Hmg Coa Reductase Inhib

Comb***

EZETIMIBE-SIMVASTATIN ORAL TABLET 10-10 MG,

10-20 MG, 10-40 MG, 10-80 MG

Tier 3

*Intestinal Cholesterol Absorption Inhibitors***

EZETIMIBE ORAL TABLET 10 MG Tier 1

*Nicotinic Acid Derivatives***

NIACIN ER (ANTIHYPERLIPIDEMIC) ORAL TABLET

EXTENDED RELEASE 1000 MG, 500 MG, 750 MG

Tier 3

Drug Name Brand Tier Generic Tier Formulary Notes

*Pcsk9 Inhibitors***

PRALUENT SUBCUTANEOUS SOLUTION AUTO-

INJECTOR 150 MG/ML, 75 MG/ML

Tier 6 PA

REPATHA PUSHTRONEX SYSTEM

SUBCUTANEOUS SOLUTION CARTRIDGE 420

MG/3.5ML

Tier 6 PA

REPATHA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 140 MG/ML

Tier 6 PA

REPATHA SURECLICK SUBCUTANEOUS

SOLUTION AUTO-INJECTOR 140 MG/ML

Tier 6 PA

*Antihypertensives*

*Ace Inhibitor & Calcium Channel Blocker

Combinations***

AMLODIPINE BESY-BENAZEPRIL HCL CAPSULE 10-

20 MG ORAL

Tier 1

AMLODIPINE BESY-BENAZEPRIL HCL CAPSULE 10-

40 MG ORAL

Tier 1

AMLODIPINE BESY-BENAZEPRIL HCL CAPSULE

2.5-10 MG ORAL

Tier 1

AMLODIPINE BESY-BENAZEPRIL HCL CAPSULE 5-

10 MG ORAL

Tier 1

AMLODIPINE BESY-BENAZEPRIL HCL CAPSULE 5-

20 MG ORAL

Tier 1

AMLODIPINE BESY-BENAZEPRIL HCL CAPSULE 5-

40 MG ORAL

Tier 3

*Ace Inhibitors & Thiazide/Thiazide-Like***

BENAZEPRIL-HYDROCHLOROTHIAZIDE ORAL

TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG, 5-6.25 MG

Tier 3

ENALAPRIL-HYDROCHLOROTHIAZIDE ORAL

TABLET 10-25 MG, 5-12.5 MG

Tier 2

FOSINOPRIL SODIUM-HCTZ ORAL TABLET 10-12.5

MG, 20-12.5 MG

Tier 3

LISINOPRIL-HYDROCHLOROTHIAZIDE ORAL

TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG

Tier 2

QUINAPRIL-HYDROCHLOROTHIAZIDE ORAL

TABLET 10-12.5 MG, 20-12.5 MG, 20-25 MG

Tier 3

*Ace Inhibitors***

BENAZEPRIL HCL ORAL TABLET 10 MG, 20 MG, 40

MG, 5 MG

Tier 1

CAPTOPRIL ORAL TABLET 100 MG, 12.5 MG, 25 MG,

50 MG

Tier 3

ENALAPRIL MALEATE ORAL TABLET 10 MG, 2.5

MG, 20 MG, 5 MG

Tier 1

FOSINOPRIL SODIUM TABLET 10 MG ORAL Tier 3

FOSINOPRIL SODIUM TABLET 20 MG ORAL Tier 1

FOSINOPRIL SODIUM TABLET 40 MG ORAL Tier 1

LISINOPRIL ORAL TABLET 10 MG, 2.5 MG, 20 MG, 30

MG, 40 MG, 5 MG

Tier 1

MOEXIPRIL HCL ORAL TABLET 15 MG, 7.5 MG Tier 3

QUINAPRIL HCL TABLET 10 MG ORAL Tier 3

Drug Name Brand Tier Generic Tier Formulary Notes

QUINAPRIL HCL TABLET 20 MG ORAL Tier 1

QUINAPRIL HCL TABLET 40 MG ORAL Tier 1

QUINAPRIL HCL TABLET 5 MG ORAL Tier 1

RAMIPRIL CAPSULE 1.25 MG ORAL Tier 3

RAMIPRIL CAPSULE 10 MG ORAL Tier 1

RAMIPRIL CAPSULE 2.5 MG ORAL Tier 1

RAMIPRIL CAPSULE 5 MG ORAL Tier 1

*Angiotensin Ii Receptor Antag & Thiazide/Thiazide-

Like***

IRBESARTAN-HYDROCHLOROTHIAZIDE ORAL

TABLET 150-12.5 MG, 300-12.5 MG

Tier 3

LOSARTAN POTASSIUM-HCTZ ORAL TABLET 100-

12.5 MG, 100-25 MG, 50-12.5 MG

Tier 1

OLMESARTAN MEDOXOMIL-HCTZ ORAL TABLET

20-12.5 MG, 40-12.5 MG, 40-25 MG

Tier 1

VALSARTAN-HYDROCHLOROTHIAZIDE TABLET

160-12.5 MG ORAL

Tier 3

VALSARTAN-HYDROCHLOROTHIAZIDE TABLET

160-25 MG ORAL

Tier 3

VALSARTAN-HYDROCHLOROTHIAZIDE TABLET

320-12.5 MG ORAL

Tier 3

VALSARTAN-HYDROCHLOROTHIAZIDE TABLET

320-25 MG ORAL

Tier 1

VALSARTAN-HYDROCHLOROTHIAZIDE TABLET

80-12.5 MG ORAL

Tier 3

*Angiotensin Ii Receptor Antagonists***

CANDESARTAN CILEXETIL ORAL TABLET 16 MG,

32 MG, 4 MG, 8 MG

Tier 3

IRBESARTAN ORAL TABLET 150 MG, 300 MG, 75 MG Tier 1

LOSARTAN POTASSIUM ORAL TABLET 100 MG, 25

MG, 50 MG

Tier 1

OLMESARTAN MEDOXOMIL ORAL TABLET 20 MG,

40 MG, 5 MG

Tier 1

VALSARTAN ORAL TABLET 160 MG, 320 MG, 40 MG,

80 MG

Tier 1

*Antiadrenergics - Centrally Acting***

CLONIDINE HCL ORAL TABLET 0.1 MG, 0.2 MG, 0.3

Tier 1

GUANFACINE HCL ORAL TABLET 1 MG, 2 MG Tier 3

METHYLDOPA ORAL TABLET 250 MG, 500 MG Tier 3

*Antiadrenergics - Peripherally Acting***

DOXAZOSIN MESYLATE ORAL TABLET 1 MG, 2 MG,

4 MG, 8 MG

Tier 1

PRAZOSIN HCL ORAL CAPSULE 1 MG, 2 MG, 5 MG Tier 3

TERAZOSIN HCL ORAL CAPSULE 1 MG, 10 MG, 2

MG, 5 MG

Tier 1

*Beta Blocker & Diuretic Combinations***

ATENOLOL-CHLORTHALIDONE TABLET 100-25 MG

ORAL

Tier 3

Drug Name Brand Tier Generic Tier Formulary Notes

ATENOLOL-CHLORTHALIDONE TABLET 50-25 MG

ORAL

Tier 1

BISOPROLOL-HYDROCHLOROTHIAZIDE TABLET

10-6.25 MG ORAL

Tier 3

BISOPROLOL-HYDROCHLOROTHIAZIDE TABLET

2.5-6.25 MG ORAL

Tier 1

BISOPROLOL-HYDROCHLOROTHIAZIDE TABLET 5-

6.25 MG ORAL

Tier 3

METOPROLOL-HYDROCHLOROTHIAZIDE ORAL

TABLET 100-25 MG, 100-50 MG, 50-25 MG

Tier 3

*Vasodilators***

HYDRALAZINE HCL ORAL TABLET 10 MG, 100 MG,

25 MG, 50 MG

Tier 1

MINOXIDIL ORAL TABLET 10 MG, 2.5 MG Tier 3

*Anti-Infective Agents - Misc.*

*Anti-Infective Agents - Misc.***

METRONIDAZOLE ORAL TABLET 250 MG, 500 MG Tier 2

TRIMETHOPRIM ORAL TABLET 100 MG Tier 3

XIFAXAN ORAL TABLET 550 MG Tier 5 PA

*Anti-Infective Misc. - Combinations***

SULFAMETHOXAZOLE-TRIMETHOPRIM ORAL

TABLET 400-80 MG, 800-160 MG

Tier 2

SULFATRIM PEDIATRIC ORAL SUSPENSION

(SULFAMETHOXAZOLE-TRIMETHOPRIM) 200-40

MG/5ML

Tier 3 Tier 3

*Carbapenems***

MEROPENEM INTRAVENOUS SOLUTION

RECONSTITUTED 2 GM

Tier 3

*Glycopeptides***

VANCOMYCIN HCL IN DEXTROSE INTRAVENOUS

SOLUTION 1.5-5 GM/300ML-%

Tier 3

VANCOMYCIN HCL ORAL CAPSULE 125 MG, 250

Tier 3

VANCOMYCIN HCL ORAL SOLUTION

RECONSTITUTED 25 MG/ML

Tier 3

*Lincosamides***

CLINDAMYCIN HCL ORAL CAPSULE 150 MG, 300

Tier 3

CLINDAMYCIN PALMITATE HCL ORAL SOLUTION

RECONSTITUTED 75 MG/5ML

Tier 3

*Oxazolidinones***

LINEZOLID ORAL SUSPENSION RECONSTITUTED

100 MG/5ML

Tier 3 PA

LINEZOLID ORAL TABLET 600 MG Tier 3 PA

*Urinary Anti-Infectives***

NITROFURANTOIN MACROCRYSTAL ORAL

CAPSULE 100 MG, 25 MG, 50 MG

Tier 3

NITROFURANTOIN MONOHYD MACRO ORAL

CAPSULE 100 MG

Tier 3

Drug Name Brand Tier Generic Tier Formulary Notes

*Antimalarials*

*Antimalarial Combinations***

ATOVAQUONE-PROGUANIL HCL ORAL TABLET

250-100 MG, 62.5-25 MG

Tier 3

*Antimalarials***

HYDROXYCHLOROQUINE SULFATE TABLET 100

MG ORAL

Tier 3

HYDROXYCHLOROQUINE SULFATE TABLET 200

MG ORAL

Tier 1

HYDROXYCHLOROQUINE SULFATE TABLET 300

MG ORAL

Tier 3

HYDROXYCHLOROQUINE SULFATE TABLET 400

MG ORAL

Tier 3

MEFLOQUINE HCL ORAL TABLET 250 MG Tier 3

*Antimyasthenic/Cholinergic Agents*

*Antimyasthenic/Cholinergic Agents***

PYRIDOSTIGMINE BROMIDE ER ORAL TABLET

EXTENDED RELEASE 180 MG

Tier 3

PYRIDOSTIGMINE BROMIDE ORAL SOLUTION 60

MG/5ML

Tier 5

PYRIDOSTIGMINE BROMIDE ORAL TABLET 30 MG,

60 MG

Tier 3

*Antimycobacterial Agents*

*Antimycobacterial Agents***

ETHAMBUTOL HCL ORAL TABLET 400 MG Tier 3

ISONIAZID ORAL SYRUP 50 MG/5ML Tier 3

ISONIAZID TABLET 100 MG ORAL Tier 3

ISONIAZID TABLET 300 MG ORAL Tier 1

PRIFTIN ORAL TABLET 150 MG Tier 4 PA

PYRAZINAMIDE ORAL TABLET 500 MG Tier 3

RIFAMPIN ORAL CAPSULE 150 MG, 300 MG Tier 3

*Antineoplastics And Adjunctive Therapies*

*Antiadrenals***

LYSODREN ORAL TABLET 500 MG Tier 4

*Antiandrogens***

BICALUTAMIDE ORAL TABLET 50 MG Tier 1

FLUTAMIDE ORAL CAPSULE 125 MG Tier 3

NILUTAMIDE ORAL TABLET 150 MG Tier 6 Specialty

*Antiestrogens***

TAMOXIFEN CITRATE ORAL TABLET 10 MG, 20 MG Tier 1

TOREMIFENE CITRATE ORAL TABLET 60 MG Tier 6

*Antimetabolites***

AZACITIDINE INJECTION SUSPENSION

RECONSTITUTED 100 MG

Tier 3 Specialty

CAPECITABINE ORAL TABLET 150 MG, 500 MG Tier 6 Specialty

CYTARABINE (PF) INJECTION SOLUTION 100

MG/ML, 20 MG/ML

Tier 3 Specialty

Drug Name Brand Tier Generic Tier Formulary Notes

CYTARABINE INJECTION SOLUTION 20 MG/ML Tier 3 Specialty

FLOXURIDINE INJECTION SOLUTION

RECONSTITUTED 0.5 GM

Tier 3 Specialty

MERCAPTOPURINE ORAL TABLET 50 MG Tier 6

METHOTREXATE SODIUM (PF) INJECTION

SOLUTION 1 GM/40ML, 250 MG/10ML, 50 MG/2ML

Tier 3

METHOTREXATE SODIUM INJECTION SOLUTION

1000 MG/40ML, 250 MG/10ML, 50 MG/2ML

Tier 3

METHOTREXATE SODIUM INJECTION SOLUTION

RECONSTITUTED 1 GM

Tier 3

METHOTREXATE SODIUM ORAL TABLET 2.5 MG Tier 1

*Antineoplastic - Akt Inhibitors***

TRUQAP ORAL TABLET 160 MG, 200 MG Tier 6 PA; Specialty; QL (64 EA per 28 days)

*Antineoplastic - Alk Inhibitors***

ALECENSA ORAL CAPSULE 150 MG Tier 6 PA; Specialty; QL (8 EA per 1 day)

ALUNBRIG ORAL TABLET THERAPY PACK 90 &

180 MG

Tier 6 PA; Specialty; QL (30 EA per 180 days)

ALUNBRIG TABLET 180 MG ORAL Tier 6 PA; Specialty; QL (1 EA per 1 day)

ALUNBRIG TABLET 30 MG ORAL Tier 6 PA; Specialty; QL (3 EA per 1 day)

ALUNBRIG TABLET 90 MG ORAL Tier 6 PA; Specialty; QL (2 EA per 1 day)

LORBRENA TABLET 100 MG ORAL Tier 6 PA; Specialty; QL (1 EA per 1 day)

LORBRENA TABLET 25 MG ORAL Tier 6 PA; Specialty; QL (3 EA per 1 day)

XALKORI CAPSULE 200 MG ORAL Tier 6 PA; Specialty; QL (5 EA per 1 day)

XALKORI CAPSULE 250 MG ORAL Tier 6 PA; Specialty; QL (4 EA per 1 day)

ZYKADIA ORAL TABLET 150 MG Tier 6 PA; Specialty; QL (3 EA per 1 day)

*Antineoplastic - Anti-Her2 Agents***

TUKYSA ORAL TABLET 150 MG, 50 MG Tier 6 PA; Specialty; QL (4 EA per 1 day)

*Antineoplastic - Bcr-Abl Kinase Inhibitors***

BOSULIF CAPSULE 100 MG ORAL Tier 6 PA; Specialty; QL (3 EA per 1 day)

BOSULIF CAPSULE 50 MG ORAL Tier 6 PA; Specialty; QL (1 EA per 1 day)

BOSULIF TABLET 100 MG ORAL Tier 6 PA; Specialty; QL (3 EA per 1 day)

BOSULIF TABLET 400 MG ORAL Tier 6 PA; Specialty; QL (1 EA per 1 day)

BOSULIF TABLET 500 MG ORAL Tier 6 PA; Specialty; QL (1 EA per 1 day)

IMATINIB MESYLATE ORAL TABLET 100 MG, 400

Tier 6 Specialty

SCEMBLIX TABLET 20 MG ORAL Tier 6 PA; Specialty; QL (20 EA per 1 day)

SCEMBLIX TABLET 40 MG ORAL Tier 6 PA; Specialty; QL (10 EA per 1 day)

SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG,

50 MG, 70 MG, 80 MG

Tier 6 PA; Specialty

TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG Tier 6 PA; Specialty; QL (4 EA per 1 day)

*Antineoplastic - Braf Kinase Inhibitors***

BRAFTOVI ORAL CAPSULE 75 MG Tier 6 PA; Specialty; QL (6 EA per 1 day)

TAFINLAR ORAL CAPSULE 50 MG, 75 MG Tier 6 PA; Specialty; QL (4 EA per 1 day)

*Antineoplastic - Btk Inhibitors***

BRUKINSA ORAL CAPSULE 80 MG Tier 6 PA; Specialty; QL (4 EA per 1 day)

CALQUENCE ORAL TABLET 100 MG Tier 6 PA; Specialty; QL (2 EA per 1 day)

Drug Name Brand Tier Generic Tier Formulary Notes

IMBRUVICA ORAL CAPSULE 140 MG, 70 MG Tier 6 PA; Specialty

IMBRUVICA ORAL SUSPENSION 70 MG/ML Tier 6 PA; Specialty; QL (8 ML per 1 day)

IMBRUVICA ORAL TABLET 420 MG, 560 MG Tier 6 PA; Specialty

JAYPIRCA ORAL TABLET 100 MG, 50 MG Tier 6 PA; Specialty; QL (2 EA per 1 day)

*Antineoplastic - Egfr Inhibitors***

ERLOTINIB HCL ORAL TABLET 100 MG, 150 MG, 25

Tier 3 Specialty

EXKIVITY ORAL CAPSULE 40 MG Tier 6 PA; Specialty; QL (4 EA per 1 day)

*Antineoplastic - Fgfr Kinase Inhibitors***

LYTGOBI (12 MG DAILY DOSE) ORAL TABLET

THERAPY PACK 4 MG

Tier 6 PA; Specialty; QL (3 EA per 1 day)

LYTGOBI (16 MG DAILY DOSE) ORAL TABLET

THERAPY PACK 4 MG

Tier 6 PA; Specialty; QL (4 EA per 1 day)

LYTGOBI (20 MG DAILY DOSE) ORAL TABLET

THERAPY PACK 4 MG

Tier 6 PA; Specialty; QL (5 EA per 1 day)

PEMAZYRE ORAL TABLET 13.5 MG, 4.5 MG, 9 MG Tier 6 PA; Specialty; QL (1 EA per 1 day)

TRUSELTIQ (100MG DAILY DOSE) ORAL

CAPSULE THERAPY PACK 100 MG

Tier 6 PA; Specialty; QL (1 EA per 1 day)

TRUSELTIQ (125MG DAILY DOSE) ORAL

CAPSULE THERAPY PACK 100 & 25 MG

Tier 6 PA; Specialty; QL (1 EA per 1 day)

TRUSELTIQ (50MG DAILY DOSE) ORAL CAPSULE

THERAPY PACK 25 MG

Tier 6 PA; Specialty; QL (1 EA per 1 day)

TRUSELTIQ (75MG DAILY DOSE) ORAL CAPSULE

THERAPY PACK 25 MG

Tier 6 PA; Specialty; QL (1 EA per 1 day)

*Antineoplastic - Gamma Secretase Inhibitors***

OGSIVEO ORAL TABLET 50 MG Tier 6 PA; Specialty; QL (6 EA per 1 day)

*Antineoplastic - Hif-2-Alpha Inhibitors***

WELIREG ORAL TABLET 40 MG Tier 6 PA; Specialty

*Antineoplastic - Histone Deacetylase Inhibitors***

ZOLINZA ORAL CAPSULE 100 MG Tier 6 PA; Specialty

*Antineoplastic - Hormonal And Related Agent

Combinations***

AKEEGA ORAL TABLET 100-500 MG, 50-500 MG Tier 6 PA; Specialty; QL (2 EA per 1 day)

*Antineoplastic - Kras Inhibitors***

KRAZATI ORAL TABLET 200 MG Tier 6 PA; Specialty; QL (6 EA per 1 day)

LUMAKRAS ORAL TABLET 120 MG, 320 MG Tier 6 PA; Specialty; QL (8 EA per 1 day)

*Antineoplastic - Mek Inhibitors***

COTELLIC ORAL TABLET 20 MG Tier 6 PA; Specialty; QL (3 EA per 1 day)

MEKINIST TABLET 0.5 MG ORAL Tier 6 PA; Specialty; QL (3 EA per 1 day)

MEKINIST TABLET 2 MG ORAL Tier 6 PA; Specialty; QL (1 EA per 1 day)

MEKTOVI ORAL TABLET 15 MG Tier 6 PA; Specialty; QL (6 EA per 1 day)

*Antineoplastic - Met Inhibitors***

TEPMETKO ORAL TABLET 225 MG Tier 6 PA; Specialty; QL (2 EA per 1 day)

*Antineoplastic - Mtor Kinase Inhibitors***

TORPENZ ORAL TABLET (EVEROLIMUS) 10 MG,

2.5 MG, 5 MG, 7.5 MG

Tier 6 Tier 6 PA; Specialty

Drug Name Brand Tier Generic Tier Formulary Notes

*Antineoplastic - Multikinase Inhibitors***

CABOMETYX ORAL TABLET 20 MG, 40 MG, 60

Tier 6 PA; Specialty; QL (1 EA per 1 day)

FOTIVDA ORAL CAPSULE 1.34 MG Tier 6 PA; Specialty; QL (0.75 EA per 1 day)

LAPATINIB DITOSYLATE ORAL TABLET 250 MG Tier 6 Specialty

PAZOPANIB HCL ORAL TABLET 200 MG Tier 6 PA; Specialty; QL (4 EA per 1 day)

RYDAPT ORAL CAPSULE 25 MG Tier 6 PA; Specialty; QL (8 EA per 1 day)

SORAFENIB TOSYLATE ORAL TABLET 200 MG Tier 6 PA; Specialty; QL (4 EA per 1 day)

SUNITINIB MALATE ORAL CAPSULE 12.5 MG, 25

MG, 37.5 MG, 50 MG

Tier 6 Specialty

VANFLYTA ORAL TABLET 17.7 MG, 26.5 MG Tier 6 PA; Specialty; QL (2 EA per 1 day)

*Antineoplastic - Proteasome Inhibitors***

BORTEZOMIB INJECTION SOLUTION

RECONSTITUTED 1 MG, 2.5 MG

Tier 3 Specialty

BORTEZOMIB INTRAVENOUS SOLUTION 3.5

MG/1.4ML

Tier 3 Specialty

NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG Tier 6 PA; Specialty; QL (4 EA per 28 days)

*Antineoplastic - Ret Inhibitors***

RETEVMO CAPSULE 40 MG ORAL Tier 6 PA; Specialty; QL (6 EA per 1 day)

RETEVMO CAPSULE 80 MG ORAL Tier 6 PA; Specialty; QL (4 EA per 1 day)

*Antineoplastic - Tropomyosin Receptor Kinase

Inhibitors***

AUGTYRO ORAL CAPSULE 40 MG Tier 6 PA; Specialty; QL (8 EA per 1 day)

ROZLYTREK CAPSULE 100 MG ORAL Tier 6 PA; Specialty; QL (1 EA per 1 day)

ROZLYTREK CAPSULE 200 MG ORAL Tier 6 PA; Specialty; QL (3 EA per 1 day)

ROZLYTREK ORAL PACKET 50 MG Tier 6 PA; Specialty; QL (2 EA per 1 day)

*Antineoplastic Antibiotics***

BLEOMYCIN SULFATE INJECTION SOLUTION

RECONSTITUTED 15 UNIT, 30 UNIT

Tier 3 Specialty

*Antineoplastic Combinations***

LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG Tier 6 PA; Specialty

*Antineoplastic Enzymes***

ONCASPAR INJECTION SOLUTION 750 UNIT/ML Tier 4 Specialty

*Antineoplastics - Photoactivated Agents***

UVADEX EXTRACORPOREAL SOLUTION 20

MCG/ML

Tier 4

*Antineoplastics Misc.***

ACTIMMUNE SUBCUTANEOUS SOLUTION 100

MCG/0.5ML

Tier 6 Specialty

ALFERON N INJECTION SOLUTION 5000000

UNIT/ML

Tier 4 Specialty

HYDROXYUREA ORAL CAPSULE 500 MG Tier 1

INTRON A INJECTION SOLUTION

RECONSTITUTED 10000000 UNIT, 18000000 UNIT,

50000000 UNIT

Tier 6 PA; Specialty

MATULANE ORAL CAPSULE 50 MG Tier 6 Specialty

Drug Name Brand Tier Generic Tier Formulary Notes

*Aromatase Inhibitors***

ANASTROZOLE ORAL TABLET 1 MG Tier 1

EXEMESTANE ORAL TABLET 25 MG Tier 1

LETROZOLE ORAL TABLET 2.5 MG Tier 1

*Chemotherapy Adjuncts - Keratinocyte Growth

Factors***

KEPIVANCE INTRAVENOUS SOLUTION

RECONSTITUTED 5.16 MG

Tier 4 Specialty

*Cyclin-Dependent Kinases (Cdk) Inhibitors***

IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG Tier 6 PA; Specialty; QL (21 EA per 28 days)

IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG Tier 6 PA; Specialty; QL (21 EA per 28 days)

KISQALI (200 MG DOSE) ORAL TABLET

THERAPY PACK

Tier 6 PA; Specialty

KISQALI (400 MG DOSE) ORAL TABLET

THERAPY PACK 200 MG

Tier 6 PA; Specialty

KISQALI (600 MG DOSE) ORAL TABLET

THERAPY PACK 200 MG

Tier 6 PA; Specialty

VERZENIO ORAL TABLET 100 MG, 150 MG, 200

MG, 50 MG

Tier 6 PA; Specialty; QL (2 EA per 1 day)

*Estrogens-Antineoplastic***

EMCYT ORAL CAPSULE 140 MG Tier 4 PA

*Folic Acid Antagonists Rescue Agents***

LEUCOVORIN CALCIUM INJECTION SOLUTION 500

MG/50ML

Tier 3

LEUCOVORIN CALCIUM INJECTION SOLUTION

RECONSTITUTED 100 MG, 200 MG, 350 MG, 50 MG

Tier 3

LEUCOVORIN CALCIUM ORAL TABLET 10 MG, 15

MG, 25 MG, 5 MG

Tier 3

*Imidazotetrazines***

TEMOZOLOMIDE ORAL CAPSULE 100 MG, 140 MG,

180 MG, 20 MG, 250 MG, 5 MG

Tier 6 Specialty

*Isocitrate Dehydrogenase-1 (Idh1) Inhibitors***

REZLIDHIA ORAL CAPSULE 150 MG Tier 6 PA; Specialty; QL (2 EA per 1 day)

TIBSOVO ORAL TABLET 250 MG Tier 6 PA; Specialty; QL (2 EA per 1 day)

*Janus Associated Kinase (Jak) Inhibitors***

VONJO ORAL CAPSULE 100 MG Tier 6 PA; Specialty; QL (4 EA per 1 day)

*Lhrh Analogs***

ELIGARD SUBCUTANEOUS KIT 22.5 MG, 30 MG, 45

MG, 7.5 MG

Tier 6 Specialty

LEUPROLIDE ACETATE INJECTION KIT 1 MG/0.2ML Tier 6 Specialty

LUPRON DEPOT (1-MONTH) INTRAMUSCULAR

KIT 3.75 MG, 7.5 MG

Tier 6 Specialty

LUPRON DEPOT (3-MONTH) INTRAMUSCULAR

KIT 11.25 MG, 22.5 MG

Tier 6 Specialty

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR

KIT 30 MG

Tier 6 Specialty

*Mitotic Inhibitors***

ETOPOSIDE ORAL CAPSULE 50 MG Tier 6 Specialty

Drug Name Brand Tier Generic Tier Formulary Notes

*Nitrogen Mustards And Related Analogues***

LEUKERAN ORAL TABLET 2 MG Tier 6 PA

MELPHALAN ORAL TABLET 2 MG Tier 3 Specialty

*Nitrosoureas***

GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40

Tier 6 PA; Specialty

*Poly (Adp-Ribose) Polymerase (Parp) Inhibitors***

LYNPARZA TABLET 100 MG ORAL Tier 6 PA; Specialty; QL (6 EA per 1 day)

LYNPARZA TABLET 150 MG ORAL Tier 6 PA; Specialty; QL (4 EA per 1 day)

TALZENNA ORAL CAPSULE 0.1 MG, 0.25 MG, 0.35

MG, 0.5 MG, 0.75 MG, 1 MG

Tier 6 PA; Specialty; QL (1 EA per 1 day)

*Progestins-Antineoplastic***

MEGESTROL ACETATE ORAL SUSPENSION 40

MG/ML, 400 MG/10ML, 800 MG/20ML

Tier 3

MEGESTROL ACETATE ORAL TABLET 20 MG, 40

Tier 3

*Selective Estrogen Receptor Degraders***

ORSERDU TABLET 345 MG ORAL Tier 6 PA; Specialty; QL (1 EA per 1 day)

ORSERDU TABLET 86 MG ORAL Tier 6 PA; Specialty; QL (3 EA per 1 day)

*Selective Retinoid X Receptor Agonists***

BEXAROTENE ORAL CAPSULE 75 MG Tier 6 Specialty

*Topoisomerase I Inhibitors***

HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG Tier 6 PA; Specialty

*Urinary Tract Protective Agents***

MESNEX ORAL TABLET 400 MG Tier 6 Specialty

*Vascular Endothelial Growth Factor (Vegf)

Inhibitors***

FRUZAQLA CAPSULE 1 MG ORAL Tier 6 PA; Specialty; QL (4 EA per 1 day)

FRUZAQLA CAPSULE 5 MG ORAL Tier 6 PA; Specialty; QL (1 EA per 1 day)

LENVIMA (10 MG DAILY DOSE) ORAL CAPSULE

THERAPY PACK

Tier 6 PA; Specialty

LENVIMA (12 MG DAILY DOSE) ORAL CAPSULE

THERAPY PACK 3 X 4 MG

Tier 6 PA; Specialty

LENVIMA (14 MG DAILY DOSE) ORAL CAPSULE

THERAPY PACK 10 & 4 MG

Tier 6 PA; Specialty

LENVIMA (18 MG DAILY DOSE) ORAL CAPSULE

THERAPY PACK 10 MG & 2 X 4 MG

Tier 6 PA; Specialty

LENVIMA (20 MG DAILY DOSE) ORAL CAPSULE

THERAPY PACK 2 X 10 MG

Tier 6 PA; Specialty

LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE

THERAPY PACK 2 X 10 MG & 4 MG

Tier 6 PA; Specialty

LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE

THERAPY PACK

Tier 6 PA; Specialty

LENVIMA (8 MG DAILY DOSE) ORAL CAPSULE

THERAPY PACK 2 X 4 MG

Tier 6 PA; Specialty

Drug Name Brand Tier Generic Tier Formulary Notes

*Antiparkinson And Related Therapy Agents*

*Antiparkinson Anticholinergics***

BENZTROPINE MESYLATE ORAL TABLET 0.5 MG, 1

MG, 2 MG

Tier 1

TRIHEXYPHENIDYL HCL ORAL TABLET 2 MG, 5 MG Tier 1

*Antiparkinson Dopaminergics***

AMANTADINE HCL ORAL CAPSULE 100 MG Tier 1

AMANTADINE HCL ORAL SOLUTION 50 MG/5ML Tier 3

AMANTADINE HCL ORAL TABLET 100 MG Tier 3

BROMOCRIPTINE MESYLATE ORAL CAPSULE 5 MG Tier 3

BROMOCRIPTINE MESYLATE ORAL TABLET 2.5 MG Tier 3

*Antiparkinson Monoamine Oxidase Inhibitors***

SELEGILINE HCL ORAL CAPSULE 5 MG Tier 3

SELEGILINE HCL ORAL TABLET 5 MG Tier 3

*Levodopa Combinations***

CARBIDOPA-LEVODOPA ER ORAL TABLET

EXTENDED RELEASE 25-100 MG, 50-200 MG

Tier 1

CARBIDOPA-LEVODOPA ORAL TABLET 10-100 MG,

25-100 MG, 25-250 MG

Tier 1

CARBIDOPA-LEVODOPA-ENTACAPONE ORAL

TABLET 12.5-50-200 MG, 18.75-75-200 MG, 25-100-200

MG, 31.25-125-200 MG, 37.5-150-200 MG, 50-200-200

Tier 3

*Nonergoline Dopamine Receptor Agonists***

APOMORPHINE HCL SUBCUTANEOUS SOLUTION

CARTRIDGE 30 MG/3ML

Tier 3 Specialty

PRAMIPEXOLE DIHYDROCHLORIDE TABLET 0.125

MG ORAL

Tier 3

PRAMIPEXOLE DIHYDROCHLORIDE TABLET 0.25

MG ORAL

Tier 1

PRAMIPEXOLE DIHYDROCHLORIDE TABLET 0.5

MG ORAL

Tier 1

PRAMIPEXOLE DIHYDROCHLORIDE TABLET 0.75

MG ORAL

Tier 1

PRAMIPEXOLE DIHYDROCHLORIDE TABLET 1 MG

ORAL

Tier 3

PRAMIPEXOLE DIHYDROCHLORIDE TABLET 1.5

MG ORAL

Tier 1

ROPINIROLE HCL TABLET 0.25 MG ORAL Tier 2

ROPINIROLE HCL TABLET 0.5 MG ORAL Tier 2

ROPINIROLE HCL TABLET 1 MG ORAL Tier 2

ROPINIROLE HCL TABLET 2 MG ORAL Tier 2

ROPINIROLE HCL TABLET 3 MG ORAL Tier 3

ROPINIROLE HCL TABLET 4 MG ORAL Tier 3

ROPINIROLE HCL TABLET 5 MG ORAL Tier 2

*Peripheral Comt Inhibitors***

ENTACAPONE ORAL TABLET 200 MG Tier 3

Drug Name Brand Tier Generic Tier Formulary Notes

*Antipsychotics/Antimanic Agents*

*Antimanic Agents***

LITHIUM CARBONATE ER ORAL TABLET

EXTENDED RELEASE 300 MG, 450 MG

Tier 3

LITHIUM CARBONATE ORAL CAPSULE 150 MG, 300

MG, 600 MG

Tier 3

*Antipsychotics - Misc.***

VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG,

6 MG

Tier 6 ST

VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 &

3 MG

Tier 6 ST

ZIPRASIDONE HCL ORAL CAPSULE 20 MG, 40 MG,

60 MG, 80 MG

Tier 3

*Benzisoxazoles***

INVEGA HAFYERA INTRAMUSCULAR

SUSPENSION PREFILLED SYRINGE 1092

MG/3.5ML, 1560 MG/5ML

Tier 6 PA; QL (2 ML per 365 days)

INVEGA SUSTENNA INTRAMUSCULAR

SUSPENSION PREFILLED SYRINGE 117

MG/0.75ML, 156 MG/ML, 234 MG/1.5ML, 39

MG/0.25ML, 78 MG/0.5ML

Tier 6

INVEGA TRINZA INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE 273 MG/0.88ML, 410

MG/1.32ML, 546 MG/1.75ML, 819 MG/2.63ML

Tier 6

RISPERIDONE ORAL SOLUTION 1 MG/ML Tier 3

RISPERIDONE ORAL TABLET 0.25 MG, 0.5 MG, 1 MG,

2 MG, 3 MG, 4 MG

Tier 3

RISPERIDONE ORAL TABLET DISPERSIBLE 0.25 MG,

0.5 MG, 1 MG, 2 MG, 3 MG, 4 MG

Tier 3

*Butyrophenones***

HALOPERIDOL LACTATE ORAL CONCENTRATE 2

MG/ML

Tier 3

HALOPERIDOL ORAL TABLET 0.5 MG, 1 MG, 10 MG,

2 MG, 20 MG, 5 MG

Tier 3

*Dibenzodiazepines***

CLOZAPINE ORAL TABLET 100 MG, 25 MG Tier 3

*Dibenzothiazepines***

QUETIAPINE FUMARATE ORAL TABLET 100 MG,

150 MG, 200 MG, 25 MG, 300 MG, 400 MG, 50 MG

Tier 3

*Dibenzoxazepines***

LOXAPINE SUCCINATE ORAL CAPSULE 10 MG, 25

Tier 3

*Dihydroindolones***

MOLINDONE HCL ORAL TABLET 10 MG, 25 MG, 5

Tier 3

*Phenothiazines***

CHLORPROMAZINE HCL ORAL CONCENTRATE 100

MG/ML, 30 MG/ML

Tier 3

CHLORPROMAZINE HCL ORAL TABLET 10 MG, 100

MG, 25 MG, 50 MG

Tier 3

Drug Name Brand Tier Generic Tier Formulary Notes

FLUPHENAZINE HCL ORAL TABLET 2.5 MG, 5 MG Tier 3

PERPHENAZINE ORAL TABLET 2 MG, 4 MG, 8 MG Tier 3

PROCHLORPERAZINE MALEATE ORAL TABLET 10

MG, 5 MG

Tier 3

PROCHLORPERAZINE RECTAL SUPPOSITORY 25

Tier 3

THIORIDAZINE HCL ORAL TABLET 10 MG, 100 MG,

25 MG, 50 MG

Tier 3

TRIFLUOPERAZINE HCL ORAL TABLET 1 MG, 10

MG, 2 MG, 5 MG

Tier 3

*Quinolinone Derivatives***

ARIPIPRAZOLE ORAL SOLUTION 1 MG/ML Tier 3 PA

ARIPIPRAZOLE ORAL TABLET 10 MG, 15 MG, 2 MG,

20 MG, 30 MG, 5 MG

Tier 3 PA

REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2

MG, 3 MG, 4 MG

Tier 6 PA; QL (1 EA per 1 day)

*Thienbenzodiazepines***

OLANZAPINE INTRAMUSCULAR SOLUTION

RECONSTITUTED 10 MG

Tier 3

OLANZAPINE ORAL TABLET 10 MG, 15 MG, 2.5 MG,

20 MG, 5 MG, 7.5 MG

Tier 3

OLANZAPINE ORAL TABLET DISPERSIBLE 10 MG,

15 MG, 20 MG, 5 MG

Tier 3

*Thioxanthenes***

THIOTHIXENE ORAL CAPSULE 1 MG, 2 MG, 5 MG Tier 3

*Antivirals*

*Antiretroviral Combinations***

ABACAVIR SULFATE-LAMIVUDINE ORAL TABLET

600-300 MG

Tier 6

BIKTARVY ORAL TABLET 50-200-25 MG Tier 6

COMPLERA ORAL TABLET 200-25-300 MG Tier 6

EFAVIRENZ-EMTRICITAB-TENOFO DF ORAL

TABLET 600-200-300 MG

Tier 6

EFAVIRENZ-LAMIVUDINE-TENOFOVIR ORAL

TABLET 400-300-300 MG, 600-300-300 MG

Tier 3

EMTRICITABINE-TENOFOVIR DF ORAL TABLET

100-150 MG, 133-200 MG, 167-250 MG, 200-300 MG

Tier 1

EVOTAZ ORAL TABLET 300-150 MG Tier 6

GENVOYA ORAL TABLET 150-150-200-10 MG Tier 6

JULUCA ORAL TABLET 50-25 MG Tier 6

LAMIVUDINE-ZIDOVUDINE ORAL TABLET 150-300

Tier 6

LOPINAVIR-RITONAVIR ORAL SOLUTION 400-100

MG/5ML

Tier 6

LOPINAVIR-RITONAVIR ORAL TABLET 100-25 MG,

200-50 MG

Tier 6

ODEFSEY ORAL TABLET 200-25-25 MG Tier 6

STRIBILD ORAL TABLET 150-150-200-300 MG Tier 6

Drug Name Brand Tier Generic Tier Formulary Notes

TRIUMEQ ORAL TABLET 600-50-300 MG Tier 6

TRIUMEQ PD ORAL TABLET SOLUBLE 60-5-30

Tier 6 QL (10 EA per 1 day)

TRIZIVIR ORAL TABLET 300-150-300 MG Tier 6

*Antiretrovirals - Capsid Inhibitors***

SUNLENCA ORAL TABLET THERAPY PACK 4 X

300 MG, 5 X 300 MG

Tier 6 PA; QL (1 EA per 180 days)

*Antiretrovirals - Ccr5 Antagonists (Entry

Inhibitor)***

MARAVIROC ORAL TABLET 150 MG, 300 MG Tier 3

*Antiretrovirals - Fusion Inhibitors***

FUZEON SUBCUTANEOUS SOLUTION

RECONSTITUTED 90 MG

Tier 6

*Antiretrovirals - Integrase Inhibitors***

ISENTRESS ORAL PACKET 100 MG Tier 6

ISENTRESS ORAL TABLET 400 MG Tier 6

ISENTRESS ORAL TABLET CHEWABLE 100 MG,

25 MG

Tier 6

TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG Tier 6

*Antiretrovirals - Protease Inhibitors***

APTIVUS ORAL CAPSULE 250 MG Tier 6

ATAZANAVIR SULFATE ORAL CAPSULE 150 MG,

200 MG, 300 MG

Tier 6

DARUNAVIR ORAL TABLET 600 MG, 800 MG Tier 6

FOSAMPRENAVIR CALCIUM ORAL TABLET 700 MG Tier 6

LEXIVA ORAL SUSPENSION 50 MG/ML Tier 6

NORVIR ORAL CAPSULE 100 MG Tier 6

NORVIR ORAL SOLUTION 80 MG/ML Tier 6

PREZISTA ORAL SUSPENSION 100 MG/ML Tier 6

PREZISTA ORAL TABLET 150 MG, 75 MG Tier 6

REYATAZ ORAL PACKET 50 MG Tier 6

RITONAVIR ORAL TABLET 100 MG Tier 6

VIRACEPT ORAL TABLET 250 MG, 625 MG Tier 6

*Antiretrovirals - Rti-Non-Nucleoside Analogues***

EDURANT ORAL TABLET 25 MG Tier 6

ETRAVIRINE ORAL TABLET 100 MG, 200 MG Tier 6

INTELENCE ORAL TABLET 25 MG Tier 6

NEVIRAPINE ER ORAL TABLET EXTENDED

RELEASE 24 HOUR 100 MG, 400 MG

Tier 3

NEVIRAPINE ORAL SUSPENSION 50 MG/5ML Tier 5

NEVIRAPINE ORAL TABLET 200 MG Tier 6

SUSTIVA ORAL CAPSULE (EFAVIRENZ) 200 MG, 50

Tier 6 Tier 3

SUSTIVA ORAL TABLET (EFAVIRENZ) 600 MG Tier 6 Tier 3

*Antiretrovirals - Rti-Nucleoside Analogues-Purines***

ABACAVIR SULFATE ORAL SOLUTION 20 MG/ML Tier 6

Drug Name Brand Tier Generic Tier Formulary Notes

ABACAVIR SULFATE ORAL TABLET 300 MG Tier 6

*Antiretrovirals - Rti-Nucleoside Analogues-

Pyrimidines***

EMTRICITABINE ORAL CAPSULE 200 MG Tier 6

EMTRIVA ORAL SOLUTION 10 MG/ML Tier 6

LAMIVUDINE ORAL TABLET 150 MG, 300 MG Tier 6

*Antiretrovirals - Rti-Nucleoside Analogues-

Thymidines***

STAVUDINE ORAL CAPSULE 15 MG, 20 MG, 30 MG,

40 MG

Tier 3

ZIDOVUDINE ORAL CAPSULE 100 MG Tier 3

ZIDOVUDINE ORAL SYRUP 50 MG/5ML Tier 3

ZIDOVUDINE ORAL TABLET 300 MG Tier 3

*Antiretrovirals - Rti-Nucleotide Analogues***

TENOFOVIR DISOPROXIL FUMARATE ORAL

TABLET 300 MG

Tier 6

VIREAD ORAL POWDER 40 MG/GM Tier 6

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG Tier 6

*Antiviral Combinations***

PAXLOVID (150/100) ORAL TABLET THERAPY

PACK 10 X 150 MG & 10 X 100MG

Tier 2

QL (6 EA per 1 day); AGE (Min 12

Years)

PAXLOVID (300/100) ORAL TABLET THERAPY

PACK 20 X 150 MG & 10 X 100MG

Tier 2

QL (6 EA per 1 day); AGE (Min 12

Years)

*Cmv Agents***

VALGANCICLOVIR HCL ORAL TABLET 450 MG Tier 3

*Hepatitis B Agents***

ADEFOVIR DIPIVOXIL ORAL TABLET 10 MG Tier 3

*Hepatitis C Agent - Combinations***

LEDIPASVIR-SOFOSBUVIR ORAL TABLET 90-400

Tier 6 PA; Specialty

MAVYRET ORAL TABLET 100-40 MG Tier 6 PA; Specialty

SOFOSBUVIR-VELPATASVIR ORAL TABLET 400-100

Tier 6 PA; Specialty

*Hepatitis C Agents***

PEGASYS SUBCUTANEOUS SOLUTION 180

MCG/ML

Tier 6 Specialty

PEGASYS SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 180 MCG/0.5ML

Tier 6 Specialty

RIBAVIRIN ORAL CAPSULE 200 MG Tier 3 Specialty

RIBAVIRIN ORAL TABLET 200 MG Tier 3 Specialty

*Herpes Agents - Purine Analogues***

ACYCLOVIR ORAL CAPSULE 200 MG Tier 1

ACYCLOVIR ORAL SUSPENSION 200 MG/5ML Tier 3

ACYCLOVIR ORAL TABLET 400 MG, 800 MG Tier 1

VALACYCLOVIR HCL ORAL TABLET 1 GM, 500 MG Tier 3

Drug Name Brand Tier Generic Tier Formulary Notes

*Herpes Agents - Thymidine Analogues***

FAMCICLOVIR ORAL TABLET 125 MG, 250 MG, 500

Tier 3

*Influenza Agents***

RIMANTADINE HCL ORAL TABLET 100 MG Tier 3

*Misc. Antivirals***

LAGEVRIO ORAL CAPSULE 200 MG Tier 2

QL (8 EA per 1 day); AGE (Min 18

Years)

*Neuraminidase Inhibitors***

OSELTAMIVIR PHOSPHATE ORAL CAPSULE 30 MG,

45 MG, 75 MG

Tier 3

OSELTAMIVIR PHOSPHATE ORAL SUSPENSION

RECONSTITUTED 6 MG/ML

Tier 3

*Rsv Agents - Nucleoside Analogues***

RIBAVIRIN INHALATION SOLUTION

RECONSTITUTED 6 GM

Tier 6 PA

*Beta Blockers*

*Alpha-Beta Blockers***

CARVEDILOL ORAL TABLET 12.5 MG, 25 MG, 3.125

MG, 6.25 MG

Tier 1

LABETALOL HCL ORAL TABLET 100 MG, 200 MG,

300 MG

Tier 1

*Beta Blockers Cardio-Selective***

ACEBUTOLOL HCL ORAL CAPSULE 200 MG, 400 MG Tier 3

ATENOLOL ORAL TABLET 100 MG, 25 MG, 50 MG Tier 2

BISOPROLOL FUMARATE ORAL TABLET 10 MG, 5

Tier 1

METOPROLOL SUCCINATE ER ORAL TABLET

EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 25

MG, 50 MG

Tier 1

METOPROLOL TARTRATE ORAL TABLET 100 MG,

25 MG, 37.5 MG, 50 MG, 75 MG

Tier 1

NEBIVOLOL HCL ORAL TABLET 10 MG, 2.5 MG, 20

MG, 5 MG

Tier 1

*Beta Blockers Non-Selective***

NADOLOL ORAL TABLET 20 MG, 40 MG, 80 MG Tier 1

PROPRANOLOL HCL ER ORAL CAPSULE

EXTENDED RELEASE 24 HOUR 120 MG, 160 MG, 60

MG, 80 MG

Tier 2

PROPRANOLOL HCL ORAL SOLUTION 20 MG/5ML,

40 MG/5ML

Tier 2 AGE (Max 10 Years)

PROPRANOLOL HCL ORAL TABLET 10 MG, 20 MG,

40 MG, 60 MG, 80 MG

Tier 2

SORINE TABLET 120 MG ORAL (SOTALOL HCL) Tier 1 Tier 1

SORINE TABLET 160 MG ORAL (SOTALOL HCL) Tier 3 Tier 3

SORINE TABLET 240 MG ORAL (SOTALOL HCL) Tier 3 Tier 3

SORINE TABLET 80 MG ORAL (SOTALOL HCL) Tier 1 Tier 1

SOTALOL HCL (AF) ORAL TABLET 120 MG, 160 MG,

80 MG

Tier 3

Drug Name Brand Tier Generic Tier Formulary Notes

*Calcium Channel Blockers*

*Calcium Channel Blockers***

AMLODIPINE BESYLATE ORAL TABLET 10 MG, 2.5

MG, 5 MG

Tier 1

CARTIA XT ORAL CAPSULE EXTENDED

RELEASE 24 HOUR (DILTIAZEM HCL ER COATED

BEADS) 120 MG, 180 MG, 240 MG, 300 MG

Tier 1 Tier 1

DILTIAZEM HCL ER ORAL CAPSULE EXTENDED

RELEASE 12 HOUR 60 MG, 90 MG

Tier 3

DILTIAZEM HCL ER ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 120 MG, 180 MG, 240 MG

Tier 1

DILTIAZEM HCL TABLET 120 MG ORAL Tier 3

DILTIAZEM HCL TABLET 30 MG ORAL Tier 1

DILTIAZEM HCL TABLET 60 MG ORAL Tier 1

DILTIAZEM HCL TABLET 90 MG ORAL Tier 3

DILT-XR ORAL CAPSULE EXTENDED RELEASE 24

HOUR 120 MG, 180 MG, 240 MG

Tier 1

FELODIPINE ER ORAL TABLET EXTENDED

RELEASE 24 HOUR 10 MG, 2.5 MG, 5 MG

Tier 1

ISRADIPINE ORAL CAPSULE 2.5 MG, 5 MG Tier 3

NIFEDIPINE ER ORAL TABLET EXTENDED

RELEASE 24 HOUR 30 MG, 60 MG, 90 MG

Tier 3

NIFEDIPINE ER OSMOTIC RELEASE ORAL TABLET

EXTENDED RELEASE 24 HOUR 30 MG, 60 MG, 90 MG

Tier 1

NIFEDIPINE ORAL CAPSULE 10 MG, 20 MG Tier 3

TAZTIA XT CAPSULE EXTENDED RELEASE 24

HOUR 120 MG ORAL (DILTIAZEM HCL ER BEADS)

Tier 1 Tier 1

TAZTIA XT CAPSULE EXTENDED RELEASE 24

HOUR 180 MG ORAL (DILTIAZEM HCL ER BEADS)

Tier 1 Tier 1

TAZTIA XT CAPSULE EXTENDED RELEASE 24

HOUR 240 MG ORAL (DILTIAZEM HCL ER BEADS)

Tier 1 Tier 1

TAZTIA XT CAPSULE EXTENDED RELEASE 24

HOUR 300 MG ORAL (DILTIAZEM HCL ER BEADS)

Tier 3 Tier 3

TAZTIA XT CAPSULE EXTENDED RELEASE 24

HOUR 360 MG ORAL (DILTIAZEM HCL ER BEADS)

Tier 1 Tier 1

TIADYLT ER CAPSULE EXTENDED RELEASE 24

HOUR 120 MG ORAL (DILTIAZEM HCL ER BEADS)

Tier 1 Tier 1

TIADYLT ER CAPSULE EXTENDED RELEASE 24

HOUR 180 MG ORAL (DILTIAZEM HCL ER BEADS)

Tier 1 Tier 1

TIADYLT ER CAPSULE EXTENDED RELEASE 24

HOUR 240 MG ORAL (DILTIAZEM HCL ER BEADS)

Tier 1 Tier 1

TIADYLT ER CAPSULE EXTENDED RELEASE 24

HOUR 300 MG ORAL (DILTIAZEM HCL ER BEADS)

Tier 3 Tier 3

TIADYLT ER CAPSULE EXTENDED RELEASE 24

HOUR 360 MG ORAL (DILTIAZEM HCL ER BEADS)

Tier 1 Tier 1

TIADYLT ER CAPSULE EXTENDED RELEASE 24

HOUR 420 MG ORAL (DILTIAZEM HCL ER BEADS)

Tier 3 Tier 3

VERAPAMIL HCL ER ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 100 MG, 120 MG, 180 MG, 200 MG,

240 MG, 300 MG, 360 MG

Tier 3

Drug Name Brand Tier Generic Tier Formulary Notes

VERAPAMIL HCL ER ORAL TABLET EXTENDED

RELEASE 120 MG, 180 MG, 240 MG

Tier 1

VERAPAMIL HCL ORAL TABLET 120 MG, 40 MG, 80

Tier 1

*Cardiotonics*

*Cardiac Glycosides***

DIGITEK ORAL TABLET (DIGOXIN) 125 MCG, 250

MCG

Tier 2 Tier 2

DIGOX ORAL TABLET (DIGOXIN) 125 MCG, 250

MCG

Tier 2 Tier 2

DIGOXIN INJECTION SOLUTION 0.25 MG/ML Tier 3

DIGOXIN ORAL SOLUTION 0.05 MG/ML Tier 3

LANOXIN PEDIATRIC INJECTION SOLUTION 0.1

MG/ML

Tier 4

*Cardiovascular Agents - Misc.*

*Calcium Channel Blocker & Hmg Coa Reductase

Inhibit Comb***

AMLODIPINE-ATORVASTATIN ORAL TABLET 10-10

MG, 10-20 MG, 10-40 MG, 10-80 MG, 2.5-10 MG, 2.5-20

MG, 2.5-40 MG, 5-10 MG, 5-20 MG, 5-40 MG, 5-80 MG

Tier 3

*Neprilysin Inhib (Arni)-Angiotensin Ii Recept Antag

Comb***

ENTRESTO ORAL CAPSULE SPRINKLE 15-16 MG,

6-6 MG

Tier 5 PA

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-

103 MG

Tier 5 PA

*Prostaglandin Vasodilators***

ORENITRAM ORAL TABLET EXTENDED

RELEASE 0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG

Tier 6 PA; Specialty

TREPROSTINIL INJECTION SOLUTION 100

MG/20ML, 20 MG/20ML, 200 MG/20ML, 50 MG/20ML

Tier 6 PA; Specialty

TYVASO INHALATION SOLUTION 0.6 MG/ML Tier 6 PA; Specialty; QL (2.9 ML per 1 day)

TYVASO REFILL INHALATION SOLUTION 0.6

MG/ML

Tier 6 PA; Specialty; QL (2.9 ML per 1 day)

TYVASO STARTER INHALATION SOLUTION 0.6

MG/ML

Tier 6 PA; Specialty; QL (2.9 ML per 1 day)

*Pulmonary Hypertension - Endothelin Receptor

Antagonists***

AMBRISENTAN ORAL TABLET 10 MG, 5 MG Tier 6 PA; Specialty; QL (1 EA per 1 day)

BOSENTAN ORAL TABLET 125 MG, 62.5 MG Tier 3 PA; Specialty; QL (2 EA per 1 day)

*Pulmonary Hypertension - Phosphodiesterase

Inhibitors***

ALYQ ORAL TABLET (TADALAFIL (PAH)) 20 MG Tier 3 Tier 3 PA; Specialty; QL (2 EA per 1 day)

SILDENAFIL CITRATE ORAL SUSPENSION

RECONSTITUTED 10 MG/ML

Tier 3 PA; Specialty

SILDENAFIL CITRATE ORAL TABLET 20 MG Tier 3 PA; Specialty; QL (3 EA per 1 day)

Drug Name Brand Tier Generic Tier Formulary Notes

*Pulmonary Hypertension - Prostacyclin Receptor

Agonist***

UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG,

1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600

MCG, 800 MCG

Tier 6 Specialty

*Cephalosporins*

*Cephalosporins - 1St Generation***

CEFADROXIL ORAL CAPSULE 500 MG Tier 2

CEFADROXIL ORAL SUSPENSION RECONSTITUTED

250 MG/5ML, 500 MG/5ML

Tier 3

CEFADROXIL ORAL TABLET 1 GM Tier 3

CEFAZOLIN SODIUM INJECTION SOLUTION

RECONSTITUTED 2 GM, 3 GM

Tier 3

CEFAZOLIN SODIUM INTRAVENOUS SOLUTION

RECONSTITUTED 2 GM, 3 GM

Tier 3

CEPHALEXIN ORAL CAPSULE 250 MG, 500 MG Tier 2

CEPHALEXIN ORAL SUSPENSION RECONSTITUTED

125 MG/5ML, 250 MG/5ML

Tier 3

CEPHALEXIN ORAL TABLET 250 MG, 500 MG Tier 3

*Cephalosporins - 2Nd Generation***

CEFACLOR ER ORAL TABLET EXTENDED RELEASE

12 HOUR 500 MG

Tier 3

CEFACLOR ORAL CAPSULE 250 MG, 500 MG Tier 3

CEFACLOR ORAL SUSPENSION RECONSTITUTED

125 MG/5ML, 250 MG/5ML, 375 MG/5ML

Tier 3

CEFPROZIL ORAL SUSPENSION RECONSTITUTED

125 MG/5ML, 250 MG/5ML

Tier 3

CEFPROZIL ORAL TABLET 250 MG, 500 MG Tier 3

CEFUROXIME AXETIL ORAL TABLET 250 MG, 500

Tier 3

CEFUROXIME SODIUM INJECTION SOLUTION

RECONSTITUTED 750 MG

Tier 3

*Cephalosporins - 3Rd Generation***

CEFDINIR ORAL CAPSULE 300 MG Tier 3

CEFDINIR ORAL SUSPENSION RECONSTITUTED 125

MG/5ML, 250 MG/5ML

Tier 3

CEFIXIME ORAL CAPSULE 400 MG Tier 3

CEFIXIME ORAL SUSPENSION RECONSTITUTED 100

MG/5ML, 200 MG/5ML

Tier 3

CEFPODOXIME PROXETIL ORAL TABLET 200 MG Tier 3

*Contraceptives*

*Biphasic Contraceptives - Oral***

AZURETTE ORAL TABLET (DESOGESTREL-

ETHINYL ESTRADIOL) 0.15-0.02/0.01 MG (21/5)

Tier 1 Tier 1

KARIVA ORAL TABLET (DESOGESTREL-ETHINYL

ESTRADIOL) 0.15-0.02/0.01 MG (21/5)

Tier 1 Tier 1

LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG /

10 MCG

Tier 1

Drug Name Brand Tier Generic Tier Formulary Notes

PIMTREA ORAL TABLET (DESOGESTREL-

ETHINYL ESTRADIOL) 0.15-0.02/0.01 MG (21/5)

Tier 1 Tier 1

SIMLIYA ORAL TABLET (DESOGESTREL-ETHINYL

ESTRADIOL) 0.15-0.02/0.01 MG (21/5)

Tier 1 Tier 1

VIORELE ORAL TABLET 0.15-0.02/0.01 MG (21/5) Tier 1

VOLNEA ORAL TABLET (DESOGESTREL-ETHINYL

ESTRADIOL) 0.15-0.02/0.01 MG (21/5)

Tier 1 Tier 1

*Combination Contraceptives - Oral***

AFIRMELLE ORAL TABLET (LEVONORGESTREL-

ETHINYL ESTRAD) 0.1-20 MG-MCG

Tier 1 Tier 1

ALTAVERA ORAL TABLET (LEVONORGESTREL-

ETHINYL ESTRAD) 0.15-30 MG-MCG

Tier 1 Tier 1

APRI ORAL TABLET (DESOGESTREL-ETHINYL

ESTRADIOL) 0.15-30 MG-MCG

Tier 1 Tier 1

AUBRA EQ ORAL TABLET (LEVONORGESTREL-

ETHINYL ESTRAD) 0.1-20 MG-MCG

Tier 1 Tier 1

AUBRA ORAL TABLET (LEVONORGESTREL-

ETHINYL ESTRAD) 0.1-20 MG-MCG

Tier 1 Tier 1

AUROVELA 1.5/30 ORAL TABLET

(NORETHINDRONE ACET-ETHINYL EST) 1.5-30 MG-

MCG

Tier 1 Tier 1

AUROVELA 1/20 ORAL TABLET

(NORETHINDRONE ACET-ETHINYL EST) 1-20 MG-

MCG

Tier 1 Tier 1

AUROVELA 24 FE ORAL TABLET 1-20 MG-

MCG(24)

Tier 1

AUROVELA FE 1.5/30 ORAL TABLET (NORETHIN

ACE-ETH ESTRAD-FE) 1.5-30 MG-MCG

Tier 1 Tier 1

AUROVELA FE 1/20 ORAL TABLET (NORETHIN

ACE-ETH ESTRAD-FE) 1-20 MG-MCG

Tier 1 Tier 1

AVIANE ORAL TABLET (LEVONORGESTREL-

ETHINYL ESTRAD) 0.1-20 MG-MCG

Tier 1 Tier 1

AYUNA ORAL TABLET (LEVONORGESTREL-

ETHINYL ESTRAD) 0.15-30 MG-MCG

Tier 1 Tier 1

BALZIVA ORAL TABLET (BRIELLYN) 0.4-35 MG-

MCG

Tier 1 Tier 1

BLISOVI 24 FE ORAL TABLET 1-20 MG-MCG(24) Tier 1

BLISOVI FE 1.5/30 ORAL TABLET (NORETHIN ACE-

ETH ESTRAD-FE) 1.5-30 MG-MCG

Tier 1 Tier 1

BLISOVI FE 1/20 ORAL TABLET (NORETHIN ACE-

ETH ESTRAD-FE) 1-20 MG-MCG

Tier 1 Tier 1

CHARLOTTE 24 FE ORAL TABLET CHEWABLE

(NORETHIN ACE-ETH ESTRAD-FE) 1-20 MG-

MCG(24)

Tier 1 Tier 1

CHATEAL EQ ORAL TABLET (LEVONORGESTREL-

ETHINYL ESTRAD) 0.15-30 MG-MCG

Tier 1 Tier 1

CHATEAL ORAL TABLET (LEVONORGESTREL-

ETHINYL ESTRAD) 0.15-30 MG-MCG

Tier 1 Tier 1

CRYSELLE-28 ORAL TABLET 0.3-30 MG-MCG Tier 1

CYRED EQ ORAL TABLET (DESOGESTREL-

ETHINYL ESTRADIOL) 0.15-30 MG-MCG

Tier 1 Tier 1

Drug Name Brand Tier Generic Tier Formulary Notes

CYRED ORAL TABLET (DESOGESTREL-ETHINYL

ESTRADIOL) 0.15-30 MG-MCG

Tier 1 Tier 1

DASETTA 1/35 ORAL TABLET (ALYACEN 1/35) 1-35

MG-MCG

Tier 1 Tier 1

DELYLA ORAL TABLET (LEVONORGESTREL-

ETHINYL ESTRAD) 0.1-20 MG-MCG

Tier 1 Tier 1

DROSPIREN-ETH ESTRAD-LEVOMEFOL ORAL

TABLET 3-0.02-0.451 MG

Tier 1

ELINEST ORAL TABLET 0.3-30 MG-MCG Tier 1

EMOQUETTE ORAL TABLET (DESOGESTREL-

ETHINYL ESTRADIOL) 0.15-30 MG-MCG

Tier 1 Tier 1

ENSKYCE ORAL TABLET (DESOGESTREL-

ETHINYL ESTRADIOL) 0.15-30 MG-MCG

Tier 1 Tier 1

ESTARYLLA ORAL TABLET (NORGESTIMATE-ETH

ESTRADIOL) 0.25-35 MG-MCG

Tier 1 Tier 1

FALMINA ORAL TABLET (LEVONORGESTREL-

ETHINYL ESTRAD) 0.1-20 MG-MCG

Tier 1 Tier 1

FEMYNOR ORAL TABLET (NORGESTIMATE-ETH

ESTRADIOL) 0.25-35 MG-MCG

Tier 1 Tier 1

FINZALA ORAL TABLET CHEWABLE (NORETHIN

ACE-ETH ESTRAD-FE) 1-20 MG-MCG(24)

Tier 1 Tier 1

GEMMILY ORAL CAPSULE (NORETHIN ACE-ETH

ESTRAD-FE) 1-20 MG-MCG(24)

Tier 1 Tier 1

HAILEY 1.5/30 ORAL TABLET (NORETHINDRONE

ACET-ETHINYL EST) 1.5-30 MG-MCG

Tier 1 Tier 1

HAILEY 24 FE ORAL TABLET 1-20 MG-MCG(24) Tier 1

HAILEY FE 1.5/30 ORAL TABLET (NORETHIN ACE-

ETH ESTRAD-FE) 1.5-30 MG-MCG

Tier 1 Tier 1

HAILEY FE 1/20 ORAL TABLET (NORETHIN ACE-

ETH ESTRAD-FE) 1-20 MG-MCG

Tier 1 Tier 1

ISIBLOOM ORAL TABLET (DESOGESTREL-

ETHINYL ESTRADIOL) 0.15-30 MG-MCG

Tier 1 Tier 1

JASMIEL ORAL TABLET (DROSPIRENONE-

ETHINYL ESTRADIOL) 3-0.02 MG

Tier 1 Tier 1

JOYEAUX ORAL TABLET (LEVONORGEST-ETH

ESTRADIOL-IRON) 0.1-20 MG-MCG(21)

Tier 1 Tier 1

JULEBER ORAL TABLET (DESOGESTREL-

ETHINYL ESTRADIOL) 0.15-30 MG-MCG

Tier 1 Tier 1

JUNEL 1.5/30 ORAL TABLET (NORETHINDRONE

ACET-ETHINYL EST) 1.5-30 MG-MCG

Tier 1 Tier 1

JUNEL 1/20 ORAL TABLET (NORETHINDRONE

ACET-ETHINYL EST) 1-20 MG-MCG

Tier 1 Tier 1

JUNEL FE 1.5/30 ORAL TABLET (NORETHIN ACE-

ETH ESTRAD-FE) 1.5-30 MG-MCG

Tier 1 Tier 1

JUNEL FE 1/20 ORAL TABLET (NORETHIN ACE-

ETH ESTRAD-FE) 1-20 MG-MCG

Tier 1 Tier 1

JUNEL FE 24 ORAL TABLET 1-20 MG-MCG(24) Tier 1

KAITLIB FE ORAL TABLET CHEWABLE

(NORETHIN-ETH ESTRADIOL-FE) 0.8-25 MG-MCG

Tier 1 Tier 1

KALLIGA ORAL TABLET (DESOGESTREL-

ETHINYL ESTRADIOL) 0.15-30 MG-MCG

Tier 1 Tier 1

Drug Name Brand Tier Generic Tier Formulary Notes

KELNOR 1/35 ORAL TABLET (ETHYNODIOL DIAC-

ETH ESTRADIOL) 1-35 MG-MCG

Tier 1 Tier 1

KELNOR 1/50 ORAL TABLET (ETHYNODIOL DIAC-

ETH ESTRADIOL) 1-50 MG-MCG

Tier 1 Tier 1

KURVELO ORAL TABLET (LEVONORGESTREL-

ETHINYL ESTRAD) 0.15-30 MG-MCG

Tier 1 Tier 1

LARIN 1.5/30 ORAL TABLET (NORETHINDRONE

ACET-ETHINYL EST) 1.5-30 MG-MCG

Tier 1 Tier 1

LARIN 1/20 ORAL TABLET (NORETHINDRONE

ACET-ETHINYL EST) 1-20 MG-MCG

Tier 1 Tier 1

LARIN 24 FE ORAL TABLET 1-20 MG-MCG(24) Tier 1

LARIN FE 1.5/30 ORAL TABLET (NORETHIN ACE-

ETH ESTRAD-FE) 1.5-30 MG-MCG

Tier 1 Tier 1

LARIN FE 1/20 ORAL TABLET (NORETHIN ACE-

ETH ESTRAD-FE) 1-20 MG-MCG

Tier 1 Tier 1

LARISSIA ORAL TABLET (LEVONORGESTREL-

ETHINYL ESTRAD) 0.1-20 MG-MCG

Tier 1 Tier 1

LAYOLIS FE ORAL TABLET CHEWABLE

(NORETHIN-ETH ESTRADIOL-FE) 0.8-25 MG-MCG

Tier 1 Tier 1

LESSINA ORAL TABLET (LEVONORGESTREL-

ETHINYL ESTRAD) 0.1-20 MG-MCG

Tier 1 Tier 1

LEVORA 0.15/30 (28) ORAL TABLET

(LEVONORGESTREL-ETHINYL ESTRAD) 0.15-30

MG-MCG

Tier 1 Tier 1

LORYNA ORAL TABLET (DROSPIRENONE-

ETHINYL ESTRADIOL) 3-0.02 MG

Tier 1 Tier 1

LOW-OGESTREL ORAL TABLET 0.3-30 MG-MCG Tier 1

LO-ZUMANDIMINE ORAL TABLET

(DROSPIRENONE-ETHINYL ESTRADIOL) 3-0.02 MG

Tier 1 Tier 1

LUTERA ORAL TABLET (LEVONORGESTREL-

ETHINYL ESTRAD) 0.1-20 MG-MCG

Tier 1 Tier 1

MARLISSA ORAL TABLET 0.15-30 MG-MCG Tier 1

MERZEE ORAL CAPSULE (NORETHIN ACE-ETH

ESTRAD-FE) 1-20 MG-MCG(24)

Tier 1 Tier 1

MIBELAS 24 FE ORAL TABLET CHEWABLE

(NORETHIN ACE-ETH ESTRAD-FE) 1-20 MG-

MCG(24)

Tier 1 Tier 1

MICROGESTIN 1.5/30 ORAL TABLET

(NORETHINDRONE ACET-ETHINYL EST) 1.5-30 MG-

MCG

Tier 1 Tier 1

MICROGESTIN 1/20 ORAL TABLET

(NORETHINDRONE ACET-ETHINYL EST) 1-20 MG-

MCG

Tier 1 Tier 1

MICROGESTIN 24 FE ORAL TABLET 1-20 MG-

MCG

Tier 1

MICROGESTIN FE 1.5/30 ORAL TABLET

(NORETHIN ACE-ETH ESTRAD-FE) 1.5-30 MG-MCG

Tier 1 Tier 1

MICROGESTIN FE 1/20 ORAL TABLET (NORETHIN

ACE-ETH ESTRAD-FE) 1-20 MG-MCG

Tier 1 Tier 1

MILI ORAL TABLET (NORGESTIMATE-ETH

ESTRADIOL) 0.25-35 MG-MCG

Tier 1 Tier 1

Drug Name Brand Tier Generic Tier Formulary Notes

MONO-LINYAH ORAL TABLET (NORGESTIMATE-

ETH ESTRADIOL) 0.25-35 MG-MCG

Tier 1 Tier 1

NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG Tier 1

NIKKI ORAL TABLET (DROSPIRENONE-ETHINYL

ESTRADIOL) 3-0.02 MG

Tier 1 Tier 1

NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-

MCG

Tier 1

NORTREL 1/35 (21) ORAL TABLET (ALYACEN 1/35)

1-35 MG-MCG

Tier 1 Tier 1

NORTREL 1/35 (28) ORAL TABLET (ALYACEN 1/35)

1-35 MG-MCG

Tier 1 Tier 1

NYLIA 1/35 ORAL TABLET (ALYACEN 1/35) 1-35

MG-MCG

Tier 1 Tier 1

NYMYO ORAL TABLET (NORGESTIMATE-ETH

ESTRADIOL) 0.25-35 MG-MCG

Tier 1 Tier 1

OCELLA ORAL TABLET (DROSPIRENONE-

ETHINYL ESTRADIOL) 3-0.03 MG

Tier 1 Tier 1

PHILITH ORAL TABLET (BRIELLYN) 0.4-35 MG-

MCG

Tier 1 Tier 1

PIRMELLA 1/35 ORAL TABLET (ALYACEN 1/35) 1-

35 MG-MCG

Tier 1 Tier 1

PORTIA-28 ORAL TABLET (LEVONORGESTREL-

ETHINYL ESTRAD) 0.15-30 MG-MCG

Tier 1 Tier 1

RECLIPSEN ORAL TABLET (DESOGESTREL-

ETHINYL ESTRADIOL) 0.15-30 MG-MCG

Tier 1 Tier 1

SPRINTEC 28 ORAL TABLET (NORGESTIMATE-

ETH ESTRADIOL) 0.25-35 MG-MCG

Tier 1 Tier 1

SRONYX ORAL TABLET (LEVONORGESTREL-

ETHINYL ESTRAD) 0.1-20 MG-MCG

Tier 1 Tier 1

SYEDA ORAL TABLET (DROSPIRENONE-ETHINYL

ESTRADIOL) 3-0.03 MG

Tier 1 Tier 1

TARINA 24 FE ORAL TABLET 1-20 MG-MCG(24) Tier 1

TARINA FE 1/20 EQ ORAL TABLET (NORETHIN

ACE-ETH ESTRAD-FE) 1-20 MG-MCG

Tier 1 Tier 1

TARINA FE 1/20 ORAL TABLET (NORETHIN ACE-

ETH ESTRAD-FE) 1-20 MG-MCG

Tier 1 Tier 1

TAYSOFY ORAL CAPSULE (NORETHIN ACE-ETH

ESTRAD-FE) 1-20 MG-MCG(24)

Tier 1 Tier 1

TURQOZ ORAL TABLET 0.3-30 MG-MCG Tier 1

TYBLUME ORAL TABLET CHEWABLE 0.1-20 MG-

MCG

Tier 1

TYDEMY ORAL TABLET (DROSPIREN-ETH

ESTRAD-LEVOMEFOL) 3-0.03-0.451 MG

Tier 1 Tier 1

VESTURA ORAL TABLET (DROSPIRENONE-

ETHINYL ESTRADIOL) 3-0.02 MG

Tier 1 Tier 1

VIENVA ORAL TABLET (LEVONORGESTREL-

ETHINYL ESTRAD) 0.1-20 MG-MCG

Tier 1 Tier 1

VYFEMLA ORAL TABLET (BRIELLYN) 0.4-35 MG-

MCG

Tier 1 Tier 1

VYLIBRA ORAL TABLET (NORGESTIMATE-ETH

ESTRADIOL) 0.25-35 MG-MCG

Tier 1 Tier 1

Drug Name Brand Tier Generic Tier Formulary Notes

WERA ORAL TABLET 0.5-35 MG-MCG Tier 1

WYMZYA FE ORAL TABLET CHEWABLE

(NORETHIN-ETH ESTRADIOL-FE) 0.4-35 MG-MCG

Tier 1 Tier 1

ZOVIA 1/35 (28) ORAL TABLET (ETHYNODIOL

DIAC-ETH ESTRADIOL) 1-35 MG-MCG

Tier 1 Tier 1

ZUMANDIMINE ORAL TABLET (DROSPIRENONE-

ETHINYL ESTRADIOL) 3-0.03 MG

Tier 1 Tier 1

*Combination Contraceptives - Transdermal***

XULANE TRANSDERMAL PATCH WEEKLY

(NORELGESTROMIN-ETH ESTRADIOL) 150-35

MCG/24HR

Tier 1 Tier 1

ZAFEMY TRANSDERMAL PATCH WEEKLY

(NORELGESTROMIN-ETH ESTRADIOL) 150-35

MCG/24HR

Tier 1 Tier 1

*Combination Contraceptives - Vaginal***

ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR Tier 1

ELURYNG VAGINAL RING (ETONOGESTREL-

ETHINYL ESTRADIOL) 0.12-0.015 MG/24HR

Tier 1 Tier 1

ENILLORING VAGINAL RING (ETONOGESTREL-

ETHINYL ESTRADIOL) 0.12-0.015 MG/24HR

Tier 1 Tier 1

HALOETTE VAGINAL RING (ETONOGESTREL-

ETHINYL ESTRADIOL) 0.12-0.015 MG/24HR

Tier 1 Tier 1

*Continuous Contraceptives - Oral***

AMETHYST ORAL TABLET (LEVONORGESTREL-

ETHINYL ESTRAD) 90-20 MCG

Tier 1 Tier 1

DOLISHALE ORAL TABLET (LEVONORGESTREL-

ETHINYL ESTRAD) 90-20 MCG

Tier 1 Tier 1

*Copper Contraceptives - Iud***

PARAGARD INTRAUTERINE COPPER

INTRAUTERINE INTRAUTERINE DEVICE

Tier 1

*Emergency Contraceptives***

AFTERA ORAL TABLET (LEVONORGESTREL) 1.5

Tier 1 Tier 1

AFTERPILL ORAL TABLET (LEVONORGESTREL)

1.5 MG

Tier 1 Tier 1

CURAE ORAL TABLET (LEVONORGESTREL) 1.5

Tier 1 Tier 1

ECONTRA EZ ORAL TABLET (LEVONORGESTREL)

1.5 MG

Tier 1 Tier 1

ECONTRA ONE-STEP ORAL TABLET

(LEVONORGESTREL) 1.5 MG

Tier 1 Tier 1

ELLA ORAL TABLET 30 MG Tier 1

HER STYLE ORAL TABLET (LEVONORGESTREL)

1.5 MG

Tier 1 Tier 1

MY CHOICE ORAL TABLET (LEVONORGESTREL)

1.5 MG

Tier 1 Tier 1

MY WAY ORAL TABLET (LEVONORGESTREL) 1.5

Tier 1 Tier 1

NEW DAY ORAL TABLET (LEVONORGESTREL) 1.5

Tier 1 Tier 1

Drug Name Brand Tier Generic Tier Formulary Notes

OPCICON ONE-STEP ORAL TABLET

(LEVONORGESTREL) 1.5 MG

Tier 1 Tier 1

OPTION 2 ORAL TABLET (LEVONORGESTREL) 1.5

Tier 1 Tier 1

PLAN B ONE-STEP ORAL TABLET

(LEVONORGESTREL) 1.5 MG

Tier 1 Tier 1

REACT ORAL TABLET (LEVONORGESTREL) 1.5

Tier 1 Tier 1

TAKE ACTION ORAL TABLET

(LEVONORGESTREL) 1.5 MG

Tier 1 Tier 1

*Extended-Cycle Contraceptives - Oral***

AMETHIA ORAL TABLET (LEVONORGEST-ETH

ESTRAD 91-DAY) 0.15-0.03 &0.01 MG

Tier 1 Tier 1

ASHLYNA ORAL TABLET (LEVONORGEST-ETH

ESTRAD 91-DAY) 0.15-0.03 &0.01 MG

Tier 1 Tier 1

CAMRESE LO ORAL TABLET (LEVONORGEST-

ETH ESTRAD 91-DAY) 0.1-0.02 & 0.01 MG

Tier 1 Tier 1

CAMRESE ORAL TABLET (LEVONORGEST-ETH

ESTRAD 91-DAY) 0.15-0.03 &0.01 MG

Tier 1 Tier 1

DAYSEE ORAL TABLET (LEVONORGEST-ETH

ESTRAD 91-DAY) 0.15-0.03 &0.01 MG

Tier 1 Tier 1

FAYOSIM ORAL TABLET (LEVONORGEST-ETH

EST & ETH EST) 42-21-21-7 DAYS

Tier 1 Tier 1

ICLEVIA ORAL TABLET (LEVONORGEST-ETH

ESTRAD 91-DAY) 0.15-0.03 MG

Tier 1 Tier 1

INTROVALE ORAL TABLET (LEVONORGEST-ETH

ESTRAD 91-DAY) 0.15-0.03 MG

Tier 1 Tier 1

JAIMIESS ORAL TABLET (LEVONORGEST-ETH

ESTRAD 91-DAY) 0.15-0.03 &0.01 MG

Tier 1 Tier 1

JOLESSA ORAL TABLET (LEVONORGEST-ETH

ESTRAD 91-DAY) 0.15-0.03 MG

Tier 1 Tier 1

LOJAIMIESS ORAL TABLET (LEVONORGEST-ETH

ESTRAD 91-DAY) 0.1-0.02 & 0.01 MG

Tier 1 Tier 1

RIVELSA ORAL TABLET (LEVONORGEST-ETH EST

& ETH EST) 42-21-21-7 DAYS

Tier 1 Tier 1

SETLAKIN ORAL TABLET (LEVONORGEST-ETH

ESTRAD 91-DAY) 0.15-0.03 MG

Tier 1 Tier 1

SIMPESSE ORAL TABLET (LEVONORGEST-ETH

ESTRAD 91-DAY) 0.15-0.03 &0.01 MG

Tier 1 Tier 1

*Four Phase Contraceptives - Oral***

NATAZIA ORAL TABLET 3/2-2/2-3/1 MG Tier 1

*Progestin Contraceptives - Implants***

NEXPLANON SUBCUTANEOUS IMPLANT 68 MG Tier 1

*Progestin Contraceptives - Injectable***

MEDROXYPROGESTERONE ACETATE

INTRAMUSCULAR SUSPENSION 150 MG/ML

Tier 1

MEDROXYPROGESTERONE ACETATE

INTRAMUSCULAR SUSPENSION PREFILLED

SYRINGE 150 MG/ML

Tier 1

Drug Name Brand Tier Generic Tier Formulary Notes

*Progestin Contraceptives - Iud***

KYLEENA INTRAUTERINE INTRAUTERINE

DEVICE 19.5 MG

Tier 1

LILETTA (52 MG) INTRAUTERINE

INTRAUTERINE DEVICE 20.1 MCG/DAY

Tier 1

MIRENA (52 MG) INTRAUTERINE INTRAUTERINE

DEVICE 20 MCG/DAY

Tier 1

SKYLA INTRAUTERINE INTRAUTERINE DEVICE

13.5 MG

Tier 1

*Progestin Contraceptives - Oral***

CAMILA ORAL TABLET (NORETHINDRONE) 0.35

Tier 1 Tier 1

DEBLITANE ORAL TABLET (NORETHINDRONE)

0.35 MG

Tier 1 Tier 1

EMZAHH ORAL TABLET (NORETHINDRONE) 0.35

Tier 1 Tier 1

ERRIN ORAL TABLET (NORETHINDRONE) 0.35 MG Tier 1 Tier 1

HEATHER ORAL TABLET (NORETHINDRONE) 0.35

Tier 1 Tier 1

INCASSIA ORAL TABLET (NORETHINDRONE) 0.35

Tier 1 Tier 1

JENCYCLA ORAL TABLET (NORETHINDRONE)

0.35 MG

Tier 1 Tier 1

LYLEQ ORAL TABLET (NORETHINDRONE) 0.35

Tier 1 Tier 1

LYZA ORAL TABLET (NORETHINDRONE) 0.35 MG Tier 1 Tier 1

NORA-BE ORAL TABLET (NORETHINDRONE) 0.35

Tier 1 Tier 1

NORLYROC ORAL TABLET (NORETHINDRONE)

0.35 MG

Tier 1 Tier 1

SHAROBEL ORAL TABLET (NORETHINDRONE)

0.35 MG

Tier 1 Tier 1

*Triphasic Contraceptives - Oral***

ARANELLE ORAL TABLET 0.5/1/0.5-35 MG-MCG Tier 1

CAZIANT ORAL TABLET 0.1/0.125/0.15 -0.025 MG Tier 1

DASETTA 7/7/7 ORAL TABLET (ALYACEN 7/7/7)

0.5/0.75/1-35 MG-MCG

Tier 1 Tier 1

ENPRESSE-28 ORAL TABLET (LEVONORG-ETH

ESTRAD TRIPHASIC) 50-30/75-40/ 125-30 MCG

Tier 1 Tier 1

LEENA ORAL TABLET 0.5/1/0.5-35 MG-MCG Tier 1

LEVONEST ORAL TABLET (LEVONORG-ETH

ESTRAD TRIPHASIC) 50-30/75-40/ 125-30 MCG

Tier 1 Tier 1

NORTREL 7/7/7 ORAL TABLET (ALYACEN 7/7/7)

0.5/0.75/1-35 MG-MCG

Tier 1 Tier 1

NYLIA 7/7/7 ORAL TABLET (ALYACEN 7/7/7)

0.5/0.75/1-35 MG-MCG

Tier 1 Tier 1

PIRMELLA 7/7/7 ORAL TABLET (ALYACEN 7/7/7)

0.5/0.75/1-35 MG-MCG

Tier 1 Tier 1

TILIA FE ORAL TABLET (NORETHINDRON-

ETHINYL ESTRAD-FE) 1-20/1-30/1-35 MG-MCG

Tier 1 Tier 1

Drug Name Brand Tier Generic Tier Formulary Notes

TRI FEMYNOR ORAL TABLET (NORGESTIM-ETH

ESTRAD TRIPHASIC) 0.18/0.215/0.25 MG-35 MCG

Tier 1 Tier 1

TRI-ESTARYLLA ORAL TABLET (NORGESTIM-

ETH ESTRAD TRIPHASIC) 0.18/0.215/0.25 MG-35

MCG

Tier 1 Tier 1

TRI-LEGEST FE ORAL TABLET (NORETHINDRON-

ETHINYL ESTRAD-FE) 1-20/1-30/1-35 MG-MCG

Tier 1 Tier 1

TRI-LINYAH ORAL TABLET (NORGESTIM-ETH

ESTRAD TRIPHASIC) 0.18/0.215/0.25 MG-35 MCG

Tier 1 Tier 1

TRI-LO-ESTARYLLA ORAL TABLET (NORGESTIM-

ETH ESTRAD TRIPHASIC) 0.18/0.215/0.25 MG-25

MCG

Tier 1 Tier 1

TRI-LO-MARZIA ORAL TABLET (NORGESTIM-ETH

ESTRAD TRIPHASIC) 0.18/0.215/0.25 MG-25 MCG

Tier 1 Tier 1

TRI-LO-MILI ORAL TABLET (NORGESTIM-ETH

ESTRAD TRIPHASIC) 0.18/0.215/0.25 MG-25 MCG

Tier 1 Tier 1

TRI-LO-SPRINTEC ORAL TABLET (NORGESTIM-

ETH ESTRAD TRIPHASIC) 0.18/0.215/0.25 MG-25

MCG

Tier 1 Tier 1

TRI-MILI ORAL TABLET (NORGESTIM-ETH

ESTRAD TRIPHASIC) 0.18/0.215/0.25 MG-35 MCG

Tier 1 Tier 1

TRI-NYMYO ORAL TABLET (NORGESTIM-ETH

ESTRAD TRIPHASIC) 0.18/0.215/0.25 MG-35 MCG

Tier 1 Tier 1

TRI-SPRINTEC ORAL TABLET (NORGESTIM-ETH

ESTRAD TRIPHASIC) 0.18/0.215/0.25 MG-35 MCG

Tier 1 Tier 1

TRIVORA (28) ORAL TABLET (LEVONORG-ETH

ESTRAD TRIPHASIC) 50-30/75-40/ 125-30 MCG

Tier 1 Tier 1

TRI-VYLIBRA LO ORAL TABLET (NORGESTIM-

ETH ESTRAD TRIPHASIC) 0.18/0.215/0.25 MG-25

MCG

Tier 1 Tier 1

TRI-VYLIBRA ORAL TABLET (NORGESTIM-ETH

ESTRAD TRIPHASIC) 0.18/0.215/0.25 MG-35 MCG

Tier 1 Tier 1

VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG Tier 1

*Corticosteroids*

*Glucocorticosteroids***

BUDESONIDE ORAL CAPSULE DELAYED RELEASE

PARTICLES 3 MG

Tier 3

DEXAMETHASONE INTENSOL ORAL

CONCENTRATE 1 MG/ML

Tier 3

DEXAMETHASONE ORAL ELIXIR 0.5 MG/5ML Tier 3

DEXAMETHASONE ORAL SOLUTION 0.5 MG/5ML Tier 3

DEXAMETHASONE TABLET 0.5 MG ORAL Tier 2

DEXAMETHASONE TABLET 0.75 MG ORAL Tier 2

DEXAMETHASONE TABLET 1 MG ORAL Tier 2

DEXAMETHASONE TABLET 1.5 MG ORAL Tier 2

DEXAMETHASONE TABLET 2 MG ORAL Tier 2

DEXAMETHASONE TABLET 4 MG ORAL Tier 3

DEXAMETHASONE TABLET 6 MG ORAL Tier 3

HYDROCORTISONE ORAL TABLET 10 MG, 20 MG, 5

Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

METHYLPREDNISOLONE ORAL TABLET 16 MG, 32

MG, 4 MG, 8 MG

Tier 3

METHYLPREDNISOLONE ORAL TABLET THERAPY

PACK 4 MG

Tier 3

METHYLPREDNISOLONE SODIUM SUCC INJECTION

SOLUTION RECONSTITUTED 1000 MG, 125 MG, 40

Tier 3

PREDNISOLONE ORAL SOLUTION 15 MG/5ML Tier 3

PREDNISOLONE SODIUM PHOSPHATE ORAL

SOLUTION 15 MG/5ML, 25 MG/5ML

Tier 3

PREDNISONE ORAL SOLUTION 5 MG/5ML Tier 3

PREDNISONE ORAL TABLET 1 MG, 10 MG, 2.5 MG,

20 MG, 5 MG, 50 MG

Tier 2

PREDNISONE ORAL TABLET THERAPY PACK 10 MG

(21), 10 MG (48), 5 MG (21), 5 MG (48)

Tier 3

*Mineralocorticoids***

FLUDROCORTISONE ACETATE ORAL TABLET 0.1

Tier 2

*Cough/Cold/Allergy*

*Antitussive - Nonnarcotic***

BENZONATATE ORAL CAPSULE 100 MG, 150 MG,

200 MG

Tier 3

*Antitussive - Opioid***

HYDROCODONE BIT-HOMATROP MBR ORAL

SOLUTION 5-1.5 MG/5ML

Tier 3 QL (240 ML Max Qty Per Fill Retail)

HYDROCODONE BIT-HOMATROP MBR ORAL

TABLET 5-1.5 MG

Tier 3 QL (6 EA per 1 day)

HYDROMET ORAL SOLUTION 5-1.5 MG/5ML Tier 3 QL (240 ML Max Qty Per Fill Retail)

*Antitussive-Expectorant***

CODITUSSIN AC ORAL LIQUID 200-10 MG/5ML Tier 4 QL (240 ML Max Qty Per Fill Retail)

G TUSSIN AC ORAL SOLUTION 100-10 MG/5ML Tier 3 QL (240 ML Max Qty Per Fill Retail)

GUAIATUSSIN AC ORAL SYRUP 100-10 MG/5ML Tier 3 QL (240 ML Max Qty Per Fill Retail)

GUAIFENESIN AC ORAL SYRUP 100-10 MG/5ML Tier 3 QL (240 ML Max Qty Per Fill Retail)

GUAIFENESIN-CODEINE ORAL SOLUTION 100-10

MG/5ML, 200-20 MG/10ML

Tier 3 QL (240 ML Max Qty Per Fill Retail)

MAXI-TUSS AC ORAL SOLUTION 100-10 MG/5ML Tier 3 QL (240 ML Max Qty Per Fill Retail)

*Misc. Respiratory Inhalants***

SODIUM CHLORIDE INHALATION NEBULIZATION

SOLUTION 0.9 %

Tier 1

*Non-Narc Antitussive-Antihistamine***

PROMETHAZINE-DM ORAL SYRUP 6.25-15 MG/5ML Tier 3

*Non-Narc Antitussive-Decongestant-Antihistamine***

PSEUDOEPH-BROMPHEN-DM ORAL SYRUP 30-2-10

MG/5ML

Tier 3

*Opioid Antitussive-Antihistamine***

HYDROCOD POLI-CHLORPHE POLI ER ORAL

SUSPENSION EXTENDED RELEASE 10-8 MG/5ML

Tier 3 QL (240 ML Max Qty Per Fill Retail)

Drug Name Brand Tier Generic Tier Formulary Notes

PROMETHAZINE-CODEINE ORAL SOLUTION 6.25-10

MG/5ML

Tier 3 QL (240 ML Max Qty Per Fill Retail)

PROMETHAZINE-CODEINE ORAL SYRUP 6.25-10

MG/5ML

Tier 3 QL (240 ML Max Qty Per Fill Retail)

*Opioid Antitussive-Decongestant-Antihistamine***

POLY-TUSSIN AC ORAL LIQUID 10-4-10 MG/5ML Tier 4 QL (240 ML Max Qty Per Fill Retail)

*Dermatologicals*

*Acne Antibiotics***

CLINDACIN ETZ EXTERNAL SWAB

(CLINDAMYCIN PHOSPHATE) 1 %

Tier 3 Tier 3

CLINDACIN-P EXTERNAL SWAB (CLINDAMYCIN

PHOSPHATE) 1 %

Tier 3 Tier 3

CLINDAMYCIN PHOSPHATE EXTERNAL GEL 1 % Tier 3

CLINDAMYCIN PHOSPHATE EXTERNAL LOTION 1

Tier 3

CLINDAMYCIN PHOSPHATE EXTERNAL SOLUTION

1 %

Tier 3

ERY EXTERNAL PAD 2 % Tier 3

ERYTHROMYCIN EXTERNAL GEL 2 % Tier 3

ERYTHROMYCIN EXTERNAL SOLUTION 2 % Tier 3

*Acne Combinations***

BENZOYL PEROXIDE-ERYTHROMYCIN EXTERNAL

GEL 5-3 %

Tier 3

CLINDAMYCIN PHOS-BENZOYL PEROX EXTERNAL

GEL 1-5 %, 1.2-2.5 %

Tier 3

SULFACETAMIDE SODIUM-SULFUR EXTERNAL

LIQUID 10-5 %

Tier 3

SULFACETAMIDE SODIUM-SULFUR EXTERNAL

SUSPENSION 9-4.25 %

Tier 3

*Acne Products***

ACCUTANE ORAL CAPSULE (ISOTRETINOIN) 10

MG, 20 MG, 30 MG, 40 MG

Tier 3 Tier 3

ADAPALENE EXTERNAL CREAM 0.1 % Tier 3

ADAPALENE EXTERNAL GEL 0.1 % Tier 3

AMNESTEEM ORAL CAPSULE (ISOTRETINOIN) 10

MG, 20 MG, 40 MG

Tier 3 Tier 3

CLARAVIS ORAL CAPSULE (ISOTRETINOIN) 10

MG, 20 MG, 30 MG, 40 MG

Tier 3 Tier 3

TRETINOIN EXTERNAL CREAM 0.025 %, 0.05 %, 0.1

Tier 3

TRETINOIN EXTERNAL GEL 0.01 %, 0.025 %, 0.05 % Tier 3

*Antibiotics - Topical***

ALTABAX EXTERNAL OINTMENT 1 % Tier 4

MUPIROCIN EXTERNAL OINTMENT 2 % Tier 3

*Antifungals - Topical Combinations***

CLOTRIMAZOLE-BETAMETHASONE EXTERNAL

CREAM 1-0.05 %

Tier 3

Drug Name Brand Tier Generic Tier Formulary Notes

CLOTRIMAZOLE-BETAMETHASONE EXTERNAL

LOTION 1-0.05 %

Tier 3

NYSTATIN-TRIAMCINOLONE EXTERNAL CREAM

100000-0.1 UNIT/GM-%

Tier 3

NYSTATIN-TRIAMCINOLONE EXTERNAL

OINTMENT 100000-0.1 UNIT/GM-%

Tier 3

*Antifungals - Topical***

CICLODAN EXTERNAL SOLUTION (CICLOPIROX)

8 %

Tier 3 Tier 3

CICLOPIROX EXTERNAL GEL 0.77 % Tier 3

CICLOPIROX EXTERNAL SHAMPOO 1 % Tier 3

CICLOPIROX OLAMINE EXTERNAL CREAM 0.77 % Tier 3

CICLOPIROX OLAMINE EXTERNAL SUSPENSION

0.77 %

Tier 3

KLAYESTA EXTERNAL POWDER (NYSTATIN)

100000 UNIT/GM

Tier 3 Tier 3

NYSTATIN EXTERNAL CREAM 100000 UNIT/GM Tier 3

NYSTATIN EXTERNAL OINTMENT 100000 UNIT/GM Tier 3

NYSTOP EXTERNAL POWDER (NYSTATIN) 100000

UNIT/GM

Tier 3 Tier 3

*Anti-Inflammatory Agents - Topical***

DICLOFENAC SODIUM EXTERNAL GEL 1 % Tier 3

DICLOFONO EXTERNAL GEL 1.6 % Tier 4

*Antineoplastic Antimetabolites - Topical***

FLUOROURACIL EXTERNAL CREAM 5 % Tier 3

FLUOROURACIL EXTERNAL SOLUTION 2 %, 5 % Tier 3

*Antipsoriatics - Systemic***

ACITRETIN ORAL CAPSULE 10 MG, 17.5 MG, 25 MG Tier 3

BIMZELX SUBCUTANEOUS SOLUTION AUTO-

INJECTOR 160 MG/ML

Tier 6 PA; Specialty; QL (2 ML per 56 days)

BIMZELX SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 160 MG/ML

Tier 6 PA; Specialty; QL (2 ML per 56 days)

SKYRIZI (150 MG DOSE) SUBCUTANEOUS

PREFILLED SYRINGE KIT 75 MG/0.83ML

Tier 6 PA; Specialty

SKYRIZI PEN SUBCUTANEOUS SOLUTION AUTO-

INJECTOR 150 MG/ML

Tier 6 PA; Specialty

SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 150 MG/ML

Tier 6 PA; Specialty

STELARA SUBCUTANEOUS SOLUTION 45

MG/0.5ML

Tier 6 PA; Specialty

STELARA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 45 MG/0.5ML, 90 MG/ML

Tier 6 PA; Specialty

TALTZ SUBCUTANEOUS SOLUTION AUTO-

INJECTOR 80 MG/ML

Tier 6 PA; Specialty

TALTZ SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 80 MG/ML

Tier 6 PA; Specialty

TREMFYA SUBCUTANEOUS SOLUTION PEN-

INJECTOR 100 MG/ML

Tier 6 PA; Specialty

Drug Name Brand Tier Generic Tier Formulary Notes

TREMFYA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 100 MG/ML

Tier 6 PA; Specialty

*Antipsoriatics***

CALCIPOTRIENE EXTERNAL SOLUTION 0.005 % Tier 3

TAZAROTENE EXTERNAL CREAM 0.1 % Tier 3 PA

TAZAROTENE EXTERNAL GEL 0.05 %, 0.1 % Tier 3

*Antiseborrheic Products***

SELENIUM SULFIDE EXTERNAL LOTION 2.5 % Tier 2

*Antivirals - Topical***

ACYCLOVIR EXTERNAL OINTMENT 5 % Tier 3

*Atopic Dermatitis - Monoclonal Antibodies***

DUPIXENT SUBCUTANEOUS SOLUTION PEN-

INJECTOR 200 MG/1.14ML, 300 MG/2ML

Tier 6 PA; Specialty

DUPIXENT SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 100 MG/0.67ML, 200

MG/1.14ML, 300 MG/2ML

Tier 6 PA; Specialty

*Burn Products***

SSD EXTERNAL CREAM (SILVER SULFADIAZINE)

1 %

Tier 2 Tier 2

*Corticosteroids - Topical***

BETAMETHASONE VALERATE EXTERNAL LOTION

0.1 %

Tier 3

BETAMETHASONE VALERATE EXTERNAL

OINTMENT 0.1 %

Tier 3

CLOBETASOL PROP EMOLLIENT BASE EXTERNAL

CREAM 0.05 %

Tier 3

CLOBETASOL PROPIONATE E EXTERNAL CREAM

0.05 %

Tier 3

CLOBETASOL PROPIONATE EXTERNAL CREAM

0.05 %

Tier 3

CLOBETASOL PROPIONATE EXTERNAL OINTMENT

0.05 %

Tier 3

CLOBETASOL PROPIONATE EXTERNAL SOLUTION

0.05 %

Tier 3

FLUOCINOLONE ACETONIDE EXTERNAL

SOLUTION 0.01 %

Tier 3

FLUOCINONIDE EXTERNAL GEL 0.05 % Tier 3

FLUOCINONIDE EXTERNAL OINTMENT 0.05 % Tier 3

FLUOCINONIDE EXTERNAL SOLUTION 0.05 % Tier 3

FLUTICASONE PROPIONATE EXTERNAL CREAM

0.05 %

Tier 3

HYDROCORTISONE EXTERNAL CREAM 2.5 % Tier 2

HYDROCORTISONE EXTERNAL OINTMENT 2.5 % Tier 2

MOMETASONE FUROATE EXTERNAL CREAM 0.1 % Tier 3

TRIAMCINOLONE ACETONIDE CREAM 0.025 %

EXTERNAL

Tier 2

TRIAMCINOLONE ACETONIDE CREAM 0.1 %

EXTERNAL

Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

TRIAMCINOLONE ACETONIDE CREAM 0.5 %

EXTERNAL

Tier 3

TRIAMCINOLONE ACETONIDE EXTERNAL LOTION

0.025 %, 0.1 %

Tier 3

TRIAMCINOLONE ACETONIDE OINTMENT 0.025 %

EXTERNAL

Tier 2

TRIAMCINOLONE ACETONIDE OINTMENT 0.1 %

EXTERNAL

Tier 2

TRIAMCINOLONE ACETONIDE OINTMENT 0.5 %

EXTERNAL

Tier 3

*Emollient/Keratolytic Agents***

UREA EXTERNAL CREAM 20 % Tier 3

*Imidazole-Related Antifungals - Topical***

ECONAZOLE NITRATE EXTERNAL CREAM 1 % Tier 3

KETOCONAZOLE EXTERNAL CREAM 2 % Tier 3

KETOCONAZOLE EXTERNAL SHAMPOO 2 % Tier 2

*Immunomodulators Imidazoquinolinamines -

Topical***

IMIQUIMOD CREAM 3.75 % EXTERNAL Tier 6

IMIQUIMOD CREAM 5 % EXTERNAL Tier 3

IMIQUIMOD PUMP EXTERNAL CREAM 3.75 % Tier 6

*Local Anesthetics - Topical***

GLYDO EXTERNAL PREFILLED SYRINGE

(LIDOCAINE HCL URETHRAL/MUCOSAL) 2 %

Tier 3 Tier 3

LIDOCAINE EXTERNAL OINTMENT 5 % Tier 3

LIDOCAINE EXTERNAL PATCH 5 % Tier 3 PA

LIDOCAINE HCL URETHRAL/MUCOSAL EXTERNAL

GEL 2 %

Tier 3

*Macrolide Immunosuppressants - Topical***

TACROLIMUS EXTERNAL OINTMENT 0.03 %, 0.1 % Tier 3 PA

*Rosacea Agents***

AZELAIC ACID EXTERNAL GEL 15 % Tier 3

METRONIDAZOLE EXTERNAL CREAM 0.75 % Tier 3

METRONIDAZOLE EXTERNAL GEL 0.75 %, 1 % Tier 3

METRONIDAZOLE EXTERNAL LOTION 0.75 % Tier 3

*Scabicides & Pediculicides***

MALATHION EXTERNAL LOTION 0.5 % Tier 3

PERMETHRIN EXTERNAL CREAM 5 % Tier 3

*Topical Anesthetic Combinations***

LIDOCAINE-PRILOCAINE EXTERNAL CREAM 2.5-2.5

Tier 3

*Type Ii 5-Alpha Reductase Inhibitors***

FINASTERIDE ORAL TABLET 1 MG Tier 3 QL (1 EA per 1 day)

*Wound Care - Growth Factor Agents***

REGRANEX EXTERNAL GEL 0.01 % Tier 4

Drug Name Brand Tier Generic Tier Formulary Notes

*Diagnostic Products*

*Diagnostic Biologicals***

APLISOL INTRADERMAL SOLUTION 5

UNIT/0.1ML

Tier 4 QL (1 ML per 30 days)

CANDIN INTRADERMAL SOLUTION (CANDIDA

ALBICANS SKN TST ANTGN)

Tier 4 Tier 4 QL (1 ML per 30 days)

TUBERSOL INTRADERMAL SOLUTION 5

UNIT/0.1ML

Tier 4 QL (1 ML per 30 days)

*Diagnostic Tests***

ACCU-CHEK AVIVA PLUS IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

ACCU-CHEK GUIDE IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

ACCU-CHEK SMARTVIEW IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

ACCUTREND GLUCOSE IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

ADVANCE INTUITION TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

ADVANCE MICRO-DRAW TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

ADVOCATE REDI-CODE IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

ADVOCATE REDI-CODE+ TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

ADVOCATE TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

AGAMATRIX AMP TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

AGAMATRIX JAZZ TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

AGAMATRIX KEYNOTE TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

AGAMATRIX PRESTO TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

ASSURE 3 TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

ASSURE 4 TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

ASSURE II CHECK IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

ASSURE II IN VITRO STRIP (BLOOD GLUCOSE

TEST)

Tier 2 Tier 2

ASSURE PLATINUM IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

ASSURE PRISM MULTI TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

ASSURE PRO TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

BIOTEL CARE TEST STRIPS IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

BLOOD GLUCOSE TEST STRIPS 333 IN VITRO STRIP Tier 2

BLULINK GLUCOSE TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

CAREONE BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

CARESENS N GLUCOSE TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

CARETOUCH TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

CLEVER CHEK AUTO-CODE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

CLEVER CHEK AUTO-CODE VOICE IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

CLEVER CHEK TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

CLEVER CHOICE AUTO-CODE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

CLEVER CHOICE MICRO TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

CLEVER CHOICE NO CODING IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

CLEVER CHOICE TALK SYSTEM IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

CONTOUR NEXT TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

CONTOUR TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

COOL BLOOD GLUCOSE TEST STRIPS IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

CVS ADVANCED GLUCOSE TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

CVS GLUCOSE METER TEST STRIPS IN VITRO STRIP Tier 2

D-CARE BLOOD GLUCOSE IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

DIASTIX IN VITRO STRIP Tier 4

DIASTIX REAGENT IN VITRO STRIP Tier 4

DIATHRIVE BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

DIATHRIVE GLUCOSE TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

DIATHRIVE+ GLUCOSE TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

DIATRUE PLUS TEST IN VITRO STRIP Tier 2

DUO-CARE TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

EASY MAX BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

EASY PLUS II GLUCOSE TEST IN VITRO STRIP Tier 2

EASY STEP TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

EASY TALK BLOOD GLUCOSE TEST IN VITRO

STRIP

Tier 2

EASY TALK PLUS II TEST STRIPS IN VITRO STRIP Tier 2

EASY TOUCH HEALTHPRO GLUCOSE IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

EASY TOUCH TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

EASY TRAK BLOOD GLUCOSE TEST IN VITRO

STRIP

Tier 2

EASY TRAK II GLUCOSE TEST IN VITRO STRIP Tier 2

EASYGLUCO IN VITRO STRIP (BLOOD GLUCOSE

TEST)

Tier 2 Tier 2

EASYMAX 15 TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

EASYMAX TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

EASYPRO BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

EASYPRO PLUS IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

ELEMENT COMPACT TEST IN VITRO STRIP Tier 2

ELEMENT TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

EMBRACE BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

EMBRACE EVO BLOOD GLUCOSE TEST IN

VITRO STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

EMBRACE PRO GLUCOSE TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

EMBRACE TALK GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

EMBRACE WAVE BLOOD GLUCOSE IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

EQ BLOOD GLUCOSE TEST IN VITRO STRIP Tier 2

EVOLUTION AUTOCODE IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

FIFTY50 GLUCOSE TEST 2.0 IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

FORA 6 CONNECT IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

FORA 6 CONNECT/GTEL TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

FORA BLOOD GLUCOSE TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

FORA D15G BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

FORA D20 BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

FORA D40/G31 BLOOD GLUCOSE IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

FORA G20 BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

FORA G30/PREM V10 GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

FORA GD20 TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

FORA GD50 BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

FORA GTEL BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

FORA TN'G ADVANCE PRO IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

FORA TN'G/TN'G VOICE IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

FORA V10 BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

FORA V12 BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

FORA V20 BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

FORA V30A BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

FORACARE GD40 TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

FORACARE PREMIUM V10 TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

FORACARE TEST N GO TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

FORTISCARE G1 TEST STRIP IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

FORTISCARE TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

FREESTYLE INSULINX TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

FREESTYLE LITE TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

FREESTYLE PRECISION NEO TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

FREESTYLE TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

GE100 BLOOD GLUCOSE TEST IN VITRO STRIP Tier 2

GENULTIMATE TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

GHT TEST IN VITRO STRIP Tier 2

GLUCO PERFECT 3 TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

GLUCOCARD 01 SENSOR PLUS IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

GLUCOCARD EXPRESSION TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

GLUCOCARD SHINE TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

GLUCOCARD VITAL TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

GLUCOCARD X-SENSOR IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

GLUCOCOM TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

GLUCONAVII BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

GLUCOSE METER TEST IN VITRO STRIP Tier 2

GNP EASY TOUCH GLUCOSE TEST IN VITRO STRIP Tier 2

GNP TRUE METRIX GLUCOSE STRIPS IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

GNP TRUETRACK SMART SYSTEM IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

GNP TRUETRACK TEST STRIPS IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

GOJJI BLOOD GLUCOSE TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

GOJJI BLOOD TEST STRIP/LANCETS IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

GOODSENSE BLOOD GLUCOSE IN VITRO STRIP Tier 2

HW EMBRACE PRO GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

HW EMBRACE TALK GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

IGLUCOSE TEST STRIPS IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

IN TOUCH BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

INFINITY BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

INFINITY VOICE IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

KROGER BLOOD GLUCOSE TEST IN VITRO STRIP Tier 2

KROGER HEALTHPRO GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

KROGER PREMIUM GLUCOSE TEST IN VITRO STRIP Tier 2

LIBERTY NEXT GENERATION TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

LIBERTY TEST IN VITRO STRIP Tier 2

MEIJER BLOOD GLUCOSE TEST IN VITRO STRIP Tier 2

MEIJER ESSENTIAL GLUCOSE TEST IN VITRO STRIP Tier 2

MEIJER TRUETEST TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

MEIJER TRUETRACK TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

MICRODOT TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

MM BLULINK GLUCOSE TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

MM EASY TOUCH GLUCOSE IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

MYGLUCOHEALTH TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

NEUTEK 2TEK TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

NOVA MAX GLUCOSE TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

ON CALL EXPRESS BLOOD GLUCOSE IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

ONE DROP TEST IN VITRO STRIP Tier 2

ONETOUCH ULTRA IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

ONETOUCH ULTRA TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

ONETOUCH VERIO IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

OPTIUMEZ TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

PHARMACIST CHOICE AUTOCODE IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

PHARMACIST CHOICE NO CODING IN VITRO STRIP Tier 2

PIP BLOOD GLUCOSE TEST STRIP IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

POCKETCHEM EZ TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

POGO AUTOMATIC TEST CARTRIDGES IN VITRO

DIAGNOSTIC TEST

Tier 1

PRECISION XTRA BLOOD GLUCOSE IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

PREMIUM BLOOD GLUCOSE TEST IN VITRO STRIP Tier 2

PRO VOICE V8/V9 GLUCOSE IN VITRO STRIP Tier 2

PRODIGY NO CODING BLOOD GLUC IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

PTS PANELS EGLU TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

QUICKTEK TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

QUINTET AC BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

QUINTET BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

REFUAH PLUS BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

RELION BLOOD GLUCOSE TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

RELION CONFIRM/MICRO TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

RELION PREMIER TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

RELION PRIME TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

RELION TRUE METRIX TEST STRIPS IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

RELION ULTIMA TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

REXALL BLOOD GLUCOSE TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

RIGHTEST GS100 BLOOD GLUCOSE IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

RIGHTEST GS300 BLOOD GLUCOSE IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

RIGHTEST GS550 BLOOD GLUCOSE IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

RIGHTEST GT333 BLOOD GLUCOSE IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

RIGHTEST GT333 GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

SMART SENSE PREMIUM TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

SMART SENSE VALUE TEST IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

SMARTEST BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

SOLUS V2 TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

SUPREME TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

TGT BLOOD GLUCOSE TEST IN VITRO STRIP Tier 2

TRUE FOCUS BLOOD GLUCOSE STRIP IN VITRO

STRIP

Tier 2

TRUE METRIX BLOOD GLUCOSE TEST IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

TRUE METRIX PRO BLOOD GLUCOSE IN VITRO

STRIP (BLOOD GLUCOSE TEST)

Tier 2 Tier 2

TRUETEST TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

TRUETRACK TEST IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

UNISTRIP1 GENERIC IN VITRO STRIP (BLOOD

GLUCOSE TEST)

Tier 2 Tier 2

VERASENS BLOOD GLUCOSE TEST IN VITRO STRIP Tier 2

VIVAGUARD INO TEST STRIPS IN VITRO STRIP

(BLOOD GLUCOSE TEST)

Tier 2 Tier 2

*Infection Tests***

MYLAB BOX COVID-19 TESTING IN VITRO KIT Tier 1 QL (8 EA per 30 days)

Drug Name Brand Tier Generic Tier Formulary Notes

*Dietary Products/Dietary Management Products*

*Nutritional Supplements***

ASILNASALRMS ORAL CAPSULE Tier 3

*Digestive Aids*

*Digestive Enzymes***

CREON ORAL CAPSULE DELAYED RELEASE

PARTICLES 12000-38000 UNIT, 24000-76000 UNIT,

3000-9500 UNIT, 36000-114000 UNIT, 6000-19000

UNIT

Tier 4 PA

PANCREAZE ORAL CAPSULE DELAYED

RELEASE PARTICLES 10500-35500 UNIT, 16800-

56800 UNIT, 21000-54700 UNIT, 2600-8800 UNIT,

37000-97300 UNIT, 4200-14200 UNIT

Tier 4 PA

*Diuretics*

*Carbonic Anhydrase Inhibitors***

ACETAZOLAMIDE ER ORAL CAPSULE EXTENDED

RELEASE 12 HOUR 500 MG

Tier 3

ACETAZOLAMIDE ORAL TABLET 125 MG, 250 MG Tier 3

ACETAZOLAMIDE SODIUM INJECTION SOLUTION

RECONSTITUTED 500 MG

Tier 3

METHAZOLAMIDE ORAL TABLET 50 MG Tier 3

*Diuretic Combinations***

AMILORIDE-HYDROCHLOROTHIAZIDE ORAL

TABLET 5-50 MG

Tier 3

SPIRONOLACTONE-HCTZ ORAL TABLET 25-25 MG Tier 1

TRIAMTERENE-HCTZ ORAL CAPSULE 37.5-25 MG Tier 1

TRIAMTERENE-HCTZ ORAL TABLET 37.5-25 MG, 75-

50 MG

Tier 1

*Loop Diuretics***

BUMETANIDE ORAL TABLET 0.5 MG, 1 MG, 2 MG Tier 3

FUROSEMIDE ORAL TABLET 20 MG, 40 MG, 80 MG Tier 1

FUROSEMIDE SOLUTION 10 MG/ML ORAL Tier 1

FUROSEMIDE SOLUTION 8 MG/ML ORAL Tier 3

SOAANZ ORAL TABLET (TORSEMIDE) 20 MG Tier 1 Tier 1

TORSEMIDE ORAL TABLET 10 MG, 100 MG, 5 MG Tier 1

*Potassium Sparing Diuretics***

AMILORIDE HCL ORAL TABLET 5 MG Tier 1

SPIRONOLACTONE ORAL TABLET 100 MG, 25 MG,

50 MG

Tier 1

*Thiazides And Thiazide-Like Diuretics***

CHLORTHALIDONE ORAL TABLET 25 MG, 50 MG Tier 1

HYDROCHLOROTHIAZIDE ORAL CAPSULE 12.5 MG Tier 1

HYDROCHLOROTHIAZIDE ORAL TABLET 12.5 MG,

25 MG, 50 MG

Tier 1

INDAPAMIDE ORAL TABLET 1.25 MG, 2.5 MG Tier 1

METOLAZONE ORAL TABLET 10 MG, 2.5 MG, 5 MG Tier 3

Drug Name Brand Tier Generic Tier Formulary Notes

*Endocrine And Metabolic Agents - Misc.*

*Bisphosphonates***

ALENDRONATE SODIUM TABLET 10 MG ORAL Tier 1 QL (30 EA per 30 days)

ALENDRONATE SODIUM TABLET 35 MG ORAL Tier 1 QL (8 EA per 28 days)

ALENDRONATE SODIUM TABLET 5 MG ORAL Tier 3 QL (30 EA per 30 days)

ALENDRONATE SODIUM TABLET 70 MG ORAL Tier 1 QL (0.143 EA per 1 day)

IBANDRONATE SODIUM ORAL TABLET 150 MG Tier 3 QL (1 EA per 30 days)

RISEDRONATE SODIUM TABLET 150 MG ORAL Tier 3 QL (1 EA per 30 days)

RISEDRONATE SODIUM TABLET 35 MG ORAL Tier 3 QL (4 EA per 28 days)

*Calcitonins***

CALCITONIN (SALMON) NASAL SOLUTION 200

UNIT/ACT

Tier 3

*Carnitine Replenisher - Agents***

LEVOCARNITINE ORAL SOLUTION 1 GM/10ML Tier 3

LEVOCARNITINE ORAL TABLET 330 MG Tier 3

LEVOCARNITINE SF ORAL SOLUTION 1 GM/10ML Tier 3

*Ckd Agent-Sodium/Hydrogen Exchanger 3 (Nhe3)

Inhibitor***

XPHOZAH ORAL TABLET 20 MG, 30 MG Tier 6 PA; Specialty; QL (2 EA per 1 day)

*Dopamine Receptor Agonists***

CABERGOLINE ORAL TABLET 0.5 MG Tier 3

*Gnrh/Lhrh Antagonists***

ORILISSA TABLET 150 MG ORAL Tier 5 PA; QL (1 EA per 1 day)

ORILISSA TABLET 200 MG ORAL Tier 5 PA; QL (2 EA per 1 day)

*Growth Hormones***

NORDITROPIN FLEXPRO SUBCUTANEOUS

SOLUTION PEN-INJECTOR 10 MG/1.5ML, 15

MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML

Tier 6 PA; Specialty

NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS

SOLUTION PEN-INJECTOR 10 MG/2ML

Tier 6 PA; Specialty

NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS

SOLUTION PEN-INJECTOR 20 MG/2ML

Tier 6 PA; Specialty

NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS

SOLUTION PEN-INJECTOR 5 MG/2ML

Tier 6 PA; Specialty

OMNITROPE SUBCUTANEOUS SOLUTION

CARTRIDGE 10 MG/1.5ML, 5 MG/1.5ML

Tier 6 PA; Specialty

OMNITROPE SUBCUTANEOUS SOLUTION

RECONSTITUTED 5.8 MG

Tier 6 PA; Specialty

SEROSTIM SUBCUTANEOUS SOLUTION

RECONSTITUTED 4 MG, 5 MG, 6 MG

Tier 6 PA; Specialty

ZORBTIVE SUBCUTANEOUS SOLUTION

RECONSTITUTED 8.8 MG

Tier 6 PA; Specialty

*Hyperparathyroid Treatment - Vitamin D Analogs***

CALCITRIOL ORAL CAPSULE 0.25 MCG, 0.5 MCG Tier 1

*Lhrh/Gnrh Agonist Analog Pituitary Suppressants***

LUPRON DEPOT-PED (1-MONTH)

INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG

Tier 6 PA; Specialty; QL (1 EA per 28 days)

Drug Name Brand Tier Generic Tier Formulary Notes

LUPRON DEPOT-PED (3-MONTH)

INTRAMUSCULAR KIT 11.25 MG, 30 MG

Tier 6 PA; Specialty; QL (1 EA per 84 days)

LUPRON DEPOT-PED (6-MONTH)

INTRAMUSCULAR KIT 45 MG

Tier 6 PA; Specialty; QL (1 EA per 168 days)

*Neurokinin 3 (Nk3) Receptor Antagonists***

VEOZAH ORAL TABLET 45 MG Tier 6 PA; QL (1 EA per 1 day)

*Ovulation Stimulants-Synthetic***

CLOMID ORAL TABLET (CLOMIPHENE CITRATE)

50 MG

Tier 3 Tier 3

*Selective Estrogen Receptor Modulators (Serms)***

RALOXIFENE HCL ORAL TABLET 60 MG Tier 1

*Vasopressin***

DESMOPRESSIN ACE SPRAY REFRIG NASAL

SOLUTION 0.01 %

Tier 3

DESMOPRESSIN ACETATE ORAL TABLET 0.1 MG,

0.2 MG

Tier 3

DESMOPRESSIN ACETATE SPRAY NASAL

SOLUTION 0.01 %

Tier 3

*Estrogens*

*Estrogen & Progestin***

AMABELZ ORAL TABLET (ESTRADIOL-

NORETHINDRONE ACET) 0.5-0.1 MG, 1-0.5 MG

Tier 3 Tier 3

COMBIPATCH TRANSDERMAL PATCH TWICE

WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY

Tier 4

FYAVOLV ORAL TABLET (NORETHINDRONE-ETH

ESTRADIOL) 0.5-2.5 MG-MCG, 1-5 MG-MCG

Tier 3 Tier 3

JINTELI ORAL TABLET (NORETHINDRONE-ETH

ESTRADIOL) 1-5 MG-MCG

Tier 3 Tier 3

MIMVEY ORAL TABLET (ESTRADIOL-

NORETHINDRONE ACET) 1-0.5 MG

Tier 3 Tier 3

PREFEST ORAL TABLET 1/1-0.09 MG (15/15) Tier 4

PREMPHASE ORAL TABLET 0.625-5 MG Tier 4

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG,

0.625-2.5 MG, 0.625-5 MG

Tier 4

*Estrogens***

ALORA TRANSDERMAL PATCH TWICE WEEKLY

(ESTRADIOL) 0.025 MG/24HR, 0.05 MG/24HR, 0.075

MG/24HR, 0.1 MG/24HR

Tier 4 Tier 3

DEPO-ESTRADIOL INTRAMUSCULAR OIL 5

MG/ML

Tier 3

DOTTI TRANSDERMAL PATCH TWICE WEEKLY

(ESTRADIOL) 0.025 MG/24HR, 0.0375 MG/24HR, 0.05

MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

Tier 3 Tier 3

ESTRADIOL ORAL TABLET 0.5 MG, 1 MG, 2 MG Tier 1

ESTRADIOL TRANSDERMAL GEL 0.75 MG/0.75GM,

0.75 MG/1.25 GM (0.06%), 1.25 MG/1.25GM

Tier 3

ESTRADIOL TRANSDERMAL PATCH WEEKLY 0.025

MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.06

MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR

Tier 3

Drug Name Brand Tier Generic Tier Formulary Notes

ESTRADIOL VALERATE INTRAMUSCULAR OIL 20

MG/ML, 40 MG/ML

Tier 3

LYLLANA TRANSDERMAL PATCH TWICE

WEEKLY (ESTRADIOL) 0.025 MG/24HR, 0.0375

MG/24HR, 0.05 MG/24HR, 0.075 MG/24HR, 0.1

MG/24HR

Tier 3 Tier 3

MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25

MG, 2.5 MG

Tier 4

MENOSTAR TRANSDERMAL PATCH WEEKLY 14

MCG/24HR

Tier 4

PREMARIN INJECTION SOLUTION

RECONSTITUTED 25 MG

Tier 4

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625

MG, 0.9 MG, 1.25 MG

Tier 4

*Fluoroquinolones*

*Fluoroquinolones***

CIPROFLOXACIN HCL TABLET 100 MG ORAL Tier 3

CIPROFLOXACIN HCL TABLET 250 MG ORAL Tier 2

CIPROFLOXACIN HCL TABLET 500 MG ORAL Tier 2

CIPROFLOXACIN HCL TABLET 750 MG ORAL Tier 2

CIPROFLOXACIN ORAL SUSPENSION

RECONSTITUTED 250 MG/5ML (5%), 500 MG/5ML

(10%)

Tier 3

LEVOFLOXACIN ORAL SOLUTION 25 MG/ML Tier 3

LEVOFLOXACIN ORAL TABLET 250 MG, 500 MG,

750 MG

Tier 2

MOXIFLOXACIN HCL ORAL TABLET 400 MG Tier 3

OFLOXACIN ORAL TABLET 400 MG Tier 3

*Gastrointestinal Agents - Misc.*

*Gallstone Solubilizing Agents***

URSODIOL ORAL CAPSULE 300 MG Tier 3

*Gastrointestinal Antiallergy Agents***

CROMOLYN SODIUM ORAL CONCENTRATE 100

MG/5ML

Tier 3

*Gastrointestinal Chloride Channel Activators***

LUBIPROSTONE ORAL CAPSULE 24 MCG Tier 3

*Gastrointestinal Stimulants***

METOCLOPRAMIDE HCL INJECTION SOLUTION 5

MG/ML

Tier 3

METOCLOPRAMIDE HCL ORAL SOLUTION 10

MG/10ML, 5 MG/5ML

Tier 1

METOCLOPRAMIDE HCL ORAL TABLET 10 MG, 5

Tier 1

*Hepatotropics - Thyroid Hormone Receptor-Beta

Agonists***

REZDIFFRA ORAL TABLET 100 MG, 60 MG, 80 MG Tier 6 PA; Specialty; QL (1 EA per 1 day)

*Inflammatory Bowel Agents***

BALSALAZIDE DISODIUM ORAL CAPSULE 750 MG Tier 3

Drug Name Brand Tier Generic Tier Formulary Notes

MESALAMINE ER ORAL CAPSULE EXTENDED

RELEASE 500 MG

Tier 3

MESALAMINE ORAL TABLET DELAYED RELEASE

1.2 GM

Tier 3

MESALAMINE RECTAL ENEMA 4 GM Tier 3

MESALAMINE RECTAL SUPPOSITORY 1000 MG Tier 3

PENTASA ORAL CAPSULE EXTENDED RELEASE

250 MG

Tier 5

SFROWASA RECTAL ENEMA 4 GM/60ML Tier 4

SULFASALAZINE ORAL TABLET 500 MG Tier 2

SULFASALAZINE ORAL TABLET DELAYED

RELEASE 500 MG

Tier 2

*Integrin Receptor Antagonists***

ENTYVIO SUBCUTANEOUS SOLUTION PEN-

INJECTOR 108 MG/0.68ML

Tier 6 PA; Specialty; QL (0.05 ML per 1 day)

*Interleukin Antagonists***

OMVOH SUBCUTANEOUS SOLUTION AUTO-

INJECTOR 100 MG/ML

Tier 6 PA; Specialty; QL (0.072 ML per 1 day)

OMVOH SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 100 MG/ML

Tier 6 PA; Specialty; QL (0.072 ML per 1 day)

SKYRIZI SUBCUTANEOUS SOLUTION

CARTRIDGE 180 MG/1.2ML, 360 MG/2.4ML

Tier 6 PA; Specialty

*Intestinal Acidifiers***

ENULOSE ORAL SOLUTION 10 GM/15ML Tier 3

GENERLAC ORAL SOLUTION 10 GM/15ML Tier 3

LACTULOSE ENCEPHALOPATHY ORAL SOLUTION

10 GM/15ML

Tier 3

*Phosphate Binder Agents***

CALCIUM ACETATE (PHOS BINDER) ORAL

CAPSULE 667 MG

Tier 2

CALCIUM ACETATE (PHOS BINDER) ORAL TABLET

667 MG

Tier 2

CALCIUM ACETATE ORAL TABLET 667 MG Tier 2

LANTHANUM CARBONATE ORAL TABLET

CHEWABLE 1000 MG, 500 MG, 750 MG

Tier 4 PA

SEVELAMER CARBONATE ORAL PACKET 0.8 GM,

2.4 GM

Tier 3

SEVELAMER CARBONATE ORAL TABLET 800 MG Tier 3

SEVELAMER HCL ORAL TABLET 400 MG, 800 MG Tier 3

*Sphingosine 1-Phosphate (S1p) Receptor Modulators

(Gi)***

VELSIPITY ORAL TABLET 2 MG Tier 6 PA; Specialty; QL (1 EA per 1 day)

*Tumor Necrosis Factor Alpha Blockers***

CIMZIA (2 SYRINGE) SUBCUTANEOUS

PREFILLED SYRINGE KIT 200 MG/ML

Tier 6 PA; Specialty

CIMZIA STARTER KIT SUBCUTANEOUS

PREFILLED SYRINGE KIT 6 X 200 MG/ML

Tier 6 PA; Specialty

CIMZIA SUBCUTANEOUS KIT 2 X 200 MG Tier 6 PA; Specialty

Drug Name Brand Tier Generic Tier Formulary Notes

*Genitourinary Agents - Miscellaneous*

*5-Alpha Reductase Inhibitors***

FINASTERIDE ORAL TABLET 5 MG Tier 1

*Alpha 1-Adrenoceptor Antagonists***

TAMSULOSIN HCL ORAL CAPSULE 0.4 MG Tier 1

*Citrates***

POTASSIUM CITRATE ER ORAL TABLET

EXTENDED RELEASE 10 MEQ (1080 MG), 5 MEQ (540

MG)

Tier 3

SOD CITRATE-CITRIC ACID ORAL SOLUTION 1.5-1

GM/15ML, 3-2 GM/30ML, 500-334 MG/5ML

Tier 3

*Igan Agents - Endothelin & Angiotensin Ii Receptor

Antag***

FILSPARI ORAL TABLET 200 MG, 400 MG Tier 6 PA; Specialty; QL (1 EA per 1 day)

*Interstitial Cystitis Agents***

ELMIRON ORAL CAPSULE 100 MG Tier 4

*Urinary Analgesics***

PHENAZO ORAL TABLET (PHENAZOPYRIDINE

HCL) 200 MG

Tier 3 Tier 3

PHENAZOPYRIDINE HCL ORAL TABLET 100 MG Tier 3

*Gout Agents*

*Gout Agent Combinations***

COLCHICINE-PROBENECID ORAL TABLET 0.5-500

Tier 3

*Gout Agents***

ALLOPURINOL ORAL TABLET 100 MG, 300 MG Tier 1

COLCHICINE ORAL TABLET 0.6 MG Tier 3

*Uricosurics***

PROBENECID ORAL TABLET 500 MG Tier 1

*Hematological Agents - Misc.*

*Direct-Acting P2y12 Inhibitors***

BRILINTA ORAL TABLET 60 MG, 90 MG Tier 5 PA; QL (2 EA per 1 day)

*Hematorheologic Agents***

PENTOXIFYLLINE ER ORAL TABLET EXTENDED

RELEASE 400 MG

Tier 3

*Phosphodiesterase Iii Inhibitors***

CILOSTAZOL ORAL TABLET 100 MG, 50 MG Tier 1

*Platelet Aggregation Inhibitor Combinations***

ASPIRIN-DIPYRIDAMOLE ER ORAL CAPSULE

EXTENDED RELEASE 12 HOUR 25-200 MG

Tier 3

*Platelet Aggregation Inhibitors***

DIPYRIDAMOLE ORAL TABLET 25 MG, 50 MG, 75

Tier 3

*Pyruvate Kinase Activators***

PYRUKYND ORAL TABLET 20 MG, 5 MG, 50 MG Tier 6 PA; Specialty; QL (2 EA per 1 day)

Drug Name Brand Tier Generic Tier Formulary Notes

PYRUKYND TAPER PACK ORAL TABLET

THERAPY PACK 5 MG, 7 X 20 MG & 7 X 5 MG, 7 X

50 MG & 7 X 20 MG

Tier 6 PA; Specialty; QL (1 EA per 1 day)

*Quinazoline Agents***

ANAGRELIDE HCL ORAL CAPSULE 0.5 MG, 1 MG Tier 3

*Thienopyridine Derivatives***

CLOPIDOGREL BISULFATE TABLET 300 MG ORAL Tier 3

CLOPIDOGREL BISULFATE TABLET 75 MG ORAL Tier 1

PRASUGREL HCL ORAL TABLET 10 MG, 5 MG Tier 2

*Hematopoietic Agents*

*Amino Acids***

L-GLUTAMINE ORAL PACKET 5 GM Tier 3

*Cobalamin Combinations***

VIT B12-METHIONINE-INOS-CHOL

INTRAMUSCULAR SOLUTION

Tier 3

*Cobalamins***

CYANOCOBALAMIN INJECTION SOLUTION 1000

MCG/ML

Tier 3

*Erythropoiesis-Stimulating Agents (Esas)***

ARANESP (ALBUMIN FREE) INJECTION

SOLUTION 100 MCG/ML, 200 MCG/ML, 25

MCG/ML, 40 MCG/ML, 60 MCG/ML

Tier 6 Specialty

ARANESP (ALBUMIN FREE) SOLUTION

PREFILLED SYRINGE 10 MCG/0.4ML INJECTION

Tier 6 Specialty

ARANESP (ALBUMIN FREE) SOLUTION

PREFILLED SYRINGE 100 MCG/0.5ML INJECTION

Tier 4 Specialty

ARANESP (ALBUMIN FREE) SOLUTION

PREFILLED SYRINGE 150 MCG/0.3ML INJECTION

Tier 4 Specialty

ARANESP (ALBUMIN FREE) SOLUTION

PREFILLED SYRINGE 200 MCG/0.4ML INJECTION

Tier 4 Specialty

ARANESP (ALBUMIN FREE) SOLUTION

PREFILLED SYRINGE 25 MCG/0.42ML INJECTION

Tier 6 Specialty

ARANESP (ALBUMIN FREE) SOLUTION

PREFILLED SYRINGE 300 MCG/0.6ML INJECTION

Tier 4 Specialty

ARANESP (ALBUMIN FREE) SOLUTION

PREFILLED SYRINGE 40 MCG/0.4ML INJECTION

Tier 6 Specialty

ARANESP (ALBUMIN FREE) SOLUTION

PREFILLED SYRINGE 500 MCG/ML INJECTION

Tier 4 Specialty

ARANESP (ALBUMIN FREE) SOLUTION

PREFILLED SYRINGE 60 MCG/0.3ML INJECTION

Tier 6 Specialty

PROCRIT INJECTION SOLUTION 40000 UNIT/ML Tier 6 PA; Specialty

*Folic Acid/Folate Combinations***

AIRAVITE ORAL TABLET (FOLBEE) 2.5-25-1 MG Tier 3 Tier 3

NUFOL ORAL TABLET (FOLBEE) 2.5-25-1 MG Tier 3 Tier 3

WESTAB ONE ORAL TABLET 2.5-25-1 MG Tier 3

*Folic Acid/Folates***

FOLIC ACID ORAL TABLET 1 MG Tier 1

KP FOLIC ACID ORAL TABLET 1 MG Tier 1

Drug Name Brand Tier Generic Tier Formulary Notes

TRUE FOLIC ACID ORAL TABLET 1 MG Tier 1

*Granulocyte Colony-Stimulating Factors (G-Csf)***

NEUPOGEN INJECTION SOLUTION 300 MCG/ML,

480 MCG/1.6ML

Tier 6 Specialty

NEUPOGEN INJECTION SOLUTION PREFILLED

SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML

Tier 6 Specialty

*Granulocyte/Macrophage Colony-Stimulating

Factor(Gm-Csf)***

LEUKINE INJECTION SOLUTION

RECONSTITUTED 250 MCG

Tier 6 PA; Specialty

*Hypoxia-Inducible Factor Prolyl Hydroxylase

Inhibitors***

JESDUVROQ ORAL TABLET 1 MG, 2 MG, 4 MG, 6

MG, 8 MG

Tier 6 PA; Specialty

*Hemostatics*

*Hemostatics - Systemic***

TRANEXAMIC ACID ORAL TABLET 650 MG Tier 3 PA

*Hypnotics/Sedatives/Sleep Disorder Agents*

*Barbiturate Hypnotics***

PHENOBARBITAL ORAL ELIXIR 20 MG/5ML Tier 3

PHENOBARBITAL ORAL TABLET 100 MG, 15 MG,

16.2 MG, 30 MG, 32.4 MG, 60 MG, 64.8 MG, 97.2 MG

Tier 3

*Benzodiazepine Hypnotics***

ESTAZOLAM ORAL TABLET 1 MG, 2 MG Tier 3

FLURAZEPAM HCL ORAL CAPSULE 15 MG, 30 MG Tier 3

MIDAZOLAM HCL (PF) INJECTION SOLUTION 10

MG/2ML, 5 MG/ML

Tier 2

MIDAZOLAM HCL INJECTION SOLUTION 10

MG/2ML, 25 MG/5ML, 5 MG/ML, 50 MG/10ML

Tier 2

TEMAZEPAM ORAL CAPSULE 15 MG, 22.5 MG, 30

MG, 7.5 MG

Tier 3

TRIAZOLAM ORAL TABLET 0.125 MG, 0.25 MG Tier 3

*Non-Benzodiazepine - Gaba-Receptor Modulators***

ESZOPICLONE ORAL TABLET 1 MG, 2 MG, 3 MG Tier 3

ZALEPLON ORAL CAPSULE 10 MG, 5 MG Tier 3

ZOLPIDEM TARTRATE ER ORAL TABLET

EXTENDED RELEASE 12.5 MG, 6.25 MG

Tier 3 QL (30 EA per 30 days)

ZOLPIDEM TARTRATE ORAL TABLET 10 MG, 5 MG Tier 2 QL (30 EA per 30 days)

*Selective Melatonin Receptor Agonists***

RAMELTEON ORAL TABLET 8 MG Tier 3

*Laxatives*

*Bowel Evacuant Combinations***

GAVILYTE-G ORAL SOLUTION RECONSTITUTED

(PEG-3350/ELECTROLYTES) 236 GM

Tier 1 Tier 1 QL (236 ML per 30 days)

GAVILYTE-N WITH FLAVOR PACK ORAL

SOLUTION RECONSTITUTED (PEG 3350-KCL-NA

BICARB-NACL) 420 GM

Tier 1 Tier 1 QL (420 ML per 30 days)

Drug Name Brand Tier Generic Tier Formulary Notes

PEG-3350/ELECTROLYTES/ASCORBAT ORAL

SOLUTION RECONSTITUTED 100 GM

Tier 1 QL (100 EA per 30 days)

PEG-KCL-NACL-NASULF-NA ASC-C ORAL

SOLUTION RECONSTITUTED 100 GM

Tier 1 QL (100 EA per 30 days)

*Laxatives - Miscellaneous***

CONSTULOSE ORAL SOLUTION 10 GM/15ML Tier 3

LACTULOSE ORAL SOLUTION 10 GM/15ML, 20

GM/30ML

Tier 3

*Saline Laxative Mixtures***

OSMOPREP ORAL TABLET 1.102-0.398 GM Tier 4

*Macrolides*

*Azithromycin***

AZITHROMYCIN ORAL PACKET 1 GM Tier 3

AZITHROMYCIN ORAL SUSPENSION

RECONSTITUTED 100 MG/5ML, 200 MG/5ML

Tier 3

AZITHROMYCIN ORAL TABLET 250 MG, 500 MG,

600 MG

Tier 3

*Clarithromycin***

CLARITHROMYCIN ER ORAL TABLET EXTENDED

RELEASE 24 HOUR 500 MG

Tier 3

CLARITHROMYCIN ORAL SUSPENSION

RECONSTITUTED 125 MG/5ML, 250 MG/5ML

Tier 3

CLARITHROMYCIN ORAL TABLET 250 MG, 500 MG Tier 3

*Erythromycins***

E.E.S. 400 ORAL TABLET (ERYTHROMYCIN

ETHYLSUCCINATE) 400 MG

Tier 4 Tier 3

ERYTHROCIN STEARATE ORAL TABLET 250 MG Tier 5

ERYTHROMYCIN BASE ORAL CAPSULE DELAYED

RELEASE PARTICLES 250 MG

Tier 3

ERYTHROMYCIN BASE ORAL TABLET 250 MG, 500

Tier 3

ERYTHROMYCIN ETHYLSUCCINATE ORAL

SUSPENSION RECONSTITUTED 400 MG/5ML

Tier 3

*Medical Devices And Supplies*

*Applicators,Cotton Balls,Etc***

ADVOCATE ALCOHOL PREP PADS PAD

(ALCOHOL PREP) 70 %

Tier 2 Tier 2

ALCOH-GLOVE CONTOURED WIPE PAD

(ALCOHOL PREP)

Tier 2 Tier 2

ALCOHOL PADS PAD 70 % Tier 2

ALCOHOL PREP PAD 70 % Tier 2

ALCOHOL PREP PADS PAD 70 % Tier 2

ALCOHOL SWABS PAD Tier 2

ALCOHOL SWABSTICK PAD (ALCOHOL PREP) Tier 2 Tier 2

AUM ALCOHOL PREP PADS PAD 70 % Tier 2

BD SWAB SINGLE USE REGULAR PAD (ALCOHOL

PREP)

Tier 2 Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

CARETOUCH ALCOHOL PREP PAD (ALCOHOL

PREP) 70 %

Tier 2 Tier 2

COMFORT TOUCH ALCOHOL PREP PAD

(ALCOHOL PREP) 70 %

Tier 2 Tier 2

CURITY ALCOHOL PREPS PAD (ALCOHOL PREP)

70 %

Tier 2 Tier 2

CVS ALCOHOL PREP PADS PAD 70 % Tier 2

CVS PREP PAD 70 % Tier 2

DROPSAFE ALCOHOL PREP PAD (ALCOHOL

PREP) 70 %

Tier 2 Tier 2

EASY COMFORT ALCOHOL PADS PAD Tier 2

EASY TOUCH ALCOHOL PREP MEDIUM PAD

(ALCOHOL PREP) 70 %

Tier 2 Tier 2

EQL ALCOHOL SWABS PAD 70 % Tier 2

FIFTY50 ALCOHOL PREP PAD (ALCOHOL PREP) 70

Tier 2 Tier 2

GLOBAL ALCOHOL PREP EASE PAD 70 % Tier 2

GNP ALCOHOL SWABS PAD 70 % Tier 2

H-E-B INCONTROL ALCOHOL PAD Tier 2

HM STERILE ALCOHOL PREP PAD Tier 2

MEIJER ALCOHOL SWABS PAD 70 % Tier 2

PHARMACIST CHOICE ALCOHOL PAD (ALCOHOL

PREP)

Tier 2 Tier 2

PRO COMFORT ALCOHOL PAD 70 % Tier 2

PURE COMFORT ALCOHOL PREP PAD Tier 2

QC ALCOHOL SWABS PAD 70 % Tier 2

RA ALCOHOL SWABS PAD 70 % Tier 2

REALITY SWABS PAD Tier 2

RELION ALCOHOL SWABS PAD (ALCOHOL PREP) Tier 2 Tier 2

SAPS CARE ALCOHOL PREP PAD 70 % Tier 2

SAPS HEALTH ALCOHOL PREP PAD Tier 2

SAPS HEALTH CARE ALCOHOL PREP PAD 70 % Tier 2

SB ALCOHOL PREP PAD 70 % Tier 2

SM ALCOHOL PREP PAD Tier 2

SURE COMFORT ALCOHOL PREP PAD 70 % Tier 2

TRUE COMFORT ALCOHOL PREP PADS PAD 70 % Tier 2

TRUE COMFORT PRO ALCOHOL PREP PAD 70 % Tier 2

ULTICARE ALCOHOL SWABS PAD (ALCOHOL

PREP)

Tier 2 Tier 2

ULTILET ALCOHOL SWABS PAD Tier 2

ULTRA-CARE ALCOHOL PREP PADS PAD 70 % Tier 2

WEBCOL ALCOHOL PREP LARGE PAD (ALCOHOL

PREP) 70 %

Tier 2 Tier 2

WEBCOL ALCOHOL PREP MEDIUM PAD

(ALCOHOL PREP) 70 %

Tier 2 Tier 2

ZEVRX STERILE ALCOHOL PREP PAD PAD 70 % Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

*Cervical Caps***

FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM Tier 1

*Condoms - Female***

FC2 FEMALE CONDOM Tier 1

*Condoms - Male***

AIMSCO LUBRICATED Tier 1

CONDOMS Tier 1

DUREX EXTRA SENSITIVE THIN (PREMIUM

CONDOMS LUBRICATED)

Tier 1 Tier 1

DUREX EXTRA SENSITIVE THIN DEVICE

(PREMIUM CONDOMS LUBRICATED)

Tier 1 Tier 1

DUREX REALFEEL DEVICE Tier 1

DUREX TROPICAL (PREMIUM CONDOMS

LUBRICATED)

Tier 1 Tier 1

FANTASY LUBRICATED (PREMIUM CONDOMS

LUBRICATED)

Tier 1 Tier 1

FANTASY LUBRICATED/SPERMICIDE (PREMIUM

CONDOMS LUBRICATED)

Tier 1 Tier 1

KAMELEON LUBRICATED (PREMIUM CONDOMS

LUBRICATED)

Tier 1 Tier 1

KIMONO Tier 1

KIMONO COLORS DEVICE (PREMIUM CONDOMS

LUBRICATED)

Tier 1 Tier 1

KIMONO MAXX-LARGE FLARE (PREMIUM

CONDOMS LUBRICATED)

Tier 1 Tier 1

KIMONO MICRO THIN PLUS Tier 1

KIMONO PLUS Tier 1

KIMONO PS Tier 1

KIMONO PS PLUS Tier 1

KIMONO SENSATION Tier 1

KIMONO SENSATION PLUS Tier 1

KIMONO SPECIAL DEVICE (PREMIUM CONDOMS

LUBRICATED)

Tier 1 Tier 1

K-Y ME & YOU EXTRA LUBRICATED DEVICE

(PREMIUM CONDOMS LUBRICATED)

Tier 1 Tier 1

K-Y ME & YOU INTENSE DEVICE (PREMIUM

CONDOMS LUBRICATED)

Tier 1 Tier 1

MAXX Tier 1

MAXX PLUS Tier 1

REALITY LATEX CONDOMS (PREMIUM

CONDOMS LUBRICATED)

Tier 1 Tier 1

REALITY LATEX/ULTRA TEXTURED DEVICE

(PREMIUM CONDOMS LUBRICATED)

Tier 1 Tier 1

REALITY LATEX/ULTRA THIN DEVICE

(PREMIUM CONDOMS LUBRICATED)

Tier 1 Tier 1

TRUE COVER DEVICE Tier 1

TRUSTEX COLOR CONDOMS + LUBE (PREMIUM

CONDOMS LUBRICATED)

Tier 1 Tier 1

Drug Name Brand Tier Generic Tier Formulary Notes

TRUSTEX LUB/RIBBED/STUDDED (PREMIUM

CONDOMS LUBRICATED)

Tier 1 Tier 1

TRUSTEX LUB/SPERMICIDE EX ST (PREMIUM

CONDOMS LUBRICATED)

Tier 1 Tier 1

TRUSTEX LUB/SPERMICIDE XL (PREMIUM

CONDOMS LUBRICATED)

Tier 1 Tier 1

TRUSTEX LUBRICATED (PREMIUM CONDOMS

LUBRICATED)

Tier 1 Tier 1

TRUSTEX LUBRICATED EX LARGE (PREMIUM

CONDOMS LUBRICATED)

Tier 1 Tier 1

TRUSTEX LUBRICATED EXTRA ST (PREMIUM

CONDOMS LUBRICATED)

Tier 1 Tier 1

TRUSTEX LUBRICATED/SPERMICIDE (PREMIUM

CONDOMS LUBRICATED)

Tier 1 Tier 1

TRUSTEX NATURAL CONDOMS + LUBE

(PREMIUM CONDOMS LUBRICATED)

Tier 1 Tier 1

TRUSTEX NON-LUBRICATED (KIMONO MICRO

THIN)

Tier 1 Tier 1

TRUSTEX RIA LUB/SPERMICIDE (PREMIUM

CONDOMS LUBRICATED)

Tier 1 Tier 1

TRUSTEX RIA LUBRICATED (PREMIUM

CONDOMS LUBRICATED)

Tier 1 Tier 1

TRUSTEX RIA NON-LUBRICATED (KIMONO

MICRO THIN)

Tier 1 Tier 1

TRUSTEX-NONOXYNOL-9/RIB/STUD (PREMIUM

CONDOMS LUBRICATED)

Tier 1 Tier 1

*Diaphragms***

CAYA VAGINAL DIAPHRAGM Tier 1

OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM Tier 1

WIDE-SEAL DIAPHRAGM 60 VAGINAL

DIAPHRAGM 2 %

Tier 1

WIDE-SEAL DIAPHRAGM 65 VAGINAL

DIAPHRAGM 2 %

Tier 1

WIDE-SEAL DIAPHRAGM 70 VAGINAL

DIAPHRAGM 2 %

Tier 1

WIDE-SEAL DIAPHRAGM 75 VAGINAL

DIAPHRAGM 2 %

Tier 1

WIDE-SEAL DIAPHRAGM 80 VAGINAL

DIAPHRAGM 2 %

Tier 1

WIDE-SEAL DIAPHRAGM 85 VAGINAL

DIAPHRAGM 2 %

Tier 1

WIDE-SEAL DIAPHRAGM 90 VAGINAL

DIAPHRAGM 2 %

Tier 1

WIDE-SEAL DIAPHRAGM 95 VAGINAL

DIAPHRAGM 2 %

Tier 1

*Glucose Monitoring Test Supplies***

1ST TIER UNILET COMFORTOUCH Tier 2

ACCU-CHEK AVIVA PLUS KIT W/DEVICE Tier 2

ACCU-CHEK FASTCLIX LANCET KIT (SELECT-

LITE DEVICE/LANCETS)

Tier 2 Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

ACCU-CHEK FASTCLIX LANCETS (LANCETS) Tier 2 Tier 2

ACCU-CHEK GUIDE KIT W/DEVICE Tier 2

ACCU-CHEK GUIDE ME KIT W/DEVICE Tier 2

ACCU-CHEK SAFE-T PRO LANCETS (LANCETS) Tier 2 Tier 2

ACCU-CHEK SOFTCLIX LANCET DEV KIT

(SELECT-LITE DEVICE/LANCETS)

Tier 2 Tier 2

ACCU-CHEK SOFTCLIX LANCETS (LANCETS) Tier 2 Tier 2

ACTI-LANCE 28G Tier 2

ACTI-LANCE LITE LANCETS 28G Tier 2

ACTI-LANCE SPECIAL LANCETS 17G Tier 2

ACTI-LANCE UNIVERSAL 23G Tier 2

ADJUSTABLE LANCING DEVICE Tier 2

ADVANCED MOBILE LANCET Tier 2

ADVOCATE LANCETS (LANCETS) Tier 2 Tier 2

ADVOCATE LANCETS 30G (LANCETS) Tier 2 Tier 2

ADVOCATE LANCING DEVICE (LANCET DEVICE) Tier 2 Tier 2

ADVOCATE RAPID-SAFE LANCING (LANCET

DEVICE)

Tier 2 Tier 2

ADVOCATE SAFETY LANCETS (LANCETS) Tier 2 Tier 2

ADVOCATE SAFETY LANCETS 26G (LANCETS) Tier 2 Tier 2

AGAMATRIX ULTRA-THIN LANCETS (LANCETS) Tier 2 Tier 2

AIMSCO TWIST LANCETS 32G Tier 2

AIMSCO TWIST LANCETS 33G (LANCETS) Tier 2 Tier 2

AQUALANCE LANCETS 30G (LANCETS) Tier 2 Tier 2

ASSURE COMFORT LANCETS 28G Tier 2

ASSURE LANCE LANCETS (LANCETS) Tier 2 Tier 2

ASSURE LANCE LANCETS 21G (LANCETS) Tier 2 Tier 2

ASSURE LANCE PLUS SAFETY 25G (LANCETS) Tier 2 Tier 2

ASSURE LANCE PLUS SAFETY 30G (LANCETS) Tier 2 Tier 2

ASSURE LANCE SAFETY LANCET 28G (LANCETS) Tier 2 Tier 2

AURORA LANCET SUPER THIN 30G Tier 2

AURORA LANCET THIN 23G Tier 2

AUTO-LANCET (LANCET DEVICE) Tier 2 Tier 2

AUTO-LANCET MINI (LANCET DEVICE) Tier 2 Tier 2

AUTOLET II CLINISAFE KIT (SELECT-LITE

DEVICE/LANCETS)

Tier 2 Tier 2

AUTOLET LANCING DEVICE (LANCET DEVICE) Tier 2 Tier 2

AUTOLET LITE CLINISAFE KIT (SELECT-LITE

DEVICE/LANCETS)

Tier 2 Tier 2

AUTOLET LITE STARTER PACK KIT (SELECT-

LITE DEVICE/LANCETS)

Tier 2 Tier 2

AUTOLET MINI (LANCET DEVICE) Tier 2 Tier 2

AUTOLET PLATFORMS (LANCET TRANSPORTER

CASE)

Tier 2 Tier 2

AUTOLET PLUS (LANCET DEVICE) Tier 2 Tier 2

BD MICROTAINER LANCETS (OTC) (LANCETS) Tier 2 Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

BD MICROTAINER LANCETS (RX) (LANCETS) Tier 1 Tier 2

CARDIOCOM LANCING DEVICE (LANCET

DEVICE)

Tier 2 Tier 2

CAREONE ADVANCED LANCING DEV Tier 2

CAREONE LANCET SUPER THIN 30G (LANCETS) Tier 2 Tier 2

CAREONE LANCET THIN 23G Tier 2

CARESENS LANCETS (LANCETS) Tier 2 Tier 2

CARESENS LANCETS 30G (LANCETS) Tier 2 Tier 2

CARETOUCH LANCING/EJECTOR (LANCET

DEVICE)

Tier 2 Tier 2

CARETOUCH SAFETY LANCETS (LANCETS) Tier 2 Tier 2

CARETOUCH SAFETY LANCETS 26G (LANCETS) Tier 2 Tier 2

CARETOUCH TWIST LANCETS 28G (LANCETS) Tier 2 Tier 2

CARETOUCH TWIST LANCETS 30G (LANCETS) Tier 2 Tier 2

CARETOUCH TWIST LANCETS 33G (LANCETS) Tier 2 Tier 2

CARETOUCH TWIST MC LANCETS 30G

(LANCETS)

Tier 2 Tier 2

CHOSEN LANCETS 30G (LANCETS) Tier 2 Tier 2

CHOSEN LANCING DEVICE (LANCET DEVICE) Tier 2 Tier 2

CHOSEN SAFETY LANCETS 28G (LANCETS) Tier 2 Tier 2

CLEANLET LANCETS 28G (LANCETS) Tier 2 Tier 2

CLEVER CHEK LANCETS (LANCETS) Tier 2 Tier 2

CLEVER CHOICE COMFORT EZ (LANCETS) Tier 2 Tier 2

CLEVER CHOICE LANCETS 21G (LANCETS) Tier 2 Tier 2

CLEVER CHOICE LANCETS 23G (LANCETS) Tier 2 Tier 2

CLEVER CHOICE LANCETS 28G (LANCETS) Tier 2 Tier 2

COAGUCHEK LANCETS (LANCETS) Tier 2 Tier 2

COMFORT ASSURED LANCETS 28G Tier 2

COMFORT ASSURED LANCETS 33G Tier 2

COMFORT LANCETS Tier 2

COMFORT TOUCH LANCETS 31G (LANCETS) Tier 2 Tier 2

COMFORT TOUCH PLUS LANCETS 28G

(LANCETS)

Tier 2 Tier 2

COMFORT TOUCH PLUS LANCETS 30G

(LANCETS)

Tier 2 Tier 2

COMFORT TOUCH TWIST LANCET 30G

(LANCETS)

Tier 2 Tier 2

CONTOUR MONITOR DEVICE Tier 2

CONTOUR NEXT LINK KIT W/DEVICE Tier 2

CONTOUR NEXT MONITOR KIT W/DEVICE Tier 2

CONTOUR NEXT ONE KIT Tier 2

CVS LANCETS 21G Tier 2

CVS LANCETS MICRO THIN 33G Tier 2

CVS LANCETS ORIGINAL Tier 2

CVS LANCETS THIN 26G Tier 2

CVS LANCETS ULTRA THIN 30G Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

CVS LANCETS ULTRA-THIN 30G Tier 2

CVS LANCING DEVICE Tier 2

CVS ULTRA THIN LANCETS Tier 2

DEXCOM G6 RECEIVER DEVICE Tier 3 PA

DEXCOM G6 SENSOR Tier 3 PA

DEXCOM G6 TRANSMITTER Tier 3 PA

DEXCOM G7 RECEIVER DEVICE Tier 3 PA

DEXCOM G7 SENSOR Tier 3 PA

DIATHRIVE LANCET ULTRA THIN 30 (LANCETS) Tier 2 Tier 2

DIATHRIVE LANCETS (LANCETS) Tier 2 Tier 2

DIATHRIVE LANCING DEVICE (LANCET DEVICE) Tier 2 Tier 2

DIATHRIVE+ GLUCOSE MONITOR DEVICE Tier 2

DROPLET GENTEEL LANCING DEVICE (LANCET

DEVICE)

Tier 2 Tier 2

DROPLET LANCETS ULTRA THIN 30G (LANCETS) Tier 2 Tier 2

DROPLET LANCING DEVICE (LANCET DEVICE) Tier 2 Tier 2

DROPLET PERSONAL LANCETS 30G (LANCETS) Tier 2 Tier 2

DRUG MART LANCETS THIN 26G Tier 2

DRUG MART LANCING DEVICE (LANCET DEVICE) Tier 2 Tier 2

DRUG MART ON-THE-GO LANCET 30G (LANCETS) Tier 2 Tier 2

DRUG MART UNILET LANCETS 28G (LANCETS) Tier 2 Tier 2

DRUG MART UNILET LANCETS 30G (LANCETS) Tier 2 Tier 2

DRUG MART UNILET LANCETS 33G (LANCETS) Tier 2 Tier 2

EASY COMFORT LANCETS Tier 2

EASY COMFORT LANCETS TWIST TOP Tier 2

EASY MINI EJECT LANCING DEVICE Tier 2

EASY MINI LANCING DEVICE Tier 2

EASY TOUCH LANCETS 21G (LANCETS) Tier 2 Tier 2

EASY TOUCH LANCETS 23G (LANCETS) Tier 2 Tier 2

EASY TOUCH LANCETS 26G (LANCETS) Tier 2 Tier 2

EASY TOUCH LANCETS 28G (LANCETS) Tier 2 Tier 2

EASY TOUCH LANCETS 28G/TWIST (LANCETS) Tier 2 Tier 2

EASY TOUCH LANCETS 30G (LANCETS) Tier 2 Tier 2

EASY TOUCH LANCETS 30G/TWIST (LANCETS) Tier 2 Tier 2

EASY TOUCH LANCETS 32G (LANCETS) Tier 2 Tier 2

EASY TOUCH LANCETS 32G/TWIST (LANCETS) Tier 2 Tier 2

EASY TOUCH LANCETS 33G/TWIST (LANCETS) Tier 2 Tier 2

EASY TOUCH LANCING DEVICE (LANCET

DEVICE)

Tier 2 Tier 2

EASY TOUCH SAFETY LANCETS 21G (LANCETS) Tier 2 Tier 2

EASY TOUCH SAFETY LANCETS 23G (LANCETS) Tier 2 Tier 2

EASY TOUCH SAFETY LANCETS 26G (LANCETS) Tier 2 Tier 2

EASY TOUCH SAFETY LANCETS 28G (LANCETS) Tier 2 Tier 2

EMBRACE LANCETS ULTRA THIN 30G (LANCETS) Tier 2 Tier 2

EMBRACE LANCING DEVICE/EJECTOR Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

EMBRACE PRESSURE ACTIVATED 21G

(LANCETS)

Tier 2 Tier 2

EMBRACE PRESSURE ACTIVATED 28G

(LANCETS)

Tier 2 Tier 2

EQL COLOR LANCETS 21G Tier 2

EQL COLOR LANCETS MICRO 33G Tier 2

EQL SUPER THIN LANCETS 30G Tier 2

EQL THIN LANCETS 26G Tier 2

E-Z JECT LANCET MICRO-THIN 33G (LANCETS) Tier 2 Tier 2

E-Z JECT LANCET SUPER THIN 30G (LANCETS) Tier 2 Tier 2

E-Z JECT LANCETS (LANCETS) Tier 2 Tier 2

E-Z JECT LANCETS 21G (LANCETS) Tier 2 Tier 2

E-Z JECT LANCETS THIN 26G (LANCETS) Tier 2 Tier 2

EZ-LETS LANCETS 21G (LANCETS) Tier 2 Tier 2

EZ-LETS LANCETS 26G (LANCETS) Tier 2 Tier 2

EZ-LETS LANCETS 28G (LANCETS) Tier 2 Tier 2

EZ-LETS LANCETS 30G (LANCETS) Tier 2 Tier 2

FIFTY50 SAFETY SEAL LANCETS (LANCETS) Tier 2 Tier 2

FIFTY50 UNILET LANCETS 33G (LANCETS) Tier 2 Tier 2

FINE 30 (LANCETS) Tier 2 Tier 2

FINGERSTIX LANCETS (LANCETS) Tier 2 Tier 2

FORA LANCETS (LANCETS) Tier 2 Tier 2

FORA LANCING DEVICE (LANCET DEVICE) Tier 2 Tier 2

FREDS PHARMACY AUTOLET LANCING Tier 2

FREDS PHARMACY UNILET LANC 28G Tier 2

FREDS PHARMACY UNILET LANC 30G Tier 2

FREESTYLE LANCETS (LANCETS) Tier 2 Tier 2

FREESTYLE LIBRE 14 DAY READER DEVICE Tier 3 PA

FREESTYLE LIBRE 14 DAY SENSOR Tier 3 PA

FREESTYLE LIBRE 2 READER DEVICE Tier 3 PA

FREESTYLE LIBRE 2 SENSOR Tier 3 PA

FREESTYLE LIBRE 3 READER DEVICE Tier 3 PA

FREESTYLE LIBRE 3 SENSOR Tier 3 PA

FREESTYLE LIBRE READER DEVICE Tier 3 PA

FREESTYLE UNISTICK II LANCETS (LANCETS) Tier 2 Tier 2

GENTEEL BUTTERFLY TOUCH LANCET

(LANCETS)

Tier 2 Tier 2

GENTEEL CONTACT TIPS (BLUE) (LANCET

TRANSPORTER CASE)

Tier 2 Tier 2

GENTEEL CONTACT TIPS (CLEAR) (LANCET

TRANSPORTER CASE)

Tier 2 Tier 2

GENTEEL CONTACT TIPS (GREEN) (LANCET

TRANSPORTER CASE)

Tier 2 Tier 2

GENTEEL CONTACT TIPS (ORANGE) (LANCET

TRANSPORTER CASE)

Tier 2 Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

GENTEEL CONTACT TIPS (RAINBOW) (LANCET

TRANSPORTER CASE)

Tier 2 Tier 2

GENTEEL CONTACT TIPS (VIOLET) (LANCET

TRANSPORTER CASE)

Tier 2 Tier 2

GENTEEL CONTACT TIPS (YELLOW) (LANCET

TRANSPORTER CASE)

Tier 2 Tier 2

GENTEEL LANCING KIT (BLUE) KIT (SELECT-

LITE DEVICE/LANCETS)

Tier 2 Tier 2

GENTEEL NOZZLES (LANCET TRANSPORTER

CASE)

Tier 2 Tier 2

GENTEEL PLUS LANCING (BLACK) (LANCET

DEVICE)

Tier 2 Tier 2

GENTEEL PLUS LANCING (PURPLE) (LANCET

DEVICE)

Tier 2 Tier 2

GENTEEL PLUS LANCING (WHITE) (LANCET

DEVICE)

Tier 2 Tier 2

GENTEEL PLUS LANCING DEV(BLUE) (LANCET

DEVICE)

Tier 2 Tier 2

GENTEEL PLUS LANCING DEV(PINK) (LANCET

DEVICE)

Tier 2 Tier 2

GENTLE-LET GP LANCETS (LANCETS) Tier 2 Tier 2

GENTLE-LET LANCETS (LANCETS) Tier 2 Tier 2

GENTLE-LET PLATFORMS (LANCET

TRANSPORTER CASE)

Tier 2 Tier 2

GLOBAL INJECT EASE LANCETS 28G Tier 2

GLOBAL INJECT EASE LANCETS 30G Tier 2

GLOBAL LANCING DEVICE Tier 2

GLUCOCOM LANCETS 28G (LANCETS) Tier 2 Tier 2

GLUCOCOM LANCETS 30G (LANCETS) Tier 2 Tier 2

GLUCOCOM LANCETS 33G (LANCETS) Tier 2 Tier 2

GNP LANCETS 21G Tier 2

GNP LANCETS THIN 26G Tier 2

GNP LANCING SYSTEM DEVICE (LANCET

DEVICE)

Tier 2 Tier 2

GNP STERILE LANCETS 28G Tier 2

GNP STERILE LANCETS 30G Tier 2

GNP STERILE LANCETS 33G Tier 2

GOJJI LANCING DEVICE/CLEAR CAP (LANCET

DEVICE)

Tier 2 Tier 2

GOJJI STERILE LANCETS (LANCETS) Tier 2 Tier 2

GOODSENSE COLOR LANCETS 33G Tier 2

GOODSENSE LANCETS 26G UNIV Tier 2

GOODSENSE LANCETS 30G Tier 2

GOODSENSE LANCETS 30G UNIV Tier 2

GOODSENSE LANCETS 33G Tier 2

GOODSENSE LANCETS 33G UNIV Tier 2

GOODSENSE LANCING DEVICE Tier 2

HAEMOLANCE (LANCETS) Tier 2 Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

HAEMOLANCE LOW FLOW LANCETS (LANCETS) Tier 2 Tier 2

HAEMOLANCE PLUS (LANCETS) Tier 2 Tier 2

HAEMOLANCE PLUS HIGH FLOW (LANCETS) Tier 2 Tier 2

HAEMOLANCE PLUS LOW FLOW (LANCETS) Tier 2 Tier 2

HAEMOLANCE PLUS MAX FLOW (LANCETS) Tier 2 Tier 2

HAEMOLANCE PLUS PEDIATRIC FLOW

(LANCETS)

Tier 2 Tier 2

HEALTH CARE LANCING DEVICE (LANCET

DEVICE)

Tier 2 Tier 2

HEALTHY ACCENTS LANCING DEVICE Tier 2

HEALTHY ACCENTS UNILET LANCETS Tier 2

H-E-B INCONTROL ADV LANCING Tier 2

H-E-B INCONTROL LANCETS 28G Tier 2

H-E-B INCONTROL LANCETS 30G Tier 2

H-E-B INCONTROL LANCETS 33G Tier 2

HYPOLANCE AST LANCING KIT (SELECT-LITE

DEVICE/LANCETS)

Tier 2 Tier 2

HY-VEE LANCETS (LANCETS) Tier 2 Tier 2

HY-VEE THIN LANCETS Tier 2

IN TOUCH LANCING DEVICE (LANCET DEVICE) Tier 2 Tier 2

IN TOUCH STERILE LANCETS 30G (LANCETS) Tier 2 Tier 2

KINNEY LANCETS Tier 2

KINNEY THIN LANCETS Tier 2

KROGER AUTOLET LANCING DEVICE (LANCET

DEVICE)

Tier 2 Tier 2

KROGER HEALTHPRO LANCET 26G (LANCETS) Tier 2 Tier 2

KROGER LANCETS Tier 2

KROGER LANCETS 21G Tier 2

KROGER LANCETS MICRO THIN 33G Tier 2

KROGER LANCETS SUPER THIN Tier 2

KROGER LANCETS THIN Tier 2

KROGER LANCETS THIN 26G Tier 2

KROGER LANCETS ULTRATHIN 30G Tier 2

KROGER LANCING DEVICE Tier 2

LANCET DEVICE WITH EJECTOR Tier 2

LANCETS 30G Tier 2

LANCETS 33G Tier 2

LANCETS MICRO THIN 33G Tier 2

LANCETS SUPER THIN 28G Tier 2

LANCETS THIN Tier 2

LANCETS ULTRA THIN (LANCETS) Tier 2 Tier 2

LANCETS ULTRA THIN 30G Tier 2

LANCING DEVICE Tier 2

LANZO (LANCET DEVICE) Tier 2 Tier 2

LEADER ADVANCED LANCING DEVICE Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

LIBERTY MEDICAL LANCETS (LANCETS) Tier 2 Tier 2

LIBERTY MINI LANCING DEVICE (LANCET

DEVICE)

Tier 2 Tier 2

LITE TOUCH LANCETS Tier 2

LITE TOUCH LANCING PEN (LANCET DEVICE) Tier 2 Tier 2

LITETOUCH LANCETS (LANCETS) Tier 2 Tier 2

LIVE BETTER ADV LANCING DEVICE Tier 2

LIVE BETTER LANCET SUPER THIN Tier 2

LIVE BETTER LANCET ULTRA THIN Tier 2

LONGS LANCETS STANDARD Tier 2

LONGS LANCETS THIN Tier 2

LONGS LANCETS ULTRA THIN Tier 2

MEDICHOICE SAFETY LANCET Tier 2

MEDICHOICE SAFETY LANCET EXTRA Tier 2

MEDICHOICE SAFETY LANCET NORM Tier 2

MEDLANCE EXTRA 21G (LANCETS) Tier 2 Tier 2

MEDLANCE LITE 25G (LANCETS) Tier 2 Tier 2

MEDLANCE PLUS EXTRA 21G (LANCETS) Tier 2 Tier 2

MEDLANCE PLUS LANCETS (LANCETS) Tier 2 Tier 2

MEDLANCE PLUS LITE 25G (LANCETS) Tier 2 Tier 2

MEDLANCE PLUS SPECIAL 0.8MM (LANCETS) Tier 2 Tier 2

MEDLANCE PLUS SUPERLITE 30G (LANCETS) Tier 2 Tier 2

MEDLANCE PLUS UNIVERSAL 21G (LANCETS) Tier 2 Tier 2

MEDLANCE UNIVERSAL 21G (LANCETS) Tier 2 Tier 2

MEIJER LANCETS (LANCETS) Tier 2 Tier 2

MEIJER LANCETS THIN (LANCETS) Tier 2 Tier 2

MEIJER LANCETS UNIVERSAL 21G (LANCETS) Tier 2 Tier 2

MEIJER LANCETS UNIVERSAL 30G (LANCETS) Tier 2 Tier 2

MEIJER LANCETS UNIVERSAL 33G (LANCETS) Tier 2 Tier 2

MEIJER SUPER THIN LANCETS (LANCETS) Tier 2 Tier 2

MICROLET LANCETS (LANCETS) Tier 2 Tier 2

MICROLET NEXT LANCING DEVICE (LANCET

DEVICE)

Tier 2 Tier 2

MINI LANCING DEVICE Tier 2

MM LANCING DEVICE (LANCET DEVICE) Tier 2 Tier 2

MM TWIST LANCETS (LANCETS) Tier 2 Tier 2

MONOLET LANCETS (LANCETS) Tier 2 Tier 2

MONOLET OPD LANCETS (LANCETS) Tier 2 Tier 2

MONOLETTOR SAFETY LANCETS (LANCETS) Tier 2 Tier 2

MPD SAFETY LANCET 21G Tier 2

MPD SAFETY LANCET 23G Tier 2

MPD SAFETY LANCET 28G Tier 2

MPD SAFETY LANCET 30G Tier 2

MULTI-LANCET DEVICE Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

MULTI-LANCET DEVICE 2 KIT (SELECT-LITE

DEVICE/LANCETS)

Tier 2 Tier 2

MYGLUCOHEALTH LANCETS 30G (LANCETS) Tier 2 Tier 2

NOVA SAFETY LANCETS 23G (LANCETS) Tier 2 Tier 2

NOVA SAFETY LANCETS 28G (LANCETS) Tier 2 Tier 2

NOVA SUREFLEX LANCETS (LANCETS) Tier 2 Tier 2

NOVA SUREFLEX LANCING DEVICE (LANCET

DEVICE)

Tier 2 Tier 2

ONETOUCH DELICA LANCETS 30G (LANCETS) Tier 2 Tier 2

ONETOUCH DELICA LANCETS 33G (LANCETS) Tier 2 Tier 2

ONETOUCH DELICA LANCING DEV (LANCET

DEVICE)

Tier 2 Tier 2

ONETOUCH DELICA PLUS LANCET30G

(LANCETS)

Tier 2 Tier 2

ONETOUCH DELICA PLUS LANCET33G

(LANCETS)

Tier 2 Tier 2

ONETOUCH DELICA PLUS LANCING (LANCET

DEVICE)

Tier 2 Tier 2

ONETOUCH DELICA SAFETY LANCING

(LANCETS)

Tier 2 Tier 2

ONETOUCH FINEPOINT LANCETS (LANCETS) Tier 2 Tier 2

ONETOUCH ULTRA 2 KIT W/DEVICE Tier 2

ONETOUCH ULTRASOFT 2 LANCETS (LANCETS) Tier 2 Tier 2

ONETOUCH ULTRASOFT LANCETS (LANCETS) Tier 2 Tier 2

ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE Tier 2

ONETOUCH VERIO IQ SYSTEM KIT W/DEVICE Tier 2

ONETOUCH VERIO KIT W/DEVICE Tier 2

ONETOUCH VERIO REFLECT KIT W/DEVICE Tier 2

PC LANCETS SUPER THIN 30G Tier 2

PERFECT LANCETS 28G (LANCETS) Tier 2 Tier 2

PERFECT LANCETS 30G (LANCETS) Tier 2 Tier 2

PHARMACIST CHOICE LANCETS (LANCETS) Tier 2 Tier 2

PHARMACY COUNTER LANCETS (LANCETS) Tier 2 Tier 2

PIP LANCETS 28G Tier 2

PIP LANCETS 30G Tier 2

POGO AUTOMATIC BLOOD GLUCOSE DEVICE Tier 1

PRECISION THINS GP LANCETS (LANCETS) Tier 2 Tier 2

PREFERRED PLUS LANCETS COLORED Tier 2

PREFERRED PLUS LANCETS THIN Tier 2

PRO COMFORT LANCETS 30G Tier 2

PRO COMFORT LANCETS 31G Tier 2

PRO COMFORT SAFETY LANCETS 30G Tier 2

PRODIGY LANCETS 28G (LANCETS) Tier 2 Tier 2

PRODIGY LANCING DEVICE (LANCET DEVICE) Tier 2 Tier 2

PRODIGY SAFETY LANCETS 26G (LANCETS) Tier 2 Tier 2

PRODIGY TWIST TOP LANCETS 28G (LANCETS) Tier 2 Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

PSS SELECT GP LANCETS (LANCETS) Tier 2 Tier 2

PSS SELECT PLATFORMS (LANCET

TRANSPORTER CASE)

Tier 2 Tier 2

PSS SELECT SAFETY LANCETS (LANCETS) Tier 2 Tier 2

PURE COMFORT LANCETS 30G Tier 2

PX ADVANCED LANCING DEVICE Tier 2

PX LANCET AUTO INJECTOR Tier 2

PX LANCETS MICROTHIN 33G Tier 2

PX LANCETS ULTRA THIN Tier 2

PX LANCETS ULTRA THIN 28G Tier 2

QC ADVANCED LANCING DEVICE Tier 2

QC LANCETS SUPER THIN 30G Tier 2

QC LANCETS ULTRA THIN Tier 2

QC UNILET LANCETS 28G Tier 2

QC UNILET LANCETS MICRO THIN Tier 2

RA E-ZJECT LANCETS 28G (LANCETS) Tier 2 Tier 2

RA E-ZJECT LANCETS THIN 26G (LANCETS) Tier 2 Tier 2

RA E-ZJECT LANCETS THIN 28G (LANCETS) Tier 2 Tier 2

RA E-ZJECT LANCETS ULTRA THIN (LANCETS) Tier 2 Tier 2

READYLANCE SAFETY LANCETS (LANCETS) Tier 2 Tier 2

REALITY LANCETS Tier 2

REALITY TRIGGER LANCETS Tier 2

RELION LANCET DEVICES 30G (LANCETS) Tier 2 Tier 2

RELION LANCETS (LANCETS) Tier 2 Tier 2

RELION LANCETS MICRO-THIN 33G (LANCETS) Tier 2 Tier 2

RELION LANCETS THIN 26G (LANCETS) Tier 2 Tier 2

RELION LANCETS ULTRA-THIN 30G (LANCETS) Tier 2 Tier 2

RELION LANCING DEVICE (LANCET DEVICE) Tier 2 Tier 2

RELION LANCING DEVICE KIT (SELECT-LITE

DEVICE/LANCETS)

Tier 2 Tier 2

RELION ULTRA THIN LANCETS 30G (LANCETS) Tier 2 Tier 2

RELION ULTRA THIN PLUS LANCETS (LANCETS) Tier 2 Tier 2

REXALL LANCETS ULTRA THIN 30G (LANCETS) Tier 2 Tier 2

RIGHTEST ALTERNATE SITE ADAPT (LANCET

TRANSPORTER CASE)

Tier 2 Tier 2

RIGHTEST GD500 LANCING DEVICE (LANCET

DEVICE)

Tier 2 Tier 2

RIGHTEST GL300 LANCETS (LANCETS) Tier 2 Tier 2

SAFE-T-LANCE (LANCETS) Tier 2 Tier 2

SAFE-T-LANCE PLUS (LANCETS) Tier 2 Tier 2

SAFETY LANCET 30G/PRESSURE ACT Tier 2

SAFETY LANCETS (LANCETS) Tier 2 Tier 2

SAFETY LANCETS 21G (LANCETS) Tier 2 Tier 2

SAFETY LANCETS 23G (LANCETS) Tier 2 Tier 2

SAFETY LANCETS 28G Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

SAPS HEALTH PLUS LANCETS Tier 2

SAPS HEALTH TWIST TOP LANCETS Tier 2

SAPS TWIST TOP LANCETS Tier 2

SAPSCARE TWIST TOP LANCETS Tier 2

SB LANCETS THIN Tier 2

SB LANCETS ULTRA THIN Tier 2

SELECT-LITE LANCING DEVICE Tier 2

SHOPKO AUTOLET LANCING DEVICE (LANCET

DEVICE)

Tier 2 Tier 2

SHOPKO ON-THE-GO LANCETS 30G (LANCETS) Tier 2 Tier 2

SHOPKO UNILET LANCETS 28G (LANCETS) Tier 2 Tier 2

SHOPKO UNILET LANCETS 30G (LANCETS) Tier 2 Tier 2

SIMPLE DIAGNOSTICS LANCING DEV (LANCET

DEVICE)

Tier 2 Tier 2

SINGLE-LET (LANCETS) Tier 2 Tier 2

SM LANCETS 33G Tier 2

SM TRUEDRAW LANCING DEVICE (LANCET

DEVICE)

Tier 2 Tier 2

SMART DIABETES VANTAGE LANCING (LANCET

DEVICE)

Tier 2 Tier 2

SMART SENSE COLOR LANCETS 33G (LANCETS) Tier 2 Tier 2

SMART SENSE STANDARD LANCETS (LANCETS) Tier 2 Tier 2

SMART SENSE SUPER THIN LANCETS (LANCETS) Tier 2 Tier 2

SMART SENSE THIN LANCETS 26G (LANCETS) Tier 2 Tier 2

SMARTEST LANCETS 28G (LANCETS) Tier 2 Tier 2

SOLUS V2 LANCETS 28G (LANCETS) Tier 2 Tier 2

SOLUS V2 LANCING DEVICE (LANCET DEVICE) Tier 2 Tier 2

SOLUS V2 TWIST LANCETS 30G (LANCETS) Tier 2 Tier 2

STERILANCE TL (LANCETS) Tier 2 Tier 2

SUPER THIN LANCETS Tier 2

SURE COMFORT LANCETS 18G Tier 2

SURE COMFORT LANCETS 21G Tier 2

SURE COMFORT LANCETS 23G Tier 2

SURE COMFORT LANCETS 28G Tier 2

SURE COMFORT LANCETS 30G Tier 2

SURE COMFORT LANCING PEN Tier 2

SURELITE LANCETS (LANCETS) Tier 2 Tier 2

TECHLITE AST LANCETS (LANCETS) Tier 2 Tier 2

TECHLITE LANCETS (LANCETS) Tier 2 Tier 2

TECHLITE LANCETS 26G (LANCETS) Tier 2 Tier 2

TGT LANCET MICRO THIN 33G Tier 2

TGT LANCET THIN 26G Tier 2

TGT LANCET ULTRA THIN 30G Tier 2

TGT LANCING DEVICE Tier 2

THINLETS GP LANCETS (LANCETS) Tier 2 Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

TODAYS HEALTH LANCING DEVICE Tier 2

TODAYS HEALTH THIN LANCETS 28G Tier 2

TODAYS HEALTH THIN LANCETS 30G Tier 2

TOPCARE LANCETS MICRO-THIN 33G Tier 2

TRAVEL LANCETS Tier 2

TRAVEL LANCETS ADVANCED 28G (LANCETS) Tier 2 Tier 2

TRUE COMFORT SAFETY LANCETS Tier 2

TRUE COMFORT TWIST TOP LANCETS Tier 2

TRUEDRAW LANCING DEVICE (LANCET DEVICE) Tier 2 Tier 2

TRUEPLUS LANCETS 26G (LANCETS) Tier 2 Tier 2

TRUEPLUS LANCETS 28G (LANCETS) Tier 2 Tier 2

TRUEPLUS LANCETS 30G (LANCETS) Tier 2 Tier 2

TRUEPLUS LANCETS 33G (LANCETS) Tier 2 Tier 2

TRUEPLUS SAFETY LANCETS 28G (LANCETS) Tier 2 Tier 2

TWIST TOP LANCETS 30G Tier 2

ULTI-LANCE AUTOMATIC (LANCET DEVICE) Tier 2 Tier 2

ULTILET CLASSIC LANCETS (LANCETS) Tier 2 Tier 2

ULTILET LANCETS (LANCETS) Tier 2 Tier 2

ULTILET SAFETY LANCETS (LANCETS) Tier 2 Tier 2

ULTILET SAFETY LANCETS 23G (LANCETS) Tier 2 Tier 2

ULTRA THIN LANCETS 31G Tier 2

ULTRA-CARE LANCETS 30G Tier 2

ULTRA-THIN II AUTO LANCET (LANCETS) Tier 2 Tier 2

ULTRA-THIN II LANCETS (LANCETS) Tier 2 Tier 2

UNILET COMFORTOUCH LANCET (LANCETS) Tier 2 Tier 2

UNILET EXCELITE (LANCETS) Tier 2 Tier 2

UNILET EXCELITE II (LANCETS) Tier 2 Tier 2

UNILET G.P. LANCET (LANCETS) Tier 2 Tier 2

UNILET G.P. SUPERLITE LANCET (LANCETS) Tier 2 Tier 2

UNILET GP 28 ULTRA THIN (LANCETS) Tier 2 Tier 2

UNILET LANCET (LANCETS) Tier 2 Tier 2

UNILET MICRO-THIN 33G (LANCETS) Tier 2 Tier 2

UNILET SUPERLITE LANCET (LANCETS) Tier 2 Tier 2

UNILET SUPER-THIN 30G (LANCETS) Tier 2 Tier 2

UNILET ULTRA-THIN 28G (LANCETS) Tier 2 Tier 2

UNISTIK 1 (LANCET TRANSPORTER CASE) Tier 2 Tier 2

UNISTIK 2 (LANCET TRANSPORTER CASE) Tier 2 Tier 2

UNISTIK 2 COMFORT (LANCET TRANSPORTER

CASE)

Tier 2 Tier 2

UNISTIK 2 EXTRA (LANCET TRANSPORTER CASE) Tier 2 Tier 2

UNISTIK 2 NEONATAL (LANCET TRANSPORTER

CASE)

Tier 2 Tier 2

UNISTIK 2 NORMAL (LANCET TRANSPORTER

CASE)

Tier 2 Tier 2

UNISTIK 2 SUPER (LANCET TRANSPORTER CASE) Tier 2 Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

UNISTIK 3 (LANCET TRANSPORTER CASE) Tier 2 Tier 2

UNISTIK 3 COMFORT (LANCET TRANSPORTER

CASE)

Tier 2 Tier 2

UNISTIK 3 EXTRA (LANCET TRANSPORTER CASE) Tier 2 Tier 2

UNISTIK 3 GENTLE (LANCETS) Tier 2 Tier 2

UNISTIK 3 NEONATAL (LANCET TRANSPORTER

CASE)

Tier 2 Tier 2

UNISTIK 3 NORMAL (LANCET TRANSPORTER

CASE)

Tier 2 Tier 2

UNISTIK CZT COMFORT (LANCET TRANSPORTER

CASE)

Tier 2 Tier 2

UNISTIK CZT NORMAL (LANCET TRANSPORTER

CASE)

Tier 2 Tier 2

UNISTIK NORMAL (LANCET TRANSPORTER CASE) Tier 2 Tier 2

UNISTIK PRO SAFETY LANCET (LANCETS) Tier 2 Tier 2

UNISTIK SAFETY LANCETS 28G (LANCETS) Tier 2 Tier 2

UNISTIK SAFETY LANCETS 30G (LANCETS) Tier 2 Tier 2

UNISTIK TOUCH SAFETY LANC 21G (LANCETS) Tier 2 Tier 2

UNISTIK TOUCH SAFETY LANC 23G (LANCETS) Tier 2 Tier 2

UNISTIK TOUCH SAFETY LANC 28G (LANCETS) Tier 2 Tier 2

UNISTIK TOUCH SAFETY LANC 30G (LANCETS) Tier 2 Tier 2

UNIVERSAL 1 LANCETS THIN 26G (LANCETS) Tier 2 Tier 2

UNIVERSAL 1 LANCETS THIN 33G (LANCETS) Tier 2 Tier 2

UNIVERSAL 1 LANCETS ULTRA THIN (LANCETS) Tier 2 Tier 2

VALUE PLUS LANCET STANDARD 21G Tier 2

VALUE PLUS LANCETS SUPER THIN Tier 2

VALUE PLUS LANCETS THIN 26G Tier 2

VALUE PLUS LANCING DEVICE Tier 2

VALUMARK LANCET SUPER THIN 30G Tier 2

VALUMARK LANCET ULTRA THIN 28G Tier 2

VERIFINE SAFE LANCET MINI 21G (LANCETS) Tier 2 Tier 2

VERIFINE SAFE LANCET MINI 23G (LANCETS) Tier 2 Tier 2

VERIFINE SAFE LANCET MINI 28G (LANCETS) Tier 2 Tier 2

VERIFINE SAFE LANCET MINI 30G (LANCETS) Tier 2 Tier 2

VERIFINE UNIVERSAL LANCETS 28G (LANCETS) Tier 2 Tier 2

VERIFINE UNIVERSAL LANCETS 30G (LANCETS) Tier 2 Tier 2

VERIFINE UNIVERSAL LANCETS 33G (LANCETS) Tier 2 Tier 2

VIDA MIA AUTOLET LANCING DEV (LANCET

DEVICE)

Tier 2 Tier 2

VIDA MIA UNILET LANCETS 28G (LANCETS) Tier 2 Tier 2

VIDA MIA UNILET LANCETS 30G (LANCETS) Tier 2 Tier 2

VIVAGUARD LANCETS (LANCETS) Tier 2 Tier 2

VIVAGUARD LANCETS 30G (LANCETS) Tier 2 Tier 2

VIVAGUARD LANCING DEVICE (LANCET DEVICE) Tier 2 Tier 2

VIVAGUARD SAFETY LANCETS 28G (LANCETS) Tier 2 Tier 2

WALGREENS ADV TRAVEL LANCETS Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

WALGREENS LANCETS (LANCETS) Tier 2 Tier 2

WALGREENS LANCETS MICRO THIN Tier 2

WALGREENS LANCETS SUPER THIN Tier 2

WALGREENS THIN LANCETS (LANCETS) Tier 2 Tier 2

WALGREENS ULTRA THIN LANCETS (LANCETS) Tier 2 Tier 2

ZEVRX TWIST TOP LANCETS 30G Tier 2

*Insulin Administration Supplies***

OMNIPOD 5 G6 INTRO (GEN 5) KIT Tier 4 PA

OMNIPOD 5 G6 PODS (GEN 5) Tier 4 PA

OMNIPOD 5 G7 INTRO (GEN 5) KIT Tier 4 PA

OMNIPOD 5 G7 PODS (GEN 5) Tier 4 PA

OMNIPOD CLASSIC PDM (GEN 3) KIT Tier 4 PA

OMNIPOD CLASSIC PODS (GEN 3) Tier 4 PA

OMNIPOD DASH INTRO (GEN 4) KIT Tier 4 PA

OMNIPOD DASH PDM (GEN 4) KIT Tier 4 PA

OMNIPOD DASH PODS (GEN 4) Tier 4 PA

*Misc. Devices***

FOLDING PADDLE WALKER Tier 1

*Needles & Syringes***

1ST TIER UNIFINE PENTIPS 29G X 12MM , 31G X 5

MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X

6 MM , 33G X 4 MM

Tier 2

1ST TIER UNIFINE PENTIPS PLUS 29G X 12MM , 31G

X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM ,

33G X 4 MM

Tier 2

ABOUTTIME PEN NEEDLE (SURE COMFORT PEN

NEEDLES) 30G X 8 MM , 31G X 5 MM

Tier 2 Tier 2

ABOUTTIME PEN NEEDLE (PEN NEEDLES 5/16")

31G X 8 MM

Tier 2 Tier 2

ABOUTTIME PEN NEEDLE (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

ADVOCATE INSULIN PEN NEEDLE (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

ADVOCATE INSULIN PEN NEEDLES (SURE

COMFORT PEN NEEDLES) 29G X 12.7MM , 31G X 5

Tier 2 Tier 2

ADVOCATE INSULIN PEN NEEDLES (PEN

NEEDLES 5/16") 31G X 8 MM

Tier 2 Tier 2

ADVOCATE INSULIN PEN NEEDLES (INSUPEN

PEN NEEDLES) 33G X 4 MM

Tier 2 Tier 2

ADVOCATE INSULIN SYRINGE (KROGER INSULIN

SYRINGE) 29G X 1/2" 0.3 ML

Tier 2 Tier 2

ADVOCATE INSULIN SYRINGE (INSULIN

SYRINGE) 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML

Tier 2 Tier 2

ADVOCATE INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 30G X 5/16" 0.3 ML, 30G X

5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML

Tier 2 Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

ADVOCATE INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 31G X 5/16" 0.5 ML, 31G X

5/16" 1 ML

Tier 2 Tier 1

ALLERGY SYRINGE 27G X 1/2" 1 ML Tier 2

AQ INSULIN SYRINGE 29G X 1/2" 1 ML Tier 2

AQ INSULIN SYRINGE 30G X 5/16" 0.5 ML Tier 2

AQ INSULIN SYRINGE 31G X 5/16" 1 ML Tier 1

AQINJECT PEN NEEDLE 31G X 5 MM , 32G X 4 MM Tier 2

ASSURE ID DUO PRO PEN NEEDLES (SURE

COMFORT PEN NEEDLES) 31G X 5 MM

Tier 2 Tier 2

ASSURE ID PRO PEN NEEDLES (PEN NEEDLES)

30G X 5 MM

Tier 2 Tier 1

ASSURE ID SAFETY PEN NEEDLES (SURE

COMFORT PEN NEEDLES) 30G X 8 MM

Tier 2 Tier 2

AUM INSULIN SAFETY PEN NEEDLE 31G X 5 MM Tier 2

AUM MINI INSULIN PEN NEEDLE 32G X 4 MM , 32G

X 5 MM , 32G X 6 MM , 32G X 8 MM , 33G X 4 MM ,

33G X 5 MM , 33G X 6 MM

Tier 2

AUM PEN NEEDLE 32G X 4 MM , 32G X 5 MM , 32G X

6 MM , 33G X 4 MM , 33G X 5 MM , 33G X 6 MM

Tier 2

AUM READYGARD DUO PEN NEEDLE (INSUPEN

PEN NEEDLES) 32G X 4 MM

Tier 2 Tier 2

AUM SAFETY PEN NEEDLE (SURE COMFORT PEN

NEEDLES) 31G X 5 MM

Tier 2 Tier 2

AURORA PEN NEEDLES 29G X 12MM , 31G X 6 MM ,

31G X 8 MM

Tier 2

AURORA UNIFINE PENTIPS 31G X 5 MM , 32G X 4

Tier 2

BD AUTOSHIELD DUO (PEN NEEDLES) 30G X 5 MM Tier 2 Tier 1

BD DISP NEEDLE 23G X 1" Tier 2

BD DISP NEEDLES 16G X 1-1/2" , 18G X 1-1/2" , 19G

X 1" , 20G X 1" , 20G X 1-1/2" , 21G X 1-1/2" , 22G X

1-1/2" , 25G X 7/8" , 27G X 1/2" , 30G X 1/2"

Tier 2

BD DISP NEEDLES (CAREPOINT SAFETY 1ST

NEEDLE) 25G X 5/8"

Tier 2 Tier 2

BD ECLIPSE SYRINGE/NEEDLE (SYRINGE) 23G X

1" 3 ML, 25G X 5/8" 3 ML

Tier 2 Tier 2

BD HYPODERMIC NEEDLE 16G X 1" , 18G X 1" ,

18G X 1-1/2" , 19G X 1" , 19G X 1-1/2" , 21G X 1" ,

21G X 2" , 22G X 1" , 22G X 1-1/2" , 23G X 1" , 23G X

3/4" , 25G X 1-1/2" , 26G X 1/2"

Tier 2

BD INSULIN SYR ULTRAFINE II (INSULIN

SYRINGE-NEEDLE U-100) 31G X 5/16" 0.3 ML

Tier 2 Tier 2

BD INSULIN SYR ULTRAFINE II (INSULIN

SYRINGE-NEEDLE U-100) 31G X 5/16" 0.5 ML

Tier 2 Tier 1

BD INSULIN SYRINGE 27.5G X 5/8" 2 ML Tier 2

BD INSULIN SYRINGE (INSULIN SYRINGE-NEEDLE

U-100) 27G X 1/2" 1 ML

Tier 2 Tier 2

BD INSULIN SYRINGE (KROGER INSULIN

SYRINGE) 29G X 1/2" 0.3 ML

Tier 2 Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

BD INSULIN SYRINGE (INSULIN SYRINGE) 29G X

1/2" 0.5 ML, 29G X 1/2" 1 ML

Tier 2 Tier 2

BD INSULIN SYRINGE HALF-UNIT (INSULIN

SYRINGE-NEEDLE U-100) 31G X 5/16" 0.3 ML

Tier 2 Tier 2

BD INSULIN SYRINGE MICROFINE 27G X 5/8" 1

Tier 2

BD INSULIN SYRINGE MICROFINE (INSULIN

SYRINGE/NEEDLE) 28G X 1/2" 0.5 ML, 28G X 1/2" 1

Tier 2 Tier 2

BD INSULIN SYRINGE U/F 1/2UNIT (INSULIN

SYRINGE-NEEDLE U-100) 31G X 5/16" 0.3 ML

Tier 2 Tier 2

BD INSULIN SYRINGE U/F (SURE COMFORT

INSULIN SYRINGE) 30G X 1/2" 0.3 ML

Tier 2 Tier 2

BD INSULIN SYRINGE U/F (SURE COMFORT

INSULIN SYRINGE) 30G X 1/2" 0.5 ML

Tier 2 Tier 1

BD INSULIN SYRINGE U/F (INSULIN SYRINGE-

NEEDLE U-100) 30G X 1/2" 1 ML, 31G X 5/16" 0.5 ML,

31G X 5/16" 1 ML

Tier 2 Tier 1

BD INSULIN SYRINGE U/F (INSULIN SYRINGE-

NEEDLE U-100) 31G X 5/16" 0.3 ML

Tier 2 Tier 2

BD INSULIN SYRINGE (KMART VALU INSULIN

SYRINGE 29G) U-100 1 ML

Tier 2 Tier 2

BD INSULIN SYRINGE U-500 31G X 6MM 0.5 ML Tier 2

BD INSULIN SYRINGE ULTRAFINE (KROGER

INSULIN SYRINGE) 29G X 1/2" 0.3 ML

Tier 2 Tier 2

BD INSULIN SYRINGE ULTRAFINE (INSULIN

SYRINGE) 29G X 1/2" 0.5 ML

Tier 2 Tier 2

BD INSULIN SYRINGE ULTRAFINE (SURE

COMFORT INSULIN SYRINGE) 30G X 1/2" 0.3 ML

Tier 2 Tier 2

BD INSULIN SYRINGE ULTRAFINE (SURE

COMFORT INSULIN SYRINGE) 30G X 1/2" 0.5 ML

Tier 2 Tier 1

BD INSULIN SYRINGE ULTRAFINE (INSULIN

SYRINGE-NEEDLE U-100) 31G X 5/16" 0.5 ML

Tier 2 Tier 1

BD INTEGRA SYRINGE (SYRINGE) 22G X 1-1/2" 3

ML, 23G X 1" 3 ML, 25G X 5/8" 3 ML

Tier 2 Tier 2

BD LUER-LOK SYRINGE 22G X 1" 3 ML, 25G X 1" 3

Tier 2

BD LUER-LOK SYRINGE (SYRINGE) 22G X 1-1/2" 3

ML, 23G X 1" 3 ML, 25G X 5/8" 3 ML

Tier 2 Tier 2

BD LUER-LOK SYRINGE (SYRINGE LUER SLIP)

25G X 5/8" 1 ML

Tier 2 Tier 2

BD PEN NEEDLE MICRO U/F (SURE COMFORT PEN

NEEDLES) 32G X 6 MM

Tier 2 Tier 2

BD PEN NEEDLE MINI U/F (SURE COMFORT PEN

NEEDLES) 31G X 5 MM

Tier 2 Tier 2

BD PEN NEEDLE NANO 2ND GEN (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

BD PEN NEEDLE NANO U/F (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

BD PEN NEEDLE ORIGINAL U/F (SURE COMFORT

PEN NEEDLES) 29G X 12.7MM

Tier 2 Tier 2

Drug Name Brand Tier Generic Tier Formulary Notes

BD PEN NEEDLE SHORT U/F (PEN NEEDLES 5/16")

31G X 8 MM

Tier 2 Tier 2

BD SAFETYGLIDE ALLERGY SYRINGE

(TUBERCULIN SYRINGE) 27G X 1/2" 1 ML

Tier 2 Tier 2

BD SAFETYGLIDE INSULIN SYRINGE (KROGER

INSULIN SYRINGE) 29G X 1/2" 0.3 ML

Tier 2 Tier 2

BD SAFETYGLIDE INSULIN SYRINGE (INSULIN

SYRINGE) 29G X 1/2" 0.5 ML

Tier 2 Tier 2

BD SAFETYGLIDE INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 30G X 5/16" 0.5 ML, 31G X

5/16" 0.3 ML

Tier 2 Tier 2

BD SAFETYGLIDE INSULIN SYRINGE (TECHLITE

INSULIN SYRINGE) 31G X 15/64" 0.3 ML, 31G X

15/64" 0.5 ML, 31G X 15/64" 1 ML

Tier 2 Tier 2

BD SAFETYGLIDE NEEDLE (CAREPOINT SAFETY

1ST NEEDLE) 25G X 5/8"

Tier 2 Tier 2

BD SYRINGE LUER-LOK 1 ML , 3 ML Tier 2

BD SYRINGE SLIP TIP (TUBERCULIN SYRINGE)

25G X 5/8" 1 ML

Tier 2 Tier 2

BD SYRINGE SLIP TIP 26G X 5/8" 1 ML Tier 2

BD SYRINGE/NEEDLE (SYRINGE) 22G X 1-1/2" 3

ML, 23G X 1" 3 ML, 25G X 5/8" 3 ML

Tier 2 Tier 2

BD SYRINGE/NEEDLE (SYRINGE LUER SLIP) 25G X

5/8" 1 ML

Tier 2 Tier 2

BD TB SYRINGE (TUBERCULIN SYRINGE) 27G X

1/2" 1 ML

Tier 2 Tier 2

BD VEO INSULIN SYR U/F 1/2UNIT (TECHLITE

INSULIN SYRINGE) 31G X 15/64" 0.3 ML

Tier 2 Tier 2

BD VEO INSULIN SYRINGE U/F (TECHLITE

INSULIN SYRINGE) 31G X 15/64" 0.3 ML, 31G X

15/64" 0.5 ML, 31G X 15/64" 1 ML

Tier 2 Tier 2

CAREFINE PEN NEEDLES (KROGER PEN

NEEDLES) 29G X 12MM

Tier 2 Tier 2

CAREFINE PEN NEEDLES (SURE COMFORT PEN

NEEDLES) 30G X 8 MM , 32G X 6 MM

Tier 2 Tier 2

CAREFINE PEN NEEDLES (MEIJER PEN NEEDLES)

31G X 6 MM

Tier 2 Tier 2

CAREFINE PEN NEEDLES (PEN NEEDLES 5/16")

31G X 8 MM

Tier 2 Tier 2

CAREFINE PEN NEEDLES (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

CAREFINE PEN NEEDLES (PRO COMFORT PEN

NEEDLES) 32G X 5 MM

Tier 2 Tier 2

CAREONE INSULIN SYRINGE 30G X 1/2" 0.3 ML, 30G

X 1/2" 0.5 ML, 30G X 1/2" 1 ML, 31G X 5/16" 0.3 ML,

31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

CAREONE UNIFINE PENTIPS 29G X 12MM , 31G X 5

MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM

Tier 2

CAREONE UNIFINE PENTIPS PLUS 29G X 12MM ,

31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM

, 33G X 4 MM

Tier 2

CAREPOINT POLY HUB NEEDLE 25G X 5/8" Tier 2

100

Drug Name Brand Tier Generic Tier Formulary Notes

CAREPOINT SAFETY1ST SYR/NEEDLE (SYRINGE)

23G X 1" 3 ML, 25G X 5/8" 3 ML

Tier 2 Tier 2

CAREPOINT SYRINGE LUER LOCK (SYRINGE)

22G X 1-1/2" 3 ML, 23G X 1" 3 ML

Tier 2 Tier 2

CAREPOINT TUBERCLN SYR/LUER SL 25G X 5/8" 1

Tier 2

CARETOUCH INSULIN SYRINGE 28G X 5/16" 1 ML,

29G X 5/16" 1 ML

Tier 2

CARETOUCH INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 30G X 5/16" 0.5 ML, 30G X

5/16" 1 ML, 31G X 5/16" 0.3 ML

Tier 2 Tier 2

CARETOUCH INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 31G X 5/16" 0.5 ML, 31G X

5/16" 1 ML

Tier 2 Tier 1

CARETOUCH LUER LOCK (SYRINGE) 23G X 1" 3

Tier 2 Tier 2

CARETOUCH LUER LOCK SYR/NEEDLE

(SYRINGE) 22G X 1-1/2" 3 ML, 25G X 5/8" 3 ML

Tier 2 Tier 2

CARETOUCH PEN NEEDLES (KROGER PEN

NEEDLES) 29G X 12MM

Tier 2 Tier 2

CARETOUCH PEN NEEDLES (SURE COMFORT PEN

NEEDLES) 31G X 5 MM

Tier 2 Tier 2

CARETOUCH PEN NEEDLES (MEIJER PEN

NEEDLES) 31G X 6 MM

Tier 2 Tier 2

CARETOUCH PEN NEEDLES (PEN NEEDLES 5/16")

31G X 8 MM

Tier 2 Tier 2

CARETOUCH PEN NEEDLES (INSUPEN PEN

NEEDLES) 32G X 4 MM , 33G X 4 MM

Tier 2 Tier 2

CARETOUCH PEN NEEDLES (PRO COMFORT PEN

NEEDLES) 32G X 5 MM

Tier 2 Tier 2

CLEVER CHOICE COMFORT EZ (KROGER PEN

NEEDLES) 29G X 12MM

Tier 2 Tier 2

CLEVER CHOICE COMFORT EZ (INSUPEN PEN

NEEDLES) 33G X 4 MM

Tier 2 Tier 2

CLICKFINE PEN NEEDLES 31G X 5 MM (SURE

COMFORT PEN NEEDLES)

Tier 2 Tier 2

CLICKFINE PEN NEEDLES 31G X 6 MM (MEIJER

PEN NEEDLES)

Tier 2 Tier 2

CLICKFINE PEN NEEDLES 31G X 8 MM Tier 2

CLICKFINE PEN NEEDLES 32G X 4 MM (INSUPEN

PEN NEEDLES)

Tier 2 Tier 2

COMFORT ASSIST INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 31G X 5/16" 0.3 ML

Tier 2 Tier 2

COMFORT EZ INSULIN SYRINGE (INSULIN

SYRINGE/NEEDLE) 28G X 1/2" 0.5 ML, 28G X 1/2" 1

Tier 2 Tier 2

COMFORT EZ INSULIN SYRINGE (KROGER

INSULIN SYRINGE) 29G X 1/2" 0.3 ML

Tier 2 Tier 2

COMFORT EZ INSULIN SYRINGE (INSULIN

SYRINGE) 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML

Tier 2 Tier 2

COMFORT EZ INSULIN SYRINGE (SURE

COMFORT INSULIN SYRINGE) 30G X 1/2" 0.3 ML

Tier 2 Tier 2

101

Drug Name Brand Tier Generic Tier Formulary Notes

COMFORT EZ INSULIN SYRINGE (SURE

COMFORT INSULIN SYRINGE) 30G X 1/2" 0.5 ML

Tier 2 Tier 1

COMFORT EZ INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 30G X 1/2" 1 ML, 31G X

5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2 Tier 1

COMFORT EZ INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 30G X 5/16" 0.3 ML, 30G X

5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML

Tier 2 Tier 2

COMFORT EZ MICRO PEN NEEDLES (INSUPEN

PEN NEEDLES) 32G X 4 MM

Tier 2 Tier 2

COMFORT EZ PEN NEEDLES (SURE COMFORT

PEN NEEDLES) 31G X 5 MM , 32G X 6 MM

Tier 2 Tier 2

COMFORT EZ PEN NEEDLES (MEIJER PEN

NEEDLES) 31G X 6 MM

Tier 2 Tier 2

COMFORT EZ PEN NEEDLES (PEN NEEDLES 5/16")

31G X 8 MM

Tier 2 Tier 2

COMFORT EZ PEN NEEDLES (INSUPEN PEN

NEEDLES) 32G X 4 MM , 33G X 4 MM

Tier 2 Tier 2

COMFORT EZ PEN NEEDLES (PRO COMFORT PEN

NEEDLES) 32G X 5 MM

Tier 2 Tier 2

COMFORT EZ PEN NEEDLES (PURE COMFORT

PEN NEEDLE) 32G X 8 MM

Tier 2 Tier 2

COMFORT EZ PEN NEEDLES (EASY COMFORT

PEN NEEDLES) 33G X 5 MM , 33G X 6 MM

Tier 2 Tier 2

COMFORT EZ PEN NEEDLES 33G X 8 MM Tier 2

COMFORT EZ PRO PEN NEEDLES (SURE

COMFORT PEN NEEDLES) 30G X 8 MM , 31G X 5

Tier 2 Tier 2

COMFORT EZ SHORT PEN NEEDLES (PEN

NEEDLES 5/16") 31G X 8 MM

Tier 2 Tier 2

COMFORT TOUCH INSULIN PEN NEED (SURE

COMFORT PEN NEEDLES) 31G X 5 MM , 32G X 6

Tier 2 Tier 2

COMFORT TOUCH INSULIN PEN NEED (MEIJER

PEN NEEDLES) 31G X 6 MM

Tier 2 Tier 2

COMFORT TOUCH INSULIN PEN NEED (PEN

NEEDLES 5/16") 31G X 8 MM

Tier 2 Tier 2

COMFORT TOUCH INSULIN PEN NEED (INSUPEN

PEN NEEDLES) 32G X 4 MM , 33G X 4 MM

Tier 2 Tier 2

COMFORT TOUCH INSULIN PEN NEED (PRO

COMFORT PEN NEEDLES) 32G X 5 MM

Tier 2 Tier 2

COMFORT TOUCH INSULIN PEN NEED (PURE

COMFORT PEN NEEDLE) 32G X 8 MM

Tier 2 Tier 2

COMFORT TOUCH INSULIN PEN NEED (EASY

COMFORT PEN NEEDLES) 33G X 5 MM , 33G X 6

Tier 2 Tier 2

DIATHRIVE PEN NEEDLE (SURE COMFORT PEN

NEEDLES) 31G X 5 MM

Tier 2 Tier 2

DIATHRIVE PEN NEEDLE (MEIJER PEN NEEDLES)

31G X 6 MM

Tier 2 Tier 2

DIATHRIVE PEN NEEDLE (PEN NEEDLES 5/16")

31G X 8 MM

Tier 2 Tier 2

102

Drug Name Brand Tier Generic Tier Formulary Notes

DIATHRIVE PEN NEEDLE (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

DROPLET INSULIN SYRINGE (KROGER INSULIN

SYRINGE) 29G X 1/2" 0.3 ML

Tier 2 Tier 2

DROPLET INSULIN SYRINGE (INSULIN SYRINGE)

29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML

Tier 2 Tier 2

DROPLET INSULIN SYRINGE (SURE COMFORT

INSULIN SYRINGE) 30G X 1/2" 0.3 ML

Tier 2 Tier 2

DROPLET INSULIN SYRINGE (SURE COMFORT

INSULIN SYRINGE) 30G X 1/2" 0.5 ML

Tier 2 Tier 1

DROPLET INSULIN SYRINGE (INSULIN SYRINGE-

NEEDLE U-100) 30G X 1/2" 1 ML, 31G X 5/16" 0.5 ML,

31G X 5/16" 1 ML

Tier 2 Tier 1

DROPLET INSULIN SYRINGE 30G X 15/64" 0.3 ML,

30G X 15/64" 0.5 ML, 30G X 15/64" 1 ML

Tier 2

DROPLET INSULIN SYRINGE (INSULIN SYRINGE-

NEEDLE U-100) 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5

ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML

Tier 2 Tier 2

DROPLET INSULIN SYRINGE (TECHLITE INSULIN

SYRINGE) 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML,

31G X 15/64" 1 ML

Tier 2 Tier 2

DROPLET PEN NEEDLES 29G X 10MM Tier 2

DROPLET PEN NEEDLES (KROGER PEN NEEDLES)

29G X 12MM

Tier 2 Tier 2

DROPLET PEN NEEDLES (SURE COMFORT PEN

NEEDLES) 30G X 8 MM , 31G X 5 MM , 32G X 6 MM

Tier 2 Tier 2

DROPLET PEN NEEDLES (MEIJER PEN NEEDLES)

31G X 6 MM

Tier 2 Tier 2

DROPLET PEN NEEDLES (PEN NEEDLES 5/16") 31G

X 8 MM

Tier 2 Tier 2

DROPLET PEN NEEDLES (INSUPEN PEN NEEDLES)

32G X 4 MM

Tier 2 Tier 2

DROPLET PEN NEEDLES (PRO COMFORT PEN

NEEDLES) 32G X 5 MM

Tier 2 Tier 2

DROPLET PEN NEEDLES (PURE COMFORT PEN

NEEDLE) 32G X 8 MM

Tier 2 Tier 2

DROPSAFE SAFETY PEN NEEDLES 31G X 5 MM , 31G

X 6 MM , 31G X 8 MM

Tier 2

DROPSAFE SAFETY SYRINGE/NEEDLE 29G X 1/2"

1 ML (INSULIN SYRINGE)

Tier 2 Tier 2

DROPSAFE SAFETY SYRINGE/NEEDLE 31G X

15/64" 0.3 ML (TECHLITE INSULIN SYRINGE)

Tier 2 Tier 2

DROPSAFE SAFETY SYRINGE/NEEDLE 31G X

15/64" 0.5 ML (TECHLITE INSULIN SYRINGE)

Tier 1 Tier 2

DROPSAFE SAFETY SYRINGE/NEEDLE 31G X

15/64" 1 ML (TECHLITE INSULIN SYRINGE)

Tier 1 Tier 2

DROPSAFE SAFETY SYRINGE/NEEDLE 31G X

5/16" 0.3 ML (INSULIN SYRINGE-NEEDLE U-100)

Tier 2 Tier 2

DROPSAFE SAFETY SYRINGE/NEEDLE 31G X

5/16" 0.5 ML (INSULIN SYRINGE-NEEDLE U-100)

Tier 1 Tier 1

DROPSAFE SAFETY SYRINGE/NEEDLE 31G X

5/16" 1 ML (INSULIN SYRINGE-NEEDLE U-100)

Tier 1 Tier 1

103

Drug Name Brand Tier Generic Tier Formulary Notes

DRUG MART UNIFINE PENTIPS 29G X 12MM , 31G X

5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM

Tier 2

DRUG MART UNIFINE PENTIPS PLUS 32G X 4 MM Tier 2

EASY COMFORT INSULIN SYRINGE 30G X 1/2" 0.5

ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.5 ML, 30G X 5/16"

1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X

5/16" 1 ML, 32G X 5/16" 0.5 ML, 32G X 5/16" 1 ML

Tier 2

EASY COMFORT PEN NEEDLES 31G X 5 MM , 31G X

6 MM , 31G X 8 MM , 32G X 4 MM , 33G X 4 MM

Tier 2

EASY GLIDE PEN NEEDLES 33G X 4 MM Tier 2

EASY TOUCH ALLERGY SYRINGE (TUBERCULIN

SYRINGE) 27G X 1/2" 1 ML

Tier 2 Tier 2

EASY TOUCH FLIPLOCK INSULIN SY (INSULIN

SYRINGE) 29G X 1/2" 1 ML

Tier 2 Tier 2

EASY TOUCH FLIPLOCK INSULIN SY (INSULIN

SYRINGE-NEEDLE U-100) 30G X 1/2" 1 ML, 31G X

5/16" 1 ML

Tier 2 Tier 1

EASY TOUCH FLIPLOCK INSULIN SY (INSULIN

SYRINGE-NEEDLE U-100) 30G X 5/16" 1 ML

Tier 2 Tier 2

EASY TOUCH FLIPLOCK SAFETY SYR (SYRINGE)

22G X 1-1/2" 3 ML, 23G X 1" 3 ML, 25G X 5/8" 3 ML

Tier 2 Tier 2

EASY TOUCH FLURINGE (SYRINGE LUER SLIP)

25G X 5/8" 1 ML

Tier 2 Tier 2

EASY TOUCH FLURINGE FLIPLOCK (SYRINGE

LUER SLIP) 25G X 5/8" 1 ML

Tier 2 Tier 2

EASY TOUCH FLURINGE SHEATHLOCK

(SYRINGE LUER SLIP) 25G X 5/8" 1 ML

Tier 2 Tier 2

EASY TOUCH INSULIN SAFETY SYR (INSULIN

SYRINGE) 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML

Tier 2 Tier 2

EASY TOUCH INSULIN SAFETY SYR (INSULIN

SYRINGE-NEEDLE U-100) 30G X 1/2" 1 ML

Tier 2 Tier 1

EASY TOUCH INSULIN SAFETY SYR (INSULIN

SYRINGE-NEEDLE U-100) 30G X 5/16" 0.5 ML

Tier 2 Tier 2

EASY TOUCH INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 27G X 1/2" 0.5 ML, 30G X

1/2" 1 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2 Tier 1

EASY TOUCH INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 27G X 1/2" 1 ML, 30G X

5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML,

31G X 5/16" 0.3 ML

Tier 2 Tier 2

EASY TOUCH INSULIN SYRINGE 27G X 5/8" 1 ML Tier 2

EASY TOUCH INSULIN SYRINGE (INSULIN

SYRINGE/NEEDLE) 28G X 1/2" 0.5 ML, 28G X 1/2" 1

Tier 2 Tier 2

EASY TOUCH INSULIN SYRINGE (INSULIN

SYRINGE) 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML

Tier 2 Tier 2

EASY TOUCH INSULIN SYRINGE (SURE COMFORT

INSULIN SYRINGE) 30G X 1/2" 0.3 ML

Tier 2 Tier 2

EASY TOUCH INSULIN SYRINGE (SURE COMFORT

INSULIN SYRINGE) 30G X 1/2" 0.5 ML

Tier 2 Tier 1

EASY TOUCH PEN NEEDLES (KROGER PEN

NEEDLES) 29G X 12MM

Tier 2 Tier 2

104

Drug Name Brand Tier Generic Tier Formulary Notes

EASY TOUCH PEN NEEDLES (PEN NEEDLES) 30G

X 5 MM

Tier 2 Tier 1

EASY TOUCH PEN NEEDLES (SURE COMFORT PEN

NEEDLES) 30G X 8 MM , 31G X 5 MM , 32G X 6 MM

Tier 2 Tier 2

EASY TOUCH PEN NEEDLES (MEIJER PEN

NEEDLES) 31G X 6 MM

Tier 2 Tier 2

EASY TOUCH PEN NEEDLES (PEN NEEDLES 5/16")

31G X 8 MM

Tier 2 Tier 2

EASY TOUCH PEN NEEDLES (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

EASY TOUCH PEN NEEDLES (PRO COMFORT PEN

NEEDLES) 32G X 5 MM

Tier 2 Tier 2

EASY TOUCH SAFETY PEN NEEDLES 29G X 5MM ,

29G X 8MM

Tier 2

EASY TOUCH SAFETY PEN NEEDLES (SURE

COMFORT PEN NEEDLES) 30G X 8 MM

Tier 2 Tier 2

EASY TOUCH SAFETY SYRINGE (SYRINGE) 22G X

1-1/2" 3 ML, 23G X 1" 3 ML, 25G X 5/8" 3 ML

Tier 2 Tier 2

EASY TOUCH SAFETY SYRINGE (SYRINGE LUER

SLIP) 25G X 5/8" 1 ML

Tier 2 Tier 2

EASY TOUCH SHEATHLOCK SYRINGE (SYRINGE)

22G X 1-1/2" 3 ML, 23G X 1" 3 ML, 25G X 5/8" 3 ML

Tier 2 Tier 2

EASY TOUCH SHEATHLOCK SYRINGE (INSULIN

SYRINGE) 29G X 1/2" 1 ML

Tier 2 Tier 2

EASY TOUCH SHEATHLOCK SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 30G X 1/2" 1 ML, 31G X

5/16" 1 ML

Tier 2 Tier 1

EASY TOUCH SHEATHLOCK SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 30G X 5/16" 1 ML

Tier 2 Tier 2

EASY TOUCH TB FLIPLOCK SYRINGE

(TUBERCULIN SYRINGE) 27G X 1/2" 1 ML

Tier 2 Tier 2

EASY TOUCH TB SHEATHLOCK SYR

(TUBERCULIN SYRINGE) 25G X 5/8" 1 ML, 27G X

1/2" 1 ML

Tier 2 Tier 2

EASY TOUCH TB SHEATHLOCK SYR 26G X 5/8" 1

Tier 2

EASYPOINT NEEDLE (CAREPOINT SAFETY 1ST

NEEDLE) 25G X 5/8"

Tier 2 Tier 2

EASYPOINT NEEDLE/SYRINGE (SYRINGE) 23G X

1" 3 ML, 25G X 5/8" 3 ML

Tier 2 Tier 2

EMBRACE PEN NEEDLES (KROGER PEN NEEDLES)

29G X 12MM

Tier 2 Tier 2

EMBRACE PEN NEEDLES (PEN NEEDLES) 30G X 5

Tier 2 Tier 1

EMBRACE PEN NEEDLES (SURE COMFORT PEN

NEEDLES) 30G X 8 MM , 31G X 5 MM

Tier 2 Tier 2

EMBRACE PEN NEEDLES (MEIJER PEN NEEDLES)

31G X 6 MM

Tier 2 Tier 2

EMBRACE PEN NEEDLES (PEN NEEDLES 5/16")

31G X 8 MM

Tier 2 Tier 2

EMBRACE PEN NEEDLES (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

105

Drug Name Brand Tier Generic Tier Formulary Notes

EQL INSULIN SYRINGE 29G X 1/2" 0.3 ML, 29G X 1/2"

0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X

5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML,

31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

EXEL COMFORT POINT INSULIN SYR (INSULIN

SYRINGE/NEEDLE) 28G X 1/2" 0.5 ML, 28G X 1/2" 1

Tier 2 Tier 2

EXEL COMFORT POINT INSULIN SYR (KROGER

INSULIN SYRINGE) 29G X 1/2" 0.3 ML

Tier 2 Tier 2

EXEL COMFORT POINT INSULIN SYR (INSULIN

SYRINGE) 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML

Tier 2 Tier 2

EXEL COMFORT POINT INSULIN SYR (INSULIN

SYRINGE-NEEDLE U-100) 30G X 5/16" 0.3 ML, 30G X

5/16" 0.5 ML, 30G X 5/16" 1 ML

Tier 2 Tier 2

EXEL COMFORT POINT PEN NEEDLE (KROGER

PEN NEEDLES) 29G X 12MM

Tier 2 Tier 2

EXEL COMFORT POINT PEN NEEDLE (MEIJER

PEN NEEDLES) 31G X 6 MM

Tier 2 Tier 2

EXEL COMFORT POINT PEN NEEDLE (PEN

NEEDLES 5/16") 31G X 8 MM

Tier 2 Tier 2

FIFTY50 PEN NEEDLES (SURE COMFORT PEN

NEEDLES) 31G X 5 MM , 32G X 6 MM

Tier 2 Tier 2

FIFTY50 PEN NEEDLES (PEN NEEDLES 5/16") 31G X

8 MM

Tier 2 Tier 2

FIFTY50 PEN NEEDLES (INSUPEN PEN NEEDLES)

32G X 4 MM

Tier 2 Tier 2

FIFTY50 SUPERIOR COMFORT SYR (INSULIN

SYRINGE-NEEDLE U-100) 31G X 5/16" 0.3 ML

Tier 2 Tier 2

FIFTY50 SUPERIOR COMFORT SYR (INSULIN

SYRINGE-NEEDLE U-100) 31G X 5/16" 0.5 ML, 31G X

5/16" 1 ML

Tier 2 Tier 1

FREDS PHARMACY UNIFINE PENTIP+ 31G X 5 MM ,

31G X 8 MM

Tier 2

FREDS PHARMACY UNIFINE PENTIPS 32G X 4 MM Tier 2

GLOBAL EASE INJECT PEN NEEDLES 29G X 12MM ,

31G X 5 MM , 31G X 8 MM , 32G X 4 MM

Tier 2

GLOBAL EASY GLIDE INSULIN SYR 31G X 15/64" 0.3

ML, 31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML, 31G X

5/16" 0.3 ML

Tier 2

GLOBAL EASY GLIDE PEN NEEDLES 32G X 4 MM Tier 2

GLOBAL INJECT EASE INSULIN SYR 28G X 1/2" 0.5

ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5

ML, 29G X 1/2" 1 ML, 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5

ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16"

0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X

5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

GLOBAL INSULIN SYRINGES 30G X 1/2" 0.3 ML, 30G

X 5/16" 0.3 ML

Tier 2

GLUCOPRO INSULIN SYRINGE (SURE COMFORT

INSULIN SYRINGE) 30G X 1/2" 0.3 ML

Tier 2 Tier 2

GLUCOPRO INSULIN SYRINGE (SURE COMFORT

INSULIN SYRINGE) 30G X 1/2" 0.5 ML

Tier 2 Tier 1

106

Drug Name Brand Tier Generic Tier Formulary Notes

GLUCOPRO INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 30G X 1/2" 1 ML, 31G X

5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2 Tier 1

GLUCOPRO INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 30G X 5/16" 0.3 ML, 30G X

5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML

Tier 2 Tier 2

GNP CLICKFINE PEN NEEDLES 31G X 6 MM , 31G X

8 MM

Tier 2

GNP INSULIN SYRINGE 28G X 1/2" 0.5 ML, 29G X 1/2"

0.3 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X

5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML,

31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1

Tier 2

GNP INSULIN SYRINGES 28GX1/2" 28G X 1/2" 1 ML Tier 2

GNP INSULIN SYRINGES 29GX1/2" 29G X 1/2" 0.5 ML,

29G X 1/2" 1 ML

Tier 2

GNP INSULIN SYRINGES 30G X 5/16" 1 ML Tier 2

GNP INSULIN SYRINGES 30GX5/16" 30G X 5/16" 0.3

Tier 2

GNP INSULIN SYRINGES 31GX5/16" 31G X 5/16" 0.3

Tier 2

GNP ULTICARE PEN NEEDLES 31G X 5 MM , 31G X 8

MM , 32G X 4 MM , 32G X 6 MM

Tier 2

GNP ULTIGUARD SAFEPACK NEEDLE (SURE

COMFORT PEN NEEDLES) 31G X 5 MM , 32G X 6

Tier 2 Tier 2

GNP ULTIGUARD SAFEPACK NEEDLE (PEN

NEEDLES 5/16") 31G X 8 MM

Tier 2 Tier 2

GNP ULTIGUARD SAFEPACK NEEDLE (INSUPEN

PEN NEEDLES) 32G X 4 MM

Tier 2 Tier 2

GNP ULTRA COM INSULIN SYRINGE 28G X 1/2" 1

Tier 2

GOODSENSE CLICKFINE PEN NEEDLE 31G X 5 MM Tier 2

GOODSENSE PEN NEEDLE PENFINE (SURE

COMFORT PEN NEEDLES) 31G X 5 MM , 32G X 6

Tier 2 Tier 2

GOODSENSE PEN NEEDLE PENFINE (PEN

NEEDLES 5/16") 31G X 8 MM

Tier 2 Tier 2

GOODSENSE PEN NEEDLE PENFINE (INSUPEN

PEN NEEDLES) 32G X 4 MM

Tier 2 Tier 2

HEALTHWISE INSULIN SYR/NEEDLE 30G X 5/16" 0.3

ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16"

0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

HEALTHWISE MICRON PEN NEEDLES 32G X 4 MM Tier 2

HEALTHWISE MINI PEN NEEDLES 31G X 6 MM Tier 2

HEALTHWISE PEN NEEDLES 29G X 12MM Tier 2

HEALTHWISE SHORT PEN NEEDLES 31G X 5 MM ,

31G X 8 MM

Tier 2

HEALTHWISE UNIFINE PENTIPS 32G X 4 MM Tier 2

HEALTHY ACCENTS UNIFINE PENTIP 29G X 12MM ,

31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM

Tier 2

107

Drug Name Brand Tier Generic Tier Formulary Notes

H-E-B INCONTROL PEN NEEDLES 29G X 12MM , 31G

X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM

Tier 2

H-E-B INCONTROL UNIFINE PENTIP (SURE

COMFORT PEN NEEDLES) 31G X 5 MM

Tier 2 Tier 2

H-E-B INCONTROL UNIFINE PENTIP (MEIJER PEN

NEEDLES) 31G X 6 MM

Tier 2 Tier 2

H-E-B INCONTROL UNIFINE PENTIP (PEN

NEEDLES 5/16") 31G X 8 MM

Tier 2 Tier 2

H-E-B INCONTROL UNIFINE PENTIP (INSUPEN

PEN NEEDLES) 32G X 4 MM , 33G X 4 MM

Tier 2 Tier 2

HM ULTICARE INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 30G X 1/2" 1 ML

Tier 2 Tier 1

HM ULTICARE INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 31G X 5/16" 0.3 ML

Tier 2 Tier 2

HM ULTICARE MINI PEN NEEDLES (SURE

COMFORT PEN NEEDLES) 31G X 5 MM

Tier 2 Tier 2

HM ULTICARE SHORT PEN NEEDLES (PEN

NEEDLES 5/16") 31G X 8 MM

Tier 2 Tier 2

INCONTROL ULTICARE PEN NEEDLES (MEIJER

PEN NEEDLES) 31G X 6 MM

Tier 2 Tier 2

INCONTROL ULTICARE PEN NEEDLES (PEN

NEEDLES 5/16") 31G X 8 MM

Tier 2 Tier 2

INCONTROL ULTICARE PEN NEEDLES (INSUPEN

PEN NEEDLES) 32G X 4 MM

Tier 2 Tier 2

INSULIN SYRINGE 28G X 1/2" 0.5 ML, 29G X 1/2" 0.3

ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X

5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML,

31G X 5/16" 1 ML

Tier 2

INSULIN SYRINGE/NEEDLE 27G X 1/2" 0.5 ML Tier 2

INSULIN SYRINGE-NEEDLE U-100 28G X 1/2" 0.5 ML

(OTC)

Tier 2

INSULIN SYRINGE-NEEDLE U-100 28G X 1/2" 0.5 ML

(RX)

Tier 2

INSULIN SYRINGE-NEEDLE U-100 28G X 1/2" 1 ML

(OTC)

Tier 2

INSULIN SYRINGE-NEEDLE U-100 28G X 1/2" 1 ML

(RX)

Tier 2

INSULIN SYRINGE-NEEDLE U-100 29G X 1/2" 0.5 ML

(OTC)

Tier 2

INSULIN SYRINGE-NEEDLE U-100 29G X 1/2" 0.5 ML

(RX)

Tier 2

INSULIN SYRINGE-NEEDLE U-100 29G X 1/2" 1 ML

(OTC)

Tier 2

INSULIN SYRINGE-NEEDLE U-100 29G X 1/2" 1 ML

(RX)

Tier 2

INSULIN SYRINGE-NEEDLE U-100 31G X 1/4" 0.3 ML Tier 2

INSULIN SYRINGE-NEEDLE U-100 31G X 1/4" 0.5 ML Tier 2

INSULIN SYRINGE-NEEDLE U-100 31G X 1/4" 1 ML Tier 2

INSUPEN PEN NEEDLES 29G X 12MM , 31G X 5 MM ,

31G X 8 MM

Tier 2

108

Drug Name Brand Tier Generic Tier Formulary Notes

INSUPEN SENSITIVE (SURE COMFORT PEN

NEEDLES) 32G X 6 MM

Tier 2 Tier 2

INSUPEN SENSITIVE (PURE COMFORT PEN

NEEDLE) 32G X 8 MM

Tier 2 Tier 2

INSUPEN ULTRAFIN (SURE COMFORT PEN

NEEDLES) 30G X 8 MM

Tier 2 Tier 2

INSUPEN ULTRAFIN (MEIJER PEN NEEDLES) 31G X

6 MM

Tier 2 Tier 2

INSUPEN ULTRAFIN (PEN NEEDLES 5/16") 31G X 8

Tier 2 Tier 2

KINRAY INSULIN SYRINGE 29G X 1/2" 0.5 ML, 31G X

5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

KMART VALU INSULIN SYRINGE 30G U-100 1 ML Tier 2

KROGER INSULIN SYRINGE 29G X 1/2" 0.5 ML, 29G

X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML,

30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5

ML, 31G X 5/16" 1 ML

Tier 2

KROGER PEN NEEDLES 31G X 5 MM , 31G X 6 MM ,

31G X 8 MM , 32G X 4 MM , 33G X 4 MM

Tier 2

LEADER INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G X

1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 29G X

1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G

X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML,

31G X 5/16" 1 ML

Tier 2

LEADER UNIFINE PENTIPS (SURE COMFORT PEN

NEEDLES) 31G X 5 MM

Tier 2 Tier 2

LEADER UNIFINE PENTIPS (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

LEADER UNIFINE PENTIPS PLUS (SURE COMFORT

PEN NEEDLES) 31G X 5 MM

Tier 2 Tier 2

LEADER UNIFINE PENTIPS PLUS (PEN NEEDLES

5/16") 31G X 8 MM

Tier 2 Tier 2

LEADER UNIFINE PENTIPS PLUS (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

LITETOUCH INSULIN SYRINGE (INSULIN

SYRINGE/NEEDLE) 28G X 1/2" 0.5 ML, 28G X 1/2" 1

Tier 2 Tier 2

LITETOUCH INSULIN SYRINGE (KROGER

INSULIN SYRINGE) 29G X 1/2" 0.3 ML

Tier 2 Tier 2

LITETOUCH INSULIN SYRINGE (INSULIN

SYRINGE) 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML

Tier 2 Tier 2

LITETOUCH INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 30G X 5/16" 0.3 ML, 30G X

5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML

Tier 2 Tier 2

LITETOUCH INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 31G X 5/16" 0.5 ML, 31G X

5/16" 1 ML

Tier 2 Tier 1

LITETOUCH PEN NEEDLES (SURE COMFORT PEN

NEEDLES) 29G X 12.7MM , 31G X 5 MM

Tier 2 Tier 2

LITETOUCH PEN NEEDLES (MEIJER PEN

NEEDLES) 31G X 6 MM

Tier 2 Tier 2

109

Drug Name Brand Tier Generic Tier Formulary Notes

LITETOUCH PEN NEEDLES (PEN NEEDLES 5/16")

31G X 8 MM

Tier 2 Tier 2

LITETOUCH PEN NEEDLES (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

LONGS INSULIN SYRINGE 31G X 5/16" 0.5 ML Tier 2

LUER LOCK SAFETY SYRINGES (SYRINGE) 22G X

1-1/2" 3 ML, 23G X 1" 3 ML, 25G X 5/8" 3 ML

Tier 2 Tier 2

MAGELLAN INSULIN SAFETY SYR (KROGER

INSULIN SYRINGE) 29G X 1/2" 0.3 ML

Tier 2 Tier 2

MAGELLAN INSULIN SAFETY SYR (INSULIN

SYRINGE) 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML

Tier 2 Tier 2

MAGELLAN INSULIN SAFETY SYR (INSULIN

SYRINGE-NEEDLE U-100) 30G X 5/16" 0.3 ML, 30G X

5/16" 0.5 ML, 30G X 5/16" 1 ML

Tier 2 Tier 2

MAGELLAN TUBERCULIN SYRINGE

(TUBERCULIN SYRINGE) 27G X 1/2" 1 ML

Tier 2 Tier 2

MARATHON MEDICAL PENTIPS (KROGER PEN

NEEDLES) 29G X 12MM

Tier 2 Tier 2

MARATHON MEDICAL PENTIPS (SURE COMFORT

PEN NEEDLES) 31G X 5 MM

Tier 2 Tier 2

MARATHON MEDICAL PENTIPS (PEN NEEDLES

5/16") 31G X 8 MM

Tier 2 Tier 2

MARATHON MEDICAL PENTIPS (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

MAXICOMFORT II PEN NEEDLE (MEIJER PEN

NEEDLES) 31G X 6 MM

Tier 2 Tier 2

MAXI-COMFORT INSULIN SYRINGE (INSULIN

SYRINGE/NEEDLE) 28G X 1/2" 0.5 ML, 28G X 1/2" 1

Tier 2 Tier 2

MAXI-COMFORT SAFETY PEN NEEDLE 29G X

5MM , 29G X 8MM

Tier 2

MAXICOMFORT SYR 27G X 1/2" (INSULIN

SYRINGE-NEEDLE U-100) 27G X 1/2" 0.5 ML

Tier 2 Tier 1

MAXICOMFORT SYR 27G X 1/2" (INSULIN

SYRINGE-NEEDLE U-100) 27G X 1/2" 1 ML

Tier 2 Tier 2

MEDIC INSULIN SYRINGE 30G X 5/16" 0.3 ML, 30G X

5/16" 0.5 ML

Tier 2

MEDICINE SHOPPE PEN NEEDLES 29G X 12MM , 31G

X 6 MM , 31G X 8 MM

Tier 2

MEIJER PEN NEEDLES 29G X 12MM , 31G X 8 MM Tier 2

MICRODOT PEN NEEDLE (MEIJER PEN NEEDLES)

31G X 6 MM

Tier 2 Tier 2

MICRODOT PEN NEEDLE (INSUPEN PEN

NEEDLES) 32G X 4 MM , 33G X 4 MM

Tier 2 Tier 2

MM INSULIN SYRINGE/NEEDLE 30G X 5/16" 0.3 ML,

30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3

ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

MM PEN NEEDLES (SURE COMFORT PEN

NEEDLES) 31G X 5 MM

Tier 2 Tier 2

MM PEN NEEDLES (MEIJER PEN NEEDLES) 31G X 6

Tier 2 Tier 2

110

Drug Name Brand Tier Generic Tier Formulary Notes

MM PEN NEEDLES (PEN NEEDLES 5/16") 31G X 8

Tier 2 Tier 2

MM PEN NEEDLES (INSUPEN PEN NEEDLES) 32G X

4 MM

Tier 2 Tier 2

MONOJECT HYPODERMIC NEEDLE (CAREPOINT

SAFETY 1ST NEEDLE) 25G X 5/8"

Tier 2 Tier 2

MONOJECT INSULIN SYRINGE 25G X 5/8" 1 ML Tier 2

MONOJECT INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 27G X 1/2" 1 ML, 30G X

5/16" 0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML

Tier 2 Tier 2

MONOJECT INSULIN SYRINGE (INSULIN

SYRINGE/NEEDLE) 28G X 1/2" 0.5 ML, 28G X 1/2" 1

Tier 2 Tier 2

MONOJECT INSULIN SYRINGE (KROGER INSULIN

SYRINGE) 29G X 1/2" 0.3 ML

Tier 2 Tier 2

MONOJECT INSULIN SYRINGE (INSULIN

SYRINGE) 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML

Tier 2 Tier 2

MONOJECT INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 31G X 5/16" 1 ML

Tier 2 Tier 1

MONOJECT INSULIN SYRINGE (KMART VALU

INSULIN SYRINGE 29G) U-100 1 ML

Tier 2 Tier 2

MONOJECT MAGELLAN SAFETY NDL

(CAREPOINT SAFETY 1ST NEEDLE) 25G X 5/8"

Tier 2 Tier 2

MONOJECT MAGELLAN SYRINGE (SYRINGE) 22G

X 1-1/2" 3 ML, 23G X 1" 3 ML, 25G X 5/8" 3 ML

Tier 2 Tier 2

MONOJECT MAGELLAN SYRINGE (SYRINGE

LUER SLIP) 25G X 5/8" 1 ML

Tier 2 Tier 2

MONOJECT SYRINGE (SYRINGE) 22G X 1-1/2" 3

ML, 23G X 1" 3 ML, 25G X 5/8" 3 ML

Tier 2 Tier 2

MONOJECT SYRINGE (TUBERCULIN SYRINGE)

27G X 1/2" 1 ML

Tier 2 Tier 2

MONOJECT TB SAFETY SYRINGE (TUBERCULIN

SYRINGE) 25G X 5/8" 1 ML

Tier 2 Tier 2

MONOJECT TB SYRINGE (TUBERCULIN SYRINGE)

25G X 5/8" 1 ML, 27G X 1/2" 1 ML

Tier 2 Tier 2

MONOJECT ULTRA COMFORT SYRINGE

(INSULIN SYRINGE/NEEDLE) 28G X 1/2" 0.5 ML, 28G

X 1/2" 1 ML

Tier 2 Tier 2

MONOJECT ULTRA COMFORT SYRINGE

(KROGER INSULIN SYRINGE) 29G X 1/2" 0.3 ML

Tier 2 Tier 2

MONOJECT ULTRA COMFORT SYRINGE

(INSULIN SYRINGE) 29G X 1/2" 0.5 ML, 29G X 1/2" 1

Tier 2 Tier 2

MONOJECT ULTRA COMFORT SYRINGE

(INSULIN SYRINGE-NEEDLE U-100) 30G X 5/16" 0.3

ML, 30G X 5/16" 0.5 ML, 31G X 5/16" 0.3 ML

Tier 2 Tier 2

MONOJECT ULTRA COMFORT SYRINGE

(INSULIN SYRINGE-NEEDLE U-100) 31G X 5/16" 0.5

Tier 2 Tier 1

MS INSULIN SYRINGE 31G X 5/16" 0.3 ML, 31G X

5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

111

Drug Name Brand Tier Generic Tier Formulary Notes

NOVOFINE AUTOCOVER PEN NEEDLE (SURE

COMFORT PEN NEEDLES) 30G X 8 MM

Tier 2 Tier 2

NOVOFINE PEN NEEDLE (SURE COMFORT PEN

NEEDLES) 32G X 6 MM

Tier 2 Tier 2

NOVOFINE PLUS PEN NEEDLE (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

PC UNIFINE PENTIPS 29G X 12MM , 31G X 5 MM ,

31G X 6 MM , 31G X 8 MM

Tier 2

PEN NEEDLES 29G X 12MM Tier 2

PEN NEEDLES 30G X 8 MM Tier 2

PEN NEEDLES 31G X 5 MM (OTC) Tier 2

PEN NEEDLES 31G X 5 MM (RX) Tier 2

PEN NEEDLES 31G X 6 MM Tier 2

PEN NEEDLES 31G X 8 MM (OTC) Tier 2

PEN NEEDLES 31G X 8 MM (RX) Tier 2

PEN NEEDLES 32G X 4 MM (OTC) Tier 2

PEN NEEDLES 32G X 4 MM (RX) Tier 2

PEN NEEDLES 32G X 5 MM Tier 2

PEN NEEDLES 32G X 6 MM Tier 2

PEN NEEDLES 33G X 4 MM Tier 2

PENTIPS (KROGER PEN NEEDLES) 29G X 12MM Tier 2 Tier 2

PENTIPS (SURE COMFORT PEN NEEDLES) 31G X 5

MM , 32G X 6 MM

Tier 2 Tier 2

PENTIPS (MEIJER PEN NEEDLES) 31G X 6 MM Tier 2 Tier 2

PENTIPS (PEN NEEDLES 5/16") 31G X 8 MM Tier 2 Tier 2

PENTIPS (INSUPEN PEN NEEDLES) 32G X 4 MM Tier 2 Tier 2

PIP PEN NEEDLES 31G X 5MM 31G X 5 MM Tier 2

PIP PEN NEEDLES 32G X 4MM 32G X 4 MM Tier 2

PRECISION SURE-DOSE SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 30G X 5/16" 0.3 ML

Tier 2 Tier 2

PREFERRED PLUS INSULIN SYRINGE 28G X 1/2" 0.5

ML, 28G X 1/2" 1 ML, 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5

ML, 29G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16"

0.5 ML, 30G X 5/16" 1 ML

Tier 2

PREFERRED PLUS UNIFINE PENTIPS 29G X 12MM ,

31G X 5 MM , 31G X 6 MM , 31G X 8 MM , 32G X 4 MM

Tier 2

PREVENT DROPSAFE PEN NEEDLES (MEIJER PEN

NEEDLES) 31G X 6 MM

Tier 2 Tier 2

PREVENT DROPSAFE PEN NEEDLES (PEN

NEEDLES 5/16") 31G X 8 MM

Tier 2 Tier 2

PREVENT SAFETY PEN NEEDLES (MEIJER PEN

NEEDLES) 31G X 6 MM

Tier 2 Tier 2

PREVENT SAFETY PEN NEEDLES (PEN NEEDLES

5/16") 31G X 8 MM

Tier 2 Tier 2

PRO COMFORT INSULIN SYRINGE (SURE

COMFORT INSULIN SYRINGE) 30G X 1/2" 0.5 ML

Tier 2 Tier 1

PRO COMFORT INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 30G X 1/2" 1 ML, 31G X

5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2 Tier 1

112

Drug Name Brand Tier Generic Tier Formulary Notes

PRO COMFORT INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 30G X 5/16" 0.5 ML, 30G X

5/16" 1 ML

Tier 2 Tier 2

PRO COMFORT PEN NEEDLES 31G X 8 MM , 32G X 4

MM , 32G X 6 MM

Tier 2

PRODIGY INSULIN SYRINGE (INSULIN

SYRINGE/NEEDLE) 28G X 1/2" 1 ML

Tier 2 Tier 2

PRODIGY INSULIN SYRINGE (INSULIN SYRINGE-

NEEDLE U-100) 31G X 5/16" 0.3 ML

Tier 2 Tier 2

PRODIGY INSULIN SYRINGE (INSULIN SYRINGE-

NEEDLE U-100) 31G X 5/16" 0.5 ML

Tier 2 Tier 1

PURE COMFORT PEN NEEDLE 32G X 4 MM , 32G X 5

MM , 32G X 6 MM

Tier 2

PURE COMFORT SAFETY PEN NEEDLE 31G X 5 MM ,

31G X 6 MM , 32G X 4 MM

Tier 2

PX EXTRA SHORT PEN NEEDLES 31G X 6 MM Tier 2

PX INSULIN SYRINGE 30G X 1/2" 0.5 ML Tier 2

PX MINI PEN NEEDLES 31G X 5 MM Tier 2

PX PEN NEEDLE 29G X 12MM , 31G X 8 MM Tier 2

PX SHORTLENGTH PEN NEEDLES 31G X 8 MM Tier 2

QC PEN NEEDLES 29G X 12MM , 31G X 6 MM , 31G X

8 MM

Tier 2

QC UNIFINE PENTIPS 32G X 4 MM Tier 2

RA INSULIN SYRINGE 29G X 1/2" 0.5 ML, 29G X 1/2"

1 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML

Tier 2

RA PEN NEEDLES 31G X 5 MM , 31G X 8 MM Tier 2

RAYA SURE PEN NEEDLE 29G X 12MM , 31G X 5 MM

, 31G X 6 MM , 31G X 8 MM

Tier 2

REALITY INSULIN SYRINGE 28G X 1/2" 0.5 ML, 28G

X 1/2" 1 ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML

Tier 2

RELION INSULIN SYRINGE (INSULIN SYRINGE)

29G X 1/2" 0.5 ML

Tier 2 Tier 2

RELION INSULIN SYRINGE (TECHLITE INSULIN

SYRINGE) 31G X 15/64" 0.3 ML, 31G X 15/64" 0.5 ML,

31G X 15/64" 1 ML

Tier 2 Tier 2

RELION INSULIN SYRINGE (INSULIN SYRINGE-

NEEDLE U-100) 31G X 5/16" 0.3 ML

Tier 2 Tier 2

RELION INSULIN SYRINGE (INSULIN SYRINGE-

NEEDLE U-100) 31G X 5/16" 0.5 ML, 31G X 5/16" 1

Tier 2 Tier 1

RELION MINI PEN NEEDLES (MEIJER PEN

NEEDLES) 31G X 6 MM

Tier 2 Tier 2

RELION PEN NEEDLES (KROGER PEN NEEDLES)

29G X 12MM

Tier 2 Tier 2

RELION PEN NEEDLES (MEIJER PEN NEEDLES)

31G X 6 MM

Tier 2 Tier 2

RELION PEN NEEDLES (PEN NEEDLES 5/16") 31G X

8 MM

Tier 2 Tier 2

RELION PEN NEEDLES (INSUPEN PEN NEEDLES)

32G X 4 MM

Tier 2 Tier 2

113

Drug Name Brand Tier Generic Tier Formulary Notes

RELION SHORT PEN NEEDLES (PEN NEEDLES

5/16") 31G X 8 MM

Tier 2 Tier 2

SAFETY PEN NEEDLES 30G X 5 MM , 30G X 8 MM Tier 2

SB INSULIN SYRINGE 29G X 1/2" 0.5 ML, 29G X 1/2" 1

ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16"

1 ML

Tier 2

SECURESAFE INSULIN SYRINGE (INSULIN

SYRINGE) 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML

Tier 2 Tier 2

SECURESAFE SAFETY PEN NEEDLES (SURE

COMFORT PEN NEEDLES) 30G X 8 MM

Tier 2 Tier 2

SECURESAFE SYRINGE/NEEDLE (SYRINGE) 22G X

1-1/2" 3 ML, 25G X 5/8" 3 ML

Tier 2 Tier 2

SECURESAFE SYRINGE/NEEDLE 25G X 1-1/2" 1

Tier 2

SHOPKO UNIFINE PENTIPS (KROGER PEN

NEEDLES) 29G X 12MM

Tier 2 Tier 2

SHOPKO UNIFINE PENTIPS (SURE COMFORT PEN

NEEDLES) 31G X 5 MM

Tier 2 Tier 2

SHOPKO UNIFINE PENTIPS (PEN NEEDLES 5/16")

31G X 8 MM

Tier 2 Tier 2

SHOPKO UNIFINE PENTIPS (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

SHOPKO UNIFINE PENTIPS PLUS (KROGER PEN

NEEDLES) 29G X 12MM

Tier 2 Tier 2

SHOPKO UNIFINE PENTIPS PLUS (SURE

COMFORT PEN NEEDLES) 31G X 5 MM

Tier 2 Tier 2

SHOPKO UNIFINE PENTIPS PLUS (PEN NEEDLES

5/16") 31G X 8 MM

Tier 2 Tier 2

SHOPKO UNIFINE PENTIPS PLUS (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

SURE COMFORT INSULIN SYRINGE 28G X 1/2" 0.5

Tier 2

SURE COMFORT INSULIN SYRINGE 28G X 1/2" 1 ML Tier 2

SURE COMFORT INSULIN SYRINGE 29G X 1/2" 0.3

Tier 2

SURE COMFORT INSULIN SYRINGE 29G X 1/2" 0.5

Tier 2

SURE COMFORT INSULIN SYRINGE 29G X 1/2" 1 ML Tier 2

SURE COMFORT INSULIN SYRINGE 30G X 1/2" 1 ML Tier 2

SURE COMFORT INSULIN SYRINGE 30G X 5/16" 0.3

ML (RX)

Tier 2

SURE COMFORT INSULIN SYRINGE 30G X 5/16" 0.5

ML (RX)

Tier 2

SURE COMFORT INSULIN SYRINGE 30G X 5/16" 1

ML (RX)

Tier 2

SURE COMFORT INSULIN SYRINGE 31G X 5/16" 0.3

ML (OTC)

Tier 2

SURE COMFORT INSULIN SYRINGE 31G X 5/16" 0.3

ML (RX)

Tier 2

SURE COMFORT INSULIN SYRINGE 31G X 5/16" 0.5

Tier 2

114

Drug Name Brand Tier Generic Tier Formulary Notes

SURE COMFORT INSULIN SYRINGE 31G X 5/16" 1

Tier 2

SURE COMFORT PEN NEEDLES 31G X 6 MM , 31G X

8 MM , 32G X 4 MM

Tier 2

SYRINGE LUER LOCK 22G X 1-1/2" 3 ML, 23G X 1" 3

ML, 25G X 5/8" 3 ML

Tier 2

TECHLITE INSULIN SYRINGE 29G X 1/2" 1 ML, 30G X

1/2" 0.5 ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G

X 5/16" 0.5 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5

ML, 31G X 5/16" 1 ML

Tier 2

TECHLITE PEN NEEDLES (KROGER PEN

NEEDLES) 29G X 12MM

Tier 2 Tier 2

TECHLITE PEN NEEDLES (SURE COMFORT PEN

NEEDLES) 31G X 5 MM , 32G X 6 MM

Tier 2 Tier 2

TECHLITE PEN NEEDLES (PEN NEEDLES 5/16")

31G X 8 MM

Tier 2 Tier 2

TECHLITE PLUS PEN NEEDLES (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

TODAYS HEALTH MINI PEN NEEDLES 31G X 6 MM Tier 2

TODAYS HEALTH PEN NEEDLES 29G X 12MM Tier 2

TODAYS HEALTH SHORT PEN NEEDLE 31G X 8 MM Tier 2

TOPCARE CLICKFINE PEN NEEDLES 31G X 6 MM ,

31G X 8 MM

Tier 2

TOPCARE ULTRA COMFORT INS SYR 29G X 1/2" 0.3

ML, 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML, 30G X 5/16"

0.3 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X

5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2

TRUE COMFORT INSULIN SYRINGE 30G X 1/2" 0.5

ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.5 ML, 30G X 5/16"

1 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML, 32G X

5/16" 1 ML

Tier 2

TRUE COMFORT PEN NEEDLES 31G X 5 MM , 31G X

6 MM , 32G X 4 MM

Tier 2

TRUE COMFORT PRO INSULIN SYR 30G X 1/2" 0.5

ML, 30G X 1/2" 1 ML, 30G X 5/16" 0.5 ML, 30G X 5/16"

1 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML, 32G X

5/16" 0.5 ML, 32G X 5/16" 1 ML

Tier 2

TRUE COMFORT PRO PEN NEEDLES 31G X 5 MM ,

31G X 6 MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM

, 32G X 6 MM , 33G X 4 MM , 33G X 5 MM , 33G X 6

Tier 2

TRUEPLUS 5-BEVEL PEN NEEDLES (SURE

COMFORT PEN NEEDLES) 29G X 12.7MM , 31G X 5

Tier 2 Tier 2

TRUEPLUS 5-BEVEL PEN NEEDLES (MEIJER PEN

NEEDLES) 31G X 6 MM

Tier 2 Tier 2

TRUEPLUS 5-BEVEL PEN NEEDLES (PEN NEEDLES

5/16") 31G X 8 MM

Tier 2 Tier 2

TRUEPLUS 5-BEVEL PEN NEEDLES (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

TRUEPLUS INSULIN SYRINGE (INSULIN

SYRINGE/NEEDLE) 28G X 1/2" 0.5 ML, 28G X 1/2" 1

Tier 2 Tier 2

115

Drug Name Brand Tier Generic Tier Formulary Notes

TRUEPLUS INSULIN SYRINGE (KROGER INSULIN

SYRINGE) 29G X 1/2" 0.3 ML

Tier 2 Tier 2

TRUEPLUS INSULIN SYRINGE (INSULIN SYRINGE)

29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML

Tier 2 Tier 2

TRUEPLUS INSULIN SYRINGE (INSULIN SYRINGE-

NEEDLE U-100) 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5

ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML

Tier 2 Tier 2

TRUEPLUS INSULIN SYRINGE (INSULIN SYRINGE-

NEEDLE U-100) 31G X 5/16" 0.5 ML, 31G X 5/16" 1

Tier 2 Tier 1

TRUEPLUS PEN NEEDLES (KROGER PEN

NEEDLES) 29G X 12MM

Tier 2 Tier 2

TRUEPLUS PEN NEEDLES (SURE COMFORT PEN

NEEDLES) 31G X 5 MM

Tier 2 Tier 2

TRUEPLUS PEN NEEDLES (MEIJER PEN NEEDLES)

31G X 6 MM

Tier 2 Tier 2

TRUEPLUS PEN NEEDLES (PEN NEEDLES 5/16")

31G X 8 MM

Tier 2 Tier 2

TRUEPLUS PEN NEEDLES (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

ULTICARE INSULIN SAFETY SYR (INSULIN

SYRINGE) 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML

Tier 2 Tier 2

ULTICARE INSULIN SYR 1/2 UNIT (SURE

COMFORT INSULIN SYRINGE) 31G X 1/4" 0.3 ML

Tier 2 Tier 1

ULTICARE INSULIN SYRINGE (INSULIN

SYRINGE/NEEDLE) 28G X 1/2" 0.5 ML, 28G X 1/2" 1

Tier 2 Tier 2

ULTICARE INSULIN SYRINGE (KROGER INSULIN

SYRINGE) 29G X 1/2" 0.3 ML

Tier 2 Tier 2

ULTICARE INSULIN SYRINGE (INSULIN SYRINGE)

29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML

Tier 2 Tier 2

ULTICARE INSULIN SYRINGE (SURE COMFORT

INSULIN SYRINGE) 30G X 1/2" 0.3 ML

Tier 2 Tier 2

ULTICARE INSULIN SYRINGE (SURE COMFORT

INSULIN SYRINGE) 30G X 1/2" 0.5 ML, 31G X 1/4" 0.3

ML, 31G X 1/4" 0.5 ML, 31G X 1/4" 1 ML

Tier 2 Tier 1

ULTICARE INSULIN SYRINGE (INSULIN SYRINGE-

NEEDLE U-100) 30G X 1/2" 1 ML, 31G X 5/16" 0.5 ML,

31G X 5/16" 1 ML

Tier 2 Tier 1

ULTICARE INSULIN SYRINGE (INSULIN SYRINGE-

NEEDLE U-100) 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5

ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML

Tier 2 Tier 2

ULTICARE MICRO PEN NEEDLES (MEIJER PEN

NEEDLES) 31G X 6 MM

Tier 2 Tier 2

ULTICARE MICRO PEN NEEDLES (PEN NEEDLES

5/16") 31G X 8 MM

Tier 2 Tier 2

ULTICARE MICRO PEN NEEDLES (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

ULTICARE MINI PEN NEEDLES (PEN NEEDLES)

30G X 5 MM

Tier 2 Tier 1

ULTICARE MINI PEN NEEDLES (MEIJER PEN

NEEDLES) 31G X 6 MM

Tier 2 Tier 2

116

Drug Name Brand Tier Generic Tier Formulary Notes

ULTICARE MINI PEN NEEDLES (SURE COMFORT

PEN NEEDLES) 32G X 6 MM

Tier 2 Tier 2

ULTICARE PEN NEEDLES (SURE COMFORT PEN

NEEDLES) 29G X 12.7MM , 31G X 5 MM

Tier 2 Tier 2

ULTICARE SHORT PEN NEEDLES (SURE

COMFORT PEN NEEDLES) 30G X 8 MM

Tier 2 Tier 2

ULTICARE SHORT PEN NEEDLES (PEN NEEDLES

5/16") 31G X 8 MM

Tier 2 Tier 2

ULTICARE SYRINGE (SYRINGE) 22G X 1-1/2" 3 ML Tier 2 Tier 2

ULTICARE TUBERCULIN SAFETY SYR

(TUBERCULIN SYRINGE) 25G X 5/8" 1 ML

Tier 2 Tier 2

ULTIGUARD SAFEPACK PEN NEEDLE (SURE

COMFORT PEN NEEDLES) 29G X 12.7MM , 31G X 5

MM , 32G X 6 MM

Tier 2 Tier 2

ULTIGUARD SAFEPACK PEN NEEDLE (MEIJER

PEN NEEDLES) 31G X 6 MM

Tier 2 Tier 2

ULTIGUARD SAFEPACK PEN NEEDLE (PEN

NEEDLES 5/16") 31G X 8 MM

Tier 2 Tier 2

ULTIGUARD SAFEPACK PEN NEEDLE (INSUPEN

PEN NEEDLES) 32G X 4 MM

Tier 2 Tier 2

ULTIGUARD SAFEPACK SYR/NEEDLE (SURE

COMFORT INSULIN SYRINGE) 30G X 1/2" 0.3 ML

Tier 2 Tier 2

ULTIGUARD SAFEPACK SYR/NEEDLE (SURE

COMFORT INSULIN SYRINGE) 30G X 1/2" 0.5 ML

Tier 2 Tier 1

ULTIGUARD SAFEPACK SYR/NEEDLE (INSULIN

SYRINGE-NEEDLE U-100) 30G X 1/2" 1 ML, 31G X

5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2 Tier 1

ULTIGUARD SAFEPACK SYR/NEEDLE (INSULIN

SYRINGE-NEEDLE U-100) 31G X 5/16" 0.3 ML

Tier 2 Tier 2

ULTILET PEN NEEDLE (SURE COMFORT PEN

NEEDLES) 29G X 12.7MM , 31G X 5 MM

Tier 2 Tier 2

ULTILET PEN NEEDLE (PEN NEEDLES 5/16") 31G X

8 MM

Tier 2 Tier 2

ULTILET PEN NEEDLE (INSUPEN PEN NEEDLES)

32G X 4 MM

Tier 2 Tier 2

ULTRA COMFORT INSULIN SYRINGE 30G X 5/16" 0.3

Tier 2

ULTRA FLO INSULIN PEN NEEDLES (KROGER

PEN NEEDLES) 29G X 12MM

Tier 2 Tier 2

ULTRA FLO INSULIN PEN NEEDLES (SURE

COMFORT PEN NEEDLES) 31G X 5 MM

Tier 2 Tier 2

ULTRA FLO INSULIN PEN NEEDLES (PEN

NEEDLES 5/16") 31G X 8 MM

Tier 2 Tier 2

ULTRA FLO INSULIN PEN NEEDLES (INSUPEN

PEN NEEDLES) 32G X 4 MM , 33G X 4 MM

Tier 2 Tier 2

ULTRA FLO INSULIN SYR 1/2 UNIT (SURE

COMFORT INSULIN SYRINGE) 30G X 1/2" 0.3 ML

Tier 2 Tier 2

ULTRA FLO INSULIN SYR 1/2 UNIT (INSULIN

SYRINGE-NEEDLE U-100) 30G X 5/16" 0.3 ML, 31G X

5/16" 0.3 ML

Tier 2 Tier 2

ULTRA FLO INSULIN SYRINGE (KROGER INSULIN

SYRINGE) 29G X 1/2" 0.3 ML

Tier 2 Tier 2

117

Drug Name Brand Tier Generic Tier Formulary Notes

ULTRA FLO INSULIN SYRINGE (INSULIN

SYRINGE) 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML

Tier 2 Tier 2

ULTRA FLO INSULIN SYRINGE (SURE COMFORT

INSULIN SYRINGE) 30G X 1/2" 0.3 ML

Tier 2 Tier 2

ULTRA FLO INSULIN SYRINGE (SURE COMFORT

INSULIN SYRINGE) 30G X 1/2" 0.5 ML

Tier 2 Tier 1

ULTRA FLO INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 30G X 1/2" 1 ML, 31G X

5/16" 0.5 ML, 31G X 5/16" 1 ML

Tier 2 Tier 1

ULTRA FLO INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 30G X 5/16" 0.3 ML, 30G X

5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML

Tier 2 Tier 2

ULTRA THIN PEN NEEDLES (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

ULTRACARE INSULIN SYRINGE 30G X 1/2" 0.5 ML,

30G X 1/2" 1 ML, 30G X 5/16" 0.3 ML, 30G X 5/16" 0.5

ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML, 31G X 5/16"

0.5 ML, 31G X 5/16" 1 ML

Tier 2

ULTRACARE PEN NEEDLES 31G X 5 MM , 31G X 6

MM , 31G X 8 MM , 32G X 4 MM , 32G X 5 MM , 32G X

6 MM , 33G X 4 MM

Tier 2

ULTRA-THIN II INS SYR SHORT (INSULIN

SYRINGE-NEEDLE U-100) 30G X 5/16" 0.3 ML, 30G X

5/16" 0.5 ML, 30G X 5/16" 1 ML, 31G X 5/16" 0.3 ML

Tier 2 Tier 2

ULTRA-THIN II INS SYR SHORT (INSULIN

SYRINGE-NEEDLE U-100) 31G X 5/16" 0.5 ML, 31G X

5/16" 1 ML

Tier 2 Tier 1

ULTRA-THIN II INSULIN SYRINGE (INSULIN

SYRINGE) 29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML

Tier 2 Tier 2

ULTRA-THIN II MINI PEN NEEDLE (SURE

COMFORT PEN NEEDLES) 31G X 5 MM

Tier 2 Tier 2

ULTRA-THIN II PEN NEEDLE SHORT (PEN

NEEDLES 5/16") 31G X 8 MM

Tier 2 Tier 2

ULTRA-THIN II PEN NEEDLES (SURE COMFORT

PEN NEEDLES) 29G X 12.7MM

Tier 2 Tier 2

UNIFINE PEN NEEDLES (INSUPEN PEN NEEDLES)

32G X 4 MM

Tier 2 Tier 2

UNIFINE PENTIPS (KROGER PEN NEEDLES) 29G X

12MM

Tier 2 Tier 2

UNIFINE PENTIPS (PEN NEEDLES) 30G X 5 MM Tier 2 Tier 1

UNIFINE PENTIPS (SURE COMFORT PEN NEEDLES)

31G X 5 MM , 32G X 6 MM

Tier 2 Tier 2

UNIFINE PENTIPS (MEIJER PEN NEEDLES) 31G X 6

Tier 2 Tier 2

UNIFINE PENTIPS (PEN NEEDLES 5/16") 31G X 8

Tier 2 Tier 2

UNIFINE PENTIPS (INSUPEN PEN NEEDLES) 32G X

4 MM , 33G X 4 MM

Tier 2 Tier 2

UNIFINE PENTIPS PLUS (KROGER PEN NEEDLES)

29G X 12MM

Tier 2 Tier 2

UNIFINE PENTIPS PLUS (PEN NEEDLES) 30G X 5

Tier 2 Tier 1

118

Drug Name Brand Tier Generic Tier Formulary Notes

UNIFINE PENTIPS PLUS (SURE COMFORT PEN

NEEDLES) 31G X 5 MM

Tier 2 Tier 2

UNIFINE PENTIPS PLUS (MEIJER PEN NEEDLES)

31G X 6 MM

Tier 2 Tier 2

UNIFINE PENTIPS PLUS (PEN NEEDLES 5/16") 31G

X 8 MM

Tier 2 Tier 2

UNIFINE PENTIPS PLUS (INSUPEN PEN NEEDLES)

32G X 4 MM , 33G X 4 MM

Tier 2 Tier 2

UNIFINE PROTECT PEN NEEDLE (PEN NEEDLES)

30G X 5 MM

Tier 2 Tier 1

UNIFINE PROTECT PEN NEEDLE (SURE COMFORT

PEN NEEDLES) 30G X 8 MM

Tier 2 Tier 2

UNIFINE PROTECT PEN NEEDLE (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

UNIFINE SAFECONTROL PEN NEEDLE (PEN

NEEDLES) 30G X 5 MM

Tier 2 Tier 1

UNIFINE SAFECONTROL PEN NEEDLE (SURE

COMFORT PEN NEEDLES) 30G X 8 MM , 31G X 5

Tier 2 Tier 2

UNIFINE SAFECONTROL PEN NEEDLE (MEIJER

PEN NEEDLES) 31G X 6 MM

Tier 2 Tier 2

UNIFINE SAFECONTROL PEN NEEDLE (PEN

NEEDLES 5/16") 31G X 8 MM

Tier 2 Tier 2

UNIFINE SAFECONTROL PEN NEEDLE (INSUPEN

PEN NEEDLES) 32G X 4 MM

Tier 2 Tier 2

UNIFINE ULTRA PEN NEEDLE (SURE COMFORT

PEN NEEDLES) 31G X 5 MM

Tier 2 Tier 2

UNIFINE ULTRA PEN NEEDLE (MEIJER PEN

NEEDLES) 31G X 6 MM

Tier 2 Tier 2

UNIFINE ULTRA PEN NEEDLE (PEN NEEDLES

5/16") 31G X 8 MM

Tier 2 Tier 2

UNIFINE ULTRA PEN NEEDLE (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

VALUE HEALTH INSULIN SYRINGE 29G X 1/2" 0.5

ML, 29G X 1/2" 1 ML

Tier 2

VALUMARK PEN NEEDLES 29G X 12MM , 31G X 6

MM , 31G X 8 MM

Tier 2

VANISHPOINT INSULIN SYRINGE (INSULIN

SYRINGE) 29G X 1/2" 1 ML

Tier 2 Tier 2

VANISHPOINT INSULIN SYRINGE 29G X 5/16" 1

ML, 30G X 3/16" 0.5 ML, 30G X 3/16" 1 ML

Tier 2

VANISHPOINT INSULIN SYRINGE (SURE

COMFORT INSULIN SYRINGE) 30G X 1/2" 0.5 ML

Tier 2 Tier 1

VANISHPOINT INSULIN SYRINGE (INSULIN

SYRINGE-NEEDLE U-100) 30G X 5/16" 0.5 ML, 30G X

5/16" 1 ML

Tier 2 Tier 2

VANISHPOINT SAFETY SYRINGE (SYRINGE) 22G

X 1-1/2" 3 ML, 23G X 1" 3 ML, 25G X 5/8" 3 ML

Tier 2 Tier 2

VANISHPOINT SYRINGE (SYRINGE) 22G X 1-1/2" 3

ML, 23G X 1" 3 ML, 25G X 5/8" 3 ML

Tier 2 Tier 2

119

Drug Name Brand Tier Generic Tier Formulary Notes

VANISHPOINT TUBERCULIN SYRINGE

(TUBERCULIN SYRINGE) 25G X 5/8" 1 ML, 27G X

1/2" 1 ML

Tier 2 Tier 2

VERIFINE INSULIN PEN NEEDLE (KROGER PEN

NEEDLES) 29G X 12MM

Tier 2 Tier 2

VERIFINE INSULIN PEN NEEDLE (SURE COMFORT

PEN NEEDLES) 31G X 5 MM , 32G X 6 MM

Tier 2 Tier 2

VERIFINE INSULIN PEN NEEDLE (PEN NEEDLES

5/16") 31G X 8 MM

Tier 2 Tier 2

VERIFINE INSULIN PEN NEEDLE (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

VERIFINE INSULIN SYRINGE (INSULIN SYRINGE)

29G X 1/2" 0.5 ML, 29G X 1/2" 1 ML

Tier 2 Tier 2

VERIFINE INSULIN SYRINGE (INSULIN SYRINGE-

NEEDLE U-100) 31G X 5/16" 0.3 ML

Tier 2 Tier 2

VERIFINE INSULIN SYRINGE (INSULIN SYRINGE-

NEEDLE U-100) 31G X 5/16" 0.5 ML, 31G X 5/16" 1

Tier 2 Tier 1

VERIFINE PLUS PEN NEEDLE (SURE COMFORT

PEN NEEDLES) 31G X 5 MM

Tier 2 Tier 2

VERIFINE PLUS PEN NEEDLE (PEN NEEDLES

5/16") 31G X 8 MM

Tier 2 Tier 2

VERIFINE PLUS PEN NEEDLE (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

VIDA MIA UNIFINE PENTIPS (KROGER PEN

NEEDLES) 29G X 12MM

Tier 2 Tier 2

VIDA MIA UNIFINE PENTIPS (MEIJER PEN

NEEDLES) 31G X 6 MM

Tier 2 Tier 2

VIDA MIA UNIFINE PENTIPS (PEN NEEDLES 5/16")

31G X 8 MM

Tier 2 Tier 2

VIDA MIA UNIFINE PENTIPS (INSUPEN PEN

NEEDLES) 32G X 4 MM

Tier 2 Tier 2

VP INSULIN SYRINGE 29G X 1/2" 0.3 ML Tier 2

WEGMANS UNIFINE PENTIPS PLUS 31G X 5 MM ,

31G X 6 MM , 31G X 8 MM , 32G X 4 MM

Tier 2

ZEVRX INSULIN SYRINGE 30G X 1/2" 0.5 ML, 30G X

1/2" 1 ML, 30G X 5/16" 0.5 ML, 30G X 5/16" 1 ML

Tier 2

ZEVRX PEN NEEDLES 31G X 5 MM , 31G X 6 MM ,

31G X 8 MM , 32G X 4 MM

Tier 2

*Spacer/Aerosol-Holding Chambers & Supplies***

AEROCHAMBER MINI CHAMBER DEVICE Tier 4

AEROCHAMBER MV Tier 4

AEROCHAMBER PLUS FLO-VU Tier 4

AEROCHAMBER PLUS FLO-VU LARGE Tier 4

AEROCHAMBER PLUS FLO-VU LARGE DEVICE Tier 4

AEROCHAMBER PLUS FLO-VU MEDIUM Tier 4

AEROCHAMBER PLUS FLO-VU MEDIUM DEVICE Tier 4

AEROCHAMBER PLUS FLO-VU SMALL Tier 4

AEROCHAMBER PLUS FLO-VU SMALL DEVICE Tier 4

AEROCHAMBER PLUS FLO-VU W/MASK Tier 4

120

Drug Name Brand Tier Generic Tier Formulary Notes

AEROCHAMBER PLUS FLOW VU Tier 4

AEROCHAMBER W/FLOWSIGNAL Tier 4

AEROCHAMBER Z-STAT PLUS Tier 4

AEROCHAMBER Z-STAT PLUS CHAMBR Tier 4

AEROCHAMBER Z-STAT PLUS/LARGE Tier 4

AEROCHAMBER Z-STAT PLUS/MEDIUM Tier 4

AEROCHAMBER Z-STAT PLUS/SMALL Tier 4

EASIVENT Tier 4

EASIVENT MASK LARGE Tier 4

EASIVENT MASK MEDIUM Tier 4

EASIVENT MASK SMALL Tier 4

*Migraine Products*

*Calcitonin Gene-Related Peptide Receptor Antag

(Cgrp)***

NURTEC ORAL TABLET DISPERSIBLE 75 MG Tier 4 PA; QL (8 EA per 30 days)

UBRELVY ORAL TABLET 100 MG, 50 MG Tier 4 PA; QL (10 EA per 30 days)

*Cgrp Receptor Antagonists - Monocolonal

Antibodies***

AIMOVIG SUBCUTANEOUS SOLUTION AUTO-

INJECTOR 140 MG/ML, 70 MG/ML

Tier 6 PA; QL (1 ML per 30 days)

AJOVY SUBCUTANEOUS SOLUTION AUTO-

INJECTOR 225 MG/1.5ML

Tier 6 PA

AJOVY SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 225 MG/1.5ML

Tier 6 PA

EMGALITY (300 MG DOSE) SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE 100 MG/ML

Tier 6 PA; QL (3 ML per 30 days)

*Ergot Combinations***

MIGERGOT RECTAL SUPPOSITORY 2-100 MG Tier 4

*Migraine Products***

DIHYDROERGOTAMINE MESYLATE NASAL

SOLUTION 4 MG/ML

Tier 3 QL (12 ML per 30 days)

*Selective Serotonin Agonists 5-Ht(1)***

ELETRIPTAN HYDROBROMIDE ORAL TABLET 20

MG, 40 MG

Tier 3 QL (12 EA per 30 days)

NARATRIPTAN HCL ORAL TABLET 1 MG, 2.5 MG Tier 3 QL (12 EA per 30 days)

RIZATRIPTAN BENZOATE ORAL TABLET 10 MG, 5

Tier 2 QL (12 EA per 30 days)

RIZATRIPTAN BENZOATE ORAL TABLET

DISPERSIBLE 10 MG, 5 MG

Tier 3 QL (12 EA per 30 days)

SUMATRIPTAN NASAL SOLUTION 20 MG/ACT, 5

MG/ACT

Tier 3 ST

SUMATRIPTAN SUCCINATE ORAL TABLET 100 MG,

25 MG, 50 MG

Tier 2 QL (12 EA per 30 days)

SUMATRIPTAN SUCCINATE REFILL SOLUTION

CARTRIDGE 4 MG/0.5ML SUBCUTANEOUS

Tier 3 QL (12 ML per 30 days)

SUMATRIPTAN SUCCINATE REFILL SOLUTION

CARTRIDGE 6 MG/0.5ML SUBCUTANEOUS

Tier 3 QL (8 ML per 30 days)

121

Drug Name Brand Tier Generic Tier Formulary Notes

SUMATRIPTAN SUCCINATE SOLUTION AUTO-

INJECTOR 4 MG/0.5ML SUBCUTANEOUS

Tier 3 QL (12 ML per 30 days)

SUMATRIPTAN SUCCINATE SOLUTION AUTO-

INJECTOR 6 MG/0.5ML SUBCUTANEOUS

Tier 3 QL (8 ML per 30 days)

SUMATRIPTAN SUCCINATE SUBCUTANEOUS

SOLUTION 6 MG/0.5ML

Tier 3 QL (8 ML per 30 days)

ZOLMITRIPTAN NASAL SOLUTION 5 MG Tier 3 ST

ZOLMITRIPTAN ORAL TABLET 2.5 MG, 5 MG Tier 3 QL (12 EA per 30 days)

ZOLMITRIPTAN ORAL TABLET DISPERSIBLE 2.5

MG, 5 MG

Tier 3 QL (12 EA per 30 days)

*Selective Serotonin Agonists 5-Ht(1F)***

REYVOW ORAL TABLET 100 MG, 50 MG Tier 6 PA; QL (4 EA per 28 days)

*Minerals & Electrolytes*

*Fluoride***

NAFRINSE DROPS ORAL SOLUTION (FLUORITAB)

0.275 (0.125 F) MG/DROP

Tier 1 Tier 1

NAFRINSE ORAL TABLET CHEWABLE (SODIUM

FLUORIDE) 2.2 (1 F) MG

Tier 1 Tier 1

SODIUM FLUORIDE ORAL SOLUTION 0.5 MG/ML Tier 1

SODIUM FLUORIDE ORAL TABLET CHEWABLE 0.55

(0.25 F) MG, 1.1 (0.5 F) MG

Tier 1

SOLUVITA ORAL SOLUTION (SODIUM FLUORIDE)

0.5 MG/ML

Tier 1 Tier 1

*Phosphate***

PHOSPHO-TRIN 250 NEUTRAL ORAL TABLET

(PHOSPHOROUS) 155-852-130 MG

Tier 2 Tier 2

WES-PHOS 250 NEUTRAL ORAL TABLET 155-852-130

Tier 2

*Potassium***

EFFER-K ORAL TABLET EFFERVESCENT 25 MEQ Tier 1

KLOR-CON 10 ORAL TABLET EXTENDED

RELEASE (POTASSIUM CHLORIDE ER) 10 MEQ

Tier 1 Tier 1

KLOR-CON M10 ORAL TABLET EXTENDED

RELEASE (POTASSIUM CHLORIDE CRYS ER) 10

MEQ

Tier 1 Tier 1

KLOR-CON M15 ORAL TABLET EXTENDED

RELEASE (POTASSIUM CHLORIDE ER) 15 MEQ

Tier 3 Tier 3

KLOR-CON M20 ORAL TABLET EXTENDED

RELEASE (POTASSIUM CHLORIDE CRYS ER) 20

MEQ

Tier 1 Tier 1

KLOR-CON ORAL PACKET (POTASSIUM

CHLORIDE) 20 MEQ

Tier 3 Tier 3

KLOR-CON ORAL TABLET EXTENDED RELEASE

(POTASSIUM CHLORIDE ER) 8 MEQ

Tier 1 Tier 1

K-PRIME ORAL TABLET EFFERVESCENT 25 MEQ Tier 1

POTASSIUM CHLORIDE CRYS ER TABLET

EXTENDED RELEASE 15 MEQ ORAL

Tier 3

POTASSIUM CHLORIDE ER ORAL CAPSULE

EXTENDED RELEASE 10 MEQ

Tier 1

122

Drug Name Brand Tier Generic Tier Formulary Notes

POTASSIUM CHLORIDE ER TABLET EXTENDED

RELEASE 20 MEQ ORAL

Tier 3

POTASSIUM CHLORIDE ORAL SOLUTION 10 %, 20

MEQ/15ML (10%), 40 MEQ/15ML (20%)

Tier 3

*Miscellaneous Therapeutic Classes*

*Antileprotics***

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200

MG, 50 MG

Tier 6 PA; Specialty; QL (2 EA per 1 day)

*Chelating Agents***

TRIENTINE HCL ORAL CAPSULE 500 MG Tier 3 Specialty

*Cyclosporine Analogs***

CYCLOSPORINE MODIFIED ORAL CAPSULE 50 MG Tier 3

CYCLOSPORINE ORAL CAPSULE 100 MG, 25 MG Tier 3

GENGRAF ORAL CAPSULE (CYCLOSPORINE

MODIFIED) 100 MG, 25 MG

Tier 3 Tier 3

GENGRAF ORAL SOLUTION (CYCLOSPORINE

MODIFIED) 100 MG/ML

Tier 3 Tier 3

SANDIMMUNE ORAL SOLUTION 100 MG/ML Tier 4

*Homeopathic Products***

HYLAFEM VAGINAL SUPPOSITORY Tier 5

*Immunomodulators For Myelodysplastic

Syndromes***

LENALIDOMIDE ORAL CAPSULE 10 MG, 15 MG, 2.5

MG, 20 MG, 25 MG, 5 MG

Tier 6 PA; Specialty; QL (1 EA per 1 day)

*Inosine Monophosphate Dehydrogenase Inhibitors***

MYCOPHENOLATE MOFETIL ORAL CAPSULE 250

Tier 3

MYCOPHENOLATE MOFETIL ORAL SUSPENSION

RECONSTITUTED 200 MG/ML

Tier 3

MYCOPHENOLATE MOFETIL ORAL TABLET 500 MG Tier 3

*Macrolide Immunosuppressants***

EVEROLIMUS ORAL TABLET 0.25 MG, 0.5 MG, 0.75

MG, 1 MG

Tier 3 PA

SIROLIMUS ORAL SOLUTION 1 MG/ML Tier 3

SIROLIMUS ORAL TABLET 0.5 MG, 1 MG, 2 MG Tier 3

TACROLIMUS ORAL CAPSULE 0.5 MG, 1 MG, 5 MG Tier 3

*Pik3ca-Related Overgrowth Spectrum Agents - Pi3k

Inhib***

VIJOICE TABLET THERAPY PACK 125 MG ORAL Tier 6 PA; Specialty; QL (1 EA per 1 day)

VIJOICE TABLET THERAPY PACK 200 & 50 MG

ORAL

Tier 6 PA; Specialty; QL (2 EA per 1 day)

VIJOICE TABLET THERAPY PACK 50 MG ORAL Tier 6 PA; Specialty; QL (1 EA per 1 day)

*Potassium Removing Agents***

LOKELMA ORAL PACKET 10 GM, 5 GM Tier 5

VELTASSA ORAL PACKET 16.8 GM, 25.2 GM, 8.4

Tier 5

*Purine Analogs***

AZATHIOPRINE TABLET 100 MG ORAL Tier 3

123

Drug Name Brand Tier Generic Tier Formulary Notes

AZATHIOPRINE TABLET 50 MG ORAL Tier 1

AZATHIOPRINE TABLET 75 MG ORAL Tier 3

*Mouth/Throat/Dental Agents*

*Anesthetics Topical Oral***

LIDOCAINE VISCOUS HCL MOUTH/THROAT

SOLUTION 2 %

Tier 3

*Anti-Infectives - Throat***

CLOTRIMAZOLE MOUTH/THROAT TROCHE 10 MG Tier 3

NYSTATIN MOUTH/THROAT SUSPENSION 100000

UNIT/ML

Tier 2

*Antiseptics - Mouth/Throat***

PERIOGARD MOUTH/THROAT SOLUTION

(CHLORHEXIDINE GLUCONATE) 0.12 %

Tier 3 Tier 3

*Fluoride Dental Products***

DENTA 5000 PLUS DENTAL CREAM (SODIUM

FLUORIDE) 1.1 %

Tier 1 Tier 1

PREVIDENT 5000 PLUS DENTAL CREAM (SODIUM

FLUORIDE) 1.1 %

Tier 1 Tier 1

SF 5000 PLUS DENTAL CREAM 1.1 % Tier 1

SODIUM FLUORIDE 5000 PLUS DENTAL CREAM 1.1

Tier 1

SODIUM FLUORIDE 5000 PPM DENTAL CREAM 1.1

Tier 1

*Saliva Stimulants***

CEVIMELINE HCL ORAL CAPSULE 30 MG Tier 3

PILOCARPINE HCL ORAL TABLET 5 MG, 7.5 MG Tier 3

*Steroids - Mouth/Throat/Dental***

KOURZEQ MOUTH/THROAT PASTE

(TRIAMCINOLONE ACETONIDE) 0.1 %

Tier 3 Tier 3

ORALONE MOUTH/THROAT PASTE

(TRIAMCINOLONE ACETONIDE) 0.1 %

Tier 3 Tier 3

*Multivitamins*

*Multivitamins***

DAILY MULTIPLE VITAMINS ORAL TABLET Tier 2

DAILY VALUE MULTIVITAMIN ORAL TABLET Tier 2

DAILY VITAMIN FORMULA ORAL TABLET Tier 2

DAILY VITAMIN ORAL TABLET Tier 2

DAILY VITAMINS ORAL TABLET Tier 2

DAILY VITE ORAL TABLET Tier 2

DAILY VITES ORAL TABLET Tier 2

DAILY-VITAMIN ORAL TABLET Tier 2

DAILY-VITE MULTIVITAMIN ORAL TABLET Tier 2

DAILY-VITE ORAL TABLET Tier 2

ESTROFACTORS ORAL TABLET (ANTI-OXIDANT) Tier 2 Tier 2

GNP ESSENTIAL ONE DAILY ORAL TABLET Tier 2

HEALTHY HAIR/SKIN/NAILS ORAL TABLET Tier 2

HIGH POTENCY MULTIVITAMIN ORAL TABLET Tier 2

124

Drug Name Brand Tier Generic Tier Formulary Notes

MULTI VITAMIN DAILY ORAL TABLET Tier 2

MULTI VITAMIN ORAL TABLET Tier 2

MULTI VITAMIN W/D-3 ORAL TABLET Tier 2

MULTIPLE VITAMIN-FOLIC ACID ORAL TABLET Tier 2

MULTIPLE VITAMINS ESSENTIAL ORAL TABLET Tier 2

MULTIPLE VITAMINS ORAL TABLET Tier 2

MULTIVITAMIN ADULT ORAL TABLET Tier 2

MULTI-VITAMIN DAILY ORAL TABLET Tier 2

MULTIVITAMIN IRON-FREE ORAL TABLET Tier 2

MULTIVITAMIN ORAL TABLET Tier 2

MULTI-VITAMIN ORAL TABLET Tier 2

NEOMULTIVITE ORAL TABLET (ANTI-OXIDANT) Tier 2 Tier 2

OMNICAP ORAL TABLET Tier 2

ONCE DAILY ORAL TABLET Tier 2

ONE DAILY ESSENTIAL ORAL TABLET (ANTI-

OXIDANT)

Tier 2 Tier 2

ONE DAILY ESSENTIALS ORAL TABLET Tier 2

ONE DAILY MULTIVITAMIN ADULT ORAL TABLET Tier 2

ONE DAILY ORAL TABLET Tier 2

ONE VITE DAILY MULTIVITAMIN ORAL TABLET

(ANTI-OXIDANT)

Tier 2 Tier 2

ONE-A-DAY ESSENTIAL ORAL TABLET (ANTI-

OXIDANT)

Tier 2 Tier 2

ONE-A-DAY MENS ORAL TABLET (ANTI-

OXIDANT)

Tier 2 Tier 2

ONE-DAILY MULTI VITAMINS ORAL TABLET Tier 2

ONE-DAILY MULTI-VITAMIN ORAL TABLET Tier 2

QC ESSENTIALS ORAL TABLET Tier 2

QUINTABS ORAL TABLET Tier 2

SM MULTIPLE VITAMINS ESSENTIAL ORAL

TABLET

Tier 2

STRESS FORMULA ORAL TABLET Tier 2

STRESSTABS ENERGY ORAL TABLET (ANTI-

OXIDANT)

Tier 2 Tier 2

TAB-A-VITE ORAL TABLET (ANTI-OXIDANT) Tier 2 Tier 2

TAB-A-VITE/BETA CAROTENE ORAL TABLET

(ANTI-OXIDANT)

Tier 2 Tier 2

THERA ORAL TABLET (ANTI-OXIDANT) Tier 2 Tier 2

THERA-MILL ORAL TABLET Tier 2

THERA-TABS ORAL TABLET Tier 2

THEREMS ORAL TABLET (ANTI-OXIDANT) Tier 2 Tier 2

TRUE DAILY VITE ORAL TABLET Tier 2

VIT E-VIT C-BETA CAROTENE ORAL TABLET 200-

250-5000

Tier 2

VITALEE ORAL TABLET Tier 2

125

Drug Name Brand Tier Generic Tier Formulary Notes

*Ped Multi Vitamins W/Fl & Fe***

MULTI-VITAMIN/FLUORIDE/IRON ORAL SOLUTION

0.25-10 MG/ML

Tier 3

*Ped Mv W/ Fluoride***

MULTIVITAMIN + FLUORIDE ORAL TABLET

CHEWABLE 0.25 MG, 0.5 MG, 1 MG

Tier 2

MULTIVITAMIN W/FLUORIDE ORAL TABLET

CHEWABLE 0.25 MG, 0.5 MG, 1 MG

Tier 2

MULTIVITAMIN/FLUORIDE ORAL SOLUTION 0.25

MG/ML

Tier 2

MULTI-VITAMIN/FLUORIDE ORAL SOLUTION 0.5

MG/ML

Tier 2

MULTI-VIT-FLOR ORAL TABLET CHEWABLE

(MULTIVITAMIN/FLUORIDE) 0.25 MG, 0.5 MG, 1 MG

Tier 2 Tier 2

POLY-VI-FLOR ORAL TABLET CHEWABLE

(MULTIVITAMIN/FLUORIDE) 0.25 MG, 0.5 MG, 1 MG

Tier 2 Tier 2

SOLUVITA WITH FLUORIDE ORAL SOLUTION

(MULTI-VITAMIN/FLUORIDE) 0.25 MG/ML

Tier 2 Tier 2

SOLUVITA WITH FLUORIDE ORAL SOLUTION

(MULTIVITAMIN/FLUORIDE) 0.5 MG/ML

Tier 2 Tier 2

*Ped Vitamins Acd W/ Fluoride***

ADC/F (0.5MG/ML) ORAL SOLUTION 0.5 MG/ML Tier 3

TRI-VITE/FLUORIDE ORAL SOLUTION 0.25 MG/ML,

0.5 MG/ML

Tier 3

VITAMINS ACD-FLUORIDE ORAL SOLUTION 0.25

MG/ML

Tier 3

*Prenatal Mv & Min W/Fe-Fa***

ATABEX EC ORAL TABLET DELAYED RELEASE

29-1 MG

Tier 4

ATABEX OB ORAL TABLET 29-1 MG Tier 2

CLASSIC PRENATAL ORAL TABLET 28-0.8 MG Tier 2

C-NATE DHA ORAL CAPSULE 28-1-200 MG Tier 2

COMPLETENATE ORAL TABLET CHEWABLE 29-1

Tier 2

CO-NATAL FA ORAL TABLET (PRENATABS FA) Tier 2 Tier 1

CONCEPT DHA ORAL CAPSULE (VIRT-C DHA)

53.5-38-1 MG

Tier 2 Tier 2

CONCEPT OB ORAL CAPSULE 130-92.4-1 MG Tier 4

CVS PRENATAL ORAL TABLET 27-0.8 MG Tier 2

ELITE-OB ORAL TABLET 50-1.25 MG Tier 4

EQL PRENATAL FORMULA ORAL TABLET 28-0.8

Tier 2

FOLIVANE-OB ORAL CAPSULE 85-1 MG Tier 4

GNP PRENATAL ORAL TABLET 28-0.8 MG Tier 2

KP PRENATAL MULTIVITAMINS ORAL TABLET 28-

0.8 MG

Tier 2

KPN PRENATAL ORAL TABLET 0.1 MG Tier 2

MASONATAL ORAL TABLET 28-0.8 MG Tier 2

126

Drug Name Brand Tier Generic Tier Formulary Notes

M-NATAL PLUS ORAL TABLET 27-1 MG Tier 2

MULTI PRENATAL ORAL TABLET 27-0.8 MG Tier 2

NATALVIT ORAL TABLET Tier 4

NEONATAL PLUS ORAL TABLET (PRENATAL) 27-1

Tier 2 Tier 2

NEONATAL PRENATAL ORAL TABLET 27-0.8 MG Tier 2

NEONATAL VITAMIN ORAL TABLET (PRENATAL)

27-0.8 MG

Tier 2 Tier 2

NIVA-PLUS ORAL TABLET (PRENATAL) 27-1 MG Tier 2 Tier 2

OBSTETRIX EC (WITH DOCUSATE) ORAL

TABLET 29-1 MG

Tier 2

OBTREX ORAL TABLET Tier 2

ONE VITE WOMENS ORAL TABLET 27-0.8 MG Tier 2

ONE-A-DAY WOMENS PRENATAL ORAL (SM ONE

DAILY PRENATAL) 28-0.8 & 440 MG

Tier 2 Tier 2

PNV PRENATAL PLUS MULTIVIT+DHA ORAL 27-1 &

312 MG

Tier 3

PNV-OMEGA ORAL CAPSULE 28-0.6-0.4-340 MG Tier 2

PNV-SELECT ORAL TABLET 27-0.6-0.4 MG Tier 2

PRENATABS RX ORAL TABLET (THRIVITE RX) 29-

1 MG

Tier 1 Tier 2

PRENATAL (W/IRON & FA) ORAL TABLET 27-0.8 MG Tier 2

PRENATAL 19 ORAL TABLET 29-1 MG Tier 2

PRENATAL 19 ORAL TABLET CHEWABLE Tier 2

PRENATAL COMPLETE ORAL TABLET 14-0.4 MG Tier 2

PRENATAL FORMULA A-FREE ORAL TABLET 9-

0.267 MG

Tier 2

PRENATAL FORTE ORAL TABLET Tier 2

PRENATAL ONE DAILY ORAL TABLET 27-0.8 MG Tier 2

PRENATAL ORAL TABLET 28-0.8 MG Tier 2

PRENATAL PLUS VITAMIN/MINERAL ORAL

TABLET 27-1 MG

Tier 2

PRENATAL VITAMIN AND MINERAL ORAL TABLET

28-0.8 MG

Tier 2

PRENATAL VITAMIN ORAL TABLET 27-0.8 MG Tier 2

PRENATAL VITAMIN PLUS LOW IRON ORAL

TABLET 27-1 MG

Tier 2

PRENATAL VITAMINS ORAL TABLET 28-0.8 MG Tier 2

PRENATAL/IRON ORAL TABLET Tier 2

PRENATAL-U ORAL CAPSULE 106.5-1 MG Tier 2

PRENATVITE PLUS ORAL TABLET 1 MG Tier 1

PRENATVITE RX ORAL TABLET 0.8 MG Tier 1

PX PRENATAL MULTIVITAMINS ORAL TABLET 28-

0.8 MG

Tier 2

QC PRENATAL ORAL TABLET 28-0.8 MG Tier 2

RA PRENATAL FORMULA ORAL TABLET 28-0.8 MG Tier 2

RA PRENATAL ORAL TABLET 28-0.8 MG Tier 2

127

Drug Name Brand Tier Generic Tier Formulary Notes

SE-NATAL 19 ORAL TABLET 29-1 MG Tier 2

SE-NATAL 19 ORAL TABLET CHEWABLE 29-1 MG Tier 2

SM PRENATAL VITAMINS ORAL TABLET 28-0.8 MG Tier 2

TARON-C DHA ORAL CAPSULE 35-1 MG Tier 2

THERANATAL CORE NUTRITION ORAL TABLET

(PRENATAL) 27-1 MG

Tier 2 Tier 2

TRICARE ORAL TABLET (PRENATAL) Tier 2 Tier 2

VINATE II ORAL TABLET 29-1 MG Tier 2

VIVA DHA ORAL CAPSULE (RELNATE DHA) 28-1-

200 MG

Tier 2 Tier 2

WESCAP-C DHA ORAL CAPSULE 53.5-38-1 MG Tier 2

WESTAB PLUS ORAL TABLET 27-1 MG Tier 2

*Prenatal Mv & Min W/Fe-Fa-Ca-Omega 3 Fish Oil***

COMPLETE NATAL DHA ORAL 29-1-200 & 200 MG Tier 2

WESNATAL DHA COMPLETE ORAL 29-1-200 & 200

Tier 2

*Prenatal Mv & Min W/Fe-Fa-Dha***

CADEAU DHA ORAL CAPSULE 29-0.4-0.8-375 MG Tier 2

CVS WOMENS PRENATAL+DHA ORAL 28-0.975 &

200 MG

Tier 2

PNV-DHA+DOCUSATE ORAL CAPSULE 27-1.25-300

Tier 2

PRENA 1 TRUE ORAL 30-1.4 & 300 MG Tier 5

PRENATAL VITAMIN/MIN +DHA ORAL CAPSULE

27-0.8-200 MG

Tier 1

PRENATAL+DHA ORAL 28-0.975 & 200 MG Tier 2

ULTRA PRENATAL + DHA ORAL CAPSULE 27-0.8-

200 MG

Tier 1

VIRT-PN DHA ORAL CAPSULE 27-0.6-0.4-300 MG Tier 2

WESCAP-PN DHA ORAL CAPSULE 27-0.6-0.4-300 MG Tier 2

ZATEAN-PN DHA ORAL CAPSULE (PNV-DHA) 27-

0.6-0.4-300 MG

Tier 2 Tier 2

*Musculoskeletal Therapy Agents*

*Central Muscle Relaxants***

BACLOFEN TABLET 10 MG ORAL Tier 2

BACLOFEN TABLET 15 MG ORAL Tier 3

BACLOFEN TABLET 20 MG ORAL Tier 2

BACLOFEN TABLET 5 MG ORAL Tier 3

CHLORZOXAZONE ORAL TABLET 500 MG Tier 3

CYCLOBENZAPRINE HCL ORAL TABLET 10 MG, 5

Tier 2

METHOCARBAMOL ORAL TABLET 500 MG, 750 MG Tier 2

ORPHENADRINE CITRATE ER ORAL TABLET

EXTENDED RELEASE 12 HOUR 100 MG

Tier 2

TIZANIDINE HCL ORAL CAPSULE 6 MG Tier 3

TIZANIDINE HCL ORAL TABLET 2 MG, 4 MG Tier 2

128

Drug Name Brand Tier Generic Tier Formulary Notes

*Direct Muscle Relaxants***

DANTROLENE SODIUM ORAL CAPSULE 100 MG, 25

MG, 50 MG

Tier 3

*Muscle Relaxant Combinations***

CARISOPRODOL-ASPIRIN-CODEINE ORAL TABLET

200-325-16 MG

Tier 3

*Nasal Agents - Systemic And Topical*

*Nasal Agents - Misc.***

NOZIN NASAL SANITIZER NASAL KIT 62 % Tier 2

NOZIN NASAL SANITIZER POPSWAB NASAL

SWAB

Tier 2

*Nasal Anticholinergics***

IPRATROPIUM BROMIDE NASAL SOLUTION 0.03 %,

0.06 %

Tier 3

*Nasal Antihistamines***

AZELASTINE HCL SOLUTION 0.1 % NASAL Tier 2

AZELASTINE HCL SOLUTION 0.15 % NASAL Tier 3

AZELASTINE HCL SOLUTION 137 MCG/SPRAY

NASAL

Tier 2

*Nasal Steroids***

ALLERGY RELIEF NASAL SUSPENSION 50

MCG/ACT

Tier 2

ALLERGY SPRAY 24 HOUR NASAL SUSPENSION 50

MCG/ACT

Tier 2

CLARISPRAY NASAL SUSPENSION (FLUTICASONE

PROPIONATE) 50 MCG/ACT

Tier 2 Tier 2

CVS FLUTICASONE PROPIONATE NASAL

SUSPENSION 50 MCG/ACT

Tier 2

EQ ALLERGY RELIEF NASAL SUSPENSION 50

MCG/ACT

Tier 2

EQL FLUTICASONE CHILDRENS NASAL

SUSPENSION 50 MCG/ACT

Tier 2

EQL FLUTICASONE PROPIONATE NASAL

SUSPENSION 50 MCG/ACT

Tier 2

FLONASE ALLERGY RELIEF NASAL SUSPENSION

(FLUTICASONE PROPIONATE) 50 MCG/ACT

Tier 2 Tier 2

FLUNISOLIDE NASAL SOLUTION 25 MCG/ACT

(0.025%)

Tier 3

FT ALLERGY RELIEF 24 HR NASAL SUSPENSION 50

MCG/ACT

Tier 2

GNP FLUTICASONE PROPIONATE NASAL

SUSPENSION 50 MCG/ACT

Tier 2

GOODSENSE 24-HR ALLERGY NASAL NASAL

SUSPENSION 50 MCG/ACT

Tier 2

HM ALLERGY RELIEF NASAL SUSPENSION 50

MCG/ACT

Tier 2

KLS ALLER-FLO NASAL SUSPENSION

(FLUTICASONE PROPIONATE) 50 MCG/ACT

Tier 2 Tier 2

MOMETASONE FUROATE NASAL SUSPENSION 50

MCG/ACT

Tier 3

129

Drug Name Brand Tier Generic Tier Formulary Notes

QC ALLERGY RELIEF NASAL SUSPENSION 50

MCG/ACT

Tier 2

SM ALLERGY RELIEF NASAL SUSPENSION 50

MCG/ACT

Tier 2

*Systemic Decongestants***

CVS NASAL DECONGESTANT ORAL TABLET 30 MG Tier 3

EQ SINUS & CONGESTION MAX STR ORAL TABLET

30 MG

Tier 3

EQL NASAL DECONGESTANT ORAL TABLET 30 MG Tier 3

FT NASAL DECONGESTANT MAX STR ORAL

TABLET 30 MG

Tier 3

GNP NASAL DECONGESTANT ORAL TABLET 30 MG Tier 3

HM NASAL DECONGESTANT ORAL TABLET 30 MG Tier 3

KP PSEUDOEPHEDRINE HCL ORAL TABLET 30 MG,

60 MG

Tier 3

MEIJER NASAL DECONGESTANT ORAL TABLET 30

Tier 3

NASAL DECONGESTANT D ORAL TABLET 30 MG Tier 3

NASAL DECONGESTANT MAX ST ORAL TABLET 30

Tier 3

NASAL DECONGESTANT ORAL TABLET 30 MG Tier 3

PSEUDOEPHEDRINE HCL ORAL TABLET 30 MG Tier 3

PX NASAL DECONGESTANT ORAL TABLET 30 MG Tier 3

QC NASAL DECONGESTANT PE ORAL TABLET 30

Tier 3

RA SINUS/CONGESTION RELIEF ORAL TABLET 30

Tier 3

RA SUPHEDRINE ORAL TABLET 30 MG Tier 3

SINUS CONGESTION MAX STRENGTH ORAL

TABLET 30 MG

Tier 3

SM NASAL DECONGESTANT MAX ST ORAL

TABLET 30 MG

Tier 3

SUDAFED ORAL TABLET (DECONGESTANT) 30

Tier 4 Tier 3

SUDAFED SINUS CONGESTION 12HR ORAL

TABLET EXTENDED RELEASE 12 HOUR 120 MG

Tier 4

SUDAFED SINUS CONGESTION ORAL TABLET

(DECONGESTANT) 30 MG

Tier 4 Tier 3

SUDOGEST MAXIMUM STRENGTH ORAL

TABLET (DECONGESTANT) 30 MG

Tier 3 Tier 3

SUDOGEST ORAL TABLET (DECONGESTANT) 30

Tier 3 Tier 3

SUDOGEST ORAL TABLET (PSEUDOEPHEDRINE

HCL) 60 MG

Tier 3 Tier 3

WAL-PHED D ORAL TABLET (DECONGESTANT) 30

Tier 3 Tier 3

130

Drug Name Brand Tier Generic Tier Formulary Notes

*Neuromuscular Agents*

*Depolarizing Muscle Relaxants***

SUCCINYLCHOLINE CHLORIDE INJECTION

SOLUTION 20 MG/ML

Tier 3

*Spinal Muscular Atrophy-Smn2 Splicing Modifiers***

EVRYSDI ORAL SOLUTION RECONSTITUTED 0.75

MG/ML

Tier 6 PA; Specialty; QL (6.7 ML per 1 day)

*Ophthalmic Agents*

*Beta-Blockers - Ophthalmic Combinations***

DORZOLAMIDE HCL-TIMOLOL MAL OPHTHALMIC

SOLUTION 2-0.5 %

Tier 1

*Beta-Blockers - Ophthalmic***

CARTEOLOL HCL OPHTHALMIC SOLUTION 1 % Tier 3

LEVOBUNOLOL HCL OPHTHALMIC SOLUTION 0.5

Tier 3

TIMOLOL MALEATE (ONCE-DAILY) OPHTHALMIC

SOLUTION 0.5 %

Tier 3

TIMOLOL MALEATE OPHTHALMIC SOLUTION 0.25

%, 0.5 %

Tier 1

*Cycloplegic Mydriatics***

ATROPINE SULFATE OPHTHALMIC OINTMENT 1 % Tier 3

ATROPINE SULFATE OPHTHALMIC SOLUTION 1 % Tier 3

*Lymphocyte Function-Associated Antigen-1 (Lfa-1)

Antag***

XIIDRA OPHTHALMIC SOLUTION 5 % Tier 5 PA

*Miotics - Direct Acting***

PILOCARPINE HCL OPHTHALMIC SOLUTION 1 %, 2

%, 4 %

Tier 3

*Ophthalmic Antiallergic***

AZELASTINE HCL OPHTHALMIC SOLUTION 0.05 % Tier 3

CROMOLYN SODIUM OPHTHALMIC SOLUTION 4 % Tier 3

OLOPATADINE HCL OPHTHALMIC SOLUTION 0.1 %,

0.2 %

Tier 3

*Ophthalmic Antibiotics***

BACITRACIN OPHTHALMIC OINTMENT 500

UNIT/GM

Tier 3

CIPROFLOXACIN HCL OPHTHALMIC SOLUTION 0.3

Tier 3

ERYTHROMYCIN OPHTHALMIC OINTMENT 5

MG/GM

Tier 3

GATIFLOXACIN OPHTHALMIC SOLUTION 0.5 % Tier 3

GENTAMICIN SULFATE OPHTHALMIC SOLUTION

0.3 %

Tier 3

LEVOFLOXACIN OPHTHALMIC SOLUTION 0.5 %, 1.5

Tier 3

MOXIFLOXACIN HCL (2X DAY) OPHTHALMIC

SOLUTION 0.5 %

Tier 3

131

Drug Name Brand Tier Generic Tier Formulary Notes

MOXIFLOXACIN HCL OPHTHALMIC SOLUTION 0.5

Tier 3

OFLOXACIN OPHTHALMIC SOLUTION 0.3 % Tier 3

TOBRAMYCIN OPHTHALMIC SOLUTION 0.3 % Tier 2

*Ophthalmic Anti-Infective Combinations***

BACITRACIN-POLYMYXIN B OPHTHALMIC

OINTMENT 500-10000 UNIT/GM

Tier 3

NEOMYCIN-BACITRACIN ZN-POLYMYX

OPHTHALMIC OINTMENT 3.5-400-10000

Tier 3

NEOMYCIN-POLYMYXIN-GRAMICIDIN

OPHTHALMIC SOLUTION 1.75-10000-.025

Tier 3

NEO-POLYCIN OPHTHALMIC OINTMENT

(NEOMYCIN-BACITRACIN ZN-POLYMYX) 3.5-400-

10000

Tier 3 Tier 3

POLYCIN OPHTHALMIC OINTMENT (AK-POLY-

BAC) 500-10000 UNIT/GM

Tier 3 Tier 3

POLYMYXIN B-TRIMETHOPRIM OPHTHALMIC

SOLUTION 10000-0.1 UNIT/ML-%

Tier 2

*Ophthalmic Antivirals***

TRIFLURIDINE OPHTHALMIC SOLUTION 1 % Tier 3

*Ophthalmic Carbonic Anhydrase Inhibitors***

DORZOLAMIDE HCL OPHTHALMIC SOLUTION 2 % Tier 3

*Ophthalmic Ectoparasiticide**

XDEMVY OPHTHALMIC SOLUTION 0.25 % Tier 6 PA; QL (10 ML per 180 days)

*Ophthalmic Immunomodulators***

RESTASIS MULTIDOSE OPHTHALMIC EMULSION

(CYCLOSPORINE) 0.05 %

Tier 5 Tier 3 PA

*Ophthalmic Local Anesthetics***

ALTACAINE OPHTHALMIC SOLUTION

(TETRACAINE HCL) 0.5 %

Tier 4 Tier 3

*Ophthalmic Nonsteroidal Anti-Inflammatory

Agents***

DICLOFENAC SODIUM OPHTHALMIC SOLUTION 0.1

Tier 3

FLURBIPROFEN SODIUM OPHTHALMIC SOLUTION

0.03 %

Tier 3

KETOROLAC TROMETHAMINE OPHTHALMIC

SOLUTION 0.4 %, 0.5 %

Tier 3

*Ophthalmic Selective Alpha Adrenergic Agonists***

BRIMONIDINE TARTRATE SOLUTION 0.1 %

OPHTHALMIC

Tier 3

BRIMONIDINE TARTRATE SOLUTION 0.15 %

OPHTHALMIC

Tier 3

BRIMONIDINE TARTRATE SOLUTION 0.2 %

OPHTHALMIC

Tier 1

*Ophthalmic Steroid Combinations***

NEOMYCIN-POLYMYXIN-DEXAMETH

OPHTHALMIC OINTMENT 3.5-10000-0.1

Tier 3

132

Drug Name Brand Tier Generic Tier Formulary Notes

NEOMYCIN-POLYMYXIN-DEXAMETH

OPHTHALMIC SUSPENSION 3.5-10000-0.1

Tier 3

NEOMYCIN-POLYMYXIN-HC OPHTHALMIC

SUSPENSION 3.5-10000-1

Tier 3

TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 % Tier 4

TOBRAMYCIN-DEXAMETHASONE OPHTHALMIC

SUSPENSION 0.3-0.1 %

Tier 3

*Ophthalmic Steroids***

DEXAMETHASONE SODIUM PHOSPHATE

OPHTHALMIC SOLUTION 0.1 %

Tier 3

FLUOROMETHOLONE OPHTHALMIC SUSPENSION

0.1 %

Tier 3

PREDNISOLONE ACETATE OPHTHALMIC

SUSPENSION 1 %

Tier 3

PREDNISOLONE SODIUM PHOSPHATE

OPHTHALMIC SOLUTION 1 %

Tier 3

*Ophthalmic Sulfonamides***

SULFACETAMIDE SODIUM OPHTHALMIC

OINTMENT 10 %

Tier 3

SULFACETAMIDE SODIUM OPHTHALMIC

SOLUTION 10 %

Tier 3

*Prostaglandins - Ophthalmic***

LATANOPROST OPHTHALMIC SOLUTION 0.005 % Tier 3

LUMIGAN OPHTHALMIC SOLUTION 0.01 % Tier 4

TRAVOPROST (BAK FREE) OPHTHALMIC

SOLUTION 0.004 %

Tier 5

*Otic Agents*

*Otic Anti-Infectives***

OFLOXACIN OTIC SOLUTION 0.3 % Tier 3

*Otic Steroid-Anti-Infective Combinations***

CIPROFLOXACIN-DEXAMETHASONE OTIC

SUSPENSION 0.3-0.1 %

Tier 3

NEOMYCIN-POLYMYXIN-HC OTIC SOLUTION 1 %,

3.5-10000-1

Tier 3

NEOMYCIN-POLYMYXIN-HC OTIC SUSPENSION 3.5-

10000-1

Tier 3

*Otic Steroids***

HYDROCORTISONE-ACETIC ACID OTIC SOLUTION

1-2 %

Tier 3

*Oxytocics*

*Oxytocics***

METHERGINE ORAL TABLET

(METHYLERGONOVINE MALEATE) 0.2 MG

Tier 3 Tier 3

*Passive Immunizing And Treatment Agents*

*Antiviral Monoclonal Antibodies***

BEYFORTUS INTRAMUSCULAR SOLUTION

PREFILLED SYRINGE 100 MG/ML, 50 MG/0.5ML

Tier 1

QL (1 ML per 365 days); AGE (Max 24

Months)

133

Drug Name Brand Tier Generic Tier Formulary Notes

*Penicillins*

*Aminopenicillins***

AMOXICILLIN ORAL CAPSULE 250 MG, 500 MG Tier 2

AMOXICILLIN ORAL SUSPENSION

RECONSTITUTED 125 MG/5ML, 200 MG/5ML, 250

MG/5ML, 400 MG/5ML

Tier 2

AMOXICILLIN ORAL TABLET 500 MG, 875 MG Tier 2

AMOXICILLIN TABLET CHEWABLE 125 MG ORAL Tier 2

AMOXICILLIN TABLET CHEWABLE 250 MG ORAL Tier 3

AMPICILLIN ORAL CAPSULE 500 MG Tier 3

AMPICILLIN SODIUM INJECTION SOLUTION

RECONSTITUTED 1 GM, 125 MG, 2 GM, 250 MG, 500

Tier 3

*Natural Penicillins***

PENICILLIN V POTASSIUM ORAL TABLET 250 MG,

500 MG

Tier 2

PENICILLIN V POTASSIUM SOLUTION

RECONSTITUTED 125 MG/5ML ORAL

Tier 3

PENICILLIN V POTASSIUM SOLUTION

RECONSTITUTED 250 MG/5ML ORAL

Tier 2

*Penicillin Combinations***

AMOXICILLIN-POT CLAVULANATE ER ORAL

TABLET EXTENDED RELEASE 12 HOUR 1000-62.5

Tier 3

AMOXICILLIN-POT CLAVULANATE ORAL

SUSPENSION RECONSTITUTED 200-28.5 MG/5ML,

250-62.5 MG/5ML, 400-57 MG/5ML, 600-42.9 MG/5ML

Tier 3

AMOXICILLIN-POT CLAVULANATE ORAL TABLET

250-125 MG, 500-125 MG, 875-125 MG

Tier 3

AMOXICILLIN-POT CLAVULANATE ORAL TABLET

CHEWABLE 200-28.5 MG, 400-57 MG

Tier 3

*Penicillinase-Resistant Penicillins***

DICLOXACILLIN SODIUM ORAL CAPSULE 250 MG,

500 MG

Tier 3

*Pharmaceutical Adjuvants*

*Semi Solid Vehicles***

OCCLUVAN EXTERNAL OINTMENT Tier 3

WHITE PETROLATUM EXTERNAL GEL Tier 3

*Progestins*

*Progestins***

MEDROXYPROGESTERONE ACETATE ORAL

TABLET 10 MG, 2.5 MG, 5 MG

Tier 1

NORETHINDRONE ACETATE ORAL TABLET 5 MG Tier 3

PROGESTERONE ORAL CAPSULE 100 MG, 200 MG Tier 3

*Psychotherapeutic And Neurological Agents - Misc.*

*Alcohol Deterrents***

ACAMPROSATE CALCIUM ORAL TABLET

DELAYED RELEASE 333 MG

Tier 3

134

Drug Name Brand Tier Generic Tier Formulary Notes

DISULFIRAM ORAL TABLET 250 MG, 500 MG Tier 3

*Cholinomimetics - Ache Inhibitors***

DONEPEZIL HCL ORAL TABLET DISPERSIBLE 10

MG, 5 MG

Tier 3

DONEPEZIL HCL TABLET 10 MG ORAL Tier 1

DONEPEZIL HCL TABLET 23 MG ORAL Tier 3

DONEPEZIL HCL TABLET 5 MG ORAL Tier 1

GALANTAMINE HYDROBROMIDE ER ORAL

CAPSULE EXTENDED RELEASE 24 HOUR 16 MG, 24

MG, 8 MG

Tier 3

GALANTAMINE HYDROBROMIDE ORAL TABLET 12

MG, 4 MG, 8 MG

Tier 3

RIVASTIGMINE TARTRATE ORAL CAPSULE 1.5 MG,

3 MG, 4.5 MG, 6 MG

Tier 3

*Movement Disorder Drug Therapy***

AUSTEDO TABLET 12 MG ORAL Tier 6 PA; Specialty; QL (4 EA per 1 day)

AUSTEDO TABLET 6 MG ORAL Tier 6 PA; Specialty; QL (2 EA per 1 day)

AUSTEDO TABLET 9 MG ORAL Tier 6 PA; Specialty; QL (4 EA per 1 day)

*Multiple Sclerosis Agents - Interferons***

AVONEX PEN INTRAMUSCULAR AUTO-

INJECTOR KIT 30 MCG/0.5ML

Tier 6 PA; Specialty; QL (4 EA per 28 days)

AVONEX PREFILLED INTRAMUSCULAR

PREFILLED SYRINGE KIT 30 MCG/0.5ML

Tier 6 PA; Specialty; QL (4 EA per 28 days)

BETASERON SUBCUTANEOUS KIT 0.3 MG Tier 6 PA; Specialty

EXTAVIA SUBCUTANEOUS KIT 0.3 MG Tier 6 PA; Specialty

REBIF REBIDOSE SUBCUTANEOUS SOLUTION

AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML

Tier 6 PA; Specialty

REBIF REBIDOSE TITRATION PACK

SUBCUTANEOUS SOLUTION AUTO-INJECTOR

6X8.8 & 6X22 MCG

Tier 6 PA; Specialty

REBIF SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 22 MCG/0.5ML, 44 MCG/0.5ML

Tier 6 PA; Specialty

REBIF TITRATION PACK SUBCUTANEOUS

SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22

MCG

Tier 6 PA; Specialty

*Multiple Sclerosis Agents - Nrf2 Pathway

Activators***

DIMETHYL FUMARATE ORAL CAPSULE DELAYED

RELEASE 120 MG, 240 MG

Tier 6 PA; Specialty

DIMETHYL FUMARATE STARTER PACK ORAL

CAPSULE DELAYED RELEASE THERAPY PACK 120

& 240 MG

Tier 6 PA; Specialty

*Multiple Sclerosis Agents - Potassium Channel

Blockers***

DALFAMPRIDINE ER ORAL TABLET EXTENDED

RELEASE 12 HOUR 10 MG

Tier 6 Specialty

*Multiple Sclerosis Agents***

GLATOPA SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE (GLATIRAMER ACETATE) 20

MG/ML, 40 MG/ML

Tier 6 Tier 6 PA; Specialty

135

Drug Name Brand Tier Generic Tier Formulary Notes

*N-Methyl-D-Aspartate (Nmda) Receptor

Antagonists***

MEMANTINE HCL ER ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG

Tier 3

MEMANTINE HCL ORAL SOLUTION 10 MG/5ML, 2

MG/ML

Tier 3

MEMANTINE HCL TABLET 10 MG ORAL Tier 1

MEMANTINE HCL TABLET 28 X 5 MG & 21 X 10 MG

ORAL

Tier 3

MEMANTINE HCL TABLET 5 MG ORAL Tier 3

*Psychotherapeutic And Neurological Agents - Misc.***

ERGOLOID MESYLATES ORAL TABLET 1 MG Tier 3

*Smoking Deterrents***

APO-VARENICLINE ORAL TABLET 0.5 MG, 1 MG Tier 1

BUPROPION HCL ER (SMOKING DET) ORAL

TABLET EXTENDED RELEASE 12 HOUR 150 MG

Tier 1

CVS NICOTINE MOUTH/THROAT GUM 2 MG, 4 MG Tier 1

CVS NICOTINE MOUTH/THROAT LOZENGE 2 MG Tier 1

CVS NICOTINE POLACRILEX MOUTH/THROAT

GUM 2 MG, 4 MG

Tier 1

CVS NICOTINE POLACRILEX MOUTH/THROAT

LOZENGE 2 MG, 4 MG

Tier 1

CVS NICOTINE TRANSDERMAL PATCH 24 HOUR 14

MG/24HR, 21 MG/24HR, 7 MG/24HR

Tier 1

EQ NICOTINE MOUTH/THROAT GUM 4 MG Tier 1

EQ NICOTINE MOUTH/THROAT LOZENGE 4 MG Tier 1

EQ NICOTINE POLACRILEX MOUTH/THROAT GUM

2 MG, 4 MG

Tier 1

EQ NICOTINE POLACRILEX MOUTH/THROAT

LOZENGE 2 MG, 4 MG

Tier 1

EQ NICOTINE STEP 3 TRANSDERMAL PATCH 24

HOUR 7 MG/24HR

Tier 1

EQ NICOTINE TRANSDERMAL PATCH 24 HOUR 14

MG/24HR, 21 MG/24HR

Tier 1

EQL NICOTINE POLACRILEX MOUTH/THROAT

LOZENGE 2 MG, 4 MG

Tier 1

FT NICOTINE MINI MOUTH/THROAT LOZENGE 2

MG, 4 MG

Tier 1

FT NICOTINE MOUTH/THROAT GUM 2 MG, 4 MG Tier 1

FT NICOTINE MOUTH/THROAT LOZENGE 2 MG, 4

Tier 1

GNP NICOTINE MINI MOUTH/THROAT LOZENGE 2

MG, 4 MG

Tier 1

GNP NICOTINE MOUTH/THROAT GUM 2 MG, 4 MG Tier 1

GNP NICOTINE POLACRILEX MOUTH/THROAT

GUM 2 MG, 4 MG

Tier 1

GNP NICOTINE POLACRILEX MOUTH/THROAT

LOZENGE 2 MG, 4 MG

Tier 1

136

Drug Name Brand Tier Generic Tier Formulary Notes

GNP NICOTINE TRANSDERMAL PATCH 24 HOUR 14

MG/24HR, 21 MG/24HR, 7 MG/24HR

Tier 1

GOODSENSE NICOTINE MOUTH/THROAT GUM 2

MG, 4 MG

Tier 1

GOODSENSE NICOTINE MOUTH/THROAT LOZENGE

2 MG, 4 MG

Tier 1

HABITROL TRANSDERMAL PATCH 24 HOUR

(NICOTINE) 21 MG/24HR

Tier 1 Tier 1

HM NICOTINE POLACRILEX MOUTH/THROAT GUM

2 MG, 4 MG

Tier 1

HM NICOTINE POLACRILEX MOUTH/THROAT

LOZENGE 2 MG, 4 MG

Tier 1

HM NICOTINE TRANSDERMAL PATCH 24 HOUR 14

MG/24HR, 21 MG/24HR, 7 MG/24HR

Tier 1

KLS QUIT2 MOUTH/THROAT GUM (NICOTINE

POLACRILEX) 2 MG

Tier 1 Tier 1

KLS QUIT2 MOUTH/THROAT LOZENGE

(NICOTINE POLACRILEX) 2 MG

Tier 1 Tier 1

KLS QUIT4 MOUTH/THROAT GUM (NICOTINE

POLACRILEX) 4 MG

Tier 1 Tier 1

KLS QUIT4 MOUTH/THROAT LOZENGE

(NICOTINE POLACRILEX) 4 MG

Tier 1 Tier 1

NICODERM CQ TRANSDERMAL PATCH 24 HOUR

(NICOTINE) 14 MG/24HR, 21 MG/24HR, 7 MG/24HR

Tier 1 Tier 1

NICORETTE MINI MOUTH/THROAT LOZENGE

(NICOTINE POLACRILEX) 2 MG, 4 MG

Tier 1 Tier 1

NICORETTE MOUTH/THROAT GUM (NICOTINE

POLACRILEX) 2 MG, 4 MG

Tier 1 Tier 1

NICORETTE MOUTH/THROAT LOZENGE

(NICOTINE POLACRILEX) 2 MG, 4 MG

Tier 1 Tier 1

NICORETTE STARTER KIT MOUTH/THROAT

GUM (NICOTINE POLACRILEX) 2 MG, 4 MG

Tier 1 Tier 1

NICOTINE MINI MOUTH/THROAT LOZENGE 2 MG, 4

Tier 1

NICOTINE POLACRILEX MINI MOUTH/THROAT

LOZENGE 2 MG

Tier 1

NICOTINE STEP 1 TRANSDERMAL PATCH 24 HOUR

21 MG/24HR

Tier 1

NICOTINE STEP 2 TRANSDERMAL PATCH 24 HOUR

14 MG/24HR

Tier 1

NICOTINE STEP 3 TRANSDERMAL PATCH 24 HOUR

7 MG/24HR

Tier 1

NICOTINE TRANSDERMAL KIT 21-14-7 MG/24HR Tier 1

NICOTROL INHALATION INHALER 10 MG Tier 1

NICOTROL NS NASAL SOLUTION 10 MG/ML Tier 1

PX STOP SMOKING AID MOUTH/THROAT GUM 2

MG, 4 MG

Tier 1

PX STOP SMOKING AID MOUTH/THROAT LOZENGE

2 MG, 4 MG

Tier 1

137

Drug Name Brand Tier Generic Tier Formulary Notes

QC NICOTINE TRANSDERMAL SYSTEM

TRANSDERMAL PATCH 24 HOUR 14 MG/24HR, 21

MG/24HR

Tier 1

RA MINI NICOTINE MOUTH/THROAT LOZENGE 2

MG, 4 MG

Tier 1

RA NICOTINE GUM MOUTH/THROAT GUM 2 MG, 4

Tier 1

RA NICOTINE MOUTH/THROAT GUM 2 MG, 4 MG Tier 1

RA NICOTINE POLACRILEX MOUTH/THROAT

LOZENGE 2 MG, 4 MG

Tier 1

RA NICOTINE TRANSDERMAL PATCH 24 HOUR 14

MG/24HR, 21 MG/24HR

Tier 1

SM NICOTINE MOUTH/THROAT GUM 4 MG Tier 1

SM NICOTINE MOUTH/THROAT LOZENGE 2 MG Tier 1

SM NICOTINE POLACRILEX MOUTH/THROAT GUM

2 MG, 4 MG

Tier 1

SM NICOTINE POLACRILEX MOUTH/THROAT

LOZENGE 2 MG, 4 MG

Tier 1

SM NICOTINE TRANSDERMAL PATCH 24 HOUR 14

MG/24HR, 21 MG/24HR, 7 MG/24HR

Tier 1

THRIVE MOUTH/THROAT GUM (NICOTINE

POLACRILEX) 2 MG

Tier 1 Tier 1

VARENICLINE TARTRATE (STARTER) ORAL

TABLET THERAPY PACK 0.5 MG X 11 & 1 MG X 42

Tier 1

VARENICLINE TARTRATE ORAL TABLET 0.5 MG, 1

Tier 1

VARENICLINE TARTRATE(CONTINUE) ORAL

TABLET 1 MG

Tier 1

*Sphingosine 1-Phosphate (S1p) Receptor

Modulators***

FINGOLIMOD HCL ORAL CAPSULE 0.5 MG Tier 6 PA; Specialty

*Respiratory Agents - Misc.*

*Cftr Potentiators***

KALYDECO ORAL PACKET 13.4 MG, 25 MG, 5.8

MG, 50 MG, 75 MG

Tier 6 PA; Specialty; QL (2 EA per 1 day)

KALYDECO ORAL TABLET 150 MG Tier 6 PA; Specialty; QL (2 EA per 1 day)

*Cystic Fibrosis Agent - Combinations***

ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG,

75-94 MG

Tier 6 PA; Specialty; QL (2 EA per 1 day)

ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG Tier 6 PA; Specialty; QL (4 EA per 1 day)

SYMDEKO ORAL TABLET THERAPY PACK 100-

150 & 150 MG, 50-75 & 75 MG

Tier 6 PA; Specialty; QL (2 EA per 1 day)

TRIKAFTA ORAL TABLET THERAPY PACK 100-

50-75 & 150 MG, 50-25-37.5 & 75 MG

Tier 6 PA; Specialty; QL (3 EA per 1 day)

*Pulmonary Fibrosis Agents***

PIRFENIDONE ORAL TABLET 534 MG Tier 3 Specialty

*Tetracyclines*

*Tetracyclines***

AVIDOXY ORAL TABLET 100 MG Tier 3

138

Drug Name Brand Tier Generic Tier Formulary Notes

DOXYCYCLINE HYCLATE CAPSULE 100 MG ORAL Tier 2

DOXYCYCLINE HYCLATE CAPSULE 50 MG ORAL Tier 3

DOXYCYCLINE HYCLATE TABLET 100 MG ORAL Tier 2

DOXYCYCLINE HYCLATE TABLET 20 MG ORAL Tier 3

DOXYCYCLINE MONOHYDRATE ORAL CAPSULE

100 MG, 50 MG

Tier 3

DOXYCYCLINE MONOHYDRATE ORAL

SUSPENSION RECONSTITUTED 25 MG/5ML

Tier 3

DOXYCYCLINE MONOHYDRATE ORAL TABLET 100

MG, 150 MG, 50 MG, 75 MG

Tier 3

MINOCYCLINE HCL CAPSULE 100 MG ORAL Tier 3

MINOCYCLINE HCL CAPSULE 50 MG ORAL Tier 2

MINOCYCLINE HCL CAPSULE 75 MG ORAL Tier 3

*Thyroid Agents*

*Antithyroid Agents***

METHIMAZOLE ORAL TABLET 10 MG, 5 MG Tier 1

PROPYLTHIOURACIL ORAL TABLET 50 MG Tier 3

*Thyroid Hormones***

ADTHYZA ORAL TABLET (THYROID) 120 MG, 15

MG, 30 MG, 60 MG, 90 MG

Tier 4 Tier 3

ARMOUR THYROID ORAL TABLET (THYROID)

120 MG, 15 MG, 30 MG, 60 MG, 90 MG

Tier 4 Tier 3

ARMOUR THYROID ORAL TABLET 180 MG, 240

MG, 300 MG

Tier 4

EUTHYROX ORAL TABLET (LEVOTHYROXINE

SODIUM) 100 MCG, 112 MCG, 125 MCG, 137 MCG,

150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75

MCG, 88 MCG

Tier 1 Tier 1

LEVO-T ORAL TABLET (LEVOTHYROXINE

SODIUM) 100 MCG, 112 MCG, 125 MCG, 137 MCG,

150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50

MCG, 75 MCG, 88 MCG

Tier 1 Tier 1

LEVOXYL ORAL TABLET (LEVOTHYROXINE

SODIUM) 100 MCG, 112 MCG, 125 MCG, 137 MCG,

150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75

MCG, 88 MCG

Tier 1 Tier 1

LIOTHYRONINE SODIUM ORAL TABLET 25 MCG, 5

MCG, 50 MCG

Tier 3

NIVA THYROID ORAL TABLET 120 MG, 15 MG, 30

MG, 60 MG, 90 MG

Tier 4

NP THYROID ORAL TABLET (THYROID) 120 MG,

15 MG

Tier 3 Tier 3

SYNTHROID ORAL TABLET (LEVOTHYROXINE

SODIUM) 100 MCG, 112 MCG, 125 MCG, 137 MCG,

150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50

MCG, 75 MCG, 88 MCG

Tier 4 Tier 1

UNITHROID ORAL TABLET (LEVOTHYROXINE

SODIUM) 100 MCG, 112 MCG, 125 MCG, 137 MCG,

150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50

MCG, 75 MCG, 88 MCG

Tier 1 Tier 1

139

Drug Name Brand Tier Generic Tier Formulary Notes

*Toxoids*

*Toxoid Combinations***

ADACEL INTRAMUSCULAR SUSPENSION 5-2-15.5

LF-MCG/0.5

Tier 1

BOOSTRIX INTRAMUSCULAR SUSPENSION 5-2.5-

18.5 LF-MCG/0.5

Tier 1

BOOSTRIX INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE 5-2.5-18.5 LF-MCG/0.5

Tier 1

TDVAX INTRAMUSCULAR SUSPENSION

(TETANUS-DIPHTHERIA TOXOIDS TD) 2-2 LF/0.5ML

Tier 1 Tier 1

TENIVAC INTRAMUSCULAR INJECTABLE 5-2

LFU

Tier 1

*Ulcer Drugs/Antispasmodics/Anticholinergics*

*Antispasmodics***

DICYCLOMINE HCL ORAL CAPSULE 10 MG Tier 3

DICYCLOMINE HCL ORAL SOLUTION 10 MG/5ML Tier 3

DICYCLOMINE HCL ORAL TABLET 20 MG Tier 3

*Belladonna Alkaloids***

HYOSCYAMINE SULFATE ER ORAL TABLET

EXTENDED RELEASE 12 HOUR 0.375 MG

Tier 3

HYOSCYAMINE SULFATE ORAL ELIXIR 0.125

MG/5ML

Tier 3

HYOSCYAMINE SULFATE ORAL TABLET 0.125 MG Tier 3

HYOSCYAMINE SULFATE ORAL TABLET

DISPERSIBLE 0.125 MG

Tier 3

HYOSCYAMINE SULFATE SUBLINGUAL TABLET

SUBLINGUAL 0.125 MG

Tier 3

HYOSYNE ORAL ELIXIR 0.125 MG/5ML Tier 3

*H-2 Antagonists***

CIMETIDINE HCL ORAL SOLUTION 300 MG/5ML Tier 3

CIMETIDINE ORAL TABLET 300 MG, 400 MG, 800

Tier 3

FAMOTIDINE ORAL SUSPENSION RECONSTITUTED

40 MG/5ML

Tier 3

FAMOTIDINE ORAL TABLET 40 MG Tier 3

NIZATIDINE ORAL CAPSULE 150 MG, 300 MG Tier 3

*Misc. Anti-Ulcer***

SUCRALFATE ORAL TABLET 1 GM Tier 3

*Ppi - Potassium-Competitive Acid Blockers (P-Cab)***

VOQUEZNA ORAL TABLET 10 MG, 20 MG Tier 5 PA; QL (1 EA per 1 day)

*Proton Pump Inhibitors***

FIRST-OMEPRAZOLE ORAL SUSPENSION 2

MG/ML

Tier 4

LANSOPRAZOLE ORAL CAPSULE DELAYED

RELEASE 30 MG

Tier 3 QL (60 EA per 30 days)

OMEPRAZOLE CAPSULE DELAYED RELEASE 10 MG

ORAL

Tier 3 QL (2 EA per 1 day)

140

Drug Name Brand Tier Generic Tier Formulary Notes

OMEPRAZOLE CAPSULE DELAYED RELEASE 20 MG

ORAL

Tier 3 QL (60 EA per 30 days)

OMEPRAZOLE CAPSULE DELAYED RELEASE 40 MG

ORAL

Tier 3 QL (60 EA per 30 days)

PANTOPRAZOLE SODIUM ORAL TABLET DELAYED

RELEASE 20 MG, 40 MG

Tier 3 QL (60 EA per 30 days)

RABEPRAZOLE SODIUM ORAL TABLET DELAYED

RELEASE 20 MG

Tier 3

*Quaternary Anticholinergics***

GLYCOPYRROLATE ORAL TABLET 1 MG, 2 MG Tier 3

METHSCOPOLAMINE BROMIDE ORAL TABLET 2.5

Tier 3

*Ulcer Drugs - Prostaglandins***

MISOPROSTOL ORAL TABLET 100 MCG, 200 MCG Tier 3

*Urinary Antispasmodics*

*Urinary Antispasmodic - Antimuscarinic

(Anticholinergic)***

DARIFENACIN HYDROBROMIDE ER ORAL TABLET

EXTENDED RELEASE 24 HOUR 15 MG, 7.5 MG

Tier 3

OXYBUTYNIN CHLORIDE ER ORAL TABLET

EXTENDED RELEASE 24 HOUR 10 MG, 15 MG, 5 MG

Tier 1

OXYBUTYNIN CHLORIDE ORAL SOLUTION 5

MG/5ML

Tier 1

OXYBUTYNIN CHLORIDE ORAL TABLET 5 MG Tier 1

OXYTROL TRANSDERMAL PATCH TWICE

WEEKLY 3.9 MG/24HR

Tier 4

SOLIFENACIN SUCCINATE ORAL TABLET 10 MG, 5

Tier 1

TOLTERODINE TARTRATE ER ORAL CAPSULE

EXTENDED RELEASE 24 HOUR 2 MG, 4 MG

Tier 3

TOLTERODINE TARTRATE ORAL TABLET 1 MG, 2

Tier 3

*Urinary Antispasmodics - Cholinergic Agonists***

BETHANECHOL CHLORIDE ORAL TABLET 10 MG,

25 MG, 5 MG, 50 MG

Tier 3

*Urinary Antispasmodics - Direct Muscle Relaxants***

FLAVOXATE HCL ORAL TABLET 100 MG Tier 3

*Vaccines*

*Bacterial Vaccines***

BEXSERO INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE

Tier 1 AGE (Max 25 Years)

MENACTRA INTRAMUSCULAR SOLUTION Tier 1

MENQUADFI INTRAMUSCULAR SOLUTION Tier 1

MENVEO INTRAMUSCULAR SOLUTION

RECONSTITUTED

Tier 1

PENBRAYA INTRAMUSCULAR SUSPENSION

RECONSTITUTED

Tier 1

PNEUMOVAX 23 INJECTION INJECTABLE 25

MCG/0.5ML

Tier 1

141

Drug Name Brand Tier Generic Tier Formulary Notes

PREVNAR 13 INTRAMUSCULAR SUSPENSION Tier 1

PREVNAR 20 INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE 0.5 ML

Tier 1

TRUMENBA INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE

Tier 1 AGE (Max 25 Years)

*Viral Vaccine Combinations***

M-M-R II INJECTION SOLUTION

RECONSTITUTED

Tier 1

*Viral Vaccines***

AFLURIA INTRAMUSCULAR SUSPENSION Tier 1

AFLURIA PRESERVATIVE FREE

INTRAMUSCULAR SUSPENSION PREFILLED

SYRINGE 0.5 ML

Tier 1

AFLURIA QUADRIVALENT INTRAMUSCULAR

SUSPENSION

Tier 1

AFLURIA QUADRIVALENT INTRAMUSCULAR

SUSPENSION PREFILLED SYRINGE 0.5 ML

Tier 1

COMIRNATY INTRAMUSCULAR SUSPENSION 30

MCG/0.3ML

Tier 1

COMIRNATY INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE 30 MCG/0.3ML

Tier 1

ENGERIX-B INJECTION SUSPENSION 20 MCG/ML Tier 1

ENGERIX-B INJECTION SUSPENSION PREFILLED

SYRINGE 10 MCG/0.5ML, 20 MCG/ML

Tier 1

FLUAD INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE 0.5 ML

Tier 1

FLUARIX INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE 0.5 ML

Tier 1

FLUARIX QUADRIVALENT INTRAMUSCULAR

SUSPENSION PREFILLED SYRINGE 0.5 ML

Tier 1

FLUBLOK QUADRIVALENT INTRAMUSCULAR

SOLUTION PREFILLED SYRINGE 0.5 ML

Tier 1

FLUCELVAX INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE 0.5 ML

Tier 1

FLUCELVAX QUADRIVALENT INTRAMUSCULAR

SUSPENSION

Tier 1

FLUCELVAX QUADRIVALENT INTRAMUSCULAR

SUSPENSION PREFILLED SYRINGE 0.5 ML

Tier 1

FLULAVAL INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE 0.5 ML

Tier 1

FLULAVAL QUADRIVALENT INTRAMUSCULAR

SUSPENSION PREFILLED SYRINGE 0.5 ML

Tier 1

FLUMIST QUADRIVALENT NASAL SUSPENSION Tier 1

FLUZONE HIGH-DOSE INTRAMUSCULAR

SUSPENSION PREFILLED SYRINGE 0.5 ML

Tier 1

FLUZONE HIGH-DOSE QUADRIVALENT

INTRAMUSCULAR SUSPENSION PREFILLED

SYRINGE 0.7 ML

Tier 1 AGE (Min 65 Years)

FLUZONE INTRAMUSCULAR SUSPENSION Tier 1

142

Drug Name Brand Tier Generic Tier Formulary Notes

FLUZONE INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE 0.5 ML

Tier 1

FLUZONE QUADRIVALENT INTRAMUSCULAR

SUSPENSION

Tier 1

FLUZONE QUADRIVALENT INTRAMUSCULAR

SUSPENSION PREFILLED SYRINGE 0.5 ML

Tier 1

GARDASIL 9 INTRAMUSCULAR SUSPENSION Tier 1 AGE (Min 9 Years and Max 26 Years)

GARDASIL 9 INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE

Tier 1 AGE (Min 9 Years and Max 26 Years)

HAVRIX INTRAMUSCULAR SUSPENSION 1440 EL

U/ML, 720 EL U/0.5ML

Tier 1

HEPLISAV-B INTRAMUSCULAR SOLUTION

PREFILLED SYRINGE 20 MCG/0.5ML

Tier 1 AGE (Min 18 Years)

MODERNA COVID-19 VAC 6M-11Y

INTRAMUSCULAR SUSPENSION 25 MCG/0.25ML

Tier 1

NOVAVAX COVID-19 VACCINE INTRAMUSCULAR

SUSPENSION 5 MCG/0.5ML

Tier 1

PFIZER COVID-19 VAC-TRIS 5-11Y

INTRAMUSCULAR SUSPENSION 10 MCG/0.3ML

Tier 1

PFIZER COVID-19 VAC-TRIS 6M-4Y

INTRAMUSCULAR SUSPENSION 3 MCG/0.3ML

Tier 1

RECOMBIVAX HB INJECTION SUSPENSION 10

MCG/ML, 5 MCG/0.5ML

Tier 1

RECOMBIVAX HB INJECTION SUSPENSION

PREFILLED SYRINGE 10 MCG/ML, 5 MCG/0.5ML

Tier 1

SHINGRIX INTRAMUSCULAR SUSPENSION

RECONSTITUTED 50 MCG/0.5ML

Tier 1 AGE (Min 50 Years)

SPIKEVAX INTRAMUSCULAR SUSPENSION 50

MCG/0.5ML

Tier 1

SPIKEVAX INTRAMUSCULAR SUSPENSION

PREFILLED SYRINGE 50 MCG/0.5ML

Tier 1

VAQTA INTRAMUSCULAR SUSPENSION 25

UNIT/0.5ML, 50 UNIT/ML

Tier 1

VARIVAX SUBCUTANEOUS INJECTABLE 1350

PFU/0.5ML

Tier 1

*Vaginal And Related Products*

*Imidazole-Related Antifungals***

TERCONAZOLE VAGINAL CREAM 0.4 %, 0.8 % Tier 3

TERCONAZOLE VAGINAL SUPPOSITORY 80 MG Tier 3

*Spermicides***

ENCARE VAGINAL SUPPOSITORY 100 MG Tier 1

OPTIONS GYNOL II CONTRACEPTIVE VAGINAL

GEL 3 %

Tier 1

TODAY SPONGE VAGINAL 1000 MG Tier 1

VCF VAGINAL CONTRACEPTIVE VAGINAL FILM

28 %

Tier 1

VCF VAGINAL CONTRACEPTIVE VAGINAL GEL 4

Tier 1

*Vaginal Anti-Infectives***

CLINDAMYCIN PHOSPHATE VAGINAL CREAM 2 % Tier 3

143

Drug Name Brand Tier Generic Tier Formulary Notes

METRONIDAZOLE VAGINAL GEL 0.75 % Tier 3

*Vaginal Estrogens***

ESTRADIOL VAGINAL CREAM 0.1 MG/GM Tier 3

ESTRING VAGINAL RING 2 MG, 7.5 MCG/24HR Tier 4

FEMRING VAGINAL RING 0.05 MG/24HR, 0.1

MG/24HR

Tier 4

PREMARIN VAGINAL CREAM 0.625 MG/GM Tier 4

YUVAFEM VAGINAL TABLET (ESTRADIOL) 10

MCG

Tier 3 Tier 3

*Vasopressors*

*Anaphylaxis Therapy Agents***

EPINEPHRINE INJECTION SOLUTION AUTO-

INJECTOR 0.3 MG/0.3ML

Tier 3

EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-

INJECTOR (EPINEPHRINE) 0.15 MG/0.3ML

Tier 3 Tier 3

*Vasopressors***

MIDODRINE HCL ORAL TABLET 5 MG Tier 1

*Vitamins*

*Vitamin D***

ERGOCALCIFEROL ORAL CAPSULE 1.25 MG (50000

UT)

Tier 2

VITAMIN D (ERGOCALCIFEROL) ORAL CAPSULE

1.25 MG (50000 UT), 50000 UNIT

Tier 2

*Vitamin K***

MEPHYTON ORAL TABLET (PHYTONADIONE) 5

Tier 4 Tier 3

144

145

Index

1ST TIER UNIFINE PENTIPS..............97

1ST TIER UNIFINE PENTIPS PLUS...97

1ST TIER UNILET COMFORTOUCH 84

ABACAVIR SULFATE...................47, 48

ABACAVIR SULFATE-

LAMIVUDINE...................................... 46

ABOUTTIME PEN NEEDLE.............97

ACAMPROSATE CALCIUM.............134

ACARBOSE...........................................28

ACCU-CHEK AVIVA PLUS........66, 84

ACCU-CHEK FASTCLIX LANCET 84

ACCU-CHEK FASTCLIX

LANCETS.............................................85

ACCU-CHEK GUIDE................... 66, 85

ACCU-CHEK GUIDE ME..................85

ACCU-CHEK SAFE-T PRO

LANCETS.............................................85

ACCU-CHEK SMARTVIEW.............66

ACCU-CHEK SOFTCLIX LANCET

DEV........................................................85

ACCU-CHEK SOFTCLIX

LANCETS.............................................85

ACCUTANE......................................... 62

ACCUTREND GLUCOSE..................66

ACEBUTOLOL HCL............................ 49

ACETAMINOPHEN-CODEINE...........16

ACETAZOLAMIDE..............................73

ACETAZOLAMIDE ER........................73

ACETAZOLAMIDE SODIUM.............73

ACITRETIN...........................................63

ACTEMRA........................................... 13

ACTEMRA ACTPEN..........................13

ACTI-LANCE 28G................................85

ACTI-LANCE LITE LANCETS 28G... 85

ACTI-LANCE SPECIAL LANCETS

17G.........................................................85

ACTI-LANCE UNIVERSAL 23G........ 85

ACTIMMUNE......................................41

ACYCLOVIR...................................48, 64

ADACEL.............................................140

ADALIMUMAB-ADAZ........................12

ADALIMUMAB-FKJP..........................12

ADALIMUMAB-FKJP (2 PEN)............12

ADALIMUMAB-FKJP (2 SYRINGE)..12

ADAPALENE........................................62

ADC/F (0.5MG/ML)............................126

ADEFOVIR DIPIVOXIL.......................48

ADJUSTABLE LANCING DEVICE....85

ADMELOG...........................................29

ADMELOG SOLOSTAR....................29

ADTHYZA..........................................139

ADULT ASPIRIN REGIMEN...............14

ADVAIR HFA.......................................22

ADVANCE INTUITION TEST..........66

ADVANCE MICRO-DRAW TEST....66

ADVANCED MOBILE LANCET........ 85

ADVOCATE ALCOHOL PREP

PADS......................................................81

ADVOCATE INSULIN PEN

NEEDLE................................................97

ADVOCATE INSULIN PEN

NEEDLES............................................. 97

ADVOCATE INSULIN SYRINGE

.......................................................... 97, 98

ADVOCATE LANCETS..................... 85

ADVOCATE LANCETS 30G.............85

ADVOCATE LANCING DEVICE.....85

ADVOCATE RAPID-SAFE

LANCING.............................................85

ADVOCATE REDI-CODE................. 66

ADVOCATE REDI-CODE+ TEST....66

ADVOCATE SAFETY LANCETS.... 85

ADVOCATE SAFETY LANCETS

26G.........................................................85

ADVOCATE TEST..............................66

AEROCHAMBER MINI

CHAMBER.........................................120

AEROCHAMBER MV......................120

AEROCHAMBER PLUS FLO-VU..120

AEROCHAMBER PLUS FLO-VU

LARGE................................................120

AEROCHAMBER PLUS FLO-VU

MEDIUM............................................ 120

AEROCHAMBER PLUS FLO-VU

SMALL................................................120

AEROCHAMBER PLUS FLO-VU

W/MASK.............................................120

AEROCHAMBER PLUS FLOW VU

.............................................................. 121

AEROCHAMBER

W/FLOWSIGNAL............................. 121

AEROCHAMBER Z-STAT PLUS...121

AEROCHAMBER Z-STAT PLUS

CHAMBR............................................121

AEROCHAMBER Z-STAT

PLUS/LARGE.................................... 121

AEROCHAMBER Z-STAT

PLUS/MEDIUM.................................121

AEROCHAMBER Z-STAT

PLUS/SMALL.................................... 121

AFIRMELLE........................................53

AFLURIA............................................142

AFLURIA PRESERVATIVE FREE142

AFLURIA QUADRIVALENT..........142

AFTERA................................................57

AFTERPILL.........................................57

AGAMATRIX AMP TEST.................66

AGAMATRIX JAZZ TEST................66

AGAMATRIX KEYNOTE TEST...... 66

AGAMATRIX PRESTO TEST.......... 66

AGAMATRIX ULTRA-THIN

LANCETS.............................................85

AIMOVIG...........................................121

AIMSCO LUBRICATED......................83

AIMSCO TWIST LANCETS 32G........ 85

AIMSCO TWIST LANCETS 33G..... 85

AIRAVITE............................................79

AJOVY................................................ 121

AKEEGA...............................................40

ALBUTEROL SULFATE......................23

ALCOH-GLOVE CONTOURED

WIPE..................................................... 81

ALCOHOL PADS..................................81

ALCOHOL PREP.................................. 81

ALCOHOL PREP PADS.......................81

ALCOHOL SWABS..............................81

ALCOHOL SWABSTICK.................. 81

ALECENSA.......................................... 39

ALENDRONATE SODIUM................. 74

ALFERON N.........................................41

ALLERGY RELIEF.............................129

ALLERGY SPRAY 24 HOUR............129

ALLERGY SYRINGE...........................98

ALLOPURINOL....................................78

ALORA..................................................75

ALPRAZOLAM.....................................21

ALPRAZOLAM ER...............................21

ALPRAZOLAM INTENSOL............. 21

ALPRAZOLAM XR..............................21

ALTABAX............................................ 62

ALTACAINE......................................132

ALTAVERA..........................................53

ALUNBRIG.......................................... 39

ALYQ.................................................... 51

AMABELZ............................................75

AMANTADINE HCL............................44

AMBRISENTAN...................................51

AMETHIA............................................ 58

AMETHYST.........................................57

AMILORIDE HCL.................................73

AMILORIDE-

HYDROCHLOROTHIAZIDE...............73

AMIODARONE HCL............................22

AMITRIPTYLINE HCL........................28

AMLODIPINE BESY-BENAZEPRIL

HCL........................................................35

AMLODIPINE BESYLATE..................50

AMLODIPINE-ATORVASTATIN.......51

AMNESTEEM......................................62

AMOXICILLIN................................... 134

AMOXICILLIN-POT

CLAVULANATE................................ 134

AMOXICILLIN-POT

CLAVULANATE ER..........................134

AMPHETAMINE-DEXTROAMPHET

ER...........................................................10

AMPHETAMINE-

DEXTROAMPHETAMINE.................. 10

AMPHET-DEXTROAMPHET 3-

BEAD ER...............................................10

AMPICILLIN.......................................134

AMPICILLIN SODIUM......................134

ANAGRELIDE HCL............................. 79

ANASTROZOLE...................................42

ANNOVERA.........................................57

ANORO ELLIPTA...............................22

APAP-CAFF-DIHYDROCODEINE.....17

APIDRA................................................ 29

APIDRA SOLOSTAR..........................29

APLISOL.............................................. 66

APOMORPHINE HCL..........................44

APO-VARENICLINE..........................136

APRI...................................................... 53

APTIVUS.............................................. 47

AQ INSULIN SYRINGE.......................98

AQINJECT PEN NEEDLE....................98

146

AQUALANCE LANCETS 30G.......... 85

ARANELLE..........................................59

ARANESP (ALBUMIN FREE).......... 79

ARIPIPRAZOLE....................................46

ARMOUR THYROID....................... 139

ASHLYNA............................................ 58

ASILNASALRMS................................ 73

ASMANEX (120 METERED

DOSES)..................................................23

ASMANEX (14 METERED DOSES).23

ASMANEX (30 METERED DOSES).24

ASMANEX (60 METERED DOSES).24

ASMANEX HFA.................................. 24

ASPIRIN 81........................................... 14

ASPIRIN ADULT LOW DOSE............ 14

ASPIRIN ADULT LOW STRENGTH..14

ASPIRIN CHILDRENS.........................14

ASPIRIN EC ADULT LOW DOSE...... 14

ASPIRIN EC ADULT LOW

STRENGTH...........................................14

ASPIRIN EC LOW DOSE.....................14

ASPIRIN EC LOW STRENGTH.......... 14

ASPIRIN LOW DOSE...........................14

ASPIRIN REGIMEN............................. 14

ASPIRIN-DIPYRIDAMOLE ER...........78

ASSURE 3 TEST..................................66

ASSURE 4 TEST..................................66

ASSURE COMFORT LANCETS 28G. 85

ASSURE ID DUO PRO PEN

NEEDLES............................................. 98

ASSURE ID PRO PEN NEEDLES.....98

ASSURE ID SAFETY PEN

NEEDLES............................................. 98

ASSURE II............................................66

ASSURE II CHECK............................ 66

ASSURE LANCE LANCETS............. 85

ASSURE LANCE LANCETS 21G..... 85

ASSURE LANCE PLUS SAFETY

25G.........................................................85

ASSURE LANCE PLUS SAFETY

30G.........................................................85

ASSURE LANCE SAFETY

LANCET 28G....................................... 85

ASSURE PLATINUM......................... 66

ASSURE PRISM MULTI TEST.........66

ASSURE PRO TEST............................66

ATABEX EC.......................................126

ATABEX OB.......................................126

ATAZANAVIR SULFATE................... 47

ATENOLOL...........................................49

ATENOLOL-CHLORTHALIDONE

.......................................................... 36, 37

ATOMOXETINE HCL..........................10

ATORVASTATIN CALCIUM..............34

ATOVAQUONE-PROGUANIL HCL...38

ATROPINE SULFATE........................131

ATROVENT HFA................................23

AUBRA..................................................53

AUBRA EQ...........................................53

AUGTYRO............................................41

AUM ALCOHOL PREP PADS.............81

AUM INSULIN SAFETY PEN

NEEDLE................................................ 98

AUM MINI INSULIN PEN NEEDLE.. 98

AUM PEN NEEDLE..............................98

AUM READYGARD DUO PEN

NEEDLE................................................98

AUM SAFETY PEN NEEDLE........... 98

AURORA LANCET SUPER THIN

30G.........................................................85

AURORA LANCET THIN 23G............85

AURORA PEN NEEDLES....................98

AURORA UNIFINE PENTIPS............. 98

AUROVELA 1.5/30..............................53

AUROVELA 1/20.................................53

AUROVELA 24 FE..............................53

AUROVELA FE 1.5/30........................53

AUROVELA FE 1/20...........................53

AUSTEDO...........................................135

AUTO-LANCET.................................. 85

AUTO-LANCET MINI........................85

AUTOLET II CLINISAFE..................85

AUTOLET LANCING DEVICE........85

AUTOLET LITE CLINISAFE...........85

AUTOLET LITE STARTER PACK..85

AUTOLET MINI..................................85

AUTOLET PLATFORMS.................. 85

AUTOLET PLUS................................. 85

AVIANE................................................ 53

AVIDOXY........................................... 138

AVONEX PEN....................................135

AVONEX PREFILLED.....................135

AYUNA..................................................53

AZACITIDINE...................................... 38

AZATHIOPRINE.........................123, 124

AZELAIC ACID....................................65

AZELASTINE HCL.....................129, 131

AZITHROMYCIN.................................81

AZURETTE..........................................52

BAC........................................................14

BACITRACIN......................................131

BACITRACIN-POLYMYXIN B.........132

BACLOFEN.........................................128

BALSALAZIDE DISODIUM............... 76

BALZIVA..............................................53

BAQSIMI ONE PACK........................ 29

BAQSIMI TWO PACK.......................29

BASAGLAR KWIKPEN.....................29

BAYER ASPIRIN EC LOW DOSE... 14

BAYER LOW DOSE........................... 14

BD AUTOSHIELD DUO.....................98

BD DISP NEEDLE...............................98

BD DISP NEEDLES.............................98

BD ECLIPSE SYRINGE/NEEDLE....98

BD HYPODERMIC NEEDLE............98

BD INSULIN SYR ULTRAFINE II...98

BD INSULIN SYRINGE................98, 99

BD INSULIN SYRINGE HALF-

UNIT......................................................99

BD INSULIN SYRINGE

MICROFINE........................................ 99

BD INSULIN SYRINGE U/F..............99

BD INSULIN SYRINGE U/F

1/2UNIT.................................................99

BD INSULIN SYRINGE U-500.......... 99

BD INSULIN SYRINGE

ULTRAFINE........................................ 99

BD INTEGRA SYRINGE....................99

BD LUER-LOK SYRINGE.................99

BD MICROTAINER LANCETS..85, 86

BD PEN NEEDLE MICRO U/F......... 99

BD PEN NEEDLE MINI U/F..............99

BD PEN NEEDLE NANO 2ND GEN.99

BD PEN NEEDLE NANO U/F............99

BD PEN NEEDLE ORIGINAL U/F...99

BD PEN NEEDLE SHORT U/F........100

BD SAFETYGLIDE ALLERGY

SYRINGE............................................100

BD SAFETYGLIDE INSULIN

SYRINGE............................................100

BD SAFETYGLIDE NEEDLE......... 100

BD SWAB SINGLE USE

REGULAR............................................81

BD SYRINGE LUER-LOK...............100

BD SYRINGE SLIP TIP....................100

BD SYRINGE/NEEDLE....................100

BD TB SYRINGE...............................100

BD VEO INSULIN SYR U/F

1/2UNIT...............................................100

BD VEO INSULIN SYRINGE U/F.. 100

BELBUCA.............................................19

BENAZEPRIL HCL...............................35

BENAZEPRIL-

HYDROCHLOROTHIAZIDE...............35

BENZONATATE...................................61

BENZOYL PEROXIDE-

ERYTHROMYCIN................................62

BENZTROPINE MESYLATE.............. 44

BETAMETHASONE VALERATE.......64

BETASERON..................................... 135

BETHANECHOL CHLORIDE........... 141

BEXAROTENE..................................... 43

BEXSERO...........................................141

BEYFORTUS......................................133

BICALUTAMIDE..................................38

BIKTARVY.......................................... 46

BIMZELX.............................................63

BIOTEL CARE TEST STRIPS..........66

BISOPROLOL FUMARATE................ 49

BISOPROLOL-

HYDROCHLOROTHIAZIDE...............37

BLEOMYCIN SULFATE......................41

BLISOVI 24 FE.................................... 53

BLISOVI FE 1.5/30..............................53

BLISOVI FE 1/20.................................53

BLOOD GLUCOSE TEST STRIPS

333..........................................................67

BLULINK GLUCOSE TEST..............67

BOOSTRIX.........................................140

BORTEZOMIB......................................41

BOSENTAN...........................................51

BOSULIF.............................................. 39

BRAFTOVI...........................................39

BREO ELLIPTA..................................22

BREYNA...............................................22

BRILINTA............................................ 78

BRIMONIDINE TARTRATE............. 132

BRIXADI...............................................19

147

BRIXADI (WEEKLY).........................19

BROMOCRIPTINE MESYLATE.........44

BRUKINSA...........................................39

BUDESONIDE................................ 24, 60

BUMETANIDE......................................73

BUPRENORPHINE...............................20

BUPRENORPHINE HCL......................19

BUPRENORPHINE HCL-

NALOXONE HCL...........................19, 20

BUPROPION HCL................................ 27

BUPROPION HCL ER (SMOKING

DET).....................................................136

BUPROPION HCL ER (SR)..................27

BUPROPION HCL ER (XL)................. 27

BUSPIRONE HCL.................................21

BUTALBITAL-APAP-CAFF-COD...... 16

BUTALBITAL-ASA-CAFF-

CODEINE.............................................. 16

BUTALBITAL-ASPIRIN-CAFFEINE..14

BUTORPHANOL TARTRATE............ 20

BYDUREON BCISE............................31

BYETTA 10 MCG PEN.......................31

BYETTA 5 MCG PEN.........................31

CABERGOLINE....................................74

CABOMETYX......................................41

CADEAU DHA....................................128

CALCIPOTRIENE.................................64

CALCITONIN (SALMON)...................74

CALCITRIOL........................................ 74

CALCIUM ACETATE.......................... 77

CALCIUM ACETATE (PHOS

BINDER)................................................77

CALQUENCE...................................... 39

CAMILA............................................... 59

CAMRESE............................................58

CAMRESE LO..................................... 58

CANDESARTAN CILEXETIL.............36

CANDIN................................................66

CAPECITABINE...................................38

CAPTOPRIL.......................................... 35

CARBAMAZEPINE..............................25

CARBAMAZEPINE ER........................25

CARBIDOPA-LEVODOPA..................44

CARBIDOPA-LEVODOPA ER............44

CARBIDOPA-LEVODOPA-

ENTACAPONE..................................... 44

CARDIOCOM LANCING DEVICE..86

CAREFINE PEN NEEDLES............ 100

CAREONE ADVANCED LANCING

DEV........................................................86

CAREONE BLOOD GLUCOSE

TEST......................................................67

CAREONE INSULIN SYRINGE........100

CAREONE LANCET SUPER THIN

30G.........................................................86

CAREONE LANCET THIN 23G..........86

CAREONE UNIFINE PENTIPS......... 100

CAREONE UNIFINE PENTIPS PLUS

.............................................................. 100

CAREPOINT POLY HUB NEEDLE..100

CAREPOINT SAFETY1ST

SYR/NEEDLE.................................... 101

CAREPOINT SYRINGE LUER

LOCK.................................................. 101

CAREPOINT TUBERCLN

SYR/LUER SL.....................................101

CARESENS LANCETS.......................86

CARESENS LANCETS 30G...............86

CARESENS N GLUCOSE TEST.......67

CARETOUCH ALCOHOL PREP.....82

CARETOUCH INSULIN SYRINGE

.............................................................. 101

CARETOUCH

LANCING/EJECTOR.........................86

CARETOUCH LUER LOCK...........101

CARETOUCH LUER LOCK

SYR/NEEDLE.................................... 101

CARETOUCH PEN NEEDLES....... 101

CARETOUCH SAFETY LANCETS. 86

CARETOUCH SAFETY LANCETS

26G.........................................................86

CARETOUCH TEST...........................67

CARETOUCH TWIST LANCETS

28G.........................................................86

CARETOUCH TWIST LANCETS

30G.........................................................86

CARETOUCH TWIST LANCETS

33G.........................................................86

CARETOUCH TWIST MC

LANCETS 30G.....................................86

CARISOPRODOL-ASPIRIN-

CODEINE............................................ 129

CARTEOLOL HCL............................. 131

CARTIA XT..........................................50

CARVEDILOL...................................... 49

CAYA.................................................... 84

CAZIANT..............................................59

CEFACLOR...........................................52

CEFACLOR ER.....................................52

CEFADROXIL.......................................52

CEFAZOLIN SODIUM.........................52

CEFDINIR..............................................52

CEFIXIME.............................................52

CEFPODOXIME PROXETIL............... 52

CEFPROZIL...........................................52

CEFUROXIME AXETIL.......................52

CEFUROXIME SODIUM..................... 52

CELECOXIB..........................................13

CEPHALEXIN.......................................52

CEVIMELINE HCL.............................124

CHARLOTTE 24 FE........................... 53

CHATEAL............................................ 53

CHATEAL EQ..................................... 53

CHILDRENS ASPIRIN.........................14

CHLORDIAZEPOXIDE HCL...............21

CHLORPROMAZINE HCL..................45

CHLORTHALIDONE........................... 73

CHLORZOXAZONE...........................128

CHOLESTYRAMINE........................... 34

CHOLESTYRAMINE LIGHT.............. 34

CHOSEN LANCETS 30G...................86

CHOSEN LANCING DEVICE...........86

CHOSEN SAFETY LANCETS 28G.. 86

CICLODAN.......................................... 63

CICLOPIROX........................................63

CICLOPIROX OLAMINE.....................63

CILOSTAZOL....................................... 78

CIMETIDINE.......................................140

CIMETIDINE HCL..............................140

CIMZIA.................................................77

CIMZIA (2 SYRINGE)........................77

CIMZIA STARTER KIT.................... 77

CIPROFLOXACIN................................76

CIPROFLOXACIN HCL...............76, 131

CIPROFLOXACIN-

DEXAMETHASONE.......................... 133

CITALOPRAM HYDROBROMIDE.... 27

CLARAVIS...........................................62

CLARISPRAY....................................129

CLARITHROMYCIN............................81

CLARITHROMYCIN ER......................81

CLASSIC PRENATAL........................126

CLEANLET LANCETS 28G..............86

CLEVER CHEK AUTO-CODE

TEST......................................................67

CLEVER CHEK AUTO-CODE

VOICE...................................................67

CLEVER CHEK LANCETS...............86

CLEVER CHEK TEST....................... 67

CLEVER CHOICE AUTO-CODE

TEST......................................................67

CLEVER CHOICE COMFORT EZ

........................................................ 86, 101

CLEVER CHOICE LANCETS 21G..86

CLEVER CHOICE LANCETS 23G..86

CLEVER CHOICE LANCETS 28G..86

CLEVER CHOICE MICRO TEST....67

CLEVER CHOICE NO CODING......67

CLEVER CHOICE TALK SYSTEM 67

CLICKFINE PEN NEEDLES...........101

CLICKFINE PEN NEEDLES..............101

CLINDACIN ETZ................................62

CLINDACIN-P.....................................62

CLINDAMYCIN HCL...........................37

CLINDAMYCIN PALMITATE HCL...37

CLINDAMYCIN PHOS-BENZOYL

PEROX...................................................62

CLINDAMYCIN PHOSPHATE... 62, 143

CLOBAZAM..........................................25

CLOBETASOL PROP EMOLLIENT

BASE......................................................64

CLOBETASOL PROPIONATE............64

CLOBETASOL PROPIONATE E.........64

CLOMID...............................................75

CLOMIPRAMINE HCL........................28

CLONAZEPAM.....................................25

CLONIDINE HCL................................. 36

CLONIDINE HCL ER...........................10

CLOPIDOGREL BISULFATE..............79

CLORAZEPATE DIPOTASSIUM........21

CLOTRIMAZOLE...............................124

CLOTRIMAZOLE-

BETAMETHASONE.......................62, 63

CLOZAPINE..........................................45

C-NATE DHA......................................126

COAGUCHEK LANCETS................. 86

CODEINE SULFATE............................17

CODITUSSIN AC..................................61

148

COLCHICINE........................................78

COLCHICINE-PROBENECID............. 78

COLESEVELAM HCL..........................34

COLESTIPOL HCL...............................34

COMBIPATCH....................................75

COMBIVENT RESPIMAT.................22

COMFORT ASSIST INSULIN

SYRINGE............................................101

COMFORT ASSURED LANCETS

28G.........................................................86

COMFORT ASSURED LANCETS

33G.........................................................86

COMFORT EZ INSULIN

SYRINGE....................................101, 102

COMFORT EZ MICRO PEN

NEEDLES........................................... 102

COMFORT EZ PEN NEEDLES......102

COMFORT EZ PRO PEN

NEEDLES........................................... 102

COMFORT EZ SHORT PEN

NEEDLES........................................... 102

COMFORT LANCETS..........................86

COMFORT TOUCH ALCOHOL

PREP......................................................82

COMFORT TOUCH INSULIN PEN

NEED...................................................102

COMFORT TOUCH LANCETS

31G.........................................................86

COMFORT TOUCH PLUS

LANCETS 28G.....................................86

COMFORT TOUCH PLUS

LANCETS 30G.....................................86

COMFORT TOUCH TWIST

LANCET 30G....................................... 86

COMIRNATY.................................... 142

COMPLERA.........................................46

COMPLETE NATAL DHA.................128

COMPLETENATE.............................. 126

CO-NATAL FA.................................. 126

CONCEPT DHA.................................126

CONCEPT OB....................................126

CONCERTA...................................10, 11

CONDOMS............................................83

CONSTULOSE......................................81

CONTOUR MONITOR.......................86

CONTOUR NEXT LINK.................... 86

CONTOUR NEXT MONITOR.......... 86

CONTOUR NEXT ONE......................86

CONTOUR NEXT TEST.................... 67

CONTOUR TEST................................ 67

COOL BLOOD GLUCOSE TEST

STRIPS..................................................67

COTELLIC...........................................40

CREON..................................................73

CROMOLYN SODIUM................ 76, 131

CRYSELLE-28.....................................53

CURAE..................................................57

CURITY ALCOHOL PREPS.............82

CVS ADVANCED GLUCOSE TEST 67

CVS ALCOHOL PREP PADS.............. 82

CVS ASPIRIN ADULT LOW DOSE....15

CVS ASPIRIN ADULT LOW

STRENGTH...........................................15

CVS ASPIRIN EC..................................15

CVS ASPIRIN LOW DOSE..................15

CVS ASPIRIN LOW STRENGTH........15

CVS FLUTICASONE PROPIONATE 129

CVS GLUCOSE METER TEST

STRIPS...................................................67

CVS LANCETS 21G............................. 86

CVS LANCETS MICRO THIN 33G.....86

CVS LANCETS ORIGINAL.................86

CVS LANCETS THIN 26G...................86

CVS LANCETS ULTRA THIN 30G.... 86

CVS LANCETS ULTRA-THIN 30G....87

CVS LANCING DEVICE......................87

CVS NASAL DECONGESTANT.......130

CVS NICOTINE.................................. 136

CVS NICOTINE POLACRILEX........ 136

CVS PRENATAL................................ 126

CVS PREP..............................................82

CVS ULTRA THIN LANCETS............ 87

CVS WOMENS PRENATAL+DHA...128

CYANOCOBALAMIN..........................79

CYCLOBENZAPRINE HCL...............128

CYCLOSPORINE................................123

CYCLOSPORINE MODIFIED........... 123

CYPROHEPTADINE HCL................... 34

CYRED..................................................54

CYRED EQ...........................................53

CYTARABINE...................................... 39

CYTARABINE (PF)..............................38

DAILY MULTIPLE VITAMINS........ 124

DAILY VALUE MULTIVITAMIN....124

DAILY VITAMIN............................... 124

DAILY VITAMIN FORMULA...........124

DAILY VITAMINS.............................124

DAILY VITE....................................... 124

DAILY VITES..................................... 124

DAILY-VITAMIN...............................124

DAILY-VITE.......................................124

DAILY-VITE MULTIVITAMIN........124

DALFAMPRIDINE ER....................... 135

DANAZOL.............................................20

DANTROLENE SODIUM.................. 129

DARIFENACIN HYDROBROMIDE

ER.........................................................141

DARUNAVIR........................................47

DASETTA 1/35.....................................54

DASETTA 7/7/7....................................59

DAYSEE................................................58

D-CARE BLOOD GLUCOSE............ 67

DEBLITANE........................................ 59

DEFERASIROX.................................... 32

DELYLA............................................... 54

DENTA 5000 PLUS............................124

DEPO-ESTRADIOL............................75

DESIPRAMINE HCL............................28

DESMOPRESSIN ACE SPRAY

REFRIG..................................................75

DESMOPRESSIN ACETATE...............75

DESMOPRESSIN ACETATE SPRAY.75

DEXAMETHASONE............................ 60

DEXAMETHASONE INTENSOL.....60

DEXAMETHASONE SODIUM

PHOSPHATE.......................................133

DEXCOM G6 RECEIVER..................87

DEXCOM G6 SENSOR.......................87

DEXCOM G6 TRANSMITTER.........87

DEXCOM G7 RECEIVER..................87

DEXCOM G7 SENSOR.......................87

DEXMETHYLPHENIDATE HCL........11

DEXMETHYLPHENIDATE HCL ER..11

DEXTROAMPHETAMINE

SULFATE.............................................. 10

DEXTROAMPHETAMINE

SULFATE ER........................................ 10

DIASTIX............................................... 67

DIASTIX REAGENT...........................67

DIATHRIVE BLOOD GLUCOSE

TEST......................................................67

DIATHRIVE GLUCOSE TEST.........67

DIATHRIVE LANCET ULTRA

THIN 30.................................................87

DIATHRIVE LANCETS.....................87

DIATHRIVE LANCING DEVICE.... 87

DIATHRIVE PEN NEEDLE.... 102, 103

DIATHRIVE+ GLUCOSE

MONITOR............................................87

DIATHRIVE+ GLUCOSE TEST.......67

DIATRUE PLUS TEST.........................67

DIAZEPAM..................................... 21, 25

DICLOFENAC POTASSIUM...............13

DICLOFENAC SODIUM........13, 63, 132

DICLOFENAC SODIUM ER................13

DICLOFONO....................................... 63

DICLOXACILLIN SODIUM..............134

DICYCLOMINE HCL.........................140

DIFLUNISAL........................................ 15

DIGITEK.............................................. 51

DIGOX.................................................. 51

DIGOXIN...............................................51

DIHYDROERGOTAMINE

MESYLATE.........................................121

DILANTIN............................................26

DILTIAZEM HCL................................. 50

DILTIAZEM HCL ER...........................50

DILT-XR................................................50

DIMETHYL FUMARATE..................135

DIMETHYL FUMARATE STARTER

PACK................................................... 135

DIPHENOXYLATE-ATROPINE......... 32

DIPYRIDAMOLE..................................78

DISOPYRAMIDE PHOSPHATE..........22

DISULFIRAM......................................135

DIVALPROEX SODIUM......................27

DIVALPROEX SODIUM ER................26

DOLISHALE........................................ 57

DONEPEZIL HCL...............................135

DORZOLAMIDE HCL........................132

DORZOLAMIDE HCL-TIMOLOL

MAL.....................................................131

DOTTI...................................................75

DOXAZOSIN MESYLATE.................. 36

DOXEPIN HCL..................................... 28

DOXYCYCLINE HYCLATE............. 139

DOXYCYCLINE MONOHYDRATE.139

DOXYLAMINE-PYRIDOXINE...........33

149

DROPLET GENTEEL LANCING

DEVICE................................................ 87

DROPLET INSULIN SYRINGE......103

DROPLET LANCETS ULTRA

THIN 30G..............................................87

DROPLET LANCING DEVICE........ 87

DROPLET PEN NEEDLES..............103

DROPLET PERSONAL LANCETS

30G.........................................................87

DROPSAFE ALCOHOL PREP..........82

DROPSAFE SAFETY PEN

NEEDLES............................................ 103

DROPSAFE SAFETY

SYRINGE/NEEDLE.......................... 103

DROSPIREN-ETH ESTRAD-

LEVOMEFOL........................................54

DRUG MART LANCETS THIN 26G...87

DRUG MART LANCING DEVICE...87

DRUG MART ON-THE-GO

LANCET 30G....................................... 87

DRUG MART UNIFINE PENTIPS.... 104

DRUG MART UNIFINE PENTIPS

PLUS.................................................... 104

DRUG MART UNILET LANCETS

28G.........................................................87

DRUG MART UNILET LANCETS

30G.........................................................87

DRUG MART UNILET LANCETS

33G.........................................................87

DULERA...............................................22

DULOXETINE HCL............................. 28

DUO-CARE TEST............................... 67

DUPIXENT...........................................64

DUREX EXTRA SENSITIVE THIN. 83

DUREX REALFEEL........................... 83

DUREX TROPICAL............................83

E.E.S. 400.............................................. 81

EASIVENT..........................................121

EASIVENT MASK LARGE............. 121

EASIVENT MASK MEDIUM..........121

EASIVENT MASK SMALL............. 121

EASY COMFORT ALCOHOL PADS..82

EASY COMFORT INSULIN

SYRINGE.............................................104

EASY COMFORT LANCETS.............. 87

EASY COMFORT LANCETS TWIST

TOP........................................................ 87

EASY COMFORT PEN NEEDLES....104

EASY GLIDE PEN NEEDLES........... 104

EASY MAX BLOOD GLUCOSE

TEST......................................................67

EASY MINI EJECT LANCING

DEVICE................................................. 87

EASY MINI LANCING DEVICE.........87

EASY PLUS II GLUCOSE TEST.........67

EASY STEP TEST...............................67

EASY TALK BLOOD GLUCOSE

TEST...................................................... 68

EASY TALK PLUS II TEST STRIPS...68

EASY TOUCH ALCOHOL PREP

MEDIUM.............................................. 82

EASY TOUCH ALLERGY

SYRINGE............................................104

EASY TOUCH FLIPLOCK

INSULIN SY....................................... 104

EASY TOUCH FLIPLOCK

SAFETY SYR..................................... 104

EASY TOUCH FLURINGE..............104

EASY TOUCH FLURINGE

FLIPLOCK.........................................104

EASY TOUCH FLURINGE

SHEATHLOCK..................................104

EASY TOUCH HEALTHPRO

GLUCOSE............................................ 68

EASY TOUCH INSULIN SAFETY

SYR......................................................104

EASY TOUCH INSULIN SYRINGE

.............................................................. 104

EASY TOUCH LANCETS 21G..........87

EASY TOUCH LANCETS 23G..........87

EASY TOUCH LANCETS 26G..........87

EASY TOUCH LANCETS 28G..........87

EASY TOUCH LANCETS

28G/TWIST...........................................87

EASY TOUCH LANCETS 30G..........87

EASY TOUCH LANCETS

30G/TWIST...........................................87

EASY TOUCH LANCETS 32G..........87

EASY TOUCH LANCETS

32G/TWIST...........................................87

EASY TOUCH LANCETS

33G/TWIST...........................................87

EASY TOUCH LANCING DEVICE. 87

EASY TOUCH PEN NEEDLES

...................................................... 104, 105

EASY TOUCH SAFETY LANCETS

21G.........................................................87

EASY TOUCH SAFETY LANCETS

23G.........................................................87

EASY TOUCH SAFETY LANCETS

26G.........................................................87

EASY TOUCH SAFETY LANCETS

28G.........................................................87

EASY TOUCH SAFETY PEN

NEEDLES........................................... 105

EASY TOUCH SAFETY SYRINGE105

EASY TOUCH SHEATHLOCK

SYRINGE............................................105

EASY TOUCH TB FLIPLOCK

SYRINGE............................................105

EASY TOUCH TB SHEATHLOCK

SYR......................................................105

EASY TOUCH TEST.......................... 68

EASY TRAK BLOOD GLUCOSE

TEST...................................................... 68

EASY TRAK II GLUCOSE TEST........68

EASYGLUCO.......................................68

EASYMAX 15 TEST............................68

EASYMAX TEST.................................68

EASYPOINT NEEDLE..................... 105

EASYPOINT NEEDLE/SYRINGE..105

EASYPRO BLOOD GLUCOSE

TEST......................................................68

EASYPRO PLUS..................................68

ECONAZOLE NITRATE......................65

ECONTRA EZ......................................57

ECONTRA ONE-STEP.......................57

ECOTRIN LOW STRENGTH........... 15

EDURANT............................................ 47

EFAVIRENZ-EMTRICITAB-

TENOFO DF..........................................46

EFAVIRENZ-LAMIVUDINE-

TENOFOVIR......................................... 46

EFFER-K............................................ 122

ELEMENT COMPACT TEST.............. 68

ELEMENT TEST.................................68

ELETRIPTAN HYDROBROMIDE....121

ELIGARD............................................. 42

ELINEST...............................................54

ELIQUIS............................................... 24

ELIQUIS DVT/PE STARTER

PACK.....................................................24

ELITE-OB...........................................126

ELLA.....................................................57

ELMIRON............................................ 78

ELURYNG............................................57

EMBRACE BLOOD GLUCOSE

TEST......................................................68

EMBRACE EVO BLOOD

GLUCOSE TEST................................. 68

EMBRACE LANCETS ULTRA

THIN 30G..............................................87

EMBRACE LANCING

DEVICE/EJECTOR...............................87

EMBRACE PEN NEEDLES.............105

EMBRACE PRESSURE

ACTIVATED 21G................................88

EMBRACE PRESSURE

ACTIVATED 28G................................88

EMBRACE PRO GLUCOSE TEST.. 68

EMBRACE TALK GLUCOSE

TEST......................................................68

EMBRACE WAVE BLOOD

GLUCOSE............................................ 68

EMCYT.................................................42

EMGALITY (300 MG DOSE).......... 121

EMOQUETTE......................................54

EMSAM.................................................27

EMTRICITABINE.................................48

EMTRICITABINE-TENOFOVIR DF...46

EMTRIVA.............................................48

EMVERM............................................. 21

EMZAHH..............................................59

ENALAPRIL MALEATE......................35

ENALAPRIL-

HYDROCHLOROTHIAZIDE...............35

ENCARE.............................................143

ENDOCET............................................ 19

ENGERIX-B....................................... 142

ENILLORING......................................57

ENOXAPARIN SODIUM............... 24, 25

ENPRESSE-28......................................59

ENSKYCE.............................................54

ENTACAPONE..................................... 44

ENTRESTO.......................................... 51

ENTYVIO............................................. 77

ENULOSE..............................................77

EPINEPHRINE.................................... 144

EPIPEN JR 2-PAK.............................144

150

EPITOL.................................................25

EQ ALLERGY RELIEF...................... 129

EQ ASPIRIN ADULT LOW DOSE......15

EQ ASPIRIN LOW DOSE.....................15

EQ BLOOD GLUCOSE TEST..............68

EQ NICOTINE.....................................136

EQ NICOTINE POLACRILEX...........136

EQ NICOTINE STEP 3....................... 136

EQ SINUS & CONGESTION MAX

STR.......................................................130

EQL ALCOHOL SWABS..................... 82

EQL ASPIRIN LOW DOSE..................15

EQL COLOR LANCETS 21G...............88

EQL COLOR LANCETS MICRO 33G.88

EQL FLUTICASONE CHILDRENS.. 129

EQL FLUTICASONE PROPIONATE 129

EQL INSULIN SYRINGE...................106

EQL NASAL DECONGESTANT.......130

EQL NICOTINE POLACRILEX........ 136

EQL PRENATAL FORMULA............126

EQL SUPER THIN LANCETS 30G..... 88

EQL THIN LANCETS 26G...................88

ERGOCALCIFEROL.......................... 144

ERGOLOID MESYLATES.................136

ERLOTINIB HCL..................................40

ERRIN...................................................59

ERY........................................................62

ERYTHROCIN STEARATE..............81

ERYTHROMYCIN........................62, 131

ERYTHROMYCIN BASE.....................81

ERYTHROMYCIN

ETHYLSUCCINATE............................ 81

ESCITALOPRAM OXALATE............. 27

ESTARYLLA........................................54

ESTAZOLAM........................................80

ESTRADIOL..................................75, 144

ESTRADIOL VALERATE....................76

ESTRING............................................144

ESTROFACTORS............................. 124

ESZOPICLONE.....................................80

ETHAMBUTOL HCL........................... 38

ETHOSUXIMIDE..................................26

ETODOLAC.......................................... 13

ETODOLAC ER.................................... 13

ETOPOSIDE.......................................... 42

ETRAVIRINE........................................47

EUTHYROX.......................................139

EVEROLIMUS.................................... 123

EVOLUTION AUTOCODE............... 68

EVOTAZ...............................................46

EVRYSDI............................................131

EXEL COMFORT POINT

INSULIN SYR.................................... 106

EXEL COMFORT POINT PEN

NEEDLE..............................................106

EXEMESTANE..................................... 42

EXKIVITY............................................40

EXTAVIA............................................135

E-Z JECT LANCET MICRO-THIN

33G.........................................................88

E-Z JECT LANCET SUPER THIN

30G.........................................................88

E-Z JECT LANCETS.......................... 88

E-Z JECT LANCETS 21G..................88

E-Z JECT LANCETS THIN 26G.......88

EZETIMIBE...........................................34

EZETIMIBE-SIMVASTATIN.............. 34

EZ-LETS LANCETS 21G...................88

EZ-LETS LANCETS 26G...................88

EZ-LETS LANCETS 28G...................88

EZ-LETS LANCETS 30G...................88

FALMINA.............................................54

FAMCICLOVIR.................................... 49

FAMOTIDINE.....................................140

FANTASY LUBRICATED................. 83

FANTASY

LUBRICATED/SPERMICIDE...........83

FARXIGA............................................. 31

FAYOSIM.............................................58

FC2 FEMALE CONDOM...................83

FELODIPINE ER...................................50

FEMCAP...............................................83

FEMRING...........................................144

FEMYNOR........................................... 54

FENOFIBRATE.....................................34

FENOFIBRATE MICRONIZED...........34

FENTANYL...........................................17

FENTANYL CITRATE.........................17

FERRIPROX........................................ 32

FIASP.................................................... 29

FIASP FLEXTOUCH..........................29

FIFTY50 ALCOHOL PREP...............82

FIFTY50 GLUCOSE TEST 2.0.......... 68

FIFTY50 PEN NEEDLES................. 106

FIFTY50 SAFETY SEAL

LANCETS.............................................88

FIFTY50 SUPERIOR COMFORT

SYR......................................................106

FIFTY50 UNILET LANCETS 33G....88

FILSPARI............................................. 78

FINASTERIDE................................ 65, 78

FINE 30................................................. 88

FINGERSTIX LANCETS................... 88

FINGOLIMOD HCL............................138

FINZALA..............................................54

FIRST-OMEPRAZOLE....................140

FLAVOXATE HCL.............................141

FLECAINIDE ACETATE..................... 22

FLONASE ALLERGY RELIEF...... 129

FLOXURIDINE.....................................39

FLUAD................................................ 142

FLUARIX............................................142

FLUARIX QUADRIVALENT..........142

FLUBLOK QUADRIVALENT.........142

FLUCELVAX.....................................142

FLUCELVAX QUADRIVALENT... 142

FLUCONAZOLE...................................33

FLUDROCORTISONE ACETATE...... 61

FLULAVAL........................................142

FLULAVAL QUADRIVALENT......142

FLUMIST QUADRIVALENT..........142

FLUNISOLIDE....................................129

FLUOCINOLONE ACETONIDE......... 64

FLUOCINONIDE.................................. 64

FLUOROMETHOLONE.....................133

FLUOROURACIL.................................63

FLUOXETINE HCL..............................27

FLUPHENAZINE HCL.........................46

FLURAZEPAM HCL............................ 80

FLURBIPROFEN.................................. 13

FLURBIPROFEN SODIUM................132

FLUTAMIDE.........................................38

FLUTICASONE PROPIONATE...........64

FLUTICASONE PROPIONATE

DISKUS..................................................24

FLUTICASONE PROPIONATE HFA..24

FLUVOXAMINE MALEATE...............27

FLUZONE...................................142, 143

FLUZONE HIGH-DOSE...................142

FLUZONE HIGH-DOSE

QUADRIVALENT.............................142

FLUZONE QUADRIVALENT.........143

FOLDING PADDLE WALKER............97

FOLIC ACID..........................................79

FOLIVANE-OB..................................126

FORA 6 CONNECT.............................68

FORA 6 CONNECT/GTEL TEST..... 68

FORA BLOOD GLUCOSE TEST..... 68

FORA D15G BLOOD GLUCOSE

TEST......................................................68

FORA D20 BLOOD GLUCOSE

TEST......................................................68

FORA D40/G31 BLOOD GLUCOSE.68

FORA G20 BLOOD GLUCOSE

TEST......................................................69

FORA G30/PREM V10 GLUCOSE

TEST......................................................69

FORA GD20 TEST.............................. 69

FORA GD50 BLOOD GLUCOSE

TEST......................................................69

FORA GTEL BLOOD GLUCOSE

TEST......................................................69

FORA LANCETS.................................88

FORA LANCING DEVICE................ 88

FORA TN'G ADVANCE PRO........... 69

FORA TN'G/TN'G VOICE.................69

FORA V10 BLOOD GLUCOSE

TEST......................................................69

FORA V12 BLOOD GLUCOSE

TEST......................................................69

FORA V20 BLOOD GLUCOSE

TEST......................................................69

FORA V30A BLOOD GLUCOSE

TEST......................................................69

FORACARE GD40 TEST...................69

FORACARE PREMIUM V10 TEST. 69

FORACARE TEST N GO TEST........69

FORTISCARE G1 TEST STRIP........69

FORTISCARE TEST...........................69

FOSAMPRENAVIR CALCIUM...........47

FOSINOPRIL SODIUM........................35

FOSINOPRIL SODIUM-HCTZ............ 35

FOTIVDA..............................................41

FRAGMIN............................................ 25

FREDS PHARMACY AUTOLET

LANCING..............................................88

FREDS PHARMACY UNIFINE

PENTIP+..............................................106

151

FREDS PHARMACY UNIFINE

PENTIPS.............................................. 106

FREDS PHARMACY UNILET LANC

28G.........................................................88

FREDS PHARMACY UNILET LANC

30G.........................................................88

FREESTYLE INSULINX TEST........ 69

FREESTYLE LANCETS.................... 88

FREESTYLE LIBRE 14 DAY

READER...............................................88

FREESTYLE LIBRE 14 DAY

SENSOR................................................88

FREESTYLE LIBRE 2 READER......88

FREESTYLE LIBRE 2 SENSOR.......88

FREESTYLE LIBRE 3 READER......88

FREESTYLE LIBRE 3 SENSOR.......88

FREESTYLE LIBRE READER.........88

FREESTYLE LITE TEST.................. 69

FREESTYLE PRECISION NEO

TEST......................................................69

FREESTYLE TEST.............................69

FREESTYLE UNISTICK II

LANCETS.............................................88

FRUZAQLA..........................................43

FT ALLERGY RELIEF 24 HR............129

FT ASPIRIN...........................................15

FT ASPIRIN LOW DOSE..................... 15

FT NASAL DECONGESTANT MAX

STR.......................................................130

FT NICOTINE..................................... 136

FT NICOTINE MINI........................... 136

FUROSEMIDE...................................... 73

FUZEON............................................... 47

FYAVOLV............................................ 75

G TUSSIN AC........................................61

GABAPENTIN...................................... 25

GALANTAMINE HYDROBROMIDE

.............................................................. 135

GALANTAMINE HYDROBROMIDE

ER.........................................................135

GARDASIL 9......................................143

GATIFLOXACIN................................ 131

GAVILYTE-G...................................... 80

GAVILYTE-N WITH FLAVOR

PACK.....................................................80

GE100 BLOOD GLUCOSE TEST........69

GEMFIBROZIL.....................................34

GEMMILY............................................54

GENERLAC...........................................77

GENGRAF..........................................123

GENTAMICIN SULFATE..................131

GENTEEL BUTTERFLY TOUCH

LANCET............................................... 88

GENTEEL CONTACT TIPS

(BLUE).................................................. 88

GENTEEL CONTACT TIPS

(CLEAR)............................................... 88

GENTEEL CONTACT TIPS

(GREEN)...............................................88

GENTEEL CONTACT TIPS

(ORANGE)............................................88

GENTEEL CONTACT TIPS

(RAINBOW)......................................... 89

GENTEEL CONTACT TIPS

(VIOLET)..............................................89

GENTEEL CONTACT TIPS

(YELLOW)........................................... 89

GENTEEL LANCING KIT (BLUE)..89

GENTEEL NOZZLES.........................89

GENTEEL PLUS LANCING

(BLACK)...............................................89

GENTEEL PLUS LANCING

(PURPLE)............................................. 89

GENTEEL PLUS LANCING

(WHITE)............................................... 89

GENTEEL PLUS LANCING

DEV(BLUE)..........................................89

GENTEEL PLUS LANCING

DEV(PINK)...........................................89

GENTLE-LET GP LANCETS............89

GENTLE-LET LANCETS..................89

GENTLE-LET PLATFORMS............89

GENULTIMATE TEST...................... 69

GENVOYA............................................46

GHT TEST............................................. 69

GLATOPA.......................................... 135

GLEOSTINE........................................ 43

GLIMEPIRIDE...................................... 32

GLIPIZIDE.............................................32

GLIPIZIDE ER.......................................32

GLIPIZIDE XL...................................... 32

GLIPIZIDE-METFORMIN HCL.......... 32

GLOBAL ALCOHOL PREP EASE......82

GLOBAL EASE INJECT PEN

NEEDLES............................................ 106

GLOBAL EASY GLIDE INSULIN

SYR...................................................... 106

GLOBAL EASY GLIDE PEN

NEEDLES............................................ 106

GLOBAL INJECT EASE INSULIN

SYR...................................................... 106

GLOBAL INJECT EASE LANCETS

28G.........................................................89

GLOBAL INJECT EASE LANCETS

30G.........................................................89

GLOBAL INSULIN SYRINGES........ 106

GLOBAL LANCING DEVICE.............89

GLUCAGON EMERGENCY................29

GLUCO PERFECT 3 TEST............... 69

GLUCOCARD 01 SENSOR PLUS.....69

GLUCOCARD EXPRESSION

TEST......................................................69

GLUCOCARD SHINE TEST.............70

GLUCOCARD VITAL TEST.............70

GLUCOCARD X-SENSOR.................70

GLUCOCOM LANCETS 28G............89

GLUCOCOM LANCETS 30G............89

GLUCOCOM LANCETS 33G............89

GLUCOCOM TEST............................ 70

GLUCONAVII BLOOD GLUCOSE

TEST......................................................70

GLUCOPRO INSULIN SYRINGE

...................................................... 106, 107

GLUCOSE METER TEST.................... 70

GLYBURIDE.........................................32

GLYBURIDE MICRONIZED...............32

GLYBURIDE-METFORMIN................32

GLYCOPYRROLATE.........................141

GLYDO................................................. 65

GLYXAMBI..........................................31

GNP ADULT ASPIRIN LOW

STRENGTH...........................................15

GNP ALCOHOL SWABS.....................82

GNP ASPIRIN....................................... 15

GNP ASPIRIN LOW DOSE..................15

GNP CLICKFINE PEN NEEDLES.....107

GNP EASY TOUCH GLUCOSE

TEST...................................................... 70

GNP ESSENTIAL ONE DAILY.........124

GNP FLUTICASONE PROPIONATE129

GNP INSULIN SYRINGE...................107

GNP INSULIN SYRINGES................ 107

GNP INSULIN SYRINGES 28GX1/2"

.............................................................. 107

GNP INSULIN SYRINGES 29GX1/2"

.............................................................. 107

GNP INSULIN SYRINGES

30GX5/16"........................................... 107

GNP INSULIN SYRINGES

31GX5/16"........................................... 107

GNP LANCETS 21G.............................89

GNP LANCETS THIN 26G...................89

GNP LANCING SYSTEM DEVICE..89

GNP NASAL DECONGESTANT.......130

GNP NICOTINE..........................136, 137

GNP NICOTINE MINI........................136

GNP NICOTINE POLACRILEX........ 136

GNP PRENATAL................................126

GNP STERILE LANCETS 28G............89

GNP STERILE LANCETS 30G............89

GNP STERILE LANCETS 33G............89

GNP TRUE METRIX GLUCOSE

STRIPS..................................................70

GNP TRUETRACK SMART

SYSTEM................................................70

GNP TRUETRACK TEST STRIPS...70

GNP ULTICARE PEN NEEDLES......107

GNP ULTIGUARD SAFEPACK

NEEDLE..............................................107

GNP ULTRA COM INSULIN

SYRINGE.............................................107

GOJJI BLOOD GLUCOSE TEST.....70

GOJJI BLOOD TEST

STRIP/LANCETS................................ 70

GOJJI LANCING DEVICE/CLEAR

CAP........................................................89

GOJJI STERILE LANCETS..............89

GOODSENSE 24-HR ALLERGY

NASAL.................................................129

GOODSENSE ASPIRIN........................15

GOODSENSE ASPIRIN LOW DOSE..15

GOODSENSE BLOOD GLUCOSE......70

GOODSENSE CLICKFINE PEN

NEEDLE.............................................. 107

GOODSENSE COLOR LANCETS

33G.........................................................89

GOODSENSE LANCETS 26G UNIV.. 89

GOODSENSE LANCETS 30G............. 89

GOODSENSE LANCETS 30G UNIV.. 89

152

GOODSENSE LANCETS 33G............. 89

GOODSENSE LANCETS 33G UNIV.. 89

GOODSENSE LANCING DEVICE......89

GOODSENSE NICOTINE.................. 137

GOODSENSE PEN NEEDLE

PENFINE............................................ 107

GRASTEK............................................ 11

GRISEOFULVIN MICROSIZE............ 33

GRISEOFULVIN

ULTRAMICROSIZE.............................33

GUAIATUSSIN AC...............................61

GUAIFENESIN AC...............................61

GUAIFENESIN-CODEINE...................61

GUANFACINE HCL.............................36

GUANFACINE HCL ER.......................10

HABITROL........................................ 137

HADLIMA............................................ 12

HADLIMA PUSHTOUCH..................12

HAEMOLANCE.................................. 89

HAEMOLANCE LOW FLOW

LANCETS.............................................90

HAEMOLANCE PLUS....................... 90

HAEMOLANCE PLUS HIGH

FLOW....................................................90

HAEMOLANCE PLUS LOW

FLOW....................................................90

HAEMOLANCE PLUS MAX

FLOW....................................................90

HAEMOLANCE PLUS

PEDIATRIC FLOW............................ 90

HAILEY 1.5/30.....................................54

HAILEY 24 FE.....................................54

HAILEY FE 1.5/30...............................54

HAILEY FE 1/20..................................54

HALOETTE..........................................57

HALOPERIDOL....................................45

HALOPERIDOL LACTATE.................45

HAVRIX..............................................143

HEALTH CARE LANCING

DEVICE................................................ 90

HEALTHWISE INSULIN

SYR/NEEDLE......................................107

HEALTHWISE MICRON PEN

NEEDLES............................................ 107

HEALTHWISE MINI PEN NEEDLES

.............................................................. 107

HEALTHWISE PEN NEEDLES.........107

HEALTHWISE SHORT PEN

NEEDLES............................................ 107

HEALTHWISE UNIFINE PENTIPS.. 107

HEALTHY ACCENTS LANCING

DEVICE................................................. 90

HEALTHY ACCENTS UNIFINE

PENTIP................................................ 107

HEALTHY ACCENTS UNILET

LANCETS..............................................90

HEALTHY HAIR/SKIN/NAILS.........124

HEATHER............................................59

H-E-B ASPIRIN.....................................15

H-E-B INCONTROL ADV LANCING.90

H-E-B INCONTROL ALCOHOL.........82

H-E-B INCONTROL LANCETS 28G.. 90

H-E-B INCONTROL LANCETS 30G.. 90

H-E-B INCONTROL LANCETS 33G.. 90

H-E-B INCONTROL PEN NEEDLES 108

H-E-B INCONTROL UNIFINE

PENTIP............................................... 108

HEPLISAV-B......................................143

HER STYLE......................................... 57

HIGH POTENCY MULTIVITAMIN..124

HM ALLERGY RELIEF..................... 129

HM ASPIRIN.........................................15

HM ASPIRIN EC LOW DOSE............. 15

HM NASAL DECONGESTANT........ 130

HM NICOTINE....................................137

HM NICOTINE POLACRILEX..........137

HM STERILE ALCOHOL PREP..........82

HM ULTICARE INSULIN

SYRINGE............................................108

HM ULTICARE MINI PEN

NEEDLES........................................... 108

HM ULTICARE SHORT PEN

NEEDLES........................................... 108

HUMALOG.................................... 29, 30

HUMALOG JUNIOR KWIKPEN..... 29

HUMALOG KWIKPEN......................29

HUMALOG MIX 50/50.......................30

HUMALOG MIX 50/50 KWIKPEN.. 30

HUMALOG MIX 75/25.......................30

HUMALOG MIX 75/25 KWIKPEN.. 30

HUMULIN 70/30..................................30

HUMULIN 70/30 KWIKPEN............. 30

HUMULIN N........................................ 30

HUMULIN N KWIKPEN....................30

HUMULIN R........................................ 30

HUMULIN R U-500

(CONCENTRATED)........................... 30

HUMULIN R U-500 KWIKPEN........ 30

HW EMBRACE PRO GLUCOSE

TEST......................................................70

HW EMBRACE TALK GLUCOSE

TEST......................................................70

HYCAMTIN......................................... 43

HYDRALAZINE HCL.......................... 37

HYDROCHLOROTHIAZIDE...............73

HYDROCOD POLI-CHLORPHE

POLI ER.................................................61

HYDROCODONE BITARTRATE ER.17

HYDROCODONE BIT-HOMATROP

MBR.......................................................61

HYDROCODONE-

ACETAMINOPHEN..............................17

HYDROCODONE-IBUPROFEN..........17

HYDROCORTISONE............... 20, 60, 64

HYDROCORTISONE ACE-

PRAMOXINE........................................ 20

HYDROCORTISONE-ACETIC ACID

.............................................................. 133

HYDROMET......................................... 61

HYDROMORPHONE HCL.................. 17

HYDROMORPHONE HCL ER............ 17

HYDROMORPHONE HCL PF.............17

HYDROXYCHLOROQUINE

SULFATE.............................................. 38

HYDROXYUREA.................................41

HYDROXYZINE HCL..........................21

HYDROXYZINE PAMOATE...............21

HYLAFEM..........................................123

HYOSCYAMINE SULFATE..............140

HYOSCYAMINE SULFATE ER........140

HYOSYNE...........................................140

HYPOLANCE AST LANCING..........90

HY-VEE LANCETS.............................90

HY-VEE THIN LANCETS....................90

IBANDRONATE SODIUM.................. 74

IBRANCE..............................................42

IBU.........................................................13

ICLEVIA...............................................58

ICOSAPENT ETHYL............................34

IGLUCOSE TEST STRIPS.................70

IMATINIB MESYLATE....................... 39

IMBRUVICA........................................40

IMIPRAMINE HCL...............................28

IMIPRAMINE PAMOATE................... 28

IMIQUIMOD......................................... 65

IMIQUIMOD PUMP............................. 65

IN TOUCH BLOOD GLUCOSE

TEST......................................................70

IN TOUCH LANCING DEVICE....... 90

IN TOUCH STERILE LANCETS

30G.........................................................90

INCASSIA.............................................59

INCONTROL ULTICARE PEN

NEEDLES........................................... 108

INCRUSE ELLIPTA........................... 23

INDAPAMIDE.......................................73

INDOMETHACIN.................................13

INDOMETHACIN ER...........................13

INFINITY BLOOD GLUCOSE

TEST......................................................70

INFINITY VOICE............................... 70

INSULIN ASPART PENFILL...............30

INSULIN DEGLUDEC FLEXTOUCH.30

INSULIN SYRINGE............................108

INSULIN SYRINGE/NEEDLE...........108

INSULIN SYRINGE-NEEDLE U-100108

INSUPEN PEN NEEDLES..................108

INSUPEN SENSITIVE......................109

INSUPEN ULTRAFIN.......................109

INTELENCE........................................ 47

INTRON A............................................41

INTROVALE........................................58

INVEGA HAFYERA........................... 45

INVEGA SUSTENNA..........................45

INVEGA TRINZA............................... 45

IPRATROPIUM BROMIDE............... 129

IPRATROPIUM-ALBUTEROL............22

IRBESARTAN.......................................36

IRBESARTAN-

HYDROCHLOROTHIAZIDE...............36

ISENTRESS..........................................47

ISIBLOOM........................................... 54

ISONIAZID............................................38

ISOSORBIDE DINITRATE..................21

ISOSORBIDE MONONITRATE..........21

ISOSORBIDE MONONITRATE ER....21

ISRADIPINE..........................................50

ITRACONAZOLE.................................33

IVERMECTIN....................................... 21

153

JAIMIESS.............................................58

JANTOVEN..........................................24

JANUMET............................................ 29

JANUMET XR..................................... 29

JANUVIA..............................................29

JARDIANCE........................................ 31

JASMIEL.............................................. 54

JAYPIRCA............................................40

JENCYCLA.......................................... 59

JESDUVROQ....................................... 80

JINTELI................................................75

JOLESSA.............................................. 58

JOYEAUX.............................................54

JULEBER..............................................54

JULUCA................................................46

JUNEL 1.5/30........................................54

JUNEL 1/20...........................................54

JUNEL FE 1.5/30..................................54

JUNEL FE 1/20.....................................54

JUNEL FE 24........................................54

KAITLIB FE.........................................54

KALLIGA.............................................54

KALYDECO.......................................138

KAMELEON LUBRICATED.............83

KARIVA................................................52

KELNOR 1/35.......................................55

KELNOR 1/50.......................................55

KEPIVANCE........................................42

KETOCONAZOLE..........................33, 65

KETOPROFEN......................................13

KETOROLAC TROMETHAMINE

........................................................ 13, 132

KIMONO................................................83

KIMONO COLORS.............................83

KIMONO MAXX-LARGE FLARE...83

KIMONO MICRO THIN PLUS............83

KIMONO PLUS.....................................83

KIMONO PS..........................................83

KIMONO PS PLUS............................... 83

KIMONO SENSATION........................ 83

KIMONO SENSATION PLUS..............83

KIMONO SPECIAL............................83

KINNEY LANCETS..............................90

KINNEY THIN LANCETS...................90

KINRAY INSULIN SYRINGE...........109

KISQALI (200 MG DOSE)................. 42

KISQALI (400 MG DOSE)................. 42

KISQALI (600 MG DOSE)................. 42

KLAYESTA..........................................63

KLOR-CON........................................122

KLOR-CON 10...................................122

KLOR-CON M10............................... 122

KLOR-CON M15............................... 122

KLOR-CON M20............................... 122

KLS ALLER-FLO..............................129

KLS ASPIRIN LOW DOSE.................. 15

KLS QUIT2.........................................137

KLS QUIT4.........................................137

KMART VALU INSULIN SYRINGE

30G.......................................................109

KOURZEQ..........................................124

KP ASPIRIN.......................................... 15

KP FOLIC ACID....................................79

KP PRENATAL MULTIVITAMINS..126

KP PSEUDOEPHEDRINE HCL.........130

KPN PRENATAL................................126

K-PRIME............................................ 122

KRAZATI............................................. 40

KROGER AUTOLET LANCING

DEVICE................................................ 90

KROGER BLOOD GLUCOSE TEST...70

KROGER HEALTHPRO

GLUCOSE TEST................................. 70

KROGER HEALTHPRO LANCET

26G.........................................................90

KROGER INSULIN SYRINGE.......... 109

KROGER LANCETS.............................90

KROGER LANCETS 21G.....................90

KROGER LANCETS MICRO THIN

33G.........................................................90

KROGER LANCETS SUPER THIN.....90

KROGER LANCETS THIN..................90

KROGER LANCETS THIN 26G..........90

KROGER LANCETS ULTRATHIN

30G.........................................................90

KROGER LANCING DEVICE.............90

KROGER PEN NEEDLES.................. 109

KROGER PREMIUM GLUCOSE

TEST...................................................... 70

KURVELO............................................55

K-Y ME & YOU EXTRA

LUBRICATED..................................... 83

K-Y ME & YOU INTENSE................ 83

KYLEENA............................................ 59

LABETALOL HCL............................... 49

LACOSAMIDE......................................25

LACTULOSE.........................................81

LACTULOSE ENCEPHALOPATHY...77

LAGEVRIO.......................................... 49

LAMICTAL STARTER......................25

LAMIVUDINE...................................... 48

LAMIVUDINE-ZIDOVUDINE............ 46

LAMOTRIGINE.................................... 25

LANCET DEVICE WITH EJECTOR...90

LANCETS 30G......................................90

LANCETS 33G......................................90

LANCETS MICRO THIN 33G............. 90

LANCETS SUPER THIN 28G..............90

LANCETS THIN................................... 90

LANCETS ULTRA THIN...................90

LANCETS ULTRA THIN 30G............. 90

LANCING DEVICE.............................. 90

LANOXIN PEDIATRIC......................51

LANSOPRAZOLE...............................140

LANTHANUM CARBONATE.............77

LANZO..................................................90

LAPATINIB DITOSYLATE.................41

LARIN 1.5/30........................................55

LARIN 1/20...........................................55

LARIN 24 FE........................................55

LARIN FE 1.5/30..................................55

LARIN FE 1/20.....................................55

LARISSIA.............................................55

LATANOPROST.................................133

LAYOLIS FE........................................55

LEADER ADVANCED LANCING

DEVICE................................................. 90

LEADER INSULIN SYRINGE...........109

LEADER UNIFINE PENTIPS..........109

LEADER UNIFINE PENTIPS PLUS

.............................................................. 109

LEDIPASVIR-SOFOSBUVIR.............. 48

LEENA.................................................. 59

LEFLUNOMIDE....................................14

LENALIDOMIDE................................123

LENVIMA (10 MG DAILY DOSE)... 43

LENVIMA (12 MG DAILY DOSE)... 43

LENVIMA (14 MG DAILY DOSE)... 43

LENVIMA (18 MG DAILY DOSE)... 43

LENVIMA (20 MG DAILY DOSE)... 43

LENVIMA (24 MG DAILY DOSE)... 43

LENVIMA (4 MG DAILY DOSE)..... 43

LENVIMA (8 MG DAILY DOSE)..... 43

LESSINA...............................................55

LETROZOLE.........................................42

LEUCOVORIN CALCIUM...................42

LEUKERAN......................................... 43

LEUKINE..............................................80

LEUPROLIDE ACETATE....................42

LEVEMIR.............................................30

LEVEMIR FLEXPEN......................... 30

LEVEMIR FLEXTOUCH...................30

LEVETIRACETAM.............................. 25

LEVOBUNOLOL HCL....................... 131

LEVOCARNITINE................................74

LEVOCARNITINE SF.......................... 74

LEVOFLOXACIN.........................76, 131

LEVONEST.......................................... 59

LEVORA 0.15/30 (28)..........................55

LEVO-T...............................................139

LEVOXYL.......................................... 139

LEXIVA................................................ 47

L-GLUTAMINE.................................... 79

LIBERTY MEDICAL LANCETS......91

LIBERTY MINI LANCING

DEVICE................................................ 91

LIBERTY NEXT GENERATION

TEST......................................................70

LIBERTY TEST.....................................70

LIDOCAINE.......................................... 65

LIDOCAINE HCL

URETHRAL/MUCOSAL......................65

LIDOCAINE VISCOUS HCL.............124

LIDOCAINE-PRILOCAINE.................65

LILETTA (52 MG)...............................59

LINEZOLID...........................................37

LIOTHYRONINE SODIUM............... 139

LISDEXAMFETAMINE

DIMESYLATE...................................... 10

LISINOPRIL.......................................... 35

LISINOPRIL-

HYDROCHLOROTHIAZIDE...............35

LITE TOUCH LANCETS......................91

LITE TOUCH LANCING PEN..........91

LITETOUCH INSULIN SYRINGE.109

LITETOUCH LANCETS....................91

LITETOUCH PEN NEEDLES.109, 110

LITHIUM CARBONATE......................45

154

LITHIUM CARBONATE ER................45

LIVE BETTER ADV LANCING

DEVICE................................................. 91

LIVE BETTER LANCET SUPER

THIN...................................................... 91

LIVE BETTER LANCET ULTRA

THIN...................................................... 91

LO LOESTRIN FE.............................. 52

LOJAIMIESS....................................... 58

LOKELMA.........................................123

LONGS INSULIN SYRINGE............. 110

LONGS LANCETS STANDARD.........91

LONGS LANCETS THIN.....................91

LONGS LANCETS ULTRA THIN.......91

LONSURF.............................................41

LOPINAVIR-RITONAVIR...................46

LORAZEPAM........................................22

LORAZEPAM INTENSOL................ 21

LORBRENA......................................... 39

LORTAB...............................................17

LORYNA...............................................55

LOSARTAN POTASSIUM...................36

LOSARTAN POTASSIUM-HCTZ....... 36

LOVASTATIN.......................................34

LOW-OGESTREL...............................55

LOXAPINE SUCCINATE.....................45

LO-ZUMANDIMINE.......................... 55

LUBIPROSTONE..................................76

LUER LOCK SAFETY SYRINGES 110

LUMAKRAS.........................................40

LUMIGAN.......................................... 133

LUPRON DEPOT (1-MONTH)..........42

LUPRON DEPOT (3-MONTH)..........42

LUPRON DEPOT (4-MONTH)..........42

LUPRON DEPOT-PED (1-MONTH) 74

LUPRON DEPOT-PED (3-MONTH) 75

LUPRON DEPOT-PED (6-MONTH) 75

LUTERA............................................... 55

LYLEQ..................................................59

LYLLANA............................................ 76

LYNPARZA..........................................43

LYSODREN..........................................38

LYTGOBI (12 MG DAILY DOSE)....40

LYTGOBI (16 MG DAILY DOSE)....40

LYTGOBI (20 MG DAILY DOSE)....40

LYZA.....................................................59

MAGELLAN INSULIN SAFETY

SYR......................................................110

MAGELLAN TUBERCULIN

SYRINGE............................................110

MALATHION........................................65

MARATHON MEDICAL PENTIPS110

MARAVIROC........................................47

MARLISSA............................................55

MASONATAL.....................................126

MATULANE.........................................41

MAVYRET........................................... 48

MAXICOMFORT II PEN NEEDLE110

MAXI-COMFORT INSULIN

SYRINGE............................................110

MAXI-COMFORT SAFETY PEN

NEEDLE..............................................110

MAXICOMFORT SYR 27G X 1/2".110

MAXI-TUSS AC....................................61

MAXX....................................................83

MAXX PLUS.........................................83

MEDIC INSULIN SYRINGE..............110

MEDICHOICE SAFETY LANCET......91

MEDICHOICE SAFETY LANCET

EXTRA...................................................91

MEDICHOICE SAFETY LANCET

NORM....................................................91

MEDICINE SHOPPE PEN NEEDLES110

MEDLANCE EXTRA 21G..................91

MEDLANCE LITE 25G......................91

MEDLANCE PLUS EXTRA 21G...... 91

MEDLANCE PLUS LANCETS..........91

MEDLANCE PLUS LITE 25G...........91

MEDLANCE PLUS SPECIAL

0.8MM................................................... 91

MEDLANCE PLUS SUPERLITE

30G.........................................................91

MEDLANCE PLUS UNIVERSAL

21G.........................................................91

MEDLANCE UNIVERSAL 21G........91

MEDROXYPROGESTERONE

ACETATE......................................58, 134

MEFLOQUINE HCL.............................38

MEGESTROL ACETATE.....................43

MEIJER ALCOHOL SWABS...............82

MEIJER BLOOD GLUCOSE TEST..... 70

MEIJER ESSENTIAL GLUCOSE

TEST...................................................... 70

MEIJER LANCETS.............................91

MEIJER LANCETS THIN................. 91

MEIJER LANCETS UNIVERSAL

21G.........................................................91

MEIJER LANCETS UNIVERSAL

30G.........................................................91

MEIJER LANCETS UNIVERSAL

33G.........................................................91

MEIJER NASAL DECONGESTANT.130

MEIJER PEN NEEDLES.....................110

MEIJER SUPER THIN LANCETS... 91

MEIJER TRUETEST TEST...............70

MEIJER TRUETRACK TEST...........70

MEKINIST............................................40

MEKTOVI............................................ 40

MELOXICAM....................................... 13

MELPHALAN....................................... 43

MEMANTINE HCL.............................136

MEMANTINE HCL ER...................... 136

MENACTRA...................................... 141

MENEST...............................................76

MENOSTAR.........................................76

MENQUADFI.....................................141

MENVEO............................................141

MEPERIDINE HCL.........................17, 18

MEPHYTON...................................... 144

MEPROBAMATE................................. 21

MERCAPTOPURINE............................39

MEROPENEM.......................................37

MERZEE...............................................55

MESALAMINE..................................... 77

MESALAMINE ER............................... 77

MESNEX...............................................43

METFORMIN HCL...............................29

METFORMIN HCL ER.........................29

METHADONE HCL..............................18

METHAZOLAMIDE.............................73

METHERGINE..................................133

METHIMAZOLE.................................139

METHOCARBAMOL.........................128

METHOTREXATE SODIUM...............39

METHOTREXATE SODIUM (PF).......39

METHSCOPOLAMINE BROMIDE...141

METHYLDOPA.................................... 36

METHYLPHENIDATE HCL................11

METHYLPHENIDATE HCL ER..........11

METHYLPHENIDATE HCL ER (CD).11

METHYLPHENIDATE HCL ER (LA).11

METHYLPREDNISOLONE.................61

METHYLPREDNISOLONE SODIUM

SUCC......................................................61

METOCLOPRAMIDE HCL..................76

METOLAZONE.....................................73

METOPROLOL SUCCINATE ER........49

METOPROLOL TARTRATE............... 49

METOPROLOL-

HYDROCHLOROTHIAZIDE...............37

METRONIDAZOLE................37, 65, 144

MEXILETINE HCL...............................22

MIBELAS 24 FE.................................. 55

MICRODOT PEN NEEDLE.............110

MICRODOT TEST..............................70

MICROGESTIN 1.5/30........................55

MICROGESTIN 1/20...........................55

MICROGESTIN 24 FE........................55

MICROGESTIN FE 1.5/30................. 55

MICROGESTIN FE 1/20.................... 55

MICROLET LANCETS......................91

MICROLET NEXT LANCING

DEVICE................................................ 91

MIDAZOLAM HCL..............................80

MIDAZOLAM HCL (PF)......................80

MIDODRINE HCL..............................144

MIGERGOT.......................................121

MILI...................................................... 55

MIMVEY.............................................. 75

MINI LANCING DEVICE.................... 91

MINOCYCLINE HCL.........................139

MINOXIDIL.......................................... 37

MIRENA (52 MG)................................59

MIRTAZAPINE.....................................27

MISOPROSTOL.................................. 141

MM ASPIRIN........................................ 15

MM BLULINK GLUCOSE TEST..... 71

MM EASY TOUCH GLUCOSE.........71

MM INSULIN SYRINGE/NEEDLE...110

MM LANCING DEVICE....................91

MM PEN NEEDLES..................110, 111

MM TWIST LANCETS...................... 91

M-M-R II.............................................142

M-NATAL PLUS.................................127

MODAFINIL..........................................11

MODERNA COVID-19 VAC 6M-

11Y.......................................................143

MOEXIPRIL HCL................................. 35

MOLINDONE HCL...............................45

155

MOMETASONE FUROATE........ 64, 129

MONOJECT HYPODERMIC

NEEDLE..............................................111

MONOJECT INSULIN SYRINGE..111

MONOJECT MAGELLAN

SAFETY NDL.....................................111

MONOJECT MAGELLAN

SYRINGE............................................111

MONOJECT SYRINGE....................111

MONOJECT TB SAFETY

SYRINGE............................................111

MONOJECT TB SYRINGE............. 111

MONOJECT ULTRA COMFORT

SYRINGE............................................111

MONOLET LANCETS....................... 91

MONOLET OPD LANCETS..............91

MONOLETTOR SAFETY

LANCETS.............................................91

MONO-LINYAH..................................56

MONTELUKAST SODIUM................. 23

MORPHINE SULFATE.........................18

MORPHINE SULFATE

(CONCENTRATE)................................18

MORPHINE SULFATE ER.................. 18

MORPHINE SULFATE ER BEADS.... 18

MOXIFLOXACIN HCL................76, 132

MOXIFLOXACIN HCL (2X DAY)....131

MPD SAFETY LANCET 21G...............91

MPD SAFETY LANCET 23G...............91

MPD SAFETY LANCET 28G...............91

MPD SAFETY LANCET 30G...............91

MS INSULIN SYRINGE.....................111

MULTAQ..............................................22

MULTI PRENATAL........................... 127

MULTI VITAMIN...............................125

MULTI VITAMIN DAILY..................125

MULTI VITAMIN W/D-3...................125

MULTI-LANCET DEVICE...................91

MULTI-LANCET DEVICE 2.............92

MULTIPLE VITAMIN-FOLIC ACID 125

MULTIPLE VITAMINS......................125

MULTIPLE VITAMINS ESSENTIAL125

MULTIVITAMIN................................125

MULTI-VITAMIN...............................125

MULTIVITAMIN + FLUORIDE........126

MULTIVITAMIN ADULT................. 125

MULTI-VITAMIN DAILY................. 125

MULTIVITAMIN IRON-FREE..........125

MULTIVITAMIN W/FLUORIDE...... 126

MULTIVITAMIN/FLUORIDE...........126

MULTI-VITAMIN/FLUORIDE..........126

MULTI-VITAMIN/FLUORIDE/IRON

.............................................................. 126

MULTI-VIT-FLOR............................126

MUPIROCIN..........................................62

MY CHOICE........................................57

MY WAY...............................................57

MYCOPHENOLATE MOFETIL........123

MYGLUCOHEALTH LANCETS

30G.........................................................92

MYGLUCOHEALTH TEST.............. 71

MYLAB BOX COVID-19 TESTING.72

NABUMETONE....................................13

NADOLOL.............................................49

NAFRINSE..........................................122

NAFRINSE DROPS...........................122

NALOXONE HCL.................................32

NALTREXONE HCL............................32

NAPROXEN.......................................... 13

NAPROXEN SODIUM......................... 13

NARATRIPTAN HCL.........................121

NARCAN...............................................32

NASAL DECONGESTANT................130

NASAL DECONGESTANT D............130

NASAL DECONGESTANT MAX ST130

NATALVIT.........................................127

NATAZIA..............................................58

NATEGLINIDE.....................................31

NEBIVOLOL HCL................................49

NECON 0.5/35 (28)...............................56

NEOMULTIVITE..............................125

NEOMYCIN SULFATE........................12

NEOMYCIN-BACITRACIN ZN-

POLYMYX.......................................... 132

NEOMYCIN-POLYMYXIN-

DEXAMETH................................132, 133

NEOMYCIN-POLYMYXIN-

GRAMICIDIN......................................132

NEOMYCIN-POLYMYXIN-HC........ 133

NEONATAL PLUS............................127

NEONATAL PRENATAL.................. 127

NEONATAL VITAMIN....................127

NEO-POLYCIN..................................132

NEUPOGEN......................................... 80

NEUTEK 2TEK TEST........................ 71

NEVIRAPINE........................................47

NEVIRAPINE ER..................................47

NEW DAY.............................................57

NEXPLANON.......................................58

NIACIN ER

(ANTIHYPERLIPIDEMIC).................. 34

NICODERM CQ................................ 137

NICORETTE......................................137

NICORETTE MINI........................... 137

NICORETTE STARTER KIT..........137

NICOTINE...........................................137

NICOTINE MINI.................................137

NICOTINE POLACRILEX MINI.......137

NICOTINE STEP 1..............................137

NICOTINE STEP 2..............................137

NICOTINE STEP 3..............................137

NICOTROL........................................ 137

NICOTROL NS..................................137

NIFEDIPINE..........................................50

NIFEDIPINE ER....................................50

NIFEDIPINE ER OSMOTIC

RELEASE.............................................. 50

NIKKI....................................................56

NILUTAMIDE.......................................38

NINLARO.............................................41

NITROFURANTOIN

MACROCRYSTAL...............................37

NITROFURANTOIN MONOHYD

MACRO................................................. 37

NITROGLYCERIN................................21

NIVA THYROID.................................139

NIVA-PLUS........................................ 127

NIZATIDINE.......................................140

NORA-BE..............................................59

NORDITROPIN FLEXPRO...............74

NORETHINDRONE ACETATE.........134

NORLYROC.........................................59

NORTREL 0.5/35 (28)......................... 56

NORTREL 1/35 (21)............................ 56

NORTREL 1/35 (28)............................ 56

NORTREL 7/7/7...................................59

NORTRIPTYLINE HCL....................... 28

NORVIR................................................47

NOVA MAX GLUCOSE TEST..........71

NOVA SAFETY LANCETS 23G....... 92

NOVA SAFETY LANCETS 28G....... 92

NOVA SUREFLEX LANCETS..........92

NOVA SUREFLEX LANCING

DEVICE................................................ 92

NOVAVAX COVID-19 VACCINE....143

NOVOFINE AUTOCOVER PEN

NEEDLE..............................................112

NOVOFINE PEN NEEDLE..............112

NOVOFINE PLUS PEN NEEDLE...112

NOVOLIN 70/30...................................30

NOVOLIN 70/30 FLEXPEN...............30

NOVOLIN 70/30 FLEXPEN

RELION................................................ 30

NOVOLIN 70/30 RELION..................30

NOVOLIN N.........................................30

NOVOLIN N FLEXPEN..................... 30

NOVOLIN N FLEXPEN RELION.....30

NOVOLIN N RELION........................ 30

NOVOLIN R.........................................31

NOVOLIN R FLEXPEN..................... 31

NOVOLIN R FLEXPEN RELION.....31

NOVOLIN R RELION........................ 31

NOVOLOG 70/30 FLEXPEN

RELION................................................ 31

NOVOLOG FLEXPEN RELION.......31

NOVOLOG MIX 70/30 RELION.......31

NOVOLOG RELION.......................... 31

NOZIN NASAL SANITIZER........... 129

NOZIN NASAL SANITIZER

POPSWAB.......................................... 129

NP THYROID.....................................139

NUCYNTA............................................18

NUCYNTA ER..................................... 18

NUFOL..................................................79

NURTEC.............................................121

NUTROPIN AQ NUSPIN 10...............74

NUTROPIN AQ NUSPIN 20...............74

NUTROPIN AQ NUSPIN 5.................74

NYLIA 1/35...........................................56

NYLIA 7/7/7..........................................59

NYMYO................................................ 56

NYSTATIN..............................33, 63, 124

NYSTATIN-TRIAMCINOLONE......... 63

NYSTOP................................................63

OBSTETRIX EC (WITH

DOCUSATE)...................................... 127

OBTREX.............................................127

OCCLUVAN.......................................134

OCELLA...............................................56

156

ODEFSEY.............................................46

OFLOXACIN.........................76, 132, 133

OGSIVEO............................................. 40

OLANZAPINE.......................................46

OLMESARTAN MEDOXOMIL...........36

OLMESARTAN MEDOXOMIL-

HCTZ......................................................36

OLOPATADINE HCL.........................131

OMEGA-3-ACID ETHYL ESTERS..... 34

OMEPRAZOLE...........................140, 141

OMNICAP............................................125

OMNIFLEX DIAPHRAGM............... 84

OMNIPOD 5 G6 INTRO (GEN 5)......97

OMNIPOD 5 G6 PODS (GEN 5)........97

OMNIPOD 5 G7 INTRO (GEN 5)......97

OMNIPOD 5 G7 PODS (GEN 5)........97

OMNIPOD CLASSIC PDM (GEN 3) 97

OMNIPOD CLASSIC PODS (GEN

3).............................................................97

OMNIPOD DASH INTRO (GEN 4)...97

OMNIPOD DASH PDM (GEN 4).......97

OMNIPOD DASH PODS (GEN 4).....97

OMNITROPE.......................................74

OMVOH................................................77

ON CALL EXPRESS BLOOD

GLUCOSE............................................ 71

ONCASPAR..........................................41

ONCE DAILY......................................125

ONDANSETRON..................................33

ONDANSETRON HCL.........................33

ONE DAILY........................................ 125

ONE DAILY ESSENTIAL................125

ONE DAILY ESSENTIALS................125

ONE DAILY MULTIVITAMIN

ADULT................................................ 125

ONE DROP TEST..................................71

ONE VITE DAILY

MULTIVITAMIN.............................. 125

ONE VITE WOMENS.........................127

ONE-A-DAY ESSENTIAL................125

ONE-A-DAY MENS...........................125

ONE-A-DAY WOMENS

PRENATAL........................................127

ONE-DAILY MULTI VITAMINS......125

ONE-DAILY MULTI-VITAMIN........125

ONETOUCH DELICA LANCETS

30G.........................................................92

ONETOUCH DELICA LANCETS

33G.........................................................92

ONETOUCH DELICA LANCING

DEV........................................................92

ONETOUCH DELICA PLUS

LANCET30G........................................ 92

ONETOUCH DELICA PLUS

LANCET33G........................................ 92

ONETOUCH DELICA PLUS

LANCING.............................................92

ONETOUCH DELICA SAFETY

LANCING.............................................92

ONETOUCH FINEPOINT

LANCETS.............................................92

ONETOUCH ULTRA..........................71

ONETOUCH ULTRA 2.......................92

ONETOUCH ULTRA TEST.............. 71

ONETOUCH ULTRASOFT 2

LANCETS.............................................92

ONETOUCH ULTRASOFT

LANCETS.............................................92

ONETOUCH VERIO.....................71, 92

ONETOUCH VERIO FLEX

SYSTEM................................................92

ONETOUCH VERIO IQ SYSTEM... 92

ONETOUCH VERIO REFLECT.......92

OPCICON ONE-STEP........................58

OPTION 2............................................. 58

OPTIONS GYNOL II

CONTRACEPTIVE...........................143

OPTIUMEZ TEST...............................71

ORALONE..........................................124

ORENCIA.............................................14

ORENCIA CLICKJECT.....................14

ORENITRAM.......................................51

ORILISSA.............................................74

ORKAMBI..........................................138

ORPHENADRINE CITRATE ER.......128

ORSERDU............................................ 43

OSELTAMIVIR PHOSPHATE.............49

OSMOPREP......................................... 81

OTEZLA............................................... 13

OXAPROZIN.........................................13

OXAZEPAM..........................................22

OXCARBAZEPINE.........................25, 26

OXYBUTYNIN CHLORIDE..............141

OXYBUTYNIN CHLORIDE ER........141

OXYCODONE HCL..............................18

OXYCODONE-ACETAMINOPHEN...19

OXYCONTIN.......................................18

OXYMORPHONE HCL........................19

OXYMORPHONE HCL ER..................19

OXYTROL..........................................141

PALFORZIA (12 MG DAILY

DOSE)....................................................11

PALFORZIA (120 MG DAILY

DOSE)....................................................11

PALFORZIA (160 MG DAILY

DOSE)....................................................11

PALFORZIA (20 MG DAILY

DOSE)....................................................11

PALFORZIA (200 MG DAILY

DOSE)....................................................11

PALFORZIA (240 MG DAILY

DOSE)....................................................12

PALFORZIA (3 MG DAILY DOSE).12

PALFORZIA (300 MG

MAINTENANCE)................................12

PALFORZIA (300 MG

TITRATION)........................................12

PALFORZIA (40 MG DAILY

DOSE)....................................................12

PALFORZIA (6 MG DAILY DOSE).12

PALFORZIA (80 MG DAILY

DOSE)....................................................12

PALFORZIA INITIAL

ESCALATION......................................12

PANCREAZE.......................................73

PANTOPRAZOLE SODIUM..............141

PARAGARD INTRAUTERINE

COPPER................................................57

PAROXETINE HCL..............................28

PAXLOVID (150/100)..........................48

PAXLOVID (300/100)..........................48

PAZOPANIB HCL.................................41

PC LANCETS SUPER THIN 30G........ 92

PC UNIFINE PENTIPS....................... 112

PEG-

3350/ELECTROLYTES/ASCORBAT..81

PEGASYS..............................................48

PEG-KCL-NACL-NASULF-NA ASC-

C............................................................. 81

PEMAZYRE.........................................40

PEN NEEDLES....................................112

PENBRAYA........................................141

PENICILLIN V POTASSIUM............ 134

PENTASA............................................. 77

PENTAZOCINE-NALOXONE HCL....20

PENTIPS.............................................112

PENTOXIFYLLINE ER........................78

PERFECT LANCETS 28G................. 92

PERFECT LANCETS 30G................. 92

PERIOGARD......................................124

PERMETHRIN...................................... 65

PERPHENAZINE.................................. 46

PFIZER COVID-19 VAC-TRIS 5-

11Y.......................................................143

PFIZER COVID-19 VAC-TRIS 6M-

4Y.........................................................143

PHARMACIST CHOICE

ALCOHOL............................................82

PHARMACIST CHOICE

AUTOCODE.........................................71

PHARMACIST CHOICE

LANCETS.............................................92

PHARMACIST CHOICE NO

CODING................................................ 71

PHARMACY COUNTER

LANCETS.............................................92

PHENAZO............................................ 78

PHENAZOPYRIDINE HCL..................78

PHENOBARBITAL...............................80

PHENYTEK..........................................26

PHENYTOIN.........................................26

PHENYTOIN INFATABS...................26

PHENYTOIN SODIUM EXTENDED..26

PHILITH...............................................56

PHOSPHO-TRIN 250 NEUTRAL....122

PILOCARPINE HCL...................124, 131

PIMTREA.............................................53

PIOGLITAZONE HCL..........................32

PIOGLITAZONE HCL-METFORMIN

HCL........................................................32

PIP BLOOD GLUCOSE TEST

STRIP.................................................... 71

PIP LANCETS 28G............................... 92

PIP LANCETS 30G............................... 92

PIP PEN NEEDLES 31G X 5MM.......112

PIP PEN NEEDLES 32G X 4MM.......112

PIRFENIDONE....................................138

PIRMELLA 1/35.................................. 56

PIRMELLA 7/7/7................................. 59

157

PIROXICAM..........................................13

PLAN B ONE-STEP............................ 58

PNEUMOVAX 23...............................141

PNV PRENATAL PLUS

MULTIVIT+DHA................................127

PNV-DHA+DOCUSATE.................... 128

PNV-OMEGA......................................127

PNV-SELECT......................................127

POCKETCHEM EZ TEST.................71

POGO AUTOMATIC BLOOD

GLUCOSE............................................ 92

POGO AUTOMATIC TEST

CARTRIDGES..................................... 71

POLYCIN............................................132

POLYMYXIN B-TRIMETHOPRIM...132

POLY-TUSSIN AC................................62

POLY-VI-FLOR.................................126

PORTIA-28...........................................56

POTASSIUM CHLORIDE..................123

POTASSIUM CHLORIDE CRYS ER.122

POTASSIUM CHLORIDE ER....122, 123

POTASSIUM CITRATE ER................. 78

PRADAXA............................................ 25

PRALUENT..........................................35

PRAMIPEXOLE

DIHYDROCHLORIDE......................... 44

PRASUGREL HCL................................79

PRAVASTATIN SODIUM................... 34

PRAZOSIN HCL................................... 36

PRECISION SURE-DOSE

SYRINGE............................................112

PRECISION THINS GP LANCETS..92

PRECISION XTRA BLOOD

GLUCOSE............................................ 71

PREDNISOLONE..................................61

PREDNISOLONE ACETATE.............133

PREDNISOLONE SODIUM

PHOSPHATE.................................61, 133

PREDNISONE.......................................61

PREFERRED PLUS INSULIN

SYRINGE.............................................112

PREFERRED PLUS LANCETS

COLORED.............................................92

PREFERRED PLUS LANCETS THIN.92

PREFERRED PLUS UNIFINE

PENTIPS.............................................. 112

PREFEST..............................................75

PREGABALIN.......................................26

PREMARIN..................................76, 144

PREMIUM BLOOD GLUCOSE TEST.71

PREMPHASE.......................................75

PREMPRO............................................75

PRENA 1 TRUE.................................. 128

PRENATABS RX...............................127

PRENATAL.........................................127

PRENATAL (W/IRON & FA).............127

PRENATAL 19....................................127

PRENATAL COMPLETE...................127

PRENATAL FORMULA A-FREE......127

PRENATAL FORTE........................... 127

PRENATAL ONE DAILY.................. 127

PRENATAL PLUS

VITAMIN/MINERAL......................... 127

PRENATAL VITAMIN.......................127

PRENATAL VITAMIN AND

MINERAL............................................127

PRENATAL VITAMIN PLUS LOW

IRON.................................................... 127

PRENATAL VITAMIN/MIN +DHA..128

PRENATAL VITAMINS.....................127

PRENATAL/IRON.............................. 127

PRENATAL+DHA..............................128

PRENATAL-U....................................127

PRENATVITE PLUS...........................127

PRENATVITE RX...............................127

PREVENT DROPSAFE PEN

NEEDLES........................................... 112

PREVENT SAFETY PEN

NEEDLES........................................... 112

PREVIDENT 5000 PLUS.................. 124

PREVNAR 13..................................... 142

PREVNAR 20..................................... 142

PREZISTA............................................47

PRIFTIN................................................38

PRIMIDONE..........................................26

PRO COMFORT ALCOHOL................82

PRO COMFORT INSULIN

SYRINGE....................................112, 113

PRO COMFORT LANCETS 30G.........92

PRO COMFORT LANCETS 31G.........92

PRO COMFORT PEN NEEDLES.......113

PRO COMFORT SAFETY LANCETS

30G.........................................................92

PRO VOICE V8/V9 GLUCOSE............71

PROBENECID.......................................78

PROCHLORPERAZINE....................... 46

PROCHLORPERAZINE MALEATE... 46

PROCRIT..............................................79

PROCTO-MED HC............................. 20

PROCTOSOL HC................................20

PROCTOZONE-HC............................ 20

PRODIGY INSULIN SYRINGE...... 113

PRODIGY LANCETS 28G.................92

PRODIGY LANCING DEVICE.........92

PRODIGY NO CODING BLOOD

GLUC.................................................... 71

PRODIGY SAFETY LANCETS 26G 92

PRODIGY TWIST TOP LANCETS

28G.........................................................92

PROGESTERONE...............................134

PROMETHAZINE HCL........................33

PROMETHAZINE-CODEINE..............62

PROMETHAZINE-DM.........................61

PROMETHEGAN................................33

PROPAFENONE HCL.......................... 22

PROPRANOLOL HCL..........................49

PROPRANOLOL HCL ER....................49

PROPYLTHIOURACIL...................... 139

PSEUDOEPH-BROMPHEN-DM..........61

PSEUDOEPHEDRINE HCL............... 130

PSS SELECT GP LANCETS..............93

PSS SELECT PLATFORMS.............. 93

PSS SELECT SAFETY LANCETS....93

PTS PANELS EGLU TEST................ 71

PULMICORT FLEXHALER............. 24

PURE COMFORT ALCOHOL PREP...82

PURE COMFORT LANCETS 30G.......93

PURE COMFORT PEN NEEDLE...... 113

PURE COMFORT SAFETY PEN

NEEDLE.............................................. 113

PX ADVANCED LANCING DEVICE.93

PX ASPIRIN.......................................... 15

PX ENTERIC ASPIRIN........................ 15

PX EXTRA SHORT PEN NEEDLES.113

PX INSULIN SYRINGE......................113

PX LANCET AUTO INJECTOR..........93

PX LANCETS MICROTHIN 33G........ 93

PX LANCETS ULTRA THIN...............93

PX LANCETS ULTRA THIN 28G.......93

PX MINI PEN NEEDLES................... 113

PX NASAL DECONGESTANT..........130

PX PEN NEEDLE................................113

PX PRENATAL MULTIVITAMINS..127

PX SHORTLENGTH PEN NEEDLES113

PX STOP SMOKING AID.................. 137

PYRAZINAMIDE..................................38

PYRIDOSTIGMINE BROMIDE...........38

PYRIDOSTIGMINE BROMIDE ER.... 38

PYRUKYND.........................................78

PYRUKYND TAPER PACK.............. 79

QC ADVANCED LANCING DEVICE 93

QC ALCOHOL SWABS........................82

QC ALLERGY RELIEF...................... 130

QC ASPIRIN LOW DOSE.............. 15, 16

QC CHILDRENS ASPIRIN.................. 16

QC ESSENTIALS................................125

QC LANCETS SUPER THIN 30G........93

QC LANCETS ULTRA THIN...............93

QC NASAL DECONGESTANT PE... 130

QC NICOTINE TRANSDERMAL

SYSTEM.............................................. 138

QC PEN NEEDLES.............................113

QC PRENATAL...................................127

QC UNIFINE PENTIPS.......................113

QC UNILET LANCETS 28G................93

QC UNILET LANCETS MICRO

THIN...................................................... 93

QUETIAPINE FUMARATE................. 45

QUICKTEK TEST...............................71

QUINAPRIL HCL........................... 35, 36

QUINAPRIL-

HYDROCHLOROTHIAZIDE...............35

QUINIDINE GLUCONATE ER............22

QUINIDINE SULFATE.........................22

QUINTABS..........................................125

QUINTET AC BLOOD GLUCOSE

TEST......................................................71

QUINTET BLOOD GLUCOSE

TEST......................................................71

QVAR REDIHALER...........................24

RA ALCOHOL SWABS........................82

RA ASPIRIN ADULT LOW DOSE......16

RA ASPIRIN ADULT LOW

STRENGTH...........................................16

RA ASPIRIN CHILDRENS.................. 16

RA ASPIRIN EC....................................16

RA ASPIRIN EC ADULT LOW ST..... 16

RA E-ZJECT LANCETS 28G............ 93

RA E-ZJECT LANCETS THIN 26G.93

158

RA E-ZJECT LANCETS THIN 28G.93

RA E-ZJECT LANCETS ULTRA

THIN......................................................93

RA INSULIN SYRINGE.....................113

RA MINI NICOTINE.......................... 138

RA NICOTINE.....................................138

RA NICOTINE GUM.......................... 138

RA NICOTINE POLACRILEX...........138

RA PEN NEEDLES.............................113

RA PRENATAL...................................127

RA PRENATAL FORMULA..............127

RA SINUS/CONGESTION RELIEF...130

RA SUPHEDRINE...............................130

RABEPRAZOLE SODIUM.................141

RALOXIFENE HCL..............................75

RAMELTEON....................................... 80

RAMIPRIL.............................................36

RANOLAZINE ER................................21

RAYA SURE PEN NEEDLE.............. 113

REACT..................................................58

READYLANCE SAFETY

LANCETS.............................................93

REALITY INSULIN SYRINGE..........113

REALITY LANCETS............................93

REALITY LATEX CONDOMS.........83

REALITY LATEX/ULTRA

TEXTURED..........................................83

REALITY LATEX/ULTRA THIN.....83

REALITY SWABS................................82

REALITY TRIGGER LANCETS..........93

REBIF..................................................135

REBIF REBIDOSE............................135

REBIF REBIDOSE TITRATION

PACK...................................................135

REBIF TITRATION PACK..............135

RECLIPSEN.........................................56

RECOMBIVAX HB...........................143

REFUAH PLUS BLOOD

GLUCOSE TEST................................. 71

REGRANEX.........................................65

RELION ALCOHOL SWABS............82

RELION BLOOD GLUCOSE TEST.71

RELION CONFIRM/MICRO TEST.71

RELION INSULIN SYRINGE......... 113

RELION LANCET DEVICES 30G....93

RELION LANCETS............................ 93

RELION LANCETS MICRO-THIN

33G.........................................................93

RELION LANCETS THIN 26G.........93

RELION LANCETS ULTRA-THIN

30G.........................................................93

RELION LANCING DEVICE............93

RELION MINI PEN NEEDLES.......113

RELION PEN NEEDLES..................113

RELION PREMIER TEST.................72

RELION PRIME TEST.......................72

RELION SHORT PEN NEEDLES...114

RELION TRUE METRIX TEST

STRIPS..................................................72

RELION ULTIMA TEST....................72

RELION ULTRA THIN LANCETS

30G.........................................................93

RELION ULTRA THIN PLUS

LANCETS.............................................93

REPAGLINIDE......................................31

REPATHA............................................ 35

REPATHA PUSHTRONEX

SYSTEM................................................35

REPATHA SURECLICK....................35

RESTASIS MULTIDOSE................. 132

RETEVMO........................................... 41

REXALL BLOOD GLUCOSE

TEST......................................................72

REXALL LANCETS ULTRA THIN

30G.........................................................93

REXULTI..............................................46

REYATAZ............................................ 47

REYVOW............................................122

REZDIFFRA.........................................76

REZLIDHIA.........................................42

RIBAVIRIN..................................... 48, 49

RIFAMPIN.............................................38

RIGHTEST ALTERNATE SITE

ADAPT.................................................. 93

RIGHTEST GD500 LANCING

DEVICE................................................ 93

RIGHTEST GL300 LANCETS.......... 93

RIGHTEST GS100 BLOOD

GLUCOSE............................................ 72

RIGHTEST GS300 BLOOD

GLUCOSE............................................ 72

RIGHTEST GS550 BLOOD

GLUCOSE............................................ 72

RIGHTEST GT333 BLOOD

GLUCOSE............................................ 72

RIGHTEST GT333 GLUCOSE

TEST......................................................72

RIMANTADINE HCL...........................49

RINVOQ................................................12

RISEDRONATE SODIUM................... 74

RISPERIDONE......................................45

RITONAVIR..........................................47

RIVASTIGMINE TARTRATE........... 135

RIVELSA.............................................. 58

RIZATRIPTAN BENZOATE..............121

ROFLUMILAST....................................23

ROPINIROLE HCL............................... 44

ROSUVASTATIN CALCIUM..............34

ROWEEPRA........................................ 26

ROXYBOND.........................................19

ROZLYTREK...................................... 41

RYDAPT............................................... 41

SAFE-T-LANCE.................................. 93

SAFE-T-LANCE PLUS....................... 93

SAFETY LANCET 30G/PRESSURE

ACT........................................................93

SAFETY LANCETS............................ 93

SAFETY LANCETS 21G.................... 93

SAFETY LANCETS 23G.................... 93

SAFETY LANCETS 28G......................93

SAFETY PEN NEEDLES....................114

SANDIMMUNE..................................123

SAPS CARE ALCOHOL PREP............82

SAPS HEALTH ALCOHOL PREP.......82

SAPS HEALTH CARE ALCOHOL

PREP...................................................... 82

SAPS HEALTH PLUS LANCETS........94

SAPS HEALTH TWIST TOP

LANCETS..............................................94

SAPS TWIST TOP LANCETS..............94

SAPSCARE TWIST TOP LANCETS...94

SAXAGLIPTIN HCL.............................29

SAXAGLIPTIN-METFORMIN ER......29

SB ALCOHOL PREP............................ 82

SB CHILDRENS ASPIRIN...................16

SB INSULIN SYRINGE......................114

SB LANCETS THIN..............................94

SB LANCETS ULTRA THIN............... 94

SB LOW DOSE ASA EC...................... 16

SCEMBLIX...........................................39

SCOPOLAMINE....................................33

SECURESAFE INSULIN SYRINGE

.............................................................. 114

SECURESAFE SAFETY PEN

NEEDLES........................................... 114

SECURESAFE SYRINGE/NEEDLE

.............................................................. 114

SELECT-LITE LANCING DEVICE.....94

SELEGILINE HCL................................44

SELENIUM SULFIDE.......................... 64

SE-NATAL 19..................................... 128

SEREVENT DISKUS...........................23

SEROSTIM...........................................74

SERTRALINE HCL...............................28

SETLAKIN........................................... 58

SEVELAMER CARBONATE...............77

SEVELAMER HCL...............................77

SF 5000 PLUS......................................124

SFROWASA......................................... 77

SHAROBEL..........................................59

SHINGRIX..........................................143

SHOPKO AUTOLET LANCING

DEVICE................................................ 94

SHOPKO ON-THE-GO LANCETS

30G.........................................................94

SHOPKO UNIFINE PENTIPS.........114

SHOPKO UNIFINE PENTIPS

PLUS....................................................114

SHOPKO UNILET LANCETS 28G...94

SHOPKO UNILET LANCETS 30G...94

SILDENAFIL CITRATE.......................51

SIMLIYA.............................................. 53

SIMPESSE............................................ 58

SIMPLE DIAGNOSTICS

LANCING DEV....................................94

SIMPONI.............................................. 12

SIMVASTATIN.....................................34

SINGLE-LET........................................94

SINUS CONGESTION MAX

STRENGTH.........................................130

SIROLIMUS........................................ 123

SKYLA.................................................. 59

SKYRIZI.........................................63, 77

SKYRIZI (150 MG DOSE)..................63

SKYRIZI PEN......................................63

SM ALCOHOL PREP............................82

SM ALLERGY RELIEF......................130

159

SM ASPIRIN ADULT LOW

STRENGTH...........................................16

SM ASPIRIN EC LOW STRENGTH....16

SM ASPIRIN LOW DOSE....................16

SM CHILDRENS ASPIRIN.................. 16

SM LANCETS 33G............................... 94

SM MULTIPLE VITAMINS

ESSENTIAL.........................................125

SM NASAL DECONGESTANT MAX

ST......................................................... 130

SM NICOTINE.................................... 138

SM NICOTINE POLACRILEX.......... 138

SM PRENATAL VITAMINS..............128

SM TRUEDRAW LANCING

DEVICE................................................ 94

SMART DIABETES VANTAGE

LANCING.............................................94

SMART SENSE COLOR LANCETS

33G.........................................................94

SMART SENSE PREMIUM TEST....72

SMART SENSE STANDARD

LANCETS.............................................94

SMART SENSE SUPER THIN

LANCETS.............................................94

SMART SENSE THIN LANCETS

26G.........................................................94

SMART SENSE VALUE TEST..........72

SMARTEST BLOOD GLUCOSE

TEST......................................................72

SMARTEST LANCETS 28G..............94

SOAANZ............................................... 73

SOD CITRATE-CITRIC ACID.............78

SODIUM CHLORIDE...........................61

SODIUM FLUORIDE......................... 122

SODIUM FLUORIDE 5000 PLUS......124

SODIUM FLUORIDE 5000 PPM....... 124

SOFOSBUVIR-VELPATASVIR.......... 48

SOLIFENACIN SUCCINATE............ 141

SOLUS V2 LANCETS 28G.................94

SOLUS V2 LANCING DEVICE.........94

SOLUS V2 TEST..................................72

SOLUS V2 TWIST LANCETS 30G...94

SOLUVITA.........................................122

SOLUVITA WITH FLUORIDE.......126

SORAFENIB TOSYLATE....................41

SORINE.................................................49

SOTALOL HCL (AF)............................49

SPIKEVAX......................................... 143

SPIRONOLACTONE............................ 73

SPIRONOLACTONE-HCTZ................ 73

SPRINTEC 28.......................................56

SPRYCEL............................................. 39

SRONYX...............................................56

SSD.........................................................64

ST JOSEPH ASPIRIN.........................16

ST JOSEPH LOW DOSE....................16

STAVUDINE.........................................48

STELARA.............................................63

STERILANCE TL................................94

STRESS FORMULA........................... 125

STRESSTABS ENERGY...................125

STRIBILD.............................................46

SUBLOCADE.......................................20

SUBVENITE.........................................26

SUBVENITE STARTER KIT-BLUE 26

SUBVENITE STARTER KIT-

GREEN..................................................26

SUBVENITE STARTER KIT-

ORANGE.............................................. 26

SUCCINYLCHOLINE CHLORIDE... 131

SUCRALFATE.................................... 140

SUDAFED...........................................130

SUDAFED SINUS CONGESTION.. 130

SUDAFED SINUS CONGESTION

12HR....................................................130

SUDOGEST........................................ 130

SUDOGEST MAXIMUM

STRENGTH........................................130

SULFACETAMIDE SODIUM............133

SULFACETAMIDE SODIUM-

SULFUR.................................................62

SULFAMETHOXAZOLE-

TRIMETHOPRIM..................................37

SULFASALAZINE................................77

SULFATRIM PEDIATRIC.................37

SULINDAC............................................13

SUMATRIPTAN..................................121

SUMATRIPTAN SUCCINATE..121, 122

SUMATRIPTAN SUCCINATE

REFILL................................................ 121

SUNITINIB MALATE.......................... 41

SUNLENCA..........................................47

SUPER THIN LANCETS......................94

SUPREME TEST................................. 72

SURE COMFORT ALCOHOL PREP...82

SURE COMFORT INSULIN

SYRINGE.....................................114, 115

SURE COMFORT LANCETS 18G.......94

SURE COMFORT LANCETS 21G.......94

SURE COMFORT LANCETS 23G.......94

SURE COMFORT LANCETS 28G.......94

SURE COMFORT LANCETS 30G.......94

SURE COMFORT LANCING PEN......94

SURE COMFORT PEN NEEDLES....115

SURELITE LANCETS........................94

SUSTIVA...............................................47

SYEDA.................................................. 56

SYMDEKO......................................... 138

SYMLINPEN 120.................................28

SYMLINPEN 60...................................29

SYNJARDY.......................................... 32

SYNJARDY XR....................................32

SYNTHROID......................................139

SYRINGE LUER LOCK..................... 115

TAB-A-VITE...................................... 125

TAB-A-VITE/BETA CAROTENE...125

TACROLIMUS..............................65, 123

TAFINLAR...........................................39

TAKE ACTION....................................58

TALTZ.................................................. 63

TALZENNA..........................................43

TAMOXIFEN CITRATE.......................38

TAMSULOSIN HCL............................. 78

TARINA 24 FE.....................................56

TARINA FE 1/20..................................56

TARINA FE 1/20 EQ........................... 56

TARON-C DHA................................. 128

TASIGNA..............................................39

TAYSOFY.............................................56

TAZAROTENE......................................64

TAZTIA XT..........................................50

TDVAX................................................140

TECHLITE AST LANCETS.............. 94

TECHLITE INSULIN SYRINGE........115

TECHLITE LANCETS....................... 94

TECHLITE LANCETS 26G...............94

TECHLITE PEN NEEDLES............ 115

TECHLITE PLUS PEN NEEDLES.115

TEMAZEPAM.......................................80

TEMOZOLOMIDE................................42

TENCON...............................................14

TENIVAC............................................140

TENOFOVIR DISOPROXIL

FUMARATE..........................................48

TEPMETKO.........................................40

TERAZOSIN HCL.................................36

TERBINAFINE HCL.............................33

TERBUTALINE SULFATE..................23

TERCONAZOLE.................................143

TESTOSTERONE..................................20

TESTOSTERONE CYPIONATE..........20

TESTOSTERONE ENANTHATE........ 20

TGT BLOOD GLUCOSE TEST........... 72

TGT LANCET MICRO THIN 33G.......94

TGT LANCET THIN 26G.....................94

TGT LANCET ULTRA THIN 30G.......94

TGT LANCING DEVICE......................94

THALOMID....................................... 123

THEOPHYLLINE ER............................24

THERA................................................125

THERA-MILL......................................125

THERANATAL CORE

NUTRITION.......................................128

THERA-TABS.....................................125

THEREMS..........................................125

THINLETS GP LANCETS.................94

THIORIDAZINE HCL...........................46

THIOTHIXENE.....................................46

THRIVE.............................................. 138

TIADYLT ER....................................... 50

TIAGABINE HCL................................. 26

TIBSOVO..............................................42

TILIA FE...............................................59

TIMOLOL MALEATE........................131

TIMOLOL MALEATE (ONCE-

DAILY)................................................ 131

TIOTROPIUM BROMIDE

MONOHYDRATE.................................23

TIVICAY...............................................47

TIZANIDINE HCL..............................128

TOBRADEX....................................... 133

TOBRAMYCIN...................................132

TOBRAMYCIN-

DEXAMETHASONE.......................... 133

TODAY SPONGE..............................143

TODAYS HEALTH LANCING

DEVICE................................................. 95

TODAYS HEALTH MINI PEN

NEEDLES............................................ 115

160

TODAYS HEALTH PEN NEEDLES. 115

TODAYS HEALTH SHORT PEN

NEEDLE.............................................. 115

TODAYS HEALTH THIN LANCETS

28G.........................................................95

TODAYS HEALTH THIN LANCETS

30G.........................................................95

TOLTERODINE TARTRATE............ 141

TOLTERODINE TARTRATE ER...... 141

TOPCARE CLICKFINE PEN

NEEDLES............................................ 115

TOPCARE LANCETS MICRO-THIN

33G.........................................................95

TOPCARE ULTRA COMFORT INS

SYR...................................................... 115

TOPIRAMATE...................................... 26

TOREMIFENE CITRATE.....................38

TORPENZ.............................................40

TORSEMIDE.........................................73

TOUJEO MAX SOLOSTAR.............. 31

TOUJEO SOLOSTAR.........................31

TRADJENTA........................................29

TRAMADOL HCL................................ 19

TRAMADOL-ACETAMINOPHEN......20

TRANEXAMIC ACID...........................80

TRANYLCYPROMINE SULFATE......27

TRAVEL LANCETS............................. 95

TRAVEL LANCETS ADVANCED

28G.........................................................95

TRAVOPROST (BAK FREE).............133

TRAZODONE HCL...............................28

TRELEGY ELLIPTA..........................22

TREMFYA......................................63, 64

TREPROSTINIL....................................51

TRETINOIN...........................................62

TRI FEMYNOR................................... 60

TRIAMCINOLONE ACETONIDE.64, 65

TRIAMTERENE-HCTZ........................73

TRIAZOLAM........................................ 80

TRICARE............................................128

TRIENTINE HCL................................123

TRI-ESTARYLLA...............................60

TRIFLUOPERAZINE HCL...................46

TRIFLURIDINE.................................. 132

TRIHEXYPHENIDYL HCL................. 44

TRIJARDY XR.....................................31

TRIKAFTA.........................................138

TRI-LEGEST FE................................. 60

TRI-LINYAH........................................60

TRI-LO-ESTARYLLA........................60

TRI-LO-MARZIA................................60

TRI-LO-MILI.......................................60

TRI-LO-SPRINTEC............................ 60

TRIMETHOBENZAMIDE HCL...........33

TRIMETHOPRIM..................................37

TRI-MILI..............................................60

TRINTELLIX.......................................28

TRI-NYMYO........................................60

TRI-SPRINTEC................................... 60

TRIUMEQ............................................ 47

TRIUMEQ PD......................................47

TRI-VITE/FLUORIDE........................ 126

TRIVORA (28)..................................... 60

TRI-VYLIBRA.....................................60

TRI-VYLIBRA LO.............................. 60

TRIZIVIR............................................. 47

TRUE COMFORT ALCOHOL PREP

PADS......................................................82

TRUE COMFORT INSULIN

SYRINGE.............................................115

TRUE COMFORT PEN NEEDLES....115

TRUE COMFORT PRO ALCOHOL

PREP...................................................... 82

TRUE COMFORT PRO INSULIN

SYR...................................................... 115

TRUE COMFORT PRO PEN

NEEDLES............................................ 115

TRUE COMFORT SAFETY

LANCETS..............................................95

TRUE COMFORT TWIST TOP

LANCETS..............................................95

TRUE COVER.......................................83

TRUE DAILY VITE............................125

TRUE FOCUS BLOOD GLUCOSE

STRIP.....................................................72

TRUE FOLIC ACID.............................. 80

TRUE METRIX BLOOD

GLUCOSE TEST................................. 72

TRUE METRIX PRO BLOOD

GLUCOSE............................................ 72

TRUEDRAW LANCING DEVICE....95

TRUEPLUS 5-BEVEL PEN

NEEDLES........................................... 115

TRUEPLUS INSULIN SYRINGE

...................................................... 115, 116

TRUEPLUS LANCETS 26G...............95

TRUEPLUS LANCETS 28G...............95

TRUEPLUS LANCETS 30G...............95

TRUEPLUS LANCETS 33G...............95

TRUEPLUS PEN NEEDLES............116

TRUEPLUS SAFETY LANCETS

28G.........................................................95

TRUETEST TEST............................... 72

TRUETRACK TEST........................... 72

TRULICITY......................................... 31

TRUMENBA.......................................142

TRUQAP...............................................39

TRUSELTIQ (100MG DAILY

DOSE)....................................................40

TRUSELTIQ (125MG DAILY

DOSE)....................................................40

TRUSELTIQ (50MG DAILY DOSE) 40

TRUSELTIQ (75MG DAILY DOSE) 40

TRUSTEX COLOR CONDOMS +

LUBE.....................................................83

TRUSTEX

LUB/RIBBED/STUDDED...................84

TRUSTEX LUB/SPERMICIDE EX

ST...........................................................84

TRUSTEX LUB/SPERMICIDE XL...84

TRUSTEX LUBRICATED................. 84

TRUSTEX LUBRICATED EX

LARGE..................................................84

TRUSTEX LUBRICATED EXTRA

ST...........................................................84

TRUSTEX

LUBRICATED/SPERMICIDE...........84

TRUSTEX NATURAL CONDOMS

+ LUBE..................................................84

TRUSTEX NON-LUBRICATED....... 84

TRUSTEX RIA LUB/SPERMICIDE.84

TRUSTEX RIA LUBRICATED.........84

TRUSTEX RIA NON-

LUBRICATED..................................... 84

TRUSTEX-NONOXYNOL-

9/RIB/STUD..........................................84

TUBERSOL.......................................... 66

TUKYSA............................................... 39

TURQOZ...............................................56

TWIST TOP LANCETS 30G................ 95

TYBLUME............................................56

TYDEMY.............................................. 56

TYVASO............................................... 51

TYVASO REFILL............................... 51

TYVASO STARTER........................... 51

UBRELVY.......................................... 121

ULTICARE ALCOHOL SWABS...... 82

ULTICARE INSULIN SAFETY

SYR......................................................116

ULTICARE INSULIN SYR 1/2

UNIT....................................................116

ULTICARE INSULIN SYRINGE....116

ULTICARE MICRO PEN

NEEDLES........................................... 116

ULTICARE MINI PEN NEEDLES

...................................................... 116, 117

ULTICARE PEN NEEDLES............ 117

ULTICARE SHORT PEN

NEEDLES........................................... 117

ULTICARE SYRINGE......................117

ULTICARE TUBERCULIN

SAFETY SYR..................................... 117

ULTIGUARD SAFEPACK PEN

NEEDLE..............................................117

ULTIGUARD SAFEPACK

SYR/NEEDLE.................................... 117

ULTI-LANCE AUTOMATIC.............95

ULTILET ALCOHOL SWABS.............82

ULTILET CLASSIC LANCETS........95

ULTILET LANCETS.......................... 95

ULTILET PEN NEEDLE..................117

ULTILET SAFETY LANCETS..........95

ULTILET SAFETY LANCETS 23G. 95

ULTRA COMFORT INSULIN

SYRINGE.............................................117

ULTRA FLO INSULIN PEN

NEEDLES........................................... 117

ULTRA FLO INSULIN SYR 1/2

UNIT....................................................117

ULTRA FLO INSULIN SYRINGE

...................................................... 117, 118

ULTRA PRENATAL + DHA..............128

ULTRA THIN LANCETS 31G............. 95

ULTRA THIN PEN NEEDLES........118

ULTRA-CARE ALCOHOL PREP

PADS......................................................82

ULTRACARE INSULIN SYRINGE...118

ULTRA-CARE LANCETS 30G............95

161

ULTRACARE PEN NEEDLES...........118

ULTRA-THIN II AUTO LANCET....95

ULTRA-THIN II INS SYR SHORT.118

ULTRA-THIN II INSULIN

SYRINGE............................................118

ULTRA-THIN II LANCETS.............. 95

ULTRA-THIN II MINI PEN

NEEDLE..............................................118

ULTRA-THIN II PEN NEEDLE

SHORT................................................118

ULTRA-THIN II PEN NEEDLES....118

UNIFINE PEN NEEDLES................ 118

UNIFINE PENTIPS........................... 118

UNIFINE PENTIPS PLUS........118, 119

UNIFINE PROTECT PEN NEEDLE

.............................................................. 119

UNIFINE SAFECONTROL PEN

NEEDLE..............................................119

UNIFINE ULTRA PEN NEEDLE....119

UNILET COMFORTOUCH

LANCET............................................... 95

UNILET EXCELITE...........................95

UNILET EXCELITE II.......................95

UNILET G.P. LANCET...................... 95

UNILET G.P. SUPERLITE

LANCET............................................... 95

UNILET GP 28 ULTRA THIN...........95

UNILET LANCET...............................95

UNILET MICRO-THIN 33G..............95

UNILET SUPERLITE LANCET....... 95

UNILET SUPER-THIN 30G...............95

UNILET ULTRA-THIN 28G..............95

UNISTIK 1............................................95

UNISTIK 2............................................95

UNISTIK 2 COMFORT...................... 95

UNISTIK 2 EXTRA.............................95

UNISTIK 2 NEONATAL.................... 95

UNISTIK 2 NORMAL.........................95

UNISTIK 2 SUPER..............................95

UNISTIK 3............................................96

UNISTIK 3 COMFORT...................... 96

UNISTIK 3 EXTRA.............................96

UNISTIK 3 GENTLE.......................... 96

UNISTIK 3 NEONATAL.................... 96

UNISTIK 3 NORMAL.........................96

UNISTIK CZT COMFORT................96

UNISTIK CZT NORMAL...................96

UNISTIK NORMAL............................96

UNISTIK PRO SAFETY LANCET... 96

UNISTIK SAFETY LANCETS 28G.. 96

UNISTIK SAFETY LANCETS 30G.. 96

UNISTIK TOUCH SAFETY LANC

21G.........................................................96

UNISTIK TOUCH SAFETY LANC

23G.........................................................96

UNISTIK TOUCH SAFETY LANC

28G.........................................................96

UNISTIK TOUCH SAFETY LANC

30G.........................................................96

UNISTRIP1 GENERIC....................... 72

UNITHROID...................................... 139

UNIVERSAL 1 LANCETS THIN

26G.........................................................96

UNIVERSAL 1 LANCETS THIN

33G.........................................................96

UNIVERSAL 1 LANCETS ULTRA

THIN......................................................96

UPTRAVI..............................................52

UREA.....................................................65

URSODIOL............................................76

UVADEX...............................................41

VALACYCLOVIR HCL....................... 48

VALGANCICLOVIR HCL................... 48

VALPROATE SODIUM....................... 27

VALPROIC ACID................................. 27

VALSARTAN........................................36

VALSARTAN-

HYDROCHLOROTHIAZIDE...............36

VALUE HEALTH INSULIN

SYRINGE.............................................119

VALUE PLUS LANCET

STANDARD 21G.................................. 96

VALUE PLUS LANCETS SUPER

THIN...................................................... 96

VALUE PLUS LANCETS THIN 26G.. 96

VALUE PLUS LANCING DEVICE.....96

VALUMARK LANCET SUPER

THIN 30G...............................................96

VALUMARK LANCET ULTRA

THIN 28G...............................................96

VALUMARK PEN NEEDLES............119

VANCOMYCIN HCL........................... 37

VANCOMYCIN HCL IN DEXTROSE 37

VANFLYTA..........................................41

VANISHPOINT INSULIN

SYRINGE............................................119

VANISHPOINT SAFETY

SYRINGE............................................119

VANISHPOINT SYRINGE...............119

VANISHPOINT TUBERCULIN

SYRINGE............................................120

VAQTA................................................143

VARENICLINE TARTRATE............. 138

VARENICLINE TARTRATE

(STARTER)..........................................138

VARENICLINE

TARTRATE(CONTINUE)..................138

VARIVAX...........................................143

VCF VAGINAL

CONTRACEPTIVE...........................143

VELIVET..............................................60

VELSIPITY.......................................... 77

VELTASSA.........................................123

VENLAFAXINE HCL...........................28

VENLAFAXINE HCL ER.....................28

VENTOLIN HFA................................. 23

VEOZAH...............................................75

VERAPAMIL HCL................................51

VERAPAMIL HCL ER....................50, 51

VERASENS BLOOD GLUCOSE

TEST...................................................... 72

VERIFINE INSULIN PEN NEEDLE

.............................................................. 120

VERIFINE INSULIN SYRINGE......120

VERIFINE PLUS PEN NEEDLE.....120

VERIFINE SAFE LANCET MINI

21G.........................................................96

VERIFINE SAFE LANCET MINI

23G.........................................................96

VERIFINE SAFE LANCET MINI

28G.........................................................96

VERIFINE SAFE LANCET MINI

30G.........................................................96

VERIFINE UNIVERSAL

LANCETS 28G.....................................96

VERIFINE UNIVERSAL

LANCETS 30G.....................................96

VERIFINE UNIVERSAL

LANCETS 33G.....................................96

VERZENIO...........................................42

VESTURA.............................................56

VICTOZA............................................. 31

VIDA MIA AUTOLET LANCING

DEV........................................................96

VIDA MIA UNIFINE PENTIPS.......120

VIDA MIA UNILET LANCETS 28G 96

VIDA MIA UNILET LANCETS 30G 96

VIENVA................................................ 56

VIIBRYD STARTER PACK.............. 28

VIJOICE............................................. 123

VILAZODONE HCL.............................28

VINATE II.......................................... 128

VIORELE...............................................53

VIRACEPT...........................................47

VIREAD................................................ 48

VIRT-PN DHA.....................................128

VIT B12-METHIONINE-INOS-CHOL 79

VIT E-VIT C-BETA CAROTENE......125

VITALEE.............................................125

VITAMIN D (ERGOCALCIFEROL)..144

VITAMINS ACD-FLUORIDE............126

VIVA DHA..........................................128

VIVAGUARD INO TEST STRIPS.... 72

VIVAGUARD LANCETS................... 96

VIVAGUARD LANCETS 30G...........96

VIVAGUARD LANCING DEVICE...96

VIVAGUARD SAFETY LANCETS

28G.........................................................96

VIVITROL............................................33

VOLNEA...............................................53

VONJO..................................................42

VOQUEZNA.......................................140

VORICONAZOLE.................................33

VP INSULIN SYRINGE......................120

VRAYLAR............................................45

VYFEMLA............................................56

VYLIBRA..............................................56

WALGREENS ADV TRAVEL

LANCETS..............................................96

WALGREENS LANCETS..................97

WALGREENS LANCETS MICRO

THIN...................................................... 97

WALGREENS LANCETS SUPER

THIN...................................................... 97

WALGREENS THIN LANCETS.......97

WALGREENS ULTRA THIN

LANCETS.............................................97

WAL-PHED D....................................130

162

WEBCOL ALCOHOL PREP

LARGE..................................................82

WEBCOL ALCOHOL PREP

MEDIUM.............................................. 82

WEGMANS UNIFINE PENTIPS

PLUS.................................................... 120

WEGOVY............................................. 10

WELIREG............................................ 40

WERA....................................................57

WESCAP-C DHA................................128

WESCAP-PN DHA..............................128

WESNATAL DHA COMPLETE........ 128

WES-PHOS 250 NEUTRAL............... 122

WESTAB ONE...................................... 79

WESTAB PLUS...................................128

WHITE PETROLATUM..................... 134

WIDE-SEAL DIAPHRAGM 60..........84

WIDE-SEAL DIAPHRAGM 65..........84

WIDE-SEAL DIAPHRAGM 70..........84

WIDE-SEAL DIAPHRAGM 75..........84

WIDE-SEAL DIAPHRAGM 80..........84

WIDE-SEAL DIAPHRAGM 85..........84

WIDE-SEAL DIAPHRAGM 90..........84

WIDE-SEAL DIAPHRAGM 95..........84

WIXELA INHUB................................. 22

WYMZYA FE.......................................57

XALKORI.............................................39

XARELTO............................................ 24

XDEMVY............................................132

XELJANZ............................................. 12

XELJANZ XR.......................................12

XIFAXAN..............................................37

XIGDUO XR.........................................32

XIIDRA............................................... 131

XOLAIR................................................23

XOPENEX HFA...................................23

XPHOZAH............................................74

XTAMPZA ER..................................... 19

XULANE...............................................57

YUSIMRY.............................................12

YUVAFEM..........................................144

ZAFEMY...............................................57

ZALEPLON........................................... 80

ZATEAN-PN DHA.............................128

ZEVRX INSULIN SYRINGE............. 120

ZEVRX PEN NEEDLES..................... 120

ZEVRX STERILE ALCOHOL PREP

PAD........................................................82

ZEVRX TWIST TOP LANCETS 30G..97

ZIDOVUDINE.......................................48

ZIPRASIDONE HCL.............................45

ZOLINZA..............................................40

ZOLMITRIPTAN................................ 122

ZOLPIDEM TARTRATE......................80

ZOLPIDEM TARTRATE ER................80

ZONISAMIDE.......................................26

ZORBTIVE...........................................74

ZOVIA 1/35 (28)...................................57

ZUMANDIMINE..................................57

ZURZUVAE..........................................27

ZYKADIA.............................................39

163