Your 2020 Formulary - Princeton University ...
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Your 2020 Formulary
Effective July 1, 2020
For the most current list of covered medications or if you have questions:
Call the number on your member ID card.
Visit your plan’s website on your member ID card to:
• Find a participating retail pharmacy by ZIP code.
• Look up possible lower-cost medication alternatives.
• Compare medication pricing and options.
Premium StandardUnderstanding your formulary
What is a formulary?
A formulary is a list of prescribed medications or other About this formulary
pharmacy care products, services or supplies chosen Where differences between
for their safety, cost, and effectiveness. Medications are this formulary and your benefit
listed by categories or classes and are placed into cost plan exist, the benefit plan
levels known as tiers. It includes both brand and generic documents rule. This may not be
prescription medications. a complete list of medications
that are covered by your plan.
To create the list, OptumRx® is guided by the Pharmacy and
Please review your benefit plan
Therapeutics Committee. This group of doctors, nurses, and
for full details.
pharmacists reviews which medications will be covered,
how well the drugs work, and overall value. They also make
sure there are safe and covered options.
How do I use my formulary?
You and your doctor can use the formulary to help you choose the most cost-effective prescription
medications. This guide tells you if a medication is generic or brand, and if special rules apply.
Bring this list with you when you see your doctor. If your medication is not listed here, please visit
your plan’s website or call the number on your member ID card.
What are tiers?
Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by
your employer or plan sponsor. This is how much you will pay when you fill a prescription.
When does the formulary change?
• Medications may move to a lower tier at any time.
•M
edications may move to a higher tier when a generic equal becomes available.
•M
edications may move to a higher tier or be excluded from coverage on January 1 or July 1 of
each year.
When a medication changes tiers, you may have to pay a different amount for that medication.
Why are some medications excluded from coverage?
A medication may be excluded from coverage under your pharmacy benefit when it works the
same as or similar to another prescription or over-the-counter (OTC) medication.
What if I don’t agree with a decision about an excluded medication?
You or your authorized representative and your doctor can ask for a coverage request by calling
the number on your member ID card.
2Medication tips
What is the difference between brand-name and
generic medications? Over-the-counter medications
Generic medications contain the same active ingredients (what An over-the-counter (OTC)
makes the medication work) as brand-name medications, medication may be the right
but they often cost less. Once the patent for a brand-name treatment option for some
medication ends, the FDA can approve a generic version with conditions. Talk to your doctor
the same active ingredients. about OTC options. Even though
OTC medications may not be
What if my doctor writes a brand-name prescription? covered by your pharmacy
If your doctor gives you a prescription for a brand-name benefit, they may cost less
medication, ask if a generic or lower-cost option could be right than a prescription medication.
for you. Generic medications are usually your lowest-cost option.
What if I am taking a specialty medication?
Specialty medications are for rare or complex conditions and are usually higher-cost medications.
Please note, not all specialty medications are listed in the formulary. Our specialty pharmacy can
provide most of your specialty medications along with helpful programs and services.
Call 1-855-427-4682 and have your prescriptions delivered right to your home or doctor’s office.
3Reading your formulary
The formulary gives you choices so you and your doctor can decide your best course of treatment.
In this formulary, brand-name medications are shown in UPPERCASE (for example, CLOBEX).
Generic medications are shown in lowercase (for example, clobetasol).
Tier information
Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your
plan may have multiple or no tiers. Please note: If you have a high-deductible plan, the tier cost
levels will apply once you meet your deductible.
Drug Tier Includes Helpful Tips
Tier 1 $
Lower-cost generics Use Tier 1 drugs for the lowest out-of-pocket costs.
and some brand name
Tier 2 $$
Mid-range cost Use Tier 2 drugs instead of Tier 3 to help reduce your
preferred brand name out-of-pocket costs.
Tier 3 $$$ Highest-cost Many Tier 3 drugs have lower-cost options in Tier 1 or 2.
non-preferred Ask your doctor if they could work for you.
Tier E Excluded May not be covered or need prior authorization. Lower-cost
options are available and covered.
Drug list information
In this drug list, some medications are noted with letters next to them to help you see which ones
may have coverage requirements or limits. Your benefit plan decides how these medications may
be covered.
M Authorized generic or cobranded product
PA Prior Authorization – Your doctor is required to give OptumRx more information
to determine coverage.
QL Quantity Limit – Medication may be limited to a certain quantity.
SP Specialty Medication – Medication is designated as specialty.
ST Step Therapy – Must try lower-cost medication(s) before a higher-cost medication
can be covered.
3P Tier 3 preferred
4Table of Contents
Analgesics - Drugs for Pain.................................................................................................................................7
Analgesics - Drugs for Pain and Inflammation.................................................................................................... 8
Anesthetics..........................................................................................................................................................8
Anti-Addiction / Substance Abuse Treatment Agents......................................................................................... 8
Antibacterials.......................................................................................................................................................8
Anticoagulants.....................................................................................................................................................9
Anticonvulsants - Drugs for Seizures................................................................................................................ 10
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia.............................................................. 10
Antidepressants.................................................................................................................................................10
Antiemetics - Drugs for Nausea and Vomiting.................................................................................................. 11
Antifungals.........................................................................................................................................................11
Antigout Agents................................................................................................................................................. 12
Antimigraine Agents.......................................................................................................................................... 12
Antineoplastics - Drugs for Cancer....................................................................................................................12
Antiparasitics..................................................................................................................................................... 13
Antiparkinson Agents........................................................................................................................................ 13
Antiplatelets.......................................................................................................................................................13
Antipsychotics - Drugs for Mood Disorders....................................................................................................... 13
Antivirals............................................................................................................................................................14
Anxiolytics - Drugs for Anxiety...........................................................................................................................14
Bipolar Agents - Drugs for Mood Disorders.......................................................................................................14
Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders..............................................14
Cardiovascular Agents - Drugs for Heart and Circulation Conditions............................................................... 15
Central Nervous System Agents - Drugs for Attention Deficit Disorder........................................................... 17
Central Nervous System Agents - Drugs for Multiple Sclerosis........................................................................ 18
Central Nervous System Agents - Miscellaneous............................................................................................. 18
Dental and Oral Agents - Drugs for Mouth and Throat Conditions....................................................................19
Dermatological Agents - Drugs for Skin Conditions.......................................................................................... 19
Diabetes - Antidiabetic Agents.......................................................................................................................... 21
Diabetes - Glucose Monitoring.......................................................................................................................... 22
Diabetes - Glycemic Agents.............................................................................................................................. 23
Diabetes - Insulins.............................................................................................................................................23
Electrolytes / Minerals / Metals / Vitamins.........................................................................................................24
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer................................................................................25
Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions.................................................25
Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment............................................. 26
Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.......................................................26
Genitourinary Agents - Drugs for Prostate Conditions...................................................................................... 26
Hormonal Agents - Adrenal............................................................................................................................... 26
Hormonal Agents - Men's Health.......................................................................................................................27
Hormonal Agents - Osteoporosis...................................................................................................................... 27
Hormonal Agents - Pituitary.............................................................................................................................. 27
Hormonal Agents - Sex Hormones and Birth Control........................................................................................28
Hormonal Agents - Thyroid............................................................................................................................... 29
Immunological Agents - Drugs for Immune System Stimulation or Suppression.............................................. 30
Inflammatory Bowel Disease Agents.................................................................................................................31
Metabolic Bone Disease Agents - Drugs for Osteoporosis............................................................................... 31
Metabolic Bone Disease Agents - Other........................................................................................................... 31
Miscellaneous Therapeutic Agents................................................................................................................... 31
Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation...........................................................32
Ophthalmic Agents - Drugs for Glaucoma.........................................................................................................32
5Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions......................................................................... 33
Otic Agents - Drugs for Ear Conditions............................................................................................................. 33
Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold........................................................33
Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions................................... 34
Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis.................................................................... 35
Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension.................................................... 35
Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm...................................................................... 36
Sleep Disorder Agents...................................................................................................................................... 36
6Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Analgesics - Drugs FIORICET/CODEINE E
for Pain hydrocodone-
ABSTRAL E acetaminophen oral 1 QL
acetaminophen- tablet
1 QL
codeine #2 hydromorphone hcl oral
1 QL
acetaminophen- tablet
1 QL
codeine #3 HYSINGLA ER 2 PA; QL
acetaminophen- KADIAN E
1 QL
codeine #4 LAZANDA E
acetaminophen- morphine sulfate er oral
1 QL 1 PA; QL
codeine oral tablet tablet extended release
APADAZ E MS CONTIN E
apap-caff- NORCO E
dihydrocodeine oral 1 QL
capsule NUCYNTA E
ARYMO ER E NUCYNTA ER E
BELBUCA 2 PA; QL OXYCODONE HCL E
BENZHYDROCODON OXYCODONE HCL ER E M
E
E-ACETAMINOPHEN oxycodone hcl oral
1 QL
butalbital-apap-caffeine 1 tablet
BUTRANS oxycodone-
TRANSDERMAL acetaminophen oral
PATCH WEEKLY 10 tablet 10-325 mg, 2.5- 1 QL
E 325 mg, 5-325 mg, 7.5-
MCG/HR, 15 MCG/HR,
20 MCG/HR, 5 325 mg
MCG/HR OXYCONTIN 2 PA; QL
CONZIP E PERCOCET E
DILAUDID ORAL E ROXICODONE E
DURAGESIC-100 E SUBSYS E
DURAGESIC-12 E TRAMADOL HCL ER
DURAGESIC-25 E ORAL CAPSULE
EXTENDED RELEASE E M
DURAGESIC-50 E 24 HOUR 100 MG, 200
DURAGESIC-75 E MG, 300 MG
fentanyl 1 PA; QL tramadol hcl oral tablet
1 QL
FENTANYL CITRATE 50 mg
E M
BUCCAL TABLET TREZIX 3 QL
FENTORA E TYLENOL WITH
E
FIORICET E CODEINE #3
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
7Drug Name Drug Tier Notes Drug Name Drug Tier Notes
TYLENOL WITH PENNSAID E
CODEINE #4 ORAL E QMIIZ ODT E
TABLET 300-60 MG
SPRIX E
ULTRACET E
VIMOVO E
ULTRAM E
VOLTAREN E
XTAMPZA ER E
ZIPSOR E
ZOHYDRO ER E
ZORVOLEX E
Analgesics - Drugs
for Pain and Anesthetics
Inflammation lidocaine external
1
ARTHROTEC E ointment
CAMBIA E lidocaine external patch
1
5%
CELEBREX E
lidocaine-prilocaine
celecoxib oral 1 QL 1
external cream
diclofenac sodium oral 1 LIDODERM E
diclofenac sodium ZTLIDO E
1 QL
transdermal gel 1 %
Anti-Addiction /
DUEXIS E Substance Abuse
etodolac oral tablet 1 Treatment Agents
FLECTOR E BUNAVAIL 3 QL
ibuprofen oral tablet 1 buprenorphine hcl
1 QL
indomethacin oral sublingual
1
capsule 25 mg, 50 mg buprenorphine hcl-
1 QL
KETOROLAC naloxone hcl
TROMETHAMINE CHANTIX 3 QL
E M
NASAL SOLUTION CHANTIX
15.75 MG/SPRAY CONTINUING MONTH 3 QL
ketorolac tromethamine PAK
1 QL
oral CHANTIX STARTING
3 QL
meloxicam oral 1 MONTH PAK
MOBIC E naltrexone hcl oral 1
nabumetone oral 1 NARCAN 2
NALFON E SUBOXONE E
NAPRELAN 3 ZUBSOLV 2 QL
naproxen oral tablet 1 Antibacterials
naproxen sodium oral ACTICLATE E
1
tablet amoxicillin oral capsule 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
8Drug Name Drug Tier Notes Drug Name Drug Tier Notes
amoxicillin oral levofloxacin oral tablet 1
suspension 1 metronidazole oral
reconstituted 1
tablet
amoxicillin oral tablet 1 metronidazole vaginal 1
amoxicillin-potassium minocycline hcl oral
clavulanate oral 1
1 capsule
suspension
reconstituted MINOLIRA E
amoxicillin-potassium mupirocin external 1
1
clavulanate oral tablet nitrofurantoin
1
azithromycin oral macrocrystal oral
suspension 1 nitrofurantoin
reconstituted monohydrate 1
azithromycin oral tablet 1 macrocrystals
cefdinir 1 NUZYRA ORAL 3
cefuroxime axetil 1 penicillin v potassium
1
oral tablet
cephalexin oral capsule 1
SEYSARA 3 ST
cephalexin oral
suspension 1 SILVADENE E
reconstituted SOLODYN E
ciprofloxacin hcl oral SOLOSEC 3
1
tablet 250 mg, 500 mg sulfamethoxazole-
1
clarithromycin oral trimethoprim oral
1
tablet TARGADOX E
clindamycin hcl oral 1 XENLETA 3
CLINDESSE 3 XEPI 3
DIFICID 3 XIMINO 3
DORYX E Anticoagulants
DORYX MPC E BEVYXXA 3 QL
doxycycline hyclate oral ELIQUIS 2 QL
1
capsule
ELIQUIS DVT/PE
doxycycline hyclate oral 2 QL
1 STARTER PACK
tablet
enoxaparin sodium 1 SP; QL
doxycycline
monohydrate oral 1 PRADAXA 2 QL
capsule warfarin sodium oral 1
doxycycline XARELTO 2 QL
1
monohydrate oral tablet
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
9Drug Name Drug Tier Notes Drug Name Drug Tier Notes
XARELTO STARTER oxcarbazepine oral
2 QL 1
PACK tablet
Anticonvulsants - OXTELLAR XR E
Drugs for Seizures QUDEXY XR E
carbamazepine oral SABRIL E SP
1
tablet
SYMPAZAN 3 PA
CARBATROL E
TEGRETOL E
DEPAKOTE E
TEGRETOL-XR E
DEPAKOTE ER E
TOPAMAX E
DEPAKOTE
E TOPAMAX SPRINKLE E
SPRINKLES
DILANTIN INFATABS E topiramate oral tablet 1
DILANTIN ORAL TRILEPTAL E
E
CAPSULE 100 MG TROKENDI XR E
DILANTIN ORAL VIMPAT 3
E
SUSPENSION ZONEGRAN E
divalproex sodium er 1 zonisamide oral 1
divalproex sodium oral Antidementia Agents
1
tablet delayed release - Drugs for
EPIDIOLEX 3 PA; SP Alzheimer's Disease
gabapentin oral and Dementia
1
capsule donepezil hcl oral tablet
1
gabapentin oral tablet 1 10 mg, 23 mg
KEPPRA ORAL E memantine hcl oral
1
tablet 10 mg, 5 mg
KEPPRA XR E
NAMZARIC 2 QL
LAMICTAL E
Antidepressants
LAMICTAL ODT E
amitriptyline hcl oral 1
LAMICTAL STARTER E
BRISDELLE E
LAMICTAL XR ORAL
TABLET EXTENDED E bupropion hcl er (sr) 1 QL
RELEASE 24 HOUR bupropion hcl er (xl)
lamotrigine er 1 oral tablet extended
1 QL
release 24 hour 150
lamotrigine oral tablet 1 mg, 300 mg
levetiracetam oral BUPROPION HCL ER
1
tablet (XL) ORAL TABLET
2 QL
NEURONTIN E EXTENDED RELEASE
ONFI E 24 HOUR 450 MG
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
10Drug Name Drug Tier Notes Drug Name Drug Tier Notes
bupropion hcl oral 1 VIIBRYD STARTER
3 QL
CELEXA E PACK
citalopram WELLBUTRIN SR E
hydrobromide oral 1 WELLBUTRIN XL E
tablet ZOLOFT E
CYMBALTA E Antiemetics - Drugs
desvenlafaxine for Nausea and
1 QL
succinate er Vomiting
doxepin hcl oral meclizine hcl oral tablet 1
capsule 10 mg, 100 metoclopramide hcl
1 1
mg, 150 mg, 50 mg, 75 oral tablet 10 mg
mg
ondansetron hcl oral
duloxetine hcl oral 1 QL 1
tablet 4 mg, 8 mg
EFFEXOR XR E ondansetron odt 1
escitalopram oxalate prochlorperazine
1 1
oral tablet maleate oral
fluoxetine hcl oral SANCUSO E
1
capsule
scopolamine 1
fluoxetine hcl oral tablet 1
VARUBI ORAL
fluvoxamine maleate 1 3 QL
TABLET 90 MG
FORFIVO XL 3 QL Antifungals
LEXAPRO E ciclopirox external
1
mirtazapine oral tablet 1 solution
nortriptyline hcl oral clotrimazole external
1 1
capsule cream
paroxetine hcl 1 clotrimazole-
PAXIL CR E betamethasone 1
external cream
PAXIL ORAL TABLET E
CRESEMBA ORAL 3
PRISTIQ E
fluconazole oral tablet 1
PROZAC E
GYNAZOLE-1 3
sertraline hcl oral tablet 1
JUBLIA E
trazodone hcl oral 1
KERYDIN 3 PA
TRINTELLIX 3 ST; QL
ketoconazole external
venlafaxine hcl 1 1
cream
venlafaxine hcl er 1 ketoconazole external
1
VIIBRYD 3 QL shampoo
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
11Drug Name Drug Tier Notes Drug Name Drug Tier Notes
nystatin external cream 1 rizatriptan benzoate 1 QL
nystatin mouth/throat 1 sumatriptan succinate
1 QL
terbinafine hcl oral 1 QL oral
terconazole vaginal TOSYMRA E
1
cream TREXIMET E
TOLSURA E ZEMBRACE
E
Antigout Agents SYMTOUCH
allopurinol oral 1 ZOMIG ORAL E
COLCHICINE ORAL ZOMIG ZMT E
E
CAPSULE Antineoplastics -
colchicine tablet 0.6 mg Drugs for Cancer
1 Made by Mylan
oral AFINITOR ORAL
colchicine tablet 0.6 mg TABLET 2.5 MG, 5 E SP
E Made by Par MG, 7.5 MG
oral
colchicine tablet 0.6 mg Made by anastrozole oral 1
E
oral Prasco ARIMIDEX E
COLCRYS 2 BELRAPZO E SP
MITIGARE E BENDAMUSTINE HCL E SP
Antimigraine Agents CABOMETYX 2 PA; SP
AIMOVIG 2 PA; QL capecitabine 1 PA; SP
AJOVY ERLEADA E SP
SUBCUTANEOUS GLEEVEC E SP
E
SOLUTION
PREFILLED SYRINGE IBRANCE ORAL
3 PA; SP
CAPSULE
eletriptan hydrobromide 1 QL
IDHIFA 3 PA; SP; QL
EMGALITY 2 PA; QL
imatinib mesylate 1 PA; SP
EMGALITY (300 MG
2 PA; QL IMBRUVICA ORAL
DOSE) 3 PA; SP
TABLET
IMITREX E
KANJINTI 2 PA; SP
IMITREX STATDOSE
E letrozole oral 1
REFILL
IMITREX STATDOSE LYNPARZA 2 PA; SP
E
SYSTEM MVASI 2 PA; SP
MAXALT E NUBEQA 3 PA; SP
MAXALT-MLT E OGIVRI E SP
ONZETRA XSAIL E REVLIMID 2 PA; SP
RELPAX E RUBRACA 2 PA; SP
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
12Drug Name Drug Tier Notes Drug Name Drug Tier Notes
RUXIENCE 2 PA; SP OSMOLEX ER E
SPRYCEL 2 PA; SP pramipexole
1
tamoxifen citrate oral 1 dihydrochloride
TARGRETIN ORAL E SP ropinirole hcl 1
temozolomide 1 PA; SP RYTARY 3 ST
TRAZIMERA 2 PA; SP Antiplatelets
TREANDA E SP ASPIRIN-
E M
OMEPRAZOLE
TRUXIMA E SP
BRILINTA 2
XPOVIO (100 MG
3 PA; SP clopidogrel bisulfate
ONCE WEEKLY) 1
oral
XPOVIO (60 MG
3 PA; SP PLAVIX E
ONCE WEEKLY)
XPOVIO (80 MG prasugrel hcl 1
3 PA; SP
ONCE WEEKLY) YOSPRALA E
XPOVIO (80 MG Antipsychotics -
3 PA; SP Drugs for Mood
TWICE WEEKLY)
XTANDI 3 PA; SP Disorders
YONSA E SP ABILIFY E
ZEJULA 2 PA; SP ABILIFY MAINTENA 3
ZIRABEV 2 PA; SP aripiprazole oral tablet 1 QL
ZYTIGA E SP ARISTADA 3
Antiparasitics ARISTADA INITIO 3
ARAKODA 3 INVEGA SUSTENNA 3
EMVERM 2 INVEGA TRINZA 3
hydroxychloroquine LATUDA 3 QL
1
sulfate oral olanzapine oral tablet 1 QL
NATROBA E PERSERIS 3
permethrin external 1 quetiapine fumarate 1 QL
PLAQUENIL E quetiapine fumarate er 1 QL
Antiparkinson Agents REXULTI 3 QL
benztropine mesylate RISPERDAL E
1
oral risperidone oral tablet 1 QL
carbidopa-levodopa SAPHRIS 2 QL
1
oral tablet
SEROQUEL E
GOCOVRI E
SEROQUEL XR E
INBRIJA 3 PA; SP
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
13Drug Name Drug Tier Notes Drug Name Drug Tier Notes
VRAYLAR 3 ST; QL VEMLIDY 3 SP
ziprasidone hcl 1 QL VOSEVI 2 PA; SP; QL
ZYPREXA E XOFLUZA (40 MG
3 QL
Antivirals DOSE)
acyclovir oral tablet 1 XOFLUZA (80 MG
3 QL
DOSE)
ATRIPLA E
ZOVIRAX E
BARACLUDE ORAL
E SP Anxiolytics - Drugs
TABLET
for Anxiety
BIKTARVY 3
alprazolam oral tablet 1 QL
CIMDUO 2
ATIVAN ORAL E
DESCOVY 3 PA
buspirone hcl oral 1
DOVATO 2
clonazepam oral tablet 1 QL
entecavir 1 SP; QL
diazepam oral tablet 1
EPCLUSA 2 PA; SP; QL
hydroxyzine hcl oral
GENVOYA 3 1
tablet
HARVONI 2 PA; SP; QL hydroxyzine pamoate
1
JULUCA 2 oral
LEDIPASVIR- KLONOPIN E
E M; SP
SOFOSBUVIR lorazepam oral tablet 1 QL
MAVYRET 2 PA; SP; QL triazolam 1 QL
ODEFSEY 3 VALIUM E
oseltamivir phosphate XANAX E
1 QL
oral
XANAX XR E
PREZCOBIX 2
Bipolar Agents -
SOFOSBUVIR- Drugs for Mood
E M; SP
VELPATASVIR Disorders
SYMFI 2 lithium carbonate er 1
SYMFI LO 2 lithium carbonate oral
1
TAMIFLU E capsule
TEMIXYS E Blood Products /
Modifiers / Volume
TIVICAY 2
Expanders - Drugs for
TRIUMEQ 2 Bleeding Disorders
TRUVADA 2 ADYNOVATE 3 SP
valacyclovir hcl oral 1 QL AFSTYLA 3 SP
VALTREX E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
14Drug Name Drug Tier Notes Drug Name Drug Tier Notes
ARANESP (ALBUMIN atorvastatin calcium
2 PA; SP 1
FREE) oral
ELOCTATE 3 SP AVAPRO E
EPOGEN E SP AZOR E
FULPHILA E SP benazepril hcl oral 1
GRANIX E SP BENICAR E
JIVI 3 SP BENICAR HCT E
MULPLETA 2 PA; SP bisoprolol fumarate 1
NEULASTA 3 PA; SP bisoprolol-
1
NEULASTA ONPRO 3 PA; SP hydrochlorothiazide
NEUPOGEN E SP bumetanide oral 1
NIVESTYM 2 PA; SP BYSTOLIC 2
NOVOEIGHT 3 SP candesartan cilexetil 1
NUWIQ 3 SP CARDIZEM LA ORAL
TABLET EXTENDED
PROCRIT E SP RELEASE 24 HOUR E
RETACRIT 2 PA; SP 180 MG, 240 MG, 300
UDENYCA 3 PA; SP MG, 360 MG, 420 MG
ULTOMIRIS 3 PA; SP cartia xt 1
ZARXIO 2 PA; SP carvedilol 1
Cardiovascular CATAPRES-TTS-1 E
Agents - Drugs for CATAPRES-TTS-2 E
Heart and Circulation CATAPRES-TTS-3 E
Conditions
chlorthalidone 1
ALTACE E
clonidine hcl oral 1
amiodarone hcl oral 1
COLESTID E
amlodipine besylate
1 COLESTID
oral E
FLAVORED
amlodipine besylate-
1 COREG E
benazepril hcl
amlodipine besylate- COREG CR E
1
valsartan CORLANOR ORAL
3 PA; QL
amlodipine-olmesartan 1 TABLET
ATACAND E COZAAR E
atenolol oral 1 CRESTOR E
atenolol-chlorthalidone 1 digoxin oral tablet 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
15Drug Name Drug Tier Notes Drug Name Drug Tier Notes
diltiazem hcl er coated INNOPRAN XL E
beads oral capsule irbesartan 1
1
extended release 24
hour irbesartan-
1
hydrochlorothiazide
dilt-xr 1
isosorbide mononitrate
DIOVAN E 1
er
DIOVAN HCT E KAPSPARGO
E
doxazosin mesylate SPRINKLE
1
oral KATERZIA E
DYAZIDE E labetalol hcl oral 1
EDARBI 3 ST LASIX E
EDARBYCLOR 3 ST LESCOL XL E
enalapril maleate oral 1 LIPITOR E
ENTRESTO 2 QL lisinopril oral 1
EXFORGE E lisinopril-
1
EXFORGE HCT E hydrochlorothiazide
ezetimibe 1 LIVALO 3 ST
ezetimibe-simvastatin 1 losartan potassium 1
fenofibrate micronized losartan potassium-hctz 1
oral capsule 134 mg, 1 LOTREL E
200 mg, 67 mg
lovastatin 1
fenofibrate oral tablet 1
LOVAZA E
fenofibric acid oral
capsule delayed 1 metoprolol succinate er 1
release metoprolol tartrate oral 1
flecainide acetate 1 MICARDIS E
furosemide oral tablet 1 MICARDIS HCT E
gemfibrozil oral 1 MULTAQ 3
guanfacine hcl 1 nadolol oral 1
HEMANGEOL 3 NIASPAN E
hydralazine hcl oral 1 nifedipine er 1
hydrochlorothiazide nifedipine er osmotic
1 1
oral release
HYZAAR E nitroglycerin sublingual 1
INDERAL LA E NITROSTAT E
INDERAL XL E NORVASC E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
16Drug Name Drug Tier Notes Drug Name Drug Tier Notes
olmesartan medoxomil TENORMIN E
1
oral TIKOSYN E
olmesartan medoxomil- TOPROL XL E
1
hctz
torsemide 1
olmesartan-amlodipine-
1 triamterene-hctz 1
hctz
omega-3-acid ethyl TRIBENZOR E
1 PA
esters TRICOR E
PRALUENT 2 PA; QL valsartan 1
PRAVACHOL E valsartan-
1
pravastatin sodium 1 hydrochlorothiazide
prazosin hcl oral 1 VASCEPA 3 PA
PRINIVIL E verapamil hcl er oral
capsule extended
propranolol hcl er 1 release 24 hour 120 1
propranolol hcl oral mg, 180 mg, 240 mg,
1
tablet 360 mg
QUESTRAN E verapamil hcl er oral
1
QUESTRAN LIGHT E tablet extended release
quinapril hcl 1 VYTORIN E
ramipril 1 WELCHOL E
RANEXA E ZESTRIL E
ranolazine er 1 ZETIA E
REPATHA 2 PA; QL ZOCOR ORAL
TABLET 10 MG, 20 E
REPATHA MG, 40 MG, 80 MG
PUSHTRONEX 2 PA; QL
SYSTEM ZYPITAMAG E
REPATHA Central Nervous
2 PA; QL System Agents -
SURECLICK
Drugs for Attention
rosuvastatin calcium 1 Deficit Disorder
simvastatin oral tablet 1 ADDERALL E
sotalol hcl oral 1 ADDERALL XR E
spironolactone oral 1 ADHANSIA XR E
TEKTURNA 2 amphetamine-
1 PA; QL
TEKTURNA HCT 2 ST dextroamphetamine
telmisartan 1 amphetamine-
1 PA; QL
telmisartan-hctz 1 dextroamphetamine er
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
17Drug Name Drug Tier Notes Drug Name Drug Tier Notes
atomoxetine hcl 1 QL glatiramer acetate 1 PA; SP; QL
CONCERTA E MAVENCLAD (10
3 PA; 3P; SP
dexmethylphenidate hcl TABS)
1 PA; QL
er MAVENCLAD (4
3 PA; 3P; SP
dexmethylphenidate hcl TABS)
1 PA; QL
oral tablet 10 mg, 5 mg MAVENCLAD (5
3 PA; 3P; SP
EVEKEO E TABS)
FOCALIN E MAVENCLAD (6
3 PA; 3P; SP
TABS)
FOCALIN XR E
MAVENCLAD (7
guanfacine hcl er 1 3 PA; 3P; SP
TABS)
INTUNIV E MAVENCLAD (8
3 PA; 3P; SP
JORNAY PM 3 PA; ST; QL TABS)
methylphenidate hcl er 1 PA; QL MAVENCLAD (9
3 PA; 3P; SP
methylphenidate hcl er TABS)
(la) oral capsule PA; 3P; SP;
MAYZENT 3
extended release 24 1 PA; QL QL
hour 10 mg, 20 mg, 30 MAYZENT STARTER PA; 3P; SP;
mg, 40 mg 3
PACK QL
methylphenidate hcl PLEGRIDY E SP
1 PA; QL
oral tablet
PLEGRIDY STARTER
RITALIN E E SP
PACK
RITALIN LA E REBIF 3 PA; SP; QL
STRATTERA E REBIF REBIDOSE 3 PA; SP; QL
VYVANSE 2 PA; QL REBIF REBIDOSE
3 PA; SP; QL
Central Nervous TITRATION PACK
System Agents - REBIF TITRATION
Drugs for Multiple 3 PA; SP; QL
PACK
Sclerosis
TECFIDERA 2 PA; SP; QL
AMPYRA 3 PA; SP; QL
Central Nervous
AUBAGIO 3 PA; SP; QL System Agents -
AVONEX PEN 2 PA; SP; QL Miscellaneous
AVONEX PREFILLED 2 PA; SP; QL ADDYI 3 PA; QL
BETASERON 2 PA; SP; QL ADIPEX-P E
COPAXONE 2 PA; SP; QL AUSTEDO 3 PA; SP; QL
EXTAVIA E SP CONTRAVE 2 PA
PA; 3P; SP; GRALISE 3 ST; QL
GILENYA 3
QL GRALISE STARTER 3 ST; QL
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
18Drug Name Drug Tier Notes Drug Name Drug Tier Notes
HORIZANT 3 PA; QL BRYHALI 3
LYRICA E CALCIPOTRIENE
E M
phentermine hcl oral EXTERNAL FOAM
1 PA
capsule 30 mg CAPEX E
phentermine hcl oral claravis 1 PA
1 PA
tablet CLINDAGEL E
pregabalin oral capsule 1 QL clindamycin phosphate-
SAXENDA 3 PA benzoyl peroxide 1
TEGSEDI 3 PA; SP external gel 1-5 %
TIGLUTIK 3 PA; SP; QL clindamycin phosphate
1
external lotion
VYLEESI 3 PA; QL
clindamycin phosphate
Dental and Oral 1
external solution
Agents - Drugs for
Mouth and Throat clindamycin phosphate
1
Conditions external swab
chlorhexidine gluconate CLINDAMYCIN
1 PHOSPHATE GEL 1 % E M
mouth/throat
EXTERNAL
lidocaine viscous hcl 1
clindamycin phosphate
Dermatological 1
gel 1 % external
Agents - Drugs for
Skin Conditions clobetasol propionate
1
external cream
ABSORICA 3 PA
clobetasol propionate
ABSORICA LD 3 PA 1
external ointment
ACANYA E clobetasol propionate
1
ACZONE EXTERNAL external solution
E
GEL 5 % CLOBEX E
ACZONE EXTERNAL CLOBEX SPRAY E
2
GEL 7.5 %
CLODERM E
ALA SCALP E
CORDRAN
APEXICON E E E
EXTERNAL TAPE
BENZACLIN E DESONATE E
BENZACLIN WITH DIFFERIN EXTERNAL
E E
PUMP CREAM
BENZAMYCIN E DIFFERIN EXTERNAL
E
betamethasone GEL 0.3 %
dipropionate external 1 DIFFERIN EXTERNAL
cream E
LOTION
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
19Drug Name Drug Tier Notes Drug Name Drug Tier Notes
DUOBRII E MICORT-HC
DUPIXENT 2 PA; SP; QL EXTERNAL CREAM E
2.5 %
ELIDEL E
MIRVASO 2
ENSTILAR 3 QL
mometasone furoate
EPIDUO E 1
external cream
EPIDUO FORTE 3 NORITATE E
EUCRISA 2 ST ONEXTON 3
FINACEA EXTERNAL ORACEA E
E
GEL
PANDEL E
fluocinonide external
1 PROPECIA E
cream
FLUOROPLEX 3 PSORCON E
FLUOROURACIL QBREXZA 3 QL
EXTERNAL CREAM 2 RETIN-A E
0.5 % RETIN-A MICRO GEL
E
fluorouracil external 0.04 %, 0.1 %
1
cream 5 % RETIN-A MICRO
HALOBETASOL PUMP EXTERNAL E
PROPIONATE E M GEL 0.04 %, 0.1 %
EXTERNAL FOAM RETIN-A MICRO
HALOG E PUMP EXTERNAL 2 PA
hydrocortisone external GEL 0.06 %, 0.08 %
1
cream SERNIVO 3
hydrocortisone external SOOLANTRA 2
1
ointment SORILUX E
imiquimod external 1 TACLONEX
IMIQUIMOD PUMP E M EXTERNAL E
IMPOYZ E OINTMENT
KENALOG EXTERNAL E TACLONEX
EXTERNAL 3 QL
LEXETTE E SUSPENSION
METROGEL E tacrolimus external
1
metronidazole external ointment
1
cream TAZORAC EXTERNAL
E
metronidazole external CREAM 0.1 %
1
gel TOPICORT SPRAY E
tretinoin external cream 1 PA
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
20Drug Name Drug Tier Notes Drug Name Drug Tier Notes
triamcinolone acetonide GLUCOPHAGE XR
1
external cream ORAL TABLET
triamcinolone acetonide EXTENDED RELEASE E
1 24 HOUR 500 MG, 750
external ointment
MG
ULTRAVATE E
GLUMETZA E
VECTICAL E
glyburide oral 1
VELTIN E
GLYXAMBI 2 ST
VERDESO E
INVOKAMET E
ZIANA E
INVOKAMET XR E
ZYCLARA E
INVOKANA E
ZYCLARA PUMP E
JANUMET 2 ST
Diabetes -
Antidiabetic Agents JANUMET XR 2 ST
ADLYXIN E JANUVIA 2 ST
ADLYXIN STARTER JARDIANCE 2 ST
E
PACK JENTADUETO 2 ST
ALOGLIPTIN JENTADUETO XR 2 ST
E M
BENZOATE KAZANO E
ALOGLIPTIN- KOMBIGLYZE XR E
E M
METFORMIN HCL
metformin hcl er 1
ALOGLIPTIN-
E M metformin hcl er (mod) E
PIOGLITAZONE
BYDUREON 2 ST; QL metformin hcl er (osm) E
BYDUREON BCISE metformin hcl oral
2 ST; QL 1
AUTOINJECTOR tablet
BYETTA 10 MCG PEN 2 ST; QL NESINA E
BYETTA 5 MCG PEN 2 ST; QL ONGLYZA E
FARXIGA 2 ST OSENI E
FORTAMET E OZEMPIC 2 ST; QL
glimepiride 1 pioglitazone hcl 1
glipizide er 1 QTERN E
glipizide ir 1 RYBELSUS 2 QL
GLUCOPHAGE ORAL SEGLUROMET E
TABLET 1000 MG, 500 E SOLIQUA 2 ST; QL
MG, 850 MG STEGLATRO E
STEGLUJAN E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
21Drug Name Drug Tier Notes Drug Name Drug Tier Notes
SYMLINPEN 60 3 PA ACCU-CHEK
SYNJARDY 2 ST SMARTVIEW E
CONTROL
SYNJARDY XR 2 ST
ACCU-CHEK
TRADJENTA 2 ST SMARTVIEW TEST E
TRULICITY 2 ST; QL STRIPS
VICTOZA 2 ST; QL ACCU-CHEK
XIGDUO XR 2 ST SOFTCLIX LANCET 2
DEVICE KIT
Diabetes - Glucose
Monitoring DEXCOM G4 / G5 / G6
RECEIVER,
ACCU-CHEK AVIVA TRANSMITTER,
E
DEVICE SENSOR (INCLUDING 2
ACCU-CHEK AVIVA PLATINUM,
CONNECT KIT E PLATINUM
W/DEVICE PEDIATRIC)
ACCU-CHEK AVIVA DEXCOM G4 / G5 / G6
E
PLUS KIT W/DEVICE RECEIVER,
ACCU-CHEK TRANSMITTER,
COMPACT PLUS E SENSOR (INCLUDING 2
CARE KIT PLATINUM,
PLATINUM
ACCU-CHEK PEDIATRIC) DEVICE
COMPACT PLUS E
CONTROL FREESTYLE LIBRE 14
E
DAY READER
ACCU-CHEK
COMPACT PLUS E FREESTYLE LIBRE 14
E
TEST STRIPS DAY SENSOR
ACCU-CHEK FREESTYLE LIBRE
E
FASTCLIX LANCET 2 READER
KIT FREESTYLE LIBRE
E
ACCU-CHEK GUIDE SENSOR SYSTEM
E
KIT W/DEVICE LANCETS 2
ACCU-CHEK GUIDE ONETOUCH ULTRA 2
E 2
CONTROL KIT W/DEVICE
ACCU-CHEK ONETOUCH ULTRA
2 QL
MULTICLIX LANCET 2 BLUE TEST STRIPS
DEVICE KIT ONETOUCH ULTRA
2
ACCU-CHEK NANO MINI KIT W/DEVICE
SMARTVIEW KIT E ONETOUCH VERIO
W/DEVICE 2
KIT W/DEVICE
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
22Drug Name Drug Tier Notes Drug Name Drug Tier Notes
ONETOUCH VERIO FIASP PENFILL E
FLEX SYSTEM KIT 2 HUMALOG 2
W/DEVICE
HUMALOG KWIKPEN 2
ONETOUCH VERIO
2 QL HUMALOG MIX 50/50
TEST STRIPS 2
KWIKPEN
ONETOUCH VERIO IQ
2 HUMALOG MIX 50/50
SYSTEM 2
VIAL
ONETOUCH VERIO
SYNC SYSTEM KIT 2 HUMALOG MIX 75/25
2
W/DEVICE KWIKPEN
V-GO 20 2 HUMALOG MIX 75/25
2
VIAL
V-GO 30 2
HUMALOG U-100
V-GO 40 2 2
JUNIOR KWIKPEN
Diabetes - Glycemic HUMULIN 70/30
Agents 2
KWIKPEN
BAQSIMI ONE PACK 2 HUMULIN 70/30 VIAL 2
BAQSIMI TWO PACK 2 HUMULIN N KWIKPEN 2
GLUCAGON HUMULIN N VIAL 2
2 Made by Lilly
EMERGENCY KIT
HUMULIN R U-500
GLUCAGON Made by 2
2 KWIKPEN
EMERGENCY KIT Fresenius
HUMULIN R U-500
GVOKE PFS 2 VIAL 2
Diabetes - Insulins (CONCENTRATED)
ADMELOG E HUMULIN R VIAL 2
ADMELOG INSULIN ASP PROT &
E E M
SOLOSTAR ASP FLEXPEN
APIDRA SOLOSTAR E INSULIN ASPART E M
APIDRA VIAL E INSULIN ASPART
E M
BASAGLAR KWIKPEN E FLEXPEN
BD AUTOSHIELD DUO INSULIN ASPART
2 E M
PEN NEEDLES PENFILL
BD ULTRA-FINE INSULIN ASPART
2 E M
INSULIN SYRINGES PROT & ASPART
BD ULTRA-FINE PEN INSULIN LISPRO E M
2
NEEDLES INSULIN LISPRO (1
E M
FIASP E UNIT DIAL)
FIASP FLEXTOUCH E LANTUS SOLOSTAR 2
LANTUS U-100 VIAL 2
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
23Drug Name Drug Tier Notes Drug Name Drug Tier Notes
LEVEMIR U-100 TOUJEO SOLOSTAR 2
E
FLEXTOUCH TRESIBA E
LEVEMIR U-100 VIAL E TRESIBA
E
NOVOFINE FLEXTOUCH
AUTOCOVER PEN 2 Electrolytes / Minerals
NEEDLE / Metals / Vitamins
NOVOFINE PEN AZESCO E
2
NEEDLE
CARNITOR ORAL E
NOVOFINE PLUS PEN
2 CARNITOR SF E
NEEDLE
NOVOLIN 70/30 cyanocobalamin
E injection solution 1000 1
FLEXPEN
mcg/ml
NOVOLIN 70/30
E ergocalciferol oral
FLEXPEN RELION 1
capsule
NOVOLIN 70/30
E folic acid oral tablet 1
RELION 1
mg, 800 mcg
NOVOLIN 70/30 VIAL E
K-TAB E
NOVOLIN N FLEXPEN E
LOKELMA 3
NOVOLIN N FLEXPEN
E multivitamin/fluoride
RELION
oral tablet chewable 1
NOVOLIN N RELION E 0.25 mg, 0.5 mg, 1 mg
NOVOLIN N VIAL E NASCOBAL 3
NOVOLIN R FLEXPEN E potassium chloride crys
1
NOVOLIN R FLEXPEN er
E
RELION potassium chloride er 1
NOVOLIN R RELION E potassium citrate er 1
NOVOLIN R VIAL E PREGENNA E
NOVOLOG FLEXPEN E PRENATE E
NOVOLOG MIX 70/30 PRENATE DHA E
E
FLEXPEN
PRENATE ELITE E
NOVOLOG MIX 70/30
E PRENATE ENHANCE E
VIAL
NOVOLOG PENFILL E PRENATE ESSENTIAL E
NOVOLOG U-100 VIAL E PRENATE MINI E
NOVOTWIST PEN PRENATE PIXIE E
2
NEEDLE PRENATE RESTORE E
TOUJEO MAX sodium fluoride oral
2 1
SOLOSTAR tablet chewable
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
24Drug Name Drug Tier Notes Drug Name Drug Tier Notes
TRINAZ E PROTONIX ORAL
VELTASSA 3 TABLET DELAYED E
RELEASE
vitamin d
(ergocalciferol) oral RABEPRAZOLE
1 SODIUM ORAL E M
capsule 1.25 mg
(50000 ut) CAPSULE SPRINKLE
ZALVIT E rabeprazole sodium
oral tablet delayed 1 QL
Gastrointestinal release
Agents - Drugs for
Acid Reflux and Ulcer ranitidine hcl oral 1
ACIPHEX E sucralfate oral tablet 1
CARAFATE ORAL ZEGERID E
E Gastrointestinal
TABLET
DEXILANT 2 QL Agents - Drugs for
Bowel, Intestine and
esomeprazole Stomach Conditions
magnesium oral
E AMITIZA E
capsule delayed
release CLENPIQ 3
famotidine oral tablet 1 dicyclomine hcl oral
1
gnp lansoprazole 1 QL capsule
lansoprazole oral dicyclomine hcl oral
1
capsule delayed 1 QL tablet
release diphenoxylate-atropine
1
misoprostol oral 1 oral tablet
NEXIUM ORAL gavilyte-g 1
CAPSULE DELAYED E glycopyrrolate oral
1
RELEASE tablet 1 mg, 2 mg
omeprazole oral GLYCOPYRROLATE
3
capsule delayed 1 QL ORAL TABLET 1.5 MG
release GOLYTELY E
omeprazole-sodium lactulose oral solution 1
E
bicarbonate
LINZESS 2 ST; QL
pantoprazole sodium
1 QL MOTEGRITY 3 ST; QL
oral
PREVACID E MOTOFEN E
PREVACID SOLUTAB MOVANTIK E
ORAL TABLET MOVIPREP E
E
DELAYED RELEASE NULYTELY WITH
DISPERSIBLE 15 MG E
FLAVOR PACKS
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
25Drug Name Drug Tier Notes Drug Name Drug Tier Notes
OMECLAMOX-PAK 2 oxybutynin chloride er 1
peg 3350-kcl-na bicarb- oxybutynin chloride oral
1 1
nacl tablet
PLENVU 3 phenazopyridine hcl
PREPOPIK 3 oral tablet 100 mg, 200 1
mg
PYLERA 2
RENAGEL E
RELISTOR E
sildenafil citrate oral
SUPREP BOWEL tablet 100 mg, 25 mg, 1 QL
3
PREP KIT 50 mg
SYMPROIC 2 ST; QL solifenacin succinate 1
TRULANCE E STAXYN E
VIBERZI 3 PA; QL STENDRA E
ZELNORM 3 PA; QL tadalafil oral 1 QL
Genetic or Enzyme tolterodine tartrate er 1
Disorder - Drugs for
Replacement, TOVIAZ 3
Modification, VELPHORO 3
Treatment VESICARE E
CERDELGA 3 PA; SP VIAGRA E
CREON 2 Genitourinary Agents
NITYR 3 PA; SP - Drugs for Prostate
PANCREAZE E Conditions
PERTZYE E alfuzosin hcl er 1
STRENSIQ 2 PA; SP AVODART E
VIOKACE E dutasteride oral 1
ZENPEP 2 finasteride oral tablet 5
1
mg
Genitourinary Agents
- Drugs for Bladder, FLOMAX E
Genital and Kidney tamsulosin hcl 1
Conditions
terazosin hcl oral
AURYXIA 3 capsule 1 mg, 10 mg, 5 1
CIALIS E mg
DEPEN TITRATABS 2 SP Hormonal Agents -
Adrenal
INTRAROSA 3
CORTEF E
LEVITRA E
dexamethasone oral
MYRBETRIQ 2 1
tablet
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
26Drug Name Drug Tier Notes Drug Name Drug Tier Notes
hydrocortisone oral 1 VOGELXO PUMP E
KENALOG INJECTION XYOSTED 3 PA
SUSPENSION 40 E Hormonal Agents -
MG/ML Osteoporosis
methylprednisolone OSPHENA 3
1
oral
raloxifene hcl 1
prednisolone oral
1 Hormonal Agents -
solution
Pituitary
prednisolone sodium
1 ACTHAR 2 PA; SP
phosphate oral solution
prednisone oral tablet 1 cabergoline 1
prednisone oral tablet CETROTIDE E SP
1
therapy pack FOLLISTIM AQ 2 PA; SP
RAYOS E PA; Made by
TAPERDEX 12-DAY 3 ganirelix acetate 1 Organon/Merc
k; SP
TAPERDEX 6-DAY 3
GENOTROPIN E SP
TAPERDEX 7-DAY 3
GENOTROPIN
Hormonal Agents - E SP
MINIQUICK
Men's Health
GONAL-F E SP
ANDRODERM 2 PA
GONAL-F RFF E SP
ANDROGEL E
GONAL-F RFF
ANDROGEL PUMP E E SP
REDIJECT
DEPO- HUMATROPE E SP
E
TESTOSTERONE
LUPRON DEPOT (1-
FORTESTA E MONTH)
2 PA; SP
TESTIM E INTRAMUSCULAR KIT
testosterone cypionate 7.5 MG
1 PA
intramuscular LUPRON DEPOT (3-
testosterone MONTH)
2 PA; SP
transdermal gel 1.62 %, INTRAMUSCULAR KIT
10 mg/act (2%), 20.25 22.5 MG
mg/1.25gm (1.62%), LUPRON DEPOT (4-
20.25 mg/act (1.62%), 1 PA MONTH)
2 PA; SP
25 mg/2.5gm (1%), INTRAMUSCULAR KIT
40.5 mg/2.5gm 30MG
(1.62%), 50 mg/5gm LUPRON DEPOT (6-
(1%) MONTH)
2 PA; SP
VOGELXO E INTRAMUSCULAR KIT
45MG
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
27Drug Name Drug Tier Notes Drug Name Drug Tier Notes
MENOPUR 3 PA; SP drospirenone-ethinyl
1
NOCDURNA 3 estradiol
NOCTIVA E DUAVEE 2
NORDITROPIN ELESTRIN 3
2 PA; SP
FLEXPRO ENDOMETRIN 2
NUTROPIN AQ enskyce 1
2 PA; SP
NUSPIN 10 errin 1
NUTROPIN AQ estarylla 1
2 PA; SP
NUSPIN 20
ESTRACE E
NUTROPIN AQ
2 PA; SP estradiol oral 1
NUSPIN 5
OMNITROPE E SP estradiol transdermal 1
ORILISSA 2 PA; QL estradiol vaginal 1
OVIDREL 3 PA; SP EVAMIST 3
SAIZEN E SP femynor 1
SAIZENPREP E SP GENERESS FE E
SANDOSTATIN E SP gianvi 1
ZOMACTON E SP IMVEXXY
3
MAINTENANCE PACK
Hormonal Agents -
Sex Hormones and IMVEXXY STARTER
3
Birth Control PACK
ANNOVERA E isibloom 1
apri 1 junel 1.5/30 1
aviane 1 junel 1/20 1
BEYAZ E junel fe 1.5/30 1
BIJUVA 3 junel fe 1/20 1
blisovi 24 fe 1 junel fe 24 1
blisovi fe 1.5/30 1 kariva 1
blisovi fe 1/20 1 kurvelo 1
CLIMARA E larin fe 1/20 1
CLIMARA PRO 2 larissia 1
cryselle-28 1 lessina 1
DELESTROGEN levonorgest-eth est &
1 QL
INTRAMUSCULAR OIL E eth est
20 MG/ML, 40 MG/ML
DIVIGEL 3
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
28Drug Name Drug Tier Notes Drug Name Drug Tier Notes
levonorgest-eth estrad ORTHO TRI-CYCLEN
E
91-day oral tablet 0.15- LO
1 QL
0.03 &0.01 mg, 0.15- ORTHO-NOVUM 1/35
0.03 mg E
(28)
levonorgestrel-ethinyl ORTHO-NOVUM 7/7/7
estrad oral tablet 0.1-20 E
1 (28)
mg-mcg, 0.15-30 mg-
mcg PREMARIN ORAL 2
LO LOESTRIN FE E PREMARIN VAGINAL 2
LOESTRIN 1.5/30 (21) E PREMPHASE 2
LOESTRIN 1/20 (21) E PREMPRO 2
LOESTRIN FE 1.5/30 E progesterone
1
micronized oral
LOESTRIN FE 1/20 E
PROMETRIUM E
low-ogestrel 1
SAFYRAL E
MAKENA 2 PA; SP
SEASONIQUE E
medroxyprogesterone
1 QL SLYND E
acetate intramuscular
medroxyprogesterone sprintec 28 1
1
acetate oral syeda 1
MINASTRIN 24 FE E TAYTULLA 3
MINIVELLE 3 tri femynor 1
MIRENA (52 MG) 3 tri-linyah 1
mono-linyah 1 tri-lo-marzia 1
NATAZIA 2 tri-lo-sprintec 1
nikki 1 tri-sprintec 1
norethindrone acetate VAGIFEM E
1
oral vienva 1
norethindrone acet- viorele 1
1
ethinyl est
VIVELLE-DOT E
norethindrone oral 1
xulane 1
norgestimate-ethinyl
1 YASMIN 28 E
estradiol triphasic
nortrel 1/35 (21) 1 YAZ E
nortrel 1/35 (28) 1 Hormonal Agents -
Thyroid
NUVARING 3
ARMOUR THYROID 3 ST
ORTHO MICRONOR E
CYTOMEL E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
29Drug Name Drug Tier Notes Drug Name Drug Tier Notes
euthyrox 1 COSENTYX
E SP
levothyroxine sodium SENSOREADY PEN
1
oral CUTAQUIG E SP
liothyronine sodium oral 1 cyclosporine modified
1 SP
methimazole oral 1 oral capsule
NATURE-THROID ENBREL MINI 3 PA; SP
ORAL TABLET 113.75 ENBREL
MG, 130 MG, 146.25 SUBCUTANEOUS
3 PA; SP
MG, 16.25 MG, 195 SOLUTION
3 ST
MG, 260 MG, 32.5 MG, PREFILLED SYRINGE
325 MG, 48.75 MG, 65 ENBREL SURECLICK 3 PA; SP
MG, 81.25 MG, 97.5
MG FIRAZYR 3 PA; SP
np thyroid oral tablet 60 HAEGARDA 3 PA; SP
1
mg HUMIRA 2 PA; SP
SYNTHROID E HUMIRA PEDIATRIC
2 PA; SP
TIROSINT E CROHNS START
TIROSINT-SOL E HUMIRA PEN 2 PA; SP
Immunological HUMIRA PEN-
2 PA; SP
Agents - Drugs for CD/UC/HS STARTER
Immune System HUMIRA PEN-
Stimulation or PS/UV/ADOL HS 2 PA; SP
Suppression START
ACTEMRA ACTPEN 3 PA; 3P; SP INFLECTRA 2 PA; SP
ACTEMRA leflunomide oral 1
3 PA; 3P; SP
SUBCUTANEOUS methotrexate oral 1
azathioprine oral 1 methotrexate sodium
1
CIMZIA 2 PA; SP oral
CIMZIA PREFILLED mycophenolate mofetil
2 PA; SP 1 SP
KIT oral capsule
CIMZIA STARTER KIT 2 PA; SP mycophenolate mofetil
1 SP
COSENTYX (300 MG oral tablet
E SP
DOSE) mycophenolate sodium 1 SP
COSENTYX 150 OLUMIANT E SP
E SP
MG/ML ORENCIA 3 PA; 3P; SP
COSENTYX ORENCIA CLICKJECT 3 PA; 3P; SP
SENSOREADY (300 E SP
MG) OTEZLA 2 PA; SP
PANZYGA E SP
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
30Drug Name Drug Tier Notes Drug Name Drug Tier Notes
PROGRAF ORAL Metabolic Bone
3 SP Disease Agents -
CAPSULE
RASUVO 2 PA; QL Drugs for
Osteoporosis
REMICADE E SP
alendronate sodium
RENFLEXIS 2 PA; SP 1
oral tablet 10 mg, 5 mg
RINVOQ 2 PA; SP alendronate sodium
RUCONEST 3 PA; SP oral tablet 35 mg, 70 1 QL
SIMPONI 2 PA; SP mg
SIMPONI ARIA 2 PA; SP BINOSTO 3 QL
sirolimus oral tablet 1 SP FORTEO
SUBCUTANEOUS
SKYRIZI (150 MG 2 PA; SP
2 PA; SP SOLUTION 600
DOSE) MCG/2.4ML
STELARA 2 PA; SP ibandronate sodium
1 QL
tacrolimus oral 1 SP oral
TAKHZYRO 3 PA; SP PROLIA 2 PA; SP; QL
TALTZ 3 PA; 3P; SP RAYALDEE 3
TREMFYA 2 PA; SP TYMLOS 2 PA; SP
XELJANZ 2 PA; SP Metabolic Bone
Disease Agents -
XELJANZ XR 2 PA; SP
Other
Inflammatory Bowel
Disease Agents calcitriol oral capsule 1
APRISO 2 SENSIPAR E
Miscellaneous
ASACOL HD E
Therapeutic Agents
CANASA E
PA; Non-
DELZICOL E BOTOX 2
Cosmetic; SP
DIPENTUM E DUROLANE 2 PA; SP
LIALDA E EUFLEXXA 2 PA; SP
mesalamine oral tablet FIRDAPSE E SP
1
delayed release
GEL-ONE E SP
PENTASA 3
GELSYN-3 2 PA; SP
PROCTOFOAM HC
2 GENVISC 850 E SP
RECTAL FOAM 1-1 %
sulfasalazine oral tablet 1 HYALGAN E SP
UCERIS ORAL E HYMOVIS E SP
UCERIS RECTAL 3 MONOVISC E SP
ORTHOVISC E SP
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
31Drug Name Drug Tier Notes Drug Name Drug Tier Notes
SODIUM ofloxacin ophthalmic 1
HYALURONATE E SP olopatadine hcl
INTRA-ARTICULAR 1
ophthalmic
SUPARTZ FX E SP PATADAY
SYNVISC E SP OPHTHALMIC E
SYNVISC ONE E SP SOLUTION 0.2 %
TRIVISC E SP PATANOL
OPHTHALMIC E
VISCO-3 E SP SOLUTION 0.1 %
Ophthalmic Agents - PAZEO E
Drugs for Eye Allergy,
Infection and PRED FORTE E
Inflammation prednisolone acetate
1
AZASITE 3 ophthalmic
BESIVANCE 3 PROLENSA 2 QL
BROMSITE E VIGAMOX E
ciprofloxacin hcl Ophthalmic Agents -
1 Drugs for Glaucoma
ophthalmic
erythromycin ALPHAGAN P
1 OPHTHALMIC 2
ophthalmic
SOLUTION 0.1 %
gentamicin sulfate
1 ALPHAGAN P
ophthalmic
OPHTHALMIC E
ILEVRO E SOLUTION 0.15 %
INVELTYS 3 AZOPT 2
ketorolac tromethamine BETIMOL 3
1
ophthalmic
brimonidine tartrate
LOTEMAX 1
3 QL ophthalmic
OPHTHALMIC GEL
COMBIGAN 2
LOTEMAX
OPHTHALMIC 3 QL COSOPT E
OINTMENT dorzolamide hcl-timolol
1
LOTEMAX mal
OPHTHALMIC E dorzolamide hcl-timolol
1
SUSPENSION mal pf
LOTEMAX SM 3 latanoprost ophthalmic 1
MOXEZA 2 LUMIGAN 2 QL
moxifloxacin hcl RHOPRESSA 2
1
ophthalmic ROCKLATAN 2 QL
NEVANAC E SIMBRINZA 2
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
32Drug Name Drug Tier Notes Drug Name Drug Tier Notes
timolol maleate Respiratory Tract /
1 Pulmonary Agents -
ophthalmic solution
TIMOPTIC E Drugs for Allergies,
Cough, Cold
TIMOPTIC OCUDOSE E
azelastine hcl nasal 1 QL
TIMOPTIC-XE E
benzonatate 1
TRAVATAN Z 3 QL
cetirizine hcl oral
VYZULTA E 1
solution
XALATAN E CLARINEX E
ZIOPTAN E CLARINEX-D 12
E
Ophthalmic Agents - HOUR
Drugs for cyproheptadine hcl oral
Miscellaneous Eye 1
tablet
Conditions
desloratadine oral
LATISSE E 1
tablet
neomycin-polymyxin- DYMISTA 2 QL
dexameth ophthalmic
1 FASENRA 2 PA; SP
suspension 3.5-10000-
0.1 FASENRA PEN 2 PA; SP
polymyxin b- fluticasone propionate
1 1
trimethoprim nasal
RESTASIS 2 PA ipratropium bromide
1
RESTASIS nasal
2 PA
MULTIDOSE levocetirizine
TOBRADEX dihydrochloride oral 1
OPHTHALMIC E tablet
SUSPENSION mometasone furoate
1 QL
tobramycin- nasal
1
dexamethasone NASONEX E
XIIDRA 2 PA NUCALA 2 PA; SP; QL
Otic Agents - Drugs OMNARIS 3 QL
for Ear Conditions promethazine hcl oral
1
CIPRODEX 2 tablet
neomycin-polymyxin-hc promethazine-codeine 1 PA; QL
1
otic suspension promethazine-dm 1
ofloxacin otic 1 pseudoephedrine-
1
OTOVEL 3 bromphen-dm
QNASL 3 QL
QNASL CHILDRENS 3 QL
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
33Drug Name Drug Tier Notes Drug Name Drug Tier Notes
XHANCE E ARNUITY ELLIPTA 2 QL
XOLAIR 2 PA; SP ASMANEX (120
E
ZETONNA 3 QL METERED DOSES)
Respiratory Tract / ASMANEX (14
E
Pulmonary Agents - METERED DOSES)
Drugs for Asthma and ASMANEX (30
E
Other Lung METERED DOSES)
Conditions ASMANEX (60
E
ADVAIR DISKUS 2 QL METERED DOSES)
ADVAIR HFA 2 QL ASMANEX (7
E
AIRDUO RESPICLICK METERED DOSES)
E
113/14 ASMANEX HFA E
AIRDUO RESPICLICK ATROVENT HFA 3 QL
E
232/14 AUVI-Q INJECTION
AIRDUO RESPICLICK SOLUTION AUTO-
E
55/14 INJECTOR 0.15 E
albuterol sulfate hfa MG/0.15ML, 0.3
aerosol solution 108 Made by MG/0.3ML
1
(90 base) mcg/act Perrigo; QL BEVESPI
E
inhalation AEROSPHERE
albuterol sulfate hfa BREO ELLIPTA 2 QL
aerosol solution 108 Made by Teva; budesonide inhalation 1 QL
1
(90 base) mcg/act QL
inhalation BUDESONIDE-
FORMOTEROL E M
ALBUTEROL FUMARATE
SULFATE HFA
AEROSOL SOLUTION Made by Par; COMBIVENT
E 2 QL
108 (90 BASE) M RESPIMAT
MCG/ACT DULERA E
INHALATION epinephrine injection
1
ALBUTEROL solution auto-injector
SULFATE HFA EPIPEN 2-PAK 3 ST
AEROSOL SOLUTION Made by
E EPIPEN JR 2-PAK E
108 (90 BASE) Prasco; M
MCG/ACT FLOVENT DISKUS 2 QL
INHALATION FLOVENT HFA 2 QL
albuterol sulfate
1 QL
inhalation
ALVESCO E
ANORO ELLIPTA 2 QL
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
34Drug Name Drug Tier Notes Drug Name Drug Tier Notes
fluticasone-salmeterol SYMBICORT 2 QL
inhalation aerosol SYMJEPI 3
powder breath
activated 100-50 1 QL TRELEGY ELLIPTA 2 QL
mcg/dose, 250-50 TUDORZA PRESSAIR E
mcg/dose, 500-50 UTIBRON NEOHALER E
mcg/dose
VENTOLIN HFA 2 QL
INCRUSE ELLIPTA 2 QL
wixela inhub 1 QL
ipratropium-albuterol 1 QL
XOPENEX HFA E
LEVALBUTEROL HFA
INHALATION YUPELRI E
E M
AEROSOL 45 Respiratory Tract /
MCG/ACT Pulmonary Agents -
LONHALA MAGNAIR Drugs for Cystic
3 QL Fibrosis
REFILL KIT
LONHALA MAGNAIR BETHKIS 2 SP
3 QL
STARTER KIT KITABIS PAK E SP
montelukast sodium PULMOZYME 2 PA; SP
1
oral tablet TOBI NEBULIZER E SP
montelukast sodium TOBI PODHALER E SP
1
oral tablet chewable
tobramycin nebulization
PERFOROMIST 3 QL solution 300 mg/5ml 1 SP
PROAIR DIGIHALER E inhalation
PROAIR HFA E TOBRAMYCIN
PROAIR RESPICLICK E NEBULIZATION
E M; SP
SOLUTION 300
PROVENTIL HFA E MG/5ML INHALATION
PULMICORT Respiratory Tract /
2 QL
FLEXHALER Pulmonary Agents -
PULMICORT Drugs for Pulmonary
E
SUSPENSION Hypertension
QVAR REDIHALER E ADCIRCA E SP
SEEBRI NEOHALER E ADEMPAS 2 PA; SP; QL
SEREVENT DISKUS 2 QL LETAIRIS E SP
SINGULAIR E OPSUMIT 2 PA; SP; QL
SPIRIVA ORENITRAM 3 PA; SP
2 QL
HANDIHALER REMODULIN E SP
SPIRIVA RESPIMAT 2 QL sildenafil citrate oral
1 PA; SP; QL
STIOLTO RESPIMAT 2 QL tablet 20 mg
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
35Drug Name Drug Tier Notes Drug Name Drug Tier Notes
TRACLEER 62.5 MG, XYREM 3 PA; SP; QL
E SP
125 MG zolpidem tartrate er 1 QL
Skeletal Muscle zolpidem tartrate oral 1 QL
Relaxants - Drugs for
Muscle Pain and
Spasm
AMRIX E
baclofen oral 1
carisoprodol oral 1
cyclobenzaprine hcl
1
oral
LORZONE 3
metaxalone 1
methocarbamol oral 1
NORGESIC FORTE E
ORPHENGESIC
E M
FORTE
SKELAXIN E
SOMA E
tizanidine hcl oral 1
ZANAFLEX E
Sleep Disorder
Agents
AMBIEN E
AMBIEN CR E
armodafinil 1 PA; QL
eszopiclone 1 QL
LUNESTA E
modafinil 1 PA; QL
NUVIGIL E
PROVIGIL E
RESTORIL E
SILENOR 3 QL
SUNOSI 2 PA; QL
temazepam 1 QL
WAKIX 3 PA; SP; QL
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
36Index of Drugs
ABILIFY.....................................13 ADMELOG................................ 23 apap-caff-dihydrocodeine........... 7
ABILIFY MAINTENA................. 13 ADMELOG SOLOSTAR........... 23 APEXICON E............................ 19
ABSORICA............................... 19 ADVAIR DISKUS...................... 34 APIDRA SOLOSTAR................ 23
ABSORICA LD..........................19 ADVAIR HFA............................ 34 APIDRA VIAL............................23
ABSTRAL....................................7 ADYNOVATE............................14 apri............................................ 28
ACANYA................................... 19 AFINITOR................................. 12 APRISO.................................... 31
ACCU-CHEK AVIVA AFSTYLA.................................. 14 ARAKODA................................ 13
CONNECT KIT W/DEVICE.......22 AIMOVIG...................................12 ARANESP (ALBUMIN FREE)... 15
ACCU-CHEK AVIVA DEVICE...22 AIRDUO RESPICLICK 113/14..34 ARIMIDEX.................................12
ACCU-CHEK AVIVA PLUS AIRDUO RESPICLICK 232/14..34 aripiprazole............................... 13
KIT W/DEVICE..........................22 AIRDUO RESPICLICK 55/14....34 ARISTADA................................ 13
ACCU-CHEK COMPACT AJOVY...................................... 12 ARISTADA INITIO.................... 13
PLUS CARE KIT....................... 22 ALA SCALP.............................. 19 armodafinil................................ 36
ACCU-CHEK COMPACT albuterol sulfate.........................34 ARMOUR THYROID.................29
PLUS CONTROL...................... 22 albuterol sulfate hfa...................34 ARNUITY ELLIPTA...................34
ACCU-CHEK COMPACT ALBUTEROL SULFATE HFA... 34 ARTHROTEC..............................8
PLUS TEST STRIPS................ 22 alendronate sodium.................. 31 ARYMO ER.................................7
ACCU-CHEK FASTCLIX alfuzosin hcl er.......................... 26 ASACOL HD............................. 31
LANCET KIT............................. 22 allopurinol..................................12 ASMANEX (120 METERED
ACCU-CHEK GUIDE ALOGLIPTIN BENZOATE........ 21 DOSES).................................... 34
CONTROL................................ 22 ALOGLIPTIN-METFORMIN ASMANEX (14 METERED
ACCU-CHEK GUIDE KIT HCL...........................................21 DOSES).................................... 34
W/DEVICE................................ 22 ALOGLIPTIN-PIOGLITAZONE. 21 ASMANEX (30 METERED
ACCU-CHEK MULTICLIX ALPHAGAN P........................... 32 DOSES).................................... 34
LANCET DEVICE KIT...............22 alprazolam................................ 14 ASMANEX (60 METERED
ACCU-CHEK NANO ALTACE.................................... 15 DOSES).................................... 34
SMARTVIEW KIT W/DEVICE...22 ALVESCO................................. 34 ASMANEX (7 METERED
ACCU-CHEK SMARTVIEW AMBIEN.................................... 36 DOSES).................................... 34
CONTROL................................ 22 AMBIEN CR.............................. 36 ASMANEX HFA........................ 34
ACCU-CHEK SMARTVIEW amiodarone hcl......................... 15 ASPIRIN-OMEPRAZOLE......... 13
TEST STRIPS...........................22 AMITIZA....................................25 ATACAND.................................15
ACCU-CHEK SOFTCLIX amitriptyline hcl......................... 10 atenolol..................................... 15
LANCET DEVICE KIT...............22 amlodipine besylate.................. 15 atenolol-chlorthalidone..............15
acetaminophen-codeine..............7 amlodipine besylate-benazepril ATIVAN..................................... 14
acetaminophen-codeine #2.........7 hcl............................................. 15 atomoxetine hcl.........................18
acetaminophen-codeine #3.........7 amlodipine besylate-valsartan.. 15 atorvastatin calcium.................. 15
acetaminophen-codeine #4.........7 amlodipine-olmesartan..............15 ATRIPLA................................... 14
ACIPHEX.................................. 25 amoxicillin............................... 8, 9 ATROVENT HFA...................... 34
ACTEMRA................................ 30 amoxicillin-potassium AUBAGIO..................................18
ACTEMRA ACTPEN.................30 clavulanate..................................9 AURYXIA.................................. 26
ACTHAR................................... 27 amphetamine- AUSTEDO.................................18
ACTICLATE................................ 8 dextroamphetamine.................. 17 AUVI-Q......................................34
acyclovir.................................... 14 amphetamine- AVAPRO................................... 15
ACZONE................................... 19 dextroamphetamine er.............. 17 aviane....................................... 28
ADCIRCA..................................35 AMPYRA...................................18 AVODART.................................26
ADDERALL............................... 17 AMRIX.......................................36 AVONEX PEN...........................18
ADDERALL XR......................... 17 anastrozole............................... 12 AVONEX PREFILLED.............. 18
ADDYI....................................... 18 ANDRODERM.......................... 27 AZASITE................................... 32
ADEMPAS................................ 35 ANDROGEL..............................27 azathioprine.............................. 30
ADHANSIA XR..........................17 ANDROGEL PUMP.................. 27 azelastine hcl............................ 33
ADIPEX-P................................. 18 ANNOVERA..............................28 AZESCO................................... 24
ADLYXIN...................................21 ANORO ELLIPTA..................... 34 azithromycin................................9
ADLYXIN STARTER PACK...... 21 APADAZ......................................7 AZOPT...................................... 32
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