2021 High Performance Formulary - (List of Covered Drugs) - The Health Plan
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2021 High Performance Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
This formulary was updated on 10/1/2021. For more recent information or other
questions, please contact The Health Plan Pharmacy Services at 1.800.624.6961
extension 7914, or visit www.heathplan.org.Pharmacy Benefit Programs How to Use Your Prescription Benefit
Prescription drugs are an integral Please present The Health Plan ID card to
component of a comprehensive health the pharmacist with your prescription. You
maintenance plan. Pharmacy benefit will be required to pay a copayment
programs at The Health Plan are developed (“copay”) at the time of service based on the
through recommendations of participating prescription plan in which you are enrolled.
physicians and pharmacists. This group of Your copayment levels are found under the
professional health care providers, known as pharmacy benefit section Pharmacy Benefit
the Pharmacy and Therapeutics Committee, of your Summary of Benefits. Your ID card
evaluates therapeutic classes of drugs and also contains important information to allow
recommends coverage guidelines for our the pharmacy to correctly submit your
pharmacy benefit programs. The committee claim. Please take it with you to the
uses current medical and pharmaceutical pharmacy.
literature along with recommendations of
Specialty Pharmacy Program
experts in various clinical specialties in its
Specialty drugs are high-cost medications
evaluation of our pharmacy benefit
including drugs manufactured by
programs. The result is a list of drugs
biotechnology. Specialty drugs may be
(formulary) to allow for the availability of
administered by injection, oral, transdermal,
appropriate medications for our members’
or inhaled. Specialty drugs are used to treat
needs. Also, the formulary and coverage
very specific diseases and require extensive
guidelines allow prescription costs and your
management for safety and effectiveness.
premium to be maintained at affordable
Dosages need to be monitored for effect
levels.
and adjustments might be needed for
Definitions adequate response to effectively treat the
Prescription – Drugs which can only be disease.
dispensed upon order (prescription) by a Specialty drug require prior authorization to
qualified provider of care. Additionally, only assure appropriate candidate for the drug.
drugs which are labeled “Caution: Federal Additionally, oversight is an integral part of
law prohibits dispensing without the prior authorization process. Dispensing
prescription” will be considered eligible. might be limited to pharmacies with specific
Generic Drug – A drug available as a skills and distribution programs to assure
chemically and therapeutically equivalent proper delivery of these medications.
copy of a brand-name drug. It is usually Diseases targeted to receive therapy are, but
available from several manufacturers. not limited to, rheumatoid arthritis, severe
Brand Drug – A prescription item only chronic psoriasis, multiple sclerosis,
available from a single-source supplier. hepatitis C, hemophilia, certain cancers,
Multi-Source Brand Drugs – Brand-name growth deficiency, cystic fibrosis, Crohn’s
drugs which are manufactured by more than disease and organ transplant.
one producer. These agents are usually Coverage for these agents are provided
available as generic equivalents. under your Specialty Pharmacy Benefit. The
list of specialty drugs is available at
www.healthplan.org/personal/products-and-
services.Drugs Requiring Prior Authorization Non-Formulary Coverage Review
Certain medications are eligible for coverage Certain non-formulary medications are
only after a patient-specific approval has eligible for coverage only after a patient-
been authorized. Patient-specific criteria specific approval has been authorized.
may include age, gender, and clinical Patient-specific criteria may include age,
conditions determined by the physician for gender, and clinical conditions determined
authorization to be granted for a specific by the physician for authorization to be
drug. A coverage determination request can granted for a specific drug. A non-formulary
be made by the member, member’s exception request can be made by the
representative or physician. To request a member, member’s representative or
coverage determination please contact physician. To request an exception please
pharmacy services at 1.800.624.6961, ext. contact pharmacy services at
7914. Standard requests for coverage 1.800.624.6961, ext. 7914. Standard
determinations will be processed within 72 requests for exceptions will be processed
hours. Requests for non-urgent coverage within 15 calendar days of receipt of the
determinations received after 5pm will be request. Requests for non-urgent coverage
processed the next business day. Urgent determinations received after 5pm will be
requests for coverage determinations will be processed the next business day. Urgent
processed within 24 hours. requests for coverage determinations will be
processed within 24 hours or receipt.
Quantity per Dispensing Event (QPC
rules) Generic Difference Policy
Generally, The Health Plan allows dispensing (copayment policy for multi-source drugs)
of approved medications up to a 34-day If a prescription order specifies that a brand-
supply per co-pay at the retail pharmacy name drug must be dispensed when the
network. Quantity per dispensing event generic equivalent is available, or the
rules (QPC) set thresholds that reduce prescription order allows for generic
exposure to unnecessary cost, without substitution and the member elects to have
creating obstacles to access for most the prescription filled with a brand-name
members. Drugs that are subject to QPC drug instead, the member must pay the
rules usually have specific limitations for brand copayment plus the difference
use approved by the FDA. Examples include between The Health Plan cost of a brand-
drugs to treat migraine headaches. These name and its generic equivalent (i.e., The
drugs, known as “triptans,” are to be used in Health Plan only pays for the generic cost).
specific doses up to a defined number of Please note: Non-formulary brand versions
headaches per month. The QPC rules allow of generic drugs require coverage review as
this specific number of triptan medications outlined above.
to be dispensed per 34-day benefit period.
Out-of-Area Emergencies
To inquire about QPC limits to request an
In situations of emergency need for a
exemption, have your provider contact
prescription outside The Health Plan service
pharmacy services at 1.800.624.6961, ext.
area, please contact The Health Plan for the
7914.
location of a participating pharmacy in that
area. Present The Health Plan ID card with
the emergency prescription and pay your
copayment. If no pharmacy in the area
participates with The Health Plan, purchasethe emergency prescription and send your washes, devices used in dental therapy.
receipt to The Health Plan. You will be Certain oral fluoride products may be
reimbursed in full, less your applicable covered as a preventative medication.
copayment, for the prescription provided • The charge for prescription drugs or
the prescription meets the guidelines devices used to promote weight loss.
specified in this document. • Treatment of hyperhidrosis (excessive
Exclusions and Limitations sweating).
• Prescriptions used to treat sexual
The following will not be covered or paid for dysfunction, either oral or topical, or
by The Health Plan: devices used for impotence.
• The charge for any prescription refill other • Appliances and therapeutic devices which
than the number set by the prescriber. may require a prescription are not
Additionally, no refills dispensed more covered. These include, but are not limited
than one year from the date or the original to, garments, splints, bandages, braces or
prescription. nebulizers regardless of intended use.
• The charge for any prescription, oral or
• Prescriptions dispenses by any other
topical, that is prescribed for cosmetic
delivery service other than Express Scripts.
purposes.
• Nutritional and/or dietary supplements, • Certain legend drugs when any version or
except as covered in the Evidence of strength becomes available over the
Coverage or required under Preventive counter.
Care Services or other laws. This includes, • Drugs in quantity which exceed the limits
but not limited to, nutritional formulas and established by The Health Plan, or which
dietary supplements that can be purchased exceed any age limits established.
over the count, which by law do not • Charges for administration of any drug.
require either a written prescription or • Drugs consumed at the time and place
dispensing by a licensed pharmacist. where they were dispenses or where the
• The charge for any medications not FDA- prescription order was issued including but
approved for use in the general not limited to samples provided from the
population. physician.
• Off label use of a drug which is not • Drugs or devices not requiring a
medically accepted. The Health Plan uses prescription by Federal Law, except for
the same guidelines as CMS for injectable insulin.
determining whether a proposed use in • Charges for lost, stolen or damaged
medically accepted. medication.
• The charge for a drug not prescribed by a • Oral immunizations and biologicals.
Health Plan qualified provider except in an • Drugs for the treatment of infertility.
emergency situation. • Compounded drugs, unless there is at
• The charge for any medication covered by least one ingredient that requires a
any Worker’s Compensation or prescription.
occupational disease laws, any other group • Drugs to promote hair growth.
policy, or government program which is
• Drugs to enhance athletic performance.
not The Health Plan’s program.
• Drugs to shorten the duration of the
• Dental-related prescriptions such as, but
common cold.
not limited to, oral fluorides, dental mouth• Allergenic Extracts A pharmacist will review the case to evaluate
• Excipients, except when used in a covered that the opioid is being utilized safely and
compounded prescription. appropriately. Additionally, the member can
• The cost of packaging, other than be limited to one prescriber and one
standard pharmacy packaging. pharmacy, if needed.
• Prescriptions filled at a Non Plan Formulary medications will be preferred
Pharmacy, except for an emergency. over non-formulary medications. Step
• Herbal or homeopathic products. therapy rules will be applied when reviewing
a request for non-formulary medications.
• Outpatient drugs for which the
Also, dosing and quantities may be limited.
manufacturer seeks to require that
associated tests or monitoring services be
purchased exclusively from the
manufacturer.
*Always check your Summary Plan
Description for your exact plan details.
Exclusions and limitations can vary by plan.
If you have questions regarding pharmacy
coverage, please call 740.695.7914.
Pain Management Program and
Opiate/Opioid Management
Pain Management Program will apply to
plans within the value program.
The acute use of opioid medications for
moderate to severe pain from acute injury,
medical treatment or surgical procedure will
be limited. The first fill of an opioid
medication will be limited to a 5 day supply.
This limit is for the first fill of an opioid
medication for a member who has no
history of opioid usage in the past 130 days.
For those members needing further
management of their pain, a prior
authorization will be required if:
• The opioid exceeds 80 morphine
milligram equivalents per day
• Is taken for greater than 90 consecutive
days
• Is a long acting opioid
• Is being taken with a medication that
could cause respiratory depression.Table of Contents
ANTI - INFECTIVES ........................................................................................................................................ 3
ANTINEOPLASTIC & IMMUNOSUPPRESSANT DRUGS ....................................................................... 6
AUTONOMIC & CNS DRUGS, NEUROLOGY & PSYCH ......................................................................... 9
CARDIOVASCULAR, HYPERTENSION & LIPIDS ................................................................................. 15
DERMATOLOGICALS/TOPICAL THERAPY .......................................................................................... 19
DIAGNOSTICS & MISCELLANEOUS AGENTS ...................................................................................... 22
EAR, NOSE & THROAT MEDICATIONS .................................................................................................. 24
ENDOCRINE/DIABETES .............................................................................................................................. 24
GASTROENTEROLOGY .............................................................................................................................. 29
IMMUNOLOGY, VACCINES & BIOTECHNOLOGY ............................................................................. 32
MUSCULOSKELETAL & RHEUMATOLOGY ......................................................................................... 34
OBSTETRICS & GYNECOLOGY................................................................................................................ 35
OPHTHALMOLOGY ..................................................................................................................................... 39
RESPIRATORY, ALLERGY, COUGH & COLD ....................................................................................... 41
UROLOGICALS .............................................................................................................................................. 43
VITAMINS, HEMATINICS & ELECTROLYTES ..................................................................................... 44
Index .................................................................................................................................................................. 46
1List of Abbreviations
ACA: Affordable Care Act.
LA: Limited Availability. This prescription may be available only at certain pharmacies. For more
information, please call Customer Service.
OTC: Over the Counter. An OTC drug is a non-prescription drug.
PA: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs.
This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, we
may not cover the drug.
QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.
ST: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical
condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat
your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for
you, we will then cover Drug B.
2Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
ANTI - INFECTIVES DESCOVY 2
ANTIFUNGAL AGENTS didanosine 1
clotrimazole 1 DOVATO 2
CRESEMBA 2 EDURANT 2
fluconazole 1 efavirenz 1
flucytosine 1 efavirenz- 1
emtricitabin-tenofov
griseofulvin 1
microsize efavirenz-lamivu- 1
tenofov disop
griseofulvin 1
ultramicrosize emtricitabine 1
itraconazole 1 emtricitabine- 1
tenofovir (tdf) oral
ketoconazole 1 tablet 100-150 mg,
NOXAFIL 2 133-200 mg, 167-
250 mg
nystatin 1
emtricitabine- 6 ACA
ORAVIG 3 tenofovir (tdf) oral
posaconazole 1 tablet 200-300 mg
terbinafine hcl 1 EMTRIVA 2
voriconazole 1 entecavir 1
ANTIVIRALS EPCLUSA 4 PA
abacavir 1 EPIVIR HBV 2
abacavir-lamivudine 1 etravirine 1
abacavir- 1 famciclovir 1 QL
lamivudine- fosamprenavir 1
zidovudine
foscarnet 3 PA
acyclovir 1
FUZEON 2 PA
adefovir 1
GENVOYA 2
amantadine hcl 1
HARVONI 4 PA
APTIVUS 2
INTELENCE 2
atazanavir 1
INVIRASE 2
BARACLUDE 2
ISENTRESS 2
BIKTARVY 2
ISENTRESS HD 2
CIMDUO 2
JULUCA 2
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
3Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
lamivudine 1 zidovudine 1
lamivudine- 1 CEPHALOSPORINS
zidovudine
cefaclor 1
LEXIVA 2
cefadroxil 1
lopinavir-ritonavir 1
cefdinir 1
nevirapine 1
cefditoren pivoxil 1
NORVIR 2
cefixime 1
ODEFSEY 2
cefpodoxime 1
oseltamivir 1 QL
cefprozil 1
PREVYMIS 2 QL
cefuroxime axetil 1
PREZISTA 2
cephalexin 1
RELENZA 3 QL
DISKHALER ERYTHROMYCINS & OTHER
MACROLIDES
REYATAZ 2
azithromycin 1
ribavirin 1 PA
clarithromycin 1
rimantadine 1
DIFICID 3 QL
ritonavir 1
e.e.s. 400 1
SELZENTRY 2
ery-tab 1
stavudine 1
erythrocin (as 1
SYNAGIS 4 PA; LA stearate)
TEMIXYS 2 erythromycin 1
tenofovir disoproxil 1 erythromycin 1
fumarate ethylsuccinate
TIVICAY 2 MISCELLANEOUS
TIVICAY PD 2 ANTIINFECTIVES
TRIUMEQ 2 albendazole 1 QL
TROGARZO 4 PA ALINIA 2 QL
valacyclovir 1 QL ARIKAYCE 4 PA; LA
valganciclovir 1 atovaquone 1
VEMLIDY 2 atovaquone- 1 QL
VIRACEPT 2 proguanil
VIREAD 2 BENZNIDAZOLE 2 QL
ZEPATIER 4 PA CAYSTON 4 PA; LA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
4Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
chloroquine 1 tobramycin in 0.225 4 PA
phosphate % nacl
clindamycin hcl 1 TRECATOR 3
clindamycin 1 XIFAXAN 2 QL
pediatric
PENICILLINS
COARTEM 2 QL
amoxicillin 1
CYCLOSERINE 3
amoxicillin-pot 1
dapsone 1 clavulanate
EMVERM 2 QL ampicillin 1
ethambutol 1 AUGMENTIN 2
hydroxychloroquine 1 dicloxacillin 1
IMPAVIDO 2 QL penicillin v 1
isoniazid 1 potassium
ivermectin 1 QL QUINOLONES
KITABIS PAK 4 PA ciprofloxacin 1
linezolid 1 PA ciprofloxacin hcl 1
mefloquine 1 QL FACTIVE 3
metronidazole 1 levofloxacin 1
neomycin 1 moxifloxacin 1
nitazoxanide 1 QL ofloxacin 1
paromomycin 1 SULFA'S & RELATED AGENTS
pentamidine 1 QL sulfadiazine 1
praziquantel 1 sulfamethoxazole- 1
trimethoprim
PRIFTIN 2
sulfatrim 1
pyrazinamide 1
pyrimethamine 4 TETRACYCLINES
quinine sulfate 1 QL avidoxy 1
rifabutin 1 demeclocycline 1
rifampin 1 doxycycline hyclate 1
SIRTURO 2 LA doxycycline 1
monohydrate
SIVEXTRO 3 PA
minocycline 1
tinidazole 1 QL
mondoxyne nl 1
tobramycin 4 PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
5Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
morgidox 1 AFINITOR 4 PA
tetracycline 1 DISPERZ
ALECENSA 4 PA
URINARY TRACT AGENTS
ALIQOPA 4 PA; LA
fosfomycin 1
tromethamine ALUNBRIG 4 PA
methenamine 1 anastrozole 1
hippurate ARRANON 4 PA
methenamine 1 azacitidine 4 PA
mandelate
azathioprine 1
nitrofurantoin 1
BALVERSA 4 PA; LA
nitrofurantoin 1
macrocrystal BAVENCIO 4 PA; LA
nitrofurantoin 1 BENDEKA 4 PA
monohyd/m-cryst BESPONSA 4 PA
trimethoprim 1 bexarotene 4 PA
VANCOMYCIN bicalutamide 1
vancomycin 1 QL BLINCYTO 4 PA
ANTINEOPLASTIC & BOSULIF 4 PA
IMMUNOSUPPRESSANT CABOMETYX 4 PA; LA
DRUGS capecitabine 4 PA
ADJUNCTIVE AGENTS CAPRELSA 4 PA; LA
KEPIVANCE 4 PA COMETRIQ 4 PA
leucovorin calcium 1 COTELLIC 4 PA; LA
MESNEX 2 cyclophosphamide 1
VISTOGARD 4 PA cyclosporine 1
XGEVA 4 PA cyclosporine 1
modified
ANTINEOPLASTIC &
IMMUNOSUPPRESSANT DRUGS CYRAMZA 4 PA
abiraterone 4 PA DARZALEX 4 PA; LA
ABRAXANE 4 PA decitabine 4 PA
ADAKVEO 4 DROXIA 2
ADCETRIS 4 PA ELIGARD 4 PA
AFINITOR 4 PA ELIGARD (3 4 PA
MONTH)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
6Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
ELIGARD (4 4 PA IMBRUVICA 4 PA
MONTH) IMFINZI 4 PA; LA
ELIGARD (6 4 PA INLYTA 4 PA
MONTH)
IRESSA 4 PA
ELZONRIS 4 PA
ISTODAX 4 PA
EMCYT 2
IXEMPRA 4 PA
ENSPRYNG 4 PA
JAKAFI 4 PA
ERBITUX 4 PA
KADCYLA 4 PA
ERIVEDGE 4 PA
KANJINTI 4 PA
ERLEADA 4 PA
KEYTRUDA 4 PA
erlotinib 4 PA
KYMRIAH 4 PA
etoposide 1
KYPROLIS 4 PA
everolimus 4 PA
(antineoplastic) lapatinib 4 PA
everolimus 1 LENVIMA 4 PA
(immunosuppressive letrozole 1
)
LEUKERAN 2
exemestane 1
leuprolide 4 PA
fludarabine 1
LIBTAYO 4 PA
flutamide 1
LONSURF 4 PA
FOLOTYN 4 PA
LORBRENA 4 PA
GAMIFANT 4 PA
LUPRON DEPOT 4 PA
GAVRETO 4 LA
LUPRON DEPOT 4 PA
GAZYVA 4 PA (3 MONTH)
gengraf 1 LUPRON DEPOT- 4 PA
GILOTRIF 4 PA PED
GLEOSTINE 2 LUPRON DEPOT- 4 PA
PED (3 MONTH)
HALAVEN 4 PA
LYNPARZA 4 PA
HYCAMTIN 4 PA
LYSODREN 4
hydroxyurea 1
MARQIBO 4 PA
IBRANCE 4 PA
MATULANE 4 PA
ICLUSIG 4 PA
megestrol 1
IDHIFA 4 PA; LA
MEKINIST 4 PA
imatinib 4 PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
7Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
melphalan 1 sirolimus 1
mercaptopurine 1 SOLTAMOX 3
methotrexate sodium 1 SOMATULINE 4 PA
methotrexate sodium 1 DEPOT
(pf) SPRYCEL 4 PA
mitoxantrone 4 PA STIVARGA 4 PA
MVASI 4 PA sunitinib 1 PA
mycophenolate 1 SUTENT 4 PA
mofetil SYLVANT 4 PA
mycophenolate 1 TABRECTA 4 PA
sodium
tacrolimus 1
MYLERAN 2
TAFINLAR 4 PA
MYLOTARG 4 PA; LA
TAGRISSO 4 PA; LA
NERLYNX 4 PA; LA
TALZENNA 4 PA
NEXAVAR 4 PA; LA
tamoxifen 1
nilutamide 1
TARGRETIN 4 PA
NINLARO 4 PA
TASIGNA 4 PA
NUBEQA 4 PA; LA
TECENTRIQ 4 PA; LA
octreotide acetate 4 PA
TEMODAR 4 PA
ODOMZO 4 PA; LA
temozolomide 4 PA
ONIVYDE 4 PA
temsirolimus 4 PA
OPDIVO 4 PA
THALOMID 4 PA
PEMAZYRE 4 PA; LA
TIBSOVO 4 PA
PERJETA 4 PA
topotecan 4 PA
POTELIGEO 4 PA
toremifene 1
PROGRAF 2
TRAZIMERA 4 PA
PURIXAN 4 PA
TREANDA 4 PA
ROZLYTREK 4 PA; LA
tretinoin 1
RUBRACA 4 PA; LA (antineoplastic)
RUXIENCE 4 TRIPTODUR 4 PA
RYDAPT 4 PA UNITUXIN 4 PA
SANDIMMUNE 2 VANTAS 4 PA
SIGNIFOR 4 PA VECTIBIX 4 PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
8Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
VELCADE 4 PA DIACOMIT 4 PA
VENCLEXTA 4 PA; LA diazepam 1
VENCLEXTA 4 PA DILANTIN 2
STARTING PACK divalproex 1
VERZENIO 4 PA; LA EPIDIOLEX 4 PA; LA
VITRAKVI 4 PA; LA epitol 1
VIZIMPRO 4 PA ethosuximide 1
VOTRIENT 4 PA felbamate 1
VYXEOS 4 PA gabapentin 1
XALKORI 4 PA lamotrigine 1
XERMELO 4 PA; LA levetiracetam 1
XOSPATA 4 PA; LA NAYZILAM 2 QL
YERVOY 4 PA oxcarbazepine 1
YESCARTA 4 PA phenobarbital 1
YONDELIS 4 PA phenytoin 1
YONSA 4 PA phenytoin sodium 1
ZEJULA 4 PA; LA extended
ZELBORAF 4 PA pregabalin 1
ZIRABEV 4 PA primidone 1
ZOLADEX 4 PA roweepra 1
ZOLINZA 4 PA rufinamide 1
ZORTRESS 2 subvenite 1
ZYDELIG 4 PA subvenite starter 1
ZYKADIA 4 PA (blue) kit
subvenite starter 1
AUTONOMIC & CNS DRUGS, (green) kit
NEUROLOGY & PSYCH subvenite starter 1
ANTICONVULSANTS (orange) kit
APTIOM 3 tiagabine 1
carbamazepine 1 topiramate 1
CELONTIN 2 valproic acid 1
clobazam 1 valproic acid (as 1
sodium salt)
clonazepam 1
vigabatrin 4 PA; LA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
9Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
vigadrone 4 PA sumatriptan 1 QL
VIMPAT 2 sumatriptan 1 QL
zonisamide 1 succinate oral
sumatriptan 1 PA; QL
ANTIPARKINSONISM AGENTS
succinate
APOKYN 4 PA; LA; QL subcutaneous
benztropine 1 sumatriptan- 1 QL
bromocriptine 1 naproxen
carbidopa 1 zolmitriptan 1 QL
carbidopa-levodopa 1 MISCELLANEOUS
NEUROLOGICAL THERAPY
carbidopa-levodopa- 1
entacapone dalfampridine 4 PA
entacapone 1 donepezil 1
INBRIJA 4 PA; QL galantamine 1
KYNMOBI 2 PA; QL memantine 1
pramipexole 1 NUEDEXTA 2
rasagiline 1 RADICAVA 4 PA
ropinirole 1 rivastigmine 1
selegiline hcl 1 rivastigmine tartrate 1
tolcapone 1 RUZURGI 4 PA
trihexyphenidyl 1 TEGSEDI 4 PA; LA
MIGRAINE & CLUSTER tetrabenazine 4 PA; QL
HEADACHE THERAPY TYSABRI 4 PA; LA
almotriptan malate 1 QL ZOLGENSMA 4 PA
dihydroergotamine 1 PA MUSCLE RELAXANTS &
injection ANTISPASMODIC THERAPY
dihydroergotamine 1 QL baclofen 1
nasal
carisoprodol 3
eletriptan 1 QL
chlorzoxazone 1
ergotamine-caffeine 1
cyclobenzaprine 1
frovatriptan 1 QL
dantrolene 1
migergot 1
metaxalone 1
naratriptan 1 QL
methocarbamol 1
rizatriptan 1 QL
orphenadrine citrate 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
10Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
orphenadrine-asa- 1 hydrocodone- 1 ST; QL
caffeine ibuprofen
orphengesic forte 1 hydromorphone oral 1 ST; QL
pyridostigmine 1 liquid
bromide hydromorphone oral 1 ST; QL
tizanidine 1 tablet
hydromorphone oral 1 PA; QL
NARCOTIC ANALGESICS
tablet extended
acetaminophen-caff- 1 ST; QL release 24 hr
dihydrocod
hydromorphone 1 ST; QL
acetaminophen- 1 ST; QL rectal
codeine
levorphanol tartrate 1 ST; QL
ascomp with codeine 1 oral tablet 2 mg
buprenorphine 1 levorphanol tartrate 1 PA; QL
buprenorphine hcl 1 oral tablet 3 mg
butalbital compound 1 methadone injection 1
w/codeine methadone oral 1 PA
butalbital- 1 methadose 1 PA
acetaminop-caf-cod
morphine 1 ST; QL
butalbital- 1 concentrate
acetaminophen
morphine oral 1 PA; QL
butalbital- 1 capsule, er
acetaminophen-caff multiphase 24 hr
butalbital-aspirin- 1 morphine oral 1 PA; QL
caffeine capsule,extend.relea
codeine sulfate 1 ST; QL se pellets
codeine-butalbital- 1 morphine oral 1 ST; QL
asa-caff solution
diskets 1 PA morphine oral tablet 1 ST; QL
dvorah 1 ST; QL morphine oral tablet 1 PA; QL
extended release
endocet 1 ST; QL
morphine rectal 1 ST; QL
fentanyl 1 QL
oxycodone 1 ST; QL
fentanyl citrate 1 PA; ST; QL
oxycodone- 1 ST; QL
hydrocodone 1 QL acetaminophen
bitartrate
OXYCONTIN 3 PA; QL
hydrocodone- 1 ST; QL
acetaminophen
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
11Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
oxymorphone oral 1 ST; QL diclofenac sodium 1
tablet oral
oxymorphone oral 1 PA; QL diclofenac sodium 1 QL
tablet extended topical
release 12 hr diclofenac- 1
prolate 1 ST; QL misoprostol
SUBLOCADE 4 PA diflunisal 1
tencon 1 ecotrin 6 ACA; OTC
vtol lq 1 ecotrin low strength 6 ACA; OTC
zebutal 1 etodolac 1
NON-NARCOTIC ANALGESICS fenoprofen 1
aspirin 6 ACA; OTC flurbiprofen 1
aspirin low dose 6 ACA; OTC ibu 1
aspir-trin 6 ACA; OTC ibuprofen 1
bayer aspirin 6 ACA; OTC indomethacin 1
buprenorphine- 1 ketoprofen 1
naloxone sublingual ketorolac 1
film 12-3 mg
KLOXXADO 2 QL
buprenorphine- 1 QL
naloxone sublingual meclofenamate 1
film 2-0.5 mg, 4-1 mefenamic acid 1
mg, 8-2 mg
meloxicam 1
buprenorphine- 1 QL
meloxicam 1
naloxone sublingual
submicronized
tablet 2-0.5 mg
nabumetone 1
buprenorphine- 1
naloxone sublingual naloxone 1 PA
tablet 8-2 mg naltrexone 1
butorphanol 1 PA; ST; QL naproxen 1
cataflam 1 naproxen sodium 1
celecoxib 1 NARCAN 2 QL
children's aspirin 6 ACA; OTC NUCYNTA 3 ST; QL
choline,magnesium 1 NUCYNTA ER 3 PA; QL
salicylate
oxaprozin 1
diclofenac potassium 1
piroxicam 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
12Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
salsalate 1 armodafinil 1 PA
st joseph aspirin 6 ACA; OTC asenapine maleate 3 QL
sulindac 1 atomoxetine 1
tolmetin 1 BELSOMRA 3
tramadol 1 ST; QL bupropion hcl 1
tramadol- 1 ST; QL buspirone 1
acetaminophen chlordiazepoxide hcl 1
VIVITROL 4 chlorpromazine 1
ZUBSOLV 2 QL citalopram 1
SUBLINGUAL
TABLET 0.7-0.18 clomipramine 1
MG, 1.4-0.36 MG, clonidine hcl 1
2.9-0.71 MG, 5.7-
1.4 MG, 8.6-2.1 MG clorazepate 1
dipotassium
ZUBSOLV 2
SUBLINGUAL clozapine 1
TABLET 11.4-2.9 desipramine 1
MG
desvenlafaxine 1
PSYCHOTHERAPEUTIC DRUGS succinate
ABILIFY 2 dexmethylphenidate 1
MAINTENA dextroamphetamine 1
alprazolam 1 dextroamphetamine- 1
alprazolam intensol 1 amphetamine
amitriptyline 1 diazepam 1
amitriptyline- 1 diazepam intensol 1
chlordiazepoxide doxepin 1
amoxapine 1 duloxetine 1
amphetamine sulfate 1 EMSAM 3
aripiprazole oral 1 ergoloid 1
solution
escitalopram oxalate 1
aripiprazole oral 1 QL
tablet estazolam 1
aripiprazole oral 1 QL eszopiclone 1
tablet,disintegrating FETZIMA 3
ARISTADA 2 fluoxetine 1
ARISTADA INITIO 2 fluphenazine hcl 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
13Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
flurazepam 1 pimozide 1
fluvoxamine 1 procentra 1
guanfacine 1 protriptyline 1
haloperidol 1 quetiapine 1 QL
haloperidol lactate 1 ramelteon 1
imipramine hcl 1 REXULTI 3 QL
imipramine pamoate 1 RISPERDAL 2
LATUDA 3 QL CONSTA
lithium carbonate 1 risperidone oral 1
solution
lorazepam 1
risperidone oral 1 QL
lorazepam intensol 1 tablet
loxapine succinate 1 risperidone oral 1 QL
maprotiline 1 tablet,disintegrating
MARPLAN 3 seconal sodium 1
methamphetamine 1 sertraline 1
methylphenidate hcl 1 SUNOSI 2
midazolam 1 thioridazine 1
mirtazapine 1 thiothixene 1
modafinil 1 PA tranylcypromine 1
molindone 1 trazodone 1
nortriptyline 1 triazolam 1
olanzapine 1 QL trifluoperazine 1
olanzapine- 1 trimipramine 1
fluoxetine TRINTELLIX 3 PA
paliperidone 1 QL venlafaxine 1
paroxetine hcl 1 VIIBRYD 3 PA
paroxetine 1 XYREM 4 PA; LA; QL
mesylate(menop.sym
) XYWAV 4 PA; LA; QL
perphenazine 1 zaleplon 1
perphenazine- 1 zenzedi 1
amitriptyline ziprasidone hcl 1 QL
phenelzine 1 zolpidem 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
14Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
ZULRESSO 4 PA atenolol 1
CARDIOVASCULAR, atenolol- 1
chlorthalidone
HYPERTENSION & LIPIDS
benazepril 1
ANTIARRHYTHMIC AGENTS
benazepril- 1
amiodarone 1 hydrochlorothiazide
disopyramide 3 betaxolol 1
phosphate
bisoprolol fumarate 1
dofetilide 1
bisoprolol- 1
flecainide 1 hydrochlorothiazide
mexiletine 1 bumetanide 1
MULTAQ 3 BYSTOLIC 3
pacerone 1 candesartan 1
propafenone 1 candesartan- 1
quinidine gluconate 1 hydrochlorothiazid
quinidine sulfate 1 captopril 1
sorine 1 captopril- 1
hydrochlorothiazide
sotalol 1
cartia xt 1
sotalol af 1
carvedilol 1
SOTYLIZE 2
carvedilol phosphate 1
ANTIHYPERTENSIVE THERAPY
chlorthalidone 1
acebutolol 1
clonidine 1
aliskiren 3
clonidine hcl 1
amiloride 1
diltiazem 1
amiloride- 1
hydrochlorothiazide dilt-xr 1
amlodipine 1 doxazosin 1
amlodipine- 1 EDARBI 3
benazepril EDARBYCLOR 3
amlodipine- 1 enalapril maleate 1
olmesartan
enalapril- 1
amlodipine- 1 hydrochlorothiazide
valsartan
eplerenone 1
amlodipine- 1
valsartan-hcthiazid epoprostenol 4 PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
15Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
epoprostenol 4 PA minoxidil 1
(glycine) moexipril 1
eprosartan 1 nadolol 1
ethacrynic acid 1 nadolol- 1
felodipine 1 bendroflumethiazide
fosinopril 1 nicardipine 1
fosinopril- 1 nifedipine 1
hydrochlorothiazide nimodipine 1
furosemide 1 nisoldipine 1
guanfacine 1 olmesartan 1
hydralazine 1 olmesartan- 1
hydrochlorothiazide 1 amlodipin-hcthiazid
indapamide 1 olmesartan- 1
irbesartan 1 hydrochlorothiazide
irbesartan- 1 ORENITRAM 4 PA
hydrochlorothiazide perindopril 1
isradipine 1 erbumine
labetalol 1 phenoxybenzamine 1
lisinopril 1 pindolol 1
lisinopril- 1 prazosin 1
hydrochlorothiazide propranolol 1
losartan 1 propranolol- 1
losartan- 1 hydrochlorothiazid
hydrochlorothiazide quinapril 1
matzim la 1 quinapril- 1
methyldopa 1 hydrochlorothiazide
methyldopa- 1 ramipril 1
hydrochlorothiazide spironolactone 1
metolazone 1 spironolacton- 1
metoprolol succinate 1 hydrochlorothiaz
metoprolol ta- 1 taztia xt 1
hydrochlorothiaz TEKTURNA HCT 3
metoprolol tartrate 1 telmisartan 1
metyrosine 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
16Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
telmisartan- 1 BENEFIX 4 PA
amlodipine BRILINTA 2
telmisartan- 1 CABLIVI 4 PA; LA
hydrochlorothiazid
CEPROTIN (BLUE 4 PA
terazosin 1 BAR)
tiadylt er 1 CEPROTIN 4 PA
timolol maleate 1 (GREEN BAR)
torsemide 1 cilostazol 1
trandolapril 1 clopidogrel 1
trandolapril- 1 COAGADEX 4 PA
verapamil CORIFACT 4 PA
treprostinil sodium 4 PA dipyridamole 1
triamterene 1 DOPTELET (15 4 PA; LA
triamterene- 1 TAB PACK)
hydrochlorothiazid ELIQUIS 2
UPTRAVI 4 PA; LA ELIQUIS DVT-PE 2
valsartan 1 TREAT 30D
valsartan- 1 START
hydrochlorothiazide ELOCTATE 4 PA
veletri 4 PA enoxaparin 4 PA
verapamil 1 ESPEROCT 4 PA
CARDIAC GLYCOSIDES FEIBA NF 4 PA
digitek 1 fondaparinux 4 PA
digox 1 HEMLIBRA 4 PA
digoxin 1 HEMOFIL M HIGH 4 PA
COAGULATION THERAPY HEMOFIL M LOW 4 PA
ADVATE 4 PA HEMOFIL M MID 4 PA
ADYNOVATE 4 PA HEMOFIL M 4 PA
SUPER HIGH
AFSTYLA 4 PA
hep flush-10 (pf) 1 PA
ALPHANATE 4 PA
heparin (porcine) 1 PA
ALPROLIX 4 PA
heparin (porcine) in 1 PA
aminocaproic acid 1 5 % dex
aspirin-dipyridamole 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
17Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
heparin (porcine) in 1 PA vitamin k 1 PA
nacl (pf) vitamin k1 1 PA
heparin 1 PA VONVENDI 4 PA
flush(porcine)-
0.9nacl warfarin 1
heparin lock flush 1 PA XARELTO 2
(porcine) XARELTO DVT-PE 2
heparin 1 PA TREAT 30D
lockflush(porcine)(pf START
) ZONTIVITY 3
heparin(porcine) in 1 PA LIPID/CHOLESTEROL LOWERING
0.45% nacl
AGENTS
heparin, porcine (pf) 1 PA
amlodipine- 1
HUMATE-P 4 PA atorvastatin
IXINITY 4 PA atorvastatin oral 6 ACA
jantoven 1 tablet 10 mg, 20 mg
JIVI 4 PA atorvastatin oral 1
tablet 40 mg, 80 mg
KOGENATE FS 4 PA
cholestyramine (with 1
KOVALTRY 4 PA sugar)
MONONINE 4 PA cholestyramine light 1
NOVOEIGHT 4 PA colesevelam 1
NOVOSEVEN RT 4 PA colestipol 1
NPLATE 4 PA ezetimibe 1
OBIZUR 4 PA ezetimibe- 1
pentoxifylline 1 simvastatin
phytonadione 1 PA fenofibrate 1
(vitamin k1) fenofibrate 1
prasugrel 1 micronized
PROFILNINE 4 PA fenofibrate 1
nanocrystallized
PROMACTA 4 PA; LA
fenofibric acid 1
RIASTAP 4 PA
fluvastatin 6 ACA
SEVENFACT 4
gemfibrozil 1
TAVALISSE 4 PA; LA
icosapent ethyl 1 PA
TRETTEN 4 PA
JUXTAPID 4 PA; LA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
18Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
LIVALO 3 nitro-bid 1
lovastatin 6 ACA nitroglycerin 1
niacin 1 nitro-time 1
omega-3 acid ethyl 1 PA DERMATOLOGICALS/TOPICA
esters
L THERAPY
pravastatin 6 ACA
ANTIPSORIATIC /
prevalite 1 ANTISEBORRHEIC
REPATHA 2 PA acitretin 1
PUSHTRONEX
calcipotriene 1
REPATHA 2 PA
SURECLICK calcipotriene- 1
betamethasone
REPATHA 2 PA
SYRINGE calcitriol 1
rosuvastatin oral 6 ACA COSENTYX 4 PA
tablet 10 mg, 5 mg COSENTYX (2 4 PA
rosuvastatin oral 1 SYRINGES)
tablet 20 mg, 40 mg COSENTYX PEN 4 PA
simvastatin oral 6 ACA COSENTYX PEN 4 PA
tablet 10 mg, 20 mg, (2 PENS)
40 mg, 5 mg
hydrocortisone- 1
simvastatin oral 1 pramoxine
tablet 80 mg
selenium sulfide 1
VASCEPA 2 PA
SKYRIZI 4 PA
MISCELLANEOUS
STELARA 4 PA
CARDIOVASCULAR AGENTS
sulfacetamide 1
CORLANOR 2 sodium
ENTRESTO 2 TALTZ 4 PA
ranolazine 3 AUTOINJECTOR
VERQUVO 2 TALTZ 4 PA
AUTOINJECTOR
VYNDAMAX 4 PA
(2 PACK)
VYNDAQEL 4 PA
TALTZ 4 PA
NITRATES AUTOINJECTOR
isosorbide dinitrate 1 (3 PACK)
isosorbide 1 TALTZ SYRINGE 4 PA
mononitrate TREMFYA 4 PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
19Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
BURN THERAPY bp 10-1 1
silver sulfadiazine 1 claravis 1
ssd 1 clindacin p 1
MISCELLANEOUS clindamycin 1 QL
DERMATOLOGICALS phosphate topical
foam
ammonium lactate 1
clindamycin 1 QL
doxepin 1 phosphate topical
DUPIXENT PEN 4 PA gel
DUPIXENT 4 PA clindamycin 1 QL
SYRINGE phosphate topical
lotion
fluorouracil 1
clindamycin 1 QL
iodine-sodium iodide 1 phosphate topical
methoxsalen 1 solution
methyl salicylate 1 clindamycin 1
PICATO 3 phosphate topical
swab
pimecrolimus 3
clindamycin-benzoyl 1
podofilox 1 peroxide
prudoxin 1 clindamycin- 1
REGRANEX 2 tretinoin
tacrolimus 1 dapsone 1
VALCHLOR 4 PA ery pads 1
VEREGEN 3 erygel 1
wintergreen oil 1 erythromycin with 1
ethanol
THERAPY FOR ACNE
erythromycin- 1
accutane 1 benzoyl peroxide
adapalene-benzoyl 1 isotretinoin 1
peroxide
ivermectin 1
amnesteem 1
metronidazole 1
avar 1
myorisan 1
avita 1
neuac 1
AZELEX 3
rosadan 1
benzepro 1
rosula cleansing 1
benzoyl peroxide 1 cloths
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
20Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
sss 10-5 1 lta pre-attached 1
sulfacetamide 1 ZTLIDO 2
sodium-sulfur
TOPICAL ANTIBACTERIALS
sulfacetamide- 1
ALTABAX 3 QL
sulfur-cleansr23
gentamicin 1 QL
sulfacleanse 8-4 1
lugols 1
tazarotene 1
mafenide acetate 1
TAZORAC 2
mupirocin 1 QL
tretinoin 1
strong iodine 1
tretinoin 1
microspheres sulfacetamide 1
sodium (acne)
zenatane 1
SULFAMYLON 2
TOPICAL ANESTHETICS
TOPICAL ANTIFUNGALS
glydo 1 QL
ciclodan 1
lidocaine hcl 1
laryngotracheal ciclopirox 1
lidocaine hcl mucous 1 QL ciclopirox-ure- 1
membrane jelly camph-menth-euc
lidocaine hcl mucous 1 QL clotrimazole 1
membrane jelly in clotrimazole- 1
applicator betamethasone
lidocaine hcl mucous 1 econazole 1
membrane solution
ERTACZO 3
lidocaine hcl- 1
hydrocortison ac EXELDERM 3
lidocaine topical 1 JUBLIA 3
adhesive ketoconazole 1
patch,medicated
ketodan 1
lidocaine topical 1 QL
ointment ketodan kit 1
lidocaine viscous 1 MENTAX 3
lidocaine-prilocaine 1 QL naftifine 1
topical cream nyamyc 1
lidocaine-prilocaine 1 nystatin 1
topical kit
nystatin- 1
lidocort 1 triamcinolone
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
21Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
nystop 1 halcinonide 3
oxiconazole 1 halobetasol 1
tavaborole 1 propionate
HALOG 3
TOPICAL ANTIVIRALS
hydrocortisone 1
acyclovir 1 QL
hydrocortisone 1
TOPICAL CORTICOSTEROIDS butyrate
ala-cort 1 hydrocortisone 1
alclometasone 1 butyr-emollient
amcinonide 1 hydrocortisone 1
valerate
apexicon e 1
mometasone 1
beser 1
nolix 1
betamethasone 1
dipropionate prednicarbate 1
betamethasone 1 scalacort 1
valerate tovet emollient 1
betamethasone, 1 triamcinolone 1
augmented acetonide
clobetasol 1 trianex 1
clobetasol-emollient 1 triderm 1
clodan 1 tritocin 1
CLODERM 3
TOPICAL ENZYMES
desonide 1
SANTYL 2
desoximetasone 1
TOPICAL SCABICIDES /
desrx 1 PEDICULICIDES
diflorasone 1 crotan 1
fluocinolone 1 ivermectin 1
fluocinolone and 1 lindane 1
shower cap
malathion 1
fluocinonide 1
permethrin 1
fluocinonide-e 1
spinosad 1
flurandrenolide 1
fluticasone 1
DIAGNOSTICS &
propionate MISCELLANEOUS AGENTS
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
22Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
IRRIGATING SOLUTIONS pilocarpine hcl 1
lactated ringers 1 PROLASTIN-C 4 PA; LA
neomycin-polymyxin 1 RAVICTI 4 PA
b gu REVCOVI 4 PA
ringer's 1 riluzole 1 PA
tis-u-sol pentalyte 1 risedronate 1
MISCELLANEOUS AGENTS sodium chloride 0.9 1 PA
acamprosate 1 %
acetic acid 1 sodium chloride 0.9 1 PA
% (flush)
anagrelide 1
sodium chloride 1 PA
aqua care sodium 1 injection
chloride
sodium chloride 1
aqua care sterile 1 irrigation
water
sodium 1
ARALAST NP 4 PA; LA phenylbutyrate
caffeine citrate 1 SOLIRIS 4 PA
CARBAGLU 4 PA; LA tiopronin 4 PA
cevimeline 1 trientine 1
CHEMET 2 water for irrigation, 1
clovique 1 sterile
deferasirox 4 PA XURIDEN 4 PA
deferiprone 4 ZEMAIRA 4 PA; LA
disulfiram 1 zoledronic acid- 4 PA
mannitol-water
droxidopa 4 PA
FERRIPROX 4 PA SMOKING DETERRENTS
GLASSIA 4 PA; LA bupropion hcl 6 ACA
(smoking deter)
INCRELEX 4 PA; LA
CHANTIX 6 ACA
levocarnitine 1
CHANTIX 6 ACA
levocarnitine (with 1 CONTINUING
sugar) MONTH BOX
midodrine 1 CHANTIX 6 ACA
nitisinone 4 PA; LA STARTING
MONTH BOX
NITYR 4 PA; LA
nicorette buccal gum 6 ACA; OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
23Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
NICORETTE 2 OTC fluocinolone 1 QL
BUCCAL acetonide oil
LOZENGE hydrocortisone- 1 QL
NICORETTE 2 OTC acetic acid
BUCCAL MINI ofloxacin 1 QL
LOZENGE
OTIC STEROID / ANTIBIOTIC
nicotine 6 ACA; OTC
CIPRO HC 3
nicotine (polacrilex) 6 ACA; OTC
ciprofloxacin- 1
quit 2 6 ACA; OTC
dexamethasone
quit 4 6 ACA; OTC
CORTISPORIN-TC 3
stop smoking aid 6 ACA; OTC
neomycin- 1
VARENICLINE 6 ACA polymyxin-hc
EAR, NOSE & THROAT ENDOCRINE/DIABETES
MEDICATIONS ADRENAL HORMONES
MISCELLANEOUS AGENTS decadron 1
azelastine nasal 1 QL dexabliss 1
aerosol,spray
dexamethasone 1
azelastine nasal 1
spray,non-aerosol dexamethasone 1
intensol
chlorhexidine 1
gluconate fludrocortisone 1
ipratropium bromide 1 QL hidex 1
olopatadine 1 QL hydrocortisone 1
oralone 1 methylprednisolone 1
paroex oral rinse 1 millipred 1
periogard 1 millipred dp 1
pilocarpine hcl 1 prednisolone 1
triamcinolone 1 prednisolone sodium 1
acetonide phosphate
MISCELLANEOUS OTIC prednisone 1
PREPARATIONS prednisone intensol 1
acetic acid 1 ANTITHYROID AGENTS
ciprofloxacin hcl 1 methimazole 1
flac otic oil 1 QL propylthiouracil 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
24Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
BLOOD GLUCOSE MONITORING OPTICHAMBER 2
DEVICES & SUPPLIES DIAMOND VHC
ONETOUCH 2 POCKET 2
ULTRA TEST CHAMBER
ONETOUCH 2 PRIMEAIRE 2
VERIO TEST PROCHAMBER 2
STRIPS
RITEFLO 2
DIABETES, SUPPLIES, & DURABLE AEROCHAMBER
MEDICAL EQUIPMENT SPACE CHAMBER 2
ACE AEROSOL 2 TRIJARDY XR 2 ST
CLOUD
ENHANCER VORTEX 2
HOLDING
AEROCHAMBER 2
CHAMBER
MINI
AEROCHAMBER 2
GLUCOSE ELEVATING AGENTS
PLUS FLOW-VU BAQSIMI 2
AEROCHAMBER 2 diazoxide 1
PLUS Z STAT GLUCAGEN 2
AEROTRACH 2 HYPOKIT
PLUS GLUCAGON 2
AEROVENT PLUS 2 (HCL)
EMERGENCY KIT
BREATHERITE 2
MDI SPACER glucagon emergency 1
kit (human)
COMPACT SPACE 2
CHAMBER GVOKE HYPOPEN 2
2-PACK
EASIVENT 2
HOLDING GVOKE PFS 2- 2
CHAMBER PACK SYRINGE
FLEXICHAMBER 2 INSULIN
GLUCAGEN 2 SYRINGES/MISCELLANEOUS
DIAGNOSTIC KIT DURABLE MEDICAL EQU
INSPIRACHAMBE 2 BD INTEGRA 2
R NEEDLE
LITEAIRE MDI 2 BD 2 OTC
CHAMBER MICROTAINER
LANCET
MICROCHAMBER 2
BD SPECIALTY 2
MICROSPACER 2 USE NEEDLES
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
25Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
BD ULTRA FINE 2 OTC INSULIN THERAPY
LANCETS
APIDRA 3
BD ULTRA-FINE 2 OTC SOLOSTAR U-100
NANO PEN INSULIN
NEEDLE
APIDRA U-100 3
LANCETS 2 OTC INSULIN
LANCING DEVICE 2 OTC BASAGLAR 2
MEDISENSE 2 OTC KWIKPEN U-100
INSULIN
MEDISENSE 2 OTC
GLUCOSE HUMALOG 2
KETONE JUNIOR KWIKPEN
U-100
OMNIPOD DASH 5 2 PA
PACK POD HUMALOG 2
KWIKPEN
OMNIPOD 2 PA INSULIN
INSULIN
MANAGEMENT HUMALOG MIX 2
50-50 INSULN U-
ONETOUCH 2 100
ULTRA CONTROL
HUMALOG MIX 2
ONETOUCH 2 QL 50-50 KWIKPEN
ULTRA2 METER
HUMALOG MIX 2
ONETOUCH 2 QL 75-25 KWIKPEN
ULTRAMINI
HUMALOG MIX 2
ONETOUCH 2 QL 75-25(U-
VERIO FLEX 100)INSULN
METER
HUMALOG U-100 2
ONETOUCH 2 QL INSULIN
VERIO IQ METER
HUMULIN 70/30 2
ONETOUCH 2 QL U-100 INSULIN
VERIO METER
HUMULIN 70/30 2
PRECISION XTRA 2 OTC U-100 KWIKPEN
KETONE-
GLUCOSE HUMULIN N NPH 2
INSULIN
SAFE-CLIP BY 2 OTC KWIKPEN
MAIL
HUMULIN N NPH 2
V-GO 20 2 U-100 INSULIN
V-GO 30 2 HUMULIN R 2
V-GO 40 2 REGULAR U-100
INSULN
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
26Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
HUMULIN R U-500 2 RELION NOVOLIN 3
(CONC) INSULIN N
HUMULIN R U-500 2 RELION NOVOLIN 3
(CONC) KWIKPEN R
LANTUS 2 TOUJEO MAX U- 2
SOLOSTAR U-100 300 SOLOSTAR
INSULIN TOUJEO 2
LANTUS U-100 2 SOLOSTAR U-300
INSULIN INSULIN
LEVEMIR 3 MISCELLANEOUS HORMONES
FLEXTOUCH U-
ALDURAZYME 4 PA
100 INSULN
BRINEURA 4 PA
LEVEMIR U-100 3
INSULIN cabergoline 1
LYUMJEV 2 calcitonin (salmon) 1 PA
KWIKPEN U-100 injection
INSULIN calcitonin (salmon) 1
LYUMJEV 2 nasal
KWIKPEN U-200 calcitriol 1 PA
INSULIN
CERDELGA 4 PA
LYUMJEV U-100 2
INSULIN CEREZYME 4 PA
NOVOLOG 3 cinacalcet 1 PA
FLEXPEN U-100 CRYSVITA 4 PA
INSULIN
danazol 1
NOVOLOG MIX 3
70-30 U-100 DDAVP 2 PA
INSULN desmopressin nasal 1 PA
NOVOLOG MIX 3 desmopressin oral 1
70-30FLEXPEN U-
doxercalciferol 1
100
ELAPRASE 4 PA
NOVOLOG 3
PENFILL U-100 FABRAZYME 4 PA
INSULIN KANUMA 4 PA
NOVOLOG U-100 3 LUMIZYME 4 PA
INSULIN ASPART
MEPSEVII 4 PA
RELION NOVOLIN 3
70/30 METHITEST 2 PA
methyltestosterone 1 PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
27Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
miglustat 4 PA; LA glipizide-metformin 1
MYALEPT 4 PA; LA glyburide 1
NAGLAZYME 4 PA; LA glyburide 1
NATPARA 4 PA; LA micronized
ORILISSA 2 PA glyburide-metformin 1
oxandrolone 1 GLYXAMBI 2 ST
PALYNZIQ 4 PA; LA INVOKAMET 3 ST
paricalcitol 1 PA JANUMET 2 ST
intravenous JANUMET XR 2 ST
paricalcitol oral 1 JANUVIA 2 ST
SAMSCA 4 PA JARDIANCE 2 ST
sapropterin 4 PA metformin 1
SOMAVERT 4 PA miglitol 1
STRENSIQ 4 PA; LA nateglinide 1
testosterone 1 PA pioglitazone 1
testosterone 1 PA pioglitazone- 1
cypionate glimepiride
testosterone 1 PA pioglitazone- 1
enanthate metformin
tolvaptan 4 PA; LA repaglinide 1
VIMIZIM 4 PA repaglinide- 1
zoledronic acid 4 PA metformin
zoledronic acid- 4 PA SEGLUROMET 2 ST
mannitol-water STEGLATRO 2 ST
NON-INSULIN HYPOGLYCEMIC STEGLUJAN 2 ST
AGENTS SYMLINPEN 120 2 PA
acarbose 1 SYMLINPEN 60 2 PA
BYDUREON 2 PA SYNJARDY 2 ST
BCISE
SYNJARDY XR 2 ST
BYETTA 2 PA
TRULICITY 2 PA
CYCLOSET 3
XIGDUO XR 2 ST
FARXIGA 2 ST
THYROID HORMONES
glimepiride 1
ARMOUR 2
glipizide 1 THYROID
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
28Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
euthyrox 1 symax-sl 1
levo-t 1 symax-sr 1
levothyroxine 1 MISCELLANEOUS
levoxyl 1 GASTROINTESTINAL AGENTS
liothyronine 1 alophen (bisacodyl) 6 ACA; OTC
np thyroid 1 alosetron 1
unithroid 1 alvimopan 1
westhroid 1 anucort-hc 1
aprepitant 1
GASTROENTEROLOGY
balsalazide 1
ANTIDIARRHEALS &
ANTISPASMODICS bisacodyl 6 ACA; OTC
anaspaz 1 bisa-lax (bisacodyl) 6 ACA; OTC
belladonna 1 ST; QL budesonide 1
alkaloids-opium calcium 1
chlordiazepoxide- 1 acetate(phosphat
clidinium bind)
dicyclomine 1 CHENODAL 4 PA; LA
diphenoxylate- 1 CHOLBAM 4 PA
atropine citrate of magnesia 6 ACA; OTC
ed-spaz 1 citroma 6 ACA; OTC
glycopyrrolate 1 clearlax 6 ACA; OTC
hyoscyamine sulfate 1 compro 1
hyosyne 1 CREON 2
loperamide 1 cromolyn 1
methscopolamine 3 CYSTADANE 4 PA
opium tincture 1 DIPENTUM 3
oscimin 1 dronabinol 1
oscimin sl 1 dulcolax 6 ACA; OTC
oscimin sr 1 (magnesium
hydroxide)
phenobarb-hyoscy- 1
atropine-scop ENTYVIO 4 PA
phenohytro 1 enulose 1
symax fastabs 1 gavilax 6 ACA; OTC
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
29Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
gavilyte-c 6 ACA milk of magnesia 6 ACA; OTC
gavilyte-g 6 ACA concentrated
gavilyte-n 6 ACA miralax 6 ACA; OTC
generlac 1 MOVANTIK 2
gentle laxative 6 ACA; OTC natura-lax 6 ACA; OTC
(bisacodyl) OCALIVA 4 PA; LA
gentlelax 6 ACA; OTC ondansetron 1
glycolax 6 ACA; OTC ondansetron hcl 1
granisetron hcl 1 oral saline laxative 6 ACA; OTC
healthylax 6 ACA; OTC PANCREAZE 2
hemmorex-hc 1 peg 3350- 6 ACA
hydrocortisone 1 electrolytes
hydrocortisone 1 peg3350-sod sul- 6 ACA
acetate nacl-kcl-asb-c
hydrocortisone- 1 peg-electrolyte soln 6 ACA
pramoxine peg-prep 6 ACA
INFLECTRA 4 PA PENTASA 2
lactulose 1 phosphate laxative 6 ACA; OTC
lanthanum 1 polyethylene glycol 6 ACA; OTC
laxaclear 6 ACA; OTC 3350
laxative (bisacodyl) 6 ACA; OTC powderlax 6 ACA; OTC
laxative peg 3350 6 ACA; OTC prochlorperazine 1
lidocaine hcl- 1 prochlorperazine 1
hydrocortison ac maleate
lidocaine- 1 procto-med hc 1
hydrocortisone-aloe procto-pak 1
LOKELMA 2 proctosol hc 1
magnesium citrate 6 ACA; OTC proctozone-hc 1
meclizine 1 purelax 6 ACA; OTC
mesalamine 1 RECTIV 2
mesalamine with 1 RELISTOR 2 PA
cleansing wipe scopolamine base 1
metoclopramide hcl 1 sevelamer carbonate 1
milk of magnesia 6 ACA; OTC sevelamer hcl 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
30Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
smoothlax 6 ACA; OTC esomeprazole 1 QL
sodium polystyrene 1 magnesium oral
sulfonate capsule,delayed
release(dr/ec) 20 mg
sps (with sorbitol) 1
esomeprazole 1
SUCRAID 4 PA magnesium oral
sulfasalazine 1 capsule,delayed
release(dr/ec) 40 mg
trilyte with flavor 6 ACA
packets esomeprazole 1 PA; QL
magnesium oral
trimethobenzamide 1 granules dr for susp
TRULANCE 2 in packet 10 mg, 20
mg
UCERIS 2
esomeprazole 1 PA
ursodiol 1
magnesium oral
VARUBI 2 granules dr for susp
VIBERZI 2 in packet 40 mg
VIOKACE 2 famotidine 1
women's gentle 6 ACA; OTC lansoprazole oral 1 QL
laxative(bisac) capsule,delayed
release(dr/ec) 15 mg
women's laxative 6 ACA; OTC
(bisacodyl) lansoprazole oral 1
capsule,delayed
ULCER THERAPY release(dr/ec) 30 mg
amoxicil- 1 QL lansoprazole oral 1 QL
clarithromy- tablet,disintegrat,
lansopraz delay rel 15 mg
cimetidine 1 lansoprazole oral 1
cimetidine hcl 1 tablet,disintegrat,
delay rel 30 mg
DEXILANT ORAL 3 PA; QL
CAPSULE,BIPHAS misoprostol 1
E DELAYED nizatidine 1
RELEAS 30 MG
omeprazole oral 1 QL
DEXILANT ORAL 3 PA capsule,delayed
CAPSULE,BIPHAS release(dr/ec) 10 mg
E DELAYED
omeprazole oral 1
RELEAS 60 MG
capsule,delayed
release(dr/ec) 20
mg, 40 mg
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
31Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
pantoprazole oral 1 glatiramer 4 PA
granules dr for susp glatopa 4 PA
in packet
KESIMPTA PEN 4 PA
pantoprazole oral 1 QL
tablet,delayed MAYZENT 4 PA
release (dr/ec) 20 MAYZENT 4 PA
mg STARTER PACK
pantoprazole oral 1 OCREVUS 4 PA
tablet,delayed
release (dr/ec) 40 PEGASYS 4 PA
mg PLEGRIDY 4 PA
rabeprazole 1 POMALYST 4 PA; LA
sucralfate 1 PONVORY 4 PA
IMMUNOLOGY, VACCINES & PONVORY 14- 4 PA
BIOTECHNOLOGY DAY STARTER
PACK
BIOTECHNOLOGY DRUGS REBIF (WITH 4 PA
FULPHILA 4 PA ALBUMIN)
LEUKINE 4 PA REBIF REBIDOSE 4 PA
MOZOBIL 4 PA REBIF TITRATION 4 PA
NIVESTYM 4 PA PACK
NYVEPRIA 4 PA REVLIMID 4 PA; LA
PROCRIT 4 PA ribavirin 4 PA
RETACRIT 4 PA VUMERITY 4 PA
ZARXIO 4 PA ZEPOSIA 4 PA
ZIEXTENZO 4 PA ZEPOSIA 4 PA
STARTER KIT
GROWTH HORMONES
ZEPOSIA 4 PA
EGRIFTA SV 4 PA STARTER PACK
OMNITROPE 4 PA INTERLEUKINS
INTERFERONS ACTIMMUNE 4 PA
AVONEX 4 PA ALFERON N 2 PA
BAFIERTAM 4 ILARIS (PF) 4 PA; LA
BETASERON 4 PA imiquimod 1
dimethyl fumarate 4 PA INTRON A 4 PA
GILENYA 4 PA PROLEUKIN 4 PA
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
32Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
VACCINES & MISCELLANEOUS FLUZONE 6 ACA
IMMUNOLOGICALS HIGHDOSE QUAD
21-22 PF
ADACEL(TDAP 6 ACA
ADOLESN/ADULT FLUZONE QUAD 6 ACA
)(PF) 2021-2022
AFLURIA QD 6 ACA FLUZONE QUAD 6 ACA
2021-22(3YR 2021-2022 (PF)
UP)(PF) GAMASTAN 4 PA
AFLURIA QD 6 ACA GAMASTAN S/D 4 PA
2021-22(6-
35MO)(PF) GAMMAGARD 4 PA
LIQUID
AFLURIA QUAD 6 ACA
2021-2022(6MO GAMMAGARD S- 4 PA
UP) D (IGA < 1
MCG/ML)
BEXSERO 6 ACA
GAMUNEX-C 4 PA
BIOTHRAX 2
GARDASIL 9 (PF) 6 ACA
BOOSTRIX TDAP 6 ACA
GRASTEK 2
BOTOX 4 PA
HAVRIX (PF) 6 ACA
DAPTACEL (DTAP 6 ACA
PEDIATRIC) (PF) HIBERIX (PF) 6 ACA
ENGERIX-B (PF) 6 ACA IMOVAX RABIES 2
VACCINE (PF)
ENGERIX-B 6 ACA
PEDIATRIC (PF) INFANRIX (DTAP) 6 ACA
(PF)
FLUAD QUAD 6 ACA
2021-22(65Y IPOL 6 ACA
UP)(PF) IXIARO (PF) 2
FLUARIX QUAD 6 ACA JANSSEN COVID- 6 ACA
2021-2022 (PF) 19 VACCINE
FLUBLOK QUAD 6 ACA (EUA)
2021-2022 (PF) MENACTRA (PF) 6 ACA
FLUCELVAX 6 ACA M-M-R II (PF) 6 ACA
QUAD 2021-2022
MODERNA 6 ACA
FLUCELVAX 6 ACA COVID-19
QUAD 2021-2022 VACCINE (EUA)
(PF)
ODACTRA 2
FLULAVAL QUAD 6 ACA
PEDVAX HIB (PF) 6 ACA
2021-2022 (PF)
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
33Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
PFIZER COVID-19 6 ACA probenecid- 1
VACCINE (EUA) colchicine
PNEUMOVAX-23 6 ACA OSTEOPOROSIS THERAPY
PREVNAR 13 (PF) 6 ACA alendronate 1
PROQUAD (PF) 6 ACA FOSAMAX PLUS 3
PROVENGE 4 PA D
QUADRACEL (PF) 6 ACA ibandronate 4 PA
intravenous
RABAVERT (PF) 2
ibandronate oral 1
RAGWITEK 2
raloxifene 1
RECOMBIVAX HB 6 ACA
(PF) risedronate 1
SHINGRIX (PF) 6 ACA TYMLOS 4 PA
STAMARIL (PF) 2 OTHER RHEUMATOLOGICALS
TDVAX 6 ACA ACTEMRA 4 PA
TETANUS,DIPHTH 6 ACA ACTEMRA 4 PA
ERIA TOX ACTPEN
PED(PF) BENLYSTA 4 PA
TRUMENBA 6 ACA ENBREL 4 PA
TWINRIX (PF) 6 ACA ENBREL MINI 4 PA
TYPHIM VI 2 ENBREL 4 PA
VARIVAX (PF) 6 ACA SURECLICK
VARIZIG 2 HUMIRA 4 PA
XEMBIFY 4 PA HUMIRA PEN 4 PA
YF-VAX (PF) 2 HUMIRA PEN 4 PA
CROHNS-UC-HS
MUSCULOSKELETAL & START
RHEUMATOLOGY HUMIRA PEN 4 PA
GOUT THERAPY PSOR-UVEITS-
ADOL HS
allopurinol 1
HUMIRA(CF) 4 PA
colchicine 1
HUMIRA(CF) PEDI 4 PA
febuxostat 1 CROHNS
KRYSTEXXA 4 PA STARTER
MITIGARE 2 HUMIRA(CF) PEN 4 PA
probenecid 1
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
34Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
HUMIRA(CF) PEN 4 PA deblitane 6 ACA
CROHNS-UC-HS dotti 1
HUMIRA(CF) PEN 4 PA eemt 1
PEDIATRIC UC
eemt hs 1
HUMIRA(CF) PEN 4 PA
PSOR-UV-ADOL errin 6 ACA
HS estradiol 1
leflunomide 1 estradiol valerate 1 PA
OTEZLA 4 PA estradiol- 1
OTEZLA 4 PA norethindrone acet
STARTER estrogens- 1
penicillamine 1 methyltestosterone
RIDAURA 2 fyavolv 1
RINVOQ 4 PA heather 6 ACA
SAVELLA 2 hydroxyprogest(pf)(p 4 PA
reg presv)
XELJANZ 4 PA
hydroxyprogesterone 4 PA
XELJANZ XR 4 PA cap(ppres)
OBSTETRICS & incassia 6 ACA
GYNECOLOGY jencycla 6 ACA
DIAPHRAGMS AND OTHER NON- jinteli 1
ORAL CONTRACEPTIVES
lyleq 6 ACA
CAYA 6 ACA
lyllana 1
CONTOURED
lyza 6 ACA
FC2 FEMALE 6 ACA; OTC
CONDOM medroxyprogesteron 6 ACA
e intramuscular
FEMCAP 6 ACA
medroxyprogesteron 1
MIRENA 6 ACA
e oral
PARAGARD T 6 ACA
MENEST 2
380A
mimvey 1
ESTROGENS & PROGESTINS
nora-be 6 ACA
amabelz 1
norethindrone 6 ACA
camila 6 ACA (contraceptive)
covaryx 1 norethindrone 1
covaryx h.s. 1 acetate
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
35Drug Name Drug Requirements Drug Name Drug Requirements
Tier / Limits Tier / Limits
norethindrone ac-eth 1 VCF 2 OTC
estradiol CONTRACEPTIVE
norlyda 6 ACA GEL
PREMARIN 3 xulane 6 ACA
progesterone 4 PA zafemy 6 ACA
progesterone 1 ORAL CONTRACEPTIVES &
micronized RELATED AGENTS
sharobel 6 ACA afirmelle 6 ACA
tulana 6 ACA after pill 6 ACA; OTC
yuvafem 1 altavera (28) 6 ACA
MISCELLANEOUS OB/GYN alyacen 1/35 (28) 6 ACA
clindamycin 1 alyacen 7/7/7 (28) 6 ACA
phosphate amethia 6 ACA
eluryng 6 ACA amethyst (28) 6 ACA
etonogestrel-ethinyl 6 ACA apri 6 ACA
estradiol
aranelle (28) 6 ACA
fem ph 1
ashlyna 6 ACA
gynol ii 6 ACA; OTC
aubra 6 ACA
isoxsuprine 1
aubra eq 6 ACA
metronidazole 1
aurovela 1.5/30 (21) 6 ACA
miconazole-3 1
aurovela 1/20 (21) 6 ACA
MYFEMBREE 2
aurovela 24 fe 6 ACA
NEXPLANON 6 ACA
aurovela fe 1.5/30 6 ACA
ORIAHNN 2 (28)
terconazole 1 aurovela fe 1-20 6 ACA
TODAY 6 ACA; OTC (28)
CONTRACEPTIVE aviane 6 ACA
SPONGE
ayuna 6 ACA
tranexamic acid 1
azurette (28) 6 ACA
TRIMO-SAN 2
balziva (28) 6 ACA
JELLY
blisovi 24 fe 6 ACA
vandazole 1
blisovi fe 1.5/30 (28) 6 ACA
VCF 2 OTC
CONTRACEPTIVE blisovi fe 1/20 (28) 6 ACA
FILM
You can find information on what the symbols and abbreviations on this table mean by going to the beginning
of this table.
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