Preferred
Drug List (PDL)
New York
Essential Plan
Effective Date: 7/1/2024
© 2024 United HealthCare Services, Inc. All Rights Reserved. CSNY24MD0167134_003
UnitedHealthcare Community Plan
®
is the brand name of UnitedHealthcare of New York, Inc.
NOTICE OF NON-DISCRIMINATION
UnitedHealthcare Community Plan complies with Federal civil rights laws. UnitedHealthcare
Community Plan does not exclude people or treat them differently because of race, color, national
origin, age, disability, or sex.
UnitedHealthcare Community Plan provides the following:
• Free aids and services to people with disabilities to help you communicate with us, such as:
– Qualied sign language interpreters
– Written information in other formats (large print, audio, accessible electronic formats,
other formats)
• Free language services to people whose rst language is not English, such as:
– Qualied interpreters
– Information written in other languages
If you need these services, please call the toll-free member phone number listed on your member
ID card.
If you believe that UnitedHealthcare Community Plan has not given you these services or
treated you differently because of race, color, national origin, age, disability, or sex, you can le
a grievance with Civil Rights Coordinator by:
Mail: Civil Rights Coordinator
UnitedHealthcare Civil Rights Grievance
P.O. Box 30608
Salt Lake City, UTAH 84130
Email: [email protected]
You can also le a civil rights complaint with the U.S. Department of Health and Human Services,
Ofce for Civil Rights by:
Web: Ofce for Civil Rights Complaint Portal at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Mail: U.S. Dept. of Health and Human Services
200 Independence Avenue SW, Room 509F, HHH Building
Washington, D.C. 20201
Phone: Toll-free 1-800-368-1019, 1-800-537-7697 (TDD)
We provide free services to help you communicate with us.
Such as, letters in other languages or large print. Or, you can
ask for an interpreter. To ask for help, please call Member
Services at 1-866-265-1893, TTY 711, 8 a.m. – 6 p.m.,
Monday – Friday.
CSNY20MC4886650_000 - Essential Plan
UnitedHealthcare Community Plan
®
is the brand name of UnitedHealthcare of New York, Inc.
Civil Rights Coordinator
U.S. Dept. of Health and Human Services
Gratuitamente al 1-800-368-1019, 1-800-537-7697 (TDD)
NOTIFICACIÓN DE LA NO-DISCRIMINACIÓN
UnitedHealthcare Community Plan cumple con los requisitos jados por las leyes Federales de
los derechos civiles. UnitedHealthcare Community Plan no excluye a las personas o las trata de
manera diferente debido a su raza, color, nacionalidad, edad, discapacidad o sexo.
UnitedHealthcare Community Plan provee lo siguiente:
• Asistencia y servicios gratuitos de ayuda para las personas con discapacidades en su
comunicación con nosotros, con:
– Intérpretes calicados en el lenguaje de señas
– Información por escrito en diferentes formatos (letras de mayor tamaño, audición,
formatos electrónicos accesibles, otros formatos)
• Servicios gratuitos con diversos idiomas para personas para quienes el inglés no es su
lengua materna, como:
– Intérpretes calicados
– Información impresa en diversos idiomas
Si usted necesita estos servicios, por favor llame gratuitamente al número anotado en su tarjeta
de identicación como miembro.
Si usted piensa que UnitedHealthcare Community Plan no le ha brindado estos servicios o le han
tratado a usted de manera diferente debido a su raza, color, nacionalidad, edad, discapacidad o
sexo, puede presentar una queja ante el Coordinador de los Derechos Civiles (Civil Rights
Coordinator) haciéndolo por:
Correo:
UnitedHealthcare Civil Rights Grievance
P.O. Box 30608
Salt Lake City, UTAH 84130
Correo electrónico: [email protected]
Usted también puede presentar una queja acerca de sus derechos civiles ante el Departamento
de Salud y Servicios Humanos de los Estados Unidos, Ocina de Derechos Civiles, por:
Internet: Sitio en internet para la Ocina de Derechos Civiles en
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Correo:
200 Independence Avenue SW, Room 509F, HHH Building
Washington, D.C. 20201
Teléfono:
Ofrecemos servicios gratuitos para ayudarle a comunicarse con
nosotros. Tales como, cartas en otros idiomas o en letra grande.
O bien, puede solicitar un intérprete. Para pedir ayuda, por favor
llame a Servicios para Miembros al 1-866-265-1893, TTY 711,
8 a.m. a 6 p.m., de lunes a viernes.
UnitedHealthcare Community Plan
®
is the brand name of UnitedHealthcare of New York, Inc.
ATTENTION: Language assistance English
services, free of charge, are available to you.
Call 1-866-265-1893 TTY/711.
ATTENTION: Language assistance services, free of charge, are
available to you. Call 1-866-265-1893 TTY/711.
English
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos
de asistencia lingüística. Llame al 1-866-265-1893 TTY/711.
Spanish/Español
注意：您可以免費獲得語言援助服務。請致電 1-866-265-1893
TTY/711。
Chinese/中文
. :
711/TTY 1-866-265-1893
Arabic/
주의: 무료 언어 지원 서비스를 이용하실 수 있습니다 .
1-866-265-1893 TTY/711 로 전화하시기 바랍니다 .
Korean/ 한국어
ВНИМАНИЕ: Если вы говорите на русском языке, то вам досту ны
бес латные услуги еревода. Звоните 1-866-265-1893 (телетай :
TTY/711).
Russian/Русский
ATTENZIONE: Nel caso in cui la lingua parlata sia l’italiano, sono
disponibili servizi di assistenza linguistica gratuiti.
Chiamare il 1-866-265-1893 TTY/711.
Italian/Italiano
ATTENTION : Si vous parlez français, des services d’aide linguistique
vous sont proposés gratuitement. Appelez le 1-866-265-1893 TTY/711.
French/Français
ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib
gratis pou ou. Rele 1-866-265-1893 TTY/ 711.
French Creole/
Kreyòl ki soti nan Fransè
,
1-866-265-1893 TTY/711 .
Yiddish/
UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z be zpłatnej
pomocy językowej. Zadzwoń pod numer 1-866-265-1893 TTY/711.
Polish/Polski
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng
mga serbisyong pantulong sa wika nang walang bayad. Tumawag sa
1-866-265-1893 TTY/711
Tagalog
: ,
1-866-265-1893 TTY/711
Bengali/
Προσοχή: Στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής
υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-866-265-1893
ΤΤΥ/711.
Greek/ Ελληνικά
LANGUAGE ASSISTANCE
CST20797_NY_EPP-EN 7/20/21
UnitedHealthcare Community Plan
List of Preferred Drugs
Frequently Asked Questions (FAQ)
Find answers here to questions you have about this UnitedHealthcare
Community Plan List of Preferred Drugs. You can read all of the FAQ
to learn more, or look for a question and answer.
1
What drugs are on the Preferred Drug List? (We call the
Preferred Drug List the “Drug List” for short.)
The drugs on the Preferred Drug List are the drugs covered by UnitedHealthcare
Community Plan. These drugs are available at pharmacies within our network. A
pharmacy is in our network if we have an agreement with them to work with us
and provide you services. We refer to these pharmacies as “network
pharmacies.”
UnitedHealthcare will cover all medically necessary drugs if:
your doctor or other prescriber says you need them to get better or stay
healthy, and
you fill the prescription at a UnitedHealthcare Community Plan network
pharmacy.
UnitedHealthcare may have additional steps to access certain drugs (see
question 5 below).
You can also see an up-to-date drug list on our website at
myuhc.com/CommunityPlan or call Member Services at 1-866-265-1893,
TTY 711. Monday – Friday, 8:00 a.m. – 6:00 p.m
CST20797_NY_EPP-EN 7/20/21
2
Does the Drug List ever change?
Yes. UnitedHealthcare Community Plan may add or remove drugs on the Drug
List during the year. Generally, the Drug List will only change if:
a cheaper drug comes along that works as well as a drug on the Drug List
now, or
we learn that a drug is not safe.
We may also change our rules about drugs. For example, we could:
Decide to require or not require prior approval for a drug. (Prior approval is
permission from UnitedHealthcare Community Plan before you can get a
drug.)
Add or change the amount of a drug you can get (called “quantity limits”).
Add or change step therapy restrictions on a drug. (Step therapy means
you must try one drug before we will cover another drug.)
Questions 3, 4 and 7 below have more information on what happens when the
Drug List changes.
You can always check the up-to-date Drug List online at
myuhc.com/CommunityPlan. You can also call Member Services
to check the current Drug List at 1-866-265-1893, TTY 711. Monday – Friday,
8:00 a.m. – 6:00 p.m
3
What happens when another drug comes along that
works as well as a drug on the Drug List now?
If you are taking a drug that is removed because another drug that works just as
well is available, we will tell you. You will get a letter letting you know about the
change. We will also tell you what alternate drugs are available to you. Contact
your doctor or other prescriber to make sure another drug will work for you.
CST20797_NY_EPP-EN 7/20/21
4
What happens when we find out a drug is not safe?
If the Food and Drug Administration (FDA) says a drug you are taking is not safe,
we will take it off the Drug List right away. We will also send you a letter telling
you that. Contact your doctor or other prescriber and ask about your other
options.
5
Are there any restrictions or limits on drug coverage? Or
are there any required actions to take in order to get
certain drugs?
Yes, some drugs have coverage rules or have limits on the amount you can get.
In some cases, your doctor must do something before you can get the drug. For
example:
Prior approval (or prior authorization): For some drugs, your doctor or
other prescriber must get approval from UnitedHealthcare before you fill
your prescription. If you don’t get approval, UnitedHealthcare may not
cover the drug.
Quantity limits: Sometimes UnitedHealthcare limits the amount of a drug
you can get.
Step therapy: Sometimes UnitedHealthcare requires you to do step
therapy. This means you will have to try drugs in a certain order for your
medical condition. You might have to try one drug before we will cover
another drug. If your doctor thinks the first drug doesn’t work for you, then
we will cover the second.
You can find out if your drug has any additional requirements or limits by looking
in the tables –below. You can also get more information by visiting our website at
myuhc.com/CommunityPlan. We have posted online documents that explain
our prior authorization and step therapy restrictions. You may also call Member
Services and ask us to send you information about our prior authorization and
step therapy restrictions.
CST20797_NY_EPP-EN 7/20/21
6
How will you know if the drug you want has limitations or
if there are required actions to take to get the drug?
The Drug List below has a column labeled “Requirements and Limits.”
7
What happens if we change our rules on how we cover
some drugs? For example, if we add prior authorization
(approval), quantity limits and/or step therapy restrictions
on a drug.
We will tell you if we add prior approval, quantity limits and/or step therapy
restrictions on a drug. We will tell you before the restriction is added. This gives
you time to talk to your doctor or other prescriber about what to do next.
8
How can you find a drug on the Drug List?
There are two ways to find a drug:
You can search for drugs alphabetically.
To search alphabetically, go to the Index of Covered Drugs.
You can search by medical condition.
To search by medical condition, find the section labeled “Table of
Contents” below. The drugs in this section are grouped into categories
depending on the type of medical conditions they are used to treat. For
example, if you have a heart condition, you should look in the category,
Cardiovascular Agents. That is where you will find drugs that treat heart
conditions.
Find the name of your drug. The page number where you can find the drug will
be next to it.
CST20797_NY_EPP-EN 7/20/21
9
What if the drug you want to take is not on the Drug List?
If you don’t see your drug on the Drug List, call Member Services (1-866-265-
1893, TTY 711) and ask about it. If you learn that UnitedHealthcare does not
prefer the drug, you can do one of these things:
Ask Member Services for a list of drugs that are similar to the one you
want to take. Then show the list to your doctor or other prescriber. He or
she can prescribe a drug on the Drug List that is like the one you want to
take. Or
You can ask the health plan to make an exception to cover your drug.
Please see question 11 for more information about exceptions.
10
What if you just joined UnitedHealthcare Community
Plan and can’t find your drug on the Drug List or have
a problem getting your drug?
We can help. We may cover a temporary 30-day supply of your drug during the
first 90 days you are a member of UnitedHealthcare. This will give you time to
talk to your doctor or other prescriber. He or she can help you decide if there is a
similar drug on the Drug List you can take instead, or whether to request an
exception.
11
Can you ask for an exception to cover your drug?
Yes. Your doctor can ask UnitedHealthcare Community Plan to make an
exception to cover a drug that is not on the Drug List.
Your doctor can also ask us to change the rules on your drug.
For example, we may limit the amount of a drug we will cover. If your drug
has a limit, your doctor can ask us to change the limit and cover more.
Other examples: Your doctor can ask us to drop step therapy restrictions
or prior approval requirements.
CST20797_NY_EPP-EN 7/20/21
12
How long does it take to get an exception?
First, we must receive some information from your doctor supporting your
request for an exception. After we receive the information, we will give you a
decision on your exception request within the time frames required by the state,
generally within 24 hours.
13
How can you ask for an exception?
To ask for an exception, you can do one of two things:
Call Member Services at 1-866-265-1893, TTY 711. A Member Services
representative will work with you and your doctor to help ask for an
exception.
Call your doctor and ask him or her to request an exception by calling the
Prior Notification Service at 1-800-310-6826, or he or she can fax a
request to 1-866-940-7328.
14
What are generic drugs?
Generic drugs are made up of the same active ingredients as brand name drugs.
They usually cost less than the brand name drug and usually don’t have well-
known names. Generic drugs are approved by the Food and Drug Administration
(FDA). In most instances, UnitedHealthcare covers generic drugs first. If your
doctor feels a brand name drug is medically necessary, you will need to ask your
doctor to submit for prior approval.
CST20797_NY_EPP-EN 7/20/21
15
What are OTC drugs?
OTC stands for “over-the-counter.” UnitedHealthcare covers some OTC drugs
when they are written as prescriptions by your provider. You can read the
UnitedHealthcare Community Plan Drug List to see what OTC drugs are
preferred.
16
Does UnitedHealthcare cover OTC non-drug products?
UnitedHealthcare covers some OTC non-drug products when they are written as
prescriptions by your provider. You can read the UnitedHealthcare Community
Plan Drug List to see what OTC non-drug products are covered.
17
What is a specialty pharmacy medication?
A specialty pharmacy medication is a drug that generally has one or more of the
following characteristics:
It’s used by a small number of people.
It treats rare, chronic and/or potentially life-threatening diseases.
It has special storage or handling requirements such as needing to be
refrigerated.
It may need close monitoring, ongoing clinical support and management
and complete patient education and engagement.
It’s a high-cost medication.
It may not be available at retail pharmacies.
It may be oral, injectable or inhaled.
Specialty pharmacy medications are available through our specialty pharmacy
network.
If you have questions, call Member Services at 1-866-265-1893, TTY 711.
CST20797_NY_EPP-EN 7/20/21
List of Preferred Drugs
The List of Preferred Drugs gives you information about the drugs covered by
UnitedHealthcare Community Plan. If you have trouble finding your drug in the
list, turn to the Index at the end of this booklet.
The first column of the chart lists the generic name of the drug. The second
column of the chart lists brand name drugs. Brand name drugs are capitalized
(e.g., CRESTOR). The third column in the list tells you if the preferred drug
covered is the brand or generic version.
The information in the “Requirements and Limits” column tells you if
UnitedHealthcare has any rules for covering your drug.
Utilization Management Restrictions
PA –
Prior approval
(or prior
authorization)
For some drugs, your doctor or other prescriber must get
approval from UnitedHealthcare Community Plan before
you fill your prescription. If you don’t get approval,
UnitedHealthcare Community Plan may not cover the drug.
QL –
Quantity limits
Sometimes UnitedHealthcare Community Plan limits the
amount of a drug you can get.
ST –
Step therapy
Sometimes UnitedHealthcare Community Plan requires you
to do step therapy. This means you will have to try drugs in
a certain order for your medical condition. You might have
to try one drug before we will cover another drug. If your
doctor thinks the first drug doesn’t work for you, then your
doctor can ask for approval to cover the second.
CST20797_NY_EPP-EN 7/20/21
Other special requirements for coverage
SP – Specialty
Pharmacy
Drug needs to be accessed through a network specialty
pharmacy. Specialty pharmacy drugs may require extra
handling, provider coordination or patient education that
can’t be done at a network retail pharmacy.
Drug Tiers
The drugs listed in the PDL have different tiers. The tiers are listed in the grid
below.
Tier Name Dru
g
Tie
r
Tier 1 Generic
Tier 2 Brand
ABBREVIATIONS
OTC = Over the Counter
PA = Prior Authorization Required
QL = Quantity Limit
ST = Step Therapy
SP = Specialty Pharmacy
You can find information on what the symbols and abbreviations in this table
mean by looking in the footnotes
.
CST20797_NY_EPP-EN 7/20/21
Table of copays for Essential Plans
*For non-preferred drugs that belong to the preventive class including
contraceptives if approved for a member after a prior auth review copays will
default to the preventive drugs copay of $0
How Displayed
in PDL booklet
Essential
Plan 1
Essential
Plan 2
Essential
Plan 3
Essential
Plan 4
Tier 1
(Generics)
“1” in Tier
column
$6 for 30
days
$15 for 90
days
$1 for 30
days
$2.50 for
90 days
$1 for 30
days
$2.50 for
90 days
$0 for both
30 and 90
days
Tier 2
(Brands)
“2” in Tier
column
$15 for 30
days
$37.50 for
90 days
$3 for 30
days
$7.50 for
90 days
$3 for 30
days
$7.50 for
90 days
$0 for both
30 and 90
days
Over the
Counter
(OTCs)
“OTC” listed in
Requirements &
Limits OR listed
in “OTC
Medications”
section
Plan
Exclusion
Plan
Exclusion
$1 for 30
days
$2.50 for
90 days
$0 for both
30 and 90
days
DME Supplies “DME Supply”
listed in
Requirements &
Limits
5%
coinsurance
for both 30
& 90 days
$0 for both
30 and 90
days
$0 for both
30 and 90
days
$0 for both
30 and 90
days
Oral
Chemotherapy
“oral chemo”
listed in
Requirements &
Limits
$0 for both
30 and 90
days
$0 for both
30 and 90
days
$0 for both
30 and 90
days
$0 for both
30 and 90
days
Preventive
Drugs*
“preventive drug”
listed in
Requirements &
Limits
$0 for both
30 and 90
days
$0 for both
30 and 90
days
$0 for both
30 and 90
days
$0 for both
30 and 90
days
Non-Preferred
Drugs (not
listed in PDL)
NOT LISTED IN
PDL
$30 for 30
days
$75 for 90
days
$3 for 30
days
$7.50 for
90 days
$3 for 30
days
$7.50 for
90 days
$0 for both
30 and 90
days
Compounds
(not listed in
PDL)
NOT LISTED IN
PDL
$30 for 30
days
$75 for 90
days
$3 for 30
days
$7.50 for
90 days
$3 for 30
days
$7.50 for
90 days
$0 for both
30 and 90
days
New York – Essential Plan
Table of Contents
Analgesics.....................................................................................................................................................................................................................4
Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions......................................................................................................8
Anesthetics................................................................................................................................................................................................................. 17
Anti-Addiction/Substance Abuse Treatment Agents...................................................................................................................................................17
Anti-Addiction/Substance Abuse Treatment Agents - Drugs for Overdose or Deterrence......................................................................................... 19
Antiandrogens - Hormone Suppressants....................................................................................................................................................................20
Antibacterials.............................................................................................................................................................................................................. 20
Antibacterials - Drugs to Treat Bacterial Infections.....................................................................................................................................................23
Anticonvulsants...........................................................................................................................................................................................................24
Antidementia Agents...................................................................................................................................................................................................26
Antidepressants.......................................................................................................................................................................................................... 27
Antiemetics................................................................................................................................................................................................................. 28
Antiemetics - Drugs to Treat Nausea and Vomiting....................................................................................................................................................29
Antifungals.................................................................................................................................................................................................................. 30
Antifungals - Drugs to Treat Fungal Infections............................................................................................................................................................31
Antigout Agents...........................................................................................................................................................................................................32
Antimigraine Agents....................................................................................................................................................................................................33
Antimigraine Agents - Drugs to Treat Migraines.........................................................................................................................................................33
Antimyasthenic Agents............................................................................................................................................................................................... 34
Antimycobacterials......................................................................................................................................................................................................34
Antineoplastics............................................................................................................................................................................................................35
Antineoplastics - Drugs to Treat Cancer.....................................................................................................................................................................38
Antineoplastics, Other - Chemotherapy Agents..........................................................................................................................................................38
Antiparasitics...............................................................................................................................................................................................................38
Antiparasitics - Drugs to Treat Parasitic Infections..................................................................................................................................................... 39
Antiparkinson Agents..................................................................................................................................................................................................40
Antipsychotics.............................................................................................................................................................................................................41
Antispasticity Agents...................................................................................................................................................................................................42
Antivirals..................................................................................................................................................................................................................... 42
Antivirals - Drugs to Treat Viral Infections...................................................................................................................................................................46
Anxiolytics...................................................................................................................................................................................................................46
Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines - ADHD Drugs................................................................................................. 46
Bipolar Agents.............................................................................................................................................................................................................47
Blood Glucose Regulators.......................................................................................................................................................................................... 47
Blood Glucose Regulators - Drugs to Regulate Blood Sugar..................................................................................................................................... 50
Blood Products and Modifiers.....................................................................................................................................................................................51
Blood Products/Modifiers/Volume Expanders - Drugs to Treat Blood Disorders........................................................................................................52
1
Cardiovascular Agents................................................................................................................................................................................................52
Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs...................................................................................................................................58
Central Nervous System Agents.................................................................................................................................................................................59
Cystic Fibrosis Agents - Drugs to treat Cystic Fibrosis............................................................................................................................................... 62
Dental and Oral Agents...............................................................................................................................................................................................62
Dermatological Agents................................................................................................................................................................................................62
Dermatological Agents - Drugs to Treat Skin Conditions............................................................................................................................................68
Diabetes - Glucose Monitoring....................................................................................................................................................................................70
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body Fluid Deficiency Drugs.............................................................................................. 73
Electrolytes/Minerals/Metals/Vitamins........................................................................................................................................................................ 73
Estrogens - Hormone Replacement/Modifying Drugs.................................................................................................................................................84
Gastrointestinal Agents...............................................................................................................................................................................................85
Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and Stomach Conditions.................................................................................................. 88
Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment.......................................................................................................... 106
Genitourinary Agents................................................................................................................................................................................................ 106
Genitourinary Agents - Drugs to Treat Bladder, Genital and Kidney Conditions...................................................................................................... 107
Glycemic Agents - Diabetic Drugs............................................................................................................................................................................ 107
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)...............................................................................................................................108
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary).............................................................................................................................. 108
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) - Drugs to Regulate Hormones............................................................................ 109
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)................................................................................................................... 109
Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins) - Drugs to Regulate Hormones..................................................................109
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)....................................................................................................110
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) - Drugs to Regulate Hormones.................................................. 118
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)............................................................................................................................... 118
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) - Drugs to Replace Thyroid Hormones..................................................................119
Hormonal Agents, Suppressant (Adrenal)................................................................................................................................................................ 119
Hormonal Agents, Suppressant (Pituitary)................................................................................................................................................................119
Hormonal Agents, Suppressant (Pituitary) - Drugs to Regulate Hormones..............................................................................................................120
Hormonal Agents, Suppressant (Thyroid).................................................................................................................................................................120
Immune Suppressants - Immune System Drugs...................................................................................................................................................... 120
Immunological Agents...............................................................................................................................................................................................121
Immunological Agents - Drugs that Stimulate or Suppress the Immune System..................................................................................................... 124
Inflammatory Bowel Disease Agents........................................................................................................................................................................ 125
Metabolic Bone Disease Agents...............................................................................................................................................................................125
Miscellaneous Therapeutic Agents...........................................................................................................................................................................126
Molecular Target Inhibitors - Chemotherapy Agents................................................................................................................................................ 138
Monoclonal Antibodies - Chemotherapy Agents.......................................................................................................................................................139
Multiple Sclerosis Agents - Multiple Sclerosis Drugs................................................................................................................................................ 139
Ophthalmic Agents....................................................................................................................................................................................................140
2
Ophthalmic Agents - Drugs to Treat Eye Conditions................................................................................................................................................ 142
Otic Agents............................................................................................................................................................................................................... 146
Otic Agents - Drugs to Treat Ear Conditions.............................................................................................................................................................147
Respiratory Tract/Pulmonary Agents........................................................................................................................................................................148
Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies, Cough, Cold and Lung Conditions....................................................................... 155
Sedatives/Hypnotics - Drugs for Sedation and Sleep...............................................................................................................................................179
Skeletal Muscle Relaxants........................................................................................................................................................................................179
Sleep Disorder Agents..............................................................................................................................................................................................179
Sleep Disorder Agents - Drugs for Sedation and Sleep............................................................................................................................................180
Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies........................................................... 181
3
Preferred Agents Non-Preferred Agents
Analgesics
Nonsteroidal Anti-inflammatory Drugs
ADVIL JUNIOR STRENGTH (brand for cvs ibuprofen childrens) - Tier
2; OTC; QL
ADVIL ORAL TABLET (brand for cvs ibuprofen) - Tier 2; OTC; QL
ALEVE ORAL TABLET (brand for all day pain relief) - Tier 2; OTC; QL
all day pain relief (generic for MEDIPROXEN) - Tier 1; OTC; QL
all day relief (generic for MEDIPROXEN) - Tier 1; OTC; QL
celecoxib oral (generic for CELEBREX) - Tier 1; QL
diclofenac potassium oral tablet 50 mg - Tier 1; QL
diclofenac sodium er - Tier 1; QL
diclofenac sodium external gel 1 % (generic for ALEVE ARTHRITIS
PAIN) - Tier 1; Brand OTC and Generic; QL
diclofenac sodium external solution 1.5 % - Tier 1; PA; QL
diclofenac sodium oral - Tier 1; QL
ec-naproxen (generic for EC-NAPROSYN) - Tier 1; QL
DUEXIS (brand for ibuprofen-famotidine) - Tier 2; PA; QL
ELYXYB - Tier 2; PA; QL
FLECTOR (brand for diclofenac epolamine) - Tier 2; PA; QL
LICART - Tier 2; PA; QL
NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 375 MG,
750 MG (brand for naproxen sodium er) - Tier 2; PA
NAPRELAN ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG
(brand for naproxen sodium er) - Tier 2; PA; QL
etodolac (generic for LODINE) - Tier 1; QL
ft all day pain relief (generic for MEDIPROXEN) - Tier 1; OTC; QL
ft ibuprofen ib childrens (generic for ADVIL JUNIOR STRENGTH) -
Tier 1; OTC; QL
ft ibuprofen oral tablet (generic for MEDI-FIRST IBUPROFEN) - Tier 1;
OTC; QL
ft pain relief oral tablet 200 mg (generic for MEDI-FIRST IBUPROFEN)
- Tier 1; OTC; QL
ibuprofen (generic for IBU) - Tier 1; QL
ibuprofen childrens oral tablet chewable 100 mg (generic for ADVIL
JUNIOR STRENGTH) - Tier 1; OTC; QL
ibuprofen ib childrens (generic for ADVIL JUNIOR STRENGTH) - Tier
1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
4
Preferred Agents Non-Preferred Agents
ibuprofen ib oral tablet 200 mg (generic for MEDI-FIRST IBUPROFEN)
- Tier 1; OTC; QL
ibuprofen infants oral suspension 50 mg/1.25ml (generic for INFANTS
ADVIL) - Tier 1; OTC; QL
ibuprofen jr oral tablet 100 mg (generic for ADVIL JUNIOR
STRENGTH) - Tier 1; OTC; QL
ibuprofen junior (generic for ADVIL JUNIOR STRENGTH) - Tier 1;
OTC; QL
ibuprofen junior strength (generic for ADVIL JUNIOR STRENGTH) -
Tier 1; OTC; QL
ibuprofen oral suspension 100 mg/5ml (generic for CHILDRENS
ADVIL) - Tier 1; QL
ibuprofen oral tablet 200 mg (generic for MEDI-FIRST IBUPROFEN) -
Tier 1; OTC; QL
ibuprofen oral tablet 400 mg, 600 mg, 800 mg (generic for IBU) - Tier
1; QL
indomethacin oral capsule - Tier 1; QL
INFANTS ADVIL (brand for cvs ibuprofen infants) - Tier 2; OTC; QL
infants ibuprofen (generic for INFANTS ADVIL) - Tier 1; OTC; QL
ketoprofen oral capsule 25 mg (generic for KIPROFEN) - Tier 1; QL
ketorolac tromethamine oral - Tier 1; QL
medi-first ibuprofen (generic for MEDI-FIRST IBUPROFEN) - Tier 1;
OTC; QL
mediproxen (generic for MEDIPROXEN) - Tier 1; OTC; QL
meloxicam oral tablet - Tier 1; QL
mm ibuprofen (generic for MEDI-FIRST IBUPROFEN) - Tier 1; OTC;
QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
5
Preferred Agents Non-Preferred Agents
MOTRIN CHILDRENS (brand for cvs ibuprofen childrens) - Tier 2;
OTC; QL
MOTRIN IB ORAL TABLET (brand for cvs ibuprofen) - Tier 2; OTC;
QL
MOTRIN INFANTS DROPS (brand for cvs ibuprofen infants) - Tier 2;
OTC; QL
nabumetone oral - Tier 1; QL
naproxen dr (generic for EC-NAPROSYN) - Tier 1; QL
naproxen oral (generic for EC-NAPROSYN) - Tier 1; QL
naproxen sodium oral tablet 220 mg (generic for MEDIPROXEN) - Tier
1; OTC; QL
oxaprozin oral tablet (generic for DAYPRO) - Tier 1; QL
piroxicam oral - Tier 1; QL
sulindac oral - Tier 1; QL
Opioid Analgesics, Long-acting
buprenorphine (generic for BUTRANS) - Tier 1; PA; QL
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr,
50 mcg/hr, 75 mcg/hr - Tier 1; PA; QL
morphine sulfate er oral tablet extended release (generic for MS
CONTIN) - Tier 1; PA; QL
oxymorphone hcl er - Tier 1; PA; QL
BELBUCA - Tier 2; PA; QL
HYSINGLA ER (brand for hydrocodone bitartrate er) - Tier 2; PA; QL
NUCYNTA ER - Tier 2; PA; QL
OXYCONTIN (brand for oxycodone hcl er) - Tier 2; PA; QL
ROXYBOND ORAL TABLET ABUSE-DETERRENT 15 MG, 30 MG, 5 MG
- Tier 2; PA; QL
XTAMPZA ER - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
6
Preferred Agents Non-Preferred Agents
Opioid Analgesics, Short-acting
acetaminophen-codeine - Tier 1; QL
ascomp-codeine (generic for ASCOMP-CODEINE) - Tier 1; QL
bac (generic for BAC) - Tier 1; QL
butalbital-acetaminophen oral tablet 50-325 mg (generic for TENCON)
- Tier 1; QL
butalbital-apap-caff-cod oral capsule 50-325-40-30 mg - Tier 1; QL
butalbital-apap-caffeine oral capsule 50-325-40 mg (generic for
ESGIC) - Tier 1; QL
butalbital-apap-caffeine oral tablet (generic for BAC) - Tier 1; QL
butalbital-asa-caff-codeine (generic for ASCOMP-CODEINE) - Tier 1;
QL
butalbital-aspirin-caffeine - Tier 1; QL
butorphanol tartrate nasal - Tier 1; QL
codeine sulfate oral tablet 30 mg, 60 mg - Tier 1; QL
apap-caff-dihydrocodeine (generic for TREZIX) - Tier 1; PA; QL
NUCYNTA - Tier 2; PA; QL
SEGLENTIS - Tier 2; PA; QL
TREZIX (brand for apap-caff-dihydrocodeine) - Tier 2; PA; QL
endocet oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg (generic for
ENDOCET) - Tier 1; QL
hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml - Tier 1;
QL
hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-
325 mg - Tier 1; QL
hydromorphone hcl oral (generic for DILAUDID) - Tier 1; QL
hydromorphone hcl rectal - Tier 1; QL
morphine sulfate (concentrate) - Tier 1; QL
morphine sulfate oral - Tier 1; QL
morphine sulfate rectal - Tier 1; QL
oxycodone hcl oral concentrate - Tier 1; QL
oxycodone hcl oral solution - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
7
Preferred Agents Non-Preferred Agents
OXYCODONE-ACETAMINOPHEN ORAL SOLUTION 5-325 MG/5ML
- Tier 2; QL
oxycodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325
mg (generic for ENDOCET) - Tier 1; QL
pentazocine-naloxone hcl - Tier 1; QL
TENCON (brand for butalbital-acetaminophen) - Tier 2; QL
tramadol hcl oral tablet 50 mg - Tier 1; QL
Opioid Dependence Treatments -
Antidotes/Deterrents/Protectants
buprenorphine hcl sublingual - Tier 1; DX2RX; QL
Analgesics - Drugs to Treat Pain, Inflammation, and Muscle and
Joint Conditions
Analgesics - Miscellaneous Analgesics
8 hour arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1; OTC; QL
8 hour arthritis relief (generic for TYLENOL 8 HOUR) - Tier 1; OTC;
QL
8 hour pain relief oral tablet extended release 650 mg (generic for
TYLENOL 8 HOUR) - Tier 1; OTC; QL
8 hour pain reliever (generic for TYLENOL 8 HOUR) - Tier 1; OTC; QL
8 hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; OTC;
QL
8hr arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; OTC;
QL
8hr muscle aches & pain (generic for TYLENOL 8 HOUR) - Tier 1;
OTC; QL
acetaminophen 8 hour (generic for TYLENOL 8 HOUR) - Tier 1; OTC;
QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
8
Preferred Agents Non-Preferred Agents
acetaminophen 8 hours (generic for TYLENOL 8 HOUR) - Tier 1;
OTC; QL
acetaminophen 8hr arth pain (generic for TYLENOL 8 HOUR) - Tier 1;
OTC; QL
acetaminophen 8hr musc ache (generic for TYLENOL 8 HOUR) - Tier
1; OTC; QL
acetaminophen childrens (generic for MAPAP CHILDRENS) - Tier 1;
OTC; QL
acetaminophen er (generic for TYLENOL 8 HOUR) - Tier 1; OTC; QL
acetaminophen ex st oral liquid 500 mg/15ml (generic for MAPAP
ACETAMINOPHEN EXTRA STR) - Tier 1; OTC
acetaminophen ex st oral tablet 500 mg (generic for MM
ACETAMINOPHEN EX STR) - Tier 1; OTC; QL
acetaminophen extra strength (generic for MM ACETAMINOPHEN EX
STR) - Tier 1; OTC; QL
acetaminophen infants (generic for MAX RELIEF JR CHILD
PAIN/FEVER) - Tier 1; OTC; QL
acetaminophen oral liquid 160 mg/5ml (generic for LITTLE REMEDIES
FOR FEVER) - Tier 1; OTC; QL
acetaminophen oral solution 160 mg/5ml, 325 mg/10.15ml, 650
mg/20.3ml - Tier 1; OTC; QL
acetaminophen oral suspension 160 mg/5ml, 650 mg/20.3ml (generic
for MAX RELIEF JR CHILD PAIN/FEVER) - Tier 1; OTC; QL
acetaminophen oral tablet 325 mg (generic for PHARBETOL) - Tier 1;
OTC; QL
acetaminophen oral tablet 500 mg (generic for MM
ACETAMINOPHEN EX STR) - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
9
Preferred Agents Non-Preferred Agents
acetaminophen oral tablet chewable 160 mg (generic for MAPAP
CHILDRENS) - Tier 1; OTC; QL
acetaminophen rectal suppository 120 mg (generic for FEVERALL
CHILDRENS) - Tier 1; OTC; QL
acetaminophen rectal suppository 650 mg (generic for FEVERALL
ADULTS) - Tier 1; OTC; QL
apra (generic for MAX RELIEF JUNIOR) - Tier 1; OTC; QL
arthritis pain oral tablet extended release 650 mg (generic for
TYLENOL 8 HOUR) - Tier 1; OTC; QL
arthritis pain relief oral tablet extended release 650 mg (generic for
TYLENOL 8 HOUR) - Tier 1; OTC; QL
arthritis pain reliever oral (generic for TYLENOL 8 HOUR) - Tier 1;
OTC; QL
betatemp childrens (generic for MAX RELIEF JR CHILD PAIN/FEVER)
- Tier 1; OTC; QL
childrens acetaminophen (generic for MAX RELIEF JR CHILD
PAIN/FEVER) - Tier 1; OTC; QL
childrens apap (generic for MAPAP CHILDRENS) - Tier 1; OTC; QL
childrens non-aspirin (generic for MAPAP CHILDRENS) - Tier 1; OTC;
QL
childrens silapap (generic for LITTLE REMEDIES FOR FEVER) - Tier
1; OTC; QL
childs non-aspirin (generic for MAPAP CHILDRENS) - Tier 1; OTC; QL
CURANOL - Tier 2; OTC; QL
ed-apap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; OTC;
QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
10
Preferred Agents Non-Preferred Agents
EXCEDRIN EXTRA STRENGTH (brand for cvs headache relief) - Tier
2; OTC
EXCEDRIN MIGRAINE (brand for cvs headache relief) - Tier 2; OTC
fever reducer/pain reliever (generic for MAX RELIEF JR CHILD
PAIN/FEVER) - Tier 1; OTC; QL
fever reducing childrens (generic for FEVERALL CHILDRENS) - Tier
1; OTC; QL
feverall adults (generic for FEVERALL ADULTS) - Tier 1; OTC; QL
feverall childrens (generic for FEVERALL CHILDRENS) - Tier 1; OTC;
QL
FEVERALL INFANTS - Tier 2; OTC; QL
FEVERALL JUNIOR STRENGTH - Tier 2; OTC; QL
ft 8 hour pain relief (generic for TYLENOL 8 HOUR) - Tier 1; OTC; QL
ft arthritis pain reliever (generic for TYLENOL 8 HOUR) - Tier 1; OTC;
QL
ft children's pain/fever (generic for MAPAP CHILDRENS) - Tier 1;
OTC; QL
ft migraine relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1;
OTC
ft pain & fever childrens (generic for MAX RELIEF JR CHILD
PAIN/FEVER) - Tier 1; OTC; QL
ft pain & fever infants (generic for MAX RELIEF JR CHILD
PAIN/FEVER) - Tier 1; OTC; QL
ft pain relief adult extra st (generic for MM ACETAMINOPHEN EX
STR) - Tier 1; OTC; QL
ft pain relief extra strength (generic for MM ACETAMINOPHEN EX
STR) - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
11
Preferred Agents Non-Preferred Agents
ft pain relief oral tablet 325 mg (generic for PHARBETOL) - Tier 1;
OTC; QL
ft pain reliever ex str adult (generic for MM ACETAMINOPHEN EX
STR) - Tier 1; OTC; QL
headache formula (generic for EXCEDRIN EXTRA STRENGTH) - Tier
1; OTC
headache relief (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1;
OTC
headache relief extra str (generic for EXCEDRIN EXTRA STRENGTH)
- Tier 1; OTC
infants pain & fever (generic for MAX RELIEF JR CHILD
PAIN/FEVER) - Tier 1; OTC; QL
infants pain relief drops (generic for MAX RELIEF JR CHILD
PAIN/FEVER) - Tier 1; OTC; QL
infants pain/fever (generic for MAX RELIEF JR CHILD PAIN/FEVER) -
Tier 1; OTC; QL
liquid acetaminophen (generic for LITTLE REMEDIES FOR FEVER) -
Tier 1; OTC; QL
liquid pain relief (generic for LITTLE REMEDIES FOR FEVER) - Tier
1; OTC; QL
mapap acetaminophen extra str (generic for MAPAP
ACETAMINOPHEN EXTRA STR) - Tier 1; OTC
mapap childrens (generic for MAPAP CHILDRENS) - Tier 1; OTC; QL
mapap oral capsule - Tier 1; OTC; QL
MAX RELIEF JR CHILD PAIN/FEVER (brand for acetaminophen) -
Tier 2; OTC; QL
MAX RELIEF JUNIOR (brand for apra) - Tier 2; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
12
Preferred Agents Non-Preferred Agents
migraine formula oral tablet 250-250-65 mg (generic for EXCEDRIN
EXTRA STRENGTH) - Tier 1; OTC
migraine headache relief (generic for EXCEDRIN EXTRA
STRENGTH) - Tier 1; OTC
migraine relief oral tablet 250-250-65 mg (generic for EXCEDRIN
EXTRA STRENGTH) - Tier 1; OTC
mm acetaminophen ex str (generic for MM ACETAMINOPHEN EX
STR) - Tier 1; OTC; QL
mm arthritis pain (generic for TYLENOL 8 HOUR) - Tier 1; OTC; QL
m-pap (generic for LITTLE REMEDIES FOR FEVER) - Tier 1; OTC;
QL
non-aspirin (generic for MM ACETAMINOPHEN EX STR) - Tier 1;
OTC; QL
non-aspirin 8 hour (generic for TYLENOL 8 HOUR) - Tier 1; OTC; QL
non-aspirin childrens (generic for MAPAP CHILDRENS) - Tier 1; OTC;
QL
non-aspirin extra strength (generic for MM ACETAMINOPHEN EX
STR) - Tier 1; OTC; QL
non-aspirin jr strength (generic for MAPAP CHILDRENS) - Tier 1;
OTC; QL
non-aspirin pain relief (generic for PHARBETOL) - Tier 1; OTC; QL
pain & fever child (generic for MAX RELIEF JR CHILD PAIN/FEVER) -
Tier 1; OTC; QL
pain & fever childrens (generic for MAPAP CHILDRENS) - Tier 1;
OTC; QL
pain & fever childrens oral suspension 160 mg/5ml (generic for MAX
RELIEF JR CHILD PAIN/FEVER) - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
13
Preferred Agents Non-Preferred Agents
pain & fever infants (generic for MAX RELIEF JR CHILD
PAIN/FEVER) - Tier 1; OTC; QL
pain and fever relief kids (generic for LITTLE REMEDIES FOR
FEVER) - Tier 1; OTC; QL
pain relief childrens oral elixir 160 mg/5ml (generic for MAX RELIEF
JUNIOR) - Tier 1; OTC; QL
pain relief childrens oral suspension (generic for MAX RELIEF JR
CHILD PAIN/FEVER) - Tier 1; OTC; QL
pain relief childrens oral tablet chewable 160 mg (generic for MAPAP
CHILDRENS) - Tier 1; OTC; QL
pain relief extra st (generic for MM ACETAMINOPHEN EX STR) - Tier
1; OTC; QL
pain relief extra strength oral capsule 500 mg - Tier 1; OTC; QL
pain relief extra strength oral liquid 500 mg/15ml (generic for MAPAP
ACETAMINOPHEN EXTRA STR) - Tier 1; OTC
pain relief extra strength oral tablet 500 mg (generic for MM
ACETAMINOPHEN EX STR) - Tier 1; OTC; QL
pain relief oral liquid 500 mg/15ml (generic for MAPAP
ACETAMINOPHEN EXTRA STR) - Tier 1; OTC
pain relief oral tablet 325 mg (generic for PHARBETOL) - Tier 1; OTC;
QL
pain relief oral tablet 500 mg (generic for MM ACETAMINOPHEN EX
STR) - Tier 1; OTC; QL
pain relief oral tablet extended release 650 mg (generic for TYLENOL
8 HOUR) - Tier 1; OTC; QL
pain relief regular strength (generic for PHARBETOL) - Tier 1; OTC;
QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
14
Preferred Agents Non-Preferred Agents
pain relief/rapid burst (generic for MAPAP ACETAMINOPHEN EXTRA
STR) - Tier 1; OTC
pain reliever childrens oral suspension 160 mg/5ml (generic for MAX
RELIEF JR CHILD PAIN/FEVER) - Tier 1; OTC; QL
pain reliever ex st oral liquid 500 mg/15ml (generic for MAPAP
ACETAMINOPHEN EXTRA STR) - Tier 1; OTC
pain reliever ex st oral tablet 500 mg (generic for MM
ACETAMINOPHEN EX STR) - Tier 1; OTC; QL
pain reliever extra strength oral tablet 250-250-65 mg (generic for
EXCEDRIN EXTRA STRENGTH) - Tier 1; OTC
pain reliever extra strength oral tablet 500 mg (generic for MM
ACETAMINOPHEN EX STR) - Tier 1; OTC; QL
pain reliever oral tablet 325 mg (generic for PHARBETOL) - Tier 1;
OTC; QL
pain reliever oral tablet 500 mg (generic for MM ACETAMINOPHEN
EX STR) - Tier 1; OTC; QL
pain reliever plus (generic for EXCEDRIN EXTRA STRENGTH) - Tier
1; OTC
pain-off (generic for EXCEDRIN EXTRA STRENGTH) - Tier 1; OTC
PANADOL CHILDRENS (brand for acetaminophen) - Tier 2; OTC; QL
PANADOL EXTRA STRENGTH (brand for acetaminophen) - Tier 2;
OTC; QL
PANADOL INFANTS (brand for acetaminophen) - Tier 2; OTC; QL
PHARBETOL (brand for acetaminophen) - Tier 2; OTC; QL
PHARBETOL EXTRA STRENGTH (brand for acetaminophen) - Tier 2;
OTC; QL
sb arthritis pain relief (generic for TYLENOL 8 HOUR) - Tier 1; OTC;
QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
15
Preferred Agents Non-Preferred Agents
sb pain reliever childrens (generic for MAX RELIEF JR CHILD
PAIN/FEVER) - Tier 1; OTC; QL
TYLENOL FOR CHILDREN + ADULTS (brand for acetaminophen) -
Tier 2; OTC; QL
TYLENOL ORAL SUSPENSION 160 MG/5ML (brand for
acetaminophen) - Tier 2; OTC; QL
TYLENOL ORAL TABLET 325 MG, 500 MG (brand for
acetaminophen) - Tier 2; OTC; QL
TYLENOL ORAL TABLET CHEWABLE 160 MG (brand for
acetaminophen) - Tier 2; OTC; QL
TYLENOL ORAL TABLET EXTENDED RELEASE 650 MG (brand for
8 hour arthritis pain) - Tier 2; OTC; QL
Nonsteroidal Anti-Inflammatory Drugs - Pain/Anti-Inflammatory
Drugs
salsalate oral - Tier 1; QL
Opioid Analgesics, Short-acting
oxycodone hcl oral tablet 10 mg, 20 mg - Tier 1; QL
oxycodone hcl oral tablet 15 mg, 30 mg (generic for ROXICODONE) -
Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
16
Preferred Agents Non-Preferred Agents
Anesthetics
Local Anesthetics
ANECREAM EXTERNAL CREAM (brand for lidocaine) - Tier 2; OTC;
QL
ASPERFLEX LIDOCAINE EXTERNAL CREAM (brand for lidocaine) -
Tier 2; OTC; QL
lidocaine external cream 4 % (generic for ANECREAM) - Tier 1; OTC;
QL
lidocaine external patch 5 % (generic for LIDOCAN) - Tier 1; DX2RX;
QL
lidocaine hcl external cream 3 % - Tier 1; QL
lidocaine viscous hcl - Tier 1; QL
lidocaine-prilocaine external cream - Tier 1; QL
lidopin external cream 3 % - Tier 1; QL
LMX 4 (brand for lidocaine) - Tier 2; OTC; QL
PROXIVOL - Tier 2; QL
Anti-Addiction/Substance Abuse Treatment Agents
Alcohol Deterrents/Anti-craving
acamprosate calcium - Tier 1; CH; QL
disulfiram oral tablet 250 mg - Tier 1; CH; QL
disulfiram oral tablet 500 mg - Tier 1; CH
naltrexone hcl oral - Tier 1
Opioid Dependence
buprenorphine hcl-naloxone hcl (generic for SUBOXONE) - Tier 1;
DX2RX; QL
SUBOXONE (brand for buprenorphine hcl-naloxone hcl) - Tier 2; DX2RX;
QL
ZUBSOLV - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
17
Preferred Agents Non-Preferred Agents
Opioid Reversal Agents
naloxone hcl injection - Tier 1; QL
naloxone hcl liquid 4 mg/0.1ml nasal (otc) (generic for NARCAN) - Tier
1; OTC; QL
naloxone hcl liquid 4 mg/0.1ml nasal (rx) (generic for NARCAN) - Tier
1; QL
NARCAN LIQUID 4 MG/0.1ML NASAL (OTC) (brand for naloxone hcl)
- Tier 2; OTC; QL
NARCAN LIQUID 4 MG/0.1ML NASAL (RX) (brand for naloxone hcl) -
Tier 2; QL
KLOXXADO - Tier 2; PA; QL
ZIMHI - Tier 2; PA; QL
Smoking Cessation Agents
habitrol (generic for HABITROL) - Tier 1; OTC; PD; QL
NICODERM CQ (brand for cvs nicotine) - Tier 2; OTC; PD; QL
nicotine step 1 (generic for HABITROL) - Tier 1; OTC; PD; QL
nicotine step 2 (generic for NICODERM CQ) - Tier 1; OTC; PD; QL
nicotine step 3 (generic for NICODERM CQ) - Tier 1; OTC; PD; QL
nicotine transdermal patch 24 hour 14 mg/24hr, 7 mg/24hr (generic for
NICODERM CQ) - Tier 1; OTC; PD; QL
nicotine transdermal patch 24 hour 21 mg/24hr (generic for
HABITROL) - Tier 1; OTC; PD; QL
nicotine transdermal system (generic for HABITROL) - Tier 1; OTC;
PD; QL
varenicline tartrate (generic for CHANTIX) - Tier 1; PA; PD; CH; QL
varenicline tartrate (starter) - Tier 1; PA; PD; CH; QL
varenicline tartrate(continue) (generic for CHANTIX) - Tier 1; PA; PD;
CH; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
18
Preferred Agents Non-Preferred Agents
Anti-Addiction/Substance Abuse Treatment Agents - Drugs for
Overdose or Deterrence
Smoking Cessation Agents - Deterrents
ft nicotine mini (generic for KLS QUIT2) - Tier 1; OTC; PD; QL
ft nicotine mouth/throat lozenge (generic for KLS QUIT2) - Tier 1;
OTC; PD; QL
mini nicotine (generic for KLS QUIT2) - Tier 1; OTC; PD; QL
NICORETTE (brand for cvs nicotine) - Tier 2; OTC; PD; QL
NICORETTE MINI (brand for cvs nicotine) - Tier 2; OTC; PD; QL
NICORETTE STARTER KIT (brand for cvs nicotine) - Tier 2; OTC; PD;
QL
nicotine gum mouth/throat gum 2 mg (generic for KLS QUIT2) - Tier 1;
OTC; PD; QL
nicotine gum mouth/throat gum 4 mg (generic for KLS QUIT4) - Tier 1;
OTC; PD; QL
nicotine gum mouth/throat lozenge 2 mg (generic for KLS QUIT2) -
Tier 1; OTC; PD; QL
nicotine gum mouth/throat lozenge 4 mg (generic for KLS QUIT4) -
Tier 1; OTC; PD; QL
nicotine mini (generic for KLS QUIT2) - Tier 1; OTC; PD; QL
nicotine mouth/throat gum 2 mg (generic for KLS QUIT2) - Tier 1;
OTC; PD; QL
nicotine mouth/throat gum 4 mg (generic for KLS QUIT4) - Tier 1;
OTC; PD; QL
nicotine mouth/throat lozenge 2 mg (generic for KLS QUIT2) - Tier 1;
OTC; PD; QL
nicotine mouth/throat lozenge 4 mg (generic for KLS QUIT4) - Tier 1;
OTC; PD; QL
nicotine polacrilex mini (generic for KLS QUIT2) - Tier 1; OTC; PD; QL
nicotine polacrilex mouth/throat (generic for KLS QUIT2) - Tier 1; OTC;
PD; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
19
Preferred Agents Non-Preferred Agents
quit2 (generic for KLS QUIT2) - Tier 1; OTC; PD; QL
quit4 (generic for KLS QUIT4) - Tier 1; OTC; PD; QL
THRIVE (brand for cvs nicotine) - Tier 2; OTC; PD; QL
Antiandrogens - Hormone Suppressants
Antineoplastics - Drugs to Treat Cancer
ORGOVYX - Tier 2; PA; SP; PD; CH; QL
Antibacterials
Aminoglycosides
neomycin sulfate oral - Tier 1; QL
Antibacterials, Other
clindamycin hcl oral capsule 150 mg, 300 mg (generic for CLEOCIN) -
Tier 1; QL
clindamycin palmitate hcl (generic for CLEOCIN) - Tier 1; QL
clindamycin phosphate vaginal (generic for CLEOCIN) - Tier 1; QL
FIRVANQ (brand for vancomycin hcl) - Tier 2; DX2RX; QL
linezolid oral suspension reconstituted (generic for ZYVOX) - Tier 1;
DX2RX; QL
linezolid oral tablet (generic for ZYVOX) - Tier 1; DX2RX
methenamine hippurate (generic for HIPREX) - Tier 1; QL
metronidazole external (generic for METROCREAM) - Tier 1; QL
metronidazole oral tablet - Tier 1; QL
metronidazole vaginal (generic for VANDAZOLE) - Tier 1; QL
nitrofurantoin macrocrystal (generic for MACRODANTIN) - Tier 1; QL
CLINDESSE - Tier 2; PA; QL
SOLOSEC - Tier 2; PA; QL
XACIATO - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
20
Preferred Agents Non-Preferred Agents
nitrofurantoin monohydrate macrocrystals (generic for MACROBID) -
Tier 1; QL
nitrofurantoin oral suspension 25 mg/5ml - Tier 1; Members >= 8 years
of age will require PA; QL; AL
tinidazole oral tablet 250 mg - Tier 1
tinidazole oral tablet 500 mg - Tier 1; QL
trimethoprim oral - Tier 1; QL
vancomycin hcl oral solution reconstituted 25 mg/ml (generic for
FIRVANQ) - Tier 1; DX2RX; QL
VANDAZOLE (brand for metronidazole) - Tier 2; QL
Beta-lactam, Cephalosporins
cefaclor oral capsule - Tier 1; QL
cefadroxil - Tier 1; QL
cefdinir - Tier 1; QL
cefixime oral capsule - Tier 1; QL
cefpodoxime proxetil oral tablet - Tier 1; QL
cefprozil - Tier 1; QL
cefuroxime axetil - Tier 1; QL
cephalexin oral capsule 250 mg, 500 mg - Tier 1; QL
cephalexin oral suspension reconstituted - Tier 1; QL
Beta-lactam, Penicillins
amoxicillin - Tier 1; QL
amoxicillin-potassium clavulanate (generic for AUGMENTIN) - Tier 1;
QL
ampicillin - Tier 1; QL
dicloxacillin sodium - Tier 1; QL
penicillin v potassium - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
21
Preferred Agents Non-Preferred Agents
Macrolides
azithromycin oral suspension reconstituted (generic for ZITHROMAX) -
Tier 1; QL
azithromycin oral tablet (generic for ZITHROMAX) - Tier 1; QL
clarithromycin er - Tier 1; QL
clarithromycin oral - Tier 1; QL
DIFICID - Tier 2; PA; QL
E.E.S. 400 (brand for erythromycin ethylsuccinate) - Tier 2; QL
ERYTHROCIN STEARATE (brand for erythromycin stearate) - Tier 2;
QL
erythromycin base oral (generic for ERY-TAB) - Tier 1; QL
erythromycin ethylsuccinate oral (generic for E.E.S. 400) - Tier 1; QL
erythromycin oral (generic for ERY-TAB) - Tier 1; QL
Quinolones
CIPRO ORAL SUSPENSION RECONSTITUTED - Tier 2; QL
ciprofloxacin hcl oral (generic for CIPRO) - Tier 1; QL
levofloxacin oral tablet - Tier 1; QL
moxifloxacin hcl oral - Tier 1; QL
ofloxacin oral - Tier 1; QL
Sulfonamides
sulfamethoxazole-trimethoprim oral (generic for BACTRIM) - Tier 1;
QL
sulfatrim pediatric (generic for SULFATRIM PEDIATRIC) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
22
Preferred Agents Non-Preferred Agents
Tetracyclines
doxycycline hyclate oral capsule (generic for VIBRAMYCIN) - Tier 1;
QL
doxycycline hyclate oral tablet 100 mg - Tier 1; QL
doxycycline monohydrate oral capsule 100 mg (generic for
MONDOXYNE NL) - Tier 1; QL
doxycycline monohydrate oral capsule 50 mg - Tier 1; QL
minocycline hcl oral capsule 100 mg, 50 mg - Tier 1; QL
mondoxyne nl (generic for MONDOXYNE NL) - Tier 1; QL
NUZYRA ORAL - Tier 2; PA; QL
ORACEA (brand for doxycycline) - Tier 2; PA
Antibacterials - Drugs to Treat Bacterial Infections
Antibacterials, Other - Antibiotics
antibiotic (generic for NEOSPORIN ORIGINAL) - Tier 1; OTC; QL
antiseptic (generic for BETADINE) - Tier 1; OTC
BETADINE EXTERNAL SOLUTION 10 % (brand for cvs povidone-
iodine) - Tier 2; OTC
first aid antibiotic external ointment , 3.5-400-5000 (generic for
NEOSPORIN ORIGINAL) - Tier 1; OTC; QL
first aid antiseptic external solution 10 % (generic for BETADINE) -
Tier 1; OTC
medi-first triple antibiotic (generic for NEOSPORIN ORIGINAL) - Tier
1; OTC; QL
NEOSPORIN ORIGINAL (brand for cvs antibiotic) - Tier 2; OTC; QL
povidone iodine (generic for BETADINE) - Tier 1; OTC
povidone-iodine external solution (generic for BETADINE) - Tier 1;
OTC
SUTAB - Tier 2; PA
SCRUB CARE POVIDONE-IODINE (brand for cvs povidone-iodine) -
Tier 2; OTC
triple antibiotic external ointment , 3.5-400-5000 , 5-400-5000 , 5-400-
5000 mg-unit (generic for NEOSPORIN ORIGINAL) - Tier 1; OTC; QL
triple antibiotic original (generic for NEOSPORIN ORIGINAL) - Tier 1;
OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
23
Preferred Agents Non-Preferred Agents
Anticonvulsants
Anticonvulsants, Other
felbamate oral suspension - Tier 1; Members >= 8 years of age will
require PA; QL; AL
felbamate oral tablet (generic for FELBATOL) - Tier 1; QL
lamotrigine oral tablet (generic for SUBVENITE) - Tier 1; QL
lamotrigine oral tablet chewable (generic for LAMICTAL) - Tier 1;
Members >= 8 years of age will require PA; QL; AL
lamotrigine starter kit-blue (generic for SUBVENITE STARTER KIT-
BLUE) - Tier 1; QL
lamotrigine starter kit-green (generic for SUBVENITE STARTER KIT-
GREEN) - Tier 1; QL
lamotrigine starter kit-orange (generic for SUBVENITE STARTER KIT-
ORANGE) - Tier 1; QL
levetiracetam oral solution (generic for KEPPRA) - Tier 1; Maximum
age of 9 years for solution; QL; AL
BRIVIACT ORAL - Tier 2; PA; QL
EPIDIOLEX - Tier 2; PA; SP; QL
FYCOMPA - Tier 2; PA; QL
TOPAMAX (brand for topiramate) - Tier 2; PA; QL
TOPAMAX SPRINKLE (brand for topiramate) - Tier 2; PA; Members >= 8
years of age will require PA; QL; AL
TROKENDI XR (brand for topiramate er) - Tier 2; PA; QL
XCOPRI (250 MG DAILY DOSE) - Tier 2; PA; QL
XCOPRI (350 MG DAILY DOSE) - Tier 2; PA; QL
XCOPRI ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG - Tier 2; PA;
QL
XCOPRI ORAL TABLET THERAPY PACK - Tier 2; PA; QL
levetiracetam oral tablet (generic for KEPPRA) - Tier 1; QL
roweepra (generic for ROWEEPRA) - Tier 1; QL
subvenite (generic for SUBVENITE) - Tier 1; QL
subvenite starter kit-blue (generic for SUBVENITE STARTER KIT-
BLUE) - Tier 1; QL
subvenite starter kit-green (generic for SUBVENITE STARTER KIT-
GREEN) - Tier 1; QL
subvenite starter kit-orange (generic for SUBVENITE STARTER KIT-
ORANGE) - Tier 1; QL
topiramate oral capsule sprinkle (generic for TOPAMAX SPRINKLE) -
Tier 1; Members >= 8 years of age will require PA; QL; AL
topiramate oral tablet (generic for TOPAMAX) - Tier 1; QL
valproic acid oral - Tier 1; QL
Calcium Channel Modifying Agents
ethosuximide oral (generic for ZARONTIN) - Tier 1; QL
methsuximide (generic for CELONTIN) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
24
Preferred Agents Non-Preferred Agents
Gamma-aminobutyric Acid (GABA) Augmenting Agents
clobazam (generic for ONFI) - Tier 1; DX2RX; QL
diazepam rectal - Tier 1; QL
gabapentin oral capsule (generic for NEURONTIN) - Tier 1; QL
gabapentin oral tablet 600 mg, 800 mg (generic for NEURONTIN) -
Tier 1; QL
NAYZILAM - Tier 2; PA; QL
phenobarbital oral - Tier 1; QL
primidone oral tablet 250 mg, 50 mg (generic for MYSOLINE) - Tier 1;
QL
tiagabine hcl - Tier 1; PA; QL; AL
VALTOCO 10 MG DOSE - Tier 2; PA; QL
VALTOCO 15 MG DOSE - Tier 2; PA; QL
VALTOCO 20 MG DOSE - Tier 2; PA; QL
VALTOCO 5 MG DOSE - Tier 2; PA; QL
SYMPAZAN - Tier 2; PA; QL
vigabatrin oral packet (generic for VIGADRONE) - Tier 1; PA; SP; QL
vigadrone oral packet (generic for VIGADRONE) - Tier 1; PA; SP; QL
vigpoder (generic for VIGADRONE) - Tier 1; PA; SP; QL
Sodium Channel Agents
carbamazepine er (generic for CARBATROL) - Tier 1; QL
carbamazepine oral (generic for EPITOL) - Tier 1; QL
DILANTIN ORAL CAPSULE 30 MG - Tier 2
epitol (generic for EPITOL) - Tier 1; QL
lacosamide oral tablet (generic for VIMPAT) - Tier 1; PA; QL; AL
oxcarbazepine oral suspension (generic for TRILEPTAL) - Tier 1;
Maximum age of 9 years for solution; QL; AL
oxcarbazepine oral tablet (generic for TRILEPTAL) - Tier 1; QL
phenytek (generic for PHENYTEK) - Tier 1; QL
phenytoin infatabs (generic for PHENYTOIN INFATABS) - Tier 1; QL
phenytoin oral (generic for DILANTIN) - Tier 1; QL
phenytoin sodium extended oral capsule 200 mg, 300 mg (generic for
PHENYTEK) - Tier 1; QL
rufinamide (generic for BANZEL) - Tier 1; DX2RX; QL
APTIOM - Tier 2; PA; QL
ZONEGRAN (brand for zonisamide) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
25
Preferred Agents Non-Preferred Agents
TEGRETOL ORAL SUSPENSION (brand for carbamazepine) - Tier 2;
QL
zonisamide oral (generic for ZONEGRAN) - Tier 1; QL
Antidementia Agents
Antidementia Agents, Other
NAMZARIC - Tier 2; PA; CH; QL; AL
Cholinesterase Inhibitors
donepezil hcl oral tablet 10 mg, 5 mg (generic for ARICEPT) - Tier 1;
Members <18 years of age will require PA; CH; QL; AL
donepezil hcl oral tablet 23 mg (generic for ARICEPT) - Tier 1; ST;
Members <18 years of age will require PA; CH; QL; AL
galantamine hydrobromide oral solution - Tier 1; CH; QL; AL
galantamine hydrobromide oral tablet 12 mg, 8 mg - Tier 1; CH; QL;
AL
galantamine hydrobromide oral tablet 4 mg - Tier 1; Members <18
years of age will require PA; CH; QL; AL
rivastigmine (generic for EXELON) - Tier 1; Members <18 years of age
will require PA; QL; AL
rivastigmine tartrate - Tier 1; CH; QL; AL
N-methyl-D-aspartate (NMDA) Receptor Antagonist
memantine hcl oral solution - Tier 1; CH; QL
memantine hcl oral tablet (generic for NAMENDA TITRATION PAK) -
Tier 1; Members <18 years of age will require PA; CH; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
26
Preferred Agents Non-Preferred Agents
Antidepressants
Antidepressants, Other
bupropion hcl er (sr) (generic for WELLBUTRIN SR) - Tier 1; PD; QL
bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300
mg (generic for WELLBUTRIN XL) - Tier 1; QL
bupropion hcl oral - Tier 1; QL
mirtazapine oral tablet 15 mg, 30 mg (generic for REMERON) - Tier 1;
Tabs (not soltabs); QL
mirtazapine oral tablet 45 mg, 7.5 mg - Tier 1; QL
perphenazine-amitriptyline oral tablet 2-10 mg, 4-10 mg, 4-25 mg, 4-50
mg - Tier 1; CH
perphenazine-amitriptyline oral tablet 2-25 mg - Tier 1; CH; QL
FORFIVO XL (brand for bupropion hcl er (xl)) - Tier 2; PA; QL
Monoamine Oxidase Inhibitors
tranylcypromine sulfate (generic for PARNATE) - Tier 1; QL
SSRI/SNRI (Selective Serotonin Reuptake Inhibitors/Serotonin
and Norepinephrine Reuptake Inhibitors)
citalopram hydrobromide oral solution - Tier 1; QL
citalopram hydrobromide oral tablet (generic for CELEXA) - Tier 1; QL
escitalopram oxalate oral tablet (generic for LEXAPRO) - Tier 1; QL
fluoxetine hcl oral capsule (generic for PROZAC) - Tier 1; QL
fluoxetine hcl oral solution - Tier 1; QL
fluvoxamine maleate - Tier 1; QL
paroxetine hcl oral tablet (generic for PAXIL) - Tier 1; QL
sertraline hcl oral concentrate (generic for ZOLOFT) - Tier 1; QL
sertraline hcl oral tablet (generic for ZOLOFT) - Tier 1; QL
trazodone hcl oral tablet 100 mg, 150 mg, 50 mg - Tier 1; QL
venlafaxine hcl - Tier 1; QL
venlafaxine hcl er oral capsule extended release 24 hour (generic for
EFFEXOR XR) - Tier 1; QL
TRINTELLIX - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
27
Preferred Agents Non-Preferred Agents
Tricyclics
amitriptyline hcl oral - Tier 1; QL
amoxapine - Tier 1; QL
clomipramine hcl oral (generic for ANAFRANIL) - Tier 1; QL
desipramine hcl oral (generic for NORPRAMIN) - Tier 1; QL
doxepin hcl oral capsule - Tier 1; QL
doxepin hcl oral concentrate - Tier 1; QL
imipramine hcl oral - Tier 1; QL
nortriptyline hcl oral (generic for PAMELOR) - Tier 1; QL
Antiemetics
Antiemetics, Other
ANTIVERT ORAL TABLET CHEWABLE (brand for cvs motion
sickness relief) - Tier 2
BONINE (brand for cvs motion sickness relief) - Tier 2; OTC
compro (generic for COMPRO) - Tier 1; QL
driminate (generic for DRIMINATE) - Tier 1; OTC
ft motion sickness oral tablet 50 mg (generic for DRIMINATE) - Tier 1;
OTC
meclizine hcl oral tablet 12.5 mg - Tier 1; QL
meclizine hcl oral tablet 25 mg (generic for DRAMAMINE) - Tier 1; QL
meclizine hcl oral tablet chewable (generic for ANTIVERT) - Tier 1;
OTC
metoclopramide hcl oral solution 5 mg/5ml - Tier 1; QL
metoclopramide hcl oral tablet (generic for REGLAN) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
28
Preferred Agents Non-Preferred Agents
motion sickness oral tablet 50 mg (generic for DRIMINATE) - Tier 1;
OTC
motion sickness relief oral tablet 50 mg (generic for DRIMINATE) - Tier
1; OTC
motion sickness relief oral tablet chewable 25 mg (generic for
ANTIVERT) - Tier 1; OTC
motion-time (generic for ANTIVERT) - Tier 1; OTC
perphenazine oral - Tier 1; QL
prochlorperazine (generic for COMPRO) - Tier 1; QL
prochlorperazine maleate oral - Tier 1; QL
promethazine hcl oral - Tier 1; QL
promethazine hcl rectal (generic for PROMETHEGAN) - Tier 1; QL
promethegan (generic for PROMETHEGAN) - Tier 1; QL
travel ease (generic for ANTIVERT) - Tier 1; OTC
trimethobenzamide hcl oral - Tier 1; QL
Emetogenic Therapy Adjuncts
aprepitant (generic for EMEND) - Tier 1; QL
dronabinol (generic for MARINOL) - Tier 1; PA; QL
ondansetron hcl oral tablet 4 mg, 8 mg - Tier 1; QL
ondansetron odt - Tier 1; QL
SANCUSO - Tier 2; PA; QL
Antiemetics - Drugs to Treat Nausea and Vomiting
Antiemetics, Other - Nausea and Vomiting Drugs
anti-nausea (generic for EMETROL) - Tier 1; OTC
anti-nausea relief (generic for EMETROL) - Tier 1; OTC
EMETROL ORAL SOLUTION (brand for anti-nausea) - Tier 2; OTC
nausea control (generic for EMETROL) - Tier 1; OTC
nausea relief oral solution 1.87-1.87-21.5 (generic for EMETROL) -
Tier 1; OTC
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
29
Preferred Agents Non-Preferred Agents
Antifungals
3 day (generic for MONISTAT 3) - Tier 1; OTC
clotrimazole mouth/throat troche 10 mg - Tier 1; QL
fluconazole oral (generic for DIFLUCAN) - Tier 1; QL
ft miconazole 7 (generic for MONISTAT 7 SIMPLY CURE) - Tier 1;
OTC; QL
griseofulvin microsize oral - Tier 1; QL
griseofulvin ultramicrosize - Tier 1; QL
itraconazole oral (generic for SPORANOX) - Tier 1; PA; QL
ketoconazole oral - Tier 1; QL
miconazole 3 - Tier 1; QL
miconazole 3 applicator vaginal kit 200 & 2 mg-% (9gm) (generic for
MONISTAT 3 COMBO PACK APP) - Tier 1; OTC; QL
miconazole 3 combo pack vaginal kit 200 & 2 mg-% (9gm) (generic for
MONISTAT 3 COMBO PACK APP) - Tier 1; OTC; QL
CRESEMBA ORAL CAPSULE 186 MG - Tier 2; PA; QL
GYNAZOLE-1 - Tier 2; PA; QL
miconazole 7 vaginal cream 2 % (generic for MONISTAT 7 SIMPLY
CURE) - Tier 1; OTC; QL
miconazole 7 vaginal suppository 100 mg - Tier 1; OTC
miconazole nitrate vaginal (generic for MONISTAT 7 SIMPLY CURE) -
Tier 1; OTC; QL
nystatin mouth/throat - Tier 1; QL
nystatin oral - Tier 1; QL
terbinafine hcl oral - Tier 1; QL
terconazole vaginal cream - Tier 1; QL
voriconazole oral tablet (generic for VFEND) - Tier 1; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
30
Preferred Agents Non-Preferred Agents
Antifungals - Drugs to Treat Fungal Infections
Antifungals - Fungal Infection Drugs
3 day vaginal - Tier 1; OTC
3-day vaginal vaginal cream 2 % - Tier 1; OTC
antifungal external cream (generic for MICATIN) - Tier 1; OTC
antifungal external powder (generic for DESENEX) - Tier 1; OTC; QL
antifungal foot care (generic for LAMISIL AT) - Tier 1; OTC; QL
antifungal miconazole (generic for MICATIN) - Tier 1; OTC
atheletes foot (generic for CRUEX PRESCRIPTION STRENGTH) -
Tier 1; OTC
athletes foot (terbinafine) (generic for LAMISIL AT) - Tier 1; OTC; QL
athletes foot external aerosol powder 2 % (generic for CRUEX
PRESCRIPTION STRENGTH) - Tier 1; OTC
athletes foot external cream 1 % (generic for LAMISIL AT) - Tier 1;
OTC; QL
athletes foot external powder 2 % (generic for DESENEX) - Tier 1;
OTC; QL
athletes foot powder spray external aerosol powder 2 % (generic for
CRUEX PRESCRIPTION STRENGTH) - Tier 1; OTC
athletes foot spray external aerosol 2 % (generic for LOTRIMIN AF) -
Tier 1; OTC
baza antifungal (generic for MICATIN) - Tier 1; OTC
clotrimazole 3 vaginal cream 2 % - Tier 1; OTC
clotrimazole 7 - Tier 1; OTC; QL
clotrimazole vaginal - Tier 1; OTC; QL
clotrimazole vaginal cream 1 % - Tier 1; OTC; QL
CRITIC-AID CLEAR AF - Tier 2; OTC
CRUEX PRESCRIPTION STRENGTH (brand for athletes foot powder
spray) - Tier 2; OTC
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
31
Preferred Agents Non-Preferred Agents
DESENEX EXTERNAL POWDER (brand for antifungal) - Tier 2; OTC;
QL
DESENEX JOCK ITCH (brand for athletes foot powder spray) - Tier 2;
OTC
foot care (terbinafine) (generic for LAMISIL AT) - Tier 1; OTC; QL
ft antifungal external cream 2 % (generic for MICATIN) - Tier 1; OTC
ft athletes foot (terbinafine) (generic for LAMISIL AT) - Tier 1; OTC; QL
jock itch external cream 1 % (generic for LAMISIL AT) - Tier 1; OTC;
QL
LAMISIL AT EXTERNAL CREAM (brand for athletes foot (terbinafine))
- Tier 2; OTC; QL
LAMISIL AT JOCK ITCH (brand for athletes foot (terbinafine)) - Tier 2;
OTC; QL
micaderm (generic for MICATIN) - Tier 1; OTC
MICATIN (brand for antifungal) - Tier 2; OTC
miconazole antifungal (generic for MICATIN) - Tier 1; OTC
miconazole nitrate external cream (generic for MICATIN) - Tier 1; OTC
miconazorb af (generic for DESENEX) - Tier 1; OTC; QL
MICRO GUARD (brand for antifungal) - Tier 2; OTC; QL
terbinafine hcl external (generic for LAMISIL AT) - Tier 1; OTC; QL
terbinafine hydrochloride external cream 1 % (generic for LAMISIL AT)
- Tier 1; OTC; QL
ZEASORB-AF (brand for antifungal) - Tier 2; OTC; QL
Antigout Agents
allopurinol oral tablet 100 mg, 300 mg - Tier 1; QL
colchicine oral tablet - Tier 1; QL
febuxostat (generic for ULORIC) - Tier 1; ST; QL
MITIGARE (brand for colchicine) - Tier 2; QL
probenecid - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
32
Preferred Agents Non-Preferred Agents
Antimigraine Agents
Ergot Alkaloids
dihydroergotamine mesylate injection - Tier 1; QL
MIGERGOT - Tier 2; QL
QULIPTA - Tier 2; PA; QL
Prophylactic
AIMOVIG - Tier 2; PA; QL
AJOVY - Tier 2; PA; QL
EMGALITY - Tier 2; PA; QL
EMGALITY (300 MG DOSE) - Tier 2; PA; QL
Antimigraine Agents - Drugs to Treat Migraines
Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonist -
Migraine Drugs
NURTEC - Tier 2; PA; QL
UBRELVY - Tier 2; PA; QL
Serotonin (5-HT) Receptor Agonists - Migraine Drugs
naratriptan hcl - Tier 1; ST; QL
rizatriptan benzoate (generic for MAXALT) - Tier 1; QL
sumatriptan nasal - Tier 1; QL
sumatriptan succinate oral (generic for IMITREX) - Tier 1; QL
sumatriptan succinate refill (generic for IMITREX STATDOSE REFILL)
- Tier 1; QL
sumatriptan succinate subcutaneous (generic for IMITREX
STATDOSE SYSTEM) - Tier 1; QL
REYVOW - Tier 2; PA; QL
ZOMIG NASAL (brand for zolmitriptan) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
33
Preferred Agents Non-Preferred Agents
Antimyasthenic Agents
Parasympathomimetics
pyridostigmine bromide er (generic for MESTINON) - Tier 1; QL
pyridostigmine bromide oral solution (generic for MESTINON) - Tier 1;
QL
pyridostigmine bromide oral tablet 60 mg (generic for MESTINON) -
Tier 1; QL
Antimycobacterials
Antimycobacterials, Other
dapsone oral - Tier 1; QL
rifabutin (generic for MYCOBUTIN) - Tier 1; QL
Antituberculars
cycloserine oral - Tier 1; QL
ethambutol hcl oral tablet 100 mg - Tier 1
ethambutol hcl oral tablet 400 mg (generic for MYAMBUTOL) - Tier 1;
QL
isoniazid oral - Tier 1; QL
PRIFTIN - Tier 2; QL
pyrazinamide oral - Tier 1; QL
rifampin oral - Tier 1; QL
SIRTURO - Tier 2; QL
TRECATOR - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
34
Preferred Agents Non-Preferred Agents
Antineoplastics
Alkylating Agents
cyclophosphamide oral capsule - Tier 1; PD; CH
CYCLOPHOSPHAMIDE ORAL TABLET - Tier 2; PD; CH
LEUKERAN - Tier 2; PD; CH
MATULANE - Tier 2; SP; PD; CH
MYLERAN - Tier 2; PD; CH
temozolomide oral capsule 100 mg, 140 mg - Tier 1; PA; SP; PD; CH
temozolomide oral capsule 180 mg, 20 mg, 250 mg, 5 mg - Tier 1; PA;
SP; PD; CH; QL
Antiandrogens
abiraterone acetate oral tablet 250 mg (generic for ZYTIGA) - Tier 1;
PA; SP; PD; CH; QL
bicalutamide (generic for CASODEX) - Tier 1; PD; CH; QL
ERLEADA ORAL TABLET 240 MG - Tier 2; SP; PD; CH; QL
ERLEADA ORAL TABLET 60 MG - Tier 2; PA; SP; PD; CH; QL
EULEXIN - Tier 2; PD; CH; QL
NUBEQA - Tier 2; PA; SP; PD; CH; QL
XTANDI - Tier 2; PA; SP; PD; CH; QL
Antiangiogenic Agents
lenalidomide (generic for REVLIMID) - Tier 1; PA; SP; QL
POMALYST - Tier 2; PA; SP; PD; CH; QL
REVLIMID (brand for lenalidomide) - Tier 2; PA; SP; QL
THALOMID - Tier 2; PA; SP; QL
Antiestrogens/Modifiers
tamoxifen citrate oral - Tier 1; PD; CH; QL
toremifene citrate (generic for FARESTON) - Tier 1; PD; CH; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
35
Preferred Agents Non-Preferred Agents
Antimetabolites
hydroxyurea oral (generic for HYDREA) - Tier 1; PD; CH; QL
mercaptopurine oral - Tier 1; PD; CH; QL
TABLOID - Tier 2; SP; PD; CH
Antineoplastics, Other
IDHIFA - Tier 2; PA; SP; PD; CH; QL
LONSURF - Tier 2; PA; SP; PD; CH; QL
NINLARO - Tier 2; PA; SP; PD; CH; QL
ZOLINZA - Tier 2; PA; SP; PD; CH; QL
Aromatase Inhibitors, 3rd Generation
anastrozole oral (generic for ARIMIDEX) - Tier 1; PD; CH; QL
exemestane (generic for AROMASIN) - Tier 1; PD; CH; QL
letrozole oral (generic for FEMARA) - Tier 1; PD; CH; QL
Enzyme Inhibitors
etoposide oral - Tier 1; PD; CH
HYCAMTIN ORAL - Tier 2; PA; SP; PD; CH
Molecular Target Inhibitors
BALVERSA - Tier 2; PA; SP; PD; CH; QL
COTELLIC - Tier 2; PA; SP; PD; CH; QL
DAURISMO - Tier 2; PA; SP; PD; CH; QL
ERIVEDGE - Tier 2; PA; SP; PD; CH; QL
everolimus oral tablet 10 mg, 2.5 mg, 5 mg (generic for AFINITOR) -
Tier 1; PA; SP; PD; CH; QL
everolimus oral tablet 7.5 mg (generic for AFINITOR) - Tier 1; PA; SP;
PD; CH
everolimus oral tablet soluble (generic for AFINITOR DISPERZ) - Tier
1; PA; SP; PD; CH; QL
IBRANCE - Tier 2; PA; SP; PD; CH; QL
JAKAFI - Tier 2; PA; SP; PD; CH; QL
LYNPARZA - Tier 2; PA; SP; PD; CH; QL
EXKIVITY - Tier 2; PA; SP; PD; CH; QL
KISQALI (200 MG DOSE) - Tier 2; PA; SP; PD; CH; QL
KISQALI (400 MG DOSE) - Tier 2; PA; SP; PD; CH; QL
KISQALI (600 MG DOSE) - Tier 2; PA; SP; PD; CH; QL
KISQALI FEMARA (200 MG DOSE) - Tier 2; PA; SP; PD; CH; QL
KISQALI FEMARA (400 MG DOSE) - Tier 2; PA; SP; PD; CH; QL
KISQALI FEMARA (600 MG DOSE) - Tier 2; PA; SP; PD; CH; QL
KOSELUGO - Tier 2; PA; PD; CH; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
36
Preferred Agents Non-Preferred Agents
MEKINIST ORAL SOLUTION RECONSTITUTED - Tier 2; SP; PD;
CH; QL
MEKINIST ORAL TABLET - Tier 2; PA; SP; PD; CH; QL
ODOMZO - Tier 2; PA; SP; PD; CH; QL
PIQRAY (200 MG DAILY DOSE) - Tier 2; PA; SP; PD; CH; QL
PIQRAY (250 MG DAILY DOSE) - Tier 2; PA; SP; PD; CH; QL
PIQRAY (300 MG DAILY DOSE) - Tier 2; PA; SP; PD; CH; QL
ROZLYTREK ORAL CAPSULE - Tier 2; PA; SP; PD; CH; QL
ROZLYTREK PACKET 50 MG ORAL - Tier 2; PA; SP; PD; CH; QL
ROZLYTREK PACKET 50 MG ORAL - Tier 2; PA; SP; PD; CH; QL;
AL
RUBRACA - Tier 2; PA; SP; PD; CH; QL
RYDAPT - Tier 2; PA; SP; PD; CH; QL
sorafenib tosylate (generic for NEXAVAR) - Tier 1; PA; SP; PD; CH;
QL
STIVARGA - Tier 2; PA; SP; PD; CH; QL
sunitinib malate oral capsule 12.5 mg, 25 mg, 50 mg (generic for
SUTENT) - Tier 1; PA; SP; PD; CH; QL
sunitinib malate oral capsule 37.5 mg (generic for SUTENT) - Tier 1;
PA; SP; PD; CH
TAFINLAR ORAL CAPSULE - Tier 2; PA; SP; PD; CH; QL
TAFINLAR ORAL TABLET SOLUBLE - Tier 2; SP; PD; CH; QL
TIBSOVO - Tier 2; PA; SP; PD; CH; QL
VENCLEXTA - Tier 2; PA; SP; PD; CH; QL
VENCLEXTA STARTING PACK - Tier 2; PA; SP; PD; CH; QL
VERZENIO - Tier 2; PA; SP; PD; CH; QL
VITRAKVI - Tier 2; PA; SP; PD; CH; QL
ZEJULA - Tier 2; PA; SP; PD; CH; QL; AL
ZELBORAF - Tier 2; PA; SP; PD; CH; QL
ZYDELIG - Tier 2; PA; SP; PD; CH; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
37
Preferred Agents Non-Preferred Agents
Retinoids
bexarotene external (generic for TARGRETIN) - Tier 1; PA; SP
bexarotene oral (generic for TARGRETIN) - Tier 1; PA; SP; PD; CH
tretinoin oral - Tier 1; SP; PD; CH
Treatment Adjuncts
leucovorin calcium oral tablet 10 mg - Tier 1; PD; CH
leucovorin calcium oral tablet 15 mg, 25 mg, 5 mg - Tier 1; PD; CH; QL
MESNEX ORAL - Tier 2; SP; PD; CH
Antineoplastics - Drugs to Treat Cancer
Antimetabolites - Chemotherapy Agents
capecitabine (generic for XELODA) - Tier 1; SP; PD; CH
Molecular Target Inhibitors - Chemotherapy Agents
SCEMBLIX - Tier 2; PA; SP; PD; CH; QL
Antineoplastics, Other - Chemotherapy Agents
Antineoplastics - Drugs to Treat Cancer
ZYKADIA - Tier 2; PA; SP; PD; CH; QL LUMAKRAS - Tier 2; PA; SP; PD; CH; QL
Antiparasitics
Anthelmintics
albendazole oral - Tier 1; DX2RX; QL
ivermectin oral (generic for STROMECTOL) - Tier 1; DX2RX; QL
praziquantel oral (generic for BILTRICIDE) - Tier 1; DX2RX; QL
EMVERM - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
38
Preferred Agents Non-Preferred Agents
Antiprotozoals
atovaquone (generic for MEPRON) - Tier 1; PA; QL
atovaquone-proguanil hcl (generic for MALARONE) - Tier 1; QL
BENZNIDAZOLE - Tier 2; DX2RX; QL
chloroquine phosphate oral - Tier 1; QL
hydroxychloroquine sulfate oral tablet 200 mg (generic for SOVUNA) -
Tier 1; QL
KRINTAFEL - Tier 2; QL
mefloquine hcl - Tier 1; QL
nitazoxanide oral (generic for ALINIA) - Tier 1; DX2RX; QL
pentamidine isethionate inhalation (generic for NEBUPENT) - Tier 1
primaquine phosphate - Tier 1
pyrimethamine oral (generic for DARAPRIM) - Tier 1; PA; SP; QL
SOVUNA ORAL TABLET 200 MG (brand for hydroxychloroquine
sulfate) - Tier 2; QL
Antiparasitics - Drugs to Treat Parasitic Infections
Pediculicides/Scabicides - Scabies and Lice Drugs
ft lice killing max st (generic for RID LICE KILLING SHAMPOO) - Tier
1; OTC
lice killing (generic for RID LICE KILLING SHAMPOO) - Tier 1; OTC
lice killing max st external shampoo 0.33-4 % (generic for RID LICE
KILLING SHAMPOO) - Tier 1; OTC
lice killing max str (generic for RID LICE KILLING SHAMPOO) - Tier 1;
OTC
lice killing max strength (generic for RID LICE KILLING SHAMPOO) -
Tier 1; OTC
lice killing maximum strength (generic for RID LICE KILLING
SHAMPOO) - Tier 1; OTC
lice killing shampoo max str (generic for RID LICE KILLING
SHAMPOO) - Tier 1; OTC
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
39
Preferred Agents Non-Preferred Agents
lice maximum strength (generic for RID LICE KILLING SHAMPOO) -
Tier 1; OTC
lice treatment external shampoo 0.33-4 % (generic for RID LICE
KILLING SHAMPOO) - Tier 1; OTC
sb lice killing max st (generic for RID LICE KILLING SHAMPOO) - Tier
1; OTC
Antiparkinson Agents
Anticholinergics
benztropine mesylate oral - Tier 1; QL
trihexyphenidyl hcl - Tier 1; QL
Antiparkinson Agents, Other
amantadine hcl oral capsule - Tier 1; QL
amantadine hcl oral solution - Tier 1; QL
entacapone - Tier 1; QL
tolcapone (generic for TASMAR) - Tier 1; QL
NOURIANZ - Tier 2; PA; QL
ONGENTYS - Tier 2; PA; QL
Dopamine Agonists
pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 1
mg, 1.5 mg - Tier 1; QL
pramipexole dihydrochloride oral tablet 0.75 mg - Tier 1
ropinirole hcl - Tier 1; QL
NEUPRO - Tier 2; PA; QL
Dopamine Precursors and/or L-Amino Acid Decarboxylase
Inhibitors
carbidopa-levodopa er - Tier 1; QL
carbidopa-levodopa oral tablet (generic for DHIVY) - Tier 1; QL
DHIVY (brand for carbidopa-levodopa) - Tier 2; QL
INBRIJA - Tier 2; PA; SP; QL
RYTARY ORAL CAPSULE EXTENDED RELEASE 23.75-95 MG, 36.25-
145 MG, 61.25-245 MG - Tier 2; PA
RYTARY ORAL CAPSULE EXTENDED RELEASE 48.75-195 MG - Tier
2; PA; QL
Monoamine Oxidase B (MAO-B) Inhibitors
selegiline hcl oral - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
40
Preferred Agents Non-Preferred Agents
Antipsychotics
1st Generation/Typical
chlorpromazine hcl oral tablet - Tier 1; QL
fluphenazine decanoate injection - Tier 1; QL
fluphenazine hcl injection - Tier 1
fluphenazine hcl oral concentrate - Tier 1
fluphenazine hcl oral elixir - Tier 1
fluphenazine hcl oral tablet - Tier 1; QL
haloperidol decanoate intramuscular (generic for HALDOL
DECANOATE) - Tier 1; QL
haloperidol oral - Tier 1; QL
loxapine succinate - Tier 1; QL
pimozide - Tier 1; CH; QL; AL
thioridazine hcl oral - Tier 1; QL
thiothixene - Tier 1; QL
trifluoperazine hcl - Tier 1; QL
2nd Generation/Atypical
ABILIFY ASIMTUFII - Tier 2; PA; QL; AL
ABILIFY MAINTENA - Tier 2; DX2RX; ST; QL; AL
aripiprazole oral tablet (generic for ABILIFY) - Tier 1; QL; AL
ARISTADA - Tier 2; DX2RX; ST; QL; AL
INVEGA HAFYERA - Tier 2; QL; AL
INVEGA SUSTENNA - Tier 2; DX2RX; ST; QL; AL
INVEGA TRINZA - Tier 2; DX2RX; QL; AL
lurasidone hcl (generic for LATUDA) - Tier 1; QL; AL
olanzapine oral tablet (generic for ZYPREXA) - Tier 1; QL; AL
PERSERIS - Tier 2; DX2RX; ST; QL; AL
quetiapine fumarate (generic for SEROQUEL) - Tier 1; QL; AL
quetiapine fumarate er (generic for SEROQUEL XR) - Tier 1; QL; AL
risperidone microspheres er (generic for RISPERDAL CONSTA) - Tier
1; DX2RX; ST; QL; AL
ARISTADA INITIO - Tier 2; PA; QL; AL
LYBALVI - Tier 2; PA; CH; QL; AL
REXULTI - Tier 2; PA; QL; AL
RISPERDAL CONSTA (brand for risperidone microspheres er) - Tier 2;
DX2RX; ST; QL; AL
VRAYLAR - Tier 2; PA; QL; AL
VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MG - Tier 2; PA;
QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
41
Preferred Agents Non-Preferred Agents
risperidone oral solution (generic for RISPERDAL) - Tier 1; Members
>= 8 years of age will require PA; QL; AL
risperidone oral tablet (generic for RISPERDAL) - Tier 1; QL; AL
RYKINDO - Tier 2; PA; QL; AL
UZEDY SUBCUTANEOUS SUSPENSION PREFILLED SYRINGE 100
MG/0.28ML - Tier 2; PA; QL; AL
ziprasidone hcl (generic for GEODON) - Tier 1; QL; AL
Treatment-Resistant
clozapine oral tablet (generic for CLOZARIL) - Tier 1; QL; AL
Antispasticity Agents
baclofen oral tablet 10 mg, 20 mg, 5 mg - Tier 1; QL
dantrolene sodium oral (generic for DANTRIUM) - Tier 1; QL
tizanidine hcl oral tablet (generic for ZANAFLEX) - Tier 1; QL
Antivirals
Anti-cytomegalovirus (CMV) Agents
valganciclovir hcl oral tablet (generic for VALCYTE) - Tier 1; QL
Anti-hepatitis B (HBV) Agents
BARACLUDE ORAL SOLUTION - Tier 2; QL
entecavir (generic for BARACLUDE) - Tier 1; QL
lamivudine oral tablet 100 mg - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
42
Preferred Agents Non-Preferred Agents
Anti-hepatitis C (HCV) Agents
EPCLUSA (brand for sofosbuvir-velpatasvir) - Tier 2; PA; SP; QL
HARVONI (brand for ledipasvir-sofosbuvir) - Tier 2; PA; SP; QL
LEDIPASVIR-SOFOSBUVIR (brand for ledipasvir-sofosbuvir) - Tier 2;
PA; SP; QL
MAVYRET ORAL PACKET - Tier 2; PA; SP; QL
MAVYRET ORAL TABLET - Tier 2; PA; Preferred for Genotypes 1, 2,
3, 4, 5,& 6; SP; QL
ribavirin oral - Tier 1; QL
SOFOSBUVIR-VELPATASVIR (brand for sofosbuvir-velpatasvir) - Tier
2; PA; SP; QL
VOSEVI - Tier 2; PA; SP; QL
ZEPATIER - Tier 2; PA; SP; QL
SOVALDI ORAL TABLET - Tier 2; PA; SP; QL
Antiherpetic Agents
acyclovir external ointment (generic for ZOVIRAX) - Tier 1; QL
acyclovir oral - Tier 1; QL
valacyclovir hcl oral (generic for VALTREX) - Tier 1; QL
Anti-HIV Agents, Integrase Inhibitors (INSTI)
BIKTARVY ORAL TABLET 30-120-15 MG - Tier 2; PA
BIKTARVY ORAL TABLET 50-200-25 MG - Tier 2; PA; QL
DOVATO - Tier 2; DX2RX; QL
GENVOYA - Tier 2; PA; QL
ISENTRESS HD - Tier 2; DX2RX; QL
ISENTRESS ORAL PACKET - Tier 2; DX2RX; Members >= 2 years of
age will require PA; QL; AL
ISENTRESS ORAL TABLET - Tier 2; DX2RX; QL
ISENTRESS ORAL TABLET CHEWABLE - Tier 2; DX2RX; QL
JULUCA - Tier 2; DX2RX; QL
STRIBILD - Tier 2; PA; QL
TIVICAY - Tier 2; DX2RX; QL
TIVICAY PD - Tier 2; DX2RX; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
43
Preferred Agents Non-Preferred Agents
Anti-HIV Agents, Non-nucleoside Reverse Transcriptase
Inhibitors (NNRTI)
COMPLERA - Tier 2; PA; QL
DELSTRIGO - Tier 2; DX2RX; QL
EDURANT - Tier 2; DX2RX; QL
efavirenz (generic for SUSTIVA) - Tier 1; DX2RX; QL
efavirenz-emtricitab-tenofo df (generic for ATRIPLA) - Tier 1; DX2RX;
QL
efavirenz-lamivudine-tenofovir (generic for SYMFI) - Tier 1; DX2RX;
QL
etravirine (generic for INTELENCE) - Tier 1; DX2RX; QL
INTELENCE ORAL TABLET 25 MG - Tier 2; DX2RX; QL
nevirapine - Tier 1; DX2RX; QL
nevirapine er - Tier 1; DX2RX; QL
SYMFI (brand for efavirenz-lamivudine-tenofovir) - Tier 2; DX2RX; QL
SYMFI LO (brand for efavirenz-lamivudine-tenofovir) - Tier 2; DX2RX; QL
Anti-HIV Agents, Nucleoside and Nucleotide Reverse
Transcriptase Inhibitors (NRTI)
abacavir sulfate (generic for ZIAGEN) - Tier 1; DX2RX; QL
abacavir sulfate-lamivudine (generic for EPZICOM) - Tier 1; DX2RX;
QL
emtricitabine (generic for EMTRIVA) - Tier 1; DX2RX; QL
emtricitabine-tenofovir df (generic for TRUVADA) - Tier 1; PD; QL
EMTRIVA ORAL SOLUTION - Tier 2; DX2RX; QL
lamivudine oral solution (generic for EPIVIR) - Tier 1; DX2RX; QL
lamivudine oral tablet 150 mg, 300 mg (generic for EPIVIR) - Tier 1;
DX2RX; QL
lamivudine-zidovudine - Tier 1; DX2RX; QL
ODEFSEY - Tier 2; DX2RX; QL
tenofovir disoproxil fumarate (generic for VIREAD) - Tier 1; PD; QL
TRIUMEQ - Tier 2; DX2RX; QL
TRIUMEQ PD - Tier 2; QL
CIMDUO - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
44
Preferred Agents Non-Preferred Agents
VIREAD ORAL POWDER - Tier 2; DX2RX; QL
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG - Tier 2; DX2RX;
QL
zidovudine (generic for RETROVIR) - Tier 1; DX2RX; QL
Anti-HIV Agents, Other
FUZEON - Tier 2; DX2RX; QL
maraviroc (generic for SELZENTRY) - Tier 1; DX2RX; QL
SELZENTRY ORAL SOLUTION - Tier 2; DX2RX; QL
TYBOST - Tier 2; DX2RX; QL
Anti-HIV Agents, Protease Inhibitors (PI)
APTIVUS - Tier 2; DX2RX; QL
atazanavir sulfate (generic for REYATAZ) - Tier 1; DX2RX; QL
EVOTAZ - Tier 2; DX2RX; QL
fosamprenavir calcium (generic for LEXIVA) - Tier 1; DX2RX; QL
lopinavir-ritonavir (generic for KALETRA) - Tier 1; DX2RX; QL
NORVIR ORAL PACKET - Tier 2; DX2RX; QL
PREZCOBIX - Tier 2; DX2RX; QL
REYATAZ ORAL PACKET - Tier 2; DX2RX; Members >= 8 years of
age will require PA; QL; AL
ritonavir (generic for NORVIR) - Tier 1; DX2RX; QL
VIRACEPT - Tier 2; DX2RX; QL
SYMTUZA - Tier 2; PA; QL
Anti-influenza Agents
oseltamivir phosphate oral capsule (generic for TAMIFLU) - Tier 1; QL
oseltamivir phosphate oral suspension reconstituted (generic for
TAMIFLU) - Tier 1; QL; AL
RELENZA DISKHALER - Tier 2; QL
rimantadine hcl - Tier 1; QL
XOFLUZA (40 MG DOSE) - Tier 2; PA; QL
XOFLUZA (80 MG DOSE) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
45
Preferred Agents Non-Preferred Agents
Antivirals - Drugs to Treat Viral Infections
Antivirals
LAGEVRIO - Tier 2; QL
PAXLOVID (150/100) - Tier 2; QL
PAXLOVID (300/100) - Tier 2; QL
Anxiolytics
Anxiolytics, Other
buspirone hcl oral - Tier 1; QL
hydroxyzine hcl oral - Tier 1; QL
hydroxyzine pamoate oral (generic for VISTARIL) - Tier 1; QL
Benzodiazepines
alprazolam oral tablet (generic for XANAX) - Tier 1; QL
chlordiazepoxide hcl - Tier 1; QL
clonazepam oral tablet (generic for KLONOPIN) - Tier 1; QL
clorazepate dipotassium - Tier 1; QL
diazepam oral solution - Tier 1; QL
diazepam oral tablet (generic for VALIUM) - Tier 1; QL
lorazepam oral tablet (generic for ATIVAN) - Tier 1; QL
oxazepam - Tier 1; QL
LOREEV XR - Tier 2; PA; QL
Attention Deficit Hyperactivity Disorder Agents, Non-
amphetamines - ADHD Drugs
Central Nervous System Agents - Drugs to Treat Nerve
Conditions
QELBREE - Tier 2; PA; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
46
Preferred Agents Non-Preferred Agents
Bipolar Agents
Mood Stabilizers
divalproex sodium er oral tablet extended release 24 hour 500 mg
(generic for DEPAKOTE ER) - Tier 1; QL
divalproex sodium oral capsule delayed release sprinkle (generic for
DEPAKOTE SPRINKLES) - Tier 1; Members >= 8 years of age will
require PA; QL; AL
divalproex sodium oral tablet delayed release (generic for
DEPAKOTE) - Tier 1; Minimum age of 2 years; QL
lithium - Tier 1; QL
lithium carbonate er (generic for LITHOBID) - Tier 1; QL
lithium carbonate oral - Tier 1; QL
Blood Glucose Regulators
Antidiabetic Agents
acarbose oral - Tier 1; QL
ALOGLIPTIN BENZOATE - Tier 2; ST; QL
ALOGLIPTIN-METFORMIN HCL - Tier 2; ST; QL
ALOGLIPTIN-PIOGLITAZONE - Tier 2; ST; QL
DAPAGLIFLOZIN PROPANEDIOL (brand for dapagliflozin
propanediol) - Tier 2; PA; QL
FARXIGA (brand for dapagliflozin propanediol) - Tier 2; PA; QL
glimepiride - Tier 1; QL
glipizide er (generic for GLUCOTROL XL) - Tier 1; QL
glipizide oral tablet 10 mg, 5 mg - Tier 1; QL
glipizide xl (generic for GLUCOTROL XL) - Tier 1; QL
glyburide micronized - Tier 1; QL
glyburide oral - Tier 1; QL
glyburide-metformin - Tier 1; QL
BYDUREON BCISE AUTOINJECTOR - Tier 2; PA; QL
BYETTA 10 MCG PEN - Tier 2; PA; QL
BYETTA 5 MCG PEN - Tier 2; PA; QL
GLYXAMBI - Tier 2; PA
JANUMET - Tier 2; PA; QL
JANUMET XR - Tier 2; PA; QL
JANUVIA - Tier 2; PA; QL
JENTADUETO - Tier 2; PA; QL
JENTADUETO XR - Tier 2; PA; QL
QTERN - Tier 2; PA; QL
SEGLUROMET - Tier 2; PA; QL
STEGLATRO - Tier 2; PA; QL
STEGLUJAN - Tier 2; PA; QL
SYMLINPEN 120 - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
47
Preferred Agents Non-Preferred Agents
INVOKAMET - Tier 2; ST; QL
INVOKAMET XR - Tier 2; ST; QL
JARDIANCE - Tier 2; ST; QL
metformin hcl er (osm) - Tier 1; PA; QL
metformin hcl er oral tablet extended release 24 hour 500 mg - Tier 1;
QL
metformin hcl er oral tablet extended release 24 hour 750 mg - Tier 1
metformin hcl oral tablet 1000 mg, 500 mg, 850 mg - Tier 1; QL
nateglinide - Tier 1; QL
OZEMPIC - Tier 2; PA; QL
OZEMPIC (2 MG/DOSE) - Tier 2; PA; QL
pioglitazone hcl (generic for ACTOS) - Tier 1; QL
repaglinide - Tier 1; QL
RYBELSUS - Tier 2; PA; QL
SYMLINPEN 60 - Tier 2; PA; QL
TRADJENTA - Tier 2; PA; QL
TRIJARDY XR - Tier 2; PA; QL
VICTOZA - Tier 2; PA; QL
XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-1000
MG (brand for dapagliflozin pro-metformin er) - Tier 2; PA
XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 10-500
MG - Tier 2; PA
XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 2.5-1000
MG, 5-500 MG - Tier 2; PA; QL
XIGDUO XR ORAL TABLET EXTENDED RELEASE 24 HOUR 5-1000
MG (brand for dapagliflozin pro-metformin er) - Tier 2; PA; QL
XULTOPHY - Tier 2; PA; QL
saxagliptin hcl (generic for ONGLYZA) - Tier 1; QL
SOLIQUA - Tier 2; ST; QL
SYNJARDY - Tier 2; ST; QL
SYNJARDY XR - Tier 2; ST; QL
TRULICITY - Tier 2; ST; QL
Glycemic Agents
BAQSIMI ONE PACK - Tier 2; QL
BAQSIMI TWO PACK - Tier 2; QL
GLUCAGEN HYPOKIT - Tier 2; QL
glucagon emergency injection kit - Tier 1; QL
GLUCAGON EMERGENCY INJECTION SOLUTION
RECONSTITUTED - Tier 2; QL
GVOKE HYPOPEN 1-PACK - Tier 2; QL
GVOKE HYPOPEN 2-PACK - Tier 2; QL
GVOKE KIT - Tier 2; QL
GVOKE PFS - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
48
Preferred Agents Non-Preferred Agents
Insulins
ADMELOG (brand for insulin lispro) - Tier 2; QL
ADMELOG SOLOSTAR (brand for insulin lispro (1 unit dial)) - Tier 2;
QL
BASAGLAR KWIKPEN (brand for insulin glargine solostar) - Tier 2; QL
HUMALOG INJECTION (brand for insulin lispro) - Tier 2; QL
HUMALOG JUNIOR KWIKPEN (brand for insulin lispro junior kwikpen)
- Tier 2; QL
HUMALOG KWIKPEN (brand for insulin lispro (1 unit dial)) - Tier 2; QL
HUMALOG MIX 75/25 - Tier 2; QL
HUMALOG MIX 75/25 KWIKPEN (brand for insulin lispro prot & lispro)
- Tier 2; QL
HUMULIN 70/30 VIAL - Tier 2; OTC; QL
HUMULIN N VIAL - Tier 2; OTC; QL
HUMULIN R VIAL - Tier 2; OTC; QL
APIDRA SOLOSTAR - Tier 2; PA; QL
APIDRA VIAL - Tier 2; PA; QL
FIASP - Tier 2; PA; QL
FIASP FLEXTOUCH - Tier 2; PA; QL
FIASP PENFILL - Tier 2; PA; QL
HUMALOG MIX 50/50 KWIKPEN - Tier 2; PA; QL
HUMALOG SUBCUTANEOUS - Tier 2; PA; QL
HUMULIN 70/30 KWIKPEN - Tier 2; PA; OTC; QL
HUMULIN N KWIKPEN - Tier 2; PA; OTC; QL
HUMULIN R U-500 KWIKPEN - Tier 2; PA; QL
HUMULIN R U-500 VIAL (CONCENTRATED) - Tier 2; PA; QL
INSULIN GLARGINE-YFGN (brand for insulin glargine-yfgn) - Tier 2; PA;
QL
LEVEMIR FLEXPEN - Tier 2; PA; QL
INSULIN ASPART PROT & ASPART (brand for insulin aspart prot &
aspart) - Tier 2; QL
INSULIN LISPRO (brand for insulin lispro) - Tier 2; QL
INSULIN LISPRO (1 UNIT DIAL) (brand for insulin lispro (1 unit dial)) -
Tier 2; QL
INSULIN LISPRO JUNIOR KWIKPEN (brand for insulin lispro junior
kwikpen) - Tier 2; QL
INSULIN LISPRO PROT & LISPRO (brand for insulin lispro prot &
lispro) - Tier 2; QL
LANTUS SOLOSTAR (brand for insulin glargine solostar) - Tier 2; QL
LANTUS U-100 VIAL (brand for insulin glargine) - Tier 2; QL
NOVOLIN 70/30 RELION - Tier 2; OTC; QL
NOVOLIN 70/30 VIAL - Tier 2; OTC; QL
NOVOLIN N RELION - Tier 2; OTC; QL
LEVEMIR U-100 VIAL - Tier 2; PA; QL
LYUMJEV - Tier 2; PA; QL
LYUMJEV KWIKPEN - Tier 2; PA; QL
NOVOLIN 70/30 FLEXPEN - Tier 2; PA; OTC; QL
NOVOLIN N FLEXPEN - Tier 2; PA; OTC; QL
NOVOLIN R FLEXPEN - Tier 2; PA; OTC; QL
NOVOLOG FLEXPEN (brand for insulin aspart flexpen) - Tier 2; PA; QL
NOVOLOG MIX 70/30 FLEXPEN (brand for insulin asp prot & asp
flexpen) - Tier 2; PA; QL
NOVOLOG PENFILL (brand for insulin aspart penfill) - Tier 2; PA; QL
SEMGLEE (YFGN) (brand for insulin glargine-yfgn) - Tier 2; PA; QL
TOUJEO MAX SOLOSTAR (brand for insulin glargine max solostar) - Tier
2; PA; QL
TOUJEO SOLOSTAR (brand for insulin glargine solostar) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
49
Preferred Agents Non-Preferred Agents
NOVOLIN N VIAL - Tier 2; OTC; QL
NOVOLIN R RELION - Tier 2; OTC; QL
NOVOLIN R VIAL - Tier 2; OTC; QL
NOVOLOG FLEXPEN RELION (brand for insulin aspart flexpen) - Tier
2; QL
NOVOLOG MIX 70/30 VIAL (brand for insulin aspart prot & aspart) -
Tier 2; QL
NOVOLOG RELION (brand for insulin aspart) - Tier 2; QL
NOVOLOG U-100 VIAL (brand for insulin aspart) - Tier 2; QL
TRESIBA (brand for insulin degludec) - Tier 2; PA; QL
TRESIBA FLEXTOUCH (brand for insulin degludec flextouch) - Tier 2;
PA; QL
Blood Glucose Regulators - Drugs to Regulate Blood Sugar
Glycemic Agents - Diabetic Drugs
GLUCO TO GO (brand for cvs glucose) - Tier 2; OTC; QL
glucose oral tablet chewable 4 gm (generic for GLUCO TO GO) - Tier
1; OTC; QL
soft glucose (generic for GLUCO TO GO) - Tier 1; OTC; QL
TRUEPLUS GLUCOSE ON THE GO (brand for cvs glucose) - Tier 2;
OTC; QL
TRUEPLUS GLUCOSE ORAL TABLET CHEWABLE (brand for cvs
glucose) - Tier 2; OTC; QL
Insulins - Diabetic Drugs
CAREPOINT POLY HUB NEEDLE 18G X 1" (brand for carepoint poly
hub needle) - Tier 2; QL; DME
MONOJECT HYPODERMIC NEEDLE 18G X 1" (brand for carepoint
poly hub needle) - Tier 2; QL; DME
NOKOR VENTED NEEDLE (brand for carepoint poly hub needle) -
Tier 2; OTC; QL; DME
REZVOGLAR KWIKPEN - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
50
Preferred Agents Non-Preferred Agents
Blood Products and Modifiers
Anticoagulants
ELIQUIS - Tier 2; QL
ELIQUIS DVT/PE STARTER PACK - Tier 2; QL
enoxaparin sodium (generic for LOVENOX) - Tier 1; QL
heparin sodium (porcine) - Tier 1
heparin sodium (porcine) pf - Tier 1
jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5
mg (generic for JANTOVEN) - Tier 1; QL
jantoven oral tablet 6 mg (generic for JANTOVEN) - Tier 1
SAVAYSA - Tier 2; QL
warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5
mg, 7.5 mg (generic for JANTOVEN) - Tier 1; QL
warfarin sodium oral tablet 6 mg (generic for JANTOVEN) - Tier 1
PRADAXA ORAL CAPSULE (brand for dabigatran etexilate mesylate) -
Tier 2; PA; QL
XARELTO - Tier 2; PA; QL
XARELTO STARTER PACK - Tier 2; PA; QL
Blood Products and Modifiers, Other
anagrelide hcl (generic for AGRYLIN) - Tier 1
ARANESP (ALBUMIN FREE) INJECTION SOLUTION - Tier 2; PA; SP
ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED
SYRINGE 10 MCG/0.4ML - Tier 2; PA; SP; QL
ARANESP (ALBUMIN FREE) INJECTION SOLUTION PREFILLED
SYRINGE 100 MCG/0.5ML, 150 MCG/0.3ML, 200 MCG/0.4ML, 25
MCG/0.42ML, 300 MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60
MCG/0.3ML - Tier 2; PA; SP
DROXIA ORAL CAPSULE 200 MG, 300 MG - Tier 2
DROXIA ORAL CAPSULE 400 MG - Tier 2; QL
EPOGEN - Tier 2; PA; SP
LEUKINE - Tier 2; PA; SP
MULPLETA - Tier 2; PA; SP; QL
NEULASTA - Tier 2; PA; SP
FULPHILA - Tier 2; PA; SP
NEUPOGEN - Tier 2; PA; SP
NIVESTYM - Tier 2; PA; SP
NYVEPRIA - Tier 2; PA; SP
RELEUKO - Tier 2; PA; SP
ZIEXTENZO - Tier 2; PA; SP
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
51
Preferred Agents Non-Preferred Agents
NEULASTA ONPRO - Tier 2; PA; SP
plerixafor (generic for MOZOBIL) - Tier 1; PA; SP; QL
PROCRIT - Tier 2; PA; SP
PROMACTA - Tier 2; PA; SP; QL
RETACRIT - Tier 2; PA; SP
UDENYCA - Tier 2; PA; SP
UDENYCA ONBODY - Tier 2; PA; SP
ZARXIO - Tier 2; PA; SP
Hemostasis Agents
aminocaproic acid oral - Tier 1; QL
tranexamic acid oral - Tier 1; DX2RX; QL
Platelet Modifying Agents
BRILINTA - Tier 2; DX2RX; QL
CABLIVI - Tier 2; PA; SP; QL
cilostazol - Tier 1; QL
clopidogrel bisulfate oral (generic for PLAVIX) - Tier 1; QL
dipyridamole oral - Tier 1; QL
prasugrel hcl (generic for EFFIENT) - Tier 1; DX2RX; QL
DOPTELET - Tier 2; PA; SP; QL
TAVALISSE - Tier 2; PA; SP; QL
Blood Products/Modifiers/Volume Expanders - Drugs to Treat
Blood Disorders
Hemostasis Agents - Drugs to Stop Bleeding
HEMLIBRA - Tier 2; PA; SP; QL
Cardiovascular Agents
Alpha-adrenergic Agonists
clonidine hcl oral - Tier 1; QL
guanfacine hcl - Tier 1; QL
METHYLDOPA - Tier 2; QL
midodrine hcl - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
52
Preferred Agents Non-Preferred Agents
Alpha-adrenergic Blocking Agents
doxazosin mesylate oral (generic for CARDURA) - Tier 1; QL
prazosin hcl oral (generic for MINIPRESS) - Tier 1; QL
Angiotensin II Receptor Antagonists
irbesartan (generic for AVAPRO) - Tier 1; QL
losartan potassium oral (generic for COZAAR) - Tier 1; QL
olmesartan medoxomil oral (generic for BENICAR) - Tier 1; QL
telmisartan (generic for MICARDIS) - Tier 1; QL
valsartan oral tablet (generic for DIOVAN) - Tier 1; QL
EDARBI - Tier 2; PA; QL
Angiotensin-converting Enzyme (ACE) Inhibitors
benazepril hcl oral (generic for LOTENSIN) - Tier 1; QL
captopril oral - Tier 1; QL
enalapril maleate oral solution (generic for EPANED) - Tier 1;
Members >= 8 years of age will require PA; QL; AL
enalapril maleate oral tablet (generic for VASOTEC) - Tier 1; QL
fosinopril sodium - Tier 1; QL
lisinopril oral (generic for ZESTRIL) - Tier 1; QL
quinapril hcl (generic for ACCUPRIL) - Tier 1; QL
ramipril (generic for ALTACE) - Tier 1; QL
trandolapril - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
53
Preferred Agents Non-Preferred Agents
Antiarrhythmics
amiodarone hcl oral tablet 200 mg, 400 mg (generic for PACERONE) -
Tier 1; QL
disopyramide phosphate (generic for NORPACE) - Tier 1; QL
dofetilide (generic for TIKOSYN) - Tier 1; QL
flecainide acetate - Tier 1; QL
mexiletine hcl oral - Tier 1; QL
NORPACE CR - Tier 2
propafenone hcl - Tier 1; QL
quinidine gluconate er - Tier 1; QL
quinidine sulfate - Tier 1; QL
sotalol hcl (af) (generic for BETAPACE AF) - Tier 1; QL
sotalol hcl oral (generic for BETAPACE) - Tier 1; QL
MULTAQ - Tier 2; PA; QL
Beta-adrenergic Blocking Agents
acebutolol hcl oral - Tier 1; QL
atenolol oral (generic for TENORMIN) - Tier 1; QL
betaxolol hcl oral - Tier 1; QL
bisoprolol fumarate oral - Tier 1; QL
carvedilol (generic for COREG) - Tier 1; QL
labetalol hcl oral - Tier 1; QL
metoprolol succinate er (generic for TOPROL XL) - Tier 1; QL
metoprolol tartrate oral tablet 100 mg, 50 mg (generic for
LOPRESSOR) - Tier 1; QL
metoprolol tartrate oral tablet 25 mg - Tier 1; QL
metoprolol tartrate oral tablet 37.5 mg, 75 mg - Tier 1
nadolol oral (generic for CORGARD) - Tier 1; QL
propranolol hcl er (generic for INDERAL LA) - Tier 1; QL
propranolol hcl oral solution 20 mg/5ml - Tier 1; QL
HEMANGEOL - Tier 2; PA; QL
propranolol hcl oral solution 40 mg/5ml - Tier 1
propranolol hcl oral tablet - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
54
Preferred Agents Non-Preferred Agents
Calcium Channel Blocking Agents, Dihydropyridines
amlodipine besylate oral (generic for NORVASC) - Tier 1; QL
felodipine er - Tier 1; QL
nifedipine er - Tier 1; QL
nifedipine er osmotic release (generic for PROCARDIA XL) - Tier 1;
QL
nifedipine oral - Tier 1; QL
nimodipine oral - Tier 1; QL
NYMALIZE - Tier 2; QL
NORLIQVA - Tier 2; PA
Calcium Channel Blocking Agents, Nondihydropyridines
cartia xt (generic for CARTIA XT) - Tier 1; QL
diltiazem hcl er beads (generic for TAZTIA XT) - Tier 1; QL
diltiazem hcl er coated beads (generic for CARDIZEM CD) - Tier 1; QL
diltiazem hcl er oral capsule extended release 12 hour - Tier 1; QL
diltiazem hcl er oral capsule extended release 24 hour - Tier 1; QL
diltiazem hcl oral (generic for CARDIZEM) - Tier 1; QL
dilt-xr - Tier 1; QL
taztia xt (generic for TAZTIA XT) - Tier 1; QL
tiadylt er (generic for TAZTIA XT) - Tier 1; QL
verapamil hcl er oral capsule extended release 24 hour 120 mg, 180
mg, 240 mg, 360 mg (generic for VERELAN) - Tier 1; QL
verapamil hcl er oral tablet extended release - Tier 1; QL
verapamil hcl oral - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
55
Preferred Agents Non-Preferred Agents
Cardiovascular Agents, Other
acetazolamide er - Tier 1; QL
acetazolamide oral - Tier 1; QL
amiloride-hydrochlorothiazide - Tier 1; QL
amlodipine besylate-benazepril hcl (generic for LOTREL) - Tier 1; QL
amlodipine besylate-valsartan (generic for EXFORGE) - Tier 1
amlodipine-olmesartan (generic for AZOR) - Tier 1
atenolol-chlorthalidone (generic for TENORETIC 100) - Tier 1; QL
benazepril-hydrochlorothiazide (generic for LOTENSIN HCT) - Tier 1;
QL
bisoprolol-hydrochlorothiazide - Tier 1; QL
captopril-hydrochlorothiazide - Tier 1; QL
digoxin oral solution - Tier 1
digoxin oral tablet 125 mcg, 250 mcg (generic for DIGOX) - Tier 1; QL
enalapril-hydrochlorothiazide (generic for VASERETIC) - Tier 1; QL
CORLANOR - Tier 2; PA; QL
EDARBYCLOR - Tier 2; PA; QL
KERENDIA - Tier 2; PA; CH; QL
TEKTURNA (brand for aliskiren fumarate) - Tier 2; PA; QL
ENTRESTO - Tier 2; PA; QL
fosinopril sodium-hctz - Tier 1; QL
irbesartan-hydrochlorothiazide (generic for AVALIDE) - Tier 1; QL
lisinopril-hydrochlorothiazide (generic for ZESTORETIC) - Tier 1; QL
losartan potassium-hctz (generic for HYZAAR) - Tier 1; QL
olmesartan medoxomil-hctz (generic for BENICAR HCT) - Tier 1; QL
pentoxifylline er - Tier 1; QL
quinapril-hydrochlorothiazide (generic for ACCURETIC) - Tier 1; QL
ranolazine er (generic for RANEXA) - Tier 1; QL
spironolactone-hctz - Tier 1; QL
triamterene-hctz - Tier 1; QL
valsartan-hydrochlorothiazide (generic for DIOVAN HCT) - Tier 1; QL
Diuretics, Loop
bumetanide oral (generic for BUMEX) - Tier 1; QL
furosemide oral solution 10 mg/ml - Tier 1; QL
furosemide oral tablet (generic for LASIX) - Tier 1; QL
SOAANZ ORAL TABLET 20 MG (brand for torsemide) - Tier 2; QL
torsemide (generic for SOAANZ) - Tier 1; QL
FUROSCIX - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
56
Preferred Agents Non-Preferred Agents
Diuretics, Potassium-sparing
amiloride hcl oral - Tier 1; QL
spironolactone oral tablet (generic for ALDACTONE) - Tier 1; QL
Diuretics, Thiazide
chlorthalidone - Tier 1; QL
DIURIL - Tier 2; QL
hydrochlorothiazide oral capsule - Tier 1; QL
hydrochlorothiazide oral tablet 12.5 mg - Tier 1
hydrochlorothiazide oral tablet 25 mg, 50 mg - Tier 1; QL
indapamide - Tier 1; QL
metolazone - Tier 1; QL
Dyslipidemics, Fibric Acid Derivatives
fenofibrate micronized oral capsule 130 mg - Tier 1
fenofibrate micronized oral capsule 134 mg, 200 mg, 67 mg - Tier 1;
QL
fenofibrate oral capsule 134 mg, 200 mg, 67 mg - Tier 1; QL
fenofibrate oral tablet (generic for FENOGLIDE) - Tier 1; QL
gemfibrozil oral (generic for LOPID) - Tier 1; QL
Dyslipidemics, HMG CoA Reductase Inhibitors
atorvastatin calcium oral (generic for LIPITOR) - Tier 1; PD; QL
lovastatin oral - Tier 1; PD; QL; AL
pravastatin sodium - Tier 1; PD; QL
rosuvastatin calcium (generic for CRESTOR) - Tier 1; PD; QL
simvastatin oral (generic for ZOCOR) - Tier 1; PD; QL
ATORVALIQ - Tier 2; PA; QL
LIVALO (brand for pitavastatin calcium) - Tier 2; PA; PD; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
57
Preferred Agents Non-Preferred Agents
Dyslipidemics, Other
cholestyramine light oral powder (generic for PREVALITE) - Tier 1
cholestyramine oral powder (generic for QUESTRAN) - Tier 1; Only
the bulk products are covered (cans) Individual packets are not
covered; QL
ezetimibe (generic for ZETIA) - Tier 1; QL
niacin er (antihyperlipidemic) - Tier 1; QL
omega-3-acid ethyl esters (generic for LOVAZA) - Tier 1; PA; QL
prevalite oral powder (generic for PREVALITE) - Tier 1
REPATHA - Tier 2; PA; NDC starting w/72511 Preferred w/PA; SP; QL
NEXLETOL - Tier 2; PA; QL
NEXLIZET - Tier 2; PA; QL
PRALUENT - Tier 2; PA; NDC starting w/72733 Preferred w/PA; SP; QL
VASCEPA (brand for icosapent ethyl) - Tier 2; PA; QL
Vasodilators, Direct-acting Arterial
hydralazine hcl oral - Tier 1; QL
minoxidil oral - Tier 1; QL
Vasodilators, Direct-acting Arterial/Venous
isosorbide dinitrate (generic for ISORDIL TITRADOSE) - Tier 1; QL
isosorbide mononitrate - Tier 1; QL
isosorbide mononitrate er - Tier 1; QL
NITRO-BID - Tier 2; QL
nitroglycerin rectal (generic for RECTIV) - Tier 1; DX2RX; QL
nitroglycerin sublingual (generic for NITROSTAT) - Tier 1; QL
nitroglycerin translingual (generic for NITROLINGUAL) - Tier 1; QL
Cardiovascular Agents, Other - Miscellaneous Cardiac Drugs
Cardiovascular Agents - Drugs to Treat Heart and Circulation
Conditions
VERQUVO - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
58
Preferred Agents Non-Preferred Agents
Central Nervous System Agents
Attention Deficit Hyperactivity Disorder Agents, Non-
amphetamines
atomoxetine hcl (generic for STRATTERA) - Tier 1; DX2RX; Diagnosis
required for 18 years of age and older; QL; AL
dexmethylphenidate hcl (generic for FOCALIN) - Tier 1; DX2RX;
Diagnosis required for 18 years of age and older; QL; AL
dexmethylphenidate hcl er (generic for FOCALIN XR) - Tier 1; DX2RX;
Diagnosis required for 18 years of age and older; QL; AL
guanfacine hcl er (generic for INTUNIV) - Tier 1; DX2RX; Diagnosis
required for 18 years of age and older; QL; AL
methylphenidate hcl er - Tier 1; DX2RX; Diagnosis required for 18
years of age and older; QL; AL
methylphenidate hcl er (cd) (generic for METADATE CD) - Tier 1;
DX2RX; Diagnosis required for 18 years of age and older; QL; AL
JORNAY PM - Tier 2; PA; QL; AL
methylphenidate hcl er (la) oral capsule extended release 24 hour 20
mg, 30 mg, 40 mg (generic for RITALIN LA) - Tier 1; DX2RX;
Diagnosis required for 18 years of age and older; QL; AL
methylphenidate hcl er (osm) oral tablet extended release 18 mg, 27
mg, 36 mg, 54 mg (generic for CONCERTA) - Tier 1; DX2RX;
Diagnosis required for 18 years of age and older; QL; AL
methylphenidate hcl oral tablet (generic for RITALIN) - Tier 1; DX2RX;
Diagnosis required for 18 years of age and older; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
59
Preferred Agents Non-Preferred Agents
Attention Deficit Hyperactivity Disorder Agents, Amphetamines
ADDERALL (brand for amphetamine-dextroamphetamine) - Tier 2;
DX2RX; Diagnosis required for 18 years of age and older; QL; AL
ADDERALL XR (brand for amphetamine-dextroamphet er) - Tier 2;
DX2RX; Diagnosis required for 18 years of age and older; QL; AL
amphetamine-dextroamphetamine (generic for ADDERALL) - Tier 1;
DX2RX; Diagnosis required for 18 years of age and older; QL; AL
amphetamine-dextroamphetamine er (generic for ADDERALL XR) -
Tier 1; DX2RX; Diagnosis required for 18 years of age and older; QL;
AL
dextroamphetamine sulfate er (generic for DEXEDRINE) - Tier 1;
DX2RX; Diagnosis required for 18 years of age and older; QL; AL
dextroamphetamine sulfate oral tablet 10 mg, 5 mg (generic for
ZENZEDI) - Tier 1; DX2RX; Diagnosis required for 18 years of age
and older; QL; AL
AZSTARYS - Tier 2; PA; QL; AL
lisdexamfetamine dimesylate oral capsule (generic for VYVANSE) -
Tier 1; DX2RX; ST; Diagnosis required for 18 years of age and older;
QL; AL
VYVANSE ORAL CAPSULE (brand for lisdexamfetamine dimesylate) -
Tier 2; DX2RX; ST; Diagnosis required for 18 years of age and older;
QL; AL
Central Nervous System, Other
AUSTEDO - Tier 2; PA; SP; CH; QL
caffeine citrate oral - Tier 1; QL; AL
INGREZZA ORAL CAPSULE - Tier 2; PA; SP; CH; QL
INGREZZA ORAL CAPSULE THERAPY PACK - Tier 2; PA; SP; CH;
QL
NUEDEXTA - Tier 2; DX2RX; CH; QL
riluzole (generic for RILUTEK) - Tier 1; QL
tetrabenazine (generic for XENAZINE) - Tier 1; DX2RX; SP; CH; QL
GRALISE ORAL TABLET 300 MG, 600 MG (brand for gabapentin (once-
daily)) - Tier 2; PA; CH; QL
HORIZANT - Tier 2; PA; CH; QL
RADICAVA ORS - Tier 2; PA; SP; QL
RADICAVA ORS STARTER KIT - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
60
Preferred Agents Non-Preferred Agents
Fibromyalgia Agents
duloxetine hcl oral capsule delayed release particles 20 mg, 30 mg, 60
mg (generic for CYMBALTA) - Tier 1; QL
pregabalin oral (generic for LYRICA) - Tier 1; QL
Multiple Sclerosis Agents
dalfampridine er (generic for AMPYRA) - Tier 1; DX2RX; SP; CH; QL
dimethyl fumarate oral (generic for TECFIDERA) - Tier 1; DX2RX; SP;
CH; QL
dimethyl fumarate starter pack (generic for TECFIDERA) - Tier 1;
DX2RX; SP; CH; QL
fingolimod hcl (generic for GILENYA) - Tier 1; DX2RX; SP; CH; QL
GILENYA ORAL CAPSULE 0.25 MG - Tier 2; DX2RX; SP; CH; QL
glatiramer acetate (generic for GLATOPA) - Tier 1; DX2RX; SP; QL
glatopa (generic for GLATOPA) - Tier 1; DX2RX; SP; QL
MAYZENT - Tier 2; PA; SP; CH; QL
MAYZENT STARTER PACK - Tier 2; PA; SP; CH; QL
PLEGRIDY STARTER PACK - Tier 2; DX2RX; SP; QL
PLEGRIDY SUBCUTANEOUS - Tier 2; DX2RX; SP; QL
teriflunomide (generic for AUBAGIO) - Tier 1; DX2RX; SP; CH; QL
AVONEX PEN - Tier 2; PA; SP; QL
AVONEX PREFILLED - Tier 2; PA; SP; QL
BAFIERTAM - Tier 2; PA; SP; CH; QL
BETASERON - Tier 2; PA; SP
COPAXONE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40
MG/ML (brand for glatiramer acetate) - Tier 2; DX2RX; SP; QL
KESIMPTA - Tier 2; PA; SP; QL
MAVENCLAD (10 TABS) - Tier 2; PA; SP; CH; QL
MAVENCLAD (4 TABS) - Tier 2; PA; SP; CH; QL
MAVENCLAD (5 TABS) - Tier 2; PA; SP; CH; QL
MAVENCLAD (6 TABS) - Tier 2; PA; SP; CH; QL
MAVENCLAD (7 TABS) - Tier 2; PA; SP; CH; QL
MAVENCLAD (8 TABS) - Tier 2; PA; SP; CH; QL
MAVENCLAD (9 TABS) - Tier 2; PA; SP; CH; QL
PLEGRIDY INTRAMUSCULAR - Tier 2; PA; SP; QL
REBIF - Tier 2; PA; SP; QL
REBIF REBIDOSE - Tier 2; PA; SP; QL
REBIF REBIDOSE TITRATION PACK - Tier 2; PA; SP; QL
REBIF TITRATION PACK - Tier 2; PA; SP; QL
VUMERITY - Tier 2; PA; SP; CH; QL
ZEPOSIA - Tier 2; PA; SP; CH; QL
ZEPOSIA 7-DAY STARTER PACK - Tier 2; PA; SP; CH; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
61
Preferred Agents Non-Preferred Agents
Cystic Fibrosis Agents - Drugs to treat Cystic Fibrosis
Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies,
Cough, Cold and Lung Conditions
BRONCHITOL - Tier 2; PA; QL
Dental and Oral Agents
chlorhexidine gluconate mouth/throat (generic for PERIOGARD) - Tier
1; QL
kourzeq (generic for KOURZEQ) - Tier 1; QL
oralone (generic for KOURZEQ) - Tier 1; QL
periogard (generic for PERIOGARD) - Tier 1; QL
pilocarpine hcl oral tablet 5 mg (generic for SALAGEN) - Tier 1; QL
pilocarpine hcl oral tablet 7.5 mg (generic for SALAGEN) - Tier 1
triamcinolone acetonide mouth/throat (generic for KOURZEQ) - Tier 1;
QL
Dermatological Agents
Acne and Rosacea Agents
acitretin - Tier 1; PA; QL
amnesteem (generic for AMNESTEEM) - Tier 1; PA; QL
azelaic acid external (generic for FINACEA) - Tier 1; QL
claravis (generic for AMNESTEEM) - Tier 1; PA; QL
DIFFERIN EXTERNAL GEL 0.1 % (brand for adapalene) - Tier 2;
OTC; QL
isotretinoin oral capsule 10 mg, 20 mg, 40 mg (generic for
AMNESTEEM) - Tier 1; PA; QL
isotretinoin oral capsule 30 mg (generic for CLARAVIS) - Tier 1; PA;
QL
tretinoin external cream (generic for RETIN-A) - Tier 1; ST; QL; AL
zenatane (generic for AMNESTEEM) - Tier 1; PA; QL
ABSORICA (brand for isotretinoin) - Tier 2; PA; QL
ABSORICA LD - Tier 2; PA; QL
EPIDUO FORTE (brand for adapalene-benzoyl peroxide) - Tier 2; PA; QL
FINACEA EXTERNAL FOAM - Tier 2; PA; QL
MIRVASO (brand for brimonidine tartrate) - Tier 2; PA; QL
ONEXTON (brand for clindamycin phos-benzoyl perox) - Tier 2; PA; QL
RETIN-A MICRO PUMP EXTERNAL GEL 0.06 % - Tier 2; PA; QL; AL
RETIN-A MICRO PUMP EXTERNAL GEL 0.08 % (brand for tretinoin
microsphere) - Tier 2; PA; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
62
Preferred Agents Non-Preferred Agents
Dermatitis and Pruitus Agents
ala-cort (generic for MEDI-FIRST HYDROCORTISONE) - Tier 1; QL
alclometasone dipropionate external ointment - Tier 1; QL
ammonium lactate external (generic for AL12) - Tier 1; QL
anti-itch aloe (generic for MEDI-FIRST HYDROCORTISONE) - Tier 1;
OTC; QL
anti-itch intensive heal (generic for MEDI-FIRST
HYDROCORTISONE) - Tier 1; OTC; QL
anti-itch max str external cream 1 % (generic for MEDI-FIRST
HYDROCORTISONE) - Tier 1; OTC; QL
anti-itch maximum strength external cream 1 % (generic for MEDI-
FIRST HYDROCORTISONE) - Tier 1; OTC; QL
betamethasone dipropionate aug (generic for DIPROLENE) - Tier 1;
QL
betamethasone dipropionate external lotion - Tier 1
BRYHALI - Tier 2; PA; QL
CLOBEX (brand for clobetasol propionate) - Tier 2; PA; QL
CLOBEX SPRAY (brand for clobetasol propionate) - Tier 2; PA; QL
betamethasone dipropionate external ointment - Tier 1; QL
betamethasone valerate external cream - Tier 1; QL
betamethasone valerate external lotion - Tier 1; QL
betamethasone valerate external ointment - Tier 1; QL
clobetasol propionate e - Tier 1; QL
clobetasol propionate external cream - Tier 1; QL
clobetasol propionate external ointment - Tier 1; QL
clobetasol propionate external solution - Tier 1; QL
cortisone maximum strength external cream (generic for MEDI-FIRST
HYDROCORTISONE) - Tier 1; OTC; QL
EUCRISA - Tier 2; ST; QL
fluocinolone acetonide body (generic for DERMA-SMOOTHE/FS
BODY) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
63
Preferred Agents Non-Preferred Agents
fluocinolone acetonide external cream 0.025 % (generic for
SYNALAR) - Tier 1; QL
fluocinolone acetonide external ointment (generic for SYNALAR) - Tier
1; QL
fluocinolone acetonide external solution - Tier 1; QL
fluocinolone acetonide scalp (generic for DERMA-SMOOTHE/FS
SCALP) - Tier 1; QL
fluocinonide emulsified base - Tier 1; QL
fluocinonide external cream (generic for VANOS) - Tier 1; QL
fluocinonide external solution - Tier 1; QL
fluticasone propionate external cream - Tier 1; QL
fluticasone propionate external ointment - Tier 1; QL
halobetasol propionate external cream - Tier 1; QL
hydrocortisone anti-itch (generic for MEDI-FIRST
HYDROCORTISONE) - Tier 1; OTC; QL
hydrocortisone butyrate external ointment - Tier 1; QL
hydrocortisone butyrate external solution - Tier 1; QL
hydrocortisone cream 1 % external (otc) (generic for MEDI-FIRST
HYDROCORTISONE) - Tier 1; OTC; QL
hydrocortisone cream 1 % external (rx) (generic for MEDI-FIRST
HYDROCORTISONE) - Tier 1; QL
hydrocortisone external cream 0.5 % - Tier 1; OTC; QL
hydrocortisone external cream 1 % (generic for MEDI-FIRST
HYDROCORTISONE) - Tier 1; OTC; QL
hydrocortisone external cream 2.5 % - Tier 1; QL
hydrocortisone external lotion 2.5 % - Tier 1; QL
hydrocortisone external ointment 0.5 % - Tier 1; OTC
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
64
Preferred Agents Non-Preferred Agents
hydrocortisone external ointment 1 % (generic for AQUAPHOR ITCH
RELIEF CHILDREN) - Tier 1; QL
hydrocortisone external ointment 2.5 % - Tier 1; QL
hydrocortisone max st external cream (generic for MEDI-FIRST
HYDROCORTISONE) - Tier 1; OTC; QL
hydrocortisone max st/12 moist (generic for MEDI-FIRST
HYDROCORTISONE) - Tier 1; OTC; QL
hydrocortisone plus external cream 1 % (generic for MEDI-FIRST
HYDROCORTISONE) - Tier 1; OTC; QL
hydrocortisone/aloe (generic for MEDI-FIRST HYDROCORTISONE) -
Tier 1; OTC; QL
hydrocortisone/aloe max str (generic for MEDI-FIRST
HYDROCORTISONE) - Tier 1; OTC; QL
instacort 5 - Tier 1; OTC; QL
LAC-HYDRIN FIVE - Tier 2; OTC; QL
medi-first hydrocortisone (generic for MEDI-FIRST
HYDROCORTISONE) - Tier 1; OTC; QL
mometasone furoate external - Tier 1; QL
pimecrolimus (generic for ELIDEL) - Tier 1; ST; Minimum age of 2
years; QL; AL
selenium sulfide external lotion - Tier 1; QL
tacrolimus external ointment 0.03 % - Tier 1; ST; Minimum age of 2
years; QL; AL
tacrolimus external ointment 0.1 % - Tier 1; ST; Minimum age of 16
years; QL; AL
triamcinolone acetonide external cream (generic for TRIDERM) - Tier
1; QL
triamcinolone acetonide external lotion 0.025 % - Tier 1
triamcinolone acetonide external lotion 0.1 % - Tier 1; QL
triamcinolone acetonide external ointment 0.025 %, 0.1 %, 0.5 % - Tier
1; QL
triderm (generic for TRIDERM) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
65
Preferred Agents Non-Preferred Agents
Dermatological Agents, Other
calcipotriene external cream - Tier 1; ST; QL
calcipotriene external ointment (generic for CALCITRENE) - Tier 1;
ST; QL
calcipotriene external solution - Tier 1; QL
calcitriol external (generic for VECTICAL) - Tier 1; ST; QL
clotrimazole-betamethasone - Tier 1; QL
fluorouracil external cream 5 % (generic for EFUDEX) - Tier 1; QL
fluorouracil external solution - Tier 1
imiquimod external cream 5 % - Tier 1; QL
methoxsalen rapid - Tier 1
podofilox external solution - Tier 1; QL
SANTYL - Tier 2; QL
silver sulfadiazine external (generic for SSD) - Tier 1; QL
ssd (generic for SSD) - Tier 1; QL
ENSTILAR - Tier 2; PA; QL
PROCTOFOAM HC - Tier 2; PA
TACLONEX (brand for calcipotriene-betameth diprop) - Tier 2; PA; QL
VECTICAL (brand for calcitriol) - Tier 2; PA; ST; QL
Pediculicides/Scabicides
lice killing (generic for NIX CREME RINSE) - Tier 1; OTC
lice treatment external liquid 1 % (generic for NIX CREME RINSE) -
Tier 1; OTC
malathion (generic for OVIDE) - Tier 1; QL
permethrin external - Tier 1; QL
spinosad (generic for NATROBA) - Tier 1; QL
SOOLANTRA (brand for ivermectin) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
66
Preferred Agents Non-Preferred Agents
Topical Anti-infectives
ciclodan (generic for CICLODAN) - Tier 1; QL
ciclopirox external solution (generic for CICLODAN) - Tier 1; QL
clindacin etz external swab (generic for CLINDACIN ETZ) - Tier 1; QL
clindacin-p (generic for CLINDACIN ETZ) - Tier 1; QL
clindamycin phosphate external gel (generic for CLINDAGEL) - Tier 1;
QL
clindamycin phosphate external lotion (generic for CLEOCIN-T) - Tier
1; QL
clindamycin phosphate external solution - Tier 1; QL
clindamycin phosphate external swab (generic for CLINDACIN ETZ) -
Tier 1; QL
clotrimazole external cream 1 % (generic for DESENEX) - Tier 1; QL
clotrimazole solution 1 % external (otc) - Tier 1; OTC; QL
clotrimazole solution 1 % external (rx) - Tier 1; QL
JUBLIA - Tier 2; PA; QL
XEPI - Tier 2; PA; QL
erythromycin external (generic for ERYGEL) - Tier 1; QL
gentamicin sulfate external - Tier 1; QL
ketoconazole external cream - Tier 1; QL
ketoconazole external shampoo - Tier 1; QL
klayesta (generic for KLAYESTA) - Tier 1; QL
mupirocin external - Tier 1; QL
nyamyc (generic for KLAYESTA) - Tier 1; QL
nystatin external (generic for KLAYESTA) - Tier 1; QL
nystop (generic for KLAYESTA) - Tier 1; QL
tgt clotrimazole external cream 1 % (generic for DESENEX) - Tier 1;
OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
67
Preferred Agents Non-Preferred Agents
Dermatological Agents - Drugs to Treat Skin Conditions
advanced healing external ointment (generic for HYDROLATUM) -
Tier 1; OTC
astringent (generic for DOMEBORO) - Tier 1; OTC
astringent solution (generic for DOMEBORO) - Tier 1; OTC
AVAR-E EMOLLIENT (brand for sss 10-5) - Tier 2
AVAR-E GREEN (brand for sss 10-5) - Tier 2
baby basics diaper rash (generic for BOUDREAUXS BUTT PASTE) -
Tier 1; OTC; QL
beauty 360 pure glycerin - Tier 1; OTC
beauty 360 soothing bath (generic for AVEENO BABY BATH
TREATMENT) - Tier 1; OTC
boro-packs (generic for DOMEBORO) - Tier 1; OTC
boudreauxs butt paste ointment 40 % external (generic for
BOUDREAUXS BUTT PASTE) - Tier 1; OTC; QL
BOUDREAUXS BUTT PASTE OINTMENT 40 % EXTERNAL (brand
for cvs diaper rash) - Tier 2; OTC; QL
bp 10-1 - Tier 1
diaper rash external ointment (generic for BOUDREAUXS BUTT
PASTE) - Tier 1; OTC; QL
DR SMITHS DIAPER - Tier 2; OTC; QL
glycerin external - Tier 1; OTC
glycerin external liquid 99.5 % - Tier 1; OTC
hydrolatum (generic for HYDROLATUM) - Tier 1; OTC
hydrophor (generic for HYDROLATUM) - Tier 1; OTC
ointment base (generic for HYDROLATUM) - Tier 1; OTC
renewal soothing bath (generic for AVEENO BABY BATH
TREATMENT) - Tier 1; OTC
sss 10-5 external cream (generic for AVAR-E EMOLLIENT) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
68
Preferred Agents Non-Preferred Agents
sulfacetamide sodium-sulfur external cream 10-5 % (generic for
AVAR-E EMOLLIENT) - Tier 1
sulfacetamide sodium-sulfur external liquid 9-4.5 % (generic for
SUMADAN WASH) - Tier 1; QL
sulfacetamide sod-sulfur wash external liquid 9-4.5 % (generic for
SUMADAN WASH) - Tier 1; QL
sulfamez wash - Tier 1
SUMADAN WASH (brand for sulfacetamide sod-sulfur wash) - Tier 2;
QL
zinc oxide external ointment 40 % (generic for BOUDREAUXS BUTT
PASTE) - Tier 1; OTC; QL
Dermatological Agents - Skin Agents
ABREVA (brand for docosanol) - Tier 2; OTC; QL
calamine external lotion , 8-8 % - Tier 1; OTC
calamine-zinc oxide external lotion - Tier 1; OTC
docosanol external (generic for ABREVA) - Tier 1; OTC; QL
ft docosanol (generic for ABREVA) - Tier 1; OTC; QL
gormel - Tier 1; OTC; QL
gormel 10 (generic for NUTRAPLUS) - Tier 1; OTC; QL
hemorrhoidal rectal suppository 0.25-3-85.5 % - Tier 1; OTC
NUTRAPLUS (brand for gormel 10) - Tier 2; OTC; QL
urea 20 intensive hydrating - Tier 1; OTC; QL
urea cream 20 % external (otc) - Tier 1; OTC; QL
urea cream 20 % external (rx) - Tier 1; QL
urea external cream 10 % (generic for NUTRAPLUS) - Tier 1; OTC;
QL
CIBINQO - Tier 2; PA; SP; QL
OPZELURA - Tier 2; PA; SP; QL
urea external lotion 10 % (generic for NUTRAPLUS) - Tier 1; OTC; QL
urea external lotion 40 % - Tier 1; QL
ureacin-10 (generic for NUTRAPLUS) - Tier 1; OTC; QL
ureacin-20 - Tier 1; OTC; QL
XERAC AC - Tier 2
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
69
Preferred Agents Non-Preferred Agents
Diabetes - Glucose Monitoring
ACCU-CHEK AVIVA DEVICE (brand for element compact control 2) -
Tier 2; OTC; QL; DME
ACCU-CHEK GUIDE CONTROL (brand for element compact control
2) - Tier 2; OTC; QL; DME
ACCU-CHEK SMARTVIEW CONTROL (brand for element compact
control 2) - Tier 2; OTC; QL; DME
ACCUTREND GLUCOSE CONTROL (brand for element compact
control 2) - Tier 2; OTC; QL; DME
BD ULTRA-FINE INSULIN SYRINGES - Tier 2; QL
BD ULTRA-FINE PEN NEEDLES (brand for 1st tier unifine pentips) -
Tier 2; QL
CARESENS CONTROL SOLUTION A/B (brand for element compact
control 2) - Tier 2; OTC; QL; DME
ACCU-CHEK AVIVA PLUS TEST STRIPS (brand for blood glucose test) -
Tier 2; PA; OTC; QL; DME
ACCU-CHEK FASTCLIX LANCET KIT (brand for select-lite
device/lancets) - Tier 2; PA; OTC; QL; DME
ACCU-CHEK GUIDE TEST STRIPS (brand for blood glucose monitor
system) - Tier 2; PA; OTC; QL; DME
ACCU-CHEK GUIDE KIT W/DEVICE (brand for blood glucose monitor
system) - Tier 2; PA; OTC; QL; DME
ACCU-CHEK SMARTVIEW (brand for blood glucose test) - Tier 2; PA;
OTC; QL; DME
ACCU-CHEK SOFTCLIX LANCET DEVICE KIT (brand for select-lite
device/lancets) - Tier 2; PA; OTC; QL; DME
BD ULTRA-FINE PEN NEEDLES (brand for 1st tier unifine pentips) - Tier
2; PA; OTC; QL; DME
CARETOUCH CONTROL SOL LEVEL 2 (brand for element compact
control 2) - Tier 2; OTC; QL; DME
CHEMSTRIP 10 MD - Tier 2; OTC; DME
CHEMSTRIP 10/SG - Tier 2; OTC; DME
CHEMSTRIP 2 GP - Tier 2; OTC; DME
CHEMSTRIP 5 OB - Tier 2; OTC; DME
CHEMSTRIP 7 - Tier 2; OTC; DME
CHEMSTRIP 9 - Tier 2; OTC; DME
CHEMSTRIP K (brand for ketone test) - Tier 2; OTC; QL; DME
CHEMSTRIP UGK - Tier 2; OTC; QL; DME
DEXCOM G6 RECEIVER - Tier 2; PA; QL; DME
DEXCOM G6 SENSOR (brand for guardian sensor 3) - Tier 2; PA; QL;
DME
DEXCOM G7 RECEIVER - Tier 2; PA; QL; DME
BLOOD GLUCOSE TEST STRIPS (brand for blood glucose test) - Tier 2;
PA; OTC; QL; DME
CONTOUR NEXT EZ KIT W/DEVICE (brand for blood glucose monitor
system) - Tier 2; PA; OTC; QL; DME
CONTOUR NEXT GEN MONITOR KIT (brand for blood glucose monitor
system) - Tier 2; PA; OTC; QL; DME
CONTOUR NEXT MONITOR KIT W/DEVICE (brand for blood glucose
monitor system) - Tier 2; PA; OTC; QL; DME
CONTOUR NEXT ONE KIT (brand for blood glucose monitoring 333) -
Tier 2; PA; OTC; QL; DME
CONTOUR NEXT GEN TEST STRIPS (brand for blood glucose test) -
Tier 2; PA; OTC; QL; DME
CONTOUR TEST STRIPS (brand for blood glucose test) - Tier 2; PA;
OTC; QL; DME
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
70
Preferred Agents Non-Preferred Agents
DEXCOM G7 SENSOR (brand for guardian sensor 3) - Tier 2; PA; QL;
DME
EASYMAX 15 LEVEL 2 CONTROL (brand for element compact
control 2) - Tier 2; OTC; QL; DME
EASYMAX 15 LEVEL 2-3 CONTROL (brand for element compact
control 2) - Tier 2; OTC; QL; DME
GLUCOSE CONTROL SOLUTIONS (brand for element compact
control 2) - Tier 2; OTC; QL; DME
FREESTYLE LIBRE 14 DAY READER - Tier 2; PA; QL; DME
FREESTYLE LIBRE 14 DAY SENSOR (brand for guardian sensor 3) -
Tier 2; PA; QL; DME
FREESTYLE LIBRE 2 READER - Tier 2; PA; QL; DME
FREESTYLE LIBRE 2 SENSOR (brand for guardian sensor 3) - Tier 2;
PA; QL; DME
FREESTYLE LIBRE 3 SENSOR (brand for guardian sensor 3) - Tier 2;
PA; QL; DME
FREESTYLE PRECISION NEO TEST (brand for blood glucose test) - Tier
2; PA; OTC; QL; DME
FREESTYLE TEST (brand for blood glucose test) - Tier 2; PA; OTC; QL;
DME
GUARDIAN SENSOR (3) (brand for guardian sensor 3) - Tier 2; PA; QL;
DME
GUARDIAN SENSOR 3 (brand for guardian sensor 3) - Tier 2; PA; QL;
DME
INSULIN PEN NEEDLES 32G X 4 MM , 32G X 6 MM (brand for 1st tier
unifine pentips) - Tier 2; PA; OTC; QL; DME
ONETOUCH ULTRA 2 KIT W/DEVICE (brand for blood glucose monitor
system) - Tier 2; PA; OTC; QL; DME
FREESTYLE LIBRE READER - Tier 2; PA; QL; DME
KETO-DIASTIX - Tier 2; OTC; QL; DME
KETONE CARE - Tier 2; OTC; QL; DME
KETONE TEST (brand for ketone test) - Tier 2; OTC; QL; DME
KETOSTIX (brand for ketone test) - Tier 2; OTC; QL; DME
LANCETS (brand for cvs lancets original) - Tier 2; OTC; QL; DME
MEDISENSE GLUCOSE KETONE CONTR (brand for element
compact control 2) - Tier 2; OTC; QL; DME
MEDISENSE HI/MID/LOW CONTROL (brand for element compact
control 2) - Tier 2; OTC; QL; DME
NEUTEK 2TEK CONTROL (brand for element compact control 2) -
Tier 2; OTC; QL; DME
ONETOUCH ULTRA 2 KIT W/DEVICE (brand for blood glucose
monitor system) - Tier 2; OTC; QL; DME
ONETOUCH ULTRA STRIP IN VITRO (brand for blood glucose test) -
Tier 2; PA; OTC; QL; DME
ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE (brand for blood
glucose monitor system) - Tier 2; PA; OTC; QL; DME
ONETOUCH VERIO REFLECT KIT W/DEVICE (brand for blood glucose
monitor system) - Tier 2; PA; OTC; QL; DME
ONETOUCH VERIO STRIP IN VITRO (brand for blood glucose test) -
Tier 2; PA; OTC; QL; DME
PRECISION XTRA BLOOD GLUCOSE (brand for blood glucose test) -
Tier 2; PA; OTC; QL; DME
RELION TRUE METRIX TEST STRIPS (brand for blood glucose test) -
Tier 2; PA; OTC; QL; DME
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
71
Preferred Agents Non-Preferred Agents
ONETOUCH ULTRA CONTROL (brand for element compact control
2) - Tier 2; OTC; QL; DME
ONETOUCH ULTRA IN VITRO LIQUID (brand for element compact
control 2) - Tier 2; OTC; QL; DME
ONETOUCH ULTRA STRIP IN VITRO (brand for blood glucose test) -
Tier 2; QL for non-insulin dependent members: allow twice daily
testing; OTC; QL; DME
ONETOUCH ULTRA TEST (brand for blood glucose test) - Tier 2; QL
for non-insulin dependent members: allow twice daily testing; OTC;
QL; DME
ONETOUCH VERIO FLEX SYSTEM KIT W/DEVICE (brand for blood
glucose monitor system) - Tier 2; OTC; QL; DME
ONETOUCH VERIO IN VITRO LIQUID (brand for element compact
control 2) - Tier 2; OTC; QL; DME
ONETOUCH VERIO REFLECT KIT W/DEVICE (brand for blood
glucose monitor system) - Tier 2; OTC; QL; DME
ONETOUCH VERIO STRIP IN VITRO (brand for blood glucose test) -
Tier 2; QL for non-insulin dependent members: allow twice daily
testing; OTC; QL; DME
PIP GLUCOSE CONTROL SOLUTION (brand for element compact
control 2) - Tier 2; OTC; QL; DME
PRECISION GLUCOSE KETONE CONTR (brand for element
compact control 2) - Tier 2; OTC; QL; DME
QUINTET CONTROL HIGH/NORMAL (brand for element compact
control 2) - Tier 2; OTC; QL; DME
TRUECONTROL GLUCOSE CONT LEV 0 (brand for element
compact control 2) - Tier 2; OTC; QL; DME
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
72
Preferred Agents Non-Preferred Agents
TRUECONTROL GLUCOSE CONT LEV 1 (brand for element
compact control 2) - Tier 2; OTC; QL; DME
VIVAGUARD INO CONTROL SOLUTION (brand for element compact
control 2) - Tier 2; OTC; QL; DME
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body
Fluid Deficiency Drugs
Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat
Vitamin, Mineral and Body Fluid Deficiencies
ACCRUFER - Tier 2; PA; PD; QL
Electrolytes/Minerals/Metals/Vitamins
Electrolyte/Mineral Replacement
carglumic acid (generic for CARBAGLU) - Tier 1; PA; SP; CH
DENTA 5000 PLUS (brand for sf 5000 plus) - Tier 2; QL
DENTAGEL (brand for sf) - Tier 2
easygel - Tier 1
fluoridex daily renewal - Tier 1
klor-con (generic for KLOR-CON) - Tier 1; QL
klor-con 10 (generic for KLOR-CON 10) - Tier 1; QL
klor-con m10 (generic for KLOR-CON M10) - Tier 1; QL
klor-con m20 (generic for KLOR-CON M20) - Tier 1; QL
potassium chloride crys er oral tablet extended release 10 meq
(generic for KLOR-CON M10) - Tier 1; QL
potassium chloride crys er oral tablet extended release 20 meq
(generic for KLOR-CON M20) - Tier 1; QL
ENDARI - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
73
Preferred Agents Non-Preferred Agents
potassium chloride er oral capsule extended release 10 meq - Tier 1;
QL
potassium chloride er oral tablet extended release 10 meq (generic for
KLOR-CON 10) - Tier 1; QL
potassium chloride er oral tablet extended release 20 meq (generic for
K-TAB) - Tier 1; QL
potassium chloride er oral tablet extended release 8 meq (generic for
KLOR-CON) - Tier 1; QL
potassium chloride oral (generic for KLOR-CON) - Tier 1; QL
potassium citrate er oral tablet extended release 10 meq (1080 mg)
(generic for UROCIT-K 10) - Tier 1; QL
potassium citrate er oral tablet extended release 15 meq (1620 mg)
(generic for UROCIT-K 15) - Tier 1
potassium citrate er oral tablet extended release 5 meq (540 mg)
(generic for UROCIT-K 5) - Tier 1
PREVIDENT (brand for sf) - Tier 2
PREVIDENT 5000 DRY MOUTH (brand for sf) - Tier 2
PREVIDENT 5000 PLUS (brand for sf 5000 plus) - Tier 2; QL
sf (generic for DENTAGEL) - Tier 1
sf 5000 plus (generic for DENTA 5000 PLUS) - Tier 1; QL
sodium fluoride 5000 plus (generic for DENTA 5000 PLUS) - Tier 1;
QL
sodium fluoride 5000 ppm dental cream (generic for DENTA 5000
PLUS) - Tier 1; QL
sodium fluoride dental cream (generic for DENTA 5000 PLUS) - Tier 1;
QL
sodium fluoride dental gel (generic for DENTAGEL) - Tier 1
sodium fluoride oral solution - Tier 1; PD; QL
sodium fluoride oral tablet chewable - Tier 1; PD; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
74
Preferred Agents Non-Preferred Agents
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body
Fluid Deficiency Drugs
BPROTECTED PEDIA IRON (brand for fe-vite iron) - Tier 2; OTC; PD;
QL
cal mag zinc +d3 (generic for ADVANCED CALCIUM/D/MAGNESIUM)
- Tier 1; OTC; QL
calcium 600/vit d/minerals oral tablet 600-200 mg-unit - Tier 1; OTC;
QL
calcium 600/vit d/minerals oral tablet chewable 600-400 mg-unit - Tier
1; OTC
calcium 600/vitamin d - Tier 1; OTC; QL
calcium 600/vitamin d-3 - Tier 1; OTC; QL
calcium 600+d oral tablet 600-10 mg-mcg - Tier 1; OTC; QL
calcium carb-cholecalciferol oral tablet 600-10 mg-mcg, 600-5 mg-mcg
- Tier 1; OTC; QL
calcium cit plus vit d-3 (generic for CALCITRATE) - Tier 1; OTC
calcium citrate + d3 maximum (generic for CALCITRATE) - Tier 1;
OTC
calcium citrate +d3 (generic for CALCITRATE) - Tier 1; OTC
calcium citrate plus vit d - Tier 1; OTC; QL
calcium citrate+d oral tablet 315-6.25 mg-mcg (generic for
CALCITRATE) - Tier 1; OTC
calcium citrate+d3 oral tablet (generic for ADVANCED
CALCIUM/D/MAGNESIUM) - Tier 1; OTC; QL
calcium citrate+d3 w/magne (generic for ADVANCED
CALCIUM/D/MAGNESIUM) - Tier 1; OTC; QL
calcium citrate-vit d - Tier 1; OTC; QL
calcium citrate-vitamin d oral tablet 315-5 mg-mcg - Tier 1; OTC; QL
calcium high potency/vitamin d - Tier 1; OTC; QL
calcium plus vitamin d - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
75
Preferred Agents Non-Preferred Agents
calcium plus vitamin d3 - Tier 1; OTC; QL
calcium/minerals/vitamin d - Tier 1; OTC
calcium-magnesium-zinc oral tablet 333-133-5 mg, 333.33-133.33-5
mg - Tier 1; OTC
electrolyte solution (generic for ENFAMIL ENFALYTE) - Tier 1; OTC;
QL
ENFAMIL ENFALYTE (brand for cvs electrolyte solution) - Tier 2;
OTC; QL
EZFE 200 - Tier 2; OTC; PD
ferate (generic for FERATE) - Tier 1; OTC; PD
FER-IN-SOL (brand for fe-vite iron) - Tier 2; OTC; PD; QL
ferosul (generic for FEROSUL) - Tier 1; OTC; PD; QL
ferretts - Tier 1; OTC; PD
ferrex 150 capsule 150 mg oral (generic for FERREX 150) - Tier 1;
OTC; PD
FERREX 150 CAPSULE 150 MG ORAL (brand for polysaccharide iron
complex) - Tier 2; OTC; PD
FERRIC X-150 (brand for polysaccharide iron complex) - Tier 2; OTC;
PD
ferrous fumarate oral tablet 324 (106 fe) mg, 324 mg (generic for
FERROCITE) - Tier 1; OTC; PD
ferrous gluconate - Tier 1; OTC; PD
ferrous gluconate oral tablet 240 (27 fe) mg (generic for FERATE) -
Tier 1; OTC; PD
ferrous gluconate oral tablet 324 (37.5 fe) mg - Tier 1; OTC; PD
ferrous gluconate oral tablet 324 (38 fe) mg - Tier 1; OTC; PD; QL
ferrous sulfate (generic for FEROSUL) - Tier 1; OTC; PD; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
76
Preferred Agents Non-Preferred Agents
ferrous sulfate oral solution 75 (15 fe) mg/ml (generic for
BPROTECTED PEDIA IRON) - Tier 1; OTC; PD; QL
ferrous sulfate oral tablet 325 (65 fe) mg (generic for FEROSUL) - Tier
1; OTC; PD; QL
ferrous sulfate oral tablet delayed release - Tier 1; OTC; PD; QL
fe-vite iron (generic for BPROTECTED PEDIA IRON) - Tier 1; OTC;
PD; QL
iferex 150 (generic for FERREX 150) - Tier 1; OTC; PD
iron (ferrous sulfate) oral solution (generic for BPROTECTED PEDIA
IRON) - Tier 1; OTC; PD; QL
iron infant/toddler (generic for BPROTECTED PEDIA IRON) - Tier 1;
OTC; PD; QL
iron oral tablet 240 (27 fe) mg (generic for FERATE) - Tier 1; OTC; PD
iron oral tablet 325 (65 fe) mg (generic for FEROSUL) - Tier 1; OTC;
PD; QL
iron supplement childrens (generic for BPROTECTED PEDIA IRON) -
Tier 1; OTC; PD; QL
K-PHOS - Tier 2; QL
magnesium oral tablet 500 mg - Tier 1; OTC
magnesium oxide -mg supplement oral tablet 400 (240 mg) mg
(generic for MAGNESIUM-OXIDE) - Tier 1; OTC
magnesium oxide -mg supplement oral tablet 500 mg - Tier 1; OTC
magnesium-oxide (generic for MAGNESIUM-OXIDE) - Tier 1; OTC
NU-IRON (brand for polysaccharide iron complex) - Tier 2; OTC; PD
ped electrolyte freeze pop (generic for ENFAMIL ENFALYTE) - Tier 1;
OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
77
Preferred Agents Non-Preferred Agents
PEDIALYTE FREEZER POPS (brand for cvs electrolyte solution) -
Tier 2; OTC; QL
PEDIALYTE ORAL SOLUTION (brand for cvs electrolyte solution) -
Tier 2; OTC; QL
PEDIALYTE SINGLES (brand for cvs electrolyte solution) - Tier 2;
OTC; QL
pediatric electrolyte oral solution (generic for ENFAMIL ENFALYTE) -
Tier 1; OTC; QL
PHOSPHA 250 NEUTRAL (brand for phosphorous) - Tier 2; QL
phosphorous (generic for PHOSPHO-TRIN 250 NEUTRAL) - Tier 1;
QL
phospho-trin 250 neutral (generic for PHOSPHO-TRIN 250 NEUTRAL)
- Tier 1; QL
PHOSPHO-TRIN K500 - Tier 2; QL
poly-iron 150 (generic for FERREX 150) - Tier 1; OTC; PD
polysaccharide iron complex (generic for FERREX 150) - Tier 1; OTC;
PD
polysaccharide-iron complex (generic for FERREX 150) - Tier 1; OTC;
PD
potassium citrate-citric acid - Tier 1
REHYDRALYTE (brand for cvs electrolyte solution) - Tier 2; OTC; QL
sod citrate-citric acid oral solution 500-334 mg/5ml - Tier 1
TRUE FERROUS SULFATE - Tier 2; OTC; PD; QL
TRUE MAGNESIUM OXIDE ORAL TABLET 500 MG - Tier 2; OTC
true magnesium oxide tablet 400 mg oral (generic for MAGNESIUM-
OXIDE) - Tier 1; OTC
TRUE MAGNESIUM OXIDE TABLET 400 MG ORAL (brand for
magnesium oxide -mg supplement) - Tier 2; OTC
ultra calcium + vitamin d3 - Tier 1; OTC; QL
wes-phos 250 neutral (generic for PHOSPHO-TRIN 250 NEUTRAL) -
Tier 1; QL
zinc gluconate - Tier 1; OTC; QL
zinc gluconate oral tablet 50 mg - Tier 1; OTC; QL
zinc oral tablet 50 mg - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
78
Preferred Agents Non-Preferred Agents
Electrolyte/Mineral/Metal Modifiers
CHEMET - Tier 2; QL
deferasirox granules (generic for JADENU SPRINKLE) - Tier 1; PA;
SP; QL
deferasirox oral packet (generic for JADENU SPRINKLE) - Tier 1; PA;
SP; QL
deferasirox oral tablet (generic for JADENU) - Tier 1; PA; SP; QL
deferasirox oral tablet soluble (generic for EXJADE) - Tier 1; PA; SP
trientine hcl oral capsule 250 mg (generic for SYPRINE) - Tier 1; PA;
SP
Phosphate Binders
calcium acetate (phos binder) (generic for CALPHRON) - Tier 1; QL
calcium acetate oral tablet 667 mg (generic for CALPHRON) - Tier 1;
QL
sevelamer carbonate oral tablet (generic for RENVELA) - Tier 1; ST;
QL
AURYXIA - Tier 2; PA; QL
VELPHORO - Tier 2; PA; QL
Potassium Binders
LOKELMA - Tier 2; PA; QL
SPS - Tier 2; QL
VELTASSA - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
79
Preferred Agents Non-Preferred Agents
Vitamins
a-25 - Tier 1; OTC; QL
aqueous vitamin d (generic for BPROTECTED PEDIA D-VITE) - Tier
1; OTC; QL
b complex vitamins - Tier 1; OTC; QL
b complex-b12 - Tier 1; OTC
b-complex oral tablet - Tier 1; OTC
b-complex with b-12 - Tier 1; OTC
b-complex/b-12 oral - Tier 1; OTC
BPROTECTED PEDIA D-VITE (brand for aqueous vitamin d) - Tier 2;
OTC; QL
CENTRUM SPECIALIST PRENATAL - Tier 2; OTC
classic prenatal - Tier 1; OTC; QL
d3 high potency oral capsule 25 mcg, 25 mcg (1000 ut) (generic for
PRONUTRIENTS VITAMIN D3) - Tier 1; OTC
d3 high potency oral capsule 250 mcg (10000 ut) (generic for IS-D
10,000) - Tier 1; OTC
d3 max st (generic for IS-D 10,000) - Tier 1; OTC
d3 oral capsule 10 mcg (400 unit), 50 mcg (2000 ut) - Tier 1; OTC; QL
d3 oral capsule 125 mcg (5000 ut) (generic for DIALYVITE VITAMIN D
5000) - Tier 1; OTC
d3 oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS
VITAMIN D3) - Tier 1; OTC
d3 oral capsule 250 mcg (generic for IS-D 10,000) - Tier 1; OTC
d-3-5 (generic for DIALYVITE VITAMIN D 5000) - Tier 1; OTC
d3-50 (generic for D3-50) - Tier 1; OTC; QL
DECARA ORAL CAPSULE 1.25 MG (50000 UT) (brand for vitamin d3)
- Tier 2; OTC; QL
DECARA ORAL CAPSULE 625 MCG (25000 UT) - Tier 2; OTC
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
80
Preferred Agents Non-Preferred Agents
DIALYVITE 800 ORAL TABLET (brand for full spectrum b/vitamin c) -
Tier 2; OTC; QL
DIALYVITE VITAMIN D 5000 (brand for cvs d3) - Tier 2; OTC
D-VI-SOL (brand for aqueous vitamin d) - Tier 2; OTC; QL
d-vite pediatric (generic for BPROTECTED PEDIA D-VITE) - Tier 1;
OTC; QL
ENFAMIL EXPECTA - Tier 2; OTC; QL
ft vitamin d3 oral tablet (generic for THERA-D 2000) - Tier 1; OTC; QL
full spectrum b/vitamin c (generic for DIALYVITE 800) - Tier 1; OTC;
QL
M-NATAL PLUS (brand for prenatal) - Tier 2; QL
NEONATAL PLUS (brand for prenatal) - Tier 2; QL
nephro vitamins (generic for DIALYVITE 800) - Tier 1; OTC; QL
NEPHRO-VITE (brand for full spectrum b/vitamin c) - Tier 2; OTC; QL
niacin er oral capsule extended release 250 mg - Tier 1; OTC; QL
niacin er oral capsule extended release 500 mg - Tier 1; OTC
niacin er oral tablet extended release 1000 mg - Tier 1; OTC
niacin er oral tablet extended release 250 mg, 500 mg (generic for
SLO-NIACIN) - Tier 1; OTC
niacin oral tablet 100 mg, 250 mg, 50 mg - Tier 1; OTC
NIVA-PLUS (brand for prenatal) - Tier 2; QL
OBSTETRIX DHA - Tier 2; OTC; QL
ONE VITE WOMENS - Tier 2; OTC; QL
ONE VITE WOMENS PLUS (brand for prenatal) - Tier 2; QL
phytonadione oral - Tier 1; QL
prenatal formula oral tablet 28-0.8 mg - Tier 1; OTC; QL
prenatal gummy oral tablet chewable 0.4-25 mg (generic for ONE A
DAY PRENATAL) - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
81
Preferred Agents Non-Preferred Agents
prenatal multi+dha - Tier 1; OTC; QL
prenatal multivitamins - Tier 1; OTC; QL
prenatal oral tablet 27-0.8 mg (generic for NEONATAL VITAMIN) - Tier
1; OTC; QL
prenatal oral tablet 27-1 mg (generic for NEONATAL PLUS) - Tier 1;
QL
prenatal oral tablet 28-0.8 mg - Tier 1; OTC; QL
prenatal vitamins oral tablet 28-0.8 mg - Tier 1; OTC; QL
prenatal/iron - Tier 1; OTC; QL
PRONUTRIENTS VITAMIN D3 (brand for cvs d3) - Tier 2; OTC
radiance platinum vitamin d3 (generic for RADIANCE PLATINUM
VITAMIN D3) - Tier 1; OTC
rena-vite (generic for DIALYVITE 800) - Tier 1; OTC; QL
SLO-NIACIN (brand for niacin er) - Tier 2; OTC
thiamine mononitrate oral - Tier 1; OTC; QL
tri-vite pediatric - Tier 1; OTC; QL
TRUE VITAMIN A - Tier 2; OTC; QL
TRUE VITAMIN B1 ORAL TABLET 100 MG - Tier 2; OTC; QL
TRUE VITAMIN B3 ORAL TABLET 100 MG, 250 MG, 50 MG - Tier 2;
OTC
TRUE VITAMIN D3 ORAL CAPSULE 1.25 MG (50000 UT) (brand for
vitamin d3) - Tier 2; OTC; QL
TRUE VITAMIN D3 ORAL CAPSULE 10 MCG (400 UNIT) - Tier 2;
OTC; QL
TRUE VITAMIN D3 ORAL CAPSULE 125 MCG (5000 UT), 25 MCG
(1000 UT) (brand for cvs d3) - Tier 2; OTC
TRUE VITAMIN D3 ORAL CAPSULE 250 MCG (10000 UT) - Tier 2;
OTC
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
82
Preferred Agents Non-Preferred Agents
TRUE VITAMIN D3 ORAL TABLET 10 MCG (400 UNIT) - Tier 2; OTC;
QL
TRUE VITAMIN D3 ORAL TABLET 125 MCG (5000 UT) (brand for
vitamin d3) - Tier 2; OTC
TRUE VITAMIN D3 ORAL TABLET 25 MCG (1000 UT) - Tier 2; OTC
vitachew vitamin d3 (generic for KIDS FIRST VITAMIN D3 GUMMIES)
- Tier 1; OTC
vitamin a oral capsule 2400 mcg (8000 ut), 3 mg, 3 mg (10000 ut) -
Tier 1; OTC; QL
vitamin b complex oral capsule - Tier 1; OTC; QL
vitamin b complex w/b-12 - Tier 1; OTC
vitamin b-1 oral tablet 100 mg - Tier 1; OTC; QL
vitamin d (cholecalciferol) oral tablet 10 mcg (400 unit) - Tier 1; OTC;
QL
vitamin d (cholecalciferol) oral tablet 25 mcg (1000 ut) (generic for
VITAMIN D-1000 MAX ST) - Tier 1; OTC
vitamin d oral capsule 25 mcg (1000 ut) (generic for PRONUTRIENTS
VITAMIN D3) - Tier 1; OTC
vitamin d oral liquid (generic for BPROTECTED PEDIA D-VITE) - Tier
1; OTC; QL
vitamin d oral tablet chewable 10 mcg (400 unit) (generic for
HEALTHY KIDS VITAMIN D3) - Tier 1; OTC
vitamin d3 oral capsule 1.25 mg (50000 ut) (generic for D3-50) - Tier 1;
OTC; QL
vitamin d3 oral capsule 125 mcg (5000 ut) (generic for DIALYVITE
VITAMIN D 5000) - Tier 1; OTC
vitamin d-3 oral capsule 125 mcg (5000 ut) (generic for DIALYVITE
VITAMIN D 5000) - Tier 1; OTC
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
83
Preferred Agents Non-Preferred Agents
vitamin d3 oral capsule 25 mcg (1000 ut) (generic for
PRONUTRIENTS VITAMIN D3) - Tier 1; OTC
vitamin d3 oral capsule 250 mcg (10000 ut) (generic for IS-D 10,000) -
Tier 1; OTC
vitamin d3 oral capsule 50 mcg (2000 ut) - Tier 1; OTC; QL
vitamin d-3 oral capsule 50 mcg (2000 ut) - Tier 1; OTC; QL
vitamin d3 oral liquid 10 mcg/ml (generic for BPROTECTED PEDIA D-
VITE) - Tier 1; OTC; QL
vitamin d3 oral tablet 10 mcg (400 unit) - Tier 1; OTC; QL
vitamin d3 oral tablet 125 mcg (5000 ut) (generic for RADIANCE
PLATINUM VITAMIN D3) - Tier 1; OTC
vitamin d3 oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000
MAX ST) - Tier 1; OTC
vitamin d-3 oral tablet 25 mcg (1000 ut) (generic for VITAMIN D-1000
MAX ST) - Tier 1; OTC
vitamin d3 oral tablet 50 mcg (2000 ut) (generic for THERA-D 2000) -
Tier 1; OTC; QL
vitamin d3 oral tablet chewable 10 mcg (400 unit) (generic for
HEALTHY KIDS VITAMIN D3) - Tier 1; OTC
vitamin d3 oral tablet chewable 25 mcg (1000 ut) (generic for KIDS
FIRST VITAMIN D3 GUMMIES) - Tier 1; OTC
vitamin d-400 oral tablet 10 mcg (400 unit) - Tier 1; OTC; QL
vitamin-b complex - Tier 1; OTC
weekly-d (generic for D3-50) - Tier 1; OTC; QL
WESTAB PLUS (brand for prenatal) - Tier 2; QL
womens prenatal+dha - Tier 1; OTC; QL
Estrogens - Hormone Replacement/Modifying Drugs
Hormonal Agents, Stimulant/Replacement/Modifying (Sex
Hormones/Modifiers) - Drugs to Regulate Hormones
MYFEMBREE - Tier 2; PA; QL
NEXTSTELLIS - Tier 2; PA; PD; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
84
Preferred Agents Non-Preferred Agents
Gastrointestinal Agents
VOQUEZNA TRIPLE PAK - Tier 2; PA; QL
Anti-Constipation Agents
constulose - Tier 1; QL
enulose - Tier 1; QL
generlac - Tier 1; QL
lactulose encephalopathy - Tier 1; QL
lactulose oral solution - Tier 1; QL
LINZESS - Tier 2; DX2RX; QL
SYMPROIC - Tier 2; DX2RX; QL
MOTEGRITY - Tier 2; PA; QL
MOVANTIK - Tier 2; PA; QL
RELISTOR SUBCUTANEOUS - Tier 2; PA; QL
TRULANCE - Tier 2; PA; QL
Anti-Diarrheal Agents
anti-diarrheal oral tablet 2 mg (generic for IMODIUM A-D) - Tier 1;
OTC
diamode (generic for IMODIUM A-D) - Tier 1; OTC
diphenoxylate-atropine (generic for LOMOTIL) - Tier 1; QL
ft anti-diarrheal oral tablet (generic for IMODIUM A-D) - Tier 1; OTC
IMODIUM A-D ORAL TABLET (brand for anti-diarrheal) - Tier 2; OTC
loperamide hcl oral capsule (generic for IMODIUM A-D) - Tier 1; QL
loperamide hcl oral tablet (generic for IMODIUM A-D) - Tier 1; OTC
meijer anti-diarrheal (generic for IMODIUM A-D) - Tier 1; OTC
MYTESI - Tier 2; DX2RX; QL
VIBERZI - Tier 2; PA; QL
Antispasmodics, Gastrointestinal
dicyclomine hcl oral capsule - Tier 1; QL
dicyclomine hcl oral solution - Tier 1
dicyclomine hcl oral tablet - Tier 1; QL
glycopyrrolate oral tablet 1 mg (generic for ROBINUL) - Tier 1
glycopyrrolate oral tablet 2 mg (generic for ROBINUL-FORTE) - Tier 1
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
85
Preferred Agents Non-Preferred Agents
Gastrointestinal Agents, Other
GATTEX - Tier 2; PA; SP; QL
gavilyte-c - Tier 1; PD; QL
gavilyte-g (generic for GAVILYTE-G) - Tier 1; PD; QL
peg 3350-kcl-na bicarb-nacl - Tier 1; PD; QL
peg-3350/electrolytes (generic for GAVILYTE-G) - Tier 1; PD; QL
ursodiol oral capsule 300 mg - Tier 1; QL
ursodiol oral tablet (generic for URSO 250) - Tier 1
CLENPIQ - Tier 2; PA; QL
MOVIPREP (brand for peg-3350/electrolytes/ascorbat) - Tier 2; PA; QL
PLENVU - Tier 2; PA; QL
PYLERA (brand for bis subcit-metronid-tetracyc) - Tier 2; PA
SUPREP BOWEL PREP KIT (brand for na sulfate-k sulfate-mg sulf) - Tier
2; PA; QL
TALICIA - Tier 2; PA; QL
Histamine2 (H2) Receptor Antagonists
acid controller (generic for PEPCID AC) - Tier 1; OTC; QL
acid reducer oral tablet 10 mg (generic for PEPCID AC) - Tier 1; OTC;
QL
acid reducer oral tablet 200 mg (generic for TAGAMET HB 200) - Tier
1; OTC
cimetidine oral tablet 200 mg (generic for TAGAMET HB 200) - Tier 1
cimetidine oral tablet 200 mg (generic for TAGAMET HB 200) - Tier 1;
OTC
cimetidine oral tablet 300 mg, 400 mg, 800 mg - Tier 1; QL
famotidine acid reducer oral tablet 10 mg (generic for PEPCID AC) -
Tier 1; OTC; QL
famotidine oral suspension reconstituted - Tier 1; QL; AL
famotidine oral tablet 10 mg (generic for PEPCID AC) - Tier 1; OTC;
QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
86
Preferred Agents Non-Preferred Agents
famotidine oral tablet 20 mg (generic for MM ACID-PEP MAXIMUM
STRENGTH) - Tier 1; QL
famotidine oral tablet 40 mg (generic for PEPCID) - Tier 1; QL
famotidine orig st (generic for PEPCID AC) - Tier 1; OTC; QL
ft acid reducer oral tablet (generic for PEPCID AC) - Tier 1; OTC; QL
heartburn prevention oral tablet 10 mg (generic for PEPCID AC) - Tier
1; OTC; QL
heartburn relief oral tablet 10 mg (generic for PEPCID AC) - Tier 1;
OTC; QL
heartburn relief oral tablet 200 mg (generic for TAGAMET HB 200) -
Tier 1; OTC
PEPCID AC (brand for acid controller) - Tier 2; OTC; QL
TAGAMET HB 200 (brand for cimetidine) - Tier 2; OTC
Protectants
misoprostol oral (generic for CYTOTEC) - Tier 1; QL
sucralfate oral suspension (generic for CARAFATE) - Tier 1; Members
10 years of age up to 65 years of age will require PA; QL
sucralfate oral tablet (generic for CARAFATE) - Tier 1; QL
Proton Pump Inhibitors
acid reducer oral capsule delayed release 20.6 (20 base) mg - Tier 1;
OTC; QL
esomeprazole magnesium oral packet (generic for NEXIUM) - Tier 1;
Members >= 2 years of age will require PA; QL; AL
ft acid reducer oral capsule delayed release (generic for PREVACID
24HR) - Tier 1; OTC; QL
lansoprazole capsule delayed release 15 mg oral (otc) (generic for
PREVACID 24HR) - Tier 1; OTC; QL
lansoprazole capsule delayed release 15 mg oral (rx) (generic for
PREVACID 24HR) - Tier 1; QL
lansoprazole oral capsule delayed release 15 mg (generic for
PREVACID 24HR) - Tier 1; OTC; QL
lansoprazole oral capsule delayed release 30 mg (generic for
PREVACID) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
87
Preferred Agents Non-Preferred Agents
NEXIUM ORAL PACKET 2.5 MG, 5 MG - Tier 2; Members >= 2 years
of age will require PA; QL; AL
omeprazole magnesium - Tier 1; OTC; QL
omeprazole magnesium oral capsule delayed release - Tier 1; OTC;
QL
omeprazole oral capsule delayed release 10 mg, 20 mg, 40 mg - Tier
1; QL
omeprazole oral capsule delayed release 20.6 (20 base) mg - Tier 1;
OTC; QL
pantoprazole sodium oral tablet delayed release (generic for
PROTONIX) - Tier 1; QL
PREVACID 24HR (brand for eq lansoprazole) - Tier 2; OTC; QL
Gastrointestinal Agents - Drugs to Treat Bowel, Intestine and
Stomach Conditions
Gastrointestinal Agents, Other - Miscellaneous Gastrointestinal
Drugs
abatinex (generic for ABATINEX) - Tier 1; OTC
acid gone (generic for ACID GONE) - Tier 1; OTC
acidophilus lactobacillus oral (generic for ABATINEX) - Tier 1; OTC
acidophilus oral capsule , 10 mg (generic for ABATINEX) - Tier 1;
OTC
acidophilus probiotic oral capsule 10 mg (generic for ABATINEX) - Tier
1; OTC
acidophilus probiotic oral tablet , 0.5 mg (generic for FLORANEX) -
Tier 1; OTC
adult 50+ probiotic (generic for FLORA VANCE) - Tier 1; OTC; QL
adult probiotic (generic for FLORA VANCE) - Tier 1; OTC; QL
advanced antacid (generic for MINTOX) - Tier 1; OTC; QL
almacone double strength (generic for ALMACONE DOUBLE
STRENGTH) - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
88
Preferred Agents Non-Preferred Agents
alum & mag hydroxide-simeth (generic for MINTOX) - Tier 1; OTC; QL
antacid & anti-gas oral suspension 200-200-20 mg/5ml (generic for
MINTOX) - Tier 1; OTC; QL
antacid & antigas oral suspension 2400-2400-240 mg/30ml (generic
for ALMACONE DOUBLE STRENGTH) - Tier 1; OTC; QL
antacid & anti-gas oral suspension 400-400-40 mg/5ml (generic for
ALMACONE DOUBLE STRENGTH) - Tier 1; OTC; QL
antacid & gas relief (generic for ALMACONE DOUBLE STRENGTH) -
Tier 1; OTC; QL
antacid advanced (generic for ALMACONE DOUBLE STRENGTH) -
Tier 1; OTC; QL
antacid advanced max st oral suspension 400-400-40 mg/5ml (generic
for ALMACONE DOUBLE STRENGTH) - Tier 1; OTC; QL
antacid anti-gas (generic for MINTOX) - Tier 1; OTC; QL
antacid anti-gas max strength (generic for ALMACONE DOUBLE
STRENGTH) - Tier 1; OTC; QL
antacid calcium (generic for CAL-GEST ANTACID) - Tier 1; OTC
antacid calcium rich (generic for CAL-GEST ANTACID) - Tier 1; OTC
antacid extra str (generic for CVS CHEWY NOT CHALKY FLAVOR) -
Tier 1; OTC
antacid extra strength oral suspension (generic for ALMACONE
DOUBLE STRENGTH) - Tier 1; OTC; QL
antacid extra strength oral tablet chewable 160-105 mg (generic for
ACID GONE) - Tier 1; OTC
antacid extra strength oral tablet chewable 750 mg (generic for CVS
CHEWY NOT CHALKY FLAVOR) - Tier 1; OTC
antacid fast relief (generic for MINTOX) - Tier 1; OTC; QL
antacid i (generic for MINTOX) - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
89
Preferred Agents Non-Preferred Agents
antacid iii (generic for ALMACONE DOUBLE STRENGTH) - Tier 1;
OTC; QL
antacid kids (generic for CVS CHEWY NOT CHALKY FLAVOR) - Tier
1; OTC
antacid liquid (generic for MINTOX) - Tier 1; OTC; QL
antacid m (generic for MINTOX) - Tier 1; OTC; QL
antacid maximum (generic for TUMS ULTRA 1000) - Tier 1; OTC
antacid maximum strength (generic for ALMACONE DOUBLE
STRENGTH) - Tier 1; OTC; QL
antacid maximum strength oral tablet chewable 1000 mg (generic for
TUMS ULTRA 1000) - Tier 1; OTC
antacid oral suspension 200-200-20 mg/5ml, 400-400-40 mg/10ml
(generic for MINTOX) - Tier 1; OTC; QL
antacid oral tablet chewable 1000 mg (generic for TUMS ULTRA
1000) - Tier 1; OTC
antacid oral tablet chewable 500 mg (generic for CAL-GEST
ANTACID) - Tier 1; OTC
antacid oral tablet chewable 750 mg (generic for CVS CHEWY NOT
CHALKY FLAVOR) - Tier 1; OTC
antacid plus antigas (generic for ALMACONE DOUBLE STRENGTH) -
Tier 1; OTC; QL
antacid regular strength oral suspension 200-200-20 mg/5ml (generic
for MINTOX) - Tier 1; OTC; QL
antacid ultra strength (generic for TUMS ULTRA 1000) - Tier 1; OTC
antacid ultra strength oral tablet chewable 1000 mg (generic for TUMS
ULTRA 1000) - Tier 1; OTC
antacid/antigas (generic for MINTOX) - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
90
Preferred Agents Non-Preferred Agents
antacid/anti-gas max st (generic for ALMACONE DOUBLE
STRENGTH) - Tier 1; OTC; QL
antacid/anti-gas oral suspension 200-200-20 mg/5ml, 400-400-40
mg/10ml (generic for MINTOX) - Tier 1; OTC; QL
antacid/anti-gas oral suspension 400-400-40 mg/5ml (generic for
ALMACONE DOUBLE STRENGTH) - Tier 1; OTC; QL
antacid/gas relief max st (generic for ALMACONE DOUBLE
STRENGTH) - Tier 1; OTC; QL
anti-diarr/ant-gas (generic for IMODIUM MULTI-SYMPTOM RELIEF) -
Tier 1; OTC
anti-diarrheal anti-gas oral tablet 2-125 mg (generic for IMODIUM
MULTI-SYMPTOM RELIEF) - Tier 1; OTC
anti-diarrheal oral suspension 262 mg/15ml (generic for SOOTHE) -
Tier 1; OTC
anti-diarrheal/anti-gas (generic for IMODIUM MULTI-SYMPTOM
RELIEF) - Tier 1; OTC
anti-gas oral capsule 180 mg (generic for GAS-X ULTRA STRENGTH)
- Tier 1; OTC
biotinex (generic for ABATINEX) - Tier 1; OTC
bismuth (generic for SOOTHE) - Tier 1; OTC; QL
bismuth subsalicylate oral (generic for SOOTHE) - Tier 1; OTC; QL
BOLSITOL (brand for acidophilus) - Tier 2; OTC
calcium antacid ex st oral tablet chewable 750 mg (generic for CVS
CHEWY NOT CHALKY FLAVOR) - Tier 1; OTC
calcium antacid extra strength (generic for CVS CHEWY NOT
CHALKY FLAVOR) - Tier 1; OTC
calcium antacid oral tablet chewable 500 mg (generic for CAL-GEST
ANTACID) - Tier 1; OTC
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
91
Preferred Agents Non-Preferred Agents
calcium carbonate antacid oral suspension - Tier 1; OTC; QL
calcium carbonate antacid oral tablet - Tier 1; OTC
calcium carbonate antacid oral tablet chewable (generic for CAL-
GEST ANTACID) - Tier 1; OTC
cal-gest antacid (generic for CAL-GEST ANTACID) - Tier 1; OTC
chewy not chalky flavor (generic for CVS CHEWY NOT CHALKY
FLAVOR) - Tier 1; OTC
childrens soothe - Tier 1; OTC
comfort gel (generic for MINTOX) - Tier 1; OTC; QL
comfort gel antacid anti-gas oral suspension 400-400-40 mg/5ml
(generic for ALMACONE DOUBLE STRENGTH) - Tier 1; OTC; QL
diarrhea (generic for SOOTHE) - Tier 1; OTC
diarrhea relief (generic for SOOTHE) - Tier 1; OTC
digestive probiotic oral capsule (generic for FLORA VANCE) - Tier 1;
OTC; QL
digestive probiotic oral capsule 250 mg (generic for FLORASTOR) -
Tier 1; OTC
diotame instydose (generic for SOOTHE) - Tier 1; OTC
enema (generic for FLEET ENEMA) - Tier 1; OTC
enema disposable (generic for FLEET ENEMA) - Tier 1; OTC
enema ready-to-use (generic for FLEET ENEMA) - Tier 1; OTC
enema rectal enema 16-6 gm/133ml (generic for FLEET ENEMA) -
Tier 1; OTC
FLEET ENEMA (brand for cvs enema disposable) - Tier 2; OTC
FLEET PEDIATRIC (brand for enema pediatric) - Tier 2; OTC
FLORA VANCE (brand for cvs adult 50+ probiotic) - Tier 2; OTC; QL
floranex tablet oral (generic for FLORANEX) - Tier 1; OTC
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
92
Preferred Agents Non-Preferred Agents
FLORANEX TABLET ORAL (brand for cvs acidophilus probiotic) - Tier
2; OTC
foaming antacid oral tablet chewable 80-20 mg - Tier 1; OTC
freeze dried acidophilus (generic for ABATINEX) - Tier 1; OTC
ft antacid & antigas (generic for ALMACONE DOUBLE STRENGTH) -
Tier 1; OTC; QL
ft antacid extra strength (generic for CVS CHEWY NOT CHALKY
FLAVOR) - Tier 1; OTC
ft antacid regular strength (generic for CAL-GEST ANTACID) - Tier 1;
OTC
ft anti-diarrheal/anti-gas (generic for IMODIUM MULTI-SYMPTOM
RELIEF) - Tier 1; OTC
ft enema saline (generic for FLEET ENEMA) - Tier 1; OTC
ft gas relief - Tier 1; OTC
ft gas relief extra strength (generic for GAS-X EXTRA STRENGTH) -
Tier 1; OTC
ft gas relief ultra strength (generic for GAS-X ULTRA STRENGTH) -
Tier 1; OTC
ft milk of magnesia (generic for DULCOLAX) - Tier 1; OTC
ft stomach relief oral suspension (generic for SOOTHE) - Tier 1; OTC
ft stomach relief oral tablet (generic for KAOPECTATE) - Tier 1; OTC
ft stomach relief oral tablet chewable (generic for SOOTHE) - Tier 1;
OTC; QL
gas relief extra strength (generic for GAS-X EXTRA STRENGTH) -
Tier 1; OTC
gas relief extra strength oral tablet chewable 125 mg (generic for GAS-
X EXTRA STRENGTH) - Tier 1; OTC
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
93
Preferred Agents Non-Preferred Agents
gas relief extstrength (generic for GAS-X EXTRA STRENGTH) - Tier
1; OTC
gas relief oral capsule 125 mg (generic for GAS-X EXTRA
STRENGTH) - Tier 1; OTC
gas relief oral capsule 180 mg (generic for GAS-X ULTRA
STRENGTH) - Tier 1; OTC
gas relief oral tablet chewable 125 mg (generic for GAS-X EXTRA
STRENGTH) - Tier 1; OTC
gas relief oral tablet chewable 80 mg - Tier 1; OTC
gas relief ultra strength (generic for GAS-X ULTRA STRENGTH) - Tier
1; OTC
gas relief ultstrength (generic for GAS-X ULTRA STRENGTH) - Tier 1;
OTC
GAS-X EXTRA STRENGTH ORAL CAPSULE (brand for eq gas relief)
- Tier 2; OTC
GAS-X EXTRA STRENGTH ORAL TABLET CHEWABLE (brand for
cvs gas relief extra strength) - Tier 2; OTC
GAS-X ULTRA STRENGTH (brand for cvs gas relief ultra strength) -
Tier 2; OTC
GAVISCON - Tier 2; OTC
GAVISCON EXTRA RELIEF FORMULA (brand for cvs heartburn relief
ex st) - Tier 2; OTC
GAVISCON EXTRA STRENGTH (brand for antacid extra strength) -
Tier 2; OTC
GELUSIL - Tier 2; OTC
geri-lanta maximum strength (generic for ALMACONE DOUBLE
STRENGTH) - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
94
Preferred Agents Non-Preferred Agents
geri-lanta oral suspension 200-200-20 mg/5ml (generic for MINTOX) -
Tier 1; OTC; QL
geri-mox (generic for MINTOX) - Tier 1; OTC; QL
heartburn antacid (generic for ACID GONE) - Tier 1; OTC
heartburn antacid ex st (generic for ACID GONE) - Tier 1; OTC
heartburn relief ex st (generic for GAVISCON EXTRA RELIEF
FORMULA) - Tier 1; OTC
heartburn relief oral tablet chewable 160-105 mg (generic for ACID
GONE) - Tier 1; OTC
heartland gas relief - Tier 1; OTC
high potency probiotic oral capsule (generic for FLORA VANCE) -
Tier 1; OTC; QL
IMODIUM MULTI-SYMPTOM RELIEF (brand for eql anti-diarrheal
anti-gas) - Tier 2; OTC
intestinex (generic for ABATINEX) - Tier 1; OTC
lactobacillus oral tablet (generic for FLORANEX) - Tier 1; OTC
lacto-pectin (generic for FLORA VANCE) - Tier 1; OTC; QL
long lasting antacid (generic for CAL-GEST ANTACID) - Tier 1; OTC
loperamide-simethicone (generic for IMODIUM MULTI-SYMPTOM
RELIEF) - Tier 1; OTC
MAALOX CHILDRENS (brand for childrens pepto) - Tier 2; OTC
MAALOX MAX ORAL SUSPENSION (brand for antacid & antigas) -
Tier 2; OTC; QL
MAALOX MULTI SYMPTOM MAX ST (brand for antacid & antigas) -
Tier 2; OTC; QL
mag-al plus (generic for MINTOX) - Tier 1; OTC; QL
mag-al plus xs (generic for ALMACONE DOUBLE STRENGTH) - Tier
1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
95
Preferred Agents Non-Preferred Agents
magnesium-aluminum-simethicone (generic for ALMACONE DOUBLE
STRENGTH) - Tier 1; OTC; QL
mega probiotic (generic for FLORA VANCE) - Tier 1; OTC; QL
meijer antacid (generic for ALMACONE DOUBLE STRENGTH) - Tier
1; OTC; QL
milk of magnesia (generic for DULCOLAX) - Tier 1; OTC
milk of magnesia oral suspension 1200 mg/15ml (generic for
DULCOLAX) - Tier 1; OTC
mintox maximum strength (generic for ALMACONE DOUBLE
STRENGTH) - Tier 1; OTC; QL
mintox plus - Tier 1; OTC
mood support probiotic (generic for FLORA VANCE) - Tier 1; OTC; QL
PEPTO-BISMOL ORAL SUSPENSION 524 MG/30ML (brand for cvs
anti-diarrheal) - Tier 2; OTC
PHAZYME (brand for cvs gas relief extra strength) - Tier 2; OTC
PHAZYME ULTRA STRENGTH (brand for cvs gas relief ultra strength)
- Tier 2; OTC
pink bismuth maximum strength (generic for SOOTHE MAXIMUM
STRENGTH) - Tier 1; OTC
pink bismuth oral suspension 262 mg/15ml (generic for SOOTHE) -
Tier 1; OTC
pink bismuth oral suspension 525 mg/15ml (generic for SOOTHE
MAXIMUM STRENGTH) - Tier 1; OTC
pink bismuth oral tablet 262 mg (generic for KAOPECTATE) - Tier 1;
OTC
pink bismuth oral tablet chewable 262 mg (generic for SOOTHE) - Tier
1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
96
Preferred Agents Non-Preferred Agents
pink bismuth ultra str (generic for SOOTHE MAXIMUM STRENGTH) -
Tier 1; OTC
pink-bismuth (generic for SOOTHE) - Tier 1; OTC; QL
probiotic blend (generic for FLORA VANCE) - Tier 1; OTC; QL
probiotic colon care (generic for FLORA VANCE) - Tier 1; OTC; QL
probiotic complex (generic for FLORA VANCE) - Tier 1; OTC; QL
probiotic maximum strength (generic for FLORA VANCE) - Tier 1;
OTC; QL
probiotic oral capsule (generic for FLORA VANCE) - Tier 1; OTC; QL
probiotic oral capsule 250 mg (generic for FLORASTOR) - Tier 1; OTC
probiotic pearls ex st (generic for FLORA VANCE) - Tier 1; OTC; QL
ready-to-use enema rectal enema (generic for FLEET ENEMA) - Tier
1; OTC
RESTORA (brand for cvs adult 50+ probiotic) - Tier 2; OTC; QL
RISAQUAD (brand for cvs adult 50+ probiotic) - Tier 2; OTC; QL
RISAQUAD-2 (brand for cvs adult 50+ probiotic) - Tier 2; OTC; QL
saccharomyces boulardii (generic for FLORASTOR) - Tier 1; OTC
saline enema (generic for FLEET ENEMA) - Tier 1; OTC
senior probiotic (generic for FLORA VANCE) - Tier 1; OTC; QL
simethicone oral capsule (generic for GAS-X EXTRA STRENGTH) -
Tier 1; OTC
simethicone oral tablet chewable (generic for GAS-X EXTRA
STRENGTH) - Tier 1; OTC
simethicone ultra strength (generic for GAS-X ULTRA STRENGTH) -
Tier 1; OTC
smooth antacid ex st oral tablet chewable 750 mg (generic for CVS
CHEWY NOT CHALKY FLAVOR) - Tier 1; OTC
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
97
Preferred Agents Non-Preferred Agents
smooth antacid extra st (generic for CVS CHEWY NOT CHALKY
FLAVOR) - Tier 1; OTC
smooth antacid extra strength (generic for CVS CHEWY NOT
CHALKY FLAVOR) - Tier 1; OTC
sodium bicarbonate oral tablet - Tier 1; OTC
soothe maximum strength (generic for SOOTHE MAXIMUM
STRENGTH) - Tier 1; OTC
soothe oral suspension (generic for SOOTHE) - Tier 1; OTC
soothe oral tablet chewable (generic for SOOTHE) - Tier 1; OTC; QL
stomach relief extra strength (generic for SOOTHE MAXIMUM
STRENGTH) - Tier 1; OTC
stomach relief max st oral suspension 525 mg/15ml (generic for
SOOTHE MAXIMUM STRENGTH) - Tier 1; OTC
stomach relief oral suspension 1050 mg/30ml, 525 mg/15ml (generic
for SOOTHE MAXIMUM STRENGTH) - Tier 1; OTC
stomach relief oral suspension 262 mg/15ml, 525 mg/30ml, 527
mg/30ml (generic for SOOTHE) - Tier 1; OTC
stomach relief oral tablet 262 mg (generic for KAOPECTATE) - Tier 1;
OTC
stomach relief oral tablet chewable 262 mg (generic for SOOTHE) -
Tier 1; OTC; QL
stomach relief plus (generic for SOOTHE MAXIMUM STRENGTH) -
Tier 1; OTC
stomach relief ultra oral suspension 525 mg/15ml (generic for
SOOTHE MAXIMUM STRENGTH) - Tier 1; OTC
TUMS (brand for antacid) - Tier 2; OTC
TUMS CHEWY BITES (brand for antacid) - Tier 2; OTC
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
98
Preferred Agents Non-Preferred Agents
TUMS E-X 750 (brand for antacid) - Tier 2; OTC
TUMS EXTRA STRENGTH 750 (brand for antacid) - Tier 2; OTC
TUMS LASTING EFFECTS (brand for antacid) - Tier 2; OTC
TUMS SMOOTHIES (brand for antacid) - Tier 2; OTC
TUMS ULTRA 1000 (brand for antacid maximum) - Tier 2; OTC
VISBIOME HIGH POTENCY ORAL CAPSULE (brand for cvs adult
50+ probiotic) - Tier 2; OTC; QL
ZELAC (brand for cvs adult 50+ probiotic) - Tier 2; QL
Laxatives - Bowel Treatment Drugs
clearlax oral powder 17 gm/scoop (generic for CLEARLAX) - Tier 1;
ONLY powder bottle; OTC; QL
daily fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1;
OTC
daily fiber oral powder 43 % (generic for REGULOID) - Tier 1; OTC
enema mineral oil (generic for FLEET OIL) - Tier 1; OTC
EVAC (brand for cvs natural fiber supplement) - Tier 2; OTC
fiber laxative oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1;
OTC
fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1; OTC
fiber oral powder 28.3 % (generic for METAMUCIL SMOOTH
TEXTURE) - Tier 1; OTC; QL
fiber oral powder 43 % (generic for REGULOID) - Tier 1; OTC
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
99
Preferred Agents Non-Preferred Agents
fiber oral powder 58.6 % (generic for METAMUCIL SMOOTH
TEXTURE) - Tier 1; OTC
fiber powder oral powder 43 % (generic for REGULOID) - Tier 1; OTC
fiber therapy oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1;
OTC
fiber therapy oral powder 28.3 % (generic for METAMUCIL SMOOTH
TEXTURE) - Tier 1; OTC; QL
FLEET OIL (brand for cvs mineral oil enema) - Tier 2; OTC
ft clearlax (generic for CLEARLAX) - Tier 1; ONLY powder bottle;
OTC; QL
ft enema mineral oil (generic for FLEET OIL) - Tier 1; OTC
ft fiber oral powder 43 % (generic for REGULOID) - Tier 1; OTC
ft mineral oil - Tier 1; OTC
gavilax oral powder (generic for CLEARLAX) - Tier 1; ONLY powder
bottle; OTC; QL
gentlelax (generic for CLEARLAX) - Tier 1; ONLY powder bottle; OTC;
QL
glycolax (generic for CLEARLAX) - Tier 1; ONLY powder bottle; OTC;
QL
laxaclear (generic for CLEARLAX) - Tier 1; ONLY powder bottle; OTC;
QL
laxative oral powder 17 gm/scoop (generic for CLEARLAX) - Tier 1;
ONLY powder bottle; OTC; QL
METAMUCIL 4 IN 1 FIBER ORAL POWDER 43 % (brand for cvs
natural daily fiber) - Tier 2; OTC
METAMUCIL FREE & NATURAL (brand for cvs natural daily fiber) -
Tier 2; OTC
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
100
Preferred Agents Non-Preferred Agents
mineral oil enema (generic for FLEET OIL) - Tier 1; OTC
mineral oil heavy oral - Tier 1
mineral oil heavy oral oil - Tier 1; OTC
mineral oil oral oil - Tier 1; OTC
mineral oil rectal enema (generic for FLEET OIL) - Tier 1; OTC
MIRALAX ORAL POWDER (brand for ft clearlax) - Tier 2; ONLY
powder bottle; OTC; QL
mm clearlax (generic for CLEARLAX) - Tier 1; ONLY powder bottle;
OTC; QL
natural daily fiber (generic for METAMUCIL SMOOTH TEXTURE) -
Tier 1; OTC
natural fiber oral capsule 0.52 gm (generic for MEDI-MUCIL) - Tier 1;
OTC
natural fiber oral powder 28.3 % (generic for METAMUCIL SMOOTH
TEXTURE) - Tier 1; OTC; QL
natural fiber oral powder 58.6 % (generic for METAMUCIL SMOOTH
TEXTURE) - Tier 1; OTC
natural fiber supplement (generic for EVAC) - Tier 1; OTC
natural vegetable (generic for HYDROCIL) - Tier 1; OTC
natura-lax (generic for CLEARLAX) - Tier 1; ONLY powder bottle;
OTC; QL
peg 3350 oral powder (generic for CLEARLAX) - Tier 1; ONLY powder
bottle; OTC; QL
polyethylene glycol 3350 oral powder (generic for CLEARLAX) - Tier 1;
ONLY powder bottle; OTC; QL
polyethylene glycol 3350-grx oral powder (generic for CLEARLAX) -
Tier 1; ONLY powder bottle; OTC; QL
purelax oral powder (generic for CLEARLAX) - Tier 1; ONLY powder
bottle; OTC; QL
reguloid oral powder 43 % (generic for REGULOID) - Tier 1; OTC
smooth lax oral powder (generic for CLEARLAX) - Tier 1; ONLY
powder bottle; OTC; QL
sorbitol oral - Tier 1; OTC
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
101
Preferred Agents Non-Preferred Agents
Laxatives - Drugs to treat Constipation
AVEDANA GLYCERIN (ADULT) (brand for cvs glycerin adult) - Tier 2;
OTC
citroma (generic for CITROMA) - Tier 1; OTC; PD; QL
CITRUCEL (brand for cvs soluble fiber therapy) - Tier 2; OTC
COLACE (brand for cvs stool softener) - Tier 2; OTC; QL
col-rite oral capsule 250 mg - Tier 1; OTC; QL
docusate calcium (generic for SURFAK) - Tier 1; OTC
docusate mini (generic for DOCUSOL MINI) - Tier 1; OTC; QL
docusate sodium oral capsule (generic for COLACE) - Tier 1; OTC; QL
docusate sodium oral liquid (generic for ONELAX DOCUSATE
SODIUM) - Tier 1; OTC; QL
docusate sodium oral syrup - Tier 1; OTC
DOCUSOL MINI (brand for docusate mini) - Tier 2; OTC; QL
docuzen (generic for SENOKOT S) - Tier 1; OTC
dss (generic for COLACE) - Tier 1; OTC; QL
easy-lax plus (generic for SENOKOT S) - Tier 1; OTC
ENEMEEZ MINI (brand for docusate mini) - Tier 2; OTC; QL
EX-LAX MAXIMUM STRENGTH (brand for cvs laxative pills max st) -
Tier 2; OTC
fiber laxative + calcium (generic for FIBERCON) - Tier 1; OTC
fiber laxative oral tablet 500 mg (generic for CITRUCEL) - Tier 1; OTC
fiber oral tablet 500 mg (generic for CITRUCEL) - Tier 1; OTC
fiber oral tablet 625 mg (generic for FIBERCON) - Tier 1; OTC
fiber therapy oral tablet 500 mg (generic for CITRUCEL) - Tier 1; OTC
fiber therapy oral tablet 625 mg (generic for FIBERCON) - Tier 1; OTC
fiber-caps (generic for FIBERCON) - Tier 1; OTC
fiber-lax (generic for FIBERCON) - Tier 1; OTC
ft fiber laxative (generic for CITRUCEL) - Tier 1; OTC
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
102
Preferred Agents Non-Preferred Agents
ft magnesium citrate (generic for CITROMA) - Tier 1; OTC; PD; QL
ft senna laxative (generic for SENOKOT) - Tier 1; OTC; QL
ft senna laxatives (generic for SENOKOT) - Tier 1; OTC; QL
ft senna-s (generic for SENOKOT S) - Tier 1; OTC
ft stool softener oral capsule (generic for COLACE) - Tier 1; OTC; QL
ft stool softener oral tablet 50-8.6 mg (generic for SENOKOT S) - Tier
1; OTC
geri-kot (generic for SENOKOT) - Tier 1; OTC; QL
glycerin (adult) rectal suppository 2 gm (generic for AVEDANA
GLYCERIN (ADULT)) - Tier 1; OTC
glycerin (infants & children) rectal suppository 1 gm - Tier 1; OTC
glycerin adult rectal suppository 2 gm (generic for AVEDANA
GLYCERIN (ADULT)) - Tier 1; OTC
glycerin child rectal suppository 1 gm, 1.2 gm - Tier 1; OTC
glycerin childrens - Tier 1; OTC
glycerin pediatric rectal suppository 1.2 gm - Tier 1; OTC
laxacin (generic for SENOKOT S) - Tier 1; OTC
laxative max str (generic for EX-LAX MAXIMUM STRENGTH) - Tier 1;
OTC
laxative pills max st (generic for EX-LAX MAXIMUM STRENGTH) -
Tier 1; OTC
laxative pills oral tablet 25 mg (generic for EX-LAX MAXIMUM
STRENGTH) - Tier 1; OTC
laxative regular strength (generic for SENNA SMOOTH) - Tier 1; OTC
magnesium citrate oral solution (generic for CITROMA) - Tier 1; OTC;
PD; QL
mm stool softener laxative (generic for COLACE) - Tier 1; OTC; QL
natural senna laxative (generic for SENOKOT) - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
103
Preferred Agents Non-Preferred Agents
natural vegetable laxative oral tablet 8.6 mg (generic for SENOKOT) -
Tier 1; OTC; QL
ONELAX DOCUSATE SODIUM (brand for docusate sodium) - Tier 2;
OTC; QL
ONELAX MAGNESIUM CITRATE (brand for cvs magnesium citrate) -
Tier 2; OTC; PD; QL
ONELAX SENNA (brand for senna) - Tier 2; OTC
p col-rite (generic for SENOKOT S) - Tier 1; OTC
PEDIA-LAX ORAL LIQUID - Tier 2; OTC
PERDIEM OVERNIGHT RELIEF (brand for laxative regular strength) -
Tier 2; OTC
sb docusate sodium/senna (generic for SENOKOT S) - Tier 1; OTC
senexon-s (generic for SENOKOT S) - Tier 1; OTC
senna lax (generic for SENOKOT) - Tier 1; OTC; QL
senna laxative (generic for SENOKOT) - Tier 1; OTC; QL
senna oral liquid (generic for ONELAX SENNA) - Tier 1; OTC
senna oral syrup (generic for ONELAX SENNA) - Tier 1; OTC
senna oral tablet (generic for SENOKOT) - Tier 1; OTC; QL
senna plus oral tablet (generic for SENOKOT S) - Tier 1; OTC
senna s (generic for SENOKOT S) - Tier 1; OTC
senna smooth (generic for SENNA SMOOTH) - Tier 1; OTC
senna-docusate sodium (generic for SENOKOT S) - Tier 1; OTC
senna-lax (generic for SENOKOT) - Tier 1; OTC; QL
senna-plus (generic for SENOKOT S) - Tier 1; OTC
senna-s (generic for SENOKOT S) - Tier 1; OTC
senna-tabs (generic for SENOKOT) - Tier 1; OTC; QL
senna-time (generic for SENOKOT) - Tier 1; OTC; QL
senna-time s (generic for SENOKOT S) - Tier 1; OTC
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
104
Preferred Agents Non-Preferred Agents
sennazon (generic for ONELAX SENNA) - Tier 1; OTC
SENOKOT (brand for cvs senna) - Tier 2; OTC; QL
SENOKOT S (brand for cvs senna plus) - Tier 2; OTC
soluble fiber therapy (generic for CITRUCEL) - Tier 1; OTC
stimulant lax plus (generic for SENOKOT S) - Tier 1; OTC
stimulant laxative (generic for SENOKOT S) - Tier 1; OTC
stool softener laxative oral capsule (generic for COLACE) - Tier 1;
OTC; QL
stool softener oral capsule 100 mg (generic for COLACE) - Tier 1;
OTC; QL
stool softener oral capsule 240 mg (generic for SURFAK) - Tier 1;
OTC
stool softener oral capsule 250 mg - Tier 1; OTC; QL
stool softener oral capsule 50 mg (generic for COLACE CLEAR) - Tier
1; OTC
stool softener pls laxative (generic for SENOKOT S) - Tier 1; OTC
stool softener plus laxative (generic for SENOKOT S) - Tier 1; OTC
stool softener/laxative (generic for SENOKOT S) - Tier 1; OTC
stool softener/laxative oral tablet (generic for SENOKOT S) - Tier 1;
OTC
vegetable lax+stool softener (generic for SENOKOT S) - Tier 1; OTC
vegetable laxative (generic for SENOKOT) - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
105
Preferred Agents Non-Preferred Agents
Genetic or Enzyme or Protein Disorder: Replacement, Modifiers,
Treatment
CHOLBAM - Tier 2; PA; SP; QL
CREON - Tier 2
CYSTAGON - Tier 2; SP; QL
NITYR - Tier 2; DX2RX; SP; CH; QL
RAVICTI - Tier 2; PA; SP; CH; QL
sapropterin dihydrochloride (generic for JAVYGTOR) - Tier 1; DX2RX;
SP; CH; QL
sodium phenylbutyrate oral powder (generic for BUPHENYL) - Tier 1;
DX2RX; SP; CH; QL
STRENSIQ - Tier 2; PA; SP
TEGSEDI - Tier 2; PA; SP; QL
VYNDAMAX - Tier 2; PA; SP; QL
VYNDAQEL - Tier 2; PA; SP; QL
CERDELGA - Tier 2; PA; SP; QL
ORFADIN (brand for nitisinone) - Tier 2; PA; SP; CH; QL
PHEBURANE - Tier 2; PA; SP; CH; QL
ZENPEP ORAL CAPSULE DELAYED RELEASE PARTICLES 10000-
32000 UNIT, 15000-47000 UNIT, 20000-63000 UNIT, 25000-79000
UNIT, 3000-10000 UNIT, 40000-126000 UNIT, 5000-24000 UNIT -
Tier 2
Genitourinary Agents
Antispasmodics, Urinary
oxybutynin chloride er - Tier 1; QL
oxybutynin chloride oral tablet 5 mg - Tier 1; QL
OXYTROL FOR WOMEN - Tier 2; OTC; QL
solifenacin succinate (generic for VESICARE) - Tier 1; QL
tolterodine tartrate (generic for DETROL) - Tier 1; ST; QL
tolterodine tartrate er (generic for DETROL LA) - Tier 1; PA; QL
trospium chloride - Tier 1; QL
MYRBETRIQ ORAL SUSPENSION RECONSTITUTED ER - Tier 2; PA;
QL; AL
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HOUR (brand
for mirabegron er) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
106
Preferred Agents Non-Preferred Agents
Benign Prostatic Hypertrophy Agents
alfuzosin hcl er (generic for UROXATRAL) - Tier 1; QL
finasteride oral tablet 5 mg (generic for PROSCAR) - Tier 1; QL
tamsulosin hcl (generic for FLOMAX) - Tier 1; QL
terazosin hcl - Tier 1; QL
Genitourinary Agents, Other
bethanechol chloride oral - Tier 1
ELMIRON - Tier 2; DX2RX; QL
penicillamine oral tablet (generic for DEPEN TITRATABS) - Tier 1;
DX2RX; SP; QL
DEPEN TITRATABS (brand for penicillamine) - Tier 2; DX2RX; SP; QL
THIOLA (brand for tiopronin) - Tier 2; PA; SP
THIOLA EC (brand for tiopronin) - Tier 2; PA; SP; QL
Genitourinary Agents - Drugs to Treat Bladder, Genital and
Kidney Conditions
Genitourinary Agents, Other - Miscellaneous Bladder, Genital,
and Kidney Conditions Drugs
azo (generic for PHENAZO) - Tier 1; OTC
phenazo oral tablet 200 mg (generic for PHENAZO) - Tier 1; QL
phenazo oral tablet 95 mg (generic for PHENAZO) - Tier 1; OTC
phenazopyridine hcl oral tablet 100 mg (generic for PYRIDIUM) - Tier
1; QL
phenazopyridine hcl oral tablet 200 mg (generic for PHENAZO) - Tier
1; QL
phenazopyridine hcl oral tablet 95 mg (generic for PHENAZO) - Tier 1;
OTC
PYRIDIUM (brand for phenazopyridine hcl) - Tier 2; QL
urinary pain relief oral tablet 95 mg (generic for PHENAZO) - Tier 1;
OTC
URO-PAIN (brand for cvs urinary pain relief) - Tier 2; OTC
Glycemic Agents - Diabetic Drugs
Blood Glucose Regulators - Drugs to Regulate Blood Sugar
ZEGALOGUE - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
107
Preferred Agents Non-Preferred Agents
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
dexamethasone intensol - Tier 1
dexamethasone oral elixir - Tier 1; QL
dexamethasone oral solution - Tier 1; QL
dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 2 mg - Tier 1
dexamethasone oral tablet 1.5 mg, 4 mg, 6 mg - Tier 1; QL
fludrocortisone acetate oral - Tier 1; QL
hydrocortisone oral tablet 10 mg, 20 mg, 5 mg (generic for CORTEF) -
Tier 1; QL
MEDROL ORAL TABLET 2 MG - Tier 2
methylprednisolone oral (generic for MEDROL) - Tier 1; QL
prednisolone oral solution - Tier 1; QL
prednisolone sodium phosphate oral solution 15 mg/5ml - Tier 1
prednisolone sodium phosphate oral solution 6.7 (5 base) mg/5ml
(generic for PEDIAPRED) - Tier 1; QL
ACTHAR - Tier 2; PA; SP; QL
CORTROPHIN - Tier 2; PA; SP; QL
prednisone oral solution - Tier 1; QL
prednisone oral tablet - Tier 1; QL
prednisone oral tablet therapy pack 10 mg (21) - Tier 1; QL
prednisone oral tablet therapy pack 10 mg (48), 5 mg (21), 5 mg (48) -
Tier 1
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
desmopressin ace spray refrig - Tier 1; QL
desmopressin acetate oral (generic for DDAVP) - Tier 1; CH; QL
desmopressin acetate spray - Tier 1; QL
EGRIFTA SV - Tier 2; DX2RX; SP; QL
INCRELEX - Tier 2; PA; SP
NOCDURNA - Tier 2; PA; QL
NOVAREL - Tier 2; PA; SP
NUTROPIN AQ NUSPIN 10 - Tier 2; PA; SP
NUTROPIN AQ NUSPIN 20 - Tier 2; PA; SP
NUTROPIN AQ NUSPIN 5 - Tier 2; PA; SP
PREGNYL (brand for chorionic gonadotropin) - Tier 2; PA; SP
GENOTROPIN - Tier 2; PA; SP
GENOTROPIN MINIQUICK - Tier 2; PA; SP
HUMATROPE - Tier 2; PA; SP
NORDITROPIN FLEXPRO - Tier 2; PA; SP
OMNITROPE - Tier 2; PA; SP
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
108
Preferred Agents Non-Preferred Agents
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) -
Drugs to Regulate Hormones
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) -
Hormone Replacement/Modifying Drugs
FOLLISTIM AQ - Tier 2; PA; SP
GONAL-F - Tier 2; PA; SP
GONAL-F RFF - Tier 2; PA; SP
GONAL-F RFF REDIJECT - Tier 2; PA; SP
OVIDREL - Tier 2; PA; SP
SKYTROFA - Tier 2; PA; SP; QL
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins)
methergine (generic for METHERGINE) - Tier 1; QL
methylergonovine maleate oral (generic for METHERGINE) - Tier 1;
QL
mifepristone oral tablet 300 mg (generic for KORLYM) - Tier 1; PA;
SP; QL
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins) - Drugs to Regulate Hormones
Hormonal Agents, Stimulant/Replacement/Modifying
(Prostaglandins) - Hormone Replacement/Modifying Drugs
mifepristone oral tablet 200 mg (generic for MIFEPREX) - Tier 1;
Coverage based on benefit; CH; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
109
Preferred Agents Non-Preferred Agents
Hormonal Agents, Stimulant/Replacement/Modifying (Sex
Hormones/Modifiers)
Androgens
danazol oral - Tier 1; QL
DEPO-TESTOSTERONE SOLUTION 200 MG/ML INTRAMUSCULAR
(brand for testosterone cypionate) - Tier 2; PA; QL
NATESTO - Tier 2; PA; QL
testosterone cypionate intramuscular (generic for DEPO-
TESTOSTERONE) - Tier 1; PA; QL
testosterone enanthate intramuscular - Tier 1; PA; QL
testosterone transdermal gel 1.62 %, 20.25 mg/act (1.62%) (generic
for ANDROGEL PUMP) - Tier 1; PA; QL
testosterone transdermal gel 12.5 mg/act (1%) (generic for VOGELXO
PUMP) - Tier 1; PA; QL
testosterone transdermal gel 20.25 mg/1.25gm (1.62%), 25 mg/2.5gm
(1%) - Tier 1; PA; QL
testosterone transdermal gel 40.5 mg/2.5gm (1.62%) - Tier 1; PA
ANDRODERM - Tier 2; PA; QL
TESTIM (brand for testosterone) - Tier 2; PA; QL
XYOSTED - Tier 2; PA; QL
Estrogens
afirmelle (generic for AFIRMELLE) - Tier 1; PD; QL; GE
ALORA (brand for estradiol) - Tier 2; QL
altavera (generic for ALTAVERA) - Tier 1; PD; QL; GE
alyacen 1/35 (generic for DASETTA 1/35) - Tier 1; PD; QL; GE
alyacen 7/7/7 (generic for DASETTA 7/7/7) - Tier 1; PD; QL; GE
apri - Tier 1; PD; QL; GE
aranelle - Tier 1; PD; QL; GE
ashlyna (generic for ASHLYNA) - Tier 1; PD; QL
aubra eq (generic for AFIRMELLE) - Tier 1; PD; QL; GE
aurovela 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; PD; QL; GE
aurovela 1/20 (generic for AUROVELA 1/20) - Tier 1; PD; QL; GE
aurovela 24 fe - Tier 1; PD; QL
aurovela fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; PD;
QL; GE
ANNOVERA - Tier 2; PA; PD; QL
BALCOLTRA (brand for levonorgest-eth estradiol-iron) - Tier 2; PA; PD;
QL
BEYAZ (brand for drospiren-eth estrad-levomefol) - Tier 2; PA; PD; QL
BIJUVA ORAL CAPSULE 1-100 MG - Tier 2; PA; QL
CLIMARA (brand for estradiol) - Tier 2; PA; QL
CLIMARA PRO - Tier 2; PA
DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.75 MG/0.75GM, 1.25
MG/1.25GM (brand for estradiol) - Tier 2; PA; QL
DIVIGEL TRANSDERMAL GEL 0.5 MG/0.5GM, 1 MG/GM (brand for
estradiol) - Tier 2; PA
ELESTRIN - Tier 2; PA
EVAMIST - Tier 2; PA
LO LOESTRIN FE - Tier 2; PA; PD; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
110
Preferred Agents Non-Preferred Agents
aurovela fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; PD; QL;
GE
aviane (generic for AFIRMELLE) - Tier 1; PD; QL; GE
ayuna (generic for ALTAVERA) - Tier 1; PD; QL; GE
azurette (generic for AZURETTE) - Tier 1; PD; QL; GE
balziva (generic for BALZIVA) - Tier 1; PD; QL; GE
blisovi 24 fe - Tier 1; PD; QL
blisovi fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; PD; QL;
GE
blisovi fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; PD; QL; GE
briellyn (generic for BALZIVA) - Tier 1; PD; QL; GE
camrese (generic for ASHLYNA) - Tier 1; PD; QL
camrese lo (generic for CAMRESE LO) - Tier 1; PD; QL
charlotte 24 fe (generic for CHARLOTTE 24 FE) - Tier 1; PD; QL; GE
NATAZIA - Tier 2; PA; PD; QL
NUVARING (brand for etonogestrel-ethinyl estradiol) - Tier 2; PA; PD; QL;
GE
SAFYRAL (brand for drospiren-eth estrad-levomefol) - Tier 2; PA; PD; QL
VIVELLE-DOT (brand for estradiol) - Tier 2; PA; QL
YASMIN 28 (brand for drospirenone-ethinyl estradiol) - Tier 2; PA; PD; QL
YAZ (brand for drospirenone-ethinyl estradiol) - Tier 2; PA; PD; QL
chateal eq (generic for ALTAVERA) - Tier 1; PD; QL; GE
cryselle-28 - Tier 1; PD; QL; GE
cyred eq - Tier 1; PD; QL; GE
dasetta 1/35 (generic for DASETTA 1/35) - Tier 1; PD; QL; GE
dasetta 7/7/7 (generic for DASETTA 7/7/7) - Tier 1; PD; QL; GE
daysee (generic for ASHLYNA) - Tier 1; PD; QL
delyla (generic for AFIRMELLE) - Tier 1; PD; QL; GE
DEPO-ESTRADIOL - Tier 2; QL
desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg (21/5)
(generic for AZURETTE) - Tier 1; PD; QL; GE
dotti (generic for DOTTI) - Tier 1; QL
drospirenone-ethinyl estradiol (generic for JASMIEL) - Tier 1; PD; QL
DUAVEE - Tier 2; QL
elinest - Tier 1; PD; QL; GE
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
111
Preferred Agents Non-Preferred Agents
eluryng (generic for ELURYNG) - Tier 1; PD; QL; GE
enilloring (generic for ELURYNG) - Tier 1; PD; QL; GE
enpresse-28 (generic for ENPRESSE-28) - Tier 1; PD; QL; GE
enskyce - Tier 1; PD; QL; GE
estarylla (generic for ESTARYLLA) - Tier 1; PD; QL; GE
estradiol oral (generic for ESTRACE) - Tier 1; QL
estradiol transdermal patch twice weekly (generic for DOTTI) - Tier 1;
QL
estradiol transdermal patch weekly (generic for CLIMARA) - Tier 1; QL
estradiol vaginal (generic for ESTRACE) - Tier 1; QL
ethynodiol diac-eth estradiol (generic for KELNOR 1/35) - Tier 1; PD;
QL; GE
etonogestrel-ethinyl estradiol (generic for ELURYNG) - Tier 1; PD; QL;
GE
falmina (generic for AFIRMELLE) - Tier 1; PD; QL; GE
finzala (generic for CHARLOTTE 24 FE) - Tier 1; PD; QL; GE
hailey 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; PD; QL; GE
hailey 24 fe - Tier 1; PD; QL
hailey fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; PD; QL;
GE
hailey fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; PD; QL; GE
haloette (generic for ELURYNG) - Tier 1; PD; QL; GE
iclevia (generic for ICLEVIA) - Tier 1; PD; QL
introvale (generic for ICLEVIA) - Tier 1; PD; QL
isibloom - Tier 1; PD; QL; GE
jaimiess (generic for ASHLYNA) - Tier 1; PD; QL
jasmiel (generic for JASMIEL) - Tier 1; PD; QL
jolessa (generic for ICLEVIA) - Tier 1; PD; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
112
Preferred Agents Non-Preferred Agents
juleber - Tier 1; PD; QL; GE
junel 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; PD; QL; GE
junel 1/20 (generic for AUROVELA 1/20) - Tier 1; PD; QL; GE
junel fe oral tablet 1.5-30 mg-mcg (generic for AUROVELA FE 1.5/30)
- Tier 1; PD; QL; GE
junel fe oral tablet 1-20 mg-mcg (generic for AUROVELA FE 1/20) -
Tier 1; PD; QL; GE
junel fe oral tablet 1-20 mg-mcg(24) - Tier 1; PD; QL
kalliga - Tier 1; PD; QL; GE
kariva (generic for AZURETTE) - Tier 1; PD; QL; GE
kelnor 1/35 (generic for KELNOR 1/35) - Tier 1; PD; QL; GE
kelnor 1/50 (generic for KELNOR 1/50) - Tier 1; PD; QL; GE
kurvelo (generic for ALTAVERA) - Tier 1; PD; QL; GE
larin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; PD; QL; GE
larin 1/20 (generic for AUROVELA 1/20) - Tier 1; PD; QL; GE
larin 24 fe - Tier 1; PD; QL
larin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; PD; QL; GE
larin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; PD; QL; GE
leena - Tier 1; PD; QL; GE
lessina (generic for AFIRMELLE) - Tier 1; PD; QL; GE
levonest (generic for ENPRESSE-28) - Tier 1; PD; QL; GE
levonorgest-eth estrad 91-day (generic for ASHLYNA) - Tier 1; PD; QL
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg (generic for
AFIRMELLE) - Tier 1; PD; QL; GE
levonorgestrel-ethinyl estrad oral tablet 0.15-30 mg-mcg (generic for
ALTAVERA) - Tier 1; PD; QL; GE
levonorg-eth estrad triphasic (generic for ENPRESSE-28) - Tier 1; PD;
QL; GE
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
113
Preferred Agents Non-Preferred Agents
levora 0.15/30 (28) (generic for ALTAVERA) - Tier 1; PD; QL; GE
lojaimiess (generic for CAMRESE LO) - Tier 1; PD; QL
loryna (generic for JASMIEL) - Tier 1; PD; QL
low-ogestrel - Tier 1; PD; QL; GE
lo-zumandimine (generic for JASMIEL) - Tier 1; PD; QL
lutera (generic for AFIRMELLE) - Tier 1; PD; QL; GE
lyllana (generic for DOTTI) - Tier 1; QL
marlissa (generic for ALTAVERA) - Tier 1; PD; QL; GE
mibelas 24 fe (generic for CHARLOTTE 24 FE) - Tier 1; PD; QL; GE
microgestin 1.5/30 (generic for AUROVELA 1.5/30) - Tier 1; PD; QL;
GE
microgestin 1/20 (generic for AUROVELA 1/20) - Tier 1; PD; QL; GE
microgestin 24 fe - Tier 1; PD; QL
microgestin fe 1.5/30 (generic for AUROVELA FE 1.5/30) - Tier 1; PD;
QL; GE
microgestin fe 1/20 (generic for AUROVELA FE 1/20) - Tier 1; PD; QL;
GE
mili (generic for ESTARYLLA) - Tier 1; PD; QL; GE
mono-linyah (generic for ESTARYLLA) - Tier 1; PD; QL; GE
necon 0.5/35 (28) - Tier 1; PD; QL; GE
nikki (generic for JASMIEL) - Tier 1; PD; QL
norelgestromin-eth estradiol (generic for XULANE) - Tier 1; PD; QL;
GE
norethin ace-eth estrad-fe oral tablet (generic for AUROVELA FE
1.5/30) - Tier 1; PD; QL; GE
norethin ace-eth estrad-fe oral tablet chewable (generic for
CHARLOTTE 24 FE) - Tier 1; PD; QL; GE
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
114
Preferred Agents Non-Preferred Agents
norethindrone acet-ethinyl est (generic for AUROVELA 1.5/30) - Tier 1;
PD; QL; GE
norethindron-ethinyl estrad-fe (generic for TILIA FE) - Tier 1; PD; QL;
GE
norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg (generic
for WYMZYA FE) - Tier 1; PD; QL
norgestimate-eth estradiol (generic for ESTARYLLA) - Tier 1; PD; QL;
GE
norgestimate-ethinyl estradiol triphasic (generic for TRI-ESTARYLLA) -
Tier 1; PD; QL; GE
nortrel 0.5/35 (28) - Tier 1; PD; QL; GE
nortrel 1/35 (21) (generic for DASETTA 1/35) - Tier 1; PD; QL; GE
nortrel 1/35 (28) (generic for DASETTA 1/35) - Tier 1; PD; QL; GE
nortrel 7/7/7 (generic for DASETTA 7/7/7) - Tier 1; PD; QL; GE
nylia 1/35 (generic for DASETTA 1/35) - Tier 1; PD; QL; GE
nylia 7/7/7 (generic for DASETTA 7/7/7) - Tier 1; PD; QL; GE
nymyo (generic for ESTARYLLA) - Tier 1; PD; QL; GE
ocella (generic for OCELLA) - Tier 1; PD; QL
philith (generic for BALZIVA) - Tier 1; PD; QL; GE
pimtrea (generic for AZURETTE) - Tier 1; PD; QL; GE
portia-28 (generic for ALTAVERA) - Tier 1; PD; QL; GE
PREMARIN ORAL - Tier 2; QL
PREMARIN VAGINAL - Tier 2; QL
PREMPHASE - Tier 2; QL
PREMPRO - Tier 2; QL
reclipsen - Tier 1; PD; QL; GE
setlakin (generic for ICLEVIA) - Tier 1; PD; QL
simliya (generic for AZURETTE) - Tier 1; PD; QL; GE
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
115
Preferred Agents Non-Preferred Agents
simpesse (generic for ASHLYNA) - Tier 1; PD; QL
sprintec 28 (generic for ESTARYLLA) - Tier 1; PD; QL; GE
sronyx (generic for AFIRMELLE) - Tier 1; PD; QL; GE
syeda (generic for OCELLA) - Tier 1; PD; QL
tarina 24 fe - Tier 1; PD; QL
tarina fe 1/20 eq (generic for AUROVELA FE 1/20) - Tier 1; PD; QL;
GE
tilia fe (generic for TILIA FE) - Tier 1; PD; QL; GE
tri-estarylla (generic for TRI-ESTARYLLA) - Tier 1; PD; QL; GE
tri-legest fe (generic for TILIA FE) - Tier 1; PD; QL; GE
tri-linyah (generic for TRI-ESTARYLLA) - Tier 1; PD; QL; GE
tri-lo-estarylla (generic for TRI-LO-ESTARYLLA) - Tier 1; PD; QL; GE
tri-lo-marzia (generic for TRI-LO-ESTARYLLA) - Tier 1; PD; QL; GE
tri-mili (generic for TRI-ESTARYLLA) - Tier 1; PD; QL; GE
tri-nymyo (generic for TRI-ESTARYLLA) - Tier 1; PD; QL; GE
tri-sprintec (generic for TRI-ESTARYLLA) - Tier 1; PD; QL; GE
trivora (28) (generic for ENPRESSE-28) - Tier 1; PD; QL; GE
tri-vylibra (generic for TRI-ESTARYLLA) - Tier 1; PD; QL; GE
tri-vylibra lo (generic for TRI-LO-ESTARYLLA) - Tier 1; PD; QL; GE
turqoz - Tier 1; PD; QL; GE
TYBLUME - Tier 2; PD; QL; GE
velivet - Tier 1; PD; QL
vestura (generic for JASMIEL) - Tier 1; PD; QL
vienva (generic for AFIRMELLE) - Tier 1; PD; QL; GE
viorele (generic for AZURETTE) - Tier 1; PD; QL; GE
volnea (generic for AZURETTE) - Tier 1; PD; QL; GE
vyfemla (generic for BALZIVA) - Tier 1; PD; QL; GE
vylibra (generic for ESTARYLLA) - Tier 1; PD; QL; GE
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
116
Preferred Agents Non-Preferred Agents
wera - Tier 1; PD; QL; GE
wymzya fe (generic for WYMZYA FE) - Tier 1; PD; QL
xulane (generic for XULANE) - Tier 1; PD; QL; GE
yuvafem (generic for YUVAFEM) - Tier 1; QL
zafemy (generic for XULANE) - Tier 1; PD; QL; GE
zovia 1/35 (28) (generic for KELNOR 1/35) - Tier 1; PD; QL; GE
zumandimine (generic for OCELLA) - Tier 1; PD; QL
Progestins
camila (generic for CAMILA) - Tier 1; PD; QL; GE
deblitane (generic for CAMILA) - Tier 1; PD; QL; GE
ELLA - Tier 2; PD; QL
emzahh (generic for CAMILA) - Tier 1; PD; QL; GE
errin (generic for CAMILA) - Tier 1; PD; QL; GE
heather (generic for CAMILA) - Tier 1; PD; QL; GE
incassia (generic for CAMILA) - Tier 1; PD; QL; GE
jencycla (generic for CAMILA) - Tier 1; PD; QL; GE
lyleq (generic for CAMILA) - Tier 1; PD; QL; GE
lyza (generic for CAMILA) - Tier 1; PD; QL; GE
medroxyprogesterone acetate intramuscular (generic for DEPO-
PROVERA) - Tier 1; PD; QL; GE
medroxyprogesterone acetate oral (generic for PROVERA) - Tier 1;
QL
ENDOMETRIN - Tier 2; PA
megestrol acetate oral suspension 40 mg/ml - Tier 1; PD; CH; QL
megestrol acetate oral tablet 20 mg - Tier 1; PD; CH
megestrol acetate oral tablet 40 mg - Tier 1; PD; CH; QL
nora-be (generic for CAMILA) - Tier 1; PD; QL; GE
norethindrone acetate oral - Tier 1; QL
norethindrone oral (generic for CAMILA) - Tier 1; PD; QL; GE
norlyroc (generic for CAMILA) - Tier 1; PD; QL; GE
progesterone oral (generic for PROMETRIUM) - Tier 1; DX2RX; QL
sharobel (generic for CAMILA) - Tier 1; PD; QL; GE
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
117
Preferred Agents Non-Preferred Agents
Selective Estrogen Receptor Modifying Agents
raloxifene hcl (generic for EVISTA) - Tier 1; PD; CH; QL OSPHENA - Tier 2; PA; CH; QL; GE
Hormonal Agents, Stimulant/Replacement/Modifying (Sex
Hormones/Modifiers) - Drugs to Regulate Hormones
Progestins - Hormone Replacement/Modifying Drugs
aftera (generic for AFTERA) - Tier 1; OTC; PD; QL; GE
curae (generic for AFTERA) - Tier 1; OTC; PD; QL; GE
econtra one-step (generic for AFTERA) - Tier 1; OTC; PD; QL; GE
her style (generic for AFTERA) - Tier 1; OTC; PD; QL; GE
levonorgestrel (generic for AFTERA) - Tier 1; OTC; PD; QL; GE
my choice (generic for AFTERA) - Tier 1; OTC; PD; QL; GE
my way (generic for AFTERA) - Tier 1; OTC; PD; QL; GE
new day (generic for AFTERA) - Tier 1; OTC; PD; QL; GE
opcicon one-step (generic for AFTERA) - Tier 1; OTC; PD; QL; GE
option 2 (generic for AFTERA) - Tier 1; OTC; PD; QL; GE
PLAN B ONE-STEP (brand for levonorgestrel) - Tier 2; OTC; PD; QL;
GE
react (generic for AFTERA) - Tier 1; OTC; PD; QL; GE
take action (generic for AFTERA) - Tier 1; OTC; PD; QL; GE
Selective Estrogen Receptor Modifying Agents - Hormone
Replacement/Modifying Drugs
CLOMID - Tier 2; CH
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
euthyrox (generic for EUTHYROX) - Tier 1; QL
levo-t (generic for EUTHYROX) - Tier 1; QL
levothyroxine sodium oral tablet (generic for EUTHYROX) - Tier 1; QL
levoxyl (generic for EUTHYROX) - Tier 1; QL
liothyronine sodium oral (generic for CYTOMEL) - Tier 1; QL
unithroid (generic for EUTHYROX) - Tier 1; QL
ERMEZA - Tier 2; PA; QL
TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125 MCG, 13 MCG,
137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG,
88 MCG (brand for levothyroxine sodium) - Tier 2; PA; QL
TIROSINT-SOL - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
118
Preferred Agents Non-Preferred Agents
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) -
Drugs to Replace Thyroid Hormones
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) -
Thyroid Replacement Drugs
ARMOUR THYROID (brand for niva thyroid) - Tier 2; PA; QL
Hormonal Agents, Suppressant (Adrenal)
LYSODREN - Tier 2; PD; CH; QL
Hormonal Agents, Suppressant (Pituitary)
cabergoline - Tier 1; CH; QL
leuprolide acetate injection - Tier 1; PA; SP; PD
LUPRON DEPOT (1-MONTH) - Tier 2; PA; SP; PD; QL
LUPRON DEPOT (3-MONTH) - Tier 2; PA; SP; PD; QL
LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG - Tier 2;
PA; SP; PD; QL
LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG - Tier 2;
PA; SP; PD; QL
LUPRON DEPOT-PED (1-MONTH) - Tier 2; PA; SP; QL
LUPRON DEPOT-PED (3-MONTH) - Tier 2; PA; SP
LUPRON DEPOT-PED (6-MONTH) - Tier 2; SP
octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml (generic
for SANDOSTATIN) - Tier 1; SP
octreotide acetate injection solution 1000 mcg/ml - Tier 1; SP; QL
FENSOLVI (6 MONTH) - Tier 2; PA; SP; QL
ORIAHNN - Tier 2; PA; QL
TRIPTODUR - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
119
Preferred Agents Non-Preferred Agents
octreotide acetate injection solution 200 mcg/ml - Tier 1; SP
octreotide acetate injection solution 500 mcg/ml (generic for
SANDOSTATIN) - Tier 1; SP; QL
octreotide acetate subcutaneous solution prefilled syringe 100 mcg/ml,
50 mcg/ml - Tier 1; SP
octreotide acetate subcutaneous solution prefilled syringe 500 mcg/ml
- Tier 1; SP; QL
ORILISSA - Tier 2; PA; CH; QL
SIGNIFOR - Tier 2; PA; SP; QL
SOMAVERT - Tier 2; PA; SP; QL
Hormonal Agents, Suppressant (Pituitary) - Drugs to Regulate
Hormones
Hormonal Agents, Suppressant (Pituitary) - Hormone
Suppressants
MENOPUR - Tier 2; PA; SP ganirelix acetate (generic for FYREMADEL) - Tier 1; PA; SP
Hormonal Agents, Suppressant (Thyroid)
Antithyroid Agents
methimazole oral - Tier 1; QL
propylthiouracil oral - Tier 1; QL
Immune Suppressants - Immune System Drugs
Immunological Agents - Drugs that Stimulate or Suppress the
Immune System
LUPKYNIS - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
120
Preferred Agents Non-Preferred Agents
Immunological Agents
Angioedema Agents
HAEGARDA - Tier 2; PA; SP; QL
icatibant acetate (generic for SAJAZIR) - Tier 1; PA; SP; QL
RUCONEST - Tier 2; PA; SP; QL
sajazir (generic for SAJAZIR) - Tier 1; PA; SP; QL
Immunological Agents, Other
ACTEMRA ACTPEN - Tier 2; PA; SP; QL
ACTEMRA SUBCUTANEOUS - Tier 2; PA; SP; QL
COSENTYX SUBCUTANEOUS SOLUTION AUTO-INJECTOR 150
MG/ML - Tier 2; PA; SP; QL
COSENTYX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
150 MG/ML, 75 MG/0.5ML - Tier 2; PA; SP; QL
COSENTYX UNOREADY - Tier 2; PA; QL
DUPIXENT - Tier 2; PA; SP; QL
ILARIS - Tier 2; PA; SP; QL
KINERET - Tier 2; PA; SP; QL
OLUMIANT ORAL TABLET 1 MG, 2 MG - Tier 2; PA; SP; QL
ORENCIA CLICKJECT - Tier 2; PA; SP; QL
ORENCIA SUBCUTANEOUS - Tier 2; PA; SP; QL
OTEZLA - Tier 2; PA; SP; QL
ADBRY - Tier 2; PA; SP; QL
ILUMYA - Tier 2; PA; SP; QL
KEVZARA - Tier 2; PA; SP; QL
SKYRIZI PEN - Tier 2; PA; SP; QL
SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier 2;
PA; SP; QL
TALTZ - Tier 2; PA; SP; QL
RINVOQ - Tier 2; PA; SP; QL
STELARA SUBCUTANEOUS - Tier 2; PA; SP; QL
SYNAGIS - Tier 2; PA; SP; QL
TREMFYA - Tier 2; PA; SP; QL
XELJANZ - Tier 2; PA; SP; QL
XELJANZ XR - Tier 2; PA; SP; QL
XOLAIR - Tier 2; PA; SP; QL
Immunostimulants
ACTIMMUNE - Tier 2; PA; SP; PD
PEGASYS - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
121
Preferred Agents Non-Preferred Agents
Immunosuppressants
azathioprine oral tablet 50 mg (generic for IMURAN) - Tier 1; QL
CIMZIA (2 SYRINGE) - Tier 2; PA; SP; QL
CIMZIA VIAL KIT - Tier 2; PA; SP; QL
CIMZIA SUBCUTANEOUS PREFILLED SYRINGE KIT 6 X 200
MG/ML - Tier 2; PA; SP; QL
cyclosporine modified (generic for GENGRAF) - Tier 1; QL
cyclosporine oral (generic for SANDIMMUNE) - Tier 1; QL
everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg, 1 mg (generic for
ZORTRESS) - Tier 1
gengraf oral capsule (generic for GENGRAF) - Tier 1; QL
HUMIRA (2 PEN) - Tier 2; PA; SP; QL
HUMIRA (2 SYRINGE) - Tier 2; PA; SP; QL
HUMIRA SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML - Tier
2; PA; SP; QL
ENBREL - Tier 2; PA; SP; QL
OTREXUP - Tier 2; PA; QL
RASUVO - Tier 2; PA; QL
TREXALL - Tier 2; PA; PD; CH
HUMIRA-PED<40KG CROHNS STARTER - Tier 2; PA; SP; QL
HUMIRA-PED>/=40KG CROHNS START - Tier 2; PA; SP; QL
HUMIRA-PED>/=40KG UC STARTER - Tier 2; PA; SP; QL
HUMIRA-PSORIASIS/UVEIT STARTER - Tier 2; PA; SP; QL
leflunomide oral (generic for ARAVA) - Tier 1; QL
methotrexate sodium (pf) - Tier 1; PD
methotrexate sodium injection - Tier 1; PD
methotrexate sodium oral - Tier 1; PD; CH
mycophenolate mofetil oral (generic for CELLCEPT) - Tier 1; QL
mycophenolate sodium (generic for MYFORTIC) - Tier 1; QL
mycophenolic acid (generic for MYFORTIC) - Tier 1; QL
SIMPONI - Tier 2; PA; SP; QL
sirolimus oral solution (generic for RAPAMUNE) - Tier 1; QL
sirolimus oral tablet 0.5 mg, 1 mg (generic for RAPAMUNE) - Tier 1;
QL
sirolimus oral tablet 2 mg (generic for RAPAMUNE) - Tier 1
tacrolimus oral capsule 0.5 mg, 5 mg (generic for PROGRAF) - Tier 1
tacrolimus oral capsule 1 mg (generic for PROGRAF) - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
122
Preferred Agents Non-Preferred Agents
Vaccines
ACTHIB - Tier 2; PD
ADACEL - Tier 2; QL
BEXSERO - Tier 2; PD; QL
BOOSTRIX - Tier 2; QL
DAPTACEL - Tier 2; QL
ENGERIX-B - Tier 2; PD; QL
GARDASIL 9 - Tier 2; PD; QL
HAVRIX - Tier 2; PD; QL
HIBERIX - Tier 2; PD
INFANRIX - Tier 2; QL
IPOL - Tier 2; PD
MENQUADFI - Tier 2; PD; QL
MENVEO - Tier 2; PD; QL
M-M-R II - Tier 2; PD; QL
PEDIARIX - Tier 2; QL
PEDVAX HIB - Tier 2; PD
PENTACEL - Tier 2; QL
PREHEVBRIO - Tier 2; PD; QL
PRIORIX - Tier 2; PD; QL
PROQUAD - Tier 2; PD; QL
QUADRACEL INTRAMUSCULAR SUSPENSION - Tier 2; QL
RECOMBIVAX HB - Tier 2; PD; QL
ROTARIX - Tier 2; PD; AL
ROTATEQ - Tier 2; PD
SHINGRIX - Tier 2; PD; QL; AL
TDVAX (brand for tetanus-diphtheria toxoids td) - Tier 2; QL
TENIVAC - Tier 2; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
123
Preferred Agents Non-Preferred Agents
TETANUS-DIPHTHERIA TOXOIDS TD (brand for tetanus-diphtheria
toxoids td) - Tier 2; QL
TRUMENBA - Tier 2; PD; QL
TWINRIX - Tier 2; PD; QL
VAQTA - Tier 2; PD; QL
VARIVAX - Tier 2; PD; QL
VAXNEUVANCE - Tier 2; PD; QL
Immunological Agents - Drugs that Stimulate or Suppress the
Immune System
Vaccines
AFLURIA QUADRIVALENT - Tier 2; PD; QL
DENGVAXIA - Tier 2; PD; QL
FLUAD QUADRIVALENT - Tier 2; PD; QL
FLUARIX QUADRIVALENT - Tier 2; PD; QL
FLUBLOK QUADRIVALENT - Tier 2; PD; QL
FLUCELVAX QUADRIVALENT - Tier 2; PD; QL
FLULAVAL QUADRIVALENT - Tier 2; PD; QL
FLUMIST QUADRIVALENT - Tier 2; PD; QL
FLUZONE HIGH-DOSE QUADRIVALENT - Tier 2; PD; QL
FLUZONE QUADRIVALENT - Tier 2; PD; QL
HEPLISAV-B - Tier 2; PD; QL; AL
HYPERTET - Tier 2; QL
NOVAVAX COVID-19 VACCINE - Tier 2; PD; QL
PNEUMOVAX 23 - Tier 2; PD; QL
PREVNAR 20 - Tier 2; PD; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
124
Preferred Agents Non-Preferred Agents
Inflammatory Bowel Disease Agents
Aminosalicylates
balsalazide disodium (generic for COLAZAL) - Tier 1; QL
LIALDA (brand for mesalamine) - Tier 2; QL
mesalamine er oral capsule 0.375 gm (generic for APRISO) - Tier 1;
QL
mesalamine rectal (generic for CANASA) - Tier 1; QL
SFROWASA - Tier 2; QL
sulfasalazine oral (generic for AZULFIDINE) - Tier 1; QL
APRISO (brand for mesalamine er) - Tier 2; PA; QL
DIPENTUM - Tier 2; PA; QL
PENTASA ORAL CAPSULE EXTENDED RELEASE 250 MG - Tier 2; PA;
QL
Glucocorticoids
budesonide oral - Tier 1; DX2RX; QL
hydrocortisone (perianal) (generic for PREPARATION H) - Tier 1; QL
hydrocortisone rectal enema 100 mg/60ml (generic for CORTENEMA)
- Tier 1; QL
PREPARATION H EXTERNAL CREAM 1 % (brand for hydrocortisone
(perianal)) - Tier 2; OTC; QL
procto-med hc (generic for PROCTO-MED HC) - Tier 1; QL
proctosol hc (generic for PROCTO-MED HC) - Tier 1; QL
proctozone-hc (generic for PROCTO-MED HC) - Tier 1; QL
CORTIFOAM - Tier 2; PA; QL
UCERIS (brand for budesonide) - Tier 2; PA; QL
Metabolic Bone Disease Agents
alendronate sodium oral solution - Tier 1; CH; QL
alendronate sodium oral tablet 10 mg, 35 mg - Tier 1; CH; QL
alendronate sodium oral tablet 70 mg (generic for FOSAMAX) - Tier 1;
CH; QL
calcitonin (salmon) nasal - Tier 1; QL
calcitriol oral capsule (generic for ROCALTROL) - Tier 1; CH; QL
calcitriol oral solution (generic for ROCALTROL) - Tier 1; Members >=
8 years of age will require PA; CH; AL
cinacalcet hcl (generic for SENSIPAR) - Tier 1; PA; CH; QL
TYMLOS - Tier 2; PA; SP; QL
FORTEO (brand for teriparatide) - Tier 2; PA; SP; QL
RAYALDEE - Tier 2; PA; CH; QL
TERIPARATIDE (RECOMBINANT) SUBCUTANEOUS SOLUTION PEN-
INJECTOR 620 MCG/2.48ML - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
125
Preferred Agents Non-Preferred Agents
Miscellaneous Therapeutic Agents
ABRYSVO - Tier 2; PD; QL
acne control cleanser (generic for CLEARSKIN) - Tier 1; OTC
acne medication 10 external lotion - Tier 1; OTC; QL
acne medication 5 external lotion - Tier 1; OTC
acne treatment external cream 10 % (generic for CLEARSKIN) - Tier
1; OTC
ADALIMUMAB-AATY (2 SYRINGE) SUBCUTANEOUS PREFILLED
SYRINGE KIT 40 MG/0.4ML (brand for adalimumab-aaty (2 syringe)) -
Tier 2; PA; SP; QL
ADALIMUMAB-ADAZ (brand for adalimumab-adaz) - Tier 2; PA; SP;
QL
ADALIMUMAB-ADBM (2 SYRINGE) SUBCUTANEOUS PREFILLED
SYRINGE KIT 10 MG/0.2ML, 20 MG/0.4ML (brand for adalimumab-
adbm (2 syringe)) - Tier 2; PA; SP; QL
BD AUTOSHIELD DUO PEN NEEDLES (brand for pen needles) - Tier 2;
PA; OTC; QL; DME
BD ULTRA-FINE INSULIN SYRINGES 30G X 1/2" 0.3 ML, 30G X 1/2" 0.5
ML (brand for careone insulin syringe) - Tier 2; PA; OTC; QL; DME
BD ULTRA-FINE INSULIN SYRINGES 30G X 1/2" 1 ML, 31G X 15/64"
0.3 ML, 31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML
(brand for techlite insulin syringe) - Tier 2; PA; OTC; QL; DME
BD ULTRA-FINE INSULIN SYRINGES 31G X 15/64" 0.5 ML, 31G X
15/64" 1 ML (brand for global easy glide insulin syr) - Tier 2; PA; OTC;
QL; DME
BD ULTRA-FINE PEN NEEDLES 29G X 12.7MM (brand for sure comfort
pen needles) - Tier 2; PA; OTC; QL; DME
BD ULTRA-FINE PEN NEEDLES 31G X 8 MM (brand for 1st tier unifine
pentips) - Tier 2; PA; OTC; QL; DME
adv acne spot treatment (generic for NEUTROGENA OIL-FREE ACNE
WASH) - Tier 1; OTC
advanced acne spot treat (generic for CLEAN & CLEAR ACNE
SCRUB) - Tier 1; OTC
ALCOHOL PREP PADS PAD , 70 % (brand for alcohol prep) - Tier 2;
OTC; QL; DME
AMJEVITA - Tier 2; PA; SP; QL
AMJEVITA-PED 15KG TO <30KG - Tier 2; PA; SP; QL
ANASPAZ (brand for hyoscyamine sulfate) - Tier 2; QL
antibiotic (generic for BACITRAYCIN PLUS) - Tier 1; OTC; QL
antifungal (tolnaftate) (generic for TINACTIN) - Tier 1; OTC; QL
antifungal tolnaftate (generic for TINACTIN) - Tier 1; OTC; QL
AREXVY - Tier 2; PD; QL
arthritis pain relieving - Tier 1; OTC; QL
EMPAVELI - Tier 2; PA; SP; QL
FYLNETRA - Tier 2; PA; SP
GUARDIAN CONNECT TRANSMITTER - Tier 2; PA; QL; DME
GUARDIAN LINK 3 TRANSMITTER - Tier 2; PA; QL; DME
HYFTOR - Tier 2; PA; QL
INSULIN PEN NEEDLES 29G X 12.7MM (brand for sure comfort pen
needles) - Tier 2; PA; OTC; QL; DME
INSULIN PEN NEEDLES 31G X 5 MM , 31G X 6 MM , 31G X 8 MM
(brand for 1st tier unifine pentips) - Tier 2; PA; OTC; QL; DME
INSULIN SYRINGES 28G X 1/2" 0.5 ML, 28G X 1/2" 1 ML (brand for
global inject ease insulin syr) - Tier 2; PA; OTC; QL; DME
INSULIN SYRINGES 29G X 1/2" 0.3 ML, 29G X 1/2" 0.5 ML, 30G X 5/16"
0.3 ML (brand for eql insulin syringe) - Tier 2; PA; OTC; QL; DME
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
126
Preferred Agents Non-Preferred Agents
aspirin adults (generic for MEDI-FIRST ASPIRIN) - Tier 1; OTC; PD;
QL
aspirin childrens (generic for BAYER LOW DOSE) - Tier 1; OTC; PD;
QL
aspirin ec oral tablet 325 mg (generic for MEDI-FIRST ASPIRIN) - Tier
1; OTC; PD; QL
aspirin ec oral tablet delayed release 325 mg (generic for BAYER
ASPIRIN) - Tier 1; OTC; PD; QL
aspirin ec oral tablet delayed release 81 mg (generic for BAYER
ASPIRIN EC LOW DOSE) - Tier 1; OTC; PD; QL
aspirin oral tablet 325 mg (generic for MEDI-FIRST ASPIRIN) - Tier 1;
OTC; PD; QL
aspirin oral tablet chewable 81 mg (generic for BAYER LOW DOSE) -
Tier 1; OTC; PD; QL
INSULIN SYRINGES 29G X 1/2" 1 ML, 30G X 5/16" 0.5 ML (brand for aq
insulin syringe) - Tier 2; PA; OTC; QL; DME
INSULIN SYRINGES 30G X 1/2" 1 ML, 31G X 15/64" 0.3 ML, 31G X
5/16" 0.3 ML, 31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML (brand for techlite
insulin syringe) - Tier 2; PA; OTC; QL; DME
INSULIN SYRINGES 30G X 5/16" 1 ML (brand for easy comfort insulin
syringe) - Tier 2; PA; OTC; QL; DME
OMNIPOD 5 G6 INTRO (GEN 5) - Tier 2; PA; QL; DME
OMNIPOD 5 G6 PODS (GEN 5) - Tier 2; PA; QL; DME
ORLADEYO - Tier 2; PA; SP; QL
QUVIVIQ - Tier 2; PA; QL
RYALTRIS - Tier 2; PA; QL; DME
SKYRIZI SUBCUTANEOUS SOLUTION CARTRIDGE - Tier 2; PA; SP;
QL
aspirin oral tablet delayed release 325 mg (generic for BAYER
ASPIRIN) - Tier 1; OTC; PD; QL
aspirin oral tablet delayed release 81 mg (generic for BAYER ASPIRIN
EC LOW DOSE) - Tier 1; OTC; PD; QL
ASPIRIN ORAL TABLET DELAYED RELEASE 81 MG (brand for
aspirin) - Tier 2; OTC; PD; QL
aspirin rectal suppository 300 mg - Tier 1; OTC; PD
aspirin regimen (generic for BAYER ASPIRIN EC LOW DOSE) - Tier
1; OTC; PD; QL
athletes foot (tolnaftate) external aerosol powder 1 % (generic for
ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1; OTC
athletes foot (tolnaftate) external cream 1 % (generic for TINACTIN) -
Tier 1; OTC; QL
VIVJOA - Tier 2; PA; QL
VOQUEZNA DUAL PAK - Tier 2; PA; QL
VTAMA - Tier 2; PA; QL
WINLEVI - Tier 2; PA; QL
YONSA - Tier 2; PA; SP; PD; CH; QL
ZORYVE EXTERNAL CREAM - Tier 2; PA; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
127
Preferred Agents Non-Preferred Agents
athletes foot powder spray external aerosol powder 1 % (generic for
ODOR EATERS FOOT/SNEAKER SPRAY) - Tier 1; OTC
athletes foot relief (generic for TINACTIN) - Tier 1; OTC
AUM ALCOHOL PREP PADS (brand for alcohol prep) - Tier 2; OTC;
QL; DME
bacitracin external (generic for BACITRAYCIN PLUS) - Tier 1; OTC;
QL
bacitracin zinc external - Tier 1; OTC; QL
bacitracin zinc first aid - Tier 1; OTC; QL
bacitracin zinc-aloe - Tier 1; OTC; QL
BAYER ASPIRIN (brand for aspirin) - Tier 2; OTC; PD; QL
BAYER LOW DOSE ORAL TABLET CHEWABLE (brand for aspirin) -
Tier 2; OTC; PD; QL
BD ECLIPSE NEEDLE 25G X 5/8" (brand for carepoint poly hub
needle) - Tier 2; OTC; QL; DME
BD ULTRA-FINE INSULIN SYRINGES 31G X 5/16" 0.3 ML (brand for
techlite insulin syringe) - Tier 2; OTC; QL; DME
BD ULTRA-FINE PEN NEEDLES 31G X 5 MM (brand for 1st tier
unifine pentips) - Tier 2; OTC; QL; DME
BENZAC AC WASH (brand for benzoyl peroxide wash) - Tier 2; QL
benzoyl peroxide external gel 2.5 % - Tier 1; OTC; QL
benzoyl peroxide external liquid (generic for MEDPURA BENZOYL
PEROXIDE) - Tier 1; OTC; QL
benzoyl peroxide wash external liquid 5 % (generic for BENZAC AC
WASH) - Tier 1; OTC; QL
BINAXNOW COVID-19 AG HOME TEST (brand for covid-19 at home
antigen test) - Tier 2; OTC; QL; DME
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
128
Preferred Agents Non-Preferred Agents
bisacodyl ec (generic for EX-LAX ULTRA) - Tier 1; OTC; PD; QL
bisacodyl laxative (generic for EX-LAX ULTRA) - Tier 1; OTC; PD; QL
bisacodyl oral (generic for EX-LAX ULTRA) - Tier 1; OTC; PD; QL
bisacodyl rectal (generic for THE MAGIC BULLET) - Tier 1; OTC; QL
bp wash external liquid 2.5 % (generic for PANOXYL) - Tier 1; OTC
BREATHE COMFORT HUMIDIFIER (brand for cvs cool mist
humidifer) - Tier 2; OTC; QL; DME
calamine external lotion - Tier 1; OTC
CALQUENCE - Tier 2; SP; PD; CH; QL
capsaicin external cream 0.025 % (generic for DERMACINRX
PENETRAL) - Tier 1; OTC; QL
capsaicin external cream 0.1 % (generic for ZOSTRIX HP) - Tier 1;
OTC; QL
capsaicin hp (generic for ZOSTRIX HP) - Tier 1; OTC; QL
capsaicin pain relief (generic for ZOSTRIX HP) - Tier 1; OTC; QL
capzix (generic for ZOSTRIX HP) - Tier 1; OTC; QL
CAREPOINT POLY HUB NEEDLE 25G X 5/8" (brand for carepoint
poly hub needle) - Tier 2; QL; DME
CAREPOINT SAFETY 1ST NEEDLE 25G X 5/8" (brand for carepoint
poly hub needle) - Tier 2; QL; DME
CARESTART COVID-19 HOME TEST (brand for covid-19 at home
antigen test) - Tier 2; OTC; QL; DME
CARETOUCH HYPODERMIC NEEDLE 25G X 5/8" (brand for
carepoint poly hub needle) - Tier 2; OTC; QL; DME
CASTIVA WARMING - Tier 2; OTC; QL
CAYA - Tier 2; PD; QL; DME
CENTRUM FLAVOR BURST KIDS (brand for cvs gummy dinos) - Tier
2; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
129
Preferred Agents Non-Preferred Agents
CENTRUM KIDS (brand for cvs gummy dinos) - Tier 2; OTC; QL
childrens aspirin oral tablet chewable 81 mg (generic for BAYER LOW
DOSE) - Tier 1; OTC; PD; QL
c-lax laxative (generic for EX-LAX ULTRA) - Tier 1; OTC; PD; QL
CLEARDETECT COVID-19 AG HOME (brand for covid-19 at home
antigen test) - Tier 2; OTC; QL; DME
clearskin (generic for CLEARSKIN) - Tier 1; OTC
CLINITEST RAPID COVID-19 TEST KIT IN VITRO (brand for covid-19
at home antigen test) - Tier 2; OTC; DME
CLINITEST RAPID COVID-19 TEST KIT IN VITRO (brand for covid-19
at home antigen test) - Tier 2; OTC; QL; DME
COMIRNATY - Tier 2; PD; QL
CONDOMS - Tier 2; OTC; PD; QL; DME
COOL MIST HUMIDIFER (brand for cvs cool mist humidifer) - Tier 2;
OTC; QL; DME
corn & callus remover (generic for COMPOUND W) - Tier 1; OTC
corn and callus remover (generic for COMPOUND W) - Tier 1; OTC
COVID-19 AT HOME ANTIGEN TEST (brand for covid-19 at home
antigen test) - Tier 2; OTC; DME
COVID-19 AT HOME TEST KIT (brand for covid-19 at home antigen
test) - Tier 2; OTC; DME
COVID-19 AT-HOME TEST KIT IN VITRO (brand for covid-19 at home
antigen test) - Tier 2; OTC; DME
COVID-19 AT-HOME TEST KIT IN VITRO (brand for covid-19 at home
antigen test) - Tier 2; OTC; QL; DME
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
130
Preferred Agents Non-Preferred Agents
CYLTEZO (2 SYRINGE) SUBCUTANEOUS PREFILLED SYRINGE
KIT 10 MG/0.2ML, 20 MG/0.4ML (brand for adalimumab-adbm (2
syringe)) - Tier 2; PA; SP; QL
daily acne wash (generic for NEUTROGENA OIL-FREE ACNE WASH)
- Tier 1; OTC
darunavir (generic for PREZISTA) - Tier 1; DX2RX; QL
DERMELEVE ADVANCED FORMULA - Tier 2; OTC
DEXCOM G6 TRANSMITTER - Tier 2; PA; QL; DME
DIATRUST COVID-19 HOME TEST (brand for covid-19 at home
antigen test) - Tier 2; OTC; QL; DME
double antibiotic external ointment 500-10000 unit/gm (generic for
POLYSPORIN) - Tier 1; OTC
DROPSAFE ALCOHOL PREP (brand for alcohol prep) - Tier 2; OTC;
QL; DME
DUREX EXTRA SENSITIVE THIN (brand for true cover) - Tier 2; OTC;
PD; QL; DME
EASIVENT (brand for breathe comfort chamber/adult) - Tier 2; QL;
DME
EASIVENT MASK LARGE (brand for breathe comfort chamber/adult) -
Tier 2; QL; DME
EASIVENT MASK MEDIUM (brand for breathe comfort chamber/adult)
- Tier 2; QL; DME
EASIVENT MASK SMALL (brand for breathe comfort chamber/adult) -
Tier 2; QL; DME
ELLUME COVID-19 HOME TEST (brand for covid-19 at home antigen
test) - Tier 2; OTC; QL; DME
enteric aspirin (generic for BAYER ASPIRIN) - Tier 1; OTC; PD; QL
EX-LAX ULTRA (brand for bisacodyl) - Tier 2; OTC; PD; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
131
Preferred Agents Non-Preferred Agents
fast relief laxative (generic for THE MAGIC BULLET) - Tier 1; OTC; QL
FASTEP COVID-19 ANTIGEN TEST (brand for covid-19 at home
antigen test) - Tier 2; OTC; DME
FC2 FEMALE CONDOM - Tier 2; OTC; PD; QL; DME
FEMCAP - Tier 2; PD; QL; DME
FLEET BISACODYL - Tier 2; OTC; QL
FLINTSTONES COMPLETE ORAL TABLET CHEWABLE (brand for
cvs gummy dinos) - Tier 2; OTC; QL
FLOWFLEX COVID-19 AG HOME TEST (brand for covid-19 at home
antigen test) - Tier 2; OTC; QL; DME
folic acid oral tablet 1 mg - Tier 1; PD; QL
folic acid oral tablet 1 mg - Tier 1; OTC; PD; QL
folic acid oral tablet 400 mcg, 800 mcg - Tier 1; OTC; PD
foot & sneaker (generic for ODOR EATERS FOOT/SNEAKER
SPRAY) - Tier 1; OTC
ft antibiotic - Tier 1; OTC; QL
ft antifungal external cream 1 % (generic for TINACTIN) - Tier 1; OTC;
QL
ft aspirin (generic for MEDI-FIRST ASPIRIN) - Tier 1; OTC; PD; QL
ft aspirin low dose (generic for BAYER ASPIRIN EC LOW DOSE) -
Tier 1; OTC; PD; QL
ft double antibiotic (generic for POLYSPORIN) - Tier 1; OTC
ft enteric coated aspirin (generic for BAYER ASPIRIN) - Tier 1; OTC;
PD; QL
ft gentle laxative (generic for THE MAGIC BULLET) - Tier 1; OTC; QL
ft laxative (generic for EX-LAX ULTRA) - Tier 1; OTC; PD; QL
fungi-guard (generic for TINACTIN) - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
132
Preferred Agents Non-Preferred Agents
gentle laxative oral tablet delayed release 5 mg (generic for EX-LAX
ULTRA) - Tier 1; OTC; PD; QL
gentle laxative rectal suppository 10 mg (generic for THE MAGIC
BULLET) - Tier 1; OTC; QL
gentle laxative womens (generic for EX-LAX ULTRA) - Tier 1; OTC;
PD; QL
genuine aspirin (generic for MEDI-FIRST ASPIRIN) - Tier 1; OTC; PD;
QL
gummy dinos (generic for CENTRUM FLAVOR BURST KIDS) - Tier 1;
OTC; QL
gummy multivitamin kids (generic for CENTRUM FLAVOR BURST
KIDS) - Tier 1; OTC; QL
HADLIMA - Tier 2; PA; SP; QL
HADLIMA PUSHTOUCH - Tier 2; PA; SP; QL
h-e-b aspirin (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1;
OTC; PD; QL
hydrocodone bit-homatrop mbr (generic for HYCODAN) - Tier 1; QL;
AL
hydromet (generic for HYCODAN) - Tier 1; QL; AL
hyoscyamine sulfate er (generic for LEVBID) - Tier 1; QL
hyoscyamine sulfate oral (generic for ANASPAZ) - Tier 1; QL
hyoscyamine sulfate sublingual (generic for LEVSIN/SL) - Tier 1; QL
hyosyne - Tier 1; QL
HYRIMOZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR 40
MG/0.4ML (brand for adalimumab-adaz) - Tier 2; PA; SP; QL
HYRIMOZ SUBCUTANEOUS SOLUTION AUTO-INJECTOR 80
MG/0.8ML - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
133
Preferred Agents Non-Preferred Agents
HYRIMOZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 10
MG/0.1 ML, 20 MG/0.2ML - Tier 2; PA; SP; QL
HYRIMOZ SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 40
MG/0.4ML (brand for adalimumab-adaz) - Tier 2; PA; SP; QL
HYRIMOZ-CROHNS/UC STARTER - Tier 2; PA; SP; QL
HYRIMOZ-PED<40KG CROHN STARTER - Tier 2; PA; SP; QL
HYRIMOZ-PED>/=40KG CROHN START - Tier 2; PA; SP; QL
HYRIMOZ-PLAQUE PSORIASIS START - Tier 2; PA; SP; QL
IHEALTH COVID-19 RAPID TEST (brand for covid-19 at home
antigen test) - Tier 2; OTC; QL; DME
INDICAID COVID-19 RAPID TEST (brand for covid-19 at home
antigen test) - Tier 2; OTC; QL; DME
INSPIREASE (brand for breathe comfort chamber/adult) - Tier 2; QL;
DME
INSPIREASE RESERVOIR BAGS - Tier 2; QL; DME
INTELISWAB COVID-19 RAPID TEST (brand for covid-19 at home
antigen test) - Tier 2; OTC; QL; DME
jock itch max st (generic for ODOR EATERS FOOT/SNEAKER
SPRAY) - Tier 1; OTC
jock itch spray powder (generic for ODOR EATERS FOOT/SNEAKER
SPRAY) - Tier 1; OTC
laxative oral tablet delayed release 5 mg (generic for EX-LAX ULTRA)
- Tier 1; OTC; PD; QL
laxative rectal suppository 10 mg (generic for THE MAGIC BULLET) -
Tier 1; OTC; QL
LEVBID (brand for hyoscyamine sulfate er) - Tier 2; QL
liquid corn & callus rem (generic for COMPOUND W) - Tier 1; OTC
liquid wart remover (generic for COMPOUND W) - Tier 1; OTC
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
134
Preferred Agents Non-Preferred Agents
liquid wart remover max st (generic for COMPOUND W) - Tier 1; OTC
magnesium oxide oral tablet 400 mg - Tier 1; OTC
magnesium oxide oral tablet 420 mg (generic for MAOX) - Tier 1; OTC
MAOX (brand for magnesium oxide) - Tier 2; OTC
MASK VORTEX/CHILD/FROG - Tier 2; OTC; QL; DME
MASK VORTEX/TODDLER/LADYBUG - Tier 2; OTC; QL; DME
medicated spot (generic for CLEAN & CLEAR ACNE SCRUB) - Tier 1;
OTC
medi-first aspirin (generic for MEDI-FIRST ASPIRIN) - Tier 1; OTC;
PD; QL
medique aspirin (generic for MEDI-FIRST ASPIRIN) - Tier 1; OTC; PD;
QL
MEDPURA BENZOYL PEROXIDE (brand for acne medication 10) -
Tier 2; OTC; QL
mm aspirin (generic for BAYER ASPIRIN EC LOW DOSE) - Tier 1;
OTC; PD; QL
MODERNA COVID-19 VAC 6M-11Y - Tier 2; PD; QL
MOUNJARO - Tier 2; PA; QL
NEODOT THERMOMETER - Tier 2; OTC; QL; DME
NEUTROGENA OIL-FREE ACNE WASH (brand for cvs adv acne spot
treatment) - Tier 2; OTC
NULEV (brand for hyoscyamine sulfate) - Tier 2; QL
OMNIFLEX DIAPHRAGM - Tier 2; PD; QL; DME; GE
ON/GO COVID-19 ANTIGEN TEST (brand for covid-19 at home
antigen test) - Tier 2; OTC; QL; DME
ON/GO ONE COVID-19 HOME TEST (brand for covid-19 at home
antigen test) - Tier 2; OTC; QL; DME
ONELAX (brand for bisacodyl) - Tier 2; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
135
Preferred Agents Non-Preferred Agents
OPILL - Tier 2; OTC; PD; QL
OVACE PLUS WASH EXTERNAL LIQUID (brand for sodium
sulfacetamide wash) - Tier 2
OVACE WASH (brand for sodium sulfacetamide wash) - Tier 2
PANOXYL (brand for bp wash) - Tier 2; OTC
PENBRAYA - Tier 2; PD; QL
PFIZER COVID-19 VAC-TRIS 5-11Y - Tier 2; PD; QL
PFIZER COVID-19 VAC-TRIS 6M-4Y - Tier 2; PD; QL
PILOT COVID-19 AT-HOME TEST (brand for covid-19 at home
antigen test) - Tier 2; OTC; DME
poly bacitracin (generic for POLYSPORIN) - Tier 1; OTC
POLYSPORIN (brand for cvs poly bacitracin) - Tier 2; OTC
PREZISTA ORAL SUSPENSION - Tier 2; DX2RX; QL
PREZISTA ORAL TABLET 150 MG, 75 MG - Tier 2; DX2RX; QL
QUICKVUE AT-HOME COVID-19 TEST (brand for covid-19 at home
antigen test) - Tier 2; OTC; QL; DME
scalp relief external liquid 3 % (generic for SCALPICIN) - Tier 1; OTC
sodium sulfacetamide wash (generic for OVACE PLUS WASH) - Tier 1
SPEEDY SWAB COVID-19 ANTIGEN (brand for covid-19 at home
antigen test) - Tier 2; OTC; DME
SPIKEVAX - Tier 2; PD; QL
ST JOSEPH LOW DOSE (brand for aspirin) - Tier 2; OTC; PD; QL
STRIVE DUAL ZONE PEAK FLOW MTR (brand for breathe ease peak
flow meter) - Tier 2; QL; DME
sulfacetamide sodium external (generic for OVACE PLUS WASH) -
Tier 1
sure result sr relief (generic for DERMACINRX PENETRAL) - Tier 1;
OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
136
Preferred Agents Non-Preferred Agents
the magic bullet (generic for THE MAGIC BULLET) - Tier 1; OTC; QL
TINACTIN EXTERNAL CREAM (brand for antifungal (tolnaftate)) - Tier
2; OTC; QL
tolnaftate antifungal external cream (generic for TINACTIN) - Tier 1;
OTC; QL
tolnaftate external cream (generic for TINACTIN) - Tier 1; OTC; QL
tolnaftate external powder (generic for LOTRIMIN AF) - Tier 1; OTC
TRUE COVER (brand for true cover) - Tier 2; OTC; PD; QL; DME
TRUE FOLIC ACID ORAL TABLET 400 MCG - Tier 2; OTC; PD
true folic acid tablet 1 mg oral - Tier 1; OTC; PD; QL
TRUE FOLIC ACID TABLET 1 MG ORAL - Tier 2; OTC; PD; QL
VAPORIZER WARM STEAM - Tier 2; OTC; QL; DME
VAXELIS - Tier 2; QL
vitachew multiple vitamin (generic for CENTRUM FLAVOR BURST
KIDS) - Tier 1; OTC; QL
wart remover external liquid 17 % (generic for COMPOUND W) - Tier
1; OTC
wart remover maximum strength external liquid (generic for
COMPOUND W) - Tier 1; OTC
WIDE-SEAL DIAPHRAGM 60 - Tier 2; PD; QL; DME
WIDE-SEAL DIAPHRAGM 65 - Tier 2; PD; QL; DME
WIDE-SEAL DIAPHRAGM 70 - Tier 2; PD; QL; DME
WIDE-SEAL DIAPHRAGM 75 - Tier 2; PD; QL; DME
WIDE-SEAL DIAPHRAGM 80 - Tier 2; PD; QL; DME
WIDE-SEAL DIAPHRAGM 85 - Tier 2; PD; QL; DME
WIDE-SEAL DIAPHRAGM 90 - Tier 2; PD; QL; DME
WIDE-SEAL DIAPHRAGM 95 - Tier 2; PD; QL; DME
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
137
Preferred Agents Non-Preferred Agents
womans laxative (generic for EX-LAX ULTRA) - Tier 1; OTC; PD; QL
womens gentle laxative (generic for EX-LAX ULTRA) - Tier 1; OTC;
PD; QL
womens laxative oral tablet delayed release 5 mg (generic for EX-LAX
ULTRA) - Tier 1; OTC; PD; QL
YUFLYMA (2 SYRINGE) SUBCUTANEOUS PREFILLED SYRINGE
KIT 40 MG/0.4ML (brand for adalimumab-aaty (2 syringe)) - Tier 2;
PA; SP; QL
ZOSTRIX HP (brand for capsaicin) - Tier 2; OTC; QL
Molecular Target Inhibitors - Chemotherapy Agents
Antineoplastics - Drugs to Treat Cancer
ALECENSA - Tier 2; PA; SP; PD; CH; QL
ALUNBRIG - Tier 2; PA; SP; PD; CH; QL
BOSULIF - Tier 2; PA; SP; PD; CH; QL
BRUKINSA - Tier 2; PA; SP; PD; CH; QL
CABOMETYX - Tier 2; PA; SP; PD; CH; QL
CAPRELSA - Tier 2; PA; SP; PD; CH; QL
COMETRIQ (100 MG DAILY DOSE) - Tier 2; PA; SP; PD; CH; QL
COMETRIQ (140 MG DAILY DOSE) - Tier 2; PA; SP; PD; CH; QL
COMETRIQ (60 MG DAILY DOSE) - Tier 2; PA; SP; PD; CH; QL
erlotinib hcl (generic for TARCEVA) - Tier 1; PA; SP; PD; CH; QL
gefitinib (generic for IRESSA) - Tier 1; PA; SP; PD; CH; QL
GILOTRIF - Tier 2; PA; SP; PD; CH; QL
ICLUSIG - Tier 2; PA; SP; PD; CH; QL
GAVRETO - Tier 2; PA; SP; PD; CH; QL
RETEVMO - Tier 2; PA; SP; PD; CH; QL
TABRECTA - Tier 2; PA; SP; PD; CH; QL
TAGRISSO - Tier 2; PA; SP; PD; CH; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
138
Preferred Agents Non-Preferred Agents
imatinib mesylate (generic for GLEEVEC) - Tier 1; PA; SP; PD; CH;
QL
IMBRUVICA - Tier 2; PA; SP; PD; CH; QL
INLYTA - Tier 2; PA; SP; PD; CH; QL
lapatinib ditosylate (generic for TYKERB) - Tier 1; PA; SP; PD; CH; QL
LENVIMA (10 MG DAILY DOSE) - Tier 2; PA; SP; PD; CH; QL
LENVIMA (12 MG DAILY DOSE) - Tier 2; PA; SP; PD; CH; QL
LENVIMA (14 MG DAILY DOSE) - Tier 2; PA; SP; PD; CH; QL
LENVIMA (18 MG DAILY DOSE) - Tier 2; PA; SP; PD; CH; QL
LENVIMA (20 MG DAILY DOSE) - Tier 2; PA; SP; PD; CH; QL
LENVIMA (24 MG DAILY DOSE) - Tier 2; PA; SP; PD; CH; QL
LENVIMA (4 MG DAILY DOSE) - Tier 2; PA; SP; PD; CH; QL
LENVIMA (8 MG DAILY DOSE) - Tier 2; PA; SP; PD; CH; QL
pazopanib hcl (generic for VOTRIENT) - Tier 1; PA; SP; PD; CH; QL
SPRYCEL - Tier 2; PA; SP; PD; CH; QL
TASIGNA - Tier 2; PA; SP; PD; CH; QL
TURALIO - Tier 2; PA; SP; PD; CH; QL; AL
XALKORI - Tier 2; PA; SP; PD; CH; QL
Monoclonal Antibodies - Chemotherapy Agents
Antineoplastics - Drugs to Treat Cancer
TRAZIMERA INTRAVENOUS SOLUTION RECONSTITUTED 150 MG -
Tier 2; PA; PD
Multiple Sclerosis Agents - Multiple Sclerosis Drugs
Central Nervous System Agents - Drugs to Treat Nerve
Conditions
PONVORY - Tier 2; PA; SP; CH; QL
PONVORY STARTER PACK - Tier 2; PA; SP; CH; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
139
Preferred Agents Non-Preferred Agents
Ophthalmic Agents
Ophthalmic Prostaglandin and Prostamide Analogs
latanoprost ophthalmic (generic for XALATAN) - Tier 1; QL LUMIGAN - Tier 2; PA; QL
VYZULTA - Tier 2; PA; QL
ZIOPTAN (brand for tafluprost (pf)) - Tier 2; PA; QL
Ophthalmic Agents, Other
altafrin (generic for ALTAFRIN) - Tier 1
atropine sulfate ophthalmic ointment - Tier 1
atropine sulfate ophthalmic solution 1 % - Tier 1; QL
bacitra-neomycin-polymyxin-hc (generic for NEO-POLYCIN HC) - Tier
1; QL
cyclopentolate hcl ophthalmic (generic for CYCLOGYL) - Tier 1; QL
CYSTARAN - Tier 2; DX2RX; SP; QL
dorzolamide hcl-timolol mal (generic for COSOPT) - Tier 1; QL
neomycin-polymyxin-dexameth ophthalmic ointment (generic for
MAXITROL) - Tier 1; QL
neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1
(generic for MAXITROL) - Tier 1; QL
neo-polycin hc (generic for NEO-POLYCIN HC) - Tier 1; QL
phenylephrine hcl ophthalmic (generic for ALTAFRIN) - Tier 1
CEQUA - Tier 2; PA; QL
COMBIGAN (brand for brimonidine tartrate-timolol) - Tier 2; PA; QL
COSOPT PF (brand for dorzolamide hcl-timolol mal pf) - Tier 2; PA
RESTASIS (brand for cyclosporine) - Tier 2; PA; QL
RESTASIS MULTIDOSE (brand for cyclosporine) - Tier 2; PA; QL
ROCKLATAN - Tier 2; PA; QL
TOBRADEX ST - Tier 2; PA; QL
TYRVAYA - Tier 2; PA; QL
VERKAZIA - Tier 2; PA; QL
ZYLET - Tier 2; PA; QL
sulfacetamide-prednisolone - Tier 1
TOBRADEX - Tier 2; QL
tobramycin-dexamethasone - Tier 1; QL
XIIDRA - Tier 2; PA; QL
Ophthalmic Anti-allergy Agents
azelastine hcl ophthalmic - Tier 1; ST
cromolyn sodium ophthalmic - Tier 1; QL
olopatadine hcl ophthalmic (generic for PATADAY) - Tier 1; OTC; QL
PATADAY OPHTHALMIC SOLUTION 0.1 %, 0.2 % (brand for
olopatadine hcl) - Tier 2; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
140
Preferred Agents Non-Preferred Agents
Ophthalmic Anti-Infectives
bacitracin ophthalmic - Tier 1; QL
bacitracin-polymyxin b (generic for POLYCIN) - Tier 1; QL
ciprofloxacin hcl ophthalmic - Tier 1; QL
erythromycin ophthalmic - Tier 1; PD; QL
gentamicin sulfate ophthalmic - Tier 1; QL
moxifloxacin hcl (2x day) - Tier 1; QL
moxifloxacin hcl ophthalmic (generic for VIGAMOX) - Tier 1; QL
neomycin-bacitracin zn-polymyx (generic for NEO-POLYCIN) - Tier 1
neomycin-polymyxin-gramicidin - Tier 1; QL
neo-polycin (generic for NEO-POLYCIN) - Tier 1
ofloxacin ophthalmic (generic for OCUFLOX) - Tier 1; QL
polycin (generic for POLYCIN) - Tier 1; QL
polymyxin b-trimethoprim - Tier 1; QL
sulfacetamide sodium ophthalmic - Tier 1; QL
AZASITE - Tier 2; PA; QL
BESIVANCE - Tier 2; PA; QL
tobramycin ophthalmic - Tier 1; QL
trifluridine - Tier 1; QL
Ophthalmic Anti-inflammatories
dexamethasone sodium phosphate ophthalmic - Tier 1
diclofenac sodium ophthalmic - Tier 1; QL
fluorometholone (generic for FML LIQUIFILM) - Tier 1; QL
flurbiprofen sodium - Tier 1; QL
ketorolac tromethamine ophthalmic solution 0.4 % (generic for
ACULAR LS) - Tier 1
ketorolac tromethamine ophthalmic solution 0.5 % (generic for
ACULAR) - Tier 1; QL
prednisolone acetate ophthalmic (generic for PRED FORTE) - Tier 1;
QL
PREDNISOLONE ACETATE P-F - Tier 2; QL
prednisolone sodium phosphate ophthalmic - Tier 1
EYSUVIS - Tier 2; PA; QL
FLAREX - Tier 2; PA; QL
ILEVRO - Tier 2; PA; QL
INVELTYS - Tier 2; PA; QL
LOTEMAX OPHTHALMIC GEL (brand for loteprednol etabonate) - Tier 2;
PA; QL
LOTEMAX OPHTHALMIC OINTMENT - Tier 2; PA; QL
LOTEMAX SM - Tier 2; PA; QL
NEVANAC - Tier 2; PA; QL
PROLENSA (brand for bromfenac sodium) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
141
Preferred Agents Non-Preferred Agents
Ophthalmic Beta-Adrenergic Blocking Agents
betaxolol hcl ophthalmic - Tier 1; QL
carteolol hcl - Tier 1
levobunolol hcl - Tier 1; QL
timolol maleate ophthalmic solution - Tier 1; QL
BETIMOL - Tier 2; PA; QL
TIMOPTIC OCUDOSE (brand for timolol maleate pf) - Tier 2; PA; QL
Ophthalmic Intraocular Pressure Lowering Agents, Other
apraclonidine hcl - Tier 1; QL
brimonidine tartrate ophthalmic solution 0.15 % (generic for
ALPHAGAN P) - Tier 1; QL
brimonidine tartrate ophthalmic solution 0.2 % - Tier 1; QL
DORZOLAMIDE HCL SOLUTION 2 % OPHTHALMIC - Tier 2; QL
dorzolamide hcl solution 2 % ophthalmic - Tier 1; QL
methazolamide oral - Tier 1; QL
PHOSPHOLINE IODIDE - Tier 2
pilocarpine hcl ophthalmic - Tier 1
ALPHAGAN P (brand for brimonidine tartrate) - Tier 2; PA; QL
RHOPRESSA - Tier 2; PA; QL
SIMBRINZA - Tier 2; PA; QL
Ophthalmic Agents - Drugs to Treat Eye Conditions
Ophthalmic Agents, Other - Miscellaneous Eye Drugs
altachlore ophthalmic ointment (generic for ALTACHLORE) - Tier 1;
OTC
altachlore ophthalmic solution (generic for ALTACHLORE) - Tier 1;
OTC; QL
altalube (generic for ALTALUBE) - Tier 1; OTC; QL
artificial tears ophthalmic solution (generic for GENTEAL TEARS) -
Tier 1; OTC
astringent eye drops (generic for VISINE-AC) - Tier 1; OTC; QL
BIOLLE TEARS (brand for cvs lubricant eye drops (pf)) - Tier 2; OTC
BION TEARS PF (brand for cvs natural tears pf) - Tier 2; OTC
carboxymethylcellulose sodium ophthalmic solution (generic for
ULTRA FRESH) - Tier 1; OTC; QL
dry-eye relief nighttime (generic for ALTALUBE) - Tier 1; OTC; QL
eye drops adv relief - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
142
Preferred Agents Non-Preferred Agents
eye drops advanced relief - Tier 1; OTC; QL
eye drops long lasting (generic for SYSTANE) - Tier 1; OTC; QL
eye drops ophthalmic solution 0.05 % (generic for VISINE RED EYE
COMFORT) - Tier 1; OTC
eye drops ophthalmic solution 0.05-0.1-1-1 % - Tier 1; OTC; QL
eye drops ophthalmic solution 0.05-0.25 % (generic for VISINE-AC) -
Tier 1; OTC; QL
eye irritation relief drops (generic for VISINE-AC) - Tier 1; OTC; QL
eye lubricant (generic for ALTALUBE) - Tier 1; OTC; QL
eye lubricant nighttime (generic for ALTALUBE) - Tier 1; OTC; QL
for sty relief (generic for ALTALUBE) - Tier 1; OTC; QL
ft eye drops (generic for VISINE RED EYE COMFORT) - Tier 1; OTC
ft lubricant eye drops ophthalmic solution 0.4-0.3 % (generic for
SYSTANE) - Tier 1; OTC; QL
ft lubricant eye drops ophthalmic solution 0.5 % (generic for BIOLLE
TEARS) - Tier 1; OTC
GENTEAL SEVERE - Tier 2; OTC; QL
GENTEAL TEARS MODERATE PF (brand for cvs natural tears pf) -
Tier 2; OTC
GENTEAL TEARS NIGHT-TIME (brand for cvs dry-eye relief
nighttime) - Tier 2; OTC; QL
GENTEAL TEARS OPHTHALMIC SOLUTION 0.1-0.2-0.3 % (brand
for artificial tears) - Tier 2; OTC
GENTEAL TEARS PF (brand for cvs natural tears pf) - Tier 2; OTC
GENTEAL TEARS SEVERE DAY/NIGHT - Tier 2; OTC; QL
HYPOTEARS (brand for cvs dry-eye relief nighttime) - Tier 2; OTC; QL
lubricant drops fast act (generic for SYSTANE) - Tier 1; OTC; QL
lubricant drops ophthalmic gel 0.25-0.3 % - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
143
Preferred Agents Non-Preferred Agents
lubricant drops ophthalmic solution (generic for SYSTANE BALANCE)
- Tier 1; OTC; QL
lubricant eye drops (pf) ophthalmic solution 0.4-0.3 % (generic for
SYSTANE HYDRATION PF) - Tier 1; OTC; QL
lubricant eye drops (pf) ophthalmic solution 0.5 % (generic for BIOLLE
TEARS) - Tier 1; OTC
lubricant eye drops ophthalmic solution 0.4-0.3 % (generic for
SYSTANE) - Tier 1; OTC; QL
lubricant eye drops ophthalmic solution 0.5 % (generic for ULTRA
FRESH) - Tier 1; OTC; QL
lubricant eye drops ophthalmic solution 0.6 % (generic for SYSTANE
BALANCE) - Tier 1; OTC; QL
lubricant eye drops pf (generic for BIOLLE TEARS) - Tier 1; OTC
lubricant eye nighttime (generic for ALTALUBE) - Tier 1; OTC; QL
lubricant eye ophthalmic solution 0.4-0.3 % (generic for SYSTANE) -
Tier 1; OTC; QL
lubricant pm (generic for ALTALUBE) - Tier 1; OTC; QL
lubricating eye drop (generic for BIOLLE TEARS) - Tier 1; OTC
lubricating eye drops (generic for SYSTANE) - Tier 1; OTC; QL
lubricating eye/overnight (generic for ALTALUBE) - Tier 1; OTC; QL
lubricating plus eye drops (generic for BIOLLE TEARS) - Tier 1; OTC
lubricating plus ophthalmic solution 0.5 % (generic for BIOLLE
TEARS) - Tier 1; OTC
lubricating plus pf (generic for BIOLLE TEARS) - Tier 1; OTC
lubricating tears ophthalmic solution 0.4-0.3 % (generic for SYSTANE)
- Tier 1; OTC; QL
lubrifresh p.m. (generic for ALTALUBE) - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
144
Preferred Agents Non-Preferred Agents
MURO 128 OPHTHALMIC OINTMENT (brand for cvs sod chloride
hypertonicity) - Tier 2; OTC
MURO 128 OPHTHALMIC SOLUTION 5 % (brand for cvs sodium
chloride) - Tier 2; OTC; QL
natural tears pf (generic for BION TEARS PF) - Tier 1; OTC
nighttime dry-eye relief (generic for ALTALUBE) - Tier 1; OTC; QL
nighttime relief lub eye (generic for ALTALUBE) - Tier 1; OTC; QL
polyvinyl alcohol ophthalmic - Tier 1; OTC
pure & gentle lubricant - Tier 1; OTC
REFRESH LACRI-LUBE (brand for cvs dry-eye relief nighttime) - Tier
2; OTC; QL
REFRESH PLUS (brand for cvs lubricant eye drops (pf)) - Tier 2; OTC
REFRESH TEARS (brand for carboxymethylcellulose sodium) - Tier 2;
OTC; QL
relief eye drops (generic for VISINE-AC) - Tier 1; OTC; QL
restore plus lubricant eye (generic for BIOLLE TEARS) - Tier 1; OTC
restore pm (generic for ALTALUBE) - Tier 1; OTC; QL
SENTIA (brand for cvs lubricant drops) - Tier 2; OTC; QL
sod chloride hypertonicity (generic for ALTACHLORE) - Tier 1; OTC
sodium chloride (hypertonic) ophthalmic ointment (generic for
ALTACHLORE) - Tier 1; OTC
sodium chloride (hypertonic) ophthalmic solution (generic for
ALTACHLORE) - Tier 1; OTC; QL
sodium chloride ophthalmic ointment 5 % (generic for ALTACHLORE)
- Tier 1; OTC
sodium chloride ophthalmic solution 5 % (generic for ALTACHLORE) -
Tier 1; OTC; QL
SYSTANE (brand for cvs lubricant drops fast act) - Tier 2; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
145
Preferred Agents Non-Preferred Agents
SYSTANE BALANCE (brand for cvs lubricant drops) - Tier 2; OTC; QL
SYSTANE COMPLETE (brand for cvs lubricant drops) - Tier 2; OTC;
QL
SYSTANE CONTACTS (brand for artificial tears) - Tier 2; OTC
SYSTANE HYDRATION PF (brand for cvs lubricant eye drops (pf)) -
Tier 2; OTC; QL
SYSTANE NIGHTTIME (brand for cvs dry-eye relief nighttime) - Tier 2;
OTC; QL
SYSTANE PRESERVATIVE FREE (brand for cvs lubricant eye drops
(pf)) - Tier 2; OTC; QL
SYSTANE ULTRA (brand for cvs lubricant drops fast act) - Tier 2;
OTC; QL
SYSTANE ULTRA PF (brand for cvs lubricant eye drops (pf)) - Tier 2;
OTC; QL
ultra fresh (generic for ULTRA FRESH) - Tier 1; OTC; QL
ultra fresh pm (generic for ALTALUBE) - Tier 1; OTC; QL
ultra lubricant drop (generic for SYSTANE) - Tier 1; OTC; QL
ultra lubricating eye drops (generic for SYSTANE) - Tier 1; OTC; QL
ultra lubricating eye drops pf (generic for SYSTANE HYDRATION PF)
- Tier 1; OTC; QL
Ophthalmic Anti-allergy Agents - Allergy, Infection and
Inflammation Drugs
NAPHCON-A (brand for allergy eye) - Tier 2; OTC
VISINE (brand for allergy eye) - Tier 2; OTC
Otic Agents
acetic acid otic - Tier 1; QL
ciprofloxacin-dexamethasone - Tier 1; DX2RX; QL
hydrocortisone-acetic acid - Tier 1; QL
neomycin-polymyxin-hc otic - Tier 1; QL
ofloxacin otic - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
146
Preferred Agents Non-Preferred Agents
Otic Agents - Drugs to Treat Ear Conditions
Otic Agents - Drugs for the Ear
CLEARCANAL EARWAX SOFTENER (brand for cvs ear drops) - Tier
2; OTC
CLINERE EARWAX REMOVAL KIT OTIC SOLUTION (brand for cvs
ear drops) - Tier 2; OTC
ear drops (generic for CLEARCANAL EARWAX SOFTENER) - Tier 1;
OTC
ear wax kit (generic for CLEARCANAL EARWAX SOFTENER) - Tier
1; OTC
ear wax removal (generic for CLEARCANAL EARWAX SOFTENER) -
Tier 1; OTC
ear wax removal system (generic for CLEARCANAL EARWAX
SOFTENER) - Tier 1; OTC
earwax removal (generic for CLEARCANAL EARWAX SOFTENER) -
Tier 1; OTC
earwax removal drops (generic for CLEARCANAL EARWAX
SOFTENER) - Tier 1; OTC
earwax removal kit otic solution 6.5 % (generic for CLEARCANAL
EARWAX SOFTENER) - Tier 1; OTC
ft earwax removal (generic for CLEARCANAL EARWAX SOFTENER)
- Tier 1; OTC
ft earwax removal kit (generic for CLEARCANAL EARWAX
SOFTENER) - Tier 1; OTC
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
147
Preferred Agents Non-Preferred Agents
Respiratory Tract/Pulmonary Agents
Antihistamines
all day allergy oral tablet 10 mg (generic for KLS ALLER-TEC) - Tier 1;
OTC; QL
allergy (cetirizine) (generic for KLS ALLER-TEC) - Tier 1; OTC; QL
allergy 24hour indoor/outdoor (generic for KLS ALLER-TEC) - Tier 1;
OTC; QL
allergy childrens oral liquid (generic for RA DIPHEDRYL ALLERGY) -
Tier 1; OTC; QL
allergy medication (generic for BANOPHEN) - Tier 1; OTC; QL
allergy medicine (generic for BANOPHEN) - Tier 1; OTC; QL
allergy oral capsule 25 mg (generic for BANOPHEN) - Tier 1; OTC; QL
allergy oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL
ALLERGY) - Tier 1; OTC; QL
allergy oral tablet 25 mg (generic for BANOPHEN) - Tier 1; OTC; QL
DYMISTA (brand for azelastine-fluticasone) - Tier 2; PA; QL; DME
allergy relief (cetirizine) oral tablet 10 mg (generic for KLS ALLER-
TEC) - Tier 1; OTC; QL
allergy relief adult (generic for RA DIPHEDRYL ALLERGY) - Tier 1;
OTC; QL
allergy relief cetirizine (generic for KLS ALLER-TEC) - Tier 1; OTC; QL
allergy relief childrens oral liquid 12.5 mg/5ml (generic for RA
DIPHEDRYL ALLERGY) - Tier 1; OTC; QL
allergy relief childrens oral tablet chewable 12.5 mg (generic for
BENADRYL ALLERGY CHILDRENS) - Tier 1; OTC; QL
allergy relief max st (generic for RA DIPHEDRYL ALLERGY) - Tier 1;
OTC; QL
allergy relief oral capsule 25 mg (generic for BANOPHEN) - Tier 1;
OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
148
Preferred Agents Non-Preferred Agents
allergy relief oral liquid 25 mg/10ml (generic for RA DIPHEDRYL
ALLERGY) - Tier 1; OTC; QL
allergy relief oral tablet 25 mg (generic for BANOPHEN) - Tier 1; OTC;
QL
allergy relief oral tablet chewable 12.5 mg (generic for BENADRYL
ALLERGY CHILDRENS) - Tier 1; OTC; QL
allergy relief(cetirizine) (generic for KLS ALLER-TEC) - Tier 1; OTC;
QL
allergy relief/indoor/outdoor oral tablet 10 mg (generic for KLS ALLER-
TEC) - Tier 1; OTC; QL
aller-tec (generic for KLS ALLER-TEC) - Tier 1; OTC; QL
anti-hist allergy (generic for BANOPHEN) - Tier 1; OTC; QL
azelastine hcl nasal solution 0.1 %, 137 mcg/spray - Tier 1; QL; DME
banophen oral capsule 25 mg (generic for BANOPHEN) - Tier 1; OTC;
QL
banophen oral tablet (generic for BANOPHEN) - Tier 1; OTC; QL
BENADRYL ALLERGY CHILDRENS ORAL LIQUID (brand for allergy
childrens) - Tier 2; OTC; QL
BENADRYL ALLERGY CHILDRENS ORAL TABLET CHEWABLE
(brand for cvs allergy relief childrens) - Tier 2; OTC; QL
BENADRYL ALLERGY ORAL TABLET (brand for allergy relief) - Tier
2; OTC; QL
BENADRYL ALLERGY ULTRATABS (brand for allergy relief) - Tier 2;
OTC; QL
cetirizine allergy relief (generic for KLS ALLER-TEC) - Tier 1; OTC; QL
cetirizine hcl oral solution (generic for KLS ALLER-TEC CHILDRENS)
- Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
149
Preferred Agents Non-Preferred Agents
cetirizine hcl oral tablet (generic for KLS ALLER-TEC) - Tier 1; OTC;
QL
childrens allergy oral liquid 12.5 mg/5ml (generic for RA DIPHEDRYL
ALLERGY) - Tier 1; OTC; QL
clemastine fumarate oral - Tier 1; QL
complete allergy (generic for BANOPHEN) - Tier 1; OTC; QL
complete allergy medicine (generic for BANOPHEN) - Tier 1; OTC; QL
complete allergy medicine oral capsule (generic for BANOPHEN) -
Tier 1; OTC; QL
complete allergy relief (generic for BANOPHEN) - Tier 1; OTC; QL
CURELIEF (brand for allergy childrens) - Tier 2; OTC; QL
cyproheptadine hcl oral - Tier 1; QL
DAYHIST ALLERGY 12 HOUR RELIEF - Tier 2; OTC; QL
diphedryl allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1;
OTC; QL
diphen (generic for BANOPHEN) - Tier 1; OTC; QL
diphenhydramine hcl childrens (generic for RA DIPHEDRYL
ALLERGY) - Tier 1; OTC; QL
diphenhydramine hcl oral capsule (generic for BANOPHEN) - Tier 1;
OTC; QL
diphenhydramine hcl oral elixir - Tier 1; QL
diphenhydramine hcl oral liquid (generic for RA DIPHEDRYL
ALLERGY) - Tier 1; OTC; QL
diphenhydramine hcl oral tablet (generic for BANOPHEN) - Tier 1;
OTC; QL
diphenhydramine hcl oral tablet chewable (generic for BENADRYL
ALLERGY CHILDRENS) - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
150
Preferred Agents Non-Preferred Agents
ft all day allergy (generic for KLS ALLER-TEC) - Tier 1; OTC; QL
ft all day allergy 24 hour (generic for KLS ALLER-TEC) - Tier 1; OTC;
QL
ft allergy relief cetirizine (generic for KLS ALLER-TEC) - Tier 1; OTC;
QL
ft allergy relief childrens oral liquid (generic for RA DIPHEDRYL
ALLERGY) - Tier 1; OTC; QL
ft allergy relief oral capsule (generic for BANOPHEN) - Tier 1; OTC;
QL
ft allergy relief oral tablet 25 mg (generic for BANOPHEN) - Tier 1;
OTC; QL
geri-dryl (generic for BANOPHEN) - Tier 1; OTC; QL
h-e-b childrens allergy (generic for RA DIPHEDRYL ALLERGY) - Tier
1; OTC; QL
indoor/outdoor allergy rlf (generic for KLS ALLER-TEC) - Tier 1; OTC;
QL
levocetirizine dihydrochloride oral tablet (generic for XYZAL ALLERGY
24HR) - Tier 1; QL
liquid allergy relief (generic for RA DIPHEDRYL ALLERGY) - Tier 1;
OTC; QL
MAXALLERGY KIDS (brand for allergy childrens) - Tier 2; OTC; QL
m-dryl (generic for RA DIPHEDRYL ALLERGY) - Tier 1; OTC; QL
MM ALLER-BEN (brand for allergy relief) - Tier 2; OTC; QL
NARAMIN (brand for allergy childrens) - Tier 2; OTC; QL
pharbedryl (generic for BANOPHEN) - Tier 1; OTC; QL
siladryl allergy (generic for RA DIPHEDRYL ALLERGY) - Tier 1; OTC;
QL
total allergy (generic for BANOPHEN) - Tier 1; OTC; QL
total allergy medicine (generic for RA DIPHEDRYL ALLERGY) - Tier 1;
OTC; QL
ZYRTEC ALLERGY ORAL TABLET (brand for all day allergy) - Tier 2;
OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
151
Preferred Agents Non-Preferred Agents
Anti-inflammatories, Inhaled Corticosteroids
ARNUITY ELLIPTA - Tier 2; QL
ASMANEX (120 METERED DOSES) - Tier 2; QL
ASMANEX (14 METERED DOSES) - Tier 2; QL
ASMANEX (30 METERED DOSES) - Tier 2; QL
ASMANEX (60 METERED DOSES) - Tier 2; QL
ASMANEX HFA - Tier 2; Members >= 8 years of age will require PA;
QL
budesonide inhalation (generic for PULMICORT) - Tier 1; Members >=
5 years of age will require PA; QL; AL
FLUTICASONE PROPIONATE HFA - Tier 2; QL
fluticasone propionate nasal (generic for CLARISPRAY) - Tier 1; QL;
DME
ALVESCO - Tier 2; PA
OMNARIS - Tier 2; PA; QL; DME
PULMICORT FLEXHALER - Tier 2; PA; QL
QNASL - Tier 2; PA; QL; DME
QNASL CHILDRENS - Tier 2; PA; QL; DME
QVAR REDIHALER - Tier 2; PA; QL
XHANCE - Tier 2; PA; QL; DME
ZETONNA - Tier 2; PA; QL; DME
Antileukotrienes
montelukast sodium oral (generic for SINGULAIR) - Tier 1; QL ZYFLO - Tier 2; PA
Bronchodilators, Anticholinergic
ATROVENT HFA - Tier 2; QL
INCRUSE ELLIPTA - Tier 2; QL
ipratropium bromide inhalation - Tier 1; QL
ipratropium bromide nasal - Tier 1; QL; DME
SPIRIVA HANDIHALER (brand for tiotropium bromide monohydrate) -
Tier 2; PA; QL
SPIRIVA RESPIMAT - Tier 2; PA; QL
YUPELRI - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
152
Preferred Agents Non-Preferred Agents
Bronchodilators, Sympathomimetic
albuterol sulfate hfa aerosol solution 108 (90 base) mcg/act inhalation
(generic for VENTOLIN HFA) - Tier 1; QL
ALBUTEROL SULFATE HFA AEROSOL SOLUTION 108 (90 BASE)
MCG/ACT INHALATION (brand for albuterol sulfate hfa) - Tier 2; QL
albuterol sulfate inhalation nebulization solution (2.5 mg/3ml) 0.083%,
2.5 mg/0.5ml - Tier 1; QL
albuterol sulfate inhalation nebulization solution 0.63 mg/3ml, 1.25
mg/3ml - Tier 1; Members >= 8 years of age will require PA; QL; AL
albuterol sulfate nebulization solution (5 mg/ml) 0.5% inhalation - Tier
1; QL
ALBUTEROL SULFATE NEBULIZATION SOLUTION (5 MG/ML) 0.5%
INHALATION - Tier 2; QL
albuterol sulfate oral syrup - Tier 1; QL
AUVI-Q (brand for epinephrine) - Tier 2; PA; QL
EPIPEN 2-PAK (brand for epinephrine) - Tier 2; PA; QL
EPIPEN JR 2-PAK (brand for epinephrine) - Tier 2; PA; QL
PERFOROMIST (brand for formoterol fumarate) - Tier 2; PA; QL
PROAIR RESPICLICK - Tier 2; PA; QL
SEREVENT DISKUS - Tier 2; PA; QL
XOPENEX HFA (brand for levalbuterol tartrate) - Tier 2; PA; QL
epinephrine injection solution auto-injector (generic for AUVI-Q) - Tier
1; QL
levalbuterol hcl inhalation - Tier 1; ST; QL
STRIVERDI RESPIMAT - Tier 2; QL
VENTOLIN HFA (brand for albuterol sulfate hfa) - Tier 2; QL
Cystic Fibrosis Agents
CAYSTON - Tier 2; DX2RX; SP; QL
KALYDECO - Tier 2; PA; SP; QL
ORKAMBI - Tier 2; PA; SP; QL
PULMOZYME - Tier 2; DX2RX; SP; QL
SYMDEKO - Tier 2; PA; SP; QL
tobramycin inhalation nebulization solution 300 mg/4ml (generic for
BETHKIS) - Tier 1; DX2RX; SP; QL
TRIKAFTA ORAL TABLET THERAPY PACK - Tier 2; PA; SP; QL
TRIKAFTA ORAL THERAPY PACK - Tier 2; PA; SP; QL; AL
TOBI PODHALER - Tier 2; PA; SP; QL
Mast Cell Stabilizers
cromolyn sodium inhalation - Tier 1; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
153
Preferred Agents Non-Preferred Agents
Phosphodiesterase Inhibitors, Airways Disease
elixophyllin (generic for ELIXOPHYLLIN) - Tier 1; QL
THEO-24 - Tier 2
theophylline er oral tablet extended release 12 hour 300 mg - Tier 1;
QL
theophylline er oral tablet extended release 12 hour 450 mg - Tier 1
theophylline er oral tablet extended release 24 hour 400 mg - Tier 1;
QL
theophylline er oral tablet extended release 24 hour 600 mg - Tier 1
theophylline oral (generic for ELIXOPHYLLIN) - Tier 1; QL
Pulmonary Antihypertensives
ADEMPAS - Tier 2; DX2RX; SP; QL
ambrisentan (generic for LETAIRIS) - Tier 1; DX2RX; SP; QL
bosentan (generic for TRACLEER) - Tier 1; DX2RX; SP; QL
OPSUMIT - Tier 2; DX2RX; SP; QL
sildenafil citrate oral suspension reconstituted (generic for REVATIO) -
Tier 1; DX2RX; SP; QL
sildenafil citrate oral tablet 20 mg (generic for REVATIO) - Tier 1;
DX2RX; SP; QL
ORENITRAM MONTH 1 - Tier 2; PA; SP; QL; AL
ORENITRAM MONTH 2 - Tier 2; PA; SP; QL; AL
ORENITRAM MONTH 3 - Tier 2; PA; SP; QL; AL
ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG, 0.25
MG, 1 MG - Tier 2; PA; SP
ORENITRAM ORAL TABLET EXTENDED RELEASE 2.5 MG, 5 MG -
Tier 2; PA; SP; QL
TADLIQ - Tier 2; PA; SP; QL
TRACLEER (brand for bosentan) - Tier 2; DX2RX; SP; QL
TYVASO DPI MAINTENANCE KIT - Tier 2; PA; SP; QL
TYVASO DPI TITRATION KIT - Tier 2; PA; SP; QL
Pulmonary Fibrosis Agents
OFEV - Tier 2; PA; SP; QL
pirfenidone oral capsule (generic for ESBRIET) - Tier 1; PA; SP; QL
pirfenidone oral tablet 267 mg, 801 mg (generic for ESBRIET) - Tier 1;
PA; SP; QL
ESBRIET (brand for pirfenidone) - Tier 2; PA; SP; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
154
Preferred Agents Non-Preferred Agents
Respiratory Tract Agents, Other
acetylcysteine inhalation solution 10 % - Tier 1; QL
acetylcysteine inhalation solution 20 % - Tier 1
FASENRA PEN - Tier 2; PA; SP; QL
NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2;
PA; SP; QL
NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE - Tier
2; PA; SP; QL
promethazine vc - Tier 1; QL; AL
TEZSPIRE SUBCUTANEOUS SOLUTION AUTO-INJECTOR - Tier 2;
PA; SP; QL
Respiratory Tract/Pulmonary Agents - Drugs to Treat Allergies,
Cough, Cold and Lung Conditions
4-WAY FAST ACTING (brand for cvs nasal spray) - Tier 2; OTC; DME
4-WAY MENTHOL (brand for cvs nasal spray) - Tier 2; OTC; DME
AFRIN SALINE NASAL MIST (brand for altamist spray) - Tier 2; OTC;
DME
altamist spray (generic for AFRIN SALINE NASAL MIST) - Tier 1;
OTC; DME
altarussin (generic for TUSNEL-EX) - Tier 1; OTC; QL; AL
AYR (brand for altamist spray) - Tier 2; OTC; DME
AYR SALINE NASAL DROPS - Tier 2; OTC; DME
BABY AYR SALINE (brand for altamist spray) - Tier 2; OTC; DME
BROMFED DM (brand for pseudoeph-bromphen-dm) - Tier 2; QL; AL
BUCKLEYS CHEST CONGESTION (brand for altarussin) - Tier 2;
OTC; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
155
Preferred Agents Non-Preferred Agents
chest congestion relief oral liquid (generic for TUSNEL-EX) - Tier 1;
OTC; QL; AL
chest congestion relief oral tablet (generic for XPECT) - Tier 1; OTC
CORICIDIN HBP COUGH/COLD (brand for cough & cold) - Tier 2;
OTC; AL
cough & cold (generic for CORICIDIN HBP COUGH/COLD) - Tier 1;
OTC; AL
cough & cold hbp (generic for CORICIDIN HBP COUGH/COLD) - Tier
1; OTC; AL
cough relief oral syrup 15 mg/5ml (generic for WAL-TUSSIN COUGH
LONG ACTING) - Tier 1; OTC; AL
cough/cold hbp (generic for CORICIDIN HBP COUGH/COLD) - Tier 1;
OTC; AL
deep sea nasal spray (generic for AFRIN SALINE NASAL MIST) - Tier
1; OTC; DME
ed bron gp - Tier 1; OTC; AL
ephrine nose drops (generic for 4-WAY FAST ACTING) - Tier 1; OTC;
DME
ft chest congestion relief (generic for XPECT) - Tier 1; OTC
ft mucus relief 12hr oral tablet extended release 12 hour 1200 mg
(generic for EQ MUCUS ER) - Tier 1; OTC; QL; AL
ft nasal decongestant pe (generic for SUDAFED PE SINUS
CONGESTION) - Tier 1; OTC; DME
ft tussin adult (generic for TUSNEL-EX) - Tier 1; OTC; QL; AL
geri-tussin oral liquid (generic for TUSNEL-EX) - Tier 1; OTC; QL; AL
guaifenesin er oral tablet extended release 12 hour 1200 mg (generic
for EQ MUCUS ER) - Tier 1; OTC; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
156
Preferred Agents Non-Preferred Agents
guaifenesin oral liquid (generic for TUSNEL-EX) - Tier 1; OTC; QL; AL
guaifenesin oral tablet 400 mg (generic for XPECT) - Tier 1; OTC
MAX TUSSIN MUCUS & CHEST CONG (brand for altarussin) - Tier 2;
OTC; QL; AL
maxi-tuss pe max - Tier 1; OTC; AL
medifin 400 (generic for XPECT) - Tier 1; OTC
medifin mucus relief child (generic for TUSNEL-EX) - Tier 1; OTC; QL;
AL
MUCINEX FAST-MAX CHEST CONG MS (brand for altarussin) - Tier
2; OTC; QL; AL
MUCINEX MAXIMUM STRENGTH (brand for cvs mucus extended
release) - Tier 2; OTC; QL; AL
mucus er maximum str (generic for EQ MUCUS ER) - Tier 1; OTC;
QL; AL
mucus er oral tablet extended release 12 hour 1200 mg (generic for
EQ MUCUS ER) - Tier 1; OTC; QL; AL
mucus extended release oral tablet extended release 12 hour 1200 mg
(generic for EQ MUCUS ER) - Tier 1; OTC; QL; AL
mucus relief 12 hour max st (generic for EQ MUCUS ER) - Tier 1;
OTC; QL; AL
mucus relief chest oral tablet 400 mg (generic for XPECT) - Tier 1;
OTC
mucus relief childrens oral liquid 100 mg/5ml (generic for TUSNEL-EX)
- Tier 1; OTC; QL; AL
mucus relief er (generic for EQ MUCUS ER) - Tier 1; OTC; QL; AL
mucus relief er oral tablet extended release 12 hour 1200 mg (generic
for EQ MUCUS ER) - Tier 1; OTC; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
157
Preferred Agents Non-Preferred Agents
mucus relief max st (generic for EQ MUCUS ER) - Tier 1; OTC; QL;
AL
mucus relief max strength oral tablet extended release 12 hour 1200
mg (generic for EQ MUCUS ER) - Tier 1; OTC; QL; AL
mucus relief oral tablet 400 mg (generic for XPECT) - Tier 1; OTC
mucus relief oral tablet extended release 12 hour 1200 mg (generic for
EQ MUCUS ER) - Tier 1; OTC; QL; AL
mucus+chest congestion (generic for TUSNEL-EX) - Tier 1; OTC; QL;
AL
mucus-er oral tablet extended release 12 hour 1200 mg (generic for
EQ MUCUS ER) - Tier 1; OTC; QL; AL
nasal decongestant pe max st (generic for SUDAFED PE SINUS
CONGESTION) - Tier 1; OTC; DME
nasal decongestant pe oral tablet 10 mg (generic for SUDAFED PE
SINUS CONGESTION) - Tier 1; OTC; DME
nasal four (generic for 4-WAY FAST ACTING) - Tier 1; OTC; DME
nasal four spray (generic for 4-WAY FAST ACTING) - Tier 1; OTC;
DME
NASAL MOIST NASAL SOLUTION (brand for altamist spray) - Tier 2;
OTC; DME
nasal moisturizing spray (generic for AFRIN SALINE NASAL MIST) -
Tier 1; OTC; DME
nasal spray fast acting (generic for 4-WAY FAST ACTING) - Tier 1;
OTC; DME
nasal spray nasal solution 1 % (generic for 4-WAY FAST ACTING) -
Tier 1; OTC; DME
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
158
Preferred Agents Non-Preferred Agents
nasal spray saline (generic for AFRIN SALINE NASAL MIST) - Tier 1;
OTC; DME
NEO-SYNEPHRINE COLD/ALLRGY EXT (brand for cvs nasal spray) -
Tier 2; OTC; DME
non-pseudo sinus decongestant (generic for SUDAFED PE SINUS
CONGESTION) - Tier 1; OTC; DME
nose drops extstrength (generic for 4-WAY FAST ACTING) - Tier 1;
OTC; DME
OCEAN FOR KIDS (brand for altamist spray) - Tier 2; OTC; DME
OCEAN NASAL SPRAY (brand for altamist spray) - Tier 2; OTC; DME
pharbinex (generic for XPECT) - Tier 1; OTC
phenylephrine hcl oral (generic for SUDAFED PE SINUS
CONGESTION) - Tier 1; OTC; DME
pseudoephedrine-bromphen-dm (generic for BROMFED DM) - Tier 1;
QL; AL
refenesen 400 (generic for XPECT) - Tier 1; OTC
saline mist spray (generic for AFRIN SALINE NASAL MIST) - Tier 1;
OTC; DME
saline nasal spray (generic for AFRIN SALINE NASAL MIST) - Tier 1;
OTC; DME
sb mucus relief (generic for XPECT) - Tier 1; OTC
siltussin sa (generic for TUSNEL-EX) - Tier 1; OTC; QL; AL
sinus pe decongestant (generic for SUDAFED PE SINUS
CONGESTION) - Tier 1; OTC; DME
sinus relief extra strength (generic for 4-WAY FAST ACTING) - Tier 1;
OTC; DME
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
159
Preferred Agents Non-Preferred Agents
sinus/congestion relief pe (generic for SUDAFED PE SINUS
CONGESTION) - Tier 1; OTC; DME
SUDAFED PE CONGESTION ORAL TABLET 10 MG (brand for cvs
sinus pe decongestant) - Tier 2; OTC; DME
SUDAFED PE SINUS CONGESTION (brand for cvs sinus pe
decongestant) - Tier 2; OTC; DME
tab tussin (generic for XPECT) - Tier 1; OTC
TRUE NASAL MOISTURIZING (brand for altamist spray) - Tier 2;
OTC; DME
tusnel-ex (generic for TUSNEL-EX) - Tier 1; OTC; QL; AL
tussin adult chest congest (generic for TUSNEL-EX) - Tier 1; OTC; QL;
AL
tussin chest congestion oral liquid 100 mg/5ml (generic for TUSNEL-
EX) - Tier 1; OTC; QL; AL
tussin cough long acting (generic for WAL-TUSSIN COUGH LONG
ACTING) - Tier 1; OTC; AL
tussin cough oral syrup (generic for WAL-TUSSIN COUGH LONG
ACTING) - Tier 1; OTC; AL
tussin expectorant adult (generic for TUSNEL-EX) - Tier 1; OTC; QL;
AL
tussin maximum strength oral syrup 15 mg/5ml (generic for WAL-
TUSSIN COUGH LONG ACTING) - Tier 1; OTC; AL
tussin mucus & chest cong (generic for TUSNEL-EX) - Tier 1; OTC;
QL; AL
tussin mucus & chest congest (generic for TUSNEL-EX) - Tier 1; OTC;
QL; AL
tussin mucus/chest congest (generic for TUSNEL-EX) - Tier 1; OTC;
QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
160
Preferred Agents Non-Preferred Agents
tussin mucus/congestion (generic for TUSNEL-EX) - Tier 1; OTC; QL;
AL
tussin mucus+chest congest (generic for TUSNEL-EX) - Tier 1; OTC;
QL; AL
tussin mucus+chest congestion (generic for TUSNEL-EX) - Tier 1;
OTC; QL; AL
tussin oral liquid 100 mg/5ml (generic for TUSNEL-EX) - Tier 1; OTC;
QL; AL
XPECT (brand for chest congestion relief) - Tier 2; OTC
Antihistamines - Allergy Drugs
12 hour allergy-d (generic for KLS ALLER-TEC D) - Tier 1; OTC; QL;
AL
all day allergy d (generic for KLS ALLER-TEC D) - Tier 1; OTC; QL; AL
all day allergy-d oral tablet extended release 12 hour 5-120 mg
(generic for KLS ALLER-TEC D) - Tier 1; OTC; QL; AL
allergy relief d oral tablet extended release 12 hour 5-120 mg (generic
for KLS ALLER-TEC D) - Tier 1; OTC; QL; AL
allergy relief oral tablet extended release 12 hour 5-120 mg (generic
for KLS ALLER-TEC D) - Tier 1; OTC; QL; AL
allergy relief/nasal decongest oral tablet extended release 12 hour
(generic for KLS ALLER-TEC D) - Tier 1; OTC; QL; AL
allergy relief-d oral tablet extended release 12 hour 5-120 mg (generic
for KLS ALLER-TEC D) - Tier 1; OTC; QL; AL
aller-tec d (generic for KLS ALLER-TEC D) - Tier 1; OTC; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
161
Preferred Agents Non-Preferred Agents
cetiri-d (generic for KLS ALLER-TEC D) - Tier 1; OTC; QL; AL
cetirizine-pseudoephedrine er (generic for KLS ALLER-TEC D) - Tier
1; OTC; QL; AL
desgen dm oral liquid (generic for DESGEN DM) - Tier 1; OTC; AL
ED A-HIST ORAL LIQUID (brand for nohist-lq) - Tier 2; OTC; QL; AL
ft all day allergy-d (generic for KLS ALLER-TEC D) - Tier 1; OTC; QL;
AL
ft tussin cf adult (generic for DESGEN DM) - Tier 1; OTC; AL
nohist-lq (generic for ED A-HIST) - Tier 1; OTC; QL; AL
ROBAFEN CF MULTI-SYMPTOM COLD (brand for ft tussin cf adult) -
Tier 2; OTC; AL
ROBITUSSIN PEAK COLD MULTI-SYM (brand for ft tussin cf adult) -
Tier 2; OTC; AL
tussin cf oral liquid 5-10-100 mg/5ml (generic for DESGEN DM) - Tier
1; OTC; AL
tussin multi-symptom cold cf (generic for DESGEN DM) - Tier 1; OTC;
AL
ZYRTEC-D ALLERGY & CONGESTION (brand for 12 hour allergy-d) -
Tier 2; OTC; QL; AL
ZYRTEC-D ALLERGY & SINUS (brand for 12 hour allergy-d) - Tier 2;
OTC; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
162
Preferred Agents Non-Preferred Agents
Antihistamines - Drugs to Treat Allergies
12hr allergy relief (generic for ALLEGRA ALLERGY) - Tier 1; OTC; QL
24hr allergy relief (generic for KLS ALLER-FEX) - Tier 1; OTC; QL
all day allergy relief oral tablet 10 mg (generic for KLS ALLERCLEAR)
- Tier 1; OTC; QL
ALLEGRA ALLERGY (brand for 12hr allergy relief) - Tier 2; OTC; QL
ALLEGRA HIVES 24HR (brand for 24hr allergy relief) - Tier 2; OTC;
QL
allerclear (generic for KLS ALLERCLEAR) - Tier 1; OTC; QL
aller-ease oral tablet 180 mg (generic for KLS ALLER-FEX) - Tier 1;
OTC; QL
aller-fex (generic for KLS ALLER-FEX) - Tier 1; OTC; QL
allerg rel child (lorat) (generic for CLARITIN ALLERGY CHILDRENS) -
Tier 1; OTC; QL
allerg relief child (lorat) (generic for CLARITIN ALLERGY
CHILDRENS) - Tier 1; OTC; QL
allergy 24-hr (generic for KLS ALLER-FEX) - Tier 1; OTC; QL
allergy childrens oral solution (generic for CLARITIN ALLERGY
CHILDRENS) - Tier 1; OTC; QL
allergy rel child (loratadine) (generic for CLARITIN ALLERGY
CHILDRENS) - Tier 1; OTC; QL
allergy relief (loratadine) oral tablet (generic for KLS ALLERCLEAR) -
Tier 1; OTC; QL
allergy relief child (generic for CLARITIN ALLERGY CHILDRENS) -
Tier 1; OTC; QL
allergy relief childrens oral solution 5 mg/5ml (generic for CLARITIN
ALLERGY CHILDRENS) - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
163
Preferred Agents Non-Preferred Agents
allergy relief oral tablet 10 mg (generic for KLS ALLERCLEAR) - Tier
1; OTC; QL
allergy relief oral tablet 180 mg (generic for KLS ALLER-FEX) - Tier 1;
OTC; QL
allergy relief oral tablet 60 mg (generic for ALLEGRA ALLERGY) - Tier
1; OTC; QL
allergy relief oral tablet dispersible 10 mg (generic for CLARITIN
REDITABS) - Tier 1; OTC; QL
allergy relief/indoor/outdoor oral tablet 180 mg (generic for KLS
ALLER-FEX) - Tier 1; OTC; QL
childrens loratadine (generic for CLARITIN ALLERGY CHILDRENS) -
Tier 1; OTC; QL
CLARITIN ALLERGY CHILDRENS (brand for allergy childrens) - Tier
2; OTC; QL
CLARITIN ORAL TABLET (brand for allergy relief) - Tier 2; OTC; QL
CLARITIN REDITABS ORAL TABLET DISPERSIBLE 10 MG (brand
for cvs allergy relief) - Tier 2; OTC; QL
ed chlorped jr (generic for DIABETIC TUSSIN ALLERGY) - Tier 1;
OTC; QL
fexofenadine hcl (generic for ALLEGRA ALLERGY) - Tier 1; OTC; QL
fexofenadine hcl oral (generic for ALLEGRA ALLERGY) - Tier 1; OTC;
QL
ft all day allergy relief (generic for KLS ALLERCLEAR) - Tier 1; OTC;
QL
ft allergy childrens (generic for CLARITIN ALLERGY CHILDRENS) -
Tier 1; OTC; QL
ft allergy relief 12 hour (generic for ALLEGRA ALLERGY) - Tier 1;
OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
164
Preferred Agents Non-Preferred Agents
ft allergy relief 24 hour (generic for KLS ALLER-FEX) - Tier 1; OTC;
QL
ft allergy relief loratadine (generic for KLS ALLERCLEAR) - Tier 1;
OTC; QL
ft allergy relief oral tablet 180 mg (generic for KLS ALLER-FEX) - Tier
1; OTC; QL
loradamed (generic for KLS ALLERCLEAR) - Tier 1; OTC; QL
loratadine allergy relief oral tablet 10 mg (generic for KLS
ALLERCLEAR) - Tier 1; OTC; QL
loratadine allergy relief oral tablet dispersible 10 mg (generic for
CLARITIN REDITABS) - Tier 1; OTC; QL
loratadine childrens oral solution (generic for CLARITIN ALLERGY
CHILDRENS) - Tier 1; OTC; QL
loratadine oral solution (generic for CLARITIN ALLERGY
CHILDRENS) - Tier 1; OTC; QL
loratadine oral tablet (generic for KLS ALLERCLEAR) - Tier 1; OTC;
QL
loratadine oral tablet dispersible (generic for CLARITIN REDITABS) -
Tier 1; OTC; QL
TRIAMINIC ALLERCHEWS (brand for cvs allergy relief) - Tier 2; OTC;
QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
165
Preferred Agents Non-Preferred Agents
Anti-Inflammatories, Inhaled Corticosteroids - Asthma/Lung
Drugs
24 hour nasal allergy (generic for NASACORT ALLERGY 24HR) - Tier
1; OTC; QL; DME
allergy spray 24 hour nasal aerosol (generic for NASACORT
ALLERGY 24HR) - Tier 1; OTC; QL; DME
ft 24 hour nasal allergy (generic for NASACORT ALLERGY 24HR) -
Tier 1; OTC; QL; DME
NASACORT ALLERGY 24HR (brand for allergy spray 24 hour) - Tier
2; OTC; QL; DME
nasal allergy 24 hour (generic for NASACORT ALLERGY 24HR) - Tier
1; OTC; QL; DME
nasal allergy nasal aerosol 55 mcg/act (generic for NASACORT
ALLERGY 24HR) - Tier 1; OTC; QL; DME
nasal allergy spray (generic for NASACORT ALLERGY 24HR) - Tier 1;
OTC; QL; DME
triamcinolone acetonide nasal (generic for NASACORT ALLERGY
24HR) - Tier 1; OTC; QL; DME
Bronchodilators, Sympathomimetic - Asthma/Lung Drugs
BREO ELLIPTA INHALATION AEROSOL POWDER BREATH
ACTIVATED 100-25 MCG/ACT, 200-25 MCG/ACT (brand for
fluticasone furoate-vilanterol) - Tier 2; QL
COMBIVENT RESPIMAT - Tier 2; QL
FLUTICASONE FUROATE-VILANTEROL (brand for fluticasone
furoate-vilanterol) - Tier 2; QL
fluticasone-salmeterol inhalation aerosol powder breath activated 100-
50 mcg/act, 250-50 mcg/act, 500-50 mcg/act (generic for WIXELA
INHUB) - Tier 1; QL
FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER
BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14
MCG/ACT - Tier 2; QL
ipratropium-albuterol - Tier 1; QL
STIOLTO RESPIMAT - Tier 2; QL
ADVAIR HFA (brand for fluticasone-salmeterol) - Tier 2; PA; QL
ANORO ELLIPTA - Tier 2; PA; QL
BEVESPI AEROSPHERE - Tier 2; PA; QL
BREZTRI AEROSPHERE - Tier 2; PA; QL
DULERA - Tier 2; PA; QL
SYMBICORT (brand for budesonide-formoterol fumarate) - Tier 2; PA;
ST; QL; AL
TRELEGY ELLIPTA - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
166
Preferred Agents Non-Preferred Agents
wixela inhub (generic for WIXELA INHUB) - Tier 1; QL
Mast Cell Stabilizers - Drugs for the Lungs
cromolyn sodium nasal (generic for NASALCROM) - Tier 1; OTC; QL;
DME
NASALCROM (brand for cromolyn sodium) - Tier 2; OTC; QL; DME
Respiratory Tract Agents, Other - Asthma/Lung Drugs
12 hour decongestant (generic for GILTUSS SEVERE SINUS) - Tier 1;
OTC; DME
12 hour nasal decongestant (generic for GILTUSS SEVERE SINUS) -
Tier 1; OTC; DME
12 hour nasal relief spray (generic for GILTUSS SEVERE SINUS) -
Tier 1; OTC; DME
12 hour nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1;
OTC; DME
ADVIL COLD/SINUS (brand for cold & sinus) - Tier 2; OTC; AL
AFRIN NODRIP ORIGINAL (brand for 12 hour decongestant) - Tier 2;
OTC; DME
allerclear d-12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1;
OTC; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
167
Preferred Agents Non-Preferred Agents
allerclear d-24hr (generic for EQ ALLERGY RELIEF NASAL
DECONG) - Tier 1; OTC; QL; AL
allergy & congestion oral tablet extended release 24 hour 10-240 mg
(generic for EQ ALLERGY RELIEF NASAL DECONG) - Tier 1; OTC;
QL; AL
allergy & congestion relief (generic for KLS ALLERCLEAR D-12HR) -
Tier 1; OTC; QL; AL
allergy nasal mist no drip (generic for GILTUSS SEVERE SINUS) -
Tier 1; OTC; DME
allergy relief d-12 (generic for KLS ALLERCLEAR D-12HR) - Tier 1;
OTC; QL; AL
allergy relief d-24 (generic for EQ ALLERGY RELIEF NASAL
DECONG) - Tier 1; OTC; QL; AL
allergy relief nasal decong (generic for EQ ALLERGY RELIEF NASAL
DECONG) - Tier 1; OTC; QL; AL
allergy relief/nasal decong (generic for EQ ALLERGY RELIEF NASAL
DECONG) - Tier 1; OTC; QL; AL
allergy relief/nasal decongest oral tablet extended release 24 hour
(generic for EQ ALLERGY RELIEF NASAL DECONG) - Tier 1; OTC;
QL; AL
allergy relief-d oral tablet extended release 12 hour 5-120 mg (generic
for KLS ALLERCLEAR D-12HR) - Tier 1; OTC; QL; AL
allergy relief-d oral tablet extended release 24 hour 10-240 mg
(generic for EQ ALLERGY RELIEF NASAL DECONG) - Tier 1; OTC;
QL; AL
allergy relief-d12 (generic for KLS ALLERCLEAR D-12HR) - Tier 1;
OTC; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
168
Preferred Agents Non-Preferred Agents
allergy/congestion relief (generic for EQ ALLERGY RELIEF NASAL
DECONG) - Tier 1; OTC; QL; AL
altarussin dm (generic for ROBAFEN DM COUGH CLEAR) - Tier 1;
OTC; QL; AL
anefrin spray (generic for GILTUSS SEVERE SINUS) - Tier 1; OTC;
DME
APRODINE (brand for cold & allergy d) - Tier 2; OTC; AL
benzonatate oral capsule 100 mg, 200 mg - Tier 1; QL; AL
chest congest/cough child (generic for DELSYM CGH/CHEST CONG
DM CHILD) - Tier 1; OTC
chest congestion relief dm oral syrup (generic for ROBAFEN DM
COUGH CLEAR) - Tier 1; OTC; QL; AL
childrens cold & allergy - Tier 1; OTC; AL
childrens cough (generic for DELSYM CGH/CHEST CONG DM
CHILD) - Tier 1; OTC
childrens mucus relief cough (generic for DELSYM CGH/CHEST
CONG DM CHILD) - Tier 1; OTC
CLARITIN-D 12 HOUR (brand for allergy relief d-12) - Tier 2; OTC;
QL; AL
CLARITIN-D 24 HOUR (brand for allergy relief d-24) - Tier 2; OTC;
QL; AL
cold & allergy - Tier 1; OTC; AL
cold & allergy childrens oral elixir 1-15 mg/5ml - Tier 1; OTC; AL
cold & cough childrens oral liquid 1-5-2.5 mg/5ml, 2.5-1-5 mg/5ml
(generic for DIMAPHEN DM COLD/COUGH) - Tier 1; OTC; QL; AL
cold & sinus (generic for ADVIL COLD/SINUS) - Tier 1; OTC; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
169
Preferred Agents Non-Preferred Agents
cold & sinus relief oral tablet 30-200 mg (generic for ADVIL
COLD/SINUS) - Tier 1; OTC; AL
cold/cough (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; OTC;
QL; AL
cold/cough childrens (generic for DIMAPHEN DM COLD/COUGH) -
Tier 1; OTC; QL; AL
cold/cough dm childrens oral liquid 2.5-1-5 mg/5ml (generic for
DIMAPHEN DM COLD/COUGH) - Tier 1; OTC; QL; AL
cold/cough dm oral liquid 2.5-1-5 mg/5ml (generic for DIMAPHEN DM
COLD/COUGH) - Tier 1; OTC; QL; AL
cough & chest congestion (generic for DELSYM CGH/CHEST CONG
DM CHILD) - Tier 1; OTC
cough childrens (generic for DELSYM CGH/CHEST CONG DM
CHILD) - Tier 1; OTC
cough dm childrens oral suspension extended release 30 mg/5ml
(generic for DELSYM) - Tier 1; OTC; QL; AL
cough dm er (generic for DELSYM) - Tier 1; OTC; QL; AL
cough dm oral suspension extended release 30 mg/5ml (generic for
DELSYM) - Tier 1; OTC; QL; AL
DELSYM CGH/CHEST CONG DM CHILD (brand for childrens cough)
- Tier 2; OTC
DELSYM COUGH CHILDRENS (brand for cough dm) - Tier 2; OTC;
QL; AL
DELSYM COUGH/CHEST CONGEST DM (brand for childrens cough)
- Tier 2; OTC
DELSYM ORAL SUSPENSION EXTENDED RELEASE (brand for
cough dm) - Tier 2; OTC; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
170
Preferred Agents Non-Preferred Agents
dextromethorphan polistirex er (generic for DELSYM) - Tier 1; OTC;
QL; AL
dextromethorphan-guaifenesin oral liquid 5-100 mg/5ml (generic for
DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; OTC
dextromethorphan-guaifenesin oral syrup (generic for ROBAFEN DM
COUGH CLEAR) - Tier 1; OTC; QL; AL
dibromm childrens cold/cgh (generic for DIMAPHEN DM
COLD/COUGH) - Tier 1; OTC; QL; AL
dimaphen dm cold/cough (generic for DIMAPHEN DM COLD/COUGH)
- Tier 1; OTC; QL; AL
dm maximum adult (generic for DELSYM CGH/CHEST CONG DM
CHILD) - Tier 1; OTC
ENDACOF-DM (brand for cold & cough childrens) - Tier 2; OTC; QL;
AL
ft 12 hour cough relief (generic for DELSYM) - Tier 1; OTC; QL; AL
ft allergy relief-d (generic for EQ ALLERGY RELIEF NASAL
DECONG) - Tier 1; OTC; QL; AL
ft cold & cough relief dm (generic for DIMAPHEN DM COLD/COUGH)
- Tier 1; OTC; QL; AL
ft mucus relief d 12 hour (generic for MUCINEX D) - Tier 1; OTC; AL
ft mucus relief dm oral tablet extended release 12 hour 30-600 mg
(generic for MUCINEX DM) - Tier 1; OTC; QL; AL
ft nasal decongestant max str oral tablet (generic for SUDOGEST) -
Tier 1; OTC; QL; DME
ft nasal decongestant max str oral tablet extended release 12 hour
(generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1; OTC;
DME
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
171
Preferred Agents Non-Preferred Agents
ft nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1; OTC;
DME
ft tussin dm max adult (generic for DELSYM CGH/CHEST CONG DM
CHILD) - Tier 1; OTC
g tussin ac - Tier 1; OTC; QL; AL
geri-tussin dm oral syrup (generic for ROBAFEN DM COUGH CLEAR)
- Tier 1; OTC; QL; AL
giltuss severe sinus (generic for GILTUSS SEVERE SINUS) - Tier 1;
OTC; DME
guaifenesin-codeine - Tier 1; OTC; QL; AL
guaifenesin-dm oral syrup (generic for ROBAFEN DM COUGH
CLEAR) - Tier 1; OTC; QL; AL
HYPERSAL INHALATION NEBULIZATION SOLUTION 7 % (brand for
sodium chloride) - Tier 2
ibuprofen cold & sinus (generic for ADVIL COLD/SINUS) - Tier 1;
OTC; AL
ibuprofen cold/sinus oral tablet 30-200 mg (generic for ADVIL
COLD/SINUS) - Tier 1; OTC; AL
ibu-profen cold/sinus oral tablet 30-200 mg (generic for ADVIL
COLD/SINUS) - Tier 1; OTC; AL
long acting nasal spray (generic for GILTUSS SEVERE SINUS) - Tier
1; OTC; DME
long lasting nasal spray (generic for GILTUSS SEVERE SINUS) - Tier
1; OTC; DME
lorata-d (generic for EQ ALLERGY RELIEF NASAL DECONG) - Tier
1; OTC; QL; AL
lorata-dine d (generic for EQ ALLERGY RELIEF NASAL DECONG) -
Tier 1; OTC; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
172
Preferred Agents Non-Preferred Agents
loratadine d 12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1;
OTC; QL; AL
loratadine-d (generic for EQ ALLERGY RELIEF NASAL DECONG) -
Tier 1; OTC; QL; AL
loratadine-d 12hr (generic for KLS ALLERCLEAR D-12HR) - Tier 1;
OTC; QL; AL
loratadine-d 24hr (generic for EQ ALLERGY RELIEF NASAL
DECONG) - Tier 1; OTC; QL; AL
maxi-tuss ac - Tier 1; OTC; QL; AL
maxi-tuss gmx (generic for DIABETIC TUSSIN DM MAX ST) - Tier 1;
OTC; AL
meijer allergy relief-d (generic for KLS ALLERCLEAR D-12HR) - Tier
1; OTC; QL; AL
MUCINEX COUGH CHILDRENS (brand for childrens cough) - Tier 2;
OTC
MUCINEX D (brand for cvs mucus d extended release) - Tier 2; OTC;
AL
MUCINEX D MAX STRENGTH (brand for cvs mucus d max st er) -
Tier 2; OTC; AL
MUCINEX DM (brand for cvs mucus dm extended release) - Tier 2;
OTC; QL; AL
MUCINEX FAST-MAX DM MAX (brand for childrens cough) - Tier 2;
OTC
MUCINEX SINUS-MAX CLEAR & COOL (brand for 12 hour
decongestant) - Tier 2; OTC; DME
MUCINEX SINUS-MAX SINUS/ALLRGY (brand for 12 hour
decongestant) - Tier 2; OTC; DME
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
173
Preferred Agents Non-Preferred Agents
mucus & cough relief child (generic for DELSYM CGH/CHEST CONG
DM CHILD) - Tier 1; OTC
mucus d (generic for MUCINEX D MAX STRENGTH) - Tier 1; OTC;
AL
mucus d extended release (generic for MUCINEX D) - Tier 1; OTC; AL
mucus d max st er (generic for MUCINEX D MAX STRENGTH) - Tier
1; OTC; AL
mucus dm (generic for MUCINEX DM) - Tier 1; OTC; QL; AL
mucus dm extended release oral tablet extended release 12 hour 30-
600 mg (generic for MUCINEX DM) - Tier 1; OTC; QL; AL
mucus relief cough childrens (generic for DELSYM CGH/CHEST
CONG DM CHILD) - Tier 1; OTC
mucus relief d max strength (generic for MUCINEX D MAX
STRENGTH) - Tier 1; OTC; AL
mucus relief d oral tablet extended release 12 hour 120-1200 mg
(generic for MUCINEX D MAX STRENGTH) - Tier 1; OTC; AL
mucus relief d oral tablet extended release 12 hour 60-600 mg
(generic for MUCINEX D) - Tier 1; OTC; AL
mucus relief dm max oral liquid 20-400 mg/20ml, 5-100 mg/5ml
(generic for DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; OTC
mucus relief dm oral liquid 20-400 mg/20ml (generic for DELSYM
CGH/CHEST CONG DM CHILD) - Tier 1; OTC
mucus relief dm oral tablet extended release 12 hour 30-600 mg
(generic for MUCINEX DM) - Tier 1; OTC; QL; AL
mucus-dm (generic for MUCINEX DM) - Tier 1; OTC; QL; AL
nasal decongestant 12hr (generic for SUDAFED SINUS
CONGESTION 12HR) - Tier 1; OTC; DME
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
174
Preferred Agents Non-Preferred Agents
nasal decongestant max st (generic for SUDOGEST) - Tier 1; OTC;
QL; DME
nasal decongestant oral tablet 30 mg (generic for SUDOGEST) - Tier
1; OTC; QL; DME
nasal decongestant oral tablet extended release 12 hour 120 mg
(generic for SUDAFED SINUS CONGESTION 12HR) - Tier 1; OTC;
DME
nasal decongestant pe oral tablet 30 mg (generic for SUDOGEST) -
Tier 1; OTC; QL; DME
nasal decongestant spray (generic for GILTUSS SEVERE SINUS) -
Tier 1; OTC; DME
nasal mist nasal solution (generic for GILTUSS SEVERE SINUS) -
Tier 1; OTC; DME
nasal mist no drip (generic for GILTUSS SEVERE SINUS) - Tier 1;
OTC; DME
nasal relief (generic for GILTUSS SEVERE SINUS) - Tier 1; OTC;
DME
nasal spray 12 hour (generic for GILTUSS SEVERE SINUS) - Tier 1;
OTC; DME
nasal spray extra moist (generic for GILTUSS SEVERE SINUS) - Tier
1; OTC; DME
nasal spray extra moisturizing (generic for GILTUSS SEVERE SINUS)
- Tier 1; OTC; DME
nasal spray nasal solution 0.05 % (generic for GILTUSS SEVERE
SINUS) - Tier 1; OTC; DME
nasal spray no drip (generic for GILTUSS SEVERE SINUS) - Tier 1;
OTC; DME
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
175
Preferred Agents Non-Preferred Agents
nasal spray sinus (generic for GILTUSS SEVERE SINUS) - Tier 1;
OTC; DME
NEBUSAL INHALATION NEBULIZATION SOLUTION 3 % (brand for
sodium chloride) - Tier 2
no drip extra moisturizing (generic for GILTUSS SEVERE SINUS) -
Tier 1; OTC; DME
no drip nasal relief (generic for GILTUSS SEVERE SINUS) - Tier 1;
OTC; DME
no drip nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1;
OTC; DME
no drip original 12 hours (generic for GILTUSS SEVERE SINUS) - Tier
1; OTC; DME
promethazine-codeine oral solution - Tier 1; QL; AL
promethazine-dm - Tier 1; QL; AL
pseudoephedrine hcl 12 hr (generic for SUDAFED SINUS
CONGESTION 12HR) - Tier 1; OTC; DME
pseudoephedrine hcl er (generic for SUDAFED SINUS CONGESTION
12HR) - Tier 1; OTC; DME
pseudoephedrine hcl oral tablet 30 mg (generic for SUDOGEST) - Tier
1; OTC; QL; DME
pseudoephedrine-guaifenesin er (generic for MUCINEX D) - Tier 1;
OTC; AL
PULMOSAL (brand for sodium chloride) - Tier 2
ROBITUSSIN 12 HOUR COUGH (brand for cough dm) - Tier 2; OTC;
QL; AL
ROBITUSSIN 12 HOUR COUGH CHILD (brand for cough dm) - Tier 2;
OTC; QL; AL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
176
Preferred Agents Non-Preferred Agents
ROBITUSSIN COUGH+CHEST CONG DM ORAL LIQUID 20-400
MG/20ML (brand for childrens cough) - Tier 2; OTC
rynex dm (generic for DIMAPHEN DM COLD/COUGH) - Tier 1; OTC;
QL; AL
rynex pe - Tier 1; OTC; AL
rynex pse - Tier 1; OTC; AL
sinus 12 hour (generic for SUDAFED SINUS CONGESTION 12HR) -
Tier 1; OTC; DME
sinus 12-hour (generic for SUDAFED SINUS CONGESTION 12HR) -
Tier 1; OTC; DME
sinus congestion max strength (generic for SUDOGEST) - Tier 1;
OTC; QL; DME
sinus nasal spray (generic for GILTUSS SEVERE SINUS) - Tier 1;
OTC; DME
sodium chloride inhalation nebulization solution 0.9 %, 10 % - Tier 1
sodium chloride inhalation nebulization solution 3 % (generic for
NEBUSAL) - Tier 1
sodium chloride inhalation nebulization solution 7 % (generic for
HYPERSAL) - Tier 1
SUDAFED (brand for cvs nasal decongestant) - Tier 2; OTC; QL; DME
SUDAFED SINUS CONGESTION (brand for cvs nasal decongestant)
- Tier 2; OTC; QL; DME
SUDAFED SINUS CONGESTION 12HR (brand for 12 hour
decongestant) - Tier 2; OTC; DME
sudogest 12 hour (generic for SUDAFED SINUS CONGESTION
12HR) - Tier 1; OTC; DME
sudogest maximum strength (generic for SUDOGEST) - Tier 1; OTC;
QL; DME
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
177
Preferred Agents Non-Preferred Agents
sudogest oral tablet 30 mg (generic for SUDOGEST) - Tier 1; OTC;
QL; DME
suphedrine 12hour (generic for SUDAFED SINUS CONGESTION
12HR) - Tier 1; OTC; DME
suphedrine maximum strength (generic for SUDAFED SINUS
CONGESTION 12HR) - Tier 1; OTC; DME
suphedrine oral tablet 30 mg (generic for SUDOGEST) - Tier 1; OTC;
QL; DME
suphedrine oral tablet extended release 12 hour 120 mg (generic for
SUDAFED SINUS CONGESTION 12HR) - Tier 1; OTC; DME
tussin cf oral liquid 30-10-100 mg/5ml - Tier 1; OTC
tussin cough dm sugar free (generic for ROBAFEN DM COUGH
CLEAR) - Tier 1; OTC; QL; AL
tussin cough/chest congest oral syrup 100-10 mg/5ml (generic for
ROBAFEN DM COUGH CLEAR) - Tier 1; OTC; QL; AL
tussin cough/chest dm max oral liquid 10-200 mg/5ml (generic for
DIABETIC TUSSIN DM MAX ST) - Tier 1; OTC; AL
tussin cough/chest dm max oral liquid 20-400 mg/20ml (generic for
DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; OTC
tussin dm cough + chest oral liquid 20-400 mg/20ml (generic for
DELSYM CGH/CHEST CONG DM CHILD) - Tier 1; OTC
tussin dm cough/chest cong (generic for ROBAFEN DM COUGH
CLEAR) - Tier 1; OTC; QL; AL
tussin dm cough/chest oral syrup 10-100 mg/5ml (generic for
ROBAFEN DM COUGH CLEAR) - Tier 1; OTC; QL; AL
tussin dm max (generic for DELSYM CGH/CHEST CONG DM CHILD)
- Tier 1; OTC
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
178
Preferred Agents Non-Preferred Agents
tussin dm max adult (generic for DELSYM CGH/CHEST CONG DM
CHILD) - Tier 1; OTC
tussin dm max daytime (generic for DELSYM CGH/CHEST CONG DM
CHILD) - Tier 1; OTC
tussin dm max st (generic for DELSYM CGH/CHEST CONG DM
CHILD) - Tier 1; OTC
tussin dm oral syrup 100-10 mg/5ml (generic for ROBAFEN DM
COUGH CLEAR) - Tier 1; OTC; QL; AL
Sedatives/Hypnotics - Drugs for Sedation and Sleep
Sleep Disorders, Other - Miscellaneous Sedation and Sleep
Drugs
XYWAV - Tier 2; PA; CH; QL
Skeletal Muscle Relaxants
chlorzoxazone oral tablet 500 mg - Tier 1; QL
cyclobenzaprine hcl oral tablet 10 mg, 5 mg - Tier 1; QL
methocarbamol oral - Tier 1; QL
orphenadrine citrate er - Tier 1; QL
LORZONE (brand for chlorzoxazone) - Tier 2; PA; QL
Sleep Disorder Agents
Sleep Promoting Agents
eszopiclone (generic for LUNESTA) - Tier 1; QL
temazepam oral capsule 15 mg, 30 mg (generic for RESTORIL) - Tier
1; QL
triazolam (generic for HALCION) - Tier 1; QL
zaleplon - Tier 1; QL
zolpidem tartrate er (generic for AMBIEN CR) - Tier 1
zolpidem tartrate oral tablet (generic for AMBIEN) - Tier 1; QL
BELSOMRA - Tier 2; PA
DAYVIGO - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
179
Preferred Agents Non-Preferred Agents
Wakefulness Promoting Agents
armodafinil (generic for NUVIGIL) - Tier 1; DX2RX; QL
modafinil oral (generic for PROVIGIL) - Tier 1; DX2RX; QL
SODIUM OXYBATE (brand for sodium oxybate) - Tier 2; PA; SP; CH; QL
SUNOSI - Tier 2; PA; QL
WAKIX - Tier 2; PA; QL
XYREM (brand for sodium oxybate) - Tier 2; PA; SP; CH; QL
Sleep Disorder Agents - Drugs for Sedation and Sleep
Sleep Disorders, Other - Drugs for Sleeping
ft nighttime sleep aid (generic for SIMPLY SLEEP) - Tier 1; PA; OTC;
QL
night time sleep aid (generic for SIMPLY SLEEP) - Tier 1; PA; OTC;
QL
nighttime sleep aid oral tablet 25 mg (generic for SIMPLY SLEEP) -
Tier 1; PA; OTC; QL
rest simply (generic for SIMPLY SLEEP) - Tier 1; PA; OTC; QL
SIMPLY SLEEP (brand for cvs sleep aid) - Tier 2; PA; OTC; QL
sleep aid (diphenhydramine) (generic for SIMPLY SLEEP) - Tier 1; PA;
OTC; QL
sleep aid nighttime (generic for SIMPLY SLEEP) - Tier 1; PA; OTC; QL
sleep aid oral tablet 25 mg (generic for SIMPLY SLEEP) - Tier 1; PA;
OTC; QL
sleep tabs (generic for SIMPLY SLEEP) - Tier 1; PA; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
180
Preferred Agents Non-Preferred Agents
Therapeutic Nutrients/Minerals/Electrolytes - Drugs to Treat
Vitamin, Mineral and Body Fluid Deficiencies
Electrolyte/Mineral Replacement - Vitamin, Mineral and Body
Fluid Deficiency Drugs
animal shapes complete (generic for CEROVITE JR) - Tier 1; OTC; QL
ascorbic acid oral tablet 500 mg (generic for EASY-C IMMUNE
HEALTH) - Tier 1; OTC; QL
BPROTECTED PEDIA POLY-VITE (brand for multivitamin infant &
toddler) - Tier 2; OTC; QL
BPROTECTED PEDIA POLY-VITE/FE (brand for pc pediatric poly-
vita/fe drop) - Tier 2; OTC; QL
BPROTECTED VITAMIN C (brand for vitamin c) - Tier 2; OTC; QL
c 500/rose hips (generic for EASY-C IMMUNE HEALTH) - Tier 1;
OTC; QL
calcium 600 - Tier 1; OTC; QL
calcium 600+d oral tablet 600-5 mg-mcg - Tier 1; OTC; QL
calcium carbonate - Tier 1; OTC; QL
calcium carbonate oral tablet 1500 (600 ca) mg - Tier 1; OTC; QL
calcium carbonate oral tablet chewable 1250 (500 ca) mg - Tier 1;
OTC; QL
calcium fast dissolution - Tier 1; OTC; QL
calcium high potency - Tier 1; OTC; QL
calcium oral tablet 1500 (600 ca) mg - Tier 1; OTC; QL
calcium oyster shell oral tablet 1250 (500 ca) mg - Tier 1; OTC; QL
calcium soft chews oral tablet chewable 500-200-40 mg-unt-mcg - Tier
1; OTC
cerovite jr (generic for CEROVITE JR) - Tier 1; OTC; QL
chewable c (generic for SUNKIST VITAMIN C) - Tier 1; OTC; QL
chewable c with rose hips (generic for SUNKIST VITAMIN C) - Tier 1;
OTC; QL
chewable childrens vitamin (generic for CEROVITE JR) - Tier 1; OTC;
QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
181
Preferred Agents Non-Preferred Agents
childrens animal shapes (generic for CEROVITE JR) - Tier 1; OTC; QL
childrens chewables/iron (generic for LAND BEFORE TIME
MULTIVITAMIN) - Tier 1; OTC; QL
childrens complete oral tablet chewable 18 mg (generic for CEROVITE
JR) - Tier 1; OTC; QL
childrens vitamins/iron (generic for LAND BEFORE TIME
MULTIVITAMIN) - Tier 1; OTC; QL
daily multivitamins/iron (generic for TAB-A-VITE/IRON/BETA
CAROTENE) - Tier 1; OTC; QL
EASY-C IMMUNE HEALTH (brand for ascorbic acid) - Tier 2; OTC; QL
effer-k oral tablet effervescent 25 meq - Tier 1; QL
ergocalciferol oral capsule (generic for DRISDOL) - Tier 1; QL
fruity c - Tier 1; OTC; QL
klor-con/ef - Tier 1; QL
k-prime - Tier 1; QL
LIVITA ADULTS (brand for support) - Tier 2; QL
multiple vitamins/iron (generic for TAB-A-VITE/IRON/BETA
CAROTENE) - Tier 1; OTC; QL
multivitamin infant & toddler oral solution (generic for BPROTECTED
PEDIA POLY-VITE) - Tier 1; OTC; QL
multi-vitamin/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) -
Tier 1; OTC; QL
OBTREX - Tier 2; OTC
one-daily multi-vitamin/iron (generic for TAB-A-VITE/IRON/BETA
CAROTENE) - Tier 1; OTC; QL
one-daily/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE) -
Tier 1; OTC; QL
oyster shell calcium oral tablet 500 mg - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
182
Preferred Agents Non-Preferred Agents
oyster shell calcium/d oral tablet 250-3.125 mg-mcg - Tier 1; OTC; QL
oyster shell calcium/vitamin d oral tablet 250-3.125 mg-mcg - Tier 1;
OTC; QL
POLY-VI-SOL (brand for multivitamin infant & toddler) - Tier 2; OTC;
QL
POLY-VITE PEDIATRIC (brand for multivitamin infant & toddler) - Tier
2; OTC; QL
prenatal gummy oral tablet chewable 0.4-113.5 mg - Tier 1; OTC
stress formula/iron (generic for TAB-A-VITE/IRON/BETA CAROTENE)
- Tier 1; OTC; QL
SUPPORT (brand for support) - Tier 2; QL
TRUE VITAMIN C ORAL TABLET 250 MG - Tier 2; OTC; QL
TRUE VITAMIN C ORAL TABLET 500 MG (brand for ascorbic acid) -
Tier 2; OTC; QL
true vitamin c tablet 1000 mg oral - Tier 1; OTC; QL
TRUE VITAMIN C TABLET 1000 MG ORAL - Tier 2; OTC; QL
vit c/rose hips - Tier 1; OTC; QL
vitamin c cr oral tablet extended release 500 mg (generic for ENDUR-
C) - Tier 1; OTC; QL
vitamin c er oral tablet extended release 1500 mg - Tier 1; OTC; QL
vitamin c oral liquid 500 mg/5ml (generic for BPROTECTED VITAMIN
C) - Tier 1; OTC; QL
vitamin c oral tablet 1000 mg, 250 mg - Tier 1; OTC; QL
vitamin c oral tablet 500 mg (generic for EASY-C IMMUNE HEALTH) -
Tier 1; OTC; QL
vitamin c oral tablet chewable 100 mg, 250 mg - Tier 1; OTC; QL
vitamin c oral tablet chewable 500 mg (generic for SUNKIST VITAMIN
C) - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
183
Preferred Agents Non-Preferred Agents
vitamin c/acerola (generic for SUNKIST VITAMIN C) - Tier 1; OTC; QL
vitamin c/rose hips oral tablet 1000 mg - Tier 1; OTC; QL
vitamin c/rose hips oral tablet 500 mg (generic for EASY-C IMMUNE
HEALTH) - Tier 1; OTC; QL
vitamin c-rose hips (generic for EASY-C IMMUNE HEALTH) - Tier 1;
OTC; QL
vitamin c-rose hips oral tablet (generic for EASY-C IMMUNE HEALTH)
- Tier 1; OTC; QL
vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut), 50000 unit
(generic for DRISDOL) - Tier 1; QL
vitamins complete childrens (generic for CEROVITE JR) - Tier 1; OTC;
QL
zinc oral tablet 50 mg (generic for IS-ZC 50) - Tier 1; OTC; QL
Vitamins - Vitamin, Mineral and Body Fluid Deficiency Drugs
b-1 - Tier 1; OTC; QL
b-12 oral tablet extended release - Tier 1; OTC
b6 - Tier 1; OTC; QL
cyanocobalamin injection solution 1000 mcg/ml (generic for DODEX) -
Tier 1; QL
DODEX (brand for cyanocobalamin) - Tier 2; QL
e - Tier 1; OTC
e-400-clear - Tier 1; OTC; QL
natural vitamin e - Tier 1; OTC; QL
pyridoxine hcl oral - Tier 1; OTC; QL
thiamine hcl oral - Tier 1; OTC; QL
TRUE VITAMIN B6 ORAL TABLET 25 MG, 50 MG - Tier 2; OTC; QL
true vitamin b6 tablet 100 mg oral - Tier 1; OTC; QL
TRUE VITAMIN B6 TABLET 100 MG ORAL - Tier 2; OTC; QL
NASCOBAL (brand for cyanocobalamin) - Tier 2; PA; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
184
Preferred Agents Non-Preferred Agents
TRUE VITAMIN E ORAL CAPSULE 450 MG, 90 MG - Tier 2; OTC
vitamin b1 - Tier 1; OTC; QL
vitamin b-1 oral tablet 250 mg - Tier 1; OTC; QL
vitamin b-12 er oral tablet extended release 1000 mcg - Tier 1; OTC
vitamin b12 oral tablet extended release 1000 mcg - Tier 1; OTC
vitamin b-12 tr oral tablet extended release 1000 mcg - Tier 1; OTC
vitamin b-6 - Tier 1; OTC; QL
vitamin b-6 er - Tier 1; OTC; QL
vitamin e natural - Tier 1; OTC
vitamin e oral capsule 134 mg (200 unit), 45 mg (100 unit), 450 mg
(1000 ut), 90 mg (200 unit) - Tier 1; OTC
vitamin e oral capsule 268 mg (400 unit) - Tier 1; OTC; QL
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
185
Prior Authorization / Class Criteria
Tier 1: Generic; Tier 2: Brand; AL: Limited to members of a certain age; CH: Oral Chemotherapy Drug; DME: Durable Medical Equipment;
DX2RX: Diagnosis Required; GE: Gender Limit; OTC: Over-the-Counter; PA: Prior Auth Required; PD: Preventative Drug; QL: Quantity Limit;
SP: Specialty Medication; ST: Step Therapy
186
Index of Drugs
12 hour allergy-d........................................ 161
12 hour decongestant................................ 167
12 hour nasal decongestant.......................167
12 hour nasal relief spray...........................167
12 hour nasal spray....................................167
12hr allergy relief........................................163
24 hour nasal allergy..................................166
24hr allergy relief........................................163
3 day............................................................ 30
3 day vaginal................................................ 31
3-day vaginal vaginal cream 2 %................. 31
4-WAY FAST ACTING............................... 155
4-WAY MENTHOL..................................... 155
8 hour arthritis pain........................................ 8
8 hour arthritis relief....................................... 8
8 hour pain relief oral tablet extended
release 650 mg.............................................. 8
8 hour pain reliever........................................ 8
8 hr arthritis pain relief....................................8
8hr arthritis pain relief.....................................8
8hr muscle aches & pain................................8
a-25.............................................................. 80
abacavir sulfate............................................ 44
abacavir sulfate-lamivudine..........................44
abatinex........................................................88
ABILIFY ASIMTUFII..................................... 41
ABILIFY MAINTENA.................................... 41
abiraterone acetate oral tablet 250 mg........ 35
ABREVA.......................................................69
ABRYSVO..................................................126
ABSORICA...................................................62
ABSORICA LD............................................. 62
acamprosate calcium................................... 17
acarbose oral............................................... 47
ACCRUFER................................................. 73
ACCU-CHEK AVIVA DEVICE......................70
ACCU-CHEK AVIVA PLUS TEST STRIPS..70
ACCU-CHEK FASTCLIX LANCET KIT........70
ACCU-CHEK GUIDE CONTROL.................70
ACCU-CHEK GUIDE KIT W/DEVICE.......... 70
ACCU-CHEK GUIDE TEST STRIPS........... 70
ACCU-CHEK SMARTVIEW......................... 70
ACCU-CHEK SMARTVIEW CONTROL...... 70
ACCU-CHEK SOFTCLIX LANCET
DEVICE KIT................................................. 70
ACCUTREND GLUCOSE CONTROL......... 70
acebutolol hcl oral........................................ 54
acetaminophen 8 hour................................... 8
acetaminophen 8 hours..................................8
acetaminophen 8hr arth pain......................... 9
acetaminophen 8hr musc ache...................... 9
acetaminophen childrens............................... 9
acetaminophen er.......................................... 9
acetaminophen ex st oral liquid 500
mg/15ml......................................................... 9
acetaminophen ex st oral tablet 500 mg........ 9
acetaminophen extra strength........................9
acetaminophen infants................................... 9
acetaminophen oral liquid 160 mg/5ml.......... 9
acetaminophen oral solution 160 mg/5ml,
325 mg/10.15ml, 650 mg/20.3ml....................9
acetaminophen oral suspension 160
mg/5ml, 650 mg/20.3ml..................................9
acetaminophen oral tablet 325 mg.................9
acetaminophen oral tablet 500 mg.................9
acetaminophen oral tablet chewable 160
mg.................................................................. 9
acetaminophen rectal suppository 120 mg.. 10
acetaminophen rectal suppository 650 mg.. 10
acetaminophen-codeine.................................7
acetazolamide er..........................................56
acetazolamide oral....................................... 56
acetic acid otic............................................146
acetylcysteine inhalation solution 10 %......155
acetylcysteine inhalation solution 20 %......155
acid controller...............................................86
acid gone......................................................88
acid reducer oral capsule delayed release
20.6 (20 base) mg........................................ 87
acid reducer oral tablet 10 mg......................86
acid reducer oral tablet 200 mg....................86
acidophilus lactobacillus oral........................88
acidophilus oral capsule , 10 mg.................88
acidophilus probiotic oral capsule 10 mg..... 88
acidophilus probiotic oral tablet , 0.5 mg.....88
acitretin.........................................................62
acne control cleanser................................. 126
acne medication 10 external lotion.............126
acne medication 5 external lotion...............126
acne treatment external cream 10 %......... 126
ACTEMRA ACTPEN.................................. 121
ACTEMRA SUBCUTANEOUS...................121
ACTHAR.................................................... 108
ACTHIB...................................................... 123
ACTIMMUNE............................................. 121
acyclovir external ointment...........................43
acyclovir oral................................................ 43
ADACEL.....................................................123
ADALIMUMAB-AATY (2 SYRINGE)
SUBCUTANEOUS PREFILLED SYRINGE
KIT 40 MG/0.4ML.......................................126
ADALIMUMAB-ADAZ.................................126
ADALIMUMAB-ADBM (2 SYRINGE)
SUBCUTANEOUS PREFILLED SYRINGE
KIT 10 MG/0.2ML, 20 MG/0.4ML............... 126
ADBRY.......................................................121
ADDERALL.................................................. 60
ADDERALL XR............................................ 60
ADEMPAS..................................................154
ADMELOG................................................... 49
ADMELOG SOLOSTAR...............................49
adult 50+ probiotic........................................88
adult probiotic...............................................88
adv acne spot treatment.............................126
187
ADVAIR HFA..............................................166
advanced acne spot treat...........................126
advanced antacid......................................... 88
advanced healing external ointment .......... 68
ADVIL COLD/SINUS..................................167
ADVIL JUNIOR STRENGTH..........................4
ADVIL ORAL TABLET................................... 4
afirmelle......................................................110
AFLURIA QUADRIVALENT....................... 124
AFRIN NODRIP ORIGINAL....................... 167
AFRIN SALINE NASAL MIST.................... 155
aftera.......................................................... 118
AIMOVIG......................................................33
AJOVY......................................................... 33
ala-cort......................................................... 63
albendazole oral...........................................38
albuterol sulfate hfa aerosol solution 108
(90 base) mcg/act inhalation...................... 153
ALBUTEROL SULFATE HFA AEROSOL
SOLUTION 108 (90 BASE) MCG/ACT
INHALATION..............................................153
albuterol sulfate inhalation nebulization
solution (2.5 mg/3ml) 0.083%, 2.5
mg/0.5ml.................................................... 153
albuterol sulfate inhalation nebulization
solution 0.63 mg/3ml, 1.25 mg/3ml............ 153
albuterol sulfate nebulization solution (5
mg/ml) 0.5% inhalation...............................153
ALBUTEROL SULFATE NEBULIZATION
SOLUTION (5 MG/ML) 0.5% INHALATION
....................................................................153
albuterol sulfate oral syrup......................... 153
alclometasone dipropionate external
ointment....................................................... 63
ALCOHOL PREP PADS PAD , 70 %........126
ALECENSA................................................ 138
alendronate sodium oral solution............... 125
alendronate sodium oral tablet 10 mg, 35
mg.............................................................. 125
alendronate sodium oral tablet 70 mg........125
ALEVE ORAL TABLET.................................. 4
alfuzosin hcl er........................................... 107
all day allergy d.......................................... 161
all day allergy oral tablet 10 mg................. 148
all day allergy relief oral tablet 10 mg.........163
all day allergy-d oral tablet extended
release 12 hour 5-120 mg.......................... 161
all day pain relief............................................ 4
all day relief.................................................... 4
ALLEGRA ALLERGY................................. 163
ALLEGRA HIVES 24HR.............................163
allerclear.....................................................163
allerclear d-12hr......................................... 167
allerclear d-24hr......................................... 167
aller-ease oral tablet 180 mg......................163
aller-fex...................................................... 163
allerg rel child (lorat)...................................163
allerg relief child (lorat)...............................163
allergy & congestion oral tablet extended
release 24 hour 10-240 mg........................ 168
allergy & congestion relief.......................... 168
allergy (cetirizine)....................................... 148
allergy 24hour indoor/outdoor.................... 148
allergy 24-hr............................................... 163
allergy childrens oral liquid.........................148
allergy childrens oral solution.....................163
allergy medication...................................... 148
allergy medicine......................................... 148
allergy nasal mist no drip........................... 168
allergy oral capsule 25 mg......................... 148
allergy oral liquid 12.5 mg/5ml................... 148
allergy oral tablet 25 mg.............................148
allergy rel child (loratadine)........................ 163
allergy relief (cetirizine) oral tablet 10 mg.. 148
allergy relief (loratadine) oral tablet............163
allergy relief adult....................................... 148
allergy relief cetirizine.................................148
allergy relief child....................................... 163
allergy relief childrens oral liquid 12.5
mg/5ml....................................................... 148
allergy relief childrens oral solution 5
mg/5ml....................................................... 163
allergy relief childrens oral tablet chewable
12.5 mg...................................................... 148
allergy relief d oral tablet extended release
12 hour 5-120 mg.......................................161
allergy relief d-12........................................168
allergy relief d-24........................................168
allergy relief max st.................................... 148
allergy relief nasal decong......................... 168
allergy relief oral capsule 25 mg................ 148
allergy relief oral liquid 25 mg/10ml............148
allergy relief oral tablet 10 mg.................... 163
allergy relief oral tablet 180 mg.................. 164
allergy relief oral tablet 25 mg.................... 149
allergy relief oral tablet 60 mg.................... 164
allergy relief oral tablet chewable 12.5 mg.149
allergy relief oral tablet dispersible 10 mg..164
allergy relief oral tablet extended release
12 hour 5-120 mg.......................................161
allergy relief(cetirizine)............................... 149
allergy relief/indoor/outdoor oral tablet 10
mg.............................................................. 149
allergy relief/indoor/outdoor oral tablet 180
mg.............................................................. 164
allergy relief/nasal decong......................... 168
allergy relief/nasal decongest oral tablet
extended release 12 hour.......................... 161
allergy relief/nasal decongest oral tablet
extended release 24 hour.......................... 168
allergy relief-d oral tablet extended release
12 hour 5-120 mg...............................161, 168
allergy relief-d oral tablet extended release
24 hour 10-240 mg.....................................168
allergy relief-d12.........................................168
allergy spray 24 hour nasal aerosol........... 166
allergy/congestion relief............................. 168
188
aller-tec...................................................... 149
aller-tec d................................................... 161
allopurinol oral tablet 100 mg, 300 mg......... 32
almacone double strength............................88
ALOGLIPTIN BENZOATE............................47
ALOGLIPTIN-METFORMIN HCL.................47
ALOGLIPTIN-PIOGLITAZONE.................... 47
ALORA....................................................... 110
ALPHAGAN P............................................ 142
alprazolam oral tablet...................................46
altachlore ophthalmic ointment.................. 142
altachlore ophthalmic solution....................142
altafrin........................................................ 140
altalube.......................................................142
altamist spray............................................. 155
altarussin....................................................155
altarussin dm..............................................169
altavera...................................................... 110
alum & mag hydroxide-simeth......................88
ALUNBRIG.................................................138
ALVESCO.................................................. 152
alyacen 1/35...............................................110
alyacen 7/7/7..............................................110
amantadine hcl oral capsule........................ 40
amantadine hcl oral solution........................ 40
ambrisentan............................................... 154
amiloride hcl oral.......................................... 57
amiloride-hydrochlorothiazide...................... 56
aminocaproic acid oral................................. 52
amiodarone hcl oral tablet 200 mg, 400 mg.54
amitriptyline hcl oral..................................... 28
AMJEVITA..................................................126
AMJEVITA-PED 15KG TO .............126
amlodipine besylate oral.............................. 55
amlodipine besylate-benazepril hcl.............. 56
amlodipine besylate-valsartan......................56
amlodipine-olmesartan.................................56
ammonium lactate external.......................... 63
amnesteem.................................................. 62
amoxapine....................................................28
amoxicillin.....................................................21
amoxicillin-potassium clavulanate................21
amphetamine-dextroamphetamine.............. 60
amphetamine-dextroamphetamine er.......... 60
ampicillin...................................................... 21
anagrelide hcl...............................................51
ANASPAZ.................................................. 126
anastrozole oral............................................36
ANDRODERM............................................110
ANECREAM EXTERNAL CREAM...............17
anefrin spray.............................................. 169
animal shapes complete............................ 181
ANNOVERA............................................... 110
ANORO ELLIPTA.......................................166
antacid & anti-gas oral suspension 200-
200-20 mg/5ml............................................. 89
antacid & antigas oral suspension 2400-
2400-240 mg/30ml....................................... 89
antacid & anti-gas oral suspension 400-
400-40 mg/5ml............................................. 89
antacid & gas relief.......................................89
antacid advanced......................................... 89
antacid advanced max st oral suspension
400-400-40 mg/5ml...................................... 89
antacid anti-gas............................................89
antacid anti-gas max strength...................... 89
antacid calcium............................................ 89
antacid calcium rich......................................89
antacid extra str............................................89
antacid extra strength oral suspension........ 89
antacid extra strength oral tablet chewable
160-105 mg.................................................. 89
antacid extra strength oral tablet chewable
750 mg......................................................... 89
antacid fast relief.......................................... 89
antacid i........................................................89
antacid iii...................................................... 89
antacid kids.................................................. 90
antacid liquid................................................ 90
antacid m......................................................90
antacid maximum......................................... 90
antacid maximum strength........................... 90
antacid maximum strength oral tablet
chewable 1000 mg....................................... 90
antacid oral suspension 200-200-20
mg/5ml, 400-400-40 mg/10ml...................... 90
antacid oral tablet chewable 1000 mg..........90
antacid oral tablet chewable 500 mg............90
antacid oral tablet chewable 750 mg............90
antacid plus antigas..................................... 90
antacid regular strength oral suspension
200-200-20 mg/5ml...................................... 90
antacid ultra strength....................................90
antacid ultra strength oral tablet chewable
1000 mg....................................................... 90
antacid/antigas............................................. 90
antacid/anti-gas max st................................ 90
antacid/anti-gas oral suspension 200-200-
20 mg/5ml, 400-400-40 mg/10ml................. 91
antacid/anti-gas oral suspension 400-400-
40 mg/5ml.................................................... 91
antacid/gas relief max st.............................. 91
antibiotic............................................... 23, 126
anti-diarr/ant-gas.......................................... 91
anti-diarrheal anti-gas oral tablet 2-125 mg. 91
anti-diarrheal oral suspension 262 mg/15ml 91
anti-diarrheal oral tablet 2 mg...................... 85
anti-diarrheal/anti-gas.................................. 91
antifungal (tolnaftate)................................. 126
antifungal external cream.............................31
antifungal external powder........................... 31
antifungal foot care.......................................31
antifungal miconazole.................................. 31
antifungal tolnaftate....................................126
anti-gas oral capsule 180 mg....................... 91
anti-hist allergy........................................... 149
anti-itch aloe.................................................63
189
anti-itch intensive heal..................................63
anti-itch max str external cream 1 %............63
anti-itch maximum strength external cream
1 %............................................................... 63
anti-nausea.................................................. 29
anti-nausea relief..........................................29
antiseptic...................................................... 23
ANTIVERT ORAL TABLET CHEWABLE.....28
apap-caff-dihydrocodeine...............................7
APIDRA SOLOSTAR................................... 49
APIDRA VIAL............................................... 49
apra.............................................................. 10
apraclonidine hcl........................................ 142
aprepitant..................................................... 29
apri............................................................. 110
APRISO......................................................125
APRODINE................................................ 169
APTIOM....................................................... 25
APTIVUS......................................................45
aqueous vitamin d........................................ 80
aranelle...................................................... 110
ARANESP (ALBUMIN FREE) INJECTION
SOLUTION...................................................51
ARANESP (ALBUMIN FREE) INJECTION
SOLUTION PREFILLED SYRINGE 10
MCG/0.4ML..................................................51
ARANESP (ALBUMIN FREE) INJECTION
SOLUTION PREFILLED SYRINGE 100
MCG/0.5ML, 150 MCG/0.3ML, 200
MCG/0.4ML, 25 MCG/0.42ML, 300
MCG/0.6ML, 40 MCG/0.4ML, 500
MCG/ML, 60 MCG/0.3ML............................ 51
AREXVY.....................................................126
aripiprazole oral tablet..................................41
ARISTADA................................................... 41
ARISTADA INITIO........................................41
armodafinil..................................................180
ARMOUR THYROID.................................. 119
ARNUITY ELLIPTA.................................... 152
arthritis pain oral tablet extended release
650 mg......................................................... 10
arthritis pain relief oral tablet extended
release 650 mg............................................ 10
arthritis pain reliever oral..............................10
arthritis pain relieving................................. 126
artificial tears ophthalmic solution ............ 142
ascomp-codeine.............................................7
ascorbic acid oral tablet 500 mg................ 181
ashlyna.......................................................110
ASMANEX (120 METERED DOSES)........ 152
ASMANEX (14 METERED DOSES).......... 152
ASMANEX (30 METERED DOSES).......... 152
ASMANEX (60 METERED DOSES).......... 152
ASMANEX HFA......................................... 152
ASPERFLEX LIDOCAINE EXTERNAL
CREAM........................................................ 17
aspirin adults.............................................. 126
aspirin childrens......................................... 127
aspirin ec oral tablet 325 mg...................... 127
aspirin ec oral tablet delayed release 325
mg.............................................................. 127
aspirin ec oral tablet delayed release 81
mg.............................................................. 127
aspirin oral tablet 325 mg...........................127
aspirin oral tablet chewable 81 mg.............127
aspirin oral tablet delayed release 325 mg 127
aspirin oral tablet delayed release 81 mg.. 127
ASPIRIN ORAL TABLET DELAYED
RELEASE 81 MG.......................................127
aspirin rectal suppository 300 mg.............. 127
aspirin regimen...........................................127
astringent..................................................... 68
astringent eye drops...................................142
astringent solution........................................ 68
atazanavir sulfate......................................... 45
atenolol oral..................................................54
atenolol-chlorthalidone................................. 56
atheletes foot................................................31
athletes foot (terbinafine)............................. 31
athletes foot (tolnaftate) external aerosol
powder 1 %................................................ 127
athletes foot (tolnaftate) external cream 1
%................................................................ 127
athletes foot external aerosol powder 2 %... 31
athletes foot external cream 1 %..................31
athletes foot external powder 2 %................31
athletes foot powder spray external aerosol
powder 1 %................................................ 127
athletes foot powder spray external aerosol
powder 2 %.................................................. 31
athletes foot relief.......................................128
athletes foot spray external aerosol 2 %...... 31
atomoxetine hcl............................................ 59
ATORVALIQ.................................................57
atorvastatin calcium oral.............................. 57
atovaquone.................................................. 39
atovaquone-proguanil hcl.............................39
atropine sulfate ophthalmic ointment......... 140
atropine sulfate ophthalmic solution 1 %....140
ATROVENT HFA....................................... 152
aubra eq..................................................... 110
AUM ALCOHOL PREP PADS................... 128
aurovela 1.5/30.......................................... 110
aurovela 1/20............................................. 110
aurovela 24 fe............................................ 110
aurovela fe 1.5/30...................................... 110
aurovela fe 1/20......................................... 110
AURYXIA..................................................... 79
AUSTEDO....................................................60
AUVI-Q.......................................................153
AVAR-E EMOLLIENT.................................. 68
AVAR-E GREEN.......................................... 68
AVEDANA GLYCERIN (ADULT)............... 102
aviane.........................................................111
AVONEX PEN..............................................61
AVONEX PREFILLED..................................61
AYR............................................................155
190
AYR SALINE NASAL DROPS................... 155
ayuna......................................................... 111
AZASITE.................................................... 141
azathioprine oral tablet 50 mg....................122
azelaic acid external.....................................62
azelastine hcl nasal solution 0.1 %, 137
mcg/spray...................................................149
azelastine hcl ophthalmic........................... 140
azithromycin oral suspension reconstituted. 22
azithromycin oral tablet................................ 22
azo............................................................. 107
AZSTARYS.................................................. 60
azurette...................................................... 111
b complex vitamins.......................................80
b complex-b12..............................................80
b-1.............................................................. 184
b-12 oral tablet extended release...............184
b6............................................................... 184
BABY AYR SALINE................................... 155
baby basics diaper rash............................... 68
bac................................................................. 7
bacitracin external...................................... 128
bacitracin ophthalmic................................. 141
bacitracin zinc external...............................128
bacitracin zinc first aid................................128
bacitracin zinc-aloe.................................... 128
bacitracin-polymyxin b................................141
bacitra-neomycin-polymyxin-hc..................140
baclofen oral tablet 10 mg, 20 mg, 5 mg......42
BAFIERTAM.................................................61
BALCOLTRA..............................................111
balsalazide disodium..................................125
BALVERSA.................................................. 36
balziva........................................................ 111
banophen oral capsule 25 mg....................149
banophen oral tablet.................................. 149
BAQSIMI ONE PACK...................................48
BAQSIMI TWO PACK.................................. 48
BARACLUDE ORAL SOLUTION................. 42
BASAGLAR KWIKPEN................................ 49
BAYER ASPIRIN........................................128
BAYER LOW DOSE ORAL TABLET
CHEWABLE............................................... 128
baza antifungal.............................................31
b-complex oral tablet ..................................80
b-complex with b-12..................................... 80
b-complex/b-12 oral..................................... 80
BD AUTOSHIELD DUO PEN NEEDLES... 128
BD ECLIPSE NEEDLE 25G X 5/8"............ 128
BD ULTRA-FINE INSULIN SYRINGES....... 70
BD ULTRA-FINE INSULIN SYRINGES
30G X 1/2" 0.3 ML, 30G X 1/2" 0.5 ML...... 128
BD ULTRA-FINE INSULIN SYRINGES
30G X 1/2" 1 ML, 31G X 15/64" 0.3 ML,
31G X 5/16" 0.3 ML, 31G X 5/16" 0.5 ML,
31G X 5/16" 1 ML.......................................128
BD ULTRA-FINE INSULIN SYRINGES
31G X 15/64" 0.5 ML, 31G X 15/64" 1 ML. 128
BD ULTRA-FINE INSULIN SYRINGES
31G X 5/16" 0.3 ML....................................128
BD ULTRA-FINE PEN NEEDLES................70
BD ULTRA-FINE PEN NEEDLES 29G X
12.7MM...................................................... 128
BD ULTRA-FINE PEN NEEDLES 31G X 5
MM............................................................. 128
BD ULTRA-FINE PEN NEEDLES 31G X 8
MM............................................................. 128
beauty 360 pure glycerin..............................68
beauty 360 soothing bath.............................68
BELBUCA...................................................... 6
BELSOMRA............................................... 179
BENADRYL ALLERGY CHILDRENS
ORAL LIQUID............................................ 149
BENADRYL ALLERGY CHILDRENS
ORAL TABLET CHEWABLE......................149
BENADRYL ALLERGY ORAL TABLET.....149
BENADRYL ALLERGY ULTRATABS........ 149
benazepril hcl oral........................................ 53
benazepril-hydrochlorothiazide.................... 56
BENZAC AC WASH...................................128
BENZNIDAZOLE..........................................39
benzonatate oral capsule 100 mg, 200 mg 169
benzoyl peroxide external gel 2.5 %.......... 128
benzoyl peroxide external liquid.................128
benzoyl peroxide wash external liquid 5 % 128
benztropine mesylate oral............................ 40
BESIVANCE...............................................141
BETADINE EXTERNAL SOLUTION 10 %...23
betamethasone dipropionate aug.................63
betamethasone dipropionate external lotion 63
betamethasone dipropionate external
ointment....................................................... 63
betamethasone valerate external cream......63
betamethasone valerate external lotion....... 63
betamethasone valerate external ointment.. 63
BETASERON............................................... 61
betatemp childrens.......................................10
betaxolol hcl ophthalmic.............................142
betaxolol hcl oral.......................................... 54
bethanechol chloride oral........................... 107
BETIMOL................................................... 142
BEVESPI AEROSPHERE..........................166
bexarotene external..................................... 38
bexarotene oral............................................ 38
BEXSERO..................................................123
BEYAZ....................................................... 111
bicalutamide................................................. 35
BIJUVA ORAL CAPSULE 1-100 MG......... 111
BIKTARVY ORAL TABLET 30-120-15 MG..43
BIKTARVY ORAL TABLET 50-200-25 MG..43
BINAXNOW COVID-19 AG HOME TEST..128
BIOLLE TEARS..........................................142
BION TEARS PF........................................142
biotinex.........................................................91
bisacodyl ec............................................... 128
bisacodyl laxative....................................... 129
bisacodyl oral............................................. 129
191
bisacodyl rectal.......................................... 129
bismuth.........................................................91
bismuth subsalicylate oral............................ 91
bisoprolol fumarate oral................................54
bisoprolol-hydrochlorothiazide..................... 56
blisovi 24 fe................................................ 111
blisovi fe 1.5/30.......................................... 111
blisovi fe 1/20............................................. 111
BLOOD GLUCOSE TEST STRIPS..............70
BOLSITOL....................................................91
BONINE....................................................... 28
BOOSTRIX.................................................123
boro-packs................................................... 68
bosentan.................................................... 154
BOSULIF....................................................138
boudreauxs butt paste ointment 40 %
external........................................................ 68
BOUDREAUXS BUTT PASTE OINTMENT
40 % EXTERNAL......................................... 68
bp 10-1......................................................... 68
bp wash external liquid 2.5 %.................... 129
BPROTECTED PEDIA D-VITE.................... 80
BPROTECTED PEDIA IRON.......................75
BPROTECTED PEDIA POLY-VITE........... 181
BPROTECTED PEDIA POLY-VITE/FE..... 181
BPROTECTED VITAMIN C....................... 181
BREATHE COMFORT HUMIDIFIER......... 129
BREO ELLIPTA INHALATION AEROSOL
POWDER BREATH ACTIVATED 100-25
MCG/ACT, 200-25 MCG/ACT....................166
BREZTRI AEROSPHERE..........................166
briellyn........................................................111
BRILINTA..................................................... 52
brimonidine tartrate ophthalmic solution
0.15 %........................................................ 142
brimonidine tartrate ophthalmic solution 0.2
%................................................................ 142
BRIVIACT ORAL..........................................24
BROMFED DM...........................................155
BRONCHITOL..............................................62
BRUKINSA.................................................138
BRYHALI......................................................63
BUCKLEYS CHEST CONGESTION..........155
budesonide inhalation................................ 152
budesonide oral..........................................125
bumetanide oral........................................... 56
buprenorphine................................................ 6
buprenorphine hcl sublingual......................... 8
buprenorphine hcl-naloxone hcl................... 17
bupropion hcl er (sr)..................................... 27
bupropion hcl er (xl) oral tablet extended
release 24 hour 150 mg, 300 mg................. 27
bupropion hcl oral.........................................27
buspirone hcl oral.........................................46
butalbital-acetaminophen oral tablet 50-
325 mg........................................................... 7
butalbital-apap-caff-cod oral capsule 50-
325-40-30 mg.................................................7
butalbital-apap-caffeine oral capsule 50-
325-40 mg...................................................... 7
butalbital-apap-caffeine oral tablet................. 7
butalbital-asa-caff-codeine............................. 7
butalbital-aspirin-caffeine............................... 7
butorphanol tartrate nasal.............................. 7
BYDUREON BCISE AUTOINJECTOR........ 47
BYETTA 10 MCG PEN................................ 47
BYETTA 5 MCG PEN.................................. 47
c 500/rose hips...........................................181
cabergoline.................................................119
CABLIVI....................................................... 52
CABOMETYX.............................................138
caffeine citrate oral.......................................60
cal mag zinc +d3.......................................... 75
calamine external lotion ........................... 129
calamine external lotion , 8-8 %.................. 69
calamine-zinc oxide external lotion.............. 69
calcipotriene external cream........................ 66
calcipotriene external ointment.................... 66
calcipotriene external solution......................66
calcitonin (salmon) nasal............................125
calcitriol external.......................................... 66
calcitriol oral capsule..................................125
calcitriol oral solution..................................125
calcium 600................................................ 181
calcium 600/vit d/minerals oral tablet 600-
200 mg-unit.................................................. 75
calcium 600/vit d/minerals oral tablet
chewable 600-400 mg-unit...........................75
calcium 600/vitamin d...................................75
calcium 600/vitamin d-3............................... 75
calcium 600+d oral tablet 600-10 mg-mcg...75
calcium 600+d oral tablet 600-5 mg-mcg...181
calcium acetate (phos binder)...................... 79
calcium acetate oral tablet 667 mg.............. 79
calcium antacid ex st oral tablet chewable
750 mg......................................................... 91
calcium antacid extra strength..................... 91
calcium antacid oral tablet chewable 500
mg................................................................ 91
calcium carb-cholecalciferol oral tablet
600-10 mg-mcg, 600-5 mg-mcg...................75
calcium carbonate...................................... 181
calcium carbonate antacid oral suspension. 91
calcium carbonate antacid oral tablet...........92
calcium carbonate antacid oral tablet
chewable...................................................... 92
calcium carbonate oral tablet 1500 (600
ca) mg........................................................ 181
calcium carbonate oral tablet chewable
1250 (500 ca) mg....................................... 181
calcium cit plus vit d-3.................................. 75
calcium citrate + d3 maximum......................75
calcium citrate +d3....................................... 75
calcium citrate plus vit d............................... 75
calcium citrate+d oral tablet 315-6.25 mg-
mcg.............................................................. 75
calcium citrate+d3 oral tablet ..................... 75
192
calcium citrate+d3 w/magne.........................75
calcium citrate-vit d...................................... 75
calcium citrate-vitamin d oral tablet 315-5
mg-mcg........................................................ 75
calcium fast dissolution.............................. 181
calcium high potency..................................181
calcium high potency/vitamin d.................... 75
calcium oral tablet 1500 (600 ca) mg......... 181
calcium oyster shell oral tablet 1250 (500
ca) mg........................................................ 181
calcium plus vitamin d.................................. 75
calcium plus vitamin d3................................ 75
calcium soft chews oral tablet chewable
500-200-40 mg-unt-mcg.............................181
calcium/minerals/vitamin d........................... 76
calcium-magnesium-zinc oral tablet 333-
133-5 mg, 333.33-133.33-5 mg....................76
cal-gest antacid............................................ 92
CALQUENCE.............................................129
camila.........................................................117
camrese..................................................... 111
camrese lo..................................................111
capecitabine................................................. 38
CAPRELSA................................................ 138
capsaicin external cream 0.025 %............. 129
capsaicin external cream 0.1 %................. 129
capsaicin hp............................................... 129
capsaicin pain relief....................................129
captopril oral.................................................53
captopril-hydrochlorothiazide....................... 56
capzix......................................................... 129
carbamazepine er........................................ 25
carbamazepine oral......................................25
carbidopa-levodopa er................................. 40
carbidopa-levodopa oral tablet.....................40
carboxymethylcellulose sodium ophthalmic
solution.......................................................142
CAREPOINT POLY HUB NEEDLE 18G X
1"..................................................................50
CAREPOINT POLY HUB NEEDLE 25G X
5/8".............................................................129
CAREPOINT SAFETY 1ST NEEDLE 25G
X 5/8"..........................................................129
CARESENS CONTROL SOLUTION A/B.....70
CARESTART COVID-19 HOME TEST......129
CARETOUCH CONTROL SOL LEVEL 2.... 70
CARETOUCH HYPODERMIC NEEDLE
25G X 5/8"..................................................129
carglumic acid.............................................. 73
carteolol hcl................................................ 142
cartia xt.........................................................55
carvedilol...................................................... 54
CASTIVA WARMING................................. 129
CAYA......................................................... 129
CAYSTON..................................................153
cefaclor oral capsule.................................... 21
cefadroxil......................................................21
cefdinir..........................................................21
cefixime oral capsule....................................21
cefpodoxime proxetil oral tablet................... 21
cefprozil........................................................21
cefuroxime axetil.......................................... 21
celecoxib oral................................................. 4
CENTRUM FLAVOR BURST KIDS........... 129
CENTRUM KIDS........................................129
CENTRUM SPECIALIST PRENATAL......... 80
cephalexin oral capsule 250 mg, 500 mg.....21
cephalexin oral suspension reconstituted.... 21
CEQUA...................................................... 140
CERDELGA............................................... 106
cerovite jr....................................................181
cetiri-d........................................................ 161
cetirizine allergy relief.................................149
cetirizine hcl oral solution........................... 149
cetirizine hcl oral tablet...............................149
cetirizine-pseudoephedrine er....................162
charlotte 24 fe............................................ 111
chateal eq...................................................111
CHEMET...................................................... 79
CHEMSTRIP 10 MD.................................... 70
CHEMSTRIP 10/SG.....................................70
CHEMSTRIP 2 GP.......................................70
CHEMSTRIP 5 OB.......................................70
CHEMSTRIP 7............................................. 70
CHEMSTRIP 9............................................. 70
CHEMSTRIP K.............................................70
CHEMSTRIP UGK....................................... 70
chest congest/cough child..........................169
chest congestion relief dm oral syrup.........169
chest congestion relief oral liquid............... 155
chest congestion relief oral tablet...............156
chewable c................................................. 181
chewable c with rose hips.......................... 181
chewable childrens vitamin........................ 181
chewy not chalky flavor................................ 92
childrens acetaminophen............................. 10
childrens allergy oral liquid 12.5 mg/5ml.... 150
childrens animal shapes.............................181
childrens apap..............................................10
childrens aspirin oral tablet chewable 81
mg.............................................................. 130
childrens chewables/iron............................182
childrens cold & allergy.............................. 169
childrens complete oral tablet chewable 18
mg.............................................................. 182
childrens cough.......................................... 169
childrens loratadine.................................... 164
childrens mucus relief cough......................169
childrens non-aspirin.................................... 10
childrens silapap.......................................... 10
childrens soothe........................................... 92
childrens vitamins/iron................................182
childs non-aspirin......................................... 10
chlordiazepoxide hcl.....................................46
chlorhexidine gluconate mouth/throat.......... 62
chloroquine phosphate oral..........................39
chlorpromazine hcl oral tablet...................... 41
193
chlorthalidone...............................................57
chlorzoxazone oral tablet 500 mg.............. 179
CHOLBAM................................................. 106
cholestyramine light oral powder..................58
cholestyramine oral powder......................... 58
CIBINQO...................................................... 69
ciclodan........................................................ 67
ciclopirox external solution........................... 67
cilostazol...................................................... 52
CIMDUO.......................................................44
cimetidine oral tablet 200 mg....................... 86
cimetidine oral tablet 300 mg, 400 mg, 800
mg................................................................ 86
CIMZIA (2 SYRINGE)................................ 122
CIMZIA SUBCUTANEOUS PREFILLED
SYRINGE KIT 6 X 200 MG/ML.................. 122
CIMZIA VIAL KIT........................................122
cinacalcet hcl..............................................125
CIPRO ORAL SUSPENSION
RECONSTITUTED.......................................22
ciprofloxacin hcl ophthalmic....................... 141
ciprofloxacin hcl oral.....................................22
ciprofloxacin-dexamethasone.................... 146
citalopram hydrobromide oral solution......... 27
citalopram hydrobromide oral tablet.............27
citroma....................................................... 102
CITRUCEL................................................. 102
claravis......................................................... 62
clarithromycin er...........................................22
clarithromycin oral........................................ 22
CLARITIN ALLERGY CHILDRENS........... 164
CLARITIN ORAL TABLET......................... 164
CLARITIN REDITABS ORAL TABLET
DISPERSIBLE 10 MG................................164
CLARITIN-D 12 HOUR.............................. 169
CLARITIN-D 24 HOUR.............................. 169
classic prenatal............................................ 80
c-lax laxative.............................................. 130
CLEARCANAL EARWAX SOFTENER...... 147
CLEARDETECT COVID-19 AG HOME..... 130
clearlax oral powder 17 gm/scoop............... 99
clearskin..................................................... 130
clemastine fumarate oral............................150
CLENPIQ..................................................... 86
CLIMARA................................................... 111
CLIMARA PRO.......................................... 111
clindacin etz external swab.......................... 67
clindacin-p.................................................... 67
clindamycin hcl oral capsule 150 mg, 300
mg................................................................ 20
clindamycin palmitate hcl............................. 20
clindamycin phosphate external gel............. 67
clindamycin phosphate external lotion......... 67
clindamycin phosphate external solution..... 67
clindamycin phosphate external swab......... 67
clindamycin phosphate vaginal.................... 20
CLINDESSE.................................................20
CLINERE EARWAX REMOVAL KIT OTIC
SOLUTION.................................................147
CLINITEST RAPID COVID-19 TEST KIT
IN VITRO....................................................130
clobazam......................................................25
clobetasol propionate e................................ 63
clobetasol propionate external cream.......... 63
clobetasol propionate external ointment...... 63
clobetasol propionate external solution........63
CLOBEX.......................................................63
CLOBEX SPRAY......................................... 63
CLOMID..................................................... 118
clomipramine hcl oral................................... 28
clonazepam oral tablet................................. 46
clonidine hcl oral.......................................... 52
clopidogrel bisulfate oral.............................. 52
clorazepate dipotassium.............................. 46
clotrimazole 3 vaginal cream 2 %................ 31
clotrimazole 7............................................... 31
clotrimazole external cream 1 %.................. 67
clotrimazole mouth/throat troche 10 mg.......30
clotrimazole solution 1 % external (otc)....... 67
clotrimazole solution 1 % external (rx)......... 67
clotrimazole vaginal......................................31
clotrimazole vaginal cream 1 %................... 31
clotrimazole-betamethasone........................ 66
clozapine oral tablet..................................... 42
codeine sulfate oral tablet 30 mg, 60 mg....... 7
COLACE.................................................... 102
colchicine oral tablet.....................................32
cold & allergy..............................................169
cold & allergy childrens oral elixir 1-15
mg/5ml....................................................... 169
cold & cough childrens oral liquid 1-5-2.5
mg/5ml, 2.5-1-5 mg/5ml............................. 169
cold & sinus................................................169
cold & sinus relief oral tablet 30-200 mg.... 169
cold/cough..................................................170
cold/cough childrens.................................. 170
cold/cough dm childrens oral liquid 2.5-1-5
mg/5ml....................................................... 170
cold/cough dm oral liquid 2.5-1-5 mg/5ml.. 170
col-rite oral capsule 250 mg....................... 102
COMBIGAN................................................140
COMBIVENT RESPIMAT.......................... 166
COMETRIQ (100 MG DAILY DOSE)......... 138
COMETRIQ (140 MG DAILY DOSE)......... 138
COMETRIQ (60 MG DAILY DOSE)........... 138
comfort gel................................................... 92
comfort gel antacid anti-gas oral
suspension 400-400-40 mg/5ml...................92
COMIRNATY..............................................130
COMPLERA................................................. 44
complete allergy......................................... 150
complete allergy medicine..........................150
complete allergy medicine oral capsule..... 150
complete allergy relief................................ 150
compro......................................................... 28
CONDOMS................................................ 130
constulose.................................................... 85
194
CONTOUR NEXT EZ KIT W/DEVICE......... 70
CONTOUR NEXT GEN MONITOR KIT....... 70
CONTOUR NEXT GEN TEST STRIPS....... 70
CONTOUR NEXT MONITOR KIT
W/DEVICE................................................... 70
CONTOUR NEXT ONE KIT......................... 70
CONTOUR TEST STRIPS...........................70
COOL MIST HUMIDIFER.......................... 130
COPAXONE SUBCUTANEOUS
SOLUTION PREFILLED SYRINGE 40
MG/ML......................................................... 61
CORICIDIN HBP COUGH/COLD...............156
CORLANOR.................................................56
corn & callus remover................................ 130
corn and callus remover.............................130
CORTIFOAM..............................................125
cortisone maximum strength external
cream........................................................... 63
CORTROPHIN........................................... 108
COSENTYX SUBCUTANEOUS
SOLUTION AUTO-INJECTOR 150 MG/ML
....................................................................121
COSENTYX SUBCUTANEOUS
SOLUTION PREFILLED SYRINGE 150
MG/ML, 75 MG/0.5ML................................121
COSENTYX UNOREADY.......................... 121
COSOPT PF.............................................. 140
COTELLIC....................................................36
cough & chest congestion.......................... 170
cough & cold.............................................. 156
cough & cold hbp....................................... 156
cough childrens.......................................... 170
cough dm childrens oral suspension
extended release 30 mg/5ml......................170
cough dm er............................................... 170
cough dm oral suspension extended
release 30 mg/5ml......................................170
cough relief oral syrup 15 mg/5ml.............. 156
cough/cold hbp...........................................156
COVID-19 AT HOME ANTIGEN TEST...... 130
COVID-19 AT HOME TEST KIT................ 130
COVID-19 AT-HOME TEST KIT IN VITRO130
CREON...................................................... 106
CRESEMBA ORAL CAPSULE 186 MG.......30
CRITIC-AID CLEAR AF............................... 31
cromolyn sodium inhalation........................153
cromolyn sodium nasal.............................. 167
cromolyn sodium ophthalmic......................140
CRUEX PRESCRIPTION STRENGTH........31
cryselle-28..................................................111
curae.......................................................... 118
CURANOL....................................................10
CURELIEF................................................. 150
cyanocobalamin injection solution 1000
mcg/ml........................................................184
cyclobenzaprine hcl oral tablet 10 mg, 5
mg.............................................................. 179
cyclopentolate hcl ophthalmic.................... 140
cyclophosphamide oral capsule................... 35
CYCLOPHOSPHAMIDE ORAL TABLET.....35
cycloserine oral............................................ 34
cyclosporine modified.................................122
cyclosporine oral........................................ 122
CYLTEZO (2 SYRINGE)
SUBCUTANEOUS PREFILLED SYRINGE
KIT 10 MG/0.2ML, 20 MG/0.4ML............... 130
cyproheptadine hcl oral.............................. 150
cyred eq..................................................... 111
CYSTAGON............................................... 106
CYSTARAN................................................140
d3 high potency oral capsule 25 mcg, 25
mcg (1000 ut)............................................... 80
d3 high potency oral capsule 250 mcg
(10000 ut).....................................................80
d3 max st......................................................80
d3 oral capsule 10 mcg (400 unit), 50 mcg
(2000 ut).......................................................80
d3 oral capsule 125 mcg (5000 ut)...............80
d3 oral capsule 25 mcg (1000 ut).................80
d3 oral capsule 250 mcg.............................. 80
d-3-5.............................................................80
d3-50............................................................ 80
daily acne wash..........................................131
daily fiber oral capsule 0.52 gm................... 99
daily fiber oral powder 43 %.........................99
daily multivitamins/iron............................... 182
dalfampridine er........................................... 61
danazol oral................................................110
dantrolene sodium oral.................................42
DAPAGLIFLOZIN PROPANEDIOL..............47
dapsone oral................................................ 34
DAPTACEL................................................ 123
darunavir.................................................... 131
dasetta 1/35............................................... 111
dasetta 7/7/7.............................................. 111
DAURISMO..................................................36
DAYHIST ALLERGY 12 HOUR RELIEF....150
daysee........................................................111
DAYVIGO...................................................179
deblitane.....................................................117
DECARA ORAL CAPSULE 1.25 MG
(50000 UT)................................................... 80
DECARA ORAL CAPSULE 625 MCG
(25000 UT)................................................... 80
deep sea nasal spray................................. 156
deferasirox granules.....................................79
deferasirox oral packet.................................79
deferasirox oral tablet...................................79
deferasirox oral tablet soluble...................... 79
DELSTRIGO................................................ 44
DELSYM CGH/CHEST CONG DM CHILD 170
DELSYM COUGH CHILDRENS................ 170
DELSYM COUGH/CHEST CONGEST DM170
DELSYM ORAL SUSPENSION
EXTENDED RELEASE.............................. 170
delyla..........................................................111
DENGVAXIA.............................................. 124
195
DENTA 5000 PLUS......................................73
DENTAGEL..................................................73
DEPEN TITRATABS.................................. 107
DEPO-ESTRADIOL................................... 111
DEPO-TESTOSTERONE SOLUTION 200
MG/ML INTRAMUSCULAR....................... 110
DERMELEVE ADVANCED FORMULA..... 131
DESENEX EXTERNAL POWDER...............31
DESENEX JOCK ITCH................................ 32
desgen dm oral liquid................................. 162
desipramine hcl oral..................................... 28
desmopressin ace spray refrig................... 108
desmopressin acetate oral......................... 108
desmopressin acetate spray...................... 108
desogestrel-ethinyl estradiol oral tablet
0.15-0.02/0.01 mg (21/5)............................111
dexamethasone intensol............................ 108
dexamethasone oral elixir.......................... 108
dexamethasone oral solution..................... 108
dexamethasone oral tablet 0.5 mg, 0.75
mg, 1 mg, 2 mg.......................................... 108
dexamethasone oral tablet 1.5 mg, 4 mg, 6
mg.............................................................. 108
dexamethasone sodium phosphate
ophthalmic..................................................141
DEXCOM G6 RECEIVER............................ 70
DEXCOM G6 SENSOR............................... 70
DEXCOM G6 TRANSMITTER................... 131
DEXCOM G7 RECEIVER............................ 70
DEXCOM G7 SENSOR............................... 70
dexmethylphenidate hcl............................... 59
dexmethylphenidate hcl er........................... 59
dextroamphetamine sulfate er......................60
dextroamphetamine sulfate oral tablet 10
mg, 5 mg...................................................... 60
dextromethorphan polistirex er...................170
dextromethorphan-guaifenesin oral liquid
5-100 mg/5ml............................................. 171
dextromethorphan-guaifenesin oral syrup..171
DHIVY.......................................................... 40
DIALYVITE 800 ORAL TABLET.................. 80
DIALYVITE VITAMIN D 5000.......................81
diamode....................................................... 85
diaper rash external ointment.......................68
diarrhea........................................................ 92
diarrhea relief............................................... 92
DIATRUST COVID-19 HOME TEST..........131
diazepam oral solution................................. 46
diazepam oral tablet.....................................46
diazepam rectal............................................25
dibromm childrens cold/cgh....................... 171
diclofenac potassium oral tablet 50 mg..........4
diclofenac sodium er...................................... 4
diclofenac sodium external gel 1 %................4
diclofenac sodium external solution 1.5 %..... 4
diclofenac sodium ophthalmic.................... 141
diclofenac sodium oral................................... 4
dicloxacillin sodium...................................... 21
dicyclomine hcl oral capsule........................ 85
dicyclomine hcl oral solution........................ 85
dicyclomine hcl oral tablet............................ 85
DIFFERIN EXTERNAL GEL 0.1 %.............. 62
DIFICID........................................................ 22
digestive probiotic oral capsule .................. 92
digestive probiotic oral capsule 250 mg....... 92
digoxin oral solution..................................... 56
digoxin oral tablet 125 mcg, 250 mcg.......... 56
dihydroergotamine mesylate injection..........33
DILANTIN ORAL CAPSULE 30 MG............ 25
diltiazem hcl er beads.................................. 55
diltiazem hcl er coated beads.......................55
diltiazem hcl er oral capsule extended
release 12 hour............................................ 55
diltiazem hcl er oral capsule extended
release 24 hour............................................ 55
diltiazem hcl oral.......................................... 55
dilt-xr............................................................ 55
dimaphen dm cold/cough........................... 171
dimethyl fumarate oral..................................61
dimethyl fumarate starter pack.....................61
diotame instydose........................................ 92
DIPENTUM................................................ 125
diphedryl allergy......................................... 150
diphen........................................................ 150
diphenhydramine hcl childrens...................150
diphenhydramine hcl oral capsule..............150
diphenhydramine hcl oral elixir...................150
diphenhydramine hcl oral liquid..................150
diphenhydramine hcl oral tablet................. 150
diphenhydramine hcl oral tablet chewable. 150
diphenoxylate-atropine.................................85
dipyridamole oral..........................................52
disopyramide phosphate.............................. 54
disulfiram oral tablet 250 mg........................ 17
disulfiram oral tablet 500 mg........................ 17
DIURIL......................................................... 57
divalproex sodium er oral tablet extended
release 24 hour 500 mg............................... 47
divalproex sodium oral capsule delayed
release sprinkle............................................ 47
divalproex sodium oral tablet delayed
release......................................................... 47
DIVIGEL TRANSDERMAL GEL 0.25
MG/0.25GM, 0.75 MG/0.75GM, 1.25
MG/1.25GM................................................111
DIVIGEL TRANSDERMAL GEL 0.5
MG/0.5GM, 1 MG/GM................................ 111
dm maximum adult.....................................171
docosanol external....................................... 69
docusate calcium....................................... 102
docusate mini............................................. 102
docusate sodium oral capsule....................102
docusate sodium oral liquid........................102
docusate sodium oral syrup....................... 102
DOCUSOL MINI.........................................102
docuzen......................................................102
DODEX...................................................... 184
196
dofetilide.......................................................54
donepezil hcl oral tablet 10 mg, 5 mg.......... 26
donepezil hcl oral tablet 23 mg.................... 26
DOPTELET.................................................. 52
DORZOLAMIDE HCL SOLUTION 2 %
OPHTHALMIC............................................142
dorzolamide hcl solution 2 % ophthalmic... 142
dorzolamide hcl-timolol mal........................140
dotti............................................................ 111
double antibiotic external ointment 500-
10000 unit/gm............................................ 131
DOVATO...................................................... 43
doxazosin mesylate oral...............................53
doxepin hcl oral capsule...............................28
doxepin hcl oral concentrate........................ 28
doxycycline hyclate oral capsule..................23
doxycycline hyclate oral tablet 100 mg........ 23
doxycycline monohydrate oral capsule 100
mg................................................................ 23
doxycycline monohydrate oral capsule 50
mg................................................................ 23
DR SMITHS DIAPER................................... 68
driminate...................................................... 28
dronabinol.................................................... 29
DROPSAFE ALCOHOL PREP.................. 131
drospirenone-ethinyl estradiol.................... 111
DROXIA ORAL CAPSULE 200 MG, 300
MG............................................................... 51
DROXIA ORAL CAPSULE 400 MG............. 51
dry-eye relief nighttime...............................142
dss..............................................................102
DUAVEE.................................................... 111
DUEXIS..........................................................4
DULERA.....................................................166
duloxetine hcl oral capsule delayed release
particles 20 mg, 30 mg, 60 mg.....................61
DUPIXENT................................................. 121
DUREX EXTRA SENSITIVE THIN............ 131
D-VI-SOL......................................................81
d-vite pediatric..............................................81
DYMISTA................................................... 150
e................................................................. 184
E.E.S. 400.................................................... 22
e-400-clear................................................. 184
ear drops.................................................... 147
ear wax kit.................................................. 147
ear wax removal.........................................147
ear wax removal system............................ 147
earwax removal..........................................147
earwax removal drops................................147
earwax removal kit otic solution 6.5 %....... 147
EASIVENT................................................. 131
EASIVENT MASK LARGE......................... 131
EASIVENT MASK MEDIUM.......................131
EASIVENT MASK SMALL......................... 131
EASY-C IMMUNE HEALTH....................... 182
easygel.........................................................73
easy-lax plus.............................................. 102
EASYMAX 15 LEVEL 2 CONTROL............. 71
EASYMAX 15 LEVEL 2-3 CONTROL..........71
ec-naproxen................................................... 4
econtra one-step........................................ 118
ED A-HIST ORAL LIQUID..........................162
ed bron gp.................................................. 156
ed chlorped jr............................................. 164
ed-apap........................................................ 10
EDARBI........................................................53
EDARBYCLOR............................................ 56
EDURANT....................................................44
efavirenz.......................................................44
efavirenz-emtricitab-tenofo df.......................44
efavirenz-lamivudine-tenofovir..................... 44
effer-k oral tablet effervescent 25 meq.......182
EGRIFTA SV..............................................108
electrolyte solution....................................... 76
ELESTRIN..................................................111
elinest.........................................................111
ELIQUIS....................................................... 51
ELIQUIS DVT/PE STARTER PACK............ 51
elixophyllin..................................................154
ELLA.......................................................... 117
ELLUME COVID-19 HOME TEST............. 131
ELMIRON...................................................107
eluryng....................................................... 111
ELYXYB......................................................... 4
EMETROL ORAL SOLUTION......................29
EMGALITY................................................... 33
EMGALITY (300 MG DOSE)........................33
EMPAVELI................................................. 131
emtricitabine.................................................44
emtricitabine-tenofovir df..............................44
EMTRIVA ORAL SOLUTION....................... 44
EMVERM..................................................... 38
emzahh...................................................... 117
enalapril maleate oral solution..................... 53
enalapril maleate oral tablet......................... 53
enalapril-hydrochlorothiazide....................... 56
ENBREL.....................................................122
ENDACOF-DM...........................................171
ENDARI........................................................73
endocet oral tablet 10-325 mg, 5-325 mg,
7.5-325 mg..................................................... 7
ENDOMETRIN........................................... 117
enema.......................................................... 92
enema disposable........................................ 92
enema mineral oil.........................................99
enema ready-to-use..................................... 92
enema rectal enema 16-6 gm/133ml........... 92
ENEMEEZ MINI......................................... 102
ENFAMIL ENFALYTE.................................. 76
ENFAMIL EXPECTA....................................81
ENGERIX-B............................................... 123
enilloring.....................................................112
enoxaparin sodium.......................................51
enpresse-28............................................... 112
enskyce...................................................... 112
ENSTILAR....................................................66
197
entacapone.................................................. 40
entecavir.......................................................42
enteric aspirin.............................................131
ENTRESTO..................................................56
enulose.........................................................85
EPCLUSA.................................................... 43
ephrine nose drops.................................... 156
EPIDIOLEX.................................................. 24
EPIDUO FORTE.......................................... 62
epinephrine injection solution auto-injector 153
EPIPEN 2-PAK...........................................153
EPIPEN JR 2-PAK..................................... 153
epitol.............................................................25
EPOGEN......................................................51
ergocalciferol oral capsule......................... 182
ERIVEDGE...................................................36
ERLEADA ORAL TABLET 240 MG............. 35
ERLEADA ORAL TABLET 60 MG............... 35
erlotinib hcl................................................. 138
ERMEZA.................................................... 118
errin............................................................ 117
ERYTHROCIN STEARATE......................... 22
erythromycin base oral.................................22
erythromycin ethylsuccinate oral..................22
erythromycin external...................................67
erythromycin ophthalmic............................ 141
erythromycin oral..........................................22
ESBRIET....................................................154
escitalopram oxalate oral tablet................... 27
esomeprazole magnesium oral packet........ 87
estarylla......................................................112
estradiol oral...............................................112
estradiol transdermal patch twice weekly...112
estradiol transdermal patch weekly............112
estradiol vaginal......................................... 112
eszopiclone................................................ 179
ethambutol hcl oral tablet 100 mg................ 34
ethambutol hcl oral tablet 400 mg................ 34
ethosuximide oral......................................... 24
ethynodiol diac-eth estradiol...................... 112
etodolac..........................................................4
etonogestrel-ethinyl estradiol..................... 112
etoposide oral...............................................36
etravirine...................................................... 44
EUCRISA..................................................... 63
EULEXIN......................................................35
euthyrox..................................................... 118
EVAC........................................................... 99
EVAMIST................................................... 112
everolimus oral tablet 0.25 mg, 0.5 mg,
0.75 mg, 1 mg............................................ 122
everolimus oral tablet 10 mg, 2.5 mg, 5 mg. 36
everolimus oral tablet 7.5 mg....................... 36
everolimus oral tablet soluble.......................36
EVOTAZ.......................................................45
EXCEDRIN EXTRA STRENGTH.................10
EXCEDRIN MIGRAINE................................11
exemestane..................................................36
EXKIVITY..................................................... 36
EX-LAX MAXIMUM STRENGTH............... 102
EX-LAX ULTRA..........................................131
eye drops adv relief....................................142
eye drops advanced relief.......................... 142
eye drops long lasting................................ 143
eye drops ophthalmic solution 0.05 %....... 143
eye drops ophthalmic solution 0.05-0.1-1-1
%................................................................ 143
eye drops ophthalmic solution 0.05-0.25 %143
eye irritation relief drops.............................143
eye lubricant...............................................143
eye lubricant nighttime............................... 143
EYSUVIS....................................................141
ezetimibe......................................................58
EZFE 200..................................................... 76
falmina........................................................112
famotidine acid reducer oral tablet 10 mg.... 86
famotidine oral suspension reconstituted.....86
famotidine oral tablet 10 mg.........................86
famotidine oral tablet 20 mg.........................86
famotidine oral tablet 40 mg.........................87
famotidine orig st..........................................87
FARXIGA..................................................... 47
FASENRA PEN..........................................155
fast relief laxative....................................... 131
FASTEP COVID-19 ANTIGEN TEST........ 132
FC2 FEMALE CONDOM............................132
febuxostat.....................................................32
felbamate oral suspension........................... 24
felbamate oral tablet.....................................24
felodipine er..................................................55
FEMCAP.................................................... 132
fenofibrate micronized oral capsule 130 mg 57
fenofibrate micronized oral capsule 134
mg, 200 mg, 67 mg...................................... 57
fenofibrate oral capsule 134 mg, 200 mg,
67 mg........................................................... 57
fenofibrate oral tablet................................... 57
FENSOLVI (6 MONTH)..............................119
fentanyl transdermal patch 72 hour 100
mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr,
75 mcg/hr....................................................... 6
ferate............................................................ 76
FER-IN-SOL.................................................76
ferosul.......................................................... 76
ferretts.......................................................... 76
ferrex 150 capsule 150 mg oral....................76
FERREX 150 CAPSULE 150 MG ORAL..... 76
FERRIC X-150............................................. 76
ferrous fumarate oral tablet 324 (106 fe)
mg, 324 mg.................................................. 76
ferrous gluconate......................................... 76
ferrous gluconate oral tablet 240 (27 fe) mg 76
ferrous gluconate oral tablet 324 (37.5 fe)
mg................................................................ 76
ferrous gluconate oral tablet 324 (38 fe) mg 76
ferrous sulfate.............................................. 76
198
ferrous sulfate oral solution 75 (15 fe)
mg/ml........................................................... 76
ferrous sulfate oral tablet 325 (65 fe) mg..... 77
ferrous sulfate oral tablet delayed release... 77
fever reducer/pain reliever........................... 11
fever reducing childrens............................... 11
feverall adults............................................... 11
feverall childrens.......................................... 11
FEVERALL INFANTS.................................. 11
FEVERALL JUNIOR STRENGTH................11
fe-vite iron.................................................... 77
fexofenadine hcl......................................... 164
fexofenadine hcl oral.................................. 164
FIASP...........................................................49
FIASP FLEXTOUCH.................................... 49
FIASP PENFILL........................................... 49
fiber laxative + calcium...............................102
fiber laxative oral capsule 0.52 gm...............99
fiber laxative oral tablet 500 mg................. 102
fiber oral capsule 0.52 gm............................99
fiber oral powder 28.3 %.............................. 99
fiber oral powder 43 %................................. 99
fiber oral powder 58.6 %.............................. 99
fiber oral tablet 500 mg.............................. 102
fiber oral tablet 625 mg.............................. 102
fiber powder oral powder 43 %.................. 100
fiber therapy oral capsule 0.52 gm.............100
fiber therapy oral powder 28.3 %............... 100
fiber therapy oral tablet 500 mg................. 102
fiber therapy oral tablet 625 mg................. 102
fiber-caps................................................... 102
fiber-lax...................................................... 102
FINACEA EXTERNAL FOAM...................... 62
finasteride oral tablet 5 mg.........................107
fingolimod hcl............................................... 61
finzala.........................................................112
first aid antibiotic external ointment , 3.5-
400-5000 ..................................................... 23
first aid antiseptic external solution 10 %..... 23
FIRVANQ..................................................... 20
FLAREX..................................................... 141
flecainide acetate......................................... 54
FLECTOR...................................................... 4
FLEET BISACODYL.................................. 132
FLEET ENEMA............................................ 92
FLEET OIL................................................. 100
FLEET PEDIATRIC......................................92
FLINTSTONES COMPLETE ORAL
TABLET CHEWABLE................................ 132
FLORA VANCE............................................92
floranex tablet oral........................................92
FLORANEX TABLET ORAL........................ 92
FLOWFLEX COVID-19 AG HOME TEST.. 132
FLUAD QUADRIVALENT.......................... 124
FLUARIX QUADRIVALENT....................... 124
FLUBLOK QUADRIVALENT......................124
FLUCELVAX QUADRIVALENT................. 124
fluconazole oral............................................ 30
fludrocortisone acetate oral........................108
FLULAVAL QUADRIVALENT.................... 124
FLUMIST QUADRIVALENT.......................124
fluocinolone acetonide body.........................63
fluocinolone acetonide external cream
0.025 %........................................................ 63
fluocinolone acetonide external ointment.....64
fluocinolone acetonide external solution...... 64
fluocinolone acetonide scalp........................ 64
fluocinonide emulsified base........................ 64
fluocinonide external cream......................... 64
fluocinonide external solution.......................64
fluoridex daily renewal..................................73
fluorometholone......................................... 141
fluorouracil external cream 5 %....................66
fluorouracil external solution........................ 66
fluoxetine hcl oral capsule............................27
fluoxetine hcl oral solution............................27
fluphenazine decanoate injection.................41
fluphenazine hcl injection............................. 41
fluphenazine hcl oral concentrate................ 41
fluphenazine hcl oral elixir............................41
fluphenazine hcl oral tablet.......................... 41
flurbiprofen sodium.....................................141
FLUTICASONE FUROATE-VILANTEROL 166
fluticasone propionate external cream......... 64
fluticasone propionate external ointment..... 64
FLUTICASONE PROPIONATE HFA......... 152
fluticasone propionate nasal...................... 152
fluticasone-salmeterol inhalation aerosol
powder breath activated 100-50 mcg/act,
250-50 mcg/act, 500-50 mcg/act................166
FLUTICASONE-SALMETEROL
INHALATION AEROSOL POWDER
BREATH ACTIVATED 113-14 MCG/ACT,
232-14 MCG/ACT, 55-14 MCG/ACT..........166
fluvoxamine maleate.................................... 27
FLUZONE HIGH-DOSE QUADRIVALENT 124
FLUZONE QUADRIVALENT..................... 124
foaming antacid oral tablet chewable 80-20
mg................................................................ 93
folic acid oral tablet 1 mg........................... 132
folic acid oral tablet 400 mcg, 800 mcg......132
FOLLISTIM AQ.......................................... 109
foot & sneaker............................................ 132
foot care (terbinafine)................................... 32
for sty relief.................................................143
FORFIVO XL................................................27
FORTEO.................................................... 125
fosamprenavir calcium................................. 45
fosinopril sodium.......................................... 53
fosinopril sodium-hctz.................................. 56
FREESTYLE LIBRE 14 DAY READER....... 71
FREESTYLE LIBRE 14 DAY SENSOR....... 71
FREESTYLE LIBRE 2 READER..................71
FREESTYLE LIBRE 2 SENSOR..................71
FREESTYLE LIBRE 3 SENSOR..................71
FREESTYLE LIBRE READER.....................71
FREESTYLE PRECISION NEO TEST........ 71
199
FREESTYLE TEST...................................... 71
freeze dried acidophilus............................... 93
fruity c.........................................................182
ft 12 hour cough relief................................ 171
ft 24 hour nasal allergy...............................166
ft 8 hour pain relief....................................... 11
ft acid reducer oral capsule delayed
release......................................................... 87
ft acid reducer oral tablet..............................87
ft all day allergy.......................................... 150
ft all day allergy 24 hour............................. 151
ft all day allergy relief................................. 164
ft all day allergy-d....................................... 162
ft all day pain relief......................................... 4
ft allergy childrens...................................... 164
ft allergy relief 12 hour................................164
ft allergy relief 24 hour................................164
ft allergy relief cetirizine..............................151
ft allergy relief childrens oral liquid............. 151
ft allergy relief loratadine............................ 165
ft allergy relief oral capsule........................ 151
ft allergy relief oral tablet 180 mg............... 165
ft allergy relief oral tablet 25 mg................. 151
ft allergy relief-d..........................................171
ft antacid & antigas.......................................93
ft antacid extra strength................................93
ft antacid regular strength............................ 93
ft antibiotic.................................................. 132
ft anti-diarrheal oral tablet............................ 85
ft anti-diarrheal/anti-gas............................... 93
ft antifungal external cream 1 %.................132
ft antifungal external cream 2 %...................32
ft arthritis pain reliever..................................11
ft aspirin......................................................132
ft aspirin low dose...................................... 132
ft athletes foot (terbinafine).......................... 32
ft chest congestion relief............................ 156
ft children's pain/fever.................................. 11
ft clearlax....................................................100
ft cold & cough relief dm.............................171
ft docosanol..................................................69
ft double antibiotic...................................... 132
ft earwax removal.......................................147
ft earwax removal kit.................................. 147
ft enema mineral oil....................................100
ft enema saline.............................................93
ft enteric coated aspirin.............................. 132
ft eye drops................................................ 143
ft fiber laxative............................................ 102
ft fiber oral powder 43 %............................ 100
ft gas relief....................................................93
ft gas relief extra strength.............................93
ft gas relief ultra strength..............................93
ft gentle laxative......................................... 132
ft ibuprofen ib childrens.................................. 4
ft ibuprofen oral tablet.................................... 4
ft laxative.................................................... 132
ft lice killing max st....................................... 39
ft lubricant eye drops ophthalmic solution
0.4-0.3 %....................................................143
ft lubricant eye drops ophthalmic solution
0.5 %.......................................................... 143
ft magnesium citrate...................................102
ft miconazole 7............................................. 30
ft migraine relief............................................11
ft milk of magnesia....................................... 93
ft mineral oil................................................100
ft motion sickness oral tablet 50 mg.............28
ft mucus relief 12hr oral tablet extended
release 12 hour 1200 mg........................... 156
ft mucus relief d 12 hour.............................171
ft mucus relief dm oral tablet extended
release 12 hour 30-600 mg........................ 171
ft nasal decongestant max str oral tablet... 171
ft nasal decongestant max str oral tablet
extended release 12 hour.......................... 171
ft nasal decongestant pe............................ 156
ft nasal spray..............................................171
ft nicotine mini.............................................. 19
ft nicotine mouth/throat lozenge................... 19
ft nighttime sleep aid.................................. 180
ft pain & fever childrens................................11
ft pain & fever infants................................... 11
ft pain relief adult extra st............................. 11
ft pain relief extra strength............................11
ft pain relief oral tablet 200 mg.......................4
ft pain relief oral tablet 325 mg.....................11
ft pain reliever ex str adult............................ 12
ft senna laxative......................................... 103
ft senna laxatives....................................... 103
ft senna-s................................................... 103
ft stomach relief oral suspension..................93
ft stomach relief oral tablet........................... 93
ft stomach relief oral tablet chewable...........93
ft stool softener oral capsule...................... 103
ft stool softener oral tablet 50-8.6 mg.........103
ft tussin adult.............................................. 156
ft tussin cf adult.......................................... 162
ft tussin dm max adult................................ 172
ft vitamin d3 oral tablet................................. 81
full spectrum b/vitamin c...............................81
FULPHILA.................................................... 51
fungi-guard................................................. 132
FUROSCIX...................................................56
furosemide oral solution 10 mg/ml............... 56
furosemide oral tablet...................................56
FUZEON...................................................... 45
FYCOMPA................................................... 24
FYLNETRA................................................ 132
g tussin ac.................................................. 172
gabapentin oral capsule............................... 25
gabapentin oral tablet 600 mg, 800 mg........25
galantamine hydrobromide oral solution...... 26
galantamine hydrobromide oral tablet 12
mg, 8 mg...................................................... 26
galantamine hydrobromide oral tablet 4 mg.26
ganirelix acetate......................................... 120
200
GARDASIL 9.............................................. 123
gas relief extra strength................................93
gas relief extra strength oral tablet
chewable 125 mg......................................... 93
gas relief extstrength....................................93
gas relief oral capsule 125 mg..................... 94
gas relief oral capsule 180 mg..................... 94
gas relief oral tablet chewable 125 mg.........94
gas relief oral tablet chewable 80 mg...........94
gas relief ultra strength.................................94
gas relief ultstrength.....................................94
GAS-X EXTRA STRENGTH ORAL
CAPSULE.................................................... 94
GAS-X EXTRA STRENGTH ORAL
TABLET CHEWABLE.................................. 94
GAS-X ULTRA STRENGTH........................ 94
GATTEX.......................................................86
gavilax oral powder.................................... 100
gavilyte-c...................................................... 86
gavilyte-g......................................................86
GAVISCON.................................................. 94
GAVISCON EXTRA RELIEF FORMULA..... 94
GAVISCON EXTRA STRENGTH................ 94
GAVRETO..................................................138
gefitinib.......................................................138
GELUSIL...................................................... 94
gemfibrozil oral.............................................57
generlac....................................................... 85
gengraf oral capsule...................................122
GENOTROPIN........................................... 108
GENOTROPIN MINIQUICK....................... 108
gentamicin sulfate external.......................... 67
gentamicin sulfate ophthalmic....................141
GENTEAL SEVERE...................................143
GENTEAL TEARS MODERATE PF.......... 143
GENTEAL TEARS NIGHT-TIME............... 143
GENTEAL TEARS OPHTHALMIC
SOLUTION 0.1-0.2-0.3 %.......................... 143
GENTEAL TEARS PF................................143
GENTEAL TEARS SEVERE DAY/NIGHT. 143
gentle laxative oral tablet delayed release
5 mg........................................................... 132
gentle laxative rectal suppository 10 mg.... 133
gentle laxative womens..............................133
gentlelax.....................................................100
genuine aspirin...........................................133
GENVOYA................................................... 43
geri-dryl...................................................... 151
geri-kot....................................................... 103
geri-lanta maximum strength........................94
geri-lanta oral suspension 200-200-20
mg/5ml......................................................... 94
geri-mox....................................................... 95
geri-tussin dm oral syrup............................172
geri-tussin oral liquid.................................. 156
GILENYA ORAL CAPSULE 0.25 MG.......... 61
GILOTRIF...................................................138
giltuss severe sinus....................................172
glatiramer acetate........................................ 61
glatopa......................................................... 61
glimepiride....................................................47
glipizide er.................................................... 47
glipizide oral tablet 10 mg, 5 mg.................. 47
glipizide xl.....................................................47
GLUCAGEN HYPOKIT................................ 48
glucagon emergency injection kit................. 48
GLUCAGON EMERGENCY INJECTION
SOLUTION RECONSTITUTED................... 48
GLUCO TO GO............................................50
GLUCOSE CONTROL SOLUTIONS........... 71
glucose oral tablet chewable 4 gm...............50
glyburide micronized.................................... 47
glyburide oral................................................47
glyburide-metformin..................................... 47
glycerin (adult) rectal suppository 2 gm..... 103
glycerin (infants & children) rectal
suppository 1 gm........................................103
glycerin adult rectal suppository 2 gm........103
glycerin child rectal suppository 1 gm, 1.2
gm.............................................................. 103
glycerin childrens....................................... 103
glycerin external........................................... 68
glycerin external liquid 99.5 %..................... 68
glycerin pediatric rectal suppository 1.2 gm
....................................................................103
glycolax...................................................... 100
glycopyrrolate oral tablet 1 mg..................... 85
glycopyrrolate oral tablet 2 mg..................... 85
GLYXAMBI...................................................47
GONAL-F................................................... 109
GONAL-F RFF........................................... 109
GONAL-F RFF REDIJECT.........................109
gormel.......................................................... 69
gormel 10..................................................... 69
GRALISE ORAL TABLET 300 MG, 600
MG............................................................... 60
griseofulvin microsize oral............................30
griseofulvin ultramicrosize............................30
guaifenesin er oral tablet extended release
12 hour 1200 mg........................................ 156
guaifenesin oral liquid................................ 156
guaifenesin oral tablet 400 mg................... 157
guaifenesin-codeine................................... 172
guaifenesin-dm oral syrup..........................172
guanfacine hcl.............................................. 52
guanfacine hcl er..........................................59
GUARDIAN CONNECT TRANSMITTER...133
GUARDIAN LINK 3 TRANSMITTER..........133
GUARDIAN SENSOR (3).............................71
GUARDIAN SENSOR 3............................... 71
gummy dinos..............................................133
gummy multivitamin kids............................ 133
GVOKE HYPOPEN 1-PACK........................48
GVOKE HYPOPEN 2-PACK........................48
GVOKE KIT..................................................48
GVOKE PFS................................................ 48
GYNAZOLE-1.............................................. 30
201
habitrol......................................................... 18
HADLIMA................................................... 133
HADLIMA PUSHTOUCH........................... 133
HAEGARDA............................................... 121
hailey 1.5/30...............................................112
hailey 24 fe.................................................112
hailey fe 1.5/30...........................................112
hailey fe 1/20..............................................112
halobetasol propionate external cream........ 64
haloette...................................................... 112
haloperidol decanoate intramuscular........... 41
haloperidol oral.............................................41
HARVONI.....................................................43
HAVRIX......................................................123
headache formula........................................ 12
headache relief.............................................12
headache relief extra str...............................12
heartburn antacid......................................... 95
heartburn antacid ex st.................................95
heartburn prevention oral tablet 10 mg........ 87
heartburn relief ex st.................................... 95
heartburn relief oral tablet 10 mg................. 87
heartburn relief oral tablet 200 mg............... 87
heartburn relief oral tablet chewable 160-
105 mg......................................................... 95
heartland gas relief.......................................95
heather....................................................... 117
h-e-b aspirin............................................... 133
h-e-b childrens allergy................................151
HEMANGEOL.............................................. 54
HEMLIBRA...................................................52
hemorrhoidal rectal suppository 0.25-3-
85.5 %.......................................................... 69
heparin sodium (porcine)............................. 51
heparin sodium (porcine) pf......................... 51
HEPLISAV-B.............................................. 124
her style......................................................118
HIBERIX.....................................................123
high potency probiotic oral capsule ............95
HORIZANT...................................................60
HUMALOG INJECTION............................... 49
HUMALOG JUNIOR KWIKPEN................... 49
HUMALOG KWIKPEN................................. 49
HUMALOG MIX 50/50 KWIKPEN................ 49
HUMALOG MIX 75/25..................................49
HUMALOG MIX 75/25 KWIKPEN................ 49
HUMALOG SUBCUTANEOUS.................... 49
HUMATROPE............................................ 108
HUMIRA (2 PEN)....................................... 122
HUMIRA (2 SYRINGE).............................. 122
HUMIRA SUBCUTANEOUS PEN-
INJECTOR KIT 80 MG/0.8ML....................122
HUMIRA-PED
....................................................................122
HUMIRA-PED>/=40KG CROHNS START.122
HUMIRA-PED>/=40KG UC STARTER...... 122
HUMIRA-PSORIASIS/UVEIT STARTER... 122
HUMULIN 70/30 KWIKPEN......................... 49
HUMULIN 70/30 VIAL.................................. 49
HUMULIN N KWIKPEN................................49
HUMULIN N VIAL........................................ 49
HUMULIN R U-500 KWIKPEN.....................49
HUMULIN R U-500 VIAL
(CONCENTRATED).....................................49
HUMULIN R VIAL........................................ 49
HYCAMTIN ORAL........................................36
hydralazine hcl oral...................................... 58
hydrochlorothiazide oral capsule..................57
hydrochlorothiazide oral tablet 12.5 mg....... 57
hydrochlorothiazide oral tablet 25 mg, 50
mg................................................................ 57
hydrocodone bit-homatrop mbr.................. 133
hydrocodone-acetaminophen oral solution
7.5-325 mg/15ml............................................ 7
hydrocodone-acetaminophen oral tablet
10-325 mg, 5-325 mg, 7.5-325 mg.................7
hydrocortisone (perianal)........................... 125
hydrocortisone anti-itch................................ 64
hydrocortisone butyrate external ointment... 64
hydrocortisone butyrate external solution.... 64
hydrocortisone cream 1 % external (otc)..... 64
hydrocortisone cream 1 % external (rx)....... 64
hydrocortisone external cream 0.5 %...........64
hydrocortisone external cream 1 %..............64
hydrocortisone external cream 2.5 %...........64
hydrocortisone external lotion 2.5 %............ 64
hydrocortisone external ointment 0.5 %.......64
hydrocortisone external ointment 1 %..........64
hydrocortisone external ointment 2.5 %.......65
hydrocortisone max st external cream......... 65
hydrocortisone max st/12 moist................... 65
hydrocortisone oral tablet 10 mg, 20 mg, 5
mg.............................................................. 108
hydrocortisone plus external cream 1 %...... 65
hydrocortisone rectal enema 100 mg/60ml 125
hydrocortisone/aloe......................................65
hydrocortisone/aloe max str......................... 65
hydrocortisone-acetic acid......................... 146
hydrolatum................................................... 68
hydromet.................................................... 133
hydromorphone hcl oral................................. 7
hydromorphone hcl rectal...............................7
hydrophor..................................................... 68
hydroxychloroquine sulfate oral tablet 200
mg................................................................ 39
hydroxyurea oral.......................................... 36
hydroxyzine hcl oral..................................... 46
hydroxyzine pamoate oral............................ 46
HYFTOR.................................................... 133
hyoscyamine sulfate er.............................. 133
hyoscyamine sulfate oral............................133
hyoscyamine sulfate sublingual................. 133
hyosyne......................................................133
HYPERSAL INHALATION NEBULIZATION
SOLUTION 7 %..........................................172
HYPERTET................................................ 124
HYPOTEARS............................................. 143
202
HYRIMOZ SUBCUTANEOUS SOLUTION
AUTO-INJECTOR 40 MG/0.4ML............... 133
HYRIMOZ SUBCUTANEOUS SOLUTION
AUTO-INJECTOR 80 MG/0.8ML............... 133
HYRIMOZ SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE 10 MG/0.1 ML, 20
MG/0.2ML.................................................. 133
HYRIMOZ SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE 40 MG/0.4ML........134
HYRIMOZ-CROHNS/UC STARTER..........134
HYRIMOZ-PED
....................................................................134
HYRIMOZ-PED>/=40KG CROHN START.134
HYRIMOZ-PLAQUE PSORIASIS START..134
HYSINGLA ER............................................... 6
IBRANCE..................................................... 36
ibuprofen........................................................ 4
ibuprofen childrens oral tablet chewable
100 mg........................................................... 4
ibuprofen cold & sinus................................172
ibuprofen cold/sinus oral tablet 30-200 mg 172
ibu-profen cold/sinus oral tablet 30-200 mg
....................................................................172
ibuprofen ib childrens..................................... 4
ibuprofen ib oral tablet 200 mg.......................4
ibuprofen infants oral suspension 50
mg/1.25ml...................................................... 5
ibuprofen jr oral tablet 100 mg....................... 5
ibuprofen junior.............................................. 5
ibuprofen junior strength................................ 5
ibuprofen oral suspension 100 mg/5ml.......... 5
ibuprofen oral tablet 200 mg.......................... 5
ibuprofen oral tablet 400 mg, 600 mg, 800
mg.................................................................. 5
icatibant acetate......................................... 121
iclevia......................................................... 112
ICLUSIG.....................................................138
IDHIFA......................................................... 36
iferex 150..................................................... 77
IHEALTH COVID-19 RAPID TEST............ 134
ILARIS........................................................121
ILEVRO...................................................... 141
ILUMYA......................................................121
imatinib mesylate....................................... 138
IMBRUVICA............................................... 139
imipramine hcl oral....................................... 28
imiquimod external cream 5 %.....................66
IMODIUM A-D ORAL TABLET.....................85
IMODIUM MULTI-SYMPTOM RELIEF........ 95
INBRIJA....................................................... 40
incassia...................................................... 117
INCRELEX................................................. 108
INCRUSE ELLIPTA....................................152
indapamide...................................................57
INDICAID COVID-19 RAPID TEST............134
indomethacin oral capsule............................. 5
indoor/outdoor allergy rlf............................ 151
INFANRIX.................................................. 123
INFANTS ADVIL............................................ 5
infants ibuprofen.............................................5
infants pain & fever...................................... 12
infants pain relief drops................................ 12
infants pain/fever..........................................12
INGREZZA ORAL CAPSULE...................... 60
INGREZZA ORAL CAPSULE THERAPY
PACK........................................................... 60
INLYTA.......................................................139
INSPIREASE..............................................134
INSPIREASE RESERVOIR BAGS............ 134
instacort 5.....................................................65
INSULIN ASPART PROT & ASPART..........49
INSULIN GLARGINE-YFGN........................ 49
INSULIN LISPRO.........................................49
INSULIN LISPRO (1 UNIT DIAL)................. 49
INSULIN LISPRO JUNIOR KWIKPEN.........49
INSULIN LISPRO PROT & LISPRO............ 49
INSULIN PEN NEEDLES 29G X 12.7MM..134
INSULIN PEN NEEDLES 31G X 5 MM ,
31G X 6 MM , 31G X 8 MM........................134
INSULIN PEN NEEDLES 32G X 4 MM ,
32G X 6 MM................................................. 71
INSULIN SYRINGES 28G X 1/2" 0.5 ML,
28G X 1/2" 1 ML.........................................134
INSULIN SYRINGES 29G X 1/2" 0.3 ML,
29G X 1/2" 0.5 ML, 30G X 5/16" 0.3 ML.... 134
INSULIN SYRINGES 29G X 1/2" 1 ML,
30G X 5/16" 0.5 ML....................................134
INSULIN SYRINGES 30G X 1/2" 1 ML,
31G X 15/64" 0.3 ML, 31G X 5/16" 0.3 ML,
31G X 5/16" 0.5 ML, 31G X 5/16" 1 ML..... 134
INSULIN SYRINGES 30G X 5/16" 1 ML....134
INTELENCE ORAL TABLET 25 MG............44
INTELISWAB COVID-19 RAPID TEST......134
intestinex...................................................... 95
introvale......................................................112
INVEGA HAFYERA......................................41
INVEGA SUSTENNA................................... 41
INVEGA TRINZA..........................................41
INVELTYS..................................................141
INVOKAMET................................................ 47
INVOKAMET XR.......................................... 48
IPOL........................................................... 123
ipratropium bromide inhalation...................152
ipratropium bromide nasal..........................152
ipratropium-albuterol.................................. 166
irbesartan..................................................... 53
irbesartan-hydrochlorothiazide.....................56
iron (ferrous sulfate) oral solution.................77
iron infant/toddler......................................... 77
iron oral tablet 240 (27 fe) mg...................... 77
iron oral tablet 325 (65 fe) mg...................... 77
iron supplement childrens............................ 77
ISENTRESS HD...........................................43
ISENTRESS ORAL PACKET.......................43
ISENTRESS ORAL TABLET....................... 43
ISENTRESS ORAL TABLET CHEWABLE.. 43
203
isibloom...................................................... 112
isoniazid oral................................................ 34
isosorbide dinitrate....................................... 58
isosorbide mononitrate.................................58
isosorbide mononitrate er.............................58
isotretinoin oral capsule 10 mg, 20 mg, 40
mg................................................................ 62
isotretinoin oral capsule 30 mg.................... 62
itraconazole oral...........................................30
ivermectin oral..............................................38
jaimiess...................................................... 112
JAKAFI......................................................... 36
jantoven oral tablet 1 mg, 10 mg, 2 mg, 2.5
mg, 3 mg, 4 mg, 5 mg, 7.5 mg..................... 51
jantoven oral tablet 6 mg..............................51
JANUMET.................................................... 48
JANUMET XR.............................................. 48
JANUVIA...................................................... 48
JARDIANCE.................................................48
jasmiel........................................................ 112
jencycla...................................................... 117
JENTADUETO............................................. 48
JENTADUETO XR....................................... 48
jock itch external cream 1 %........................ 32
jock itch max st...........................................134
jock itch spray powder................................134
jolessa........................................................ 112
JORNAY PM................................................ 59
JUBLIA......................................................... 67
juleber........................................................ 112
JULUCA....................................................... 43
junel 1.5/30.................................................113
junel 1/20....................................................113
junel fe oral tablet 1.5-30 mg-mcg..............113
junel fe oral tablet 1-20 mg-mcg.................113
junel fe oral tablet 1-20 mg-mcg(24).......... 113
kalliga......................................................... 113
KALYDECO................................................153
kariva..........................................................113
kelnor 1/35................................................. 113
kelnor 1/50................................................. 113
KERENDIA...................................................56
KESIMPTA................................................... 61
ketoconazole external cream....................... 67
ketoconazole external shampoo.................. 67
ketoconazole oral......................................... 30
KETO-DIASTIX............................................ 71
KETONE CARE........................................... 71
KETONE TEST............................................ 71
ketoprofen oral capsule 25 mg.......................5
ketorolac tromethamine ophthalmic
solution 0.4 %.............................................141
ketorolac tromethamine ophthalmic
solution 0.5 %.............................................141
ketorolac tromethamine oral...........................5
KETOSTIX................................................... 71
KEVZARA.................................................. 121
KINERET....................................................121
KISQALI (200 MG DOSE)............................36
KISQALI (400 MG DOSE)............................36
KISQALI (600 MG DOSE)............................36
KISQALI FEMARA (200 MG DOSE)............36
KISQALI FEMARA (400 MG DOSE)............36
KISQALI FEMARA (600 MG DOSE)............36
klayesta........................................................ 67
klor-con........................................................ 73
klor-con 10................................................... 73
klor-con m10................................................ 73
klor-con m20................................................ 73
klor-con/ef.................................................. 182
KLOXXADO................................................. 18
KOSELUGO................................................. 36
kourzeq........................................................ 62
K-PHOS....................................................... 77
k-prime....................................................... 182
KRINTAFEL................................................. 39
kurvelo........................................................113
labetalol hcl oral........................................... 54
LAC-HYDRIN FIVE...................................... 65
lacosamide oral tablet.................................. 25
lactobacillus oral tablet.................................95
lacto-pectin...................................................95
lactulose encephalopathy.............................85
lactulose oral solution...................................85
LAGEVRIO...................................................46
LAMISIL AT EXTERNAL CREAM................32
LAMISIL AT JOCK ITCH..............................32
lamivudine oral solution................................44
lamivudine oral tablet 100 mg...................... 42
lamivudine oral tablet 150 mg, 300 mg........ 44
lamivudine-zidovudine..................................44
lamotrigine oral tablet...................................24
lamotrigine oral tablet chewable...................24
lamotrigine starter kit-blue............................24
lamotrigine starter kit-green......................... 24
lamotrigine starter kit-orange....................... 24
LANCETS.....................................................71
lansoprazole capsule delayed release 15
mg oral (otc)................................................. 87
lansoprazole capsule delayed release 15
mg oral (rx)...................................................87
lansoprazole oral capsule delayed release
15 mg........................................................... 87
lansoprazole oral capsule delayed release
30 mg........................................................... 87
LANTUS SOLOSTAR.................................. 49
LANTUS U-100 VIAL................................... 49
lapatinib ditosylate......................................139
larin 1.5/30................................................. 113
larin 1/20.................................................... 113
larin 24 fe................................................... 113
larin fe 1.5/30............................................. 113
larin fe 1/20................................................ 113
latanoprost ophthalmic............................... 140
laxacin........................................................ 103
laxaclear.....................................................100
laxative max str.......................................... 103
204
laxative oral powder 17 gm/scoop..............100
laxative oral tablet delayed release 5 mg...134
laxative pills max st.................................... 103
laxative pills oral tablet 25 mg.................... 103
laxative rectal suppository 10 mg...............134
laxative regular strength.............................103
LEDIPASVIR-SOFOSBUVIR....................... 43
leena.......................................................... 113
leflunomide oral..........................................122
lenalidomide................................................. 35
LENVIMA (10 MG DAILY DOSE)...............139
LENVIMA (12 MG DAILY DOSE)...............139
LENVIMA (14 MG DAILY DOSE)...............139
LENVIMA (18 MG DAILY DOSE)...............139
LENVIMA (20 MG DAILY DOSE)...............139
LENVIMA (24 MG DAILY DOSE)...............139
LENVIMA (4 MG DAILY DOSE).................139
LENVIMA (8 MG DAILY DOSE).................139
lessina........................................................ 113
letrozole oral.................................................36
leucovorin calcium oral tablet 10 mg............38
leucovorin calcium oral tablet 15 mg, 25
mg, 5 mg...................................................... 38
LEUKERAN..................................................35
LEUKINE......................................................51
leuprolide acetate injection.........................119
levalbuterol hcl inhalation...........................153
LEVBID...................................................... 134
LEVEMIR FLEXPEN.................................... 49
LEVEMIR U-100 VIAL..................................49
levetiracetam oral solution........................... 24
levetiracetam oral tablet............................... 24
levobunolol hcl........................................... 142
levocetirizine dihydrochloride oral tablet.... 151
levofloxacin oral tablet..................................22
levonest......................................................113
levonorgest-eth estrad 91-day................... 113
levonorgestrel.............................................118
levonorgestrel-ethinyl estrad oral tablet
0.1-20 mg-mcg........................................... 113
levonorgestrel-ethinyl estrad oral tablet
0.15-30 mg-mcg......................................... 113
levonorg-eth estrad triphasic......................113
levora 0.15/30 (28)..................................... 113
levo-t.......................................................... 118
levothyroxine sodium oral tablet.................118
levoxyl........................................................ 118
LIALDA.......................................................125
LICART.......................................................... 5
lice killing................................................39, 66
lice killing max st external shampoo 0.33-4
%.................................................................. 39
lice killing max str......................................... 39
lice killing max strength................................ 39
lice killing maximum strength....................... 39
lice killing shampoo max str......................... 39
lice maximum strength................................. 39
lice treatment external liquid 1 %................. 66
lice treatment external shampoo 0.33-4 %...40
lidocaine external cream 4 %....................... 17
lidocaine external patch 5 %........................ 17
lidocaine hcl external cream 3 %................. 17
lidocaine viscous hcl.................................... 17
lidocaine-prilocaine external cream..............17
lidopin external cream 3 %...........................17
linezolid oral suspension reconstituted........ 20
linezolid oral tablet....................................... 20
LINZESS...................................................... 85
liothyronine sodium oral............................. 118
liquid acetaminophen................................... 12
liquid allergy relief...................................... 151
liquid corn & callus rem.............................. 134
liquid pain relief............................................ 12
liquid wart remover.....................................134
liquid wart remover max st......................... 134
lisdexamfetamine dimesylate oral capsule...60
lisinopril oral................................................. 53
lisinopril-hydrochlorothiazide........................56
lithium...........................................................47
lithium carbonate er......................................47
lithium carbonate oral...................................47
LIVALO.........................................................57
LIVITA ADULTS......................................... 182
LMX 4...........................................................17
LO LOESTRIN FE......................................114
lojaimiess................................................... 114
LOKELMA.................................................... 79
long acting nasal spray.............................. 172
long lasting antacid...................................... 95
long lasting nasal spray..............................172
LONSURF.................................................... 36
loperamide hcl oral capsule......................... 85
loperamide hcl oral tablet............................. 85
loperamide-simethicone............................... 95
lopinavir-ritonavir..........................................45
loradamed.................................................. 165
lorata-d....................................................... 172
loratadine allergy relief oral tablet 10 mg... 165
loratadine allergy relief oral tablet
dispersible 10 mg....................................... 165
loratadine childrens oral solution................165
lorata-dine d............................................... 172
loratadine d 12hr........................................ 172
loratadine oral solution............................... 165
loratadine oral tablet...................................165
loratadine oral tablet dispersible................ 165
loratadine-d................................................ 173
loratadine-d 12hr........................................ 173
loratadine-d 24hr........................................ 173
lorazepam oral tablet....................................46
LOREEV XR.................................................46
loryna......................................................... 114
LORZONE..................................................179
losartan potassium oral................................ 53
losartan potassium-hctz............................... 56
LOTEMAX OPHTHALMIC GEL................. 141
205
LOTEMAX OPHTHALMIC OINTMENT......141
LOTEMAX SM............................................141
lovastatin oral............................................... 57
low-ogestrel................................................114
loxapine succinate........................................41
lo-zumandimine..........................................114
lubricant drops fast act............................... 143
lubricant drops ophthalmic gel 0.25-0.3 %. 143
lubricant drops ophthalmic solution............143
lubricant eye drops (pf) ophthalmic solution
0.4-0.3 %....................................................144
lubricant eye drops (pf) ophthalmic solution
0.5 %.......................................................... 144
lubricant eye drops ophthalmic solution
0.4-0.3 %....................................................144
lubricant eye drops ophthalmic solution 0.5
%................................................................ 144
lubricant eye drops ophthalmic solution 0.6
%................................................................ 144
lubricant eye drops pf.................................144
lubricant eye nighttime............................... 144
lubricant eye ophthalmic solution 0.4-0.3 %
....................................................................144
lubricant pm................................................144
lubricating eye drop....................................144
lubricating eye drops.................................. 144
lubricating eye/overnight............................ 144
lubricating plus eye drops.......................... 144
lubricating plus ophthalmic solution 0.5 %. 144
lubricating plus pf....................................... 144
lubricating tears ophthalmic solution 0.4-
0.3 %.......................................................... 144
lubrifresh p.m............................................. 144
LUMAKRAS................................................. 38
LUMIGAN...................................................140
LUPKYNIS................................................. 120
LUPRON DEPOT (1-MONTH)................... 119
LUPRON DEPOT (3-MONTH)................... 119
LUPRON DEPOT (4-MONTH)
INTRAMUSCULAR KIT 30MG...................119
LUPRON DEPOT (6-MONTH)
INTRAMUSCULAR KIT 45MG...................119
LUPRON DEPOT-PED (1-MONTH).......... 119
LUPRON DEPOT-PED (3-MONTH).......... 119
LUPRON DEPOT-PED (6-MONTH).......... 119
lurasidone hcl............................................... 41
lutera.......................................................... 114
LYBALVI.......................................................41
lyleq............................................................117
lyllana......................................................... 114
LYNPARZA.................................................. 36
LYSODREN............................................... 119
LYUMJEV.....................................................49
LYUMJEV KWIKPEN................................... 49
lyza.............................................................117
MAALOX CHILDRENS................................ 95
MAALOX MAX ORAL SUSPENSION.......... 95
MAALOX MULTI SYMPTOM MAX ST.........95
mag-al plus...................................................95
mag-al plus xs.............................................. 95
magnesium citrate oral solution................. 103
magnesium oral tablet 500 mg.....................77
magnesium oxide -mg supplement oral
tablet 400 (240 mg) mg................................ 77
magnesium oxide -mg supplement oral
tablet 500 mg............................................... 77
magnesium oxide oral tablet 400 mg......... 135
magnesium oxide oral tablet 420 mg......... 135
magnesium-aluminum-simethicone............. 95
magnesium-oxide.........................................77
malathion......................................................66
MAOX.........................................................135
mapap acetaminophen extra str...................12
mapap childrens...........................................12
mapap oral capsule......................................12
maraviroc..................................................... 45
marlissa......................................................114
MASK VORTEX/CHILD/FROG.................. 135
MASK VORTEX/TODDLER/LADYBUG.....135
MATULANE..................................................35
MAVENCLAD (10 TABS)............................. 61
MAVENCLAD (4 TABS)............................... 61
MAVENCLAD (5 TABS)............................... 61
MAVENCLAD (6 TABS)............................... 61
MAVENCLAD (7 TABS)............................... 61
MAVENCLAD (8 TABS)............................... 61
MAVENCLAD (9 TABS)............................... 61
MAVYRET ORAL PACKET..........................43
MAVYRET ORAL TABLET.......................... 43
MAX RELIEF JR CHILD PAIN/FEVER........ 12
MAX RELIEF JUNIOR................................. 12
MAX TUSSIN MUCUS & CHEST CONG...157
MAXALLERGY KIDS................................. 151
maxi-tuss ac............................................... 173
maxi-tuss gmx............................................ 173
maxi-tuss pe max....................................... 157
MAYZENT.................................................... 61
MAYZENT STARTER PACK....................... 61
m-dryl......................................................... 151
meclizine hcl oral tablet 12.5 mg..................28
meclizine hcl oral tablet 25 mg.....................28
meclizine hcl oral tablet chewable................28
medicated spot...........................................135
medifin 400.................................................157
medifin mucus relief child...........................157
medi-first aspirin.........................................135
medi-first hydrocortisone..............................65
medi-first ibuprofen........................................ 5
medi-first triple antibiotic.............................. 23
mediproxen.................................................... 5
medique aspirin..........................................135
MEDISENSE GLUCOSE KETONE
CONTR........................................................ 71
MEDISENSE HI/MID/LOW CONTROL........ 71
MEDPURA BENZOYL PEROXIDE............135
MEDROL ORAL TABLET 2 MG.................108
206
medroxyprogesterone acetate
intramuscular..............................................117
medroxyprogesterone acetate oral............ 117
mefloquine hcl.............................................. 39
mega probiotic..............................................96
megestrol acetate oral suspension 40
mg/ml......................................................... 117
megestrol acetate oral tablet 20 mg...........117
megestrol acetate oral tablet 40 mg...........117
meijer allergy relief-d..................................173
meijer antacid...............................................96
meijer anti-diarrheal..................................... 85
MEKINIST ORAL SOLUTION
RECONSTITUTED.......................................36
MEKINIST ORAL TABLET...........................37
meloxicam oral tablet..................................... 5
memantine hcl oral solution......................... 26
memantine hcl oral tablet............................. 26
MENOPUR.................................................120
MENQUADFI..............................................123
MENVEO....................................................123
mercaptopurine oral..................................... 36
mesalamine er oral capsule 0.375 gm....... 125
mesalamine rectal...................................... 125
MESNEX ORAL........................................... 38
METAMUCIL 4 IN 1 FIBER ORAL
POWDER 43 %..........................................100
METAMUCIL FREE & NATURAL.............. 100
metformin hcl er (osm)................................. 48
metformin hcl er oral tablet extended
release 24 hour 500 mg............................... 48
metformin hcl er oral tablet extended
release 24 hour 750 mg............................... 48
metformin hcl oral tablet 1000 mg, 500 mg,
850 mg......................................................... 48
methazolamide oral....................................142
methenamine hippurate............................... 20
methergine................................................. 109
methimazole oral........................................120
methocarbamol oral................................... 179
methotrexate sodium (pf)........................... 122
methotrexate sodium injection................... 122
methotrexate sodium oral...........................122
methoxsalen rapid........................................66
methsuximide............................................... 24
METHYLDOPA............................................ 52
methylergonovine maleate oral.................. 109
methylphenidate hcl er................................. 59
methylphenidate hcl er (cd)..........................59
methylphenidate hcl er (la) oral capsule
extended release 24 hour 20 mg, 30 mg,
40 mg........................................................... 59
methylphenidate hcl er (osm) oral tablet
extended release 18 mg, 27 mg, 36 mg, 54
mg................................................................ 59
methylphenidate hcl oral tablet.................... 59
methylprednisolone oral............................. 108
metoclopramide hcl oral solution 5 mg/5ml..28
metoclopramide hcl oral tablet..................... 28
metolazone...................................................57
metoprolol succinate er................................ 54
metoprolol tartrate oral tablet 100 mg, 50
mg................................................................ 54
metoprolol tartrate oral tablet 25 mg............ 54
metoprolol tartrate oral tablet 37.5 mg, 75
mg................................................................ 54
metronidazole external.................................20
metronidazole oral tablet..............................20
metronidazole vaginal.................................. 20
mexiletine hcl oral........................................ 54
mibelas 24 fe..............................................114
micaderm..................................................... 32
MICATIN...................................................... 32
miconazole 3................................................ 30
miconazole 3 applicator vaginal kit 200 & 2
mg-% (9gm)................................................. 30
miconazole 3 combo pack vaginal kit 200 &
2 mg-% (9gm).............................................. 30
miconazole 7 vaginal cream 2 %................. 30
miconazole 7 vaginal suppository 100 mg... 30
miconazole antifungal.................................. 32
miconazole nitrate external cream............... 32
miconazole nitrate vaginal............................30
miconazorb af...............................................32
MICRO GUARD........................................... 32
microgestin 1.5/30......................................114
microgestin 1/20.........................................114
microgestin 24 fe........................................114
microgestin fe 1.5/30..................................114
microgestin fe 1/20.....................................114
midodrine hcl................................................52
mifepristone oral tablet 200 mg..................109
mifepristone oral tablet 300 mg..................109
MIGERGOT..................................................33
migraine formula oral tablet 250-250-65 mg 12
migraine headache relief..............................13
migraine relief oral tablet 250-250-65 mg.... 13
mili..............................................................114
milk of magnesia.......................................... 96
milk of magnesia oral suspension 1200
mg/15ml....................................................... 96
mineral oil enema.......................................100
mineral oil heavy oral................................. 101
mineral oil heavy oral oil ...........................101
mineral oil oral oil ..................................... 101
mineral oil rectal enema ........................... 101
mini nicotine................................................. 19
minocycline hcl oral capsule 100 mg, 50
mg................................................................ 23
minoxidil oral................................................ 58
mintox maximum strength............................ 96
mintox plus................................................... 96
MIRALAX ORAL POWDER....................... 101
mirtazapine oral tablet 15 mg, 30 mg...........27
mirtazapine oral tablet 45 mg, 7.5 mg..........27
MIRVASO.....................................................62
misoprostol oral............................................87
207
MITIGARE....................................................32
mm acetaminophen ex str............................13
MM ALLER-BEN........................................ 151
mm arthritis pain...........................................13
mm aspirin..................................................135
mm clearlax................................................101
mm ibuprofen................................................. 5
mm stool softener laxative......................... 103
M-M-R II..................................................... 123
M-NATAL PLUS........................................... 81
modafinil oral..............................................180
MODERNA COVID-19 VAC 6M-11Y......... 135
mometasone furoate external...................... 65
mondoxyne nl...............................................23
MONOJECT HYPODERMIC NEEDLE 18G
X 1"...............................................................50
mono-linyah................................................114
montelukast sodium oral............................ 152
mood support probiotic.................................96
morphine sulfate (concentrate)...................... 7
morphine sulfate er oral tablet extended
release........................................................... 6
morphine sulfate oral......................................7
morphine sulfate rectal...................................7
MOTEGRITY................................................85
motion sickness oral tablet 50 mg................28
motion sickness relief oral tablet 50 mg....... 29
motion sickness relief oral tablet chewable
25 mg........................................................... 29
motion-time.................................................. 29
MOTRIN CHILDRENS................................... 5
MOTRIN IB ORAL TABLET........................... 6
MOTRIN INFANTS DROPS...........................6
MOUNJARO...............................................135
MOVANTIK.................................................. 85
MOVIPREP.................................................. 86
moxifloxacin hcl (2x day)............................141
moxifloxacin hcl ophthalmic....................... 141
moxifloxacin hcl oral.....................................22
m-pap........................................................... 13
MUCINEX COUGH CHILDRENS.............. 173
MUCINEX D............................................... 173
MUCINEX D MAX STRENGTH................. 173
MUCINEX DM............................................ 173
MUCINEX FAST-MAX CHEST CONG MS 157
MUCINEX FAST-MAX DM MAX................ 173
MUCINEX MAXIMUM STRENGTH........... 157
MUCINEX SINUS-MAX CLEAR & COOL.. 173
MUCINEX SINUS-MAX SINUS/ALLRGY.. 173
mucus & cough relief child......................... 173
mucus d......................................................174
mucus d extended release......................... 174
mucus d max st er......................................174
mucus dm...................................................174
mucus dm extended release oral tablet
extended release 12 hour 30-600 mg........ 174
mucus er maximum str...............................157
mucus er oral tablet extended release 12
hour 1200 mg............................................. 157
mucus extended release oral tablet
extended release 12 hour 1200 mg........... 157
mucus relief 12 hour max st....................... 157
mucus relief chest oral tablet 400 mg........ 157
mucus relief childrens oral liquid 100
mg/5ml....................................................... 157
mucus relief cough childrens......................174
mucus relief d max strength....................... 174
mucus relief d oral tablet extended release
12 hour 120-1200 mg.................................174
mucus relief d oral tablet extended release
12 hour 60-600 mg.....................................174
mucus relief dm max oral liquid 20-400
mg/20ml, 5-100 mg/5ml............................. 174
mucus relief dm oral liquid 20-400 mg/20ml
....................................................................174
mucus relief dm oral tablet extended
release 12 hour 30-600 mg........................ 174
mucus relief er............................................157
mucus relief er oral tablet extended release
12 hour 1200 mg........................................ 157
mucus relief max st.................................... 157
mucus relief max strength oral tablet
extended release 12 hour 1200 mg........... 158
mucus relief oral tablet 400 mg.................. 158
mucus relief oral tablet extended release
12 hour 1200 mg........................................ 158
mucus+chest congestion............................158
mucus-dm.................................................. 174
mucus-er oral tablet extended release 12
hour 1200 mg............................................. 158
MULPLETA.................................................. 51
MULTAQ...................................................... 54
multiple vitamins/iron..................................182
multivitamin infant & toddler oral solution .182
multi-vitamin/iron........................................ 182
mupirocin external........................................67
MURO 128 OPHTHALMIC OINTMENT.....144
MURO 128 OPHTHALMIC SOLUTION 5
%................................................................ 145
my choice................................................... 118
my way....................................................... 118
mycophenolate mofetil oral........................ 122
mycophenolate sodium.............................. 122
mycophenolic acid......................................122
MYFEMBREE.............................................. 84
MYLERAN....................................................35
MYRBETRIQ ORAL SUSPENSION
RECONSTITUTED ER...............................106
MYRBETRIQ ORAL TABLET EXTENDED
RELEASE 24 HOUR.................................. 106
MYTESI........................................................85
nabumetone oral............................................ 6
nadolol oral...................................................54
naloxone hcl injection...................................18
naloxone hcl liquid 4 mg/0.1ml nasal (otc)... 18
naloxone hcl liquid 4 mg/0.1ml nasal (rx).....18
naltrexone hcl oral........................................17
208
NAMZARIC.................................................. 26
NAPHCON-A..............................................146
NAPRELAN ORAL TABLET EXTENDED
RELEASE 24 HOUR 375 MG, 750 MG......... 6
NAPRELAN ORAL TABLET EXTENDED
RELEASE 24 HOUR 500 MG........................ 6
naproxen dr.................................................... 6
naproxen oral................................................. 6
naproxen sodium oral tablet 220 mg..............6
NARAMIN...................................................151
naratriptan hcl.............................................. 33
NARCAN LIQUID 4 MG/0.1ML NASAL
(OTC)........................................................... 18
NARCAN LIQUID 4 MG/0.1ML NASAL
(RX)..............................................................18
NASACORT ALLERGY 24HR................... 166
nasal allergy 24 hour..................................166
nasal allergy nasal aerosol 55 mcg/act...... 166
nasal allergy spray..................................... 166
nasal decongestant 12hr............................174
nasal decongestant max st........................ 174
nasal decongestant oral tablet 30 mg........ 175
nasal decongestant oral tablet extended
release 12 hour 120 mg............................. 175
nasal decongestant pe max st................... 158
nasal decongestant pe oral tablet 10 mg... 158
nasal decongestant pe oral tablet 30 mg... 175
nasal decongestant spray.......................... 175
nasal four................................................... 158
nasal four spray..........................................158
nasal mist nasal solution............................ 175
nasal mist no drip....................................... 175
NASAL MOIST NASAL SOLUTION...........158
nasal moisturizing spray.............................158
nasal relief..................................................175
nasal spray 12 hour....................................175
nasal spray extra moist.............................. 175
nasal spray extra moisturizing....................175
nasal spray fast acting............................... 158
nasal spray nasal solution 0.05 %..............175
nasal spray nasal solution 1 %...................158
nasal spray no drip.....................................175
nasal spray saline...................................... 158
nasal spray sinus....................................... 175
NASALCROM............................................ 167
NASCOBAL................................................184
NATAZIA.................................................... 114
nateglinide....................................................48
NATESTO.................................................. 110
natural daily fiber........................................101
natural fiber oral capsule 0.52 gm..............101
natural fiber oral powder 28.3 %................ 101
natural fiber oral powder 58.6 %................ 101
natural fiber supplement.............................101
natural senna laxative................................ 103
natural tears pf........................................... 145
natural vegetable........................................101
natural vegetable laxative oral tablet 8.6
mg.............................................................. 103
natural vitamin e.........................................184
natura-lax................................................... 101
nausea control..............................................29
nausea relief oral solution 1.87-1.87-21.5 ...29
NAYZILAM................................................... 25
NEBUSAL INHALATION NEBULIZATION
SOLUTION 3 %..........................................176
necon 0.5/35 (28)....................................... 114
NEODOT THERMOMETER.......................135
neomycin sulfate oral................................... 20
neomycin-bacitracin zn-polymyx................ 141
neomycin-polymyxin-dexameth ophthalmic
ointment..................................................... 140
neomycin-polymyxin-dexameth ophthalmic
suspension 3.5-10000-0.1 .........................140
neomycin-polymyxin-gramicidin................. 141
neomycin-polymyxin-hc otic....................... 146
NEONATAL PLUS....................................... 81
neo-polycin.................................................141
neo-polycin hc............................................ 140
NEOSPORIN ORIGINAL............................. 23
NEO-SYNEPHRINE COLD/ALLRGY EXT.159
nephro vitamins............................................81
NEPHRO-VITE.............................................81
NEULASTA.................................................. 51
NEULASTA ONPRO.................................... 51
NEUPOGEN.................................................52
NEUPRO......................................................40
NEUTEK 2TEK CONTROL.......................... 71
NEUTROGENA OIL-FREE ACNE WASH. 135
NEVANAC..................................................141
nevirapine.....................................................44
nevirapine er................................................ 44
new day......................................................118
NEXIUM ORAL PACKET 2.5 MG, 5 MG..... 87
NEXLETOL.................................................. 58
NEXLIZET.................................................... 58
NEXTSTELLIS............................................. 84
niacin er (antihyperlipidemic)....................... 58
niacin er oral capsule extended release
250 mg......................................................... 81
niacin er oral capsule extended release
500 mg......................................................... 81
niacin er oral tablet extended release 1000
mg................................................................ 81
niacin er oral tablet extended release 250
mg, 500 mg.................................................. 81
niacin oral tablet 100 mg, 250 mg, 50 mg.... 81
NICODERM CQ........................................... 18
NICORETTE................................................ 19
NICORETTE MINI........................................19
NICORETTE STARTER KIT........................ 19
nicotine gum mouth/throat gum 2 mg...........19
nicotine gum mouth/throat gum 4 mg...........19
nicotine gum mouth/throat lozenge 2 mg..... 19
nicotine gum mouth/throat lozenge 4 mg..... 19
nicotine mini................................................. 19
nicotine mouth/throat gum 2 mg...................19
209
nicotine mouth/throat gum 4 mg...................19
nicotine mouth/throat lozenge 2 mg............. 19
nicotine mouth/throat lozenge 4 mg............. 19
nicotine polacrilex mini................................. 19
nicotine polacrilex mouth/throat................... 19
nicotine step 1.............................................. 18
nicotine step 2.............................................. 18
nicotine step 3.............................................. 18
nicotine transdermal patch 24 hour 14
mg/24hr, 7 mg/24hr......................................18
nicotine transdermal patch 24 hour 21
mg/24hr........................................................ 18
nicotine transdermal system........................ 18
nifedipine er..................................................55
nifedipine er osmotic release....................... 55
nifedipine oral...............................................55
night time sleep aid.................................... 180
nighttime dry-eye relief...............................145
nighttime relief lub eye............................... 145
nighttime sleep aid oral tablet 25 mg......... 180
nikki............................................................ 114
nimodipine oral.............................................55
NINLARO..................................................... 36
nitazoxanide oral.......................................... 39
NITRO-BID...................................................58
nitrofurantoin macrocrystal...........................20
nitrofurantoin monohydrate macrocrystals... 20
nitrofurantoin oral suspension 25 mg/5ml.... 21
nitroglycerin rectal........................................ 58
nitroglycerin sublingual.................................58
nitroglycerin translingual.............................. 58
NITYR........................................................ 106
NIVA-PLUS.................................................. 81
NIVESTYM...................................................52
no drip extra moisturizing........................... 176
no drip nasal relief......................................176
no drip nasal spray.....................................176
no drip original 12 hours.............................176
NOCDURNA.............................................. 108
nohist-lq......................................................162
NOKOR VENTED NEEDLE......................... 50
non-aspirin................................................... 13
non-aspirin 8 hour........................................ 13
non-aspirin childrens.................................... 13
non-aspirin extra strength............................ 13
non-aspirin jr strength.................................. 13
non-aspirin pain relief...................................13
non-pseudo sinus decongestant................ 159
nora-be.......................................................117
NORDITROPIN FLEXPRO........................ 108
norelgestromin-eth estradiol.......................114
norethin ace-eth estrad-fe oral tablet......... 114
norethin ace-eth estrad-fe oral tablet
chewable.................................................... 114
norethindrone acetate oral......................... 117
norethindrone acet-ethinyl est....................114
norethindrone oral...................................... 117
norethindron-ethinyl estrad-fe.................... 115
norethin-eth estradiol-fe oral tablet
chewable 0.4-35 mg-mcg...........................115
norgestimate-eth estradiol..........................115
norgestimate-ethinyl estradiol triphasic......115
NORLIQVA...................................................55
norlyroc...................................................... 117
NORPACE CR............................................. 54
nortrel 0.5/35 (28).......................................115
nortrel 1/35 (21)..........................................115
nortrel 1/35 (28)..........................................115
nortrel 7/7/7................................................ 115
nortriptyline hcl oral...................................... 28
NORVIR ORAL PACKET............................. 45
nose drops extstrength...............................159
NOURIANZ.................................................. 40
NOVAREL.................................................. 108
NOVAVAX COVID-19 VACCINE............... 124
NOVOLIN 70/30 FLEXPEN..........................49
NOVOLIN 70/30 RELION.............................49
NOVOLIN 70/30 VIAL.................................. 49
NOVOLIN N FLEXPEN................................ 49
NOVOLIN N RELION................................... 49
NOVOLIN N VIAL.........................................49
NOVOLIN R FLEXPEN................................ 50
NOVOLIN R RELION................................... 50
NOVOLIN R VIAL.........................................50
NOVOLOG FLEXPEN..................................50
NOVOLOG FLEXPEN RELION................... 50
NOVOLOG MIX 70/30 FLEXPEN................ 50
NOVOLOG MIX 70/30 VIAL.........................50
NOVOLOG PENFILL................................... 50
NOVOLOG RELION.....................................50
NOVOLOG U-100 VIAL............................... 50
NUBEQA...................................................... 35
NUCALA SUBCUTANEOUS SOLUTION
AUTO-INJECTOR...................................... 155
NUCALA SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE.............................. 155
NUCYNTA......................................................7
NUCYNTA ER................................................6
NUEDEXTA..................................................60
NU-IRON......................................................77
NULEV....................................................... 135
NURTEC...................................................... 33
NUTRAPLUS............................................... 69
NUTROPIN AQ NUSPIN 10.......................108
NUTROPIN AQ NUSPIN 20.......................108
NUTROPIN AQ NUSPIN 5.........................108
NUVARING................................................ 115
NUZYRA ORAL............................................23
nyamyc.........................................................67
nylia 1/35....................................................115
nylia 7/7/7...................................................115
NYMALIZE................................................... 55
nymyo.........................................................115
nystatin external........................................... 67
nystatin mouth/throat....................................30
nystatin oral..................................................30
nystop...........................................................67
210
NYVEPRIA................................................... 52
OBSTETRIX DHA........................................ 81
OBTREX.................................................... 182
OCEAN FOR KIDS.................................... 159
OCEAN NASAL SPRAY............................ 159
ocella..........................................................115
octreotide acetate injection solution 100
mcg/ml, 50 mcg/ml..................................... 119
octreotide acetate injection solution 1000
mcg/ml........................................................119
octreotide acetate injection solution 200
mcg/ml........................................................119
octreotide acetate injection solution 500
mcg/ml........................................................120
octreotide acetate subcutaneous solution
prefilled syringe 100 mcg/ml, 50 mcg/ml....120
octreotide acetate subcutaneous solution
prefilled syringe 500 mcg/ml...................... 120
ODEFSEY.................................................... 44
ODOMZO..................................................... 37
OFEV......................................................... 154
ofloxacin ophthalmic...................................141
ofloxacin oral................................................ 22
ofloxacin otic.............................................. 146
ointment base...............................................68
olanzapine oral tablet................................... 41
olmesartan medoxomil oral.......................... 53
olmesartan medoxomil-hctz......................... 56
olopatadine hcl ophthalmic.........................140
OLUMIANT ORAL TABLET 1 MG, 2 MG...121
omega-3-acid ethyl esters............................58
omeprazole magnesium...............................88
omeprazole magnesium oral capsule
delayed release............................................88
omeprazole oral capsule delayed release
10 mg, 20 mg, 40 mg................................... 88
omeprazole oral capsule delayed release
20.6 (20 base) mg........................................ 88
OMNARIS.................................................. 152
OMNIFLEX DIAPHRAGM.......................... 135
OMNIPOD 5 G6 INTRO (GEN 5)...............135
OMNIPOD 5 G6 PODS (GEN 5)................135
OMNITROPE............................................. 108
ON/GO COVID-19 ANTIGEN TEST.......... 135
ON/GO ONE COVID-19 HOME TEST.......135
ondansetron hcl oral tablet 4 mg, 8 mg........29
ondansetron odt........................................... 29
ONE VITE WOMENS...................................81
ONE VITE WOMENS PLUS........................ 81
one-daily multi-vitamin/iron........................ 182
one-daily/iron..............................................182
ONELAX.....................................................135
ONELAX DOCUSATE SODIUM................ 104
ONELAX MAGNESIUM CITRATE............. 104
ONELAX SENNA....................................... 104
ONETOUCH ULTRA 2 KIT W/DEVICE....... 71
ONETOUCH ULTRA CONTROL................. 71
ONETOUCH ULTRA IN VITRO LIQUID...... 72
ONETOUCH ULTRA STRIP IN VITRO........72
ONETOUCH ULTRA TEST..........................72
ONETOUCH VERIO FLEX SYSTEM KIT
W/DEVICE................................................... 72
ONETOUCH VERIO IN VITRO LIQUID.......72
ONETOUCH VERIO REFLECT KIT
W/DEVICE................................................... 72
ONETOUCH VERIO STRIP IN VITRO........ 72
ONEXTON................................................... 62
ONGENTYS................................................. 40
opcicon one-step........................................118
OPILL......................................................... 135
OPSUMIT...................................................154
option 2...................................................... 118
OPZELURA..................................................69
ORACEA...................................................... 23
oralone......................................................... 62
ORENCIA CLICKJECT.............................. 121
ORENCIA SUBCUTANEOUS....................121
ORENITRAM MONTH 1............................ 154
ORENITRAM MONTH 2............................ 154
ORENITRAM MONTH 3............................ 154
ORENITRAM ORAL TABLET EXTENDED
RELEASE 0.125 MG, 0.25 MG, 1 MG....... 154
ORENITRAM ORAL TABLET EXTENDED
RELEASE 2.5 MG, 5 MG........................... 154
ORFADIN................................................... 106
ORGOVYX................................................... 20
ORIAHNN...................................................120
ORILISSA...................................................120
ORKAMBI...................................................153
ORLADEYO............................................... 136
orphenadrine citrate er............................... 179
oseltamivir phosphate oral capsule..............45
oseltamivir phosphate oral suspension
reconstituted.................................................45
OSPHENA..................................................118
OTEZLA..................................................... 121
OTREXUP..................................................122
OVACE PLUS WASH EXTERNAL LIQUID136
OVACE WASH...........................................136
OVIDREL................................................... 109
oxaprozin oral tablet.......................................6
oxazepam.....................................................46
oxcarbazepine oral suspension....................25
oxcarbazepine oral tablet............................. 25
oxybutynin chloride er................................ 106
oxybutynin chloride oral tablet 5 mg...........106
oxycodone hcl oral concentrate..................... 7
oxycodone hcl oral solution............................7
oxycodone hcl oral tablet 10 mg, 20 mg...... 16
oxycodone hcl oral tablet 15 mg, 30 mg...... 16
OXYCODONE-ACETAMINOPHEN ORAL
SOLUTION 5-325 MG/5ML............................7
oxycodone-acetaminophen oral tablet 10-
325 mg, 5-325 mg, 7.5-325 mg......................8
OXYCONTIN..................................................6
oxymorphone hcl er........................................6
OXYTROL FOR WOMEN.......................... 106
211
oyster shell calcium oral tablet 500 mg...... 182
oyster shell calcium/d oral tablet 250-3.125
mg-mcg...................................................... 182
oyster shell calcium/vitamin d oral tablet
250-3.125 mg-mcg..................................... 183
OZEMPIC.....................................................48
OZEMPIC (2 MG/DOSE)............................. 48
p col-rite..................................................... 104
pain & fever child..........................................13
pain & fever childrens...................................13
pain & fever childrens oral suspension 160
mg/5ml......................................................... 13
pain & fever infants...................................... 13
pain and fever relief kids.............................. 14
pain relief childrens oral elixir 160 mg/5ml... 14
pain relief childrens oral suspension............ 14
pain relief childrens oral tablet chewable
160 mg......................................................... 14
pain relief extra st.........................................14
pain relief extra strength oral capsule 500
mg................................................................ 14
pain relief extra strength oral liquid 500
mg/15ml....................................................... 14
pain relief extra strength oral tablet 500 mg.14
pain relief oral liquid 500 mg/15ml............... 14
pain relief oral tablet 325 mg........................14
pain relief oral tablet 500 mg........................14
pain relief oral tablet extended release 650
mg................................................................ 14
pain relief regular strength........................... 14
pain relief/rapid burst....................................14
pain reliever childrens oral suspension 160
mg/5ml......................................................... 15
pain reliever ex st oral liquid 500 mg/15ml...15
pain reliever ex st oral tablet 500 mg........... 15
pain reliever extra strength oral tablet 250-
250-65 mg.................................................... 15
pain reliever extra strength oral tablet 500
mg................................................................ 15
pain reliever oral tablet 325 mg....................15
pain reliever oral tablet 500 mg....................15
pain reliever plus.......................................... 15
pain-off......................................................... 15
PANADOL CHILDRENS.............................. 15
PANADOL EXTRA STRENGTH.................. 15
PANADOL INFANTS....................................15
PANOXYL.................................................. 136
pantoprazole sodium oral tablet delayed
release......................................................... 88
paroxetine hcl oral tablet.............................. 27
PATADAY OPHTHALMIC SOLUTION 0.1
%, 0.2 %.....................................................140
PAXLOVID (150/100)...................................46
PAXLOVID (300/100)...................................46
pazopanib hcl............................................. 139
ped electrolyte freeze pop............................77
PEDIA-LAX ORAL LIQUID.........................104
PEDIALYTE FREEZER POPS.....................77
PEDIALYTE ORAL SOLUTION................... 78
PEDIALYTE SINGLES.................................78
PEDIARIX.................................................. 123
pediatric electrolyte oral solution ................78
PEDVAX HIB..............................................123
peg 3350 oral powder................................ 101
peg 3350-kcl-na bicarb-nacl.........................86
peg-3350/electrolytes...................................86
PEGASYS.................................................. 121
PENBRAYA................................................136
penicillamine oral tablet..............................107
penicillin v potassium................................... 21
PENTACEL................................................ 123
pentamidine isethionate inhalation...............39
PENTASA ORAL CAPSULE EXTENDED
RELEASE 250 MG.....................................125
pentazocine-naloxone hcl.............................. 8
pentoxifylline er............................................ 56
PEPCID AC..................................................87
PEPTO-BISMOL ORAL SUSPENSION
524 MG/30ML.............................................. 96
PERDIEM OVERNIGHT RELIEF...............104
PERFOROMIST.........................................153
periogard...................................................... 62
permethrin external...................................... 66
perphenazine oral........................................ 29
perphenazine-amitriptyline oral tablet 2-10
mg, 4-10 mg, 4-25 mg, 4-50 mg...................27
perphenazine-amitriptyline oral tablet 2-25
mg................................................................ 27
PERSERIS................................................... 41
PFIZER COVID-19 VAC-TRIS 5-11Y........ 136
PFIZER COVID-19 VAC-TRIS 6M-4Y....... 136
pharbedryl.................................................. 151
PHARBETOL............................................... 15
PHARBETOL EXTRA STRENGTH..............15
pharbinex................................................... 159
PHAZYME....................................................96
PHAZYME ULTRA STRENGTH.................. 96
PHEBURANE.............................................106
phenazo oral tablet 200 mg........................107
phenazo oral tablet 95 mg..........................107
phenazopyridine hcl oral tablet 100 mg..... 107
phenazopyridine hcl oral tablet 200 mg..... 107
phenazopyridine hcl oral tablet 95 mg....... 107
phenobarbital oral........................................ 25
phenylephrine hcl ophthalmic.....................140
phenylephrine hcl oral................................ 159
phenytek.......................................................25
phenytoin infatabs........................................ 25
phenytoin oral...............................................25
phenytoin sodium extended oral capsule
200 mg, 300 mg........................................... 25
philith..........................................................115
PHOSPHA 250 NEUTRAL...........................78
PHOSPHOLINE IODIDE............................142
phosphorous................................................ 78
phospho-trin 250 neutral.............................. 78
212
PHOSPHO-TRIN K500................................ 78
phytonadione oral.........................................81
pilocarpine hcl ophthalmic..........................142
pilocarpine hcl oral tablet 5 mg.................... 62
pilocarpine hcl oral tablet 7.5 mg................. 62
PILOT COVID-19 AT-HOME TEST........... 136
pimecrolimus................................................ 65
pimozide.......................................................41
pimtrea....................................................... 115
pink bismuth maximum strength.................. 96
pink bismuth oral suspension 262 mg/15ml. 96
pink bismuth oral suspension 525 mg/15ml. 96
pink bismuth oral tablet 262 mg................... 96
pink bismuth oral tablet chewable 262 mg... 96
pink bismuth ultra str.................................... 96
pink-bismuth.................................................97
pioglitazone hcl............................................ 48
PIP GLUCOSE CONTROL SOLUTION.......72
PIQRAY (200 MG DAILY DOSE).................37
PIQRAY (250 MG DAILY DOSE).................37
PIQRAY (300 MG DAILY DOSE).................37
pirfenidone oral capsule............................. 154
pirfenidone oral tablet 267 mg, 801 mg......154
piroxicam oral.................................................6
PLAN B ONE-STEP................................... 118
PLEGRIDY INTRAMUSCULAR................... 61
PLEGRIDY STARTER PACK...................... 61
PLEGRIDY SUBCUTANEOUS.................... 61
PLENVU.......................................................86
plerixafor...................................................... 52
PNEUMOVAX 23....................................... 124
podofilox external solution............................66
poly bacitracin............................................ 136
polycin........................................................ 141
polyethylene glycol 3350 oral powder........ 101
polyethylene glycol 3350-grx oral powder 101
poly-iron 150................................................ 78
polymyxin b-trimethoprim........................... 141
polysaccharide iron complex........................78
polysaccharide-iron complex........................78
POLYSPORIN............................................136
polyvinyl alcohol ophthalmic.......................145
POLY-VI-SOL.............................................183
POLY-VITE PEDIATRIC............................ 183
POMALYST..................................................35
PONVORY................................................. 139
PONVORY STARTER PACK.....................139
portia-28..................................................... 115
potassium chloride crys er oral tablet
extended release 10 meq.............................73
potassium chloride crys er oral tablet
extended release 20 meq.............................73
potassium chloride er oral capsule
extended release 10 meq.............................73
potassium chloride er oral tablet extended
release 10 meq............................................ 74
potassium chloride er oral tablet extended
release 20 meq............................................ 74
potassium chloride er oral tablet extended
release 8 meq.............................................. 74
potassium chloride oral................................ 74
potassium citrate er oral tablet extended
release 10 meq (1080 mg)........................... 74
potassium citrate er oral tablet extended
release 15 meq (1620 mg)........................... 74
potassium citrate er oral tablet extended
release 5 meq (540 mg)............................... 74
potassium citrate-citric acid..........................78
povidone iodine............................................ 23
povidone-iodine external solution.................23
PRADAXA ORAL CAPSULE....................... 51
PRALUENT.................................................. 58
pramipexole dihydrochloride oral tablet
0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 1.5 mg... 40
pramipexole dihydrochloride oral tablet
0.75 mg........................................................ 40
prasugrel hcl.................................................52
pravastatin sodium....................................... 57
praziquantel oral...........................................38
prazosin hcl oral........................................... 53
PRECISION GLUCOSE KETONE CONTR. 72
PRECISION XTRA BLOOD GLUCOSE.......72
prednisolone acetate ophthalmic............... 141
PREDNISOLONE ACETATE P-F.............. 141
prednisolone oral solution.......................... 108
prednisolone sodium phosphate
ophthalmic..................................................141
prednisolone sodium phosphate oral
solution 15 mg/5ml..................................... 108
prednisolone sodium phosphate oral
solution 6.7 (5 base) mg/5ml......................108
prednisone oral solution............................. 108
prednisone oral tablet.................................108
prednisone oral tablet therapy pack 10 mg
(21).............................................................108
prednisone oral tablet therapy pack 10 mg
(48), 5 mg (21), 5 mg (48).......................... 108
pregabalin oral............................................. 61
PREGNYL.................................................. 108
PREHEVBRIO............................................123
PREMARIN ORAL..................................... 115
PREMARIN VAGINAL................................115
PREMPHASE.............................................115
PREMPRO................................................. 115
prenatal formula oral tablet 28-0.8 mg......... 81
prenatal gummy oral tablet chewable 0.4-
113.5 mg.................................................... 183
prenatal gummy oral tablet chewable 0.4-
25 mg........................................................... 81
prenatal multi+dha........................................81
prenatal multivitamins.................................. 82
prenatal oral tablet 27-0.8 mg...................... 82
prenatal oral tablet 27-1 mg......................... 82
prenatal oral tablet 28-0.8 mg...................... 82
prenatal vitamins oral tablet 28-0.8 mg........ 82
prenatal/iron................................................. 82
213
PREPARATION H EXTERNAL CREAM 1
%................................................................ 125
PREVACID 24HR.........................................88
prevalite oral powder....................................58
PREVIDENT.................................................74
PREVIDENT 5000 DRY MOUTH.................74
PREVIDENT 5000 PLUS............................. 74
PREVNAR 20.............................................124
PREZCOBIX................................................ 45
PREZISTA ORAL SUSPENSION.............. 136
PREZISTA ORAL TABLET 150 MG, 75
MG............................................................. 136
PRIFTIN....................................................... 34
primaquine phosphate..................................39
primidone oral tablet 250 mg, 50 mg............25
PRIORIX.................................................... 123
PROAIR RESPICLICK............................... 153
probenecid................................................... 32
probiotic blend..............................................97
probiotic colon care...................................... 97
probiotic complex......................................... 97
probiotic maximum strength......................... 97
probiotic oral capsule................................... 97
probiotic oral capsule 250 mg...................... 97
probiotic pearls ex st.................................... 97
prochlorperazine.......................................... 29
prochlorperazine maleate oral......................29
PROCRIT..................................................... 52
PROCTOFOAM HC..................................... 66
procto-med hc............................................ 125
proctosol hc................................................125
proctozone-hc............................................ 125
progesterone oral....................................... 117
PROLENSA................................................141
PROMACTA.................................................52
promethazine hcl oral...................................29
promethazine hcl rectal................................ 29
promethazine vc.........................................155
promethazine-codeine oral solution........... 176
promethazine-dm....................................... 176
promethegan................................................ 29
PRONUTRIENTS VITAMIN D3....................82
propafenone hcl........................................... 54
propranolol hcl er......................................... 54
propranolol hcl oral solution 20 mg/5ml....... 54
propranolol hcl oral solution 40 mg/5ml....... 54
propranolol hcl oral tablet.............................54
propylthiouracil oral.................................... 120
PROQUAD................................................. 123
PROXIVOL...................................................17
pseudoephedrine hcl 12 hr.........................176
pseudoephedrine hcl er..............................176
pseudoephedrine hcl oral tablet 30 mg...... 176
pseudoephedrine-bromphen-dm................159
pseudoephedrine-guaifenesin er................176
PULMICORT FLEXHALER........................ 152
PULMOSAL................................................176
PULMOZYME............................................ 153
pure & gentle lubricant............................... 145
purelax oral powder....................................101
PYLERA....................................................... 86
pyrazinamide oral.........................................34
PYRIDIUM..................................................107
pyridostigmine bromide er............................34
pyridostigmine bromide oral solution............34
pyridostigmine bromide oral tablet 60 mg.... 34
pyridoxine hcl oral...................................... 184
pyrimethamine oral.......................................39
QELBREE.................................................... 46
QNASL....................................................... 152
QNASL CHILDRENS................................. 152
QTERN.........................................................48
QUADRACEL INTRAMUSCULAR
SUSPENSION............................................123
quetiapine fumarate..................................... 41
quetiapine fumarate er................................. 41
QUICKVUE AT-HOME COVID-19 TEST... 136
quinapril hcl.................................................. 53
quinapril-hydrochlorothiazide....................... 56
quinidine gluconate er.................................. 54
quinidine sulfate........................................... 54
QUINTET CONTROL HIGH/NORMAL........ 72
quit2............................................................. 19
quit4............................................................. 20
QULIPTA......................................................33
QUVIVIQ.................................................... 136
QVAR REDIHALER................................... 152
radiance platinum vitamin d3....................... 82
RADICAVA ORS.......................................... 60
RADICAVA ORS STARTER KIT..................60
raloxifene hcl.............................................. 118
ramipril......................................................... 53
ranolazine er................................................ 56
RASUVO.................................................... 122
RAVICTI..................................................... 106
RAYALDEE................................................ 125
react........................................................... 118
ready-to-use enema rectal enema ............. 97
REBIF...........................................................61
REBIF REBIDOSE....................................... 61
REBIF REBIDOSE TITRATION PACK........ 61
REBIF TITRATION PACK............................61
reclipsen.....................................................115
RECOMBIVAX HB..................................... 123
refenesen 400............................................ 159
REFRESH LACRI-LUBE............................145
REFRESH PLUS........................................145
REFRESH TEARS..................................... 145
reguloid oral powder 43 %......................... 101
REHYDRALYTE...........................................78
RELENZA DISKHALER............................... 45
RELEUKO.................................................... 52
relief eye drops...........................................145
RELION TRUE METRIX TEST STRIPS...... 72
RELISTOR SUBCUTANEOUS.................... 85
rena-vite....................................................... 82
renewal soothing bath.................................. 68
214
repaglinide....................................................48
REPATHA.................................................... 58
rest simply.................................................. 180
RESTASIS................................................. 140
RESTASIS MULTIDOSE........................... 140
RESTORA....................................................97
restore plus lubricant eye........................... 145
restore pm.................................................. 145
RETACRIT................................................... 52
RETEVMO................................................. 139
RETIN-A MICRO PUMP EXTERNAL GEL
0.06 %.......................................................... 62
RETIN-A MICRO PUMP EXTERNAL GEL
0.08 %.......................................................... 62
REVLIMID.................................................... 35
REXULTI...................................................... 41
REYATAZ ORAL PACKET.......................... 45
REYVOW..................................................... 33
REZVOGLAR KWIKPEN............................. 50
RHOPRESSA.............................................142
ribavirin oral..................................................43
rifabutin........................................................ 34
rifampin oral................................................. 34
riluzole..........................................................60
rimantadine hcl.............................................45
RINVOQ..................................................... 121
RISAQUAD.................................................. 97
RISAQUAD-2............................................... 97
RISPERDAL CONSTA.................................41
risperidone microspheres er.........................41
risperidone oral solution............................... 41
risperidone oral tablet...................................42
ritonavir........................................................ 45
rivastigmine.................................................. 26
rivastigmine tartrate......................................26
rizatriptan benzoate......................................33
ROBAFEN CF MULTI-SYMPTOM COLD..162
ROBITUSSIN 12 HOUR COUGH.............. 176
ROBITUSSIN 12 HOUR COUGH CHILD.. 176
ROBITUSSIN COUGH+CHEST CONG
DM ORAL LIQUID 20-400 MG/20ML.........176
ROBITUSSIN PEAK COLD MULTI-SYM...162
ROCKLATAN............................................. 140
ropinirole hcl.................................................40
rosuvastatin calcium.....................................57
ROTARIX................................................... 123
ROTATEQ..................................................123
roweepra...................................................... 24
ROXYBOND ORAL TABLET ABUSE-
DETERRENT 15 MG, 30 MG, 5 MG..............6
ROZLYTREK ORAL CAPSULE................... 37
ROZLYTREK PACKET 50 MG ORAL..........37
RUBRACA....................................................37
RUCONEST............................................... 121
rufinamide.................................................... 25
RYALTRIS..................................................136
RYBELSUS.................................................. 48
RYDAPT.......................................................37
RYKINDO.....................................................42
rynex dm.................................................... 177
rynex pe..................................................... 177
rynex pse....................................................177
RYTARY ORAL CAPSULE EXTENDED
RELEASE 23.75-95 MG, 36.25-145 MG,
61.25-245 MG.............................................. 40
RYTARY ORAL CAPSULE EXTENDED
RELEASE 48.75-195 MG.............................40
saccharomyces boulardii..............................97
SAFYRAL...................................................115
sajazir.........................................................121
saline enema................................................97
saline mist spray........................................ 159
saline nasal spray...................................... 159
salsalate oral................................................ 16
SANCUSO................................................... 29
SANTYL....................................................... 66
sapropterin dihydrochloride........................106
SAVAYSA.................................................... 51
saxagliptin hcl...............................................48
sb arthritis pain relief.................................... 15
sb docusate sodium/senna........................ 104
sb lice killing max st..................................... 40
sb mucus relief........................................... 159
sb pain reliever childrens............................. 15
scalp relief external liquid 3 %....................136
SCEMBLIX................................................... 38
SCRUB CARE POVIDONE-IODINE............ 23
SEGLENTIS................................................... 8
SEGLUROMET............................................ 48
selegiline hcl oral..........................................40
selenium sulfide external lotion.................... 65
SELZENTRY ORAL SOLUTION..................45
SEMGLEE (YFGN)...................................... 50
senexon-s...................................................104
senior probiotic.............................................97
senna lax....................................................104
senna laxative............................................ 104
senna oral liquid......................................... 104
senna oral syrup.........................................104
senna oral tablet.........................................104
senna plus oral tablet................................. 104
senna s.......................................................104
senna smooth.............................................104
senna-docusate sodium............................. 104
senna-lax....................................................104
senna-plus..................................................104
senna-s...................................................... 104
senna-tabs................................................. 104
senna-time................................................. 104
senna-time s...............................................104
sennazon....................................................104
SENOKOT..................................................105
SENOKOT S.............................................. 105
SENTIA...................................................... 145
SEREVENT DISKUS................................. 153
sertraline hcl oral concentrate...................... 27
sertraline hcl oral tablet................................ 27
215
setlakin....................................................... 115
sevelamer carbonate oral tablet...................79
sf.................................................................. 74
sf 5000 plus..................................................74
SFROWASA...............................................125
sharobel..................................................... 117
SHINGRIX..................................................123
SIGNIFOR..................................................120
siladryl allergy............................................ 151
sildenafil citrate oral suspension
reconstituted...............................................154
sildenafil citrate oral tablet 20 mg...............154
siltussin sa..................................................159
silver sulfadiazine external........................... 66
SIMBRINZA................................................142
simethicone oral capsule..............................97
simethicone oral tablet chewable................. 97
simethicone ultra strength............................ 97
simliya........................................................ 115
simpesse.................................................... 115
SIMPLY SLEEP......................................... 180
SIMPONI.................................................... 122
simvastatin oral............................................ 57
sinus 12 hour..............................................177
sinus 12-hour............................................. 177
sinus congestion max strength...................177
sinus nasal spray....................................... 177
sinus pe decongestant............................... 159
sinus relief extra strength........................... 159
sinus/congestion relief pe...........................159
sirolimus oral solution.................................122
sirolimus oral tablet 0.5 mg, 1 mg.............. 122
sirolimus oral tablet 2 mg........................... 122
SIRTURO..................................................... 34
SKYRIZI PEN.............................................121
SKYRIZI SUBCUTANEOUS SOLUTION
CARTRIDGE.............................................. 136
SKYRIZI SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE.............................. 121
SKYTROFA................................................109
sleep aid (diphenhydramine)......................180
sleep aid nighttime..................................... 180
sleep aid oral tablet 25 mg......................... 180
sleep tabs...................................................180
SLO-NIACIN.................................................82
smooth antacid ex st oral tablet chewable
750 mg......................................................... 97
smooth antacid extra st................................ 97
smooth antacid extra strength......................98
smooth lax oral powder.............................. 101
SOAANZ ORAL TABLET 20 MG................. 56
sod chloride hypertonicity...........................145
sod citrate-citric acid oral solution 500-334
mg/5ml......................................................... 78
sodium bicarbonate oral tablet..................... 98
sodium chloride (hypertonic) ophthalmic
ointment..................................................... 145
sodium chloride (hypertonic) ophthalmic
solution.......................................................145
sodium chloride inhalation nebulization
solution 0.9 %, 10 %.................................. 177
sodium chloride inhalation nebulization
solution 3 %................................................177
sodium chloride inhalation nebulization
solution 7 %................................................177
sodium chloride ophthalmic ointment 5 %..145
sodium chloride ophthalmic solution 5 %... 145
sodium fluoride 5000 plus............................ 74
sodium fluoride 5000 ppm dental cream...... 74
sodium fluoride dental cream....................... 74
sodium fluoride dental gel............................ 74
sodium fluoride oral solution........................ 74
sodium fluoride oral tablet chewable............74
SODIUM OXYBATE...................................180
sodium phenylbutyrate oral powder........... 106
sodium sulfacetamide wash....................... 136
SOFOSBUVIR-VELPATASVIR....................43
soft glucose.................................................. 50
solifenacin succinate.................................. 106
SOLIQUA..................................................... 48
SOLOSEC....................................................21
soluble fiber therapy...................................105
SOMAVERT............................................... 120
SOOLANTRA............................................... 66
soothe maximum strength............................98
soothe oral suspension................................ 98
soothe oral tablet chewable......................... 98
sorafenib tosylate......................................... 37
sorbitol oral.................................................101
sotalol hcl (af)...............................................54
sotalol hcl oral.............................................. 54
SOVALDI ORAL TABLET............................ 43
SOVUNA ORAL TABLET 200 MG...............39
SPEEDY SWAB COVID-19 ANTIGEN...... 136
SPIKEVAX................................................. 136
spinosad.......................................................66
SPIRIVA HANDIHALER.............................152
SPIRIVA RESPIMAT..................................152
spironolactone oral tablet............................. 57
spironolactone-hctz...................................... 56
sprintec 28..................................................116
SPRYCEL.................................................. 139
SPS.............................................................. 79
sronyx.........................................................116
ssd................................................................66
sss 10-5 external cream...............................68
ST JOSEPH LOW DOSE...........................136
STEGLATRO............................................... 48
STEGLUJAN................................................ 48
STELARA SUBCUTANEOUS....................121
stimulant lax plus........................................105
stimulant laxative........................................105
STIOLTO RESPIMAT................................ 166
STIVARGA................................................... 37
stomach relief extra strength........................98
stomach relief max st oral suspension 525
mg/15ml....................................................... 98
216
stomach relief oral suspension 1050
mg/30ml, 525 mg/15ml.................................98
stomach relief oral suspension 262
mg/15ml, 525 mg/30ml, 527 mg/30ml..........98
stomach relief oral tablet 262 mg................. 98
stomach relief oral tablet chewable 262 mg.98
stomach relief plus....................................... 98
stomach relief ultra oral suspension 525
mg/15ml....................................................... 98
stool softener laxative oral capsule............ 105
stool softener oral capsule 100 mg............ 105
stool softener oral capsule 240 mg............ 105
stool softener oral capsule 250 mg............ 105
stool softener oral capsule 50 mg.............. 105
stool softener pls laxative...........................105
stool softener plus laxative.........................105
stool softener/laxative................................ 105
stool softener/laxative oral tablet................105
STRENSIQ.................................................106
stress formula/iron......................................183
STRIBILD..................................................... 43
STRIVE DUAL ZONE PEAK FLOW MTR..136
STRIVERDI RESPIMAT.............................153
SUBOXONE.................................................17
subvenite......................................................24
subvenite starter kit-blue.............................. 24
subvenite starter kit-green............................24
subvenite starter kit-orange..........................24
sucralfate oral suspension........................... 87
sucralfate oral tablet.....................................87
SUDAFED.................................................. 177
SUDAFED PE CONGESTION ORAL
TABLET 10 MG..........................................160
SUDAFED PE SINUS CONGESTION....... 160
SUDAFED SINUS CONGESTION.............177
SUDAFED SINUS CONGESTION 12HR...177
sudogest 12 hour....................................... 177
sudogest maximum strength...................... 177
sudogest oral tablet 30 mg.........................177
sulfacetamide sodium external...................136
sulfacetamide sodium ophthalmic.............. 141
sulfacetamide sodium-sulfur external
cream 10-5 %...............................................68
sulfacetamide sodium-sulfur external liquid
9-4.5 %.........................................................69
sulfacetamide sod-sulfur wash external
liquid 9-4.5 %............................................... 69
sulfacetamide-prednisolone....................... 140
sulfamethoxazole-trimethoprim oral............. 22
sulfamez wash............................................. 69
sulfasalazine oral....................................... 125
sulfatrim pediatric......................................... 22
sulindac oral................................................... 6
SUMADAN WASH....................................... 69
sumatriptan nasal.........................................33
sumatriptan succinate oral........................... 33
sumatriptan succinate refill...........................33
sumatriptan succinate subcutaneous...........33
sunitinib malate oral capsule 12.5 mg, 25
mg, 50 mg.................................................... 37
sunitinib malate oral capsule 37.5 mg..........37
SUNOSI..................................................... 180
suphedrine 12hour..................................... 178
suphedrine maximum strength...................178
suphedrine oral tablet 30 mg......................178
suphedrine oral tablet extended release 12
hour 120 mg............................................... 178
SUPPORT..................................................183
SUPREP BOWEL PREP KIT....................... 86
sure result sr relief......................................136
SUTAB......................................................... 23
syeda..........................................................116
SYMBICORT..............................................166
SYMDEKO................................................. 153
SYMFI.......................................................... 44
SYMFI LO.................................................... 44
SYMLINPEN 120......................................... 48
SYMLINPEN 60........................................... 48
SYMPAZAN................................................. 25
SYMPROIC.................................................. 85
SYMTUZA.................................................... 45
SYNAGIS................................................... 121
SYNJARDY.................................................. 48
SYNJARDY XR............................................ 48
SYSTANE.................................................. 145
SYSTANE BALANCE.................................145
SYSTANE COMPLETE..............................146
SYSTANE CONTACTS..............................146
SYSTANE HYDRATION PF.......................146
SYSTANE NIGHTTIME..............................146
SYSTANE PRESERVATIVE FREE........... 146
SYSTANE ULTRA......................................146
SYSTANE ULTRA PF................................ 146
tab tussin....................................................160
TABLOID......................................................36
TABRECTA................................................ 139
TACLONEX..................................................66
tacrolimus external ointment 0.03 %............ 65
tacrolimus external ointment 0.1 %.............. 65
tacrolimus oral capsule 0.5 mg, 5 mg........ 122
tacrolimus oral capsule 1 mg..................... 122
TADLIQ...................................................... 154
TAFINLAR ORAL CAPSULE....................... 37
TAFINLAR ORAL TABLET SOLUBLE.........37
TAGAMET HB 200.......................................87
TAGRISSO.................................................139
take action..................................................118
TALICIA........................................................86
TALTZ........................................................ 121
tamoxifen citrate oral....................................35
tamsulosin hcl............................................ 107
tarina 24 fe................................................. 116
tarina fe 1/20 eq......................................... 116
TASIGNA................................................... 139
TAVALISSE..................................................52
taztia xt.........................................................55
TDVAX....................................................... 123
217
TEGRETOL ORAL SUSPENSION.............. 25
TEGSEDI................................................... 106
TEKTURNA..................................................56
telmisartan....................................................53
temazepam oral capsule 15 mg, 30 mg..... 179
temozolomide oral capsule 100 mg, 140
mg................................................................ 35
temozolomide oral capsule 180 mg, 20 mg,
250 mg, 5 mg............................................... 35
TENCON........................................................ 8
TENIVAC....................................................123
tenofovir disoproxil fumarate........................ 44
terazosin hcl............................................... 107
terbinafine hcl external................................. 32
terbinafine hcl oral........................................30
terbinafine hydrochloride external cream 1
%.................................................................. 32
terconazole vaginal cream........................... 30
teriflunomide.................................................61
TERIPARATIDE (RECOMBINANT)
SUBCUTANEOUS SOLUTION PEN-
INJECTOR 620 MCG/2.48ML....................125
TESTIM...................................................... 110
testosterone cypionate intramuscular........ 110
testosterone enanthate intramuscular........110
testosterone transdermal gel 1.62 %, 20.25
mg/act (1.62%)...........................................110
testosterone transdermal gel 12.5 mg/act
(1%)............................................................110
testosterone transdermal gel 20.25
mg/1.25gm (1.62%), 25 mg/2.5gm (1%).... 110
testosterone transdermal gel 40.5
mg/2.5gm (1.62%)......................................110
TETANUS-DIPHTHERIA TOXOIDS TD.... 123
tetrabenazine............................................... 60
TEZSPIRE SUBCUTANEOUS SOLUTION
AUTO-INJECTOR...................................... 155
tgt clotrimazole external cream 1 %............. 67
THALOMID...................................................35
the magic bullet.......................................... 136
THEO-24.................................................... 154
theophylline er oral tablet extended release
12 hour 300 mg.......................................... 154
theophylline er oral tablet extended release
12 hour 450 mg.......................................... 154
theophylline er oral tablet extended release
24 hour 400 mg.......................................... 154
theophylline er oral tablet extended release
24 hour 600 mg.......................................... 154
theophylline oral......................................... 154
thiamine hcl oral......................................... 184
thiamine mononitrate oral.............................82
THIOLA...................................................... 107
THIOLA EC................................................ 107
thioridazine hcl oral...................................... 41
thiothixene....................................................41
THRIVE........................................................ 20
tiadylt er........................................................55
tiagabine hcl................................................. 25
TIBSOVO..................................................... 37
tilia fe..........................................................116
timolol maleate ophthalmic solution........... 142
TIMOPTIC OCUDOSE...............................142
TINACTIN EXTERNAL CREAM.................137
tinidazole oral tablet 250 mg........................ 21
tinidazole oral tablet 500 mg........................ 21
TIROSINT ORAL CAPSULE 100 MCG,
112 MCG, 125 MCG, 13 MCG, 137 MCG,
150 MCG, 175 MCG, 200 MCG, 25 MCG,
50 MCG, 75 MCG, 88 MCG....................... 118
TIROSINT-SOL.......................................... 118
TIVICAY....................................................... 43
TIVICAY PD................................................. 43
tizanidine hcl oral tablet................................42
TOBI PODHALER...................................... 153
TOBRADEX............................................... 140
TOBRADEX ST..........................................140
tobramycin inhalation nebulization solution
300 mg/4ml................................................ 153
tobramycin ophthalmic............................... 141
tobramycin-dexamethasone.......................140
tolcapone......................................................40
tolnaftate antifungal external cream........... 137
tolnaftate external cream............................137
tolnaftate external powder..........................137
tolterodine tartrate...................................... 106
tolterodine tartrate er..................................106
TOPAMAX....................................................24
TOPAMAX SPRINKLE.................................24
topiramate oral capsule sprinkle.................. 24
topiramate oral tablet................................... 24
toremifene citrate......................................... 35
torsemide..................................................... 56
total allergy.................................................151
total allergy medicine................................. 151
TOUJEO MAX SOLOSTAR......................... 50
TOUJEO SOLOSTAR.................................. 50
TRACLEER................................................ 154
TRADJENTA................................................ 48
tramadol hcl oral tablet 50 mg........................8
trandolapril................................................... 53
tranexamic acid oral..................................... 52
tranylcypromine sulfate................................ 27
travel ease....................................................29
TRAZIMERA INTRAVENOUS SOLUTION
RECONSTITUTED 150 MG.......................139
trazodone hcl oral tablet 100 mg, 150 mg,
50 mg........................................................... 27
TRECATOR................................................. 34
TRELEGY ELLIPTA................................... 166
TREMFYA.................................................. 121
TRESIBA......................................................50
TRESIBA FLEXTOUCH............................... 50
tretinoin external cream................................62
tretinoin oral................................................. 38
TREXALL................................................... 122
218
TREZIX.......................................................... 8
triamcinolone acetonide external cream...... 65
triamcinolone acetonide external lotion
0.025 %........................................................ 65
triamcinolone acetonide external lotion 0.1
%.................................................................. 65
triamcinolone acetonide external ointment
0.025 %, 0.1 %, 0.5 %..................................65
triamcinolone acetonide mouth/throat.......... 62
triamcinolone acetonide nasal....................166
TRIAMINIC ALLERCHEWS....................... 165
triamterene-hctz........................................... 56
triazolam.....................................................179
triderm.......................................................... 65
trientine hcl oral capsule 250 mg................. 79
tri-estarylla..................................................116
trifluoperazine hcl......................................... 41
trifluridine....................................................141
trihexyphenidyl hcl........................................40
TRIJARDY XR..............................................48
TRIKAFTA ORAL TABLET THERAPY
PACK......................................................... 153
TRIKAFTA ORAL THERAPY PACK.......... 153
tri-legest fe................................................. 116
tri-linyah......................................................116
tri-lo-estarylla..............................................116
tri-lo-marzia................................................ 116
trimethobenzamide hcl oral.......................... 29
trimethoprim oral.......................................... 21
tri-mili..........................................................116
TRINTELLIX.................................................27
tri-nymyo.................................................... 116
triple antibiotic external ointment , 3.5-400-
5000 , 5-400-5000 , 5-400-5000 mg-unit..... 23
triple antibiotic original..................................23
TRIPTODUR.............................................. 120
tri-sprintec.................................................. 116
TRIUMEQ.....................................................44
TRIUMEQ PD...............................................44
tri-vite pediatric.............................................82
trivora (28)..................................................116
tri-vylibra.....................................................116
tri-vylibra lo.................................................116
TROKENDI XR.............................................24
trospium chloride........................................106
TRUE COVER............................................137
TRUE FERROUS SULFATE........................78
TRUE FOLIC ACID ORAL TABLET 400
MCG...........................................................137
true folic acid tablet 1 mg oral.................... 137
TRUE FOLIC ACID TABLET 1 MG ORAL. 137
TRUE MAGNESIUM OXIDE ORAL
TABLET 500 MG..........................................78
true magnesium oxide tablet 400 mg oral.... 78
TRUE MAGNESIUM OXIDE TABLET 400
MG ORAL.....................................................78
TRUE NASAL MOISTURIZING................. 160
TRUE VITAMIN A........................................ 82
TRUE VITAMIN B1 ORAL TABLET 100
MG............................................................... 82
TRUE VITAMIN B3 ORAL TABLET 100
MG, 250 MG, 50 MG....................................82
TRUE VITAMIN B6 ORAL TABLET 25 MG,
50 MG........................................................ 184
true vitamin b6 tablet 100 mg oral..............184
TRUE VITAMIN B6 TABLET 100 MG
ORAL......................................................... 184
TRUE VITAMIN C ORAL TABLET 250 MG
....................................................................183
TRUE VITAMIN C ORAL TABLET 500 MG
....................................................................183
true vitamin c tablet 1000 mg oral.............. 183
TRUE VITAMIN C TABLET 1000 MG
ORAL......................................................... 183
TRUE VITAMIN D3 ORAL CAPSULE 1.25
MG (50000 UT)............................................ 82
TRUE VITAMIN D3 ORAL CAPSULE 10
MCG (400 UNIT).......................................... 82
TRUE VITAMIN D3 ORAL CAPSULE 125
MCG (5000 UT), 25 MCG (1000 UT)........... 82
TRUE VITAMIN D3 ORAL CAPSULE 250
MCG (10000 UT)..........................................82
TRUE VITAMIN D3 ORAL TABLET 10
MCG (400 UNIT).......................................... 82
TRUE VITAMIN D3 ORAL TABLET 125
MCG (5000 UT)............................................83
TRUE VITAMIN D3 ORAL TABLET 25
MCG (1000 UT)............................................83
TRUE VITAMIN E ORAL CAPSULE 450
MG, 90 MG.................................................184
TRUECONTROL GLUCOSE CONT LEV 0. 72
TRUECONTROL GLUCOSE CONT LEV 1. 72
TRUEPLUS GLUCOSE ON THE GO.......... 50
TRUEPLUS GLUCOSE ORAL TABLET
CHEWABLE................................................. 50
TRULANCE..................................................85
TRULICITY...................................................48
TRUMENBA............................................... 124
TUMS........................................................... 98
TUMS CHEWY BITES................................. 98
TUMS E-X 750............................................. 98
TUMS EXTRA STRENGTH 750.................. 99
TUMS LASTING EFFECTS......................... 99
TUMS SMOOTHIES.................................... 99
TUMS ULTRA 1000..................................... 99
TURALIO....................................................139
turqoz......................................................... 116
tusnel-ex.....................................................160
tussin adult chest congest..........................160
tussin cf oral liquid 30-10-100 mg/5ml....... 178
tussin cf oral liquid 5-10-100 mg/5ml......... 162
tussin chest congestion oral liquid 100
mg/5ml....................................................... 160
tussin cough dm sugar free........................178
tussin cough long acting.............................160
tussin cough oral syrup.............................. 160
219
tussin cough/chest congest oral syrup 100-
10 mg/5ml.................................................. 178
tussin cough/chest dm max oral liquid 10-
200 mg/5ml................................................ 178
tussin cough/chest dm max oral liquid 20-
400 mg/20ml.............................................. 178
tussin dm cough + chest oral liquid 20-400
mg/20ml..................................................... 178
tussin dm cough/chest cong.......................178
tussin dm cough/chest oral syrup 10-100
mg/5ml....................................................... 178
tussin dm max............................................ 178
tussin dm max adult................................... 178
tussin dm max daytime.............................. 179
tussin dm max st........................................ 179
tussin dm oral syrup 100-10 mg/5ml.......... 179
tussin expectorant adult............................. 160
tussin maximum strength oral syrup 15
mg/5ml....................................................... 160
tussin mucus & chest cong........................ 160
tussin mucus & chest congest....................160
tussin mucus/chest congest....................... 160
tussin mucus/congestion............................160
tussin mucus+chest congest......................161
tussin mucus+chest congestion................. 161
tussin multi-symptom cold cf...................... 162
tussin oral liquid 100 mg/5ml......................161
TWINRIX.................................................... 124
TYBLUME.................................................. 116
TYBOST.......................................................45
TYLENOL FOR CHILDREN + ADULTS.......16
TYLENOL ORAL SUSPENSION 160
MG/5ML....................................................... 16
TYLENOL ORAL TABLET 325 MG, 500
MG............................................................... 16
TYLENOL ORAL TABLET CHEWABLE
160 MG........................................................ 16
TYLENOL ORAL TABLET EXTENDED
RELEASE 650 MG.......................................16
TYMLOS.................................................... 125
TYRVAYA.................................................. 140
TYVASO DPI MAINTENANCE KIT............154
TYVASO DPI TITRATION KIT................... 154
UBRELVY.................................................... 33
UCERIS......................................................125
UDENYCA....................................................52
UDENYCA ONBODY................................... 52
ultra calcium + vitamin d3.............................78
ultra fresh................................................... 146
ultra fresh pm............................................. 146
ultra lubricant drop..................................... 146
ultra lubricating eye drops.......................... 146
ultra lubricating eye drops pf...................... 146
unithroid..................................................... 118
urea 20 intensive hydrating.......................... 69
urea cream 20 % external (otc)....................69
urea cream 20 % external (rx)......................69
urea external cream 10 %............................ 69
urea external lotion 10 %............................. 69
urea external lotion 40 %............................. 69
ureacin-10.................................................... 69
ureacin-20.................................................... 69
urinary pain relief oral tablet 95 mg............107
URO-PAIN..................................................107
ursodiol oral capsule 300 mg....................... 86
ursodiol oral tablet........................................86
UZEDY SUBCUTANEOUS SUSPENSION
PREFILLED SYRINGE 100 MG/0.28ML......42
valacyclovir hcl oral...................................... 43
valganciclovir hcl oral tablet......................... 42
valproic acid oral.......................................... 24
valsartan oral tablet......................................53
valsartan-hydrochlorothiazide...................... 56
VALTOCO 10 MG DOSE............................. 25
VALTOCO 15 MG DOSE............................. 25
VALTOCO 20 MG DOSE............................. 25
VALTOCO 5 MG DOSE............................... 25
vancomycin hcl oral solution reconstituted
25 mg/ml...................................................... 21
VANDAZOLE............................................... 21
VAPORIZER WARM STEAM.....................137
VAQTA....................................................... 124
varenicline tartrate........................................18
varenicline tartrate (starter).......................... 18
varenicline tartrate(continue)........................18
VARIVAX....................................................124
VASCEPA.................................................... 58
VAXELIS.................................................... 137
VAXNEUVANCE........................................ 124
VECTICAL....................................................66
vegetable lax+stool softener...................... 105
vegetable laxative...................................... 105
velivet......................................................... 116
VELPHORO................................................. 79
VELTASSA...................................................79
VENCLEXTA................................................37
VENCLEXTA STARTING PACK..................37
venlafaxine hcl............................................. 27
venlafaxine hcl er oral capsule extended
release 24 hour............................................ 27
VENTOLIN HFA......................................... 153
verapamil hcl er oral capsule extended
release 24 hour 120 mg, 180 mg, 240 mg,
360 mg......................................................... 55
verapamil hcl er oral tablet extended
release......................................................... 55
verapamil hcl oral......................................... 55
VERKAZIA................................................. 140
VERQUVO................................................... 58
VERZENIO...................................................37
vestura....................................................... 116
VIBERZI....................................................... 85
VICTOZA......................................................48
vienva.........................................................116
vigabatrin oral packet................................... 25
vigadrone oral packet...................................25
220
vigpoder....................................................... 25
viorele.........................................................116
VIRACEPT................................................... 45
VIREAD ORAL POWDER............................44
VIREAD ORAL TABLET 150 MG, 200 MG,
250 MG........................................................ 45
VISBIOME HIGH POTENCY ORAL
CAPSULE.................................................... 99
VISINE....................................................... 146
vit c/rose hips............................................. 183
vitachew multiple vitamin........................... 137
vitachew vitamin d3......................................83
vitamin a oral capsule 2400 mcg (8000 ut),
3 mg, 3 mg (10000 ut)..................................83
vitamin b complex oral capsule.................... 83
vitamin b complex w/b-12.............................83
vitamin b1...................................................185
vitamin b-1 oral tablet 100 mg......................83
vitamin b-1 oral tablet 250 mg....................185
vitamin b-12 er oral tablet extended
release 1000 mcg.......................................185
vitamin b12 oral tablet extended release
1000 mcg................................................... 185
vitamin b-12 tr oral tablet extended release
1000 mcg................................................... 185
vitamin b-6..................................................185
vitamin b-6 er............................................. 185
vitamin c cr oral tablet extended release
500 mg....................................................... 183
vitamin c er oral tablet extended release
1500 mg..................................................... 183
vitamin c oral liquid 500 mg/5ml.................183
vitamin c oral tablet 1000 mg, 250 mg....... 183
vitamin c oral tablet 500 mg....................... 183
vitamin c oral tablet chewable 100 mg, 250
mg.............................................................. 183
vitamin c oral tablet chewable 500 mg....... 183
vitamin c/acerola........................................ 183
vitamin c/rose hips oral tablet 1000 mg......184
vitamin c/rose hips oral tablet 500 mg........184
vitamin c-rose hips..................................... 184
vitamin c-rose hips oral tablet.................... 184
vitamin d (cholecalciferol) oral tablet 10
mcg (400 unit).............................................. 83
vitamin d (cholecalciferol) oral tablet 25
mcg (1000 ut)............................................... 83
vitamin d (ergocalciferol) oral capsule 1.25
mg (50000 ut), 50000 unit.......................... 184
vitamin d oral capsule 25 mcg (1000 ut)...... 83
vitamin d oral liquid...................................... 83
vitamin d oral tablet chewable 10 mcg (400
unit).............................................................. 83
vitamin d3 oral capsule 1.25 mg (50000 ut). 83
vitamin d3 oral capsule 125 mcg (5000 ut).. 83
vitamin d-3 oral capsule 125 mcg (5000 ut). 83
vitamin d3 oral capsule 25 mcg (1000 ut).... 83
vitamin d3 oral capsule 250 mcg (10000 ut) 84
vitamin d3 oral capsule 50 mcg (2000 ut).... 84
vitamin d-3 oral capsule 50 mcg (2000 ut)... 84
vitamin d3 oral liquid 10 mcg/ml...................84
vitamin d3 oral tablet 10 mcg (400 unit)....... 84
vitamin d3 oral tablet 125 mcg (5000 ut)......84
vitamin d3 oral tablet 25 mcg (1000 ut)........84
vitamin d-3 oral tablet 25 mcg (1000 ut).......84
vitamin d3 oral tablet 50 mcg (2000 ut)........84
vitamin d3 oral tablet chewable 10 mcg
(400 unit)...................................................... 84
vitamin d3 oral tablet chewable 25 mcg
(1000 ut).......................................................84
vitamin d-400 oral tablet 10 mcg (400 unit)..84
vitamin e natural.........................................185
vitamin e oral capsule 134 mg (200 unit),
45 mg (100 unit), 450 mg (1000 ut), 90 mg
(200 unit).................................................... 185
vitamin e oral capsule 268 mg (400 unit)... 185
vitamin-b complex........................................ 84
vitamins complete childrens....................... 184
VITRAKVI.....................................................37
VIVAGUARD INO CONTROL SOLUTION...73
VIVELLE-DOT............................................116
VIVJOA...................................................... 137
volnea.........................................................116
VOQUEZNA DUAL PAK............................ 137
VOQUEZNA TRIPLE PAK........................... 85
voriconazole oral tablet................................ 30
VOSEVI........................................................43
VRAYLAR.................................................... 42
VRAYLAR ORAL CAPSULE THERAPY
PACK 1.5 & 3 MG........................................ 42
VTAMA.......................................................137
VUMERITY...................................................61
vyfemla.......................................................116
vylibra.........................................................116
VYNDAMAX............................................... 106
VYNDAQEL................................................106
VYVANSE ORAL CAPSULE........................60
VYZULTA................................................... 140
WAKIX........................................................180
warfarin sodium oral tablet 1 mg, 10 mg, 2
mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 7.5 mg........ 51
warfarin sodium oral tablet 6 mg.................. 51
wart remover external liquid 17 %..............137
wart remover maximum strength external
liquid...........................................................137
weekly-d....................................................... 84
wera........................................................... 116
wes-phos 250 neutral...................................78
WESTAB PLUS............................................84
WIDE-SEAL DIAPHRAGM 60....................137
WIDE-SEAL DIAPHRAGM 65....................137
WIDE-SEAL DIAPHRAGM 70....................137
WIDE-SEAL DIAPHRAGM 75....................137
WIDE-SEAL DIAPHRAGM 80....................137
WIDE-SEAL DIAPHRAGM 85....................137
WIDE-SEAL DIAPHRAGM 90....................137
WIDE-SEAL DIAPHRAGM 95....................137
WINLEVI.................................................... 137
221
wixela inhub............................................... 166
womans laxative.........................................137
womens gentle laxative..............................138
womens laxative oral tablet delayed
release 5 mg.............................................. 138
womens prenatal+dha..................................84
wymzya fe.................................................. 117
XACIATO..................................................... 21
XALKORI....................................................139
XARELTO.................................................... 51
XARELTO STARTER PACK........................51
XCOPRI (250 MG DAILY DOSE).................24
XCOPRI (350 MG DAILY DOSE).................24
XCOPRI ORAL TABLET 100 MG, 150 MG,
200 MG, 50 MG............................................24
XCOPRI ORAL TABLET THERAPY PACK. 24
XELJANZ................................................... 121
XELJANZ XR............................................. 121
XEPI............................................................. 67
XERAC AC...................................................69
XHANCE.................................................... 152
XIGDUO XR ORAL TABLET EXTENDED
RELEASE 24 HOUR 10-1000 MG............... 48
XIGDUO XR ORAL TABLET EXTENDED
RELEASE 24 HOUR 10-500 MG................. 48
XIGDUO XR ORAL TABLET EXTENDED
RELEASE 24 HOUR 2.5-1000 MG, 5-500
MG............................................................... 48
XIGDUO XR ORAL TABLET EXTENDED
RELEASE 24 HOUR 5-1000 MG................. 48
XIIDRA....................................................... 140
XOFLUZA (40 MG DOSE)........................... 45
XOFLUZA (80 MG DOSE)........................... 45
XOLAIR...................................................... 121
XOPENEX HFA..........................................153
XPECT....................................................... 161
XTAMPZA ER................................................ 6
XTANDI........................................................ 35
xulane.........................................................117
XULTOPHY..................................................48
XYOSTED.................................................. 110
XYREM...................................................... 180
XYWAV...................................................... 179
YASMIN 28................................................ 117
YAZ............................................................ 117
YONSA.......................................................138
YUFLYMA (2 SYRINGE)
SUBCUTANEOUS PREFILLED SYRINGE
KIT 40 MG/0.4ML.......................................138
YUPELRI....................................................152
yuvafem......................................................117
zafemy........................................................117
zaleplon......................................................179
ZARXIO........................................................52
ZEASORB-AF.............................................. 32
ZEGALOGUE.............................................107
ZEJULA........................................................37
ZELAC..........................................................99
ZELBORAF.................................................. 37
zenatane...................................................... 62
ZENPEP ORAL CAPSULE DELAYED
RELEASE PARTICLES 10000-32000
UNIT, 15000-47000 UNIT, 20000-63000
UNIT, 25000-79000 UNIT, 3000-10000
UNIT, 40000-126000 UNIT, 5000-24000
UNIT...........................................................106
ZEPATIER....................................................43
ZEPOSIA......................................................61
ZEPOSIA 7-DAY STARTER PACK............. 61
ZETONNA.................................................. 152
zidovudine.................................................... 45
ZIEXTENZO................................................. 52
ZIMHI........................................................... 18
zinc gluconate.............................................. 78
zinc gluconate oral tablet 50 mg.................. 78
zinc oral tablet 50 mg........................... 78, 184
zinc oxide external ointment 40 %............... 69
ZIOPTAN....................................................140
ziprasidone hcl............................................. 42
ZOLINZA...................................................... 36
zolpidem tartrate er.................................... 179
zolpidem tartrate oral tablet........................179
ZOMIG NASAL.............................................33
ZONEGRAN.................................................26
zonisamide oral............................................ 26
ZORYVE EXTERNAL CREAM.................. 138
ZOSTRIX HP..............................................138
zovia 1/35 (28)........................................... 117
ZUBSOLV.................................................... 17
zumandimine..............................................117
ZYDELIG......................................................37
ZYFLO........................................................152
ZYKADIA......................................................38
ZYLET........................................................ 140
ZYRTEC ALLERGY ORAL TABLET..........151
ZYRTEC-D ALLERGY & CONGESTION...162
ZYRTEC-D ALLERGY & SINUS................ 162
222
