Blue Cross Community Health Plans
Formulary (List of Drugs)
Effective Date: 4/1/2022 - 4/1/2023
Member Services: 1-877-860-2837 (TTY/TDD: 711)
www.bcchpil.com
IL_BCCHP_RX_Formulary22 Approved 06162022 244775.0222
Blue Cross Community
Health Plans
SM
Department of Healthcare & Family Services
07/01/2024
1Member Services: 1-877-860-2837 • TTY/TDD: 711 • 24/7 Nurseline: 1-888-343-2697
WHEN YOU NEED TO CONTACT MEMBER SERVICES
Our goal is to serve your health care needs through all of life’s changes. If you have any questions, our team stands
ready to help.
Call 1-877-860-2837 (TTY/TDD: 711)
We are open 24 hours a day, seven (7) days a week. The call is free.
A live agent can be reached from 8 a.m. to 5 p.m. Central time, Monday through Friday.
Self-service or a voicemail can be used 24 hours a day, seven days a week, including weekends and holidays.
Website www.bcchpil.com
Write Blue Cross Community Health Plans
c/o Member Services
P.O. B ox 3 418
Scranton, PA 18505
2 Member Services: 1-877-860-2837 • TTY/TDD: 711 • www.bcchpil.com
What is the Blue Cross Community Health Plans (the “Plan”) drug list?
The drug list (sometimes called a formulary) is a list showing the drugs that can be covered by the plan.
The drugs listed will be covered as long as you:
Ɣ Have a medical need for them
Ɣ Fill the medication orders at an in-network pharmacy
Ɣ Follow the other plan rules
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What will I pay?
You do not pay for covered drugs.
Can the drug list change?
Yes, it can change. Coverage may change if:
Ɣ A new, less expensive generic drug becomes available
Ɣ New information about a drug shows it to be unsafe or less effective
You will be told in writing when the drug list does change.
How do I use the drug list?
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1. Category
Ɣ The list of covered drugs that begins on page 1 gives you information about the drugs covered by Blue Cross Community
Health Plans (BCCHP
SM
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of this book.
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drugs are listed in lowercase italics (e.g. FLSURÀR[DFLQ).
– The information in the ‘Necessary actions, restrictions, or limits on use’ column tells you if BCCHP has any rules for
covering your drug.
Ɣ The drugs are listed in categories, or groups, based on the type of medical conditions they treat. (For example, drugs
used to treat a heart condition are listed under Cardiovascular Agents).
Ɣ If you know what your drug is used for, look for the group in the drug list.
Ɣ Then, look under that group for your drug.
2. Alphabetical Listing
Ɣ Look for your drug in the back of this book.
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3Member Services: 1-877-860-2837 • TTY/TDD: 711 • 24/7 Nurseline: 1-888-343-2697
What are generic drugs?
A generic drug is approved by the Food and Drug Administration (FDA) as having the same active ingredient as the brand name
drug, but often costs less. The plan covers both brand name drugs and generic drugs.
Are there any limits on my coverage?
Added conditions or limits on some covered drugs may include:
Ɣ Prior Authorization (PA):<RXRU\RXUGRFWRUPD\QHHGWRJHWDSSURYDOEHIRUH\RX¿OO\RXUPHGLFDWLRQRUGHUV,I\RXGRQRW
get approval, the plan may not cover the drug.
Ɣ Quantity Limits (QL): For certain drugs, the plan limits the amount that will be covered.
Ɣ Step Therapy (ST):,QVRPHFDVHVWKHSODQUHTXLUHV\RXWR¿UVWWU\FHUWDLQGUXJVEHIRUHDQRWKHUGUXJFDQEHFRYHUHG
For example, if Drug A and Drug B both treat your medical condition, the plan may not cover Drug B unless you try Drug A
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Ɣ Age Limits (AL): Some drugs have limits based on the members age. This is a safety program to prevent harmful side
effects. It follows age limits allowed by the FDA.
Ɣ Morphine Equivalent (ME) Dosing: ME dosing is a tool used to help prevent members from taking too much pain
medication (opioids). This tool allows Blue Cross Community Health Plans to calculate the total daily dose of pain
medications a member is taking no matter which opioid they are prescribed. The current daily ME limit in Illinois is
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prescription(s).
Ɣ Specialty Pharmacy Split Fill Program (SF): Specialty drugs are certain prescription medications used to treat complex,
chronic conditions like cancer, rheumatoid arthritis and multiple sclerosis. These drugs are an important part of many
treatment plans. They can cause side effects which may lead to your doctor making changes to the dose or stopping the
drug entirely. As you go through treatment, your doctor may make changes to the treatment plan until the best dose is
established for you. This may take a few months. The reason for the Specialty Pharmacy Split Fill Program for members
newly starting therapy is to:
– Prevent unnecessary prescriptions at inappropriate doses
– 0LQLPL]HZDVWHRIWKHVHGUXJV
– Manage side effects
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start to receive a full one-month supply for the rest of your therapy.
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Providers may submit coverage exception requests by fax (1-877-243-6930), phone 1-800-285-9426 (TTY/TDD 711), or by
website (MyPrime.com or CoverMyMeds.com3URYLGHUVPD\¿QGIRUPVRQMyPrime.com.
4 Member Services: 1-877-860-2837 • TTY/TDD: 711 • www.bcchpil.com
Does the plan pay for over-the-counter (OTC) drugs?
Yes, the plan pays for certain OTC drugs with a valid medication order from your doctor, and you may get those at no cost.
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and for quantities up to a 30-day supply.
What if my drug is not on the drug list?
Contact Member Services and ask if your drug is covered. If you learn that the plan does not cover your drug, you
have two options:
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Ɣ Ask Member Services about making an exception to cover your drug. Send in a statement from your doctor backing your
request. We must decide within 24 hours of getting your doctor’s statement.
We usually only approve requests for exceptions if the other drugs included on our list or the added use limits would make your
treatment less effective and/or would be harmful to your health.
Which drug categories are not covered by the plan drug list?
The following drug categories are not covered by your plan:
Ɣ Anorexia, weight loss or weight gain drugs
Ɣ Bulk chemicals
Ɣ Cosmetic enhancing drugs
Ɣ Diagnostic agents
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Ɣ Experimental and investigational drugs
Ɣ Erectile dysfunction drugs prescribed to treat impotence
Ɣ Fertility drugs
Ɣ General anesthetic drugs
Ɣ Over-the-counter products not otherwise included on the
plan’s drug list
Ɣ Surgical supply/medical devices
Ɣ Medications considered “unreasonable, unnecessary,
and/or excessive” according to the standards of
Medicaid, clinical practice guidelines and FDA labeling.
For More Information
For more details about your plan’s drug coverage, please review your member handbook and other plan materials.
If you have any questions, please visit our website at www.bcchpil.com.
You can also call Member Services at 1-877-860-2837. TTY/TDD users, please call 711. We are available 24 hours a day,
seven (7) days a week. The call is free.
5Member Services: 1-877-860-2837 • TTY/TDD: 711 • 24/7 Nurseline: 1-888-343-2697
For Language Assistance
Interpreter Services
We can arrange for someone to help you speak with us in any language. These services are free. If your doctor does not speak
your language, we can arrange for a translator to help you. Please call Member Services at the number above.
Hearing Problems
For our members with hearing problems, we offer TTY/TDD service free of charge. The line is open 24 hours a day, seven days
a week at 711.
Other Languages and Formats
You can get this document in Spanish, or speak with someone about this information in other languages for free.
Call 1-877-860-2837 (TTY/TDD: 711). The call is free. You can also call Member Services, toll-free, to request this information
in other alternative formats such as braille, large print and other forms. Call Toll Free: 1-877-860-2837 (TTY/TDD: 711). We are
available 24 hours a day, seven (7) days a week. The call is free.
If any information in this formulary (List of Drugs) is missing or inaccurate, please email BCCHPFormular[email protected].
You can also call Member Services toll-free at: 1-877-860-2837, TTY/TDD 711. The call is free.
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
1
Drug Name
Preferred Status Drug Status / Restriction
ADHD / ANTI-NARCOLEPSY AGENTS : AMPHETAMINES
ADDERALL – amphetamine-dextroamphetamine tab 5 mg,
7.5 mg, 10 mg, 12.5 mg, 15 mg, 30 mg
NP
PA (<=5 yr & >=19 yr),
QL (60 tablets/30 days)
ADDERALL – amphetamine-dextroamphetamine tab 20 mg
NP
PA (<=5 yr & >=19 yr),
QL (90 tablets/30 days)
ADDERALL XR – amphetamine-dextroamphetamine cap er 24hr
5 mg, 10 mg, 15 mg, 20 mg, 25 mg, 30 mg
NP
PA (<=5 yr & >=19 yr), QL
(30 capsules/30 days)
ADZENYS XR-ODT – amphetamine tab extended release
disintegrating 3.1 mg, 6.3 mg
NP
PA (<=5 yr & >=19 yr),
QL (60 tablets/30 days)
ADZENYS XR-ODT – amphetamine tab extended release
disintegrating 9.4 mg, 12.5 mg, 15.7 mg, 18.8 mg
NP
PA (<=5 yr & >=19 yr),
QL (30 tablets/30 days)
amphetamine sulfate tab 5 mg (Evekeo)
NP
PA (<=5 yr & >=19 yr),
QL (90 tablets/30 days)
amphetamine sulfate tab 10 mg (Evekeo)
NP
PA (<=5 yr & >=19 yr), QL
(180 tablets/30 days)
amphetamine-dextroamphetamine cap er 24hr 5 mg, 10 mg,
15 mg, 20 mg, 25 mg, 30 mg (Adderall xr)
P
PA (<=5 yr & >=19 yr), QL
(30 capsules/30 days)
amphetamine-dextroamphetamine tab 5 mg, 7.5 mg, 10 mg,
12.5 mg, 15 mg, 30 mg (Adderall)
P
PA (<=5 yr & >=19 yr),
QL (60 tablets/30 days)
amphetamine-dextroamphetamine tab 20 mg (Adderall)
P
PA (<=5 yr & >=19 yr),
QL (90 tablets/30 days)
amphetamine-dextroamphetamine 3-bead cap er 24hr 12.5 mg,
25 mg, 37.5 mg, 50 mg (Mydayis)
NP
PA (<=5 yr & >=19 yr), QL
(30 capsules/30 days)
DEXEDRINE – dextroamphetamine sulfate cap er 24hr 10 mg
NP
PA (<=5 yr & >=19 yr), QL
(120 capsules/30 days)
dextroamphetamine sulfate cap er 24hr 5 mg (Dexedrine)
NP
PA (<=5 yr & >=19 yr), QL
(90 capsules/30 days)
dextroamphetamine sulfate cap er 24hr 10 mg, 15 mg
(Dexedrine)
NP
PA (<=5 yr & >=19 yr), QL
(120 capsules/30 days)
dextroamphetamine sulfate oral solution 5 mg/5ml
NP
PA (<=5 yr & >=19 yr),
QL (1800 mls/30 days)
dextroamphetamine sulfate tab 2.5 mg, 5 mg, 7.5 mg, 15 mg,
20 mg
NP
PA (<=5 yr & >=19 yr),
QL (90 tablets/30 days)
dextroamphetamine sulfate tab 10 mg
NP
PA (<=5 yr & >=19 yr), QL
(180 tablets/30 days)
dextroamphetamine sulfate tab 30 mg
NP
PA (<=5 yr & >=19 yr),
QL (60 tablets/30 days)
DYANAVEL XR – amphetamine extended release susp 2.5 mg/
ml
P
PA (<=5 yr & >=19 yr),
QL (240 mls/30 days)
DYANAVEL XR – amphetamine chew tab extended release
5 mg, 10 mg, 15 mg, 20 mg
NP
PA (<=5 yr & >=19 yr),
QL (30 tablets/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
2
Drug Name
Preferred Status Drug Status / Restriction
EVEKEO – amphetamine sulfate tab 5 mg
NP
PA (<=5 yr & >=19 yr),
QL (90 tablets/30 days)
EVEKEO – amphetamine sulfate tab 10 mg
NP
PA (<=5 yr & >=19 yr), QL
(180 tablets/30 days)
lisdexamfetamine dimesylate cap 10 mg, 20 mg, 30 mg, 40 mg,
50 mg, 60 mg, 70 mg (Vyvanse)
NP
PA (<=5 yr & >=19 yr), QL
(30 capsules/30 days)
lisdexamfetamine dimesylate chew tab 10 mg, 20 mg, 30 mg,
40 mg, 50 mg, 60 mg (Vyvanse)
NP
PA (<=5 yr & >=19 yr),
QL (30 tablets/30 days)
methamphetamine hcl tab 5 mg (Desoxyn)
NP
PA (<=5 yr & >=19 yr), QL
(150 tablets/30 days)
MYDAYIS – amphetamine-dextroamphetamine 3-bead cap er
24hr 12.5 mg, 25 mg, 37.5 mg, 50 mg
NP
PA (<=5 yr & >=19 yr), QL
(30 capsules/30 days)
VYVANSE – lisdexamfetamine dimesylate cap 10 mg, 20 mg,
30 mg, 40 mg, 50 mg, 60 mg, 70 mg
P
PA (<=5 yr & >=19 yr), QL
(30 capsules/30 days)
VYVANSE – lisdexamfetamine dimesylate chew tab 10 mg,
20 mg, 30 mg, 40 mg, 50 mg, 60 mg
P
PA (<=5 yr & >=19 yr),
QL (30 tablets/30 days)
XELSTRYM – dextroamphetamine td patch 4.5 mg/9hr, 9 mg/9hr,
13.5 mg/9hr, 18 mg/9hr
NP
PA (<=5 yr & >=19 yr), QL
(30 patches/30 days)
ADHD / ANTI-NARCOLEPSY AGENTS : MISC
atomoxetine hcl cap 10 mg (base equiv), 18 mg (base equiv),
25 mg (base equiv), 40 mg (base equiv) (Strattera)
NP
PA (<=5 yr & >=19 yr), QL
(60 capsules/30 days)
atomoxetine hcl cap 60 mg (base equiv), 80 mg (base equiv),
100 mg (base equiv) (Strattera)
NP
PA (<=5 yr & >=19 yr), QL
(30 capsules/30 days)
clonidine hcl tab er 12hr 0.1 mg (Kapvay)
P
QL (120 tablets/30 days), 90
guanfacine hcl tab er 24hr 1 mg (base equiv), 2 mg (base equiv),
3 mg (base equiv), 4 mg (base equiv) (Intuniv)
P
QL (30 tablets/30 days), 90
INTUNIV – guanfacine hcl tab er 24hr 1 mg (base equiv), 2 mg
(base equiv), 3 mg (base equiv), 4 mg (base equiv)
NP
PA (<=5 yr & >=19 yr), QL
(30 tablets/30 days), 90
QELBREE – viloxazine hcl cap er 24hr 100 mg
NP
PA (<=5 yr & >=19 yr), QL
(30 capsules/30 days)
QELBREE – viloxazine hcl cap er 24hr 150 mg
NP
PA (<=5 yr & >=19 yr), QL
(60 capsules/30 days)
QELBREE – viloxazine hcl cap er 24hr 200 mg
NP
PA (<=5 yr & >=19 yr), QL
(90 capsules/30 days)
STRATTERA – atomoxetine hcl cap 10 mg (base equiv), 18 mg
(base equiv), 25 mg (base equiv), 40 mg (base equiv)
P
PA (<=5 yr & >=19 yr), QL
(60 capsules/30 days)
STRATTERA – atomoxetine hcl cap 60 mg (base equiv), 80 mg
(base equiv), 100 mg (base equiv)
P
PA (<=5 yr & >=19 yr), QL
(30 capsules/30 days)
SUNOSI – solriamfetol hcl tab 75 mg (base equiv), 150 mg (base
equiv)
NP
PA, QL (30 tablets/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
3
Drug Name
Preferred Status Drug Status / Restriction
WAKIX – pitolisant hcl tab 4.45 mg (base equivalent), 17.8 mg
(base equivalent)
NP
PA, QL (60 tablets/30
days), SP
ADHD / ANTI-NARCOLEPSY AGENTS : STIMULANTS
APTENSIO XR – methylphenidate hcl cap er 24hr 10 mg (xr),
15 mg (xr), 20 mg (xr), 30 mg (xr), 40 mg (xr), 50 mg (xr),
60 mg (xr)
NP
PA (<=5 yr & >=19 yr), QL
(30 capsules/30 days)
armodafinil tab 50 mg, 150 mg, 200 mg, 250 mg (Nuvigil)
NP
PA, 90
AZSTARYS – serdexmethylphenidate-dexmethylphenidate cap
26.1-5.2 mg, 39.2-7.8 mg, 52.3-10.4 mg
NP
PA (<=5 yr & >=19 yr), QL
(30 capsules/30 days)
CONCERTA – methylphenidate hcl tab er osmotic release (osm)
18 mg, 27 mg, 54 mg
P
PA (<=5 yr & >=19 yr),
QL (30 tablets/30 days)
CONCERTA – methylphenidate hcl tab er osmotic release (osm)
36 mg
P
PA (<=5 yr & >=19 yr),
QL (60 tablets/30 days)
COTEMPLA XR-ODT – methylphenidate tab extended release
disintegrating 8.6 mg
NP
PA (<=5 yr & >=19 yr),
QL (30 tablets/30 days)
COTEMPLA XR-ODT – methylphenidate tab extended release
disintegrating 17.3 mg, 25.9 mg
NP
PA (<=5 yr & >=19 yr),
QL (60 tablets/30 days)
DAYTRANA – methylphenidate td patch 10 mg/9hr, 15 mg/9hr,
20 mg/9hr, 30 mg/9hr
P
PA (<=5 yr & >=19 yr), QL
(30 patches/30 days)
dexmethylphenidate hcl cap er 24 hr 5 mg, 10 mg, 15 mg, 20 mg,
25 mg, 30 mg, 35 mg, 40 mg (Focalin xr)
NP
PA (<=5 yr & >=19 yr), QL
(30 capsules/30 days)
dexmethylphenidate hcl tab 2.5 mg, 5 mg, 10 mg (Focalin)
P
PA (<=5 yr & >=19 yr),
QL (60 tablets/30 days)
FOCALIN – dexmethylphenidate hcl tab 2.5 mg, 5 mg, 10 mg
NP
PA (<=5 yr & >=19 yr),
QL (60 tablets/30 days)
FOCALIN XR – dexmethylphenidate hcl cap er 24 hr 5 mg,
10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40 mg
P
PA (<=5 yr & >=19 yr), QL
(30 capsules/30 days)
JORNAY PM – methylphenidate hcl cap delayed er 24hr 20 mg
(pm), 40 mg (pm), 60 mg (pm), 80 mg (pm), 100 mg (pm)
P
PA (<=5 yr & >=19 yr), QL
(30 capsules/30 days)
METHYLIN – methylphenidate hcl soln 5 mg/5ml
NP
PA (<=5 yr & >=19 yr),
QL (450 mls/30 days)
METHYLIN – methylphenidate hcl soln 10 mg/5ml
NP
PA (<=5 yr & >=19 yr),
QL (900 mls/30 days)
methylphenidate hcl cap er 10 mg (cd), 20 mg (cd), 30 mg (cd),
40 mg (cd), 50 mg (cd), 60 mg (cd)
NP
PA (<=5 yr & >=19 yr), QL
(30 capsules/30 days)
methylphenidate hcl cap er 24hr 10 mg (la), 20 mg (la), 40 mg
(la) (Ritalin la)
NP
PA (<=5 yr & >=19 yr), QL
(30 capsules/30 days)
methylphenidate hcl cap er 24hr 30 mg (la) (Ritalin la)
NP
PA (<=5 yr & >=19 yr), QL
(60 capsules/30 days)
methylphenidate hcl cap er 24hr 60 mg (la)
NP
PA (<=5 yr & >=19 yr), QL
(30 capsules/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
4
Drug Name
Preferred Status Drug Status / Restriction
methylphenidate hcl cap er 24hr 10 mg (xr), 15 mg (xr), 20 mg
(xr), 30 mg (xr), 40 mg (xr), 50 mg (xr), 60 mg (xr) (Aptensio xr)
NP
PA (<=5 yr & >=19 yr), QL
(30 capsules/30 days)
methylphenidate hcl chew tab 2.5 mg, 5 mg
NP
PA (<=5 yr & >=19 yr),
QL (90 tablets/30 days)
methylphenidate hcl chew tab 10 mg
NP
PA (<=5 yr & >=19 yr), QL
(180 tablets/30 days)
methylphenidate hcl soln 5 mg/5ml (Methylin)
NP
PA (<=5 yr & >=19 yr),
QL (450 mls/30 days)
methylphenidate hcl soln 10 mg/5ml (Methylin)
NP
PA (<=5 yr & >=19 yr),
QL (900 mls/30 days)
methylphenidate hcl tab er osmotic release (osm) 18 mg, 27 mg,
54 mg (Concerta)
NP
PA (<=5 yr & >=19 yr),
QL (30 tablets/30 days)
methylphenidate hcl tab er osmotic release (osm) 36 mg
(Concerta)
NP
PA (<=5 yr & >=19 yr),
QL (60 tablets/30 days)
methylphenidate hcl tab er 10 mg, 20 mg
P
PA (<=5 yr & >=19 yr),
QL (90 tablets/30 days)
methylphenidate hcl tab 5 mg, 10 mg, 20 mg (Ritalin)
P
PA (<=5 yr & >=19 yr),
QL (90 tablets/30 days)
METHYLPHENIDATE HYDROCHLORIDE ER – methylphenidate
hcl tab er osmotic release (osm) 45 mg, 63 mg, 72 mg
NP
PA (<=5 yr & >=19 yr),
QL (30 tablets/30 days)
METHYLPHENIDATE HYDROCHLORIDE ER – methylphenidate
hcl tab er 24hr 18 mg, 27 mg, 54 mg
NP
PA (<=5 yr & >=19 yr),
QL (30 tablets/30 days)
METHYLPHENIDATE HYDROCHLORIDE ER – methylphenidate
hcl tab er 24hr 36 mg
NP
PA (<=5 yr & >=19 yr),
QL (60 tablets/30 days)
methylphenidate td patch 10 mg/9hr, 15 mg/9hr, 20 mg/9hr,
30 mg/9hr (Daytrana)
NP
PA (<=5 yr & >=19 yr), QL
(30 patches/30 days)
modafinil tab 100 mg, 200 mg (Provigil)
P
90
NUVIGIL – armodafinil tab 50 mg, 150 mg, 200 mg, 250 mg
NP
PA, 90
PROVIGIL – modafinil tab 100 mg, 200 mg
NP
PA, 90
QUILLICHEW ER – methylphenidate hcl chew tab extended
release 20 mg, 40 mg
NP
PA (<=5 yr & >=19 yr),
QL (30 tablets/30 days)
QUILLICHEW ER – methylphenidate hcl chew tab extended
release 30 mg
NP
PA (<=5 yr & >=19 yr),
QL (60 tablets/30 days)
QUILLIVANT XR – methylphenidate hcl for er susp 25 mg/5ml
(5 mg/ml)
NP
PA (<=5 yr & >=19 yr),
QL (360 mls/30 days)
RELEXXII – methylphenidate hcl tab er osmotic release (osm)
36 mg
NP
PA (<=5 yr & >=19 yr),
QL (60 tablets/30 days)
RELEXXII – methylphenidate hcl tab er osmotic release (osm)
18 mg, 27 mg, 45 mg, 54 mg, 63 mg, 72 mg
NP
PA (<=5 yr & >=19 yr),
QL (30 tablets/30 days)
RITALIN – methylphenidate hcl tab 5 mg, 10 mg, 20 mg
NP
PA (<=5 yr & >=19 yr),
QL (90 tablets/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
5
Drug Name
Preferred Status Drug Status / Restriction
RITALIN LA – methylphenidate hcl cap er 24hr 10 mg (la), 20 mg
(la), 40 mg (la)
NP
PA (<=5 yr & >=19 yr), QL
(30 capsules/30 days)
RITALIN LA – methylphenidate hcl cap er 24hr 30 mg (la)
NP
PA (<=5 yr & >=19 yr), QL
(60 capsules/30 days)
AGENTS FOR SICKLE CELL DISEASE
ADAKVEO – crizanlizumab-tmca iv soln 100 mg/10ml
NP
PA, SP
CASGEVY – exagamglogene autotemcel iv susp
NP
PA, SP
DROXIA – hydroxyurea cap 200 mg, 300 mg, 400 mg
P
ENDARI – glutamine (sickle cell) powd pack 5 gm
P
SP
LYFGENIA – lovotibeglogene autotemcel iv susp
NP
PA
OXBRYTA – voxelotor tab 300 mg, 500 mg
NP
PA, QL (90 tablets/30
days), SP
OXBRYTA – voxelotor tab for oral susp 300 mg
NP
PA, QL (90 tablets/30
days), SP
SIKLOS – hydroxyurea tab 100 mg, 1000 mg
NP
PA
ANALGESICS - ANTI-INFLAMMATORY : MISC
ARAVA – leflunomide tab 10 mg, 20 mg
NP
PA, 90
leflunomide tab 10 mg, 20 mg (Arava)
P
90
methotrexate sodium inj pf 50 mg/2ml (25 mg/ml)
SC
methotrexate sodium inj 50 mg/2ml (25 mg/ml)
SC
OTREXUP – methotrexate soln pf auto-injector 10 mg/0.4ml,
12.5 mg/0.4ml, 15 mg/0.4ml, 17.5 mg/0.4ml, 20 mg/0.4ml,
22.5 mg/0.4ml, 25 mg/0.4ml
NP
PA, 90
RASUVO – methotrexate soln pf auto-injector 7.5 mg/0.15ml,
10 mg/0.2ml, 12.5 mg/0.25ml, 15 mg/0.3ml, 17.5 mg/0.35ml,
20 mg/0.4ml, 22.5 mg/0.45ml, 25 mg/0.5ml, 30 mg/0.6ml
NP
PA, 90
RIDAURA – auranofin cap 3 mg
NP
PA, 90
ANALGESICS - ANTI-INFLAMMATORY : NONSTEROIDAL ANTI-INFLAMMATORY AGENTS (NSAIDs)
ARTHROTEC 50 – diclofenac w/ misoprostol tab delayed release
50-0.2 mg
NP
PA, QL (120
tablets/30 days), 90
ARTHROTEC 75 – diclofenac w/ misoprostol tab delayed release
75-0.2 mg
NP
PA, QL (90 tablets/30
days), 90
CELEBREX – celecoxib cap 50 mg, 100 mg, 200 mg
NP
PA, QL (60 capsules/30
days), 90
CELEBREX – celecoxib cap 400 mg
NP
PA, QL (30 capsules/30
days), 90
celecoxib cap 50 mg, 100 mg, 200 mg (Celebrex)
P
QL (60 capsules/30 days), 90
celecoxib cap 400 mg (Celebrex)
P
QL (30 capsules/30 days), 90
DAYPRO – oxaprozin tab 600 mg
NP
PA, QL (90 tablets/30
days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
6
Drug Name
Preferred Status Drug Status / Restriction
diclofenac potassium cap 25 mg (Zipsor)
NP
PA, QL (120
capsules/30 days)
diclofenac potassium tab 25 mg
NP
PA, QL (240
tablets/30 days), 90
diclofenac potassium tab 50 mg
P
QL (120 tablets/30 days), 90
diclofenac sodium tab delayed release 25 mg, 50 mg
P
QL (120 tablets/30 days), 90
diclofenac sodium tab delayed release 75 mg
P
QL (60 tablets/30 days), 90
diclofenac sodium tab er 24hr 100 mg
P
QL (60 tablets/30 days), 90
diclofenac w/ misoprostol tab delayed release 50-0.2 mg
(Arthrotec 50)
NP
PA, QL (120
tablets/30 days), 90
diclofenac w/ misoprostol tab delayed release 75-0.2 mg
(Arthrotec 75)
NP
PA, QL (90 tablets/30
days), 90
DUEXIS – ibuprofen-famotidine tab 800-26.6 mg
NP
PA, QL (90 tablets/30
days), 90
etodolac cap 200 mg, 300 mg
P
QL (90 capsules/30 days), 90
etodolac tab er 24hr 400 mg, 500 mg
P
QL (60 tablets/30 days), 90
etodolac tab er 24hr 600 mg
P
QL (30 tablets/30 days), 90
etodolac tab 400 mg (Lodine)
P
QL (60 tablets/30 days), 90
etodolac tab 500 mg
P
QL (60 tablets/30 days), 90
fenoprofen calcium cap 400 mg (Nalfon)
NP
PA, QL (240
capsules/30 days), 90
fenoprofen calcium tab 600 mg (Nalfon)
NP
PA, QL (150
tablets/30 days), 90
FLURBIPROFEN – flurbiprofen tab 50 mg
P
QL (180 tablets/30 days), 90
flurbiprofen tab 100 mg
P
QL (90 tablets/30 days), 90
ibuprofen susp 100 mg/5ml
NP
PA, QL (1000 mls/30 days)
ibuprofen tab 400 mg, 800 mg
P
QL (120 tablets/30 days), 90
ibuprofen tab 600 mg
P
QL (150 tablets/30 days), 90
ibuprofen-famotidine tab 800-26.6 mg (Duexis)
NP
PA, QL (90 tablets/30
days), 90
indomethacin cap er 75 mg
P
QL (60 capsules/30 days), 90
indomethacin cap 25 mg
P
QL (90 capsules/30 days), 90
indomethacin cap 50 mg
P
QL (60 capsules/30 days), 90
indomethacin suppos 50 mg
P
QL (120 suppositories/30
days), 90
indomethacin susp 25 mg/5ml (Indocin)
P
QL (1200 mls/30 days), 90
KETOPROFEN ER – ketoprofen cap er 24hr 200 mg
NP
PA, QL (30 capsules/30
days), 90
ketorolac tromethamine tab 10 mg
P
QL (20 tablets/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
7
Drug Name
Preferred Status Drug Status / Restriction
MECLOFENAMATE SODIUM – meclofenamate sodium cap
50 mg
NP
PA, QL (120
capsules/30 days), 90
MECLOFENAMATE SODIUM – meclofenamate sodium cap
100 mg
NP
PA, QL (60 capsules/30
days), 90
mefenamic acid cap 250 mg
NP
PA, QL (60 capsules/30
days), 90
meloxicam cap 5 mg (Vivlodex)
NP
PA, QL (60 capsules/30
days), 90
meloxicam cap 10 mg (Vivlodex)
NP
PA, QL (30 capsules/30
days), 90
meloxicam tab 7.5 mg (Mobic)
P
QL (60 tablets/30 days), 90
meloxicam tab 15 mg (Mobic)
P
QL (30 tablets/30 days), 90
nabumetone tab 500 mg
P
QL (120 tablets/30 days), 90
nabumetone tab 750 mg
P
QL (60 tablets/30 days), 90
NALFON – fenoprofen calcium cap 400 mg
NP
PA, QL (240
capsules/30 days), 90
NALFON – fenoprofen calcium tab 600 mg
NP
PA, QL (150
tablets/30 days), 90
NAPRELAN – naproxen sodium tab er 24hr 375 mg (base equiv)
NP
PA, QL (120
tablets/30 days), 90
NAPRELAN – naproxen sodium tab er 24hr 500 mg (base equiv)
NP
PA, QL (90 tablets/30
days), 90
NAPRELAN – naproxen sodium tab er 24hr 750 mg (base equiv)
NP
PA, QL (60 tablets/30
days), 90
naproxen sodium tab er 24hr 375 mg (base equiv) (Naprelan)
NP
PA, QL (120
tablets/30 days), 90
naproxen sodium tab er 24hr 500 mg (base equiv) (Naprelan)
NP
PA, QL (90 tablets/30
days), 90
naproxen sodium tab er 24hr 750 mg (base equiv) (Naprelan)
NP
PA, QL (60 tablets/30
days), 90
naproxen sodium tab 275 mg
P
QL (150 tablets/30 days), 90
naproxen sodium tab 550 mg
P
QL (90 tablets/30 days), 90
naproxen susp 125 mg/5ml (Naprosyn)
P
QL (1800 mls/30 days), 90
naproxen tab ec 375 mg (Ec-naprosyn)
P
QL (120 tablets/30 days), 90
naproxen tab ec 500 mg (Ec-naproxen)
P
QL (90 tablets/30 days), 90
naproxen tab 250 mg
P
QL (150 tablets/30 days), 90
naproxen tab 375 mg
P
QL (120 tablets/30 days), 90
naproxen tab 500 mg
P
QL (90 tablets/30 days), 90
naproxen-esomeprazole magnesium tab dr 375-20 mg,
500-20 mg (Vimovo)
NP
PA, QL (60 tablets/30
days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
8
Drug Name
Preferred Status Drug Status / Restriction
oxaprozin tab 600 mg (Daypro)
NP
PA, QL (90 tablets/30
days), 90
piroxicam cap 10 mg (Feldene)
NP
PA, QL (60 capsules/30
days), 90
piroxicam cap 20 mg (Feldene)
NP
PA, QL (30 capsules/30
days), 90
RELAFEN DS – nabumetone tab 1000 mg
NP
PA, QL (60 tablets/30 days)
sulindac tab 150 mg, 200 mg
P
QL (60 tablets/30 days), 90
TOLMETIN SODIUM – tolmetin sodium cap 400 mg
NP
PA, QL (90 capsules/30
days), 90
VIMOVO – naproxen-esomeprazole magnesium tab dr
375-20 mg, 500-20 mg
NP
PA, QL (60 tablets/30
days), 90
ANALGESICS - NONNARCOTIC
butalbital-acetaminophen cap 50-300 mg (Butalbital/
acetaminophen)
NP
PA, QL (180
capsules/30 days)
butalbital-acetaminophen tab 50-300 mg, 50-325 mg
P
QL (180 tablets/30 days)
butalbital-acetaminophen-caffeine cap 50-300-40 mg (Fioricet)
P
QL (180 capsules/30 days)
butalbital-acetaminophen-caffeine cap 50-325-40 mg
P
QL (180 capsules/30 days)
butalbital-acetaminophen-caffeine tab 50-325-40 mg (Esgic)
P
QL (180 tablets/30 days)
butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal)
P
QL (180 capsules/30 days)
diflunisal tab 500 mg
P
QL (90 tablets/30 days), 90
ESGIC – butalbital-acetaminophen-caffeine tab 50-325-40 mg
NP
PA, QL (180 tablets/30 days)
FIORICET – butalbital-acetaminophen-caffeine cap
50-300-40 mg
NP
PA, QL (180
capsules/30 days)
salsalate tab 500 mg, 750 mg
P
90
ANALGESICS : OPIOID
BELBUCA – buprenorphine hcl buccal film 75 mcg (base
equivalent), 150 mcg (base equivalent), 300 mcg (base
equivalent), 450 mcg (base equivalent), 600 mcg (base
equivalent), 750 mcg (base equivalent), 900 mcg (base
equivalent)
NP
ME, PA, QL (60
films/30 days)
BRIXADI – buprenorphine extended release soln pref syr
64 mg/0.18ml, 96 mg/0.27ml, 128 mg/0.36ml
P
BRIXADI – buprenorphine ext rel soln pref syr (weekly)
8 mg/0.16ml, (weekly) 16 mg/0.32ml, (weekly) 24 mg/0.48ml,
(weekly) 32 mg/0.64ml
P
buprenorphine hcl sl tab 2 mg (base equiv)
P
ME, QL (360 tablets/30 days)
buprenorphine hcl sl tab 8 mg (base equiv)
P
ME, QL (90 tablets/30 days)
buprenorphine td patch weekly 5 mcg/hr, 7.5 mcg/hr, 10 mcg/hr,
15 mcg/hr, 20 mcg/hr (Butrans)
NP
ME, PA, QL (4
patches/28 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
9
Drug Name
Preferred Status Drug Status / Restriction
butorphanol tartrate nasal soln 10 mg/ml
NP
ME, PA, QL (2
bottles/30 days)
BUTRANS – buprenorphine td patch weekly 5 mcg/hr, 7.5 mcg/
hr, 10 mcg/hr, 15 mcg/hr, 20 mcg/hr
NP
ME, PA, QL (4
patches/28 days)
CODEINE SULFATE – codeine sulfate tab 15 mg, 30 mg, 60 mg
P
ME, QL (180 tablets/30 days)
codeine sulfate tab 30 mg (Codeine sulfate)
P
ME, QL (180 tablets/30 days)
CONZIP – tramadol hcl cap er 24hr biphasic release 100 mg,
200 mg, 300 mg
NP
ME, PA, QL (30
capsules/30 days)
DILAUDID – hydromorphone hcl tab 2 mg, 4 mg, 8 mg
NP
ME, PA, QL (180
tablets/30 days)
DILAUDID – hydromorphone hcl liqd 1 mg/ml
NP
ME, PA, QL (1440
mls/30 days)
FENTANYL CITRATE – fentanyl citrate buccal tab 100 mcg (base
equiv), 200 mcg (base equiv), 400 mcg (base equiv), 600 mcg
(base equiv), 800 mcg (base equiv)
NP
ME, PA, QL (120
tablets/30 days)
fentanyl citrate lozenge on a handle 200 mcg, 400 mcg, 600 mcg,
800 mcg, 1200 mcg, 1600 mcg (Actiq)
NP
ME, PA, QL (120
lozenges/30 days)
fentanyl td patch 72hr 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/
hr, 100 mcg/hr (Duragesic)
NP
ME, PA, QL (15
patches/30 days)
fentanyl td patch 72hr 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr
NP
ME, PA, QL (15
patches/30 days)
FENTORA – fentanyl citrate buccal tab 100 mcg (base equiv),
200 mcg (base equiv), 400 mcg (base equiv), 600 mcg (base
equiv), 800 mcg (base equiv)
NP
ME, PA, QL (120
tablets/30 days)
HYDROCODONE BITARTRATE ER – hydrocodone bitartrate
cap er 12hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg
NP
ME, PA, QL (60
capsules/30 days)
hydrocodone bitartrate tab er 24hr deter 20 mg, 30 mg, 40 mg,
60 mg, 80 mg, 100 mg, 120 mg (Hysingla er)
NP
ME, PA, QL (30
tablets/30 days)
HYDROMORPHONE HCL – hydromorphone hcl suppos 3 mg
P
ME, QL (120
suppositories/30 days)
hydromorphone hcl liqd 1 mg/ml (Dilaudid)
P
ME, QL (1440 mls/30 days)
hydromorphone hcl tab er 24hr 8 mg, 12 mg, 16 mg, 32 mg
NP
ME, PA, QL (30
tablets/30 days)
hydromorphone hcl tab 2 mg, 4 mg, 8 mg (Dilaudid)
P
ME, QL (180 tablets/30 days)
HYSINGLA ER – hydrocodone bitartrate tab er 24hr deter 20 mg,
30 mg, 40 mg, 60 mg, 80 mg, 100 mg, 120 mg
NP
ME, PA, QL (30
tablets/30 days)
LEVORPHANOL TARTRATE – levorphanol tartrate tab 3 mg
NP
ME, PA, QL (120
tablets/30 days)
levorphanol tartrate tab 2 mg
NP
ME, PA, QL (120
tablets/30 days)
MEPERIDINE HCL – meperidine hcl oral soln 50 mg/5ml
NP
ME, PA, QL (1800
mls/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
10
Drug Name
Preferred Status Drug Status / Restriction
meperidine hcl tab 50 mg
NP
ME, PA, QL (360
tablets/30 days)
METHADONE HCL – methadone hcl soln 5 mg/5ml
NP
ME, PA, QL (900
mls/30 days)
METHADONE HCL – methadone hcl soln 10 mg/5ml
NP
ME, PA, QL (450
mls/30 days)
methadone hcl conc 10 mg/ml (Methadose)
NP
ME, PA, QL (90 mls/30 days)
methadone hcl soln 5 mg/5ml (Methadone hcl)
NP
ME, PA, QL (900
mls/30 days)
methadone hcl soln 10 mg/5ml (Methadone hcl)
NP
ME, PA, QL (450
mls/30 days)
methadone hcl tab for oral susp 40 mg
NP
ME, PA, QL (90
tablets/30 days)
methadone hcl tab 5 mg, 10 mg (Dolophine)
NP
ME, PA, QL (90
tablets/30 days)
METHADOSE – methadone hcl conc 10 mg/ml
NP
ME, PA, QL (90 mls/30 days)
METHADOSE SUGAR-FREE – methadone hcl conc 10 mg/ml
NP
ME, PA, QL (90 mls/30 days)
MORPHINE SULFATE – morphine sulfate suppos 5 mg, 10 mg,
20 mg, 30 mg
P
ME, QL (180
suppositories/30 days)
MORPHINE SULFATE – morphine sulfate tab 15 mg
P
ME, QL (360 tablets/30 days)
MORPHINE SULFATE – morphine sulfate tab 30 mg
P
ME, QL (180 tablets/30 days)
MORPHINE SULFATE – morphine sulfate oral soln 10 mg/5ml
P
ME, QL (2700 mls/30 days)
MORPHINE SULFATE – morphine sulfate oral soln 20 mg/5ml
P
ME, QL (1350 mls/30 days)
MORPHINE SULFATE – morphine sulfate oral soln 100 mg/5ml
(20 mg/ml)
P
ME, QL (270 mls/30 days)
MORPHINE SULFATE ER – morphine sulfate cap er 24hr 10 mg,
20 mg, 30 mg, 50 mg, 60 mg, 80 mg, 100 mg
NP
ME, PA, QL (60
capsules/30 days)
MORPHINE SULFATE ER – morphine sulfate beads cap er 24hr
30 mg, 45 mg, 60 mg, 75 mg, 90 mg, 120 mg
NP
ME, PA, QL (30
capsules/30 days)
morphine sulfate oral soln 10 mg/5ml
P
ME, QL (2700 mls/30 days)
morphine sulfate oral soln 100 mg/5ml (20 mg/ml)
P
ME, QL (270 mls/30 days)
morphine sulfate tab er 15 mg, 30 mg, 60 mg, 100 mg, 200 mg
(Ms contin)
P
ME, QL (90 tablets/30 days)
morphine sulfate tab 15 mg (Morphine sulfate)
P
ME, QL (360 tablets/30 days)
morphine sulfate tab 30 mg (Morphine sulfate)
P
ME, QL (180 tablets/30 days)
MS CONTIN – morphine sulfate tab er 15 mg, 30 mg, 60 mg,
100 mg, 200 mg
NP
ME, PA, QL (90
tablets/30 days)
NUCYNTA – tapentadol hcl tab 50 mg, 75 mg, 100 mg
NP
ME, PA, QL (180
tablets/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
11
Drug Name
Preferred Status Drug Status / Restriction
NUCYNTA ER – tapentadol hcl tab er 12hr 50 mg, 100 mg,
150 mg, 200 mg, 250 mg
NP
ME, PA, QL (60
tablets/30 days)
oxycodone hcl cap 5 mg
P
ME, QL (360
capsules/30 days)
oxycodone hcl conc 100 mg/5ml (20 mg/ml)
P
ME, QL (270 mls/30 days)
OXYCODONE HCL ER – oxycodone hcl tab er 12hr deter 10 mg,
20 mg, 40 mg, 80 mg
NP
ME, PA, QL (120
tablets/30 days)
oxycodone hcl soln 5 mg/5ml
P
ME, QL (5400 mls/30 days)
oxycodone hcl tab 5 mg (Roxicodone)
P
ME, QL (360 tablets/30 days)
oxycodone hcl tab 10 mg, 20 mg
P
ME, QL (180 tablets/30 days)
oxycodone hcl tab 15 mg, 30 mg (Roxicodone)
P
ME, QL (180 tablets/30 days)
OXYCONTIN – oxycodone hcl tab er 12hr deter 10 mg, 15 mg,
20 mg, 30 mg, 40 mg, 60 mg, 80 mg
NP
ME, PA, QL (120
tablets/30 days)
oxymorphone hcl tab 5 mg
NP
ME, PA, QL (180
tablets/30 days)
oxymorphone hcl tab 10 mg (Opana)
NP
ME, PA, QL (180
tablets/30 days)
OXYMORPHONE HYDROCHLORIDE ER – oxymorphone hcl
tab er 12hr 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg, 30 mg, 40 mg
NP
ME, PA, QL (60
tablets/30 days)
pentazocine w/ naloxone hcl tab 50-0.5 mg
NP
ME, PA, QL (360
tablets/30 days)
ROXICODONE – oxycodone hcl tab 15 mg, 30 mg
NP
ME, PA, QL (180
tablets/30 days)
ROXYBOND – oxycodone hcl tab abuse deter 5 mg
NP
ME, PA, QL (360
tablets/30 days)
ROXYBOND – oxycodone hcl tab abuse deter 15 mg, 30 mg
NP
ME, PA, QL (180
tablets/30 days)
SUBLOCADE – buprenorphine extended release soln pref syr
100 mg/0.5ml
P
QL (.5 mls/30 days)
SUBLOCADE – buprenorphine extended release soln pref syr
300 mg/1.5ml
P
QL (1.5 mls/30 days)
TRAMADOL HCL ER – tramadol hcl tab er 24hr biphasic release
100 mg, 200 mg, 300 mg
NP
ME, PA, QL (30
tablets/30 days)
TRAMADOL HCL ER – tramadol hcl cap er 24hr biphasic release
100 mg, 200 mg, 300 mg
NP
ME, PA, QL (30
capsules/30 days)
tramadol hcl tab er 24hr 100 mg, 200 mg, 300 mg
NP
ME, PA, QL (30
tablets/30 days)
tramadol hcl tab 50 mg (Ultram)
P
ME, QL (240 tablets/30 days)
tramadol hcl tab 100 mg
NP
ME, PA, QL (120
tablets/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
12
Drug Name
Preferred Status Drug Status / Restriction
TRAMADOL HYDROCHLORIDE – tramadol hcl tab 25 mg
NP
ME, PA, QL (240
tablets/30 days)
TRAMADOL HYDROCHLORIDE – tramadol hcl oral soln 5 mg/
ml
NP
ME, PA, QL (2400
mls/30 days)
XTAMPZA ER – oxycodone cap er 12hr abuse-deterrent 9 mg,
13.5 mg, 18 mg, 27 mg, 36 mg
NP
ME, PA, QL (240
capsules/30 days)
ANALGESICS : OPIOID COMBINATIONS
acetaminophen w/ codeine tab 300-15 mg (Tylenol/codeine)
P
ME, QL (360 tablets/30 days)
acetaminophen w/ codeine tab 300-30 mg (Tylenol/codeine #3)
P
ME, QL (360 tablets/30 days)
acetaminophen w/ codeine tab 300-60 mg
P
ME, QL (180 tablets/30 days)
ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE –
acetaminophen-caffeine-dihydrocodeine cap 320.5-30-16 mg
NP
ME, PA, QL (300
capsules/30 days)
ACETAMINOPHEN/CODEINE – acetaminophen w/ codeine soln
120-12 mg/5ml
P
ME, QL (2700 mls/30 days)
butalbital-acetaminophen-caff w/ cod cap 50-300-40-30 mg
(Fioricet/codeine)
NP
ME, PA, QL (180
capsules/30 days)
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30 mg
NP
ME, PA, QL (180
capsules/30 days)
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg (Fiorinal/
codeine #3)
P
ME, QL (180
capsules/30 days)
FIORICET/CODEINE – butalbital-acetaminophen-caff w/ cod cap
50-300-40-30 mg
NP
ME, PA, QL (180
capsules/30 days)
hydrocodone-acetaminophen soln 7.5-325 mg/15ml
P
ME, QL (2700 mls/30 days)
hydrocodone-acetaminophen tab 10-325 mg, 7.5-325 mg (Norco)
P
ME, QL (180 tablets/30 days)
hydrocodone-acetaminophen tab 5-300 mg
P
ME, QL (240 tablets/30 days)
hydrocodone-acetaminophen tab 7.5-300 mg, 10-300 mg
P
ME, QL (180 tablets/30 days)
hydrocodone-acetaminophen tab 5-325 mg (Norco)
P
ME, QL (240 tablets/30 days)
hydrocodone-ibuprofen tab 7.5-200 mg
P
ME, QL (150 tablets/30 days)
HYDROCODONE/IBUPROFEN – hydrocodone-ibuprofen tab
5-200 mg, 10-200 mg
P
ME, QL (150 tablets/30 days)
NALOCET – oxycodone w/ acetaminophen tab 2.5-300 mg
NP
ME, PA, QL (360
tablets/30 days)
OXYCODONE HYDROCHLORIDE/ACETAMINOPHEN –
oxycodone w/ acetaminophen soln 5-325 mg/5ml
P
ME, QL (1800 mls/30 days)
oxycodone w/ acetaminophen tab 2.5-325 mg, 5-325 mg
(Percocet)
P
ME, QL (360 tablets/30 days)
oxycodone w/ acetaminophen tab 7.5-325 mg (Percocet)
P
ME, QL (240 tablets/30 days)
oxycodone w/ acetaminophen tab 10-325 mg (Percocet)
P
ME, QL (180 tablets/30 days)
PERCOCET – oxycodone w/ acetaminophen tab 2.5-325 mg,
5-325 mg
NP
ME, PA, QL (360
tablets/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
13
Drug Name
Preferred Status Drug Status / Restriction
PERCOCET – oxycodone w/ acetaminophen tab 7.5-325 mg
NP
ME, PA, QL (240
tablets/30 days)
PERCOCET – oxycodone w/ acetaminophen tab 10-325 mg
NP
ME, PA, QL (180
tablets/30 days)
PROLATE – oxycodone w/ acetaminophen tab 5-300 mg
NP
ME, PA, QL (360
tablets/30 days)
PROLATE – oxycodone w/ acetaminophen tab 7.5-300 mg
NP
ME, PA, QL (240
tablets/30 days)
PROLATE – oxycodone w/ acetaminophen tab 10-300 mg
NP
ME, PA, QL (180
tablets/30 days)
PROLATE – oxycodone w/ acetaminophen soln 10-300 mg/5ml
NP
ME, PA, QL (900
mls/30 days)
SEGLENTIS – celecoxib-tramadol hcl tab 56-44 mg
NP
ME, PA, QL (120
tablets/30 days)
tramadol-acetaminophen tab 37.5-325 mg (Ultracet)
NP
ME, PA, QL (240
tablets/30 days)
ANAPHYLAXIS THERAPY AGENTS
AUVI-Q – epinephrine solution auto-injector 0.1 mg/0.1ml,
0.15 mg/0.15ml (1:1000), 0.3 mg/0.3ml (1:1000)
P
QL (4 pens/1 prescription)
EPINEPHRINE – epinephrine solution auto-injector
0.15 mg/0.15ml (1:1000), 0.3 mg/0.3ml (1:1000)
P
QL (4 pens/1 prescription)
epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000)
(Epipen-jr 2-pak)
P
QL (4 pens/1 prescription)
epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000) (Epipen
2-pak)
P
QL (4 pens/1 prescription)
EPIPEN 2-PAK – epinephrine solution auto-injector 0.3 mg/0.3ml
(1:1000)
NP
PA, QL (4 pens/1
prescription)
EPIPEN-JR 2-PAK – epinephrine solution auto-injector
0.15 mg/0.3ml (1:2000)
NP
PA, QL (4 pens/1
prescription)
ANORECTAL AGENTS
ANUSOL-HC – hydrocortisone perianal cream 2.5%
NP
PA
budesonide rectal foam 2 mg/act (Uceris)
NP
PA
CORTENEMA – hydrocortisone enema 100 mg/60ml
NP
PA
CORTIFOAM – hydrocortisone acetate perianal foam 10%
(90 mg/dose)
NP
PA
hydrocortisone enema 100 mg/60ml (Cortenema)
P
hydrocortisone perianal cream 1% (Proctocort)
P
hydrocortisone perianal cream 2.5% (Anusol-hc)
P
LIDOCAINE HCL-HYDROCORTISONE ACETATE WITH ALOE –
lidocaine-hydrocortisone acetate rectal gel 2.8-0.55%
NP
PA
LIDOCAINE HCL/HYDROCORTISONE ACETATE – lidocaine-
hydrocortisone acetate rectal cream kit 3-1%
NP
PA
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
14
Drug Name
Preferred Status Drug Status / Restriction
lidocaine-hydrocortisone acetate perianal cream 3-0.5%
NP
PA
lidocaine-hydrocortisone acetate rectal cream kit 2-2%, 3-0.5%
NP
PA
lidocaine-hydrocortisone acetate rectal gel kit 3-2.5%
NP
PA
PROCTOFOAM HC – hydrocortisone acetate w/ pramoxine
perianal foam 1-1%
NP
PA
RECTIV – nitroglycerin oint 0.4%
NP
PA
UCERIS – budesonide rectal foam 2 mg/act
NP
PA
ANTIANXIETY AGENTS : BENZODIAZEPINES
ALPRAZOLAM INTENSOL – alprazolam conc 1 mg/ml
P
QL (180 mls/30 days)
alprazolam orally disintegrating tab 0.25 mg, 0.5 mg, 1 mg
NP
PA, QL (120 tablets/30 days)
alprazolam orally disintegrating tab 2 mg
NP
PA, QL (90 tablets/30 days)
alprazolam tab er 24hr 0.5 mg, 1 mg (Xanax xr)
NP
PA, QL (30 tablets/30 days)
alprazolam tab er 24hr 2 mg (Xanax xr)
NP
PA, QL (90 tablets/30 days)
alprazolam tab er 24hr 3 mg (Xanax xr)
NP
PA, QL (60 tablets/30 days)
alprazolam tab 0.25 mg, 0.5 mg, 1 mg (Xanax)
P
QL (120 tablets/30 days)
alprazolam tab 2 mg (Xanax)
P
QL (90 tablets/30 days)
ATIVAN – lorazepam tab 0.5 mg, 1 mg
NP
PA, QL (90 tablets/30 days)
ATIVAN – lorazepam tab 2 mg
NP
PA, QL (150 tablets/30 days)
chlordiazepoxide hcl cap 5 mg, 10 mg, 25 mg
P
QL (120 capsules/30 days)
clorazepate dipotassium tab 3.75 mg
P
QL (90 tablets/30 days)
clorazepate dipotassium tab 7.5 mg (Tranxene t)
P
QL (90 tablets/30 days)
clorazepate dipotassium tab 15 mg
P
QL (120 tablets/30 days)
diazepam conc 5 mg/ml
P
QL (240 mls/30 days)
diazepam oral soln 1 mg/ml
P
QL (1200 mls/30 days)
diazepam tab 2 mg, 5 mg, 10 mg (Valium)
P
QL (120 tablets/30 days)
lorazepam conc 2 mg/ml
P
QL (150 mls/30 days)
lorazepam tab 0.5 mg, 1 mg (Ativan)
P
QL (90 tablets/30 days)
lorazepam tab 2 mg (Ativan)
P
QL (150 tablets/30 days)
LOREEV XR – lorazepam cap er 24hr sprinkle 1 mg, 1.5 mg
NP
PA, QL (30 capsules/30 days)
LOREEV XR – lorazepam cap er 24hr sprinkle 2 mg
NP
PA, QL (150
capsules/30 days)
LOREEV XR – lorazepam cap er 24hr sprinkle 3 mg
NP
PA, QL (90 capsules/30 days)
oxazepam cap 10 mg, 15 mg
P
QL (120 capsules/30 days)
oxazepam cap 30 mg
P
QL (60 capsules/30 days)
XANAX – alprazolam tab 0.25 mg, 0.5 mg, 1 mg
NP
PA, QL (120 tablets/30 days)
XANAX – alprazolam tab 2 mg
NP
PA, QL (90 tablets/30 days)
XANAX XR – alprazolam tab er 24hr 0.5 mg, 1 mg
NP
PA, QL (30 tablets/30 days)
XANAX XR – alprazolam tab er 24hr 2 mg
NP
PA, QL (90 tablets/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
15
Drug Name
Preferred Status Drug Status / Restriction
XANAX XR – alprazolam tab er 24hr 3 mg
NP
PA, QL (60 tablets/30 days)
ANTIANXIETY AGENTS : MISC
buspirone hcl tab 5 mg, 7.5 mg, 10 mg, 15 mg, 30 mg
P
hydroxyzine hcl syrup 10 mg/5ml
P
hydroxyzine hcl tab 10 mg, 25 mg, 50 mg
P
HYDROXYZINE PAMOATE – hydroxyzine pamoate cap 100 mg
P
hydroxyzine pamoate cap 25 mg, 50 mg (Vistaril)
P
meprobamate tab 200 mg, 400 mg
NP
PA
VISTARIL – hydroxyzine pamoate cap 25 mg
NP
PA
ANTIASTHMATIC AND BRONCHODILATOR AGENTS : ADRENERGIC COMBINATIONS
ADVAIR DISKUS – fluticasone-salmeterol aer powder ba
100-50 mcg/act, 250-50 mcg/act, 500-50 mcg/act
P
QL (60 blisters/30 days), 90
ADVAIR HFA – fluticasone-salmeterol inhal aerosol 45-21 mcg/
act, 115-21 mcg/act, 230-21 mcg/act
P
QL (1 inhaler/30 days), 90
AIRDUO RESPICLICK 113/14 – fluticasone-salmeterol aer
powder ba 113-14 mcg/act
P
QL (1 inhaler/30 days), 90
AIRDUO RESPICLICK 232/14 – fluticasone-salmeterol aer
powder ba 232-14 mcg/act
P
QL (1 inhaler/30 days), 90
AIRDUO RESPICLICK 55/14 – fluticasone-salmeterol aer
powder ba 55-14 mcg/act
P
QL (1 inhaler/30 days), 90
AIRSUPRA – albuterol-budesonide inhalation aerosol 90-80 mcg/
act
NP
PA, QL (3 inhalers/30 days)
ANORO ELLIPTA – umeclidinium-vilanterol aero powd ba
62.5-25 mcg/act
P
QL (60 blisters/30 days), 90
BEVESPI AEROSPHERE – glycopyrrolate-formoterol fumarate
aerosol 9-4.8 mcg/act
NP
PA, QL (1 inhaler/30
days), 90
BREO ELLIPTA – fluticasone furoate-vilanterol aero powd ba
50-25 mcg/act
NP
PA, QL (1 inhaler/30
days), 90
BREO ELLIPTA – fluticasone furoate-vilanterol aero powd ba
100-25 mcg/act, 200-25 mcg/act
NP
PA, QL (60 blisters/30
days), 90
BREZTRI AEROSPHERE – budesonide-glycopyrrolate-
formoterol aers 160-9-4.8 mcg/act
NP
PA, QL (1 inhaler/30
days), 90
budesonide-formoterol fumarate dihyd aerosol 80-4.5 mcg/act,
160-4.5 mcg/act (Symbicort)
NP
PA, QL (3 inhalers/30
days), 90
COMBIVENT RESPIMAT – ipratropium-albuterol inhal aerosol
soln 20-100 mcg/act
NP
PA, QL (2 inhalers/30
days), 90
DUAKLIR PRESSAIR – aclidinium br-formoterol fum aero pow br
act 400-12 mcg/act
NP
PA, QL (1 inhaler/30
days), 90
DULERA – mometasone furoate-formoterol fumarate aerosol
50-5 mcg/act, 100-5 mcg/act, 200-5 mcg/act
P
QL (3 inhalers/30 days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
16
Drug Name
Preferred Status Drug Status / Restriction
FLUTICASONE FUROATE/VILANTEROL ELLIPTA – fluticasone
furoate-vilanterol aero powd ba 100-25 mcg/act, 200-25 mcg/
act
NP
PA, QL (60 blisters/30
days), 90
FLUTICASONE PROPIONATE/SALMETEROL – fluticasone-
salmeterol aer powder ba 55-14 mcg/act, 113-14 mcg/act,
232-14 mcg/act
NP
PA, QL (1 inhaler/30
days), 90
FLUTICASONE PROPIONATE/SALMETEROL HFA –
fluticasone-salmeterol inhal aerosol 45-21 mcg/act,
115-21 mcg/act, 230-21 mcg/act
NP
PA, QL (1 inhaler/30
days), 90
fluticasone-salmeterol aer powder ba 100-50 mcg/act,
250-50 mcg/act, 500-50 mcg/act (Advair diskus)
NP
PA, QL (60 blisters/30
days), 90
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml
P
QL (180 containers/30
days), 90
STIOLTO RESPIMAT – tiotropium br-olodaterol inhal aero soln
2.5-2.5 mcg/act
NP
PA, QL (1 inhaler/30
days), 90
SYMBICORT – budesonide-formoterol fumarate dihyd aerosol
80-4.5 mcg/act, 160-4.5 mcg/act
P
QL (3 inhalers/30 days), 90
TRELEGY ELLIPTA – fluticasone-umeclidinium-vilanterol aepb
100-62.5-25 mcg/act, 200-62.5-25 mcg/act
NP
PA, QL (1 inhaler/30
days), 90
wixela inhub aer powder ba 100-50 mcg/dose, 250-50 mcg/dose,
500-50 mcg/dose (Advair diskus)
NP
PA, QL (60 blisters/30
days), 90
ANTIASTHMATIC AND BRONCHODILATOR AGENTS : ANTICHOLINERGICS
ATROVENT HFA – ipratropium bromide hfa inhal aerosol
17 mcg/act
P
QL (2 inhalers/30 days), 90
cromolyn sodium soln nebu 20 mg/2ml
P
QL (240 mls/30 days), 90
INCRUSE ELLIPTA – umeclidinium br aero powd breath act
62.5 mcg/act (base eq)
P
QL (30 blisters/30 days), 90
ipratropium bromide inhal soln 0.02%
P
QL (125 cartridges/30
days), 90
SPIRIVA HANDIHALER – tiotropium bromide monohydrate inhal
cap 18 mcg (base equiv)
P
QL (30 capsules/30 days), 90
SPIRIVA RESPIMAT – tiotropium bromide monohydrate inhal
aerosol 1.25 mcg/act
P
QL (4 grams/30 days), 90
SPIRIVA RESPIMAT – tiotropium bromide monohydrate inhal
aerosol 2.5 mcg/act
P
QL (1 inhaler/30 days), 90
tiotropium bromide monohydrate inhal cap 18 mcg (base equiv)
(Spiriva handihaler)
P
QL (30 capsules/30 days), 90
TUDORZA PRESSAIR – aclidinium bromide aerosol powd breath
activated 400 mcg/act
NP
PA, QL (1 pack/30 days), 90
YUPELRI – revefenacin inhalation solution 175 mcg/3ml
NP
PA, 90
ANTIASTHMATIC AND BRONCHODILATOR AGENTS : BETA ADRENERGICS
ALBUTEROL SULFATE HFA – albuterol sulfate inhal aero
108 mcg/act (90mcg base equiv)
P
QL (3 inhalers/30 days)
albuterol sulfate inhal aero 108 mcg/act (90mcg base equiv)
P
QL (3 inhalers/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
17
Drug Name
Preferred Status Drug Status / Restriction
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml), 0.63 mg/3ml
(base equiv), 1.25 mg/3ml (base equiv)
P
QL (125 containers/30 days)
albuterol sulfate soln nebu 0.5% (5 mg/ml)
P
QL (60 mls/30 days)
albuterol sulfate syrup 2 mg/5ml
NP
PA
albuterol sulfate tab 2 mg, 4 mg
NP
PA
arformoterol tartrate soln nebu 15 mcg/2ml (base equiv)
(Brovana)
NP
PA
BROVANA – arformoterol tartrate soln nebu 15 mcg/2ml (base
equiv)
NP
PA
formoterol fumarate soln nebu 20 mcg/2ml (Perforomist)
NP
PA, 90
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base equiv)
NP
PA, QL (90
containers/30 days)
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv), 0.63 mg/3ml
(base equiv), 1.25 mg/3ml (base equiv)
NP
PA, QL (96
containers/30 days)
LEVALBUTEROL TARTRATE HFA – levalbuterol tartrate inhal
aerosol 45 mcg/act (base equiv)
NP
PA, QL (2 inhalers/30 days)
PERFOROMIST – formoterol fumarate soln nebu 20 mcg/2ml
NP
PA, 90
PROAIR RESPICLICK – albuterol sulfate aer pow ba 108 mcg/
act (90 mcg base equiv)
NP
PA, QL (3 inhalers/30 days)
PROVENTIL HFA – albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv)
P
QL (3 inhalers/30 days)
SEREVENT DISKUS – salmeterol xinafoate aer pow ba 50 mcg/
act (base equiv)
P
QL (60 blisters/30 days), 90
STRIVERDI RESPIMAT – olodaterol hcl inhal aerosol soln
2.5 mcg/act (base equiv)
NP
PA, QL (1 inhaler/30
days), 90
terbutaline sulfate tab 2.5 mg, 5 mg
P
90
VENTOLIN HFA – albuterol sulfate inhal aero 108 mcg/act
(90mcg base equiv)
NP
PA, QL (3 inhalers/30 days)
XOPENEX HFA – levalbuterol tartrate inhal aerosol 45 mcg/act
(base equiv)
NP
PA, QL (2 inhalers/30 days)
ANTIASTHMATIC AND BRONCHODILATOR AGENTS : LEUKOTRIENE MODULATORS
ACCOLATE – zafirlukast tab 10 mg, 20 mg
NP
PA, QL (60 tablets/30
days), 90
montelukast sodium chew tab 4 mg (base equiv), 5 mg (base
equiv) (Singulair)
P
QL (30 tablets/30 days), 90
montelukast sodium oral granules packet 4 mg (base equiv)
(Singulair)
P
QL (30 packets/30 days), 90
montelukast sodium tab 10 mg (base equiv) (Singulair)
P
QL (30 tablets/30 days), 90
SINGULAIR – montelukast sodium tab 10 mg (base equiv)
NP
PA, QL (30 tablets/30
days), 90
SINGULAIR – montelukast sodium chew tab 4 mg (base equiv),
5 mg (base equiv)
NP
PA, QL (30 tablets/30
days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
18
Drug Name
Preferred Status Drug Status / Restriction
SINGULAIR – montelukast sodium oral granules packet 4 mg
(base equiv)
NP
PA, QL (30 packets/30
days), 90
zafirlukast tab 10 mg, 20 mg (Accolate)
P
QL (60 tablets/30 days), 90
zileuton tab er 12hr 600 mg
NP
PA, QL (120 tablets/30 days)
ZYFLO – zileuton tab 600 mg
NP
PA, QL (120 tablets/30 days)
ANTIASTHMATIC AND BRONCHODILATOR AGENTS : MISC
DALIRESP – roflumilast tab 250 mcg
NP
PA
DALIRESP – roflumilast tab 500 mcg
NP
PA, 90
roflumilast tab 250 mcg (Daliresp)
NP
PA
roflumilast tab 500 mcg (Daliresp)
NP
PA, 90
THEO-24 – theophylline cap er 24hr 100 mg, 200 mg, 300 mg,
400 mg
P
90
theophylline elixir 80 mg/15ml
P
90
THEOPHYLLINE ER – theophylline tab er 12hr 100 mg, 200 mg
P
90
theophylline soln 80 mg/15ml
P
90
theophylline tab er 12hr 300 mg, 450 mg
P
90
theophylline tab er 24hr 400 mg, 600 mg
P
90
ANTIASTHMATIC AND BRONCHODILATOR AGENTS : MONOCLONAL ANTIBODIES
ADBRY – tralokinumab-ldrm subcutaneous soln prefilled syr
150 mg/ml
NP
PA, QL (4 syringes/28
days), SP
CIBINQO – abrocitinib tab 50 mg, 100 mg, 200 mg
NP
PA, QL (30 tablets/30
days), SP
CINQAIR – reslizumab iv infusion soln 100 mg/10ml (10 mg/ml)
NP
PA, SP
DUPIXENT – dupilumab subcutaneous soln pen-injector
200 mg/1.14ml, 300 mg/2ml
P
PA, QL (2 pens/28 days), SP
DUPIXENT – dupilumab subcutaneous soln prefilled syringe
200 mg/1.14ml, 300 mg/2ml
P
PA, QL (2 syringes/28
days), SP
FASENRA – benralizumab subcutaneous soln prefilled syringe
30 mg/ml
P
PA, QL (1 syringe/56
days), SP
FASENRA PEN – benralizumab subcutaneous soln auto-injector
30 mg/ml
P
PA, QL (1 pen/56 days), SP
NUCALA – mepolizumab subcutaneous solution auto-injector
100 mg/ml
P
PA, QL (3 syringes/28
days), SP
NUCALA – mepolizumab for inj 100 mg
P
PA, QL (3 vials/28 days), SP
NUCALA – mepolizumab subcutaneous solution pref syringe
40 mg/0.4ml
P
PA, QL (1 syringe/28
days), SP
NUCALA – mepolizumab subcutaneous solution pref syringe
100 mg/ml
P
PA, QL (3 syringes/28
days), SP
OPZELURA – ruxolitinib phosphate cream 1.5%
NP
PA, QL (60 grams/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
19
Drug Name
Preferred Status Drug Status / Restriction
TEZSPIRE – tezepelumab-ekko subcutaneous soln auto-inj
210 mg/1.91ml
NP
PA, QL (1 pen/28 days), SP
TEZSPIRE – tezepelumab-ekko subcutaneous soln pref syr
210 mg/1.91ml
NP
PA, SP
XOLAIR – omalizumab subcutaneous soln prefilled syringe
75 mg/0.5ml, 150 mg/ml, 300 mg/2ml
P
PA, SP
XOLAIR – omalizumab for inj 150 mg
P
PA, SP
ANTIASTHMATIC AND BRONCHODILATOR AGENTS : STEROID INHALANTS
ALVESCO – ciclesonide inhal aerosol 80 mcg/act
NP
PA, QL (1 inhaler/30
days), 90
ALVESCO – ciclesonide inhal aerosol 160 mcg/act
NP
PA, QL (2 inhalers/30
days), 90
ARNUITY ELLIPTA – fluticasone furoate aerosol powder breath
activ 50 mcg/act, 100 mcg/act, 200 mcg/act
NP
PA, QL (30 blisters/30
days), 90
ASMANEX HFA – mometasone furoate inhal aerosol suspension
50 mcg/act, 100 mcg/act, 200 mcg/act
NP
PA, QL (1 inhaler/30
days), 90
ASMANEX TWISTHALER 120 METERED DOSES –
mometasone furoate inhal powd 220 mcg/act (breath activated)
P
QL (1 inhaler/30 days), 90
ASMANEX TWISTHALER 30 METERED DOSES – mometasone
furoate inhal powd 110 mcg/act (breath activated), 220 mcg/act
(breath activated)
P
QL (1 inhaler/30 days), 90
ASMANEX TWISTHALER 60 METERED DOSES – mometasone
furoate inhal powd 220 mcg/act (breath activated)
P
QL (1 inhaler/30 days), 90
budesonide inhalation susp 0.25 mg/2ml, 0.5 mg/2ml (Pulmicort)
P
QL (2 packages/30 days), 90
budesonide inhalation susp 1 mg/2ml (Pulmicort)
P
QL (60 mls/30 days), 90
FLUTICASONE PROPIONATE DISKUS – fluticasone propionate
aer pow ba 50 mcg/act, 100 mcg/act
NP
PA, QL (1 inhaler/30
days), 90
FLUTICASONE PROPIONATE DISKUS – fluticasone propionate
aer pow ba 250 mcg/act
NP
PA, QL (4 inhalers/30
days), 90
FLUTICASONE PROPIONATE HFA – fluticasone propionate hfa
inhal aero 44 mcg/act
P
QL (1 inhaler/30 days), 90
FLUTICASONE PROPIONATE HFA – fluticasone propionate hfa
inhal aer 110 mcg/act
P
QL (1 inhaler/30 days), 90
FLUTICASONE PROPIONATE HFA – fluticasone propionate hfa
inhal aer 220 mcg/act
P
QL (2 inhalers/30 days), 90
PULMICORT – budesonide inhalation susp 0.25 mg/2ml,
0.5 mg/2ml
NP
PA, QL (60 containers/30
days), 90
PULMICORT – budesonide inhalation susp 1 mg/2ml
NP
PA, QL (30 containers/30
days), 90
PULMICORT FLEXHALER – budesonide inhal aero powd
90 mcg/act (breath activated)
NP
PA, QL (1 inhaler/30
days), 90
PULMICORT FLEXHALER – budesonide inhal aero powd
180 mcg/act (breath activated)
NP
PA, QL (2 inhalers/30
days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
20
Drug Name
Preferred Status Drug Status / Restriction
QVAR REDIHALER – beclomethasone diprop hfa breath act inh
aer 40 mcg/act
NP
PA, QL (1 inhaler/30
days), 90
QVAR REDIHALER – beclomethasone diprop hfa breath act inh
aer 80 mcg/act
NP
PA, QL (2 inhalers/30
days), 90
ANTIBIOITCS : FLUOROQUINOLONES
BAXDELA – delafloxacin meglumine tab 450 mg (base equiv)
NP
PA, QL (28 tablets/180 days)
CIPRO – ciprofloxacin for oral susp 250 mg/5ml (5%)
(5 gm/100ml), 500 mg/5ml (10%) (10 gm/100ml)
NP
PA
CIPRO – ciprofloxacin hcl tab 250 mg (base equiv), 500 mg
(base equiv)
NP
PA
CIPROFLOXACIN HCL – ciprofloxacin hcl tab 100 mg (base
equiv)
P
ciprofloxacin hcl tab 250 mg (base equiv), 500 mg (base equiv)
(Cipro)
P
ciprofloxacin hcl tab 750 mg (base equiv)
P
levofloxacin oral soln 25 mg/ml
P
levofloxacin tab 250 mg
P
levofloxacin tab 500 mg, 750 mg (Levaquin)
P
moxifloxacin hcl tab 400 mg (base equiv)
P
OFLOXACIN – ofloxacin tab 300 mg
NP
PA
ofloxacin tab 400 mg
NP
PA
ANTIBIOTICS : AMINOGLYCOSIDES
neomycin sulfate tab 500 mg
P
ANTIBIOTICS : AMINOGLYCOSIDES - INHALED
ARIKAYCE – amikacin sulfate liposome inhal susp 590 mg/8.4ml
(base eq)
NP
PA, QL (28 vials/28 days), SP
BETHKIS – tobramycin nebu soln 300 mg/4ml
NP
PA, QL (56 containers/56
days), SP
KITABIS PAK – tobramycin nebu soln 300 mg/5ml
P
QL (56 containers/56
days), SP
TOBI – tobramycin nebu soln 300 mg/5ml
NP
PA, QL (56 containers/56
days), SP
TOBI PODHALER – tobramycin inhal cap 28 mg
NP
PA, QL (224
capsules/56 days), SP
TOBRAMYCIN – tobramycin nebu soln 300 mg/5ml
NP
PA, QL (56 containers/56
days), SP
tobramycin nebu soln 300 mg/5ml (Tobi)
NP
PA, QL (280
ampules/56 days), SP
tobramycin nebu soln 300 mg/4ml (Bethkis)
NP
PA, QL (56 units/56 days), SP
ANTIBIOTICS : ANTI-INFECTIVE AGENTS
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
21
Drug Name
Preferred Status Drug Status / Restriction
AEMCOLO – rifamycin sodium tab delayed release 194 mg
(base equiv)
NP
PA
atovaquone susp 750 mg/5ml (Mepron)
P
BACTRIM – sulfamethoxazole-trimethoprim tab 400-80 mg
NP
PA
BACTRIM DS – sulfamethoxazole-trimethoprim tab 800-160 mg
NP
PA
CAYSTON – aztreonam lysine for inhal soln 75 mg (base
equivalent)
NP
PA, QL (1 container/56
days), SP
CLEOCIN – clindamycin hcl cap 75 mg, 150 mg, 300 mg
NP
PA
CLEOCIN PEDIATRIC GRANULES – clindamycin palmitate hcl
for soln 75 mg/5ml (base equiv)
NP
PA
clindamycin hcl cap 75 mg, 150 mg, 300 mg (Cleocin)
P
clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)
(Cleocin pediatric granules)
P
dapsone tab 25 mg, 100 mg
P
FIRVANQ – vancomycin hcl for oral soln 25 mg/ml (base
equivalent), 50 mg/ml (base equivalent)
NP
PA
FLAGYL – metronidazole cap 375 mg
NP
PA
fosfomycin tromethamine powd pack 3 gm (base equivalent)
(Monurol)
P
HIPREX – methenamine hippurate tab 1 gm
NP
PA
LAMPIT – nifurtimox tab 30 mg, 120 mg
NP
PA
LIKMEZ – metronidazole susp 500 mg/5ml
NP
PA, QL (400 mls/10 days)
linezolid for susp 100 mg/5ml (Zyvox)
NP
PA, QL (600 mls/180 days)
linezolid tab 600 mg (Zyvox)
NP
PA, QL (56 tablets/180 days)
MACROBID – nitrofurantoin monohydrate macrocrystalline cap
100 mg
NP
PA
MACRODANTIN – nitrofurantoin macrocrystalline cap 25 mg,
50 mg, 100 mg
NP
PA
MEPRON – atovaquone susp 750 mg/5ml
NP
PA
methenamine hippurate tab 1 gm (Hiprex)
P
methenamine mandelate tab 0.5 gm, 1 gm
P
methenamine-hyosc-meth blue-sod phos-phen sal cap 118 mg,
120 mg
NP
PA
methenamine-hyoscamine-meth blue-sod phos tab 81.6 mg
(Urogesic-blue)
NP
PA
metronidazole cap 375 mg (Flagyl)
NP
PA
metronidazole tab 250 mg, 500 mg (Flagyl)
P
NEBUPENT – pentamidine isethionate for nebulization soln
300 mg
P
nitazoxanide tab 500 mg (Alinia)
NP
PA, QL (6 tablets/30 days)
NITROFURANTOIN – nitrofurantoin susp 50 mg/5ml
P
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
22
Drug Name
Preferred Status Drug Status / Restriction
nitrofurantoin macrocrystalline cap 25 mg, 50 mg, 100 mg
(Macrodantin)
P
nitrofurantoin monohydrate macrocrystalline cap 100 mg
(Macrobid)
P
nitrofurantoin susp 25 mg/5ml
P
pentamidine isethionate for nebulization soln 300 mg (Nebupent)
P
SIVEXTRO – tedizolid phosphate tab 200 mg
NP
PA, QL (6 tablets/180 days)
SOLOSEC – secnidazole granules packet 2 gm
NP
PA
SULFADIAZINE – sulfadiazine tab 500 mg
P
sulfamethoxazole-trimethoprim susp 200-40 mg/5ml
P
sulfamethoxazole-trimethoprim tab 400-80 mg (Bactrim)
P
sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim ds)
P
tinidazole tab 250 mg, 500 mg
NP
PA
TRIMETHOPRIM – trimethoprim tab 100 mg
P
trimethoprim tab 100 mg
P
URIBEL – methenamine-hyosc-meth blue-benz acid-phenyl sal
tab 81.6mg
NP
PA
UROGESIC-BLUE – methenamine-hyoscamine-meth blue-sod
phos tab 81.6 mg
NP
PA
VANCOCIN – vancomycin hcl cap 125 mg (base equivalent),
250 mg (base equivalent)
NP
PA, QL (120
capsules/30 days)
vancomycin hcl cap 125 mg (base equivalent) (Vancocin hcl)
P
QL (120 capsules/30 days)
vancomycin hcl cap 250 mg (base equivalent) (Vancocin)
P
QL (120 capsules/30 days)
vancomycin hcl for oral soln 25 mg/ml (base equivalent) (Firvanq)
P
vancomycin hcl for oral soln 50 mg/ml (base equivalent)
(Vancomycin hydrochlo)
P
XIFAXAN – rifaximin tab 200 mg
NP
PA, QL (9 tablets/30 days)
XIFAXAN – rifaximin tab 550 mg
NP
PA, QL (126 tablets/365 days)
ZYVOX – linezolid tab 600 mg
NP
PA, QL (56 tablets/180 days)
ZYVOX – linezolid for susp 100 mg/5ml
NP
PA, QL (4 bottles/180 days)
ANTIBIOTICS : ANTIMYCOBACTERIAL AGENTS
cycloserine cap 250 mg
P
ethambutol hcl tab 100 mg
P
ethambutol hcl tab 400 mg (Myambutol)
P
ISONIAZID – isoniazid tab 100 mg
P
90
isoniazid syrup 50 mg/5ml
P
90
isoniazid tab 300 mg
P
90
MYAMBUTOL – ethambutol hcl tab 400 mg
NP
PA
MYCOBUTIN – rifabutin cap 150 mg
NP
PA
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
23
Drug Name
Preferred Status Drug Status / Restriction
PRETOMANID – pretomanid tab 200 mg
NP
PA
PRIFTIN – rifapentine tab 150 mg
P
pyrazinamide tab 500 mg
P
rifabutin cap 150 mg (Mycobutin)
P
rifampin cap 150 mg, 300 mg (Rifadin)
P
SIRTURO – bedaquiline fumarate tab 20 mg (base equiv),
100 mg (base equiv)
NP
PA
TRECATOR – ethionamide tab 250 mg
P
ANTIBIOTICS : CEPHALOSPORINS
CEFACLOR – cefaclor cap 250 mg, 500 mg
P
CEFACLOR ER – cefaclor monohydrate tab er 12hr 500 mg
NP
PA
CEFADROXIL – cefadroxil tab 1 gm
P
cefadroxil cap 500 mg
P
cefadroxil for susp 250 mg/5ml, 500 mg/5ml
P
cefdinir cap 300 mg
P
cefdinir for susp 125 mg/5ml, 250 mg/5ml
P
cefixime cap 400 mg (Suprax)
P
cefixime for susp 100 mg/5ml, 200 mg/5ml (Suprax)
NP
PA
cefpodoxime proxetil for susp 50 mg/5ml, 100 mg/5ml
NP
PA
cefpodoxime proxetil tab 100 mg, 200 mg
NP
PA
cefprozil for susp 125 mg/5ml, 250 mg/5ml
P
cefprozil tab 250 mg, 500 mg
NP
PA
cefuroxime axetil tab 250 mg, 500 mg
P
CEPHALEXIN – cephalexin tab 250 mg, 500 mg
P
cephalexin cap 250 mg, 500 mg, 750 mg (Keflex)
P
cephalexin for susp 125 mg/5ml, 250 mg/5ml
P
ANTIBIOTICS : MACROLIDES
AZITHROMYCIN – azithromycin powd pack for susp 1 gm
P
azithromycin for susp 100 mg/5ml, 200 mg/5ml (Zithromax)
P
azithromycin tab 250 mg, 500 mg (Zithromax)
P
QL (60 tablets/180 days)
azithromycin tab 600 mg
P
QL (60 tablets/180 days)
CLARITHROMYCIN – clarithromycin for susp 125 mg/5ml,
250 mg/5ml
P
clarithromycin tab er 24hr 500 mg
P
QL (28 tablets/180 days)
clarithromycin tab 250 mg, 500 mg
P
DIFICID – fidaxomicin tab 200 mg
P
DIFICID – fidaxomicin for susp 40 mg/ml
P
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
24
Drug Name
Preferred Status Drug Status / Restriction
E.E.S. GRANULES – erythromycin ethylsuccinate for susp
200 mg/5ml
P
E.E.S. 400 – erythromycin ethylsuccinate tab 400 mg
P
ERYPED 200 – erythromycin ethylsuccinate for susp 200 mg/5ml
P
ERYPED 400 – erythromycin ethylsuccinate for susp 400 mg/5ml
P
ERYTHROCIN STEARATE – erythromycin stearate tab 250 mg
P
ERYTHROMYCIN – erythromycin w/ delayed release particles
cap 250 mg
P
ERYTHROMYCIN ETHYLSUCCINATE – erythromycin
ethylsuccinate tab 400 mg
P
erythromycin ethylsuccinate for susp 200 mg/5ml
(E.e.s. granules)
P
erythromycin ethylsuccinate for susp 400 mg/5ml (Eryped 400)
P
erythromycin tab delayed release 250 mg, 333 mg, 500 mg
P
erythromycin tab 250 mg, 500 mg
P
ZITHROMAX – azithromycin for susp 100 mg/5ml, 200 mg/5ml
NP
PA
ZITHROMAX – azithromycin tab 250 mg, 500 mg
NP
PA, QL (60 tablets/180 days)
ZITHROMAX – azithromycin powd pack for susp 1 gm
P
ZITHROMAX TRI-PAK – azithromycin tab 500 mg
NP
PA, QL (60 tablets/180 days)
ZITHROMAX Z-PAK – azithromycin tab 250 mg
NP
PA, QL (60 tablets/180 days)
ANTIBIOTICS : PENICILLINS
AMOXICILLIN – amoxicillin (trihydrate) chew tab 125 mg, 250 mg
P
amoxicillin (trihydrate) cap 250 mg, 500 mg
P
amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml,
250 mg/5ml, 400 mg/5ml
P
amoxicillin (trihydrate) tab 500 mg, 875 mg
P
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml,
400-57 mg/5ml
P
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin)
P
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml (Augmentin
es-600)
P
amoxicillin & k clavulanate tab 250-125 mg, 875-125 mg
P
amoxicillin & k clavulanate tab 500-125 mg (Augmentin)
P
AMOXICILLIN/CLAVULANATE POTASSIUM – amoxicillin & k
clavulanate chew tab 200-28.5 mg, 400-57 mg
P
AMOXICILLIN/CLAVULANATE POTASSIUM – amoxicillin & k
clavulanate tab er 12hr 1000-62.5 mg
NP
PA
ampicillin cap 500 mg
P
AUGMENTIN – amoxicillin & k clavulanate for susp
125-31.25 mg/5ml
P
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
25
Drug Name
Preferred Status Drug Status / Restriction
AUGMENTIN ES-600 – amoxicillin & k clavulanate for susp
600-42.9 mg/5ml
NP
PA
dicloxacillin sodium cap 250 mg, 500 mg
P
PENICILLIN V POTASSIUM – penicillin v potassium for soln
125 mg/5ml, 250 mg/5ml
P
penicillin v potassium tab 250 mg, 500 mg
P
ANTIBIOTICS : TETRACYCLINES
demeclocycline hcl tab 150 mg, 300 mg
P
DORYX MPC – doxycycline hyclate tab delayed release 60 mg,
120 mg
NP
PA
doxycycline hyclate cap 50 mg
P
doxycycline hyclate cap 100 mg (Vibramycin)
P
DOXYCYCLINE HYCLATE DR – doxycycline hyclate tab delayed
release 80 mg
NP
PA
doxycycline hyclate tab delayed release 50 mg, 200 mg (Doryx)
NP
PA
doxycycline hyclate tab delayed release 75 mg, 100 mg, 150 mg
NP
PA
doxycycline hyclate tab 20 mg, 50 mg, 100 mg
P
doxycycline hyclate tab 75 mg, 150 mg (Acticlate)
P
doxycycline monohydrate cap 50 mg, 75 mg, 100 mg, 150 mg
P
doxycycline monohydrate for susp 25 mg/5ml (Vibramycin)
P
doxycycline monohydrate tab 50 mg, 75 mg, 100 mg, 150 mg
P
minocycline hcl cap 50 mg (Minocin)
P
minocycline hcl cap 75 mg, 100 mg
P
minocycline hcl tab er 24hr 45 mg, 90 mg, 135 mg
NP
PA
minocycline hcl tab er 24hr 55 mg, 65 mg, 80 mg, 105 mg,
115 mg (Solodyn)
NP
PA
minocycline hcl tab 50 mg, 75 mg, 100 mg
P
MINOLIRA – minocycline hcl tab er 24hr biphasic release
105 mg, 135 mg
NP
PA
NUZYRA – omadacycline tosylate tab 150 mg (base equivalent)
NP
PA, QL (30 tablets/180 days)
SOLODYN – minocycline hcl tab er 24hr 55 mg, 65 mg, 80 mg,
105 mg, 115 mg
NP
PA
tetracycline hcl cap 250 mg, 500 mg
P
VIBRAMYCIN – doxycycline hyclate cap 100 mg
NP
PA
ANTICOAGULANTS : COUMARIN
warfarin sodium tab 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg,
6 mg, 7.5 mg, 10 mg (Coumadin)
P
ANTICOAGULANTS : DIRECT FACTOR XA INHIBITORS & MISC
dabigatran etexilate mesylate cap 75 mg (etexilate base eq),
150 mg (etexilate base eq) (Pradaxa)
NP
PA, QL (60 capsules/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
26
Drug Name
Preferred Status Drug Status / Restriction
dabigatran etexilate mesylate cap 110 mg (etexilate base eq)
(Pradaxa)
NP
PA, QL (120
capsules/30 days)
ELIQUIS – apixaban tab 2.5 mg
P
PA, QL (60 tablets/30 days)
ELIQUIS – apixaban tab 5 mg
P
PA, QL (74 tablets/19 days)
ELIQUIS STARTER PACK – apixaban tab starter pack 5 mg
P
PA, QL (74 tablets/180 days)
PRADAXA – dabigatran etexilate mesylate cap 75 mg (etexilate
base eq), 150 mg (etexilate base eq)
NP
PA, QL (60 capsules/30 days)
PRADAXA – dabigatran etexilate mesylate cap 110 mg (etexilate
base eq)
NP
PA, QL (120
capsules/30 days)
PRADAXA – dabigatran etexilate mesylate pellet pack 20 mg,
150 mg
NP
PA, QL (60 packets/30 days)
PRADAXA – dabigatran etexilate mesylate pellet pack 30 mg,
40 mg, 50 mg, 110 mg
NP
PA, QL (120 packets/30 days)
SAVAYSA – edoxaban tosylate tab 15 mg (base equivalent),
30 mg (base equivalent), 60 mg (base equivalent)
NP
PA, QL (30 tablets/30 days)
XARELTO – rivaroxaban for susp 1 mg/ml
NP
PA, QL (4 bottles/30 days)
XARELTO – rivaroxaban tab 2.5 mg
P
QL (60 tablets/30 days)
XARELTO – rivaroxaban tab 10 mg
P
QL (39 Days/365 Days)
XARELTO – rivaroxaban tab 15 mg
P
PA, QL (60 tablets/30 days)
XARELTO – rivaroxaban tab 20 mg
P
PA, QL (30 tablets/30 days)
XARELTO STARTER PACK – rivaroxaban tab starter therapy
pack 15 mg & 20 mg
P
PA, QL (51 tablets/30 days)
ANTICOAGULANTS : HEPARIN AND HEPARINOID-LIKE AGENTS
ARIXTRA – fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml,
5 mg/0.4ml, 7.5 mg/0.6ml, 10 mg/0.8ml
NP
PA, QL (30
syringes/365 days)
enoxaparin sodium inj soln pref syr 30 mg/0.3ml, 40 mg/0.4ml,
60 mg/0.6ml, 80 mg/0.8ml, 100 mg/ml, 120 mg/0.8ml, 150 mg/
ml (Lovenox)
P
QL (30 syringes/365 days)
enoxaparin sodium inj 300 mg/3ml (Lovenox)
P
QL (30 vials/365 days)
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml, 5 mg/0.4ml,
7.5 mg/0.6ml, 10 mg/0.8ml (Arixtra)
P
QL (30 syringes/365 days)
FRAGMIN – dalteparin sodium soln prefilled syr 2500 unit/0.2ml,
5000 unit/0.2ml, 7500 unit/0.3ml, 10000 unit/ml, 12500
unit/0.5ml, 15000 unit/0.6ml, 18000 unit/0.72ml
P
QL (30 syringes/365 days)
FRAGMIN – dalteparin sodium subcutaneous soln 10000
unit/4ml, 95000 unit/3.8ml
P
QL (30 vials/365 days)
HEPARIN SODIUM – heparin sodium (porcine) inj soln pref syr
5000 unit/0.5ml
P
HEPARIN SODIUM – heparin sodium (porcine) pf inj 5000 unit/ml
P
heparin sodium (porcine) inj 1000 unit/ml, 5000 unit/ml, 10000
unit/ml, 20000 unit/ml
P
heparin sodium (porcine) pf inj 5000 unit/0.5ml
P
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
27
Drug Name
Preferred Status Drug Status / Restriction
LOVENOX – enoxaparin sodium inj soln pref syr 30 mg/0.3ml,
40 mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml, 100 mg/ml,
120 mg/0.8ml, 150 mg/ml
NP
PA, QL (30
syringes/365 days)
LOVENOX – enoxaparin sodium inj 300 mg/3ml
NP
PA, QL (30 vials/365 days)
ANTICONVULSANTS
APTIOM – eslicarbazepine acetate tab 200 mg, 400 mg, 600 mg,
800 mg
NP
90
BANZEL – rufinamide tab 200 mg, 400 mg
NP
90
BANZEL – rufinamide susp 40 mg/ml
NP
90
BRIVIACT – brivaracetam tab 10 mg, 25 mg, 50 mg, 75 mg,
100 mg
NP
90
BRIVIACT – brivaracetam oral soln 10 mg/ml
NP
90
carbamazepine cap er 12hr 100 mg, 200 mg, 300 mg (Carbatrol)
NP
90
carbamazepine chew tab 100 mg
P
90
carbamazepine susp 100 mg/5ml (Tegretol)
P
90
carbamazepine tab er 12hr 100 mg, 200 mg, 400 mg (Tegretol-
xr)
P
90
carbamazepine tab 200 mg (Tegretol)
P
90
CARBATROL – carbamazepine cap er 12hr 100 mg, 200 mg,
300 mg
NP
90
CELONTIN – methsuximide cap 300 mg
NP
90
clobazam suspension 2.5 mg/ml (Onfi)
NP
QL (480 mls/30 days)
clobazam tab 10 mg, 20 mg (Onfi)
NP
QL (60 tablets/30 days)
clonazepam orally disintegrating tab 0.125 mg, 0.25 mg, 0.5 mg,
1 mg
NP
QL (90 tablets/30 days)
clonazepam orally disintegrating tab 2 mg
NP
QL (60 tablets/30 days)
clonazepam tab 0.5 mg, 1 mg (Klonopin)
P
QL (90 tablets/30 days)
clonazepam tab 2 mg (Klonopin)
P
QL (60 tablets/30 days)
DEPAKOTE – divalproex sodium tab delayed release 125 mg,
250 mg, 500 mg
NP
90
DEPAKOTE ER – divalproex sodium tab er 24 hr 250 mg,
500 mg
NP
90
DEPAKOTE SPRINKLES – divalproex sodium cap delayed
release sprinkle 125 mg
NP
90
DIACOMIT – stiripentol cap 250 mg, 500 mg
NP
DIACOMIT – stiripentol packet 250 mg, 500 mg
NP
DIAZEPAM RECTAL GEL – diazepam rectal gel delivery system
2.5 mg
P
QL (2 packs/30 days)
diazepam rectal gel delivery system 10 mg, 20 mg (Diastat
acudial)
P
QL (2 packs/30 days)
DILANTIN – phenytoin sodium extended cap 30 mg, 100 mg
NP
90
DILANTIN INFATABS – phenytoin chew tab 50 mg
NP
90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
28
Drug Name
Preferred Status Drug Status / Restriction
DILANTIN-125 – phenytoin susp 125 mg/5ml
NP
90
divalproex sodium cap delayed release sprinkle 125 mg
(Depakote sprinkles)
P
90
divalproex sodium tab delayed release 125 mg, 250 mg, 500 mg
(Depakote)
P
90
divalproex sodium tab er 24 hr 250 mg, 500 mg (Depakote er)
P
90
ELEPSIA XR – levetiracetam tab er 24hr 1000 mg, 1500 mg
NP
90
EPIDIOLEX – cannabidiol soln 100 mg/ml
NP
PA
EPRONTIA – topiramate oral soln 25 mg/ml
NP
90
ethosuximide cap 250 mg (Zarontin)
P
90
ethosuximide soln 250 mg/5ml (Zarontin)
P
90
felbamate susp 600 mg/5ml (Felbatol)
NP
90
felbamate tab 400 mg, 600 mg (Felbatol)
NP
90
FELBATOL – felbamate tab 400 mg, 600 mg
NP
90
FINTEPLA – fenfluramine hcl oral soln 2.2 mg/ml
NP
PA, QL (360 mls/30 days)
FYCOMPA – perampanel tab 2 mg, 4 mg, 6 mg, 8 mg, 10 mg,
12 mg
NP
90
FYCOMPA – perampanel susp 0.5 mg/ml
NP
90
gabapentin cap 100 mg (Neurontin)
P
QL (720 capsules/30
days), 90
gabapentin cap 300 mg (Neurontin)
P
QL (240 capsules/30
days), 90
gabapentin cap 400 mg (Neurontin)
P
QL (180 capsules/30
days), 90
gabapentin oral soln 250 mg/5ml (Neurontin)
P
QL (1500 mls/30 days), 90
gabapentin tab 600 mg (Neurontin)
P
QL (120 tablets/30 days), 90
gabapentin tab 800 mg (Neurontin)
P
QL (90 tablets/30 days), 90
KEPPRA – levetiracetam tab 250 mg, 500 mg, 750 mg, 1000 mg
NP
90
KEPPRA – levetiracetam oral soln 100 mg/ml
NP
90
KEPPRA XR – levetiracetam tab er 24hr 500 mg, 750 mg
NP
90
KLONOPIN – clonazepam tab 0.5 mg, 1 mg
NP
QL (90 tablets/30 days)
KLONOPIN – clonazepam tab 2 mg
NP
QL (60 tablets/30 days)
lacosamide oral solution 10 mg/ml (Vimpat)
NP
90
lacosamide tab 50 mg, 100 mg, 150 mg, 200 mg (Vimpat)
NP
90
LAMICTAL – lamotrigine tab 25 mg, 100 mg, 150 mg, 200 mg
NP
90
LAMICTAL CHEWABLE DISPERSIBLE – lamotrigine tab
chewable dispersible 5 mg, 25 mg
NP
90
LAMICTAL ODT – lamotrigine orally disintegrating tab 25 mg,
50 mg, 100 mg, 200 mg
NP
90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
29
Drug Name
Preferred Status Drug Status / Restriction
LAMICTAL ODT – lamotrigine tab disint 21 x 25 mg & 7 x 50 mg
titration kit
NP
LAMICTAL ODT – lamotrigine tab disint 42 x 50mg & 14 x 100mg
titration kit
NP
LAMICTAL ODT – lamotrigine tab disint 25 (14) & 50 mg (14) &
100 mg (7) kit
NP
LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE –
lamotrigine tab 25 mg (42) & 100 mg (7) starter kit
NP
LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT TAKING
VALPROATE – lamotrigine tab 84 x 25 mg & 14 x 100 mg
starter kit
NP
LAMICTAL STARTER/TAKING VALPROATE – lamotrigine tab 35
x 25 mg starter kit
NP
LAMICTAL XR – lamotrigine tab er 24hr 25 mg, 50 mg, 100 mg,
200 mg, 250 mg, 300 mg
NP
90
LAMICTAL XR – lamotrigine tab er 24hr 21 x 25 mg & 7 x 50 mg
titration kit
NP
LAMICTAL XR – lamotrigine tab er 24hr 25 (14) & 50 mg (14) &
100 mg(7) kit
NP
LAMICTAL XR – lamotrigine tab er 24hr 50 (14) & 100 mg(14) &
200 mg(7) kit
NP
lamotrigine orally disintegrating tab 25 mg, 50 mg, 100 mg,
200 mg (Lamictal odt)
NP
90
lamotrigine tab chewable dispersible 5 mg, 25 mg (Lamictal
chewable dispersible)
P
90
lamotrigine tab disint 21 x 25 mg & 7 x 50 mg titration kit
(Lamictal odt)
NP
lamotrigine tab disint 42 x 50mg & 14 x 100mg titration kit
(Lamictal odt)
NP
lamotrigine tab disint 25 (14) & 50 mg (14) & 100 mg (7) kit
(Lamictal odt)
NP
lamotrigine tab er 24hr 25 mg, 50 mg, 100 mg, 200 mg, 250 mg,
300 mg (Lamictal xr)
NP
90
lamotrigine tab 25 mg, 100 mg, 150 mg, 200 mg (Lamictal)
P
90
lamotrigine tab 35 x 25 mg starter kit (Lamictal starter/taking
valproate)
NP
lamotrigine tab 25 mg (42) & 100 mg (7) starter kit (Lamictal
starter/not taking carbamazepine)
NP
lamotrigine tab 84 x 25 mg & 14 x 100 mg starter kit (Lamictal
starter/taking carbamazepine/not taking valproate)
NP
levetiracetam oral soln 100 mg/ml (Keppra)
P
90
levetiracetam tab er 24hr 500 mg, 750 mg (Keppra xr)
P
90
levetiracetam tab 250 mg, 500 mg, 750 mg, 1000 mg (Keppra)
P
90
LYRICA – pregabalin cap 25 mg, 50 mg, 75 mg, 100 mg,
150 mg, 200 mg, 225 mg, 300 mg
NP
PA, QL (90 capsules/30
days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
30
Drug Name
Preferred Status Drug Status / Restriction
LYRICA – pregabalin soln 20 mg/ml
NP
PA, QL (900 mls/30 days), 90
methsuximide cap 300 mg (Celontin)
NP
90
MOTPOLY XR – lacosamide cap er 24hr 100 mg, 150 mg,
200 mg
NP
90
MYSOLINE – primidone tab 50 mg, 250 mg
NP
90
NAYZILAM – midazolam nasal spray soln 5 mg/0.1 ml
NP
QL (10 sprays/30 days)
NEURONTIN – gabapentin oral soln 250 mg/5ml
NP
PA, QL (1500
mls/30 days), 90
NEURONTIN – gabapentin cap 100 mg
NP
PA, QL (720
capsules/30 days), 90
NEURONTIN – gabapentin cap 300 mg
NP
PA, QL (240
capsules/30 days), 90
NEURONTIN – gabapentin cap 400 mg
NP
PA, QL (180
capsules/30 days), 90
NEURONTIN – gabapentin tab 600 mg
NP
PA, QL (120
tablets/30 days), 90
NEURONTIN – gabapentin tab 800 mg
NP
PA, QL (90 tablets/30
days), 90
ONFI – clobazam tab 10 mg, 20 mg
NP
QL (60 tablets/30 days)
ONFI – clobazam suspension 2.5 mg/ml
NP
QL (480 mls/30 days)
oxcarbazepine susp 300 mg/5ml (60 mg/ml) (Trileptal)
P
90
oxcarbazepine tab 150 mg, 300 mg, 600 mg (Trileptal)
P
90
OXTELLAR XR – oxcarbazepine tab er 24hr 150 mg, 300 mg,
600 mg
NP
90
phenytoin chew tab 50 mg (Dilantin infatabs)
P
90
phenytoin sodium extended cap 100 mg (Dilantin)
P
90
phenytoin sodium extended cap 200 mg, 300 mg (Phenytek)
P
90
phenytoin susp 125 mg/5ml (Dilantin-125)
P
90
pregabalin cap 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg,
225 mg, 300 mg (Lyrica)
P
QL (90 capsules/30 days), 90
pregabalin soln 20 mg/ml (Lyrica)
P
QL (900 mls/30 days), 90
PRIMIDONE – primidone tab 125 mg
P
90
primidone tab 50 mg, 250 mg (Mysoline)
P
90
QUDEXY XR – topiramate cap er 24hr sprinkle 25 mg, 50 mg,
100 mg, 150 mg
NP
PA, QL (30 capsules/30
days), 90
QUDEXY XR – topiramate cap er 24hr sprinkle 200 mg
NP
PA, QL (60 capsules/30
days), 90
rufinamide susp 40 mg/ml (Banzel)
NP
90
rufinamide tab 200 mg, 400 mg (Banzel)
NP
90
SABRIL – vigabatrin tab 500 mg
NP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
31
Drug Name
Preferred Status Drug Status / Restriction
SABRIL – vigabatrin powd pack 500 mg
NP
SPRITAM – levetiracetam tab disintegrating soluble 250 mg,
500 mg, 750 mg, 1000 mg
NP
90
SYMPAZAN – clobazam oral film 5 mg
NP
QL (240 films/30 days)
SYMPAZAN – clobazam oral film 10 mg, 20 mg
NP
QL (60 films/30 days)
TEGRETOL – carbamazepine tab 200 mg
NP
90
TEGRETOL – carbamazepine susp 100 mg/5ml
NP
90
TEGRETOL-XR – carbamazepine tab er 12hr 100 mg, 200 mg,
400 mg
NP
90
tiagabine hcl tab 2 mg, 4 mg, 12 mg, 16 mg (Gabitril)
NP
90
TOPAMAX – topiramate tab 25 mg, 50 mg, 100 mg, 200 mg
NP
90
TOPAMAX SPRINKLE – topiramate sprinkle cap 15 mg, 25 mg
NP
90
topiramate cap er 24hr sprinkle 25 mg, 50 mg, 100 mg, 150 mg
(Qudexy xr)
NP
PA, QL (30 capsules/30
days), 90
topiramate cap er 24hr sprinkle 200 mg (Qudexy xr)
NP
PA, QL (60 capsules/30
days), 90
topiramate cap er 24hr 25 mg, 50 mg, 100 mg (Trokendi xr)
NP
PA, QL (30 capsules/30
days), 90
topiramate cap er 24hr 200 mg (Trokendi xr)
NP
PA, QL (60 capsules/30
days), 90
topiramate sprinkle cap 15 mg, 25 mg (Topamax sprinkle)
P
90
topiramate tab 25 mg, 50 mg, 100 mg, 200 mg (Topamax)
P
90
TRILEPTAL – oxcarbazepine tab 150 mg, 300 mg, 600 mg
NP
90
TRILEPTAL – oxcarbazepine susp 300 mg/5ml (60 mg/ml)
NP
90
TROKENDI XR – topiramate cap er 24hr 25 mg, 50 mg, 100 mg
NP
PA, QL (30 capsules/30
days), 90
TROKENDI XR – topiramate cap er 24hr 200 mg
NP
PA, QL (60 capsules/30
days), 90
valproate sodium oral soln 250 mg/5ml (base equiv)
P
90
valproic acid cap 250 mg
P
90
VALTOCO 10 MG DOSE – diazepam nasal spray 10 mg/0.1 ml
NP
QL (5 boxes/30 days)
VALTOCO 15 MG DOSE – diazepam nasal spray ther pack 2 x
7.5 mg/0.1ml (15 mg dose)
NP
QL (5 boxes/30 days)
VALTOCO 20 MG DOSE – diazepam nasal spray ther pack 2 x
10 mg/0.1ml (20 mg dose)
NP
QL (5 boxes/30 days)
VALTOCO 5 MG DOSE – diazepam nasal spray 5 mg/0.1 ml
NP
QL (5 boxes/30 days)
vigabatrin powd pack 500 mg (Sabril)
NP
vigabatrin tab 500 mg (Sabril)
NP
VIMPAT – lacosamide tab 50 mg, 100 mg, 150 mg, 200 mg
NP
90
VIMPAT – lacosamide oral solution 10 mg/ml
NP
90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
32
Drug Name
Preferred Status Drug Status / Restriction
XCOPRI – cenobamate tab 25 mg, 50 mg, 100 mg, 150 mg,
200 mg
P
XCOPRI – cenobamate tab titration pack 14 x 12.5 mg & 14 x
25 mg, 14 x 50 mg & 14 x 100 mg, 14 x 150 mg & 14 x 200 mg
P
XCOPRI – cenobamate tab pack 100 mg & 150 mg tabs (250 mg
daily dose)
P
XCOPRI – cenobamate tab pack 150 mg & 200 mg tabs (350 mg
daily dose)
P
ZARONTIN – ethosuximide cap 250 mg
NP
90
ZARONTIN – ethosuximide soln 250 mg/5ml
NP
90
ZONISADE – zonisamide oral susp 100 mg/5ml (20 mg/ml)
NP
90
zonisamide cap 25 mg, 100 mg (Zonegran)
P
90
zonisamide cap 50 mg
P
90
ZTALMY – ganaxolone susp 50 mg/ml
NP
90
ANTIDEPRESSANTS : MISC
amitriptyline hcl tab 10 mg, 25 mg, 50 mg, 75 mg, 100 mg,
150 mg
P
90
amoxapine tab 25 mg, 50 mg, 100 mg, 150 mg
NP
PA, 90
ANAFRANIL – clomipramine hcl cap 25 mg, 50 mg, 75 mg
NP
PA, 90
APLENZIN – bupropion hbr tab er 24hr 174 mg, 348 mg, 522 mg
NP
PA, QL (30 tablets/30
days), 90
AUVELITY – dextromethorphan hbr-bupropion hcl tab er
45-105 mg
NP
PA, QL (60 tablets/30
days), 90
bupropion hcl tab er 12hr 100 mg, 150 mg, 200 mg (Wellbutrin
sr)
P
QL (60 tablets/30 days), 90
bupropion hcl tab er 24hr 150 mg, 300 mg (Wellbutrin xl)
P
QL (30 tablets/30 days), 90
bupropion hcl tab 75 mg
P
QL (60 tablets/30 days), 90
bupropion hcl tab 100 mg
P
QL (120 tablets/30 days), 90
BUPROPION HYDROCHLORIDE ER (XL) – bupropion hcl tab er
24hr 450 mg
P
QL (30 tablets/30 days), 90
clomipramine hcl cap 25 mg, 50 mg, 75 mg (Anafranil)
P
90
desipramine hcl tab 10 mg, 25 mg (Norpramin)
P
90
desipramine hcl tab 50 mg, 75 mg, 100 mg, 150 mg
P
90
doxepin hcl cap 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg
P
90
doxepin hcl conc 10 mg/ml
P
90
EMSAM – selegiline td patch 24hr 6 mg/24hr, 9 mg/24hr,
12 mg/24hr
NP
PA, 90
FORFIVO XL – bupropion hcl tab er 24hr 450 mg
NP
PA, QL (30 tablets/30
days), 90
imipramine hcl tab 10 mg, 25 mg, 50 mg
P
90
imipramine pamoate cap 75 mg, 100 mg, 125 mg, 150 mg
NP
PA, 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
33
Drug Name
Preferred Status Drug Status / Restriction
MARPLAN – isocarboxazid tab 10 mg
NP
PA, 90
mirtazapine orally disintegrating tab 15 mg, 30 mg, 45 mg
(Remeron soltab)
P
QL (30 tablets/30 days), 90
mirtazapine tab 7.5 mg, 45 mg
P
QL (30 tablets/30 days), 90
mirtazapine tab 15 mg, 30 mg (Remeron)
P
QL (30 tablets/30 days), 90
NARDIL – phenelzine sulfate tab 15 mg
NP
PA, 90
NEFAZODONE HYDROCHLORIDE – nefazodone hcl tab 50 mg,
100 mg, 150 mg, 200 mg, 250 mg
NP
PA, 90
NORPRAMIN – desipramine hcl tab 10 mg, 25 mg
NP
PA, 90
nortriptyline hcl cap 10 mg, 25 mg, 50 mg, 75 mg (Pamelor)
P
90
nortriptyline hcl soln 10 mg/5ml
P
90
PAMELOR – nortriptyline hcl cap 10 mg, 25 mg, 50 mg, 75 mg
NP
PA, 90
PHENELZINE SULFATE – phenelzine sulfate tab 15 mg
P
90
protriptyline hcl tab 5 mg, 10 mg
P
90
REMERON – mirtazapine tab 15 mg, 30 mg
NP
PA, QL (30 tablets/30
days), 90
REMERON SOLTAB – mirtazapine orally disintegrating tab
15 mg, 30 mg, 45 mg
NP
PA, QL (30 tablets/30
days), 90
SPRAVATO 56MG DOSE – esketamine hcl nasal soln 28 mg/
device x 2 (56 mg dose pack)
NP
PA, QL (8 packs/28 days), SP
SPRAVATO 84MG DOSE – esketamine hcl nasal soln 28 mg/
device x 3 (84 mg dose pack)
NP
PA, QL (8 packs/28 days), SP
tranylcypromine sulfate tab 10 mg (Parnate)
P
90
trazodone hcl tab 50 mg, 100 mg, 150 mg, 300 mg
P
90
trimipramine maleate cap 25 mg, 50 mg, 100 mg
NP
PA, 90
TRINTELLIX – vortioxetine hbr tab 5 mg (base equiv), 10 mg
(base equiv), 20 mg (base equiv)
NP
PA, QL (30 tablets/30
days), 90
VIIBRYD – vilazodone hcl tab 10 mg, 20 mg, 40 mg
NP
PA, QL (30 tablets/30
days), 90
vilazodone hcl tab 10 mg, 20 mg, 40 mg (Viibryd)
NP
PA, QL (30 tablets/30
days), 90
WELLBUTRIN SR – bupropion hcl tab er 12hr 100 mg, 150 mg,
200 mg
NP
PA, QL (60 tablets/30
days), 90
WELLBUTRIN XL – bupropion hcl tab er 24hr 150 mg, 300 mg
NP
PA, QL (30 tablets/30
days), 90
ZURZUVAE – zuranolone cap 20 mg, 25 mg
NP
PA, QL (28
capsules/365 days)
ZURZUVAE – zuranolone cap 30 mg
NP
PA, QL (14
capsules/365 days)
ANTIDEPRESSANTS : SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIs)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
34
Drug Name
Preferred Status Drug Status / Restriction
CELEXA – citalopram hydrobromide tab 10 mg (base equiv),
20 mg (base equiv), 40 mg (base equiv)
NP
PA, QL (30 tablets/30
days), 90
CITALOPRAM HYDROBROMIDE – citalopram hydrobromide
cap 30 mg
NP
PA, QL (30 capsules/30
days), 90
citalopram hydrobromide oral soln 10 mg/5ml
P
QL (600 mls/30 days), 90
citalopram hydrobromide tab 10 mg (base equiv), 20 mg (base
equiv), 40 mg (base equiv) (Celexa)
P
QL (30 tablets/30 days), 90
escitalopram oxalate soln 5 mg/5ml (base equiv)
P
QL (600 mls/30 days), 90
escitalopram oxalate tab 5 mg (base equiv), 10 mg (base equiv),
20 mg (base equiv) (Lexapro)
P
QL (30 tablets/30 days), 90
FLUOXETINE DR – fluoxetine hcl cap delayed release 90 mg
NP
PA, QL (4 capsules/28
days), 90
fluoxetine hcl cap 10 mg (Prozac)
P
QL (30 capsules/30 days), 90
fluoxetine hcl cap 20 mg (Prozac)
P
QL (120 capsules/30
days), 90
fluoxetine hcl cap 40 mg (Prozac)
P
QL (60 capsules/30 days), 90
fluoxetine hcl solution 20 mg/5ml
P
QL (600 mls/30 days), 90
fluoxetine hcl tab 10 mg
P
QL (30 tablets/30 days), 90
fluoxetine hcl tab 20 mg
P
QL (120 tablets/30 days), 90
fluoxetine hcl tab 60 mg (Fluoxetine hydrochloride)
P
QL (30 tablets/30 days), 90
FLUOXETINE HYDROCHLORIDE – fluoxetine hcl tab 60 mg
P
QL (30 tablets/30 days), 90
fluvoxamine maleate cap er 24hr 100 mg, 150 mg
NP
PA, QL (60 capsules/30
days), 90
fluvoxamine maleate tab 25 mg, 50 mg
P
QL (30 tablets/30 days), 90
fluvoxamine maleate tab 100 mg
P
QL (90 tablets/30 days), 90
LEXAPRO – escitalopram oxalate tab 5 mg (base equiv), 10 mg
(base equiv), 20 mg (base equiv)
NP
PA, QL (30 tablets/30
days), 90
paroxetine hcl oral susp 10 mg/5ml (base equiv) (Paxil)
P
QL (900 mls/30 days), 90
paroxetine hcl tab er 24hr 12.5 mg (Paxil cr)
NP
PA, QL (30 tablets/30
days), 90
paroxetine hcl tab er 24hr 25 mg, 37.5 mg (Paxil cr)
NP
PA, QL (60 tablets/30
days), 90
paroxetine hcl tab 10 mg, 20 mg, 40 mg (Paxil)
P
QL (30 tablets/30 days), 90
paroxetine hcl tab 30 mg (Paxil)
P
QL (60 tablets/30 days), 90
PAXIL – paroxetine hcl oral susp 10 mg/5ml (base equiv)
NP
PA, QL (900 mls/30 days), 90
PAXIL – paroxetine hcl tab 10 mg, 20 mg, 40 mg
NP
PA, QL (30 tablets/30
days), 90
PAXIL – paroxetine hcl tab 30 mg
NP
PA, QL (60 tablets/30
days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
35
Drug Name
Preferred Status Drug Status / Restriction
PAXIL CR – paroxetine hcl tab er 24hr 12.5 mg
NP
PA, QL (30 tablets/30
days), 90
PAXIL CR – paroxetine hcl tab er 24hr 25 mg, 37.5 mg
NP
PA, QL (60 tablets/30
days), 90
PROZAC – fluoxetine hcl cap 10 mg
NP
PA, QL (30 capsules/30
days), 90
PROZAC – fluoxetine hcl cap 20 mg
NP
PA, QL (120
capsules/30 days), 90
PROZAC – fluoxetine hcl cap 40 mg
NP
PA, QL (60 capsules/30
days), 90
sertraline hcl oral concentrate for solution 20 mg/ml (Zoloft)
P
QL (300 mls/30 days), 90
sertraline hcl tab 25 mg (Zoloft)
P
QL (45 tablets/30 days), 90
sertraline hcl tab 50 mg (Zoloft)
P
QL (30 tablets/30 days), 90
sertraline hcl tab 100 mg (Zoloft)
P
QL (60 tablets/30 days), 90
SERTRALINE HYDROCHLORIDE – sertraline hcl cap 150 mg,
200 mg
NP
PA, QL (30 capsules/30
days), 90
ZOLOFT – sertraline hcl oral concentrate for solution 20 mg/ml
NP
PA, QL (300 mls/30 days), 90
ZOLOFT – sertraline hcl tab 25 mg
NP
PA, QL (45 tablets/30
days), 90
ZOLOFT – sertraline hcl tab 50 mg
NP
PA, QL (30 tablets/30
days), 90
ZOLOFT – sertraline hcl tab 100 mg
NP
PA, QL (60 tablets/30
days), 90
ANTIDEPRESSANTS : SELECTIVE SEROTONIN-NOREPINEPHRINE REUPTAKE INHIBITOR (SNRIs)
CYMBALTA – duloxetine hcl enteric coated pellets cap 20 mg
(base eq), 60 mg (base eq)
NP
PA, QL (60 capsules/30
days), 90
CYMBALTA – duloxetine hcl enteric coated pellets cap 30 mg
(base eq)
NP
PA, QL (90 capsules/30
days), 90
DESVENLAFAXINE ER – desvenlafaxine tab er 24hr 50 mg,
100 mg
NP
PA, QL (30 tablets/30
days), 90
desvenlafaxine succinate tab er 24hr 25 mg (base equiv), 50 mg
(base equiv), 100 mg (base equiv) (Pristiq)
NP
PA, QL (60 tablets/30
days), 90
duloxetine hcl enteric coated pellets cap 20 mg (base eq), 60 mg
(base eq) (Cymbalta)
P
QL (60 capsules/30 days), 90
duloxetine hcl enteric coated pellets cap 30 mg (base eq)
(Cymbalta)
P
QL (90 capsules/30 days), 90
duloxetine hcl enteric coated pellets cap 40 mg (base eq)
P
QL (90 capsules/30 days), 90
EFFEXOR XR – venlafaxine hcl cap er 24hr 37.5 mg (base
equivalent), 150 mg (base equivalent)
NP
PA, QL (30 capsules/30
days), 90
EFFEXOR XR – venlafaxine hcl cap er 24hr 75 mg (base
equivalent)
NP
PA, QL (90 capsules/30
days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
36
Drug Name
Preferred Status Drug Status / Restriction
FETZIMA – levomilnacipran hcl cap er 24hr 20 mg (base
equivalent), 40 mg (base equivalent), 80 mg (base equivalent),
120 mg (base equivalent)
NP
PA, QL (30 capsules/30
days), 90
FETZIMA TITRATION PACK – levomilnacipran hcl cap er 24hr
20 & 40 mg therapy pack
NP
PA, QL (28 tablets/180 days)
PRISTIQ – desvenlafaxine succinate tab er 24hr 25 mg (base
equiv), 50 mg (base equiv), 100 mg (base equiv)
NP
PA, QL (60 tablets/30
days), 90
VENLAFAXINE BESYLATE ER – venlafaxine besylate tab er
24hr 112.5 mg
P
QL (30 tablets/30 days), 90
venlafaxine hcl cap er 24hr 37.5 mg (base equivalent), 150 mg
(base equivalent) (Effexor xr)
P
QL (30 capsules/30 days), 90
venlafaxine hcl cap er 24hr 75 mg (base equivalent) (Effexor xr)
P
QL (90 capsules/30 days), 90
venlafaxine hcl tab er 24hr 37.5 mg (base equivalent), 150 mg
(base equivalent), 225 mg (base equivalent)
NP
PA, QL (30 tablets/30
days), 90
venlafaxine hcl tab er 24hr 75 mg (base equivalent)
NP
PA, QL (90 tablets/30
days), 90
venlafaxine hcl tab 25 mg (base equivalent), 37.5 mg (base
equivalent), 50 mg (base equivalent), 75 mg (base equivalent),
100 mg (base equivalent)
P
QL (90 tablets/30 days), 90
ANTIDIABETICS : COMBINATIONS
ACTOPLUS MET – pioglitazone hcl-metformin hcl tab 15-850 mg
NP
PA, QL (90 tablets/30
days), 90
ALOGLIPTIN/METFORMIN HCL – alogliptin-metformin hcl tab
12.5-500 mg
NP
PA, QL (60 tablets/30
days), ST, 90
ALOGLIPTIN/METFORMIN HYDROCHLORIDE – alogliptin-
metformin hcl tab 12.5-1000 mg
NP
PA, QL (60 tablets/30
days), ST, 90
ALOGLIPTIN/PIOGLITAZONE – alogliptin-pioglitazone tab
12.5-30 mg, 25-15 mg, 25-30 mg, 25-45 mg
NP
PA, QL (30 tablets/30
days), ST, 90
DAPAGLIFLOZIN PROPANEDIOL/METFORMIN
HYDROCHLORIDE – dapagliflozin prop-metformin hcl tab er
24hr 5-1000 mg
NP
PA, QL (60 tablets/30
days), ST, 90
DAPAGLIFLOZIN PROPANEDIOL/METFORMIN
HYDROCHLORIDE – dapagliflozin prop-metformin hcl tab er
24hr 10-1000 mg
NP
PA, QL (30 tablets/30
days), ST, 90
DUETACT – pioglitazone hcl-glimepiride tab 30-2 mg, 30-4 mg
NP
PA, QL (30 tablets/30
days), 90
glipizide-metformin hcl tab 2.5-250 mg, 2.5-500 mg, 5-500 mg
P
QL (120 tablets/30 days), 90
glyburide-metformin tab 1.25-250 mg, 2.5-500 mg, 5-500 mg
P
QL (120 tablets/30 days), 90
GLYXAMBI – empagliflozin-linagliptin tab 10-5 mg, 25-5 mg
NP
PA, QL (30 tablets/30
days), ST, 90
INVOKAMET – canagliflozin-metformin hcl tab 50-500 mg,
50-1000 mg, 150-500 mg, 150-1000 mg
NP
PA, QL (60 tablets/30
days), ST, 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
37
Drug Name
Preferred Status Drug Status / Restriction
INVOKAMET XR – canagliflozin-metformin hcl tab er 24hr
50-500 mg, 50-1000 mg, 150-500 mg, 150-1000 mg
NP
PA, QL (60 tablets/30
days), ST, 90
JANUMET – sitagliptin-metformin hcl tab 50-500 mg, 50-1000 mg
NP
PA, QL (60 tablets/30
days), ST, 90
JANUMET XR – sitagliptin-metformin hcl tab er 24hr 50-500 mg,
100-1000 mg
NP
PA, QL (30 tablets/30
days), ST, 90
JANUMET XR – sitagliptin-metformin hcl tab er 24hr 50-1000 mg
NP
PA, QL (60 tablets/30
days), ST, 90
JENTADUETO – linagliptin-metformin hcl tab 2.5-500 mg,
2.5-850 mg, 2.5-1000 mg
NP
PA, QL (60 tablets/30
days), ST, 90
JENTADUETO XR – linagliptin-metformin hcl tab er 24hr
2.5-1000 mg
NP
PA, QL (60 tablets/30
days), ST, 90
JENTADUETO XR – linagliptin-metformin hcl tab er 24hr
5-1000 mg
NP
PA, QL (30 tablets/30
days), ST, 90
pioglitazone hcl-glimepiride tab 30-2 mg, 30-4 mg (Duetact)
NP
PA, QL (30 tablets/30
days), 90
pioglitazone hcl-metformin hcl tab 15-500 mg, 15-850 mg
(Actoplus met)
NP
PA, QL (90 tablets/30
days), 90
QTERN – dapagliflozin-saxagliptin tab 5-5 mg, 10-5 mg
NP
PA, QL (30 tablets/30
days), ST, 90
saxagliptin-metformin hcl tab er 24hr 2.5-1000 mg (Kombiglyze
xr)
NP
PA, QL (60 tablets/30
days), 90
saxagliptin-metformin hcl tab er 24hr 5-500 mg, 5-1000 mg
(Kombiglyze xr)
NP
PA, QL (30 tablets/30
days), 90
SEGLUROMET – ertugliflozin-metformin hcl tab 2.5-500 mg
NP
PA, QL (120 tablets/30
days), ST, 90
SEGLUROMET – ertugliflozin-metformin hcl tab 2.5-1000 mg,
7.5-500 mg, 7.5-1000 mg
NP
PA, QL (60 tablets/30
days), ST, 90
SOLIQUA 100/33 – insulin glargine-lixisenatide sol pen-inj
100-33 unit-mcg/ml
NP
PA, QL (6 pens/30 days), 90
STEGLUJAN – ertugliflozin-sitagliptin tab 5-100 mg, 15-100 mg
NP
PA, QL (30 tablets/30
days), ST, 90
SYNJARDY – empagliflozin-metformin hcl tab 5-500 mg,
5-1000 mg, 12.5-500 mg, 12.5-1000 mg
NP
PA, QL (60 tablets/30
days), ST, 90
SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr
5-1000 mg, 10-1000 mg, 12.5-1000 mg
NP
PA, QL (60 tablets/30
days), ST, 90
SYNJARDY XR – empagliflozin-metformin hcl tab er 24hr
25-1000 mg
NP
PA, QL (30 tablets/30
days), ST, 90
TRIJARDY XR – empagliflozin-linagliptin-metformin tab er 24hr
5-2.5-1000mg
NP
PA, QL (60 tablets/30
days), ST, 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
38
Drug Name
Preferred Status Drug Status / Restriction
TRIJARDY XR – empagliflozin-linagliptin-metformin tab er 24hr
10-5-1000 mg, 25-5-1000 mg
NP
PA, QL (30 tablets/30
days), ST, 90
TRIJARDY XR – empagliflozin-linaglip-metformin tab er 24hr
12.5-2.5-1000mg
NP
PA, QL (60 tablets/30
days), ST, 90
XIGDUO XR – dapagliflozin prop-metformin hcl tab er 24hr
2.5-1000 mg, 5-1000 mg
NP
PA, QL (60 tablets/30
days), ST, 90
XIGDUO XR – dapagliflozin prop-metformin hcl tab er 24hr
5-500 mg, 10-500 mg, 10-1000 mg
NP
PA, QL (30 tablets/30
days), ST, 90
XULTOPHY 100/3.6 – insulin degludec-liraglutide sol pen-inj
100-3.6 unit-mg/ml
NP
PA, QL (5 pens/30 days), 90
ANTIDIABETICS : DIPEPTIDYL PEPTIDASE-4 (DPP-4) INHIBITORS
ALOGLIPTIN – alogliptin benzoate tab 6.25 mg (base equiv),
12.5 mg (base equiv), 25 mg (base equiv)
NP
PA, QL (30 tablets/30
days), ST, 90
JANUVIA – sitagliptin phosphate tab 25 mg (base equiv), 50 mg
(base equiv), 100 mg (base equiv)
P
QL (30 tablets/30 days), 90
ONGLYZA – saxagliptin hcl tab 5 mg (base equiv)
NP
PA, QL (30 tablets/30
days), ST, 90
saxagliptin hcl tab 2.5 mg (base equiv), 5 mg (base equiv)
(Onglyza)
NP
PA, QL (30 tablets/30
days), 90
TRADJENTA – linagliptin tab 5 mg
P
QL (30 tablets/30 days), 90
ZITUVIO – sitagliptin tab 25 mg, 50 mg, 100 mg
NP
PA, QL (30 tablets/30
days), ST, 90
ANTIDIABETICS : INCRETIN MIMETIC AGENTS (GLP-1 RECEPTOR AGONISTS)
BYDUREON BCISE – exenatide extended release susp auto-
injector 2 mg/0.85ml
NP
PA, QL (4 pens/28 days), ST
BYETTA – exenatide soln pen-injector 5 mcg/0.02ml,
10 mcg/0.04ml
NP
PA, QL (1 pen/30 days), ST
MOUNJARO – tirzepatide soln pen-injector 2.5 mg/0.5ml
NP
PA, QL (4 pens/180 days), ST
MOUNJARO – tirzepatide soln pen-injector 5 mg/0.5ml,
7.5 mg/0.5ml, 10 mg/0.5ml, 12.5 mg/0.5ml, 15 mg/0.5ml
NP
PA, QL (4 pens/28 days), ST
OZEMPIC – semaglutide soln pen-inj 0.25 or 0.5 mg/dose
(2 mg/3ml), 1 mg/dose (4 mg/3ml), 2 mg/dose (8 mg/3ml)
NP
PA, QL (1 pen/28 days), ST
RYBELSUS – semaglutide tab 3 mg
P
QL (30 tablets/180
days), ST, 90
RYBELSUS – semaglutide tab 7 mg, 14 mg
P
QL (30 tablets/30
days), ST, 90
TRULICITY – dulaglutide soln pen-injector 0.75 mg/0.5ml,
1.5 mg/0.5ml, 3 mg/0.5ml, 4.5 mg/0.5ml
P
QL (4 pens/28 days)
VICTOZA – liraglutide soln pen-injector 18 mg/3ml (6 mg/ml)
P
QL (3 pens/30 days)
ANTIDIABETICS : INSULIN
ADMELOG – insulin lispro inj soln 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
39
Drug Name
Preferred Status Drug Status / Restriction
ADMELOG SOLOSTAR – insulin lispro soln pen-injector 100
unit/ml (1 unit dial)
NP
PA, QL (45 mls/30 days), 90
AFREZZA – insulin regular (human) inhalation powder 4 unit/
cartridge
NP
PA, QL (1170
cartridges/30 days), 90
AFREZZA – insulin regular (human) inhalation powder 8 unit/
cartridge
NP
PA, QL (7 packs/30 days), 90
AFREZZA – insulin regular (human) inhalation powder 12 unit/
cartridge
NP
PA, QL (4 packs/30 days), 90
AFREZZA – insulin regular (human) inhal powd 90 x 4 unit & 90 x
8 unit
NP
PA, QL (720
cartridges/30 days), 90
AFREZZA – insulin regular (human) inh powd 90 x 8 unit & 90 x
12 unit
NP
PA, QL (3 packs/30 days), 90
AFREZZA – insulin regular (human) inh powd 60x4 & 60x8 &
60x12 ut/cart
NP
PA, QL (540
cartridges/30 days), 90
APIDRA – insulin glulisine inj 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
APIDRA SOLOSTAR – insulin glulisine soln pen-injector inj 100
unit/ml
NP
PA, QL (45 mls/30 days), 90
BASAGLAR KWIKPEN – insulin glargine soln pen-injector 100
unit/ml
NP
PA, QL (45 mls/30 days), 90
BASAGLAR TEMPO PEN – insulin glargine pen-inj with
transmitter port 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
FIASP – insulin aspart (with niacinamide) inj 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
FIASP FLEXTOUCH – insulin aspart (with niacinamide) sol pen-
inj 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
FIASP PENFILL – insulin aspart (with niacinamide) soln cartridge
100 unit/ml
NP
PA, QL (45 mls/30 days), 90
FIASP PUMPCART – insulin aspart (with niacinamide) soln
cartridge 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
HUMALOG – insulin lispro soln cartridge 100 unit/ml
P
QL (45 mls/30 days), 90
HUMALOG – insulin lispro inj soln 100 unit/ml
P
QL (45 mls/30 days), 90
HUMALOG JUNIOR KWIKPEN – insulin lispro soln pen-injector
100 unit/ml (0.5 unit dial)
P
QL (45 mls/30 days), 90
HUMALOG KWIKPEN – insulin lispro soln pen-injector 100 unit/
ml (1 unit dial)
P
QL (45 mls/30 days), 90
HUMALOG KWIKPEN – insulin lispro soln pen-injector 200 unit/
ml
P
QL (24 mls/30 days), 90
HUMALOG MIX 50/50 – insulin lispro protamine & lispro inj 100
unit/ml (50-50)
P
QL (45 mls/30 days), 90
HUMALOG MIX 50/50 KWIKPEN – insulin lispro prot & lispro sus
pen-inj 100 unit/ml (50-50)
P
QL (45 mls/30 days), 90
HUMALOG MIX 75/25 – insulin lispro prot & lispro inj 100 unit/ml
(75-25)
P
QL (45 mls/30 days), 90
HUMALOG MIX 75/25 KWIKPEN – insulin lispro prot & lispro sus
pen-inj 100 unit/ml (75-25)
P
QL (45 mls/30 days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
40
Drug Name
Preferred Status Drug Status / Restriction
HUMALOG TEMPO PEN – insulin lispro soln pen-inj w/
transmitter port 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
HUMULIN N – insulin nph (human) (isophane) inj 100 unit/ml
P
QL (45 mls/30 days), 90
HUMULIN N KWIKPEN – insulin nph (human) (isophane) susp
pen-injector 100 unit/ml
P
QL (45 mls/30 days), 90
HUMULIN R – insulin regular (human) inj 100 unit/ml
P
QL (45 mls/30 days), 90
HUMULIN R U-500 (CONCENTRATED) – insulin regular
(human) inj 500 unit/ml
P
QL (20 mls/30 days), 90
HUMULIN R U-500 KWIKPEN – insulin regular (human) soln
pen-injector 500 unit/ml
P
QL (12 mls/30 days), 90
HUMULIN 70/30 – insulin nph isophane & regular human inj 100
unit/ml (70-30)
P
QL (45 mls/30 days), 90
HUMULIN 70/30 KWIKPEN – insulin nph & regular susp pen-inj
100 unit/ml (70-30)
P
QL (45 mls/30 days), 90
INSULIN ASPART – insulin aspart inj soln 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
INSULIN ASPART FLEXPEN – insulin aspart soln pen-injector
100 unit/ml
NP
PA, QL (45 mls/30 days), 90
INSULIN ASPART PENFILL – insulin aspart soln cartridge 100
unit/ml
NP
PA, QL (45 mls/30 days), 90
INSULIN ASPART PROTAMINE/INSULIN ASPART FLEXPEN –
insulin aspart prot & aspart sus pen-inj 100 unit/ml (70-30)
NP
PA, QL (45 mls/30 days), 90
INSULIN ASPART PROTAMINE/INSULIN ASPART FLEXPEN –
insulin aspart prot & aspart (human) inj 100 unit/ml (70-30)
NP
PA, QL (45 mls/30 days), 90
INSULIN DEGLUDEC – insulin degludec inj 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
INSULIN DEGLUDEC FLEXTOUCH – insulin degludec soln pen-
injector 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
INSULIN DEGLUDEC FLEXTOUCH – insulin degludec soln pen-
injector 200 unit/ml
NP
PA, QL (27 mls/30 days), 90
INSULIN GLARGINE MAX SOLOSTAR – insulin glargine soln
pen-injector 300 unit/ml (2 unit dial)
NP
PA, QL (18 mls/30 days), 90
INSULIN GLARGINE SOLOSTAR – insulin glargine soln pen-
injector 300 unit/ml (1 unit dial)
NP
PA, QL (18 mls/30 days), 90
INSULIN GLARGINE-YFGN – insulin glargine-yfgn soln pen-
injector 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
INSULIN GLARGINE-YFGN – insulin glargine-yfgn inj 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
INSULIN LISPRO – insulin lispro inj soln 100 unit/ml
P
QL (45 mls/30 days), 90
INSULIN LISPRO JUNIOR KWIKPEN – insulin lispro soln pen-
injector 100 unit/ml (0.5 unit dial)
P
QL (45 mls/30 days), 90
INSULIN LISPRO KWIKPEN – insulin lispro soln pen-injector 100
unit/ml (1 unit dial)
P
QL (45 mls/30 days), 90
INSULIN LISPRO PROTAMINE/INSULIN LISPRO KWIKPEN –
insulin lispro prot & lispro sus pen-inj 100 unit/ml (75-25)
P
QL (45 mls/30 days), 90
LANTUS – insulin glargine inj 100 unit/ml
P
QL (45 mls/30 days), 90
LANTUS SOLOSTAR – insulin glargine soln pen-injector 100
unit/ml
P
QL (45 mls/30 days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
41
Drug Name
Preferred Status Drug Status / Restriction
LEVEMIR – insulin detemir inj 100 unit/ml
P
QL (45 mls/30 days), 90
LEVEMIR FLEXPEN – insulin detemir soln pen-injector 100 unit/
ml
P
QL (45 mls/30 days), 90
LYUMJEV – insulin lispro-aabc inj 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
LYUMJEV KWIKPEN – insulin lispro-aabc soln pen-inj 100 unit/
ml (1 unit dial)
NP
PA, QL (45 mls/30 days), 90
LYUMJEV KWIKPEN – insulin lispro-aabc soln pen-injector 200
unit/ml
NP
PA, QL (24 mls/30 days), 90
LYUMJEV TEMPO PEN – insulin lispro-aabc soln pen-inj w/
transmit port 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
NOVOLIN N – insulin nph (human) (isophane) inj 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
NOVOLIN N FLEXPEN – insulin nph (human) (isophane) susp
pen-injector 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
NOVOLIN N FLEXPEN RELION – insulin nph (human)
(isophane) susp pen-injector 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
NOVOLIN N RELION – insulin nph (human) (isophane) inj 100
unit/ml
NP
PA, QL (45 mls/30 days), 90
NOVOLIN R – insulin regular (human) inj 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
NOVOLIN R FLEXPEN – insulin regular (human) soln pen-
injector 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
NOVOLIN R FLEXPEN RELION – insulin regular (human) soln
pen-injector 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
NOVOLIN R RELION – insulin regular (human) inj 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
NOVOLIN 70/30 – insulin nph isophane & regular human inj 100
unit/ml (70-30)
NP
PA, QL (45 mls/30 days), 90
NOVOLIN 70/30 FLEXPEN – insulin nph & regular susp pen-inj
100 unit/ml (70-30)
NP
PA, QL (45 mls/30 days), 90
NOVOLIN 70/30 FLEXPEN RELION – insulin nph & regular susp
pen-inj 100 unit/ml (70-30)
NP
PA, QL (45 mls/30 days), 90
NOVOLIN 70/30 RELION – insulin nph isophane & regular
human inj 100 unit/ml (70-30)
NP
PA, QL (45 mls/30 days), 90
NOVOLOG – insulin aspart inj soln 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
NOVOLOG FLEXPEN – insulin aspart soln pen-injector 100 unit/
ml
NP
PA, QL (45 mls/30 days), 90
NOVOLOG FLEXPEN RELION – insulin aspart soln pen-injector
100 unit/ml
NP
PA, QL (45 mls/30 days), 90
NOVOLOG MIX 70/30 – insulin aspart prot & aspart (human) inj
100 unit/ml (70-30)
NP
PA, QL (45 mls/30 days), 90
NOVOLOG MIX 70/30 PREFILLED FLEXPEN – insulin aspart
prot & aspart sus pen-inj 100 unit/ml (70-30)
NP
PA, QL (45 mls/30 days), 90
NOVOLOG MIX 70/30 PREFILLED FLEXPEN RELION – insulin
aspart prot & aspart sus pen-inj 100 unit/ml (70-30)
NP
PA, QL (45 mls/30 days), 90
NOVOLOG MIX 70/30 RELION – insulin aspart prot & aspart
(human) inj 100 unit/ml (70-30)
NP
PA, QL (45 mls/30 days), 90
NOVOLOG PENFILL – insulin aspart soln cartridge 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
42
Drug Name
Preferred Status Drug Status / Restriction
NOVOLOG RELION – insulin aspart inj soln 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
REZVOGLAR KWIKPEN – insulin glargine-aglr soln pen-injector
100 unit/ml
NP
PA, QL (45 mls/30 days), 90
SEMGLEE – insulin glargine-yfgn soln pen-injector 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
SEMGLEE – insulin glargine-yfgn inj 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
TOUJEO MAX SOLOSTAR – insulin glargine soln pen-injector
300 unit/ml (2 unit dial)
NP
PA, QL (18 mls/30 days), 90
TOUJEO SOLOSTAR – insulin glargine soln pen-injector 300
unit/ml (1 unit dial)
NP
PA, QL (18 mls/30 days), 90
TRESIBA – insulin degludec inj 100 unit/ml
NP
PA, QL (45 mls/30 days), 90
TRESIBA FLEXTOUCH – insulin degludec soln pen-injector 100
unit/ml
NP
PA, QL (45 mls/30 days), 90
TRESIBA FLEXTOUCH – insulin degludec soln pen-injector 200
unit/ml
NP
PA, QL (27 mls/30 days), 90
ANTIDIABETICS : MISC
acarbose tab 25 mg, 50 mg (Precose)
P
QL (180 tablets/30 days), 90
acarbose tab 100 mg (Precose)
P
QL (90 tablets/30 days), 90
ACTOS – pioglitazone hcl tab 15 mg (base equiv), 30 mg (base
equiv), 45 mg (base equiv)
NP
PA, QL (30 tablets/30
days), 90
BAQSIMI ONE PACK – glucagon nasal powder 3 mg/dose
P
QL (6 packs/365 days)
BAQSIMI TWO PACK – glucagon nasal powder 3 mg/dose
P
QL (6 packs/365 days)
CYCLOSET – bromocriptine mesylate tab 0.8 mg (base
equivalent)
NP
PA, QL (180
tablets/30 days), 90
diazoxide susp 50 mg/ml (Proglycem)
P
glimepiride tab 1 mg, 2 mg, 4 mg (Amaryl)
P
QL (60 tablets/30 days), 90
GLIPIZIDE – glipizide tab 2.5 mg
P
QL (30 tablets/30 days), 90
glipizide tab er 24hr 2.5 mg, 10 mg (Glucotrol xl)
P
QL (60 tablets/30 days), 90
glipizide tab er 24hr 5 mg (Glucotrol xl)
P
QL (90 tablets/30 days), 90
glipizide tab 5 mg, 10 mg (Glucotrol)
P
QL (120 tablets/30 days), 90
GLUCAGEN HYPOKIT – glucagon hcl (rdna) for inj 1 mg (base
equiv)
NP
PA, QL (6 kits/365 days)
GLUCAGON EMERGENCY KIT FOR LOW BLOOD SUGAR
– glucagon (rdna) for inj kit 1 mg
NP
PA, QL (6 kits/365 days)
GLUCAGON EMERGENCY KIT FOR LOW BLOOD SUGAR
– glucagon hcl for inj 1 mg
NP
PA, QL (6 kits/365 days)
GLUCOTROL XL – glipizide tab er 24hr 2.5 mg, 10 mg
NP
PA, QL (60 tablets/30
days), 90
GLUCOTROL XL – glipizide tab er 24hr 5 mg
NP
PA, QL (90 tablets/30
days), 90
GLUMETZA – metformin hcl tab er 24hr modified release 500 mg
NP
PA, QL (90 tablets/30
days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
43
Drug Name
Preferred Status Drug Status / Restriction
GLUMETZA – metformin hcl tab er 24hr modified release
1000 mg
NP
PA, QL (60 tablets/30
days), 90
GLYBURIDE MICRONIZED – glyburide micronized tab 1.5 mg
P
QL (120 tablets/30 days), 90
GLYBURIDE MICRONIZED – glyburide micronized tab 3 mg,
6 mg
P
QL (60 tablets/30 days), 90
glyburide tab 1.25 mg, 2.5 mg
P
QL (60 tablets/30 days), 90
glyburide tab 5 mg
P
QL (120 tablets/30 days), 90
GVOKE HYPOPEN 1-PACK – glucagon subcutaneous solution
auto-injector 0.5 mg/0.1ml, 1 mg/0.2ml
P
QL (6 pens/365 days)
GVOKE HYPOPEN 2-PACK – glucagon subcutaneous solution
auto-injector 0.5 mg/0.1ml, 1 mg/0.2ml
P
QL (6 pens/365 days)
GVOKE KIT – glucagon subcutaneous soln 1 mg/0.2ml
P
QL (6 kits/365 days)
GVOKE PFS – glucagon subcutaneous soln pref syringe
1 mg/0.2ml
P
QL (6 syringes/365 days)
KORLYM – mifepristone tab 300 mg
NP
PA, QL (120
tablets/30 days), SP
metformin hcl oral soln 500 mg/5ml (Riomet)
NP
PA, QL (750 mls/30 days), 90
metformin hcl tab er 24hr 500 mg
P
QL (120 tablets/30 days), 90
metformin hcl tab er 24hr 750 mg
P
QL (60 tablets/30 days), 90
metformin hcl tab er 24hr osmotic 500 mg (Fortamet)
NP
PA, QL (90 tablets/30
days), 90
metformin hcl tab er 24hr osmotic 1000 mg (Fortamet)
NP
PA, QL (60 tablets/30
days), 90
metformin hcl tab er 24hr modified release 500 mg (Glumetza)
NP
PA, QL (90 tablets/30
days), 90
metformin hcl tab er 24hr modified release 1000 mg (Glumetza)
NP
PA, QL (60 tablets/30
days), 90
metformin hcl tab 500 mg
P
QL (120 tablets/30 days), 90
metformin hcl tab 850 mg
P
QL (90 tablets/30 days), 90
metformin hcl tab 1000 mg
P
QL (60 tablets/30 days), 90
METFORMIN HYDROCHLORIDE – metformin hcl tab 625 mg
NP
PA, QL (120
tablets/30 days), 90
mifepristone tab 300 mg (Korlym)
NP
PA, QL (120
tablets/30 days), SP
MIGLITOL – miglitol tab 25 mg
P
QL (120 tablets/30 days), 90
MIGLITOL – miglitol tab 50 mg, 100 mg
P
QL (90 tablets/30 days), 90
nateglinide tab 60 mg (Starlix)
P
QL (120 tablets/30 days), 90
nateglinide tab 120 mg (Starlix)
P
QL (90 tablets/30 days), 90
pioglitazone hcl tab 15 mg (base equiv), 30 mg (base equiv),
45 mg (base equiv) (Actos)
P
QL (30 tablets/30 days), 90
PROGLYCEM – diazoxide susp 50 mg/ml
P
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
44
Drug Name
Preferred Status Drug Status / Restriction
repaglinide tab 0.5 mg
NP
PA, QL (120
tablets/30 days), 90
repaglinide tab 1 mg
NP
PA, QL (480
tablets/30 days), 90
repaglinide tab 2 mg
NP
PA, QL (240
tablets/30 days), 90
SYMLINPEN 120 – pramlintide acetate pen-inj 2700 mcg/2.7ml
(1000 mcg/ml)
NP
PA
SYMLINPEN 60 – pramlintide acetate pen-inj 1500 mcg/1.5ml
(1000 mcg/ml)
NP
PA
ZEGALOGUE – dasiglucagon hcl subcutaneous soln auto-inj
0.6 mg/0.6ml
P
QL (6 pens/365 days)
ZEGALOGUE – dasiglucagon hcl subcutaneous soln pref syringe
0.6 mg/0.6ml
P
QL (6 syringes/365 days)
ANTIDIABETICS : SODIUM-GLUCOSE CO-TRANSPORTER 2 (SGLT2) INHIBITORS
DAPAGLIFLOZIN PROPANEDIOL – dapagliflozin propanediol
tab 5 mg (base equivalent), 10 mg (base equivalent)
NP
PA, QL (30 tablets/30
days), 90
FARXIGA – dapagliflozin propanediol tab 5 mg (base equivalent),
10 mg (base equivalent)
P
QL (30 tablets/30 days), 90
INVOKANA – canagliflozin tab 100 mg, 300 mg
P
QL (30 tablets/30 days), 90
JARDIANCE – empagliflozin tab 10 mg, 25 mg
P
QL (30 tablets/30 days), 90
STEGLATRO – ertugliflozin l-pyroglutamic acid tab 5 mg (base
equiv)
NP
PA, QL (60 tablets/30
days), ST, 90
STEGLATRO – ertugliflozin l-pyroglutamic acid tab 15 mg (base
equiv)
NP
PA, QL (30 tablets/30
days), ST, 90
ANTIDIARRHEALS
diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)
SC
loperamide hcl cap 2 mg
SC
ANTIDOTES AND SPECIFIC ANTAGONISTS : ANTIDOTES - CHELATING AGENTS
CHEMET – succimer cap 100 mg
P
CUPRIMINE – penicillamine cap 250 mg
NP
PA, SP
CUVRIOR – trientine tetrahydrochloride tab 300 mg
NP
PA, QL (300 tablets/30
days), SF, SP
deferasirox granules packet 90 mg, 180 mg (Jadenu sprinkle)
NP
PA, QL (30 packets/30
days), SF, SP
deferasirox granules packet 360 mg (Jadenu sprinkle)
NP
PA, QL (180 packets/30
days), SF, SP
deferasirox tab for oral susp 125 mg, 250 mg (Exjade)
NP
PA, QL (30 tablets/30
days), SF, SP
deferasirox tab for oral susp 500 mg (Exjade)
NP
PA, QL (90 tablets/30
days), SF, SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
45
Drug Name
Preferred Status Drug Status / Restriction
deferasirox tab 90 mg, 180 mg (Jadenu)
NP
PA, QL (30 tablets/30
days), SF, SP
deferasirox tab 360 mg (Jadenu)
NP
PA, QL (180 tablets/30
days), SF, SP
deferiprone tab 500 mg (Ferriprox)
NP
PA, QL (540 tablets/30
days), SF, SP
deferiprone tab 1000 mg (Ferriprox)
NP
PA, QL (270 tablets/30
days), SF, SP
DEPEN TITRATABS – penicillamine tab 250 mg
P
SP
EXJADE – deferasirox tab for oral susp 125 mg, 250 mg
NP
PA, QL (30 tablets/30
days), SF, SP
EXJADE – deferasirox tab for oral susp 500 mg
NP
PA, QL (90 tablets/30
days), SF, SP
FERRIPROX – deferiprone oral soln 100 mg/ml
NP
PA, QL (2700
mls/30 days), SP
FERRIPROX – deferiprone tab 500 mg
NP
PA, QL (540 tablets/30
days), SF, SP
FERRIPROX – deferiprone tab 1000 mg
NP
PA, QL (270 tablets/30
days), SF, SP
FERRIPROX TWICE-A-DAY – deferiprone (twice daily) tab
1000 mg
NP
PA, QL (270 tablets/30
days), SF, SP
JADENU – deferasirox tab 90 mg, 180 mg
NP
PA, QL (30 tablets/30
days), SF, SP
JADENU – deferasirox tab 360 mg
NP
PA, QL (180 tablets/30
days), SF, SP
JADENU SPRINKLE – deferasirox granules packet 90 mg,
180 mg
NP
PA, QL (30 packets/30
days), SF, SP
JADENU SPRINKLE – deferasirox granules packet 360 mg
NP
PA, QL (180 packets/30
days), SF, SP
penicillamine cap 250 mg (Cuprimine)
P
SP
penicillamine tab 250 mg (Depen titratabs)
P
SP
SYPRINE – trientine hcl cap 250 mg
NP
PA, QL (240 capsules/30
days), SF, SP
trientine hcl cap 250 mg (Syprine)
P
QL (240 capsules/30
days), SF, SP
TRIENTINE HYDROCHLORIDE – trientine hcl cap 500 mg
P
QL (120 capsules/30
days), SP
ANTIEMETICS : 5-HT3 RECEPTOR ANTAGONISTS
ANZEMET – dolasetron mesylate tab 50 mg
NP
PA, QL (10 tablets/30 days)
granisetron hcl tab 1 mg
NP
PA, QL (20 tablets/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
46
Drug Name
Preferred Status Drug Status / Restriction
ondansetron hcl oral soln 4 mg/5ml
P
QL (300 mls/30 days)
ondansetron hcl tab 4 mg, 8 mg (Zofran)
P
QL (30 tablets/30 days)
ondansetron orally disintegrating tab 4 mg, 8 mg
P
QL (30 tablets/30 days)
SANCUSO – granisetron td patch 3.1 mg/24hr (contains
34.3 mg)
NP
PA, QL (3 patches/30 days)
ANTIEMETICS : MISC
AKYNZEO – netupitant-palonosetron cap 300-0.5 mg
NP
PA, QL (3 capsules/30 days)
ANTIVERT – meclizine hcl chew tab 25 mg
NP
PA
ANTIVERT – meclizine hcl tab 50 mg
NP
PA
BONJESTA – doxylamine-pyridoxine tab er 20-20 mg
NP
PA, QL (60 tablets/30 days)
DICLEGIS – doxylamine-pyridoxine tab delayed release
10-10 mg
NP
PA, QL (120 tablets/30 days)
doxylamine-pyridoxine tab delayed release 10-10 mg (Diclegis)
NP
PA, QL (120 tablets/30 days)
dronabinol cap 2.5 mg, 5 mg, 10 mg
NP
PA, QL (60 capsules/30 days)
MARINOL – dronabinol cap 2.5 mg
NP
PA, QL (60 capsules/30 days)
meclizine hcl tab 12.5 mg, 25 mg
P
MECLIZINE HYDROCHLORIDE – meclizine hcl tab 50 mg
P
scopolamine td patch 72hr 1 mg/3days (Transderm-scop)
P
TRANSDERM-SCOP – scopolamine td patch 72hr 1 mg/3days
P
trimethobenzamide hcl cap 300 mg (Tigan)
NP
PA
ANTIEMETICS : SUBSTANCE P/NEUROKININ 1 (NK1) RECEPTOR ANTAGONISTS
aprepitant capsule therapy pack 80 & 125 mg (Emend tripack)
P
QL (9 capsules/30 days)
aprepitant capsule 40 mg (Emend)
P
QL (2 capsules/30 days)
aprepitant capsule 80 mg (Emend)
P
QL (6 capsules/30 days)
aprepitant capsule 125 mg
P
QL (3 capsules/30 days)
EMEND – aprepitant capsule 80 mg
NP
PA, QL (6 capsules/30 days)
EMEND – aprepitant for oral susp 125 mg (125 mg/5ml)
NP
PA, QL (9 kits/30 days)
EMEND TRIPACK – aprepitant capsule therapy pack 80 &
125 mg
NP
PA, QL (9 capsules/30 days)
ANTIFUNGALS
ANCOBON – flucytosine cap 250 mg, 500 mg
NP
PA
BREXAFEMME – ibrexafungerp citrate tab 150 mg
NP
PA, QL (4 tablets/90 days)
CRESEMBA – isavuconazonium sulfate cap 74.5 mg
(isavuconazole 40 mg), 186 mg (isavuconazole 100 mg)
NP
PA
DIFLUCAN – fluconazole tab 100 mg, 200 mg
NP
PA, QL (30 tablets/30 days)
DIFLUCAN – fluconazole for susp 10 mg/ml, 40 mg/ml
NP
PA, QL (35 mls/30 days)
fluconazole for susp 10 mg/ml, 40 mg/ml (Diflucan)
P
QL (35 mls/30 days)
fluconazole tab 50 mg, 100 mg, 150 mg, 200 mg (Diflucan)
P
QL (30 tablets/30 days)
flucytosine cap 250 mg, 500 mg (Ancobon)
NP
PA
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
47
Drug Name
Preferred Status Drug Status / Restriction
griseofulvin microsize susp 125 mg/5ml
P
griseofulvin microsize tab 500 mg
P
griseofulvin ultramicrosize tab 125 mg, 250 mg
P
itraconazole cap 100 mg (Sporanox)
P
QL (120 capsules/30 days)
itraconazole oral soln 10 mg/ml (Sporanox)
NP
PA, QL (1200 mls/30 days)
ketoconazole tab 200 mg
P
NOXAFIL – posaconazole tab delayed release 100 mg
NP
PA
NOXAFIL – posaconazole susp 40 mg/ml
NP
PA
NOXAFIL – posaconazole for delayed release susp packet
300 mg
NP
PA
nystatin tab 500000 unit
P
posaconazole susp 40 mg/ml (Noxafil)
NP
PA
posaconazole tab delayed release 100 mg (Noxafil)
NP
PA
SPORANOX – itraconazole oral soln 10 mg/ml
NP
PA, QL (1200 mls/30 days)
SPORANOX – itraconazole cap 100 mg
NP
PA, QL (120
capsules/30 days)
terbinafine hcl tab 250 mg
P
QL (90 tablets/365 days)
TOLSURA – itraconazole cap 65 mg
NP
PA, QL (120
capsules/30 days)
VFEND – voriconazole tab 50 mg, 200 mg
NP
PA
VFEND – voriconazole for susp 40 mg/ml
NP
PA
VIVJOA – oteseconazole cap therapy pack 150 mg (12 weeks)
NP
PA, QL (18
capsules/180 days)
voriconazole for susp 40 mg/ml (Vfend)
NP
PA
voriconazole tab 50 mg, 200 mg (Vfend)
NP
PA
ANTIHISTAMINES
CARBINOXAMINE MALEATE – carbinoxamine maleate soln
4 mg/5ml
SC
carbinoxamine maleate tab 4 mg
SC
cyproheptadine hcl syrup 2 mg/5ml
SC
cyproheptadine hcl tab 4 mg
SC
desloratadine tab 5 mg (Clarinex)
SC
DIPHENHYDRAMINE HCL – diphenhydramine hcl elixir
12.5 mg/5ml
SC
levocetirizine dihydrochloride tab 5 mg
SC
promethazine hcl oral soln 6.25 mg/5ml
SC
promethazine hcl suppos 12.5 mg, 25 mg
SC
promethazine hcl tab 12.5 mg, 25 mg, 50 mg
SC
ANTIHYPERLIPIDEMICS
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
48
Drug Name
Preferred Status Drug Status / Restriction
ALTOPREV – lovastatin tab er 24hr 20 mg, 40 mg, 60 mg
NP
PA, QL (30 tablets/30
days), 90
ATORVALIQ – atorvastatin calcium susp 20 mg/5ml (4mg/ml)
(base equiv)
NP
PA, QL (600 mls/30 days), 90
atorvastatin calcium tab 10 mg (base equivalent), 20 mg (base
equivalent), 40 mg (base equivalent), 80 mg (base equivalent)
(Lipitor)
P
QL (30 tablets/30 days), 90
cholestyramine light powder packets 4 gm
P
90
cholestyramine light powder 4 gm/dose (Questran light)
P
90
cholestyramine powder packets 4 gm (Questran)
P
90
cholestyramine powder 4 gm/dose (Questran)
P
90
choline fenofibrate cap dr 45 mg (fenofibric acid equiv) (Trilipix)
P
QL (60 capsules/30 days), 90
choline fenofibrate cap dr 135 mg (fenofibric acid equiv) (Trilipix)
P
QL (30 capsules/30 days), 90
colesevelam hcl packet for susp 3.75 gm (Welchol)
NP
PA, QL (30 packets/30
days), 90
colesevelam hcl tab 625 mg (Welchol)
NP
PA, 90
COLESTID – colestipol hcl tab 1 gm
NP
PA, 90
COLESTID – colestipol hcl granules 5 gm
NP
PA, 90
colestipol hcl granule packets 5 gm (Colestid flavored)
NP
PA, 90
colestipol hcl granules 5 gm (Colestid flavored)
NP
PA, 90
colestipol hcl tab 1 gm (Colestid)
NP
PA, 90
CRESTOR – rosuvastatin calcium tab 5 mg, 10 mg, 20 mg,
40 mg
NP
PA, QL (30 tablets/30
days), 90
EZALLOR SPRINKLE – rosuvastatin calcium sprinkle cap 5 mg
(base equivalent), 10 mg (base equivalent), 20 mg (base
equivalent), 40 mg (base equivalent)
NP
PA, QL (30 capsules/30
days), 90
ezetimibe tab 10 mg (Zetia)
P
90
ezetimibe-simvastatin tab 10-10 mg, 10-20 mg, 10-40 mg,
10-80 mg (Vytorin)
NP
PA, QL (30 tablets/30
days), 90
FENOFIBRATE – fenofibrate cap 50 mg
P
QL (60 capsules/30 days), 90
FENOFIBRATE – fenofibrate cap 150 mg
P
QL (30 capsules/30 days), 90
fenofibrate micronized cap 43 mg
P
QL (60 capsules/30 days), 90
fenofibrate micronized cap 67 mg, 130 mg, 134 mg, 200 mg
P
QL (30 capsules/30 days), 90
fenofibrate tab 40 mg (Fenoglide)
P
QL (60 tablets/30 days), 90
fenofibrate tab 48 mg (Tricor)
P
QL (60 tablets/30 days), 90
fenofibrate tab 54 mg
P
QL (60 tablets/30 days), 90
fenofibrate tab 120 mg (Fenoglide)
P
QL (30 tablets/30 days), 90
fenofibrate tab 145 mg (Tricor)
P
QL (30 tablets/30 days), 90
fenofibrate tab 160 mg
P
QL (30 tablets/30 days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
49
Drug Name
Preferred Status Drug Status / Restriction
FENOGLIDE – fenofibrate tab 40 mg
NP
PA, QL (60 tablets/30
days), 90
FENOGLIDE – fenofibrate tab 120 mg
NP
PA, QL (30 tablets/30
days), 90
fluvastatin sodium cap 20 mg (base equivalent), 40 mg (base
equivalent)
NP
PA, QL (60 capsules/30
days), 90
fluvastatin sodium tab er 24 hr 80 mg (base equivalent) (Lescol
xl)
NP
PA, QL (30 tablets/30
days), 90
gemfibrozil tab 600 mg (Lopid)
P
QL (60 tablets/30 days), 90
icosapent ethyl cap 0.5 gm (Vascepa)
NP
PA, QL (240
capsules/30 days)
icosapent ethyl cap 1 gm (Vascepa)
NP
PA, QL (120
capsules/30 days)
JUXTAPID – lomitapide mesylate cap 5 mg (base equiv), 10 mg
(base equiv)
NP
PA, QL (30 capsules/30
days), SP
JUXTAPID – lomitapide mesylate cap 20 mg (base equiv), 30 mg
(base equiv)
NP
PA, QL (60 capsules/30
days), SP
LEQVIO – inclisiran sodium subcutaneous soln pref syr
284 mg/1.5ml
NP
PA
LESCOL XL – fluvastatin sodium tab er 24 hr 80 mg (base
equivalent)
NP
PA, QL (30 tablets/30
days), 90
LIPITOR – atorvastatin calcium tab 10 mg (base equivalent),
20 mg (base equivalent), 40 mg (base equivalent), 80 mg
(base equivalent)
NP
PA, QL (30 tablets/30
days), 90
LIPOFEN – fenofibrate cap 50 mg
NP
PA, QL (60 capsules/30
days), 90
LIPOFEN – fenofibrate cap 150 mg
NP
PA, QL (30 capsules/30
days), 90
LIVALO – pitavastatin calcium tab 1 mg, 2 mg
NP
PA, QL (45 tablets/30
days), 90
LIVALO – pitavastatin calcium tab 4 mg
NP
PA, QL (30 tablets/30
days), 90
LOPID – gemfibrozil tab 600 mg
NP
PA, QL (60 tablets/30
days), 90
lovastatin tab 10 mg, 20 mg, 40 mg
P
QL (60 tablets/30 days), 90
LOVAZA – omega-3-acid ethyl esters cap 1 gm
NP
PA, 90
NEXLETOL – bempedoic acid tab 180 mg
NP
PA, QL (30 tablets/30 days)
NEXLIZET – bempedoic acid-ezetimibe tab 180-10 mg
NP
PA, QL (30 tablets/30 days)
niacin tab er 500 mg (antihyperlipidemic) (Niaspan)
NP
PA, QL (30 tablets/30
days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
50
Drug Name
Preferred Status Drug Status / Restriction
niacin tab er 750 mg (antihyperlipidemic), 1000 mg
(antihyperlipidemic) (Niaspan)
NP
PA, QL (60 tablets/30
days), 90
omega-3-acid ethyl esters cap 1 gm (Lovaza)
NP
PA, 90
pitavastatin calcium tab 1 mg, 2 mg (Livalo)
NP
PA, QL (45 tablets/30
days), 90
pitavastatin calcium tab 4 mg (Livalo)
NP
PA, QL (30 tablets/30
days), 90
PRALUENT – alirocumab subcutaneous solution auto-injector
75 mg/ml, 150 mg/ml
NP
PA, QL (2 pens/28 days)
pravastatin sodium tab 10 mg
P
QL (45 tablets/30 days), 90
pravastatin sodium tab 20 mg, 40 mg (Pravachol)
P
QL (45 tablets/30 days), 90
pravastatin sodium tab 80 mg
P
QL (30 tablets/30 days), 90
QUESTRAN – cholestyramine powder 4 gm/dose
NP
PA, 90
QUESTRAN – cholestyramine powder packets 4 gm
NP
PA, 90
QUESTRAN LIGHT – cholestyramine light powder 4 gm/dose
NP
PA, 90
REPATHA – evolocumab subcutaneous soln prefilled syringe
140 mg/ml
NP
PA, QL (2 syringes/28 days)
REPATHA PUSHTRONEX SYSTEM – evolocumab
subcutaneous soln cartridge/infusor 420 mg/3.5ml
NP
PA, QL (2 systems/30 days)
REPATHA SURECLICK – evolocumab subcutaneous soln auto-
injector 140 mg/ml
NP
PA, QL (2 syringes/28 days)
rosuvastatin calcium tab 5 mg, 10 mg, 20 mg, 40 mg (Crestor)
P
QL (30 tablets/30 days), 90
simvastatin tab 5 mg
P
QL (30 tablets/30 days), 90
simvastatin tab 10 mg, 20 mg, 40 mg, 80 mg (Zocor)
P
QL (30 tablets/30 days), 90
TRICOR – fenofibrate tab 48 mg
NP
PA, QL (60 tablets/30
days), 90
TRICOR – fenofibrate tab 145 mg
NP
PA, QL (30 tablets/30
days), 90
TRILIPIX – choline fenofibrate cap dr 45 mg (fenofibric acid
equiv)
NP
PA, QL (60 tablets/30
days), 90
TRILIPIX – choline fenofibrate cap dr 135 mg (fenofibric acid
equiv)
NP
PA, QL (30 capsules/30
days), 90
VASCEPA – icosapent ethyl cap 0.5 gm
NP
PA, QL (240
capsules/30 days)
VASCEPA – icosapent ethyl cap 1 gm
NP
PA, QL (120
capsules/30 days)
VYTORIN – ezetimibe-simvastatin tab 10-10 mg, 10-20 mg,
10-40 mg, 10-80 mg
NP
PA, QL (30 tablets/30
days), 90
WELCHOL – colesevelam hcl tab 625 mg
NP
PA, 90
WELCHOL – colesevelam hcl packet for susp 3.75 gm
NP
PA, QL (30 packets/30
days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
51
Drug Name
Preferred Status Drug Status / Restriction
ZETIA – ezetimibe tab 10 mg
NP
PA, 90
ZOCOR – simvastatin tab 10 mg, 20 mg, 40 mg
NP
PA, QL (30 tablets/30
days), 90
ZYPITAMAG – pitavastatin magnesium tab 2 mg (base equiv)
NP
PA, QL (45 tablets/30
days), 90
ZYPITAMAG – pitavastatin magnesium tab 4 mg (base equiv)
NP
PA, QL (30 tablets/30
days), 90
ANTIMYASTHENIC AGENTS
FIRDAPSE – amifampridine phosphate tab 10 mg (base
equivalent)
NP
PA, QL (240
tablets/30 days), SP
MESTINON – pyridostigmine bromide oral soln 60 mg/5ml
NP
PA
MESTINON – pyridostigmine bromide tab 60 mg
NP
PA
MESTINON TIMESPAN – pyridostigmine bromide tab er 180 mg
NP
PA
PYRIDOSTIGMINE BROMIDE – pyridostigmine bromide tab
30 mg
P
pyridostigmine bromide oral soln 60 mg/5ml (Mestinon)
P
pyridostigmine bromide tab er 180 mg (Mestinon timespan)
P
pyridostigmine bromide tab 60 mg (Mestinon)
P
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : ALKYLATING AGENTS
CYCLOPHOSPHAMIDE – cyclophosphamide cap 25 mg, 50 mg
P
CYCLOPHOSPHAMIDE – cyclophosphamide tab 25 mg, 50 mg
P
cyclophosphamide cap 25 mg, 50 mg (Cyclophosphamide)
P
temozolomide cap 5 mg, 20 mg, 100 mg, 140 mg, 180 mg,
250 mg (Temodar)
P
SP
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : ANTIMETABOLITES
capecitabine tab 150 mg, 500 mg (Xeloda)
NP
PA, SP
JYLAMVO – methotrexate oral soln 2 mg/ml
NP
PA
mercaptopurine tab 50 mg
P
methotrexate sodium tab 2.5 mg (base equiv)
P
ONUREG – azacitidine tab 200 mg, 300 mg
NP
PA, QL (14 tablets/28
days), SP
PURIXAN – mercaptopurine susp 2000 mg/100ml (20 mg/ml)
NP
PA, SP
TREXALL – methotrexate sodium tab 5 mg (base equiv), 7.5 mg
(base equiv), 10 mg (base equiv), 15 mg (base equiv)
P
XATMEP – methotrexate oral soln 2.5 mg/ml
NP
PA
XELODA – capecitabine tab 150 mg, 500 mg
NP
PA, SP
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : ANTINEOPLASTIC -HORMONAL AND RELATED
abiraterone acetate tab 250 mg (Zytiga)
P
QL (120 tablets/30
days), SF, SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
52
Drug Name
Preferred Status Drug Status / Restriction
abiraterone acetate tab 500 mg (Zytiga)
P
QL (60 tablets/30
days), SF, SP
AKEEGA – niraparib tosylate-abiraterone acetate tab 50-500 mg,
100-500 mg
NP
PA, QL (60 tablets/30
days), SF, SP
anastrozole tab 1 mg (Arimidex)
P
90
ARIMIDEX – anastrozole tab 1 mg
NP
PA, 90
AROMASIN – exemestane tab 25 mg
NP
PA, 90
bicalutamide tab 50 mg (Casodex)
P
CASODEX – bicalutamide tab 50 mg
NP
PA, SP
EMCYT – estramustine phosphate sodium cap 140 mg
P
SP
ERLEADA – apalutamide tab 60 mg
NP
PA, QL (120
tablets/30 days), SP
ERLEADA – apalutamide tab 240 mg
NP
PA, QL (30 tablets/30
days), SP
exemestane tab 25 mg (Aromasin)
P
90
FARESTON – toremifene citrate tab 60 mg (base equivalent)
NP
PA, SP
FEMARA – letrozole tab 2.5 mg
NP
PA, 90
letrozole tab 2.5 mg (Femara)
P
90
LYSODREN – mitotane tab 500 mg
P
SP
megestrol acetate susp 40 mg/ml
P
megestrol acetate tab 20 mg, 40 mg
P
nilutamide tab 150 mg (Nilandron)
P
SP
NUBEQA – darolutamide tab 300 mg
NP
PA, QL (120 tablets/30
days), SF, SP
ORGOVYX – relugolix tab 120 mg
NP
PA, QL (30 tablets/30
days), SP
ORSERDU – elacestrant hydrochloride tab 86 mg
P
QL (90 tablets/30 days), SP
ORSERDU – elacestrant hydrochloride tab 345 mg
P
QL (30 tablets/30 days), SP
SOLTAMOX – tamoxifen citrate oral soln 10 mg/5ml (base
equivalent)
P
tamoxifen citrate tab 10 mg (base equivalent), 20 mg (base
equivalent)
P
toremifene citrate tab 60 mg (base equivalent) (Fareston)
P
SP
XTANDI – enzalutamide cap 40 mg
NP
PA, QL (120 capsules/30
days), SF, SP
XTANDI – enzalutamide tab 40 mg
NP
PA, QL (120 tablets/30
days), SF, SP
XTANDI – enzalutamide tab 80 mg
NP
PA, QL (60 tablets/30
days), SF, SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
53
Drug Name
Preferred Status Drug Status / Restriction
YONSA – abiraterone acetate micronized tab 125 mg
NP
PA, QL (120 tablets/30
days), SF, SP
ZYTIGA – abiraterone acetate tab 250 mg
NP
PA, QL (120 tablets/30
days), SF, SP
ZYTIGA – abiraterone acetate tab 500 mg
NP
PA, QL (60 tablets/30
days), SF, SP
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : ANTINEOPLASTIC ENZYME INHIBITORS
AFINITOR – everolimus tab 2.5 mg, 5 mg, 7.5 mg, 10 mg
NP
PA, QL (30 tablets/30
days), SF, SP
AFINITOR DISPERZ – everolimus tab for oral susp 2 mg, 5 mg
NP
PA, QL (60 tablets/30
days), SP
AFINITOR DISPERZ – everolimus tab for oral susp 3 mg
NP
PA, QL (90 tablets/30
days), SP
ALECENSA – alectinib hcl cap 150 mg (base equivalent)
NP
PA, QL (240
capsules/30 days), SP
ALUNBRIG – brigatinib tab initiation therapy pack 90 mg &
180 mg
NP
PA, QL (1 pack/180 days), SP
ALUNBRIG – brigatinib tab 30 mg
NP
PA, QL (120
tablets/30 days), SP
ALUNBRIG – brigatinib tab 90 mg, 180 mg
NP
PA, QL (30 tablets/30
days), SP
AUGTYRO – repotrectinib cap 40 mg
NP
PA, QL (240
capsules/30 days), SP
AYVAKIT – avapritinib tab 25 mg, 50 mg, 100 mg, 200 mg,
300 mg
NP
PA, QL (30 tablets/30
days), SF, SP
BALVERSA – erdafitinib tab 3 mg
NP
PA, QL (84 tablets/28
days), SF, SP
BALVERSA – erdafitinib tab 4 mg
NP
PA, QL (56 tablets/28
days), SF, SP
BALVERSA – erdafitinib tab 5 mg
NP
PA, QL (28 tablets/28
days), SF, SP
BOSULIF – bosutinib cap 50 mg
NP
PA, QL (30 capsules/30
days), SP
BOSULIF – bosutinib cap 100 mg
NP
PA, QL (150
capsules/30 days), SP
BOSULIF – bosutinib tab 100 mg
NP
PA, QL (90 tablets/30
days), SF, SP
BOSULIF – bosutinib tab 400 mg, 500 mg
NP
PA, QL (30 tablets/30
days), SF, SP
BRAFTOVI – encorafenib cap 75 mg
NP
PA, QL (180
capsules/30 days), SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
54
Drug Name
Preferred Status Drug Status / Restriction
BRUKINSA – zanubrutinib cap 80 mg
NP
PA, QL (120
capsules/30 days), SP
CABOMETYX – cabozantinib s-malate tab 20 mg (base
equivalent), 40 mg (base equivalent), 60 mg (base equivalent)
NP
PA, QL (30 tablets/30
days), SF, SP
CALQUENCE – acalabrutinib maleate tab 100 mg
NP
PA, QL (60 tablets/30
days), SF, SP
CAPRELSA – vandetanib tab 100 mg
P
QL (60 tablets/30 days), SP
CAPRELSA – vandetanib tab 300 mg
P
QL (30 tablets/30 days), SP
COMETRIQ – cabozantinib s-malate cap 3 x 20 mg (60 mg dose)
kit
NP
PA, QL (1 carton/28
days), SF, SP
COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg
(100 dose) kit
NP
PA, QL (1 carton/28
days), SF, SP
COMETRIQ – cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg
(140 dose) kit
NP
PA, QL (1 carton/28
days), SF, SP
COPIKTRA – duvelisib cap 15 mg, 25 mg
NP
PA, QL (56 capsules/28
days), SF, SP
COTELLIC – cobimetinib fumarate tab 20 mg (base equivalent)
NP
PA, QL (63 tablets/28
days), SP
erlotinib hcl tab 25 mg (base equivalent) (Tarceva)
P
QL (60 tablets/30
days), SF, SP
erlotinib hcl tab 100 mg (base equivalent), 150 mg (base
equivalent) (Tarceva)
P
QL (30 tablets/30
days), SF, SP
everolimus tab for oral susp 2 mg, 5 mg (Afinitor disperz)
NP
PA, QL (60 tablets/30
days), SP
everolimus tab for oral susp 3 mg (Afinitor disperz)
NP
PA, QL (90 tablets/30
days), SP
everolimus tab 2.5 mg, 5 mg, 7.5 mg, 10 mg (Afinitor)
NP
PA, QL (30 tablets/30
days), SF, SP
EXKIVITY – mobocertinib succinate cap 40 mg
NP
PA, SF, SP
FOTIVDA – tivozanib hcl cap 0.89 mg (base equivalent), 1.34 mg
(base equivalent)
NP
PA, QL (21 capsules/28
days), SP
FRUZAQLA – fruquintinib cap 1 mg
NP
PA, QL (84 capsules/28
days), SP
FRUZAQLA – fruquintinib cap 5 mg
NP
PA, QL (21 capsules/28
days), SP
GAVRETO – pralsetinib cap 100 mg
NP
PA, QL (120 capsules/30
days), SF, SP
gefitinib tab 250 mg (Iressa)
P
QL (30 tablets/30
days), SF, SP
GILOTRIF – afatinib dimaleate tab 20 mg (base equivalent),
30 mg (base equivalent), 40 mg (base equivalent)
NP
PA, QL (30 tablets/30
days), SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
55
Drug Name
Preferred Status Drug Status / Restriction
GLEEVEC – imatinib mesylate tab 100 mg (base equivalent)
NP
PA, QL (90 tablets/30
days), SF, SP
GLEEVEC – imatinib mesylate tab 400 mg (base equivalent)
NP
PA, QL (60 tablets/30
days), SF, SP
IBRANCE – palbociclib cap 75 mg, 100 mg, 125 mg
NP
PA, QL (21 capsules/28
days), SP
IBRANCE – palbociclib tab 75 mg, 100 mg, 125 mg
NP
PA, QL (21 tablets/28
days), SP
ICLUSIG – ponatinib hcl tab 10 mg (base equiv), 15 mg (base
equiv), 30 mg (base equiv), 45 mg (base equiv)
NP
PA, QL (30 tablets/30
days), SF, SP
IDHIFA – enasidenib mesylate tab 50 mg (base equivalent),
100 mg (base equivalent)
NP
PA, QL (30 tablets/30
days), SP
imatinib mesylate tab 100 mg (base equivalent) (Gleevec)
NP
PA, QL (90 tablets/30
days), SF, SP
imatinib mesylate tab 400 mg (base equivalent) (Gleevec)
NP
PA, QL (60 tablets/30
days), SF, SP
IMBRUVICA – ibrutinib tab 140 mg, 280 mg, 420 mg
NP
PA, QL (30 tablets/30
days), SP
IMBRUVICA – ibrutinib oral susp 70 mg/ml
NP
PA, QL (216 mls/30 days), SP
IMBRUVICA – ibrutinib cap 70 mg
NP
PA, QL (30 capsules/30
days), SP
IMBRUVICA – ibrutinib cap 140 mg
NP
PA, QL (90 capsules/30
days), SP
INLYTA – axitinib tab 1 mg
NP
PA, QL (180 tablets/30
days), SF, SP
INLYTA – axitinib tab 5 mg
NP
PA, QL (120 tablets/30
days), SF, SP
INREBIC – fedratinib hcl cap 100 mg
NP
PA, QL (120 capsules/30
days), SF, SP
IRESSA – gefitinib tab 250 mg
P
QL (30 tablets/30
days), SF, SP
JAKAFI – ruxolitinib phosphate tab 5 mg (base equivalent),
10 mg (base equivalent), 15 mg (base equivalent), 20 mg
(base equivalent), 25 mg (base equivalent)
P
QL (60 tablets/30
days), SF, SP
JAYPIRCA – pirtobrutinib tab 50 mg
NP
PA, QL (30 tablets/30
days), SF, SP
JAYPIRCA – pirtobrutinib tab 100 mg
NP
PA, QL (60 tablets/30
days), SF, SP
KISQALI – ribociclib succinate tab pack 200 mg daily dose
NP
PA, QL (21 tablets/28
days), SP
KISQALI – ribociclib succinate tab pack 400 mg daily dose
(200 mg tab)
NP
PA, QL (42 tablets/28
days), SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
56
Drug Name
Preferred Status Drug Status / Restriction
KISQALI – ribociclib succinate tab pack 600 mg daily dose
(200 mg tab)
NP
PA, QL (63 tablets/28
days), SP
KOSELUGO – selumetinib sulfate cap 10 mg
NP
PA, QL (240
capsules/30 days), SP
KOSELUGO – selumetinib sulfate cap 25 mg
NP
PA, QL (120
capsules/30 days), SP
KRAZATI – adagrasib tab 200 mg
NP
PA, QL (180 tablets/30
days), SF, SP
lapatinib ditosylate tab 250 mg (base equiv) (Tykerb)
NP
PA, QL (180
tablets/30 days), SP
LENVIMA 10 MG DAILY DOSE – lenvatinib cap therapy pack
10 mg (10 mg daily dose)
NP
PA, QL (30 capsules/30
days), SF, SP
LENVIMA 12MG DAILY DOSE – lenvatinib cap therapy pack 3 x
4 mg (12 mg daily dose)
NP
PA, QL (90 capsules/30
days), SF, SP
LENVIMA 14 MG DAILY DOSE – lenvatinib cap therapy pack 10
& 4 mg (14 mg daily dose)
NP
PA, QL (60 capsules/30
days), SF, SP
LENVIMA 18 MG DAILY DOSE – lenvatinib cap ther pack 10 mg
& 2 x 4 mg (18 mg daily dose)
NP
PA, QL (90 capsules/30
days), SF, SP
LENVIMA 20 MG DAILY DOSE – lenvatinib cap therapy pack 2 x
10 mg (20 mg daily dose)
NP
PA, QL (60 capsules/30
days), SF, SP
LENVIMA 24 MG DAILY DOSE – lenvatinib cap ther pack 2 x
10 mg & 4 mg (24 mg daily dose)
NP
PA, QL (90 capsules/30
days), SF, SP
LENVIMA 4 MG DAILY DOSE – lenvatinib cap therapy pack
4 mg (4 mg daily dose)
NP
PA, QL (30 capsules/30
days), SF, SP
LENVIMA 8 MG DAILY DOSE – lenvatinib cap therapy pack 2 x
4 mg (8 mg daily dose)
NP
PA, QL (60 capsules/30
days), SF, SP
LORBRENA – lorlatinib tab 25 mg
NP
PA, QL (90 tablets/30
days), SF, SP
LORBRENA – lorlatinib tab 100 mg
NP
PA, QL (30 tablets/30
days), SF, SP
LUMAKRAS – sotorasib tab 120 mg
NP
PA, QL (240 tablets/30
days), SF, SP
LUMAKRAS – sotorasib tab 320 mg
NP
PA, QL (90 tablets/30
days), SF, SP
LYNPARZA – olaparib tab 100 mg, 150 mg
NP
PA, QL (120 tablets/30
days), SF, SP
LYTGOBI – futibatinib tab therapy pack 4 mg (12 mg daily dose)
NP
PA, QL (84 tablets/28
days), SF, SP
LYTGOBI – futibatinib tab therapy pack 4 mg (16 mg daily dose)
NP
PA, QL (112 tablets/28
days), SF, SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
57
Drug Name
Preferred Status Drug Status / Restriction
LYTGOBI – futibatinib tab therapy pack 4 mg (20 mg daily dose)
NP
PA, QL (140 tablets/28
days), SF, SP
MEKINIST – trametinib dimethyl sulfoxide for soln 0.05 mg/ml
(base eq)
NP
PA, QL (1170
mls/28 days), SP
MEKINIST – trametinib dimethyl sulfoxide tab 0.5 mg (base
equivalent)
NP
PA, QL (90 tablets/30
days), SP
MEKINIST – trametinib dimethyl sulfoxide tab 2 mg (base
equivalent)
NP
PA, QL (60 tablets/30
days), SP
MEKTOVI – binimetinib tab 15 mg
NP
PA, QL (180
tablets/30 days), SP
NERLYNX – neratinib maleate tab 40 mg (base equivalent)
NP
PA, QL (180 tablets/30
days), SF, SP
NEXAVAR – sorafenib tosylate tab 200 mg (base equivalent)
P
QL (120 tablets/30
days), SF, SP
NINLARO – ixazomib citrate cap 2.3 mg (base equivalent), 3 mg
(base equivalent), 4 mg (base equivalent)
NP
PA, QL (3 capsules/28
days), SP
OJJAARA – momelotinib dihydrochloride tab 100 mg, 150 mg,
200 mg
NP
PA, QL (30 tablets/30
days), SP
pazopanib hcl tab 200 mg (base equiv) (Votrient)
P
QL (120 tablets/30
days), SF, SP
PEMAZYRE – pemigatinib tab 4.5 mg, 9 mg, 13.5 mg
NP
PA, QL (14 tablets/21
days), SP
PIQRAY 200MG DAILY DOSE – alpelisib tab therapy pack
200 mg daily dose
NP
PA, QL (1 pack/28 days), SP
PIQRAY 250MG DAILY DOSE – alpelisib tab pack 250 mg daily
dose (200 mg & 50 mg tabs)
NP
PA, QL (1 box/28 days), SP
PIQRAY 300MG DAILY DOSE – alpelisib tab pack 300 mg daily
dose (2x150 mg tab)
NP
PA, QL (1 box/28 days), SP
QINLOCK – ripretinib tab 50 mg
NP
PA, QL (90 tablets/30
days), SP
RETEVMO – selpercatinib cap 40 mg
NP
PA, QL (180 capsules/30
days), SF, SP
RETEVMO – selpercatinib cap 80 mg
NP
PA, QL (120 capsules/30
days), SF, SP
REZLIDHIA – olutasidenib cap 150 mg
NP
PA, QL (60 capsules/30
days), SF, SP
ROZLYTREK – entrectinib pellet pack 50 mg
NP
PA, QL (336
packets/28 days), SP
ROZLYTREK – entrectinib cap 100 mg
NP
PA, QL (30 capsules/30
days), SF, SP
ROZLYTREK – entrectinib cap 200 mg
NP
PA, QL (90 capsules/30
days), SF, SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
58
Drug Name
Preferred Status Drug Status / Restriction
RUBRACA – rucaparib camsylate tab 200 mg (base equivalent),
250 mg (base equivalent), 300 mg (base equivalent)
NP
PA, QL (120 tablets/30
days), SF, SP
RYDAPT – midostaurin cap 25 mg
NP
PA, QL (240
capsules/30 days), SP
SCEMBLIX – asciminib hcl tab 20 mg
NP
PA, QL (60 tablets/30
days), SP
SCEMBLIX – asciminib hcl tab 40 mg
NP
PA, QL (300
tablets/30 days), SP
sorafenib tosylate tab 200 mg (base equivalent) (Nexavar)
P
QL (120 tablets/30
days), SF, SP
SPRYCEL – dasatinib tab 20 mg
NP
PA, QL (90 tablets/30
days), SF, SP
SPRYCEL – dasatinib tab 50 mg, 70 mg, 80 mg, 100 mg, 140 mg
NP
PA, QL (30 tablets/30
days), SF, SP
STIVARGA – regorafenib tab 40 mg
NP
PA, QL (84 tablets/28
days), SP
sunitinib malate cap 12.5 mg (base equivalent) (Sutent)
P
QL (90 capsules/30
days), SF, SP
sunitinib malate cap 25 mg (base equivalent), 37.5 mg (base
equivalent), 50 mg (base equivalent) (Sutent)
P
QL (30 capsules/30
days), SF, SP
SUTENT – sunitinib malate cap 12.5 mg (base equivalent)
P
QL (90 capsules/30
days), SF, SP
SUTENT – sunitinib malate cap 25 mg (base equivalent),
37.5 mg (base equivalent), 50 mg (base equivalent)
P
QL (30 capsules/30
days), SF, SP
TABRECTA – capmatinib hcl tab 150 mg, 200 mg
NP
PA, QL (112
tablets/28 days), SP
TAFINLAR – dabrafenib mesylate cap 50 mg (base equivalent),
75 mg (base equivalent)
NP
PA, QL (120
capsules/30 days), SP
TAFINLAR – dabrafenib mesylate tab for oral susp 10 mg (base
equiv)
NP
PA, QL (840
tablets/28 days), SP
TAGRISSO – osimertinib mesylate tab 40 mg (base equivalent),
80 mg (base equivalent)
NP
PA, QL (30 tablets/30
days), SF, SP
TALZENNA – talazoparib tosylate cap 0.25 mg (base equivalent)
NP
PA, QL (90 capsules/30
days), SF, SP
TALZENNA – talazoparib tosylate cap 0.1 mg (base equivalent),
0.35 mg (base equivalent), 0.5 mg (base equivalent), 0.75 mg
(base equivalent), 1 mg (base equivalent)
NP
PA, QL (30 capsules/30
days), SF, SP
TARCEVA – erlotinib hcl tab 25 mg (base equivalent)
NP
PA, QL (60 tablets/30
days), SF, SP
TARCEVA – erlotinib hcl tab 100 mg (base equivalent), 150 mg
(base equivalent)
NP
PA, QL (30 tablets/30
days), SF, SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
59
Drug Name
Preferred Status Drug Status / Restriction
TASIGNA – nilotinib hcl cap 50 mg (base equivalent), 150 mg
(base equivalent), 200 mg (base equivalent)
NP
PA, QL (120 capsules/30
days), SF, SP
TAZVERIK – tazemetostat hbr tab 200 mg
NP
PA, QL (240
tablets/30 days), SP
TEPMETKO – tepotinib hcl tab 225 mg
NP
PA, QL (60 tablets/30
days), SF, SP
TIBSOVO – ivosidenib tab 250 mg
NP
PA, QL (60 tablets/30
days), SP
TRUQAP – capivasertib tab 160 mg, 200 mg
NP
PA, QL (64 tablets/28
days), SP
TUKYSA – tucatinib tab 50 mg
NP
PA, QL (300
tablets/30 days), SP
TUKYSA – tucatinib tab 150 mg
NP
PA, QL (120
tablets/30 days), SP
TURALIO – pexidartinib hcl cap 125 mg (base equivalent)
NP
PA, QL (120
capsules/30 days), SP
TYKERB – lapatinib ditosylate tab 250 mg (base equiv)
NP
PA, QL (180
tablets/30 days), SP
VANFLYTA – quizartinib dihydrochloride tab 17.7 mg
NP
PA, QL (28 tablets/28
days), SP
VANFLYTA – quizartinib dihydrochloride tab 26.5 mg
NP
PA, QL (56 tablets/28
days), SP
VERZENIO – abemaciclib tab 50 mg, 100 mg, 150 mg, 200 mg
NP
PA, QL (60 tablets/30
days), SF, SP
VITRAKVI – larotrectinib sulfate oral soln 20 mg/ml (base
equivalent)
NP
PA, QL (300 mls/30 days), SP
VITRAKVI – larotrectinib sulfate cap 25 mg (base equivalent)
NP
PA, QL (180 capsules/30
days), SF, SP
VITRAKVI – larotrectinib sulfate cap 100 mg (base equivalent)
NP
PA, QL (60 capsules/30
days), SF, SP
VIZIMPRO – dacomitinib tab 15 mg, 30 mg, 45 mg
NP
PA, QL (30 tablets/30
days), SF, SP
VONJO – pacritinib citrate cap 100 mg
NP
PA, QL (120 capsules/30
days), SF, SP
VOTRIENT – pazopanib hcl tab 200 mg (base equiv)
P
QL (120 tablets/30
days), SF, SP
XALKORI – crizotinib cap 200 mg, 250 mg
NP
PA, QL (120 capsules/30
days), SF, SP
XALKORI – crizotinib cap sprinkle 20 mg, 50 mg
NP
PA, QL (120 capsules/30
days), SF, SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
60
Drug Name
Preferred Status Drug Status / Restriction
XALKORI – crizotinib cap sprinkle 150 mg
NP
PA, QL (180 capsules/30
days), SF, SP
XOSPATA – gilteritinib fumarate tablet 40 mg (base equivalent)
NP
PA, QL (90 tablets/30
days), SF, SP
ZEJULA – niraparib tosylate tab 100 mg (base equivalent),
200 mg (base equivalent), 300 mg (base equivalent)
NP
PA, QL (30 tablets/30
days), SP
ZELBORAF – vemurafenib tab 240 mg
NP
PA, QL (240
tablets/30 days), SP
ZOLINZA – vorinostat cap 100 mg
NP
PA, QL (120 capsules/30
days), SF, SP
ZYDELIG – idelalisib tab 100 mg, 150 mg
NP
PA, QL (60 tablets/30
days), SP
ZYKADIA – ceritinib tab 150 mg
NP
PA, QL (90 tablets/30
days), SF, SP
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : CHEMOTHERAPY RESCUE / ANTIDOTE AGENTS
IWILFIN – eflornithine hcl tab 192 mg
NP
PA, QL (240
tablets/30 days), SP
leucovorin calcium tab 5 mg, 10 mg, 15 mg, 25 mg
P
MESNEX – mesna tab 400 mg
P
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : MISC
ACTIMMUNE – interferon gamma-1b inj 100 mcg/0.5ml
(2000000 unit/0.5ml)
SC
PA, QL (12 vials/28 days), SP
bexarotene cap 75 mg (Targretin)
P
SF, SP
DAURISMO – glasdegib maleate tab 25 mg (base equivalent)
NP
PA, QL (60 tablets/30
days), SF, SP
DAURISMO – glasdegib maleate tab 100 mg (base equivalent)
NP
PA, QL (30 tablets/30
days), SF, SP
ERIVEDGE – vismodegib cap 150 mg
P
QL (30 capsules/30
days), SF, SP
HYCAMTIN – topotecan hcl cap 0.25 mg (base equiv), 1 mg
(base equiv)
P
SP
HYDREA – hydroxyurea cap 500 mg
NP
PA
hydroxyurea cap 500 mg (Hydrea)
P
INQOVI – decitabine-cedazuridine tab 35-100 mg
NP
PA, QL (5 tablets/28
days), SP
KISQALI FEMARA 200 DOSE – ribociclib 200 mg dose (200 mg
tab) & letrozole 2.5 mg tbpk
NP
PA, QL (49 tablets/28
days), SP
KISQALI FEMARA 400 DOSE – ribociclib 400 mg dose (200 mg
tab) & letrozole 2.5 mg tbpk
NP
PA, QL (70 tablets/28
days), SP
KISQALI FEMARA 600 DOSE – ribociclib 600 mg dose (200 mg
tab) & letrozole 2.5 mg tbpk
NP
PA, QL (91 tablets/28
days), SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
61
Drug Name
Preferred Status Drug Status / Restriction
LONSURF – trifluridine-tipiracil tab 15-6.14 mg
NP
PA, QL (60 tablets/28
days), SP
LONSURF – trifluridine-tipiracil tab 20-8.19 mg
NP
PA, QL (80 tablets/28
days), SP
LUPRON DEPOT (1-MONTH) – leuprolide acetate for inj kit
3.75 mg, 7.5 mg
SC
PA, SP
LUPRON DEPOT (3-MONTH) – leuprolide acetate (3 month) for
inj kit 11.25 mg, 22.5 mg
SC
PA, SP
LUPRON DEPOT (4-MONTH) – leuprolide acetate (4 month) for
inj kit 30 mg
SC
PA, SP
LUPRON DEPOT (6-MONTH) – leuprolide acetate (6 month) for
inj kit 45 mg
SC
PA, SP
MATULANE – procarbazine hcl cap 50 mg
P
SP
ODOMZO – sonidegib phosphate cap 200 mg (base equivalent)
NP
PA, QL (30 capsules/30
days), SF, SP
POMALYST – pomalidomide cap 1 mg, 2 mg, 3 mg, 4 mg
NP
PA, QL (21 capsules/30
days), SP
TARGRETIN – bexarotene cap 75 mg
NP
PA, SF, SP
tretinoin cap 10 mg
P
SP
VENCLEXTA – venetoclax tab 10 mg
NP
PA, QL (60 tablets/30
days), SP
VENCLEXTA – venetoclax tab 50 mg
NP
PA, QL (30 tablets/30
days), SP
VENCLEXTA – venetoclax tab 100 mg
NP
PA, QL (180
tablets/30 days), SP
VENCLEXTA STARTING PACK – venetoclax tab therapy starter
pack 10 & 50 & 100 mg
NP
PA, QL (1 pack/180 days), SP
XPOVIO – selinexor tab therapy pack 40 mg (40 mg once
weekly), 40 mg (40 mg twice weekly), 40 mg (80 mg once
weekly), 50 mg (100 mg once weekly), 60 mg (60 mg once
weekly)
NP
PA, QL (1 box/28
days), SF, SP
XPOVIO 60 MG TWICE WEEKLY – selinexor tab therapy pack
20 mg (60 mg twice weekly)
NP
PA, QL (24 tablets/28
days), SF, SP
XPOVIO 80 MG TWICE WEEKLY – selinexor tab therapy pack
20 mg (80 mg twice weekly)
NP
PA, QL (32 tablets/28
days), SF, SP
ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES : MITOTIC INHIBITORS
ETOPOSIDE – etoposide cap 50 mg
P
SP
ANTIPARASITICS : ANTHELMINTICS
albendazole tab 200 mg (Albenza)
NP
PA
BENZNIDAZOLE – benznidazole tab 12.5 mg, 100 mg
NP
PA
BILTRICIDE – praziquantel tab 600 mg
NP
PA
EMVERM – mebendazole chew tab 100 mg
NP
PA
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
62
Drug Name
Preferred Status Drug Status / Restriction
ivermectin tab 3 mg (Stromectol)
NP
PA
praziquantel tab 600 mg (Biltricide)
P
STROMECTOL – ivermectin tab 3 mg
NP
PA
ANTIPARASITICS : ANTIMALARIALS
atovaquone-proguanil hcl tab 62.5-25 mg, 250-100 mg
(Malarone)
P
QL (30 tablets/90 days)
chloroquine phosphate tab 250 mg, 500 mg
P
COARTEM – artemether-lumefantrine tab 20-120 mg
NP
PA
DARAPRIM – pyrimethamine tab 25 mg
NP
PA, QL (90 tablets/30 days)
hydroxychloroquine sulfate tab 100 mg, 300 mg, 400 mg
P
hydroxychloroquine sulfate tab 200 mg (Plaquenil)
P
KRINTAFEL – tafenoquine succinate tab 150 mg (base
equivalent)
NP
PA
MALARONE – atovaquone-proguanil hcl tab 62.5-25 mg,
250-100 mg
NP
PA, QL (30 tablets/90 days)
mefloquine hcl tab 250 mg
P
PRIMAQUINE PHOSPHATE – primaquine phosphate tab
26.3 mg (15 mg base)
P
primaquine phosphate tab 26.3 mg (15 mg base) (Primaquine
phosphate)
P
pyrimethamine tab 25 mg (Daraprim)
NP
PA, QL (90 tablets/30 days)
QUALAQUIN – quinine sulfate cap 324 mg
NP
PA
quinine sulfate cap 324 mg (Qualaquin)
NP
PA
ANTIPARKINSON AND RELATED THERAPY AGENTS
amantadine hcl cap 100 mg
P
90
amantadine hcl soln 50 mg/5ml
P
amantadine hcl tab 100 mg
P
90
APOKYN – apomorphine hcl soln cartridge 30 mg/3ml
NP
PA, QL (60 mls/30 days), SP
apomorphine hcl soln cartridge 30 mg/3ml (Apokyn)
NP
PA, QL (60 mls/30 days), SP
AZILECT – rasagiline mesylate tab 0.5 mg (base equiv), 1 mg
(base equiv)
NP
PA
benztropine mesylate tab 0.5 mg, 1 mg, 2 mg
P
90
bromocriptine mesylate cap 5 mg (base equivalent) (Parlodel)
P
90
bromocriptine mesylate tab 2.5 mg (base equivalent) (Parlodel)
P
90
carbidopa & levodopa tab er 25-100 mg, 50-200 mg
P
carbidopa & levodopa tab 10-100 mg, 25-100 mg, 25-250 mg
(Sinemet)
P
carbidopa tab 25 mg (Lodosyn)
P
carbidopa-levodopa-entacapone tabs 12.5-50-200 mg (Stalevo
50)
NP
PA
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
63
Drug Name
Preferred Status Drug Status / Restriction
carbidopa-levodopa-entacapone tabs 18.75-75-200 mg (Stalevo
75)
NP
PA
carbidopa-levodopa-entacapone tabs 25-100-200 mg (Stalevo
100)
NP
PA
carbidopa-levodopa-entacapone tabs 31.25-125-200 mg (Stalevo
125)
NP
PA
carbidopa-levodopa-entacapone tabs 37.5-150-200 mg (Stalevo
150)
NP
PA
carbidopa-levodopa-entacapone tabs 50-200-200 mg (Stalevo
200)
NP
PA
CARBIDOPA/LEVODOPA ODT – carbidopa & levodopa orally
disintegrating tab 10-100 mg, 25-100 mg, 25-250 mg
NP
PA
DHIVY – carbidopa & levodopa tab 25-100 mg
NP
PA
entacapone tab 200 mg (Comtan)
P
90
GOCOVRI – amantadine hcl cap er 24hr 68.5 mg (base
equivalent), 137 mg (base equivalent)
NP
PA, SF, SP
INBRIJA – levodopa inhal powder cap 42 mg
NP
PA, SP
LODOSYN – carbidopa tab 25 mg
NP
PA
MIRAPEX ER – pramipexole dihydrochloride tab er 24hr
0.375 mg, 0.75 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg
NP
PA
NEUPRO – rotigotine td patch 24hr 1 mg/24hr, 2 mg/24hr,
3 mg/24hr, 4 mg/24hr, 6 mg/24hr, 8 mg/24hr
NP
PA
NOURIANZ – istradefylline tab 20 mg, 40 mg
NP
PA, SP
ONGENTYS – opicapone cap 25 mg, 50 mg
NP
PA
OSMOLEX ER – amantadine hcl tab er 24hr 129 mg (base
equivalent), 193 mg (base equivalent)
NP
PA
PARLODEL – bromocriptine mesylate cap 5 mg (base
equivalent)
NP
PA, 90
PARLODEL – bromocriptine mesylate tab 2.5 mg (base
equivalent)
NP
PA, 90
pramipexole dihydrochloride tab er 24hr 0.375 mg, 0.75 mg,
1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg (Mirapex er)
NP
PA
pramipexole dihydrochloride tab 0.125 mg, 0.5 mg, 0.75 mg,
1 mg, 1.5 mg (Mirapex)
P
pramipexole dihydrochloride tab 0.25 mg
P
rasagiline mesylate tab 0.5 mg (base equiv), 1 mg (base equiv)
(Azilect)
NP
PA
ropinirole hydrochloride tab er 24hr 2 mg (base equivalent), 4 mg
(base equivalent), 8 mg (base equivalent)
NP
PA
ropinirole hydrochloride tab er 24hr 6 mg (base equivalent),
12 mg (base equivalent) (Requip xl)
NP
PA
ropinirole hydrochloride tab 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg,
4 mg, 5 mg
P
RYTARY – carbidopa & levodopa cap er 23.75-95 mg,
36.25-145 mg, 48.75-195 mg, 61.25-245 mg
NP
PA
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
64
Drug Name
Preferred Status Drug Status / Restriction
selegiline hcl cap 5 mg
P
selegiline hcl tab 5 mg
P
SINEMET – carbidopa & levodopa tab 10-100 mg, 25-100 mg
NP
PA
STALEVO 150 – carbidopa-levodopa-entacapone tabs
37.5-150-200 mg
NP
PA
TASMAR – tolcapone tab 100 mg
NP
PA, 90
tolcapone tab 100 mg (Tasmar)
NP
PA, 90
TRIHEXYPHENIDYL HCL – trihexyphenidyl hcl oral soln 0.4 mg/
ml
P
trihexyphenidyl hcl tab 2 mg, 5 mg
P
90
XADAGO – safinamide mesylate tab 50 mg (base equiv), 100 mg
(base equiv)
NP
PA
ZELAPAR – selegiline hcl orally disintegrating tab 1.25 mg
NP
PA
ANTIPSYCHOTICS / ANTIMANIC AGENTS : BENZISOXAZOLES
FANAPT – iloperidone tab 1 mg, 2 mg, 4 mg, 6 mg, 8 mg, 10 mg,
12 mg
NP
PA, QL (60 tablets/30
days), 90
FANAPT TITRATION PACK – iloperidone tab 1 mg & 2 mg &
4 mg & 6 mg titration pak
NP
PA, QL (8 tablets/180 days)
INVEGA – paliperidone tab er 24hr 3 mg, 9 mg
NP
PA, QL (30 tablets/30
days), 90
INVEGA – paliperidone tab er 24hr 6 mg
NP
PA, QL (60 tablets/30
days), 90
INVEGA HAFYERA – paliperidone palmitate er susp pref syr
1,092 mg/3.5ml, 1,560 mg/5ml
P
QL (1 syringe/180 days), ST
INVEGA SUSTENNA – paliperidone palmitate er susp pref
syr 39 mg/0.25ml, 78 mg/0.5ml, 117 mg/0.75ml, 156 mg/ml,
234 mg/1.5ml
P
QL (1 kit/28 days), ST
INVEGA TRINZA – paliperidone palmitate er susp pref
syr 273 mg/0.88ml, 410 mg/1.32ml, 546 mg/1.75ml,
819 mg/2.63ml
P
QL (1 syringe/84 days), ST
paliperidone tab er 24hr 1.5 mg, 3 mg, 9 mg (Invega)
NP
PA, QL (30 tablets/30
days), 90
paliperidone tab er 24hr 6 mg (Invega)
NP
PA, QL (60 tablets/30
days), 90
PERSERIS – risperidone subcutaneous for er susp prefilled syr
90 mg, 120 mg
P
QL (1 syringe/28 days), ST
RISPERDAL – risperidone soln 1 mg/ml
NP
PA, QL (480 mls/30 days), 90
RISPERDAL – risperidone tab 0.5 mg, 1 mg, 2 mg, 4 mg
NP
PA, QL (120
tablets/30 days), 90
RISPERDAL – risperidone tab 3 mg
NP
PA, QL (60 tablets/30
days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
65
Drug Name
Preferred Status Drug Status / Restriction
RISPERDAL CONSTA – risperidone microspheres for im
extended rel susp 12.5 mg, 25 mg, 37.5 mg, 50 mg
NP
PA, QL (2 vials/28 days), ST
risperidone microspheres for im extended rel susp 12.5 mg,
25 mg, 37.5 mg, 50 mg (Risperdal consta)
NP
PA, QL (2 vials/28 days), ST
RISPERIDONE ODT – risperidone orally disintegrating tab
0.25 mg
NP
PA, QL (60 tablets/30
days), 90
risperidone orally disintegrating tab 0.5 mg, 1 mg, 2 mg, 3 mg
NP
PA, QL (60 tablets/30
days), 90
risperidone orally disintegrating tab 4 mg
NP
PA, QL (120
tablets/30 days), 90
risperidone soln 1 mg/ml (Risperdal)
P
QL (480 mls/30 days), 90
risperidone tab 0.25 mg
P
QL (120 tablets/30 days), 90
risperidone tab 0.5 mg, 1 mg, 2 mg, 4 mg (Risperdal)
P
QL (120 tablets/30 days), 90
risperidone tab 3 mg (Risperdal)
P
QL (60 tablets/30 days), 90
RYKINDO – risperidone for im extended release suspension
25 mg, 37.5 mg, 50 mg
NP
PA, QL (2 vials/28 days), ST
UZEDY – risperidone subcutaneous er susp pref syr
50 mg/0.14ml, 75 mg/0.21ml, 100 mg/0.28ml, 125 mg/0.35ml
P
QL (1 syringe/28 days), ST
UZEDY – risperidone subcutaneous er susp pref syr
150 mg/0.42ml, 200 mg/0.56ml, 250 mg/0.7ml
P
QL (1 syringe/56 days), ST
ANTIPSYCHOTICS / ANTIMANIC AGENTS : DIBENZAPINES
ADASUVE – loxapine aerosol powder breath activated 10 mg
NP
PA
asenapine maleate sl tab 2.5 mg (base equiv), 5 mg (base
equiv), 10 mg (base equiv) (Saphris)
NP
PA, QL (60 tablets/30
days), 90
CLOZAPINE ODT – clozapine orally disintegrating tab 12.5 mg
NP
PA, QL (60 tablets/30 days)
clozapine orally disintegrating tab 25 mg, 100 mg, 150 mg
NP
PA, QL (60 tablets/30 days)
clozapine orally disintegrating tab 200 mg
NP
PA, QL (120 tablets/30 days)
clozapine tab 25 mg, 50 mg (Clozaril)
P
QL (90 tablets/30 days)
clozapine tab 100 mg (Clozaril)
P
QL (270 tablets/30 days)
clozapine tab 200 mg (Clozaril)
P
QL (120 tablets/30 days)
CLOZARIL – clozapine tab 25 mg, 50 mg
NP
PA, QL (90 tablets/30 days)
CLOZARIL – clozapine tab 100 mg
NP
PA, QL (270 tablets/30 days)
CLOZARIL – clozapine tab 200 mg
NP
PA, QL (120 tablets/30 days)
loxapine succinate cap 5 mg, 10 mg, 25 mg, 50 mg
P
90
olanzapine for im inj 10 mg (Zyprexa)
NP
PA, QL (90 vials/30 days)
olanzapine orally disintegrating tab 5 mg, 10 mg, 15 mg, 20 mg
(Zyprexa zydis)
P
QL (30 tablets/30 days), 90
olanzapine tab 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg
(Zyprexa)
P
QL (30 tablets/30 days), 90
QUETIAPINE FUMARATE – quetiapine fumarate tab 150 mg
P
QL (30 tablets/30 days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
66
Drug Name
Preferred Status Drug Status / Restriction
quetiapine fumarate tab er 24hr 50 mg, 300 mg, 400 mg
(Seroquel xr)
P
QL (60 tablets/30 days), 90
quetiapine fumarate tab er 24hr 150 mg, 200 mg (Seroquel xr)
P
QL (30 tablets/30 days), 90
quetiapine fumarate tab 25 mg, 50 mg, 100 mg, 200 mg
(Seroquel)
P
QL (90 tablets/30 days), 90
quetiapine fumarate tab 300 mg, 400 mg (Seroquel)
P
QL (60 tablets/30 days), 90
SAPHRIS – asenapine maleate sl tab 2.5 mg (base equiv), 5 mg
(base equiv), 10 mg (base equiv)
NP
PA, QL (60 tablets/30
days), 90
SECUADO – asenapine td patch 24 hr 3.8 mg/24hr, 5.7 mg/24hr,
7.6 mg/24hr
NP
PA, QL (30 patches/30 days)
SEROQUEL – quetiapine fumarate tab 25 mg, 50 mg, 100 mg,
200 mg
NP
PA, QL (90 tablets/30
days), 90
SEROQUEL – quetiapine fumarate tab 300 mg, 400 mg
NP
PA, QL (60 tablets/30
days), 90
SEROQUEL XR – quetiapine fumarate tab er 24hr 50 mg,
300 mg, 400 mg
NP
PA, QL (60 tablets/30
days), 90
SEROQUEL XR – quetiapine fumarate tab er 24hr 150 mg,
200 mg
NP
PA, QL (30 tablets/30
days), 90
VERSACLOZ – clozapine susp 50 mg/ml
NP
PA, QL (540 mls/30 days)
ZYPREXA – olanzapine tab 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg,
20 mg
NP
PA, QL (30 tablets/30
days), 90
ZYPREXA – olanzapine for im inj 10 mg
NP
PA, QL (90 vials/30 days)
ZYPREXA RELPREVV – olanzapine pamoate for extended rel im
susp 210 mg (base eq), 300 mg (base eq)
NP
PA, QL (2 vials/28 days)
ZYPREXA RELPREVV – olanzapine pamoate for extended rel im
susp 405 mg (base eq)
NP
PA, QL (1 vial/28 days)
ZYPREXA ZYDIS – olanzapine orally disintegrating tab 5 mg,
10 mg, 15 mg, 20 mg
NP
PA, QL (30 tablets/30
days), 90
ANTIPSYCHOTICS / ANTIMANIC AGENTS : MISC
CAPLYTA – lumateperone tosylate cap 10.5 mg, 21 mg, 42 mg
NP
PA, QL (30 capsules/30 days)
chlorpromazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg, 200 mg
P
90
CHLORPROMAZINE HYDROCHLORIDE – chlorpromazine hcl
conc 30 mg/ml, 100 mg/ml
P
90
EQUETRO – carbamazepine (mood) cap er 12hr 100 mg,
200 mg, 300 mg
NP
PA, 90
FLUPHENAZINE HCL – fluphenazine hcl oral conc 5 mg/ml
P
90
fluphenazine hcl tab 1 mg, 2.5 mg, 5 mg, 10 mg
P
90
FLUPHENAZINE HYDROCHLORIDE – fluphenazine hcl elixir
2.5 mg/5ml
P
90
GEODON – ziprasidone hcl cap 20 mg, 40 mg, 60 mg, 80 mg
NP
PA, QL (60 capsules/30
days), 90
GEODON – ziprasidone mesylate for inj 20 mg (base equivalent)
NP
PA, QL (60 vials/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
67
Drug Name
Preferred Status Drug Status / Restriction
haloperidol lactate oral conc 2 mg/ml
P
90
haloperidol tab 0.5 mg, 1 mg, 2 mg, 5 mg, 10 mg, 20 mg
P
90
LATUDA – lurasidone hcl tab 20 mg, 40 mg, 60 mg, 120 mg
NP
PA, QL (30 tablets/30
days), 90
LATUDA – lurasidone hcl tab 80 mg
NP
PA, QL (60 tablets/30
days), 90
LITHIUM CARBONATE – lithium carbonate cap 150 mg, 300 mg,
600 mg
P
90
lithium carbonate cap 150 mg, 600 mg (Lithium carbonate)
P
90
lithium carbonate cap 300 mg
P
90
lithium carbonate tab er 300 mg (Lithobid)
P
90
lithium carbonate tab er 450 mg
P
90
lithium carbonate tab 300 mg
P
90
lithium oral solution 8 meq/5ml
P
90
LITHOBID – lithium carbonate tab er 300 mg
NP
PA, 90
lurasidone hcl tab 20 mg, 40 mg, 60 mg, 120 mg (Latuda)
P
QL (30 tablets/30 days), 90
lurasidone hcl tab 80 mg (Latuda)
P
QL (60 tablets/30 days), 90
MOLINDONE HYDROCHLORIDE – molindone hcl tab 5 mg,
10 mg, 25 mg
NP
PA, 90
NUPLAZID – pimavanserin tartrate cap 34 mg (base equivalent)
NP
PA, QL (30 capsules/30 days)
NUPLAZID – pimavanserin tartrate tab 10 mg (base equivalent)
NP
PA, QL (30 tablets/30 days)
perphenazine tab 2 mg, 4 mg, 8 mg, 16 mg
P
90
prochlorperazine maleate tab 5 mg (base equivalent), 10 mg
(base equivalent)
P
90
prochlorperazine suppos 25 mg
P
thioridazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg
P
90
thiothixene cap 1 mg, 2 mg, 5 mg, 10 mg
P
90
trifluoperazine hcl tab 1 mg (base equivalent), 2 mg (base
equivalent), 5 mg (base equivalent), 10 mg (base equivalent)
P
90
VRAYLAR – cariprazine hcl cap therapy pack 1.5 mg (1) & 3 mg
(6)
NP
PA, QL (1 pack/180 days)
VRAYLAR – cariprazine hcl cap 1.5 mg (base equivalent), 3 mg
(base equivalent), 4.5 mg (base equivalent), 6 mg (base
equivalent)
NP
PA, QL (30 capsules/30
days), 90
ziprasidone hcl cap 20 mg, 40 mg, 60 mg, 80 mg (Geodon)
P
QL (60 capsules/30 days), 90
ziprasidone mesylate for inj 20 mg (base equivalent) (Geodon)
NP
PA, QL (60 vials/30 days)
ANTIPSYCHOTICS / ANTIMANIC AGENTS : QUINOLINONE DERIVATIVES
ABILIFY – aripiprazole tab 2 mg, 5 mg, 10 mg, 15 mg, 20 mg,
30 mg
NP
PA, QL (30 tablets/30
days), 90
ABILIFY ASIMTUFII – aripiprazole im er susp prefilled syringe
720 mg/2.4ml, 960 mg/3.2ml
P
QL (1 syringe/56 days), ST
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
68
Drug Name
Preferred Status Drug Status / Restriction
ABILIFY MAINTENA – aripiprazole im for extended release susp
300 mg, 400 mg
P
QL (1 syringe/28 days), ST
ABILIFY MAINTENA – aripiprazole im for er susp prefilled
syringe 300 mg, 400 mg
P
QL (1 syringe/28 days), ST
ABILIFY MYCITE MAINTENANCE KIT – aripiprazole tab 2 mg
with sensor&strips (for pod) maint pak
NP
PA, QL (30 tablets/30 days)
ABILIFY MYCITE MAINTENANCE KIT – aripiprazole tab 5 mg
with sensor&strips (for pod) maint pak
NP
PA, QL (30 tablets/30 days)
ABILIFY MYCITE MAINTENANCE KIT – aripiprazole tab 10 mg
with sensor&strips(for pod) maint pak
NP
PA, QL (30 tablets/30 days)
ABILIFY MYCITE MAINTENANCE KIT – aripiprazole tab 15 mg
with sensor&strips(for pod) maint pak
NP
PA, QL (30 tablets/30 days)
ABILIFY MYCITE MAINTENANCE KIT – aripiprazole tab 20 mg
with sensor&strips(for pod) maint pak
NP
PA, QL (30 tablets/30 days)
ABILIFY MYCITE MAINTENANCE KIT – aripiprazole tab 30 mg
with sensor&strips(for pod) maint pak
NP
PA, QL (30 tablets/30 days)
ABILIFY MYCITE STARTER KIT – aripiprazole tab 2 mg with
sensor, strips & pod starter pak
NP
PA, QL (30 tablets/30 days)
ABILIFY MYCITE STARTER KIT – aripiprazole tab 5 mg with
sensor, strips & pod starter pak
NP
PA, QL (30 tablets/30 days)
ABILIFY MYCITE STARTER KIT – aripiprazole tab 10 mg with
sensor, strips & pod starter pak
NP
PA, QL (30 tablets/30 days)
ABILIFY MYCITE STARTER KIT – aripiprazole tab 15 mg with
sensor, strips & pod starter pak
NP
PA, QL (30 tablets/30 days)
ABILIFY MYCITE STARTER KIT – aripiprazole tab 20 mg with
sensor, strips & pod starter pak
NP
PA, QL (30 tablets/30 days)
ABILIFY MYCITE STARTER KIT – aripiprazole tab 30 mg with
sensor, strips & pod starter pak
NP
PA, QL (30 tablets/30 days)
aripiprazole oral solution 1 mg/ml
NP
PA, QL (150 mls/30 days), 90
aripiprazole orally disintegrating tab 10 mg, 15 mg
NP
PA, QL (30 tablets/30
days), 90
aripiprazole tab 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg
(Abilify)
P
QL (30 tablets/30 days), 90
ARISTADA – aripiprazole lauroxil im er susp prefilled syr
441 mg/1.6ml, 662 mg/2.4ml, 882 mg/3.2ml
P
QL (1 syringe/28 days), ST
ARISTADA – aripiprazole lauroxil im er susp prefilled syr
1064 mg/3.9ml
P
QL (1 syringe/56 days), ST
ARISTADA INITIO – aripiprazole lauroxil im er susp prefilled syr
675 mg/2.4ml
P
QL (1 kit/180 days), ST
REXULTI – brexpiprazole tab 0.25 mg, 0.5 mg, 1 mg, 2 mg,
3 mg, 4 mg
NP
PA, QL (30 tablets/30
days), 90
ANTIVIRALS : ANTIRETROVIRALS (HIV)
abacavir sulfate soln 20 mg/ml (base equiv) (Ziagen)
P
QL (960 mls/30 days)
abacavir sulfate tab 300 mg (base equiv) (Ziagen)
P
QL (60 tablets/30 days)
abacavir sulfate-lamivudine tab 600-300 mg (Epzicom)
P
QL (30 tablets/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
69
Drug Name
Preferred Status Drug Status / Restriction
APRETUDE – cabotegravir im extended release susp
600 mg/3ml
P
APTIVUS – tipranavir cap 250 mg
P
QL (120 capsules/30 days)
atazanavir sulfate cap 150 mg (base equiv), 300 mg (base equiv)
(Reyataz)
P
QL (30 capsules/30 days)
atazanavir sulfate cap 200 mg (base equiv) (Reyataz)
P
QL (60 capsules/30 days)
BIKTARVY – bictegravir-emtricitabine-tenofovir af tab
30-120-15 mg, 50-200-25 mg
P
QL (30 tablets/30 days)
CABENUVA – cabotegravir 400 mg/2ml & rilpivirine 600 mg/2ml
im susp er
P
QL (1 kit/28 days)
CABENUVA – cabotegravir 600 mg/3ml & rilpivirine 900 mg/3ml
im susp er
P
QL (1 kit/28 days)
CIMDUO – lamivudine-tenofovir disoproxil fumarate tab
300-300 mg
NP
PA, QL (30 tablets/30 days)
COMPLERA – emtricitabine-rilpivirine-tenofovir df tab
200-25-300 mg
P
QL (30 tablets/30 days)
darunavir tab 600 mg (Prezista)
P
QL (60 tablets/30 days)
darunavir tab 800 mg (Prezista)
P
QL (30 tablets/30 days)
DELSTRIGO – doravirine-lamivudine-tenofovir df tab
100-300-300 mg
P
QL (30 tablets/30 days)
DESCOVY – emtricitabine-tenofovir alafenamide fumarate tab
120-15 mg, 200-25 mg
P
QL (30 tablets/30 days)
DOVATO – dolutegravir sodium-lamivudine tab 50-300 mg (base
eq)
P
QL (30 tablets/30 days)
EDURANT – rilpivirine hcl tab 25 mg (base equivalent)
P
QL (30 tablets/30 days)
EFAVIRENZ – efavirenz cap 50 mg
P
QL (90 tablets/30 days)
EFAVIRENZ – efavirenz cap 200 mg
P
QL (60 tablets/30 days)
efavirenz tab 600 mg (Sustiva)
P
QL (30 tablets/30 days)
efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg (Atripla)
P
QL (30 tablets/30 days)
efavirenz-lamivudine-tenofovir df tab 400-300-300 mg (Symfi lo)
NP
PA, QL (30 tablets/30 days)
efavirenz-lamivudine-tenofovir df tab 600-300-300 mg (Symfi)
NP
PA, QL (30 tablets/30 days)
emtricitabine caps 200 mg (Emtriva)
P
QL (30 capsules/30 days)
emtricitabine-tenofovir disoproxil fumarate tab 100-150 mg,
133-200 mg, 167-250 mg, 200-300 mg (Truvada)
P
QL (30 tablets/30 days)
EMTRIVA – emtricitabine caps 200 mg
P
QL (30 capsules/30 days)
EMTRIVA – emtricitabine soln 10 mg/ml
P
QL (720 mls/30 days)
EPIVIR – lamivudine oral soln 10 mg/ml
NP
PA, QL (960 mls/30 days)
EPIVIR – lamivudine tab 150 mg
NP
PA, QL (60 tablets/30 days)
EPIVIR – lamivudine tab 300 mg
NP
PA, QL (30 tablets/30 days)
etravirine tab 100 mg, 200 mg (Intelence)
P
QL (60 tablets/30 days)
EVOTAZ – atazanavir sulfate-cobicistat tab 300-150 mg (base
equiv)
NP
PA, QL (30 tablets/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
70
Drug Name
Preferred Status Drug Status / Restriction
fosamprenavir calcium tab 700 mg (base equiv) (Lexiva)
P
QL (120 tablets/30 days)
FUZEON – enfuvirtide for inj 90 mg
NP
PA, QL (1 kit/30 days)
GENVOYA – elvitegrav-cobic-emtricitab-tenofov af tab
150-150-200-10 mg
P
QL (30 tablets/30 days)
INTELENCE – etravirine tab 25 mg
P
QL (120 tablets/30 days)
INTELENCE – etravirine tab 100 mg, 200 mg
P
QL (60 tablets/30 days)
ISENTRESS – raltegravir potassium chew tab 25 mg (base
equiv), 100 mg (base equiv)
P
QL (180 tablets/30 days)
ISENTRESS – raltegravir potassium packet for susp 100 mg
(base equiv)
P
QL (60 packets/30 days)
ISENTRESS – raltegravir potassium tab 400 mg (base equiv)
P
QL (60 tablets/30 days)
ISENTRESS HD – raltegravir potassium tab 600 mg (base equiv)
P
QL (60 tablets/30 days)
JULUCA – dolutegravir sodium-rilpivirine hcl tab 50-25 mg (base
eq)
NP
PA, QL (30 tablets/30 days)
KALETRA – lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/
ml)
NP
PA, QL (480 mls/30 days)
KALETRA – lopinavir-ritonavir tab 100-25 mg
P
QL (180 tablets/30 days)
KALETRA – lopinavir-ritonavir tab 200-50 mg
P
QL (120 tablets/30 days)
lamivudine oral soln 10 mg/ml (Epivir)
P
QL (4 bottles/30 days)
lamivudine tab 150 mg (Epivir)
P
QL (60 tablets/30 days)
lamivudine tab 300 mg (Epivir)
P
QL (30 tablets/30 days)
lamivudine-zidovudine tab 150-300 mg (Combivir)
P
QL (60 tablets/30 days)
lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) (Kaletra)
P
QL (480 mls/30 days)
lopinavir-ritonavir tab 100-25 mg (Kaletra)
P
QL (180 tablets/30 days)
lopinavir-ritonavir tab 200-50 mg (Kaletra)
P
QL (120 tablets/30 days)
maraviroc tab 150 mg (Selzentry)
NP
PA, QL (60 tablets/30 days)
maraviroc tab 300 mg (Selzentry)
NP
PA, QL (120 tablets/30 days)
NEVIRAPINE – nevirapine susp 50 mg/5ml
P
QL (5 bottles/30 days)
nevirapine tab er 24hr 400 mg (Viramune xr)
P
QL (30 tablets/30 days)
nevirapine tab 200 mg (Viramune)
P
QL (60 tablets/30 days)
NORVIR – ritonavir tab 100 mg
P
QL (180 tablets/30 days)
NORVIR – ritonavir powder packet 100 mg
P
QL (180 packets/30 days)
ODEFSEY – emtricitabine-rilpivirine-tenofovir af tab
200-25-25 mg
P
QL (30 tablets/30 days)
PIFELTRO – doravirine tab 100 mg
NP
PA, QL (30 tablets/30 days)
PREZCOBIX – darunavir-cobicistat tab 800-150 mg
NP
PA, QL (30 tablets/30 days)
PREZISTA – darunavir oral susp 100 mg/ml
P
QL (2 bottles/30 days)
PREZISTA – darunavir tab 75 mg
P
QL (300 tablets/30 days)
PREZISTA – darunavir tab 150 mg
P
QL (180 tablets/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
71
Drug Name
Preferred Status Drug Status / Restriction
PREZISTA – darunavir tab 600 mg
P
QL (60 tablets/30 days)
PREZISTA – darunavir tab 800 mg
P
QL (30 tablets/30 days)
RETROVIR – zidovudine cap 100 mg
NP
PA, QL (180
capsules/30 days)
RETROVIR – zidovudine syrup 10 mg/ml
NP
PA, QL (1920 mls/30 days)
REYATAZ – atazanavir sulfate oral powder packet 50 mg (base
equiv)
P
QL (240 packets/30 days)
REYATAZ – atazanavir sulfate cap 200 mg (base equiv)
P
QL (60 capsules/30 days)
REYATAZ – atazanavir sulfate cap 300 mg (base equiv)
P
QL (30 capsules/30 days)
ritonavir tab 100 mg (Norvir)
P
QL (180 tablets/30 days)
RUKOBIA – fostemsavir tromethamine tab er 12hr 600 mg
NP
PA, QL (60 tablets/30 days)
SELZENTRY – maraviroc oral soln 20 mg/ml
NP
PA, QL (8 bottles/30 days)
SELZENTRY – maraviroc tab 150 mg
NP
PA, QL (60 tablets/30 days)
SELZENTRY – maraviroc tab 300 mg
NP
PA, QL (120 tablets/30 days)
STRIBILD – elvitegrav-cobic-emtricitab-tenofovdf tab
150-150-200-300 mg
NP
PA, QL (30 tablets/30 days)
SUNLENCA – lenacapavir sodium subcutaneous soln
463.5 mg/1.5ml
P
QL (2 vials/180 days)
SUNLENCA – lenacapavir sodium tab therapy pack 4 x 300 mg
P
QL (4 tablets/365 days)
SUNLENCA – lenacapavir sodium tab therapy pack 5 x 300 mg
P
QL (5 tablets/365 days)
SYMFI – efavirenz-lamivudine-tenofovir df tab 600-300-300 mg
P
QL (30 tablets/30 days)
SYMFI LO – efavirenz-lamivudine-tenofovir df tab
400-300-300 mg
P
QL (30 tablets/30 days)
SYMTUZA – darunavir-cobic-emtricitab-tenofov af tab
800-150-200-10 mg
P
QL (30 tablets/30 days)
tenofovir disoproxil fumarate tab 300 mg (Viread)
P
QL (30 tablets/30 days)
TIVICAY – dolutegravir sodium tab 50 mg (base equiv)
P
QL (60 tablets/30 days)
TIVICAY PD – dolutegravir sodium tab for oral susp 5 mg (base
equiv)
P
QL (360 tablets/30 days)
TRIUMEQ – abacavir-dolutegravir-lamivudine tab 600-50-300 mg
P
QL (30 tablets/30 days)
TRIUMEQ PD – abacavir-dolutegravir-lamivudine tab for oral sus
60-5-30 mg
P
QL (180 tablets/30 days)
TROGARZO – ibalizumab-uiyk iv soln 200 mg/1.33ml (150 mg/
ml)
P
PA
TRUVADA – emtricitabine-tenofovir disoproxil fumarate tab
100-150 mg, 133-200 mg, 167-250 mg, 200-300 mg
P
QL (30 tablets/30 days)
TYBOST – cobicistat tab 150 mg
NP
PA, QL (30 tablets/30 days)
VIRACEPT – nelfinavir mesylate tab 250 mg
P
QL (270 tablets/30 days)
VIRACEPT – nelfinavir mesylate tab 625 mg
P
QL (120 tablets/30 days)
VIREAD – tenofovir disoproxil fumarate tab 150 mg, 200 mg,
250 mg, 300 mg
P
QL (30 tablets/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
72
Drug Name
Preferred Status Drug Status / Restriction
VIREAD – tenofovir disoproxil fumarate oral powder 40 mg/gm
P
QL (4 bottles/30 days)
ZIAGEN – abacavir sulfate soln 20 mg/ml (base equiv)
P
QL (4 bottles/30 days)
zidovudine cap 100 mg (Retrovir)
P
QL (180 capsules/30 days)
zidovudine syrup 10 mg/ml (Retrovir)
P
QL (8 bottles/30 days)
zidovudine tab 300 mg
P
QL (60 tablets/30 days)
ANTIVIRALS : HEPATITIS B AGENTS
adefovir dipivoxil tab 10 mg (Hepsera)
NP
PA
BARACLUDE – entecavir tab 0.5 mg, 1 mg
NP
PA
BARACLUDE – entecavir oral soln 0.05 mg/ml
NP
PA
entecavir tab 0.5 mg, 1 mg (Baraclude)
P
lamivudine tab 100 mg (hbv) (Epivir hbv)
NP
PA
VEMLIDY – tenofovir alafenamide fumarate tab 25 mg
NP
PA
ANTIVIRALS : HEPATITIS C AGENTS
EPCLUSA – sofosbuvir-velpatasvir pellet pack 150-37.5 mg,
200-50 mg
NP
PA, QL (28 packets/28
days), SP
EPCLUSA – sofosbuvir-velpatasvir tab 200-50 mg
NP
PA, QL (28 tablets/28
days), SP
EPCLUSA – sofosbuvir-velpatasvir tab 400-100 mg
NP
PA, QL (30 tablets/30
days), SP
HARVONI – ledipasvir-sofosbuvir pellet pack 33.75-150 mg,
45-200 mg
NP
PA, QL (28 packets/28
days), SP
HARVONI – ledipasvir-sofosbuvir tab 45-200 mg
NP
PA, QL (28 tablets/28
days), SP
HARVONI – ledipasvir-sofosbuvir tab 90-400 mg
NP
PA, QL (30 tablets/30
days), SP
LEDIPASVIR/SOFOSBUVIR – ledipasvir-sofosbuvir tab
90-400 mg
NP
PA, QL (30 tablets/30
days), SP
MAVYRET – glecaprevir-pibrentasvir tab 100-40 mg
P
QL (90 tablets/30 days), SP
MAVYRET – glecaprevir-pibrentasvir pellet pack 50-20 mg
P
QL (140 packets/28 days), SP
PEGASYS – peginterferon alfa-2a soln prefilled syr
180 mcg/0.5ml
NP
PA, SP
PEGASYS – peginterferon alfa-2a inj 180 mcg/ml
NP
PA, SP
RIBAVIRIN – ribavirin cap 200 mg
P
SP
RIBAVIRIN – ribavirin tab 200 mg
P
SP
SOFOSBUVIR/VELPATASVIR – sofosbuvir-velpatasvir tab
400-100 mg
P
QL (30 tablets/30 days), SP
SOVALDI – sofosbuvir tab 200 mg, 400 mg
NP
PA, QL (30 tablets/30
days), SP
SOVALDI – sofosbuvir pellet pack 150 mg, 200 mg
NP
PA, QL (28 packets/28
days), SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
73
Drug Name
Preferred Status Drug Status / Restriction
VOSEVI – sofosbuvir-velpatasvir-voxilaprevir tab
400-100-100 mg
NP
PA, QL (30 tablets/30
days), SP
ZEPATIER – elbasvir-grazoprevir tab 50-100 mg
NP
PA, QL (30 tablets/30
days), SP
ANTIVIRALS : MISC
acyclovir cap 200 mg
P
acyclovir susp 200 mg/5ml (Zovirax)
P
acyclovir tab 400 mg, 800 mg
P
famciclovir tab 125 mg, 250 mg, 500 mg
NP
PA
LAGEVRIO – molnupiravir cap 200 mg
P
QL (40 capsules/90 days)
LIVTENCITY – maribavir tab 200 mg
P
PA, QL (120
tablets/30 days), SP
oseltamivir phosphate cap 30 mg (base equiv), 45 mg (base
equiv), 75 mg (base equiv) (Tamiflu)
P
QL (20 capsules/120 days)
oseltamivir phosphate for susp 6 mg/ml (base equiv) (Tamiflu)
P
QL (300 mls/120 days)
PAXLOVID – nirmatrelvir tab 10 x 150 mg & ritonavir tab 10 x
100 mg pak
P
QL (20 tablets/90 days)
PAXLOVID – nirmatrelvir tab 20 x 150 mg & ritonavir tab 10 x
100 mg pak
P
QL (30 tablets/90 days)
PREVYMIS – letermovir tab 240 mg, 480 mg
P
PA, QL (200 tablets/365 days)
RELENZA DISKHALER – zanamivir aerosol powder breath
activated 5 mg/act
P
QL (40 blisters/120 days)
ribavirin for inhal soln 6 gm (Virazole)
P
RIMANTADINE HYDROCHLORIDE – rimantadine hydrochloride
tab 100 mg
NP
PA
SITAVIG – acyclovir buccal tab 50 mg
NP
PA
TAMIFLU – oseltamivir phosphate cap 30 mg (base equiv),
45 mg (base equiv), 75 mg (base equiv)
NP
PA, QL (20
capsules/120 days)
TAMIFLU – oseltamivir phosphate for susp 6 mg/ml (base equiv)
NP
PA, QL (300 mls/120 days)
valacyclovir hcl tab 500 mg, 1 gm (Valtrex)
P
VALCYTE – valganciclovir hcl tab 450 mg (base equivalent)
NP
PA
VALCYTE – valganciclovir hcl for soln 50 mg/ml (base equiv)
NP
PA
valganciclovir hcl for soln 50 mg/ml (base equiv) (Valcyte)
NP
PA
valganciclovir hcl tab 450 mg (base equivalent) (Valcyte)
P
VALTREX – valacyclovir hcl tab 500 mg, 1 gm
NP
PA
VIRAZOLE – ribavirin for inhal soln 6 gm
NP
PA
XOFLUZA – baloxavir marboxil tab therapy pack 1 x 40 mg
(40 mg dose), 1 x 80 mg (80 mg dose)
NP
PA, QL (2 tablets/120 days)
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ACE INHIBITOR COMBINATIONS
ACCURETIC – quinapril-hydrochlorothiazide tab 10-12.5 mg,
20-12.5 mg
NP
PA, 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
74
Drug Name
Preferred Status Drug Status / Restriction
amlodipine besylate-benazepril hcl cap 2.5-10 mg, 5-40 mg
P
90
amlodipine besylate-benazepril hcl cap 5-10 mg, 5-20 mg,
10-20 mg, 10-40 mg (Lotrel)
P
90
benazepril & hydrochlorothiazide tab 5-6.25 mg
P
90
benazepril & hydrochlorothiazide tab 10-12.5 mg, 20-12.5 mg,
20-25 mg (Lotensin hct)
P
90
CAPTOPRIL/HYDROCHLOROTHIAZIDE – captopril &
hydrochlorothiazide tab 25-15 mg, 25-25 mg, 50-15 mg,
50-25 mg
P
90
enalapril maleate & hydrochlorothiazide tab 5-12.5 mg
P
90
enalapril maleate & hydrochlorothiazide tab 10-25 mg (Vaseretic)
P
90
fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg,
20-12.5 mg
P
90
lisinopril & hydrochlorothiazide tab 10-12.5 mg, 20-12.5 mg,
20-25 mg (Zestoretic)
P
90
LOTENSIN HCT – benazepril & hydrochlorothiazide tab
10-12.5 mg, 20-12.5 mg, 20-25 mg
NP
PA, 90
LOTREL – amlodipine besylate-benazepril hcl cap 5-10 mg,
5-20 mg, 10-20 mg, 10-40 mg
NP
PA, 90
quinapril-hydrochlorothiazide tab 10-12.5 mg, 20-12.5 mg,
20-25 mg (Accuretic)
P
90
TRANDOLAPRIL/VERAPAMIL HCL ER – trandolapril-verapamil
hcl tab er 1-240 mg, 2-180 mg, 2-240 mg, 4-240 mg
P
90
VASERETIC – enalapril maleate & hydrochlorothiazide tab
10-25 mg
NP
PA, 90
ZESTORETIC – lisinopril & hydrochlorothiazide tab 10-12.5 mg,
20-12.5 mg, 20-25 mg
NP
PA, 90
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ACE INHIBITORS
ACCUPRIL – quinapril hcl tab 5 mg, 10 mg, 20 mg, 40 mg
NP
PA, 90
ALTACE – ramipril cap 1.25 mg, 2.5 mg, 5 mg, 10 mg
NP
PA, 90
benazepril hcl tab 5 mg
P
90
benazepril hcl tab 10 mg, 20 mg, 40 mg (Lotensin)
P
90
captopril tab 12.5 mg, 25 mg, 50 mg, 100 mg
P
90
enalapril maleate oral soln 1 mg/ml (Epaned)
NP
PA, QL (1200
mls/30 days), 90
enalapril maleate tab 2.5 mg, 5 mg, 10 mg, 20 mg (Vasotec)
P
90
EPANED – enalapril maleate oral soln 1 mg/ml
NP
PA, QL (1200
mls/30 days), 90
fosinopril sodium tab 10 mg, 20 mg, 40 mg
P
90
lisinopril tab 2.5 mg, 5 mg, 30 mg, 40 mg (Zestril)
P
90
lisinopril tab 10 mg, 20 mg (Prinivil)
P
90
LOTENSIN – benazepril hcl tab 10 mg, 20 mg, 40 mg
NP
PA, 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
75
Drug Name
Preferred Status Drug Status / Restriction
moexipril hcl tab 7.5 mg, 15 mg
P
90
PERINDOPRIL ERBUMINE – perindopril erbumine tab 2 mg,
8 mg
NP
PA, 90
perindopril erbumine tab 4 mg
NP
PA, 90
QBRELIS – lisinopril oral soln 1 mg/ml
NP
PA, QL (2400
mls/30 days), 90
quinapril hcl tab 5 mg, 10 mg, 20 mg, 40 mg (Accupril)
P
90
ramipril cap 1.25 mg, 2.5 mg, 5 mg, 10 mg (Altace)
P
90
trandolapril tab 1 mg, 2 mg, 4 mg
P
90
VASOTEC – enalapril maleate tab 2.5 mg, 5 mg, 10 mg, 20 mg
NP
PA, 90
ZESTRIL – lisinopril tab 2.5 mg, 5 mg, 10 mg, 20 mg, 30 mg,
40 mg
NP
PA, 90
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ANGIOTENSIN II RECEPTOR BLOCKER COMB
amlodipine besylate-olmesartan medoxomil tab 5-20 mg,
5-40 mg, 10-20 mg, 10-40 mg (Azor)
NP
PA, QL (30 tablets/30
days), 90
amlodipine besylate-valsartan tab 5-160 mg, 5-320 mg,
10-160 mg, 10-320 mg (Exforge)
NP
PA, QL (30 tablets/30
days), 90
amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg,
5-160-25 mg, 10-160-12.5 mg, 10-160-25 mg, 10-320-25 mg
(Exforge hct)
NP
PA, QL (30 tablets/30
days), 90
ATACAND HCT – candesartan cilexetil-hydrochlorothiazide tab
16-12.5 mg, 32-12.5 mg, 32-25 mg
NP
PA, QL (30 tablets/30
days), 90
AVALIDE – irbesartan-hydrochlorothiazide tab 150-12.5 mg,
300-12.5 mg
NP
PA, QL (30 tablets/30
days), 90
AZOR – amlodipine besylate-olmesartan medoxomil tab
5-20 mg, 5-40 mg, 10-20 mg, 10-40 mg
NP
PA, QL (30 tablets/30
days), 90
BENICAR HCT – olmesartan medoxomil-hydrochlorothiazide tab
20-12.5 mg, 40-12.5 mg, 40-25 mg
NP
PA, QL (30 tablets/30
days), 90
candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg,
32-12.5 mg, 32-25 mg (Atacand hct)
NP
PA, QL (30 tablets/30
days), 90
DIOVAN HCT – valsartan-hydrochlorothiazide tab 80-12.5 mg,
160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg
NP
PA, QL (30 tablets/30
days), 90
EDARBYCLOR – azilsartan medoxomil-chlorthalidone tab
40-12.5 mg, 40-25 mg
NP
PA, QL (30 tablets/30
days), 90
EXFORGE – amlodipine besylate-valsartan tab 5-160 mg,
5-320 mg, 10-160 mg, 10-320 mg
NP
PA, QL (30 tablets/30
days), 90
EXFORGE HCT – amlodipine-valsartan-hydrochlorothiazide tab
5-160-12.5 mg, 5-160-25 mg, 10-160-12.5 mg, 10-160-25 mg,
10-320-25 mg
NP
PA, QL (30 tablets/30
days), 90
HYZAAR – losartan potassium & hydrochlorothiazide tab
50-12.5 mg, 100-12.5 mg, 100-25 mg
NP
PA, QL (30 tablets/30
days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
76
Drug Name
Preferred Status Drug Status / Restriction
irbesartan-hydrochlorothiazide tab 150-12.5 mg, 300-12.5 mg
(Avalide)
P
QL (30 tablets/30 days), 90
losartan potassium & hydrochlorothiazide tab 50-12.5 mg,
100-12.5 mg, 100-25 mg (Hyzaar)
P
QL (30 tablets/30 days), 90
MICARDIS HCT – telmisartan-hydrochlorothiazide tab
40-12.5 mg, 80-25 mg
NP
PA, QL (30 tablets/30
days), 90
MICARDIS HCT – telmisartan-hydrochlorothiazide tab
80-12.5 mg
NP
PA, QL (60 tablets/30
days), 90
olmesartan medoxomil-hydrochlorothiazide tab 20-12.5 mg,
40-12.5 mg, 40-25 mg (Benicar hct)
NP
PA, QL (30 tablets/30
days), 90
olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5 mg,
40-5-12.5 mg, 40-5-25 mg, 40-10-12.5 mg, 40-10-25 mg
(Tribenzor)
NP
PA, QL (30 tablets/30
days), 90
telmisartan-hydrochlorothiazide tab 40-12.5 mg, 80-25 mg
(Micardis hct)
NP
PA, QL (30 tablets/30
days), 90
telmisartan-hydrochlorothiazide tab 80-12.5 mg (Micardis hct)
NP
PA, QL (60 tablets/30
days), 90
TELMISARTAN/AMLODIPINE – telmisartan-amlodipine tab
40-5 mg, 40-10 mg, 80-5 mg, 80-10 mg
NP
PA, QL (30 tablets/30
days), 90
TRIBENZOR – olmesartan-amlodipine-hydrochlorothiazide tab
20-5-12.5 mg, 40-5-12.5 mg, 40-5-25 mg, 40-10-12.5 mg,
40-10-25 mg
NP
PA, QL (30 tablets/30
days), 90
valsartan-hydrochlorothiazide tab 80-12.5 mg, 160-12.5 mg,
160-25 mg, 320-12.5 mg, 320-25 mg (Diovan hct)
P
QL (30 tablets/30 days), 90
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ANGIOTENSIN IIRECEPTOR BLOCKERS
ATACAND – candesartan cilexetil tab 4 mg, 8 mg, 16 mg
NP
PA, QL (60 tablets/30
days), 90
ATACAND – candesartan cilexetil tab 32 mg
NP
PA, QL (30 tablets/30
days), 90
AVAPRO – irbesartan tab 75 mg, 150 mg, 300 mg
NP
PA, QL (30 tablets/30
days), 90
BENICAR – olmesartan medoxomil tab 5 mg
NP
PA, QL (60 tablets/30
days), 90
BENICAR – olmesartan medoxomil tab 20 mg, 40 mg
NP
PA, QL (30 tablets/30
days), 90
candesartan cilexetil tab 4 mg, 8 mg, 16 mg (Atacand)
NP
PA, QL (60 tablets/30
days), 90
candesartan cilexetil tab 32 mg (Atacand)
NP
PA, QL (30 tablets/30
days), 90
COZAAR – losartan potassium tab 25 mg, 50 mg
NP
PA, QL (60 tablets/30
days), 90
COZAAR – losartan potassium tab 100 mg
NP
PA, QL (30 tablets/30
days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
77
Drug Name
Preferred Status Drug Status / Restriction
DIOVAN – valsartan tab 40 mg, 80 mg, 160 mg
NP
PA, QL (60 tablets/30
days), 90
DIOVAN – valsartan tab 320 mg
NP
PA, QL (30 tablets/30
days), 90
EDARBI – azilsartan medoxomil tab 40 mg, 80 mg
NP
PA, QL (30 tablets/30
days), 90
irbesartan tab 75 mg, 150 mg, 300 mg (Avapro)
P
QL (30 tablets/30 days), 90
losartan potassium tab 25 mg, 50 mg (Cozaar)
P
QL (60 tablets/30 days), 90
losartan potassium tab 100 mg (Cozaar)
P
QL (30 tablets/30 days), 90
MICARDIS – telmisartan tab 20 mg, 40 mg, 80 mg
NP
PA, QL (30 tablets/30
days), 90
olmesartan medoxomil tab 5 mg (Benicar)
NP
PA, QL (60 tablets/30
days), 90
olmesartan medoxomil tab 20 mg, 40 mg (Benicar)
NP
PA, QL (30 tablets/30
days), 90
telmisartan tab 20 mg, 40 mg, 80 mg (Micardis)
NP
PA, QL (30 tablets/30
days), 90
VALSARTAN – valsartan oral soln 4 mg/ml
P
QL (2400 mls/30 days), 90
valsartan tab 40 mg, 80 mg, 160 mg (Diovan)
P
QL (60 tablets/30 days), 90
valsartan tab 320 mg (Diovan)
P
QL (30 tablets/30 days), 90
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : ANTIADRENERGICS
CARDURA – doxazosin mesylate tab 1 mg, 2 mg, 4 mg
NP
PA, QL (30 tablets/30
days), 90
CARDURA – doxazosin mesylate tab 8 mg
NP
PA, QL (60 tablets/30
days), 90
clonidine hcl tab 0.1 mg, 0.2 mg, 0.3 mg (Catapres)
P
90
CLONIDINE HYDROCHLORIDE ER – clonidine hcl tab er 24hr
0.17 mg (base equivalent)
NP
PA, 90
clonidine td patch weekly 0.1 mg/24hr (Catapres-tts-1)
P
clonidine td patch weekly 0.2 mg/24hr (Catapres-tts-2)
P
clonidine td patch weekly 0.3 mg/24hr (Catapres-tts-3)
P
doxazosin mesylate tab 1 mg, 2 mg, 4 mg (Cardura)
P
QL (30 tablets/30 days), 90
doxazosin mesylate tab 8 mg (Cardura)
P
QL (60 tablets/30 days), 90
guanfacine hcl tab 1 mg, 2 mg
P
90
METHYLDOPA – methyldopa tab 250 mg, 500 mg
P
90
MINIPRESS – prazosin hcl cap 2 mg, 5 mg
NP
PA, 90
prazosin hcl cap 1 mg, 2 mg, 5 mg (Minipress)
P
90
terazosin hcl cap 1 mg (base equivalent), 2 mg (base equivalent),
5 mg (base equivalent)
P
QL (30 capsules/30 days), 90
terazosin hcl cap 10 mg (base equivalent)
P
QL (60 capsules/30 days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
78
Drug Name
Preferred Status Drug Status / Restriction
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : BETA-BLOCKER COMBINATIONS
atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50)
P
90
atenolol & chlorthalidone tab 100-25 mg (Tenoretic 100)
P
90
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg, 5-6.25 mg,
10-6.25 mg (Ziac)
P
90
metoprolol & hydrochlorothiazide tab 50-25 mg (Lopressor hct)
P
90
metoprolol & hydrochlorothiazide tab 100-25 mg, 100-50 mg
P
90
TENORETIC 100 – atenolol & chlorthalidone tab 100-25 mg
NP
PA, 90
TENORETIC 50 – atenolol & chlorthalidone tab 50-25 mg
NP
PA, 90
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : BETA-BLOCKERS
acebutolol hcl cap 200 mg, 400 mg
P
90
atenolol tab 25 mg, 50 mg, 100 mg (Tenormin)
P
90
BETAPACE – sotalol hcl tab 80 mg, 120 mg, 160 mg
NP
PA, 90
BETAPACE AF – sotalol hcl (afib/afl) tab 80 mg, 120 mg, 160 mg
NP
PA, 90
betaxolol hcl tab 10 mg, 20 mg
P
90
bisoprolol fumarate tab 5 mg, 10 mg
P
90
BYSTOLIC – nebivolol hcl tab 2.5 mg (base equivalent), 5 mg
(base equivalent), 10 mg (base equivalent), 20 mg (base
equivalent)
NP
PA, 90
carvedilol phosphate cap er 24hr 10 mg, 20 mg, 40 mg, 80 mg
(Coreg cr)
NP
PA, 90
carvedilol tab 3.125 mg, 6.25 mg, 12.5 mg, 25 mg (Coreg)
P
90
CORGARD – nadolol tab 20 mg, 40 mg
NP
PA, 90
HEMANGEOL – propranolol hcl oral soln 4.28 mg/ml (3.75 mg/ml
base equiv)
P
PA, 90
INDERAL LA – propranolol hcl cap er 24hr 60 mg, 80 mg,
120 mg, 160 mg
NP
PA, 90
INDERAL XL – propranolol hcl sustained-release beads cap er
24hr 80 mg, 120 mg
NP
PA, 90
INNOPRAN XL – propranolol hcl sustained-release beads cap er
24hr 80 mg, 120 mg
NP
PA, 90
KAPSPARGO SPRINKLE – metoprolol succ cap er 24hr sprinkle
25 mg (tartrate equiv), 50 mg (tartrate equiv), 100 mg (tartrate
equiv), 200 mg (tartrate equiv)
NP
PA, 90
labetalol hcl tab 100 mg, 200 mg, 300 mg
P
90
LOPRESSOR – metoprolol tartrate tab 50 mg, 100 mg
NP
PA, 90
metoprolol succinate tab er 24hr 25 mg (tartrate equiv), 50 mg
(tartrate equiv), 100 mg (tartrate equiv), 200 mg (tartrate equiv)
(Toprol xl)
P
90
metoprolol tartrate tab 25 mg, 37.5 mg, 75 mg
P
90
metoprolol tartrate tab 50 mg, 100 mg (Lopressor)
P
90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
79
Drug Name
Preferred Status Drug Status / Restriction
nadolol tab 20 mg, 40 mg, 80 mg (Corgard)
P
90
nebivolol hcl tab 2.5 mg (base equivalent), 5 mg (base
equivalent), 10 mg (base equivalent), 20 mg (base equivalent)
(Bystolic)
NP
PA, 90
pindolol tab 5 mg, 10 mg
P
90
PROPRANOLOL HCL – propranolol hcl oral soln 40 mg/5ml
P
90
propranolol hcl cap er 24hr 60 mg, 80 mg, 120 mg, 160 mg
(Inderal la)
P
90
propranolol hcl oral soln 20 mg/5ml
P
90
propranolol hcl tab 10 mg, 20 mg, 40 mg, 60 mg, 80 mg
P
90
sotalol hcl (afib/afl) tab 80 mg, 120 mg, 160 mg (Betapace af)
NP
PA, 90
sotalol hcl tab 80 mg, 120 mg, 160 mg (Betapace)
P
90
sotalol hcl tab 240 mg
P
90
SOTYLIZE – sotalol hcl oral solution 5 mg/ml
NP
PA, QL (1920
mls/30 days), 90
TENORMIN – atenolol tab 25 mg, 50 mg, 100 mg
NP
PA, 90
timolol maleate tab 5 mg, 10 mg, 20 mg
P
90
TOPROL XL – metoprolol succinate tab er 24hr 25 mg (tartrate
equiv), 50 mg (tartrate equiv), 100 mg (tartrate equiv), 200 mg
(tartrate equiv)
NP
PA, 90
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : CALCIUM CHANNELBLOCKERS
amlodipine besylate tab 2.5 mg (base equivalent), 5 mg (base
equivalent), 10 mg (base equivalent) (Norvasc)
P
90
CARDIZEM – diltiazem hcl tab 30 mg, 60 mg, 120 mg
NP
PA, 90
CARDIZEM CD – diltiazem hcl coated beads cap er 24hr
120 mg, 180 mg, 240 mg, 300 mg, 360 mg
NP
PA, 90
CARDIZEM LA – diltiazem hcl tab er 24hr 120 mg, 180 mg,
240 mg, 300 mg, 360 mg, 420 mg
NP
PA
diltiazem hcl cap er 12hr 60 mg, 90 mg, 120 mg
P
90
diltiazem hcl cap er 24hr 120 mg, 180 mg, 240 mg
P
90
diltiazem hcl coated beads cap er 24hr 120 mg, 180 mg, 240 mg,
300 mg, 360 mg (Cardizem cd)
P
90
diltiazem hcl extended release beads cap er 24hr 120 mg,
180 mg, 240 mg, 300 mg, 360 mg, 420 mg (Tiazac)
P
90
diltiazem hcl tab er 24hr 120 mg, 180 mg, 240 mg, 300 mg,
360 mg, 420 mg (Cardizem la)
P
diltiazem hcl tab 30 mg, 60 mg, 120 mg (Cardizem)
P
90
diltiazem hcl tab 90 mg
P
90
felodipine tab er 24hr 2.5 mg, 5 mg, 10 mg
P
90
isradipine cap 2.5 mg, 5 mg
NP
PA, 90
KATERZIA – amlodipine benzoate oral susp 1 mg/ml (base
equivalent)
NP
PA, QL (300 mls/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
80
Drug Name
Preferred Status Drug Status / Restriction
LEVAMLODIPINE – levamlodipine maleate tab 2.5 mg, 5 mg
NP
PA, 90
nicardipine hcl cap 20 mg, 30 mg
NP
PA, 90
nifedipine cap 10 mg (Procardia)
P
90
nifedipine cap 20 mg
P
90
nifedipine tab er 24hr 30 mg, 60 mg, 90 mg
P
90
nifedipine tab er 24hr osmotic release 30 mg, 60 mg, 90 mg
(Procardia xl)
P
90
nimodipine cap 30 mg
P
NISOLDIPINE ER – nisoldipine tab er 24hr 20 mg, 25.5 mg,
30 mg, 40 mg
NP
PA, 90
nisoldipine tab er 24hr 8.5 mg, 17 mg, 34 mg (Sular)
NP
PA, 90
NORLIQVA – amlodipine besylate oral soln 1 mg/ml (base
equivalent)
NP
PA, QL (300 mls/30 days)
NORVASC – amlodipine besylate tab 2.5 mg (base equivalent),
5 mg (base equivalent), 10 mg (base equivalent)
NP
PA, 90
NYMALIZE – nimodipine oral soln 6 mg/ml
NP
PA
PROCARDIA XL – nifedipine tab er 24hr osmotic release 30 mg,
60 mg, 90 mg
NP
PA, 90
SULAR – nisoldipine tab er 24hr 8.5 mg, 17 mg, 34 mg
NP
PA, 90
TIAZAC – diltiazem hcl extended release beads cap er 24hr
120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg
NP
PA, 90
verapamil hcl cap er 24hr 120 mg, 180 mg, 240 mg (Verelan)
P
90
VERAPAMIL HCL ER – verapamil hcl cap er 24hr 300 mg
P
90
VERAPAMIL HCL SR – verapamil hcl cap er 24hr 360 mg
P
90
verapamil hcl tab er 120 mg, 180 mg, 240 mg (Calan sr)
P
90
verapamil hcl tab 40 mg, 80 mg, 120 mg
P
90
VERAPAMIL HYDROCHLORIDE ER – verapamil hcl cap er 24hr
100 mg, 200 mg
P
90
VERELAN – verapamil hcl cap er 24hr 120 mg, 180 mg, 240 mg,
360 mg
NP
PA, 90
VERELAN PM – verapamil hcl cap er 24hr 100 mg, 200 mg,
300 mg
NP
PA, 90
CARDIOVASCULAR AGENTS - ANTIHYPERTENSIVES : MISC
aliskiren fumarate tab 150 mg (base equivalent), 300 mg (base
equivalent) (Tekturna)
NP
PA, QL (30 tablets/30
days), 90
DEMSER – metyrosine cap 250 mg
P
eplerenone tab 25 mg, 50 mg (Inspra)
NP
PA, 90
hydralazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg
P
90
INSPRA – eplerenone tab 25 mg, 50 mg
NP
PA, 90
metyrosine cap 250 mg (Demser)
P
minoxidil tab 2.5 mg, 10 mg
P
90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
81
Drug Name
Preferred Status Drug Status / Restriction
phenoxybenzamine hcl cap 10 mg (Dibenzyline)
NP
PA
TEKTURNA – aliskiren fumarate tab 150 mg (base equivalent),
300 mg (base equivalent)
NP
PA, QL (30 tablets/30
days), 90
CARDIOVASCULAR AGENTS - CARDIOTONICS : CARDIAC GLYCOSIDES
DIGOXIN – digoxin oral soln 0.05 mg/ml
P
90
digoxin oral soln 0.05 mg/ml (Digoxin)
P
90
digoxin tab 62.5 mcg (0.0625 mg) (Lanoxin)
NP
PA, 90
digoxin tab 125 mcg (0.125 mg), 250 mcg (0.25 mg) (Lanoxin)
P
90
CARDIOVASCULAR AGENTS : ANTIANGINAL AGENTS
ASPRUZYO SPRINKLE – ranolazine er granules packet 500 mg,
1000 mg
NP
PA, QL (60 packets/30
days), 90
ISORDIL TITRADOSE – isosorbide dinitrate tab 5 mg, 40 mg
NP
PA, 90
isosorbide dinitrate tab 5 mg, 40 mg (Isordil titradose)
P
90
isosorbide dinitrate tab 10 mg, 20 mg, 30 mg
P
90
ISOSORBIDE MONONITRATE – isosorbide mononitrate tab
10 mg, 20 mg
P
90
isosorbide mononitrate tab er 24hr 30 mg, 60 mg, 120 mg
P
90
NITRO-BID – nitroglycerin oint 2%
P
NITRO-DUR – nitroglycerin td patch 24hr 0.1 mg/hr, 0.2 mg/hr,
0.3 mg/hr, 0.4 mg/hr, 0.6 mg/hr, 0.8 mg/hr
NP
PA, 90
NITRO-TIME – nitroglycerin cap er 2.5 mg, 6.5 mg, 9 mg
SC
90
nitroglycerin sl tab 0.3 mg, 0.4 mg, 0.6 mg (Nitrostat)
P
nitroglycerin td patch 24hr 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr,
0.6 mg/hr (Nitro-dur)
P
90
nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) (Nitrolingual
pumpspray)
NP
PA
NITROLINGUAL – nitroglycerin tl soln 0.4 mg/spray (400 mcg/
spray)
NP
PA
NITROSTAT – nitroglycerin sl tab 0.3 mg, 0.4 mg, 0.6 mg
NP
PA
ranolazine tab er 12hr 500 mg, 1000 mg (Ranexa)
NP
PA, 90
CARDIOVASCULAR AGENTS : ANTIARRHYTHMICS
amiodarone hcl tab 100 mg, 200 mg, 400 mg
P
90
disopyramide phosphate cap 100 mg, 150 mg (Norpace)
P
90
dofetilide cap 125 mcg (0.125 mg), 250 mcg (0.25 mg), 500 mcg
(0.5 mg) (Tikosyn)
P
flecainide acetate tab 50 mg, 100 mg, 150 mg
P
90
mexiletine hcl cap 150 mg, 200 mg, 250 mg
P
90
MULTAQ – dronedarone hcl tab 400 mg (base equivalent)
NP
PA, 90
NORPACE – disopyramide phosphate cap 100 mg, 150 mg
NP
PA, 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
82
Drug Name
Preferred Status Drug Status / Restriction
NORPACE CR – disopyramide phosphate cap er 12hr 100 mg,
150 mg
P
90
propafenone hcl cap er 12hr 225 mg, 325 mg, 425 mg (Rythmol
sr)
NP
PA, 90
propafenone hcl tab 150 mg, 225 mg, 300 mg
P
90
quinidine gluconate tab er 324 mg
P
90
QUINIDINE SULFATE – quinidine sulfate tab 200 mg, 300 mg
P
90
TIKOSYN – dofetilide cap 125 mcg (0.125 mg), 250 mcg
(0.25 mg), 500 mcg (0.5 mg)
NP
PA
CARDIOVASCULAR AGENTS : DIURETICS
acetazolamide cap er 12hr 500 mg
P
90
acetazolamide tab 125 mg, 250 mg
P
90
ALDACTONE – spironolactone tab 25 mg, 50 mg, 100 mg
NP
PA, 90
amiloride hcl tab 5 mg
P
90
AMILORIDE/HYDROCHLOROTHIAZIDE – amiloride &
hydrochlorothiazide tab 5-50 mg
P
90
bumetanide tab 0.5 mg, 1 mg, 2 mg (Bumex)
P
90
BUMEX – bumetanide tab 0.5 mg
NP
PA, 90
CAROSPIR – spironolactone susp 25 mg/5ml
NP
PA
chlorthalidone tab 25 mg, 50 mg
P
90
dichlorphenamide tab 50 mg (Keveyis)
NP
PA
DIURIL – chlorothiazide susp 250 mg/5ml
P
90
EDECRIN – ethacrynic acid tab 25 mg
NP
PA, 90
ethacrynic acid tab 25 mg (Edecrin)
P
90
FUROSEMIDE – furosemide oral soln 8 mg/ml
P
90
furosemide oral soln 10 mg/ml
P
90
furosemide tab 20 mg, 40 mg, 80 mg (Lasix)
P
90
hydrochlorothiazide cap 12.5 mg
P
90
hydrochlorothiazide tab 12.5 mg, 25 mg, 50 mg
P
90
indapamide tab 1.25 mg, 2.5 mg
P
90
KEVEYIS – dichlorphenamide tab 50 mg
NP
PA, QL (120 tablets/30 days)
LASIX – furosemide tab 20 mg, 40 mg, 80 mg
NP
PA, 90
methazolamide tab 25 mg, 50 mg
P
90
metolazone tab 2.5 mg, 5 mg, 10 mg
P
90
spironolactone & hydrochlorothiazide tab 25-25 mg (Aldactazide)
P
90
spironolactone susp 25 mg/5ml (Carospir)
NP
PA
spironolactone tab 25 mg, 50 mg, 100 mg (Aldactone)
P
90
THALITONE – chlorthalidone tab 15 mg
NP
PA, 90
torsemide tab 5 mg, 10 mg, 20 mg, 100 mg
P
90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
83
Drug Name
Preferred Status Drug Status / Restriction
triamterene & hydrochlorothiazide cap 37.5-25 mg (Dyazide)
P
90
triamterene & hydrochlorothiazide tab 37.5-25 mg (Maxzide-25)
P
90
triamterene & hydrochlorothiazide tab 75-50 mg (Maxzide)
P
90
triamterene cap 50 mg, 100 mg (Dyrenium)
P
90
CARDIOVASCULAR AGENTS : MISC
amlodipine besylate-atorvastatin calcium tab 2.5-10 mg,
2.5-20 mg, 2.5-40 mg
NP
PA, 90
amlodipine besylate-atorvastatin calcium tab 5-10 mg, 5-20 mg,
5-40 mg, 5-80 mg, 10-10 mg, 10-20 mg, 10-40 mg, 10-80 mg
(Caduet)
NP
PA, 90
BIDIL – isosorbide dinitrate-hydralazine hcl tab 20-37.5 mg
P
90
CADUET – amlodipine besylate-atorvastatin calcium tab
5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg, 10-10 mg, 10-20 mg,
10-40 mg, 10-80 mg
NP
PA, 90
CAMZYOS – mavacamten cap 2.5 mg, 10 mg, 15 mg
NP
PA, QL (30 capsules/30
days), SP
CAMZYOS – mavacamten cap 5 mg
NP
PA, QL (30 capsule/30
days), SP
CIALIS – tadalafil tab 5 mg
NP
PA
CORLANOR – ivabradine hcl tab 5 mg (base equiv), 7.5 mg
(base equiv)
NP
PA, QL (60 tablets/30 days)
CORLANOR – ivabradine hcl oral soln 5 mg/5ml (base equiv)
NP
PA, QL (600 mls/30 days)
droxidopa cap 100 mg (Northera)
NP
PA, QL (450
capsules/30 days)
droxidopa cap 200 mg, 300 mg (Northera)
NP
PA, QL (180
capsules/30 days)
ENTRESTO – sacubitril-valsartan tab 24-26 mg
P
QL (180 tablets/30 days), 90
ENTRESTO – sacubitril-valsartan tab 49-51 mg, 97-103 mg
P
QL (60 tablets/30 days), 90
isosorbide dinitrate-hydralazine hcl tab 20-37.5 mg (Bidil)
P
90
midodrine hcl tab 2.5 mg, 5 mg, 10 mg
P
NORTHERA – droxidopa cap 100 mg
NP
PA, QL (450
capsules/30 days)
NORTHERA – droxidopa cap 200 mg, 300 mg
NP
PA, QL (180
capsules/30 days)
tadalafil tab 5 mg (Cialis)
NP
PA
VERQUVO – vericiguat tab 2.5 mg, 5 mg, 10 mg
P
PA, QL (30 tablets/30 days)
VYNDAMAX – tafamidis cap 61 mg
NP
PA, QL (30 capsules/30
days), SP
VYNDAQEL – tafamidis meglumine (cardiac) cap 20 mg
NP
PA, QL (120
capsules/30 days), SP
CARDIOVASCULAR AGENTS : PULMONARY HYPERTENSION
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
84
Drug Name
Preferred Status Drug Status / Restriction
ADCIRCA – tadalafil tab 20 mg (pah)
P
PA, QL (60 tablets/30
days), SP
ADEMPAS – riociguat tab 0.5 mg, 1 mg, 1.5 mg, 2 mg, 2.5 mg
NP
PA, QL (90 tablets/30
days), SP
ambrisentan tab 5 mg, 10 mg (Letairis)
NP
PA, QL (30 tablets/30
days), SP
bosentan tab 62.5 mg, 125 mg (Tracleer)
NP
PA, QL (60 tablets/30
days), SP
epoprostenol sodium for inj 0.5 mg, 1.5 mg (Flolan)
P
PA, SP
FLOLAN – epoprostenol sodium for inj 0.5 mg, 1.5 mg
P
PA, SP
LETAIRIS – ambrisentan tab 5 mg, 10 mg
P
PA, QL (30 tablets/30
days), SP
LIQREV – sildenafil citrate oral susp 10 mg/ml
NP
PA, QL (2 bottles/30
days), SP
OPSUMIT – macitentan tab 10 mg
NP
PA, QL (30 tablets/30
days), SP
ORENITRAM – treprostinil diolamine tab er 0.125 mg (base
equiv), 0.25 mg (base equiv), 1 mg (base equiv), 2.5 mg (base
equiv), 5 mg (base equiv)
NP
PA, QL (300
tablets/30 days), SP
ORENITRAM TITRATION KIT MONTH 1 – treprostinil tab er titr
pk (mo1) 126 x0.125mg & 42 x0.25mg
NP
PA, QL (1 package/180
days), SP
ORENITRAM TITRATION KIT MONTH 2 – treprostinil tab er titr
pk (mo2) 126 x0.125mg & 210 x0.25mg
NP
PA, QL (1 package/180
days), SP
ORENITRAM TITRATION KIT MONTH 3 – treprostinil tab er titr
pk(mo3)126x0.125mg&42x0.25mg&84x1mg
NP
PA, QL (1 package/180
days), SP
REMODULIN – treprostinil inj soln 20 mg/20ml (1 mg/ml),
50 mg/20ml (2.5 mg/ml), 100 mg/20ml (5 mg/ml), 200 mg/20ml
(10 mg/ml)
NP
PA, SP
REVATIO – sildenafil citrate tab 20 mg
NP
PA, QL (90 tablets/30
days), SP
REVATIO – sildenafil citrate for suspension 10 mg/ml
P
PA, QL (2 bottles/30
days), SP
REVATIO – sildenafil citrate iv soln 10 mg/12.5ml (base
equivalent)
NP
PA, SP
sildenafil citrate for suspension 10 mg/ml (Revatio)
NP
PA, QL (2 bottles/30
days), SP
sildenafil citrate iv soln 10 mg/12.5ml (base equivalent) (Revatio)
NP
PA, SP
sildenafil citrate tab 20 mg (Revatio)
P
PA, QL (90 tablets/30
days), SP
tadalafil tab 20 mg (pah) (Adcirca)
P
PA, QL (60 tablets/30
days), SP
TADLIQ – tadalafil oral susp 20 mg/5ml (pah)
NP
PA, QL (300 mls/30 days), SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
85
Drug Name
Preferred Status Drug Status / Restriction
TRACLEER – bosentan tab 62.5 mg, 125 mg
P
PA, QL (60 tablets/30
days), SP
TRACLEER – bosentan tab for oral susp 32 mg
P
PA, QL (120
tablets/30 days), SP
treprostinil inj soln 20 mg/20ml (1 mg/ml), 50 mg/20ml (2.5 mg/
ml), 100 mg/20ml (5 mg/ml), 200 mg/20ml (10 mg/ml)
(Remodulin)
NP
PA, SP
TYVASO – treprostinil inhalation solution 0.6 mg/ml
NP
PA, QL (81.2
mls/28 days), SP
TYVASO DPI MAINTENANCE KIT – treprostinil inh powder
16 mcg/cartridge, 32 mcg/cartridge, 48 mcg/cartridge, 64 mcg/
cartridge
NP
PA, QL (112
cartridges/28 days), SP
TYVASO DPI TITRATION KIT – treprostinil inh powd 112 x
16mcg & 112 x 32mcg & 28 x 48mcg
NP
PA, QL (252
cartridges/180 days), SP
TYVASO REFILL – treprostinil inhalation solution 0.6 mg/ml
NP
PA, QL (81.2
mls/28 days), SP
TYVASO STARTER – treprostinil inhalation solution 0.6 mg/ml
NP
PA, QL (1 kit/180 days), SP
UPTRAVI – selexipag tab 200 mcg, 400 mcg, 600 mcg, 800 mcg,
1000 mcg, 1200 mcg, 1400 mcg, 1600 mcg
NP
PA, QL (60 tablets/30
days), SP
UPTRAVI – selexipag for iv soln 1800 mcg
NP
PA, SP
UPTRAVI TITRATION PACK – selexipag tab therapy pack
200 mcg (140) & 800 mcg (60)
NP
PA, QL (200
tablets/180 days), SP
VELETRI – epoprostenol sodium for inj 0.5 mg, 1.5 mg
NP
PA, SP
VENTAVIS – iloprost inhalation solution 10 mcg/ml, 20 mcg/ml
NP
PA, QL (270 cartridges/30
days), SF, SP
CENTRAL NERVOUS SYSTEM AGENTS : MISC
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base equiv)
SC
CONTRACEPTIVES : COMBINATION CONTRACEPTIVES
ANNOVERA – segesterone ace-ethinyl estradiol va ring
0.15-0.013 mg/24hr
P
QL (1 ring/365 days)
BALCOLTRA – levonorgestrel-ethinyl estradiol-fe tab
0.1 mg-20 mcg (21)
P
QL (28 tablets/21 days), 90
BEYAZ – drospirenone-ethinyl estrad-levomefolate tab
3-0.02-0.451 mg
P
QL (28 tablets/21 days), 90
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5)
(Mircette)
P
QL (28 tablets/21 days), 90
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg
P
QL (28 tablets/21 days), 90
drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg
(Beyaz)
P
QL (28 tablets/21 days), 90
drospirenone-ethinyl estrad-levomefolate tab 3-0.03-0.451 mg
(Safyral)
P
QL (28 tablets/21 days), 90
drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz)
P
QL (28 tablets/21 days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
86
Drug Name
Preferred Status Drug Status / Restriction
drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin 28)
P
QL (28 tablets/21 days), 90
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg,
1 mg-50 mcg
P
QL (28 tablets/21 days), 90
etonogestrel-ethinyl estradiol va ring 0.12-0.015 mg/24hr
(Nuvaring)
P
QL (1 ring/21 days), 90
levonor-eth est tab 0.15-0.02/0.025/0.03 mg &eth est 0.01 mg
(Quartette)
P
QL (28 tablets/21 days), 90
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7)
(Loseasonique)
P
QL (28 tablets/21 days), 90
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7)
(Seasonique)
P
QL (84 tablets/63 days), 90
levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg
P
QL (28 tablets/21 days), 90
levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg,
0.15 mg-30 mcg
P
QL (28 tablets/21 days), 90
levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg
P
QL (28 tablets/21 days), 90
levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg
P
QL (28 tablets/21 days), 90
levonorgestrel-ethinyl estradiol-fe tab 0.1 mg-20 mcg (21)
(Balcoltra)
P
QL (28 tablets/21 days), 90
LO LOESTRIN FE – norethin-eth estradiol-fe tab 1 mg-10 mcg
(24)/10 mcg (2)
P
QL (28 tablets/21 days), 90
NATAZIA – estradiol valerate-dienogest tab
3 mg /2-2 mg/2-3 mg/1 mg
P
QL (28 tablets/21 days), 90
NEXTSTELLIS – drospirenone-estetrol tab 3-14.2 mg
P
QL (28 tablets/21 days), 90
norelgestromin-ethinyl estradiol td ptwk 150-35 mcg/24hr
P
QL (3 patches/21 days), 90
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg,
0.5 mg-35 mcg, 1 mg-35 mcg
P
QL (28 tablets/21 days), 90
norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg
P
QL (28 tablets/21 days), 90
norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg
(Generess fe)
P
QL (28 tablets/21 days), 90
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg
(Estrostep fe)
P
QL (28 tablets/21 days), 90
norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg (Loestrin
1/20-21)
P
QL (28 tablets/21 days), 90
norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg
(Loestrin 1.5/30-21)
P
QL (28 tablets/21 days), 90
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg
(Loestrin fe 1/20)
P
QL (28 tablets/21 days), 90
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg
(Loestrin fe 1.5/30)
P
QL (28 tablets/21 days), 90
norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg (24)
(Minastrin 24 fe)
P
QL (28 tablets/21 days), 90
norethindrone ace-ethinyl estradiol-fe cap 1 mg-20 mcg (24)
(Taytulla)
P
QL (28 capsules/21 days), 90
norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24)
P
QL (28 tablets/21 days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
87
Drug Name
Preferred Status Drug Status / Restriction
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg
(Ortho-novum 7/7/7)
P
QL (28 tablets/21 days), 90
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg
P
QL (28 tablets/21 days), 90
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg
P
QL (28 tablets/21 days), 90
norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg
(Ortho tri-cyclen lo)
P
QL (28 tablets/21 days), 90
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg
P
QL (28 tablets/21 days), 90
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg
P
QL (28 tablets/21 days), 90
NUVARING – etonogestrel-ethinyl estradiol va ring
0.12-0.015 mg/24hr
P
QL (1 ring/21 days), 90
SAFYRAL – drospirenone-ethinyl estrad-levomefolate tab
3-0.03-0.451 mg
P
QL (28 tablets/21 days), 90
TAYTULLA – norethindrone ace-ethinyl estradiol-fe cap
1 mg-20 mcg (24)
P
QL (28 capsules/21 days), 90
TWIRLA – levonorgestrel-ethinyl estradiol td ptwk
120-30 mcg/24hr
P
QL (3 patches/21 days), 90
TYBLUME – levonorgestrel & ethinyl estradiol chew tab
0.1 mg-20 mcg
P
QL (28 tablets/21 days), 90
VELIVET – desogest-ethin est tab
0.1-0.025/0.125-0.025/0.15-0.025mg-mg
P
QL (28 tablets/21 days), 90
YASMIN 28 – drospirenone-ethinyl estradiol tab 3-0.03 mg
P
QL (28 tablets/21 days), 90
YAZ – drospirenone-ethinyl estradiol tab 3-0.02 mg
P
QL (28 tablets/21 days), 90
CONTRACEPTIVES : EMERGENCY CONTRACEPTIVES
ELLA – ulipristal acetate tab 30 mg
P
levonorgestrel tab 1.5 mg
P
CONTRACEPTIVES : PROGESTIN CONTRACEPTIVES
DEPO-PROVERA CONTRACEPTIVE – medroxyprogesterone
acetate im susp 150 mg/ml
P
90
DEPO-PROVERA CONTRACEPTIVE – medroxyprogesterone
acetate im susp prefilled syr 150 mg/ml
P
90
DEPO-SUBQ PROVERA 104 – medroxyprogesterone acetate
susp pref syr 104 mg/0.65ml
P
90
medroxyprogesterone acetate im susp prefilled syr 150 mg/ml
(Depo-provera contraceptive)
P
90
medroxyprogesterone acetate im susp 150 mg/ml (Depo-provera
contraceptive)
P
90
norethindrone tab 0.35 mg (Ortho micronor)
P
QL (28 tablets/21 days), 90
SLYND – drospirenone tab 4 mg
P
QL (28 tablets/21 days), 90
CORTICOSTEROIDS
AGAMREE – vamorolone oral susp 40 mg/ml
NP
PA, QL (300 mls/30 days), SP
ALKINDI SPRINKLE – hydrocortisone cap sprinkle 0.5 mg, 1 mg,
2 mg, 5 mg
NP
PA, SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
88
Drug Name
Preferred Status Drug Status / Restriction
budesonide delayed release particles cap 3 mg (Entocort ec)
NP
PA
budesonide tab er 24hr 9 mg (Uceris)
NP
PA
CORTEF – hydrocortisone tab 5 mg, 10 mg, 20 mg
NP
PA
CORTISONE ACETATE – cortisone acetate tab 25 mg
NP
PA
DEXAMETHASONE – dexamethasone soln 0.5 mg/5ml
P
dexamethasone elixir 0.5 mg/5ml
P
DEXAMETHASONE INTENSOL – dexamethasone conc 1 mg/ml
P
dexamethasone tab therapy pack 1.5 mg (21)
P
dexamethasone tab 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg,
6 mg
P
DEXAMETHASONE 10-DAY DOSE PACK – dexamethasone tab
therapy pack 1.5 mg (35)
P
DEXAMETHASONE 13-DAY DOSE PACK – dexamethasone tab
therapy pack 1.5 mg (51)
P
EMFLAZA – deflazacort susp 22.75 mg/ml
NP
PA, SP
EMFLAZA – deflazacort tab 6 mg
NP
PA, QL (60 tablets/30
days), SP
EMFLAZA – deflazacort tab 18 mg
NP
PA, QL (30 tablets/30
days), SP
EMFLAZA – deflazacort tab 30 mg, 36 mg
NP
PA, SP
fludrocortisone acetate tab 0.1 mg
P
90
HEMADY – dexamethasone tab 20 mg
NP
PA
hydrocortisone tab 5 mg, 10 mg, 20 mg (Cortef)
P
MEDROL – methylprednisolone tab 2 mg, 4 mg, 8 mg, 16 mg
NP
PA
MEDROL DOSEPAK – methylprednisolone tab therapy pack
4 mg (21)
NP
PA
methylprednisolone tab therapy pack 4 mg (21) (Medrol dosepak)
P
methylprednisolone tab 4 mg, 8 mg, 16 mg, 32 mg (Medrol)
P
prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base)
(Pediapred)
P
prednisolone sod phosphate oral soln 15 mg/5ml (base equiv)
P
prednisolone sod phosphate oral soln 10 mg/5ml (base equiv)
P
QL (900 mls/30 days)
prednisolone sod phosphate oral soln 20 mg/5ml (base equiv)
P
QL (450 mls/30 days)
PREDNISOLONE SODIUM PHOSPHATE ODT – prednisolone
sod phos orally disintegr tab 10 mg (base eq), 15 mg (base
eq), 30 mg (base eq)
NP
PA
prednisolone sodium phosphate oral soln 25 mg/5ml (base eq)
P
prednisolone soln 15 mg/5ml
P
prednisolone tab 5 mg
P
PREDNISONE – prednisone oral soln 5 mg/5ml
P
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
89
Drug Name
Preferred Status Drug Status / Restriction
PREDNISONE INTENSOL – prednisone conc 5 mg/ml
P
prednisone tab therapy pack 5 mg (21), 5 mg (48), 10 mg (21),
10 mg (48)
P
prednisone tab 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg, 50 mg
P
RAYOS – prednisone tab delayed release 1 mg, 2 mg, 5 mg
NP
PA, QL (30 tablets/30 days)
TAPERDEX 12-DAY – dexamethasone tab therapy pack 1.5 mg
(49)
NP
PA
TAPERDEX 7-DAY – dexamethasone tab therapy pack 1.5 mg
(27)
NP
PA
taperdex 6-day
NP
PA
TARPEYO – budesonide delayed release cap 4 mg
NP
PA, QL (120
capsules/30 days)
UCERIS – budesonide tab er 24hr 9 mg
NP
PA
DERMATOLOGICALS : ACNE PRODUCTS
ABSORICA – isotretinoin cap 10 mg, 20 mg, 25 mg, 30 mg,
35 mg, 40 mg
NP
PA (>=25 yr)
ABSORICA LD – isotretinoin micronized cap 8 mg, 16 mg,
24 mg, 32 mg
NP
PA (>=25 yr)
ACANYA – clindamycin phosphate-benzoyl peroxide gel
1.2-2.5%
NP
PA (>=25 yr)
adapalene cream 0.1% (Differin)
NP
PA (>=25 yr)
adapalene gel 0.3% (Differin)
NP
PA (>=25 yr)
adapalene-benzoyl peroxide gel 0.1-2.5% (Epiduo)
NP
PA (>=25 yr)
adapalene-benzoyl peroxide gel 0.3-2.5% (Epiduo forte)
NP
PA (>=25 yr)
ADAPALENE/BENZOYL PEROXIDE – adapalene-benzoyl
peroxide pad 0.1-2.5%
NP
PA (>=25 yr)
ALTRENO – tretinoin lotion 0.05%
NP
PA (>=25 yr)
ARAZLO – tazarotene (acne) lotion 0.045%
NP
PA (>=25 yr)
ATRALIN – tretinoin gel 0.05%
NP
PA (>=25 yr)
BENZAMYCIN – benzoyl peroxide-erythromycin gel 5-3%
NP
PA (>=25 yr)
benzoyl peroxide-erythromycin gel 5-3% (Benzamycin)
P
PA (>=25 yr)
CABTREO – adapalene-benzoyl peroxide-clindamycin gel
0.15-3.1-1.2%
NP
PA (>=25 yr)
CLEOCIN-T – clindamycin phosphate lotion 1%
NP
PA (>=25 yr)
CLINDACIN ETZ – clindamycin phosphate swab 1% & cleanser
kit
NP
PA (>=25 yr)
CLINDAGEL – clindamycin phosphate gel 1%
NP
PA (>=25 yr)
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2 (1)-5%
NP
PA (>=25 yr)
clindamycin phosphate foam 1% (Evoclin)
NP
PA (>=25 yr)
clindamycin phosphate gel 1%
P
PA (>=25 yr)
clindamycin phosphate lotion 1% (Cleocin-t)
P
PA (>=25 yr)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
90
Drug Name
Preferred Status Drug Status / Restriction
clindamycin phosphate soln 1%
P
PA (>=25 yr), QL
(180 mls/30 days)
clindamycin phosphate swab 1%
P
PA (>=25 yr)
clindamycin phosphate-benzoyl peroxide gel 1-5% (Benzaclin)
NP
PA (>=25 yr)
clindamycin phosphate-benzoyl peroxide gel 1.2-2.5% (Acanya)
NP
PA (>=25 yr)
clindamycin phosphate-benzoyl peroxide gel 1.2-3.75%
(Onexton)
NP
PA (>=25 yr)
clindamycin phosphate-tretinoin gel 1.2-0.025% (Ziana)
NP
PA (>=25 yr)
dapsone gel 5%, 7.5% (Aczone)
NP
PA (>=25 yr)
ERY – erythromycin pads 2%
NP
PA (>=25 yr)
ERYGEL – erythromycin gel 2%
NP
PA (>=25 yr), QL (180
grams/30 days)
erythromycin gel 2% (Erygel)
P
PA (>=25 yr), QL (180
grams/30 days)
erythromycin soln 2%
P
PA (>=25 yr), QL
(180 mls/30 days)
FABIOR – tazarotene (acne) foam 0.1%
NP
PA (>=25 yr)
isotretinoin cap 10 mg, 20 mg, 30 mg, 40 mg
NP
PA (>=25 yr)
isotretinoin cap 25 mg, 35 mg (Absorica)
NP
PA (>=25 yr)
KLARON – sulfacetamide sodium lotion 10% (acne)
NP
PA (>=25 yr)
ONEXTON – clindamycin phosphate-benzoyl peroxide gel
1.2-3.75%
NP
PA (>=25 yr)
RETIN-A – tretinoin cream 0.025%, 0.05%, 0.1%
NP
PA (>=25 yr)
RETIN-A – tretinoin gel 0.01%, 0.025%
NP
PA (>=25 yr)
RETIN-A MICRO – tretinoin microsphere gel 0.04%, 0.06%,
0.1%
NP
PA (>=25 yr)
RETIN-A MICRO PUMP – tretinoin microsphere gel 0.04%,
0.08%, 0.1%
NP
PA (>=25 yr)
SSS 10-5 – sulfacetamide sodium w/ sulfur foam 10-5%
NP
PA (>=25 yr)
sulfacetamide sodium lotion 10% (acne) (Klaron)
NP
PA (>=25 yr)
sulfacetamide sodium w/ sulfur cleanser 9-4% (Sumaxin wash)
NP
PA (>=25 yr)
sulfacetamide sodium w/ sulfur cleanser 9-4.5% (Sumadan
wash)
NP
PA (>=25 yr)
sulfacetamide sodium w/ sulfur cleanser 9.8-4.8% (Plexion
cleanser)
NP
PA (>=25 yr)
sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar ls cleanser)
NP
PA (>=25 yr)
sulfacetamide sodium w/ sulfur cleanser 10-5%
NP
PA (>=25 yr)
sulfacetamide sodium w/ sulfur cream 10-2% (Avar-e ls)
NP
PA (>=25 yr)
sulfacetamide sodium w/ sulfur cream 10-5%
NP
PA (>=25 yr)
sulfacetamide sodium w/ sulfur emulsion 10-1%
NP
PA (>=25 yr)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
91
Drug Name
Preferred Status Drug Status / Restriction
sulfacetamide sodium w/ sulfur susp 8-4%
NP
PA (>=25 yr)
sulfacetamide sodium w/ sulfur susp 10-5%
NP
PA
SUMADAN KIT – sulfacetamide sod-sulfur wash 9-4.5% & skin
cleanser kit
NP
PA (>=25 yr)
SUMADAN WASH – sulfacetamide sodium w/ sulfur cleanser
9-4.5%
NP
PA (>=25 yr)
SUMAXIN – sulfacetamide sodium w/ sulfur cleansing pad 10-4%
NP
PA (>=25 yr)
SUMAXIN CP KIT – sulfacetamide sod-sulfur pad 10-4% & skin
cleanser kit
NP
PA (>=25 yr)
TAZAROTENE – tazarotene (acne) foam 0.1%
NP
PA (>=25 yr)
tretinoin cream 0.025%, 0.05%, 0.1% (Retin-a)
P
PA (>=25 yr)
tretinoin gel 0.01%, 0.025% (Retin-a)
P
PA (>=25 yr)
tretinoin gel 0.05% (Atralin)
P
PA (>=25 yr)
tretinoin microsphere gel 0.04%, 0.1% (Retin-a micro)
NP
PA (>=25 yr)
tretinoin microsphere gel 0.08% (Retin-a micro pump)
NP
PA (>=25 yr)
WINLEVI – clascoterone cream 1%
NP
PA (>=25 yr)
ZIANA – clindamycin phosphate-tretinoin gel 1.2-0.025%
NP
PA (>=25 yr)
DERMATOLOGICALS : ANTIBIOTICS
gentamicin sulfate cream 0.1%
P
QL (120 grams/90 days)
gentamicin sulfate oint 0.1%
P
QL (120 grams/90 days)
mupirocin calcium cream 2%
NP
PA
mupirocin oint 2%
P
NEO-SYNALAR – neomycin sulfate-fluocinolone acetonide
cream 0.5-0.025%
NP
PA
XEPI – ozenoxacin cream 1%
NP
PA
DERMATOLOGICALS : ANTIFUNGALS
ciclopirox gel 0.77%
NP
PA, QL (180 grams/30 days)
ciclopirox olamine cream 0.77% (base equiv) (Loprox)
NP
PA, QL (180 grams/30 days)
ciclopirox olamine susp 0.77% (base equiv) (Loprox)
NP
PA, QL (180 mls/30 days)
ciclopirox shampoo 1% (Loprox shampoo)
NP
PA
ciclopirox solution 8% (Penlac Nail Lacquer)
NP
PA, QL (6.6 mls/30 days)
CICLOPIROX TREATMENT – ciclopirox solution kit 8%
NP
PA
clotrimazole cream 1%
P
clotrimazole soln 1%
NP
PA
clotrimazole w/ betamethasone cream 1-0.05%
NP
PA
clotrimazole w/ betamethasone lotion 1-0.05%
NP
PA
econazole nitrate cream 1%
P
QL (170 grams/30 days)
ERTACZO – sertaconazole nitrate cream 2%
NP
PA
JUBLIA – efinaconazole soln 10%
NP
PA, QL (4 mls/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
92
Drug Name
Preferred Status Drug Status / Restriction
ketoconazole cream 2%
P
QL (180 grams/30 days)
ketoconazole foam 2% (Extina)
NP
PA, QL (100 grams/30 days)
ketoconazole shampoo 2% (Nizoral)
P
LULICONAZOLE – luliconazole cream 1%
NP
PA
LUZU – luliconazole cream 1%
NP
PA
MICONAZOLE NITRATE/ZINC OXIDE/WHITE PETROLATUM –
miconazole-zinc oxide-white petrolatum oint 0.25-15-81.35%
NP
PA
MYCOZYL HC – tolnaftate-hydrocortisone liquid 1-0.667%
NP
PA
NAFTIFINE HCL – naftifine hcl cream 1%
NP
PA
naftifine hcl cream 2% (Naftin)
NP
PA
naftifine hcl gel 2% (Naftin)
NP
PA
NAFTIN – naftifine hcl gel 1%, 2%
NP
PA
nystatin cream 100000 unit/gm
P
nystatin oint 100000 unit/gm
P
nystatin topical powder 100000 unit/gm
P
nystatin-triamcinolone cream 100000-0.1 unit/gm-%
NP
PA
nystatin-triamcinolone oint 100000-0.1 unit/gm-%
NP
PA
oxiconazole nitrate cream 1% (Oxistat)
NP
PA
OXISTAT – oxiconazole nitrate lotion 1%
NP
PA
tavaborole soln 5% (Kerydin)
NP
PA, QL (4 mls/30 days)
VUSION – miconazole-zinc oxide-white petrolatum oint
0.25-15-81.35%
NP
PA
DERMATOLOGICALS : ANTIPSORIATICS
acitretin cap 10 mg, 25 mg (Soriatane)
NP
PA
acitretin cap 17.5 mg
NP
PA
BIMZELX – bimekizumab-bkzx subcutaneous soln auto-injector
160 mg/ml
NP
PA, QL (2 pens/56 days), SP
BIMZELX – bimekizumab-bkzx subcutaneous soln prefilled syr
160 mg/ml
NP
PA, QL (2 syringes/56
days), SP
CALCIPOTRIENE – calcipotriene foam 0.005%
NP
PA
calcipotriene cream 0.005% (Dovonex)
P
calcipotriene oint 0.005%
P
calcipotriene soln 0.005% (50 mcg/ml)
P
CALCITRIOL – calcitriol oint 3 mcg/gm
NP
PA
COSENTYX – secukinumab subcutaneous soln prefilled syringe
75 mg/0.5ml, 150 mg/ml
P
PA, QL (1 syringe/28
days), SP
COSENTYX – secukinumab subcutaneous pref syr 150 mg/ml
(300 mg dose)
P
PA, QL (2 syringes/28
days), SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
93
Drug Name
Preferred Status Drug Status / Restriction
COSENTYX SENSOREADY PEN – secukinumab subcutaneous
soln auto-injector 150 mg/ml
P
PA, QL (1 syringe/28
days), SP
COSENTYX SENSOREADY PEN – secukinumab subcutaneous
auto-inj 150 mg/ml (300 mg dose)
P
PA, QL (2 syringes/28
days), SP
COSENTYX UNOREADY – secukinumab subcutaneous soln
auto-injector 300 mg/2ml
P
PA, QL (1 pen/28 days), SP
ILUMYA – tildrakizumab-asmn subcutaneous soln pref syringe
100 mg/ml
NP
PA, QL (1 syringe/84
days), SP
METHOXSALEN – methoxsalen rapid cap 10 mg
NP
PA
SILIQ – brodalumab subcutaneous soln prefilled syringe
210 mg/1.5ml
NP
PA, QL (2 syringes/28
days), SP
SKYRIZI – risankizumab-rzaa soln prefilled syringe 150 mg/ml
NP
PA, QL (1 syringe/84
days), SP
SKYRIZI PEN – risankizumab-rzaa soln auto-injector 150 mg/ml
NP
PA, QL (1 pen/84 days), SP
SORILUX – calcipotriene foam 0.005%
NP
PA
SOTYKTU – deucravacitinib tab 6 mg
NP
PA, QL (30 tablets/30
days), SP
STELARA – ustekinumab inj 45 mg/0.5ml
NP
PA, QL (1 vial/84 days), SP
STELARA – ustekinumab soln prefilled syringe 45 mg/0.5ml
NP
PA, QL (1 syringe/84
days), SP
STELARA – ustekinumab soln prefilled syringe 90 mg/ml
NP
PA, QL (1 syringe/56
days), SP
TALTZ – ixekizumab subcutaneous soln auto-injector 80 mg/ml
NP
PA, QL (1 syringe/28
days), SP
TALTZ – ixekizumab subcutaneous soln prefilled syringe 80 mg/
ml
NP
PA, QL (1 syringe/28
days), SP
tazarotene cream 0.1% (Tazorac)
NP
PA (>=25 yr)
tazarotene gel 0.05%, 0.1% (Tazorac)
NP
PA (>=25 yr)
TREMFYA – guselkumab soln pen-injector 100 mg/ml
NP
PA, QL (1 injection/56
days), SP
TREMFYA – guselkumab soln prefilled syringe 100 mg/ml
NP
PA, QL (1 syringe/56
days), SP
VTAMA – tapinarof cream 1%
NP
PA
ZORYVE – roflumilast cream 0.3%
NP
PA
DERMATOLOGICALS : CORTICOSTEROIDS - TOPICAL
alclometasone dipropionate cream 0.05%
P
alclometasone dipropionate oint 0.05%
P
APEXICON E – diflorasone diacetate emollient base cream
0.05%
NP
PA, QL (100 grams/30 days)
BETAMETHASONE DIPROPIONATE – betamethasone
dipropionate augmented gel 0.05%
NP
PA, QL (180 grams/90 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
94
Drug Name
Preferred Status Drug Status / Restriction
betamethasone dipropionate augmented cream 0.05%
(Diprolene af)
NP
PA, QL (100 grams/30 days)
betamethasone dipropionate augmented lotion 0.05%
NP
PA, QL (180 mls/90 days)
betamethasone dipropionate augmented oint 0.05% (Diprolene)
NP
PA, QL (180 grams/90 days)
betamethasone dipropionate cream 0.05%
NP
PA, QL (100 grams/30 days)
betamethasone dipropionate lotion 0.05%
NP
PA, QL (100 mls/30 days)
betamethasone dipropionate oint 0.05%
NP
PA, QL (100 grams/30 days)
betamethasone valerate aerosol foam 0.12% (Luxiq)
NP
PA
betamethasone valerate cream 0.1% (base equivalent)
P
betamethasone valerate lotion 0.1% (base equivalent)
P
betamethasone valerate oint 0.1% (base equivalent)
P
BRYHALI – halobetasol propionate lotion 0.01%
NP
PA, QL (100 grams/30 days)
calcipotriene-betamethasone dipropionate oint 0.005-0.064%
(Taclonex)
NP
PA, QL (120 grams/30 days)
calcipotriene-betamethasone dipropionate susp 0.005-0.064%
(Taclonex)
NP
PA, QL (120 grams/30 days)
clobetasol propionate cream 0.05% (Temovate)
P
QL (180 grams/90 days)
clobetasol propionate emollient base cream 0.05%
P
clobetasol propionate emulsion foam 0.05% (Olux-e)
NP
PA, QL (180 grams/90 days)
clobetasol propionate foam 0.05% (Olux)
NP
PA, QL (180 grams/90 days)
clobetasol propionate gel 0.05%
P
clobetasol propionate lotion 0.05% (Clobex)
NP
PA, QL (180 mls/90 days)
clobetasol propionate oint 0.05% (Temovate)
P
QL (180 grams/90 days)
clobetasol propionate shampoo 0.05% (Clobex)
NP
PA
clobetasol propionate soln 0.05%
P
QL (180 mls/90 days)
clobetasol propionate spray 0.05% (Clobex)
NP
PA, QL (180 mls/90 days)
clocortolone pivalate cream 0.1% (Cloderm)
NP
PA
CLODERM – clocortolone pivalate cream 0.1%
NP
PA
DERMA-SMOOTHE/FS BODY – fluocinolone acetonide oil
0.01% (body oil)
NP
PA
DERMA-SMOOTHE/FS SCALP – fluocinolone acetonide oil
0.01% (scalp oil)
NP
PA
desonide cream 0.05% (Desowen)
P
desonide lotion 0.05%
NP
PA
desonide oint 0.05%
P
desoximetasone cream 0.05%, 0.25% (Topicort)
NP
PA, QL (100 grams/30 days)
desoximetasone gel 0.05% (Topicort)
NP
PA, QL (100 grams/30 days)
desoximetasone oint 0.05%, 0.25% (Topicort)
NP
PA, QL (100 grams/30 days)
desoximetasone spray 0.25% (Topicort)
NP
PA, QL (100 mls/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
95
Drug Name
Preferred Status Drug Status / Restriction
DIFLORASONE DIACETATE – diflorasone diacetate cream
0.05%
P
QL (100 grams/30 days)
diflorasone diacetate oint 0.05%
P
QL (100 grams/30 days)
DIPROLENE – betamethasone dipropionate augmented oint
0.05%
NP
PA, QL (180 grams/90 days)
DUOBRII – halobetasol propionate-tazarotene lotion
0.01-0.045%
NP
PA, QL (100 grams/30 days)
ENSTILAR – calcipotriene-betamethasone dipropionate foam
0.005-0.064%
NP
PA, QL (120 grams/30 days)
EPIFOAM – pramoxine-hc aerosol foam 1-1%
NP
PA
FLUOCINOLONE ACETONIDE – fluocinolone acetonide cream
0.01%
P
fluocinolone acetonide cream 0.025% (Synalar)
P
fluocinolone acetonide oil 0.01% (body oil) (Derma-smoothe/fs
body)
P
fluocinolone acetonide oil 0.01% (scalp oil) (Derma-smoothe/fs
scalp)
P
fluocinolone acetonide oint 0.025% (Synalar)
P
fluocinolone acetonide soln 0.01% (Synalar)
P
fluocinonide cream 0.05%
P
QL (100 grams/30 days)
fluocinonide cream 0.1% (Vanos)
P
QL (120 grams/90 days)
fluocinonide emulsified base cream 0.05%
P
QL (100 grams/30 days)
fluocinonide gel 0.05%
P
QL (100 grams/30 days)
fluocinonide oint 0.05%
P
QL (100 grams/30 days)
fluocinonide soln 0.05%
P
QL (100 mls/30 days)
FLURANDRENOLIDE – flurandrenolide cream 0.05%
NP
PA
FLURANDRENOLIDE – flurandrenolide lotion 0.05%
NP
PA
FLUTICASONE PROPIONATE – fluticasone propionate lotion
0.05%
NP
PA
fluticasone propionate cream 0.05%
P
fluticasone propionate oint 0.005%
P
halcinonide cream 0.1% (Halog)
NP
PA, QL (100 grams/30 days)
halobetasol propionate cream 0.05%
P
QL (180 grams/90 days)
halobetasol propionate foam 0.05% (Lexette)
NP
PA, QL (180 grams/90 days)
halobetasol propionate oint 0.05%
P
QL (180 grams/90 days)
HALOG – halcinonide soln 0.1%
NP
PA, QL (120 mls/30 days)
HALOG – halcinonide cream 0.1%
NP
PA, QL (100 grams/30 days)
HALOG – halcinonide oint 0.1%
NP
PA, QL (100 grams/30 days)
HYDROCORTISONE BUTYRATE – hydrocortisone butyrate soln
0.1%
NP
PA
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
96
Drug Name
Preferred Status Drug Status / Restriction
HYDROCORTISONE BUTYRATE – hydrocortisone butyrate
cream 0.1%
NP
PA
hydrocortisone butyrate lotion 0.1% (Locoid)
NP
PA
hydrocortisone butyrate oint 0.1%
NP
PA
HYDROCORTISONE COMPLETE KIT – hydrocortisone lotion
2% & cleanser liq therapy pack
NP
PA
hydrocortisone cream 1%, 2.5%
P
hydrocortisone lotion 2.5%
P
hydrocortisone oint 1%, 2.5%
P
hydrocortisone valerate cream 0.2%
P
hydrocortisone valerate oint 0.2%
P
HYDROXYM – hydrocortisone gel 2%
NP
PA
LEXETTE – halobetasol propionate foam 0.05%
NP
PA, QL (180 grams/90 days)
LOCOID – hydrocortisone butyrate lotion 0.1%
NP
PA
LOCOID LIPOCREAM – hydrocortisone butyrate hydrophilic lipo
base cream 0.1%
NP
PA
mometasone furoate cream 0.1%
P
mometasone furoate oint 0.1%
P
QL (100 grams/30 days)
mometasone furoate solution 0.1% (lotion)
P
PANDEL – hydrocortisone probutate cream 0.1%
NP
PA
RADIAURA – lidocaine-hydrocortisone acetate cream 3-0.5%
NP
PA
SYNALAR – fluocinolone acetonide oint 0.025%
NP
PA
SYNALAR – fluocinolone acetonide cream 0.025%
NP
PA
TACLONEX – calcipotriene-betamethasone dipropionate susp
0.005-0.064%
NP
PA, QL (120 grams/30 days)
TEXACORT – hydrocortisone soln 2.5%
NP
PA
TOPICORT – desoximetasone cream 0.05%, 0.25%
NP
PA, QL (100 grams/30 days)
TOPICORT – desoximetasone gel 0.05%
NP
PA, QL (100 grams/30 days)
triamcinolone acetonide aerosol soln 0.147 mg/gm (Kenalog)
NP
PA
triamcinolone acetonide cream 0.025%, 0.1%
P
triamcinolone acetonide cream 0.5%
P
QL (100 grams/30 days)
triamcinolone acetonide lotion 0.025%, 0.1%
P
triamcinolone acetonide oint 0.025%, 0.1%
P
triamcinolone acetonide oint 0.05%
NP
PA
triamcinolone acetonide oint 0.5%
P
QL (100 grams/30 days)
ULTRAVATE – halobetasol propionate lotion 0.05%
NP
PA, QL (180 mls/90 days)
VANOS – fluocinonide cream 0.1%
NP
PA, QL (120 grams/90 days)
DERMATOLOGICALS : MISC
acyclovir cream 5% (Zovirax)
NP
PA
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
97
Drug Name
Preferred Status Drug Status / Restriction
acyclovir oint 5% (Zovirax)
NP
PA
ALADERM PLUS – dermatological products misc - emulsion
NP
PA
AMELUZ – aminolevulinic acid hcl gel 10%
NP
PA
azelaic acid gel 15% (Finacea)
NP
PA (>=25 yr)
BENSAL HP – salicylic acid oint 3%
NP
PA
bexarotene gel 1% (Targretin)
NP
PA, SP
brimonidine tartrate gel 0.33% (base equivalent) (Mirvaso)
NP
PA
CARAC – fluorouracil cream 0.5%
NP
PA, QL (30 grams/180 days)
CONDYLOX – podofilox gel 0.5%
P
DENAVIR – penciclovir cream 1%
NP
PA
DERMACINRX LIDOGEL – lidocaine hcl gel 2.8%
NP
PA, QL (120 grams/30 days)
DICLOFENAC EPOLAMINE – diclofenac epolamine patch 1.3%
NP
PA, QL (60 patches/30 days)
diclofenac sod soln 1.5% & capsaicin cream 0.025% ther pack
(Dermacinrx lexitral)
NP
PA
diclofenac sodium (actinic keratoses) gel 3%
NP
PA, QL (2 tubes/180 days)
diclofenac sodium gel 1% (1.16% diethylamine equiv) (Voltaren)
NP
PA, QL (200 grams/30 days)
diclofenac sodium soln 1.5%
NP
PA, QL (150 mls/30 days)
diclofenac sodium soln 2% (Pennsaid)
NP
PA, QL (112 grams/28 days)
doxepin hcl cream 5% (Prudoxin)
NP
PA, QL (45 grams/180 days)
doxycycline (rosacea) cap delayed release 40 mg (Oracea)
NP
PA
EFUDEX – fluorouracil cream 5%
NP
PA, QL (240 grams/180 days)
ELIDEL – pimecrolimus cream 1%
P
QL (60 days
supply/120 days), ST
EUCRISA – crisaborole oint 2%
P
QL (60 days
supply/120 days), ST
FINACEA – azelaic acid foam 15%
NP
PA (>=25 yr)
FLECTOR – diclofenac epolamine patch 1.3%
NP
PA, QL (60 patches/30 days)
FLUOROURACIL – fluorouracil soln 2%
NP
PA
FLUOROURACIL – fluorouracil cream 0.5%
NP
PA, QL (30 grams/180 days)
fluorouracil cream 5% (Efudex)
NP
PA, QL (240 grams/180 days)
fluorouracil soln 5%
NP
PA
HYCLODEX – hypochlorous acid soln 0.012%
NP
PA
HYFTOR – sirolimus gel 0.2%
NP
PA, QL (7 tubes/84 days)
HYLATOPIC PLUS – dermatological products misc - cream
NP
PA
imiquimod cream 3.75% (Zyclara Pump)
NP
PA, QL (15 grams/180 days)
imiquimod cream 3.75% (Zyclara Pump)
NP
PA, QL (56 packets/180 days)
imiquimod cream 5% (Aldara)
P
QL (48 packets/180 days)
ivermectin cream 1%
NP
PA, QL (45 grams/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
98
Drug Name
Preferred Status Drug Status / Restriction
lactic acid (ammonium lactate) cream 12%
NP
PA
lactic acid (ammonium lactate) lotion 12%
P
LEVULAN KERASTICK – aminolevulinic acid hcl for soln 20%
(stick applicator)
P
LICART – diclofenac epolamine patch 24hr 1.3%
NP
PA, QL (30 patches/30 days)
lidocaine hcl cream 3%
P
QL (120 grams/30 days)
lidocaine hcl soln 4%
P
QL (120 mls/30 days)
lidocaine hcl urethral/mucosal gel prefilled syringe 2%
P
QL (120 grams/30 days)
LIDOCAINE HYDROCHLORIDE – lidocaine hcl cream 4.12%
NP
PA, QL (120 grams/30 days)
lidocaine oint 5%
P
QL (71 grams/25 days)
lidocaine patch 5% (Lidoderm)
P
QL (90 patches/30 days)
lidocaine-prilocaine cream kit 2.5-2.5%
NP
PA
lidocaine-prilocaine cream 2.5-2.5%
NP
PA, QL (30 grams/60 days)
LIDODERM – lidocaine patch 5%
NP
PA, QL (90 patches/30 days)
LIDOREX – lidocaine hcl gel 2.8%
NP
PA, QL (120 grams/30 days)
LIDOTRAL – lidocaine hcl cream 3.88%
NP
PA, QL (120 grams/30 days)
LIDOTRAL/MENTHOL – lidocaine-menthol liquid spray 5-3%
NP
PA
LIDOTRAN – lidocaine hcl cream 3.88%
NP
PA, QL (120 grams/30 days)
LYDEXA – lidocaine hcl cream 4.12%
NP
PA, QL (120 grams/30 days)
mafenide acetate packet for topical soln 5% (50 gm) (Sulfamylon)
P
metronidazole cream 0.75% (Metrocream)
P
metronidazole gel 0.75%
P
metronidazole gel 1% (Metrogel)
P
QL (60 grams/30 days)
metronidazole lotion 0.75% (Metrolotion)
P
NORITATE – metronidazole cream 1%
NP
PA (>=25 yr)
NUVAIL – dermatological products misc - solution
NP
PA
OVACE PLUS – sulfacetamide sodium lotion 9.8%
NP
PA
penciclovir cream 1% (Denavir)
NP
PA
PENNSAID – diclofenac sodium soln 2%
NP
PA, QL (112 grams/28 days)
pimecrolimus cream 1% (Elidel)
P
QL (60 days
supply/120 days), ST
PODOCON-25 – podophyllum resin soln 25%
NP
PA
PODOFILOX – podofilox soln 0.5%
P
podofilox gel 0.5% (Condylox)
P
PRUDOXIN – doxepin hcl cream 5%
NP
PA, QL (45 grams/180 days)
QUTENZA – capsaicin patch 8% & cleansing gel kit
NP
PA
RHOFADE – oxymetazoline hcl cream 1%
NP
PA
SALICATE – salicylic acid liquid 10%
NP
PA
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
99
Drug Name
Preferred Status Drug Status / Restriction
SALICYLIC ACID – salicylic acid oint 3%
P
salicylic acid film forming liquid 27.5% (Virasal)
P
salicylic acid foam 6% (Salvax)
NP
PA
salicylic acid gel 6% (Keralyt)
P
SALYCIM – salicylic acid cream 6%
NP
PA
selenium sulfide lotion 2.5%
P
selenium sulfide shampoo 2.25%
NP
PA
SILVADENE – silver sulfadiazine cream 1%
NP
PA
SILVER NITRATE – silver nitrate soln 0.5%
NP
PA
silver sulfadiazine cream 1% (Silvadene)
P
sulfacetamide sodium cleansing gel 10% (Ovace plus wash)
NP
PA
sulfacetamide sodium liquid 10% (Ovace wash)
NP
PA
SULFAMYLON – mafenide acetate cream 85 mg/gm
P
tacrolimus oint 0.03%, 0.1% (Protopic)
P
QL (60 days
supply/120 days), ST
TARGRETIN – bexarotene gel 1%
P
SP
UREA – urea cream 39.5%
P
urea cream 20%, 39%, 40%
P
urea cream 41% (Utopic)
P
UREA HYDRATING – urea in lactic acid vehicle foam 35%
NP
PA
urea lotion 40%
P
UREA/SALICYLIC ACID – salicylic acid & urea cream 2-39.5%
NP
PA
VALCHLOR – mechlorethamine hcl gel 0.016% (base equivalent)
NP
PA, SP
VEREGEN – sinecatechins oint 15%
NP
PA
VYJUVEK – beremagene geperpavec-svdt gel 5,000,000,000
pfu/2.5ml
NP
PA, SP
XERAC AC – aluminum chloride in alcohol solution 6.25%
NP
PA
XERESE – acyclovir-hydrocortisone cream 5-1%
NP
PA
XYLIDERM – lidocaine patch 5% & adhesive sheet kit
NP
PA
YCANTH – cantharidin soln 0.7%
NP
PA
ZONALON – doxepin hcl cream 5%
NP
PA, QL (45 grams/180 days)
ZORYVE – roflumilast foam 0.3%
NP
PA
ZOVIRAX – acyclovir cream 5%
NP
PA
ZOVIRAX – acyclovir oint 5%
NP
PA
ZTLIDO – lidocaine patch 1.8% (36 mg)
NP
PA, QL (90 systems/30 days)
ZYCLARA – imiquimod cream 3.75%
NP
PA, QL (56 packets/180 days)
ZYCLARA PUMP – imiquimod cream 2.5%, 3.75%
NP
PA, QL (15 grams/180 days)
DERMATOLOGICALS : SCABICIDES & PEDICULICIDES
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
100
Drug Name
Preferred Status Drug Status / Restriction
CROTAN – crotamiton lotion 10%
NP
PA
malathion lotion 0.5% (Ovide)
NP
PA
NATROBA – spinosad susp 0.9%
P
permethrin cream 5% (Elimite)
P
permethrin creme rinse 1%
P
pyrethrins-piperonyl butoxide shampoo 0.33-4%
P
SPINOSAD – spinosad susp 0.9%
NP
PA
DIGESTIVE ENZYMES
CREON – pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000
unit, 6000-19000-30000 unit, 12000-38000-60000 unit,
24000-76000-120000 unit, 36000-114000-180000 unit
P
PERTZYE – pancrelipase (lip-prot-amyl) dr cap
4000-14375-15125 unit, 8000-28750-30250 unit,
16000-57500-60500 unit, 24000-86250-90750 unit
NP
PA
VIOKACE – pancrelipase (lip-prot-amyl) tab 10440-39150-39150
unit, 20880-78300-78300 unit
NP
PA
ZENPEP – pancrelipase (lip-prot-amyl) dr cap
3000-10000-14000 unit, 5000-17000-24000 unit,
10000-32000-42000 unit, 15000-47000-63000 unit,
20000-63000-84000 unit, 25000-79000-105000 unit,
40000-126000-168000 unit, 60000-189600-252600 unit
P
ENDOCRINE AND METABOLIC AGENTS : BONE DENSITY REGULATORS
ACTONEL – risedronate sodium tab 35 mg
NP
PA, QL (4 tablets/28 days), 90
ACTONEL – risedronate sodium tab 150 mg
NP
PA, QL (1 tablets/30 days), 90
ALENDRONATE SODIUM – alendronate sodium tab 5 mg
P
QL (30 tablets/30 days), 90
alendronate sodium oral soln 70 mg/75ml
P
QL (300 mls/28 days), 90
alendronate sodium tab 10 mg
P
QL (30 tablets/30 days), 90
alendronate sodium tab 35 mg
P
QL (4 tablets/28 days), 90
alendronate sodium tab 70 mg (Fosamax)
P
QL (4 tablets/28 days), 90
ATELVIA – risedronate sodium tab delayed release 35 mg
NP
PA, QL (4 tablets/28 days), 90
BINOSTO – alendronate sodium effervescent tab 70 mg
NP
PA, QL (4 tablets/28 days), 90
calcitonin (salmon) nasal soln 200 unit/act
P
90
FOSAMAX – alendronate sodium tab 70 mg
NP
PA, QL (4 tablets/28 days), 90
FOSAMAX PLUS D – alendronate sodium-cholecalciferol tab
70-2800 mg-unit, 70-5600 mg-unit
NP
PA, QL (4 tablets/28 days), 90
ibandronate sodium tab 150 mg (base equivalent) (Boniva)
NP
PA, QL (1 tablet/30 days), 90
risedronate sodium tab delayed release 35 mg (Atelvia)
NP
PA, QL (4 tablets/28 days), 90
risedronate sodium tab 5 mg, 30 mg (Actonel)
NP
PA, QL (30 tablets/30
days), 90
risedronate sodium tab 35 mg (Actonel)
NP
PA, QL (4 tablets/28 days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
101
Drug Name
Preferred Status Drug Status / Restriction
risedronate sodium tab 150 mg (Actonel)
NP
PA, QL (1 tablets/30 days), 90
ENDOCRINE AND METABOLIC AGENTS : GROWTH HORMONES
GENOTROPIN – somatropin for subcutaneous inj cartridge 5 mg,
12 mg (36 unit)
P
PA, SP
GENOTROPIN MINIQUICK – somatropin for subcutaneous inj
prefilled syr 0.2 mg, 0.4 mg, 0.6 mg, 0.8 mg, 1 mg, 1.2 mg,
1.4 mg, 1.6 mg, 1.8 mg, 2 mg
P
PA, SP
HUMATROPE – somatropin for inj cartridge 6 mg (18 unit),
12 mg (36 unit), 24 mg
NP
PA, SP
MYCAPSSA – octreotide acetate cap delayed release 20 mg
NP
PA, QL (120
capsules/30 days), SP
NGENLA – somatrogon-ghla solution pen-injector 24 mg/1.2ml
(20 mg/ml), 60 mg/1.2ml (50 mg/ml)
NP
PA, SP
NORDITROPIN FLEXPRO – somatropin solution pen-injector
5 mg/1.5ml, 10 mg/1.5ml, 15 mg/1.5ml, 30 mg/3ml
NP
PA, SP
NUTROPIN AQ NUSPIN 10 – somatropin solution pen-injector
10 mg/2ml
NP
PA, SP
NUTROPIN AQ NUSPIN 20 – somatropin solution pen-injector
20 mg/2ml
NP
PA, SP
NUTROPIN AQ NUSPIN 5 – somatropin solution pen-injector
5 mg/2ml
NP
PA, SP
OCTREOTIDE ACETATE – octreotide acetate subcutaneous soln
pref syr 50 mcg/ml, 100 mcg/ml, 500 mcg/ml
NP
PA, QL (90 syringes/30
days), SP
octreotide acetate inj 50 mcg/ml (0.05 mg/ml), 100 mcg/ml
(0.1 mg/ml) (Sandostatin)
NP
PA, QL (90 mls/30 days), SP
octreotide acetate inj 200 mcg/ml (0.2 mg/ml)
NP
PA, QL (90 mls/30 days), SP
octreotide acetate inj 500 mcg/ml (0.5 mg/ml) (Sandostatin)
NP
PA, QL (90 vials/30 days), SP
octreotide acetate inj 1000 mcg/ml (1 mg/ml)
NP
PA, QL (30 vials/30 days), SP
OMNITROPE – somatropin solution cartridge 5 mg/1.5ml,
10 mg/1.5ml
NP
PA, SP
OMNITROPE – somatropin for inj 5.8 mg
NP
PA, SP
SAIZEN – somatropin (non-refrigerated) for inj 5 mg
NP
PA, SP
SANDOSTATIN – octreotide acetate inj 50 mcg/ml (0.05 mg/ml),
100 mcg/ml (0.1 mg/ml)
NP
PA, QL (90 mls/30 days), SP
SANDOSTATIN – octreotide acetate inj 500 mcg/ml (0.5 mg/ml)
NP
PA, QL (90 vials/30 days), SP
SANDOSTATIN LAR DEPOT – octreotide acetate for im inj kit
10 mg, 20 mg, 30 mg
NP
PA, QL (1 kit/28 days), SP
SEROSTIM – somatropin (non-refrigerated) for subcutaneous inj
4 mg, 5 mg, 6 mg
NP
PA, SP
SKYTROFA – lonapegsomatropin-tcgd for subcutaneous inj
cartridge 3 mg, 3.6 mg, 4.3 mg, 5.2 mg, 6.3 mg, 7.6 mg,
9.1 mg, 11 mg
NP
PA, SP
SKYTROFA – lonapegsomatropin-tcgd for subcutaneous inj cart
13.3 mg
NP
PA, SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
102
Drug Name
Preferred Status Drug Status / Restriction
SOGROYA – somapacitan-beco solution pen-injector
5 mg/1.5ml, 10 mg/1.5ml, 15 mg/1.5ml
NP
PA, SP
ZOMACTON – somatropin for subcutaneous inj 5 mg
NP
PA, SP
ZOMACTON – somatropin for inj 10 mg
NP
PA, SP
ENDOCRINE AND METABOLIC AGENTS : MISC
betaine powder for oral solution (Cystadane)
NP
PA, QL (180
grams/30 days), SP
BUPHENYL – sodium phenylbutyrate tab 500 mg
NP
PA, SP
BUPHENYL – sodium phenylbutyrate oral powder 3 gm/
teaspoonful
NP
PA, SP
cabergoline tab 0.5 mg
P
CARBAGLU – carglumic acid soluble tab 200 mg
NP
PA, SP
carglumic acid soluble tab 200 mg manufacturer Burel Pharma
(Carbaglu)
NP
PA, SP
carglumic acid soluble tab 200 mg manufacturer Eton Pharma
(Carbaglu)
P
PA, SP
CARNITOR – levocarnitine tab 330 mg
NP
PA, 90
CARNITOR – levocarnitine oral soln 1 gm/10ml (10%)
NP
PA, 90
CARNITOR SF – levocarnitine oral soln 1 gm/10ml (10%)
NP
PA, 90
cinacalcet hcl tab 30 mg (base equiv), 60 mg (base equiv), 90 mg
(base equiv) (Sensipar)
NP
PA
CYSTADANE – betaine powder for oral solution
NP
PA, QL (180
grams/30 days), SP
DDAVP – desmopressin acetate tab 0.1 mg, 0.2 mg
NP
PA, 90
desmopressin acetate nasal spray soln 0.01% (Ddavp)
P
desmopressin acetate nasal spray soln 0.01% (refrigerated)
P
desmopressin acetate tab 0.1 mg, 0.2 mg (Ddavp)
P
90
EGRIFTA SV – tesamorelin acetate for inj 2 mg (base equiv)
NP
PA, SP
EVISTA – raloxifene hcl tab 60 mg
NP
PA, 90
GALAFOLD – migalastat hcl cap 123 mg (base equivalent)
NP
PA, QL (14 capsules/28
days), SP
INCRELEX – mecasermin inj 40 mg/4ml (10 mg/ml)
NP
PA, SP
ISTURISA – osilodrostat phosphate tab 1 mg
NP
PA, QL (240
tablets/30 days), SP
ISTURISA – osilodrostat phosphate tab 5 mg
NP
PA, QL (360
tablets/30 days), SP
JYNARQUE – tolvaptan tab therapy pack 15 mg, 30 & 15 mg, 45
& 15 mg, 60 & 30 mg, 90 & 30 mg
NP
PA, QL (56 tablets/28
days), SP
JYNARQUE – tolvaptan tab 15 mg
NP
PA, QL (60 tablets/30
days), SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
103
Drug Name
Preferred Status Drug Status / Restriction
JYNARQUE – tolvaptan tab 30 mg
NP
PA, QL (30 tablets/30
days), SP
KERENDIA – finerenone tab 10 mg, 20 mg
P
PA, QL (30 tablets/30 days)
KUVAN – sapropterin dihydrochloride tab 100 mg
NP
PA, SF, SP
KUVAN – sapropterin dihydrochloride powder packet 100 mg,
500 mg
NP
PA, SF, SP
LANREOTIDE ACETATE – lanreotide acetate extended release
inj 120 mg/0.5ml
NP
PA, QL (1 syringe/28
days), SP
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor)
NP
PA, 90
levocarnitine tab 330 mg (Carnitor)
NP
PA, 90
LUPRON DEPOT-PED (1-MONTH) – leuprolide acetate for inj
pediatric kit 7.5 mg, 11.25 mg, 15 mg
SC
PA, SP
LUPRON DEPOT-PED (3-MONTH) – leuprolide acetate (3
month) for inj pediatric kit 11.25 mg, 30 mg
SC
PA, SP
methylergonovine maleate tab 0.2 mg
SC
mifepristone tab 200 mg (Mifeprex)
P
nitisinone cap 2 mg, 5 mg, 10 mg, 20 mg (Orfadin)
P
SP
NITYR – nitisinone tab 2 mg, 5 mg, 10 mg
NP
PA, SP
NOCDURNA – desmopressin acetate sublingual tab 27.7 mcg,
55.3 mcg
NP
PA, QL (30 tablets/30 days)
OLPRUVA – sodium phenylbutyrate packet for susp 2 gm
therapy pack
NP
PA, SP
OLPRUVA – sodium phenylbutyrate packet for susp 3 gm
therapy pack
NP
PA, SP
OLPRUVA – sodium phenylbutyrate packet for susp 4 gm
therapy pack
NP
PA, SP
OLPRUVA – sodium phenylbutyrate packet for susp 5 gm
therapy pack
NP
PA, SP
OLPRUVA – sodium phenylbutyrate packet for susp 6 gm
therapy pack
NP
PA, SP
OLPRUVA – sodium phenylbutyrate packet for susp 6.67 gm
therapy pack
NP
PA, SP
ORFADIN – nitisinone cap 2 mg, 5 mg, 10 mg, 20 mg
P
SP
ORFADIN – nitisinone susp 4 mg/ml
NP
PA, SP
ORILISSA – elagolix sodium tab 150 mg (base equiv)
P
PA, QL (30 tablets/30 days)
ORILISSA – elagolix sodium tab 200 mg (base equiv)
P
PA, QL (60 tablets/30 days)
OSPHENA – ospemifene tab 60 mg
NP
PA, 90
PHEBURANE – sodium phenylbutyrate oral pellets 483 mg/gm
NP
PA, SP
raloxifene hcl tab 60 mg (Evista)
NP
PA, 90
RAVICTI – glycerol phenylbutyrate liquid 1.1 gm/ml
NP
PA, SP
RECORLEV – levoketoconazole tab 150 mg
NP
PA, QL (240
tablets/30 days), SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
104
Drug Name
Preferred Status Drug Status / Restriction
SAMSCA – tolvaptan tab 15 mg
NP
PA, QL (30 tablets/365
days), SP
SAMSCA – tolvaptan tab 30 mg
NP
PA, QL (60 tablets/365
days), SP
sapropterin dihydrochloride powder packet 100 mg, 500 mg
(Kuvan)
NP
PA, SF, SP
sapropterin dihydrochloride tab 100 mg (Kuvan)
NP
PA, SF, SP
SENSIPAR – cinacalcet hcl tab 30 mg (base equiv), 60 mg (base
equiv), 90 mg (base equiv)
NP
PA
SIGNIFOR – pasireotide diaspartate inj 0.3 mg/ml (base equiv),
0.6 mg/ml (base equiv), 0.9 mg/ml (base equiv)
NP
PA, QL (60 mls/30 days), SP
SIGNIFOR LAR – pasireotide pamoate for im er susp 10 mg
(base equiv), 20 mg (base equiv), 30 mg (base equiv), 40 mg
(base equiv), 60 mg (base equiv)
NP
PA, QL (1 kit/28 days)
sodium phenylbutyrate oral powder 3 gm/teaspoonful (Buphenyl)
NP
PA, SP
sodium phenylbutyrate tab 500 mg (Buphenyl)
NP
PA, SP
SOMATULINE DEPOT – lanreotide acetate extended release inj
60 mg/0.2ml, 90 mg/0.3ml, 120 mg/0.5ml
NP
PA, QL (1 syringe/28
days), SP
STRENSIQ – asfotase alfa subcutaneous inj 18 mg/0.45ml,
28 mg/0.7ml, 40 mg/ml, 80 mg/0.8ml
SC
PA, SP
SYNAREL – nafarelin acetate nasal soln 2 mg/ml (200 mcg/act)
(base eq)
NP
PA, SP
tolvaptan tab 15 mg (Samsca)
NP
PA, QL (30 tablets/365
days), SP
tolvaptan tab 30 mg (Samsca)
NP
PA, QL (60 tablets/365
days), SP
TYMLOS – abaloparatide subcutaneous soln pen-injector
3120 mcg/1.56ml
SC
PA, QL (1 pen/30 days), SP
ENDOCRINE AND METABOLIC AGENTS : VITAMIN D ANALOGS
calcitriol cap 0.25 mcg, 0.5 mcg (Rocaltrol)
P
90
calcitriol oral soln 1 mcg/ml (Rocaltrol)
P
90
doxercalciferol cap 0.5 mcg, 1 mcg, 2.5 mcg
P
90
paricalcitol cap 1 mcg, 2 mcg (Zemplar)
NP
PA, 90
paricalcitol cap 4 mcg
NP
PA, 90
RAYALDEE – calcifediol cap er 30 mcg
NP
PA, QL (60 capsules/30
days), 90
ROCALTROL – calcitriol cap 0.25 mcg, 0.5 mcg
NP
PA, 90
ROCALTROL – calcitriol oral soln 1 mcg/ml
NP
PA, 90
ZEMPLAR – paricalcitol cap 1 mcg, 2 mcg
NP
PA, 90
ESTROGENS
ACTIVELLA – estradiol & norethindrone acetate tab 1-0.5 mg
NP
PA, 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
105
Drug Name
Preferred Status Drug Status / Restriction
ANGELIQ – drospirenone-estradiol tab 0.25-0.5 mg, 0.5-1 mg
NP
PA, 90
BIJUVA – estradiol-progesterone cap 0.5-100 mg, 1-100 mg
NP
PA, 90
CLIMARA – estradiol td patch weekly 0.025 mg/24hr,
0.0375 mg/24hr (37.5 mcg/24hr), 0.05 mg/24hr, 0.06 mg/24hr,
0.075 mg/24hr, 0.1 mg/24hr
NP
PA, QL (4 patches/28
days), 90
CLIMARA PRO – estradiol-levonorgestrel td patch weekly
0.045-0.015 mg/day
NP
PA, 90
COMBIPATCH – estradiol-norethindrone ace td pttw
0.05-0.14 mg/day, 0.05-0.25 mg/day
P
90
DELESTROGEN – estradiol valerate im in oil 10 mg/ml, 20 mg/
ml, 40 mg/ml
NP
PA
DEPO-ESTRADIOL – estradiol cypionate im in oil 5 mg/ml
NP
PA
DIVIGEL – estradiol td gel 0.25 mg/0.25gm (0.1%), 0.5 mg/0.5gm
(0.1%), 0.75 mg/0.75gm (0.1%), 1 mg/gm (0.1%),
1.25 mg/1.25gm (0.1%)
NP
PA, 90
DUAVEE – conjugated estrogens-bazedoxifene tab 0.45-20 mg
NP
PA, 90
ELESTRIN – estradiol gel 0.06% (0.52 mg/0.87 gm metered-
dose pump)
NP
PA, 90
ESTRACE – estradiol tab 0.5 mg, 1 mg, 2 mg
NP
PA, 90
estradiol & norethindrone acetate tab 0.5-0.1 mg
P
90
estradiol & norethindrone acetate tab 1-0.5 mg (Activella)
P
90
estradiol tab 0.5 mg, 1 mg, 2 mg (Estrace)
P
90
estradiol td gel 0.25 mg/0.25gm (0.1%), 0.5 mg/0.5gm (0.1%),
0.75 mg/0.75gm (0.1%), 1 mg/gm (0.1%), 1.25 mg/1.25gm
(0.1%) (Divigel)
NP
PA, 90
estradiol td patch twice weekly 0.025 mg/24hr, 0.0375 mg/24hr,
0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr (Vivelle-dot)
P
QL (8 patches/28 days), 90
estradiol td patch weekly 0.025 mg/24hr, 0.0375 mg/24hr
(37.5 mcg/24hr), 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr,
0.1 mg/24hr (Climara)
P
QL (4 patches/28 days), 90
estradiol valerate im in oil 10 mg/ml, 20 mg/ml, 40 mg/ml
(Delestrogen)
NP
PA
EVAMIST – estradiol transdermal spray 1.53 mg/spray
NP
PA, 90
MENEST – esterified estrogens tab 0.3 mg, 0.625 mg, 1.25 mg,
2.5 mg
P
90
MENOSTAR – estradiol td patch weekly 14 mcg/24hr
NP
PA, QL (4 patches/28
days), 90
MINIVELLE – estradiol td patch twice weekly 0.025 mg/24hr,
0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr
NP
PA, QL (8 patches/28
days), 90
MYFEMBREE – relugolix-estradiol-norethindrone acetate tab
40-1-0.5 mg
P
PA, QL (30 tablets/30 days)
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5 mcg
(Femhrt low dose)
NP
PA, 90
norethindrone acetate-ethinyl estradiol tab 1 mg-5 mcg
NP
PA, 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
106
Drug Name
Preferred Status Drug Status / Restriction
ORIAHNN – elagolix-estrad-noreth 300-1-0.5mg & elagolix
300mg cap pack
P
PA, QL (1 box/28 days)
PREMARIN – estrogens, conjugated tab 0.3 mg, 0.45 mg,
0.625 mg, 0.9 mg, 1.25 mg
P
90
PREMPHASE – conj est 0.625(14)/conj est-medroxypro ac tab
0.625-5mg(14)
P
90
PREMPRO – conjugated estrogen-medroxyprogest acetate tab
0.3-1.5 mg, 0.45-1.5 mg, 0.625-2.5 mg, 0.625-5 mg
P
90
VIVELLE-DOT – estradiol td patch twice weekly 0.025 mg/24hr,
0.0375 mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr
NP
PA, QL (8 patches/28
days), 90
GASTROINTESTINAL AGENTS : INFLAMMATORY BOWEL AGENTS
APRISO – mesalamine cap er 24hr 0.375 gm
NP
PA, 90
AZULFIDINE – sulfasalazine tab 500 mg
NP
PA, 90
AZULFIDINE EN-TABS – sulfasalazine tab delayed release
500 mg
NP
PA, 90
balsalazide disodium cap 750 mg (Colazal)
P
CANASA – mesalamine suppos 1000 mg
NP
PA
COLAZAL – balsalazide disodium cap 750 mg
NP
PA
DELZICOL – mesalamine cap dr 400 mg
NP
PA, 90
DIPENTUM – olsalazine sodium cap 250 mg
NP
PA, 90
LIALDA – mesalamine tab delayed release 1.2 gm
NP
PA, 90
mesalamine cap dr 400 mg (Delzicol)
NP
PA, 90
mesalamine cap er 24hr 0.375 gm (Apriso)
NP
PA, 90
mesalamine cap er 500 mg (Pentasa)
P
90
MESALAMINE DR – mesalamine tab delayed release 800 mg
NP
PA
mesalamine enema 4 gm
P
mesalamine rectal enema 4 gm & cleanser wipe kit (Rowasa)
NP
PA
mesalamine suppos 1000 mg (Canasa)
P
mesalamine tab delayed release 1.2 gm (Lialda)
NP
PA, 90
PENTASA – mesalamine cap er 250 mg, 500 mg
P
90
ROWASA – mesalamine rectal enema 4 gm & cleanser wipe kit
NP
PA
SFROWASA – mesalamine sulfite-free (sf) enema 4 gm/60ml
P
sulfasalazine tab delayed release 500 mg (Azulfidine en-tabs)
P
90
sulfasalazine tab 500 mg (Azulfidine)
P
90
GASTROINTESTINAL AGENTS : MISC
alosetron hcl tab 0.5 mg (base equiv), 1 mg (base equiv)
(Lotronex)
NP
PA, QL (60 tablets/30 days)
AMITIZA – lubiprostone cap 8 mcg, 24 mcg
NP
PA, QL (60 capsules/30
days), 90
CHENODAL – chenodiol tab 250 mg
NP
PA, SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
107
Drug Name
Preferred Status Drug Status / Restriction
CHOLBAM – cholic acid cap 50 mg, 250 mg
NP
PA, SP
cromolyn sodium oral conc 100 mg/5ml (Gastrocrom)
P
90
GASTROCROM – cromolyn sodium oral conc 100 mg/5ml
NP
PA, 90
GATTEX – teduglutide (rdna) for inj kit 5 mg
NP
PA, SP
GIMOTI – metoclopramide hcl nasal spray 15 mg/act
NP
PA
IBSRELA – tenapanor hcl tab 50 mg
NP
PA, QL (60 tablets/30
days), 90
lactulose (encephalopathy) solution 10 gm/15ml
P
90
LINZESS – linaclotide cap 72 mcg, 145 mcg, 290 mcg
NP
PA, QL (30 capsules/30 days)
LOTRONEX – alosetron hcl tab 0.5 mg (base equiv), 1 mg (base
equiv)
NP
PA, QL (60 tablets/30 days)
lubiprostone cap 8 mcg, 24 mcg (Amitiza)
NP
PA, QL (60 capsules/30
days), 90
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base equiv)
P
metoclopramide hcl tab 5 mg (base equivalent), 10 mg (base
equivalent) (Reglan)
P
METOCLOPRAMIDE ODT – metoclopramide hcl orally
disintegrating tab 5 mg (base eq)
NP
PA
MOTEGRITY – prucalopride succinate tab 1 mg (base
equivalent), 2 mg (base equivalent)
NP
PA, QL (30 tablets/30 days)
MOVANTIK – naloxegol oxalate tab 12.5 mg (base equivalent),
25 mg (base equivalent)
NP
PA, QL (30 tablets/30 days)
OCALIVA – obeticholic acid tab 5 mg, 10 mg
NP
PA, QL (30 tablets/30
days), SF, SP
REGLAN – metoclopramide hcl tab 5 mg (base equivalent),
10 mg (base equivalent)
NP
PA
RELISTOR – methylnaltrexone bromide tab 150 mg
NP
PA, QL (90 tablets/30 days)
RELISTOR – methylnaltrexone bromide inj 8 mg/0.4ml (20 mg/
ml), 12 mg/0.6ml (20 mg/ml)
NP
PA, QL (30 syringes/30 days)
RELISTOR – methylnaltrexone bromide inj 12 mg/0.6ml (20 mg/
ml)
NP
PA, QL (60 vials/30 days)
RELTONE – ursodiol cap 200 mg, 400 mg
NP
PA
SYMPROIC – naldemedine tosylate tab 0.2 mg (base equivalent)
NP
PA, QL (30 tablets/30 days)
TRULANCE – plecanatide tab 3 mg
NP
PA, QL (30 tablets/30 days)
URSO FORTE – ursodiol tab 500 mg
NP
PA, 90
URSO 250 – ursodiol tab 250 mg
NP
PA, 90
ursodiol cap 300 mg (Actigall)
P
90
ursodiol tab 250 mg (Urso 250)
NP
PA, 90
ursodiol tab 500 mg (Urso forte)
NP
PA, 90
VIBERZI – eluxadoline tab 75 mg, 100 mg
NP
PA, QL (60 tablets/30 days)
GASTROINTESTINAL AGENTS : PHOSPHATE BINDER AGENTS
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
108
Drug Name
Preferred Status Drug Status / Restriction
AURYXIA – ferric citrate tab 1 gm (210 mg ferric iron)
NP
PA, 90
calcium acetate (phosphate binder) cap 667 mg (169 mg ca)
P
90
calcium acetate (phosphate binder) tab 667 mg
P
90
FOSRENOL – lanthanum carbonate chew tab 500 mg
(elemental), 750 mg (elemental), 1000 mg (elemental)
NP
PA, 90
FOSRENOL – lanthanum carbonate oral powder pack 750 mg
(elemental), 1000 mg (elemental)
P
90
lanthanum carbonate chew tab 500 mg (elemental), 750 mg
(elemental), 1000 mg (elemental) (Fosrenol)
P
90
RENVELA – sevelamer carbonate tab 800 mg
NP
PA, 90
RENVELA – sevelamer carbonate packet 0.8 gm, 2.4 gm
NP
PA, 90
sevelamer carbonate packet 0.8 gm, 2.4 gm (Renvela)
NP
PA, 90
sevelamer carbonate tab 800 mg (Renvela)
P
90
sevelamer hcl tab 400 mg
P
90
sevelamer hcl tab 800 mg (Renagel)
P
90
VELPHORO – sucroferric oxyhydroxide chew tab 500 mg
NP
PA, 90
GENITOURINARY AGENTS : MISC
CYSTAGON – cysteamine bitartrate cap 50 mg
P
SP
ELMIRON – pentosan polysulfate sodium caps 100 mg
NP
PA
K-PHOS NO 2 – potassium & sodium acid phosphates tab
305-700 mg
NP
PA
LITHOSTAT – acetohydroxamic acid tab 250 mg
NP
PA
ORACIT – sodium citrate & citric acid soln 490-640 mg/5ml
P
phenazopyridine hcl tab 100 mg, 200 mg (Pyridium)
P
pot & sod citrates w/ cit ac soln 550-500-334 mg/5ml
NP
PA
potassium citrate & citric acid soln 1100-334 mg/5ml
NP
PA
potassium citrate tab er 5 meq (540 mg) (Urocit-k 5)
NP
PA
potassium citrate tab er 10 meq (1080 mg) (Urocit-k 10)
NP
PA
potassium citrate tab er 15 meq (1620 mg) (Urocit-k 15)
NP
PA
PROCYSBI – cysteamine bitartrate delayed release granules
packet 75 mg, 300 mg
NP
PA, SP
PROCYSBI – cysteamine bitartrate cap delayed release 25 mg
(base equiv), 75 mg (base equiv)
NP
PA, SP
PYRIDIUM – phenazopyridine hcl tab 100 mg, 200 mg
NP
PA
sodium chloride irrigation soln 0.9%
SC
sodium citrate & citric acid soln 500-334 mg/5ml
P
THIOLA – tiopronin tab 100 mg
NP
PA
THIOLA EC – tiopronin tab delayed release 100 mg, 300 mg
NP
PA
tiopronin tab 100 mg (Thiola)
NP
PA
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
109
Drug Name
Preferred Status Drug Status / Restriction
UROCIT-K 10 – potassium citrate tab er 10 meq (1080 mg)
NP
PA
UROCIT-K 15 – potassium citrate tab er 15 meq (1620 mg)
NP
PA
UROCIT-K 5 – potassium citrate tab er 5 meq (540 mg)
NP
PA
GENITOURINARY AGENTS : PROSTATIC HYPERTROPHY AGENTS
alfuzosin hcl tab er 24hr 10 mg (Uroxatral)
P
QL (30 tablets/30 days), 90
CARDURA XL – doxazosin mesylate tab er 24 hr 4 mg (base
equiv), 8 mg (base equiv)
NP
PA, QL (30 tablets/30
days), 90
dutasteride cap 0.5 mg (Avodart)
NP
PA, QL (30 capsules/30
days), 90
dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)
NP
PA, QL (30 capsules/30
days), 90
finasteride tab 5 mg (Proscar)
P
QL (30 tablets/30 days), 90
FLOMAX – tamsulosin hcl cap 0.4 mg
NP
PA, QL (60 capsules/30
days), 90
JALYN – dutasteride-tamsulosin hcl cap 0.5-0.4 mg
NP
PA, QL (30 capsules/30
days), 90
PROSCAR – finasteride tab 5 mg
NP
PA, QL (30 tablets/30
days), 90
RAPAFLO – silodosin cap 4 mg, 8 mg
NP
PA, QL (30 capsules/30
days), 90
silodosin cap 4 mg, 8 mg (Rapaflo)
NP
PA, QL (60 capsules/30
days), 90
tamsulosin hcl cap 0.4 mg (Flomax)
P
QL (60 capsules/30 days), 90
GLUCOSE MONITORING SUPPLIES : CGMs
DEXCOM G6 RECEIVER – continuous glucose system receiver
P
PA, QL (1 receiver/365 days)
DEXCOM G6 SENSOR – continuous glucose system sensor
P
PA, QL (3 sensors/30 days)
DEXCOM G6 TRANSMITTER – continuous glucose system
transmitter
P
PA, QL (1
transmitter/90 days)
DEXCOM G7 RECEIVER – continuous glucose system receiver
P
PA, QL (1 receiver/365 days)
DEXCOM G7 SENSOR – continuous glucose system sensor
P
PA, QL (3 sensors/30 days)
ENLITE GLUCOSE SENSOR – continuous glucose system
sensor
NP
PA, QL (5 sensors/30 days)
EVERSENSE E3 SENSOR/HOLDER – continuous glucose
system sensor
NP
PA, QL (1 sensor/90 days)
EVERSENSE E3 SMART TRANSMITTER – continuous glucose
system transmitter
NP
PA, QL (1
transmitter/90 days)
EVERSENSE SENSOR/HOLDER KIT – continuous glucose
system sensor
NP
PA, QL (1 sensor/90 days)
EVERSENSE SMART TRANSMITTER – continuous glucose
system transmitter
NP
PA, QL (1
transmitter/90 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
110
Drug Name
Preferred Status Drug Status / Restriction
FREESTYLE LIBRE 14 DAY/READER/FLASH MONITORING
SYSTEM – continuous glucose system receiver
P
PA, QL (1 receiver/365 days)
FREESTYLE LIBRE 14 DAY/SENSOR/FLASH MONITORING
SYSTEM – continuous glucose system sensor
P
PA, QL (2 sensors/28 days)
FREESTYLE LIBRE 2/READER/FLASH GLUCOSE
MONITORING SYSTEM – continuous glucose system receiver
P
PA, QL (1 receiver/365 days)
FREESTYLE LIBRE 2/SENSOR/FLASH GLUCOSE
MONITORING SYSTEM – continuous glucose system sensor
P
PA, QL (2 sensors/28 days)
FREESTYLE LIBRE 3/READER/GLUCOSE MONITORING
SYSTEM – continuous glucose system receiver
P
PA, QL (1 receiver/365 days)
FREESTYLE LIBRE 3/SENSOR/GLUCOSE MONITORING
SYSTEM – continuous glucose system sensor
P
PA, QL (2 sensors/28 days)
FREESTYLE LIBRE/READER/FLASH MONITORING SYSTEM –
continuous glucose system receiver
NP
PA, QL (1 receiver/365 days)
GUARDIAN CONNECT TRANSMITTER – continuous glucose
system transmitter
NP
PA, QL (1
transmitter/90 days)
GUARDIAN LINK 3 TRANSMITTER KIT – continuous glucose
system transmitter
NP
PA, QL (1
transmitter/90 days)
GUARDIAN REAL-TIME CHARGER REPLACEMENT –
continuous glucose monitor supplies
NP
PA
GUARDIAN REAL-TIME REPLACEMENT MONITOR –
continuous glucose system receiver
NP
PA, QL (1 receiver/365 days)
GUARDIAN REAL-TIME TEST PLUG REPLACEMENT –
continuous glucose monitor supplies
NP
PA
GUARDIAN SENSOR (3) – continuous glucose system sensor
NP
PA, QL (5 sensors/30 days)
GUARDIAN 4 GLUCOSE SENSOR – continuous glucose system
sensor
NP
PA, QL (5 sensors/30 days)
GUARDIAN 4 TRANSMITTER KIT – continuous glucose system
transmitter
NP
PA, QL (1
transmitter/90 days)
MINILINK REAL-TIME TRANSMITTER – continuous glucose
system transmitter
NP
PA, QL (1
transmitter/90 days)
MINIMED 630G GUARDIAN PRESS STARTER TRANSMITTER
KIT – continuous glucose system transmitter
NP
PA, QL (1
transmitter/90 days)
OVAL TAPE – continuous glucose monitor supplies
NP
PA
PARADIGM REAL-TIME TRANSMITTER – continuous glucose
system transmitter
NP
PA, QL (1
transmitter/90 days)
GLUCOSE MONITORING SUPPLIES : INSULIN INFUSION DISPOSABLE PUMP
OMNIPOD CLASSIC PODS (GEN 3) – insulin infusion
disposable pump reservoir
P
PA, QL (30 pods/30 days)
OMNIPOD DASH INTRO KIT (GEN 4) – insulin infusion
disposable pump kit
P
PA, QL (1 kit/720 days)
OMNIPOD DASH PDM KIT (GEN 4) – insulin infusion disposable
pump kit
P
PA, QL (1 kit/720 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
111
Drug Name
Preferred Status Drug Status / Restriction
OMNIPOD DASH PODS (GEN 4) – insulin infusion disposable
pump reservoir
P
PA, QL (30 pods/30 days)
OMNIPOD GO 10 UNITS/DAY – insulin infusion disposable
pump kit 10 unit/24hr
NP
PA, QL (10 kits/30 days)
OMNIPOD GO 15 UNITS/DAY – insulin infusion disposable
pump kit 15 unit/24hr
NP
PA, QL (10 kits/30 days)
OMNIPOD GO 20 UNITS/DAY – insulin infusion disposable
pump kit 20 unit/24hr
NP
PA, QL (10 kits/30 days)
OMNIPOD GO 25 UNITS/DAY – insulin infusion disposable
pump kit 25 unit/24hr
NP
PA, QL (10 kits/30 days)
OMNIPOD GO 30 UNITS/DAY – insulin infusion disposable
pump kit 30 unit/24hr
NP
PA, QL (10 kits/30 days)
OMNIPOD GO 35 UNITS/DAY – insulin infusion disposable
pump kit 35 unit/24hr
NP
PA, QL (10 kits/30 days)
OMNIPOD GO 40 UNITS/DAY – insulin infusion disposable
pump kit 40 unit/24hr
NP
PA, QL (10 kits/30 days)
OMNIPOD 5 G6 INTRO KIT (GEN 5) – insulin infusion
disposable pump kit
P
PA, QL (1 kit/720 days)
OMNIPOD 5 G6 PODS (GEN 5) – insulin infusion disposable
pump reservoir
P
PA, QL (30 pods/30 days)
OMNIPOD 5 G7 INTRO KIT (GEN 5) – insulin infusion
disposable pump kit
P
PA, QL (1 kit/720 days)
OMNIPOD 5 G7 PODS (GEN 5) – insulin infusion disposable
pump reservoir
P
PA, QL (30 pods/30 days)
V-GO 20 – insulin infusion disposable pump kit 20 unit/24hr
NP
PA, QL (30 systems/30 days)
V-GO 30 – insulin infusion disposable pump kit 30 unit/24hr
NP
PA, QL (30 systems/30 days)
V-GO 40 – insulin infusion disposable pump kit 40 unit/24hr
NP
PA, QL (30 systems/30 days)
GOUT AGENTS
ALLOPURINOL – allopurinol tab 200 mg
P
90
allopurinol tab 100 mg, 300 mg (Zyloprim)
P
90
colchicine cap 0.6 mg (Mitigare)
NP
PA
colchicine tab 0.6 mg (Colcrys)
NP
PA
colchicine w/ probenecid tab 0.5-500 mg
P
90
febuxostat tab 40 mg, 80 mg (Uloric)
NP
PA, QL (30 tablets/30
days), 90
MITIGARE – colchicine cap 0.6 mg
NP
PA
probenecid tab 500 mg
P
90
ULORIC – febuxostat tab 40 mg, 80 mg
NP
PA, QL (30 tablets/30
days), 90
HEMATOLOGICAL AGENTS : ANTIHEMOPHILIC PRODUCTS
ADVATE – antihemophilic factor recomb (rahf-pfm) for inj 250
unit, 500 unit, 1000 unit, 1500 unit, 2000 unit, 3000 unit, 4000
unit
P
PA, SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
112
Drug Name
Preferred Status Drug Status / Restriction
ADYNOVATE – antihemophilic factor recomb pegylated for inj
250 unit, 500 unit, 750 unit, 1000 unit, 1500 unit, 2000 unit,
3000 unit
P
PA, SP
AFSTYLA – antihemophilic fact rcmb single chain for inj kit 250
unit, 500 unit, 1000 unit, 1500 unit, 2000 unit, 2500 unit, 3000
unit
P
PA, SP
ALPHANATE – antihemophilic factor/vwf (human) for inj 250 unit,
500 unit, 1000 unit, 1500 unit, 2000 unit
P
PA, SP
ALPHANINE SD – coagulation factor ix for inj 500 unit, 1000 unit,
1500 unit
P
PA, SP
ALPROLIX – coagulation factor ix (recomb) (rfixfc) for inj 250
unit, 500 unit, 1000 unit, 2000 unit, 3000 unit, 4000 unit
P
PA, SP
BENEFIX – coagulation factor ix (recombinant) for inj kit 250 unit,
500 unit, 1000 unit, 2000 unit, 3000 unit
P
PA, SP
COAGADEX – coagulation factor x (human) for inj 250 unit, 500
unit
P
PA, SP
CORIFACT – factor xiii concentrate (human) for inj kit 1000-1600
unit
P
PA, SP
ELOCTATE – antihemophilic factor rcmb (bdd-rfviiifc) for inj 250
unit, 500 unit, 750 unit, 1000 unit, 1500 unit, 2000 unit, 3000
unit, 4000 unit, 5000 unit, 6000 unit
P
PA, SP
ESPEROCT – antihemophilic factor recomb glycopeg-exei for inj
500 unit, 1000 unit, 1500 unit, 2000 unit, 3000 unit
P
PA, SP
FEIBA – antiinhibitor coagulant complex for iv soln 500 unit, 1000
unit, 2500 unit
P
PA, SP
HEMLIBRA – emicizumab-kxwh subcutaneous soln 12 mg/0.4ml
(30 mg/ml), 30 mg/ml, 60 mg/0.4ml (150 mg/ml), 105 mg/0.7ml
(150 mg/ml), 150 mg/ml, 300 mg/2ml (150 mg/ml)
P
PA, SP
HEMOFIL M – antihemophilic factor (human) for inj 250 unit, 500
unit, 1000 unit, 1700 unit
P
PA, SP
HUMATE-P – antihemophilic factor/vwf (human) for inj 250-600
unit, 500-1200 unit, 1000-2400 unit
P
PA, SP
IDELVION – coagulation factor ix (recomb) (rix-fp) for inj 250 unit,
500 unit, 1000 unit, 2000 unit, 3500 unit
P
PA, SP
IXINITY – coagulation factor ix (recombinant) for inj 250 unit, 500
unit, 1000 unit, 1500 unit, 2000 unit, 3000 unit
P
PA, SP
JIVI – antihemophil fact rcmb(bdd-rfviii peg-aucl) for inj 500 unit
P
PA, SP
JIVI – antihemophil fact rcmb(bdd-rfviii peg-aucl)for inj 1000 unit,
2000 unit, 3000 unit
P
PA, SP
KOATE – antihemophilic factor (human) for inj 250 unit, 500 unit,
1000 unit
P
PA, SP
KOATE-DVI – antihemophilic factor (human) for inj 500 unit, 1000
unit
P
PA, SP
KOGENATE FS – antihemophilic factor recomb (rfviii) for inj kit
250 unit, 500 unit, 1000 unit, 2000 unit, 3000 unit
P
PA, SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
113
Drug Name
Preferred Status Drug Status / Restriction
KOVALTRY – antihemophilic factor recomb (rahf-pfm) for inj 250
unit, 500 unit, 1000 unit, 2000 unit, 3000 unit
P
PA, SP
NOVOEIGHT – antihemophilic fact rcmb (bd trunc-rfviii) for inj
250 unit, 500 unit, 1000 unit, 1500 unit, 2000 unit, 3000 unit
P
PA, SP
NOVOSEVEN RT – coagulation factor viia (recomb) for inj
1 mg (1000 mcg), 2 mg (2000 mcg), 5 mg (5000 mcg), 8 mg
(8000 mcg)
P
PA, SP
NUWIQ – antihemophilic factor rcmb (bdd-rfviii,sim) for inj 250
unit, 500 unit
P
PA, SP
NUWIQ – antihemophilic fact rcmb (bdd-rfviii,sim) for inj 1000
unit, 1500 unit, 2000 unit, 2500 unit, 3000 unit, 4000 unit
P
PA, SP
NUWIQ – antihemophil fact rcmb (bdd-rfviii,sim) for inj kit 250
unit, 500 unit
P
PA, SP
NUWIQ – antihemophil fact rcmb(bdd-rfviii,sim) for inj kit 1000
unit, 1500 unit, 2000 unit, 2500 unit, 3000 unit, 4000 unit
P
PA, SP
OBIZUR – antihemophilic factor (recomb porc) rpfviii for inj 500
unit
P
PA, SP
PROFILNINE – factor ix complex for inj 500 unit, 1000 unit, 1500
unit
P
PA, SP
REBINYN – coagulation factor ix recomb glycopegylated for inj
500 unt, 1000 unt, 2000 unt, 3000 unt
P
PA, SP
RECOMBINATE – antihemophilic factor recomb (rfviii) for inj
220-400 unit, 401-800 unit, 801-1240 unit, 1241-1800 unit,
1801-2400 unit
P
PA, SP
RIXUBIS – coagulation factor ix (recombinant) for inj 250 unit,
500 unit, 1000 unit, 2000 unit, 3000 unit
P
PA, SP
SEVENFACT – coagulation factor viia (recom)-jncw for inj 1 mg
(1000 mcg), 5 mg (5000 mcg)
P
PA, SP
TRETTEN – coagulation factor xiii a-subunit for inj 2500 unit
P
PA, SP
VONVENDI – von willebrand factor (recombinant) for inj 650 unit,
1300 unit
P
PA, SP
WILATE – antihemophilic factor/vwf (human) for inj 500-500 unit
kit
P
PA, SP
WILATE – antihemophilic factor/vwf (human) for inj 1000-1000
unit kit
P
PA, SP
XYNTHA – antihemophil fact rcmb (bdd-rfviii,mor) for inj kit 250
unit, 500 unit
P
PA, SP
XYNTHA – antihemophil fact rcmb(bdd-rfviii,mor) for inj kit 1000
unit, 2000 unit
P
PA, SP
XYNTHA SOLOFUSE – antihemophil fact rcmb (bdd-rfviii,mor)
for inj kit 250 unit, 500 unit
P
PA, SP
XYNTHA SOLOFUSE – antihemophil fact rcmb(bdd-rfviii,mor) for
inj kit 1000 unit, 2000 unit, 3000 unit
P
PA, SP
HEMATOLOGICAL AGENTS : MISC
ADZYNMA – adamts13 recombinant-krhn for inj kit 500 unit,
1500 unit
NP
PA, SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
114
Drug Name
Preferred Status Drug Status / Restriction
BERINERT – c1 esterase inhibitor (human) for iv inj kit 500 unit
P
PA, QL (10 vials/30 days), SP
CINRYZE – c1 esterase inhibitor (human) for iv inj 500 unit
NP
PA, QL (20 vials/30 days), SP
EMPAVELI – pegcetacoplan subcutaneous soln 1080 mg/20ml
(54 mg/ml)
NP
PA, QL (8 vials/28 days), SP
ENJAYMO – sutimlimab-jome iv soln 1100 mg/22ml (50 mg/ml)
NP
PA, SP
FABHALTA – iptacopan hcl cap 200 mg
NP
PA, QL (60 capsules/30
days), SP
FIRAZYR – icatibant acetate subcutaneous soln pref syr
30 mg/3ml
NP
PA, QL (6 syringes/30
days), SP
HAEGARDA – c1 esterase inhibitor (human) for subcutaneous inj
2000 unit
NP
PA, QL (27 vials/28 days), SP
HAEGARDA – c1 esterase inhibitor (human) for subcutaneous inj
3000 unit
NP
PA, QL (18 vials/28 days), SP
icatibant acetate subcutaneous soln pref syr 30 mg/3ml (Firazyr)
NP
PA, QL (6 syringes/30
days), SP
KALBITOR – ecallantide inj 10 mg/ml
NP
PA, QL (4 boxes/30 days), SP
ORLADEYO – berotralstat hcl cap 110 mg, 150 mg
NP
PA, QL (30 capsules/30
days), SP
pentoxifylline tab er 400 mg
P
RUCONEST – c1 esterase inhibitor (recombinant) for iv inj 2100
unit
NP
PA, QL (8 vials/30 days), SP
SOLIRIS – eculizumab iv soln 300 mg/30ml (10 mg/ml) (for
infusion)
NP
PA, SP
TAKHZYRO – lanadelumab-flyo soln pref syringe 150 mg/ml,
300 mg/2ml (150 mg/ml)
NP
PA, QL (2 syringes/28
days), SP
TAKHZYRO – lanadelumab-flyo inj 300 mg/2ml (150 mg/ml)
NP
PA, QL (2 vials/28 days), SP
TAVALISSE – fostamatinib disodium tab 100 mg (base
equivalent), 150 mg (base equivalent)
NP
PA, QL (60 tablets/30
days), SP
TAVNEOS – avacopan cap 10 mg
NP
PA, QL (180
capsules/30 days), SP
tranexamic acid tab 650 mg (Lysteda)
SC
ULTOMIRIS – ravulizumab-cwvz iv soln 300 mg/3ml (100 mg/ml),
1100 mg/11ml (100 mg/ml)
NP
PA, SP
VEOPOZ – pozelimab-bbfg inj soln 400 mg/2ml
NP
PA, SP
ZILBRYSQ – zilucoplan sodium subcutaneous soln pref syr
16.6 mg/0.416ml, 23 mg/0.574ml, 32.4 mg/0.81ml
NP
PA, SP
HEMATOLOGICAL AGENTS : PLATELET AGGREGATION INHIBITORS
AGRYLIN – anagrelide hcl cap 0.5 mg
NP
PA
anagrelide hcl cap 0.5 mg (Agrylin)
P
anagrelide hcl cap 1 mg
P
aspirin-dipyridamole cap er 12hr 25-200 mg (Aggrenox)
P
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
115
Drug Name
Preferred Status Drug Status / Restriction
BRILINTA – ticagrelor tab 60 mg, 90 mg
P
cilostazol tab 50 mg, 100 mg
NP
PA
clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)
P
clopidogrel bisulfate tab 300 mg (base equiv)
P
dipyridamole tab 25 mg, 50 mg, 75 mg
P
EFFIENT – prasugrel hcl tab 5 mg (base equiv), 10 mg (base
equiv)
NP
PA
PLAVIX – clopidogrel bisulfate tab 75 mg (base equiv)
NP
PA
prasugrel hcl tab 5 mg (base equiv), 10 mg (base equiv) (Effient)
NP
PA
HEMATOPOIETIC AGENTS : HEMATOPOIETIC GROWTH FACTORS
ARANESP ALBUMIN FREE – darbepoetin alfa soln prefilled
syringe 10 mcg/0.4ml, 25 mcg/0.42ml, 40 mcg/0.4ml,
60 mcg/0.3ml, 100 mcg/0.5ml, 150 mcg/0.3ml, 200 mcg/0.4ml,
300 mcg/0.6ml, 500 mcg/ml
NP
PA, SP
ARANESP ALBUMIN FREE – darbepoetin alfa soln inj 25 mcg/
ml, 40 mcg/ml, 60 mcg/ml, 100 mcg/ml, 200 mcg/ml
NP
PA, SP
DOPTELET – avatrombopag maleate tab 20 mg (base equiv)
NP
PA, QL (60 tablets/30
days), SP
EPOGEN – epoetin alfa inj 2000 unit/ml, 3000 unit/ml, 4000 unit/
ml, 10000 unit/ml, 20000 unit/ml
P
PA, SP
FULPHILA – pegfilgrastim-jmdb soln prefilled syringe 6 mg/0.6ml
NP
PA, SP
FYLNETRA – pegfilgrastim-pbbk soln prefilled syringe
6 mg/0.6ml
NP
PA, SP
GRANIX – tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml,
480 mcg/0.8ml
NP
PA, SP
GRANIX – tbo-filgrastim subcutaneous inj 300 mcg/ml,
480 mcg/1.6ml (300 mcg/ml)
NP
PA, SP
JESDUVROQ – daprodustat tab 1 mg, 2 mg, 4 mg, 6 mg, 8 mg
NP
PA, SP
LEUKINE – sargramostim lyophilized for inj 250 mcg
P
SP
MIRCERA – methoxy peg-epoetin beta soln prefilled syr
30 mcg/0.3ml, 50 mcg/0.3ml, 75 mcg/0.3ml, 100 mcg/0.3ml,
120 mcg/0.3ml, 150 mcg/0.3ml, 200 mcg/0.3ml
NP
PA
MULPLETA – lusutrombopag tab 3 mg
NP
PA, QL (7 tablets/7 days), SP
NEULASTA – pegfilgrastim soln prefilled syringe 6 mg/0.6ml
NP
PA, SP
NEULASTA ONPRO KIT – pegfilgrastim soln prefilled syringe kit
6 mg/0.6ml
NP
PA, SP
NEUPOGEN – filgrastim soln prefilled syringe 300 mcg/0.5ml,
480 mcg/0.8ml (600 mcg/ml)
P
SP
NEUPOGEN – filgrastim inj 300 mcg/ml, 480 mcg/1.6ml
(300 mcg/ml)
P
SP
NIVESTYM – filgrastim-aafi soln prefilled syringe 300 mcg/0.5ml,
480 mcg/0.8ml
NP
PA, SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
116
Drug Name
Preferred Status Drug Status / Restriction
NIVESTYM – filgrastim-aafi inj 300 mcg/ml, 480 mcg/1.6ml
(300 mcg/ml)
NP
PA, SP
NPLATE – romiplostim for inj 125 mcg, 250 mcg, 500 mcg
NP
PA, SP
NYVEPRIA – pegfilgrastim-apgf soln prefilled syringe 6 mg/0.6ml
NP
PA, SP
PROCRIT – epoetin alfa inj 2000 unit/ml, 3000 unit/ml, 4000 unit/
ml, 10000 unit/ml, 20000 unit/ml, 40000 unit/ml
P
PA, SP
PROMACTA – eltrombopag olamine powder pack for susp 25 mg
(base equiv), 12.5 mg (base eq)
NP
PA, QL (30 packets/30
days), SP
PROMACTA – eltrombopag olamine tab 12.5 mg (base equiv),
25 mg (base equiv)
NP
PA, QL (30 tablets/30
days), SP
PROMACTA – eltrombopag olamine tab 50 mg (base equiv),
75 mg (base equiv)
NP
PA, QL (60 tablets/30
days), SP
REBLOZYL – luspatercept-aamt for subcutaneous inj 25 mg,
75 mg
NP
PA, SP
RELEUKO – filgrastim-ayow soln prefilled syringe
300 mcg/0.5ml, 480 mcg/0.8ml
NP
PA, SP
RETACRIT – epoetin alfa-epbx inj 2000 unit/ml, 3000 unit/ml,
4000 unit/ml, 10000 unit/ml, 20000 unit/ml, 40000 unit/ml
NP
PA, SP
ROLVEDON – eflapegrastim-xnst soln prefilled syringe
13.2 mg/0.6ml
NP
PA, SP
STIMUFEND – pegfilgrastim-fpgk soln prefilled syringe
6 mg/0.6ml
NP
PA, SP
UDENYCA – pegfilgrastim-cbqv soln auto-injector 6 mg/0.6ml
NP
PA, SP
UDENYCA – pegfilgrastim-cbqv soln prefilled syringe 6 mg/0.6ml
NP
PA, SP
UDENYCA ONBODY – pegfilgrastim-cbqv soln prefill syr/infusion
dev 6 mg/0.6ml
NP
PA, SP
ZARXIO – filgrastim-sndz soln prefilled syringe 300 mcg/0.5ml,
480 mcg/0.8ml
NP
PA, SP
ZIEXTENZO – pegfilgrastim-bmez soln prefilled syringe
6 mg/0.6ml
NP
PA, SP
HEMATOPOIETIC AGENTS : MISC
cyanocobalamin inj 1000 mcg/ml
SC
folic acid tab 1 mg
SC
HYPNOTICS / SEDATIVES / SLEEP DISORDER AGENTS : BENZODIAZEPINE HYPNOTICS
DORAL – quazepam tab 15 mg
NP
PA, QL (30 tablets/30 days)
estazolam tab 1 mg, 2 mg
P
QL (30 tablets/30 days)
FLURAZEPAM HYDROCHLORIDE – flurazepam hcl cap 15 mg,
30 mg
NP
PA, QL (30 capsules/30 days)
HALCION – triazolam tab 0.25 mg
NP
PA, QL (60 tablets/30 days)
midazolam hcl syrup 2 mg/ml (base equivalent)
NP
PA, QL (10 mls/30 days)
QUAZEPAM – quazepam tab 15 mg
P
QL (30 tablets/30 days)
RESTORIL – temazepam cap 7.5 mg, 15 mg, 22.5 mg, 30 mg
NP
PA, QL (30 capsules/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
117
Drug Name
Preferred Status Drug Status / Restriction
temazepam cap 7.5 mg, 15 mg, 22.5 mg, 30 mg (Restoril)
P
QL (30 capsules/30 days)
triazolam tab 0.125 mg
P
QL (60 tablets/30 days)
triazolam tab 0.25 mg (Halcion)
P
QL (60 tablets/30 days)
HYPNOTICS / SEDATIVES / SLEEP DISORDER AGENTS : MISC
BELSOMRA – suvorexant tab 5 mg, 10 mg, 15 mg, 20 mg
NP
PA, QL (30 tablets/30 days)
DAYVIGO – lemborexant tab 5 mg, 10 mg
NP
PA, QL (30 tablets/30 days)
doxepin hcl (sleep) tab 3 mg (base equiv), 6 mg (base equiv)
(Silenor)
NP
PA, QL (30 tablets/30 days)
HETLIOZ – tasimelteon capsule 20 mg
NP
PA, QL (30 capsules/30
days), SP
HETLIOZ LQ – tasimelteon oral susp 4 mg/ml
NP
PA, QL (158 mls/30 days), SP
phenobarbital elixir 20 mg/5ml
P
90
phenobarbital tab 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg,
64.8 mg, 97.2 mg, 100 mg
P
90
QUVIVIQ – daridorexant hcl tab 25 mg, 50 mg
NP
PA, QL (30 tablets/30 days)
ramelteon tab 8 mg (Rozerem)
NP
PA, QL (30 tablets/30 days)
ROZEREM – ramelteon tab 8 mg
NP
PA, QL (30 tablets/30 days)
tasimelteon capsule 20 mg (Hetlioz)
NP
PA, QL (30 capsules/30
days), SP
HYPNOTICS / SEDATIVES / SLEEP DISORDER AGENTS : NON - BENZODIAZEPINE HYPNOTICS
AMBIEN – zolpidem tartrate tab 5 mg, 10 mg
NP
PA, QL (30 tablets/30 days)
AMBIEN CR – zolpidem tartrate tab er 6.25 mg, 12.5 mg
NP
PA, QL (30 tablets/30 days)
EDLUAR – zolpidem tartrate sl tab 5 mg, 10 mg
NP
PA, QL (30 tablets/30 days)
eszopiclone tab 1 mg, 2 mg, 3 mg (Lunesta)
NP
PA, QL (30 tablets/30 days)
zaleplon cap 5 mg, 10 mg
NP
PA, QL (30 capsules/30 days)
ZOLPIDEM TARTRATE – zolpidem tartrate cap 7.5 mg
NP
PA, QL (30 capsules/30 days)
ZOLPIDEM TARTRATE – zolpidem tartrate sl tab 1.75 mg,
3.5 mg
NP
PA, QL (30 tablets/30 days)
zolpidem tartrate tab er 6.25 mg, 12.5 mg (Ambien cr)
NP
PA, QL (30 tablets/30 days)
zolpidem tartrate tab 5 mg, 10 mg (Ambien)
P
QL (30 tablets/30 days)
IMMUNIZING AGENTS
ABRYSVO – rsv pre-fusion f a&b vac recomb for im soln
120 mcg/0.5ml
SC
PA (<=59 yr)
ACAM2000 – smallpox vaccine for percutaneous inj
SC
ACTHIB – haemophilus b polysaccharide conjugate vaccine for
inj
SC
ADACEL – tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-
mcg/0.5ml
SC
AREXVY – rsvpref3 vaccine recomb adjuvanted for im susp
120 mcg/0.5ml
SC
AL (>=60 yr)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
118
Drug Name
Preferred Status Drug Status / Restriction
BCG VACCINE – bcg vaccine for inj soln 50 mg
SC
BEXSERO – meningococcal vac b (recomb omv adjuv) inj
prefilled syringe
SC
BIOTHRAX – anthrax vaccine adsorbed inj
SC
BOOSTRIX – tet-diph-acell pertuss ad pref syr 5-2.5-18.5 lf-
mcg/0.5ml
SC
BOOSTRIX – tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-
mcg/0.5ml
SC
COMIRNATY 2023-24 – covid-19 mrna vac tris-pfizer im susp
pref syr 30 mcg/0.3ml
SC
COMIRNATY 2023-24 – covid-19 mrna vac tris-sucrose-pfizer im
susp 30 mcg/0.3ml
SC
DAPTACEL – diph, acellular pert & tet tox inj 15 lf-23 mcg-5
lf/0.5ml
SC
DENGVAXIA – dengue virus vaccine live tetravalent for
subcutaneous susp
SC
ENGERIX-B – hepatitis b vaccine (recombinant) susp pref syr
10 mcg/0.5ml, 20 mcg/ml
SC
ENGERIX-B – hepatitis b vaccine (recombinant) susp 20 mcg/ml
SC
GARDASIL 9 – human papillomavirus (hpv) 9-valent recomb vac
susp pref syr
SC
GARDASIL 9 – human papillomavirus (hpv) 9-valent recomb vac
im susp
SC
HAVRIX – hepatitis a vaccine inj susp 720 el unit/0.5ml, 1440 el
unit/ml
SC
HEPLISAV-B – hepatitis b vaccine recomb adjuvanted pref syr
20 mcg/0.5ml
SC
HIBERIX – haemophilus b polysaccharide conjugate vac for inj
10 mcg
SC
IMOVAX RABIES (H.D.C.V.) – rabies virus vaccine, hdc for inj
susp
SC
INFANRIX – diph, acellular pert & tet tox inj 25 lf-58 mcg-10
lf/0.5ml
SC
IPOL INACTIVATED IPV – poliovirus vaccine, ipv injection
SC
IXCHIQ – chikungunya virus vaccine live for im solution
SC
IXIARO – japanese encephalitis vaccine inactivated adsorbed inj
SC
JYNNEOS – smallpox & monkeypox vac, live, non-replicating inj
0.5 ml
SC
KINRIX – diph-tetanus-acell pert-polio, ipv vacc susp pref syr
0.5 ml
SC
M-M-R II – measles-mumps-rubella virus vaccines for inj soln
SC
MENQUADFI – meningococcal (a, c, y, and w-135) tetanus
conjugate vaccine
SC
MENVEO – meningococcal (a, c, y, and w-135) oligo conj vac im
soln
SC
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
119
Drug Name
Preferred Status Drug Status / Restriction
MENVEO – meningococcal (a, c, y, and w-135) oligo conj vac for
inj
SC
PEDIARIX – diph-tet tox-acell pert-hep b-polio ipv vac susp pref
syr
SC
PEDVAX HIB – haemophilus b polysaccharide conj vac im susp
7.5 mcg/0.5 ml
SC
PENBRAYA – meningococcal acyw (tet conj)-mening b (rcmb)
vacc for inj
SC
PENTACEL – diph-ac per-tet tox ad-poliov-haemoph b poly vac
for im susp
SC
PNEUMOVAX 23 – pneumococcal vaccine polyvalent inj
25 mcg/0.5ml
SC
PNEUMOVAX 23/1 DOSE – pneumococcal vaccine polyvalent inj
25 mcg/0.5ml
SC
PREHEVBRIO – hepatitis b vaccine 3-antigen (recombinant)
susp 10 mcg/ml
SC
PREVNAR 20 – pneumococcal 20-valent conjugate vaccine sus
pref syr 0.5 ml
SC
PRIORIX – measles-mumps-rubella virus vaccines for
subcutaneous susp
SC
PROQUAD – measles-mumps-rubella-varicella virus vaccines for
susp
SC
QUADRACEL – diph-tetanus tox ad-acell pert & polio virus, ipv
vac inj
SC
QUADRACEL – diph-tetanus-acell pert-polio, ipv vacc susp pref
syr 0.5 ml
SC
RABAVERT – rabies vaccine, pcec for inj
SC
RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp pref
syr 5 mcg/0.5ml, 10 mcg/ml
SC
RECOMBIVAX HB – hepatitis b vaccine (recombinant) susp
5 mcg/0.5ml, 10 mcg/ml, 40 mcg/ml
SC
ROTARIX – rotavirus vaccine, live oral susp
SC
ROTATEQ – rotavirus vaccine, live oral pentavalent soln
SC
SHINGRIX – zoster vac recombinant adjuvanted for im inj
50 mcg/0.5ml
SC
AL (>=50 yr), QL (2
vaccines/1 lifetime)
SPIKEVAX COVID-19 VACCINE /2023-24 – covid-19 mrna
vaccine-moderna im susp pref syr 50 mcg/0.5ml
SC
SPIKEVAX COVID-19 VACCINE /2023-24 – covid-19 (sars-
cov-2)mrna vacc-moderna im susp 50 mcg/0.5ml
SC
SYNAGIS – palivizumab im soln 50 mg/0.5ml, 100 mg/ml
SC
PA, SP
TDVAX – tetanus-diphtheria toxoids (td) inj 2-2 lf/0.5ml
SC
TENIVAC – tetanus-diphtheria toxoids (td) inj 5-2 lfu
SC
TICOVAC – tick-borne encephalit vac inact susp pref syr
1.2 mcg/0.25ml, 2.4 mcg/0.5ml
SC
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
120
Drug Name
Preferred Status Drug Status / Restriction
TRUMENBA – meningococcal group b vac (recomb) im susp
prefilled syr
SC
TWINRIX – hep a-hep b vaccine susp pref syr 720-20 elu-mcg/ml
SC
TYPHIM VI – typhoid vi polysaccharide vacc im soln pref syr
25 mcg/0.5ml
SC
TYPHIM VI – typhoid vi polysaccharide intramuscular vac inj
25 mcg/0.5ml
SC
VAQTA – hepatitis a vaccine inj susp 25 unit/0.5ml, 50 unit/ml
SC
VARIVAX – varicella virus vac live for subcutaneous inj 1350
pfu/0.5ml
SC
VAXCHORA – cholera vaccine live attenuated for oral susp
SC
VAXELIS – diph-tet tox-ac pert ad-polio ipv-hib-hep b rec susp
pre syr
SC
VAXELIS – diph-tet tox-ac pert ad-polio ipv-hib-hepatitis b recmb
susp
SC
VAXNEUVANCE – pneumococcal 15-valent conjugate vaccine
sus pref syr 0.5 ml
SC
VIVOTIF – typhoid vaccine cap delayed release
SC
YF-VAX – yellow fever vaccine subcutaneous inj
SC
IMMUNOSUPPRESSIVE AGENTS
ASTAGRAF XL – tacrolimus cap er 24hr 0.5 mg, 1 mg, 5 mg
NP
PA
azathioprine tab 50 mg (Imuran)
P
azathioprine tab 75 mg, 100 mg
NP
PA
CELLCEPT – mycophenolate mofetil cap 250 mg
NP
PA
CELLCEPT – mycophenolate mofetil tab 500 mg
NP
PA
CELLCEPT – mycophenolate mofetil for oral susp 200 mg/ml
NP
PA
cyclosporine cap 25 mg, 100 mg (Sandimmune)
P
cyclosporine modified cap 25 mg, 100 mg (Neoral)
P
cyclosporine modified cap 50 mg
P
cyclosporine modified oral soln 100 mg/ml (Neoral)
P
ENVARSUS XR – tacrolimus tab er 24hr 0.75 mg, 1 mg, 4 mg
NP
PA
everolimus tab 0.25 mg, 0.5 mg, 0.75 mg, 1 mg (Zortress)
NP
PA
IMURAN – azathioprine tab 50 mg
NP
PA
LUPKYNIS – voclosporin cap 7.9 mg
NP
PA, QL (180
capsules/30 days), SP
mycophenolate mofetil cap 250 mg (Cellcept)
P
mycophenolate mofetil for oral susp 200 mg/ml (Cellcept)
P
mycophenolate mofetil tab 500 mg (Cellcept)
P
mycophenolate sodium tab dr 180 mg (mycophenolic acid equiv),
360 mg (mycophenolic acid equiv) (Myfortic)
P
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
121
Drug Name
Preferred Status Drug Status / Restriction
MYFORTIC – mycophenolate sodium tab dr 180 mg
(mycophenolic acid equiv), 360 mg (mycophenolic acid equiv)
NP
PA
NEORAL – cyclosporine modified cap 25 mg, 100 mg
NP
PA
NEORAL – cyclosporine modified oral soln 100 mg/ml
NP
PA
PROGRAF – tacrolimus cap 0.5 mg, 1 mg, 5 mg
NP
PA
PROGRAF – tacrolimus packet for susp 0.2 mg, 1 mg
NP
PA
RAPAMUNE – sirolimus tab 0.5 mg, 1 mg, 2 mg
NP
PA
RAPAMUNE – sirolimus oral soln 1 mg/ml
NP
PA
SANDIMMUNE – cyclosporine cap 25 mg, 100 mg
NP
PA
SANDIMMUNE – cyclosporine oral soln 100 mg/ml
P
sirolimus oral soln 1 mg/ml (Rapamune)
P
sirolimus tab 0.5 mg, 1 mg, 2 mg (Rapamune)
P
tacrolimus cap 0.5 mg, 1 mg, 5 mg (Prograf)
P
ZORTRESS – everolimus tab 0.25 mg, 0.5 mg, 0.75 mg, 1 mg
NP
PA
LAXATIVES
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm (Golytely)
SC
peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/flavor
pack)
SC
MALE HORMONES
danazol cap 50 mg, 100 mg, 200 mg
SC
PA
testosterone cypionate im inj in oil 100 mg/ml, 200 mg/ml (Depo-
testosterone)
SC
PA, QL (10 mls/28 days), 90
TESTOSTERONE ENANTHATE – testosterone enanthate im inj
in oil 200 mg/ml
SC
PA, QL (1 vial/28 days), 90
MIGRAINE PRODUCTS : MISC
diclofenac potassium (migraine) packet 50 mg (Cambia)
NP
PA, QL (9 packets/30 days)
dihydroergotamine mesylate nasal spray 4 mg/ml (Migranal)
NP
PA, QL (8 mls/28 days)
ELYXYB – celecoxib oral soln 120 mg/4.8ml (25 mg/ml)
NP
PA, QL (6 bottles/30 days)
MIGERGOT – ergotamine w/ caffeine suppos 2-100 mg
P
MIGRANAL – dihydroergotamine mesylate nasal spray 4 mg/ml
NP
PA, QL (8 mls/28 days)
sumatriptan-naproxen sodium tab 85-500 mg (Treximet)
NP
PA, QL (18 tablets/30 days)
TRUDHESA – dihydroergotamine mesylate hfa nasal aerosol
0.725 mg/act
NP
PA, QL (12 mls/28 days)
MIGRAINE PRODUCTS : CALCITONIN GENE-RELATED PEPTIDE (CGRP) R
AIMOVIG – erenumab-aooe subcutaneous soln auto-injector
70 mg/ml, 140 mg/ml
P
PA, QL (1 syringe/28
days), 90
AJOVY – fremanezumab-vfrm subcutaneous soln auto-inj
225 mg/1.5ml
P
PA, QL (3 syringes/84
days), 90
AJOVY – fremanezumab-vfrm subcutaneous soln pref syr
225 mg/1.5ml
P
PA, QL (3 syringes/84
days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
122
Drug Name
Preferred Status Drug Status / Restriction
EMGALITY – galcanezumab-gnlm subcutaneous soln auto-
injector 120 mg/ml
P
PA, QL (1 syringe/28
days), 90
EMGALITY – galcanezumab-gnlm subcutaneous soln prefilled
syr 100 mg/ml
P
PA, QL (9 syringes/180
days), 90
EMGALITY – galcanezumab-gnlm subcutaneous soln prefilled
syr 120 mg/ml
P
PA, QL (1 syringe/28
days), 90
NURTEC – rimegepant sulfate tab disint 75 mg
P
PA, QL (54 tablets/90 days)
QULIPTA – atogepant tab 10 mg, 30 mg, 60 mg
P
PA, QL (30 tablets/30 days)
UBRELVY – ubrogepant tab 50 mg, 100 mg
P
PA, QL (16 tablets/30 days)
VYEPTI – eptinezumab-jjmr iv soln 100 mg/ml
NP
PA, QL (3 vials/90 days)
ZAVZPRET – zavegepant hcl nasal spray 10 mg/act
NP
PA, QL (8 devices/30 days)
MIGRAINE PRODUCTS : SELECTIVE SEROTONIN AGONISTS 5-HT(1F)
almotriptan malate tab 6.25 mg, 12.5 mg
NP
PA, QL (18 tablets/30 days)
eletriptan hydrobromide tab 20 mg (base equivalent), 40 mg
(base equivalent) (Relpax)
NP
PA, QL (18 tablets/30 days)
FROVA – frovatriptan succinate tab 2.5 mg (base equivalent)
NP
PA, QL (18 tablets/30 days)
frovatriptan succinate tab 2.5 mg (base equivalent) (Frova)
NP
PA, QL (18 tablets/30 days)
IMITREX – sumatriptan succinate tab 25 mg, 50 mg, 100 mg
NP
PA, QL (18 tablets/30 days)
IMITREX STATDOSE REFILL – sumatriptan succinate solution
cartridge 4 mg/0.5ml, 6 mg/0.5ml
NP
PA, QL (12 doses/30 days)
IMITREX STATDOSE SYSTEM – sumatriptan succinate solution
auto-injector 4 mg/0.5ml, 6 mg/0.5ml
NP
PA, QL (12 doses/30 days)
MAXALT – rizatriptan benzoate tab 10 mg (base equivalent)
NP
PA, QL (18 tablets/30 days)
MAXALT-MLT – rizatriptan benzoate oral disintegrating tab 10 mg
(base eq)
NP
PA, QL (18 tablets/30 days)
naratriptan hcl tab 1 mg (base equiv), 2.5 mg (base equiv)
(Amerge)
NP
PA, QL (18 tablets/30 days)
RELPAX – eletriptan hydrobromide tab 20 mg (base equivalent),
40 mg (base equivalent)
NP
PA, QL (18 tablets/30 days)
REYVOW – lasmiditan succinate tab 50 mg
NP
PA, QL (4 tablets/30 days)
REYVOW – lasmiditan succinate tab 100 mg
NP
PA, QL (8 tablets/30 days)
rizatriptan benzoate oral disintegrating tab 5 mg (base eq)
P
QL (18 tablets/30 days)
rizatriptan benzoate oral disintegrating tab 10 mg (base eq)
(Maxalt-mlt)
P
QL (18 tablets/30 days)
rizatriptan benzoate tab 5 mg (base equivalent)
P
QL (18 tablets/30 days)
rizatriptan benzoate tab 10 mg (base equivalent) (Maxalt)
P
QL (18 tablets/30 days)
sumatriptan nasal spray 5 mg/act, 20 mg/act (Imitrex)
P
QL (12 units/30 days)
sumatriptan succinate inj 6 mg/0.5ml (Imitrex)
P
QL (12 vials/30 days)
SUMATRIPTAN SUCCINATE REFILL – sumatriptan succinate
solution cartridge 4 mg/0.5ml, 6 mg/0.5ml
P
QL (12 doses/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
123
Drug Name
Preferred Status Drug Status / Restriction
sumatriptan succinate solution auto-injector 4 mg/0.5ml,
6 mg/0.5ml (Imitrex statdose system)
P
QL (12 doses/30 days)
sumatriptan succinate tab 25 mg, 50 mg, 100 mg (Imitrex)
P
QL (18 tablets/30 days)
TOSYMRA – sumatriptan nasal spray 10 mg/act
NP
PA, QL (18 sprays/30 days)
ZEMBRACE SYMTOUCH – sumatriptan succinate solution auto-
injector 3 mg/0.5ml
NP
PA, QL (24 doses/30 days)
zolmitriptan nasal spray 5 mg/spray unit (Zomig)
NP
PA, QL (12 units/30 days)
zolmitriptan orally disintegrating tab 2.5 mg, 5 mg (Zomig zmt)
NP
PA, QL (18 tablets/30 days)
zolmitriptan tab 2.5 mg, 5 mg (Zomig)
NP
PA, QL (18 tablets/30 days)
ZOMIG – zolmitriptan nasal spray 5 mg/spray unit
NP
PA, QL (12 units/30 days)
MINERALS AND ELECTROLYTES
fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu cap
SC
fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240 mg
SC
fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1 mg
SC
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1 mg
SC
folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg, 2.5-25-1 mg
SC
iron combination cap
SC
iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg (Corvite
150)
SC
K-PHOS – potassium phosphate monobasic tab 500 mg
SC
pot phos monobasic w/sod phos di & monobas tab
155-852-130mg (K-phos neutral)
SC
potassium bicarbonate effer tab 25 meq
SC
potassium chloride cap er 8 meq, 10 meq
SC
potassium chloride microencapsulated crys er tab 10 meq, 20
meq
SC
potassium chloride oral soln 10% (20 meq/15ml), 20% (40
meq/15ml)
SC
potassium chloride powder packet 20 meq
SC
potassium chloride tab er 10 meq (K-tab)
SC
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf), 0.5 mg f
(from 1.1 mg naf), 1 mg f (from 2.2 mg naf)
SC
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml naf)
SC
MISCELLANEOUS THERAPEUTIC CLASSES
BENLYSTA – belimumab subcutaneous solution auto-injector
200 mg/ml
NP
PA, QL (4 syringes/28
days), SP
BENLYSTA – belimumab subcutaneous solution prefilled syringe
200 mg/ml
NP
PA, QL (4 syringes/28
days), SP
JOENJA – leniolisib phosphate tab 70 mg
NP
PA, QL (60 tablets/30
days), SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
124
Drug Name
Preferred Status Drug Status / Restriction
lactated ringer's for irrigation
SC
lenalidomide cap 2.5 mg, 5 mg, 10 mg (Revlimid)
NP
PA, QL (30 capsules/30
days), SP
lenalidomide cap 15 mg, 20 mg, 25 mg (Revlimid)
NP
PA, QL (21 capsules/28
days), SP
LOKELMA – sodium zirconium cyclosilicate for susp packet
5 gm, 10 gm
NP
PA
REVLIMID – lenalidomide cap 2.5 mg, 5 mg, 10 mg
NP
PA, QL (30 capsules/30
days), SP
REVLIMID – lenalidomide cap 15 mg, 20 mg, 25 mg
NP
PA, QL (21 capsules/28
days), SP
REZUROCK – belumosudil mesylate tab 200 mg
NP
PA, QL (60 tablets/30
days), SP
ringer's solution for irrigation
SC
RYSTIGGO – rozanolixizumab-noli subcutaneous soln
280 mg/2ml
NP
PA, SP
sodium polystyrene sulfonate powder
P
SPS – sodium polystyrene sulfonate oral susp 15 gm/60ml
NP
PA
THALOMID – thalidomide cap 50 mg
NP
PA, QL (90 capsules/30
days), SP
THALOMID – thalidomide cap 100 mg
NP
PA, QL (120
capsules/30 days), SP
VELTASSA – patiromer sorbitex calcium for susp packet 8.4 gm
(base eq), 16.8 gm (base eq), 25.2 gm (base eq)
NP
PA
VYVGART – efgartigimod alfa-fcab iv soln 400 mg/20ml
NP
PA, SP
VYVGART HYTRULO – efgartigimod alf-hyaluronidase-qvfc sol
180-2000 mg-unit/ml
NP
PA, SP
MOUTH / THROAT / DENTAL AGENTS
AQUORAL – artificial saliva - solution
NP
PA
cevimeline hcl cap 30 mg (Evoxac)
NP
PA
chlorhexidine gluconate soln 0.12% (Peridex)
P
clotrimazole troche 10 mg
P
EVOXAC – cevimeline hcl cap 30 mg
NP
PA
GELX – oral wound care products - gel
NP
PA
LIDOCAINE HCL – lidocaine hcl laryngotracheal soln 4%
P
lidocaine hcl viscous soln 2%
P
nystatin susp 100000 unit/ml
P
ORAVIG – miconazole buccal tab 50 mg (mouth-throat)
NP
PA
pilocarpine hcl tab 5 mg, 7.5 mg (Salagen)
P
sodium fluoride cream 1.1% (Prevident 5000 plus)
NP
PA
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
125
Drug Name
Preferred Status Drug Status / Restriction
sodium fluoride gel 1.1% (0.5% f) (Prevident fluoride)
NP
PA
sodium fluoride paste 1.1% (Prevident 5000 boost)
NP
PA
triamcinolone acetonide dental paste 0.1%
P
MULTIVITAMINS : MISC
b-complex w/ c & folic acid cap 1 mg
SC
b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx)
SC
b-complex w/ c & folic acid tab 5 mg
SC
CORVITA – multiple vitamins w/ minerals tab
SC
FOLBEE PLUS CZ – b-complex w/ c-biotin-minerals & folic acid
tab 5 mg
SC
multiple vitamins w/ minerals tab (Strovite forte)
SC
MULTIVITAMINS : PRENATAL VITAMINS
CITRANATAL ASSURE – prenat w/o a w/fecbn-fegl-dss-fa tab &
dha cap 300 mg pack
NP
PA
CITRANATAL B-CALM – prenat w/o a w/fecbn-feglu-fa tab
20-1 mg & vit b6 tab pak
NP
PA
CITRANATAL HARMONY – prenat w/o a w/fe fum-fe cbn-dss-fa-
dha cap 27-1-260 mg
NP
PA
CITRANATAL MEDLEY – prenat w/o a w/fe fum-fe cbn-fa-dha
cap 27-1-200 mg
NP
PA
CITRANATAL 90 DHA – prenat w/o a w/fecbn-fegl-dss-fa tab 90
&dha cap 300mg pak
NP
PA
COMPLETE NATAL DHA – prenat-fe bis-fe prot succ-fa-ca tab &
omega 3 cap 200 pk
NP
PA
COMPLETENATE – prenatal vit w/ fe fumarate-fa chew tab
29-1 mg
P
DERMACINRX PRETRATE – prenatal multivitamins & minerals
w/ iron & fa tab 1 mg
NP
PA
ELITE-OB – prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg
P
ENBRACE HR – prenatal vit w/ fe gly cys-fa-omega 3 fatty acids
cap
NP
PA
FOLIVANE-OB – prenatal w/o a w/fe fum-fe poly-fa cap 85-1 mg
NP
PA
M-NATAL PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg
P
NATAL PNV – prenatal vit w/ fe gluconate-fa tab 6-0.5 mg
NP
PA
NESTABS – prenatal vit w/o vit a w/ fe bisglycinate-fa tab
32-1 mg
NP
PA
NESTABS DHA – prenat w/o a w/ fe bisglyc-fa tab 32-1 mg &
omega cap pack
NP
PA
NESTABS ONE – prenat w/o a w/fecbn-bisg-methylf-dha cap
38-1-225 mg
NP
PA
NIVA-PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg
P
OB COMPLETE – prenatal vit w/ iron carbonyl-fa tab 50-1.25 mg
P
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
126
Drug Name
Preferred Status Drug Status / Restriction
OB COMPLETE ONE – prenatal w/o a w/fecbn-fe asp glyc-fa-fish
cap 50-1-476 mg
NP
PA
OB COMPLETE PETITE – prenat w/o a w/fecbn-feaspglyc-fa-
omega cap 35-5-1-200 mg
NP
PA
OB COMPLETE PREMIER – prenatal vit w/ fe cbn-fe asp glyc-fa
tab 30-20-1 mg
NP
PA
OB COMPLETE/DHA – prenat w/ iron cbn-fe asp glyc-fa-omega
cap 30-10-1-200 mg
NP
PA
PNV-DHA – prenat w/o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
NP
PA
PNV-DHA+DOCUSATE – prenatal w/o vit a w/ fe fum-dss-fa-dha
cap 27-1.25-300 mg
NP
PA
PNV-OMEGA – prenat w/o a w/ fe fumarate-methylfolate-fa-
omega 3 cap
NP
PA
PNV-SELECT – prenatal vit w/ fe fum-methylfolate-fa tab
27-0.6-0.4 mg
NP
PA
PREMESISRX – prenatal w/ calcium-vit b6-vit b12-fa-ginger tab
1 mg
NP
PA
PRENAISSANCE – prenatal w/o vit a w/ fe fum-dss-fa-dha cap
29-1.25-325 mg
NP
PA
PRENAISSANCE PLUS – prenatal w/o a w/fe cbn-dss-fa-dha
cap 28-1-250 mg
NP
PA
PRENATAL PLUS VITAMIN AND MINERAL – prenatal vit w/ fe
fumarate-fa tab 27-1 mg
P
PRENATE – prenat mv & min w/ l-methylfolate-fa chew tab
0.6-0.4 mg
NP
PA
PRENATE AM – prenatal w/ calcium-vit b6-vit b12-fa-ginger tab
1 mg
NP
PA
PRENATE DHA – prenat w/o a w/feaspg-methfol-fa-dha cap
18-0.6-0.4-300 mg
NP
PA
PRENATE ELITE – prenatal w/ fe asp gly-l methylfol-fa tab
20-0.6-0.4 mg
NP
PA
PRENATE ENHANCE – prenat w/o a w/fefum-methfol-fa-dha cap
28-0.6-0.4-400 mg
NP
PA
PRENATE ESSENTIAL – prenat w/o a w/feaspg-methfol-fa-dha
cap 18-0.6-0.4-300 mg
NP
PA
PRENATE MINI – prenat w/oa w/fecb-feasp-meth-fa-dha cap
18-0.6-0.4-350 mg
NP
PA
PRENATE PIXIE – prenat w/o a w/feaspg-methfol-fa-dha cap
10-0.6-0.4-200 mg
NP
PA
PRENATE RESTORE – prenat w/o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-400 mg
NP
PA
PRENATRIX – prenatal vit w/ fe fumarate-fa tab 27-1 mg
NP
PA
PRENATRYL – prenatal vit w/ fe fumarate-fa tab 27-1 mg
NP
PA
PRIMACARE – prenat w/o a w/feasp-methlf-fa-omeg cap
30-0.75-0.25-470mg
NP
PA
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
127
Drug Name
Preferred Status Drug Status / Restriction
RELNATE DHA – prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg
NP
PA
SE-NATAL 19 – prenatal vit w/ dss-fe fumarate-fa tab 29-1 mg
P
SE-NATAL 19 – prenatal vit w/ fe fumarate-fa chew tab 29-1 mg
P
SELECT-OB – prenatal vit w/ fe polysac cmplx-fa chew tab
29-1 mg
NP
PA
SELECT-OB – prenat w/ fepolycmplx-methylfol-fa chew tab
29-0.6-0.4 mg
NP
PA
SELECT-OB+DHA – prenatal mv w/fe poly-fa chw 29-1 mg & dha
cap 250 mg pak
NP
PA
TARON-C DHA – prenatal w/fe fum-fe poly -fa-omega 3 cap
35-1 mg
NP
PA
THRIVITE RX – prenatal vit w/ iron carbonyl-fa tab 29-1 mg
P
TRICARE – prenatal vit w/ fe fumarate-fa tab 27-1 mg
P
TRINATAL RX 1 – prenatal vit w/ fe fumarate-fa tab 60-1 mg
P
TRISTART DHA – prenat w/o a w/fecbn-methylf-fa-dha cap
31-0.6-0.4-200 mg
NP
PA
VINATE DHA RF – prenat w/o a w/fefum-methylfol-omegas cap
27-1.13 mg
NP
PA
VITAFOL FE+ – prenat w/fe poly-methylfol-fa-dha cap
90-0.6-0.4-200 mg
NP
PA
VITAFOL GUMMIES – prenat vit w/ fe phos-fa-omega chew tab
3.33-0.333-34.8 mg
NP
PA
VITAFOL STRIPS – prenatal w/ b6-b12-cholecalciferol-folic acid
film 1 mg
NP
PA
VITAFOL ULTRA – prenat w/fe poly-methylfol-fa-dha cap
29-0.6-0.4-200 mg
NP
PA
VITAFOL-NANO – prenatal w/o a w/ fefum-l methylfol-fa tab
18-0.6-0.4 mg
NP
PA
VITAFOL-OB – prenatal vit w/ fe fumarate-fa tab 65-1 mg
P
VITAFOL-OB+DHA – prenatal mv w/fe fum-fa tab 65-1 mg & dha
cap 250 mg pack
NP
PA
VITAFOL-ONE – prenatal mv w/ fe polysac cmplx-fa-dha cap
29-1-200 mg
NP
PA
VITAMEDMD ONE RX/QUATREFOLIC – prenat w/o a w/fefum-
methfol-fa-dha cap 30-0.6-0.4-200 mg
NP
PA
VITAPEARL – prenat w/oa w/fefum-na fered-fa-dha cap er
30-1.4-200 mg
NP
PA
WESCAP-C DHA – prenatal w/fe fum-fe poly -fa-omega 3 cap
53.5-38-1 mg
NP
PA
WESCAP-PN DHA – prenat w/o a w/fefum-methfol-fa-dha cap
27-0.6-0.4-300 mg
NP
PA
WESNATAL DHA COMPLETE – prenat-fe bis-fe prot succ-fa-ca
tab & omega 3 cap 200 pk
NP
PA
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
128
Drug Name
Preferred Status Drug Status / Restriction
WESNATE DHA – prenatal vit w/ fe fum-fa-omega 3 cap
28-1-200 mg
NP
PA
WESTAB PLUS – prenatal vit w/ fe fumarate-fa tab 27-1 mg
P
WESTGEL DHA – prenat w/o a w/fecbn-methylf-fa-dha cap
31-0.6-0.4-200 mg
NP
PA
MUSCULOSKELETAL THERAPY AGENTS
AMRIX – cyclobenzaprine hcl cap er 24hr 15 mg, 30 mg
NP
PA
BACLOFEN – baclofen oral soln 5 mg/5ml
NP
PA, QL (2400 mls/30 days)
BACLOFEN – baclofen oral soln 10 mg/5ml
NP
PA, QL (1200 mls/30 days)
baclofen susp 25 mg/5ml (Fleqsuvy)
P
QL (480 mls/30 days)
baclofen tab 5 mg, 10 mg, 20 mg
P
carisoprodol tab 250 mg, 350 mg (Soma)
NP
PA
chlorzoxazone tab 250 mg, 375 mg, 500 mg, 750 mg
P
cyclobenzaprine hcl cap er 24hr 15 mg, 30 mg (Amrix)
NP
PA
cyclobenzaprine hcl tab 5 mg, 10 mg
P
cyclobenzaprine hcl tab 7.5 mg (Fexmid)
P
DANTRIUM – dantrolene sodium cap 25 mg
NP
PA
dantrolene sodium cap 25 mg, 50 mg (Dantrium)
P
dantrolene sodium cap 100 mg
P
FLEQSUVY – baclofen susp 25 mg/5ml
NP
PA, QL (480 mls/30 days)
LYVISPAH – baclofen granules packet 5 mg, 10 mg, 20 mg
NP
PA, QL (120 packets/30 days)
metaxalone tab 400 mg
NP
PA
metaxalone tab 800 mg (Skelaxin)
NP
PA
methocarbamol tab 500 mg
P
methocarbamol tab 750 mg (Robaxin-750)
P
NORGESIC FORTE – orphenadrine w/ aspirin & caffeine tab
50-770-60 mg
NP
PA
orphenadrine citrate tab er 12hr 100 mg
P
orphenadrine w/ aspirin & caffeine tab 25-385-30 mg
P
orphenadrine w/ aspirin & caffeine tab 50-770-60 mg (Norgesic
forte)
P
SOHONOS – palovarotene cap 1 mg, 1.5 mg, 2.5 mg, 5 mg,
10 mg
NP
PA, SP
SOMA – carisoprodol tab 250 mg, 350 mg
NP
PA
tizanidine hcl cap 2 mg (base equivalent), 4 mg (base
equivalent), 6 mg (base equivalent) (Zanaflex)
NP
PA, QL (180
capsules/30 days)
tizanidine hcl tab 2 mg (base equivalent)
P
QL (180 tablets/30 days)
tizanidine hcl tab 4 mg (base equivalent) (Zanaflex)
P
QL (180 tablets/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
129
Drug Name
Preferred Status Drug Status / Restriction
ZANAFLEX – tizanidine hcl cap 2 mg (base equivalent), 4 mg
(base equivalent), 6 mg (base equivalent)
NP
PA, QL (180
capsules/30 days)
ZANAFLEX – tizanidine hcl tab 4 mg (base equivalent)
NP
PA, QL (180 tablets/30 days)
NASAL AGENTS - SYSTEMIC AND TOPICAL : MISC
azelastine hcl nasal spray 0.1% (137 mcg/spray), 0.15%
(205.5 mcg/spray)
P
QL (2 bottles/30 days)
azelastine hcl-fluticasone prop nasal spray 137-50 mcg/act
(Dymista)
NP
PA, QL (1 bottle/30 days)
DYMISTA – azelastine hcl-fluticasone prop nasal spray
137-50 mcg/act
NP
PA, QL (1 bottle/30 days)
flunisolide nasal soln 25 mcg/act (0.025%)
P
QL (3 bottles/30 days)
fluticasone propionate nasal susp 50 mcg/act
P
QL (1 bottle/30 days)
ipratropium bromide nasal soln 0.03% (21 mcg/spray)
NP
PA, QL (2 bottles/30 days), 90
ipratropium bromide nasal soln 0.06% (42 mcg/spray)
NP
PA, QL (3 bottles/30 days), 90
mometasone furoate nasal susp 50 mcg/act (Nasonex)
NP
PA, QL (2 inhalers/30 days)
olopatadine hcl nasal soln 0.6% (Patanase)
P
QL (1 inhaler/30 days)
OMNARIS – ciclesonide nasal susp 50 mcg/act
NP
PA, QL (1 inhaler/30 days)
PROPEL MINI/STRAIGHT DELIVERY SYSTEM – mometasone
furoate nasal implant 370 mcg
NP
PA
QNASL – beclomethasone dipropionate nasal aerosol 80 mcg/
act
NP
PA, QL (1 inhaler/30 days)
QNASL CHILDRENS – beclomethasone dipropionate nasal
aerosol 40 mcg/act
NP
PA, QL (1 inhaler/30 days)
RYALTRIS – olopatadine hcl-mometasone furoate nasal susp
665-25 mcg/act
NP
PA, QL (1 bottle/30 days)
SINUVA – mometasone furoate sinus implant 1350 mcg
NP
PA
XHANCE – fluticasone propionate nasal exhaler susp 93 mcg/act
NP
PA, QL (32 mls/30 days)
ZETONNA – ciclesonide nasal aerosol soln 37 mcg/act (50 mcg/
valve)
NP
PA, QL (1 bottle/30 days)
NEUROMUSCULAR AGENTS
DAYBUE – trofinetide oral soln 200 mg/ml
NP
PA, QL (8 bottles/30
days), SP
EXSERVAN – riluzole oral film 50 mg
NP
PA
RADICAVA ORS – edaravone oral susp 105 mg/5ml
NP
PA, QL (50 mls/28 days), SP
RADICAVA ORS STARTER KIT – edaravone oral susp
105 mg/5ml
NP
PA, QL (70 mls/180 days), SP
RELYVRIO – sodium phenylbutyrate-taurursodiol powd pack
3-1 gm
NP
PA, QL (1 box/28 days), SP
RILUTEK – riluzole tab 50 mg
NP
PA
riluzole tab 50 mg (Rilutek)
P
TEGLUTIK – riluzole susp 50 mg/10ml
NP
PA, QL (600 mls/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
130
Drug Name
Preferred Status Drug Status / Restriction
OPHTHALMIC AGENTS : BETA-BLOCKERS - OPHTHALMIC
BETAXOLOL HCL – betaxolol hcl ophth soln 0.5%
P
BETIMOL – timolol ophth soln 0.25%, 0.5%
NP
PA
BETOPTIC-S – betaxolol hcl ophth susp 0.25%
NP
PA
brimonidine tartrate-timolol maleate ophth soln 0.2-0.5%
(Combigan)
NP
PA
CARTEOLOL HCL – carteolol hcl ophth soln 1%
P
COMBIGAN – brimonidine tartrate-timolol maleate ophth soln
0.2-0.5%
NP
PA
COSOPT – dorzolamide hcl-timolol maleate ophth soln 2-0.5%
NP
PA
COSOPT PF – dorzolamide hcl-timolol maleate pf ophth soln
2-0.5%
NP
PA
dorzolamide hcl-timolol maleate ophth soln 2-0.5% (Cosopt)
P
dorzolamide hcl-timolol maleate pf ophth soln 2-0.5% (Cosopt pf)
NP
PA
ISTALOL – timolol maleate ophth soln 0.5% (once-daily)
NP
PA
LEVOBUNOLOL HCL – levobunolol hcl ophth soln 0.5%
P
timolol maleate ophth gel forming soln 0.25%, 0.5% (Timoptic-xe)
P
timolol maleate ophth soln 0.25%, 0.5% (Timoptic)
P
timolol maleate ophth soln 0.5% (once-daily) (Istalol)
P
timolol maleate preservative free ophth soln 0.25%, 0.5%
(Timoptic ocudose)
NP
PA
TIMOPTIC OCUDOSE – timolol maleate preservative free ophth
soln 0.25%, 0.5%
NP
PA
OPHTHALMIC AGENTS : MISC
ACULAR – ketorolac tromethamine ophth soln 0.5%
NP
PA
ACULAR LS – ketorolac tromethamine ophth soln 0.4%
NP
PA
ACUVAIL – ketorolac tromethamine (pf) ophth soln 0.45%
NP
PA
AKTEN – lidocaine hcl ophth gel 3.5%
NP
PA
ALCAINE – proparacaine hcl ophth soln 0.5%
NP
PA
ALPHAGAN P – brimonidine tartrate ophth soln 0.1%, 0.15%
P
APRACLONIDINE – apraclonidine hcl ophth soln 0.5% (base
equivalent)
NP
PA
ATROPINE SULFATE – atropine sulfate ophth soln 1%
P
ATROPINE SULFATE – atropine sulfate ophth oint 1%
P
atropine sulfate ophth soln 1% (Atropine sulfate)
P
AZOPT – brinzolamide ophth susp 1%
NP
PA
bimatoprost ophth soln 0.03%
NP
PA, QL (2.5 mls/30 days)
brimonidine tartrate ophth soln 0.1%, 0.15% (Alphagan p)
P
brimonidine tartrate ophth soln 0.2%
P
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
131
Drug Name
Preferred Status Drug Status / Restriction
brinzolamide ophth susp 1% (Azopt)
NP
PA
bromfenac sodium ophth soln 0.07% (base equivalent)
(Prolensa)
NP
PA
bromfenac sodium ophth soln 0.075% (base equivalent)
(Bromsite)
NP
PA
bromfenac sodium ophth soln 0.09% (base equiv) (once-daily)
NP
PA
BROMSITE – bromfenac sodium ophth soln 0.075% (base
equivalent)
NP
PA
CEQUA – cyclosporine (ophth) soln 0.09% (pf)
NP
PA, QL (60 vials/30 days)
CYCLOGYL – cyclopentolate hcl ophth soln 0.5%, 1%, 2%
NP
PA
CYCLOMYDRIL – cyclopentolate w/ phenylephrine ophth soln
0.2-1%
P
cyclopentolate hcl ophth soln 1% (Cyclogyl)
P
cyclosporine (ophth) emulsion 0.05% (Restasis)
NP
PA, QL (60 vials/30 days)
CYSTADROPS – cysteamine hcl ophth soln 0.37% (base
equivalent)
NP
PA, QL (4 bottles/28
days), SP
CYSTARAN – cysteamine hcl ophth soln 0.44% (base
equivalent)
NP
PA, QL (4 bottles/30
days), SP
diclofenac sodium ophth soln 0.1%
P
dorzolamide hcl ophth soln 2% (Trusopt)
P
FLUORESCEIN SODIUM/BENOXINATE HYDROCHLORIDE –
fluorescein w/ benoxinate ophth soln 0.3-0.4%
NP
PA
FLURBIPROFEN SODIUM – flurbiprofen sodium ophth soln
0.03%
P
GLOSTRIPS – fluorescein sodium ophth strips 1 mg
NP
PA
IHEEZO – chloroprocaine hcl ophth gel 3%
NP
PA
ILEVRO – nepafenac ophth susp 0.3%
NP
PA
IOPIDINE – apraclonidine hcl ophth soln 1% (base equivalent)
NP
PA
IYUZEH – latanoprost (pf) ophth soln 0.005%
NP
PA, QL (30
containers/30 days)
ketorolac tromethamine ophth soln 0.4% (Acular ls)
P
ketorolac tromethamine ophth soln 0.5% (Acular)
P
LACRISERT – artificial tear ophth insert
P
latanoprost ophth soln 0.005% (Xalatan)
P
QL (1 bottle/30 days)
LUMIGAN – bimatoprost ophth soln 0.01%
NP
PA, QL (1 bottle/30 days)
MYDRIACYL – tropicamide ophth soln 1%
NP
PA
NEVANAC – nepafenac ophth susp 0.1%
NP
PA
OXERVATE – cenegermin-bkbj ophth soln 0.002% (20 mcg/ml)
NP
PA, QL (56 vials/56 days), SP
phenylephrine hcl ophth soln 2.5%, 10%
NP
PA
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
132
Drug Name
Preferred Status Drug Status / Restriction
PHOSPHOLINE IODIDE – echothiophate iodide ophth for soln
0.125%
NP
PA
pilocarpine hcl ophth soln 1%, 2%, 4% (Isopto carpine)
P
PROLENSA – bromfenac sodium ophth soln 0.07% (base
equivalent)
NP
PA
proparacaine hcl ophth soln 0.5% (Alcaine)
NP
PA
RESTASIS – cyclosporine (ophth) emulsion 0.05%
NP
PA, QL (60 vials/30 days)
RESTASIS MULTIDOSE – cyclosporine (ophth) emulsion 0.05%
NP
PA, QL (5.5 mls/30 days)
RHOPRESSA – netarsudil dimesylate ophth soln 0.02%
NP
PA, QL (1 bottle/30 days)
ROCKLATAN – netarsudil dimesylate-latanoprost ophth soln
0.02-0.005%
NP
PA, QL (1 bottle/30 days)
SIMBRINZA – brinzolamide-brimonidine tartrate ophth susp
1-0.2%
NP
PA
tafluprost preservative free (pf) ophth soln 0.0015% (Zioptan)
NP
PA, QL (30 units/30 days)
tetracaine hcl ophth soln 0.5%
NP
PA
TRAVATAN Z – travoprost ophth soln 0.004% (benzalkonium
free) (bak free)
NP
PA, QL (2.5 mls/30 days)
travoprost ophth soln 0.004% (benzalkonium free) (bak free)
(Travatan z)
NP
PA, QL (2.5 mls/30 days)
tropicamide ophth soln 0.5%
P
tropicamide ophth soln 1% (Mydriacyl)
P
VERKAZIA – cyclosporine (ophth) emulsion 0.1%
NP
PA, QL (120 vials/30 days)
VEVYE – cyclosporine (ophth) soln 0.1%
NP
PA, QL (1 bottle/30 days)
VUITY – pilocarpine hcl ophth soln 1.25%
NP
PA, QL (5 mls/30 days)
VYZULTA – latanoprostene bunod ophth soln 0.024%
NP
PA, QL (2.5 mls/30 days)
XALATAN – latanoprost ophth soln 0.005%
NP
PA, QL (1 bottle/30 days)
XELPROS – latanoprost ophth emulsion 0.005%
NP
PA, QL (2.5 mls/30 days)
XIIDRA – lifitegrast ophth soln 5%
NP
PA, QL (60 single-use
container(s)/30 days)
ZIOPTAN – tafluprost preservative free (pf) ophth soln 0.0015%
NP
PA, QL (30 units/30 days)
OPHTHALMIC AGENTS : OPHTHALMIC ANTI-INFECTIVES
AZASITE – azithromycin ophth soln 1%
NP
PA
BACITRACIN – bacitracin ophth oint 500 unit/gm
P
bacitracin-polymyxin b ophth oint
P
BESIVANCE – besifloxacin hcl ophth susp 0.6% (base equiv)
NP
PA
BETADINE OPHTHALMIC PREP – povidone-iodine ophth soln
5%
NP
PA
CILOXAN – ciprofloxacin hcl ophth oint 0.3%
P
ciprofloxacin hcl ophth soln 0.3% (base equivalent) (Ciloxan)
P
ERYTHROMYCIN – erythromycin ophth oint 5 mg/gm
P
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
133
Drug Name
Preferred Status Drug Status / Restriction
erythromycin ophth oint 5 mg/gm
P
gatifloxacin ophth soln 0.5% (Zymaxid)
NP
PA
gentamicin sulfate ophth soln 0.3%
P
moxifloxacin hcl ophth soln 0.5% (base equiv) (Vigamox)
NP
PA
MOXIFLOXACIN HYDROCHLORIDE – moxifloxacin hcl ophth
soln 0.5% (base eq) (2 times daily)
NP
PA
NATACYN – natamycin ophth susp 5%
NP
PA
neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin
P
NEOMYCIN/POLYMYXIN/GRAMICIDIN – neomycin-polymy-
gramicid op sol 1.75-10000-0.025mg-unt-mg/ml
P
OCUFLOX – ofloxacin ophth soln 0.3%
NP
PA
ofloxacin ophth soln 0.3% (Ocuflox)
P
polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%
(Polytrim)
P
SULFACETAMIDE SODIUM – sulfacetamide sodium ophth oint
10%
P
sulfacetamide sodium ophth soln 10% (Bleph-10)
P
tobramycin ophth soln 0.3% (Tobrex)
P
QL (15 mls/30 days)
TOBREX – tobramycin ophth oint 0.3%
P
TRIFLURIDINE – trifluridine ophth soln 1%
P
VIGAMOX – moxifloxacin hcl ophth soln 0.5% (base equiv)
NP
PA
XDEMVY – lotilaner ophth soln 0.25%
NP
PA, QL (1 bottle/50 days)
ZIRGAN – ganciclovir ophth gel 0.15%
P
OPHTHALMIC AGENTS : OPHTHALMIC ANTIALLERGIC
ALOMIDE – lodoxamide tromethamine ophth soln 0.1%
NP
PA
azelastine hcl ophth soln 0.05%
P
bepotastine besilate ophth soln 1.5% (Bepreve)
NP
PA
BEPREVE – bepotastine besilate ophth soln 1.5%
NP
PA
CROMOLYN SODIUM – cromolyn sodium ophth soln 4%
P
epinastine hcl ophth soln 0.05%
NP
PA
olopatadine hcl ophth soln 0.2% (base equivalent)
NP
PA
ZERVIATE – cetirizine hcl ophth soln 0.24% (base equiv)
NP
PA
OPHTHALMIC AGENTS : OPHTHALMIC STEROIDS
ALREX – loteprednol etabonate ophth susp 0.2%
P
bacitracin-polymyxin-neomycin-hc ophth oint 1%
P
DEXAMETHASONE SODIUM PHOSPHATE – dexamethasone
sodium phosphate ophth soln 0.1%
P
DEXTENZA – dexamethasone (ophth) insert 0.4 mg
NP
PA
difluprednate ophth emulsion 0.05% (Durezol)
NP
PA
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
134
Drug Name
Preferred Status Drug Status / Restriction
DUREZOL – difluprednate ophth emulsion 0.05%
NP
PA
EYSUVIS – loteprednol etabonate ophth susp 0.25%
NP
PA, QL (2 bottles/90 days)
FLAREX – fluorometholone acetate ophth susp 0.1%
P
fluorometholone ophth susp 0.1% (Fml liquifilm)
P
FML FORTE – fluorometholone ophth susp 0.25%
P
FML LIQUIFILM – fluorometholone ophth susp 0.1%
NP
PA
INVELTYS – loteprednol etabonate ophth susp 1%
NP
PA
LOTEMAX – loteprednol etabonate ophth oint 0.5%
NP
PA
LOTEMAX – loteprednol etabonate ophth susp 0.5%
NP
PA
LOTEMAX – loteprednol etabonate ophth gel 0.5%
NP
PA
LOTEMAX SM – loteprednol etabonate ophth gel 0.38%
NP
PA
loteprednol etabonate ophth gel 0.5% (Lotemax)
NP
PA
loteprednol etabonate ophth susp 0.2% (Alrex)
P
loteprednol etabonate ophth susp 0.5% (Lotemax)
P
MAXIDEX – dexamethasone ophth susp 0.1%
P
MAXITROL – neomycin-polymyxin-dexamethasone ophth susp
0.1%
NP
PA
MAXITROL – neomycin-polymyxin-dexamethasone ophth oint
0.1%
NP
PA
neomycin-polymyxin-dexamethasone ophth oint 0.1% (Maxitrol)
P
neomycin-polymyxin-dexamethasone ophth susp 0.1% (Maxitrol)
P
NEOMYCIN/POLYMYXIN/HYDROCORTISONE – neomycin-
polymyxin-hc ophth susp
P
PRED FORTE – prednisolone acetate ophth susp 1%
NP
PA
PRED MILD – prednisolone acetate ophth susp 0.12%
P
PREDNISOLONE ACETATE – prednisolone acetate ophth susp
1%
P
PREDNISOLONE SODIUM PHOSPHATE – prednisolone sodium
phosphate ophth soln 1%
P
SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM
PHOSPHATE – sulfacetamide sodium-prednisolone ophth soln
10-0.23(0.25)%
NP
PA
TOBRADEX – tobramycin-dexamethasone ophth oint 0.3-0.1%
NP
PA
TOBRADEX ST – tobramycin-dexamethasone ophth susp
0.3-0.05%
NP
PA
tobramycin-dexamethasone ophth susp 0.3-0.1% (Tobradex)
P
ZYLET – loteprednol etabonate-tobramycin ophth susp 0.5-0.3%
NP
PA
OTIC AGENTS
acetic acid otic soln 2%
P
CIPROFLOXACIN – ciprofloxacin hcl otic soln 0.2% (base
equivalent)
NP
PA
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
135
Drug Name
Preferred Status Drug Status / Restriction
DERMOTIC – fluocinolone acetonide (otic) oil 0.01%
NP
PA
fluocinolone acetonide (otic) oil 0.01% (Dermotic)
NP
PA
hydrocortisone w/ acetic acid otic soln 1-2% (Hydrocortisone/
aceti)
NP
PA
HYDROCORTISONE/ACETIC ACID – hydrocortisone w/ acetic
acid otic soln 1-2%
NP
PA
ofloxacin otic soln 0.3%
P
OTIC AGENTS : OTIC COMBINATIONS
ciprofloxacin-dexamethasone otic susp 0.3-0.1% (Ciprodex)
P
CIPROFLOXACIN/FLUOCINOLONE ACETONIDE PF –
ciprofloxacin-fluocinolone aceton (pf) otic soln 0.3-0.025%
NP
PA
CORTISPORIN-TC – neomycin-colistin-hc-thonzonium otic susp
3.3-3-10-0.5 mg/ml
NP
PA
neomycin-polymyxin-hc otic soln 1%
P
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1%
P
PROGESTINS
medroxyprogesterone acetate tab 2.5 mg, 5 mg, 10 mg (Provera)
P
90
megestrol acetate susp 625 mg/5ml (Megace es)
NP
PA, 90
norethindrone acetate tab 5 mg (Aygestin)
NP
PA, 90
progesterone cap 100 mg, 200 mg (Prometrium)
P
90
progesterone im in oil 50 mg/ml
P
PROMETRIUM – progesterone cap 100 mg, 200 mg
NP
PA, 90
PROVERA – medroxyprogesterone acetate tab 2.5 mg, 5 mg,
10 mg
NP
PA, 90
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS : ANTIDEMENTIA AGENTS
ADLARITY – donepezil hydrochloride td patch weekly 5 mg/day,
10 mg/day
NP
PA, QL (4 patches/28
days), 90
ADUHELM – aducanumab-avwa iv soln 170 mg/1.7ml (100 mg/
ml), 300 mg/3ml (100 mg/ml)
NP
PA, SP
ARICEPT – donepezil hydrochloride tab 5 mg, 10 mg, 23 mg
NP
PA, QL (30 tablets/30
days), 90
donepezil hydrochloride orally disintegrating tab 5 mg, 10 mg
P
QL (30 tablets/30 days), 90
donepezil hydrochloride tab 5 mg, 10 mg, 23 mg (Aricept)
P
QL (30 tablets/30 days), 90
EXELON – rivastigmine td patch 24hr 4.6 mg/24hr, 9.5 mg/24hr,
13.3 mg/24hr
NP
PA, QL (30 patches/30
days), 90
GALANTAMINE HYDROBROMIDE – galantamine hydrobromide
oral soln 4 mg/ml
NP
PA, QL (200 mls/30 days), 90
galantamine hydrobromide cap er 24hr 8 mg, 16 mg, 24 mg
(Razadyne er)
NP
PA, QL (30 capsules/30
days), 90
galantamine hydrobromide tab 4 mg (Razadyne)
NP
PA, QL (60 tablets/30
days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
136
Drug Name
Preferred Status Drug Status / Restriction
galantamine hydrobromide tab 8 mg, 12 mg
NP
PA, QL (60 tablets/30
days), 90
LEQEMBI – lecanemab-irmb iv soln 200 mg/2ml (100 mg/ml),
500 mg/5ml (100 mg/ml)
NP
PA, SP
memantine hcl cap er 24hr 7 mg, 14 mg, 21 mg, 28 mg
(Namenda xr)
NP
PA, QL (30 capsules/30
days), 90
memantine hcl oral solution 2 mg/ml
NP
PA, QL (360 mls/30 days), 90
memantine hcl tab 5 mg, 10 mg (Namenda)
P
QL (60 tablets/30 days), 90
memantine hcl tab 28 x 5 mg & 21 x 10 mg titration pack
(Namenda titration pack)
NP
PA, QL (49 tablets/180 days)
NAMENDA TITRATION PAK – memantine hcl tab 28 x 5 mg & 21
x 10 mg titration pack
NP
PA, QL (49 tablets/180 days)
NAMENDA XR – memantine hcl cap er 24hr 14 mg, 21 mg,
28 mg
NP
PA, QL (30 capsules/30
days), 90
NAMZARIC – memantine-donepezil cap er 24hr 7 & 14 & 21 &
28-10 mg pack
NP
PA, QL (28
capsules/180 days)
NAMZARIC – memantine hcl-donepezil hcl cap er 24hr 7-10 mg,
14-10 mg, 21-10 mg, 28-10 mg
NP
PA, QL (30 capsules/30
days), 90
rivastigmine tartrate cap 1.5 mg (base equivalent), 3 mg (base
equivalent), 4.5 mg (base equivalent), 6 mg (base equivalent)
NP
PA, QL (60 capsules/30
days), 90
rivastigmine td patch 24hr 4.6 mg/24hr, 9.5 mg/24hr,
13.3 mg/24hr (Exelon)
NP
PA, QL (30 patches/30
days), 90
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS : MISC
AMVUTTRA – vutrisiran sodium soln prefilled syringe
25 mg/0.5ml
NP
PA, QL (1 syringe/90
days), SP
AUSTEDO – deutetrabenazine tab 6 mg, 9 mg, 12 mg
P
PA, QL (120
tablets/30 days), SP
AUSTEDO XR – deutetrabenazine tab er 24hr 6 mg, 12 mg,
24 mg
P
PA, QL (90 tablets/30
days), SP
AUSTEDO XR PATIENT TITRATION KIT – deutetrabenazine tab
er titration pack 6 mg & 12 mg & 24 mg
P
PA, QL (1 pack/180 days), SP
CHLORDIAZEPOXIDE/AMITRIPTYLINE – chlordiazepoxide-
amitriptyline tab 5-12.5 mg
P
QL (120 tablets/30 days), 90
CHLORDIAZEPOXIDE/AMITRIPTYLINE – chlordiazepoxide-
amitriptyline tab 10-25 mg
P
QL (180 tablets/30 days), 90
ERGOLOID MESYLATES – ergoloid mesylates tab 1 mg
P
90
FLUOXETINE HYDROCHLORIDE – fluoxetine hcl (pmdd) tab
10 mg, 20 mg
NP
PA, 90
gabapentin (once-daily) tab 300 mg (Gralise)
NP
PA, QL (30 tablets/30
days), 90
gabapentin (once-daily) tab 600 mg (Gralise)
NP
PA, QL (90 tablets/30
days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
137
Drug Name
Preferred Status Drug Status / Restriction
GRALISE – gabapentin (once-daily) tab 300 mg, 450 mg, 750 mg
NP
PA, QL (30 tablets/30
days), 90
GRALISE – gabapentin (once-daily) tab 600 mg
NP
PA, QL (90 tablets/30
days), 90
GRALISE – gabapentin (once-daily) tab 900 mg
NP
PA, QL (60 tablets/30
days), 90
HORIZANT – gabapentin enacarbil tab er 300 mg, 600 mg
NP
PA, QL (60 tablets/30
days), 90
INGREZZA – valbenazine tosylate cap therapy pack 40 mg (7) &
80 mg (21)
P
PA, QL (28 capsules/180
days), SP
INGREZZA – valbenazine tosylate cap 40 mg (base equiv),
60 mg (base equiv), 80 mg (base equiv)
P
PA, QL (30 capsules/30
days), SP
LYBALVI – olanzapine-samidorphan l-malate tab 5-10 mg,
10-10 mg, 15-10 mg, 20-10 mg
NP
PA, QL (30 tablets/30
days), 90
LYRICA CR – pregabalin tab er 24hr 82.5 mg, 165 mg
NP
PA, QL (30 tablets/30 days)
LYRICA CR – pregabalin tab er 24hr 330 mg
NP
PA, QL (60 tablets/30 days)
NUEDEXTA – dextromethorphan hbr-quinidine sulfate cap
20-10 mg
NP
PA, QL (60 capsules/30
days), 90
olanzapine-fluoxetine hcl cap 3-25 mg, 6-25 mg, 6-50 mg,
12-50 mg (Symbyax)
NP
PA, QL (30 capsules/30
days), 90
olanzapine-fluoxetine hcl cap 12-25 mg
NP
PA, QL (30 capsules/30
days), 90
paroxetine mesylate cap 7.5 mg (base equiv) (Brisdelle)
NP
PA, 90
PERPHENAZINE/AMITRIPTYLINE – perphenazine-amitriptyline
tab 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg
P
90
PIMOZIDE – pimozide tab 1 mg, 2 mg
P
90
pregabalin tab er 24hr 82.5 mg, 165 mg (Lyrica cr)
NP
PA, QL (30 tablets/30 days)
pregabalin tab er 24hr 330 mg (Lyrica cr)
NP
PA, QL (60 tablets/30 days)
SAVELLA – milnacipran hcl tab 12.5 mg, 25 mg, 50 mg, 100 mg
NP
PA, QL (60 tablets/30
days), 90
SAVELLA TITRATION PACK – milnacipran hcl tab 12.5 mg (5) &
25 mg (8) & 50 mg (42) pak
NP
PA, QL (1 kit/180 days)
SODIUM OXYBATE – sodium oxybate oral solution 500 mg/ml
NP
PA, QL (540 mls/30 days), SP
SYMBYAX – olanzapine-fluoxetine hcl cap 3-25 mg, 6-25 mg
NP
PA, QL (30 capsules/30
days), 90
TEGSEDI – inotersen sod subcutaneous pref syr 284 mg/1.5ml
(base eq)
NP
PA, QL (4 syringes/28
days), SP
tetrabenazine tab 12.5 mg (Xenazine)
NP
PA, QL (240
tablets/30 days), SP
tetrabenazine tab 25 mg (Xenazine)
NP
PA, QL (120
tablets/30 days), SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
138
Drug Name
Preferred Status Drug Status / Restriction
WAINUA – eplontersen sodium subcutaneous soln auto-inj
45 mg/0.8ml
NP
PA, QL (1 pen/30 days), SP
XENAZINE – tetrabenazine tab 12.5 mg
NP
PA, QL (240
tablets/30 days), SP
XENAZINE – tetrabenazine tab 25 mg
NP
PA, QL (120
tablets/30 days), SP
XYREM – sodium oxybate oral solution 500 mg/ml
NP
PA, QL (540 mls/30 days), SP
XYWAV – calcium, mag, potassium, & sod oxybates oral soln
500 mg/ml
NP
PA, QL (540 mls/30 days), SP
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS : MULTIPLE SCLEROSIS AGENTS
AMPYRA – dalfampridine tab er 12hr 10 mg
NP
PA, QL (60 tablets/30
days), SF, SP
AUBAGIO – teriflunomide tab 7 mg, 14 mg
NP
PA, QL (30 tablets/30
days), SF, SP
AVONEX – interferon beta-1a im prefilled syringe kit
30 mcg/0.5ml
NP
PA, QL (1 kit/28 days), SP
AVONEX PEN – interferon beta-1a im auto-injector kit
30 mcg/0.5ml
NP
PA, QL (1 kit/28 days), SP
BAFIERTAM – monomethyl fumarate capsule delayed release
95 mg
NP
PA, QL (120
capsules/30 days), SP
BETASERON – interferon beta-1b for inj kit 0.3 mg
P
QL (15 vials/30 days), SP
BRIUMVI – ublituximab-xiiy soln for iv infusion 150 mg/6ml
NP
PA, QL (3 vials/180 days), SP
COPAXONE – glatiramer acetate soln prefilled syringe 20 mg/ml
P
QL (30 syringes/30 days), SP
COPAXONE – glatiramer acetate soln prefilled syringe 40 mg/ml
P
QL (12 syringes/28 days), SP
dalfampridine tab er 12hr 10 mg (Ampyra)
NP
PA, QL (60 tablets/30
days), SF, SP
dimethyl fumarate capsule delayed release 120 mg (Tecfidera)
P
QL (56 capsules/180
days), SP
dimethyl fumarate capsule delayed release 240 mg (Tecfidera)
P
QL (60 capsules/30 days), SP
dimethyl fumarate capsule dr starter pack 120 mg & 240 mg
(Tecfidera starter pack)
P
QL (60 capsules/180
days), SP
EXTAVIA – interferon beta-1b for inj kit 0.3 mg
NP
PA, QL (15 vials/30 days), SP
fingolimod hcl cap 0.5 mg (base equiv) (Gilenya)
NP
PA, QL (30 capsules/30
days), SP
GILENYA – fingolimod hcl cap 0.25 mg (base equiv)
NP
PA, QL (30 capsules/30
days), SP
GILENYA – fingolimod hcl cap 0.5 mg (base equiv)
P
PA, QL (30 capsules/30
days), SP
glatiramer acetate soln prefilled syringe 20 mg/ml (Copaxone)
NP
PA, QL (30 syringes/30
days), SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
139
Drug Name
Preferred Status Drug Status / Restriction
glatiramer acetate soln prefilled syringe 40 mg/ml (Copaxone)
NP
PA, QL (12 syringes/28
days), SP
KESIMPTA – ofatumumab soln auto-injector 20 mg/0.4ml
NP
PA, QL (1 pen/28 days), SP
LEMTRADA – alemtuzumab iv inj 12 mg/1.2ml (10 mg/ml)
NP
PA, QL (5 vials/365 days), SP
MAVENCLAD – cladribine tab therapy pack 10 mg (4 tabs),
10 mg (8 tabs)
NP
PA, QL (8 tablets/301
days), SP
MAVENCLAD – cladribine tab therapy pack 10 mg (5 tabs)
NP
PA, QL (10 tablets/301
days), SP
MAVENCLAD – cladribine tab therapy pack 10 mg (6 tabs)
NP
PA, QL (12 tablets/301
days), SP
MAVENCLAD – cladribine tab therapy pack 10 mg (7 tabs)
NP
PA, QL (14 tablets/301
days), SP
MAVENCLAD – cladribine tab therapy pack 10 mg (9 tabs)
NP
PA, QL (9 tablets/301
days), SP
MAVENCLAD – cladribine tab therapy pack 10 mg (10 tabs)
NP
PA, QL (20 tablets/301
days), SP
MAYZENT – siponimod fumarate tab 0.25 mg (base equiv)
NP
PA, QL (120
tablets/30 days), SP
MAYZENT – siponimod fumarate tab 1 mg (base equiv), 2 mg
(base equiv)
NP
PA, QL (30 tablets/30
days), SP
MAYZENT STARTER PACK – siponimod fumarate tab 0.25 mg
(7) starter pack
NP
PA, QL (1 pack/180 days), SP
MAYZENT STARTER PACK – siponimod fumarate tab 0.25 mg
(12) starter pack
NP
PA, QL (1 pack/180 days), SP
OCREVUS – ocrelizumab soln for iv infusion 300 mg/10ml
NP
PA, QL (2 vials/180 days), SP
PLEGRIDY – peginterferon beta-1a soln pen-injector
125 mcg/0.5ml
NP
PA, QL (2 pens/28 days), SP
PLEGRIDY – peginterferon beta-1a soln prefilled syringe
125 mcg/0.5ml
NP
PA, QL (1 syringe/28
days), SP
PLEGRIDY – peginterferon beta-1a im soln prefilled syr
125 mcg/0.5ml
NP
PA, QL (2 syringes/28
days), SP
PLEGRIDY STARTER PACK – peginterferon beta-1a soln pen-inj
63 & 94 mcg/0.5ml pack
NP
PA, QL (1 kit/180 days), SP
PLEGRIDY STARTER PACK – peginterferon beta-1a soln pref
syr 63 & 94 mcg/0.5ml pack
NP
PA, QL (1 kit/180 days), SP
PONVORY – ponesimod tab 20 mg
NP
PA, QL (30 tablets/30
days), SP
PONVORY 14-DAY STARTER PACK – ponesimod tab starter
pack 2,3,4,5,6,7,8,9 &10 mg
NP
PA, QL (1 pack/180 days), SP
REBIF – interferon beta-1a soln pref syr 22 mcg/0.5ml,
44 mcg/0.5ml
P
QL (12 syringes/28 days), SP
REBIF REBIDOSE – interferon beta-1a soln auto-inj
22 mcg/0.5ml, 44 mcg/0.5ml
P
QL (12 syringes/28 days), SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
140
Drug Name
Preferred Status Drug Status / Restriction
REBIF REBIDOSE TITRATION – interferon beta-1a auto-inj
6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml
P
QL (1 kit/180 days), SP
REBIF TITRATION PACK – interferon beta-1a pref syr
6x8.8 mcg/0.2ml & 6x22 mcg/0.5ml
P
QL (1 kit/180 days), SP
TASCENSO ODT – fingolimod lauryl sulfate tablet disintegrating
0.25 mg, 0.5 mg
NP
PA, QL (30 tablets/30
days), SP
TECFIDERA – dimethyl fumarate capsule delayed release
120 mg
P
QL (56 capsules/180
days), SP
TECFIDERA – dimethyl fumarate capsule delayed release
240 mg
P
QL (60 capsules/30 days), SP
TECFIDERA STARTER PACK – dimethyl fumarate capsule dr
starter pack 120 mg & 240 mg
P
QL (60 capsules/180
days), SP
teriflunomide tab 7 mg, 14 mg (Aubagio)
NP
PA, QL (30 tablets/30
days), SF, SP
TYSABRI – natalizumab for iv inj conc 300 mg/15ml
NP
PA, QL (1 vial/28 days), SP
VUMERITY – diroximel fumarate capsule delayed release
231 mg
NP
PA, QL (120
capsules/30 days), SP
ZEPOSIA – ozanimod hcl cap 0.92 mg
NP
PA, QL (30 capsules/30
days), SP
ZEPOSIA STARTER KIT – ozanimod cap pack 4 x 0.23 mg & 3 x
0.46 mg & 21 x 0.92 mg
NP
PA, QL (28 capsules/180
days), SP
ZEPOSIA 7-DAY STARTER PACK – ozanimod cap pack 4 x
0.23 mg & 3 x 0.46 mg
NP
PA, QL (7 capsules/180
days), SP
PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS : SMOKING DETERRENTS
bupropion hcl (smoking deterrent) tab er 12hr 150 mg
P
QL (180 days/365 days)
nicotine polacrilex gum 2 mg, 4 mg
P
QL (180 days/365 days)
nicotine polacrilex lozenge 2 mg, 4 mg
P
QL (180 days/365 days)
nicotine td patch 24hr 7 mg/24hr, 14 mg/24hr, 21 mg/24hr
P
QL (180 days/365 days)
NICOTINE TRANSDERMAL SYSTEM – nicotine td patch 24 hr
kit 21-14-7 mg/24hr
P
QL (180 days/365 days)
NICOTROL INHALER – nicotine inhaler system 10 mg (4 mg
delivered)
P
QL (180 days/365 days)
NICOTROL NS – nicotine nasal spray 10 mg/ml (0.5 mg/spray)
P
QL (180 days/365 days)
varenicline tartrate tab 0.5 mg (base equiv), 1 mg (base equiv)
P
QL (180/365 days)
varenicline tartrate tab 11 x 0.5 mg & 42 x 1 mg start pack
P
QL (180 days/365 days)
RESPIRATORY AGENTS : CYSTIC FIBROSIS AGENTS
BRONCHITOL – mannitol inhal cap 40 mg
NP
PA, SP
BRONCHITOL TOLERANCE TEST – mannitol inhal cap 40 mg
NP
PA, SP
KALYDECO – ivacaftor tab 150 mg
NP
PA, QL (60 tablets/30
days), SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
141
Drug Name
Preferred Status Drug Status / Restriction
KALYDECO – ivacaftor packet 5.8 mg, 13.4 mg
NP
PA, QL (60 packets/30
days), SP
KALYDECO – ivacaftor packet 25 mg, 50 mg, 75 mg
NP
PA, QL (56 packets/28
days), SP
ORKAMBI – lumacaftor-ivacaftor tab 100-125 mg, 200-125 mg
NP
PA, QL (120
tablets/30 days), SP
ORKAMBI – lumacaftor-ivacaftor granules packet 75-94 mg,
100-125 mg, 150-188 mg
NP
PA, QL (60 packets/30
days), SP
PULMOZYME – dornase alfa inhal soln 2.5 mg/2.5ml
P
SP
SYMDEKO – tezacaftor-ivacaftor 50-75 mg & ivacaftor 75 mg tab
tbpk
NP
PA, QL (60 tablets/30
days), SP
SYMDEKO – tezacaftor-ivacaftor 100-150 mg & ivacaftor 150 mg
tab tbpk
NP
PA, QL (60 tablets/30
days), SP
TRIKAFTA – elexacaf-tezacaf-ivacaf 80-40-60 mg& ivacaf
59.5mg thpk gran
NP
PA, QL (56 packets/28
days), SP
TRIKAFTA – elexacaf-tezacaf-ivacaf 100-50-75 mg& ivacaf 75mg
thpk gran
NP
PA, QL (56 packets/28
days), SP
TRIKAFTA – elexacaf-tezacaf-ivacaf 50-25-37.5 mg & ivacaftor
75 mg tbpk
NP
PA, QL (90 tablets/30
days), SP
TRIKAFTA – elexacaf-tezacaf-ivacaf 100-50-75 mg &ivacaftor
150 mg tbpk
NP
PA, QL (90 tablets/30
days), SP
RESPIRATORY AGENTS : MISC
acetylcysteine inhal soln 10%, 20%
SC
ESBRIET – pirfenidone cap 267 mg
NP
PA, QL (270
capsules/30 days), SP
ESBRIET – pirfenidone tab 267 mg
NP
PA, QL (270
tablets/30 days), SP
ESBRIET – pirfenidone tab 801 mg
NP
PA, QL (90 tablets/30
days), SP
OFEV – nintedanib esylate cap 100 mg (base equivalent),
150 mg (base equivalent)
NP
PA, QL (60 capsules/30
days), SF, SP
PIRFENIDONE – pirfenidone tab 534 mg
NP
PA, QL (21 tablets/180
days), SP
pirfenidone cap 267 mg (Esbriet)
NP
PA, QL (270
capsules/30 days), SP
pirfenidone tab 267 mg (Esbriet)
NP
PA, QL (270
tablets/30 days), SP
pirfenidone tab 801 mg (Esbriet)
NP
PA, QL (90 tablets/30
days), SP
promethazine w/ codeine syrup 6.25-10 mg/5ml
SC
AL (>=18 yr), ME
sodium chloride soln nebu 0.9%, 3%, 10%
SC
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
142
Drug Name
Preferred Status Drug Status / Restriction
sodium chloride soln nebu 7% (Hyper-sal)
SC
SUBSTANCE USE DISORDER AGENTS
acamprosate calcium tab delayed release 333 mg
P
90
buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base equiv)
(Suboxone)
P
ME, QL (360 films/30 days)
buprenorphine hcl-naloxone hcl sl film 4-1 mg (base equiv)
(Suboxone)
P
ME, QL (180 films/30 days)
buprenorphine hcl-naloxone hcl sl film 8-2 mg (base equiv)
(Suboxone)
P
ME, QL (90 films/30 days)
buprenorphine hcl-naloxone hcl sl film 12-3 mg (base equiv)
(Suboxone)
P
ME, QL (60 films/30 days)
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base equiv)
P
ME, QL (360 tablets/30 days)
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base equiv)
P
ME, QL (90 tablets/30 days)
DISULFIRAM – disulfiram tab 500 mg
P
90
disulfiram tab 250 mg (Antabuse)
P
90
KLOXXADO – naloxone hcl nasal spray 8 mg/0.1ml
P
LUCEMYRA – lofexidine hcl tab 0.18 mg (base equivalent)
P
NALMEFENE HYDROCHLORIDE – nalmefene hcl inj 1 mg/ml
(base equiv)
P
naloxone hcl inj 0.4 mg/ml, 4 mg/10ml
P
naloxone hcl nasal spray 4 mg/0.1ml (Narcan)
P
naloxone hcl soln prefilled syringe 2 mg/2ml
P
NALOXONE HYDROCHLORIDE – naloxone hcl soln cartridge
0.4 mg/ml
P
naltrexone hcl tab 50 mg
P
NARCAN – naloxone hcl nasal spray 4 mg/0.1ml
P
OPVEE – nalmefene hcl nasal spray 2.7 mg/0.1ml (base equiv)
P
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 2-0.5 mg
(base equiv)
P
ME, QL (360 films/30 days)
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 4-1 mg
(base equiv)
P
ME, QL (180 films/30 days)
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 8-2 mg
(base equiv)
P
ME, QL (90 films/30 days)
SUBOXONE – buprenorphine hcl-naloxone hcl sl film 12-3 mg
(base equiv)
P
ME, QL (60 films/30 days)
VIVITROL – naltrexone for im extended release susp 380 mg
P
QL (1 vial/28 days)
ZIMHI – naloxone hcl soln prefilled syringe 5 mg/0.5ml
P
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 0.7-0.18 mg
(base eq)
P
ME, QL (1020
tablets/30 days)
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 1.4-0.36 mg
(base eq)
P
ME, QL (510 tablets/30 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
143
Drug Name
Preferred Status Drug Status / Restriction
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 2.9-0.71 mg
(base eq)
P
ME, QL (240 tablets/30 days)
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 5.7-1.4 mg
(base eq)
P
ME, QL (120 tablets/30 days)
ZUBSOLV – buprenorphine hcl-naloxone hcl sl tab 8.6-2.1 mg
(base eq), 11.4-2.9 mg (base eq)
P
ME, QL (60 tablets/30 days)
THYROID AGENTS
ADTHYZA – thyroid tab 15 mg (1/4 grain), 16.25 mg, 30 mg
(1/2 grain), 32.5 mg, 60 mg (1 grain), 65 mg, 90 mg (1
1/2 grain), 97.5 mg, 120 mg (2 grain), 130 mg
P
90
ARMOUR THYROID – thyroid tab 15 mg (1/4 grain), 30 mg
(1/2 grain), 60 mg (1 grain), 90 mg (1 1/2 grain), 120 mg
(2 grain), 180 mg (3 grain), 240 mg (4 grain), 300 mg (5 grain)
P
90
CYTOMEL – liothyronine sodium tab 5 mcg, 25 mcg, 50 mcg
NP
PA, 90
ERMEZA – levothyroxine sodium oral solution 150 mcg/5ml
NP
PA
LEVOTHYROXINE SODIUM – levothyroxine sodium cap
13 mcg, 25 mcg, 50 mcg, 75 mcg, 88 mcg, 100 mcg, 112 mcg,
125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg
NP
PA, 90
levothyroxine sodium tab 25 mcg, 50 mcg, 75 mcg, 88 mcg,
100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg,
200 mcg, 300 mcg (Synthroid)
P
90
liothyronine sodium tab 5 mcg, 25 mcg, 50 mcg (Cytomel)
P
90
methimazole tab 5 mg, 10 mg (Tapazole)
P
90
NIVA THYROID – thyroid tab 15 mg (1/4 grain), 30 mg
(1/2 grain), 60 mg (1 grain), 90 mg (1 1/2 grain), 120 mg
(2 grain)
P
90
NP THYROID 120 – thyroid tab 120 mg (2 grain)
P
90
NP THYROID 15 – thyroid tab 15 mg (1/4 grain)
P
90
NP THYROID 30 – thyroid tab 30 mg (1/2 grain)
P
90
NP THYROID 60 – thyroid tab 60 mg (1 grain)
P
90
NP THYROID 90 – thyroid tab 90 mg (1 1/2 grain)
P
90
propylthiouracil tab 50 mg
P
90
SYNTHROID – levothyroxine sodium tab 25 mcg, 50 mcg,
75 mcg, 88 mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg,
150 mcg, 175 mcg, 200 mcg, 300 mcg
NP
PA, 90
THYQUIDITY – levothyroxine sodium oral solution 100 mcg/5ml
NP
PA
THYROID – thyroid tab 15 mg (1/4 grain), 30 mg (1/2 grain),
60 mg (1 grain), 90 mg (1 1/2 grain), 120 mg (2 grain)
P
90
TIROSINT – levothyroxine sodium cap 13 mcg, 25 mcg,
37.5 mcg, 44 mcg, 50 mcg, 62.5 mcg, 75 mcg, 88 mcg,
100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg,
200 mcg
NP
PA, 90
TIROSINT-SOL – levothyroxine sodium oral solution 13 mcg/ml,
25 mcg/ml, 37.5 mcg/ml, 44 mcg/ml, 50 mcg/ml, 62.5 mcg/ml,
NP
PA
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
144
Drug Name
Preferred Status Drug Status / Restriction
75 mcg/ml, 88 mcg/ml, 100 mcg/ml, 112 mcg/ml, 125 mcg/ml,
137 mcg/ml, 150 mcg/ml, 175 mcg/ml, 200 mcg/ml
TUMOR NECROSIS FACTOR ALPHA INHIBITORS AND MISC IMMUNOSUPPRESSIVES
ABRILADA – adalimumab-afzb prefilled syringe kit 20 mg/0.4ml,
40 mg/0.8ml
NP
PA, QL (2 syringes/28
days), SP
ABRILADA 1-PEN KIT – adalimumab-afzb auto-injector kit
40 mg/0.8ml
NP
PA, QL (2 pens/28 days), SP
ABRILADA 2-PEN KIT – adalimumab-afzb auto-injector kit
40 mg/0.8ml
NP
PA, QL (2 pens/28 days), SP
ACTEMRA – tocilizumab subcutaneous soln prefilled syringe
162 mg/0.9ml
NP
PA, QL (4 syringes/28
days), SP
ACTEMRA – tocilizumab iv inj 80 mg/4ml
NP
PA, QL (10 vials/28 days), SP
ACTEMRA – tocilizumab iv inj 200 mg/10ml
NP
PA, QL (4 vials/28 days), SP
ACTEMRA – tocilizumab iv inj 400 mg/20ml
NP
PA, QL (2 vials/28 days), SP
ACTEMRA ACTPEN – tocilizumab subcutaneous soln auto-
injector 162 mg/0.9ml
NP
PA, QL (4 pens/28 days), SP
ADALIMUMAB-AACF (2 PEN) – adalimumab-aacf auto-injector
kit 40 mg/0.8ml
NP
PA, QL (1 kit/28 days), SP
ADALIMUMAB-ADAZ – adalimumab-adaz soln auto-injector
40 mg/0.4ml
NP
PA, QL (2 pens/28 days), SP
ADALIMUMAB-ADAZ – adalimumab-adaz soln prefilled syringe
40 mg/0.4ml
NP
PA, QL (2 syringes/28
days), SP
ADALIMUMAB-ADBM – adalimumab-adbm auto-injector kit
40 mg/0.4ml
NP
PA, QL (2 pens/28 days), SP
ADALIMUMAB-ADBM – adalimumab-adbm auto-injector kit
40 mg/0.8ml
NP
PA, QL (1 kit/28 days), SP
ADALIMUMAB-ADBM – adalimumab-adbm prefilled syringe kit
10 mg/0.2ml, 20 mg/0.4ml, 40 mg/0.8ml
NP
PA, QL (2 syringes/28
days), SP
ADALIMUMAB-ADBM – adalimumab-adbm prefilled syringe kit
40 mg/0.4ml
NP
PA, QL (2 pens/28 days), SP
ADALIMUMAB-ADBM CROHNS/UC/HS STARTER –
adalimumab-adbm auto-injector kit 40 mg/0.8ml
NP
PA, QL (1 kit/180 days), SP
ADALIMUMAB-ADBM PSORIASIS/UVEITIS STARTER –
adalimumab-adbm auto-injector kit 40 mg/0.8ml
NP
PA, QL (1 kit/180 days), SP
ADALIMUMAB-ADBM STARTER PACKAGE FOR CROHNS
DISEASE/UC/HS – adalimumab-adbm auto-injector kit
40 mg/0.4ml
NP
PA, QL (1 kit/180 days), SP
ADALIMUMAB-ADBM STARTER PACKAGE FOR PSORIASIS/
UVEITIS – adalimumab-adbm auto-injector kit 40 mg/0.4ml
NP
PA, QL (1 kit/180 days), SP
ADALIMUMAB-FKJP – adalimumab-fkjp auto-injector kit
40 mg/0.8ml
NP
PA, QL (2 syringes/28
days), SP
ADALIMUMAB-FKJP – adalimumab-fkjp prefilled syringe kit
20 mg/0.4ml, 40 mg/0.8ml
NP
PA, QL (2 syringes/28
days), SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
145
Drug Name
Preferred Status Drug Status / Restriction
AMJEVITA – adalimumab-atto soln auto-injector 40 mg/0.4ml,
40 mg/0.8ml, 80 mg/0.8ml
NP
PA, QL (2 pens/28 days), SP
AMJEVITA – adalimumab-atto soln prefilled syringe 10 mg/0.2ml,
20 mg/0.2ml, 20 mg/0.4ml, 40 mg/0.4ml, 40 mg/0.8ml
NP
PA, QL (2 syringes/28
days), SP
ARCALYST – rilonacept for inj 220 mg
NP
PA, QL (8 vials/28 days), SP
AVSOLA – infliximab-axxq for iv inj 100 mg
NP
PA, SP
CIMZIA – certolizumab pegol for inj kit 2 x 200 mg
NP
PA, QL (2 kits/28 days), SP
CIMZIA – certolizumab pegol prefilled syringe kit 200 mg/ml
P
PA, QL (2 kits/28 days), SP
CIMZIA STARTER KIT – certolizumab pegol prefilled syringe kit 6
x 200 mg/ml
P
PA, QL (1 kit/180 days), SP
CYLTEZO – adalimumab-adbm auto-injector kit 40 mg/0.4ml
NP
PA, QL (2 pens/28 days), SP
CYLTEZO – adalimumab-adbm auto-injector kit 40 mg/0.8ml
NP
PA, QL (1 kit/28 days), SP
CYLTEZO – adalimumab-adbm prefilled syringe kit 10 mg/0.2ml,
20 mg/0.4ml, 40 mg/0.8ml
NP
PA, QL (2 syringes/28
days), SP
CYLTEZO – adalimumab-adbm prefilled syringe kit 40 mg/0.4ml
NP
PA, QL (2 pens/28 days), SP
CYLTEZO STARTER PACKAGE FOR CROHNS DISEASE/
UC/HS – adalimumab-adbm auto-injector kit 40 mg/0.4ml,
40 mg/0.8ml
NP
PA, QL (1 kit/180 days), SP
CYLTEZO STARTER PACKAGE FOR PSORIASIS –
adalimumab-adbm auto-injector kit 40 mg/0.8ml
NP
PA, QL (1 kit/180 days), SP
CYLTEZO STARTER PACKAGE FOR PSORIASIS/UVEITIS –
adalimumab-adbm auto-injector kit 40 mg/0.4ml
NP
PA, QL (1 kit/180 days), SP
ENBREL – etanercept subcutaneous soln prefilled syringe
25 mg/0.5ml, 50 mg/ml
P
PA, QL (4 syringes/28
days), SP
ENBREL – etanercept subcutaneous inj 25 mg/0.5ml
P
PA, QL (8 vials/28 days), SP
ENBREL MINI – etanercept subcutaneous solution cartridge
50 mg/ml
P
PA, QL (4 cartridges/28
days), SP
ENBREL SURECLICK – etanercept subcutaneous solution auto-
injector 50 mg/ml
P
PA, QL (4 syringes/28
days), SP
ENTYVIO – vedolizumab soln pen-injector 108 mg/0.68ml
NP
PA, QL (2 pens/28 days), SP
ENTYVIO – vedolizumab for iv solution 300 mg
NP
PA, QL (1 vial/56 days), SP
HADLIMA – adalimumab-bwwd soln prefilled syringe
40 mg/0.4ml, 40 mg/0.8ml
NP
PA, QL (2 syringes/28
days), SP
HADLIMA PUSHTOUCH – adalimumab-bwwd soln auto-injector
40 mg/0.4ml, 40 mg/0.8ml
NP
PA, QL (2 pens/28 days), SP
HULIO – adalimumab-fkjp auto-injector kit 40 mg/0.8ml
NP
PA, QL (2 syringes/28
days), SP
HULIO – adalimumab-fkjp prefilled syringe kit 20 mg/0.4ml,
40 mg/0.8ml
NP
PA, QL (2 syringes/28
days), SP
HUMIRA – adalimumab prefilled syringe kit 10 mg/0.1ml,
20 mg/0.2ml, 40 mg/0.8ml, 40 mg/0.4ml
P
PA, QL (2 syringes/28
days), SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
146
Drug Name
Preferred Status Drug Status / Restriction
HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK –
adalimumab prefilled syringe kit 80 mg/0.8ml
P
PA, QL (3 syringes/180
days), SP
HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK –
adalimumab prefilled syringe kit 80 mg/0.8ml & 40 mg/0.4ml
P
PA, QL (2 syringes/180
days), SP
HUMIRA PEN – adalimumab pen-injector kit 40 mg/0.8ml,
40 mg/0.4ml, 80 mg/0.8ml
P
PA, QL (2 pens/28 days), SP
HUMIRA PEN-CD/UC/HS STARTER – adalimumab pen-injector
kit 80 mg/0.8ml
P
PA, QL (1 kit/180 days), SP
HUMIRA PEN-PEDIATRIC UC STARTER KIT – adalimumab
pen-injector kit 80 mg/0.8ml
P
PA, QL (1 kit/180 days), SP
HUMIRA PEN-PS/UV STARTER – adalimumab pen-injector kit
80 mg/0.8ml & 40 mg/0.4ml
P
PA, QL (1 kit/180 days), SP
HYRIMOZ – adalimumab-adaz soln auto-injector 40 mg/0.4ml,
80 mg/0.8ml
NP
PA, QL (2 pens/28 days), SP
HYRIMOZ – adalimumab-adaz soln prefilled syringe
10 mg/0.1ml, 20 mg/0.2ml, 40 mg/0.4ml
NP
PA, QL (2 syringes/28
days), SP
HYRIMOZ CROHN'S DISEASE AND ULCERATIVE COLITIS
STARTER PACK – adalimumab-adaz soln auto-injector
80 mg/0.8ml
NP
PA, QL (1 kit/180 days), SP
HYRIMOZ PEDIATRIC CROHN'S DISEASE STARTER PACK –
adalimumab-adaz soln prefilled syr 80 mg/0.8ml & 40 mg/0.4ml
NP
PA, QL (1 kit/180 days), SP
HYRIMOZ PEDIATRIC CROHNS DISEASE STARTER PACK –
adalimumab-adaz soln prefilled syringe 80 mg/0.8ml
NP
PA, QL (1 kit/180 days), SP
HYRIMOZ PLAQUE PSORIASIS STARTER PACK –
adalimumab-adaz soln auto-injector 80 mg/0.8ml &
40 mg/0.4ml
NP
PA, QL (1 kit/180 days), SP
IDACIO (2 PEN) – adalimumab-aacf auto-injector kit 40 mg/0.8ml
NP
PA, QL (2 pens/28 days), SP
IDACIO (2 SYRINGE) – adalimumab-aacf prefilled syringe kit
40 mg/0.8ml
NP
PA, QL (2 syringes/28
days), SP
IDACIO STARTER PACKAGE FOR CROHNS DISEASE –
adalimumab-aacf auto-injector kit 40 mg/0.8ml
NP
PA, QL (1 kit/180 days), SP
IDACIO STARTER PACKAGE FOR PLAQUE PSORIASIS –
adalimumab-aacf auto-injector kit 40 mg/0.8ml
NP
PA, QL (1 kit/180 days), SP
ILARIS – canakinumab subcutaneous inj 150 mg/ml
NP
PA, QL (2 vials/28 days), SP
INFLECTRA – infliximab-dyyb for iv inj 100 mg
NP
PA, SP
INFLIXIMAB – infliximab for iv inj 100 mg
NP
PA, SP
KEVZARA – sarilumab subcutaneous solution auto-injector
150 mg/1.14ml, 200 mg/1.14ml
NP
PA, QL (2 pens/28 days), SP
KEVZARA – sarilumab subcutaneous soln prefilled syringe
150 mg/1.14ml, 200 mg/1.14ml
NP
PA, QL (2 syringes/28
days), SP
KINERET – anakinra subcutaneous soln prefilled syringe
100 mg/0.67ml
NP
PA, QL (28 syringes/28
days), SP
OLUMIANT – baricitinib tab 1 mg, 2 mg, 4 mg
NP
PA, QL (30 tablets/30
days), SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
147
Drug Name
Preferred Status Drug Status / Restriction
OMVOH – mirikizumab-mrkz subcutaneous soln auto-injector
100 mg/ml
NP
PA, QL (2 pens/28 days), SP
OMVOH – mirikizumab-mrkz iv soln 300 mg/15ml (20 mg/ml)
NP
PA, QL (3 vials/180 days), SP
ORENCIA – abatacept subcutaneous soln prefilled syringe
50 mg/0.4ml, 87.5 mg/0.7ml, 125 mg/ml
NP
PA, QL (4 syringes/28
days), SP
ORENCIA – abatacept for iv soln 250 mg
NP
PA, QL (4 vials/28 days), SP
ORENCIA CLICKJECT – abatacept subcutaneous soln auto-
injector 125 mg/ml
NP
PA, QL (4 syringes/28
days), SP
OTEZLA – apremilast tab starter therapy pack 10 mg & 20 mg &
30 mg
NP
PA, QL (1 kit/180 days), SP
OTEZLA – apremilast tab 30 mg
NP
PA, QL (60 tablets/30
days), SP
REMICADE – infliximab for iv inj 100 mg
NP
PA, SP
RENFLEXIS – infliximab-abda for iv inj 100 mg
NP
PA, SP
RINVOQ – upadacitinib tab er 24hr 15 mg, 30 mg
NP
PA, QL (30 tablets/30
days), SP
RINVOQ – upadacitinib tab er 24hr 45 mg
NP
PA, QL (84 tablets/365
days), SP
SIMPONI – golimumab subcutaneous soln auto-injector
50 mg/0.5ml, 100 mg/ml
NP
PA, QL (1 syringe/28
days), SP
SIMPONI – golimumab subcutaneous soln prefilled syringe
50 mg/0.5ml, 100 mg/ml
NP
PA, QL (1 syringe/28
days), SP
SIMPONI ARIA – golimumab iv soln 50 mg/4ml
NP
PA, QL (5 vials/56 days), SP
SKYRIZI – risankizumab-rzaa subcutaneous soln cartridge
180 mg/1.2ml, 360 mg/2.4ml
NP
PA, QL (1 cartridge/56
days), SP
SKYRIZI – risankizumab-rzaa iv soln 600 mg/10ml (60 mg/ml)
NP
PA, QL (3 vials/180 days), SP
STELARA – ustekinumab iv soln 130 mg/26ml (5 mg/ml) (for iv
infusion)
NP
PA, QL (4 vials/180 days), SP
XELJANZ – tofacitinib citrate oral soln 1 mg/ml (base equivalent)
P
PA, QL (240 mls/30 days), SP
XELJANZ – tofacitinib citrate tab 5 mg (base equivalent)
P
PA, QL (60 tablets/30
days), SP
XELJANZ – tofacitinib citrate tab 10 mg (base equivalent)
P
PA, QL (240
tablets/365 days), SP
XELJANZ XR – tofacitinib citrate tab er 24hr 11 mg (base
equivalent)
P
PA, QL (30 tablets/30
days), SP
XELJANZ XR – tofacitinib citrate tab er 24hr 22 mg (base
equivalent)
P
PA, QL (120
tablets/365 days), SP
YUFLYMA CD/UC/HS STARTER – adalimumab-aaty auto-
injector kit 80 mg/0.8ml
NP
PA, QL (1 kit/180 days), SP
YUFLYMA 1-PEN KIT – adalimumab-aaty auto-injector kit
40 mg/0.4ml, 80 mg/0.8ml
NP
PA, QL (2 pens/28 days), SP
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
148
Drug Name
Preferred Status Drug Status / Restriction
YUFLYMA 2-PEN KIT – adalimumab-aaty auto-injector kit
40 mg/0.4ml
NP
PA, QL (2 syringes/28
days), SP
YUFLYMA 2-SYRINGE KIT – adalimumab-aaty prefilled syringe
kit 20 mg/0.2ml
NP
PA, QL (1 kit/28 days), SP
YUFLYMA 2-SYRINGE KIT – adalimumab-aaty prefilled syringe
kit 40 mg/0.4ml
NP
PA, QL (2 syringes/28
days), SP
YUSIMRY – adalimumab-aqvh soln pen-injector 40 mg/0.8ml
NP
PA, QL (2 pens/28 days), SP
ULCER DRUGS / ANTISPASMODICS / ANTICHOLINERGICS : H-2 ANTAGONISTS
cimetidine tab 200 mg
P
cimetidine tab 300 mg, 400 mg, 800 mg
P
90
famotidine for susp 40 mg/5ml
P
90
famotidine tab 20 mg, 40 mg (Pepcid)
P
90
NIZATIDINE – nizatidine cap 150 mg, 300 mg
P
90
PEPCID – famotidine tab 20 mg, 40 mg
NP
PA, 90
ULCER DRUGS / ANTISPASMODICS / ANTICHOLINERGICS : MISC
bismuth subcit-metronidazole-tetracycline cap 140-125-125 mg
(Pylera)
NP
PA
CARAFATE – sucralfate tab 1 gm
NP
PA, 90
CARAFATE – sucralfate susp 1 gm/10ml
P
QL (1200 mls/30 days), 90
chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg (Librax)
NP
PA
CUVPOSA – glycopyrrolate oral soln 1 mg/5ml
NP
PA, 90
CYTOTEC – misoprostol tab 100 mcg, 200 mcg
NP
PA, 90
dicyclomine hcl cap 10 mg
P
dicyclomine hcl oral soln 10 mg/5ml
P
dicyclomine hcl tab 20 mg
P
GLYCATE – glycopyrrolate tab 1.5 mg
NP
PA
glycopyrrolate oral soln 1 mg/5ml (Cuvposa)
P
90
glycopyrrolate tab 1 mg, 2 mg
P
hyoscyamine sulfate elixir 0.125 mg/5ml
P
90
hyoscyamine sulfate sl tab 0.125 mg (Levsin/sl)
P
90
hyoscyamine sulfate soln 0.125 mg/ml
P
90
hyoscyamine sulfate tab disint 0.125 mg (Anaspaz)
P
90
hyoscyamine sulfate tab er 12hr 0.375 mg (Levbid)
P
90
hyoscyamine sulfate tab 0.125 mg (Levsin)
P
90
KONVOMEP – omeprazole-sodium bicarbonate for oral susp
2-84 mg/ml
NP
PA, QL (120 Days
Supply/365 Days)
LANSOPRAZOLE/AMOXICILLIN/CLARITHROMYCIN – amoxicil
cap &clarithro tab &lansopraz cap dr 500 &500 &30mg
NP
PA
LEVSIN – hyoscyamine sulfate tab 0.125 mg
NP
PA, 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
149
Drug Name
Preferred Status Drug Status / Restriction
LEVSIN/SL – hyoscyamine sulfate sl tab 0.125 mg
NP
PA, 90
LIBRAX – chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg
NP
PA
methscopolamine bromide tab 2.5 mg, 5 mg
NP
PA
misoprostol tab 100 mcg, 200 mcg (Cytotec)
P
90
omeprazole-sodium bicarbonate cap 20-1100 mg, 40-1100 mg
(Zegerid)
NP
PA, QL (120 days
supply/365 days)
omeprazole-sodium bicarbonate powd pack for susp
20-1680 mg, 40-1680 mg (Zegerid)
NP
PA, QL (120 days
supply/365 days)
PYLERA – bismuth subcit-metronidazole-tetracycline cap
140-125-125 mg
NP
PA
ROBINUL – glycopyrrolate tab 1 mg
NP
PA
ROBINUL FORTE – glycopyrrolate tab 2 mg
NP
PA
sucralfate susp 1 gm/10ml (Carafate)
P
QL (1200 mls/30 day), 90
sucralfate tab 1 gm (Carafate)
P
90
TALICIA – amoxicillin-rifabutin-omeprazole cap dr
250-12.5-10 mg
NP
PA
ZEGERID – omeprazole-sodium bicarbonate cap 20-1100 mg,
40-1100 mg
NP
PA, QL (120 days
supply/365 days)
ZEGERID – omeprazole-sodium bicarbonate powd pack for susp
20-1680 mg, 40-1680 mg
NP
PA, QL (120 days
supply/365 days)
ULCER DRUGS / ANTISPASMODICS / ANTICHOLINERGICS : PROTON PUMP INHIBITORS
DEXILANT – dexlansoprazole cap delayed release 30 mg, 60 mg
NP
PA, QL (120 days
supply/365 days)
dexlansoprazole cap delayed release 30 mg, 60 mg (Dexilant)
NP
PA, QL (120 days
supply/365 days)
esomeprazole magnesium cap delayed release 20 mg (base eq),
40 mg (base eq) (Nexium)
NP
PA, QL (120 days
supply/365 days)
esomeprazole magnesium for delayed release susp packet
10 mg, 20 mg, 40 mg (Nexium)
NP
PA, QL (120 days
supply/365 days)
FIRST PANTOPRAZOLE – pantoprazole sodium susp 4 mg/ml
(compound kit)
NP
PA
lansoprazole cap delayed release 15 mg, 30 mg (Prevacid)
NP
PA, QL (120 days
supply/365 days)
lansoprazole tab delayed release orally disintegrating 15 mg,
30 mg (Prevacid solutab)
P
QL (120 days
supply/365 days)
NEXIUM – esomeprazole magnesium cap delayed release
20 mg (base eq), 40 mg (base eq)
NP
PA, QL (120 days
supply/365 days)
NEXIUM – esomeprazole magnesium for delayed release susp
pack 2.5 mg
NP
PA, QL (120 days
supply/365 days)
NEXIUM – esomeprazole magnesium for delayed release susp
packet 5 mg, 10 mg, 20 mg, 40 mg
NP
PA, QL (120 days
supply/365 days)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
150
Drug Name
Preferred Status Drug Status / Restriction
omeprazole cap delayed release 10 mg, 20 mg, 40 mg
P
QL (120 days
supply/365 days)
pantoprazole sodium ec tab 20 mg (base equiv), 40 mg (base
equiv) (Protonix)
P
QL (120 days
supply/365 days)
pantoprazole sodium for delayed release susp packet 40 mg
(Protonix)
NP
PA, QL (120 days
supply/365 days)
PREVACID – lansoprazole cap delayed release 30 mg
NP
PA, QL (120 days
supply/365 days)
PREVACID SOLUTAB – lansoprazole tab delayed release orally
disintegrating 15 mg, 30 mg
NP
PA, QL (120 days
supply/365 days)
PRILOSEC – omeprazole magnesium for delayed release susp
packet 2.5 mg, 10 mg
NP
PA, QL (120 days
supply/365 days)
PROTONIX – pantoprazole sodium ec tab 20 mg (base equiv),
40 mg (base equiv)
NP
PA, QL (120 days
supply/365 days)
PROTONIX – pantoprazole sodium for delayed release susp
packet 40 mg
NP
PA, QL (120 days
supply/365 days)
rabeprazole sodium ec tab 20 mg (Aciphex)
NP
PA, QL (120 days
supply/365 days)
URINARY ANTISPASMODICS
bethanechol chloride tab 5 mg, 10 mg
P
bethanechol chloride tab 25 mg, 50 mg (Urecholine)
P
darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv)
(Enablex)
NP
PA, QL (30 tablets/30
days), 90
darifenacin hydrobromide tab er 24hr 15 mg (base equiv)
NP
PA, QL (30 tablets/30
days), 90
DETROL – tolterodine tartrate tab 1 mg, 2 mg
NP
PA, QL (60 tablets/30
days), 90
DETROL LA – tolterodine tartrate cap er 24hr 2 mg, 4 mg
NP
PA, QL (30 capsules/30
days), 90
fesoterodine fumarate tab er 24hr 4 mg, 8 mg (Toviaz)
NP
PA, QL (30 tablets/30
days), 90
flavoxate hcl tab 100 mg
NP
PA, 90
GELNIQUE – oxybutynin chloride td gel 10%
NP
PA, QL (30 packets/30
days), 90
GEMTESA – vibegron tab 75 mg
NP
PA, QL (30 tablets/30
days), 90
MYRBETRIQ – mirabegron granules for oral extended release
susp 8 mg/ml
NP
PA, QL (300 mls/28 days), 90
MYRBETRIQ – mirabegron tab er 24 hr 25 mg, 50 mg
NP
PA, QL (30 tablets/30
days), 90
OXYBUTYNIN CHLORIDE – oxybutynin chloride tab 2.5 mg
P
QL (90 tablets/30 days), 90
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
151
Drug Name
Preferred Status Drug Status / Restriction
oxybutynin chloride solution 5 mg/5ml
P
QL (600 mls/30 days), 90
oxybutynin chloride tab er 24hr 5 mg (Ditropan xl)
P
QL (30 tablets/30 days), 90
oxybutynin chloride tab er 24hr 10 mg (Ditropan xl)
P
QL (60 tablets/30 days), 90
oxybutynin chloride tab er 24hr 15 mg
P
QL (60 tablets/30 days), 90
oxybutynin chloride tab 5 mg
P
QL (120 tablets/30 days), 90
OXYTROL – oxybutynin td patch twice weekly 3.9 mg/24hr
NP
PA, QL (8 patches/28
days), 90
solifenacin succinate tab 5 mg, 10 mg (Vesicare)
P
QL (30 tablets/30 days), 90
tolterodine tartrate cap er 24hr 2 mg, 4 mg (Detrol la)
NP
PA, QL (30 capsules/30
days), 90
tolterodine tartrate tab 1 mg, 2 mg (Detrol)
NP
PA, QL (60 tablets/30
days), 90
TOVIAZ – fesoterodine fumarate tab er 24hr 4 mg, 8 mg
NP
PA, QL (30 tablets/30
days), 90
trospium chloride cap er 24hr 60 mg
NP
PA, QL (30 capsules/30
days), 90
trospium chloride tab 20 mg
NP
PA, QL (60 tablets/30
days), 90
VESICARE – solifenacin succinate tab 5 mg, 10 mg
NP
PA, QL (30 tablets/30
days), 90
VESICARE LS – solifenacin succinate susp 5 mg/5ml (1 mg/ml)
NP
PA, QL (300 mls/30 days), 90
VAGINAL PRODUCTS
CLEOCIN – clindamycin phosphate vaginal cream 2%
NP
PA
CLEOCIN – clindamycin phosphate vaginal suppos 100 mg
P
clindamycin phosphate vaginal cream 2% (Cleocin)
P
CLINDESSE – clindamycin phosphate (one dose) vaginal cream
2%
NP
PA
CRINONE – progesterone vaginal gel 4%, 8%
NP
PA
ENDOMETRIN – progesterone vaginal insert 100 mg
P
ESTRACE – estradiol vaginal cream 0.1 mg/gm
NP
PA
estradiol vaginal cream 0.1 mg/gm (Estrace)
P
estradiol vaginal tab 10 mcg (Vagifem)
NP
PA, 90
ESTRING – estradiol vaginal ring 2 mg (7.5 mcg/24hrs)
NP
PA, 90
FEMRING – estradiol acetate vaginal ring 0.05 mg/24hr,
0.1 mg/24hr
NP
PA, 90
GYNAZOLE-1 – butoconazole nitrate (one dose) vaginal cream
2%
NP
PA
IMVEXXY MAINTENANCE PACK – estradiol vaginal insert
4 mcg, 10 mcg
NP
PA
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
152
Drug Name
Preferred Status Drug Status / Restriction
IMVEXXY STARTER PACK – estradiol vaginal insert starter pack
4 mcg, 10 mcg
NP
PA
INTRAROSA – prasterone vaginal insert 6.5 mg
NP
PA, 90
metronidazole vaginal gel 0.75%
P
MICONAZOLE 3 – miconazole nitrate vaginal suppos 200 mg
P
NUVESSA – metronidazole vaginal gel 1.3%
NP
PA
PHEXXI – lactic acid-citric acid-potassium bitartrate gel
1.8-1-0.4%
P
PREMARIN – estrogens, conjugated vaginal cream 0.625 mg/gm
P
90
terconazole vaginal cream 0.4%, 0.8%
P
terconazole vaginal suppos 80 mg
P
VAGIFEM – estradiol vaginal tab 10 mcg
NP
PA, 90
VANDAZOLE – metronidazole vaginal gel 0.75%
NP
PA
XACIATO – clindamycin phosphate vaginal gel 2%
NP
PA
VITAMINS
ergocalciferol cap 1.25 mg (50000 unit) (Drisdol)
SC
phytonadione tab 5 mg (Mephyton)
SC
OTC ANALGESICS - NONNARCOTIC
acetaminophen cap 500 mg
SC
acetaminophen chew tab 80 mg, 160 mg
SC
acetaminophen liquid 160 mg/5ml
SC
acetaminophen soln 160 mg/5ml
SC
acetaminophen suppos 120 mg
SC
acetaminophen susp 160 mg/5ml
SC
acetaminophen tab 325 mg, 500 mg
SC
aspirin chew tab 81 mg
SC
90
aspirin tab delayed release 81 mg, 325 mg
SC
90
aspirin tab 325 mg
SC
90
OTC ANTACIDS
alum & mag hydroxide-simethicone susp 200-200-20 mg/5ml,
400-400-40 mg/5ml
SC
calcium carbonate (antacid) chew tab 500 mg, 750 mg, 1000 mg
SC
magnesium oxide tab 400 mg
SC
sodium bicarbonate tab 325 mg, 650 mg
SC
OTC ANTIDIARRHEALS
bismuth subsalicylate susp 262 mg/15ml
SC
loperamide hcl tab 2 mg
SC
OTC ANTIHISTAMINES
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
153
Drug Name
Preferred Status Drug Status / Restriction
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)
SC
cetirizine hcl tab 5 mg, 10 mg
SC
chlorpheniramine maleate tab 4 mg
SC
diphenhydramine hcl cap 25 mg, 50 mg
SC
diphenhydramine hcl liquid 12.5 mg/5ml
SC
diphenhydramine hcl tab 25 mg
SC
fexofenadine hcl tab 60 mg, 180 mg
SC
loratadine oral soln 5 mg/5ml
SC
loratadine tab 10 mg
SC
OTC COUGH/COLD/ALLERGY
brompheniramine & phenylephrine elixir 1-2.5 mg/5ml
SC
dextromethorphan-guaifenesin liquid 10-100 mg/5ml
SC
guaifenesin liquid 100 mg/5ml
SC
guaifenesin-codeine soln 100-10 mg/5ml
SC
ME
phenylephrine-guaifenesin tab 10-400 mg
SC
RU-HIST D – brompheniramine & phenylephrine tab 4-10 mg
SC
OTC GASTROINTESTINAL AGENTS : MISC
simethicone chew tab 80 mg
SC
simethicone susp 40 mg/0.6ml
SC
OTC GLUCOSE MONITORING SUPPLIES : DEVICES AND KITS
ONETOUCH ULTRA 2 – blood glucose monitoring kit w/ device
P
QL (2 systems/365 days)
ONETOUCH VERIO FLEX BLOOD GLUCOSE MONITORING
SYSTEM – blood glucose monitoring kit w/ device
P
QL (2 systems/365 days)
OTC GLUCOSE MONITORING SUPPLIES : MISC
ALCOHOL PREP PADS AND SWABS - VARIOUS – alcohol
swabs
SC
QL (200 swabs/30 days)
LANCETS - ONETOUCH AND LIFESCAN PRODUCTS – lancets
SC
QL (200 units/30 days)
ONETOUCH DELICA PLUS LANCING DEVICE – lancet devices
SC
ONETOUCH ULTRA CONTROL – blood glucose calibration -
liquid
SC
ONETOUCH ULTRA CONTROL SOLUTION – blood glucose
calibration - liquid
SC
ONETOUCH VERIO LEVEL 3 CONTROL SOLUTION –
blood glucose calibration - liquid
SC
ONETOUCH VERIO LEVEL 4 CONTROL SOLUTION –
blood glucose calibration - liquid - high
SC
OTC GLUCOSE MONITORING SUPPLIES : TEST STRIPS
ONETOUCH ULTRA – glucose blood test strip
P
QL (102 strips/30 days
w/o insulin or 153
strips/30 days w/ insulin)
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
154
Drug Name
Preferred Status Drug Status / Restriction
ONETOUCH VERIO TEST STRIP – glucose blood test strip
P
QL (102 strips/30 days
w/o insulin or 153
strips/30 days w/ insulin)
OTC LAXATIVES
bisacodyl tab delayed release 5 mg
SC
docusate sodium cap 100 mg
SC
docusate sodium liquid 150 mg/15ml
SC
FLEET LIQUID GLYCERIN SUPPOSITORIES – glycerin enema
adult 5.4 gm/average delivered dose
SC
KONSYL DAILY FIBER – psyllium powder 60.3%
SC
magnesium citrate soln
SC
PEDIA-LAX – glycerin liquid suppos 2.8 gm (2.7 ml)
SC
polyethylene glycol 3350 oral powder 17 gm/scoop
SC
psyllium powder 28.3%, 43%
SC
sennosides tab 8.6 mg
SC
OTC DIABETIC SUPPLIES
ALL OTHER INSULIN PEN NEEDLES
NP
PA, QL (200 insulin
pen needles/30 days)
ALL OTHER INSULIN SYRINGES
NP
PA, QL (200 insulin
syringes/30 days)
INSULIN PEN NEEDLES - TRUEPLUS
P
QL (200 insulin pen
needles/30 days)
INSULIN SYRINGES - TRUEPLUS
P
QL (200 insulin
syringes/30 days)
OTC MINERALS AND ELECTROLYTES
calcium carbonate-cholecalciferol tab 500 mg-5 mcg(200 unit)
SC
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe),
220 mg/5ml (44 mg/5ml elemental fe), 300 mg/5ml (60 mg/5ml
elemental fe)
SC
ferrous sulfate tab ec 325 mg (65 mg fe equivalent)
SC
ferrous sulfate tab 325 mg (65 mg elemental fe)
SC
magnesium oxide tab 400 mg (240 mg elemental mg)
SC
oral electrolyte solution
SC
OTC MULTIVITAMINS
multiple vitamin tab
SC
multiple vitamins w/ minerals cap
SC
MULTIVITAMIN INFANT/TODDLER – pediatric multiple vitamin
drops
SC
pediatric multiple vitamin chew tab
SC
PRESERVISION AREDS 2 – multiple vitamins w/ minerals cap
SC
2024
P = Preferred Drug AL = Age Limit ME = Morphine Equivalent SP = Specialty Drug
NP = Non-Preferred Drug PA = Prior Authorization QL = Quantity Limits ST = Step Therapy
SC = Supplemental Coverage SF = Split Fill 90 = 90 days at mail order
Effective Date: July 2024
155
Drug Name
Preferred Status Drug Status / Restriction
PRESERVISION AREDS 2 + MULTI VITAMIN – multiple vitamins
w/ minerals cap
SC
VITAMIN A/C/D INFANT/TODDLER – pediatric vitamins adc
drops 250 mcg-10 mcg-50mg/ml
SC
OTC NASAL PRODUCTS
phenylephrine hcl tab 10 mg
SC
saline nasal spray 0.65%
SC
OTC OTHER SUPPLEMENTS
omega-3 fatty acids cap 500 mg, 1000 mg
SC
OTC TOPICAL ANTI-INFECTIVES
bacitracin oint 500 unit/gm
SC
bacitracin zinc oint 500 unit/gm
SC
miconazole nitrate cream 2%
SC
tolnaftate soln 1%
NP
PA
OTC TOPICAL CORTICOSTEROIDS
hydrocortisone cream 0.5%
SC
hydrocortisone oint 0.5%
SC
OTC TOPICAL EAR PRODUCTS
carbamide peroxide 6.5% otic soln
SC
OTC TOPICAL EYE PRODUCTS
artificial tear ophth solution
SC
ketotifen fumarate ophth soln 0.035%
SC
tetrahydroz-dextran-peg-povidone ophth soln 0.05-0.1-1-1%
SC
OTC TOPICAL PRODUCTS : MISC
LAC-HYDRIN FIVE – lactic acid (ammonium lactate) lotion 5%
SC
vitamins a & d oint
SC
zinc oxide oint 20%
SC
OTC VITAMINS
ascorbic acid tab 500 mg
SC
cholecalciferol cap 50 mcg (2000 unit), 125 mcg (5000 unit),
250 mcg (10000 unit), 1.25 mg (50000 unit)
SC
cholecalciferol oral liquid 10 mcg/ml (400 unit/ml)
SC
cholecalciferol tab 10 mcg (400 unit), 25 mcg (1000 unit),
1.25 mg (50000 unit)
SC
cyanocobalamin tab 250 mcg, 500 mcg, 1000 mcg
SC
DECARA – cholecalciferol cap 625 mcg (25000 unit)
SC
folic acid tab 400 mcg
SC
pyridoxine hcl tab 25 mg, 50 mg, 100 mg
SC
2024
Effective Date: July 2024
156
INDEX
A
abacavir sulfate-lamivudine tab 600-300 mg
(Epzicom).......................................................................... 68
abacavir sulfate soln 20 mg/ml (base equiv) (Ziagen)...... 68
abacavir sulfate tab 300 mg (base equiv) (Ziagen)...........68
ABILIFY...............................................................................67
ABILIFY ASIMTUFII........................................................... 67
ABILIFY MAINTENA.......................................................... 68
ABILIFY MYCITE MAINTENANCE KIT.............................68
ABILIFY MYCITE STARTER KIT.......................................68
abiraterone acetate tab 250 mg (Zytiga)........................... 51
abiraterone acetate tab 500 mg (Zytiga)........................... 52
ABRILADA........................................................................ 144
ABRILADA 1-PEN KIT..................................................... 144
ABRILADA 2-PEN KIT..................................................... 144
ABRYSVO.........................................................................117
ABSORICA......................................................................... 89
ABSORICA LD................................................................... 89
ACAM2000........................................................................117
acamprosate calcium tab delayed release 333 mg.........142
ACANYA..............................................................................89
acarbose tab 25 mg, 50 mg (Precose)..............................42
acarbose tab 100 mg (Precose)........................................ 42
ACCOLATE.........................................................................17
ACCUPRIL..........................................................................74
ACCURETIC....................................................................... 73
acebutolol hcl cap 200 mg, 400 mg.................................. 78
ACETAMINOPHEN/CAFFEINE/DIHYDROCODEINE...... 12
ACETAMINOPHEN/CODEINE...........................................12
acetaminophen cap 500 mg............................................ 152
acetaminophen chew tab 80 mg, 160 mg....................... 152
acetaminophen liquid 160 mg/5ml...................................152
acetaminophen soln 160 mg/5ml.....................................152
acetaminophen suppos 120 mg...................................... 152
acetaminophen susp 160 mg/5ml................................... 152
acetaminophen tab 325 mg, 500 mg...............................152
acetaminophen w/ codeine tab 300-60 mg....................... 12
acetaminophen w/ codeine tab 300-15 mg (Tylenol/
codeine).............................................................................12
acetaminophen w/ codeine tab 300-30 mg (Tylenol/
codeine #3)....................................................................... 12
acetazolamide cap er 12hr 500 mg...................................82
acetazolamide tab 125 mg, 250 mg.................................. 82
acetic acid otic soln 2%................................................... 134
acetylcysteine inhal soln 10%, 20%................................ 141
acitretin cap 17.5 mg......................................................... 92
acitretin cap 10 mg, 25 mg (Soriatane).............................92
ACTEMRA........................................................................ 144
ACTEMRA ACTPEN........................................................ 144
ACTHIB............................................................................. 117
ACTIMMUNE...................................................................... 60
ACTIVELLA.......................................................................104
ACTONEL......................................................................... 100
ACTOPLUS MET................................................................36
ACTOS................................................................................42
ACULAR............................................................................130
ACULAR LS......................................................................130
ACUVAIL........................................................................... 130
acyclovir cap 200 mg......................................................... 73
acyclovir cream 5% (Zovirax)............................................ 96
acyclovir oint 5% (Zovirax)................................................ 97
acyclovir susp 200 mg/5ml (Zovirax).................................73
acyclovir tab 400 mg, 800 mg........................................... 73
ADACEL............................................................................117
ADAKVEO.............................................................................5
ADALIMUMAB-AACF (2 PEN)........................................ 144
ADALIMUMAB-ADAZ....................................................... 144
ADALIMUMAB-ADBM...................................................... 144
ADALIMUMAB-ADBM CROHNS/UC/HS STARTER.......144
ADALIMUMAB-ADBM PSORIASIS/UVEITIS
STARTER........................................................................144
ADALIMUMAB-ADBM STARTER PACKAGE FOR
CROHNS DISEASE/UC/HS...........................................144
ADALIMUMAB-ADBM STARTER PACKAGE FOR
PSORIASIS/UVEITIS..................................................... 144
ADALIMUMAB-FKJP........................................................144
ADAPALENE/BENZOYL PEROXIDE................................ 89
adapalene-benzoyl peroxide gel 0.1-2.5% (Epiduo)......... 89
adapalene-benzoyl peroxide gel 0.3-2.5% (Epiduo
forte).................................................................................. 89
adapalene cream 0.1% (Differin).......................................89
adapalene gel 0.3% (Differin)............................................ 89
ADASUVE...........................................................................65
ADBRY................................................................................18
ADCIRCA............................................................................ 84
ADDERALL........................................................................... 1
ADDERALL XR.....................................................................1
adefovir dipivoxil tab 10 mg (Hepsera)..............................72
ADEMPAS...........................................................................84
ADLARITY........................................................................ 135
ADMELOG.......................................................................... 38
ADMELOG SOLOSTAR..................................................... 39
ADTHYZA......................................................................... 143
ADUHELM........................................................................ 135
ADVAIR DISKUS................................................................ 15
ADVAIR HFA...................................................................... 15
ADVATE............................................................................ 111
ADYNOVATE.................................................................... 112
ADZENYS XR-ODT..............................................................1
ADZYNMA........................................................................ 113
AEMCOLO.......................................................................... 21
AFINITOR........................................................................... 53
AFINITOR DISPERZ.......................................................... 53
AFREZZA............................................................................39
AFSTYLA.......................................................................... 112
AGAMREE.......................................................................... 87
AGRYLIN.......................................................................... 114
AIMOVIG...........................................................................121
AIRDUO RESPICLICK 113/14...........................................15
2024
Effective Date: July 2024
157
AIRDUO RESPICLICK 232/14.......................................... 15
AIRDUO RESPICLICK 55/14............................................ 15
AIRSUPRA..........................................................................15
AJOVY.............................................................................. 121
AKEEGA............................................................................. 52
AKTEN.............................................................................. 130
AKYNZEO...........................................................................46
ALADERM PLUS................................................................97
albendazole tab 200 mg (Albenza)....................................61
ALBUTEROL SULFATE HFA.............................................16
albuterol sulfate inhal aero 108 mcg/act (90mcg base
equiv).................................................................................16
albuterol sulfate soln nebu 0.5% (5 mg/ml).......................17
albuterol sulfate soln nebu 0.083% (2.5 mg/3ml), 0.63
mg/3ml (base equiv), 1.25 mg/3ml (base equiv)............. 17
albuterol sulfate syrup 2 mg/5ml....................................... 17
albuterol sulfate tab 2 mg, 4 mg........................................17
ALCAINE...........................................................................130
alclometasone dipropionate cream 0.05%........................ 93
alclometasone dipropionate oint 0.05%............................ 93
ALCOHOL PREP PADS AND SWABS - VARIOUS........ 153
ALDACTONE...................................................................... 82
ALECENSA.........................................................................53
ALENDRONATE SODIUM............................................... 100
alendronate sodium oral soln 70 mg/75ml...................... 100
alendronate sodium tab 10 mg........................................100
alendronate sodium tab 35 mg........................................100
alendronate sodium tab 70 mg (Fosamax)..................... 100
alfuzosin hcl tab er 24hr 10 mg (Uroxatral).....................109
aliskiren fumarate tab 150 mg (base equivalent), 300 mg
(base equivalent) (Tekturna)............................................ 80
ALKINDI SPRINKLE...........................................................87
ALLOPURINOL.................................................................111
allopurinol tab 100 mg, 300 mg (Zyloprim)..................... 111
ALL OTHER INSULIN PEN NEEDLES........................... 154
ALL OTHER INSULIN SYRINGES..................................154
almotriptan malate tab 6.25 mg, 12.5 mg....................... 122
ALOGLIPTIN.......................................................................38
ALOGLIPTIN/METFORMIN HCL.......................................36
ALOGLIPTIN/METFORMIN HYDROCHLORIDE..............36
ALOGLIPTIN/PIOGLITAZONE...........................................36
ALOMIDE..........................................................................133
alosetron hcl tab 0.5 mg (base equiv), 1 mg (base equiv)
(Lotronex)........................................................................106
ALPHAGAN P...................................................................130
ALPHANATE.....................................................................112
ALPHANINE SD............................................................... 112
ALPRAZOLAM INTENSOL................................................ 14
alprazolam orally disintegrating tab 2 mg..........................14
alprazolam orally disintegrating tab 0.25 mg, 0.5 mg, 1
mg......................................................................................14
alprazolam tab er 24hr 0.5 mg, 1 mg (Xanax xr).............. 14
alprazolam tab er 24hr 2 mg (Xanax xr)........................... 14
alprazolam tab er 24hr 3 mg (Xanax xr)........................... 14
alprazolam tab 0.25 mg, 0.5 mg, 1 mg (Xanax)................14
alprazolam tab 2 mg (Xanax)............................................ 14
ALPROLIX........................................................................ 112
ALREX.............................................................................. 133
ALTACE...............................................................................74
ALTOPREV......................................................................... 48
ALTRENO........................................................................... 89
alum & mag hydroxide-simethicone susp 200-200-20
mg/5ml, 400-400-40 mg/5ml.......................................... 152
ALUNBRIG..........................................................................53
ALVESCO........................................................................... 19
amantadine hcl cap 100 mg.............................................. 62
amantadine hcl soln 50 mg/5ml.........................................62
amantadine hcl tab 100 mg............................................... 62
AMBIEN............................................................................ 117
AMBIEN CR......................................................................117
ambrisentan tab 5 mg, 10 mg (Letairis)............................ 84
AMELUZ..............................................................................97
AMILORIDE/HYDROCHLOROTHIAZIDE......................... 82
amiloride hcl tab 5 mg....................................................... 82
amiodarone hcl tab 100 mg, 200 mg, 400 mg.................. 81
AMITIZA............................................................................ 106
amitriptyline hcl tab 10 mg, 25 mg, 50 mg, 75 mg, 100 mg,
150 mg.............................................................................. 32
AMJEVITA.........................................................................145
amlodipine besylate-atorvastatin calcium tab 2.5-10 mg,
2.5-20 mg, 2.5-40 mg.......................................................83
amlodipine besylate-atorvastatin calcium tab 5-10 mg,
5-20 mg, 5-40 mg, 5-80 mg, 10-10 mg, 10-20 mg, 10-40
mg, 10-80 mg (Caduet)....................................................83
amlodipine besylate-benazepril hcl cap 2.5-10 mg, 5-40
mg......................................................................................74
amlodipine besylate-benazepril hcl cap 5-10 mg, 5-20 mg,
10-20 mg, 10-40 mg (Lotrel)............................................74
amlodipine besylate-olmesartan medoxomil tab 5-20 mg,
5-40 mg, 10-20 mg, 10-40 mg (Azor).............................. 75
amlodipine besylate tab 2.5 mg (base equivalent),
5 mg (base equivalent), 10 mg (base equivalent)
(Norvasc)...........................................................................79
amlodipine besylate-valsartan tab 5-160 mg, 5-320 mg,
10-160 mg, 10-320 mg (Exforge).................................... 75
amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5
mg, 5-160-25 mg, 10-160-12.5 mg, 10-160-25 mg,
10-320-25 mg (Exforge hct).............................................75
amoxapine tab 25 mg, 50 mg, 100 mg, 150 mg............... 32
AMOXICILLIN..................................................................... 24
AMOXICILLIN/CLAVULANATE POTASSIUM................... 24
amoxicillin & k clavulanate for susp 200-28.5 mg/5ml,
400-57 mg/5ml..................................................................24
amoxicillin & k clavulanate for susp 250-62.5 mg/5ml
(Augmentin).......................................................................24
amoxicillin & k clavulanate for susp 600-42.9 mg/5ml
(Augmentin es-600).......................................................... 24
amoxicillin & k clavulanate tab 250-125 mg, 875-125
mg......................................................................................24
amoxicillin & k clavulanate tab 500-125 mg
(Augmentin).......................................................................24
amoxicillin (trihydrate) cap 250 mg, 500 mg..................... 24
2024
Effective Date: July 2024
158
amoxicillin (trihydrate) for susp 125 mg/5ml, 200 mg/5ml,
250 mg/5ml, 400 mg/5ml................................................. 24
amoxicillin (trihydrate) tab 500 mg, 875 mg...................... 24
amphetamine-dextroamphetamine 3-bead cap er 24hr
12.5 mg, 25 mg, 37.5 mg, 50 mg (Mydayis)......................1
amphetamine-dextroamphetamine cap er 24hr 5 mg, 10
mg, 15 mg, 20 mg, 25 mg, 30 mg (Adderall xr).................1
amphetamine-dextroamphetamine tab 5 mg, 7.5 mg, 10
mg, 12.5 mg, 15 mg, 30 mg (Adderall)..............................1
amphetamine-dextroamphetamine tab 20 mg
(Adderall).............................................................................1
amphetamine sulfate tab 5 mg (Evekeo)............................ 1
amphetamine sulfate tab 10 mg (Evekeo).......................... 1
ampicillin cap 500 mg........................................................ 24
AMPYRA...........................................................................138
AMRIX...............................................................................128
AMVUTTRA...................................................................... 136
ANAFRANIL........................................................................32
anagrelide hcl cap 1 mg.................................................. 114
anagrelide hcl cap 0.5 mg (Agrylin).................................114
anastrozole tab 1 mg (Arimidex)....................................... 52
ANCOBON..........................................................................46
ANGELIQ.......................................................................... 105
ANNOVERA........................................................................85
ANORO ELLIPTA............................................................... 15
ANTIVERT.......................................................................... 46
ANUSOL-HC.......................................................................13
ANZEMET...........................................................................45
APEXICON E......................................................................93
APIDRA...............................................................................39
APIDRA SOLOSTAR..........................................................39
APLENZIN.......................................................................... 32
APOKYN............................................................................. 62
apomorphine hcl soln cartridge 30 mg/3ml (Apokyn)........62
APRACLONIDINE............................................................ 130
aprepitant capsule 125 mg................................................ 46
aprepitant capsule 40 mg (Emend)................................... 46
aprepitant capsule 80 mg (Emend)................................... 46
aprepitant capsule therapy pack 80 & 125 mg (Emend
tripack)...............................................................................46
APRETUDE........................................................................ 69
APRISO.............................................................................106
APTENSIO XR..................................................................... 3
APTIOM.............................................................................. 27
APTIVUS.............................................................................69
AQUORAL........................................................................ 124
ARANESP ALBUMIN FREE............................................ 115
ARAVA...................................................................................5
ARAZLO..............................................................................89
ARCALYST....................................................................... 145
AREXVY............................................................................117
arformoterol tartrate soln nebu 15 mcg/2ml (base equiv)
(Brovana)...........................................................................17
ARICEPT.......................................................................... 135
ARIKAYCE.......................................................................... 20
ARIMIDEX...........................................................................52
aripiprazole orally disintegrating tab 10 mg, 15 mg...........68
aripiprazole oral solution 1 mg/ml......................................68
aripiprazole tab 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, 30 mg
(Abilify).............................................................................. 68
ARISTADA.......................................................................... 68
ARISTADA INITIO.............................................................. 68
ARIXTRA.............................................................................26
armodafinil tab 50 mg, 150 mg, 200 mg, 250 mg
(Nuvigil)............................................................................... 3
ARMOUR THYROID........................................................ 143
ARNUITY ELLIPTA............................................................ 19
AROMASIN.........................................................................52
ARTHROTEC 50.................................................................. 5
ARTHROTEC 75.................................................................. 5
artificial tear ophth solution..............................................155
ascorbic acid tab 500 mg................................................ 155
asenapine maleate sl tab 2.5 mg (base equiv), 5 mg (base
equiv), 10 mg (base equiv) (Saphris).............................. 65
ASMANEX HFA.................................................................. 19
ASMANEX TWISTHALER 30 METERED DOSES........... 19
ASMANEX TWISTHALER 60 METERED DOSES........... 19
ASMANEX TWISTHALER 120 METERED DOSES......... 19
aspirin chew tab 81 mg................................................... 152
aspirin-dipyridamole cap er 12hr 25-200 mg
(Aggrenox)...................................................................... 114
aspirin tab delayed release 81 mg, 325 mg.................... 152
aspirin tab 325 mg........................................................... 152
ASPRUZYO SPRINKLE.....................................................81
ASTAGRAF XL................................................................. 120
ATACAND........................................................................... 76
ATACAND HCT.................................................................. 75
atazanavir sulfate cap 150 mg (base equiv), 300 mg
(base equiv) (Reyataz).....................................................69
atazanavir sulfate cap 200 mg (base equiv) (Reyataz).....69
ATELVIA............................................................................ 100
atenolol & chlorthalidone tab 50-25 mg (Tenoretic 50)......78
atenolol & chlorthalidone tab 100-25 mg (Tenoretic
100)................................................................................... 78
atenolol tab 25 mg, 50 mg, 100 mg (Tenormin)................ 78
ATIVAN................................................................................14
atomoxetine hcl cap 10 mg (base equiv), 18 mg (base
equiv), 25 mg (base equiv), 40 mg (base equiv)
(Strattera)............................................................................ 2
atomoxetine hcl cap 60 mg (base equiv), 80 mg (base
equiv), 100 mg (base equiv) (Strattera).............................2
ATORVALIQ........................................................................ 48
atorvastatin calcium tab 10 mg (base equivalent), 20 mg
(base equivalent), 40 mg (base equivalent), 80 mg (base
equivalent) (Lipitor)...........................................................48
atovaquone-proguanil hcl tab 62.5-25 mg, 250-100 mg
(Malarone).........................................................................62
atovaquone susp 750 mg/5ml (Mepron)........................... 21
ATRALIN............................................................................. 89
ATROPINE SULFATE...................................................... 130
atropine sulfate ophth soln 1% (Atropine sulfate)........... 130
ATROVENT HFA................................................................ 16
2024
Effective Date: July 2024
159
AUBAGIO..........................................................................138
AUGMENTIN...................................................................... 24
AUGMENTIN ES-600.........................................................25
AUGTYRO.......................................................................... 53
AURYXIA.......................................................................... 108
AUSTEDO.........................................................................136
AUSTEDO XR.................................................................. 136
AUSTEDO XR PATIENT TITRATION KIT....................... 136
AUVELITY...........................................................................32
AUVI-Q................................................................................13
AVALIDE..............................................................................75
AVAPRO..............................................................................76
AVONEX........................................................................... 138
AVONEX PEN.................................................................. 138
AVSOLA............................................................................ 145
AYVAKIT..............................................................................53
AZASITE........................................................................... 132
azathioprine tab 75 mg, 100 mg......................................120
azathioprine tab 50 mg (Imuran)..................................... 120
azelaic acid gel 15% (Finacea)......................................... 97
azelastine hcl-fluticasone prop nasal spray 137-50 mcg/
act (Dymista)...................................................................129
azelastine hcl nasal spray 0.1% (137 mcg/spray), 0.15%
(205.5 mcg/spray)...........................................................129
azelastine hcl ophth soln 0.05%......................................133
AZILECT............................................................................. 62
AZITHROMYCIN................................................................ 23
azithromycin for susp 100 mg/5ml, 200 mg/5ml
(Zithromax)........................................................................23
azithromycin tab 600 mg................................................... 23
azithromycin tab 250 mg, 500 mg (Zithromax)..................23
AZOPT.............................................................................. 130
AZOR.................................................................................. 75
AZSTARYS........................................................................... 3
AZULFIDINE..................................................................... 106
AZULFIDINE EN-TABS.................................................... 106
B
BACITRACIN.................................................................... 132
bacitracin oint 500 unit/gm...............................................155
bacitracin-polymyxin b ophth oint.................................... 132
bacitracin-polymyxin-neomycin-hc ophth oint 1%........... 133
bacitracin zinc oint 500 unit/gm....................................... 155
BACLOFEN.......................................................................128
baclofen susp 25 mg/5ml (Fleqsuvy)...............................128
baclofen tab 5 mg, 10 mg, 20 mg................................... 128
BACTRIM............................................................................ 21
BACTRIM DS..................................................................... 21
BAFIERTAM......................................................................138
BALCOLTRA.......................................................................85
balsalazide disodium cap 750 mg (Colazal)....................106
BALVERSA......................................................................... 53
BANZEL.............................................................................. 27
BAQSIMI ONE PACK.........................................................42
BAQSIMI TWO PACK........................................................ 42
BARACLUDE...................................................................... 72
BASAGLAR KWIKPEN...................................................... 39
BASAGLAR TEMPO PEN................................................. 39
BAXDELA............................................................................20
BCG VACCINE................................................................. 118
b-complex w/ c & folic acid cap 1 mg..............................125
b-complex w/ c & folic acid tab 5 mg.............................. 125
b-complex w/ c & folic acid tab 1 mg (Nephro-vite rx).....125
BELBUCA............................................................................. 8
BELSOMRA...................................................................... 117
benazepril & hydrochlorothiazide tab 5-6.25 mg...............74
benazepril & hydrochlorothiazide tab 10-12.5 mg, 20-12.5
mg, 20-25 mg (Lotensin hct)............................................74
benazepril hcl tab 5 mg..................................................... 74
benazepril hcl tab 10 mg, 20 mg, 40 mg (Lotensin).......... 74
BENEFIX...........................................................................112
BENICAR............................................................................ 76
BENICAR HCT................................................................... 75
BENLYSTA........................................................................123
BENSAL HP....................................................................... 97
BENZAMYCIN.................................................................... 89
BENZNIDAZOLE................................................................ 61
benzoyl peroxide-erythromycin gel 5-3%
(Benzamycin).................................................................... 89
benztropine mesylate tab 0.5 mg, 1 mg, 2 mg..................62
bepotastine besilate ophth soln 1.5% (Bepreve).............133
BEPREVE......................................................................... 133
BERINERT........................................................................114
BESIVANCE......................................................................132
BETADINE OPHTHALMIC PREP....................................132
betaine powder for oral solution (Cystadane)................. 102
BETAMETHASONE DIPROPIONATE...............................93
betamethasone dipropionate augmented cream 0.05%
(Diprolene af).................................................................... 94
betamethasone dipropionate augmented lotion 0.05%.....94
betamethasone dipropionate augmented oint 0.05%
(Diprolene)........................................................................ 94
betamethasone dipropionate cream 0.05%.......................94
betamethasone dipropionate lotion 0.05%........................ 94
betamethasone dipropionate oint 0.05%...........................94
betamethasone valerate aerosol foam 0.12% (Luxiq).......94
betamethasone valerate cream 0.1% (base
equivalent).........................................................................94
betamethasone valerate lotion 0.1% (base
equivalent).........................................................................94
betamethasone valerate oint 0.1% (base equivalent)....... 94
BETAPACE......................................................................... 78
BETAPACE AF................................................................... 78
BETASERON.................................................................... 138
BETAXOLOL HCL............................................................ 130
betaxolol hcl tab 10 mg, 20 mg......................................... 78
bethanechol chloride tab 5 mg, 10 mg............................150
bethanechol chloride tab 25 mg, 50 mg (Urecholine)..... 150
BETHKIS.............................................................................20
BETIMOL.......................................................................... 130
BETOPTIC-S.................................................................... 130
BEVESPI AEROSPHERE..................................................15
2024
Effective Date: July 2024
160
bexarotene cap 75 mg (Targretin)..................................... 60
bexarotene gel 1% (Targretin)........................................... 97
BEXSERO.........................................................................118
BEYAZ.................................................................................85
bicalutamide tab 50 mg (Casodex)....................................52
BIDIL................................................................................... 83
BIJUVA..............................................................................105
BIKTARVY...........................................................................69
BILTRICIDE.........................................................................61
bimatoprost ophth soln 0.03%......................................... 130
BIMZELX.............................................................................92
BINOSTO..........................................................................100
BIOTHRAX........................................................................118
bisacodyl tab delayed release 5 mg................................154
bismuth subcit-metronidazole-tetracycline cap
140-125-125 mg (Pylera)............................................... 148
bismuth subsalicylate susp 262 mg/15ml........................152
bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg, 5-6.25
mg, 10-6.25 mg (Ziac)......................................................78
bisoprolol fumarate tab 5 mg, 10 mg................................ 78
BONJESTA......................................................................... 46
BOOSTRIX....................................................................... 118
bosentan tab 62.5 mg, 125 mg (Tracleer).........................84
BOSULIF.............................................................................53
BRAFTOVI.......................................................................... 53
BREO ELLIPTA.................................................................. 15
BREXAFEMME...................................................................46
BREZTRI AEROSPHERE..................................................15
BRILINTA.......................................................................... 115
brimonidine tartrate gel 0.33% (base equivalent)
(Mirvaso)........................................................................... 97
brimonidine tartrate ophth soln 0.2%...............................130
brimonidine tartrate ophth soln 0.1%, 0.15% (Alphagan
p)..................................................................................... 130
brimonidine tartrate-timolol maleate ophth soln 0.2-0.5%
(Combigan)..................................................................... 130
brinzolamide ophth susp 1% (Azopt)...............................131
BRIUMVI........................................................................... 138
BRIVIACT............................................................................27
BRIXADI................................................................................8
bromfenac sodium ophth soln 0.075% (base equivalent)
(Bromsite)........................................................................131
bromfenac sodium ophth soln 0.07% (base equivalent)
(Prolensa)........................................................................131
bromfenac sodium ophth soln 0.09% (base equiv) (once-
daily)................................................................................131
bromocriptine mesylate cap 5 mg (base equivalent)
(Parlodel)...........................................................................62
bromocriptine mesylate tab 2.5 mg (base equivalent)
(Parlodel)...........................................................................62
brompheniramine & phenylephrine elixir 1-2.5
mg/5ml.............................................................................153
BROMSITE....................................................................... 131
BRONCHITOL.................................................................. 140
BRONCHITOL TOLERANCE TEST................................ 140
BROVANA...........................................................................17
BRUKINSA..........................................................................54
BRYHALI.............................................................................94
budesonide delayed release particles cap 3 mg (Entocort
ec)......................................................................................88
budesonide-formoterol fumarate dihyd aerosol 80-4.5
mcg/act, 160-4.5 mcg/act (Symbicort).............................15
budesonide inhalation susp 0.25 mg/2ml, 0.5 mg/2ml
(Pulmicort).........................................................................19
budesonide inhalation susp 1 mg/2ml (Pulmicort)............ 19
budesonide rectal foam 2 mg/act (Uceris)........................ 13
budesonide tab er 24hr 9 mg (Uceris).............................. 88
bumetanide tab 0.5 mg, 1 mg, 2 mg (Bumex)...................82
BUMEX............................................................................... 82
BUPHENYL.......................................................................102
buprenorphine hcl-naloxone hcl sl film 2-0.5 mg (base
equiv) (Suboxone).......................................................... 142
buprenorphine hcl-naloxone hcl sl film 4-1 mg (base
equiv) (Suboxone).......................................................... 142
buprenorphine hcl-naloxone hcl sl film 8-2 mg (base
equiv) (Suboxone).......................................................... 142
buprenorphine hcl-naloxone hcl sl film 12-3 mg (base
equiv) (Suboxone).......................................................... 142
buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg (base
equiv)...............................................................................142
buprenorphine hcl-naloxone hcl sl tab 8-2 mg (base
equiv)...............................................................................142
buprenorphine hcl sl tab 2 mg (base equiv)........................8
buprenorphine hcl sl tab 8 mg (base equiv)........................8
buprenorphine td patch weekly 5 mcg/hr, 7.5 mcg/hr, 10
mcg/hr, 15 mcg/hr, 20 mcg/hr (Butrans)............................ 8
bupropion hcl (smoking deterrent) tab er 12hr 150
mg....................................................................................140
bupropion hcl tab er 12hr 100 mg, 150 mg, 200 mg
(Wellbutrin sr)................................................................... 32
bupropion hcl tab er 24hr 150 mg, 300 mg (Wellbutrin
xl).......................................................................................32
bupropion hcl tab 75 mg....................................................32
bupropion hcl tab 100 mg..................................................32
BUPROPION HYDROCHLORIDE ER (XL)...................... 32
buspirone hcl tab 5 mg, 7.5 mg, 10 mg, 15 mg, 30 mg.....15
butalbital-acetaminophen-caffeine cap 50-325-40 mg........ 8
butalbital-acetaminophen-caffeine cap 50-300-40 mg
(Fioricet).............................................................................. 8
butalbital-acetaminophen-caffeine tab 50-325-40 mg
(Esgic)................................................................................. 8
butalbital-acetaminophen-caff w/ cod cap 50-325-40-30
mg......................................................................................12
butalbital-acetaminophen-caff w/ cod cap 50-300-40-30
mg (Fioricet/codeine)........................................................12
butalbital-acetaminophen cap 50-300 mg (Butalbital/
acetaminophen).................................................................. 8
butalbital-acetaminophen tab 50-300 mg, 50-325 mg.........8
butalbital-aspirin-caffeine cap 50-325-40 mg (Fiorinal).......8
butalbital-aspirin-caff w/ codeine cap 50-325-40-30 mg
(Fiorinal/codeine #3).........................................................12
butorphanol tartrate nasal soln 10 mg/ml............................9
2024
Effective Date: July 2024
161
BUTRANS............................................................................. 9
BYDUREON BCISE........................................................... 38
BYETTA.............................................................................. 38
BYSTOLIC.......................................................................... 78
C
CABENUVA.........................................................................69
cabergoline tab 0.5 mg.................................................... 102
CABOMETYX..................................................................... 54
CABTREO...........................................................................89
CADUET............................................................................. 83
caffeine citrate oral soln 60 mg/3ml (10 mg/ml base
equiv).................................................................................85
CALCIPOTRIENE...............................................................92
calcipotriene-betamethasone dipropionate oint
0.005-0.064% (Taclonex)................................................. 94
calcipotriene-betamethasone dipropionate susp
0.005-0.064% (Taclonex)................................................. 94
calcipotriene cream 0.005% (Dovonex)............................ 92
calcipotriene oint 0.005%...................................................92
calcipotriene soln 0.005% (50 mcg/ml)............................. 92
calcitonin (salmon) nasal soln 200 unit/act..................... 100
CALCITRIOL.......................................................................92
calcitriol cap 0.25 mcg, 0.5 mcg (Rocaltrol).................... 104
calcitriol oral soln 1 mcg/ml (Rocaltrol)........................... 104
calcium acetate (phosphate binder) cap 667 mg (169 mg
ca)....................................................................................108
calcium acetate (phosphate binder) tab 667 mg............. 108
calcium carbonate (antacid) chew tab 500 mg, 750 mg,
1000 mg..........................................................................152
calcium carbonate-cholecalciferol tab 500 mg-5 mcg(200
unit)..................................................................................154
CALQUENCE......................................................................54
CAMZYOS.......................................................................... 83
CANASA........................................................................... 106
candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg,
32-12.5 mg, 32-25 mg (Atacand hct)...............................75
candesartan cilexetil tab 4 mg, 8 mg, 16 mg
(Atacand)...........................................................................76
candesartan cilexetil tab 32 mg (Atacand)........................ 76
capecitabine tab 150 mg, 500 mg (Xeloda)...................... 51
CAPLYTA............................................................................ 66
CAPRELSA.........................................................................54
CAPTOPRIL/HYDROCHLOROTHIAZIDE.........................74
captopril tab 12.5 mg, 25 mg, 50 mg, 100 mg.................. 74
CARAC................................................................................97
CARAFATE....................................................................... 148
CARBAGLU...................................................................... 102
carbamazepine cap er 12hr 100 mg, 200 mg, 300 mg
(Carbatrol)......................................................................... 27
carbamazepine chew tab 100 mg..................................... 27
carbamazepine susp 100 mg/5ml (Tegretol)..................... 27
carbamazepine tab er 12hr 100 mg, 200 mg, 400 mg
(Tegretol-xr).......................................................................27
carbamazepine tab 200 mg (Tegretol).............................. 27
carbamide peroxide 6.5% otic soln................................. 155
CARBATROL...................................................................... 27
CARBIDOPA/LEVODOPA ODT......................................... 63
carbidopa & levodopa tab er 25-100 mg, 50-200 mg........62
carbidopa & levodopa tab 10-100 mg, 25-100 mg, 25-250
mg (Sinemet).................................................................... 62
carbidopa-levodopa-entacapone tabs 12.5-50-200 mg
(Stalevo 50)...................................................................... 62
carbidopa-levodopa-entacapone tabs 18.75-75-200 mg
(Stalevo 75)...................................................................... 63
carbidopa-levodopa-entacapone tabs 25-100-200 mg
(Stalevo 100).................................................................... 63
carbidopa-levodopa-entacapone tabs 31.25-125-200 mg
(Stalevo 125).................................................................... 63
carbidopa-levodopa-entacapone tabs 37.5-150-200 mg
(Stalevo 150).................................................................... 63
carbidopa-levodopa-entacapone tabs 50-200-200 mg
(Stalevo 200).................................................................... 63
carbidopa tab 25 mg (Lodosyn).........................................62
CARBINOXAMINE MALEATE........................................... 47
carbinoxamine maleate tab 4 mg...................................... 47
CARDIZEM......................................................................... 79
CARDIZEM CD...................................................................79
CARDIZEM LA................................................................... 79
CARDURA.......................................................................... 77
CARDURA XL.................................................................. 109
carglumic acid soluble tab 200 mg (Carbaglu)................102
carisoprodol tab 250 mg, 350 mg (Soma).......................128
CARNITOR....................................................................... 102
CARNITOR SF................................................................. 102
CAROSPIR......................................................................... 82
CARTEOLOL HCL........................................................... 130
carvedilol phosphate cap er 24hr 10 mg, 20 mg, 40 mg,
80 mg (Coreg cr)..............................................................78
carvedilol tab 3.125 mg, 6.25 mg, 12.5 mg, 25 mg
(Coreg).............................................................................. 78
CASGEVY.............................................................................5
CASODEX.......................................................................... 52
CAYSTON........................................................................... 21
CEFACLOR.........................................................................23
CEFACLOR ER.................................................................. 23
CEFADROXIL..................................................................... 23
cefadroxil cap 500 mg........................................................23
cefadroxil for susp 250 mg/5ml, 500 mg/5ml.................... 23
cefdinir cap 300 mg........................................................... 23
cefdinir for susp 125 mg/5ml, 250 mg/5ml........................ 23
cefixime cap 400 mg (Suprax)...........................................23
cefixime for susp 100 mg/5ml, 200 mg/5ml (Suprax)........23
cefpodoxime proxetil for susp 50 mg/5ml, 100 mg/5ml.....23
cefpodoxime proxetil tab 100 mg, 200 mg........................ 23
cefprozil for susp 125 mg/5ml, 250 mg/5ml...................... 23
cefprozil tab 250 mg, 500 mg............................................23
cefuroxime axetil tab 250 mg, 500 mg.............................. 23
CELEBREX...........................................................................5
celecoxib cap 50 mg, 100 mg, 200 mg (Celebrex)............. 5
celecoxib cap 400 mg (Celebrex)........................................5
CELEXA.............................................................................. 34
2024
Effective Date: July 2024
162
CELLCEPT....................................................................... 120
CELONTIN..........................................................................27
CEPHALEXIN..................................................................... 23
cephalexin cap 250 mg, 500 mg, 750 mg (Keflex)............23
cephalexin for susp 125 mg/5ml, 250 mg/5ml.................. 23
CEQUA............................................................................. 131
cetirizine hcl oral soln 1 mg/ml (5 mg/5ml)......................153
cetirizine hcl tab 5 mg, 10 mg......................................... 153
cevimeline hcl cap 30 mg (Evoxac).................................124
CHEMET............................................................................. 44
CHENODAL...................................................................... 106
CHLORDIAZEPOXIDE/AMITRIPTYLINE........................136
chlordiazepoxide hcl cap 5 mg, 10 mg, 25 mg..................14
chlordiazepoxide hcl-clidinium bromide cap 5-2.5 mg
(Librax)............................................................................ 148
chlorhexidine gluconate soln 0.12% (Peridex)................ 124
chloroquine phosphate tab 250 mg, 500 mg.....................62
chlorpheniramine maleate tab 4 mg................................ 153
chlorpromazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg,
200 mg.............................................................................. 66
CHLORPROMAZINE HYDROCHLORIDE........................ 66
chlorthalidone tab 25 mg, 50 mg.......................................82
chlorzoxazone tab 250 mg, 375 mg, 500 mg, 750
mg....................................................................................128
CHOLBAM........................................................................ 107
cholecalciferol cap 50 mcg (2000 unit), 125 mcg (5000
unit), 250 mcg (10000 unit), 1.25 mg (50000 unit)........ 155
cholecalciferol oral liquid 10 mcg/ml (400 unit/ml).......... 155
cholecalciferol tab 10 mcg (400 unit), 25 mcg (1000 unit),
1.25 mg (50000 unit)......................................................155
cholestyramine light powder 4 gm/dose (Questran
light)...................................................................................48
cholestyramine light powder packets 4 gm....................... 48
cholestyramine powder 4 gm/dose (Questran)................. 48
cholestyramine powder packets 4 gm (Questran).............48
choline fenofibrate cap dr 45 mg (fenofibric acid equiv)
(Trilipix)..............................................................................48
choline fenofibrate cap dr 135 mg (fenofibric acid equiv)
(Trilipix)..............................................................................48
CIALIS.................................................................................83
CIBINQO............................................................................. 18
ciclopirox gel 0.77%........................................................... 91
ciclopirox olamine cream 0.77% (base equiv)
(Loprox)............................................................................. 91
ciclopirox olamine susp 0.77% (base equiv) (Loprox).......91
ciclopirox shampoo 1% (Loprox shampoo)....................... 91
ciclopirox solution 8% (Penlac Nail Lacquer).................... 91
CICLOPIROX TREATMENT.............................................. 91
cilostazol tab 50 mg, 100 mg.......................................... 115
CILOXAN.......................................................................... 132
CIMDUO..............................................................................69
cimetidine tab 200 mg..................................................... 148
cimetidine tab 300 mg, 400 mg, 800 mg.........................148
CIMZIA.............................................................................. 145
CIMZIA STARTER KIT.....................................................145
cinacalcet hcl tab 30 mg (base equiv), 60 mg (base
equiv), 90 mg (base equiv) (Sensipar).......................... 102
CINQAIR............................................................................. 18
CINRYZE.......................................................................... 114
CIPRO.................................................................................20
CIPROFLOXACIN............................................................ 134
CIPROFLOXACIN/FLUOCINOLONE ACETONIDE
PF.................................................................................... 135
ciprofloxacin-dexamethasone otic susp 0.3-0.1%
(Ciprodex)....................................................................... 135
CIPROFLOXACIN HCL......................................................20
ciprofloxacin hcl ophth soln 0.3% (base equivalent)
(Ciloxan)..........................................................................132
ciprofloxacin hcl tab 750 mg (base equiv).........................20
ciprofloxacin hcl tab 250 mg (base equiv), 500 mg (base
equiv) (Cipro).................................................................... 20
CITALOPRAM HYDROBROMIDE..................................... 34
citalopram hydrobromide oral soln 10 mg/5ml.................. 34
citalopram hydrobromide tab 10 mg (base equiv), 20 mg
(base equiv), 40 mg (base equiv) (Celexa)..................... 34
CITRANATAL ASSURE....................................................125
CITRANATAL B-CALM.....................................................125
CITRANATAL 90 DHA......................................................125
CITRANATAL HARMONY................................................125
CITRANATAL MEDLEY....................................................125
CLARITHROMYCIN........................................................... 23
clarithromycin tab er 24hr 500 mg.....................................23
clarithromycin tab 250 mg, 500 mg................................... 23
CLEOCIN............................................................................ 21
CLEOCIN PEDIATRIC GRANULES.................................. 21
CLEOCIN-T.........................................................................89
CLIMARA.......................................................................... 105
CLIMARA PRO.................................................................105
CLINDACIN ETZ................................................................ 89
CLINDAGEL........................................................................89
clindamycin hcl cap 75 mg, 150 mg, 300 mg
(Cleocin)............................................................................ 21
clindamycin palmitate hcl for soln 75 mg/5ml (base equiv)
(Cleocin pediatric granules)............................................. 21
clindamycin phosphate-benzoyl peroxide gel 1.2-2.5%
(Acanya)............................................................................ 90
clindamycin phosphate-benzoyl peroxide gel 1-5%
(Benzaclin)........................................................................ 90
clindamycin phosphate-benzoyl peroxide gel 1.2-3.75%
(Onexton).......................................................................... 90
clindamycin phosphate foam 1% (Evoclin)....................... 89
clindamycin phosphate gel 1%.......................................... 89
clindamycin phosphate lotion 1% (Cleocin-t).................... 89
clindamycin phosphate soln 1%........................................ 90
clindamycin phosphate swab 1%...................................... 90
clindamycin phosphate-tretinoin gel 1.2-0.025%
(Ziana)............................................................................... 90
clindamycin phosphate vaginal cream 2% (Cleocin).......151
clindamycin phosph-benzoyl peroxide (refrig) gel 1.2
(1)-5%................................................................................89
CLINDESSE......................................................................151
2024
Effective Date: July 2024
163
clobazam suspension 2.5 mg/ml (Onfi)............................. 27
clobazam tab 10 mg, 20 mg (Onfi)....................................27
clobetasol propionate cream 0.05% (Temovate)...............94
clobetasol propionate emollient base cream 0.05%..........94
clobetasol propionate emulsion foam 0.05% (Olux-e)...... 94
clobetasol propionate foam 0.05% (Olux)......................... 94
clobetasol propionate gel 0.05%....................................... 94
clobetasol propionate lotion 0.05% (Clobex).....................94
clobetasol propionate oint 0.05% (Temovate)................... 94
clobetasol propionate shampoo 0.05% (Clobex).............. 94
clobetasol propionate soln 0.05%......................................94
clobetasol propionate spray 0.05% (Clobex).................... 94
clocortolone pivalate cream 0.1% (Cloderm).................... 94
CLODERM.......................................................................... 94
clomipramine hcl cap 25 mg, 50 mg, 75 mg
(Anafranil)..........................................................................32
clonazepam orally disintegrating tab 2 mg........................27
clonazepam orally disintegrating tab 0.125 mg, 0.25 mg,
0.5 mg, 1 mg.................................................................... 27
clonazepam tab 0.5 mg, 1 mg (Klonopin)......................... 27
clonazepam tab 2 mg (Klonopin).......................................27
clonidine hcl tab er 12hr 0.1 mg (Kapvay).......................... 2
clonidine hcl tab 0.1 mg, 0.2 mg, 0.3 mg (Catapres)........ 77
CLONIDINE HYDROCHLORIDE ER................................ 77
clonidine td patch weekly 0.1 mg/24hr (Catapres-
tts-1).................................................................................. 77
clonidine td patch weekly 0.2 mg/24hr (Catapres-
tts-2).................................................................................. 77
clonidine td patch weekly 0.3 mg/24hr (Catapres-
tts-3).................................................................................. 77
clopidogrel bisulfate tab 300 mg (base equiv).................115
clopidogrel bisulfate tab 75 mg (base equiv) (Plavix)......115
clorazepate dipotassium tab 3.75 mg................................14
clorazepate dipotassium tab 15 mg...................................14
clorazepate dipotassium tab 7.5 mg (Tranxene t)............. 14
clotrimazole cream 1%.......................................................91
clotrimazole soln 1%.......................................................... 91
clotrimazole troche 10 mg............................................... 124
clotrimazole w/ betamethasone cream 1-0.05%............... 91
clotrimazole w/ betamethasone lotion 1-0.05%.................91
CLOZAPINE ODT.............................................................. 65
clozapine orally disintegrating tab 200 mg........................ 65
clozapine orally disintegrating tab 25 mg, 100 mg, 150
mg......................................................................................65
clozapine tab 25 mg, 50 mg (Clozaril).............................. 65
clozapine tab 100 mg (Clozaril).........................................65
clozapine tab 200 mg (Clozaril).........................................65
CLOZARIL.......................................................................... 65
COAGADEX......................................................................112
COARTEM.......................................................................... 62
CODEINE SULFATE............................................................ 9
codeine sulfate tab 30 mg (Codeine sulfate)...................... 9
COLAZAL..........................................................................106
colchicine cap 0.6 mg (Mitigare)......................................111
colchicine tab 0.6 mg (Colcrys)....................................... 111
colchicine w/ probenecid tab 0.5-500 mg........................111
colesevelam hcl packet for susp 3.75 gm (Welchol)......... 48
colesevelam hcl tab 625 mg (Welchol)............................. 48
COLESTID.......................................................................... 48
colestipol hcl granule packets 5 gm (Colestid
flavored)............................................................................ 48
colestipol hcl granules 5 gm (Colestid flavored)................48
colestipol hcl tab 1 gm (Colestid)...................................... 48
COMBIGAN...................................................................... 130
COMBIPATCH.................................................................. 105
COMBIVENT RESPIMAT...................................................15
COMETRIQ.........................................................................54
COMIRNATY 2023-24......................................................118
COMPLERA........................................................................69
COMPLETE NATAL DHA................................................ 125
COMPLETENATE.............................................................125
CONCERTA.......................................................................... 3
CONDYLOX........................................................................97
CONZIP.................................................................................9
COPAXONE......................................................................138
COPIKTRA..........................................................................54
CORGARD..........................................................................78
CORIFACT........................................................................112
CORLANOR........................................................................83
CORTEF............................................................................. 88
CORTENEMA..................................................................... 13
CORTIFOAM...................................................................... 13
CORTISONE ACETATE..................................................... 88
CORTISPORIN-TC...........................................................135
CORVITA.......................................................................... 125
COSENTYX........................................................................ 92
COSENTYX SENSOREADY PEN.....................................93
COSENTYX UNOREADY.................................................. 93
COSOPT...........................................................................130
COSOPT PF.....................................................................130
COTELLIC.......................................................................... 54
COTEMPLA XR-ODT...........................................................3
COZAAR............................................................................. 76
CREON............................................................................. 100
CRESEMBA........................................................................46
CRESTOR...........................................................................48
CRINONE......................................................................... 151
CROMOLYN SODIUM..................................................... 133
cromolyn sodium oral conc 100 mg/5ml
(Gastrocrom)...................................................................107
cromolyn sodium soln nebu 20 mg/2ml.............................16
CROTAN........................................................................... 100
CUPRIMINE........................................................................44
CUVPOSA........................................................................ 148
CUVRIOR............................................................................44
cyanocobalamin inj 1000 mcg/ml.................................... 116
cyanocobalamin tab 250 mcg, 500 mcg, 1000 mcg........155
cyclobenzaprine hcl cap er 24hr 15 mg, 30 mg
(Amrix).............................................................................128
cyclobenzaprine hcl tab 5 mg, 10 mg............................. 128
cyclobenzaprine hcl tab 7.5 mg (Fexmid)....................... 128
CYCLOGYL...................................................................... 131
2024
Effective Date: July 2024
164
CYCLOMYDRIL................................................................131
cyclopentolate hcl ophth soln 1% (Cyclogyl)...................131
CYCLOPHOSPHAMIDE.....................................................51
cyclophosphamide cap 25 mg, 50 mg
(Cyclophosphamide).........................................................51
cycloserine cap 250 mg.....................................................22
CYCLOSET.........................................................................42
cyclosporine cap 25 mg, 100 mg (Sandimmune)............120
cyclosporine modified cap 50 mg.................................... 120
cyclosporine modified cap 25 mg, 100 mg (Neoral)........120
cyclosporine modified oral soln 100 mg/ml (Neoral)....... 120
cyclosporine (ophth) emulsion 0.05% (Restasis)............ 131
CYLTEZO..........................................................................145
CYLTEZO STARTER PACKAGE FOR CROHNS
DISEASE/UC/HS............................................................ 145
CYLTEZO STARTER PACKAGE FOR PSORIASIS....... 145
CYLTEZO STARTER PACKAGE FOR PSORIASIS/
UVEITIS.......................................................................... 145
CYMBALTA......................................................................... 35
cyproheptadine hcl syrup 2 mg/5ml...................................47
cyproheptadine hcl tab 4 mg............................................. 47
CYSTADANE.................................................................... 102
CYSTADROPS................................................................. 131
CYSTAGON...................................................................... 108
CYSTARAN.......................................................................131
CYTOMEL.........................................................................143
CYTOTEC.........................................................................148
D
dabigatran etexilate mesylate cap 75 mg (etexilate base
eq), 150 mg (etexilate base eq) (Pradaxa)......................25
dabigatran etexilate mesylate cap 110 mg (etexilate base
eq) (Pradaxa)....................................................................26
dalfampridine tab er 12hr 10 mg (Ampyra)..................... 138
DALIRESP.......................................................................... 18
danazol cap 50 mg, 100 mg, 200 mg............................. 121
DANTRIUM....................................................................... 128
dantrolene sodium cap 100 mg....................................... 128
dantrolene sodium cap 25 mg, 50 mg (Dantrium)...........128
DAPAGLIFLOZIN PROPANEDIOL.................................... 44
DAPAGLIFLOZIN PROPANEDIOL/METFORMIN
HYDROCHLORIDE.......................................................... 36
dapsone gel 5%, 7.5% (Aczone)....................................... 90
dapsone tab 25 mg, 100 mg............................................. 21
DAPTACEL....................................................................... 118
DARAPRIM......................................................................... 62
darifenacin hydrobromide tab er 24hr 15 mg (base
equiv)...............................................................................150
darifenacin hydrobromide tab er 24hr 7.5 mg (base equiv)
(Enablex).........................................................................150
darunavir tab 600 mg (Prezista)........................................ 69
darunavir tab 800 mg (Prezista)........................................ 69
DAURISMO.........................................................................60
DAYBUE............................................................................129
DAYPRO............................................................................... 5
DAYTRANA...........................................................................3
DAYVIGO..........................................................................117
DDAVP.............................................................................. 102
DECARA........................................................................... 155
deferasirox granules packet 90 mg, 180 mg (Jadenu
sprinkle).............................................................................44
deferasirox granules packet 360 mg (Jadenu
sprinkle).............................................................................44
deferasirox tab for oral susp 125 mg, 250 mg
(Exjade)............................................................................. 44
deferasirox tab for oral susp 500 mg (Exjade).................. 44
deferasirox tab 90 mg, 180 mg (Jadenu).......................... 45
deferasirox tab 360 mg (Jadenu)...................................... 45
deferiprone tab 500 mg (Ferriprox)................................... 45
deferiprone tab 1000 mg (Ferriprox)................................. 45
DELESTROGEN...............................................................105
DELSTRIGO....................................................................... 69
DELZICOL........................................................................ 106
demeclocycline hcl tab 150 mg, 300 mg...........................25
DEMSER.............................................................................80
DENAVIR............................................................................ 97
DENGVAXIA..................................................................... 118
DEPAKOTE.........................................................................27
DEPAKOTE ER.................................................................. 27
DEPAKOTE SPRINKLES...................................................27
DEPEN TITRATABS...........................................................45
DEPO-ESTRADIOL..........................................................105
DEPO-PROVERA CONTRACEPTIVE.............................. 87
DEPO-SUBQ PROVERA 104............................................87
DERMACINRX LIDOGEL.................................................. 97
DERMACINRX PRETRATE............................................. 125
DERMA-SMOOTHE/FS BODY..........................................94
DERMA-SMOOTHE/FS SCALP........................................ 94
DERMOTIC.......................................................................135
DESCOVY.......................................................................... 69
desipramine hcl tab 50 mg, 75 mg, 100 mg, 150 mg........ 32
desipramine hcl tab 10 mg, 25 mg (Norpramin)................32
desloratadine tab 5 mg (Clarinex)..................................... 47
desmopressin acetate nasal spray soln 0.01%
(Ddavp)............................................................................102
desmopressin acetate nasal spray soln 0.01%
(refrigerated)................................................................... 102
desmopressin acetate tab 0.1 mg, 0.2 mg (Ddavp)........ 102
desogest-eth estrad & eth estrad tab 0.15-0.02/0.01
mg(21/5) (Mircette)........................................................... 85
desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg......... 85
desonide cream 0.05% (Desowen)................................... 94
desonide lotion 0.05%........................................................94
desonide oint 0.05%.......................................................... 94
desoximetasone cream 0.05%, 0.25% (Topicort)..............94
desoximetasone gel 0.05% (Topicort)............................... 94
desoximetasone oint 0.05%, 0.25% (Topicort)..................94
desoximetasone spray 0.25% (Topicort)........................... 94
DESVENLAFAXINE ER..................................................... 35
desvenlafaxine succinate tab er 24hr 25 mg (base equiv),
50 mg (base equiv), 100 mg (base equiv) (Pristiq)......... 35
DETROL............................................................................150
2024
Effective Date: July 2024
165
DETROL LA......................................................................150
DEXAMETHASONE........................................................... 88
DEXAMETHASONE 10-DAY DOSE PACK.......................88
DEXAMETHASONE 13-DAY DOSE PACK.......................88
dexamethasone elixir 0.5 mg/5ml......................................88
DEXAMETHASONE INTENSOL....................................... 88
DEXAMETHASONE SODIUM PHOSPHATE..................133
dexamethasone tab 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg,
4 mg, 6 mg....................................................................... 88
dexamethasone tab therapy pack 1.5 mg (21)................. 88
DEXCOM G6 RECEIVER................................................109
DEXCOM G7 RECEIVER................................................109
DEXCOM G6 SENSOR................................................... 109
DEXCOM G7 SENSOR................................................... 109
DEXCOM G6 TRANSMITTER.........................................109
DEXEDRINE......................................................................... 1
DEXILANT........................................................................ 149
dexlansoprazole cap delayed release 30 mg, 60 mg
(Dexilant).........................................................................149
dexmethylphenidate hcl cap er 24 hr 5 mg, 10 mg, 15 mg,
20 mg, 25 mg, 30 mg, 35 mg, 40 mg (Focalin xr)............. 3
dexmethylphenidate hcl tab 2.5 mg, 5 mg, 10 mg
(Focalin).............................................................................. 3
DEXTENZA.......................................................................133
dextroamphetamine sulfate cap er 24hr 10 mg, 15 mg
(Dexedrine)......................................................................... 1
dextroamphetamine sulfate cap er 24hr 5 mg
(Dexedrine)......................................................................... 1
dextroamphetamine sulfate oral solution 5 mg/5ml.............1
dextroamphetamine sulfate tab 10 mg................................ 1
dextroamphetamine sulfate tab 30 mg................................ 1
dextroamphetamine sulfate tab 2.5 mg, 5 mg, 7.5 mg, 15
mg, 20 mg...........................................................................1
dextromethorphan-guaifenesin liquid 10-100 mg/5ml..... 153
DHIVY................................................................................. 63
DIACOMIT.......................................................................... 27
diazepam conc 5 mg/ml.....................................................14
diazepam oral soln 1 mg/ml.............................................. 14
DIAZEPAM RECTAL GEL..................................................27
diazepam rectal gel delivery system 10 mg, 20 mg
(Diastat acudial)................................................................27
diazepam tab 2 mg, 5 mg, 10 mg (Valium)....................... 14
diazoxide susp 50 mg/ml (Proglycem).............................. 42
dichlorphenamide tab 50 mg (Keveyis)............................. 82
DICLEGIS........................................................................... 46
DICLOFENAC EPOLAMINE.............................................. 97
diclofenac potassium cap 25 mg (Zipsor)........................... 6
diclofenac potassium (migraine) packet 50 mg
(Cambia)......................................................................... 121
diclofenac potassium tab 25 mg..........................................6
diclofenac potassium tab 50 mg..........................................6
diclofenac sodium (actinic keratoses) gel 3%................... 97
diclofenac sodium gel 1% (1.16% diethylamine equiv)
(Voltaren)...........................................................................97
diclofenac sodium ophth soln 0.1%.................................131
diclofenac sodium soln 1.5%............................................. 97
diclofenac sodium soln 2% (Pennsaid)............................. 97
diclofenac sodium tab delayed release 75 mg....................6
diclofenac sodium tab delayed release 25 mg, 50 mg........ 6
diclofenac sodium tab er 24hr 100 mg................................6
diclofenac sod soln 1.5% & capsaicin cream 0.025% ther
pack (Dermacinrx lexitral)................................................ 97
diclofenac w/ misoprostol tab delayed release 50-0.2 mg
(Arthrotec 50)......................................................................6
diclofenac w/ misoprostol tab delayed release 75-0.2 mg
(Arthrotec 75)......................................................................6
dicloxacillin sodium cap 250 mg, 500 mg......................... 25
dicyclomine hcl cap 10 mg.............................................. 148
dicyclomine hcl oral soln 10 mg/5ml............................... 148
dicyclomine hcl tab 20 mg............................................... 148
DIFICID............................................................................... 23
DIFLORASONE DIACETATE.............................................95
diflorasone diacetate oint 0.05%....................................... 95
DIFLUCAN.......................................................................... 46
diflunisal tab 500 mg............................................................8
difluprednate ophth emulsion 0.05% (Durezol)............... 133
DIGOXIN............................................................................. 81
digoxin oral soln 0.05 mg/ml (Digoxin).............................. 81
digoxin tab 125 mcg (0.125 mg), 250 mcg (0.25 mg)
(Lanoxin)........................................................................... 81
digoxin tab 62.5 mcg (0.0625 mg) (Lanoxin).................... 81
dihydroergotamine mesylate nasal spray 4 mg/ml
(Migranal)........................................................................ 121
DILANTIN............................................................................27
DILANTIN-125.................................................................... 28
DILANTIN INFATABS......................................................... 27
DILAUDID............................................................................. 9
diltiazem hcl cap er 12hr 60 mg, 90 mg, 120 mg.............. 79
diltiazem hcl cap er 24hr 120 mg, 180 mg, 240 mg.......... 79
diltiazem hcl coated beads cap er 24hr 120 mg, 180 mg,
240 mg, 300 mg, 360 mg (Cardizem cd).........................79
diltiazem hcl extended release beads cap er 24hr 120 mg,
180 mg, 240 mg, 300 mg, 360 mg, 420 mg (Tiazac)...... 79
diltiazem hcl tab er 24hr 120 mg, 180 mg, 240 mg, 300
mg, 360 mg, 420 mg (Cardizem la).................................79
diltiazem hcl tab 90 mg......................................................79
diltiazem hcl tab 30 mg, 60 mg, 120 mg (Cardizem).........79
dimethyl fumarate capsule delayed release 120 mg
(Tecfidera)....................................................................... 138
dimethyl fumarate capsule delayed release 240 mg
(Tecfidera)....................................................................... 138
dimethyl fumarate capsule dr starter pack 120 mg & 240
mg (Tecfidera starter pack)............................................ 138
DIOVAN...............................................................................77
DIOVAN HCT......................................................................75
DIPENTUM....................................................................... 106
DIPHENHYDRAMINE HCL................................................47
diphenhydramine hcl cap 25 mg, 50 mg......................... 153
diphenhydramine hcl liquid 12.5 mg/5ml......................... 153
diphenhydramine hcl tab 25 mg...................................... 153
diphenoxylate w/ atropine tab 2.5-0.025 mg (Lomotil)...... 44
DIPROLENE....................................................................... 95
2024
Effective Date: July 2024
166
dipyridamole tab 25 mg, 50 mg, 75 mg...........................115
disopyramide phosphate cap 100 mg, 150 mg
(Norpace).......................................................................... 81
DISULFIRAM.................................................................... 142
disulfiram tab 250 mg (Antabuse)................................... 142
DIURIL................................................................................ 82
divalproex sodium cap delayed release sprinkle 125 mg
(Depakote sprinkles).........................................................28
divalproex sodium tab delayed release 125 mg, 250 mg,
500 mg (Depakote).......................................................... 28
divalproex sodium tab er 24 hr 250 mg, 500 mg
(Depakote er)....................................................................28
DIVIGEL............................................................................ 105
docusate sodium cap 100 mg......................................... 154
docusate sodium liquid 150 mg/15ml.............................. 154
dofetilide cap 125 mcg (0.125 mg), 250 mcg (0.25 mg),
500 mcg (0.5 mg) (Tikosyn).............................................81
donepezil hydrochloride orally disintegrating tab 5 mg, 10
mg....................................................................................135
donepezil hydrochloride tab 5 mg, 10 mg, 23 mg
(Aricept)...........................................................................135
DOPTELET....................................................................... 115
DORAL..............................................................................116
DORYX MPC......................................................................25
dorzolamide hcl ophth soln 2% (Trusopt)........................131
dorzolamide hcl-timolol maleate ophth soln 2-0.5%
(Cosopt)...........................................................................130
dorzolamide hcl-timolol maleate pf ophth soln 2-0.5%
(Cosopt pf)...................................................................... 130
DOVATO..............................................................................69
doxazosin mesylate tab 1 mg, 2 mg, 4 mg (Cardura)....... 77
doxazosin mesylate tab 8 mg (Cardura)........................... 77
doxepin hcl cap 10 mg, 25 mg, 50 mg, 75 mg, 100 mg,
150 mg.............................................................................. 32
doxepin hcl conc 10 mg/ml................................................32
doxepin hcl cream 5% (Prudoxin)..................................... 97
doxepin hcl (sleep) tab 3 mg (base equiv), 6 mg (base
equiv) (Silenor)............................................................... 117
doxercalciferol cap 0.5 mcg, 1 mcg, 2.5 mcg..................104
doxycycline hyclate cap 50 mg..........................................25
doxycycline hyclate cap 100 mg (Vibramycin).................. 25
DOXYCYCLINE HYCLATE DR......................................... 25
doxycycline hyclate tab delayed release 75 mg, 100 mg,
150 mg.............................................................................. 25
doxycycline hyclate tab delayed release 50 mg, 200 mg
(Doryx)...............................................................................25
doxycycline hyclate tab 20 mg, 50 mg, 100 mg................ 25
doxycycline hyclate tab 75 mg, 150 mg (Acticlate)........... 25
doxycycline monohydrate cap 50 mg, 75 mg, 100 mg, 150
mg......................................................................................25
doxycycline monohydrate for susp 25 mg/5ml
(Vibramycin)...................................................................... 25
doxycycline monohydrate tab 50 mg, 75 mg, 100 mg, 150
mg......................................................................................25
doxycycline (rosacea) cap delayed release 40 mg
(Oracea)............................................................................ 97
doxylamine-pyridoxine tab delayed release 10-10 mg
(Diclegis)........................................................................... 46
dronabinol cap 2.5 mg, 5 mg, 10 mg................................ 46
drospirenone-ethinyl estradiol tab 3-0.03 mg (Yasmin
28)..................................................................................... 86
drospirenone-ethinyl estradiol tab 3-0.02 mg (Yaz).......... 85
drospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451
mg (Beyaz)....................................................................... 85
drospirenone-ethinyl estrad-levomefolate tab 3-0.03-0.451
mg (Safyral)...................................................................... 85
DROXIA................................................................................ 5
droxidopa cap 200 mg, 300 mg (Northera)....................... 83
droxidopa cap 100 mg (Northera)..................................... 83
DUAKLIR PRESSAIR.........................................................15
DUAVEE............................................................................105
DUETACT........................................................................... 36
DUEXIS.................................................................................6
DULERA..............................................................................15
duloxetine hcl enteric coated pellets cap 40 mg (base
eq)..................................................................................... 35
duloxetine hcl enteric coated pellets cap 20 mg (base eq),
60 mg (base eq) (Cymbalta)............................................35
duloxetine hcl enteric coated pellets cap 30 mg (base eq)
(Cymbalta).........................................................................35
DUOBRII............................................................................. 95
DUPIXENT..........................................................................18
DUREZOL.........................................................................134
dutasteride cap 0.5 mg (Avodart).................................... 109
dutasteride-tamsulosin hcl cap 0.5-0.4 mg (Jalyn)..........109
DYANAVEL XR..................................................................... 1
DYMISTA.......................................................................... 129
E
econazole nitrate cream 1%.............................................. 91
EDARBI...............................................................................77
EDARBYCLOR................................................................... 75
EDECRIN............................................................................ 82
EDLUAR............................................................................117
EDURANT...........................................................................69
E.E.S. 400.......................................................................... 24
E.E.S. GRANULES............................................................ 24
EFAVIRENZ........................................................................ 69
efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg
(Atripla)..............................................................................69
efavirenz-lamivudine-tenofovir df tab 600-300-300 mg
(Symfi)............................................................................... 69
efavirenz-lamivudine-tenofovir df tab 400-300-300 mg
(Symfi lo)...........................................................................69
efavirenz tab 600 mg (Sustiva)..........................................69
EFFEXOR XR.....................................................................35
EFFIENT........................................................................... 115
EFUDEX..............................................................................97
EGRIFTA SV.................................................................... 102
ELEPSIA XR.......................................................................28
ELESTRIN........................................................................ 105
2024
Effective Date: July 2024
167
eletriptan hydrobromide tab 20 mg (base equivalent), 40
mg (base equivalent) (Relpax).......................................122
ELIDEL................................................................................97
ELIQUIS.............................................................................. 26
ELIQUIS STARTER PACK.................................................26
ELITE-OB..........................................................................125
ELLA....................................................................................87
ELMIRON..........................................................................108
ELOCTATE........................................................................112
ELYXYB............................................................................ 121
EMCYT................................................................................52
EMEND............................................................................... 46
EMEND TRIPACK.............................................................. 46
EMFLAZA............................................................................88
EMGALITY........................................................................122
EMPAVELI.........................................................................114
EMSAM............................................................................... 32
emtricitabine caps 200 mg (Emtriva).................................69
emtricitabine-tenofovir disoproxil fumarate tab 100-150
mg, 133-200 mg, 167-250 mg, 200-300 mg
(Truvada)........................................................................... 69
EMTRIVA............................................................................ 69
EMVERM............................................................................ 61
enalapril maleate & hydrochlorothiazide tab 5-12.5
mg......................................................................................74
enalapril maleate & hydrochlorothiazide tab 10-25 mg
(Vaseretic)......................................................................... 74
enalapril maleate oral soln 1 mg/ml (Epaned)...................74
enalapril maleate tab 2.5 mg, 5 mg, 10 mg, 20 mg
(Vasotec)........................................................................... 74
ENBRACE HR.................................................................. 125
ENBREL............................................................................145
ENBREL MINI...................................................................145
ENBREL SURECLICK..................................................... 145
ENDARI.................................................................................5
ENDOMETRIN..................................................................151
ENGERIX-B...................................................................... 118
ENJAYMO.........................................................................114
ENLITE GLUCOSE SENSOR......................................... 109
enoxaparin sodium inj 300 mg/3ml (Lovenox).................. 26
enoxaparin sodium inj soln pref syr 30 mg/0.3ml, 40
mg/0.4ml, 60 mg/0.6ml, 80 mg/0.8ml, 100 mg/ml, 120
mg/0.8ml, 150 mg/ml (Lovenox)...................................... 26
ENSTILAR.......................................................................... 95
entacapone tab 200 mg (Comtan).....................................63
entecavir tab 0.5 mg, 1 mg (Baraclude)............................72
ENTRESTO.........................................................................83
ENTYVIO.......................................................................... 145
ENVARSUS XR................................................................ 120
EPANED..............................................................................74
EPCLUSA........................................................................... 72
EPIDIOLEX......................................................................... 28
EPIFOAM............................................................................ 95
epinastine hcl ophth soln 0.05%......................................133
EPINEPHRINE....................................................................13
epinephrine solution auto-injector 0.15 mg/0.3ml (1:2000)
(Epipen-jr 2-pak)...............................................................13
epinephrine solution auto-injector 0.3 mg/0.3ml (1:1000)
(Epipen 2-pak).................................................................. 13
EPIPEN-JR 2-PAK............................................................. 13
EPIPEN 2-PAK................................................................... 13
EPIVIR................................................................................ 69
eplerenone tab 25 mg, 50 mg (Inspra)..............................80
EPOGEN...........................................................................115
epoprostenol sodium for inj 0.5 mg, 1.5 mg (Flolan).........84
EPRONTIA..........................................................................28
EQUETRO.......................................................................... 66
ergocalciferol cap 1.25 mg (50000 unit) (Drisdol)........... 152
ERGOLOID MESYLATES................................................136
ERIVEDGE......................................................................... 60
ERLEADA........................................................................... 52
erlotinib hcl tab 100 mg (base equivalent), 150 mg (base
equivalent) (Tarceva)........................................................54
erlotinib hcl tab 25 mg (base equivalent) (Tarceva).......... 54
ERMEZA........................................................................... 143
ERTACZO........................................................................... 91
ERY..................................................................................... 90
ERYGEL..............................................................................90
ERYPED 200......................................................................24
ERYPED 400......................................................................24
ERYTHROCIN STEARATE................................................24
ERYTHROMYCIN...............................................................24
ERYTHROMYCIN ETHYLSUCCINATE............................ 24
erythromycin ethylsuccinate for susp 200 mg/5ml (E.e.s.
granules)........................................................................... 24
erythromycin ethylsuccinate for susp 400 mg/5ml (Eryped
400)................................................................................... 24
erythromycin gel 2% (Erygel)............................................ 90
erythromycin ophth oint 5 mg/gm.................................... 133
erythromycin soln 2%.........................................................90
erythromycin tab delayed release 250 mg, 333 mg, 500
mg......................................................................................24
erythromycin tab 250 mg, 500 mg.....................................24
ESBRIET...........................................................................141
escitalopram oxalate soln 5 mg/5ml (base equiv)............. 34
escitalopram oxalate tab 5 mg (base equiv), 10 mg (base
equiv), 20 mg (base equiv) (Lexapro)............................. 34
ESGIC................................................................................... 8
esomeprazole magnesium cap delayed release 20 mg
(base eq), 40 mg (base eq) (Nexium)........................... 149
esomeprazole magnesium for delayed release susp
packet 10 mg, 20 mg, 40 mg (Nexium)......................... 149
ESPEROCT...................................................................... 112
estazolam tab 1 mg, 2 mg...............................................116
ESTRACE......................................................................... 105
estradiol & norethindrone acetate tab 0.5-0.1 mg........... 105
estradiol & norethindrone acetate tab 1-0.5 mg
(Activella)........................................................................ 105
estradiol tab 0.5 mg, 1 mg, 2 mg (Estrace).....................105
2024
Effective Date: July 2024
168
estradiol td gel 0.25 mg/0.25gm (0.1%), 0.5 mg/0.5gm
(0.1%), 0.75 mg/0.75gm (0.1%), 1 mg/gm (0.1%), 1.25
mg/1.25gm (0.1%) (Divigel)........................................... 105
estradiol td patch twice weekly 0.025 mg/24hr, 0.0375
mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr
(Vivelle-dot)..................................................................... 105
estradiol td patch weekly 0.025 mg/24hr, 0.0375 mg/24hr
(37.5 mcg/24hr), 0.05 mg/24hr, 0.06 mg/24hr, 0.075
mg/24hr, 0.1 mg/24hr (Climara).....................................105
estradiol vaginal cream 0.1 mg/gm (Estrace)..................151
estradiol vaginal tab 10 mcg (Vagifem)...........................151
estradiol valerate im in oil 10 mg/ml, 20 mg/ml, 40 mg/ml
(Delestrogen).................................................................. 105
ESTRING.......................................................................... 151
eszopiclone tab 1 mg, 2 mg, 3 mg (Lunesta)..................117
ethacrynic acid tab 25 mg (Edecrin)..................................82
ethambutol hcl tab 100 mg................................................ 22
ethambutol hcl tab 400 mg (Myambutol)...........................22
ethosuximide cap 250 mg (Zarontin).................................28
ethosuximide soln 250 mg/5ml (Zarontin)......................... 28
ethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg,
1 mg-50 mcg.................................................................... 86
etodolac cap 200 mg, 300 mg.............................................6
etodolac tab er 24hr 600 mg............................................... 6
etodolac tab er 24hr 400 mg, 500 mg.................................6
etodolac tab 500 mg............................................................ 6
etodolac tab 400 mg (Lodine)..............................................6
etonogestrel-ethinyl estradiol va ring 0.12-0.015 mg/24hr
(Nuvaring)......................................................................... 86
ETOPOSIDE....................................................................... 61
etravirine tab 100 mg, 200 mg (Intelence)........................ 69
EUCRISA............................................................................ 97
EVAMIST...........................................................................105
EVEKEO............................................................................... 2
everolimus tab for oral susp 2 mg, 5 mg (Afinitor
disperz)..............................................................................54
everolimus tab for oral susp 3 mg (Afinitor disperz)..........54
everolimus tab 2.5 mg, 5 mg, 7.5 mg, 10 mg (Afinitor)..... 54
everolimus tab 0.25 mg, 0.5 mg, 0.75 mg, 1 mg
(Zortress).........................................................................120
EVERSENSE E3 SENSOR/HOLDER............................. 109
EVERSENSE E3 SMART TRANSMITTER.....................109
EVERSENSE SENSOR/HOLDER KIT............................109
EVERSENSE SMART TRANSMITTER.......................... 109
EVISTA..............................................................................102
EVOTAZ.............................................................................. 69
EVOXAC........................................................................... 124
EXELON............................................................................135
exemestane tab 25 mg (Aromasin)................................... 52
EXFORGE.......................................................................... 75
EXFORGE HCT..................................................................75
EXJADE.............................................................................. 45
EXKIVITY............................................................................ 54
EXSERVAN.......................................................................129
EXTAVIA........................................................................... 138
EYSUVIS.......................................................................... 134
EZALLOR SPRINKLE........................................................ 48
ezetimibe-simvastatin tab 10-10 mg, 10-20 mg, 10-40 mg,
10-80 mg (Vytorin)............................................................48
ezetimibe tab 10 mg (Zetia)...............................................48
F
FABHALTA........................................................................ 114
FABIOR............................................................................... 90
famciclovir tab 125 mg, 250 mg, 500 mg.......................... 73
famotidine for susp 40 mg/5ml........................................ 148
famotidine tab 20 mg, 40 mg (Pepcid)............................ 148
FANAPT.............................................................................. 64
FANAPT TITRATION PACK...............................................64
FARESTON.........................................................................52
FARXIGA.............................................................................44
FASENRA........................................................................... 18
FASENRA PEN.................................................................. 18
febuxostat tab 40 mg, 80 mg (Uloric)..............................111
fe fumarate-vit c-vit b12-fa cap 460 (151 fe)-60-0.01-1
mg....................................................................................123
fe fumarate w/ b12-vit c-fa-ifc cap 110-0.015-75-0.5-240
mg....................................................................................123
fe fum-iron polysacch complex-fa-b cmplx-c-zn-mn-cu
cap...................................................................................123
FEIBA................................................................................112
felbamate susp 600 mg/5ml (Felbatol).............................. 28
felbamate tab 400 mg, 600 mg (Felbatol)......................... 28
FELBATOL.......................................................................... 28
felodipine tab er 24hr 2.5 mg, 5 mg, 10 mg...................... 79
FEMARA............................................................................. 52
FEMRING......................................................................... 151
FENOFIBRATE................................................................... 48
fenofibrate micronized cap 43 mg..................................... 48
fenofibrate micronized cap 67 mg, 130 mg, 134 mg, 200
mg......................................................................................48
fenofibrate tab 54 mg.........................................................48
fenofibrate tab 160 mg.......................................................48
fenofibrate tab 40 mg (Fenoglide)..................................... 48
fenofibrate tab 120 mg (Fenoglide)................................... 48
fenofibrate tab 48 mg (Tricor)............................................ 48
fenofibrate tab 145 mg (Tricor).......................................... 48
FENOGLIDE....................................................................... 49
fenoprofen calcium cap 400 mg (Nalfon)............................ 6
fenoprofen calcium tab 600 mg (Nalfon)............................. 6
FENTANYL CITRATE...........................................................9
fentanyl citrate lozenge on a handle 200 mcg, 400 mcg,
600 mcg, 800 mcg, 1200 mcg, 1600 mcg (Actiq)..............9
fentanyl td patch 72hr 37.5 mcg/hr, 62.5 mcg/hr, 87.5
mcg/hr..................................................................................9
fentanyl td patch 72hr 12 mcg/hr, 25 mcg/hr, 50 mcg/hr,
75 mcg/hr, 100 mcg/hr (Duragesic)................................... 9
FENTORA............................................................................. 9
FERRIPROX....................................................................... 45
FERRIPROX TWICE-A-DAY..............................................45
ferrous fumarate-fa-b complex-c-zn-mg-mn-cu tab 106-1
mg....................................................................................123
2024
Effective Date: July 2024
169
ferrous sulfate soln 75 mg/ml (15 mg/ml elemental fe),
220 mg/5ml (44 mg/5ml elemental fe), 300 mg/5ml (60
mg/5ml elemental fe)......................................................154
ferrous sulfate tab ec 325 mg (65 mg fe equivalent).......154
ferrous sulfate tab 325 mg (65 mg elemental fe)............ 154
fesoterodine fumarate tab er 24hr 4 mg, 8 mg
(Toviaz)............................................................................150
FETZIMA.............................................................................36
FETZIMA TITRATION PACK............................................. 36
fexofenadine hcl tab 60 mg, 180 mg...............................153
FIASP..................................................................................39
FIASP FLEXTOUCH.......................................................... 39
FIASP PENFILL..................................................................39
FIASP PUMPCART............................................................39
FINACEA.............................................................................97
finasteride tab 5 mg (Proscar)......................................... 109
fingolimod hcl cap 0.5 mg (base equiv) (Gilenya)........... 138
FINTEPLA...........................................................................28
FIORICET............................................................................. 8
FIORICET/CODEINE......................................................... 12
FIRAZYR...........................................................................114
FIRDAPSE.......................................................................... 51
FIRST PANTOPRAZOLE.................................................149
FIRVANQ............................................................................ 21
FLAGYL.............................................................................. 21
FLAREX............................................................................ 134
flavoxate hcl tab 100 mg................................................. 150
flecainide acetate tab 50 mg, 100 mg, 150 mg................. 81
FLECTOR........................................................................... 97
FLEET LIQUID GLYCERIN SUPPOSITORIES...............154
FLEQSUVY.......................................................................128
FLOLAN.............................................................................. 84
FLOMAX........................................................................... 109
fluconazole for susp 10 mg/ml, 40 mg/ml (Diflucan)......... 46
fluconazole tab 50 mg, 100 mg, 150 mg, 200 mg
(Diflucan)........................................................................... 46
flucytosine cap 250 mg, 500 mg (Ancobon)......................46
fludrocortisone acetate tab 0.1 mg.................................... 88
flunisolide nasal soln 25 mcg/act (0.025%).....................129
FLUOCINOLONE ACETONIDE.........................................95
fluocinolone acetonide cream 0.025% (Synalar)...............95
fluocinolone acetonide oil 0.01% (body oil) (Derma-
smoothe/fs body).............................................................. 95
fluocinolone acetonide oil 0.01% (scalp oil) (Derma-
smoothe/fs scalp)............................................................. 95
fluocinolone acetonide oint 0.025% (Synalar)...................95
fluocinolone acetonide (otic) oil 0.01% (Dermotic)..........135
fluocinolone acetonide soln 0.01% (Synalar).................... 95
fluocinonide cream 0.05%................................................. 95
fluocinonide cream 0.1% (Vanos)......................................95
fluocinonide emulsified base cream 0.05%.......................95
fluocinonide gel 0.05%.......................................................95
fluocinonide oint 0.05%......................................................95
fluocinonide soln 0.05%..................................................... 95
FLUORESCEIN SODIUM/BENOXINATE
HYDROCHLORIDE........................................................ 131
fluorometholone ophth susp 0.1% (Fml liquifilm)............ 134
FLUOROURACIL................................................................97
fluorouracil cream 5% (Efudex)......................................... 97
fluorouracil soln 5%............................................................97
FLUOXETINE DR...............................................................34
fluoxetine hcl cap 10 mg (Prozac).....................................34
fluoxetine hcl cap 20 mg (Prozac).....................................34
fluoxetine hcl cap 40 mg (Prozac).....................................34
fluoxetine hcl solution 20 mg/5ml...................................... 34
fluoxetine hcl tab 10 mg.................................................... 34
fluoxetine hcl tab 20 mg.................................................... 34
fluoxetine hcl tab 60 mg (Fluoxetine hydrochloride)..........34
FLUOXETINE HYDROCHLORIDE....................................34
FLUPHENAZINE HCL........................................................66
fluphenazine hcl tab 1 mg, 2.5 mg, 5 mg, 10 mg.............. 66
FLUPHENAZINE HYDROCHLORIDE...............................66
FLURANDRENOLIDE........................................................ 95
FLURAZEPAM HYDROCHLORIDE................................ 116
FLURBIPROFEN.................................................................. 6
FLURBIPROFEN SODIUM.............................................. 131
flurbiprofen tab 100 mg........................................................6
FLUTICASONE FUROATE/VILANTEROL ELLIPTA.........16
FLUTICASONE PROPIONATE......................................... 95
FLUTICASONE PROPIONATE/SALMETEROL................16
FLUTICASONE PROPIONATE/SALMETEROL HFA........16
fluticasone propionate cream 0.05%................................. 95
FLUTICASONE PROPIONATE DISKUS...........................19
FLUTICASONE PROPIONATE HFA................................. 19
fluticasone propionate nasal susp 50 mcg/act................ 129
fluticasone propionate oint 0.005%................................... 95
fluticasone-salmeterol aer powder ba 100-50 mcg/act,
250-50 mcg/act, 500-50 mcg/act (Advair diskus)............ 16
fluvastatin sodium cap 20 mg (base equivalent), 40 mg
(base equivalent).............................................................. 49
fluvastatin sodium tab er 24 hr 80 mg (base equivalent)
(Lescol xl)..........................................................................49
fluvoxamine maleate cap er 24hr 100 mg, 150 mg........... 34
fluvoxamine maleate tab 100 mg...................................... 34
fluvoxamine maleate tab 25 mg, 50 mg............................ 34
FML FORTE..................................................................... 134
FML LIQUIFILM................................................................134
FOCALIN...............................................................................3
FOCALIN XR........................................................................ 3
FOLBEE PLUS CZ...........................................................125
folic acid tab 400 mcg......................................................155
folic acid tab 1 mg........................................................... 116
folic acid-vitamin b6-vitamin b12 tab 2.2-25-0.5 mg,
2.5-25-1 mg.................................................................... 123
FOLIVANE-OB..................................................................125
fondaparinux sodium subcutaneous inj 2.5 mg/0.5ml, 5
mg/0.4ml, 7.5 mg/0.6ml, 10 mg/0.8ml (Arixtra)............... 26
FORFIVO XL...................................................................... 32
formoterol fumarate soln nebu 20 mcg/2ml
(Perforomist)..................................................................... 17
FOSAMAX........................................................................ 100
FOSAMAX PLUS D......................................................... 100
2024
Effective Date: July 2024
170
fosamprenavir calcium tab 700 mg (base equiv)
(Lexiva)..............................................................................70
fosfomycin tromethamine powd pack 3 gm (base
equivalent) (Monurol)........................................................21
fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg,
20-12.5 mg........................................................................74
fosinopril sodium tab 10 mg, 20 mg, 40 mg......................74
FOSRENOL...................................................................... 108
FOTIVDA.............................................................................54
FRAGMIN............................................................................26
FREESTYLE LIBRE 2/READER/FLASH GLUCOSE
MONITORING SYSTEM................................................ 110
FREESTYLE LIBRE/READER/FLASH MONITORING
SYSTEM..........................................................................110
FREESTYLE LIBRE 3/READER/GLUCOSE
MONITORING SYSTEM................................................ 110
FREESTYLE LIBRE 2/SENSOR/FLASH GLUCOSE
MONITORING SYSTEM................................................ 110
FREESTYLE LIBRE 3/SENSOR/GLUCOSE
MONITORING SYSTEM................................................ 110
FREESTYLE LIBRE 14 DAY/READER/FLASH
MONITORING SYSTEM................................................ 110
FREESTYLE LIBRE 14 DAY/SENSOR/FLASH
MONITORING SYSTEM................................................ 110
FROVA.............................................................................. 122
frovatriptan succinate tab 2.5 mg (base equivalent)
(Frova).............................................................................122
FRUZAQLA.........................................................................54
FULPHILA.........................................................................115
FUROSEMIDE....................................................................82
furosemide oral soln 10 mg/ml.......................................... 82
furosemide tab 20 mg, 40 mg, 80 mg (Lasix)................... 82
FUZEON............................................................................. 70
FYCOMPA...........................................................................28
FYLNETRA....................................................................... 115
G
gabapentin cap 100 mg (Neurontin)..................................28
gabapentin cap 300 mg (Neurontin)..................................28
gabapentin cap 400 mg (Neurontin)..................................28
gabapentin (once-daily) tab 300 mg (Gralise).................136
gabapentin (once-daily) tab 600 mg (Gralise).................136
gabapentin oral soln 250 mg/5ml (Neurontin)................... 28
gabapentin tab 600 mg (Neurontin)...................................28
gabapentin tab 800 mg (Neurontin)...................................28
GALAFOLD.......................................................................102
GALANTAMINE HYDROBROMIDE................................ 135
galantamine hydrobromide cap er 24hr 8 mg, 16 mg, 24
mg (Razadyne er).......................................................... 135
galantamine hydrobromide tab 8 mg, 12 mg.................. 136
galantamine hydrobromide tab 4 mg (Razadyne)........... 135
GARDASIL 9.................................................................... 118
GASTROCROM................................................................107
gatifloxacin ophth soln 0.5% (Zymaxid).......................... 133
GATTEX............................................................................ 107
GAVRETO...........................................................................54
gefitinib tab 250 mg (Iressa)..............................................54
GELNIQUE....................................................................... 150
GELX.................................................................................124
gemfibrozil tab 600 mg (Lopid)..........................................49
GEMTESA........................................................................ 150
GENOTROPIN..................................................................101
GENOTROPIN MINIQUICK............................................. 101
gentamicin sulfate cream 0.1%......................................... 91
gentamicin sulfate oint 0.1%..............................................91
gentamicin sulfate ophth soln 0.3%.................................133
GENVOYA...........................................................................70
GEODON............................................................................ 66
GILENYA...........................................................................138
GILOTRIF............................................................................54
GIMOTI............................................................................. 107
glatiramer acetate soln prefilled syringe 20 mg/ml
(Copaxone)..................................................................... 138
glatiramer acetate soln prefilled syringe 40 mg/ml
(Copaxone)..................................................................... 139
GLEEVEC........................................................................... 55
glimepiride tab 1 mg, 2 mg, 4 mg (Amaryl).......................42
GLIPIZIDE...........................................................................42
glipizide-metformin hcl tab 2.5-250 mg, 2.5-500 mg, 5-500
mg......................................................................................36
glipizide tab er 24hr 2.5 mg, 10 mg (Glucotrol xl)............. 42
glipizide tab er 24hr 5 mg (Glucotrol xl)............................ 42
glipizide tab 5 mg, 10 mg (Glucotrol)................................ 42
GLOSTRIPS..................................................................... 131
GLUCAGEN HYPOKIT...................................................... 42
GLUCAGON EMERGENCY KIT FOR LOW BLOOD
SUGAR..............................................................................42
GLUCOTROL XL................................................................42
GLUMETZA........................................................................ 42
glyburide-metformin tab 1.25-250 mg, 2.5-500 mg, 5-500
mg......................................................................................36
GLYBURIDE MICRONIZED...............................................43
glyburide tab 5 mg............................................................. 43
glyburide tab 1.25 mg, 2.5 mg...........................................43
GLYCATE..........................................................................148
glycopyrrolate oral soln 1 mg/5ml (Cuvposa)..................148
glycopyrrolate tab 1 mg, 2 mg.........................................148
GLYXAMBI..........................................................................36
GOCOVRI........................................................................... 63
GRALISE.......................................................................... 137
granisetron hcl tab 1 mg....................................................45
GRANIX............................................................................ 115
griseofulvin microsize susp 125 mg/5ml........................... 47
griseofulvin microsize tab 500 mg..................................... 47
griseofulvin ultramicrosize tab 125 mg, 250 mg................47
guaifenesin-codeine soln 100-10 mg/5ml........................153
guaifenesin liquid 100 mg/5ml......................................... 153
guanfacine hcl tab er 24hr 1 mg (base equiv), 2 mg (base
equiv), 3 mg (base equiv), 4 mg (base equiv) (Intuniv)..... 2
guanfacine hcl tab 1 mg, 2 mg..........................................77
GUARDIAN CONNECT TRANSMITTER........................ 110
GUARDIAN 4 GLUCOSE SENSOR................................110
2024
Effective Date: July 2024
171
GUARDIAN LINK 3 TRANSMITTER KIT........................ 110
GUARDIAN REAL-TIME CHARGER
REPLACEMENT............................................................. 110
GUARDIAN REAL-TIME REPLACEMENT
MONITOR....................................................................... 110
GUARDIAN REAL-TIME TEST PLUG
REPLACEMENT............................................................. 110
GUARDIAN SENSOR (3)................................................ 110
GUARDIAN 4 TRANSMITTER KIT................................. 110
GVOKE HYPOPEN 1-PACK..............................................43
GVOKE HYPOPEN 2-PACK..............................................43
GVOKE KIT........................................................................ 43
GVOKE PFS.......................................................................43
GYNAZOLE-1................................................................... 151
H
HADLIMA.......................................................................... 145
HADLIMA PUSHTOUCH................................................. 145
HAEGARDA......................................................................114
halcinonide cream 0.1% (Halog)....................................... 95
HALCION.......................................................................... 116
halobetasol propionate cream 0.05%................................ 95
halobetasol propionate foam 0.05% (Lexette).................. 95
halobetasol propionate oint 0.05%.................................... 95
HALOG................................................................................95
haloperidol lactate oral conc 2 mg/ml................................67
haloperidol tab 0.5 mg, 1 mg, 2 mg, 5 mg, 10 mg, 20
mg......................................................................................67
HARVONI............................................................................72
HAVRIX............................................................................. 118
HEMADY.............................................................................88
HEMANGEOL..................................................................... 78
HEMLIBRA........................................................................112
HEMOFIL M......................................................................112
HEPARIN SODIUM............................................................ 26
heparin sodium (porcine) inj 1000 unit/ml, 5000 unit/ml,
10000 unit/ml, 20000 unit/ml............................................26
heparin sodium (porcine) pf inj 5000 unit/0.5ml................ 26
HEPLISAV-B..................................................................... 118
HETLIOZ...........................................................................117
HETLIOZ LQ.....................................................................117
HIBERIX............................................................................118
HIPREX...............................................................................21
HORIZANT........................................................................137
HULIO............................................................................... 145
HUMALOG..........................................................................39
HUMALOG JUNIOR KWIKPEN.........................................39
HUMALOG KWIKPEN........................................................39
HUMALOG MIX 50/50....................................................... 39
HUMALOG MIX 75/25....................................................... 39
HUMALOG MIX 50/50 KWIKPEN..................................... 39
HUMALOG MIX 75/25 KWIKPEN..................................... 39
HUMALOG TEMPO PEN...................................................40
HUMATE-P....................................................................... 112
HUMATROPE................................................................... 101
HUMIRA............................................................................ 145
HUMIRA PEDIATRIC CROHNS DISEASE STARTER
PACK...............................................................................146
HUMIRA PEN................................................................... 146
HUMIRA PEN-CD/UC/HS STARTER.............................. 146
HUMIRA PEN-PEDIATRIC UC STARTER KIT............... 146
HUMIRA PEN-PS/UV STARTER.....................................146
HUMULIN 70/30................................................................. 40
HUMULIN 70/30 KWIKPEN...............................................40
HUMULIN N........................................................................40
HUMULIN N KWIKPEN..................................................... 40
HUMULIN R........................................................................40
HUMULIN R U-500 (CONCENTRATED)...........................40
HUMULIN R U-500 KWIKPEN.......................................... 40
HYCAMTIN......................................................................... 60
HYCLODEX........................................................................ 97
hydralazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg........... 80
HYDREA............................................................................. 60
hydrochlorothiazide cap 12.5 mg.......................................82
hydrochlorothiazide tab 12.5 mg, 25 mg, 50 mg...............82
HYDROCODONE/IBUPROFEN........................................ 12
hydrocodone-acetaminophen soln 7.5-325 mg/15ml........ 12
hydrocodone-acetaminophen tab 5-300 mg......................12
hydrocodone-acetaminophen tab 7.5-300 mg, 10-300
mg......................................................................................12
hydrocodone-acetaminophen tab 10-325 mg, 7.5-325 mg
(Norco).............................................................................. 12
hydrocodone-acetaminophen tab 5-325 mg (Norco)........ 12
HYDROCODONE BITARTRATE ER................................... 9
hydrocodone bitartrate tab er 24hr deter 20 mg, 30 mg, 40
mg, 60 mg, 80 mg, 100 mg, 120 mg (Hysingla er)............9
hydrocodone-ibuprofen tab 7.5-200 mg............................ 12
HYDROCORTISONE/ACETIC ACID...............................135
HYDROCORTISONE BUTYRATE.....................................95
hydrocortisone butyrate lotion 0.1% (Locoid)....................96
hydrocortisone butyrate oint 0.1%..................................... 96
HYDROCORTISONE COMPLETE KIT.............................96
hydrocortisone cream 0.5%............................................. 155
hydrocortisone cream 1%, 2.5%........................................96
hydrocortisone enema 100 mg/60ml (Cortenema)............13
hydrocortisone lotion 2.5%................................................ 96
hydrocortisone oint 0.5%................................................. 155
hydrocortisone oint 1%, 2.5%............................................96
hydrocortisone perianal cream 2.5% (Anusol-hc)............. 13
hydrocortisone perianal cream 1% (Proctocort)................13
hydrocortisone tab 5 mg, 10 mg, 20 mg (Cortef).............. 88
hydrocortisone valerate cream 0.2%.................................96
hydrocortisone valerate oint 0.2%..................................... 96
hydrocortisone w/ acetic acid otic soln 1-2%
(Hydrocortisone/aceti).....................................................135
HYDROMORPHONE HCL...................................................9
hydromorphone hcl liqd 1 mg/ml (Dilaudid).........................9
hydromorphone hcl tab er 24hr 8 mg, 12 mg, 16 mg, 32
mg........................................................................................9
hydromorphone hcl tab 2 mg, 4 mg, 8 mg (Dilaudid).......... 9
hydroxychloroquine sulfate tab 100 mg, 300 mg, 400
mg......................................................................................62
2024
Effective Date: July 2024
172
hydroxychloroquine sulfate tab 200 mg (Plaquenil).......... 62
HYDROXYM....................................................................... 96
hydroxyurea cap 500 mg (Hydrea)....................................60
hydroxyzine hcl syrup 10 mg/5ml...................................... 15
hydroxyzine hcl tab 10 mg, 25 mg, 50 mg........................ 15
HYDROXYZINE PAMOATE............................................... 15
hydroxyzine pamoate cap 25 mg, 50 mg (Vistaril)............15
HYFTOR............................................................................. 97
HYLATOPIC PLUS............................................................. 97
hyoscyamine sulfate elixir 0.125 mg/5ml........................ 148
hyoscyamine sulfate sl tab 0.125 mg (Levsin/sl).............148
hyoscyamine sulfate soln 0.125 mg/ml........................... 148
hyoscyamine sulfate tab disint 0.125 mg (Anaspaz).......148
hyoscyamine sulfate tab er 12hr 0.375 mg (Levbid)....... 148
hyoscyamine sulfate tab 0.125 mg (Levsin)....................148
HYRIMOZ......................................................................... 146
HYRIMOZ CROHN'S DISEASE AND ULCERATIVE
COLITIS STARTER PACK............................................. 146
HYRIMOZ PEDIATRIC CROHN'S DISEASE STARTER
PACK...............................................................................146
HYRIMOZ PEDIATRIC CROHNS DISEASE STARTER
PACK...............................................................................146
HYRIMOZ PLAQUE PSORIASIS STARTER PACK........146
HYSINGLA ER..................................................................... 9
HYZAAR..............................................................................75
I
ibandronate sodium tab 150 mg (base equivalent)
(Boniva)........................................................................... 100
IBRANCE............................................................................ 55
IBSRELA...........................................................................107
ibuprofen-famotidine tab 800-26.6 mg (Duexis)..................6
ibuprofen susp 100 mg/5ml................................................. 6
ibuprofen tab 600 mg...........................................................6
ibuprofen tab 400 mg, 800 mg............................................ 6
icatibant acetate subcutaneous soln pref syr 30 mg/3ml
(Firazyr)........................................................................... 114
ICLUSIG..............................................................................55
icosapent ethyl cap 0.5 gm (Vascepa).............................. 49
icosapent ethyl cap 1 gm (Vascepa)................................. 49
IDACIO (2 PEN)............................................................... 146
IDACIO STARTER PACKAGE FOR CROHNS
DISEASE.........................................................................146
IDACIO STARTER PACKAGE FOR PLAQUE
PSORIASIS.....................................................................146
IDACIO (2 SYRINGE)...................................................... 146
IDELVION..........................................................................112
IDHIFA.................................................................................55
IHEEZO.............................................................................131
ILARIS...............................................................................146
ILEVRO............................................................................. 131
ILUMYA............................................................................... 93
imatinib mesylate tab 100 mg (base equivalent)
(Gleevec)...........................................................................55
imatinib mesylate tab 400 mg (base equivalent)
(Gleevec)...........................................................................55
IMBRUVICA........................................................................ 55
imipramine hcl tab 10 mg, 25 mg, 50 mg..........................32
imipramine pamoate cap 75 mg, 100 mg, 125 mg, 150
mg......................................................................................32
imiquimod cream 5% (Aldara)........................................... 97
imiquimod cream 3.75% (Zyclara Pump).......................... 97
IMITREX............................................................................122
IMITREX STATDOSE REFILL......................................... 122
IMITREX STATDOSE SYSTEM.......................................122
IMOVAX RABIES (H.D.C.V.)............................................118
IMURAN............................................................................ 120
IMVEXXY MAINTENANCE PACK................................... 151
IMVEXXY STARTER PACK.............................................152
INBRIJA.............................................................................. 63
INCRELEX........................................................................ 102
INCRUSE ELLIPTA............................................................ 16
indapamide tab 1.25 mg, 2.5 mg.......................................82
INDERAL LA.......................................................................78
INDERAL XL.......................................................................78
indomethacin cap er 75 mg................................................. 6
indomethacin cap 25 mg..................................................... 6
indomethacin cap 50 mg..................................................... 6
indomethacin suppos 50 mg................................................6
indomethacin susp 25 mg/5ml (Indocin)..............................6
INFANRIX......................................................................... 118
INFLECTRA...................................................................... 146
INFLIXIMAB...................................................................... 146
INGREZZA........................................................................137
INLYTA................................................................................ 55
INNOPRAN XL................................................................... 78
INQOVI................................................................................60
INREBIC..............................................................................55
INSPRA...............................................................................80
INSULIN ASPART.............................................................. 40
INSULIN ASPART FLEXPEN............................................ 40
INSULIN ASPART PENFILL.............................................. 40
INSULIN ASPART PROTAMINE/INSULIN ASPART
FLEXPEN..........................................................................40
INSULIN DEGLUDEC........................................................ 40
INSULIN DEGLUDEC FLEXTOUCH.................................40
INSULIN GLARGINE MAX SOLOSTAR............................40
INSULIN GLARGINE SOLOSTAR.....................................40
INSULIN GLARGINE-YFGN.............................................. 40
INSULIN LISPRO............................................................... 40
INSULIN LISPRO JUNIOR KWIKPEN.............................. 40
INSULIN LISPRO KWIKPEN............................................. 40
INSULIN LISPRO PROTAMINE/INSULIN LISPRO
KWIKPEN..........................................................................40
INSULIN PEN NEEDLES - TRUEPLUS..........................154
INSULIN SYRINGES - TRUEPLUS................................ 154
INTELENCE........................................................................70
INTRAROSA..................................................................... 152
INTUNIV................................................................................2
INVEGA...............................................................................64
INVEGA HAFYERA............................................................64
INVEGA SUSTENNA......................................................... 64
2024
Effective Date: July 2024
173
INVEGA TRINZA................................................................ 64
INVELTYS.........................................................................134
INVOKAMET.......................................................................36
INVOKAMET XR................................................................ 37
INVOKANA......................................................................... 44
IOPIDINE.......................................................................... 131
IPOL INACTIVATED IPV..................................................118
ipratropium-albuterol nebu soln 0.5-2.5(3) mg/3ml........... 16
ipratropium bromide inhal soln 0.02%...............................16
ipratropium bromide nasal soln 0.03% (21 mcg/
spray).............................................................................. 129
ipratropium bromide nasal soln 0.06% (42 mcg/
spray).............................................................................. 129
irbesartan-hydrochlorothiazide tab 150-12.5 mg, 300-12.5
mg (Avalide)......................................................................76
irbesartan tab 75 mg, 150 mg, 300 mg (Avapro).............. 77
IRESSA............................................................................... 55
iron combination cap........................................................123
iron-folic acid-vit c-vit b6-vit b12-zinc tab 150-1.25 mg
(Corvite 150)................................................................... 123
ISENTRESS........................................................................70
ISENTRESS HD................................................................. 70
ISONIAZID.......................................................................... 22
isoniazid syrup 50 mg/5ml................................................. 22
isoniazid tab 300 mg..........................................................22
ISORDIL TITRADOSE....................................................... 81
isosorbide dinitrate-hydralazine hcl tab 20-37.5 mg
(Bidil)................................................................................. 83
isosorbide dinitrate tab 10 mg, 20 mg, 30 mg...................81
isosorbide dinitrate tab 5 mg, 40 mg (Isordil titradose)..... 81
ISOSORBIDE MONONITRATE......................................... 81
isosorbide mononitrate tab er 24hr 30 mg, 60 mg, 120
mg......................................................................................81
isotretinoin cap 10 mg, 20 mg, 30 mg, 40 mg...................90
isotretinoin cap 25 mg, 35 mg (Absorica)......................... 90
isradipine cap 2.5 mg, 5 mg.............................................. 79
ISTALOL............................................................................130
ISTURISA......................................................................... 102
itraconazole cap 100 mg (Sporanox)................................ 47
itraconazole oral soln 10 mg/ml (Sporanox)......................47
ivermectin cream 1%......................................................... 97
ivermectin tab 3 mg (Stromectol)...................................... 62
IWILFIN............................................................................... 60
IXCHIQ..............................................................................118
IXIARO.............................................................................. 118
IXINITY..............................................................................112
IYUZEH............................................................................. 131
J
JADENU..............................................................................45
JADENU SPRINKLE.......................................................... 45
JAKAFI................................................................................ 55
JALYN............................................................................... 109
JANUMET........................................................................... 37
JANUMET XR.....................................................................37
JANUVIA............................................................................. 38
JARDIANCE........................................................................44
JAYPIRCA...........................................................................55
JENTADUETO.................................................................... 37
JENTADUETO XR..............................................................37
JESDUVROQ....................................................................115
JIVI.................................................................................... 112
JOENJA............................................................................ 123
JORNAY PM......................................................................... 3
JUBLIA................................................................................ 91
JULUCA.............................................................................. 70
JUXTAPID........................................................................... 49
JYLAMVO........................................................................... 51
JYNARQUE...................................................................... 102
JYNNEOS......................................................................... 118
K
KALBITOR........................................................................ 114
KALETRA............................................................................70
KALYDECO.......................................................................140
KAPSPARGO SPRINKLE.................................................. 78
KATERZIA...........................................................................79
KEPPRA..............................................................................28
KEPPRA XR....................................................................... 28
KERENDIA........................................................................103
KESIMPTA........................................................................ 139
ketoconazole cream 2%.....................................................92
ketoconazole foam 2% (Extina).........................................92
ketoconazole shampoo 2% (Nizoral).................................92
ketoconazole tab 200 mg.................................................. 47
KETOPROFEN ER...............................................................6
ketorolac tromethamine ophth soln 0.5% (Acular).......... 131
ketorolac tromethamine ophth soln 0.4% (Acular ls).......131
ketorolac tromethamine tab 10 mg......................................6
ketotifen fumarate ophth soln 0.035%.............................155
KEVEYIS.............................................................................82
KEVZARA......................................................................... 146
KINERET.......................................................................... 146
KINRIX.............................................................................. 118
KISQALI.............................................................................. 55
KISQALI FEMARA 200 DOSE.......................................... 60
KISQALI FEMARA 400 DOSE.......................................... 60
KISQALI FEMARA 600 DOSE.......................................... 60
KITABIS PAK...................................................................... 20
KLARON............................................................................. 90
KLONOPIN......................................................................... 28
KLOXXADO...................................................................... 142
KOATE.............................................................................. 112
KOATE-DVI.......................................................................112
KOGENATE FS................................................................ 112
KONSYL DAILY FIBER....................................................154
KONVOMEP..................................................................... 148
KORLYM............................................................................. 43
KOSELUGO........................................................................56
KOVALTRY....................................................................... 113
K-PHOS............................................................................ 123
K-PHOS NO 2.................................................................. 108
2024
Effective Date: July 2024
174
KRAZATI............................................................................. 56
KRINTAFEL.........................................................................62
KUVAN.............................................................................. 103
L
labetalol hcl tab 100 mg, 200 mg, 300 mg........................ 78
LAC-HYDRIN FIVE.......................................................... 155
lacosamide oral solution 10 mg/ml (Vimpat)..................... 28
lacosamide tab 50 mg, 100 mg, 150 mg, 200 mg
(Vimpat).............................................................................28
LACRISERT......................................................................131
lactated ringer's for irrigation........................................... 124
lactic acid (ammonium lactate) cream 12%...................... 98
lactic acid (ammonium lactate) lotion 12%........................98
lactulose (encephalopathy) solution 10 gm/15ml............ 107
LAGEVRIO..........................................................................73
LAMICTAL...........................................................................28
LAMICTAL CHEWABLE DISPERSIBLE............................28
LAMICTAL ODT..................................................................28
LAMICTAL STARTER/NOT TAKING
CARBAMAZEPINE........................................................... 29
LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT
TAKING VALPROATE...................................................... 29
LAMICTAL STARTER/TAKING VALPROATE................... 29
LAMICTAL XR.................................................................... 29
lamivudine oral soln 10 mg/ml (Epivir).............................. 70
lamivudine tab 150 mg (Epivir)..........................................70
lamivudine tab 300 mg (Epivir)..........................................70
lamivudine tab 100 mg (hbv) (Epivir hbv)......................... 72
lamivudine-zidovudine tab 150-300 mg (Combivir)...........70
lamotrigine orally disintegrating tab 25 mg, 50 mg, 100
mg, 200 mg (Lamictal odt)...............................................29
lamotrigine tab chewable dispersible 5 mg, 25 mg
(Lamictal chewable dispersible).......................................29
lamotrigine tab disint 25 (14) & 50 mg (14) & 100 mg (7)
kit (Lamictal odt)............................................................... 29
lamotrigine tab disint 21 x 25 mg & 7 x 50 mg titration kit
(Lamictal odt).................................................................... 29
lamotrigine tab disint 42 x 50mg & 14 x 100mg titration kit
(Lamictal odt).................................................................... 29
lamotrigine tab er 24hr 25 mg, 50 mg, 100 mg, 200 mg,
250 mg, 300 mg (Lamictal xr)..........................................29
lamotrigine tab 25 mg, 100 mg, 150 mg, 200 mg
(Lamictal)...........................................................................29
lamotrigine tab 25 mg (42) & 100 mg (7) starter kit
(Lamictal starter/not taking carbamazepine)................... 29
lamotrigine tab 84 x 25 mg & 14 x 100 mg starter
kit (Lamictal starter/taking carbamazepine/not taking
valproate).......................................................................... 29
lamotrigine tab 35 x 25 mg starter kit (Lamictal starter/
taking valproate)............................................................... 29
LAMPIT............................................................................... 21
LANCETS - ONETOUCH AND LIFESCAN
PRODUCTS.................................................................... 153
LANREOTIDE ACETATE................................................. 103
LANSOPRAZOLE/AMOXICILLIN/
CLARITHROMYCIN....................................................... 148
lansoprazole cap delayed release 15 mg, 30 mg
(Prevacid)........................................................................149
lansoprazole tab delayed release orally disintegrating 15
mg, 30 mg (Prevacid solutab)........................................149
lanthanum carbonate chew tab 500 mg (elemental), 750
mg (elemental), 1000 mg (elemental) (Fosrenol).......... 108
LANTUS.............................................................................. 40
LANTUS SOLOSTAR.........................................................40
lapatinib ditosylate tab 250 mg (base equiv) (Tykerb).......56
LASIX.................................................................................. 82
latanoprost ophth soln 0.005% (Xalatan)........................ 131
LATUDA.............................................................................. 67
LEDIPASVIR/SOFOSBUVIR..............................................72
leflunomide tab 10 mg, 20 mg (Arava)................................5
LEMTRADA...................................................................... 139
lenalidomide cap 2.5 mg, 5 mg, 10 mg (Revlimid).......... 124
lenalidomide cap 15 mg, 20 mg, 25 mg (Revlimid).........124
LENVIMA 4 MG DAILY DOSE.......................................... 56
LENVIMA 8 MG DAILY DOSE.......................................... 56
LENVIMA 10 MG DAILY DOSE........................................ 56
LENVIMA 12MG DAILY DOSE..........................................56
LENVIMA 14 MG DAILY DOSE........................................ 56
LENVIMA 18 MG DAILY DOSE........................................ 56
LENVIMA 20 MG DAILY DOSE........................................ 56
LENVIMA 24 MG DAILY DOSE........................................ 56
LEQEMBI.......................................................................... 136
LEQVIO...............................................................................49
LESCOL XL........................................................................ 49
LETAIRIS............................................................................ 84
letrozole tab 2.5 mg (Femara)........................................... 52
leucovorin calcium tab 5 mg, 10 mg, 15 mg, 25 mg......... 60
LEUKINE...........................................................................115
levalbuterol hcl soln nebu conc 1.25 mg/0.5ml (base
equiv).................................................................................17
levalbuterol hcl soln nebu 0.31 mg/3ml (base equiv), 0.63
mg/3ml (base equiv), 1.25 mg/3ml (base equiv)............. 17
LEVALBUTEROL TARTRATE HFA................................... 17
LEVAMLODIPINE............................................................... 80
LEVEMIR............................................................................ 41
LEVEMIR FLEXPEN.......................................................... 41
levetiracetam oral soln 100 mg/ml (Keppra)..................... 29
levetiracetam tab er 24hr 500 mg, 750 mg (Keppra
xr)...................................................................................... 29
levetiracetam tab 250 mg, 500 mg, 750 mg, 1000 mg
(Keppra)............................................................................ 29
LEVOBUNOLOL HCL...................................................... 130
levocarnitine oral soln 1 gm/10ml (10%) (Carnitor).........103
levocarnitine tab 330 mg (Carnitor)................................. 103
levocetirizine dihydrochloride tab 5 mg............................. 47
levofloxacin oral soln 25 mg/ml......................................... 20
levofloxacin tab 250 mg.....................................................20
levofloxacin tab 500 mg, 750 mg (Levaquin).................... 20
levonor-eth est tab 0.15-0.02/0.025/0.03 mg &eth est 0.01
mg (Quartette).................................................................. 86
2024
Effective Date: July 2024
175
levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03
mg......................................................................................86
levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg, 0.15
mg-30 mcg........................................................................86
levonorgestrel-eth estra tab
0.05-30/0.075-40/0.125-30mg-mcg..................................86
levonorgestrel-ethinyl estradiol (continuous) tab 90-20
mcg....................................................................................86
levonorgestrel-ethinyl estradiol-fe tab 0.1 mg-20 mcg (21)
(Balcoltra)..........................................................................86
levonorgestrel tab 1.5 mg.................................................. 87
levonorg-eth est tab 0.1-0.02mg(84) & eth est tab
0.01mg(7) (Loseasonique)............................................... 86
levonorg-eth est tab 0.15-0.03mg(84) & eth est tab
0.01mg(7) (Seasonique)...................................................86
LEVORPHANOL TARTRATE...............................................9
levorphanol tartrate tab 2 mg.............................................. 9
LEVOTHYROXINE SODIUM........................................... 143
levothyroxine sodium tab 25 mcg, 50 mcg, 75 mcg, 88
mcg, 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg,
175 mcg, 200 mcg, 300 mcg (Synthroid)...................... 143
LEVSIN............................................................................. 148
LEVSIN/SL........................................................................149
LEVULAN KERASTICK..................................................... 98
LEXAPRO........................................................................... 34
LEXETTE............................................................................ 96
LIALDA..............................................................................106
LIBRAX............................................................................. 149
LICART............................................................................... 98
LIDOCAINE HCL..............................................................124
LIDOCAINE HCL/HYDROCORTISONE ACETATE.......... 13
lidocaine hcl cream 3%......................................................98
LIDOCAINE HCL-HYDROCORTISONE ACETATE WITH
ALOE.................................................................................13
lidocaine hcl soln 4%......................................................... 98
lidocaine hcl urethral/mucosal gel prefilled syringe
2%..................................................................................... 98
lidocaine hcl viscous soln 2%..........................................124
LIDOCAINE HYDROCHLORIDE....................................... 98
lidocaine-hydrocortisone acetate perianal cream
3-0.5%............................................................................... 14
lidocaine-hydrocortisone acetate rectal cream kit 2-2%,
3-0.5%............................................................................... 14
lidocaine-hydrocortisone acetate rectal gel kit 3-2.5%......14
lidocaine oint 5%................................................................ 98
lidocaine patch 5% (Lidoderm).......................................... 98
lidocaine-prilocaine cream 2.5-2.5%................................. 98
lidocaine-prilocaine cream kit 2.5-2.5%.............................98
LIDODERM......................................................................... 98
LIDOREX............................................................................ 98
LIDOTRAL.......................................................................... 98
LIDOTRAL/MENTHOL....................................................... 98
LIDOTRAN..........................................................................98
LIKMEZ............................................................................... 21
linezolid for susp 100 mg/5ml (Zyvox)...............................21
linezolid tab 600 mg (Zyvox)............................................. 21
LINZESS........................................................................... 107
liothyronine sodium tab 5 mcg, 25 mcg, 50 mcg
(Cytomel).........................................................................143
LIPITOR.............................................................................. 49
LIPOFEN.............................................................................49
LIQREV............................................................................... 84
lisdexamfetamine dimesylate cap 10 mg, 20 mg, 30 mg,
40 mg, 50 mg, 60 mg, 70 mg (Vyvanse)...........................2
lisdexamfetamine dimesylate chew tab 10 mg, 20 mg, 30
mg, 40 mg, 50 mg, 60 mg (Vyvanse)................................2
lisinopril & hydrochlorothiazide tab 10-12.5 mg, 20-12.5
mg, 20-25 mg (Zestoretic)............................................... 74
lisinopril tab 2.5 mg, 5 mg, 30 mg, 40 mg (Zestril)............74
lisinopril tab 10 mg, 20 mg (Prinivil).................................. 74
LITHIUM CARBONATE......................................................67
lithium carbonate cap 300 mg........................................... 67
lithium carbonate cap 150 mg, 600 mg (Lithium
carbonate)......................................................................... 67
lithium carbonate tab er 450 mg........................................67
lithium carbonate tab er 300 mg (Lithobid)....................... 67
lithium carbonate tab 300 mg............................................ 67
lithium oral solution 8 meq/5ml..........................................67
LITHOBID............................................................................67
LITHOSTAT.......................................................................108
LIVALO................................................................................49
LIVTENCITY....................................................................... 73
LOCOID.............................................................................. 96
LOCOID LIPOCREAM....................................................... 96
LODOSYN.......................................................................... 63
LOKELMA......................................................................... 124
LO LOESTRIN FE..............................................................86
LONSURF...........................................................................61
loperamide hcl cap 2 mg................................................... 44
loperamide hcl tab 2 mg.................................................. 152
LOPID................................................................................. 49
lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml)
(Kaletra).............................................................................70
lopinavir-ritonavir tab 100-25 mg (Kaletra)........................ 70
lopinavir-ritonavir tab 200-50 mg (Kaletra)........................ 70
LOPRESSOR......................................................................78
loratadine oral soln 5 mg/5ml.......................................... 153
loratadine tab 10 mg........................................................153
lorazepam conc 2 mg/ml................................................... 14
lorazepam tab 0.5 mg, 1 mg (Ativan)................................14
lorazepam tab 2 mg (Ativan)............................................. 14
LORBRENA........................................................................ 56
LOREEV XR....................................................................... 14
losartan potassium & hydrochlorothiazide tab 50-12.5 mg,
100-12.5 mg, 100-25 mg (Hyzaar).................................. 76
losartan potassium tab 25 mg, 50 mg (Cozaar)................77
losartan potassium tab 100 mg (Cozaar).......................... 77
LOTEMAX.........................................................................134
LOTEMAX SM.................................................................. 134
LOTENSIN.......................................................................... 74
LOTENSIN HCT................................................................. 74
loteprednol etabonate ophth gel 0.5% (Lotemax)........... 134
2024
Effective Date: July 2024
176
loteprednol etabonate ophth susp 0.2% (Alrex).............. 134
loteprednol etabonate ophth susp 0.5% (Lotemax)........ 134
LOTREL.............................................................................. 74
LOTRONEX...................................................................... 107
lovastatin tab 10 mg, 20 mg, 40 mg..................................49
LOVAZA.............................................................................. 49
LOVENOX...........................................................................27
loxapine succinate cap 5 mg, 10 mg, 25 mg, 50 mg.........65
lubiprostone cap 8 mcg, 24 mcg (Amitiza)......................107
LUCEMYRA...................................................................... 142
LULICONAZOLE................................................................ 92
LUMAKRAS........................................................................ 56
LUMIGAN..........................................................................131
LUPKYNIS........................................................................ 120
LUPRON DEPOT (1-MONTH)...........................................61
LUPRON DEPOT (3-MONTH)...........................................61
LUPRON DEPOT (4-MONTH)...........................................61
LUPRON DEPOT (6-MONTH)...........................................61
LUPRON DEPOT-PED (1-MONTH)................................103
LUPRON DEPOT-PED (3-MONTH)................................103
lurasidone hcl tab 20 mg, 40 mg, 60 mg, 120 mg
(Latuda)............................................................................. 67
lurasidone hcl tab 80 mg (Latuda).....................................67
LUZU...................................................................................92
LYBALVI............................................................................ 137
LYDEXA.............................................................................. 98
LYFGENIA.............................................................................5
LYNPARZA..........................................................................56
LYRICA............................................................................... 29
LYRICA CR.......................................................................137
LYSODREN.........................................................................52
LYTGOBI.............................................................................56
LYUMJEV............................................................................41
LYUMJEV KWIKPEN......................................................... 41
LYUMJEV TEMPO PEN.................................................... 41
LYVISPAH......................................................................... 128
M
MACROBID.........................................................................21
MACRODANTIN................................................................. 21
mafenide acetate packet for topical soln 5% (50 gm)
(Sulfamylon)...................................................................... 98
magnesium citrate soln.................................................... 154
magnesium oxide tab 400 mg......................................... 152
magnesium oxide tab 400 mg (240 mg elemental
mg).................................................................................. 154
MALARONE........................................................................62
malathion lotion 0.5% (Ovide)......................................... 100
maraviroc tab 150 mg (Selzentry)..................................... 70
maraviroc tab 300 mg (Selzentry)..................................... 70
MARINOL............................................................................46
MARPLAN...........................................................................33
MATULANE.........................................................................61
MAVENCLAD....................................................................139
MAVYRET........................................................................... 72
MAXALT............................................................................ 122
MAXALT-MLT....................................................................122
MAXIDEX..........................................................................134
MAXITROL........................................................................134
MAYZENT......................................................................... 139
MAYZENT STARTER PACK............................................139
meclizine hcl tab 12.5 mg, 25 mg..................................... 46
MECLIZINE HYDROCHLORIDE....................................... 46
MECLOFENAMATE SODIUM..............................................7
MEDROL.............................................................................88
MEDROL DOSEPAK..........................................................88
medroxyprogesterone acetate im susp 150 mg/ml (Depo-
provera contraceptive)......................................................87
medroxyprogesterone acetate im susp prefilled syr 150
mg/ml (Depo-provera contraceptive)............................... 87
medroxyprogesterone acetate tab 2.5 mg, 5 mg, 10 mg
(Provera)......................................................................... 135
mefenamic acid cap 250 mg............................................... 7
mefloquine hcl tab 250 mg................................................ 62
megestrol acetate susp 40 mg/ml..................................... 52
megestrol acetate susp 625 mg/5ml (Megace es).......... 135
megestrol acetate tab 20 mg, 40 mg................................ 52
MEKINIST........................................................................... 57
MEKTOVI............................................................................ 57
meloxicam cap 5 mg (Vivlodex).......................................... 7
meloxicam cap 10 mg (Vivlodex)........................................ 7
meloxicam tab 7.5 mg (Mobic)............................................ 7
meloxicam tab 15 mg (Mobic)............................................. 7
memantine hcl cap er 24hr 7 mg, 14 mg, 21 mg, 28 mg
(Namenda xr)..................................................................136
memantine hcl oral solution 2 mg/ml...............................136
memantine hcl tab 5 mg, 10 mg (Namenda)...................136
memantine hcl tab 28 x 5 mg & 21 x 10 mg titration pack
(Namenda titration pack)................................................136
MENEST........................................................................... 105
MENOSTAR......................................................................105
MENQUADFI.................................................................... 118
MENVEO.......................................................................... 118
MEPERIDINE HCL...............................................................9
meperidine hcl tab 50 mg.................................................. 10
meprobamate tab 200 mg, 400 mg................................... 15
MEPRON............................................................................ 21
mercaptopurine tab 50 mg.................................................51
mesalamine cap dr 400 mg (Delzicol).............................106
mesalamine cap er 24hr 0.375 gm (Apriso)....................106
mesalamine cap er 500 mg (Pentasa)............................ 106
MESALAMINE DR............................................................106
mesalamine enema 4 gm................................................ 106
mesalamine rectal enema 4 gm & cleanser wipe kit
(Rowasa).........................................................................106
mesalamine suppos 1000 mg (Canasa)......................... 106
mesalamine tab delayed release 1.2 gm (Lialda)........... 106
MESNEX............................................................................. 60
MESTINON......................................................................... 51
MESTINON TIMESPAN..................................................... 51
metaxalone tab 400 mg................................................... 128
metaxalone tab 800 mg (Skelaxin)..................................128
2024
Effective Date: July 2024
177
metformin hcl oral soln 500 mg/5ml (Riomet)................... 43
metformin hcl tab er 24hr 500 mg..................................... 43
metformin hcl tab er 24hr 750 mg..................................... 43
metformin hcl tab er 24hr modified release 500 mg
(Glumetza)........................................................................ 43
metformin hcl tab er 24hr modified release 1000 mg
(Glumetza)........................................................................ 43
metformin hcl tab er 24hr osmotic 500 mg (Fortamet)...... 43
metformin hcl tab er 24hr osmotic 1000 mg
(Fortamet)..........................................................................43
metformin hcl tab 500 mg..................................................43
metformin hcl tab 850 mg..................................................43
metformin hcl tab 1000 mg................................................43
METFORMIN HYDROCHLORIDE.....................................43
METHADONE HCL............................................................ 10
methadone hcl conc 10 mg/ml (Methadose)..................... 10
methadone hcl soln 5 mg/5ml (Methadone hcl)................ 10
methadone hcl soln 10 mg/5ml (Methadone hcl).............. 10
methadone hcl tab for oral susp 40 mg............................ 10
methadone hcl tab 5 mg, 10 mg (Dolophine)....................10
METHADOSE..................................................................... 10
METHADOSE SUGAR-FREE............................................10
methamphetamine hcl tab 5 mg (Desoxyn)........................ 2
methazolamide tab 25 mg, 50 mg.....................................82
methenamine hippurate tab 1 gm (Hiprex)........................21
methenamine-hyoscamine-meth blue-sod phos tab 81.6
mg (Urogesic-blue)........................................................... 21
methenamine-hyosc-meth blue-sod phos-phen sal cap
118 mg, 120 mg............................................................... 21
methenamine mandelate tab 0.5 gm, 1 gm...................... 21
methimazole tab 5 mg, 10 mg (Tapazole).......................143
methocarbamol tab 500 mg.............................................128
methocarbamol tab 750 mg (Robaxin-750).....................128
methotrexate sodium inj 50 mg/2ml (25 mg/ml).................. 5
methotrexate sodium inj pf 50 mg/2ml (25 mg/ml).............. 5
methotrexate sodium tab 2.5 mg (base equiv)..................51
METHOXSALEN.................................................................93
methscopolamine bromide tab 2.5 mg, 5 mg.................. 149
methsuximide cap 300 mg (Celontin)................................30
METHYLDOPA................................................................... 77
methylergonovine maleate tab 0.2 mg............................ 103
METHYLIN............................................................................ 3
methylphenidate hcl cap er 24hr 60 mg (la)........................3
methylphenidate hcl cap er 24hr 10 mg (la), 20 mg (la), 40
mg (la) (Ritalin la)...............................................................3
methylphenidate hcl cap er 24hr 30 mg (la) (Ritalin la).......3
methylphenidate hcl cap er 24hr 10 mg (xr), 15 mg (xr),
20 mg (xr), 30 mg (xr), 40 mg (xr), 50 mg (xr), 60 mg (xr)
(Aptensio xr)....................................................................... 4
methylphenidate hcl cap er 10 mg (cd), 20 mg (cd), 30 mg
(cd), 40 mg (cd), 50 mg (cd), 60 mg (cd).......................... 3
methylphenidate hcl chew tab 10 mg..................................4
methylphenidate hcl chew tab 2.5 mg, 5 mg.......................4
methylphenidate hcl soln 5 mg/5ml (Methylin).................... 4
methylphenidate hcl soln 10 mg/5ml (Methylin).................. 4
methylphenidate hcl tab er 10 mg, 20 mg...........................4
methylphenidate hcl tab er osmotic release (osm) 18 mg,
27 mg, 54 mg (Concerta)...................................................4
methylphenidate hcl tab er osmotic release (osm) 36 mg
(Concerta)........................................................................... 4
methylphenidate hcl tab 5 mg, 10 mg, 20 mg (Ritalin)........4
METHYLPHENIDATE HYDROCHLORIDE ER................... 4
methylphenidate td patch 10 mg/9hr, 15 mg/9hr, 20
mg/9hr, 30 mg/9hr (Daytrana)............................................4
methylprednisolone tab 4 mg, 8 mg, 16 mg, 32 mg
(Medrol)............................................................................. 88
methylprednisolone tab therapy pack 4 mg (21) (Medrol
dosepak)............................................................................88
metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) (base
equiv)...............................................................................107
metoclopramide hcl tab 5 mg (base equivalent), 10 mg
(base equivalent) (Reglan).............................................107
METOCLOPRAMIDE ODT.............................................. 107
metolazone tab 2.5 mg, 5 mg, 10 mg............................... 82
metoprolol & hydrochlorothiazide tab 100-25 mg, 100-50
mg......................................................................................78
metoprolol & hydrochlorothiazide tab 50-25 mg
(Lopressor hct)..................................................................78
metoprolol succinate tab er 24hr 25 mg (tartrate equiv),
50 mg (tartrate equiv), 100 mg (tartrate equiv), 200 mg
(tartrate equiv) (Toprol xl).................................................78
metoprolol tartrate tab 25 mg, 37.5 mg, 75 mg.................78
metoprolol tartrate tab 50 mg, 100 mg (Lopressor)...........78
metronidazole cap 375 mg (Flagyl)................................... 21
metronidazole cream 0.75% (Metrocream)....................... 98
metronidazole gel 0.75%................................................... 98
metronidazole gel 1% (Metrogel).......................................98
metronidazole lotion 0.75% (Metrolotion)..........................98
metronidazole tab 250 mg, 500 mg (Flagyl)..................... 21
metronidazole vaginal gel 0.75%.....................................152
metyrosine cap 250 mg (Demser)..................................... 80
mexiletine hcl cap 150 mg, 200 mg, 250 mg.................... 81
MICARDIS.......................................................................... 77
MICARDIS HCT..................................................................76
MICONAZOLE 3...............................................................152
MICONAZOLE NITRATE/ZINC OXIDE/WHITE
PETROLATUM..................................................................92
miconazole nitrate cream 2%.......................................... 155
midazolam hcl syrup 2 mg/ml (base equivalent)............. 116
midodrine hcl tab 2.5 mg, 5 mg, 10 mg............................ 83
mifepristone tab 300 mg (Korlym)..................................... 43
mifepristone tab 200 mg (Mifeprex).................................103
MIGERGOT...................................................................... 121
MIGLITOL........................................................................... 43
MIGRANAL....................................................................... 121
MINILINK REAL-TIME TRANSMITTER.......................... 110
MINIMED 630G GUARDIAN PRESS STARTER
TRANSMITTER KIT....................................................... 110
MINIPRESS........................................................................ 77
MINIVELLE....................................................................... 105
minocycline hcl cap 75 mg, 100 mg..................................25
minocycline hcl cap 50 mg (Minocin)................................ 25
2024
Effective Date: July 2024
178
minocycline hcl tab er 24hr 45 mg, 90 mg, 135 mg.......... 25
minocycline hcl tab er 24hr 55 mg, 65 mg, 80 mg, 105 mg,
115 mg (Solodyn)............................................................. 25
minocycline hcl tab 50 mg, 75 mg, 100 mg...................... 25
MINOLIRA...........................................................................25
minoxidil tab 2.5 mg, 10 mg.............................................. 80
MIRAPEX ER..................................................................... 63
MIRCERA......................................................................... 115
mirtazapine orally disintegrating tab 15 mg, 30 mg, 45 mg
(Remeron soltab)..............................................................33
mirtazapine tab 7.5 mg, 45 mg..........................................33
mirtazapine tab 15 mg, 30 mg (Remeron)........................ 33
misoprostol tab 100 mcg, 200 mcg (Cytotec)..................149
MITIGARE.........................................................................111
M-M-R II............................................................................118
M-NATAL PLUS................................................................125
modafinil tab 100 mg, 200 mg (Provigil)............................. 4
moexipril hcl tab 7.5 mg, 15 mg........................................ 75
MOLINDONE HYDROCHLORIDE.....................................67
mometasone furoate cream 0.1%..................................... 96
mometasone furoate nasal susp 50 mcg/act
(Nasonex)........................................................................129
mometasone furoate oint 0.1%..........................................96
mometasone furoate solution 0.1% (lotion).......................96
montelukast sodium chew tab 4 mg (base equiv), 5 mg
(base equiv) (Singulair).................................................... 17
montelukast sodium oral granules packet 4 mg (base
equiv) (Singulair).............................................................. 17
montelukast sodium tab 10 mg (base equiv)
(Singulair)..........................................................................17
MORPHINE SULFATE....................................................... 10
MORPHINE SULFATE ER.................................................10
morphine sulfate oral soln 10 mg/5ml............................... 10
morphine sulfate oral soln 100 mg/5ml (20 mg/ml)........... 10
morphine sulfate tab er 15 mg, 30 mg, 60 mg, 100 mg,
200 mg (Ms contin).......................................................... 10
morphine sulfate tab 15 mg (Morphine sulfate).................10
morphine sulfate tab 30 mg (Morphine sulfate).................10
MOTEGRITY.....................................................................107
MOTPOLY XR.................................................................... 30
MOUNJARO....................................................................... 38
MOVANTIK....................................................................... 107
moxifloxacin hcl ophth soln 0.5% (base equiv)
(Vigamox)........................................................................133
moxifloxacin hcl tab 400 mg (base equiv).........................20
MOXIFLOXACIN HYDROCHLORIDE............................. 133
MS CONTIN....................................................................... 10
MULPLETA....................................................................... 115
MULTAQ..............................................................................81
multiple vitamins w/ minerals cap....................................154
multiple vitamins w/ minerals tab (Strovite forte).............125
multiple vitamin tab.......................................................... 154
MULTIVITAMIN INFANT/TODDLER................................ 154
mupirocin calcium cream 2%.............................................91
mupirocin oint 2%...............................................................91
MYAMBUTOL..................................................................... 22
MYCAPSSA...................................................................... 101
MYCOBUTIN...................................................................... 22
mycophenolate mofetil cap 250 mg (Cellcept)................ 120
mycophenolate mofetil for oral susp 200 mg/ml
(Cellcept).........................................................................120
mycophenolate mofetil tab 500 mg (Cellcept).................120
mycophenolate sodium tab dr 180 mg (mycophenolic
acid equiv), 360 mg (mycophenolic acid equiv)
(Myfortic)......................................................................... 120
MYCOZYL HC.................................................................... 92
MYDAYIS.............................................................................. 2
MYDRIACYL..................................................................... 131
MYFEMBREE................................................................... 105
MYFORTIC....................................................................... 121
MYRBETRIQ.....................................................................150
MYSOLINE......................................................................... 30
N
nabumetone tab 500 mg......................................................7
nabumetone tab 750 mg......................................................7
nadolol tab 20 mg, 40 mg, 80 mg (Corgard)..................... 79
NAFTIFINE HCL.................................................................92
naftifine hcl cream 2% (Naftin).......................................... 92
naftifine hcl gel 2% (Naftin)............................................... 92
NAFTIN............................................................................... 92
NALFON................................................................................7
NALMEFENE HYDROCHLORIDE.................................. 142
NALOCET........................................................................... 12
naloxone hcl inj 0.4 mg/ml, 4 mg/10ml............................142
naloxone hcl nasal spray 4 mg/0.1ml (Narcan)...............142
naloxone hcl soln prefilled syringe 2 mg/2ml.................. 142
NALOXONE HYDROCHLORIDE.................................... 142
naltrexone hcl tab 50 mg................................................. 142
NAMENDA TITRATION PAK........................................... 136
NAMENDA XR..................................................................136
NAMZARIC....................................................................... 136
NAPRELAN...........................................................................7
naproxen-esomeprazole magnesium tab dr 375-20 mg,
500-20 mg (Vimovo)...........................................................7
naproxen sodium tab er 24hr 375 mg (base equiv)
(Naprelan)........................................................................... 7
naproxen sodium tab er 24hr 500 mg (base equiv)
(Naprelan)........................................................................... 7
naproxen sodium tab er 24hr 750 mg (base equiv)
(Naprelan)........................................................................... 7
naproxen sodium tab 275 mg..............................................7
naproxen sodium tab 550 mg..............................................7
naproxen susp 125 mg/5ml (Naprosyn).............................. 7
naproxen tab ec 375 mg (Ec-naprosyn)..............................7
naproxen tab ec 500 mg (Ec-naproxen)..............................7
naproxen tab 250 mg...........................................................7
naproxen tab 375 mg...........................................................7
naproxen tab 500 mg...........................................................7
naratriptan hcl tab 1 mg (base equiv), 2.5 mg (base equiv)
(Amerge)......................................................................... 122
NARCAN...........................................................................142
2024
Effective Date: July 2024
179
NARDIL............................................................................... 33
NATACYN......................................................................... 133
NATAL PNV...................................................................... 125
NATAZIA..............................................................................86
nateglinide tab 60 mg (Starlix)...........................................43
nateglinide tab 120 mg (Starlix).........................................43
NATROBA.........................................................................100
NAYZILAM.......................................................................... 30
nebivolol hcl tab 2.5 mg (base equivalent), 5 mg (base
equivalent), 10 mg (base equivalent), 20 mg (base
equivalent) (Bystolic)........................................................ 79
NEBUPENT........................................................................ 21
NEFAZODONE HYDROCHLORIDE................................. 33
NEOMYCIN/POLYMYXIN/GRAMICIDIN......................... 133
NEOMYCIN/POLYMYXIN/HYDROCORTISONE............ 134
neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt
op oin.............................................................................. 133
neomycin-polymyxin-dexamethasone ophth oint 0.1%
(Maxitrol)......................................................................... 134
neomycin-polymyxin-dexamethasone ophth susp 0.1%
(Maxitrol)......................................................................... 134
neomycin-polymyxin-hc otic soln 1%.............................. 135
neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/
ml-1%.............................................................................. 135
neomycin sulfate tab 500 mg............................................ 20
NEORAL........................................................................... 121
NEO-SYNALAR.................................................................. 91
NERLYNX........................................................................... 57
NESTABS..........................................................................125
NESTABS DHA................................................................ 125
NESTABS ONE................................................................ 125
NEULASTA....................................................................... 115
NEULASTA ONPRO KIT................................................. 115
NEUPOGEN..................................................................... 115
NEUPRO.............................................................................63
NEURONTIN.......................................................................30
NEVANAC.........................................................................131
NEVIRAPINE...................................................................... 70
nevirapine tab er 24hr 400 mg (Viramune xr)................... 70
nevirapine tab 200 mg (Viramune).................................... 70
NEXAVAR........................................................................... 57
NEXIUM............................................................................ 149
NEXLETOL......................................................................... 49
NEXLIZET...........................................................................49
NEXTSTELLIS....................................................................86
NGENLA........................................................................... 101
niacin tab er 750 mg (antihyperlipidemic), 1000 mg
(antihyperlipidemic) (Niaspan)......................................... 50
niacin tab er 500 mg (antihyperlipidemic) (Niaspan).........49
nicardipine hcl cap 20 mg, 30 mg..................................... 80
nicotine polacrilex gum 2 mg, 4 mg................................ 140
nicotine polacrilex lozenge 2 mg, 4 mg...........................140
nicotine td patch 24hr 7 mg/24hr, 14 mg/24hr, 21
mg/24hr........................................................................... 140
NICOTINE TRANSDERMAL SYSTEM........................... 140
NICOTROL INHALER...................................................... 140
NICOTROL NS................................................................. 140
nifedipine cap 20 mg..........................................................80
nifedipine cap 10 mg (Procardia)...................................... 80
nifedipine tab er 24hr 30 mg, 60 mg, 90 mg..................... 80
nifedipine tab er 24hr osmotic release 30 mg, 60 mg, 90
mg (Procardia xl).............................................................. 80
nilutamide tab 150 mg (Nilandron).................................... 52
nimodipine cap 30 mg........................................................80
NINLARO............................................................................ 57
NISOLDIPINE ER...............................................................80
nisoldipine tab er 24hr 8.5 mg, 17 mg, 34 mg (Sular)....... 80
nitazoxanide tab 500 mg (Alinia)....................................... 21
nitisinone cap 2 mg, 5 mg, 10 mg, 20 mg (Orfadin)........ 103
NITRO-BID..........................................................................81
NITRO-DUR........................................................................81
NITROFURANTOIN............................................................21
nitrofurantoin macrocrystalline cap 25 mg, 50 mg, 100 mg
(Macrodantin).................................................................... 22
nitrofurantoin monohydrate macrocrystalline cap 100 mg
(Macrobid)......................................................................... 22
nitrofurantoin susp 25 mg/5ml........................................... 22
nitroglycerin sl tab 0.3 mg, 0.4 mg, 0.6 mg (Nitrostat)...... 81
nitroglycerin td patch 24hr 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr,
0.6 mg/hr (Nitro-dur).........................................................81
nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray)
(Nitrolingual pumpspray).................................................. 81
NITROLINGUAL................................................................. 81
NITROSTAT........................................................................ 81
NITRO-TIME....................................................................... 81
NITYR............................................................................... 103
NIVA-PLUS....................................................................... 125
NIVA THYROID................................................................ 143
NIVESTYM........................................................................115
NIZATIDINE...................................................................... 148
NOCDURNA..................................................................... 103
NORDITROPIN FLEXPRO.............................................. 101
norelgestromin-ethinyl estradiol td ptwk 150-35
mcg/24hr........................................................................... 86
norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35
mcg....................................................................................86
norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25
mcg (Generess fe)............................................................86
norethindrone & ethinyl estradiol tab 0.4 mg-35 mcg, 0.5
mg-35 mcg, 1 mg-35 mcg................................................86
norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg
(Loestrin fe 1/20).............................................................. 86
norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30
mcg (Loestrin fe 1.5/30)...................................................86
norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg
(Loestrin 1/20-21)............................................................. 86
norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg
(Loestrin 1.5/30-21).......................................................... 86
norethindrone ace-eth estradiol-fe chew tab 1 mg-20 mcg
(24) (Minastrin 24 fe)........................................................86
norethindrone ace-ethinyl estradiol-fe cap 1 mg-20 mcg
(24) (Taytulla)....................................................................86
2024
Effective Date: July 2024
180
norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg
(24).................................................................................... 86
norethindrone acetate-ethinyl estradiol tab 1 mg-5
mcg..................................................................................105
norethindrone acetate-ethinyl estradiol tab 0.5 mg-2.5
mcg (Femhrt low dose).................................................. 105
norethindrone acetate tab 5 mg (Aygestin)..................... 135
norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-
mcg (Estrostep fe)............................................................ 86
norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-
mcg....................................................................................87
norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-
mcg (Ortho-novum 7/7/7)................................................. 87
norethindrone tab 0.35 mg (Ortho micronor).....................87
NORGESIC FORTE......................................................... 128
norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg....... 87
norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35
mg-mcg............................................................................. 87
norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25
mg-mcg (Ortho tri-cyclen lo)............................................ 87
norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg..............87
NORITATE.......................................................................... 98
NORLIQVA..........................................................................80
NORPACE...........................................................................81
NORPACE CR....................................................................82
NORPRAMIN...................................................................... 33
NORTHERA........................................................................83
nortriptyline hcl cap 10 mg, 25 mg, 50 mg, 75 mg
(Pamelor)...........................................................................33
nortriptyline hcl soln 10 mg/5ml.........................................33
NORVASC...........................................................................80
NORVIR.............................................................................. 70
NOURIANZ......................................................................... 63
NOVOEIGHT.................................................................... 113
NOVOLIN 70/30................................................................. 41
NOVOLIN 70/30 FLEXPEN............................................... 41
NOVOLIN 70/30 FLEXPEN RELION.................................41
NOVOLIN 70/30 RELION.................................................. 41
NOVOLIN N........................................................................41
NOVOLIN N FLEXPEN......................................................41
NOVOLIN N FLEXPEN RELION....................................... 41
NOVOLIN N RELION.........................................................41
NOVOLIN R........................................................................41
NOVOLIN R FLEXPEN......................................................41
NOVOLIN R FLEXPEN RELION....................................... 41
NOVOLIN R RELION.........................................................41
NOVOLOG..........................................................................41
NOVOLOG FLEXPEN........................................................41
NOVOLOG FLEXPEN RELION.........................................41
NOVOLOG MIX 70/30....................................................... 41
NOVOLOG MIX 70/30 PREFILLED FLEXPEN.................41
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
RELION............................................................................. 41
NOVOLOG MIX 70/30 RELION.........................................41
NOVOLOG PENFILL..........................................................41
NOVOLOG RELION...........................................................42
NOVOSEVEN RT.............................................................113
NOXAFIL.............................................................................47
NPLATE............................................................................ 116
NP THYROID 15.............................................................. 143
NP THYROID 30.............................................................. 143
NP THYROID 60.............................................................. 143
NP THYROID 90.............................................................. 143
NP THYROID 120............................................................143
NUBEQA............................................................................. 52
NUCALA..............................................................................18
NUCYNTA........................................................................... 10
NUCYNTA ER.................................................................... 11
NUEDEXTA.......................................................................137
NUPLAZID.......................................................................... 67
NURTEC........................................................................... 122
NUTROPIN AQ NUSPIN 5.............................................. 101
NUTROPIN AQ NUSPIN 10............................................ 101
NUTROPIN AQ NUSPIN 20............................................ 101
NUVAIL............................................................................... 98
NUVARING......................................................................... 87
NUVESSA.........................................................................152
NUVIGIL................................................................................4
NUWIQ..............................................................................113
NUZYRA............................................................................. 25
NYMALIZE.......................................................................... 80
nystatin cream 100000 unit/gm......................................... 92
nystatin oint 100000 unit/gm..............................................92
nystatin susp 100000 unit/ml........................................... 124
nystatin tab 500000 unit.................................................... 47
nystatin topical powder 100000 unit/gm............................ 92
nystatin-triamcinolone cream 100000-0.1 unit/gm-%........92
nystatin-triamcinolone oint 100000-0.1 unit/gm-%............ 92
NYVEPRIA........................................................................116
O
OB COMPLETE............................................................... 125
OB COMPLETE/DHA.......................................................126
OB COMPLETE ONE...................................................... 126
OB COMPLETE PETITE................................................. 126
OB COMPLETE PREMIER............................................. 126
OBIZUR.............................................................................113
OCALIVA...........................................................................107
OCREVUS........................................................................ 139
OCTREOTIDE ACETATE.................................................101
octreotide acetate inj 200 mcg/ml (0.2 mg/ml)................ 101
octreotide acetate inj 1000 mcg/ml (1 mg/ml)................. 101
octreotide acetate inj 50 mcg/ml (0.05 mg/ml), 100 mcg/ml
(0.1 mg/ml) (Sandostatin)...............................................101
octreotide acetate inj 500 mcg/ml (0.5 mg/ml)
(Sandostatin)...................................................................101
OCUFLOX.........................................................................133
ODEFSEY...........................................................................70
ODOMZO............................................................................ 61
OFEV................................................................................ 141
OFLOXACIN....................................................................... 20
ofloxacin ophth soln 0.3% (Ocuflox)................................133
2024
Effective Date: July 2024
181
ofloxacin otic soln 0.3%................................................... 135
ofloxacin tab 400 mg..........................................................20
OJJAARA............................................................................ 57
olanzapine-fluoxetine hcl cap 12-25 mg..........................137
olanzapine-fluoxetine hcl cap 3-25 mg, 6-25 mg, 6-50 mg,
12-50 mg (Symbyax)......................................................137
olanzapine for im inj 10 mg (Zyprexa)...............................65
olanzapine orally disintegrating tab 5 mg, 10 mg, 15 mg,
20 mg (Zyprexa zydis)..................................................... 65
olanzapine tab 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg, 20
mg (Zyprexa).................................................................... 65
olmesartan-amlodipine-hydrochlorothiazide tab 20-5-12.5
mg, 40-5-12.5 mg, 40-5-25 mg, 40-10-12.5 mg, 40-10-25
mg (Tribenzor).................................................................. 76
olmesartan medoxomil-hydrochlorothiazide tab 20-12.5
mg, 40-12.5 mg, 40-25 mg (Benicar hct).........................76
olmesartan medoxomil tab 20 mg, 40 mg (Benicar)......... 77
olmesartan medoxomil tab 5 mg (Benicar)....................... 77
olopatadine hcl nasal soln 0.6% (Patanase)................... 129
olopatadine hcl ophth soln 0.2% (base equivalent).........133
OLPRUVA......................................................................... 103
OLUMIANT....................................................................... 146
omega-3-acid ethyl esters cap 1 gm (Lovaza).................. 50
omega-3 fatty acids cap 500 mg, 1000 mg.....................155
omeprazole cap delayed release 10 mg, 20 mg, 40
mg....................................................................................150
omeprazole-sodium bicarbonate cap 20-1100 mg,
40-1100 mg (Zegerid).....................................................149
omeprazole-sodium bicarbonate powd pack for susp
20-1680 mg, 40-1680 mg (Zegerid)...............................149
OMNARIS......................................................................... 129
OMNIPOD CLASSIC PODS (GEN 3)............................. 110
OMNIPOD DASH INTRO KIT (GEN 4)........................... 110
OMNIPOD DASH PDM KIT (GEN 4).............................. 110
OMNIPOD DASH PODS (GEN 4)...................................111
OMNIPOD 5 G6 INTRO KIT (GEN 5)............................. 111
OMNIPOD 5 G7 INTRO KIT (GEN 5)............................. 111
OMNIPOD GO 10 UNITS/DAY........................................111
OMNIPOD GO 15 UNITS/DAY........................................111
OMNIPOD GO 20 UNITS/DAY........................................111
OMNIPOD GO 25 UNITS/DAY........................................111
OMNIPOD GO 30 UNITS/DAY........................................111
OMNIPOD GO 35 UNITS/DAY........................................111
OMNIPOD GO 40 UNITS/DAY........................................111
OMNIPOD 5 G6 PODS (GEN 5).....................................111
OMNIPOD 5 G7 PODS (GEN 5).....................................111
OMNITROPE.................................................................... 101
OMVOH.............................................................................147
ondansetron hcl oral soln 4 mg/5ml.................................. 46
ondansetron hcl tab 4 mg, 8 mg (Zofran)..........................46
ondansetron orally disintegrating tab 4 mg, 8 mg............. 46
ONETOUCH DELICA PLUS LANCING DEVICE............ 153
ONETOUCH ULTRA........................................................ 153
ONETOUCH ULTRA 2..................................................... 153
ONETOUCH ULTRA CONTROL..................................... 153
ONETOUCH ULTRA CONTROL SOLUTION................. 153
ONETOUCH VERIO FLEX BLOOD GLUCOSE
MONITORING SYSTEM................................................ 153
ONETOUCH VERIO LEVEL 3 CONTROL
SOLUTION......................................................................153
ONETOUCH VERIO LEVEL 4 CONTROL
SOLUTION......................................................................153
ONETOUCH VERIO TEST STRIP.................................. 154
ONEXTON.......................................................................... 90
ONFI....................................................................................30
ONGENTYS........................................................................63
ONGLYZA........................................................................... 38
ONUREG............................................................................ 51
OPSUMIT............................................................................84
OPVEE..............................................................................142
OPZELURA.........................................................................18
ORACIT.............................................................................108
oral electrolyte solution.................................................... 154
ORAVIG............................................................................ 124
ORENCIA..........................................................................147
ORENCIA CLICKJECT.................................................... 147
ORENITRAM...................................................................... 84
ORENITRAM TITRATION KIT MONTH 1......................... 84
ORENITRAM TITRATION KIT MONTH 2......................... 84
ORENITRAM TITRATION KIT MONTH 3......................... 84
ORFADIN.......................................................................... 103
ORGOVYX..........................................................................52
ORIAHNN......................................................................... 106
ORILISSA......................................................................... 103
ORKAMBI......................................................................... 141
ORLADEYO...................................................................... 114
orphenadrine citrate tab er 12hr 100 mg.........................128
orphenadrine w/ aspirin & caffeine tab 25-385-30
mg....................................................................................128
orphenadrine w/ aspirin & caffeine tab 50-770-60 mg
(Norgesic forte)............................................................... 128
ORSERDU.......................................................................... 52
oseltamivir phosphate cap 30 mg (base equiv), 45 mg
(base equiv), 75 mg (base equiv) (Tamiflu).....................73
oseltamivir phosphate for susp 6 mg/ml (base equiv)
(Tamiflu).............................................................................73
OSMOLEX ER....................................................................63
OSPHENA........................................................................ 103
OTEZLA............................................................................ 147
OTREXUP.............................................................................5
OVACE PLUS.....................................................................98
OVAL TAPE...................................................................... 110
oxaprozin tab 600 mg (Daypro)...........................................8
oxazepam cap 30 mg........................................................ 14
oxazepam cap 10 mg, 15 mg............................................14
OXBRYTA............................................................................. 5
oxcarbazepine susp 300 mg/5ml (60 mg/ml)
(Trileptal)........................................................................... 30
oxcarbazepine tab 150 mg, 300 mg, 600 mg
(Trileptal)........................................................................... 30
OXERVATE....................................................................... 131
oxiconazole nitrate cream 1% (Oxistat).............................92
2024
Effective Date: July 2024
182
OXISTAT............................................................................. 92
OXTELLAR XR...................................................................30
OXYBUTYNIN CHLORIDE.............................................. 150
oxybutynin chloride solution 5 mg/5ml............................ 151
oxybutynin chloride tab er 24hr 15 mg............................151
oxybutynin chloride tab er 24hr 5 mg (Ditropan xl)......... 151
oxybutynin chloride tab er 24hr 10 mg (Ditropan xl)....... 151
oxybutynin chloride tab 5 mg...........................................151
oxycodone hcl cap 5 mg....................................................11
oxycodone hcl conc 100 mg/5ml (20 mg/ml).................... 11
OXYCODONE HCL ER..................................................... 11
oxycodone hcl soln 5 mg/5ml............................................ 11
oxycodone hcl tab 10 mg, 20 mg...................................... 11
oxycodone hcl tab 15 mg, 30 mg (Roxicodone)................11
oxycodone hcl tab 5 mg (Roxicodone)..............................11
OXYCODONE HYDROCHLORIDE/
ACETAMINOPHEN...........................................................12
oxycodone w/ acetaminophen tab 2.5-325 mg, 5-325 mg
(Percocet)..........................................................................12
oxycodone w/ acetaminophen tab 7.5-325 mg
(Percocet)..........................................................................12
oxycodone w/ acetaminophen tab 10-325 mg
(Percocet)..........................................................................12
OXYCONTIN.......................................................................11
oxymorphone hcl tab 5 mg................................................ 11
oxymorphone hcl tab 10 mg (Opana)................................11
OXYMORPHONE HYDROCHLORIDE ER....................... 11
OXYTROL.........................................................................151
OZEMPIC............................................................................38
P
paliperidone tab er 24hr 1.5 mg, 3 mg, 9 mg (Invega)...... 64
paliperidone tab er 24hr 6 mg (Invega).............................64
PAMELOR...........................................................................33
PANDEL.............................................................................. 96
pantoprazole sodium ec tab 20 mg (base equiv), 40 mg
(base equiv) (Protonix)...................................................150
pantoprazole sodium for delayed release susp packet 40
mg (Protonix).................................................................. 150
PARADIGM REAL-TIME TRANSMITTER.......................110
paricalcitol cap 4 mcg...................................................... 104
paricalcitol cap 1 mcg, 2 mcg (Zemplar)......................... 104
PARLODEL......................................................................... 63
paroxetine hcl oral susp 10 mg/5ml (base equiv)
(Paxil)................................................................................ 34
paroxetine hcl tab er 24hr 25 mg, 37.5 mg (Paxil cr)........ 34
paroxetine hcl tab er 24hr 12.5 mg (Paxil cr).................... 34
paroxetine hcl tab 10 mg, 20 mg, 40 mg (Paxil)............... 34
paroxetine hcl tab 30 mg (Paxil)........................................34
paroxetine mesylate cap 7.5 mg (base equiv)
(Brisdelle)........................................................................ 137
PAXIL.................................................................................. 34
PAXIL CR............................................................................35
PAXLOVID.......................................................................... 73
pazopanib hcl tab 200 mg (base equiv) (Votrient)............ 57
PEDIA-LAX....................................................................... 154
PEDIARIX......................................................................... 119
pediatric multiple vitamin chew tab..................................154
PEDVAX HIB.................................................................... 119
PEGASYS...........................................................................72
peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm
(Golytely).........................................................................121
peg 3350-kcl-sod bicarb-nacl for soln 420 gm (Nulytely/
flavor pack)..................................................................... 121
PEMAZYRE........................................................................ 57
PENBRAYA....................................................................... 119
penciclovir cream 1% (Denavir).........................................98
penicillamine cap 250 mg (Cuprimine).............................. 45
penicillamine tab 250 mg (Depen titratabs).......................45
PENICILLIN V POTASSIUM.............................................. 25
penicillin v potassium tab 250 mg, 500 mg....................... 25
PENNSAID..........................................................................98
PENTACEL....................................................................... 119
pentamidine isethionate for nebulization soln 300 mg
(Nebupent)........................................................................ 22
PENTASA..........................................................................106
pentazocine w/ naloxone hcl tab 50-0.5 mg......................11
pentoxifylline tab er 400 mg............................................ 114
PEPCID.............................................................................148
PERCOCET........................................................................ 12
PERFOROMIST................................................................. 17
PERINDOPRIL ERBUMINE...............................................75
perindopril erbumine tab 4 mg...........................................75
permethrin cream 5% (Elimite)........................................ 100
permethrin creme rinse 1%............................................. 100
PERPHENAZINE/AMITRIPTYLINE.................................137
perphenazine tab 2 mg, 4 mg, 8 mg, 16 mg..................... 67
PERSERIS..........................................................................64
PERTZYE..........................................................................100
PHEBURANE....................................................................103
phenazopyridine hcl tab 100 mg, 200 mg (Pyridium)......108
PHENELZINE SULFATE.................................................... 33
phenobarbital elixir 20 mg/5ml.........................................117
phenobarbital tab 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60
mg, 64.8 mg, 97.2 mg, 100 mg..................................... 117
phenoxybenzamine hcl cap 10 mg (Dibenzyline)..............81
phenylephrine-guaifenesin tab 10-400 mg...................... 153
phenylephrine hcl ophth soln 2.5%, 10%........................ 131
phenylephrine hcl tab 10 mg........................................... 155
phenytoin chew tab 50 mg (Dilantin infatabs)................... 30
phenytoin sodium extended cap 200 mg, 300 mg
(Phenytek).........................................................................30
phenytoin sodium extended cap 100 mg (Dilantin)........... 30
phenytoin susp 125 mg/5ml (Dilantin-125)........................30
PHEXXI............................................................................. 152
PHOSPHOLINE IODIDE..................................................132
phytonadione tab 5 mg (Mephyton).................................152
PIFELTRO...........................................................................70
pilocarpine hcl ophth soln 1%, 2%, 4% (Isopto
carpine)........................................................................... 132
pilocarpine hcl tab 5 mg, 7.5 mg (Salagen).................... 124
pimecrolimus cream 1% (Elidel)........................................ 98
2024
Effective Date: July 2024
183
PIMOZIDE.........................................................................137
pindolol tab 5 mg, 10 mg...................................................79
pioglitazone hcl-glimepiride tab 30-2 mg, 30-4 mg
(Duetact)............................................................................37
pioglitazone hcl-metformin hcl tab 15-500 mg, 15-850 mg
(Actoplus met)...................................................................37
pioglitazone hcl tab 15 mg (base equiv), 30 mg (base
equiv), 45 mg (base equiv) (Actos)................................. 43
PIQRAY 200MG DAILY DOSE.......................................... 57
PIQRAY 250MG DAILY DOSE.......................................... 57
PIQRAY 300MG DAILY DOSE.......................................... 57
PIRFENIDONE................................................................. 141
pirfenidone cap 267 mg (Esbriet).................................... 141
pirfenidone tab 267 mg (Esbriet)..................................... 141
pirfenidone tab 801 mg (Esbriet)..................................... 141
piroxicam cap 10 mg (Feldene)...........................................8
piroxicam cap 20 mg (Feldene)...........................................8
pitavastatin calcium tab 1 mg, 2 mg (Livalo).....................50
pitavastatin calcium tab 4 mg (Livalo)............................... 50
PLAVIX..............................................................................115
PLEGRIDY........................................................................139
PLEGRIDY STARTER PACK...........................................139
PNEUMOVAX 23..............................................................119
PNEUMOVAX 23/1 DOSE............................................... 119
PNV-DHA..........................................................................126
PNV-DHA+DOCUSATE................................................... 126
PNV-OMEGA....................................................................126
PNV-SELECT................................................................... 126
PODOCON-25.................................................................... 98
PODOFILOX....................................................................... 98
podofilox gel 0.5% (Condylox)...........................................98
polyethylene glycol 3350 oral powder 17 gm/scoop....... 154
polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1%
(Polytrim).........................................................................133
POMALYST.........................................................................61
PONVORY........................................................................ 139
PONVORY 14-DAY STARTER PACK............................. 139
posaconazole susp 40 mg/ml (Noxafil)............................. 47
posaconazole tab delayed release 100 mg (Noxafil)........ 47
pot & sod citrates w/ cit ac soln 550-500-334
mg/5ml.............................................................................108
potassium bicarbonate effer tab 25 meq.........................123
potassium chloride cap er 8 meq, 10 meq...................... 123
potassium chloride microencapsulated crys er tab 10
meq, 20 meq.................................................................. 123
potassium chloride oral soln 10% (20 meq/15ml), 20% (40
meq/15ml)....................................................................... 123
potassium chloride powder packet 20 meq.....................123
potassium chloride tab er 10 meq (K-tab).......................123
potassium citrate & citric acid soln 1100-334 mg/5ml..... 108
potassium citrate tab er 5 meq (540 mg) (Urocit-k 5)......108
potassium citrate tab er 10 meq (1080 mg) (Urocit-k
10)................................................................................... 108
potassium citrate tab er 15 meq (1620 mg) (Urocit-k
15)................................................................................... 108
pot phos monobasic w/sod phos di & monobas tab
155-852-130mg (K-phos neutral)...................................123
PRADAXA...........................................................................26
PRALUENT.........................................................................50
pramipexole dihydrochloride tab er 24hr 0.375 mg, 0.75
mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg (Mirapex
er)...................................................................................... 63
pramipexole dihydrochloride tab 0.25 mg......................... 63
pramipexole dihydrochloride tab 0.125 mg, 0.5 mg, 0.75
mg, 1 mg, 1.5 mg (Mirapex)............................................ 63
prasugrel hcl tab 5 mg (base equiv), 10 mg (base equiv)
(Effient)............................................................................115
pravastatin sodium tab 10 mg........................................... 50
pravastatin sodium tab 80 mg........................................... 50
pravastatin sodium tab 20 mg, 40 mg (Pravachol)............50
praziquantel tab 600 mg (Biltricide)...................................62
prazosin hcl cap 1 mg, 2 mg, 5 mg (Minipress)................ 77
PRED FORTE.................................................................. 134
PRED MILD...................................................................... 134
PREDNISOLONE ACETATE........................................... 134
PREDNISOLONE SODIUM PHOSPHATE......................134
PREDNISOLONE SODIUM PHOSPHATE ODT...............88
prednisolone sodium phosphate oral soln 25 mg/5ml
(base eq)...........................................................................88
prednisolone sod phosphate oral soln 15 mg/5ml (base
equiv).................................................................................88
prednisolone sod phosphate oral soln 10 mg/5ml (base
equiv).................................................................................88
prednisolone sod phosphate oral soln 20 mg/5ml (base
equiv).................................................................................88
prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml
base) (Pediapred).............................................................88
prednisolone soln 15 mg/5ml.............................................88
prednisolone tab 5 mg....................................................... 88
PREDNISONE.................................................................... 88
PREDNISONE INTENSOL................................................ 89
prednisone tab 1 mg, 2.5 mg, 5 mg, 10 mg, 20 mg, 50
mg......................................................................................89
prednisone tab therapy pack 5 mg (21), 5 mg (48), 10 mg
(21), 10 mg (48)............................................................... 89
pregabalin cap 25 mg, 50 mg, 75 mg, 100 mg, 150 mg,
200 mg, 225 mg, 300 mg (Lyrica)................................... 30
pregabalin soln 20 mg/ml (Lyrica)..................................... 30
pregabalin tab er 24hr 82.5 mg, 165 mg (Lyrica cr)........ 137
pregabalin tab er 24hr 330 mg (Lyrica cr).......................137
PREHEVBRIO.................................................................. 119
PREMARIN....................................................................... 106
PREMESISRX.................................................................. 126
PREMPHASE................................................................... 106
PREMPRO........................................................................106
PRENAISSANCE..............................................................126
PRENAISSANCE PLUS...................................................126
PRENATAL PLUS VITAMIN AND MINERAL...................126
PRENATE......................................................................... 126
PRENATE AM.................................................................. 126
PRENATE DHA................................................................ 126
2024
Effective Date: July 2024
184
PRENATE ELITE..............................................................126
PRENATE ENHANCE...................................................... 126
PRENATE ESSENTIAL....................................................126
PRENATE MINI................................................................ 126
PRENATE PIXIE...............................................................126
PRENATE RESTORE...................................................... 126
PRENATRIX......................................................................126
PRENATRYL.....................................................................126
PRESERVISION AREDS 2..............................................154
PRESERVISION AREDS 2 + MULTI VITAMIN...............155
PRETOMANID....................................................................23
PREVACID........................................................................150
PREVACID SOLUTAB......................................................150
PREVNAR 20................................................................... 119
PREVYMIS......................................................................... 73
PREZCOBIX....................................................................... 70
PREZISTA...........................................................................70
PRIFTIN.............................................................................. 23
PRILOSEC........................................................................150
PRIMACARE.....................................................................126
PRIMAQUINE PHOSPHATE............................................. 62
primaquine phosphate tab 26.3 mg (15 mg base)
(Primaquine phosphate)................................................... 62
PRIMIDONE........................................................................30
primidone tab 50 mg, 250 mg (Mysoline)..........................30
PRIORIX........................................................................... 119
PRISTIQ..............................................................................36
PROAIR RESPICLICK....................................................... 17
probenecid tab 500 mg....................................................111
PROCARDIA XL.................................................................80
prochlorperazine maleate tab 5 mg (base equivalent), 10
mg (base equivalent)........................................................67
prochlorperazine suppos 25 mg........................................ 67
PROCRIT..........................................................................116
PROCTOFOAM HC........................................................... 14
PROCYSBI....................................................................... 108
PROFILNINE.................................................................... 113
progesterone cap 100 mg, 200 mg (Prometrium)........... 135
progesterone im in oil 50 mg/ml...................................... 135
PROGLYCEM..................................................................... 43
PROGRAF........................................................................ 121
PROLATE............................................................................13
PROLENSA...................................................................... 132
PROMACTA......................................................................116
promethazine hcl oral soln 6.25 mg/5ml........................... 47
promethazine hcl suppos 12.5 mg, 25 mg........................ 47
promethazine hcl tab 12.5 mg, 25 mg, 50 mg...................47
promethazine w/ codeine syrup 6.25-10 mg/5ml............ 141
PROMETRIUM................................................................. 135
propafenone hcl cap er 12hr 225 mg, 325 mg, 425 mg
(Rythmol sr)...................................................................... 82
propafenone hcl tab 150 mg, 225 mg, 300 mg................. 82
proparacaine hcl ophth soln 0.5% (Alcaine)....................132
PROPEL MINI/STRAIGHT DELIVERY SYSTEM........... 129
PROPRANOLOL HCL........................................................79
propranolol hcl cap er 24hr 60 mg, 80 mg, 120 mg, 160
mg (Inderal la).................................................................. 79
propranolol hcl oral soln 20 mg/5ml.................................. 79
propranolol hcl tab 10 mg, 20 mg, 40 mg, 60 mg, 80
mg......................................................................................79
propylthiouracil tab 50 mg............................................... 143
PROQUAD........................................................................119
PROSCAR........................................................................ 109
PROTONIX....................................................................... 150
protriptyline hcl tab 5 mg, 10 mg.......................................33
PROVENTIL HFA............................................................... 17
PROVERA........................................................................ 135
PROVIGIL............................................................................. 4
PROZAC............................................................................. 35
PRUDOXIN......................................................................... 98
psyllium powder 28.3%, 43%.......................................... 154
PULMICORT.......................................................................19
PULMICORT FLEXHALER................................................ 19
PULMOZYME................................................................... 141
PURIXAN............................................................................ 51
PYLERA............................................................................ 149
pyrazinamide tab 500 mg.................................................. 23
pyrethrins-piperonyl butoxide shampoo 0.33-4%............100
PYRIDIUM........................................................................ 108
PYRIDOSTIGMINE BROMIDE.......................................... 51
pyridostigmine bromide oral soln 60 mg/5ml
(Mestinon)......................................................................... 51
pyridostigmine bromide tab er 180 mg (Mestinon
timespan)...........................................................................51
pyridostigmine bromide tab 60 mg (Mestinon).................. 51
pyridoxine hcl tab 25 mg, 50 mg, 100 mg.......................155
pyrimethamine tab 25 mg (Daraprim)................................62
Q
QBRELIS.............................................................................75
QELBREE............................................................................. 2
QINLOCK............................................................................ 57
QNASL.............................................................................. 129
QNASL CHILDRENS....................................................... 129
QTERN................................................................................37
QUADRACEL....................................................................119
QUALAQUIN.......................................................................62
QUAZEPAM...................................................................... 116
QUDEXY XR...................................................................... 30
QUESTRAN........................................................................ 50
QUESTRAN LIGHT............................................................50
QUETIAPINE FUMARATE.................................................65
quetiapine fumarate tab er 24hr 50 mg, 300 mg, 400 mg
(Seroquel xr)..................................................................... 66
quetiapine fumarate tab er 24hr 150 mg, 200 mg
(Seroquel xr)..................................................................... 66
quetiapine fumarate tab 25 mg, 50 mg, 100 mg, 200 mg
(Seroquel)......................................................................... 66
quetiapine fumarate tab 300 mg, 400 mg (Seroquel)........66
QUILLICHEW ER................................................................. 4
QUILLIVANT XR...................................................................4
2024
Effective Date: July 2024
185
quinapril hcl tab 5 mg, 10 mg, 20 mg, 40 mg
(Accupril)........................................................................... 75
quinapril-hydrochlorothiazide tab 10-12.5 mg, 20-12.5 mg,
20-25 mg (Accuretic)........................................................74
quinidine gluconate tab er 324 mg.................................... 82
QUINIDINE SULFATE........................................................ 82
quinine sulfate cap 324 mg (Qualaquin)........................... 62
QULIPTA........................................................................... 122
QUTENZA...........................................................................98
QUVIVIQ........................................................................... 117
QVAR REDIHALER............................................................ 20
R
RABAVERT.......................................................................119
rabeprazole sodium ec tab 20 mg (Aciphex).................. 150
RADIAURA......................................................................... 96
RADICAVA ORS...............................................................129
RADICAVA ORS STARTER KIT......................................129
raloxifene hcl tab 60 mg (Evista).....................................103
ramelteon tab 8 mg (Rozerem)....................................... 117
ramipril cap 1.25 mg, 2.5 mg, 5 mg, 10 mg (Altace)......... 75
ranolazine tab er 12hr 500 mg, 1000 mg (Ranexa).......... 81
RAPAFLO..........................................................................109
RAPAMUNE......................................................................121
rasagiline mesylate tab 0.5 mg (base equiv), 1 mg (base
equiv) (Azilect).................................................................. 63
RASUVO............................................................................... 5
RAVICTI............................................................................ 103
RAYALDEE....................................................................... 104
RAYOS................................................................................89
REBIF................................................................................139
REBIF REBIDOSE........................................................... 139
REBIF REBIDOSE TITRATION.......................................140
REBIF TITRATION PACK................................................ 140
REBINYN.......................................................................... 113
REBLOZYL....................................................................... 116
RECOMBINATE................................................................113
RECOMBIVAX HB............................................................119
RECORLEV...................................................................... 103
RECTIV............................................................................... 14
REGLAN........................................................................... 107
RELAFEN DS....................................................................... 8
RELENZA DISKHALER..................................................... 73
RELEUKO.........................................................................116
RELEXXII.............................................................................. 4
RELISTOR........................................................................ 107
RELNATE DHA.................................................................127
RELPAX............................................................................ 122
RELTONE......................................................................... 107
RELYVRIO........................................................................ 129
REMERON..........................................................................33
REMERON SOLTAB.......................................................... 33
REMICADE....................................................................... 147
REMODULIN...................................................................... 84
RENFLEXIS...................................................................... 147
RENVELA......................................................................... 108
repaglinide tab 0.5 mg....................................................... 44
repaglinide tab 1 mg.......................................................... 44
repaglinide tab 2 mg.......................................................... 44
REPATHA............................................................................50
REPATHA PUSHTRONEX SYSTEM................................ 50
REPATHA SURECLICK..................................................... 50
RESTASIS.........................................................................132
RESTASIS MULTIDOSE..................................................132
RESTORIL........................................................................ 116
RETACRIT........................................................................ 116
RETEVMO.......................................................................... 57
RETIN-A..............................................................................90
RETIN-A MICRO................................................................ 90
RETIN-A MICRO PUMP.................................................... 90
RETROVIR......................................................................... 71
REVATIO............................................................................. 84
REVLIMID......................................................................... 124
REXULTI............................................................................. 68
REYATAZ............................................................................ 71
REYVOW.......................................................................... 122
REZLIDHIA......................................................................... 57
REZUROCK......................................................................124
REZVOGLAR KWIKPEN................................................... 42
RHOFADE...........................................................................98
RHOPRESSA................................................................... 132
RIBAVIRIN.......................................................................... 72
ribavirin for inhal soln 6 gm (Virazole)...............................73
RIDAURA.............................................................................. 5
rifabutin cap 150 mg (Mycobutin)...................................... 23
rifampin cap 150 mg, 300 mg (Rifadin).............................23
RILUTEK...........................................................................129
riluzole tab 50 mg (Rilutek)..............................................129
RIMANTADINE HYDROCHLORIDE..................................73
ringer's solution for irrigation............................................124
RINVOQ............................................................................ 147
risedronate sodium tab delayed release 35 mg
(Atelvia)........................................................................... 100
risedronate sodium tab 5 mg, 30 mg (Actonel)............... 100
risedronate sodium tab 35 mg (Actonel)......................... 100
risedronate sodium tab 150 mg (Actonel)....................... 101
RISPERDAL........................................................................64
RISPERDAL CONSTA....................................................... 65
risperidone microspheres for im extended rel susp 12.5
mg, 25 mg, 37.5 mg, 50 mg (Risperdal consta).............. 65
RISPERIDONE ODT.......................................................... 65
risperidone orally disintegrating tab 4 mg......................... 65
risperidone orally disintegrating tab 0.5 mg, 1 mg, 2 mg, 3
mg......................................................................................65
risperidone soln 1 mg/ml (Risperdal).................................65
risperidone tab 0.25 mg.....................................................65
risperidone tab 0.5 mg, 1 mg, 2 mg, 4 mg (Risperdal)......65
risperidone tab 3 mg (Risperdal)....................................... 65
RITALIN.................................................................................4
RITALIN LA...........................................................................5
ritonavir tab 100 mg (Norvir)..............................................71
2024
Effective Date: July 2024
186
rivastigmine tartrate cap 1.5 mg (base equivalent), 3 mg
(base equivalent), 4.5 mg (base equivalent), 6 mg (base
equivalent).......................................................................136
rivastigmine td patch 24hr 4.6 mg/24hr, 9.5 mg/24hr, 13.3
mg/24hr (Exelon)............................................................ 136
RIXUBIS............................................................................113
rizatriptan benzoate oral disintegrating tab 5 mg (base
eq)................................................................................... 122
rizatriptan benzoate oral disintegrating tab 10 mg (base
eq) (Maxalt-mlt).............................................................. 122
rizatriptan benzoate tab 5 mg (base equivalent)............. 122
rizatriptan benzoate tab 10 mg (base equivalent)
(Maxalt)........................................................................... 122
ROBINUL.......................................................................... 149
ROBINUL FORTE............................................................ 149
ROCALTROL.................................................................... 104
ROCKLATAN.................................................................... 132
roflumilast tab 250 mcg (Daliresp).....................................18
roflumilast tab 500 mcg (Daliresp).....................................18
ROLVEDON...................................................................... 116
ropinirole hydrochloride tab er 24hr 2 mg (base
equivalent), 4 mg (base equivalent), 8 mg (base
equivalent).........................................................................63
ropinirole hydrochloride tab er 24hr 6 mg (base
equivalent), 12 mg (base equivalent) (Requip xl)............63
ropinirole hydrochloride tab 0.25 mg, 0.5 mg, 1 mg, 2 mg,
3 mg, 4 mg, 5 mg............................................................ 63
rosuvastatin calcium tab 5 mg, 10 mg, 20 mg, 40 mg
(Crestor)............................................................................ 50
ROTARIX.......................................................................... 119
ROTATEQ......................................................................... 119
ROWASA.......................................................................... 106
ROXICODONE................................................................... 11
ROXYBOND....................................................................... 11
ROZEREM........................................................................ 117
ROZLYTREK.......................................................................57
RUBRACA.......................................................................... 58
RUCONEST......................................................................114
rufinamide susp 40 mg/ml (Banzel)...................................30
rufinamide tab 200 mg, 400 mg (Banzel)..........................30
RU-HIST D....................................................................... 153
RUKOBIA............................................................................ 71
RYALTRIS......................................................................... 129
RYBELSUS.........................................................................38
RYDAPT..............................................................................58
RYKINDO............................................................................65
RYSTIGGO....................................................................... 124
RYTARY.............................................................................. 63
S
SABRIL............................................................................... 30
SAFYRAL............................................................................87
SAIZEN............................................................................. 101
SALICATE........................................................................... 98
SALICYLIC ACID............................................................... 99
salicylic acid film forming liquid 27.5% (Virasal)................99
salicylic acid foam 6% (Salvax)......................................... 99
salicylic acid gel 6% (Keralyt)............................................99
saline nasal spray 0.65%.................................................155
salsalate tab 500 mg, 750 mg............................................. 8
SALYCIM.............................................................................99
SAMSCA...........................................................................104
SANCUSO.......................................................................... 46
SANDIMMUNE................................................................. 121
SANDOSTATIN.................................................................101
SANDOSTATIN LAR DEPOT.......................................... 101
SAPHRIS............................................................................ 66
sapropterin dihydrochloride powder packet 100 mg, 500
mg (Kuvan)..................................................................... 104
sapropterin dihydrochloride tab 100 mg (Kuvan)............ 104
SAVAYSA............................................................................ 26
SAVELLA.......................................................................... 137
SAVELLA TITRATION PACK...........................................137
saxagliptin hcl tab 2.5 mg (base equiv), 5 mg (base equiv)
(Onglyza)...........................................................................38
saxagliptin-metformin hcl tab er 24hr 5-500 mg, 5-1000
mg (Kombiglyze xr).......................................................... 37
saxagliptin-metformin hcl tab er 24hr 2.5-1000 mg
(Kombiglyze xr).................................................................37
SCEMBLIX..........................................................................58
scopolamine td patch 72hr 1 mg/3days (Transderm-
scop)..................................................................................46
SECUADO.......................................................................... 66
SEGLENTIS........................................................................13
SEGLUROMET...................................................................37
SELECT-OB......................................................................127
SELECT-OB+DHA............................................................127
selegiline hcl cap 5 mg...................................................... 64
selegiline hcl tab 5 mg.......................................................64
selenium sulfide lotion 2.5%.............................................. 99
selenium sulfide shampoo 2.25%......................................99
SELZENTRY.......................................................................71
SEMGLEE...........................................................................42
SE-NATAL 19................................................................... 127
sennosides tab 8.6 mg.................................................... 154
SENSIPAR........................................................................ 104
SEREVENT DISKUS..........................................................17
SEROQUEL........................................................................ 66
SEROQUEL XR..................................................................66
SEROSTIM....................................................................... 101
sertraline hcl oral concentrate for solution 20 mg/ml
(Zoloft)............................................................................... 35
sertraline hcl tab 25 mg (Zoloft)........................................ 35
sertraline hcl tab 50 mg (Zoloft)........................................ 35
sertraline hcl tab 100 mg (Zoloft)...................................... 35
SERTRALINE HYDROCHLORIDE....................................35
sevelamer carbonate packet 0.8 gm, 2.4 gm
(Renvela).........................................................................108
sevelamer carbonate tab 800 mg (Renvela)................... 108
sevelamer hcl tab 400 mg............................................... 108
sevelamer hcl tab 800 mg (Renagel).............................. 108
SEVENFACT.....................................................................113
2024
Effective Date: July 2024
187
SFROWASA..................................................................... 106
SHINGRIX.........................................................................119
SIGNIFOR.........................................................................104
SIGNIFOR LAR................................................................ 104
SIKLOS................................................................................. 5
sildenafil citrate for suspension 10 mg/ml (Revatio)..........84
sildenafil citrate iv soln 10 mg/12.5ml (base equivalent)
(Revatio)............................................................................84
sildenafil citrate tab 20 mg (Revatio).................................84
SILIQ................................................................................... 93
silodosin cap 4 mg, 8 mg (Rapaflo)................................ 109
SILVADENE........................................................................ 99
SILVER NITRATE...............................................................99
silver sulfadiazine cream 1% (Silvadene)......................... 99
SIMBRINZA...................................................................... 132
simethicone chew tab 80 mg...........................................153
simethicone susp 40 mg/0.6ml........................................ 153
SIMPONI...........................................................................147
SIMPONI ARIA................................................................. 147
simvastatin tab 5 mg..........................................................50
simvastatin tab 10 mg, 20 mg, 40 mg, 80 mg (Zocor).......50
SINEMET............................................................................ 64
SINGULAIR.........................................................................17
SINUVA............................................................................. 129
sirolimus oral soln 1 mg/ml (Rapamune).........................121
sirolimus tab 0.5 mg, 1 mg, 2 mg (Rapamune)...............121
SIRTURO............................................................................ 23
SITAVIG...............................................................................73
SIVEXTRO..........................................................................22
SKYRIZI.............................................................................. 93
SKYRIZI PEN..................................................................... 93
SKYTROFA.......................................................................101
SLYND.................................................................................87
sodium bicarbonate tab 325 mg, 650 mg........................152
sodium chloride irrigation soln 0.9%................................108
sodium chloride soln nebu 0.9%, 3%, 10%.....................141
sodium chloride soln nebu 7% (Hyper-sal)..................... 142
sodium citrate & citric acid soln 500-334 mg/5ml............108
sodium fluoride chew tab 0.25 mg f (from 0.55 mg naf),
0.5 mg f (from 1.1 mg naf), 1 mg f (from 2.2 mg
naf).................................................................................. 123
sodium fluoride cream 1.1% (Prevident 5000 plus)........ 124
sodium fluoride gel 1.1% (0.5% f) (Prevident
fluoride)........................................................................... 125
sodium fluoride paste 1.1% (Prevident 5000 boost)....... 125
sodium fluoride soln 0.5 mg/ml f (from 1.1 mg/ml
naf).................................................................................. 123
SODIUM OXYBATE......................................................... 137
sodium phenylbutyrate oral powder 3 gm/teaspoonful
(Buphenyl).......................................................................104
sodium phenylbutyrate tab 500 mg (Buphenyl)...............104
sodium polystyrene sulfonate powder............................. 124
SOFOSBUVIR/VELPATASVIR...........................................72
SOGROYA........................................................................ 102
SOHONOS........................................................................128
solifenacin succinate tab 5 mg, 10 mg (Vesicare)...........151
SOLIQUA 100/33............................................................... 37
SOLIRIS............................................................................ 114
SOLODYN.......................................................................... 25
SOLOSEC...........................................................................22
SOLTAMOX.........................................................................52
SOMA................................................................................128
SOMATULINE DEPOT.....................................................104
sorafenib tosylate tab 200 mg (base equivalent)
(Nexavar)...........................................................................58
SORILUX............................................................................ 93
sotalol hcl (afib/afl) tab 80 mg, 120 mg, 160 mg (Betapace
af)...................................................................................... 79
sotalol hcl tab 240 mg....................................................... 79
sotalol hcl tab 80 mg, 120 mg, 160 mg (Betapace).......... 79
SOTYKTU........................................................................... 93
SOTYLIZE...........................................................................79
SOVALDI.............................................................................72
SPIKEVAX COVID-19 VACCINE /2023-24..................... 119
SPINOSAD....................................................................... 100
SPIRIVA HANDIHALER..................................................... 16
SPIRIVA RESPIMAT.......................................................... 16
spironolactone & hydrochlorothiazide tab 25-25 mg
(Aldactazide)..................................................................... 82
spironolactone susp 25 mg/5ml (Carospir)....................... 82
spironolactone tab 25 mg, 50 mg, 100 mg
(Aldactone)........................................................................82
SPORANOX........................................................................47
SPRAVATO 56MG DOSE.................................................. 33
SPRAVATO 84MG DOSE.................................................. 33
SPRITAM............................................................................ 31
SPRYCEL........................................................................... 58
SPS................................................................................... 124
SSS 10-5............................................................................ 90
STALEVO 150.................................................................... 64
STEGLATRO...................................................................... 44
STEGLUJAN.......................................................................37
STELARA............................................................................93
STIMUFEND..................................................................... 116
STIOLTO RESPIMAT......................................................... 16
STIVARGA.......................................................................... 58
STRATTERA.........................................................................2
STRENSIQ........................................................................104
STRIBILD............................................................................ 71
STRIVERDI RESPIMAT..................................................... 17
STROMECTOL...................................................................62
SUBLOCADE......................................................................11
SUBOXONE......................................................................142
sucralfate susp 1 gm/10ml (Carafate)............................. 149
sucralfate tab 1 gm (Carafate).........................................149
SULAR................................................................................ 80
SULFACETAMIDE SODIUM............................................ 133
SULFACETAMIDE SODIUM/PREDNISOLONE SODIUM
PHOSPHATE.................................................................. 134
sulfacetamide sodium cleansing gel 10% (Ovace plus
wash).................................................................................99
sulfacetamide sodium liquid 10% (Ovace wash)...............99
2024
Effective Date: July 2024
188
sulfacetamide sodium lotion 10% (acne) (Klaron).............90
sulfacetamide sodium ophth soln 10% (Bleph-10)..........133
sulfacetamide sodium w/ sulfur cleanser 10-5%............... 90
sulfacetamide sodium w/ sulfur cleanser 10-2% (Avar ls
cleanser)............................................................................90
sulfacetamide sodium w/ sulfur cleanser 9.8-4.8%
(Plexion cleanser).............................................................90
sulfacetamide sodium w/ sulfur cleanser 9-4.5%
(Sumadan wash).............................................................. 90
sulfacetamide sodium w/ sulfur cleanser 9-4% (Sumaxin
wash).................................................................................90
sulfacetamide sodium w/ sulfur cream 10-5%...................90
sulfacetamide sodium w/ sulfur cream 10-2% (Avar-e
ls).......................................................................................90
sulfacetamide sodium w/ sulfur emulsion 10-1%.............. 90
sulfacetamide sodium w/ sulfur susp 8-4%....................... 91
sulfacetamide sodium w/ sulfur susp 10-5%..................... 91
SULFADIAZINE.................................................................. 22
sulfamethoxazole-trimethoprim susp 200-40 mg/5ml....... 22
sulfamethoxazole-trimethoprim tab 400-80 mg
(Bactrim)............................................................................22
sulfamethoxazole-trimethoprim tab 800-160 mg (Bactrim
ds)......................................................................................22
SULFAMYLON....................................................................99
sulfasalazine tab delayed release 500 mg (Azulfidine en-
tabs)................................................................................ 106
sulfasalazine tab 500 mg (Azulfidine)..............................106
sulindac tab 150 mg, 200 mg.............................................. 8
SUMADAN KIT................................................................... 91
SUMADAN WASH..............................................................91
sumatriptan-naproxen sodium tab 85-500 mg
(Treximet)........................................................................ 121
sumatriptan nasal spray 5 mg/act, 20 mg/act
(Imitrex)........................................................................... 122
sumatriptan succinate inj 6 mg/0.5ml (Imitrex)................122
SUMATRIPTAN SUCCINATE REFILL.............................122
sumatriptan succinate solution auto-injector 4 mg/0.5ml, 6
mg/0.5ml (Imitrex statdose system)...............................123
sumatriptan succinate tab 25 mg, 50 mg, 100 mg
(Imitrex)........................................................................... 123
SUMAXIN............................................................................91
SUMAXIN CP KIT.............................................................. 91
sunitinib malate cap 25 mg (base equivalent), 37.5 mg
(base equivalent), 50 mg (base equivalent) (Sutent)...... 58
sunitinib malate cap 12.5 mg (base equivalent)
(Sutent)..............................................................................58
SUNLENCA........................................................................ 71
SUNOSI................................................................................ 2
SUTENT..............................................................................58
SYMBICORT.......................................................................16
SYMBYAX.........................................................................137
SYMDEKO........................................................................ 141
SYMFI................................................................................. 71
SYMFI LO...........................................................................71
SYMLINPEN 60..................................................................44
SYMLINPEN 120................................................................44
SYMPAZAN.........................................................................31
SYMPROIC.......................................................................107
SYMTUZA...........................................................................71
SYNAGIS.......................................................................... 119
SYNALAR........................................................................... 96
SYNAREL......................................................................... 104
SYNJARDY.........................................................................37
SYNJARDY XR.................................................................. 37
SYNTHROID.....................................................................143
SYPRINE............................................................................ 45
T
TABRECTA......................................................................... 58
TACLONEX.........................................................................96
tacrolimus cap 0.5 mg, 1 mg, 5 mg (Prograf)..................121
tacrolimus oint 0.03%, 0.1% (Protopic)............................. 99
tadalafil tab 5 mg (Cialis)...................................................83
tadalafil tab 20 mg (pah) (Adcirca).................................... 84
TADLIQ............................................................................... 84
TAFINLAR........................................................................... 58
tafluprost preservative free (pf) ophth soln 0.0015%
(Zioptan)..........................................................................132
TAGRISSO..........................................................................58
TAKHZYRO.......................................................................114
TALICIA.............................................................................149
TALTZ..................................................................................93
TALZENNA..........................................................................58
TAMIFLU............................................................................. 73
tamoxifen citrate tab 10 mg (base equivalent), 20 mg
(base equivalent).............................................................. 52
tamsulosin hcl cap 0.4 mg (Flomax)............................... 109
taperdex 6-day....................................................................89
TAPERDEX 7-DAY............................................................. 89
TAPERDEX 12-DAY........................................................... 89
TARCEVA............................................................................58
TARGRETIN....................................................................... 61
TARON-C DHA.................................................................127
TARPEYO........................................................................... 89
TASCENSO ODT............................................................. 140
TASIGNA.............................................................................59
tasimelteon capsule 20 mg (Hetlioz)............................... 117
TASMAR............................................................................. 64
tavaborole soln 5% (Kerydin)............................................ 92
TAVALISSE....................................................................... 114
TAVNEOS......................................................................... 114
TAYTULLA.......................................................................... 87
TAZAROTENE.................................................................... 91
tazarotene cream 0.1% (Tazorac)..................................... 93
tazarotene gel 0.05%, 0.1% (Tazorac).............................. 93
TAZVERIK...........................................................................59
TDVAX.............................................................................. 119
TECFIDERA......................................................................140
TECFIDERA STARTER PACK........................................ 140
TEGLUTIK........................................................................ 129
TEGRETOL.........................................................................31
TEGRETOL-XR.................................................................. 31
2024
Effective Date: July 2024
189
TEGSEDI.......................................................................... 137
TEKTURNA.........................................................................81
TELMISARTAN/AMLODIPINE........................................... 76
telmisartan-hydrochlorothiazide tab 40-12.5 mg, 80-25 mg
(Micardis hct).................................................................... 76
telmisartan-hydrochlorothiazide tab 80-12.5 mg (Micardis
hct).....................................................................................76
telmisartan tab 20 mg, 40 mg, 80 mg (Micardis)...............77
temazepam cap 7.5 mg, 15 mg, 22.5 mg, 30 mg
(Restoril)..........................................................................117
temozolomide cap 5 mg, 20 mg, 100 mg, 140 mg, 180
mg, 250 mg (Temodar).................................................... 51
TENIVAC...........................................................................119
tenofovir disoproxil fumarate tab 300 mg (Viread)............ 71
TENORETIC 50..................................................................78
TENORETIC 100................................................................78
TENORMIN.........................................................................79
TEPMETKO........................................................................ 59
terazosin hcl cap 10 mg (base equivalent)....................... 77
terazosin hcl cap 1 mg (base equivalent), 2 mg (base
equivalent), 5 mg (base equivalent)................................ 77
terbinafine hcl tab 250 mg................................................. 47
terbutaline sulfate tab 2.5 mg, 5 mg..................................17
terconazole vaginal cream 0.4%, 0.8%...........................152
terconazole vaginal suppos 80 mg..................................152
teriflunomide tab 7 mg, 14 mg (Aubagio)........................ 140
testosterone cypionate im inj in oil 100 mg/ml, 200 mg/ml
(Depo-testosterone)........................................................121
TESTOSTERONE ENANTHATE..................................... 121
tetrabenazine tab 12.5 mg (Xenazine)............................ 137
tetrabenazine tab 25 mg (Xenazine)............................... 137
tetracaine hcl ophth soln 0.5%........................................ 132
tetracycline hcl cap 250 mg, 500 mg................................ 25
tetrahydroz-dextran-peg-povidone ophth soln
0.05-0.1-1-1%................................................................. 155
TEXACORT.........................................................................96
TEZSPIRE...........................................................................19
THALITONE........................................................................82
THALOMID....................................................................... 124
THEO-24............................................................................. 18
theophylline elixir 80 mg/15ml........................................... 18
THEOPHYLLINE ER.......................................................... 18
theophylline soln 80 mg/15ml............................................ 18
theophylline tab er 12hr 300 mg, 450 mg......................... 18
theophylline tab er 24hr 400 mg, 600 mg......................... 18
THIOLA............................................................................. 108
THIOLA EC.......................................................................108
thioridazine hcl tab 10 mg, 25 mg, 50 mg, 100 mg........... 67
thiothixene cap 1 mg, 2 mg, 5 mg, 10 mg.........................67
THRIVITE RX................................................................... 127
THYQUIDITY.................................................................... 143
THYROID..........................................................................143
tiagabine hcl tab 2 mg, 4 mg, 12 mg, 16 mg (Gabitril)...... 31
TIAZAC............................................................................... 80
TIBSOVO............................................................................ 59
TICOVAC.......................................................................... 119
TIKOSYN............................................................................ 82
timolol maleate ophth gel forming soln 0.25%, 0.5%
(Timoptic-xe)................................................................... 130
timolol maleate ophth soln 0.25%, 0.5% (Timoptic)........ 130
timolol maleate ophth soln 0.5% (once-daily)
(Istalol).............................................................................130
timolol maleate preservative free ophth soln 0.25%, 0.5%
(Timoptic ocudose)......................................................... 130
timolol maleate tab 5 mg, 10 mg, 20 mg...........................79
TIMOPTIC OCUDOSE..................................................... 130
tinidazole tab 250 mg, 500 mg.......................................... 22
tiopronin tab 100 mg (Thiola).......................................... 108
tiotropium bromide monohydrate inhal cap 18 mcg (base
equiv) (Spiriva handihaler)............................................... 16
TIROSINT......................................................................... 143
TIROSINT-SOL.................................................................143
TIVICAY.............................................................................. 71
TIVICAY PD........................................................................ 71
tizanidine hcl cap 2 mg (base equivalent), 4 mg (base
equivalent), 6 mg (base equivalent) (Zanaflex)............. 128
tizanidine hcl tab 2 mg (base equivalent)........................128
tizanidine hcl tab 4 mg (base equivalent) (Zanaflex).......128
TOBI.................................................................................... 20
TOBI PODHALER.............................................................. 20
TOBRADEX...................................................................... 134
TOBRADEX ST................................................................ 134
TOBRAMYCIN....................................................................20
tobramycin-dexamethasone ophth susp 0.3-0.1%
(Tobradex)....................................................................... 134
tobramycin nebu soln 300 mg/4ml (Bethkis)..................... 20
tobramycin nebu soln 300 mg/5ml (Tobi).......................... 20
tobramycin ophth soln 0.3% (Tobrex)..............................133
TOBREX........................................................................... 133
tolcapone tab 100 mg (Tasmar)........................................ 64
TOLMETIN SODIUM............................................................8
tolnaftate soln 1%............................................................ 155
TOLSURA........................................................................... 47
tolterodine tartrate cap er 24hr 2 mg, 4 mg (Detrol
la).....................................................................................151
tolterodine tartrate tab 1 mg, 2 mg (Detrol).....................151
tolvaptan tab 15 mg (Samsca)........................................ 104
tolvaptan tab 30 mg (Samsca)........................................ 104
TOPAMAX...........................................................................31
TOPAMAX SPRINKLE....................................................... 31
TOPICORT..........................................................................96
topiramate cap er 24hr 25 mg, 50 mg, 100 mg (Trokendi
xr)...................................................................................... 31
topiramate cap er 24hr 200 mg (Trokendi xr)....................31
topiramate cap er 24hr sprinkle 25 mg, 50 mg, 100 mg,
150 mg (Qudexy xr)......................................................... 31
topiramate cap er 24hr sprinkle 200 mg (Qudexy xr)........31
topiramate sprinkle cap 15 mg, 25 mg (Topamax
sprinkle).............................................................................31
topiramate tab 25 mg, 50 mg, 100 mg, 200 mg
(Topamax)......................................................................... 31
TOPROL XL........................................................................79
2024
Effective Date: July 2024
190
toremifene citrate tab 60 mg (base equivalent)
(Fareston)..........................................................................52
torsemide tab 5 mg, 10 mg, 20 mg, 100 mg..................... 82
TOSYMRA........................................................................ 123
TOUJEO MAX SOLOSTAR............................................... 42
TOUJEO SOLOSTAR........................................................ 42
TOVIAZ............................................................................. 151
TRACLEER.........................................................................85
TRADJENTA....................................................................... 38
tramadol-acetaminophen tab 37.5-325 mg (Ultracet)....... 13
TRAMADOL HCL ER.........................................................11
tramadol hcl tab er 24hr 100 mg, 200 mg, 300 mg........... 11
tramadol hcl tab 100 mg....................................................11
tramadol hcl tab 50 mg (Ultram)........................................11
TRAMADOL HYDROCHLORIDE...................................... 12
TRANDOLAPRIL/VERAPAMIL HCL ER........................... 74
trandolapril tab 1 mg, 2 mg, 4 mg..................................... 75
tranexamic acid tab 650 mg (Lysteda)............................ 114
TRANSDERM-SCOP......................................................... 46
tranylcypromine sulfate tab 10 mg (Parnate).................... 33
TRAVATAN Z.................................................................... 132
travoprost ophth soln 0.004% (benzalkonium free) (bak
free) (Travatan z)............................................................132
trazodone hcl tab 50 mg, 100 mg, 150 mg, 300 mg......... 33
TRECATOR.........................................................................23
TRELEGY ELLIPTA........................................................... 16
TREMFYA........................................................................... 93
treprostinil inj soln 20 mg/20ml (1 mg/ml), 50 mg/20ml (2.5
mg/ml), 100 mg/20ml (5 mg/ml), 200 mg/20ml (10 mg/ml)
(Remodulin).......................................................................85
TRESIBA.............................................................................42
TRESIBA FLEXTOUCH..................................................... 42
tretinoin cap 10 mg............................................................ 61
tretinoin cream 0.025%, 0.05%, 0.1% (Retin-a)................91
tretinoin gel 0.01%, 0.025% (Retin-a)............................... 91
tretinoin gel 0.05% (Atralin)............................................... 91
tretinoin microsphere gel 0.04%, 0.1% (Retin-a
micro)................................................................................ 91
tretinoin microsphere gel 0.08% (Retin-a micro pump).....91
TRETTEN......................................................................... 113
TREXALL............................................................................ 51
triamcinolone acetonide aerosol soln 0.147 mg/gm
(Kenalog)...........................................................................96
triamcinolone acetonide cream 0.5%................................ 96
triamcinolone acetonide cream 0.025%, 0.1%..................96
triamcinolone acetonide dental paste 0.1%.................... 125
triamcinolone acetonide lotion 0.025%, 0.1%................... 96
triamcinolone acetonide oint 0.05%.................................. 96
triamcinolone acetonide oint 0.5%.....................................96
triamcinolone acetonide oint 0.025%, 0.1%...................... 96
triamterene & hydrochlorothiazide cap 37.5-25 mg
(Dyazide)........................................................................... 83
triamterene & hydrochlorothiazide tab 37.5-25 mg
(Maxzide-25)..................................................................... 83
triamterene & hydrochlorothiazide tab 75-50 mg
(Maxzide)...........................................................................83
triamterene cap 50 mg, 100 mg (Dyrenium)..................... 83
triazolam tab 0.125 mg.................................................... 117
triazolam tab 0.25 mg (Halcion)...................................... 117
TRIBENZOR....................................................................... 76
TRICARE.......................................................................... 127
TRICOR.............................................................................. 50
trientine hcl cap 250 mg (Syprine).................................... 45
TRIENTINE HYDROCHLORIDE....................................... 45
trifluoperazine hcl tab 1 mg (base equivalent), 2 mg
(base equivalent), 5 mg (base equivalent), 10 mg (base
equivalent).........................................................................67
TRIFLURIDINE................................................................. 133
TRIHEXYPHENIDYL HCL................................................. 64
trihexyphenidyl hcl tab 2 mg, 5 mg................................... 64
TRIJARDY XR.................................................................... 37
TRIKAFTA.........................................................................141
TRILEPTAL......................................................................... 31
TRILIPIX..............................................................................50
trimethobenzamide hcl cap 300 mg (Tigan)......................46
TRIMETHOPRIM................................................................ 22
trimethoprim tab 100 mg....................................................22
trimipramine maleate cap 25 mg, 50 mg, 100 mg.............33
TRINATAL RX 1............................................................... 127
TRINTELLIX........................................................................33
TRISTART DHA................................................................127
TRIUMEQ............................................................................71
TRIUMEQ PD..................................................................... 71
TROGARZO........................................................................71
TROKENDI XR................................................................... 31
tropicamide ophth soln 0.5%........................................... 132
tropicamide ophth soln 1% (Mydriacyl)........................... 132
trospium chloride cap er 24hr 60 mg.............................. 151
trospium chloride tab 20 mg............................................ 151
TRUDHESA...................................................................... 121
TRULANCE.......................................................................107
TRULICITY......................................................................... 38
TRUMENBA......................................................................120
TRUQAP............................................................................. 59
TRUVADA........................................................................... 71
TUDORZA PRESSAIR.......................................................16
TUKYSA..............................................................................59
TURALIO.............................................................................59
TWINRIX...........................................................................120
TWIRLA...............................................................................87
TYBLUME........................................................................... 87
TYBOST..............................................................................71
TYKERB..............................................................................59
TYMLOS........................................................................... 104
TYPHIM VI........................................................................120
TYSABRI...........................................................................140
TYVASO..............................................................................85
TYVASO DPI MAINTENANCE KIT................................... 85
TYVASO DPI TITRATION KIT........................................... 85
TYVASO REFILL................................................................ 85
TYVASO STARTER............................................................85
2024
Effective Date: July 2024
191
U
UBRELVY..........................................................................122
UCERIS...............................................................................14
UDENYCA........................................................................ 116
UDENYCA ONBODY....................................................... 116
ULORIC.............................................................................111
ULTOMIRIS.......................................................................114
ULTRAVATE........................................................................96
UPTRAVI.............................................................................85
UPTRAVI TITRATION PACK............................................. 85
UREA.................................................................................. 99
UREA/SALICYLIC ACID.................................................... 99
urea cream 20%, 39%, 40%..............................................99
urea cream 41% (Utopic)...................................................99
UREA HYDRATING........................................................... 99
urea lotion 40%.................................................................. 99
URIBEL............................................................................... 22
UROCIT-K 5..................................................................... 109
UROCIT-K 10................................................................... 109
UROCIT-K 15................................................................... 109
UROGESIC-BLUE.............................................................. 22
URSO 250........................................................................ 107
ursodiol cap 300 mg (Actigall)......................................... 107
ursodiol tab 250 mg (Urso 250).......................................107
ursodiol tab 500 mg (Urso forte)..................................... 107
URSO FORTE.................................................................. 107
UZEDY................................................................................ 65
V
VAGIFEM.......................................................................... 152
valacyclovir hcl tab 500 mg, 1 gm (Valtrex)...................... 73
VALCHLOR.........................................................................99
VALCYTE............................................................................ 73
valganciclovir hcl for soln 50 mg/ml (base equiv)
(Valcyte)............................................................................ 73
valganciclovir hcl tab 450 mg (base equivalent)
(Valcyte)............................................................................ 73
valproate sodium oral soln 250 mg/5ml (base equiv)........31
valproic acid cap 250 mg...................................................31
VALSARTAN....................................................................... 77
valsartan-hydrochlorothiazide tab 80-12.5 mg, 160-12.5
mg, 160-25 mg, 320-12.5 mg, 320-25 mg (Diovan
hct).....................................................................................76
valsartan tab 40 mg, 80 mg, 160 mg (Diovan)..................77
valsartan tab 320 mg (Diovan).......................................... 77
VALTOCO 5 MG DOSE..................................................... 31
VALTOCO 10 MG DOSE................................................... 31
VALTOCO 15 MG DOSE................................................... 31
VALTOCO 20 MG DOSE................................................... 31
VALTREX............................................................................ 73
VANCOCIN......................................................................... 22
vancomycin hcl cap 250 mg (base equivalent)
(Vancocin)......................................................................... 22
vancomycin hcl cap 125 mg (base equivalent) (Vancocin
hcl).....................................................................................22
vancomycin hcl for oral soln 25 mg/ml (base equivalent)
(Firvanq)............................................................................ 22
vancomycin hcl for oral soln 50 mg/ml (base equivalent)
(Vancomycin hydrochlo)................................................... 22
VANDAZOLE.................................................................... 152
VANFLYTA.......................................................................... 59
VANOS................................................................................96
VAQTA...............................................................................120
varenicline tartrate tab 0.5 mg (base equiv), 1 mg (base
equiv)...............................................................................140
varenicline tartrate tab 11 x 0.5 mg & 42 x 1 mg start
pack.................................................................................140
VARIVAX........................................................................... 120
VASCEPA............................................................................50
VASERETIC........................................................................74
VASOTEC........................................................................... 75
VAXCHORA...................................................................... 120
VAXELIS........................................................................... 120
VAXNEUVANCE............................................................... 120
VELETRI............................................................................. 85
VELIVET............................................................................. 87
VELPHORO...................................................................... 108
VELTASSA........................................................................ 124
VEMLIDY............................................................................ 72
VENCLEXTA.......................................................................61
VENCLEXTA STARTING PACK........................................ 61
VENLAFAXINE BESYLATE ER.........................................36
venlafaxine hcl cap er 24hr 37.5 mg (base equivalent),
150 mg (base equivalent) (Effexor xr)............................. 36
venlafaxine hcl cap er 24hr 75 mg (base equivalent)
(Effexor xr)........................................................................ 36
venlafaxine hcl tab er 24hr 75 mg (base equivalent)........ 36
venlafaxine hcl tab er 24hr 37.5 mg (base equivalent),
150 mg (base equivalent), 225 mg (base equivalent)..... 36
venlafaxine hcl tab 25 mg (base equivalent), 37.5 mg
(base equivalent), 50 mg (base equivalent), 75 mg (base
equivalent), 100 mg (base equivalent)............................ 36
VENTAVIS...........................................................................85
VENTOLIN HFA..................................................................17
VEOPOZ........................................................................... 114
verapamil hcl cap er 24hr 120 mg, 180 mg, 240 mg
(Verelan)............................................................................80
VERAPAMIL HCL ER........................................................ 80
VERAPAMIL HCL SR........................................................ 80
verapamil hcl tab er 120 mg, 180 mg, 240 mg (Calan
sr)...................................................................................... 80
verapamil hcl tab 40 mg, 80 mg, 120 mg..........................80
VERAPAMIL HYDROCHLORIDE ER................................80
VEREGEN.......................................................................... 99
VERELAN........................................................................... 80
VERELAN PM.................................................................... 80
VERKAZIA........................................................................ 132
VERQUVO.......................................................................... 83
VERSACLOZ...................................................................... 66
VERZENIO..........................................................................59
VESICARE........................................................................151
2024
Effective Date: July 2024
192
VESICARE LS.................................................................. 151
VEVYE.............................................................................. 132
VFEND................................................................................ 47
V-GO 20............................................................................111
V-GO 30............................................................................111
V-GO 40............................................................................111
VIBERZI............................................................................ 107
VIBRAMYCIN......................................................................25
VICTOZA.............................................................................38
vigabatrin powd pack 500 mg (Sabril)...............................31
vigabatrin tab 500 mg (Sabril)........................................... 31
VIGAMOX......................................................................... 133
VIIBRYD..............................................................................33
vilazodone hcl tab 10 mg, 20 mg, 40 mg (Viibryd)............33
VIMOVO................................................................................8
VIMPAT............................................................................... 31
VINATE DHA RF.............................................................. 127
VIOKACE.......................................................................... 100
VIRACEPT.......................................................................... 71
VIRAZOLE.......................................................................... 73
VIREAD...............................................................................71
VISTARIL............................................................................ 15
VITAFOL FE+................................................................... 127
VITAFOL GUMMIES........................................................ 127
VITAFOL-NANO............................................................... 127
VITAFOL-OB.....................................................................127
VITAFOL-OB+DHA...........................................................127
VITAFOL-ONE.................................................................. 127
VITAFOL STRIPS.............................................................127
VITAFOL ULTRA.............................................................. 127
VITAMEDMD ONE RX/QUATREFOLIC.......................... 127
VITAMIN A/C/D INFANT/TODDLER................................155
vitamins a & d oint........................................................... 155
VITAPEARL...................................................................... 127
VITRAKVI............................................................................59
VIVELLE-DOT.................................................................. 106
VIVITROL..........................................................................142
VIVJOA............................................................................... 47
VIVOTIF............................................................................ 120
VIZIMPRO...........................................................................59
VONJO................................................................................59
VONVENDI....................................................................... 113
voriconazole for susp 40 mg/ml (Vfend)............................47
voriconazole tab 50 mg, 200 mg (Vfend).......................... 47
VOSEVI...............................................................................73
VOTRIENT..........................................................................59
VRAYLAR............................................................................67
VTAMA................................................................................ 93
VUITY................................................................................132
VUMERITY....................................................................... 140
VUSION.............................................................................. 92
VYEPTI............................................................................. 122
VYJUVEK............................................................................99
VYNDAMAX........................................................................83
VYNDAQEL........................................................................ 83
VYTORIN............................................................................ 50
VYVANSE............................................................................. 2
VYVGART.........................................................................124
VYVGART HYTRULO...................................................... 124
VYZULTA.......................................................................... 132
W
WAINUA............................................................................138
WAKIX...................................................................................3
warfarin sodium tab 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5
mg, 6 mg, 7.5 mg, 10 mg (Coumadin)............................ 25
WELCHOL.......................................................................... 50
WELLBUTRIN SR.............................................................. 33
WELLBUTRIN XL...............................................................33
WESCAP-C DHA............................................................. 127
WESCAP-PN DHA........................................................... 127
WESNATAL DHA COMPLETE........................................ 127
WESNATE DHA............................................................... 128
WESTAB PLUS................................................................ 128
WESTGEL DHA............................................................... 128
WILATE............................................................................. 113
WINLEVI............................................................................. 91
wixela inhub aer powder ba 100-50 mcg/dose, 250-50
mcg/dose, 500-50 mcg/dose (Advair diskus).................. 16
X
XACIATO...........................................................................152
XADAGO.............................................................................64
XALATAN.......................................................................... 132
XALKORI.............................................................................59
XANAX................................................................................ 14
XANAX XR......................................................................... 14
XARELTO............................................................................26
XARELTO STARTER PACK.............................................. 26
XATMEP..............................................................................51
XCOPRI.............................................................................. 32
XDEMVY...........................................................................133
XELJANZ.......................................................................... 147
XELJANZ XR....................................................................147
XELODA..............................................................................51
XELPROS......................................................................... 132
XELSTRYM...........................................................................2
XENAZINE........................................................................ 138
XEPI.................................................................................... 91
XERAC AC......................................................................... 99
XERESE..............................................................................99
XHANCE........................................................................... 129
XIFAXAN............................................................................. 22
XIGDUO XR....................................................................... 38
XIIDRA.............................................................................. 132
XOFLUZA............................................................................73
XOLAIR............................................................................... 19
XOPENEX HFA.................................................................. 17
XOSPATA............................................................................ 60
XPOVIO.............................................................................. 61
XPOVIO 60 MG TWICE WEEKLY.................................... 61
XPOVIO 80 MG TWICE WEEKLY.................................... 61
XTAMPZA ER.....................................................................12
2024
Effective Date: July 2024
193
XTANDI............................................................................... 52
XULTOPHY 100/3.6........................................................... 38
XYLIDERM..........................................................................99
XYNTHA............................................................................113
XYNTHA SOLOFUSE...................................................... 113
XYREM............................................................................. 138
XYWAV..............................................................................138
Y
YASMIN 28......................................................................... 87
YAZ......................................................................................87
YCANTH............................................................................. 99
YF-VAX............................................................................. 120
YONSA................................................................................53
YUFLYMA CD/UC/HS STARTER.................................... 147
YUFLYMA 1-PEN KIT...................................................... 147
YUFLYMA 2-PEN KIT...................................................... 148
YUFLYMA 2-SYRINGE KIT............................................. 148
YUPELRI.............................................................................16
YUSIMRY..........................................................................148
Z
zafirlukast tab 10 mg, 20 mg (Accolate)............................18
zaleplon cap 5 mg, 10 mg............................................... 117
ZANAFLEX....................................................................... 129
ZARONTIN..........................................................................32
ZARXIO.............................................................................116
ZAVZPRET....................................................................... 122
ZEGALOGUE......................................................................44
ZEGERID.......................................................................... 149
ZEJULA...............................................................................60
ZELAPAR............................................................................ 64
ZELBORAF......................................................................... 60
ZEMBRACE SYMTOUCH................................................123
ZEMPLAR......................................................................... 104
ZENPEP............................................................................100
ZEPATIER........................................................................... 73
ZEPOSIA.......................................................................... 140
ZEPOSIA 7-DAY STARTER PACK..................................140
ZEPOSIA STARTER KIT................................................. 140
ZERVIATE.........................................................................133
ZESTORETIC..................................................................... 74
ZESTRIL............................................................................. 75
ZETIA.................................................................................. 51
ZETONNA.........................................................................129
ZIAGEN...............................................................................72
ZIANA..................................................................................91
zidovudine cap 100 mg (Retrovir)..................................... 72
zidovudine syrup 10 mg/ml (Retrovir)................................72
zidovudine tab 300 mg...................................................... 72
ZIEXTENZO......................................................................116
ZILBRYSQ........................................................................ 114
zileuton tab er 12hr 600 mg.............................................. 18
ZIMHI................................................................................ 142
zinc oxide oint 20%..........................................................155
ZIOPTAN...........................................................................132
ziprasidone hcl cap 20 mg, 40 mg, 60 mg, 80 mg
(Geodon)........................................................................... 67
ziprasidone mesylate for inj 20 mg (base equivalent)
(Geodon)........................................................................... 67
ZIRGAN.............................................................................133
ZITHROMAX.......................................................................24
ZITHROMAX TRI-PAK....................................................... 24
ZITHROMAX Z-PAK...........................................................24
ZITUVIO.............................................................................. 38
ZOCOR............................................................................... 51
ZOLINZA............................................................................. 60
zolmitriptan nasal spray 5 mg/spray unit (Zomig)........... 123
zolmitriptan orally disintegrating tab 2.5 mg, 5 mg (Zomig
zmt)..................................................................................123
zolmitriptan tab 2.5 mg, 5 mg (Zomig)............................ 123
ZOLOFT.............................................................................. 35
ZOLPIDEM TARTRATE................................................... 117
zolpidem tartrate tab er 6.25 mg, 12.5 mg (Ambien
cr).................................................................................... 117
zolpidem tartrate tab 5 mg, 10 mg (Ambien)...................117
ZOMACTON..................................................................... 102
ZOMIG.............................................................................. 123
ZONALON...........................................................................99
ZONISADE..........................................................................32
zonisamide cap 50 mg.......................................................32
zonisamide cap 25 mg, 100 mg (Zonegran)..................... 32
ZORTRESS...................................................................... 121
ZORYVE............................................................................. 93
ZOVIRAX............................................................................ 99
ZTALMY.............................................................................. 32
ZTLIDO............................................................................... 99
ZUBSOLV..........................................................................142
ZURZUVAE.........................................................................33
ZYCLARA............................................................................99
ZYCLARA PUMP............................................................... 99
ZYDELIG.............................................................................60
ZYFLO.................................................................................18
ZYKADIA.............................................................................60
ZYLET............................................................................... 134
ZYPITAMAG....................................................................... 51
ZYPREXA........................................................................... 66
ZYPREXA RELPREVV...................................................... 66
ZYPREXA ZYDIS............................................................... 66
ZYTIGA............................................................................... 53
ZYVOX................................................................................ 22
IL_BCCHP_MLI22 Filed 02092022
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This Formulary (Drug List) was updated on 4/1/2022.
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Blue Cross Community
Health Plans
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Department of Healthcare & Family Services
07/01/2024