Blue Cross MedicareRx Value (PDP)
SM
2023 Formulary
(List of Covered Drugs)
PLEASE READ:
THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN
HPMS Approved Formulary File ID: 00023189, Version 18
This formulary was updated on 11/13/2023. For more recent information or other questions, please contact
Blue Cross MedicareRx
SM
Customer Service at 1-888-285-2249 or, for TTY users, 711, 8:00 a.m. – 8:00 p.m.,
local time, 7 days a week. If you are calling from April 1 through September 30, alternate technologies (for
example, voicemail) will be used on weekends and holidays, or visit www.getbluenm.com/pdp/druglist.
Important Message About What You Pay for Vaccines Our plan covers most Part D vaccines at no cost
to you, even if you haven’t paid your deductible. Call Customer Services for more information.
Important Message About What You Pay for Insulin You won’t pay more than $35 for a one-month supply
of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t
paid your deductible.
Y0096_NMCOMPV23_C 484216.1123
11/13/2023
Blue Cross MedicareRx
2023 Formulary
(List of Covered Drugs)
Note to existing members: This formulary has changed since last year. Please review this document
to make sure it still contains the drugs you take.
When this drug list (formulary) refers to "we", "us", or "our", it means, HCSC Insurance Services
Company (HISC). When it refers to "plan" or "our plan," it means Blue Cross MedicareRx.
This document includes a list of the drugs (formulary) for our plan which is current as of
November 2023. For an updated formulary, please contact us. Our contact information, along with
the date we last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits,
formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2023,
and from time to time during the year.
11/13/2023
i
What is the Blue Cross MedicareRx Formulary?
A formulary is a list of covered drugs selected by Blue Cross MedicareRx in consultation with a team of
health care providers, which represents the prescription therapies believed to be a necessary part of a
quality treatment program. Blue Cross MedicareRx will generally cover the drugs listed in our formulary as
long as the drug is medically necessary, the prescription is filled at a Blue Cross MedicareRx network
pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please
review your Evidence of Coverage.
Can the Formulary (drug list) change?
Most changes in drug coverage happen on January 1, but "we" or Blue Cross MedicareRx may add or remove
drugs on the Drug List during the year, move them to different cost-sharing tiers, or add new restrictions.
We must follow the Medicare rules in making these changes.
Changes that can affect you this year: In the below cases, you will be affected by coverage changes
during the year:
New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing
it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or
fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug
on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. If you
are currently taking that brand name drug, we may not tell you in advance before we make that change,
but we will later provide you with information about the specific change(s) we have made.
If we make such a change, you or your prescriber can ask us to make an exception and continue to
cover the brand name drug for you. The notice we provide you will also include information on how
to request an exception, and you can find information in the section below titled "How do I request
an exception to the Blue Cross MedicareRx's Formulary?"
Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary
to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove
the drug from our formulary and provide notice to members who take the drug.
Other changes. We may make other changes that affect members currently taking a drug. For instance,
we may add a generic drug that is not new to market to replace a brand-name drug currently on the
formulary, or add new restrictions to the brand-name drug or move it to a different cost sharing tier or
both. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary
or add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to
a higher cost-sharing tier, we must notify affected members of the change at least 30 days before the
change becomes effective, or at the time the member requests a refill of the drug, at which time the
member will receive a 30-day supply of the drug.
If we make these other changes, you or your prescriber can ask us to make an exception and continue
to cover the brand name drug for you. The notice we provide you will also include information on
how to request an exception, and you can also find information in the section below entitled "How
do I request an exception to the Blue Cross MedicareRx's Formulary?"
Changes that will not affect you if you are currently taking the drug. Generally, if you are taking a drug
on our 2023 formulary that was covered at the beginning of the year, we will not discontinue or reduce
coverage of the drug during the 2023 coverage year except as described above. This means these drugs
will remain available at the same cost sharing and with no new restrictions for those members taking them
for the remainder of the coverage year. You will not get direct notice this year about changes that do not
affect you. However, on January 1 of the next year, such changes would affect you, and it is important to
check the Drug List for the new benefit year for any changes to drugs.
11/13/2023
ii
The enclosed formulary is current as of 11/13/2023. To get updated information about the drugs covered
by Blue Cross MedicareRx, please contact us. Our contact information appears on the front and back cover
pages. Formulary publications are updated and posted online on a monthly basis with applicable changes,
including negative changes. The web address is located on the front and back cover of this formulary.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on
the type of medical conditions that they are used to treat. For example, drugs used to treat a heart
condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for,
look for the category name in the list that begins on page 1. Then look under the category name for your
drug.
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index that begins
on page 69. The Index provides an alphabetical list of all of the drugs included in this document. Both
brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next
to your drug, you will see the page number where you can find coverage information. Turn to the page
listed in the Index and find the name of your drug in the first column of the list.
What are generic drugs?
Blue Cross MedicareRx covers both brand name drugs and generic drugs. A generic drug is approved by
the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less
than brand name drugs.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements and
limits may include:
Prior Authorization:Blue Cross MedicareRx requires you or your physician to get prior authorization
for certain drugs. This means that you will need to get approval from Blue Cross MedicareRx before you
fill your prescriptions. If you don’t get approval, Blue Cross MedicareRx may not cover the drug.
Quantity Limits: For certain drugs, Blue Cross MedicareRx limits the amount of the drug that Blue Cross
MedicareRx will cover. For example, Blue Cross MedicareRx provides 60 tablets per 30-day prescription
for Losartan 25 mg. This may be in addition to a standard one-month or three-month supply.
Step Therapy: In some cases, Blue Cross MedicareRx requires you to first try certain drugs to treat your
medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B
both treat your medical condition, Blue Cross MedicareRx may not cover Drug B unless you try Drug A
first. If Drug A does not work for you, Blue Cross MedicareRx will then cover Drug B.
You can find out if your drug has any additional requirements or limits by looking in the formulary that
begins on page 1. You can also get more information about the restrictions applied to specific covered drugs
by visiting our website. We have posted online documents that explain our prior authorization and step
therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date
we last updated the formulary, appears on the front and back cover pages.
You can ask Blue Cross MedicareRx to make an exception to these restrictions or limits or for a list of other,
similar drugs that may treat your health condition. See the section, "How do I request an exception to the
Blue Cross MedicareRx's formulary?" on page iv for information about how to request an exception.
11/13/2023
iii
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service
and ask if your drug is covered.
If you learn that Blue Cross MedicareRx does not cover your drug, you have two options:
You can ask Customer Service for a list of similar drugs that are covered by Blue Cross MedicareRx. When
you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered
by Blue Cross MedicareRx.
You can ask Blue Cross MedicareRx to make an exception and cover your drug. See below for information
about how to request an exception.
How do I request an exception to the Blue Cross MedicareRx's Formulary?
You can ask Blue Cross MedicareRx to make an exception to our coverage rules. There are several types of
exceptions that you can ask us to make.
You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered
at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a
lower cost-sharing level.
You can ask us to cover a formulary drug at a lower cost-sharing level, unless the drug is on the specialty
tier. If approved, this would lower the amount you must pay for your drug.
You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, Blue
Cross MedicareRx limits the amount of the drug that we will cover. If your drug has a quantity limit, you
can ask us to waive the limit and cover a greater amount.
Generally, Blue Cross MedicareRx will only approve your request for an exception if the alternative drugs
included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not
be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask us for an initial coverage decision for a formulary, tier, or utilization restriction
exception. When you request a formulary, tier, or utilization restriction exception you should submit
a statement from your prescriber or physician supporting your request. Generally, we must make our
decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited
(fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to
72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than
24 hours after we get a supporting statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or
requesting an exception?
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you
may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need
a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide
if you should switch to an appropriate drug that we cover or request a formulary exception so that we will
cover the drug you take. While you talk to your doctor to determine the right course of action for you, we
may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover
a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refills to provide up to
a maximum of a 30-day supply of medication. After your first 30-day supply, we will not pay for these drugs,
even if you have been a member of the plan less than 90 days.
11/13/2023
iv
If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your
ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will
cover a 31-day emergency supply of that drug while you pursue a formulary exception.
You may have changes that take you from one treatment setting to another. During this level of care change,
drugs may be prescribed that are not covered by your plan. If this happens, you and your doctor must use
your plan’s exception and appeals processes. However, when you are admitted to, or discharged from, a
long-term care setting, you may not have access to the drugs you were previously given. You may get a refill
upon admission or discharge to prevent a gap in care.
For more information
For more detailed information about your Blue Cross MedicareRx prescription drug coverage, please review
your Evidence of Coverage and other plan materials.
If you have questions about Blue Cross MedicareRx, please contact us. Our contact information, along with
the date we last updated the formulary, appears on the front and back cover pages.
If you have general questions about Medicare prescription drug coverage, please call Medicare at
1-800-MEDICARE (1-800-633-4227) 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or,
visit https://www.medicare.gov.
11/13/2023
v
Blue Cross MedicareRx's Formulary
The formulary below provides coverage information about the drugs covered by Blue Cross MedicareRx. If
you have trouble finding your drug in the list, turn to the Index that begins on page 69.
The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LANTUS) and
generic drugs are listed in lower-case italics (e.g., metformin).
The information in the Requirements/Limits column tells you if Blue Cross MedicareRx has any special
requirements for coverage of your drug.
Most drugs included in this formulary are available via mail-order benefit. Contact us for details. Our contact
information appears on the front and back cover pages.
KEY
Tier 1 = Preferred Generic
Tier 2 = Generic
Tier 3 = Preferred Brand
Tier 4 = Non-Preferred Drug
Tier 5 = Specialty Tier
BD = Drugs that may be covered under Medicare Part B or Part D depending on the circumstance. These
drugs require prior authorization to determine coverage under Part B or Part D. Information may need to
be provided that describes the use or the place where the drug is received to determine coverage.
PA = Prior Authorization
QL = Quantity Limits
ST = Step Therapy
* = Limited Distribution Drug. This prescription may be available only at certain pharmacies. For more
information consult your Pharmacy Directory or call Customer Service at 1-888-285-2249, 8:00 a.m. – 8:00
p.m., local time, 7 days a week. If you are calling from April 1 through September 30, alternate technologies
(for example, voicemail) will be used on weekends and holidays. TTY users should call 711.
# = High Risk Medication (HRM). Medicine that may be unsafe in patients greater than 65 years of age. Our
formulary does include coverage for some of these drugs, but alternatives may be found in lower co-pay
tiers. Please discuss with your doctor if there are alternatives to these medications that would be appropriate
for you to use.
^ = We provide additional coverage of this prescription drug in the coverage gap. Please refer to our Evidence
of Coverage for more information about this coverage.
† = High cost drug, consider Split Fill (2-week supply) for copay management if intolerant or change in
therapy.
Copayment and Coinsurance Amounts:
For more information on Copayment and Coinsurance, please review your Evidence of Coverage.
Preferred Generic: Tier 1 copay/coinsurance-Generic drugs covered under your Medicare plan at the lowest
copay/coinsurance
Generic: Tier 2 copay/coinsurance-Generic drugs and some brand drugs other than those considered
Preferred Generic drugs covered under your Medicare prescription drug plan at the highest generic copay/
coinsurance
11/13/2023
vi
Preferred Brand: Tier 3 copay/coinsurance-Brand drugs covered under your Medicare prescription drug
plan at the lowest brand copay/coinsurance
Non-Preferred Drug: Tier 4 copay/coinsurance-Brand drugs and certain generic drugs other than those
considered preferred Brand drugs that are covered under your Medicare prescription drug plan at the
highest brand copay/coinsurance
Specialty Tier: Tier 5 copay/coinsurance medications are usually high cost therapies that can be used to
treat chronic conditions such as rheumatoid arthritis, cancer, multiple sclerosis or rare and complex diseases.
They frequently require special handling, administration, and storage, as well as close clinic monitoring and
management.
2023 DOSAGE FORM ABBREVIATION KEY
adsorbedadactuationact
aerosol powder blisteraepbadjuvantadjuv
atrial fibrillation/atrial flutterafib/aflaerosolaer, aers, aero
breath activatedba, br act,
breath act,
breath activ
applicatorapp
capsulescap, capsbioequivalent allergy unitbau
continuous deliverycdcartridgecart
controlled release capsulecpcrchewable tabletschew tab
conjugate, conjugatedconjconcentrateconc
crystalscryscreamcrm
disintegratingdisint,
disintegr
deterrentdeter
enteric coatedecdelayed-releasedr
emulsionemulenzyme-linked immunosorbent
assay
el, elu
extractextextended releaseer, extended,
extended rel,
xr
genitourinarygugramgm
immunoglobulinglob, ighourhr
inhalationinh, inhalintramuscularim
index of reactivityirinjectioninj
literlintravenousiv
lipophiliclipolong actingla
liquidliq, liqdflocculation unitslf, lfu
microgrammcgmaintenancemaint
miscellaneousmiscmilliequivalentmeq
millilitermlmilligrammg
11/13/2023
vii
2023 DOSAGE FORM ABBREVIATION KEY
nebulesnebumillion unitsmu
ointmentoin, ointoral contraceptiveoc
ophthalmicop, ophthouter membrane vesiclesomv
pulmonary arterial hypertensionpahosmoticosm
preservative-freepfpackpak
powderpow, powdplaque forming unitspfu
prefilledpref, prefillpremenstrual dysphoric disorderpmdd
patch weeklyptwkpatch twice weeklypttw
refrigeraterefrigrecombinantrecomb
solutionsol, solnsublingualsl
suppositoriessupp, suppossquare centimetersqcm
syringesyrsuspensionsus, susp
controlled release tablettbcrtabletstab, tabs
enteric coated tablettbecdispersible tablettbdp
transdermaltdtablet packtbpk
translingualtltherapyther
vaginalvaunitunt, ut
vaccinevac, vacc
11/13/2023
viii
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
1
Drug Name
Drug Tier Requirements/Limits
Analgesics
acetaminophen w/ codeine soln 120-12 mg/5ml
3 QL (2700 mls/30 days)
acetaminophen w/ codeine tab 300-15 mg, 300-30 mg
3 QL (360 tablets/30 days)
acetaminophen w/ codeine tab 300-60 mg
3 QL (180 tablets/30 days)
butalbital-acetaminophen tab 50-325 mg#
3 QL (180 tablets/30 days)
butalbital-acetaminophen-caffeine cap 50-300-40 mg,
50-325-40 mg#
3 QL (180 capsules/30 days)
butalbital-acetaminophen-caffeine tab 50-325-40 mg#
3 QL (180 tablets/30 days)
butalbital-aspirin-caffeine cap 50-325-40 mg#
3 QL (180 capsules/30 days)
butorphanol tartrate nasal soln 10 mg/ml
4 QL (48 mls/30 days)
celecoxib cap 50 mg, 100 mg, 200 mg
2 QL (60 capsules/30 days)
celecoxib cap 400 mg
2 QL (30 capsules/30 days)
CODEINE SULFATE - codeine sulfate tab 15 mg, 60 mg 4 QL (180 tablets/30 days)
codeine sulfate tab 30 mg
3 QL (180 tablets/30 days)
diclofenac potassium tab 50 mg
2 QL (120 tablets/30 days)
diclofenac sodium gel 1%
2
diclofenac sodium tab delayed release 25 mg
2 QL (240 tablets/30 days)
diclofenac sodium tab delayed release 50 mg
2 QL (120 tablets/30 days)
diclofenac sodium tab delayed release 75 mg
2 QL (60 tablets/30 days)
diclofenac sodium tab er 24hr 100 mg
2 QL (60 tablets/30 days)
diclofenac w/ misoprostol tab delayed release 50-0.2 mg
3 QL (120 tablets/30 days)
diclofenac w/ misoprostol tab delayed release 75-0.2 mg
3 QL (90 tablets/30 days)
etodolac cap 200 mg
2 QL (150 capsules/30 days)
etodolac cap 300 mg
2 QL (90 capsules/30 days)
etodolac tab er 24hr 400 mg, 500 mg
2 QL (60 tablets/30 days)
etodolac tab er 24hr 600 mg
2 QL (30 tablets/30 days)
etodolac tab 400 mg, 500 mg
2 QL (60 tablets/30 days)
fentanyl citrate lozenge on a handle 200 mcg
4 PA, QL (120 lozenges/30 days)
fentanyl citrate lozenge on a handle 400 mcg, 600 mcg, 800 mcg,
1200 mcg, 1600 mcg
5 PA, QL (120 lozenges/30 days)
fentanyl td patch 72hr 12 mcg/hr, 75 mcg/hr, 100 mcg/hr
4 PA, QL (15 patches/30 days)
fentanyl td patch 72hr 25 mcg/hr, 50 mcg/hr
3 PA, QL (15 patches/30 days)
flurbiprofen tab 100 mg
2 QL (90 tablets/30 days)
hydrocodone bitartrate cap er 12hr 10 mg
4 PA, QL (60 capsules/30 days)
hydrocodone bitartrate cap er 12hr 15 mg
4 PA, QL (60 capsules/30 days)
hydrocodone bitartrate cap er 12hr 20 mg
4 PA, QL (60 capsules/30 days)
hydrocodone bitartrate cap er 12hr 30 mg
4 PA, QL (60 capsules/30 days)
hydrocodone bitartrate cap er 12hr 40 mg
4 PA, QL (60 capsules/30 days)
hydrocodone bitartrate cap er 12hr 50 mg
4 PA, QL (60 capsules/30 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
2
Drug Name
Drug Tier Requirements/Limits
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
4 QL (2700 mls/30 days)
hydrocodone-acetaminophen tab 10-325 mg, 7.5-325 mg
3 QL (180 tablets/30 days)
hydrocodone-acetaminophen tab 5-300 mg
4 QL (240 tablets/30 days)
hydrocodone-acetaminophen tab 7.5-300 mg, 10-300 mg
4 QL (180 tablets/30 days)
hydrocodone-acetaminophen tab 5-325 mg
3 QL (240 tablets/30 days)
hydrocodone-ibuprofen tab 10-200 mg
4 QL (150 tablets/30 days)
hydrocodone-ibuprofen tab 7.5-200 mg
3 QL (150 tablets/30 days)
HYDROCODONE/IBUPROFEN - hydrocodone-ibuprofen tab
5-200 mg
4 QL (150 tablets/30 days)
hydromorphone hcl inj 2 mg/ml
4 BD
hydromorphone hcl liqd 1 mg/ml
4 QL (1440 mls/30 days)
hydromorphone hcl preservative free inj 2 mg/ml
4 BD
hydromorphone hcl preservative free inj 10 mg/ml
4 BD
hydromorphone hcl tab 2 mg, 4 mg, 8 mg
3 QL (180 tablets/30 days)
ibuprofen susp 100 mg/5ml
2
ibuprofen tab 400 mg^
1 QL (240 tablets/30 days)
ibuprofen tab 600 mg^
1 QL (150 tablets/30 days)
ibuprofen tab 800 mg^
1 QL (120 tablets/30 days)
meloxicam tab 7.5 mg^
1 QL (60 tablets/30 days)
meloxicam tab 15 mg^
1 QL (30 tablets/30 days)
methadone hcl tab 5 mg
3 QL (180 tablets/30 days)
methadone hcl tab 10 mg
3 QL (360 tablets/30 days)
morphine sulfate oral soln 20 mg/5ml
3 QL (1350 mls/30 days)
morphine sulfate oral soln 10 mg/5ml
3 QL (2700 mls/30 days)
morphine sulfate oral soln 100 mg/5ml (20 mg/ml)
3 QL (270 mls/30 days)
morphine sulfate tab er 15 mg, 30 mg, 60 mg
3 PA, QL (90 tablets/30 days)
morphine sulfate tab er 100 mg, 200 mg
4 PA, QL (90 tablets/30 days)
morphine sulfate tab 15 mg
4 QL (360 tablets/30 days)
morphine sulfate tab 30 mg
4 QL (180 tablets/30 days)
nabumetone tab 500 mg
2 QL (120 tablets/30 days)
nabumetone tab 750 mg
2 QL (60 tablets/30 days)
naproxen sodium tab 275 mg
2 QL (150 tablets/30 days)
naproxen sodium tab 550 mg
2 QL (90 tablets/30 days)
naproxen susp 125 mg/5ml
4 QL (1800 mls/30 days)
naproxen tab ec 375 mg
2 QL (120 tablets/30 days)
naproxen tab ec 500 mg
2 QL (90 tablets/30 days)
naproxen tab 250 mg^
1 QL (180 tablets/30 days)
naproxen tab 375 mg^
1 QL (120 tablets/30 days)
naproxen tab 500 mg^
1 QL (90 tablets/30 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
3
Drug Name
Drug Tier Requirements/Limits
oxaprozin tab 600 mg
2 QL (90 tablets/30 days)
oxycodone hcl tab 5 mg
3 QL (360 tablets/30 days)
oxycodone hcl tab 10 mg, 15 mg, 20 mg, 30 mg
3 QL (180 tablets/30 days)
oxycodone w/ acetaminophen tab 2.5-325 mg
4 QL (360 tablets/30 days)
oxycodone w/ acetaminophen tab 5-325 mg
3 QL (360 tablets/30 days)
oxycodone w/ acetaminophen tab 7.5-325 mg
3 QL (240 tablets/30 days)
oxycodone w/ acetaminophen tab 10-325 mg
3 QL (180 tablets/30 days)
piroxicam cap 10 mg
2 QL (60 capsules/30 days)
piroxicam cap 20 mg
2 QL (30 capsules/30 days)
sulindac tab 150 mg, 200 mg
2 QL (60 tablets/30 days)
TENCON - butalbital-acetaminophen tab 50-325 mg# 4 QL (180 tablets/30 days)
tramadol hcl tab er 24hr 100 mg, 200 mg, 300 mg
3 PA, QL (30 tablets/30 days)
tramadol hcl tab 50 mg
2 QL (240 tablets/30 days)
tramadol-acetaminophen tab 37.5-325 mg
3 QL (240 tablets/30 days)
Anesthetics
lidocaine hcl laryngotracheal soln 4%
2
lidocaine hcl soln 4%
2 PA, QL (150 mls/30 days)
lidocaine hcl viscous soln 2%
2
lidocaine oint 5%
2 PA, QL (100 grams/30 days)
lidocaine patch 5%
3 PA, QL (90 patches/30 days)
lidocaine-prilocaine cream 2.5-2.5%
2 PA, QL (60 grams/30 days)
ZTLIDO - lidocaine patch 1.8% (36 mg) 4 PA, QL (90 patches/30 days)
Anti-Addiction/Substance Abuse Treatment Agents
acamprosate calcium tab delayed release 333 mg
3
buprenorphine hcl sl tab 2 mg, 8 mg
3 QL (90 tablets/30 days)
buprenorphine hcl-naloxone hcl sl film 2-0.5 mg
3 QL (120 films/30 days)
buprenorphine hcl-naloxone hcl sl film 4-1 mg, 8-2 mg, 12-3 mg
3 QL (60 films/30 days)
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg
2 QL (120 tablets/30 days)
buprenorphine hcl-naloxone hcl sl tab 8-2 mg
2 QL (90 tablets/30 days)
bupropion hcl (smoking deterrent) tab er 12hr 150 mg
2
disulfiram tab 250 mg
2
disulfiram tab 500 mg
3
KLOXXADO - naloxone hcl nasal spray 8 mg/0.1ml 4
naloxone hcl inj 0.4 mg/ml, 4 mg/10ml
2
naloxone hcl nasal spray 4 mg/0.1ml
3
naloxone hcl soln cartridge 0.4 mg/ml
2
naloxone hcl soln prefilled syringe 2 mg/2ml
2
naltrexone hcl tab 50 mg
2
NARCAN - naloxone hcl nasal spray 4 mg/0.1ml 4
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
4
Drug Name
Drug Tier Requirements/Limits
NICOTROL INHALER - nicotine inhaler system 10 mg (4 mg
delivered)
4
NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/spray) 4
varenicline tartrate tab 0.5 mg, 1 mg
3
varenicline tartrate tab 11 x 0.5 mg & 42 x 1 mg start pack
3
VIVITROL - naltrexone for im extended release susp 380 mg 5
Antibacterials
amikacin sulfate inj 500 mg/2ml (250 mg/ml), 1 gm/4ml (250 mg/ml)
4
amoxicillin (trihydrate) cap 250 mg, 500 mg^
1
amoxicillin (trihydrate) chew tab 125 mg
2
amoxicillin (trihydrate) chew tab 250 mg
2
amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml,
250 mg/5ml, 400 mg/5ml^
1
amoxicillin (trihydrate) tab 500 mg, 875 mg^
1
amoxicillin & k clavulanate chew tab 200-28.5 mg
2
amoxicillin & k clavulanate chew tab 400-57 mg
2
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml,
400-57 mg/5ml, 600-42.9 mg/5ml
2
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
3
amoxicillin & k clavulanate tab 250-125 mg, 500-125 mg,
875-125 mg
2
AMOXICILLIN/CLAVULANATE POTASSIUM ER - amoxicillin & k
clavulanate tab er 12hr 1000-62.5 mg
4
ampicillin & sulbactam sodium for inj 3 (2-1) gm
4
ampicillin & sulbactam sodium for iv soln 3 (2-1) gm
4
ampicillin cap 500 mg
2
ampicillin sodium for inj 250 mg, 500 mg, 1 gm, 2 gm
4
ampicillin sodium for iv soln 1 gm
4
ampicillin sodium for iv soln 2 gm, 10 gm
4
AZITHROMYCIN - azithromycin powd pack for susp 1 gm 4
azithromycin for susp 100 mg/5ml, 200 mg/5ml
2
azithromycin iv for soln 500 mg
4
azithromycin tab 250 mg, 500 mg, 600 mg
2
aztreonam for inj 1 gm
4
BICILLIN L-A - penicillin g benzathine im susp pref syr 600000 unit/
ml, 2400000 unit/4ml, 1200000 unit/2ml
4
cefaclor cap 250 mg
2
cefaclor cap 500 mg
2
cefadroxil cap 500 mg
2
cefadroxil for susp 250 mg/5ml, 500 mg/5ml
2
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
5
Drug Name
Drug Tier Requirements/Limits
cefadroxil tab 1 gm
3
CEFAZOLIN - cefazolin sodium for iv soln 2 gm 4
cefazolin sodium (bulk) for inj 100 gm
4
cefazolin sodium (bulk) for inj 300 gm
4
cefazolin sodium for inj 2 gm
4
cefazolin sodium for inj 500 mg, 1 gm, 10 gm
4
cefazolin sodium for iv soln 1 gm
4
cefazolin sodium for iv soln 1 gm and dextrose 4% (50 ml)
4
cefazolin sodium-dextrose iv solution 1 gm/50ml-4%
4
cefdinir cap 300 mg
2
cefdinir for susp 125 mg/5ml, 250 mg/5ml
2
cefepime hcl for inj 1 gm
4
cefepime hcl for iv soln 1 gm and dextrose 5% (50 ml)
4
cefepime hcl for iv soln 2 gm and dextrose 5% (50 ml)
4
cefepime hcl for iv soln 2 gm
4
cefepime hcl iv soln 1 gm/50ml
4
cefepime hcl iv soln 2 gm/100ml
4
cefixime cap 400 mg
3
cefoxitin sodium for iv soln 1 gm, 2 gm, 10 gm
4
cefoxitin sodium iv for soln 1 gm and dextrose 4% (50 ml)
4
cefoxitin sodium iv for soln 2 gm and dextrose 2.2% (50 ml)
4
cefpodoxime proxetil for susp 50 mg/5ml, 100 mg/5ml
4
cefpodoxime proxetil tab 100 mg, 200 mg
2
cefprozil for susp 125 mg/5ml, 250 mg/5ml
2
cefprozil tab 250 mg, 500 mg
2
ceftazidime for inj 1 gm, 6 gm
4
ceftazidime for iv soln 1 gm and dextrose 5% (50ml)
4
ceftazidime for iv soln 2 gm and dextrose 5% (50ml)
4
ceftazidime for iv soln 2 gm
4
ceftriaxone sodium (bulk) for inj 100 gm
4
ceftriaxone sodium for inj 250 mg, 500 mg, 1 gm, 2 gm, 10 gm
4
ceftriaxone sodium for iv soln 1 gm and dextrose 3.74% 50 ml
4
ceftriaxone sodium for iv soln 2 gm and dextrose 2.22% 50 ml
4
ceftriaxone sodium for iv soln 1 gm, 2 gm
4
ceftriaxone sodium in dextrose inj 20 mg/ml
4
ceftriaxone sodium in dextrose inj 40 mg/ml
4
cefuroxime axetil tab 250 mg, 500 mg
2
cefuroxime sodium for inj 750 mg
4
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
6
Drug Name
Drug Tier Requirements/Limits
cefuroxime sodium for iv soln 1.5 gm
4
cephalexin cap 250 mg, 500 mg^
1
cephalexin cap 750 mg
3
cephalexin for susp 125 mg/5ml, 250 mg/5ml
2
CIPROFLOXACIN HCL - ciprofloxacin hcl tab 100 mg 4
ciprofloxacin hcl tab 250 mg, 500 mg, 750 mg^
1
ciprofloxacin 200 mg/100ml in d5w
4
ciprofloxacin 400 mg/200ml in d5w
4
CLARITHROMYCIN - clarithromycin for susp 125 mg/5ml,
250 mg/5ml
4
clarithromycin tab er 24hr 500 mg
3
clarithromycin tab 250 mg, 500 mg
3
clindamycin hcl cap 75 mg, 150 mg, 300 mg
2
clindamycin palmitate hcl for soln 75 mg/5ml
4
clindamycin phosphate gel 1%
2
clindamycin phosphate in d5w iv soln 300 mg/50ml, 600 mg/50ml,
900 mg/50ml
4
clindamycin phosphate in nacl 0.9% iv soln 300 mg/50ml
4
clindamycin phosphate in nacl 0.9% iv soln 600 mg/50ml
4
clindamycin phosphate in nacl 0.9% iv soln 900 mg/50ml
4
clindamycin phosphate inj 300 mg/2ml, 600 mg/4ml, 900 mg/6ml,
9 gm/60ml
4
clindamycin phosphate lotion 1%
2
clindamycin phosphate soln 1%
2
clindamycin phosphate swab 1%
3
clindamycin phosphate vaginal cream 2%
2
colistimethate sod for inj 150 mg (colistin base activity)
4
DALVANCE - dalbavancin hcl for iv soln 500 mg 5
daptomycin for iv soln 500 mg
5
demeclocycline hcl tab 150 mg, 300 mg
4
dicloxacillin sodium cap 250 mg, 500 mg
2
DIFICID - fidaxomicin for susp 40 mg/ml 5 QL (1 bottle/10 days)
DIFICID - fidaxomicin tab 200 mg 5 QL (20 tablets/10 days)
doxycycline hyclate cap 50 mg, 100 mg
2
doxycycline hyclate for inj 100 mg
4
doxycycline hyclate tab 20 mg, 100 mg
2
doxycycline monohydrate cap 50 mg, 100 mg
2
doxycycline monohydrate cap 75 mg
3
doxycycline monohydrate cap 150 mg
4
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
7
Drug Name
Drug Tier Requirements/Limits
doxycycline monohydrate tab 50 mg, 75 mg, 100 mg
2
doxycycline monohydrate tab 150 mg
3
ertapenem sodium for inj 1 gm
4
ERY - erythromycin pads 2% 4
ERYTHROCIN LACTOBIONATE - erythromycin lactobionate for inj
500 mg
4
ERYTHROCIN STEARATE - erythromycin stearate tab 250 mg 4
erythromycin ethylsuccinate for susp 200 mg/5ml, 400 mg/5ml
4
erythromycin lactobionate for inj 500 mg
4
erythromycin soln 2%
2
erythromycin tab delayed release 250 mg, 500 mg
3
erythromycin tab delayed release 333 mg
4
erythromycin tab 250 mg, 500 mg
4
erythromycin w/ delayed release particles cap 250 mg
4
gentamicin in saline inj 1.2 mg/ml
4
gentamicin sulfate inj 40 mg/ml
4
GENTAMICIN SULFATE PEDIATRIC - gentamicin sulfate inj 10 mg/
ml
4
GENTAMICIN SULFATE/0.9% SODIUM CHLORIDE - gentamicin in
saline inj 1 mg/ml, 1.6 mg/ml
4
imipenem-cilastatin intravenous for soln 500 mg
4
IMIPENEM/CILASTATIN - imipenem-cilastatin intravenous for soln
250 mg
4
IMPAVIDO - miltefosine cap 50 mg 5
ISOTONIC GENTAMICIN - gentamicin in saline inj 0.8 mg/ml 4
levofloxacin in d5w iv soln 250 mg/50ml, 500 mg/100ml,
750 mg/150ml
4
levofloxacin iv soln 25 mg/ml
4
levofloxacin oral soln 25 mg/ml
4
levofloxacin tab 250 mg, 500 mg, 750 mg^
1
linezolid for susp 100 mg/5ml
5 PA
linezolid in sodium chloride iv soln 600 mg/300ml-0.9%
4
linezolid iv soln 600 mg/300ml (2 mg/ml)
4
linezolid tab 600 mg
3 PA
meropenem & sodium chloride 0.9% for iv soln 1 gm/50ml
4
meropenem & sodium chloride 0.9% for iv soln 500 mg/50ml
4
meropenem iv for soln 500 mg, 1 gm
4
methenamine hippurate tab 1 gm
2
metronidazole cap 375 mg
3
metronidazole iv soln 500 mg/100ml
4
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
8
Drug Name
Drug Tier Requirements/Limits
metronidazole tab 250 mg, 500 mg^
1
metronidazole vaginal gel 0.75%
2
minocycline hcl cap 50 mg, 75 mg, 100 mg
2
minocycline hcl tab 50 mg, 75 mg, 100 mg
3
moxifloxacin hcl iv solution 400 mg/250ml
4
moxifloxacin hcl tab 400 mg
2
moxifloxacin hcl 400 mg/250ml in sodium chloride 0.8% inj
4
nafcillin sodium for inj 1 gm, 2 gm
4
nafcillin sodium for iv soln 10 gm
4
nafcillin sodium in dextrose inj 1 gm/50ml
4
nafcillin sodium in dextrose inj 2 gm/100ml
4
neomycin sulfate tab 500 mg
2
nitrofurantoin macrocrystalline cap 50 mg, 100 mg#
3
nitrofurantoin monohydrate macrocrystalline cap 100 mg#
3
ofloxacin tab 400 mg
3
paromomycin sulfate cap 250 mg
4
penicillin g potassium for inj 5000000 unit, 20000000 unit
4
PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE -
penicillin g potassium inj 20000 unit/ml in dextrose, 60000 unit/ml
in dextrose
4
PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE -
penicillin g potassium inj 40000 unit/ml in dextrose
3
PENICILLIN G SODIUM - penicillin g sodium for inj 5000000 unit 4
penicillin v potassium for soln 125 mg/5ml
2
penicillin v potassium for soln 250 mg/5ml
2
penicillin v potassium tab 250 mg, 500 mg^
1
piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm)
4
piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm), 4.5 gm
(4-0.5 gm)
4
SIVEXTRO - tedizolid phosphate for iv soln 200 mg 5
SIVEXTRO - tedizolid phosphate tab 200 mg 5 PA
STREPTOMYCIN SULFATE - streptomycin sulfate for inj 1 gm 4
sulfadiazine tab 500 mg
4
sulfamethoxazole-trimethoprim susp 200-40 mg/5ml
2
sulfamethoxazole-trimethoprim tab 400-80 mg, 800-160 mg^
1
SUPRAX - cefixime chew tab 100 mg, 200 mg 4
TAZICEF - ceftazidime for iv soln 1 gm, 6 gm 4
TEFLARO - ceftaroline fosamil for iv soln 400 mg, 600 mg 5
tetracycline hcl cap 250 mg
3
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
9
Drug Name
Drug Tier Requirements/Limits
tetracycline hcl cap 500 mg
4
tigecycline for iv soln 50 mg
5
TOBRAMYCIN SULFATE - tobramycin sulfate inj 10 mg/ml 4
tobramycin sulfate for inj 1.2 gm
4
tobramycin sulfate inj 2 gm/50ml (40 mg/ml)
4
tobramycin sulfate inj 80 mg/2ml (40 mg/ml), 1.2 gm/30ml (40 mg/
ml)
4
trimethoprim tab 100 mg
2
VANCOMYCIN - vancomycin hcl iv soln 2000 mg/400ml 4
VANCOMYCIN - vancomycin hcl-sodium chloride iv soln
500 mg/100ml-0.9%, 750 mg/150ml-0.9%
4
VANCOMYCIN HCL - vancomycin hcl-sodium chloride iv soln
1 gm/200ml-0.9%
4
vancomycin hcl cap 125 mg
4 QL (120 capsules/30 days)
vancomycin hcl cap 250 mg
4 QL (240 capsules/30 days)
vancomycin hcl for iv soln 100 gm
4
vancomycin hcl for iv soln 500 mg, 750 mg, 1 gm, 1.25 gm, 1.5 gm,
5 gm, 10 gm
4
VANCOMYCIN HYDROCHLORIDE - vancomycin hcl iv soln
500 mg/100ml, 750 mg/150ml, 1000 mg/200ml, 1250 mg/250ml,
1500 mg/300ml, 1750 mg/350ml
4
VANCOMYCIN HYDROCHLORIDE/DEXTROSE - vancomycin
hcl-dextrose iv soln 500 mg/100ml-5%, 750 mg/150ml-5%,
1 gm/200ml-5%
4
VANDAZOLE - metronidazole vaginal gel 0.75% 3
ZOSYN - piperacillin sod-tazobactam sod in dex iv soln
2-0.25gm/50ml, 4-0.5gm/100ml
4
ZOSYN - piperacillin sod-tazobactam sod in dex iv sol
3-0.375gm/50ml
4
Anticonvulsants
APTIOM - eslicarbazepine acetate tab 200 mg, 400 mg, 600 mg,
800 mg
5
BRIVIACT - brivaracetam iv soln 50 mg/5ml 4
BRIVIACT - brivaracetam oral soln 10 mg/ml 5
BRIVIACT - brivaracetam tab 10 mg, 25 mg, 50 mg, 75 mg, 100 mg 5
carbamazepine cap er 12hr 100 mg, 200 mg, 300 mg
2
carbamazepine chew tab 100 mg
2
carbamazepine susp 100 mg/5ml
4
carbamazepine tab er 12hr 100 mg, 200 mg, 400 mg
2
carbamazepine tab 200 mg
2
CELONTIN - methsuximide cap 300 mg 4
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
10
Drug Name
Drug Tier Requirements/Limits
clobazam suspension 2.5 mg/ml
4 PA, QL (480 mls/30 days)
clobazam tab 10 mg, 20 mg
4 PA, QL (60 tablets/30 days)
DIACOMIT - stiripentol cap 250 mg, 500 mg* 5
DIACOMIT - stiripentol packet 250 mg, 500 mg* 5
DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system
2.5 mg
4 QL (5 twin pack(s)/30 days)
diazepam rectal gel delivery system 10 mg, 20 mg
4 QL (5 twin pack(s)/30 days)
DILANTIN - phenytoin sodium extended cap 30 mg 4
divalproex sodium cap delayed release sprinkle 125 mg
2
divalproex sodium tab delayed release 125 mg, 250 mg, 500 mg
2
divalproex sodium tab er 24 hr 250 mg, 500 mg
2
EPIDIOLEX - cannabidiol soln 100 mg/ml* 5 PA
EPRONTIA - topiramate oral soln 25 mg/ml 4
ethosuximide cap 250 mg
3
ethosuximide soln 250 mg/5ml
4
felbamate susp 600 mg/5ml
5
felbamate tab 400 mg, 600 mg
4
FINTEPLA - fenfluramine hcl oral soln 2.2 mg/ml 5 PA, QL (360 mls/30 days)
FYCOMPA - perampanel susp 0.5 mg/ml 4
FYCOMPA - perampanel tab 2 mg, 4 mg, 6 mg, 8 mg, 10 mg,
12 mg
4
gabapentin cap 100 mg^
1 QL (1080 capsules/30 days)
gabapentin cap 300 mg^
1 QL (360 capsules/30 days)
gabapentin cap 400 mg^
1 QL (270 capsules/30 days)
gabapentin oral soln 250 mg/5ml
3 QL (2160 mls/30 days)
gabapentin tab 600 mg
2 QL (180 tablets/30 days)
gabapentin tab 800 mg
2 QL (135 tablets/30 days)
lacosamide iv inj 200 mg/20ml (10 mg/ml)
4
lacosamide oral solution 10 mg/ml
4
lacosamide tab 50 mg, 100 mg, 150 mg, 200 mg
4
lamotrigine tab chewable dispersible 5 mg, 25 mg
3
lamotrigine tab er 24hr 25 mg, 50 mg, 100 mg, 200 mg, 300 mg
4
lamotrigine tab 25 mg, 100 mg, 150 mg, 200 mg^
1
levetiracetam in sodium chloride iv soln 500 mg/100ml,
1000 mg/100ml, 1500 mg/100ml
4
levetiracetam oral soln 100 mg/ml
3
levetiracetam tab er 24hr 500 mg, 750 mg
2
levetiracetam tab 250 mg, 500 mg, 750 mg, 1000 mg
2
methsuximide cap 300 mg
4
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
11
Drug Name
Drug Tier Requirements/Limits
NAYZILAM - midazolam nasal spray soln 5 mg/0.1 ml 4 QL (10 bottles/30 days)
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
4
oxcarbazepine tab 150 mg, 300 mg, 600 mg
2
phenobarbital elixir 20 mg/5ml#
4
phenobarbital tab 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg,
64.8 mg, 97.2 mg, 100 mg#
2
phenytoin chew tab 50 mg
3
phenytoin sodium extended cap 100 mg, 200 mg, 300 mg
2
phenytoin susp 125 mg/5ml
3
pregabalin cap 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg
2 QL (90 capsules/30 days)
pregabalin cap 225 mg, 300 mg
2 QL (60 capsules/30 days)
pregabalin soln 20 mg/ml
3 QL (900 mls/30 days)
PRIMIDONE - primidone tab 125 mg 4
primidone tab 50 mg, 250 mg
2
rufinamide susp 40 mg/ml
5
rufinamide tab 200 mg
4
rufinamide tab 400 mg
5
SPRITAM - levetiracetam tab disintegrating soluble 250 mg,
500 mg, 750 mg, 1000 mg
4
SYMPAZAN - clobazam oral film 5 mg 4 PA, QL (240 films/30 days)
SYMPAZAN - clobazam oral film 10 mg, 20 mg 5 PA, QL (60 films/30 days)
tiagabine hcl tab 2 mg, 4 mg, 12 mg, 16 mg
4
topiramate sprinkle cap 15 mg, 25 mg
2
topiramate tab 25 mg, 50 mg, 100 mg, 200 mg^
1
valproate sodium inj 100 mg/ml
4
valproate sodium oral soln 250 mg/5ml
2
valproic acid cap 250 mg
2
VALTOCO 10 MG DOSE - diazepam nasal spray 10 mg/0.1 ml 4 QL (5 twin pack(s)/30 days)
VALTOCO 15 MG DOSE - diazepam nasal spray ther pack 2 x
7.5 mg/0.1ml
4 QL (5 twin pack(s)/30 days)
VALTOCO 20 MG DOSE - diazepam nasal spray ther pack 2 x
10 mg/0.1ml
4 QL (5 twin pack(s)/30 days)
VALTOCO 5 MG DOSE - diazepam nasal spray 5 mg/0.1 ml 4 QL (5 twin pack(s)/30 days)
vigabatrin powd pack 500 mg*
5 QL (180 packets/30 days)
vigabatrin tab 500 mg*
5 QL (180 tablets/30 days)
XCOPRI - cenobamate tab pack 100 mg & 150 mg tabs (250 mg
daily dose)
5
XCOPRI - cenobamate tab pack 150 mg & 200 mg tabs (350 mg
daily dose)
5
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
12
Drug Name
Drug Tier Requirements/Limits
XCOPRI - cenobamate tab titration pack 14 x 12.5 mg & 14 x
25 mg
4
XCOPRI - cenobamate tab titration pack 14 x 50 mg & 14 x
100 mg, 14 x 150 mg & 14 x 200 mg
5
XCOPRI - cenobamate tab 50 mg, 100 mg, 150 mg, 200 mg 5
ZONISADE - zonisamide oral susp 100 mg/5ml (20 mg/ml) 4
zonisamide cap 25 mg, 50 mg, 100 mg
2
ZTALMY - ganaxolone susp 50 mg/ml 5
Antidementia Agents
donepezil hydrochloride orally disintegrating tab 5 mg, 10 mg
2
donepezil hydrochloride tab 5 mg, 10 mg, 23 mg^
1
GALANTAMINE HYDROBROMIDE - galantamine hydrobromide
oral soln 4 mg/ml
4
galantamine hydrobromide cap er 24hr 8 mg, 16 mg, 24 mg
2
galantamine hydrobromide tab 4 mg, 8 mg, 12 mg
3
memantine hcl cap er 24hr 7 mg, 14 mg, 21 mg, 28 mg
4 PA (<=29 yr)
memantine hcl oral solution 2 mg/ml
4 PA (<=29 yr)
memantine hcl tab 5 mg, 10 mg
2 PA (<=29 yr)
memantine hcl tab 28 x 5 mg & 21 x 10 mg titration pack
3 PA (<=29 yr)
rivastigmine tartrate cap 1.5 mg, 3 mg, 4.5 mg, 6 mg
3
rivastigmine td patch 24hr 4.6 mg/24hr, 9.5 mg/24hr, 13.3 mg/24hr
4
Antidepressants
amitriptyline hcl tab 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg#
2
amoxapine tab 25 mg, 50 mg, 100 mg, 150 mg#
3
AUVELITY - dextromethorphan hbr-bupropion hcl tab er 45-105 mg 5 QL (60 tablets/30 days)
bupropion hcl tab er 12hr 100 mg
2 QL (90 tablets/30 days)
bupropion hcl tab er 12hr 150 mg, 200 mg
2 QL (60 tablets/30 days)
bupropion hcl tab er 24hr 150 mg
2 QL (90 tablets/30 days)
bupropion hcl tab er 24hr 300 mg
2 QL (30 tablets/30 days)
bupropion hcl tab 75 mg
2 QL (60 tablets/30 days)
bupropion hcl tab 100 mg
2 QL (120 tablets/30 days)
citalopram hydrobromide oral soln 10 mg/5ml
3 QL (600 mls/30 days)
citalopram hydrobromide tab 10 mg, 20 mg^
1 QL (45 tablets/30 days)
citalopram hydrobromide tab 40 mg^
1 QL (30 tablets/30 days)
clomipramine hcl cap 25 mg, 50 mg, 75 mg#
4
desipramine hcl tab 10 mg, 25 mg, 50 mg, 75 mg, 100 mg,
150 mg#
3
desvenlafaxine succinate tab er 24hr 25 mg, 50 mg, 100 mg
2 QL (30 tablets/30 days)
doxepin hcl cap 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg#
3
doxepin hcl conc 10 mg/ml#
4
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
13
Drug Name
Drug Tier Requirements/Limits
duloxetine hcl enteric coated pellets cap 20 mg, 60 mg
2 QL (60 capsules/30 days)
duloxetine hcl enteric coated pellets cap 30 mg
2 QL (90 capsules/30 days)
EMSAM - selegiline td patch 24hr 6 mg/24hr, 9 mg/24hr,
12 mg/24hr
5 PA, QL (30 patches/30 days)
escitalopram oxalate soln 5 mg/5ml
4 QL (600 mls/30 days)
escitalopram oxalate tab 5 mg, 10 mg^
1 QL (45 tablets/30 days)
escitalopram oxalate tab 20 mg^
1 QL (30 tablets/30 days)
FETZIMA - levomilnacipran hcl cap er 24hr 20 mg, 40 mg, 80 mg,
120 mg
4 QL (30 capsules/30 days)
FETZIMA TITRATION PACK - levomilnacipran hcl cap er 24hr 20 &
40 mg therapy pack
4 QL (28 capsules/28 days)
FLUOXETINE DR - fluoxetine hcl cap delayed release 90 mg 4 QL (4 capsules/28 days)
fluoxetine hcl cap 10 mg^
1 QL (90 capsules/30 days)
fluoxetine hcl cap 20 mg^
1 QL (120 capsules/30 days)
fluoxetine hcl cap 40 mg^
1 QL (60 capsules/30 days)
fluoxetine hcl solution 20 mg/5ml
3 QL (600 mls/30 days)
fluoxetine hcl tab 10 mg
2 QL (90 tablets/30 days)
fluoxetine hcl tab 20 mg
2 QL (120 tablets/30 days)
fluvoxamine maleate tab 25 mg, 50 mg
3 QL (30 tablets/30 days)
fluvoxamine maleate tab 100 mg
3 QL (90 tablets/30 days)
imipramine hcl tab 10 mg, 25 mg, 50 mg#
2
MARPLAN - isocarboxazid tab 10 mg 4
mirtazapine orally disintegrating tab 15 mg, 30 mg, 45 mg
2 QL (30 tablets/30 days)
mirtazapine tab 7.5 mg, 30 mg, 45 mg
2 QL (30 tablets/30 days)
mirtazapine tab 15 mg
2 QL (45 tablets/30 days)
NEFAZODONE HYDROCHLORIDE - nefazodone hcl tab 50 mg,
250 mg
4
NEFAZODONE HYDROCHLORIDE - nefazodone hcl tab 100 mg,
150 mg, 200 mg
3
nortriptyline hcl cap 10 mg, 25 mg, 50 mg, 75 mg#
2
nortriptyline hcl soln 10 mg/5ml#
4
paroxetine hcl oral susp 10 mg/5ml#
4 QL (900 mls/30 days)
paroxetine hcl tab er 24hr 12.5 mg#
3 QL (30 tablets/30 days)
paroxetine hcl tab er 24hr 25 mg, 37.5 mg#
3 QL (60 tablets/30 days)
paroxetine hcl tab 10 mg, 40 mg#
2 QL (45 tablets/30 days)
paroxetine hcl tab 20 mg#
2 QL (30 tablets/30 days)
paroxetine hcl tab 30 mg#
2 QL (60 tablets/30 days)
phenelzine sulfate tab 15 mg
2
protriptyline hcl tab 5 mg, 10 mg#
4
sertraline hcl oral concentrate for solution 20 mg/ml
4 QL (300 mls/30 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
14
Drug Name
Drug Tier Requirements/Limits
sertraline hcl tab 25 mg, 50 mg^
1 QL (45 tablets/30 days)
sertraline hcl tab 100 mg^
1 QL (60 tablets/30 days)
tranylcypromine sulfate tab 10 mg
4
trazodone hcl tab 50 mg, 100 mg, 150 mg^
1
trazodone hcl tab 300 mg
2
trimipramine maleate cap 25 mg, 50 mg, 100 mg#
3
TRINTELLIX - vortioxetine hbr tab 5 mg, 10 mg, 20 mg 4 QL (30 tablets/30 days)
VENLAFAXINE BESYLATE ER - venlafaxine besylate tab er 24hr
112.5 mg
4 QL (60 tablets/30 days)
venlafaxine hcl cap er 24hr 37.5 mg
2 QL (60 capsules/30 days)
venlafaxine hcl cap er 24hr 75 mg
2 QL (90 capsules/30 days)
venlafaxine hcl cap er 24hr 150 mg
2 QL (30 capsules/30 days)
venlafaxine hcl tab 25 mg, 37.5 mg, 50 mg, 75 mg, 100 mg
2 QL (90 tablets/30 days)
VIIBRYD STARTER PACK - vilazodone hcl tab starter kit 10 (7) &
20 (23) mg
4 QL (1 kit/30 days)
vilazodone hcl tab 10 mg, 20 mg, 40 mg
4 QL (30 tablets/30 days)
Antiemetics
aprepitant capsule therapy pack 80 & 125 mg
4 BD
aprepitant capsule 40 mg, 80 mg, 125 mg
4 BD
chlorpromazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg, 200 mg
4 PA (>=65 yr)
CHLORPROMAZINE HYDROCHLORIDE - chlorpromazine hcl
conc 30 mg/ml, 100 mg/ml
4 PA (>=65 yr)
dronabinol cap 2.5 mg, 5 mg, 10 mg
4 BD
granisetron hcl tab 1 mg
3 BD
meclizine hcl tab 12.5 mg, 25 mg#
2
ondansetron hcl oral soln 4 mg/5ml
2
ondansetron hcl tab 24 mg
2
ondansetron hcl tab 4 mg, 8 mg
2
ondansetron orally disintegrating tab 4 mg, 8 mg
2
perphenazine tab 2 mg, 4 mg, 8 mg, 16 mg
2 PA (>=65 yr)
prochlorperazine edisylate inj 10 mg/2ml
4
prochlorperazine maleate tab 5 mg, 10 mg
2
prochlorperazine suppos 25 mg
3
promethazine hcl suppos 12.5 mg, 25 mg#
3 PA (>=65 yr)
promethazine hcl syrup 6.25 mg/5ml#
3 PA (>=65 yr)
promethazine hcl tab 12.5 mg, 25 mg, 50 mg#
2 PA (>=65 yr)
scopolamine td patch 72hr 1 mg/3days#
4 PA (>=65 yr)
Antifungals
AMBISOME - amphotericin b liposome iv for susp 50 mg 5 BD
AMPHOTERICIN B - amphotericin b for iv soln 50 mg 4 BD
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
15
Drug Name
Drug Tier Requirements/Limits
amphotericin b liposome iv for susp 50 mg
5 BD
caspofungin acetate for iv soln 50 mg, 70 mg
4
ciclopirox gel 0.77%
2
ciclopirox olamine cream 0.77%
2
ciclopirox olamine susp 0.77%
2
ciclopirox shampoo 1%
2
ciclopirox solution 8%
2 QL (6.6 mls/30 days)
clotrimazole cream 1%
2
clotrimazole troche 10 mg
2
CRESEMBA - isavuconazonium sulfate cap 74.5 mg
(isavuconazole 40 mg), 186 mg (isavuconazole 100 mg)
5 PA
econazole nitrate cream 1%
2
fluconazole for susp 10 mg/ml, 40 mg/ml
3
fluconazole in nacl 0.9% inj 200 mg/100ml, 400 mg/200ml
4
fluconazole tab 50 mg, 100 mg, 150 mg, 200 mg
2
flucytosine cap 250 mg, 500 mg
5
griseofulvin microsize susp 125 mg/5ml
4
griseofulvin microsize tab 500 mg
4
griseofulvin ultramicrosize tab 125 mg, 250 mg
3
itraconazole cap 100 mg
4 QL (120 capsules/30 days)
ketoconazole cream 2%
2
ketoconazole shampoo 2%
2
ketoconazole tab 200 mg
2
micafungin sodium for iv soln 50 mg
4
micafungin sodium for iv soln 100 mg
5
NOXAFIL - posaconazole for delayed release susp packet 300 mg 5 PA
NOXAFIL - posaconazole susp 40 mg/ml 5 PA
nystatin cream 100000 unit/gm
2
nystatin oint 100000 unit/gm
2
nystatin susp 100000 unit/ml
2
nystatin tab 500000 unit
2
nystatin topical powder 100000 unit/gm
2
posaconazole susp 40 mg/ml
5 PA
posaconazole tab delayed release 100 mg
5 PA
terbinafine hcl tab 250 mg^
1 QL (30 tablets/30 days)
terconazole vaginal cream 0.4%, 0.8%
2
terconazole vaginal suppos 80 mg
2
voriconazole for inj 200 mg
4 PA
voriconazole for susp 40 mg/ml
4 PA
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
16
Drug Name
Drug Tier Requirements/Limits
voriconazole tab 50 mg, 200 mg
4 PA
Antigout Agents
allopurinol tab 100 mg, 300 mg^
1
colchicine tab 0.6 mg
3
colchicine w/ probenecid tab 0.5-500 mg
2
probenecid tab 500 mg
2
Antimigraine Agents
AIMOVIG - erenumab-aooe subcutaneous soln auto-injector 70 mg/
ml
3 PA, QL (2 pens/30 days)
AIMOVIG - erenumab-aooe subcutaneous soln auto-injector
140 mg/ml
3 PA, QL (1 pen/30 days)
dihydroergotamine mesylate nasal spray 4 mg/ml
5 PA, QL (8 mls/28 days)
EMGALITY - galcanezumab-gnlm subcutaneous soln auto-injector
120 mg/ml
3 PA, QL (2 pens/30 days)
EMGALITY - galcanezumab-gnlm subcutaneous soln prefilled syr
100 mg/ml
3 PA, QL (3 syringes/30 days)
EMGALITY - galcanezumab-gnlm subcutaneous soln prefilled syr
120 mg/ml
3 PA, QL (2 syringes/30 days)
ergotamine w/ caffeine tab 1-100 mg
3
naratriptan hcl tab 1 mg, 2.5 mg
2 QL (18 tablets/30 days)
NURTEC - rimegepant sulfate tab disint 75 mg 3 PA, QL (16 tablets/30 days)
rizatriptan benzoate oral disintegrating tab 5 mg, 10 mg
3 QL (18 tablets/30 days)
rizatriptan benzoate tab 5 mg, 10 mg
2 QL (18 tablets/30 days)
sumatriptan nasal spray 5 mg/act, 20 mg/act
3 QL (12 units (2
packages)/30 days)
sumatriptan succinate inj 6 mg/0.5ml
3 QL (10 doses/30 days)
sumatriptan succinate solution auto-injector 4 mg/0.5ml, 6 mg/0.5ml
3 QL (12 doses/30 days)
sumatriptan succinate solution cartridge 4 mg/0.5ml, 6 mg/0.5ml
3 QL (12 doses/30 days)
sumatriptan succinate tab 25 mg, 50 mg, 100 mg
2 QL (18 tablets/30 days)
UBRELVY - ubrogepant tab 50 mg, 100 mg 3 PA, QL (16 tablets/30 days)
Antimyasthenic Agents
pyridostigmine bromide oral soln 60 mg/5ml
4
pyridostigmine bromide tab er 180 mg
4
pyridostigmine bromide tab 60 mg
2
Antimycobacterials
dapsone tab 25 mg, 100 mg
2
ethambutol hcl tab 100 mg, 400 mg
3
isoniazid tab 100 mg
2
isoniazid tab 300 mg^
1
PRIFTIN - rifapentine tab 150 mg 4
pyrazinamide tab 500 mg
3
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
17
Drug Name
Drug Tier Requirements/Limits
rifabutin cap 150 mg
4
rifampin cap 150 mg, 300 mg
2
rifampin for inj 600 mg
4
SIRTURO - bedaquiline fumarate tab 20 mg, 100 mg* 5
TRECATOR - ethionamide tab 250 mg 4
Antineoplastics
abiraterone acetate tab 250 mg†
5 PA, QL (120 tablets/30 days)
AKEEGA - niraparib tosylate-abiraterone acetate tab 50-500 mg,
100-500 mg†
5 PA, QL (60 tablets/30 days)
ALECENSA - alectinib hcl cap 150 mg* 5 PA, QL (240 capsules/30 days)
ALUNBRIG - brigatinib tab initiation therapy pack 90 mg & 180 mg* 5 PA, QL (30 tablets/30 days)
ALUNBRIG - brigatinib tab 30 mg* 5 PA, QL (120 tablets/30 days)
ALUNBRIG - brigatinib tab 90 mg, 180 mg* 5 PA, QL (30 tablets/30 days)
anastrozole tab 1 mg^
1
arsenic trioxide iv soln 10 mg/10ml (1 mg/ml)
4
arsenic trioxide iv soln 12 mg/6ml (2 mg/ml)
5
AYVAKIT - avapritinib tab 25 mg, 50 mg, 100 mg, 200 mg, 300 mg† 5 PA, QL (30 tablets/30 days)
BALVERSA - erdafitinib tab 3 mg† 5 PA, QL (90 tablets/30 days)
BALVERSA - erdafitinib tab 4 mg† 5 PA, QL (60 tablets/30 days)
BALVERSA - erdafitinib tab 5 mg† 5 PA, QL (30 tablets/30 days)
bexarotene cap 75 mg†
5 PA
bexarotene gel 1%
5 PA
bicalutamide tab 50 mg
2
BOSULIF - bosutinib tab 100 mg† 5 PA, QL (180 tablets/30 days)
BOSULIF - bosutinib tab 400 mg, 500 mg† 5 PA, QL (30 tablets/30 days)
BRAFTOVI - encorafenib cap 75 mg* 5 PA, QL (180 capsules/30 days)
BRUKINSA - zanubrutinib cap 80 mg 5 PA, QL (120 capsules/30 days)
CABOMETYX - cabozantinib s-malate tab 20 mg, 40 mg, 60 mg†* 5 PA, QL (30 tablets/30 days)
CALQUENCE - acalabrutinib cap 100 mg†* 5 PA, QL (60 capsules/30 days)
CALQUENCE - acalabrutinib maleate tab 100 mg†* 5 PA, QL (60 tablets/30 days)
CAPRELSA - vandetanib tab 100 mg* 5 PA, QL (60 tablets/30 days)
CAPRELSA - vandetanib tab 300 mg* 5 PA, QL (30 tablets/30 days)
carmustine for inj 100 mg
4
COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100
dose) kit*
5 PA, QL (56 capsules/28 days)
COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140
dose) kit*
5 PA, QL (112 capsules/28 days)
COMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60 mg dose)
kit*
5 PA, QL (84 capsules/28 days)
COPIKTRA - duvelisib cap 15 mg, 25 mg* 5 PA, QL (56 capsules/28 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
18
Drug Name
Drug Tier Requirements/Limits
COSELA - trilaciclib dihydrochloride for iv soln 300 mg 5
COTELLIC - cobimetinib fumarate tab 20 mg* 5 PA, QL (63 tablets/28 days)
CYCLOPHOSPHAMIDE - cyclophosphamide tab 25 mg, 50 mg 3 BD
cyclophosphamide cap 25 mg, 50 mg
3 BD
DAURISMO - glasdegib maleate tab 25 mg† 5 PA, QL (60 tablets/30 days)
DAURISMO - glasdegib maleate tab 100 mg† 5 PA, QL (30 tablets/30 days)
decitabine for inj 50 mg
5
docetaxel for inj conc 20 mg/ml, 80 mg/4ml (20 mg/ml), 160 mg/8ml
(20 mg/ml)
5
docetaxel soln for iv infusion 20 mg/2ml, 80 mg/8ml, 160 mg/16ml
5
EMCYT - estramustine phosphate sodium cap 140 mg 4
ERIVEDGE - vismodegib cap 150 mg†* 5 PA, QL (30 capsules/30 days)
ERLEADA - apalutamide tab 60 mg* 5 PA, QL (120 tablets/30 days)
ERLEADA - apalutamide tab 240 mg* 5 PA, QL (30 tablets/30 days)
erlotinib hcl tab 25 mg†
5 PA, QL (60 tablets/30 days)
erlotinib hcl tab 100 mg, 150 mg†
5 PA, QL (30 tablets/30 days)
EULEXIN - flutamide cap 125 mg 5
everolimus tab for oral susp 2 mg, 5 mg
5 PA, QL (60 tablets/30 days)
everolimus tab for oral susp 3 mg
5 PA, QL (90 tablets/30 days)
everolimus tab 2.5 mg, 7.5 mg, 10 mg†
5 PA, QL (30 tablets/30 days)
everolimus tab 5 mg†
5 PA, QL (60 tablets/30 days)
exemestane tab 25 mg
3
EXKIVITY - mobocertinib succinate cap 40 mg†* 5 PA, QL (120 capsules/30 days)
fluorouracil iv soln 500 mg/10ml (50 mg/ml), 1 gm/20ml (50 mg/ml),
2.5 gm/50ml (50 mg/ml), 5 gm/100ml (50 mg/ml)
4 BD
FOLOTYN - pralatrexate iv inj 20 mg/ml, 40 mg/2ml 5 PA
FOTIVDA - tivozanib hcl cap 0.89 mg, 1.34 mg* 5 PA, QL (21 capsules/28 days)
fulvestrant inj soln pref syr 250 mg/5ml
5 PA
GAVRETO - pralsetinib cap 100 mg† 5 PA, QL (120 capsules/30 days)
gefitinib tab 250 mg†
5 PA, QL (30 tablets/30 days)
GILOTRIF - afatinib dimaleate tab 20 mg, 30 mg, 40 mg* 5 PA, QL (30 tablets/30 days)
GLEOSTINE - lomustine cap 10 mg, 40 mg 4
GLEOSTINE - lomustine cap 100 mg 5
hydroxyurea cap 500 mg
2
IBRANCE - palbociclib cap 75 mg, 100 mg, 125 mg* 5 PA, QL (21 capsules/28 days)
IBRANCE - palbociclib tab 75 mg, 100 mg, 125 mg* 5 PA, QL (21 tablets/28 days)
ICLUSIG - ponatinib hcl tab 10 mg, 15 mg, 30 mg, 45 mg†* 5 PA, QL (30 tablets/30 days)
IDHIFA - enasidenib mesylate tab 50 mg, 100 mg* 5 PA, QL (30 tablets/30 days)
ifosfamide iv inj 1 gm/20ml (50 mg/ml), 3 gm/60ml (50 mg/ml)
4
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
19
Drug Name
Drug Tier Requirements/Limits
imatinib mesylate tab 100 mg†
5 PA, QL (90 tablets/30 days)
imatinib mesylate tab 400 mg†
5 PA, QL (60 tablets/30 days)
IMBRUVICA - ibrutinib cap 70 mg* 5 PA, QL (30 capsules/30 days)
IMBRUVICA - ibrutinib cap 140 mg* 5 PA, QL (120 capsules/30 days)
IMBRUVICA - ibrutinib oral susp 70 mg/ml* 5 PA, QL (3 bottles/30 days)
IMBRUVICA - ibrutinib tab 420 mg* 5 PA, QL (30 tablets/30 days)
INLYTA - axitinib tab 1 mg†* 5 PA, QL (180 tablets/30 days)
INLYTA - axitinib tab 5 mg†* 5 PA, QL (120 tablets/30 days)
INQOVI - decitabine-cedazuridine tab 35-100 mg 5 PA, QL (5 tablets/28 days)
INREBIC - fedratinib hcl cap 100 mg† 5 PA, QL (120 capsules/30 days)
IRESSA - gefitinib tab 250 mg†* 5 PA, QL (30 tablets/30 days)
JAKAFI - ruxolitinib phosphate tab 5 mg, 10 mg, 15 mg, 20 mg,
25 mg†*
5 PA, QL (60 tablets/30 days)
JAYPIRCA - pirtobrutinib tab 50 mg† 5 PA, QL (30 tablets/30 days)
JAYPIRCA - pirtobrutinib tab 100 mg† 5 PA, QL (60 tablets/30 days)
KISQALI - ribociclib succinate tab pack 200 mg daily dose 5 PA, QL (21 tablets/28 days)
KISQALI - ribociclib succinate tab pack 400 mg daily dose (200 mg
tab)
5 PA, QL (42 tablets/28 days)
KISQALI - ribociclib succinate tab pack 600 mg daily dose (200 mg
tab)
5 PA, QL (63 tablets/28 days)
KISQALI FEMARA 200 DOSE - ribociclib 200 mg dose (200 mg
tab) & letrozole 2.5 mg tbpk
5 PA, QL (49 tablets/28 days)
KISQALI FEMARA 400 DOSE - ribociclib 400 mg dose (200 mg
tab) & letrozole 2.5 mg tbpk
5 PA, QL (70 tablets/28 days)
KISQALI FEMARA 600 DOSE - ribociclib 600 mg dose (200 mg
tab) & letrozole 2.5 mg tbpk
5 PA, QL (91 tablets/28 days)
KOSELUGO - selumetinib sulfate cap 10 mg 5 PA, QL (240 capsules/30 days)
KOSELUGO - selumetinib sulfate cap 25 mg 5 PA, QL (120 capsules/30 days)
KRAZATI - adagrasib tab 200 mg† 5 PA, QL (180 tablets/30 days)
lapatinib ditosylate tab 250 mg
5 PA, QL (180 tablets/30 days)
lenalidomide caps 2.5 mg
5 PA, QL (30 capsules/30 days)
lenalidomide cap 5 mg, 10 mg
5 PA, QL (30 capsules/30 days)
lenalidomide cap 15 mg, 20 mg, 25 mg
5 PA, QL (21 capsules/28 days)
LENVIMA 10 MG DAILY DOSE - lenvatinib cap therapy pack
10 mg*
5 PA, QL (30 capsules/30 days)
LENVIMA 12MG DAILY DOSE - lenvatinib cap therapy pack 3 x
4 mg*
5 PA, QL (90 capsules/30 days)
LENVIMA 14 MG DAILY DOSE - lenvatinib cap therapy pack 10 &
4 mg*
5 PA, QL (60 capsules/30 days)
LENVIMA 18 MG DAILY DOSE - lenvatinib cap ther pack 10 mg &
2 x 4 mg*
5 PA, QL (90 capsules/30 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
20
Drug Name
Drug Tier Requirements/Limits
LENVIMA 20 MG DAILY DOSE - lenvatinib cap therapy pack 2 x
10 mg*
5 PA, QL (60 capsules/30 days)
LENVIMA 24 MG DAILY DOSE - lenvatinib cap ther pack 2 x 10 mg
& 4 mg*
5 PA, QL (90 capsules/30 days)
LENVIMA 4 MG DAILY DOSE - lenvatinib cap therapy pack 4 mg* 5 PA, QL (30 capsules/30 days)
LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 2 x
4 mg*
5 PA, QL (60 capsules/30 days)
letrozole tab 2.5 mg^
1
leucovorin calcium tab 5 mg
2
leucovorin calcium tab 10 mg, 15 mg, 25 mg
3
LEUKERAN - chlorambucil tab 2 mg 5
LONSURF - trifluridine-tipiracil tab 15-6.14 mg 5 PA, QL (100 tablets/28 days)
LONSURF - trifluridine-tipiracil tab 20-8.19 mg 5 PA, QL (80 tablets/28 days)
LORBRENA - lorlatinib tab 25 mg† 5 PA, QL (90 tablets/30 days)
LORBRENA - lorlatinib tab 100 mg† 5 PA, QL (30 tablets/30 days)
LUMAKRAS - sotorasib tab 120 mg†* 5 PA, QL (240 tablets/30 days)
LUMAKRAS - sotorasib tab 320 mg†* 5 PA, QL (90 tablets/30 days)
LUMOXITI - moxetumomab pasudotox-tdfk for iv soln 1 mg* 5 PA
LYNPARZA - olaparib tab 100 mg, 150 mg†* 5 PA, QL (120 tablets/30 days)
LYTGOBI - futibatinib tab therapy pack 4 mg (12 mg daily dose) 5 PA, QL (84 tablets/28 days)
LYTGOBI - futibatinib tab therapy pack 4 mg (16 mg daily dose) 5 PA, QL (112 tablets/28 days)
LYTGOBI - futibatinib tab therapy pack 4 mg (20 mg daily dose) 5 PA, QL (140 tablets/28 days)
MARGENZA - margetuximab-cmkb iv soln 250 mg/10ml (25 mg/ml) 5 PA
MATULANE - procarbazine hcl cap 50 mg* 5 PA
MEKINIST - trametinib dimethyl sulfoxide for soln 0.05 mg/ml 5 PA, QL (13 bottles/28 days)
MEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg* 5 PA, QL (90 tablets/30 days)
MEKINIST - trametinib dimethyl sulfoxide tab 2 mg* 5 PA, QL (30 tablets/30 days)
MEKTOVI - binimetinib tab 15 mg* 5 PA, QL (180 tablets/30 days)
mercaptopurine tab 50 mg
2
MESNEX - mesna tab 400 mg 5
nelarabine iv soln 5 mg/ml
5 PA
NERLYNX - neratinib maleate tab 40 mg†* 5 PA, QL (180 tablets/30 days)
nilutamide tab 150 mg
5
NINLARO - ixazomib citrate cap 2.3 mg, 3 mg, 4 mg 5 PA, QL (3 capsules/28 days)
NUBEQA - darolutamide tab 300 mg† 5 PA, QL (120 tablets/30 days)
ODOMZO - sonidegib phosphate cap 200 mg†* 5 PA, QL (30 capsules/30 days)
OJJAARA - momelotinib dihydrochloride tab 100 mg, 150 mg,
200 mg
5 PA, QL (30 tablets/30 days)
ONTRUZANT - trastuzumab-dttb for iv soln 150 mg, 420 mg 5 PA
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
21
Drug Name
Drug Tier Requirements/Limits
ONUREG - azacitidine tab 200 mg, 300 mg 5 PA, QL (14 tablets/28 days)
OPDIVO - nivolumab iv soln 40 mg/4ml, 100 mg/10ml,
120 mg/12ml, 240 mg/24ml
5 PA
ORSERDU - elacestrant hydrochloride tab 86 mg 5 PA, QL (90 tablets/30 days)
ORSERDU - elacestrant hydrochloride tab 345 mg 5 PA, QL (30 tablets/30 days)
PANRETIN - alitretinoin gel 0.1% 5 PA
pazopanib hcl tab 200 mg†
5 PA, QL (120 tablets/30 days)
PEMAZYRE - pemigatinib tab 4.5 mg, 9 mg, 13.5 mg 5 PA, QL (14 tablets/21 days)
PIQRAY 200MG DAILY DOSE - alpelisib tab therapy pack 200 mg
daily dose
5 PA, QL (30 tablets/30 days)
PIQRAY 250MG DAILY DOSE - alpelisib tab pack 250 mg daily
dose (200 mg & 50 mg tabs)
5 PA, QL (60 tablets/30 days)
PIQRAY 300MG DAILY DOSE - alpelisib tab pack 300 mg daily
dose (2x150 mg tab)
5 PA, QL (60 tablets/30 days)
POMALYST - pomalidomide cap 1 mg, 2 mg, 3 mg, 4 mg* 5 PA, QL (21 capsules/28 days)
PURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/ml)* 5
QINLOCK - ripretinib tab 50 mg 5 PA, QL (90 tablets/30 days)
RETEVMO - selpercatinib cap 40 mg† 5 PA, QL (180 capsules/30 days)
RETEVMO - selpercatinib cap 80 mg† 5 PA, QL (120 capsules/30 days)
REVLIMID - lenalidomide caps 2.5 mg* 5 PA, QL (30 capsules/30 days)
REVLIMID - lenalidomide cap 5 mg, 10 mg* 5 PA, QL (30 capsules/30 days)
REVLIMID - lenalidomide cap 15 mg, 20 mg, 25 mg* 5 PA, QL (21 capsules/28 days)
REZLIDHIA - olutasidenib cap 150 mg† 5 PA, QL (60 capsules/30 days)
ROZLYTREK - entrectinib cap 100 mg† 5 PA, QL (150 capsules/30 days)
ROZLYTREK - entrectinib cap 200 mg† 5 PA, QL (90 capsules/30 days)
RUBRACA - rucaparib camsylate tab 200 mg, 250 mg, 300 mg†* 5 PA, QL (120 tablets/30 days)
RYDAPT - midostaurin cap 25 mg 5 PA, QL (240 capsules/30 days)
SCEMBLIX - asciminib hcl tab 20 mg 5 PA, QL (60 tablets/30 days)
SCEMBLIX - asciminib hcl tab 40 mg 5 PA, QL (300 tablets/30 days)
SOLTAMOX - tamoxifen citrate oral soln 10 mg/5ml 5
sorafenib tosylate tab 200 mg†
5 PA, QL (120 tablets/30 days)
SPRYCEL - dasatinib tab 20 mg† 5 PA, QL (90 tablets/30 days)
SPRYCEL - dasatinib tab 50 mg, 70 mg, 80 mg, 100 mg, 140 mg† 5 PA, QL (30 tablets/30 days)
STIVARGA - regorafenib tab 40 mg* 5 PA, QL (84 tablets/28 days)
sunitinib malate cap 12.5 mg†
5 PA, QL (90 capsules/30 days)
sunitinib malate cap 25 mg, 37.5 mg, 50 mg†
5 PA, QL (30 capsules/30 days)
SYNRIBO - omacetaxine mepesuccinate for inj 3.5 mg 5 PA
TABLOID - thioguanine tab 40 mg 4
TABRECTA - capmatinib hcl tab 150 mg, 200 mg 5 PA, QL (120 tablets/30 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
22
Drug Name
Drug Tier Requirements/Limits
TAFINLAR - dabrafenib mesylate cap 50 mg, 75 mg* 5 PA, QL (120 capsules/30 days)
TAFINLAR - dabrafenib mesylate tab for oral susp 10 mg 5 PA, QL (4 bottles/28 days)
TAGRISSO - osimertinib mesylate tab 40 mg, 80 mg†* 5 PA, QL (30 tablets/30 days)
TALZENNA - talazoparib tosylate cap 0.1 mg, 0.35 mg† 5 PA, QL (30 capsules/30 days)
TALZENNA - talazoparib tosylate cap 0.25 mg, 0.5 mg, 0.75 mg,
1 mg†*
5 PA, QL (30 capsules/30 days)
tamoxifen citrate tab 10 mg, 20 mg
2
TASIGNA - nilotinib hcl cap 50 mg† 5 PA, QL (120 capsules/30 days)
TASIGNA - nilotinib hcl cap 150 mg, 200 mg 5 PA, QL (120 capsules/30 days)
TAZVERIK - tazemetostat hbr tab 200 mg 5 PA, QL (240 tablets/30 days)
TEPMETKO - tepotinib hcl tab 225 mg†* 5 PA, QL (60 tablets/30 days)
THALOMID - thalidomide cap 50 mg, 100 mg 5 PA, QL (30 capsules/30 days)
THALOMID - thalidomide cap 150 mg, 200 mg 5 PA, QL (60 capsules/30 days)
TIBSOVO - ivosidenib tab 250 mg* 5 PA, QL (60 tablets/30 days)
toremifene citrate tab 60 mg
5
tretinoin cap 10 mg
5 PA
TUKYSA - tucatinib tab 50 mg 5 PA, QL (300 tablets/30 days)
TUKYSA - tucatinib tab 150 mg 5 PA, QL (120 tablets/30 days)
TURALIO - pexidartinib hcl cap 125 mg 5 PA, QL (120 capsules/30 days)
VALCHLOR - mechlorethamine hcl gel 0.016%* 5
VANFLYTA - quizartinib dihydrochloride tab 17.7 mg, 26.5 mg 5 PA, QL (60 tablets/30 days)
VENCLEXTA - venetoclax tab 10 mg* 3 PA, QL (60 tablets/30 days)
VENCLEXTA - venetoclax tab 50 mg* 5 PA, QL (30 tablets/30 days)
VENCLEXTA - venetoclax tab 100 mg* 5 PA, QL (180 tablets/30 days)
VENCLEXTA STARTING PACK - venetoclax tab therapy starter
pack 10 & 50 & 100 mg*
5 PA, QL (1 pack (42
tablets)/28 days)
VERZENIO - abemaciclib tab 50 mg, 100 mg, 150 mg, 200 mg* 5 PA, QL (60 tablets/30 days)
VITRAKVI - larotrectinib sulfate cap 25 mg†* 5 PA, QL (180 capsules/30 days)
VITRAKVI - larotrectinib sulfate cap 100 mg†* 5 PA, QL (60 capsules/30 days)
VITRAKVI - larotrectinib sulfate oral soln 20 mg/ml* 5 PA, QL (300 mls/30 days)
VIZIMPRO - dacomitinib tab 15 mg, 30 mg, 45 mg†* 5 PA, QL (30 tablets/30 days)
VONJO - pacritinib citrate cap 100 mg† 5 PA, QL (120 capsules/30 days)
VOTRIENT - pazopanib hcl tab 200 mg†* 5 PA, QL (120 tablets/30 days)
WELIREG - belzutifan tab 40 mg†* 5 PA, QL (90 tablets/30 days)
XALKORI - crizotinib cap 200 mg, 250 mg†* 5 PA, QL (120 capsules/30 days)
XOSPATA - gilteritinib fumarate tablet 40 mg† 5 PA, QL (90 tablets/30 days)
XPOVIO - selinexor tab therapy pack 40 mg (40 mg once weekly),
40 mg (40 mg twice weekly), 40 mg (80 mg once weekly), 50 mg
(100 mg once weekly), 60 mg (60 mg once weekly)*
5 PA, QL (1 box/28 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
23
Drug Name
Drug Tier Requirements/Limits
XPOVIO 60 MG TWICE WEEKLY - selinexor tab therapy pack
20 mg*
5 PA, QL (1 box/28 days)
XPOVIO 80 MG TWICE WEEKLY - selinexor tab therapy pack
20 mg*
5 PA, QL (1 box/28 days)
XTANDI - enzalutamide cap 40 mg†* 5 PA, QL (120 capsules/30 days)
XTANDI - enzalutamide tab 40 mg†* 5 PA, QL (120 tablets/30 days)
XTANDI - enzalutamide tab 80 mg†* 5 PA, QL (60 tablets/30 days)
ZEJULA - niraparib tosylate cap 100 mg†* 5 PA, QL (90 capsules/30 days)
ZEJULA - niraparib tosylate tab 100 mg, 200 mg, 300 mg* 5 PA, QL (30 tablets/30 days)
ZELBORAF - vemurafenib tab 240 mg* 5 PA, QL (240 tablets/30 days)
ZOLINZA - vorinostat cap 100 mg† 5 PA, QL (120 capsules/30 days)
ZYDELIG - idelalisib tab 100 mg, 150 mg* 5 PA, QL (60 tablets/30 days)
ZYKADIA - ceritinib tab 150 mg†* 5 PA, QL (90 tablets/30 days)
Antiparasitics
albendazole tab 200 mg
4
atovaquone susp 750 mg/5ml
4 PA, QL (600 mls/30 days)
atovaquone-proguanil hcl tab 62.5-25 mg, 250-100 mg
3
BENZNIDAZOLE - benznidazole tab 12.5 mg, 100 mg 4
chloroquine phosphate tab 250 mg
4
chloroquine phosphate tab 500 mg
2
COARTEM - artemether-lumefantrine tab 20-120 mg 4
hydroxychloroquine sulfate tab 200 mg
2
ivermectin tab 3 mg
3 PA
mefloquine hcl tab 250 mg
3
nitazoxanide tab 500 mg
5 QL (20 tablets/30 days)
pentamidine isethionate for inj soln 300 mg
4
pentamidine isethionate for nebulization soln 300 mg
3 BD
praziquantel tab 600 mg
4
primaquine phosphate tab 26.3 mg (15 mg base)
4
pyrimethamine tab 25 mg
5 PA
quinine sulfate cap 324 mg
3 PA
Antiparkinson Agents
amantadine hcl cap 100 mg
2
amantadine hcl soln 50 mg/5ml
2
amantadine hcl tab 100 mg
2
APOKYN - apomorphine hcl soln cartridge 30 mg/3ml* 5 PA, QL (60 mls/30 days)
apomorphine hcl soln cartridge 30 mg/3ml
5 PA, QL (60 mls/30 days)
benztropine mesylate tab 0.5 mg, 1 mg, 2 mg#
2 PA (>=65 yr)
bromocriptine mesylate cap 5 mg
4
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
24
Drug Name
Drug Tier Requirements/Limits
bromocriptine mesylate tab 2.5 mg
3
carbidopa & levodopa orally disintegrating tab 10-100 mg
4
carbidopa & levodopa orally disintegrating tab 25-100 mg
4
carbidopa & levodopa orally disintegrating tab 25-250 mg
4
carbidopa & levodopa tab er 25-100 mg, 50-200 mg
2
carbidopa & levodopa tab 10-100 mg, 25-100 mg, 25-250 mg
2
carbidopa tab 25 mg
4
carbidopa-levodopa-entacapone tabs 12.5-50-200 mg,
18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg,
37.5-150-200 mg, 50-200-200 mg
4
entacapone tab 200 mg
3
INBRIJA - levodopa inhal powder cap 42 mg 5 PA, QL (300 capsules/30 days)
NEUPRO - rotigotine td patch 24hr 1 mg/24hr, 2 mg/24hr,
3 mg/24hr, 4 mg/24hr, 6 mg/24hr, 8 mg/24hr
4
pramipexole dihydrochloride tab 0.125 mg, 0.25 mg, 0.5 mg,
0.75 mg, 1 mg, 1.5 mg^
1
rasagiline mesylate tab 0.5 mg, 1 mg
4
ropinirole hydrochloride tab er 24hr 2 mg, 4 mg, 6 mg, 8 mg, 12 mg
4
ropinirole hydrochloride tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg,
4 mg, 5 mg
2
RYTARY - carbidopa & levodopa cap er 23.75-95 mg,
36.25-145 mg, 48.75-195 mg, 61.25-245 mg
3
selegiline hcl cap 5 mg
2
selegiline hcl tab 5 mg
3
tolcapone tab 100 mg
5
Antipsychotics
ABILIFY ASIMTUFII - aripiprazole im er susp prefilled syringe
720 mg/2.4ml, 960 mg/3.2ml
5 QL (1 syringe/56 days)
ABILIFY MAINTENA - aripiprazole im for er susp prefilled syringe
300 mg, 400 mg
5 QL (1 syringe/28 days)
ABILIFY MAINTENA - aripiprazole im for extended release susp
300 mg, 400 mg
5 QL (1 vial/28 days)
aripiprazole oral solution 1 mg/ml
4 PA (>=65 yr), QL
(750 mls/30 days)
aripiprazole orally disintegrating tab 10 mg, 15 mg
5 PA (>=65 yr), QL (60
tablets/30 days)
aripiprazole tab 2 mg, 5 mg
2 PA (>=65 yr), QL (45
tablets/30 days)
aripiprazole tab 10 mg, 15 mg, 20 mg, 30 mg
2 PA (>=65 yr), QL (30
tablets/30 days)
ARISTADA - aripiprazole lauroxil im er susp prefilled syr
441 mg/1.6ml, 662 mg/2.4ml, 882 mg/3.2ml
4 QL (1 syringe/28 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
25
Drug Name
Drug Tier Requirements/Limits
ARISTADA - aripiprazole lauroxil im er susp prefilled syr
1064 mg/3.9ml
4 QL (1 syringe/56 days)
ARISTADA INITIO - aripiprazole lauroxil im er susp prefilled syr
675 mg/2.4ml
4 QL (1 syringe/42 days)
asenapine maleate sl tab 2.5 mg, 5 mg, 10 mg
4 PA (>=65 yr), QL (60
tablets/30 days)
CAPLYTA - lumateperone tosylate cap 10.5 mg, 21 mg, 42 mg 5 QL (30 capsules/30 days)
CLOZAPINE ODT - clozapine orally disintegrating tab 12.5 mg 4 PA (>=65 yr), QL (90
tablets/30 days)
clozapine orally disintegrating tab 25 mg, 100 mg
4 PA (>=65 yr), QL (270
tablets/30 days)
clozapine orally disintegrating tab 150 mg
4 PA (>=65 yr), QL (180
tablets/30 days)
clozapine orally disintegrating tab 200 mg
4 PA (>=65 yr), QL (120
tablets/30 days)
clozapine tab 25 mg, 50 mg
2 PA (>=65 yr), QL (90
tablets/30 days)
clozapine tab 100 mg
2 PA (>=65 yr), QL (270
tablets/30 days)
clozapine tab 200 mg
3 PA (>=65 yr), QL (120
tablets/30 days)
FANAPT - iloperidone tab 1 mg, 2 mg, 4 mg 4 PA (>=65 yr), QL (60
tablets/30 days)
FANAPT - iloperidone tab 6 mg, 8 mg, 10 mg, 12 mg 5 PA (>=65 yr), QL (60
tablets/30 days)
FANAPT TITRATION PACK - iloperidone tab 1 mg & 2 mg & 4 mg
& 6 mg titration pak
4 PA (>=65 yr), QL (7 packs
(56 tablets)/28 days)
fluphenazine decanoate inj 25 mg/ml
4 PA (>=65 yr)
FLUPHENAZINE HCL - fluphenazine hcl inj 2.5 mg/ml 4 PA (>=65 yr)
FLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/ml 4 PA (>=65 yr)
fluphenazine hcl tab 1 mg, 2.5 mg, 5 mg, 10 mg
4 PA (>=65 yr)
FLUPHENAZINE HYDROCHLORIDE - fluphenazine hcl elixir
2.5 mg/5ml
4 PA (>=65 yr)
haloperidol decanoate im soln 50 mg/ml, 100 mg/ml
4 PA (>=65 yr)
haloperidol lactate inj 5 mg/ml
4 PA (>=65 yr)
haloperidol lactate oral conc 2 mg/ml
3 PA (>=65 yr)
haloperidol tab 0.5 mg, 1 mg, 2 mg, 5 mg, 10 mg, 20 mg
2 PA (>=65 yr)
INVEGA HAFYERA - paliperidone palmitate er susp pref syr
1,092 mg/3.5ml, 1,560 mg/5ml
5 QL (1 kit/180 days)
INVEGA SUSTENNA - paliperidone palmitate er susp pref syr
39 mg/0.25ml
4 QL (1 kit/28 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
26
Drug Name
Drug Tier Requirements/Limits
INVEGA SUSTENNA - paliperidone palmitate er susp pref syr
78 mg/0.5ml, 117 mg/0.75ml, 156 mg/ml, 234 mg/1.5ml
5 QL (1 kit/28 days)
INVEGA TRINZA - paliperidone palmitate er susp pref syr
273 mg/0.88ml, 410 mg/1.32ml, 546 mg/1.75ml, 819 mg/2.63ml
5 QL (1 kit/84 days)
LATUDA - lurasidone hcl tab 20 mg, 40 mg, 60 mg, 120 mg 5 QL (30 tablets/30 days)
LATUDA - lurasidone hcl tab 80 mg 5 QL (60 tablets/30 days)
loxapine succinate cap 5 mg, 10 mg, 25 mg
3 PA (>=65 yr)
loxapine succinate cap 50 mg
2 PA (>=65 yr)
lurasidone hcl tab 20 mg, 40 mg, 60 mg, 120 mg
5 QL (30 tablets/30 days)
lurasidone hcl tab 80 mg
5 QL (60 tablets/30 days)
LYBALVI - olanzapine-samidorphan l-malate tab 5-10 mg,
10-10 mg, 15-10 mg, 20-10 mg
5 PA (>=65 yr), QL (30
tablets/30 days)
MOLINDONE HYDROCHLORIDE - molindone hcl tab 5 mg, 10 mg,
25 mg
4 PA (>=65 yr)
NUPLAZID - pimavanserin tartrate cap 34 mg* 5 PA, QL (30 capsules/30 days)
NUPLAZID - pimavanserin tartrate tab 10 mg* 5 PA, QL (30 tablets/30 days)
olanzapine for im inj 10 mg
4 PA (>=65 yr), QL
(90 vials/30 days)
olanzapine orally disintegrating tab 5 mg, 10 mg, 15 mg, 20 mg
4 PA (>=65 yr), QL (30
tablets/30 days)
olanzapine tab 2.5 mg, 5 mg, 7.5 mg, 10 mg
2 PA (>=65 yr), QL (45
tablets/30 days)
olanzapine tab 15 mg, 20 mg
2 PA (>=65 yr), QL (30
tablets/30 days)
paliperidone tab er 24hr 1.5 mg, 3 mg, 9 mg
4 PA (>=65 yr), QL (30
tablets/30 days)
paliperidone tab er 24hr 6 mg
4 PA (>=65 yr), QL (60
tablets/30 days)
PERSERIS - risperidone subcutaneous for er susp prefilled syr
90 mg, 120 mg
5 QL (1 syringe/28 days)
PIMOZIDE - pimozide tab 1 mg, 2 mg 4
QUETIAPINE FUMARATE - quetiapine fumarate tab 150 mg 4 PA (>=65 yr), QL (150
tablets/30 days)
quetiapine fumarate tab er 24hr 50 mg, 300 mg, 400 mg
2 PA (>=65 yr), QL (60
tablets/30 days)
quetiapine fumarate tab er 24hr 150 mg, 200 mg
2 PA (>=65 yr), QL (30
tablets/30 days)
quetiapine fumarate tab 25 mg, 50 mg, 100 mg, 200 mg
2 PA (>=65 yr), QL (120
tablets/30 days)
quetiapine fumarate tab 300 mg, 400 mg
2 PA (>=65 yr), QL (60
tablets/30 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
27
Drug Name
Drug Tier Requirements/Limits
REXULTI - brexpiprazole tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg,
4 mg
4 PA (>=65 yr), QL (30
tablets/30 days)
RISPERDAL CONSTA - risperidone microspheres for im extended
rel susp 12.5 mg, 25 mg, 37.5 mg
4 QL (2 vials/28 days)
RISPERDAL CONSTA - risperidone microspheres for im extended
rel susp 50 mg
5 QL (2 vials/28 days)
RISPERIDONE ODT - risperidone orally disintegrating tab 0.25 mg 4 PA (>=65 yr), QL (60
tablets/30 days)
risperidone orally disintegrating tab 0.5 mg, 1 mg, 2 mg, 3 mg
4 PA (>=65 yr), QL (60
tablets/30 days)
risperidone orally disintegrating tab 4 mg
4 PA (>=65 yr), QL (120
tablets/30 days)
risperidone soln 1 mg/ml
3 PA (>=65 yr), QL
(480 mls/30 days)
risperidone tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg^
1 PA (>=65 yr), QL (60
tablets/30 days)
risperidone tab 4 mg^
1 PA (>=65 yr), QL (120
tablets/30 days)
SECUADO - asenapine td patch 24 hr 3.8 mg/24hr, 5.7 mg/24hr,
7.6 mg/24hr
5 PA (>=65 yr), QL (30
patches/30 days)
thioridazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg
3 PA (>=65 yr)
thiothixene cap 1 mg, 2 mg, 5 mg, 10 mg
2 PA (>=65 yr)
trifluoperazine hcl tab 1 mg, 2 mg, 5 mg, 10 mg
3 PA (>=65 yr)
UZEDY - risperidone subcutaneous er susp pref syr 50 mg/0.14ml,
75 mg/0.21ml, 100 mg/0.28ml, 125 mg/0.35ml
5 QL (1 syringe/28 days)
UZEDY - risperidone subcutaneous er susp pref syr
150 mg/0.42ml, 200 mg/0.56ml, 250 mg/0.7ml
5 QL (1 syringe/56 days)
VERSACLOZ - clozapine susp 50 mg/ml 4 PA (>=65 yr), QL
(540 mls/30 days)
VRAYLAR - cariprazine hcl cap 1.5 mg, 3 mg, 4.5 mg, 6 mg 4 QL (30 capsules/30 days)
ziprasidone hcl cap 20 mg, 40 mg
2 QL (90 capsules/30 days)
ziprasidone hcl cap 60 mg, 80 mg
2 QL (60 capsules/30 days)
ziprasidone mesylate for inj 20 mg
3 PA (>=65 yr), QL
(60 vials/30 days)
ZYPREXA RELPREVV - olanzapine pamoate for extended rel im
susp 210 mg
4 PA (>=65 yr), QL
(2 vials/28 days)
ZYPREXA RELPREVV - olanzapine pamoate for extended rel im
susp 300 mg
5 PA (>=65 yr), QL
(2 vials/28 days)
ZYPREXA RELPREVV - olanzapine pamoate for extended rel im
susp 405 mg
5 PA (>=65 yr), QL (1 vial/28 days)
Antispasticity Agents
baclofen tab 5 mg, 10 mg, 20 mg
2
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
28
Drug Name
Drug Tier Requirements/Limits
dantrolene sodium cap 25 mg, 50 mg, 100 mg
2
tizanidine hcl tab 2 mg, 4 mg^
1
Antivirals
abacavir sulfate soln 20 mg/ml
4 QL (960 mls/30 days)
abacavir sulfate tab 300 mg
3 QL (60 tablets/30 days)
abacavir sulfate-lamivudine tab 600-300 mg
4 QL (30 tablets/30 days)
abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg
5 QL (60 tablets/30 days)
acyclovir cap 200 mg^
1
acyclovir oint 5%
3 PA
acyclovir sodium iv soln 50 mg/ml
4 BD
acyclovir susp 200 mg/5ml
4
acyclovir tab 400 mg, 800 mg^
1
adefovir dipivoxil tab 10 mg
4
APTIVUS - tipranavir cap 250 mg 5 QL (120 capsules/30 days)
atazanavir sulfate cap 150 mg, 300 mg
4 QL (30 capsules/30 days)
atazanavir sulfate cap 200 mg
4 QL (60 capsules/30 days)
BARACLUDE - entecavir oral soln 0.05 mg/ml 5
BIKTARVY - bictegravir-emtricitabine-tenofovir af tab
30-120-15 mg, 50-200-25 mg
5 QL (30 tablets/30 days)
CIMDUO - lamivudine-tenofovir disoproxil fumarate tab 300-300 mg 5 QL (30 tablets/30 days)
COMPLERA - emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg
5 QL (30 tablets/30 days)
darunavir tab 600 mg
5 QL (60 tablets/30 days)
darunavir tab 800 mg
5 QL (30 tablets/30 days)
DELSTRIGO - doravirine-lamivudine-tenofovir df tab
100-300-300 mg
5 QL (30 tablets/30 days)
DESCOVY - emtricitabine-tenofovir alafenamide fumarate tab
120-15 mg, 200-25 mg
5 QL (30 tablets/30 days)
DOVATO - dolutegravir sodium-lamivudine tab 50-300 mg 5 QL (30 tablets/30 days)
EDURANT - rilpivirine hcl tab 25 mg 5 QL (30 tablets/30 days)
efavirenz cap 200 mg
4 QL (120 capsules/30 days)
efavirenz cap 50 mg
2 QL (90 capsules/30 days)
efavirenz tab 600 mg
4 QL (30 tablets/30 days)
efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg
5 QL (30 tablets/30 days)
efavirenz-lamivudine-tenofovir df tab 400-300-300 mg,
600-300-300 mg
5 QL (30 tablets/30 days)
emtricitabine caps 200 mg
4 QL (30 capsules/30 days)
emtricitabine-tenofovir disoproxil fumarate tab 100-150 mg,
133-200 mg, 167-250 mg, 200-300 mg
5 QL (30 tablets/30 days)
EMTRIVA - emtricitabine soln 10 mg/ml 4 QL (850 mls/30 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
29
Drug Name
Drug Tier Requirements/Limits
entecavir tab 0.5 mg, 1 mg
4
EPCLUSA - sofosbuvir-velpatasvir pellet pack 150-37.5 mg,
200-50 mg
5 PA
EPCLUSA - sofosbuvir-velpatasvir tab 200-50 mg, 400-100 mg 5 PA
etravirine tab 100 mg
4 QL (60 tablets/30 days)
etravirine tab 200 mg
5 QL (60 tablets/30 days)
EVOTAZ - atazanavir sulfate-cobicistat tab 300-150 mg 5 QL (30 tablets/30 days)
famciclovir tab 125 mg, 250 mg, 500 mg
2
fosamprenavir calcium tab 700 mg
4 QL (120 tablets/30 days)
FUZEON - enfuvirtide for inj 90 mg 5 QL (60 vials/30 days)
GENVOYA - elvitegrav-cobic-emtricitab-tenofov af tab
150-150-200-10 mg
5 QL (30 tablets/30 days)
HARVONI - ledipasvir-sofosbuvir pellet pack 33.75-150 mg,
45-200 mg
5 PA
HARVONI - ledipasvir-sofosbuvir tab 45-200 mg, 90-400 mg 5 PA
INTELENCE - etravirine tab 25 mg 4 QL (120 tablets/30 days)
ISENTRESS - raltegravir potassium chew tab 25 mg, 100 mg 3 QL (180 tablets/30 days)
ISENTRESS - raltegravir potassium packet for susp 100 mg 4 QL (60 packets/30 days)
ISENTRESS - raltegravir potassium tab 400 mg 5 QL (60 tablets/30 days)
ISENTRESS HD - raltegravir potassium tab 600 mg 5 QL (60 tablets/30 days)
JULUCA - dolutegravir sodium-rilpivirine hcl tab 50-25 mg 5 QL (30 tablets/30 days)
LAGEVRIO - molnupiravir cap 200 mg 4
lamivudine oral soln 10 mg/ml
3 QL (960 mls/30 days)
lamivudine tab 100 mg (hbv)
3
lamivudine tab 150 mg
3 QL (60 tablets/30 days)
lamivudine tab 300 mg
3 QL (30 tablets/30 days)
lamivudine-zidovudine tab 150-300 mg
3 QL (60 tablets/30 days)
LEDIPASVIR/SOFOSBUVIR - ledipasvir-sofosbuvir tab 90-400 mg 5 PA
LEXIVA - fosamprenavir calcium susp 50 mg/ml 4 QL (1800 mls/30 days)
lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)
4 QL (480 mls/30 days)
lopinavir-ritonavir tab 100-25 mg
4 QL (300 tablets/30 days)
lopinavir-ritonavir tab 200-50 mg
5 QL (120 tablets/30 days)
maraviroc tab 150 mg
5 QL (60 tablets/30 days)
maraviroc tab 300 mg
5 QL (120 tablets/30 days)
nevirapine susp 50 mg/5ml
4 QL (1200 mls/30 days)
nevirapine tab er 24hr 400 mg
3 QL (30 tablets/30 days)
nevirapine tab 200 mg
2 QL (60 tablets/30 days)
NORVIR - ritonavir oral soln 80 mg/ml 4 QL (480 mls/30 days)
NORVIR - ritonavir powder packet 100 mg 4 QL (360 packets/30 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
30
Drug Name
Drug Tier Requirements/Limits
ODEFSEY - emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg 5 QL (30 tablets/30 days)
oseltamivir phosphate cap 30 mg
2 QL (168 capsules/365 days)
oseltamivir phosphate cap 45 mg, 75 mg
2 QL (84 capsules/365 days)
oseltamivir phosphate for susp 6 mg/ml
3 QL (1080 mls/365 days)
PAXLOVID - nirmatrelvir tab 10 x 150 mg & ritonavir tab 10 x
100 mg pak
4 QL (20 tablets/30 days)
PAXLOVID - nirmatrelvir tab 20 x 150 mg & ritonavir tab 10 x
100 mg pak
4 QL (30 tablets/30 days)
PIFELTRO - doravirine tab 100 mg 5 QL (30 tablets/30 days)
PREVYMIS - letermovir tab 240 mg, 480 mg 5 QL (30 tablets/30 days)
PREZCOBIX - darunavir-cobicistat tab 800-150 mg 5 QL (30 tablets/30 days)
PREZISTA - darunavir oral susp 100 mg/ml 5 QL (400 mls/30 days)
PREZISTA - darunavir tab 75 mg 4 QL (300 tablets/30 days)
PREZISTA - darunavir tab 150 mg 5 QL (180 tablets/30 days)
PREZISTA - darunavir tab 600 mg 5 QL (60 tablets/30 days)
PREZISTA - darunavir tab 800 mg 5 QL (30 tablets/30 days)
RELENZA DISKHALER - zanamivir aerosol powder breath
activated 5 mg/act
4 QL (6 boxes/365 days)
REYATAZ - atazanavir sulfate oral powder packet 50 mg 5 QL (240 packets/30 days)
ribavirin cap 200 mg
3
ribavirin tab 200 mg
3
RIMANTADINE HYDROCHLORIDE - rimantadine hydrochloride tab
100 mg
4
ritonavir tab 100 mg
3 QL (360 tablets/30 days)
RUKOBIA - fostemsavir tromethamine tab er 12hr 600 mg 5 QL (60 tablets/30 days)
SELZENTRY - maraviroc oral soln 20 mg/ml 5 QL (1840 mls/30 days)
SELZENTRY - maraviroc tab 25 mg 4 QL (240 tablets/30 days)
SELZENTRY - maraviroc tab 75 mg 5 QL (60 tablets/30 days)
SOFOSBUVIR/VELPATASVIR - sofosbuvir-velpatasvir tab
400-100 mg
5 PA
SOVALDI - sofosbuvir pellet pack 150 mg, 200 mg 5 PA
SOVALDI - sofosbuvir tab 200 mg, 400 mg 5 PA
STRIBILD - elvitegrav-cobic-emtricitab-tenofovdf tab
150-150-200-300 mg
5 QL (30 tablets/30 days)
SUNLENCA - lenacapavir sodium tab therapy pack 4 x 300 mg 5 QL (4 tablets/28 days)
SUNLENCA - lenacapavir sodium tab therapy pack 5 x 300 mg 5 QL (5 tablets/28 days)
SYMTUZA - darunavir-cobic-emtricitab-tenofov af tab
800-150-200-10 mg
5 QL (30 tablets/30 days)
tenofovir disoproxil fumarate tab 300 mg
2 QL (30 tablets/30 days)
TIVICAY - dolutegravir sodium tab 10 mg 4 QL (240 tablets/30 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
31
Drug Name
Drug Tier Requirements/Limits
TIVICAY - dolutegravir sodium tab 25 mg, 50 mg 5 QL (60 tablets/30 days)
TIVICAY PD - dolutegravir sodium tab for oral susp 5 mg 5 QL (360 tablets/30 days)
TRIUMEQ - abacavir-dolutegravir-lamivudine tab 600-50-300 mg 5 QL (30 tablets/30 days)
TRIUMEQ PD - abacavir-dolutegravir-lamivudine tab for oral sus
60-5-30 mg
5 QL (180 tablets/30 days)
TRIZIVIR - abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg
5 QL (60 tablets/30 days)
TYBOST - cobicistat tab 150 mg 3 QL (30 tablets/30 days)
valacyclovir hcl tab 500 mg, 1 gm
2
valganciclovir hcl for soln 50 mg/ml
5
valganciclovir hcl tab 450 mg
3
VIRACEPT - nelfinavir mesylate tab 250 mg 5 QL (270 tablets/30 days)
VIRACEPT - nelfinavir mesylate tab 625 mg 4 QL (120 tablets/30 days)
VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/gm 5 QL (240 grams/30 days)
VIREAD - tenofovir disoproxil fumarate tab 150 mg, 200 mg,
250 mg
5 QL (30 tablets/30 days)
VOSEVI - sofosbuvir-velpatasvir-voxilaprevir tab 400-100-100 mg 5 PA
XOFLUZA - baloxavir marboxil tab therapy pack 1 x 40 mg (40 mg
dose)
4 QL (4 tablets/365 days)
XOFLUZA - baloxavir marboxil tab therapy pack 1 x 80 mg (80 mg
dose)
4 QL (2 tablets/365 days)
ZEPATIER - elbasvir-grazoprevir tab 50-100 mg 5 PA
zidovudine cap 100 mg
2 QL (180 capsules/30 days)
zidovudine syrup 10 mg/ml
4 QL (1920 mls/30 days)
zidovudine tab 300 mg
2 QL (60 tablets/30 days)
Anxiolytics
alprazolam tab 0.25 mg, 0.5 mg, 1 mg^
1 QL (120 tablets/30 days)
alprazolam tab 2 mg^
1 QL (150 tablets/30 days)
buspirone hcl tab 5 mg, 7.5 mg, 10 mg, 15 mg, 30 mg
2
clonazepam orally disintegrating tab 0.125 mg, 0.25 mg, 0.5 mg,
1 mg
4 QL (90 tablets/30 days)
clonazepam orally disintegrating tab 2 mg
4 QL (300 tablets/30 days)
clonazepam tab 0.5 mg, 1 mg^
1 QL (120 tablets/30 days)
clonazepam tab 2 mg^
1 QL (300 tablets/30 days)
clorazepate dipotassium tab 3.75 mg
3 PA, QL (120 tablets/30 days)
clorazepate dipotassium tab 7.5 mg
3 PA, QL (360 tablets/30 days)
clorazepate dipotassium tab 15 mg
3 PA, QL (180 tablets/30 days)
diazepam conc 5 mg/ml
3 PA, QL (240 mls/30 days)
diazepam oral soln 1 mg/ml
2 PA, QL (1200 mls/30 days)
diazepam tab 2 mg, 5 mg, 10 mg^
1 PA, QL (120 tablets/30 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
32
Drug Name
Drug Tier Requirements/Limits
hydroxyzine hcl syrup 10 mg/5ml#
4 PA (>=65 yr)
hydroxyzine hcl tab 10 mg, 25 mg, 50 mg#
2 PA (>=65 yr)
lorazepam conc 2 mg/ml
2 PA, QL (150 mls/30 days)
lorazepam tab 0.5 mg, 1 mg^
1 PA, QL (120 tablets/30 days)
lorazepam tab 2 mg^
1 PA, QL (150 tablets/30 days)
oxazepam cap 10 mg, 15 mg, 30 mg
4 PA, QL (120 capsules/30 days)
Bipolar Agents
LITHIUM - lithium oral solution 8 meq/5ml 4
lithium carbonate cap 150 mg, 300 mg^
1
lithium carbonate cap 600 mg^
1
lithium carbonate tab er 300 mg, 450 mg
2
lithium carbonate tab 300 mg^
1
Blood Glucose Regulators
acarbose tab 25 mg
2 QL (360 tablets/30 days)
acarbose tab 50 mg
2 QL (180 tablets/30 days)
acarbose tab 100 mg
2 QL (90 tablets/30 days)
ALCOHOL SWABS 3
BAQSIMI ONE PACK - glucagon nasal powder 3 mg/dose 4 QL (4 devices/30 days)
BAQSIMI TWO PACK - glucagon nasal powder 3 mg/dose 4 QL (4 devices/30 days)
BYDUREON BCISE - exenatide extended release susp auto-
injector 2 mg/0.85ml
3 QL (4 pens/28 days), ST
BYETTA - exenatide soln pen-injector 5 mcg/0.02ml 4 QL (2 pens/30 days), ST
BYETTA - exenatide soln pen-injector 10 mcg/0.04ml 4 QL (1 pen/30 days), ST
CYCLOSET - bromocriptine mesylate tab 0.8 mg 4 QL (180 tablets/30 days)
diazoxide susp 50 mg/ml
4
FARXIGA - dapagliflozin propanediol tab 5 mg 3 QL (60 tablets/30 days)
FARXIGA - dapagliflozin propanediol tab 10 mg 3 QL (30 tablets/30 days)
GAUZE PADS 2" X 2" 3
glimepiride tab 1 mg#^
1 QL (240 tablets/30 days)
glimepiride tab 2 mg#^
1 QL (120 tablets/30 days)
glimepiride tab 4 mg#^
1 QL (60 tablets/30 days)
glipizide tab er 24hr 2.5 mg^
1 QL (240 tablets/30 days)
glipizide tab er 24hr 5 mg^
1 QL (120 tablets/30 days)
glipizide tab er 24hr 10 mg^
1 QL (60 tablets/30 days)
glipizide tab 5 mg^
1 QL (240 tablets/30 days)
glipizide tab 10 mg^
1 QL (120 tablets/30 days)
glipizide-metformin hcl tab 2.5-250 mg^
1 QL (240 tablets/30 days)
glipizide-metformin hcl tab 2.5-500 mg, 5-500 mg^
1 QL (120 tablets/30 days)
GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj 1 mg 3 QL (4 kits/30 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
33
Drug Name
Drug Tier Requirements/Limits
glucagon (rdna) for inj kit 1 mg
3 QL (4 kits/30 days)
GLUCAGON EMERGENCY KIT - glucagon (rdna) for inj kit 1 mg 3 QL (4 kits/30 days)
GLUCAGON EMERGENCY KIT FOR LOW BLOOD SUGAR
- glucagon hcl for inj 1 mg
3 QL (4 kits/30 days)
glyburide micronized tab 1.5 mg#
2 QL (240 tablets/30 days)
glyburide micronized tab 3 mg#
2 QL (120 tablets/30 days)
glyburide micronized tab 6 mg#
2 QL (60 tablets/30 days)
glyburide tab 1.25 mg#
2 QL (480 tablets/30 days)
glyburide tab 2.5 mg#
2 QL (240 tablets/30 days)
glyburide tab 5 mg#
2 QL (120 tablets/30 days)
glyburide-metformin tab 1.25-250 mg#
2 QL (240 tablets/30 days)
glyburide-metformin tab 2.5-500 mg, 5-500 mg#
2 QL (120 tablets/30 days)
GLYXAMBI - empagliflozin-linagliptin tab 10-5 mg, 25-5 mg 4 QL (30 tablets/30 days)
GVOKE HYPOPEN 1-PACK - glucagon subcutaneous solution
auto-injector 0.5 mg/0.1ml, 1 mg/0.2ml
4 QL (4 syringes/30 days)
GVOKE HYPOPEN 2-PACK - glucagon subcutaneous solution
auto-injector 0.5 mg/0.1ml, 1 mg/0.2ml
4 QL (4 syringes/30 days)
GVOKE KIT - glucagon subcutaneous soln 1 mg/0.2ml 4 QL (4 vials/30 days)
GVOKE PFS - glucagon subcutaneous soln pref syringe
0.5 mg/0.1ml, 1 mg/0.2ml
4 QL (4 syringes/30 days)
HUMALOG - insulin lispro inj soln 100 unit/ml 3 QL (60 mls/30 days)
HUMALOG - insulin lispro soln cartridge 100 unit/ml 3 QL (20 cartridges/30 days)
HUMALOG JUNIOR KWIKPEN - insulin lispro soln pen-injector 100
unit/ml (0.5 unit dial)
3 QL (20 pens/30 days)
HUMALOG KWIKPEN - insulin lispro soln pen-injector 100 unit/ml
(1 unit dial), 200 unit/ml
3 QL (20 pens/30 days)
HUMALOG MIX 50/50 - insulin lispro protamine & lispro inj 100
unit/ml (50-50)
3 QL (6 vials/30 days)
HUMALOG MIX 50/50 KWIKPEN - insulin lispro prot & lispro sus
pen-inj 100 unit/ml (50-50)
3 QL (20 pens/30 days)
HUMALOG MIX 75/25 - insulin lispro prot & lispro inj 100 unit/ml
(75-25)
3 QL (6 vials/30 days)
HUMALOG MIX 75/25 KWIKPEN - insulin lispro prot & lispro sus
pen-inj 100 unit/ml (75-25)
3 QL (20 pens/30 days)
HUMALOG TEMPO PEN - insulin lispro soln pen-inj w/transmitter
port 100 unit/ml
3 QL (20 pens/30 days)
HUMULIN N - insulin nph (human) (isophane) inj 100 unit/ml 3 QL (60 mls/30 days)
HUMULIN N KWIKPEN - insulin nph (human) (isophane) susp pen-
injector 100 unit/ml
3 QL (20 pens/30 days)
HUMULIN R - insulin regular (human) inj 100 unit/ml 3 QL (60 mls/30 days)
HUMULIN R U-500 (CONCENTRATE) - insulin regular (human) inj
500 unit/ml
3 BD
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
34
Drug Name
Drug Tier Requirements/Limits
HUMULIN R U-500 KWIKPEN - insulin regular (human) soln pen-
injector 500 unit/ml
3 QL (20 pens/30 days)
HUMULIN 70/30 - insulin nph isophane & regular human inj 100
unit/ml (70-30)
3 QL (60 mls/30 days)
HUMULIN 70/30 KWIKPEN - insulin nph & regular susp pen-inj 100
unit/ml (70-30)
3 QL (20 pens/30 days)
INSULIN INJECTION DEVICE 3
INSULIN SYRINGE/NEEDLE 3
JANUMET - sitagliptin-metformin hcl tab 50-500 mg, 50-1000 mg 3 QL (60 tablets/30 days)
JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-500 mg,
50-1000 mg
3 QL (60 tablets/30 days)
JANUMET XR - sitagliptin-metformin hcl tab er 24hr 100-1000 mg 3 QL (30 tablets/30 days)
JANUVIA - sitagliptin phosphate tab 25 mg 3 QL (120 tablets/30 days)
JANUVIA - sitagliptin phosphate tab 50 mg 3 QL (60 tablets/30 days)
JANUVIA - sitagliptin phosphate tab 100 mg 3 QL (30 tablets/30 days)
JARDIANCE - empagliflozin tab 10 mg 3 QL (60 tablets/30 days)
JARDIANCE - empagliflozin tab 25 mg 3 QL (30 tablets/30 days)
LANTUS - insulin glargine inj 100 unit/ml 3 QL (6 vials/30 days)
LANTUS SOLOSTAR - insulin glargine soln pen-injector 100 unit/ml 3 QL (20 pens/30 days)
LEVEMIR - insulin detemir inj 100 unit/ml 3 QL (6 vials/30 days)
LEVEMIR FLEXPEN - insulin detemir soln pen-injector 100 unit/ml 3 QL (20 pens/30 days)
LEVEMIR FLEXTOUCH - insulin detemir soln pen-injector 100 unit/
ml
3 QL (20 pens/30 days)
LYUMJEV - insulin lispro-aabc inj 100 unit/ml 3 QL (6 vials/30 days)
LYUMJEV KWIKPEN - insulin lispro-aabc soln pen-injector 200
unit/ml
3 QL (20 pens/30 days)
LYUMJEV KWIKPEN - insulin lispro-aabc soln pen-inj 100 unit/ml
(1 unit dial)
3 QL (20 pens/30 days)
LYUMJEV TEMPO PEN - insulin lispro-aabc soln pen-inj w/transmit
port 100 unit/ml
3 QL (20 pens/30 days)
metformin hcl tab er 24hr 500 mg^
1 QL (120 tablets/30 days)
metformin hcl tab er 24hr 750 mg^
1 QL (60 tablets/30 days)
metformin hcl tab 500 mg^
1 QL (150 tablets/30 days)
metformin hcl tab 850 mg^
1 QL (90 tablets/30 days)
metformin hcl tab 1000 mg^
1 QL (75 tablets/30 days)
nateglinide tab 60 mg
2 QL (180 tablets/30 days)
nateglinide tab 120 mg
2 QL (90 tablets/30 days)
OMNIPOD CLASSIC PODS (GEN 3) - insulin infusion disposable
pump reservoir
3
OMNIPOD DASH INTRO KIT (GEN 4) - insulin infusion disposable
pump kit
3
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
35
Drug Name
Drug Tier Requirements/Limits
OMNIPOD DASH PDM KIT (GEN 4) - insulin infusion disposable
pump kit
3
OMNIPOD DASH PODS (GEN 4) - insulin infusion disposable
pump reservoir
3
OMNIPOD GO 10 UNITS/DAY - insulin infusion disposable pump
kit 10 unit/24hr
3
OMNIPOD GO 15 UNITS/DAY - insulin infusion disposable pump
kit 15 unit/24hr
3
OMNIPOD GO 20 UNITS/DAY - insulin infusion disposable pump
kit 20 unit/24hr
3
OMNIPOD GO 25 UNITS/DAY - insulin infusion disposable pump
kit 25 unit/24hr
3
OMNIPOD GO 30 UNITS/DAY - insulin infusion disposable pump
kit 30 unit/24hr
3
OMNIPOD GO 35 UNITS/DAY - insulin infusion disposable pump
kit 35 unit/24hr
3
OMNIPOD GO 40 UNITS/DAY - insulin infusion disposable pump
kit 40 unit/24hr
3
OMNIPOD 5 G6 INTRO KIT (GEN 5) - insulin infusion disposable
pump kit
3
OMNIPOD 5 G6 PODS (GEN 5) - insulin infusion disposable pump
reservoir
3
OZEMPIC - semaglutide soln pen-inj 0.25 or 0.5 mg/dose
(2 mg/3ml), 1 mg/dose (4 mg/3ml), 2 mg/dose (8 mg/3ml)
3 QL (1 pen/28 days), ST
pioglitazone hcl tab 15 mg^
1 QL (90 tablets/30 days)
pioglitazone hcl tab 30 mg, 45 mg^
1 QL (30 tablets/30 days)
pioglitazone hcl-glimepiride tab 30-2 mg, 30-4 mg#
3 QL (30 tablets/30 days)
pioglitazone hcl-metformin hcl tab 15-500 mg, 15-850 mg
2 QL (90 tablets/30 days)
repaglinide tab 0.5 mg^
1 QL (960 tablets/30 days)
repaglinide tab 1 mg^
1 QL (480 tablets/30 days)
repaglinide tab 2 mg^
1 QL (240 tablets/30 days)
RYBELSUS - semaglutide tab 3 mg, 7 mg, 14 mg 3 QL (30 tablets/30 days), ST
SYMLINPEN 120 - pramlintide acetate pen-inj 2700 mcg/2.7ml
(1000 mcg/ml)
5
SYMLINPEN 60 - pramlintide acetate pen-inj 1500 mcg/1.5ml
(1000 mcg/ml)
5
SYNJARDY - empagliflozin-metformin hcl tab 5-500 mg 3 QL (120 tablets/30 days)
SYNJARDY - empagliflozin-metformin hcl tab 5-1000 mg,
12.5-500 mg, 12.5-1000 mg
3 QL (60 tablets/30 days)
SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr
5-1000 mg, 10-1000 mg, 12.5-1000 mg
3 QL (60 tablets/30 days)
SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr
25-1000 mg
3 QL (30 tablets/30 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
36
Drug Name
Drug Tier Requirements/Limits
TOUJEO MAX SOLOSTAR - insulin glargine soln pen-injector 300
unit/ml (2 unit dial)
3 QL (60 mls/30 days)
TOUJEO SOLOSTAR - insulin glargine soln pen-injector 300 unit/
ml (1 unit dial)
3 QL (60 mls/30 days)
TRESIBA - insulin degludec inj 100 unit/ml 3 QL (6 vials/30 days)
TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 100
unit/ml, 200 unit/ml
3 QL (20 pens/30 days)
TRULICITY - dulaglutide soln pen-injector 0.75 mg/0.5ml,
1.5 mg/0.5ml, 3 mg/0.5ml, 4.5 mg/0.5ml
3 QL (4 pens/28 days), ST
V-GO 20 - insulin infusion disposable pump kit 20 unit/24hr 3
V-GO 30 - insulin infusion disposable pump kit 30 unit/24hr 3
V-GO 40 - insulin infusion disposable pump kit 40 unit/24hr 3
VICTOZA - liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) 3 QL (3 pens/30 days), ST
XIGDUO XR - dapagliflozin prop-metformin hcl tab er 24hr
2.5-1000 mg, 5-500 mg, 5-1000 mg
3 QL (60 tablets/30 days)
XIGDUO XR - dapagliflozin prop-metformin hcl tab er 24hr
10-500 mg, 10-1000 mg
3 QL (30 tablets/30 days)
Blood Products and Modifiers
anagrelide hcl cap 0.5 mg, 1 mg
3
ARANESP ALBUMIN FREE - darbepoetin alfa soln inj 25 mcg/ml,
40 mcg/ml, 60 mcg/ml
4 PA
ARANESP ALBUMIN FREE - darbepoetin alfa soln inj 100 mcg/ml,
200 mcg/ml
5 PA
ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe
10 mcg/0.4ml, 25 mcg/0.42ml, 40 mcg/0.4ml
4 PA
ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe
60 mcg/0.3ml, 100 mcg/0.5ml, 150 mcg/0.3ml, 200 mcg/0.4ml,
300 mcg/0.6ml, 500 mcg/ml
5 PA
aspirin-dipyridamole cap er 12hr 25-200 mg
4
BRILINTA - ticagrelor tab 60 mg, 90 mg 3
CABLIVI - caplacizumab-yhdp for inj kit 11 mg 5
cilostazol tab 50 mg, 100 mg
2
clopidogrel bisulfate tab 75 mg^
1
dabigatran etexilate mesylate cap 75 mg, 150 mg
4 QL (60 capsules/30 days)
dipyridamole tab 25 mg, 50 mg, 75 mg#
2
ELIQUIS - apixaban tab 2.5 mg 3 QL (60 tablets/30 days)
ELIQUIS - apixaban tab 5 mg 3 QL (74 tablets/30 days)
ELIQUIS STARTER PACK - apixaban tab starter pack 5 mg 3 QL (74 tablets/30 days)
enoxaparin sodium inj soln pref syr 30 mg/0.3ml, 40 mg/0.4ml,
60 mg/0.6ml, 80 mg/0.8ml, 100 mg/ml, 120 mg/0.8ml, 150 mg/ml
4 QL (30 syringes/90 days)
enoxaparin sodium inj 300 mg/3ml
4 QL (10 vials/90 days)
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml
4 QL (30 syringes/90 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
37
Drug Name
Drug Tier Requirements/Limits
fondaparinux sodium subcutaneous inj 5 mg/0.4ml, 7.5 mg/0.6ml,
10 mg/0.8ml
5 QL (30 syringes/90 days)
FULPHILA - pegfilgrastim-jmdb soln prefilled syringe 6 mg/0.6ml 5 PA
GRANIX - tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml,
480 mcg/0.8ml
5 PA
GRANIX - tbo-filgrastim subcutaneous inj 300 mcg/ml,
480 mcg/1.6ml (300 mcg/ml)
5 PA
heparin sodium (porcine) inj soln pref syr 5000 unit/0.5ml
3
heparin sodium (porcine) inj 1000 unit/ml, 5000 unit/ml, 10000 unit/
ml, 20000 unit/ml
3
heparin sodium (porcine) pf inj 5000 unit/ml
3
heparin sodium (porcine) pf inj 5000 unit/0.5ml
3
LEUKINE - sargramostim lyophilized for inj 250 mcg 5 PA
NIVESTYM - filgrastim-aafi inj 300 mcg/ml, 480 mcg/1.6ml
(300 mcg/ml)
5 PA
NIVESTYM - filgrastim-aafi soln prefilled syringe 300 mcg/0.5ml,
480 mcg/0.8ml
5 PA
PRADAXA - dabigatran etexilate mesylate cap 110 mg 4 QL (120 capsules/30 days)
prasugrel hcl tab 5 mg, 10 mg
2
PROCRIT - epoetin alfa inj 2000 unit/ml, 3000 unit/ml, 4000 unit/ml,
10000 unit/ml
4 PA
PROCRIT - epoetin alfa inj 20000 unit/ml, 40000 unit/ml 5 PA
PROMACTA - eltrombopag olamine powder pack for susp 25 mg,
12.5 mg*
5 PA
PROMACTA - eltrombopag olamine tab 12.5 mg, 25 mg, 50 mg,
75 mg*
5 PA
RETACRIT - epoetin alfa-epbx inj 2000 unit/ml, 3000 unit/ml, 4000
unit/ml, 10000 unit/ml, 20000 unit/ml, 40000 unit/ml
4 PA
tranexamic acid tab 650 mg
3
UDENYCA - pegfilgrastim-cbqv soln auto-injector 6 mg/0.6ml 5 PA
UDENYCA - pegfilgrastim-cbqv soln prefilled syringe 6 mg/0.6ml 5 PA
warfarin sodium tab 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg,
7.5 mg, 10 mg^
1
XARELTO - rivaroxaban for susp 1 mg/ml 3 QL (4 bottles/30 days)
XARELTO - rivaroxaban tab 2.5 mg, 15 mg 3 QL (60 tablets/30 days)
XARELTO - rivaroxaban tab 10 mg, 20 mg 3 QL (30 tablets/30 days)
XARELTO STARTER PACK - rivaroxaban tab starter therapy pack
15 mg & 20 mg
3 QL (51 tablets/30 days)
ZIEXTENZO - pegfilgrastim-bmez soln prefilled syringe 6 mg/0.6ml 5 PA
ZONTIVITY - vorapaxar sulfate tab 2.08 mg 4
Cardiovascular Agents
acebutolol hcl cap 200 mg, 400 mg
2
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
38
Drug Name
Drug Tier Requirements/Limits
acetazolamide cap er 12hr 500 mg
2
acetazolamide tab 125 mg, 250 mg
2
aliskiren fumarate tab 150 mg, 300 mg
2 QL (30 tablets/30 days)
amiloride & hydrochlorothiazide tab 5-50 mg
2
amiloride hcl tab 5 mg
2
amiodarone hcl tab 100 mg
4
amiodarone hcl tab 200 mg, 400 mg
2
amlodipine besylate tab 2.5 mg, 5 mg, 10 mg^
1
amlodipine besylate-atorvastatin calcium tab 2.5-10 mg, 2.5-20 mg,
2.5-40 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg, 10-10 mg,
10-20 mg, 10-40 mg, 10-80 mg
2
amlodipine besylate-benazepril hcl cap 2.5-10 mg, 5-10 mg,
5-20 mg, 5-40 mg, 10-20 mg, 10-40 mg^
1
amlodipine besylate-olmesartan medoxomil tab 5-20 mg, 5-40 mg,
10-20 mg, 10-40 mg
2 QL (30 tablets/30 days)
amlodipine besylate-valsartan tab 5-160 mg, 5-320 mg, 10-160 mg,
10-320 mg^
1 QL (30 tablets/30 days)
amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg,
5-160-25 mg, 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg
2 QL (30 tablets/30 days)
atenolol & chlorthalidone tab 50-25 mg, 100-25 mg^
1
atenolol tab 25 mg, 50 mg, 100 mg^
1
atorvastatin calcium tab 10 mg, 20 mg, 40 mg^
1 QL (45 tablets/30 days)
atorvastatin calcium tab 80 mg^
1 QL (30 tablets/30 days)
benazepril & hydrochlorothiazide tab 5-6.25 mg, 10-12.5 mg,
20-12.5 mg, 20-25 mg^
1
benazepril hcl tab 5 mg, 10 mg, 20 mg, 40 mg^
1
betaxolol hcl tab 10 mg, 20 mg
2
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg, 5-6.25 mg,
10-6.25 mg^
1
bisoprolol fumarate tab 5 mg, 10 mg
2
bumetanide inj 0.25 mg/ml
4
bumetanide tab 0.5 mg, 1 mg, 2 mg
2
candesartan cilexetil tab 4 mg, 8 mg, 16 mg
2 QL (60 tablets/30 days)
candesartan cilexetil tab 32 mg
2 QL (30 tablets/30 days)
candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg,
32-12.5 mg, 32-25 mg
2 QL (30 tablets/30 days)
captopril tab 12.5 mg, 25 mg, 50 mg, 100 mg
2
carvedilol tab 3.125 mg, 6.25 mg, 12.5 mg, 25 mg^
1
chlorthalidone tab 25 mg, 50 mg
2
cholestyramine light powder packets 4 gm
3
cholestyramine light powder 4 gm/dose
3
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
39
Drug Name
Drug Tier Requirements/Limits
cholestyramine powder packets 4 gm
3
cholestyramine powder 4 gm/dose
3
choline fenofibrate cap dr 45 mg
2 QL (60 capsules/30 days)
choline fenofibrate cap dr 135 mg
2 QL (30 capsules/30 days)
clonidine hcl tab 0.1 mg, 0.2 mg, 0.3 mg^
1
clonidine td patch weekly 0.1 mg/24hr, 0.2 mg/24hr, 0.3 mg/24hr
2
colestipol hcl granule packets 5 gm
3
colestipol hcl granules 5 gm
3
colestipol hcl tab 1 gm
2
CORLANOR - ivabradine hcl oral soln 5 mg/5ml 3 PA, QL (600 mls/30 days)
CORLANOR - ivabradine hcl tab 5 mg, 7.5 mg 3 PA, QL (60 tablets/30 days)
digoxin oral soln 0.05 mg/ml#
4 QL (150 mls/30 days)
digoxin tab 125 mcg (0.125 mg), 250 mcg (0.25 mg)#
2 QL (30 tablets/30 days)
diltiazem hcl cap er 12hr 60 mg, 90 mg, 120 mg
2
diltiazem hcl cap er 24hr 120 mg, 180 mg, 240 mg
2
diltiazem hcl coated beads cap er 24hr 120 mg, 180 mg, 240 mg,
300 mg, 360 mg
2
diltiazem hcl extended release beads cap er 24hr 120 mg, 180 mg,
240 mg, 300 mg, 360 mg, 420 mg
2
diltiazem hcl tab er 24hr 120 mg, 180 mg, 240 mg, 300 mg,
360 mg, 420 mg
2
diltiazem hcl tab 30 mg, 60 mg, 90 mg, 120 mg
2
dofetilide cap 125 mcg (0.125 mg), 250 mcg (0.25 mg), 500 mcg
(0.5 mg)
4
doxazosin mesylate tab 1 mg, 2 mg, 4 mg, 8 mg
2 QL (60 tablets/30 days)
droxidopa cap 100 mg, 200 mg, 300 mg
5 PA
enalapril maleate & hydrochlorothiazide tab 5-12.5 mg, 10-25 mg^
1
enalapril maleate tab 2.5 mg, 5 mg, 10 mg, 20 mg^
1
ENTRESTO - sacubitril-valsartan tab 24-26 mg 3 QL (180 tablets/30 days)
ENTRESTO - sacubitril-valsartan tab 49-51 mg, 97-103 mg 3 QL (60 tablets/30 days)
eplerenone tab 25 mg, 50 mg
2
ezetimibe tab 10 mg
2 QL (30 tablets/30 days)
ezetimibe-simvastatin tab 10-10 mg, 10-20 mg, 10-40 mg,
10-80 mg
2 QL (30 tablets/30 days)
felodipine tab er 24hr 2.5 mg, 5 mg, 10 mg
2
fenofibrate micronized cap 67 mg, 134 mg, 200 mg
2 QL (30 capsules/30 days)
fenofibrate tab 48 mg, 54 mg
2 QL (60 tablets/30 days)
fenofibrate tab 145 mg, 160 mg
2 QL (30 tablets/30 days)
flecainide acetate tab 50 mg, 100 mg, 150 mg
2
fluvastatin sodium cap 20 mg, 40 mg
2 QL (60 capsules/30 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
40
Drug Name
Drug Tier Requirements/Limits
fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg,
20-12.5 mg^
1
fosinopril sodium tab 10 mg, 20 mg, 40 mg^
1
furosemide inj 10 mg/ml
4
furosemide oral soln 8 mg/ml
2
furosemide oral soln 10 mg/ml
2
furosemide tab 20 mg, 40 mg, 80 mg^
1
gemfibrozil tab 600 mg^
1 QL (60 tablets/30 days)
guanfacine hcl tab 1 mg, 2 mg#
3
hydralazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg^
1
hydrochlorothiazide cap 12.5 mg^
1
hydrochlorothiazide tab 12.5 mg, 25 mg, 50 mg^
1
icosapent ethyl cap 0.5 gm
3 QL (240 capsules/30 days)
icosapent ethyl cap 1 gm
3 QL (120 capsules/30 days)
indapamide tab 1.25 mg, 2.5 mg^
1
irbesartan tab 75 mg, 150 mg, 300 mg^
1 QL (30 tablets/30 days)
irbesartan-hydrochlorothiazide tab 150-12.5 mg, 300-12.5 mg^
1 QL (30 tablets/30 days)
isosorbide dinitrate tab 5 mg, 10 mg, 20 mg, 30 mg
2
isosorbide mononitrate tab er 24hr 30 mg, 60 mg^
1
isosorbide mononitrate tab er 24hr 120 mg
2
isosorbide mononitrate tab 10 mg
2
isosorbide mononitrate tab 20 mg^
1
isradipine cap 2.5 mg, 5 mg
2
KERENDIA - finerenone tab 10 mg, 20 mg 3 PA, QL (30 tablets/30 days)
labetalol hcl tab 100 mg, 200 mg, 300 mg
2
lisinopril & hydrochlorothiazide tab 10-12.5 mg, 20-12.5 mg,
20-25 mg^
1
lisinopril tab 2.5 mg, 5 mg, 10 mg, 20 mg, 30 mg, 40 mg^
1
losartan potassium & hydrochlorothiazide tab 50-12.5 mg,
100-12.5 mg, 100-25 mg^
1 QL (30 tablets/30 days)
losartan potassium tab 25 mg, 50 mg^
1 QL (60 tablets/30 days)
losartan potassium tab 100 mg^
1 QL (30 tablets/30 days)
lovastatin tab 10 mg, 20 mg, 40 mg^
1 QL (60 tablets/30 days)
methazolamide tab 25 mg
3
methazolamide tab 50 mg
4
metolazone tab 2.5 mg, 5 mg, 10 mg
2
metoprolol & hydrochlorothiazide tab 50-25 mg, 100-25 mg,
100-50 mg
2
metoprolol succinate tab er 24hr 25 mg, 50 mg, 100 mg, 200 mg^
1
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
41
Drug Name
Drug Tier Requirements/Limits
metoprolol tartrate tab 25 mg, 50 mg, 100 mg^
1
metoprolol tartrate tab 37.5 mg, 75 mg
2
metyrosine cap 250 mg
5
mexiletine hcl cap 150 mg, 200 mg, 250 mg
3
midodrine hcl tab 2.5 mg, 5 mg, 10 mg
3
minoxidil tab 2.5 mg, 10 mg
2
moexipril hcl tab 7.5 mg, 15 mg^
1
MULTAQ - dronedarone hcl tab 400 mg 4
nadolol tab 20 mg, 40 mg, 80 mg
2
nebivolol hcl tab 2.5 mg, 5 mg, 10 mg, 20 mg
3
niacin tab er 500 mg
3 QL (30 tablets/30 days)
niacin tab er 750 mg, 1000 mg
3 QL (60 tablets/30 days)
nicardipine hcl cap 20 mg, 30 mg
3
nifedipine tab er 24hr 30 mg, 60 mg, 90 mg
2
nifedipine tab er 24hr osmotic release 30 mg, 60 mg, 90 mg
2
nimodipine cap 30 mg
4
NISOLDIPINE ER - nisoldipine tab er 24hr 20 mg, 30 mg, 40 mg 4
NISOLDIPINE ER - nisoldipine tab er 24hr 25.5 mg 3
nisoldipine tab er 24hr 8.5 mg, 17 mg, 34 mg
3
NITRO-BID - nitroglycerin oint 2% 4
nitroglycerin sl tab 0.3 mg, 0.4 mg, 0.6 mg
2
nitroglycerin td patch 24hr 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/
hr
2
nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)
3
olmesartan medoxomil tab 5 mg^
1 QL (60 tablets/30 days)
olmesartan medoxomil tab 20 mg, 40 mg^
1 QL (30 tablets/30 days)
olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg,
40-12.5 mg, 40-25 mg^
1 QL (30 tablets/30 days)
olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5 mg,
40-5-12.5 mg, 40-5-25 mg, 40-10-12.5 mg, 40-10-25 mg
2 QL (30 tablets/30 days)
omega-3-acid ethyl esters cap 1 gm
2
pentoxifylline tab er 400 mg
2
perindopril erbumine tab 2 mg, 4 mg, 8 mg^
1
phenoxybenzamine hcl cap 10 mg
5
pindolol tab 5 mg, 10 mg
2
pravastatin sodium tab 10 mg, 20 mg, 40 mg^
1 QL (45 tablets/30 days)
pravastatin sodium tab 80 mg^
1 QL (30 tablets/30 days)
prazosin hcl cap 1 mg, 2 mg, 5 mg
2
propafenone hcl cap er 12hr 225 mg, 325 mg, 425 mg
4
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
42
Drug Name
Drug Tier Requirements/Limits
propafenone hcl tab 150 mg, 225 mg, 300 mg
2
propranolol hcl cap er 24hr 60 mg, 80 mg, 120 mg, 160 mg
2
propranolol hcl oral soln 20 mg/5ml
2
propranolol hcl oral soln 40 mg/5ml
2
propranolol hcl tab 10 mg, 20 mg, 40 mg, 60 mg, 80 mg
2
quinapril hcl tab 5 mg, 10 mg, 20 mg, 40 mg^
1
quinapril-hydrochlorothiazide tab 20-12.5 mg, 20-25 mg^
1
quinidine gluconate tab er 324 mg
4
quinidine sulfate tab 200 mg
2
quinidine sulfate tab 300 mg
2
ramipril cap 1.25 mg, 2.5 mg, 5 mg, 10 mg^
1
ranolazine tab er 12hr 500 mg, 1000 mg
2 QL (60 tablets/30 days)
RECTIV - nitroglycerin oint 0.4% 4
REPATHA - evolocumab subcutaneous soln prefilled syringe
140 mg/ml
3 PA, QL (2 syringes/28 days)
REPATHA PUSHTRONEX SYSTEM - evolocumab subcutaneous
soln cartridge/infusor 420 mg/3.5ml
3 PA, QL (2 systems/28 days)
REPATHA SURECLICK - evolocumab subcutaneous soln auto-
injector 140 mg/ml
3 PA, QL (2 pens/28 days)
rosuvastatin calcium tab 5 mg, 10 mg, 20 mg^
1 QL (45 tablets/30 days)
rosuvastatin calcium tab 40 mg^
1 QL (30 tablets/30 days)
simvastatin tab 5 mg, 10 mg, 40 mg^
1 QL (45 tablets/30 days)
simvastatin tab 20 mg^
1 QL (60 tablets/30 days)
simvastatin tab 80 mg^
1 QL (30 tablets/30 days)
sotalol hcl (afib/afl) tab 80 mg, 120 mg, 160 mg
2
sotalol hcl tab 80 mg, 120 mg, 160 mg, 240 mg
2
spironolactone & hydrochlorothiazide tab 25-25 mg^
1
spironolactone tab 25 mg, 50 mg, 100 mg^
1
telmisartan tab 20 mg, 40 mg, 80 mg^
1 QL (30 tablets/30 days)
telmisartan-amlodipine tab 40-5 mg, 40-10 mg, 80-5 mg, 80-10 mg
2 QL (30 tablets/30 days)
telmisartan-hydrochlorothiazide tab 40-12.5 mg, 80-25 mg
2 QL (30 tablets/30 days)
telmisartan-hydrochlorothiazide tab 80-12.5 mg
2 QL (60 tablets/30 days)
terazosin hcl cap 1 mg^
1 QL (90 capsules/30 days)
terazosin hcl cap 2 mg, 5 mg, 10 mg^
1 QL (60 capsules/30 days)
timolol maleate tab 5 mg, 10 mg, 20 mg
2
torsemide tab 5 mg, 10 mg, 20 mg, 100 mg^
1
trandolapril tab 1 mg, 2 mg, 4 mg^
1
trandolapril-verapamil hcl tab er 1-240 mg
2
trandolapril-verapamil hcl tab er 2-180 mg
2
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
43
Drug Name
Drug Tier Requirements/Limits
trandolapril-verapamil hcl tab er 2-240 mg
2
trandolapril-verapamil hcl tab er 4-240 mg
2
triamterene & hydrochlorothiazide cap 37.5-25 mg^
1
triamterene & hydrochlorothiazide tab 37.5-25 mg, 75-50 mg^
1
valsartan tab 40 mg, 80 mg, 160 mg^
1 QL (60 tablets/30 days)
valsartan tab 320 mg^
1 QL (30 tablets/30 days)
valsartan-hydrochlorothiazide tab 80-12.5 mg, 160-12.5 mg,
160-25 mg, 320-12.5 mg, 320-25 mg^
1 QL (30 tablets/30 days)
VASCEPA - icosapent ethyl cap 0.5 gm 3 QL (240 capsules/30 days)
verapamil hcl cap er 24hr 100 mg
4
verapamil hcl cap er 24hr 120 mg, 180 mg, 240 mg
2
verapamil hcl cap er 24hr 200 mg
4
verapamil hcl cap er 24hr 300 mg
4
verapamil hcl cap er 24hr 360 mg
2
verapamil hcl tab er 120 mg, 180 mg, 240 mg
2
verapamil hcl tab 40 mg, 80 mg, 120 mg^
1
Central Nervous System Agents
amphetamine-dextroamphetamine cap er 24hr 5 mg, 10 mg,
15 mg, 20 mg, 25 mg, 30 mg
3 QL (30 capsules/30 days)
amphetamine-dextroamphetamine tab 5 mg, 7.5 mg, 10 mg,
12.5 mg, 15 mg, 30 mg
3 QL (60 tablets/30 days)
amphetamine-dextroamphetamine tab 20 mg
3 QL (90 tablets/30 days)
atomoxetine hcl cap 10 mg, 18 mg, 25 mg, 40 mg
3 QL (60 capsules/30 days)
atomoxetine hcl cap 60 mg, 80 mg, 100 mg
3 QL (30 capsules/30 days)
AVONEX - interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)
AVONEX PEN - interferon beta-1a im auto-injector kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)
BETASERON - interferon beta-1b for inj kit 0.3 mg 5 PA, QL (15 vials/
syringes/30 days)
clonidine hcl tab er 12hr 0.1 mg
3 QL (120 tablets/30 days)
COPAXONE - glatiramer acetate soln prefilled syringe 20 mg/ml 5 PA, QL (30 syringes/30 days)
COPAXONE - glatiramer acetate soln prefilled syringe 40 mg/ml 5 PA, QL (12 syringes/28 days)
dalfampridine tab er 12hr 10 mg†
3 PA
dexmethylphenidate hcl tab 2.5 mg, 5 mg, 10 mg
3 PA, QL (60 tablets/30 days)
dextroamphetamine sulfate cap er 24hr 5 mg
3 QL (90 capsules/30 days)
dextroamphetamine sulfate cap er 24hr 10 mg, 15 mg
3 QL (120 capsules/30 days)
dextroamphetamine sulfate tab 5 mg
3 QL (90 tablets/30 days)
dextroamphetamine sulfate tab 10 mg
3 QL (180 tablets/30 days)
dimethyl fumarate capsule delayed release 120 mg, 240 mg
5 PA, QL (60 capsules/30 days)
dimethyl fumarate capsule dr starter pack 120 mg & 240 mg
5 PA, QL (60 capsules/30 days)
fingolimod hcl cap 0.5 mg
5 PA, QL (30 capsules/30 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
44
Drug Name
Drug Tier Requirements/Limits
glatiramer acetate soln prefilled syringe 20 mg/ml
5 PA, QL (30 syringes/30 days)
glatiramer acetate soln prefilled syringe 40 mg/ml
5 PA, QL (12 syringes/28 days)
guanfacine hcl tab er 24hr 1 mg, 2 mg, 3 mg, 4 mg#
3 QL (30 tablets/30 days)
lisdexamfetamine dimesylate cap 10 mg, 20 mg, 30 mg, 40 mg,
50 mg, 60 mg, 70 mg
3 QL (30 capsules/30 days)
MAYZENT - siponimod fumarate tab 0.25 mg 3 PA, QL (120 tablets/30 days)
MAYZENT - siponimod fumarate tab 1 mg, 2 mg 5 PA, QL (30 tablets/30 days)
MAYZENT STARTER PACK - siponimod fumarate tab 0.25 mg (7)
starter pack
3 PA, QL (1 pack/28 days)
MAYZENT STARTER PACK - siponimod fumarate tab 0.25 mg (12)
starter pack
3 PA, QL (1 pack/28 days)
methylphenidate hcl soln 5 mg/5ml
4 PA, QL (450 mls/30 days)
methylphenidate hcl soln 10 mg/5ml
4 PA, QL (900 mls/30 days)
methylphenidate hcl tab er 10 mg
4 PA, QL (90 tablets/30 days)
methylphenidate hcl tab er 20 mg
3 PA, QL (90 tablets/30 days)
methylphenidate hcl tab 5 mg, 10 mg, 20 mg
3 PA, QL (90 tablets/30 days)
NUEDEXTA - dextromethorphan hbr-quinidine sulfate cap
20-10 mg
3 PA, QL (60 capsules/30 days)
PLEGRIDY - peginterferon beta-1a soln pen-injector 125 mcg/0.5ml 5 PA, QL (2 syringes/28 days)
PLEGRIDY - peginterferon beta-1a soln prefilled syringe
125 mcg/0.5ml
5 PA, QL (2 syringes/28 days)
PLEGRIDY - peginterferon beta-1a im soln prefilled syr
125 mcg/0.5ml
5 PA, QL (2 syringes/28 days)
PLEGRIDY STARTER PACK - peginterferon beta-1a soln pen-inj
63 & 94 mcg/0.5ml pack
5 PA, QL (2 syringes/28 days)
PLEGRIDY STARTER PACK - peginterferon beta-1a soln pref syr
63 & 94 mcg/0.5ml pack
5 PA, QL (2 syringes/28 days)
REBIF - interferon beta-1a soln pref syr 22 mcg/0.5ml,
44 mcg/0.5ml
5 PA, QL (12 syringes/28 days)
REBIF REBIDOSE - interferon beta-1a soln auto-inj 22 mcg/0.5ml,
44 mcg/0.5ml
5 PA, QL (12 syringes/28 days)
REBIF REBIDOSE TITRATION PACK - interferon beta-1a auto-inj
6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml
5 PA, QL (1 box/28 days)
REBIF TITRATION PACK - interferon beta-1a pref syr
6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml
5 PA, QL (1 box/28 days)
riluzole tab 50 mg
3
tetrabenazine tab 12.5 mg
5 PA, QL (240 tablets/30 days)
tetrabenazine tab 25 mg
5 PA, QL (120 tablets/30 days)
VUMERITY - diroximel fumarate capsule delayed release 231 mg 5 PA, QL (120 capsules/30 days)
Dental and Oral Agents
cevimeline hcl cap 30 mg
4
chlorhexidine gluconate soln 0.12%^
1
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
45
Drug Name
Drug Tier Requirements/Limits
pilocarpine hcl tab 5 mg, 7.5 mg
2
triamcinolone acetonide dental paste 0.1%
2
Dermatological Agents
acitretin cap 10 mg, 17.5 mg, 25 mg
4
alclometasone dipropionate cream 0.05%
2 QL (120 grams/30 days)
alclometasone dipropionate oint 0.05%
2 QL (120 grams/30 days)
azelaic acid gel 15%
3
AZELEX - azelaic acid cream 20% 4
benzoyl peroxide-erythromycin gel 5-3%
3
BETAMETHASONE DIPROPIONATE AUGMENTED -
betamethasone dipropionate augmented gel 0.05%
3 QL (200 grams/28 days)
betamethasone dipropionate augmented cream 0.05%
3 QL (200 grams/28 days)
betamethasone dipropionate augmented lotion 0.05%
3 QL (210 mls/30 days)
betamethasone dipropionate augmented oint 0.05%
3 QL (200 grams/28 days)
betamethasone dipropionate cream 0.05%
2 QL (135 grams/30 days)
betamethasone dipropionate lotion 0.05%
2 QL (120 mls/30 days)
betamethasone dipropionate oint 0.05%
2 QL (135 grams/30 days)
betamethasone valerate cream 0.1%
2 QL (135 grams/30 days)
betamethasone valerate lotion 0.1%
2 QL (120 mls/30 days)
betamethasone valerate oint 0.1%
2 QL (135 grams/30 days)
calcipotriene cream 0.005%
3 QL (120 grams/30 days)
calcipotriene oint 0.005%
4 QL (120 grams/30 days)
calcipotriene soln 0.005% (50 mcg/ml)
3 QL (120 mls/30 days)
clindamycin phosphate-benzoyl peroxide gel 1-5%
3
clobetasol propionate cream 0.05%
2 QL (210 grams/28 days)
clobetasol propionate emollient base cream 0.05%
2 QL (210 grams/28 days)
clobetasol propionate foam 0.05%
3 QL (200 grams/28 days)
clobetasol propionate gel 0.05%
2 QL (210 grams/28 days)
clobetasol propionate oint 0.05%
2 QL (210 grams/28 days)
clobetasol propionate shampoo 0.05%
3 QL (236 mls/30 days)
clobetasol propionate soln 0.05%
2 QL (200 mls/28 days)
clotrimazole w/ betamethasone cream 1-0.05%
2
clotrimazole w/ betamethasone lotion 1-0.05%
3
desonide cream 0.05%
2 QL (120 grams/30 days)
desonide lotion 0.05%
4 QL (118 mls/30 days)
desonide oint 0.05%
3 QL (120 grams/30 days)
desoximetasone cream 0.05%, 0.25%
4 QL (120 grams/30 days)
desoximetasone gel 0.05%
4 QL (120 grams/30 days)
desoximetasone oint 0.25%
4 QL (120 grams/30 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
46
Drug Name
Drug Tier Requirements/Limits
diclofenac sodium (actinic keratoses) gel 3%
4 PA
FINACEA - azelaic acid foam 15% 3
fluocinolone acetonide cream 0.01%
2 QL (120 grams/30 days)
fluocinolone acetonide cream 0.025%
3 QL (120 grams/30 days)
fluocinolone acetonide oil 0.01% (body oil), 0.01% (scalp oil)
4 QL (118.28 mls/30 days)
fluocinolone acetonide oint 0.025%
3 QL (120 grams/30 days)
fluocinolone acetonide soln 0.01%
4 QL (120 mls/30 days)
fluocinonide cream 0.05%
2 QL (120 grams/30 days)
fluocinonide emulsified base cream 0.05%
2 QL (120 grams/30 days)
fluocinonide gel 0.05%
2 QL (120 grams/30 days)
fluocinonide oint 0.05%
2 QL (120 grams/30 days)
fluocinonide soln 0.05%
2 QL (120 mls/30 days)
FLUOROURACIL - fluorouracil cream 0.5% 5
FLUOROURACIL - fluorouracil soln 2%, 5% 3
fluorouracil cream 5%
3
fluticasone propionate cream 0.05%
2 QL (120 grams/30 days)
fluticasone propionate oint 0.005%
2 QL (120 grams/30 days)
gentamicin sulfate cream 0.1%
2
gentamicin sulfate oint 0.1%
2
halobetasol propionate cream 0.05%
2 QL (200 grams/28 days)
halobetasol propionate oint 0.05%
3 QL (200 grams/28 days)
hydrocortisone butyrate cream 0.1%
2 QL (135 grams/30 days)
hydrocortisone butyrate hydrophilic lipo base cream 0.1%
2 QL (135 grams/30 days)
hydrocortisone butyrate oint 0.1%
2 QL (135 grams/30 days)
hydrocortisone butyrate soln 0.1%
3 QL (120 mls/30 days)
hydrocortisone cream 1%
2
hydrocortisone cream 2.5%
2 QL (454 grams/30 days)
hydrocortisone lotion 2.5%
2 QL (118 mls/30 days)
hydrocortisone oint 1%^
1
hydrocortisone oint 2.5%^
1 QL (454 grams/30 days)
hydrocortisone valerate cream 0.2%
3 QL (120 grams/30 days)
hydrocortisone valerate oint 0.2%
3 QL (120 grams/30 days)
imiquimod cream 5%
2 PA
isotretinoin cap 10 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg
4
ivermectin cream 1%
3 PA
lactic acid (ammonium lactate) cream 12%
2
lactic acid (ammonium lactate) lotion 12%
2
malathion lotion 0.5%
4
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
47
Drug Name
Drug Tier Requirements/Limits
METHOXSALEN - methoxsalen rapid cap 10 mg 5
metronidazole cream 0.75%
3
metronidazole gel 0.75%, 1%
3
metronidazole lotion 0.75%
3
mometasone furoate cream 0.1%
2 QL (135 grams/30 days)
mometasone furoate oint 0.1%
2 QL (135 grams/30 days)
mometasone furoate solution 0.1% (lotion)
2 QL (120 mls/30 days)
mupirocin calcium cream 2%
3 QL (30 grams/30 days)
mupirocin oint 2%
2 QL (30 grams/30 days)
nystatin-triamcinolone cream 100000-0.1 unit/gm-%
2
nystatin-triamcinolone oint 100000-0.1 unit/gm-%
2
ORACEA - doxycycline (rosacea) cap delayed release 40 mg 4
permethrin cream 5%
2
pimecrolimus cream 1%
4 PA
podofilox soln 0.5%
2
REGRANEX - becaplermin gel 0.01% 5 PA, QL (15 grams/30 days)
SANTYL - collagenase oint 250 unit/gm 3 QL (180 grams/30 days)
selenium sulfide lotion 2.5%
2
silver sulfadiazine cream 1%
2
sulfacetamide sodium lotion 10% (acne)
3
tacrolimus oint 0.03%, 0.1%
4 PA
tazarotene cream 0.1%
3 PA
tazarotene gel 0.05%, 0.1%
4 PA
TAZORAC - tazarotene cream 0.05% 4 PA
tretinoin cream 0.025%, 0.05%, 0.1%
3 PA
tretinoin gel 0.01%, 0.025%
3 PA
triamcinolone acetonide cream 0.025%, 0.1%, 0.5%
2 QL (454 grams/30 days)
triamcinolone acetonide lotion 0.025%, 0.1%
2 QL (120 mls/30 days)
triamcinolone acetonide oint 0.025%, 0.1%
2 QL (454 grams/30 days)
triamcinolone acetonide oint 0.5%
2 QL (120 grams/30 days)
Electrolytes/Minerals/Metals/Vitamins
AURYXIA - ferric citrate tab 1 gm (210 mg ferric iron) 5 PA, QL (360 tablets/30 days)
calcium acetate cap 667 mg (169 mg ca)
2
calcium acetate tab 667 mg
2
carglumic acid soluble tab 200 mg
5 PA
CHEMET - succimer cap 100 mg 4
deferasirox granules packet 90 mg, 180 mg, 360 mg†
5 PA
deferasirox tab for oral susp 125 mg, 250 mg, 500 mg†
5 PA
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
48
Drug Name
Drug Tier Requirements/Limits
deferasirox tab 90 mg, 180 mg, 360 mg†
5 PA
dextrose inj 5%, 10%
4
dextrose 2.5% w/ sodium chloride 0.45%
4
dextrose 5% w/ sodium chloride 0.2%, 0.33%, 0.45%, 0.9%
4
FOSRENOL - lanthanum carbonate oral powder pack 750 mg 5 QL (180 packets/30 days)
FOSRENOL - lanthanum carbonate oral powder pack 1000 mg 5 QL (120 packets/30 days)
INTRALIPID - fat emulsion plant based (soy) iv emulsion 20% 4 BD
kcl 20 meq/l (0.149%) in nacl 0.45% inj
4
kcl 20 meq/l (0.15%) in nacl 0.45% inj
4
kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj
4
kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj
4
kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.225% inj
4
kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj
4
kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj
4
kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj
4
lanthanum carbonate chew tab 500 mg
4 QL (90 tablets/30 days)
lanthanum carbonate chew tab 750 mg
4 QL (180 tablets/30 days)
lanthanum carbonate chew tab 1000 mg
4 QL (120 tablets/30 days)
magnesium sulfate inj 50%
4
NUTRILIPID - fat emulsion plant based (soy) iv emulsion 20% 4 BD
potassium chloride cap er 8 meq, 10 meq
2
potassium chloride inj 2 meq/ml
4
potassium chloride microencapsulated crys er tab 10 meq, 15 meq,
20 meq
2
potassium chloride oral soln 10% (20 meq/15ml), 20% (40
meq/15ml)
4
potassium chloride tab er 8 meq (600 mg), 10 meq, 20 meq
(1500 mg)
2
potassium chloride 20 meq/l (0.15%) in dextrose 5% inj
4
POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS -
potassium chloride 20 meq/l (0.15%) in d5w lactated ringers
4
potassium citrate tab er 5 meq (540 mg)
2
potassium citrate tab er 10 meq (1080 mg), 15 meq (1620 mg)
3
sevelamer carbonate packet 0.8 gm
4 QL (270 packets/30 days)
sevelamer carbonate packet 2.4 gm
4 QL (90 packets/30 days)
sevelamer carbonate tab 800 mg
4
sodium chloride irrigation soln 0.9%
2
sodium chloride iv soln 0.45%, 0.9%
4
sodium chloride preservative free inj 0.9%
4
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
49
Drug Name
Drug Tier Requirements/Limits
sodium polystyrene sulfonate powder
3
SPS - sodium polystyrene sulfonate oral susp 15 gm/60ml 2
tolvaptan tab 15 mg, 30 mg
5 PA
TRAVASOL - amino acid infusion 10% 4 BD
trientine hcl cap 250 mg†
5 PA, QL (240 capsules/30 days)
TROPHAMINE - amino acid infusion 10% 4 BD
VELPHORO - sucroferric oxyhydroxide chew tab 500 mg 5 QL (180 tablets/30 days)
VELTASSA - patiromer sorbitex calcium for susp packet 8.4 gm,
16.8 gm, 25.2 gm
3
Gastrointestinal Agents
alosetron hcl tab 0.5 mg
4 PA, QL (60 tablets/30 days)
alosetron hcl tab 1 mg
5 PA, QL (60 tablets/30 days)
bismuth subcit-metronidazole-tetracycline cap 140-125-125 mg
4
CHENODAL - chenodiol tab 250 mg* 5 PA
cimetidine tab 200 mg, 300 mg, 400 mg, 800 mg
2
dicyclomine hcl cap 10 mg#
2 PA (>=65 yr)
dicyclomine hcl oral soln 10 mg/5ml#
4 PA (>=65 yr)
dicyclomine hcl tab 20 mg#
2 PA (>=65 yr)
diphenoxylate w/ atropine tab 2.5-0.025 mg#
3 PA (>=65 yr)
esomeprazole magnesium cap delayed release 20 mg, 40 mg
2 QL (30 capsules/30 days)
esomeprazole magnesium for delayed release susp packet 10 mg,
20 mg, 40 mg
3 QL (30 packets/30 days)
famotidine for susp 40 mg/5ml
4
famotidine tab 20 mg, 40 mg^
1
GATTEX - teduglutide (rdna) for inj kit 5 mg* 5 PA
GAVILYTE-C - peg 3350-kcl-na bicarb-nacl-na sulfate for soln
240 gm
2
glycopyrrolate tab 1 mg, 2 mg
2
lactulose (encephalopathy) solution 10 gm/15ml
2
lactulose solution 10 gm/15ml
2
lansoprazole cap delayed release 15 mg, 30 mg
2 QL (30 capsules/30 days)
LINZESS - linaclotide cap 72 mcg, 145 mcg, 290 mcg 3 QL (30 capsules/30 days)
loperamide hcl cap 2 mg
2
lubiprostone cap 8 mcg
4 QL (120 capsules/30 days)
lubiprostone cap 24 mcg
4 QL (60 capsules/30 days)
methscopolamine bromide tab 2.5 mg, 5 mg#
3
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml)
2
metoclopramide hcl tab 5 mg, 10 mg^
1
misoprostol tab 100 mcg, 200 mcg
2
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
50
Drug Name
Drug Tier Requirements/Limits
MOVANTIK - naloxegol oxalate tab 12.5 mg, 25 mg 3
MYALEPT - metreleptin for subcutaneous inj 11.3 mg* 5 PA
NIZATIDINE - nizatidine cap 150 mg 4
nizatidine cap 300 mg
2
OCALIVA - obeticholic acid tab 5 mg, 10 mg†* 5 PA, QL (30 tablets/30 days)
omeprazole cap delayed release 10 mg^
1 QL (30 capsules/30 days)
omeprazole cap delayed release 20 mg, 40 mg^
1 QL (60 capsules/30 days)
pantoprazole sodium ec tab 20 mg^
1 QL (30 tablets/30 days)
pantoprazole sodium ec tab 40 mg^
1 QL (60 tablets/30 days)
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm^
1
peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln 100 gm^
1
peg 3350-kcl-sod bicarb-nacl for soln 420 gm^
1
PYLERA - bismuth subcit-metronidazole-tetracycline cap
140-125-125 mg
5
rabeprazole sodium ec tab 20 mg
2 QL (30 tablets/30 days)
sucralfate susp 1 gm/10ml
4
sucralfate tab 1 gm
2
SUPREP BOWEL PREP KIT - sod sulfate-pot sulf-mg sulf oral sol
17.5-3.13-1.6 gm/177ml
4
SUTAB - sod sulfate-mg sulfate-pot chloride tab 1479-225-188 mg 4
ursodiol cap 300 mg
3
ursodiol tab 250 mg, 500 mg
3
VIBERZI - eluxadoline tab 75 mg, 100 mg 5 PA, QL (60 tablets/30 days)
XIFAXAN - rifaximin tab 550 mg 5 PA, QL (90 tablets/30 days)
Genetic or Enzyme or Protein Disorder: Replacement, Modifiers, Treatment
betaine powder for oral solution
5
CREON - pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000
unit, 6000-19000-30000 unit, 12000-38000-60000 unit,
24000-76000-120000 unit, 36000-114000-180000 unit
3
cromolyn sodium oral conc 100 mg/5ml
4
CYSTAGON - cysteamine bitartrate cap 50 mg, 150 mg* 4 PA
levocarnitine oral soln 1 gm/10ml (10%)
4
levocarnitine tab 330 mg
2
miglustat cap 100 mg*
5 PA, QL (90 capsules/30 days)
nitisinone cap 2 mg, 5 mg, 10 mg, 20 mg
5
ORFADIN - nitisinone cap 20 mg* 5
ORFADIN - nitisinone susp 4 mg/ml* 5
PALYNZIQ - pegvaliase-pqpz subcutaneous soln pref syringe
2.5 mg/0.5ml, 10 mg/0.5ml, 20 mg/ml
5 PA
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
51
Drug Name
Drug Tier Requirements/Limits
PROLASTIN-C - alpha1-proteinase inhibitor (human) for iv soln
1000 mg*
5 PA
PROLASTIN-C - alpha1-proteinase inhibitor (human) inj
1000 mg/20ml*
5 PA
REVCOVI - elapegademase-lvlr im soln 2.4 mg/1.5ml (1.6 mg/ml) 5
sapropterin dihydrochloride powder packet 100 mg, 500 mg†
5 PA
sapropterin dihydrochloride tab 100 mg†
5 PA
sodium phenylbutyrate oral powder 3 gm/teaspoonful
5 PA
sodium phenylbutyrate tab 500 mg
5 PA
VYNDAMAX - tafamidis cap 61 mg 5 PA, QL (30 capsules/30 days)
VYNDAQEL - tafamidis meglumine (cardiac) cap 20 mg 5 PA, QL (120 capsules/30 days)
ZENPEP - pancrelipase (lip-prot-amyl) dr cap 3000-10000-14000
unit, 5000-17000-24000 unit, 10000-32000-42000 unit,
15000-47000-63000 unit, 20000-63000-84000 unit,
25000-79000-105000 unit, 40000-126000-168000 unit
3
ZOKINVY - lonafarnib cap 50 mg, 75 mg 5 PA, QL (120 capsules/30 days)
Genitourinary Agents
alfuzosin hcl tab er 24hr 10 mg^
1 QL (30 tablets/30 days)
bethanechol chloride tab 5 mg, 10 mg, 25 mg, 50 mg
2
dutasteride cap 0.5 mg
2 QL (30 capsules/30 days)
dutasteride-tamsulosin hcl cap 0.5-0.4 mg
3 QL (30 capsules/30 days)
finasteride tab 5 mg^
1 QL (30 tablets/30 days)
MYRBETRIQ - mirabegron granules for oral extended release susp
8 mg/ml
3 QL (3 bottles/28 days)
MYRBETRIQ - mirabegron tab er 24 hr 25 mg, 50 mg 3 QL (30 tablets/30 days)
oxybutynin chloride solution 5 mg/5ml
3 QL (600 mls/30 days)
oxybutynin chloride tab er 24hr 5 mg
2 QL (30 tablets/30 days)
oxybutynin chloride tab er 24hr 10 mg
2 QL (90 tablets/30 days)
oxybutynin chloride tab er 24hr 15 mg
2 QL (60 tablets/30 days)
oxybutynin chloride tab 5 mg
2 QL (120 tablets/30 days)
penicillamine tab 250 mg
5
silodosin cap 4 mg, 8 mg
3 QL (30 capsules/30 days)
solifenacin succinate tab 5 mg, 10 mg
2 QL (30 tablets/30 days)
tamsulosin hcl cap 0.4 mg^
1 QL (60 capsules/30 days)
tolterodine tartrate cap er 24hr 2 mg, 4 mg
2 QL (30 capsules/30 days)
tolterodine tartrate tab 1 mg, 2 mg
2 QL (60 tablets/30 days)
trospium chloride tab 20 mg
2 QL (60 tablets/30 days)
Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)
dexamethasone elixir 0.5 mg/5ml
3
dexamethasone soln 0.5 mg/5ml
3
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
52
Drug Name
Drug Tier Requirements/Limits
dexamethasone tab therapy pack 1.5 mg (21)
2
dexamethasone tab therapy pack 1.5 mg (35)
2
dexamethasone tab therapy pack 1.5 mg (51)
2
dexamethasone tab 0.5 mg
2
dexamethasone tab 0.75 mg
2
dexamethasone tab 1 mg
2
dexamethasone tab 1.5 mg, 2 mg, 4 mg, 6 mg
2
fludrocortisone acetate tab 0.1 mg
2
HEMADY - dexamethasone tab 20 mg 4
hydrocortisone tab 5 mg, 10 mg, 20 mg
2
methylprednisolone tab therapy pack 4 mg (21)
2
methylprednisolone tab 4 mg, 8 mg, 16 mg, 32 mg
2
prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base)
2
prednisolone sod phosphate oral soln 15 mg/5ml
2
prednisolone sodium phosphate oral soln 25 mg/5ml
3
prednisolone soln 15 mg/5ml
2
prednisone oral soln 5 mg/5ml
2
prednisone tab therapy pack 5 mg (21), 5 mg (48), 10 mg (21),
10 mg (48)
2
prednisone tab 1 mg, 2.5 mg, 20 mg^
1
prednisone tab 5 mg, 10 mg, 50 mg
2
Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)
desmopressin acetate nasal spray soln 0.01% (refrigerated), 0.01%
4
desmopressin acetate tab 0.1 mg, 0.2 mg
2
INCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml)* 5
OMNITROPE - somatropin for inj 5.8 mg 5 PA
OMNITROPE - somatropin solution cartridge 5 mg/1.5ml,
10 mg/1.5ml
5 PA
Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)
ANDRODERM - testosterone td patch 24hr 2 mg/24hr, 4 mg/24hr 3 PA, QL (30 patches/30 days)
COMBIPATCH - estradiol-norethindrone ace td pttw 0.05-0.14 mg/
day, 0.05-0.25 mg/day#
4
danazol cap 50 mg, 100 mg, 200 mg
3 PA
DEPO-ESTRADIOL - estradiol cypionate im in oil 5 mg/ml 4
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5)
3
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
3
drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg
3
drospirenone-ethinyl estrad-levomefolate tab 3-0.03-0.451 mg#
3
drospirenone-ethinyl estradiol tab 3-0.02 mg
3
drospirenone-ethinyl estradiol tab 3-0.03 mg#
3
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
53
Drug Name
Drug Tier Requirements/Limits
DUAVEE - conjugated estrogens-bazedoxifene tab 0.45-20 mg# 4
estradiol & norethindrone acetate tab 0.5-0.1 mg#
4
estradiol & norethindrone acetate tab 1-0.5 mg#
3
estradiol tab 0.5 mg, 1 mg, 2 mg#
2
estradiol td gel 0.25 mg/0.25gm (0.1%), 0.5 mg/0.5gm (0.1%),
0.75 mg/0.75gm (0.1%), 1 mg/gm (0.1%), 1.25 mg/1.25gm
(0.1%)#
4
estradiol td patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr,
0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr#
2
estradiol td patch weekly 0.025 mg/24hr, 0.0375 mg/24hr
(37.5 mcg/24hr), 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr,
0.1 mg/24hr#
2
estradiol vaginal cream 0.1 mg/gm
2
estradiol vaginal tab 10 mcg
4
estradiol valerate im in oil 10 mg/ml, 20 mg/ml, 40 mg/ml
3
ESTRING - estradiol vaginal ring 2 mg (7.5 mcg/24hrs) 4
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg,
1 mg-50 mcg
3
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7)
3
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7)
3
levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg
3
levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg,
0.15 mg-30 mcg
3
levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg
3
levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg
3
medroxyprogesterone acetate im susp prefilled syr 150 mg/ml
4
medroxyprogesterone acetate im susp 150 mg/ml
4
medroxyprogesterone acetate tab 2.5 mg, 5 mg, 10 mg^
1
megestrol acetate susp 40 mg/ml#
4
megestrol acetate tab 20 mg, 40 mg#
2
MENEST - esterified estrogens tab 0.3 mg, 0.625 mg, 1.25 mg,
2.5 mg#
4
methyltestosterone cap 10 mg
5 PA
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg,
0.5 mg-35 mcg
3
norethindrone & ethinyl estradiol tab 1 mg-35 mcg#
3
norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg
3
norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg#
3
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg
3
norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg,
1.5 mg-30 mcg
3
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
54
Drug Name
Drug Tier Requirements/Limits
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg,
1.5 mg-30 mcg
3
norethindrone ace-ethinyl estradiol-fe cap 1 mg-20 mcg (24)
3
norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24)
3
norethindrone acetate tab 5 mg
2
norethindrone tab 0.35 mg
3
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg,
0.5-35/1-35/0.5-35 mg-mcg
3
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg
3
norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg,
0.18-35/0.215-35/0.25-35 mg-mcg
3
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg
3
PREMARIN - estrogens, conjugated tab 0.3 mg, 0.45 mg,
0.625 mg, 0.9 mg, 1.25 mg#
3
PREMARIN - estrogens, conjugated vaginal cream 0.625 mg/gm 3
PREMPHASE - conj est 0.625(14)/conj est-medroxypro ac tab
0.625-5mg(14)#
3
PREMPRO - conjugated estrogen-medroxyprogest acetate tab
0.3-1.5 mg, 0.45-1.5 mg, 0.625-2.5 mg, 0.625-5 mg#
3
progesterone cap 100 mg, 200 mg
2
raloxifene hcl tab 60 mg
2
testosterone cypionate im inj in oil 100 mg/ml, 200 mg/ml
3 PA
TESTOSTERONE ENANTHATE - testosterone enanthate im inj in
oil 200 mg/ml
3 PA
testosterone td gel 25 mg/2.5gm (1%)
3 PA, QL (90 packets/30 days)
testosterone td gel 50 mg/5gm (1%)
3 PA, QL (60 units/30 days)
testosterone td gel 12.5 mg/act (1%)
3 PA, QL (4 pump bottles/30 days)
testosterone td gel 20.25 mg/1.25gm (1.62%)
4 PA, QL (30 packets/30 days)
testosterone td gel 40.5 mg/2.5gm (1.62%)
4 PA, QL (60 packets/30 days)
testosterone td gel 20.25 mg/act (1.62%)
4 PA, QL (2 pump bottles/30 days)
testosterone td soln 30 mg/act
4 PA, QL (2 pump bottles/30 days)
VELIVET - desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg
3
Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)
levothyroxine sodium tab 25 mcg (euthyrox, levo-t, levoxyl,
unithroid)^
1
levothyroxine sodium tab 50 mcg (euthyrox, levo-t, levoxyl,
unithroid)^
1
levothyroxine sodium tab 75 mcg (euthyrox, levo-t, levoxyl,
unithroid)^
1
levothyroxine sodium tab 88 mcg (euthyrox, levo-t, levoxyl,
unithroid)^
1
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
55
Drug Name
Drug Tier Requirements/Limits
levothyroxine sodium tab 100 mcg (euthyrox, levo-t, levoxyl,
unithroid)^
1
levothyroxine sodium tab 112 mcg (euthyrox, levo-t, levoxyl,
unithroid)^
1
levothyroxine sodium tab 125 mcg (euthyrox, levo-t, levoxyl,
unithroid)^
1
levothyroxine sodium tab 137 mcg (euthyrox, levo-t, levoxyl,
unithroid)^
1
levothyroxine sodium tab 150 mcg (euthyrox, levo-t, levoxyl,
unithroid)^
1
levothyroxine sodium tab 175 mcg (euthyrox, levo-t, levoxyl,
unithroid)^
1
levothyroxine sodium tab 200 mcg (euthyrox, levo-t, levoxyl,
unithroid)^
1
levothyroxine sodium tab 300 mcg (levo-t, unithroid)^
1
liothyronine sodium tab 5 mcg, 25 mcg, 50 mcg
2
SYNTHROID - levothyroxine sodium tab 25 mcg, 50 mcg, 75 mcg,
88 mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg,
175 mcg, 200 mcg, 300 mcg
3
Hormonal Agents, Suppressant (Adrenal)
KORLYM - mifepristone tab 300 mg* 5 PA, QL (120 tablets/30 days)
LYSODREN - mitotane tab 500 mg 5
Hormonal Agents, Suppressant (Pituitary)
cabergoline tab 0.5 mg
2
ELIGARD - leuprolide acetate (3 month) for subcutaneous inj kit
22.5mg
4 PA
ELIGARD - leuprolide acetate (4 month) for subcutaneous inj kit
30 mg
4 PA
ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit
45 mg
4 PA
ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 mg 4 PA
FIRMAGON - degarelix acetate for inj 80 mg 4
FIRMAGON - degarelix acetate for inj 120 mg/vial (240 mg dose) 5
LEUPROLIDE ACETATE - leuprolide acetate (3 month) for inj
22.5 mg
4 PA
leuprolide acetate inj kit 1 mg/0.2ml (5 mg/ml)
4 PA
LUPRON DEPOT (1-MONTH) - leuprolide acetate for inj kit
3.75 mg, 7.5 mg
5 PA
LUPRON DEPOT (3-MONTH) - leuprolide acetate (3 month) for inj
kit 11.25 mg, 22.5 mg
5 PA
LUPRON DEPOT (4-MONTH) - leuprolide acetate (4 month) for inj
kit 30 mg
5 PA
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
56
Drug Name
Drug Tier Requirements/Limits
LUPRON DEPOT (6-MONTH) - leuprolide acetate (6 month) for inj
kit 45 mg
5 PA
LUPRON DEPOT-PED - leuprolide acet (6 month) for im inj
pediatric kit 45 mg
5 PA
LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for inj
pediatric kit 7.5 mg, 11.25 mg, 15 mg
5 PA
LUPRON DEPOT-PED (3-MONTH) - leuprolide acetate (3 month)
for inj pediatric kit 11.25 mg, 30 mg
5 PA
octreotide acetate inj 50 mcg/ml (0.05 mg/ml), 100 mcg/ml (0.1 mg/
ml), 200 mcg/ml (0.2 mg/ml), 500 mcg/ml (0.5 mg/ml), 1000 mcg/
ml (1 mg/ml)
4 PA
octreotide acetate subcutaneous soln pref syr 100 mcg/ml
4 PA
octreotide acetate subcutaneous soln pref syr 50 mcg/ml
4 PA
octreotide acetate subcutaneous soln pref syr 500 mcg/ml
4 PA
ORGOVYX - relugolix tab 120 mg* 5 PA, QL (90 tablets/30 days)
SIGNIFOR - pasireotide diaspartate inj 0.3 mg/ml, 0.6 mg/ml,
0.9 mg/ml*
5 PA
SOMAVERT - pegvisomant for inj 10 mg, 15 mg, 20 mg, 25 mg,
30 mg*
5 PA
SYNAREL - nafarelin acetate nasal soln 2 mg/ml (200 mcg/act) 5
TRELSTAR MIXJECT - triptorelin pamoate for im susp 3.75 mg,
11.25 mg
4 PA
TRELSTAR MIXJECT - triptorelin pamoate for im susp 22.5 mg 5 PA
Hormonal Agents, Suppressant (Thyroid)
methimazole tab 5 mg, 10 mg^
1
propylthiouracil tab 50 mg
2
Immunological Agents
ABRYSVO - rsv pre-fusion f a&b vac recomb for im soln
120 mcg/0.5ml
3
ACTHIB - haemophilus b polysaccharide conjugate vaccine for inj 3
ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml (2000000
unit/0.5ml)*
5 PA
ADACEL - tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml 3
ARCALYST - rilonacept for inj 220 mg* 5 PA
AREXVY - rsvpref3 vaccine recomb adjuvanted for im susp
120 mcg/0.5ml
3
ATGAM - lymphocyte immune globulin anti-thymocyte g inj 50 mg/
ml(eq)
5 BD
azathioprine tab 50 mg
2 BD
azathioprine tab 75 mg, 100 mg
4 BD
BCG VACCINE - bcg vaccine for inj soln 50 mg 3
BENLYSTA - belimumab for iv soln 120 mg, 400 mg 5 PA
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
57
Drug Name
Drug Tier Requirements/Limits
BENLYSTA - belimumab subcutaneous solution auto-injector
200 mg/ml
5 PA
BENLYSTA - belimumab subcutaneous solution prefilled syringe
200 mg/ml
5 PA
BESREMI - ropeginterferon alfa-2b-njft soln prefilled syr 500 mcg/
ml
5 PA, QL (2 syringes/28 days)
BEXSERO - meningococcal vac b (recomb omv adjuv) inj prefilled
syringe
3
BOOSTRIX - tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-
mcg/0.5ml
3
BOOSTRIX - tet-diph-acell pertuss ad pref syr 5-2.5-18.5 lf-
mcg/0.5ml
3
CINRYZE - c1 esterase inhibitor (human) for iv inj 500 unit* 5 PA, QL (20 vials/30 days)
COSENTYX - secukinumab subcutaneous pref syr 150 mg/ml
(300 mg dose)*
5 PA
COSENTYX - secukinumab subcutaneous soln prefilled syringe
75 mg/0.5ml
5 PA
COSENTYX - secukinumab subcutaneous soln prefilled syringe
150 mg/ml*
5 PA
COSENTYX SENSOREADY PEN - secukinumab subcutaneous
auto-inj 150 mg/ml (300 mg dose)*
5 PA
COSENTYX SENSOREADY PEN - secukinumab subcutaneous
soln auto-injector 150 mg/ml*
5 PA
COSENTYX UNOREADY - secukinumab subcutaneous soln auto-
injector 300 mg/2ml*
5 PA
cyclosporine cap 25 mg
3 BD
cyclosporine cap 100 mg
4 BD
cyclosporine modified cap 25 mg, 50 mg, 100 mg
3 BD
cyclosporine modified oral soln 100 mg/ml
4 BD
CYLTEZO - adalimumab-adbm auto-injector kit 40 mg/0.8ml 5 PA
CYLTEZO - adalimumab-adbm prefilled syringe kit 10 mg/0.2ml,
20 mg/0.4ml, 40 mg/0.8ml
5 PA
CYLTEZO STARTER PACKAGE FOR CROHNS DISEASE/UC/HS
- adalimumab-adbm auto-injector kit 40 mg/0.8ml
5 PA
CYLTEZO STARTER PACKAGE FOR PSORIASIS - adalimumab-
adbm auto-injector kit 40 mg/0.8ml
5 PA
DAPTACEL - diph, acellular pert & tet tox inj 15 lf-23 mcg-5 lf/0.5ml 3
DENGVAXIA - dengue virus vaccine live tetravalent for
subcutaneous susp
3
DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC -
diphtheria-tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml
3
DUPIXENT - dupilumab subcutaneous soln pen-injector
200 mg/1.14ml, 300 mg/2ml
5 PA
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
58
Drug Name
Drug Tier Requirements/Limits
DUPIXENT - dupilumab subcutaneous soln prefilled syringe
100 mg/0.67ml, 200 mg/1.14ml, 300 mg/2ml
5 PA
ENBREL - etanercept subcutaneous inj 25 mg/0.5ml 5 PA
ENBREL - etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml, 50 mg/ml
5 PA
ENBREL MINI - etanercept subcutaneous solution cartridge 50 mg/
ml
5 PA
ENBREL SURECLICK - etanercept subcutaneous solution auto-
injector 50 mg/ml
5 PA
ENGERIX-B - hepatitis b vaccine (recombinant) susp pref syr
10 mcg/0.5ml, 20 mcg/ml
3 BD
ENGERIX-B - hepatitis b vaccine (recombinant) susp 20 mcg/ml 3 BD
everolimus tab 0.25 mg, 0.5 mg, 0.75 mg, 1 mg
5 BD
GAMMAGARD LIQUID - immune globulin (human) iv or
subcutaneous soln 1 gm/10ml, 2.5 gm/25ml, 5 gm/50ml,
10 gm/100ml, 20 gm/200ml, 30 gm/300ml
5 BD, PA
GAMMAGARD S/D - immune globulin (human) iv for soln 5 gm,
10 gm
5 BD, PA
GAMMAPLEX - immune globulin (human) iv soln 5 gm/100ml,
10 gm/200ml, 20 gm/400ml, 5 gm/50ml, 10 gm/100ml,
20 gm/200ml
5 BD, PA
GAMUNEX-C - immune globulin (human) iv or subcutaneous soln
1 gm/10ml, 2.5 gm/25ml, 5 gm/50ml, 10 gm/100ml, 20 gm/200ml,
40 gm/400ml
5 BD, PA
GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac im
susp
3
GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac
susp pref syr
3
HAEGARDA - c1 esterase inhibitor (human) for subcutaneous inj
2000 unit*
5 PA, QL (24 vials/30 days)
HAEGARDA - c1 esterase inhibitor (human) for subcutaneous inj
3000 unit*
5 PA, QL (16 vials/30 days)
HAVRIX - hepatitis a vaccine inj susp 720 el unit/0.5ml, 1440 el
unit/ml
3
HEPLISAV-B - hepatitis b vaccine recomb adjuvanted pref syr
20 mcg/0.5ml
3 BD
HIBERIX - haemophilus b polysaccharide conjugate vac for inj
10 mcg
3
HUMIRA - adalimumab prefilled syringe kit 10 mg/0.1ml,
20 mg/0.2ml, 40 mg/0.8ml, 40 mg/0.4ml
5 PA
HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -
adalimumab prefilled syringe kit 80 mg/0.8ml, 80 mg/0.8ml &
40 mg/0.4ml
5 PA
HUMIRA PEN - adalimumab pen-injector kit 40 mg/0.8ml,
40 mg/0.4ml, 80 mg/0.8ml
5 PA
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
59
Drug Name
Drug Tier Requirements/Limits
HUMIRA PEN-CD/UC/HS STARTER - adalimumab pen-injector kit
40 mg/0.8ml, 80 mg/0.8ml
5 PA
HUMIRA PEN-PEDIATRIC UC STARTER PACK - adalimumab
pen-injector kit 80 mg/0.8ml
5 PA
HUMIRA PEN-PS/UV STARTER - adalimumab pen-injector kit
40 mg/0.8ml, 80 mg/0.8ml & 40 mg/0.4ml
5 PA
icatibant acetate subcutaneous soln pref syr 30 mg/3ml
5 PA, QL (6 syringes/30 days)
IMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc for inj susp 3 BD
INFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml 3
IPOL INACTIVATED IPV - poliovirus vaccine, ipv injection 3
IXIARO - japanese encephalitis vaccine inactivated adsorbed inj 3
JYNNEOS - smallpox & monkeypox vac, live, non-replicating inj
0.5 ml
3 BD
KINRIX - diph-tetanus-acell pert-polio, ipv vacc susp pref syr 0.5 ml 3
leflunomide tab 10 mg, 20 mg
3
M-M-R II - measles-mumps-rubella virus vaccines for inj soln 3
MENACTRA - meningococcal (a, c, y, and w-135) diphth conjugate
vaccine
3
MENQUADFI - meningococcal (a, c, y, and w-135) tetanus
conjugate vaccine
3
MENVEO - meningococcal (a, c, y, and w-135) oligo conj vac for inj 3
MENVEO - meningococcal (a, c, y, and w-135) oligo conj vac im
soln
3
methotrexate sodium inj pf 50 mg/2ml (25 mg/ml), 250 mg/10ml
(25 mg/ml), 1000 mg/40ml (25 mg/ml)^
1
methotrexate sodium inj 250 mg/10ml (25 mg/ml)^
1
methotrexate sodium inj 50 mg/2ml (25 mg/ml)^
1
methotrexate sodium tab 2.5 mg
2
mycophenolate mofetil cap 250 mg
2 BD
mycophenolate mofetil for oral susp 200 mg/ml
5 BD
mycophenolate mofetil tab 500 mg
2 BD
mycophenolate sodium tab dr 180 mg, 360 mg
4 BD
PEDIARIX - diph-tet tox-acell pert-hep b-polio ipv vac susp pref syr 3
PEDVAX HIB - haemophilus b polysaccharide conj vac im susp
7.5 mcg/0.5 ml
3
PEGASYS - peginterferon alfa-2a inj 180 mcg/ml 5 PA
PEGASYS - peginterferon alfa-2a soln prefilled syr 180 mcg/0.5ml 5 PA
PENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly vac for
im susp
3
PREHEVBRIO - hepatitis b vaccine 3-antigen (recombinant) susp
10 mcg/ml
3 BD
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
60
Drug Name
Drug Tier Requirements/Limits
PRIORIX - measles-mumps-rubella virus vaccines for
subcutaneous susp
3
PROGRAF - tacrolimus inj 5 mg/ml 4 BD
PROGRAF - tacrolimus packet for susp 0.2 mg, 1 mg 4 BD
PROQUAD - measles-mumps-rubella-varicella virus vaccines for
susp
3
QUADRACEL - diph-tetanus tox ad-acell pert & polio virus, ipv vac
inj
3
QUADRACEL - diph-tetanus-acell pert-polio, ipv vacc susp pref syr
0.5 ml
3
RABAVERT - rabies vaccine, pcec for inj 3 BD
RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp pref syr
5 mcg/0.5ml, 10 mcg/ml
3 BD
RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp
5 mcg/0.5ml, 10 mcg/ml, 40 mcg/ml
3 BD
RIDAURA - auranofin cap 3 mg 5
RINVOQ - upadacitinib tab er 24hr 15 mg, 30 mg, 45 mg 5 PA
ROTARIX - rotavirus vaccine, live for oral susp 3
ROTARIX - rotavirus vaccine, live oral susp 3
ROTATEQ - rotavirus vaccine, live oral pentavalent soln 3
SANDIMMUNE - cyclosporine oral soln 100 mg/ml 4 BD
SHINGRIX - zoster vac recombinant adjuvanted for im inj
50 mcg/0.5ml
3 QL (2 vaccines/lifetime; >=18 yr)
SIMULECT - basiliximab for iv soln 10 mg, 20 mg 5 BD
sirolimus oral soln 1 mg/ml
4 BD
sirolimus tab 0.5 mg, 1 mg, 2 mg
4 BD
SKYRIZI - risankizumab-rzaa iv soln 600 mg/10ml (60 mg/ml) 5 PA
SKYRIZI - risankizumab-rzaa soln prefilled syringe 150 mg/ml 5 PA
SKYRIZI - risankizumab-rzaa subcutaneous soln cartridge
180 mg/1.2ml, 360 mg/2.4ml
5 PA
SKYRIZI PEN - risankizumab-rzaa soln auto-injector 150 mg/ml 5 PA
STAMARIL - yellow fever vaccine for inj suspension 3
STELARA - ustekinumab inj 45 mg/0.5ml 5 PA
STELARA - ustekinumab iv soln 130 mg/26ml (5 mg/ml) (for iv
infusion)
5 PA
STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml, 90 mg/
ml
5 PA
tacrolimus cap 0.5 mg, 1 mg
2 BD
tacrolimus cap 5 mg
3 BD
TDVAX - tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml 3 BD
TENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu 3 BD
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
61
Drug Name
Drug Tier Requirements/Limits
TICOVAC - tick-borne encephalit vac inact susp pref syr
1.2 mcg/0.25ml, 2.4 mcg/0.5ml
3
TREMFYA - guselkumab soln pen-injector 100 mg/ml 5 PA
TREMFYA - guselkumab soln prefilled syringe 100 mg/ml 5 PA
TRUMENBA - meningococcal group b vac (recomb) im susp
prefilled syr
3
TWINRIX - hep a-hep b vaccine susp pref syr 720-20 elu-mcg/ml 3
TYPHIM VI - typhoid vi polysaccharide intramuscular vac inj
25 mcg/0.5ml
3
TYPHIM VI - typhoid vi polysaccharide vacc im soln pref syr
25 mcg/0.5ml
3
VAQTA - hepatitis a vaccine inj susp 25 unit/0.5ml, 50 unit/ml 3
VARIVAX - varicella virus vac live for subcutaneous inj 1350
pfu/0.5ml
3
XATMEP - methotrexate oral soln 2.5 mg/ml 4 BD
XELJANZ - tofacitinib citrate oral soln 1 mg/ml 5 PA
XELJANZ - tofacitinib citrate tab 5 mg, 10 mg 5 PA
XELJANZ XR - tofacitinib citrate tab er 24hr 11 mg, 22 mg 5 PA
XOLAIR - omalizumab for inj 150 mg* 5 PA
XOLAIR - omalizumab subcutaneous soln prefilled syringe
75 mg/0.5ml, 150 mg/ml*
5 PA
YF-VAX - yellow fever vaccine subcutaneous inj 3
Inflammatory Bowel Disease Agents
balsalazide disodium cap 750 mg
3
budesonide delayed release particles cap 3 mg
4 PA, QL (90 capsules/30 days)
budesonide tab er 24hr 9 mg
5 PA, QL (30 tablets/30 days)
DIPENTUM - olsalazine sodium cap 250 mg 5
hydrocortisone enema 100 mg/60ml
3
hydrocortisone perianal cream 1%
2
hydrocortisone perianal cream 2.5%
2 QL (454 grams/30 days)
mesalamine cap dr 400 mg
4 QL (180 capsules/30 days)
mesalamine cap er 24hr 0.375 gm
4 QL (120 capsules/30 days)
mesalamine cap er 500 mg
4 QL (240 capsules/30 days)
mesalamine enema 4 gm
4
mesalamine rectal enema 4 gm & cleanser wipe kit
4
mesalamine suppos 1000 mg
4
mesalamine tab delayed release 800 mg
4 QL (180 tablets/30 days)
mesalamine tab delayed release 1.2 gm
4 QL (120 tablets/30 days)
PENTASA - mesalamine cap er 250 mg 4 QL (480 capsules/30 days)
PENTASA - mesalamine cap er 500 mg 4 QL (240 capsules/30 days)
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
62
Drug Name
Drug Tier Requirements/Limits
sulfasalazine tab delayed release 500 mg
2
sulfasalazine tab 500 mg
2
Metabolic Bone Disease Agents
alendronate sodium tab 10 mg^
1 QL (120 tablets/30 days)
alendronate sodium tab 35 mg, 70 mg^
1 QL (4 tablets/28 days)
calcitonin (salmon) nasal soln 200 unit/act
2
calcitriol cap 0.25 mcg, 0.5 mcg
2
calcitriol oral soln 1 mcg/ml
4
cinacalcet hcl tab 30 mg
4 PA
cinacalcet hcl tab 60 mg, 90 mg
5 PA
FORTEO - teriparatide (recombinant) soln pen-inj 600 mcg/2.4ml 5 PA
ibandronate sodium tab 150 mg
2 QL (1 tablet/28 days)
NATPARA - parathyroid hormone (recombinant) for inj cartridge
25 mcg, 50 mcg, 75 mcg, 100 mcg*
5 PA, QL (2 cartridges/28 days)
paricalcitol cap 1 mcg, 2 mcg, 4 mcg
2
PROLIA - denosumab inj soln prefilled syringe 60 mg/ml 4 PA
risedronate sodium tab delayed release 35 mg
3 QL (4 tablets/28 days)
risedronate sodium tab 5 mg, 30 mg
3 QL (30 tablets/30 days)
risedronate sodium tab 35 mg
2 QL (4 tablets/28 days)
risedronate sodium tab 150 mg
2 QL (1 tablet/28 days)
TERIPARATIDE - teriparatide (recombinant) soln pen-inj
620 mcg/2.48ml
5 PA
TYMLOS - abaloparatide subcutaneous soln pen-injector
3120 mcg/1.56ml
5 PA
XGEVA - denosumab inj 120 mg/1.7ml 5 PA
zoledronic acid inj conc for iv infusion 4 mg/5ml
4
Ophthalmic Agents
ALPHAGAN P - brimonidine tartrate ophth soln 0.1%, 0.15% 3
atropine sulfate ophth soln 1%
3
azelastine hcl ophth soln 0.05%
3
BACITRACIN - bacitracin ophth oint 500 unit/gm 3
bacitracin-polymyxin b ophth oint
2
bacitracin-polymyxin-neomycin-hc ophth oint 1%
2
BESIVANCE - besifloxacin hcl ophth susp 0.6% 3
betaxolol hcl ophth soln 0.5%
2
BETOPTIC-S - betaxolol hcl ophth susp 0.25% 4
bimatoprost ophth soln 0.03%
3 QL (15 mls/75 days)
brimonidine tartrate ophth soln 0.15%
3
brimonidine tartrate ophth soln 0.2%
2
brimonidine tartrate-timolol maleate ophth soln 0.2-0.5%
3
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
63
Drug Name
Drug Tier Requirements/Limits
brinzolamide ophth susp 1%
4
bromfenac sodium ophth soln 0.09% (once-daily)
3
carteolol hcl ophth soln 1%
2
ciprofloxacin hcl ophth soln 0.3%
2
cromolyn sodium ophth soln 4%
2
CYSTADROPS - cysteamine hcl ophth soln 0.37%* 5 PA
CYSTARAN - cysteamine hcl ophth soln 0.44%* 5 PA
dexamethasone sodium phosphate ophth soln 0.1%
3
diclofenac sodium ophth soln 0.1%
2
difluprednate ophth emulsion 0.05%
3
dorzolamide hcl ophth soln 2%
2
dorzolamide hcl-timolol maleate ophth soln 2-0.5%
2
epinastine hcl ophth soln 0.05%
2
erythromycin ophth oint 5 mg/gm
2
EYSUVIS - loteprednol etabonate ophth susp 0.25% 4 PA
fluorometholone ophth susp 0.1%
2
flurbiprofen sodium ophth soln 0.03%
2
gentamicin sulfate ophth soln 0.3%
2
ILEVRO - nepafenac ophth susp 0.3% 4
INVELTYS - loteprednol etabonate ophth susp 1% 4
ketorolac tromethamine ophth soln 0.4%, 0.5%
2
LACRISERT - artificial tear ophth insert 4
latanoprost ophth soln 0.005%^
1 QL (15 mls/75 days)
levobunolol hcl ophth soln 0.5%
2
LUMIGAN - bimatoprost ophth soln 0.01% 3 QL (15 mls/75 days)
moxifloxacin hcl ophth soln 0.5% (generic for Vigamox)
2
moxifloxacin hcl ophth soln 0.5% (2 times daily) (generic for
Moxeza)
2
NATACYN - natamycin ophth susp 5% 4
neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin
2
neomycin-polymyxin-dexamethasone ophth oint 0.1%
2
neomycin-polymyxin-dexamethasone ophth susp 0.1%
2
NEOMYCIN/POLYMYXIN/GRAMICIDIN - neomycin-polymy-
gramicid op sol 1.75-10000-0.025mg-unt-mg/ml
3
ofloxacin ophth soln 0.3%
2
olopatadine hcl ophth soln 0.1%, 0.2%
2
pilocarpine hcl ophth soln 1%, 2%, 4%
2
polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%^
1
prednisolone acetate ophth susp 1%
3
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
64
Drug Name
Drug Tier Requirements/Limits
prednisolone sodium phosphate ophth soln 1%
3
PROLENSA - bromfenac sodium ophth soln 0.07% 3
RESTASIS - cyclosporine (ophth) emulsion 0.05% 3 QL (60 vials/30 days)
RESTASIS MULTIDOSE - cyclosporine (ophth) emulsion 0.05% 3 QL (2 bottles/30 days)
RHOPRESSA - netarsudil dimesylate ophth soln 0.02% 3 PA
ROCKLATAN - netarsudil dimesylate-latanoprost ophth soln
0.02-0.005%
3 PA
SIMBRINZA - brinzolamide-brimonidine tartrate ophth susp 1-0.2% 3
SULFACETAMIDE SODIUM - sulfacetamide sodium ophth oint
10%
3
sulfacetamide sodium ophth soln 10%
2
sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)%
2
timolol maleate ophth gel forming soln 0.25%, 0.5%
3
timolol maleate ophth soln 0.25%, 0.5%^
1
timolol maleate ophth soln 0.5% (once-daily)
2
TOBRADEX - tobramycin-dexamethasone ophth oint 0.3-0.1% 4
tobramycin ophth soln 0.3%^
1
tobramycin-dexamethasone ophth susp 0.3-0.1%
2
travoprost ophth soln 0.004%
3 QL (15 mls/75 days)
TRIFLURIDINE - trifluridine ophth soln 1% 3
Otic Agents
acetic acid otic soln 2%
2
fluocinolone acetonide (otic) oil 0.01%
2
hydrocortisone w/ acetic acid otic soln 1-2%
3
neomycin-polymyxin-hc otic soln 1%
2
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%
2
ofloxacin otic soln 0.3%
2
Respiratory Tract/Pulmonary Agents
acetylcysteine inhal soln 10%, 20%
2 BD
ADEMPAS - riociguat tab 0.5 mg, 1 mg, 1.5 mg, 2 mg, 2.5 mg* 5 PA, QL (90 tablets/30 days)
ADVAIR DISKUS - fluticasone-salmeterol aer powder ba
100-50 mcg/act, 250-50 mcg/act, 500-50 mcg/act
3 QL (1 inhaler/30 days)
ADVAIR HFA - fluticasone-salmeterol inhal aerosol 45-21 mcg/act,
115-21 mcg/act, 230-21 mcg/act
3 QL (1 canister/30 days)
albuterol sulfate inhal aero 108 mcg/act (generics for ProAir HFA
and Proventil HFA)
3 QL (36 grams/30 days)
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml), 0.5% (5 mg/ml),
0.63 mg/3ml, 1.25 mg/3ml
2 BD
albuterol sulfate syrup 2 mg/5ml
2
albuterol sulfate tab 2 mg, 4 mg
3
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
65
Drug Name
Drug Tier Requirements/Limits
ambrisentan tab 5 mg, 10 mg*
5 PA, QL (30 tablets/30 days)
ANORO ELLIPTA - umeclidinium-vilanterol aero powd ba
62.5-25 mcg/act
3 QL (1 package/30 days)
ARNUITY ELLIPTA - fluticasone furoate aerosol powder breath
activ 50 mcg/act, 100 mcg/act, 200 mcg/act
3 QL (30 blisters/30 days)
ASMANEX HFA - mometasone furoate inhal aerosol suspension
50 mcg/act, 100 mcg/act, 200 mcg/act
3 QL (1 canister/30 days)
ASMANEX TWISTHALER 120 METERED DOSES - mometasone
furoate inhal powd 220 mcg/act
3 QL (1 canister/30 days)
ASMANEX TWISTHALER 14 METERED DOSES - mometasone
furoate inhal powd 220 mcg/act
3 QL (1 canister/30 days)
ASMANEX TWISTHALER 30 METERED DOSES - mometasone
furoate inhal powd 110 mcg/act, 220 mcg/act
3 QL (1 canister/30 days)
ASMANEX TWISTHALER 60 METERED DOSES - mometasone
furoate inhal powd 220 mcg/act
3 QL (1 canister/30 days)
ATROVENT HFA - ipratropium bromide hfa inhal aerosol 17 mcg/
act
4 QL (2 canisters/30 days)
azelastine hcl nasal spray 0.1% (137 mcg/spray), 0.15%
(205.5 mcg/spray)
2 QL (2 bottles/30 days)
bosentan tab 62.5 mg, 125 mg*
4 PA, QL (60 tablets/30 days)
BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba
50-25 mcg/act, 100-25 mcg/act, 200-25 mcg/act
3 QL (1 package/30 days)
BREZTRI AEROSPHERE - budesonide-glycopyrrolate-formoterol
aers 160-9-4.8 mcg/act
3 QL (1 canister/30 days)
budesonide inhalation susp 0.25 mg/2ml, 0.5 mg/2ml, 1 mg/2ml
4 BD
budesonide-formoterol fumarate dihyd aerosol 80-4.5 mcg/act,
160-4.5 mcg/act
3 QL (1 canister/30 days)
CLEMASTINE FUMARATE - clemastine fumarate tab 2.68 mg# 4 PA (>=65 yr)
COMBIVENT RESPIMAT - ipratropium-albuterol inhal aerosol soln
20-100 mcg/act
4 QL (2 canisters/30 days)
cromolyn sodium soln nebu 20 mg/2ml
4 BD
cyproheptadine hcl syrup 2 mg/5ml#
3 PA (>=65 yr)
cyproheptadine hcl tab 4 mg#
3 PA (>=65 yr)
DULERA - mometasone furoate-formoterol fumarate aerosol
50-5 mcg/act, 100-5 mcg/act, 200-5 mcg/act
3 QL (1 canister/30 days)
EPINEPHRINE - epinephrine solution auto-injector 0.15 mg/0.15ml
(1:1000)
3
EPINEPHRINE (authorized generic for Adrenaclick 0.3 mg/0.3 mL)
- epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)
3
epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000)
3
epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) (generic
for EpiPen 2-Pak)
3
FASENRA - benralizumab subcutaneous soln prefilled syringe
30 mg/ml
5 PA
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
66
Drug Name
Drug Tier Requirements/Limits
FASENRA PEN - benralizumab subcutaneous soln auto-injector
30 mg/ml
5 PA
FLOVENT DISKUS - fluticasone propionate aer pow ba 50 mcg/act,
100 mcg/act
3 QL (1 inhaler/30 days)
FLOVENT DISKUS - fluticasone propionate aer pow ba 250 mcg/
act
3 QL (4 inhalers/30 days)
FLOVENT HFA - fluticasone propionate hfa inhal aero 44 mcg/act
(50/valve)
3 QL (1 canister/30 days)
FLOVENT HFA - fluticasone propionate hfa inhal aer 110 mcg/act
(125/valve)
3 QL (1 canister/30 days)
FLOVENT HFA - fluticasone propionate hfa inhal aer 220 mcg/act
(250/valve)
3 QL (2 canisters/30 days)
flunisolide nasal soln 25 mcg/act (0.025%)
3 QL (3 bottles/30 days)
fluticasone propionate nasal susp 50 mcg/act
2 QL (1 bottle/30 days)
FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-
salmeterol aer powder ba 55-14 mcg/act, 113-14 mcg/act,
232-14 mcg/act
3 QL (1 inhaler/30 days)
INCRUSE ELLIPTA - umeclidinium br aero powd breath act
62.5 mcg/act
3 QL (30 blisters/30 days)
ipratropium bromide inhal soln 0.02%
2 BD
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
2 QL (2 bottles/30 days)
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
2 QL (3 bottles/30 days)
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
2 BD
KALYDECO - ivacaftor packet 5.8 mg, 13.4 mg, 25 mg, 50 mg,
75 mg*
5 PA, QL (60 packets/30 days)
KALYDECO - ivacaftor tab 150 mg* 5 PA, QL (60 tablets/30 days)
levocetirizine dihydrochloride tab 5 mg^
1
mometasone furoate nasal susp 50 mcg/act
2 QL (2 bottles/30 days)
montelukast sodium chew tab 4 mg, 5 mg
2
montelukast sodium oral granules packet 4 mg
2
montelukast sodium tab 10 mg^
1
OFEV - nintedanib esylate cap 100 mg, 150 mg†* 5 PA, QL (60 capsules/30 days)
olopatadine hcl nasal soln 0.6%
3 QL (1 bottle/30 days)
OPSUMIT - macitentan tab 10 mg* 5 PA, QL (30 tablets/30 days)
ORKAMBI - lumacaftor-ivacaftor granules packet 75-94 mg,
100-125 mg, 150-188 mg*
5 PA, QL (60 packets/30 days)
ORKAMBI - lumacaftor-ivacaftor tab 100-125 mg, 200-125 mg* 5 PA, QL (120 tablets/30 days)
pirfenidone cap 267 mg
5 PA, QL (270 capsules/30 days)
pirfenidone tab 267 mg
5 PA, QL (270 tablets/30 days)
pirfenidone tab 801 mg
5 PA, QL (90 tablets/30 days)
PULMOZYME - dornase alfa inhal soln 2.5 mg/2.5ml 5 BD
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
67
Drug Name
Drug Tier Requirements/Limits
roflumilast tab 250 mcg, 500 mcg
4 PA, QL (30 tablets/30 days)
SEREVENT DISKUS - salmeterol xinafoate aer pow ba 50 mcg/act 3 QL (1 inhaler/30 days)
sildenafil citrate tab 20 mg
3 PA, QL (90 tablets/30 days)
SPIRIVA HANDIHALER - tiotropium bromide monohydrate inhal
cap 18 mcg
3 QL (30 capsules/30 days)
SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhal
aerosol 1.25 mcg/act, 2.5 mcg/act
3 QL (1 inhaler/30 days)
STIOLTO RESPIMAT - tiotropium br-olodaterol inhal aero soln
2.5-2.5 mcg/act
3 QL (1 canister/30 days)
SYMBICORT - budesonide-formoterol fumarate dihyd aerosol
80-4.5 mcg/act, 160-4.5 mcg/act
3 QL (1 canister/30 days)
SYMDEKO - tezacaftor-ivacaftor 50-75 mg & ivacaftor 75 mg tab
tbpk
5 PA, QL (60 tablets/30 days)
SYMDEKO - tezacaftor-ivacaftor 100-150 mg & ivacaftor 150 mg
tab tbpk
5 PA, QL (60 tablets/30 days)
tadalafil tab 20 mg (pah)
4 PA, QL (60 tablets/30 days)
terbutaline sulfate tab 2.5 mg, 5 mg
4
THEO-24 - theophylline cap er 24hr 100 mg, 200 mg, 300 mg,
400 mg
4
theophylline tab er 12hr 300 mg, 450 mg
4
theophylline tab er 24hr 400 mg, 600 mg
2
tobramycin nebu soln 300 mg/5ml
5 BD, PA
TRACLEER - bosentan tab for oral susp 32 mg* 5 PA, QL (120 tablets/30 days)
TRELEGY ELLIPTA - fluticasone-umeclidinium-vilanterol aepb
100-62.5-25 mcg/act, 200-62.5-25 mcg/act
3 QL (60 blisters/30 days)
TRIKAFTA - elexacaf-tezacaf-ivacaf 80-40-60 mg& ivacaf 59.5mg
thpk gran
5 PA, QL (60 packets/30 days)
TRIKAFTA - elexacaf-tezacaf-ivacaf 100-50-75 mg& ivacaf 75mg
thpk gran
5 PA, QL (60 packets/30 days)
TRIKAFTA - elexacaf-tezacaf-ivacaf 50-25-37.5 mg & ivacaftor
75 mg tbpk
5 PA, QL (90 tablets/30 days)
TRIKAFTA - elexacaf-tezacaf-ivacaf 100-50-75 mg &ivacaftor
150 mg tbpk
5 PA, QL (90 tablets/30 days)
UPTRAVI - selexipag tab 200 mcg, 400 mcg, 600 mcg, 800 mcg,
1000 mcg, 1200 mcg, 1400 mcg, 1600 mcg*
5 PA, QL (60 tablets/30 days)
UPTRAVI TITRATION PACK - selexipag tab therapy pack 200 mcg
(140) & 800 mcg (60)*
5 PA, QL (1 pack (200
tablets)/28 days)
VENTAVIS - iloprost inhalation solution 10 mcg/ml, 20 mcg/ml 5 BD, PA, QL (270 mls/30 days)
VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (36 grams/30 days)
XHANCE - fluticasone propionate nasal exhaler susp 93 mcg/act 4 QL (2 bottles/30 days)
XOPENEX HFA - levalbuterol tartrate inhal aerosol 45 mcg/act 4 QL (2 canisters/30 days)
zafirlukast tab 10 mg, 20 mg
2
2023
You can find information on what the symbols and abbreviations on this table mean by going to the beginning of
this table.
68
Drug Name
Drug Tier Requirements/Limits
Skeletal Muscle Relaxants
cyclobenzaprine hcl tab 5 mg, 10 mg#
2
methocarbamol tab 500 mg, 750 mg#
2
Sleep Disorder Agents
armodafinil tab 50 mg, 150 mg, 200 mg, 250 mg
3 PA, QL (30 tablets/30 days)
BELSOMRA - suvorexant tab 5 mg, 10 mg, 15 mg, 20 mg 3 PA, QL (30 tablets/30 days)
DAYVIGO - lemborexant tab 5 mg, 10 mg 3 PA, QL (30 tablets/30 days)
doxepin hcl (sleep) tab 3 mg, 6 mg
3 QL (30 tablets/30 days)
modafinil tab 100 mg, 200 mg
3 PA, QL (30 tablets/30 days)
ramelteon tab 8 mg
3 QL (30 tablets/30 days)
tasimelteon capsule 20 mg
5 PA, QL (30 capsules/30 days)
temazepam cap 7.5 mg
4 QL (30 capsules/30 days)
temazepam cap 15 mg, 30 mg^
1 QL (30 capsules/30 days)
WAKIX - pitolisant hcl tab 4.45 mg, 17.8 mg 5 PA, QL (60 tablets/30 days)
XYREM - sodium oxybate oral solution 500 mg/ml* 5 PA, QL (540 mls/30 days)
XYWAV - calcium, mag, potassium, & sod oxybates oral soln
500 mg/ml*
5 PA, QL (540 mls/30 days)
zaleplon cap 5 mg#
2 QL (30 capsules/30 days)
zaleplon cap 10 mg#
2 QL (60 capsules/30 days)
zolpidem tartrate tab 5 mg, 10 mg#
2 QL (30 tablets/30 days)
2023
69
INDEX
A
abacavir sulfate-lamivudine tab 600-300
mg................................................................................28
abacavir sulfate-lamivudine-zidovudine tab
300-150-300 mg........................................................28
abacavir sulfate soln 20 mg/ml.................................. 28
abacavir sulfate tab 300 mg....................................... 28
ABILIFY ASIMTUFII.....................................................24
ABILIFY MAINTENA....................................................24
abiraterone acetate tab 250 mg.................................17
ABRYSVO..................................................................... 56
acamprosate calcium tab delayed release 333
mg..................................................................................3
acarbose tab 100 mg.................................................. 32
acarbose tab 25 mg.................................................... 32
acarbose tab 50 mg.................................................... 32
acebutolol hcl cap 200 mg, 400 mg.......................... 37
acetaminophen w/ codeine soln 120-12
mg/5ml.......................................................................... 1
acetaminophen w/ codeine tab 300-15 mg, 300-30
mg..................................................................................1
acetaminophen w/ codeine tab 300-60
mg..................................................................................1
acetazolamide cap er 12hr 500 mg...........................38
acetazolamide tab 125 mg, 250 mg.......................... 38
acetic acid otic soln 2%.............................................. 64
acetylcysteine inhal soln 10%, 20%.......................... 64
acitretin cap 10 mg, 17.5 mg, 25 mg.........................45
ACTHIB..........................................................................56
ACTIMMUNE................................................................ 56
acyclovir cap 200 mg.................................................. 28
acyclovir oint 5%.......................................................... 28
acyclovir sodium iv soln 50 mg/ml.............................28
acyclovir susp 200 mg/5ml......................................... 28
acyclovir tab 400 mg, 800 mg....................................28
ADACEL........................................................................ 56
adefovir dipivoxil tab 10 mg........................................28
ADEMPAS..................................................................... 64
ADVAIR DISKUS..........................................................64
ADVAIR HFA.................................................................64
AIMOVIG....................................................................... 16
AKEEGA........................................................................ 17
albendazole tab 200 mg............................................. 23
albuterol sulfate inhal aero 108 mcg/act (generics for
ProAir HFA and Proventil HFA)...............................64
albuterol sulfate soln nebu 0.083% (2.5
mg/3ml), 0.5% (5 mg/ml), 0.63 mg/3ml, 1.25
mg/3ml........................................................................ 64
albuterol sulfate syrup 2 mg/5ml................................64
albuterol sulfate tab 2 mg, 4 mg................................ 64
alclometasone dipropionate cream
0.05%..........................................................................45
alclometasone dipropionate oint
0.05%..........................................................................45
ALCOHOL SWABS......................................................32
ALECENSA................................................................... 17
alendronate sodium tab 10 mg.................................. 62
alendronate sodium tab 35 mg, 70 mg..................... 62
alfuzosin hcl tab er 24hr 10 mg................................. 51
aliskiren fumarate tab 150 mg, 300 mg.....................38
allopurinol tab 100 mg, 300 mg................................. 16
alosetron hcl tab 0.5 mg............................................. 49
alosetron hcl tab 1 mg................................................ 49
ALPHAGAN P...............................................................62
alprazolam tab 0.25 mg, 0.5 mg, 1 mg..................... 31
alprazolam tab 2 mg....................................................31
ALUNBRIG.................................................................... 17
amantadine hcl cap 100 mg....................................... 23
amantadine hcl soln 50 mg/5ml................................. 23
amantadine hcl tab 100 mg........................................23
AMBISOME...................................................................14
ambrisentan tab 5 mg, 10 mg.................................... 65
amikacin sulfate inj 500 mg/2ml (250 mg/ml), 1
gm/4ml (250 mg/ml)................................................... 4
amiloride & hydrochlorothiazide tab 5-50
mg................................................................................38
amiloride hcl tab 5 mg.................................................38
amiodarone hcl tab 100 mg........................................38
amiodarone hcl tab 200 mg, 400 mg.........................38
amitriptyline hcl tab 10 mg, 25 mg, 50 mg, 75 mg,
100 mg, 150 mg........................................................12
amlodipine besylate-atorvastatin calcium tab 2.5-10
mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20 mg, 5-40
mg, 5-80 mg, 10-10 mg, 10-20 mg, 10-40 mg,
10-80 mg....................................................................38
amlodipine besylate-benazepril hcl cap 2.5-10 mg,
5-10 mg, 5-20 mg, 5-40 mg, 10-20 mg, 10-40
mg................................................................................38
amlodipine besylate-olmesartan medoxomil tab 5-20
mg, 5-40 mg, 10-20 mg, 10-40 mg.........................38
amlodipine besylate tab 2.5 mg, 5 mg, 10
mg................................................................................38
amlodipine besylate-valsartan tab 5-160 mg, 5-320
mg, 10-160 mg, 10-320 mg.....................................38
amlodipine-valsartan-hydrochlorothiazide tab
5-160-12.5 mg, 5-160-25 mg, 10-160-12.5 mg,
10-160-25 mg, 10-320-25 mg................................. 38
amoxapine tab 25 mg, 50 mg, 100 mg, 150
mg................................................................................12
AMOXICILLIN/CLAVULANATE POTASSIUM
ER..................................................................................4
2023
70
amoxicillin (trihydrate) cap 250 mg, 500
mg..................................................................................4
amoxicillin (trihydrate) chew tab 125 mg.....................4
amoxicillin (trihydrate) chew tab 250 mg.....................4
amoxicillin (trihydrate) for susp 125 mg/5ml, 200
mg/5ml, 250 mg/5ml, 400 mg/5ml............................ 4
amoxicillin (trihydrate) tab 500 mg, 875
mg..................................................................................4
amoxicillin & k clavulanate chew tab 200-28.5
mg..................................................................................4
amoxicillin & k clavulanate chew tab 400-57
mg..................................................................................4
amoxicillin & k clavulanate for susp
200-28.5 mg/5ml, 400-57 mg/5ml, 600-42.9
mg/5ml.......................................................................... 4
amoxicillin & k clavulanate for susp 250-62.5
mg/5ml.......................................................................... 4
amoxicillin & k clavulanate tab 250-125 mg, 500-125
mg, 875-125 mg..........................................................4
amphetamine-dextroamphetamine cap er 24hr 5 mg,
10 mg, 15 mg, 20 mg, 25 mg, 30 mg..................... 43
amphetamine-dextroamphetamine tab 20
mg................................................................................43
amphetamine-dextroamphetamine tab 5 mg, 7.5 mg,
10 mg, 12.5 mg, 15 mg, 30 mg.............................. 43
AMPHOTERICIN B......................................................14
amphotericin b liposome iv for susp 50
mg................................................................................15
ampicillin & sulbactam sodium for inj 3 (2-1)
gm..................................................................................4
ampicillin & sulbactam sodium for iv soln 3 (2-1)
gm..................................................................................4
ampicillin cap 500 mg....................................................4
ampicillin sodium for inj 250 mg, 500 mg, 1 gm, 2
gm..................................................................................4
ampicillin sodium for iv soln 1 gm................................4
ampicillin sodium for iv soln 2 gm, 10
gm..................................................................................4
anagrelide hcl cap 0.5 mg, 1 mg............................... 36
anastrozole tab 1 mg...................................................17
ANDRODERM.............................................................. 52
ANORO ELLIPTA.........................................................65
APOKYN........................................................................23
apomorphine hcl soln cartridge 30
mg/3ml........................................................................ 23
aprepitant capsule 40 mg, 80 mg, 125
mg................................................................................14
aprepitant capsule therapy pack 80 & 125
mg................................................................................14
APTIOM........................................................................... 9
APTIVUS....................................................................... 28
ARANESP ALBUMIN FREE.......................................36
ARCALYST....................................................................56
AREXVY........................................................................ 56
aripiprazole orally disintegrating tab 10 mg, 15
mg................................................................................24
aripiprazole oral solution 1 mg/ml..............................24
aripiprazole tab 10 mg, 15 mg, 20 mg, 30
mg................................................................................24
aripiprazole tab 2 mg, 5 mg....................................... 24
ARISTADA.....................................................................24
ARISTADA INITIO........................................................25
armodafinil tab 50 mg, 150 mg, 200 mg, 250
mg................................................................................68
ARNUITY ELLIPTA...................................................... 65
arsenic trioxide iv soln 10 mg/10ml (1 mg/
ml)................................................................................17
arsenic trioxide iv soln 12 mg/6ml (2 mg/
ml)................................................................................17
asenapine maleate sl tab 2.5 mg, 5 mg, 10
mg................................................................................25
ASMANEX HFA............................................................65
ASMANEX TWISTHALER 120 METERED
DOSES....................................................................... 65
ASMANEX TWISTHALER 14 METERED
DOSES....................................................................... 65
ASMANEX TWISTHALER 30 METERED
DOSES....................................................................... 65
ASMANEX TWISTHALER 60 METERED
DOSES....................................................................... 65
aspirin-dipyridamole cap er 12hr 25-200
mg................................................................................36
atazanavir sulfate cap 150 mg, 300
mg................................................................................28
atazanavir sulfate cap 200 mg................................... 28
atenolol & chlorthalidone tab 50-25 mg, 100-25
mg................................................................................38
atenolol tab 25 mg, 50 mg, 100 mg...........................38
ATGAM.......................................................................... 56
atomoxetine hcl cap 10 mg, 18 mg, 25 mg, 40
mg................................................................................43
atomoxetine hcl cap 60 mg, 80 mg, 100
mg................................................................................43
atorvastatin calcium tab 10 mg, 20 mg, 40
mg................................................................................38
atorvastatin calcium tab 80 mg.................................. 38
atovaquone-proguanil hcl tab 62.5-25 mg, 250-100
mg................................................................................23
atovaquone susp 750 mg/5ml....................................23
atropine sulfate ophth soln 1%.................................. 62
ATROVENT HFA..........................................................65
AURYXIA.......................................................................47
AUVELITY..................................................................... 12
AVONEX........................................................................ 43
2023
71
AVONEX PEN.............................................................. 43
AYVAKIT........................................................................ 17
azathioprine tab 50 mg............................................... 56
azathioprine tab 75 mg, 100 mg................................ 56
azelaic acid gel 15%................................................... 45
azelastine hcl nasal spray 0.1% (137 mcg/spray),
0.15% (205.5 mcg/spray)........................................ 65
azelastine hcl ophth soln 0.05%................................ 62
AZELEX......................................................................... 45
AZITHROMYCIN............................................................ 4
azithromycin for susp 100 mg/5ml, 200
mg/5ml.......................................................................... 4
azithromycin iv for soln 500 mg................................... 4
azithromycin tab 250 mg, 500 mg, 600
mg..................................................................................4
aztreonam for inj 1 gm.................................................. 4
B
BACITRACIN................................................................ 62
bacitracin-polymyxin b ophth oint.............................. 62
bacitracin-polymyxin-neomycin-hc ophth oint
1%............................................................................... 62
baclofen tab 5 mg, 10 mg, 20 mg..............................27
balsalazide disodium cap 750 mg............................. 61
BALVERSA....................................................................17
BAQSIMI ONE PACK.................................................. 32
BAQSIMI TWO PACK................................................. 32
BARACLUDE................................................................ 28
BCG VACCINE............................................................. 56
BELSOMRA.................................................................. 68
benazepril & hydrochlorothiazide tab 5-6.25 mg,
10-12.5 mg, 20-12.5 mg, 20-25 mg........................38
benazepril hcl tab 5 mg, 10 mg, 20 mg, 40
mg................................................................................38
BENLYSTA.................................................................... 56
BENZNIDAZOLE..........................................................23
benzoyl peroxide-erythromycin gel
5-3%............................................................................45
benztropine mesylate tab 0.5 mg, 1 mg, 2
mg................................................................................23
BESIVANCE..................................................................62
BESREMI...................................................................... 57
betaine powder for oral solution.................................50
BETAMETHASONE DIPROPIONATE
AUGMENTED............................................................45
betamethasone dipropionate augmented cream
0.05%..........................................................................45
betamethasone dipropionate augmented lotion
0.05%..........................................................................45
betamethasone dipropionate augmented oint
0.05%..........................................................................45
betamethasone dipropionate cream
0.05%..........................................................................45
betamethasone dipropionate lotion
0.05%..........................................................................45
betamethasone dipropionate oint
0.05%..........................................................................45
betamethasone valerate cream 0.1%....................... 45
betamethasone valerate lotion 0.1%.........................45
betamethasone valerate oint 0.1%............................ 45
BETASERON................................................................ 43
betaxolol hcl ophth soln 0.5%.................................... 62
betaxolol hcl tab 10 mg, 20 mg..................................38
bethanechol chloride tab 5 mg, 10 mg, 25 mg, 50
mg................................................................................51
BETOPTIC-S.................................................................62
bexarotene cap 75 mg................................................ 17
bexarotene gel 1%.......................................................17
BEXSERO..................................................................... 57
bicalutamide tab 50 mg...............................................17
BICILLIN L-A...................................................................4
BIKTARVY..................................................................... 28
bimatoprost ophth soln 0.03%................................... 62
bismuth subcit-metronidazole-tetracycline cap
140-125-125 mg........................................................49
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg,
5-6.25 mg, 10-6.25 mg............................................ 38
bisoprolol fumarate tab 5 mg, 10 mg.........................38
BOOSTRIX....................................................................57
bosentan tab 62.5 mg, 125 mg.................................. 65
BOSULIF....................................................................... 17
BRAFTOVI.....................................................................17
BREO ELLIPTA............................................................ 65
BREZTRI AEROSPHERE.......................................... 65
BRILINTA.......................................................................36
brimonidine tartrate ophth soln 0.15%...................... 62
brimonidine tartrate ophth soln 0.2%........................ 62
brimonidine tartrate-timolol maleate ophth soln
0.2-0.5%..................................................................... 62
brinzolamide ophth susp 1%...................................... 63
BRIVIACT........................................................................ 9
bromfenac sodium ophth soln 0.09% (once-
daily)............................................................................63
bromocriptine mesylate cap 5 mg..............................23
bromocriptine mesylate tab 2.5 mg........................... 24
BRUKINSA.................................................................... 17
budesonide delayed release particles cap 3
mg................................................................................61
budesonide-formoterol fumarate dihyd aerosol
80-4.5 mcg/act, 160-4.5 mcg/act............................ 65
budesonide inhalation susp 0.25 mg/2ml, 0.5
mg/2ml, 1 mg/2ml..................................................... 65
budesonide tab er 24hr 9 mg.....................................61
2023
72
bumetanide inj 0.25 mg/ml......................................... 38
bumetanide tab 0.5 mg, 1 mg, 2 mg......................... 38
buprenorphine hcl-naloxone hcl sl film 2-0.5
mg..................................................................................3
buprenorphine hcl-naloxone hcl sl film 4-1 mg, 8-2
mg, 12-3 mg................................................................ 3
buprenorphine hcl-naloxone hcl sl tab 2-0.5
mg..................................................................................3
buprenorphine hcl-naloxone hcl sl tab 8-2
mg..................................................................................3
buprenorphine hcl sl tab 2 mg, 8 mg...........................3
bupropion hcl (smoking deterrent) tab er 12hr 150
mg..................................................................................3
bupropion hcl tab 100 mg...........................................12
bupropion hcl tab 75 mg.............................................12
bupropion hcl tab er 12hr 100 mg............................. 12
bupropion hcl tab er 12hr 150 mg, 200
mg................................................................................12
bupropion hcl tab er 24hr 150 mg............................. 12
bupropion hcl tab er 24hr 300 mg............................. 12
buspirone hcl tab 5 mg, 7.5 mg, 10 mg, 15 mg, 30
mg................................................................................31
butalbital-acetaminophen-caffeine cap 50-300-40
mg, 50-325-40 mg...................................................... 1
butalbital-acetaminophen-caffeine tab 50-325-40
mg..................................................................................1
butalbital-acetaminophen tab 50-325
mg..................................................................................1
butalbital-aspirin-caffeine cap 50-325-40
mg..................................................................................1
butorphanol tartrate nasal soln 10 mg/
ml................................................................................... 1
BYDUREON BCISE.....................................................32
BYETTA......................................................................... 32
C
cabergoline tab 0.5 mg............................................... 55
CABLIVI......................................................................... 36
CABOMETYX............................................................... 17
calcipotriene cream 0.005%....................................... 45
calcipotriene oint 0.005%............................................45
calcipotriene soln 0.005% (50 mcg/ml)..................... 45
calcitonin (salmon) nasal soln 200 unit/
act................................................................................62
calcitriol cap 0.25 mcg, 0.5 mcg................................ 62
calcitriol oral soln 1 mcg/ml........................................ 62
calcium acetate cap 667 mg (169 mg
ca)................................................................................47
calcium acetate tab 667 mg....................................... 47
CALQUENCE................................................................17
candesartan cilexetil-hydrochlorothiazide tab 16-12.5
mg, 32-12.5 mg, 32-25 mg......................................38
candesartan cilexetil tab 32 mg................................. 38
candesartan cilexetil tab 4 mg, 8 mg, 16
mg................................................................................38
CAPLYTA.......................................................................25
CAPRELSA................................................................... 17
captopril tab 12.5 mg, 25 mg, 50 mg, 100
mg................................................................................38
carbamazepine cap er 12hr 100 mg, 200 mg, 300
mg..................................................................................9
carbamazepine chew tab 100 mg................................9
carbamazepine susp 100 mg/5ml................................9
carbamazepine tab 200 mg..........................................9
carbamazepine tab er 12hr 100 mg, 200 mg, 400
mg..................................................................................9
carbidopa & levodopa orally disintegrating tab
10-100 mg..................................................................24
carbidopa & levodopa orally disintegrating tab
25-100 mg..................................................................24
carbidopa & levodopa orally disintegrating tab
25-250 mg..................................................................24
carbidopa & levodopa tab 10-100 mg, 25-100 mg,
25-250 mg..................................................................24
carbidopa & levodopa tab er 25-100 mg, 50-200
mg................................................................................24
carbidopa-levodopa-entacapone tabs 12.5-50-200
mg, 18.75-75-200 mg, 25-100-200 mg,
31.25-125-200 mg, 37.5-150-200 mg, 50-200-200
mg................................................................................24
carbidopa tab 25 mg................................................... 24
carglumic acid soluble tab 200 mg............................ 47
carmustine for inj 100 mg........................................... 17
carteolol hcl ophth soln 1%........................................ 63
carvedilol tab 3.125 mg, 6.25 mg, 12.5 mg, 25
mg................................................................................38
caspofungin acetate for iv soln 50 mg, 70
mg................................................................................15
cefaclor cap 250 mg......................................................4
cefaclor cap 500 mg......................................................4
cefadroxil cap 500 mg................................................... 4
cefadroxil for susp 250 mg/5ml, 500
mg/5ml.......................................................................... 4
cefadroxil tab 1 gm........................................................ 5
CEFAZOLIN.................................................................... 5
cefazolin sodium (bulk) for inj 100 gm.........................5
cefazolin sodium (bulk) for inj 300 gm.........................5
cefazolin sodium-dextrose iv solution 1
gm/50ml-4%................................................................. 5
cefazolin sodium for inj 2 gm....................................... 5
cefazolin sodium for inj 500 mg, 1 gm, 10
gm..................................................................................5
cefazolin sodium for iv soln 1 gm................................ 5
2023
73
cefazolin sodium for iv soln 1 gm and dextrose 4%
(50 ml).......................................................................... 5
cefdinir cap 300 mg....................................................... 5
cefdinir for susp 125 mg/5ml, 250
mg/5ml.......................................................................... 5
cefepime hcl for inj 1 gm.............................................. 5
cefepime hcl for iv soln 1 gm and dextrose 5% (50
ml)..................................................................................5
cefepime hcl for iv soln 2 gm....................................... 5
cefepime hcl for iv soln 2 gm and dextrose 5% (50
ml)..................................................................................5
cefepime hcl iv soln 1 gm/50ml....................................5
cefepime hcl iv soln 2 gm/100ml..................................5
cefixime cap 400 mg..................................................... 5
cefoxitin sodium for iv soln 1 gm, 2 gm, 10
gm..................................................................................5
cefoxitin sodium iv for soln 1 gm and dextrose 4%
(50 ml).......................................................................... 5
cefoxitin sodium iv for soln 2 gm and dextrose 2.2%
(50 ml).......................................................................... 5
cefpodoxime proxetil for susp 50 mg/5ml, 100
mg/5ml.......................................................................... 5
cefpodoxime proxetil tab 100 mg, 200
mg..................................................................................5
cefprozil for susp 125 mg/5ml, 250
mg/5ml.......................................................................... 5
cefprozil tab 250 mg, 500 mg.......................................5
ceftazidime for inj 1 gm, 6 gm......................................5
ceftazidime for iv soln 1 gm and dextrose 5%
(50ml)............................................................................ 5
ceftazidime for iv soln 2 gm..........................................5
ceftazidime for iv soln 2 gm and dextrose 5%
(50ml)............................................................................ 5
ceftriaxone sodium (bulk) for inj 100 gm..................... 5
ceftriaxone sodium for inj 250 mg, 500 mg, 1 gm, 2
gm, 10 gm....................................................................5
ceftriaxone sodium for iv soln 1 gm, 2
gm..................................................................................5
ceftriaxone sodium for iv soln 1 gm and dextrose
3.74% 50 ml................................................................ 5
ceftriaxone sodium for iv soln 2 gm and dextrose
2.22% 50 ml................................................................ 5
ceftriaxone sodium in dextrose inj 20 mg/
ml................................................................................... 5
ceftriaxone sodium in dextrose inj 40 mg/
ml................................................................................... 5
cefuroxime axetil tab 250 mg, 500 mg........................ 5
cefuroxime sodium for inj 750 mg................................5
cefuroxime sodium for iv soln 1.5 gm..........................6
celecoxib cap 400 mg................................................... 1
celecoxib cap 50 mg, 100 mg, 200 mg....................... 1
CELONTIN...................................................................... 9
cephalexin cap 250 mg, 500 mg..................................6
cephalexin cap 750 mg................................................. 6
cephalexin for susp 125 mg/5ml, 250
mg/5ml.......................................................................... 6
cevimeline hcl cap 30 mg........................................... 44
CHEMET........................................................................47
CHENODAL.................................................................. 49
chlorhexidine gluconate soln 0.12%..........................44
chloroquine phosphate tab 250 mg........................... 23
chloroquine phosphate tab 500 mg........................... 23
chlorpromazine hcl tab 10 mg, 25 mg, 50 mg, 100
mg, 200 mg............................................................... 14
CHLORPROMAZINE
HYDROCHLORIDE.................................................. 14
chlorthalidone tab 25 mg, 50 mg............................... 38
cholestyramine light powder 4 gm/
dose............................................................................ 38
cholestyramine light powder packets 4
gm................................................................................38
cholestyramine powder 4 gm/dose............................39
cholestyramine powder packets 4 gm.......................39
choline fenofibrate cap dr 135 mg............................. 39
choline fenofibrate cap dr 45 mg............................... 39
ciclopirox gel 0.77%.................................................... 15
ciclopirox olamine cream 0.77%................................ 15
ciclopirox olamine susp 0.77%...................................15
ciclopirox shampoo 1%............................................... 15
ciclopirox solution 8%..................................................15
cilostazol tab 50 mg, 100 mg..................................... 36
CIMDUO........................................................................ 28
cimetidine tab 200 mg, 300 mg, 400 mg, 800
mg................................................................................49
cinacalcet hcl tab 30 mg.............................................62
cinacalcet hcl tab 60 mg, 90 mg................................ 62
CINRYZE.......................................................................57
ciprofloxacin 200 mg/100ml in d5w............................. 6
ciprofloxacin 400 mg/200ml in d5w............................. 6
CIPROFLOXACIN HCL.................................................6
ciprofloxacin hcl ophth soln 0.3%.............................. 63
ciprofloxacin hcl tab 250 mg, 500 mg, 750
mg..................................................................................6
citalopram hydrobromide oral soln 10
mg/5ml........................................................................ 12
citalopram hydrobromide tab 10 mg, 20
mg................................................................................12
citalopram hydrobromide tab 40 mg..........................12
CLARITHROMYCIN.......................................................6
clarithromycin tab 250 mg, 500 mg............................. 6
clarithromycin tab er 24hr 500 mg............................... 6
CLEMASTINE FUMARATE........................................ 65
clindamycin hcl cap 75 mg, 150 mg, 300
mg..................................................................................6
2023
74
clindamycin palmitate hcl for soln 75
mg/5ml.......................................................................... 6
clindamycin phosphate-benzoyl peroxide gel
1-5%............................................................................45
clindamycin phosphate gel 1%.................................... 6
clindamycin phosphate in d5w iv soln 300 mg/50ml,
600 mg/50ml, 900 mg/50ml.......................................6
clindamycin phosphate inj 300 mg/2ml, 600 mg/4ml,
900 mg/6ml, 9 gm/60ml............................................. 6
clindamycin phosphate in nacl 0.9% iv soln 300
mg/50ml........................................................................ 6
clindamycin phosphate in nacl 0.9% iv soln 600
mg/50ml........................................................................ 6
clindamycin phosphate in nacl 0.9% iv soln 900
mg/50ml........................................................................ 6
clindamycin phosphate lotion 1%................................ 6
clindamycin phosphate soln 1%...................................6
clindamycin phosphate swab 1%.................................6
clindamycin phosphate vaginal cream
2%..................................................................................6
clobazam suspension 2.5 mg/ml............................... 10
clobazam tab 10 mg, 20 mg.......................................10
clobetasol propionate cream 0.05%.......................... 45
clobetasol propionate emollient base cream
0.05%..........................................................................45
clobetasol propionate foam 0.05%............................ 45
clobetasol propionate gel 0.05%................................45
clobetasol propionate oint 0.05%.............................. 45
clobetasol propionate shampoo 0.05%.....................45
clobetasol propionate soln 0.05%..............................45
clomipramine hcl cap 25 mg, 50 mg, 75
mg................................................................................12
clonazepam orally disintegrating tab 0.125 mg, 0.25
mg, 0.5 mg, 1 mg..................................................... 31
clonazepam orally disintegrating tab 2
mg................................................................................31
clonazepam tab 0.5 mg, 1 mg................................... 31
clonazepam tab 2 mg..................................................31
clonidine hcl tab 0.1 mg, 0.2 mg, 0.3
mg................................................................................39
clonidine hcl tab er 12hr 0.1 mg................................ 43
clonidine td patch weekly 0.1 mg/24hr, 0.2 mg/24hr,
0.3 mg/24hr................................................................39
clopidogrel bisulfate tab 75 mg.................................. 36
clorazepate dipotassium tab 15 mg...........................31
clorazepate dipotassium tab 3.75 mg....................... 31
clorazepate dipotassium tab 7.5 mg......................... 31
clotrimazole cream 1%................................................15
clotrimazole troche 10 mg.......................................... 15
clotrimazole w/ betamethasone cream
1-0.05%...................................................................... 45
clotrimazole w/ betamethasone lotion
1-0.05%...................................................................... 45
CLOZAPINE ODT........................................................ 25
clozapine orally disintegrating tab 150
mg................................................................................25
clozapine orally disintegrating tab 200
mg................................................................................25
clozapine orally disintegrating tab 25 mg, 100
mg................................................................................25
clozapine tab 100 mg..................................................25
clozapine tab 200 mg..................................................25
clozapine tab 25 mg, 50 mg.......................................25
COARTEM.....................................................................23
CODEINE SULFATE......................................................1
codeine sulfate tab 30 mg............................................ 1
colchicine tab 0.6 mg.................................................. 16
colchicine w/ probenecid tab 0.5-500
mg................................................................................16
colestipol hcl granule packets 5 gm.......................... 39
colestipol hcl granules 5 gm.......................................39
colestipol hcl tab 1 gm................................................ 39
colistimethate sod for inj 150 mg (colistin base
activity)..........................................................................6
COMBIPATCH.............................................................. 52
COMBIVENT RESPIMAT........................................... 65
COMETRIQ...................................................................17
COMPLERA.................................................................. 28
COPAXONE.................................................................. 43
COPIKTRA.................................................................... 17
CORLANOR..................................................................39
COSELA........................................................................ 18
COSENTYX.................................................................. 57
COSENTYX SENSOREADY PEN............................ 57
COSENTYX UNOREADY...........................................57
COTELLIC.....................................................................18
CREON.......................................................................... 50
CRESEMBA.................................................................. 15
cromolyn sodium ophth soln 4%................................63
cromolyn sodium oral conc 100
mg/5ml........................................................................ 50
cromolyn sodium soln nebu 20 mg/2ml.................... 65
cyclobenzaprine hcl tab 5 mg, 10 mg....................... 68
CYCLOPHOSPHAMIDE............................................. 18
cyclophosphamide cap 25 mg, 50 mg...................... 18
CYCLOSET...................................................................32
cyclosporine cap 100 mg............................................57
cyclosporine cap 25 mg.............................................. 57
cyclosporine modified cap 25 mg, 50 mg, 100
mg................................................................................57
cyclosporine modified oral soln 100 mg/
ml.................................................................................57
CYLTEZO...................................................................... 57
2023
75
CYLTEZO STARTER PACKAGE FOR CROHNS
DISEASE/UC/HS...................................................... 57
CYLTEZO STARTER PACKAGE FOR
PSORIASIS................................................................57
cyproheptadine hcl syrup 2 mg/5ml...........................65
cyproheptadine hcl tab 4 mg......................................65
CYSTADROPS............................................................. 63
CYSTAGON.................................................................. 50
CYSTARAN................................................................... 63
D
dabigatran etexilate mesylate cap 75 mg, 150
mg................................................................................36
dalfampridine tab er 12hr 10 mg................................43
DALVANCE......................................................................6
danazol cap 50 mg, 100 mg, 200 mg........................52
dantrolene sodium cap 25 mg, 50 mg, 100
mg................................................................................28
dapsone tab 25 mg, 100 mg...................................... 16
DAPTACEL....................................................................57
daptomycin for iv soln 500 mg..................................... 6
darunavir tab 600 mg.................................................. 28
darunavir tab 800 mg.................................................. 28
DAURISMO...................................................................18
DAYVIGO.......................................................................68
decitabine for inj 50 mg.............................................. 18
deferasirox granules packet 90 mg, 180 mg, 360
mg................................................................................47
deferasirox tab 90 mg, 180 mg, 360
mg................................................................................48
deferasirox tab for oral susp 125 mg, 250 mg, 500
mg................................................................................47
DELSTRIGO................................................................. 28
demeclocycline hcl tab 150 mg, 300 mg.....................6
DENGVAXIA................................................................. 57
DEPO-ESTRADIOL..................................................... 52
DESCOVY.....................................................................28
desipramine hcl tab 10 mg, 25 mg, 50 mg, 75 mg,
100 mg, 150 mg........................................................12
desmopressin acetate nasal spray soln 0.01%
(refrigerated), 0.01%................................................ 52
desmopressin acetate tab 0.1 mg, 0.2
mg................................................................................52
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5)..................................................................... 52
desogestrel & ethinyl estradiol tab 0.15 mg-30
mcg..............................................................................52
desonide cream 0.05%............................................... 45
desonide lotion 0.05%.................................................45
desonide oint 0.05%....................................................45
desoximetasone cream 0.05%, 0.25%..................... 45
desoximetasone gel 0.05%........................................ 45
desoximetasone oint 0.25%....................................... 45
desvenlafaxine succinate tab er 24hr 25 mg, 50 mg,
100 mg....................................................................... 12
dexamethasone elixir 0.5 mg/5ml..............................51
dexamethasone sodium phosphate ophth soln
0.1%............................................................................ 63
dexamethasone soln 0.5 mg/5ml...............................51
dexamethasone tab 0.5 mg........................................52
dexamethasone tab 0.75 mg......................................52
dexamethasone tab 1.5 mg, 2 mg, 4 mg, 6
mg................................................................................52
dexamethasone tab 1 mg........................................... 52
dexamethasone tab therapy pack 1.5 mg
(21).............................................................................. 52
dexamethasone tab therapy pack 1.5 mg
(35).............................................................................. 52
dexamethasone tab therapy pack 1.5 mg
(51).............................................................................. 52
dexmethylphenidate hcl tab 2.5 mg, 5 mg, 10
mg................................................................................43
dextroamphetamine sulfate cap er 24hr 10 mg, 15
mg................................................................................43
dextroamphetamine sulfate cap er 24hr 5
mg................................................................................43
dextroamphetamine sulfate tab 10 mg......................43
dextroamphetamine sulfate tab 5 mg........................43
dextrose 2.5% w/ sodium chloride
0.45%..........................................................................48
dextrose 5% w/ sodium chloride 0.2%, 0.33%,
0.45%, 0.9%.............................................................. 48
dextrose inj 5%, 10%.................................................. 48
DIACOMIT.....................................................................10
diazepam conc 5 mg/ml..............................................31
diazepam oral soln 1 mg/ml....................................... 31
DIAZEPAM RECTAL GEL.......................................... 10
diazepam rectal gel delivery system 10 mg, 20
mg................................................................................10
diazepam tab 2 mg, 5 mg, 10 mg..............................31
diazoxide susp 50 mg/ml............................................ 32
diclofenac potassium tab 50 mg.................................. 1
diclofenac sodium (actinic keratoses) gel
3%............................................................................... 46
diclofenac sodium gel 1%............................................. 1
diclofenac sodium ophth soln 0.1%...........................63
diclofenac sodium tab delayed release 25
mg..................................................................................1
diclofenac sodium tab delayed release 50
mg..................................................................................1
diclofenac sodium tab delayed release 75
mg..................................................................................1
diclofenac sodium tab er 24hr 100 mg........................ 1
2023
76
diclofenac w/ misoprostol tab delayed release 50-0.2
mg..................................................................................1
diclofenac w/ misoprostol tab delayed release 75-0.2
mg..................................................................................1
dicloxacillin sodium cap 250 mg, 500
mg..................................................................................6
dicyclomine hcl cap 10 mg......................................... 49
dicyclomine hcl oral soln 10 mg/5ml......................... 49
dicyclomine hcl tab 20 mg.......................................... 49
DIFICID............................................................................ 6
difluprednate ophth emulsion 0.05%.........................63
digoxin oral soln 0.05 mg/ml...................................... 39
digoxin tab 125 mcg (0.125 mg), 250 mcg (0.25
mg).............................................................................. 39
dihydroergotamine mesylate nasal spray 4 mg/
ml.................................................................................16
DILANTIN...................................................................... 10
diltiazem hcl cap er 12hr 60 mg, 90 mg, 120
mg................................................................................39
diltiazem hcl cap er 24hr 120 mg, 180 mg, 240
mg................................................................................39
diltiazem hcl coated beads cap er 24hr 120 mg, 180
mg, 240 mg, 300 mg, 360 mg.................................39
diltiazem hcl extended release beads cap er 24hr
120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420
mg................................................................................39
diltiazem hcl tab 30 mg, 60 mg, 90 mg, 120
mg................................................................................39
diltiazem hcl tab er 24hr 120 mg, 180 mg, 240 mg,
300 mg, 360 mg, 420 mg........................................ 39
dimethyl fumarate capsule delayed release 120 mg,
240 mg....................................................................... 43
dimethyl fumarate capsule dr starter pack 120 mg &
240 mg....................................................................... 43
DIPENTUM....................................................................61
diphenoxylate w/ atropine tab 2.5-0.025
mg................................................................................49
DIPHTHERIA/TETANUS TOXOIDS ADSORBED
PEDIATRIC................................................................ 57
dipyridamole tab 25 mg, 50 mg, 75 mg.....................36
disulfiram tab 250 mg....................................................3
disulfiram tab 500 mg....................................................3
divalproex sodium cap delayed release sprinkle 125
mg................................................................................10
divalproex sodium tab delayed release 125 mg, 250
mg, 500 mg............................................................... 10
divalproex sodium tab er 24 hr 250 mg, 500
mg................................................................................10
docetaxel for inj conc 20 mg/ml, 80 mg/4ml (20 mg/
ml), 160 mg/8ml (20 mg/ml).................................... 18
docetaxel soln for iv infusion 20 mg/2ml, 80 mg/8ml,
160 mg/16ml..............................................................18
dofetilide cap 125 mcg (0.125 mg), 250 mcg (0.25
mg), 500 mcg (0.5 mg)............................................ 39
donepezil hydrochloride orally disintegrating tab 5
mg, 10 mg..................................................................12
donepezil hydrochloride tab 5 mg, 10 mg, 23
mg................................................................................12
dorzolamide hcl ophth soln 2%..................................63
dorzolamide hcl-timolol maleate ophth soln
2-0.5%........................................................................ 63
DOVATO........................................................................ 28
doxazosin mesylate tab 1 mg, 2 mg, 4 mg, 8
mg................................................................................39
doxepin hcl (sleep) tab 3 mg, 6 mg........................... 68
doxepin hcl cap 10 mg, 25 mg, 50 mg, 75 mg, 100
mg, 150 mg............................................................... 12
doxepin hcl conc 10 mg/ml.........................................12
doxycycline hyclate cap 50 mg, 100 mg..................... 6
doxycycline hyclate for inj 100 mg...............................6
doxycycline hyclate tab 20 mg, 100 mg...................... 6
doxycycline monohydrate cap 150 mg........................6
doxycycline monohydrate cap 50 mg, 100
mg..................................................................................6
doxycycline monohydrate cap 75 mg.......................... 6
doxycycline monohydrate tab 150 mg.........................7
doxycycline monohydrate tab 50 mg, 75 mg, 100
mg..................................................................................7
dronabinol cap 2.5 mg, 5 mg, 10 mg.........................14
drospirenone-ethinyl estradiol tab 3-0.02
mg................................................................................52
drospirenone-ethinyl estradiol tab 3-0.03
mg................................................................................52
drospirenone-ethinyl estrad-levomefolate tab
3-0.02-0.451 mg........................................................52
drospirenone-ethinyl estrad-levomefolate tab
3-0.03-0.451 mg........................................................52
droxidopa cap 100 mg, 200 mg, 300
mg................................................................................39
DUAVEE........................................................................ 53
DULERA........................................................................ 65
duloxetine hcl enteric coated pellets cap 20 mg, 60
mg................................................................................13
duloxetine hcl enteric coated pellets cap 30
mg................................................................................13
DUPIXENT.................................................................... 57
dutasteride cap 0.5 mg............................................... 51
dutasteride-tamsulosin hcl cap 0.5-0.4
mg................................................................................51
E
econazole nitrate cream 1%.......................................15
EDURANT..................................................................... 28
efavirenz cap 200 mg..................................................28
2023
77
efavirenz cap 50 mg....................................................28
efavirenz-emtricitabine-tenofovir df tab 600-200-300
mg................................................................................28
efavirenz-lamivudine-tenofovir df tab 400-300-300
mg, 600-300-300 mg................................................28
efavirenz tab 600 mg...................................................28
ELIGARD.......................................................................55
ELIQUIS.........................................................................36
ELIQUIS STARTER PACK......................................... 36
EMCYT.......................................................................... 18
EMGALITY.................................................................... 16
EMSAM..........................................................................13
emtricitabine caps 200 mg......................................... 28
emtricitabine-tenofovir disoproxil fumarate tab
100-150 mg, 133-200 mg, 167-250 mg, 200-300
mg................................................................................28
EMTRIVA....................................................................... 28
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg, 10-25 mg............................................................ 39
enalapril maleate tab 2.5 mg, 5 mg, 10 mg, 20
mg................................................................................39
ENBREL........................................................................ 58
ENBREL MINI...............................................................58
ENBREL SURECLICK................................................ 58
ENGERIX-B.................................................................. 58
enoxaparin sodium inj 300 mg/3ml............................36
enoxaparin sodium inj soln pref syr 30 mg/0.3ml, 40
mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml, 100 mg/ml,
120 mg/0.8ml, 150 mg/ml........................................36
entacapone tab 200 mg.............................................. 24
entecavir tab 0.5 mg, 1 mg.........................................29
ENTRESTO...................................................................39
EPCLUSA......................................................................29
EPIDIOLEX................................................................... 10
epinastine hcl ophth soln 0.05%................................63
EPINEPHRINE............................................................. 65
epinephrine solution auto-injector 0.15 mg/0.3ml
(1:2000)...................................................................... 65
epinephrine solution auto-injector 0.3 mg/0.3ml
(1:1000) (generic for EpiPen 2-Pak)...................... 65
eplerenone tab 25 mg, 50 mg....................................39
EPRONTIA.................................................................... 10
ergotamine w/ caffeine tab 1-100 mg........................16
ERIVEDGE....................................................................18
ERLEADA......................................................................18
erlotinib hcl tab 100 mg, 150 mg............................... 18
erlotinib hcl tab 25 mg.................................................18
ertapenem sodium for inj 1 gm.................................... 7
ERY.................................................................................. 7
ERYTHROCIN LACTOBIONATE.................................7
ERYTHROCIN STEARATE.......................................... 7
erythromycin ethylsuccinate for susp 200 mg/5ml,
400 mg/5ml.................................................................. 7
erythromycin lactobionate for inj 500 mg.................... 7
erythromycin ophth oint 5 mg/gm.............................. 63
erythromycin soln 2%.................................................... 7
erythromycin tab 250 mg, 500 mg............................... 7
erythromycin tab delayed release 250 mg, 500
mg..................................................................................7
erythromycin tab delayed release 333
mg..................................................................................7
erythromycin w/ delayed release particles cap 250
mg..................................................................................7
escitalopram oxalate soln 5 mg/5ml.......................... 13
escitalopram oxalate tab 20 mg.................................13
escitalopram oxalate tab 5 mg, 10 mg...................... 13
esomeprazole magnesium cap delayed release 20
mg, 40 mg..................................................................49
esomeprazole magnesium for delayed release susp
packet 10 mg, 20 mg, 40 mg.................................. 49
estradiol & norethindrone acetate tab 0.5-0.1
mg................................................................................53
estradiol & norethindrone acetate tab 1-0.5
mg................................................................................53
estradiol tab 0.5 mg, 1 mg, 2 mg...............................53
estradiol td gel 0.25 mg/0.25gm (0.1%), 0.5
mg/0.5gm (0.1%), 0.75 mg/0.75gm (0.1%), 1 mg/
gm (0.1%), 1.25 mg/1.25gm (0.1%)....................... 53
estradiol td patch twice weekly 0.025 mg/24hr,
0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1
mg/24hr...................................................................... 53
estradiol td patch weekly 0.025 mg/24hr,
0.0375 mg/24hr (37.5 mcg/24hr), 0.05
mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1
mg/24hr...................................................................... 53
estradiol vaginal cream 0.1 mg/gm........................... 53
estradiol vaginal tab 10 mcg...................................... 53
estradiol valerate im in oil 10 mg/ml, 20 mg/ml, 40
mg/ml.......................................................................... 53
ESTRING.......................................................................53
ethambutol hcl tab 100 mg, 400 mg..........................16
ethosuximide cap 250 mg...........................................10
ethosuximide soln 250 mg/5ml.................................. 10
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35
mcg, 1 mg-50 mcg................................................... 53
etodolac cap 200 mg..................................................... 1
etodolac cap 300 mg..................................................... 1
etodolac tab 400 mg, 500 mg...................................... 1
etodolac tab er 24hr 400 mg, 500 mg......................... 1
etodolac tab er 24hr 600 mg........................................ 1
etravirine tab 100 mg.................................................. 29
etravirine tab 200 mg.................................................. 29
EULEXIN....................................................................... 18
2023
78
everolimus tab 0.25 mg, 0.5 mg, 0.75 mg, 1
mg................................................................................58
everolimus tab 2.5 mg, 7.5 mg, 10 mg......................18
everolimus tab 5 mg....................................................18
everolimus tab for oral susp 2 mg, 5
mg................................................................................18
everolimus tab for oral susp 3 mg............................. 18
EVOTAZ.........................................................................29
exemestane tab 25 mg............................................... 18
EXKIVITY...................................................................... 18
EYSUVIS....................................................................... 63
ezetimibe-simvastatin tab 10-10 mg, 10-20 mg,
10-40 mg, 10-80 mg.................................................39
ezetimibe tab 10 mg....................................................39
F
famciclovir tab 125 mg, 250 mg, 500
mg................................................................................29
famotidine for susp 40 mg/5ml...................................49
famotidine tab 20 mg, 40 mg..................................... 49
FANAPT.........................................................................25
FANAPT TITRATION PACK....................................... 25
FARXIGA....................................................................... 32
FASENRA......................................................................65
FASENRA PEN............................................................ 66
felbamate susp 600 mg/5ml....................................... 10
felbamate tab 400 mg, 600 mg.................................. 10
felodipine tab er 24hr 2.5 mg, 5 mg, 10
mg................................................................................39
fenofibrate micronized cap 67 mg, 134 mg, 200
mg................................................................................39
fenofibrate tab 145 mg, 160 mg.................................39
fenofibrate tab 48 mg, 54 mg.....................................39
fentanyl citrate lozenge on a handle 200
mcg................................................................................1
fentanyl citrate lozenge on a handle 400 mcg, 600
mcg, 800 mcg, 1200 mcg, 1600 mcg....................... 1
fentanyl td patch 72hr 12 mcg/hr, 75 mcg/hr, 100
mcg/hr........................................................................... 1
fentanyl td patch 72hr 25 mcg/hr, 50 mcg/
hr....................................................................................1
FETZIMA....................................................................... 13
FETZIMA TITRATION PACK......................................13
FINACEA....................................................................... 46
finasteride tab 5 mg.....................................................51
fingolimod hcl cap 0.5 mg...........................................43
FINTEPLA..................................................................... 10
FIRMAGON...................................................................55
flecainide acetate tab 50 mg, 100 mg, 150
mg................................................................................39
FLOVENT DISKUS......................................................66
FLOVENT HFA............................................................. 66
fluconazole for susp 10 mg/ml, 40 mg/
ml.................................................................................15
fluconazole in nacl 0.9% inj 200 mg/100ml, 400
mg/200ml....................................................................15
fluconazole tab 50 mg, 100 mg, 150 mg, 200
mg................................................................................15
flucytosine cap 250 mg, 500 mg................................15
fludrocortisone acetate tab 0.1 mg............................ 52
flunisolide nasal soln 25 mcg/act
(0.025%)..................................................................... 66
fluocinolone acetonide (otic) oil 0.01%..................... 64
fluocinolone acetonide cream 0.01%........................ 46
fluocinolone acetonide cream 0.025%...................... 46
fluocinolone acetonide oil 0.01% (body oil), 0.01%
(scalp oil)....................................................................46
fluocinolone acetonide oint 0.025%...........................46
fluocinolone acetonide soln 0.01%............................ 46
fluocinonide cream 0.05%.......................................... 46
fluocinonide emulsified base cream
0.05%..........................................................................46
fluocinonide gel 0.05%................................................ 46
fluocinonide oint 0.05%...............................................46
fluocinonide soln 0.05%.............................................. 46
fluorometholone ophth susp 0.1%............................. 63
FLUOROURACIL......................................................... 46
fluorouracil cream 5%................................................. 46
fluorouracil iv soln 500 mg/10ml (50 mg/ml), 1
gm/20ml (50 mg/ml), 2.5 gm/50ml (50 mg/ml), 5
gm/100ml (50 mg/ml)............................................... 18
FLUOXETINE DR........................................................ 13
fluoxetine hcl cap 10 mg.............................................13
fluoxetine hcl cap 20 mg.............................................13
fluoxetine hcl cap 40 mg.............................................13
fluoxetine hcl solution 20 mg/5ml.............................. 13
fluoxetine hcl tab 10 mg..............................................13
fluoxetine hcl tab 20 mg..............................................13
fluphenazine decanoate inj 25 mg/ml........................25
FLUPHENAZINE HCL.................................................25
fluphenazine hcl tab 1 mg, 2.5 mg, 5 mg, 10
mg................................................................................25
FLUPHENAZINE HYDROCHLORIDE...................... 25
flurbiprofen sodium ophth soln 0.03%.......................63
flurbiprofen tab 100 mg................................................. 1
FLUTICASONE PROPIONATE/
SALMETEROL.......................................................... 66
fluticasone propionate cream 0.05%.........................46
fluticasone propionate nasal susp 50 mcg/
act................................................................................66
fluticasone propionate oint 0.005%........................... 46
fluvastatin sodium cap 20 mg, 40 mg....................... 39
fluvoxamine maleate tab 100 mg...............................13
2023
79
fluvoxamine maleate tab 25 mg, 50
mg................................................................................13
FOLOTYN......................................................................18
fondaparinux sodium subcutaneous inj 2.5
mg/0.5ml.....................................................................36
fondaparinux sodium subcutaneous inj 5 mg/0.4ml,
7.5 mg/0.6ml, 10 mg/0.8ml......................................37
FORTEO........................................................................62
fosamprenavir calcium tab 700 mg........................... 29
fosinopril sodium & hydrochlorothiazide tab 10-12.5
mg, 20-12.5 mg.........................................................40
fosinopril sodium tab 10 mg, 20 mg, 40
mg................................................................................40
FOSRENOL.................................................................. 48
FOTIVDA....................................................................... 18
FULPHILA..................................................................... 37
fulvestrant inj soln pref syr 250 mg/5ml.................... 18
furosemide inj 10 mg/ml..............................................40
furosemide oral soln 10 mg/ml...................................40
furosemide oral soln 8 mg/ml.....................................40
furosemide tab 20 mg, 40 mg, 80 mg....................... 40
FUZEON........................................................................ 29
FYCOMPA..................................................................... 10
G
gabapentin cap 100 mg.............................................. 10
gabapentin cap 300 mg.............................................. 10
gabapentin cap 400 mg.............................................. 10
gabapentin oral soln 250 mg/5ml.............................. 10
gabapentin tab 600 mg............................................... 10
gabapentin tab 800 mg............................................... 10
GALANTAMINE HYDROBROMIDE.......................... 12
galantamine hydrobromide cap er 24hr 8 mg, 16 mg,
24 mg..........................................................................12
galantamine hydrobromide tab 4 mg, 8 mg, 12
mg................................................................................12
GAMMAGARD LIQUID............................................... 58
GAMMAGARD S/D......................................................58
GAMMAPLEX............................................................... 58
GAMUNEX-C................................................................ 58
GARDASIL 9.................................................................58
GATTEX.........................................................................49
GAUZE PADS 2" X 2"................................................. 32
GAVILYTE-C................................................................. 49
GAVRETO..................................................................... 18
gefitinib tab 250 mg..................................................... 18
gemfibrozil tab 600 mg............................................... 40
gentamicin in saline inj 1.2 mg/ml................................7
GENTAMICIN SULFATE/0.9% SODIUM
CHLORIDE...................................................................7
gentamicin sulfate cream 0.1%..................................46
gentamicin sulfate inj 40 mg/ml....................................7
gentamicin sulfate oint 0.1%...................................... 46
gentamicin sulfate ophth soln 0.3%...........................63
GENTAMICIN SULFATE PEDIATRIC......................... 7
GENVOYA..................................................................... 29
GILOTRIF...................................................................... 18
glatiramer acetate soln prefilled syringe 20 mg/
ml.................................................................................44
glatiramer acetate soln prefilled syringe 40 mg/
ml.................................................................................44
GLEOSTINE..................................................................18
glimepiride tab 1 mg....................................................32
glimepiride tab 2 mg....................................................32
glimepiride tab 4 mg....................................................32
glipizide-metformin hcl tab 2.5-250 mg..................... 32
glipizide-metformin hcl tab 2.5-500 mg, 5-500
mg................................................................................32
glipizide tab 10 mg...................................................... 32
glipizide tab 5 mg.........................................................32
glipizide tab er 24hr 10 mg.........................................32
glipizide tab er 24hr 2.5 mg........................................32
glipizide tab er 24hr 5 mg...........................................32
GLUCAGEN HYPOKIT............................................... 32
glucagon (rdna) for inj kit 1 mg.................................. 33
GLUCAGON EMERGENCY KIT............................... 33
GLUCAGON EMERGENCY KIT FOR LOW BLOOD
SUGAR....................................................................... 33
glyburide-metformin tab 1.25-250 mg....................... 33
glyburide-metformin tab 2.5-500 mg, 5-500
mg................................................................................33
glyburide micronized tab 1.5 mg................................33
glyburide micronized tab 3 mg................................... 33
glyburide micronized tab 6 mg................................... 33
glyburide tab 1.25 mg................................................. 33
glyburide tab 2.5 mg....................................................33
glyburide tab 5 mg.......................................................33
glycopyrrolate tab 1 mg, 2 mg................................... 49
GLYXAMBI.................................................................... 33
granisetron hcl tab 1 mg.............................................14
GRANIX......................................................................... 37
griseofulvin microsize susp 125
mg/5ml........................................................................ 15
griseofulvin microsize tab 500 mg............................. 15
griseofulvin ultramicrosize tab 125 mg, 250
mg................................................................................15
guanfacine hcl tab 1 mg, 2 mg.................................. 40
guanfacine hcl tab er 24hr 1 mg, 2 mg, 3 mg, 4
mg................................................................................44
GVOKE HYPOPEN 1-PACK...................................... 33
GVOKE HYPOPEN 2-PACK...................................... 33
GVOKE KIT...................................................................33
GVOKE PFS................................................................. 33
2023
80
H
HAEGARDA.................................................................. 58
halobetasol propionate cream 0.05%........................46
halobetasol propionate oint 0.05%............................ 46
haloperidol decanoate im soln 50 mg/ml, 100 mg/
ml.................................................................................25
haloperidol lactate inj 5 mg/ml................................... 25
haloperidol lactate oral conc 2 mg/ml........................25
haloperidol tab 0.5 mg, 1 mg, 2 mg, 5 mg, 10 mg, 20
mg................................................................................25
HARVONI...................................................................... 29
HAVRIX..........................................................................58
HEMADY....................................................................... 52
heparin sodium (porcine) inj 1000 unit/ml, 5000 unit/
ml, 10000 unit/ml, 20000 unit/ml.............................37
heparin sodium (porcine) inj soln pref syr 5000
unit/0.5ml....................................................................37
heparin sodium (porcine) pf inj 5000
unit/0.5ml....................................................................37
heparin sodium (porcine) pf inj 5000 unit/
ml.................................................................................37
HEPLISAV-B................................................................. 58
HIBERIX........................................................................ 58
HUMALOG.................................................................... 33
HUMALOG JUNIOR KWIKPEN.................................33
HUMALOG KWIKPEN.................................................33
HUMALOG MIX 50/50.................................................33
HUMALOG MIX 50/50 KWIKPEN............................. 33
HUMALOG MIX 75/25.................................................33
HUMALOG MIX 75/25 KWIKPEN............................. 33
HUMALOG TEMPO PEN........................................... 33
HUMIRA.........................................................................58
HUMIRA PEDIATRIC CROHNS DISEASE
STARTER PACK....................................................... 58
HUMIRA PEN............................................................... 58
HUMIRA PEN-CD/UC/HS STARTER........................59
HUMIRA PEN-PEDIATRIC UC STARTER
PACK...........................................................................59
HUMIRA PEN-PS/UV STARTER...............................59
HUMULIN 70/30...........................................................34
HUMULIN 70/30 KWIKPEN....................................... 34
HUMULIN N.................................................................. 33
HUMULIN N KWIKPEN.............................................. 33
HUMULIN R.................................................................. 33
HUMULIN R U-500 (CONCENTRATE).....................33
HUMULIN R U-500 KWIKPEN...................................34
hydralazine hcl tab 10 mg, 25 mg, 50 mg, 100
mg................................................................................40
hydrochlorothiazide cap 12.5 mg...............................40
hydrochlorothiazide tab 12.5 mg, 25 mg, 50
mg................................................................................40
HYDROCODONE/IBUPROFEN...................................2
hydrocodone-acetaminophen soln 7.5-325
mg/15ml........................................................................ 2
hydrocodone-acetaminophen tab 10-325 mg,
7.5-325 mg...................................................................2
hydrocodone-acetaminophen tab 5-300
mg..................................................................................2
hydrocodone-acetaminophen tab 5-325
mg..................................................................................2
hydrocodone-acetaminophen tab 7.5-300 mg,
10-300 mg....................................................................2
hydrocodone bitartrate cap er 12hr 10
mg..................................................................................1
hydrocodone bitartrate cap er 12hr 15
mg..................................................................................1
hydrocodone bitartrate cap er 12hr 20
mg..................................................................................1
hydrocodone bitartrate cap er 12hr 30
mg..................................................................................1
hydrocodone bitartrate cap er 12hr 40
mg..................................................................................1
hydrocodone bitartrate cap er 12hr 50
mg..................................................................................1
hydrocodone-ibuprofen tab 10-200 mg....................... 2
hydrocodone-ibuprofen tab 7.5-200 mg......................2
hydrocortisone butyrate cream 0.1%........................ 46
hydrocortisone butyrate hydrophilic lipo base cream
0.1%............................................................................ 46
hydrocortisone butyrate oint 0.1%............................. 46
hydrocortisone butyrate soln 0.1%............................ 46
hydrocortisone cream 1%...........................................46
hydrocortisone cream 2.5%........................................46
hydrocortisone enema 100 mg/60ml.........................61
hydrocortisone lotion 2.5%......................................... 46
hydrocortisone oint 1%............................................... 46
hydrocortisone oint 2.5%............................................ 46
hydrocortisone perianal cream 1%............................ 61
hydrocortisone perianal cream 2.5%.........................61
hydrocortisone tab 5 mg, 10 mg, 20
mg................................................................................52
hydrocortisone valerate cream 0.2%.........................46
hydrocortisone valerate oint 0.2%............................. 46
hydrocortisone w/ acetic acid otic soln
1-2%............................................................................64
hydromorphone hcl inj 2 mg/ml....................................2
hydromorphone hcl liqd 1 mg/ml..................................2
hydromorphone hcl preservative free inj 10 mg/
ml................................................................................... 2
hydromorphone hcl preservative free inj 2 mg/
ml................................................................................... 2
hydromorphone hcl tab 2 mg, 4 mg, 8
mg..................................................................................2
hydroxychloroquine sulfate tab 200 mg.................... 23
2023
81
hydroxyurea cap 500 mg............................................ 18
hydroxyzine hcl syrup 10 mg/5ml.............................. 32
hydroxyzine hcl tab 10 mg, 25 mg, 50
mg................................................................................32
I
ibandronate sodium tab 150 mg................................ 62
IBRANCE.......................................................................18
ibuprofen susp 100 mg/5ml.......................................... 2
ibuprofen tab 400 mg.................................................... 2
ibuprofen tab 600 mg.................................................... 2
ibuprofen tab 800 mg.................................................... 2
icatibant acetate subcutaneous soln pref syr 30
mg/3ml........................................................................ 59
ICLUSIG........................................................................ 18
icosapent ethyl cap 0.5 gm........................................ 40
icosapent ethyl cap 1 gm............................................40
IDHIFA............................................................................18
ifosfamide iv inj 1 gm/20ml (50 mg/ml), 3 gm/60ml
(50 mg/ml)..................................................................18
ILEVRO..........................................................................63
imatinib mesylate tab 100 mg.................................... 19
imatinib mesylate tab 400 mg.................................... 19
IMBRUVICA.................................................................. 19
IMIPENEM/CILASTATIN............................................... 7
imipenem-cilastatin intravenous for soln 500
mg..................................................................................7
imipramine hcl tab 10 mg, 25 mg, 50
mg................................................................................13
imiquimod cream 5%...................................................46
IMOVAX RABIES (H.D.C.V.)...................................... 59
IMPAVIDO........................................................................7
INBRIJA......................................................................... 24
INCRELEX.................................................................... 52
INCRUSE ELLIPTA..................................................... 66
indapamide tab 1.25 mg, 2.5 mg............................... 40
INFANRIX...................................................................... 59
INLYTA........................................................................... 19
INQOVI.......................................................................... 19
INREBIC........................................................................ 19
INSULIN INJECTION DEVICE...................................34
INSULIN SYRINGE/NEEDLE.....................................34
INTELENCE.................................................................. 29
INTRALIPID.................................................................. 48
INVEGA HAFYERA..................................................... 25
INVEGA SUSTENNA.................................................. 25
INVEGA TRINZA..........................................................26
INVELTYS..................................................................... 63
IPOL INACTIVATED IPV.............................................59
ipratropium-albuterol nebu soln 0.5-2.5(3)
mg/3ml........................................................................ 66
ipratropium bromide inhal soln 0.02%.......................66
ipratropium bromide nasal soln 0.03% (21 mcg/
spray).......................................................................... 66
ipratropium bromide nasal soln 0.06% (42 mcg/
spray).......................................................................... 66
irbesartan-hydrochlorothiazide tab 150-12.5 mg,
300-12.5 mg.............................................................. 40
irbesartan tab 75 mg, 150 mg, 300 mg..................... 40
IRESSA..........................................................................19
ISENTRESS..................................................................29
ISENTRESS HD...........................................................29
isoniazid tab 100 mg................................................... 16
isoniazid tab 300 mg................................................... 16
isosorbide dinitrate tab 5 mg, 10 mg, 20 mg, 30
mg................................................................................40
isosorbide mononitrate tab 10 mg............................. 40
isosorbide mononitrate tab 20 mg............................. 40
isosorbide mononitrate tab er 24hr 120
mg................................................................................40
isosorbide mononitrate tab er 24hr 30 mg, 60
mg................................................................................40
ISOTONIC GENTAMICIN............................................. 7
isotretinoin cap 10 mg, 20 mg, 25 mg, 30 mg, 35 mg,
40 mg..........................................................................46
isradipine cap 2.5 mg, 5 mg.......................................40
itraconazole cap 100 mg............................................ 15
ivermectin cream 1%...................................................46
ivermectin tab 3 mg..................................................... 23
IXIARO...........................................................................59
J
JAKAFI...........................................................................19
JANUMET......................................................................34
JANUMET XR...............................................................34
JANUVIA........................................................................34
JARDIANCE..................................................................34
JAYPIRCA..................................................................... 19
JULUCA.........................................................................29
JYNNEOS......................................................................59
K
KALYDECO................................................................... 66
kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45%
inj................................................................................. 48
kcl 20 meq/l (0.149%) in nacl 0.45%
inj................................................................................. 48
kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2%
inj................................................................................. 48
kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.225%
inj................................................................................. 48
kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45%
inj................................................................................. 48
kcl 20 meq/l (0.15%) in nacl 0.45% inj...................... 48
2023
82
kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45%
inj................................................................................. 48
kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45%
inj................................................................................. 48
KERENDIA.................................................................... 40
ketoconazole cream 2%..............................................15
ketoconazole shampoo 2%........................................ 15
ketoconazole tab 200 mg........................................... 15
ketorolac tromethamine ophth soln 0.4%,
0.5%............................................................................ 63
KINRIX........................................................................... 59
KISQALI.........................................................................19
KISQALI FEMARA 200 DOSE...................................19
KISQALI FEMARA 400 DOSE...................................19
KISQALI FEMARA 600 DOSE...................................19
KLOXXADO.....................................................................3
KORLYM........................................................................55
KOSELUGO.................................................................. 19
KRAZATI........................................................................19
L
labetalol hcl tab 100 mg, 200 mg, 300
mg................................................................................40
lacosamide iv inj 200 mg/20ml (10 mg/
ml)................................................................................10
lacosamide oral solution 10 mg/ml............................ 10
lacosamide tab 50 mg, 100 mg, 150 mg, 200
mg................................................................................10
LACRISERT.................................................................. 63
lactic acid (ammonium lactate) cream
12%............................................................................. 46
lactic acid (ammonium lactate) lotion
12%............................................................................. 46
lactulose (encephalopathy) solution 10
gm/15ml......................................................................49
lactulose solution 10 gm/15ml....................................49
LAGEVRIO.................................................................... 29
lamivudine oral soln 10 mg/ml................................... 29
lamivudine tab 100 mg (hbv)......................................29
lamivudine tab 150 mg................................................29
lamivudine tab 300 mg................................................29
lamivudine-zidovudine tab 150-300 mg.................... 29
lamotrigine tab 25 mg, 100 mg, 150 mg, 200
mg................................................................................10
lamotrigine tab chewable dispersible 5 mg, 25
mg................................................................................10
lamotrigine tab er 24hr 25 mg, 50 mg, 100 mg, 200
mg, 300 mg............................................................... 10
lansoprazole cap delayed release 15 mg, 30
mg................................................................................49
lanthanum carbonate chew tab 1000
mg................................................................................48
lanthanum carbonate chew tab 500
mg................................................................................48
lanthanum carbonate chew tab 750
mg................................................................................48
LANTUS.........................................................................34
LANTUS SOLOSTAR.................................................. 34
lapatinib ditosylate tab 250 mg.................................. 19
latanoprost ophth soln 0.005%.................................. 63
LATUDA.........................................................................26
LEDIPASVIR/SOFOSBUVIR...................................... 29
leflunomide tab 10 mg, 20 mg................................... 59
lenalidomide cap 15 mg, 20 mg, 25
mg................................................................................19
lenalidomide cap 5 mg, 10 mg...................................19
lenalidomide caps 2.5 mg...........................................19
LENVIMA 10 MG DAILY DOSE.................................19
LENVIMA 12MG DAILY DOSE.................................. 19
LENVIMA 14 MG DAILY DOSE.................................19
LENVIMA 18 MG DAILY DOSE.................................19
LENVIMA 20 MG DAILY DOSE.................................20
LENVIMA 24 MG DAILY DOSE.................................20
LENVIMA 4 MG DAILY DOSE................................... 20
LENVIMA 8 MG DAILY DOSE................................... 20
letrozole tab 2.5 mg.....................................................20
leucovorin calcium tab 10 mg, 15 mg, 25
mg................................................................................20
leucovorin calcium tab 5 mg.......................................20
LEUKERAN...................................................................20
LEUKINE....................................................................... 37
LEUPROLIDE ACETATE............................................ 55
leuprolide acetate inj kit 1 mg/0.2ml (5 mg/
ml)................................................................................55
LEVEMIR.......................................................................34
LEVEMIR FLEXPEN................................................... 34
LEVEMIR FLEXTOUCH..............................................34
levetiracetam in sodium chloride iv soln
500 mg/100ml, 1000 mg/100ml, 1500
mg/100ml....................................................................10
levetiracetam oral soln 100 mg/ml.............................10
levetiracetam tab 250 mg, 500 mg, 750 mg, 1000
mg................................................................................10
levetiracetam tab er 24hr 500 mg, 750
mg................................................................................10
levobunolol hcl ophth soln 0.5%................................ 63
levocarnitine oral soln 1 gm/10ml
(10%).......................................................................... 50
levocarnitine tab 330 mg............................................ 50
levocetirizine dihydrochloride tab 5 mg.....................66
levofloxacin in d5w iv soln 250 mg/50ml, 500
mg/100ml, 750 mg/150ml.......................................... 7
levofloxacin iv soln 25 mg/ml....................................... 7
levofloxacin oral soln 25 mg/ml....................................7
2023
83
levofloxacin tab 250 mg, 500 mg, 750
mg..................................................................................7
levonorgestrel & ethinyl estradiol (91-day) tab
0.15-0.03 mg............................................................. 53
levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg,
0.15 mg-30 mcg........................................................53
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg........................53
levonorgestrel-ethinyl estradiol (continuous) tab
90-20 mcg.................................................................. 53
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
0.01mg(7)................................................................... 53
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab
0.01mg(7)................................................................... 53
levothyroxine sodium tab 100 mcg (euthyrox, levo-t,
levoxyl, unithroid)......................................................55
levothyroxine sodium tab 112 mcg (euthyrox, levo-t,
levoxyl, unithroid)......................................................55
levothyroxine sodium tab 125 mcg (euthyrox, levo-t,
levoxyl, unithroid)......................................................55
levothyroxine sodium tab 137 mcg (euthyrox, levo-t,
levoxyl, unithroid)......................................................55
levothyroxine sodium tab 150 mcg (euthyrox, levo-t,
levoxyl, unithroid)......................................................55
levothyroxine sodium tab 175 mcg (euthyrox, levo-t,
levoxyl, unithroid)......................................................55
levothyroxine sodium tab 200 mcg (euthyrox, levo-t,
levoxyl, unithroid)......................................................55
levothyroxine sodium tab 25 mcg (euthyrox, levo-t,
levoxyl, unithroid)......................................................54
levothyroxine sodium tab 300 mcg (levo-t,
unithroid).....................................................................55
levothyroxine sodium tab 50 mcg (euthyrox, levo-t,
levoxyl, unithroid)......................................................54
levothyroxine sodium tab 75 mcg (euthyrox, levo-t,
levoxyl, unithroid)......................................................54
levothyroxine sodium tab 88 mcg (euthyrox, levo-t,
levoxyl, unithroid)......................................................54
LEXIVA...........................................................................29
lidocaine hcl laryngotracheal soln 4%......................... 3
lidocaine hcl soln 4%.....................................................3
lidocaine hcl viscous soln 2%.......................................3
lidocaine oint 5%............................................................ 3
lidocaine patch 5%.........................................................3
lidocaine-prilocaine cream 2.5-2.5%........................... 3
linezolid for susp 100 mg/5ml.......................................7
linezolid in sodium chloride iv soln 600
mg/300ml-0.9%........................................................... 7
linezolid iv soln 600 mg/300ml (2 mg/
ml)..................................................................................7
linezolid tab 600 mg...................................................... 7
LINZESS........................................................................49
liothyronine sodium tab 5 mcg, 25 mcg, 50
mcg..............................................................................55
lisdexamfetamine dimesylate cap 10 mg, 20 mg, 30
mg, 40 mg, 50 mg, 60 mg, 70 mg.......................... 44
lisinopril & hydrochlorothiazide tab 10-12.5 mg,
20-12.5 mg, 20-25 mg............................................. 40
lisinopril tab 2.5 mg, 5 mg, 10 mg, 20 mg, 30 mg, 40
mg................................................................................40
LITHIUM........................................................................ 32
lithium carbonate cap 150 mg, 300 mg.....................32
lithium carbonate cap 600 mg....................................32
lithium carbonate tab 300 mg.....................................32
lithium carbonate tab er 300 mg, 450
mg................................................................................32
LONSURF..................................................................... 20
loperamide hcl cap 2 mg............................................ 49
lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/
ml)................................................................................29
lopinavir-ritonavir tab 100-25 mg............................... 29
lopinavir-ritonavir tab 200-50 mg............................... 29
lorazepam conc 2 mg/ml............................................ 32
lorazepam tab 0.5 mg, 1 mg...................................... 32
lorazepam tab 2 mg.................................................... 32
LORBRENA.................................................................. 20
losartan potassium & hydrochlorothiazide
tab 50-12.5 mg, 100-12.5 mg, 100-25
mg................................................................................40
losartan potassium tab 100 mg..................................40
losartan potassium tab 25 mg, 50 mg.......................40
lovastatin tab 10 mg, 20 mg, 40 mg.......................... 40
loxapine succinate cap 50 mg....................................26
loxapine succinate cap 5 mg, 10 mg, 25
mg................................................................................26
lubiprostone cap 24 mcg............................................ 49
lubiprostone cap 8 mcg...............................................49
LUMAKRAS.................................................................. 20
LUMIGAN...................................................................... 63
LUMOXITI......................................................................20
LUPRON DEPOT (1-MONTH)...................................55
LUPRON DEPOT (3-MONTH)...................................55
LUPRON DEPOT (4-MONTH)...................................55
LUPRON DEPOT (6-MONTH)...................................56
LUPRON DEPOT-PED............................................... 56
LUPRON DEPOT-PED (1-MONTH)..........................56
LUPRON DEPOT-PED (3-MONTH)..........................56
lurasidone hcl tab 20 mg, 40 mg, 60 mg, 120
mg................................................................................26
lurasidone hcl tab 80 mg............................................ 26
LYBALVI.........................................................................26
LYNPARZA.................................................................... 20
LYSODREN...................................................................55
LYTGOBI....................................................................... 20
2023
84
LYUMJEV...................................................................... 34
LYUMJEV KWIKPEN...................................................34
LYUMJEV TEMPO PEN............................................. 34
M
magnesium sulfate inj 50%........................................ 48
malathion lotion 0.5%.................................................. 46
maraviroc tab 150 mg................................................. 29
maraviroc tab 300 mg................................................. 29
MARGENZA..................................................................20
MARPLAN..................................................................... 13
MATULANE................................................................... 20
MAYZENT......................................................................44
MAYZENT STARTER PACK...................................... 44
meclizine hcl tab 12.5 mg, 25 mg..............................14
medroxyprogesterone acetate im susp 150 mg/
ml.................................................................................53
medroxyprogesterone acetate im susp prefilled syr
150 mg/ml.................................................................. 53
medroxyprogesterone acetate tab 2.5 mg, 5 mg, 10
mg................................................................................53
mefloquine hcl tab 250 mg......................................... 23
megestrol acetate susp 40 mg/ml..............................53
megestrol acetate tab 20 mg, 40 mg.........................53
MEKINIST......................................................................20
MEKTOVI.......................................................................20
meloxicam tab 15 mg.................................................... 2
meloxicam tab 7.5 mg................................................... 2
memantine hcl cap er 24hr 7 mg, 14 mg, 21 mg, 28
mg................................................................................12
memantine hcl oral solution 2 mg/ml.........................12
memantine hcl tab 28 x 5 mg & 21 x 10 mg titration
pack.............................................................................12
memantine hcl tab 5 mg, 10 mg................................ 12
MENACTRA.................................................................. 59
MENEST........................................................................53
MENQUADFI................................................................ 59
MENVEO....................................................................... 59
mercaptopurine tab 50 mg......................................... 20
meropenem & sodium chloride 0.9% for iv soln 1
gm/50ml........................................................................ 7
meropenem & sodium chloride 0.9% for iv soln 500
mg/50ml........................................................................ 7
meropenem iv for soln 500 mg, 1 gm..........................7
mesalamine cap dr 400 mg........................................61
mesalamine cap er 24hr 0.375 gm............................61
mesalamine cap er 500 mg........................................61
mesalamine enema 4 gm........................................... 61
mesalamine rectal enema 4 gm & cleanser wipe
kit................................................................................. 61
mesalamine suppos 1000 mg.................................... 61
mesalamine tab delayed release 1.2
gm................................................................................61
mesalamine tab delayed release 800
mg................................................................................61
MESNEX........................................................................20
metformin hcl tab 1000 mg.........................................34
metformin hcl tab 500 mg...........................................34
metformin hcl tab 850 mg...........................................34
metformin hcl tab er 24hr 500 mg............................. 34
metformin hcl tab er 24hr 750 mg............................. 34
methadone hcl tab 10 mg.............................................2
methadone hcl tab 5 mg............................................... 2
methazolamide tab 25 mg.......................................... 40
methazolamide tab 50 mg.......................................... 40
methenamine hippurate tab 1 gm................................7
methimazole tab 5 mg, 10 mg................................... 56
methocarbamol tab 500 mg, 750 mg........................ 68
methotrexate sodium inj 250 mg/10ml (25 mg/
ml)................................................................................59
methotrexate sodium inj 50 mg/2ml (25 mg/
ml)................................................................................59
methotrexate sodium inj pf 50 mg/2ml (25 mg/ml),
250 mg/10ml (25 mg/ml), 1000 mg/40ml (25 mg/
ml)................................................................................59
methotrexate sodium tab 2.5 mg............................... 59
METHOXSALEN.......................................................... 47
methscopolamine bromide tab 2.5 mg, 5
mg................................................................................49
methsuximide cap 300 mg......................................... 10
methylphenidate hcl soln 10 mg/5ml.........................44
methylphenidate hcl soln 5 mg/5ml........................... 44
methylphenidate hcl tab 5 mg, 10 mg, 20
mg................................................................................44
methylphenidate hcl tab er 10 mg............................. 44
methylphenidate hcl tab er 20 mg............................. 44
methylprednisolone tab 4 mg, 8 mg, 16 mg, 32
mg................................................................................52
methylprednisolone tab therapy pack 4 mg
(21).............................................................................. 52
methyltestosterone cap 10 mg...................................53
metoclopramide hcl soln 5 mg/5ml (10
mg/10ml).....................................................................49
metoclopramide hcl tab 5 mg, 10 mg........................ 49
metolazone tab 2.5 mg, 5 mg, 10 mg....................... 40
metoprolol & hydrochlorothiazide tab 50-25 mg,
100-25 mg, 100-50 mg............................................ 40
metoprolol succinate tab er 24hr 25 mg, 50 mg, 100
mg, 200 mg............................................................... 40
metoprolol tartrate tab 25 mg, 50 mg, 100
mg................................................................................41
metoprolol tartrate tab 37.5 mg, 75 mg.....................41
metronidazole cap 375 mg........................................... 7
2023
85
metronidazole cream 0.75%.......................................47
metronidazole gel 0.75%, 1%.................................... 47
metronidazole iv soln 500 mg/100ml...........................7
metronidazole lotion 0.75%........................................ 47
metronidazole tab 250 mg, 500 mg.............................8
metronidazole vaginal gel 0.75%.................................8
metyrosine cap 250 mg.............................................. 41
mexiletine hcl cap 150 mg, 200 mg, 250
mg................................................................................41
micafungin sodium for iv soln 100 mg.......................15
micafungin sodium for iv soln 50 mg.........................15
midodrine hcl tab 2.5 mg, 5 mg, 10 mg.....................41
miglustat cap 100 mg..................................................50
minocycline hcl cap 50 mg, 75 mg, 100
mg..................................................................................8
minocycline hcl tab 50 mg, 75 mg, 100
mg..................................................................................8
minoxidil tab 2.5 mg, 10 mg....................................... 41
mirtazapine orally disintegrating tab 15 mg, 30 mg,
45 mg..........................................................................13
mirtazapine tab 15 mg................................................ 13
mirtazapine tab 7.5 mg, 30 mg, 45 mg..................... 13
misoprostol tab 100 mcg, 200 mcg........................... 49
M-M-R II........................................................................ 59
modafinil tab 100 mg, 200 mg................................... 68
moexipril hcl tab 7.5 mg, 15 mg.................................41
MOLINDONE HYDROCHLORIDE............................ 26
mometasone furoate cream 0.1%............................. 47
mometasone furoate nasal susp 50 mcg/
act................................................................................66
mometasone furoate oint 0.1%.................................. 47
mometasone furoate solution 0.1%
(lotion).........................................................................47
montelukast sodium chew tab 4 mg, 5
mg................................................................................66
montelukast sodium oral granules packet 4
mg................................................................................66
montelukast sodium tab 10 mg..................................66
morphine sulfate oral soln 100 mg/5ml (20 mg/
ml)..................................................................................2
morphine sulfate oral soln 10 mg/5ml......................... 2
morphine sulfate oral soln 20 mg/5ml......................... 2
morphine sulfate tab 15 mg..........................................2
morphine sulfate tab 30 mg..........................................2
morphine sulfate tab er 100 mg, 200 mg.................... 2
morphine sulfate tab er 15 mg, 30 mg, 60
mg..................................................................................2
MOVANTIK....................................................................50
moxifloxacin hcl 400 mg/250ml in sodium chloride
0.8% inj.........................................................................8
moxifloxacin hcl iv solution 400
mg/250ml......................................................................8
moxifloxacin hcl ophth soln 0.5% (2 times daily)
(generic fo r Moxeza)...............................................63
moxifloxacin hcl ophth soln 0.5% (generic for
Vigamox).................................................................... 63
moxifloxacin hcl tab 400 mg.........................................8
MULTAQ........................................................................ 41
mupirocin calcium cream 2%..................................... 47
mupirocin oint 2%........................................................ 47
MYALEPT...................................................................... 50
mycophenolate mofetil cap 250 mg...........................59
mycophenolate mofetil for oral susp 200 mg/
ml.................................................................................59
mycophenolate mofetil tab 500 mg........................... 59
mycophenolate sodium tab dr 180 mg, 360
mg................................................................................59
MYRBETRIQ.................................................................51
N
nabumetone tab 500 mg............................................... 2
nabumetone tab 750 mg............................................... 2
nadolol tab 20 mg, 40 mg, 80 mg..............................41
nafcillin sodium for inj 1 gm, 2 gm............................... 8
nafcillin sodium for iv soln 10 gm.................................8
nafcillin sodium in dextrose inj 1
gm/50ml........................................................................ 8
nafcillin sodium in dextrose inj 2
gm/100ml......................................................................8
naloxone hcl inj 0.4 mg/ml, 4 mg/10ml........................3
naloxone hcl nasal spray 4 mg/0.1ml..........................3
naloxone hcl soln cartridge 0.4 mg/ml.........................3
naloxone hcl soln prefilled syringe 2
mg/2ml.......................................................................... 3
naltrexone hcl tab 50 mg.............................................. 3
naproxen sodium tab 275 mg.......................................2
naproxen sodium tab 550 mg.......................................2
naproxen susp 125 mg/5ml.......................................... 2
naproxen tab 250 mg.................................................... 2
naproxen tab 375 mg.................................................... 2
naproxen tab 500 mg.................................................... 2
naproxen tab ec 375 mg...............................................2
naproxen tab ec 500 mg...............................................2
naratriptan hcl tab 1 mg, 2.5 mg................................16
NARCAN..........................................................................3
NATACYN...................................................................... 63
nateglinide tab 120 mg............................................... 34
nateglinide tab 60 mg..................................................34
NATPARA...................................................................... 62
NAYZILAM.....................................................................11
nebivolol hcl tab 2.5 mg, 5 mg, 10 mg, 20
mg................................................................................41
NEFAZODONE HYDROCHLORIDE......................... 13
nelarabine iv soln 5 mg/ml..........................................20
2023
86
NEOMYCIN/POLYMYXIN/
GRAMICIDIN............................................................. 63
neomycin-bacitrac zn-polymyx
5(3.5)mg-400unt-10000unt op oin..........................63
neomycin-polymyxin-dexamethasone ophth oint
0.1%............................................................................ 63
neomycin-polymyxin-dexamethasone ophth susp
0.1%............................................................................ 63
neomycin-polymyxin-hc otic soln 1%........................ 64
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000
unit/ml-1%.................................................................. 64
neomycin sulfate tab 500 mg....................................... 8
NERLYNX......................................................................20
NEUPRO....................................................................... 24
nevirapine susp 50 mg/5ml........................................ 29
nevirapine tab 200 mg................................................ 29
nevirapine tab er 24hr 400 mg...................................29
niacin tab er 500 mg................................................... 41
niacin tab er 750 mg, 1000 mg.................................. 41
nicardipine hcl cap 20 mg, 30 mg..............................41
NICOTROL INHALER................................................... 4
NICOTROL NS............................................................... 4
nifedipine tab er 24hr 30 mg, 60 mg, 90
mg................................................................................41
nifedipine tab er 24hr osmotic release 30 mg, 60 mg,
90 mg..........................................................................41
nilutamide tab 150 mg.................................................20
nimodipine cap 30 mg.................................................41
NINLARO.......................................................................20
NISOLDIPINE ER........................................................ 41
nisoldipine tab er 24hr 8.5 mg, 17 mg, 34
mg................................................................................41
nitazoxanide tab 500 mg............................................ 23
nitisinone cap 2 mg, 5 mg, 10 mg, 20
mg................................................................................50
NITRO-BID.................................................................... 41
nitrofurantoin macrocrystalline cap 50 mg, 100
mg..................................................................................8
nitrofurantoin monohydrate macrocrystalline cap 100
mg..................................................................................8
nitroglycerin sl tab 0.3 mg, 0.4 mg, 0.6
mg................................................................................41
nitroglycerin td patch 24hr 0.1 mg/hr, 0.2 mg/hr, 0.4
mg/hr, 0.6 mg/hr........................................................41
nitroglycerin tl soln 0.4 mg/spray (400 mcg/
spray).......................................................................... 41
NIVESTYM.................................................................... 37
NIZATIDINE...................................................................50
nizatidine cap 300 mg................................................. 50
norethindrone & ethinyl estradiol-fe chew tab 0.4
mg-35 mcg.................................................................53
norethindrone & ethinyl estradiol-fe chew tab 0.8
mg-25 mcg.................................................................53
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg,
0.5 mg-35 mcg.......................................................... 53
norethindrone & ethinyl estradiol tab 1 mg-35
mcg..............................................................................53
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20
mcg, 1.5 mg-30 mcg................................................ 54
norethindrone ace & ethinyl estradiol tab 1 mg-20
mcg, 1.5 mg-30 mcg................................................ 53
norethindrone ace-ethinyl estradiol-fe cap 1 mg-20
mcg (24)..................................................................... 54
norethindrone ace-ethinyl estradiol-fe tab 1 mg-20
mcg (24)..................................................................... 54
norethindrone acetate tab 5 mg.................................54
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35
mg-mcg.......................................................................53
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35
mg-mcg, 0.5-35/1-35/0.5-35 mg-mcg.................... 54
norethindrone tab 0.35 mg......................................... 54
norgestimate & ethinyl estradiol tab 0.25 mg-35
mcg..............................................................................54
norgestimate-eth estrad tab
0.18-25/0.215-25/0.25-25 mg-mcg,
0.18-35/0.215-35/0.25-35 mg-mcg.........................54
norgestrel & ethinyl estradiol tab 0.3 mg-30
mcg..............................................................................54
nortriptyline hcl cap 10 mg, 25 mg, 50 mg, 75
mg................................................................................13
nortriptyline hcl soln 10 mg/5ml................................. 13
NORVIR.........................................................................29
NOXAFIL....................................................................... 15
NUBEQA........................................................................20
NUEDEXTA................................................................... 44
NUPLAZID.....................................................................26
NURTEC........................................................................16
NUTRILIPID.................................................................. 48
nystatin cream 100000 unit/gm..................................15
nystatin oint 100000 unit/gm...................................... 15
nystatin susp 100000 unit/ml......................................15
nystatin tab 500000 unit..............................................15
nystatin topical powder 100000 unit/
gm................................................................................15
nystatin-triamcinolone cream 100000-0.1 unit/gm-
%..................................................................................47
nystatin-triamcinolone oint 100000-0.1 unit/gm-
%..................................................................................47
O
OCALIVA....................................................................... 50
octreotide acetate inj 50 mcg/ml (0.05 mg/ml), 100
mcg/ml (0.1 mg/ml), 200 mcg/ml (0.2 mg/ml),
2023
87
500 mcg/ml (0.5 mg/ml), 1000 mcg/ml (1 mg/
ml)................................................................................56
octreotide acetate subcutaneous soln pref syr 100
mcg/ml........................................................................ 56
octreotide acetate subcutaneous soln pref syr 500
mcg/ml........................................................................ 56
octreotide acetate subcutaneous soln pref syr 50
mcg/ml........................................................................ 56
ODEFSEY..................................................................... 30
ODOMZO...................................................................... 20
OFEV............................................................................. 66
ofloxacin ophth soln 0.3%...........................................63
ofloxacin otic soln 0.3%.............................................. 64
ofloxacin tab 400 mg..................................................... 8
OJJAARA...................................................................... 20
olanzapine for im inj 10 mg........................................ 26
olanzapine orally disintegrating tab 5 mg, 10 mg, 15
mg, 20 mg..................................................................26
olanzapine tab 15 mg, 20 mg.................................... 26
olanzapine tab 2.5 mg, 5 mg, 7.5 mg, 10
mg................................................................................26
olmesartan-amlodipine-hydrochlorothiazide tab
20-5-12.5 mg, 40-5-12.5 mg, 40-5-25 mg,
40-10-12.5 mg, 40-10-25 mg.................................. 41
olmesartan medoxomil-hydrochlorothiazide tab
20-12.5 mg, 40-12.5 mg, 40-25 mg........................41
olmesartan medoxomil tab 20 mg, 40
mg................................................................................41
olmesartan medoxomil tab 5 mg............................... 41
olopatadine hcl nasal soln 0.6%................................ 66
olopatadine hcl ophth soln 0.1%, 0.2%.....................63
omega-3-acid ethyl esters cap 1 gm......................... 41
omeprazole cap delayed release 10
mg................................................................................50
omeprazole cap delayed release 20 mg, 40
mg................................................................................50
OMNIPOD 5 G6 INTRO KIT (GEN 5)....................... 35
OMNIPOD 5 G6 PODS (GEN 5)............................... 35
OMNIPOD CLASSIC PODS (GEN 3)....................... 34
OMNIPOD DASH INTRO KIT (GEN 4).....................34
OMNIPOD DASH PDM KIT (GEN 4)........................ 35
OMNIPOD DASH PODS (GEN 4)............................. 35
OMNIPOD GO 10 UNITS/DAY.................................. 35
OMNIPOD GO 15 UNITS/DAY.................................. 35
OMNIPOD GO 20 UNITS/DAY.................................. 35
OMNIPOD GO 25 UNITS/DAY.................................. 35
OMNIPOD GO 30 UNITS/DAY.................................. 35
OMNIPOD GO 35 UNITS/DAY.................................. 35
OMNIPOD GO 40 UNITS/DAY.................................. 35
OMNITROPE................................................................ 52
ondansetron hcl oral soln 4 mg/5ml.......................... 14
ondansetron hcl tab 24 mg.........................................14
ondansetron hcl tab 4 mg, 8 mg................................ 14
ondansetron orally disintegrating tab 4 mg, 8
mg................................................................................14
ONTRUZANT................................................................20
ONUREG.......................................................................21
OPDIVO.........................................................................21
OPSUMIT...................................................................... 66
ORACEA........................................................................47
ORFADIN.......................................................................50
ORGOVYX.................................................................... 56
ORKAMBI...................................................................... 66
ORSERDU.................................................................... 21
oseltamivir phosphate cap 30 mg..............................30
oseltamivir phosphate cap 45 mg, 75
mg................................................................................30
oseltamivir phosphate for susp 6 mg/
ml.................................................................................30
oxaprozin tab 600 mg....................................................3
oxazepam cap 10 mg, 15 mg, 30 mg........................32
oxcarbazepine susp 300 mg/5ml (60 mg/
ml)................................................................................11
oxcarbazepine tab 150 mg, 300 mg, 600
mg................................................................................11
oxybutynin chloride solution 5 mg/5ml...................... 51
oxybutynin chloride tab 5 mg..................................... 51
oxybutynin chloride tab er 24hr 10 mg......................51
oxybutynin chloride tab er 24hr 15 mg......................51
oxybutynin chloride tab er 24hr 5 mg........................ 51
oxycodone hcl tab 10 mg, 15 mg, 20 mg, 30
mg..................................................................................3
oxycodone hcl tab 5 mg................................................3
oxycodone w/ acetaminophen tab 10-325
mg..................................................................................3
oxycodone w/ acetaminophen tab 2.5-325
mg..................................................................................3
oxycodone w/ acetaminophen tab 5-325
mg..................................................................................3
oxycodone w/ acetaminophen tab 7.5-325
mg..................................................................................3
OZEMPIC...................................................................... 35
P
paliperidone tab er 24hr 1.5 mg, 3 mg, 9
mg................................................................................26
paliperidone tab er 24hr 6 mg....................................26
PALYNZIQ..................................................................... 50
PANRETIN.....................................................................21
pantoprazole sodium ec tab 20 mg........................... 50
pantoprazole sodium ec tab 40 mg........................... 50
paricalcitol cap 1 mcg, 2 mcg, 4 mcg........................ 62
paromomycin sulfate cap 250 mg................................8
paroxetine hcl oral susp 10 mg/5ml.......................... 13
2023
88
paroxetine hcl tab 10 mg, 40 mg............................... 13
paroxetine hcl tab 20 mg............................................ 13
paroxetine hcl tab 30 mg............................................ 13
paroxetine hcl tab er 24hr 12.5 mg........................... 13
paroxetine hcl tab er 24hr 25 mg, 37.5
mg................................................................................13
PAXLOVID.....................................................................30
pazopanib hcl tab 200 mg.......................................... 21
PEDIARIX......................................................................59
PEDVAX HIB................................................................ 59
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236
gm................................................................................50
peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln
100 gm....................................................................... 50
peg 3350-kcl-sod bicarb-nacl for soln 420
gm................................................................................50
PEGASYS..................................................................... 59
PEMAZYRE.................................................................. 21
penicillamine tab 250 mg............................................51
penicillin g potassium for inj 5000000 unit, 20000000
unit.................................................................................8
PENICILLIN G POTASSIUM IN ISO-OSMOTIC
DEXTROSE................................................................. 8
PENICILLIN G SODIUM............................................... 8
penicillin v potassium for soln 125
mg/5ml.......................................................................... 8
penicillin v potassium for soln 250
mg/5ml.......................................................................... 8
penicillin v potassium tab 250 mg, 500
mg..................................................................................8
PENTACEL....................................................................59
pentamidine isethionate for inj soln 300
mg................................................................................23
pentamidine isethionate for nebulization soln 300
mg................................................................................23
PENTASA...................................................................... 61
pentoxifylline tab er 400 mg....................................... 41
perindopril erbumine tab 2 mg, 4 mg, 8
mg................................................................................41
permethrin cream 5%.................................................. 47
perphenazine tab 2 mg, 4 mg, 8 mg, 16
mg................................................................................14
PERSERIS.................................................................... 26
phenelzine sulfate tab 15 mg..................................... 13
phenobarbital elixir 20 mg/5ml................................... 11
phenobarbital tab 15 mg, 16.2 mg, 30 mg, 32.4 mg,
60 mg, 64.8 mg, 97.2 mg, 100 mg......................... 11
phenoxybenzamine hcl cap 10 mg............................41
phenytoin chew tab 50 mg......................................... 11
phenytoin sodium extended cap 100 mg, 200 mg,
300 mg....................................................................... 11
phenytoin susp 125 mg/5ml....................................... 11
PIFELTRO..................................................................... 30
pilocarpine hcl ophth soln 1%, 2%, 4%.....................63
pilocarpine hcl tab 5 mg, 7.5 mg................................45
pimecrolimus cream 1%..............................................47
PIMOZIDE..................................................................... 26
pindolol tab 5 mg, 10 mg............................................41
pioglitazone hcl-glimepiride tab 30-2 mg, 30-4
mg................................................................................35
pioglitazone hcl-metformin hcl tab 15-500 mg,
15-850 mg..................................................................35
pioglitazone hcl tab 15 mg..........................................35
pioglitazone hcl tab 30 mg, 45 mg.............................35
piperacillin sod-tazobactam na for inj 3.375 gm
(3-0.375 gm)................................................................ 8
piperacillin sod-tazobactam sod for inj 2.25 gm
(2-0.25 gm), 4.5 gm (4-0.5 gm).................................8
PIQRAY 200MG DAILY DOSE...................................21
PIQRAY 250MG DAILY DOSE...................................21
PIQRAY 300MG DAILY DOSE...................................21
pirfenidone cap 267 mg.............................................. 66
pirfenidone tab 267 mg............................................... 66
pirfenidone tab 801 mg............................................... 66
piroxicam cap 10 mg..................................................... 3
piroxicam cap 20 mg..................................................... 3
PLEGRIDY.................................................................... 44
PLEGRIDY STARTER PACK..................................... 44
podofilox soln 0.5%..................................................... 47
polymyxin b-trimethoprim ophth soln 10000 unit/
ml-0.1%...................................................................... 63
POMALYST................................................................... 21
posaconazole susp 40 mg/ml.................................... 15
posaconazole tab delayed release 100
mg................................................................................15
POTASSIUM CHLORIDE/DEXTROSE/LACTATED
RINGERS................................................................... 48
potassium chloride 20 meq/l (0.15%) in dextrose 5%
inj................................................................................. 48
potassium chloride cap er 8 meq, 10
meq............................................................................. 48
potassium chloride inj 2 meq/ml................................ 48
potassium chloride microencapsulated crys er tab 10
meq, 15 meq, 20 meq..............................................48
potassium chloride oral soln 10% (20 meq/15ml),
20% (40 meq/15ml).................................................. 48
potassium chloride tab er 8 meq (600 mg), 10 meq,
20 meq (1500 mg)....................................................48
potassium citrate tab er 10 meq (1080 mg), 15 meq
(1620 mg)...................................................................48
potassium citrate tab er 5 meq (540
mg).............................................................................. 48
PRADAXA..................................................................... 37
2023
89
pramipexole dihydrochloride tab 0.125 mg, 0.25 mg,
0.5 mg, 0.75 mg, 1 mg, 1.5 mg.............................. 24
prasugrel hcl tab 5 mg, 10 mg................................... 37
pravastatin sodium tab 10 mg, 20 mg, 40
mg................................................................................41
pravastatin sodium tab 80 mg....................................41
praziquantel tab 600 mg............................................. 23
prazosin hcl cap 1 mg, 2 mg, 5 mg........................... 41
prednisolone acetate ophth susp 1%........................ 63
prednisolone sodium phosphate ophth soln
1%............................................................................... 64
prednisolone sodium phosphate oral soln 25
mg/5ml........................................................................ 52
prednisolone sod phosphate oral soln 15
mg/5ml........................................................................ 52
prednisolone sod phosph oral soln 6.7 mg/5ml (5
mg/5ml base).............................................................52
prednisolone soln 15 mg/5ml..................................... 52
prednisone oral soln 5 mg/5ml...................................52
prednisone tab 1 mg, 2.5 mg, 20 mg........................ 52
prednisone tab 5 mg, 10 mg, 50 mg......................... 52
prednisone tab therapy pack 5 mg (21), 5 mg (48),
10 mg (21), 10 mg (48)............................................52
pregabalin cap 225 mg, 300 mg................................ 11
pregabalin cap 25 mg, 50 mg, 75 mg, 100 mg, 150
mg, 200 mg............................................................... 11
pregabalin soln 20 mg/ml........................................... 11
PREHEVBRIO.............................................................. 59
PREMARIN................................................................... 54
PREMPHASE............................................................... 54
PREMPRO.................................................................... 54
PREVYMIS....................................................................30
PREZCOBIX................................................................. 30
PREZISTA..................................................................... 30
PRIFTIN.........................................................................16
primaquine phosphate tab 26.3 mg (15 mg
base)........................................................................... 23
PRIMIDONE..................................................................11
primidone tab 50 mg, 250 mg.................................... 11
PRIORIX........................................................................ 60
probenecid tab 500 mg............................................... 16
prochlorperazine edisylate inj 10
mg/2ml........................................................................ 14
prochlorperazine maleate tab 5 mg, 10
mg................................................................................14
prochlorperazine suppos 25 mg................................ 14
PROCRIT...................................................................... 37
progesterone cap 100 mg, 200 mg........................... 54
PROGRAF.....................................................................60
PROLASTIN-C..............................................................51
PROLENSA...................................................................64
PROLIA..........................................................................62
PROMACTA.................................................................. 37
promethazine hcl suppos 12.5 mg, 25
mg................................................................................14
promethazine hcl syrup 6.25 mg/5ml........................ 14
promethazine hcl tab 12.5 mg, 25 mg, 50
mg................................................................................14
propafenone hcl cap er 12hr 225 mg, 325 mg, 425
mg................................................................................41
propafenone hcl tab 150 mg, 225 mg, 300
mg................................................................................42
propranolol hcl cap er 24hr 60 mg, 80 mg, 120 mg,
160 mg....................................................................... 42
propranolol hcl oral soln 20 mg/5ml.......................... 42
propranolol hcl oral soln 40 mg/5ml.......................... 42
propranolol hcl tab 10 mg, 20 mg, 40 mg, 60 mg, 80
mg................................................................................42
propylthiouracil tab 50 mg.......................................... 56
PROQUAD.................................................................... 60
protriptyline hcl tab 5 mg, 10 mg............................... 13
PULMOZYME............................................................... 66
PURIXAN.......................................................................21
PYLERA.........................................................................50
pyrazinamide tab 500 mg........................................... 16
pyridostigmine bromide oral soln 60
mg/5ml........................................................................ 16
pyridostigmine bromide tab 60 mg............................ 16
pyridostigmine bromide tab er 180 mg......................16
pyrimethamine tab 25 mg........................................... 23
Q
QINLOCK...................................................................... 21
QUADRACEL................................................................60
QUETIAPINE FUMARATE......................................... 26
quetiapine fumarate tab 25 mg, 50 mg, 100 mg, 200
mg................................................................................26
quetiapine fumarate tab 300 mg, 400
mg................................................................................26
quetiapine fumarate tab er 24hr 150 mg, 200
mg................................................................................26
quetiapine fumarate tab er 24hr 50 mg, 300 mg, 400
mg................................................................................26
quinapril hcl tab 5 mg, 10 mg, 20 mg, 40
mg................................................................................42
quinapril-hydrochlorothiazide tab 20-12.5 mg, 20-25
mg................................................................................42
quinidine gluconate tab er 324 mg............................ 42
quinidine sulfate tab 200 mg...................................... 42
quinidine sulfate tab 300 mg...................................... 42
quinine sulfate cap 324 mg........................................ 23
R
RABAVERT................................................................... 60
rabeprazole sodium ec tab 20 mg............................. 50
2023
90
raloxifene hcl tab 60 mg............................................. 54
ramelteon tab 8 mg..................................................... 68
ramipril cap 1.25 mg, 2.5 mg, 5 mg, 10
mg................................................................................42
ranolazine tab er 12hr 500 mg, 1000
mg................................................................................42
rasagiline mesylate tab 0.5 mg, 1 mg....................... 24
REBIF.............................................................................44
REBIF REBIDOSE.......................................................44
REBIF REBIDOSE TITRATION PACK......................44
REBIF TITRATION PACK........................................... 44
RECOMBIVAX HB....................................................... 60
RECTIV..........................................................................42
REGRANEX.................................................................. 47
RELENZA DISKHALER.............................................. 30
repaglinide tab 0.5 mg................................................ 35
repaglinide tab 1 mg....................................................35
repaglinide tab 2 mg....................................................35
REPATHA...................................................................... 42
REPATHA PUSHTRONEX SYSTEM........................ 42
REPATHA SURECLICK.............................................. 42
RESTASIS..................................................................... 64
RESTASIS MULTIDOSE.............................................64
RETACRIT.....................................................................37
RETEVMO.....................................................................21
REVCOVI...................................................................... 51
REVLIMID......................................................................21
REXULTI........................................................................27
REYATAZ.......................................................................30
REZLIDHIA....................................................................21
RHOPRESSA............................................................... 64
ribavirin cap 200 mg....................................................30
ribavirin tab 200 mg.....................................................30
RIDAURA...................................................................... 60
rifabutin cap 150 mg....................................................17
rifampin cap 150 mg, 300 mg.................................... 17
rifampin for inj 600 mg................................................ 17
riluzole tab 50 mg........................................................ 44
RIMANTADINE HYDROCHLORIDE......................... 30
RINVOQ.........................................................................60
risedronate sodium tab 150 mg................................. 62
risedronate sodium tab 35 mg................................... 62
risedronate sodium tab 5 mg, 30 mg.........................62
risedronate sodium tab delayed release 35
mg................................................................................62
RISPERDAL CONSTA................................................ 27
RISPERIDONE ODT................................................... 27
risperidone orally disintegrating tab 0.5 mg, 1 mg, 2
mg, 3 mg....................................................................27
risperidone orally disintegrating tab 4
mg................................................................................27
risperidone soln 1 mg/ml............................................ 27
risperidone tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3
mg................................................................................27
risperidone tab 4 mg................................................... 27
ritonavir tab 100 mg.................................................... 30
rivastigmine tartrate cap 1.5 mg, 3 mg, 4.5 mg, 6
mg................................................................................12
rivastigmine td patch 24hr 4.6 mg/24hr, 9.5 mg/24hr,
13.3 mg/24hr............................................................. 12
rizatriptan benzoate oral disintegrating tab 5 mg, 10
mg................................................................................16
rizatriptan benzoate tab 5 mg, 10 mg....................... 16
ROCKLATAN.................................................................64
roflumilast tab 250 mcg, 500 mcg............................. 67
ropinirole hydrochloride tab 0.25 mg, 0.5 mg, 1 mg, 2
mg, 3 mg, 4 mg, 5 mg............................................. 24
ropinirole hydrochloride tab er 24hr 2 mg, 4 mg, 6
mg, 8 mg, 12 mg...................................................... 24
rosuvastatin calcium tab 40 mg................................. 42
rosuvastatin calcium tab 5 mg, 10 mg, 20
mg................................................................................42
ROTARIX....................................................................... 60
ROTATEQ......................................................................60
ROZLYTREK.................................................................21
RUBRACA.....................................................................21
rufinamide susp 40 mg/ml.......................................... 11
rufinamide tab 200 mg................................................ 11
rufinamide tab 400 mg................................................ 11
RUKOBIA...................................................................... 30
RYBELSUS................................................................... 35
RYDAPT........................................................................ 21
RYTARY.........................................................................24
S
SANDIMMUNE............................................................. 60
SANTYL.........................................................................47
sapropterin dihydrochloride powder packet 100 mg,
500 mg....................................................................... 51
sapropterin dihydrochloride tab 100
mg................................................................................51
SCEMBLIX.................................................................... 21
scopolamine td patch 72hr 1 mg/3days.................... 14
SECUADO.....................................................................27
selegiline hcl cap 5 mg............................................... 24
selegiline hcl tab 5 mg................................................ 24
selenium sulfide lotion 2.5%.......................................47
SELZENTRY................................................................. 30
SEREVENT DISKUS...................................................67
sertraline hcl oral concentrate for solution 20 mg/
ml.................................................................................13
sertraline hcl tab 100 mg............................................ 14
sertraline hcl tab 25 mg, 50 mg................................. 14
sevelamer carbonate packet 0.8 gm......................... 48
2023
91
sevelamer carbonate packet 2.4 gm......................... 48
sevelamer carbonate tab 800 mg.............................. 48
SHINGRIX..................................................................... 60
SIGNIFOR..................................................................... 56
sildenafil citrate tab 20 mg..........................................67
silodosin cap 4 mg, 8 mg........................................... 51
silver sulfadiazine cream 1%......................................47
SIMBRINZA...................................................................64
SIMULECT.................................................................... 60
simvastatin tab 20 mg................................................. 42
simvastatin tab 5 mg, 10 mg, 40 mg......................... 42
simvastatin tab 80 mg................................................. 42
sirolimus oral soln 1 mg/ml.........................................60
sirolimus tab 0.5 mg, 1 mg, 2 mg.............................. 60
SIRTURO.......................................................................17
SIVEXTRO...................................................................... 8
SKYRIZI.........................................................................60
SKYRIZI PEN............................................................... 60
sodium chloride irrigation soln 0.9%......................... 48
sodium chloride iv soln 0.45%, 0.9%........................ 48
sodium chloride preservative free inj
0.9%............................................................................ 48
sodium phenylbutyrate oral powder 3 gm/
teaspoonful.................................................................51
sodium phenylbutyrate tab 500 mg........................... 51
sodium polystyrene sulfonate powder.......................49
SOFOSBUVIR/VELPATASVIR................................... 30
solifenacin succinate tab 5 mg, 10 mg......................51
SOLTAMOX...................................................................21
SOMAVERT.................................................................. 56
sorafenib tosylate tab 200 mg....................................21
sotalol hcl (afib/afl) tab 80 mg, 120 mg, 160
mg................................................................................42
sotalol hcl tab 80 mg, 120 mg, 160 mg, 240
mg................................................................................42
SOVALDI....................................................................... 30
SPIRIVA HANDIHALER.............................................. 67
SPIRIVA RESPIMAT....................................................67
spironolactone & hydrochlorothiazide tab 25-25
mg................................................................................42
spironolactone tab 25 mg, 50 mg, 100
mg................................................................................42
SPRITAM....................................................................... 11
SPRYCEL......................................................................21
SPS................................................................................ 49
STAMARIL.....................................................................60
STELARA...................................................................... 60
STIOLTO RESPIMAT.................................................. 67
STIVARGA.....................................................................21
STREPTOMYCIN SULFATE........................................ 8
STRIBILD...................................................................... 30
sucralfate susp 1 gm/10ml......................................... 50
sucralfate tab 1 gm......................................................50
SULFACETAMIDE SODIUM...................................... 64
sulfacetamide sodium lotion 10%
(acne)..........................................................................47
sulfacetamide sodium ophth soln 10%..................... 64
sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%..........................................................64
sulfadiazine tab 500 mg................................................8
sulfamethoxazole-trimethoprim susp 200-40
mg/5ml.......................................................................... 8
sulfamethoxazole-trimethoprim tab 400-80 mg,
800-160 mg..................................................................8
sulfasalazine tab 500 mg............................................62
sulfasalazine tab delayed release 500
mg................................................................................62
sulindac tab 150 mg, 200 mg.......................................3
sumatriptan nasal spray 5 mg/act, 20 mg/
act................................................................................16
sumatriptan succinate inj 6 mg/0.5ml........................16
sumatriptan succinate solution auto-injector 4
mg/0.5ml, 6 mg/0.5ml.............................................. 16
sumatriptan succinate solution cartridge 4 mg/0.5ml,
6 mg/0.5ml................................................................. 16
sumatriptan succinate tab 25 mg, 50 mg, 100
mg................................................................................16
sunitinib malate cap 12.5 mg..................................... 21
sunitinib malate cap 25 mg, 37.5 mg, 50
mg................................................................................21
SUNLENCA...................................................................30
SUPRAX.......................................................................... 8
SUPREP BOWEL PREP KIT..................................... 50
SUTAB........................................................................... 50
SYMBICORT.................................................................67
SYMDEKO.................................................................... 67
SYMLINPEN 120......................................................... 35
SYMLINPEN 60............................................................35
SYMPAZAN...................................................................11
SYMTUZA..................................................................... 30
SYNAREL......................................................................56
SYNJARDY................................................................... 35
SYNJARDY XR............................................................ 35
SYNRIBO...................................................................... 21
SYNTHROID................................................................. 55
T
TABLOID........................................................................21
TABRECTA....................................................................21
tacrolimus cap 0.5 mg, 1 mg......................................60
tacrolimus cap 5 mg.................................................... 60
tacrolimus oint 0.03%, 0.1%.......................................47
tadalafil tab 20 mg (pah).............................................67
TAFINLAR..................................................................... 22
2023
92
TAGRISSO.................................................................... 22
TALZENNA....................................................................22
tamoxifen citrate tab 10 mg, 20 mg........................... 22
tamsulosin hcl cap 0.4 mg..........................................51
TASIGNA....................................................................... 22
tasimelteon capsule 20 mg.........................................68
tazarotene cream 0.1%...............................................47
tazarotene gel 0.05%, 0.1%....................................... 47
TAZICEF.......................................................................... 8
TAZORAC......................................................................47
TAZVERIK..................................................................... 22
TDVAX........................................................................... 60
TEFLARO........................................................................ 8
telmisartan-amlodipine tab 40-5 mg, 40-10 mg, 80-5
mg, 80-10 mg............................................................ 42
telmisartan-hydrochlorothiazide tab 40-12.5 mg,
80-25 mg....................................................................42
telmisartan-hydrochlorothiazide tab 80-12.5
mg................................................................................42
telmisartan tab 20 mg, 40 mg, 80 mg....................... 42
temazepam cap 15 mg, 30 mg.................................. 68
temazepam cap 7.5 mg.............................................. 68
TENCON..........................................................................3
TENIVAC....................................................................... 60
tenofovir disoproxil fumarate tab 300
mg................................................................................30
TEPMETKO.................................................................. 22
terazosin hcl cap 1 mg................................................42
terazosin hcl cap 2 mg, 5 mg, 10 mg........................ 42
terbinafine hcl tab 250 mg.......................................... 15
terbutaline sulfate tab 2.5 mg, 5 mg..........................67
terconazole vaginal cream 0.4%, 0.8%.....................15
terconazole vaginal suppos 80 mg............................15
TERIPARATIDE............................................................ 62
testosterone cypionate im inj in oil 100 mg/ml, 200
mg/ml.......................................................................... 54
TESTOSTERONE ENANTHATE............................... 54
testosterone td gel 12.5 mg/act (1%)........................ 54
testosterone td gel 20.25 mg/1.25gm
(1.62%)....................................................................... 54
testosterone td gel 20.25 mg/act
(1.62%)....................................................................... 54
testosterone td gel 25 mg/2.5gm (1%)......................54
testosterone td gel 40.5 mg/2.5gm
(1.62%)....................................................................... 54
testosterone td gel 50 mg/5gm (1%)......................... 54
testosterone td soln 30 mg/act...................................54
tetrabenazine tab 12.5 mg..........................................44
tetrabenazine tab 25 mg............................................. 44
tetracycline hcl cap 250 mg..........................................8
tetracycline hcl cap 500 mg..........................................9
THALOMID....................................................................22
THEO-24........................................................................67
theophylline tab er 12hr 300 mg, 450
mg................................................................................67
theophylline tab er 24hr 400 mg, 600
mg................................................................................67
thioridazine hcl tab 10 mg, 25 mg, 50 mg, 100
mg................................................................................27
thiothixene cap 1 mg, 2 mg, 5 mg, 10
mg................................................................................27
tiagabine hcl tab 2 mg, 4 mg, 12 mg, 16
mg................................................................................11
TIBSOVO.......................................................................22
TICOVAC....................................................................... 61
tigecycline for iv soln 50 mg......................................... 9
timolol maleate ophth gel forming soln 0.25%,
0.5%............................................................................ 64
timolol maleate ophth soln 0.25%,
0.5%............................................................................ 64
timolol maleate ophth soln 0.5% (once-
daily)............................................................................64
timolol maleate tab 5 mg, 10 mg, 20
mg................................................................................42
TIVICAY......................................................................... 30
TIVICAY PD.................................................................. 31
tizanidine hcl tab 2 mg, 4 mg..................................... 28
TOBRADEX...................................................................64
tobramycin-dexamethasone ophth susp
0.3-0.1%..................................................................... 64
tobramycin nebu soln 300 mg/5ml............................ 67
tobramycin ophth soln 0.3%.......................................64
TOBRAMYCIN SULFATE............................................. 9
tobramycin sulfate for inj 1.2 gm..................................9
tobramycin sulfate inj 2 gm/50ml (40 mg/
ml)..................................................................................9
tobramycin sulfate inj 80 mg/2ml (40 mg/ml), 1.2
gm/30ml (40 mg/ml)................................................... 9
tolcapone tab 100 mg................................................. 24
tolterodine tartrate cap er 24hr 2 mg, 4
mg................................................................................51
tolterodine tartrate tab 1 mg, 2 mg............................ 51
tolvaptan tab 15 mg, 30 mg....................................... 49
topiramate sprinkle cap 15 mg, 25 mg......................11
topiramate tab 25 mg, 50 mg, 100 mg, 200
mg................................................................................11
toremifene citrate tab 60 mg...................................... 22
torsemide tab 5 mg, 10 mg, 20 mg, 100
mg................................................................................42
TOUJEO MAX SOLOSTAR........................................36
TOUJEO SOLOSTAR..................................................36
TRACLEER................................................................... 67
tramadol-acetaminophen tab 37.5-325
mg..................................................................................3
2023
93
tramadol hcl tab 50 mg................................................. 3
tramadol hcl tab er 24hr 100 mg, 200 mg, 300
mg..................................................................................3
trandolapril tab 1 mg, 2 mg, 4 mg..............................42
trandolapril-verapamil hcl tab er 1-240
mg................................................................................42
trandolapril-verapamil hcl tab er 2-180
mg................................................................................42
trandolapril-verapamil hcl tab er 2-240
mg................................................................................43
trandolapril-verapamil hcl tab er 4-240
mg................................................................................43
tranexamic acid tab 650 mg....................................... 37
tranylcypromine sulfate tab 10 mg............................ 14
TRAVASOL....................................................................49
travoprost ophth soln 0.004%.................................... 64
trazodone hcl tab 300 mg...........................................14
trazodone hcl tab 50 mg, 100 mg, 150
mg................................................................................14
TRECATOR...................................................................17
TRELEGY ELLIPTA.....................................................67
TRELSTAR MIXJECT..................................................56
TREMFYA......................................................................61
TRESIBA....................................................................... 36
TRESIBA FLEXTOUCH.............................................. 36
tretinoin cap 10 mg......................................................22
tretinoin cream 0.025%, 0.05%, 0.1%.......................47
tretinoin gel 0.01%, 0.025%....................................... 47
triamcinolone acetonide cream 0.025%, 0.1%,
0.5%............................................................................ 47
triamcinolone acetonide dental paste
0.1%............................................................................ 45
triamcinolone acetonide lotion 0.025%,
0.1%............................................................................ 47
triamcinolone acetonide oint 0.025%,
0.1%............................................................................ 47
triamcinolone acetonide oint 0.5%.............................47
triamterene & hydrochlorothiazide cap 37.5-25
mg................................................................................43
triamterene & hydrochlorothiazide tab 37.5-25 mg,
75-50 mg....................................................................43
trientine hcl cap 250 mg............................................. 49
trifluoperazine hcl tab 1 mg, 2 mg, 5 mg, 10
mg................................................................................27
TRIFLURIDINE............................................................. 64
TRIKAFTA..................................................................... 67
trimethoprim tab 100 mg............................................... 9
trimipramine maleate cap 25 mg, 50 mg, 100
mg................................................................................14
TRINTELLIX..................................................................14
TRIUMEQ...................................................................... 31
TRIUMEQ PD............................................................... 31
TRIZIVIR........................................................................31
TROPHAMINE..............................................................49
trospium chloride tab 20 mg.......................................51
TRULICITY....................................................................36
TRUMENBA.................................................................. 61
TUKYSA........................................................................ 22
TURALIO....................................................................... 22
TWINRIX........................................................................61
TYBOST........................................................................ 31
TYMLOS........................................................................ 62
TYPHIM VI.................................................................... 61
U
UBRELVY...................................................................... 16
UDENYCA.....................................................................37
UPTRAVI....................................................................... 67
UPTRAVI TITRATION PACK......................................67
ursodiol cap 300 mg....................................................50
ursodiol tab 250 mg, 500 mg..................................... 50
UZEDY...........................................................................27
V
valacyclovir hcl tab 500 mg, 1 gm............................. 31
VALCHLOR................................................................... 22
valganciclovir hcl for soln 50 mg/ml.......................... 31
valganciclovir hcl tab 450 mg.....................................31
valproate sodium inj 100 mg/ml................................. 11
valproate sodium oral soln 250 mg/5ml.................... 11
valproic acid cap 250 mg............................................11
valsartan-hydrochlorothiazide tab 80-12.5 mg,
160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25
mg................................................................................43
valsartan tab 320 mg...................................................43
valsartan tab 40 mg, 80 mg, 160 mg.........................43
VALTOCO 10 MG DOSE............................................ 11
VALTOCO 15 MG DOSE............................................ 11
VALTOCO 20 MG DOSE............................................ 11
VALTOCO 5 MG DOSE.............................................. 11
VANCOMYCIN................................................................9
VANCOMYCIN HCL.......................................................9
vancomycin hcl cap 125 mg.........................................9
vancomycin hcl cap 250 mg.........................................9
vancomycin hcl for iv soln 100 gm.............................. 9
vancomycin hcl for iv soln 500 mg, 750 mg, 1 gm,
1.25 gm, 1.5 gm, 5 gm, 10 gm..................................9
VANCOMYCIN HYDROCHLORIDE............................ 9
VANCOMYCIN HYDROCHLORIDE/
DEXTROSE................................................................. 9
VANDAZOLE...................................................................9
VANFLYTA.....................................................................22
VAQTA........................................................................... 61
varenicline tartrate tab 0.5 mg, 1 mg...........................4
2023
94
varenicline tartrate tab 11 x 0.5 mg & 42 x 1 mg start
pack...............................................................................4
VARIVAX........................................................................61
VASCEPA...................................................................... 43
VELIVET........................................................................ 54
VELPHORO.................................................................. 49
VELTASSA.................................................................... 49
VENCLEXTA................................................................. 22
VENCLEXTA STARTING PACK................................ 22
VENLAFAXINE BESYLATE ER................................. 14
venlafaxine hcl cap er 24hr 150 mg.......................... 14
venlafaxine hcl cap er 24hr 37.5 mg......................... 14
venlafaxine hcl cap er 24hr 75 mg............................ 14
venlafaxine hcl tab 25 mg, 37.5 mg, 50 mg, 75 mg,
100 mg....................................................................... 14
VENTAVIS..................................................................... 67
VENTOLIN HFA........................................................... 67
verapamil hcl cap er 24hr 100 mg............................. 43
verapamil hcl cap er 24hr 120 mg, 180 mg, 240
mg................................................................................43
verapamil hcl cap er 24hr 200 mg............................. 43
verapamil hcl cap er 24hr 300 mg............................. 43
verapamil hcl cap er 24hr 360 mg............................. 43
verapamil hcl tab 40 mg, 80 mg, 120
mg................................................................................43
verapamil hcl tab er 120 mg, 180 mg, 240
mg................................................................................43
VERSACLOZ................................................................ 27
VERZENIO.................................................................... 22
V-GO 20........................................................................ 36
V-GO 30........................................................................ 36
V-GO 40........................................................................ 36
VIBERZI.........................................................................50
VICTOZA....................................................................... 36
vigabatrin powd pack 500 mg.................................... 11
vigabatrin tab 500 mg................................................. 11
VIIBRYD STARTER PACK......................................... 14
vilazodone hcl tab 10 mg, 20 mg, 40
mg................................................................................14
VIRACEPT.................................................................... 31
VIREAD..........................................................................31
VITRAKVI...................................................................... 22
VIVITROL........................................................................ 4
VIZIMPRO..................................................................... 22
VONJO...........................................................................22
voriconazole for inj 200 mg........................................ 15
voriconazole for susp 40 mg/ml................................. 15
voriconazole tab 50 mg, 200 mg............................... 16
VOSEVI..........................................................................31
VOTRIENT.................................................................... 22
VRAYLAR...................................................................... 27
VUMERITY....................................................................44
VYNDAMAX.................................................................. 51
VYNDAQEL...................................................................51
W
WAKIX............................................................................68
warfarin sodium tab 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg,
5 mg, 6 mg, 7.5 mg, 10 mg.....................................37
WELIREG...................................................................... 22
X
XALKORI....................................................................... 22
XARELTO...................................................................... 37
XARELTO STARTER PACK....................................... 37
XATMEP........................................................................ 61
XCOPRI......................................................................... 11
XELJANZ.......................................................................61
XELJANZ XR................................................................ 61
XGEVA...........................................................................62
XHANCE........................................................................67
XIFAXAN........................................................................50
XIGDUO XR..................................................................36
XOFLUZA...................................................................... 31
XOLAIR..........................................................................61
XOPENEX HFA............................................................ 67
XOSPATA...................................................................... 22
XPOVIO......................................................................... 22
XPOVIO 60 MG TWICE WEEKLY.............................23
XPOVIO 80 MG TWICE WEEKLY.............................23
XTANDI.......................................................................... 23
XYREM.......................................................................... 68
XYWAV.......................................................................... 68
Y
YF-VAX.......................................................................... 61
Z
zafirlukast tab 10 mg, 20 mg......................................67
zaleplon cap 10 mg..................................................... 68
zaleplon cap 5 mg....................................................... 68
ZEJULA..........................................................................23
ZELBORAF................................................................... 23
ZENPEP........................................................................ 51
ZEPATIER..................................................................... 31
zidovudine cap 100 mg............................................... 31
zidovudine syrup 10 mg/ml.........................................31
zidovudine tab 300 mg................................................31
ZIEXTENZO.................................................................. 37
ziprasidone hcl cap 20 mg, 40 mg.............................27
ziprasidone hcl cap 60 mg, 80 mg.............................27
ziprasidone mesylate for inj 20 mg............................27
ZOKINVY.......................................................................51
zoledronic acid inj conc for iv infusion 4
mg/5ml........................................................................ 62
2023
95
ZOLINZA........................................................................23
zolpidem tartrate tab 5 mg, 10 mg.............................68
ZONISADE.................................................................... 12
zonisamide cap 25 mg, 50 mg, 100
mg................................................................................12
ZONTIVITY....................................................................37
ZOSYN.............................................................................9
ZTALMY.........................................................................12
ZTLIDO............................................................................ 3
ZYDELIG....................................................................... 23
ZYKADIA....................................................................... 23
ZYPREXA RELPREVV............................................... 27
Blue Cross and Blue Shield of New Mexico complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Cross and Blue Shield of
New Mexico does not exclude people or treat them differently because of race, color, national origin, age,
disability, or sex.
Blue Cross and Blue Shield of New Mexico:
Provides free aids and services to people with disabilities to communicate effectively with us, such as:
Qualified sign language interpreters
Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:
Qualified interpreters
Information written in other languages
If you need these services, contact a Civil Rights Coordinator.
If you believe that Blue Cross and Blue Shield of state} has failed to provide these services or discriminated
in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance
with: Civil Rights Coordinator, Office of Civil Rights Coordinator, 300 E. Randolph St., 35
th
floor, Chicago,
Illinois 60601, 1-855-664-7270, TTY/TDD: 1-855-661-6965, Fax: 1-855-661-6960. You can file a grievance by
phone, mail, or fax. If you need help filing a grievance, a Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for
Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Y0096_NMCOMPV23_C 484216.1123
This formulary was updated on 11/13/2023. For more recent information or other questions, please contact
Blue Cross MedicareRx Customer Service at 1-888-285-2249 or, for TTY users, 711, 8:00 a.m. – 8:00 p.m.,
local time, 7 days a week. If you are calling from April 1 through September 30, alternate technologies (for
example, voicemail) will be used on weekends and holidays, or visit www.getbluenm.com/pdp/druglist.
Prescription drug plans provided by HCSC Insurance Services Company (HISC), an Independent Licensee of
the Blue Cross and Blue Shield Association. A Medicare-approved Part D sponsor. Enrollment in HISC’s plans
depends on contract renewal.
