Medicare Prescription Drug Plans - 2024 Cigna Healthcare

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Medicare Prescription Drug Plans

2024 Cigna Healthcare

Comprehensive Drug List

(Formulary)

Please read:

This document contains information about

all of the drugs we cover in this plan.

Plan covered

Cigna Healthcare Secure Rx (PDP)

HPMS Approved Formulary File Submission 00024185, Version Number 20.

This formulary was updated on 9/1/2024. For more recent information or other questions, please contact Cigna Healthcare Customer

Service, at 1-800-222-6700 (TTY users should call 711), 8 a.m. - 8 p.m. local time, 7 days a week. Our automated phone system may

answer your call during weekends from April 1 - September 30, or visit CignaMedicare.com.

The Formulary and pharmacy network may change at any time.

September 2024

September 2024 1

Note to existing customers: This formulary has changed since last year. Please review this document to make sure

that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Cigna Healthcare. When it refers to “plan” or

“our plan,” it means Cigna Healthcare Secure Rx (PDP).

This document includes a list of the drugs (formulary) for our plans, which is current as of September 2024. 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, 2025, and from time to time during the year.

What is the Cigna Healthcare Comprehensive Drug List?

A drug list is a list of covered drugs selected by Cigna

Healthcare 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. Cigna Healthcare

will generally cover the drugs listed in our drug list as long as

the drug is medically necessary, the prescription is filled at a

Cigna Healthcare network pharmacy, and other plan rules are

followed. For more information on how to fill your prescriptions,

please review your Evidence of Coverage (EOC).

Can the Drug List (formulary) change?

Most changes in drug coverage happen on January 1, but we

may add or remove drugs on the drug list during the year, move

them to different cost-sharing tiers, or add new restrictions. We

must follow 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 also find information in the section entitled “How do

I request an exception to the Cigna Healthcare Drug List?”

• Drugs removed from the market. If the Food and Drug

Administration (FDA) deems a drug on our drug list to be

unsafe or the drug’s manufacturer removes the drug from the

market, we will immediately remove the drug from our drug

list and provide notice to customers who take the drug.

• Other changes. We may make other changes that affect

customers currently taking a drug. For instance, we may

add a generic drug that is not new to the market to replace

a brand name drug currently on the drug list, 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 and/or studies. If we remove drugs

from our drug list, 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 customers

of the change at least 30 days before the change becomes

effective, or at the time the customer requests a refill of the

drug, at which time the customer 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 find information in the section below titled

“How do I request an exception to the Cigna Healthcare

Drug List?”

Changes that will not affect you if you are currently taking

the drug. Generally, if you are taking a drug on our 2024 drug

list that was covered at the beginning of the year, we will not

discontinue or reduce coverage of the drug during the 2024

coverage year except as described above. This means these

drugs will remain available at the same cost-sharing and with

September 2024 2

no new restrictions for those customers 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.

The enclosed drug list is current as of September 2024. To

get updated information about the drugs covered by Cigna

Healthcare, please contact us. Our contact information appears

on the front and back cover pages. If there are significant

changes made to the printed drug list within the covered year,

you may be notified by mail identifying the changes. Drug lists

located on our website are reviewed and updated on a monthly

basis.

How do I use the Drug List?

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

Medical Condition

The drug list begins on page 10. The drugs in this drug list

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, HYPERTENSION / LIPIDS.” If you know

what your drug is used for, look for the category name in the list

that begins on page 10. Then look under the category name for

your drug.

Covered Drug Index

If you are not sure what category to look under, you should look

for your drug in the Covered Drugs Index that begins on page

58. The Covered Drugs 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 Covered Drug Index and find the name of your drug

in the drug name column of the list.

What are generic drugs?

Cigna Healthcare 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: Cigna Healthcare requires you or your

doctor to get prior authorization for certain drugs. This means

that you will need to get approval from Cigna Healthcare

before you fill these prescriptions. If you don’t get approval,

Cigna Healthcare may not cover the drug.

• Quantity Limits: For certain drugs, Cigna Healthcare limits

the amount of the drug that Cigna Healthcare will cover. For

example, Cigna Healthcare allows for 1 tablet per day for

atorvastatin 40mg. This applies to a standard one-month

supply (for total quantity of 30 per 30 days) or three-month

supply (for total quantity of 90 per 90 days).

• Step Therapy: In some cases, Cigna Healthcare 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, Cigna

Healthcare may not cover Drug B unless you try Drug A first.

If Drug A does not work for you, Cigna Healthcare will then

cover Drug B.

• Non-Extended Days Supply: For certain drugs, Cigna

Healthcare limits the amount of the drug that Cigna

Healthcare will cover to only a 30-day supply or less, at

one time. For example, customers who have not had any

recent fill of opioid pain medications within the past 108 days

(referred to as “opioid naïve”) are limited to a maximum of 7

days’ supply of opioid pain medication. Customers who have

received a recent fill of an opioid pain medication (not opioid

naïve) are limited to up to a month’s supply of that medication

at one time. Other high cost drugs may be subject to a non-

extended day supply restriction, as well.

You can find out if your drug has any additional requirements

or limits by looking in the drug list that begins on page 10. 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

drug list, appears on the front and back cover pages.

You can ask Cigna Healthcare 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 Cigna Healthcare drug list?” on page 3 for

information about how to request an exception.

September 2024 3

Options for Maintenance Medications

Taking the medications prescribed by your doctor (or other

prescriber) is important to your health.

We are committed to helping you control your chronic conditions

by making it easy for you to receive your maintenance

medications. There are several ways we can work together

to accomplish this goal:

• Talk with your doctor about whether a 90-day supply of your

ongoing, stable medications may be appropriate. Taking

these medications every day as prescribed is important for

your overall health, and getting 90-day prescriptions of these

medications can help ensure that you do not miss a dose.

• You can receive a 90-day supply at most retail pharmacies or

through one of our mail-order pharmacies.

• Talk to your pharmacist if you are experiencing any new

challenges with your maintenance medications.

How can I use my prescription drug coverage to save

money on my medications?

There may be opportunities for you to save money on your

medications using your Cigna Healthcare coverage.

• Ask your doctor (or other prescriber) if there are any lower-

cost generic alternatives available for any of your current

medications.

• Some plans may offer a $0 copay for Tier 1 generic drugs

filled at a preferred retail and/or mail-order pharmacies.

Check the Drug Tier and Cost-share Tables on page 6 to see

if your plan offers these savings.

• Explore whether the ‘CMS Extra Help’ program may offer

additional financial support for your medications.

• If your medication is not covered in the Cigna Healthcare drug

list, talk with your doctor about alternative medications which

are covered on the drug list.

What if my drug is not on the Drug List?

If your drug is not included in this drug list, you should first

contact Customer Service and ask if your drug is covered. If

you learn that Cigna Healthcare does not cover your drug, you

have two options:

• You can ask Customer Service for a list of similar drugs that

are covered by Cigna Healthcare. When you receive the list,

show it to your doctor and ask them to prescribe a similar

drug that is covered by Cigna Healthcare.

• You can ask Cigna Healthcare to make an exception and

cover your drug. See the next section for information about

how to request an exception.

How do I request an exception to the Cigna Healthcare

Drug List?

You can ask Cigna Healthcare 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 drug

list. 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 waive coverage restrictions or limits on

your drug. For example, for certain drugs, Cigna Healthcare

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.

• 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. This applies to the following circumstances:

– If the drug you’re taking is a brand name drug, you can

ask us to cover your drug at the cost-sharing amount

that applies to the lowest tier that contains brand name

alternatives for treating your condition.

– If the drug you’re taking is a generic drug, you can ask us

to cover your drug at the cost-sharing amount that applies

to the lowest tier that contains either brand or generic

alternatives for treating your condition.

– If the drug you’re taking is a biological product, you can

ask us to cover your drug at the cost-sharing amount that

applies to the lowest tier that contains biological product

alternatives for treating your condition.

Please note, if we grant your request to cover a drug that is

not on our drug list, you may not ask us to provide this drug

at a lower cost-sharing level.

Generally, Cigna Healthcare will only approve your request for

an exception if the alternative drug is included in our drug list,

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 drug list, tiering or utilization restriction exception. When

you request a drug list, tiering or utilization restriction

exception you should submit a statement from your

prescriber or doctor 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

September 2024 4

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 existing customer in our plan you may be taking

drugs that are not on our drug list. Or, you may be taking a drug

that is on our drug list 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 drug list 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 up to a

30-day supply, in certain cases during the first 90 days you are

a customer of our plan.

For each of your drugs that is not on our drug list 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 30-day supply of

medication. After your first 30-day supply, we will not pay for

these drugs without a drug list exception, even if you have been

a customer of the plan less than 90 days.

If you are a resident of a long-term care facility and you need a

drug that is not on our drug list 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 drug list exception.

In order to accommodate unexpected transitions of our

customers that do not leave time for advanced planning, such

as level-of-care changes due to discharge from a hospital to a

nursing facility or to a home, Cigna Healthcare will allow a one-

time 31-day supply (unless the prescription is written for fewer

days).

Cigna Healthcare’s Drug List

The comprehensive drug list that begins on page 10 provides

coverage information about all of the drugs covered by Cigna

Healthcare. If you have trouble finding your drug in the list, turn

to the Covered Drug Index that begins on page 58.

The first column of the chart lists the drug name. Brand name

drugs are capitalized (e.g., TRELEGY ELLIPTA) and generic

drugs are listed in lower-case italics (e.g., atorvastatin).

The information in the Requirements/Limits column tells you if

Cigna Healthcare has any special requirements for coverage of

your drug.

We provide quantity limits on certain drugs which are indicated

with a QL in the Covered Drugs by Category list on page 10

along with the amount dispensed per the days supplied. (For

example: atorvastatin 40mg QL 30/30; this means the drug

atorvastatin 40mg is limited to 30 tablets per 30 days. For 90-

day supplies, this quantity limit would be expanded to 90 tablets

per 90 days).

(TTY 711), or you can visit CignaMedicare.com for the most

current Pharmacy Directory.

For more information

For more detailed information about your Cigna Healthcare prescription drug coverage, please review your Evidence of

Coverage (EOC) and other plan materials. To access a copy of your most recent EOC, go to CignaMedicare.com.

If you have questions about Cigna Healthcare, please contact us. Our contact information, along with the date we last updated

the drug list, 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 http://www.medicare.gov.

What is a preferred network pharmacy?

If your plan has preferred network pharmacies, you will typically

save money by using these pharmacies. Your prescription

drug costs (like a copay or coinsurance) will typically be less

at a preferred network pharmacy because it has a preferred

agreement with your plan. If you need help finding a network

pharmacy, please call Customer Service at 1-800-222-6700

September 2024 5

Drug Tier and Cost-Share Table

The following table represents the plan service area, the drug

tier number as it appears on the drug list, and the cost-share

amount for that tier number. Tier 1 is for Preferred Generic

drugs. Tier 2 is for Generic drugs. Tier 3 is for Preferred Brand

drugs. Tier 4 is for Non-Preferred drugs. Tier 5 is for Specialty

tier drugs. Please refer to the following chart. You may also refer

to your Evidence of Coverage (EOC) document for additional

details.

Cigna Healthcare is not always able to keep all generic

medications in the Preferred Generic and Generic drug tiers.

Some generic medications may be in Tier 3, Tier 4, or Tier 5.

Keep in mind that the name “Tier 3: Preferred Brand Drugs”

isjust a description of the majority of the drugs in the tier. It does

not mean that there are only brand drugs in that tier.

For customers receiving Extra Help: Your Low Income

Subsidy (LIS) copay level will be based on how the Food

and Drug Administration (FDA) classifies certain drugs. Due

to this, a generic drug may receive a preferred brand copay,

or a preferred brand drug may receive a generic drug copay.

Please see your LIS Rider for additional information on these

copay levels. Or call Customer Service for further clarification

regarding a specific drug.

Locate your drug cost

To locate your drug cost, please refer to the table(s) on the next few pages to find your service area and the

Prescription Drug plan in which you are currently enrolled or would like to enroll.

If you qualified for Extra Help with your drug costs, your costs may be different from those described in these tables.

Please refer to your Evidence of Coverage (EOC) or call Customer Service to find out what your costs are.

Cigna Healthcare uses preferred network pharmacies. See your Pharmacy Directory or visit CignaMedicare.com to

search for a preferred retail or mail-order pharmacy near you.

For insulins that are covered by our plans, you will pay only $35 for each 30-day script and $0 for each covered adult vaccine.

Long-term care (LTC) and home infusion pharmacies use standard pharmacy cost-sharing. For LTC you can get up to a 31-day supply.

At an out-of-network pharmacy you will pay the in-network pharmacy copay or percentage of the cost plus the amount that the out of

network pharmacy billed charges are higher than our typical standard retail pharmacy billed charges. If you receive Extra Help, these

costs do not apply. You typically pay only a low copay.

September 2024 6

Preferred

Retail Cost-sharing

30 day supply

60 and 90-day copays are

2x and 3x the 30-day copays

Regional States Tier 1 Tier 2 Tier 3 Tier 4 Tier 5

Northern NE (NH,ME) $0 $3 16% 42% 25%

Central NE (CT, MA, RI, VT) $0 $3 16% 46% 25%

New York $0 $3 16% 42% 25%

New Jersey $0 $3 16% 45% 25%

Mid-Atlantic (DE, DC, MD) $0 $3 16% 42% 25%

Pennsylvania, West Virginia $0 $3 16% 42% 25%

Virginia $0 $3 17% 48% 25%

North Carolina $0 $3 17% 47% 25%

South Carolina $0 $3 17% 46% 25%

Georgia $0 $3 17% 46% 25%

Florida $0 $3 17% 43% 25%

Alabama, Tennessee $0 $3 17% 46% 25%

Michigan $0 $3 16% 42% 25%

Ohio $0 $3 16% 43% 25%

Indiana, Kentucky $0 $3 16% 46% 25%

Wisconsin $0 $2 16% 40% 25%

Illinois $0 $3 17% 48% 25%

Missouri $0 $3 16% 47% 25%

Arkansas $0 $3 16% 42% 25%

Mississippi $0 $3 16% 43% 25%

Louisiana $0 $3 16% 42% 25%

Texas $0 $3 16% 48% 25%

Oklahoma $0 $3 16% 46% 25%

Kansas $0 $3 16% 43% 25%

Upper MW and N. Plains* $0 $3 16% 47% 25%

New Mexico $0 $3 16% 42% 25%

Colorado $0 $3 16% 41% 25%

Arizona $0 $3 16% 42% 25%

Nevada $0 $3 16% 43% 25%

Oregon, Washington $0 $3 16% 41% 25%

Idaho, Utah $0 $3 16% 43% 25%

California $0 $3 16% 40% 25%

Hawaii $0 $3 17% 42% 25%

Alaska $0 $3 17% 41% 25%

Puerto Rico $0 $3 19% 50% 25%

*IA, MN, MT, ND, NE, SD, WY associated with the regional states of Upper MW and N. Plains.

September 2024 7

Standard

Retail Cost-sharing

30 day supply

60 and 90-day copays are

2x and 3x the 30-day copays

Regional States Tier 1 Tier 2 Tier 3 Tier 4 Tier 5

Northern NE (NH,ME) $4 $8 16% 43% 25%

Central NE (CT, MA, RI, VT) $4 $8 16% 46% 25%

New York $3 $7 16% 43% 25%

New Jersey $4 $8 16% 46% 25%

Mid-Atlantic (DE, DC, MD) $4 $8 16% 43% 25%

Pennsylvania, West Virginia $4 $8 16% 43% 25%

Virginia $4 $10 17% 48% 25%

North Carolina $4 $10 17% 48% 25%

South Carolina $4 $10 17% 47% 25%

Georgia $4 $10 17% 47% 25%

Florida $4 $10 17% 44% 25%

Alabama, Tennessee $4 $10 17% 46% 25%

Michigan $3 $7 16% 42% 25%

Ohio $4 $10 17% 44% 25%

Indiana, Kentucky $4 $9 17% 47% 25%

Wisconsin $2 $7 16% 40% 25%

Illinois $4 $10 17% 48% 25%

Missouri $4 $10 17% 48% 25%

Arkansas $4 $10 17% 43% 25%

Mississippi $4 $10 17% 43% 25%

Louisiana $4 $7 17% 43% 25%

Texas $4 $10 17% 48% 25%

Oklahoma $4 $10 17% 46% 25%

Kansas $4 $8 17% 43% 25%

Upper MW and N. Plains* $4 $10 17% 47% 25%

New Mexico $4 $10 17% 42% 25%

Colorado $4 $8 17% 42% 25%

Arizona $4 $10 17% 42% 25%

Nevada $4 $9 17% 44% 25%

Oregon, Washington $4 $8 17% 42% 25%

Idaho, Utah $4 $8 17% 43% 25%

California $2 $7 17% 40% 25%

Hawaii $4 $9 17% 42% 25%

Alaska $4 $10 17% 42% 25%

Puerto Rico $4 $10 20% 50% 25%

*IA, MN, MT, ND, NE, SD, WY associated with the regional states of Upper MW and N. Plains.

September 2024 8

Preferred

Mail-order Cost-sharing

90 day supply

Regional States

Northern NE (NH,ME)

Central NE (CT, MA, RI, VT)

New York

New Jersey

Mid-Atlantic (DE, DC, MD)

Pennsylvania, West Virginia

Virginia

North Carolina

South Carolina

Georgia

Florida

Alabama, Tennessee

Michigan

Ohio

Indiana, Kentucky

Wisconsin

Illinois

Missouri

Arkansas

Mississippi

Louisiana

Texas

Oklahoma

Kansas

Upper MW and N. Plains*

New Mexico

Colorado

Arizona

Nevada

Oregon, Washington

Idaho, Utah

California

Hawaii

Alaska

Puerto Rico

$0 copay Tier 1

$3 copay Tier 2 ($2 in Wisconsin)

All other drug Tiers,

see Preferred Retail chart.

*IA, MN, MT, ND, NE, SD, WY associated with the regional states of Upper MW and N. Plains.

September 2024 9

Drug List Table of Contents:

The drugs on the drug list are grouped into categories depending on the type of medical condition they are used to treat.

If you know what your drug is used for, look for the category name in the list below. Then look under the category name

within the drug list for your drug.

Page

ANTI - INFECTIVES ...................................................................................................................................................................10

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS ........................................................................................................16

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH ...........................................................................................................23

CARDIOVASCULAR, HYPERTENSION / LIPIDS ....................................................................................................................33

DERMATOLOGICALS/TOPICAL THERAPY ...........................................................................................................................36

DIAGNOSTICS / MISCELLANEOUS AGENTS ........................................................................................................................39

EAR, NOSE / THROAT MEDICATIONS ....................................................................................................................................40

ENDOCRINE/DIABETES ...........................................................................................................................................................40

GASTROENTEROLOGY ...........................................................................................................................................................44

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY ...................................................................................................................46

MISCELLANEOUS SUPPLIES .................................................................................................................................................47

MUSCULOSKELETAL / RHEUMATOLOGY ............................................................................................................................48

OBSTETRICS / GYNECOLOGY ...............................................................................................................................................50

OPHTHALMOLOGY ..................................................................................................................................................................53

RESPIRATORY AND ALLERGY ...............................................................................................................................................54

UROLOGICALS .........................................................................................................................................................................56

VITAMINS, HEMATINICS / ELECTROLYTES ..........................................................................................................................56

Drug List Key:

B/D – This prescription drug has a Part B versus D

administrative prior authorization requirement. This drug

may be covered under Medicare Part B or D depending on

circumstances.

LA – Limited Availability. This prescription may be available

only at certain pharmacies. For more information consult

your Pharmacy Directory or call Cigna Healthcare Customer

Service, at 1-800-222-6700 (TTY users should call 711),

8 a.m. – 8 p.m. local time, 7 days a week. Our automated

phone system may answer your call during weekends from

April 1 – September 30, or visit CignaMedicare.com.

NDS – Non-extended day supply medication. This drug is

only available for a one month supply.

PA – This drug requires prior authorization

QL – This drug has quantity limits

ST – This drug has step therapy requirements

V – This vaccine is provided at no cost when used based on

recommendations by the Centers for Disease Control and

Prevention’s (CDC) Advisory Committee on Immunization

Practices (ACIP).

Generally all medications on the drug list are available

through mail-order, except when special circumstances

or situations prohibit mailing a particular medication to

your home.

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

Covered Drugs By Category

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

ANTI - INFECTIVES

ANTIFUNGAL AGENTS

ABELCET 4 PA

amphotericin b 4 PA

amphotericin b liposome 5 PA; NDS

caspofungin intravenous recon

soln 50 mg

5 PA; NDS

caspofungin intravenous recon

soln 70 mg

4 PA

clotrimazole mucous

membrane

CRESEMBA ORAL 4

uconazole in nacl (iso-osm) 4 PA

uconazole oral suspension for

reconstitution

uconazole oral tablet 2

ucytosine 5 NDS

griseofulvin microsize 4

griseofulvin ultramicrosize 4

itraconazole oral capsule 4 QL (120/30)

itraconazole oral solution 4

ketoconazole oral 3

nystatin oral 3

posaconazole oral tablet,

delayed release (dr/ec)

5 QL (96/30); NDS

terbinane hcl oral 2

voriconazole intravenous 4 PA

voriconazole oral suspension

for reconstitution

5 NDS

voriconazole oral tablet 4

ANTIVIRALS

abacavir oral solution 3 QL (960/30)

abacavir oral tablet 4 QL (60/30)

abacavir-lamivudine 3 QL (30/30)

acyclovir oral capsule 2

acyclovir oral suspension

200 mg/5 ml

acyclovir oral tablet 2

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

acyclovir sodium intravenous

solution

4 B/D PA

amantadine hcl 3

APRETUDE 4

APTIVUS 4 QL (120/30)

atazanavir oral capsule

150 mg, 300 mg

4 QL (30/30)

atazanavir oral capsule 200 mg 4 QL (60/30)

BARACLUDE ORAL

SOLUTION

4 QL (630/30)

BIKTARVY 5 NDS

CABENUVA 4

CIMDUO 4

COMPLERA 4 QL (30/30)

darunavir oral tablet 600 mg 5 QL (60/30); NDS

darunavir oral tablet 800 mg 5 QL (30/30); NDS

DELSTRIGO 4

DESCOVY 4 QL (30/30)

DOVATO 5 NDS

EDURANT 4 QL (30/30)

efavirenz oral capsule 200 mg 4 QL (120/30)

efavirenz oral capsule 50 mg 4 QL (180/30)

efavirenz oral tablet 4 QL (30/30)

efavirenz-emtricitabin-tenofov 5 QL (30/30); NDS

efavirenz-lamivu-tenofov disop

oral tablet 400-300-300 mg

4 QL (30/30)

efavirenz-lamivu-tenofov disop

oral tablet 600-300-300 mg

emtricitabine 3 QL (30/30)

emtricitabine-tenofovir (tdf)

oral tablet 100-150 mg,

167-250 mg, 200-300 mg

4 QL (30/30)

emtricitabine-tenofovir (tdf) oral

tablet 133-200 mg

5 QL (30/30); NDS

EMTRIVA ORAL SOLUTION 3 QL (680/28)

entecavir 4 QL (30/30)

EPCLUSA ORAL PELLETS IN

PACKET 150-37.5 MG

5 PA; QL (28/28);

NDS

Covered Drugs By Category

*$0 cost share for Paxlovid

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

EPCLUSA ORAL PELLETS IN

PACKET 200-50 MG

5 PA; QL (56/28);

NDS

EPCLUSA ORAL TABLET

200-50 MG

5 PA; QL (56/28);

NDS

EPCLUSA ORAL TABLET

400-100 MG

5 PA; QL (28/28);

NDS

etravirine 4 QL (60/30)

EVOTAZ 4 QL (30/30)

famciclovir 4 QL (60/30)

fosamprenavir 5 QL (120/30); NDS

FUZEON SUBCUTANEOUS

RECON SOLN

5 QL (60/30); NDS

HARVONI ORAL PELLETS IN

PACKET 33.75-150 MG

5 PA; QL (28/28);

NDS

HARVONI ORAL PELLETS IN

PACKET 45-200 MG

5 PA; QL (56/28);

NDS

HARVONI ORAL TABLET

45-200 MG

5 PA; QL (56/28);

NDS

HARVONI ORAL TABLET

90-400 MG

5 PA; QL (28/28);

NDS

INTELENCE ORAL TABLET

25 MG

4 QL (120/30)

ISENTRESS HD 5 NDS

ISENTRESS ORAL POWDER

IN PACKET

4 QL (60/30)

ISENTRESS ORAL TABLET 5 QL (120/30); NDS

ISENTRESS ORAL TABLET,

CHEWABLE 100 MG

5 QL (180/30); NDS

ISENTRESS ORAL TABLET,

CHEWABLE 25 MG

3 QL (180/30)

JULUCA 5 NDS

LAGEVRIO (EUA) 3 QL (40/180)

lamivudine oral solution 3 QL (900/30)

lamivudine oral tablet 100 mg,

300 mg

3 QL (30/30)

lamivudine oral tablet 150 mg 3 QL (60/30)

lamivudine-zidovudine 3 QL (60/30)

LEXIVA ORAL SUSPENSION 4 QL (1575/28)

lopinavir-ritonavir oral solution 4

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

lopinavir-ritonavir oral tablet

100-25 mg

4 QL (300/30)

lopinavir-ritonavir oral tablet

200-50 mg

4 QL (120/30)

maraviroc oral tablet 150 mg 5 QL (60/30); NDS

maraviroc oral tablet 300 mg 5 QL (120/30); NDS

MAVYRET ORAL PELLETS IN

PACKET

5 PA; QL (168/28);

NDS

MAVYRET ORAL TABLET 5 PA; QL (84/28);

NDS

nevirapine oral suspension 4 QL (1200/30)

nevirapine oral tablet 3 QL (60/30)

nevirapine oral tablet extended

release 24 hr 100 mg

4 QL (90/30)

nevirapine oral tablet extended

release 24 hr 400 mg

4 QL (30/30)

NORVIR ORAL POWDER IN

PACKET

ODEFSEY 4 QL (30/30)

oseltamivir oral capsule 3

oseltamivir oral suspension for

reconstitution

PAXLOVID ORAL TABLETS,

DOSE PACK 150-100 MG

3 QL (20/180)

PAXLOVID ORAL TABLETS,

DOSE PACK 300 MG (150 MG

X 2)-100 MG

3 QL (30/180)

PIFELTRO 4

PREVYMIS 5 QL (30/30); NDS

PREZCOBIX 4 QL (30/30)

PREZISTA ORAL

SUSPENSION

5 QL (400/30); NDS

PREZISTA ORAL TABLET

150 MG

4 QL (240/30)

PREZISTA ORAL TABLET

75 MG

4 QL (480/30)

RETROVIR INTRAVENOUS 4

REYATAZ ORAL POWDER IN

PACKET

5 QL (240/30); NDS

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

ribavirin oral capsule 3

ribavirin oral tablet 200 mg 3

rimantadine 4

ritonavir 3 QL (360/30)

RUKOBIA 5 NDS

SELZENTRY ORAL

SOLUTION

5 NDS

SELZENTRY ORAL TABLET

25 MG

SELZENTRY ORAL TABLET

75 MG

5 NDS

STRIBILD 5 QL (30/30); NDS

SUNLENCA 5 NDS

SYMTUZA 4

tenofovir disoproxil fumarate 4 QL (30/30)

TIVICAY ORAL TABLET

10 MG

4 QL (60/30)

TIVICAY ORAL TABLET

25 MG, 50 MG

5 QL (60/30); NDS

TIVICAY PD 4 QL (180/30)

TRIUMEQ 4 QL (30/30)

TRIUMEQ PD 4 QL (300/30)

TRIZIVIR 5 QL (60/30); NDS

TROGARZO 5 NDS

valacyclovir oral tablet 1 gram 3 QL (120/30)

valacyclovir oral tablet 500 mg 3 QL (60/30)

valganciclovir oral recon soln 5 NDS

valganciclovir oral tablet 3

VEKLURY 5 QL (4/180); NDS

VEMLIDY 5 NDS

VIRACEPT ORAL TABLET

250 MG

4 QL (270/30)

VIRACEPT ORAL TABLET

625 MG

4 QL (120/30)

VIREAD ORAL POWDER 5 QL (240/30); NDS

VIREAD ORAL TABLET

150 MG, 200 MG, 250 MG

5 QL (30/30); NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

VOSEVI 5 PA; QL (28/28);

NDS

XOFLUZA ORAL TABLET

40 MG, 80 MG

zidovudine oral capsule 4 QL (180/30)

zidovudine oral syrup 4 QL (1680/28)

zidovudine oral tablet 2 QL (60/30)

CEPHALOSPORINS

cefaclor oral capsule 4

cefaclor oral suspension for

reconstitution 125 mg/5 ml,

250 mg/5 ml, 375 mg/5 ml

cefaclor oral tablet extended

release 12 hr

cefadroxil oral capsule 3

cefadroxil oral suspension for

reconstitution 250 mg/5 ml,

500 mg/5 ml

cefadroxil oral tablet 3

CEFAZOLIN IN DEXTROSE

(ISO-OS) INTRAVENOUS

PIGGYBACK 1 GRAM/50 ML,

2 GRAM/100 ML,

2 GRAM/50 ML

cefazolin injection recon soln

1 gram, 10 gram, 100 gram,

3 gram, 300 gram, 500 mg

CEFAZOLIN INJECTION

RECON SOLN 2 GRAM

cefazolin intravenous recon

soln 1 gram, 3 gram

CEFAZOLIN INTRAVENOUS

RECON SOLN 2 GRAM

cefdinir 4

CEFEPIME IN DEXTROSE 5% 4

CEFEPIME IN DEXTROSE,

ISO-OSM

cefepime injection 4

cefepime intravenous 4 PA

cexime 4

cefotetan injection 4 PA

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

cefoxitin 4 PA

CEFOXITIN IN DEXTROSE,

ISO-OSM

4 PA

cefpodoxime 4

cefprozil 3

ceftazidime 4 PA

ceftriaxone 4

ceftriaxone in dextrose, iso-os 4

cefuroxime axetil oral tablet 3

cefuroxime sodium injection

recon soln 750 mg

4 PA

cefuroxime sodium intravenous 4 PA

cephalexin oral capsule

250 mg, 500 mg

cephalexin oral suspension for

reconstitution

tazicef 4 PA

TEFLARO 4 PA

ERYTHROMYCINS / OTHER MACROLIDES

azithromycin intravenous 4 PA

AZITHROMYCIN ORAL

PACKET

azithromycin oral suspension

for reconstitution

azithromycin oral tablet 2

clarithromycin 4

DIFICID ORAL SUSPENSION

FOR RECONSTITUTION

5 QL (136/10); NDS

DIFICID ORAL TABLET 5 QL (20/10); NDS

erythrocin (as stearate) oral

tablet 250 mg

erythrocin intravenous recon

soln 500 mg

4 PA

erythromycin ethylsuccinate

oral suspension for

reconstitution 200 mg/5 ml

erythromycin oral capsule,

delayed release (dr/ec)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

erythromycin oral tablet 4

MISCELLANEOUS ANTIINFECTIVES

albendazole 5 NDS

amikacin injection solution

1,000 mg/4 ml, 500 mg/2 ml

4 PA

ARIKAYCE 4 PA; LA

atovaquone 4

atovaquone-proguanil 4

aztreonam 4 PA

bacitracin intramuscular 4

CAYSTON 5 PA; LA; QL (84/28);

NDS

chloramphenicol sod succinate 4

chloroquine phosphate 3

clindamycin hcl 2

CLINDAMYCIN IN 0.9%

SOD CHLOR

4 PA

CLINDAMYCIN IN 5%

DEXTROSE

4 PA

clindamycin palmitate hcl 4

clindamycin pediatric 4

clindamycin phosphate

injection

4 PA

COARTEM 4 QL (24/30)

colistin (colistimethate na) 4 PA

cycloserine 4

dapsone oral 3

daptomycin 5 NDS

DAPTOMYCIN IN 0.9%

SOD CHLOR

5 NDS

emverm 4

ertapenem 4

ethambutol 4

FIRVANQ 4 QL (450/10)

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

gentamicin in nacl (iso-osm)

intravenous piggyback

100 mg/100 ml, 100 mg/50 ml,

120 mg/100 ml, 60 mg/50 ml,

80 mg/100 ml, 80 mg/50 ml

4 PA

gentamicin injection solution

40 mg/ml

4 PA

gentamicin sulfate (ped) (pf) 4 PA

hydroxychloroquine 3

imipenem-cilastatin 4

isoniazid oral solution 4

isoniazid oral tablet 2

ivermectin oral 3 PA

lincomycin 4 PA

linezolid in dextrose 5% 4 PA

linezolid oral suspension for

reconstitution

5 QL (1800/30); NDS

linezolid oral tablet 3 QL (60/30)

LINEZOLID-0.9% SODIUM

CHLORIDE

4 PA

meoquine 3

meropenem intravenous recon

soln 1 gram, 500 mg

MEROPENEM-0.9% SODIUM

CHLORIDE

METRO I.V. 4 PA

metronidazole in nacl (iso-os) 4 PA

metronidazole oral tablet 2

neomycin 2

nitazoxanide 5 QL (20/10); NDS

paromomycin 4

pentamidine inhalation 3 B/D PA; QL (1/28)

pentamidine injection 4

praziquantel 4

PRIFTIN 4

primaquine 4

pyrazinamide 4

pyrimethamine 5 PA; NDS

quinine sulfate 4 PA; QL (42/7)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

rifabutin 4

rifampin 4

SIRTURO 4 PA; LA

SIVEXTRO INTRAVENOUS 5 PA; QL (6/28); NDS

SIVEXTRO ORAL 5 QL (6/28); NDS

streptomycin 4 PA

tigecycline 5 PA; NDS

tobramycin in 0.225% nacl 5 B/D PA; QL

(280/28); NDS

tobramycin sulfate 4 PA

TRECATOR 3

VANCOMYCIN IN 0.9%

SODIUM CHL INTRAVENOUS

PIGGYBACK

VANCOMYCIN IN DEXTROSE

5% INTRAVENOUS

PIGGYBACK 1 GRAM/200 ML,

500 MG/100 ML,

750 MG/150 ML

vancomycin injection 4

vancomycin intravenous recon

soln 1,000 mg, 1.25 gram,

1.5 gram, 10 gram, 5 gram,

500 mg, 750 mg

vancomycin oral capsule

125 mg

4 PA; QL (40/10)

vancomycin oral capsule

250 mg

4 PA; QL (80/10)

vancomycin oral recon soln

25 mg/ml

4 QL (450/10)

VANCOMYCIN-DILUENT

COMBO NO.1

XIFAXAN ORAL TABLET

200 MG

4 PA; QL (9/30)

XIFAXAN ORAL TABLET

550 MG

5 PA; QL (90/30);

NDS

PENICILLINS

amoxicillin oral capsule 2

amoxicillin oral suspension for

reconstitution

amoxicillin oral tablet 2

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

amoxicillin oral tablet,

chewable 125 mg, 250 mg

amoxicillin-pot clavulanate oral

suspension for reconstitution

200-28.5 mg/5 ml,

400-57 mg/5 ml,

600-42.9 mg/5 ml

amoxicillin-pot clavulanate oral

suspension for reconstitution

250-62.5 mg/5 ml

amoxicillin-pot clavulanate oral

tablet

amoxicillin-pot clavulanate oral

tablet extended release 12 hr

amoxicillin-pot clavulanate oral

tablet, chewable 200-28.5 mg

amoxicillin-pot clavulanate oral

tablet, chewable 400-57 mg

ampicillin oral capsule 500 mg 2

ampicillin sodium 4 PA

ampicillin-sulbactam 4 PA

BICILLIN L-A 4 PA

dicloxacillin 2

EXTENCILLINE 4 PA

NAFCILLIN IN DEXTROSE

ISO-OSM INTRAVENOUS

PIGGYBACK 2 GRAM/100 ML

4 PA

nafcillin injection 4 PA

oxacillin 4 PA

penicillin g potassium 4 PA

penicillin v potassium 2

pzerpen-g 4 PA

piperacillin-tazobactam 4

QUINOLONES

ciprooxacin hcl oral tablet

100 mg

ciprooxacin hcl oral tablet

250 mg, 500 mg, 750 mg

ciprooxacin in 5% dextrose 4 PA

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

ciprooxacin oral suspension,

microcapsule recon

500 mg/5 ml

levooxacin in d5w 4 PA

levooxacin oral solution 4

levooxacin oral tablet 2

moxioxacin oral 4

MOXIFLOXACIN-SOD.ACE,

SUL-WATER

4 PA

moxioxacin-sod.chloride (iso) 4 PA

SULFA'S / RELATED AGENTS

sulfadiazine 4

sulfamethoxazole-trimethoprim

intravenous

4 PA

sulfamethoxazole-trimethoprim

oral suspension

sulfamethoxazole-trimethoprim

oral tablet

TETRACYCLINES

doxy-100 4 PA

doxycycline hyclate

intravenous

4 PA

doxycycline hyclate oral

capsule

doxycycline hyclate oral tablet

100 mg, 20 mg

doxycycline monohydrate oral

capsule 100 mg, 50 mg

doxycycline monohydrate oral

suspension for reconstitution

doxycycline monohydrate oral

tablet

minocycline oral capsule 2

tetracycline oral capsule 4

URINARY TRACT AGENTS

methenamine hippurate 4

nitrofurantoin monohyd/m-cryst 3

trimethoprim 2

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

VANCOMYCIN

VANCOMYCIN IN

DEXTROSE 5%

INTRAVENOUS PIGGYBACK

1.25 GRAM/250 ML,

1.5 GRAM/300 ML

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

ADJUNCTIVE AGENTS

leucovorin calcium injection 4

leucovorin calcium oral tablet

10 mg, 15 mg, 25 mg

leucovorin calcium oral tablet

5 mg

mesna 4 B/D PA

MESNEX ORAL 5 NDS

XGEVA 5 PA; QL (1.7/28);

NDS

ANTINEOPLASTIC / IMMUNOSUPPRESSANT DRUGS

abiraterone oral tablet 250 mg 4 PA; QL (120/30)

abiraterone oral tablet 500 mg 4 PA; QL (60/30)

ABRAXANE 5 PA; NDS

ADCETRIS 4 PA

adstiladrin 5 PA; QL (4/90); NDS

AKEEGA 5 PA; QL (60/30);

NDS

ALECENSA 5 PA; QL (240/30);

NDS

ALIQOPA 5 PA; NDS

ALUNBRIG ORAL TABLET

180 MG, 90 MG

5 PA; QL (30/30);

NDS

ALUNBRIG ORAL TABLET

30 MG

5 PA; QL (60/30);

NDS

ALUNBRIG ORAL TABLETS,

DOSE PACK

5 PA; QL (60/365);

NDS

anastrozole 2

ANKTIVA 5 PA; NDS

arsenic trioxide 4 B/D PA

AUGTYRO 5 PA; QL (240/30);

NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

AYVAKIT 5 PA; LA; QL (30/30);

NDS

azacitidine 4 B/D PA

azathioprine oral tablet 50 mg 2 B/D PA

azathioprine sodium 4 B/D PA

BALVERSA 5 PA; LA; NDS

BAVENCIO 5 PA; NDS

BELEODAQ 4 B/D PA

bendamustine 5 B/D PA; NDS

BENDEKA 5 B/D PA; NDS

BESPONSA 5 PA; NDS

bexarotene 5 PA; NDS

bicalutamide 3

BLENREP 4 PA

bleomycin 4 B/D PA

BLINCYTO INTRAVENOUS

KIT

4 B/D PA

BORTEZOMIB INJECTION 5 PA; NDS

BOSULIF ORAL CAPSULE

100 MG

5 PA; QL (90/30);

NDS

BOSULIF ORAL CAPSULE

50 MG

5 PA; QL (30/30);

NDS

BOSULIF ORAL TABLET

100 MG

5 PA; QL (90/30);

NDS

BOSULIF ORAL TABLET

400 MG, 500 MG

5 PA; QL (30/30);

NDS

BRAFTOVI 5 PA; LA; QL

(180/30); NDS

BRUKINSA 5 PA; LA; NDS

busulfan 5 B/D PA; NDS

CABOMETYX 5 PA; LA; QL (30/30);

NDS

CALQUENCE 5 PA; LA; QL (60/30);

NDS

CALQUENCE

(ACALABRUTINIB MAL)

5 PA; LA; QL (60/30);

NDS

CAPRELSA ORAL TABLET

100 MG

5 PA; LA; QL (60/30);

NDS

CAPRELSA ORAL TABLET

300 MG

5 PA; LA; QL (30/30);

NDS

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

carboplatin intravenous

solution

4 B/D PA

carmustine intravenous recon

soln 100 mg

4 B/D PA

cisplatin intravenous solution 4 B/D PA

cladribine 4 B/D PA

clofarabine 4 B/D PA

COLUMVI 5 PA; QL (30/21);

NDS

COMETRIQ ORAL CAPSULE

100 MG/DAY (80 MG

X1-20 MG X1)

5 PA; QL (56/28);

NDS

COMETRIQ ORAL CAPSULE

140 MG/DAY (80 MG

X1-20 MG X3)

5 PA; QL (112/28);

NDS

COMETRIQ ORAL CAPSULE

60 MG/DAY (20 MG X 3/DAY)

5 PA; QL (84/28);

NDS

COPIKTRA 5 PA; LA; QL (60/30);

NDS

COTELLIC 5 PA; LA; QL (63/28);

NDS

cyclophosphamide intravenous

recon soln

5 B/D PA; NDS

CYCLOPHOSPHAMIDE

INTRAVENOUS SOLUTION

5 B/D PA; NDS

cyclophosphamide oral capsule 3 B/D PA

cyclophosphamide oral tablet

25 mg

3 B/D PA

CYCLOPHOSPHAMIDE ORAL

TABLET 50 MG

3 B/D PA

cyclosporine intravenous 4 B/D PA

cyclosporine modied 4 B/D PA

cyclosporine oral capsule 4 B/D PA

CYRAMZA 5 PA; NDS

cytarabine 4 B/D PA

cytarabine (pf) 4 B/D PA

dacarbazine 4 B/D PA

dactinomycin 4 B/D PA

DANYELZA 4 PA

DARZALEX 5 PA; NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

DARZALEX FASPRO 5 PA; NDS

daunorubicin 4 B/D PA

DAURISMO ORAL TABLET

100 MG

5 PA; QL (30/30);

NDS

DAURISMO ORAL TABLET

25 MG

5 PA; QL (60/30);

NDS

decitabine 4 B/D PA

docetaxel 4 B/D PA

doxorubicin intravenous recon

soln 50 mg

4 B/D PA

doxorubicin intravenous

solution

4 B/D PA

doxorubicin, peg-liposomal 4 B/D PA

DROXIA 4

ELREXFIO 5 PA; NDS

ELZONRIS 5 PA; NDS

EMPLICITI 4 PA

ENHERTU 5 PA; NDS

ENVARSUS XR 4 B/D PA

epirubicin intravenous solution 4 B/D PA

EPKINLY 4 PA

ERBITUX 4 B/D PA

eribulin 5 PA; NDS

ERIVEDGE 5 PA; QL (30/30);

NDS

ERLEADA 5 PA; QL (120/30);

NDS

erlotinib oral tablet 100 mg,

150 mg

5 PA; QL (30/30);

NDS

erlotinib oral tablet 25 mg 5 PA; QL (60/30);

NDS

ETOPOPHOS 4 B/D PA

etoposide intravenous 3 B/D PA

everolimus (antineoplastic) oral

tablet

5 PA; QL (30/30);

NDS

everolimus (antineoplastic) oral

tablet for suspension 2 mg

5 PA; QL (150/30);

NDS

everolimus (antineoplastic) oral

tablet for suspension 3 mg,

5 mg

5 PA; QL (56/28);

NDS

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

everolimus

(immunosuppressive) oral

tablet 0.25 mg

4 B/D PA

everolimus

(immunosuppressive) oral

tablet 0.5 mg, 0.75 mg, 1 mg

5 B/D PA; NDS

EVOMELA 5 PA; NDS

exemestane 4

FARYDAK 5 PA; QL (6/21); NDS

FIRMAGON KIT W DILUENT

SYRINGE

4 B/D PA

oxuridine 4 B/D PA

udarabine 4 B/D PA

uorouracil intravenous 4 B/D PA

FOLOTYN 5 B/D PA; NDS

FOTIVDA 5 PA; LA; QL (21/28);

NDS

FRUZAQLA ORAL CAPSULE

1 MG

5 PA; QL (84/28);

NDS

FRUZAQLA ORAL CAPSULE

5 MG

5 PA; QL (21/28);

NDS

fulvestrant 5 B/D PA; NDS

FYARRO 4 PA; LA

GAVRETO 5 PA; LA; QL

(120/30); NDS

GAZYVA 5 PA; NDS

getinib 5 PA; QL (30/30);

NDS

gemcitabine intravenous recon

soln

4 B/D PA

gemcitabine intravenous

solution 1 gram/26.3 ml

(38 mg/ml), 2 gram/52.6 ml

(38 mg/ml), 200 mg/5.26 ml

(38 mg/ml)

4 B/D PA

GEMCITABINE

INTRAVENOUS SOLUTION

100 MG/ML

4 B/D PA

gengraf 4 B/D PA

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

GILOTRIF 5 PA; QL (30/30);

NDS

GLEOSTINE 4

HALAVEN 5 PA; NDS

hydroxyurea 2

IBRANCE 5 PA; QL (21/28);

NDS

ICLUSIG 5 PA; QL (30/30);

NDS

idarubicin 4 B/D PA

IDHIFA 5 PA; LA; QL (30/30);

NDS

ifosfamide intravenous recon

soln 1 gram

4 B/D PA

IFOSFAMIDE INTRAVENOUS

RECON SOLN 3 GRAM

4 B/D PA

ifosfamide intravenous solution 4 B/D PA

imatinib oral tablet 100 mg 5 PA; QL (180/30);

NDS

imatinib oral tablet 400 mg 5 PA; QL (60/30);

NDS

IMBRUVICA ORAL CAPSULE

140 MG

5 PA; QL (120/30);

NDS

IMBRUVICA ORAL CAPSULE

70 MG

5 PA; QL (30/30);

NDS

IMBRUVICA ORAL

SUSPENSION

5 PA; QL (324/30);

NDS

IMBRUVICA ORAL TABLET

140 MG, 280 MG, 420 MG

5 PA; QL (30/30);

NDS

IMDELLTRA 4 PA

IMFINZI 5 PA; NDS

IMJUDO 5 PA; LA; NDS

INFUGEM 5 B/D PA; NDS

INLYTA ORAL TABLET 1 MG 5 PA; QL (180/30);

NDS

INLYTA ORAL TABLET 5 MG 5 PA; QL (120/30);

NDS

INQOVI 5 PA; QL (5/28); NDS

INREBIC 5 PA; LA; QL

(120/30); NDS

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

irinotecan 4 B/D PA

IWILFIN 5 PA; LA; QL

(240/30); NDS

IXEMPRA 4 B/D PA

JAKAFI 5 PA; QL (60/30);

NDS

JAYPIRCA 5 PA; NDS

JEMPERLI 4 PA

JEVTANA 4 B/D PA

JYLAMVO 5 PA; NDS

KADCYLA 5 PA; NDS

KANJINTI 5 PA; NDS

KEYTRUDA 5 PA; NDS

KIMMTRAK 4 PA

KISQALI FEMARA CO-PACK

ORAL TABLET 200 MG/

DAY(200 MG X 1)-2.5 MG

5 PA; QL (49/28);

NDS

KISQALI FEMARA CO-PACK

ORAL TABLET 400 MG/

DAY(200 MG X 2)-2.5 MG

5 PA; QL (70/28);

NDS

KISQALI FEMARA CO-PACK

ORAL TABLET 600 MG/

DAY(200 MG X 3)-2.5 MG

5 PA; QL (91/28);

NDS

KISQALI ORAL TABLET

200 MG/DAY (200 MG X 1)

5 PA; QL (21/28);

NDS

KISQALI ORAL TABLET

400 MG/DAY (200 MG X 2)

5 PA; QL (42/28);

NDS

KISQALI ORAL TABLET

600 MG/DAY (200 MG X 3)

5 PA; QL (63/28);

NDS

KLISYRI 4 ST; QL (5/30)

KOSELUGO ORAL CAPSULE

10 MG

5 PA; QL (240/30);

NDS

KOSELUGO ORAL CAPSULE

25 MG

5 PA; QL (120/30);

NDS

KRAZATI 5 PA; QL (180/30);

NDS

KYPROLIS 5 B/D PA; NDS

lapatinib 5 PA; QL (180/30);

NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

lenalidomide 5 PA; QL (28/28);

NDS

LENVIMA ORAL CAPSULE

10 MG/DAY (10 MG X 1), 4 MG

5 PA; QL (30/30);

NDS

LENVIMA ORAL CAPSULE

12 MG/DAY (4 MG X 3),

18 MG/DAY (10 MG X 1-4 MG

X2), 24 MG/DAY (10 MG X

2-4 MG X 1)

5 PA; QL (90/30);

NDS

LENVIMA ORAL CAPSULE

14 MG/DAY (10 MG X 1-4 MG

X 1), 20 MG/DAY (10 MG X 2),

8 MG/DAY (4 MG X 2)

5 PA; QL (60/30);

NDS

letrozole 2

LEUKERAN 4

leuprolide (3 month) 4 PA

leuprolide subcutaneous kit 4 PA

LIBTAYO 5 PA; NDS

LONSURF ORAL TABLET

15-6.14 MG

5 PA; QL (100/28);

NDS

LONSURF ORAL TABLET

20-8.19 MG

5 PA; QL (80/28);

NDS

LOQTORZI 5 PA; NDS

LORBRENA ORAL TABLET

100 MG

5 PA; QL (30/30);

NDS

LORBRENA ORAL TABLET

25 MG

5 PA; QL (90/30);

NDS

LUMAKRAS ORAL TABLET

120 MG

5 PA; QL (240/30);

NDS

LUMAKRAS ORAL TABLET

320 MG

5 PA; QL (90/30);

NDS

LUNSUMIO 5 PA; LA; NDS

LUPRON DEPOT 5 PA; NDS

LUPRON DEPOT (3 MONTH) 4 PA

LUPRON DEPOT (4 MONTH) 4 PA

LUPRON DEPOT (6 MONTH) 4 PA

LUPRON DEPOT-

PED (3 MONTH)

INTRAMUSCULAR SYRINGE

KIT 11.25 MG

4 PA

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

LUPRON DEPOT-

PED (3 MONTH)

INTRAMUSCULAR SYRINGE

KIT 30 MG

5 PA; NDS

LUPRON DEPOT-PED

INTRAMUSCULAR KIT

5 PA; NDS

LUPRON DEPOT-PED

INTRAMUSCULAR SYRINGE

KIT

4 PA

LYNPARZA 5 PA; QL (120/30);

NDS

LYSODREN 5 NDS

LYTGOBI ORAL TABLET

12 MG/DAY (4 MG X 3)

5 PA; LA; QL (90/30);

NDS

LYTGOBI ORAL TABLET

16 MG/DAY (4 MG X 4)

5 PA; LA; QL

(120/30); NDS

LYTGOBI ORAL TABLET

20 MG/DAY (4 MG X 5)

5 PA; LA; QL

(150/30); NDS

MARGENZA 5 PA; NDS

MATULANE 5 NDS

megestrol oral suspension

400 mg/10 ml (10 ml),

400 mg/10 ml (40 mg/ml),

800 mg/20 ml (20 ml)

4 PA

megestrol oral tablet 20 mg 4 PA

megestrol oral tablet 40 mg 3 PA

MEKINIST ORAL RECON

SOLN

5 PA; QL (1350/30);

NDS

MEKINIST ORAL TABLET

0.5 MG

5 PA; QL (90/30);

NDS

MEKINIST ORAL TABLET

2 MG

5 PA; QL (30/30);

NDS

MEKTOVI 5 PA; LA; QL

(180/30); NDS

melphalan hcl 5 B/D PA; NDS

mercaptopurine 4

methotrexate sodium (pf) 4 B/D PA

methotrexate sodium injection 4 B/D PA

methotrexate sodium oral 3

mitomycin intravenous 4 B/D PA

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

mitoxantrone 4 B/D PA

MONJUVI 4 PA

MVASI 5 PA; NDS

mycophenolate mofetil (hcl) 4 B/D PA

mycophenolate mofetil oral

capsule

3 B/D PA

mycophenolate mofetil oral

suspension for reconstitution

5 B/D PA; NDS

mycophenolate mofetil oral

tablet

4 B/D PA

mycophenolate sodium 4 B/D PA

MYLOTARG 5 PA; NDS

nelarabine 4 B/D PA

NERLYNX 5 PA; LA; NDS

NEXAVAR 5 PA; QL (120/30);

NDS

nilutamide 5 NDS

NINLARO 5 PA; QL (3/28); NDS

NIPENT 4 B/D PA

NUBEQA 5 PA; LA; QL

(120/30); NDS

NULOJIX 5 B/D PA; NDS

octreotide acetate 4 PA

ODOMZO 5 PA; LA; QL (30/30);

NDS

OGIVRI 5 PA; NDS

OJEMDA ORAL TABLET

400 MG/WEEK (100 MG X 4)

5 PA; QL (16/28);

NDS

OJEMDA ORAL TABLET

500 MG/WEEK (100 MG X 5)

5 PA; QL (20/28);

NDS

OJEMDA ORAL TABLET

600 MG/WEEK (100 MG X 6)

5 PA; QL (24/28);

NDS

OJJAARA 5 PA; QL (30/30);

NDS

ONCASPAR 4 B/D PA

ONIVYDE 4 PA

ONUREG 4 PA; QL (14/28)

OPDIVO 5 PA; NDS

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

OPDUALAG 4 PA

ORGOVYX 4 PA; LA; QL (30/28)

ORSERDU 5 PA; NDS

oxaliplatin 4 B/D PA

paclitaxel 4 B/D PA

PACLITAXEL PROTEIN-

BOUND

5 PA; NDS

PADCEV 4 PA

pazopanib 5 PA; QL (120/30);

NDS

PEMAZYRE 5 PA; LA; QL (14/21);

NDS

pemetrexed disodium

intravenous recon soln

5 PA; NDS

PERJETA 5 PA; NDS

PHESGO 5 PA; NDS

PIQRAY 5 PA; NDS

POLIVY 5 PA; NDS

POMALYST 5 PA; LA; QL (21/28);

NDS

PORTRAZZA 4 B/D PA

POTELIGEO 5 PA; NDS

PRALATREXATE 5 B/D PA; NDS

PROGRAF INTRAVENOUS 4 B/D PA

PROGRAF ORAL GRANULES

IN PACKET

4 B/D PA

PURIXAN 4

QINLOCK 5 PA; LA; QL (90/30);

NDS

RETEVMO ORAL CAPSULE

40 MG

5 PA; LA; QL

(180/30); NDS

RETEVMO ORAL CAPSULE

80 MG

5 PA; LA; QL

(120/30); NDS

REZLIDHIA 5 PA; QL (60/30);

NDS

REZUROCK 5 PA; LA; QL (30/30);

NDS

romidepsin intravenous recon

soln

5 PA; NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

ROMIDEPSIN INTRAVENOUS

SOLUTION

5 PA; NDS

ROZLYTREK ORAL CAPSULE

100 MG

5 PA; QL (150/30);

NDS

ROZLYTREK ORAL CAPSULE

200 MG

5 PA; QL (90/30);

NDS

ROZLYTREK ORAL PELLETS

IN PACKET

5 PA; QL (360/30);

NDS

RUBRACA 5 PA; LA; QL

(120/30); NDS

RUXIENCE 5 PA; NDS

RYBREVANT 4 PA

RYDAPT 5 PA; QL (224/28);

NDS

RYLAZE 4 B/D PA

SANDIMMUNE ORAL

SOLUTION

4 B/D PA

SARCLISA 4 PA

SCEMBLIX ORAL TABLET

100 MG

5 PA; QL (120/30);

NDS

SCEMBLIX ORAL TABLET

20 MG

5 PA; QL (600/30);

NDS

SCEMBLIX ORAL TABLET

40 MG

5 PA; QL (300/30);

NDS

SIGNIFOR 5 PA; NDS

SIMULECT 5 B/D PA; NDS

sirolimus 4 B/D PA

SOLTAMOX 4

SOMATULINE DEPOT 5 PA; NDS

sorafenib 5 PA; QL (120/30);

NDS

SPRYCEL ORAL TABLET

100 MG, 140 MG, 50 MG,

80 MG

5 PA; QL (30/30);

NDS

SPRYCEL ORAL TABLET

20 MG, 70 MG

5 PA; QL (60/30);

NDS

STIVARGA 5 PA; QL (84/28);

NDS

sunitinib malate 5 PA; QL (30/30);

NDS

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

TABLOID 4

TABRECTA 5 PA; NDS

tacrolimus oral capsule 4 B/D PA

TAFINLAR ORAL CAPSULE 5 PA; QL (120/30);

NDS

TAFINLAR ORAL TABLET

FOR SUSPENSION

5 PA; QL (840/28);

NDS

TAGRISSO 5 PA; LA; QL (30/30);

NDS

TALVEY 4 PA

TALZENNA ORAL CAPSULE

0.1 MG, 0.35 MG, 0.5 MG,

0.75 MG, 1 MG

5 PA; QL (30/30);

NDS

TALZENNA ORAL CAPSULE

0.25 MG

5 PA; QL (90/30);

NDS

tamoxifen 2

TASIGNA ORAL CAPSULE

150 MG, 200 MG

5 PA; QL (112/28);

NDS

TASIGNA ORAL CAPSULE

50 MG

5 PA; QL (120/30);

NDS

TAZVERIK 4 PA; LA

TECENTRIQ 5 PA; NDS

TECVAYLI 4 PA

TEMODAR INTRAVENOUS 4 B/D PA

temsirolimus 4 B/D PA

TEPMETKO 5 PA; LA; QL (60/30);

NDS

THALOMID ORAL CAPSULE

100 MG, 50 MG

5 PA; QL (28/28);

NDS

THALOMID ORAL CAPSULE

150 MG, 200 MG

5 PA; QL (56/28);

NDS

thiotepa 4 PA

TIBSOVO 5 PA; NDS

TIVDAK 4 PA

topotecan intravenous recon

soln

5 B/D PA; NDS

topotecan intravenous solution 4 B/D PA

toremifene 5 NDS

TRAZIMERA 5 PA; NDS

TREANDA 5 B/D PA; NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

TRELSTAR INTRAMUSCULAR

SUSPENSION FOR

RECONSTITUTION

4 PA

tretinoin (antineoplastic) 5 NDS

TRIPTODUR 4 PA; QL (1/168)

TRODELVY 4 PA

TRUQAP 5 PA; QL (64/28);

NDS

TRUXIMA 5 PA; NDS

TUKYSA ORAL TABLET

150 MG

5 PA; LA; QL

(120/30); NDS

TUKYSA ORAL TABLET

50 MG

5 PA; LA; QL

(300/30); NDS

TURALIO ORAL CAPSULE

125 MG

5 PA; LA; QL

(120/30); NDS

UNITUXIN 5 PA; NDS

valrubicin 4 B/D PA

VANFLYTA 5 PA; QL (56/28);

NDS

VECTIBIX 5 PA; NDS

VENCLEXTA ORAL TABLET

10 MG

4 PA; LA; QL (60/30)

VENCLEXTA ORAL TABLET

100 MG

5 PA; LA; QL

(120/30); NDS

VENCLEXTA ORAL TABLET

50 MG

5 PA; LA; QL (30/30);

NDS

VENCLEXTA STARTING PACK 5 PA; LA; QL

(84/365); NDS

VERZENIO 5 PA; LA; QL (60/30);

NDS

vinblastine 4 B/D PA

vincristine 4 B/D PA

vinorelbine 4 B/D PA

VITRAKVI ORAL CAPSULE

100 MG

5 PA; LA; QL (60/30);

NDS

VITRAKVI ORAL CAPSULE

25 MG

5 PA; LA; QL

(180/30); NDS

VITRAKVI ORAL SOLUTION 5 PA; LA; QL

(300/30); NDS

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

VIZIMPRO 5 PA; QL (30/30);

NDS

VONJO 5 PA; QL (120/30);

NDS

VOTRIENT 5 PA; QL (120/30);

NDS

VYXEOS 5 B/D PA; NDS

WELIREG 5 PA; LA; QL (90/30);

NDS

XALKORI ORAL CAPSULE 5 PA; QL (60/30);

NDS

XALKORI ORAL PELLET

150 MG

5 PA; QL (180/30);

NDS

XALKORI ORAL PELLET

20 MG, 50 MG

5 PA; QL (120/30);

NDS

XATMEP 4 PA

XERMELO 5 PA; LA; QL (84/28);

NDS

XOSPATA 5 PA; LA; NDS

XPOVIO 5 PA; LA; NDS

XTANDI ORAL CAPSULE 5 PA; QL (120/30);

NDS

XTANDI ORAL TABLET 40 MG 5 PA; QL (120/30);

NDS

XTANDI ORAL TABLET 80 MG 5 PA; QL (60/30);

NDS

YERVOY 5 PA; NDS

YONDELIS 5 PA; NDS

ZALTRAP 4 B/D PA

ZANOSAR 4 B/D PA

ZEJULA ORAL TABLET 5 PA; LA; QL (30/30);

NDS

ZELBORAF 5 PA; QL (240/30);

NDS

ZEPZELCA 4 PA

ZIRABEV 5 PA; NDS

ZOLADEX 4 B/D PA

ZOLINZA 5 PA; QL (120/30);

NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

ZYDELIG 5 PA; QL (60/30);

NDS

ZYKADIA 5 PA; QL (90/30);

NDS

ZYNLONTA 4 PA

ZYNYZ 5 PA; NDS

AUTONOMIC / CNS DRUGS, NEUROLOGY / PSYCH

ANTICONVULSANTS

APTIOM ORAL TABLET

200 MG

4 QL (180/30)

APTIOM ORAL TABLET

400 MG

4 QL (90/30)

APTIOM ORAL TABLET

600 MG, 800 MG

4 QL (60/30)

BRIVIACT INTRAVENOUS 4

BRIVIACT ORAL SOLUTION 4 QL (600/30)

BRIVIACT ORAL TABLET 4 QL (60/30)

carbamazepine oral capsule, er

multiphase 12 hr

carbamazepine oral

suspension 100 mg/5 ml

carbamazepine oral tablet 3

carbamazepine oral tablet

extended release 12 hr

carbamazepine oral tablet,

chewable

CELONTIN ORAL CAPSULE

300 MG

clobazam oral suspension 4 PA; QL (480/30)

clobazam oral tablet 10 mg 4 PA; QL (120/30)

clobazam oral tablet 20 mg 4 PA; QL (60/30)

clonazepam oral tablet 0.5 mg,

1 mg

2 QL (120/30)

clonazepam oral tablet 2 mg 2 QL (300/30)

clonazepam oral tablet,

disintegrating 0.125 mg,

0.25 mg

4 QL (90/30)

clonazepam oral tablet,

disintegrating 0.5 mg, 1 mg

4 QL (120/30)

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

clonazepam oral tablet,

disintegrating 2 mg

4 QL (300/30)

DIACOMIT 5 LA; NDS

diazepam rectal 4

dilantin 4

divalproex oral capsule,

delayed rel sprinkle

divalproex oral tablet extended

release 24 hr

divalproex oral tablet, delayed

release (dr/ec)

EPIDIOLEX 5 PA; LA; NDS

epitol 3

EPRONTIA 4 PA

ethosuximide 4

felbamate 4

FINTEPLA 4 PA; LA; QL (360/30)

fosphenytoin 3

FYCOMPA ORAL

SUSPENSION

4 QL (720/30)

FYCOMPA ORAL TABLET

10 MG, 12 MG, 8 MG

4 QL (30/30)

FYCOMPA ORAL TABLET

2 MG, 4 MG, 6 MG

4 QL (60/30)

gabapentin oral capsule

100 mg, 300 mg

2 QL (360/30)

gabapentin oral capsule

400 mg

2 QL (270/30)

gabapentin oral solution 4 QL (2160/30)

gabapentin oral tablet 600 mg 2 QL (180/30)

gabapentin oral tablet 800 mg 2 QL (120/30)

lacosamide intravenous 4 QL (1200/30)

lacosamide oral solution 4 QL (1200/30)

lacosamide oral tablet 100 mg,

150 mg, 200 mg

3 QL (60/30)

lacosamide oral tablet 50 mg 3 QL (120/30)

lamotrigine oral tablet 2

lamotrigine oral tablet,

chewable dispersible

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

lamotrigine oral tablets, dose

pack

levetiracetam in nacl

(iso-os) intravenous

piggyback 1,000 mg/100 ml,

1,500 mg/100 ml,

500 mg/100 ml

levetiracetam intravenous 3

levetiracetam oral solution 3

levetiracetam oral tablet

1,000 mg, 750 mg

levetiracetam oral tablet

250 mg, 500 mg

levetiracetam oral tablet

extended release 24 hr

LIBERVANT 5 PA; QL (10/30);

NDS

methsuximide 3

MOTPOLY XR ORAL

CAPSULE, EXTENDED

RELEASE 24HR 100 MG

4 ST; QL (120/30)

MOTPOLY XR ORAL

CAPSULE, EXTENDED

RELEASE 24HR 150 MG,

200 MG

5 ST; QL (60/30);

NDS

NAYZILAM 4 PA; QL (10/30)

oxcarbazepine oral suspension 4

oxcarbazepine oral tablet 3

phenobarbital oral elixir 4 PA; QL (1500/30)

phenobarbital oral tablet 4 PA; QL (120/30)

phenobarbital sodium injection

solution

phenytoin oral suspension 2

phenytoin oral tablet, chewable 3

phenytoin sodium extended

oral capsule 100 mg, 200 mg

phenytoin sodium extended

oral capsule 300 mg

phenytoin sodium intravenous

solution

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

pregabalin oral capsule

100 mg, 150 mg, 25 mg,

50 mg, 75 mg

4 QL (120/30)

pregabalin oral capsule 200 mg 4 QL (90/30)

pregabalin oral capsule

225 mg, 300 mg

4 QL (60/30)

pregabalin oral solution 3 QL (900/30)

primidone oral tablet 125 mg 4

primidone oral tablet 250 mg,

50 mg

roweepra oral tablet 500 mg 2

runamide oral suspension 5 PA; NDS

runamide oral tablet 3 PA

SPRITAM 4

subvenite 2

subvenite starter (blue) kit 2

subvenite starter (green) kit 2

subvenite starter (orange) kit 2

SYMPAZAN 5 PA; QL (60/30);

NDS

tiagabine 4

topiramate oral capsule,

sprinkle

3 PA

topiramate oral tablet 2 PA

valproate sodium 3

valproic acid 2

valproic acid (as sodium salt) 2

VALTOCO 4 PA; QL (10/30)

vigabatrin 5 PA; LA; QL

(180/30); NDS

vigadrone 5 PA; LA; QL

(180/30); NDS

vigpoder 5 PA; LA; QL

(180/30); NDS

XCOPRI MAINTENANCE

PACK ORAL TABLET 250MG/

DAY(150 MG X1-100MG

X1), 350 MG/DAY (200 MG

X1-150MG X1)

4 PA; QL (56/28)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

XCOPRI ORAL TABLET

100 MG

4 PA; QL (120/30)

XCOPRI ORAL TABLET

150 MG, 200 MG

4 PA; QL (60/30)

XCOPRI ORAL TABLET

25 MG

4 PA; QL (480/30)

XCOPRI ORAL TABLET

50 MG

4 PA; QL (240/30)

XCOPRI TITRATION PACK 4 PA; QL (56/365)

ZONISADE 5 PA; NDS

zonisamide oral capsule

100 mg

3 PA

zonisamide oral capsule

25 mg, 50 mg

2 PA

ZTALMY 4 PA; LA; QL

(1080/30)

ANTIPARKINSONISM AGENTS

benztropine injection 4

benztropine oral 2 PA

bromocriptine 4

carbidopa 4

carbidopa-levodopa oral tablet 2

carbidopa-levodopa oral tablet

extended release

carbidopa-levodopa oral tablet,

disintegrating

entacapone 4

GOCOVRI 4 ST

INBRIJA INHALATION

CAPSULE, W/INHALATION

DEVICE

5 PA; QL (300/30);

NDS

ONGENTYS 3

pramipexole oral tablet 2

rasagiline 4

ropinirole oral tablet 2

RYTARY 4 ST

selegiline hcl 3

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

MIGRAINE / CLUSTER HEADACHE THERAPY

AJOVY AUTOINJECTOR 3 PA; QL (1.5/30)

AJOVY SYRINGE 3 PA; QL (1.5/30)

dihydroergotamine nasal 4 PA; QL (8/28)

ergotamine-caffeine 3

naratriptan 3 QL (18/28)

NURTEC ODT 3 PA; QL (16/30)

rizatriptan oral tablet 3 QL (36/28)

rizatriptan oral tablet,

disintegrating

4 QL (36/28)

sumatriptan nasal spray,

non-aerosol 20 mg/actuation

4 QL (18/28)

sumatriptan nasal spray,

non-aerosol 5 mg/actuation

4 QL (36/28)

sumatriptan succinate oral 2 QL (18/28)

SUMATRIPTAN SUCCINATE

SUBCUTANEOUS

CARTRIDGE

4 QL (8/28)

sumatriptan succinate

subcutaneous pen injector

4 QL (8/28)

sumatriptan succinate

subcutaneous solution

4 QL (8/28)

MISCELLANEOUS NEUROLOGICAL THERAPY

ADLARITY 4 ST; QL (4/28)

AUSTEDO ORAL TABLET

12 MG, 9 MG

5 PA; LA; QL

(120/30); NDS

AUSTEDO ORAL TABLET

6 MG

5 PA; LA; QL (60/30);

NDS

AUSTEDO XR ORAL TABLET

EXTENDED RELEASE 24 HR

12 MG

5 PA; LA; QL

(120/30); NDS

AUSTEDO XR ORAL TABLET

EXTENDED RELEASE 24 HR

24 MG

5 PA; LA; QL (60/30);

NDS

AUSTEDO XR ORAL TABLET

EXTENDED RELEASE 24 HR

30 MG, 36 MG, 42 MG, 48 MG

5 PA; QL (30/30);

NDS

AUSTEDO XR ORAL TABLET

EXTENDED RELEASE 24 HR

6 MG

5 PA; LA; QL

(240/30); NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

AUSTEDO XR TITRATION

KT(WK1-4) ORAL TABLET, EXT

REL 24HR DOSE PACK 6 MG

(14)-12 MG (14)-24 MG (14)

5 PA; QL (84/365);

NDS

dalfampridine 3 PA; QL (60/30)

donepezil oral tablet 10 mg 2 QL (60/30)

donepezil oral tablet 5 mg 2 QL (30/30)

donepezil oral tablet,

disintegrating 10 mg

2 QL (60/30)

donepezil oral tablet,

disintegrating 5 mg

2 QL (30/30)

galantamine oral capsule, ext

rel. pellets 24 hr

4 QL (30/30)

galantamine oral solution 4 QL (200/30)

galantamine oral tablet 3 QL (60/30)

glatiramer subcutaneous

syringe 20 mg/ml

4 PA; QL (30/30)

glatiramer subcutaneous

syringe 40 mg/ml

4 PA; QL (12/28)

glatopa subcutaneous syringe

20 mg/ml

4 PA; QL (30/30)

glatopa subcutaneous syringe

40 mg/ml

4 PA; QL (12/28)

INGREZZA 5 PA; LA; QL (30/30);

NDS

INGREZZA INITIATION

PK(TARDIV)

5 PA; LA; QL

(56/365); NDS

KESIMPTA PEN 5 PA; QL (1.2/28);

NDS

memantine oral solution 4 PA; QL (300/30)

memantine oral tablet 10 mg 3 PA; QL (60/30)

memantine oral tablet 5 mg 3 PA; QL (90/30)

MEMANTINE ORAL TABLETS,

DOSE PACK

3 PA; QL (98/365)

NAMZARIC 3 PA

NUEDEXTA 5 PA; NDS

OCREVUS 4 PA

RADICAVA 4 PA

rivastigmine 4

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

rivastigmine tartrate 4 QL (60/30)

tetrabenazine oral tablet

12.5 mg

4 PA; QL (240/30)

tetrabenazine oral tablet 25 mg 4 PA; QL (120/30)

VUMERITY 5 PA; QL (120/30);

NDS

ZEPOSIA 5 PA; QL (30/30);

NDS

ZEPOSIA STARTER KIT

(28-DAY)

5 PA; QL (56/365);

NDS

ZEPOSIA STARTER PACK

(7-DAY)

5 PA; QL (14/365);

NDS

MUSCLE RELAXANTS / ANTISPASMODIC THERAPY

baclofen oral tablet 10 mg,

20 mg, 5 mg

BACLOFEN ORAL TABLET

15 MG

cyclobenzaprine oral tablet

10 mg, 5 mg

3 PA

dantrolene oral 4

methocarbamol oral tablet

500 mg, 750 mg

3 PA

pyridostigmine bromide oral

tablet 60 mg

pyridostigmine bromide oral

tablet extended release

tizanidine oral tablet 2

NARCOTIC ANALGESICS

acetaminophen-codeine oral

solution 120-12 mg/5 ml

3 QL (4500/30); NDS

acetaminophen-codeine oral

tablet 300-15 mg, 300-30 mg

3 QL (360/30); NDS

acetaminophen-codeine oral

tablet 300-60 mg

3 QL (180/30); NDS

buprenorphine hcl injection 4 NDS

buprenorphine hcl sublingual 3 PA

endocet 3 QL (360/30); NDS

fentanyl citrate buccal lozenge

on a handle 1,200 mcg,

1,600 mcg, 400 mcg, 600 mcg,

800 mcg

5 PA; QL (120/30);

NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

fentanyl citrate buccal lozenge

on a handle 200 mcg

4 PA; QL (120/30);

NDS

fentanyl transdermal patch 72

hour 100 mcg/hr, 12 mcg/hr,

25 mcg/hr, 50 mcg/hr, 75 mcg/hr

4 QL (10/30); NDS

hydrocodone-acetaminophen

oral solution 7.5-325 mg/15 ml

4 QL (5550/30); NDS

hydrocodone-acetaminophen

oral tablet 10-325 mg,

5-325 mg, 7.5-325 mg

3 QL (360/30); NDS

hydrocodone-ibuprofen oral

tablet 7.5-200 mg

4 QL (50/30); NDS

hydromorphone oral liquid 4 QL (2400/30); NDS

hydromorphone oral tablet 4 QL (180/30); NDS

INFUMORPH P/F 4 B/D PA; NDS

methadone injection solution 4 NDS

methadone intensol 4 QL (90/30); NDS

methadone oral concentrate 4 QL (90/30); NDS

methadone oral solution

10 mg/5 ml

4 QL (600/30); NDS

methadone oral solution

5 mg/5 ml

4 QL (1200/30); NDS

methadone oral tablet 10 mg 3 QL (120/30); NDS

methadone oral tablet 5 mg 3 QL (240/30); NDS

morphine (pf) injection solution

0.5 mg/ml, 1 mg/ml

4 NDS

morphine concentrate oral

solution

4 QL (900/30); NDS

MORPHINE INJECTION

SOLUTION

4 NDS

MORPHINE INJECTION

SYRINGE 2 MG/ML, 4 MG/ML

4 NDS

morphine intravenous solution

10 mg/ml, 4 mg/ml, 8 mg/ml

4 NDS

MORPHINE INTRAVENOUS

SYRINGE 10 MG/ML, 2 MG/

ML, 4 MG/ML

4 NDS

morphine oral solution 4 QL (900/30); NDS

morphine oral tablet 3 QL (180/30); NDS

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

morphine oral tablet extended

release

3 QL (120/30); NDS

oxycodone oral tablet 10 mg,

15 mg, 20 mg, 30 mg

3 QL (180/30); NDS

oxycodone oral tablet 5 mg 3 QL (360/30); NDS

oxycodone-acetaminophen oral

tablet 10-325 mg, 2.5-325 mg,

5-325 mg, 7.5-325 mg

3 QL (360/30); NDS

oxymorphone oral tablet

extended release 12 hr

4 QL (90/30); NDS

NON-NARCOTIC ANALGESICS

buprenorphine-naloxone

sublingual tablet 2-0.5 mg

2 QL (360/30)

buprenorphine-naloxone

sublingual tablet 8-2 mg

2 QL (90/30)

butorphanol nasal 4 QL (10/28); NDS

celecoxib 4 QL (60/30)

diclofenac potassium oral

tablet 50 mg

diclofenac sodium oral 2

diclofenac sodium topical drops 4 QL (300/28)

diclofenac sodium topical gel

3 QL (1000/28)

diunisal 4

EC-NAPROXEN ORAL

TABLET, DELAYED RELEASE

(DR/EC) 375 MG

ec-naproxen oral tablet,

delayed release (dr/ec) 500 mg

urbiprofen oral tablet 100 mg 2

ibu 1

ibuprofen oral suspension 4

ibuprofen oral tablet 400 mg,

600 mg, 800 mg

KLOXXADO 3

meloxicam oral tablet 15 mg 1

meloxicam oral tablet 7.5 mg 1 QL (60/30)

nabumetone 2

naloxone injection solution 2

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

naloxone injection syringe

1 mg/ml

naloxone nasal 3

naltrexone 3

naproxen oral suspension 4

naproxen oral tablet 1

naproxen oral tablet, delayed

release (dr/ec) 375 mg

naproxen oral tablet, delayed

release (dr/ec) 500 mg

naproxen sodium oral tablet

275 mg, 550 mg

oxaprozin oral tablet 4

sulindac 2

tramadol oral tablet 50 mg 2 QL (240/30); NDS

tramadol-acetaminophen 2 QL (240/30); NDS

VIVITROL 5 NDS

ZIMHI 4

ZUBSOLV SUBLINGUAL

TABLET 0.7-0.18 MG,

1.4-0.36 MG, 11.4-2.9 MG,

2.9-0.71 MG, 5.7-1.4 MG

3 QL (30/30); NDS

ZUBSOLV SUBLINGUAL

TABLET 8.6-2.1 MG

3 QL (60/30); NDS

PSYCHOTHERAPEUTIC DRUGS

ABILIFY ASIMTUFII

INTRAMUSCULAR

SUSPENSION, EXTENDED

REL SYRING 720 MG/2.4 ML

4 QL (2.4/56)

ABILIFY ASIMTUFII

INTRAMUSCULAR

SUSPENSION, EXTENDED

REL SYRING 960 MG/3.2 ML

4 QL (3.2/56)

ABILIFY MAINTENA 4 QL (1/28)

alprazolam oral tablet 0.25 mg,

0.5 mg, 1 mg

2 QL (120/30)

alprazolam oral tablet 2 mg 2 QL (150/30)

amitriptyline 4

amoxapine 3

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

aripiprazole oral solution 4

aripiprazole oral tablet 10 mg,

15 mg, 2 mg, 5 mg

4 QL (60/30)

aripiprazole oral tablet 20 mg,

30 mg

4 QL (30/30)

aripiprazole oral tablet,

disintegrating

4 QL (60/30)

ARISTADA INITIO 4 QL (4.8/365)

ARISTADA INTRAMUSCULAR

SUSPENSION, EXTENDED

REL SYRING 1,064 MG/3.9 ML

4 QL (3.9/56)

ARISTADA INTRAMUSCULAR

SUSPENSION, EXTENDED

REL SYRING 441 MG/1.6 ML

4 QL (1.6/28)

ARISTADA INTRAMUSCULAR

SUSPENSION, EXTENDED

REL SYRING 662 MG/2.4 ML

4 QL (2.4/28)

ARISTADA INTRAMUSCULAR

SUSPENSION, EXTENDED

REL SYRING 882 MG/3.2 ML

4 QL (3.2/28)

asenapine maleate sublingual

tablet 10 mg, 2.5 mg

4 QL (60/30)

asenapine maleate sublingual

tablet 5 mg

4 QL (90/30)

atomoxetine oral capsule

10 mg, 18 mg, 25 mg, 40 mg

4 QL (60/30)

atomoxetine oral capsule

100 mg, 60 mg, 80 mg

4 QL (30/30)

AUVELITY 4 ST; QL (60/30)

BELSOMRA 3 QL (30/30)

bupropion hcl oral tablet

100 mg

3 QL (120/30)

bupropion hcl oral tablet 75 mg 3 QL (180/30)

bupropion hcl oral tablet

extended release 24 hr 150 mg

3 QL (90/30)

bupropion hcl oral tablet

extended release 24 hr 300 mg

3 QL (30/30)

bupropion hcl oral tablet

sustained-release 12 hr

100 mg

3 QL (120/30)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

bupropion hcl oral tablet

sustained-release 12 hr

150 mg, 200 mg

3 QL (60/30)

buspirone 2

CAPLYTA 4 QL (30/30)

chlorpromazine 4

citalopram oral solution 4

citalopram oral tablet 10 mg,

20 mg

1 QL (60/30)

citalopram oral tablet 40 mg 1 QL (30/30)

clomipramine 4

clorazepate dipotassium oral

tablet 15 mg

4 QL (180/30)

clorazepate dipotassium oral

tablet 3.75 mg

4 QL (90/30)

clorazepate dipotassium oral

tablet 7.5 mg

4 QL (360/30)

clozapine oral tablet 100 mg,

200 mg

clozapine oral tablet 25 mg,

50 mg

clozapine oral tablet,

disintegrating

desipramine 4

desvenlafaxine succinate oral

tablet extended release 24 hr

100 mg

4 QL (120/30)

desvenlafaxine succinate oral

tablet extended release 24 hr

25 mg

4 QL (60/30)

desvenlafaxine succinate oral

tablet extended release 24 hr

50 mg

4 QL (90/30)

dexmethylphenidate oral tablet 3

dextroamphetamine sulfate

oral capsule, extended release

dextroamphetamine sulfate

oral tablet

dextroamphetamine-

amphetamine oral capsule,

extended release 24hr

4 QL (60/30)

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

dextroamphetamine-

amphetamine oral tablet 10 mg

3 QL (180/30)

dextroamphetamine-

amphetamine oral tablet

12.5 mg, 30 mg, 7.5 mg

3 QL (60/30)

dextroamphetamine-

amphetamine oral tablet 15 mg

3 QL (120/30)

dextroamphetamine-

amphetamine oral tablet 20 mg

3 QL (90/30)

dextroamphetamine-

amphetamine oral tablet 5 mg

3 QL (360/30)

diazepam injection 2

diazepam intensol 3 QL (360/30)

diazepam oral concentrate 3 QL (360/30)

diazepam oral solution 4 QL (1800/30)

diazepam oral tablet 2 QL (180/30)

doxepin oral capsule 4

doxepin oral concentrate 4

doxepin oral tablet 4 QL (30/30)

duloxetine oral capsule,

delayed release (dr/ec) 20 mg,

60 mg

3 QL (60/30)

duloxetine oral capsule,

delayed release (dr/ec) 30 mg

3 QL (120/30)

EMSAM 4 QL (30/30)

escitalopram oxalate oral

solution

4 QL (600/30)

escitalopram oxalate oral tablet

10 mg, 5 mg

2 QL (60/30)

escitalopram oxalate oral tablet

20 mg

2 QL (30/30)

FANAPT ORAL TABLET 1 MG,

10 MG, 12 MG, 2 MG, 4 MG,

6 MG

4 PA; QL (60/30)

FANAPT ORAL TABLET 8 MG 4 PA; QL (90/30)

FANAPT ORAL TABLETS,

DOSE PACK

4 PA; QL (16/365)

FETZIMA ORAL CAPSULE,

EXT REL 24HR DOSE PACK

20 MG (2)- 40 MG (26)

4 ST; QL (56/365)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

FETZIMA ORAL CAPSULE,

EXTENDED RELEASE 24 HR

4 ST; QL (30/30)

uoxetine oral capsule 10 mg 2 QL (120/30)

uoxetine oral capsule 20 mg,

40 mg

2 QL (90/30)

uoxetine oral solution 2

uphenazine decanoate 4

uphenazine hcl injection 4

uphenazine hcl oral

concentrate

uphenazine hcl oral elixir 4

uphenazine hcl oral tablet 3

uvoxamine oral tablet 100 mg 3 QL (90/30)

uvoxamine oral tablet 25 mg 2 QL (90/30)

uvoxamine oral tablet 50 mg 2 QL (120/30)

guanfacine oral tablet extended

release 24 hr

4 QL (30/30)

haloperidol decanoate 4

haloperidol lactate injection 4

haloperidol lactate oral 2

haloperidol oral tablet 0.5 mg,

2 mg, 20 mg

haloperidol oral tablet 1 mg,

10 mg, 5 mg

imipramine hcl 4

INVEGA HAFYERA

INTRAMUSCULAR SYRINGE

1,092 MG/3.5 ML

4 QL (3.5/180)

INVEGA HAFYERA

INTRAMUSCULAR SYRINGE

1,560 MG/5 ML

4 QL (5/180)

INVEGA SUSTENNA

INTRAMUSCULAR SYRINGE

117 MG/0.75 ML

4 QL (0.75/28)

INVEGA SUSTENNA

INTRAMUSCULAR SYRINGE

156 MG/ML

4 QL (1/28)

INVEGA SUSTENNA

INTRAMUSCULAR SYRINGE

234 MG/1.5 ML

4 QL (1.5/28)

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

INVEGA SUSTENNA

INTRAMUSCULAR SYRINGE

39 MG/0.25 ML

4 QL (0.25/28)

INVEGA SUSTENNA

INTRAMUSCULAR SYRINGE

78 MG/0.5 ML

4 QL (0.5/28)

INVEGA TRINZA

INTRAMUSCULAR SYRINGE

273 MG/0.88 ML

4 QL (0.88/90)

INVEGA TRINZA

INTRAMUSCULAR SYRINGE

410 MG/1.32 ML

4 QL (1.32/90)

INVEGA TRINZA

INTRAMUSCULAR SYRINGE

546 MG/1.75 ML

4 QL (1.75/90)

INVEGA TRINZA

INTRAMUSCULAR SYRINGE

819 MG/2.63 ML

4 QL (2.63/90)

lithium carbonate 2

lithium citrate 2

lorazepam injection solution 4

lorazepam injection syringe

2 mg/ml

lorazepam intensol 3 QL (150/30)

lorazepam oral concentrate 3 QL (150/30)

lorazepam oral syringe 3 QL (150/30)

lorazepam oral tablet 0.5 mg,

1 mg

2 QL (90/30)

lorazepam oral tablet 2 mg 2 QL (150/30)

loxapine succinate 4

lurasidone oral tablet 120 mg,

20 mg, 40 mg, 60 mg

4 QL (30/30)

lurasidone oral tablet 80 mg 4 QL (60/30)

MARPLAN 4 QL (180/30)

metadate er 4

methylphenidate hcl oral tablet 4 QL (90/30)

methylphenidate hcl oral tablet

extended release

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

methylphenidate hcl oral tablet

extended release 24hr 18 mg,

18 mg (bx rating), 27 mg,

27 mg (bx rating), 36 mg,

36 mg (bx rating), 54 mg,

54 mg (bx rating)

mirtazapine oral tablet 2

mirtazapine oral tablet,

disintegrating

3 QL (30/30)

modanil oral tablet 100 mg 3 PA; QL (30/30)

modanil oral tablet 200 mg 3 PA; QL (60/30)

molindone oral tablet 10 mg,

25 mg

molindone oral tablet 5 mg 4

nefazodone 4

nortriptyline oral capsule 2

nortriptyline oral solution 3

NUPLAZID 4 PA; QL (30/30)

olanzapine intramuscular 4 QL (30/30)

olanzapine oral tablet 10 mg,

2.5 mg, 5 mg, 7.5 mg

4 QL (60/30)

olanzapine oral tablet 15 mg,

20 mg

4 QL (30/30)

olanzapine oral tablet,

disintegrating 10 mg, 5 mg

4 QL (60/30)

olanzapine oral tablet,

disintegrating 15 mg, 20 mg

4 QL (30/30)

paliperidone oral tablet

extended release 24hr 1.5 mg,

9 mg

4 PA; QL (30/30)

paliperidone oral tablet

extended release 24hr 3 mg,

6 mg

4 PA; QL (60/30)

paroxetine hcl oral suspension 4 QL (900/30)

paroxetine hcl oral tablet 10 mg 2 QL (180/30)

paroxetine hcl oral tablet

20 mg, 40 mg

2 QL (30/30)

paroxetine hcl oral tablet 30 mg 2 QL (60/30)

perphenazine 4

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

perphenazine-amitriptyline 4

PERSERIS 4 QL (1/28)

phenelzine 3

pimozide 4

protriptyline 4

quetiapine oral tablet 100 mg,

25 mg, 50 mg

2 QL (120/30)

quetiapine oral tablet 150 mg,

200 mg

2 QL (90/30)

quetiapine oral tablet 300 mg,

400 mg

2 QL (60/30)

QUILLICHEW ER ORAL

TABLET, CHEW, IR-ER.

BIPHASIC24HR 20 MG,

30 MG

4 PA; QL (60/30)

QUILLICHEW ER ORAL

TABLET, CHEW, IR-ER.

BIPHASIC24HR 40 MG

4 PA; QL (30/30)

REXULTI ORAL TABLET 4 QL (30/30)

RISPERDAL CONSTA 4 QL (2/28)

risperidone oral solution 4

risperidone oral tablet 0.25 mg,

0.5 mg, 4 mg

2 QL (120/30)

risperidone oral tablet 1 mg 2 QL (180/30)

risperidone oral tablet 2 mg 2 QL (90/30)

risperidone oral tablet 3 mg 2 QL (60/30)

risperidone oral tablet,

disintegrating 0.25 mg, 0.5 mg,

4 mg

4 QL (120/30)

risperidone oral tablet,

disintegrating 1 mg

4 QL (180/30)

risperidone oral tablet,

disintegrating 2 mg

4 QL (90/30)

risperidone oral tablet,

disintegrating 3 mg

4 QL (60/30)

SECUADO 4 QL (30/30)

sertraline oral concentrate 4

sertraline oral tablet 1 QL (60/30)

SODIUM OXYBATE 5 PA; LA; QL

(540/30); NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

SPRAVATO NASAL SPRAY,

NON-AEROSOL 56 MG

(28 MG X 2)

4 PA; QL (16/28)

SPRAVATO NASAL SPRAY,

NON-AEROSOL 84 MG

(28 MG X 3)

4 PA; QL (18/28)

tasimelteon 5 PA; QL (30/30);

NDS

thioridazine 4

thiothixene 4

tranylcypromine 4

trazodone 2

triuoperazine oral tablet 1 mg 3

triuoperazine oral tablet

10 mg, 2 mg, 5 mg

trimipramine 4

TRINTELLIX 4 ST; QL (30/30)

UZEDY SUBCUTANEOUS

SUSPENSION, EXTENDED

REL SYRING 100 MG/0.28 ML

4 QL (0.28/28)

UZEDY SUBCUTANEOUS

SUSPENSION, EXTENDED

REL SYRING 125 MG/0.35 ML

4 QL (0.35/28)

UZEDY SUBCUTANEOUS

SUSPENSION, EXTENDED

REL SYRING 150 MG/0.42 ML

4 QL (0.42/56)

UZEDY SUBCUTANEOUS

SUSPENSION, EXTENDED

REL SYRING 200 MG/0.56 ML

4 QL (0.56/56)

UZEDY SUBCUTANEOUS

SUSPENSION, EXTENDED

REL SYRING 250 MG/0.7 ML

4 QL (0.7/56)

UZEDY SUBCUTANEOUS

SUSPENSION, EXTENDED

REL SYRING 50 MG/0.14 ML

4 QL (0.14/28)

UZEDY SUBCUTANEOUS

SUSPENSION, EXTENDED

REL SYRING 75 MG/0.21 ML

4 QL (0.21/28)

venlafaxine oral capsule,

extended release 24hr 150 mg,

37.5 mg

2 QL (60/30)

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

venlafaxine oral capsule,

extended release 24hr 75 mg

2 QL (90/30)

venlafaxine oral tablet 100 mg,

25 mg, 37.5 mg

2 QL (90/30)

venlafaxine oral tablet 50 mg,

75 mg

2 QL (120/30)

VERSACLOZ 4

vilazodone 4 QL (30/30)

VRAYLAR ORAL CAPSULE 4 QL (30/30)

ziprasidone hcl oral capsule

20 mg

4 QL (180/30)

ziprasidone hcl oral capsule

40 mg

4 QL (120/30)

ziprasidone hcl oral capsule

60 mg, 80 mg

4 QL (60/30)

ziprasidone mesylate 4 QL (6/30)

zolpidem oral tablet 2 QL (30/30)

ZURZUVAE 4 PA

ZYPREXA RELPREVV

INTRAMUSCULAR

SUSPENSION FOR

RECONSTITUTION 210 MG,

300 MG

4 PA; QL (2/28)

ZYPREXA RELPREVV

INTRAMUSCULAR

SUSPENSION FOR

RECONSTITUTION 405 MG

4 PA; QL (1/28)

CARDIOVASCULAR, HYPERTENSION / LIPIDS

ANTIARRHYTHMIC AGENTS

amiodarone intravenous

solution

4 B/D PA

amiodarone oral tablet 100 mg,

400 mg

amiodarone oral tablet 200 mg 2

dofetilide 4

ecainide 4

LIDOCAINE (PF)

INTRAVENOUS SOLUTION

lidocaine (pf) intravenous

syringe

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

mexiletine 4

pacerone oral tablet 100 mg,

400 mg

pacerone oral tablet 200 mg 2

propafenone 4

quinidine sulfate oral tablet 2

sorine oral tablet 120 mg,

160 mg

sotalol af 2

sotalol oral 2

SOTYLIZE 4

ANTIHYPERTENSIVE THERAPY

acebutolol 2

amiloride 2

amiloride-hydrochlorothiazide 2

amlodipine 1

amlodipine-benazepril 1

amlodipine-valsartan 1

amlodipine-valsartan-hcthiazid 3

atenolol 1

atenolol-chlorthalidone 2

benazepril 1

benazepril-hydrochlorothiazide 1

betaxolol oral 3

bisoprolol fumarate 2

bisoprolol-hydrochlorothiazide 1

bumetanide injection 4

bumetanide oral tablet 0.5 mg,

1 mg

bumetanide oral tablet 2 mg 3

candesartan oral tablet 16 mg,

4 mg, 8 mg

3 QL (60/30)

candesartan oral tablet 32 mg 3 QL (30/30)

candesartan-hydrochlorothiazid 3

captopril 4

cartia xt 3

carvedilol 1

chlorothiazide sodium 4

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

chlorthalidone oral tablet

25 mg, 50 mg

clonidine 4 QL (4/28)

clonidine hcl oral tablet 2

diltiazem hcl intravenous 4

diltiazem hcl oral capsule, ext.

rel 24h degradable

diltiazem hcl oral capsule,

extended release 12 hr

diltiazem hcl oral capsule,

extended release 24 hr

120 mg, 180 mg, 240 mg,

300 mg, 420 mg

diltiazem hcl oral capsule,

extended release 24hr 120 mg,

180 mg, 240 mg, 300 mg

diltiazem hcl oral tablet 2

diltiazem hcl oral tablet

extended release 24 hr

120 mg, 180 mg, 240 mg,

300 mg, 360 mg

DILTIAZEM HCL ORAL

TABLET EXTENDED

RELEASE 24 HR 420 MG

dilt-xr 3

doxazosin oral tablet 1 mg,

2 mg, 4 mg

2 QL (30/30)

doxazosin oral tablet 8 mg 2 QL (60/30)

EDARBI 4

EDARBYCLOR 4

enalapril maleate oral tablet 1

enalapril-hydrochlorothiazide 1

ethacrynate sodium 4

felodipine 2

fosinopril 1

fosinopril-hydrochlorothiazide 1

furosemide injection solution 4

furosemide oral solution 10 mg/

ml, 40 mg/5 ml (8 mg/ml)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

FUROSEMIDE ORAL

SOLUTION 40 MG/4 ML

furosemide oral tablet 1

hydralazine injection 4

hydralazine oral 1

hydrochlorothiazide 1

indapamide 2

irbesartan 1 QL (30/30)

irbesartan-hydrochlorothiazide 1 QL (30/30)

isosorbide-hydralazine 3 QL (180/30)

KERENDIA 3 PA; QL (30/30)

labetalol oral 1

lisinopril 1

lisinopril-hydrochlorothiazide 1

losartan 1 QL (60/30)

losartan-hydrochlorothiazide

oral tablet 100-12.5 mg,

100-25 mg

1 QL (30/30)

losartan-hydrochlorothiazide

oral tablet 50-12.5 mg

1 QL (60/30)

matzim la 3

metolazone 3

metoprolol succinate 2

metoprolol ta-hydrochlorothiaz 3

metoprolol tartrate oral tablet

100 mg, 25 mg, 50 mg

metyrosine 5 PA; NDS

minoxidil oral 2

moexipril 1

nicardipine intravenous

solution

nicardipine oral 4

nifedipine oral tablet extended

release

nifedipine oral tablet extended

release 24hr

nimodipine 4

olmesartan 1

olmesartan-hydrochlorothiazide 3

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

ORENITRAM 4 PA

ORENITRAM MONTH

1 TITRATION KT

4 PA

ORENITRAM MONTH

2 TITRATION KT

4 PA

ORENITRAM MONTH

3 TITRATION KT

4 PA

perindopril erbumine 1

pindolol 3

prazosin 4

propranolol oral capsule,

extended release 24 hr

propranolol oral solution 4

propranolol oral tablet 2

quinapril 1

quinapril-hydrochlorothiazide 2

ramipril 1

spironolactone oral tablet 2

spironolacton-hydrochlorothiaz 2

telmisartan 1

terazosin oral capsule 1 mg,

2 mg, 5 mg

1 QL (30/30)

terazosin oral capsule 10 mg 1 QL (60/30)

tiadylt er 3

timolol maleate oral 4

torsemide oral 2

trandolapril 1

triamterene-hydrochlorothiazid 1

valsartan oral tablet 160 mg,

40 mg, 80 mg

1 QL (60/30)

valsartan oral tablet 320 mg 1 QL (30/30)

valsartan-hydrochlorothiazide 1 QL (30/30)

verapamil intravenous solution 4

verapamil oral capsule, 24 hr

er pellet ct

verapamil oral capsule, ext rel.

pellets 24 hr 120 mg, 180 mg,

240 mg

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

VERAPAMIL ORAL CAPSULE,

EXT REL. PELLETS 24 HR

360 MG

verapamil oral tablet 2

verapamil oral tablet extended

release

COAGULATION THERAPY

aminocaproic acid oral 4

BRILINTA 4 QL (60/30)

cilostazol 2

clopidogrel oral tablet 300 mg 4

clopidogrel oral tablet 75 mg 1 QL (30/30)

dipyridamole oral 3

DOPTELET (10 TAB PACK) 5 PA; LA; NDS

DOPTELET (15 TAB PACK) 5 PA; LA; NDS

DOPTELET (30 TAB PACK) 5 PA; LA; NDS

ELIQUIS 3

ELIQUIS DVT-PE TREAT 30D

START

enoxaparin 4

fondaparinux 4

HEPARIN (PORCINE) IN 5%

DEX

heparin (porcine) in nacl (pf)

intravenous parenteral solution

heparin (porcine) injection

solution

HEPARIN(PORCINE) IN

0.45% NACL INTRAVENOUS

PARENTERAL SOLUTION

25,000 UNIT/250 ML,

25,000 UNIT/500 ML

heparin, porcine (pf) injection

syringe 5,000 unit/0.5 ml

jantoven 1

pentoxifylline 2

prasugrel 3

PROMACTA ORAL POWDER

IN PACKET 12.5 MG

5 PA; QL (360/30);

NDS

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

PROMACTA ORAL POWDER

IN PACKET 25 MG

5 PA; QL (180/30);

NDS

PROMACTA ORAL TABLET

12.5 MG, 25 MG, 50 MG

5 PA; LA; QL (30/30);

NDS

PROMACTA ORAL TABLET

75 MG

5 PA; LA; QL (60/30);

NDS

warfarin 1

XARELTO 3

XARELTO DVT-PE TREAT

30D START

LIPID/CHOLESTEROL LOWERING AGENTS

atorvastatin 1 QL (30/30)

cholestyramine (with sugar) 3

cholestyramine light 3

cholestyramine-aspartame 3

colestipol oral granules 4

colestipol oral packet 4

colestipol oral tablet 3

ezetimibe 2 QL (30/30)

ezetimibe-simvastatin 1 QL (30/30)

fenobrate micronized oral

capsule 134 mg, 200 mg,

67 mg

fenobrate nanocrystallized 2

fenobrate oral tablet 160 mg,

54 mg

fenobric acid (choline) 2

uvastatin oral capsule 20 mg 1 QL (30/30)

uvastatin oral capsule 40 mg 1 QL (60/30)

uvastatin oral tablet extended

release 24 hr

1 QL (30/30)

gembrozil 2

icosapent ethyl 4

lovastatin oral tablet 10 mg 1 QL (30/30)

lovastatin oral tablet 20 mg,

40 mg

1 QL (60/30)

NEXLETOL 3 PA; QL (30/30)

NEXLIZET 3 PA; QL (30/30)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

niacin oral tablet extended

release 24 hr

pitavastatin calcium 1 QL (30/30)

pravastatin 1 QL (30/30)

prevalite 3

REPATHA PUSHTRONEX 3 PA; QL (7/28)

REPATHA SURECLICK 3 PA; QL (6/28)

REPATHA SYRINGE 3 PA; QL (6/28)

rosuvastatin 1 QL (30/30)

simvastatin 1 QL (30/30)

MISCELLANEOUS CARDIOVASCULAR AGENTS

CORLANOR ORAL TABLET 4 PA; QL (60/30)

digoxin injection solution 4

digoxin oral solution 4

digoxin oral tablet 125 mcg

(0.125 mg), 250 mcg (0.25 mg)

digoxin oral tablet 62.5 mcg

(0.0625 mg)

ENTRESTO 3 QL (60/30)

LANOXIN PEDIATRIC 4

ranolazine 4 QL (60/30)

VERQUVO 3 PA; QL (30/30)

VYNDAQEL 4 PA

NITRATES

isosorbide dinitrate oral tablet

10 mg, 20 mg, 30 mg, 5 mg

isosorbide mononitrate 2

nitroglycerin intravenous 4 B/D PA

nitroglycerin sublingual 3

nitroglycerin transdermal patch

24 hour

nitroglycerin translingual 4

DERMATOLOGICALS/TOPICAL THERAPY

ANTIPSORIATIC / ANTISEBORRHEIC

acitretin 4 PA

calcipotriene scalp 3 QL (120/30)

calcipotriene topical cream 4 QL (120/30)

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

calcipotriene topical ointment 4 QL (120/30)

selenium sulde topical lotion 2

SKYRIZI SUBCUTANEOUS

PEN INJECTOR

5 PA; QL (2/28); NDS

SKYRIZI SUBCUTANEOUS

SYRINGE 150 MG/ML

5 PA; QL (2/28); NDS

STELARA SUBCUTANEOUS

SOLUTION

5 PA; QL (0.5/28);

NDS

STELARA SUBCUTANEOUS

SYRINGE 45 MG/0.5 ML

5 PA; QL (0.5/28);

NDS

STELARA SUBCUTANEOUS

SYRINGE 90 MG/ML

5 PA; QL (1/28); NDS

TALTZ AUTOINJECTOR 5 PA; QL (4/28); NDS

TALTZ SYRINGE 5 PA; QL (4/28); NDS

MISCELLANEOUS DERMATOLOGICALS

ammonium lactate 3

DUPIXENT PEN

SUBCUTANEOUS PEN

INJECTOR 200 MG/1.14 ML

5 PA; QL (4.56/28);

NDS

DUPIXENT PEN

SUBCUTANEOUS PEN

INJECTOR 300 MG/2 ML

5 PA; QL (8/28); NDS

DUPIXENT SYRINGE

SUBCUTANEOUS SYRINGE

100 MG/0.67 ML

5 PA; QL (1.34/28);

NDS

DUPIXENT SYRINGE

SUBCUTANEOUS SYRINGE

200 MG/1.14 ML

5 PA; QL (4.56/28);

NDS

DUPIXENT SYRINGE

SUBCUTANEOUS SYRINGE

300 MG/2 ML

5 PA; QL (8/28); NDS

uorouracil topical cream 5% 3

uorouracil topical solution 3

glydo 3 QL (60/30)

imiquimod topical cream in

packet 5%

lidocaine (pf) injection solution 4

lidocaine hcl injection solution 4

lidocaine hcl mucous

membrane solution 4%

(40 mg/ml)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

lidocaine topical adhesive

patch,medicated 5%

4 PA; QL (90/30)

lidocaine viscous 2

lidocaine-prilocaine topical

cream

4 QL (30/30)

methoxsalen 4

PANRETIN 5 NDS

podolox topical solution 4

REGRANEX 5 PA; NDS

SANTYL 4

SILVER SULFADIAZINE 3

SSD 3

tacrolimus topical 4 PA; QL (100/30)

VALCHLOR 5 PA; NDS

ZTLIDO 4 PA; QL (90/30)

THERAPY FOR ACNE

adapalene topical gel 0.3% 4 QL (45/30)

claravis 4

clindamycin phosphate topical

gel

4 QL (120/30)

clindamycin phosphate topical

gel, once daily

4 QL (120/30)

clindamycin phosphate topical

lotion

3 QL (120/30)

clindamycin phosphate topical

solution

4 QL (120/30)

clindamycin phosphate topical

swab

4 QL (60/30)

ery pads 4

erythromycin with ethanol

topical gel

erythromycin with ethanol

topical solution

erythromycin-benzoyl peroxide 4

isotretinoin oral capsule 10 mg,

20 mg, 30 mg, 40 mg

metronidazole topical 4

tazarotene topical cream 3 PA

tazarotene topical gel 4 PA

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

tretinoin microspheres topical

gel 0.1%

4 PA

tretinoin microspheres topical

gel with pump 0.1%

4 PA

tretinoin topical cream 4 PA

tretinoin topical gel 0.01% 3 PA

tretinoin topical gel 0.025%,

0.05%

4 PA

TOPICAL ANESTHETICS

lidocaine hcl laryngotracheal 3

lidocaine hcl mucous

membrane jelly in applicator

3 QL (60/30)

lidocaine hcl mucous

membrane solution 2%

TOPICAL ANTIBACTERIALS

gentamicin topical cream 4 QL (60/30)

gentamicin topical ointment 3

mupirocin 2 QL (44/30)

mupirocin calcium 4 QL (30/30)

sulfacetamide sodium (acne) 4

TOPICAL ANTIFUNGALS

ciclodan topical solution 4

ciclopirox topical cream 4 QL (90/28)

ciclopirox topical shampoo 4 QL (120/28)

ciclopirox topical solution 4 QL (6.6/28)

ciclopirox topical suspension 4 QL (60/28)

clotrimazole topical cream 3 QL (45/28)

clotrimazole topical solution 3 QL (30/28)

clotrimazole-betamethasone

topical cream

4 QL (45/28)

econazole 4 QL (85/28)

ketoconazole topical cream 2 QL (60/28)

ketoconazole topical shampoo 2 QL (120/28)

klayesta 3 QL (180/30)

nyamyc 3 QL (180/30)

nystatin topical cream 2 QL (30/28)

nystatin topical ointment 2 QL (30/28)

nystatin topical powder 3 QL (180/30)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

nystatin-triamcinolone 4 QL (60/28)

nystop 3 QL (180/30)

TOPICAL CORTICOSTEROIDS

ala-cort topical cream 1% 2

alclometasone 3

betamethasone dipropionate 4

betamethasone valerate topical

cream

betamethasone valerate topical

lotion

betamethasone valerate topical

ointment

betamethasone, augmented

topical cream

betamethasone, augmented

topical gel

betamethasone, augmented

topical lotion

betamethasone, augmented

topical ointment

desoximetasone topical cream 4

desoximetasone topical gel 4

desoximetasone topical

ointment

uocinolone and shower cap 4

uocinolone topical cream

0.01%

uocinolone topical cream

0.025%

uocinolone topical oil 4

uocinolone topical ointment 4

uocinolone topical solution 4

uocinonide topical cream

0.05%

3 QL (120/30)

uocinonide topical gel 4 QL (120/30)

uocinonide topical ointment 4 QL (120/30)

uocinonide topical solution 4 QL (120/30)

uticasone propionate topical

cream

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

uticasone propionate topical

ointment

halobetasol propionate topical

cream

halobetasol propionate topical

ointment

hydrocortisone topical cream

1%, 2.5%

hydrocortisone topical lotion

2.5%

hydrocortisone topical ointment

1%, 2.5%

mometasone topical 2

triamcinolone acetonide topical

cream

triamcinolone acetonide topical

lotion

triamcinolone acetonide topical

ointment 0.025%, 0.1%, 0.5%

triderm topical cream 0.1% 2

TOPICAL SCABICIDES / PEDICULICIDES

malathion 4

permethrin 3

DIAGNOSTICS / MISCELLANEOUS AGENTS

IRRIGATING SOLUTIONS

LACTATED RINGERS

IRRIGATION

neomycin-polymyxin b gu 4

RINGER'S IRRIGATION 4

TIS-U-SOL PENTALYTE 4

MISCELLANEOUS AGENTS

acamprosate 4

anagrelide 3

carglumic acid 5 PA; NDS

CHEMET 4 PA

CLINIMIX 4.25%/D5W SULFIT

FREE

4 B/D PA

CUVRIOR 5 PA; QL (300/30);

NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

D10%-0.45% SODIUM

CHLORIDE

d2.5%-0.45% sodium chloride 4

d5% and 0.9% sodium chloride 4

d5%-0.45% sodium chloride 4

deferasirox oral tablet 180 mg,

360 mg

5 PA; NDS

deferasirox oral tablet 90 mg 4 PA

DEXTROSE 10% AND 0.2%

NACL

dextrose 10% in water (d10w) 4

DEXTROSE 25% IN WATER

(D25W)

dextrose 5% in water (d5w)

intravenous parenteral solution

DEXTROSE 5% IN WATER

(D5W) INTRAVENOUS

PIGGYBACK

DEXTROSE 5%-LACTATED

RINGERS

dextrose 5%-0.2% sod chloride 4

dextrose 5%-0.3% sod.chloride 4

DEXTROSE 50% IN WATER

(D50W) INTRAVENOUS

PARENTERAL SOLUTION

dextrose 50% in water (d50w)

intravenous syringe

DEXTROSE 70% IN WATER

(D70W)

disulram 4

droxidopa oral capsule 100 mg 4 PA; QL (90/30)

droxidopa oral capsule 200 mg,

300 mg

4 PA; QL (180/30)

ENDARI 5 PA; QL (180/30);

NDS

GLASSIA 5 PA; LA; NDS

INCRELEX 4 PA; LA

kionex (with sorbitol) 3

levocarnitine (with sugar) 4

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

levocarnitine oral solution

100 mg/ml

LEVOCARNITINE ORAL

TABLET

midodrine 4

nitisinone 5 NDS

pilocarpine hcl oral 4

PROLASTIN-C

INTRAVENOUS SOLUTION

5 PA; LA; NDS

REZDIFFRA 5 PA; QL (30/30);

NDS

riluzole 3

SODIUM CHLORIDE 0.9%

INTRAVENOUS

SODIUM CHLORIDE

IRRIGATION

sodium phenylbutyrate 5 PA; NDS

sodium polystyrene sulfonate

oral powder

sps (with sorbitol) oral 3

trientine oral capsule 250 mg 5 PA; QL (240/30);

NDS

TZIELD 4 PA; LA; QL (14/720)

VELPHORO 3

VELTASSA 4

WATER FOR IRRIGATION,

STERILE

XIAFLEX 4 PA

zoledronic acid-mannitol-

water intravenous piggyback

5 mg/100 ml

4 B/D PA

SMOKING DETERRENTS

bupropion hcl (smoking deter) 3 QL (60/30)

NICOTROL 4

varenicline 4

EAR, NOSE / THROAT MEDICATIONS

MISCELLANEOUS AGENTS

azelastine nasal spray,

non-aerosol 137 mcg (0.1%)

3 QL (60/30)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

chlorhexidine gluconate

mucous membrane

uoride (sodium) dental 2

ipratropium bromide nasal

spray, non-aerosol 21 mcg

(0.03%)

2 QL (30/30)

ipratropium bromide nasal

spray, non-aerosol 42 mcg

(0.06%)

3 QL (30/30)

oralone 4

periogard 2

sodium uoride 5000 dry

mouth

sodium uoride 5000 plus 2

sodium uoride-pot nitrate 2

triamcinolone acetonide dental 4

MISCELLANEOUS OTIC PREPARATIONS

acetic acid otic (ear) 3

ac otic oil 4

uocinolone acetonide oil 4

hydrocortisone-acetic acid 4

ooxacin otic (ear) 4

OTIC STEROID / ANTIBIOTIC

ciprooxacin-dexamethasone 3

neomycin-polymyxin-hc otic

(ear)

ENDOCRINE/DIABETES

ADRENAL HORMONES

cortisone 4

DEPO-MEDROL 4

dexamethasone intensol 4

dexamethasone oral elixir 3

dexamethasone oral solution 3

dexamethasone oral tablet 2

dexamethasone sodium phos

(pf) injection solution 10 mg/ml

dexamethasone sodium

phosphate injection solution

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

udrocortisone 2

hydrocortisone oral 3

methylpred dp 2

methylprednisolone 2

methylprednisolone acetate 4

methylprednisolone sodium

succ injection recon soln

125 mg, 40 mg

methylprednisolone sodium

succ intravenous

prednisolone oral solution 4

prednisolone sodium

phosphate oral solution

15 mg/5 ml (3 mg/ml),

15 mg/5 ml (5 ml), 25 mg/5 ml

(5 mg/ml), 5 mg base/5 ml

(6.7 mg/5 ml)

prednisone intensol 4

prednisone oral solution 4

prednisone oral tablet 2

prednisone oral tablets, dose

pack

SOLU-CORTEF ACT-O-VIAL

(PF)

triamcinolone acetonide

injection suspension 40 mg/ml

ANTITHYROID AGENTS

methimazole oral tablet 10 mg,

5 mg

propylthiouracil 3

DIABETES THERAPY

acarbose oral tablet 100 mg 3 QL (90/30)

acarbose oral tablet 25 mg 3 QL (360/30)

acarbose oral tablet 50 mg 3 QL (180/30)

BAQSIMI 3

diazoxide 4

DROPLET MICRON PEN

NEEDLE

3 QL (200/30)

DROPLET PEN NEEDLE

NEEDLE 30 GAUGE X 5/16"

3 QL (200/30)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

DROPSAFE ALCOHOL PREP

PADS

DROPSAFE PEN NEEDLE

NEEDLE 31 GAUGE X 3/16"

3 QL (200/30)

glimepiride oral tablet 1 mg 1 QL (240/30)

glimepiride oral tablet 2 mg 1 QL (120/30)

glimepiride oral tablet 4 mg 1 QL (60/30)

glipizide oral tablet 10 mg 1 QL (120/30)

GLIPIZIDE ORAL TABLET

2.5 MG

3 QL (30/30)

glipizide oral tablet 5 mg 1 QL (240/30)

glipizide oral tablet extended

release 24hr 10 mg

1 QL (60/30)

glipizide oral tablet extended

release 24hr 2.5 mg

1 QL (240/30)

glipizide oral tablet extended

release 24hr 5 mg

1 QL (120/30)

glipizide-metformin oral tablet

2.5-250 mg

1 QL (240/30)

glipizide-metformin oral tablet

2.5-500 mg, 5-500 mg

1 QL (120/30)

GLUCAGON (HCL)

EMERGENCY KIT

glucagon emergency kit

(human)

GLYXAMBI 3 QL (30/30)

GVOKE 3

GVOKE HYPOPEN 1-PACK 3

GVOKE HYPOPEN 2-PACK 3

GVOKE PFS 1-PACK

SYRINGE SUBCUTANEOUS

SYRINGE 1 MG/0.2 ML

GVOKE PFS 2-PACK

SYRINGE SUBCUTANEOUS

SYRINGE 1 MG/0.2 ML

HUMALOG JUNIOR KWIKPEN

U-100

HUMALOG KWIKPEN

INSULIN

HUMALOG MIX

50-50 INSULIN U-100

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

HUMALOG MIX

50-50 KWIKPEN

HUMALOG MIX

75-25 KWIKPEN

HUMALOG MIX 75-25(U-100)

INSULIN

HUMALOG U-100 INSULIN 3

HUMULIN

70/30 U-100 INSULIN

HUMULIN

70/30 U-100 KWIKPEN

HUMULIN N NPH INSULIN

KWIKPEN

HUMULIN N NPH

U-100 INSULIN

HUMULIN R REGULAR

U-100 INSULIN

HUMULIN R U-500 (CONC)

INSULIN

5 NDS

HUMULIN R U-500 (CONC)

KWIKPEN

5 NDS

INSULIN LISPRO 3

INSULIN LISPRO PROTAMIN-

LISPRO

INVOKAMET 3 QL (60/30)

INVOKAMET XR 3 QL (60/30)

INVOKANA 3 QL (30/30)

JANUMET 3 QL (60/30)

JANUMET XR ORAL TABLET,

ER MULTIPHASE 24 HR

100-1,000 MG

3 QL (30/30)

JANUMET XR ORAL TABLET,

ER MULTIPHASE 24 HR

50-1,000 MG, 50-500 MG

3 QL (60/30)

JANUVIA 3 QL (30/30)

JARDIANCE 3 QL (30/30)

JENTADUETO 3 QL (60/30)

JENTADUETO XR ORAL

TABLET, IR - ER, BIPHASIC

24HR 2.5-1,000 MG

3 QL (60/30)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

JENTADUETO XR ORAL

TABLET, IR - ER, BIPHASIC

24HR 5-1,000 MG

3 QL (30/30)

LANTUS SOLOSTAR

U-100 INSULIN

LANTUS U-100 INSULIN 3

LYUMJEV KWIKPEN

U-100 INSULIN

LYUMJEV KWIKPEN

U-200 INSULIN

LYUMJEV U-100 INSULIN 3

metformin oral solution 4 QL (765/30)

metformin oral tablet 1,000 mg 1 QL (75/30)

metformin oral tablet 500 mg 1 QL (150/30)

metformin oral tablet 850 mg 1 QL (90/30)

metformin oral tablet extended

release 24 hr 500 mg

1 QL (120/30)

metformin oral tablet extended

release 24 hr 750 mg

1 QL (60/30)

MOUNJARO 3 PA; QL (2/28)

nateglinide oral tablet 120 mg 3 QL (90/30)

nateglinide oral tablet 60 mg 3 QL (180/30)

OMNIPOD 5 G6 INTRO KIT

(GEN 5)

3 QL (1/365)

OMNIPOD 5 G6 PODS (GEN

3 QL (20/30)

OMNIPOD CLASSIC PODS

(GEN 3)

3 QL (20/30)

OMNIPOD DASH INTRO KIT

(GEN 4)

3 QL (1/365)

OMNIPOD DASH PODS (GEN

3 QL (20/30)

OMNIPOD GO PODS 3 QL (10/30)

OMNIPOD GO PODS

10 UNITS/DAY

3 QL (10/30)

OMNIPOD GO PODS

15 UNITS/DAY

3 QL (10/30)

OMNIPOD GO PODS

20 UNITS/DAY

3 QL (10/30)

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

OMNIPOD GO PODS

25 UNITS/DAY

3 QL (10/30)

OMNIPOD GO PODS

30 UNITS/DAY

3 QL (10/30)

OMNIPOD GO PODS

40 UNITS/DAY

3 QL (10/30)

OZEMPIC SUBCUTANEOUS

PEN INJECTOR 0.25 MG OR

0.5 MG (2 MG/3 ML), 1 MG/

DOSE (4 MG/3 ML), 2 MG/

DOSE (8 MG/3 ML)

3 PA; QL (3/28)

PENTIPS 3 QL (200/30)

pioglitazone 1 QL (30/30)

repaglinide oral tablet 0.5 mg 4 QL (960/30)

repaglinide oral tablet 1 mg 4 QL (480/30)

repaglinide oral tablet 2 mg 4 QL (240/30)

RYBELSUS 3 PA; QL (30/30)

SOLIQUA 100/33 3 QL (15/25)

SYNJARDY 3 QL (60/30)

SYNJARDY XR ORAL

TABLET, IR - ER, BIPHASIC

24HR 10-1,000 MG,

12.5-1,000 MG, 5-1,000 MG

3 QL (60/30)

SYNJARDY XR ORAL

TABLET, IR - ER, BIPHASIC

24HR 25-1,000 MG

3 QL (30/30)

TOUJEO MAX

U-300 SOLOSTAR

TOUJEO SOLOSTAR

U-300 INSULIN

TRADJENTA 3 QL (30/30)

TRESIBA FLEXTOUCH U-100 3

TRESIBA FLEXTOUCH U-200 3

TRESIBA U-100 INSULIN 3

TRIJARDY XR ORAL TABLET,

IR - ER, BIPHASIC 24HR 10-5-

1,000 MG, 25-5-1,000 MG

3 QL (30/30)

TRIJARDY XR ORAL

TABLET, IR - ER, BIPHASIC

24HR 12.5-2.5-1,000 MG,

5-2.5-1,000 MG

3 QL (60/30)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

TRUEPLUS INSULIN 3 QL (200/30)

TRUEPLUS PEN NEEDLE 3 QL (200/30)

TRULICITY 3 PA; QL (2/28)

UNIFINE PENTIPS MAXFLOW 3 QL (200/30)

UNIFINE PENTIPS NEEDLE

29 GAUGE X 1/2", 31 GAUGE

X 1/4", 31 GAUGE X

3/16", 31 GAUGE X 5/16",

32 GAUGE X 1/4", 32 GAUGE

X 5/32", 33 GAUGE X 5/32"

3 QL (200/30)

UNIFINE PENTIPS PLUS 3 QL (200/30)

UNIFINE PENTIPS PLUS

MAXFLOW

3 QL (200/30)

UNIFINE SAFECONTROL 3 QL (200/30)

UNIFINE ULTRA PEN

NEEDLE

3 QL (200/30)

V-GO 20 3

V-GO 30 3

V-GO 40 3

XULTOPHY 100/3.6 3 QL (15/30)

MISCELLANEOUS HORMONES

ALDURAZYME 5 PA; NDS

cabergoline 3

calcitonin (salmon) nasal 3

calcitriol intravenous solution

1 mcg/ml

calcitriol oral capsule 2

calcitriol oral solution 3

CEREZYME INTRAVENOUS

RECON SOLN 400 UNIT

5 PA; NDS

CHORIONIC

GONADOTROPIN, HUMAN

INTRAMUSCULAR

4 PA

cinacalcet oral tablet 30 mg,

60 mg

4 QL (60/30)

cinacalcet oral tablet 90 mg 4 QL (120/30)

danazol 4

desmopressin injection 4

desmopressin nasal spray with

pump

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

desmopressin nasal spray,

non-aerosol 10 mcg/spray

(0.1 ml)

desmopressin oral 3

doxercalciferol 4

ELAPRASE 5 PA; NDS

FABRAZYME 5 NDS

KORLYM 5 PA; QL (120/30);

NDS

LUMIZYME 5 PA; NDS

mifepristone oral tablet 300 mg 5 PA; QL (120/30);

NDS

miglustat 5 LA; NDS

NAGLAZYME 5 PA; NDS

pamidronate 4

paricalcitol oral 4

RAYALDEE 5 NDS

sapropterin 5 PA; NDS

SOMAVERT 5 PA; QL (30/30);

NDS

SYNAREL 4

testosterone cypionate 3

testosterone enanthate 4

testosterone transdermal gel 4 PA; QL (300/30)

testosterone transdermal gel in

metered-dose pump 12.5 mg/

1.25 gram (1%)

4 PA; QL (300/30)

testosterone transdermal gel

in packet 1% (25 mg/2.5gram),

1% (50 mg/5 gram)

4 PA; QL (300/30)

TOLVAPTAN ORAL TABLET

15 MG

5 PA; QL (120/30);

NDS

tolvaptan oral tablet 30 mg 5 PA; QL (60/30);

NDS

zoledronic acid intravenous

solution

4 B/D PA

zoledronic acid-mannitol-

water intravenous piggyback

4 mg/100 ml

4 B/D PA

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

ZOLEDRONIC AC-MANNITOL-

0.9NACL

4 B/D PA

THYROID HORMONES

euthyrox 2

levothyroxine oral tablet 2

LEVOXYL ORAL TABLET

100 MCG, 112 MCG,

125 MCG, 137 MCG,

150 MCG, 175 MCG,

200 MCG, 25 MCG, 50 MCG,

75 MCG, 88 MCG

liothyronine oral 3

SYNTHROID 4

UNITHROID 4

GASTROENTEROLOGY

ANTIDIARRHEALS / ANTISPASMODICS

dicyclomine oral capsule 2

dicyclomine oral solution 4

dicyclomine oral tablet 2

diphenoxylate-atropine 4

glycopyrrolate (pf) 4

glycopyrrolate (pf) in water

injection

glycopyrrolate (pf) in

water intravenous syringe

0.4 mg/2 ml (0.2 mg/ml)

glycopyrrolate oral tablet 1 mg,

2 mg

loperamide oral capsule 2

MISCELLANEOUS GASTROINTESTINAL AGENTS

alosetron 4 PA

aprepitant 4 B/D PA

balsalazide 4

betaine 5 NDS

budesonide oral 4

CLENPIQ 4

compro 4

constulose 2

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

CORTIFOAM 4

cromolyn oral 3

dronabinol 4 B/D PA; QL (60/30)

enulose 2

GATTEX 30-VIAL 5 PA; NDS

GATTEX ONE-VIAL 5 PA; NDS

gavilyte-c 2

gavilyte-n 2

generlac 2

granisetron hcl oral 3 B/D PA

hydrocortisone rectal 3

hydrocortisone topical cream

with perineal applicator

lactulose oral solution 2

LINZESS 3 QL (30/30)

meclizine oral tablet 12.5 mg,

25 mg

mesalamine oral capsule,

extended release 24hr

mesalamine rectal enema 4

mesalamine with cleansing

wipe

metoclopramide hcl oral

solution

metoclopramide hcl oral tablet 2

MOVANTIK 4 QL (30/30)

nitroglycerin rectal 4

OCALIVA 4 PA; LA; QL (30/30)

ondansetron hcl (pf) 4

ondansetron hcl intravenous 4

ondansetron hcl oral solution 4 B/D PA

ondansetron hcl oral tablet

4 mg, 8 mg

2 B/D PA

ondansetron oral tablet,

disintegrating 4 mg, 8 mg

2 B/D PA

palonosetron intravenous

solution 0.25 mg/5 ml

peg 3350-electrolytes 2

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

peg-electrolyte soln 2

prochlorperazine 4

prochlorperazine edisylate

injection solution 10 mg/2 ml

(5 mg/ml)

prochlorperazine maleate 2

procto-med hc 2

proctosol hc topical 2

proctozone-hc 2

RECTIV 4

REMICADE 5 PA; QL (20/30);

NDS

SANCUSO 5 NDS

scopolamine base 4 QL (10/30)

SKYRIZI INTRAVENOUS 5 PA; QL (30/180);

NDS

SKYRIZI SUBCUTANEOUS

WEARABLE INJECTOR

180 MG/1.2 ML (150 MG/ML)

5 PA; QL (1.2/56);

NDS

SKYRIZI SUBCUTANEOUS

WEARABLE INJECTOR

360 MG/2.4 ML (150 MG/ML)

5 PA; QL (2.4/56);

NDS

sodium, potassium, mag

sulfates oral recon soln

17.5-3.13-1.6 gram

SODIUM, POTASSIUM, MAG

SULFATES ORAL RECON

SOLN 17.5-3.13-1.6 GRAM

2 PACK (480ML)

SUCRAID 4 PA

SUFLAVE 4

sulfasalazine oral tablet 2

SULFASALAZINE ORAL

TABLET, DELAYED RELEASE

(DR/EC)

SUTAB 4

TRULANCE 4

ursodiol oral capsule 300 mg 3

ursodiol oral tablet 4

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

ZENPEP ORAL CAPSULE,

DELAYED RELEASE (DR/EC)

10,000-32,000 -42,000 UNIT,

15,000-47,000 -63,000 UNIT,

20,000-63,000- 84,000 UNIT,

25,000-79,000- 105,000 UNIT,

3,000-10,000 -14,000-UNIT,

40,000-126,000- 168,000 UNIT,

5,000-17,000- 24,000 UNIT,

60,000-189,600- 252,600 UNIT

ULCER THERAPY

famotidine oral suspension for

reconstitution

famotidine oral tablet 20 mg 4

famotidine oral tablet 40 mg 3

misoprostol 3

omeprazole oral capsule,

delayed release (dr/ec)

2 QL (60/30)

pantoprazole oral tablet,

delayed release (dr/ec)

2 QL (60/30)

sucralfate oral tablet 2

TALICIA 4 QL (168/180)

IMMUNOLOGY, VACCINES / BIOTECHNOLOGY

BIOTECHNOLOGY DRUGS

ACTIMMUNE 5 PA; NDS

ARCALYST 5 PA; NDS

AVONEX 5 PA; QL (1/28); NDS

BESREMI 5 PA; LA; QL (2/28);

NDS

BETASERON

SUBCUTANEOUS KIT

5 PA; QL (14/28);

NDS

GENOTROPIN 5 PA; NDS

GENOTROPIN MINIQUICK 5 PA; NDS

NIVESTYM 5 PA; NDS

PEGASYS SUBCUTANEOUS

SOLUTION

5 PA; QL (4/28); NDS

PEGASYS SUBCUTANEOUS

SYRINGE

5 PA; QL (2/28); NDS

PLERIXAFOR 5 B/D PA; NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

PROCRIT 4 PA

RETACRIT 4 PA

ZIEXTENZO 4 PA

VACCINES / MISCELLANEOUS IMMUNOLOGICALS

ABRYSVO (PF) 3 PA; V; QL (1/365)

ACTHIB (PF) 3

ADACEL(TDAP ADOLESN/

ADULT)(PF)

3 V

AREXVY (PF) 3 PA; V; QL (1/365)

ATGAM 4 B/D PA

BCG VACCINE, LIVE (PF) 4 V

BEXSERO 3 V

BOOSTRIX TDAP 3 V

BOTOX 4 PA

DAPTACEL (DTAP

PEDIATRIC) (PF)

DENGVAXIA (PF) 3

ENGERIX-B (PF) 3 B/D PA; V

ENGERIX-B PEDIATRIC (PF) 3 B/D PA; V

fomepizole 5 NDS

GARDASIL 9 (PF) 4 V

HAVRIX (PF)

INTRAMUSCULAR SYRINGE

1,440 ELISA UNIT/ML

3 V

HAVRIX (PF)

INTRAMUSCULAR SYRINGE

720 ELISA UNIT/0.5 ML

HEPLISAV-B (PF) 3 B/D PA; V

HIBERIX (PF) 3

HIZENTRA SUBCUTANEOUS

SOLUTION

4 B/D PA

IMOVAX RABIES VACCINE

(PF)

4 V

INFANRIX (DTAP) (PF) 3

IPOL 3 V

IXCHIQ (PF) 3 V

IXIARO (PF) 4 V

JYNNEOS (PF) 3 V

KINRIX (PF) 3

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

MENACTRA (PF)

INTRAMUSCULAR SOLUTION

3 V

MENQUADFI (PF) 3 V

MENVEO A-C-Y-W-135-DIP

(PF)

3 V

M-M-R II (PF) 3 V

MRESVIA (PF) 3 PA; V; QL (1/365)

PANZYGA 5 B/D PA; NDS

PEDIARIX (PF) 3

PEDVAX HIB (PF) 3

PENBRAYA (PF) 3 V

PENTACEL (PF)

INTRAMUSCULAR KIT

15LF-48MCG-62DU

-10 MCG/0.5ML

PREHEVBRIO (PF) 3 B/D PA; V

PRIORIX (PF) 3 V

PROQUAD (PF) 3

QUADRACEL (PF) 3

RABAVERT (PF) 3 V

RECOMBIVAX HB (PF) 3 B/D PA; V

ROTARIX 3

ROTATEQ VACCINE 3

SHINGRIX (PF) 3 V; QL (2/999)

STAMARIL (PF) 4 V

TDVAX 3 V

TENIVAC (PF) 3 V

TETANUS, DIPHTHERIA TOX

PED (PF)

TICE BCG 4 B/D PA

TICOVAC INTRAMUSCULAR

SYRINGE 1.2 MCG/0.25 ML

TICOVAC INTRAMUSCULAR

SYRINGE 2.4 MCG/0.5 ML

3 V

TRUMENBA 3 V

TWINRIX (PF) 3 V

TYPHIM VI 3 V

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

VAQTA (PF)

INTRAMUSCULAR

SUSPENSION 25 UNIT/0.5 ML

VAQTA (PF)

INTRAMUSCULAR

SUSPENSION 50 UNIT/ML

3 V

VAQTA (PF)

INTRAMUSCULAR SYRINGE

25 UNIT/0.5 ML

VAQTA (PF)

INTRAMUSCULAR SYRINGE

50 UNIT/ML

3 V

VARIVAX (PF) 3 V

VARIZIG 4

YF-VAX (PF) 3 V

MISCELLANEOUS SUPPLIES

ALCOHOL PADS 3

ASSURE ID INSULIN SAFETY

SYRINGE 1 ML 29 GAUGE X

1/2"

3 QL (200/30)

BD SAFETYGLIDE INSULIN

SYRINGE SYRINGE 1 ML

31 GAUGE X 15/64"

3 QL (200/30)

BD ULTRA-FINE MICRO PEN

NEEDLE

3 QL (200/30)

BD ULTRA-FINE MINI PEN

NEEDLE

3 QL (200/30)

BD ULTRA-FINE NANO PEN

NEEDLE

3 QL (200/30)

BD ULTRA-FINE SHORT PEN

NEEDLE

3 QL (200/30)

GAUZE PAD TOPICAL

BANDAGE 2 X 2 "

INSULIN SYRINGE-NEEDLE

U-100 SYRINGE 0.3 ML

29 GAUGE, 1 ML 29 GAUGE

X 1/2", 1/2 ML 28 GAUGE

3 QL (200/30)

PEN NEEDLE, DIABETIC

NEEDLE 29 GAUGE X 1/2"

3 QL (200/30)

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

TECHLITE INSULIN SYRINGE

SYRINGE 1 ML 30 GAUGE

X 1/2", 1 ML 31 GAUGE X

15/64", 1 ML 31 GAUGE X

5/16

3 QL (200/30)

TECHLITE INSULIN

SYR(HALF UNIT) SYRINGE

0.3 ML 31 GAUGE X 15/64",

0.3 ML 31 GAUGE X 5/16",

0.5 ML 30 GAUGE X 1/2",

0.5 ML 31 GAUGE X 15/64",

0.5 ML 31 GAUGE X 5/16"

3 QL (200/30)

TECHLITE PEN NEEDLE

NEEDLE 29 GAUGE X

1/2", 31 GAUGE X 3/16",

31 GAUGE X 5/16",

32 GAUGE X 1/4", 32 GAUGE

X 5/32"

3 QL (200/30)

MUSCULOSKELETAL / RHEUMATOLOGY

GOUT THERAPY

allopurinol oral tablet 100 mg,

300 mg

colchicine oral tablet 3 QL (120/30)

febuxostat 4 ST

MITIGARE 3 QL (120/30)

probenecid 3

probenecid-colchicine 3

OSTEOPOROSIS THERAPY

alendronate oral tablet 10 mg 1 QL (30/30)

alendronate oral tablet 35 mg,

70 mg

2 QL (4/28)

FORTEO 5 PA; QL (2.4/28);

NDS

ibandronate oral 3 QL (1/28)

PROLIA 4 QL (1/180)

raloxifene 3 QL (30/30)

TYMLOS 5 PA; QL (1.56/30);

NDS

OTHER RHEUMATOLOGICALS

ADALIMUMAB-ADAZ 5 PA; QL (1.6/28);

NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

ADALIMUMAB-ADBM

SUBCUTANEOUS PEN

INJECTOR KIT (PREFERRED

NDCS STARTING WITH

00597)

5 PA; QL (4/28); NDS

ADALIMUMAB-ADBM

SUBCUTANEOUS SYRINGE

KIT 10 MG/0.2 ML,

20 MG/0.4 ML (PREFERRED

NDCS STARTING WITH

00597)

5 PA; QL (2/28); NDS

ADALIMUMAB-ADBM

SUBCUTANEOUS SYRINGE

KIT 40 MG/0.4 ML,

40 MG/0.8 ML (PREFERRED

NDCS STARTING WITH

00597)

5 PA; QL (4/28); NDS

ADALIMUMAB-ADBM(CF)

PEN CROHNS (PREFERRED

NDCS STARTING WITH

00597)

5 PA; QL (12/365);

NDS

ADALIMUMAB-ADBM(CF)

PEN PS-UV (PREFERRED

NDCS STARTING WITH

00597)

5 PA; QL (8/365);

NDS

BENLYSTA INTRAVENOUS 5 PA; NDS

CYLTEZO(CF) PEN 5 PA; QL (4/28); NDS

CYLTEZO(CF) PEN

CROHN'S-UC-HS

5 PA; QL (12/365);

NDS

CYLTEZO(CF) PEN

PSORIASIS-UV

5 PA; QL (8/365);

NDS

CYLTEZO(CF)

SUBCUTANEOUS SYRINGE

KIT 10 MG/0.2 ML,

20 MG/0.4 ML

5 PA; QL (2/28); NDS

CYLTEZO(CF)

SUBCUTANEOUS SYRINGE

KIT 40 MG/0.4 ML,

40 MG/0.8 ML

5 PA; QL (4/28); NDS

ENBREL MINI 5 PA; QL (8/28); NDS

ENBREL SUBCUTANEOUS

SOLUTION

5 PA; QL (8/28); NDS

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

ENBREL SUBCUTANEOUS

SYRINGE

5 PA; QL (8/28); NDS

ENBREL SURECLICK 5 PA; QL (8/28); NDS

HUMIRA PEN (PREFERRED

NDCS STARTING WITH

00074)

5 PA; QL (4/28); NDS

HUMIRA SUBCUTANEOUS

SYRINGE KIT 40 MG/0.8 ML

(PREFERRED NDCS

STARTING WITH 00074)

5 PA; QL (4/28); NDS

HUMIRA(CF) PEDI CROHNS

STARTER SUBCUTANEOUS

SYRINGE KIT 80 MG/0.8 ML

(PREFERRED NDCS

STARTING WITH 00074)

5 PA; QL (6/365);

NDS

HUMIRA(CF) PEDI CROHNS

STARTER SUBCUTANEOUS

SYRINGE KIT

80 MG/0.8 ML-40 MG/0.4 ML

(PREFERRED NDCS

STARTING WITH 00074)

5 PA; QL (4/365);

NDS

HUMIRA(CF) PEN CROHNS-

UC-HS (PREFERRED NDCS

STARTING WITH 00074)

5 PA; QL (6/365);

NDS

HUMIRA(CF) PEN PEDIATRIC

UC (PREFERRED NDCS

STARTING WITH 00074)

5 PA; QL (4/180);

NDS

HUMIRA(CF) PEN PSOR-

UV-ADOL HS (PREFERRED

NDCS STARTING WITH

00074)

5 PA; QL (6/365);

NDS

HUMIRA(CF) PEN

SUBCUTANEOUS PEN

INJECTOR KIT 40 MG/0.4 ML

(PREFERRED NDCS

STARTING WITH 00074)

5 PA; QL (4/28); NDS

HUMIRA(CF) PEN

SUBCUTANEOUS PEN

INJECTOR KIT 80 MG/0.8 ML

(PREFERRED NDCS

STARTING WITH 00074)

5 PA; QL (2/28); NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

HUMIRA(CF)

SUBCUTANEOUS SYRINGE

KIT 10 MG/0.1 ML,

20 MG/0.2 ML (PREFERRED

NDCS STARTING WITH

00074)

5 PA; QL (2/28); NDS

HUMIRA(CF)

SUBCUTANEOUS

SYRINGE KIT 40 MG/0.4 ML

(PREFERRED NDCS

STARTING WITH 00074)

5 PA; QL (4/28); NDS

HYRIMOZ PEN CROHN'S-UC

STARTER (PREFERRED

NDCS STARTING WITH

61314)

5 PA; QL (4.8/365);

NDS

HYRIMOZ PEN PSORIASIS

STARTER (PREFERRED

NDCS STARTING WITH

61314)

5 PA; QL (3.2/365);

NDS

HYRIMOZ(CF) PEDI CROHN

STARTER SUBCUTANEOUS

SYRINGE 80 MG/0.8 ML

(PREFERRED NDCS

STARTING WITH 61314)

5 PA; QL (3.2/365);

NDS

HYRIMOZ(CF) PEDI CROHN

STARTER SUBCUTANEOUS

SYRINGE 80 MG/0.8 ML-

40 MG/0.4 ML (PREFERRED

NDCS STARTING WITH

61314)

5 PA; QL (2.4/365);

NDS

HYRIMOZ(CF) PEN

(PREFERRED NDCS

STARTING WITH 61314)

5 PA; QL (1.6/28);

NDS

HYRIMOZ(CF)

SUBCUTANEOUS SYRINGE

10 MG/0.1 ML (PREFERRED

NDCS STARTING WITH

61314)

5 PA; QL (0.2/28);

NDS

HYRIMOZ(CF)

SUBCUTANEOUS SYRINGE

20 MG/0.2 ML (PREFERRED

NDCS STARTING WITH

61314)

5 PA; QL (0.4/28);

NDS

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

HYRIMOZ(CF)

SUBCUTANEOUS SYRINGE

40 MG/0.4 ML (PREFERRED

NDCS STARTING WITH

61314)

5 PA; QL (1.6/28);

NDS

leunomide 3 QL (30/30)

ORENCIA CLICKJECT 5 PA; QL (4/28); NDS

ORENCIA SUBCUTANEOUS

SYRINGE 125 MG/ML

5 PA; QL (4/28); NDS

ORENCIA SUBCUTANEOUS

SYRINGE 50 MG/0.4 ML

5 PA; QL (1.6/28);

NDS

ORENCIA SUBCUTANEOUS

SYRINGE 87.5 MG/0.7 ML

5 PA; QL (2.8/28);

NDS

OTEZLA 5 PA; QL (60/30);

NDS

OTEZLA STARTER ORAL

TABLETS, DOSE PACK 10 MG

(4)-20 MG (4)-30 MG (47)

5 PA; QL (110/365);

NDS

penicillamine 5 NDS

RINVOQ LQ 5 PA; QL (360/30);

NDS

RINVOQ ORAL TABLET

EXTENDED RELEASE 24 HR

15 MG, 30 MG

5 PA; QL (30/30);

NDS

RINVOQ ORAL TABLET

EXTENDED RELEASE 24 HR

45 MG

5 PA; QL (84/180);

NDS

OBSTETRICS / GYNECOLOGY

ESTROGENS / PROGESTINS

camila 4

deblitane 4

DEPO-SUBQ PROVERA 104 4

dotti 3 QL (8/28)

DUAVEE 4 PA

emzahh 4

errin 4

estradiol oral 2

estradiol transdermal patch

semiweekly

3 QL (8/28)

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

estradiol transdermal patch

weekly

3 QL (4/28)

estradiol vaginal 4

estradiol valerate 4

heather 4

incassia 4

jencycla 4

lyza 4

medroxyprogesterone

intramuscular

medroxyprogesterone oral 2

NORA-BE 4

norethindrone (contraceptive) 4

norethindrone acetate 4

PREMARIN INJECTION 4

PREMARIN ORAL 3

PREMARIN VAGINAL 3

PREMPRO 3

progesterone micronized 3

sharobel 4

yuvafem 4

MISCELLANEOUS OB/GYN

clindamycin phosphate vaginal 3

etonogestrel-ethinyl estradiol 4

metronidazole vaginal gel

0.75% (37.5mg/5 gram)

terconazole 4

tranexamic acid oral 3

VANDAZOLE 4

ORAL CONTRACEPTIVES / RELATED AGENTS

armelle 4

altavera (28) 4

alyacen 1/35 (28) 4

alyacen 7/7/7 (28) 4

amethia 4

amethyst (28) 4

apri 4

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

aranelle (28) 4

ashlyna 4

aubra eq 4

aurovela 1.5/30 (21) 4

aurovela 1/20 (21) 4

aurovela 24 fe 4

aurovela fe 1.5/30 (28) 4

aurovela fe 1-20 (28) 4

aviane 4

ayuna 4

azurette (28) 4

balziva (28) 4

blisovi 24 fe 4

blisovi fe 1.5/30 (28) 4

blisovi fe 1/20 (28) 4

briellyn 4

CAMRESE 4

CAMRESE LO 4

charlotte 24 fe 4

chateal eq (28) 4

cryselle (28) 4

cyred eq 4

dasetta 1/35 (28) 4

dasetta 7/7/7 (28) 4

daysee 4

desog-e. estradiol/e. estradiol 4

desogestrel-ethinyl estradiol 4

dolishale 4

drospirenone-e. estradiol-lm.

fa oral tablet 3-0.02-0.451 mg

(24) (4)

DROSPIRENONE-E.

ESTRADIOL-LM.FA ORAL

TABLET 3-0.03-0.451 MG (21)

(7)

drospirenone-ethinyl estradiol 4

elinest 4

enpresse 4

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

enskyce 4

estarylla 4

ethynodiol diac-eth estradiol 4

falmina (28) 4

nzala 4

gemmily 4

hailey 4

hailey 24 fe 4

hailey fe 1.5/30 (28) 4

hailey fe 1/20 (28) 4

iclevia 4

isibloom 4

jaimiess 4

jasmiel (28) 4

JOLESSA 4

joyeaux 4

juleber 4

junel 1.5/30 (21) 4

junel 1/20 (21) 4

junel fe 1.5/30 (28) 4

junel fe 1/20 (28) 4

junel fe 24 4

kaitlib fe 4

kalliga 4

kariva (28) 4

kelnor 1/35 (28) 4

kelnor 1-50 (28) 4

kurvelo (28) 4

l norgest/e. estradiol-e. estrad 4

larin 1.5/30 (21) 4

larin 1/20 (21) 4

larin 24 fe 4

larin fe 1.5/30 (28) 4

larin fe 1/20 (28) 4

LAYOLIS FE 4

leena 28 4

lessina 4

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

levonest (28) 4

levonorgest-eth.estradiol-iron 4

levonorgestrel-ethinyl estrad 4

levonorg-eth estrad triphasic 4

levora-28 4

lojaimiess 4

loryna (28) 4

low-ogestrel (28) 4

lo-zumandimine (28) 4

lutera (28) 4

marlissa (28) 4

merzee 4

microgestin 1.5/30 (21) 4

microgestin 1/20 (21) 4

microgestin fe 1.5/30 (28) 4

microgestin fe 1/20 (28) 4

mili 4

mono-linyah 4

necon 0.5/35 (28) 4

nikki (28) 4

noreth-ethinyl estradiol-iron 4

norethindrone ac-eth estradiol

oral tablet 1-20 mg-mcg,

1.5-30 mg-mcg

norethindrone-e. estradiol-iron 4

norgestimate-ethinyl estradiol 4

nortrel 0.5/35 (28) 4

nortrel 1/35 (21) 4

nortrel 1/35 (28) 4

nortrel 7/7/7 (28) 4

nylia 1/35 (28) 4

nylia 7/7/7 (28) 4

nymyo 4

ocella 4

philith 4

pimtrea (28) 4

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

portia 28 4

reclipsen (28) 4

RIVELSA 4

setlakin 4

simliya (28) 4

simpesse 4

sprintec (28) 4

sronyx 4

syeda 4

tarina 24 fe 4

tarina fe 1-20 eq (28) 4

tilia fe 4

tri-estarylla 4

tri-legest fe 4

tri-linyah 4

tri-lo-estarylla 4

tri-lo-marzia 4

tri-lo-mili 4

tri-lo-sprintec 4

tri-mili 4

tri-nymyo 4

tri-sprintec (28) 4

trivora (28) 4

tri-vylibra 4

tri-vylibra lo 4

turqoz (28) 4

TYBLUME 4

tydemy 4

velivet triphasic regimen (28) 4

vestura (28) 4

vienva 4

viorele (28) 4

volnea (28) 4

vyfemla (28) 4

vylibra 4

wera (28) 4

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

wymzya fe 4

zovia 1-35 (28) 4

zumandimine (28) 4

OPHTHALMOLOGY

ANTIBIOTICS

bacitracin ophthalmic (eye) 4

bacitracin-polymyxin b 2

BESIVANCE 4

ciprooxacin hcl ophthalmic

(eye)

erythromycin ophthalmic (eye) 2

gentamicin ophthalmic (eye)

drops

moxioxacin ophthalmic (eye) 3

NATACYN 4

neomycin-bacitracin-polymyxin 4

neomycin-polymyxin-gramicidin 3

ooxacin ophthalmic (eye) 2

polycin 2

polymyxin b sulf-trimethoprim 2

tobramycin ophthalmic (eye) 2

ANTIVIRALS

triuridine 3

zirgan 4

BETA-BLOCKERS

carteolol 2

levobunolol ophthalmic (eye)

drops 0.5%

timolol maleate ophthalmic

(eye) drops

timolol maleate ophthalmic

(eye) gel forming solution

MISCELLANEOUS OPHTHALMOLOGICS

atropine ophthalmic (eye)

drops 1%

azelastine ophthalmic (eye) 4

cromolyn ophthalmic (eye) 2

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

cyclosporine ophthalmic (eye) 4

CYSTARAN 5 PA; NDS

EYLEA 4 PA; QL (0.1/28)

MIEBO (PF) 3 QL (3/30)

OXERVATE 4 PA; QL (112/56)

pilocarpine hcl ophthalmic

(eye) drops 1%, 2%, 4%

sulfacetamide sodium

ophthalmic (eye) drops

sulfacetamide-prednisolone 2

XDEMVY 4 PA; QL (10/42)

XIIDRA 3 QL (60/30)

NON-STEROIDAL ANTI-INFLAMMATORY AGENTS

diclofenac sodium ophthalmic

(eye)

urbiprofen sodium 3

KETOROLAC OPHTHALMIC

(EYE) DROPS 0.4%

ketorolac ophthalmic (eye)

drops 0.5%

ORAL DRUGS FOR GLAUCOMA

acetazolamide oral capsule,

extended release

acetazolamide oral tablet 3

acetazolamide sodium 4

methazolamide 4

OTHER GLAUCOMA DRUGS

brimonidine-timolol 4

dorzolamide 2

dorzolamide-timolol 2

latanoprost 1

LUMIGAN OPHTHALMIC

(EYE) DROPS 0.01%

RHOPRESSA 4 ST

ROCKLATAN 4 ST

SIMBRINZA 4

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

STEROID-ANTIBIOTIC COMBINATIONS

neomycin-bacitracin-poly-hc 3

neomycin-polymyxin

b-dexameth

neomycin-polymyxin-hc

ophthalmic (eye)

TOBRADEX ST 3

tobramycin-dexamethasone 3

STEROIDS

dexamethasone sodium

phosphate ophthalmic (eye)

diuprednate 3

EYSUVIS 4 QL (16.6/30)

FLUOROMETHOLONE 3

LOTEMAX OPHTHALMIC

(EYE) OINTMENT

LOTEMAX SM 4

loteprednol etabonate 4

PREDNISOLONE ACETATE 3

prednisolone sodium

phosphate ophthalmic (eye)

SYMPATHOMIMETICS

ALPHAGAN P OPHTHALMIC

(EYE) DROPS 0.1%

apraclonidine 4

brimonidine ophthalmic (eye)

drops 0.1%

brimonidine ophthalmic (eye)

drops 0.15%

brimonidine ophthalmic (eye)

drops 0.2%

RESPIRATORY AND ALLERGY

ANTIHISTAMINE / ANTIALLERGENIC AGENTS

desloratadine oral tablet 3 QL (30/30)

diphenhydramine hcl injection

solution 50 mg/ml

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

EPINEPHRINE INJECTION

AUTO-INJECTOR

0.15 MG/0.15 ML,

0.3 MG/0.3 ML

3 QL (2/30)

epinephrine injection auto-

injector 0.15 mg/0.3 ml,

0.3 mg/0.3 ml

3 QL (2/30)

epinephrine injection solution

1 mg/ml

hydroxyzine hcl oral tablet 4 PA

hydroxyzine pamoate 3 PA

levocetirizine oral tablet 2 QL (30/30)

promethazine oral syrup 4 PA

promethazine oral tablet 2 PA

PULMONARY AGENTS

acetylcysteine 4 B/D PA

ADEMPAS 5 PA; LA; QL (90/30);

NDS

ADVAIR HFA 3 QL (12/30)

albuterol sulfate inhalation

hfa aerosol inhaler 90 mcg/

actuation

3 QL (17/30)

albuterol sulfate inhalation

hfa aerosol inhaler 90 mcg/

actuation (nda020503)

3 QL (13.4/30)

albuterol sulfate inhalation

hfa aerosol inhaler 90 mcg/

actuation (nda020983)

3 QL (36/30)

albuterol sulfate inhalation

solution for nebulization

2 B/D PA

albuterol sulfate oral syrup 2

albuterol sulfate oral tablet 4

ambrisentan 5 PA; LA; QL (30/30);

NDS

ANORO ELLIPTA 3 QL (60/30)

arformoterol 4 B/D PA

ARNUITY ELLIPTA 3 QL (30/30)

ATROVENT HFA 4 QL (25.8/30)

BREO ELLIPTA 3 QL (60/30)

breyna 4 QL (10.3/30)

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

budesonide inhalation 4 B/D PA; QL

(120/30)

CINRYZE 5 PA; NDS

COMBIVENT RESPIMAT 4 QL (8/30)

cromolyn inhalation 4 B/D PA

unisolide 3 QL (50/30)

uticasone propionate nasal 2 QL (16/30)

icatibant 5 PA; QL (18/30);

NDS

INCRUSE ELLIPTA 3 QL (30/30)

ipratropium bromide inhalation 2 B/D PA

ipratropium-albuterol 2 B/D PA

KALYDECO 5 PA; QL (56/28);

NDS

montelukast oral granules in

packet

4 QL (30/30)

montelukast oral tablet 2 QL (30/30)

montelukast oral tablet,

chewable

2 QL (30/30)

NUCALA SUBCUTANEOUS

AUTO-INJECTOR

5 PA; LA; QL (3/28);

NDS

NUCALA SUBCUTANEOUS

SYRINGE 100 MG/ML

5 PA; LA; QL (3/28);

NDS

NUCALA SUBCUTANEOUS

SYRINGE 40 MG/0.4 ML

5 PA; LA; QL (0.4/28);

NDS

OFEV 5 PA; QL (60/30);

NDS

OPSUMIT 5 PA; NDS

ORKAMBI ORAL GRANULES

IN PACKET

5 PA; QL (56/28);

NDS

ORKAMBI ORAL TABLET 5 PA; QL (112/28);

NDS

pirfenidone oral capsule 5 PA; QL (270/30);

NDS

pirfenidone oral tablet 267 mg 5 PA; QL (270/30);

NDS

pirfenidone oral tablet 534 mg,

801 mg

5 PA; QL (90/30);

NDS

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

PULMOZYME 5 B/D PA; QL

(150/30); NDS

roumilast 4 PA; QL (30/30)

RYALTRIS 4 ST

sajazir 5 PA; QL (18/30);

NDS

SEREVENT DISKUS 3 QL (60/30)

sildenal (pulm. hypertension)

oral tablet

3 PA; QL (90/30)

terbutaline 4

theophylline oral tablet

extended release 12 hr

100 mg, 200 mg, 300 mg

theophylline oral tablet

extended release 12 hr 450 mg

theophylline oral tablet

extended release 24 hr 400 mg

theophylline oral tablet

extended release 24 hr 600 mg

TRELEGY ELLIPTA 3 QL (60/30)

TRIKAFTA ORAL GRANULES

IN PACKET, SEQUENTIAL

5 PA; QL (56/28);

NDS

TRIKAFTA ORAL TABLETS,

SEQUENTIAL

5 PA; QL (84/28);

NDS

TYVASO 4 B/D PA

TYVASO INSTITUTIONAL

START KIT

4 B/D PA

TYVASO REFILL KIT 4 B/D PA

TYVASO STARTER KIT 4 B/D PA

VENTAVIS 4 PA

VENTOLIN HFA 3 QL (36/30)

XOLAIR SUBCUTANEOUS

AUTO-INJECTOR 150 MG/ML,

300 MG/2 ML

5 PA; LA; QL (8/28);

NDS

XOLAIR SUBCUTANEOUS

AUTO-INJECTOR

75 MG/0.5 ML

5 PA; LA; QL (1/28);

NDS

XOLAIR SUBCUTANEOUS

RECON SOLN

5 PA; LA; QL (8/28);

NDS

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

XOLAIR SUBCUTANEOUS

SYRINGE 150 MG/ML,

300 MG/2 ML

5 PA; LA; QL (8/28);

NDS

XOLAIR SUBCUTANEOUS

SYRINGE 75 MG/0.5 ML

5 PA; LA; QL (1/28);

NDS

zarlukast 4 QL (60/30)

UROLOGICALS

ANTICHOLINERGICS / ANTISPASMODICS

GEMTESA 4 QL (30/30)

MYRBETRIQ ORAL TABLET

EXTENDED RELEASE 24 HR

oxybutynin chloride oral syrup 2

oxybutynin chloride oral tablet

5 mg

oxybutynin chloride oral tablet

extended release 24hr

4 QL (60/30)

tolterodine oral capsule,

extended release 24hr

4 ST

tolterodine oral tablet 4

BENIGN PROSTATIC HYPERPLASIA(BPH) THERAPY

alfuzosin 2

dutasteride 2

nasteride oral tablet 5 mg 2 QL (30/30)

tamsulosin 2 QL (60/30)

MISCELLANEOUS UROLOGICALS

bethanechol chloride 3

CYSTAGON 4 LA

ELMIRON 4

k-phos original 4

potassium citrate oral tablet

extended release

RENACIDIN 4

VITAMINS, HEMATINICS / ELECTROLYTES

ELECTROLYTES

calcium acetate (phosphat

bind)

3 QL (360/30)

klor-con 2

KLOR-CON 10 2

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

KLOR-CON 8 2

klor-con m10 2

klor-con m20 2

lactated ringers intravenous 4

magnesium sulfate in d5w

intravenous piggyback

1 gram/100 ml

magnesium sulfate in water 4

magnesium sulfate injection 4

POTASSIUM

CHLORID-D5-0.45% NACL

POTASSIUM CHLORIDE IN

0.9% NACL INTRAVENOUS

PARENTERAL SOLUTION

20 MEQ/L, 40 MEQ/L

potassium chloride in 5% dex

intravenous parenteral solution

10 meq/l

POTASSIUM CHLORIDE

IN 5% DEX INTRAVENOUS

PARENTERAL SOLUTION

20 MEQ/L

POTASSIUM CHLORIDE

IN LR-D5 INTRAVENOUS

PARENTERAL SOLUTION

20 MEQ/L

potassium chloride in water

intravenous piggyback

10 meq/100 ml, 10 meq/50 ml,

20 meq/100 ml, 20 meq/50 ml,

40 meq/100 ml

potassium chloride intravenous 4

potassium chloride oral

capsule, extended release

potassium chloride oral liquid 4

potassium chloride oral packet 2

potassium chloride oral tablet

extended release

Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drug

You can nd information on what the symbols and abbreviations on this table mean by going to page 9.

September 2024

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

potassium chloride oral tablet,

er particles/crystals

potassium chloride-0.45% nacl 4

POTASSIUM

CHLORIDE-D5-0.2% NACL

INTRAVENOUS PARENTERAL

SOLUTION 20 MEQ/L

POTASSIUM

CHLORIDE-D5-0.9% NACL

RINGER'S INTRAVENOUS 4

sodium bicarbonate

intravenous syringe

sodium chloride 0.45%

intravenous

sodium chloride 3% hypertonic 4

SODIUM CHLORIDE 5%

HYPERTONIC

sodium chloride intravenous 4

MISCELLANEOUS NUTRITION PRODUCTS

CLINIMIX 5%/D15W

SULFITE FREE

4 B/D PA

CLINIMIX 4.25%/D10W

SULF FREE

4 B/D PA

CLINIMIX 5%-D20W

(SULFITE-FREE)

4 B/D PA

CLINIMIX 6%-D5W

(SULFITE-FREE)

4 B/D PA

CLINIMIX 8%-D10W

(SULFITE-FREE)

4 B/D PA

CLINIMIX 8%-D14W

(SULFITE-FREE)

4 B/D PA

CLINIMIX E 4.25%/D10W

SUL FREE

4 B/D PA

clinisol sf 15% 4 B/D PA

ELECTROLYTE-48 IN D5W 4

INTRALIPID INTRAVENOUS

EMULSION 20%, 30%

4 B/D PA

KABIVEN 4 B/D PA

PERIKABIVEN 4 B/D PA

plenamine 4 B/D PA

DRUG NAME

DRUG

TIER

REQUIREMENTS/

LIMITS

premasol 10% 4 B/D PA

PROSOL 20% 4 B/D PA

TRAVASOL 10% 4 B/D PA

TROPHAMINE 10% 4 B/D PA

VITAMINS / HEMATINICS

BAL-CARE DHA 3

C-NATE DHA 3

COMPLETE NATAL DHA 3

ELITE-OB 3

uoride (sodium) oral tablet 1

uoride (sodium) oral tablet,

chewable 1 mg (2.2 mg sod.

uoride)

FOLIVANE-OB 3

ludent uoride oral tablet,

chewable 1 mg (2.2 mg sod.

uoride)

M-NATAL PLUS 3

PNV-DHA 3

PNV-OMEGA 3

PNV-SELECT 3

PR NATAL 400 3

PR NATAL 400 EC 3

PR NATAL 430 3

PR NATAL 430 EC 3

PRENATAL PLUS (CALCIUM

CARB)

PRENATAL VITAMIN PLUS

LOW IRON

SE-NATAL 19 CHEWABLE 3

SE-NATAL-19 3

TARON-C DHA 3

TRINATAL RX 1 3

wescap-pn dha 3

wesnate dha 3

WESTAB PLUS 3

WESTGEL DHA 2

DRUG PAGE DRUG PAGE

September 2024

Covered Drugs Index

abacavir-lamivudine ........................................................................ 10

abacavir oral solution

...................................................................... 10

abacavir oral tablet .......................................................................... 10

ABELCET ........................................................................................... 10

ABILIFY ASIMTUFII INTRAMUSCULAR SUSPENSION,

EXTENDED REL SYRING 720 MG/2.4 ML ............................. 28

ABILIFY ASIMTUFII INTRAMUSCULAR SUSPENSION,

EXTENDED REL SYRING 960 MG/3.2 ML

............................. 28

ABILIFY MAINTENA ....................................................................... 28

abiraterone oral tablet 250 mg ..................................................... 16

abiraterone oral tablet 500 mg ..................................................... 16

ABRAXANE ....................................................................................... 16

ABRYSVO (PF) ................................................................................ 46

acamprosate

...................................................................................... 39

acarbose oral tablet 25 mg ........................................................... 41

acarbose oral tablet 50 mg ........................................................... 41

acarbose oral tablet 100 mg ......................................................... 41

acebutolol ........................................................................................... 33

acetaminophen-codeine oral solution 120-12 mg/5 ml ......... 27

acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg

..... 27

acetaminophen-codeine oral tablet 300-60 mg ...................... 27

acetazolamide oral capsule, extended release ....................... 53

acetazolamide oral tablet ............................................................... 53

acetazolamide sodium .................................................................... 53

acetic acid otic (ear) ........................................................................ 40

acetylcysteine

................................................................................... 54

acitretin ............................................................................................... 36

ACTHIB (PF) ..................................................................................... 46

ACTIMMUNE .................................................................................... 46

acyclovir oral capsule ..................................................................... 10

acyclovir oral suspension 200 mg/5 ml ..................................... 10

acyclovir oral tablet

.......................................................................... 10

acyclovir sodium intravenous solution ....................................... 10

ADACEL(TDAP ADOLESN/ADULT)(PF) .................................. 46

ADALIMUMAB-ADAZ ..................................................................... 48

ADALIMUMAB-ADBM(CF) PEN CROHNS

(PREFERRED NDCS STARTING WITH 00597) .................... 48

ADALIMUMAB-ADBM(CF) PEN PS-UV

(PREFERRED NDCS STARTING WITH 00597) .................... 48

ADALIMUMAB-ADBM SUBCUTANEOUS PEN

INJECTOR KIT (PREFERRED NDCS STARTING

WITH 00597) ..................................................................................... 48

ADALIMUMAB-ADBM SUBCUTANEOUS SYRINGE

KIT 10 MG/0.2 ML, 20 MG/0.4 ML (PREFERRED

NDCS STARTING WITH 00597) ................................................. 48

ADALIMUMAB-ADBM SUBCUTANEOUS SYRINGE

KIT 40 MG/0.4 ML, 40 MG/0.8 ML (PREFERRED

NDCS STARTING WITH 00597) ................................................. 48

adapalene topical gel 0.3% ........................................................... 37

ADCETRIS ......................................................................................... 16

ADEMPAS .......................................................................................... 54

ADLARITY ......................................................................................... 26

adstiladrin ........................................................................................... 16

ADVAIR HFA ..................................................................................... 54

armelle .............................................................................................. 50

AJOVY AUTOINJECTOR .............................................................. 26

AJOVY SYRINGE ............................................................................ 26

AKEEGA ............................................................................................. 16

ala-cort topical cream 1% .............................................................. 38

albendazole ....................................................................................... 13

albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/

actuation ............................................................................................. 54

albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/

actuation (nda020503) ................................................................... 54

albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/

actuation (nda020983) ................................................................... 54

albuterol sulfate inhalation solution for nebulization .............. 54

albuterol sulfate oral syrup ............................................................ 54

albuterol sulfate oral tablet ............................................................ 54

alclometasone ................................................................................... 38

ALCOHOL PADS ............................................................................. 47

ALDURAZYME ................................................................................. 43

ALECENSA........................................................................................ 16

alendronate oral tablet 10 mg ...................................................... 48

alendronate oral tablet 35 mg, 70 mg ........................................ 48

alfuzosin.............................................................................................. 56

ALIQOPA ............................................................................................ 16

allopurinol oral tablet 100 mg, 300 mg ...................................... 48

alosetron ............................................................................................. 44

ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1% ............. 54

alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg ......................... 28

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

alprazolam oral tablet 2 mg .......................................................... 28

altavera (28) ...................................................................................... 50

ALUNBRIG ORAL TABLET 30 MG ............................................ 16

ALUNBRIG ORAL TABLET 180 MG, 90 MG ........................... 16

ALUNBRIG ORAL TABLETS, DOSE PACK ............................ 16

alyacen 1/35 (28) ............................................................................. 50

alyacen 7/7/7 (28) ............................................................................ 50

amantadine hcl ................................................................................. 10

ambrisentan ....................................................................................... 54

amethia ............................................................................................... 50

amethyst (28) .................................................................................... 50

amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml ...... 13

amiloride ............................................................................................. 33

amiloride-hydrochlorothiazide ...................................................... 33

aminocaproic acid oral ................................................................... 35

amiodarone intravenous solution ................................................ 33

amiodarone oral tablet 100 mg, 400 mg ................................... 33

amiodarone oral tablet 200 mg .................................................... 33

amitriptyline........................................................................................ 28

amlodipine .......................................................................................... 33

amlodipine-benazepril .................................................................... 33

amlodipine-valsartan ....................................................................... 33

amlodipine-valsartan-hcthiazid .................................................... 33

ammonium lactate ........................................................................... 37

amoxapine ......................................................................................... 28

amoxicillin oral capsule .................................................................. 14

amoxicillin oral suspension for reconstitution .......................... 14

amoxicillin oral tablet ...................................................................... 14

amoxicillin oral tablet, chewable 125 mg, 250 mg ................. 15

amoxicillin-pot clavulanate oral suspension for

reconstitution 200-28.5 mg/5 ml, 400-57 mg/5 ml,

600-42.9 mg/5 ml ............................................................................. 15

amoxicillin-pot clavulanate oral suspension for

reconstitution 250-62.5 mg/5 ml .................................................. 15

amoxicillin-pot clavulanate oral tablet ........................................ 15

amoxicillin-pot clavulanate oral tablet, chewable

200-28.5 mg ...................................................................................... 15

amoxicillin-pot clavulanate oral tablet, chewable

400-57 mg .......................................................................................... 15

amoxicillin-pot clavulanate oral tablet extended

release 12 hr ..................................................................................... 15

amphotericin b .................................................................................. 10

amphotericin b liposome ................................................................ 10

ampicillin oral capsule 500 mg ..................................................... 15

ampicillin sodium .............................................................................. 15

ampicillin-sulbactam ........................................................................ 15

anagrelide .......................................................................................... 39

anastrozole ........................................................................................ 16

ANKTIVA ............................................................................................ 16

ANORO ELLIPTA ............................................................................. 54

apraclonidine ..................................................................................... 54

aprepitant ........................................................................................... 44

APRETUDE ....................................................................................... 10

apri ....................................................................................................... 50

APTIOM ORAL TABLET 200 MG ................................................ 23

APTIOM ORAL TABLET 400 MG ................................................ 23

APTIOM ORAL TABLET 600 MG, 800 MG .............................. 23

APTIVUS ............................................................................................ 10

aranelle (28) ...................................................................................... 51

ARCALYST ........................................................................................ 46

AREXVY (PF).................................................................................... 46

arformoterol ....................................................................................... 54

ARIKAYCE ......................................................................................... 13

aripiprazole oral solution ................................................................ 29

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 5 mg................. 29

aripiprazole oral tablet 20 mg, 30 mg ........................................ 29

aripiprazole oral tablet, disintegrating ........................................ 29

ARISTADA INITIO ............................................................................ 29

ARISTADA INTRAMUSCULAR SUSPENSION,

EXTENDED REL SYRING 1,064 MG/3.9 ML ......................... 29

ARISTADA INTRAMUSCULAR SUSPENSION,

EXTENDED REL SYRING 441 MG/1.6 ML ............................. 29

ARISTADA INTRAMUSCULAR SUSPENSION,

EXTENDED REL SYRING 662 MG/2.4 ML ............................. 29

ARISTADA INTRAMUSCULAR SUSPENSION,

EXTENDED REL SYRING 882 MG/3.2 ML ............................. 29

ARNUITY ELLIPTA.......................................................................... 54

arsenic trioxide.................................................................................. 16

asenapine maleate sublingual tablet 5 mg ............................... 29

asenapine maleate sublingual tablet 10 mg, 2.5 mg ............. 29

ashlyna ................................................................................................ 51

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

ASSURE ID INSULIN SAFETY SYRINGE 1 ML 29

GAUGE X 1/2" .................................................................................. 47

atazanavir oral capsule 150 mg, 300 mg .................................. 10

atazanavir oral capsule 200 mg ................................................... 10

atenolol ............................................................................................... 33

atenolol-chlorthalidone ................................................................... 33

ATGAM................................................................................................ 46

atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg ...... 29

atomoxetine oral capsule 100 mg, 60 mg, 80 mg .................. 29

atorvastatin ........................................................................................ 36

atovaquone ........................................................................................ 13

atovaquone-proguanil ..................................................................... 13

atropine ophthalmic (eye) drops 1% .......................................... 53

ATROVENT HFA .............................................................................. 54

aubra eq.............................................................................................. 51

AUGTYRO ......................................................................................... 16

aurovela 1.5/30 (21) ........................................................................ 51

aurovela 1/20 (21)............................................................................ 51

aurovela 24 fe ................................................................................... 51

aurovela fe 1.5/30 (28) ................................................................... 51

aurovela fe 1-20 (28) ...................................................................... 51

AUSTEDO ORAL TABLET 6 MG ................................................ 26

AUSTEDO ORAL TABLET 12 MG, 9 MG ................................. 26

AUSTEDO XR ORAL TABLET EXTENDED RELEASE

24 HR 6 MG ....................................................................................... 26

AUSTEDO XR ORAL TABLET EXTENDED RELEASE

24 HR 12 MG .................................................................................... 26

AUSTEDO XR ORAL TABLET EXTENDED RELEASE

24 HR 24 MG .................................................................................... 26

AUSTEDO XR ORAL TABLET EXTENDED RELEASE

24 HR 30 MG, 36 MG, 42 MG, 48 MG ...................................... 26

AUSTEDO XR TITRATION KT(WK1-4) ORAL TABLET,

EXT REL 24HR DOSE PACK 6 MG (14)-12 MG

(14)-24 MG (14) ................................................................................ 26

AUVELITY .......................................................................................... 29

aviane .................................................................................................. 51

AVONEX ............................................................................................. 46

ayuna ................................................................................................... 51

AYVAKIT ............................................................................................. 16

azacitidine .......................................................................................... 16

azathioprine oral tablet 50 mg ...................................................... 16

azathioprine sodium ........................................................................ 16

azelastine nasal spray,

non-aerosol 137 mcg (0.1%) ........................................................ 40

azelastine ophthalmic (eye) .......................................................... 53

azithromycin intravenous ............................................................... 13

AZITHROMYCIN ORAL PACKET ............................................... 13

azithromycin oral suspension for reconstitution ...................... 13

azithromycin oral tablet .................................................................. 13

aztreonam .......................................................................................... 13

azurette (28) ...................................................................................... 51

bacitracin intramuscular ................................................................. 13

bacitracin ophthalmic (eye) ........................................................... 53

bacitracin-polymyxin b .................................................................... 53

baclofen oral tablet 10 mg, 20 mg, 5 mg .................................. 27

BACLOFEN ORAL TABLET 15 MG ........................................... 27

BAL-CARE DHA ............................................................................... 57

balsalazide ......................................................................................... 44

BALVERSA ........................................................................................ 16

balziva (28) ........................................................................................ 51

BAQSIMI ............................................................................................. 41

BARACLUDE ORAL SOLUTION ................................................ 10

BAVENCIO ......................................................................................... 16

BCG VACCINE, LIVE (PF) ............................................................ 46

BD SAFETYGLIDE INSULIN SYRINGE SYRINGE

1 ML 31 GAUGE X 15/64" ............................................................. 47

BD ULTRA-FINE MICRO PEN NEEDLE .................................. 47

BD ULTRA-FINE MINI PEN NEEDLE ....................................... 47

BD ULTRA-FINE NANO PEN NEEDLE .................................... 47

BD ULTRA-FINE SHORT PEN NEEDLE .................................. 47

BELEODAQ ....................................................................................... 16

BELSOMRA ....................................................................................... 29

benazepril ........................................................................................... 33

benazepril-hydrochlorothiazide .................................................... 33

bendamustine ................................................................................... 16

BENDEKA .......................................................................................... 16

BENLYSTA INTRAVENOUS ......................................................... 48

benztropine injection ....................................................................... 25

benztropine oral ................................................................................ 25

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

BESIVANCE ...................................................................................... 53

BESPONSA ....................................................................................... 16

BESREMI ........................................................................................... 46

betaine ................................................................................................ 44

betamethasone, augmented topical cream .............................. 38

betamethasone, augmented topical gel .................................... 38

betamethasone, augmented topical lotion ................................ 38

betamethasone, augmented topical ointment ......................... 38

betamethasone dipropionate ........................................................ 38

betamethasone valerate topical cream ..................................... 38

betamethasone valerate topical lotion ....................................... 38

betamethasone valerate topical ointment ................................. 38

BETASERON SUBCUTANEOUS KIT ....................................... 46

betaxolol oral ..................................................................................... 33

bethanechol chloride ....................................................................... 56

bexarotene ......................................................................................... 16

BEXSERO .......................................................................................... 46

bicalutamide ...................................................................................... 16

BICILLIN L-A ..................................................................................... 15

BIKTARVY .......................................................................................... 10

bisoprolol fumarate .......................................................................... 33

bisoprolol-hydrochlorothiazide ..................................................... 33

BLENREP .......................................................................................... 16

bleomycin ........................................................................................... 16

BLINCYTO INTRAVENOUS KIT ................................................. 16

blisovi 24 fe ........................................................................................ 51

blisovi fe 1.5/30 (28) ........................................................................ 51

blisovi fe 1/20 (28) ........................................................................... 51

BOOSTRIX TDAP ............................................................................ 46

BORTEZOMIB INJECTION .......................................................... 16

BOSULIF ORAL CAPSULE 50 MG ............................................ 16

BOSULIF ORAL CAPSULE 100 MG ......................................... 16

BOSULIF ORAL TABLET 100 MG .............................................. 16

BOSULIF ORAL TABLET 400 MG, 500 MG ............................ 16

BOTOX................................................................................................ 46

BRAFTOVI ......................................................................................... 16

BREO ELLIPTA ................................................................................ 54

breyna ................................................................................................. 54

briellyn ................................................................................................. 51

BRILINTA ........................................................................................... 35

brimonidine ophthalmic (eye) drops 0.1% ................................ 54

brimonidine ophthalmic (eye) drops 0.2% ................................ 54

brimonidine ophthalmic (eye) drops 0.15% .............................. 54

brimonidine-timolol .......................................................................... 53

BRIVIACT INTRAVENOUS ........................................................... 23

BRIVIACT ORAL SOLUTION ....................................................... 23

BRIVIACT ORAL TABLET ............................................................. 23

bromocriptine .................................................................................... 25

BRUKINSA ........................................................................................ 16

budesonide inhalation ..................................................................... 55

budesonide oral ................................................................................ 44

bumetanide injection ....................................................................... 33

bumetanide oral tablet 0.5 mg, 1 mg ......................................... 33

bumetanide oral tablet 2 mg ......................................................... 33

buprenorphine hcl injection ........................................................... 27

buprenorphine hcl sublingual ....................................................... 27

buprenorphine-naloxone sublingual tablet 2-0.5 mg ............. 28

buprenorphine-naloxone sublingual tablet 8-2 mg ................. 28

bupropion hcl oral tablet 75 mg ................................................... 29

bupropion hcl oral tablet 100 mg ................................................. 29

bupropion hcl oral tablet extended release 24 hr 150 mg ...... 29

bupropion hcl oral tablet extended release 24 hr 300 mg ...... 29

bupropion hcl oral tablet sustained-release 12 hr 100 mg...... 29

bupropion hcl oral tablet sustained-release 12 hr

150 mg, 200 mg ............................................................................... 29

bupropion hcl (smoking deter) ..................................................... 40

buspirone ............................................................................................ 29

busulfan .............................................................................................. 16

butorphanol nasal ............................................................................ 28

CABENUVA ....................................................................................... 10

cabergoline ........................................................................................ 43

CABOMETYX ................................................................................... 16

calcipotriene scalp ........................................................................... 36

calcipotriene topical cream ........................................................... 36

calcipotriene topical ointment ....................................................... 37

calcitonin (salmon) nasal ............................................................... 43

calcitriol intravenous solution 1 mcg/ml ..................................... 43

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

calcitriol oral capsule ...................................................................... 43

calcitriol oral solution ...................................................................... 43

calcium acetate (phosphat bind) ................................................. 56

CALQUENCE .................................................................................... 16

CALQUENCE (ACALABRUTINIB MAL) ................................... 16

camila .................................................................................................. 50

CAMRESE ......................................................................................... 51

CAMRESE LO .................................................................................. 51

candesartan-hydrochlorothiazid .................................................. 33

candesartan oral tablet 16 mg, 4 mg, 8 mg ............................. 33

candesartan oral tablet 32 mg ..................................................... 33

CAPLYTA............................................................................................ 29

CAPRELSA ORAL TABLET 100 MG ......................................... 16

CAPRELSA ORAL TABLET 300 MG ......................................... 16

captopril .............................................................................................. 33

carbamazepine oral capsule, er multiphase 12 hr ................. 23

carbamazepine oral suspension 100 mg/5 ml ......................... 23

carbamazepine oral tablet ............................................................. 23

carbamazepine oral tablet, chewable ........................................ 23

carbamazepine oral tablet extended release 12 hr................ 23

carbidopa ............................................................................................ 25

carbidopa-levodopa oral tablet .................................................... 25

carbidopa-levodopa oral tablet, disintegrating ........................ 25

carbidopa-levodopa oral tablet extended release .................. 25

carboplatin intravenous solution .................................................. 17

carglumic acid ................................................................................... 39

carmustine intravenous recon soln 100 mg ............................. 17

carteolol .............................................................................................. 53

cartia xt ............................................................................................... 33

carvedilol ............................................................................................ 33

caspofungin intravenous recon soln 50 mg ............................. 10

caspofungin intravenous recon soln 70 mg ............................. 10

CAYSTON .......................................................................................... 13

cefaclor oral capsule ....................................................................... 12

cefaclor oral suspension for reconstitution

125 mg/5 ml, 250 mg/5 ml, 375 mg/5 ml .................................. 12

cefaclor oral tablet extended release 12 hr .............................. 12

cefadroxil oral capsule .................................................................... 12

cefadroxil oral suspension for reconstitution

250 mg/5 ml, 500 mg/5 ml ............................................................. 12

cefadroxil oral tablet ........................................................................ 12

CEFAZOLIN IN DEXTROSE (ISO-OS) INTRAVENOUS

PIGGYBACK 1 GRAM/50 ML, 2 GRAM/100 ML,

2 GRAM/50 ML ................................................................................. 12

cefazolin injection recon soln 1 gram, 10 gram,

100 gram, 3 gram, 300 gram, 500 mg ....................................... 12

CEFAZOLIN INJECTION RECON SOLN 2 GRAM ............... 12

cefazolin intravenous recon soln 1 gram, 3 gram .................. 12

CEFAZOLIN INTRAVENOUS RECON SOLN 2 GRAM ....... 12

cefdinir ................................................................................................. 12

CEFEPIME IN DEXTROSE 5% ................................................... 12

CEFEPIME IN DEXTROSE, ISO-OSM ..................................... 12

cefepime injection ............................................................................ 12

cefepime intravenous...................................................................... 12

cexime ............................................................................................... 12

cefotetan injection ............................................................................ 12

cefoxitin ............................................................................................... 13

CEFOXITIN IN DEXTROSE, ISO-OSM .................................... 13

cefpodoxime ...................................................................................... 13

cefprozil .............................................................................................. 13

ceftazidime ......................................................................................... 13

ceftriaxone ......................................................................................... 13

ceftriaxone in dextrose, iso-os ..................................................... 13

cefuroxime axetil oral tablet .......................................................... 13

cefuroxime sodium injection recon soln 750 mg ..................... 13

cefuroxime sodium intravenous ................................................... 13

celecoxib ............................................................................................. 28

CELONTIN ORAL CAPSULE 300 MG ...................................... 23

cephalexin oral capsule 250 mg, 500 mg ................................. 13

cephalexin oral suspension for reconstitution ......................... 13

CEREZYME INTRAVENOUS RECON SOLN 400 UNIT ..... 43

charlotte 24 fe ................................................................................... 51

chateal eq (28) .................................................................................. 51

CHEMET ............................................................................................ 39

chloramphenicol sod succinate.................................................... 13

chlorhexidine gluconate mucous membrane ........................... 40

chloroquine phosphate ................................................................... 13

chlorothiazide sodium ..................................................................... 33

chlorpromazine ................................................................................. 29

chlorthalidone oral tablet 25 mg, 50 mg .................................... 34

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

cholestyramine-aspartame ............................................................ 36

cholestyramine light ........................................................................ 36

cholestyramine (with sugar) .......................................................... 36

CHORIONIC GONADOTROPIN, HUMAN

INTRAMUSCULAR ......................................................................... 43

ciclodan topical solution ................................................................. 38

ciclopirox topical cream .................................................................. 38

ciclopirox topical shampoo ............................................................ 38

ciclopirox topical solution ............................................................... 38

ciclopirox topical suspension ........................................................ 38

cilostazol ............................................................................................. 35

CIMDUO ............................................................................................. 10

cinacalcet oral tablet 30 mg, 60 mg ............................................ 43

cinacalcet oral tablet 90 mg .......................................................... 43

CINRYZE ............................................................................................ 55

ciprooxacin-dexamethasone ...................................................... 40

ciprooxacin hcl ophthalmic (eye) ............................................... 53

ciprooxacin hcl oral tablet 100 mg ............................................ 15

ciprooxacin hcl oral tablet 250 mg, 500 mg, 750 mg........... 15

ciprooxacin in 5% dextrose ......................................................... 15

ciprooxacin oral suspension, microcapsule recon

500 mg/5 ml ....................................................................................... 15

cisplatin intravenous solution ....................................................... 17

citalopram oral solution .................................................................. 29

citalopram oral tablet 10 mg, 20 mg ........................................... 29

citalopram oral tablet 40 mg ......................................................... 29

cladribine ............................................................................................ 17

claravis ................................................................................................ 37

clarithromycin .................................................................................... 13

CLENPIQ ............................................................................................ 44

clindamycin hcl ................................................................................. 13

CLINDAMYCIN IN 0.9%

SOD CHLOR ..................................................................................... 13

CLINDAMYCIN IN 5% DEXTROSE ........................................... 13

clindamycin palmitate hcl ............................................................... 13

clindamycin pediatric ...................................................................... 13

clindamycin phosphate injection .................................................. 13

clindamycin phosphate topical gel .............................................. 37

clindamycin phosphate topical gel, once daily ........................ 37

clindamycin phosphate topical lotion ......................................... 37

clindamycin phosphate topical solution ..................................... 37

clindamycin phosphate topical swab .......................................... 37

clindamycin phosphate vaginal .................................................... 50

CLINIMIX 4.25%/D5W SULFIT FREE ....................................... 39

CLINIMIX 4.25%/D10W

SULF FREE ....................................................................................... 57

CLINIMIX 5%/D15W

SULFITE FREE ................................................................................ 57

CLINIMIX 5%-D20W (SULFITE-FREE) .................................... 57

CLINIMIX 6%-D5W

(SULFITE-FREE) ............................................................................. 57

CLINIMIX 8%-D10W (SULFITE-FREE) .................................... 57

CLINIMIX 8%-D14W

(SULFITE-FREE) ............................................................................. 57

CLINIMIX E 4.25%/D10W

SUL FREE .......................................................................................... 57

clinisol sf 15% ................................................................................... 57

clobazam oral suspension ............................................................. 23

clobazam oral tablet 10 mg ........................................................... 23

clobazam oral tablet 20 mg ........................................................... 23

clofarabine ......................................................................................... 17

clomipramine ..................................................................................... 29

clonazepam oral tablet 0.5 mg, 1 mg ......................................... 23

clonazepam oral tablet 2 mg ........................................................ 23

clonazepam oral tablet, disintegrating 0.5 mg, 1 mg ............. 23

clonazepam oral tablet, disintegrating 0.125 mg, 0.25 mg ..... 23

clonazepam oral tablet, disintegrating 2 mg ............................ 24

clonidine.............................................................................................. 34

clonidine hcl oral tablet ................................................................... 34

clopidogrel oral tablet 75 mg ........................................................ 35

clopidogrel oral tablet 300 mg ...................................................... 35

clorazepate dipotassium oral tablet 3.75 mg ........................... 29

clorazepate dipotassium oral tablet 7.5 mg ............................. 29

clorazepate dipotassium oral tablet 15 mg ............................... 29

clotrimazole-betamethasone topical cream ............................. 38

clotrimazole mucous membrane ................................................. 10

clotrimazole topical cream ............................................................. 38

clotrimazole topical solution .......................................................... 38

clozapine oral tablet 25 mg, 50 mg ............................................. 29

clozapine oral tablet 100 mg, 200 mg ........................................ 29

clozapine oral tablet, disintegrating ............................................ 29

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

C-NATE DHA .................................................................................... 57

COARTEM ......................................................................................... 13

colchicine oral tablet ....................................................................... 48

colestipol oral granules .................................................................. 36

colestipol oral packet ...................................................................... 36

colestipol oral tablet ........................................................................ 36

colistin (colistimethate na) ............................................................. 13

COLUMVI ........................................................................................... 17

COMBIVENT RESPIMAT .............................................................. 55

COMETRIQ ORAL CAPSULE 60 MG/DAY

(20 MG X 3/DAY) ............................................................................. 17

COMETRIQ ORAL CAPSULE 100 MG/DAY

(80 MG X1-20 MG X1) ................................................................... 17

COMETRIQ ORAL CAPSULE 140 MG/DAY

(80 MG X1-20 MG X3) ................................................................... 17

COMPLERA ...................................................................................... 10

COMPLETE NATAL DHA .............................................................. 57

compro ................................................................................................ 44

constulose .......................................................................................... 44

COPIKTRA ........................................................................................ 17

CORLANOR ORAL TABLET ........................................................ 36

CORTIFOAM ..................................................................................... 45

cortisone ............................................................................................. 40

COTELLIC ......................................................................................... 17

CRESEMBA ORAL .......................................................................... 10

cromolyn inhalation ......................................................................... 55

cromolyn ophthalmic (eye) ............................................................ 53

cromolyn oral ..................................................................................... 45

cryselle (28) ....................................................................................... 51

CUVRIOR ........................................................................................... 39

cyclobenzaprine oral tablet 10 mg, 5 mg .................................. 27

cyclophosphamide intravenous recon soln .............................. 17

CYCLOPHOSPHAMIDE INTRAVENOUS SOLUTION ........ 17

cyclophosphamide oral capsule .................................................. 17

cyclophosphamide oral tablet 25 mg ......................................... 17

CYCLOPHOSPHAMIDE ORAL TABLET 50 MG .................... 17

cycloserine ......................................................................................... 13

cyclosporine intravenous ............................................................... 17

cyclosporine modied ..................................................................... 17

cyclosporine ophthalmic (eye) ..................................................... 53

cyclosporine oral capsule .............................................................. 17

CYLTEZO(CF) PEN ........................................................................ 48

CYLTEZO(CF) PEN CROHN'S-UC-HS .................................... 48

CYLTEZO(CF) PEN PSORIASIS-UV ........................................ 48

CYLTEZO(CF) SUBCUTANEOUS SYRINGE KIT

10 MG/0.2 ML, 20 MG/0.4 ML ..................................................... 48

CYLTEZO(CF) SUBCUTANEOUS SYRINGE KIT

40 MG/0.4 ML, 40 MG/0.8 ML ..................................................... 48

CYRAMZA ......................................................................................... 17

cyred eq .............................................................................................. 51

CYSTAGON ....................................................................................... 56

CYSTARAN ....................................................................................... 53

cytarabine ........................................................................................... 17

cytarabine (pf) ................................................................................... 17

d2.5%-0.45% sodium chloride ..................................................... 39

d5%-0.45% sodium chloride ......................................................... 39

d5% and 0.9% sodium chloride ................................................... 39

D10%-0.45% SODIUM CHLORIDE ........................................... 39

dacarbazine ....................................................................................... 17

dactinomycin ..................................................................................... 17

dalfampridine ..................................................................................... 26

danazol ............................................................................................... 43

dantrolene oral .................................................................................. 27

DANYELZA ........................................................................................ 17

dapsone oral ...................................................................................... 13

DAPTACEL (DTAP PEDIATRIC) (PF) ........................................ 46

daptomycin ........................................................................................ 13

DAPTOMYCIN IN 0.9%

SOD CHLOR ..................................................................................... 13

darunavir oral tablet 600 mg ......................................................... 10

darunavir oral tablet 800 mg ......................................................... 10

DARZALEX ........................................................................................ 17

DARZALEX FASPRO ..................................................................... 17

dasetta 1/35 (28) .............................................................................. 51

dasetta 7/7/7 (28) ............................................................................. 51

daunorubicin ...................................................................................... 17

DAURISMO ORAL TABLET 25 MG ........................................... 17

DAURISMO ORAL TABLET 100 MG ......................................... 17

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

daysee ................................................................................................. 51

deblitane ............................................................................................. 50

decitabine ........................................................................................... 17

deferasirox oral tablet 90 mg ........................................................ 39

deferasirox oral tablet 180 mg, 360 mg ..................................... 39

DELSTRIGO ...................................................................................... 10

DENGVAXIA (PF) ............................................................................ 46

DEPO-MEDROL .............................................................................. 40

DEPO-SUBQ PROVERA 104 ...................................................... 50

DESCOVY ......................................................................................... 10

desipramine ....................................................................................... 29

desloratadine oral tablet ................................................................ 54

desmopressin injection ................................................................... 43

desmopressin nasal spray, non-aerosol

10 mcg/spray (0.1 ml) ..................................................................... 44

desmopressin nasal spray with pump........................................ 43

desmopressin oral ........................................................................... 44

desog-e. estradiol/e. estradiol ...................................................... 51

desogestrel-ethinyl estradiol ......................................................... 51

desoximetasone topical cream .................................................... 38

desoximetasone topical gel .......................................................... 38

desoximetasone topical ointment ................................................ 38

desvenlafaxine succinate oral tablet extended

release 24 hr 25 mg ........................................................................ 29

desvenlafaxine succinate oral tablet extended

release 24 hr 50 mg ........................................................................ 29

desvenlafaxine succinate oral tablet extended

release 24 hr 100 mg ...................................................................... 29

dexamethasone intensol ................................................................ 40

dexamethasone oral elixir ............................................................. 40

dexamethasone oral solution ....................................................... 40

dexamethasone oral tablet ............................................................ 40

dexamethasone sodium phos (pf) injection

solution 10 mg/ml ............................................................................. 40

dexamethasone sodium phosphate injection solution .......... 40

dexamethasone sodium phosphate ophthalmic (eye) .......... 54

dexmethylphenidate oral tablet .................................................... 29

dextroamphetamine-amphetamine oral capsule,

extended release 24hr .................................................................... 29

dextroamphetamine-amphetamine oral tablet 5 mg .............. 30

dextroamphetamine-amphetamine oral tablet 10 mg ........... 30

dextroamphetamine-amphetamine oral tablet

12.5 mg, 30 mg, 7.5 mg ................................................................. 30

dextroamphetamine-amphetamine oral tablet 15 mg ........... 30

dextroamphetamine-amphetamine oral tablet 20 mg ........... 30

dextroamphetamine sulfate oral capsule, extended release .... 29

dextroamphetamine sulfate oral tablet ...................................... 29

dextrose 5%-0.2% sod chloride ................................................... 39

dextrose 5%-0.3% sod.chloride ................................................... 39

dextrose 5% in water (d5w) intravenous parenteral solution .... 39

DEXTROSE 5% IN WATER (D5W) INTRAVENOUS

PIGGYBACK ..................................................................................... 39

DEXTROSE 5%-LACTATED RINGERS ................................... 39

DEXTROSE 10% AND 0.2% NACL ........................................... 39

dextrose 10% in water (d10w) ..................................................... 39

DEXTROSE 25% IN WATER (D25W) ....................................... 39

DEXTROSE 50% IN WATER (D50W) INTRAVENOUS

PARENTERAL SOLUTION ........................................................... 39

dextrose 50% in water (d50w) intravenous syringe ............... 39

DEXTROSE 70% IN WATER (D70W) ....................................... 39

DIACOMIT ......................................................................................... 24

diazepam injection ........................................................................... 30

diazepam intensol ............................................................................ 30

diazepam oral concentrate ............................................................ 30

diazepam oral solution ................................................................... 30

diazepam oral tablet ........................................................................ 30

diazepam rectal ................................................................................ 24

diazoxide ............................................................................................ 41

diclofenac potassium oral tablet 50 mg ..................................... 28

diclofenac sodium ophthalmic (eye) ........................................... 53

diclofenac sodium oral .................................................................... 28

diclofenac sodium topical drops .................................................. 28

diclofenac sodium topical gel 1% ................................................ 28

dicloxacillin ......................................................................................... 15

dicyclomine oral capsule................................................................ 44

dicyclomine oral solution................................................................ 44

dicyclomine oral tablet .................................................................... 44

DIFICID ORAL SUSPENSION FOR RECONSTITUTION ... 13

DIFICID ORAL TABLET ................................................................. 13

diunisal .............................................................................................. 28

diuprednate ...................................................................................... 54

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

digoxin injection solution ................................................................ 36

digoxin oral solution ........................................................................ 36

digoxin oral tablet 62.5 mcg (0.0625 mg) ................................. 36

digoxin oral tablet 125 mcg (0.125 mg), 250 mcg (0.25 mg) .... 36

dihydroergotamine nasal ............................................................... 26

dilantin ................................................................................................. 24

diltiazem hcl intravenous ............................................................... 34

diltiazem hcl oral capsule, extended release 12 hr ................ 34

diltiazem hcl oral capsule, extended release 24hr

120 mg, 180 mg, 240 mg, 300 mg .............................................. 34

diltiazem hcl oral capsule, extended release 24 hr

120 mg, 180 mg, 240 mg, 300 mg, 420 mg ............................. 34

diltiazem hcl oral capsule, ext. rel 24h degradable ................ 34

diltiazem hcl oral tablet ................................................................... 34

diltiazem hcl oral tablet extended release 24 hr 120 mg,

180 mg, 240 mg, 300 mg, 360 mg .............................................. 34

DILTIAZEM HCL ORAL TABLET EXTENDED RELEASE

24 HR 420 MG .................................................................................. 34

dilt-xr .................................................................................................... 34

diphenhydramine hcl injection solution 50 mg/ml ................... 54

diphenoxylate-atropine ................................................................... 44

dipyridamole oral .............................................................................. 35

disulram ............................................................................................ 39

divalproex oral capsule, delayed rel sprinkle ........................... 24

divalproex oral tablet, delayed release (dr/ec) ........................ 24

divalproex oral tablet extended release 24 hr ......................... 24

docetaxel ............................................................................................ 17

dofetilide ............................................................................................. 33

dolishale.............................................................................................. 51

donepezil oral tablet 5 mg ............................................................. 26

donepezil oral tablet 10 mg ........................................................... 26

donepezil oral tablet, disintegrating 5 mg ................................. 26

donepezil oral tablet, disintegrating 10 mg ............................... 26

DOPTELET (10 TAB PACK) ......................................................... 35

DOPTELET (15 TAB PACK) ......................................................... 35

DOPTELET (30 TAB PACK) ......................................................... 35

dorzolamide ....................................................................................... 53

dorzolamide-timolol ......................................................................... 53

dotti ...................................................................................................... 50

DOVATO ............................................................................................. 10

doxazosin oral tablet 1 mg, 2 mg, 4 mg .................................... 34

doxazosin oral tablet 8 mg ............................................................ 34

doxepin oral capsule ....................................................................... 30

doxepin oral concentrate ............................................................... 30

doxepin oral tablet ........................................................................... 30

doxercalciferol ................................................................................... 44

doxorubicin intravenous recon soln 50 mg ............................... 17

doxorubicin intravenous solution ................................................. 17

doxorubicin, peg-liposomal ........................................................... 17

doxy-100 ............................................................................................. 15

doxycycline hyclate intravenous .................................................. 15

doxycycline hyclate oral capsule ................................................. 15

doxycycline hyclate oral tablet 100 mg, 20 mg ....................... 15

doxycycline monohydrate oral capsule 100 mg, 50 mg ....... 15

doxycycline monohydrate oral suspension for

reconstitution ..................................................................................... 15

doxycycline monohydrate oral tablet .......................................... 15

dronabinol .......................................................................................... 45

DROPLET MICRON PEN NEEDLE ........................................... 41

DROPLET PEN NEEDLE NEEDLE 30 GAUGE X 5/16" .......... 41

DROPSAFE ALCOHOL PREP PADS ........................................ 41

DROPSAFE PEN NEEDLE NEEDLE 31 GAUGE X 3/16" ...... 41

drospirenone-e. estradiol-lm.fa oral tablet

3-0.02-0.451 mg (24) (4)................................................................ 51

DROSPIRENONE-E. ESTRADIOL-LM.FA ORAL

TABLET 3-0.03-0.451 MG (21) (7) ............................................. 51

drospirenone-ethinyl estradiol ...................................................... 51

DROXIA .............................................................................................. 17

droxidopa oral capsule 100 mg.................................................... 39

droxidopa oral capsule 200 mg, 300 mg ................................... 39

DUAVEE ............................................................................................. 50

duloxetine oral capsule, delayed release (dr/ec) 20 mg,

60 mg ................................................................................................... 30

duloxetine oral capsule, delayed release (dr/ec) 30 mg ....... 30

DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR

200 MG/1.14 ML .............................................................................. 37

DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR

300 MG/2 ML .................................................................................... 37

DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE

100 MG/0.67 ML .............................................................................. 37

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE

200 MG/1.14 ML .............................................................................. 37

DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE

300 MG/2 ML .................................................................................... 37

dutasteride ......................................................................................... 56

EC-NAPROXEN ORAL TABLET, DELAYED RELEASE

(DR/EC) 375 MG .............................................................................. 28

ec-naproxen oral tablet, delayed release (dr/ec)

500 mg ................................................................................................ 28

econazole ........................................................................................... 38

EDARBI .............................................................................................. 34

EDARBYCLOR ................................................................................. 34

EDURANT .......................................................................................... 10

efavirenz-emtricitabin-tenofov ...................................................... 10

efavirenz-lamivu-tenofov disop oral tablet 400-300-300 mg ..... 10

efavirenz-lamivu-tenofov disop oral tablet 600-300-300 mg ..... 10

efavirenz oral capsule 50 mg ....................................................... 10

efavirenz oral capsule 200 mg ..................................................... 10

efavirenz oral tablet ......................................................................... 10

ELAPRASE ........................................................................................ 44

ELECTROLYTE-48 IN D5W ......................................................... 57

elinest .................................................................................................. 51

ELIQUIS.............................................................................................. 35

ELIQUIS DVT-PE TREAT 30D START ...................................... 35

ELITE-OB ........................................................................................... 57

ELMIRON ........................................................................................... 56

ELREXFIO ......................................................................................... 17

ELZONRIS ......................................................................................... 17

EMPLICITI ......................................................................................... 17

EMSAM ............................................................................................... 30

emtricitabine ...................................................................................... 10

emtricitabine-tenofovir (tdf) oral tablet 100-150 mg,

167-250 mg, 200-300 mg .............................................................. 10

emtricitabine-tenofovir (tdf) oral tablet 133-200 mg ............... 10

EMTRIVA ORAL SOLUTION ........................................................ 10

emverm ............................................................................................... 13

emzahh ............................................................................................... 50

enalapril-hydrochlorothiazide ....................................................... 34

enalapril maleate oral tablet.......................................................... 34

ENBREL MINI ................................................................................... 48

ENBREL SUBCUTANEOUS SOLUTION ................................. 48

ENBREL SUBCUTANEOUS SYRINGE .................................... 49

ENBREL SURECLICK .................................................................... 49

ENDARI .............................................................................................. 39

endocet ............................................................................................... 27

ENGERIX-B PEDIATRIC (PF) ..................................................... 46

ENGERIX-B (PF) ............................................................................. 46

ENHERTU .......................................................................................... 17

enoxaparin ......................................................................................... 35

enpresse ............................................................................................. 51

enskyce ............................................................................................... 51

entacapone ........................................................................................ 25

entecavir ............................................................................................. 10

ENTRESTO ....................................................................................... 36

enulose ............................................................................................... 45

ENVARSUS XR ................................................................................ 17

EPCLUSA ORAL PELLETS IN PACKET 150-37.5 MG ........ 10

EPCLUSA ORAL PELLETS IN PACKET 200-50 MG ........... 11

EPCLUSA ORAL TABLET 200-50 MG ...................................... 11

EPCLUSA ORAL TABLET 400-100 MG .................................... 11

EPIDIOLEX ........................................................................................ 24

epinephrine injection auto-injector 0.15 mg/0.3 ml,

0.3 mg/0.3 ml .................................................................................... 54

EPINEPHRINE INJECTION AUTO-INJECTOR

0.15 MG/0.15 ML, 0.3 MG/0.3 ML .............................................. 54

epinephrine injection solution 1 mg/ml ...................................... 54

epirubicin intravenous solution .................................................... 17

epitol .................................................................................................... 24

EPKINLY ............................................................................................. 17

EPRONTIA ........................................................................................ 24

ERBITUX ............................................................................................ 17

ergotamine-caffeine ........................................................................ 26

eribulin ................................................................................................. 17

ERIVEDGE ........................................................................................ 17

ERLEADA .......................................................................................... 17

erlotinib oral tablet 25 mg .............................................................. 17

erlotinib oral tablet 100 mg, 150 mg ........................................... 17

errin ...................................................................................................... 50

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

ertapenem .......................................................................................... 13

ery pads .............................................................................................. 37

erythrocin (as stearate) oral tablet 250 mg .............................. 13

erythrocin intravenous recon soln 500 mg ............................... 13

erythromycin-benzoyl peroxide .................................................... 37

erythromycin ethylsuccinate oral suspension for

reconstitution 200 mg/5 ml ............................................................ 13

erythromycin ophthalmic (eye) ..................................................... 53

erythromycin oral capsule, delayed release (dr/ec) ............... 13

erythromycin oral tablet .................................................................. 13

erythromycin with ethanol topical gel ......................................... 37

erythromycin with ethanol topical solution ................................ 37

escitalopram oxalate oral solution .............................................. 30

escitalopram oxalate oral tablet 10 mg, 5 mg .......................... 30

escitalopram oxalate oral tablet 20 mg ...................................... 30

estarylla .............................................................................................. 51

estradiol oral ...................................................................................... 50

estradiol transdermal patch semiweekly ................................... 50

estradiol transdermal patch weekly ............................................ 50

estradiol vaginal ............................................................................... 50

estradiol valerate .............................................................................. 50

ethacrynate sodium ......................................................................... 34

ethambutol ......................................................................................... 13

ethosuximide ..................................................................................... 24

ethynodiol diac-eth estradiol ......................................................... 51

etonogestrel-ethinyl estradiol ....................................................... 50

ETOPOPHOS ................................................................................... 17

etoposide intravenous .................................................................... 17

etravirine ............................................................................................. 11

euthyrox .............................................................................................. 44

everolimus (antineoplastic) oral tablet ....................................... 17

everolimus (antineoplastic) oral tablet for suspension 2 mg ..... 17

everolimus (antineoplastic) oral tablet for suspension

3 mg, 5 mg ......................................................................................... 17

everolimus (immunosuppressive) oral tablet 0.5 mg,

0.75 mg, 1 mg ................................................................................... 18

everolimus (immunosuppressive) oral tablet 0.25 mg .......... 18

EVOMELA .......................................................................................... 18

EVOTAZ .............................................................................................. 11

exemestane ....................................................................................... 18

EXTENCILLINE ................................................................................ 15

EYLEA ................................................................................................. 53

EYSUVIS ............................................................................................ 54

ezetimibe ............................................................................................ 36

ezetimibe-simvastatin ..................................................................... 36

FABRAZYME .................................................................................... 44

falmina (28) ........................................................................................ 51

famciclovir .......................................................................................... 11

famotidine oral suspension for reconstitution .......................... 46

famotidine oral tablet 20 mg ......................................................... 46

famotidine oral tablet 40 mg ......................................................... 46

FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG,

4 MG, 6 MG ....................................................................................... 30

FANAPT ORAL TABLET 8 MG .................................................... 30

FANAPT ORAL TABLETS, DOSE PACK .................................. 30

FARYDAK .......................................................................................... 18

febuxostat ........................................................................................... 48

felbamate ............................................................................................ 24

felodipine ............................................................................................ 34

fenobrate micronized oral capsule 134 mg, 200 mg,

67 mg ................................................................................................... 36

fenobrate nanocrystallized .......................................................... 36

fenobrate oral tablet 160 mg, 54 mg ........................................ 36

fenobric acid (choline) .................................................................. 36

fentanyl citrate buccal lozenge on a handle 1,200 mcg,

1,600 mcg, 400 mcg, 600 mcg, 800 mcg.................................. 27

fentanyl citrate buccal lozenge on a handle 200 mcg ........... 27

fentanyl transdermal patch 72 hour 100 mcg/hr,

12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr ........................... 27

FETZIMA ORAL CAPSULE, EXTENDED RELEASE

24 HR .................................................................................................. 30

FETZIMA ORAL CAPSULE, EXT REL 24HR DOSE

PACK 20 MG (2)- 40 MG (26) ...................................................... 30

nasteride oral tablet 5 mg ............................................................ 56

FINTEPLA .......................................................................................... 24

nzala .................................................................................................. 51

FIRMAGON KIT W DILUENT SYRINGE .................................. 18

FIRVANQ ............................................................................................ 13

ac otic oil .......................................................................................... 40

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

ecainide ............................................................................................ 33

oxuridine ........................................................................................... 18

uconazole in nacl (iso-osm) ........................................................ 10

uconazole oral suspension for reconstitution ........................ 10

uconazole oral tablet ..................................................................... 10

ucytosine .......................................................................................... 10

udarabine ......................................................................................... 18

udrocortisone .................................................................................. 41

unisolide ........................................................................................... 55

uocinolone acetonide oil .............................................................. 40

uocinolone and shower cap ........................................................ 38

uocinolone topical cream 0.01% ............................................... 38

uocinolone topical cream 0.025% ............................................. 38

uocinolone topical oil .................................................................... 38

uocinolone topical ointment ........................................................ 38

uocinolone topical solution .......................................................... 38

uocinonide topical cream 0.05% ............................................... 38

uocinonide topical gel ................................................................... 38

uocinonide topical ointment ........................................................ 38

uocinonide topical solution .......................................................... 38

uoride (sodium) dental ................................................................. 40

uoride (sodium) oral tablet .......................................................... 57

uoride (sodium) oral tablet, chewable 1 mg

(2.2 mg sod. uoride) ...................................................................... 57

FLUOROMETHOLONE ................................................................. 54

uorouracil intravenous .................................................................. 18

uorouracil topical cream 5% ....................................................... 37

uorouracil topical solution ............................................................ 37

uoxetine oral capsule 10 mg ...................................................... 30

uoxetine oral capsule 20 mg, 40 mg ........................................ 30

uoxetine oral solution .................................................................... 30

uphenazine decanoate ................................................................. 30

uphenazine hcl injection .............................................................. 30

uphenazine hcl oral concentrate ............................................... 30

uphenazine hcl oral elixir ............................................................. 30

uphenazine hcl oral tablet ........................................................... 30

urbiprofen oral tablet 100 mg ..................................................... 28

urbiprofen sodium .......................................................................... 53

uticasone propionate nasal ......................................................... 55

uticasone propionate topical cream ......................................... 38

uticasone propionate topical ointment ..................................... 39

uvastatin oral capsule 20 mg ..................................................... 36

uvastatin oral capsule 40 mg ..................................................... 36

uvastatin oral tablet extended release 24 hr .......................... 36

uvoxamine oral tablet 25 mg ...................................................... 30

uvoxamine oral tablet 50 mg ...................................................... 30

uvoxamine oral tablet 100 mg .................................................... 30

FOLIVANE-OB .................................................................................. 57

FOLOTYN .......................................................................................... 18

fomepizole .......................................................................................... 46

fondaparinux ...................................................................................... 35

FORTEO ............................................................................................. 48

fosamprenavir ................................................................................... 11

fosinopril ............................................................................................. 34

fosinopril-hydrochlorothiazide ...................................................... 34

fosphenytoin ...................................................................................... 24

FOTIVDA ............................................................................................ 18

FRUZAQLA ORAL CAPSULE 1 MG .......................................... 18

FRUZAQLA ORAL CAPSULE 5 MG .......................................... 18

fulvestrant ........................................................................................... 18

furosemide injection solution ........................................................ 34

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)...... 34

FUROSEMIDE ORAL SOLUTION 40 MG/4 ML ..................... 34

furosemide oral tablet ..................................................................... 34

FUZEON SUBCUTANEOUS RECON SOLN .......................... 11

FYARRO ............................................................................................. 18

FYCOMPA ORAL SUSPENSION ............................................... 24

FYCOMPA ORAL TABLET 2 MG, 4 MG, 6 MG ...................... 24

FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG ................. 24

gabapentin oral capsule 100 mg, 300 mg ................................ 24

gabapentin oral capsule 400 mg ................................................. 24

gabapentin oral solution ................................................................. 24

gabapentin oral tablet 600 mg ..................................................... 24

gabapentin oral tablet 800 mg ..................................................... 24

galantamine oral capsule, ext rel. pellets 24 hr ...................... 26

galantamine oral solution ............................................................... 26

galantamine oral tablet ................................................................... 26

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

GARDASIL 9 (PF) ............................................................................ 46

GATTEX 30-VIAL ............................................................................. 45

GATTEX ONE-VIAL ........................................................................ 45

GAUZE PAD TOPICAL BANDAGE 2 X 2 " .............................. 47

gavilyte-c ............................................................................................ 45

gavilyte-n ............................................................................................ 45

GAVRETO .......................................................................................... 18

GAZYVA ............................................................................................. 18

getinib ................................................................................................ 18

gemcitabine intravenous recon soln ........................................... 18

gemcitabine intravenous solution 1 gram/26.3 ml

(38 mg/ml), 2 gram/52.6 ml (38 mg/ml), 200 mg/

5.26 ml (38 mg/ml) ........................................................................... 18

GEMCITABINE INTRAVENOUS SOLUTION

100 MG/ML ........................................................................................ 18

gembrozil .......................................................................................... 36

gemmily .............................................................................................. 51

GEMTESA ......................................................................................... 56

generlac .............................................................................................. 45

gengraf ................................................................................................ 18

GENOTROPIN.................................................................................. 46

GENOTROPIN MINIQUICK .......................................................... 46

gentamicin injection solution 40 mg/ml ...................................... 14

gentamicin in nacl (iso-osm) intravenous piggyback

100 mg/100 ml, 100 mg/50 ml, 120 mg/100 ml,

60 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml ................................ 14

gentamicin ophthalmic (eye) drops ............................................. 53

gentamicin sulfate (ped) (pf) ......................................................... 14

gentamicin topical cream ............................................................... 38

gentamicin topical ointment .......................................................... 38

GILOTRIF ........................................................................................... 18

GLASSIA ............................................................................................ 39

glatiramer subcutaneous syringe 20 mg/ml ............................. 26

glatiramer subcutaneous syringe 40 mg/ml ............................. 26

glatopa subcutaneous syringe 20 mg/ml .................................. 26

glatopa subcutaneous syringe 40 mg/ml .................................. 26

GLEOSTINE ...................................................................................... 18

glimepiride oral tablet 1 mg ........................................................... 41

glimepiride oral tablet 2 mg ........................................................... 41

glimepiride oral tablet 4 mg ........................................................... 41

glipizide-metformin oral tablet 2.5-250 mg ............................... 41

glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg........... 41

GLIPIZIDE ORAL TABLET 2.5 MG ............................................ 41

glipizide oral tablet 5 mg ................................................................ 41

glipizide oral tablet 10 mg .............................................................. 41

glipizide oral tablet extended release 24hr 2.5 mg ................ 41

glipizide oral tablet extended release 24hr 5 mg .................... 41

glipizide oral tablet extended release 24hr 10 mg ................. 41

glucagon emergency kit (human) ................................................ 41

GLUCAGON (HCL) EMERGENCY KIT .................................... 41

glycopyrrolate oral tablet 1 mg, 2 mg ......................................... 44

glycopyrrolate (pf) ............................................................................ 44

glycopyrrolate (pf) in water injection ........................................... 44

glycopyrrolate (pf) in water intravenous syringe

0.4 mg/2 ml (0.2 mg/ml) ................................................................. 44

glydo .................................................................................................... 37

GLYXAMBI ......................................................................................... 41

GOCOVRI .......................................................................................... 25

granisetron hcl oral .......................................................................... 45

griseofulvin microsize ..................................................................... 10

griseofulvin ultramicrosize ............................................................. 10

guanfacine oral tablet extended release 24 hr ........................ 30

GVOKE ............................................................................................... 41

GVOKE HYPOPEN 1-PACK ........................................................ 41

GVOKE HYPOPEN 2-PACK ........................................................ 41

GVOKE PFS 1-PACK SYRINGE SUBCUTANEOUS

SYRINGE 1 MG/0.2 ML ................................................................. 41

GVOKE PFS 2-PACK SYRINGE SUBCUTANEOUS

SYRINGE 1 MG/0.2 ML ................................................................. 41

hailey ................................................................................................... 51

hailey 24 fe ........................................................................................ 51

hailey fe 1.5/30 (28) ........................................................................ 51

hailey fe 1/20 (28) ............................................................................ 51

HALAVEN ........................................................................................... 18

halobetasol propionate topical cream ........................................ 39

halobetasol propionate topical ointment ................................... 39

haloperidol decanoate .................................................................... 30

haloperidol lactate injection .......................................................... 30

haloperidol lactate oral ................................................................... 30

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

haloperidol oral tablet 0.5 mg, 2 mg, 20 mg ............................ 30

haloperidol oral tablet 1 mg, 10 mg, 5 mg ................................ 30

HARVONI ORAL PELLETS IN PACKET 33.75-150 MG ...... 11

HARVONI ORAL PELLETS IN PACKET 45-200 MG ............ 11

HARVONI ORAL TABLET 45-200 MG ...................................... 11

HARVONI ORAL TABLET 90-400 MG ...................................... 11

HAVRIX (PF) INTRAMUSCULAR SYRINGE 1,440

ELISA UNIT/ML ................................................................................ 46

HAVRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA

UNIT/0.5 ML ...................................................................................... 46

heather ................................................................................................ 50

HEPARIN(PORCINE) IN 0.45% NACL INTRAVENOUS

PARENTERAL SOLUTION 25,000 UNIT/250 ML,

25,000 UNIT/500 ML ...................................................................... 35

HEPARIN (PORCINE) IN 5% DEX ............................................. 35

heparin (porcine) injection solution ............................................. 35

heparin (porcine) in nacl (pf) intravenous parenteral

solution ................................................................................................ 35

heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml ....... 35

HEPLISAV-B (PF) ............................................................................ 46

HIBERIX (PF) .................................................................................... 46

HIZENTRA SUBCUTANEOUS SOLUTION ............................. 46

HUMALOG JUNIOR KWIKPEN U-100 ..................................... 41

HUMALOG KWIKPEN INSULIN ................................................. 41

HUMALOG MIX 50-50 INSULIN U-100 .................................... 41

HUMALOG MIX 50-50 KWIKPEN............................................... 42

HUMALOG MIX 75-25 KWIKPEN............................................... 42

HUMALOG MIX 75-25(U-100)INSULIN .................................... 42

HUMALOG U-100 INSULIN .......................................................... 42

HUMIRA(CF) PEDI CROHNS STARTER

SUBCUTANEOUS SYRINGE KIT

80 MG/0.8 ML-40 MG/0.4 ML (PREFERRED

NDCS STARTING WITH 00074) ................................................. 49

HUMIRA(CF) PEDI CROHNS STARTER

SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML

(PREFERRED NDCS STARTING WITH 00074) .................... 49

HUMIRA(CF) PEN CROHNS-UC-HS

(PREFERRED NDCS STARTING WITH 00074) .................... 49

HUMIRA(CF) PEN PEDIATRIC UC

(PREFERRED NDCS STARTING WITH 00074) .................... 49

HUMIRA(CF) PEN PSOR-UV-ADOL HS

(PREFERRED NDCS STARTING WITH 00074) .................... 49

HUMIRA(CF) PEN SUBCUTANEOUS PEN

INJECTOR KIT 40 MG/0.4 ML (PREFERRED

NDCS STARTING WITH 00074) ................................................. 49

HUMIRA(CF) PEN SUBCUTANEOUS PEN

INJECTOR KIT 80 MG/0.8 ML (PREFERRED

NDCS STARTING WITH 00074) ................................................. 49

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT

10 MG/0.1 ML, 20 MG/0.2 ML (PREFERRED NDCS

STARTING WITH 00074) .............................................................. 49

HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT

40 MG/0.4 ML (PREFERRED NDCS STARTING WITH

00074) ................................................................................................. 49

HUMIRA PEN (PREFERRED NDCS STARTING WITH

00074) ................................................................................................. 49

HUMIRA SUBCUTANEOUS SYRINGE KIT

40 MG/0.8 ML (PREFERRED NDCS STARTING

WITH 00074) ..................................................................................... 49

HUMULIN 70/30 U-100 INSULIN ................................................ 42

HUMULIN 70/30 U-100 KWIKPEN ............................................. 42

HUMULIN N NPH INSULIN KWIKPEN ..................................... 42

HUMULIN N NPH U-100 INSULIN ............................................. 42

HUMULIN R REGULAR U-100 INSULIN ................................. 42

HUMULIN R U-500 (CONC) INSULIN ....................................... 42

HUMULIN R U-500 (CONC) KWIKPEN .................................... 42

hydralazine injection ....................................................................... 34

hydralazine oral ................................................................................ 34

hydrochlorothiazide ......................................................................... 34

hydrocodone-acetaminophen oral solution

7.5-325 mg/15 ml ............................................................................. 27

hydrocodone-acetaminophen oral tablet 10-325 mg,

5-325 mg, 7.5-325 mg .................................................................... 27

hydrocodone-ibuprofen oral tablet 7.5-200 mg ....................... 27

hydrocortisone-acetic acid ............................................................ 40

hydrocortisone oral .......................................................................... 41

hydrocortisone rectal ...................................................................... 45

hydrocortisone topical cream 1%, 2.5% .................................... 39

hydrocortisone topical cream with perineal applicator .......... 45

hydrocortisone topical lotion 2.5% .............................................. 39

hydrocortisone topical ointment 1%, 2.5% ............................... 39

hydromorphone oral liquid ............................................................. 27

hydromorphone oral tablet ............................................................ 27

hydroxychloroquine ......................................................................... 14

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

hydroxyurea ....................................................................................... 18

hydroxyzine hcl oral tablet ............................................................. 54

hydroxyzine pamoate...................................................................... 54

HYRIMOZ(CF) PEDI CROHN STARTER

SUBCUTANEOUS SYRINGE 80 MG/0.8 ML-

40 MG/0.4 ML (PREFERRED NDCS STARTING

WITH 61314) ..................................................................................... 49

HYRIMOZ(CF) PEDI CROHN STARTER

SUBCUTANEOUS SYRINGE 80 MG/0.8 ML

(PREFERRED NDCS STARTING WITH 61314) .................... 49

HYRIMOZ(CF) PEN (PREFERRED NDCS

STARTING WITH 61314) .............................................................. 49

HYRIMOZ(CF) SUBCUTANEOUS SYRINGE

10 MG/0.1 ML (PREFERRED NDCS STARTING

WITH 61314) ..................................................................................... 49

HYRIMOZ(CF) SUBCUTANEOUS SYRINGE

20 MG/0.2 ML (PREFERRED NDCS STARTING

WITH 61314) ..................................................................................... 49

HYRIMOZ(CF) SUBCUTANEOUS SYRINGE

40 MG/0.4 ML (PREFERRED NDCS STARTING

WITH 61314) ..................................................................................... 50

HYRIMOZ PEN CROHN'S-UC STARTER

(PREFERRED NDCS STARTING WITH 61314) .................... 49

HYRIMOZ PEN PSORIASIS STARTER

(PREFERRED NDCS STARTING WITH 61314) .................... 49

ibandronate oral ............................................................................... 48

IBRANCE ........................................................................................... 18

ibu ......................................................................................................... 28

ibuprofen oral suspension ............................................................. 28

ibuprofen oral tablet 400 mg, 600 mg, 800 mg ....................... 28

icatibant .............................................................................................. 55

iclevia ................................................................................................... 51

ICLUSIG ............................................................................................. 18

icosapent ethyl .................................................................................. 36

idarubicin ............................................................................................ 18

IDHIFA ................................................................................................. 18

ifosfamide intravenous recon soln 1 gram ................................ 18

IFOSFAMIDE INTRAVENOUS RECON SOLN 3 GRAM ..... 18

ifosfamide intravenous solution ................................................... 18

imatinib oral tablet 100 mg ............................................................ 18

imatinib oral tablet 400 mg ............................................................ 18

IMBRUVICA ORAL CAPSULE 70 MG....................................... 18

IMBRUVICA ORAL CAPSULE 140 MG .................................... 18

IMBRUVICA ORAL SUSPENSION............................................. 18

IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG ....... 18

IMDELLTRA ....................................................................................... 18

IMFINZI ............................................................................................... 18

imipenem-cilastatin .......................................................................... 14

imipramine hcl ................................................................................... 30

imiquimod topical cream in packet 5% ...................................... 37

IMJUDO .............................................................................................. 18

IMOVAX RABIES VACCINE (PF) ............................................... 46

INBRIJA INHALATION CAPSULE, W/INHALATION

DEVICE .............................................................................................. 25

incassia ............................................................................................... 50

INCRELEX ......................................................................................... 39

INCRUSE ELLIPTA ......................................................................... 55

indapamide ........................................................................................ 34

INFANRIX (DTAP) (PF) .................................................................. 46

INFUGEM ........................................................................................... 18

INFUMORPH P/F............................................................................. 27

INGREZZA ......................................................................................... 26

INGREZZA INITIATION PK(TARDIV) ........................................ 26

INLYTA ORAL TABLET 1 MG ....................................................... 18

INLYTA ORAL TABLET 5 MG ....................................................... 18

INQOVI ............................................................................................... 18

INREBIC ............................................................................................. 18

INSULIN LISPRO ............................................................................ 42

INSULIN LISPRO PROTAMIN-LISPRO .................................... 42

INSULIN SYRINGE-NEEDLE U-100 SYRINGE

0.3 ML 29 GAUGE, 1 ML 29 GAUGE X 1/2",

1/2 ML 28 GAUGE ........................................................................... 47

INTELENCE ORAL TABLET 25 MG .......................................... 11

INTRALIPID INTRAVENOUS EMULSION 20%, 30% .......... 57

INVEGA HAFYERA INTRAMUSCULAR SYRINGE

1,092 MG/3.5 ML ............................................................................. 30

INVEGA HAFYERA INTRAMUSCULAR SYRINGE

1,560 MG/5 ML ................................................................................. 30

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE

39 MG/0.25 ML ................................................................................. 31

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE

78 MG/0.5 ML ................................................................................... 31

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE

117 MG/0.75 ML ............................................................................... 30

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE

156 MG/ML ........................................................................................ 30

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE

234 MG/1.5 ML ................................................................................. 30

INVEGA TRINZA INTRAMUSCULAR SYRINGE

273 MG/0.88 ML .............................................................................. 31

INVEGA TRINZA INTRAMUSCULAR SYRINGE

410 MG/1.32 ML .............................................................................. 31

INVEGA TRINZA INTRAMUSCULAR SYRINGE

546 MG/1.75 ML .............................................................................. 31

INVEGA TRINZA INTRAMUSCULAR SYRINGE

819 MG/2.63 ML .............................................................................. 31

INVOKAMET ..................................................................................... 42

INVOKAMET XR .............................................................................. 42

INVOKANA ........................................................................................ 42

IPOL ..................................................................................................... 46

ipratropium-albuterol ....................................................................... 55

ipratropium bromide inhalation .................................................... 55

ipratropium bromide nasal spray, non-aerosol

21 mcg (0.03%) ................................................................................ 40

ipratropium bromide nasal spray, non-aerosol

42 mcg (0.06%) ................................................................................ 40

irbesartan ........................................................................................... 34

irbesartan-hydrochlorothiazide .................................................... 34

irinotecan ............................................................................................ 19

ISENTRESS HD ............................................................................... 11

ISENTRESS ORAL POWDER IN PACKET ............................. 11

ISENTRESS ORAL TABLET ........................................................ 11

ISENTRESS ORAL TABLET, CHEWABLE 25 MG ................ 11

ISENTRESS ORAL TABLET, CHEWABLE 100 MG .............. 11

isibloom ............................................................................................... 51

isoniazid oral solution ..................................................................... 14

isoniazid oral tablet .......................................................................... 14

isosorbide dinitrate oral tablet 10 mg, 20 mg,

30 mg, 5 mg ....................................................................................... 36

isosorbide-hydralazine ................................................................... 34

isosorbide mononitrate ................................................................... 36

isotretinoin oral capsule 10 mg, 20 mg, 30 mg,

40 mg ................................................................................................... 37

itraconazole oral capsule ............................................................... 10

itraconazole oral solution ............................................................... 10

ivermectin oral .................................................................................. 14

IWILFIN ............................................................................................... 19

IXCHIQ (PF) ...................................................................................... 46

IXEMPRA ........................................................................................... 19

IXIARO (PF) ...................................................................................... 46

jaimiess ............................................................................................... 51

JAKAFI ................................................................................................ 19

jantoven .............................................................................................. 35

JANUMET .......................................................................................... 42

JANUMET XR ORAL TABLET, ER MULTIPHASE

24 HR 50-1,000 MG, 50-500 MG ................................................ 42

JANUMET XR ORAL TABLET, ER MULTIPHASE

24 HR 100-1,000 MG...................................................................... 42

JANUVIA ............................................................................................ 42

JARDIANCE ...................................................................................... 42

jasmiel (28) ........................................................................................ 51

JAYPIRCA .......................................................................................... 19

JEMPERLI ......................................................................................... 19

jencycla ............................................................................................... 50

JENTADUETO .................................................................................. 42

JENTADUETO XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 2.5-1,000 MG ................................................... 42

JENTADUETO XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 5-1,000 MG ...................................................... 42

JEVTANA ........................................................................................... 19

JOLESSA ........................................................................................... 51

joyeaux ................................................................................................ 51

juleber .................................................................................................. 51

JULUCA .............................................................................................. 11

junel 1.5/30 (21) ............................................................................... 51

junel 1/20 (21) ................................................................................... 51

junel fe 1.5/30 (28) ........................................................................... 51

junel fe 1/20 (28) .............................................................................. 51

junel fe 24 ........................................................................................... 51

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

JYLAMVO .......................................................................................... 19

JYNNEOS (PF) ................................................................................. 46

KABIVEN ............................................................................................ 57

KADCYLA .......................................................................................... 19

kaitlib fe ............................................................................................... 51

kalliga .................................................................................................. 51

KALYDECO ....................................................................................... 55

KANJINTI ........................................................................................... 19

kariva (28) .......................................................................................... 51

kelnor 1/35 (28) ................................................................................ 51

kelnor 1-50 (28) ................................................................................ 51

KERENDIA ........................................................................................ 34

KESIMPTA PEN ............................................................................... 26

ketoconazole oral ............................................................................. 10

ketoconazole topical cream .......................................................... 38

ketoconazole topical shampoo .................................................... 38

KETOROLAC OPHTHALMIC (EYE) DROPS 0.4% .............. 53

ketorolac ophthalmic (eye) drops 0.5% ..................................... 53

KEYTRUDA ....................................................................................... 19

KIMMTRAK ........................................................................................ 19

KINRIX (PF) ....................................................................................... 46

kionex (with sorbitol) ....................................................................... 39

KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/

DAY(200 MG X 1)-2.5 MG ............................................................ 19

KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/

DAY(200 MG X 2)-2.5 MG ............................................................ 19

KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/

DAY(200 MG X 3)-2.5 MG ............................................................ 19

KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1) ........... 19

KISQALI ORAL TABLET 400 MG/DAY (200 MG X 2) ........... 19

KISQALI ORAL TABLET 600 MG/DAY (200 MG X 3) ........... 19

klayesta ............................................................................................... 38

KLISYRI .............................................................................................. 19

klor-con ............................................................................................... 56

KLOR-CON 8 .................................................................................... 56

KLOR-CON 10 .................................................................................. 56

klor-con m10 ...................................................................................... 56

klor-con m20 ...................................................................................... 56

KLOXXADO ....................................................................................... 28

KORLYM ............................................................................................. 44

KOSELUGO ORAL CAPSULE 10 MG ...................................... 19

KOSELUGO ORAL CAPSULE 25 MG ...................................... 19

k-phos original .................................................................................. 56

KRAZATI ............................................................................................. 19

kurvelo (28) ........................................................................................ 51

KYPROLIS ......................................................................................... 19

labetalol oral ...................................................................................... 34

lacosamide intravenous ................................................................. 24

lacosamide oral solution ................................................................ 24

lacosamide oral tablet 50 mg ....................................................... 24

lacosamide oral tablet 100 mg, 150 mg, 200 mg ................... 24

lactated ringers intravenous.......................................................... 56

LACTATED RINGERS IRRIGATION .......................................... 39

lactulose oral solution ..................................................................... 45

LAGEVRIO (EUA)............................................................................ 11

lamivudine oral solution ................................................................. 11

lamivudine oral tablet 100 mg, 300 mg ..................................... 11

lamivudine oral tablet 150 mg ...................................................... 11

lamivudine-zidovudine .................................................................... 11

lamotrigine oral tablet ..................................................................... 24

lamotrigine oral tablet, chewable dispersible ........................... 24

lamotrigine oral tablets, dose pack ............................................. 24

LANOXIN PEDIATRIC .................................................................... 36

LANTUS SOLOSTAR U-100 INSULIN ...................................... 42

LANTUS U-100 INSULIN .............................................................. 42

lapatinib .............................................................................................. 19

larin 1.5/30 (21) ................................................................................ 51

larin 1/20 (21) .................................................................................... 51

larin 24 fe ............................................................................................ 51

larin fe 1.5/30 (28)............................................................................ 51

larin fe 1/20 (28) ............................................................................... 51

latanoprost ......................................................................................... 53

LAYOLIS FE ...................................................................................... 51

leena 28 .............................................................................................. 51

leunomide ........................................................................................ 50

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

lenalidomide ...................................................................................... 19

LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1),

4 MG .................................................................................................... 19

LENVIMA ORAL CAPSULE 12 MG/DAY (4 MG X 3),

18 MG/DAY (10 MG X 1-4 MG X2), 24 MG/DAY

(10 MG X 2-4 MG X 1) ................................................................... 19

LENVIMA ORAL CAPSULE 14 MG/DAY (10 MG X

1-4 MG X 1), 20 MG/DAY (10 MG X 2), 8 MG/DAY

(4 MG X 2) ......................................................................................... 19

lessina ................................................................................................. 51

letrozole .............................................................................................. 19

leucovorin calcium injection .......................................................... 16

leucovorin calcium oral tablet 5 mg ............................................ 16

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg ............. 16

LEUKERAN ....................................................................................... 19

leuprolide (3 month) ........................................................................ 19

leuprolide subcutaneous kit .......................................................... 19

levetiracetam in nacl (iso-os) intravenous piggyback

1,000 mg/100 ml, 1,500 mg/100 ml, 500 mg/100 ml ............. 24

levetiracetam intravenous ............................................................. 24

levetiracetam oral solution ............................................................ 24

levetiracetam oral tablet 1,000 mg, 750 mg ............................. 24

levetiracetam oral tablet 250 mg, 500 mg ................................ 24

levetiracetam oral tablet extended release 24 hr ................... 24

levobunolol ophthalmic (eye) drops 0.5% ................................. 53

levocarnitine oral solution 100 mg/ml ........................................ 40

LEVOCARNITINE ORAL TABLET .............................................. 40

levocarnitine (with sugar) ............................................................... 39

levocetirizine oral tablet ................................................................. 54

levooxacin in d5w .......................................................................... 15

levooxacin oral solution................................................................ 15

levooxacin oral tablet .................................................................... 15

levonest (28) ...................................................................................... 52

levonorgest-eth.estradiol-iron ....................................................... 52

levonorgestrel-ethinyl estrad ........................................................ 52

levonorg-eth estrad triphasic ........................................................ 52

levora-28 ............................................................................................. 52

levothyroxine oral tablet ................................................................. 44

LEVOXYL ORAL TABLET 100 MCG, 112 MCG,

125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG,

25 MCG, 50 MCG, 75 MCG, 88 MCG ....................................... 44

LEXIVA ORAL SUSPENSION ...................................................... 11

LIBERVANT ....................................................................................... 24

LIBTAYO ............................................................................................. 19

lidocaine hcl injection solution ...................................................... 37

lidocaine hcl laryngotracheal ........................................................ 38

lidocaine hcl mucous membrane jelly in applicator ................ 38

lidocaine hcl mucous membrane solution 2% ......................... 38

lidocaine hcl mucous membrane solution 4%

(40 mg/ml) .......................................................................................... 37

lidocaine (pf) injection solution ..................................................... 37

LIDOCAINE (PF) INTRAVENOUS SOLUTION ...................... 33

lidocaine (pf) intravenous syringe ............................................... 33

lidocaine-prilocaine topical cream ............................................... 37

lidocaine topical adhesive patch,medicated 5% ..................... 37

lidocaine viscous .............................................................................. 37

lincomycin .......................................................................................... 14

LINEZOLID-0.9% SODIUM CHLORIDE ................................... 14

linezolid in dextrose 5% ................................................................. 14

linezolid oral suspension for reconstitution .............................. 14

linezolid oral tablet ........................................................................... 14

LINZESS ............................................................................................. 45

liothyronine oral ................................................................................ 44

lisinopril ............................................................................................... 34

lisinopril-hydrochlorothiazide ........................................................ 34

lithium carbonate .............................................................................. 31

lithium citrate ..................................................................................... 31

l norgest/e. estradiol-e. estrad ..................................................... 51

lojaimiess ............................................................................................ 52

LONSURF ORAL TABLET 15-6.14 MG .................................... 19

LONSURF ORAL TABLET 20-8.19 MG .................................... 19

loperamide oral capsule ................................................................. 44

lopinavir-ritonavir oral solution ..................................................... 11

lopinavir-ritonavir oral tablet 100-25 mg .................................... 11

lopinavir-ritonavir oral tablet 200-50 mg .................................... 11

LOQTORZI ......................................................................................... 19

lorazepam injection solution ......................................................... 31

lorazepam injection syringe 2 mg/ml .......................................... 31

lorazepam intensol .......................................................................... 31

lorazepam oral concentrate .......................................................... 31

lorazepam oral syringe ................................................................... 31

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

lorazepam oral tablet 0.5 mg, 1 mg ............................................ 31

lorazepam oral tablet 2 mg ........................................................... 31

LORBRENA ORAL TABLET 25 MG ........................................... 19

LORBRENA ORAL TABLET 100 MG ......................................... 19

loryna (28) .......................................................................................... 52

losartan ............................................................................................... 34

losartan-hydrochlorothiazide oral tablet 50-12.5 mg ............. 34

losartan-hydrochlorothiazide oral tablet 100-12.5 mg,

100-25 mg .......................................................................................... 34

LOTEMAX OPHTHALMIC (EYE) OINTMENT ........................ 54

LOTEMAX SM .................................................................................. 54

loteprednol etabonate ..................................................................... 54

lovastatin oral tablet 10 mg ........................................................... 36

lovastatin oral tablet 20 mg, 40 mg ............................................. 36

low-ogestrel (28) .............................................................................. 52

loxapine succinate ........................................................................... 31

lo-zumandimine (28) ....................................................................... 52

ludent uoride oral tablet, chewable 1 mg (2.2 mg sod.

uoride) ............................................................................................... 57

LUMAKRAS ORAL TABLET 120 MG ........................................ 19

LUMAKRAS ORAL TABLET 320 MG ........................................ 19

LUMIGAN OPHTHALMIC (EYE) DROPS 0.01% ................... 53

LUMIZYME ........................................................................................ 44

LUNSUMIO ........................................................................................ 19

LUPRON DEPOT ............................................................................ 19

LUPRON DEPOT (3 MONTH) ..................................................... 19

LUPRON DEPOT (4 MONTH) ..................................................... 19

LUPRON DEPOT (6 MONTH) ..................................................... 19

LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR

SYRINGE KIT 11.25 MG ............................................................... 19

LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR

SYRINGE KIT 30 MG ..................................................................... 20

LUPRON DEPOT-PED INTRAMUSCULAR KIT .................... 20

LUPRON DEPOT-PED INTRAMUSCULAR SYRINGE

KIT ........................................................................................................ 20

lurasidone oral tablet 80 mg ......................................................... 31

lurasidone oral tablet 120 mg, 20 mg, 40 mg, 60 mg ............ 31

lutera (28) ........................................................................................... 52

LYNPARZA ........................................................................................ 20

LYSODREN ....................................................................................... 20

LYTGOBI ORAL TABLET 12 MG/DAY (4 MG X 3) ................ 20

LYTGOBI ORAL TABLET 16 MG/DAY (4 MG X 4) ................ 20

LYTGOBI ORAL TABLET 20 MG/DAY (4 MG X 5) ................ 20

LYUMJEV KWIKPEN U-100 INSULIN ....................................... 42

LYUMJEV KWIKPEN U-200 INSULIN ....................................... 42

LYUMJEV U-100 INSULIN ............................................................ 42

lyza ....................................................................................................... 50

magnesium sulfate in d5w intravenous piggyback

1 gram/100 ml ................................................................................... 56

magnesium sulfate injection ......................................................... 56

magnesium sulfate in water .......................................................... 56

malathion ............................................................................................ 39

maraviroc oral tablet 150 mg ........................................................ 11

maraviroc oral tablet 300 mg ........................................................ 11

MARGENZA ...................................................................................... 20

marlissa (28) ...................................................................................... 52

MARPLAN .......................................................................................... 31

MATULANE ....................................................................................... 20

matzim la ............................................................................................ 34

MAVYRET ORAL PELLETS IN PACKET ................................. 11

MAVYRET ORAL TABLET ............................................................ 11

meclizine oral tablet 12.5 mg, 25 mg ......................................... 45

medroxyprogesterone intramuscular ......................................... 50

medroxyprogesterone oral ............................................................ 50

meoquine ......................................................................................... 14

megestrol oral suspension 400 mg/10 ml (10 ml),

400 mg/10 ml (40 mg/ml), 800 mg/20 ml (20 ml) ................... 20

megestrol oral tablet 20 mg .......................................................... 20

megestrol oral tablet 40 mg .......................................................... 20

MEKINIST ORAL RECON SOLN ................................................ 20

MEKINIST ORAL TABLET 0.5 MG ............................................. 20

MEKINIST ORAL TABLET 2 MG ................................................. 20

MEKTOVI ........................................................................................... 20

meloxicam oral tablet 7.5 mg ....................................................... 28

meloxicam oral tablet 15 mg ......................................................... 28

melphalan hcl .................................................................................... 20

memantine oral solution ................................................................. 26

memantine oral tablet 5 mg .......................................................... 26

memantine oral tablet 10 mg ........................................................ 26

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

MEMANTINE ORAL TABLETS, DOSE PACK ......................... 26

MENACTRA (PF) INTRAMUSCULAR SOLUTION ............... 47

MENQUADFI (PF) ........................................................................... 47

MENVEO A-C-Y-W-135-DIP (PF) ............................................... 47

mercaptopurine ................................................................................. 20

MEROPENEM-0.9% SODIUM CHLORIDE ............................. 14

meropenem intravenous recon soln 1 gram, 500 mg ........... 14

merzee ................................................................................................ 52

mesalamine oral capsule, extended release 24hr ................. 45

mesalamine rectal enema ............................................................. 45

mesalamine with cleansing wipe ................................................. 45

mesna .................................................................................................. 16

MESNEX ORAL ............................................................................... 16

metadate er........................................................................................ 31

metformin oral solution ................................................................... 42

metformin oral tablet 1,000 mg .................................................... 42

metformin oral tablet 500 mg ........................................................ 42

metformin oral tablet 850 mg ........................................................ 42

metformin oral tablet extended release 24 hr 500 mg .......... 42

metformin oral tablet extended release 24 hr 750 mg .......... 42

methadone injection solution ........................................................ 27

methadone intensol ......................................................................... 27

methadone oral concentrate ......................................................... 27

methadone oral solution 5 mg/5 ml ............................................ 27

methadone oral solution 10 mg/5 ml .......................................... 27

methadone oral tablet 5 mg .......................................................... 27

methadone oral tablet 10 mg ........................................................ 27

methazolamide ................................................................................. 53

methenamine hippurate ................................................................. 15

methimazole oral tablet 10 mg, 5 mg ......................................... 41

methocarbamol oral tablet 500 mg, 750 mg ............................ 27

methotrexate sodium injection ..................................................... 20

methotrexate sodium oral .............................................................. 20

methotrexate sodium (pf) ............................................................... 20

methoxsalen ...................................................................................... 37

methsuximide .................................................................................... 24

methylphenidate hcl oral tablet .................................................... 31

methylphenidate hcl oral tablet extended release .................. 31

methylphenidate hcl oral tablet extended release 24hr

18 mg, 18 mg (bx rating), 27 mg, 27 mg (bx rating),

36 mg, 36 mg (bx rating), 54 mg, 54 mg (bx rating) .............. 31

methylpred dp ................................................................................... 41

methylprednisolone ......................................................................... 41

methylprednisolone acetate .......................................................... 41

methylprednisolone sodium succ injection recon soln

125 mg, 40 mg .................................................................................. 41

methylprednisolone sodium succ intravenous ........................ 41

metoclopramide hcl oral solution ................................................. 45

metoclopramide hcl oral tablet ..................................................... 45

metolazone ........................................................................................ 34

metoprolol succinate ....................................................................... 34

metoprolol ta-hydrochlorothiaz .................................................... 34

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg ........... 34

METRO I.V. ........................................................................................ 14

metronidazole in nacl (iso-os) ...................................................... 14

metronidazole oral tablet ............................................................... 14

metronidazole topical ...................................................................... 37

metronidazole vaginal gel 0.75% (37.5mg/5 gram) ............... 50

metyrosine ......................................................................................... 34

mexiletine ........................................................................................... 33

microgestin 1.5/30 (21) .................................................................. 52

microgestin 1/20 (21) ...................................................................... 52

microgestin fe 1.5/30 (28) .............................................................. 52

microgestin fe 1/20 (28) ................................................................. 52

midodrine ............................................................................................ 40

MIEBO (PF) ....................................................................................... 53

mifepristone oral tablet 300 mg ................................................... 44

miglustat ............................................................................................. 44

mili ........................................................................................................ 52

minocycline oral capsule................................................................ 15

minoxidil oral ..................................................................................... 34

mirtazapine oral tablet .................................................................... 31

mirtazapine oral tablet, disintegrating ........................................ 31

misoprostol ........................................................................................ 46

MITIGARE .......................................................................................... 48

mitomycin intravenous .................................................................... 20

mitoxantrone ...................................................................................... 20

M-M-R II (PF) .................................................................................... 47

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

M-NATAL PLUS ................................................................................ 57

modanil oral tablet 100 mg.......................................................... 31

modanil oral tablet 200 mg.......................................................... 31

moexipril ............................................................................................. 34

molindone oral tablet 5 mg ............................................................ 31

molindone oral tablet 10 mg, 25 mg ........................................... 31

mometasone topical ........................................................................ 39

MONJUVI ........................................................................................... 20

mono-linyah ....................................................................................... 52

montelukast oral granules in packet ........................................... 55

montelukast oral tablet ................................................................... 55

montelukast oral tablet, chewable .............................................. 55

morphine concentrate oral solution ............................................ 27

MORPHINE INJECTION SOLUTION ........................................ 27

MORPHINE INJECTION SYRINGE 2 MG/ML,

4 MG/ML ............................................................................................. 27

morphine intravenous solution 10 mg/ml, 4 mg/ml,

8 mg/ml ............................................................................................... 27

MORPHINE INTRAVENOUS SYRINGE 10 MG/ML,

2 MG/ML, 4 MG/ML ......................................................................... 27

morphine oral solution .................................................................... 27

morphine oral tablet ........................................................................ 27

morphine oral tablet extended release ...................................... 28

morphine (pf) injection solution 0.5 mg/ml, 1 mg/ml .............. 27

MOTPOLY XR ORAL CAPSULE, EXTENDED

RELEASE 24HR 100 MG .............................................................. 24

MOTPOLY XR ORAL CAPSULE, EXTENDED

RELEASE 24HR 150 MG, 200 MG ............................................ 24

MOUNJARO ...................................................................................... 42

MOVANTIK ........................................................................................ 45

moxioxacin ophthalmic (eye) ...................................................... 53

moxioxacin oral .............................................................................. 15

MOXIFLOXACIN-SOD.ACE, SUL-WATER .............................. 15

moxioxacin-sod.chloride (iso)..................................................... 15

MRESVIA (PF) .................................................................................. 47

mupirocin ............................................................................................ 38

mupirocin calcium ............................................................................ 38

MVASI ................................................................................................. 20

mycophenolate mofetil (hcl) .......................................................... 20

mycophenolate mofetil oral capsule ........................................... 20

mycophenolate mofetil oral suspension for reconstitution ... 20

mycophenolate mofetil oral tablet ............................................... 20

mycophenolate sodium .................................................................. 20

MYLOTARG ....................................................................................... 20

MYRBETRIQ ORAL TABLET EXTENDED RELEASE

24 HR .................................................................................................. 56

nabumetone ....................................................................................... 28

NAFCILLIN IN DEXTROSE ISO-OSM INTRAVENOUS

PIGGYBACK 2 GRAM/100 ML .................................................... 15

nafcillin injection ............................................................................... 15

NAGLAZYME .................................................................................... 44

naloxone injection solution ............................................................ 28

naloxone injection syringe 1 mg/ml ............................................ 28

naloxone nasal.................................................................................. 28

naltrexone .......................................................................................... 28

NAMZARIC ........................................................................................ 26

naproxen oral suspension ............................................................. 28

naproxen oral tablet ........................................................................ 28

naproxen oral tablet, delayed release (dr/ec) 375 mg .......... 28

naproxen oral tablet, delayed release (dr/ec) 500 mg .......... 28

naproxen sodium oral tablet 275 mg, 550 mg ......................... 28

naratriptan .......................................................................................... 26

NATACYN ........................................................................................... 53

nateglinide oral tablet 60 mg ........................................................ 42

nateglinide oral tablet 120 mg ...................................................... 42

NAYZILAM ......................................................................................... 24

necon 0.5/35 (28) ............................................................................. 52

nefazodone ........................................................................................ 31

nelarabine .......................................................................................... 20

neomycin ............................................................................................ 14

neomycin-bacitracin-poly-hc ......................................................... 54

neomycin-bacitracin-polymyxin.................................................... 53

neomycin-polymyxin b-dexameth ............................................... 54

neomycin-polymyxin b gu .............................................................. 39

neomycin-polymyxin-gramicidin .................................................. 53

neomycin-polymyxin-hc ophthalmic (eye) ................................ 54

neomycin-polymyxin-hc otic (ear) ............................................... 40

NERLYNX .......................................................................................... 20

nevirapine oral suspension ........................................................... 11

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

nevirapine oral tablet ...................................................................... 11

nevirapine oral tablet extended release 24 hr 100 mg.......... 11

nevirapine oral tablet extended release 24 hr 400 mg.......... 11

NEXAVAR ........................................................................................... 20

NEXLETOL ........................................................................................ 36

NEXLIZET .......................................................................................... 36

niacin oral tablet extended release 24 hr .................................. 36

nicardipine intravenous solution .................................................. 34

nicardipine oral ................................................................................. 34

NICOTROL ........................................................................................ 40

nifedipine oral tablet extended release ...................................... 34

nifedipine oral tablet extended release 24hr ............................ 34

nikki (28) ............................................................................................. 52

nilutamide ........................................................................................... 20

nimodipine .......................................................................................... 34

NINLARO ........................................................................................... 20

NIPENT ............................................................................................... 20

nitazoxanide ...................................................................................... 14

nitisinone ............................................................................................ 40

nitrofurantoin monohyd/m-cryst ................................................... 15

nitroglycerin intravenous ................................................................ 36

nitroglycerin rectal............................................................................ 45

nitroglycerin sublingual ................................................................... 36

nitroglycerin transdermal patch 24 hour .................................... 36

nitroglycerin translingual ................................................................ 36

NIVESTYM ........................................................................................ 46

NORA-BE ........................................................................................... 50

noreth-ethinyl estradiol-iron .......................................................... 52

norethindrone acetate ..................................................................... 50

norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg,

1.5-30 mg-mcg.................................................................................. 52

norethindrone (contraceptive) ...................................................... 50

norethindrone-e. estradiol-iron ..................................................... 52

norgestimate-ethinyl estradiol ...................................................... 52

nortrel 0.5/35 (28) ............................................................................ 52

nortrel 1/35 (21) ................................................................................ 52

nortrel 1/35 (28) ................................................................................ 52

nortrel 7/7/7 (28) ............................................................................... 52

nortriptyline oral capsule ................................................................ 31

nortriptyline oral solution ................................................................ 31

NORVIR ORAL POWDER IN PACKET ..................................... 11

NUBEQA ............................................................................................ 20

NUCALA SUBCUTANEOUS AUTO-INJECTOR ..................... 55

NUCALA SUBCUTANEOUS SYRINGE 40 MG/0.4 ML ....... 55

NUCALA SUBCUTANEOUS SYRINGE 100 MG/ML ............ 55

NUEDEXTA ....................................................................................... 26

NULOJIX ............................................................................................ 20

NUPLAZID ......................................................................................... 31

NURTEC ODT .................................................................................. 26

nyamyc ................................................................................................ 38

nylia 1/35 (28) ................................................................................... 52

nylia 7/7/7 (28) .................................................................................. 52

nymyo .................................................................................................. 52

nystatin oral ....................................................................................... 10

nystatin topical cream ..................................................................... 38

nystatin topical ointment ................................................................ 38

nystatin topical powder ................................................................... 38

nystatin-triamcinolone ..................................................................... 38

nystop .................................................................................................. 38

OCALIVA ............................................................................................ 45

ocella ................................................................................................... 52

OCREVUS ......................................................................................... 26

octreotide acetate ............................................................................ 20

ODEFSEY .......................................................................................... 11

ODOMZO ........................................................................................... 20

OFEV ................................................................................................... 55

ooxacin ophthalmic (eye) ............................................................ 53

ooxacin otic (ear) ........................................................................... 40

OGIVRI ............................................................................................... 20

OJEMDA ORAL TABLET 400 MG/WEEK (100 MG X 4) ..... 20

OJEMDA ORAL TABLET 500 MG/WEEK (100 MG X 5) ..... 20

OJEMDA ORAL TABLET 600 MG/WEEK (100 MG X 6) ..... 20

OJJAARA ........................................................................................... 20

olanzapine intramuscular ............................................................... 31

olanzapine oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg ............. 31

olanzapine oral tablet 15 mg, 20 mg .......................................... 31

olanzapine oral tablet, disintegrating 10 mg, 5 mg ................ 31

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

olanzapine oral tablet, disintegrating 15 mg, 20 mg .............. 31

olmesartan ......................................................................................... 34

olmesartan-hydrochlorothiazide .................................................. 34

omeprazole oral capsule, delayed release (dr/ec) ................. 46

OMNIPOD 5 G6 INTRO KIT (GEN 5) ........................................ 42

OMNIPOD 5 G6 PODS (GEN 5) ................................................. 42

OMNIPOD CLASSIC PODS (GEN 3) ........................................ 42

OMNIPOD DASH INTRO KIT (GEN 4) ..................................... 42

OMNIPOD DASH PODS (GEN 4) .............................................. 42

OMNIPOD GO PODS ..................................................................... 42

OMNIPOD GO PODS 10 UNITS/DAY ....................................... 42

OMNIPOD GO PODS 15 UNITS/DAY ....................................... 42

OMNIPOD GO PODS 20 UNITS/DAY ....................................... 42

OMNIPOD GO PODS 25 UNITS/DAY ....................................... 43

OMNIPOD GO PODS 30 UNITS/DAY ....................................... 43

OMNIPOD GO PODS 40 UNITS/DAY ....................................... 43

ONCASPAR ....................................................................................... 20

ondansetron hcl intravenous ........................................................ 45

ondansetron hcl oral solution ....................................................... 45

ondansetron hcl oral tablet 4 mg, 8 mg ..................................... 45

ondansetron hcl (pf) ........................................................................ 45

ondansetron oral tablet, disintegrating 4 mg, 8 mg................ 45

ONGENTYS ...................................................................................... 25

ONIVYDE ........................................................................................... 20

ONUREG ............................................................................................ 20

OPDIVO .............................................................................................. 20

OPDUALAG ....................................................................................... 21

OPSUMIT ........................................................................................... 55

oralone ................................................................................................ 40

ORENCIA CLICKJECT .................................................................. 50

ORENCIA SUBCUTANEOUS SYRINGE 50 MG/0.4 ML ..... 50

ORENCIA SUBCUTANEOUS SYRINGE 87.5 MG/0.7 ML ...... 50

ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML .......... 50

ORENITRAM ..................................................................................... 35

ORENITRAM MONTH 1 TITRATION KT .................................. 35

ORENITRAM MONTH 2 TITRATION KT .................................. 35

ORENITRAM MONTH 3 TITRATION KT .................................. 35

ORGOVYX ......................................................................................... 21

ORKAMBI ORAL GRANULES IN PACKET ............................. 55

ORKAMBI ORAL TABLET ............................................................. 55

ORSERDU ......................................................................................... 21

oseltamivir oral capsule ................................................................. 11

oseltamivir oral suspension for reconstitution ......................... 11

OTEZLA .............................................................................................. 50

OTEZLA STARTER ORAL TABLETS, DOSE

PACK 10 MG (4)-20 MG (4)-30 MG (47) .................................. 50

oxacillin ............................................................................................... 15

oxaliplatin ........................................................................................... 21

oxaprozin oral tablet ........................................................................ 28

oxcarbazepine oral suspension ................................................... 24

oxcarbazepine oral tablet .............................................................. 24

OXERVATE ........................................................................................ 53

oxybutynin chloride oral syrup ..................................................... 56

oxybutynin chloride oral tablet 5 mg ........................................... 56

oxybutynin chloride oral tablet extended release 24hr ......... 56

oxycodone-acetaminophen oral tablet 10-325 mg,

2.5-325 mg, 5-325 mg, 7.5-325 mg ............................................ 28

oxycodone oral tablet 5 mg ........................................................... 28

oxycodone oral tablet 10 mg, 15 mg, 20 mg, 30 mg ............. 28

oxymorphone oral tablet extended release 12 hr ................... 28

OZEMPIC SUBCUTANEOUS PEN INJECTOR

0.25 MG OR 0.5 MG (2 MG/3 ML), 1 MG/DOSE

(4 MG/3 ML), 2 MG/DOSE (8 MG/3 ML)................................... 43

pacerone oral tablet 100 mg, 400 mg ........................................ 33

pacerone oral tablet 200 mg ......................................................... 33

paclitaxel ............................................................................................. 21

PACLITAXEL PROTEIN-BOUND ................................................ 21

PADCEV ............................................................................................. 21

paliperidone oral tablet extended release 24hr

1.5 mg, 9 mg ..................................................................................... 31

paliperidone oral tablet extended release 24hr

3 mg, 6 mg ......................................................................................... 31

palonosetron intravenous solution 0.25 mg/5 ml .................... 45

pamidronate ....................................................................................... 44

PANRETIN ......................................................................................... 37

pantoprazole oral tablet, delayed release (dr/ec) ................... 46

PANZYGA .......................................................................................... 47

paricalcitol oral .................................................................................. 44

paromomycin ..................................................................................... 14

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

paroxetine hcl oral suspension .................................................... 31

paroxetine hcl oral tablet 10 mg .................................................. 31

paroxetine hcl oral tablet 20 mg, 40 mg .................................... 31

paroxetine hcl oral tablet 30 mg .................................................. 31

PAXLOVID ORAL TABLETS, DOSE PACK 150-100 MG .... 11

PAXLOVID ORAL TABLETS, DOSE PACK 300 MG (150 MG

X 2)-100 MG ...................................................................................... 11

pazopanib ........................................................................................... 21

PEDIARIX (PF) ................................................................................. 47

PEDVAX HIB (PF) ........................................................................... 47

peg 3350-electrolytes ..................................................................... 45

PEGASYS SUBCUTANEOUS SOLUTION .............................. 46

PEGASYS SUBCUTANEOUS SYRINGE ................................ 46

peg-electrolyte soln ......................................................................... 45

PEMAZYRE ....................................................................................... 21

pemetrexed disodium intravenous recon soln ......................... 21

PENBRAYA (PF) .............................................................................. 47

penicillamine ...................................................................................... 50

penicillin g potassium...................................................................... 15

penicillin v potassium ...................................................................... 15

PEN NEEDLE, DIABETIC NEEDLE 29 GAUGE X 1/2" ....... 47

PENTACEL (PF) INTRAMUSCULAR KIT

15LF-48MCG-62DU -10 MCG/0.5ML ........................................ 47

pentamidine inhalation ................................................................... 14

pentamidine injection ...................................................................... 14

PENTIPS ............................................................................................ 43

pentoxifylline ...................................................................................... 35

PERIKABIVEN .................................................................................. 57

perindopril erbumine ....................................................................... 35

periogard ............................................................................................ 40

PERJETA ........................................................................................... 21

permethrin .......................................................................................... 39

perphenazine .................................................................................... 31

perphenazine-amitriptyline ............................................................ 32

PERSERIS ......................................................................................... 32

pzerpen-g ......................................................................................... 15

phenelzine .......................................................................................... 32

phenobarbital oral elixir .................................................................. 24

phenobarbital oral tablet ................................................................ 24

phenobarbital sodium injection solution .................................... 24

phenytoin oral suspension ............................................................ 24

phenytoin oral tablet, chewable ................................................... 24

phenytoin sodium extended oral capsule 100 mg, 200 mg ...... 24

phenytoin sodium extended oral capsule 300 mg .................. 24

phenytoin sodium intravenous solution ..................................... 24

PHESGO ............................................................................................ 21

philith ................................................................................................... 52

PIFELTRO .......................................................................................... 11

pilocarpine hcl ophthalmic (eye) drops 1%, 2%, 4% ............. 53

pilocarpine hcl oral ........................................................................... 40

pimozide ............................................................................................. 32

pimtrea (28) ....................................................................................... 52

pindolol ................................................................................................ 35

pioglitazone........................................................................................ 43

piperacillin-tazobactam .................................................................. 15

PIQRAY ............................................................................................... 21

pirfenidone oral capsule ................................................................. 55

pirfenidone oral tablet 267 mg ..................................................... 55

pirfenidone oral tablet 534 mg, 801 mg ..................................... 55

pitavastatin calcium ......................................................................... 36

plenamine ........................................................................................... 57

PLERIXAFOR ................................................................................... 46

PNV-DHA ........................................................................................... 57

PNV-OMEGA .................................................................................... 57

PNV-SELECT .................................................................................... 57

podolox topical solution................................................................ 37

POLIVY ............................................................................................... 21

polycin ................................................................................................. 53

polymyxin b sulf-trimethoprim ...................................................... 53

POMALYST ....................................................................................... 21

portia 28 .............................................................................................. 52

PORTRAZZA .................................................................................... 21

posaconazole oral tablet, delayed release (dr/ec) ................. 10

POTASSIUM CHLORID-D5-0.45% NACL ............................... 56

potassium chloride-0.45% nacl .................................................... 57

POTASSIUM CHLORIDE-D5-0.2% NACL

INTRAVENOUS PARENTERAL SOLUTION

20 MEQ/L ........................................................................................... 57

POTASSIUM CHLORIDE-D5-0.9% NACL ............................... 57

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

POTASSIUM CHLORIDE IN 0.9% NACL

INTRAVENOUS PARENTERAL SOLUTION

20 MEQ/L, 40 MEQ/L ..................................................................... 56

potassium chloride in 5% dex intravenous

parenteral solution 10 meq/l ......................................................... 56

POTASSIUM CHLORIDE IN 5% DEX INTRAVENOUS

PARENTERAL SOLUTION 20 MEQ/L ...................................... 56

POTASSIUM CHLORIDE IN LR-D5 INTRAVENOUS

PARENTERAL SOLUTION 20 MEQ/L ...................................... 56

potassium chloride intravenous ................................................... 56

potassium chloride in water intravenous piggyback

10 meq/100 ml, 10 meq/50 ml, 20 meq/100 ml,

20 meq/50 ml, 40 meq/100 ml ..................................................... 56

potassium chloride oral capsule, extended release ............... 56

potassium chloride oral liquid ....................................................... 56

potassium chloride oral packet .................................................... 56

potassium chloride oral tablet, er particles/crystals ............... 57

potassium chloride oral tablet extended release .................... 56

potassium citrate oral tablet extended release ....................... 56

POTELIGEO ...................................................................................... 21

PRALATREXATE ............................................................................. 21

pramipexole oral tablet ................................................................... 25

prasugrel ............................................................................................. 35

pravastatin ......................................................................................... 36

praziquantel ....................................................................................... 14

prazosin .............................................................................................. 35

PREDNISOLONE ACETATE ........................................................ 54

prednisolone oral solution ............................................................. 41

prednisolone sodium phosphate ophthalmic (eye) ................ 54

prednisolone sodium phosphate oral solution

15 mg/5 ml (3 mg/ml), 15 mg/5 ml (5 ml), 25 mg/5 ml

(5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml) .................................. 41

prednisone intensol ......................................................................... 41

prednisone oral solution ................................................................. 41

prednisone oral tablet ..................................................................... 41

prednisone oral tablets, dose pack ............................................. 41

pregabalin oral capsule 100 mg, 150 mg, 25 mg,

50 mg, 75 mg .................................................................................... 25

pregabalin oral capsule 200 mg .................................................. 25

pregabalin oral capsule 225 mg, 300 mg.................................. 25

pregabalin oral solution .................................................................. 25

PREHEVBRIO (PF) ......................................................................... 47

PREMARIN INJECTION ................................................................ 50

PREMARIN ORAL ........................................................................... 50

PREMARIN VAGINAL .................................................................... 50

premasol 10% ................................................................................... 57

PREMPRO ......................................................................................... 50

PRENATAL PLUS (CALCIUM CARB) ....................................... 57

PRENATAL VITAMIN PLUS LOW IRON ................................... 57

prevalite .............................................................................................. 36

PREVYMIS ........................................................................................ 11

PREZCOBIX ...................................................................................... 11

PREZISTA ORAL SUSPENSION ................................................ 11

PREZISTA ORAL TABLET 75 MG .............................................. 11

PREZISTA ORAL TABLET 150 MG ............................................ 11

PRIFTIN .............................................................................................. 14

primaquine ......................................................................................... 14

primidone oral tablet 125 mg ........................................................ 25

primidone oral tablet 250 mg, 50 mg ......................................... 25

PRIORIX (PF) ................................................................................... 47

PR NATAL 400 .................................................................................. 57

PR NATAL 400 EC ........................................................................... 57

PR NATAL 430 .................................................................................. 57

PR NATAL 430 EC ........................................................................... 57

probenecid ......................................................................................... 48

probenecid-colchicine ..................................................................... 48

prochlorperazine .............................................................................. 45

prochlorperazine edisylate injection solution

10 mg/2 ml (5 mg/ml) ...................................................................... 45

prochlorperazine maleate .............................................................. 45

PROCRIT ........................................................................................... 46

procto-med hc ................................................................................... 45

proctosol hc topical .......................................................................... 45

proctozone-hc ................................................................................... 45

progesterone micronized ............................................................... 50

PROGRAF INTRAVENOUS ......................................................... 21

PROGRAF ORAL GRANULES IN PACKET ............................ 21

PROLASTIN-C INTRAVENOUS SOLUTION .......................... 40

PROLIA ............................................................................................... 48

PROMACTA ORAL POWDER IN PACKET 12.5 MG ............ 35

PROMACTA ORAL POWDER IN PACKET 25 MG ............... 36

PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG ........ 36

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

PROMACTA ORAL TABLET 75 MG ........................................... 36

promethazine oral syrup ................................................................ 54

promethazine oral tablet ................................................................ 54

propafenone ...................................................................................... 33

propranolol oral capsule, extended release 24 hr .................. 35

propranolol oral solution ................................................................ 35

propranolol oral tablet ..................................................................... 35

propylthiouracil.................................................................................. 41

PROQUAD (PF) ............................................................................... 47

PROSOL 20% ................................................................................... 57

protriptyline ........................................................................................ 32

PULMOZYME ................................................................................... 55

PURIXAN ........................................................................................... 21

pyrazinamide ..................................................................................... 14

pyridostigmine bromide oral tablet 60 mg ................................. 27

pyridostigmine bromide oral tablet extended release ........... 27

pyrimethamine .................................................................................. 14

QINLOCK ........................................................................................... 21

QUADRACEL (PF) .......................................................................... 47

quetiapine oral tablet 100 mg, 25 mg, 50 mg .......................... 32

quetiapine oral tablet 150 mg, 200 mg ...................................... 32

quetiapine oral tablet 300 mg, 400 mg ...................................... 32

QUILLICHEW ER ORAL TABLET, CHEW, IR-ER.

BIPHASIC24HR 20 MG, 30 MG .................................................. 32

QUILLICHEW ER ORAL TABLET, CHEW, IR-ER.

BIPHASIC24HR 40 MG ................................................................. 32

quinapril .............................................................................................. 35

quinapril-hydrochlorothiazide ....................................................... 35

quinidine sulfate oral tablet ........................................................... 33

quinine sulfate ................................................................................... 14

RABAVERT (PF) .............................................................................. 47

RADICAVA ......................................................................................... 26

raloxifene ............................................................................................ 48

ramipril ................................................................................................ 35

ranolazine ........................................................................................... 36

rasagiline ............................................................................................ 25

RAYALDEE ........................................................................................ 44

reclipsen (28) .................................................................................... 52

RECOMBIVAX HB (PF) ................................................................. 47

RECTIV ............................................................................................... 45

REGRANEX ...................................................................................... 37

REMICADE ........................................................................................ 45

RENACIDIN ....................................................................................... 56

repaglinide oral tablet 0.5 mg ....................................................... 43

repaglinide oral tablet 1 mg .......................................................... 43

repaglinide oral tablet 2 mg .......................................................... 43

REPATHA PUSHTRONEX ............................................................ 36

REPATHA SURECLICK ................................................................. 36

REPATHA SYRINGE ...................................................................... 36

RETACRIT ......................................................................................... 46

RETEVMO ORAL CAPSULE 40 MG ......................................... 21

RETEVMO ORAL CAPSULE 80 MG ......................................... 21

RETROVIR INTRAVENOUS ........................................................ 11

REXULTI ORAL TABLET ............................................................... 32

REYATAZ ORAL POWDER IN PACKET................................... 11

REZDIFFRA ...................................................................................... 40

REZLIDHIA ........................................................................................ 21

REZUROCK ...................................................................................... 21

RHOPRESSA ................................................................................... 53

ribavirin oral capsule ....................................................................... 12

ribavirin oral tablet 200 mg ............................................................ 12

rifabutin ............................................................................................... 14

rifampin ............................................................................................... 14

riluzole ................................................................................................. 40

rimantadine ........................................................................................ 12

RINGER'S INTRAVENOUS .......................................................... 57

RINGER'S IRRIGATION ................................................................ 39

RINVOQ LQ ....................................................................................... 50

RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR

15 MG, 30 MG .................................................................................. 50

RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR

45 MG .................................................................................................. 50

RISPERDAL CONSTA ................................................................... 32

risperidone oral solution ................................................................. 32

risperidone oral tablet 0.25 mg, 0.5 mg, 4 mg ......................... 32

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

risperidone oral tablet 1 mg .......................................................... 32

risperidone oral tablet 2 mg .......................................................... 32

risperidone oral tablet 3 mg .......................................................... 32

risperidone oral tablet, disintegrating 0.25 mg, 0.5 mg,

4 mg ..................................................................................................... 32

risperidone oral tablet, disintegrating 1 mg .............................. 32

risperidone oral tablet, disintegrating 2 mg .............................. 32

risperidone oral tablet, disintegrating 3 mg .............................. 32

ritonavir ............................................................................................... 12

rivastigmine........................................................................................ 26

rivastigmine tartrate ......................................................................... 27

RIVELSA ............................................................................................ 52

rizatriptan oral tablet ....................................................................... 26

rizatriptan oral tablet, disintegrating ........................................... 26

ROCKLATAN ..................................................................................... 53

roumilast ........................................................................................... 55

romidepsin intravenous recon soln ............................................. 21

ROMIDEPSIN INTRAVENOUS SOLUTION ............................ 21

ropinirole oral tablet ......................................................................... 25

rosuvastatin ....................................................................................... 36

ROTARIX ............................................................................................ 47

ROTATEQ VACCINE ...................................................................... 47

roweepra oral tablet 500 mg ......................................................... 25

ROZLYTREK ORAL CAPSULE 100 MG .................................. 21

ROZLYTREK ORAL CAPSULE 200 MG .................................. 21

ROZLYTREK ORAL PELLETS IN PACKET ............................ 21

RUBRACA ......................................................................................... 21

runamide oral suspension ........................................................... 25

runamide oral tablet ...................................................................... 25

RUKOBIA ........................................................................................... 12

RUXIENCE ........................................................................................ 21

RYALTRIS .......................................................................................... 55

RYBELSUS ........................................................................................ 43

RYBREVANT ..................................................................................... 21

RYDAPT ............................................................................................. 21

RYLAZE .............................................................................................. 21

RYTARY.............................................................................................. 25

sajazir .................................................................................................. 55

SANCUSO

......................................................................................... 45

SANDIMMUNE ORAL SOLUTION ............................................. 21

SANTYL .............................................................................................. 37

sapropterin ......................................................................................... 44

SARCLISA ......................................................................................... 21

SCEMBLIX ORAL TABLET 20 MG ............................................. 21

SCEMBLIX ORAL TABLET 40 MG

............................................. 21

SCEMBLIX ORAL TABLET 100 MG .......................................... 21

scopolamine base ............................................................................ 45

SECUADO ......................................................................................... 32

selegiline hcl ...................................................................................... 25

selenium sulde topical lotion ...................................................... 37

SELZENTRY ORAL SOLUTION

................................................. 12

SELZENTRY ORAL TABLET 25 MG ......................................... 12

SELZENTRY ORAL TABLET 75 MG ......................................... 12

SE-NATAL-19 .................................................................................... 57

SE-NATAL 19 CHEWABLE ........................................................... 57

SEREVENT DISKUS ...................................................................... 55

sertraline oral concentrate

............................................................. 32

sertraline oral tablet ......................................................................... 32

setlakin ................................................................................................ 52

sharobel .............................................................................................. 50

SHINGRIX (PF) ................................................................................ 47

SIGNIFOR .......................................................................................... 21

sildenal (pulm. hypertension) oral tablet

................................. 55

SILVER SULFADIAZINE ................................................................ 37

SIMBRINZA ....................................................................................... 53

simliya (28) ........................................................................................ 52

simpesse ............................................................................................ 52

SIMULECT ......................................................................................... 21

simvastatin

......................................................................................... 36

sirolimus.............................................................................................. 21

SIRTURO ........................................................................................... 14

SIVEXTRO INTRAVENOUS ......................................................... 14

SIVEXTRO ORAL ............................................................................ 14

SKYRIZI INTRAVENOUS .............................................................. 45

SKYRIZI SUBCUTANEOUS PEN INJECTOR

........................ 37

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

SKYRIZI SUBCUTANEOUS SYRINGE 150 MG/ML ............. 37

SKYRIZI SUBCUTANEOUS WEARABLE INJECTOR

180 MG/1.2 ML (150 MG/ML) ...................................................... 45

SKYRIZI SUBCUTANEOUS WEARABLE INJECTOR

360 MG/2.4 ML (150 MG/ML) ...................................................... 45

sodium bicarbonate intravenous syringe .................................. 57

SODIUM CHLORIDE 0.9% INTRAVENOUS ........................... 40

sodium chloride 0.45% intravenous ........................................... 57

sodium chloride 3% hypertonic .................................................... 57

SODIUM CHLORIDE 5% HYPERTONIC ................................. 57

sodium chloride intravenous ......................................................... 57

SODIUM CHLORIDE IRRIGATION ............................................ 40

sodium uoride 5000 dry mouth .................................................. 40

sodium uoride 5000 plus ............................................................. 40

sodium uoride-pot nitrate ............................................................. 40

SODIUM OXYBATE ........................................................................ 32

sodium phenylbutyrate ................................................................... 40

sodium polystyrene sulfonate oral powder ............................... 40

sodium, potassium, mag sulfates oral recon soln

17.5-3.13-1.6 gram .......................................................................... 45

SODIUM, POTASSIUM, MAG SULFATES ORAL

RECON SOLN 17.5-3.13-1.6 GRAM 2 PACK (480ML) ....... 45

SOLIQUA 100/33 ............................................................................. 43

SOLTAMOX ....................................................................................... 21

SOLU-CORTEF ACT-O-VIAL (PF) ............................................. 41

SOMATULINE DEPOT ................................................................... 21

SOMAVERT ....................................................................................... 44

sorafenib ............................................................................................. 21

sorine oral tablet 120 mg, 160 mg .............................................. 33

sotalol af ............................................................................................. 33

sotalol oral .......................................................................................... 33

SOTYLIZE .......................................................................................... 33

spironolactone oral tablet .............................................................. 35

spironolacton-hydrochlorothiaz .................................................... 35

SPRAVATO NASAL SPRAY, NON-AEROSOL 56 MG

(28 MG X 2) ....................................................................................... 32

SPRAVATO NASAL SPRAY, NON-AEROSOL 84 MG

(28 MG X 3) ....................................................................................... 32

sprintec (28) ....................................................................................... 52

SPRITAM ............................................................................................ 25

SPRYCEL ORAL TABLET 20 MG, 70 MG ............................... 21

SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG,

80 MG .................................................................................................. 21

sps (with sorbitol) oral ..................................................................... 40

sronyx .................................................................................................. 52

SSD ...................................................................................................... 37

STAMARIL (PF) ................................................................................ 47

STELARA SUBCUTANEOUS SOLUTION ............................... 37

STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML ..... 37

STELARA SUBCUTANEOUS SYRINGE 90 MG/ML ............ 37

STIVARGA ......................................................................................... 21

streptomycin ...................................................................................... 14

STRIBILD ........................................................................................... 12

subvenite ............................................................................................ 25

subvenite starter (blue) kit ............................................................. 25

subvenite starter (green) kit .......................................................... 25

subvenite starter (orange) kit ........................................................ 25

SUCRAID ........................................................................................... 45

sucralfate oral tablet ........................................................................ 46

SUFLAVE ........................................................................................... 45

sulfacetamide-prednisolone .......................................................... 53

sulfacetamide sodium (acne) ....................................................... 38

sulfacetamide sodium ophthalmic (eye) drops ........................ 53

sulfadiazine ........................................................................................ 15

sulfamethoxazole-trimethoprim intravenous ............................ 15

sulfamethoxazole-trimethoprim oral suspension .................... 15

sulfamethoxazole-trimethoprim oral tablet ............................... 15

sulfasalazine oral tablet ................................................................. 45

SULFASALAZINE ORAL TABLET, DELAYED

RELEASE (DR/EC) ......................................................................... 45

sulindac ............................................................................................... 28

sumatriptan nasal spray,

non-aerosol 5 mg/actuation .......................................................... 26

sumatriptan nasal spray,

non-aerosol 20 mg/actuation ........................................................ 26

sumatriptan succinate oral ............................................................ 26

SUMATRIPTAN SUCCINATE SUBCUTANEOUS

CARTRIDGE ..................................................................................... 26

sumatriptan succinate subcutaneous pen injector ................. 26

sumatriptan succinate subcutaneous solution ........................ 26

sunitinib malate ................................................................................. 21

SUNLENCA ....................................................................................... 12

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

SUTAB ................................................................................................ 45

syeda ................................................................................................... 52

SYMPAZAN ....................................................................................... 25

SYMTUZA .......................................................................................... 12

SYNAREL .......................................................................................... 44

SYNJARDY........................................................................................ 43

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC

24HR 10-1,000 MG, 12.5-1,000 MG, 5-1,000 MG ................. 43

SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC

24HR 25-1,000 MG ......................................................................... 43

SYNTHROID ..................................................................................... 44

TABLOID ............................................................................................ 22

TABRECTA ........................................................................................ 22

tacrolimus oral capsule .................................................................. 22

tacrolimus topical ............................................................................. 37

TAFINLAR ORAL CAPSULE ........................................................ 22

TAFINLAR ORAL TABLET FOR SUSPENSION .................... 22

TAGRISSO ......................................................................................... 22

TALICIA ............................................................................................... 46

TALTZ AUTOINJECTOR ................................................................ 37

TALTZ SYRINGE ............................................................................. 37

TALVEY ............................................................................................... 22

TALZENNA ORAL CAPSULE 0.1 MG, 0.35 MG, 0.5 MG,

0.75 MG, 1 MG ................................................................................. 22

TALZENNA ORAL CAPSULE 0.25 MG ..................................... 22

tamoxifen ............................................................................................ 22

tamsulosin .......................................................................................... 56

tarina 24 fe ......................................................................................... 52

tarina fe 1-20 eq (28) ...................................................................... 52

TARON-C DHA ................................................................................. 57

TASIGNA ORAL CAPSULE 50 MG ............................................ 22

TASIGNA ORAL CAPSULE 150 MG, 200 MG ........................ 22

tasimelteon ........................................................................................ 32

tazarotene topical cream ............................................................... 37

tazarotene topical gel...................................................................... 37

tazicef .................................................................................................. 13

TAZVERIK .......................................................................................... 22

TDVAX ................................................................................................ 47

TECENTRIQ ...................................................................................... 22

TECHLITE INSULIN SYR(HALF UNIT) SYRINGE 0.3 ML

31 GAUGE X 15/64", 0.3 ML 31 GAUGE X 5/16", 0.5 ML

30 GAUGE X 1/2", 0.5 ML 31 GAUGE X 15/64", 0.5 ML

31 GAUGE X 5/16" ........................................................................... 48

TECHLITE INSULIN SYRINGE SYRINGE 1 ML 30

GAUGE X 1/2", 1 ML 31 GAUGE X 15/64", 1 ML 31

GAUGE X 5/16 ................................................................................. 48

TECHLITE PEN NEEDLE NEEDLE 29 GAUGE X

1/2", 31 GAUGE X 3/16", 31 GAUGE X 5/16",

32 GAUGE X 1/4", 32 GAUGE X 5/32" ..................................... 48

TECVAYLI .......................................................................................... 22

TEFLARO ........................................................................................... 13

telmisartan ......................................................................................... 35

TEMODAR INTRAVENOUS ......................................................... 22

temsirolimus ...................................................................................... 22

TENIVAC (PF) ................................................................................... 47

tenofovir disoproxil fumarate ........................................................ 12

TEPMETKO ....................................................................................... 22

terazosin oral capsule 1 mg, 2 mg, 5 mg .................................. 35

terazosin oral capsule 10 mg ....................................................... 35

terbinane hcl oral ........................................................................... 10

terbutaline .......................................................................................... 55

terconazole ........................................................................................ 50

testosterone cypionate ................................................................... 44

testosterone enanthate .................................................................. 44

testosterone transdermal gel ........................................................ 44

testosterone transdermal gel in metered-dose

pump 12.5 mg/ 1.25 gram (1%) ................................................... 44

testosterone transdermal gel in packet 1%

(25 mg/2.5gram), 1% (50 mg/5 gram) ....................................... 44

TETANUS, DIPHTHERIA TOX PED (PF) ................................. 47

tetrabenazine oral tablet 12.5 mg ............................................... 27

tetrabenazine oral tablet 25 mg ................................................... 27

tetracycline oral capsule ................................................................ 15

THALOMID ORAL CAPSULE 100 MG, 50 MG ...................... 22

THALOMID ORAL CAPSULE 150 MG, 200 MG .................... 22

theophylline oral tablet extended release 12 hr 100 mg,

200 mg, 300 mg ............................................................................... 55

theophylline oral tablet extended release 12 hr 450 mg ...... 55

theophylline oral tablet extended release 24 hr 400 mg ...... 55

theophylline oral tablet extended release 24 hr 600 mg ...... 55

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

thioridazine ........................................................................................ 32

thiotepa ............................................................................................... 22

thiothixene .......................................................................................... 32

tiadylt er .............................................................................................. 35

tiagabine ............................................................................................. 25

TIBSOVO ........................................................................................... 22

TICE BCG .......................................................................................... 47

TICOVAC INTRAMUSCULAR SYRINGE

1.2 MCG/0.25 ML ............................................................................ 47

TICOVAC INTRAMUSCULAR SYRINGE

2.4 MCG/0.5 ML ............................................................................... 47

tigecycline .......................................................................................... 14

tilia fe ................................................................................................... 52

timolol maleate ophthalmic (eye) drops .................................... 53

timolol maleate ophthalmic (eye) gel forming solution .......... 53

timolol maleate oral ......................................................................... 35

TIS-U-SOL PENTALYTE ................................................................ 39

TIVDAK ............................................................................................... 22

TIVICAY ORAL TABLET 10 MG .................................................. 12

TIVICAY ORAL TABLET 25 MG, 50 MG ................................... 12

TIVICAY PD ....................................................................................... 12

tizanidine oral tablet ........................................................................ 27

TOBRADEX ST ................................................................................ 54

tobramycin-dexamethasone ......................................................... 54

tobramycin in 0.225% nacl ............................................................ 14

tobramycin ophthalmic (eye) ........................................................ 53

tobramycin sulfate............................................................................ 14

tolterodine oral capsule, extended release 24hr ..................... 56

tolterodine oral tablet ...................................................................... 56

TOLVAPTAN ORAL TABLET 15 MG .......................................... 44

tolvaptan oral tablet 30 mg ............................................................ 44

topiramate oral capsule, sprinkle ................................................ 25

topiramate oral tablet ...................................................................... 25

topotecan intravenous recon soln ............................................... 22

topotecan intravenous solution .................................................... 22

toremifene .......................................................................................... 22

torsemide oral ................................................................................... 35

TOUJEO MAX U-300 SOLOSTAR ............................................. 43

TOUJEO SOLOSTAR U-300 INSULIN ...................................... 43

TRADJENTA ..................................................................................... 43

tramadol-acetaminophen ............................................................... 28

tramadol oral tablet 50 mg ............................................................ 28

trandolapril ......................................................................................... 35

tranexamic acid oral ........................................................................ 50

tranylcypromine ................................................................................ 32

TRAVASOL 10% .............................................................................. 57

TRAZIMERA ...................................................................................... 22

trazodone ........................................................................................... 32

TREANDA .......................................................................................... 22

TRECATOR ....................................................................................... 14

TRELEGY ELLIPTA ........................................................................ 55

TRELSTAR INTRAMUSCULAR SUSPENSION FOR

RECONSTITUTION ........................................................................ 22

TRESIBA FLEXTOUCH U-100 .................................................... 43

TRESIBA FLEXTOUCH U-200 .................................................... 43

TRESIBA U-100 INSULIN ............................................................. 43

tretinoin (antineoplastic) ................................................................. 22

tretinoin microspheres topical gel 0.1% .................................... 38

tretinoin microspheres topical gel with pump 0.1% ................ 38

tretinoin topical cream .................................................................... 38

tretinoin topical gel 0.01% ............................................................. 38

tretinoin topical gel 0.025%, 0.05% ............................................ 38

triamcinolone acetonide dental .................................................... 40

triamcinolone acetonide injection suspension 40 mg/ml ...... 41

triamcinolone acetonide topical cream ...................................... 39

triamcinolone acetonide topical lotion ........................................ 39

triamcinolone acetonide topical ointment 0.025%,

0.1%, 0.5% ........................................................................................ 39

triamterene-hydrochlorothiazid .................................................... 35

triderm topical cream 0.1% ........................................................... 39

trientine oral capsule 250 mg ....................................................... 40

tri-estarylla ......................................................................................... 52

triuoperazine oral tablet 1 mg .................................................... 32

triuoperazine oral tablet 10 mg, 2 mg, 5 mg .......................... 32

triuridine ............................................................................................ 53

TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC

24HR 10-5-1,000 MG, 25-5-1,000 MG ...................................... 43

TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC

24HR 12.5-2.5-1,000 MG, 5-2.5-1,000 MG ............................. 43

TRIKAFTA ORAL GRANULES IN PACKET, SEQUENTIAL .... 55

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

TRIKAFTA ORAL TABLETS, SEQUENTIAL ............................ 55

tri-legest fe ......................................................................................... 52

tri-linyah .............................................................................................. 52

tri-lo-estarylla ..................................................................................... 52

tri-lo-marzia ........................................................................................ 52

tri-lo-mili .............................................................................................. 52

tri-lo-sprintec ...................................................................................... 52

trimethoprim ....................................................................................... 15

tri-mili ................................................................................................... 52

trimipramine ....................................................................................... 32

TRINATAL RX 1 ................................................................................ 57

TRINTELLIX ...................................................................................... 32

tri-nymyo ............................................................................................. 52

TRIPTODUR ..................................................................................... 22

tri-sprintec (28).................................................................................. 52

TRIUMEQ ........................................................................................... 12

TRIUMEQ PD ................................................................................... 12

trivora (28) .......................................................................................... 52

tri-vylibra ............................................................................................. 52

tri-vylibra lo ........................................................................................ 52

TRIZIVIR ............................................................................................. 12

TRODELVY ........................................................................................ 22

TROGARZO ...................................................................................... 12

TROPHAMINE 10% ........................................................................ 57

TRUEPLUS INSULIN ..................................................................... 43

TRUEPLUS PEN NEEDLE ........................................................... 43

TRULANCE ....................................................................................... 45

TRULICITY ........................................................................................ 43

TRUMENBA ...................................................................................... 47

TRUQAP ............................................................................................. 22

TRUXIMA ........................................................................................... 22

TUKYSA ORAL TABLET 50 MG.................................................. 22

TUKYSA ORAL TABLET 150 MG ............................................... 22

TURALIO ORAL CAPSULE 125 MG ......................................... 22

turqoz (28) .......................................................................................... 52

TWINRIX (PF) ................................................................................... 47

TYBLUME .......................................................................................... 52

tydemy ................................................................................................. 52

TYMLOS ............................................................................................. 48

TYPHIM VI ......................................................................................... 47

TYVASO ............................................................................................. 55

TYVASO INSTITUTIONAL START KIT ..................................... 55

TYVASO REFILL KIT ...................................................................... 55

TYVASO STARTER KIT ................................................................ 55

TZIELD ................................................................................................ 40

UNIFINE PENTIPS MAXFLOW ................................................... 43

UNIFINE PENTIPS NEEDLE 29 GAUGE X 1/2", 31

GAUGE X 1/4", 31 GAUGE X 3/16", 31 GAUGE X

5/16", 32 GAUGE X 1/4", 32 GAUGE X 5/32", 33

GAUGE X 5/32" ................................................................................ 43

UNIFINE PENTIPS PLUS ............................................................. 43

UNIFINE PENTIPS PLUS MAXFLOW ...................................... 43

UNIFINE SAFECONTROL ............................................................ 43

UNIFINE ULTRA PEN NEEDLE .................................................. 43

UNITHROID ....................................................................................... 44

UNITUXIN .......................................................................................... 22

ursodiol oral capsule 300 mg ....................................................... 45

ursodiol oral tablet ........................................................................... 45

UZEDY SUBCUTANEOUS SUSPENSION,

EXTENDED REL SYRING 50 MG/0.14 ML ............................. 32

UZEDY SUBCUTANEOUS SUSPENSION,

EXTENDED REL SYRING 75 MG/0.21 ML ............................. 32

UZEDY SUBCUTANEOUS SUSPENSION,

EXTENDED REL SYRING 100 MG/0.28 ML........................... 32

UZEDY SUBCUTANEOUS SUSPENSION,

EXTENDED REL SYRING 125 MG/0.35 ML........................... 32

UZEDY SUBCUTANEOUS SUSPENSION,

EXTENDED REL SYRING 150 MG/0.42 ML........................... 32

UZEDY SUBCUTANEOUS SUSPENSION,

EXTENDED REL SYRING 200 MG/0.56 ML........................... 32

UZEDY SUBCUTANEOUS SUSPENSION,

EXTENDED REL SYRING 250 MG/0.7 ML ............................. 32

valacyclovir oral tablet 1 gram ..................................................... 12

valacyclovir oral tablet 500 mg .................................................... 12

VALCHLOR ........................................................................................ 37

valganciclovir oral recon soln ....................................................... 12

valganciclovir oral tablet ................................................................ 12

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

valproate sodium .............................................................................. 25

valproic acid ....................................................................................... 25

valproic acid (as sodium salt) ....................................................... 25

valrubicin ............................................................................................ 22

valsartan-hydrochlorothiazide ...................................................... 35

valsartan oral tablet 160 mg, 40 mg, 80 mg ............................ 35

valsartan oral tablet 320 mg ......................................................... 35

VALTOCO ........................................................................................... 25

VANCOMYCIN-DILUENT COMBO NO.1 ................................. 14

VANCOMYCIN IN 0.9% SODIUM CHL INTRAVENOUS

PIGGYBACK ..................................................................................... 14

VANCOMYCIN IN DEXTROSE 5% INTRAVENOUS

PIGGYBACK 1.25 GRAM/250 ML, 1.5 GRAM/300 ML ........ 16

VANCOMYCIN IN DEXTROSE 5% INTRAVENOUS

PIGGYBACK 1 GRAM/200 ML, 500 MG/100 ML,

750 MG/150 ML ................................................................................ 14

vancomycin injection ....................................................................... 14

vancomycin intravenous recon soln 1,000 mg,

1.25 gram, 1.5 gram, 10 gram, 5 gram, 500 mg,

750 mg ................................................................................................ 14

vancomycin oral capsule 125 mg ................................................ 14

vancomycin oral capsule 250 mg ................................................ 14

vancomycin oral recon soln 25 mg/ml ....................................... 14

VANDAZOLE ..................................................................................... 50

VANFLYTA ......................................................................................... 22

VAQTA (PF) INTRAMUSCULAR SUSPENSION

25 UNIT/0.5 ML ................................................................................ 47

VAQTA (PF) INTRAMUSCULAR SUSPENSION

50 UNIT/ML ....................................................................................... 47

VAQTA (PF) INTRAMUSCULAR SYRINGE

25 UNIT/0.5 ML ................................................................................ 47

VAQTA (PF) INTRAMUSCULAR SYRINGE

50 UNIT/ML ....................................................................................... 47

varenicline .......................................................................................... 40

VARIVAX (PF) ................................................................................... 47

VARIZIG .............................................................................................. 47

VECTIBIX ........................................................................................... 22

VEKLURY .......................................................................................... 12

velivet triphasic regimen (28) ....................................................... 52

VELPHORO ....................................................................................... 40

VELTASSA ......................................................................................... 40

VEMLIDY ............................................................................................ 12

VENCLEXTA ORAL TABLET 10 MG ......................................... 22

VENCLEXTA ORAL TABLET 50 MG ......................................... 22

VENCLEXTA ORAL TABLET 100 MG ....................................... 22

VENCLEXTA STARTING PACK .................................................. 22

venlafaxine oral capsule, extended release 24hr 75 mg ........ 33

venlafaxine oral capsule, extended release 24hr 150 mg,

37.5 mg ............................................................................................... 32

venlafaxine oral tablet 50 mg, 75 mg ......................................... 33

venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg ..................... 33

VENTAVIS .......................................................................................... 55

VENTOLIN HFA ............................................................................... 55

verapamil intravenous solution .................................................... 35

verapamil oral capsule, 24 hr er pellet ct .................................. 35

verapamil oral capsule, ext rel. pellets 24 hr 120 mg,

180 mg, 240 mg ............................................................................... 35

VERAPAMIL ORAL CAPSULE, EXT REL. PELLETS

24 HR 360 MG .................................................................................. 35

verapamil oral tablet ........................................................................ 35

verapamil oral tablet extended release ..................................... 35

VERQUVO ......................................................................................... 36

VERSACLOZ .................................................................................... 33

VERZENIO ........................................................................................ 22

vestura (28)........................................................................................ 52

V-GO 20 .............................................................................................. 43

V-GO 30 .............................................................................................. 43

V-GO 40 .............................................................................................. 43

vienva .................................................................................................. 52

vigabatrin ............................................................................................ 25

vigadrone ............................................................................................ 25

vigpoder .............................................................................................. 25

vilazodone .......................................................................................... 33

vinblastine .......................................................................................... 22

vincristine ........................................................................................... 22

vinorelbine .......................................................................................... 22

viorele (28) ......................................................................................... 52

VIRACEPT ORAL TABLET 250 MG ........................................... 12

VIRACEPT ORAL TABLET 625 MG ........................................... 12

VIREAD ORAL POWDER ............................................................. 12

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG ............. 12

VITRAKVI ORAL CAPSULE 25 MG ........................................... 22

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

VITRAKVI ORAL CAPSULE 100 MG ........................................ 22

VITRAKVI ORAL SOLUTION ....................................................... 22

VIVITROL ........................................................................................... 28

VIZIMPRO .......................................................................................... 23

volnea (28) ......................................................................................... 52

VONJO ................................................................................................ 23

voriconazole intravenous ............................................................... 10

voriconazole oral suspension for reconstitution ...................... 10

voriconazole oral tablet .................................................................. 10

VOSEVI .............................................................................................. 12

VOTRIENT ......................................................................................... 23

VRAYLAR ORAL CAPSULE ......................................................... 33

VUMERITY ........................................................................................ 27

vyfemla (28) ....................................................................................... 52

vylibra .................................................................................................. 52

VYNDAQEL ....................................................................................... 36

VYXEOS ............................................................................................. 23

warfarin ............................................................................................... 36

WATER FOR IRRIGATION, STERILE ....................................... 40

WELIREG ........................................................................................... 23

wera (28) ............................................................................................ 52

wescap-pn dha ................................................................................. 57

wesnate dha ...................................................................................... 57

WESTAB PLUS ................................................................................ 57

WESTGEL DHA ............................................................................... 57

wymzya fe .......................................................................................... 53

XALKORI ORAL CAPSULE .......................................................... 23

XALKORI ORAL PELLET 20 MG, 50 MG ................................ 23

XALKORI ORAL PELLET 150 MG ............................................. 23

XARELTO ........................................................................................... 36

XARELTO DVT-PE TREAT 30D START ................................... 36

XATMEP ............................................................................................. 23

XCOPRI MAINTENANCE PACK ORAL TABLET

250MG/DAY(150 MG X1-100MG X1), 350 MG/DAY

(200 MG X1-150MG X1) ................................................................ 25

XCOPRI ORAL TABLET 25 MG .................................................. 25

XCOPRI ORAL TABLET 50 MG .................................................. 25

XCOPRI ORAL TABLET 100 MG ................................................ 25

XCOPRI ORAL TABLET 150 MG, 200 MG .............................. 25

XCOPRI TITRATION PACK .......................................................... 25

XDEMVY ............................................................................................ 53

XERMELO ......................................................................................... 23

XGEVA ................................................................................................ 16

XIAFLEX ............................................................................................. 40

XIFAXAN ORAL TABLET 200 MG .............................................. 14

XIFAXAN ORAL TABLET 550 MG .............................................. 14

XIIDRA ................................................................................................ 53

XOFLUZA ORAL TABLET 40 MG, 80 MG................................ 12

XOLAIR SUBCUTANEOUS AUTO-INJECTOR

75 MG/0.5 ML ................................................................................... 55

XOLAIR SUBCUTANEOUS AUTO-INJECTOR

150 MG/ML, 300 MG/2 ML ........................................................... 55

XOLAIR SUBCUTANEOUS RECON SOLN ............................ 55

XOLAIR SUBCUTANEOUS SYRINGE 75 MG/0.5 ML ......... 56

XOLAIR SUBCUTANEOUS SYRINGE 150 MG/ML,

300 MG/2 ML .................................................................................... 56

XOSPATA ........................................................................................... 23

XPOVIO .............................................................................................. 23

XTANDI ORAL CAPSULE ............................................................. 23

XTANDI ORAL TABLET 40 MG ................................................... 23

XTANDI ORAL TABLET 80 MG ................................................... 23

XULTOPHY 100/3.6 ........................................................................ 43

YERVOY ............................................................................................. 23

YF-VAX (PF) ...................................................................................... 47

YONDELIS ......................................................................................... 23

yuvafem .............................................................................................. 50

zarlukast ........................................................................................... 56

ZALTRAP ........................................................................................... 23

ZANOSAR .......................................................................................... 23

ZEJULA ORAL TABLET ................................................................. 23

ZELBORAF ........................................................................................ 23

Covered Drugs Index

DRUG PAGE DRUG PAGE

September 2024

ZENPEP ORAL CAPSULE, DELAYED RELEASE

(DR/EC) 10,000-32,000 -42,000 UNIT, 15,000-47,000

-63,000 UNIT, 20,000-63,000- 84,000 UNIT, 25,000-

79,000- 105,000 UNIT, 3,000-10,000 -14,000-UNIT,

40,000-126,000- 168,000 UNIT, 5,000-17,000-

24,000 UNIT, 60,000-189,600- 252,600 UNIT ........................ 46

ZEPOSIA ............................................................................................ 27

ZEPOSIA STARTER KIT

(28-DAY) ............................................................................................. 27

ZEPOSIA STARTER PACK (7-DAY) .......................................... 27

ZEPZELCA ........................................................................................ 23

zidovudine oral capsule ................................................................. 12

zidovudine oral syrup ...................................................................... 12

zidovudine oral tablet ...................................................................... 12

ZIEXTENZO ...................................................................................... 46

ZIMHI ................................................................................................... 28

ziprasidone hcl oral capsule 20 mg ............................................ 33

ziprasidone hcl oral capsule 40 mg ............................................ 33

ziprasidone hcl oral capsule 60 mg, 80 mg .............................. 33

ziprasidone mesylate ...................................................................... 33

ZIRABEV ............................................................................................ 23

zirgan ................................................................................................... 53

ZOLADEX .......................................................................................... 23

zoledronic acid intravenous solution .......................................... 44

zoledronic acid-mannitol-water intravenous piggyback

4 mg/100 ml ....................................................................................... 44

zoledronic acid-mannitol-water intravenous piggyback

5 mg/100 ml ....................................................................................... 40

ZOLEDRONIC AC-MANNITOL-0.9NACL ................................. 44

ZOLINZA ............................................................................................ 23

zolpidem oral tablet ......................................................................... 33

ZONISADE ........................................................................................ 25

zonisamide oral capsule 25 mg, 50 mg ..................................... 25

zonisamide oral capsule 100 mg ................................................. 25

zovia 1-35 (28) .................................................................................. 53

ZTALMY .............................................................................................. 25

ZTLIDO ............................................................................................... 37

ZUBSOLV SUBLINGUAL TABLET 0.7-0.18 MG,

1.4-0.36 MG, 11.4-2.9 MG, 2.9-0.71 MG, 5.7-1.4 MG .......... 28

ZUBSOLV SUBLINGUAL TABLET 8.6-2.1 MG....................... 28

zumandimine (28) ............................................................................ 53

ZURZUVAE ........................................................................................ 33

ZYDELIG ............................................................................................ 23

ZYKADIA ............................................................................................ 23

ZYNLONTA ........................................................................................ 23

ZYNYZ ................................................................................................ 23

ZYPREXA RELPREVV INTRAMUSCULAR

SUSPENSION FOR RECONSTITUTION

210 MG, 300 MG ............................................................................. 33

ZYPREXA RELPREVV INTRAMUSCULAR

SUSPENSION FOR RECONSTITUTION 405 MG ................ 33

Notes

INT_22_822907_C 23_MLI_NOND_PDP

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