Select Drug Program® Formulary

Effective October 1, 2023

[Link]
 INFORMATION FOR MEMBERS AND PROVIDERS

This Select Drug Program® Formulary is intended to help members and providers understand prescription
drug coverage under the Independence Blue Cross Select Drug Program Formulary. We are committed to
providing comprehensive prescription drug coverage. To achieve this, we include a formulary feature in your
prescription drug benefit. The drugs are approved by the U.S. Food and Drug Administration (FDA). They are
also reviewed by our Pharmacy and Therapeutics Committee, a group of doctors and pharmacists from the area.
These prescription drugs have been added to the Select Drug Program Formulary for their reported medical
effectiveness, safety, and value.
The pharmacy benefits manager monitors all drugs to ensure they are safe and effective.
Please note: Prescription drug benefits vary by group. Therefore, a drug on this formulary does not imply
coverage. Drug coverage is based on medical necessity. This formulary guide was current at the time of printing
and is subject to change. Please call Customer Service at the number listed on the back of your ID card if you
have any questions about your prescription drug benefits. Please discuss any questions or concerns about your
drug therapy with your provider or pharmacist.

What is a formulary?
A formulary is a list of prescribed medications or other pharmacy care products, services or supplies chosen
for their safety, cost, and effectiveness. Medications are listed by categories or classes and are placed into cost
levels known as tiers. It includes both brand and generic prescription medications.
This list is guided by the Pharmacy and Therapeutics Committee. The committee reviews which medications
will be covered, how well the drugs work, and overall value. They also make sure there are safe and covered
options.

What are tiers?

Tiers are the different cost levels you pay for a medication. Each drug on the formulary is in a tier.

Select Formulary Tier Structure

Below is a summary of tiers in the general order from lowest to highest level of cost-share. Benefits vary by
group, so the inclusion of a drug in this formulary does not guarantee coverage. All cost-share tiers may not be
available on all plans.
- Low-Cost Generic (availability varies by benefit)
- Generic
- Preferred Brand
- Non-preferred Drug
- Specialty (availability varies by benefit)

• G enerally, if a brand-name drug has a generic equivalent, the brand-name drug is non-preferred while
the generic equivalent is covered at the generic level of cost-sharing.
For example: Cipro® is the brand drug and is considered non-preferred; its generic equivalent
ciprofloxacin is available at the generic level of cost-sharing.
• Some brand-name drugs without generic equivalents and generic drugs are also considered
non-preferred. This is because there are other more cost-effective alternatives covered on the
formulary to treat the same condition.
Covered generic drugs not listed in the formulary guide are available at the generic level of cost-sharing;
covered brand drugs not listed in the formulary guide are available at the non-preferred level of cost-sharing.

(continued)
1
The Low-Cost Generic [LCG] Tier offers copays lower than the cost-share for the generic tier, when possible.
This applies to certain generic drugs that are typically used to treat chronic conditions such as high blood
pressure, high cholesterol, diabetes, heart failure, and depression. Benefits may vary. Not all plans provide this
incentive. The drug list is subject to change. When this incentive is not available on a plan, these drugs will be
covered at the generic cost-share level.

Specialty Drugs [SP] meet certain criteria, including, but not limited to drugs used to treat rare, complex,
or chronic diseases, drugs that have complex storage and/or shipping requirements, and drugs that require
comprehensive patient monitoring and/or education. Specialty drugs covered under the pharmacy benefit may
be managed by your pharmacy benefit managers Specialty Pharmacy Program. Benefits may vary, and many
plans cover specialty drugs on a specialty tier with higher cost-sharing. For cost-sharing purposes, drugs on the
specialty tier are not eligible for tier lowering.

What are Affordable Care Act (ACA) Preventive Medications?

Certain preventive medications, as described in the Patient Protection and Affordable Care Act and detailed by
the U.S. Preventive Services Task Force, are covered without cost-sharing with a prescription when provided by
a participating retail or mail-order pharmacy.
The following categories of drugs may be available at no member cost-share with a prescription. Please note
that individual benefits may vary. Always refer to your benefits to determine your coverage. This list is subject
to change. Refer to the searchable drug lookup tool on your health insurance plan’s website to check the status
of a specific drug.

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2
 Category Product(s) Available at $0 at the Pharmacy
Aspirin products (OTC) aspirin 81mg (tab/chewable)
For women after 12 weeks’ gestation who are at high
risk for preeclampsia
Bowel Preparations generic bowel preparation products such as
Bowel preparation for colonoscopy needed for Gavilyte-C™, Gavilyte-G™, Gavilyte-N™,
preventive colon cancer screening, for ages 45-75 Gavilyte-H™ with bisacodyl,
polyethylene glycol (PEG) 3350 oral powder,
Trilyte® w/packets
Breast cancer chemo prevention tamoxifen 20mg
For asymptomatic females age 35 years and older
without a prior diagnosis of breast cancer, ductal
carcinoma in situ, or lobular carcinoma in situ, who
are at high risk for breast cancer and at low risk for
adverse effects from breast cancer chemoprevention
Contraceptives - Oral: some generics such as Amethia, Cryselle-28,
Includes, but not limited to, oral, injectable, Emoquette, Fayosim, Necon, Ocella, Sprintec,
transdermal, diaphragms, cervical caps, intravaginal Trivora
devices, condoms, and contraceptive film and jelly - Injectable: all generics such as
(in accordance with the women’s preventive services medroxyprogesterone injection
provisions of the ACA). - Transdermal: Xulane® patches
Note: IUDs and implantable products are covered - Diaphragms
under the medical benefit. - Cervical Caps
- Condoms
- Contraceptive film
- Contraceptive gel/jelly/foam: such as VCF® foam
12.5%, 28%, Options Conceptrol® 4%, Options
Gynol® 3%, Phexxi®
- Emergency: all generics such as levonorgestrel
1.5mg tab, My Way® 1.5mg tab
- Intravaginal devices: etonogestrel-ethinyl estradiol
vaginal ring
Fluoride sodium fluoride 1.1 (0.5f) mg/ml solution
For children ages 6 months to 16 years. Includes sodium fluoride 0.55 (0.25f) mg chewable tab
generics strengths up to 0.5mg Fluoritab 0.275 (0.125f) mg/drop solution
Fluoritab 1.1 (0.5f) mg chewable tab
Folic acid folic acid 400mcg tab
For women planning for or capable of folic acid 800mcg tab
pregnancy. Limited to 0.4 to 0.8mg of folic acid. folic acid 0.8mg capsule
For women younger than 51 years of age (including generic prenatal vitamins with
the above listed folic acid dose)

3 (continued)
 Category Product(s) Available at $0 at the Pharmacy
Tobacco Cessation Medication varenicline tab
For adults ages 18+ years, who use tobacco products bupropion SR (generic Zyban®) tablet
and want to quit nicotine polacrilex lozenge
nicotine patch 24 hour transdermal
Nicotrol® Inhaler
Nicotrol® NS Solution
Statins lovastatin 10mg
Low-to-moderate dose statin for prevention of lovastatin 20mg
cardiovascular disease, recommended for ages 40-75 lovastatin 40mg
years without a history of CVD when 1 or more CVD
risk factors are present (e.g., dyslipidemia, diabetes,
hypertension, or smoking) and a calculated 10-year
risk of a cardiovascular event of 10% or greater
HIV PrEP Emtricitabine-Tenofovir Disoproxil Fumarate Tab
Preexposure prophylaxis (PrEP) with effective anti- 200-300mg
retroviral therapy for persons who are at high risk of Tenofovir 300mg
HIV acquisition
Vaccines - Influenza: Afluria®, Fluzone [Quad]®, Fluzone®,
To prevent certain illnesses in infants, children, and Fluarix®, Flumist®, Flublok®, Fluad®, Flucelvax®,
adults. Include immunizations to prevent Influenza, Flulaval®
Pneumococcal, and Shingles - Pneumococcal: Prevnar 13®, Pneumovax 23®,
Prevnar 20™**, Vaxneuvance®
- Shingles: Shingrix®*

*Note: Applies to members at least 19 years of age.

Cost share applies for members 18 years of age.

**Note: Applies to members at least 19 years of age.

Cost share applies for members under 19 years of
age.

4 (continued)
 PROCEDURES THAT SUPPORT SAFE PRESCRIBING
Independence Blue Cross utilizes an independent pharmacy benefits management (PBM) company, to
manage the administration of its prescription drug programs. As our PBM, they are responsible for
providing a network of participating pharmacies, administering pharmacy benefits, and providing customer
service to our members and their providers. The effectiveness and safety of drugs and drug-prescribing
patterns are monitored by the Pharmacy benefit manager. Several procedures, such as prior authorization, age
limits, and quantity limits, have been established to support safe prescribing patterns and to provide optimal
clinical outcomes for members.
What is prior authorization?
Prior authorization is a requirement that your provider obtain approval from your health plan for coverage of,
or payment for, prescription drugs. Independence Blue Cross requires prior authorization of certain covered
drugs to confirm that the drug prescribed is medically necessary, clinically appropriate, and is being prescribed
according to FDA approved labeled or medically accepted use. The approval criteria were developed and
approved by the Pharmacy and Therapeutics Committee, a group of physicians and pharmacists from the
area. Using these approved criteria, clinical pharmacists evaluate requests for these drugs based on clinical
data, information submitted by the member’s provider, and the member’s available prescription drug therapy
history. The clinical pharmacists’ evaluation may include a review of potential drug-drug interactions or
contraindications, appropriate dosing and length of therapy, and utilization of other drug therapies, if necessary.
Please note, coverage of certain drugs on the formulary (e.g., weight loss drugs) requires a benefit rider. Please
contact the health insurance plan for member eligibility information and benefit details.
Claim dollar limits are placed to require review for clinical appropriateness on prescription claims exceeding a
defined dollar limit threshold. The member’s provider will need to submit a prior authorization request to any
claim exceeding $10,000.
Without prior authorization, the member’s prescription will not be covered at the retail or mail-
order pharmacy. The prior authorization review process may take up to two business days once complete
information from the provider has been received. Incomplete information may result in a delayed decision.
Prior authorization approvals for some drugs may have a limited timeframe, for example six to twelve months.
If the prior authorization approval for a drug is limited to a certain time frame, an expiration date will be given
at the time the approval is made. If the provider wants a member to continue the drug therapy as requested after
the expiration date, a new prior authorization request will need to be submitted and approved for coverage to
continue.
Safety Edits
Safety edits are applied to prescription medications to ensure safe and appropriate use of drugs. They are
designed to align with the clinical practice guideline and FDA approved use outlined in the manufacturer
package insert. Some of these safety edits will prompt member counseling at the point of sale, while some
will require prior authorization review. Safety edits include age limits, quantity limits, morphine milligram
equivalent (MME) limits, and concurrent drug utilization review (cDUR). Each safety edit is described below.
Age Limits
Some drugs, such as zafirlukast, are approved by the FDA only for individuals age five and older. If the
member’s prescription falls outside of the FDA guidelines, it may not be covered unless prior authorization is
obtained. In addition, an age limit may be applied when certain drugs are more likely to be used in certain age
groups. For example, drugs to treat Alzheimer’s disease may require prior authorization for use in young adults.
The provider may request coverage for drugs outside of the age limit when medically necessary. The approval
criteria for this review were developed and approved by the Pharmacy and Therapeutics Committee. The
member should contact the provider to initiate the prior authorization process.

5 (continued)
Quantity Limits
Quantity limits are designed to allow a sufficient supply of medication based upon FDA-approved maximum
daily doses, standard dosing, and/or length of therapy of a drug. Independence Blue Cross has several different
types of quantity limits that are explained in detail below. The purpose of these limits is to ensure safe and
appropriate utilization. If a member requires more than the limit, the member’s provider will need to submit
a prior authorization request. Similar to other prior authorization requests, quantity limit override requests for
certain drugs may have a limited approval timeframe.
• Quantity Over Time: This quantity limit is based on dosing guidelines over a rolling time period. For
example, if a drug has a quantity limit over a 30-day time period and a member went to the pharmacy on
January 1, 2023, for one of these medications, the plan would have looked back 30 days to December 2, 2022,
to see how much medication was dispensed. The purpose of these limits is to prevent the dispensing of
excessive quantities. Examples of quantity limits over time are:
◦ Etonogestrel-ethinyl estradiol (Nuvaring®) = 1 ring per 28 days
◦ Ibandronate (Boniva®) 150mg = 1 tablet per 30 days
◦ Sumatriptan (Imitrex®) 50mg = 18 tablets per 30 days
◦D
 iabetic supplies such as blood glucose test strips = 200 strips per 30 days
◦ Sildenafil (Viagra®), tadalafil (Cialis® 10mg, 20mg) = 8 tablets per 30 days
• Maximum daily dose: This quantity limit defines the maximum number of units of the drug allowed per
day. Examples of maximum daily dose quantity limits are:
◦ Zolpidem (Ambien®) = 1 tablet per day
◦ Oxycodone/acetaminophen (Percocet®) 5/325mg = 12 tablets per day
◦ Guanfacine Extended Release 24 Hour = 1 tablet per day
• Refill too soon: This limit is in place to encourage appropriate utilization and minimize stockpiling of
prescription medications. Based on this edit, a member can receive a refill of a prescription after 75%
utilization. Additional refills will be covered once 75% of the supply has been consumed. The following
examples illustrate how refill too soon limit works:
◦ A 30 days’ supply of a prescription filled on 1/1/2023 will be refillable again on or after 1/24/2023
◦ A 90 days’ supply of a prescription filled on 7/1/2023 will be refillable again on or after 9/7/2023
• Day Supply Limit: This limit is based on the day supply and not the quantity. However, quantity limits
may apply as well. Day Supply Limits apply to some classes of drugs, such as opioids. If a quantity limit
applies, the member will also be limited to the maximum daily dose for that drug. The following are
examples of drugs that have a day supply and a quantity limit:
◦ Short acting opioids, such as oxycodone/acetaminophen 5mg/325mg
•D
 ay supply limit = Two 5 days’ supplies limit per 60 days for adults, two 3 days’ supply limit
for children under 18 years of age.

◦ Butalbital containing headache agents, such as butalbital/aspirin

• Day supply limit = 5-day supply per 30 days
• Quantity Limit = 6 tablets per 1 day
•M aximum quantity allowed without prior authorization = 30 tablets (6 tablets per day for 5
days)

6 (continued)
 ◦ Opioid containing cough and cold products, such as hydrocodone/homatropine
•D  ay supply limit = Two 5-days’ supplies limit per 60 days for adults, and two 3 days’ supply
limit for children under 18 years of age
• Quantity Limit = 30ml per 1 day
• Maximum quantity allowed without prior authorization = 150ml (30ml per day for 5 days)

Morphine Milligram Equivalent (MME) Limit

Independence Blue Cross applies additional safety measures to opioid products by limiting the total daily
dose. This limit accounts for various opioid products through a measurement called the Morphine Milligram
Equivalent (MME) dose. The MME is a number that is used to determine and compare the potency of opioid
medications. It helps to identify when additional caution is needed. The daily limit is calculated based on the
number of opioid drugs, their potencies and the total daily usage. Prior authorization is required for an opioid
dose that exceeds 90 MME per day. MME Limit applies to the opioid products containing the active ingredients
listed below:

Active Ingredient
codeine dihydrocodeine fentanyl hydrocodone
hydromorphone levorphanol meperidine methadone
morphine Opium oxycodone oxymorphone
tapentadol Tramadol benzhydrocodone

Cumulative Stimulant Limit

Central nervous system (CNS) stimulants such as amphetamine and methylphenidate, when used in high
doses, are associated with increased risk for cardiac related adverse events such as hypertension and new or
worsening psychosis including manic behavior. Cumulative stimulant limit is a safety measure designed to
ensure the provider has assessed the members for alternative medication and advised the members about the
risks associated with stimulant use. The cumulative stimulant limit works by calculating the total daily stimulant
dose by the drug’s active ingredient. Stimulant claims that exceed the limit outlined below would require prior
authorization.

Active ingredient Medications impacted High cumulative daily dose

(brands and generics)
Amphetamine Adzenys ER[ODT], Dyanavel, 60mg/day
Evekeo [ODT]
Amphetamine-Dextroamphetamine Adderall [IR/XR], Mydayis 60mg/day
Dextroamphetamine Dexedrine, Zenzedi, ProCentra 60mg/day
Lisdexamfetamine Vyvanse 70mg/day
Methamphetamine Desoxyn 60mg/day
Dexmethylphenidate Focalin [IR/XR] 40mg/day
Methylphenidate Ritalin [IR/LA], Daytrana, 72mg/day
Cotempla, Metadate [ER/CD],
Methylin, Quillivant XR, Concerta,
Aptensio XR, QuilliChew ER,
Jornay PM, Adhansia XR
Serdexmethylphenidate Azstarys™ 52.3mg/day
*Prior authorization and other safety edits including quantity limit and age limit continue to apply.

7 (continued)
Concurrent Drug Utilization Review (cDUR)
These reviews are built into the pharmacy claim adjudication system to review a member’s prescription history
for possible drug related problems including drug-drug interactions and drug therapy duplications. Drugs
may reject at the Point-of-Sale (POS) and/or generate a message to the dispensing pharmacist when there is a
safety concern. The dispensing pharmacist can review the issue with the provider and override the rejection if
appropriate for most edits. Examples of cDURs are:
• Drug-drug interaction: sildenafil (Viagra®/Revatio®) and nitroglycerin in combination may lead to
potentially fatal hypotension.
• Drug therapy duplication: Simvastatin and atorvastatin in combination will trigger a message in the
claim adjudication system to alert the dispensing pharmacist there is a duplication of statin therapy.
To determine if a covered prescription drug prescribed for you has a prior authorization requirement, an age
limit, a quantity limit, or a morphine milligram equivalent (MME) limit, see the plan website at [Link]
[Link]/resources/for-providers/policies-and-guidelines/pharmacy-information or call your pharmacy benefit
manager at the phone number on the back of your ID card.

How to submit a Prior Authorization?

Here is the process to request a prior authorization/preapproval or override:
1. The provider prescribing the drug can access electronic prior authorization (ePA) platforms such as
CoverMyMeds® and SureScripts™ to submit a prior authorization request. Alternatively, the provider
can complete a prior authorization fax form or write a letter of medical necessity and submit it to your
pharmacy benefit manager by fax at 1-888-671-5285. The forms are available online at: [Link]
com/resources/for-providers/policies-and-guidelines/pharmacy-information.
2. The pharmacy benefit manager will review the prior authorization request or letter of medical necessity.
If a clinical pharmacist cannot approve the request based on established criteria, a medical director will
review the document.
3. A decision is made regarding the request.
• If approved, the provider will be notified of the approval via fax and/or telephone, and the pharmacy
claim adjudication system will be coded with the approval. Note: ePA approval can occur in real
time, this means the member can be approved for the drug prior to leaving the provider’s office with
a prescription. The member may call the Customer Service phone number on his or her ID card to
determine if the request is approved.
• If denied, the prescribing provider will be notified via letter, fax, or telephone. The member is also
notified via letter. The appeals process is detailed within the denial letters sent to the member and
provider.

8 (continued)
Formulary Exception Requests
Tier exceptions: Providers may request consideration for preferred coverage of a non-preferred drug when
there has been a trial of, or contraindication to, at least three formulary alternatives when applicable.
• Requests for a generic medication that is located on the non-preferred drug tier to be lowered to the
generic tier will be approved if the exception criteria are met.
• Requests for a brand medication that is located on the non-preferred drug tier to be lowered to the
preferred brand tier will be approved if the exception criteria are met.
Please note, restrictions apply to formulary exception requests. Drugs on the generic tier, the preferred brand
tier and the specialty tier are not eligible for tier exceptions. Tier exceptions are not available under some plans;
please refer to the member benefit booklet for details.
When requesting an exception, the provider should complete the formulary exception request form, providing
detail to support the request, and fax the request to 1-888-671-5285. If the formulary exception request is
approved for a non-preferred drug, the drug will pay at the appropriate preferred brand or generic level of
cost-sharing. If the request is denied, the member and provider will receive a denial letter with the appropriate
appeals language.
Appealing a decision
If a request for prior authorization or exception results in a denial, the member, or the provider on the member’s
behalf (with the member’s consent), may file an appeal. Both the member and his or her provider will receive
written notification of a denial, which will include the appropriate telephone number and address to direct
an appeal. To assist in the appeals process, it is recommended that the provider be involved to provide any
additional information on the basis of the appeal.

9 (continued)
Prior authorization applies to all formulations of the following specific drugs, including but not limited to,
tablet, capsule, and oral suspensions.*+

Abilify® Altabax™ Avita® butalbital-acetaminophen

Abilify Mycite® Altace® Avodart® 50-300mg
Maintenance/Starter Altuviiio™
Altuviiio™ Axert® Buphenyl®
Pak Alunbrig™ Axiron® buprenorphine patch
abiraterone Alvesco® Ayvakit™ Bupropion ER 450mg
Absorica™ Amaryl® azelastine/fluticasone Butrans®
Absorica LD™ Ambien® spray Bydureon BCise®
Abstral® Ambien CR® Azelex® Byetta®
Acanya® Amerge® Azor® Bylvay™
Bylvay ™
Accrufer® Amitiza® Azstarys™ Bynfezia Pen™
Accupril® Amjevita™
Amjevita ™ Azulfidine® Byvalson™
Aciphex® amphetamine ER susp Baclofen 5mg/5ml soln Cabometyx™
Actemra® SC amphetamine Banzel® Caduet®
Acticlate™ (generic Evekeo) Basaglar® Calcipotriene foam
Actimmune® Ampyra™ Bebulin® Calquence®
Actiq® Amrix® Beconase AQ® Cambia®
Actonel® Amzeeq™ Belbuca™ Camzyos™
Camzyos ™
Actos® Anaprox® DS Belsomra® Canasa Supp
®

Aczone® Anafranil™
Anafranil ™ Belviq® [XR] Capex®
adapalene pad Androderm® BeneFIX® Caplyta™
Adbry™
Adbry ™ Inj Androgel® Benicar® Caprelsa®
Adcirca™ Angeliq® Benicar HCT® Carac®
Adderall® Anusol-HC® Cream Benlysta® Carafate® Tab/Susp
Addyi® Apidra® Benzaclin® Carbaglu®
Adempas® Apidra® SoloSTAR® Benzamycin® Carbatrol®
Adhansia™ ™ XR Aplenzin™ Benzamycinpak® Cardizem®
Adipex-P® Apokyn® benzphetamine Cardizem® CD
Adlarity® apomorphine inj Bepreve® Cardizem® LA
Adlyxin™ Aptensio XR® Berinert® Cardura® [XL]
Admelog® Aptiom® Besremi® carglumic
Advate® Arava® Bethkis® Neb CaroSpir®
Adynovate® Arazlo™
Arazlo ™ lotion Betoptic-S® Cataflam®
Adzenys™ XR-ODT Aricept® Bevespi Aerosphere™ Caverject®
Aerospan™ Arikayce® bexarotene Cayston™
Afinitor® Arimidex® Binosto® Celebrex®
Afrezza® ArmonAir™
ArmonAir ™ Boniva® Celexa®
Afstyla® Digihaler® Bonjesta® Cequa™
Cequa ™
AirDuo® Digihaler® ArmonAir™ bosentan Cerdelga™
AirDuo® RespiClick® RespiClick® Bosulif® Cholbam®
Ajovy® Arthrotec® Brand prenatal vitamins1 Cialis®
Aklief® Arymo™ ER Bravelle® Cibinqo™
Cibinqo ™
Aktipak™ Asacol®HD Breeze®2 test strips/ Ciclodan®
Ala-Scalp® Asmanex® glucometer Cimzia®
Alecensa® Asmanex® HFA Brexafemme® Cinryze®
Alkindi® Sprinkle Atacand® (HCT) Briviact® Citalopram 30mg Cap
Allopurinol 200mg Tab Ativan® BromSite® Clarinex®
Alocril® Atorvaliq® Bronchitol® Clarinex-D®
Alora® Atralin® Brukinsa™ clemastine syrup
Alphanate® Austedo™ Budesonide-formoterol Cleocin®
Alphanine® SD Auvelity™
Auvelity ™ Butal/Apap Tab Cleocin T®
Alprolix™ Auvi-Q® 0.15mg, 0.3mg 25-325mg Clindagel®
Alrex® Avapro®/Avalide®
(continued)
10
clindamycin/benzoyl Dexilant™ Elmiron® Fasenra®
peroxide 1%/5% dexlansoprazole Eloctate™ febuxostat
clobazam dexlansoprazole DR Elyxyb™
Elyxyb ™ Feiba®
Clobex® D.H.E.® 45 Embeda® Felbatol®
Cloderm® Dhivy® Emflaza™ Femring®
clonidine ER 24HR tab Diabetic test strips2 Emgality® fentanyl citrate-OTFC
clovique Dibenzyline® Empaveli™ Inj Fentanyl citrate tablet
Coagadex® dichlorphenate tab Enbrel® fentanyl transdermal
Colazal® Diclegis® Endari™ Fentora®
Colcrys® diclofenac cap 25mg Enspryng™
Enspryng ™ Ferriprox®
Colestid® Diclofenac cap 35mg Entadfi™
Entadfi ™ Fetzima™
Cometriq™ diclofenac gel 3% Entocort® EC Fiasp®
Comtempla XR ODT™ diclofenac soln 2% Entresto™ Filspari™
Filspari ™
Concerta® diethylpropion HCL Epclusa® Fintepla®
Conjupri® Differin® Epidiolex® Fioricet® Cap
Contrave ER® Diflucan® susp/tab EpiPen® Fioricet® with Codeine
Conzip™ dihydroergotamine EpiPen® Jr. Fiorinal® with Codeine
Cordran® Dilaudid® Eprontia™
Eprontia ™ Firazyr®
Coreg® Diovan® (HCT) Epsolay® Flector® patch
Coreg® CR Ditropan XL® Erivedge™ Fleqsuvy™
Fleqsuvy ™ Susp
Corifact® Dojolvi™ Erleada® Flomax ®

Corlanor® Dolophine® erlotinib Fluticasone HFA AER

Cosentyx™ Doral® Ermeza™
Ermeza ™ Fluticasone/Salmeterol
Cotellic™ Doryx® DR Ertaczo® AER
Cozaar®/Hyzaar® Doryx® MPC Esbriet® Flutic/Vilan INH
Cresemba® doxepin tablet Esgic® cap/tab Focalin® XR
Crestor® doxycycline DR 40 mg esomeprazole ForFivo XL®
Crinone® Gel 8% Doxycycline Hyclate DR esomeprazole granules Fortamet®
Cuprimine® 80mg Esperoct® Forteo™
Cutivate® Doxycycline Hyclate Tab Estrace® Cream Fortesta™
cyclobenzaprine ER 50mg eszopiclone 3mg Fotivda®
Cystadrops® doxylamine-pyridoxine Eucrisa™ FreeStyle Libre Reader,
Cystaran™ Drizalma Sprinkle™
Sprinkle™ Eulexin® Sensor, Reader Device
Daklinza™ droxidopa Evekeo™ FreeStyle test strips/
Dartisla ODT™
ODT™ Duac® everolimus glucometer
Daybue™
Daybue ™ Duaklir® (generic for Afinitor) Frova®
Daypro® Duetact® Evista® Fulyzaq™
Daytrana™ Dulera® Evoclin® foam Fuzeon®
Dayvigo™
Dayvigo ™ Duobrii™
Duobrii ™ Evoxac® Gattex®
DDAVP® Dupixent® Evrysdi™
Evrysdi ™ Gavreto®
deferasirox tab/granules Duragesic® Evzio™ Gelnique®
deferiprone tab Durlaza® Exalgo™ Gemtesa®
Degludec Flextouch Duzallo® Exelderm® Genotropin®
Delatestryl® Dyanavel XR™ Exforge® (HCT) Geodon®
Delzicol® Dymista® Exjade® Gilotrif™
Demerol® EC-Naprosyn® Exkivity™
Exkivity ™ Gimoti™
Gimoti ™
Desonate® Ecoza™ Extavia® Gleevec®
Desowen® Edarbi™ Extina® Gloperba®
Desoxyn® Edarbyclor™ Ezetimibe/Atorvastatin Glucagen® Hypokit®
Detrol® Edex® Ezetimibe/Rosuvastatin Glucagon Emergency Kit
Detrol® LA Edluar™ Ezzalor™ Sprinkle Cap (Lilly)
dexchlorpheniramine soln Effexor XR® Fabior® Glucotrol® XL
Dexcom® Receiver, Effient® Factive® Gocovri®
Sensor, Transmitter Elepsia™ XR Fanapt™
Fanapt ™ Golytely®
Dexedrine® Elidel® Farydak® Gonal-f®
(continued)
11
Gralise™ insulin lispro inj protamin Lastacaft® Menopur®
Grastek® Intermezzo® Lazanda® Mestinon®
Gvoke™ HypoPen® Intrarosa® ledipasvir-sofosbuvir metaxolone tab
Gvoke™ PFS Inj Intuniv™ lenalidomide Metformin 625mg
Haegarda® Invega™ Lenvima™ methadone
Halcion® Invokamet® [XR] Lescol® XL Methadose™
Methadose ™ concentrate
Halog® Invokana® Letairis® [SF]
Harvoni™ Iressa® Levamlodipine Methitest™
Helixate® FS Isturisa® Levemir® methylphenidate ER (XR)
Hemlibra® Soln Ixinity® Levitra® methyltestosterone
Hemmorex-HC® Supp Jadenu™
Jadenu ™ tab/granules levothyroxine cap Micardis® (HCT)
Hemofil® M Jakafi™ Lexapro® Miconazole-zinc oint
Hetlioz™ Jalyn™
Jalyn ™ Lexette® miglustat
Horizant™ Jatenzo® Librax® Migranal®
Humalog® Javygtor™
Javygtor ™ Licart™
Licart™ Millipred®
Humate-P® Jaypirca™
Jaypirca ™ Lidoderm® Minivelle®
Humatrope® Jentadueto™ Lipitor® Minocin®
Humira® Jornay™ PM Livalo® minocycline ER cap
Humulin® Jublia® Livmarli® Mitigare®
Hycamtin® Juxtapid™ Livtencity™ Mobic®
hydrocodone ER Jynarque® Locoid® mometasone furoate
hydromorphone ER Kadian® Locoid® lipocream Monoclate-P®
Hyftor™
Hyftor ™ Kalydeco™ Lomaira™ Monodox®
Hysingla™ Kapvay® Lonhala™ Magnair™ Mononine®
Ibrance® Katerzia™
Katerzia ™ Lonsurf® Monurol®
Ibsrela® Kazano® Loprox® MorphaBond™ ER
Ibudone® Kenalog™ Lorbrena® morphine ER
icatibant inj Keppra® Loreev XR™
XR™ Motegrity™
Iclusig™ Kerendia® Lortab ®
Mounjaro®
Idelvion® Kerydin™ Lorzone® Movantik®
Idhifa® ketoprofen cap Lotrel® MoviPrep®
imatinib mesylate Ketorolac Tromethamine Lotronex® MS Contin®
Imbruvica™ Keveyis™ Lovaza® Muse®
Imcivree™
Imcivree ™ Kevzara® Lucemyra™ Myalept™
imiquimod cream/pump Khedezla® Luliconazole Mycapssa®
Imitrex® Kineret® Lumakras™ Mydayis™
Impeklo™
Impeklo ™ Kisqali™ Lunesta® Myfembree®
Impoyz™
Impoyz ™ Kitabis® Pak Neb Lupkynis™
Lupkynis ™ Mysoline™
Inbrija® Klisyri® Luxiq® Mytesi™
Increlex® Klonopin® Luzu® Nalfon®
Incruse® Ellipta® Koate®-DVI Lybalvi® Nalocet®
Inderal® LA Kogenate® FS LymePak™ Naprelan®
indomethacin 20mg Konvomep™
Konvomep ™ Lynparza™ Naprosyn®
Ingrezza™ Korlym™ Lyrica® Cap naproxen sodium ER
Inlyta® Koselugo™
Koselugo ™ Lyrica® CR 750mg
Innopran® XL Krazati® Lyrica® Soln Nascobal®
Inqovi® Kristalose® Pak Lytgobi® Nasonex®
Inrebic® Kuvan® Lyumjev™ Natesto™
Inspra® Kynamro® Lyvispah™
Lyvispah ™ Natpara®
insulin aspart Kynmobi™ Mis/Kit Mavenclad® Nayzilam®
insulin aspart protamin Kyzatrex™
Kyzatrex ™ Mavyret™ Nerlynx™
Insulin Degludec Lactulose Pak Maxalt® (MLT) Nesina®
insulin glargine Lamictal® (ODT) Mekinist® Nestabs® One
insulin lispro Lansoprazole Solutab meloxicam cap Neupro®
insulin lispro inj junior lapatinib Meloxicam susp Neurontin®
(continued)
12
Nexavar® Opsumit® Picato® Rapaflo®
Nexiclon™
Nexiclon ™ XR Opzelura™ Piqray® Rasuvo™
Nexium® Oracea® pirfenidone Ravicti™
Nexletol™
Nexletol ™ Oralair® Plaquenil® Rayaldee®
Nexlizet™
Nexlizet ™ Orencia® SQ Plavix® Rayos®
Niaspan® ER Orenitram™ Plenvu® Rebif® Rebidose®
Ninlaro® Orfadin® Pogo Automatic® Rebinyn®
nitisinone Orgovyx™
Orgovyx ™ Mis Monitor Recombinate™
Nityr® Oriahnn ®
Pogo Automatic® Recorlev®
Noctiva™ Orilissa® Test Cartridge RediTrex®
Non Preferred Diabetic Orkambi™ Pomalyst® Regimex®
Meters Orladeyo™
Orladeyo ™ Ponvory™
Ponvory ™ Regranex®
Norco® orlistat cap Pradaxa Pak
®
Relafen™
Relafen ™
Norditropin® orphenadrine-asa-caffeine Praluent® Relafen™
Relafen ™DS
Norgesic™
Norgesic ™ Orphengesic® Forte Pramosone® Relexxii®
Norgesic™
Norgesic ™ Forte Orserdu™
Orserdu ™ Precision Glucometer ReliOn®
Norliqva ®
Ortikos™ Precision XTRA® Relistor®
Northera™ Oseni® Test Strips Relpax®
Norvasc® Osmoprep® Pred Forte® Reltone™
Reltone ™
Nourianz™
Nourianz ™ Otezla™ pregabalin ER tab Relyvrio™
Relyvrio ™ Pak
Novoeight® Otrexup™ Pretomanid® Repatha™
Novolin® Relion Oxaydo® Prevacid® Rescula®
Novolog® Relion Oxbryta™
Oxbryta ™ Prilosec® Restoril®
Novoseven® RT oxiconazole nitrate Primlev™™ Retevmo™
Noxafil® Oxistat® Pristiq™ Retin-A® (Micro)
Nubeqa™
Nubeqa ™ Oxtellar® XR ProAir®Digihaler™ Revatio™
Nucala® Soln Oxybutynin Sol Proctocort® Supp 30mg Revlimid®
Nucynta® oxycodone/ Procysbi® Reyvow™
Nucynta ER® acetaminophen Profilnine® Rezlidhia™
Nuedexta™ oxycodone/APAP tab Prolate™
Prolate™ Rezurock™
Nulibry™
Nulibry ™ oxycodone ER Promacta® Rezvoglar™
Nulytely® Oxycontin® Protonix® Riastap®
Nuplazid™ oxymorphone ER Protopic® Rinvoq™
Nurtec™
Nurtec ™ chw ODT Oxytrol® Patch Proventil® HFA Risperdal®
Nutropin® (AQ) Ozempic® Provigil® Ritalin® LA
Nuvessa™
Nuvessa ™ Ozobax™
Ozobax ™ Prozac® Ritalin® Tab
Nuvigil ®
Palforzia™
Palforzia ™ cap/powder Pulmicort Respules® Rixubis™
Nuwiq® Pamelor™ Pyrukynd® Roszet®
Obizur® Pancreaze® Qdolo® Roxicodone®
Ocaliva™ Pandel® Qelbree™ RoxyBond™
Odactra® SL Panretin® Qinlock™ Rozerem®
Odomzo® pantoprazole pak Qnasl™ Rozlytrek™
Rozlytrek ™
Ofev® Patanase® Qsymia® ER Rubraca®
Olumiant® Paxil® [CR] Qtern® Ruconest®
Olux®[E] Pemazyre™
Pemazyre ™ Qudexy® XR rufinamide
Omnitrope® penicillamine capsule Questran® Light Rukobia®
OneTouch® Glucometers Penlac® Questran® Packet/Powder Ruzurgi®
OneTouch® Test Strips Pennsaid® Qulipta™ Ryaltris® Spray
Onfi® Pepcid® QuilliChew ER™ Rybelsus®
Ongentys® Percocet® Quillivant XR™ Ryclora™
Onmel™ Pertzye® Quviviq™
Quviviq ™ Rydapt®
Onureg® Pexeva® Qvar RediHaler® Rytary™
Onzetra Xsail™ Pheburane® Mis rabeprazole Rythmol SR®
Opana® phendimetrazine tartrate Radicava ORS® Sabril®
Opana ER® Phoslyra® Ragwitek™ Saizen®
(continued)
13
sajazir inj sumatriptan/naproxen Topamax® tab Valtrex™
Samsca™ sunitinib Topicort® vardenafil [ODT]
Saphris® Sunosi™ topiramate ER sprinkle Vascepa®
sapropterin pow/tab Sutent® Tosymra™
Tosymra ™ Vasotec®
Saxenda® Sylatron™ Toviaz™ Vecamyl™
Scemblix® Symbyax™ Tracleer® Veltin™
Secuado® Symdeko® Tradjenta™ Venclexta®
Seglentis® Symlin® tramadol soln 5mg/ml Venlafaxine Tab 112.5mg
Segluromet® Sympazan™ Film Tremfya™ Ventavis®
Semglee™ Synalar® Tresiba® Ventolin® HFA
Sensipar® Syprine® tretinoin caps Verdeso®
Sernivo™ Tabrecta™ Tretten® Veregen®
Seroquel® [XR] tadalafil (generic Adcirca) Treximet™ Verelan® ER, PM
Serostim® Tadliq® triamcinolone 0.05% Verkazia®
Sertraline Caps Tafinlar® ointment Verquvo®
Sevenfact® Tagrisso™ Trianex® Verzenio™
Signifor® Takhzyro® Tribenzor® Vesicare®
sildenafil Taltz Autoinjector® trientine Viagra®
Silenor® Talzenna® Trikafta™ Viberzi™
Siliq™ Tanzeum™ Trileptal® tab/susp Vibramycin®
Simponi™ Tarceva® Trilipix® Victoza®
Singulair® Targadox™ Trintellix® Viekira Pak™
Sirturo™ Targretin® Tritocin™ vigabatrin tab/packet
Sivextro™ Tarpeyo™ Trokendi®XR vigadrone
Skelaxin® Tascenso ODT™ Trudhesa™
Trudhesa ™ Viibryd®
Skyclarys™ Tasigna® Trulance™ Vijoice®
Skyrizi™ tasimelteon Trulicity® Vivelle Dot®
Skytrofa® tavaborole soln 5% Truseltiq™ Vivjoa®
Soaanz® Tavneos® Tudorza® Pressair® Vivlodex™
Sodium Oxybate Sol tazarotene AER Tukysa™
Tukysa ™ Vogelxo®
sofosbuvir-velpatasvir Tazorac® Turalio™
Turalio ™ Voltaren XR®
Solaraze® Gel Tazverik™ Twyneo® Vonjo™
Solodyn® Tecfidera® Twynsta® Vonvendi
Solosec® Gra Technivie™ Tykerb® Vosevi™
Somavert® Tegretol® [XR] Tylenol® w/Codeine Votrient™
Sonata® Tekturna® (HCT) Tymlos™ Voxzogo™
sorafenib Temodar® Oral Tyvaso® Vtama®
Sorilux® temozolomide Ubrelvy™ Vuity™
Sotyktu™ Tenoretic® Uceris® Vusion®
Sovaldi™ Tenormin® Ukoniq® Vyleesi™
Spritam® OD Tepmetko® Uloric® Vyndamax®
Sprix® Teriparatide® inj Ultracet® Vyndaqel®
Sprycel® Testim® Ultram® Vytorin™
Staxyn™ testosterone enanthate Ultravate® Vyzulta™
Steglatro™ testosterone topical Upneeq® Wakix®
Steglujan™ Texacort® Uptravi® Wegovy™ Inj
Stelara® Tezspire® Inj Uroxatral® Welchol®
Stendra™ Thalomid® Urso® [Forte] Welireg™
Stivarga® Thyquidity™ Ursodiol cap Wellbutrin® SR
Strattera™ Tirosint® Utibron™ Neohaler Wellbutrin® XL
Strensiq™ Tivorbex® Vagifem® Wilate®
Striant® Tlando™
Tlando ™ Valchlor™ Winlevi®
Subsys® Tobi Neb
®
Valium® Xaciato™
Xaciato ™ Gel
Sucraid® tolvaptan Valsartan Soln Xadago™
sulconazole Topamax® Sprinkle Valtoco® Xalkori®

14 (continued)
 Xanax® [XR] Xtampza® XR Zetia® Zomig Nasal Spray
Xcopri® pak/tab Xtandi® Ziana® Zonegran®
Xeljanz® [XR] Xultophy® zileuton ER tab Zonisade™
Zonisade ™
Xelstrym™
Xelstrym ™ Xuriden™ Zilxi™ Zorbtive™
Xenazine™ Xyntha® Zioptan™ Zorvolex®
Xenical® Xyrem® Zipsor™ Zoryve®
Xerese® Xywav™
Xywav ™ Zmax™ Ztalmy®
Xermelo™ Yupelri® Zocor® Ztlido™
Xhance™ MIS 93mcg Zavesca® Zohydro® ER Zurampic®
Xifaxan® Zebutal® Zokinvy® Zyclara™ cream/pump
Xiidra™ Zejula™ Zolinza® Zydelig®
Ximino ER™ Zelboraf® zolmitriptan spray Zyflo® Tab
Xodol® Zelnorm® Zoloft® Zykadia®
Xolair® Zembrace Symtouch™ Zolpidem 10mg Zyloprim®
Xolegel® Zenzedi® Zolpidem ER 12.5mg Zypitamag™
Xopenex HFA® Zepatier™ Zolpidem SL 3.5mg Zyprexa™
Zyprexa ™
Xopenex® Soln Zerviate™ Zomacton™ Zyprexa™
Zyprexa ™ Zydis®
Xpovio™ Pak Zestril® Zomig® (ZMT) Zytiga™
Zyvox®

1
All brand prenatal vitamins require prior authorization.
All diabetic test strips require prior authorization except for Contour®.
2 

* Compound products with total cost equal to or greater than $75 per prescription
+
Prescription claims exceeding the dollar limit threshold of $10,000 per claim

15
Reading the formulary drug list
How can I tell if a drug is generic or brand?
The formulary gives you choices so you and your doctor can decide your best course of treatment. In this
formulary, brand-name medications start with an uppercase letter and are written in bold. Generic medications
are shown in lowercase and in italic.

Brand name Drug Starts with UPPERCASE in Bold Ex: Augmentin

Generic drug Lowercase italic Ex: avidoxy

Tier information
Tiers are the different cost levels you pay for a medication. Each drug on the formulary is in a tier. Below is a
reference guide to use as you review your formulary to see the abbreviation for each drug tier on the formulary
list.
Drug Tier Abbreviation
Generic G
Non-preferred Drug NPD
Specialty Drug SP
Low-cost Generic LCG
Preferred Brand PB
$0 Preventive Drug ACA

Drug list requirements and/or limits

Some medications are noted with letters next to them to help you see which drugs may have coverage
requirements and/or limits. Below is a reference guide to use as you review your formulary to see the
abbreviation for each requirement/limit on the formulary list.

Requirements/Limits Abbreviation
Prior Authorization PA
Quantity Limits Apply QL
Age Limit AL
Limited Distribution Drug LDD
Day Supply Limit 5DS
Requires Rider R
Quantity Over Time Q/T
Morphine Milligram Equivalent MME

16
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
ANTIBIOTICS & OTHER DRUGS USED FOR azithromycin G
INFECTION Bactrim,
Bactrim DS NPD
abacavir sulfate G Baraclude NPD, SP
tab, soln
abacavir sulfate/ Baxdela NPD QL
G
lamivudine Benznidazole NPD
abacavir/ Bethkis Neb NPD, SP PA
lamivudine/ G
zidovudine Biaxin NPD
Acticlate NPD AL, PA Biktarvy NPD
acyclovir LCG Biltricide NPD
acyclovir 5% Brexafemme NPD PA, QL
G QL cefaclor
cream G
adefovir dipivoxil G, SP cefaclor ER G
Aemcolo DR NPD QL cefadroxil LCG
albendazole G cefdinir G
Alinia NPD QL cefixime susp/cap G
Altabax NPD PA ceftibuten G
amoxicillin G Ceftin NPD
Amoxicillin cefuroxime axetil G
775mg PB
cephalexin G
amoxicillin/ chlorhexidine
G LCG
clavulanate gluconate soln
amoxicillin/ chloroquine
clavulanate G G
phosphate
extended-release
Cimduo NPD
ampicillin G
Cipro NPD
Amzeeq NPD PA
Cipro XR NPD
Ancobon NPD
ciprofloxacin LCG
Arakoda NPD
ciprofloxacin ER
Arikayce NPD, SP PA G
tabs
atazanavir G clarithromycin G
atovaquone G clarithromycin
atovaquone/ G
G ER
proguanil Cleocin NPD PA
Atripla NPD Clindesse
Augmentin Cream NPD
NPD
Augmentin XR NPD clotrimazole G
Avelox NPD troches
avidoxy G Combivir NPD

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
17
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
Complera PB Doxycycline
Cresemba NPD PA, QL hyclate tab DR NPD QL, QT
200mg
Crixivan PB
doxycycline
Daklinza NPD, SP PA, QL, Q/T monohydrate G
dapsone tab G 50mg, 75mg,
Daraprim Tab NPD, SP 100mg tab
Daxbia NPD doxycycline
monohydrate cap G
Delstrigo NPD 50mg, 100mg
demeclocycline G Doxycycline
Depen Titrate PB, SP monohydrate
cap 75mg, NPD AL
Descovy NPD 150mg
dicloxacillin G Doxycycline
didanosine G monohydrate NPD AL
Dificid tab/susp NPD QL tab 150mg
Diflucan tab/ Edurant PB
susp NPD PA
E.E.S. NPD
Doryx 50mg efavirenz G
DR tablet NPD PA
efavirenz-
Doryx 200mg emtricitab- G
DR tablet NPD PA, QL
tenofovir tab
Doryx MPC Tab efavirenz-
60mg NPD PA
lamivudine- G
Dovato NPD tenofovir tab
doxycycline DR Egaten 250mg
G PA tablet NPD
40mg
Doxycycline emtricitabine cap G
hyclate DR NPD PA emtricitabine-
80mg tenofovir
disoproxil
Doxycycline fumarate tab G
hyclate tab NPD AL 100-150mg,
75mg, 150mg 133-200mg,
Doxycycline 167-250mg
hyclate tab NPD PA emtricitabine-
50mg tenofovir
disoproxil G, ACA QL
Doxycycline fumarate tab
hyclate tab DR NPD 200-300mg
50mg, 100mg Emtriva NPD
Doxycycline Emverm NPD QL
hyclate tab DR NPD AL
75mg, 150mg entecavir G, SP
Epclusa PB, SP PA, QL, Q/T

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
18
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
Epivir NPD isoniazid G
Epzicom NPD itraconazole G
EryPed NPD ivermectin G
Ery-Tab NPD Juluca NPD
Erythrocin NPD Kaletra Tabs/
Soln NPD
erythromycin G Kalydeco Tabs/
delayed release NPD, SP PA, LDD
erythromycin Pack
G Keflex NPD
ethylsuccinate
erythromycin ketoconazole tab G
G
stearate Krintafel NPD
ethambutol G Lamisil Tabs NPD
etravirine G lamivudine G, SP
famciclovir G 100mg tab
Firvanq Soln NPD AL lamivudine tablet G
Flagyl NPD 150mg, 300mg
fluconazole lamivudine/
G G
suspension zidovudine
fluconazole tabs LCG Lampit tab NPD
flucytosine G Ledipasvir-
sofosbuvir tablet NPD, SP PA, QL
Flumadine NPD 90-400mg
fosamprenavir Levaquin NPD
G
calcium tab
levofloxacin tab LCG
fosfomycin pow G
Lexiva NPD
Fuzeon NPD PA
linezolid G QL
griseofulvin G Livtencity NPD PA, QL
microsize
griseofulvin lopinavir/
G G
ultramicrosize ritonavir
Gris-PEG NPD Luliconazole
cream NPD PA
Harvoni PB, SP PA, QL, Q/T
Lymepak NPD PA
Hepsera NPD, SP
Macrodantin NPD
Hiprex NPD
Malarone NPD
Humatin NPD
maraviroc tab G
hydroxychlor- G Mavyret PB, SP PA, QL, Q/T
oquine
Impavido NPD Q/T mefloquine G
Intelence NPD Mepron NPD
Invirase PB methenamine G
hippurate
Isentress PB

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
19
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
metronidazole LCG oseltamivir caps/ G QL
Minocin NPD PA soln
minocycline caps G Paxlovid Tab NPD QL, AL
Minocycline Pegasys NPD, SP
ER cap 135mg, NPD Q/T, PA PegIntron NPD, SP
45mg, and 90mg penicillin v
minocycline ER potassium LCG
G Q/T
tablet solution
minocycline penicillin v
G G
tablet potassium tablet
Minolira NPD PA, Q/T pentamidine INH G
moderiba G, SP Pifeltro NPD
Molnupiravir Plaquenil NPD PA
200mg NPD QL, AL
posaconazole G QL
Mondoxyne NL potassium iodide
75mg cap NPD AL, Q/T G
soln
Monurol Pak praziquantel G
Granules NPD PA
Pretomanid NPD PA
Moxatag NPD
Prevymis NPD, SP
moxifloxacin hcl G
Prezista PB
Myambutol NPD
pyrimethamin G, SP
Mycobutin NPD
Qualaquin NPD QL
Mytesi NPD PA
quinine sulfate G QL
Nebupent INH NPD
Relenza NPD QL, AL
nevirapine G
Retrovir NPD
nevirapine ER G
Reyataz NPD
nitazoxanide G QL
Rezurock NPD, SP PA, QL
nitrofurantoin LCG ribasphere
macrocrystals
ribapak G, SP
nitrofurantoin 200mg & 400mg/
G AL
susp 400mg & 600mg
Norvir powder PB rifabutin G
Norvir tablet NPD Rifadin NPD
Noxafil NPD PA, QL rifampin G
Nuvessa gel NPD PA rimantadine G
Nuzyra NPD QL ritonavir G
Onmel NPD PA Rukobia NPD PA
Oracea NPD PA Selzentry NPD
Orkambi tablet/ Seysara NPD Q/T, PA
packet NPD, SP PA, LDD

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
20
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
Sirturo NPD PA Tobi Podhaler
Cap NPD, SP
Sitavig NPD QL
Sivextro NPD PA, QL tobramycin G, SP
nebulization soln.
Sklice Lot 0.5% NPD
Tolsura NPD
Skyclarys cap NPD, SP PA
Trikafta NPD, SP PA
Sofosbuvir-
velpatasvir Triumeq PB
tablet 400- NPD, SP PA, QL Trizivir NPD
100mg Truvada NPD
Solodyn NPD PA, QL, Q/T valacyclovir tab G
Solosec GRA NPD PA Valcyte Soln NPD AL
Sovaldi NPD, SP PA, QL, Q/T Valcyte Tab NPD
Sporanox NPD valganciclovir
SSKI Solution G AL
NPD soln
stavudine G valganciclovir G
Stribild PB tab
Stromectol NPD Valtrex NPD PA
sulfamethoxazole/ vancomycin G
LCG Vemlidy NPD, SP
tmp
Sunlenca NPD Vfend NPD
Suprax Susp Vibramycin NPD PA
100mg/5ml, NPD Videx EC NPD
200mg/5ml Viekira Pak NPD, SP PA, QL, Q/T
Sustiva NPD Viekira XR NPD, SP PA, QL, Q/T
Symfi NPD Viramune NPD
Symfi-Lo NPD Viramune XR NPD
Symtuza NPD Vivjoa NPD PA, QL
Talicia NPD Vocabria NPD
Tamiflu NPD QL Viread NPD
Targadox NPD PA voriconazole G
Technivie NPD, SP PA, QL, Q/T Vosevi PB, SP PA, QL, Q/T
Temixys NPD Xenleta NPD QL
tenofovir G Xepi Cream 1% NPD PA
terbinafine tabs LCG Xifaxan 200mg NPD QL
Tindamax NPD Xifaxan 550mg NPD PA, QL, Q/T
tinidazole G Ximino ER NPD PA, Q/T
Tivicay PD NPD Xofluza Tab NPD QL
Tobi Neb Xofluza therapy
Solution NPD, SP PA NPD Q/T
pack

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
21
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
Zepatier NPD PA, QL, Q/T Copiktra NPD, SP PA
Zerit NPD Cotellic NPD, SP PA, LDD
Ziagen NPD cyclophos- G
zidovudine G phamide caps
Zithromax NPD Cyclophos-
phamide tabs NPD
Zmax NPD PA
cyclosporine G
Zovirax NPD
Cytoxan NPD, SP
Zyvox NPD PA, QL danazol G
CANCER & ORGAN TRANSPLANT DRUGS Danocrine NPD
Daurismo NPD, SP PA
abiraterone G, SP PA
Deltasone NPD
Afinitor NPD, SP PA
Emcyt NPD
Alecensa NPD, SP PA
Erivedge NPD, SP PA
Alkeran NPD, SP
Erleada NPD, SP PA
Alunbrig
tab/pak NPD, SP PA erlotinib G, SP PA
anastrazole G etoposide G, SP
Arimidex NPD PA Eulexin NPD PA
Aromasin NPD everolimus
(generic for G, SP PA
Ayvakit NPD, SP PA, QL Afinitor)
Azasan NPD everolimus
azathioprine G (generic for G
Balversa NPD, SP PA Zortress)
Benlysta NPD, SP PA exemestane G
Besremi NPD, SP PA Exkivity NPD, SP PA
bexarotene G, SP PA Fareston tab NPD
bexarotene gel G, SP PA Farydak NPD, SP PA, LDD
bicalutamide G Femara NPD
Bosulif NPD, SP PA flutamide G
Braftovi NPD, SP PA Fotivda NPD, SP PA
Brukinsa NPD, SP PA Gavreto NPD, SP PA
Cabometyx NPD, SP PA Gilotrif NPD, SP PA
Calquence NPD, SP PA Gleevec NPD, SP PA
capecitabine G, SP Gleostine NPD, SP
Caprelsa NPD, SP PA Hexalen NPD
Casodex NPD Hycamtin NPD, SP PA
Cellcept NPD Hydrea NPD
Cometriq NPD, SP PA hydroxyurea G

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
22
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
Hyftor Gel 0.2% NPD PA mercaptopurine G
Ibrance PB, SP PA, LDD Mesnex NPD, SP
Iclusig NPD, SP PA methotrexate tab G
Idhifa NPD, SP PA mycophenolate G
imatinib mesylate G, SP PA mycophenolic G
Imbruvica NPD, SP PA acid
Imuran NPD Myfortic NPD
Inlyta NPD, SP PA Myleran NPD
Inqovi tab NPD, SP PA Neoral NPD
Inrebic NPD, SP PA Nerlynx NPD, SP PA
Iressa tab NPD, SP PA Nexavar NPD, SP PA
Jaypirca tab NPD, SP PA Nilandron NPD, SP
Kisqali NPD, SP PA, LDD nilutamide G, SP
Koselugo NPD, SP PA Ninlaro NPD, SP PA
Krazati NPD, SP PA Nubeqa NPD, SP PA
lapatinib G, SP PA Odomzo NPD, SP PA
lenalidomide G, SP PA Onureg NPD, SP PA
Lenvima NPD, SP PA, LDD Orgovyx NPD, SP PA
letrozole G Orserdu tab NPD, SP PA
leucovorin Ortikos ER Cap NPD PA
G Pemazyre
calcium NPD, SP PA
Leukeran PB Piqray NPD, SP PA
leuprolide G, SP Pomalyst NPD, SP PA
Lonsurf NPD, SP PA prednisone LCG
Lorbrena NPD, SP PA prednisone
Lumakras NPD, SP PA therapy pack/ G
solution/
Lupkynis NPD, SP PA, QL concentrate
Lynparza PB, SP PA Prograf cap/
packets NPD
Lysodren NPD
Lytgobi NPD, SP PA Protopic NPD PA
Matulane PB, SP Purixan NPD, SP
Mavenclad pak NPD, SP PA Qinlock tab NPD, SP PA
Megace NPD Rapamune
1mg/ml Sol NPD
megestrol G
megestrol acetate G Rapamune tab NPD
Mekinist NPD, SP PA RediTrex Inj NPD PA
Mektovi NPD, SP PA Retevmo cap NPD, SP PA
melphalan G, SP Revlimid NPD, SP PA

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
23
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
Rezlidhia NPD, SP PA Tykerb NPD, SP PA
Rozlytrek NPD, SP PA Ukoniq NPD, SP PA
Rubraca PB, SP PA Valchlor NPD, SP PA
Rydapt NPD, SP PA Venclexta NPD, SP PA
Sandimmune, Verzenio PB, SP PA
Neoral NPD
Vitrakvi NPD, SP PA
Scemblix NPD, SP PA, QL Vizimpro NPD, SP PA
Siklos NPD Vonjo NPD, SP PA
sirolimus tab/ Votrient NPD, SP PA
G
soln
Welireg NPD, SP PA
sorafenib G, SP PA
Xalkori NPD, SP PA
Sprycel NPD, SP PA
Xatmep NPD AL
Stivarga NPD, SP PA
Xeloda NPD, SP
sunitinib G, SP PA
Xospata NPD, SP PA
Sutent NPD, SP PA
Xpovio Pak NPD, SP PA
Tabloid NPD
Xtandi NPD, SP PA, LDD
Tabrecta tab NPD, SP PA
Yonsa NPD, SP PA
tacrolimus G
Zejula PB, SP PA, LDD
Tafinlar NPD, SP PA
Zelboraf NPD, SP PA, LDD
Tagrisso NPD, SP PA
Zolinza NPD, SP PA, LDD
Talzenna NPD, SP PA
Zortress NPD
tamoxifen 10mg G
Zydelig NPD, SP PA, LDD
Tarceva NPD, SP PA
Zykadia NPD, SP PA, LDD
Targretin cap NPD, SP PA
Zytiga NPD, SP PA, LDD
Tasigna NPD, SP PA
Tazverik 200mg NPD, SP PA PAIN, NERVOUS SYSTEM, & PSYCH
Temodar NPD, SP PA Abilify NPD PA
temozolomide G, SP PA Abilify Mycite NPD PA
Tepmetko NPD, SP PA Abilify
Thalomid NPD, SP PA Mycite Tab
Maintenance/ NPD PA
thioguanine G
Starter Pak
Tibsovo NPD, SP PA
Abstral NPD PA, QL, MME
toremifene tab G
acamprosate DR
tretinoin caps G, SP PA G
tab 333mg
Trexall tab NPD acetaminophen/ LCG AL, QL, 5DS, MME
Truseltiq NPD, SP PA codeine
Tukysa NPD, SP PA Actiq NPD PA, QL, MME
Turalio NPD, SP PA Adderall NPD PA, QL

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
24
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
Adderall XR NPD QL Apadaz NPD PA, QL, 5DS, MME
Adhansia XR Aplenzin NPD PA
Capsule NPD PA, QL
Apokyn
Adipex-P NPD PA, R Solution
Cartridge NPD, SP PA
Adlarity Dis NPD PA, AL
30 mg/3ml
Adzenys ER
Susp NPD PA, QL apomorphine inj G, SP PA
30mg/3ml
Adzenys XR
NPD PA, QL Apo-Varenicline NPD, ACA QL
ODT
Aptensio XR NPD PA, QL
Aimovig PB PA
Aptiom NPD PA
Ajovy PB PA
Aricept NPD PA, AL
Allzital 25-
325mg NPD PA, QL, 5DS aripiprazole G
almotriptan armodafinil G
G QL, AL
maleate Arymo ER NPD PA, QL, MME
alprazolam LCG AL asenapine tab G
alprazolam ER G AL sub
amantadine G Ativan NPD PA, AL
Ambien NPD PA, QL atomoxetine G QL
Ambien CR NPD PA, QL Aubagio NPD, SP
Amerge NPD PA, QL, AL Austedo NPD, SP PA
amitriptyline hcl G Auvelity NPD PA
amoxapine G Avonex PB, SP QL
amphetamine Axert NPD PA, QL, AL
aspartate/ Azilect NPD
amphetamine G QL
sulfate/dextro- Azstarys NPD PA, QL
amphetamine Banzel NPD PA
amphetamine Banzel Susp NPD PA
aspartate/ Belbuca PB PA, QL, MME
amphetamine G QL
sulfate/dextro- Belsomra NPD PA, QL
amphetamine ER Belviq [XR] NPD PA, R
Amphetamine benzphetamine G R, PA
ER suspension NPD PA, QL
Benzhydro- PA, QL, 5DS,
amphetamine codone-aceta- NPD
G QL minophen MME
tablet
amphetamine benztropine G
tablet (generic G PA, QL Betaseron PB, SP QL
Evekeo)
Brisdelle NPD
Anafranil NPD PA
Briviact NPD PA
Antabuse NPD

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
25
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
Briviact soln NPD PA, AL Carbatrol NPD PA
bromocriptine carbidopa G
G
mesylate carbidopa/
Bunavail NPD QL G
levodopa
buprenorphine carbidopa/
G QL G
hcl/naloxone hcl levodopa ER
buprenorphine carbidopa/
G PA, QL, MME G
patch levodopa ODT
buprenorphine SL G QL carbidopa/
bupropion G levodopa/ G
entacapone
bupropion ER G QL carisoprodol- QL, 5DS, AL,
150mg G
aspirin-codeine MME
Bupropion ER
450mg NPD PA Cataflam NPD PA
bupropion SR G Celexa NPD PA
bupropion XL G Celontin PB
Buspar NPD Chantix NPD QL
buspirone G chlordiazepoxide LCG AL
Butal/Apap Tab chlorpromazine
NPD PA, QL, 5DS G
25-325mg HCl
Butalbital- citalopram LCG
acetaminophen NPD PA, QL, 5DS Citalopram
50-300mg 30mg Cap NPD PA
butalbital/apap/ clobazam G PA
G QL, 5DS
caffeine
clobazam susp G PA, AL
butalbital/apap/ QL, 5DS, AL,
G clomipramine
caffeine/codeine MME G
HCl
butalbital/ QL, 5DS, AL, clonazepam G
aspirin/caffeine/ G MME
codeine clorazepate
dipotassium G AL
butorphanol QL, 5DS, AL,
G
tartrate nasal MME clozapine G
Butrans NPD PA, QL, MME clozapine ODT G
Cafergot NPD Clozaril NPD
Cambia Packet NPD PA codeine tabs G QL, 5DS, AL, MME
Capcof Syrup NPD QL, 5DS, AL, MME coditussin AC G QL, AL, 5DS, MME
Caplyta NPD PA liquid
carbamazepine G Comtan NPD
carbamazepine Concerta NPD PA, QL
G AL Contrave ER
susp NPD PA, R
carbamazepine Conzip NPD PA, AL, QL, MME
G
XR
Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
26
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
Copaxone PB, SP QL Diclofenac cap
35mg NPD PA
Cotempla XR
ODT NPD PA, QL
diclofenac G
Cymbalta NPD PA potassium
Dantrium NPD diclofenac G
powder
Dantrolene NPD
diclofenac
Daybue Soln NPD, SP PA G
sodium
Daypro NPD PA diclofenac G
Daytrana NPD PA, QL sodium gel 1%
Dayvigo NPD PA, QL diethylpropion G R, PA
Demerol NPD PA, QL, 5DS, MME diflunisal G
Depakene NPD dihydrocodein/ QL, 5DS, AL,
G
Depakote NPD APAP/caff MME
Depakote ER NPD dihydrocodeine/ QL, 5DS, AL,
G
aspirin/caffeine MME
Depakote
Sprinkle Caps NPD dihydroergo- G PA
tamine inj
desipramine G
dihydroergo-
Desoxyn NPD PA, QL tamine G PA
Desvenlafaxine nasal spray
ER 24 HR PB
Dilantin
Dexedrine NPD PA, QL chewable tablets PB
dexmethyl- Dilaudid NPD PA, QL, 5DS, MME
G QL
phenidate ER dimethyl
dexmethyl- G, SP
G QL fumarate DR cap
phenidate hcl disulfiram G
dextroam- divalproex
G QL G
phetamine sodium
dextroam- divalproex
G QL G
phetamine ER sodium ER
D.H.E.45 NPD PA divalproex
Dhivy NPD PA G
sprinkle cap
Diacomit NPD, SP PA Dolophine NPD PA, QL, MME
Diastat NPD donepezil LCG AL
diazepam hydrochloride
G
rectal gel Doral NPD PA, AL
diazepam doxepin capsule G
G
solution doxepin tablet G PA
diazepam tabs LCG Drizalma
diclofenac cap Sprinkle NPD PA
G PA, QL
25mg duloxetine G

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
27
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
Duragesic patch NPD PA, QL, MME fentanyl citrate G PA, QL, MME
Dyanavel XR NPD PA, QL OTFC
Effexor XR NPD PA Fentanyl citrate
tablet NPD PA, QL, MME
Eldepryl NPD
fentanyl
Elepsia XR NPD PA G PA, QL, MME
transdermal
eletriptan G QL, AL Fentora NPD PA, QL, MME
Embeda NPD PA, QL, MME Fetzima NPD PA
Emgality fingolimod G, SP
(300mg Dose)
Prefilled Pen PB PA, QL Fintepla sol NPD, SP PA
100mg/ml Fioricet Cap NPD PA, QL, 5DS
Emgality Fioricet QL, AL, 5DS, PA,
with codeine NPD
Prefilled Pen/ MME
Auto-Injector NPD PA
Fiorinal QL, AL, 5DS, PA,
120mg/ml with codeine NPD MME
endocet G 5DS, QL, MME fluoxetine G QL (Weekly Only)
entacapone G fluoxetine 10mg, LCG
Epidiolex Soln NPD, SP PA 20mg, 40mg
Eprontia NPD PA fluoxetine soln G AL
ergotamine fluphenazine G
G
tartrate/caffeine flurazepam G QL, AL
escitalopram LCG flurbiprofen G
Esgic cap/tab NPD PA, QL, 5DS fluvoxamine G
estazolam G QL, AL fluvoxamine ER G
eszopiclone G PA, QL (3mg only) Focalin NPD QL
ethosuximide G Focalin XR NPD PA, QL
etodolac G ForFivo XL NPD PA
Evekeo [ODT] NPD PA, QL Frova NPD PA, QL, AL
Evzio NPD PA, QL Frovatriptan
succinate NPD QL, AL
Exalgo NPD PA, QL, MME
Exelon NPD AL Fycompa NPD
Exservan Mis NPD gabapentin G
Extavia NPD, SP PA gabapentin soln G AL
Fanapt NPD PA Gabitril NPD
Fazaclo NPD galantamine G AL
felbamate G galantamine ER G AL
Felbatol NPD PA Geodon NPD PA
Feldene NPD Gilenya NPD, SP
Fenoprofen glatiramer
NPD PA G, SP QL
calcium acetate

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
28
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
glatopa G, SP QL Jornay PM
Capsule NPD PA, QL
Gocovri NPD PA
Gralise Mis NPD PA Kadian ER NPD PA, QL, MME
guaifenesin- Kapvay NPD PA, QL
QL, AL, 5DS,
codeine soln LCG Keppra NPD PA
10mg/5ml MME
Keppra XR NPD PA
guanfacine ER G QL ketoprofen G
Halcion NPD PA, QL, AL ketorolac G
haloperidol G Khedezla NPD PA
Hetlioz Cap NPD, SP PA, QL Klonopin NPD PA
Hetlioz LQ Susp NPD, SP PA Kloxxado Liq PB QL
Horizant NPD PA Kynmobi Mis NPD, SP PA, QL
hydrocodone ER G PA, QL, MME Kynmobi Kit
Titration NPD, SP PA
hydrocodone/ QL, 5DS, AL,
LCG
acetaminophen MME lacosamide G
hydrocodone- QL, 5DS, AL, Lamictal NPD PA
G
homatropine tab MME
Lamictal ODT NPD PA
hydromorphone G PA, QL, MME Lamictal XR NPD PA
ER
hydromorphone lamotrigine G
G QL, 5DS, MME
IR lamotrigine ER G
Hysingla ER NPD PA, QL, MME lamotrigine ODT G
Ibudone QL, AL, 5DS, PA, lamotrigine ODT
NPD G
MME kit
ibuprofen/ QL, 5DS, MME, Latuda NPD
G
hydrocodone AL Lazanda NPD PA, QL, MME
Imcivree Inj levetiracetam G
NPD, SP PA
10mg/ml
levetiracetam ER G
imipramine G
levorphanol G QL, 5DS, MME
Imitrex NPD AL
Lexapro NPD PA
Inbrija NPD, SP PA
Librax NPD PA
Indocin susp NPD AL
Licart Dis 1.3% NPD PA, QL
Ingrezza NPD, SP PA
lithium carbonate G
Intermezzo NPD PA, QL
lithium carbonate
Intuniv NPD PA, QL G
ER
Invega ER Lithobid NPD
tablet NPD PA
Lodine NPD
isometheptene/
dichloralphen- G Lodosyn NPD
azone/apap Lomaira NPD PA, R
Jakafi NPD, SP PA, LDD lorazepam LCG AL

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
29
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
lorazaepam methylphenidate
G AL G QL
concentrate ER (LA)
Loreev XR NPD PA Methlyphen-
idate ER (XR) NPD PA, QL
Lortab NPD QL, 5DS, AL, PA
lortab elixir LCG QL, MME methylphenidate G QL
loxapine G pad
Lucemyra NPD PA, QL, Q/T Midrin NPD
Lunesta NPD PA, QL Migranal NPD PA
lurasidone tab G Mirapex NPD
Lybalvi NPD PA Mirapex ER NPD
Lyrica Cap NPD PA mirtazapine G
Lyrica CR NPD PA modafinil G
Lyrica soln NPD PA, AL molindone hcl G
MorphaBond
maprotiline G ER NPD PA, QL, MME
Maxalt, Maxalt- morphine IR G QL, 5DS, MME
MLT NPD AL, QL
Mayzent tablet, morphine sulfate G PA, QL, MME
starter pak NPD, SP ER
m-clear wc soln NPD AL, QL, 5DS, MME morphine G QL, 5DS, MME
suppositories
meclofenamate G MS Contin NPD PA, QL, MME
memantine G AL Mydayis NPD PA, QL
memantine ER G AL Mysoline NPD PA
meperidine HCl G QL, 5DS, MME
nabumetone G
meprobamate G Nalfon NPD PA
Mestinon syrup NPD PA, AL Nalocet NPD PA, QL, 5DS, MME
Mestinon [ER]
Tab NPD PA Naloxone
Injection 2mg NPD QL
methadone LCG PA, QL, MME
naloxone spray G QL
Methadose
concentrate [SF] NPD PA, QL, MME naltrexone 50mg G
Methamphet- Namenda [XR] NPD AL
amine NPD QL Namzaric NPD AL
methocarbamol naratriptan G QL, AL
LCG
500mg, 750mg Narcan 4mg/
actuation spray PB QL
Methylin NPD QL
methylphenidate G QL Nardil NPD
methylphenidate Nayzilam NPD PA, QL
G QL
ER nefazodone G
methylphenidate Neupro Patch NPD PA
G QL
ER (CD)

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
30
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
Neurontin NPD PA Oxycodone/ PA, QL, 5DS,
acetaminophen NPD
Neurontin soln NPD PA, AL MME
ninjacof-XG QL, AL, 5DS, Oxycodone/
G APAP 2.5-
liquid MME PA, QL, 5DS,
300mg, NPD
Norpramin NPD 5-300mg, MME
nortriptyline G 10-300mg tab
nortriptyline soln G AL oxycodone/ G QL, 5DS, MME
Nourianz NPD PA aspirin
Nucynta NPD QL, 5DS, MME oxycodone/ G QL, 5DS, MME
ibuprofen
Nucynta ER NPD PA, QL, MME
OxyContin NPD PA, QL, MME
Nuplazid NPD PA
oxymorphone ER G PA, QL, MME
Nurtec chw
75mg ODT PB PA, QL, AL oxymorphone IR G QL, 5DS, MME
Nuvigil NPD PA paliperidone er G
tablet
olanzapine LCG
Pamelor NPD PA
olanzapine ODT LCG
Parlodel NPD
olanzapine/ G Parnate NPD
fluoxetine hcl
Onfi NPD PA paroxetine G
Onfi Susp NPD PA, AL paroxetine ER G
Ongentys NPD PA Paxil CR NPD PA
Onzetra Xsail NPD PA, QL, AL Paxil Tab/Susp NPD PA
Opana NPD QL, 5DS, PA, MME pentazocine- G QL, 5DS, MME
naloxone
Opana ER NPD PA, QL, MME
Percocet NPD QL, 5DS, PA, MME
Orap NPD
perphenazine G
Osmolex ER NPD
Pexeva NPD PA
oxaprozin G
phendimetrazine
Oxaydo NPD PA, QL, 5DS, MME G PA, R
tartrate
oxazepam G AL phenelzine G
oxcarbazepine phenobarbital G
G AL
susp
phentermine hcl LCG PA, R
oxcarbazepine G Phenytek NPD
tab
Oxtellar XR NPD PA phenytoin G
Oxycodone ER pimozide G
tablet NPD PA, QL, MME piroxicam G
oxycodone IR G QL, 5DS, MME Plegridy PB, SP QL
oxycodone/ Ponvory NPD, SP PA
G QL, 5DS, MME
acetaminophen pramipexole G

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
31
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
pramipexole ER G Rebif Rebidose NPD, SP PA, QL
pregabalin cap G Regimex NPD PA, R
pregabalin ER Relafen NPD PA
G PA
tab Relafen DS NPD PA
pregabalin soln G AL Relexxii NPD PA, QL
primidone G Relpax NPD PA, QL, AL
Primlev NPD PA, QL, 5DS, MME Relyvrio Pak NPD, SP PA
Pristiq NPD PA Remeron NPD
Procentra Remeron
1mg/ml NPD QL NPD
SolTab
Prolate Sol Requip NPD
10/300mg NPD PA, QL, 5DS, MME
Requip XL NPD
Prolate tab NPD PA, QL, 5DS, MME
Restoril NPD PA, AL
promethegan G Rexulti NPD
supp
Provigil NPD PA Reyvow NPD PA, QL, AL
Prozac NPD PA Rilutek NPD
pyridostigmine G riluzole G
pyridostigmine Risperdal NPD PA
G AL
soln risperidone LCG
Qdolo Soln Ritalin LA NPD PA, QL
5mg/ml NPD PA, QL, AL
Ritalin Tab NPD PA, QL
Qelbree NPD PA, QL rivastigmine G AL
Qmiiz ODT NPD PA rizatriptan
Qsymia ER NPD PA, R G QL, AL
benzoate
quazepam G QL, AL Robaxin NPD
Qudexy XR NPD PA ropinirole G
quetiapine ER G ropinirole ER G
quetiapine LCG Roxicodone NPD QL, 5DS, PA, MME
fumarate Roxybond NPD QL, 5DS, PA, MME
Quillichew ER NPD PA, QL Rozerem NPD PA, QL
Quillivant XR NPD PA, QL rufinamide susp
Qulipta PB PA, QL G PA
40mg/ml
Quviviq NPD PA, QL rufinamide tab G PA
Radicava ORS Rytary NPD PA
Susp NPD, SP PA
Sabril NPD, SP PA
ramelteon G QL Saphris NPD PA
rasagiline G Saxenda NPD PA, R
Razadyne NPD AL Secuado Patch NPD PA
Razadyne ER NPD AL

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
32
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
Seglentis 56- tetrabenazine G, SP PA
44mg Tab NPD PA, QL
thioridazine G
selegiline HCl G thiothixene G
Seroquel NPD PA tiagabine hcl G
Seroquel XR NPD PA Tiglutik Susp NPD
sertraline LCG Tivorbex NPD PA
Sertraline Caps Tofranil NPD
NPD PA
150mg, 200mg
tolcapone G
Silenor NPD PA
tolmetin sodium G
Sinemet NPD
Topamax NPD PA
Sinemet CR NPD
Topamax
Sodium Oxybate Sprinkle NPD PA
Sol NPD, SP PA, QL
Capsules
Sonata NPD PA, QL topiramate G
Spritam Oral topiramate ER
Disintegrating NPD PA G
cap
Tab
topiramate
Sprix G PA
NPD PA, QL sprinkle cap
Nasal Spray
Tosymra Nasal
Stalevo NPD Solution NPD PA, QL, AL
Strattera NPD PA, QL tramadol LCG QL, AL, MME
Suboxone Tramadol ER
Sublingual Film NPD QL NPD QL, AL, MME
cap
Subsys NPD PA, QL, MME tramadol ER
sulindac G G QL, AL, MME
(biphasic) tablet
sumatriptan G QL, AL tramadol ER G QL, AL, MME
sumatriptan/ tablet
G PA, QL
naproxen Tramadol soln
5mg/ml NPD PA, QL, AL, MME
Sunosi PB PA
Sylatron NPD, SP PA tramadol/ G QL, AL, MME
acetaminophen
Symbyax NPD PA
Tranxene T NPD AL
Sympazan Film NPD PA
tranycypromine
Tascenso ODT NPD, SP PA G
sulfate
tasimelteon G, SP PA, QL trazodone G
Tasmar NPD Treximet NPD PA, QL, AL
Tecfidera NPD, SP PA, LDD Trezix NPD
Tegretol susp NPD PA, AL triazolam G QL, AL
Tegretol [XR] NPD PA trifluoperazine G
temazepam G QL, AL trihexyphenidyl LCG
teriflunomid G, SP

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
33
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
Trileptal Susp NPD PA, AL Xelstrym Pad NPD PA, QL
Trileptal Tab NPD PA Xenazine NPD
trimipramine G Xodol, Norco NPD QL, 5DS, PA, AL,
Trintellix NPD PA MME
Trokendi XR NPD PA Xtampza ER PB PA, QL, MME
Trudhesa AER NPD PA, QL Xyrem NPD, SP PA, QL
trymine CG AL, QL, 5DS, Xywav Soln NPD, SP PA, QL
G zaleplon G QL
liquid MME
Tylenol w/ AL, QL, 5DS, PA, Zarontin NPD
Codeine NPD MME Zebutal Cap
50-325-40mg NPD PA, QL, 5DS
Ubrelvy PB PA, QL, AL
Ultracet NPD QL, AL, PA, MME Zembrace
Symtouch NPD PA, QL
Ultram NPD QL, AL, PA, MME
Zenzedi NPD PA, QL
Valium NPD PA
Zimhi Soln NPD QL
valproic acid G
ziprasidone G
Valtoco NPD PA, QL
Zohydro ER NPD PA, QL, MME
Vanatol S/LQ NPD PA, QL, 5DS
zolmitriptan G QL, AL
varenicline G, ACA QL
zolmitriptan
varenicline pak G, ACA G PA, QL, AL
spray
venlafaxine G Zoloft NPD PA
venlafaxine ER G PA, QL
Venlafaxine Tab zolpidem tartrate LCG
NPD PA (10mg only)
112.5mg zolpidem tartrate PA, QL
vigabatrin G, SP PA G
ER (12.5mg only)
vigadrone G, SP PA zolpidem tartrate PA, QL
G
Vimpat tab, soln NPD SL (3.5mg only)
Virtussin AC w/ Zomig NPD PA, QL, AL
ALC liquid NPD QL, 5DS, MME
Zonegran NPD PA
Vivlodex NPD PA Zonisade Susp NPD PA
Vraylar NPD zonisamide G
Vyvanse PB QL Zorvolex NPD PA
Wakix NPD, SP PA, QL Ztalmy Susp NPD, SP PA
Wellbutrin SR NPD PA Zubsolv PB QL
Wellbutrin XL NPD PA Zyban NPD QL
Xadago NPD PA Zyprexa NPD PA
Xanax NPD PA, AL Zyprexa Zydis NPD PA
Xanax XR NPD PA, AL
Xcopri pak/tab NPD PA

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
34
 DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS
LIMITS TIER LIMITS

HEART, BLOOD PRESSURE, & amlodipine/ G

CHOLESTEROL valsartan
amlodipine/
Accupril NPD PA G
valsartan/HCTZ
Accuretic NPD anagrelide G
acebutolol G Antara NPD
acetazolamide G Arixtra NPD
acetazolamide ER G aspirin- G
Actimmune NPD, SP PA dipyridamole er
Adalat CC NPD Aspruzyo Spr
Gra NPD
Adcirca NPD, SP PA
Adempas PB, SP PA Atacand NPD PA
Advate PB, SP PA Atacand HCT NPD PA
Adynovate NPD, SP PA atenolol LCG
Afstyla NPD, SP PA atenolol/ G
chlorthalidone
Aggrenox NPD
Atorvaliq Susp NPD PA
Agrylin NPD
atorvastatin LCG
Aldactazide NPD
atorvastatin/
Aldactone NPD G
amlodipine
aliskiren G Avalide NPD PA
Alphanate PB, SP PA Avapro NPD PA
Alphanine NPD, SP PA Azor NPD PA
Alprolix NPD, SP PA, LDD Bebulin NPD, SP PA
Altace NPD PA benazepril LCG
Altoprev NPD benazepril/HCTZ G
Altuviiio Inj NPD, SP PA BeneFIX PB, SP PA
ambrisentan G, SP PA Benicar NPD PA
Amicar NPD Benicar HCT NPD PA
amiloride G Betapace AF NPD
amiloride/HCTZ G betaxolol G
aminocaproic Bevyxxa NPD QL
G
acid
Bidil NPD
amiodarone G
bisoprolol G
amlodipine LCG
bisoprolol/HCTZ G
amlodipine
besylate/ G bumetanide G
olmesartan Bystolic NPD
amlodipine/ Byvalson NPD PA
G
benazepril Caduet NPD PA

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
35
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
Calan NPD Coreg CR NPD PA
Calan SR NPD Corgard NPD
Camzyos NPD, SP QL, PA Corifact NPD PA
candesartan G Corlanor NPD PA
candesartan/ Corzide NPD
hydrochloro- G Coumadin PB
thiazide
Cozaar NPD PA
captopril G
Crestor NPD PA
captopril/HCTZ G
dabigatran cap G
Cardizem NPD PA
Demadex NPD
Cardizem CD NPD PA
Dibenzyline NPD PA
Cardizem LA NPD PA
digitek G
Cardura NPD PA
digox G
Carospir NPD PA
digoxin G
cartia XT G
dilt-CD G
carvedilol LCG
diltiazem HCl G
carvedilol ER G
diltiazem HCl CD G
Catapres tablets NPD
diltiazem HCl ER G
Catapres-TTS NPD
diltiazem HCl LA G
chlorothiazide G
diltiazem HCl SR G
chlorthalidone G
diltzac ER G
cholestyramine G
Diovan NPD PA
cholestyramine G Diovan HCT NPD PA
light
cilostazol G dipyridamole G
clonidine ER disopyramide G
G QL
12 HR tab dofetilide G
Clonidine ER doxazosin
24HR tab NPD PA G
mesylate
clonidine IR droxidopa G, SP PA
LCG
tablet Durlaza NPD PA
clonidine patches G Dutoprol NPD
clopidogrel G Dyazide NPD
Coagadex NPD, SP PA Dyrenium NPD
colesevelam G Edarbi NPD PA
Colestid NPD PA Edarbyclor NPD PA
colestipol HCl G Edecrin NPD
Conjupri NPD PA Effient NPD PA
Coreg NPD PA Eliquis PB

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
36
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
Eloctate NPD, SP PA fosinopril G
Elyxyb Sol NPD PA, QL fosinopril/HCTZ G
enalapril G Fragmin NPD
enalapril/HCTZ G Furoscix Kit
80mg/10ml NPD
enalapril solution G AL
enoxaparin G furosemide LCG
solution
Entadfi NPD PA, QL
furosemide tabs LCG
Entresto PB QL
gemfibrozil G
Epaned Sol
1mg/ml NPD AL guanfacine G
eplerenone G Helixate FS NPD, SP PA
eprosartan G PA Hemlibra Soln NPD, SP PA
Esperoct NPD, SP PA Hemofil M NPD, SP PA
ethacrynic acid G Humate-P PB, SP PA
Exforge NPD PA hydralazine LCG
Exforge HCT NPD PA hydrochloro- LCG
thiazide
Ezzalor
Sprinkle Cap NPD PA Hyzaar NPD PA
ezetimibe G icosapent cap G
Ezetimibe/ indapamide G
Atorvastatin NPD PA Inderal LA NPD PA
Ezetimibe/ InnoPran XL NPD PA
Rosuvastatin NPD PA
Inspra NPD PA
ezetimibe/ irbesartan G
G
simvastatin
irbesartan
Feiba NPD, SP PA hydrochloro- G
felodipine ER G thiazide
fenofibrate G Isordil
Titradose Tabs NPD
Fenofibrate
Micronized NPD
isosorb dinitrate- G
fenofibrate hydralazine
G
nanocrystallized isosorbide G
fenofibric acid G dinitrate
Fenoglide NPD isosorbide G
dinitrate ER
Fibricor NPD
isosorbide
flecainide G G
mononitrate
Flolipid susp NPD AL isosorbide G
fluvastatin mononitrate ER
G
sodium isradipine G
fondaparinux G

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
37
 DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS
LIMITS TIER LIMITS
Ixinity NPD, SP PA metoprolol G
jantoven G tartrate/HCT
Jivi NPD, SP PA Mevacor NPD
Juxtapid NPD, SP PA mexiletine HCl G
Kapspargo NPD PA Micardis NPD PA
Katerzia Susp NPD PA, AL Micardis HCT NPD PA
Kerendia NPD PA Microzide NPD
Koate-DVI PB, SP PA Minipress NPD
Kogenate FS NPD, SP PA minitran G
Kynamro NPD, SP PA minoxidil G
labetalol HCl G moexipril G
Lanoxin NPD moexipril/HCTZ G
Lasix NPD Monoclate-P NPD, SP PA
Lescol XL NPD PA Mononine PB, SP PA
Letairis NPD, SP PA Mulpleta NPD, SP PA
Levamlodipine NPD PA Multaq PB
Lipitor NPD PA nadolol G
Lipofen NPD nadolol-
bendroflume G
lisinopril LCG thiazide
lisinopril/HCTZ LCG nebivolol G
Livalo NPD PA Nexiclon XR NPD PA
Lopid NPD Nexletol PB PA
Lopressor HCT NPD Nexlizet PB PA
losartan LCG niacin ER G
losartan-HCTZ G Niaspan ER NPD PA
Lotensin NPD nicardipine G
Lotrel NPD PA nifedical XL G
lovastatin G nifedipine G
Lovaza NPD PA Nymalize Sol NPD
Lovenox NPD nifedipine ER G
Maxzide NPD nimodipine G
methyldopa G nisoldipine ER G
metolazone G Nitro-Bid PB
metoprolol Nitro-Dur NPD
G
succinate
nitro-time cap G
metoprolol LCG Nitro-Time CR
tartrate NPD
Cap

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
38
 DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS
LIMITS TIER LIMITS
nitroglycerin ER LCG prasugrel G
nitroglycerin Pravachol NPD
G
patches pravastatin G
nitroglycerin SL G prazosin G
nitroglycerin prevalite G
G
spray
Prinivil NPD PA
Nitrolingual
Spray NPD Procardia NPD
Nitromist NPD Procardia XL NPD
Nitrostat SL NPD Profilnine NPD, SP PA
Nocdurna SL NPD Promacta NPD, SP PA
Norliqva Soln NPD PA, AL propafenone G
Norpace NPD propafenone ER G
Northera NPD, SP PA propranolol G
Norvasc NPD PA propranolol ER G
Novoeight PB, SP PA propranolol/ G
HCTZ
NovoSeven RT NPD, SP PA
Qbrelis NPD AL
Nuwiq PB, SP PA
Questran
Obizur NPD PA NPD PA
Packet/Powder
olmesartan G Questran Light NPD PA
medoxomil
olmesartan/ quinapril G
G quinapril/HCTZ G
amlodipine/hctz
olmesartan/hctz G ramipril G
omega-3 acid Ranexa NPD
G
ethyl esters ranolazine tab ER G
Opsumit PB, SP PA Rebinyn Soln NPD, SP PA
Orenitram NPD, SP PA Recombinate PB, SP PA
pacerone G Repatha PB PA
pentoxifylline ER G Revatio NPD, SP PA
perindopril G Riastap NPD PA
Persantine NPD Rixubis NPD, SP PA
phenoxybenz- rosuvastatin G
G PA
amine hcl
Roszet NPD PA
pindolol ER G Rythmol NPD
Plavix NPD PA Rythmol SR NPD PA
Pradaxa PB Samsca NPD, SP PA, LDD
Pradaxa Pak NPD PA Sevenfact Inj NPD, SP PA
Praluent NPD PA

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
39
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
sildenafil citrate tolvaptan 15mg,
20mg tab, G, SP PA G, SP PA
30mg tab
10mg/ml susp Toprol XL NPD
sildenafil citrate torsemide G
25mg, 50mg, LCG QL
100mg Tracleer PB, SP PA, LDD
simvastatin LCG trandolapril G
Simvastatin trandolapril/
NPD AL G
susp verapamil ER
Soaanz NPD PA Tretten NPD, SP PA
sotalol HCl G triamterene/ G
HCTZ
Sotylize soln NPD
triamterene cap G
spironolactone G
Tribenzor NPD PA
spironolactone/
HCTZ G Tricor NPD
Stimate NPD Trilipix NPD PA
Sular NPD Twynsta NPD PA
tadalafil (generic Tyvaso NPD, SP PA
G, SP PA
Adcirca) Uptravi NPD, SP PA
tadalafil (generic valsartan G
G QL
Cialis)
valsartan/
Tadliq Susp NPD, SP PA hydrochloro- G
Tarka NPD thiazide
taztia XT G Valsartan Soln NPD PA, AL
Tekturna/ Vascepa NPD PA
Tekturna HCT NPD PA
Vaseretic NPD
telmisartan G Vasotec NPD PA
telmisartan- vecamyl G PA
G
amlodipine
Ventavis NPD, SP PA
telmisartan/
hydrochloro- G verapamil HCl G
thiazide verapamil HCl ER G
Tenoretic NPD PA Verelan ER, PM NPD PA
Tenormin NPD PA Verquvo NPD PA, QL
Thalitone NPD Vijoice NPD, SP PA, QL
tiadylt ER G Vonvendi NPD, SP PA
Tiazac NPD Voxzogo NPD, SP PA
ticlopidine HCl G Vyndaqel,
Vyndamax NPD, SP PA
Tikosyn NPD
timolol maleate Vytorin NPD PA
G
tab warfarin G

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
40
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
Welchol NPD PA alclometasone G
Wilate PB, SP PA cream, ointment
Xarelto PB Aldara NPD
Xyntha PB, SP PA Altreno
NPD PA, AL
0.05% lotion
Zestoretic NPD
amcinonide G
Zestril NPD PA
anthralin G
Zetia NPD PA
ApexiCon E NPD PA
Ziac NPD
Arazlo lotion
Zocor NPD PA 0.045% NPD PA, AL
Zypitamag NPD PA Atralin NPD PA, AL
SKIN MEDICATIONS avita G AL
azelaic acid gel
Absorica NPD PA G
15%
Absorica LD NPD PA Azelex NPD PA
Acanya NPD PA Benzaclin NPD PA
accutane cap G Benzamycin gel NPD PA
acitretin G Benzamycinpak NPD PA
acyclovir cream/ benzoyl peroxide/
LCG G
oint erythromycin
Aczone NPD PA, AL beser lotion G
Adapalene 0.05%
0.1% lotion NPD AL
betamethasone
G
adapalene dipropionate
G AL
0.1% soln betamethasone G
adapalene valerate
G AL
0.3% gel betamethasone/ G
adapalene cream G AL clotrimazole
adapalene- brimonidine gel G
benzoyl-peroxide G AL 0.33%
gel Bryhali lotion
0.01% NPD PA
Adapalene pad
0.1% NPD PA, AL
calcipotriene G
Adbry Inj cream
150mg/ml PB, SP PA
Calcipotriene
foam NPD PA
Aklief Cream
0.005% NPD PA, AL
calcipotriene-
Aktipak NPD PA betamethasone dp G
oint
ala-cort cream LCG
calcipotriene-
Ala-Scalp Lotion NPD PA betamethasone dp G
susp

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
41
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
calcitriol Derma-Smoothe
G NPD PA
ointment FS
Capex NPD PA Dermatop NPD
Carac NPD PA Desonate NPD PA
Centany 2% desonide gel
oint NPD G
0.05%
Cibinqo Tab PB, SP PA Desowen NPD PA
ciclopirox desoximetasone
G
0.77% cream cream, gel, G
ciclopirox ointment
G
8% solution diclofenac G PA
ciclopirox cream, 3% gel
gel, shampoo, G Differin
suspension 0.1% cream NPD PA, AL
Cleocin T NPD PA Differin
0.1% lotion NPD PA, AL
Clindagel NPD PA
clindamycin, Differin
0.3% gel NPD PA, AL
clindamycin- G
benzoyl peroxide Diflorasone
gel [w/pump] NPD PA
diacetate
Clindamycin/ Diprolene,
benzoyl NPD PA NPD
Diprolene AF
peroxide 1-5%
Dovonex cream NPD
clindamycin/ G AL doxepin cream
tretinoin gel G QL
5%
clobetasol
cream, ointment, G Duac NPD PA
solution Duobrii Lotion NPD PA
Clobex NPD PA Dupixent PB, SP PA
Clocortolone econazole G
pivalate NPD PA
Ecoza NPD PA
clodan G
Efudex cream NPD, SP
Cloderm NPD PA
Elidel NPD PA
Condylox NPD
Elimite NPD
Cordran NPD PA
Elocon NPD
Cosentyx NPD, SP PA
Enstilar NPD
Crotan Lotion NPD
Epiduo NPD AL
Cutivate NPD PA
Epiduo Forte
dapsone gel 5% G AL gel NPD AL
dapsone gel 7.5% G AL Epsolay Cream NPD PA
Denavir NPD QL Ertaczo NPD PA

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
42
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
Erygel NPD hydrocortisone G
erythromycin gel, butyrate/emoll
G
soln, swabs hydrocortisone G
Eucrisa PB PA supp
Eurax Lotion NPD hydrocortisone G
valerate 0.2%
Evoclin NPD PA
hydrocortisone/
Exelderm NPD PA G
lidocaine HCl
Extina NPD PA imiquimod cream G PA
Fabior NPD PA, AL Imiquimod
Fasenra PB, SP PA Cream 3.75% NPD PA
Finacea NPD PA Pump
fluocinolone Impeklo Lotion
0.05% NPD PA
acetonide cream, G
sol, oil Impoyz Cream
NPD PA
fluocinonide gel, 0.025%
G
ointment isotretinoin G
Fluorouracil Jublia NPD PA
cream 0.5% PB
Kenalog Spray NPD PA
fluorouracil Kerydin NPD PA
G, SP
solution 2%
ketoconazole
Flurandrenolide G
NPD PA cream
cream, lotn, oint
ketoconazole
fluticasone G
shampoo
propionate G
cream, lotn, oint. Klisyri Oint 1% NPD PA
gentamicin Klaron NPD
topical cream, G Lexette Foam
ointment 0.05% NPD PA
halcinonide lidocaine patch
G G
cream 0.1% 5%
halobetasol lidocaine
G
propionate solution, gel, G
Halobetasol ointment
propionate foam NPD PA Lidoderm NPD PA
0.05%
Locoid NPD PA
Halog NPD PA
Locoid
hydrocortisone Lipocream NPD PA
G
2.5%
Loprox NPD PA
hydrocortisone
butyrate 0.1% G Lotrisone NPD
hydrocortisone Luxiq NPD PA
LCG Luzu NPD PA
lot 0.1%

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
43
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
malathion lotion G permethrin G
methoxsalen G pimecrolimus cre G
MetroCream NPD 1%
MetroGel NPD podofilox soln G
MetroLotion NPD Pramosone
cream/lotion NPD PA
metronidazole G prednicarbate
cream, lotion, gel G
ointment
Miconazole-zinc
ointment NPD PA prilocaine/ G
lidocaine
Mirvaso PB
Proctocort Supp
mometasone 30mg NPD PA
cream, ointment, LCG
solution Proctofoam HC PB
mupirocin cream, Prudoxin cream
G 5% NPD QL
ointment
naftifine cream, Qbrexza Pad
G 2.4% NPD PA, QL
gel
Naftin NPD Retin-A NPD PA, AL
Natroba NPD Retin-A Micro NPD PA, AL
Nizoral Rhofade
1% cream NPD PA
NPD
shampoo
selenium sulfide
Noritate NPD PA G
shampoo/lotion
nystatin/ Sernivo NPD PA
triamcinolone LCG
cream, ointment Siliq NPD, SP PA
nystatin Silvadene NPD
LCG
suspension silver LCG
Olux [E] NPD PA sulfadiazine
Onexton NPD Skyrizi Inj PB, SP PA
Opzelura sodium
Cream PB PA, QL sulfacetamide G
suspension
Ovide NPD
Solaraze NPD PA
Oxiconazole
nitrate NPD PA Soolantra PB
Oxistat NPD PA Soriatane NPD
Oxsoralen Ultra NPD Sorilux Foam NPD PA
Pandel NPD PA spinosad G
Panretin Gel NPD PA SSD cream LCG
penciclovir Sulconazole
G QL cream/solution NPD PA
cream
Penlac NPD PA Sulfamylon NPD

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
44
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
Synalar NPD PA Xaciato Gel NPD PA
Taclonex NPD Xerese Cream NPD PA
Taltz Xolegel NPD PA
Autoinjector NPD, SP PA
Ziana NPD PA, AL
Targretin gel NPD, SP PA Zilxi Aer NPD PA
tavaborole soln Zonalon cream
G PA NPD QL
5% 5%
Tazarotene AER NPD PA, AL Zoryve Cream NPD PA
0.1%
Zovirax cream NPD QL
tazarotene gel G AL
Zovirax oint NPD
Tazorac cream/
gel NPD PA, QL Ztlido Patch NPD PA, QL
Temovate NPD Zyclara Cream NPD PA
Texacort soln NPD PA
Zyclara Pump NPD PA
Topicort NPD PA
Tremfya PB, SP PA EAR, NOSE, THROAT MEDICATIONS
tretinoin gel, acetasol HC,
G AL
cream acetic acid HC G
Tretinoin otic
microspheres NPD AL azelastine G
gel
Bactroban nasal
triamcinolone oint PB
G
acetonide
Cetraxal NPD
Triamcinolone
oint 0.05% NPD PA cevimeline hcl G
Trianex NPD PA Ciprodex NPD
triderm cream LCG ciprofloxacin G
Tritocin oint ciprofloxacin-
NPD PA dexamethasone G
0.05% otic susp
Twyneo 0.1-3% Ciprofloxacin-
Cream NPD PA, AL
fluocinolone PF NPD
Ultravate NPD PA otic soln
Vectical NPD cortane B otic G
Veltin NPD PA, AL drops
Verdeso NPD PA Dermotic NPD
Veregen Oint NPD PA, QL Evoxac NPD PA
Vtama Cream NPD PA fluocinolone G
acetonide oil
Vusion NPD PA
mometasone
Winlevi Cream G PA
NPD PA furoate nasal spray
1%
Nasonex NPD PA
Wynzora Cream NPD

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
45
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
neomycin/ Armour Thyroid NPD
polymyxin/ LCG Axiron NPD PA
hydrocortisone
Bafiertam DR
ofloxacin otic LCG Cap PB, SP
olopatadine G Baqsimi PB
Omnaris NPD Basaglar NPD PA, QL
Patanase NPD PA betaine powder G, SP
pilocarpine HCl G Breeze2
Qnasl NPD PA Glucometer PB PA, QL
ribavirin G, SP Breeze2
Test Strips NPD PA, QL
Ryaltris Spray
NPD PA Bydureon PB PA
665-25mcg/act
Salagen NPD Byetta PB PA
Virazole NPD, SP Bynfezia Pen NPD, SP PA
Vuity NPD PA calcitriol G
Xhance NPD PA capsules
Zetonna Carnitor NPD
NPD
Cetrotide Kit NPD, SP R
DIABETES, THYROID, STEROIDS, & OTHER
cinacalcet G
MISCELLANEOUS HORMONES
Contour
acarbose G Glucometer PB QL
Actos NPD PA Contour Next
Test Strips PB QL
Adthyza tab NPD
Adlyxin NPD PA Contour
Test Strips PB QL
Admelog NPD PA, QL
Cortef NPD
Afrezza NPD PA
Cortisone tab NPD
Alkindi Sprinkle
Cap NPD PA Cytomel NPD
Alogliptin benz/ danazol G
metformin hcl PB
DDAVP NPD PA
Alogliptin benz/ Degludec
pioglitazone PB NPD PA, QL
Flextouch Inj
Alogliptin Delatestryl NPD PA
benzoate PB
Demser NPD
Amaryl NPD PA
desmopressin
Androderm G
NPD PA acetate
patch
Desmopressin
Androgel 1.62% Nasal Soln NPD
Packet, Pump NPD PA
Dexabliss tab
Androgel 1% NPD PA 1.5mg NPD
Apidra NPD PA, QL

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
46
 DRUG
DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER
TIER LIMITS
LIMITS TIER LIMITS
dexamethasone G Freestyle
dexamethasone InsuLinx NPD PA, QL
tablet 6-day, G Test Strips
10-day, 13-day FreeStyle Libre
Dexcom Reader, Sensor, NPD PA, QL
Continuous Reader Device
Glucose PB PA, QL Freestyle Lite
Test Strips NPD PA, QL
Monitor
Receiver Freestyle
Test Strips NPD PA, QL
Dexcom
Continuous Genotropin NPD, SP PA
Glucose PB PA, QL
Monitor glimepiride G
Transmitter glipizide G
Dexcom glipizide ER G
Continuous glipizide XL G
Glucose PB PA, QL
Monitor G7, G6, Glucagen Inj
Hypokit NPD PA
G5, G4 Sensors
Dexpak pak glucagon
NPD emergency kit G
10-day, 13-day
(generic)
diazoxide
suspension G Glucagon
50mg/ml Emergency Kit NPD PA
(Lilly)
doxercalciferol G
Glucophage NPD
Duetact NPD PA
Glucophage XR NPD
Dxevo 11-day
Pak 1.5mg NPD Glucotrol XL NPD PA
Emflaza NPD PA Glucovance NPD
Enspryng Inj NPD, SP PA glyburide G
Ermeza Soln NPD PA glyburide G
micronized
euthyrox G
Glynase NPD
Evrysdi Soln NPD, SP PA
Glyset NPD
Farxiga PB
Glyxambi PB
Fiasp NPD PA, QL
Gvoke HypoPen NPD PA
fludrocortisone G Gvoke PFS inj NPD PA
acetate
Fortamet NPD PA Hectorol NPD
Forteo NPD, SP PA, Q/T Hemady NPD
Fortesta NPD PA Humalog NPD PA, QL
Freestyle Humatrope NPD, SP PA
Glucometer PB PA, QL
Humulin NPD PA, QL

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
47
 DRUG REQUIREMENTS/
REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS
LIMITS TIER LIMITS
Humulin levo-T tab G
R U-500 levoxyl G
(Concentrated PB QL
and KwikPen) Lilly Glucagon
NPD PA
hydrocortisone G Emergency Kit
Increlex NPD, SP PA, LDD liothyronine G
Insulin aspart Lyumjev Inj/
NPD PA, QL NPD PA, QL
inj Pen
Insulin aspart Medtronic
protamin inj NPD PA, QL Continuous
flexpen Glucose NPD PA, QL
Monitor
Insulin Receiver
Degludec Inj NPD PA, QL
Medtronic
Insulin Glargine NPD PA, QL Continuous
Insulin lispro Glucose
NPD PA, QL Monitor NPD PA, QL
100 units/ml
Insulin lispro inj Guardian
junior NPD PA, QL Transmitter
Insulin lispro Medtronic
inj protamin NPD PA, QL Continuous
Glucose
Invokamet [XR] NPD PA Monitor Enlite, NPD PA, QL
Invokana NPD PA MiniMed
Janumet PB Guardian
Sensors
Janumet XR PB
Medrol NPD
Januvia PB
metformin LCG
Jardiance PB
Metformin
Jatenzo NPD PA 625mg NPD PA
Jentadueto metformin ER
tablet NPD PA
(generic for G
Jentadueto XR NPD PA Glucophage XR)
Kazano tablet NPD PA metformin HCL G AL
500mg/5ml soln
Kesimpta Inj PB, SP
metformin/
Kombiglyze XR PB glyburide G
Korlym tablet NPD, SP PA methimazole G
Kyzatrex NPD PA Methitest Tab NPD PA
Lantus PB QL methylpred-
Levemir NPD PA, QL, AL G
nisolone
levocarnitine LCG methylpred-
Levothyroxine nisolone therapy G
cap NPD PA pak
levothyroxine tab G

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
48
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
methyltest- Orilissa PB PA, QL
G PA
osterone Oseni NPD PA
metyrosine G Oxandrin NPD
miglitol G oxandrolone G QL
Millipred NPD PA Ozempic PB PA
Mounjaro Inj PB PA paricalcitol G
Myalept NPD, SP PA pioglitazone G
Mycapssa cap NPD, SP PA pioglitazone/ G
nateglinide G glimepiride
Natesto NPD PA Pogo Automatic
Mis Monitor PB PA, QL
Natpara NPD, SP PA
Nature-Throid NPD Pogo Automatic
Test Cartridge NPD PA, QL
Nesina tablet NPD PA
Prandin NPD
Noctiva
Emulsion NPD Precision
Glucometer PB PA, QL
Non Preferred
Diabetic Meters PB PA, QL Precision XTRA
Test Strips NPD PA, QL
Norditropin PB, SP PA
Precose NPD
Novolin PB QL
prednisolone G
Novolin R PB QL
Prelone NPD
Novolin Relion NPD PA, QL
Procysbi NPD, SP PA
Novolog PB QL
Proglycem Susp NPD
Novolog Relion NPD PA, QL
propylthiouracil G
NP thyroid G
Qtern NPD PA
Nutropin AQ PB, SP PA
Rayos NPD PA
Omnipod 5
Pack PB Regranex gel NPD PA
Omnipod Dash repaglinide G
System PB Rezvoglar Inj NPD PA, QL
Omnipod Dash Riomet [ER]
5 Pack PB solution/
suspension NPD AL
Omnipod
Starter Kit PB 500mg/5ml
Omnitrope NPD, SP PA Rocaltrol
capsules NPD
One Touch
Glucometers PB PA, QL Rybelsus PB PA, QL
One Touch Saizen NPD, SP PA
Test Strips NPD PA, QL
Segluromet NPD PA
Onglyza PB Semglee Inj
NPD PA, QL
Orapred ODT NPD 100U/ml

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
49
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
Sensipar NPD PA Veripred soln
20mg/5ml NPD
Serostim NPD, SP PA, LDD
Signifor NPD, SP PA Victoza PB PA
Skytrofa NPD, SP PA Vogelxo NPD PA
Soliqua PB Wegovy Inj NPD PA, R
Somavert NPD, SP PA Westhroid NPD
Starlix NPD WP Thyroid NPD
Steglatro NPD PA Xigduo XR PB
Steglujan NPD PA Xultophy NPD PA
Striant buccal Xyosted Soln NPD PA
system NPD PA
Zcort 7-day tab NPD
Symlin PB PA Zegalogue Inj PB
Synjardy PB Zemplar NPD
Synjardy XR PB Zomacton NPD, SP PA
Synthroid NPD
STOMACH, ULCER, & BOWEL MEDS
Tanzeum NPD PA
Tapazole NPD Aciphex NPD PA, QL
Teriparatide inj PB, SP PA, Q/T Aciphex
Sprinkle NPD PA, QL, AL
Testim Gel NPD PA
testosterone gel Actigall NPD
G PA Amitiza NPD PA
10mg/act (2%)
testosterone gel amoxicill-
G PA clarithro- G
1%, 1.62%
testosterone lansoprazole
solution G PA Ampyra NPD, SP PA, QL
30mg/act Anusol-HC
cream NPD PA
Thyquidity Soln NPD PA, AL
Tirosint NPD PA aprepitant G QL
Tlando NPD PA Asacol HD NPD PA
tolbutamide G Azulfidine NPD PA
Toujeo Solostar PB QL balsalazide G
Tradjenta tablet NPD PA Bentyl NPD
Tresiba NPD PA, QL, AL bismth/metr/cap G
Trijardy XR PB tetracycline
Trulicity PB PA Bonjesta NPD PA
Tymlos PB, SP PA, Q/T budesonide ER G
tab
Uceris NPD PA
Bylvay PB, SP PA
unithroid G
Canasa supp NPD PA

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
50
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
Carafate tabs/ Golytely
susp NPD PA solution
reconstituted NPD PA
Chenodal NPD, SP
227.1gm
chlordiaze- G Golytely
poxide/clidinium
solution
Cholbam NPD, SP PA reconstituted NPD PA, QL
cimetidine G 236gm
Clenpiq Soln NPD granisetron G
Colazal NPD PA Hemmorex-HC
Supp NPD PA
Colocort NPD
Creon PB hydrocortisone LCG
cream
cromolyn sodium G hydrocortisone
solution G
retention enema
Cytotec NPD
Ibsrela NPD PA
Delzicol NPD PA
Konvomep Soln NPD PA
Dexilant NPD PA, QL
Kristalose Pak NPD PA
dexlansoprazole G PA, QL
Lactulose pak NPD PA
dexlansoprazole G PA, QL lactulose soln G
DR cap
Diclegis NPD PA lansoprazole cap G QL
dicyclomine G lansoprazole G PA, QL
solutab
diphenoxylate
HCl/atropine G Lialda NPD
doxylamine- Linzess PB
G PA Livmarli Sol NPD, SP PA
pyridoxine
dronabinol G Lomotil NPD
Emend NPD QL loperamide G
Emverm NPD QL lubiprostone cap G
Endari powder NPD PA Marinol NPD
Entocort EC NPD PA meclizine LCG
esomeprazole G PA, QL mesalamine G
esomeprazole mesalamine DR G
G PA, QL
granules mesalamine G
Esomeprazole rectal susp
strontium NPD PA, QL
metoclopramide G
famotidine 40mg Metoclopramide
G NPD
tab, suspension odt
Gastrocrom NPD misoprostol LCG
Gattex NPD, SP PA Motegrity tab NPD PA
Gimoti Spray NPD PA, Q/T Movantik NPD PA

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
51
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
MoviPrep Protonix
packets NPD PA, QL
Solution
Reconstituted NPD PA
Pylera NPD
100gm Oral
rabeprazole DR
Nexium capsule NPD PA, QL G QL
tab 20mg
Nexium packets NPD PA, QL, AL Rabeprazole
nizatidine Sprinkle Cap NPD PA, QL
G
solution 10mg
Nulytely NPD PA, QL ranitidine 300mg G
Omeclamox-Pak NPD Ravicti NPD, SP PA
omeprazole G QL Recorlev 150mg
Tab NPD, SP PA, QL
ondansetron HCl LCG
Orlistat Cap NPD PA, R Reglan NPD
Osmoprep tab NPD PA Relistor NPD PA
Pancreaze NPD PA Reltone NPD PA
pancrelipase EC/ scopolamine
G G
SA patch
pantoprazole G QL SFRowasa
enema NPD
pantoprazole pak G PA, QL
sodium/
peg-kcl-nacl- potassium sol G
nasulf-na asc-c G magnesium
soln reconstituted
sucralfate tabs G
PEG 3350 &
electrolytes G sulfasalazine G
Peg-Prep NPD QL Suprep Bowel
Prep Kit NPD
Pentasa NPD
Sutab NPD
Pepcid tabs,
suspension NPD PA Symproic PB
Pertzye NPD PA Syndros NPD
Pheburane Mis Tarpeyo NPD PA, QL
483/gm NPD, SP PA
Tigan NPD
Plenvu Soln NPD PA Transderm-
Scop patch NPD
Prevacid caps NPD PA, QL
Prevacid trimetho-
NPD PA, QL G
SoluTab benzamide
Prilosec packets NPD PA, QL Trulance NPD PA
prochlorperazine Urso 250 Tab NPD PA
G Urso Forte Tab
suppository NPD PA
prochlorperazine Ursodiol Cap NPD PA
G
tabs ursodiol tab G
Protonix NPD PA, QL Varubi NPD

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
52
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
Viberzi NPD PA carisoprodol G
Viokace NPD PA Celebrex NPD PA
Voquezna Pak NPD celecoxib G
Xenical NPD PA, R chlorzoxazone
Xermelo NPD PA 375mg, 500mg, G
Zantac NPD 750mg
Zegerid packets NPD PA, QL Cimzia PB, SP PA
Zelnorm Colchicine Cap
NPD PA 0.6mg NPD
Zenpep PB colchicine 0.6mg
Zofran NPD G
tab
Zorbtive NPD, SP PA colchicine/ G
Zuplenz NPD probenecid
Colcrys NPD PA
BONE, JOINT, & MUSCLE
Cuprimine NPD, SP PA
Actemra SC NPD, SP PA Cuvposa NPD
Actonel NPD PA, QL cyclobenzaprine LCG
alendronate LCG QL Cyclobenza-
prine ER NPD PA
allopurinol G
Allopurinol Dantrium NPD
200mg Tab NPD PA
dantrolene G
alosetron hcl G Dartisla ODT NPD PA, QL
Amjevita Inj PB, SP PA Diclofenac
Amrix NPD PA epolamine
transdermal NPD PA, QL
Anaprox DS NPD PA 1.3%
Arava NPD PA diclofenac
Arcalyst NPD, SP PA G
potassium
Arthrotec NPD PA diclofenac G
Atelvia NPD QL sodium DR
baclofen G diclofenac G
sodium ER
Baclofen
5mg/5ml soln NPD PA diclofenac G
sodium soln 1.5%
Binosto NPD PA, QL
diclofenac soln G PA
Boniva NPD PA, QL 2%
calcitonin- diclofenac/
G G
salmon inj misoprostol
calcitonin- EC-Naprosyn NPD PA
salmon G Enbrel PB, SP PA
(rDNA origin)
nasal spray etidronate G
disodium

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
53
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
etodolac G meclofenamate G
febuxostat G PA meloxicam cap G PA
Feldene NPD Meloxicam susp NPD PA
Fenoprofen meloxicam tab LCG
calcium NPD PA
Metaxalone NPD PA
Fenortho NPD PA Miacalcin NPD
fesoterodine tab Mitigare NPD PA
G
ER
Mobic NPD PA
Fexmid NPD
nabumetone G
Flector Patch NPD PA, QL
Nalfon NPD PA
Fleqsuvy Susp
NPD PA, QL Naprelan NPD PA
25mg/5ml
Naprosyn NPD PA
flurbiprofen G
Naprosyn susp NPD AL
Fosamax NPD QL
naproxen sodium LCG
Fosamax Plus D NPD QL
naproxen sodium
Gloperba Soln NPD PA G
DR
glycopyrrolate naproxen sodium
oral solution G G
ER
1mg/5ml
naproxen sodium
glycopyrrolate G PA
G ER 750mg
tab
naproxen sodium
Humira PB, SP PA G AL
susp
ibandronate G QL Norgesic Forte
Tab NPD PA
ibuprofen LCG
indomethacin G Norgesic Tab NPD PA
Indomethacin Olumiant NPD, SP PA
20mg capsule NPD PA
Orencia NPD, SP PA
indomethacin SR G Orphenadrine-
asa-caffeine NPD PA
Ketoprofen
25mg cap NPD PA
orphenadrine ER G
ketoprofen ER G Orphengesic
Forte Tab NPD PA
ketorolac G
Ketorolac sol Otezla PB, SP PA
tromethamine NPD PA, QL
Otrexup NPD PA
Kevzara NPD, SP PA oxaprozin G
Kineret NPD, SP PA Ozobax Soln NPD PA
leflunomide G Pennsaid NPD PA
Lorzone NPD PA piroxicam G
Lotronex NPD PA probenecid G
Lyvispah Gra NPD PA

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
54
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
raloxifene hcl G aurovela 24 FE G
Rasuvo PB PA 1/20
risedronate G QL Aygestin NPD
risedronate DR G QL Balcoltra NPD
Robaxin NPD Beyaz NPD
salsalate tab G Bijuva cap NPD
silodosin G blisovi 24 FE G
1/20
Simponi PB, SP PA
Bravelle NPD, SP PA, QL, R
Skelaxin NPD PA
Brevicon NPD
Soma NPD PA
Cenestin PB
Sotyktu NPD, SP PA
cetrorelix inj G, SP
Stelara PB PA
charlotte 24
sulindac G G
chew FE 1/20
tizanidine LCG Cleocin vaginal NPD PA
tolmetin G Climara patch PB
Toviaz NPD PA clomiphene
Uloric NPD PA G
citrate
Viibryd NPD PA Crinone Gel 4% NPD
vilazodone G Crinone Gel 8% NPD PA
Voltaren Gel NPD Cyclessa NPD
Xeljanz [XR] PB, SP PA Depo SubqQ
Provera NPD QL
Zanaflex NPD PA
Zeposia NPD, SP Depo-Provera NPD QL
Zipsor NPD PA, QL Desogen NPD
Zurampic desogestrel-
NPD PA G
ethinyl estradiol
200mg
Diflucan NPD PA
Zyloprim NPD PA
FEMALE, HORMONE REPLACEMENT, & Divigel NPD
BIRTH CONTROL drospirenone- ACA
ethinyl estradiol
The Injectable Fertility Agents in this section are
eluryng mis ACA QL
covered only under certain benefits programs.
Please check your handbook to determine coverage. Endometrin
Insert 100mcg PB
Activella NPD Vaginal
Addyi NPD PA Estrace Cream NPD PA
Alora NPD PA Estrace Tab NPD
Angeliq NPD PA estradiol G
Annovera Mis NPD QL estradiol cream G
0.1%

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
55
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
estradiol medroxypro-
G
transdermal gesterone LCG
Estring PB acetate tab
estropipate G melodetta chew G
24 FE
Estrostep FE NPD
Menest NPD
Evista NPD PA
Menopur NPD, SP PA, QL, R
fayosim tab G
Metrogel
Femcon FE NPD vaginal NPD
FemHRT NPD metronidazole LCG
Femring NPD PA metronidazole G
finzala chew FE vaginal gel
G
1/20 mibelas 24 chew G
Follistim AQ PB, SP QL, R FE
Gemmily cap microgestin 24
ACA G
1/20 FE 1/20
Generess FE NPD Minastrin 24 FE NPD
Gonal-f NPD, SP PA, QL, R Minivelle NPD PA
hailey 1.5/30 ACA Mircette NPD
hailey 24 FE Myfembree PB PA
G Natazia NPD
1/20
Imvexxy PB Nextstellis NPD
Intrarosa NPD PA nore/eth/fer chew G
junel FE 24 tab G 0.4mg-35mcg
kaitlib FE chew G norethin-ethynil- G
fer cap 1/20
layolis FE chew G
norethindrone G
leena tab G
norethindrone
levonorgestrel- G
G acetate
ethinyl estradiol
norethindrone-
levonorgestrel/ ACA
ACA ethinyl estradiol
my way/next dose
norethindrone-
Loestrin NPD ACA
mestranol
Lo Loestrin FE PB norgestimate- ACA
Loseasonique NPD ethinyl estradiol
lyllana Dis G norgestrel-ethinyl ACA
estradiol
Lysteda NPD
Nuvaring NPD QL
medroxypro-
gesterone OB Complete NPD PA
ACA QL
acetate Oriahnn cap PB PA
suspension IM Ortho Micronor NPD

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
56
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
Ortho Novum NPD Yasmin NPD
Ortho Tri- YAZ NPD
Cyclen NPD
yuvafem G
Ortho Tri- Zafemy DIS ACA QL
Cyclen Lo NPD
Ortho Cyclen NPD EYE MEDICATIONS
Ovidrel PB, SP R Acular/Acular LS NPD
Plan B One-Step NPD QL Alcaine NPD
Premarin PB Alocril Soln NPD PA
Premarin Alphagan P
vaginal cream PB NPD
0.15% soln
Premphase PB Alphagan P
0.01% soln PB
Prempro PB
progesterone, Alrex NPD PA
G
micronized apraclonidine G
Prometrium NPD atropine sulfate G
Provera NPD azelastine HCL G
Quartette NPD drops
raloxifene G Azopt NPD
Safyral NPD bacitracin ophth G
Seasonique NPD bacitracin/
Slynd NPD polymyxin B G
ophth oint
Synarel NPD
bepotastine G
tarina 24 FE tab G
Bepreve NPD PA
Taytulla NPD
Besivance PB
terconazole G Betagan NPD
cream
tilia FE tab G betaxolol G
tri-legest FE G Betimol NPD
Tri-norinyl NPD Betoptic S NPD PA
Twirla Dis NPD QL bimatoprost G
tydemi tab G Bleph 10 NPD
Vagifem NPD PA Blephamide
S.O.P. ointment NPD
Vandazole NPD
brimonidine
Vivelle Dot NPD PA G
tartrate
Vyleesi NPD PA, QL brimonidine/
wymzya Fe tablet timolol soln G
G 0.2-0.5%
chewable
xulane ACA QL

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
57
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
brinzolamide sus flurbiprofen G
G
1% FML Liquifilm
Bromsite sol suspension NPD
0.075% NPD PA
gentak oint 0.3% G
carteolol G OP
Cequa Sol gentamicin ophth LCG
NPD PA, QL
0.09% homatropine LCG
Ciloxan Sol NPD opthalmic
ciprofloxacin G homatropaire sol G
5% OP
Combigan soln
NPD Ilevro Susp 0.3% NPD PA
0.2-0.5%
Cosopt NPD Inveltys Susp 1% NPD
Cosopt PF NPD Iopidine NPD
cromolyn ophth G Isopto Carpine NPD
Cyclogyl NPD Istalol Drops NPD
cyclopentolate ketorolac opth
G G
HCl soln
cyclosporine Lastacaft NPD PA
G QL latanoprost
emulsion G
Cystadrops Soln NPD, SP PA, QL levobunolol G
dexamethasone levofloxacin
G G
ophth ophth soln
Diamox Sequels NPD Lotemax [SM] NPD
diclofenac soln loteprednol susp G
G 0.5%
0.1% opth
difluprednate Lumigan PB
G
emu Maxitrol NPD
dorzolamide HCl methazolamide G
G
2%
Moxeza NPD
dorzolamide- G moxifloxacin
timolol G
ophthalmic soln
Durezol Emu NPD
Mydriacyl NPD
Elestat NPD
neomycin/
epinastine HCl G polymyxin B/ G
erythromycin dexamethasone
etyhylsuccinate G Neosporin soln NPD
susp
Nevanac Susp
erythromycin 0.1% NPD PA
G
ophth oint
Ocufen NPD
Eysuvis Ophth NPD
Ocuflox NPD
fluorometholone G
ofloxacin G

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
58
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
olopatadine hcl G Timoptic NPD
Omnipred NPD Timoptic XE NPD
Oxervate soln Tobradex NPD
200mcg/ml NPD, SP PA, QL
tobramycin-
Patanol G
NPD dexamethasone
Phospholine tobramycin
Iodide PB LCG
ophthalmic
pilocarpine G Tobrex NPD
polymyxin B/neo/ Travatan Z NPD
G
bacitracin travoprost G
polymyxin B/neo/ trifluridine G
G
gramicidin
trimethoprim
polymyxin B/ sulfate/ G
trimethoprim LCG polymyxin B
soln
trimethoprim tab G
Polytrim NPD
tropicamide LCG
Pred-Forte NPD PA
Trusopt NPD
prednisolone G Tyrvaya Sol NPD QL
acetate
prednisolone Upneeq Soln NPD PA
sodium LCG Verkazia Emu
phosphate 0.1% NPD QL, PA
prednisolone/ Vigamox NPD
sodium G Viroptic NPD
sulfacetamide
Vyzulta Soln
Prolensa sol 0.024% OP NPD PA
0.07% PB
Xalatan NPD
proparacaine G
Xelpros
Rescula NPD PA Emulsion NPD PA
Restasis 0.005%
Emulsion 0.05 NPD QL Xiidra PB
% Ophthalmic
Zerviate Drops
Restasis 0.24% NPD PA
Multiodose PB QL
Zioptan NPD PA
Rhopressa Soln
0.02% NPD Zymaxid NPD
Rocklatan Soln ALLERGY, COUGH & COLD, LUNG MEDS
0.02-0.005% NPD PA
Simbrinza Susp Accolate NPD AL
1-0.2% PB PA
acetylcysteine G
sulfacetamide G Advair Diskus PB
tafluprost soln G Advair HFA PB
timolol ophth G Aerospan NPD PA
Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
59
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
AirDuo Brovana Neb NPD
Digihaler NPD PA
budesonide susp. G
AirDuo Budesonide-
NPD PA NPD PA
RespiClick formoterol
albuterol AER carbinoxamine G
G QL
HFA Cayston NPD, SP PA
albuterol
sulfate er G cheratussin AC G 5DS, QL, AL, MME
albuterol sulfate cheratussin DAC G 5DS, QL, AL, MME
nebulizer soln, G Clarinex NPD PA
syrup, tab Clarinex-D NPD PA, AL
Alvesco NPD PA clemastine syrup NPD PA
Anoro Ellipta PB clemastine tab G
arformoterol neb Combivent
G PB
15/2ml Respimat
ArmonAir cromolyn
Digihaler NPD PA G
inhalation soln
ArmonAir cyproheptadine LCG
RespiClick NPD PA
dalfampridin ER G, SP PA, QL
Arnuity
Ellipta PB Daliresp NPD
Asmanex NPD PA desrx gel 0.05% G
Asmanex HFA NPD PA Dexchlor-
pheniramine NPD PA
Atrovent HFA PB soln
Auvi-Q 0.1mg NPD QL, AL Duaklir NPD PA
Auvi-Q 0.15mg Dulera NPD PA
and 0.3mg NPD PA, QL
Dymista NPD PA
azelastine G Elixophyllin
nasal spray NPD
Elixir
azelastine/
fluticasone spray G PA Epinephrine
pen 0.15mg PB QL
137-50
Beconase AQ NPD PA epinephrine pen G QL
0.3mg
benzonatate LCG
EpiPen NPD PA, QL
Bevespi
Aerosphere NPD PA EpiPen Jr. NPD PA, QL
bosentan G, SP PA Esbriet NPD, SP PA, LDD
Breo Ellipta PB Filspari tab NPD, SP PA
Breztri Flovent Diskus PB
Aerosphere PB Flovent HFA PB
bromfed DM G flunisolide G
Bronchitol Cap NPD PA

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
60
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
Flutic/Vilan Kuvan NPD, SP PA
INH NPD PA
levalbuterol neb G
Fluticasone HFA NPD PA Levalbuterol
AER tartrate HFA NPD QL
fluticasone Lonhala
propionate nasal G Magnair Soln NPD PA
susp
metaproterenol G
Fluticasone/
Salmeterol AER NPD PA montelukast LCG
sodium
fluticasone-
salmeterol AER G Nucala Soln PB, SP PA
powder Obredon NPD QL, 5DS, AL, MME
formoterol neb Odactra SL NPD PA
G
20/2ml Ofev NPD, SP PA
Grastek NPD PA Oralair NPD PA
Hycofenix NPD QL, 5DS
Palforzia cap/
hydrocodon-cpm- QL, 5DS, AL, powder NPD, SP PA
G
phenylephrine MME
Perforomist Neb NPD
hydrocod-cpm- QL, 5DS, AL,
G pirfenidone G, SP PA
pseudoephedrine MME
hydrocodone bit/ QL, 5DS, AL, ProAir
G Digihaler NPD PA, QL
homatrop syrup MME
hydrocodone- ProAir HFA NPD QL
QL, 5DS, AL, ProAir
chlorphenira- G MME NPD QL
mine susp RespiClick
hydromet G QL, 5DS, AL, MME promethazine G
hydroxyzine HCL promethazine/
LCG LCG QL, 5DS, AL, MME
syrup codeine
hydroxyzine HCl promethazine/
LCG
tabs dextrometh- G
hydroxyzine orphan
pamoate LCG
promethazine/ G
HyperSal NPD phenylephrine
Incruse Ellipta NPD PA Proventil HFA NPD PA, QL
ipratropium- Pulmicort
G Flexhaler PB
albuterol
ipratropium Pulmicort
G Respules NPD PA
inhalation soln
ipratropium Pulmozyme PB, SP
G
nasal spray Qvar NPD PA
Isturisa NPD, SP QL, PA Ragwitek NPD PA
Javygtor Pak NPD, SP PA Rebetol NPD, SP
Kitabis Pak NPD, SP PA, LDD Rezira NPD QL, 5DS, AL, MME

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
61
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
roflumilast G Vistaril NPD
Ryclora NPD PA Vituz NPD QL, 5DS, AL, MME
Ryvent NPD VoSpire ER NPD
sapropterin pow/ wixela inhub aer G
G, SP PA
tab Xhance NPD PA
Seebri NPD PA Xolair Inj PB, SP PA
Semprex-D NPD QL Xopenex
Serevent Diskus PB Nebulization NPD PA
Singulair NPD PA Soln
sodium chloride Xopenex HFA NPD PA, QL
G Yupelri Soln NPD PA
inhalation
Spiriva PB Z-Tuss AC NPD QL, 5DS, AL, MME
Stiolto Respimat PB zafirlukast G AL
Striverdi zileuton ER 600mg G PA
Respimat Aer PB Zutripro NPD QL, 5DS, AL, MME
Solution
Zyflo 600mg tab NPD PA
Symbicort PB
Zyflo CR 600mg NPD AL
Symdeko NPD, SP PA
Symjepi Inj NPD QL URINARY & PROSTATE MEDS
terbutaline Accrufer NPD PA
G
sulfate tabs
alfuzosin G
Tessalon Perles NPD
Anaspaz NPD
Tezspire Inj NPD, SP PA
Avodart NPD PA, AL
Theo-24 PB
bethanechol G
theochron G
Cardura NPD PA
theophylline soln G
Caverject PB PA, QL
theophylline G Cialis NPD PA, QL
extended release
Thiola [EC] NPD, SP darifenacin ER G
tiopronin G, SP Detrol NPD PA
Tracleer NPD, SP PA Detrol LA NPD PA
Trelegy Ellipta PB Ditropan XL NPD PA
Tudorza doxazosin
NPD PA G
Pressair mesylate
Tussicap NPD QL, 5DS, AL, MME dutasteride G AL
Tuxarin ER tabs NPD QL, 5DS, AL, MME dutasteride/ G
tamsulosin hcl
Tuzistra XR NPD QL, 5DS, AL, MME
Edex NPD PA, QL
Utibron
NPD PA ED-Spaz NPD
Neohaler
Ventolin HFA NPD PA, QL Elmiron NPD PA

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
62
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
Enablex NPD Urecholine NPD
finasteride G AL Urocit-K NPD
flavoxate G Uroxatral NPD PA
Flomax NPD PA vardenafil G PA, QL
Gelnique Gel NPD PA vardenafil ODT G PA, QL
Gemtesa NPD PA Vesicare NPD PA
hyoscyamine LCG Viagra NPD PA, QL
hyosyne G
VITAMINS & ELECTROLYTES
IFE-PG 20 NPD PA, QL
Jalyn NPD PA Brand Prenatal
Vitamins NPD PA
Levbid NPD
Buphenyl NPD, SP PA
Levitra NPD PA, QL
Calciferol NPD
Levsin NPD
Dailyvite w/Zinc
Muse PB PA, QL & NephlexRx NPD
Myrbetriq PB Dojolvi Liq NPD PA
Nulev NPD Duzallo NPD PA
oscimin LCG ergocalciferol G
Oxybutynin Sol fluoritab chew
5mg/5ml NPD PA LCG
tab
oxybutynin syrup LCG Fosrenol NPD
oxybutynin [XR] G Jynarque NPD, SP PA
Oxytrol Patch NPD PA K-Phos NPD
phenazopyridine G K-Tab NPD
potassium citrate klor-Con G
G
ER
lanthanum
Proscar NPD AL G
chewable tab
Pyridium NPD Lokelma PAK NPD
Rapaflo NPD PA Mephyton NPD
solifenacin G multivitamin with
Staxyn NPD PA, QL fluoride drops, G
Stendra NPD PA, QL tabs
Symax NPD Nascobal NPD PA
tamsulosin G nebusal
nebulization G
terazosin G solution
tolterodine Nestabs One NPD PA
G
tartrate
Phospho-trin
tolterodine tab K500 NPD
G
tartrate LA
phytonadione tab G
trospium chloride G

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
63
 DRUG REQUIREMENTS/ DRUG REQUIREMENTS/
DRUG NAME + DRUG NAME +
TIER LIMITS TIER LIMITS
potassium Doptelet NPD, SP PA
bicarbonate/ Empaveli Inj NPD, SP PA
G
potassium citrate
effervescent Exjade NPD PA
potassium Ferriprox NPD PA
G
chloride Firazyr NPD, SP PA, QL
pulmosal Firdapse NPD, SP PA
nebulization G Galafold NPD, SP PA, QL
solution
ganirelix acetate
Quflora NPD G, SP R
soln
Rayaldee NPD PA Haegarda NPD, SP PA
sodium fluoride icatibant inj G, SP PA
G
chew tab
Idelvion NPD, SP PA
sodium
phenylbutyrate G, SP Jadenu tab/
granules NPD PA
tab
Tri-Vi-Flor, Keveyis NPD, SP PA
Poly-Vi-Flor kionex
NPD G
with and suspension
without iron Metopirone NPD
DIAGNOSTICS & MISCELLANEOUS AGENTS midodrine HCl G
miglustat G, SP PA
Berinert NPD, SP PA
nitisinone G, SP PA
Cablivi Kit NPD, SP QL
Nityr NPD, SP PA
calcium acetate G
Novarel
Carbaglu NPD, SP PA 5000 units NPD, SP
carglumic G, SP PA Novarel
Cerdelga NPD, SP PA 10000 units PB, SP
Chemet PB Nulibry Inj NPD, SP PA
Chorionic Ocaliva NPD, SP PA
gonadotropin NPD, SP
Orfadin NPD, SP PA
Cinryze NPD, SP PA Orladeyo NPD, SP PA
clovique G, SP PA Oxbryta NPD, SP PA
Cystadane NPD, SP Palynziq NPD, SP PA
Cystagon NPD, SP PA penicillamine G, SP PA
deferasirox tab/ capsule
G PA
granules penicillamine G, SP
deferiprone tab G PA tablet
D-Penamine PhosLo NPD
125mg tablet NPD, SP
Phoslyra NPD PA
dichlorphenate phospha G
G, SP PA
tab

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
64
 DRUG REQUIREMENTS/
DRUG NAME + TIER LIMITS
Potaba NPD
pregnyl G, SP
Pyrukynd NPD, SP PA
Renagel NPD
Renvela NPD
Ridaura NPD, SP
Rinvoq PB, SP PA
Ruconest NPD, SP PA
Ruzurgi NPD, SP PA
sajazir inj G, SP PA, QL
sevelamer G
carbonate
Strensiq NPD, SP PA
Sucraid Solution
8500 unit/ml NPD, SP PA
Syprine NPD, SP PA
Takhzyro Inj NPD, SP PA
Tavalisse NPD, SP PA
Tavneos NPD, SP PA
Tegsedi NPD, SP PA
trientine G, SP PA
V-GO PB
Vumerity PB, SP
Xuriden NPD, SP PA
Zavesca NPD, SP PA
Zokinvy NPD, SP PA

Bold type = Brand Name Drug Lower case italic = Generic drug
PA = Prior Authorization QL = Quantity Limits Apply SP = Specialty Drug AL = Age Limit LCG = Low Cost Generic
LDD = Limited Distribution Drug 5DS = Day Supply Limit R = Requires Rider G = Generic Q/T = Quantity Over Time
PB = Preferred Brand NPD = Non Preferred Drug ACA = $0 Preventative Drug MME = Morphine Milligram Equivalent
+ = Claim Dollar Limit
65
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66
Discrimination is Against the Law
If you need these services, contact our Civil Rights
This Plan complies with applicable Federal civil rights Coordinator. If you believe that This Plan has failed
laws and does not discriminate on the basis of race, to provide these services or discriminated in another
color, national origin, age, disability, or sex. This Plan way on the basis of race, color, national origin, age,
does not exclude people or treat them differently disability, or sex, you can file a grievance with our Civil
because of race, color, national origin, age, disability, Rights Coordinator. You can file a grievance in the
or sex. following ways: In person or by mail: ATTN: Civil
Rights Coordinator, 1 9 0 1 M a r k e t S t r e e t ,
This Plan provides: P h i l a d e l p h i a , P A 1 9 1 0 3 , By phone: 1-888-377-
 Free aids and services to people with disabilities 3933 (TTY: 711) By fax: 215-761-0245, By email:
to communicate effectively with us, such as: civilrightscoordinator@[Link]. If you need
qualified sign language interpreters, and written help filing a grievance, our Civil Rights Coordinator is
information in other formats (large print, audio, available to help you.
accessible electronic formats, other formats).
 Free language services to people whose You can also file a civil rights complaint with the U.S.
primary language is not English, such as: Department of Health and Human Services, Office for
qualified interpreters and information written in Civil Rights electronically through the Office for Civil
other languages. Rights Complaint Portal, available at
[Link] or by mail
or phone at: U.S. Department of Health and Human
Services, 200 Independence Avenue SW., Room
509F, HHH Building, Washington, DC 20201, 1-800-
368-1019, 800-537-7697 (TDD). Complaint forms are
available at
[Link]

Taglines as of 12/31/2022

67
 Index
Index

acyclovir 5% cream, 17
A
acyclovir cream/oint, 41
abacavir sulfate tab, soln, 17
Aczone, 41
abacavir sulfate/lamivudine, 17
Adalat CC, 35
abacavir/lamivudine/zidovudine, 17
Adapalene 0.1% lotion, 41
Abilify, 24
adapalene 0.1% soln, 41
Abilify Mycite, 24
adapalene 0.3% gel, 41
Abilify Mycite Tab Maintenance/Starter Pak, 24
adapalene cream, 41
abiraterone, 22
Adapalene pad 0.1%, 41
Absorica, 41
adapalene-benzoyl-peroxide gel, 41
Absorica LD, 41
Adbry Inj 150mg/ml, 41
Abstral, 24
Adcirca, 35, 40
acamprosate DR tab 333mg, 24
Adderall, 24–25
Acanya, 41
Adderall XR, 25
acarbose, 46
Addyi, 55
Accolate, 59
adefovir dipivoxil, 17
Accrufer, 62
Adempas, 35
Accupril, 35
Adhansia XR Capsule, 25
Accuretic, 35
Adipex-P, 25
accutane cap, 41
Adlarity Dis, 25
acebutolol, 35
Adlyxin, 46
acetaminophen/codeine, 24
Admelog, 46
acetasol HC, acetic acid HC otic, 45
Adthyza tab, 46
acetazolamide, 35
Advair Diskus, 59
acetazolamide ER, 35
Advair HFA, 59
acetylcysteine, 59
Advate, 35
Aciphex, 50
Adynovate, 35
Aciphex Sprinkle, 50
Adzenys ER Susp, 25
acitretin, 41
Adzenys XR ODT, 25
Actemra SC, 53
Aemcolo DR, 17
Acticlate, 17
Aerospan, 59
Actigall, 50
Afinitor, 22
Actimmune, 35
Afrezza, 46
Actiq, 24
Afstyla, 35
Activella, 55
Aggrenox, 35
Actonel, 53
Agrylin, 35
Actos, 46
Aimovig, 25
Acular/Acular LS, 57
AirDuo Digihaler, 60
acyclovir, 17, 41
i
 Index
INDEX

AirDuo RespiClick, 60 Altuviiio Inj, 35

Ajovy, 25 Alunbrig tab/pak, 22
Aklief Cream 0.005%, 41 Alvesco, 60
Aktipak, 41 amantadine, 25
ala-cort cream, 41 Amaryl, 46
Ala-Scalp Lotion, 41 Ambien, 25
albendazole, 17 Ambien CR, 25
albuterol AER HFA, 60 ambrisentan, 35
albuterol sulfate er, 60 amcinonide, 41
albuterol sulfate nebulizer soln, syrup, tab, 60 Amerge, 25
Alcaine, 57 Amicar, 35
alclometasone cream, ointment, 41 amiloride, 35
Aldactazide, 35 amiloride/HCTZ, 35
Aldactone, 35 aminocaproic acid, 35
Aldara, 41 amiodarone, 35
Alecensa, 22 Amitiza, 50
alendronate, 53 amitriptyline hcl, 25
alfuzosin, 62 Amjevita Inj, 53
Alinia, 17 amlodipine, 35, 39
aliskiren, 35 amlodipine besylate/olmesartan, 35
Alkeran, 22 amlodipine/benazepril, 35
Alkindi Sprinkle Cap, 46 amlodipine/valsartan, 35
allopurinol, 53 amlodipine/valsartan/HCTZ, 35
Allopurinol 200mg Tab, 53 amoxapine, 25
Allzital 25-325mg, 25 amoxicill-clarithro-lansoprazole, 50
almotriptan maleate, 25 amoxicillin, 17
Alocril Soln, 57 Amoxicillin 775mg, 17
Alogliptin benz/metformin hcl, 46 amoxicillin/clavulanate, 17
Alogliptin benz/pioglitazone, 46 amoxicillin/clavulanate extended-release, 17
Alogliptin benzoate, 46 amphetamine aspartate/amphetamine
Alora, 55 sulfate/dextroamphetamine, 25
alosetron hcl, 53 amphetamine aspartate/amphetamine
Alphagan P 0.01% soln, 57 sulfate/dextroamphetamine ER, 25
Alphagan P 0.15% soln, 57 Amphetamine ER suspension, 25
Alphanate, 35 amphetamine tablet, 25
Alphanine, 35 amphetamine tablet (generic Evekeo), 25
alprazolam, 25 ampicillin, 17
alprazolam ER, 25 Ampyra, 50
Alprolix, 35 Amrix, 53
Alrex, 57 Amzeeq, 17
Altabax, 17 Anafranil, 25
Altace, 35 anagrelide, 35
Altoprev, 35 Anaprox DS, 53
Altreno 0.05% lotion, 41 Anaspaz, 62
anastrazole, 22
ii
 Index
INDEX

Ancobon, 17 aspirin-dipyridamole er, 35

Androderm patch, 46 Aspruzyo Spr Gra, 35
Androgel 1%, 46 Atacand, 35
Androgel 1.62% Packet, Pump, 46 Atacand HCT, 35
Angeliq, 55 atazanavir, 17
Annovera Mis, 55 Atelvia, 53
Anoro Ellipta, 60 atenolol, 35
Antabuse, 25 atenolol/chlorthalidone, 35
Antara, 35 Ativan, 25
anthralin, 41 atomoxetine, 25
Anusol-HC cream, 50 Atorvaliq Susp, 35
Apadaz, 25 atorvastatin, 35
ApexiCon E, 41 atorvastatin/amlodipine, 35
Apidra, 46 atovaquone, 17
Aplenzin, 25 atovaquone/proguanil, 17
Apo-Varenicline, 25 Atralin, 41
Apokyn Solution Cartridge 30 mg/3ml, 25 Atripla, 17
apomorphine inj 30mg/3ml, 25 atropine sulfate, 57
apraclonidine, 57 Atrovent HFA, 60
aprepitant, 50 Aubagio, 25
Aptensio XR, 25 Augmentin, 17
Aptiom, 25 Augmentin XR, 17
Arakoda, 17 aurovela 24 FE 1/20, 55
Arava, 53 Austedo, 25
Arazlo lotion 0.045%, 41 Auvelity, 25
Arcalyst, 53 Auvi-Q 0.1mg, 60
arformoterol neb 15/2ml, 60 Auvi-Q 0.15mg and 0.3mg, 60
Aricept, 25 Avalide, 35
Arikayce, 17 Avapro, 35
Arimidex, 22 Avelox, 17
aripiprazole, 25 avidoxy, 17
Arixtra, 35 avita, 41
armodafinil, 25 Avodart, 62
ArmonAir Digihaler, 60 Avonex, 25
ArmonAir RespiClick, 60 Axert, 25
Armour Thyroid, 46 Axiron, 46
Arnuity Ellipta, 60 Aygestin, 55
Aromasin, 22 Ayvakit, 22
Arthrotec, 53 Azasan, 22
Arymo ER, 25 azathioprine, 22
Asacol HD, 50 azelaic acid gel 15%, 41
asenapine tab sub, 25 azelastine, 45, 57, 60
Asmanex, 60 azelastine HCL drops, 57
Asmanex HFA, 60 azelastine nasal spray, 60

iii
 Index
INDEX

azelastine/fluticasone spray 137-50, 60 benzoyl peroxide/erythromycin, 41

Azelex, 41 benzphetamine, 25
Azilect, 25 benztropine, 25
azithromycin, 17 bepotastine, 57
Azopt, 57 Bepreve, 57
Azor, 35 Berinert, 64
Azstarys, 25 beser lotion 0.05%, 41
Azulfidine, 50 Besivance, 57
Besremi, 22
B Betagan, 57
bacitracin ophth, 57 betaine powder, 46
bacitracin/polymyxin B ophth oint, 57 betamethasone dipropionate, 41
baclofen, 53 betamethasone valerate, 41
Baclofen 5mg/5ml soln, 53 betamethasone/clotrimazole, 41
Bactrim, Bactrim DS, 17 Betapace AF, 35
Bactroban nasal oint, 45 Betaseron, 25
Bafiertam DR Cap, 46 betaxolol, 35, 57
Balcoltra, 55 bethanechol, 62
balsalazide, 50 Bethkis Neb, 17
Balversa, 22 Betimol, 57
Banzel, 25 Betoptic S, 57
Banzel Susp, 25 Bevespi Aerosphere, 60
Baqsimi, 46 Bevyxxa, 35
Baraclude, 17 bexarotene, 22
Basaglar, 46 bexarotene gel, 22
Baxdela, 17 Beyaz, 55
Bebulin, 35 Biaxin, 17
Beconase AQ, 60 bicalutamide, 22
Belbuca, 25 Bidil, 35
Belsomra, 25 Bijuva cap, 55
Belviq [XR], 25 Biktarvy, 17
benazepril, 35 Biltricide, 17
benazepril/HCTZ, 35 bimatoprost, 57
BeneFIX, 35 Binosto, 53
Benicar, 35 bismth/metr/cap tetracycline, 50
Benicar HCT, 35 bisoprolol, 35
Benlysta, 22 bisoprolol/HCTZ, 35
Bentyl, 50 Bleph 10, 57
Benzaclin, 41 Blephamide S.O.P. ointment, 57
Benzamycin gel, 41 blisovi 24 FE 1/20, 55
Benzamycinpak, 41 Boniva, 53
Benzhydrocodone-acetaminophen, 25 Bonjesta, 50
Benznidazole, 17 bosentan, 60
benzonatate, 60 Bosulif, 22

iv
 Index
INDEX

Braftovi, 22 butorphanol tartrate nasal, 26

Brand Prenatal Vitamins, 63 Butrans, 26
Bravelle, 55 Bydureon, 46
Breeze2 Glucometer, 46 Byetta, 46
Breeze2 Test Strips, 46 Bylvay, 50
Breo Ellipta, 60 Bynfezia Pen, 46
Brevicon, 55 Bystolic, 35
Brexafemme, 17 Byvalson, 35
Breztri Aerosphere, 60
brimonidine gel 0.33%, 41 C
brimonidine tartrate, 57 Cablivi Kit, 64
brimonidine/timolol soln 0.2-0.5%, 57 Cabometyx, 22
brinzolamide sus 1%, 58 Caduet, 35
Brisdelle, 25 Cafergot, 26
Briviact, 25–26 Calan, 36
Briviact soln, 26 Calan SR, 36
bromfed DM, 60 Calciferol, 63
bromocriptine mesylate, 26 calcipotriene cream, 41
Bromsite sol 0.075%, 58 Calcipotriene foam, 41
Bronchitol Cap, 60 calcipotriene-betamethasone dp oint, 41
Brovana Neb, 60 calcipotriene-betamethasone dp susp, 41
Brukinsa, 22 calcitonin-salmon (rDNA origin) nasal spray, 53
Bryhali lotion 0.01%, 41 calcitonin-salmon inj, 53
budesonide ER tab, 50 calcitriol capsules, 46
budesonide susp., 60 calcitriol ointment, 42
Budesonide-formoterol, 60 calcium acetate, 64
bumetanide, 35 Calquence, 22
Bunavail, 26 Cambia Packet, 26
Buphenyl, 63 Camzyos, 36
buprenorphine hcl/naloxone hcl, 26 Canasa supp, 50
buprenorphine patch, 26 candesartan, 36
buprenorphine SL, 26 candesartan/hydrochlorothiazide, 36
bupropion, 26 Capcof Syrup, 26
bupropion ER 150mg, 26 capecitabine, 22
Bupropion ER 450mg, 26 Capex, 42
bupropion SR, 26 Caplyta, 26
bupropion XL, 26 Caprelsa, 22
Buspar, 26 captopril, 36
buspirone, 26 captopril/HCTZ, 36
Butal/Apap Tab 25-325mg, 26 Carac, 42
Butalbital-acetaminophen 50-300mg, 26 Carafate tabs/susp, 51
butalbital/apap/caffeine, 26 Carbaglu, 64
butalbital/apap/caffeine/codeine, 26 carbamazepine, 26
butalbital/aspirin/caffeine/codeine, 26 carbamazepine susp, 26

v
 Index
INDEX

carbamazepine XR, 26 Cerdelga, 64

Carbatrol, 26 Cetraxal, 45
carbidopa, 26 cetrorelix inj, 55
carbidopa/levodopa, 26 Cetrotide Kit, 46
carbidopa/levodopa ER, 26 cevimeline hcl, 45
carbidopa/levodopa ODT, 26 Chantix, 26
carbidopa/levodopa/entacapone, 26 charlotte 24 chew FE 1/20, 55
carbinoxamine, 60 Chemet, 64
Cardizem, 36 Chenodal, 51
Cardizem CD, 36 cheratussin AC, 60
Cardizem LA, 36 cheratussin DAC, 60
Cardura, 36, 62 chlordiazepoxide, 26, 51
carglumic, 64 chlordiazepoxide/clidinium, 51
carisoprodol, 53 chlorhexidine gluconate soln, 17
carisoprodol-aspirin-codeine, 26 chloroquine phosphate, 17
Carnitor, 46 chlorothiazide, 36
Carospir, 36 chlorpromazine HCl, 26
carteolol, 58 chlorthalidone, 35–36
cartia XT, 36 chlorzoxazone 375mg, 500mg, 750mg, 53
carvedilol, 36 Cholbam, 51
carvedilol ER, 36 cholestyramine, 36
Casodex, 22 cholestyramine light, 36
Cataflam, 26 Chorionic gonadotropin, 64
Catapres tablets, 36 Cialis, 40, 62
Catapres-TTS, 36 Cibinqo Tab, 42
Caverject, 62 ciclopirox 0.77% cream, 42
Cayston, 60 ciclopirox 8% solution, 42
cefaclor, 17 ciclopirox cream, gel, shampoo, suspension, 42
cefaclor ER, 17 cilostazol, 36
cefadroxil, 17 Ciloxan Sol, 58
cefdinir, 17 Cimduo, 17
cefixime susp/cap, 17 cimetidine, 51
ceftibuten, 17 Cimzia, 53
Ceftin, 17 cinacalcet, 46
cefuroxime axetil, 17 Cinryze, 64
Celebrex, 53 Cipro, 17
celecoxib, 53 Cipro XR, 17
Celexa, 26 Ciprodex, 45
Cellcept, 22 ciprofloxacin, 17, 45, 58
Celontin, 26 ciprofloxacin ER tabs, 17
Cenestin, 55 ciprofloxacin-dexamethasone otic susp, 45
Centany 2% oint, 42 Ciprofloxacin-fluocinolone PF otic soln, 45
cephalexin, 17 citalopram, 26
Cequa Sol 0.09%, 58 Citalopram 30mg Cap, 26

vi
 Index
INDEX

Clarinex, 60 Colcrys, 53
Clarinex-D, 60 colesevelam, 36
clarithromycin, 17 Colestid, 36
clarithromycin ER, 17 colestipol HCl, 36
clemastine syrup, 60 Colocort, 51
clemastine tab, 60 Combigan soln 0.2-0.5%, 58
Clenpiq Soln, 51 Combivent Respimat, 60
Cleocin, 17, 42, 55 Combivir, 17
Cleocin T, 42 Cometriq, 22
Cleocin vaginal, 55 Complera, 18
Climara patch, 55 Comtan, 26
Clindagel, 42 Concerta, 26
clindamycin, clindamycin-benzoyl peroxide gel Condylox, 42
[w/pump], 42 Conjupri, 36
Clindamycin/ benzoyl peroxide 1-5%, 42 Contour Glucometer, 46
clindamycin/tretinoin gel, 42 Contour Next Test Strips, 46
Clindesse Cream, 17 Contour Test Strips, 46
clobazam, 26 Contrave ER, 26
clobazam susp, 26 Conzip, 26
clobetasol cream, ointment, solution, 42 Copaxone, 27
Clobex, 42 Copiktra, 22
Clocortolone pivalate, 42 Cordran, 42
clodan, 42 Coreg, 36
Cloderm, 42 Coreg CR, 36
clomiphene citrate, 55 Corgard, 36
clomipramine HCl, 26 Corifact, 36
clonazepam, 26 Corlanor, 36
clonidine ER 12 HR tab, 36 cortane B otic drops, 45
Clonidine ER 24HR tab, 36 Cortef, 46
clonidine IR tablet, 36 Cortisone tab, 46
clonidine patches, 36 Corzide, 36
clopidogrel, 36 Cosentyx, 42
clorazepate dipotassium, 26 Cosopt, 58
clotrimazole troches, 17 Cosopt PF, 58
clovique, 64 Cotellic, 22
clozapine, 26 Cotempla XR ODT, 27
clozapine ODT, 26 Coumadin, 36
Clozaril, 26 Cozaar, 36
Coagadex, 36 Creon, 51
codeine tabs, 26 Cresemba, 18
coditussin AC liquid, 26 Crestor, 36
Colazal, 51 Crinone Gel 4%, 55
colchicine 0.6mg tab, 53 Crinone Gel 8%, 55
Colchicine Cap 0.6mg, 53 Crixivan, 18
colchicine/probenecid, 53
vii
 Index
INDEX

cromolyn inhalation soln, 60 Daurismo, 22

cromolyn ophth, 58 Daxbia, 18
cromolyn sodium solution, 51 Daybue Soln, 27
Crotan Lotion, 42 Daypro, 27
Cuprimine, 53 Daytrana, 27
Cutivate, 42 Dayvigo, 27
Cuvposa, 53 DDAVP, 46
Cyclessa, 55 deferasirox tab/granules, 64
cyclobenzaprine, 53 deferiprone tab, 64
Cyclobenzaprine ER, 53 Degludec Flextouch Inj, 46
Cyclogyl, 58 Delatestryl, 46
cyclopentolate HCl, 58 Delstrigo, 18
cyclophosphamide caps, 22 Deltasone, 22
Cyclophosphamide tabs, 22 Delzicol, 51
cyclosporine, 22, 58 Demadex, 36
cyclosporine emulsion, 58 demeclocycline, 18
Cymbalta, 27 Demerol, 27
cyproheptadine, 60 Demser, 46
Cystadane, 64 Denavir, 42
Cystadrops Soln, 58 Depakene, 27
Cystagon, 64 Depakote, 27
Cytomel, 46 Depakote ER, 27
Cytotec, 51 Depakote Sprinkle Caps, 27
Cytoxan, 22 Depen Titrate, 18
Depo SubqQ Provera, 55
D Depo-Provera, 55
D-Penamine 125mg tablet, 64 Derma-Smoothe FS, 42
D.H.E.45, 27 Dermatop, 42
dabigatran cap, 36 Dermotic, 45
Dailyvite w/Zinc & NephlexRx, 63 Descovy, 18
Daklinza, 18 desipramine, 27
dalfampridin ER, 60 desmopressin acetate, 46
Daliresp, 60 Desmopressin Nasal Soln, 46
danazol, 22, 46 Desogen, 55
Danocrine, 22 desogestrel-ethinyl estradiol, 55
Dantrium, 27, 53 Desonate, 42
Dantrolene, 27 desonide gel 0.05%, 42
dantrolene, 53 Desowen, 42
dapsone gel 5%, 42 desoximetasone cream, gel, ointment, 42
dapsone gel 7.5%, 42 Desoxyn, 27
dapsone tab, 18 desrx gel 0.05%, 60
Daraprim Tab, 18 Desvenlafaxine ER 24 HR, 27
darifenacin ER, 62 Detrol, 62
Dartisla ODT, 53 Detrol LA, 62

viii
 Index
INDEX

Dexabliss tab 1.5mg, 46 dicloxacillin, 18

dexamethasone, 47, 58–59 dicyclomine, 51
dexamethasone ophth, 58 didanosine, 18
dexamethasone tablet 6-day, 10-day, 13-day, diethylpropion, 27
47 Differin 0.1% cream, 42
Dexchlorpheniramine soln, 60 Differin 0.1% lotion, 42
Dexcom Continuous Glucose Monitor G7, G6, Differin 0.3% gel, 42
G5, G4 Sensors, 47 Dificid tab/susp, 18
Dexcom Continuous Glucose Monitor Receiver, Diflorasone diacetate, 42
47 Diflucan, 18, 55
Dexcom Continuous Glucose Monitor Diflucan tab/susp, 18
Transmitter, 47 diflunisal, 27
Dexedrine, 27 difluprednate emu, 58
Dexilant, 51 digitek, 36
dexlansoprazole, 51 digox, 36
dexlansoprazole DR cap, 51 digoxin, 36
dexmethylphenidate ER, 27 dihydrocodein/APAP/caff, 27
dexmethylphenidate hcl, 27 dihydrocodeine/aspirin/caffeine, 27
Dexpak pak 10-day, 13-day, 47 dihydroergotamine inj, 27
dextroamphetamine, 25, 27 dihydroergotamine nasal spray, 27
dextroamphetamine ER, 27 Dilantin chewable tablets, 27
Dhivy, 27 Dilaudid, 27
Diacomit, 27 dilt-CD, 36
Diamox Sequels, 58 diltiazem HCl, 36
Diastat, 27 diltiazem HCl CD, 36
diazepam solution, 27 diltiazem HCl ER, 36
diazepam tabs, 27 diltiazem HCl LA, 36
diazoxide suspension 50mg/ml, 47 diltiazem HCl SR, 36
Dibenzyline, 36 diltzac ER, 36
dichlorphenate tab, 64 dimethyl fumarate DR cap, 27
Diclegis, 51 Diovan, 36
diclofenac 3% gel, 42 Diovan HCT, 36
diclofenac cap 25mg, 27 diphenoxylate HCl/atropine, 51
Diclofenac cap 35mg, 27 Diprolene, Diprolene AF, 42
Diclofenac epolamine transdermal 1.3%, 53 dipyridamole, 36
diclofenac potassium, 27, 53 disopyramide, 36
diclofenac powder, 27 disulfiram, 27
diclofenac sodium, 27, 53 Ditropan XL, 62
diclofenac sodium DR, 53 divalproex sodium, 27
diclofenac sodium ER, 53 divalproex sodium ER, 27
diclofenac sodium gel 1%, 27 divalproex sprinkle cap, 27
diclofenac sodium soln 1.5%, 53 Divigel, 55
diclofenac soln 0.1% opth, 58 dofetilide, 36
diclofenac soln 2%, 53 Dojolvi Liq, 63
diclofenac/misoprostol, 53
ix
 Index
INDEX

Dolophine, 27 Dutoprol, 36
donepezil hydrochloride, 27 Duzallo, 63
Doptelet, 64 Dxevo 11-day Pak 1.5mg, 47
Doral, 27 Dyanavel XR, 28
Doryx 50mg DR tablet, 18 Dyazide, 36
Doryx 200mg DR tablet, 18 Dymista, 60
Doryx MPC Tab 60mg, 18 Dyrenium, 36
dorzolamide HCl 2%, 58
dorzolamide-timolol, 58 E
Dovato, 18 E.E.S., 18
Dovonex cream, 42 EC-Naprosyn, 53
doxazosin mesylate, 36, 62 econazole, 42
doxepin capsule, 27 Ecoza, 42
doxepin cream 5%, 42 ED-Spaz, 62
doxepin tablet, 27 Edarbi, 36
doxercalciferol, 47 Edarbyclor, 36
doxycycline DR 40mg, 18 Edecrin, 36
Doxycycline hyclate DR 80mg, 18 Edex, 62
Doxycycline hyclate tab 50mg, 18 Edurant, 18
Doxycycline hyclate tab 75mg, 150mg, 18 efavirenz, 18
Doxycycline hyclate tab DR 50mg, 100mg, 18 efavirenz-emtricitab-tenofovir tab, 18
Doxycycline hyclate tab DR 75mg, 150mg, 18 efavirenz-lamivudine-tenofovir tab, 18
Doxycycline hyclate tab DR 200mg, 18 Effexor XR, 28
doxycycline monohydrate 50mg, 75mg, 100mg Effient, 36
tab, 18 Efudex cream, 42
doxycycline monohydrate cap 50mg, 100mg, 18 Egaten 250mg tablet, 18
Doxycycline monohydrate cap 75mg, 150mg, 18 Eldepryl, 28
Doxycycline monohydrate tab 150mg, 18 Elepsia XR, 28
doxylamine-pyridoxine, 51 Elestat, 58
Drizalma Sprinkle, 27 eletriptan, 28
dronabinol, 51 Elidel, 42
drospirenone-ethinyl estradiol, 55 Elimite, 42
droxidopa, 36 Eliquis, 36
Duac, 42 Elixophyllin Elixir, 60
Duaklir, 60 Elmiron, 62
Duetact, 47 Elocon, 42
Dulera, 60 Eloctate, 37
duloxetine, 27 eluryng mis, 55
Duobrii Lotion, 42 Elyxyb Sol, 37
Dupixent, 42 Embeda, 28
Duragesic patch, 28 Emcyt, 22
Durezol Emu, 58 Emend, 51
Durlaza, 36 Emflaza, 47
dutasteride, 62
dutasteride/tamsulosin hcl, 62
x
 Index
INDEX

Emgality (300mg Dose) Prefilled Pen 100mg/ml, ergotamine tartrate/caffeine, 28

28 Erivedge, 22
Emgality Prefilled Pen/Auto-Injector 120mg/ml, Erleada, 22
28 erlotinib, 22
Empaveli Inj, 64 Ermeza Soln, 47
emtricitabine cap, 18 Ertaczo, 42
emtricitabine-tenofovir disoproxil fumarate tab Ery-Tab, 19
100-150mg, 133-200mg,167-250mg, 18 Erygel, 43
emtricitabine-tenofovir disoproxil fumarate tab EryPed, 19
200-300mg, 18 Erythrocin, 19
Emtriva, 18 erythromycin delayed release, 19
Emverm, 18, 51 erythromycin ethylsuccinate, 19
Enablex, 63 erythromycin etyhylsuccinate susp, 58
enalapril, 37 erythromycin gel, soln, swabs, 43
enalapril solution, 37 erythromycin ophth oint, 58
enalapril/HCTZ, 37 erythromycin stearate, 19
Enbrel, 53 Esbriet, 60
Endari powder, 51 escitalopram, 28
endocet, 28 Esgic cap/tab, 28
Endometrin Insert 100mcg Vaginal, 55 esomeprazole, 51
enoxaparin, 37 esomeprazole granules, 51
Enspryng Inj, 47 Esomeprazole strontium, 51
Enstilar, 42 Esperoct, 37
entacapone, 26, 28 estazolam, 28
Entadfi, 37 Estrace Cream, 55
entecavir, 18 Estrace Tab, 55
Entocort EC, 51 estradiol, 55–56
Entresto, 37 estradiol cream 0.1%, 55
Epaned Sol 1mg/ml, 37 estradiol transdermal, 56
Epclusa, 18 Estring, 56
Epidiolex Soln, 28 estropipate, 56
Epiduo, 42 Estrostep FE, 56
Epiduo Forte gel, 42 eszopiclone, 28
epinastine HCl, 58 ethacrynic acid, 37
epinephrine pen 0.3mg, 60 ethambutol, 19
Epinephrine pen 0.15mg, 60 ethosuximide, 28
EpiPen, 60 etidronate disodium, 53
EpiPen Jr., 60 etodolac, 28, 54
Epivir, 19 etoposide, 22
eplerenone, 37 etravirine, 19
Eprontia, 28 Eucrisa, 43
eprosartan, 37 Eulexin, 22
Epsolay Cream, 42 Eurax Lotion, 43
Epzicom, 19 euthyrox, 47
ergocalciferol, 63
xi
 Index
INDEX

Evekeo [ODT], 28 Femcon FE, 56

everolimus (generic for Afinitor), 22 FemHRT, 56
everolimus (generic for Zortress), 22 Femring, 56
Evista, 56 fenofibrate, 37
Evoclin, 43 Fenofibrate Micronized, 37
Evoxac, 45 fenofibrate nanocrystallized, 37
Evrysdi Soln, 47 fenofibric acid, 37
Evzio, 28 Fenoglide, 37
Exalgo, 28 Fenoprofen calcium, 28, 54
Exelderm, 43 Fenortho, 54
Exelon, 28 fentanyl citrate OTFC, 28
exemestane, 22 Fentanyl citrate tablet, 28
Exforge, 37 fentanyl transdermal, 28
Exforge HCT, 37 Fentora, 28
Exjade, 64 Ferriprox, 64
Exkivity, 22 fesoterodine tab ER, 54
Exservan Mis, 28 Fetzima, 28
Extavia, 28 Fexmid, 54
Extina, 43 Fiasp, 47
Eysuvis Ophth, 58 Fibricor, 37
ezetimibe, 37 Filspari tab, 60
Ezetimibe/Atorvastatin, 37 Finacea, 43
Ezetimibe/Rosuvastatin, 37 finasteride, 63
ezetimibe/simvastatin, 37 fingolimod, 28
Ezzalor Sprinkle Cap, 37 Fintepla sol, 28
finzala chew FE 1/20, 56
F Fioricet Cap, 28
Fabior, 43 Fioricet with codeine, 28
famciclovir, 19 Fiorinal with codeine, 28
famotidine 40mg tab, suspension, 51 Firazyr, 64
Fanapt, 28 Firdapse, 64
Fareston tab, 22 Firvanq Soln, 19
Farxiga, 47 Flagyl, 19
Farydak, 22 flavoxate, 63
Fasenra, 43 flecainide, 37
fayosim tab, 56 Flector Patch, 54
Fazaclo, 28 Fleqsuvy Susp 25mg/5ml, 54
febuxostat, 54 Flolipid susp, 37
Feiba, 37 Flomax, 63
felbamate, 28 Flovent Diskus, 60
Felbatol, 28 Flovent HFA, 60
Feldene, 28, 54 fluconazole suspension, 19
felodipine ER, 37 fluconazole tabs, 19
Femara, 22 flucytosine, 19

xii
 Index
INDEX

fludrocortisone acetate, 47 Fotivda, 22

Flumadine, 19 Fragmin, 37
flunisolide, 60 Freestyle Glucometer, 47
fluocinolone acetonide cream, sol, oil, 43 Freestyle InsuLinx Test Strips, 47
fluocinolone acetonide oil, 45 FreeStyle Libre Reader, Sensor, Reader Device,
fluocinonide gel, ointment, 43 47
fluoritab chew tab, 63 Freestyle Lite Test Strips, 47
fluorometholone, 58 Freestyle Test Strips, 47
Fluorouracil cream 0.5%, 43 Frova, 28
fluorouracil solution 2%, 43 Frovatriptan succinate, 28
fluoxetine, 28, 31 Furoscix Kit 80mg/10ml, 37
fluoxetine 10mg, 20mg, 40mg, 28 furosemide solution, 37
fluoxetine soln, 28 furosemide tabs, 37
fluphenazine, 28 Fuzeon, 19
Flurandrenolide cream, lotn, oint, 43 Fycompa, 28
flurazepam, 28
flurbiprofen, 28, 54, 58 G
flutamide, 22 gabapentin, 28
Flutic/Vilan INH, 61 gabapentin soln, 28
Fluticasone HFA AER, 61 Gabitril, 28
fluticasone propionate cream, lotn, oint., 43 Galafold, 64
fluticasone propionate nasal susp, 61 galantamine, 28
fluticasone-salmeterol AER powder, 61 galantamine ER, 28
Fluticasone/Salmeterol AER, 61 ganirelix acetate soln, 64
fluvastatin sodium, 37 Gastrocrom, 51
fluvoxamine, 28 Gattex, 51
fluvoxamine ER, 28 Gavreto, 22
FML Liquifilm suspension, 58 Gelnique Gel, 63
Focalin, 28 gemfibrozil, 37
Focalin XR, 28 Gemmily cap 1/20, 56
Follistim AQ, 56 Gemtesa, 63
fondaparinux, 37 Generess FE, 56
ForFivo XL, 28 Genotropin, 47
formoterol neb 20/2ml, 61 gentak oint 0.3% OP, 58
Fortamet, 47 gentamicin ophth, 58
Forteo, 47 gentamicin topical cream, ointment, 43
Fortesta, 47 Geodon, 28
Fosamax, 54 Gilenya, 28
Fosamax Plus D, 54 Gilotrif, 22
fosamprenavir calcium tab, 19 Gimoti Spray, 51
fosfomycin pow, 19 glatiramer acetate, 28
fosinopril, 37 glatopa, 29
fosinopril/HCTZ, 37 Gleevec, 22
Fosrenol, 63 Gleostine, 22

xiii
 Index
INDEX

glimepiride, 47, 49 haloperidol, 29

glipizide, 47 Harvoni, 19
glipizide ER, 47 Hectorol, 47
glipizide XL, 47 Helixate FS, 37
Gloperba Soln, 54 Hemady, 47
Glucagen Inj Hypokit, 47 Hemlibra Soln, 37
glucagon emergency kit (generic), 47 Hemmorex-HC Supp, 51
Glucagon Emergency Kit (Lilly), 47 Hemofil M, 37
Glucophage, 47–48 Hepsera, 19
Glucophage XR, 47–48 Hetlioz Cap, 29
Glucotrol XL, 47 Hetlioz LQ Susp, 29
Glucovance, 47 Hexalen, 22
glyburide, 47–48 Hiprex, 19
glyburide micronized, 47 homatropaire sol 5% OP, 58
glycopyrrolate oral solution 1mg/5ml, 54 homatropine opthalmic, 58
glycopyrrolate tab, 54 Horizant, 29
Glynase, 47 Humalog, 47
Glyset, 47 Humate-P, 37
Glyxambi, 47 Humatin, 19
Gocovri, 29 Humatrope, 47
Golytely solution reconstituted 227.1gm, 51 Humira, 54
Golytely solution reconstituted 236gm, 51 Humulin, 47–48
Gonal-f, 56 Humulin R U-500 (Concentrated and KwikPen),
Gralise Mis, 29 48
granisetron, 51 Hycamtin, 22
Grastek, 61 Hycofenix, 61
Gris-PEG, 19 hydralazine, 37
griseofulvin microsize, 19 Hydrea, 22
griseofulvin ultramicrosize, 19 hydrochlorothiazide, 36–37, 40
guaifenesin-codeine soln 10mg/5ml, 29 hydrocod-cpm-pseudoephedrine, 61
guanfacine, 29, 37 hydrocodon-cpm-phenylephrine, 61
guanfacine ER, 29 hydrocodone bit/homatrop syrup, 61
Gvoke HypoPen, 47 hydrocodone ER, 29
Gvoke PFS inj, 47 hydrocodone-chlorpheniramine susp, 61
hydrocodone-homatropine tab, 29
H hydrocodone/acetaminophen, 29
Haegarda, 64 hydrocortisone, 43, 46, 48, 51
hailey 1.5/30, 56 hydrocortisone 2.5%, 43
hailey 24 FE 1/20, 56 hydrocortisone butyrate 0.1%, 43
halcinonide cream 0.1%, 43 hydrocortisone butyrate/emoll, 43
Halcion, 29 hydrocortisone cream, 51
halobetasol propionate, 43 hydrocortisone lot 0.1%, 43
Halobetasol propionate foam 0.05%, 43 hydrocortisone retention enema, 51
Halog, 43 hydrocortisone supp, 43

xiv
 Index
INDEX

hydrocortisone valerate 0.2%, 43 Increlex, 48

hydrocortisone/lidocaine HCl, 43 Incruse Ellipta, 61
hydromet, 61 indapamide, 37
hydromorphone ER, 29 Inderal LA, 37
hydromorphone IR, 29 Indocin susp, 29
hydroxychloroquine, 19 indomethacin, 54
hydroxyurea, 22 Indomethacin 20mg capsule, 54
hydroxyzine HCL syrup, 61 indomethacin SR, 54
hydroxyzine HCl tabs, 61 Ingrezza, 29
hydroxyzine pamoate, 61 Inlyta, 23
Hyftor Gel 0.2%, 23 InnoPran XL, 37
hyoscyamine, 63 Inqovi tab, 23
hyosyne, 63 Inrebic, 23
HyperSal, 61 Inspra, 37
Hysingla ER, 29 Insulin aspart inj, 48
Hyzaar, 37 Insulin aspart protamin inj flexpen, 48
Insulin Degludec Inj, 48
I Insulin Glargine, 48
ibandronate, 54 Insulin lispro 100 units/ml, 48
Ibrance, 23 Insulin lispro inj junior, 48
Ibsrela, 51 Insulin lispro inj protamin, 48
Ibudone, 29 Intelence, 19
ibuprofen, 29, 31, 54 Intermezzo, 29
ibuprofen/hydrocodone, 29 Intrarosa, 56
icatibant inj, 64 Intuniv, 29
Iclusig, 23 Invega ER tablet, 29
icosapent cap, 37 Inveltys Susp 1%, 58
Idelvion, 64 Invirase, 19
Idhifa, 23 Invokamet [XR], 48
IFE-PG 20, 63 Invokana, 48
Ilevro Susp 0.3%, 58 Iopidine, 58
imatinib mesylate, 23 ipratropium inhalation soln, 61
Imbruvica, 23 ipratropium nasal spray, 61
Imcivree Inj 10mg/ml, 29 ipratropium-albuterol, 61
imipramine, 29 irbesartan, 37
imiquimod cream, 43 irbesartan hydrochlorothiazide, 37
Imiquimod Cream 3.75% Pump, 43 Iressa tab, 23
Imitrex, 29 Isentress, 19
Impavido, 19 isometheptene/dichloralphenazone/apap, 29
Impeklo Lotion 0.05%, 43 isoniazid, 19
Impoyz Cream 0.025%, 43 Isopto Carpine, 58
Imuran, 23 Isordil Titradose Tabs, 37
Imvexxy, 56 isosorb dinitrate-hydralazine, 37
Inbrija, 29 isosorbide dinitrate, 37

xv
 Index
INDEX

isosorbide dinitrate ER, 37 Keflex, 19

isosorbide mononitrate, 37 Kenalog Spray, 43
isosorbide mononitrate ER, 37 Keppra, 29
isotretinoin, 43 Keppra XR, 29
isradipine, 37 Kerendia, 38
Istalol Drops, 58 Kerydin, 43
Isturisa, 61 Kesimpta Inj, 48
itraconazole, 19 ketoconazole cream, 43
ivermectin, 19 ketoconazole shampoo, 43
Ixinity, 38 ketoconazole tab, 19
ketoprofen, 29, 54
J Ketoprofen 25mg cap, 54
Jadenu tab/granules, 64 ketoprofen ER, 54
Jakafi, 29 ketorolac, 29, 54, 58
Jalyn, 63 ketorolac opth soln, 58
jantoven, 38 Ketorolac sol tromethamine, 54
Janumet, 48 Keveyis, 64
Janumet XR, 48 Kevzara, 54
Januvia, 48 Khedezla, 29
Jardiance, 48 Kineret, 54
Jatenzo, 48 kionex suspension, 64
Javygtor Pak, 61 Kisqali, 23
Jaypirca tab, 23 Kitabis Pak, 61
Jentadueto tablet, 48 Klaron, 43
Jentadueto XR, 48 Klisyri Oint 1%, 43
Jivi, 38 Klonopin, 29
Jornay PM Capsule, 29 klor-Con, 63
Jublia, 43 Kloxxado Liq, 29
Juluca, 19 Koate-DVI, 38
junel FE 24 tab, 56 Kogenate FS, 38
Juxtapid, 38 Kombiglyze XR, 48
Jynarque, 63 Konvomep Soln, 51
Korlym tablet, 48
K Koselugo, 23
K-Phos, 63 Krazati, 23
K-Tab, 63 Krintafel, 19
Kadian ER, 29 Kristalose Pak, 51
kaitlib FE chew, 56 Kuvan, 61
Kaletra Tabs/Soln, 19 Kynamro, 38
Kalydeco Tabs/Pack, 19 Kynmobi Kit Titration, 29
Kapspargo, 38 Kynmobi Mis, 29
Kapvay, 29 Kyzatrex, 48
Katerzia Susp, 38
Kazano tablet, 48

xvi
 Index
INDEX

Levbid, 63
L
Levemir, 48
labetalol HCl, 38
levetiracetam, 29
lacosamide, 29
levetiracetam ER, 29
Lactulose pak, 51
Levitra, 63
lactulose soln, 51
levo-T tab, 48
Lamictal, 29
levobunolol, 58
Lamictal ODT, 29
levocarnitine, 48
Lamictal XR, 29
levofloxacin ophth soln, 58
Lamisil Tabs, 19
levofloxacin tab, 19
lamivudine 100mg tab, 19
levonorgestrel-ethinyl estradiol, 56
lamivudine tablet 150mg, 300mg, 19
levonorgestrel/my way/next dose, 56
lamivudine/zidovudine, 19
levorphanol, 29
lamotrigine, 29
Levothyroxine cap, 48
lamotrigine ER, 29
levothyroxine tab, 48
lamotrigine ODT, 29
levoxyl, 48
lamotrigine ODT kit, 29
Levsin, 63
Lampit tab, 19
Lexapro, 29
Lanoxin, 38
Lexette Foam 0.05%, 43
lansoprazole cap, 51
Lexiva, 19
lansoprazole solutab, 51
Lialda, 51
lanthanum chewable tab, 63
Librax, 29
Lantus, 48
Licart Dis 1.3%, 29
lapatinib, 23
lidocaine patch 5%, 43
Lasix, 38
lidocaine solution, gel, ointment, 43
Lastacaft, 58
Lidoderm, 43
latanoprost, 58
Lilly Glucagon Emergency Kit, 48
Latuda, 29
linezolid, 19
layolis FE chew, 56
Linzess, 51
Lazanda, 29
liothyronine, 48
Ledipasvir-sofosbuvir tablet 90-400mg, 19
Lipitor, 38
leena tab, 56
Lipofen, 38
leflunomide, 54
lisinopril, 38
lenalidomide, 23
lisinopril/HCTZ, 38
Lenvima, 23
lithium carbonate, 29
Lescol XL, 38
lithium carbonate ER, 29
Letairis, 38
Lithobid, 29
letrozole, 23
Livalo, 38
leucovorin calcium, 23
Livmarli Sol, 51
Leukeran, 23
Livtencity, 19
leuprolide, 23
Lo Loestrin FE, 56
levalbuterol neb, 61
Locoid, 43
Levalbuterol tartrate HFA, 61
Locoid Lipocream, 43
Levamlodipine, 38
Lodine, 29
Levaquin, 19

xvii
 Index
INDEX

Lodosyn, 29 Lymepak, 19
Loestrin, 56 Lynparza, 23
Lokelma PAK, 63 Lyrica Cap, 30
Lomaira, 29 Lyrica CR, 30
Lomotil, 51 Lyrica soln, 30
Lonhala Magnair Soln, 61 Lysodren, 23
Lonsurf, 23 Lysteda, 56
loperamide, 51 Lytgobi, 23
Lopid, 38 Lyumjev Inj/Pen, 48
lopinavir/ritonavir, 19 Lyvispah Gra, 54
Lopressor HCT, 38
Loprox, 43 M
lorazaepam concentrate, 30 m-clear wc soln, 30
lorazepam, 29 Macrodantin, 19
Lorbrena, 23 Malarone, 19
Loreev XR, 30 malathion lotion, 44
Lortab, 30 maprotiline, 30
lortab elixir, 30 maraviroc tab, 19
Lorzone, 54 Marinol, 51
losartan, 38 Matulane, 23
losartan-HCTZ, 38 Mavenclad pak, 23
Loseasonique, 56 Mavyret, 19
Lotemax [SM], 58 Maxalt, Maxalt-MLT, 30
Lotensin, 38 Maxitrol, 58
loteprednol susp 0.5%, 58 Maxzide, 38
Lotrel, 38 Mayzent tablet, starter pak, 30
Lotrisone, 43 meclizine, 51
Lotronex, 54 meclofenamate, 30, 54
lovastatin, 38 Medrol, 48
Lovaza, 38 medroxyprogesterone acetate suspension IM,
Lovenox, 38 56
loxapine, 30 medroxyprogesterone acetate tab, 56
lubiprostone cap, 51 Medtronic Continuous Glucose Monitor Enlite,
Lucemyra, 30 MiniMed Guardian Sensors, 48
Luliconazole cream, 19 Medtronic Continuous Glucose Monitor Guardian
Lumakras, 23 Transmitter, 48
Lumigan, 58 Medtronic Continuous Glucose Monitor Receiver,
Lunesta, 30 48
Lupkynis, 23 mefloquine, 19
lurasidone tab, 30 Megace, 23
Luxiq, 43 megestrol, 23
Luzu, 43 megestrol acetate, 23
Lybalvi, 30 Mekinist, 23
lyllana Dis, 56 Mektovi, 23

xviii
 Index
INDEX

melodetta chew 24 FE, 56 methylphenidate pad, 30

meloxicam cap, 54 methylprednisolone, 48
Meloxicam susp, 54 methylprednisolone therapy pak, 48
meloxicam tab, 54 methyltestosterone, 49
melphalan, 23 metoclopramide, 51
memantine, 30 Metoclopramide odt, 51
memantine ER, 30 metolazone, 38
Menest, 56 Metopirone, 64
Menopur, 56 metoprolol succinate, 38
meperidine HCl, 30 metoprolol tartrate, 38
Mephyton, 63 metoprolol tartrate/HCT, 38
meprobamate, 30 MetroCream, 44
Mepron, 19 MetroGel, 44
mercaptopurine, 23 Metrogel vaginal, 56
mesalamine, 51 MetroLotion, 44
mesalamine DR, 51 metronidazole, 20, 44, 56
mesalamine rectal susp, 51 metronidazole cream, lotion, gel, 44
Mesnex, 23 metronidazole vaginal gel, 56
Mestinon [ER] Tab, 30 metyrosine, 49
Mestinon syrup, 30 Mevacor, 38
metaproterenol, 61 mexiletine HCl, 38
Metaxalone, 54 Miacalcin, 54
metformin, 46, 48 mibelas 24 chew FE, 56
Metformin 625mg, 48 Micardis, 38
metformin ER (generic for Glucophage XR), 48 Micardis HCT, 38
metformin HCL 500mg/5ml soln, 48 Miconazole-zinc ointment, 44
metformin/glyburide, 48 microgestin 24 FE 1/20, 56
methadone, 30 Microzide, 38
Methadose concentrate [SF], 30 midodrine HCl, 64
Methamphetamine, 30 Midrin, 30
methazolamide, 58 miglitol, 49
methenamine hippurate, 19 miglustat, 64
methimazole, 48 Migranal, 30
Methitest Tab, 48 Millipred, 49
Methlyphenidate ER (XR), 30 Minastrin 24 FE, 56
methocarbamol 500mg, 750mg, 30 Minipress, 38
methotrexate tab, 23 minitran, 38
methoxsalen, 44 Minivelle, 56
methyldopa, 38 Minocin, 20
Methylin, 30 minocycline caps, 20
methylphenidate, 30 Minocycline ER cap 135mg, 45mg, and 90mg,
methylphenidate ER, 30 20
methylphenidate ER (CD), 30 minocycline ER tablet, 20
methylphenidate ER (LA), 30 minocycline tablet, 20

xix
 Index
INDEX

Minolira, 20 Mycapssa cap, 49

minoxidil, 38 Mycobutin, 20
Mirapex, 30 mycophenolate, 23
Mirapex ER, 30 mycophenolic acid, 23
Mircette, 56 Mydayis, 30
mirtazapine, 30 Mydriacyl, 58
Mirvaso, 44 Myfembree, 56
misoprostol, 51, 53 Myfortic, 23
Mitigare, 54 Myleran, 23
Mobic, 54 Myrbetriq, 63
modafinil, 30 Mysoline, 30
moderiba, 20 Mytesi, 20
moexipril, 38
moexipril/HCTZ, 38 N
molindone hcl, 30 nabumetone, 30, 54
Molnupiravir 200mg, 20 nadolol, 38
mometasone cream, ointment, solution, 44 nadolol-bendroflume thiazide, 38
mometasone furoate nasal spray, 45 naftifine cream, gel, 44
Mondoxyne NL 75mg cap, 20 Naftin, 44
Monoclate-P, 38 Nalfon, 30, 54
Mononine, 38 Nalocet, 30
montelukast sodium, 61 Naloxone Injection 2mg, 30
Monurol Pak Granules, 20 naloxone spray, 30
MorphaBond ER, 30 naltrexone 50mg, 30
morphine IR, 30 Namenda [XR], 30
morphine sulfate ER, 30 Namzaric, 30
morphine suppositories, 30 Naprelan, 54
Motegrity tab, 51 Naprosyn, 53–54
Mounjaro Inj, 49 Naprosyn susp, 54
Movantik, 51 naproxen sodium, 54
MoviPrep Solution Reconstituted 100gm Oral, naproxen sodium DR, 54
52 naproxen sodium ER, 54
Moxatag, 20 naproxen sodium ER 750mg, 54
Moxeza, 58 naproxen sodium susp, 54
moxifloxacin hcl, 20 naratriptan, 30
moxifloxacin ophthalmic soln, 58 Narcan 4mg/actuation spray, 30
MS Contin, 30 Nardil, 30
Mulpleta, 38 Nascobal, 63
Multaq, 38 Nasonex, 45
multivitamin with fluoride drops, tabs, 63 Natazia, 56
mupirocin cream, ointment, 44 nateglinide, 49
Muse, 63 Natesto, 49
Myalept, 49 Natpara, 49
Myambutol, 20 Natroba, 44

xx
 Index
INDEX

Nature-Throid, 49 nitrofurantoin macrocrystals, 20

Nayzilam, 30 nitrofurantoin susp, 20
nebivolol, 38 nitroglycerin ER, 39
Nebupent INH, 20 nitroglycerin patches, 39
nebusal nebulization solution, 63 nitroglycerin SL, 39
nefazodone, 30 nitroglycerin spray, 39
neomycin/polymyxin B/dexamethasone, 58 Nitrolingual Spray, 39
neomycin/polymyxin/ hydrocortisone, 46 Nitromist, 39
Neoral, 23–24 Nitrostat SL, 39
Neosporin soln, 58 Nityr, 64
Nerlynx, 23 nizatidine solution, 52
Nesina tablet, 49 Nizoral shampoo, 44
Nestabs One, 63 Nocdurna SL, 39
Neupro Patch, 30 Noctiva Emulsion, 49
Neurontin, 31 Non Preferred Diabetic Meters, 49
Neurontin soln, 31 Norditropin, 49
Nevanac Susp 0.1%, 58 nore/eth/fer chew 0.4mg-35mcg, 56
nevirapine, 20 norethin-ethynil-fer cap 1/20, 56
nevirapine ER, 20 norethindrone, 56
Nexavar, 23 norethindrone acetate, 56
Nexiclon XR, 38 norethindrone-ethinyl estradiol, 56
Nexium capsule, 52 norethindrone-mestranol, 56
Nexium packets, 52 Norgesic Forte Tab, 54
Nexletol, 38 Norgesic Tab, 54
Nexlizet, 38 norgestimate-ethinyl estradiol, 56
Nextstellis, 56 norgestrel-ethinyl estradiol, 56
niacin ER, 38 Noritate, 44
Niaspan ER, 38 Norliqva Soln, 39
nicardipine, 38 Norpace, 39
nifedical XL, 38 Norpramin, 31
nifedipine, 38 Northera, 39
nifedipine ER, 38 nortriptyline, 31
Nilandron, 23 nortriptyline soln, 31
nilutamide, 23 Norvasc, 39
nimodipine, 38 Norvir powder, 20
ninjacof-XG liquid, 31 Norvir tablet, 20
Ninlaro, 23 Nourianz, 31
nisoldipine ER, 38 Novarel 5000 units, 64
nitazoxanide, 20 Novarel 10000 units, 64
nitisinone, 64 Novoeight, 39
Nitro-Bid, 38 Novolin, 49
Nitro-Dur, 38 Novolin R, 49
nitro-time cap, 38 Novolin Relion, 49
Nitro-Time CR Cap, 38 Novolog, 49

xxi
 Index
INDEX

Novolog Relion, 49 Olux [E], 44

NovoSeven RT, 39 Omeclamox-Pak, 52
Noxafil, 20 omega-3 acid ethyl esters, 39
NP thyroid, 49 omeprazole, 52
Nubeqa, 23 Omnaris, 46
Nucala Soln, 61 Omnipod 5 Pack, 49
Nucynta, 31 Omnipod Dash 5 Pack, 49
Nucynta ER, 31 Omnipod Dash System, 49
Nulev, 63 Omnipod Starter Kit, 49
Nulibry Inj, 64 Omnipred, 59
Nulytely, 52 Omnitrope, 49
Nuplazid, 31 ondansetron HCl, 52
Nurtec chw 75mg ODT, 31 One Touch Glucometers, 49
Nutropin AQ, 49 One Touch Test Strips, 49
Nuvaring, 56 Onexton, 44
Nuvessa gel, 20 Onfi, 31
Nuvigil, 31 Onfi Susp, 31
Nuwiq, 39 Ongentys, 31
Nuzyra, 20 Onglyza, 49
Nymalize Sol, 38 Onmel, 20
nystatin suspension, 44 Onureg, 23
nystatin/triamcinolone cream, ointment, 44 Onzetra Xsail, 31
Opana, 31
O Opana ER, 31
OB Complete, 56 Opsumit, 39
Obizur, 39 Opzelura Cream, 44
Obredon, 61 Oracea, 20
Ocaliva, 64 Oralair, 61
Ocufen, 58 Orap, 31
Ocuflox, 58 Orapred ODT, 49
Odactra SL, 61 Orencia, 54
Odomzo, 23 Orenitram, 39
Ofev, 61 Orfadin, 64
ofloxacin, 46, 58 Orgovyx, 23
ofloxacin otic, 46 Oriahnn cap, 56
olanzapine, 31 Orilissa, 49
olanzapine ODT, 31 Orkambi tablet/packet, 20
olanzapine/fluoxetine hcl, 31 Orladeyo, 64
olmesartan medoxomil, 39 Orlistat Cap, 52
olmesartan/amlodipine/hctz, 39 orphenadrine ER, 54
olmesartan/hctz, 39 Orphenadrine-asa-caffeine, 54
olopatadine, 46, 59 Orphengesic Forte Tab, 54
olopatadine hcl, 59 Orserdu tab, 23
Olumiant, 54 Ortho Cyclen, 57

xxii
 Index
INDEX

Ortho Micronor, 56
P
Ortho Novum, 57
pacerone, 39
Ortho Tri-Cyclen, 57
Palforzia cap/powder, 61
Ortho Tri-Cyclen Lo, 57
paliperidone er tablet, 31
Ortikos ER Cap, 23
Palynziq, 64
oscimin, 63
Pamelor, 31
oseltamivir caps/soln, 20
Pancreaze, 52
Oseni, 49
pancrelipase EC/SA, 52
Osmolex ER, 31
Pandel, 44
Osmoprep tab, 52
Panretin Gel, 44
Otezla, 54
pantoprazole, 52
Otrexup, 54
pantoprazole pak, 52
Ovide, 44
paricalcitol, 49
Ovidrel, 57
Parlodel, 31
Oxandrin, 49
Parnate, 31
oxandrolone, 49
paroxetine, 31
oxaprozin, 31, 54
paroxetine ER, 31
Oxaydo, 31
Patanase, 46
oxazepam, 31
Patanol, 59
Oxbryta, 64
Paxil CR, 31
oxcarbazepine susp, 31
Paxil Tab/Susp, 31
oxcarbazepine tab, 31
Paxlovid Tab, 20
Oxervate soln 200mcg/ml, 59
PEG 3350 & electrolytes, 52
Oxiconazole nitrate, 44
peg-kcl-nacl-nasulf-na asc-c soln reconstituted,
Oxistat, 44
52
Oxsoralen Ultra, 44
Peg-Prep, 52
Oxtellar XR, 31
Pegasys, 20
oxybutynin [XR], 63
PegIntron, 20
Oxybutynin Sol 5mg/5ml, 63
Pemazyre, 23
oxybutynin syrup, 63
penciclovir cream, 44
Oxycodone ER tablet, 31
penicillamine capsule, 64
oxycodone IR, 31
penicillamine tablet, 64
Oxycodone/acetaminophen, 31
penicillin v potassium solution, 20
oxycodone/acetaminophen, 31
penicillin v potassium tablet, 20
Oxycodone/APAP 2.5-300mg, 5-300mg,
Penlac, 44
10-300mg tab, 31
Pennsaid, 54
oxycodone/aspirin, 31
pentamidine INH, 20
oxycodone/ibuprofen, 31
Pentasa, 52
OxyContin, 31
pentazocine-naloxone, 31
oxymorphone ER, 31
pentoxifylline ER, 39
oxymorphone IR, 31
Pepcid tabs, suspension, 52
Oxytrol Patch, 63
Percocet, 31
Ozempic, 49
Perforomist Neb, 61
Ozobax Soln, 54
perindopril, 39

xxiii
 Index
INDEX

permethrin, 44 Pomalyst, 23
perphenazine, 31 Ponvory, 31
Persantine, 39 posaconazole, 20
Pertzye, 52 Potaba, 65
Pexeva, 31 potassium bicarbonate/potassium citrate
Pheburane Mis 483/gm, 52 effervescent, 64
phenazopyridine, 63 potassium chloride, 64
phendimetrazine tartrate, 31 potassium citrate ER, 63
phenelzine, 31 potassium iodide soln, 20
phenobarbital, 31 Pradaxa, 39
phenoxybenzamine hcl, 39 Pradaxa Pak, 39
phentermine hcl, 31 Praluent, 39
Phenytek, 31 pramipexole, 31–32
phenytoin, 31 pramipexole ER, 32
PhosLo, 64 Pramosone cream/lotion, 44
Phoslyra, 64 Prandin, 49
phospha, 64 prasugrel, 39
Phospho-trin tab K500, 63 Pravachol, 39
Phospholine Iodide, 59 pravastatin, 39
phytonadione tab, 63 praziquantel, 20
Pifeltro, 20 prazosin, 39
pilocarpine, 46, 59 Precision Glucometer, 49
pilocarpine HCl, 46 Precision XTRA Test Strips, 49
pimecrolimus cre 1%, 44 Precose, 49
pimozide, 31 Pred-Forte, 59
pindolol ER, 39 prednicarbate ointment, 44
pioglitazone, 46, 49 prednisolone, 49, 59
pioglitazone/glimepiride, 49 prednisolone acetate, 59
Piqray, 23 prednisolone sodium phosphate, 59
pirfenidone, 61 prednisolone/sodium sulfacetamide, 59
piroxicam, 31, 54 prednisone, 23
Plan B One-Step, 57 prednisone therapy pack/solution/concentrate,
Plaquenil, 20 23
Plavix, 39 pregabalin cap, 32
Plegridy, 31 pregabalin ER tab, 32
Plenvu Soln, 52 pregabalin soln, 32
podofilox soln, 44 pregnyl, 65
Pogo Automatic Mis Monitor, 49 Prelone, 49
Pogo Automatic Test Cartridge, 49 Premarin, 57
polymyxin B, 57–59 Premarin vaginal cream, 57
polymyxin B/neo/bacitracin, 59 Premphase, 57
polymyxin B/neo/gramicidin, 59 Prempro, 57
polymyxin B/trimethoprim soln, 59 Pretomanid, 20
Polytrim, 59 Prevacid caps, 52
Prevacid SoluTab, 52
xxiv
 Index
INDEX

prevalite, 39 Protonix packets, 52

Prevymis, 20 Protopic, 23
Prezista, 20 Proventil HFA, 61
prilocaine/lidocaine, 44 Provera, 55, 57
Prilosec packets, 52 Provigil, 32
primidone, 32 Prozac, 32
Primlev, 32 Prudoxin cream 5%, 44
Prinivil, 39 Pulmicort Flexhaler, 61
Pristiq, 32 Pulmicort Respules, 61
ProAir Digihaler, 61 pulmosal nebulization solution, 64
ProAir HFA, 61 Pulmozyme, 61
ProAir RespiClick, 61 Purixan, 23
probenecid, 53–54 Pylera, 52
Procardia, 39 Pyridium, 63
Procardia XL, 39 pyridostigmine, 32
Procentra 1mg/ml, 32 pyridostigmine soln, 32
prochlorperazine suppository, 52 pyrimethamin, 20
prochlorperazine tabs, 52 Pyrukynd, 65
Proctocort Supp 30mg, 44
Proctofoam HC, 44 Q
Procysbi, 49 Qbrelis, 39
Profilnine, 39 Qbrexza Pad 2.4%, 44
progesterone, micronized, 57 Qdolo Soln 5mg/ml, 32
Proglycem Susp, 49 Qelbree, 32
Prograf cap/packets, 23 Qinlock tab, 23
Prolate Sol 10/300mg, 32 Qmiiz ODT, 32
Prolate tab, 32 Qnasl, 46
Prolensa sol 0.07%, 59 Qsymia ER, 32
Promacta, 39 Qtern, 49
promethazine, 61 Qualaquin, 20
promethazine/codeine, 61 Quartette, 57
promethazine/dextromethorphan, 61 quazepam, 32
promethazine/phenylephrine, 61 Qudexy XR, 32
promethegan supp, 32 Questran Light, 39
Prometrium, 57 Questran Packet/Powder, 39
propafenone, 39 quetiapine ER, 32
propafenone ER, 39 quetiapine fumarate, 32
proparacaine, 59 Quflora, 64
propranolol, 39 Quillichew ER, 32
propranolol ER, 39 Quillivant XR, 32
propranolol/HCTZ, 39 quinapril, 39
propylthiouracil, 49 quinapril/HCTZ, 39
Proscar, 63 quinine sulfate, 20
Protonix, 52 Qulipta, 32

xxv
 Index
INDEX

Quviviq, 32 Renagel, 65
Qvar, 61 Renvela, 65
repaglinide, 49
R Repatha, 39
rabeprazole DR tab 20mg, 52 Requip, 32
Rabeprazole Sprinkle Cap 10mg, 52 Requip XL, 32
Radicava ORS Susp, 32 Rescula, 59
Ragwitek, 61 Restasis Emulsion 0.05 % Ophthalmic, 59
raloxifene, 55, 57 Restasis Multiodose, 59
raloxifene hcl, 55 Restoril, 32
ramelteon, 32 Retevmo cap, 23
ramipril, 39 Retin-A, 44
Ranexa, 39 Retin-A Micro, 44
ranitidine 300mg, 52 Retrovir, 20
ranolazine tab ER, 39 Revatio, 39
Rapaflo, 63 Revlimid, 23
Rapamune 1mg/ml Sol, 23 Rexulti, 32
Rapamune tab, 23 Reyataz, 20
rasagiline, 32 Reyvow, 32
Rasuvo, 55 Rezira, 61
Ravicti, 52 Rezlidhia, 24
Rayaldee, 64 Rezurock, 20
Rayos, 49 Rezvoglar Inj, 49
Razadyne, 32 Rhofade 1% cream, 44
Razadyne ER, 32 Rhopressa Soln 0.02%, 59
Rebetol, 61 Riastap, 39
Rebif Rebidose, 32 ribasphere ribapak 200mg & 400mg/400mg &
Rebinyn Soln, 39 600mg, 20
Recombinate, 39 ribavirin, 46
Recorlev 150mg Tab, 52 Ridaura, 65
RediTrex Inj, 23 rifabutin, 20
Regimex, 32 Rifadin, 20
Reglan, 52 rifampin, 20
Regranex gel, 49 Rilutek, 32
Relafen, 32 riluzole, 32
Relafen DS, 32 rimantadine, 20
Relenza, 20 Rinvoq, 65
Relexxii, 32 Riomet [ER] solution/suspension 500mg/5ml, 49
Relistor, 52 risedronate, 55
Relpax, 32 risedronate DR, 55
Reltone, 52 Risperdal, 32
Relyvrio Pak, 32 risperidone, 32
Remeron, 32 Ritalin LA, 32
Remeron SolTab, 32 Ritalin Tab, 32
ritonavir, 19–20
xxvi
 Index
INDEX

rivastigmine, 32 Seasonique, 57
Rixubis, 39 Secuado Patch, 32
rizatriptan benzoate, 32 Seebri, 62
Robaxin, 32, 55 Seglentis 56-44mg Tab, 33
Rocaltrol capsules, 49 Segluromet, 49
Rocklatan Soln 0.02-0.005%, 59 selegiline HCl, 33
roflumilast, 62 selenium sulfide shampoo/lotion, 44
ropinirole, 32 Selzentry, 20
ropinirole ER, 32 Semglee Inj 100U/ml, 49
rosuvastatin, 39 Semprex-D, 62
Roszet, 39 Sensipar, 50
Roxicodone, 32 Serevent Diskus, 62
Roxybond, 32 Sernivo, 44
Rozerem, 32 Seroquel, 33
Rozlytrek, 24 Seroquel XR, 33
Rubraca, 24 Serostim, 50
Ruconest, 65 sertraline, 33
rufinamide susp 40mg/ml, 32 Sertraline Caps 150mg, 200mg, 33
rufinamide tab, 32 sevelamer carbonate, 65
Rukobia, 20 Sevenfact Inj, 39
Ruzurgi, 65 Seysara, 20
Ryaltris Spray 665-25mcg/act, 46 SFRowasa enema, 52
Rybelsus, 49 Signifor, 50
Ryclora, 62 Siklos, 24
Rydapt, 24 sildenafil citrate 20mg tab, 10mg/ml susp, 40
Rytary, 32 sildenafil citrate 25mg, 50mg, 100mg, 40
Rythmol, 39 Silenor, 33
Rythmol SR, 39 Siliq, 44
Ryvent, 62 silodosin, 55
Silvadene, 44
S silver sulfadiazine, 44
Sabril, 32 Simbrinza Susp 1-0.2%, 59
Safyral, 57 Simponi, 55
Saizen, 49 simvastatin, 37, 40
sajazir inj, 65 Simvastatin susp, 40
Salagen, 46 Sinemet, 33
salsalate tab, 55 Sinemet CR, 33
Samsca, 39 Singulair, 62
Sandimmune, Neoral, 24 sirolimus tab/soln, 24
Saphris, 32 Sirturo, 21
sapropterin pow/tab, 62 Sitavig, 21
Saxenda, 32 Sivextro, 21
Scemblix, 24 Skelaxin, 55
scopolamine patch, 52 Sklice Lot 0.5%, 21

xxvii
 Index
INDEX

Skyclarys cap, 21 Stelara, 55

Skyrizi Inj, 44 Stendra, 63
Skytrofa, 50 Stimate, 40
Slynd, 57 Stiolto Respimat, 62
Soaanz, 40 Stivarga, 24
sodium chloride inhalation, 62 Strattera, 33
sodium fluoride chew tab, 64 Strensiq, 65
Sodium Oxybate Sol, 33 Striant buccal system, 50
sodium phenylbutyrate tab, 64 Stribild, 21
sodium sulfacetamide suspension, 44 Striverdi Respimat Aer Solution, 62
sodium/potassium sol magnesium, 52 Stromectol, 21
Sofosbuvir-velpatasvir tablet 400-100mg, 21 Suboxone Sublingual Film, 33
Solaraze, 44 Subsys, 33
solifenacin, 63 Sucraid Solution 8500 unit/ml, 65
Soliqua, 50 sucralfate tabs, 52
Solodyn, 21 Sular, 40
Solosec GRA, 21 Sulconazole cream/solution, 44
Soma, 55 sulfacetamide, 44, 59
Somavert, 50 sulfamethoxazole/tmp, 21
Sonata, 33 Sulfamylon, 44
Soolantra, 44 sulfasalazine, 52
sorafenib, 24 sulindac, 33, 55
Soriatane, 44 sumatriptan, 33
Sorilux Foam, 44 sumatriptan/naproxen, 33
sotalol HCl, 40 sunitinib, 24
Sotyktu, 55 Sunlenca, 21
Sotylize soln, 40 Sunosi, 33
Sovaldi, 21 Suprax Susp 100mg/5ml, 200mg/5ml, 21
spinosad, 44 Suprep Bowel Prep Kit, 52
Spiriva, 62 Sustiva, 21
spironolactone, 40 Sutab, 52
spironolactone/HCTZ, 40 Sutent, 24
Sporanox, 21 Sylatron, 33
Spritam Oral Disintegrating Tab, 33 Symax, 63
Sprix Nasal Spray, 33 Symbicort, 62
Sprycel, 24 Symbyax, 33
SSD cream, 44 Symdeko, 62
SSKI Solution, 21 Symfi, 21
Stalevo, 33 Symfi-Lo, 21
Starlix, 50 Symjepi Inj, 62
stavudine, 21 Symlin, 50
Staxyn, 63 Sympazan Film, 33
Steglatro, 50 Symproic, 52
Steglujan, 50 Symtuza, 21

xxviii
 Index
INDEX

Synalar, 45 tazarotene gel, 45

Synarel, 57 Tazorac cream/gel, 45
Syndros, 52 taztia XT, 40
Synjardy, 50 Tazverik 200mg, 24
Synjardy XR, 50 Tecfidera, 33
Synthroid, 50 Technivie, 21
Syprine, 65 Tegretol [XR], 33
Tegretol susp, 33
T Tegsedi, 65
Tabloid, 24 Tekturna/Tekturna HCT, 40
Tabrecta tab, 24 telmisartan, 40
Taclonex, 45 telmisartan-amlodipine, 40
tacrolimus, 24 telmisartan/hydrochlorothiazide, 40
tadalafil (generic Adcirca), 40 temazepam, 33
tadalafil (generic Cialis), 40 Temixys, 21
Tadliq Susp, 40 Temodar, 24
Tafinlar, 24 Temovate, 45
tafluprost soln, 59 temozolomide, 24
Tagrisso, 24 tenofovir, 21
Takhzyro Inj, 65 Tenoretic, 40
Talicia, 21 Tenormin, 40
Taltz Autoinjector, 45 Tepmetko, 24
Talzenna, 24 terazosin, 63
Tamiflu, 21 terbinafine tabs, 21
tamoxifen 10mg, 24 terbutaline sulfate tabs, 62
tamsulosin, 62–63 terconazole cream, 57
Tanzeum, 50 teriflunomid, 33
Tapazole, 50 Teriparatide inj, 50
Tarceva, 24 Tessalon Perles, 62
Targadox, 21 Testim Gel, 50
Targretin cap, 24 testosterone gel 1%, 1.62%, 50
Targretin gel, 45 testosterone gel 10mg/act (2%), 50
tarina 24 FE tab, 57 testosterone solution 30mg/act, 50
Tarka, 40 tetrabenazine, 33
Tarpeyo, 52 Texacort soln, 45
Tascenso ODT, 33 Tezspire Inj, 62
Tasigna, 24 Thalitone, 40
tasimelteon, 33 Thalomid, 24
Tasmar, 33 Theo-24, 62
tavaborole soln 5%, 45 theochron, 62
Tavalisse, 65 theophylline extended release, 62
Tavneos, 65 theophylline soln, 62
Taytulla, 57 thioguanine, 24
Tazarotene AER 0.1%, 45 Thiola [EC], 62

xxix
 Index
INDEX

thioridazine, 33 topiramate ER cap, 33

thiothixene, 33 topiramate sprinkle cap, 33
Thyquidity Soln, 50 Toprol XL, 40
tiadylt ER, 40 toremifene tab, 24
tiagabine hcl, 33 torsemide, 40
Tiazac, 40 Tosymra Nasal Solution, 33
Tibsovo, 24 Toujeo Solostar, 50
ticlopidine HCl, 40 Toviaz, 55
Tigan, 52 Tracleer, 40, 62
Tiglutik Susp, 33 Tradjenta tablet, 50
Tikosyn, 40 tramadol, 33
tilia FE tab, 57 tramadol ER (biphasic) tablet, 33
timolol maleate tab, 40 Tramadol ER cap, 33
timolol ophth, 59 tramadol ER tablet, 33
Timoptic, 59 Tramadol soln 5mg/ml, 33
Timoptic XE, 59 tramadol/acetaminophen, 33
Tindamax, 21 trandolapril, 40
tinidazole, 21 trandolapril/verapamil ER, 40
tiopronin, 62 Transderm-Scop patch, 52
Tirosint, 50 Tranxene T, 33
Tivicay PD, 21 tranycypromine sulfate, 33
Tivorbex, 33 Travatan Z, 59
tizanidine, 55 travoprost, 59
Tlando, 50 trazodone, 33
Tobi Neb Solution, 21 Trelegy Ellipta, 62
Tobi Podhaler Cap, 21 Tremfya, 45
Tobradex, 59 Tresiba, 50
tobramycin nebulization soln., 21 tretinoin caps, 24
tobramycin ophthalmic, 59 tretinoin gel, cream, 45
tobramycin- dexamethasone, 59 Tretinoin microspheres gel, 45
Tobrex, 59 Tretten, 40
Tofranil, 33 Trexall tab, 24
tolbutamide, 50 Treximet, 33
tolcapone, 33 Trezix, 33
tolmetin, 33, 55 tri-legest FE, 57
tolmetin sodium, 33 Tri-norinyl, 57
Tolsura, 21 Tri-Vi-Flor, Poly-Vi-Flor with and without iron,
tolterodine tartrate, 63 64
tolterodine tartrate LA, 63 triamcinolone acetonide, 45
tolvaptan 15mg, 30mg tab, 40 Triamcinolone oint 0.05%, 45
Topamax, 33 triamterene cap, 40
Topamax Sprinkle Capsules, 33 triamterene/HCTZ, 40
Topicort, 45 Trianex, 45
topiramate, 33 triazolam, 33

xxx
 Index
INDEX

Tribenzor, 40 Tyvaso, 40
Tricor, 40
triderm cream, 45 U
trientine, 65 Ubrelvy, 34
trifluoperazine, 33 Uceris, 50
trifluridine, 59 Ukoniq, 24
trihexyphenidyl, 33 Uloric, 55
Trijardy XR, 50 Ultracet, 34
Trikafta, 21 Ultram, 34
Trileptal Susp, 34 Ultravate, 45
Trileptal Tab, 34 unithroid, 50
Trilipix, 40 Upneeq Soln, 59
trimethobenzamide, 52 Uptravi, 40
trimethoprim sulfate/, 59 Urecholine, 63
trimethoprim tab, 59 Urocit-K, 63
trimipramine, 34 Uroxatral, 63
Trintellix, 34 Urso 250 Tab, 52
Tritocin oint 0.05%, 45 Urso Forte Tab, 52
Triumeq, 21 Ursodiol Cap, 52
Trizivir, 21 ursodiol tab, 52
Trokendi XR, 34 Utibron Neohaler, 62
tropicamide, 59
trospium chloride, 63 V
Trudhesa AER, 34 V-GO, 65
Trulance, 52 Vagifem, 57
Trulicity, 50 valacyclovir tab, 21
Truseltiq, 24 Valchlor, 24
Trusopt, 59 Valcyte Soln, 21
Truvada, 21 Valcyte Tab, 21
trymine CG liquid, 34 valganciclovir soln, 21
Tudorza Pressair, 62 valganciclovir tab, 21
Tukysa, 24 Valium, 34
Turalio, 24 valproic acid, 34
Tussicap, 62 valsartan, 35, 40
Tuxarin ER tabs, 62 Valsartan Soln, 40
Tuzistra XR, 62 valsartan/hydrochlorothiazide, 40
Twirla Dis, 57 Valtoco, 34
Twyneo 0.1-3% Cream, 45 Valtrex, 21
Twynsta, 40 Vanatol S/LQ, 34
tydemi tab, 57 vancomycin, 21
Tykerb, 24 Vandazole, 57
Tylenol w/Codeine, 34 vardenafil, 63
Tymlos, 50 vardenafil ODT, 63
Tyrvaya Sol, 59 varenicline, 34

xxxi
 Index
INDEX

varenicline pak, 34 Viread, 21

Varubi, 52 Viroptic, 59
Vascepa, 40 Virtussin AC w/ALC liquid, 34
Vaseretic, 40 Vistaril, 62
Vasotec, 40 Vitrakvi, 24
vecamyl, 40 Vituz, 62
Vectical, 45 Vivelle Dot, 57
Veltin, 45 Vivjoa, 21
Vemlidy, 21 Vivlodex, 34
Venclexta, 24 Vizimpro, 24
venlafaxine, 34 Vocabria, 21
venlafaxine ER, 34 Vogelxo, 50
Venlafaxine Tab 112.5mg, 34 Voltaren Gel, 55
Ventavis, 40 Vonjo, 24
Ventolin HFA, 62 Vonvendi, 40
verapamil HCl, 40 Voquezna Pak, 53
verapamil HCl ER, 40 voriconazole, 21
Verdeso, 45 Vosevi, 21
Veregen Oint, 45 VoSpire ER, 62
Verelan ER, PM, 40 Votrient, 24
Veripred soln 20mg/5ml, 50 Voxzogo, 40
Verkazia Emu 0.1%, 59 Vraylar, 34
Verquvo, 40 Vtama Cream, 45
Verzenio, 24 Vuity, 46
Vesicare, 63 Vumerity, 65
Vfend, 21 Vusion, 45
Viagra, 63 Vyleesi, 57
Viberzi, 53 Vyndaqel, Vyndamax, 40
Vibramycin, 21 Vytorin, 40
Victoza, 50 Vyvanse, 34
Videx EC, 21 Vyzulta Soln 0.024% OP, 59
Viekira Pak, 21
Viekira XR, 21 W
vigabatrin, 34 Wakix, 34
vigadrone, 34 warfarin, 40
Vigamox, 59 Wegovy Inj, 50
Viibryd, 55 Welchol, 41
Vijoice, 40 Welireg, 24
vilazodone, 55 Wellbutrin SR, 34
Vimpat tab, soln, 34 Wellbutrin XL, 34
Viokace, 53 Westhroid, 50
Viramune, 21 Wilate, 41
Viramune XR, 21 Winlevi Cream 1%, 45
Virazole, 46 wixela inhub aer, 62

xxxii
 Index
INDEX

WP Thyroid, 50 Xyntha, 41
wymzya Fe tablet chewable, 57 Xyosted Soln, 50
Wynzora Cream, 45 Xyrem, 34
Xywav Soln, 34
X
Xaciato Gel, 45 Y
Xadago, 34 Yasmin, 57
Xalatan, 59 YAZ, 57
Xalkori, 24 Yonsa, 24
Xanax, 34 Yupelri Soln, 62
Xanax XR, 34 yuvafem, 57
Xarelto, 41
Xatmep, 24 Z
Xcopri pak/tab, 34 Z-Tuss AC, 62
Xeljanz [XR], 55 Zafemy DIS, 57
Xeloda, 24 zafirlukast, 62
Xelpros Emulsion 0.005%, 59 zaleplon, 34
Xelstrym Pad, 34 Zanaflex, 55
Xenazine, 34 Zantac, 53
Xenical, 53 Zarontin, 34
Xenleta, 21 Zavesca, 65
Xepi Cream 1%, 21 Zcort 7-day tab, 50
Xerese Cream, 45 Zebutal Cap 50-325-40mg, 34
Xermelo, 53 Zegalogue Inj, 50
Xhance, 46, 62 Zegerid packets, 53
Xifaxan 200mg, 21 Zejula, 24
Xifaxan 550mg, 21 Zelboraf, 24
Xigduo XR, 50 Zelnorm, 53
Xiidra, 59 Zembrace Symtouch, 34
Ximino ER, 21 Zemplar, 50
Xodol, Norco, 34 Zenpep, 53
Xofluza Tab, 21 Zenzedi, 34
Xofluza therapy pack, 21 Zepatier, 22
Xolair Inj, 62 Zeposia, 55
Xolegel, 45 Zerit, 22
Xopenex HFA, 62 Zerviate Drops 0.24%, 59
Xopenex Nebulization Soln, 62 Zestoretic, 41
Xospata, 24 Zestril, 41
Xpovio Pak, 24 Zetia, 41
Xtampza ER, 34 Zetonna, 46
Xtandi, 24 Ziac, 41
xulane, 57 Ziagen, 22
Xultophy, 50 Ziana, 45
Xuriden, 65 zidovudine, 17, 19, 22

xxxiii
 Index
INDEX

zileuton ER 600mg, 62 Zykadia, 24

Zilxi Aer, 45 Zyloprim, 55
Zimhi Soln, 34 Zymaxid, 59
Zioptan, 59 Zypitamag, 41
ziprasidone, 34 Zyprexa, 34
Zipsor, 55 Zyprexa Zydis, 34
Zithromax, 22 Zytiga, 24
Zmax, 22 Zyvox, 22
Zocor, 41
Zofran, 53
Zohydro ER, 34
Zokinvy, 65
Zolinza, 24
zolmitriptan, 34
zolmitriptan spray, 34
Zoloft, 34
zolpidem tartrate, 34
zolpidem tartrate ER, 34
zolpidem tartrate SL, 34
Zomacton, 50
Zomig, 34
Zonalon cream 5%, 45
Zonegran, 34
Zonisade Susp, 34
zonisamide, 34
Zorbtive, 53
Zortress, 22, 24
Zorvolex, 34
Zoryve Cream, 45
Zovirax, 22, 45
Zovirax cream, 45
Zovirax oint, 45
Ztalmy Susp, 34
Ztlido Patch, 45
Zubsolv, 34
Zuplenz, 53
Zurampic 200mg, 55
Zutripro, 62
Zyban, 34
Zyclara Cream, 45
Zyclara Pump, 45
Zydelig, 24
Zyflo 600mg tab, 62
Zyflo CR 600mg, 62

xxxiv
 Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan,
Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent
licensees of the Blue Cross and Blue Shield Association.

10/23
Independence