Your 2021 Premium Standard Formulary - University of ...
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Your 2021 Premium Standard Formulary
Effective July 1, 2021
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.Understanding 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.
• Medications may move to a higher tier when a generic equal becomes available.
• Medications 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 An over-the-counter (OTC)
(offer the same effect) as brand-name medications, but they medication may be the right
often cost less. Once the patent for a brand-name medication treatment option for some
ends, the FDA can approve a generic version with the same conditions. Talk to your doctor
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 used to treat complex conditions. These high-cost medications may
be injected, infused or taken by mouth. 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 tep Therapy – Must try lower-cost medication(s) before a higher-cost medication
S
can be covered.
3P Tier 3 preferred
4University of California Student Health Insurance Program
Table 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.................................................................................................................. 9
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia.............................................................. 10
Antidepressants.................................................................................................................................................10
Antiemetics - Drugs for Nausea and Vomiting.................................................................................................. 11
Antifungals.........................................................................................................................................................11
Antigout Agents................................................................................................................................................. 11
Antimigraine Agents.......................................................................................................................................... 11
Antineoplastics - Drugs for Cancer....................................................................................................................12
Antiparasitics..................................................................................................................................................... 13
Antiparkinson Agents........................................................................................................................................ 13
Antiplatelets.......................................................................................................................................................13
Antipsychotics - Drugs for Mood Disorders....................................................................................................... 13
Antivirals............................................................................................................................................................13
Anxiolytics - Drugs for Anxiety...........................................................................................................................14
Bipolar Agents - Drugs for Mood Disorders.......................................................................................................14
Blood Products and Modifiers - Drugs for Blood 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........................................................................ 17
Central Nervous System Agents - Miscellaneous............................................................................................. 18
Dental and Oral Agents - Drugs for Mouth and Throat Conditions....................................................................18
Dermatological Agents - Drugs for Skin Conditions.......................................................................................... 18
Diabetes - Antidiabetic Agents.......................................................................................................................... 20
Diabetes - Glucose Monitoring.......................................................................................................................... 21
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.................................................26
Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment............................................. 26
Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.......................................................27
Genitourinary Agents - Drugs for Prostate Conditions...................................................................................... 27
Hormonal Agents - Adrenal............................................................................................................................... 27
Hormonal Agents - Men's Health.......................................................................................................................27
Hormonal Agents - Osteoporosis...................................................................................................................... 28
Hormonal Agents - Pituitary.............................................................................................................................. 28
Hormonal Agents - Sex Hormones and Birth Control........................................................................................28
Hormonal Agents - Thyroid............................................................................................................................... 30
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
5Ophthalmic Agents - Drugs for Glaucoma.........................................................................................................32
Ophthalmic 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................................... 33
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...................................................................... 35
Sleep Disorder Agents...................................................................................................................................... 35
6Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Analgesics - Drugs HYSINGLA ER 2 PA; QL
for Pain LAZANDA E PA; QL
acetaminophen- morphine sulfate
1 QL
codeine #2 (concentrate) oral
1 QL
acetaminophen- solution 100 mg/5ml,
1 QL
codeine #3 20 mg/ml
acetaminophen- morphine sulfate (pf) 1
1 QL
codeine #4 morphine sulfate er oral
1 PA; QL
acetaminophen- tablet extended release
codeine oral tablet 300- 1 QL MORPHINE SULFATE
15 mg, 300-60 mg INJECTION 3
APADAZ E QL SOLUTION 1 MG/ML
apap-caff- morphine sulfate
dihydrocodeine oral 1 QL injection solution 2 1
capsule mg/ml, 4 mg/ml
BELBUCA 2 PA; QL MORPHINE SULFATE
BENZHYDROCODON INTRAVENOUS 3
E QL SOLUTION 0.5 MG/ML
E-ACETAMINOPHEN
butalbital-apap-caffeine 1 MORPHINE SULFATE
INTRAVENOUS 3
BUTRANS SOLUTION 1 MG/ML
TRANSDERMAL
PATCH WEEKLY 10 morphine sulfate oral
E PA; QL 1 QL
MCG/HR, 15 MCG/HR, solution
20 MCG/HR, 5 MS CONTIN E PA; QL
MCG/HR NUCYNTA E QL
CONZIP E PA; QL NUCYNTA ER E PA; QL
DILAUDID ORAL E QL OXYCODONE HCL ER E PA; QL
DURAGESIC-100 E PA; QL oxycodone hcl oral
1 QL
DURAGESIC-12 E PA; QL tablet
DURAGESIC-25 E PA; QL oxycodone-
DURAGESIC-50 E PA; QL acetaminophen oral
tablet 10-325 mg, 2.5- 1 QL
DURAGESIC-75 E PA; QL 325 mg, 5-325 mg, 7.5-
fentanyl 1 PA; QL 325 mg
FENTANYL CITRATE OXYCONTIN 2 PA; QL
E PA; QL
BUCCAL TABLET PERCOCET E QL
FENTORA E PA; QL QDOLO E QL
FIORICET E ROXICODONE E QL
FIORICET/CODEINE E SUBSYS E PA; QL
hydrocodone- TRAMADOL HCL ER
acetaminophen oral 1 QL ORAL CAPSULE
tablet E PA; QL
EXTENDED RELEASE
hydromorphone hcl oral 24 HOUR
1 QL
tablet
7Drug Name Drug Tier Notes Drug Name Drug Tier Notes
tramadol hcl oral tablet PENNSAID E PA
1 QL
50 mg QMIIZ ODT E
TREZIX 3 QL RELAFEN E
ULTRACET E QL RELAFEN DS E
ULTRAM E QL SPRIX E PA; QL
XTAMPZA ER 2 PA; QL VIMOVO E PA; QL
ZOHYDRO ER E PA; QL VOLTAREN E QL
Analgesics - Drugs ZIPSOR E
for Pain and
Inflammation ZORVOLEX E
ARTHROTEC E Anesthetics
CAMBIA E lidocaine external patch
1
5%
CELEBREX E QL
lidocaine-prilocaine
celecoxib oral 1 QL 1
external cream
DICLOFENAC CAP LIDODERM E
E
35MG
ZTLIDO E PA
DICLOFENAC PATCH
E QL Anti-Addiction /
1.3%
Substance Abuse
diclofenac sodium Treatment Agents
1 QL
external gel 1 %
BUNAVAIL 3 QL
diclofenac sodium oral 1
buprenorphine hcl
DUEXIS E PA; QL 1 QL
sublingual
etodolac oral tablet 1 buprenorphine hcl-
1 QL
FLECTOR E QL naloxone hcl
ibuprofen oral tablet CHANTIX STARTING
3 PV; QL
400 mg, 600 mg, 800 1 MONTH PAK
mg naltrexone hcl oral 1
indomethacin oral NARCAN 2
1
capsule 25 mg, 50 mg
SUBOXONE E QL
KETOROLAC
TROMETHAMINE E PA; QL ZUBSOLV 2 QL
NASAL Antibacterials
ketorolac tromethamine ACTICLATE E
1 QL
oral amoxicillin oral capsule 1
LICART E amoxicillin oral
meloxicam oral tablet 1 suspension 1
MOBIC E reconstituted
nabumetone oral 1 amoxicillin oral tablet 1
NALFON E amoxicillin-potassium
clavulanate oral
naproxen oral tablet 1 1
suspension
naproxen sodium oral reconstituted
1
tablet 275 mg, 550 mg
8Drug Name Drug Tier Notes Drug Name Drug Tier Notes
amoxicillin-potassium nitrofurantoin
1 1
clavulanate oral tablet macrocrystal
azithromycin oral nitrofurantoin
suspension 1 monohydrate 1
reconstituted macrocrystals
azithromycin oral tablet 1 NUZYRA ORAL 3
cefdinir 1 penicillin v potassium
1
cefuroxime axetil 1 oral tablet
cephalexin oral capsule 1 SEYSARA 3 ST
cephalexin oral SILVADENE E
suspension 1 SOLODYN E
reconstituted SOLOSEC 3
ciprofloxacin hcl oral sulfamethoxazole-
1 1
tablet 250 mg, 500 mg trimethoprim oral tablet
clarithromycin oral TARGADOX E
1
tablet
XENLETA 3
clindamycin hcl oral 1
XEPI 3
CLINDESSE 3
XIMINO 3
DIFICID ORAL
3 Anticoagulants
TABLET
DORYX E ELIQUIS 2 QL
DORYX MPC E ELIQUIS DVT/PE
2 QL
STARTER PACK
doxycycline hyclate oral
1 enoxaparin sodium 1 QL
capsule
doxycycline hyclate oral PRADAXA 2 QL
1
tablet 100 mg, 20 mg warfarin sodium oral 1
DOXYCYCLINE XARELTO 2 QL
HYCLATE ORAL XARELTO STARTER
E 2 QL
TABLET DELAYED PACK
RELEASE 80 MG
Anticonvulsants -
doxycycline Drugs for Seizures
monohydrate oral 1
capsule 100 mg, 50 mg BRIVIACT
3
INTRAVENOUS
doxycycline
1 BRIVIACT ORAL 3 ST
monohydrate oral tablet
levofloxacin oral tablet 1 carbamazepine oral
1
tablet
metronidazole oral
1 CARBATROL E
tablet
metronidazole vaginal 1 DEPAKOTE E
minocycline hcl oral DEPAKOTE ER E
1
capsule DEPAKOTE
E
MINOLIRA E SPRINKLES
mupirocin external 1 DILANTIN INFATABS E
9Drug Name Drug Tier Notes Drug Name Drug Tier Notes
DILANTIN ORAL VIMPAT 3
E
CAPSULE 100 MG XCOPRI 3 ST
DILANTIN ORAL ZONEGRAN E
E
SUSPENSION
zonisamide oral 1
divalproex sodium er 1
Antidementia Agents
divalproex sodium oral - Drugs for
1
tablet delayed release Alzheimer's Disease
EPIDIOLEX 3 PA and Dementia
FYCOMPA 3 donepezil hcl oral tablet
1
gabapentin oral 10 mg, 23 mg
1
capsule memantine hcl oral
1
gabapentin oral tablet 1 tablet 10 mg, 5 mg
KEPPRA ORAL E NAMZARIC 2 QL
KEPPRA XR E Antidepressants
LAMICTAL E amitriptyline hcl oral 1
LAMICTAL ODT E BRISDELLE E QL
LAMICTAL STARTER E bupropion hcl er (sr) 1 QL
LAMICTAL XR ORAL bupropion hcl er (xl)
TABLET EXTENDED E oral tablet extended
1 QL
RELEASE 24 HOUR release 24 hour 150
mg, 300 mg
lamotrigine er 1
BUPROPION HCL ER
lamotrigine oral tablet 1 (XL) ORAL TABLET
E QL
levetiracetam oral EXTENDED RELEASE
1
tablet 24 HOUR 450 MG
NAYZILAM 3 QL bupropion hcl oral 1
NEURONTIN E CELEXA E
ONFI E PA citalopram
oxcarbazepine oral hydrobromide oral 1
1 tablet
tablet
OXTELLAR XR E CYMBALTA E QL
QUDEXY XR E desvenlafaxine
1 QL
succinate er
SABRIL E PA
doxepin hcl oral
SYMPAZAN 3 PA capsule 10 mg, 100
1
TEGRETOL E mg, 25 mg, 50 mg, 75
TEGRETOL-XR E mg
TOPAMAX E duloxetine hcl oral 1 QL
TOPAMAX SPRINKLE E EFFEXOR XR E
topiramate oral tablet 1 escitalopram oxalate
1
oral tablet
TRILEPTAL E
fluoxetine hcl oral
TROKENDI XR 3 ST 1
capsule
VALTOCO 3 QL
10Drug Name Drug Tier Notes Drug Name Drug Tier Notes
fluoxetine hcl oral tablet SANCUSO E QL
1
10 mg, 60 mg scopolamine 1
fluvoxamine maleate 1 VARUBI (180 MG
3 QL
FORFIVO XL E QL DOSE)
LEXAPRO E Antifungals
mirtazapine oral tablet 1 ciclopirox external
1
nortriptyline hcl oral solution
1
capsule clotrimazole external
1
paroxetine hcl 1 cream
PAXIL CR E clotrimazole-
betamethasone 1
PAXIL ORAL TABLET E external cream
PRISTIQ E QL CRESEMBA ORAL 3
PROZAC E fluconazole oral tablet 1
sertraline hcl oral tablet 1 GYNAZOLE-1 3
trazodone hcl oral 1 JUBLIA E PA
TRINTELLIX 3 ST; QL KERYDIN 3 PA
venlafaxine hcl 1 ketoconazole external
1
venlafaxine hcl er oral cream
capsule extended 1 ketoconazole external
release 24 hour 1
shampoo
venlafaxine hcl er oral nystatin external cream 1
tablet extended release 1
24 hour 225 mg nystatin mouth/throat 1
VIIBRYD 3 QL terbinafine hcl oral 1 QL
VIIBRYD STARTER terconazole vaginal
3 QL 1
PACK cream
WELLBUTRIN SR E QL TOLSURA E PA
WELLBUTRIN XL E QL Antigout Agents
ZOLOFT E allopurinol oral 1
Antiemetics - Drugs COLCHICINE ORAL
E
for Nausea and CAPSULE
Vomiting colchicine oral tablet 1
GIMOTI E COLCRYS E
meclizine hcl oral tablet febuxostat 1 ST
1
12.5 mg, 25 mg GLOPERBA E
metoclopramide hcl MITIGARE E
1
oral tablet 10 mg
Antimigraine Agents
ondansetron hcl oral
1 AIMOVIG
tablet 4 mg, 8 mg
SUBCUTANEOUS
ondansetron odt 1 SOLUTION AUTO- 2 PA
prochlorperazine INJECTOR 140
1
maleate oral MG/ML, 70 MG/ML
11Drug Name Drug Tier Notes Drug Name Drug Tier Notes
AJOVY E PA GAVRETO E PA
eletriptan hydrobromide 1 QL GLEEVEC E PA
EMGALITY 2 PA HERZUMA E PA
EMGALITY (300 MG IBRANCE ORAL
2 PA 3 PA
DOSE) TABLET
IMITREX E QL IDHIFA 3 PA; QL
IMITREX STATDOSE INQOVI E PA
E QL
REFILL KANJINTI 2 PA
IMITREX STATDOSE KEYTRUDA 3 PA
E QL
SYSTEM
letrozole oral 1
MAXALT E QL
LYNPARZA 2 PA
MAXALT-MLT E QL
MVASI 2 PA
NURTEC 2 PA
NUBEQA 3 PA
ONZETRA XSAIL E QL
OGIVRI E PA
RELPAX E QL
ONTRUZANT E PA
REYVOW E PA
PHESGO 2 PA
rizatriptan benzoate 1 QL
REVLIMID 2 PA
sumatriptan succinate
1 QL ROZLYTREK 3 PA
oral
TOSYMRA E QL RUBRACA 2 PA
TREXIMET E QL RUXIENCE 2 PA
UBRELVY 2 PA SPRYCEL 2 PA
ZEMBRACE TABRECTA E PA
E QL
SYMTOUCH TAGRISSO ORAL
3 PA; QL
ZOMIG ORAL E QL TABLET 40 MG
ZOMIG ZMT E QL TAGRISSO ORAL
3 PA
TABLET 80 MG
Antineoplastics -
Drugs for Cancer tamoxifen citrate oral 1
AFINITOR ORAL TARGRETIN
3 PA
TABLET 2.5 MG, 5 E PA; QL EXTERNAL
MG, 7.5 MG TARGRETIN ORAL E PA
ALECENSA 2 PA TAZVERIK E PA
ALUNBRIG 2 PA; QL TRAZIMERA
anastrozole oral 1 INTRAVENOUS
SOLUTION 2 PA
ARIMIDEX E RECONSTITUTED 420
BELRAPZO E PA MG
CABOMETYX 2 PA TREANDA E PA
CALQUENCE 3 PA TRUXIMA E PA
capecitabine 1 PA VELCADE 2 PA
DARZALEX FASPRO E PA VITRAKVI 3 PA
ERLEADA E PA
12Drug Name Drug Tier Notes Drug Name Drug Tier Notes
XTANDI ORAL Antipsychotics -
3 PA Drugs for Mood
CAPSULE
YONSA E PA Disorders
ZEJULA 2 PA ABILIFY E QL
ZIRABEV 2 PA ABILIFY MAINTENA 3
ZYTIGA E PA aripiprazole oral tablet 1 QL
Antiparasitics ARISTADA 3
ARAKODA 3 ARISTADA INITIO 3
EMVERM 2 INVEGA SUSTENNA 3
hydroxychloroquine INVEGA TRINZA 3
1
sulfate oral LATUDA 3 QL
NATROBA E olanzapine oral tablet 1 QL
PLAQUENIL E PERSERIS 3
Antiparkinson Agents quetiapine fumarate 1 QL
benztropine mesylate quetiapine fumarate er 1 QL
1
oral REXULTI 3 QL
carbidopa-levodopa RISPERDAL E QL
1
oral tablet
risperidone oral tablet 1 QL
GOCOVRI E PA
SAPHRIS E ST; QL
INBRIJA 3 PA
SECUADO
KYNMOBI 3 PA; QL TRANSDERMAL
E QL
KYNMOBI TITRATION PATCH 24 HOUR 3.8
3 PA; QL
KIT MG/24HR
NOURIANZ 3 PA SECUADO
ONGENTYS 3 ST TRANSDERMAL
PATCH 24 HOUR 5.7 E
OSMOLEX ER E PA MG/24HR, 7.6
pramipexole MG/24HR
1
dihydrochloride SEROQUEL E QL
ropinirole hcl 1 SEROQUEL XR E QL
RYTARY 3 ST VRAYLAR 3 ST; QL
Antiplatelets ziprasidone hcl 1 QL
ASPIRIN- ZYPREXA
E QL E
OMEPRAZOLE INTRAMUSCULAR
BRILINTA 2 ZYPREXA ORAL E QL
clopidogrel bisulfate Antivirals
1
oral
acyclovir oral tablet 1
PLAVIX E
ATRIPLA E
prasugrel hcl 1
BARACLUDE ORAL
YOSPRALA E QL E QL
TABLET
BIKTARVY 3
CIMDUO 2
13Drug Name Drug Tier Notes Drug Name Drug Tier Notes
DESCOVY E PA; PV clonazepam oral tablet 1 QL
DOVATO 2 diazepam oral tablet 1
entecavir 1 QL hydroxyzine hcl oral
1
EPCLUSA 2 PA; QL tablet
GENVOYA 3 hydroxyzine pamoate
1
oral
HARVONI 2 PA; QL
KLONOPIN E QL
JULUCA 2
lorazepam oral tablet 1 QL
LEDIPASVIR-
E PA; QL triazolam 1 QL
SOFOSBUVIR
MAVYRET 2 PA; QL VALIUM E
ODEFSEY 3 XANAX E QL
PREZCOBIX 2 XANAX XR E QL
RUKOBIA 2 Bipolar Agents -
Drugs for Mood
SOFOSBUVIR- Disorders
E PA; QL
VELPATASVIR
lithium carbonate er 1
SYMFI 2
lithium carbonate oral
SYMFI LO 2 1
capsule
TAMIFLU E QL Blood Products and
TEMIXYS E Modifiers - Drugs for
Blood Disorders
TIVICAY 2
TRIUMEQ 2 ARANESP (ALBUMIN
2 PA
FREE)
TRUVADA ORAL
TABLET 100-150 MG, EPOGEN E PA
E
133-200 MG, 167-250 ESPEROCT E
MG FULPHILA E PA
TRUVADA ORAL GRANIX E PA
E PA
TABLET 200-300 MG
MULPLETA 2 PA
valacyclovir hcl oral 1 QL
NEULASTA 3 PA
VALTREX E QL
NEULASTA ONPRO 3 PA
VEMLIDY 3
NEUPOGEN E PA
VOSEVI 2 PA; QL
NIVESTYM 2 PA
XOFLUZA (40 MG
3 QL NPLATE 3 PA
DOSE)
XOFLUZA (80 MG PROCRIT E PA
3 QL
DOSE) RETACRIT 2 PA
ZOVIRAX E SEVENFACT E
Anxiolytics - Drugs SOLIRIS 3 PA
for Anxiety UDENYCA E PA
alprazolam oral tablet 1 QL ULTOMIRIS 3 PA
ATIVAN ORAL E QL ZARXIO 2 PA
buspirone hcl oral 1 ZIEXTENZO 3 PA
14Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Cardiovascular chlorthalidone 1
Agents - Drugs for clonidine hcl oral 1
Heart and Circulation
Conditions COLESTID E
ALTACE E COLESTID
E
FLAVORED
amiodarone hcl oral 1
CONJUPRI E
amlodipine besylate
1 CONSENSI ORAL
oral
TABLET 10-200 MG, 5- E
amlodipine besylate- 200 MG
1
benazepril hcl
CONSENSI ORAL
amlodipine besylate- E QL
1 TABLET 2.5-200 MG
valsartan
COREG E
amlodipine-olmesartan 1
COREG CR E
ATACAND E
CORLANOR 3 PA; QL
atenolol oral 1
COZAAR E
atenolol-chlorthalidone 1
CRESTOR E
atorvastatin calcium
oral tablet 10 mg, 20 1 PV digoxin oral tablet 1
mg diltiazem hcl er coated
atorvastatin calcium beads oral capsule
1
oral tablet 40 mg, 80 1 extended release 24
mg hour
AVAPRO E DIOVAN E
AZOR E DIOVAN HCT E
benazepril hcl oral 1 doxazosin mesylate
1
oral
BENICAR E
EDARBI 3 ST
BENICAR HCT E
EDARBYCLOR 3 ST
bisoprolol fumarate oral 1
enalapril maleate oral 1
bisoprolol-
1 ENTRESTO 2 QL
hydrochlorothiazide
bumetanide oral 1 EXFORGE E
BYSTOLIC 2 EXFORGE HCT E
candesartan cilexetil 1 ezetimibe 1
CARDIZEM LA ORAL ezetimibe-simvastatin 1
TABLET EXTENDED fenofibrate micronized
RELEASE 24 HOUR E oral capsule 134 mg, 1
180 MG, 240 MG, 300 200 mg, 67 mg
MG, 360 MG, 420 MG fenofibrate oral tablet
cartia xt 1 145 mg, 160 mg, 48 1
carvedilol 1 mg, 54 mg
CATAPRES-TTS-1 E fenofibric acid oral
capsule delayed 1
CATAPRES-TTS-2 E release
CATAPRES-TTS-3 E
15Drug Name Drug Tier Notes Drug Name Drug Tier Notes
flecainide acetate 1 NIASPAN E
furosemide oral tablet 1 nifedipine er 1
gemfibrozil oral 1 nifedipine er osmotic
1
guanfacine hcl 1 release
HEMANGEOL 3 nitroglycerin sublingual 1
hydralazine hcl oral 1 NITROSTAT E
hydrochlorothiazide NORVASC E
1
oral olmesartan medoxomil
1
HYZAAR E oral
INDERAL LA E olmesartan medoxomil-
1
hctz
INDERAL XL E
olmesartan-amlodipine-
INNOPRAN XL E 1
hctz
irbesartan 1 omega-3-acid ethyl
1 PA
irbesartan- esters
1
hydrochlorothiazide PRALUENT 2 PA; QL
isosorbide mononitrate pravastatin sodium 1
1
er
prazosin hcl oral 1
KAPSPARGO
E PRINIVIL E
SPRINKLE
KATERZIA E propranolol hcl er 1
labetalol hcl oral 1 propranolol hcl oral
1
tablet
LASIX E
QUESTRAN E
LESCOL XL E
QUESTRAN LIGHT E
LIPITOR E
ramipril 1
lisinopril oral 1
RANEXA E
lisinopril-
1 ranolazine er 1
hydrochlorothiazide
LIVALO E ST REPATHA 2 PA; QL
losartan potassium oral 1 REPATHA
PUSHTRONEX 2 PA; QL
losartan potassium-hctz 1 SYSTEM
LOTREL E REPATHA
2 PA; QL
lovastatin oral 1 PV SURECLICK
LOVAZA E PA rosuvastatin calcium 1
metoprolol succinate er 1 simvastatin oral tablet
metoprolol tartrate oral 1 10 mg, 20 mg, 40 mg, 5 1 PV
mg
MICARDIS E
simvastatin oral tablet
MICARDIS HCT E 1
80 mg
MULTAQ 3 sotalol hcl oral 1
NEXLETOL 2 PA; QL spironolactone oral 1
NEXLIZET 2 PA; QL TEKTURNA 2
16Drug Name Drug Tier Notes Drug Name Drug Tier Notes
TEKTURNA HCT 2 ST FOCALIN XR E PA; QL
telmisartan 1 guanfacine hcl er 1
telmisartan-hctz 1 INTUNIV E
TENORMIN E JORNAY PM 3 ST; QL
TIKOSYN E methylphenidate hcl er
TOPROL XL E (la) oral capsule
extended release 24 1 PA; QL
torsemide 1 hour 10 mg, 20 mg, 30
triamterene-hctz 1 mg, 40 mg
TRIBENZOR E methylphenidate hcl er
1 PA; QL
TRICOR E (xr)
valsartan 1 methylphenidate hcl er
oral tablet extended 1 PA; QL
valsartan- release
1
hydrochlorothiazide
methylphenidate hcl
VASCEPA 2 PA 1 PA; QL
oral tablet
verapamil hcl er oral RITALIN E PA; QL
1
tablet extended release
RITALIN LA E PA; QL
VYTORIN E
STRATTERA E QL
WELCHOL E
VYVANSE 2 PA; QL
ZESTRIL E
Central Nervous
ZETIA E System Agents -
ZOCOR E Drugs for Multiple
Sclerosis
ZYPITAMAG E ST; QL
Central Nervous AMPYRA 3 PA; QL
System Agents - AUBAGIO 3 PA; QL
Drugs for Attention AVONEX PEN 2 PA; QL
Deficit Disorder
AVONEX PREFILLED 2 PA; QL
ADDERALL E PA; QL
BAFIERTAM 2 PA; QL
ADDERALL XR E PA; QL
BETASERON 2 PA; QL
ADHANSIA XR E PA; QL
COPAXONE 2 PA; QL
amphetamine-
1 PA; QL EXTAVIA E PA; QL
dextroamphetamine
amphetamine- GILENYA 3 PA; QL
1 PA; QL
dextroamphetamine er KESIMPTA 2 PA; QL
atomoxetine hcl 1 QL MAVENCLAD 3 PA
CONCERTA E PA; QL MAYZENT 3 PA; QL
dexmethylphenidate hcl PLEGRIDY E PA; QL
1 PA; QL
er PLEGRIDY STARTER
E PA; QL
dexmethylphenidate hcl PACK
1 PA; QL
oral tablet 10 mg, 5 mg REBIF E PA; QL
EVEKEO E PA; QL REBIF REBIDOSE E PA; QL
FOCALIN E PA; QL
17Drug Name Drug Tier Notes Drug Name Drug Tier Notes
REBIF REBIDOSE adapalene external gel 1 PA
E PA; QL
TITRATION PACK AKLIEF E PA
REBIF TITRATION ALA SCALP E
E PA; QL
PACK
AMZEEQ 3
TECFIDERA E PA; QL
APEXICON E E
VUMERITY 2 PA; QL
ARAZLO E PA
ZEPOSIA 3 PA; QL
AVITA E PA
ZEPOSIA 7-DAY
3 PA; QL BENZACLIN E
STARTER PACK
ZEPOSIA STARTER BENZACLIN WITH
3 PA; QL E
KIT PUMP
Central Nervous BENZAMYCIN E
System Agents - betamethasone
Miscellaneous dipropionate external 1
ADDYI 3 PA; QL cream
ADIPEX-P E PA CALCIPOTRIENE
E
EXTERNAL FOAM
AUSTEDO 3 PA; QL
CAPEX E
CONTRAVE E PA
claravis 1 PA
GRALISE ORAL
3 ST; QL CLINDAGEL E
TABLET
HORIZANT 3 PA; QL clindamycin phosphate-
benzoyl peroxide 1
INGREZZA 3 PA; QL external gel 1-5 %
LYRICA E QL clindamycin phosphate
1
pregabalin oral capsule 1 QL external lotion
TEGSEDI 3 PA clindamycin phosphate
1
TIGLUTIK 3 PA external solution
VYLEESI 3 PA; QL clindamycin phosphate
1
external swab
Dental and Oral
Agents - Drugs for CLINDAMYCIN
Mouth and Throat PHOSPHATE GEL 1 % E
Conditions EXTERNAL
chlorhexidine gluconate clindamycin phosphate
1 1
mouth/throat gel 1 % external
lidocaine viscous hcl 1 clobetasol propionate
1
external cream
Dermatological
Agents - Drugs for clobetasol propionate
1
Skin Conditions external ointment
ABSORICA LD 3 PA clobetasol propionate
1
external solution
ACANYA E
CLOBEX E
ACZONE EXTERNAL
E CLOBEX SPRAY E
GEL 5 %
ACZONE EXTERNAL CLODERM E
2
GEL 7.5 %
18Drug Name Drug Tier Notes Drug Name Drug Tier Notes
CORDRAN imiquimod external
E 1
EXTERNAL TAPE cream 5 %
DAPSONE GEL 7.5 % IMIQUIMOD PUMP E
E
EXTERNAL IMPEKLO E
DESONATE E IMPOYZ E
DIFFERIN EXTERNAL KENALOG EXTERNAL E
E PA
CREAM
LEXETTE E
DIFFERIN EXTERNAL
E PA METROGEL E
GEL 0.3 %
DIFFERIN EXTERNAL metronidazole external
E PA 1
LOTION cream
DUOBRII E PA metronidazole external
1
gel
DUPIXENT 2 PA; QL
MIRVASO 3
ELIDEL E
mometasone furoate
EPIDUO E 1
external cream
EPIDUO FORTE 3 NORITATE E
EUCRISA 2 ST ONEXTON 3
FABIOR E PA ORACEA E
FINACEA EXTERNAL PANDEL E
3
FOAM
pimecrolimus 1 ST
FINACEA EXTERNAL
3 ST PROPECIA E
GEL
fluocinonide external PSORCON E
1
cream 0.05 % QBREXZA 3 QL
fluocinonide external RETIN-A E PA
1
solution RETIN-A MICRO GEL
E PA
FLUOROPLEX 3 0.04 %, 0.1 %
FLUOROURACIL RETIN-A MICRO
EXTERNAL CREAM 2 PUMP EXTERNAL E PA
0.5 % GEL 0.04 %, 0.1 %
fluorouracil external RETIN-A MICRO
1
cream 5 % PUMP EXTERNAL 2 PA
HALOBETASOL GEL 0.06 %, 0.08 %
PROPIONATE E RHOFADE 3
EXTERNAL FOAM SERNIVO 3
HALOG EXTERNAL SOOLANTRA 3
E
CREAM
SORILUX E
HALOG EXTERNAL
E TACLONEX
OINTMENT
EXTERNAL E QL
hydrocortisone external OINTMENT
1
cream 1 %, 2.5 %
TACLONEX
hydrocortisone external EXTERNAL 3 QL
1
ointment 1 %, 2.5 % SUSPENSION
19Drug Name Drug Tier Notes Drug Name Drug Tier Notes
tacrolimus external glyburide oral 1
1
ointment GLYXAMBI 2 ST
TAZAROTENE INVOKAMET E
E PA
EXTERNAL FOAM
INVOKAMET XR E
TAZORAC E PA
INVOKANA E
TOPICORT SPRAY E
JANUMET 2 ST
tretinoin external cream 1 PA
JANUMET XR 2 ST
triamcinolone acetonide
1 JANUVIA 2 ST
external cream
triamcinolone acetonide JARDIANCE 2 ST
external ointment 0.025 1 JENTADUETO 2 ST
%, 0.1 %, 0.5 % JENTADUETO XR 2 ST
TRIANEX E KAZANO E
ULTRAVATE E KOMBIGLYZE XR E
VECTICAL E metformin hcl er 1
VELTIN E metformin hcl er (mod) E PA
VERDESO E metformin hcl er (osm) E
ZIANA E metformin hcl oral
1
ZILXI 3 ST tablet
ZYCLARA E NESINA E
ZYCLARA PUMP E ONGLYZA E
Diabetes - OSENI E
Antidiabetic Agents
OZEMPIC
ADLYXIN E QL SUBCUTANEOUS
ADLYXIN STARTER SOLUTION PEN- 2 ST; QL
E QL INJECTOR 2
PACK
MG/1.5ML
ALOGLIPTIN
E pioglitazone hcl 1
BENZOATE
ALOGLIPTIN- QTERN E
E
METFORMIN HCL RYBELSUS 2 ST; QL
ALOGLIPTIN- SEGLUROMET E
E
PIOGLITAZONE SOLIQUA 2 ST; QL
BYDUREON BCISE STEGLATRO E
2 ST; QL
AUTOINJECTOR
STEGLUJAN E
BYETTA 10 MCG PEN 2 ST; QL
SYMLINPEN 120 3 PA
BYETTA 5 MCG PEN 2 ST; QL
SYMLINPEN 60 3 PA
FARXIGA 2 ST
SYNJARDY 2 ST
FORTAMET E
SYNJARDY XR 2 ST
glimepiride 1
TRADJENTA 2 ST
glipizide er 1
TRIJARDY XR 2 ST
glipizide ir 1
TRULICITY 2 ST; QL
GLUMETZA E PA
20Drug Name Drug Tier Notes Drug Name Drug Tier Notes
VICTOZA 2 ST; QL CONTOUR CONTROL
2
XIGDUO XR 2 ST SOLUTION
Diabetes - Glucose CONTOUR MONITOR
2
Monitoring DEVICE
ACCU-CHEK AVIVA CONTOUR MONITOR
E 2
DEVICE KIT W/DEVICE
ACCU-CHEK AVIVA CONTOUR NEXT
E 2
PLUS KIT W/DEVICE CONTROL SOLUTION
ACCU-CHEK AVIVA CONTOUR NEXT EZ
E QL 2
PLUS TEST STRIPS KIT W/DEVICE
ACCU-CHEK CONTOUR NEXT
COMPACT PLUS E MONITOR KIT 2
CONTROL W/DEVICE
ACCU-CHEK CONTOUR NEXT ONE
2
COMPACT PLUS E QL KIT
TEST STRIPS CONTOUR NEXT
2 QL
ACCU-CHEK TEST STRIPS
FASTCLIX LANCET 2 CONTOUR TEST
2 QL
KIT STRIPS
ACCU-CHEK GUIDE EASY TRAK II
E E
TEST STRIPS CONTROL
ACCU-CHEK GUIDE EASY TRAK II
E E QL
CONTROL GLUCOSE TEST
ACCU-CHEK GUIDE EASYMAX CONTROL E
E QL
TEST STRIPS EMBRACE TALK
E
ACCU-CHEK GUIDE BLOOD GLUCOSE
E
KIT W/DEVICE EMBRACE TALK
E
ACCU-CHEK GLUCOSE CONTROL
SMARTVIEW E EMBRACE TALK
CONTROL E QL
GLUCOSE TEST
ACCU-CHEK EMBRACE TALK
SMARTVIEW TEST E QL MONITORING E
STRIPS SYSTEM
ACCU-CHEK EVENCARE PROVIEW
SOFTCLIX LANCET 2 GLUCOSE TEST IN E QL
DEVICE KIT VITRO STRIP
AGAMATRIX PRESTO FORA 6 CONNECT E QL
E QL
TEST
FORA GTEL BLOOD
ASSURE PLATINUM E QL E
GLUCOSE SYSTEM
BIOTEL CARE BLOOD FORA GTEL BLOOD
E E QL
GLUCOSE GLUCOSE TEST
BLOOD GLUCOSE FORA TN'G ADVANCE
E QL E QL
TEST PRO IN VITRO
CARETOUCH TEST E QL FORTISCARE
E
CONTROL
21Drug Name Drug Tier Notes Drug Name Drug Tier Notes
FREESTYLE HW EMBRACE PRO
E E QL
FREEDOM LITE GLUCOSE TEST
FREESTYLE HW EMBRACE TALK
E E
INSULINX SYSTEM BLOOD GLUCOSE
FREESTYLE HW EMBRACE TALK
E QL E QL
INSULINX TEST GLUCOSE TEST
FREESTYLE LIBRE 14 INFINITY BLOOD
E E QL
DAY READER GLUCOSE TEST
FREESTYLE LIBRE 14 KROGER
E
DAY SENSOR HEALTHPRO E QL
FREESTYLE LIBRE 2 GLUCOSE TEST
E
READER LANCETS IN VITRO
E QL
FREESTYLE LIBRE 2 STRIP
E
SENSOR MICRODOT TEST E QL
FREESTYLE LIBRE ONETOUCH ULTRA E QL
E
READER ONETOUCH ULTRA 2
E
FREESTYLE LIBRE KIT W/DEVICE
E
SENSOR SYSTEM ONETOUCH ULTRA
E
FREESTYLE LITE MINI KIT W/DEVICE
E QL
TEST ONETOUCH VERIO
E
FREESTYLE KIT W/DEVICE
PRECISION NEO E QL ONETOUCH VERIO
TEST FLEX SYSTEM KIT E
FREESTYLE TEST E QL W/DEVICE
GLUCOCARD 01 ONETOUCH VERIO IN
E QL
SENSOR PLUS VITRO SOLUTION E
GLUCOCARD HIGH
E QL
EXPRESSION TEST ONETOUCH VERIO
E QL
GLUCOCARD SHINE TEST STRIPS
E
CONNEX ONETOUCH VERIO IQ
E
GLUCOCARD SHINE SYSTEM
E
EXPRESS ONETOUCH VERIO
E
GLUCOCARD SHINE REFLECT
E QL
TEST ONETOUCH VERIO
GLUCOCARD VITAL SYNC SYSTEM KIT E
E QL W/DEVICE
TEST
GOJJI BLOOD POGO AUTOMATIC
E QL E
GLUCOSE TEST BLOOD GLUCOSE
GOJJI CONTROL E PRECISION PCX
E QL
PLUS TEST
HARMONY BLOOD
GLUCOSE TEST IN E QL PRECISION QID TEST E QL
VITRO STRIP PRECISION SOF-
E QL
HW EMBRACE PRO TACT TEST
E
GLUCOSE METER PRECISION XTRA
E QL
BLOOD GLUCOSE
22Drug Name Drug Tier Notes Drug Name Drug Tier Notes
PRECISION XTRA GVOKE HYPOPEN 1-
E 2
DEVICE PACK
RELION BLOOD GVOKE HYPOPEN 2-
E QL 2
GLUCOSE TEST PACK
SURESTEP PRO GVOKE PFS 2
E
HIGH GLUCOSE Diabetes - Insulins
SURESTEP PRO LOW ADMELOG E
E
GLUCOSE
ADMELOG
SURESTEP PRO E
E SOLOSTAR
NORMAL GLUCOSE
APIDRA SOLOSTAR E
TRUE METRIX BLOOD
E QL APIDRA VIAL E
GLUCOSE TEST
TRUE METRIX LEVEL BASAGLAR KWIKPEN E
E
1 BD AUTOSHIELD DUO
2
TRUE METRIX LEVEL PEN NEEDLES
E
2 BD ULTRA-FINE
2
TRUE METRIX LEVEL INSULIN SYRINGES
E
3 BD ULTRA-FINE PEN
2
TRUE METRIX PRO NEEDLES
E QL
BLOOD GLUCOSE BD VEO INSULIN SYR
2
TRUETRACK TEST E QL U/F 1/2UNIT
UNISTRIP CONTROL FIASP E
IN VITRO SOLUTION E FIASP FLEXTOUCH E
LOW FIASP PENFILL E
V-GO 20 2 HUMALOG 2
V-GO 30 2 HUMALOG KWIKPEN 2
V-GO 40 2 HUMALOG MIX 50/50
2
VIVAGUARD INO KWIKPEN
E
CONTROL SOLUTION HUMALOG MIX 50/50
2
VIVAGUARD INO VIAL
E
GLUCOSE METER HUMALOG MIX 75/25
2
VIVAGUARD INO KWIKPEN
E QL
TEST STRIPS HUMALOG MIX 75/25
Diabetes - Glycemic 2
VIAL
Agents
HUMALOG U-100
2
BAQSIMI ONE PACK 2 JUNIOR KWIKPEN
BAQSIMI TWO PACK 2 HUMULIN 70/30
2
glucagon emergency kit KWIKPEN
1
1 mg injection 1 mg HUMULIN 70/30 VIAL 2
GLUCAGON HUMULIN N KWIKPEN 2
EMERGENCY KIT 1 3 HUMULIN N VIAL 2
MG INJECTION 1 MG
HUMULIN R U-500
GLUCAGON 2
2 KWIKPEN
EMERGENCY KIT
23Drug Name Drug Tier Notes Drug Name Drug Tier Notes
HUMULIN R U-500 NOVOLIN N RELION E
2
VIAL NOVOLIN N VIAL E
HUMULIN R VIAL 2 NOVOLIN R FLEXPEN E
INSULIN ASP PROT & NOVOLIN R FLEXPEN
E E
ASP FLEXPEN RELION
INSULIN ASPART E NOVOLIN R RELION E
INSULIN ASPART NOVOLIN R VIAL E
E
FLEXPEN
NOVOLOG FLEXPEN E
INSULIN ASPART
E NOVOLOG MIX 70/30
PENFILL E
FLEXPEN
INSULIN ASPART
E NOVOLOG MIX 70/30
PROT & ASPART E
VIAL
INSULIN LISPRO E
NOVOLOG PENFILL E
INSULIN LISPRO (1
E NOVOLOG U-100 VIAL E
UNIT DIAL)
INSULIN LISPRO NOVOTWIST PEN
E 2
JUNIOR KWIKPEN NEEDLE
INSULIN LISPRO SEMGLEE E
E
PROT & LISPRO TOUJEO MAX
2
LANTUS SOLOSTAR 2 SOLOSTAR
LANTUS U-100 VIAL 2 TOUJEO SOLOSTAR 2
LEVEMIR U-100 TRESIBA E
E
FLEXTOUCH TRESIBA
E
LEVEMIR U-100 VIAL E FLEXTOUCH
LYUMJEV KWIKPEN 2 Electrolytes / Minerals
/ Metals / Vitamins
LYUMJEV VIAL 2
AZESCHEW
NOVOFINE PRENATAL/POSTNAT E
AUTOCOVER PEN 2 AL
NEEDLE
AZESCO E
NOVOFINE PEN
2 CARNITOR ORAL E
NEEDLE
NOVOFINE PLUS PEN CARNITOR SF E
2
NEEDLE CITRANATAL BLOOM E
NOVOLIN 70/30 cyanocobalamin
E
FLEXPEN injection solution 1000 1
NOVOLIN 70/30 mcg/ml
E
FLEXPEN RELION DEXIFOL E
NOVOLIN 70/30 ENBRACE HR E
E
RELION ergocalciferol oral
1
NOVOLIN 70/30 VIAL E capsule
NOVOLIN N FLEXPEN E folic acid oral tablet 1
1
NOVOLIN N FLEXPEN mg
E
RELION FOLIC-K E
24Drug Name Drug Tier Notes Drug Name Drug Tier Notes
FOLITIN-Z E TRINAZ E
FOLTREXYL E TRISTART DHA E
GENICIN VITA-Q E TRONVITE E
GENICIN VITA-S E VELTASSA 3
HYLAVITE E VENEXA E
HYLAZINC E VITAFOL FE+ E
klor-con m20 1 VITAFOL-NANO E
K-TAB E VITAFOL-OB+DHA E
LOKELMA 3 vitamin d
LORID E (ergocalciferol) oral
1
capsule 1.25 mg
MULTIPRO E (50000 ut)
NASCOBAL 3 VITASURE E
NESTABS ONE E VITRANOL FE E
NICADAN E VITREXATE E
NICAZEL E VITREXATE FE E
NICAZEL FORTE E VITREXYL E
NICOMIDE E VITREXYL + IRON E
PNV TABS 20-1 E WESTGEL DHA E
potassium chloride crys XVITE E
1
er
ZALVIT E
potassium chloride er 1
ZYVANA E
potassium citrate er 1
Gastrointestinal
PREGEN DHA E Agents - Drugs for
PREGENNA E Acid Reflux and Ulcer
PRENATE E ACIPHEX E ST; QL
PRENATE DHA E CARAFATE ORAL
E
PRENATE ELITE E TABLET
PRENATE ENHANCE E DEXILANT 2 QL
PRENATE ESSENTIAL E esomeprazole
magnesium oral
PRENATE MINI E 1 QL
capsule delayed
PRENATE PIXIE E release
PRENATE RESTORE E famotidine oral
PRENATRIX E suspension 1
reconstituted
PRENATRYL E
famotidine oral tablet
PRIMACARE E 1
20 mg, 40 mg
QUFLORA FE E lansoprazole oral
REMEDIENT E capsule delayed 1 QL
sodium fluoride oral release
1 PV
tablet chewable misoprostol oral 1
25Drug Name Drug Tier Notes Drug Name Drug Tier Notes
NEXIUM ORAL lactulose oral solution 1
CAPSULE DELAYED E QL LINZESS 2 ST; QL
RELEASE
LUBIPROSTONE E QL
omeprazole oral
capsule delayed 1 QL MOTEGRITY 3 ST; QL
release MOTOFEN E
omeprazole-sodium MOVANTIK E QL
E QL
bicarbonate MOVIPREP E
pantoprazole sodium NULYTELY LEMON-
oral tablet delayed 1 QL E
LIME
release
OMECLAMOX-PAK 2
PREVACID E QL
OSMOPREP E
PREVACID SOLUTAB E ST; QL
peg 3350-kcl-na bicarb-
PROTONIX ORAL 1 PV
nacl
TABLET DELAYED E QL
RELEASE PLENVU E
RABEPRAZOLE PYLERA 2
SODIUM ORAL E ST; QL RELISTOR E QL
CAPSULE SPRINKLE SUPREP BOWEL
3
rabeprazole sodium PREP KIT
oral tablet delayed 1 QL SYMPROIC 2 ST; QL
release
TRULANCE E QL
sucralfate oral tablet 1
VIBERZI 3 PA; QL
ZEGERID ORAL
E QL ZELNORM 3 QL
CAPSULE
ZEGERID ORAL Genetic or Enzyme
E ST; QL Disorder - Drugs for
PACKET
Replacement,
Gastrointestinal Modification,
Agents - Drugs for Treatment
Bowel, Intestine and
Stomach Conditions CERDELGA 3 PA
AMITIZA E QL CREON 2
CLENPIQ 3 EXONDYS 51 E PA
dicyclomine hcl oral KUVAN E PA
1
capsule NITYR 3 PA
dicyclomine hcl oral ORFADIN 3 PA
1
tablet PANCREAZE E
diphenoxylate-atropine PERTZYE E
1
oral tablet
STRENSIQ
glycopyrrolate oral SUBCUTANEOUS
1
tablet 1 mg, 2 mg SOLUTION 28 2 PA
GOLYTELY E MG/0.7ML, 40 MG/ML,
hyoscyamine sulfate sl 1 80 MG/0.8ML
hyoscyamine sulfate VIOKACE E
1
sublingual VYONDYS 53 E PA
26Drug Name Drug Tier Notes Drug Name Drug Tier Notes
ZENPEP 2 terazosin hcl oral
ZOLGENSMA 3 PA capsule 1 mg, 10 mg, 5 1
mg
Genitourinary Agents
- Drugs for Bladder, Hormonal Agents -
Genital and Kidney Adrenal
Conditions ALKINDI SPRINKLE E
AURYXIA 3 CORTEF E
CIALIS E QL dexamethasone oral
1
DEPEN TITRATABS 2 tablet
ELMIRON E PA HEMADY E
LEVITRA ORAL hydrocortisone oral 1
E QL
TABLET 20 MG KENALOG INJECTION
MYRBETRIQ 2 SUSPENSION 40 E
MG/ML
oxybutynin chloride er 1
methylprednisolone
oxybutynin chloride oral 1
1 oral tablet therapy pack
tablet
prednisolone sodium
phenazopyridine hcl 1
phosphate oral solution
oral tablet 100 mg, 200 1
mg prednisone oral tablet 1
RENAGEL E prednisone oral tablet
1
therapy pack
sildenafil citrate oral
tablet 100 mg, 25 mg, 1 QL RAYOS E
50 mg Hormonal Agents -
solifenacin succinate 1 Men's Health
STENDRA E QL ANDRODERM 2 PA
tadalafil oral 1 QL ANDROGEL E PA
tolterodine tartrate er 1 ANDROGEL PUMP E PA
TOVIAZ 3 AVEED E PA
VELPHORO 3 DEPO-
E PA
TESTOSTERONE
VESICARE E
FORTESTA E PA
VIAGRA E QL
JATENZO E PA
Genitourinary Agents
- Drugs for Prostate NATESTO E PA
Conditions TESTIM E PA
alfuzosin hcl er 1 TESTOPEL E PA
AVODART E testosterone cypionate
1 PA
dutasteride oral 1 intramuscular
finasteride oral tablet 5
1
mg
FLOMAX E
tamsulosin hcl 1
27Drug Name Drug Tier Notes Drug Name Drug Tier Notes
testosterone LUPRON DEPOT (6-
transdermal gel 1.62 %, MONTH)
2 PA
10 mg/act (2%), 20.25 INTRAMUSCULAR KIT
mg/1.25gm (1.62%), 45MG
20.25 mg/act (1.62%), 1 PA MYCAPSSA E PA
25 mg/2.5gm (1%),
40.5 mg/2.5gm NOCDURNA 3
(1.62%), 50 mg/5gm NORDITROPIN
2 PA
(1%) FLEXPRO
VOGELXO E PA NUTROPIN AQ
2 PA
VOGELXO PUMP E PA NUSPIN 10
XYOSTED 3 PA NUTROPIN AQ
2 PA
NUSPIN 20
Hormonal Agents -
Osteoporosis NUTROPIN AQ
2 PA
NUSPIN 5
OSPHENA 3
OMNITROPE E PA
Hormonal Agents -
Pituitary ORILISSA 2 PA; QL
ACTHAR 2 PA SAIZEN E PA
BYNFEZIA PEN E PA SAIZENPREP E PA
cabergoline 1 SANDOSTATIN E PA
CETROTIDE E PA SIGNIFOR E PA; QL
FENSOLVI (6 MONTH) 3 PA; QL SOMATULINE DEPOT 3 PA
GENOTROPIN E PA SUPPRELIN LA 2 PA; QL
GENOTROPIN TRIPTODUR 3 PA; QL
E PA
MINIQUICK ZOMACTON E PA
GONAL-F E PA ZOMACTON (FOR
E PA
GONAL-F RFF E PA ZOMA-JET 10)
GONAL-F RFF Hormonal Agents -
E PA Sex Hormones and
REDIJECT
Birth Control
HUMATROPE E PA
ANNOVERA E QL
ISTURISA E PA
apri 1 PV
LUPRON DEPOT (1-
MONTH) aurovela fe 1/20 1 PV
2 PA
INTRAMUSCULAR KIT aviane 1 PV
7.5 MG BEYAZ E
LUPRON DEPOT (3- BIJUVA 3
MONTH)
2 PA blisovi 24 fe 1 PV
INTRAMUSCULAR KIT
22.5 MG blisovi fe 1.5/30 1 PV
LUPRON DEPOT (4- blisovi fe 1/20 1 PV
MONTH) CLIMARA E
2 PA
INTRAMUSCULAR KIT
30MG CLIMARA PRO 2
cryselle-28 1 PV
28Drug Name Drug Tier Notes Drug Name Drug Tier Notes
DELESTROGEN levonorgestrel-ethinyl
INTRAMUSCULAR OIL E estrad oral tablet 0.1-20
1 PV
20 MG/ML, 40 MG/ML mg-mcg, 0.15-30 mg-
DIVIGEL 3 mcg
dotti 1 LO LOESTRIN FE 3
drospirenone-ethinyl LOESTRIN 1.5/30 (21) E
1 PV
estradiol LOESTRIN 1/20 (21) E
DUAVEE 2 LOESTRIN FE 1.5/30 E
ELESTRIN 3 LOESTRIN FE 1/20 E
ENDOMETRIN 2 loryna 1 PV
enskyce 1 PV MAKENA 2 PA
estarylla 1 PV medroxyprogesterone
1
ESTRACE E acetate oral
estradiol oral 1 MINASTRIN 24 FE E
estradiol transdermal 1 mono-linyah 1 PV
estradiol vaginal 1 NATAZIA 2 PV
estradiol-norethindrone nikki 1 PV
1
acet norethin ace-eth
1 PV
ESTROGEL 3 estrad-fe oral tablet
EVAMIST 3 norethindrone acetate
1
oral
GENERESS FE E
norethindrone acet-
IMVEXXY 1 PV
3 ethinyl est
MAINTENANCE PACK
norethindrone oral 1 PV
IMVEXXY STARTER
3 norgestimate-ethinyl
PACK 1 PV
estradiol triphasic
isibloom 1 PV
nortrel 1/35 (21) 1 PV
junel 1.5/30 1 PV
nortrel 1/35 (28) 1 PV
junel 1/20 1 PV
ORIAHNN 2 PA; QL
junel fe 1.5/30 1 PV
ORTHO MICRONOR E
junel fe 1/20 1 PV
PREMARIN ORAL 2
junel fe 24 1 PV
PREMARIN VAGINAL 2
kurvelo 1 PV
PREMPHASE 2
larin fe 1/20 1 PV
PREMPRO 2
larissia 1 PV
PROMETRIUM E
lessina 1 PV
SAFYRAL E
levonorgest-eth est &
1 PV; QL SEASONIQUE E QL
eth est
levonorgest-eth estrad SLYND E
91-day oral tablet 0.15- sprintec 28 1 PV
1 PV; QL
0.03 &0.01 mg, 0.15- syeda 1 PV
0.03 mg
tri femynor 1 PV
29Drug Name Drug Tier Notes Drug Name Drug Tier Notes
tri-estarylla 1 PV CIMZIA 2 PA
tri-lo-marzia 1 PV CIMZIA PREFILLED
2 PA
tri-lo-mili 1 PV KIT
tri-lo-sprintec 1 PV CIMZIA STARTER KIT 2 PA
tri-sprintec 1 PV COSENTYX (300 MG
E PA
DOSE)
TWIRLA E
COSENTYX 150
VAGIFEM E E PA
MG/ML
vienva 1 PV COSENTYX
VIVELLE-DOT E ST SENSOREADY (300 E PA
YASMIN 28 E MG)
YAZ E COSENTYX
E PA
SENSOREADY PEN
Hormonal Agents -
Thyroid CUTAQUIG E PA
ARMOUR THYROID 3 ST cyclosporine modified
1
oral capsule
CYTOMEL E
ENBREL MINI 3 PA
euthyrox 1
ENBREL
LEVOTHYROXINE SUBCUTANEOUS
SODIUM ORAL E 3 PA
SOLUTION
CAPSULE PREFILLED SYRINGE
levothyroxine sodium ENBREL SURECLICK 3 PA
1
oral tablet
FIRAZYR 3 PA; QL
levoxyl 1
GAMMAGARD 3 PA
liothyronine sodium oral 1
HUMIRA 2 PA
methimazole oral 1
HUMIRA PEDIATRIC
np thyroid oral tablet 30 2 PA
1 CROHNS START
mg, 60 mg
HUMIRA PEN 2 PA
SYNTHROID E
HUMIRA PEN-
THYQUIDITY E 2 PA
CD/UC/HS STARTER
TIROSINT E HUMIRA PEN-
TIROSINT-SOL E PS/UV/ADOL HS 2 PA
Immunological START
Agents - Drugs for HUMIRA PEN-
Immune System PSOR/UVEIT 2 PA
Stimulation or STARTER
Suppression INFLECTRA 2 PA
ACTEMRA ACTPEN 3 PA leflunomide oral 1
ACTEMRA methotrexate oral 1
3 PA
SUBCUTANEOUS
methotrexate sodium
ASCENIV E PA 1
oral
AVSOLA 2 PA mycophenolate mofetil
1
azathioprine oral 1 oral capsule
30Drug Name Drug Tier Notes Drug Name Drug Tier Notes
mycophenolate mofetil hydrocortisone
1 1
oral tablet (perianal)
mycophenolate sodium 1 LIALDA E
OLUMIANT E PA mesalamine oral tablet
1
ORENCIA CLICKJECT 3 PA delayed release
ORENCIA ORTIKOS E
SUBCUTANEOUS PENTASA 3
SOLUTION 3 PA PROCTOFOAM HC 2
PREFILLED SYRINGE
125 MG/ML sulfasalazine oral tablet 1
OTEZLA 2 PA UCERIS ORAL E
PANZYGA E PA UCERIS RECTAL 3
RASUVO 2 PA; QL Metabolic Bone
Disease Agents -
REDITREX E PA; QL Drugs for
REMICADE E PA Osteoporosis
RENFLEXIS E PA alendronate sodium
1
RINVOQ 2 PA oral tablet 10 mg, 5 mg
SIMPONI 2 PA alendronate sodium
oral tablet 35 mg, 70 1 QL
SIMPONI ARIA 2 PA mg
SKYRIZI (150 MG BINOSTO 3 QL
2 PA; QL
DOSE)
FORTEO E PA
STELARA
2 PA ibandronate sodium
INTRAVENOUS 1 QL
oral
STELARA
2 PA; QL PROLIA 2 PA; QL
SUBCUTANEOUS
tacrolimus oral 1 RAYALDEE 3
TAKHZYRO 3 PA TERIPARATIDE
2 PA
(RECOMBINANT)
TALTZ 3 PA
TYMLOS 2 PA
TREMFYA 2 PA
XGEVA 2 PA
XELJANZ ORAL
3 PA Metabolic Bone
SOLUTION
Disease Agents -
XELJANZ ORAL Other
2 PA
TABLET
calcitriol oral capsule 1
XELJANZ XR 2 PA
SENSIPAR E PA
XEMBIFY 3 PA
Miscellaneous
Inflammatory Bowel Therapeutic Agents
Disease Agents
BOTOX 2 PA
APRISO 2
DOJOLVI E PA
ASACOL HD E
DUROLANE 2 PA
CANASA E
ENDARI 3 PA
DELZICOL E
EUFLEXXA 2 PA
DIPENTUM E
31Drug Name Drug Tier Notes Drug Name Drug Tier Notes
FIRDAPSE E PA moxifloxacin hcl (2x
1
GEL-ONE E PA day)
GELSYN-3 2 PA moxifloxacin hcl
1
ophthalmic solution
GENVISC 850 E PA
NEVANAC E QL
HYALGAN E PA
ofloxacin ophthalmic 1
HYMOVIS E PA
olopatadine hcl
MONOVISC E PA 1
ophthalmic
ORTHOVISC E PA PRED FORTE E
OXBRYTA E PA; QL prednisolone acetate
1
PALFORZIA E PA ophthalmic
PHEXXI E PA; QL PROLENSA 2 QL
SUPARTZ FX E PA VIGAMOX E
SYNVISC E PA ZERVIATE E
SYNVISC ONE E PA Ophthalmic Agents -
Drugs for Glaucoma
TRILURON E PA
TRIVISC E PA ALPHAGAN P
OPHTHALMIC 2
VILTEPSO E PA SOLUTION 0.1 %
VISCO-3 E PA ALPHAGAN P
Ophthalmic Agents - OPHTHALMIC E
Drugs for Eye Allergy, SOLUTION 0.15 %
Infection and AZOPT 3
Inflammation
BETIMOL 3
AZASITE 3
brimonidine tartrate
BEPREVE E ST 1
ophthalmic
BESIVANCE 3 COMBIGAN 2
BROMSITE E QL COSOPT E
ciprofloxacin hcl COSOPT PF E
1
ophthalmic
dorzolamide hcl-timolol
erythromycin 1
1 mal
ophthalmic
latanoprost ophthalmic 1
FLAREX 3
LUMIGAN 2 QL
ILEVRO E QL
RHOPRESSA 3 QL
INVELTYS 3
ROCKLATAN 3 QL
ketorolac tromethamine
1 SIMBRINZA 2
ophthalmic
LOTEMAX timolol maleate
1
OPHTHALMIC E ophthalmic solution
SUSPENSION timolol maleate pf 1
LOTEMAX SM 3 TIMOPTIC E
MOXEZA 2 TIMOPTIC OCUDOSE E
TIMOPTIC-XE E
32Drug Name Drug Tier Notes Drug Name Drug Tier Notes
VYZULTA E QL cetirizine hcl oral
1
XALATAN E solution
ZIOPTAN E QL CLARINEX E
Ophthalmic Agents - CLARINEX-D 12
E
Drugs for HOUR
Miscellaneous Eye cyproheptadine hcl oral
1
Conditions tablet
BEOVU E PA DYMISTA 2 QL
CEQUA E PA FASENRA 2 PA
LASTACAFT E ST FASENRA PEN 2 PA
LATISSE E fluticasone propionate
1
neomycin-polymyxin- nasal
dexameth ophthalmic ipratropium bromide
1 1
suspension 3.5-10000- nasal
0.1 levocetirizine
polymyxin b- dihydrochloride oral 1
1
trimethoprim tablet
RESTASIS 2 PA mometasone furoate
1 QL
RESTASIS nasal
2 PA
MULTIDOSE NASONEX E QL
TOBRADEX NUCALA 2 PA; QL
OPHTHALMIC E OMNARIS 3 QL
SUSPENSION
promethazine hcl oral
TOBRADEX ST 3 1
tablet
tobramycin- promethazine-dm 1
1
dexamethasone
pseudoephedrine-
XIIDRA 2 PA 1
bromphen-dm
Otic Agents - Drugs QNASL 3 QL
for Ear Conditions
QNASL CHILDRENS 3 QL
CIPRODEX E
XHANCE E QL
ciprofloxacin-
1 XOLAIR 2 PA
dexamethasone
neomycin-polymyxin-hc ZETONNA 3 QL
1
otic Respiratory Tract /
ofloxacin otic 1 Pulmonary Agents -
Drugs for Asthma and
Respiratory Tract / Other Lung
Pulmonary Agents - Conditions
Drugs for Allergies,
Cough, Cold ADVAIR DISKUS 2 QL
azelastine hcl nasal 1 QL ADVAIR HFA 2 QL
azelastine-fluticasone 1 QL AIRDUO DIGIHALER E QL
benzonatate 1 AIRDUO RESPICLICK
E QL
113/14
33Drug Name Drug Tier Notes Drug Name Drug Tier Notes
AIRDUO RESPICLICK BEVESPI
E QL E QL
232/14 AEROSPHERE
AIRDUO RESPICLICK BREO ELLIPTA 2 QL
E QL
55/14 BREZTRI
2 QL
albuterol sulfate hfa AEROSPHERE
aerosol solution 108 budesonide inhalation 1 QL
1 QL
(90 base) mcg/act
inhalation BUDESONIDE-
FORMOTEROL E QL
ALBUTEROL FUMARATE
SULFATE HFA
AEROSOL SOLUTION COMBIVENT
E QL 2 QL
108 (90 BASE) RESPIMAT
MCG/ACT DUAKLIR PRESSAIR E QL
INHALATION DULERA E QL
albuterol sulfate epinephrine injection
inhalation nebulization 1
solution auto-injector
solution (2.5 mg/3ml) 1 QL
0.083%, 0.63 mg/3ml, EPIPEN 2-PAK 3 ST
1.25 mg/3ml EPIPEN JR 2-PAK E
albuterol sulfate FLOVENT DISKUS 2 QL
inhalation nebulization FLOVENT HFA 2 QL
1
solution (5 mg/ml)
0.5%, 2.5 mg/0.5ml fluticasone-salmeterol
inhalation aerosol
ALVESCO E QL powder breath
ANORO ELLIPTA 2 QL activated 100-50 1 QL
ARMONAIR mcg/dose, 250-50
E QL mcg/dose, 500-50
DIGIHALER
mcg/dose
ARNUITY ELLIPTA 2 QL
INCRUSE ELLIPTA E QL
ASMANEX (120
E QL ipratropium-albuterol 1 QL
METERED DOSES)
ASMANEX (14 LEVALBUTEROL HFA
E QL INHALATION
METERED DOSES) E QL
AEROSOL 45
ASMANEX (30 MCG/ACT
E QL
METERED DOSES)
LONHALA MAGNAIR
ASMANEX (60 3 QL
E QL REFILL KIT
METERED DOSES)
LONHALA MAGNAIR
ASMANEX (7 3 QL
E QL STARTER KIT
METERED DOSES)
montelukast sodium
ASMANEX HFA E QL 1
oral tablet
ATROVENT HFA 3 QL montelukast sodium
1
AUVI-Q INJECTION oral tablet chewable
SOLUTION AUTO- PERFOROMIST 3 QL
INJECTOR 0.15 E
MG/0.15ML, 0.3 PROAIR DIGIHALER E QL
MG/0.3ML PROAIR HFA 2 QL
PROAIR RESPICLICK 2 QL
34Drug Name Drug Tier Notes Drug Name Drug Tier Notes
PROVENTIL HFA E QL Respiratory Tract /
PULMICORT Pulmonary Agents -
2 QL Drugs for Pulmonary
FLEXHALER
Hypertension
PULMICORT
E QL ADCIRCA E PA; QL
SUSPENSION
QVAR REDIHALER E QL ADEMPAS 2 PA; QL
SEEBRI NEOHALER E QL LETAIRIS E PA; QL
SEREVENT DISKUS 2 QL OPSUMIT 2 PA; QL
SINGULAIR E ORENITRAM 3 PA
SPIRIVA REMODULIN E PA
2 QL
HANDIHALER sildenafil citrate oral
1 PA; QL
SPIRIVA RESPIMAT 2 QL tablet 20 mg
STIOLTO RESPIMAT 2 QL TRACLEER 62.5 MG,
E PA; QL
125 MG
STRIVERDI
2 QL Skeletal Muscle
RESPIMAT
Relaxants - Drugs for
SYMBICORT 2 QL Muscle Pain and
SYMJEPI 3 Spasm
TRELEGY ELLIPTA 2 QL AMRIX E
TUDORZA PRESSAIR E QL baclofen oral 1
UTIBRON NEOHALER E QL carisoprodol oral 1
VENTOLIN HFA 2 QL cyclobenzaprine hcl
1
wixela inhub 1 QL oral tablet 10 mg, 5 mg
XOPENEX HFA E QL metaxalone 1
YUPELRI 3 QL methocarbamol oral 1
Respiratory Tract / NORGESIC FORTE E
Pulmonary Agents - ORPHENGESIC
E
Drugs for Cystic FORTE
Fibrosis OZOBAX E
BETHKIS E SKELAXIN E
CAYSTON E PA SOMA E
KITABIS PAK E tizanidine hcl oral tablet 1
PULMOZYME 2 PA VANADOM E
TOBI NEBULIZER E ZANAFLEX E
TOBI PODHALER 3 QL Sleep Disorder
TOBRAMYCIN Agents
NEBULIZATION AMBIEN E QL
E
SOLUTION 300
MG/5ML INHALATION AMBIEN CR E QL
TRIKAFTA 3 PA; QL armodafinil 1 PA; QL
BELSOMRA 3 ST; QL
DAYVIGO 3 ST; QL
eszopiclone 1 QL
35Drug Name Drug Tier Notes
LUNESTA E QL
modafinil 1 PA; QL
NUVIGIL E PA; QL
PROVIGIL E PA; QL
RESTORIL E QL
SILENOR 3 QL
SUNOSI 2 PA; QL
temazepam 1 QL
WAKIX 3 PA; QL
XYREM 3 PA; QL
zolpidem tartrate er 1 QL
zolpidem tartrate oral 1 QL
36Index of Drugs
ABILIFY.....................................13 AIRDUO DIGIHALER................33 APIDRA SOLOSTAR................ 23
ABILIFY MAINTENA................. 13 AIRDUO RESPICLICK 113/14..33 APIDRA VIAL............................23
ABSORICA LD..........................18 AIRDUO RESPICLICK 232/14..34 apri............................................ 28
ACANYA................................... 18 AIRDUO RESPICLICK 55/14....34 APRISO.................................... 31
ACCU-CHEK AVIVA DEVICE...21 AJOVY...................................... 12 ARAKODA................................ 13
ACCU-CHEK AVIVA PLUS AKLIEF......................................18 ARANESP (ALBUMIN FREE)... 14
KIT W/DEVICE..........................21 ALA SCALP.............................. 18 ARAZLO....................................18
ACCU-CHEK COMPACT albuterol sulfate.........................34 ARIMIDEX.................................12
PLUS CONTROL...................... 21 albuterol sulfate hfa...................34 aripiprazole............................... 13
ACCU-CHEK COMPACT ALBUTEROL SULFATE HFA... 34 ARISTADA................................ 13
PLUS TEST STRIPS................ 21 ALECENSA...............................12 ARISTADA INITIO.................... 13
ACCU-CHEK FASTCLIX alendronate sodium.................. 31 armodafinil................................ 35
LANCET KIT............................. 21 alfuzosin hcl er.......................... 27 ARMONAIR DIGIHALER.......... 34
ACCU-CHEK GUIDE ALKINDI SPRINKLE................. 27 ARMOUR THYROID.................30
CONTROL................................ 21 allopurinol..................................11 ARNUITY ELLIPTA...................34
ACCU-CHEK GUIDE KIT ALOGLIPTIN BENZOATE........ 20 ARTHROTEC..............................8
W/DEVICE................................ 21 ALOGLIPTIN-METFORMIN ASACOL HD............................. 31
ACCU-CHEK GUIDE TEST HCL...........................................20 ASCENIV.................................. 30
STRIPS..................................... 21 ALOGLIPTIN-PIOGLITAZONE. 20 ASMANEX (120 METERED
ACCU-CHEK SMARTVIEW ALPHAGAN P........................... 32 DOSES).................................... 34
CONTROL................................ 21 alprazolam................................ 14 ASMANEX (14 METERED
ACCU-CHEK SMARTVIEW ALTACE.................................... 15 DOSES).................................... 34
TEST STRIPS...........................21 ALUNBRIG................................12 ASMANEX (30 METERED
ACCU-CHEK SOFTCLIX ALVESCO................................. 34 DOSES).................................... 34
LANCET DEVICE KIT...............21 AMBIEN.................................... 35 ASMANEX (60 METERED
acetaminophen-codeine..............7 AMBIEN CR.............................. 35 DOSES).................................... 34
acetaminophen-codeine #2.........7 amiodarone hcl......................... 15 ASMANEX (7 METERED
acetaminophen-codeine #3.........7 AMITIZA....................................26 DOSES).................................... 34
acetaminophen-codeine #4.........7 amitriptyline hcl......................... 10 ASMANEX HFA........................ 34
ACIPHEX.................................. 25 amlodipine besylate.................. 15 ASPIRIN-OMEPRAZOLE......... 13
ACTEMRA................................ 30 amlodipine besylate-benazepril ASSURE PLATINUM................ 21
ACTEMRA ACTPEN.................30 hcl............................................. 15 ATACAND.................................15
ACTHAR................................... 28 amlodipine besylate-valsartan.. 15 atenolol..................................... 15
ACTICLATE................................ 8 amlodipine-olmesartan..............15 atenolol-chlorthalidone..............15
acyclovir.................................... 13 amoxicillin................................... 8 ATIVAN..................................... 14
ACZONE................................... 18 amoxicillin-potassium atomoxetine hcl.........................17
adapalene................................. 18 clavulanate..............................8, 9 atorvastatin calcium.................. 15
ADCIRCA..................................35 amphetamine- ATRIPLA................................... 13
ADDERALL............................... 17 dextroamphetamine.................. 17 ATROVENT HFA...................... 34
ADDERALL XR......................... 17 amphetamine- AUBAGIO..................................17
ADDYI....................................... 18 dextroamphetamine er.............. 17 aurovela fe 1/20........................ 28
ADEMPAS................................ 35 AMPYRA...................................17 AURYXIA.................................. 27
ADHANSIA XR..........................17 AMRIX.......................................35 AUSTEDO.................................18
ADIPEX-P................................. 18 AMZEEQ...................................18 AUVI-Q......................................34
ADLYXIN...................................20 anastrozole............................... 12 AVAPRO................................... 15
ADLYXIN STARTER PACK...... 20 ANDRODERM.......................... 27 AVEED......................................27
ADMELOG................................ 23 ANDROGEL..............................27 aviane....................................... 28
ADMELOG SOLOSTAR........... 23 ANDROGEL PUMP.................. 27 AVITA........................................18
ADVAIR DISKUS...................... 33 ANNOVERA..............................28 AVODART.................................27
ADVAIR HFA............................ 33 ANORO ELLIPTA..................... 34 AVONEX PEN...........................17
AFINITOR................................. 12 APADAZ......................................7 AVONEX PREFILLED.............. 17
AGAMATRIX PRESTO TEST...21 apap-caff-dihydrocodeine........... 7 AVSOLA....................................30
AIMOVIG...................................11 APEXICON E............................ 18 AZASITE................................... 32
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