Plan for your
best health
2023 Aetna Pharmacy Drug Guide
Advanced Control Plan - Aetna: Student Health
Aetna.com
2417506-01-01 (07/23)
Aetna is the brand name used for products and services provided by one or more of the Aetna group of
subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). Aetna Pharmacy
Management refers to an internal business unit of Aetna Health Management, LLC. Aetna Pharmacy
Management administers, but does not offer, insure or otherwise underwrite the prescription drug benefits
portion of your health plan and has no financial responsibility therefor.
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
Table of Contents
INFORMATIONAL SECTION..................................................................................................................4
ANALGESICS - DRUGS TO TREAT PAIN AND INFLAMMATION.................................................14
ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS....................................................................26
ANTINEOPLASTIC AGENTS - DRUGS TO TREAT CANCER.......................................................... 41
CARDIOVASCULAR - DRUGS TO TREAT HEART AND CIRCULATION CONDITIONS...........53
CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT NERVOUS SYSTEM DISORDERS............68
ENDOCRINE AND METABOLIC - DRUGS TO TREAT DIABETES AND REGULATE
HORMONES........................................................................................................................................... 107
GASTROINTESTINAL - DRUGS TO TREAT STOMACH AND INTESTINAL DISORDERS.......149
GENITOURINARY - DRUGS TO TREAT GENITAL AND URINARY TRACT CONDITIONS...157
HEMATOLOGIC - DRUGS TO TREAT BLOOD DISORDERS......................................................... 161
IMMUNOLOGIC AGENTS - DRUGS TO TREAT DISORDERS OF THE IMMUNE SYSTEM.....170
NUTRITIONAL/SUPPLEMENTS - VITAMINS AND SUPPLEMENTS............................................183
OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS................................................................189
OTHER.....................................................................................................................................................195
RESPIRATORY - DRUGS TO TREAT BREATHING DISORDERS................................................. 195
TOPICAL - DRUGS TO TREAT EAR AND SKIN CONDITIONS.....................................................208
TOC-3
How to use this guide
Your guide includes a list of commonly used drugs covered on your pharmacy plan. The amount you pay
depends on the drug your doctor prescribes. It’s either a flat fee or a percentage of the prescriptions price
after you meet your deductible, if applicable. Preferred generic drugs cost less. Preferred brand drugs will
have a higher cost.
Your plan includes
• Brand and generic drugs that are hand-picked for
their quality and effectiveness
• A specialty pharmacy that fills specialty prescriptions
(ones that are injected, infused or taken by mouth) —
and provides services that include personal
support, helpful resources and training, and
free secure home delivery
• A home delivery pharmacy that delivers
maintenance drugs to your home or wherever
you choose (for drugs that are taken regularly to
treat conditions like diabetes or asthma)
What you can expect to pay
With your pharmacy plan, the amount you pay depends
on the drug your doctor prescribes. It’s either a flat fee or
a percentage of the drug’s/medicine’s price.
Each drug is grouped as a generic, a brand or a
specialty drug. The preferred drugs within these
groups will generally save you money compared
to a non-preferred drug. Typically, generic drugs
are less expensive than brands.
Specialty prescription drugs typically include higher-cost
drugs that require special handling, special storage or
monitoring. These types of drugs may include, but are
not limited to, drugs that are injected, infused, inhaled
or taken by mouth.
You’re covered for all types of medicine — some more
expensive, and some less.
Preferred generic: the lowest cost
Preferred brand: a slightly higher cost
Non-preferred brand and generic: a higher cost
Preferred Specialty: lower cost for specialty drugs
Non-preferred Specialty: higher cost for
non-preferred specialty drugs
Your pharmacy plan may not have all the coverage levels
listed above so check your plan documents to see how
much you will pay.
For your exact coverage and cost, and
to learn more about your plan
Visit the website that’s on your member ID card.
Then log in to your account, where you can:
• Find out the coverage* and estimate of cost for
specific drugs
• View your deductibles and plan limits
Order medications
Check your pharmacy order status
• Get a member ID card
• View your claims, Explanation of Benefits and more.
* Check your plan documents for coverage information. Your plan may not cover certain drugs such as infertility,
erectile dysfunction, weight loss and smoking cessation.
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Have more questions about your
pharmacy benefits?
We’re here to help. There are several ways you can
learn more about your benefits:
• Check your Plan Design and Benefits Summary in
your enrollment kit.
• Call the toll-free number on your member ID card.
• Review our pharmacy frequently asked questions
(FAQs) and answers. Just visit the website that’s on
your member ID card to search for the “Pharmacy FAQ.
Specialty Pharmacy Network
An in-network specialty pharmacy can fill your
prescriptions for specialty drugs. These are the types
of drugs that may be injected, infused or taken by mouth.
They often need special storage and handling. And they
need to be delivered quickly. A nurse or pharmacist may
monitor you during your treatment,
if needed. With this type of pharmacy, you can get
this medicine sent right to your home.
How to get started with a specialty pharmacy
Ordering your prescriptions through our specialty
pharmacy is easy. And we typically offer a 30-day
medicine supply.
To transfer your prescription, just call us toll-free
at 1-866-353-1892.
For a new prescription, your doctor can send it to
us in one of four ways:
1. Electronically: Through e-prescribe
2. Fax: 1-800-323-2445
3. Phone: 1-800-237-2767
If you mail in your own prescription, please send it
with a completed Patient Profile Form. To find this form,
just visit the website that’s on your member ID card,
to search for the “Patient Profile Form.
CVS Caremark Mail Service Pharmacy
You can have maintenance drugs sent right to your home
or anywhere else you choose by CVS Caremark Mail
Service Pharmacy. These are drugs that are taken
regularly for chronic conditions like diabetes or asthma.
Depending on your plan, you can get up to a 90-day
supply of medicine for less cost. It’s fast and convenient,
and standard shipping is always free.
Get started right away
You can submit your order using one of these options:
1. Online — Visit your secure member website and
sign in to your account. There you can add or
remove your prescriptions.
2. Phone — Call us toll-free, 24/7 at 1-888-792-3862.
If you need the help of a telephone device for the
hard of hearing, call 1-877-833-2779.
3. Mail — Get a new prescription from your doctor. Then
mail it to us with a completed order form. You can find
the form on your secure member website. The mailing
address is on the form.
Your doctor can submit your order using one of
these options:
1. Online — They can submit your prescriptions using
the e-prescribe services on our provider website.
2. Fax — They can fax your prescription to
1-877-270-3317. Make sure they include your member
ID number, date of birth and mailing address on the
fax cover sheet. Only a doctor may fax a prescription.
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Frequently asked questions
How can I save on prescriptions?
Here are some tips to pay less out of pocket for your
prescription drugs:
• Ask your doctor to consider prescribing drugs that
are on the Pharmacy Drug Guide (formulary).
• Ask your doctor to consider prescribing generic
drugs instead of brand-name drugs.
• Our home delivery pharmacy may save you money.
For more information, visit the website on your
member ID card and log in to your account.
What are generic drugs?
Generic drugs are proven to be just as safe and effective
as brand-name drugs. They contain the same active
ingredients in the same amounts as the brand-name
drugs and work the same way. So they have the same
risks and benefits as brand-name drugs. However, they
typically cost less.
When appropriate, your doctor may decide to prescribe
a generic drug or allow the pharmacist to substitute a
generic drug.
What is precertification?
Precertification is one way that we can help you and your
doctor find safe, appropriate drugs and keep costs down.
Precertification means that you or your doctor need to
get approval from the plan before certain drugs will be
covered. Generally, precertification applies to drugs that:
• Are often taken in the wrong way
• Should only be used for certain conditions
• Often cost more than other drugs that are proven
to be just as effective
Keep in mind that your doctor must contact us to request
approval of coverage for these drugs.
What is step therapy?
Some drugs require step therapy. This means that
you must try one or more prerequisite drug(s) before
a step therapy drug is covered.
The prerequisite drugs have U.S. Food and Drug
Administration (FDA) approval and may cost less. They
treat the same condition as the step therapy drug.
If you don’t try the appropriate prerequisite drug first, you
may need to pay full cost for the step-therapy drug.
What are quantity limits?
Quantity limits help your doctor and pharmacist make
sure that you use your drug correctly and safely. We use
medical guidelines and FDA-approved recommendations
from drug makers to set these coverage limits. The
quantity limit program includes:
Dose efficiency edits — Limits prescription coverage
to one dose per day for drugs that have approval for
once-daily dosing
Maximum daily dose — If a prescription is lower than
the minimum or higher than the maximum allowed
dose, a message is sent to the pharmacy
Quantity limits over time — Limits prescription
coverage to a specific number of units over a specific
amount of time
What if I need a drug that requires an exception
to the precertification, step therapy or quantity
limits requirements? Or what if I need a drug
that’s not covered under my plan?
In certain cases, you or your prescriber can request a
medical exception to the precertification, step therapy
or quantity limits requirements or for a drug that’s not
covered on your plan. You can ask for your request to be
expedited. Expedited coverage decisions are made
within 24 hours.
We’ll then contact you or your prescriber with our
decision. All medically necessary outpatient prescription
drugs will be covered. If a medical exception is approved,
you only need to pay the copay after the deductible.
This amount is based on your pharmacy plan design.
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How can your provider request a medical
exception?
Submit their request through our secure provider
website on www.availity.com.
Call the Aetna Pharmacy Precertification Unit: Non-
Specialty 1-800-294-5979 or
Specialty 1-866-814-5506.
Fax the completed request form to:
Non-Specialty
1-888-836-0730 or
Specialty 1-866-249-6155.
Mail the completed request form to:
Medical Exception to Pharmacy Prior Authorization Unit
1300 East Campbell Road Richardson, TX 75081
Pharmacy and Therapeutics (P&T) committee
The services of an independent National Pharmacy and
Therapeutics Committee (“P&T Committee”) are utilized
to approve safe and clinically effective drug therapies.
The P&T Committee is an external advisory body of
clinical professionals from across the United States. The
P&T Committee’s voting members include physicians,
pharmacists, a pharmacoeconomist and a medical
ethicist, all of whom have a broad background of clinical
and academic expertise regarding prescription drugs.
Voting members of the P&T Committee are not
employees of CVS Caremark and must disclose any
financial relationship or conflicts of interest with any
pharmaceutical manufacturers.
Can the formulary change during the year?
The formulary can change throughout the year.
Some reasons why it can change include:
• New drugs are approved.
• Existing drugs are removed from the market.
• Prescription drugs may become available over the
counter (without a prescription). Over-the-counter drugs
are not generally covered in a formulary.
• Brand-name drugs lose patent protection and generic
versions become available. When this happens, the
generic drug will be covered in place of the brand-
name drug. The brand-name drug is likely to become
non-formulary or covered at a higher cost. See the
What are generic drugs?” section above for more
information.
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Commercial 1557 Nondiscrimination Notice
Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently
based on their race, color, national origin, sex, age, or disability.
Aetna provides free aids/services to people with disabilities and to people who need language assistance.
If you need a qualified interpreter, written information in other formats, translation or other services, call the
number on your ID card.
If you believe we have failed to provide these services or otherwise discriminated based on a protected class
noted above, you can also file a grievance with the Civil Rights Coordinator by contacting:
Civil Rights Coordinator,
P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779),
1-800-648-7817, TTY: 711,
Fax: 859-425-3379 (CA HMO customers: 860-262-7705),
You can also file a civil rights complaint with the U.S. Department of Health and Human Services,
Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at:
U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building,
Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary
companies, including Aetna Life Insurance Company and their affiliates (Aetna).
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Remember to visit the website on your member ID card. Then sign
in to your account for the most up-to-date information.
Please note that if your prescription drug benefits plan changes, the information here may no longer apply.
Medications on the Aetna Drug Guide, precertification, step-therapy and quantity limits lists are subject to change.
Health benefits and health insurance plans are offered, administered and/or underwritten by Aetna Health Inc., Aetna
Health Insurance Company of New York, Aetna Health Assurance Pennsylvania Inc., Aetna Health Insurance company
and/or Aetna Life Insurance Company (Aetna). In Florida, by Aetna Health Inc. and/or Aetna Life Insurance Company. In
Utah and Wyoming by Aetna Health of Utah Inc. and Aetna Life Insurance Company. In Maryland, by Aetna Health Inc.,
151 Farmington Avenue, Hartford, CT 06156. Each insurer has sole financial responsibility for its own products. Pharmacy
benefits are administered through an affiliated pharmacy benefit manager, CVS Caremark. Aetna is part of the CVS
Health family of companies.
Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations
and conditions of coverage. To check coverage and copay information for a specific medicine, log into your member
website. For questions, please call the toll-free number on the back of your member ID card.
The drugs on the Pharmacy Drug Guide (formulary), Formulary Exclusions, Precertification, and Quantity Limit Lists are
subject to change. The quantity limits and step therapy drug coverage review programs are not available in all service
areas. However, these programs are available to self-funded plans.
Information is subject to change. In accordance with state law, changes to drug coverage are not effective for commercial
fully insured plans (including HMOs) in Louisiana, Texas, and in most circumstances Connecticut and New York, until the
plans’ renewal date.
In accordance with state law, certain fully insured commercial California members (except Federal Employee Health
Benefit Plan members) who obtained approval from an Aetna plan for coverage of drugs that are later added to the
Preauthorization or Step Therapy Lists or removed from the Pharmacy Drug Guide will continue to have those drugs
covered, for as long as the treating in-network provider continues prescribing them, provided that the drug is appropriately
prescribed and is considered safe and effective for treating the enrollee’s medical condition. Aetna reserves the right to
periodically request clinical information from your provider to assess your medical condition and the appropriateness of
your ongoing treatment. Failure to provide clinical information could result in subsequent denial of coverage for this
medication.
In accordance with state law, fully insured Commercial Connecticut preferred provider organization (PPO) members
(except Federal Employee Health Benefit Plan members) who are receiving coverage for drugs that are added to the
Precertification or Step-Therapy Lists will continue to have those drugs covered for as long as the prescriber prescribes
them, provided the drug is medically necessary and more medically beneficial than other covered drugs. Nothing in this
section shall preclude the prescribing provider from prescribing another drug covered by the plan that is medically
appropriate for the enrollee, nor shall anything in this section be construed to prohibit generic drug substitutions.
In accordance with state law, commercial fully insured (including HMO) members in Connecticut, Louisiana, New Mexico
and Texas (except Federal Employee Health Benefit Plan members) who are receiving coverage for drugs that are added
or removed from the Pharmacy Drug Guide and Specialty Drug List will continue to have those drugs covered at the same
benefit level until their plans renewal date. In Texas, preauthorization approval is known as “preservice utilization review.
It is not verification” as defined by Texas law. Preauthorization means a determination that healthcare services proposed
to be provided to a patient are medically necessary and appropriate.
In certain states, including Arkansas, Colorado, Connecticut, Delaware, Georgia, Illinois, Louisiana, Maryland, Minnesota,
North Dakota, Pennsylvania and Texas, step therapy programs do not apply to fully insured members utilizing prescription
drugs for the treatment of stage-four advanced, metastatic cancer.
This document contains trademarks or registered trademarks of CVS Pharmacy, Inc. or one of its affiliates; it may also
contain references to products that are trademarks or registered trademarks of entities not affiliated with CVS Health.
This material is for information only. It contains only a partial, general description of plan benefits or programs and does
not constitute a contract. See plan documents for a complete description of benefits, exclusions, limitations and conditions
of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent
contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care
or guarantee access to health services. Information is subject to change. CVS Caremark Mail Service Pharmacy is part of
the CVS Health family of companies.
Aetna.com
©2022 Aetna Inc.
lowercase italics = Generic drugs
UPPERCASE = Brand name
drugs
Drug Tier
CE = Copay Exception: Available
to some members at no cost with a
prescription from your provider
when obtained at an in-network
pharmacy. Certain limitations
may apply.
NF = Non-formulary, not covered
unless exception request granted
NP = Non-Preferred Brand and
Generic
NPSP = Non-Preferred Specialty
PB = Preferred Brand
PG = Preferred Generic
PSP = Preferred Specialty
Coverage Requirements and Limits
AL = Age Limit
IBC = Indication Based Coverage
LGC = Lowest Generic Copay
Applies
N10 = Drug Coverage for Student
Health members.
N7 = Drug tier when CE does not
apply
N8 = Drug Specific Coverage
PA = Prior Authorization
QL = Quantity Limit
QLR = Quantity Limit Restriction
Based on Age
Select OTC = Select OTC
Program if your pharmacy plan
includes this program you may
have coverage for products noted
with a doctors prescription.
Please see your plan benefit
information for specific coverage
details.
SPC = Select Plan Coverage:
Only available for select plans.
Refer to member plan documents
for coverage.
ST = Step Therapy
STX = Safer and/or more effective
treatments are available
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ANALGESICS - DRUGS TO TREAT PAIN AND
INFLAMMATION
COX-2 INHIBITORS
CELEBREX ORAL CAPSULE 100 MG, 200 MG, 400 MG,
50 MG (celecoxib)
NF
celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg NP
ELYXYB ORAL SOLUTION 120 MG/4.8ML (celecoxib
(migraine))
NF
GOUT
allopurinol oral tablet 100 mg, 300 mg PG
N8 (Listing does not include
certain NDCs)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
14
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
allopurinol oral tablet 200 mg NF
colchicine oral capsule 0.6 mg NF
colchicine oral tablet 0.6 mg PG
QL (120 TABLETS per 25
DAYs)
colchicine-probenecid oral tablet 0.5-500 mg PG
COLCRYS ORAL TABLET 0.6 MG (colchicine) NF
febuxostat oral tablet 40 mg, 80 mg PG
KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML
(pegloticase)
NPSP PA
MITIGARE ORAL CAPSULE 0.6 MG (colchicine) PB
QL (60 CAPSULES per 25
days)
probenecid oral tablet 500 mg PG
ULORIC ORAL TABLET 40 MG, 80 MG (febuxostat) NF
MISCELLANEOUS
PRIALT INTRATHECAL SOLUTION 100 MCG/ML, 500
MCG/20ML, 500 MCG/5ML (ziconotide acetate)
NPSP
NON-OPIOID ANALGESICS
ALLZITAL ORAL TABLET 25-325 MG (butalbital-
acetaminophen)
NF
butalbital-apap-caffeine (Bac Oral Tablet 50-325-40 Mg) PG
STX; QL (48 tablets per 25
days)
butalbital-acetaminophen (Bupap Oral Tablet 50-300 Mg) NF
butalbital-acetaminophen oral capsule 50-300 mg NF
butalbital-acetaminophen oral tablet 50-325 mg PG
STX; QL (48 TABLETS per
25 DAYs)
butalbital-apap-caffeine oral capsule 50-300-40 mg, 50-325-40
mg
NF
butalbital-apap-caffeine oral tablet 50-325-40 mg PG
STX; QL (48 TABLETS per
25 days)
butalbital-aspirin-caffeine oral capsule 50-325-40 mg PG
STX; N8 (Listing does not
include certain NDCs); QL
(48 CAPSULES per 25
DAYs)
ESGIC ORAL TABLET 50-325-40 MG (butalbital-apap-
caffeine)
NP
STX; QL (48 TABLETS per
25 DAYs)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
15
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
FIORICET ORAL CAPSULE 50-300-40 MG (butalbital-
apap-caffeine)
NF
NSAIDS
CAMBIA ORAL PACKET 50 MG (diclofenac
potassium(migraine))
NF
diclofenac potassium oral capsule 25 mg NF
diclofenac potassium oral tablet 25 mg NF
diclofenac potassium oral tablet 50 mg PG
diclofenac potassium(migraine) oral packet 50 mg NF
diclofenac sodium er oral tablet extended release 24 hour 100
mg
PG
diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75
mg
PG
etodolac er oral tablet extended release 24 hour 400 mg, 500 mg,
600 mg
PG
etodolac oral capsule 200 mg, 300 mg PG
etodolac oral tablet 400 mg, 500 mg PG
fenoprofen calcium oral capsule 200 mg, 400 mg NF
fenoprofen calcium oral tablet 600 mg NF
N10 (Non-Preferred Generic
tier applies to Student
Health members residing in
Connecticut.)
flurbiprofen oral tablet 100 mg, 50 mg PG
ibuprofen (Ibu Oral Tablet 600 Mg) PG
ibuprofen oral tablet 400 mg, 600 mg, 800 mg PG
INDOCIN ORAL SUSPENSION 25 MG/5ML
(indomethacin)
NF
INDOCIN RECTAL SUPPOSITORY 50 MG (indomethacin) NF
indomethacin oral capsule 25 mg, 50 mg PG STX
ketoprofen er oral capsule extended release 24 hour 200 mg NF
ketoprofen oral capsule 25 mg, 50 mg NF
ketorolac tromethamine nasal solution 15.75 mg/spray NF
ketorolac tromethamine oral tablet 10 mg PG
QL (20 TABLETS per 25
DAYs)
LODINE ORAL TABLET 400 MG (etodolac) NF
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
16
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
diclofenac potassium (Lofena Oral Tablet 25 Mg) NF
meclofenamate sodium oral capsule 100 mg, 50 mg PG
mefenamic acid oral capsule 250 mg NP
N8 (Listing does not include
certain NDCs)
meloxicam oral capsule 10 mg, 5 mg NF
meloxicam oral suspension 7.5 mg/5ml NF
meloxicam oral tablet 15 mg, 7.5 mg PG
nabumetone oral tablet 500 mg, 750 mg PG
N8 (Listing does not include
certain NDCs)
NAPRELAN ORAL TABLET EXTENDED RELEASE 24
HOUR 375 MG, 500 MG, 750 MG (naproxen sodium)
NF
NAPROSYN ORAL SUSPENSION 125 MG/5ML
(naproxen)
NF
naproxen oral suspension 125 mg/5ml NF
naproxen oral tablet 250 mg, 375 mg, 500 mg PG
naproxen oral tablet delayed release 375 mg, 500 mg PG
naproxen sodium er oral tablet extended release 24 hour 375 mg,
500 mg, 750 mg
NF
naproxen sodium oral tablet 275 mg, 550 mg PG
oxaprozin oral tablet 600 mg PG
piroxicam oral capsule 10 mg, 20 mg PG
RELAFEN DS ORAL TABLET 1000 MG (nabumetone) NF
SPRIX NASAL SOLUTION 15.75 MG/SPRAY (ketorolac
tromethamine)
NF
sulindac oral tablet 150 mg, 200 mg PG
ZIPSOR ORAL CAPSULE 25 MG (diclofenac potassium) NF
ZORVOLEX ORAL CAPSULE 18 MG, 35 MG (diclofenac) NF
NSAIDS, COMBINATIONS
ARTHROTEC ORAL TABLET DELAYED RELEASE 50-
0.2 MG, 75-0.2 MG (diclofenac-misoprostol)
NF
diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 75-
0.2 mg
PG
DUEXIS ORAL TABLET 800-26.6 MG (ibuprofen-
famotidine)
NF
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
17
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ibuprofen-famotidine oral tablet 800-26.6 mg NF
N10 (Non-Preferred Generic
tier applies to Student
Health members residing in
Connecticut.)
naproxen-esomeprazole mg oral tablet delayed release 375-20
mg, 500-20 mg
NF
VIMOVO ORAL TABLET DELAYED RELEASE 375-20
MG, 500-20 MG (naproxen-esomeprazole)
NF
OPIOID ANALGESICS
acetaminophen-codeine oral solution 120-12 mg/5ml PG
N8 (Subject to initial limit);
QL (2700 ML per 25 days)
acetaminophen-codeine oral tablet 300-15 mg PG
N8 (Subject to initial limit);
QL (400 TABLETS per 25
DAYs)
acetaminophen-codeine oral tablet 300-30 mg PG
N8 (Subject to initial limit);
QL (360 TABLETS per 25
Days)
acetaminophen-codeine oral tablet 300-60 mg PG
N8 (Subject to initial limit);
QL (180 TABLETS per 25
Days)
ACTIQ BUCCAL LOZENGE ON A HANDLE 1200 MCG,
1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG
(fentanyl citrate)
NP
PA; QL (120 LOZENGES
per 25 DAYs)
APADAZ ORAL TABLET 4.08-325 MG, 6.12-325 MG,
8.16-325 MG (benzhydrocodone-acetaminophen)
NF
apap-caff-dihydrocodeine oral capsule 320.5-30-16 mg NP
N8 (Subject to initial limit);
QL (300 CAPSULES per 25
days)
benzhydrocodone-acetaminophen oral tablet 4.08-325 mg, 6.12-
325 mg, 8.16-325 mg
NF
butalbital-apap-caff-cod oral capsule 50-300-40-30 mg PG
STX; N8 (Listing does not
include certain NDCs); QL
(48 CAPSULES per 25
DAYs)
butalbital-apap-caff-cod oral capsule 50-325-40-30 mg PG
STX; QL (48 CAPSULES
per 25 DAYs)
butalbital-asa-caff-codeine oral capsule 50-325-40-30 mg PG
STX; QL (48 CAPSULES
per 25 DAYs)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
18
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
butorphanol tartrate nasal solution 10 mg/ml NP
QL (2 BOTTLES per 25
DAYs)
codeine sulfate oral tablet 30 mg PG
N8 (Subject to initial limit);
QL (42 TABLETS per 25
days)
codeine sulfate oral tablet 60 mg NP
N8 (Subject to initial limit);
QL (42 TABLETS per 25
days)
CONZIP ORAL CAPSULE EXTENDED RELEASE 24
HOUR 100 MG (tramadol hcl)
NP
ST; QL (30 CAPSULES per
25 DAYs)
CONZIP ORAL CAPSULE EXTENDED RELEASE 24
HOUR 200 MG, 300 MG (tramadol hcl)
NP ST
DILAUDID ORAL LIQUID 1 MG/ML (hydromorphone hcl) NP
N8 (Subject to initial limit);
QL (480 ML per 25 days)
DILAUDID ORAL TABLET 2 MG (hydromorphone hcl) NP
N8 (Subject to initial limit);
QL (180 TABLETS per 25
days)
DILAUDID ORAL TABLET 4 MG (hydromorphone hcl) NP
N8 (Subject to initial limit);
QL (120 TABLETS per 25
days)
DILAUDID ORAL TABLET 8 MG (hydromorphone hcl) NP
N8 (Subject to initial limit);
QL (60 TABLETS per 25
days)
fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg,
200 mcg, 400 mcg, 600 mcg, 800 mcg
NP
PA; QL (120 LOZENGES
per 25 DAYs)
fentanyl citrate buccal tablet 100 mcg, 200 mcg, 400 mcg, 600
mcg, 800 mcg
PG
PA; QL (120 TABLETS per
25 DAYs)
fentanyl transdermal patch 72 hour 100 mcg/hr, 50 mcg/hr, 62.5
mcg/hr, 75 mcg/hr, 87.5 mcg/hr
PG ST
fentanyl transdermal patch 72 hour 12 mcg/hr, 25 mcg/hr, 37.5
mcg/hr
PG
ST; QL (10 PATCHES per
25 DAYs)
FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400
MCG, 600 MCG, 800 MCG (fentanyl citrate)
NF
FIORICET/CODEINE ORAL CAPSULE 50-300-40-30 MG
(butalbital-apap-caff-cod)
NP
STX; QL (48 CAPSULES
per 25 DAYs)
hydrocodone bitartrate er oral capsule extended release 12 hour
10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 50 mg
NF
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
19
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
hydrocodone bitartrate er oral tablet er 24 hour abuse-deterrent
100 mg, 120 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg
NF
hydrocodone-acetaminophen oral solution 7.5-325 mg/15ml NP
N8 (Subject to initial limit);
QL (2700 ML per 25 days)
hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg,
7.5-300 mg, 7.5-325 mg
PG
N8 (Subject to initial limit);
QL (180 TABLETS per 25
days)
hydrocodone-acetaminophen oral tablet 5-300 mg, 5-325 mg PG
N8 (Subject to initial limit);
QL (240 TABLETS per 25
days)
hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200
mg
PG
N8 (Subject to initial limit);
QL (50 TABLETS per 25
days)
hydromorphone hcl er oral tablet extended release 24 hour 12
mg, 16 mg, 8 mg
NP
ST; QL (30 TABLETS per
25 DAYs)
hydromorphone hcl er oral tablet extended release 24 hour 32
mg
NP ST
hydromorphone hcl oral liquid 1 mg/ml PG
N8 (Subject to initial limit);
QL (480 ML per 25 days)
hydromorphone hcl oral tablet 2 mg PG
N8 (Subject to initial limit);
QL (180 TABLETS per 25
days)
hydromorphone hcl oral tablet 4 mg PG
N8 (Subject to initial limit);
QL (120 TABLETS per 25
days)
hydromorphone hcl oral tablet 8 mg PG
N8 (Subject to initial limit);
QL (60 TABLETS per 25
days)
HYSINGLA ER ORAL TABLET ER 24 HOUR ABUSE-
DETERRENT 100 MG, 120 MG, 20 MG, 30 MG, 40 MG,
60 MG, 80 MG (hydrocodone bitartrate)
NF
levorphanol tartrate oral tablet 2 mg, 3 mg NF
meperidine hcl oral solution 50 mg/5ml NF
meperidine hcl oral tablet 50 mg NF
methadone hcl (Methadone Hcl Intensol Oral Concentrate 10
Mg/Ml)
NP ST; QL (45 ML per 25 days)
methadone hcl oral concentrate 10 mg/ml NP QL (30 ML per 25 days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
20
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
methadone hcl oral solution 10 mg/5ml PG
ST; QL (225 ML per 25
days)
methadone hcl oral solution 5 mg/5ml PG
ST; QL (450 ML per 25
DAYs)
methadone hcl oral tablet 10 mg PG
ST; QL (30 TABLETS per
25 days)
methadone hcl oral tablet 5 mg PG
ST; QL (90 TABLETS per
25 DAYs)
methadone hcl oral tablet soluble 40 mg PG
QL (9 TABLETS per 25
DAYs)
METHADOSE ORAL CONCENTRATE 10 MG/ML
(methadone hcl)
NP QL (30 ML per 25 DAYs)
METHADOSE SUGAR-FREE ORAL CONCENTRATE 10
MG/ML (methadone hcl)
NP QL (30 ML per 25 DAYs)
morphine sulfate (concentrate) oral solution 100 mg/5ml PG
N8 (Subject to initial limit);
QL (135 ML per 25 days)
morphine sulfate er beads oral capsule extended release 24 hour
120 mg
PG ST
morphine sulfate er beads oral capsule extended release 24 hour
30 mg, 45 mg, 60 mg, 75 mg, 90 mg
PG
ST; QL (30 CAPSULES per
25 DAYs)
morphine sulfate er oral capsule extended release 24 hour 10 mg,
20 mg, 30 mg
PG
ST; QL (60 CAPSULES per
25 days)
morphine sulfate er oral capsule extended release 24 hour 100
mg
PG ST
morphine sulfate er oral capsule extended release 24 hour 50 mg,
60 mg, 80 mg
PG
ST; QL (30 CAPSULES per
25 days)
morphine sulfate er oral tablet extended release 100 mg, 200 mg,
60 mg
PG ST
morphine sulfate er oral tablet extended release 15 mg, 30 mg PG
ST; QL (90 TABLETS per
25 days)
morphine sulfate oral solution 10 mg/5ml PG
N8 (Subject to initial limit);
QL (900 ML per 25 days)
morphine sulfate oral solution 20 mg/5ml PG
N8 (Subject to initial limit);
QL (675 ML per 25 days)
morphine sulfate oral tablet 15 mg PG
N8 (Subject to initial limit);
QL (180 TABLETS per 25
days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
21
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
morphine sulfate oral tablet 30 mg PG
N8 (Subject to initial limit);
QL (90 TABLETS per 25
days)
MS CONTIN ORAL TABLET EXTENDED RELEASE 100
MG, 200 MG, 60 MG (morphine sulfate)
NP ST
MS CONTIN ORAL TABLET EXTENDED RELEASE 15
MG, 30 MG (morphine sulfate)
NP
ST; QL (90 TABLETS per
25 DAYs)
nalocet oral tablet 2.5-300 mg NF
NUCYNTA ER ORAL TABLET EXTENDED RELEASE
12 HOUR 100 MG, 150 MG, 200 MG, 250 MG, 50 MG
(tapentadol hcl)
NF
NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG
(tapentadol hcl)
NF
OXAYDO ORAL TABLET 5 MG, 7.5 MG (oxycodone hcl) NF
oxycodone hcl er oral tablet er 12 hour abuse-deterrent 10 mg,
20 mg
PG
ST; QL (60 TABLETS per
25 days)
oxycodone hcl er oral tablet er 12 hour abuse-deterrent 40 mg,
80 mg
PG ST
oxycodone hcl oral capsule 5 mg PG
N8 (Subject to initial limit);
QL (180 CAPSULES per 25
days)
oxycodone hcl oral concentrate 100 mg/5ml PG
N8 (Subject to initial limit);
QL (90 ML per 25 days)
oxycodone hcl oral solution 5 mg/5ml PG
N8 (Subject to initial limit);
QL (900 ML per 25 days)
oxycodone hcl oral tablet 10 mg, 5 mg PG
N8 (Subject to initial limit);
QL (180 TABLETS per 25
days)
oxycodone hcl oral tablet 15 mg PG
N8 (Subject to initial limit);
QL (120 TABLETS per 25
days)
oxycodone hcl oral tablet 20 mg PG
N8 (Subject to initial limit);
QL (90 TABLETS per 25
days)
oxycodone hcl oral tablet 30 mg PG
N8 (Subject to initial limit);
QL (60 TABLETS per 25
days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
22
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
oxycodone-acetaminophen oral solution 10-300 mg/5ml, 5-325
mg/5ml
NF
oxycodone-acetaminophen oral tablet 10-300 mg, 2.5-300 mg, 5-
300 mg, 7.5-300 mg
NF
oxycodone-acetaminophen oral tablet 10-325 mg PG
N8 (Subject to initial limit);
QL (180 TABLETS per 25
DAYs)
oxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg PG
N8 (Subject to initial limit);
QL (360 TABLETS per 25
days)
oxycodone-acetaminophen oral tablet 7.5-325 mg PG
N8 (Subject to initial limit);
QL (240 TABLETS per 25
days)
OXYCONTIN ORAL TABLET ER 12 HOUR ABUSE-
DETERRENT 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60
MG, 80 MG (oxycodone hcl)
NF
oxymorphone hcl er oral tablet extended release 12 hour 10 mg,
15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg
NF
oxymorphone hcl oral tablet 10 mg PG
N8 (Subject to initial limit);
QL (90 TABLETS per 25
days)
oxymorphone hcl oral tablet 5 mg PG
N8 (Subject to initial limit);
QL (180 TABLETS per 25
days)
PERCOCET ORAL TABLET 10-325 MG, 2.5-325 MG, 5-
325 MG, 7.5-325 MG (oxycodone-acetaminophen)
NF
PROLATE ORAL SOLUTION 10-300 MG/5ML
(oxycodone-acetaminophen)
NF
PROLATE ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300
MG (oxycodone-acetaminophen)
NF
QDOLO ORAL SOLUTION 5 MG/ML (tramadol hcl) NF
ROXICODONE ORAL TABLET 15 MG (oxycodone hcl) NP
N8 (Subject to initial limit);
QL (120 TABLETS per 25
days)
ROXICODONE ORAL TABLET 30 MG (oxycodone hcl) NP
N8 (Subject to initial limit);
QL (60 TABLETS per 25
days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
23
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ROXYBOND ORAL TABLET ABUSE-DETERRENT 15
MG, 30 MG, 5 MG (oxycodone hcl)
NF
SEGLENTIS ORAL TABLET 56-44 MG (celecoxib-tramadol
hcl)
NF
SUBSYS SUBLINGUAL LIQUID 100 MCG, 1200 (600 X 2)
MCG, 1600 (800 X 2) MCG, 200 MCG, 400 MCG, 600
MCG, 800 MCG (fentanyl)
NF
tramadol hcl (er biphasic) oral capsule extended release 24 hour
100 mg, 200 mg, 300 mg
NF
tramadol hcl (er biphasic) oral tablet extended release 24 hour
100 mg
PG
ST; QL (30 TABLETS per
25 days)
tramadol hcl (er biphasic) oral tablet extended release 24 hour
200 mg, 300 mg
PG ST
tramadol hcl er oral tablet extended release 24 hour 100 mg PG
ST; QL (30 TABLETS per
25 days)
tramadol hcl er oral tablet extended release 24 hour 200 mg, 300
mg
PG ST
tramadol hcl oral solution 5 mg/ml NF
tramadol hcl oral tablet 100 mg NF
tramadol hcl oral tablet 50 mg PG
N8 (Subject to initial limit);
QL (180 TABLETS per 25
days)
tramadol-acetaminophen oral tablet 37.5-325 mg PG
N8 (Subject to initial limit);
QL (40 TABLETS per 25
days)
XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE-
DETERRENT 13.5 MG, 18 MG, 27 MG, 9 MG (oxycodone)
PB
ST; QL (60 CAPSULES per
25 days)
XTAMPZA ER ORAL CAPSULE ER 12 HOUR ABUSE-
DETERRENT 36 MG (oxycodone)
PB ST
OPIOID PARTIAL AGONISTS
BELBUCA BUCCAL FILM 150 MCG, 300 MCG, 450
MCG, 75 MCG (buprenorphine hcl)
PB
ST; QL (60 FILMS per 25
DAYs)
BELBUCA BUCCAL FILM 600 MCG, 750 MCG, 900
MCG (buprenorphine hcl)
PB ST
buprenorphine transdermal patch weekly 10 mcg/hr, 5 mcg/hr,
7.5 mcg/hr
PG
ST; QL (4 PATCH
WEEKLY per 25 days)
buprenorphine transdermal patch weekly 15 mcg/hr, 20 mcg/hr PG ST
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
24
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
BUTRANS TRANSDERMAL PATCH WEEKLY 10
MCG/HR, 15 MCG/HR, 20 MCG/HR, 5 MCG/HR, 7.5
MCG/HR (buprenorphine)
NF
pentazocine-naloxone hcl oral tablet 50-0.5 mg NP
STX; N8 (Subject to initial
limit.); QL (120 TABLETS
per 25 days)
SUBLOCADE SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE 100 MG/0.5ML, 300 MG/1.5ML
(buprenorphine)
PSP
SALICYLATES
aspirin childrens oral tablet chewable 81 mg CE
N7 (Not Covered); QL (100
TABLETS per 30 DAYs);
AL (Min 12 Years and Max
59 Years)
aspirin oral tablet delayed release 81 mg CE
N7 (Not Covered); QL (100
TABLETS per 30 Days);
AL (Min 12 Years and Max
59 Years)
diflunisal oral tablet 500 mg PG
N8 (Listing does not include
certain NDCs)
VISCOSUPPLEMENTS
DUROLANE INTRA-ARTICULAR PREFILLED
SYRINGE 60 MG/3ML (sodium hyaluronate (viscosup))
PSP PA
EUFLEXXA INTRA-ARTICULAR SOLUTION
PREFILLED SYRINGE 20 MG/2ML (sodium hyaluronate
(viscosup))
PSP PA
GEL-ONE INTRA-ARTICULAR PREFILLED SYRINGE
30 MG/3ML (cross-linked hyaluronate)
NF
GELSYN-3 INTRA-ARTICULAR SOLUTION
PREFILLED SYRINGE 16.8 MG/2ML (sodium hyaluronate
(viscosup))
PSP PA
GENVISC 850 INTRA-ARTICULAR SOLUTION
PREFILLED SYRINGE 25 MG/2.5ML (sodium hyaluronate
(viscosup))
NF
HYALGAN INTRA-ARTICULAR SOLUTION 20
MG/2ML (sodium hyaluronate (viscosup))
NF
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
25
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
HYALGAN INTRA-ARTICULAR SOLUTION
PREFILLED SYRINGE 20 MG/2ML (sodium hyaluronate
(viscosup))
NF
HYMOVIS INTRA-ARTICULAR SOLUTION
PREFILLED SYRINGE 24 MG/3ML (hyaluronan)
NF
MONOVISC INTRA-ARTICULAR SOLUTION
PREFILLED SYRINGE 88 MG/4ML (hyaluronan)
NF
ORTHOVISC INTRA-ARTICULAR SOLUTION
PREFILLED SYRINGE 30 MG/2ML (hyaluronan)
NF
SUPARTZ FX INTRA-ARTICULAR SOLUTION
PREFILLED SYRINGE 25 MG/2.5ML (sodium hyaluronate
(viscosup))
PSP PA
SYNOJOYNT INTRA-ARTICULAR SOLUTION
PREFILLED SYRINGE 20 MG/2ML (sodium hyaluronate
(viscosup))
NF
SYNVISC INTRA-ARTICULAR SOLUTION
PREFILLED SYRINGE 16 MG/2ML (hylan)
NF
SYNVISC ONE INTRA-ARTICULAR SOLUTION
PREFILLED SYRINGE 48 MG/6ML (hylan)
NF
TRILURON INTRA-ARTICULAR SOLUTION
PREFILLED SYRINGE 20 MG/2ML (sodium hyaluronate
(viscosup))
NF
TRIVISC INTRA-ARTICULAR SOLUTION PREFILLED
SYRINGE 25 MG/2.5ML (sodium hyaluronate (viscosup))
NF
VISCO-3 INTRA-ARTICULAR SOLUTION PREFILLED
SYRINGE 25 MG/2.5ML (sodium hyaluronate (viscosup))
NF
ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS
ANTHELMINTICS - DRUGS FOR WORM INFECTION
albendazole oral tablet 200 mg NP
QL (336 TABLETS per 365
days)
BILTRICIDE ORAL TABLET 600 MG (praziquantel) NP
QL (24 TABLETS per 365
DAYs)
EMVERM ORAL TABLET CHEWABLE 100 MG
(mebendazole)
NP
QL (12 TABLETS per 365
days)
ivermectin oral tablet 3 mg PG
praziquantel oral tablet 600 mg PG
QL (24 TABLETS per 365
DAYs)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
26
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ANTI-BACTERIALS - MISCELLANEOUS
ARIKAYCE INHALATION SUSPENSION 590 MG/8.4ML
(amikacin sulfate liposome)
NPSP PA
HUMATIN ORAL CAPSULE 250 MG (paromomycin
sulfate)
NF
neomycin sulfate oral tablet 500 mg PG
paromomycin sulfate oral capsule 250 mg PG
sulfadiazine oral tablet 500 mg NF
sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5ml PG
sulfamethoxazole-trimethoprim oral tablet 400-80 mg, 800-160
mg
PG
tinidazole oral tablet 250 mg, 500 mg NP
ANTIFUNGALS - DRUGS TO TREAT FUNGAL
INFECTIONS
BREXAFEMME ORAL TABLET 150 MG (ibrexafungerp
citrate)
NP
ST; QL (4 TABLETS per 7
DAYs)
CRESEMBA ORAL CAPSULE 186 MG (isavuconazonium
sulfate)
NF
fluconazole oral suspension reconstituted 10 mg/ml, 40 mg/ml PG
fluconazole oral tablet 100 mg, 150 mg, 200 mg, 50 mg PG
flucytosine oral capsule 250 mg NP STX
flucytosine oral capsule 500 mg NF
griseofulvin microsize oral suspension 125 mg/5ml PG
N8 (Listing does not include
certain NDCs)
griseofulvin microsize oral tablet 500 mg PG
griseofulvin ultramicrosize oral tablet 125 mg, 250 mg PG
itraconazole oral capsule 100 mg PG
itraconazole oral solution 10 mg/ml NP PA
ketoconazole oral tablet 200 mg PG PA; STX
NOXAFIL ORAL PACKET 300 MG (posaconazole) NF
NOXAFIL ORAL SUSPENSION 40 MG/ML (posaconazole) NF
NOXAFIL ORAL TABLET DELAYED RELEASE 100
MG (posaconazole)
NF
nystatin oral tablet 500000 unit PG
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
27
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
posaconazole oral suspension 40 mg/ml NF
posaconazole oral tablet delayed release 100 mg NF
SPORANOX ORAL CAPSULE 100 MG (itraconazole) NF
SPORANOX ORAL SOLUTION 10 MG/ML (itraconazole) NF
terbinafine hcl oral tablet 250 mg PG
tolsura oral capsule 65 mg NF
VIVJOA ORAL CAPSULE THERAPY PACK 150 MG
(oteseconazole)
NP
PA; QL (18 CAPSULES per
336 DAYs)
voriconazole oral suspension reconstituted 40 mg/ml PG
voriconazole oral tablet 200 mg, 50 mg PG
ANTIMALARIALS - DRUGS TO TREAT MALARIA
ARAKODA ORAL TABLET 100 MG (tafenoquine
succinate)
NF
atovaquone-proguanil hcl oral tablet 250-100 mg, 62.5-25 mg NP
chloroquine phosphate oral tablet 250 mg, 500 mg PG
hydroxychloroquine sulfate oral tablet 100 mg, 300 mg, 400 mg NF
KRINTAFEL ORAL TABLET 150 MG (tafenoquine
succinate)
NF
mefloquine hcl oral tablet 250 mg NP
primaquine phosphate oral tablet 26.3 (15 base) mg PG
quinine sulfate oral capsule 324 mg NP
ANTIRETROVIRAL AGENTS - DRUGS TO SUPPRESS
HIV/AIDS INFECTION
abacavir sulfate oral solution 20 mg/ml PG QL (900 ML per 30 DAYs)
abacavir sulfate oral tablet 300 mg PG
QL (60 TABLETS per 30
DAYs)
APTIVUS ORAL CAPSULE 250 MG (tipranavir) NF
atazanavir sulfate oral capsule 150 mg, 300 mg PG
QL (30 CAPSULES per 30
DAYs)
atazanavir sulfate oral capsule 200 mg PG
QL (60 CAPSULES per 30
DAYs)
EDURANT ORAL TABLET 25 MG (rilpivirine hcl) PB
QL (60 TABLETS per 30
DAYs)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
28
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
efavirenz oral capsule 200 mg, 50 mg PG
QL (90 CAPSULES per 30
DAYs)
efavirenz oral tablet 600 mg PG
QL (30 TABLETS per 30
days)
emtricitabine oral capsule 200 mg PG
QL (30 TABLETS per 30
DAYs)
EMTRIVA ORAL CAPSULE 200 MG (emtricitabine) PB
QL (30 CAPSULES per 30
DAYs)
EMTRIVA ORAL SOLUTION 10 MG/ML (emtricitabine) PB QL (680 ML per 28 DAYs)
EPIVIR ORAL SOLUTION 10 MG/ML (lamivudine) NP QL (900 mls per 30 days)
EPIVIR ORAL TABLET 150 MG (lamivudine) NP QL (60 tablets per 30 days)
EPIVIR ORAL TABLET 300 MG (lamivudine) NP QL (30 tablets per 30 days)
etravirine oral tablet 100 mg PG
QL (120 TABLETS per 30
DAYs)
etravirine oral tablet 200 mg PG
QL (60 TABLETS per 30
DAYs)
fosamprenavir calcium oral tablet 700 mg PG
QL (120 TABLETS per 30
DAYs)
FUZEON SUBCUTANEOUS SOLUTION
RECONSTITUTED 90 MG (enfuvirtide)
PSP
PA; QL (60 SOLUTION
RECONSTITUTED per 30
days)
INTELENCE ORAL TABLET 100 MG, 25 MG (etravirine) PB
QL (120 TABLETS per 30
DAYs)
INTELENCE ORAL TABLET 200 MG (etravirine) PB
QL (60 TABLETS per 30
DAYs)
ISENTRESS HD ORAL TABLET 600 MG (raltegravir
potassium)
PB
QL (60 TABLETS per 30
DAYs)
ISENTRESS ORAL PACKET 100 MG (raltegravir
potassium)
PB
QL (60 PACKETS per 30
days)
ISENTRESS ORAL TABLET 400 MG (raltegravir
potassium)
PB
QL (120 TABLETS per 30
DAYs)
ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25
MG (raltegravir potassium)
PB
QL (180 TABLETS per 30
DAYs)
lamivudine oral solution 10 mg/ml PG QL (900 ML per 30 DAYs)
lamivudine oral tablet 150 mg PG
QL (60 TABLETS per 30
days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
29
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
lamivudine oral tablet 300 mg PG
QL (30 TABLETS per 30
days)
LEXIVA ORAL SUSPENSION 50 MG/ML (fosamprenavir
calcium)
NF
LEXIVA ORAL TABLET 700 MG (fosamprenavir calcium) NF
maraviroc oral tablet 150 mg PG
QL (60 TABLETS per 30
DAYs)
maraviroc oral tablet 300 mg PG
QL (120 TABLETS per 30
DAYs)
nevirapine er oral tablet extended release 24 hour 100 mg PG
QL (90 TABLETS per 30
days)
nevirapine er oral tablet extended release 24 hour 400 mg PG
QL (30 TABLETS per 30
DAYs)
nevirapine oral suspension 50 mg/5ml PG QL (1200 ML per 30 days)
nevirapine oral tablet 200 mg PG
QL (60 TABLETS per 30
DAYs)
NORVIR ORAL PACKET 100 MG (ritonavir) PB
QL (360 PACKETS per 30
DAYs)
NORVIR ORAL TABLET 100 MG (ritonavir) PB
QL (360 TABLETS per 30
DAYs)
PIFELTRO ORAL TABLET 100 MG (doravirine) NF
PREZISTA ORAL SUSPENSION 100 MG/ML (darunavir) PB QL (400 ML per 30 DAYs)
PREZISTA ORAL TABLET 150 MG (darunavir) PB
QL (180 TABLETS per 30
DAYs)
PREZISTA ORAL TABLET 600 MG (darunavir) PB
QL (60 TABLETS per 30
DAYs)
PREZISTA ORAL TABLET 75 MG (darunavir) PB
QL (300 TABLETS per 30
DAYs)
PREZISTA ORAL TABLET 800 MG (darunavir) PB
QL (30 TABLETS per 30
DAYs)
RETROVIR ORAL CAPSULE 100 MG (zidovudine) NP
QL (180 CAPSULES per 30
DAYs)
RETROVIR ORAL SYRUP 50 MG/5ML (zidovudine) NP QL (1800 ML per 30 DAYs)
REYATAZ ORAL CAPSULE 200 MG (atazanavir sulfate) NP
QL (60 CAPSULES per 30
days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
30
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
REYATAZ ORAL CAPSULE 300 MG (atazanavir sulfate) NP
QL (30 CAPSULES per 30
days)
REYATAZ ORAL PACKET 50 MG (atazanavir sulfate) NP
QL (180 PACKET per 30
days)
ritonavir oral tablet 100 mg PG
QL (360 TABLETS per 30
DAYs)
RUKOBIA ORAL TABLET EXTENDED RELEASE 12
HOUR 600 MG (fostemsavir tromethamine)
NP
QL (60 TABLETS per 30
days)
SELZENTRY ORAL SOLUTION 20 MG/ML (maraviroc) NF
SELZENTRY ORAL TABLET 150 MG, 25 MG, 300 MG,
75 MG (maraviroc)
NF
stavudine oral capsule 15 mg, 40 mg PG
QL (60 CAPSULES per 30
DAYs)
stavudine oral capsule 20 mg, 30 mg PG
QL (60 CAPSULES per 30
days)
SUNLENCA ORAL TABLET THERAPY PACK 4 X 300
MG, 5 X 300 MG (lenacapavir sodium)
NF
SUNLENCA SUBCUTANEOUS SOLUTION 463.5
MG/1.5ML (lenacapavir sodium)
NF
SUSTIVA ORAL TABLET 600 MG (efavirenz) NP
QL (30 TABLETS per 30
DAYs)
tenofovir disoproxil fumarate oral tablet 300 mg PG
QL (30 TABLETS per 30
DAYs)
TIVICAY ORAL TABLET 10 MG (dolutegravir sodium) PB
QL (240 TABLETS per 30
days)
TIVICAY ORAL TABLET 25 MG, 50 MG (dolutegravir
sodium)
PB
QL (60 TABLETS per 30
DAYs)
TIVICAY PD ORAL TABLET SOLUBLE 5 MG
(dolutegravir sodium)
PB
QL (360 TABLETS per 30
days)
TYBOST ORAL TABLET 150 MG (cobicistat) NP
QL (30 TABLETS per 30
DAYs)
VIRACEPT ORAL TABLET 250 MG, 625 MG (nelfinavir
mesylate)
NF
VIREAD ORAL POWDER 40 MG/GM (tenofovir disoproxil
fumarate)
NP QL (240 GM per 30 days)
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG, 300
MG (tenofovir disoproxil fumarate)
NP
QL (30 TABLETS per 30
days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
31
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ZIAGEN ORAL SOLUTION 20 MG/ML (abacavir sulfate) NP QL (900 ML per 30 days)
ZIAGEN ORAL TABLET 300 MG (abacavir sulfate) NP QL (60 tablets per 30 days)
zidovudine oral capsule 100 mg PG
QL (180 CAPSULES per 30
days)
zidovudine oral syrup 50 mg/5ml PG QL (1800 ML per 30 DAYs)
zidovudine oral tablet 300 mg PG
QL (60 TABLETS per 30
days)
ANTIRETROVIRAL COMBINATION AGENTS - DRUGS
TO SUPPRESS HIV/AIDS INFECTION
abacavir sulfate-lamivudine oral tablet 600-300 mg PG
QL (30 TABLETS per 30
days)
BIKTARVY ORAL TABLET 30-120-15 MG (bictegravir-
emtricitab-tenofov)
PB
QL (30 TABLETS per 30
days)
BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir-
emtricitab-tenofov)
PB
QL (30 TABLETS per 30
DAYs)
CIMDUO ORAL TABLET 300-300 MG (lamivudine-
tenofovir)
PB
QL (30 TABLETS per 30
DAYs)
COMBIVIR ORAL TABLET 150-300 MG (lamivudine-
zidovudine)
NP QL (60 tablets per 30 days)
COMPLERA ORAL TABLET 200-25-300 MG (emtricitab-
rilpivir-tenofovir)
NF
DELSTRIGO ORAL TABLET 100-300-300 MG (doravirin-
lamivudin-tenofov df)
NF
DESCOVY ORAL TABLET 120-15 MG, 200-25 MG
(emtricitabine-tenofovir af)
PB
QL (30 TABLETS per 30
DAYs)
DOVATO ORAL TABLET 50-300 MG (dolutegravir-
lamivudine)
PB
QL (30 TABLETS per 30
days)
efavirenz-emtricitab-tenofo df oral tablet 600-200-300 mg PG
QL (30 TABLETS per 30
Days)
efavirenz-lamivudine-tenofovir oral tablet 400-300-300 mg, 600-
300-300 mg
PG
QL (30 TABLETS per 30
DAYs)
emtricitabine-tenofovir df oral tablet 100-150 mg, 133-200 mg,
167-250 mg
PG
QL (30 TABLETS per 30
DAYs)
emtricitabine-tenofovir df oral tablet 200-300 mg CE
N7 (PG); N8 ($0 copay
applies for pre-exposure
prophylaxis only); QL (30
TABLETS per 30 days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
32
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
EPZICOM ORAL TABLET 600-300 MG (abacavir sulfate-
lamivudine)
NP
QL (30 TABLETS per 30
DAYs)
EVOTAZ ORAL TABLET 300-150 MG (atazanavir-
cobicistat)
PB
QL (30 TABLETS per 30
DAYs)
GENVOYA ORAL TABLET 150-150-200-10 MG (elviteg-
cobic-emtricit-tenofaf)
PB
QL (30 TABLETS per 30
DAYs)
JULUCA ORAL TABLET 50-25 MG (dolutegravir-
rilpivirine)
NP
QL (30 TABLETS per 30
DAYs)
KALETRA ORAL SOLUTION 400-100 MG/5ML
(lopinavir-ritonavir)
NP QL (480 ML per 30 days)
KALETRA ORAL TABLET 100-25 MG (lopinavir-ritonavir) NP
QL (300 TABLETS per 30
days)
KALETRA ORAL TABLET 200-50 MG (lopinavir-ritonavir) NP
QL (120 TABLETS per 30
days)
lamivudine-zidovudine oral tablet 150-300 mg PG
QL (60 TABLETS per 30
days)
lopinavir-ritonavir oral solution 400-100 mg/5ml PG QL (480 ML per 30 days)
lopinavir-ritonavir oral tablet 100-25 mg PG
QL (300 TABLETS per 30
days)
lopinavir-ritonavir oral tablet 200-50 mg PG
QL (120 TABLETS per 30
DAYs)
ODEFSEY ORAL TABLET 200-25-25 MG (emtricitab-
rilpivir-tenofov af)
PB
QL (30 TABLETS per 30
DAYs)
PREZCOBIX ORAL TABLET 800-150 MG (darunavir-
cobicistat)
PB
QL (30 TABLETS per 30
DAYs)
STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg-
cobic-emtricit-tenofdf)
NF
SYMFI LO ORAL TABLET 400-300-300 MG (efavirenz-
lamivudine-tenofovir)
NP
QL (30 TABLETS per 30
days)
SYMFI ORAL TABLET 600-300-300 MG (efavirenz-
lamivudine-tenofovir)
NP
QL (30 TABLETS per 30
days)
SYMTUZA ORAL TABLET 800-150-200-10 MG (darun-
cobic-emtricit-tenofaf)
PB
QL (30 TABLETS per 30
days)
TRIUMEQ ORAL TABLET 600-50-300 MG (abacavir-
dolutegravir-lamivud)
PB
QL (30 TABLETS per 30
DAYs)
TRIUMEQ PD ORAL TABLET SOLUBLE 60-5-30 MG
(abacavir-dolutegravir-lamivud)
PB
QL (180 TABLETS per 30
days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
33
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
TRIZIVIR ORAL TABLET 300-150-300 MG (abacavir-
lamivudine-zidovudine)
NP
QL (60 TABLETS per 30
DAYs)
TRUVADA ORAL TABLET 100-150 MG, 133-200 MG,
167-250 MG, 200-300 MG (emtricitabine-tenofovir df)
NF
ANTITUBERCULAR AGENTS - DRUGS TO TREAT
TUBERCULOSIS
cycloserine oral capsule 250 mg NP
ethambutol hcl oral tablet 100 mg, 400 mg PG
isoniazid oral syrup 50 mg/5ml PG
isoniazid oral tablet 100 mg, 300 mg PG
pretomanid oral tablet 200 mg NP PA
pyrazinamide oral tablet 500 mg PG
rifabutin oral capsule 150 mg PG
rifampin oral capsule 150 mg, 300 mg PG
SIRTURO ORAL TABLET 100 MG, 20 MG (bedaquiline
fumarate)
NPSP PA
ANTIVIRALS - DRUGS TO TREAT VIRAL INFECTIONS
acyclovir oral capsule 200 mg PG
acyclovir oral suspension 200 mg/5ml PG
acyclovir oral tablet 400 mg, 800 mg PG
adefovir dipivoxil oral tablet 10 mg PG
BARACLUDE ORAL SOLUTION 0.05 MG/ML (entecavir) NPSP
PA; QL (630 ML per 30
days)
BARACLUDE ORAL TABLET 0.5 MG, 1 MG (entecavir) NF
cidofovir intravenous solution 75 mg/ml PG
entecavir oral tablet 0.5 mg, 1 mg PG
QL (30 TABLETS per 30
days)
famciclovir oral tablet 125 mg, 250 mg, 500 mg PG
ganciclovir intravenous solution 500 mg/250ml NF
ganciclovir sodium intravenous solution 500 mg/10ml NF
ganciclovir sodium intravenous solution reconstituted 500 mg PG
lamivudine oral tablet 100 mg PG
LIVTENCITY ORAL TABLET 200 MG (maribavir) NPSP
PA; QL (120 TABLETS per
30 days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
34
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
oseltamivir phosphate oral capsule 30 mg PG
QL (40 CAPSULES per 90
days)
oseltamivir phosphate oral capsule 45 mg, 75 mg PG
QL (20 CAPSULES per 90
days)
oseltamivir phosphate oral suspension reconstituted 6 mg/ml PG QL (360 ML per 90 days)
PREVYMIS ORAL TABLET 240 MG, 480 MG (letermovir) NP QL (1 TABLET per 1 DAY)
RELENZA DISKHALER INHALATION AEROSOL
POWDER BREATH ACTIVATED 5 MG/ACT (zanamivir)
PB QL (2 inhalers per 90 days)
rimantadine hcl oral tablet 100 mg PG
SITAVIG BUCCAL TABLET 50 MG (acyclovir) NF
TAMIFLU ORAL CAPSULE 30 MG (oseltamivir phosphate) NP
QL (40 CAPSULES per 90
DAYs)
TAMIFLU ORAL CAPSULE 45 MG, 75 MG (oseltamivir
phosphate)
NP
QL (20 CAPSULES per 90
DAYs)
TAMIFLU ORAL SUSPENSION RECONSTITUTED 6
MG/ML (oseltamivir phosphate)
NP QL (360 ML per 90 days)
valacyclovir hcl oral tablet 1 gm, 500 mg PG
VALCYTE ORAL SOLUTION RECONSTITUTED 50
MG/ML (valganciclovir hcl)
NF
VALCYTE ORAL TABLET 450 MG (valganciclovir hcl) NF
valganciclovir hcl oral solution reconstituted 50 mg/ml PG
PA; QL (1000 ML per 30
days)
valganciclovir hcl oral tablet 450 mg PG
PA; QL (120 TABLETS per
30 days)
VALTREX ORAL TABLET 1 GM, 500 MG (valacyclovir
hcl)
NF
VEMLIDY ORAL TABLET 25 MG (tenofovir alafenamide
fumarate)
NF
XERESE EXTERNAL CREAM 5-1 % (acyclovir-
hydrocortisone)
NF
XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY
PACK 1 X 40 MG (baloxavir marboxil)
NF
XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY
PACK 1 X 80 MG (baloxavir marboxil)
NF
CEPHALOSPORINS - DRUGS TO TREAT INFECTIONS
cefaclor oral capsule 250 mg, 500 mg PG
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
35
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml,
375 mg/5ml
PG
cefadroxil oral capsule 500 mg PG
cefadroxil oral suspension reconstituted 250 mg/5ml, 500
mg/5ml
PG
cefadroxil oral tablet 1 gm PG
cefdinir oral capsule 300 mg PG
cefdinir oral suspension reconstituted 125 mg/5ml, 250 mg/5ml PG
cefixime oral capsule 400 mg NP
cefixime oral suspension reconstituted 100 mg/5ml, 200 mg/5ml NP
cefpodoxime proxetil oral suspension reconstituted 100 mg/5ml,
50 mg/5ml
PG
cefpodoxime proxetil oral tablet 100 mg, 200 mg PG
cefprozil oral suspension reconstituted 125 mg/5ml, 250 mg/5ml PG
cefprozil oral tablet 250 mg, 500 mg PG
cefuroxime axetil oral tablet 250 mg, 500 mg PG
cephalexin oral capsule 250 mg, 500 mg PG
N8 (Listing does not include
certain NDCs)
cephalexin oral capsule 750 mg PG
cephalexin oral suspension reconstituted 125 mg/5ml, 250
mg/5ml
PG
cephalexin oral tablet 250 mg, 500 mg PG
SUPRAX ORAL CAPSULE 400 MG (cefixime) PB
SUPRAX ORAL SUSPENSION RECONSTITUTED 200
MG/5ML, 500 MG/5ML (cefixime)
PB
SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG
(cefixime)
PB
ERYTHROMYCINS/MACROLIDES - DRUGS TO
TREAT INFECTIONS
azithromycin oral packet 1 gm PG
azithromycin oral suspension reconstituted 100 mg/5ml, 200
mg/5ml
PG
azithromycin oral tablet 250 mg, 500 mg, 600 mg PG
clarithromycin er oral tablet extended release 24 hour 500 mg PG
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
36
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
clarithromycin oral suspension reconstituted 125 mg/5ml, 250
mg/5ml
PG
clarithromycin oral tablet 250 mg, 500 mg PG
DIFICID ORAL SUSPENSION RECONSTITUTED 40
MG/ML (fidaxomicin)
PB
DIFICID ORAL TABLET 200 MG (fidaxomicin) PB
E.E.S. GRANULES ORAL SUSPENSION
RECONSTITUTED 200 MG/5ML (erythromycin
ethylsuccinate)
NF
ERYPED 200 ORAL SUSPENSION RECONSTITUTED
200 MG/5ML (erythromycin ethylsuccinate)
NF
ERYPED 400 ORAL SUSPENSION RECONSTITUTED
400 MG/5ML (erythromycin ethylsuccinate)
NF
erythromycin base (Ery-Tab Oral Tablet Delayed Release 250
Mg, 333 Mg, 500 Mg)
PG
ERYTHROCIN STEARATE ORAL TABLET 250 MG
(erythromycin stearate)
PG
erythromycin base oral capsule delayed release particles 250 mg PG
erythromycin base oral tablet 250 mg, 500 mg PG
erythromycin ethylsuccinate oral suspension reconstituted 200
mg/5ml, 400 mg/5ml
PG
erythromycin ethylsuccinate oral tablet 400 mg PG
FLUOROQUINOLONES - DRUGS TO TREAT
INFECTIONS
ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg PG
levofloxacin oral solution 25 mg/ml PG
levofloxacin oral tablet 250 mg, 500 mg, 750 mg PG
moxifloxacin hcl oral tablet 400 mg PG
HEPATITIS C
EPCLUSA ORAL PACKET 150-37.5 MG, 200-50 MG
(sofosbuvir-velpatasvir)
PSP
PA; IBC (Preferred for all
genotypes); QL (28
PELLETS per 28 DAYs)
EPCLUSA ORAL TABLET 200-50 MG (sofosbuvir-
velpatasvir)
PSP
PA; IBC (Preferred for all
genotypes); QL (28
TABLETS per 28 DAYs)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
37
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
EPCLUSA ORAL TABLET 400-100 MG (sofosbuvir-
velpatasvir)
PSP
PA; IBC (Preferred for all
genotypes); QL (28
TABLETS per 28 days)
HARVONI ORAL PACKET 33.75-150 MG, 45-200 MG
(ledipasvir-sofosbuvir)
PSP
PA; QL (28 PACKET per
28 DAYs)
HARVONI ORAL TABLET 45-200 MG, 90-400 MG
(ledipasvir-sofosbuvir)
PSP
PA; IBC (Preferred for
genotypes 1,4,5,6); QL (28
TABLETS per 28 days)
ledipasvir-sofosbuvir oral tablet 90-400 mg NF
MAVYRET ORAL PACKET 50-20 MG (glecaprevir-
pibrentasvir)
NF
MAVYRET ORAL TABLET 100-40 MG (glecaprevir-
pibrentasvir)
NF
PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML
(peginterferon alfa-2a)
NF
PEGASYS SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 180 MCG/0.5ML (peginterferon alfa-2a)
NF
ribavirin oral capsule 200 mg PG PA
ribavirin oral tablet 200 mg PG PA
sofosbuvir-velpatasvir oral tablet 400-100 mg NF
SOVALDI ORAL PACKET 150 MG, 200 MG (sofosbuvir) NPSP
PA; QL (28 PELLETS per
28 days)
SOVALDI ORAL TABLET 200 MG, 400 MG (sofosbuvir) NPSP
PA; QL (28 TABLETS per
28 days)
VOSEVI ORAL TABLET 400-100-100 MG (sofosbuv-
velpatasv-voxilaprev)
PSP
PA; IBC (Preferred for all
genotypes); QL (28
TABLETS per 28 days)
ZEPATIER ORAL TABLET 50-100 MG (elbasvir-
grazoprevir)
NF
MISCELLANEOUS
ALINIA ORAL SUSPENSION RECONSTITUTED 100
MG/5ML (nitazoxanide)
NP
QL (540 ML per 25 DAYs);
AL (Min 1 Years)
ALINIA ORAL TABLET 500 MG (nitazoxanide) NP
QL (20 TABLETS per 25
DAYs); AL (Min 12 Years)
atovaquone oral suspension 750 mg/5ml PG
clindamycin hcl oral capsule 150 mg, 300 mg, 75 mg PG
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
38
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
clindamycin palmitate hcl oral solution reconstituted 75 mg/5ml PG
colistimethate sodium (cba) injection solution reconstituted 150
mg
PG
dapsone oral tablet 100 mg, 25 mg PG
DARAPRIM ORAL TABLET 25 MG (pyrimethamine) NF
FIRVANQ ORAL SOLUTION RECONSTITUTED 25
MG/ML, 50 MG/ML (vancomycin hcl)
NF
linezolid oral suspension reconstituted 100 mg/5ml PG PA
linezolid oral tablet 600 mg PG
PA; N8 (Listing does not
include certain NDCs)
MACRODANTIN ORAL CAPSULE 100 MG, 25 MG, 50
MG (nitrofurantoin macrocrystal)
NF
MEPRON ORAL SUSPENSION 750 MG/5ML (atovaquone) PB
methenamine hippurate oral tablet 1 gm PG
methenamine mandelate oral tablet 0.5 gm, 1 gm PG
metronidazole oral capsule 375 mg PG
metronidazole oral tablet 250 mg, 500 mg PG
nitazoxanide oral tablet 500 mg PG
QL (20 TABLETS per 25
DAYs); AL (Min 12 Years)
nitrofurantoin macrocrystal oral capsule 100 mg, 25 mg, 50 mg PG
nitrofurantoin monohyd macro oral capsule 100 mg PG
nitrofurantoin oral suspension 25 mg/5ml NP
N8 (Listing does not include
certain NDCs)
pentamidine isethionate inhalation solution reconstituted 300 mg PG
pyrimethamine oral tablet 25 mg PG
SIVEXTRO ORAL TABLET 200 MG (tedizolid phosphate) NP PA
SOLOSEC ORAL PACKET 2 GM (secnidazole) NF
VANCOCIN ORAL CAPSULE 125 MG (vancomycin hcl) NP
QL (80 CAPSULES per 10
Days)
vancomycin hcl oral capsule 125 mg, 250 mg NP
QL (80 CAPSULES per 10
days)
vancomycin hcl oral solution reconstituted 25 mg/ml, 50 mg/ml NF
vancomycin hcl oral solution reconstituted 250 mg/5ml NP QL (450 ML per 10 DAYs)
XIFAXAN ORAL TABLET 200 MG (rifaximin) NF
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
39
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
XIFAXAN ORAL TABLET 550 MG (rifaximin) PB PA
ZYVOX ORAL SUSPENSION RECONSTITUTED 100
MG/5ML (linezolid)
NF
ZYVOX ORAL TABLET 600 MG (linezolid) NF
PENICILLINS - DRUGS TO TREAT INFECTIONS
amoxicillin oral capsule 250 mg, 500 mg PG
amoxicillin oral suspension reconstituted 125 mg/5ml, 200
mg/5ml, 250 mg/5ml, 400 mg/5ml
PG
amoxicillin oral tablet 500 mg, 875 mg PG
amoxicillin oral tablet chewable 125 mg, 250 mg PG
amoxicillin-pot clavulanate er oral tablet extended release 12
hour 1000-62.5 mg
PG
amoxicillin-pot clavulanate oral suspension reconstituted 200-
28.5 mg/5ml, 250-62.5 mg/5ml, 400-57 mg/5ml, 600-42.9
mg/5ml
PG
amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg PG
amoxicillin-pot clavulanate oral tablet 875-125 mg PG
N8 (Listing does not include
certain NDCs)
amoxicillin-pot clavulanate oral tablet chewable 200-28.5 mg,
400-57 mg
PG
ampicillin oral capsule 500 mg PG
dicloxacillin sodium oral capsule 250 mg, 500 mg PG
penicillin v potassium oral solution reconstituted 125 mg/5ml,
250 mg/5ml
PG
penicillin v potassium oral tablet 250 mg, 500 mg PG
TETRACYCLINES - DRUGS TO TREAT INFECTIONS
demeclocycline hcl oral tablet 150 mg, 300 mg NP
DORYX MPC ORAL TABLET DELAYED RELEASE 120
MG, 60 MG (doxycycline hyclate)
NF
DORYX ORAL TABLET DELAYED RELEASE 200 MG,
50 MG, 80 MG (doxycycline hyclate)
NF
doxycycline hyclate oral capsule 100 mg, 50 mg PG
doxycycline hyclate oral tablet 100 mg PG
doxycycline hyclate oral tablet 150 mg, 50 mg, 75 mg NF
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
40
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
doxycycline hyclate oral tablet 20 mg PG
N8 (Listing does not include
certain NDCs)
doxycycline hyclate oral tablet delayed release 100 mg, 150 mg,
200 mg, 50 mg, 75 mg, 80 mg
NF
doxycycline monohydrate oral capsule 100 mg, 50 mg PG
doxycycline monohydrate oral capsule 150 mg, 75 mg NF
doxycycline monohydrate oral suspension reconstituted 25
mg/5ml
PG
doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75
mg
NP
minocycline hcl er oral capsule extended release 24 hour 135 mg,
45 mg, 90 mg
NF
minocycline hcl er oral tablet extended release 24 hour 105 mg,
115 mg, 135 mg, 45 mg, 55 mg, 65 mg, 80 mg, 90 mg
NF
minocycline hcl oral capsule 100 mg, 50 mg, 75 mg PG
minocycline hcl oral tablet 100 mg, 50 mg, 75 mg NP
MINOLIRA ORAL TABLET EXTENDED RELEASE 24
HOUR 105 MG, 135 MG (minocycline hcl)
NF
NUZYRA ORAL TABLET 150 MG (omadacycline tosylate) NPSP
PA; QL (30 TABLETS per
14 DAYs)
SEYSARA ORAL TABLET 100 MG, 150 MG, 60 MG
(sarecycline hcl)
NF
SOLODYN ORAL TABLET EXTENDED RELEASE 24
HOUR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG
(minocycline hcl)
NF
doxycycline hyclate (Targadox Oral Tablet 50 Mg) NF
tetracycline hcl oral capsule 250 mg, 500 mg PG
QL (120 CAPSULES per 25
days)
VIBRAMYCIN ORAL SUSPENSION RECONSTITUTED
25 MG/5ML (doxycycline monohydrate)
NP
XIMINO ORAL CAPSULE EXTENDED RELEASE 24
HOUR 135 MG, 45 MG, 90 MG (minocycline hcl)
NF
ANTINEOPLASTIC AGENTS - DRUGS TO TREAT
CANCER
ALKYLATING AGENTS
ALKERAN ORAL TABLET 2 MG (melphalan) CE N7 (NP)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
41
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
cyclophosphamide oral capsule 25 mg, 50 mg CE N7 (PG)
GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG
(lomustine)
CE N7 (NPSP)
LEUKERAN ORAL TABLET 2 MG (chlorambucil) CE N7 (PB)
MATULANE ORAL CAPSULE 50 MG (procarbazine hcl) CE N7 (PSP)
melphalan oral tablet 2 mg CE N7 (PG)
MYLERAN ORAL TABLET 2 MG (busulfan) CE N7 (PB)
temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250
mg, 5 mg
CE PA; N7 (PG)
ANTIMETABOLITES
capecitabine oral tablet 150 mg, 500 mg CE PA; N7 (PG)
INQOVI ORAL TABLET 35-100 MG (decitabine-
cedazuridine)
CE
PA; N7 (NPSP); QL (5
TABLETS per 28 days)
LONSURF ORAL TABLET 15-6.14 MG (trifluridine-
tipiracil)
CE
PA; N7 (PSP); QL (100
TABLETS per 30 days)
LONSURF ORAL TABLET 20-8.19 MG (trifluridine-
tipiracil)
CE
PA; N7 (PSP); QL (80
TABLETS per 30 days)
mercaptopurine oral tablet 50 mg CE N7 (PG)
methotrexate sodium (pf) injection solution 1 gm/40ml, 250
mg/10ml, 50 mg/2ml
PG
methotrexate sodium injection solution 250 mg/10ml, 50 mg/2ml PG
methotrexate sodium injection solution reconstituted 1 gm PG
ONUREG ORAL TABLET 200 MG, 300 MG (azacitidine) CE
PA; N7 (NPSP); QL (14
TABLETS per 28 days)
PURIXAN ORAL SUSPENSION 2000 MG/100ML
(mercaptopurine)
CE PA; N7 (NPSP)
TABLOID ORAL TABLET 40 MG (thioguanine) CE N7 (PB)
TREXALL ORAL TABLET 10 MG, 15 MG, 5 MG, 7.5 MG
(methotrexate sodium)
CE N7 (PB)
XATMEP ORAL SOLUTION 2.5 MG/ML (methotrexate) CE N7 (NPSP)
XELODA ORAL TABLET 150 MG, 500 MG (capecitabine) CE PA; ST; N7 (NPSP)
ANTINEOPLASTIC, BCL-2 INHIBITORS
VENCLEXTA ORAL TABLET 10 MG, 50 MG (venetoclax) CE
PA; N7 (NPSP); QL (120
TABLETS per 30 days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
42
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
VENCLEXTA ORAL TABLET 100 MG (venetoclax) CE
PA; N7 (NPSP); QL (180
TABLETS per 30 days)
VENCLEXTA STARTING PACK ORAL TABLET
THERAPY PACK 10 & 50 & 100 MG (venetoclax)
CE
PA; N7 (NPSP); QL (1
TABLET THERAPY
PACK per 28 days)
BIOLOGIC RESPONSE MODIFIERS
BESREMI SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 500 MCG/ML (ropeginterferon alfa-2b-njft)
NPSP
PA; QL (2 SYRINGES per
28 days)
DAURISMO ORAL TABLET 100 MG, 25 MG (glasdegib
maleate)
CE N7 (NF)
ERIVEDGE ORAL CAPSULE 150 MG (vismodegib) CE
PA; N7 (PSP); QL (30
CAPSULES per 30 days)
POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG
(pomalidomide)
CE
PA; N7 (NPSP); QL (21
CAPSULES per 28 days)
REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 5
MG (lenalidomide)
CE
PA; N7 (PSP); QL (28
CAPSULES per 28 days)
REVLIMID ORAL CAPSULE 20 MG, 25 MG
(lenalidomide)
CE
PA; N7 (PSP); QL (21
CAPSULES per 28 days)
THALOMID ORAL CAPSULE 100 MG, 50 MG
(thalidomide)
PSP
PA; QL (28 CAPSULES per
28 days)
THALOMID ORAL CAPSULE 150 MG, 200 MG
(thalidomide)
PSP
PA; QL (56 CAPSULES per
28 days)
HORMONAL ANTINEOPLASTIC AGENTS
abiraterone acetate oral tablet 250 mg CE
PA; N7 (PSP); QL (120
TABLETS per 30 days)
abiraterone acetate oral tablet 500 mg CE
PA; N7 (PSP); QL (60
TABLETS per 30 DAYs)
anastrozole oral tablet 1 mg CE
N7 (PG); AL (Min 35
Years)
bicalutamide oral tablet 50 mg CE N7 (PG)
ELIGARD SUBCUTANEOUS KIT 22.5 MG (leuprolide
acetate (3 month))
PSP PA
ELIGARD SUBCUTANEOUS KIT 30 MG (leuprolide
acetate (4 month))
PSP PA
ELIGARD SUBCUTANEOUS KIT 45 MG (leuprolide
acetate (6 month))
PSP PA
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
43
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ELIGARD SUBCUTANEOUS KIT 7.5 MG (leuprolide
acetate)
PSP PA
ERLEADA ORAL TABLET 240 MG (apalutamide) CE
PA; N7 (PSP); QL (30
TABLETS per 30 DAYs)
ERLEADA ORAL TABLET 60 MG (apalutamide) CE
PA; N7 (PSP); QL (120
TABLETS per 30 days)
EULEXIN ORAL CAPSULE 125 MG (flutamide) CE N7 (NF)
exemestane oral tablet 25 mg CE
N7 (PG); AL (Min 35
Years)
FASLODEX INTRAMUSCULAR SOLUTION
PREFILLED SYRINGE 250 MG/5ML (fulvestrant)
NPSP PA
FIRMAGON (240 MG DOSE) SUBCUTANEOUS
SOLUTION RECONSTITUTED 120 MG/VIAL (degarelix
acetate)
NF
FIRMAGON SUBCUTANEOUS SOLUTION
RECONSTITUTED 80 MG (degarelix acetate)
NF
fulvestrant intramuscular solution prefilled syringe 250 mg/5ml PSP PA
letrozole oral tablet 2.5 mg CE N7 (PG)
leuprolide acetate injection kit 1 mg/0.2ml PSP PA
LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT
3.75 MG (leuprolide acetate)
NPSP PA
LUPRON DEPOT (1-MONTH) INTRAMUSCULAR KIT
7.5 MG (leuprolide acetate)
NF
LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT
11.25 MG (leuprolide acetate (3 month))
NPSP PA
LUPRON DEPOT (3-MONTH) INTRAMUSCULAR KIT
22.5 MG (leuprolide acetate (3 month))
NF
LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT
30 MG (leuprolide acetate (4 month))
NF
LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT
45 MG (leuprolide acetate (6 month))
NF
LYSODREN ORAL TABLET 500 MG (mitotane) CE N7 (PSP)
megestrol acetate oral suspension 40 mg/ml CE N7 (PG)
megestrol acetate oral tablet 20 mg, 40 mg CE N7 (PG)
NILANDRON ORAL TABLET 150 MG (nilutamide) CE N7 (NF)
nilutamide oral tablet 150 mg CE N7 (PG)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
44
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
NUBEQA ORAL TABLET 300 MG (darolutamide) CE
PA; N7 (PSP); QL (120
TABLETS per 30 days)
ORGOVYX ORAL TABLET 120 MG (relugolix) CE
PA; N7 (NPSP); QL (30
TABLETS per 30 days)
ORSERDU ORAL TABLET 345 MG, 86 MG (elacestrant
hydrochloride)
CE N7 (NF)
tamoxifen citrate oral tablet 10 mg, 20 mg CE
N7 (PG); AL (Min 35
Years)
toremifene citrate oral tablet 60 mg CE N7 (PG)
TRELSTAR MIXJECT INTRAMUSCULAR
SUSPENSION RECONSTITUTED 11.25 MG, 22.5 MG,
3.75 MG (triptorelin pamoate)
NF
XTANDI ORAL CAPSULE 40 MG (enzalutamide) CE
PA; N7 (PSP); QL (120
CAPSULES per 30 days)
XTANDI ORAL TABLET 40 MG (enzalutamide) CE
PA; N7 (PSP); QL (120
TABLETS per 30 DAYs)
XTANDI ORAL TABLET 80 MG (enzalutamide) CE
PA; N7 (PSP); QL (60
TABLETS per 30 DAYs)
YONSA ORAL TABLET 125 MG (abiraterone acetate
micronized)
CE
PA; N7 (PSP); QL (120
TABLETS per 30 days)
ZYTIGA ORAL TABLET 250 MG, 500 MG (abiraterone
acetate)
CE N7 (NF)
KINASE INHIBITORS
AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3
MG, 5 MG (everolimus)
CE N7 (Not Covered)
AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5
MG (everolimus)
CE N7 (NF)
ALECENSA ORAL CAPSULE 150 MG (alectinib hcl) CE
PA; N7 (PSP); QL (240
CAPSULES per 30 days)
ALUNBRIG ORAL TABLET 180 MG, 90 MG (brigatinib) CE
PA; N7 (PSP); QL (30
TABLETS per 30 days)
ALUNBRIG ORAL TABLET 30 MG (brigatinib) CE
PA; N7 (PSP); QL (120
TABLETS per 30 days)
ALUNBRIG ORAL TABLET THERAPY PACK 90 & 180
MG (brigatinib)
CE
PA; N7 (PSP); QL (30
TABLETS per 30 days)
AYVAKIT ORAL TABLET 100 MG, 200 MG, 25 MG, 300
MG, 50 MG (avapritinib)
CE N7 (NF)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
45
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
BALVERSA ORAL TABLET 3 MG (erdafitinib) CE
PA; N7 (NPSP); QL (84
TABLETS per 28 days)
BALVERSA ORAL TABLET 4 MG (erdafitinib) CE
PA; N7 (NPSP); QL (56
TABLETS per 28 days)
BALVERSA ORAL TABLET 5 MG (erdafitinib) CE
PA; N7 (NPSP); QL (28
TABLETS per 28 days)
BOSULIF ORAL TABLET 100 MG (bosutinib) CE
PA; N7 (PSP); QL (90
TABLETS per 30 days)
BOSULIF ORAL TABLET 400 MG, 500 MG (bosutinib) CE
PA; N7 (PSP); QL (30
TABLETS per 30 days)
BRAFTOVI ORAL CAPSULE 75 MG (encorafenib) CE
PA; N7 (PSP); QL (180
CAPSULES per 30 days)
BRUKINSA ORAL CAPSULE 80 MG (zanubrutinib) CE
PA; N7 (PSP); QL (120
CAPSULES per 30 days)
CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG
(cabozantinib s-malate)
CE
PA; N7 (PSP); QL (30
TABLETS per 30 days)
CALQUENCE ORAL TABLET 100 MG (acalabrutinib
maleate)
CE
PA; N7 (PSP); QL (60
TABLETS per 30 days)
CAPRELSA ORAL TABLET 100 MG (vandetanib) CE
PA; N7 (NPSP); QL (60
TABLETS per 30 days)
CAPRELSA ORAL TABLET 300 MG (vandetanib) CE
PA; N7 (NPSP); QL (30
TABLETS per 30 days)
COMETRIQ (100 MG DAILY DOSE) ORAL KIT 80 & 20
MG (cabozantinib s-malate)
CE
PA; N7 (NPSP); QL (56
CAPSULES per 28 days)
COMETRIQ (140 MG DAILY DOSE) ORAL KIT 3 X 20
MG & 80 MG (cabozantinib s-malate)
CE
PA; N7 (NPSP); QL (112
CAPSULES per 28 days)
COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG
(cabozantinib s-malate)
CE
PA; N7 (NPSP); QL (1 KIT
per 28 days)
COPIKTRA ORAL CAPSULE 15 MG, 25 MG (duvelisib) CE
PA; N7 (PSP); QL (56
CAPSULES per 28 days)
COTELLIC ORAL TABLET 20 MG (cobimetinib fumarate) CE
PA; N7 (PSP); QL (63
TABLETS per 21 days)
erlotinib hcl oral tablet 100 mg, 150 mg CE
PA; N7 (PSP); QL (30
TABLETS per 30 DAYs)
erlotinib hcl oral tablet 25 mg CE
PA; N7 (PSP); QL (60
TABLETS per 30 days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
46
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
everolimus oral tablet 10 mg, 2.5 mg, 5 mg, 7.5 mg CE
PA; N7 (PSP); QL (30
TABLETS per 30 DAYs)
everolimus oral tablet soluble 2 mg, 5 mg CE
PA; N7 (PSP); QL (60
TABLETS per 30 DAYs)
everolimus oral tablet soluble 3 mg CE
PA; N7 (PSP); QL (90
TABLETS per 30 DAYs)
EXKIVITY ORAL CAPSULE 40 MG (mobocertinib
succinate)
CE N7 (NF)
FOTIVDA ORAL CAPSULE 0.89 MG, 1.34 MG (tivozanib
hcl)
CE N7 (NF)
GAVRETO ORAL CAPSULE 100 MG (pralsetinib) CE
PA; N7 (PSP); QL (120
CAPSULES per 30 days)
gefitinib oral tablet 250 mg CE
PA; N7 (PSP); QL (30
TABLETS per 30 DAYs)
GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG
(afatinib dimaleate)
CE
PA; N7 (NPSP); QL (30
TABLETS per 30 days)
GLEEVEC ORAL TABLET 100 MG, 400 MG (imatinib
mesylate)
CE N7 (NF)
IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG
(palbociclib)
CE
PA; N7 (PSP); QL (21
CAPSULES per 28 days)
IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG
(palbociclib)
CE
PA; N7 (PSP); QL (21
TABLETS per 28 days)
ICLUSIG ORAL TABLET 10 MG, 15 MG, 30 MG, 45 MG
(ponatinib hcl)
CE N7 (NF)
imatinib mesylate oral tablet 100 mg CE
PA; N7 (PG); QL (120
TABLETS per 30 days)
imatinib mesylate oral tablet 400 mg CE
PA; N7 (PG); QL (60
TABLETS per 30 days)
IMBRUVICA ORAL CAPSULE 140 MG (ibrutinib) CE
PA; N7 (PSP); QL (90
CAPSULES per 30 days)
IMBRUVICA ORAL CAPSULE 70 MG (ibrutinib) CE
PA; N7 (PSP); QL (30
CAPSULES per 30 days)
IMBRUVICA ORAL SUSPENSION 70 MG/ML (ibrutinib) CE
PA; N7 (PSP); QL (216 ML
per 36 days)
IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG
(ibrutinib)
CE
PA; N7 (PSP); QL (30
TABLETS per 30 days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
47
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
INLYTA ORAL TABLET 1 MG (axitinib) CE
PA; N7 (PSP); QL (240
TABLETS per 30 days)
INLYTA ORAL TABLET 5 MG (axitinib) CE
PA; N7 (PSP); QL (120
TABLETS per 30 days)
INREBIC ORAL CAPSULE 100 MG (fedratinib hcl) CE N7 (NF)
IRESSA ORAL TABLET 250 MG (gefitinib) CE
PA; N7 (PSP); QL (30
TABLETS per 30 days)
JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5
MG (ruxolitinib phosphate)
CE
PA; N7 (NPSP); QL (60
TABLETS per 30 days)
JAYPIRCA ORAL TABLET 100 MG, 50 MG (pirtobrutinib) CE N7 (NF)
KISQALI (200 MG DOSE) ORAL TABLET THERAPY
PACK 200 MG (ribociclib succinate)
CE
PA; N7 (PSP); QL (63
TABLETS per 28 days)
KISQALI (400 MG DOSE) ORAL TABLET THERAPY
PACK 200 MG (ribociclib succinate)
CE
PA; N7 (PSP); QL (63
TABLETS per 28 days)
KISQALI (600 MG DOSE) ORAL TABLET THERAPY
PACK 200 MG (ribociclib succinate)
CE
PA; N7 (PSP); QL (63
TABLETS per 28 days)
KISQALI FEMARA (200 MG DOSE) ORAL TABLET
THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole)
CE
PA; N7 (PSP); QL (49
TABLETS per 28 days)
KISQALI FEMARA (400 MG DOSE) ORAL TABLET
THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole)
CE
PA; N7 (PSP); QL (70
TABLETS per 28 days)
KISQALI FEMARA (600 MG DOSE) ORAL TABLET
THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole)
CE
PA; N7 (PSP); QL (91
TABLETS per 28 days)
KOSELUGO ORAL CAPSULE 10 MG (selumetinib sulfate) CE
PA; N7 (PSP); QL (240
CAPSULES per 30 days)
KOSELUGO ORAL CAPSULE 25 MG (selumetinib sulfate) CE
PA; N7 (PSP); QL (120
CAPSULES per 30 days)
lapatinib ditosylate oral tablet 250 mg CE
PA; N7 (PSP); QL (180
TABLETS per 30 DAYs)
LENVIMA (10 MG DAILY DOSE) ORAL CAPSULE
THERAPY PACK 10 MG (lenvatinib mesylate)
CE
PA; N7 (PSP); QL (30
CAPSULES per 30 days)
LENVIMA (12 MG DAILY DOSE) ORAL CAPSULE
THERAPY PACK 3 X 4 MG (lenvatinib mesylate)
CE
PA; N7 (PSP); QL (90
CAPSULES per 30 days)
LENVIMA (14 MG DAILY DOSE) ORAL CAPSULE
THERAPY PACK 10 & 4 MG (lenvatinib mesylate)
CE
PA; N7 (PSP); QL (60
CAPSULES per 30 days)
LENVIMA (18 MG DAILY DOSE) ORAL CAPSULE
THERAPY PACK 10 MG & 2 X 4 MG (lenvatinib mesylate)
CE
PA; N7 (PSP); QL (90
CAPSULES per 30 days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
48
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
LENVIMA (20 MG DAILY DOSE) ORAL CAPSULE
THERAPY PACK 2 X 10 MG (lenvatinib mesylate)
CE
PA; N7 (PSP); QL (60
CAPSULES per 30 days)
LENVIMA (24 MG DAILY DOSE) ORAL CAPSULE
THERAPY PACK 2 X 10 MG & 4 MG (lenvatinib mesylate)
CE
PA; N7 (PSP); QL (90
CAPSULES per 30 days)
LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE
THERAPY PACK 4 MG (lenvatinib mesylate)
CE
PA; N7 (PSP); QL (30
CAPSULES per 30 days)
LENVIMA (8 MG DAILY DOSE) ORAL CAPSULE
THERAPY PACK 2 X 4 MG (lenvatinib mesylate)
CE
PA; N7 (PSP); QL (60
CAPSULES per 30 days)
LORBRENA ORAL TABLET 100 MG (lorlatinib) CE
PA; N7 (NPSP); QL (30
TABLETS per 30 days)
LORBRENA ORAL TABLET 25 MG (lorlatinib) CE
PA; N7 (NPSP); QL (90
TABLETS per 30 days)
lytgobi (12 mg daily dose) oral tablet therapy pack 4 mg CE N7 (NF)
lytgobi (16 mg daily dose) oral tablet therapy pack 4 mg CE N7 (NF)
lytgobi (20 mg daily dose) oral tablet therapy pack 4 mg CE N7 (NF)
MEKINIST ORAL TABLET 0.5 MG (trametinib dimethyl
sulfoxide)
CE N7 (NF)
MEKINIST ORAL TABLET 2 MG (trametinib dimethyl
sulfoxide)
CE N7 (Not Covered)
MEKTOVI ORAL TABLET 15 MG (binimetinib) CE
PA; N7 (PSP); QL (180
TABLETS per 30 days)
NERLYNX ORAL TABLET 40 MG (neratinib maleate) CE
PA; N7 (NPSP); QL (180
TABLETS per 30 days)
NEXAVAR ORAL TABLET 200 MG (sorafenib tosylate) CE
PA; N7 (PSP); QL (120
TABLETS per 30 days)
PEMAZYRE ORAL TABLET 13.5 MG, 4.5 MG, 9 MG
(pemigatinib)
CE N7 (NF)
PIQRAY (200 MG DAILY DOSE) ORAL TABLET
THERAPY PACK 200 MG (alpelisib)
CE
PA; N7 (NPSP); QL (28
TABLETS per 28 days)
PIQRAY (250 MG DAILY DOSE) ORAL TABLET
THERAPY PACK 200 & 50 MG (alpelisib)
CE
PA; N7 (NPSP); QL (56
TABLETS per 28 days)
PIQRAY (300 MG DAILY DOSE) ORAL TABLET
THERAPY PACK 2 X 150 MG (alpelisib)
CE
PA; N7 (NPSP); QL (56
TABLETS per 28 days)
QINLOCK ORAL TABLET 50 MG (ripretinib) CE N7 (NF)
RETEVMO ORAL CAPSULE 40 MG (selpercatinib) CE
PA; N7 (PSP); QL (60
TABLETS per 30 days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
49
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
RETEVMO ORAL CAPSULE 80 MG (selpercatinib) CE
PA; N7 (PSP); QL (120
TABLETS per 30 days)
ROZLYTREK ORAL CAPSULE 100 MG (entrectinib) CE
PA; N7 (PSP); QL (30
CAPSULES per 30 days)
ROZLYTREK ORAL CAPSULE 200 MG (entrectinib) CE
PA; N7 (PSP); QL (90
CAPSULES per 30 days)
RYDAPT ORAL CAPSULE 25 MG (midostaurin) CE
PA; N7 (PSP); QL (224
CAPSULES per 28 days)
SCEMBLIX ORAL TABLET 20 MG, 40 MG (asciminib hcl) CE N7 (NF)
sorafenib tosylate oral tablet 200 mg CE
PA; N7 (PSP); QL (120
TABLETS per 30 DAYs)
SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70
MG, 80 MG (dasatinib)
CE
PA; N7 (PSP); QL (30
TABLETS per 30 days)
SPRYCEL ORAL TABLET 20 MG (dasatinib) CE
PA; N7 (PSP); QL (90
TABLETS per 30 days)
STIVARGA ORAL TABLET 40 MG (regorafenib) CE
PA; N7 (PSP); QL (84
TABLETS per 28 days)
sunitinib malate oral capsule 12.5 mg, 25 mg, 37.5 mg, 50 mg CE
PA; N7 (PSP); QL (30
CAPSULES per 30 DAYs)
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50
MG (sunitinib malate)
CE N7 (NF)
TABRECTA ORAL TABLET 150 MG, 200 MG (capmatinib
hcl)
CE N7 (NF)
TAFINLAR ORAL CAPSULE 50 MG, 75 MG (dabrafenib
mesylate)
CE N7 (Not Covered)
TAGRISSO ORAL TABLET 40 MG, 80 MG (osimertinib
mesylate)
CE
PA; N7 (PSP); QL (30
TABLETS per 30 days)
TARCEVA ORAL TABLET 100 MG, 150 MG (erlotinib hcl) CE
PA; N7 (NPSP); QL (30
TABLETS per 30 days)
TARCEVA ORAL TABLET 25 MG (erlotinib hcl) CE
PA; N7 (NPSP); QL (60
TABLETS per 30 days)
TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MG
(nilotinib hcl)
CE N7 (NF)
TEPMETKO ORAL TABLET 225 MG (tepotinib hcl) CE N7 (NF)
TUKYSA ORAL TABLET 150 MG, 50 MG (tucatinib) CE
PA; N7 (NPSP); QL (120
TABLETS per 30 days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
50
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
TURALIO ORAL CAPSULE 125 MG (pexidartinib hcl) CE N7 (NF)
TYKERB ORAL TABLET 250 MG (lapatinib ditosylate) CE
PA; N7 (NPSP); QL (180
TABLETS per 30 days)
VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50
MG (abemaciclib)
CE
PA; N7 (NPSP); QL (56
TABLETS per 28 days)
VITRAKVI ORAL CAPSULE 100 MG (larotrectinib sulfate) CE
PA; N7 (PSP); QL (60
CAPSULES per 30 days)
VITRAKVI ORAL CAPSULE 25 MG (larotrectinib sulfate) CE
PA; N7 (PSP); QL (180
CAPSULES per 30 days)
VITRAKVI ORAL SOLUTION 20 MG/ML (larotrectinib
sulfate)
CE
PA; N7 (PSP); QL (300 ML
per 30 days)
VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG
(dacomitinib)
CE N7 (NF)
VONJO ORAL CAPSULE 100 MG (pacritinib citrate) CE
PA; N7 (NPSP); QL (120
CAPSULES per 30 days)
VOTRIENT ORAL TABLET 200 MG (pazopanib hcl) CE N7 (NF)
XALKORI ORAL CAPSULE 200 MG, 250 MG (crizotinib) CE N7 (NF)
XOSPATA ORAL TABLET 40 MG (gilteritinib fumarate) CE
PA; N7 (PSP); QL (90
TABLETS per 30 days)
ZELBORAF ORAL TABLET 240 MG (vemurafenib) CE
PA; N7 (PSP); QL (240
TABLETS per 30 days)
ZYDELIG ORAL TABLET 100 MG, 150 MG (idelalisib) CE
PA; N7 (PSP); QL (60
TABLETS per 30 days)
ZYKADIA ORAL TABLET 150 MG (ceritinib) CE
PA; N7 (PSP); QL (90
TABLETS per 30 days)
MISCELLANEOUS
bexarotene oral capsule 75 mg CE PA; N7 (PSP)
hydroxyurea oral capsule 500 mg CE N7 (PG)
IDHIFA ORAL TABLET 100 MG, 50 MG (enasidenib
mesylate)
CE
PA; N7 (NPSP); QL (30
TABLETS per 30 days)
KRAZATI ORAL TABLET 200 MG (adagrasib) CE N7 (NF)
LUMAKRAS ORAL TABLET 120 MG (sotorasib) CE
PA; N7 (NPSP); QL (240
TABLETS per 30 days)
LUMAKRAS ORAL TABLET 320 MG (sotorasib) CE
PA; N7 (NPSP); QL (90
TABLETS per 30 DAYs)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
51
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
LYNPARZA ORAL TABLET 100 MG, 150 MG (olaparib) CE
PA; N7 (PSP); QL (120
TABLETS per 30 days)
ODOMZO ORAL CAPSULE 200 MG (sonidegib phosphate) CE
PA; N7 (PSP); QL (30
CAPSULES per 30 days)
REZLIDHIA ORAL CAPSULE 150 MG (olutasidenib) CE N7 (NF)
RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG
(rucaparib camsylate)
CE N7 (NF)
SYNRIBO SUBCUTANEOUS SOLUTION
RECONSTITUTED 3.5 MG (omacetaxine mepesuccinate)
NPSP PA
TALZENNA ORAL CAPSULE 0.25 MG, 0.5 MG, 0.75
MG, 1 MG (talazoparib tosylate)
CE N7 (NF)
TARGRETIN ORAL CAPSULE 75 MG (bexarotene) CE N7 (NF)
TAZVERIK ORAL TABLET 200 MG (tazemetostat hbr) CE N7 (NF)
TIBSOVO ORAL TABLET 250 MG (ivosidenib) CE
PA; N7 (NPSP); QL (60
TABLETS per 30 days)
tretinoin oral capsule 10 mg CE N7 (PG)
VISTOGARD ORAL PACKET 10 GM (uridine triacetate) PSP
QL (20 PACKETS per 5
DAYs)
WELIREG ORAL TABLET 40 MG (belzutifan) CE N7 (NF)
XPOVIO (100 MG ONCE WEEKLY) ORAL TABLET
THERAPY PACK 50 MG (selinexor)
CE
PA; N7 (NPSP); QL (8
TABLETS per 28 days)
XPOVIO (40 MG ONCE WEEKLY) ORAL TABLET
THERAPY PACK 40 MG (selinexor)
CE
PA; N7 (NPSP); QL (4
TABLETS per 28 days)
XPOVIO (40 MG TWICE WEEKLY) ORAL TABLET
THERAPY PACK 40 MG (selinexor)
CE
PA; N7 (NPSP); QL (8
TABLETS per 28 days)
XPOVIO (60 MG ONCE WEEKLY) ORAL TABLET
THERAPY PACK 60 MG (selinexor)
CE
PA; N7 (NPSP); QL (4
TABLETS per 28 days)
XPOVIO (60 MG TWICE WEEKLY) ORAL TABLET
THERAPY PACK 20 MG (selinexor)
CE
PA; N7 (NPSP); QL (24
TABLETS per 28 days)
XPOVIO (80 MG ONCE WEEKLY) ORAL TABLET
THERAPY PACK 40 MG (selinexor)
CE
PA; N7 (NPSP); QL (8
TABLETS per 28 days)
XPOVIO (80 MG TWICE WEEKLY) ORAL TABLET
THERAPY PACK 20 MG (selinexor)
CE
PA; N7 (NPSP); QL (32
TABLETS per 28 days)
ZEJULA ORAL CAPSULE 100 MG (niraparib tosylate) CE
PA; N7 (PSP); QL (90
CAPSULES per 30 days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
52
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ZOLINZA ORAL CAPSULE 100 MG (vorinostat) CE
PA; N7 (PSP); QL (120
CAPSULES per 30 days)
PROTEASOME INHIBITORS
NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG
(ixazomib citrate)
CE
PA; N7 (PSP); QL (3
CAPSULES per 28 days)
PROTECTIVE AGENTS
leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg CE N7 (PG)
TOPOISOMERASE INHIBITORS
etoposide oral capsule 50 mg CE N7 (PG)
HYCAMTIN ORAL CAPSULE 0.25 MG, 1 MG (topotecan
hcl)
CE PA; N7 (NPSP)
CARDIOVASCULAR - DRUGS TO TREAT HEART AND
CIRCULATION CONDITIONS
ACE INHIBITOR COMBINATIONS - DRUGS TO TREAT
HIGH BLOOD PRESSURE
amlodipine besy-benazepril hcl oral capsule 10-20 mg, 10-40 mg,
2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg
PG LGC
benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5
mg, 20-25 mg, 5-6.25 mg
PG LGC
captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg,
50-15 mg, 50-25 mg
NF
enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg PG LGC
fosinopril sodium-hctz oral tablet 10-12.5 mg, 20-12.5 mg PG LGC
lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5
mg, 20-25 mg
PG LGC
PRESTALIA ORAL TABLET 14-10 MG, 3.5-2.5 MG, 7-5
MG (perindopril arg-amlodipine)
NF
quinapril-hydrochlorothiazide oral tablet 20-12.5 mg, 20-25 mg PG LGC
trandolapril-verapamil hcl er oral tablet extended release 1-240
mg
PG
ZESTORETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG,
20-25 MG (lisinopril-hydrochlorothiazide)
NF
ACE INHIBITORS - DRUGS TO TREAT HIGH BLOOD
PRESSURE
benazepril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg PG LGC
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
53
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg PG LGC
enalapril maleate oral solution 1 mg/ml PG
enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg PG LGC
EPANED ORAL SOLUTION 1 MG/ML (enalapril maleate) NF
fosinopril sodium oral tablet 10 mg, 20 mg, 40 mg PG LGC
lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg PG LGC
moexipril hcl oral tablet 15 mg, 7.5 mg PG
perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg NP
quinapril hcl oral tablet 10 mg, 20 mg, 40 mg, 5 mg PG LGC
ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg PG LGC
trandolapril oral tablet 1 mg, 2 mg, 4 mg PG LGC
ALDOSTERONE RECEPTOR ANTAGONISTS - DRUGS
TO TREAT HIGH BLOOD PRESSURE
eplerenone oral tablet 25 mg, 50 mg NP
ALPHA BLOCKERS - DRUGS TO TREAT HIGH BLOOD
PRESSURE
doxazosin mesylate oral tablet 1 mg, 2 mg, 4 mg, 8 mg PG
prazosin hcl oral capsule 1 mg, 2 mg, 5 mg PG
terazosin hcl oral capsule 1 mg, 10 mg, 2 mg, 5 mg PG
LGC; N8 (Listing does not
include certain NDCs)
ANGIOTENSIN II RECEPTOR ANTAGONIST
COMBINATIONS - DRUGS TO TREAT HIGH BLOOD
PRESSURE
amlodipine besylate-valsartan oral tablet 10-160 mg, 10-320 mg,
5-160 mg, 5-320 mg
PG LGC
amlodipine-olmesartan oral tablet 10-20 mg, 10-40 mg, 5-20 mg,
5-40 mg
NP
amlodipine-valsartan-hctz oral tablet 10-160-12.5 mg, 10-160-25
mg, 10-320-25 mg, 5-160-12.5 mg, 5-160-25 mg
PG
ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5
MG, 32-25 MG (candesartan cilexetil-hctz)
NF
AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-
40 MG (amlodipine-olmesartan)
NF
BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG,
40-25 MG (olmesartan medoxomil-hctz)
NF
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
54
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
candesartan cilexetil-hctz oral tablet 16-12.5 mg, 32-12.5 mg,
32-25 mg
PG
DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG,
320-12.5 MG, 320-25 MG, 80-12.5 MG (valsartan-
hydrochlorothiazide)
NF
EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG
(azilsartan-chlorthalidone)
NF
EXFORGE HCT ORAL TABLET 10-160-12.5 MG, 10-160-
25 MG, 10-320-25 MG, 5-160-12.5 MG, 5-160-25 MG
(amlodipine-valsartan-hctz)
NF
EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160
MG, 5-320 MG (amlodipine besylate-valsartan)
NF
HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-
12.5 MG (losartan potassium-hctz)
NF
irbesartan-hydrochlorothiazide oral tablet 150-12.5 mg, 300-
12.5 mg
PG LGC
losartan potassium-hctz oral tablet 100-12.5 mg, 100-25 mg, 50-
12.5 mg
PG LGC
MICARDIS HCT ORAL TABLET 40-12.5 MG, 80-12.5
MG, 80-25 MG (telmisartan-hctz)
NF
olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg,
40-25 mg
PG
olmesartan-amlodipine-hctz oral tablet 20-5-12.5 mg, 40-10-
12.5 mg, 40-10-25 mg, 40-5-12.5 mg, 40-5-25 mg
NP
telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10
mg, 80-5 mg
NP
telmisartan-hctz oral tablet 40-12.5 mg, 80-12.5 mg, 80-25 mg PG
valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25
mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg
PG LGC
ANGIOTENSIN II RECEPTOR ANTAGONISTS - DRUGS
TO TREAT HIGH BLOOD PRESSURE
ATACAND ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG
(candesartan cilexetil)
NF
BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG
(olmesartan medoxomil)
NF
candesartan cilexetil oral tablet 16 mg, 32 mg, 4 mg, 8 mg PG LGC
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
55
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
COZAAR ORAL TABLET 100 MG, 25 MG, 50 MG
(losartan potassium)
NF
DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80
MG (valsartan)
NF
EDARBI ORAL TABLET 40 MG, 80 MG (azilsartan
medoxomil)
NF
irbesartan oral tablet 150 mg, 300 mg, 75 mg PG LGC
losartan potassium oral tablet 100 mg, 25 mg, 50 mg PG LGC
MICARDIS ORAL TABLET 20 MG, 40 MG, 80 MG
(telmisartan)
NF
olmesartan medoxomil oral tablet 20 mg, 40 mg, 5 mg PG
telmisartan oral tablet 20 mg, 40 mg, 80 mg PG LGC
valsartan oral solution 4 mg/ml NF
valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg PG LGC
ANTIARRHYTHMICS - DRUGS TO CONTROL HEART
RHYTHM
amiodarone hcl oral tablet 100 mg, 200 mg, 400 mg PG
BETAPACE AF ORAL TABLET 120 MG, 160 MG, 80 MG
(sotalol hcl af)
NF
BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG
(sotalol hcl)
NF
disopyramide phosphate oral capsule 100 mg, 150 mg PG
dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg PSP PA
flecainide acetate oral tablet 100 mg, 150 mg, 50 mg PG
MULTAQ ORAL TABLET 400 MG (dronedarone hcl) NF
NORPACE ORAL CAPSULE 100 MG, 150 MG
(disopyramide phosphate)
NF
propafenone hcl er oral capsule extended release 12 hour 225
mg, 325 mg, 425 mg
PG
propafenone hcl oral tablet 150 mg, 225 mg, 300 mg PG
quinidine sulfate oral tablet 200 mg, 300 mg NF
sotalol hcl (af) oral tablet 120 mg PG LGC
sotalol hcl (af) oral tablet 160 mg, 80 mg PG
sotalol hcl oral tablet 120 mg, 80 mg PG LGC
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
56
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
sotalol hcl oral tablet 160 mg, 240 mg PG
TIKOSYN ORAL CAPSULE 125 MCG, 250 MCG, 500
MCG (dofetilide)
NPSP PA; ST
ANTILIPEMICS, ACL INHIBITORS/COMBINATIONS -
DRUGS TO TREAT HIGH CHOLESTEROL
NEXLETOL ORAL TABLET 180 MG (bempedoic acid) PB
NEXLIZET ORAL TABLET 180-10 MG (bempedoic acid-
ezetimibe)
PB
ANTILIPEMICS, BILE ACID RESINS - DRUGS TO
TREAT HIGH CHOLESTEROL
cholestyramine light oral packet 4 gm PG
cholestyramine light oral powder 4 gm/dose PG
cholestyramine oral packet 4 gm PG
cholestyramine oral powder 4 gm/dose PG
N8 (Listing does not include
certain NDCs)
colesevelam hcl oral packet 3.75 gm PG
colesevelam hcl oral tablet 625 mg PG
colestipol hcl oral granules 5 gm PG
colestipol hcl oral packet 5 gm PG
colestipol hcl oral tablet 1 gm PG
ANTILIPEMICS, CHOLESTEROL ABSORPTION
INHIBITOR - DRUGS TO TREAT HIGH
CHOLESTEROL
ezetimibe oral tablet 10 mg PG
ZETIA ORAL TABLET 10 MG (ezetimibe) NF
ANTILIPEMICS, FIBRATES - DRUGS TO TREAT HIGH
CHOLESTEROL
fenofibrate micronized oral capsule 130 mg, 90 mg NF
fenofibrate micronized oral capsule 134 mg, 67 mg PG
fenofibrate micronized oral capsule 43 mg NP
fenofibrate oral capsule 150 mg NP
fenofibrate oral capsule 200 mg PG
fenofibrate oral capsule 50 mg NF
fenofibrate oral tablet 120 mg, 40 mg NF
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
57
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
fenofibrate oral tablet 145 mg, 160 mg, 48 mg, 54 mg PG
fenofibric acid oral capsule delayed release 135 mg, 45 mg PG
fenofibric acid oral tablet 105 mg, 35 mg NP
FENOGLIDE ORAL TABLET 120 MG (fenofibrate) NF
FIBRICOR ORAL TABLET 105 MG (fenofibric acid) NF
gemfibrozil oral tablet 600 mg PG LGC
TRICOR ORAL TABLET 145 MG, 48 MG (fenofibrate) NF
ANTILIPEMICS, HMG-COA REDUCTASE INHIBITORS
- DRUGS TO TREAT HIGH CHOLESTEROL
ALTOPREV ORAL TABLET EXTENDED RELEASE 24
HOUR 20 MG, 40 MG, 60 MG (lovastatin)
NF
ATORVALIQ ORAL SUSPENSION 20 MG/5ML
(atorvastatin calcium)
NF
atorvastatin calcium oral tablet 10 mg, 20 mg CE
LGC; N7 (PG); AL (Min 40
Years and Max 75 Years)
atorvastatin calcium oral tablet 40 mg, 80 mg PG LGC
CRESTOR ORAL TABLET 10 MG, 20 MG, 40 MG, 5 MG
(rosuvastatin calcium)
NF
EZALLOR SPRINKLE ORAL CAPSULE SPRINKLE 10
MG, 20 MG, 40 MG, 5 MG (rosuvastatin calcium)
NF
flolipid oral suspension 20 mg/5ml, 40 mg/5ml NF
fluvastatin sodium er oral tablet extended release 24 hour 80 mg PG
fluvastatin sodium oral capsule 20 mg, 40 mg PG
LESCOL XL ORAL TABLET EXTENDED RELEASE 24
HOUR 80 MG (fluvastatin sodium)
NF
LIPITOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG
(atorvastatin calcium)
NF
LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG (pitavastatin
calcium)
NF
lovastatin oral tablet 10 mg, 20 mg, 40 mg PG LGC
pravastatin sodium oral tablet 10 mg, 20 mg, 40 mg, 80 mg PG LGC
rosuvastatin calcium oral tablet 10 mg, 20 mg, 40 mg, 5 mg PG LGC
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg CE
LGC; N7 (PG); AL (Min 40
Years and Max 75 Years)
simvastatin oral tablet 80 mg PG LGC
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
58
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ZYPITAMAG ORAL TABLET 2 MG, 4 MG (pitavastatin
magnesium)
NF
ANTILIPEMICS, HMG-COA REDUCTASE
INHIBITORS/COMBINATIONS - DRUGS TO TREAT
HIGH CHOLESTEROL
ezetimibe-rosuvastatin oral tablet 10-10 mg, 10-20 mg, 10-40
mg, 10-5 mg
NF
ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg,
10-80 mg
PG
ROSZET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG,
10-5 MG (ezetimibe-rosuvastatin)
NF
ANTILIPEMICS, MISCELLANEOUS - DRUGS TO
TREAT HIGH CHOLESTEROL
JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 5
MG (lomitapide mesylate)
NF
niacin er (antihyperlipidemic) oral tablet extended release 1000
mg, 500 mg, 750 mg
PG
NIACOR ORAL TABLET 500 MG (niacin
(antihyperlipidemic))
NF
ANTILIPEMICS, OMEGA-3 FATTY ACIDS - DRUGS TO
TREAT HIGH CHOLESTEROL
icosapent ethyl oral capsule 0.5 gm, 1 gm NF
LOVAZA ORAL CAPSULE 1 GM (omega-3-acid ethyl
esters)
NF
omega-3-acid ethyl esters oral capsule 1 gm PG
VASCEPA ORAL CAPSULE 0.5 GM, 1 GM (icosapent
ethyl)
PB
N8 (Listing does not include
certain NDCs)
ANTILIPEMICS, PCSK9 INHIBITORS - DRUGS TO
TREAT HIGH CHOLESTEROL
PRALUENT SUBCUTANEOUS SOLUTION AUTO-
INJECTOR 150 MG/ML, 75 MG/ML (alirocumab)
NF
REPATHA PUSHTRONEX SYSTEM SUBCUTANEOUS
SOLUTION CARTRIDGE 420 MG/3.5ML (evolocumab)
PSP
PA; QL (1 CARTRIDGE
per 28 days)
REPATHA SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 140 MG/ML (evolocumab)
PSP
PA; QL (3 SYRINGES per
28 days)
REPATHA SURECLICK SUBCUTANEOUS SOLUTION
AUTO-INJECTOR 140 MG/ML (evolocumab)
PSP
PA; QL (3 PENS per 28
days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
59
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
BETA-BLOCKER/DIURETIC COMBINATIONS - DRUGS
TO TREAT HIGH BLOOD PRESSURE AND HEART
CONDITIONS
atenolol-chlorthalidone oral tablet 100-25 mg PG
atenolol-chlorthalidone oral tablet 50-25 mg PG
N8 (Listing does not include
certain NDCs)
bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25
mg, 5-6.25 mg
PG LGC
metoprolol-hydrochlorothiazide oral tablet 100-25 mg, 100-50
mg, 50-25 mg
PG
BETA-BLOCKERS - DRUGS TO TREAT HIGH BLOOD
PRESSURE AND HEART CONDITIONS
acebutolol hcl oral capsule 200 mg, 400 mg PG
atenolol oral tablet 100 mg, 25 mg, 50 mg PG LGC
betaxolol hcl oral tablet 10 mg, 20 mg PG
bisoprolol fumarate oral tablet 10 mg, 5 mg PG
BYSTOLIC ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG
(nebivolol hcl)
NF
carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg PG LGC
carvedilol phosphate er oral capsule extended release 24 hour 10
mg, 20 mg, 40 mg, 80 mg
NP
N8 (Listing does not include
certain NDCs)
COREG CR ORAL CAPSULE EXTENDED RELEASE 24
HOUR 10 MG, 20 MG, 40 MG, 80 MG (carvedilol phosphate)
NF
INDERAL LA ORAL CAPSULE EXTENDED RELEASE
24 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol
hcl)
NF
INDERAL XL ORAL CAPSULE EXTENDED RELEASE
24 HOUR 120 MG, 80 MG (propranolol hcl sr beads)
NF
INNOPRAN XL ORAL CAPSULE EXTENDED
RELEASE 24 HOUR 120 MG, 80 MG (propranolol hcl sr
beads)
NF
KAPSPARGO SPRINKLE ORAL CAPSULE ER 24
HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG
(metoprolol succinate)
NF
labetalol hcl oral tablet 100 mg, 200 mg, 300 mg PG
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
60
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
metoprolol succinate er oral tablet extended release 24 hour 100
mg, 200 mg, 25 mg, 50 mg
PG LGC
metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg PG LGC
metoprolol tartrate oral tablet 37.5 mg, 75 mg PG
nadolol oral tablet 20 mg, 40 mg, 80 mg PG
nebivolol hcl oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg NF
pindolol oral tablet 10 mg, 5 mg PG
propranolol hcl er oral capsule extended release 24 hour 120 mg,
160 mg, 60 mg, 80 mg
PG
propranolol hcl oral solution 20 mg/5ml, 40 mg/5ml PG
propranolol hcl oral tablet 10 mg, 20 mg, 40 mg, 80 mg PG LGC
propranolol hcl oral tablet 60 mg PG
timolol maleate oral tablet 10 mg, 20 mg, 5 mg PG
TOPROL XL ORAL TABLET EXTENDED RELEASE 24
HOUR 100 MG, 200 MG, 25 MG, 50 MG (metoprolol
succinate)
NF
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC
COMBINATIONS - DRUGS TO TREAT HIGH BLOOD
PRESSURE AND HEART CONDITIONS
amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg, 10-40
mg, 10-80 mg, 2.5-10 mg, 2.5-20 mg, 2.5-40 mg, 5-10 mg, 5-20
mg, 5-40 mg, 5-80 mg
NP
CALCIUM CHANNEL BLOCKERS - DRUGS TO TREAT
HIGH BLOOD PRESSURE AND HEART CONDITIONS
amlodipine besylate oral tablet 10 mg, 2.5 mg, 5 mg PG LGC
CARDIZEM CD ORAL CAPSULE EXTENDED
RELEASE 24 HOUR 120 MG, 180 MG, 240 MG, 300 MG,
360 MG (diltiazem hcl coated beads)
NF
CARDIZEM LA ORAL TABLET EXTENDED RELEASE
24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420
MG (diltiazem hcl)
NF
CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG
(diltiazem hcl)
NF
CONJUPRI ORAL TABLET 2.5 MG, 5 MG (levamlodipine
maleate)
NF
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
61
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
diltiazem hcl er beads oral capsule extended release 24 hour 120
mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg
PG
diltiazem hcl er coated beads oral capsule extended release 24
hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg
PG
diltiazem hcl er oral capsule extended release 12 hour 120 mg,
60 mg, 90 mg
PG
diltiazem hcl er oral tablet extended release 24 hour 120 mg NF
diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg PG LGC
dilt-xr oral capsule extended release 24 hour 120 mg, 180 mg,
240 mg
PG
felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg,
5 mg
PG
isradipine oral capsule 2.5 mg, 5 mg PG
KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine
benzoate)
NF
levamlodipine maleate oral tablet 2.5 mg, 5 mg NF
diltiazem hcl (Matzim La Oral Tablet Extended Release 24
Hour 180 Mg, 240 Mg, 300 Mg, 360 Mg, 420 Mg)
NF
nicardipine hcl oral capsule 20 mg, 30 mg PG
N8 (Listing does not include
certain NDCs)
nifedipine er oral tablet extended release 24 hour 30 mg, 60 mg,
90 mg
PG
nifedipine er osmotic release oral tablet extended release 24 hour
30 mg, 60 mg, 90 mg
PG
N8 (Listing does not include
certain NDCs)
nimodipine oral capsule 30 mg PG
nisoldipine er oral tablet extended release 24 hour 17 mg, 20 mg,
25.5 mg, 30 mg, 34 mg, 40 mg, 8.5 mg
PG
NORLIQVA ORAL SOLUTION 1 MG/ML (amlodipine
besylate)
NF
NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG
(amlodipine besylate)
NF
verapamil hcl er capsule extended release 24 hour 100 mg oral NF
verapamil hcl er capsule extended release 24 hour 100 mg oral PG
verapamil hcl er oral capsule extended release 24 hour 120 mg,
180 mg, 200 mg, 240 mg, 300 mg, 360 mg
PG
verapamil hcl er oral tablet extended release 120 mg PG LGC
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
62
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
verapamil hcl er oral tablet extended release 180 mg, 240 mg PG
verapamil hcl oral tablet 120 mg, 40 mg, 80 mg PG LGC
DIGITALIS GLYCOSIDES - DRUGS TO TREAT HEART
CONDITIONS
digoxin oral solution 0.05 mg/ml PG
digoxin oral tablet 125 mcg, 250 mcg, 62.5 mcg PG
LANOXIN ORAL TABLET 125 MCG, 250 MCG (digoxin) NF
DIRECT RENIN INHIBITORS/COMBINATIONS -
DRUGS TO TREAT HEART CONDITIONS
aliskiren fumarate oral tablet 150 mg, 300 mg PG
TEKTURNA HCT ORAL TABLET 300-12.5 MG, 300-25
MG (aliskiren-hydrochlorothiazide)
PB ST
DIURETICS - DRUGS TO TREAT HEART CONDITIONS
acetazolamide er oral capsule extended release 12 hour 500 mg NP
acetazolamide oral tablet 125 mg, 250 mg PG
amiloride hcl oral tablet 5 mg PG
amiloride-hydrochlorothiazide oral tablet 5-50 mg PG LGC
bumetanide oral tablet 0.5 mg, 1 mg, 2 mg PG
CAROSPIR ORAL SUSPENSION 25 MG/5ML
(spironolactone)
NF
chlorthalidone oral tablet 25 mg, 50 mg PG
dichlorphenamide oral tablet 50 mg PSP
PA; QL (120 TABLETS per
30 DAYs)
DYRENIUM ORAL CAPSULE 100 MG, 50 MG
(triamterene)
NF
ethacrynic acid oral tablet 25 mg NP
furosemide oral tablet 20 mg, 40 mg, 80 mg PG LGC
hydrochlorothiazide oral capsule 12.5 mg PG LGC
hydrochlorothiazide oral tablet 12.5 mg PG LGC
hydrochlorothiazide oral tablet 25 mg, 50 mg PG
LGC; N8 (Listing does not
include certain NDCs)
indapamide oral tablet 1.25 mg, 2.5 mg PG
KEVEYIS ORAL TABLET 50 MG (dichlorphenamide) NPSP
PA; QL (120 TABLETS per
30 days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
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07/01/2023
63
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
methazolamide oral tablet 25 mg, 50 mg PG
metolazone oral tablet 10 mg, 2.5 mg, 5 mg PG
SOAANZ ORAL TABLET 20 MG, 40 MG, 60 MG
(torsemide)
NF
spironolactone oral tablet 100 mg, 25 mg, 50 mg PG LGC
spironolactone-hctz oral tablet 25-25 mg PG
THALITONE ORAL TABLET 15 MG (chlorthalidone) NF
torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg PG
triamterene oral capsule 100 mg, 50 mg PG
triamterene-hctz oral capsule 37.5-25 mg PG
LGC; N8 (Listing does not
include certain NDCs)
triamterene-hctz oral tablet 37.5-25 mg, 75-50 mg PG LGC
HEART FAILURE
BIDIL ORAL TABLET 20-37.5 MG (isosorb dinitrate-
hydralazine)
PB
CORLANOR ORAL TABLET 5 MG, 7.5 MG (ivabradine
hcl)
PB
ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103
MG (sacubitril-valsartan)
PB
isosorb dinitrate-hydralazine oral tablet 20-37.5 mg PG
VERQUVO ORAL TABLET 10 MG, 2.5 MG, 5 MG
(vericiguat)
PB
VYNDAMAX ORAL CAPSULE 61 MG (tafamidis) NPSP
PA; QL (30 CAPSULES per
30 days)
VYNDAQEL ORAL CAPSULE 20 MG (tafamidis
meglumine (cardiac))
NF
MISCELLANEOUS
ASPRUZYO SPRINKLE ORAL PACKET 1000 MG, 500
MG (ranolazine)
NF
CAMZYOS ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 5
MG (mavacamten)
NPSP
PA; QL (30 CAPSULES per
30 days)
clonidine hcl er oral tablet extended release 24 hour 0.17 mg NF
clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg PG LGC
clonidine transdermal patch weekly 0.1 mg/24hr, 0.2 mg/24hr,
0.3 mg/24hr
NP
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
DIBENZYLINE ORAL CAPSULE 10 MG
(phenoxybenzamine hcl)
NP
ST; QL (360 CAPSULES
per 25 days)
droxidopa oral capsule 100 mg PSP
PA; QL (90 CAPSULES per
30 DAYs)
droxidopa oral capsule 200 mg, 300 mg PSP
PA; QL (180 CAPSULES
per 30 DAYs)
guanfacine hcl oral tablet 1 mg, 2 mg PG
hydralazine hcl oral tablet 10 mg, 100 mg, 50 mg PG
hydralazine hcl oral tablet 25 mg PG LGC
methyldopa oral tablet 250 mg, 500 mg NF
metyrosine oral capsule 250 mg NP
midodrine hcl oral tablet 10 mg, 2.5 mg, 5 mg PG
minoxidil oral tablet 10 mg, 2.5 mg PG
NEXICLON XR ORAL TABLET EXTENDED RELEASE
24 HOUR 0.17 MG (clonidine hcl)
NF
NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG
(droxidopa)
NF
phenoxybenzamine hcl oral capsule 10 mg PG
ranolazine er oral tablet extended release 12 hour 1000 mg, 500
mg
PG
VECAMYL ORAL TABLET 2.5 MG (mecamylamine hcl) NP PA
NITRATES - DRUGS TO TREAT HEART CONDITIONS
GONITRO SUBLINGUAL PACKET 400 MCG
(nitroglycerin)
NF
ISORDIL TITRADOSE ORAL TABLET 40 MG, 5 MG
(isosorbide dinitrate)
NF
isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg PG
isosorbide dinitrate oral tablet 40 mg NF
isosorbide mononitrate er oral tablet extended release 24 hour
120 mg, 30 mg, 60 mg
PG
isosorbide mononitrate oral tablet 10 mg, 20 mg PG
nitroglycerin sublingual tablet sublingual 0.3 mg, 0.4 mg, 0.6 mg PG
nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr,
0.4 mg/hr, 0.6 mg/hr
PG
nitroglycerin translingual solution 0.4 mg/spray PG
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
PULMONARY ARTERIAL HYPERTENSION - DRUGS
TO TREAT PULMONARY HYPERTENSION
ADCIRCA ORAL TABLET 20 MG (tadalafil (pah)) NF
ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG,
2.5 MG (riociguat)
PSP
PA; QL (90 TABLETS per
30 days)
tadalafil (pah) (Alyq Oral Tablet 20 Mg) PSP
PA; QL (60 TABLETS per
30 DAYs)
ambrisentan oral tablet 10 mg, 5 mg PSP
PA; QL (30 TABLETS per
30 DAYs)
bosentan oral tablet 125 mg PSP
PA; QL (60 TABLETS per
30 days)
bosentan oral tablet 62.5 mg PSP
PA; QL (60 TABLETS per
30 DAYs)
epoprostenol sodium intravenous solution reconstituted 0.5 mg,
1.5 mg
PSP PA
FLOLAN INTRAVENOUS SOLUTION
RECONSTITUTED 0.5 MG, 1.5 MG (epoprostenol sodium)
NPSP PA
LETAIRIS ORAL TABLET 10 MG, 5 MG (ambrisentan) NF
OPSUMIT ORAL TABLET 10 MG (macitentan) PSP
PA; QL (30 TABLETS per
30 days)
ORENITRAM MONTH 1 ORAL TABLET EXTENDED
RELEASE THERAPY PACK 0.125 & 0.25 MG (treprostinil
diolamine)
PSP PA
ORENITRAM MONTH 2 ORAL TABLET EXTENDED
RELEASE THERAPY PACK 0.125 & 0.25 MG (treprostinil
diolamine)
PSP PA
ORENITRAM MONTH 3 ORAL TABLET EXTENDED
RELEASE THERAPY PACK 0.125 & 0.25 &1 MG
(treprostinil diolamine)
PSP PA
ORENITRAM ORAL TABLET EXTENDED RELEASE
0.125 MG, 0.25 MG, 1 MG, 2.5 MG, 5 MG (treprostinil
diolamine)
PSP PA
REMODULIN INJECTION SOLUTION 100 MG/20ML, 20
MG/20ML, 200 MG/20ML, 50 MG/20ML (treprostinil)
NF
REVATIO INTRAVENOUS SOLUTION 10 MG/12.5ML
(sildenafil citrate)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
REVATIO ORAL SUSPENSION RECONSTITUTED 10
MG/ML (sildenafil citrate)
NF
REVATIO ORAL TABLET 20 MG (sildenafil citrate) NF
sildenafil citrate intravenous solution 10 mg/12.5ml PSP PA
sildenafil citrate oral suspension reconstituted 10 mg/ml PSP
PA; QL (784 ML per 30
days)
sildenafil citrate oral tablet 20 mg PG
PA; QL (360 TABLETS per
30 days)
tadalafil (pah) oral tablet 20 mg PSP
PA; QL (60 TABLETS per
30 days)
TADLIQ ORAL SUSPENSION 20 MG/5ML (tadalafil
(pah))
NF
TRACLEER ORAL TABLET 125 MG, 62.5 MG (bosentan) NF
TRACLEER ORAL TABLET SOLUBLE 32 MG (bosentan) NF
treprostinil injection solution 100 mg/20ml, 20 mg/20ml, 200
mg/20ml, 50 mg/20ml
PSP PA
TYVASO DPI MAINTENANCE KIT INHALATION
POWDER 16 MCG, 32 MCG, 48 MCG, 64 MCG
(treprostinil)
NF
TYVASO DPI TITRATION KIT INHALATION POWDER
112 X 16MCG & 84 X 32MCG, 16 & 32 & 48 MCG
(treprostinil)
NF
TYVASO INHALATION SOLUTION 0.6 MG/ML
(treprostinil)
NPSP PA; QL (28 ML per 28 days)
TYVASO REFILL INHALATION SOLUTION 0.6
MG/ML (treprostinil)
NPSP PA; QL (28 ML per 28 days)
TYVASO STARTER INHALATION SOLUTION 0.6
MG/ML (treprostinil)
NPSP PA; QL (28 ML per 28 days)
UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400
MCG, 1600 MCG, 400 MCG, 600 MCG, 800 MCG
(selexipag)
PSP
PA; QL (60 TABLETS per
30 days)
UPTRAVI ORAL TABLET 200 MCG (selexipag) PSP
PA; QL (140 TABLETS per
28 days)
UPTRAVI ORAL TABLET THERAPY PACK 200 & 800
MCG (selexipag)
PSP
PA; QL (1 TABLET
THERAPY PACK per 28
days)
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07/01/2023
67
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
VELETRI INTRAVENOUS SOLUTION
RECONSTITUTED 0.5 MG, 1.5 MG (epoprostenol sodium)
NPSP PA
VENTAVIS INHALATION SOLUTION 10 MCG/ML, 20
MCG/ML (iloprost)
NPSP
PA; QL (270 ML per 30
days)
CENTRAL NERVOUS SYSTEM - DRUGS TO TREAT
NERVOUS SYSTEM DISORDERS
ALCOHOL DETERRENTS
acamprosate calcium oral tablet delayed release 333 mg NP
disulfiram oral tablet 250 mg PG
disulfiram oral tablet 500 mg PG
N8 (Listing does not include
certain NDCs)
ANTIANXIETY - DRUGS TO TREAT ANXIETY
alprazolam er oral tablet extended release 24 hour 0.5 mg, 1 mg,
2 mg
PG
QL (150 TABLETS per 25
DAYs)
alprazolam er oral tablet extended release 24 hour 3 mg PG
QL (90 TABLETS per 25
DAYs)
ALPRAZOLAM INTENSOL ORAL CONCENTRATE 1
MG/ML (alprazolam)
NP QL (300 ML per 25 days)
alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg PG
QL (150 TABLETS per 25
days)
alprazolam oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg PG
QL (150 TABLETS per 25
days)
ANAFRANIL ORAL CAPSULE 25 MG, 50 MG
(clomipramine hcl)
NP
QLR (QL applies to
members age 65 and older);
QL (150 CAPSULES per 25
days); AL (Max 65 Years)
ANAFRANIL ORAL CAPSULE 75 MG (clomipramine hcl) NP
QLR (QL applies to
members age 65 and older);
QL (90 CAPSULES per 25
days); AL (Max 65 Years)
ATIVAN ORAL TABLET 0.5 MG, 1 MG, 2 MG
(lorazepam)
NF
buspirone hcl oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg PG
chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg PG
N8 (Listing does not include
certain NDCs); QL (360
CAPSULES per 25 DAYs)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
68
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
clomipramine hcl oral capsule 25 mg, 50 mg PG
QLR (QL applies to
members age 65 and older);
QL (150 CAPSULES per 25
days); AL (Max 65 Years)
clomipramine hcl oral capsule 75 mg PG
QLR (QL applies to
members age 65 and older);
QL (90 CAPSULES per 25
days); AL (Max 65 Years)
fluvoxamine maleate er oral capsule extended release 24 hour
100 mg, 150 mg
PG
fluvoxamine maleate oral tablet 100 mg, 25 mg, 50 mg PG
lorazepam (Lorazepam Intensol Oral Concentrate 2 Mg/Ml) PG QL (150 ML per 25 DAYs)
lorazepam oral tablet 0.5 mg PG
QL (150 TABLETS per 25
days)
lorazepam oral tablet 1 mg, 2 mg PG
QL (150 TABLETS per 25
DAYs)
LOREEV XR ORAL CAPSULE ER 24 HOUR SPRINKLE
1 MG, 1.5 MG, 2 MG (lorazepam)
NP
QL (150 CAPSULES per 25
days)
LOREEV XR ORAL CAPSULE ER 24 HOUR SPRINKLE
3 MG (lorazepam)
NP
QL (90 CAPSULES per 25
days)
oxazepam oral capsule 10 mg, 15 mg, 30 mg PG
QL (120 CAPSULES per 25
DAYs)
XANAX ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG
(alprazolam)
NF
XANAX XR ORAL TABLET EXTENDED RELEASE 24
HOUR 0.5 MG, 1 MG, 2 MG, 3 MG (alprazolam)
NF
ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND
MEMORY LOSS
ADLARITY TRANSDERMAL PATCH WEEKLY 10
MG/DAY, 5 MG/DAY (donepezil hcl)
NF
donepezil hcl oral tablet 10 mg, 5 mg PG
donepezil hcl oral tablet 23 mg NP
donepezil hcl oral tablet dispersible 10 mg, 5 mg PG
ergoloid mesylates oral tablet 1 mg NP STX
EXELON TRANSDERMAL PATCH 24 HOUR 13.3
MG/24HR, 4.6 MG/24HR, 9.5 MG/24HR (rivastigmine)
NP PA
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
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07/01/2023
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
galantamine hydrobromide er oral capsule extended release 24
hour 16 mg, 24 mg, 8 mg
NP
galantamine hydrobromide oral solution 4 mg/ml NP
galantamine hydrobromide oral tablet 12 mg, 4 mg, 8 mg NP
memantine hcl er oral capsule extended release 24 hour 14 mg,
21 mg, 28 mg, 7 mg
PG PA; AL (Min 29 Years)
memantine hcl oral solution 2 mg/ml PG PA; AL (Min 29 Years)
memantine hcl oral tablet 10 mg, 5 mg PG
PA; N8 (Listing does not
include certain NDCs); AL
(Min 29 Years)
memantine hcl oral tablet 28 x 5 mg & 21 x 10 mg PG PA; AL (Min 29 Years)
NAMENDA ORAL TABLET 10 MG, 5 MG (memantine hcl) NP PA; AL (Min 29 Years)
NAMENDA TITRATION PAK ORAL TABLET 28 X 5
MG & 21 X 10 MG (memantine hcl)
NP PA; AL (Min 29 Years)
NAMENDA XR ORAL CAPSULE EXTENDED
RELEASE 24 HOUR 14 MG, 21 MG, 28 MG, 7 MG
(memantine hcl)
NF
NAMZARIC ORAL CAPSULE ER 24 HOUR THERAPY
PACK 7 & 14 & 21 &28 -10 MG (memantine hcl-donepezil hcl)
PB PA
NAMZARIC ORAL CAPSULE EXTENDED RELEASE 24
HOUR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG
(memantine hcl-donepezil hcl)
PB PA
rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg NP PA
rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6
mg/24hr, 9.5 mg/24hr
NP PA
ANTIDEPRESSANTS - DRUGS TO TREAT
DEPRESSION
amitriptyline hcl oral tablet 10 mg PG
QLR (QL applies to
members age 65 and older);
QL (150 TABLETS per 25
days); AL (Max 65 Years)
amitriptyline hcl oral tablet 100 mg, 150 mg, 75 mg PG AL (Max 65 Years)
amitriptyline hcl oral tablet 25 mg PG
QLR (QL applies to
members age 65 and older);
QL (60 TABLETS per 25
days); AL (Max 65 Years)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
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07/01/2023
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
amitriptyline hcl oral tablet 50 mg PG
QLR (QL applies to
members age 65 and older);
QL (30 TABLETS per 25
days); AL (Max 65 Years)
amoxapine oral tablet 100 mg, 25 mg, 50 mg PG
QLR (QL applies to
members age 65 and older);
QL (90 TABLETS per 25
days); AL (Max 65 Years)
amoxapine oral tablet 150 mg PG
QLR (QL applies to
members age 65 and older);
QL (60 TABLETS per 25
days); AL (Max 65 Years)
AUVELITY ORAL TABLET EXTENDED RELEASE 45-
105 MG (dextromethorphan-bupropion)
NF
bupropion hcl er (sr) oral tablet extended release 12 hour 100
mg, 150 mg, 200 mg
PG
bupropion hcl er (xl) oral tablet extended release 24 hour 150
mg, 300 mg
PG
bupropion hcl er (xl) oral tablet extended release 24 hour 450
mg
NF
bupropion hcl oral tablet 100 mg, 75 mg PG
citalopram hydrobromide oral capsule 30 mg NF
citalopram hydrobromide oral solution 10 mg/5ml PG
citalopram hydrobromide oral tablet 10 mg, 20 mg, 40 mg PG LGC
CYMBALTA ORAL CAPSULE DELAYED RELEASE
PARTICLES 20 MG, 30 MG, 60 MG (duloxetine hcl)
NF
desipramine hcl oral tablet 10 mg, 25 mg, 50 mg PG
QLR (QL applies to
members age 65 and older);
QL (90 TABLETS per 25
days); AL (Max 65 Years)
desipramine hcl oral tablet 100 mg, 150 mg PG
QLR (QL applies to
members age 65 and older);
QL (30 TABLETS per 25
days); AL (Max 65 Years)
desipramine hcl oral tablet 75 mg PG
QLR (QL applies to
members age 65 and older);
QL (60 TABLETS per 25
days); AL (Max 65 Years)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
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07/01/2023
71
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
desvenlafaxine er oral tablet extended release 24 hour 100 mg,
50 mg
NF
desvenlafaxine succinate er oral tablet extended release 24 hour
100 mg, 25 mg, 50 mg
NP
ST; QL (30 TABLETS per
25 days)
doxepin hcl oral capsule 10 mg, 25 mg, 50 mg PG
QLR (QL applies to
members age 65 and older);
N8 (Listing does not include
certain NDCs); QL (90
CAPSULES per 25 days);
AL (Max 65 Years)
doxepin hcl oral capsule 100 mg PG
QLR (QL applies to
members age 65 and older);
N8 (Listing does not include
certain NDCs); QL (30
CAPSULES per 25 days);
AL (Max 65 Years)
doxepin hcl oral capsule 150 mg PG
QLR (QL applies to
members age 65 and older);
QL (30 CAPSULES per 25
days); AL (Max 65 Years)
doxepin hcl oral capsule 75 mg PG
QLR (QL applies to
members age 65 and older);
N8 (Listing does not include
certain NDCs); QL (60
CAPSULES per 25 days);
AL (Max 65 Years)
doxepin hcl oral concentrate 10 mg/ml PG
QLR (QL applies to
members age 65 and older);
QL (450 ML per 25 days);
AL (Max 65 Years)
DRIZALMA SPRINKLE ORAL CAPSULE DELAYED
RELEASE SPRINKLE 20 MG, 30 MG, 40 MG, 60 MG
(duloxetine hcl)
NF
duloxetine hcl oral capsule delayed release particles 20 mg, 30
mg, 40 mg, 60 mg
PG
EFFEXOR XR ORAL CAPSULE EXTENDED RELEASE
24 HOUR 150 MG, 37.5 MG, 75 MG (venlafaxine hcl)
NF
escitalopram oxalate oral solution 5 mg/5ml PG
escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg PG
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07/01/2023
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
FETZIMA ORAL CAPSULE EXTENDED RELEASE 24
HOUR 120 MG, 20 MG, 40 MG, 80 MG (levomilnacipran
hcl)
NF
FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR
THERAPY PACK 20 & 40 MG (levomilnacipran hcl)
NF
fluoxetine hcl oral capsule 10 mg, 20 mg, 40 mg PG LGC
fluoxetine hcl oral capsule delayed release 90 mg PG
fluoxetine hcl oral solution 20 mg/5ml PG
fluoxetine hcl oral tablet 10 mg, 20 mg PG
fluoxetine hcl oral tablet 60 mg NF
imipramine hcl oral tablet 10 mg PG
QLR (QL applies to
members age 65 and older);
QL (120 TABLETS per 25
days); AL (Max 65 Years)
imipramine hcl oral tablet 25 mg PG
QLR (QL applies to
members age 65 and older);
N8 (Listing does not include
certain NDCs.); QL (120
TABLETS per 25 days); AL
(Max 65 Years)
imipramine hcl oral tablet 50 mg PG
QLR (QL applies to
members age 65 and older);
QL (60 TABLETS per 25
days); AL (Max 65 Years)
imipramine pamoate oral capsule 100 mg, 75 mg NP
QLR (QL applies to
members age 65 and older);
QL (30 CAPSULES per 25
days); AL (Max 65 Years)
imipramine pamoate oral capsule 125 mg, 150 mg NP AL (Max 65 Years)
LEXAPRO ORAL TABLET 10 MG, 20 MG, 5 MG
(escitalopram oxalate)
NF
mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg PG
mirtazapine oral tablet dispersible 15 mg, 30 mg, 45 mg PG
nefazodone hcl oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50
mg
NP STX
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07/01/2023
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
NORPRAMIN ORAL TABLET 10 MG, 25 MG
(desipramine hcl)
NP
QLR (QL applies to
members age 65 and older);
QL (90 TABLETS per 25
days); AL (Max 65 Years)
nortriptyline hcl oral capsule 10 mg PG
QLR (QL applies to
members age 65 and older);
QL (150 CAPSULES per 25
days); AL (Max 65 Years)
nortriptyline hcl oral capsule 25 mg PG
QLR (QL applies to
members age 65 and older);
QL (60 CAPSULES per 25
days); AL (Max 65 Years)
nortriptyline hcl oral capsule 50 mg PG
QLR (QL applies to
members age 65 and older);
QL (30 CAPSULES per 25
days); AL (Max 65 Years)
nortriptyline hcl oral capsule 75 mg PG AL (Max 65 Years)
nortriptyline hcl oral solution 10 mg/5ml PG
QLR (QL applies to
members age 65 and older);
QL (750 ML per 25 days);
AL (Max 65 Years)
PAMELOR ORAL CAPSULE 10 MG (nortriptyline hcl) NP
QLR (QL applies to
members age 65 and older);
QL (150 CAPSULES per 25
days); AL (Max 65 Years)
PAMELOR ORAL CAPSULE 25 MG (nortriptyline hcl) NP
QLR (QL applies to
members age 65 and older);
QL (60 CAPSULES per 25
days); AL (Max 65 Years)
PAMELOR ORAL CAPSULE 50 MG (nortriptyline hcl) NP
QLR (QL applies to
members age 65 and older);
QL (30 CAPSULES per 25
days); AL (Max 65 Years)
PAMELOR ORAL CAPSULE 75 MG (nortriptyline hcl) NP AL (Max 65 Years)
paroxetine hcl er oral tablet extended release 24 hour 12.5 mg,
25 mg
PG
paroxetine hcl er oral tablet extended release 24 hour 37.5 mg PG
N8 (Listing does not include
certain NDCs)
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07/01/2023
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
paroxetine hcl oral suspension 10 mg/5ml NF
paroxetine hcl oral tablet 10 mg, 20 mg, 30 mg, 40 mg PG
LGC; N8 (Listing does not
include certain NDCs)
PAXIL CR ORAL TABLET EXTENDED RELEASE 24
HOUR 12.5 MG, 25 MG, 37.5 MG (paroxetine hcl)
NF
PAXIL ORAL SUSPENSION 10 MG/5ML (paroxetine hcl) NF
PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG
(paroxetine hcl)
NF
PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG
(paroxetine mesylate)
NF
phenelzine sulfate oral tablet 15 mg PG
PRISTIQ ORAL TABLET EXTENDED RELEASE 24
HOUR 100 MG, 25 MG, 50 MG (desvenlafaxine succinate)
NF
protriptyline hcl oral tablet 10 mg PG
QLR (QL applies to
members age 65 and older);
QL (60 TABLETS per 25
days); AL (Max 65 Years)
protriptyline hcl oral tablet 5 mg PG
QLR (QL applies to
members age 65 and older);
QL (90 TABLETS per 25
days); AL (Max 65 Years)
PROZAC ORAL CAPSULE 10 MG, 20 MG, 40 MG
(fluoxetine hcl)
NF
sertraline hcl oral capsule 150 mg, 200 mg NF
sertraline hcl oral concentrate 20 mg/ml PG
sertraline hcl oral tablet 100 mg, 25 mg, 50 mg PG LGC
SPRAVATO (56 MG DOSE) NASAL SOLUTION
THERAPY PACK 28 MG/DEVICE (esketamine hcl)
NPSP PA
SPRAVATO (84 MG DOSE) NASAL SOLUTION
THERAPY PACK 28 MG/DEVICE (esketamine hcl)
NPSP PA
tranylcypromine sulfate oral tablet 10 mg PG
trazodone hcl oral tablet 100 mg, 150 mg, 300 mg, 50 mg PG
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07/01/2023
75
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
trimipramine maleate oral capsule 100 mg NP
QLR (QL applies to
members age 65 and older);
N8 (Listing does not include
certain NDCs); QL (30
CAPSULES per 25 days);
AL (Max 65 Years)
trimipramine maleate oral capsule 25 mg, 50 mg NP
QLR (QL applies to
members age 65 and older);
N8 (Listing does not include
certain NDCs); QL (60
CAPSULES per 25 days);
AL (Max 65 Years)
TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG
(vortioxetine hbr)
PB ST
venlafaxine besylate er oral tablet extended release 24 hour
112.5 mg
NF
venlafaxine hcl er oral capsule extended release 24 hour 150 mg,
37.5 mg, 75 mg
PG
venlafaxine hcl er oral tablet extended release 24 hour 150 mg,
37.5 mg, 75 mg
NF
venlafaxine hcl er oral tablet extended release 24 hour 225 mg NP
N8 (Listing does not include
certain NDCs)
venlafaxine hcl oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75
mg
PG
VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG
(vilazodone hcl)
NF
VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG
(vilazodone hcl)
NF
vilazodone hcl oral tablet 10 mg, 20 mg, 40 mg NF
ZOLOFT ORAL CONCENTRATE 20 MG/ML (sertraline
hcl)
NF
ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG
(sertraline hcl)
NF
ANTIPARKINSONIAN AGENTS - DRUGS TO TREAT
PARKINSONS DISEASE
amantadine hcl oral capsule 100 mg PG
amantadine hcl oral solution 50 mg/5ml PG
N8 (Listing does not include
certain NDCs)
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07/01/2023
76
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
amantadine hcl oral tablet 100 mg PG
APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE
30 MG/3ML (apomorphine hcl)
NF
apomorphine hcl subcutaneous solution cartridge 30 mg/3ml NF
benztropine mesylate oral tablet 0.5 mg, 1 mg, 2 mg PG
bromocriptine mesylate oral capsule 5 mg PG
bromocriptine mesylate oral tablet 2.5 mg PG
carbidopa oral tablet 25 mg PG
carbidopa-levodopa er oral tablet extended release 25-100 mg,
50-200 mg
PG
carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250
mg
PG
carbidopa-levodopa-entacapone oral tablet 12.5-50-200 mg,
18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-
200 mg, 50-200-200 mg
NP
DHIVY ORAL TABLET 25-100 MG (carbidopa-levodopa) NP
DUOPA ENTERAL SUSPENSION 4.63-20 MG/ML
(carbidopa-levodopa)
NPSP PA
entacapone oral tablet 200 mg PG
GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24
HOUR 137 MG, 68.5 MG (amantadine hcl)
NF
INBRIJA INHALATION CAPSULE 42 MG (levodopa) PSP
PA; QL (300 CAPSULES
per 30 days)
KYNMOBI SUBLINGUAL FILM 10 MG, 15 MG, 20 MG,
25 MG, 30 MG (apomorphine hcl)
PSP
PA; QL (150 FILMS per 30
days)
NEUPRO TRANSDERMAL PATCH 24 HOUR 1
MG/24HR, 2 MG/24HR, 3 MG/24HR, 4 MG/24HR, 6
MG/24HR, 8 MG/24HR (rotigotine)
PB
NOURIANZ ORAL TABLET 20 MG, 40 MG (istradefylline) NF
ONGENTYS ORAL CAPSULE 25 MG, 50 MG (opicapone) NF
OSMOLEX ER ORAL TABLET EXTENDED RELEASE
24 HOUR 129 MG, 193 MG (amantadine hcl)
NF
pramipexole dihydrochloride er oral tablet extended release 24
hour 0.375 mg, 0.75 mg, 1.5 mg, 2.25 mg, 3 mg, 3.75 mg, 4.5 mg
NP
pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5
mg, 0.75 mg, 1 mg, 1.5 mg
PG
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07/01/2023
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
rasagiline mesylate oral tablet 0.5 mg, 1 mg PG
ropinirole hcl er oral tablet extended release 24 hour 12 mg, 2
mg, 4 mg, 6 mg, 8 mg
NP
ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4
mg, 5 mg
PG
RYTARY ORAL CAPSULE EXTENDED RELEASE
23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG
(carbidopa-levodopa)
PB
selegiline hcl oral capsule 5 mg PG
selegiline hcl oral tablet 5 mg PG
SINEMET ORAL TABLET 10-100 MG, 25-100 MG
(carbidopa-levodopa)
NP
tolcapone oral tablet 100 mg NP STX
trihexyphenidyl hcl oral solution 0.4 mg/ml PG
trihexyphenidyl hcl oral tablet 2 mg, 5 mg PG
XADAGO ORAL TABLET 100 MG, 50 MG (safinamide
mesylate)
NF
ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG
(selegiline hcl)
NF
ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSES
ABILIFY ASIMTUFII INTRAMUSCULAR PREFILLED
SYRINGE 720 MG/2.4ML, 960 MG/3.2ML (aripiprazole)
NF
ABILIFY MAINTENA INTRAMUSCULAR PREFILLED
SYRINGE 300 MG, 400 MG (aripiprazole)
PB
ABILIFY MAINTENA INTRAMUSCULAR
SUSPENSION RECONSTITUTED ER 300 MG, 400 MG
(aripiprazole)
PB
ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG,
30 MG, 5 MG (aripiprazole)
NF
aripiprazole oral solution 1 mg/ml PG
aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg PG
aripiprazole oral tablet dispersible 10 mg, 15 mg PG
ARISTADA INITIO INTRAMUSCULAR PREFILLED
SYRINGE 675 MG/2.4ML (aripiprazole lauroxil)
NP
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07/01/2023
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ARISTADA INTRAMUSCULAR PREFILLED SYRINGE
1064 MG/3.9ML, 441 MG/1.6ML, 662 MG/2.4ML, 882
MG/3.2ML (aripiprazole lauroxil)
NP
asenapine maleate sublingual tablet sublingual 10 mg, 2.5 mg, 5
mg
PG
CAPLYTA ORAL CAPSULE 10.5 MG, 21 MG, 42 MG
(lumateperone tosylate)
NF
chlorpromazine hcl oral concentrate 100 mg/ml, 30 mg/ml NF
chlorpromazine hcl oral tablet 10 mg, 100 mg, 200 mg, 25 mg,
50 mg
PG
clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg PG
clozapine oral tablet dispersible 100 mg, 12.5 mg, 150 mg, 200
mg, 25 mg
PG
FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4
MG, 6 MG, 8 MG (iloperidone)
NF
FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 &
6 MG (iloperidone)
NF
fluphenazine hcl oral concentrate 5 mg/ml PG
fluphenazine hcl oral elixir 2.5 mg/5ml PG
fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg PG
GEODON INTRAMUSCULAR SOLUTION
RECONSTITUTED 20 MG (ziprasidone mesylate)
NF
GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80
MG (ziprasidone hcl)
NF
haloperidol lactate oral concentrate 2 mg/ml PG
haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg PG
INVEGA HAFYERA INTRAMUSCULAR SUSPENSION
PREFILLED SYRINGE 1092 MG/3.5ML, 1560 MG/5ML
(paliperidone palmitate)
NF
INVEGA ORAL TABLET EXTENDED RELEASE 24
HOUR 1.5 MG, 3 MG, 9 MG (paliperidone)
NP
PA; QL (30 TABLETS per
25 DAYs)
INVEGA ORAL TABLET EXTENDED RELEASE 24
HOUR 6 MG (paliperidone)
NP
PA; QL (60 TABLETS per
25 DAYs)
INVEGA TRINZA INTRAMUSCULAR SUSPENSION
PREFILLED SYRINGE 273 MG/0.88ML, 410 MG/1.32ML,
546 MG/1.75ML, 819 MG/2.63ML (paliperidone palmitate)
NF
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07/01/2023
79
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60
MG, 80 MG (lurasidone hcl)
NF
loxapine succinate oral capsule 10 mg, 5 mg PG
N8 (Listing does not include
certain NDCs)
loxapine succinate oral capsule 25 mg, 50 mg PG
lurasidone hcl oral tablet 120 mg, 20 mg, 40 mg, 60 mg, 80 mg PG
NUPLAZID ORAL CAPSULE 34 MG (pimavanserin
tartrate)
NPSP
PA; QL (30 CAPSULES per
30 days)
NUPLAZID ORAL TABLET 10 MG (pimavanserin tartrate) NPSP
PA; QL (30 TABLETS per
30 days)
olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5
mg
PG
olanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mg PG
paliperidone er oral tablet extended release 24 hour 1.5 mg, 3
mg, 6 mg, 9 mg
NP
perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg PG
PERSERIS SUBCUTANEOUS PREFILLED SYRINGE
120 MG, 90 MG (risperidone)
PB
quetiapine fumarate er oral tablet extended release 24 hour 150
mg, 200 mg, 300 mg, 400 mg, 50 mg
NP
quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg,
400 mg, 50 mg
PG
quetiapine fumarate oral tablet 150 mg NF
REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2
MG, 3 MG, 4 MG (brexpiprazole)
NP
PA; QL (30 TABLETS per
25 days)
risperidone oral solution 1 mg/ml PG
risperidone oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg PG
risperidone oral tablet dispersible 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3
mg, 4 mg
PG
SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10
MG, 2.5 MG, 5 MG (asenapine maleate)
NP
SECUADO TRANSDERMAL PATCH 24 HOUR 3.8
MG/24HR, 5.7 MG/24HR, 7.6 MG/24HR (asenapine)
NF
SEROQUEL XR ORAL TABLET EXTENDED RELEASE
24 HOUR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG
(quetiapine fumarate)
NF
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07/01/2023
80
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
thioridazine hcl oral tablet 10 mg, 100 mg, 25 mg, 50 mg PG
thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg PG
trifluoperazine hcl oral tablet 1 mg, 10 mg, 2 mg, 5 mg PG
VERSACLOZ ORAL SUSPENSION 50 MG/ML (clozapine) NP PA
VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG (cariprazine
hcl)
PB
PA; QL (60 CAPSULES per
25 DAYs)
VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG (cariprazine
hcl)
PB
PA; QL (30 CAPSULES per
25 DAYs)
VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3
MG (cariprazine hcl)
PB
PA; QL (60 CAPSULES per
25 DAYs)
ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg PG
ziprasidone mesylate intramuscular solution reconstituted 20 mg PG
ANTISEIZURE AGENTS - DRUGS TO TREAT
SEIZURES
APTIOM ORAL TABLET 200 MG, 400 MG, 600 MG, 800
MG (eslicarbazepine acetate)
PB
BANZEL ORAL SUSPENSION 40 MG/ML (rufinamide) NF
BANZEL ORAL TABLET 200 MG, 400 MG (rufinamide) NF
BRIVIACT ORAL SOLUTION 10 MG/ML (brivaracetam) NP PA
BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50
MG, 75 MG (brivaracetam)
NP PA
carbamazepine er oral capsule extended release 12 hour 100 mg,
200 mg, 300 mg
PG
carbamazepine er oral tablet extended release 12 hour 100 mg,
200 mg, 400 mg
PG
carbamazepine oral suspension 100 mg/5ml PG
carbamazepine oral tablet 200 mg PG
carbamazepine oral tablet chewable 100 mg PG
clobazam oral suspension 2.5 mg/ml PG PA
clobazam oral tablet 10 mg, 20 mg PG PA
clonazepam oral tablet 0.5 mg, 1 mg, 2 mg PG
N8 (Listing does not include
certain NDCs); QL (300
TABLETS per 25 days)
clonazepam oral tablet dispersible 0.125 mg, 0.25 mg, 0.5 mg, 1
mg, 2 mg
PG
QL (300 TABLETS per 25
days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
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07/01/2023
81
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg PG
QL (180 TABLETS per 25
days)
DEPAKOTE ER ORAL TABLET EXTENDED RELEASE
24 HOUR 250 MG, 500 MG (divalproex sodium)
NF
DEPAKOTE ORAL TABLET DELAYED RELEASE 125
MG, 250 MG, 500 MG (divalproex sodium)
NF
DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED
RELEASE SPRINKLE 125 MG (divalproex sodium)
NF
DIACOMIT ORAL CAPSULE 250 MG, 500 MG
(stiripentol)
NF
DIACOMIT ORAL PACKET 250 MG, 500 MG (stiripentol) NF
DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG
(diazepam)
NF
DIASTAT PEDIATRIC RECTAL GEL 2.5 MG (diazepam) NF
diazepam (Diazepam Intensol Oral Concentrate 5 Mg/Ml) PG QL (240 ML per 25 days)
diazepam oral solution 5 mg/5ml PG QL (1200 ML per 25 days)
diazepam oral tablet 10 mg, 2 mg, 5 mg PG
QL (120 TABLETS per 25
days)
diazepam rectal gel 10 mg, 2.5 mg, 20 mg PG
DILANTIN INFATABS ORAL TABLET CHEWABLE 50
MG (phenytoin)
NF
DILANTIN ORAL CAPSULE 100 MG, 30 MG (phenytoin
sodium extended)
NF
DILANTIN ORAL SUSPENSION 125 MG/5ML (phenytoin) NF
divalproex sodium er oral tablet extended release 24 hour 250
mg, 500 mg
PG
divalproex sodium oral capsule delayed release sprinkle 125 mg PG
divalproex sodium oral tablet delayed release 125 mg, 500 mg PG
divalproex sodium oral tablet delayed release 250 mg PG
N8 (Listing does not include
certain NDCs)
ELEPSIA XR ORAL TABLET EXTENDED RELEASE 24
HOUR 1000 MG, 1500 MG (levetiracetam)
NF
EPIDIOLEX ORAL SOLUTION 100 MG/ML (cannabidiol) NPSP
PA; QL (800 ML per 30
days)
EPRONTIA ORAL SOLUTION 25 MG/ML (topiramate) NF
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07/01/2023
82
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ethosuximide oral capsule 250 mg PG
ethosuximide oral solution 250 mg/5ml PG
felbamate oral suspension 600 mg/5ml PG
felbamate oral tablet 400 mg, 600 mg PG
FINTEPLA ORAL SOLUTION 2.2 MG/ML (fenfluramine
hcl)
NF
FYCOMPA ORAL SUSPENSION 0.5 MG/ML (perampanel) PB
FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG,
6 MG, 8 MG (perampanel)
PB
gabapentin oral capsule 100 mg, 300 mg, 400 mg PG
QL (6 CAPSULES per 1
day)
gabapentin oral solution 250 mg/5ml PG QL (72 ML per 1 day)
gabapentin oral solution 300 mg/6ml PG QL (72 ML per 1 Day)
gabapentin oral tablet 600 mg PG QL (6 TABLETS per 1 day)
gabapentin oral tablet 800 mg PG QL (4 TABLETS per 1 day)
KEPPRA ORAL SOLUTION 100 MG/ML (levetiracetam) NF
KEPPRA ORAL TABLET 1000 MG, 250 MG, 500 MG, 750
MG (levetiracetam)
NF
KEPPRA XR ORAL TABLET EXTENDED RELEASE 24
HOUR 500 MG, 750 MG (levetiracetam)
NF
KLONOPIN ORAL TABLET 0.5 MG, 1 MG, 2 MG
(clonazepam)
NP
QL (300 TABLETS per 25
days)
lacosamide oral solution 10 mg/ml PG
N8 (Listing does not include
certain NDCs)
lacosamide oral tablet 100 mg, 150 mg, 200 mg, 50 mg PG
LAMICTAL ODT ORAL KIT 21 X 25 MG & 7 X 50 MG,
25 & 50 & 100 MG, 42 X 50 MG & 14X100 MG (lamotrigine)
NF
LAMICTAL ODT ORAL TABLET DISPERSIBLE 100
MG, 200 MG, 25 MG, 50 MG (lamotrigine)
NF
LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG,
25 MG (lamotrigine)
NF
LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG
(lamotrigine)
NF
LAMICTAL STARTER ORAL KIT 35 X 25 MG, 42 X 25
MG & 7 X 100 MG, 84 X 25 MG & 14X100 MG (lamotrigine)
NF
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07/01/2023
83
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
LAMICTAL XR ORAL KIT 21 X 25 MG & 7 X 50 MG, 25
& 50 & 100 MG, 50 & 100 & 200 MG (lamotrigine)
NF
LAMICTAL XR ORAL TABLET EXTENDED RELEASE
24 HOUR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50
MG (lamotrigine)
NF
lamotrigine er oral tablet extended release 24 hour 100 mg, 200
mg, 25 mg, 250 mg, 300 mg, 50 mg
PG
N8 (Listing does not include
certain NDCs)
lamotrigine oral kit 25 & 50 & 100 mg PG
lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg PG
lamotrigine oral tablet chewable 25 mg, 5 mg PG
lamotrigine oral tablet dispersible 100 mg, 200 mg, 25 mg, 50
mg
NP
lamotrigine starter kit-blue oral kit 35 x 25 mg PG
lamotrigine starter kit-green oral kit 84 x 25 mg & 14x100 mg PG
lamotrigine starter kit-orange oral kit 42 x 25 mg & 7 x 100 mg PG
levetiracetam er oral tablet extended release 24 hour 500 mg,
750 mg
PG
levetiracetam oral solution 100 mg/ml PG
levetiracetam oral tablet 1000 mg, 250 mg, 500 mg, 750 mg PG
LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225
MG, 25 MG, 300 MG, 50 MG, 75 MG (pregabalin)
NF
LYRICA ORAL SOLUTION 20 MG/ML (pregabalin) NF
NAYZILAM NASAL SOLUTION 5 MG/0.1ML (midazolam
(anticonvulsant))
PB
QL (10 SOLUTION per 25
days)
NEURONTIN ORAL CAPSULE 100 MG, 300 MG, 400
MG (gabapentin)
NP
QL (6 CAPSULES per 1
day)
NEURONTIN ORAL SOLUTION 250 MG/5ML
(gabapentin)
NP QL (72 ML per 1 day)
NEURONTIN ORAL TABLET 600 MG (gabapentin) NP QL (6 TABLETS per 1 day)
NEURONTIN ORAL TABLET 800 MG (gabapentin) NP QL (4 TABLETS per 1 day)
ONFI ORAL SUSPENSION 2.5 MG/ML (clobazam) NF
ONFI ORAL TABLET 10 MG, 20 MG (clobazam) NF
oxcarbazepine oral suspension 300 mg/5ml PG
oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg PG
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07/01/2023
84
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
OXTELLAR XR ORAL TABLET EXTENDED RELEASE
24 HOUR 150 MG, 300 MG, 600 MG (oxcarbazepine)
PB
phenobarbital oral elixir 20 mg/5ml PG
phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4
mg, 60 mg, 64.8 mg, 97.2 mg
PG
phenytoin oral suspension 125 mg/5ml PG
phenytoin oral tablet chewable 50 mg PG
phenytoin sodium extended oral capsule 100 mg, 200 mg, 300
mg
PG
pregabalin oral capsule 100 mg, 150 mg, 25 mg, 50 mg, 75 mg PG
QL (120 CAPSULES per 25
days)
pregabalin oral capsule 200 mg PG
QL (90 CAPSULES per 25
days)
pregabalin oral capsule 225 mg, 300 mg PG
QL (60 CAPSULES per 25
days)
pregabalin oral solution 20 mg/ml PG QL (900 ML per 25 days)
primidone oral tablet 125 mg NF
primidone oral tablet 250 mg PG
primidone oral tablet 50 mg PG
N8 (Listing does not include
certain NDCs)
QUDEXY XR ORAL CAPSULE ER 24 HOUR SPRINKLE
100 MG, 150 MG, 200 MG, 25 MG, 50 MG (topiramate)
NP
rufinamide oral suspension 40 mg/ml PG PA
rufinamide oral tablet 200 mg, 400 mg PG PA
SABRIL ORAL PACKET 500 MG (vigabatrin) NF
SABRIL ORAL TABLET 500 MG (vigabatrin) NF
SPRITAM ORAL TABLET DISINTEGRATING
SOLUBLE 1000 MG, 250 MG, 500 MG, 750 MG
(levetiracetam)
NF
SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG
(clobazam)
NF
TEGRETOL ORAL SUSPENSION 100 MG/5ML
(carbamazepine)
NF
TEGRETOL ORAL TABLET 200 MG (carbamazepine) NF
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07/01/2023
85
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
TEGRETOL-XR ORAL TABLET EXTENDED RELEASE
12 HOUR 100 MG, 200 MG, 400 MG (carbamazepine)
NF
tiagabine hcl oral tablet 12 mg, 16 mg, 2 mg, 4 mg PG
topiramate er oral capsule er 24 hour sprinkle 100 mg, 150 mg,
200 mg, 25 mg, 50 mg
NF
topiramate er oral capsule extended release 24 hour 100 mg, 200
mg, 25 mg, 50 mg
PG
topiramate oral capsule sprinkle 15 mg, 25 mg PG
topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg PG
TRILEPTAL ORAL SUSPENSION 300 MG/5ML
(oxcarbazepine)
NF
TRILEPTAL ORAL TABLET 150 MG, 300 MG, 600 MG
(oxcarbazepine)
NF
TROKENDI XR ORAL CAPSULE EXTENDED
RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG
(topiramate)
PB
VALIUM ORAL TABLET 10 MG, 2 MG, 5 MG (diazepam) NP
QL (120 TABLETS per 25
days)
valproic acid oral capsule 250 mg PG
valproic acid oral solution 250 mg/5ml PG
VALTOCO 10 MG DOSE NASAL LIQUID 10 MG/0.1ML
(diazepam)
PB
QL (10 BLISTER per 25
days)
VALTOCO 15 MG DOSE NASAL LIQUID THERAPY
PACK 7.5 MG/0.1ML (diazepam)
PB
QL (10 BLISTER per 25
days)
VALTOCO 20 MG DOSE NASAL LIQUID THERAPY
PACK 10 MG/0.1ML (diazepam)
PB
QL (10 BLISTER per 25
days)
VALTOCO 5 MG DOSE NASAL LIQUID 5 MG/0.1ML
(diazepam)
PB
QL (10 BLISTER per 25
days)
vigabatrin oral packet 500 mg PSP
PA; QL (180 PACKETS per
30 days)
vigabatrin oral tablet 500 mg PSP
PA; QL (180 TABLETS per
30 days)
vigabatrin (Vigadrone Oral Packet 500 Mg) PSP
PA; QL (180 PACKETS per
30 days)
VIMPAT ORAL SOLUTION 10 MG/ML (lacosamide) NF
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07/01/2023
86
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50
MG (lacosamide)
NF
XCOPRI (250 MG DAILY DOSE) ORAL TABLET
THERAPY PACK 100 & 150 MG (cenobamate)
PB
XCOPRI (350 MG DAILY DOSE) ORAL TABLET
THERAPY PACK 150 & 200 MG (cenobamate)
PB
XCOPRI ORAL TABLET 100 MG, 150 MG, 200 MG, 50
MG (cenobamate)
PB
XCOPRI ORAL TABLET THERAPY PACK 14 X 12.5 MG
& 14 X 25 MG, 14 X 150 MG & 14 X200 MG, 14 X 50 MG &
14 X100 MG (cenobamate)
PB
ZONEGRAN ORAL CAPSULE 100 MG, 25 MG
(zonisamide)
NF
ZONISADE ORAL SUSPENSION 100 MG/5ML
(zonisamide)
NF
zonisamide oral capsule 100 mg, 25 mg, 50 mg PG
ZTALMY ORAL SUSPENSION 50 MG/ML (ganaxolone) NF
ATTENTION DEFICIT HYPERACTIVITY DISORDER -
DRUGS TO TREAT ADHD
ADDERALL ORAL TABLET 10 MG, 12.5 MG, 15 MG, 20
MG, 30 MG, 5 MG, 7.5 MG (amphetamine-
dextroamphetamine)
NF
ADDERALL XR ORAL CAPSULE EXTENDED
RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30
MG, 5 MG (amphetamine-dextroamphetamine)
NF
ADZENYS XR-ODT ORAL TABLET EXTENDED
RELEASE DISPERSIBLE 12.5 MG, 15.7 MG, 18.8 MG, 3.1
MG, 6.3 MG, 9.4 MG (amphetamine)
NF
amphetamine sulfate oral tablet 10 mg, 5 mg NP
STX; QL (120 TABLETS
per 25 days)
amphetamine-dextroamphet er oral capsule extended release 24
hour 10 mg, 5 mg
PG
QL (90 CAPSULES per 25
days)
amphetamine-dextroamphet er oral capsule extended release 24
hour 15 mg, 20 mg, 25 mg, 30 mg
PG
QL (30 CAPSULES per 25
days)
amphetamine-dextroamphetamine oral tablet 10 mg PG
QL (90 TABLETS per 25
DAYs)
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07/01/2023
87
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
amphetamine-dextroamphetamine oral tablet 12.5 mg, 5 mg, 7.5
mg
PG
QL (90 TABLETS per 25
days)
amphetamine-dextroamphetamine oral tablet 15 mg PG
QL (60 TABLETS per 25
days)
amphetamine-dextroamphetamine oral tablet 20 mg PG
QL (60 TABLETS per 25
DAYs)
amphetamine-dextroamphetamine oral tablet 30 mg PG
QL (30 TABLETS per 25
DAYs)
APTENSIO XR ORAL CAPSULE EXTENDED RELEASE
24 HOUR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 50 MG,
60 MG (methylphenidate hcl)
NF
atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg PG
QL (120 CAPSULES per 25
DAYs)
atomoxetine hcl oral capsule 100 mg, 60 mg, 80 mg PG
QL (30 CAPSULES per 25
DAYs)
atomoxetine hcl oral capsule 40 mg PG
QL (60 CAPSULES per 25
DAYs)
AZSTARYS ORAL CAPSULE 26.1-5.2 MG, 39.2-7.8 MG,
52.3-10.4 MG (serdexmethylphen-dexmethylphen)
PB
QL (30 CAPSULES per 25
days)
CONCERTA ORAL TABLET EXTENDED RELEASE 18
MG, 27 MG, 36 MG, 54 MG (methylphenidate hcl)
NF
COTEMPLA XR-ODT ORAL TABLET EXTENDED
RELEASE DISPERSIBLE 17.3 MG, 25.9 MG, 8.6 MG
(methylphenidate)
NF
DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15
MG/9HR, 20 MG/9HR, 30 MG/9HR (methylphenidate)
NF
DESOXYN ORAL TABLET 5 MG (methamphetamine hcl) NP
QL (150 TABLETS per 25
days)
DEXEDRINE ORAL CAPSULE EXTENDED RELEASE
24 HOUR 10 MG (dextroamphetamine sulfate)
NP
ST; QL (120 CAPSULES
per 25 days)
DEXEDRINE ORAL CAPSULE EXTENDED RELEASE
24 HOUR 15 MG (dextroamphetamine sulfate)
NP
ST; QL (60 CAPSULES per
25 days)
dexmethylphenidate hcl er oral capsule extended release 24 hour
10 mg, 15 mg, 20 mg, 5 mg
PG
QL (60 CAPSULES per 25
DAYs)
dexmethylphenidate hcl er oral capsule extended release 24 hour
25 mg, 30 mg, 40 mg
PG
QL (30 CAPSULES per 25
DAYs)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
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07/01/2023
88
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
dexmethylphenidate hcl er oral capsule extended release 24 hour
35 mg
PG
QL (30 CAPSULES per 25
days)
dexmethylphenidate hcl oral tablet 10 mg PG
QL (60 TABLETS per 25
days)
dexmethylphenidate hcl oral tablet 2.5 mg, 5 mg PG
QL (120 TABLETS per 25
days)
dextroamphetamine sulfate er oral capsule extended release 24
hour 10 mg, 5 mg
PG
QL (120 CAPSULES per 25
days)
dextroamphetamine sulfate er oral capsule extended release 24
hour 15 mg
PG
QL (60 CAPSULES per 25
days)
dextroamphetamine sulfate oral solution 5 mg/5ml PG QL (1200 ML per 25 DAYs)
dextroamphetamine sulfate oral tablet 10 mg, 5 mg PG
QL (120 TABLETS per 25
DAYs)
DYANAVEL XR ORAL SUSPENSION EXTENDED
RELEASE 2.5 MG/ML (amphetamine)
NF
DYANAVEL XR ORAL TABLET CHEWABLE
EXTENDED RELEASE 10 MG, 15 MG, 20 MG, 5 MG
(amphetamine)
NF
EVEKEO ODT ORAL TABLET DISPERSIBLE 10 MG, 15
MG, 20 MG, 5 MG (amphetamine sulfate)
NF
EVEKEO ORAL TABLET 10 MG, 5 MG (amphetamine
sulfate)
NF
FOCALIN ORAL TABLET 10 MG (dexmethylphenidate hcl) NP
QL (60 TABLETS per 25
DAYs)
FOCALIN ORAL TABLET 2.5 MG, 5 MG
(dexmethylphenidate hcl)
NP
QL (120 TABLETS per 25
DAYs)
FOCALIN XR ORAL CAPSULE EXTENDED RELEASE
24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30 MG, 35 MG,
40 MG, 5 MG (dexmethylphenidate hcl)
NF
guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2
mg, 3 mg, 4 mg
NP
INTUNIV ORAL TABLET EXTENDED RELEASE 24
HOUR 1 MG, 2 MG, 3 MG, 4 MG (guanfacine hcl)
NF
JORNAY PM ORAL CAPSULE EXTENDED RELEASE
24 HOUR 100 MG, 20 MG, 40 MG, 60 MG, 80 MG
(methylphenidate hcl)
NF
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
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07/01/2023
89
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
KAPVAY ORAL TABLET EXTENDED RELEASE 12
HOUR 0.1 MG (clonidine hcl)
NF
methamphetamine hcl oral tablet 5 mg PG
STX; QL (150 TABLETS
per 25 DAYs)
METHYLIN ORAL SOLUTION 10 MG/5ML
(methylphenidate hcl)
NP QL (900 ML per 25 DAYs)
METHYLIN ORAL SOLUTION 5 MG/5ML
(methylphenidate hcl)
NP QL (1800 ML per 25 DAYs)
methylphenidate hcl er (cd) oral capsule extended release 10
mg, 20 mg, 30 mg
PG
QL (60 CAPSULES per 25
DAYs)
methylphenidate hcl er (cd) oral capsule extended release 40
mg, 50 mg, 60 mg
PG
QL (30 CAPSULES per 25
DAYs)
methylphenidate hcl er (la) oral capsule extended release 24
hour 10 mg
PG
QL (60 CAPSULES per 25
DAYs)
methylphenidate hcl er (la) oral capsule extended release 24
hour 20 mg, 30 mg
PG
QL (60 CAPSULES per 25
days)
methylphenidate hcl er (la) oral capsule extended release 24
hour 40 mg, 60 mg
PG
QL (30 CAPSULES per 25
days)
methylphenidate hcl er (osm) oral tablet extended release 18
mg, 27 mg, 36 mg
PG
QL (60 TABLETS per 25
days)
methylphenidate hcl er (osm) oral tablet extended release 45
mg, 63 mg
NF
methylphenidate hcl er (osm) oral tablet extended release 54 mg PG
QL (30 TABLETS per 25
days)
methylphenidate hcl er (osm) oral tablet extended release 72 mg NP
QL (30 TABLETS per 25
days)
methylphenidate hcl er (xr) oral capsule extended release 24
hour 10 mg, 15 mg, 20 mg, 30 mg
PG
QL (60 CAPSULES per 25
DAYs)
methylphenidate hcl er (xr) oral capsule extended release 24
hour 40 mg, 50 mg, 60 mg
PG
QL (30 CAPSULES per 25
DAYs)
methylphenidate hcl er oral tablet extended release 10 mg, 20
mg
PG
QL (90 TABLETS per 25
DAYs)
methylphenidate hcl er oral tablet extended release 24 hour 18
mg, 27 mg, 36 mg, 54 mg
NF
methylphenidate hcl oral solution 10 mg/5ml PG QL (900 ML per 25 days)
methylphenidate hcl oral solution 5 mg/5ml PG QL (1800 ML per 25 days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
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07/01/2023
90
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
methylphenidate hcl oral tablet 10 mg, 5 mg PG
QL (180 TABLETS per 25
DAYs)
methylphenidate hcl oral tablet 20 mg PG
QL (90 TABLETS per 25
DAYs)
methylphenidate hcl oral tablet chewable 10 mg, 2.5 mg, 5 mg NP
QL (180 TABLETS per 25
DAYs)
methylphenidate transdermal patch 10 mg/9hr, 15 mg/9hr, 20
mg/9hr, 30 mg/9hr
NF
MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24
HOUR 12.5 MG, 25 MG, 37.5 MG, 50 MG (amphetamine-
dextroamphetamine)
NF
dextroamphetamine sulfate (Procentra Oral Solution 5
Mg/5Ml)
PG QL (1200 ML per 25 days)
QELBREE ORAL CAPSULE EXTENDED RELEASE 24
HOUR 100 MG, 150 MG, 200 MG (viloxazine hcl)
PB
QL (90 CAPSULES per 25
days)
QUILLICHEW ER ORAL TABLET CHEWABLE
EXTENDED RELEASE 20 MG, 30 MG, 40 MG
(methylphenidate hcl)
NF
QUILLIVANT XR ORAL SUSPENSION
RECONSTITUTED ER 25 MG/5ML (methylphenidate hcl)
NF
RELEXXII ORAL TABLET EXTENDED RELEASE 45
MG, 63 MG, 72 MG (methylphenidate hcl)
NF
RITALIN LA ORAL CAPSULE EXTENDED RELEASE
24 HOUR 10 MG, 20 MG, 30 MG (methylphenidate hcl)
NP
QL (60 CAPSULES per 25
DAYs)
RITALIN LA ORAL CAPSULE EXTENDED RELEASE
24 HOUR 40 MG (methylphenidate hcl)
NP
QL (30 CAPSULES per 25
DAYs)
RITALIN ORAL TABLET 10 MG, 5 MG (methylphenidate
hcl)
NP
QL (180 TABLETS per 25
DAYs)
RITALIN ORAL TABLET 20 MG (methylphenidate hcl) NP
QL (90 TABLETS per 25
DAYs)
STRATTERA ORAL CAPSULE 10 MG, 18 MG, 25 MG
(atomoxetine hcl)
NP
QL (120 CAPSULES per 25
DAYs)
STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG
(atomoxetine hcl)
NP
QL (30 CAPSULES per 25
DAYs)
STRATTERA ORAL CAPSULE 40 MG (atomoxetine hcl) NP
QL (60 CAPSULES per 25
DAYs)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
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07/01/2023
91
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG
(lisdexamfetamine dimesylate)
PB
QL (60 CAPSULES per 25
DAYs)
VYVANSE ORAL CAPSULE 40 MG, 50 MG, 60 MG, 70
MG (lisdexamfetamine dimesylate)
PB
QL (30 CAPSULES per 25
DAYs)
VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG,
30 MG (lisdexamfetamine dimesylate)
PB
QL (60 TABLETS per 25
DAYs)
VYVANSE ORAL TABLET CHEWABLE 40 MG, 50 MG,
60 MG (lisdexamfetamine dimesylate)
PB
QL (30 TABLETS per 25
DAYs)
XELSTRYM TRANSDERMAL PATCH 13.5 MG/9HR, 18
MG/9HR, 4.5 MG/9HR, 9 MG/9HR (dextroamphetamine)
NF
dextroamphetamine sulfate (Zenzedi Oral Tablet 15 Mg, 20
Mg)
PG
QL (60 TABLETS per 25
days)
ZENZEDI ORAL TABLET 2.5 MG, 7.5 MG
(dextroamphetamine sulfate)
PG
QL (120 TABLETS per 25
days)
dextroamphetamine sulfate (Zenzedi Oral Tablet 30 Mg) PG
QL (30 TABLETS per 25
days)
FIBROMYALGIA
SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50
MG (milnacipran hcl)
NP ST
SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MG
(milnacipran hcl)
NP ST
HYPNOTICS - DRUGS TO TREAT INSOMNIA
AMBIEN CR ORAL TABLET EXTENDED RELEASE
12.5 MG, 6.25 MG (zolpidem tartrate)
NP
ST; QL (15 TABLETS per
25 days)
AMBIEN ORAL TABLET 10 MG, 5 MG (zolpidem tartrate) NP
ST; QL (15 TABLETS per
25 days)
BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5
MG (suvorexant)
NF
DAYVIGO ORAL TABLET 10 MG, 5 MG (lemborexant) NF
DORAL ORAL TABLET 15 MG (quazepam) NP
STX; QL (15 TABLETS per
25 days)
doxepin hcl oral tablet 3 mg, 6 mg PG
QLR (QL applies to
members age 65 and older);
QL (30 TABLETS per 25
days); AL (Max 65 Years)
EDLUAR SUBLINGUAL TABLET SUBLINGUAL 10
MG, 5 MG (zolpidem tartrate)
NF
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
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07/01/2023
92
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
estazolam oral tablet 1 mg, 2 mg PG
QL (15 TABLETS per 25
DAYs)
eszopiclone oral tablet 1 mg, 2 mg, 3 mg PG
QL (15 TABLETS per 25
DAYs)
HALCION ORAL TABLET 0.25 MG (triazolam) NP
QL (10 TABLETS per 25
DAYs)
HETLIOZ LQ ORAL SUSPENSION 4 MG/ML
(tasimelteon)
NPSP PA; QL (5 ML per 1 day)
HETLIOZ ORAL CAPSULE 20 MG (tasimelteon) NPSP
PA; QL (30 CAPSULES per
30 days)
LUNESTA ORAL TABLET 1 MG, 2 MG, 3 MG
(eszopiclone)
NF
midazolam hcl oral syrup 2 mg/ml NP
quazepam oral tablet 15 mg NF
QUVIVIQ ORAL TABLET 25 MG, 50 MG (daridorexant
hcl)
NF
ramelteon oral tablet 8 mg PG
QL (15 TABLETS per 25
DAYs)
RESTORIL ORAL CAPSULE 15 MG, 22.5 MG, 30 MG, 7.5
MG (temazepam)
NP
QL (15 CAPSULES per 25
DAYs)
ROZEREM ORAL TABLET 8 MG (ramelteon) NF
SILENOR ORAL TABLET 3 MG, 6 MG (doxepin hcl) NF
tasimelteon oral capsule 20 mg PSP
PA; QL (30 CAPSULES per
30 DAYs)
temazepam oral capsule 15 mg, 30 mg PG
QL (15 CAPSULES per 25
DAYs)
temazepam oral capsule 22.5 mg, 7.5 mg PG
QL (15 CAPSULES per 25
days)
triazolam oral tablet 0.125 mg, 0.25 mg PG
QL (10 TABLETS per 25
DAYs)
zaleplon oral capsule 10 mg, 5 mg PG
QL (15 CAPSULES per 25
DAYs)
zolpidem tartrate er oral tablet extended release 12.5 mg NP
ST; QL (15 TABLETS per
25 DAYs)
zolpidem tartrate er oral tablet extended release 6.25 mg NP
ST; QL (15 TABLETS per
25 days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
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07/01/2023
93
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
zolpidem tartrate oral tablet 10 mg, 5 mg PG
QL (15 TABLETS per 25
DAYs)
zolpidem tartrate sublingual tablet sublingual 1.75 mg, 3.5 mg NF
ZOLPIMIST ORAL SOLUTION 5 MG/ACT (zolpidem
tartrate)
NF
MIGRAINE - DRUGS TO TREAT SEVERE HEADACHES
AIMOVIG SUBCUTANEOUS SOLUTION AUTO-
INJECTOR 140 MG/ML, 70 MG/ML (erenumab-aooe)
PB
ST; QL (1 SYRINGE per 25
days)
AJOVY SUBCUTANEOUS SOLUTION AUTO-
INJECTOR 225 MG/1.5ML (fremanezumab-vfrm)
PB
ST; QL (3 ML per 75
DAYs)
AJOVY SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 225 MG/1.5ML (fremanezumab-vfrm)
PB ST; QL (3 ML per 75 days)
almotriptan malate oral tablet 12.5 mg, 6.25 mg NP
QL (12 TABLETS per 25
days)
CAFERGOT ORAL TABLET 1-100 MG (ergotamine-
caffeine)
NF
dihydroergotamine mesylate injection solution 1 mg/ml NP
dihydroergotamine mesylate nasal solution 4 mg/ml NF
eletriptan hydrobromide oral tablet 20 mg, 40 mg NP
QL (12 TABLETS per 25
DAYs)
EMGALITY (300 MG DOSE) SUBCUTANEOUS
SOLUTION PREFILLED SYRINGE 100 MG/ML
(galcanezumab-gnlm)
PB ST; QL (3 ML per 25 days)
EMGALITY SUBCUTANEOUS SOLUTION AUTO-
INJECTOR 120 MG/ML (galcanezumab-gnlm)
PB
ST; QL (2 syringes first
month, then 1 syringe per 25
days)
EMGALITY SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 120 MG/ML (galcanezumab-gnlm)
PB
ST; QL (2 syringes first
month, then 1 syringe per 25
days)
ergotamine-caffeine oral tablet 1-100 mg NF
FROVA ORAL TABLET 2.5 MG (frovatriptan succinate) NP
ST; QL (18 TABLETS per
25 DAYs)
frovatriptan succinate oral tablet 2.5 mg NP
QL (18 TABLETS per 25
days)
IMITREX NASAL SOLUTION 20 MG/ACT (sumatriptan) NP
ST; QL (12 SPRAYS per 25
DAYs)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
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07/01/2023
94
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
IMITREX NASAL SOLUTION 5 MG/ACT (sumatriptan) NP
ST; QL (24 SPRAYS per 25
DAYs)
IMITREX ORAL TABLET 100 MG, 25 MG, 50 MG
(sumatriptan succinate)
NP
ST; QL (12 TABLETS per
25 DAYs)
IMITREX STATDOSE REFILL SUBCUTANEOUS
SOLUTION CARTRIDGE 4 MG/0.5ML (sumatriptan
succinate)
NP
ST; QL (18 SYRINGES per
25 DAYs)
IMITREX STATDOSE REFILL SUBCUTANEOUS
SOLUTION CARTRIDGE 6 MG/0.5ML (sumatriptan
succinate)
NP
ST; QL (12 CARTRIDGES
per 25 days)
IMITREX STATDOSE SYSTEM SUBCUTANEOUS
SOLUTION AUTO-INJECTOR 4 MG/0.5ML (sumatriptan
succinate)
NP
ST; QL (18 SYRINGES per
25 DAYs)
IMITREX STATDOSE SYSTEM SUBCUTANEOUS
SOLUTION AUTO-INJECTOR 6 MG/0.5ML (sumatriptan
succinate)
NP
ST; QL (12 INJECTIONS
per 25 days)
MAXALT ORAL TABLET 10 MG (rizatriptan benzoate) NF
MAXALT-MLT ORAL TABLET DISPERSIBLE 10 MG
(rizatriptan benzoate)
NF
MIGERGOT RECTAL SUPPOSITORY 2-100 MG
(ergotamine-caffeine)
NF
MIGRANAL NASAL SOLUTION 4 MG/ML
(dihydroergotamine mesylate)
NF
naratriptan hcl oral tablet 1 mg, 2.5 mg PG
QL (12 TABLETS per 25
DAYs)
NURTEC ORAL TABLET DISPERSIBLE 75 MG
(rimegepant sulfate)
PB
ST; QL (16 TABLETS per
25 days)
ONZETRA XSAIL NASAL EXHALER POWDER 11
MG/NOSEPC (sumatriptan succinate)
NP
ST; QL (8 POUCHES per
25 days)
QULIPTA ORAL TABLET 10 MG, 30 MG, 60 MG
(atogepant)
PB
ST; QL (30 TABLETS per
25 days)
RELPAX ORAL TABLET 20 MG, 40 MG (eletriptan
hydrobromide)
NP
ST; QL (12 TABLETS per
25 DAYs)
REYVOW ORAL TABLET 100 MG (lasmiditan succinate) NP
ST; QL (8 TABLETS per 25
days)
REYVOW ORAL TABLET 50 MG (lasmiditan succinate) NP
ST; QL (4 TABLETS per 25
days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
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07/01/2023
95
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
rizatriptan benzoate oral tablet 10 mg, 5 mg PG
QL (18 TABLETS per 25
DAYs)
rizatriptan benzoate oral tablet dispersible 10 mg, 5 mg PG
QL (18 TABLETS per 25
DAYs)
sumatriptan nasal solution 20 mg/act PG
QL (12 SPRAYS per 25
DAYs)
sumatriptan nasal solution 5 mg/act PG
QL (24 SPRAYS per 25
DAYs)
sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg PG
QL (12 TABLETS per 25
DAYs)
sumatriptan succinate refill subcutaneous solution cartridge 4
mg/0.5ml
PG
QL (18 SYRINGES per 25
days)
sumatriptan succinate refill subcutaneous solution cartridge 6
mg/0.5ml
PG
QL (12 CARTRIDGES per
25 days)
sumatriptan succinate subcutaneous solution 6 mg/0.5ml PG QL (12 ML per 25 days)
sumatriptan succinate subcutaneous solution auto-injector 4
mg/0.5ml
PG QL (18 ML per 25 days)
sumatriptan succinate subcutaneous solution auto-injector 6
mg/0.5ml
PG QL (12 ML per 25 days)
sumatriptan-naproxen sodium oral tablet 85-500 mg NF
TOSYMRA NASAL SOLUTION 10 MG/ACT (sumatriptan) NF
TREXIMET ORAL TABLET 85-500 MG (sumatriptan-
naproxen sodium)
NF
TRUDHESA NASAL AEROSOL SOLUTION 0.725
MG/ACT (dihydroergotamine mesylate hfa)
NP
QL (3 PACKAGES per 25
days)
UBRELVY ORAL TABLET 100 MG, 50 MG (ubrogepant) PB
ST; QL (16 TABLETS per
25 days)
ZEMBRACE SYMTOUCH SUBCUTANEOUS
SOLUTION AUTO-INJECTOR 3 MG/0.5ML (sumatriptan
succinate)
NP
ST; QL (24 INJECTORS
per 25 DAYs)
zolmitriptan nasal solution 5 mg PG
QL (12 SPRAYS per 25
DAYs)
zolmitriptan oral tablet 2.5 mg, 5 mg PG
QL (12 TABLETS per 25
days)
zolmitriptan oral tablet dispersible 2.5 mg, 5 mg PG
QL (12 TABLETS per 25
days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
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07/01/2023
96
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ZOMIG NASAL SOLUTION 2.5 MG, 5 MG (zolmitriptan) NP
ST; QL (12 SPRAYS per 25
days)
ZOMIG ORAL TABLET 2.5 MG, 5 MG (zolmitriptan) NP
ST; QL (12 TABLETS per
25 days)
MISCELLANEOUS
DAYBUE ORAL SOLUTION 200 MG/ML (trofinetide) NPSP
PA; QL (3600 ML per 30
days)
EVRYSDI ORAL SOLUTION RECONSTITUTED 0.75
MG/ML (risdiplam)
NPSP
PA; QL (2 BOTTLES per 24
days)
EXSERVAN ORAL FILM 50 MG (riluzole) NF
FIRDAPSE ORAL TABLET 10 MG (amifampridine
phosphate)
NPSP
PA; QL (240 TABLETS per
30 DAYs)
lithium carbonate er oral tablet extended release 300 mg, 450
mg
PG
lithium carbonate oral capsule 150 mg, 300 mg, 600 mg PG
lithium carbonate oral tablet 300 mg PG
MESTINON ORAL SOLUTION 60 MG/5ML
(pyridostigmine bromide)
NF
MESTINON ORAL TABLET 60 MG (pyridostigmine
bromide)
NF
pyridostigmine bromide er oral tablet extended release 180 mg PG
pyridostigmine bromide oral solution 60 mg/5ml PG
pyridostigmine bromide oral tablet 30 mg NF
pyridostigmine bromide oral tablet 60 mg PG
RADICAVA ORS ORAL SUSPENSION 105 MG/5ML
(edaravone)
NPSP
PA; QL (50 ML per 28
DAYs)
RADICAVA ORS STARTER KIT ORAL SUSPENSION
105 MG/5ML (edaravone)
NPSP
PA; QL (70 ML per 28
DAYs)
RELYVRIO ORAL PACKET 3-1 GM (phenylbutyrate-
taurursodiol)
NF
riluzole oral tablet 50 mg PG
SKYCLARYS ORAL CAPSULE 50 MG (omaveloxolone) NF
TIGLUTIK ORAL SUSPENSION 50 MG/10ML (riluzole) NF
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07/01/2023
97
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
MOVEMENT DISORDERS
AUSTEDO ORAL TABLET 12 MG, 9 MG
(deutetrabenazine)
PSP
PA; QL (120 TABLETS per
30 days)
AUSTEDO ORAL TABLET 6 MG (deutetrabenazine) PSP
PA; QL (60 TABLETS per
30 days)
AUSTEDO XR ORAL TABLET EXTENDED RELEASE
24 HOUR 12 MG (deutetrabenazine)
PSP
PA; QL (120 TABLETS per
30 DAYs)
AUSTEDO XR ORAL TABLET EXTENDED RELEASE
24 HOUR 24 MG (deutetrabenazine)
PSP
PA; QL (60 TABLETS per
30 DAYs)
AUSTEDO XR ORAL TABLET EXTENDED RELEASE
24 HOUR 6 MG (deutetrabenazine)
PSP
PA; QL (90 TABLETS per
30 DAYs)
INGREZZA ORAL CAPSULE 40 MG, 60 MG, 80 MG
(valbenazine tosylate)
PSP
PA; QL (30 CAPSULES per
30 days)
INGREZZA ORAL CAPSULE THERAPY PACK 40 & 80
MG (valbenazine tosylate)
PSP
PA; QL (1 CAPSULE
THERAPY PACK per 28
days)
tetrabenazine oral tablet 12.5 mg PSP
PA; QL (240 TABLETS per
30 days)
tetrabenazine oral tablet 25 mg PSP
PA; QL (120 TABLETS per
30 days)
XENAZINE ORAL TABLET 12.5 MG, 25 MG
(tetrabenazine)
NF
MULTIPLE SCLEROSIS AGENTS - DRUGS TO TREAT
MULTIPLE SCLEROSIS
AMPYRA ORAL TABLET EXTENDED RELEASE 12
HOUR 10 MG (dalfampridine)
NPSP
PA; ST; QL (60 TABLETS
per 30 days)
AUBAGIO ORAL TABLET 14 MG, 7 MG (teriflunomide) NF
AVONEX PEN INTRAMUSCULAR AUTO-INJECTOR
KIT 30 MCG/0.5ML (interferon beta-1a)
PSP
PA; QL (4 SYRINGES per
28 days)
AVONEX PREFILLED INTRAMUSCULAR PREFILLED
SYRINGE KIT 30 MCG/0.5ML (interferon beta-1a)
PSP
PA; QL (4 SYRINGES per
28 days)
BAFIERTAM ORAL CAPSULE DELAYED RELEASE 95
MG (monomethyl fumarate)
NF
BETASERON SUBCUTANEOUS KIT 0.3 MG (interferon
beta-1b)
PSP
PA; QL (14 INJECTIONS
per 28 days)
COPAXONE SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE 20 MG/ML (glatiramer acetate)
PSP PA; QL (30 ML per 30 days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
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07/01/2023
98
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
COPAXONE SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE 40 MG/ML (glatiramer acetate)
PSP PA; QL (12 ML per 28 days)
dalfampridine er oral tablet extended release 12 hour 10 mg PSP
PA; QL (60 TABLETS per
30 days)
dimethyl fumarate oral capsule delayed release 120 mg PSP
PA; N8 (Listing does not
include certain NDCs); QL
(14 CAPSULES per 28
DAYs)
dimethyl fumarate oral capsule delayed release 240 mg PSP
PA; QL (60 CAPSULES per
30 DAYs)
dimethyl fumarate starter pack oral 120 & 240 mg PSP
PA; QL (1 KIT per 30
DAYs)
EXTAVIA SUBCUTANEOUS KIT 0.3 MG (interferon beta-
1b)
NF
fingolimod hcl oral capsule 0.5 mg PSP
PA; QL (30 CAPSULES per
30 days)
GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG (fingolimod
hcl)
NF
glatiramer acetate subcutaneous solution prefilled syringe 20
mg/ml
PSP PA; QL (30 ML per 30 days)
glatiramer acetate subcutaneous solution prefilled syringe 40
mg/ml
PSP PA; QL (12 ML per 28 days)
glatiramer acetate (Glatopa Subcutaneous Solution Prefilled
Syringe 20 Mg/Ml)
PSP PA; QL (30 ML per 30 days)
glatiramer acetate (Glatopa Subcutaneous Solution Prefilled
Syringe 40 Mg/Ml)
PSP PA; QL (12 ML per 28 days)
KESIMPTA SUBCUTANEOUS SOLUTION AUTO-
INJECTOR 20 MG/0.4ML (ofatumumab)
PSP PA; QL (1 PEN per 28 days)
MAVENCLAD (10 TABS) ORAL TABLET THERAPY
PACK 10 MG (cladribine)
NPSP
PA; QL (20 TABLETS per
270 days)
MAVENCLAD (4 TABS) ORAL TABLET THERAPY
PACK 10 MG (cladribine)
NPSP
PA; QL (20 TABLETS per
270 days)
MAVENCLAD (5 TABS) ORAL TABLET THERAPY
PACK 10 MG (cladribine)
NPSP
PA; QL (20 TABLETS per
270 days)
MAVENCLAD (6 TABS) ORAL TABLET THERAPY
PACK 10 MG (cladribine)
NPSP
PA; QL (20 TABLETS per
270 days)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
MAVENCLAD (7 TABS) ORAL TABLET THERAPY
PACK 10 MG (cladribine)
NPSP
PA; QL (20 TABLETS per
270 days)
MAVENCLAD (8 TABS) ORAL TABLET THERAPY
PACK 10 MG (cladribine)
NPSP
PA; QL (20 TABLETS per
270 days)
MAVENCLAD (9 TABS) ORAL TABLET THERAPY
PACK 10 MG (cladribine)
NPSP
PA; QL (20 TABLETS per
270 days)
MAYZENT ORAL TABLET 0.25 MG (siponimod fumarate) PSP
PA; QL (12 TABLETS per 5
days)
MAYZENT ORAL TABLET 1 MG (siponimod fumarate) PSP
PA; QL (30 TABLETS per
30 days)
MAYZENT ORAL TABLET 2 MG (siponimod fumarate) PSP
PA; QL (30 TABLETS per
30 DAYs)
MAYZENT STARTER PACK ORAL TABLET THERAPY
PACK 0.25 MG (siponimod fumarate)
PSP
PA; QL (7 TABLETS per 4
days)
MAYZENT STARTER PACK ORAL TABLET THERAPY
PACK 12 X 0.25 MG (siponimod fumarate)
PSP
PA; QL (12 TABLETS per 5
Days)
PLEGRIDY INTRAMUSCULAR SOLUTION
PREFILLED SYRINGE 125 MCG/0.5ML (peginterferon
beta-1a)
NPSP
PA; QL (2 INJECTIONS
per 28 days)
PLEGRIDY STARTER PACK SUBCUTANEOUS
SOLUTION PEN-INJECTOR 63 & 94 MCG/0.5ML
(peginterferon beta-1a)
NPSP
PA; QL (2 INJECTIONS
per 28 days)
PLEGRIDY STARTER PACK SUBCUTANEOUS
SOLUTION PREFILLED SYRINGE 63 & 94 MCG/0.5ML
(peginterferon beta-1a)
NPSP
PA; QL (2 INJECTIONS
per 28 days)
PLEGRIDY SUBCUTANEOUS SOLUTION PEN-
INJECTOR 125 MCG/0.5ML (peginterferon beta-1a)
NPSP
PA; QL (2 INJECTIONS
per 28 days)
PLEGRIDY SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 125 MCG/0.5ML (peginterferon beta-1a)
NPSP
PA; QL (2 INJECTIONS
per 28 days)
PONVORY ORAL TABLET 20 MG (ponesimod) NPSP
PA; QL (30 TABLETS per
30 days)
PONVORY STARTER PACK ORAL TABLET THERAPY
PACK 2-3-4-5-6-7-8-9 & 10 MG (ponesimod)
NPSP
PA; QL (14 TABLETS per
14 days)
REBIF REBIDOSE SUBCUTANEOUS SOLUTION
AUTO-INJECTOR 22 MCG/0.5ML, 44 MCG/0.5ML
(interferon beta-1a)
PSP
PA; QL (12 PENS per 28
days)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
REBIF REBIDOSE TITRATION PACK
SUBCUTANEOUS SOLUTION AUTO-INJECTOR 6X8.8
& 6X22 MCG (interferon beta-1a)
PSP PA; QL (1 ML per 28 days)
REBIF SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 22 MCG/0.5ML, 44 MCG/0.5ML (interferon beta-
1a)
PSP
PA; QL (12 SYRINGES per
28 DAYs)
REBIF TITRATION PACK SUBCUTANEOUS
SOLUTION PREFILLED SYRINGE 6X8.8 & 6X22 MCG
(interferon beta-1a)
PSP PA; QL (1 ML per 28 days)
TASCENSO ODT ORAL TABLET DISPERSIBLE 0.25
MG, 0.5 MG (fingolimod lauryl sulfate)
NF
TECFIDERA ORAL 120 & 240 MG (dimethyl fumarate) NF
TECFIDERA ORAL CAPSULE DELAYED RELEASE 120
MG, 240 MG (dimethyl fumarate)
NF
teriflunomide oral tablet 14 mg, 7 mg PSP
PA; QL (30 TABLETS per
30 DAYs)
TYSABRI INTRAVENOUS CONCENTRATE 300
MG/15ML (natalizumab)
PSP PA; QL (1 ML per 28 days)
VUMERITY ORAL CAPSULE DELAYED RELEASE 231
MG (diroximel fumarate)
PSP
PA; QL (120 CAPSULES
per 30 days)
ZEPOSIA 7-DAY STARTER PACK ORAL CAPSULE
THERAPY PACK 4 X 0.23MG & 3 X 0.46MG (ozanimod
hcl)
PSP
PA; ST; IBC (Preferred
agent for Ulcerative Colitis);
QL (1 PACK per 7 days)
ZEPOSIA ORAL CAPSULE 0.92 MG (ozanimod hcl) PSP
PA; ST; IBC (Preferred
agent for Ulcerative Colitis);
QL (30 CAPSULES per 30
days)
ZEPOSIA STARTER KIT ORAL CAPSULE THERAPY
PACK 0.23MG & 0.46MG & 0.92MG (ozanimod hcl)
PSP
PA; ST; IBC (Preferred
agent for Ulcerative Colitis);
QL (1 KIT per 30 days)
MUSCULOSKELETAL THERAPY AGENTS
AMRIX ORAL CAPSULE EXTENDED RELEASE 24
HOUR 15 MG, 30 MG (cyclobenzaprine hcl)
NF
baclofen oral solution 5 mg/5ml NF
baclofen oral suspension 25 mg/5ml NF
baclofen oral tablet 10 mg, 20 mg, 5 mg PG
N8 (Listing does not include
certain NDCs)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
BOTOX INJECTION SOLUTION RECONSTITUTED 100
UNIT, 200 UNIT (onabotulinumtoxina)
NF
carisoprodol oral tablet 250 mg NF
carisoprodol oral tablet 350 mg PG
N8 (Listing does not include
certain NDCs); QL (84
TABLETS per 28 DAYs)
chlorzoxazone oral tablet 250 mg, 375 mg, 750 mg NF
chlorzoxazone oral tablet 500 mg PG
N8 (Listing does not include
certain NDCs)
cyclobenzaprine hcl er oral capsule extended release 24 hour 15
mg, 30 mg
NF
cyclobenzaprine hcl oral tablet 10 mg, 5 mg PG
cyclobenzaprine hcl oral tablet 7.5 mg NF
dantrolene sodium oral capsule 100 mg, 25 mg, 50 mg PG
DYSPORT INTRAMUSCULAR SOLUTION
RECONSTITUTED 300 UNIT, 500 UNIT
(abobotulinumtoxina)
NPSP PA
FLEQSUVY ORAL SUSPENSION 25 MG/5ML (baclofen) NF
LYVISPAH ORAL PACKET 10 MG, 20 MG, 5 MG
(baclofen)
NF
metaxalone oral tablet 400 mg NF
metaxalone oral tablet 800 mg NP
methocarbamol oral tablet 1000 mg NF
methocarbamol oral tablet 500 mg, 750 mg PG
N8 (Listing does not include
certain NDCs)
norgesic forte oral tablet 50-770-60 mg NF
orphenadrine-aspirin-caffeine (Norgesic Oral Tablet 25-385-30
Mg)
NF
orphenadrine-aspirin-caffeine oral tablet 25-385-30 mg NF
orphenadrine-aspirin-caffeine (Orphengesic Forte Oral Tablet
50-770-60 Mg)
NF
OZOBAX ORAL SOLUTION 5 MG/5ML (baclofen) NF
SOMA ORAL TABLET 250 MG, 350 MG (carisoprodol) NP
QL (84 TABLETS per 28
DAYs)
tizanidine hcl oral capsule 2 mg, 4 mg, 6 mg NP
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
tizanidine hcl oral tablet 2 mg, 4 mg PG
XEOMIN INTRAMUSCULAR SOLUTION
RECONSTITUTED 100 UNIT, 200 UNIT, 50 UNIT
(incobotulinumtoxina)
NPSP PA
NARCOLEPSY/CATAPLEXY - DRUGS FOR SLEEP
DISORDERS
armodafinil oral tablet 150 mg, 200 mg, 250 mg PG
PA; QL (30 TABLETS per
25 days)
armodafinil oral tablet 50 mg PG
PA; QL (60 TABLETS per
25 days)
modafinil oral tablet 100 mg, 200 mg PG
PA; QL (60 TABLETS per
25 days)
NUVIGIL ORAL TABLET 150 MG, 200 MG, 250 MG, 50
MG (armodafinil)
NF
PROVIGIL ORAL TABLET 100 MG, 200 MG (modafinil) NF
sodium oxybate oral solution 500 mg/ml NF
SUNOSI ORAL TABLET 150 MG, 75 MG (solriamfetol hcl) PB
PA; QL (30 TABLETS per
25 days)
WAKIX ORAL TABLET 17.8 MG, 4.45 MG (pitolisant hcl) PSP
PA; QL (60 TABLETS per
30 days)
XYREM ORAL SOLUTION 500 MG/ML (sodium oxybate) NPSP
PA; QL (540 ML per 30
days)
XYWAV ORAL SOLUTION 500 MG/ML (ca, mg, k, and na
oxybates)
PSP
PA; QL (540 ML per 30
days)
OPIOID AGONIST/ANTAGONIST
buprenorphine hcl-naloxone hcl sublingual film 12-3 mg PG QL (60 FILM per 25 days)
buprenorphine hcl-naloxone hcl sublingual film 2-0.5 mg, 4-1
mg, 8-2 mg
PG QL (90 FILM per 25 days)
buprenorphine hcl-naloxone hcl sublingual tablet sublingual 2-
0.5 mg, 8-2 mg
CE
N7 (PG); QL (90 TABLETS
per 25 days)
SUBOXONE SUBLINGUAL FILM 12-3 MG, 2-0.5 MG, 4-
1 MG, 8-2 MG (buprenorphine hcl-naloxone hcl)
NF
ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 0.7-
0.18 MG, 1.4-0.36 MG, 2.9-0.71 MG, 5.7-1.4 MG
(buprenorphine hcl-naloxone hcl)
PB
QL (90 TABLETS per 25
DAYs)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 11.4-
2.9 MG (buprenorphine hcl-naloxone hcl)
PB
QL (30 TABLETS per 25
DAYs)
ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 8.6-
2.1 MG (buprenorphine hcl-naloxone hcl)
PB
QL (60 TABLETS per 25
DAYs)
OPIOID ANTAGONIST
KLOXXADO NASAL LIQUID 8 MG/0.1ML (naloxone hcl) NP QL (4 SPRAYS per 25 days)
naloxone hcl injection solution 0.4 mg/ml, 4 mg/10ml PG
naloxone hcl injection solution cartridge 0.4 mg/ml PG
naloxone hcl injection solution prefilled syringe 2 mg/2ml PG
naloxone hcl nasal liquid 4 mg/0.1ml PG QL (4 SPRAYS per 25 days)
naltrexone hcl oral tablet 50 mg CE N7 (PG)
NARCAN NASAL LIQUID 4 MG/0.1ML (naloxone hcl) NP QL (4 SPRAYS per 25 days)
VIVITROL INTRAMUSCULAR SUSPENSION
RECONSTITUTED 380 MG (naltrexone)
NPSP QL (380 MG per 28 days)
ZIMHI INJECTION SOLUTION PREFILLED SYRINGE
5 MG/0.5ML (naloxone hcl)
NF
OPIOID PARTIAL AGONISTS
buprenorphine hcl sublingual tablet sublingual 2 mg, 8 mg CE
N7 (PG); QL (90 TABLETS
per 25 DAYs)
POSTHERPETIC NEURALGIA (PHN)
GRALISE ORAL TABLET 300 MG (gabapentin (once-
daily))
PB
ST; QL (150 TABLETS per
25 days)
GRALISE ORAL TABLET 450 MG (gabapentin (once-
daily))
PB
ST; QL (90 TABLETS per
25 DAYs)
GRALISE ORAL TABLET 600 MG (gabapentin (once-
daily))
PB
ST; QL (90 TABLETS per
25 days)
GRALISE ORAL TABLET 750 MG, 900 MG (gabapentin
(once-daily))
PB
ST; QL (60 TABLETS per
25 DAYs)
HORIZANT ORAL TABLET EXTENDED RELEASE 300
MG, 600 MG (gabapentin enacarbil)
NF
LYRICA CR ORAL TABLET EXTENDED RELEASE 24
HOUR 165 MG, 330 MG, 82.5 MG (pregabalin)
NF
pregabalin er oral tablet extended release 24 hour 165 mg, 330
mg, 82.5 mg
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
PSYCHOTHERAPEUTIC-MISC
ADDYI ORAL TABLET 100 MG (flibanserin) NP SPC
chlordiazepoxide-amitriptyline oral tablet 10-25 mg NP
QLR (QL applies to
members age 65 and older);
QL (60 TABLETS per 25
days); AL (Max 65 Years)
chlordiazepoxide-amitriptyline oral tablet 5-12.5 mg NP
QLR (QL applies to
members age 65 and older);
QL (120 TABLETS per 25
days); AL (Max 65 Years)
fluoxetine hcl (pmdd) oral tablet 10 mg, 20 mg NF
LUCEMYRA ORAL TABLET 0.18 MG (lofexidine hcl) NF
LYBALVI ORAL TABLET 10-10 MG, 15-10 MG, 20-10
MG, 5-10 MG (olanzapine-samidorphan)
NF
NUEDEXTA ORAL CAPSULE 20-10 MG
(dextromethorphan-quinidine)
NF
olanzapine-fluoxetine hcl oral capsule 12-25 mg, 12-50 mg, 3-25
mg, 6-25 mg, 6-50 mg
NP STX
paroxetine mesylate oral capsule 7.5 mg NF
perphenazine-amitriptyline oral tablet 2-10 mg PG
QLR (QL applies to
members age 65 and older);
QL (150 TABLETS per 25
days); AL (Max 65 Years)
perphenazine-amitriptyline oral tablet 2-25 mg, 4-25 mg PG
QLR (QL applies to
members age 65 and older);
QL (60 TABLETS per 25
days); AL (Max 65 Years)
perphenazine-amitriptyline oral tablet 4-10 mg PG
QLR (QL applies to
members age 65 and older);
QL (120 TABLETS per 25
days); AL (Max 65 Years)
perphenazine-amitriptyline oral tablet 4-50 mg PG
QLR (QL applies to
members age 65 and older);
QL (30 TABLETS per 25
days); AL (Max 65 Years)
pimozide oral tablet 1 mg, 2 mg NP
VYLEESI SUBCUTANEOUS SOLUTION AUTO-
INJECTOR 1.75 MG/0.3ML (bremelanotide acetate)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
SMOKING DETERRENTS
bupropion hcl er (smoking det) oral tablet extended release 12
hour 150 mg
CE
N7 (PG); N8 ($0 copay
limited to 2 treatment
cycles/year); QL (2
TREATMENT per 365
days)
cvs nicotine polacrilex mouth/throat gum 2 mg CE
N7 (Not Covered); N8 ($0
copay limited to 2 treatment
cycles/year); QL (2
TREATMENT per 365
DAYs)
cvs nicotine polacrilex mouth/throat gum 4 mg CE
N7 (Not Covered); N8 ($0
copay limited to 2 treatment
cycles/year); QL (2
treatment cycles per 1 year)
cvs nicotine polacrilex mouth/throat lozenge 2 mg CE
N7 (Not Covered); N8 ($0
copay limited to 2 treatment
cycles/year); QL (2
TREATMENT CYCLES
per 1 YEAR)
cvs nicotine polacrilex mouth/throat lozenge 4 mg CE
N7 (Not Covered); N8 ($0
copay limited to 2 treatment
cycles/year); QL (2
treatment cycles per 1 year)
cvs nicotine transdermal patch 24 hour 14 mg/24hr CE
N7 (Not Covered); N8 ($0
copay limited to 2 treatment
cycles/year); QL (2
treatment cycles per 1 year)
cvs nicotine transdermal patch 24 hour 21 mg/24hr, 7 mg/24hr CE
N7 (Not Covered); N8 ($0
copay limited to 2 treatment
cycles/year); QL (2
TREATMENT CYCLES
per 1 YEAR)
NICOTROL INHALATION INHALER 10 MG (nicotine) CE
N7 (NP); N8 ($0 copay
limited to 2 treatment
cycles/year); QL (168 DAYS
OF TREATMENT per 365
days)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
NICOTROL NS NASAL SOLUTION 10 MG/ML (nicotine) CE
N7 (NP); N8 ($0 copay
limited to 2 treatment
cycles/year); QL (168 DAYS
OF TREATMENT per 365
days)
varenicline tartrate oral tablet 0.5 mg, 1 mg CE
N7 (PG); N8 ($0 limited to 2
treatment cycles/year); QL
(2 TREATMENT CYCLES
per 365 days)
varenicline tartrate oral tablet therapy pack 0.5 mg x 11 & 1 mg
x 42
CE
N7 (PG); N8 ($0 copay
limited to 2 treatment
cycles/year); QL (2
TREATMENT per 365
days)
ENDOCRINE AND METABOLIC - DRUGS TO TREAT
DIABETES AND REGULATE HORMONES
ACROMEGALY - DRUGS TO TREAT CONDITIONS
THAT CAUSE EXCESSIVE GROWTH
lanreotide acetate subcutaneous solution 120 mg/0.5ml NF
MYCAPSSA ORAL CAPSULE DELAYED RELEASE 20
MG (octreotide acetate)
NF
octreotide acetate injection solution 100 mcg/ml, 50 mcg/ml, 500
mcg/ml
PG PA; QL (90 ML per 30 days)
octreotide acetate injection solution 1000 mcg/ml PG PA; QL (45 ML per 30 days)
octreotide acetate injection solution 200 mcg/ml PG
PA; QL (225 ML per 30
days)
octreotide acetate subcutaneous solution prefilled syringe 100
mcg/ml, 50 mcg/ml, 500 mcg/ml
PG PA; QL (90 ML per 30 days)
SANDOSTATIN INJECTION SOLUTION 100 MCG/ML,
50 MCG/ML, 500 MCG/ML (octreotide acetate)
NPSP
PA; QL (90 ML per 30
DAYs)
SANDOSTATIN LAR DEPOT INTRAMUSCULAR KIT
10 MG, 20 MG, 30 MG (octreotide acetate)
NF
SOMATULINE DEPOT SUBCUTANEOUS SOLUTION
120 MG/0.5ML, 60 MG/0.2ML, 90 MG/0.3ML (lanreotide
acetate)
PSP
PA; QL (1 INJECTION per
28 days)
SOMAVERT SUBCUTANEOUS SOLUTION
RECONSTITUTED 10 MG, 15 MG, 20 MG, 25 MG, 30 MG
(pegvisomant)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ANDROGENS
TLANDO ORAL CAPSULE 112.5 MG (testosterone
undecanoate)
NF
ANDROGENS - DRUGS TO REGULATE MALE
HORMONES
ANDRODERM TRANSDERMAL PATCH 24 HOUR 2
MG/24HR, 4 MG/24HR (testosterone)
NP PA
ANDROGEL PUMP TRANSDERMAL GEL 20.25
MG/ACT (1.62%) (testosterone)
NF
AVEED INTRAMUSCULAR SOLUTION 750 MG/3ML
(testosterone undecanoate)
NPSP PA
FORTESTA TRANSDERMAL GEL 10 MG/ACT (2%)
(testosterone)
NF
JATENZO ORAL CAPSULE 158 MG, 198 MG, 237 MG
(testosterone undecanoate)
NP PA
KYZATREX ORAL CAPSULE 100 MG, 150 MG, 200 MG
(testosterone undecanoate)
NF
methitest oral tablet 10 mg NP PA; STX
methyltestosterone oral capsule 10 mg PG PA; STX
NATESTO NASAL GEL 5.5 MG/ACT (testosterone) PB PA
oxandrolone oral tablet 10 mg, 2.5 mg NP PA
TESTIM TRANSDERMAL GEL 50 MG/5GM (1%)
(testosterone)
NF
testosterone cypionate injection solution 200 mg/ml NF
testosterone cypionate intramuscular solution 100 mg/ml, 200
mg/ml
PG PA
testosterone enanthate intramuscular solution 200 mg/ml PG PA
testosterone transdermal gel 10 mg/act (2%), 20.25 mg/1.25gm
(1.62%), 20.25 mg/act (1.62%), 25 mg/2.5gm (1%), 40.5
mg/2.5gm (1.62%)
PG PA
testosterone transdermal gel 12.5 mg/act (1%), 50 mg/5gm
(1%)
PG
PA; N8 (Listing does not
include certain NDCs)
testosterone transdermal solution 30 mg/act NP PA
VOGELXO PUMP TRANSDERMAL GEL 12.5 MG/ACT
(1%) (testosterone)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%)
(testosterone)
NF
XYOSTED SUBCUTANEOUS SOLUTION AUTO-
INJECTOR 100 MG/0.5ML, 50 MG/0.5ML, 75 MG/0.5ML
(testosterone enanthate)
NP PA
ANTIDIABETICS, ALPHA-GLUCOSIDASE
INHIBITORS
acarbose oral tablet 100 mg, 25 mg, 50 mg PG
N8 (Listing does not include
certain NDCs)
miglitol oral tablet 100 mg, 25 mg, 50 mg PG
ANTIDIABETICS, AMYLIN ANALOGS
SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-
INJECTOR 2700 MCG/2.7ML (pramlintide acetate)
PB ST
SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-
INJECTOR 1500 MCG/1.5ML (pramlintide acetate)
PB ST
ANTIDIABETICS, BIGUANIDE
GLUMETZA ORAL TABLET EXTENDED RELEASE 24
HOUR 1000 MG, 500 MG (metformin hcl)
NF
metformin hcl er (mod) oral tablet extended release 24 hour
1000 mg, 500 mg
NF
metformin hcl er (osm) oral tablet extended release 24 hour
1000 mg, 500 mg
NF
metformin hcl er oral tablet extended release 24 hour 500 mg PG LGC
metformin hcl er oral tablet extended release 24 hour 750 mg PG
metformin hcl oral solution 500 mg/5ml NP
metformin hcl oral tablet 1000 mg, 500 mg PG LGC
metformin hcl oral tablet 625 mg NF
metformin hcl oral tablet 850 mg CE
LGC; N7 (PG); AL (Min 35
Years and Max 70 Years)
RIOMET ORAL SOLUTION 500 MG/5ML (metformin hcl) NF
ANTIDIABETICS, BIGUANIDE/ SULFONYLUREA
COMBINATIONS
glipizide-metformin hcl oral tablet 2.5-250 mg, 2.5-500 mg, 5-
500 mg
PG LGC
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ANTIDIABETICS, DIPEPTIDYL PEPTIDASE-4
INHIBITORS
alogliptin benzoate oral tablet 12.5 mg, 25 mg, 6.25 mg NF
JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG
(sitagliptin phosphate)
NF
NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG
(alogliptin benzoate)
NF
ONGLYZA ORAL TABLET 2.5 MG, 5 MG (saxagliptin hcl) NF
TRADJENTA ORAL TABLET 5 MG (linagliptin) PB ST
ANTIDIABETICS, DOPAMINE RECEPTOR AGONISTS
CYCLOSET ORAL TABLET 0.8 MG (bromocriptine
mesylate)
NF
ANTIDIABETICS, DPP-4 INHIBITOR COMBINATIONS
alogliptin-metformin hcl oral tablet 12.5-1000 mg, 12.5-500 mg NF
alogliptin-pioglitazone oral tablet 12.5-30 mg, 25-15 mg, 25-30
mg, 25-45 mg
NF
JANUMET ORAL TABLET 50-1000 MG, 50-500 MG
(sitagliptin-metformin hcl)
NF
JANUMET XR ORAL TABLET EXTENDED RELEASE
24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG
(sitagliptin-metformin hcl)
NF
JENTADUETO ORAL TABLET 2.5-1000 MG, 2.5-500 MG,
2.5-850 MG (linagliptin-metformin hcl)
PB ST
JENTADUETO XR ORAL TABLET EXTENDED
RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG (linagliptin-
metformin hcl)
PB ST
KAZANO ORAL TABLET 12.5-1000 MG, 12.5-500 MG
(alogliptin-metformin hcl)
NF
KOMBIGLYZE XR ORAL TABLET EXTENDED
RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG, 5-500 MG
(saxagliptin-metformin)
NF
OSENI ORAL TABLET 12.5-30 MG, 25-15 MG, 25-30 MG,
25-45 MG (alogliptin-pioglitazone)
NF
TRIJARDY XR ORAL TABLET EXTENDED RELEASE
24 HOUR 10-5-1000 MG, 12.5-2.5-1000 MG, 25-5-1000 MG,
5-2.5-1000 MG (empagliflozin-linaglip-metform)
PB ST
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ANTIDIABETICS, INCRETIN MIMETIC AGENTS
BYDUREON BCISE SUBCUTANEOUS AUTO-
INJECTOR 2 MG/0.85ML (exenatide)
NF
BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION
PEN-INJECTOR 10 MCG/0.04ML (exenatide)
NF
BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION
PEN-INJECTOR 5 MCG/0.02ML (exenatide)
NF
MOUNJARO SUBCUTANEOUS SOLUTION PEN-
INJECTOR 10 MG/0.5ML, 12.5 MG/0.5ML, 15 MG/0.5ML,
2.5 MG/0.5ML, 5 MG/0.5ML, 7.5 MG/0.5ML (tirzepatide)
NF
OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS
SOLUTION PEN-INJECTOR 2 MG/3ML (semaglutide)
PB
PA; QL (1 PEN per 28
DAYs)
OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION
PEN-INJECTOR 4 MG/3ML (semaglutide)
PB
PA; QL (1 PEN per 28
DAYs)
OZEMPIC (2 MG/DOSE) SUBCUTANEOUS SOLUTION
PEN-INJECTOR 8 MG/3ML (semaglutide)
PB PA; QL (1 PEN per 28 days)
RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG
(semaglutide)
PB
PA; QL (30 TABLETS per
30 days)
TRULICITY SUBCUTANEOUS SOLUTION PEN-
INJECTOR 0.75 MG/0.5ML, 1.5 MG/0.5ML, 3 MG/0.5ML,
4.5 MG/0.5ML (dulaglutide)
PB
PA; QL (4 PENS per 21
DAYs)
VICTOZA SUBCUTANEOUS SOLUTION PEN-
INJECTOR 18 MG/3ML (liraglutide)
PB
PA; QL (3 PENS per 25
DAYs)
ANTIDIABETICS, INCRETIN MIMETIC
COMBINATION AGENTS
SOLIQUA SUBCUTANEOUS SOLUTION PEN-
INJECTOR 100-33 UNT-MCG/ML (insulin glargine-
lixisenatide)
PB ST
XULTOPHY SUBCUTANEOUS SOLUTION PEN-
INJECTOR 100-3.6 UNIT-MG/ML (insulin degludec-
liraglutide)
PB ST
ANTIDIABETICS, INSULIN
ADMELOG INJECTION SOLUTION 100 UNIT/ML
(insulin lispro)
NF
ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION
PEN-INJECTOR 100 UNIT/ML (insulin lispro)
NF
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Coverage Requirements and
Limits
AFREZZA INHALATION POWDER 12 UNIT, 4 UNIT,
60X4 &60X8 & 60X12 UNIT, 8 UNIT, 90 X 4 UNIT & 90X8
UNIT, 90 X 8 UNIT & 90X12 UNIT (insulin regular human)
NF
APIDRA INJECTION SOLUTION 100 UNIT/ML (insulin
glulisine)
NF
APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION
PEN-INJECTOR 100 UNIT/ML (insulin glulisine)
NF
BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION
PEN-INJECTOR 100 UNIT/ML (insulin glargine)
PB
BASAGLAR TEMPO PEN SUBCUTANEOUS
SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin
glargine)
NF
FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION
PEN-INJECTOR 100 UNIT/ML (insulin aspart
(w/niacinamide))
PB
FIASP INJECTION SOLUTION 100 UNIT/ML (insulin
aspart (w/niacinamide))
PB
FIASP PENFILL SUBCUTANEOUS SOLUTION
CARTRIDGE 100 UNIT/ML (insulin aspart (w/niacinamide))
PB
HUMALOG INJECTION SOLUTION 100 UNIT/ML
(insulin lispro)
NF
HUMALOG JUNIOR KWIKPEN SUBCUTANEOUS
SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin lispro)
NF
HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION
PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin
lispro)
NF
HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS
SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML
(insulin lispro prot & lispro)
NF
HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION
(50-50) 100 UNIT/ML (insulin lispro prot & lispro)
NF
HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS
SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML
(insulin lispro prot & lispro)
NF
HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION
(75-25) 100 UNIT/ML (insulin lispro prot & lispro)
NF
HUMALOG SUBCUTANEOUS SOLUTION
CARTRIDGE 100 UNIT/ML (insulin lispro)
NF
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Coverage Requirements and
Limits
HUMALOG TEMPO PEN SUBCUTANEOUS SOLUTION
PEN-INJECTOR 100 UNIT/ML (insulin lispro)
NF
HUMULIN 70/30 KWIKPEN SUBCUTANEOUS
SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML
(insulin nph isophane & regular)
NF
HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70-
30) 100 UNIT/ML (insulin nph isophane & regular)
NF
HUMULIN N KWIKPEN SUBCUTANEOUS
SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph
human (isophane))
NF
HUMULIN N SUBCUTANEOUS SUSPENSION 100
UNIT/ML (insulin nph human (isophane))
NF
HUMULIN R INJECTION SOLUTION 100 UNIT/ML
(insulin regular human)
NF
HUMULIN R U-500 (CONCENTRATED)
SUBCUTANEOUS SOLUTION 500 UNIT/ML (insulin
regular human)
PB
HUMULIN R U-500 KWIKPEN SUBCUTANEOUS
SOLUTION PEN-INJECTOR 500 UNIT/ML (insulin regular
human)
PB
insulin asp prot & asp flexpen subcutaneous suspension pen-
injector (70-30) 100 unit/ml
NF
insulin aspart flexpen subcutaneous solution pen-injector 100
unit/ml
NF
insulin aspart injection solution 100 unit/ml NF
insulin aspart penfill subcutaneous solution cartridge 100 unit/ml NF
insulin aspart prot & aspart subcutaneous suspension (70-30)
100 unit/ml
NF
insulin degludec flextouch subcutaneous solution pen-injector
100 unit/ml, 200 unit/ml
NF
insulin degludec subcutaneous solution 100 unit/ml NF
insulin glargine solostar subcutaneous solution pen-injector 100
unit/ml
NF
insulin glargine subcutaneous solution 100 unit/ml NF
insulin glargine-yfgn subcutaneous solution 100 unit/ml NF
insulin glargine-yfgn subcutaneous solution pen-injector 100
unit/ml
NF
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Coverage Requirements and
Limits
insulin lispro (1 unit dial) subcutaneous solution pen-injector
100 unit/ml
NF
insulin lispro injection solution 100 unit/ml NF
insulin lispro junior kwikpen subcutaneous solution pen-injector
100 unit/ml
NF
insulin lispro prot & lispro subcutaneous suspension pen-injector
(75-25) 100 unit/ml
NF
LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION
PEN-INJECTOR 100 UNIT/ML (insulin glargine)
NF
LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML
(insulin glargine)
NF
LEVEMIR FLEXPEN SUBCUTANEOUS SOLUTION
PEN-INJECTOR 100 UNIT/ML (insulin detemir)
PB
LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML
(insulin detemir)
PB
LYUMJEV INJECTION SOLUTION 100 UNIT/ML (insulin
lispro-aabc)
NF
LYUMJEV KWIKPEN SUBCUTANEOUS SOLUTION
PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin
lispro-aabc)
NF
LYUMJEV TEMPO PEN SUBCUTANEOUS SOLUTION
PEN-INJECTOR 100 UNIT/ML (insulin lispro-aabc)
NF
MYXREDLIN INTRAVENOUS SOLUTION 100-0.9
UT/100ML-% (insulin regular(human) in nacl)
NF
NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS
SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML
(insulin nph isophane & regular)
NF
NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS
SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML
(insulin nph isophane & regular)
PB
NOVOLIN 70/30 RELION SUBCUTANEOUS
SUSPENSION (70-30) 100 UNIT/ML (insulin nph isophane &
regular)
NF
NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30)
100 UNIT/ML (insulin nph isophane & regular)
PB
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
NOVOLIN N FLEXPEN RELION SUBCUTANEOUS
SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph
human (isophane))
NF
NOVOLIN N FLEXPEN SUBCUTANEOUS
SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph
human (isophane))
PB
NOVOLIN N RELION SUBCUTANEOUS SUSPENSION
100 UNIT/ML (insulin nph human (isophane))
NF
NOVOLIN N SUBCUTANEOUS SUSPENSION 100
UNIT/ML (insulin nph human (isophane))
PB
NOVOLIN R FLEXPEN INJECTION SOLUTION PEN-
INJECTOR 100 UNIT/ML (insulin regular human)
PB
NOVOLIN R FLEXPEN RELION INJECTION
SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin regular
human)
NF
NOVOLIN R INJECTION SOLUTION 100 UNIT/ML
(insulin regular human)
PB
NOVOLIN R RELION INJECTION SOLUTION 100
UNIT/ML (insulin regular human)
NF
NOVOLOG 70/30 FLEXPEN RELION SUBCUTANEOUS
SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML
(insulin aspart prot & aspart)
NF
NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION
PEN-INJECTOR 100 UNIT/ML (insulin aspart)
PB
NOVOLOG INJECTION SOLUTION 100 UNIT/ML
(insulin aspart)
PB
NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS
SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML
(insulin aspart prot & aspart)
PB
NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION
(70-30) 100 UNIT/ML (insulin aspart prot & aspart)
PB
NOVOLOG PENFILL SUBCUTANEOUS SOLUTION
CARTRIDGE 100 UNIT/ML (insulin aspart)
PB
REZVOGLAR KWIKPEN SUBCUTANEOUS SOLUTION
PEN-INJECTOR 100 UNIT/ML (insulin glargine-aglr)
NF
SEMGLEE (YFGN) SUBCUTANEOUS SOLUTION 100
UNIT/ML (insulin glargine-yfgn)
NF
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Coverage Requirements and
Limits
SEMGLEE (YFGN) SUBCUTANEOUS SOLUTION PEN-
INJECTOR 100 UNIT/ML (insulin glargine-yfgn)
NF
TOUJEO MAX SOLOSTAR SUBCUTANEOUS
SOLUTION PEN-INJECTOR 300 UNIT/ML (insulin
glargine)
PB
TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION
PEN-INJECTOR 300 UNIT/ML (insulin glargine)
PB
TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION
PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin
degludec)
PB
TRESIBA SUBCUTANEOUS SOLUTION 100 UNIT/ML
(insulin degludec)
PB
ANTIDIABETICS, INSULIN SENSITIZER
ACTOS ORAL TABLET 15 MG, 30 MG, 45 MG
(pioglitazone hcl)
NF
pioglitazone hcl oral tablet 15 mg, 30 mg, 45 mg PG LGC
ANTIDIABETICS, INSULIN SENSITIZER/BIGUANIDE
COMBINATION
pioglitazone hcl-metformin hcl oral tablet 15-500 mg, 15-850 mg PG
ANTIDIABETICS, INSULIN
SENSITIZER/SULFONYLUREA COMBINATION
pioglitazone hcl-glimepiride oral tablet 30-2 mg, 30-4 mg PG
ANTIDIABETICS, MEGLITINIDE
nateglinide oral tablet 120 mg, 60 mg PG LGC
repaglinide oral tablet 0.5 mg, 1 mg, 2 mg NP
ANTIDIABETICS, MISCELLANEOUS
KORLYM ORAL TABLET 300 MG (mifepristone) NF
ANTIDIABETICS, SODIUM-GLUCOSE
COTRANSPORTER-2 (SGLT2) INHIBITOR
COMBINATIONS
INVOKAMET ORAL TABLET 150-1000 MG, 150-500 MG,
50-1000 MG, 50-500 MG (canagliflozin-metformin hcl)
NF
INVOKAMET XR ORAL TABLET EXTENDED
RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000
MG, 50-500 MG (canagliflozin-metformin hcl)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
SEGLUROMET ORAL TABLET 2.5-1000 MG, 2.5-500
MG, 7.5-1000 MG, 7.5-500 MG (ertugliflozin-metformin hcl)
NF
SYNJARDY ORAL TABLET 12.5-1000 MG, 12.5-500 MG,
5-1000 MG, 5-500 MG (empagliflozin-metformin hcl)
PB ST
SYNJARDY XR ORAL TABLET EXTENDED RELEASE
24 HOUR 10-1000 MG, 12.5-1000 MG, 25-1000 MG, 5-1000
MG (empagliflozin-metformin hcl)
PB ST
XIGDUO XR ORAL TABLET EXTENDED RELEASE 24
HOUR 10-1000 MG, 10-500 MG, 2.5-1000 MG, 5-1000 MG,
5-500 MG (dapagliflozin-metformin hcl)
PB ST
ANTIDIABETICS, SODIUM-GLUCOSE
COTRANSPORTER-2 (SGLT2) INHIBITOR/DPP-4
INHIBITOR COMBINATIONS
GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG
(empagliflozin-linagliptin)
PB ST
QTERN ORAL TABLET 10-5 MG, 5-5 MG (dapagliflozin-
saxagliptin)
NF
STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG
(ertugliflozin-sitagliptin)
NF
ANTIDIABETICS, SODIUM-GLUCOSE
COTRANSPORTER-2 (SGLT2) INHIBITORS
FARXIGA ORAL TABLET 10 MG, 5 MG (dapagliflozin
propanediol)
PB ST
INVOKANA ORAL TABLET 100 MG, 300 MG
(canagliflozin)
NF
JARDIANCE ORAL TABLET 10 MG, 25 MG
(empagliflozin)
PB ST
STEGLATRO ORAL TABLET 15 MG, 5 MG (ertugliflozin
l-pyroglutamicac)
NF
ANTIDIABETICS, SULFONYLUREA
glimepiride oral tablet 1 mg, 2 mg, 4 mg PG LGC
glipizide er oral tablet extended release 24 hour 10 mg, 2.5 mg, 5
mg
PG LGC
glipizide oral tablet 10 mg, 5 mg PG LGC
glipizide xl oral tablet extended release 24 hour 10 mg, 2.5 mg, 5
mg
PG LGC
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Coverage Requirements and
Limits
ANTIOBESITY
ADIPEX-P ORAL CAPSULE 37.5 MG (phentermine hcl) NP PA; SPC
ADIPEX-P ORAL TABLET 37.5 MG (phentermine hcl) NP PA; SPC
benzphetamine hcl oral tablet 50 mg PG PA; SPC
CONTRAVE ORAL TABLET EXTENDED RELEASE 12
HOUR 8-90 MG (naltrexone-bupropion hcl)
NF
diethylpropion hcl er oral tablet extended release 24 hour 75 mg PG
PA; SPC ; N8 (Listing does
not include certain NDCs)
diethylpropion hcl oral tablet 25 mg PG PA; SPC
LOMAIRA ORAL TABLET 8 MG (phentermine hcl) NF
orlistat oral capsule 120 mg PG PA; SPC
phendimetrazine tartrate er oral capsule extended release 24
hour 105 mg
NF
phendimetrazine tartrate oral tablet 35 mg PG PA; SPC
phentermine hcl oral capsule 15 mg, 30 mg, 37.5 mg PG PA; SPC
phentermine hcl oral tablet 37.5 mg PG PA; SPC
QSYMIA ORAL CAPSULE EXTENDED RELEASE 24
HOUR 11.25-69 MG, 15-92 MG, 3.75-23 MG, 7.5-46 MG
(phentermine-topiramate)
PB SPC
SAXENDA SUBCUTANEOUS SOLUTION PEN-
INJECTOR 18 MG/3ML (liraglutide -weight management)
PB PA; SPC
WEGOVY SUBCUTANEOUS SOLUTION AUTO-
INJECTOR 0.25 MG/0.5ML, 0.5 MG/0.5ML, 1 MG/0.5ML,
1.7 MG/0.75ML, 2.4 MG/0.75ML (semaglutide-weight
management)
PB PA; SPC
XENICAL ORAL CAPSULE 120 MG (orlistat) NF
BISPHOSPHONATES - DRUGS TO TREAT BONE LOSS
ACTONEL ORAL TABLET 150 MG (risedronate sodium) NP
ST; QL (1 TABLET per 21
days)
ACTONEL ORAL TABLET 35 MG (risedronate sodium) NP
ST; QL (4 TABLETS per 21
days)
alendronate sodium oral solution 70 mg/75ml PG
alendronate sodium oral tablet 10 mg, 35 mg, 5 mg, 70 mg PG
ATELVIA ORAL TABLET DELAYED RELEASE 35 MG
(risedronate sodium)
NP
ST; QL (4 TABLETS per 21
days)
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Coverage Requirements and
Limits
BINOSTO ORAL TABLET EFFERVESCENT 70 MG
(alendronate sodium)
NP
ST; QL (4 TABLETS per 21
days)
FOSAMAX ORAL TABLET 70 MG (alendronate sodium) NP
ST; QL (4 TABLETS per 21
days)
FOSAMAX PLUS D ORAL TABLET 70-2800 MG-UNIT,
70-5600 MG-UNIT (alendronate-cholecalciferol)
NP
ST; QL (4 TABLETS per 21
days)
ibandronate sodium intravenous solution 3 mg/3ml PG
ibandronate sodium oral tablet 150 mg NP
pamidronate disodium intravenous solution 30 mg/10ml, 90
mg/10ml
PG
pamidronate disodium intravenous solution 6 mg/ml NPSP
RECLAST INTRAVENOUS SOLUTION 5 MG/100ML
(zoledronic acid)
NPSP PA
risedronate sodium oral tablet 150 mg, 30 mg, 35 mg, 5 mg NP
risedronate sodium oral tablet delayed release 35 mg NP
zoledronic acid intravenous concentrate 4 mg/5ml PG PA
zoledronic acid intravenous solution 4 mg/100ml NPSP PA
zoledronic acid intravenous solution 5 mg/100ml PG PA
zoledronic acid solution 4 mg/100ml intravenous PSP PA
zoledronic acid solution 4 mg/100ml intravenous NPSP PA
CALCIUM RECEPTOR AGONISTS
cinacalcet hcl oral tablet 30 mg, 60 mg PSP
PA; QL (60 TABLETS per
30 days)
cinacalcet hcl oral tablet 90 mg PSP
PA; QL (120 TABLETS per
30 days)
PARSABIV INTRAVENOUS SOLUTION 10 MG/2ML, 2.5
MG/0.5ML, 5 MG/ML (etelcalcetide hcl)
NF
SENSIPAR ORAL TABLET 30 MG, 60 MG (cinacalcet hcl) NPSP
PA; QL (60 TABLETS per
30 days)
SENSIPAR ORAL TABLET 90 MG (cinacalcet hcl) NPSP
PA; QL (120 TABLETS per
30 days)
CARNITINE DEFICIENCY AGENTS
CARNITOR ORAL SOLUTION 1 GM/10ML (levocarnitine) NF
CARNITOR ORAL TABLET 330 MG (levocarnitine) NF
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Coverage Requirements and
Limits
CARNITOR SF ORAL SOLUTION 1 GM/10ML
(levocarnitine)
NF
levocarnitine oral solution 1 gm/10ml PG
levocarnitine oral tablet 330 mg PG
CHELATING AGENTS
CUPRIMINE ORAL CAPSULE 250 MG (penicillamine) NF
CUVRIOR ORAL TABLET 300 MG (trientine
tetrahydrochloride)
NF
deferasirox granules oral packet 180 mg, 360 mg, 90 mg PSP PA
deferasirox oral tablet 180 mg, 360 mg, 90 mg PSP PA
deferasirox oral tablet soluble 125 mg, 250 mg, 500 mg PSP PA
deferiprone oral tablet 1000 mg, 500 mg PSP PA
deferoxamine mesylate injection solution reconstituted 2 gm,
500 mg
NPSP PA
DEPEN TITRATABS ORAL TABLET 250 MG
(penicillamine)
NP PA
DESFERAL INJECTION SOLUTION RECONSTITUTED
500 MG (deferoxamine mesylate)
NF
EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG,
500 MG (deferasirox)
NF
FERRIPROX ORAL SOLUTION 100 MG/ML (deferiprone) NF
FERRIPROX ORAL TABLET 1000 MG, 500 MG
(deferiprone)
NF
FERRIPROX TWICE-A-DAY ORAL TABLET 1000 MG
(deferiprone)
NF
JADENU ORAL TABLET 180 MG, 360 MG, 90 MG
(deferasirox)
NF
JADENU SPRINKLE ORAL PACKET 180 MG, 360 MG,
90 MG (deferasirox)
NF
LOKELMA ORAL PACKET 10 GM, 5 GM (sodium
zirconium cyclosilicate)
NF
penicillamine oral capsule 250 mg PSP PA
penicillamine oral tablet 250 mg PG PA
sodium polystyrene sulfonate oral powder PG
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Coverage Requirements and
Limits
SPS ORAL SUSPENSION 15 GM/60ML (sodium polystyrene
sulfonate)
PG
SYPRINE ORAL CAPSULE 250 MG (trientine hcl) NF
trientine hcl oral capsule 250 mg PSP PA
VELTASSA ORAL PACKET 16.8 GM, 25.2 GM, 8.4 GM
(patiromer sorbitex calcium)
PB
CONTRACEPTIVES - PRODUCTS FOR BIRTH
CONTROL
AFTERA ORAL TABLET 1.5 MG (levonorgestrel) CE N7 (Not Covered)
levonorgestrel-ethinyl estrad (Altavera Oral Tablet 0.15-30 Mg-
Mcg)
CE N7 (PG)
alyacen 1/35 oral tablet 1-35 mg-mcg CE N7 (PG)
alyacen 7/7/7 oral tablet 0.5/0.75/1-35 mg-mcg CE N7 (PG)
levonorgest-eth estrad 91-day (Amethia Oral Tablet 0.15-0.03
&0.01 Mg)
CE N7 (PG)
levonorgestrel-ethinyl estrad (Amethyst Oral Tablet 90-20
Mcg)
CE N7 (PG)
ANNOVERA VAGINAL RING 0.013-0.15 MG/24HR
(segesterone-ethinyl estradiol)
CE
N7 (PB); QL (1 RING per
300 days)
desogestrel-ethinyl estradiol (Apri Oral Tablet 0.15-30 Mg-
Mcg)
CE N7 (PG)
norethin-eth estrad triphasic (Aranelle Oral Tablet 0.5/1/0.5-35
Mg-Mcg)
CE N7 (PG)
levonorgestrel-ethinyl estrad (Aubra Eq Oral Tablet 0.1-20 Mg-
Mcg)
CE N7 (PG)
desogestrel-ethinyl estradiol (Azurette Oral Tablet 0.15-
0.02/0.01 Mg (21/5))
CE N7 (PG)
BALCOLTRA ORAL TABLET 0.1-20 MG-MCG(21)
(levonorgest-eth estrad-fe bisg)
CE N7 (NF)
norethindrone-eth estradiol (Balziva Oral Tablet 0.4-35 Mg-
Mcg)
CE N7 (PG)
BEYAZ ORAL TABLET 3-0.02-0.451 MG (drospiren-eth
estrad-levomefol)
NF
norethin ace-eth estrad-fe (Blisovi 24 Fe Oral Tablet 1-20 Mg-
Mcg(24))
CE N7 (PG)
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Coverage Requirements and
Limits
norethin ace-eth estrad-fe (Blisovi Fe 1.5/30 Oral Tablet 1.5-30
Mg-Mcg)
CE N7 (PG)
norethin ace-eth estrad-fe (Blisovi Fe 1/20 Oral Tablet 1-20
Mg-Mcg)
CE N7 (PG)
norethindrone (Camila Oral Tablet 0.35 Mg) CE N7 (PG)
levonorgest-eth estrad 91-day (Camrese Lo Oral Tablet 0.1-
0.02 & 0.01 Mg)
CE N7 (PG)
levonorgest-eth estrad 91-day (Camrese Oral Tablet 0.15-0.03
&0.01 Mg)
CE N7 (PG)
CAYA VAGINAL DIAPHRAGM (diaphragm arc-spring) CE
N7 (NP); QL (1
DIAPHRAGM per 300
days)
condoms CE
N7 (Not Covered); QL (12
CONDOMS per 25 DAYs)
norgestrel-ethinyl estradiol (Cryselle-28 Oral Tablet 0.3-30 Mg-
Mcg)
CE N7 (PG)
DEPO-SUBQ PROVERA 104 SUBCUTANEOUS
SUSPENSION PREFILLED SYRINGE 104 MG/0.65ML
(medroxyprogesterone acetate)
CE N7 (NF)
desogestrel-ethinyl estradiol oral tablet 0.15-0.02/0.01 mg
(21/5)
CE N7 (PG)
drospiren-eth estrad-levomefol oral tablet 3-0.02-0.451 mg, 3-
0.03-0.451 mg
CE N7 (PG)
drospirenone-ethinyl estradiol oral tablet 3-0.02 mg, 3-0.03 mg CE N7 (PG)
ELLA ORAL TABLET 30 MG (ulipristal acetate) CE N7 (NP)
etonogestrel-ethinyl estradiol (Eluryng Vaginal Ring 0.12-0.015
Mg/24Hr)
CE N7 (Not Covered)
levonorg-eth estrad triphasic (Enpresse-28 Oral Tablet 50-
30/75-40/ 125-30 Mcg)
CE N7 (PG)
norgestimate-eth estradiol (Estarylla Oral Tablet 0.25-35 Mg-
Mcg)
CE N7 (PG)
ethynodiol diac-eth estradiol oral tablet 1-35 mg-mcg, 1-50 mg-
mcg
CE N7 (PG)
etonogestrel-ethinyl estradiol vaginal ring 0.12-0.015 mg/24hr CE N7 (Not Covered)
levonorgest-eth estrad 91-day (Fayosim Oral Tablet 42-21-21-7
Days)
CE N7 (PG)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
FC2 FEMALE CONDOM (condoms - female) CE
N7 (NP); QL (12
CONDOMS per 25 days)
FEMCAP VAGINAL DEVICE 22 MM, 26 MM, 30 MM
(cervical caps)
CE
N7 (NP); QL (1 DEVICE
per 300 days)
levonorgest-eth estrad 91-day (Introvale Oral Tablet 0.15-0.03
Mg)
CE N7 (PG)
norethindrone acet-ethinyl est (Junel 1.5/30 Oral Tablet 1.5-30
Mg-Mcg)
CE N7 (PG)
norethindrone acet-ethinyl est (Junel 1/20 Oral Tablet 1-20 Mg-
Mcg)
CE N7 (PG)
norethin ace-eth estrad-fe (Junel Fe 1.5/30 Oral Tablet 1.5-30
Mg-Mcg)
CE N7 (PG)
norethin ace-eth estrad-fe (Junel Fe 24 Oral Tablet 1-20 Mg-
Mcg(24))
CE N7 (PG)
norethin-eth estradiol-fe (Kaitlib Fe Oral Tablet Chewable 0.8-
25 Mg-Mcg)
CE N7 (PG)
ethynodiol diac-eth estradiol (Kelnor 1/50 Oral Tablet 1-50
Mg-Mcg)
CE N7 (PG)
KYLEENA INTRAUTERINE INTRAUTERINE DEVICE
19.5 MG (levonorgestrel)
CE
N7 (PB); QL (1
INTRAUTERINE
DEVICE per 300 days)
levonorgest-eth estrad 91-day oral tablet 0.15-0.03 mg CE N7 (PG)
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-30
mg-mcg
CE N7 (PG)
LILETTA (52 MG) INTRAUTERINE INTRAUTERINE
DEVICE 20.1 MCG/DAY (levonorgestrel)
CE N7 (NF)
LO LOESTRIN FE ORAL TABLET 1 MG-10 MCG / 10
MCG (norethin-eth estrad-fe biphas)
CE N7 (PB)
medroxyprogesterone acetate intramuscular suspension 150
mg/ml
CE
N7 (PG); QL (4 ML per 300
days)
medroxyprogesterone acetate intramuscular suspension prefilled
syringe 150 mg/ml
CE
N7 (PG); QL (4 ML per 300
days)
MINASTRIN 24 FE ORAL TABLET CHEWABLE 1-20
MG-MCG(24) (norethin ace-eth estrad-fe)
NF
MIRENA (52 MG) INTRAUTERINE INTRAUTERINE
DEVICE 20 MCG/DAY (levonorgestrel)
CE
N7 (PB); QL (1
INTRAUTERINE
DEVICE per 300 Days)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
NATAZIA ORAL TABLET 3/2-2/2-3/1 MG (estradiol
valerate-dienogest)
CE N7 (PB)
norethindrone-eth estradiol (Necon 0.5/35 (28) Oral Tablet 0.5-
35 Mg-Mcg)
CE N7 (PG)
NEXPLANON SUBCUTANEOUS IMPLANT 68 MG
(etonogestrel)
CE
N7 (NP); QL (1 IMPLANT
per 300 days)
NEXTSTELLIS ORAL TABLET 3-14.2 MG (drospirenone-
estetrol)
CE N7 (NF)
norethin ace-eth estrad-fe oral capsule 1-20 mg-mcg(24) CE N7 (PG)
norethin ace-eth estrad-fe oral tablet 1-20 mg-mcg CE N7 (PG)
norethin ace-eth estrad-fe oral tablet chewable 1-20 mg-
mcg(24)
CE N7 (PG)
norethindrone acet-ethinyl est oral tablet 1-20 mg-mcg CE N7 (PG)
norethindrone oral tablet 0.35 mg CE N7 (PG)
norethin-eth estradiol-fe oral tablet chewable 0.4-35 mg-mcg,
0.8-25 mg-mcg
CE N7 (PG)
norgestimate-eth estradiol oral tablet 0.25-35 mg-mcg CE N7 (PG)
norgestim-eth estrad triphasic oral tablet 0.18/0.215/0.25 mg-25
mcg, 0.18/0.215/0.25 mg-35 mcg
CE N7 (PG)
norethindrone-eth estradiol (Nortrel 0.5/35 (28) Oral Tablet
0.5-35 Mg-Mcg)
CE N7 (PG)
norethindrone-eth estradiol (Nortrel 1/35 (21) Oral Tablet 1-35
Mg-Mcg)
CE N7 (PG)
norethin-eth estrad triphasic (Nortrel 7/7/7 Oral Tablet
0.5/0.75/1-35 Mg-Mcg)
CE N7 (PG)
NUVARING VAGINAL RING 0.12-0.015 MG/24HR
(etonogestrel-ethinyl estradiol)
PB QL (13 RING per 300 days)
OMNIFLEX DIAPHRAGM VAGINAL DIAPHRAGM
(diaphragms)
CE
N7 (NP); QL (1
DIAPHRAGM per 300
days)
PARAGARD INTRAUTERINE COPPER
INTRAUTERINE INTRAUTERINE DEVICE (copper)
CE
N7 (NP); QL (1
INTRAUTERINE
DEVICE per 300 days)
QUARTETTE ORAL TABLET 42-21-21-7 DAYS
(levonorgest-eth estrad 91-day)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
desogestrel-ethinyl estradiol (Reclipsen Oral Tablet 0.15-30
Mg-Mcg)
CE N7 (PG)
levonorgest-eth estrad 91-day (Rivelsa Oral Tablet 42-21-21-7
Days)
CE N7 (PG)
SAFYRAL ORAL TABLET 3-0.03-0.451 MG (drospiren-eth
estrad-levomefol)
NP
SEASONIQUE ORAL TABLET 0.15-0.03 &0.01 MG
(levonorgest-eth estrad 91-day)
NF
SKYLA INTRAUTERINE INTRAUTERINE DEVICE
13.5 MG (levonorgestrel)
CE
N7 (PB); QL (1
INTRAUTERINE
DEVICE per 300 days)
SLYND ORAL TABLET 4 MG (drospirenone) CE N7 (NF)
TAYTULLA ORAL CAPSULE 1-20 MG-MCG(24)
(norethin ace-eth estrad-fe)
NF
norethindron-ethinyl estrad-fe (Tilia Fe Oral Tablet 1-20/1-
30/1-35 Mg-Mcg)
CE N7 (PG)
norethindron-ethinyl estrad-fe (Tri-Legest Fe Oral Tablet 1-
20/1-30/1-35 Mg-Mcg)
CE N7 (PG)
norgestim-eth estrad triphasic (Tri-Lo-Sprintec Oral Tablet
0.18/0.215/0.25 Mg-25 Mcg)
CE N7 (PG)
TWIRLA TRANSDERMAL PATCH WEEKLY 120-30
MCG/24HR (levonorgestrel-eth estradiol)
CE N7 (NF)
TYBLUME ORAL TABLET CHEWABLE 0.1-20 MG-
MCG (levonorgestrel-ethinyl estrad)
CE N7 (Not Covered)
VELIVET ORAL TABLET 0.1/0.125/0.15 -0.025 MG
(desogestrel-ethinyl estradiol)
CE N7 (PG)
WIDE-SEAL DIAPHRAGM 60 VAGINAL DIAPHRAGM
2 % (diaphragm wide seal)
CE
N7 (NP); QL (1
DIAPHRAGM per 300
days)
WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM
2 % (diaphragm wide seal)
CE
N7 (NP); QL (1
DIAPHRAGM per 300
days)
WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM
2 % (diaphragm wide seal)
CE
N7 (NP); QL (1
DIAPHRAGM per 300
days)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM
2 % (diaphragm wide seal)
CE
N7 (NP); QL (1
DIAPHRAGM per 300
days)
WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM
2 % (diaphragm wide seal)
CE
N7 (NP); QL (1
DIAPHRAGM per 300
days)
WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM
2 % (diaphragm wide seal)
CE
N7 (NP); QL (1
DIAPHRAGM per 300
days)
WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM
2 % (diaphragm wide seal)
CE
N7 (NP); QL (1
DIAPHRAGM per 300
days)
WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM
2 % (diaphragm wide seal)
CE
N7 (NP); QL (1
DIAPHRAGM per 300
days)
norelgestromin-eth estradiol (Xulane Transdermal Patch
Weekly 150-35 Mcg/24Hr)
CE N7 (PG)
YASMIN 28 ORAL TABLET 3-0.03 MG (drospirenone-
ethinyl estradiol)
NF
YAZ ORAL TABLET 3-0.02 MG (drospirenone-ethinyl
estradiol)
NF
CORTISOL SYNTHESIS INHIBITORS
ISTURISA ORAL TABLET 1 MG, 10 MG, 5 MG
(osilodrostat phosphate)
NF
RECORLEV ORAL TABLET 150 MG (levoketoconazole) NF
DIABETIC SUPPLIES
ACCU-CHEK AVIVA PLUS IN VITRO STRIP (glucose
blood)
PB
QL (150 TEST STRIPS per
25 days)
ACCU-CHEK FASTCLIX LANCETS (lancets) NP
ACCU-CHEK GUIDE IN VITRO STRIP (glucose blood) PB
QL (150 TEST STRIPS per
25 days)
ACCU-CHEK SMARTVIEW IN VITRO STRIP (glucose
blood)
PB
QL (150 TEST STRIPS per
25 days)
ACCU-CHEK SOFTCLIX LANCETS (lancets) NP
ACCUTREND GLUCOSE IN VITRO STRIP (glucose
blood)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ADVANCE INTUITION TEST IN VITRO STRIP (glucose
blood)
NF
ADVANCE MICRO-DRAW TEST IN VITRO STRIP
(glucose blood)
NF
ADVOCATE REDI-CODE IN VITRO STRIP (glucose
blood)
NF
ADVOCATE REDI-CODE+ TEST IN VITRO STRIP
(glucose blood)
NF
ADVOCATE TEST IN VITRO STRIP (glucose blood) NF
AGAMATRIX AMP TEST IN VITRO STRIP (glucose
blood)
NF
AGAMATRIX JAZZ TEST IN VITRO STRIP (glucose
blood)
NF
AGAMATRIX KEYNOTE TEST IN VITRO STRIP
(glucose blood)
NF
AGAMATRIX PRESTO TEST IN VITRO STRIP (glucose
blood)
NF
alcohol swabs pad NP
ASSURE 3 TEST IN VITRO STRIP (glucose blood) NF
ASSURE 4 TEST IN VITRO STRIP (glucose blood) NF
ASSURE II CHECK IN VITRO STRIP (glucose blood) NF
ASSURE II IN VITRO STRIP (glucose blood) NF
ASSURE LANCE LANCETS (lancets) NP
ASSURE PLATINUM IN VITRO STRIP (glucose blood) NF
ASSURE PRISM MULTI TEST IN VITRO STRIP (glucose
blood)
NF
ASSURE PRO TEST IN VITRO STRIP (glucose blood) NF
BD INSULIN SYRINGE U-500 31G X 6MM 0.5 ML
(insulin syringe/needle u-500)
PB
N8 (BD syringes and needles
are the only preferred
options)
BD LANCET ULTRAFINE 30G (lancets) NP
BD LANCET ULTRAFINE 33G (lancets) NP
BD MICROTAINER LANCETS (lancets) NP
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
BD PEN NEEDLE MICRO U/F 32G X 6 MM (insulin pen
needle)
PB
N8 (BD syringes and needles
are the only preferred
options)
BD PEN NEEDLE MINI U/F 31G X 5 MM (insulin pen
needle)
PB
N8 (BD syringes and needles
are the only preferred
options)
BD PEN NEEDLE NANO 2ND GEN 32G X 4 MM (insulin
pen needle)
PB
N8 (BD syringes and needles
are the only preferred
options)
BD PEN NEEDLE NANO U/F 32G X 4 MM (insulin pen
needle)
PB
N8 (BD syringes and needles
are the only preferred
options)
BD PEN NEEDLE ORIGINAL U/F 29G X 12.7MM (insulin
pen needle)
PB
N8 (BD syringes and needles
are the only preferred
options)
BD PEN NEEDLE SHORT U/F 31G X 8 MM (insulin pen
needle)
PB
N8 (BD syringes and needles
are the only preferred
options)
blood glucose test in vitro strip NF
CAREONE LANCET SUPER THIN 30G (lancets) NP
CARESENS LANCETS (lancets) NP
CARESENS N GLUCOSE TEST IN VITRO STRIP (glucose
blood)
NF
CARETOUCH TEST IN VITRO STRIP (glucose blood) NF
CLEVER CHEK AUTO-CODE TEST IN VITRO STRIP
(glucose blood)
NF
CLEVER CHEK AUTO-CODE VOICE IN VITRO STRIP
(glucose blood)
NF
CLEVER CHEK TEST IN VITRO STRIP (glucose blood) NF
CLEVER CHOICE AUTO-CODE TEST IN VITRO STRIP
(glucose blood)
NF
CLEVER CHOICE MICRO TEST IN VITRO STRIP
(glucose blood)
NF
CLEVER CHOICE NO CODING IN VITRO STRIP
(glucose blood)
NF
CLEVER CHOICE TALK SYSTEM IN VITRO STRIP
(glucose blood)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
COAGUCHEK LANCETS (lancets) NP
comfort assured lancets 28g NP
comfort assured lancets 33g NP
COMFORT TOUCH LANCETS 31G (lancets) NP
COMFORT TOUCH PLUS LANCETS 30G (lancets) NP
CONTOUR NEXT TEST IN VITRO STRIP (glucose blood) NF
CONTOUR TEST IN VITRO STRIP (glucose blood) NF
COOL BLOOD GLUCOSE TEST STRIPS IN VITRO
STRIP (glucose blood)
NF
CVS ADVANCED GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
D-CARE BLOOD GLUCOSE IN VITRO STRIP (glucose
blood)
NF
DEXCOM G6 RECEIVER DEVICE (continuous blood gluc
receiver)
PB
DEXCOM G6 SENSOR (continuous blood gluc sensor) PB
QL (3 SENSORS per 25
days)
DEXCOM G6 TRANSMITTER (continuous blood gluc
transmit)
PB
DEXCOM G7 RECEIVER DEVICE (continuous blood gluc
receiver)
PB
DEXCOM G7 SENSOR (continuous blood gluc sensor) PB
QL (3 SENSORS per 25
days)
DIATHRIVE GLUCOSE TEST IN VITRO STRIP (glucose
blood)
NF
diatrue plus test in vitro strip NF
DROPLET PERSONAL LANCETS 30G (lancets) NP
DUO-CARE TEST IN VITRO STRIP (glucose blood) NF
easy plus ii glucose test in vitro strip NF
EASY STEP TEST IN VITRO STRIP (glucose blood) NF
easy talk blood glucose test in vitro strip NF
EASY TOUCH LANCETS 21G (lancets) NP
EASY TOUCH LANCETS 23G (lancets) NP
EASY TOUCH LANCETS 26G (lancets) NP
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
EASY TOUCH LANCETS 28G (lancets) NP
EASY TOUCH LANCETS 28G/TWIST (lancets) NP
EASY TOUCH LANCETS 30G (lancets) NP
EASY TOUCH LANCETS 32G (lancets) NP
EASY TOUCH LANCETS 32G/TWIST (lancets) NP
EASY TOUCH LANCING DEVICE (lancet devices) NP
EASY TOUCH SAFETY LANCETS 21G (lancets) NP
EASY TOUCH SAFETY LANCETS 23G (lancets) NP
EASY TOUCH SAFETY LANCETS 26G (lancets) NP
EASY TOUCH SAFETY LANCETS 28G (lancets) NP
easy trak blood glucose test in vitro strip NF
EASYGLUCO IN VITRO STRIP (glucose blood) NF
EASYMAX 15 TEST IN VITRO STRIP (glucose blood) NF
EASYMAX TEST IN VITRO STRIP (glucose blood) NF
EASYPRO BLOOD GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
EASYPRO PLUS IN VITRO STRIP (glucose blood) NF
element compact test in vitro strip NF
ELEMENT TEST IN VITRO STRIP (glucose blood) NF
EMBRACE BLOOD GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
EMBRACE EVO BLOOD GLUCOSE TEST IN VITRO
STRIP (glucose blood)
NF
EMBRACE PRO GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
EMBRACE TALK GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
ENLITE GLUCOSE SENSOR (continuous blood gluc sensor) NF
eq blood glucose test in vitro strip NF
EVERSENSE SENSOR/HOLDER (continuous blood gluc
sensor)
NF
EVERSENSE SMART TRANSMITTER (continuous blood
gluc transmit)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
EVOLUTION AUTOCODE IN VITRO STRIP (glucose
blood)
NF
FIFTY50 GLUCOSE TEST 2.0 IN VITRO STRIP (glucose
blood)
NF
FINGERSTIX LANCETS (lancets) NP
FORA 6 CONNECT IN VITRO STRIP (glucose blood) NF
FORA BLOOD GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
FORA D15G BLOOD GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
FORA D20 BLOOD GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
FORA D40/G31 BLOOD GLUCOSE IN VITRO STRIP
(glucose blood)
NF
FORA G20 BLOOD GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
FORA G30/PREM V10 GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
FORA GD20 TEST IN VITRO STRIP (glucose blood) NF
FORA GD50 BLOOD GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
FORA GTEL BLOOD GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
FORA TN'G ADVANCE PRO IN VITRO STRIP (glucose
blood)
NF
FORA TN'G/TN'G VOICE IN VITRO STRIP (glucose
blood)
NF
FORA V10 BLOOD GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
FORA V12 BLOOD GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
FORA V20 BLOOD GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
FORA V30A BLOOD GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
FORACARE GD40 TEST IN VITRO STRIP (glucose blood) NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
FORACARE PREMIUM V10 TEST IN VITRO STRIP
(glucose blood)
NF
FORACARE TEST N GO TEST IN VITRO STRIP (glucose
blood)
NF
FORTISCARE TEST IN VITRO STRIP (glucose blood) NF
FREESTYLE INSULINX TEST IN VITRO STRIP (glucose
blood)
NF
FREESTYLE LANCETS (lancets) NP
FREESTYLE LIBRE 14 DAY SENSOR (continuous blood
gluc sensor)
NF
FREESTYLE LIBRE 2 SENSOR (continuous blood gluc
sensor)
NF
freestyle libre 3 sensor NF
FREESTYLE LIBRE READER DEVICE (continuous blood
gluc receiver)
NF
FREESTYLE LITE TEST IN VITRO STRIP (glucose blood) NF
FREESTYLE PRECISION NEO TEST IN VITRO STRIP
(glucose blood)
NF
FREESTYLE TEST IN VITRO STRIP (glucose blood) NF
ge100 blood glucose test in vitro strip NF
GENULTIMATE TEST IN VITRO STRIP (glucose blood) NF
ght test in vitro strip NF
GLUCO PERFECT 3 TEST IN VITRO STRIP (glucose
blood)
NF
GLUCOCARD 01 SENSOR PLUS IN VITRO STRIP
(glucose blood)
NF
GLUCOCARD EXPRESSION TEST IN VITRO STRIP
(glucose blood)
NF
GLUCOCARD SHINE TEST IN VITRO STRIP (glucose
blood)
NF
GLUCOCARD VITAL TEST IN VITRO STRIP (glucose
blood)
NF
GLUCOCARD X-SENSOR IN VITRO STRIP (glucose
blood)
NF
GLUCOCOM TEST IN VITRO STRIP (glucose blood) NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
GLUCONAVII BLOOD GLUCOSE TEST IN VITRO
STRIP (glucose blood)
NF
glucose control in vitro solution NP
glucose meter test in vitro strip NF
gnp easy touch glucose test in vitro strip NF
GOJJI BLOOD TEST STRIP/LANCETS IN VITRO STRIP
(glucose blood)
NF
goodsense blood glucose in vitro strip NF
GUARDIAN LINK 3 TRANSMITTER (continuous blood
gluc transmit)
NF
GUARDIAN REAL-TIME REPLACE PED DEVICE
(continuous blood gluc receiver)
NF
GUARDIAN SENSOR (3) (continuous blood gluc sensor) NF
guardian sensor 3 NF
HW EMBRACE PRO GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
HW EMBRACE TALK GLUCOSE TEST IN VITRO
STRIP (glucose blood)
NF
IGLUCOSE TEST STRIPS IN VITRO STRIP (glucose
blood)
NF
IN TOUCH BLOOD GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
INFINITY BLOOD GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
INFINITY VOICE IN VITRO STRIP (glucose blood) NF
lancets super thin 28g NP
LANCETS ULTRA THIN (lancets) NP
lancets ultra thin 30g NP
LIBERTY NEXT GENERATION TEST IN VITRO STRIP
(glucose blood)
NF
liberty test in vitro strip NF
lite touch lancets NP
LITETOUCH LANCETS (lancets) NP
meijer essential glucose test in vitro strip NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
MEIJER TRUETEST TEST IN VITRO STRIP (glucose
blood)
NF
MEIJER TRUETRACK TEST IN VITRO STRIP (glucose
blood)
NF
MICRODOT TEST IN VITRO STRIP (glucose blood) NF
MICROLET LANCETS (lancets) NP
MYGLUCOHEALTH TEST IN VITRO STRIP (glucose
blood)
NF
NEUTEK 2TEK TEST IN VITRO STRIP (glucose blood) NF
NOVA MAX GLUCOSE TEST IN VITRO STRIP (glucose
blood)
NF
OMNIPOD 5 G6 INTRO (GEN 5) KIT (insulin disposable
pump)
PB
OMNIPOD 5 G6 POD (GEN 5) (insulin disposable pump) PB
OMNIPOD CLASSIC PODS (GEN 3) (insulin disposable
pump)
PB
OMNIPOD DASH INTRO (GEN 4) KIT (insulin disposable
pump)
PB
OMNIPOD DASH PDM (GEN 4) KIT (insulin disposable
pump)
PB
OMNIPOD DASH PODS (GEN 4) (insulin disposable pump) PB
OMNIPOD GO KIT 10 UNIT/24HR, 15 UNIT/24HR, 20
UNIT/24HR, 25 UNIT/24HR, 30 UNIT/24HR, 35
UNIT/24HR, 40 UNIT/24HR (insulin disposable pump)
NF
one drop test in vitro strip NF
ONETOUCH DELICA PLUS LANCET30G (lancets) PB
ONETOUCH DELICA SAFETY LANCING (lancet devices) PB
ONETOUCH ULTRA IN VITRO STRIP (glucose blood) PB
QL (150 TEST STRIPS per
25 days)
ONETOUCH ULTRASOFT 2 LANCETS (lancets) PB
ONETOUCH VERIO IN VITRO STRIP (glucose blood) PB
QL (150 TEST STRIPS per
25 days)
OPTIUMEZ TEST IN VITRO STRIP (glucose blood) NF
PHARMACIST CHOICE AUTOCODE IN VITRO STRIP
(glucose blood)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
pharmacist choice no coding in vitro strip NF
POCKETCHEM EZ TEST IN VITRO STRIP (glucose blood) NF
POGO AUTOMATIC TEST CARTRIDGES IN VITRO
DIAGNOSTIC TEST (glucose blood)
NF
PRECISION THINS GP LANCETS (lancets) NP
PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP
(glucose blood)
NF
premium blood glucose test in vitro strip NF
pro voice v8/v9 glucose in vitro strip NF
PRODIGY NO CODING BLOOD GLUC IN VITRO
STRIP (glucose blood)
NF
PTS PANELS EGLU TEST IN VITRO STRIP (glucose
blood)
NF
QUICKTEK TEST IN VITRO STRIP (glucose blood) NF
QUINTET AC BLOOD GLUCOSE TEST IN VITRO
STRIP (glucose blood)
NF
QUINTET BLOOD GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
REFUAH PLUS BLOOD GLUCOSE TEST IN VITRO
STRIP (glucose blood)
NF
RELION BLOOD GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
RELION CONFIRM/MICRO TEST IN VITRO STRIP
(glucose blood)
NF
RELION PRIME TEST IN VITRO STRIP (glucose blood) NF
RELION ULTIMA TEST IN VITRO STRIP (glucose blood) NF
RIGHTEST GS100 BLOOD GLUCOSE IN VITRO STRIP
(glucose blood)
NF
RIGHTEST GS300 BLOOD GLUCOSE IN VITRO STRIP
(glucose blood)
NF
RIGHTEST GS550 BLOOD GLUCOSE IN VITRO STRIP
(glucose blood)
NF
sapscare twist top lancets NP
SIMPLE DIAGNOSTICS LANCING DEV (lancet devices) NP
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Coverage Requirements and
Limits
SMART SENSE PREMIUM TEST IN VITRO STRIP
(glucose blood)
NF
SMARTEST BLOOD GLUCOSE TEST IN VITRO STRIP
(glucose blood)
NF
SOLUS V2 TEST IN VITRO STRIP (glucose blood) NF
super thin lancets NP
SUPREME TEST IN VITRO STRIP (glucose blood) NF
true focus blood glucose strip in vitro strip NF
TRUE METRIX BLOOD GLUCOSE TEST IN VITRO
STRIP (glucose blood)
NF
TRUEPLUS LANCETS 26G (lancets) NP
TRUEPLUS LANCETS 30G (lancets) NP
TRUEPLUS SAFETY LANCETS 28G (lancets) NP
TRUETEST TEST IN VITRO STRIP (glucose blood) NF
TRUETRACK TEST IN VITRO STRIP (glucose blood) NF
UNISTRIP1 GENERIC IN VITRO STRIP (glucose blood) NF
verasens blood glucose test in vitro strip NF
V-GO 20 KIT 20 UNIT/24HR (insulin disposable pump) PB
V-GO 30 KIT 30 UNIT/24HR (insulin disposable pump) PB
V-GO 40 KIT 40 UNIT/24HR (insulin disposable pump) PB
ENDOMETRIOSIS
danazol oral capsule 100 mg, 200 mg, 50 mg PG
N8 (Listing does not include
certain NDCs)
ORILISSA ORAL TABLET 150 MG, 200 MG (elagolix
sodium)
PB PA
ENZYME REPLACEMENTS - DRUGS FOR
REPLACEMENT, MODIFICATION, TREATMENT
ALDURAZYME INTRAVENOUS SOLUTION 2.9
MG/5ML (laronidase)
NPSP PA
betaine oral powder PSP PA
BUPHENYL ORAL POWDER 3 GM/TSP (sodium
phenylbutyrate)
NF
BUPHENYL ORAL TABLET 500 MG (sodium
phenylbutyrate)
NF
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Limits
CARBAGLU ORAL TABLET SOLUBLE 200 MG
(carglumic acid)
NF
carglumic acid oral tablet soluble 200 mg PSP PA
CERDELGA ORAL CAPSULE 84 MG (eliglustat tartrate) PSP
PA; QL (56 CAPSULES per
28 days)
CEREZYME INTRAVENOUS SOLUTION
RECONSTITUTED 400 UNIT (imiglucerase)
PSP
PA; QL (15 VIALS per 14
days)
CYSTADANE ORAL POWDER (betaine) NF
CYSTAGON ORAL CAPSULE 150 MG, 50 MG
(cysteamine bitartrate)
PSP PA
ELAPRASE INTRAVENOUS SOLUTION 6 MG/3ML
(idursulfase)
NPSP PA
ELELYSO INTRAVENOUS SOLUTION
RECONSTITUTED 200 UNIT (taliglucerase alfa)
NF
FABRAZYME INTRAVENOUS SOLUTION
RECONSTITUTED 35 MG, 5 MG (agalsidase beta)
NPSP PA
KANUMA INTRAVENOUS SOLUTION 20 MG/10ML
(sebelipase alfa)
NPSP PA
KUVAN ORAL PACKET 100 MG, 500 MG (sapropterin
dihydrochloride)
NF
KUVAN ORAL TABLET 100 MG (sapropterin
dihydrochloride)
NF
LUMIZYME INTRAVENOUS SOLUTION
RECONSTITUTED 50 MG (alglucosidase alfa)
NPSP PA
miglustat oral capsule 100 mg PSP
PA; QL (90 CAPSULES per
30 days)
MYALEPT SUBCUTANEOUS SOLUTION
RECONSTITUTED 11.3 MG (metreleptin)
NPSP
PA; QL (30 SOLUTION
RECONSTITUTED per 30
days)
NAGLAZYME INTRAVENOUS SOLUTION 1 MG/ML
(galsulfase)
NPSP PA
PALYNZIQ SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 10 MG/0.5ML, 2.5 MG/0.5ML, 20 MG/ML
(pegvaliase-pqpz)
NF
PHEBURANE ORAL PELLET 483 MG/GM (sodium
phenylbutyrate)
NPSP PA; QL (672 G per 30 days)
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Coverage Requirements and
Limits
RAVICTI ORAL LIQUID 1.1 GM/ML (glycerol
phenylbutyrate)
NF
sapropterin dihydrochloride oral packet 100 mg, 500 mg PSP PA
sapropterin dihydrochloride oral tablet 100 mg PSP PA
sodium phenylbutyrate oral powder 3 gm/tsp PSP PA; QL (600 G per 30 days)
sodium phenylbutyrate oral tablet 500 mg PSP
PA; QL (1200 TABLETS
per 30 days)
STRENSIQ SUBCUTANEOUS SOLUTION 18
MG/0.45ML, 28 MG/0.7ML, 40 MG/ML, 80 MG/0.8ML
(asfotase alfa)
NPSP PA
VIMIZIM INTRAVENOUS SOLUTION 5 MG/5ML
(elosulfase alfa)
NPSP PA
VPRIV INTRAVENOUS SOLUTION RECONSTITUTED
400 UNIT (velaglucerase alfa)
NPSP
PA; QL (15 SOLUTION
RECONSTITUTED per 14
days)
ZAVESCA ORAL CAPSULE 100 MG (miglustat) NPSP
PA; QL (90 CAPSULES per
30 days)
ESTROGENS - DRUGS TO REGULATE FEMALE
HORMONES
ALORA TRANSDERMAL PATCH TWICE WEEKLY
0.025 MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR (estradiol)
NF
estradiol-norethindrone acet (Amabelz Oral Tablet 0.5-0.1 Mg,
1-0.5 Mg)
PG
ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG
(drospirenone-estradiol)
NF
BIJUVA ORAL CAPSULE 1-100 MG (estradiol-
progesterone)
PB
CLIMARA PRO TRANSDERMAL PATCH WEEKLY
0.045-0.015 MG/DAY (estradiol-levonorgestrel)
PB
CLIMARA TRANSDERMAL PATCH WEEKLY 0.025
MG/24HR, 0.0375 MG/24HR, 0.05 MG/24HR, 0.06
MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR (estradiol)
NF
COMBIPATCH TRANSDERMAL PATCH TWICE
WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY
(estradiol-norethindrone acet)
PB
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Coverage Requirements and
Limits
DIVIGEL TRANSDERMAL GEL 0.25 MG/0.25GM, 0.5
MG/0.5GM, 0.75 MG/0.75GM, 1 MG/GM, 1.25
MG/1.25GM (estradiol)
PB
DUAVEE ORAL TABLET 0.45-20 MG (conj estrogens-
bazedoxifene)
NF N10 (NP,PA applies)
ELESTRIN TRANSDERMAL GEL 0.52 MG/0.87 GM
(0.06%) (estradiol)
NF
estradiol oral tablet 0.5 mg, 1 mg, 2 mg PG
estradiol transdermal gel 0.25 mg/0.25gm, 0.5 mg/0.5gm, 0.75
mg/0.75gm, 1 mg/gm, 1.25 mg/1.25gm
PG
estradiol transdermal patch twice weekly 0.025 mg/24hr, 0.0375
mg/24hr, 0.05 mg/24hr, 0.075 mg/24hr, 0.1 mg/24hr
PG
estradiol transdermal patch weekly 0.025 mg/24hr, 0.0375
mg/24hr, 0.05 mg/24hr, 0.06 mg/24hr, 0.075 mg/24hr, 0.1
mg/24hr
PG
estradiol vaginal cream 0.1 mg/gm PG
estradiol vaginal tablet 10 mcg NF
estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml PG
estradiol-norethindrone acet oral tablet 0.5-0.1 mg PG
ESTRING VAGINAL RING 2 MG (estradiol) NF
ESTROGEL TRANSDERMAL GEL 0.75 MG/1.25 GM
(0.06%) (estradiol)
NF
EVAMIST TRANSDERMAL SOLUTION 1.53
MG/SPRAY (estradiol)
PB
norethindrone-eth estradiol (Fyavolv Oral Tablet 0.5-2.5 Mg-
Mcg, 1-5 Mg-Mcg)
PG
IMVEXXY MAINTENANCE PACK VAGINAL INSERT
10 MCG, 4 MCG (estradiol)
PB
IMVEXXY STARTER PACK VAGINAL INSERT 10
MCG, 4 MCG (estradiol)
PB
norethindrone-eth estradiol (Jinteli Oral Tablet 1-5 Mg-Mcg) PG
MENEST ORAL TABLET 0.3 MG, 0.625 MG, 1.25 MG, 2.5
MG (esterified estrogens)
NF
MENOSTAR TRANSDERMAL PATCH WEEKLY 14
MCG/24HR (estradiol)
NF
estradiol-norethindrone acet (Mimvey Oral Tablet 1-0.5 Mg) PG
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Coverage Requirements and
Limits
MINIVELLE TRANSDERMAL PATCH TWICE
WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05
MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR (estradiol)
NF
MYFEMBREE ORAL TABLET 40-1-0.5 MG (relugolix-
estradiol-norethind)
PB PA
ORIAHNN ORAL CAPSULE THERAPY PACK 300-1-0.5
& 300 MG (elagolix-estradiol-norethind)
PB PA
PREFEST ORAL TABLET 1/1-0.09 MG (15/15) (estradiol-
norgestimate)
NF
PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG,
0.9 MG, 1.25 MG (estrogens conjugated)
NF
PREMARIN VAGINAL CREAM 0.625 MG/GM (estrogens,
conjugated)
NF
PREMPHASE ORAL TABLET 0.625-5 MG (conj estrog-
medroxyprogest ace)
NF
PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG,
0.625-2.5 MG, 0.625-5 MG (conj estrog-medroxyprogest ace)
NF
VAGIFEM VAGINAL TABLET 10 MCG (estradiol) PB
VIVELLE-DOT TRANSDERMAL PATCH TWICE
WEEKLY 0.025 MG/24HR, 0.0375 MG/24HR, 0.05
MG/24HR, 0.075 MG/24HR, 0.1 MG/24HR (estradiol)
NF
estradiol (Yuvafem Vaginal Tablet 10 Mcg) NF
FERTILITY REGULATORS
CETROTIDE SUBCUTANEOUS KIT 0.25 MG (cetrorelix
acetate)
PSP PA
chorionic gonadotropin intramuscular solution reconstituted
10000 unit
NF
CLOMID ORAL TABLET 50 MG (clomiphene citrate) NP SPC
FOLLISTIM AQ SUBCUTANEOUS SOLUTION 300
UNT/0.36ML, 600 UNT/0.72ML, 900 UNT/1.08ML
(follitropin beta)
NF
ganirelix acetate solution prefilled syringe 250 mcg/0.5ml
subcutaneous
NPSP PA; SPC
ganirelix acetate solution prefilled syringe 250 mcg/0.5ml
subcutaneous
PSP PA; SPC
GONAL-F INJECTION SOLUTION RECONSTITUTED
1050 UNIT, 450 UNIT (follitropin alfa)
PSP PA; SPC
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Limits
GONAL-F RFF REDIJECT SUBCUTANEOUS
SOLUTION PEN-INJECTOR 300 UNIT/0.5ML, 450
UNT/0.75ML, 900 UNIT/1.5ML (follitropin alfa)
PSP PA; SPC
GONAL-F RFF SUBCUTANEOUS SOLUTION
RECONSTITUTED 75 UNIT (follitropin alfa)
PSP PA; SPC
MENOPUR SUBCUTANEOUS SOLUTION
RECONSTITUTED 75 UNIT (menotropins)
PSP PA; SPC
NOVAREL INTRAMUSCULAR SOLUTION
RECONSTITUTED 10000 UNIT, 5000 UNIT (chorionic
gonadotropin)
NF
OVIDREL SUBCUTANEOUS INJECTABLE 250
MCG/0.5ML (choriogonadotropin alfa)
PSP PA; SPC
PREGNYL INTRAMUSCULAR SOLUTION
RECONSTITUTED 10000 UNIT (chorionic gonadotropin)
NF
GLUCOCORTICOIDS - DRUGS TO TREAT
INFLAMMATORY RESPONSE
ALKINDI SPRINKLE ORAL CAPSULE SPRINKLE 0.5
MG, 1 MG, 2 MG, 5 MG (hydrocortisone)
NF
cortisone acetate oral tablet 25 mg NF
dexabliss oral tablet therapy pack 1.5 mg (39) NF
dexamethasone oral elixir 0.5 mg/5ml PG
N8 (Listing does not include
certain NDCs)
dexamethasone oral solution 0.5 mg/5ml PG
dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg,
4 mg, 6 mg
PG
dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg
(35), 1.5 mg (51)
PG
DXEVO 11-DAY ORAL TABLET THERAPY PACK 1.5
MG (dexamethasone)
NF
EMFLAZA ORAL SUSPENSION 22.75 MG/ML
(deflazacort)
NF
EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 MG, 6 MG
(deflazacort)
NF
fludrocortisone acetate oral tablet 0.1 mg PG
HEMADY ORAL TABLET 20 MG (dexamethasone) NF
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Limits
dexamethasone (Hidex 6-Day Oral Tablet Therapy Pack 1.5
Mg (21))
PG
hydrocortisone oral tablet 10 mg, 5 mg PG
N8 (Listing does not include
certain NDCs)
hydrocortisone oral tablet 20 mg PG
methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg PG
methylprednisolone oral tablet therapy pack 4 mg PG
prednisolone (Millipred Oral Tablet 5 Mg) NF
prednisolone oral solution 15 mg/5ml PG
prednisolone sodium phosphate oral solution 10 mg/5ml, 20
mg/5ml
NF
prednisolone sodium phosphate oral solution 15 mg/5ml, 25
mg/5ml, 6.7 (5 base) mg/5ml
PG
prednisolone sodium phosphate oral tablet dispersible 10 mg, 15
mg, 30 mg
NP
prednisone oral solution 5 mg/5ml PG
prednisone oral tablet 1 mg, 5 mg PG
N8 (Listing does not include
certain NDCs)
prednisone oral tablet 10 mg, 2.5 mg, 20 mg, 50 mg PG
prednisone oral tablet therapy pack 10 mg (21), 10 mg (48), 5
mg (21), 5 mg (48)
PG
RAYOS ORAL TABLET DELAYED RELEASE 1 MG, 2
MG, 5 MG (prednisone)
NF
TAPERDEX 12-DAY ORAL TABLET THERAPY PACK
1.5 MG (49) (dexamethasone)
NF
dexamethasone (Taperdex 6-Day Oral Tablet Therapy Pack
1.5 Mg, 1.5 Mg (21))
NF
TAPERDEX 7-DAY ORAL TABLET THERAPY PACK
1.5 MG (27) (dexamethasone)
NF
GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT
LOW BLOOD SUGAR
BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE
(glucagon)
PB
BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE
(glucagon)
PB
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Coverage Requirements and
Limits
BD GLUCOSE ORAL TABLET CHEWABLE 5 GM
(dextrose (diabetic use))
NP
diazoxide oral suspension 50 mg/ml PG
GLUCAGEN HYPOKIT INJECTION SOLUTION
RECONSTITUTED 1 MG (glucagon hcl (rdna))
NF
glucagon emergency injection solution reconstituted 1 mg/ml NF
glucagon emergency kit 1 mg injection PG
glucagon emergency kit 1 mg injection NF
glucose oral tablet chewable 4 gm NP
gnp glucose gummies oral tablet chewable 2 gm PG
GVOKE HYPOPEN 1-PACK SUBCUTANEOUS
SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML, 1
MG/0.2ML (glucagon)
PB
GVOKE HYPOPEN 2-PACK SUBCUTANEOUS
SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML, 1
MG/0.2ML (glucagon)
PB
GVOKE KIT SUBCUTANEOUS SOLUTION 1 MG/0.2ML
(glucagon)
PB
GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon)
PB
ZEGALOGUE SUBCUTANEOUS SOLUTION AUTO-
INJECTOR 0.6 MG/0.6ML (dasiglucagon hcl)
PB
ZEGALOGUE SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE 0.6 MG/0.6ML (dasiglucagon hcl)
PB
GROWTH IMPROVEMENT AGENTS - DRUGS TO
PROMOTE GROWTH
VOXZOGO SUBCUTANEOUS SOLUTION
RECONSTITUTED 0.4 MG, 0.56 MG, 1.2 MG (vosoritide)
NPSP
PA; QL (30 VIALS per 30
days)
HEREDITARY TYROSINEMIA TYPE 1 AGENTS -
DRUGS FOR REPLACEMENT, MODIFICATION,
TREATMENT
nitisinone oral capsule 10 mg, 2 mg, 5 mg PSP PA
NITYR ORAL TABLET 10 MG, 2 MG, 5 MG (nitisinone) NF
ORFADIN ORAL CAPSULE 10 MG, 2 MG, 20 MG, 5 MG
(nitisinone)
PSP PA
ORFADIN ORAL SUSPENSION 4 MG/ML (nitisinone) PSP PA
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Limits
HUMAN GROWTH HORMONES - DRUGS TO
REGULATE PITUITARY HORMONES
GENOTROPIN MINIQUICK SUBCUTANEOUS
PREFILLED SYRINGE 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 (somatropin)
PSP PA
GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG,
5 MG (somatropin)
PSP PA
HUMATROPE INJECTION CARTRIDGE 12 MG, 24 MG,
6 MG (somatropin)
NF
NORDITROPIN FLEXPRO SUBCUTANEOUS
SOLUTION PEN-INJECTOR 10 MG/1.5ML, 15
MG/1.5ML, 30 MG/3ML, 5 MG/1.5ML (somatropin)
PSP PA
NUTROPIN AQ NUSPIN 10 SUBCUTANEOUS
SOLUTION PEN-INJECTOR 10 MG/2ML (somatropin)
NF
NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS
SOLUTION PEN-INJECTOR 20 MG/2ML (somatropin)
NF
NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS
SOLUTION PEN-INJECTOR 5 MG/2ML (somatropin)
NF
OMNITROPE SUBCUTANEOUS SOLUTION
CARTRIDGE 10 MG/1.5ML, 5 MG/1.5ML (somatropin)
NF
OMNITROPE SUBCUTANEOUS SOLUTION
RECONSTITUTED 5.8 MG (somatropin)
NF
SAIZEN INJECTION SOLUTION RECONSTITUTED 5
MG, 8.8 MG (somatropin (non-refrigerated))
NF
SAIZENPREP INJECTION SOLUTION
RECONSTITUTED 8.8 MG (somatropin (non-refrigerated))
NF
SEROSTIM SUBCUTANEOUS SOLUTION
RECONSTITUTED 4 MG, 5 MG, 6 MG (somatropin (non-
refrigerated))
NPSP PA
SKYTROFA SUBCUTANEOUS CARTRIDGE 11 MG,
13.3 MG, 3 MG, 3.6 MG, 4.3 MG, 5.2 MG, 6.3 MG, 7.6 MG,
9.1 MG (lonapegsomatropin-tcgd)
NF
ZOMACTON SUBCUTANEOUS SOLUTION
RECONSTITUTED 10 MG, 5 MG (somatropin)
NF
ZORBTIVE SUBCUTANEOUS SOLUTION
RECONSTITUTED 8.8 MG (somatropin (non-refrigerated))
NPSP PA
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Limits
LUTEINIZING HORMONE-RELEASING HORMONE
(LHRH) AGONISTS
FENSOLVI (6 MONTH) SUBCUTANEOUS KIT 45 MG
(leuprolide acetate (6 month))
PSP PA
LUPRON DEPOT-PED (1-MONTH) INTRAMUSCULAR
KIT 11.25 MG, 15 MG, 7.5 MG (leuprolide acetate)
PSP PA
LUPRON DEPOT-PED (3-MONTH) INTRAMUSCULAR
KIT 11.25 MG (PED), 30 MG (leuprolide acetate (3 month))
PSP PA
LUPRON DEPOT-PED (6-MONTH) INTRAMUSCULAR
KIT 45 MG (leuprolide acetate (6 month))
PSP PA
SYNAREL NASAL SOLUTION 2 MG/ML (nafarelin
acetate)
NP PA
TRIPTODUR INTRAMUSCULAR SUSPENSION
RECONSTITUTED ER 22.5 MG (triptorelin pamoate)
PSP PA
MINERALOCORTICOID RECEPTOR ANTAGONISTS -
DRUGS TO TREAT CHRONIC KIDNEY DISEASE
ASSOCIATED WITH TYPE 2 DIABETES
KERENDIA ORAL TABLET 10 MG, 20 MG (finerenone) PB
MISCELLANEOUS
ACTHAR INJECTION GEL 80 UNIT/ML (corticotropin) NPSP PA; QL (35 ML per 21 days)
cabergoline oral tablet 0.5 mg PG
calcitonin (salmon) nasal solution 200 unit/act PG
CORTROPHIN INJECTION GEL 80 UNIT/ML
(corticotropin)
NPSP PA; QL (35 ML per 21 days)
EVENITY SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 105 MG/1.17ML (romosozumab-aqqg)
NF
FORTEO SUBCUTANEOUS SOLUTION PEN-
INJECTOR 600 MCG/2.4ML (teriparatide (recombinant))
PSP
PA; QL (1 PEN per 28
Days)
GALAFOLD ORAL CAPSULE 123 MG (migalastat hcl) NPSP
PA; QL (14 CAPSULES per
28 days)
IMCIVREE SUBCUTANEOUS SOLUTION 10 MG/ML
(setmelanotide acetate)
NF
INCRELEX SUBCUTANEOUS SOLUTION 40 MG/4ML
(mecasermin)
NPSP PA
INTRAROSA VAGINAL INSERT 6.5 MG (prasterone) NF
JYNARQUE ORAL TABLET 15 MG, 30 MG (tolvaptan) NF
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Coverage Requirements and
Limits
JYNARQUE ORAL TABLET THERAPY PACK 15 MG,
30 & 15 MG, 45 & 15 MG, 60 & 30 MG, 90 & 30 MG
(tolvaptan)
NF
methylergonovine maleate (Methergine Oral Tablet 0.2 Mg) PG QL (4 TABLETS per 1 day)
methylergonovine maleate oral tablet 0.2 mg PG
QL (4 TABLETS per 1
DAY)
OSPHENA ORAL TABLET 60 MG (ospemifene) NF N10 (NP,PA applies)
PROLIA SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 60 MG/ML (denosumab)
PSP
PA; QL (60 ML per 168
days)
raloxifene hcl oral tablet 60 mg CE
N7 (PG); AL (Min 35
Years)
SAMSCA ORAL TABLET 15 MG, 30 MG (tolvaptan) NPSP PA
SIGNIFOR LAR INTRAMUSCULAR SUSPENSION
RECONSTITUTED ER 10 MG, 20 MG, 30 MG, 40 MG, 60
MG (pasireotide pamoate)
NF
SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML,
0.6 MG/ML, 0.9 MG/ML (pasireotide diaspartate)
NPSP PA; QL (60 ML per 30 days)
teriparatide (recombinant) subcutaneous solution pen-injector
620 mcg/2.48ml
NF
tolvaptan oral tablet 15 mg, 30 mg PSP PA
TYMLOS SUBCUTANEOUS SOLUTION PEN-
INJECTOR 3120 MCG/1.56ML (abaloparatide)
PSP
PA; QL (1 PEN per 30
DAYs)
VIJOICE ORAL TABLET THERAPY PACK 125 MG, 200
& 50 MG, 50 MG (alpelisib)
NF
XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7ML
(denosumab)
NPSP PA
XURIDEN ORAL PACKET 2 GM (uridine triacetate) NPSP
QL (4 PACKETS per 1
DAY)
ZOKINVY ORAL CAPSULE 50 MG, 75 MG (lonafarnib) NPSP
PA; QL (120 CAPSULES
per 30 days)
PHOSPHATE BINDER AGENTS - DRUGS TO
REGULATE CALCIUM AND PHOSPHORUS LEVELS
AURYXIA ORAL TABLET 1 GM 210 MG(FE) (ferric
citrate)
PB
calcium acetate (phos binder) oral capsule 667 mg PG
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
FOSRENOL ORAL PACKET 1000 MG, 750 MG
(lanthanum carbonate)
NF
FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500
MG, 750 MG (lanthanum carbonate)
NF
lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750
mg
NF
RENVELA ORAL PACKET 0.8 GM, 2.4 GM (sevelamer
carbonate)
NF
RENVELA ORAL TABLET 800 MG (sevelamer carbonate) NF
sevelamer carbonate oral packet 0.8 gm, 2.4 gm PG
sevelamer carbonate oral tablet 800 mg PG
sevelamer hcl oral tablet 400 mg, 800 mg PG
VELPHORO ORAL TABLET CHEWABLE 500 MG
(sucroferric oxyhydroxide)
PB
POLYNEUROPATHY
TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 284 MG/1.5ML (inotersen sodium)
PSP
PA; QL (4 syringes per 28
days)
PROGESTINS - DRUGS TO REGULATE FEMALE
HORMONES
CRINONE VAGINAL GEL 4 %, 8 % (progesterone) NF
medroxyprogesterone acetate oral tablet 10 mg, 2.5 mg, 5 mg PG
megestrol acetate oral suspension 625 mg/5ml CE N7 (NP)
norethindrone acetate oral tablet 5 mg PG
progesterone oral capsule 100 mg, 200 mg PG
PROMETRIUM ORAL CAPSULE 100 MG, 200 MG
(progesterone)
NF
THYROID AGENTS - DRUGS TO REGULATE
THYROID LEVELS
ADTHYZA ORAL TABLET 130 MG, 16.25 MG, 32.5 MG,
65 MG, 97.5 MG (thyroid)
NF
CYTOMEL ORAL TABLET 25 MCG, 5 MCG, 50 MCG
(liothyronine sodium)
NF
ERMEZA ORAL SOLUTION 150 MCG/5ML (levothyroxine
sodium)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
levothyroxine sodium oral capsule 100 mcg, 112 mcg, 125 mcg,
13 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 50 mcg,
75 mcg, 88 mcg
NF
levothyroxine sodium oral tablet 100 mcg, 112 mcg, 125 mcg,
137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg,
75 mcg, 88 mcg
PG
liothyronine sodium oral tablet 25 mcg, 5 mcg, 50 mcg PG
methimazole oral tablet 10 mg, 5 mg PG
propylthiouracil oral tablet 50 mg PG
THYQUIDITY ORAL SOLUTION 100 MCG/5ML
(levothyroxine sodium)
NF
TIROSINT ORAL CAPSULE 100 MCG, 112 MCG, 125
MCG, 13 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG,
25 MCG, 37.5 MCG, 44 MCG, 50 MCG, 62.5 MCG, 75
MCG, 88 MCG (levothyroxine sodium)
NF
TIROSINT-SOL ORAL SOLUTION 100 MCG/ML, 112
MCG/ML, 125 MCG/ML, 13 MCG/ML, 137 MCG/ML, 150
MCG/ML, 175 MCG/ML, 200 MCG/ML, 25 MCG/ML, 37.5
MCG/ML, 44 MCG/ML, 50 MCG/ML, 62.5 MCG/ML, 75
MCG/ML, 88 MCG/ML (levothyroxine sodium)
NF
VASOPRESSINS - DRUGS TO REGULATE PITUITARY
HORMONES
DDAVP ORAL TABLET 0.1 MG, 0.2 MG (desmopressin
acetate)
NP
desmopressin ace spray refrig nasal solution 0.01 % PG
desmopressin acetate nasal solution 1.5 mg/ml NPSP PA
desmopressin acetate oral tablet 0.1 mg, 0.2 mg PG
desmopressin acetate spray nasal solution 0.01 % PG
NOCDURNA SUBLINGUAL TABLET SUBLINGUAL
27.7 MCG, 55.3 MCG (desmopressin acetate)
NP PA
VITAMINS - VITAMINS AND SUPPLEMENTS
RAYALDEE ORAL CAPSULE EXTENDED RELEASE 30
MCG (calcifediol)
NP ST
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
GASTROINTESTINAL - DRUGS TO TREAT STOMACH
AND INTESTINAL DISORDERS
ANTICHOLINERGICS
CUVPOSA ORAL SOLUTION 1 MG/5ML (glycopyrrolate) NP
DARTISLA ODT ORAL TABLET DISPERSIBLE 1.7 MG
(glycopyrrolate)
NF
dicyclomine hcl oral capsule 10 mg PG
dicyclomine hcl oral tablet 20 mg PG
N8 (Listing does not include
certain NDCs)
GLYCATE ORAL TABLET 1.5 MG (glycopyrrolate) NF
glycopyrrolate oral solution 1 mg/5ml PG
glycopyrrolate oral tablet 1 mg, 2 mg NP
glycopyrrolate oral tablet 1.5 mg NF
methscopolamine bromide oral tablet 2.5 mg, 5 mg NP
ROBINUL ORAL TABLET 1 MG (glycopyrrolate) NF
ROBINUL-FORTE ORAL TABLET 2 MG (glycopyrrolate) NF
ANTIDIARRHEALS
diphenoxylate-atropine oral liquid 2.5-0.025 mg/5ml PG
diphenoxylate-atropine oral tablet 2.5-0.025 mg PG
MOTOFEN ORAL TABLET 1-0.025 MG (difenoxin-
atropine)
NF
MYTESI ORAL TABLET DELAYED RELEASE 125 MG
(crofelemer)
NF
ANTIEMETICS - DRUGS FOR NAUSEA AND
VOMITING
AKYNZEO ORAL CAPSULE 300-0.5 MG (netupitant-
palonosetron)
NF
ANTIVERT ORAL TABLET 50 MG (meclizine hcl) NF
ANZEMET ORAL TABLET 50 MG (dolasetron mesylate) NF
aprepitant oral capsule 125 mg PG
QL (2 CAPSULES per 21
days)
aprepitant oral capsule 40 mg PG
QL (3 CAPSULES per 180
DAYs)
aprepitant oral capsule 80 & 125 mg PG
QL (2 PACKS per 21
DAYs)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
aprepitant oral capsule 80 mg PG
QL (4 CAPSULES per 21
days)
prochlorperazine (Compro Rectal Suppository 25 Mg) PG
doxylamine-pyridoxine oral tablet delayed release 10-10 mg PG
dronabinol oral capsule 10 mg, 2.5 mg, 5 mg NP
PA; QL (120 CAPSULES
per 25 DAYs)
EMEND ORAL CAPSULE 80 MG (aprepitant) NF
EMEND ORAL SUSPENSION RECONSTITUTED 125
MG/5ML (aprepitant)
NF
EMEND TRI-PACK ORAL CAPSULE 80 & 125 MG
(aprepitant)
NF
granisetron hcl oral tablet 1 mg NP
QL (12 TABLETS per 21
days)
MARINOL ORAL CAPSULE 2.5 MG (dronabinol) NP
PA; QL (120 CAPSULES
per 25 days)
metoclopramide hcl oral solution 10 mg/10ml PG
N8 (Listing does not include
certain NDCs)
metoclopramide hcl oral solution 5 mg/5ml PG
metoclopramide hcl oral tablet 10 mg, 5 mg PG
metoclopramide hcl oral tablet dispersible 5 mg PG
ondansetron hcl oral solution 4 mg/5ml PG QL (200 ML per 21 DAYs)
ondansetron hcl oral tablet 24 mg PG
QL (2 TABLETS per 21
days)
ondansetron hcl oral tablet 4 mg, 8 mg PG
QL (18 TABLETS per 21
DAYs)
ondansetron oral tablet dispersible 4 mg, 8 mg PG
QL (18 TABLETS per 21
DAYs)
prochlorperazine maleate oral tablet 10 mg, 5 mg PG
promethazine hcl oral syrup 6.25 mg/5ml PG
promethazine hcl oral tablet 12.5 mg, 25 mg, 50 mg PG
promethazine hcl rectal suppository 12.5 mg, 25 mg PG
PROMETHEGAN RECTAL SUPPOSITORY 50 MG
(promethazine hcl)
PG
SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR
(granisetron)
PB
QL (2 PATCHES per 21
days)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
scopolamine transdermal patch 72 hour 1 mg/3days PG
SYNDROS ORAL SOLUTION 5 MG/ML (dronabinol) NF
TRANSDERM-SCOP TRANSDERMAL PATCH 72
HOUR 1 MG/3DAYS (scopolamine base)
NF
trimethobenzamide hcl oral capsule 300 mg PG
VARUBI (180 MG DOSE) ORAL TABLET THERAPY
PACK 2 X 90 MG (rolapitant hcl)
NF
ANTISPASMODICS - DRUGS FOR MUSCLE SPASM
chlordiazepoxide-clidinium oral capsule 5-2.5 mg NP
N8 (Listing does not include
certain NDCs)
LIBRAX ORAL CAPSULE 5-2.5 MG (chlordiazepoxide-
clidinium)
NF
H2-RECEPTOR ANTAGONISTS - DRUGS FOR ULCERS
AND STOMACH ACID
cimetidine oral tablet 300 mg, 400 mg, 800 mg PG
famotidine oral tablet 40 mg PG
nizatidine oral capsule 150 mg, 300 mg PG
INFLAMMATORY BOWEL DISEASE - BOWEL,
INTESTINE, AND STOMACH CONDITION DRUGS
APRISO ORAL CAPSULE EXTENDED RELEASE 24
HOUR 0.375 GM (mesalamine)
NP
balsalazide disodium oral capsule 750 mg PG
budesonide er oral tablet extended release 24 hour 9 mg NF
budesonide oral capsule delayed release particles 3 mg PG
budesonide rectal foam 2 mg NF
CANASA RECTAL SUPPOSITORY 1000 MG (mesalamine) NF
COLAZAL ORAL CAPSULE 750 MG (balsalazide disodium) NF
CORTIFOAM EXTERNAL FOAM 10 % (hydrocortisone
acetate)
PB
DELZICOL ORAL CAPSULE DELAYED RELEASE 400
MG (mesalamine)
NF
DIPENTUM ORAL CAPSULE 250 MG (olsalazine sodium) NP PA
LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM
(mesalamine)
NF
mesalamine er oral capsule extended release 24 hour 0.375 gm PG
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
mesalamine er oral capsule extended release 500 mg PG
mesalamine oral capsule delayed release 400 mg PG
mesalamine oral tablet delayed release 1.2 gm, 800 mg PG
mesalamine rectal enema 4 gm PG
mesalamine rectal suppository 1000 mg PG
N8 (Listing does not include
certain NDCs)
ORTIKOS ORAL CAPSULE EXTENDED RELEASE 24
HOUR 6 MG, 9 MG (budesonide)
NF
PENTASA ORAL CAPSULE EXTENDED RELEASE 250
MG, 500 MG (mesalamine)
NF
ROWASA RECTAL KIT 4 GM (mesalamine-cleanser) NF
SFROWASA RECTAL ENEMA 4 GM/60ML (mesalamine) NF
sulfasalazine oral tablet 500 mg PG
sulfasalazine oral tablet delayed release 500 mg PG
UCERIS ORAL TABLET EXTENDED RELEASE 24
HOUR 9 MG (budesonide)
PB
UCERIS RECTAL FOAM 2 MG/ACT (budesonide) NF
IRRITABLE BOWEL SYNDROME WITH
CONSTIPATION
AMITIZA ORAL CAPSULE 24 MCG, 8 MCG
(lubiprostone)
NF
IBSRELA ORAL TABLET 50 MG (tenapanor hcl) NF
LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG
(linaclotide)
PB
lubiprostone oral capsule 24 mcg, 8 mcg PG
N8 (Listing does not include
certain NDCs)
IRRITABLE BOWEL SYNDROME WITH DIARRHEA
alosetron hcl oral tablet 0.5 mg, 1 mg PG PA
LOTRONEX ORAL TABLET 0.5 MG, 1 MG (alosetron hcl) NP PA
VIBERZI ORAL TABLET 100 MG, 75 MG (eluxadoline) PB PA
LAXATIVES - DRUGS FOR CONSTIPATION
CLENPIQ ORAL SOLUTION 10-3.5-12 MG-GM -
GM/160ML, 10-3.5-12 MG-GM -GM/175ML (sod
picosulfate-mag ox-cit acd)
CE
N7 (PB); N8 ($0 copay for
members age 45 through
75); AL (Min 45 Years and
Max 75 Years)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
enulose oral solution 10 gm/15ml PG
GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240
GM (peg 3350-kcl-nabcb-nacl-nasulf)
PG
peg 3350-kcl-nabcb-nacl-nasulf (Gavilyte-G Oral Solution
Reconstituted 236 Gm)
PG
GOLYTELY ORAL SOLUTION RECONSTITUTED 236
GM (peg 3350-kcl-nabcb-nacl-nasulf)
NF
KRISTALOSE ORAL PACKET 10 GM (lactulose) NP
lactulose oral packet 10 gm NF
lactulose oral solution 10 gm/15ml PG
MOVIPREP ORAL SOLUTION RECONSTITUTED 100
GM (peg-kcl-nacl-nasulf-na asc-c)
NF
na sulfate-k sulfate-mg sulf oral solution 17.5-3.13-1.6
gm/177ml
CE
N7 (PG); N8 ($0 copay for
members age 45 through
75); AL (Min 45 Years and
Max 75 Years)
OSMOPREP ORAL TABLET 1.102-0.398 GM (sod phos
mono-sod phos dibasic)
NF
peg 3350-kcl-na bicarb-nacl oral solution reconstituted 420 gm PG
peg-3350/electrolytes oral solution reconstituted 236 gm PG
peg-kcl-nacl-nasulf-na asc-c oral solution reconstituted 100 gm CE N7 (NF)
PEG-PREP ORAL KIT 5-210 MG-GM (bisacodyl-peg-kcl-
nabicar-nacl)
CE
N7 (NP); N8 ($0 copay for
members age 45 through
75); AL (Min 45 Years and
Max 75 Years)
PLENVU ORAL SOLUTION RECONSTITUTED 140 GM
(peg-kcl-nacl-nasulf-na asc-c)
CE
N7 (NF); N8 ($0 copay for
members age 45 through 75,
otherwise not covered)
SUPREP BOWEL PREP KIT ORAL SOLUTION 17.5-3.13-
1.6 GM/177ML (na sulfate-k sulfate-mg sulf)
NF
SUTAB ORAL TABLET 1479-225-188 MG (sodium sulfate-
mag sulfate-kcl)
CE
N7 (NF); N8 ($0 copay for
members age 45 through 75,
otherwise not covered)
MISCELLANEOUS
BYLVAY (PELLETS) ORAL CAPSULE SPRINKLE 200
MCG, 600 MCG (odevixibat)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
BYLVAY ORAL CAPSULE 1200 MCG, 400 MCG
(odevixibat)
NF
CARAFATE ORAL SUSPENSION 1 GM/10ML (sucralfate) NF
CARAFATE ORAL TABLET 1 GM (sucralfate) NF
CHENODAL ORAL TABLET 250 MG (chenodiol) NPSP PA
CHOLBAM ORAL CAPSULE 250 MG, 50 MG (cholic acid) NPSP PA
GATTEX SUBCUTANEOUS KIT 5 MG (teduglutide
(rdna))
NPSP PA; QL (1 KIT per 30 days)
GIMOTI NASAL SOLUTION 15 MG/ACT (metoclopramide
hcl)
NF
LIVMARLI ORAL SOLUTION 9.5 MG/ML (maralixibat
chloride)
NPSP PA; QL (90 ML per 30 days)
misoprostol oral tablet 100 mcg, 200 mcg PG
MOTEGRITY ORAL TABLET 1 MG, 2 MG (prucalopride
succinate)
NF
MOVANTIK ORAL TABLET 12.5 MG, 25 MG (naloxegol
oxalate)
NF
OCALIVA ORAL TABLET 10 MG, 5 MG (obeticholic acid) NPSP
PA; QL (30 TABLETS per
30 days)
RELISTOR ORAL TABLET 150 MG (methylnaltrexone
bromide)
NF
RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML,
8 MG/0.4ML (methylnaltrexone bromide)
NF
RELTONE ORAL CAPSULE 200 MG, 400 MG (ursodiol) NF
SUCRAID ORAL SOLUTION 8500 UNIT/ML (sacrosidase) NPSP
PA; QL (3 BOTTLES per 25
days)
sucralfate oral suspension 1 gm/10ml NF
sucralfate oral tablet 1 gm PG
N8 (Listing does not include
certain NDCs)
SYMPROIC ORAL TABLET 0.2 MG (naldemedine tosylate) PB PA
ursodiol oral capsule 200 mg, 400 mg NF
ursodiol oral capsule 300 mg PG
ursodiol oral tablet 250 mg, 500 mg NP
XERMELO ORAL TABLET 250 MG (telotristat etiprate) NPSP
PA; QL (90 TABLETS per
30 days)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
PANCREATIC ENZYMES
CREON ORAL CAPSULE DELAYED RELEASE
PARTICLES 12000-38000 UNIT, 24000-76000 UNIT, 3000-
9500 UNIT, 36000-114000 UNIT, 6000-19000 UNIT
(pancrelipase (lip-prot-amyl))
PB
PANCREAZE ORAL CAPSULE DELAYED RELEASE
PARTICLES 10500-35500 UNIT, 16800-56800 UNIT, 21000-
54700 UNIT, 2600-8800 UNIT, 37000-97300 UNIT, 4200-
14200 UNIT (pancrelipase (lip-prot-amyl))
NF
PERTZYE ORAL CAPSULE DELAYED RELEASE
PARTICLES 16000-57500 UNIT, 24000-86250 UNIT, 4000-
14375 UNIT, 8000-28750 UNIT (pancrelipase (lip-prot-amyl))
NF
VIOKACE ORAL TABLET 10440-39150 UNIT, 20880-
78300 UNIT (pancrelipase (lip-prot-amyl))
PB
ZENPEP ORAL CAPSULE DELAYED RELEASE
PARTICLES 10000-32000 UNIT, 15000-47000 UNIT, 20000-
63000 UNIT, 25000-79000 UNIT, 3000-10000 UNIT, 40000-
126000 UNIT, 5000-24000 UNIT (pancrelipase (lip-prot-
amyl))
PB
PROTON PUMP INHIBITORS - DRUGS FOR ULCERS
AND STOMACH ACID
ACIPHEX ORAL TABLET DELAYED RELEASE 20 MG
(rabeprazole sodium)
NF
DEXILANT ORAL CAPSULE DELAYED RELEASE 30
MG, 60 MG (dexlansoprazole)
NF
dexlansoprazole oral capsule delayed release 30 mg, 60 mg NF
esomeprazole magnesium oral capsule delayed release 20 mg, 40
mg
PG
QL (90 CAPSULES per 365
DAYs)
esomeprazole magnesium oral packet 10 mg, 20 mg, 40 mg PG
QL (90 PACKET per 365
DAYs)
esomeprazole magnesium oral tablet delayed release 20 mg PG
Select OTC; QL (90
TABLETS per 365 DAYs)
KONVOMEP ORAL SUSPENSION RECONSTITUTED 2-
84 MG/ML (omeprazole-sodium bicarbonate)
NF
lansoprazole oral capsule delayed release 30 mg PG
QL (90 CAPSULES per 365
DAYs)
lansoprazole oral tablet delayed release dispersible 30 mg NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
NEXIUM 24HR ORAL TABLET DELAYED RELEASE 20
MG (esomeprazole magnesium)
PG
Select OTC; QL (90 tablets
per 365 days)
NEXIUM ORAL CAPSULE DELAYED RELEASE 40 MG
(esomeprazole magnesium)
NF
NEXIUM ORAL PACKET 10 MG, 2.5 MG, 20 MG, 40
MG, 5 MG (esomeprazole magnesium)
NF
omeprazole magnesium oral capsule delayed release 20.6 (20
base) mg
PG
Select OTC; QL (90
CAPSULES per 365 days)
omeprazole magnesium oral tablet delayed release 20 mg PG
Select OTC; QL (90
TABLETS per 365 DAYs)
omeprazole oral capsule delayed release 10 mg, 40 mg PG
QL (90 CAPSULES per 365
days)
omeprazole oral capsule delayed release 20 mg PG
Select OTC; QL (90
CAPSULES per 365 days)
omeprazole-sodium bicarbonate oral capsule 20-1100 mg PG
QL (90 CAPSULES per 365
DAYs)
omeprazole-sodium bicarbonate oral capsule 40-1100 mg NF
omeprazole-sodium bicarbonate oral packet 20-1680 mg, 40-
1680 mg
NF
pantoprazole sodium oral packet 40 mg NF
pantoprazole sodium oral tablet delayed release 20 mg, 40 mg PG
N8 (Listing does not include
certain NDCs); QL (90
TABLETS per 365 days)
PREVACID ORAL CAPSULE DELAYED RELEASE 30
MG (lansoprazole)
NF
PREVACID SOLUTAB ORAL TABLET DELAYED
RELEASE DISPERSIBLE 30 MG (lansoprazole)
NF
PRILOSEC ORAL PACKET 10 MG, 2.5 MG (omeprazole
magnesium)
NF
PRILOSEC OTC ORAL TABLET DELAYED RELEASE
20 MG (omeprazole magnesium)
PG
Select OTC; QL (90
TABLETS per 365 DAYs)
PROTONIX ORAL PACKET 40 MG (pantoprazole sodium) NF
PROTONIX ORAL TABLET DELAYED RELEASE 20
MG, 40 MG (pantoprazole sodium)
NF
qc lansoprazole oral capsule delayed release 15 mg PG
Select OTC; QL (90
CAPSULES per 365 DAYs)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ra omeprazole oral tablet delayed release 20 mg PG
Select OTC; QL (90
TABLETS per 365 days)
rabeprazole sodium oral capsule sprinkle 10 mg NP
QL (90 CAPSULES per 365
DAYs)
rabeprazole sodium oral tablet delayed release 20 mg PG
QL (90 TABLETS per 365
days)
ZEGERID ORAL CAPSULE 40-1100 MG (omeprazole-
sodium bicarbonate)
NF
ZEGERID ORAL PACKET 20-1680 MG, 40-1680 MG
(omeprazole-sodium bicarbonate)
NF
RECTAL, CORTICOSTEROIDS
hydrocortisone (perianal) external cream 2.5 % PG
PROCTOCORT EXTERNAL CREAM 1 % (hydrocortisone) NF
PROCTOFOAM HC EXTERNAL FOAM 1-1 %
(hydrocortisone ace-pramoxine)
PB
hydrocortisone (Proctozone-Hc External Cream 2.5 %) PG
ULCER THERAPY COMBINATIONS
amoxicill-clarithro-lansopraz oral therapy pack 500 & 500 & 30
mg
PG
bismuth/metronidaz/tetracyclin oral capsule 140-125-125 mg PG
HELIDAC THERAPY ORAL (metronid-tetracyc-bis subsal) NF
PYLERA ORAL CAPSULE 140-125-125 MG (bis subcit-
metronid-tetracyc)
PB
TALICIA ORAL CAPSULE DELAYED RELEASE 250-
12.5-10 MG (amoxicill-rifabutin-omeprazole)
PB
GENITOURINARY - DRUGS TO TREAT GENITAL AND
URINARY TRACT CONDITIONS
BENIGN PROSTATIC HYPERPLASIA - DRUGS TO
TREAT ENLARGED PROSTATE
alfuzosin hcl er oral tablet extended release 24 hour 10 mg PG
dutasteride oral capsule 0.5 mg PG
dutasteride-tamsulosin hcl oral capsule 0.5-0.4 mg PG
ENTADFI ORAL CAPSULE 5-5 MG (finasteride-tadalafil) NF
finasteride oral tablet 5 mg PG
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
JALYN ORAL CAPSULE 0.5-0.4 MG (dutasteride-
tamsulosin hcl)
NF
PROSCAR ORAL TABLET 5 MG (finasteride) NP
RAPAFLO ORAL CAPSULE 4 MG, 8 MG (silodosin) NF
silodosin oral capsule 4 mg, 8 mg PG
tamsulosin hcl oral capsule 0.4 mg PG
UROXATRAL ORAL TABLET EXTENDED RELEASE
24 HOUR 10 MG (alfuzosin hcl)
NF
CONTRACEPTIVES - PRODUCTS FOR BIRTH
CONTROL
ENCARE VAGINAL SUPPOSITORY 100 MG (nonoxynol-
9)
CE N7 (Not Covered)
OPTIONS GYNOL II CONTRACEPTIVE VAGINAL GEL
3 % (nonoxynol-9)
CE N7 (Not Covered)
PHEXXI VAGINAL GEL 1.8-1-0.4 % (lactic ac-citric ac-pot
bitart)
CE N7 (NP)
SHUR-SEAL CONTRACEPTIVE VAGINAL GEL 2 %
(nonoxynol-9)
CE N7 (Not Covered)
TODAY SPONGE VAGINAL 1000 MG (nonoxynol-9) CE N7 (Not Covered)
VCF VAGINAL CONTRACEPTIVE VAGINAL FILM 28
% (nonoxynol-9)
CE N7 (Not Covered)
VCF VAGINAL CONTRACEPTIVE VAGINAL FOAM
12.5 % (nonoxynol-9)
CE N7 (Not Covered)
VCF VAGINAL CONTRACEPTIVE VAGINAL GEL 4 %
(nonoxynol-9)
CE N7 (Not Covered)
ERECTILE DYSFUNCTION
CAVERJECT IMPULSE INTRACAVERNOSAL KIT 10
MCG, 20 MCG (alprostadil (vasodilator))
NP
SPC ; QL (6 KITS per 25
days)
CAVERJECT INTRACAVERNOSAL SOLUTION
RECONSTITUTED 40 MCG (alprostadil (vasodilator))
NP
SPC ; QL (6 VIALS per 25
days)
CIALIS ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG
(tadalafil)
NF
EDEX INTRACAVERNOSAL KIT 10 MCG, 20 MCG, 40
MCG (alprostadil (vasodilator))
NP
SPC ; QL (6 VIALS per 25
days)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
MUSE URETHRAL PELLET 1000 MCG, 250 MCG, 500
MCG (alprostadil (vasodilator))
PB
SPC ; QL (6
SUPPOSITORIES per 25
days)
phenylephrine hcl intracavernosal solution 2 mg/2ml NF
quad-mix intracavernosal solution reconstituted 150-10-0.1-1
mg
NF
sildenafil citrate oral tablet 100 mg, 25 mg, 50 mg PG
SPC ; QL (6 TABLETS per
25 DAYs)
STENDRA ORAL TABLET 100 MG, 200 MG, 50 MG
(avanafil)
NF
super quad-mix intracavernosal solution reconstituted 150-20-
0.2-2 mg
NF
tadalafil oral tablet 10 mg, 20 mg PG
SPC ; QL (6 TABLETS per
25 DAYs)
tadalafil oral tablet 2.5 mg PG
SPC ; QL (30 TABLETS per
25 DAYs)
tadalafil oral tablet 5 mg PG
SPC ; QL (30 TABLETS per
25 days)
vardenafil hcl oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg PG
SPC ; QL (6 TABLETS per
25 days)
vardenafil hcl oral tablet dispersible 10 mg PG
VIAGRA ORAL TABLET 100 MG, 25 MG, 50 MG
(sildenafil citrate)
NF
ESTROGENS - DRUGS TO REGULATE FEMALE
HORMONES
FEMRING VAGINAL RING 0.05 MG/24HR, 0.1
MG/24HR (estradiol acetate)
NF
MISCELLANEOUS
bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg PG
ELMIRON ORAL CAPSULE 100 MG (pentosan polysulfate
sodium)
NF
FILSPARI ORAL TABLET 200 MG, 400 MG (sparsentan) NF
LITHOSTAT ORAL TABLET 250 MG (acetohydroxamic
acid)
NF
pot & sod cit-cit ac oral solution 550-500-334 mg/5ml PG
N8 (Listing does not include
certain NDCs)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
potassium citrate er oral tablet extended release 10 meq (1080
mg), 15 meq (1620 mg), 5 meq (540 mg)
PG
PROCYSBI ORAL CAPSULE DELAYED RELEASE 25
MG, 75 MG (cysteamine bitartrate)
NF
PROCYSBI ORAL PACKET 300 MG, 75 MG (cysteamine
bitartrate)
NF
TARPEYO ORAL CAPSULE DELAYED RELEASE 4 MG
(budesonide)
NF
THIOLA EC ORAL TABLET DELAYED RELEASE 100
MG, 300 MG (tiopronin)
NF
THIOLA ORAL TABLET 100 MG (tiopronin) NF
tiopronin oral tablet 100 mg PSP PA
PROGESTINS - DRUGS TO REGULATE FEMALE
HORMONES
ENDOMETRIN VAGINAL INSERT 100 MG
(progesterone)
PB
URINARY ANTISPASMODICS - DRUGS TO TREAT
URINARY INCONTINENCE
darifenacin hydrobromide er oral tablet extended release 24
hour 15 mg, 7.5 mg
NP
DETROL LA ORAL CAPSULE EXTENDED RELEASE
24 HOUR 2 MG, 4 MG (tolterodine tartrate)
NF
DITROPAN XL ORAL TABLET EXTENDED RELEASE
24 HOUR 5 MG (oxybutynin chloride)
NP
ST; QL (30 TABLETS per
25 days)
fesoterodine fumarate er oral tablet extended release 24 hour 4
mg, 8 mg
PG
flavoxate hcl oral tablet 100 mg PG
GELNIQUE TRANSDERMAL GEL 10 % (oxybutynin
chloride)
NF
GEMTESA ORAL TABLET 75 MG (vibegron) PB
ST; QL (30 TABLETS per
25 days)
MYRBETRIQ ORAL SUSPENSION RECONSTITUTED
ER 8 MG/ML (mirabegron)
NF
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24
HOUR 25 MG, 50 MG (mirabegron)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
oxybutynin chloride er oral tablet extended release 24 hour 10
mg, 15 mg, 5 mg
PG
N8 (Listing does not include
certain NDCs)
oxybutynin chloride oral solution 5 mg/5ml NF
oxybutynin chloride oral syrup 5 mg/5ml PG
oxybutynin chloride oral tablet 2.5 mg NF
oxybutynin chloride oral tablet 5 mg PG
solifenacin succinate oral tablet 10 mg, 5 mg PG
tolterodine tartrate er oral capsule extended release 24 hour 2
mg, 4 mg
PG
tolterodine tartrate oral tablet 1 mg, 2 mg PG
TOVIAZ ORAL TABLET EXTENDED RELEASE 24
HOUR 4 MG, 8 MG (fesoterodine fumarate)
NF
trospium chloride er oral capsule extended release 24 hour 60
mg
PG
trospium chloride oral tablet 20 mg PG
VESICARE ORAL TABLET 10 MG, 5 MG (solifenacin
succinate)
NF
VAGINAL ANTI-INFECTIVES - DRUGS TO TREAT
VAGINAL INFECTIONS
clindamycin phosphate vaginal cream 2 % PG
metronidazole vaginal gel 0.75 % PG
miconazole 3 vaginal suppository 200 mg NP
NUVESSA VAGINAL GEL 1.3 % (metronidazole) NF
terconazole vaginal cream 0.4 %, 0.8 % PG
terconazole vaginal suppository 80 mg PG
HEMATOLOGIC - DRUGS TO TREAT BLOOD
DISORDERS
ANTICOAGULANTS - BLOOD THINNERS
dabigatran etexilate mesylate oral capsule 150 mg, 75 mg NF
ELIQUIS DVT/PE STARTER PACK ORAL TABLET
THERAPY PACK 5 MG (apixaban)
PB
ELIQUIS ORAL TABLET 2.5 MG, 5 MG (apixaban) PB
enoxaparin sodium injection solution 300 mg/3ml PG
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
enoxaparin sodium injection solution prefilled syringe 100
mg/ml, 120 mg/0.8ml, 150 mg/ml, 30 mg/0.3ml, 40 mg/0.4ml, 60
mg/0.6ml, 80 mg/0.8ml
PG
fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5
mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml
NP
FRAGMIN SUBCUTANEOUS SOLUTION 10000
UNIT/4ML, 95000 UNIT/3.8ML (dalteparin sodium)
NF
FRAGMIN SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000
UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000
UNIT/0.2ML, 7500 UNIT/0.3ML (dalteparin sodium)
NF
heparin sodium (porcine) injection solution 1000 unit/ml, 10000
unit/ml, 20000 unit/ml, 5000 unit/ml
PG
heparin sodium (porcine) pf injection solution 5000 unit/0.5ml PG
PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG
(dabigatran etexilate mesylate)
NF
PRADAXA ORAL PACKET 110 MG, 150 MG, 20 MG, 30
MG, 40 MG, 50 MG (dabigatran etexilate mesylate)
NF
SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG
(edoxaban tosylate)
NF
warfarin sodium oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4
mg, 5 mg, 6 mg, 7.5 mg
PG LGC
XARELTO ORAL SUSPENSION RECONSTITUTED 1
MG/ML (rivaroxaban)
PB
XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20
MG (rivaroxaban)
PB
XARELTO STARTER PACK ORAL TABLET THERAPY
PACK 15 & 20 MG (rivaroxaban)
PB
BLEEDING DISORDERS AGENTS
ALPHANATE INTRAVENOUS SOLUTION
RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT,
250 UNIT, 500 UNIT (antihemophilic factor-vwf)
NPSP PA
CABLIVI INJECTION KIT 11 MG (caplacizumab-yhdp) NF
COAGADEX INTRAVENOUS SOLUTION
RECONSTITUTED 250 UNIT, 500 UNIT (coagulation
factor x (human))
NPSP PA
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
CORIFACT INTRAVENOUS KIT 1000-1600 UNIT (factor
xiii concentrate human)
NPSP PA
FEIBA INTRAVENOUS SOLUTION RECONSTITUTED
1000 UNIT, 2500 UNIT, 500 UNIT (antiinhibitor coagulant
cmplx)
NF
FIBRYGA INTRAVENOUS SOLUTION
RECONSTITUTED (fibrinogen concentrate (human))
NPSP PA
HUMATE-P INTRAVENOUS SOLUTION
RECONSTITUTED 1000-2400 UNIT, 250-600 UNIT, 500-
1200 UNIT (antihemophilic factor-vwf)
NPSP PA
KCENTRA INTRAVENOUS KIT 1000 UNIT, 500 UNIT
(prothrombin complex conc human)
NPSP PA
NOVOSEVEN RT INTRAVENOUS SOLUTION
RECONSTITUTED 1 MG, 2 MG, 5 MG, 8 MG (coagulation
factor viia recomb)
PSP PA
RIASTAP INTRAVENOUS SOLUTION
RECONSTITUTED (fibrinogen concentrate (human))
NPSP PA
SEVENFACT INTRAVENOUS SOLUTION
RECONSTITUTED 1 MG, 5 MG (coagulation factor viia-
jncw)
PSP PA
TRETTEN INTRAVENOUS SOLUTION
RECONSTITUTED 2000-3125 UNIT (coagulation factor xiii
a-sub)
NPSP PA
VONVENDI INTRAVENOUS SOLUTION
RECONSTITUTED 1300 UNIT, 650 UNIT (von willebrand
factor (recomb))
NF
WILATE INTRAVENOUS KIT 1000-1000 UNIT, 500-500
UNIT (antihemophilic factor-vwf)
NPSP PA
HEMATOPOIETIC GROWTH FACTORS
ARANESP (ALBUMIN FREE) INJECTION SOLUTION
100 MCG/ML, 200 MCG/ML, 25 MCG/ML, 40 MCG/ML,
60 MCG/ML (darbepoetin alfa)
PSP PA
ARANESP (ALBUMIN FREE) INJECTION SOLUTION
PREFILLED SYRINGE 10 MCG/0.4ML, 100 MCG/0.5ML,
150 MCG/0.3ML, 200 MCG/0.4ML, 25 MCG/0.42ML, 300
MCG/0.6ML, 40 MCG/0.4ML, 500 MCG/ML, 60
MCG/0.3ML (darbepoetin alfa)
PSP PA
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
DOPTELET ORAL TABLET 20 MG (avatrombopag
maleate)
PSP
PA; QL (60 TABLETS per
30 days)
EPOGEN INJECTION SOLUTION 10000 UNIT/ML, 2000
UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000
UNIT/ML (epoetin alfa)
NF
FULPHILA SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 6 MG/0.6ML (pegfilgrastim-jmdb)
NF
FYLNETRA SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 6 MG/0.6ML (pegfilgrastim-pbbk)
NF
GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML,
480 MCG/1.6ML (tbo-filgrastim)
NF
GRANIX SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML (tbo-
filgrastim)
NF
LEUKINE INJECTION SOLUTION RECONSTITUTED
250 MCG (sargramostim)
NF
MIRCERA INJECTION SOLUTION PREFILLED
SYRINGE 100 MCG/0.3ML, 120 MCG/0.3ML, 150
MCG/0.3ML, 200 MCG/0.3ML, 30 MCG/0.3ML, 50
MCG/0.3ML, 75 MCG/0.3ML (methoxy peg-epoetin beta)
NF
MULPLETA ORAL TABLET 3 MG (lusutrombopag) NPSP
PA; QL (7 TABLETS per 14
days)
NEULASTA ONPRO SUBCUTANEOUS PREFILLED
SYRINGE KIT 6 MG/0.6ML (pegfilgrastim)
NF
NEULASTA SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 6 MG/0.6ML (pegfilgrastim)
NF
NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480
MCG/1.6ML (filgrastim)
NF
NEUPOGEN INJECTION SOLUTION PREFILLED
SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML (filgrastim)
NF
NIVESTYM INJECTION SOLUTION 300 MCG/ML, 480
MCG/1.6ML (filgrastim-aafi)
PSP PA
NIVESTYM INJECTION SOLUTION PREFILLED
SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML (filgrastim-
aafi)
PSP PA
NPLATE SUBCUTANEOUS SOLUTION
RECONSTITUTED 125 MCG, 250 MCG, 500 MCG
(romiplostim)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
NYVEPRIA SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 6 MG/0.6ML (pegfilgrastim-apgf)
NF
PROCRIT INJECTION SOLUTION 10000 UNIT/ML, 2000
UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000
UNIT/ML, 40000 UNIT/ML (epoetin alfa)
PSP PA
PROMACTA ORAL PACKET 12.5 MG (eltrombopag
olamine)
PSP
PA; QL (120 PACKETS per
30 days)
PROMACTA ORAL PACKET 25 MG (eltrombopag
olamine)
PSP
PA; QL (180 PACKETS per
30 days)
PROMACTA ORAL TABLET 12.5 MG, 25 MG
(eltrombopag olamine)
PSP
PA; QL (30 TABLETS per
30 days)
PROMACTA ORAL TABLET 50 MG, 75 MG (eltrombopag
olamine)
PSP
PA; QL (60 TABLETS per
30 days)
RELEUKO INJECTION SOLUTION 300 MCG/ML
(filgrastim-ayow)
NF
releuko injection solution 480 mcg/1.6ml NF
releuko subcutaneous solution prefilled syringe 300 mcg/0.5ml,
480 mcg/0.8ml
NF
RETACRIT INJECTION SOLUTION 10000 UNIT/ML,
2000 UNIT/ML, 20000 UNIT/ML, 3000 UNIT/ML, 4000
UNIT/ML, 40000 UNIT/ML (epoetin alfa-epbx)
PSP PA
ROLVEDON SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE 13.2 MG/0.6ML (eflapegrastim-
xnst)
NF
STIMUFEND SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE 6 MG/0.6ML (pegfilgrastim-fpgk)
NF
UDENYCA SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 6 MG/0.6ML (pegfilgrastim-cbqv)
NF
ZARXIO INJECTION SOLUTION PREFILLED
SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML (filgrastim-
sndz)
NF
ZIEXTENZO SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE 6 MG/0.6ML (pegfilgrastim-bmez)
PSP
PA; QL (2 INJECTIONS
per 28 days)
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Coverage Requirements and
Limits
HEMOPHILIA A AGENTS
ADVATE INTRAVENOUS SOLUTION
RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT,
250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT (antihemophil
factor (rahf-pfm))
PSP PA
adynovate intravenous solution reconstituted 1000 unit, 1500
unit, 2000 unit, 250 unit, 3000 unit, 500 unit, 750 unit
PSP PA
AFSTYLA INTRAVENOUS KIT 1000 UNIT, 1500 UNIT,
2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 500 UNIT
(antihemophil fact single chain)
PSP PA
ALTUVIIIO INTRAVENOUS SOLUTION
RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT,
3000 UNIT, 4000 UNIT, 500 UNIT (antihem fact fc-vwf-xten-
ehtl)
NF
ELOCTATE INTRAVENOUS SOLUTION
RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT,
250 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT, 5000 UNIT,
6000 UNIT, 750 UNIT (antihem fact (bdd-rfviiifc))
PSP PA
ESPEROCT INTRAVENOUS SOLUTION
RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT,
3000 UNIT, 500 UNIT (antihemoph fact rcmb gpeg-exei)
PSP PA
HEMLIBRA SUBCUTANEOUS SOLUTION 105
MG/0.7ML, 150 MG/ML, 30 MG/ML, 60 MG/0.4ML
(emicizumab-kxwh)
NPSP PA
HEMOFIL M INTRAVENOUS SOLUTION
RECONSTITUTED 1000 UNIT, 1700 UNIT, 250 UNIT, 500
UNIT (antihemophilic factor)
NPSP PA
JIVI INTRAVENOUS SOLUTION RECONSTITUTED
1000 UNIT, 2000 UNIT, 3000 UNIT, 500 UNIT (ahf (bdd-
rfviii peg-aucl))
PSP PA
KOATE INTRAVENOUS SOLUTION
RECONSTITUTED 1000 UNIT, 250 UNIT, 500 UNIT
(antihemophilic factor)
NPSP PA
KOATE-DVI INTRAVENOUS SOLUTION
RECONSTITUTED 1000 UNIT, 500 UNIT (antihemophilic
factor)
NPSP PA
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
KOGENATE FS INTRAVENOUS KIT 1000 UNIT, 2000
UNIT, 250 UNIT, 3000 UNIT, 500 UNIT (antihem factor
recomb (rfviii))
PSP PA
KOVALTRY INTRAVENOUS SOLUTION
RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT,
3000 UNIT, 500 UNIT (antihemophil factor (rahf-pfm))
PSP PA
NOVOEIGHT INTRAVENOUS SOLUTION
RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT,
250 UNIT, 3000 UNIT, 500 UNIT (antihemophil fact bd
truncated)
PSP PA
NUWIQ INTRAVENOUS KIT 1000 UNIT, 1500 UNIT,
2000 UNIT, 250 UNIT, 2500 UNIT, 3000 UNIT, 4000 UNIT,
500 UNIT (antihem fact (bdd-rfviii,sim))
PSP PA
NUWIQ INTRAVENOUS SOLUTION
RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT,
250 UNIT, 2500 UNIT, 3000 UNIT, 4000 UNIT, 500 UNIT
(antihem fact (bdd-rfviii,sim))
PSP PA
obizur intravenous solution reconstituted 500 unit NF
RECOMBINATE INTRAVENOUS SOLUTION
RECONSTITUTED 1241-1800 UNIT, 1801-2400 UNIT,
220-400 UNIT, 401-800 UNIT, 801-1240 UNIT (antihem
factor recomb (rfviii))
NPSP PA
XYNTHA INTRAVENOUS KIT 1000 UNIT, 2000 UNIT,
250 UNIT, 500 UNIT (antihem fact (bdd-rfviii,mor))
PSP PA
XYNTHA SOLOFUSE INTRAVENOUS KIT 1000 UNIT,
2000 UNIT, 250 UNIT, 3000 UNIT, 500 UNIT (antihem fact
(bdd-rfviii,mor))
PSP PA
HEMOPHILIA B AGENTS
ALPHANINE SD INTRAVENOUS SOLUTION
RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT
(coagulation factor ix)
NPSP PA
ALPROLIX INTRAVENOUS SOLUTION
RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT,
3000 UNIT, 4000 UNIT, 500 UNIT (coagulation factor ix
(rfixfc))
PSP PA
BENEFIX INTRAVENOUS KIT 1000 UNIT, 2000 UNIT,
250 UNIT, 3000 UNIT, 500 UNIT (coagulation factor ix
(recomb))
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
IDELVION INTRAVENOUS SOLUTION
RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT,
3500 UNIT, 500 UNIT (coagulation factor ix (rix-fp))
NPSP PA
IXINITY INTRAVENOUS SOLUTION
RECONSTITUTED 1000 UNIT, 1500 UNIT, 2000 UNIT,
250 UNIT, 3000 UNIT, 500 UNIT (coagulation factor ix
(recomb))
NF
PROFILNINE INTRAVENOUS SOLUTION
RECONSTITUTED 1000 UNIT, 1500 UNIT, 500 UNIT
(factor ix complex)
NPSP PA
REBINYN INTRAVENOUS SOLUTION
RECONSTITUTED 1000 UNIT, 2000 UNIT, 3000 UNIT,
500 UNIT (coagulation factor ix glycopeg)
PSP PA
rixubis intravenous solution reconstituted 1000 unit, 2000 unit,
250 unit, 3000 unit, 500 unit
NF
MISCELLANEOUS
AGRYLIN ORAL CAPSULE 0.5 MG (anagrelide hcl) NP
QL (180 CAPSULES per 25
DAYs)
AMICAR ORAL SOLUTION 0.25 GM/ML (aminocaproic
acid)
NF
aminocaproic acid oral solution 0.25 gm/ml PG
aminocaproic acid oral tablet 1000 mg, 500 mg PG
anagrelide hcl oral capsule 0.5 mg PG
QL (180 CAPSULES per 25
days)
anagrelide hcl oral capsule 1 mg PG
QL (90 CAPSULES per 25
days)
cilostazol oral tablet 100 mg, 50 mg PG
QL (60 TABLETS per 25
DAYs)
pentoxifylline er oral tablet extended release 400 mg PG
PYRUKYND ORAL TABLET 20 MG, 5 MG, 50 MG
(mitapivat sulfate)
NF
PYRUKYND TAPER PACK ORAL TABLET THERAPY
PACK 5 MG, 7 X 20 MG & 7 X 5 MG, 7 X 50 MG & 7 X 20
MG (mitapivat sulfate)
NF
TAVALISSE ORAL TABLET 100 MG, 150 MG
(fostamatinib disodium)
PSP
PA; QL (60 TABLETS per
30 days)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
TAVNEOS ORAL CAPSULE 10 MG (avacopan) NPSP
PA; QL (180 CAPSULES
per 30 days)
tranexamic acid oral tablet 650 mg NP
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA
(PNH) AGENTS
EMPAVELI SUBCUTANEOUS SOLUTION 1080
MG/20ML (pegcetacoplan)
PSP
PA; QL (10 VIALS per 30
days)
PLATELET AGGREGATION INHIBITORS - BLOOD
THINNERS
aspirin-dipyridamole er oral capsule extended release 12 hour
25-200 mg
PG
QL (60 CAPSULES per 25
days)
BRILINTA ORAL TABLET 60 MG (ticagrelor) PB
QL (60 TABLETS per 25
DAYs)
BRILINTA ORAL TABLET 90 MG (ticagrelor) PB
QL (60 TABLETS per 25
days)
clopidogrel bisulfate oral tablet 300 mg, 75 mg PG
dipyridamole oral tablet 25 mg, 75 mg PG
QL (120 TABLETS per 25
days)
dipyridamole oral tablet 50 mg PG
QL (240 TABLETS per 25
days)
EFFIENT ORAL TABLET 10 MG, 5 MG (prasugrel hcl) NP
QL (30 TABLETS per 25
days)
PLAVIX ORAL TABLET 75 MG (clopidogrel bisulfate) NF
prasugrel hcl oral tablet 10 mg, 5 mg NP
QL (30 TABLETS per 25
DAYs)
YOSPRALA ORAL TABLET DELAYED RELEASE 325-
40 MG, 81-40 MG (aspirin-omeprazole)
NF
ZONTIVITY ORAL TABLET 2.08 MG (vorapaxar sulfate) NF
SICKLE CELL DISEASE
ENDARI ORAL PACKET 5 GM (glutamine (sickle cell)) PSP
PA; QL (180 PACKETS per
30 days)
OXBRYTA ORAL TABLET 300 MG, 500 MG (voxelotor) NF
OXBRYTA ORAL TABLET SOLUBLE 300 MG (voxelotor) NF
SIKLOS ORAL TABLET 100 MG, 1000 MG (hydroxyurea) PB
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
VITAMINS - VITAMINS AND SUPPLEMENTS
NASCOBAL NASAL SOLUTION 500 MCG/0.1ML
(cyanocobalamin)
NF
IMMUNOLOGIC AGENTS - DRUGS TO TREAT
DISORDERS OF THE IMMUNE SYSTEM
ALLERGENIC EXTRACTS
GRASTEK SUBLINGUAL TABLET SUBLINGUAL 2800
BAU (timothy grass pollen allergen)
PB PA
ODACTRA SUBLINGUAL TABLET SUBLINGUAL 12
SQ-HDM (dust mite mixed allergen ext)
NP PA
ORALAIR SUBLINGUAL TABLET SUBLINGUAL 300
IR (grass mix pollens allergen ext)
PSP PA
PALFORZIA (12 MG DAILY DOSE) ORAL 2 X 1 MG &
10 MG (peanut powder-dnfp)
NF
PALFORZIA (120 MG DAILY DOSE) ORAL 20 MG & 100
MG (peanut powder-dnfp)
NF
PALFORZIA (160 MG DAILY DOSE) ORAL 3 X 20 MG &
100 MG (peanut powder-dnfp)
NF
PALFORZIA (20 MG DAILY DOSE) ORAL 20 MG
(peanut powder-dnfp)
NF
PALFORZIA (200 MG DAILY DOSE) ORAL 2 X 100 MG
(peanut powder-dnfp)
NF
PALFORZIA (240 MG DAILY DOSE) ORAL 2 X 20 MG &
2 X 100 MG (peanut powder-dnfp)
NF
PALFORZIA (3 MG DAILY DOSE) ORAL 3 X 1 MG
(peanut powder-dnfp)
NF
PALFORZIA (300 MG MAINTENANCE) ORAL PACKET
300 MG (peanut powder-dnfp)
NF
PALFORZIA (300 MG TITRATION) ORAL PACKET 300
MG (peanut powder-dnfp)
NF
PALFORZIA (40 MG DAILY DOSE) ORAL 2 X 20 MG
(peanut powder-dnfp)
NF
PALFORZIA (6 MG DAILY DOSE) ORAL 6 X 1 MG
(peanut powder-dnfp)
NF
PALFORZIA (80 MG DAILY DOSE) ORAL 4 X 20 MG
(peanut powder-dnfp)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
PALFORZIA INITIAL ESCALATION ORAL 0.5 & 1 & 1.5
& 3 & 6 MG (peanut powder-dnfp)
NF
RAGWITEK SUBLINGUAL TABLET SUBLINGUAL 12
AMB A 1-U (short ragweed pollen ext)
PB PA
AUTOIMMUNE AGENTS (PHYSICIAN-
ADMINISTERED)
ACTEMRA INTRAVENOUS SOLUTION 200 MG/10ML,
400 MG/20ML, 80 MG/4ML (tocilizumab)
NF
AVSOLA INTRAVENOUS SOLUTION
RECONSTITUTED 100 MG (infliximab-axxq)
NF
ENTYVIO INTRAVENOUS SOLUTION
RECONSTITUTED 300 MG (vedolizumab)
NF
IBC (Available as NPSP
with PA for Ulcerative
Colitis)
ILUMYA SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 100 MG/ML (tildrakizumab-asmn)
PSP
PA; QL (1 SYRINGE per
90 days)
INFLECTRA INTRAVENOUS SOLUTION
RECONSTITUTED 100 MG (infliximab-dyyb)
NF
infliximab intravenous solution reconstituted 100 mg NF
ORENCIA INTRAVENOUS SOLUTION
RECONSTITUTED 250 MG (abatacept)
NF
REMICADE INTRAVENOUS SOLUTION
RECONSTITUTED 100 MG (infliximab)
PSP
PA; QL (5 VIALS per 42
days)
RENFLEXIS INTRAVENOUS SOLUTION
RECONSTITUTED 100 MG (infliximab-abda)
NF
SIMPONI ARIA INTRAVENOUS SOLUTION 50
MG/4ML (golimumab)
PSP
PA; QL (200 MG per 56
days)
AUTOIMMUNE AGENTS (SELF-ADMINISTERED)
ACTEMRA ACTPEN SUBCUTANEOUS SOLUTION
AUTO-INJECTOR 162 MG/0.9ML (tocilizumab)
NF
ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 162 MG/0.9ML (tocilizumab)
NF
AMJEVITA SUBCUTANEOUS SOLUTION AUTO-
INJECTOR 40 MG/0.8ML (adalimumab-atto)
NPSP
PA; N8 (Listing does not
include certain NDCs); QL
(4 PENS per 28 DAYs)
AMJEVITA SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 20 MG/0.4ML, 40 MG/0.8ML (adalimumab-atto)
NPSP
PA; QL (4 INJECTIONS
per 28 DAYs)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
CIMZIA STARTER KIT SUBCUTANEOUS PREFILLED
SYRINGE KIT 6 X 200 MG/ML (certolizumab pegol)
PSP
PA; ST; IBC (Preferred
agent for Non-
radiographical Axial
Spondyloarthritis and
preferred agent for
Ankylosing Spondylitis,
Crohn's, Psoriasis, Psoriatic
Arthritis, and Rheumatoid
Arthritis after the failure of
two preferred agents.); QL
(1 KIT per 28 days)
CIMZIA SUBCUTANEOUS PREFILLED SYRINGE KIT
2 X 200 MG/ML (certolizumab pegol)
PSP
PA; ST; IBC (Preferred
agent for Non-
radiographical Axial
Spondyloarthritis and
preferred agent for
Ankylosing Spondylitis,
Crohn's, Psoriasis, Psoriatic
Arthritis, and Rheumatoid
Arthritis after the failure of
two preferred agents.); QL
(2 KITS per 28 Days)
COSENTYX (300 MG DOSE) SUBCUTANEOUS
SOLUTION PREFILLED SYRINGE 150 MG/ML
(secukinumab)
PSP
PA; ST; IBC (Preferred
agent for Ankylosing
Spondylitis, Psoriatic
Arthritis and Non-
radiographical Axial
Spondyloarthritis. Not
covered for Psoriasis); QL (1
BOX per 28 days)
COSENTYX SENSOREADY (300 MG) SUBCUTANEOUS
SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab)
PSP
PA; ST; IBC (Preferred
agent for Ankylosing
Spondylitis, Psoriatic
Arthritis and Non-
radiographical Axial
Spondyloarthritis. Not
covered for Psoriasis); QL (1
BOX per 28 days)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
COSENTYX SENSOREADY PEN SUBCUTANEOUS
SOLUTION AUTO-INJECTOR 150 MG/ML (secukinumab)
PSP
PA; ST; IBC (Preferred
agent for Ankylosing
Spondylitis, Psoriatic
Arthritis and Non-
radiographical Axial
Spondyloarthritis. Not
covered for Psoriasis); QL (1
BOX per 28 days)
COSENTYX SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 150 MG/ML (secukinumab)
PSP
PA; ST; IBC (Preferred
agent for Ankylosing
Spondylitis, Psoriatic
Arthritis and Non-
radiographical Axial
Spondyloarthritis. Not
covered for Psoriasis); QL (1
BOX per 28 days)
COSENTYX SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 75 MG/0.5ML (secukinumab)
PSP
PA; ST; IBC (Preferred
agent for Ankylosing
Spondylitis, Psoriatic
Arthritis and Non-
radiographical Axial
Spondyloarthritis. Not
covered for Psoriasis); QL (1
SYRINGE per 28 days)
ENBREL MINI SUBCUTANEOUS SOLUTION
CARTRIDGE 50 MG/ML (etanercept)
PSP
PA; ST; IBC (Preferred
agent for all conditions
except Psoriasis); QL (4
CARTRIDGES per 28
days)
ENBREL SUBCUTANEOUS SOLUTION 25 MG/0.5ML
(etanercept)
PSP
PA; ST; IBC (Preferred
agent for all conditions
except Psoriasis); QL (8
VIALS per 28 days)
ENBREL SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 25 MG/0.5ML (etanercept)
PSP
PA; ST; IBC (Preferred
agent for all conditions
except Psoriasis); QL (8
SYRINGES per 28 days)
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Coverage Requirements and
Limits
ENBREL SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 50 MG/ML (etanercept)
PSP
PA; ST; IBC (Preferred
agent for all conditions
except Psoriasis); QL (4
SYRINGES per 28 days)
ENBREL SURECLICK SUBCUTANEOUS SOLUTION
AUTO-INJECTOR 50 MG/ML (etanercept)
PSP
PA; ST; IBC (Preferred
agent for all conditions
except Psoriasis); QL (4
SYRINGES per 28 days)
HUMIRA PEDIATRIC CROHNS START
SUBCUTANEOUS PREFILLED SYRINGE KIT 80
MG/0.8ML, 80 MG/0.8ML & 40MG/0.4ML (adalimumab)
PSP
PA; ST; QL (1 KIT per 28
days)
HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT
40 MG/0.4ML (adalimumab)
PSP
PA; ST; QL (4
INJECTIONS per 28 days)
HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT
40 MG/0.8ML (adalimumab)
PSP
PA; ST; QL (4 PENS per 28
DAYs)
HUMIRA PEN SUBCUTANEOUS PEN-INJECTOR KIT
80 MG/0.8ML (adalimumab)
PSP
PA; ST; QL (1 kit per 28
days)
HUMIRA PEN-CD/UC/HS STARTER SUBCUTANEOUS
PEN-INJECTOR KIT 40 MG/0.8ML, 80 MG/0.8ML
(adalimumab)
PSP
PA; ST; QL (1 KIT per 28
days)
HUMIRA PEN-PS/UV/ADOL HS START
SUBCUTANEOUS PEN-INJECTOR KIT 40 MG/0.8ML
(adalimumab)
PSP
PA; ST; QL (1 KIT per 28
days)
HUMIRA PEN-PSOR/UVEIT STARTER
SUBCUTANEOUS PEN-INJECTOR KIT 80 MG/0.8ML &
40MG/0.4ML (adalimumab)
PSP
PA; ST; QL (1 KIT per 28
days)
HUMIRA SUBCUTANEOUS PREFILLED SYRINGE
KIT 10 MG/0.1ML (adalimumab)
PSP
PA; ST; QL (2
INJECTIONS per 28 days)
HUMIRA SUBCUTANEOUS PREFILLED SYRINGE
KIT 20 MG/0.2ML, 40 MG/0.4ML, 40 MG/0.8ML
(adalimumab)
PSP
PA; ST; QL (4
INJECTIONS per 28 days)
KEVZARA SUBCUTANEOUS SOLUTION AUTO-
INJECTOR 150 MG/1.14ML, 200 MG/1.14ML (sarilumab)
PSP
PA; ST; IBC (Preferred
agent for Rheumatoid
Arthritis); QL (2 PENS per
28 days)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
KEVZARA SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 150 MG/1.14ML, 200 MG/1.14ML (sarilumab)
PSP
PA; ST; IBC (Preferred
agent for Rheumatoid
Arthritis); QL (2
SYRINGES per 28 days)
KINERET SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 100 MG/0.67ML (anakinra)
NF
OLUMIANT ORAL TABLET 1 MG, 2 MG, 4 MG
(baricitinib)
NF
ORENCIA CLICKJECT SUBCUTANEOUS SOLUTION
AUTO-INJECTOR 125 MG/ML (abatacept)
PSP
PA; ST; IBC (Preferred
agent for Rheumatoid
Arthritis. Not covered for
other conditions); QL (4
SYRINGES per 28 days)
ORENCIA SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 125 MG/ML, 50 MG/0.4ML, 87.5 MG/0.7ML
(abatacept)
PSP
PA; ST; IBC (Preferred
agent for Rheumatoid
Arthritis. Not covered for
other conditions); QL (4
SYRINGES per 28 days)
OTEZLA ORAL TABLET 30 MG (apremilast) PSP
PA; IBC (Preferred agent
for Psoriasis and Psoriatic
Arthritis); QL (60
TABLETS per 30 days)
OTEZLA ORAL TABLET THERAPY PACK 10 & 20 & 30
MG (apremilast)
PSP
PA; IBC (Preferred agent
for Psoriasis and Psoriatic
Arthritis); QL (55
TABLETS per 28 days)
RINVOQ ORAL TABLET EXTENDED RELEASE 24
HOUR 15 MG (upadacitinib)
PSP
PA; IBC (Preferred agent
for Rheumatoid Arthritis,
Psoriatic Arthritis, Atopic
Dermatitis, Ankylosing
Spondylitis, Ulcerative
Colitis and Non-
radiographical Axial
Spondyloarthritis); QL (30
TABLETS per 30 days)
RINVOQ ORAL TABLET EXTENDED RELEASE 24
HOUR 30 MG (upadacitinib)
PSP
PA; IBC (Preferred agent
for Atopic Dermatitis,
Ulcerative Colitis); QL (30
TABLETS per 30 days)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
RINVOQ ORAL TABLET EXTENDED RELEASE 24
HOUR 45 MG (upadacitinib)
PSP
PA; IBC (Preferred agent
for Ulcerative Colitis); QL
(56 TABLETS per 56
DAYs)
SILIQ SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 210 MG/1.5ML (brodalumab)
NF
SIMPONI SUBCUTANEOUS SOLUTION AUTO-
INJECTOR 100 MG/ML, 50 MG/0.5ML (golimumab)
NF
SIMPONI SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 100 MG/ML, 50 MG/0.5ML (golimumab)
NF
SKYRIZI PEN SUBCUTANEOUS SOLUTION AUTO-
INJECTOR 150 MG/ML (risankizumab-rzaa)
PSP
PA; IBC (Preferred agent
for Psoriasis and Psoriatic
Arthritis); QL (1 SYRINGE
per 84 days)
SKYRIZI SUBCUTANEOUS SOLUTION CARTRIDGE
180 MG/1.2ML (risankizumab-rzaa)
PSP
PA; IBC (Preferred agent
for Crohn's Disease); QL (1
CARTRIDGE per 56
DAYs)
SKYRIZI SUBCUTANEOUS SOLUTION CARTRIDGE
360 MG/2.4ML (risankizumab-rzaa)
PSP
PA; IBC (Preferred agent
for Crohn's Disease); QL (1
CARTRIDGE per 56 days)
SKYRIZI SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 150 MG/ML (risankizumab-rzaa)
PSP
PA; IBC (Preferred agent
for Psoriasis and Psoriatic
Arthritis); QL (1 SYRINGE
per 84 days)
STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5ML
(ustekinumab)
PSP
PA; IBC (Preferred agent
for Crohn's Disease,
Psoriasis, Psoriatic Arthritis,
Ulcerative Colitis); QL (1
SYRINGE per 84 days)
STELARA SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 45 MG/0.5ML (ustekinumab)
PSP
PA; IBC (Preferred agent
for Crohn's Disease,
Psoriasis, Psoriatic Arthritis,
Ulcerative Colitis); QL (1
SYRINGE per 84 days)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
STELARA SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 90 MG/ML (ustekinumab)
PSP
PA; IBC (Preferred agent
for Crohn's Disease,
Psoriasis, Psoriatic Arthritis,
Ulcerative Colitis); QL (1
SYRINGE per 56 days)
TALTZ SUBCUTANEOUS SOLUTION AUTO-
INJECTOR 80 MG/ML (ixekizumab)
PSP
PA; ST; IBC (Preferred
agent for Psoriasis. Not
covered for Psoriatic
Arthritis, Non-
Radiographic Axial
Spondyloarthritis or
Ankylosing Spondylitis); QL
(1 INJECTION per 28 days)
TALTZ SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 80 MG/ML (ixekizumab)
PSP
PA; ST; IBC (Preferred
agent for Psoriasis. Not
covered for Psoriatic
Arthritis, Non-
Radiographic Axial
Spondyloarthritis or
Ankylosing Spondylitis); QL
(1 INJECTION per 28 days)
TREMFYA SUBCUTANEOUS SOLUTION PEN-
INJECTOR 100 MG/ML (guselkumab)
PSP
PA; IBC (Preferred agent
for Psoriasis and Psoriatic
Arthritis); QL (1 ML per 56
DAYs)
TREMFYA SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 100 MG/ML (guselkumab)
PSP
PA; IBC (Preferred agent
for Psoriasis and Psoriatic
Arthritis); QL (1 ML per 56
days)
XELJANZ ORAL SOLUTION 1 MG/ML (tofacitinib citrate) PSP
PA; ST; IBC (Preferred
agent for Rheumatoid
Arthritis, Ulcerative Colitis.
Not covered for Psoriatic
Arthritis, Ankylosing
Spondylitis); QL (240 ML
per 24 days)
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Coverage Requirements and
Limits
XELJANZ ORAL TABLET 10 MG, 5 MG (tofacitinib
citrate)
PSP
PA; ST; IBC (Preferred
agent for Rheumatoid
Arthritis, Ulcerative Colitis.
Not covered for Psoriatic
Arthritis, Ankylosing
Spondylitis); QL (60
TABLETS per 30 days)
XELJANZ XR ORAL TABLET EXTENDED RELEASE 24
HOUR 11 MG, 22 MG (tofacitinib citrate)
PSP
PA; ST; IBC (Preferred
agent for Rheumatoid
Arthritis, Ulcerative Colitis.
Not covered for Psoriatic
Arthritis, Ankylosing
Spondylitis); QL (30
TABLETS per 30 days)
DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS
(DMARDS) - DRUGS TO TREAT RHEUMATOID
ARTHRITIS
hydroxychloroquine sulfate oral tablet 200 mg PG
leflunomide oral tablet 10 mg, 20 mg PG
methotrexate oral tablet 2.5 mg CE N7 (PG)
OTREXUP SUBCUTANEOUS SOLUTION 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 (methotrexate (anti-rheumatic))
NF
RASUVO SUBCUTANEOUS SOLUTION AUTO-
INJECTOR 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, 7.5
MG/0.15ML (methotrexate (anti-rheumatic))
PSP PA; QL (4 ML per 28 days)
REDITREX SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 10 MG/0.4ML, 12.5 MG/0.5ML, 15 MG/0.6ML,
17.5 MG/0.7ML, 20 MG/0.8ML, 22.5 MG/0.9ML, 25
MG/ML, 7.5 MG/0.3ML (methotrexate (anti-rheumatic))
NF
HEREDITARY ANGIOEDEMA
BERINERT INTRAVENOUS KIT 500 UNIT (c1 esterase
inhibitor (human))
NF
CINRYZE INTRAVENOUS SOLUTION
RECONSTITUTED 500 UNIT (c1 esterase inhibitor
(human))
NF
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Coverage Requirements and
Limits
FIRAZYR SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 30 MG/3ML (icatibant acetate)
NF
HAEGARDA SUBCUTANEOUS SOLUTION
RECONSTITUTED 2000 UNIT, 3000 UNIT (c1 esterase
inhibitor (human))
NPSP
PA; QL (20 VIALS per 30
days)
icatibant acetate subcutaneous solution prefilled syringe 30
mg/3ml
PSP
PA; QL (45 SYRINGES per
90 days)
KALBITOR SUBCUTANEOUS SOLUTION 10 MG/ML
(ecallantide)
NPSP PA; QL (30 ML per 90 days)
ORLADEYO ORAL CAPSULE 110 MG, 150 MG
(berotralstat hcl)
PSP
PA; QL (28 CAPSULES per
28 days)
RUCONEST INTRAVENOUS SOLUTION
RECONSTITUTED 2100 UNIT (c1 esterase inhibitor
(recomb))
PSP
PA; QL (60 VIALS per 90
days)
TAKHZYRO SUBCUTANEOUS SOLUTION 300
MG/2ML (lanadelumab-flyo)
PSP PA; QL (2 ML per 28 days)
TAKHZYRO SUBCUTANEOUS SOLUTION
PREFILLED SYRINGE 150 MG/ML, 300 MG/2ML
(lanadelumab-flyo)
PSP
PA; QL (2 SYRINGES per
28 DAYs)
IMMUNOGLOBULIN
ASCENIV INTRAVENOUS SOLUTION 5 GM/50ML
(immune globulin (human)-slra)
NF
BIVIGAM INTRAVENOUS SOLUTION 10 GM/100ML, 5
GM/50ML (immune globulin (human))
NPSP PA
CUTAQUIG SUBCUTANEOUS SOLUTION 1 GM/6ML,
1.65 GM/10ML, 2 GM/12ML, 3.3 GM/20ML, 4 GM/24ML, 8
GM/48ML (immune globulin (human)-hipp)
PSP PA
CUVITRU SUBCUTANEOUS SOLUTION 1 GM/5ML, 10
GM/50ML, 2 GM/10ML, 4 GM/20ML, 8 GM/40ML (immune
globulin (human))
NF
FLEBOGAMMA DIF INTRAVENOUS SOLUTION 0.5
GM/10ML, 10 GM/100ML, 10 GM/200ML, 2.5 GM/50ML,
20 GM/200ML, 20 GM/400ML, 5 GM/100ML, 5 GM/50ML
(immune globulin (human))
NPSP PA
GAMMAGARD INJECTION SOLUTION 1 GM/10ML, 10
GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML,
5 GM/50ML (immune globulin (human))
NPSP PA
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Limits
GAMMAGARD S/D LESS IGA INTRAVENOUS
SOLUTION RECONSTITUTED 10 GM, 5 GM (immune
globulin (human))
NPSP PA
GAMMAKED INJECTION SOLUTION 1 GM/10ML, 10
GM/100ML, 20 GM/200ML, 5 GM/50ML (immune globulin
(human))
NPSP PA
GAMMAPLEX INTRAVENOUS SOLUTION 10
GM/100ML, 10 GM/200ML, 20 GM/200ML, 20 GM/400ML,
5 GM/100ML, 5 GM/50ML (immune globulin (human))
NPSP PA
GAMUNEX-C INJECTION SOLUTION 1 GM/10ML, 10
GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 40 GM/400ML,
5 GM/50ML (immune globulin (human))
NPSP PA
HIZENTRA SUBCUTANEOUS SOLUTION 1 GM/5ML,
10 GM/50ML, 2 GM/10ML, 4 GM/20ML (immune globulin
(human))
NPSP PA
HIZENTRA SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 1 GM/5ML, 2 GM/10ML, 4 GM/20ML (immune
globulin (human))
NPSP PA
HYPERRHO S/D INTRAMUSCULAR SOLUTION
PREFILLED SYRINGE 1500 UNIT, 250 UNIT (rho d
immune globulin)
NPSP
HYPERTET INTRAMUSCULAR SOLUTION
PREFILLED SYRINGE 250 UNIT/ML (tetanus immune
globulin)
NPSP
HYQVIA SUBCUTANEOUS KIT 10 GM/100ML, 2.5
GM/25ML, 20 GM/200ML, 30 GM/300ML, 5 GM/50ML
(immune globulin-hyaluronidase)
NF
IMOGAM RABIES-HT INJECTION SOLUTION 300
UNIT/2ML (rabies immune globulin)
NPSP
kedrab injection solution 1500 unit/10ml, 300 unit/2ml NPSP
MICRHOGAM ULTRA-FILTERED PLUS
INTRAMUSCULAR SOLUTION PREFILLED SYRINGE
250 UNIT (rho d immune globulin)
NPSP
OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10
GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 20
GM/200ML, 30 GM/300ML, 5 GM/100ML, 5 GM/50ML
(immune globulin (human))
NPSP PA
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Limits
PANZYGA INTRAVENOUS SOLUTION 1 GM/10ML, 10
GM/100ML, 2.5 GM/25ML, 20 GM/200ML, 30 GM/300ML,
5 GM/50ML (immune globulin (human)-ifas)
NF
PRIVIGEN INTRAVENOUS SOLUTION 10 GM/100ML,
20 GM/200ML, 40 GM/400ML, 5 GM/50ML (immune
globulin (human))
NPSP PA
RHOGAM ULTRA-FILTERED PLUS
INTRAMUSCULAR SOLUTION PREFILLED SYRINGE
1500 UNIT (rho d immune globulin)
NPSP
RHOPHYLAC INJECTION SOLUTION PREFILLED
SYRINGE 1500 UNIT/2ML (rho d immune globulin)
NPSP
VARIZIG INTRAMUSCULAR SOLUTION 125
UNIT/1.2ML (varicella-zoster immune glob)
NPSP
WINRHO SDF INJECTION SOLUTION 1500
UNIT/1.3ML, 15000 UNIT/13ML, 2500 UNIT/2.2ML, 5000
UNIT/4.4ML (rho d immune globulin)
NPSP
XEMBIFY SUBCUTANEOUS SOLUTION 1 GM/5ML, 10
GM/50ML, 2 GM/10ML, 4 GM/20ML (immune globulin
(human)-klhw)
NF
IMMUNOMODULATORS
ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000
UNIT/0.5ML (interferon gamma-1b)
NPSP PA
ARCALYST SUBCUTANEOUS SOLUTION
RECONSTITUTED 220 MG (rilonacept)
NF
JOENJA ORAL TABLET 70 MG (leniolisib phosphate) NF
IMMUNOSUPPRESSANTS
ATGAM INTRAVENOUS INJECTABLE 50 MG/ML
(lymphocyte,anti-thymo imm glob)
NP
azathioprine oral tablet 100 mg, 50 mg, 75 mg PG
BENLYSTA INTRAVENOUS SOLUTION
RECONSTITUTED 120 MG, 400 MG (belimumab)
NPSP
PA; QL (4 SOLUTION
RECONSTITUTED per 28
days)
BENLYSTA SUBCUTANEOUS SOLUTION AUTO-
INJECTOR 200 MG/ML (belimumab)
NPSP
PA; QL (4 INJECTIONS
per 28 days)
BENLYSTA SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 200 MG/ML (belimumab)
NPSP
PA; QL (4 INJECTIONS
per 28 days)
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Coverage Requirements and
Limits
CELLCEPT INTRAVENOUS INTRAVENOUS
SOLUTION RECONSTITUTED 500 MG (mycophenolate
mofetil hcl)
NF
cyclosporine intravenous solution 50 mg/ml PG
cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg PG
cyclosporine modified oral solution 100 mg/ml PG
cyclosporine oral capsule 100 mg, 25 mg PG
ENSPRYNG SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 120 MG/ML (satralizumab-mwge)
PSP
PA; QL (1 SYRINGE per
28 days)
everolimus oral tablet 0.25 mg, 0.5 mg, 0.75 mg, 1 mg PG
cyclosporine modified (Gengraf Oral Capsule 100 Mg, 25 Mg) PG
cyclosporine modified (Gengraf Oral Solution 100 Mg/Ml) PG
IMURAN ORAL TABLET 50 MG (azathioprine) NP
LUPKYNIS ORAL CAPSULE 7.9 MG (voclosporin) NF
mycophenolate mofetil oral capsule 250 mg PG
mycophenolate mofetil oral suspension reconstituted 200 mg/ml PG
mycophenolate mofetil oral tablet 500 mg PG
mycophenolate sodium oral tablet delayed release 180 mg, 360
mg
PG
NEORAL ORAL CAPSULE 100 MG, 25 MG (cyclosporine
modified)
NPSP
NEORAL ORAL SOLUTION 100 MG/ML (cyclosporine
modified)
NPSP
PROGRAF INTRAVENOUS SOLUTION 5 MG/ML
(tacrolimus)
NPSP
REZUROCK ORAL TABLET 200 MG (belumosudil
mesylate)
NF
SANDIMMUNE INTRAVENOUS SOLUTION 50 MG/ML
(cyclosporine)
NPSP
SANDIMMUNE ORAL CAPSULE 100 MG, 25 MG
(cyclosporine)
NPSP
SANDIMMUNE ORAL SOLUTION 100 MG/ML
(cyclosporine)
NPSP
SIMULECT INTRAVENOUS SOLUTION
RECONSTITUTED 10 MG, 20 MG (basiliximab)
NP
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
sirolimus oral solution 1 mg/ml PG
sirolimus oral tablet 0.5 mg, 1 mg, 2 mg PG
tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg PG
THYMOGLOBULIN INTRAVENOUS SOLUTION
RECONSTITUTED 25 MG (anti-thymocyte glob (rabbit))
NP
MISCELLANEOUS
ILARIS SUBCUTANEOUS SOLUTION 150 MG/ML
(canakinumab)
PSP PA
SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML,
50 MG/0.5ML (palivizumab)
NPSP PA
NUTRITIONAL/SUPPLEMENTS - VITAMINS AND
SUPPLEMENTS
ELECTROLYTES
fluoritab oral solution 0.275 (0.125 f) mg/drop CE
N7 (Not Covered); AL
(Max 5 Years)
potassium chloride (Klor-Con 10 Oral Tablet Extended
Release 10 Meq)
PG
potassium chloride crys er (Klor-Con M10 Oral Tablet
Extended Release 10 Meq)
PG
potassium chloride crys er (Klor-Con M15 Oral Tablet
Extended Release 15 Meq)
PG
potassium chloride crys er (Klor-Con M20 Oral Tablet
Extended Release 20 Meq)
PG
potassium chloride (Klor-Con Oral Packet 20 Meq) NP
potassium chloride (Klor-Con Oral Tablet Extended Release 8
Meq)
PG
N8 (Listing does not include
certain NDCs)
potassium chloride crys er oral tablet extended release 10 meq,
20 meq
PG
potassium chloride er oral capsule extended release 10 meq, 8
meq
PG
potassium chloride er oral tablet extended release 10 meq, 20
meq
PG
potassium chloride er oral tablet extended release 8 meq PG
N8 (Listing does not include
certain NDCs)
potassium chloride oral solution 20 meq/15ml (10%) PG
potassium chloride oral solution 40 meq/15ml (20%) NP
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
sodium fluoride oral solution 1.1 (0.5 f) mg/ml CE
N7 (Not Covered); AL
(Max 5 Years)
sodium fluoride oral tablet 1.1 (0.5 f) mg CE
N7 (Not Covered); AL
(Max 5 Years)
sodium fluoride oral tablet 2.2 (1 f) mg PG
sodium fluoride oral tablet chewable 0.55 (0.25 f) mg, 1.1 (0.5
f) mg
CE
N7 (Not Covered); AL
(Max 5 Years)
sodium fluoride oral tablet chewable 2.2 (1 f) mg PG
PRENATAL VITAMINS
ATABEX EC ORAL TABLET DELAYED RELEASE 29-1
MG (prenatal vit-dss-fe cbn-fa)
NF
azesco oral tablet 13-1 mg NF
CITRANATAL 90 DHA ORAL 90-1 & 300 MG (prenat w/o
a-fecbgl-dss-fa-dha)
NF
CITRANATAL ASSURE ORAL 35-1 & 300 MG (prenat w/o
a-fecbgl-dss-fa-dha)
NF
CITRANATAL B-CALM ORAL 20-1 MG & 2 X 25 MG
(prenat w/o a fecbnfeglu-fa &b6)
NF
CITRANATAL BLOOM ORAL TABLET 90-1 MG
(prenatal-dss-fecb-fegl-fa)
NF
CITRANATAL DHA ORAL 27-1 & 250 MG (prenat w/o a-
fecbgl-dss-fa-dha)
NF
CITRANATAL HARMONY ORAL CAPSULE 27-1-260
MG (prenat-fefmcb-dss-fa-dha w/o a)
NF
CITRANATAL MEDLEY ORAL CAPSULE 27-1-200 MG
(prenat-fecb-fefum-fa-dha w/o a)
NF
complete natal dha oral 29-1-200 & 200 mg NF
completenate oral tablet chewable 29-1 mg NF
CONCEPT OB ORAL CAPSULE 130-92.4-1 MG (prenat w/o
a vit-fefum-fepo-fa)
NF
DUET DHA 400 ORAL 25-1 & 400 MG (prenat-fepoly-fered-
fa-omega 3)
NF
DUET DHA BALANCED ORAL 25-1 & 267 MG (prenat-
fepoly-fered-fa-omega 3)
NF
ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa-
omega)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
FOLIVANE-OB ORAL CAPSULE 85-1 MG (prenat w/o a
vit-fefum-fepo-fa)
NF
INATAL GT ORAL TABLET (prenatal vit-dss-fe cbn-fa) PG
jenliva prenatal/postnatal oral capsule 1 mg NF
kosher prenatal plus iron oral tablet 30-1 mg NF
multi-mac oral tablet 15-0.75-1 mg NF
NATACHEW ORAL TABLET CHEWABLE 28-1 MG
(prenatal vit-fe fum-fe bisg-fa)
NF
natal pnv oral tablet 6-0.5 mg NF
NATALVIT ORAL TABLET (prenatal vit-fe fumarate-fa) NF
NEEVO DHA ORAL CAPSULE 27-1.13 MG (prenat w/oa-
fefum-methf-omegas)
NF
neonatal + dha oral 29-1 & 200 mg NF
neonatal 19 oral tablet 1 mg NF
neonatal fe oral tablet 90-1 mg NF
NESTABS DHA ORAL 32-1 MG (prenat-w/oa-fe bisgly-fa-
omega)
NF
NESTABS ONE ORAL CAPSULE 38-1-225 MG (prenat-fe-
methylfol-dha w/o a)
NF
NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o
vit a)
NF
OB COMPLETE ONE ORAL CAPSULE 50-1-476 MG
(prenat-fecbn-feaspgl-fa-fish)
NF
OB COMPLETE ORAL TABLET 50-1.25 MG (prenatal vit-
iron carbonyl-fa)
NF
OB COMPLETE PETITE ORAL CAPSULE 35-5-1-200 MG
(prenat-fecbn-feaspgl-fa-omega)
NF
OB COMPLETE PREMIER ORAL TABLET 30-20-1 MG
(prenatal-fe cbn-fe asp gly-fa)
NF
OB COMPLETE/DHA ORAL CAPSULE 30-10-1-200 MG
(prenat-fecbn-feaspgl-fa-omega)
NF
OBSTETRIX DHA ORAL 29-1 & 387 MG (prenatal-fecbn-
fa-dss-omega 3)
NF
OBSTETRIX ONE ORAL CAPSULE 38-1-225 MG (prenat-
fe-methyl-dss-dha w/o a)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
pnv prenatal plus multivit+dha oral 27-1 & 312 mg NF
pnv tabs 20-1 oral tablet 20-1 mg NF
pnv-dha oral capsule 27-0.6-0.4-300 mg PG
pnv-dha+docusate oral capsule 27-1.25-300 mg NF
pnv-omega oral capsule 28-0.6-0.4-340 mg NF
pregen dha oral capsule 28-1-35 mg NF
pregenna oral tablet 20-1 mg NF
prena 1 true oral 30-1.4 & 300 mg NF
prenaissance oral capsule 29-1.25-325 mg NF
prenaissance plus oral capsule 28-1-250 mg NF
PRENATAL-U ORAL CAPSULE 106.5-1 MG (prenatal w/o
a vit-fe fum-fa)
NF
PRENATE AM ORAL TABLET 1 MG (prenatal ca-b6-b12-
fa-ginger)
NF
PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG
(prenat-feasp-meth-fa-dha w/o a)
NF
PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG
(prenatal-feaspgly-methylfol-fa)
NF
PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400
MG (prenat w/o a-fe-methfol-fa-dha)
NF
PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG
(prenat-fecbn-feasp-meth-fa-dha)
NF
PRENATE ORAL TABLET CHEWABLE 0.6-0.4 MG
(prenat mv-min-methylfolate-fa)
NF
PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG
(prenat-feasp-meth-fa-dha w/o a)
NF
PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400
MG (prenat w/o a-fe-methfol-fa-dha)
NF
prenatvite plus oral tablet 1 mg NF
PRIMACARE ORAL CAPSULE 30-1-470 MG (pren-fe-
meth-fa-omeg w/o a)
NF
PROVIDA OB ORAL CAPSULE 20-20-1.25 MG (prenat w/o
a vit-fefum-fepo-fa)
NF
SELECT-OB ORAL TABLET CHEWABLE 29-0.6-0.4 MG
(prenat vit-fepoly-methylfol-fa)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
SELECT-OB ORAL TABLET CHEWABLE 29-1 MG
(prenatal vit-fe psac cmplx-fa)
NF
SELECT-OB+DHA ORAL 29-1 & 250 MG (prenatal vit-
fepoly-fa-dha)
NF
TARON-C DHA ORAL CAPSULE 35-1 MG (prenat-fefum-
fepo-fa-omega 3)
NF
TRINATE ORAL TABLET (prenatal vit-fe fumarate-fa) PG
tristart dha oral capsule 31-0.6-0.4-200 mg NF
VINATE II ORAL TABLET 29-1 MG (prenatal vit w/ fe bisg-
fa)
NF
VINATE ONE ORAL TABLET 60-1 MG (prenatal vit-fe
fumarate-fa)
NF
virt-pn dha oral capsule 27-0.6-0.4-300 mg NF
VITAFOL FE+ ORAL CAPSULE 90-0.6-0.4-200 MG
(prenat-fe poly-methfol-fa-dha)
NF
VITAFOL GUMMIES ORAL TABLET CHEWABLE 3.33-
0.333-34.8 MG (prenatal vit-fe phos-fa-omega)
NF
VITAFOL STRIPS ORAL FILM 1 MG (prenatal-b6-b12-d3-
folic acid)
NF
VITAFOL ULTRA ORAL CAPSULE 29-0.6-0.4-200 MG
(prenat-fe poly-methfol-fa-dha)
NF
VITAFOL-NANO ORAL TABLET 18-0.6-0.4 MG (prenatal-
fe fum-methf-fa w/o a)
NF
VITAFOL-OB ORAL TABLET (prenatal vit-fe fumarate-fa) NF
VITAFOL-OB+DHA ORAL 65-1 & 250 MG (prenatal mv-
min-fe fum-fa-dha)
NF
VITAFOL-ONE ORAL CAPSULE 29-1-200 MG (prenatal
vit-fepoly-fa-dha)
NF
VITAMEDMD REDICHEW RX ORAL TABLET
CHEWABLE 1.4 MG (prenat-b2-b6-b12-d3-fa)
NF
VITAPEARL ORAL CAPSULE EXTENDED RELEASE
30-1.4-200 MG (prenat-fefum-fered-fa-dha w/oa)
NF
VIVA DHA ORAL CAPSULE 28-1-200 MG (prenatal vit-fe
fum-fa-omega)
NF
wescap-c dha oral capsule 53.5-38-1 mg NF
westgel dha oral capsule 31-0.6-0.4-200 mg NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
zalvit oral tablet 13-1 mg NF
VITAMINS - VITAMINS AND SUPPLEMENTS
ACCRUFER ORAL CAPSULE 30 MG (ferric maltol) NF
ASCOR INTRAVENOUS SOLUTION 25000 MG/50ML
(ascorbic acid)
NF
calcitriol oral capsule 0.25 mcg, 0.5 mcg PG
calcitriol oral solution 1 mcg/ml PG
cyanocobalamin injection solution 1000 mcg/ml PG
b complex-c-folic acid (Dexifol Oral Tablet 5 Mg) NF
doxercalciferol oral capsule 0.5 mcg, 1 mcg, 2.5 mcg PG
N8 (Listing does not include
certain NDCs)
FA-8 ORAL CAPSULE 0.8 MG (folic acid) CE
N7 (Not Covered); QL (100
CAPSULES per 30 days);
AL (Max 55 Years)
FERRO-PLEX ORAL TABLET 115-1 MG (fe fum-fa-c-e-
b12-intrins fact)
NF
FLORIVA ORAL LIQUID 0.25-400 MG-UNIT/ML (sodium
fluoride-vitamin d)
NF
FLORIVA ORAL TABLET CHEWABLE 0.25 MG, 0.5
MG, 1 MG (ped multiple vit-minerals-fl)
NF
folbee plus oral tablet PG
FOLGARD OS ORAL TABLET 500-1.1 MG (multiple vit-
min-calcium-fa)
NF
folic acid oral tablet 400 mcg CE
N7 (Not Covered); QL (100
tablets per 30 days); AL
(Max 55 Years)
folic acid oral tablet 800 mcg CE
N7 (Not Covered); QL (100
TABLETS per 30 DAYs);
AL (Max 55 Years)
na ferric gluc cplx in sucrose intravenous solution 12.5 mg/ml PG
NEPHPLEX RX ORAL TABLET (b complex-c-zn-folic acid) NF
NICOMIDE ORAL TABLET 750-27-2-0.5 MG (niacinamide-
zn-cu-methfo-se-cr)
NF
nicotinamide oral tablet 750-27-2-0.5 mg NF
paricalcitol oral capsule 1 mcg, 2 mcg, 4 mcg PG
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
phytonadione oral tablet 5 mg PG
QL (25 TABLETS per 25
days)
POLY-VI-FLOR ORAL SUSPENSION 0.25 MG/ML
(pediatric multivitamins-fl)
NF
POLY-VI-FLOR/IRON ORAL SUSPENSION 0.25-7
MG/ML (ped multivitamins-fl-iron)
NF
POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE 0.5-
10 MG (ped multivitamins-fl-iron)
NF
QUFLORA FE ORAL TABLET CHEWABLE 0.25 MG
(multi vit-min-fluoride-fe-fa)
NF
QUFLORA FE PEDIATRIC ORAL LIQUID 0.25-9.5
MG/ML (ped multivitamins-fl-iron)
NF
QUFLORA GUMMIES ORAL TABLET CHEWABLE
0.125 MG (pediatric multivitamins-fl)
NF
RENATABS WITH IRON ORAL 1 & 100 MG (b complex-c-
biotin-e-fa-fe cbn)
NF
reno caps oral capsule 1 mg PG Select OTC
TRIFERIC HEMODIALYSIS PACKET 272 MG (ferric
pyrophosphate citrate)
NF
tri-vi-floro oral suspension 0.25 mg/ml NF
VENOFER INTRAVENOUS SOLUTION 20 MG/ML (iron
sucrose)
NPSP
vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut) PG
OPHTHALMIC - DRUGS TO TREAT EYE CONDITIONS
ANTIALLERGICS - DRUGS TO TREAT ALLERGIES
azelastine hcl ophthalmic solution 0.05 % PG
bepotastine besilate ophthalmic solution 1.5 % NF
BEPREVE OPHTHALMIC SOLUTION 1.5 % (bepotastine
besilate)
NF
cromolyn sodium ophthalmic solution 4 % PG
epinastine hcl ophthalmic solution 0.05 % PG
ketotifen fumarate ophthalmic solution 0.025 % PG Select OTC
ZADITOR OPHTHALMIC SOLUTION 0.025 % (ketotifen
fumarate)
PG Select OTC
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ZERVIATE OPHTHALMIC SOLUTION 0.24 % (cetirizine
hcl)
NF
ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMA
ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %, 0.15 %
(brimonidine tartrate)
PB
AZOPT OPHTHALMIC SUSPENSION 1 % (brinzolamide) NF
betaxolol hcl ophthalmic solution 0.5 % PG
BETIMOL OPHTHALMIC SOLUTION 0.25 %, 0.5 %
(timolol hemihydrate)
NF
BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 %
(betaxolol hcl)
NF
bimatoprost ophthalmic solution 0.03 % PG
brimonidine tartrate ophthalmic solution 0.15 % NP
brimonidine tartrate ophthalmic solution 0.2 % PG
brimonidine tartrate-timolol ophthalmic solution 0.2-0.5 % PG
brinzolamide ophthalmic suspension 1 % NF N10 (NP)
carteolol hcl ophthalmic solution 1 % PG
COMBIGAN OPHTHALMIC SOLUTION 0.2-0.5 %
(brimonidine tartrate-timolol)
NF
COSOPT PF OPHTHALMIC SOLUTION 2-0.5 %
(dorzolamide hcl-timolol mal)
NF
dorzolamide hcl ophthalmic solution 2 % PG
dorzolamide hcl-timolol mal ophthalmic solution 22.3-6.8 mg/ml PG
dorzolamide hcl-timolol mal pf ophthalmic solution 2-0.5 % PG
ISTALOL OPHTHALMIC SOLUTION 0.5 % (timolol
maleate)
NF
latanoprost ophthalmic solution 0.005 % PG
levobunolol hcl ophthalmic solution 0.5 % PG
LUMIGAN OPHTHALMIC SOLUTION 0.01 %
(bimatoprost)
NF
pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % PG
RHOPRESSA OPHTHALMIC SOLUTION 0.02 %
(netarsudil dimesylate)
NF
ROCKLATAN OPHTHALMIC SOLUTION 0.02-0.005 %
(netarsudil-latanoprost)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 %
(brinzolamide-brimonidine)
PB
tafluprost (pf) ophthalmic solution 0.0015 % PG
timolol maleate (once-daily) ophthalmic solution 0.5 % NP
timolol maleate (Timolol Maleate Ocudose Ophthalmic
Solution 0.5 %)
NF
timolol maleate ophthalmic gel forming solution 0.25 %, 0.5 % PG
timolol maleate ophthalmic solution 0.25 %, 0.5 % PG
timolol maleate pf ophthalmic solution 0.25 % NF
TIMOPTIC OCUDOSE OPHTHALMIC SOLUTION 0.25
%, 0.5 % (timolol maleate)
NF
TRAVATAN Z OPHTHALMIC SOLUTION 0.004 %
(travoprost)
NF
travoprost (bak free) ophthalmic solution 0.004 % PG
VYZULTA OPHTHALMIC SOLUTION 0.024 %
(latanoprostene bunod)
NF
XELPROS OPHTHALMIC EMULSION 0.005 %
(latanoprost)
NF
ZIOPTAN OPHTHALMIC SOLUTION 0.0015 %
(tafluprost)
PB
ANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS
TO TREAT INFECTIONS AND INFLAMMATION
neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-
0.1
PG
neomycin-polymyxin-dexameth ophthalmic suspension 3.5-
10000-0.1
PG
sulfacetamide-prednisolone ophthalmic solution 10-0.23 % PG
TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 %
(tobramycin-dexamethasone)
NF
TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 %
(tobramycin-dexamethasone)
NF
TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 %
(tobramycin-dexamethasone)
NF
tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % PG
ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 %
(loteprednol-tobramycin)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ANTI-INFECTIVES - DRUGS TO TREAT INFECTIONS
AZASITE OPHTHALMIC SOLUTION 1 % (azithromycin) NF
bacitracin ophthalmic ointment 500 unit/gm PG
bacitracin-polymyxin b ophthalmic ointment 500-10000 unit/gm PG
BESIVANCE OPHTHALMIC SUSPENSION 0.6 %
(besifloxacin hcl)
NF N10 (NP)
CILOXAN OPHTHALMIC OINTMENT 0.3 %
(ciprofloxacin hcl)
NF
ciprofloxacin hcl ophthalmic solution 0.3 % PG
erythromycin ophthalmic ointment 5 mg/gm PG
gatifloxacin ophthalmic solution 0.5 % NP
gentamicin sulfate ophthalmic solution 0.3 % PG QL (20 ML per 25 days)
KLARITY-A OPHTHALMIC SOLUTION 1 %
(azithromycin)
NF
levofloxacin ophthalmic solution 1.5 % NF
moxifloxacin hcl (2x day) ophthalmic solution 0.5 % PG
moxifloxacin hcl ophthalmic solution 0.5 % PG
ofloxacin ophthalmic solution 0.3 % PG
polymyxin b-trimethoprim ophthalmic solution 10000-0.1
unit/ml-%
PG
sulfacetamide sodium ophthalmic ointment 10 % PG
sulfacetamide sodium ophthalmic solution 10 % PG
tobramycin ophthalmic solution 0.3 % PG
trifluridine ophthalmic solution 1 % PG
ZIRGAN OPHTHALMIC GEL 0.15 % (ganciclovir) NF N10 (NP)
ZYMAXID OPHTHALMIC SOLUTION 0.5 %
(gatifloxacin)
NF
ANTI-INFLAMMATORIES - DRUGS TO TREAT
INFLAMMATION
ACUVAIL OPHTHALMIC SOLUTION 0.45 % (ketorolac
tromethamine)
NF
ALREX OPHTHALMIC SUSPENSION 0.2 % (loteprednol
etabonate)
NF
bromfenac sodium (once-daily) ophthalmic solution 0.09 % NP
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
BROMSITE OPHTHALMIC SOLUTION 0.075 %
(bromfenac sodium)
NF
dexamethasone sodium phosphate ophthalmic solution 0.1 % PG
diclofenac sodium ophthalmic solution 0.1 % PG
difluprednate ophthalmic emulsion 0.05 % PG
EYSUVIS OPHTHALMIC SUSPENSION 0.25 %
(loteprednol etabonate)
NP
PA; QL (2 BOTTLES per 90
days)
FLAREX OPHTHALMIC SUSPENSION 0.1 %
(fluorometholone acetate)
NF
fluorometholone ophthalmic suspension 0.1 % PG
flurbiprofen sodium ophthalmic solution 0.03 % PG
FML FORTE OPHTHALMIC SUSPENSION 0.25 %
(fluorometholone)
NF
FML LIQUIFILM OPHTHALMIC SUSPENSION 0.1 %
(fluorometholone)
NF
ILEVRO OPHTHALMIC SUSPENSION 0.3 % (nepafenac) NF
INVELTYS OPHTHALMIC SUSPENSION 1 % (loteprednol
etabonate)
NF
ketorolac tromethamine ophthalmic solution 0.4 % NP
ketorolac tromethamine ophthalmic solution 0.5 % PG
LOTEMAX OPHTHALMIC GEL 0.5 % (loteprednol
etabonate)
NF
LOTEMAX OPHTHALMIC OINTMENT 0.5 % (loteprednol
etabonate)
NF
LOTEMAX OPHTHALMIC SUSPENSION 0.5 %
(loteprednol etabonate)
NF
LOTEMAX SM OPHTHALMIC GEL 0.38 % (loteprednol
etabonate)
NF
loteprednol etabonate ophthalmic gel 0.5 % NF
loteprednol etabonate ophthalmic suspension 0.5 % PG
MAXIDEX OPHTHALMIC SUSPENSION 0.1 %
(dexamethasone)
NF
NEVANAC OPHTHALMIC SUSPENSION 0.1 %
(nepafenac)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
PRED FORTE OPHTHALMIC SUSPENSION 1 %
(prednisolone acetate)
NF
PRED MILD OPHTHALMIC SUSPENSION 0.12 %
(prednisolone acetate)
NF
prednisolone acetate ophthalmic suspension 1 % PG
PROLENSA OPHTHALMIC SOLUTION 0.07 %
(bromfenac sodium)
NF
DRY EYE DISEASE
CEQUA OPHTHALMIC SOLUTION 0.09 % (cyclosporine) NF
cyclosporine ophthalmic emulsion 0.05 % NF
RESTASIS MULTIDOSE OPHTHALMIC EMULSION
0.05 % (cyclosporine)
PB
RESTASIS OPHTHALMIC EMULSION 0.05 %
(cyclosporine)
PB
XIIDRA OPHTHALMIC SOLUTION 5 % (lifitegrast) PB
MISCELLANEOUS
atropine sulfate ophthalmic solution 1 % PG
CYSTADROPS OPHTHALMIC SOLUTION 0.37 %
(cysteamine hcl)
NF
CYSTARAN OPHTHALMIC SOLUTION 0.44 %
(cysteamine hcl)
NPSP
PA; QL (4 BOTTLES per 28
days)
LACRISERT OPHTHALMIC INSERT 5 MG (artificial tear
insert)
NF
OXERVATE OPHTHALMIC SOLUTION 0.002 %
(cenegermin-bkbj)
NPSP PA; QL (2 ML per 7 DAYs)
tropicamide ophthalmic solution 0.5 %, 1 % PG
TYRVAYA NASAL SOLUTION 0.03 MG/ACT (varenicline
tartrate)
NF
UPNEEQ OPHTHALMIC SOLUTION 0.1 %
(oxymetazoline hcl)
NF
VERKAZIA OPHTHALMIC EMULSION 0.1 %
(cyclosporine)
NF
VISUDYNE INTRAVENOUS SOLUTION
RECONSTITUTED 15 MG (verteporfin)
NPSP PA
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
RETINAL DISORDERS
BYOOVIZ INTRAVITREAL SOLUTION 0.5 MG/0.05ML
(ranibizumab-nuna)
NF
CIMERLI INTRAVITREAL SOLUTION 0.3 MG/0.05ML,
0.5 MG/0.05ML (ranibizumab-eqrn)
NF
EYLEA INTRAVITREAL SOLUTION 2 MG/0.05ML
(aflibercept)
PSP PA
EYLEA INTRAVITREAL SOLUTION PREFILLED
SYRINGE 2 MG/0.05ML (aflibercept)
PSP PA
LUCENTIS INTRAVITREAL SOLUTION 0.3 MG/0.05ML
(ranibizumab)
PSP PA
LUCENTIS INTRAVITREAL SOLUTION PREFILLED
SYRINGE 0.3 MG/0.05ML, 0.5 MG/0.05ML (ranibizumab)
PSP PA
OTHER
IRRIGATION SOLUTIONS
sterile water for irrigation irrigation solution NP STX
RESPIRATORY - DRUGS TO TREAT BREATHING
DISORDERS
ALPHA-1 ANTITRYPSIN DEFICIENCY AGENTS -
DRUGS FOR REPLACEMENT, MODIFICATION,
TREATMENT
ARALAST NP INTRAVENOUS SOLUTION
RECONSTITUTED 1000 MG, 500 MG (alpha1-proteinase
inhibitor)
NF
GLASSIA INTRAVENOUS SOLUTION 1000 MG/50ML
(alpha1-proteinase inhibitor)
NF
PROLASTIN-C INTRAVENOUS SOLUTION 1000
MG/20ML (alpha1-proteinase inhibitor)
PSP PA
PROLASTIN-C INTRAVENOUS SOLUTION
RECONSTITUTED 1000 MG (alpha1-proteinase inhibitor)
PSP PA
ZEMAIRA INTRAVENOUS SOLUTION
RECONSTITUTED 1000 MG (alpha1-proteinase inhibitor)
PSP PA
ANAPHYLAXIS TREATMENT AGENTS
AUVI-Q INJECTION SOLUTION AUTO-INJECTOR 0.1
MG/0.1ML, 0.15 MG/0.15ML, 0.3 MG/0.3ML (epinephrine)
PB
QL (4 INJECTIONS per 25
days)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
epinephrine injection solution auto-injector 0.15 mg/0.15ml PG
QL (4 INJECTIONS per 25
DAYs)
epinephrine injection solution auto-injector 0.15 mg/0.3ml, 0.3
mg/0.3ml
PG
QL (4 SOLUTION AUTO-
INJECTOR per 25 days)
EPINEPHRINESNAP-V INJECTION KIT 1 MG/ML
(epinephrine)
NF
EPIPEN 2-PAK INJECTION SOLUTION AUTO-
INJECTOR 0.3 MG/0.3ML (epinephrine)
PB
QL (4 INJECTIONS per 25
DAYs)
EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-
INJECTOR 0.15 MG/0.3ML (epinephrine)
PB
QL (4 INJECTIONS per 25
DAYs)
SYMJEPI INJECTION SOLUTION PREFILLED
SYRINGE 0.15 MG/0.3ML, 0.3 MG/0.3ML (epinephrine)
NF
ANTICHOLINERGIC/BETA AGONIST
COMBINATIONS - DRUGS TO TREAT COPD
AIRDUO RESPICLICK 113/14 INHALATION AEROSOL
POWDER BREATH ACTIVATED 113-14 MCG/ACT
(fluticasone-salmeterol)
NF
AIRDUO RESPICLICK 232/14 INHALATION AEROSOL
POWDER BREATH ACTIVATED 232-14 MCG/ACT
(fluticasone-salmeterol)
NF
AIRDUO RESPICLICK 55/14 INHALATION AEROSOL
POWDER BREATH ACTIVATED 55-14 MCG/ACT
(fluticasone-salmeterol)
NF
ANORO ELLIPTA INHALATION AEROSOL POWDER
BREATH ACTIVATED 62.5-25 MCG/ACT (umeclidinium-
vilanterol)
PB QL (1 package per 25 days)
BEVESPI AEROSPHERE INHALATION AEROSOL 9-4.8
MCG/ACT (glycopyrrolate-formoterol)
NF
BREZTRI AEROSPHERE INHALATION AEROSOL 160-
9-4.8 MCG/ACT (budeson-glycopyrrol-formoterol)
PB
QL (1 PACKAGE per 25
days)
COMBIVENT RESPIMAT INHALATION AEROSOL
SOLUTION 20-100 MCG/ACT (ipratropium-albuterol)
NP
QL (2 PACKAGES per 25
days)
fluticasone-salmeterol inhalation aerosol powder breath
activated 113-14 mcg/act, 232-14 mcg/act, 55-14 mcg/act
NF
ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml PG
QL (6 BOXES per 25
DAYs)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
STIOLTO RESPIMAT INHALATION AEROSOL
SOLUTION 2.5-2.5 MCG/ACT (tiotropium bromide-
olodaterol)
PB
QL (1 PACKAGE per 25
days)
ANTICHOLINERGIC/BETA AGONIST/STEROID
COMBINATIONS - DRUGS TO TREAT ASTHMA AND
COPD
TRELEGY ELLIPTA INHALATION AEROSOL
POWDER BREATH ACTIVATED 100-62.5-25 MCG/ACT,
200-62.5-25 MCG/ACT (fluticasone-umeclidin-vilant)
PB QL (1 package per 25 days)
ANTICHOLINERGICS
ATROVENT HFA INHALATION AEROSOL SOLUTION
17 MCG/ACT (ipratropium bromide hfa)
NF
INCRUSE ELLIPTA INHALATION AEROSOL POWDER
BREATH ACTIVATED 62.5 MCG/ACT (umeclidinium
bromide)
NF
ipratropium bromide inhalation solution 0.02 % PG QL (5 ML per 25 days)
ipratropium bromide nasal solution 0.03 %, 0.06 % PG
LONHALA MAGNAIR REFILL KIT INHALATION
SOLUTION 25 MCG/ML (glycopyrrolate)
NF
LONHALA MAGNAIR STARTER KIT INHALATION
SOLUTION 25 MCG/ML (glycopyrrolate)
NF
SPIRIVA HANDIHALER INHALATION CAPSULE 18
MCG (tiotropium bromide monohydrate)
PB
QL (1 PACKAGE per 25
DAYs)
SPIRIVA RESPIMAT INHALATION AEROSOL
SOLUTION 1.25 MCG/ACT (tiotropium bromide
monohydrate)
PB
QL (1 PACKAGE per 25
DAYs)
SPIRIVA RESPIMAT INHALATION AEROSOL
SOLUTION 2.5 MCG/ACT (tiotropium bromide
monohydrate)
PB
QL (1 PACKAGE per 25
days)
TUDORZA PRESSAIR INHALATION AEROSOL
POWDER BREATH ACTIVATED 400 MCG/ACT
(aclidinium bromide)
NF
YUPELRI INHALATION SOLUTION 175 MCG/3ML
(revefenacin)
PB QL (30 ML per 25 days)
ANTIHISTAMINE COMBINATIONS
azelastine-fluticasone nasal suspension 137-50 mcg/act PG QL (1 GM per 25 DAYs)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
DYMISTA NASAL SUSPENSION 137-50 MCG/ACT
(azelastine-fluticasone)
NF
RYALTRIS NASAL SUSPENSION 665-25 MCG/ACT
(olopatadine-mometasone)
NF
ANTIHISTAMINES - DRUGS TO TREAT ALLERGIES
ALLEGRA ALLERGY CHILDRENS ORAL
SUSPENSION 30 MG/5ML (fexofenadine hcl)
PG Select OTC
ALLEGRA ALLERGY CHILDRENS ORAL TABLET
DISPERSIBLE 30 MG (fexofenadine hcl)
PG Select OTC
ALLEGRA ALLERGY ORAL TABLET 180 MG, 60 MG
(fexofenadine hcl)
PG Select OTC
allergy relief oral capsule 10 mg PG Select OTC
azelastine hcl nasal solution 0.1 % PG
QL (2 BOTTLES per 25
DAYs)
carbinoxamine maleate oral tablet 4 mg PG
carbinoxamine maleate oral tablet 6 mg NF
cetirizine hcl allergy child oral solution 5 mg/5ml PG Select OTC
cetirizine hcl oral tablet 10 mg, 5 mg PG Select OTC
cetirizine hcl oral tablet chewable 10 mg, 5 mg PG Select OTC
CLARITIN ALLERGY CHILDRENS ORAL SOLUTION
5 MG/5ML (loratadine)
PG Select OTC
CLARITIN ORAL CAPSULE 10 MG (loratadine) PG Select OTC
CLARITIN ORAL TABLET 10 MG (loratadine) PG Select OTC
CLARITIN ORAL TABLET CHEWABLE 10 MG
(loratadine)
PG LGC; Select OTC
CLARITIN ORAL TABLET CHEWABLE 5 MG
(loratadine)
PG Select OTC
CLARITIN REDITABS ORAL TABLET DISPERSIBLE 10
MG, 5 MG (loratadine)
PG Select OTC
clemastine fumarate oral syrup 0.67 mg/5ml NF
cvs allergy relief childrens oral suspension 30 mg/5ml PG Select OTC
cyproheptadine hcl oral syrup 2 mg/5ml PG
cyproheptadine hcl oral tablet 4 mg PG
N8 (Listing does not include
certain NDCs)
desloratadine oral tablet 5 mg PG
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
desloratadine oral tablet dispersible 2.5 mg, 5 mg NP
eq loratadine childrens oral tablet chewable 5 mg PG Select OTC
fexofenadine hcl oral tablet 180 mg PG Select OTC
hydroxyzine hcl oral syrup 10 mg/5ml PG
hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg PG
N8 (Listing does not include
certain NDCs)
hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg PG
KARBINAL ER ORAL SUSPENSION EXTENDED
RELEASE 4 MG/5ML (carbinoxamine maleate)
NP ST
kp fexofenadine hcl oral tablet 60 mg PG Select OTC
levocetirizine dihydrochloride oral tablet 5 mg PG Select OTC
loratadine oral capsule 10 mg PG Select OTC
loratadine oral tablet 10 mg PG Select OTC
olopatadine hcl nasal solution 0.6 % NP
QL (1 BOTTLE per 25
days)
PATANASE NASAL SOLUTION 0.6 % (olopatadine hcl) NP
QL (1 BOTTLE per 25
days)
RYCLORA ORAL SOLUTION 2 MG/5ML
(dexchlorpheniramine maleate)
NF
RYVENT ORAL TABLET 6 MG (carbinoxamine maleate) NF
sm loratadine allergy relief oral tablet dispersible 10 mg PG Select OTC
sm loratadine oral solution 5 mg/5ml PG Select OTC
XYZAL ALLERGY 24HR ORAL TABLET 5 MG
(levocetirizine dihydrochloride)
PG Select OTC
ZYRTEC ALLERGY ORAL CAPSULE 10 MG (cetirizine
hcl)
PG Select OTC
ZYRTEC ALLERGY ORAL TABLET 10 MG (cetirizine
hcl)
PG Select OTC
ZYRTEC CHILDRENS ALLERGY ORAL SOLUTION 1
MG/ML (cetirizine hcl)
PG Select OTC
ZYRTEC CHILDRENS ALLERGY ORAL TABLET
CHEWABLE 2.5 MG (cetirizine hcl)
PG LGC; Select OTC
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
BETA AGONISTS - DRUGS TO TREAT ASTHMA AND
COPD
albuterol sulfate hfa inhalation aerosol solution 108 (90 base)
mcg/act
PG
N8 (Listing does not include
certain NDCs); QL (2 GM
per 25 DAYs)
albuterol sulfate inhalation nebulization solution (2.5 mg/3ml)
0.083%, 0.63 mg/3ml
PG
QL (5 BOXES per 25
DAYs)
albuterol sulfate inhalation nebulization solution 1.25 mg/3ml PG QL (5 BOXES per 25 days)
albuterol sulfate inhalation nebulization solution 2.5 mg/0.5ml PG QL (60 ML per 25 days)
albuterol sulfate oral syrup 2 mg/5ml PG
albuterol sulfate oral tablet 2 mg, 4 mg PG
arformoterol tartrate inhalation nebulization solution 15
mcg/2ml
NF
BROVANA INHALATION NEBULIZATION SOLUTION
15 MCG/2ML (arformoterol tartrate)
NF
formoterol fumarate inhalation nebulization solution 20 mcg/2ml PG
QL (2 BOXES per 25
DAYs)
levalbuterol hcl inhalation nebulization solution 0.31 mg/3ml,
0.63 mg/3ml, 1.25 mg/3ml
PG QL (300 ML per 25 days)
levalbuterol hcl inhalation nebulization solution 1.25 mg/0.5ml PG
QL (45 NEBULIZATION
SOLUTION per 25 days)
levalbuterol tartrate inhalation aerosol 45 mcg/act NP
QL (2 INHALERS per 25
DAYs)
PERFOROMIST INHALATION NEBULIZATION
SOLUTION 20 MCG/2ML (formoterol fumarate)
NP QL (60 VIALS per 25 days)
PROAIR DIGIHALER INHALATION AEROSOL
POWDER BREATH ACTIVATED 108 (90 BASE)
MCG/ACT (albuterol sulfate (sensor))
NF
PROAIR RESPICLICK INHALATION AEROSOL
POWDER BREATH ACTIVATED 108 (90 BASE)
MCG/ACT (albuterol sulfate)
NF
PROVENTIL HFA INHALATION AEROSOL SOLUTION
108 (90 BASE) MCG/ACT (albuterol sulfate)
NF
SEREVENT DISKUS INHALATION AEROSOL
POWDER BREATH ACTIVATED 50 MCG/ACT
(salmeterol xinafoate)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
STRIVERDI RESPIMAT INHALATION AEROSOL
SOLUTION 2.5 MCG/ACT (olodaterol hcl)
PB
QL (1 PACKAGE per 25
DAYs)
terbutaline sulfate oral tablet 2.5 mg, 5 mg PG
N8 (Listing does not include
certain NDCs)
VENTOLIN HFA INHALATION AEROSOL SOLUTION
108 (90 BASE) MCG/ACT (albuterol sulfate)
NF
XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT
(levalbuterol tartrate)
NF
COLD/COUGH
ALLEGRA-D ALLERGY & CONGESTION ORAL
TABLET EXTENDED RELEASE 12 HOUR 60-120 MG
(fexofenadine-pseudoephedrine)
PG Select OTC
ALLEGRA-D ALLERGY & CONGESTION ORAL
TABLET EXTENDED RELEASE 24 HOUR 180-240 MG
(fexofenadine-pseudoephedrine)
PG Select OTC
benzonatate oral capsule 100 mg, 200 mg PG
benzonatate oral capsule 150 mg NP
cetirizine-pseudoephedrine er oral tablet extended release 12
hour 5-120 mg
PG Select OTC
CLARITIN-D 12 HOUR ORAL TABLET EXTENDED
RELEASE 12 HOUR 5-120 MG (loratadine-pseudoephedrine)
PG Select OTC
CLARITIN-D 24 HOUR ORAL TABLET EXTENDED
RELEASE 24 HOUR 10-240 MG (loratadine-
pseudoephedrine)
PG Select OTC
coditussin ac oral liquid 200-10 mg/5ml PG
Select OTC; QL (60 ML per
1 day)
fexofenadine-pseudoephed er oral tablet extended release 12
hour 60-120 mg
PG Select OTC
fexofenadine-pseudoephed er oral tablet extended release 24
hour 180-240 mg
PG Select OTC
HYCODAN ORAL SOLUTION 5-1.5 MG/5ML
(hydrocodone bit-homatrop mbr)
NF
HYCODAN ORAL TABLET 5-1.5 MG (hydrocodone bit-
homatrop mbr)
NF
hydrocod poli-chlorphe poli er oral suspension extended release
10-8 mg/5ml
NP
hydrocodone bit-homatrop mbr oral solution 5-1.5 mg/5ml PG QL (30 ML per 1 day)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
hydrocodone bit-homatrop mbr oral tablet 5-1.5 mg PG QL (6 TABLETS per 1 day)
loratadine-d 24hr oral tablet extended release 24 hour 10-240
mg
PG Select OTC
m-clear wc oral solution 100-6.33 mg/5ml PG Select OTC
promethazine vc oral syrup 6.25-5 mg/5ml PG
promethazine vc/codeine oral syrup 6.25-5-10 mg/5ml PG QL (30 ML per 1 DAY)
promethazine-codeine oral solution 6.25-10 mg/5ml PG QL (30 ML per 1 DAY)
promethazine-dm oral syrup 6.25-15 mg/5ml PG
pseudoeph-bromphen-dm oral syrup 30-2-10 mg/5ml PG
N8 (Listing does not include
certain NDCs)
sm loratadine d 12hr oral tablet extended release 12 hour 5-120
mg
PG Select OTC
TUXARIN ER ORAL TABLET EXTENDED RELEASE
12 HOUR 54.3-8 MG (chlorpheniramine-codeine)
NF
TUZISTRA XR ORAL SUSPENSION EXTENDED
RELEASE 14.7-2.8 MG/5ML (codeine polst-chlorphen polst)
NF
ZYRTEC-D ALLERGY & CONGESTION ORAL TABLET
EXTENDED RELEASE 12 HOUR 5-120 MG (cetirizine-
pseudoephedrine)
PG Select OTC
CYSTIC FIBROSIS
BETHKIS INHALATION NEBULIZATION SOLUTION
300 MG/4ML (tobramycin)
NF
BRONCHITOL INHALATION CAPSULE 40 MG
(mannitol (cystic fibrosis))
NF
CAYSTON INHALATION SOLUTION
RECONSTITUTED 75 MG (aztreonam lysine)
NF
KALYDECO ORAL PACKET 25 MG, 50 MG, 75 MG
(ivacaftor)
NPSP
PA; QL (56 PACKET per
28 days)
KALYDECO ORAL TABLET 150 MG (ivacaftor) NPSP
PA; QL (1 carton per 28
days)
KITABIS PAK INHALATION NEBULIZATION
SOLUTION 300 MG/5ML (tobramycin)
NF
ORKAMBI ORAL PACKET 100-125 MG, 150-188 MG
(lumacaftor-ivacaftor)
NPSP
PA; QL (56 PACKET per
28 days)
ORKAMBI ORAL PACKET 75-94 MG (lumacaftor-
ivacaftor)
NPSP
PA; QL (56 PACKETS per
28 days)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG
(lumacaftor-ivacaftor)
NPSP
PA; QL (112 TABLETS per
28 days)
PULMOZYME INHALATION SOLUTION 2.5 MG/2.5ML
(dornase alfa)
NPSP
PA; QL (150 ML per 30
Days)
SYMDEKO ORAL TABLET THERAPY PACK 100-150 &
150 MG, 50-75 & 75 MG (tezacaftor-ivacaftor)
NPSP
PA; QL (56 TABLETS per
28 days)
TOBI INHALATION NEBULIZATION SOLUTION 300
MG/5ML (tobramycin)
NF
TOBI PODHALER INHALATION CAPSULE 28 MG
(tobramycin)
NF
tobramycin inhalation nebulization solution 300 mg/4ml PSP
PA; QL (224 ML per 28
DAYs)
tobramycin inhalation nebulization solution 300 mg/5ml PSP
PA; QL (280 ML per 28
days)
TRIKAFTA ORAL TABLET THERAPY PACK 100-50-75
& 150 MG, 50-25-37.5 & 75 MG (elexacaftor-tezacaftor-
ivacaft)
NPSP
PA; QL (84 TABLETS per
28 days)
TRIKAFTA ORAL THERAPY PACK 100-50-75 & 75 MG,
80-40-60 & 59.5 MG (elexacaftor-tezacaftor-ivacaft)
NPSP PA
LEUKOTRIENE MODIFIERS
zileuton er oral tablet extended release 12 hour 600 mg NF N10 (NP)
ZYFLO ORAL TABLET 600 MG (zileuton) NF
LEUKOTRIENE RECEPTOR ANTAGONISTS - DRUGS
TO TREAT ASTHMA AND ALLERGIES
montelukast sodium oral packet 4 mg PG
montelukast sodium oral tablet 10 mg PG
montelukast sodium oral tablet chewable 4 mg, 5 mg PG
SINGULAIR ORAL PACKET 4 MG (montelukast sodium) NF
SINGULAIR ORAL TABLET 10 MG (montelukast sodium) NF
SINGULAIR ORAL TABLET CHEWABLE 4 MG, 5 MG
(montelukast sodium)
NF
zafirlukast oral tablet 10 mg, 20 mg PG
MAST CELL STABILIZERS - DRUGS TO TREAT
ALLERGIES
cromolyn sodium inhalation nebulization solution 20 mg/2ml PG
QL (2 BOXES per 25
DAYs)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
MISCELLANEOUS
acetylcysteine inhalation solution 10 %, 20 % PG
DALIRESP ORAL TABLET 250 MCG, 500 MCG
(roflumilast)
NF
roflumilast oral tablet 250 mcg, 500 mcg PG
sodium chloride inhalation nebulization solution 10 %, 3 % PG
NASAL STEROIDS - DRUGS TO TREAT ALLERGIES
BECONASE AQ NASAL SUSPENSION 42 MCG/SPRAY
(beclomethasone diprop monohyd)
NF
budesonide nasal suspension 32 mcg/act PG
Select OTC; QL (2 packages
per 25 days)
FLONASE ALLERGY RELIEF NASAL SUSPENSION 50
MCG/ACT (fluticasone propionate)
PG
Select OTC; QL (1 ML per
25 DAYs)
flunisolide nasal solution 25 mcg/act (0.025%) PG
QL (3 CONTAINERS per
25 DAYs)
fluticasone propionate nasal suspension 50 mcg/act PG
Select OTC; QL (1 ML per
25 DAYs)
mometasone furoate nasal suspension 50 mcg/act PG
QL (2 PACKAGES per 25
days)
NASACORT ALLERGY 24HR NASAL AEROSOL 55
MCG/ACT (triamcinolone acetonide)
PG
Select OTC; QL (1
PACKAGE per 25 DAYs)
OMNARIS NASAL SUSPENSION 50 MCG/ACT
(ciclesonide)
NF
QNASL CHILDRENS NASAL AEROSOL SOLUTION 40
MCG/ACT (beclomethasone diprop (nasal))
NF
QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT
(beclomethasone diprop (nasal))
NF
triamcinolone acetonide nasal aerosol 55 mcg/act PG
Select OTC; QL (1 ML per
25 DAYs)
XHANCE NASAL EXHALER SUSPENSION 93
MCG/ACT (fluticasone propionate)
NP
PA; QL (2 PACKAGES per
25 days)
ZETONNA NASAL AEROSOL SOLUTION 37 MCG/ACT
(ciclesonide)
NF
PULMONARY FIBROSIS AGENTS
ESBRIET ORAL CAPSULE 267 MG (pirfenidone) NF
ESBRIET ORAL TABLET 267 MG, 801 MG (pirfenidone) NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
OFEV ORAL CAPSULE 100 MG, 150 MG (nintedanib
esylate)
PSP
PA; QL (60 CAPSULES per
30 days)
pirfenidone oral capsule 267 mg PSP
PA; QL (270 CAPSULES
per 30 DAYs)
pirfenidone oral tablet 267 mg PSP
PA; QL (270 TABLETS per
30 Days)
pirfenidone oral tablet 534 mg NF
pirfenidone oral tablet 801 mg PSP
PA; QL (90 TABLETS per
30 Days)
SEVERE ASTHMA AGENTS
DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 100 MG/0.67ML (dupilumab)
PSP
PA; QL (2 SYRINGES per
28 Days)
FASENRA PEN SUBCUTANEOUS SOLUTION AUTO-
INJECTOR 30 MG/ML (benralizumab)
PSP
PA; QL (1 ML per 56
DAYs)
FASENRA SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 30 MG/ML (benralizumab)
PSP PA; QL (1 ML per 56 days)
NUCALA SUBCUTANEOUS SOLUTION AUTO-
INJECTOR 100 MG/ML (mepolizumab)
PSP PA; QL (3 ML per 28 days)
NUCALA SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 100 MG/ML (mepolizumab)
PSP PA; QL (3 ML per 28 days)
NUCALA SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 40 MG/0.4ML (mepolizumab)
PSP
PA; QL (1 SYRINGE per
28 DAYs)
NUCALA SUBCUTANEOUS SOLUTION
RECONSTITUTED 100 MG (mepolizumab)
NF
TEZSPIRE SUBCUTANEOUS SOLUTION AUTO-
INJECTOR 210 MG/1.91ML (tezepelumab-ekko)
PSP PA; QL (1 PEN per 28 days)
XOLAIR SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 150 MG/ML (omalizumab)
PSP
PA; QL (8 SYRINGES per
28 days)
XOLAIR SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 75 MG/0.5ML (omalizumab)
PSP PA; QL (2 ML per 28 days)
XOLAIR SUBCUTANEOUS SOLUTION
RECONSTITUTED 150 MG (omalizumab)
PSP
PA; QL (8 VIALS per 28
days)
STEROID INHALANTS - DRUGS TO TREAT ASTHMA
ALVESCO INHALATION AEROSOL SOLUTION 160
MCG/ACT, 80 MCG/ACT (ciclesonide)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ARMONAIR DIGIHALER INHALATION AEROSOL
POWDER BREATH ACTIVATED 113 MCG/ACT, 232
MCG/ACT, 55 MCG/ACT (fluticasone propionate(sensor))
NF
ARNUITY ELLIPTA INHALATION AEROSOL
POWDER BREATH ACTIVATED 100 MCG/ACT, 200
MCG/ACT, 50 MCG/ACT (fluticasone furoate)
NF
ASMANEX (120 METERED DOSES) INHALATION
AEROSOL POWDER BREATH ACTIVATED 220
MCG/ACT (mometasone furoate)
NF
ASMANEX (30 METERED DOSES) INHALATION
AEROSOL POWDER BREATH ACTIVATED 110
MCG/ACT, 220 MCG/ACT (mometasone furoate)
NF
ASMANEX (60 METERED DOSES) INHALATION
AEROSOL POWDER BREATH ACTIVATED 220
MCG/ACT (mometasone furoate)
NF
ASMANEX HFA INHALATION AEROSOL 100
MCG/ACT, 200 MCG/ACT, 50 MCG/ACT (mometasone
furoate)
NF
budesonide inhalation suspension 0.25 mg/2ml PG QL (3 ML per 25 days)
budesonide inhalation suspension 0.5 mg/2ml PG QL (2 ML per 25 days)
budesonide inhalation suspension 1 mg/2ml PG QL (1 ML per 25 days)
FLOVENT DISKUS INHALATION AEROSOL POWDER
BREATH ACTIVATED 100 MCG/ACT, 250 MCG/ACT, 50
MCG/ACT (fluticasone propionate (inhal))
NF
FLOVENT HFA INHALATION AEROSOL 110
MCG/ACT, 220 MCG/ACT, 44 MCG/ACT (fluticasone
propionate hfa)
NF
fluticasone propionate hfa inhalation aerosol 110 mcg/act, 220
mcg/act, 44 mcg/act
NF
PULMICORT FLEXHALER INHALATION AEROSOL
POWDER BREATH ACTIVATED 180 MCG/ACT
(budesonide)
PB
QL (2 AEROSOL
POWDER BREATH
ACTIVATED per 25 days)
PULMICORT FLEXHALER INHALATION AEROSOL
POWDER BREATH ACTIVATED 90 MCG/ACT
(budesonide)
PB
QL (3 AEROSOL
POWDER BREATH
ACTIVATED per 25 days)
PULMICORT INHALATION SUSPENSION 0.25
MG/2ML, 0.5 MG/2ML, 1 MG/2ML (budesonide)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
QVAR REDIHALER INHALATION AEROSOL BREATH
ACTIVATED 40 MCG/ACT, 80 MCG/ACT (beclomethasone
diprop hfa)
NF
N8 (Covered for members
age 5 years and younger)
STEROID/BETA-AGONIST COMBINATIONS - DRUGS
TO TREAT ASTHMA AND COPD
ADVAIR DISKUS INHALATION AEROSOL POWDER
BREATH ACTIVATED 100-50 MCG/ACT, 250-50
MCG/ACT, 500-50 MCG/ACT (fluticasone-salmeterol)
PB
QL (1 INHALER per 25
days)
ADVAIR HFA INHALATION AEROSOL 115-21
MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT
(fluticasone-salmeterol)
NF
AIRDUO DIGIHALER INHALATION AEROSOL
POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-
14 MCG/ACT, 55-14 MCG/ACT (fluticasone-
salmeterol(sensor))
NF
BREO ELLIPTA INHALATION AEROSOL POWDER
BREATH ACTIVATED 100-25 MCG/ACT, 200-25
MCG/ACT (fluticasone furoate-vilanterol)
PB
N8 (Listing does not include
certain NDCs); QL (1
package per 25 days)
budesonide-formoterol fumarate inhalation aerosol 160-4.5
mcg/act, 80-4.5 mcg/act
NF
DUAKLIR PRESSAIR INHALATION AEROSOL
POWDER BREATH ACTIVATED 400-12 MCG/ACT
(aclidinium br-formoterol fum)
NF
DULERA INHALATION AEROSOL 100-5 MCG/ACT,
200-5 MCG/ACT, 50-5 MCG/ACT (mometasone furo-
formoterol fum)
NF
fluticasone furoate-vilanterol inhalation aerosol powder breath
activated 100-25 mcg/act, 200-25 mcg/act
NF
fluticasone-salmeterol inhalation aerosol 115-21 mcg/act, 230-
21 mcg/act, 45-21 mcg/act
NF
fluticasone-salmeterol inhalation aerosol powder breath
activated 100-50 mcg/act, 250-50 mcg/act, 500-50 mcg/act
NF
SYMBICORT INHALATION AEROSOL 160-4.5
MCG/ACT, 80-4.5 MCG/ACT (budesonide-formoterol
fumarate)
PB
QL (3 PACKAGES per 25
days)
fluticasone-salmeterol (Wixela Inhub Inhalation Aerosol
Powder Breath Activated 100-50 Mcg/Act, 250-50 Mcg/Act,
500-50 Mcg/Act)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
XANTHINES - DRUGS TO TREAT COPD
THEO-24 ORAL CAPSULE EXTENDED RELEASE 24
HOUR 100 MG, 200 MG, 300 MG, 400 MG (theophylline)
NF
theophylline er oral tablet extended release 12 hour 300 mg, 450
mg
PG
theophylline er oral tablet extended release 24 hour 400 mg, 600
mg
PG
theophylline oral elixir 80 mg/15ml PG
theophylline oral solution 80 mg/15ml PG
TOPICAL - DRUGS TO TREAT EAR AND SKIN
CONDITIONS
DERMATOLOGY, ACNE
ABSORICA LD ORAL CAPSULE 16 MG, 24 MG, 32 MG,
8 MG (isotretinoin micronized)
NF
ABSORICA ORAL CAPSULE 10 MG, 20 MG, 25 MG, 30
MG, 35 MG, 40 MG (isotretinoin)
NF
ACANYA EXTERNAL GEL 1.2-2.5 % (clindamycin phos-
benzoyl perox)
NF
isotretinoin (Accutane Oral Capsule 20 Mg, 30 Mg, 40 Mg) NP PA
ACZONE EXTERNAL GEL 5 %, 7.5 % (dapsone) NF
adapalene external cream 0.1 % NP
PA; QL (45 G per 25 days);
AL (Max 35 Years)
adapalene external gel 0.1 % PG
PA; Select OTC; QL (45 G
per 25 days); AL (Max 35
Years)
adapalene external gel 0.3 % NP
PA; QL (45 G per 25 days);
AL (Max 35 Years)
adapalene external pad 0.1 % NF
adapalene external solution 0.1 % NF
adapalene-benzoyl peroxide external gel 0.1-2.5 %, 0.3-2.5 % PG PA; AL (Max 35 Years)
AKLIEF EXTERNAL CREAM 0.005 % (trifarotene) PB PA
ALTRENO EXTERNAL LOTION 0.05 % (tretinoin) NF
isotretinoin (Amnesteem Oral Capsule 10 Mg, 20 Mg, 40 Mg) NP PA
AMZEEQ EXTERNAL FOAM 4 % (minocycline hcl
micronized)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ARAZLO EXTERNAL LOTION 0.045 % (tazarotene) PB PA; AL (Max 35 Years)
ATRALIN EXTERNAL GEL 0.05 % (tretinoin) NF
tretinoin (Avita External Gel 0.025 %) PG PA; AL (Max 35 Years)
AZELEX EXTERNAL CREAM 20 % (azelaic acid) NF
benzoyl peroxide-erythromycin external gel 5-3 % PG
isotretinoin (Claravis Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40
Mg)
NP PA
CLEOCIN-T EXTERNAL LOTION 1 % (clindamycin
phosphate)
NP QL (60 ML per 25 DAYs)
clindamycin phosphate (Clindacin-P External Swab 1 %) PG
CLINDAGEL EXTERNAL GEL 1 % (clindamycin
phosphate)
NF
clindamycin phos-benzoyl perox external gel 1.2-2.5 % PG
clindamycin phos-benzoyl perox external gel 1-5 %, 1.2-5 % NP
clindamycin phosphate external foam 1 % NP
N8 (Listing does not include
certain NDCs)
clindamycin phosphate external gel 1 % NP
N8 (Listing does not include
certain NDCs); QL (75 G
per 25 days)
clindamycin phosphate external lotion 1 % NP QL (60 ML per 25 days)
clindamycin phosphate external solution 1 % NP QL (60 ML per 25 days)
clindamycin-tretinoin external gel 1.2-0.025 % NP
PA; N8 (Listing does not
include certain NDCs); AL
(Max 35 Years)
dapsone external gel 5 %, 7.5 % PG
DIFFERIN EXTERNAL CREAM 0.1 % (adapalene) NP
PA; QL (45 G per 25 days);
AL (Max 35 Years)
DIFFERIN EXTERNAL GEL 0.1 % (adapalene) PG
PA; Select OTC; QL (45 G
per 25 days); AL (Max 35
Years)
DIFFERIN EXTERNAL GEL 0.3 % (adapalene) NP
PA; QL (45 G per 25 days);
AL (Max 35 Years)
DIFFERIN EXTERNAL LOTION 0.1 % (adapalene) NF
EPIDUO EXTERNAL GEL 0.1-2.5 % (adapalene-benzoyl
peroxide)
PB PA; AL (Max 35 Years)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
EPIDUO FORTE EXTERNAL GEL 0.3-2.5 % (adapalene-
benzoyl peroxide)
PB PA; AL (Max 35 Years)
ery external pad 2 % PG
ERYGEL EXTERNAL GEL 2 % (erythromycin) NP QL (60 G per 25 DAYs)
erythromycin external gel 2 % PG QL (60 G per 25 days)
erythromycin external solution 2 % PG QL (60 ML per 25 days)
FABIOR EXTERNAL FOAM 0.1 % (tazarotene) NF
isotretinoin oral capsule 10 mg, 20 mg, 25 mg, 30 mg, 35 mg, 40
mg
NP PA
KLARON EXTERNAL LOTION 10 % (sulfacetamide
sodium (acne))
NP ST
ONEXTON EXTERNAL GEL 1.2-3.75 % (clindamycin phos-
benzoyl perox)
PB
RETIN-A EXTERNAL CREAM 0.025 %, 0.05 %, 0.1 %
(tretinoin)
NP PA; AL (Max 35 Years)
RETIN-A EXTERNAL GEL 0.01 %, 0.025 % (tretinoin) NP PA; AL (Max 35 Years)
RETIN-A MICRO EXTERNAL GEL 0.04 %, 0.1 %
(tretinoin microsphere)
NP PA; AL (Max 35 Years)
RETIN-A MICRO PUMP EXTERNAL GEL 0.04 %, 0.06
%, 0.08 %, 0.1 % (tretinoin microsphere)
NP PA; AL (Max 35 Years)
sulfacetamide sodium (acne) external lotion 10 % PG
tazarotene external foam 0.1 % NF
tretinoin external cream 0.025 %, 0.05 %, 0.1 % PG PA; AL (Max 35 Years)
tretinoin external gel 0.01 % PG PA; AL (Max 35 Years)
tretinoin external gel 0.05 % NP PA; AL (Max 35 Years)
tretinoin microsphere external gel 0.04 %, 0.1 % PG PA; AL (Max 35 Years)
TWYNEO EXTERNAL CREAM 0.1-3 % (tretinoin-benzoyl
peroxide)
PB
VELTIN EXTERNAL GEL 1.2-0.025 % (clindamycin-
tretinoin)
NF
WINLEVI EXTERNAL CREAM 1 % (clascoterone) PB PA
isotretinoin (Zenatane Oral Capsule 10 Mg, 20 Mg, 30 Mg, 40
Mg)
NP PA
ZIANA EXTERNAL GEL 1.2-0.025 % (clindamycin-
tretinoin)
NF
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
DERMATOLOGY, ACTINIC KERATOSIS
CARAC EXTERNAL CREAM 0.5 % (fluorouracil) NF
fluorouracil external cream 0.5 % NF
fluorouracil external cream 5 % PG
fluorouracil external solution 2 %, 5 % PG
imiquimod external cream 5 % PG QL (2 BOXES per 21 days)
imiquimod pump external cream 3.75 % NP PA
KLISYRI EXTERNAL OINTMENT 1 % (tirbanibulin) NF
ZYCLARA EXTERNAL CREAM 3.75 % (imiquimod) NF
ZYCLARA PUMP EXTERNAL CREAM 2.5 %, 3.75 %
(imiquimod)
NF
DERMATOLOGY, ANTIBIOTICS
gentamicin sulfate external cream 0.1 % PG QL (120 G per 25 days)
gentamicin sulfate external ointment 0.1 % PG QL (120 G per 25 days)
mafenide acetate external packet 5 % PG
mupirocin calcium external cream 2 % NF
mupirocin external ointment 2 % PG QL (30 GM per 25 DAYs)
NEO-SYNALAR EXTERNAL CREAM 0.5-0.025 %
(neomycin-fluocinolone)
NF
silver sulfadiazine external cream 1 % PG
silver sulfadiazine (Ssd External Cream 1 %) PG
XEPI EXTERNAL CREAM 1 % (ozenoxacin) NP PA; QL (30 G per 25 DAYs)
DERMATOLOGY, ANTIFUNGALS
ciclopirox external gel 0.77 % NP
ciclopirox external shampoo 1 % NP
ciclopirox external solution 8 % PG
PA; STX; QL (6.6 ML per
21 days)
ciclopirox olamine external cream 0.77 % PG
ciclopirox olamine external suspension 0.77 % NP
clotrimazole-betamethasone external cream 1-0.05 % PG
STX; QL (60 GM per 25
days)
clotrimazole-betamethasone external lotion 1-0.05 % PG
STX; QL (60 ML per 25
days)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
econazole nitrate external cream 1 % NP QL (85 GM per 25 days)
ECOZA EXTERNAL FOAM 1 % (econazole nitrate) NF
ERTACZO EXTERNAL CREAM 2 % (sertaconazole nitrate) NF
EXELDERM EXTERNAL CREAM 1 % (sulconazole
nitrate)
NP
ST; QL (60 GRAMS per 25
days)
EXELDERM EXTERNAL SOLUTION 1 % (sulconazole
nitrate)
NP ST; QL (60 ML per 25 days)
JUBLIA EXTERNAL SOLUTION 10 % (efinaconazole) NP PA; QL (4 ML per 21 days)
KERYDIN EXTERNAL SOLUTION 5 % (tavaborole) NF
ketoconazole external cream 2 % PG
ketoconazole external foam 2 % NF
LOPROX EXTERNAL SHAMPOO 1 % (ciclopirox) NP ST
LOPROX EXTERNAL SUSPENSION 0.77 % (ciclopirox
olamine)
NF
luliconazole external cream 1 % NF
LUZU EXTERNAL CREAM 1 % (luliconazole) NF
miconazole-zinc oxide-petrolat external ointment 0.25-15-81.35
%
NP
naftifine hcl external cream 1 %, 2 % NP
naftifine hcl external gel 2 % NF
NAFTIN EXTERNAL GEL 1 %, 2 % (naftifine hcl) NF
nystatin external cream 100000 unit/gm PG
nystatin external ointment 100000 unit/gm PG
nystatin-triamcinolone external cream 100000-0.1 unit/gm-% PG
STX; QL (60 GM per 25
days)
nystatin-triamcinolone external ointment 100000-0.1 unit/gm-% PG
STX; QL (60 GM per 25
DAYs)
oxiconazole nitrate external cream 1 % NP
N8 (Listing does not include
certain NDCs); QL (60 G
per 25 days)
OXISTAT EXTERNAL CREAM 1 % (oxiconazole nitrate) NF
OXISTAT EXTERNAL LOTION 1 % (oxiconazole nitrate) NF
sulconazole nitrate external cream 1 % PG
QL (60 GRAMS per 25
days)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
sulconazole nitrate external solution 1 % PG QL (60 ML per 25 days)
tavaborole external solution 5 % NF
VUSION EXTERNAL OINTMENT 0.25-15-81.35 %
(miconazole-zinc oxide-petrolat)
NF
DERMATOLOGY, ANTIPRURITIC
doxepin hcl external cream 5 % NF
PRUDOXIN EXTERNAL CREAM 5 % (doxepin hcl
(antipruritic))
NP ST; QL (45 G per 25 days)
ZONALON EXTERNAL CREAM 5 % (doxepin hcl
(antipruritic))
NP ST; QL (45 G per 25 days)
DERMATOLOGY, ANTIPSORIATICS
acitretin oral capsule 10 mg, 17.5 mg, 25 mg PG
PA; QL (60 CAPSULES per
25 days)
calcipotriene external cream 0.005 % NF
calcipotriene external foam 0.005 % NF
calcipotriene external ointment 0.005 % NP ST; QL (60 GM per 25 days)
calcipotriene external solution 0.005 % NP ST; QL (60 ML per 25 days)
calcitriol external ointment 3 mcg/gm NF
methoxsalen rapid oral capsule 10 mg PG
SORILUX EXTERNAL FOAM 0.005 % (calcipotriene) NF
SOTYKTU ORAL TABLET 6 MG (deucravacitinib) NF
tazarotene external cream 0.1 % PG PA; AL (Max 35 Years)
tazarotene external gel 0.05 %, 0.1 % NF
TAZORAC EXTERNAL CREAM 0.05 %, 0.1 % (tazarotene) NF
TAZORAC EXTERNAL GEL 0.05 %, 0.1 % (tazarotene) NF
VECTICAL EXTERNAL OINTMENT 3 MCG/GM
(calcitriol)
NF
VTAMA EXTERNAL CREAM 1 % (tapinarof) NF
WYNZORA EXTERNAL CREAM 0.005-0.064 %
(calcipotriene-betameth diprop)
NF
ZORYVE EXTERNAL CREAM 0.3 % (roflumilast) NF
DERMATOLOGY, ANTISEBORRHEICS
ketoconazole external shampoo 2 % PG
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
DERMATOLOGY, ATOPIC DERMATITIS
ADBRY SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 150 MG/ML (tralokinumab-ldrm)
PSP
PA; QL (4 SYRINGES per
28 days)
CIBINQO ORAL TABLET 100 MG, 200 MG, 50 MG
(abrocitinib)
PSP
PA; QL (30 TABLETS per
30 days)
DUPIXENT SUBCUTANEOUS SOLUTION PEN-
INJECTOR 200 MG/1.14ML (dupilumab)
PSP
PA; QL (2 PENS per 28
Days)
DUPIXENT SUBCUTANEOUS SOLUTION PEN-
INJECTOR 300 MG/2ML (dupilumab)
PSP
PA; QL (4 PENS per 28
Days)
DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 200 MG/1.14ML (dupilumab)
PSP
PA; QL (2 SYRINGES per
28 Days)
DUPIXENT SUBCUTANEOUS SOLUTION PREFILLED
SYRINGE 300 MG/2ML (dupilumab)
PSP
PA; QL (4 SYRINGES per
28 Days)
OPZELURA EXTERNAL CREAM 1.5 % (ruxolitinib
phosphate)
NP PA; QL (60 G per 28 DAYs)
DERMATOLOGY, CORTICOSTEROIDS
alclometasone dipropionate external cream 0.05 % PG QL (120 GM per 25 DAYs)
alclometasone dipropionate external ointment 0.05 % PG QL (120 GM per 25 DAYs)
amcinonide external lotion 0.1 % NP QL (120 ML per 25 DAYs)
amcinonide external ointment 0.1 % NP
PA; QL (180 GM per 25
DAYs)
APEXICON E EXTERNAL CREAM 0.05 % (diflorasone
diacet emoll base)
NF
betamethasone dipropionate aug external cream 0.05 % PG QL (120 GM per 25 DAYs)
betamethasone dipropionate aug external gel 0.05 % PG QL (120 GM per 25 DAYs)
betamethasone dipropionate aug external lotion 0.05 % PG QL (120 ML per 25 days)
betamethasone dipropionate aug external ointment 0.05 % PG QL (120 GM per 25 DAYs)
betamethasone dipropionate external cream 0.05 % PG QL (120 GM per 25 DAYs)
betamethasone dipropionate external lotion 0.05 % PG QL (120 ML per 25 DAYs)
betamethasone dipropionate external ointment 0.05 % NF
betamethasone valerate external cream 0.1 % NP QL (120 GM per 25 DAYs)
betamethasone valerate external foam 0.12 % NP QL (120 GM per 25 DAYs)
betamethasone valerate external lotion 0.1 % NP QL (120 ML per 25 DAYs)
betamethasone valerate external ointment 0.1 % NP QL (120 GM per 25 DAYs)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
BRYHALI EXTERNAL LOTION 0.01 % (halobetasol
propionate)
PB QL (120 GM per 25 days)
calcipotriene-betameth diprop external ointment 0.005-0.064 % NF
calcipotriene-betameth diprop external suspension 0.005-0.064
%
NF
CAPEX EXTERNAL SHAMPOO 0.01 % (fluocinolone
acetonide)
NF
clobetasol propionate e external cream 0.05 % NP QL (120 GM per 25 DAYs)
clobetasol propionate emulsion external foam 0.05 % NF
clobetasol propionate external cream 0.05 % NP QL (120 GM per 25 DAYs)
clobetasol propionate external foam 0.05 % NP QL (120 GM per 25 days)
clobetasol propionate external gel 0.05 % NP QL (120 GM per 25 DAYs)
clobetasol propionate external liquid 0.05 % NF
clobetasol propionate external lotion 0.05 % NP QL (120 ML per 25 DAYs)
clobetasol propionate external ointment 0.05 % NP QL (120 GM per 25 DAYs)
clobetasol propionate external shampoo 0.05 % NP QL (120 ML per 25 DAYs)
clobetasol propionate external solution 0.05 % NP QL (120 ML per 25 DAYs)
CLOBEX EXTERNAL LOTION 0.05 % (clobetasol
propionate)
NP
PA; QL (180 ML per 25
DAYs)
CLOBEX EXTERNAL SHAMPOO 0.05 % (clobetasol
propionate)
NP
PA; QL (180 ML per 25
DAYs)
CLOBEX SPRAY EXTERNAL LIQUID 0.05 % (clobetasol
propionate)
NF
clocortolone pivalate external cream 0.1 % NF
CLODERM EXTERNAL CREAM 0.1 % (clocortolone
pivalate)
NP
PA; QL (180 GRAMS per
25 days)
CORDRAN EXTERNAL CREAM 0.05 % (flurandrenolide) NF
CORDRAN EXTERNAL LOTION 0.05 % (flurandrenolide) NF
CORDRAN EXTERNAL TAPE 4 MCG/SQCM
(flurandrenolide)
NF
DERMA-SMOOTHE/FS BODY EXTERNAL OIL 0.01 %
(fluocinolone acetonide)
NP
PA; QL (180 ML per 25
DAYs)
DERMA-SMOOTHE/FS SCALP EXTERNAL OIL 0.01 %
(fluocinolone acetonide)
NP
PA; QL (180 ML per 25
DAYs)
desonide external cream 0.05 % NP QL (120 GM per 25 DAYs)
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Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
desonide external gel 0.05 % NF
desonide external lotion 0.05 % NP QL (120 ML per 25 days)
desonide external ointment 0.05 % NP QL (120 GM per 25 DAYs)
DESOWEN EXTERNAL CREAM 0.05 % (desonide) NP
PA; QL (180 GM per 25
DAYs)
desoximetasone external cream 0.05 %, 0.25 % NP QL (120 GM per 25 DAYs)
desoximetasone external gel 0.05 % NP QL (120 GM per 25 DAYs)
desoximetasone external liquid 0.25 % PG QL (120 ML per 25 days)
desoximetasone external ointment 0.05 % NF
desoximetasone external ointment 0.25 % NP QL (120 GM per 25 DAYs)
desonide (Desrx External Gel 0.05 %) NF
diflorasone diacetate external cream 0.05 % NF
diflorasone diacetate external ointment 0.05 % NF
DIPROLENE EXTERNAL OINTMENT 0.05 %
(betamethasone dipropionate aug)
NP
PA; QL (180 GRAMS per
25 days)
DUOBRII EXTERNAL LOTION 0.01-0.045 % (halobetasol
prop-tazarotene)
NF
ENSTILAR EXTERNAL FOAM 0.005-0.064 %
(calcipotriene-betameth diprop)
PB
fluocinolone acetonide body external oil 0.01 % PG QL (120 ML per 25 days)
fluocinolone acetonide external cream 0.01 %, 0.025 % NP QL (120 GM per 25 DAYs)
fluocinolone acetonide external ointment 0.025 % NP QL (120 GM per 25 DAYs)
fluocinolone acetonide external solution 0.01 % PG QL (120 ML per 25 days)
fluocinolone acetonide scalp external oil 0.01 % PG QL (120 ML per 25 days)
fluocinonide emulsified base external cream 0.05 % PG QL (120 GM per 25 DAYs)
fluocinonide external cream 0.05 % NP QL (120 GM per 25 DAYs)
fluocinonide external cream 0.1 % NF
fluocinonide external gel 0.05 % NP QL (120 GM per 25 DAYs)
fluocinonide external ointment 0.05 % NP QL (120 GM per 25 DAYs)
fluocinonide external solution 0.05 % PG QL (120 ML per 25 days)
flurandrenolide external cream 0.05 % NF
flurandrenolide external lotion 0.05 % NF
fluticasone propionate external cream 0.05 % NP QL (120 GM per 25 DAYs)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
216
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
fluticasone propionate external lotion 0.05 % NP QL (120 ML per 25 days)
fluticasone propionate external ointment 0.005 % PG QL (120 GM per 25 DAYs)
halcinonide external cream 0.1 % NF
halobetasol propionate external cream 0.05 % NP QL (120 GM per 25 DAYs)
halobetasol propionate external foam 0.05 % NF
halobetasol propionate external ointment 0.05 % NP QL (120 GM per 25 DAYs)
HALOG EXTERNAL CREAM 0.1 % (halcinonide) NF
HALOG EXTERNAL OINTMENT 0.1 % (halcinonide) NF
HALOG EXTERNAL SOLUTION 0.1 % (halcinonide) NF
hydrocortisone butyr lipo base external cream 0.1 % NF
hydrocortisone butyrate external cream 0.1 % PG QL (120 GM per 25 DAYs)
hydrocortisone butyrate external lotion 0.1 % NF
hydrocortisone butyrate external ointment 0.1 % PG QL (120 GM per 25 DAYs)
hydrocortisone butyrate external solution 0.1 % PG QL (120 ML per 25 DAYs)
hydrocortisone external cream 2.5 % PG QL (120 GM per 25 DAYs)
hydrocortisone external lotion 2.5 % PG QL (120 ML per 25 DAYs)
hydrocortisone external ointment 2.5 % PG QL (120 GM per 25 DAYs)
hydrocortisone valerate external cream 0.2 % PG QL (120 G per 25 days)
hydrocortisone valerate external ointment 0.2 % PG QL (120 G per 25 days)
IMPEKLO EXTERNAL LOTION 0.15 MG/ACT (0.05%)
(clobetasol propionate)
NF
IMPOYZ EXTERNAL CREAM 0.025 % (clobetasol
propionate)
NF
KENALOG EXTERNAL AEROSOL SOLUTION 0.147
MG/GM (triamcinolone acetonide)
NF
LEXETTE EXTERNAL FOAM 0.05 % (halobetasol
propionate)
NF
LOCOID EXTERNAL LOTION 0.1 % (hydrocortisone
butyrate)
NP
PA; QL (180 ML per 25
DAYs)
LOCOID LIPOCREAM EXTERNAL CREAM 0.1 %
(hydrocortisone butyr lipo base)
NP
PA; QL (180 GM per 25
DAYs)
LUXIQ EXTERNAL FOAM 0.12 % (betamethasone valerate) NF
mometasone furoate external cream 0.1 % NP QL (120 GM per 25 DAYs)
mometasone furoate external ointment 0.1 % NP QL (120 GM per 25 DAYs)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
217
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
mometasone furoate external solution 0.1 % PG QL (120 ML per 25 DAYs)
OLUX-E EXTERNAL FOAM 0.05 % (clobetasol propionate
emulsion)
NF
PANDEL EXTERNAL CREAM 0.1 % (hydrocortisone
probutate)
NP
PA; QL (180 GM per 25
DAYs)
SERNIVO EXTERNAL EMULSION 0.05 % (betamethasone
dipropionate)
NP
PA; STX; QL (120 ML per
25 DAYs)
SYNALAR EXTERNAL CREAM 0.025 % (fluocinolone
acetonide)
NP
PA; QL (180 GM per 25
DAYs)
SYNALAR EXTERNAL OINTMENT 0.025 % (fluocinolone
acetonide)
NP
PA; QL (180 GM per 25
DAYs)
SYNALAR EXTERNAL SOLUTION 0.01 % (fluocinolone
acetonide)
NP
PA; QL (180 ML per 25
DAYs)
TACLONEX EXTERNAL OINTMENT 0.005-0.064 %
(calcipotriene-betameth diprop)
PB
TACLONEX EXTERNAL SUSPENSION 0.005-0.064 %
(calcipotriene-betameth diprop)
PB
TEXACORT EXTERNAL SOLUTION 2.5 %
(hydrocortisone)
NP
PA; QL (180 ML per 25
DAYs)
TOPICORT EXTERNAL CREAM 0.05 %, 0.25 %
(desoximetasone)
NP
PA; QL (180 GM per 25
DAYs)
TOPICORT EXTERNAL GEL 0.05 % (desoximetasone) NP
PA; QL (180 GM per 25
DAYs)
TOPICORT EXTERNAL OINTMENT 0.05 %, 0.25 %
(desoximetasone)
NP
PA; QL (180 GM per 25
DAYs)
TOPICORT SPRAY EXTERNAL LIQUID 0.25 %
(desoximetasone)
NP
PA; QL (180 ML per 25
DAYs)
clobetasol propionate emulsion (Tovet External Foam 0.05 %) NF
triamcinolone acetonide external aerosol solution 0.147 mg/gm NF
triamcinolone acetonide external cream 0.025 %, 0.1 %, 0.5 % PG QL (120 GM per 25 DAYs)
triamcinolone acetonide external lotion 0.025 %, 0.1 % PG QL (120 ML per 25 DAYs)
triamcinolone acetonide external ointment 0.025 %, 0.1 % PG QL (120 GM per 25 DAYs)
triamcinolone acetonide external ointment 0.5 % PG QL (120 G per 25 days)
TRIDESILON EXTERNAL CREAM 0.05 % (desonide) NP
PA; QL (180 GM per 25
DAYs)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
218
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
ULTRAVATE EXTERNAL LOTION 0.05 % (halobetasol
propionate)
NF
VANOS EXTERNAL CREAM 0.1 % (fluocinonide) NF
VERDESO EXTERNAL FOAM 0.05 % (desonide) NF
DERMATOLOGY, LOCAL ANESTHETICS
lidocaine external ointment 5 % NP QL (50 GM per 25 DAYs)
lidocaine external patch 5 % NP
PA; QL (90 PATCHES per
25 DAYs)
lidocaine hcl external solution 4 % PG QL (50 ML per 25 DAYs)
lidocaine-prilocaine external cream 2.5-2.5 % PG QL (30 G per 25 days)
LIDODERM EXTERNAL PATCH 5 % (lidocaine) NP
PA; QL (90 PATCHES per
25 DAYs)
PLIAGLIS EXTERNAL CREAM 7-7 % (lidocaine-
tetracaine)
NF
SX1 MEDICATED POST-OPERATIVE EXTERNAL KIT
2 % (lidocaine hcl & post-op system)
NF
SYNERA EXTERNAL PATCH 70-70 MG (lidocaine-
tetracaine)
NP
QL (2 PATCHES per 25
DAYs)
ZTLIDO EXTERNAL PATCH 1.8 % (lidocaine) NP
QL (90 PATCHES per 25
days)
DERMATOLOGY, MISCELLANEOUS SKIN AND
MUCOUS MEMBRANE
ABREVA EXTERNAL CREAM 10 % (docosanol) PG Select OTC
acyclovir external cream 5 % NF
acyclovir external ointment 5 % NP
ALFERON N INJECTION SOLUTION 5000000 UNIT/ML
(interferon alfa-n3)
NPSP
AMELUZ EXTERNAL GEL 10 % (aminolevulinic acid hcl) NF
bexarotene external gel 1 % PSP PA
DENAVIR EXTERNAL CREAM 1 % (penciclovir) NF
diclofenac epolamine external patch 1.3 % PG
STX; QL (30 PATCHES per
25 Days)
diclofenac sodium external gel 3 % NP PA; QL (100 G per 25 days)
diclofenac sodium external solution 1.5 % PG
PA; QL (300 ML per 21
days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
219
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
diclofenac sodium external solution 2 % NF
docosanol external cream 10 % PG Select OTC
ELIDEL EXTERNAL CREAM 1 % (pimecrolimus) NF
EUCRISA EXTERNAL OINTMENT 2 % (crisaborole) PB
FLECTOR EXTERNAL PATCH 1.3 % (diclofenac
epolamine)
NF
HYFTOR EXTERNAL GEL 0.2 % (sirolimus) NF
LEVULAN KERASTICK EXTERNAL SOLUTION
RECONSTITUTED 20 % (aminolevulinic acid hcl)
NPSP QL (1 STICK per 25 DAYs)
LICART EXTERNAL PATCH 24 HOUR 1.3 % (diclofenac
epolamine)
NF
penciclovir external cream 1 % NF
PENNSAID EXTERNAL SOLUTION 2 % (diclofenac
sodium)
NF
pimecrolimus external cream 1 % NP PA
podofilox external solution 0.5 % PG
SANTYL EXTERNAL OINTMENT 250 UNIT/GM
(collagenase)
NP PA
tacrolimus external ointment 0.03 %, 0.1 % NP PA
TARGRETIN EXTERNAL GEL 1 % (bexarotene) NF
VALCHLOR EXTERNAL GEL 0.016 % (mechlorethamine
hcl (topical))
NPSP PA; QL (2 GM per 30 days)
VEREGEN EXTERNAL OINTMENT 15 % (sinecatechins) NF
ZOVIRAX EXTERNAL CREAM 5 % (acyclovir) NF
ZOVIRAX EXTERNAL OINTMENT 5 % (acyclovir) NF
DERMATOLOGY, ROSACEA
azelaic acid external gel 15 % NP
brimonidine tartrate external gel 0.33 % NF
doxycycline oral capsule delayed release 40 mg NF
EPSOLAY EXTERNAL CREAM 5 % (benzoyl peroxide) NF
FINACEA EXTERNAL FOAM 15 % (azelaic acid) PB PA
FINACEA EXTERNAL GEL 15 % (azelaic acid) NF
ivermectin external cream 1 % NF
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
220
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
METROCREAM EXTERNAL CREAM 0.75 %
(metronidazole)
NP ST; QL (60 G per 25 days)
METROGEL EXTERNAL GEL 1 % (metronidazole) NF
METROLOTION EXTERNAL LOTION 0.75 %
(metronidazole)
NP QL (60 ML per 25 DAYs)
metronidazole external cream 0.75 % PG QL (60 G per 25 days)
metronidazole external gel 0.75 % PG QL (60 G per 25 days)
metronidazole external gel 1 % NP QL (60 G per 25 days)
metronidazole external lotion 0.75 % PG QL (60 ML per 25 days)
MIRVASO EXTERNAL GEL 0.33 % (brimonidine tartrate) NF
NORITATE EXTERNAL CREAM 1 % (metronidazole) NF
ORACEA ORAL CAPSULE DELAYED RELEASE 40 MG
(doxycycline)
PB
RHOFADE EXTERNAL CREAM 1 % (oxymetazoline hcl) NF
SOOLANTRA EXTERNAL CREAM 1 % (ivermectin) PB
ZILXI EXTERNAL FOAM 1.5 % (minocycline hcl
micronized)
NF
DERMATOLOGY, SCABICIDES AND PEDICULICIDES
CROTAN EXTERNAL LOTION 10 % (crotamiton) PG
malathion external lotion 0.5 % PG
permethrin external cream 5 % PG
spinosad external suspension 0.9 % PG
DERMATOLOGY, WOUND CARE AGENTS
acetic acid irrigation solution 0.25 % PG
REGRANEX EXTERNAL GEL 0.01 % (becaplermin) NP PA; QL (30 G per 25 days)
MOUTH/THROAT/DENTAL AGENTS
cevimeline hcl oral capsule 30 mg PG
chlorhexidine gluconate mouth/throat solution 0.12 % PG
clotrimazole mouth/throat troche 10 mg PG
QL (90 LOZENGES per 25
days)
lidocaine viscous hcl mouth/throat solution 2 % PG
nystatin mouth/throat suspension 100000 unit/ml PG
ORAVIG BUCCAL TABLET 50 MG (miconazole) NP
QL (14 TABLETS per 25
days)
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
221
Prescription Drug Name Drug Tier
Coverage Requirements and
Limits
pilocarpine hcl oral tablet 5 mg, 7.5 mg PG
triamcinolone acetonide mouth/throat paste 0.1 % PG
OTIC - DRUGS TO TREAT CONDITIONS OF THE EAR
acetic acid otic solution 2 % PG
CIPRO HC OTIC SUSPENSION 0.2-1 % (ciprofloxacin-
hydrocortisone)
NF N10 (NP)
CIPRODEX OTIC SUSPENSION 0.3-0.1 % (ciprofloxacin-
dexamethasone)
NF
ciprofloxacin hcl otic solution 0.2 % NP
ciprofloxacin-dexamethasone otic suspension 0.3-0.1 % PG
ciprofloxacin-fluocinolone pf otic solution 0.3-0.025 % NF N10 (NP)
fluocinolone acetonide otic oil 0.01 % NP
hydrocortisone-acetic acid otic solution 1-2 % PG
neomycin-polymyxin-hc otic solution 1 % PG
neomycin-polymyxin-hc otic suspension 3.5-10000-1 PG
ofloxacin otic solution 0.3 % PG
OTOVEL OTIC SOLUTION 0.3-0.025 % (ciprofloxacin-
fluocinolone)
NF
2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health
The formulary is updated annually in July
07/01/2023
222
Index
abacavir sulfate........................ 28
abacavir sulfate-lamivudine...... 32
ABILIFY................................ 78
ABILIFY ASIMTUFII...........78
ABILIFY MAINTENA..........78
abiraterone acetate...................43
ABREVA.............................. 219
ABSORICA.......................... 208
ABSORICA LD....................208
acamprosate calcium................ 68
ACANYA............................. 208
acarbose.................................109
ACCRUFER.........................188
ACCU-CHEK AVIVA PLUS
...............................................126
ACCU-CHEK FASTCLIX
LANCETS............................ 126
ACCU-CHEK GUIDE.........126
ACCU-CHEK
SMARTVIEW...................... 126
ACCU-CHEK SOFTCLIX
LANCETS............................ 126
Accutane................................208
ACCUTREND GLUCOSE..126
acebutolol hcl........................... 60
acetaminophen-codeine.............18
acetazolamide.......................... 63
acetazolamide er...................... 63
acetic acid.......................221, 222
acetylcysteine.........................204
ACIPHEX.............................155
acitretin..................................213
ACTEMRA...........................171
ACTEMRA ACTPEN..........171
ACTHAR..............................145
ACTIMMUNE..................... 181
ACTIQ....................................18
ACTONEL............................118
ACTOS..................................116
ACUVAIL............................ 192
acyclovir...........................34, 219
ACZONE.............................. 208
adapalene............................... 208
adapalene-benzoyl peroxide.... 208
ADBRY................................ 214
ADCIRCA..............................66
ADDERALL.......................... 87
ADDERALL XR....................87
ADDYI................................. 105
adefovir dipivoxil......................34
ADEMPAS............................. 66
ADIPEX-P............................ 118
ADLARITY........................... 69
ADMELOG..........................111
ADMELOG SOLOSTAR.....111
ADTHYZA...........................147
ADVAIR DISKUS............... 207
ADVAIR HFA..................... 207
ADVANCE INTUITION
TEST.....................................127
ADVANCE MICRO-DRAW
TEST.....................................127
ADVATE.............................. 166
ADVOCATE REDI-CODE..127
ADVOCATE REDI-CODE+
TEST.....................................127
ADVOCATE TEST.............. 127
adynovate...............................166
ADZENYS XR-ODT............. 87
AFINITOR.............................45
AFINITOR DISPERZ........... 45
AFREZZA............................112
AFSTYLA............................ 166
AFTERA.............................. 121
AGAMATRIX AMP TEST..127
AGAMATRIX JAZZ TEST.127
AGAMATRIX KEYNOTE
TEST.....................................127
AGAMATRIX PRESTO
TEST.....................................127
AGRYLIN............................168
AIMOVIG.............................. 94
AIRDUO DIGIHALER.......207
AIRDUO RESPICLICK
113/14.................................... 196
AIRDUO RESPICLICK
232/14.................................... 196
AIRDUO RESPICLICK
55/14......................................196
AJOVY................................... 94
AKLIEF................................208
AKYNZEO...........................149
albendazole.............................. 26
albuterol sulfate......................200
albuterol sulfate hfa................200
alclometasone dipropionate.....214
alcohol swabs......................... 127
ALDURAZYME..................136
ALECENSA........................... 45
alendronate sodium.................118
ALFERON N....................... 219
alfuzosin hcl er....................... 157
ALINIA.................................. 38
aliskiren fumarate.................... 63
ALKERAN.............................41
ALKINDI SPRINKLE.........141
ALLEGRA ALLERGY........198
ALLEGRA ALLERGY
CHILDRENS....................... 198
ALLEGRA-D ALLERGY &
CONGESTION.....................201
allergy relief...........................198
allopurinol.......................... 14, 15
ALLZITAL.............................15
almotriptan malate...................94
alogliptin benzoate..................110
alogliptin-metformin hcl......... 110
alogliptin-pioglitazone............ 110
ALORA.................................138
alosetron hcl...........................152
ALPHAGAN P.....................190
ALPHANATE...................... 162
ALPHANINE SD.................167
alprazolam............................... 68
alprazolam er........................... 68
ALPRAZOLAM INTENSOL 68
ALPROLIX.......................... 167
ALREX.................................192
Altavera.................................121
ALTOPREV........................... 58
ALTRENO........................... 208
ALTUVIIIO..........................166
ALUNBRIG........................... 45
ALVESCO............................ 205
alyacen 1/35........................... 121
alyacen 7/7/7.......................... 121
Alyq........................................ 66
Amabelz................................ 138
amantadine hcl................... 76, 77
AMBIEN................................ 92
AMBIEN CR..........................92
ambrisentan............................. 66
amcinonide............................. 214
AMELUZ............................. 219
Amethia.................................121
Amethyst............................... 121
AMICAR.............................. 168
223
amiloride hcl............................ 63
amiloride-hydrochlorothiazide.. 63
aminocaproic acid...................168
amiodarone hcl.........................56
AMITIZA............................. 152
amitriptyline hcl................. 70, 71
AMJEVITA.......................... 171
amlodipine besy-benazepril hcl..53
amlodipine besylate.................. 61
amlodipine besylate-valsartan...54
amlodipine-atorvastatin............61
amlodipine-olmesartan............. 54
amlodipine-valsartan-hctz.........54
Amnesteem............................208
amoxapine............................... 71
amoxicill-clarithro-lansopraz..157
amoxicillin............................... 40
amoxicillin-pot clavulanate.......40
amoxicillin-pot clavulanate er...40
amphetamine sulfate.................87
amphetamine-dextroamphet er. 87
amphetamine-
dextroamphetamine............ 87, 88
ampicillin................................. 40
AMPYRA...............................98
AMRIX.................................101
AMZEEQ..............................208
ANAFRANIL........................ 68
anagrelide hcl......................... 168
anastrozole...............................43
ANDRODERM....................108
ANDROGEL PUMP............108
ANGELIQ............................ 138
ANNOVERA........................121
ANORO ELLIPTA...............196
ANTIVERT.......................... 149
ANZEMET...........................149
APADAZ................................18
apap-caff-dihydrocodeine......... 18
APEXICON E.......................214
APIDRA............................... 112
APIDRA SOLOSTAR..........112
APOKYN............................... 77
apomorphine hcl.......................77
aprepitant....................... 149, 150
Apri....................................... 121
APRISO................................ 151
APTENSIO XR...................... 88
APTIOM.................................81
APTIVUS................................28
ARAKODA............................28
ARALAST NP......................195
Aranelle.................................121
ARANESP (ALBUMIN
FREE)...................................163
ARAZLO.............................. 209
ARCALYST......................... 181
arformoterol tartrate.............. 200
ARIKAYCE........................... 27
aripiprazole..............................78
ARISTADA............................79
ARISTADA INITIO.............. 78
armodafinil.............................103
ARMONAIR DIGIHALER.206
ARNUITY ELLIPTA...........206
ARTHROTEC........................17
ASCENIV............................. 179
ASCOR................................. 188
asenapine maleate.................... 79
ASMANEX (120 METERED
DOSES).................................206
ASMANEX (30 METERED
DOSES).................................206
ASMANEX (60 METERED
DOSES).................................206
ASMANEX HFA................. 206
aspirin......................................25
aspirin childrens....................... 25
aspirin-dipyridamole er...........169
ASPRUZYO SPRINKLE.......64
ASSURE 3 TEST..................127
ASSURE 4 TEST..................127
ASSURE II........................... 127
ASSURE II CHECK.............127
ASSURE LANCE
LANCETS............................ 127
ASSURE PLATINUM......... 127
ASSURE PRISM MULTI
TEST.....................................127
ASSURE PRO TEST............127
ATABEX EC........................ 184
ATACAND............................ 55
ATACAND HCT................... 54
atazanavir sulfate.....................28
ATELVIA............................. 118
atenolol....................................60
atenolol-chlorthalidone.............60
ATGAM................................181
ATIVAN.................................68
atomoxetine hcl........................88
ATORVALIQ.........................58
atorvastatin calcium................. 58
atovaquone...............................38
atovaquone-proguanil hcl..........28
ATRALIN............................ 209
atropine sulfate.......................194
ATROVENT HFA............... 197
AUBAGIO..............................98
Aubra Eq...............................121
AURYXIA............................146
AUSTEDO............................. 98
AUSTEDO XR.......................98
AUVELITY............................71
AUVI-Q................................ 195
AVEED.................................108
Avita......................................209
AVONEX PEN.......................98
AVONEX PREFILLED.........98
AVSOLA...............................171
AYVAKIT.............................. 45
AZASITE..............................192
azathioprine........................... 181
azelaic acid.............................220
azelastine hcl.................. 189, 198
azelastine-fluticasone..............197
AZELEX...............................209
azesco.................................... 184
azithromycin............................ 36
AZOPT..................................190
AZOR..................................... 54
AZSTARYS............................88
Azurette.................................121
Bac.......................................... 15
bacitracin............................... 192
bacitracin-polymyxin b...........192
baclofen..................................101
BAFIERTAM.........................98
BALCOLTRA...................... 121
balsalazide disodium...............151
BALVERSA............................46
Balziva...................................121
BANZEL................................ 81
BAQSIMI ONE PACK.........142
BAQSIMI TWO PACK........ 142
BARACLUDE........................34
BASAGLAR KWIKPEN..... 112
BASAGLAR TEMPO PEN..112
BD GLUCOSE..................... 143
BD INSULIN SYRINGE U-
500.........................................127
224
BD LANCET ULTRAFINE
30G........................................127
BD LANCET ULTRAFINE
33G........................................127
BD MICROTAINER
LANCETS............................ 127
BD PEN NEEDLE MICRO
U/F........................................128
BD PEN NEEDLE MINI
U/F........................................128
BD PEN NEEDLE NANO
2ND GEN.............................128
BD PEN NEEDLE NANO
U/F........................................128
BD PEN NEEDLE
ORIGINAL U/F...................128
BD PEN NEEDLE SHORT
U/F........................................128
BECONASE AQ...................204
BELBUCA..............................24
BELSOMRA...........................92
benazepril hcl........................... 53
benazepril-hydrochlorothiazide.53
BENEFIX............................. 167
BENICAR.............................. 55
BENICAR HCT..................... 54
BENLYSTA..........................181
benzhydrocodone-
acetaminophen......................... 18
benzonatate............................201
benzoyl peroxide-erythromycin
...............................................209
benzphetamine hcl.................. 118
benztropine mesylate................ 77
bepotastine besilate.................189
BEPREVE.............................189
BERINERT.......................... 178
BESIVANCE........................ 192
BESREMI...............................43
betaine................................... 136
betamethasone dipropionate....214
betamethasone dipropionate
aug.........................................214
betamethasone valerate...........214
BETAPACE............................56
BETAPACE AF......................56
BETASERON.........................98
betaxolol hcl..................... 60, 190
bethanechol chloride............... 159
BETHKIS............................. 202
BETIMOL.............................190
BETOPTIC-S........................ 190
BEVESPI AEROSPHERE....196
bexarotene........................51, 219
BEYAZ................................. 121
bicalutamide.............................43
BIDIL..................................... 64
BIJUVA................................ 138
BIKTARVY............................32
BILTRICIDE..........................26
bimatoprost............................190
BINOSTO............................. 119
bismuth/metronidaz/tetracyclin
...............................................157
bisoprolol fumarate.................. 60
bisoprolol-hydrochlorothiazide..60
BIVIGAM.............................179
Blisovi 24 Fe..........................121
Blisovi Fe 1.5/30.................... 122
Blisovi Fe 1/20....................... 122
blood glucose test................... 128
bosentan...................................66
BOSULIF............................... 46
BOTOX.................................102
BRAFTOVI............................ 46
BREO ELLIPTA.................. 207
BREXAFEMME.................... 27
BREZTRI AEROSPHERE.. 196
BRILINTA........................... 169
brimonidine tartrate........ 190, 220
brimonidine tartrate-timolol....190
brinzolamide...........................190
BRIVIACT............................. 81
bromfenac sodium (once-daily)
...............................................192
bromocriptine mesylate............ 77
BROMSITE.......................... 193
BRONCHITOL.................... 202
BROVANA...........................200
BRUKINSA........................... 46
BRYHALI............................ 215
budesonide...............151, 204, 206
budesonide er..........................151
budesonide-formoterol
fumarate................................ 207
bumetanide...............................63
Bupap......................................15
BUPHENYL.........................136
buprenorphine.......................... 24
buprenorphine hcl................... 104
buprenorphine hcl-naloxone hcl
...............................................103
bupropion hcl........................... 71
bupropion hcl er (smoking det)
...............................................106
bupropion hcl er (sr)................ 71
bupropion hcl er (xl)................71
buspirone hcl............................ 68
butalbital-acetaminophen......... 15
butalbital-apap-caff-cod........... 18
butalbital-apap-caffeine............15
butalbital-asa-caff-codeine....... 18
butalbital-aspirin-caffeine.........15
butorphanol tartrate................. 19
BUTRANS............................. 25
BYDUREON BCISE............111
BYETTA 10 MCG PEN....... 111
BYETTA 5 MCG PEN......... 111
BYLVAY.............................. 154
BYLVAY (PELLETS).......... 153
BYOOVIZ.............................195
BYSTOLIC.............................60
cabergoline.............................145
CABLIVI.............................. 162
CABOMETYX....................... 46
CAFERGOT...........................94
calcipotriene...........................213
calcipotriene-betameth diprop.215
calcitonin (salmon)................ 145
calcitriol......................... 188, 213
calcium acetate (phos binder).146
CALQUENCE........................46
CAMBIA................................ 16
Camila...................................122
Camrese.................................122
Camrese Lo........................... 122
CAMZYOS.............................64
CANASA.............................. 151
candesartan cilexetil.................55
candesartan cilexetil-hctz......... 55
capecitabine............................. 42
CAPEX................................. 215
CAPLYTA..............................79
CAPRELSA............................46
captopril...................................54
captopril-hydrochlorothiazide...53
CARAC.................................211
CARAFATE.........................154
CARBAGLU........................ 137
carbamazepine......................... 81
225
carbamazepine er..................... 81
carbidopa................................. 77
carbidopa-levodopa.................. 77
carbidopa-levodopa er.............. 77
carbidopa-levodopa-entacapone 77
carbinoxamine maleate...........198
CARDIZEM...........................61
CARDIZEM CD.................... 61
CARDIZEM LA.....................61
CAREONE LANCET
SUPER THIN 30G............... 128
CARESENS LANCETS....... 128
CARESENS N GLUCOSE
TEST.....................................128
CARETOUCH TEST........... 128
carglumic acid........................ 137
carisoprodol........................... 102
CARNITOR......................... 119
CARNITOR SF....................120
CAROSPIR............................ 63
carteolol hcl............................190
carvedilol................................. 60
carvedilol phosphate er............. 60
CAVERJECT........................158
CAVERJECT IMPULSE..... 158
CAYA................................... 122
CAYSTON............................202
cefaclor.............................. 35, 36
cefadroxil.................................36
cefdinir.....................................36
cefixime................................... 36
cefpodoxime proxetil................36
cefprozil...................................36
cefuroxime axetil..................... 36
CELEBREX............................14
celecoxib..................................14
CELLCEPT
INTRAVENOUS..................182
cephalexin................................36
CEQUA.................................194
CERDELGA.........................137
CEREZYME.........................137
cetirizine hcl...........................198
cetirizine hcl allergy child....... 198
cetirizine-pseudoephedrine er.. 201
CETROTIDE........................140
cevimeline hcl......................... 221
CHENODAL........................154
chlordiazepoxide hcl.................68
chlordiazepoxide-amitriptyline105
chlordiazepoxide-clidinium..... 151
chlorhexidine gluconate.......... 221
chloroquine phosphate.............. 28
chlorpromazine hcl................... 79
chlorthalidone.......................... 63
chlorzoxazone........................ 102
CHOLBAM.......................... 154
cholestyramine......................... 57
cholestyramine light................. 57
chorionic gonadotropin........... 140
CIALIS..................................158
CIBINQO..............................214
ciclopirox............................... 211
ciclopirox olamine.................. 211
cidofovir...................................34
cilostazol................................168
CILOXAN............................ 192
CIMDUO................................32
CIMERLI............................. 195
cimetidine...............................151
CIMZIA................................172
CIMZIA STARTER KIT..... 172
cinacalcet hcl..........................119
CINRYZE.............................178
CIPRO HC............................222
CIPRODEX.......................... 222
ciprofloxacin hcl........37, 192, 222
ciprofloxacin-dexamethasone..222
ciprofloxacin-fluocinolone pf.. 222
citalopram hydrobromide..........71
CITRANATAL 90 DHA...... 184
CITRANATAL ASSURE.... 184
CITRANATAL B-CALM.... 184
CITRANATAL BLOOM..... 184
CITRANATAL DHA...........184
CITRANATAL HARMONY
...............................................184
CITRANATAL MEDLEY...184
Claravis................................. 209
clarithromycin..........................37
clarithromycin er......................36
CLARITIN........................... 198
CLARITIN ALLERGY
CHILDRENS....................... 198
CLARITIN REDITABS.......198
CLARITIN-D 12 HOUR......201
CLARITIN-D 24 HOUR......201
clemastine fumarate................198
CLENPIQ............................. 152
CLEOCIN-T......................... 209
CLEVER CHEK AUTO-
CODE TEST.........................128
CLEVER CHEK AUTO-
CODE VOICE...................... 128
CLEVER CHEK TEST........ 128
CLEVER CHOICE AUTO-
CODE TEST.........................128
CLEVER CHOICE MICRO
TEST.....................................128
CLEVER CHOICE NO
CODING.............................. 128
CLEVER CHOICE TALK
SYSTEM...............................128
CLIMARA............................138
CLIMARA PRO...................138
Clindacin-P............................209
CLINDAGEL.......................209
clindamycin hcl.........................38
clindamycin palmitate hcl......... 39
clindamycin phos-benzoyl
perox......................................209
clindamycin phosphate.... 161, 209
clindamycin-tretinoin..............209
clobazam..................................81
clobetasol propionate..............215
clobetasol propionate e........... 215
clobetasol propionate emulsion215
CLOBEX...............................215
CLOBEX SPRAY.................215
clocortolone pivalate...............215
CLODERM.......................... 215
CLOMID.............................. 140
clomipramine hcl...................... 69
clonazepam.............................. 81
clonidine...................................64
clonidine hcl............................. 64
clonidine hcl er......................... 64
clopidogrel bisulfate................169
clorazepate dipotassium............82
clotrimazole........................... 221
clotrimazole-betamethasone....211
clozapine..................................79
COAGADEX........................162
COAGUCHEK LANCETS..129
codeine sulfate..........................19
coditussin ac...........................201
COLAZAL............................151
colchicine................................. 15
colchicine-probenecid............... 15
COLCRYS..............................15
226
colesevelam hcl.........................57
colestipol hcl............................ 57
colistimethate sodium (cba)..... 39
COMBIGAN........................ 190
COMBIPATCH.................... 138
COMBIVENT RESPIMAT..196
COMBIVIR............................ 32
COMETRIQ (100 MG
DAILY DOSE)....................... 46
COMETRIQ (140 MG
DAILY DOSE)....................... 46
COMETRIQ (60 MG DAILY
DOSE).....................................46
comfort assured lancets 28g.... 129
comfort assured lancets 33g.... 129
COMFORT TOUCH
LANCETS 31G.....................129
COMFORT TOUCH PLUS
LANCETS 30G.....................129
COMPLERA.......................... 32
complete natal dha..................184
completenate.......................... 184
Compro................................. 150
CONCEPT OB......................184
CONCERTA.......................... 88
condoms................................. 122
CONJUPRI.............................61
CONTOUR NEXT TEST.....129
CONTOUR TEST................ 129
CONTRAVE.........................118
CONZIP..................................19
COOL BLOOD GLUCOSE
TEST STRIPS.......................129
COPAXONE.....................98, 99
COPIKTRA............................46
CORDRAN.......................... 215
COREG CR............................60
CORIFACT.......................... 163
CORLANOR..........................64
CORTIFOAM...................... 151
cortisone acetate.....................141
CORTROPHIN.................... 145
COSENTYX......................... 173
COSENTYX (300 MG
DOSE)...................................172
COSENTYX
SENSOREADY (300 MG)... 172
COSENTYX
SENSOREADY PEN........... 173
COSOPT PF..........................190
COTELLIC.............................46
COTEMPLA XR-ODT.......... 88
COZAAR................................56
CREON.................................155
CRESEMBA...........................27
CRESTOR.............................. 58
CRINONE............................ 147
cromolyn sodium.............189, 203
CROTAN..............................221
Cryselle-28.............................122
CUPRIMINE........................120
CUTAQUIG......................... 179
CUVITRU............................ 179
CUVPOSA............................ 149
CUVRIOR............................ 120
CVS ADVANCED
GLUCOSE TEST................. 129
cvs allergy relief childrens.......198
cvs nicotine.............................106
cvs nicotine polacrilex.............106
cyanocobalamin......................188
cyclobenzaprine hcl.................102
cyclobenzaprine hcl er.............102
cyclophosphamide.................... 42
cycloserine............................... 34
CYCLOSET..........................110
cyclosporine....................182, 194
cyclosporine modified............. 182
CYMBALTA..........................71
cyproheptadine hcl..................198
CYSTADANE...................... 137
CYSTADROPS.....................194
CYSTAGON.........................137
CYSTARAN.........................194
CYTOMEL...........................147
dabigatran etexilate mesylate. 161
dalfampridine er....................... 99
DALIRESP........................... 204
danazol...................................136
dantrolene sodium...................102
dapsone............................ 39, 209
DARAPRIM.......................... 39
darifenacin hydrobromide er... 160
DARTISLA ODT................. 149
DAURISMO.......................... 43
DAYBUE................................97
DAYTRANA......................... 88
DAYVIGO..............................92
D-CARE BLOOD
GLUCOSE............................129
DDAVP.................................148
deferasirox............................. 120
deferasirox granules............... 120
deferiprone............................. 120
deferoxamine mesylate........... 120
DELSTRIGO..........................32
DELZICOL...........................151
demeclocycline hcl....................40
DENAVIR............................ 219
DEPAKOTE...........................82
DEPAKOTE ER.....................82
DEPAKOTE SPRINKLES.... 82
DEPEN TITRATABS.......... 120
DEPO-SUBQ PROVERA
104.........................................122
DERMA-SMOOTHE/FS
BODY................................... 215
DERMA-SMOOTHE/FS
SCALP.................................. 215
DESCOVY..............................32
DESFERAL..........................120
desipramine hcl.........................71
desloratadine...................198, 199
desmopressin ace spray refrig. 148
desmopressin acetate.............. 148
desmopressin acetate spray.....148
desogestrel-ethinyl estradiol....122
desonide..........................215, 216
DESOWEN...........................216
desoximetasone...................... 216
DESOXYN............................. 88
Desrx.....................................216
desvenlafaxine er......................72
desvenlafaxine succinate er.......72
DETROL LA........................160
dexabliss................................ 141
dexamethasone.......................141
dexamethasone sodium
phosphate...............................193
DEXCOM G6 RECEIVER.. 129
DEXCOM G6 SENSOR.......129
DEXCOM G6
TRANSMITTER..................129
DEXCOM G7 RECEIVER.. 129
DEXCOM G7 SENSOR.......129
DEXEDRINE.........................88
Dexifol...................................188
DEXILANT..........................155
dexlansoprazole......................155
dexmethylphenidate hcl............ 89
227
dexmethylphenidate hcl er...88, 89
dextroamphetamine sulfate.......89
dextroamphetamine sulfate er...89
DHIVY................................... 77
DIACOMIT............................82
DIASTAT ACUDIAL............82
DIASTAT PEDIATRIC.........82
DIATHRIVE GLUCOSE
TEST.....................................129
diatrue plus test...................... 129
diazepam..................................82
Diazepam Intensol.................. 82
diazoxide................................143
DIBENZYLINE..................... 65
dichlorphenamide..................... 63
diclofenac epolamine...............219
diclofenac potassium.................16
diclofenac
potassium(migraine)................16
diclofenac sodium
.......................... 16, 193, 219, 220
diclofenac sodium er................. 16
diclofenac-misoprostol..............17
dicloxacillin sodium..................40
dicyclomine hcl.......................149
diethylpropion hcl...................118
diethylpropion hcl er...............118
DIFFERIN........................... 209
DIFICID.................................37
diflorasone diacetate...............216
diflunisal.................................. 25
difluprednate.......................... 193
digoxin.....................................63
dihydroergotamine mesylate..... 94
DILANTIN............................ 82
DILANTIN INFATABS........82
DILAUDID............................19
diltiazem hcl.............................62
diltiazem hcl er.........................62
diltiazem hcl er beads............... 62
diltiazem hcl er coated beads.... 62
dilt-xr...................................... 62
dimethyl fumarate.................... 99
dimethyl fumarate starter pack.99
DIOVAN................................ 56
DIOVAN HCT....................... 55
DIPENTUM.........................151
diphenoxylate-atropine........... 149
DIPROLENE........................216
dipyridamole.......................... 169
disopyramide phosphate............56
disulfiram.................................68
DITROPAN XL................... 160
divalproex sodium.................... 82
divalproex sodium er................ 82
DIVIGEL..............................139
docosanol............................... 220
dofetilide..................................56
donepezil hcl.............................69
DOPTELET..........................164
DORAL.................................. 92
DORYX..................................40
DORYX MPC........................ 40
dorzolamide hcl...................... 190
dorzolamide hcl-timolol mal....190
dorzolamide hcl-timolol mal pf190
DOVATO................................32
doxazosin mesylate...................54
doxepin hcl..................72, 92, 213
doxercalciferol....................... 188
doxycycline............................ 220
doxycycline hyclate.............40, 41
doxycycline monohydrate......... 41
doxylamine-pyridoxine........... 150
DRIZALMA SPRINKLE...... 72
dronabinol.............................. 150
DROPLET PERSONAL
LANCETS 30G.....................129
drospiren-eth estrad-levomefol 122
drospirenone-ethinyl estradiol. 122
droxidopa.................................65
DUAKLIR PRESSAIR........ 207
DUAVEE..............................139
DUET DHA 400................... 184
DUET DHA BALANCED...184
DUEXIS................................. 17
DULERA..............................207
duloxetine hcl...........................72
DUOBRII............................. 216
DUO-CARE TEST............... 129
DUOPA.................................. 77
DUPIXENT.................. 205, 214
DUROLANE..........................25
dutasteride............................. 157
dutasteride-tamsulosin hcl.......157
DXEVO 11-DAY..................141
DYANAVEL XR................... 89
DYMISTA............................ 198
DYRENIUM..........................63
DYSPORT............................ 102
E.E.S. GRANULES................37
easy plus ii glucose test........... 129
EASY STEP TEST................129
easy talk blood glucose test.....129
EASY TOUCH LANCETS
21G........................................129
EASY TOUCH LANCETS
23G........................................129
EASY TOUCH LANCETS
26G........................................129
EASY TOUCH LANCETS
28G........................................130
EASY TOUCH LANCETS
28G/TWIST...........................130
EASY TOUCH LANCETS
30G........................................130
EASY TOUCH LANCETS
32G........................................130
EASY TOUCH LANCETS
32G/TWIST...........................130
EASY TOUCH LANCING
DEVICE................................130
EASY TOUCH SAFETY
LANCETS 21G.....................130
EASY TOUCH SAFETY
LANCETS 23G.....................130
EASY TOUCH SAFETY
LANCETS 26G.....................130
EASY TOUCH SAFETY
LANCETS 28G.....................130
easy trak blood glucose test.... 130
EASYGLUCO...................... 130
EASYMAX 15 TEST............130
EASYMAX TEST................ 130
EASYPRO BLOOD
GLUCOSE TEST................. 130
EASYPRO PLUS..................130
econazole nitrate.................... 212
ECOZA................................. 212
EDARBI................................. 56
EDARBYCLOR.....................55
EDEX....................................158
EDLUAR................................92
EDURANT............................ 28
efavirenz.................................. 29
efavirenz-emtricitab-tenofo df...32
efavirenz-lamivudine-tenofovir..32
EFFEXOR XR....................... 72
EFFIENT..............................169
ELAPRASE.......................... 137
228
ELELYSO.............................137
element compact test.............. 130
ELEMENT TEST.................130
ELEPSIA XR..........................82
ELESTRIN........................... 139
eletriptan hydrobromide........... 94
ELIDEL................................ 220
ELIGARD........................ 43, 44
ELIQUIS...............................161
ELIQUIS DVT/PE
STARTER PACK.................161
ELLA.................................... 122
ELMIRON............................159
ELOCTATE..........................166
Eluryng..................................122
ELYXYB................................ 14
EMBRACE BLOOD
GLUCOSE TEST................. 130
EMBRACE EVO BLOOD
GLUCOSE TEST................. 130
EMBRACE PRO GLUCOSE
TEST.....................................130
EMBRACE TALK
GLUCOSE TEST................. 130
EMEND................................150
EMEND TRI-PACK............ 150
EMFLAZA........................... 141
EMGALITY...........................94
EMGALITY (300 MG
DOSE).....................................94
EMPAVELI.......................... 169
emtricitabine............................ 29
emtricitabine-tenofovir df......... 32
EMTRIVA..............................29
EMVERM.............................. 26
enalapril maleate......................54
enalapril-hydrochlorothiazide... 53
ENBRACE HR.....................184
ENBREL....................... 173, 174
ENBREL MINI.................... 173
ENBREL SURECLICK....... 174
ENCARE.............................. 158
ENDARI...............................169
ENDOMETRIN................... 160
ENLITE GLUCOSE
SENSOR............................... 130
enoxaparin sodium.......... 161, 162
Enpresse-28........................... 122
ENSPRYNG.........................182
ENSTILAR...........................216
entacapone............................... 77
ENTADFI.............................157
entecavir.................................. 34
ENTRESTO............................64
ENTYVIO.............................171
enulose................................... 153
EPANED................................ 54
EPCLUSA.........................37, 38
EPIDIOLEX........................... 82
EPIDUO............................... 209
EPIDUO FORTE................. 210
epinastine hcl..........................189
epinephrine.............................196
EPINEPHRINESNAP-V......196
EPIPEN 2-PAK.................... 196
EPIPEN JR 2-PAK............... 196
EPIVIR................................... 29
eplerenone................................54
EPOGEN.............................. 164
epoprostenol sodium................. 66
EPRONTIA............................ 82
EPSOLAY.............................220
EPZICOM.............................. 33
eq blood glucose test............... 130
eq loratadine childrens............199
ergoloid mesylates.................... 69
ergotamine-caffeine..................94
ERIVEDGE............................43
ERLEADA............................. 44
erlotinib hcl..............................46
ERMEZA..............................147
ERTACZO............................212
ery......................................... 210
ERYGEL.............................. 210
ERYPED 200..........................37
ERYPED 400..........................37
Ery-Tab...................................37
ERYTHROCIN STEARATE 37
erythromycin...................192, 210
erythromycin base.................... 37
erythromycin ethylsuccinate..... 37
ESBRIET.............................. 204
escitalopram oxalate................ 72
ESGIC.....................................15
esomeprazole magnesium........155
ESPEROCT.......................... 166
Estarylla................................ 122
estazolam.................................93
estradiol................................. 139
estradiol valerate.................... 139
estradiol-norethindrone acet... 139
ESTRING............................. 139
ESTROGEL..........................139
eszopiclone...............................93
ethacrynic acid......................... 63
ethambutol hcl..........................34
ethosuximide............................ 83
ethynodiol diac-eth estradiol... 122
etodolac................................... 16
etodolac er............................... 16
etonogestrel-ethinyl estradiol.. 122
etoposide..................................53
etravirine..................................29
EUCRISA............................. 220
EUFLEXXA...........................25
EULEXIN.............................. 44
EVAMIST.............................139
EVEKEO................................ 89
EVEKEO ODT.......................89
EVENITY.............................145
everolimus.........................47, 182
EVERSENSE
SENSOR/HOLDER............. 130
EVERSENSE SMART
TRANSMITTER..................130
EVOLUTION AUTOCODE 131
EVOTAZ................................ 33
EVRYSDI...............................97
EXELDERM........................ 212
EXELON................................ 69
exemestane...............................44
EXFORGE............................. 55
EXFORGE HCT.................... 55
EXJADE............................... 120
EXKIVITY............................. 47
EXSERVAN...........................97
EXTAVIA...............................99
EYLEA................................. 195
EYSUVIS..............................193
EZALLOR SPRINKLE......... 58
ezetimibe..................................57
ezetimibe-rosuvastatin.............. 59
ezetimibe-simvastatin............... 59
FA-8......................................188
FABIOR............................... 210
FABRAZYME..................... 137
famciclovir............................... 34
famotidine.............................. 151
FANAPT................................ 79
229
FANAPT TITRATION
PACK..................................... 79
FARXIGA............................ 117
FASENRA............................205
FASENRA PEN................... 205
FASLODEX........................... 44
Fayosim.................................122
FC2 FEMALE CONDOM... 123
febuxostat................................ 15
FEIBA...................................163
felbamate................................. 83
felodipine er............................. 62
FEMCAP.............................. 123
FEMRING........................... 159
fenofibrate..........................57, 58
fenofibrate micronized..............57
fenofibric acid.......................... 58
FENOGLIDE.........................58
fenoprofen calcium................... 16
FENSOLVI (6 MONTH)......145
fentanyl....................................19
fentanyl citrate.........................19
FENTORA............................. 19
FERRIPROX........................120
FERRIPROX TWICE-A-
DAY......................................120
FERRO-PLEX......................188
fesoterodine fumarate er......... 160
FETZIMA.............................. 73
FETZIMA TITRATION........73
fexofenadine hcl..................... 199
fexofenadine-pseudoephed er.. 201
FIASP................................... 112
FIASP FLEXTOUCH.......... 112
FIASP PENFILL..................112
FIBRICOR............................. 58
FIBRYGA............................ 163
FIFTY50 GLUCOSE TEST
2.0..........................................131
FILSPARI.............................159
FINACEA.............................220
finasteride.............................. 157
FINGERSTIX LANCETS... 131
fingolimod hcl...........................99
FINTEPLA.............................83
FIORICET..............................16
FIORICET/CODEINE...........19
FIRAZYR.............................179
FIRDAPSE.............................97
FIRMAGON.......................... 44
FIRMAGON (240 MG
DOSE).....................................44
FIRVANQ.............................. 39
FLAREX.............................. 193
flavoxate hcl...........................160
FLEBOGAMMA DIF..........179
flecainide acetate......................56
FLECTOR............................ 220
FLEQSUVY..........................102
FLOLAN................................ 66
flolipid..................................... 58
FLONASE ALLERGY
RELIEF................................ 204
FLORIVA.............................188
FLOVENT DISKUS............ 206
FLOVENT HFA...................206
fluconazole...............................27
flucytosine................................27
fludrocortisone acetate........... 141
flunisolide...............................204
fluocinolone acetonide.....216, 222
fluocinolone acetonide body.... 216
fluocinolone acetonide scalp....216
fluocinonide............................216
fluocinonide emulsified base....216
fluoritab................................. 183
fluorometholone..................... 193
fluorouracil............................ 211
fluoxetine hcl............................73
fluoxetine hcl (pmdd).............105
fluphenazine hcl........................79
flurandrenolide....................... 216
flurbiprofen.............................. 16
flurbiprofen sodium.................193
fluticasone furoate-vilanterol.. 207
fluticasone propionate
................................204, 216, 217
fluticasone propionate hfa.......206
fluticasone-salmeterol..... 196, 207
fluvastatin sodium.................... 58
fluvastatin sodium er................ 58
fluvoxamine maleate.................69
fluvoxamine maleate er.............69
FML FORTE........................193
FML LIQUIFILM................193
FOCALIN.............................. 89
FOCALIN XR........................89
folbee plus.............................. 188
FOLGARD OS..................... 188
folic acid................................ 188
FOLIVANE-OB....................185
FOLLISTIM AQ...................140
fondaparinux sodium.............. 162
FORA 6 CONNECT.............131
FORA BLOOD GLUCOSE
TEST.....................................131
FORA D15G BLOOD
GLUCOSE TEST................. 131
FORA D20 BLOOD
GLUCOSE TEST................. 131
FORA D40/G31 BLOOD
GLUCOSE............................131
FORA G20 BLOOD
GLUCOSE TEST................. 131
FORA G30/PREM V10
GLUCOSE TEST................. 131
FORA GD20 TEST.............. 131
FORA GD50 BLOOD
GLUCOSE TEST................. 131
FORA GTEL BLOOD
GLUCOSE TEST................. 131
FORA TN'G ADVANCE
PRO...................................... 131
FORA TN'G/TN'G VOICE.. 131
FORA V10 BLOOD
GLUCOSE TEST................. 131
FORA V12 BLOOD
GLUCOSE TEST................. 131
FORA V20 BLOOD
GLUCOSE TEST................. 131
FORA V30A BLOOD
GLUCOSE TEST................. 131
FORACARE GD40 TEST....131
FORACARE PREMIUM
V10 TEST..............................132
FORACARE TEST N GO
TEST.....................................132
formoterol fumarate............... 200
FORTEO.............................. 145
FORTESTA..........................108
FORTISCARE TEST........... 132
FOSAMAX...........................119
FOSAMAX PLUS D............ 119
fosamprenavir calcium..............29
fosinopril sodium...................... 54
fosinopril sodium-hctz...............53
FOSRENOL......................... 147
FOTIVDA.............................. 47
FRAGMIN........................... 162
230
FREESTYLE INSULINX
TEST.....................................132
FREESTYLE LANCETS.....132
FREESTYLE LIBRE 14
DAY SENSOR..................... 132
FREESTYLE LIBRE 2
SENSOR............................... 132
freestyle libre 3 sensor............ 132
FREESTYLE LIBRE
READER..............................132
FREESTYLE LITE TEST....132
FREESTYLE PRECISION
NEO TEST............................132
FREESTYLE TEST..............132
FROVA...................................94
frovatriptan succinate...............94
FULPHILA.......................... 164
fulvestrant................................44
furosemide................................63
FUZEON................................29
Fyavolv................................. 139
FYCOMPA.............................83
FYLNETRA.........................164
gabapentin............................... 83
GALAFOLD........................ 145
galantamine hydrobromide....... 70
galantamine hydrobromide er... 70
GAMMAGARD...................179
GAMMAGARD S/D LESS
IGA....................................... 180
GAMMAKED......................180
GAMMAPLEX.................... 180
GAMUNEX-C......................180
ganciclovir................................34
ganciclovir sodium....................34
ganirelix acetate.....................140
gatifloxacin............................192
GATTEX.............................. 154
GAVILYTE-C...................... 153
Gavilyte-G.............................153
GAVRETO............................. 47
ge100 blood glucose test..........132
gefitinib....................................47
GELNIQUE..........................160
GEL-ONE...............................25
GELSYN-3............................. 25
gemfibrozil...............................58
GEMTESA........................... 160
Gengraf................................. 182
GENOTROPIN.................... 144
GENOTROPIN
MINIQUICK........................144
gentamicin sulfate........... 192, 211
GENULTIMATE TEST.......132
GENVISC 850........................ 25
GENVOYA............................ 33
GEODON...............................79
ght test................................... 132
GILENYA.............................. 99
GILOTRIF............................. 47
GIMOTI................................154
GLASSIA..............................195
glatiramer acetate.................... 99
Glatopa................................... 99
GLEEVEC..............................47
GLEOSTINE..........................42
glimepiride............................. 117
glipizide..................................117
glipizide er..............................117
glipizide xl..............................117
glipizide-metformin hcl........... 109
GLUCAGEN HYPOKIT.....143
glucagon emergency............... 143
GLUCO PERFECT 3 TEST.132
GLUCOCARD 01 SENSOR
PLUS.....................................132
GLUCOCARD
EXPRESSION TEST............132
GLUCOCARD SHINE
TEST.....................................132
GLUCOCARD VITAL
TEST.....................................132
GLUCOCARD X-SENSOR.132
GLUCOCOM TEST.............132
GLUCONAVII BLOOD
GLUCOSE TEST................. 133
glucose................................... 143
glucose control....................... 133
glucose meter test................... 133
GLUMETZA........................109
GLYCATE............................149
glycopyrrolate........................ 149
GLYXAMBI.........................117
gnp easy touch glucose test..... 133
gnp glucose gummies.............. 143
GOCOVRI..............................77
GOJJI BLOOD TEST
STRIP/LANCETS................ 133
GOLYTELY.........................153
GONAL-F............................ 140
GONAL-F RFF....................141
GONAL-F RFF REDIJECT 141
GONITRO..............................65
goodsense blood glucose..........133
GRALISE............................. 104
granisetron hcl........................150
GRANIX.............................. 164
GRASTEK............................170
griseofulvin microsize............... 27
griseofulvin ultramicrosize........27
guanfacine hcl.......................... 65
guanfacine hcl er...................... 89
GUARDIAN LINK 3
TRANSMITTER..................133
GUARDIAN REAL-TIME
REPLACE PED....................133
GUARDIAN SENSOR (3)...133
guardian sensor 3....................133
GVOKE HYPOPEN 1-
PACK....................................143
GVOKE HYPOPEN 2-
PACK....................................143
GVOKE KIT........................ 143
GVOKE PFS.........................143
HAEGARDA....................... 179
halcinonide............................. 217
HALCION..............................93
halobetasol propionate............217
HALOG................................ 217
haloperidol............................... 79
haloperidol lactate....................79
HARVONI..............................38
HELIDAC THERAPY.........157
HEMADY............................ 141
HEMLIBRA......................... 166
HEMOFIL M....................... 166
heparin sodium (porcine)....... 162
heparin sodium (porcine) pf... 162
HETLIOZ............................... 93
HETLIOZ LQ.........................93
Hidex 6-Day.......................... 142
HIZENTRA..........................180
HORIZANT......................... 104
HUMALOG......................... 112
HUMALOG JUNIOR
KWIKPEN........................... 112
HUMALOG KWIKPEN......112
HUMALOG MIX 50/50....... 112
HUMALOG MIX 50/50
KWIKPEN........................... 112
231
HUMALOG MIX 75/25....... 112
HUMALOG MIX 75/25
KWIKPEN........................... 112
HUMALOG TEMPO PEN.. 113
HUMATE-P......................... 163
HUMATIN.............................27
HUMATROPE.....................144
HUMIRA..............................174
HUMIRA PEDIATRIC
CROHNS START................ 174
HUMIRA PEN.....................174
HUMIRA PEN-CD/UC/HS
STARTER............................ 174
HUMIRA PEN-
PS/UV/ADOL HS START....174
HUMIRA PEN-
PSOR/UVEIT STARTER.... 174
HUMULIN 70/30................. 113
HUMULIN 70/30
KWIKPEN........................... 113
HUMULIN N.......................113
HUMULIN N KWIKPEN...113
HUMULIN R.......................113
HUMULIN R U-500
(CONCENTRATED)........... 113
HUMULIN R U-500
KWIKPEN........................... 113
HW EMBRACE PRO
GLUCOSE TEST................. 133
HW EMBRACE TALK
GLUCOSE TEST................. 133
HYALGAN...................... 25, 26
HYCAMTIN.......................... 53
HYCODAN.......................... 201
hydralazine hcl......................... 65
hydrochlorothiazide..................63
hydrocod poli-chlorphe poli er.201
hydrocodone bitartrate er....19, 20
hydrocodone bit-homatrop mbr
....................................... 201, 202
hydrocodone-acetaminophen.....20
hydrocodone-ibuprofen............. 20
hydrocortisone................ 142, 217
hydrocortisone (perianal).......157
hydrocortisone butyr lipo base 217
hydrocortisone butyrate..........217
hydrocortisone valerate...........217
hydrocortisone-acetic acid...... 222
hydromorphone hcl...................20
hydromorphone hcl er...............20
hydroxychloroquine sulfate28, 178
hydroxyurea.............................51
hydroxyzine hcl...................... 199
hydroxyzine pamoate..............199
HYFTOR..............................220
HYMOVIS..............................26
HYPERRHO S/D................. 180
HYPERTET..........................180
HYQVIA...............................180
HYSINGLA ER..................... 20
HYZAAR............................... 55
ibandronate sodium................ 119
IBRANCE.............................. 47
IBSRELA..............................152
Ibu...........................................16
ibuprofen..................................16
ibuprofen-famotidine................ 18
icatibant acetate.....................179
ICLUSIG................................ 47
icosapent ethyl......................... 59
IDELVION........................... 168
IDHIFA..................................51
IGLUCOSE TEST STRIPS.. 133
ILARIS................................. 183
ILEVRO................................193
ILUMYA.............................. 171
imatinib mesylate..................... 47
IMBRUVICA......................... 47
IMCIVREE...........................145
imipramine hcl..........................73
imipramine pamoate.................73
imiquimod.............................. 211
imiquimod pump.....................211
IMITREX......................... 94, 95
IMITREX STATDOSE
REFILL.................................. 95
IMITREX STATDOSE
SYSTEM.................................95
IMOGAM RABIES-HT....... 180
IMPEKLO............................ 217
IMPOYZ...............................217
IMURAN..............................182
IMVEXXY
MAINTENANCE PACK.....139
IMVEXXY STARTER
PACK....................................139
IN TOUCH BLOOD
GLUCOSE TEST................. 133
INATAL GT.........................185
INBRIJA.................................77
INCRELEX.......................... 145
INCRUSE ELLIPTA............197
indapamide...............................63
INDERAL LA........................60
INDERAL XL........................60
INDOCIN...............................16
indomethacin............................16
INFINITY BLOOD
GLUCOSE TEST................. 133
INFINITY VOICE............... 133
INFLECTRA........................171
infliximab...............................171
INGREZZA............................98
INLYTA................................. 48
INNOPRAN XL.....................60
INQOVI..................................42
INREBIC................................48
insulin asp prot & asp flexpen. 113
insulin aspart..........................113
insulin aspart flexpen..............113
insulin aspart penfill............... 113
insulin aspart prot & aspart.....113
insulin degludec...................... 113
insulin degludec flextouch....... 113
insulin glargine....................... 113
insulin glargine solostar.......... 113
insulin glargine-yfgn............... 113
insulin lispro...........................114
insulin lispro (1 unit dial)....... 114
insulin lispro junior kwikpen... 114
insulin lispro prot & lispro.......114
INTELENCE..........................29
INTRAROSA....................... 145
Introvale................................123
INTUNIV............................... 89
INVEGA.................................79
INVEGA HAFYERA............ 79
INVEGA TRINZA.................79
INVELTYS...........................193
INVOKAMET......................116
INVOKAMET XR............... 116
INVOKANA.........................117
ipratropium bromide...............197
ipratropium-albuterol............. 196
irbesartan.................................56
irbesartan-hydrochlorothiazide. 55
IRESSA...................................48
ISENTRESS........................... 29
ISENTRESS HD.................... 29
isoniazid...................................34
232
ISORDIL TITRADOSE.........65
isosorb dinitrate-hydralazine.....64
isosorbide dinitrate...................65
isosorbide mononitrate............. 65
isosorbide mononitrate er..........65
isotretinoin............................. 210
isradipine................................. 62
ISTALOL..............................190
ISTURISA............................ 126
itraconazole............................. 27
ivermectin.........................26, 220
IXINITY...............................168
JADENU.............................. 120
JADENU SPRINKLE..........120
JAKAFI..................................48
JALYN..................................158
JANUMET........................... 110
JANUMET XR.....................110
JANUVIA.............................110
JARDIANCE........................117
JATENZO.............................108
JAYPIRCA.............................48
jenliva prenatal/postnatal........185
JENTADUETO.................... 110
JENTADUETO XR............. 110
Jinteli.....................................139
JIVI....................................... 166
JOENJA................................181
JORNAY PM......................... 89
JUBLIA.................................212
JULUCA.................................33
Junel 1.5/30............................123
Junel 1/20...............................123
Junel Fe 1.5/30.......................123
Junel Fe 24............................ 123
JUXTAPID.............................59
JYNARQUE................. 145, 146
Kaitlib Fe.............................. 123
KALBITOR..........................179
KALETRA............................. 33
KALYDECO........................ 202
KANUMA............................137
KAPSPARGO SPRINKLE....60
KAPVAY................................90
KARBINAL ER................... 199
KATERZIA............................62
KAZANO............................. 110
KCENTRA...........................163
kedrab....................................180
Kelnor 1/50............................123
KENALOG...........................217
KEPPRA.................................83
KEPPRA XR..........................83
KERENDIA......................... 145
KERYDIN............................212
KESIMPTA............................ 99
ketoconazole............. 27, 212, 213
ketoprofen................................16
ketoprofen er............................16
ketorolac tromethamine.... 16, 193
ketotifen fumarate..................189
KEVEYIS............................... 63
KEVZARA....................174, 175
KINERET.............................175
KISQALI (200 MG DOSE).... 48
KISQALI (400 MG DOSE).... 48
KISQALI (600 MG DOSE).... 48
KISQALI FEMARA (200
MG DOSE).............................48
KISQALI FEMARA (400
MG DOSE).............................48
KISQALI FEMARA (600
MG DOSE).............................48
KITABIS PAK......................202
KLARITY-A........................ 192
KLARON............................. 210
KLISYRI.............................. 211
KLONOPIN........................... 83
Klor-Con...............................183
Klor-Con 10.......................... 183
Klor-Con M10.......................183
Klor-Con M15.......................183
Klor-Con M20.......................183
KLOXXADO........................104
KOATE.................................166
KOATE-DVI........................ 166
KOGENATE FS...................167
KOMBIGLYZE XR............. 110
KONVOMEP........................155
KORLYM.............................116
KOSELUGO.......................... 48
kosher prenatal plus iron.........185
KOVALTRY........................ 167
kp fexofenadine hcl.................199
KRAZATI.............................. 51
KRINTAFEL......................... 28
KRISTALOSE......................153
KRYSTEXXA........................15
KUVAN................................137
KYLEENA........................... 123
KYNMOBI.............................77
KYZATREX.........................108
labetalol hcl..............................60
lacosamide............................... 83
LACRISERT........................ 194
lactulose.................................153
LAMICTAL........................... 83
LAMICTAL ODT.................. 83
LAMICTAL STARTER.........83
LAMICTAL XR.....................84
lamivudine.....................29, 30, 34
lamivudine-zidovudine.............. 33
lamotrigine...............................84
lamotrigine er...........................84
lamotrigine starter kit-blue.......84
lamotrigine starter kit-green.....84
lamotrigine starter kit-orange...84
lancets super thin 28g............. 133
LANCETS ULTRA THIN...133
lancets ultra thin 30g.............. 133
LANOXIN..............................63
lanreotide acetate................... 107
lansoprazole........................... 155
lanthanum carbonate.............. 147
LANTUS.............................. 114
LANTUS SOLOSTAR......... 114
lapatinib ditosylate...................48
latanoprost.............................190
LATUDA................................80
ledipasvir-sofosbuvir.................38
leflunomide.............................178
LENVIMA (10 MG DAILY
DOSE).....................................48
LENVIMA (12 MG DAILY
DOSE).....................................48
LENVIMA (14 MG DAILY
DOSE).....................................48
LENVIMA (18 MG DAILY
DOSE).....................................48
LENVIMA (20 MG DAILY
DOSE).....................................49
LENVIMA (24 MG DAILY
DOSE).....................................49
LENVIMA (4 MG DAILY
DOSE).....................................49
LENVIMA (8 MG DAILY
DOSE).....................................49
LESCOL XL........................... 58
LETAIRIS.............................. 66
letrozole...................................44
233
leucovorin calcium....................53
LEUKERAN..........................42
LEUKINE............................ 164
leuprolide acetate..................... 44
levalbuterol hcl....................... 200
levalbuterol tartrate................200
levamlodipine maleate.............. 62
LEVEMIR............................ 114
LEVEMIR FLEXPEN..........114
levetiracetam............................84
levetiracetam er........................84
levobunolol hcl........................190
levocarnitine...........................120
levocetirizine dihydrochloride..199
levofloxacin...................... 37, 192
levonorgest-eth estrad 91-day. 123
levonorgestrel-ethinyl estrad... 123
levorphanol tartrate..................20
levothyroxine sodium..............148
LEVULAN KERASTICK....220
LEXAPRO..............................73
LEXETTE.............................217
LEXIVA..................................30
LIALDA............................... 151
LIBERTY NEXT
GENERATION TEST..........133
liberty test..............................133
LIBRAX............................... 151
LICART................................220
lidocaine.................................219
lidocaine hcl........................... 219
lidocaine viscous hcl................221
lidocaine-prilocaine................ 219
LIDODERM.........................219
LILETTA (52 MG)............... 123
linezolid................................... 39
LINZESS.............................. 152
liothyronine sodium................ 148
LIPITOR.................................58
lisinopril...................................54
lisinopril-hydrochlorothiazide... 53
lite touch lancets.....................133
LITETOUCH LANCETS.....133
lithium carbonate..................... 97
lithium carbonate er................. 97
LITHOSTAT........................ 159
LIVALO..................................58
LIVMARLI...........................154
LIVTENCITY........................ 34
LO LOESTRIN FE...............123
LOCOID............................... 217
LOCOID LIPOCREAM.......217
LODINE.................................16
Lofena.....................................17
LOKELMA...........................120
LOMAIRA........................... 118
LONHALA MAGNAIR
REFILL KIT........................ 197
LONHALA MAGNAIR
STARTER KIT.....................197
LONSURF............................. 42
lopinavir-ritonavir.................... 33
LOPROX.............................. 212
loratadine...............................199
loratadine-d 24hr....................202
lorazepam................................ 69
Lorazepam Intensol.................69
LORBRENA.......................... 49
LOREEV XR..........................69
losartan potassium....................56
losartan potassium-hctz............55
LOTEMAX...........................193
LOTEMAX SM.................... 193
loteprednol etabonate............. 193
LOTRONEX.........................152
lovastatin................................. 58
LOVAZA................................ 59
loxapine succinate.................... 80
lubiprostone............................152
LUCEMYRA........................105
LUCENTIS...........................195
luliconazole............................ 212
LUMAKRAS......................... 51
LUMIGAN...........................190
LUMIZYME........................ 137
LUNESTA..............................93
LUPKYNIS.......................... 182
LUPRON DEPOT (1-
MONTH)................................44
LUPRON DEPOT (3-
MONTH)................................44
LUPRON DEPOT (4-
MONTH)................................44
LUPRON DEPOT (6-
MONTH)................................44
LUPRON DEPOT-PED (1-
MONTH).............................. 145
LUPRON DEPOT-PED (3-
MONTH).............................. 145
LUPRON DEPOT-PED (6-
MONTH).............................. 145
lurasidone hcl........................... 80
LUXIQ..................................217
LUZU................................... 212
LYBALVI............................. 105
LYNPARZA...........................52
LYRICA................................. 84
LYRICA CR.........................104
LYSODREN...........................44
lytgobi (12 mg daily dose)........49
lytgobi (16 mg daily dose)........49
lytgobi (20 mg daily dose)........49
LYUMJEV............................114
LYUMJEV KWIKPEN........114
LYUMJEV TEMPO PEN.... 114
LYVISPAH...........................102
MACRODANTIN..................39
mafenide acetate.....................211
malathion............................... 221
maraviroc.................................30
MARINOL........................... 150
MATULANE......................... 42
Matzim La...............................62
MAVENCLAD (10 TABS).....99
MAVENCLAD (4 TABS).......99
MAVENCLAD (5 TABS).......99
MAVENCLAD (6 TABS).......99
MAVENCLAD (7 TABS).....100
MAVENCLAD (8 TABS).....100
MAVENCLAD (9 TABS).....100
MAVYRET............................ 38
MAXALT............................... 95
MAXALT-MLT..................... 95
MAXIDEX........................... 193
MAYZENT...........................100
MAYZENT STARTER
PACK....................................100
m-clear wc..............................202
meclofenamate sodium............. 17
medroxyprogesterone acetate
....................................... 123, 147
mefenamic acid.........................17
mefloquine hcl.......................... 28
megestrol acetate..............44, 147
meijer essential glucose test.... 133
MEIJER TRUETEST TEST 134
MEIJER TRUETRACK
TEST.....................................134
MEKINIST.............................49
234
MEKTOVI..............................49
meloxicam................................17
melphalan.................................42
memantine hcl.......................... 70
memantine hcl er...................... 70
MENEST.............................. 139
MENOPUR.......................... 141
MENOSTAR........................ 139
meperidine hcl.......................... 20
MEPRON............................... 39
mercaptopurine........................ 42
mesalamine............................ 152
mesalamine er................. 151, 152
MESTINON........................... 97
metaxalone.............................102
metformin hcl......................... 109
metformin hcl er..................... 109
metformin hcl er (mod)..........109
metformin hcl er (osm).......... 109
methadone hcl.....................20, 21
Methadone Hcl Intensol..........20
METHADOSE....................... 21
METHADOSE SUGAR-
FREE......................................21
methamphetamine hcl...............90
methazolamide......................... 64
methenamine hippurate.............39
methenamine mandelate........... 39
Methergine............................ 146
methimazole........................... 148
methitest................................ 108
methocarbamol.......................102
methotrexate..........................178
methotrexate sodium................ 42
methotrexate sodium (pf)........ 42
methoxsalen rapid.................. 213
methscopolamine bromide.......149
methyldopa.............................. 65
methylergonovine maleate.......146
METHYLIN...........................90
methylphenidate....................... 91
methylphenidate hcl............ 90, 91
methylphenidate hcl er..............90
methylphenidate hcl er (cd)......90
methylphenidate hcl er (la)...... 90
methylphenidate hcl er (osm)... 90
methylphenidate hcl er (xr)......90
methylprednisolone.................142
methyltestosterone..................108
metoclopramide hcl.................150
metolazone...............................64
metoprolol succinate er.............61
metoprolol tartrate...................61
metoprolol-hydrochlorothiazide 60
METROCREAM..................221
METROGEL........................ 221
METROLOTION................. 221
metronidazole............39, 161, 221
metyrosine................................65
MICARDIS............................ 56
MICARDIS HCT................... 55
miconazole 3...........................161
miconazole-zinc oxide-petrolat212
MICRHOGAM ULTRA-
FILTERED PLUS................ 180
MICRODOT TEST.............. 134
MICROLET LANCETS.......134
midazolam hcl.......................... 93
midodrine hcl............................65
MIGERGOT.......................... 95
miglitol...................................109
miglustat................................ 137
MIGRANAL.......................... 95
Millipred................................142
Mimvey................................. 139
MINASTRIN 24 FE............. 123
MINIVELLE........................ 140
minocycline hcl.........................41
minocycline hcl er.....................41
MINOLIRA............................41
minoxidil..................................65
MIRCERA............................164
MIRENA (52 MG)............... 123
mirtazapine.............................. 73
MIRVASO............................ 221
misoprostol.............................154
MITIGARE............................ 15
modafinil................................103
moexipril hcl............................ 54
mometasone furoate.204, 217, 218
MONOVISC........................... 26
montelukast sodium................203
morphine sulfate................. 21, 22
morphine sulfate (concentrate).21
morphine sulfate er...................21
morphine sulfate er beads......... 21
MOTEGRITY...................... 154
MOTOFEN...........................149
MOUNJARO........................111
MOVANTIK........................ 154
MOVIPREP..........................153
moxifloxacin hcl............... 37, 192
moxifloxacin hcl (2x day)......192
MS CONTIN.......................... 22
MULPLETA.........................164
MULTAQ...............................56
multi-mac...............................185
mupirocin............................... 211
mupirocin calcium.................. 211
MUSE................................... 159
MYALEPT........................... 137
MYCAPSSA......................... 107
mycophenolate mofetil............182
mycophenolate sodium............182
MYDAYIS..............................91
MYFEMBREE..................... 140
MYGLUCOHEALTH TEST
...............................................134
MYLERAN............................ 42
MYRBETRIQ.......................160
MYTESI............................... 149
MYXREDLIN......................114
na ferric gluc cplx in sucrose...188
na sulfate-k sulfate-mg sulf.....153
nabumetone..............................17
nadolol.....................................61
naftifine hcl............................ 212
NAFTIN............................... 212
NAGLAZYME.....................137
nalocet..................................... 22
naloxone hcl........................... 104
naltrexone hcl.........................104
NAMENDA........................... 70
NAMENDA TITRATION
PAK........................................ 70
NAMENDA XR.....................70
NAMZARIC.......................... 70
NAPRELAN.......................... 17
NAPROSYN.......................... 17
naproxen..................................17
naproxen sodium...................... 17
naproxen sodium er.................. 17
naproxen-esomeprazole mg.......18
naratriptan hcl......................... 95
NARCAN............................. 104
NASACORT ALLERGY
24HR.....................................204
NASCOBAL......................... 170
NATACHEW....................... 185
natal pnv................................ 185
235
NATALVIT.......................... 185
NATAZIA............................ 124
nateglinide..............................116
NATESTO............................ 108
NAYZILAM...........................84
nebivolol hcl............................. 61
Necon 0.5/35 (28)...................124
NEEVO DHA....................... 185
nefazodone hcl..........................73
neomycin sulfate.......................27
neomycin-polymyxin-dexameth
...............................................191
neomycin-polymyxin-hc..........222
neonatal + dha....................... 185
neonatal 19.............................185
neonatal fe..............................185
NEORAL..............................182
NEO-SYNALAR..................211
NEPHPLEX RX...................188
NERLYNX.............................49
NESINA................................110
NESTABS.............................185
NESTABS DHA................... 185
NESTABS ONE....................185
NEULASTA......................... 164
NEULASTA ONPRO.......... 164
NEUPOGEN........................ 164
NEUPRO................................77
NEURONTIN........................84
NEUTEK 2TEK TEST.........134
NEVANAC...........................193
nevirapine.................................30
nevirapine er.............................30
NEXAVAR.............................49
NEXICLON XR.....................65
NEXIUM..............................156
NEXIUM 24HR................... 156
NEXLETOL........................... 57
NEXLIZET.............................57
NEXPLANON......................124
NEXTSTELLIS.................... 124
niacin er (antihyperlipidemic).. 59
NIACOR.................................59
nicardipine hcl..........................62
NICOMIDE..........................188
nicotinamide...........................188
NICOTROL..........................106
NICOTROL NS....................107
nifedipine er............................. 62
nifedipine er osmotic release..... 62
NILANDRON........................44
nilutamide................................ 44
nimodipine................................62
NINLARO..............................53
nisoldipine er............................62
nitazoxanide.............................39
nitisinone................................143
nitrofurantoin...........................39
nitrofurantoin macrocrystal......39
nitrofurantoin monohyd macro. 39
nitroglycerin.............................65
NITYR..................................143
NIVESTYM..........................164
nizatidine................................151
NOCDURNA....................... 148
NORDITROPIN FLEXPRO144
norethin ace-eth estrad-fe....... 124
norethindrone......................... 124
norethindrone acetate............. 147
norethindrone acet-ethinyl est. 124
norethin-eth estradiol-fe..........124
Norgesic................................ 102
norgesic forte......................... 102
norgestimate-eth estradiol.......124
norgestim-eth estrad triphasic.124
NORITATE..........................221
NORLIQVA........................... 62
NORPACE............................. 56
NORPRAMIN....................... 74
NORTHERA..........................65
Nortrel 0.5/35 (28)................. 124
Nortrel 1/35 (21).................... 124
Nortrel 7/7/7.......................... 124
nortriptyline hcl........................74
NORVASC............................. 62
NORVIR.................................30
NOURIANZ...........................77
NOVA MAX GLUCOSE
TEST.....................................134
NOVAREL........................... 141
NOVOEIGHT.......................167
NOVOLIN 70/30...................114
NOVOLIN 70/30 FLEXPEN 114
NOVOLIN 70/30 FLEXPEN
RELION............................... 114
NOVOLIN 70/30 RELION...114
NOVOLIN N........................ 115
NOVOLIN N FLEXPEN..... 115
NOVOLIN N FLEXPEN
RELION............................... 115
NOVOLIN N RELION........ 115
NOVOLIN R........................ 115
NOVOLIN R FLEXPEN..... 115
NOVOLIN R FLEXPEN
RELION............................... 115
NOVOLIN R RELION........ 115
NOVOLOG...........................115
NOVOLOG 70/30 FLEXPEN
RELION............................... 115
NOVOLOG FLEXPEN........115
NOVOLOG MIX 70/30........ 115
NOVOLOG MIX 70/30
FLEXPEN............................ 115
NOVOLOG PENFILL......... 115
NOVOSEVEN RT................ 163
NOXAFIL.............................. 27
NPLATE...............................164
NUBEQA................................45
NUCALA............................. 205
NUCYNTA............................ 22
NUCYNTA ER...................... 22
NUEDEXTA........................ 105
NUPLAZID............................80
NURTEC................................95
NUTROPIN AQ NUSPIN 10
...............................................144
NUTROPIN AQ NUSPIN 20
...............................................144
NUTROPIN AQ NUSPIN 5 144
NUVARING........................ 124
NUVESSA............................ 161
NUVIGIL............................. 103
NUWIQ................................ 167
NUZYRA............................... 41
nystatin..................... 27, 212, 221
nystatin-triamcinolone............212
NYVEPRIA..........................165
OB COMPLETE...................185
OB COMPLETE ONE..........185
OB COMPLETE PETITE.... 185
OB COMPLETE PREMIER 185
OB COMPLETE/DHA.........185
obizur.....................................167
OBSTETRIX DHA...............185
OBSTETRIX ONE............... 185
OCALIVA.............................154
OCTAGAM..........................180
octreotide acetate................... 107
ODACTRA...........................170
ODEFSEY.............................. 33
236
ODOMZO...............................52
OFEV....................................205
ofloxacin.........................192, 222
olanzapine................................80
olanzapine-fluoxetine hcl........ 105
olmesartan medoxomil............. 56
olmesartan medoxomil-hctz......55
olmesartan-amlodipine-hctz......55
olopatadine hcl....................... 199
OLUMIANT.........................175
OLUX-E............................... 218
omega-3-acid ethyl esters..........59
omeprazole.............................156
omeprazole magnesium...........156
omeprazole-sodium
bicarbonate............................ 156
OMNARIS............................204
OMNIFLEX DIAPHRAGM124
OMNIPOD 5 G6 INTRO
(GEN 5).................................134
OMNIPOD 5 G6 POD (GEN
5)........................................... 134
OMNIPOD CLASSIC PODS
(GEN 3).................................134
OMNIPOD DASH INTRO
(GEN 4).................................134
OMNIPOD DASH PDM
(GEN 4).................................134
OMNIPOD DASH PODS
(GEN 4).................................134
OMNIPOD GO.................... 134
OMNITROPE.......................144
ondansetron............................150
ondansetron hcl...................... 150
one drop test...........................134
ONETOUCH DELICA
PLUS LANCET30G............. 134
ONETOUCH DELICA
SAFETY LANCING............134
ONETOUCH ULTRA......... 134
ONETOUCH ULTRASOFT
2 LANCETS..........................134
ONETOUCH VERIO...........134
ONEXTON...........................210
ONFI...................................... 84
ONGENTYS.......................... 77
ONGLYZA...........................110
ONUREG...............................42
ONZETRA XSAIL.................95
OPSUMIT...............................66
OPTIONS GYNOL II
CONTRACEPTIVE............. 158
OPTIUMEZ TEST............... 134
OPZELURA......................... 214
ORACEA..............................221
ORALAIR............................ 170
ORAVIG...............................221
ORENCIA.....................171, 175
ORENCIA CLICKJECT......175
ORENITRAM........................66
ORENITRAM MONTH 1..... 66
ORENITRAM MONTH 2..... 66
ORENITRAM MONTH 3..... 66
ORFADIN............................143
ORGOVYX............................ 45
ORIAHNN........................... 140
ORILISSA............................ 136
ORKAMBI....................202, 203
ORLADEYO........................ 179
orlistat................................... 118
orphenadrine-aspirin-caffeine..102
Orphengesic Forte................. 102
ORSERDU............................. 45
ORTHOVISC......................... 26
ORTIKOS.............................152
oseltamivir phosphate............... 35
OSENI...................................110
OSMOLEX ER.......................77
OSMOPREP......................... 153
OSPHENA............................146
OTEZLA...............................175
OTOVEL...............................222
OTREXUP............................178
OVIDREL.............................141
oxandrolone........................... 108
oxaprozin.................................17
OXAYDO...............................22
oxazepam.................................69
OXBRYTA........................... 169
oxcarbazepine.......................... 84
OXERVATE.........................194
oxiconazole nitrate................. 212
OXISTAT............................. 212
OXTELLAR XR.................... 85
oxybutynin chloride................ 161
oxybutynin chloride er............ 161
oxycodone hcl.......................... 22
oxycodone hcl er.......................22
oxycodone-acetaminophen........23
OXYCONTIN........................ 23
oxymorphone hcl......................23
oxymorphone hcl er.................. 23
OZEMPIC (0.25 OR 0.5
MG/DOSE)...........................111
OZEMPIC (1 MG/DOSE).... 111
OZEMPIC (2 MG/DOSE).... 111
OZOBAX.............................. 102
PALFORZIA (12 MG
DAILY DOSE)..................... 170
PALFORZIA (120 MG
DAILY DOSE)..................... 170
PALFORZIA (160 MG
DAILY DOSE)..................... 170
PALFORZIA (20 MG
DAILY DOSE)..................... 170
PALFORZIA (200 MG
DAILY DOSE)..................... 170
PALFORZIA (240 MG
DAILY DOSE)..................... 170
PALFORZIA (3 MG DAILY
DOSE)...................................170
PALFORZIA (300 MG
MAINTENANCE)............... 170
PALFORZIA (300 MG
TITRATION)....................... 170
PALFORZIA (40 MG
DAILY DOSE)..................... 170
PALFORZIA (6 MG DAILY
DOSE)...................................170
PALFORZIA (80 MG
DAILY DOSE)..................... 170
PALFORZIA INITIAL
ESCALATION..................... 171
paliperidone er..........................80
PALYNZIQ.......................... 137
PAMELOR.............................74
pamidronate disodium.............119
PANCREAZE.......................155
PANDEL.............................. 218
pantoprazole sodium...............156
PANZYGA........................... 181
PARAGARD
INTRAUTERINE COPPER 124
paricalcitol............................. 188
paromomycin sulfate................ 27
paroxetine hcl...........................75
paroxetine hcl er.......................74
paroxetine mesylate................105
PARSABIV...........................119
PATANASE..........................199
237
PAXIL.................................... 75
PAXIL CR..............................75
peg 3350-kcl-na bicarb-nacl....153
peg-3350/electrolytes..............153
PEGASYS...............................38
peg-kcl-nacl-nasulf-na asc-c....153
PEG-PREP............................153
PEMAZYRE.......................... 49
penciclovir..............................220
penicillamine.......................... 120
penicillin v potassium................40
PENNSAID.......................... 220
pentamidine isethionate............ 39
PENTASA............................ 152
pentazocine-naloxone hcl..........25
pentoxifylline er..................... 168
PERCOCET............................23
PERFOROMIST.................. 200
perindopril erbumine.................54
permethrin..............................221
perphenazine............................ 80
perphenazine-amitriptyline..... 105
PERSERIS..............................80
PERTZYE.............................155
PEXEVA.................................75
PHARMACIST CHOICE
AUTOCODE........................ 134
pharmacist choice no coding... 135
PHEBURANE......................137
phendimetrazine tartrate.........118
phendimetrazine tartrate er.....118
phenelzine sulfate..................... 75
phenobarbital........................... 85
phenoxybenzamine hcl..............65
phentermine hcl...................... 118
phenylephrine hcl....................159
phenytoin................................. 85
phenytoin sodium extended.......85
PHEXXI................................158
phytonadione..........................189
PIFELTRO.............................30
pilocarpine hcl.................190, 222
pimecrolimus.......................... 220
pimozide.................................105
pindolol....................................61
pioglitazone hcl...................... 116
pioglitazone hcl-glimepiride.... 116
pioglitazone hcl-metformin hcl 116
PIQRAY (200 MG DAILY
DOSE).....................................49
PIQRAY (250 MG DAILY
DOSE).....................................49
PIQRAY (300 MG DAILY
DOSE).....................................49
pirfenidone............................. 205
piroxicam.................................17
PLAVIX................................169
PLEGRIDY.......................... 100
PLEGRIDY STARTER
PACK....................................100
PLENVU.............................. 153
PLIAGLIS............................ 219
pnv prenatal plus multivit+dha 186
pnv tabs 20-1.......................... 186
pnv-dha.................................. 186
pnv-dha+docusate...................186
pnv-omega..............................186
POCKETCHEM EZ TEST...135
podofilox................................220
POGO AUTOMATIC TEST
CARTRIDGES.....................135
polymyxin b-trimethoprim...... 192
POLY-VI-FLOR...................189
POLY-VI-FLOR/IRON........189
POMALYST...........................43
PONVORY........................... 100
PONVORY STARTER
PACK....................................100
posaconazole............................28
pot & sod cit-cit ac..................159
potassium chloride..................183
potassium chloride crys er.......183
potassium chloride er..............183
potassium citrate er................ 160
PRADAXA...........................162
PRALUENT...........................59
pramipexole dihydrochloride.....77
pramipexole dihydrochloride er.77
prasugrel hcl...........................169
pravastatin sodium................... 58
praziquantel............................. 26
prazosin hcl..............................54
PRECISION THINS GP
LANCETS............................ 135
PRECISION XTRA BLOOD
GLUCOSE............................135
PRED FORTE......................194
PRED MILD........................ 194
prednisolone........................... 142
prednisolone acetate............... 194
prednisolone sodium phosphate142
prednisone.............................. 142
PREFEST............................. 140
pregabalin................................ 85
pregabalin er.......................... 104
pregen dha..............................186
pregenna................................ 186
PREGNYL........................... 141
PREMARIN.........................140
premium blood glucose test..... 135
PREMPHASE.......................140
PREMPRO........................... 140
prena 1 true............................186
prenaissance...........................186
prenaissance plus....................186
PRENATAL-U.....................186
PRENATE............................186
PRENATE AM.....................186
PRENATE DHA.................. 186
PRENATE ELITE................186
PRENATE ENHANCE........186
PRENATE MINI..................186
PRENATE PIXIE.................186
PRENATE RESTORE......... 186
prenatvite plus........................ 186
PRESTALIA...........................53
pretomanid...............................34
PREVACID.......................... 156
PREVACID SOLUTAB....... 156
PREVYMIS............................ 35
PREZCOBIX..........................33
PREZISTA............................. 30
PRIALT..................................15
PRILOSEC........................... 156
PRILOSEC OTC...................156
PRIMACARE.......................186
primaquine phosphate...............28
primidone.................................85
PRISTIQ.................................75
PRIVIGEN........................... 181
pro voice v8/v9 glucose............135
PROAIR DIGIHALER........200
PROAIR RESPICLICK....... 200
probenecid................................15
Procentra.................................91
prochlorperazine maleate........150
PROCRIT............................. 165
PROCTOCORT....................157
PROCTOFOAM HC............ 157
Proctozone-Hc.......................157
238
PROCYSBI...........................160
PRODIGY NO CODING
BLOOD GLUC.....................135
PROFILNINE...................... 168
progesterone...........................147
PROGRAF........................... 182
PROLASTIN-C.................... 195
PROLATE.............................. 23
PROLENSA..........................194
PROLIA................................146
PROMACTA........................165
promethazine hcl.................... 150
promethazine vc......................202
promethazine vc/codeine......... 202
promethazine-codeine............. 202
promethazine-dm....................202
PROMETHEGAN............... 150
PROMETRIUM...................147
propafenone hcl........................56
propafenone hcl er.................... 56
propranolol hcl......................... 61
propranolol hcl er..................... 61
propylthiouracil......................148
PROSCAR............................ 158
PROTONIX..........................156
protriptyline hcl........................75
PROVENTIL HFA...............200
PROVIDA OB...................... 186
PROVIGIL........................... 103
PROZAC................................ 75
PRUDOXIN......................... 213
pseudoeph-bromphen-dm........ 202
PTS PANELS EGLU TEST. 135
PULMICORT.......................206
PULMICORT
FLEXHALER...................... 206
PULMOZYME.....................203
PURIXAN..............................42
PYLERA...............................157
pyrazinamide............................34
pyridostigmine bromide............ 97
pyridostigmine bromide er........ 97
pyrimethamine......................... 39
PYRUKYND....................... 168
PYRUKYND TAPER
PACK....................................168
qc lansoprazole.......................156
QDOLO.................................. 23
QELBREE.............................. 91
QINLOCK..............................49
QNASL................................. 204
QNASL CHILDRENS......... 204
QSYMIA...............................118
QTERN.................................117
quad-mix................................159
QUARTETTE...................... 124
quazepam.................................93
QUDEXY XR.........................85
quetiapine fumarate..................80
quetiapine fumarate er..............80
QUFLORA FE..................... 189
QUFLORA FE PEDIATRIC
...............................................189
QUFLORA GUMMIES.......189
QUICKTEK TEST............... 135
QUILLICHEW ER.................91
QUILLIVANT XR.................91
quinapril hcl............................. 54
quinapril-hydrochlorothiazide...53
quinidine sulfate....................... 56
quinine sulfate.......................... 28
QUINTET AC BLOOD
GLUCOSE TEST................. 135
QUINTET BLOOD
GLUCOSE TEST................. 135
QULIPTA...............................95
QUVIVIQ............................... 93
QVAR REDIHALER...........207
ra omeprazole.........................157
rabeprazole sodium.................157
RADICAVA ORS.................. 97
RADICAVA ORS
STARTER KIT...................... 97
RAGWITEK.........................171
raloxifene hcl..........................146
ramelteon.................................93
ramipril....................................54
ranolazine er............................ 65
RAPAFLO............................158
rasagiline mesylate................... 78
RASUVO.............................. 178
RAVICTI.............................. 138
RAYALDEE.........................148
RAYOS.................................142
REBIF...................................101
REBIF REBIDOSE.............. 100
REBIF REBIDOSE
TITRATION PACK.............101
REBIF TITRATION PACK 101
REBINYN............................ 168
RECLAST.............................119
Reclipsen............................... 125
RECOMBINATE................. 167
RECORLEV......................... 126
REDITREX..........................178
REFUAH PLUS BLOOD
GLUCOSE TEST................. 135
REGRANEX........................221
RELAFEN DS........................17
RELENZA DISKHALER......35
RELEUKO........................... 165
releuko................................... 165
RELEXXII............................. 91
RELION BLOOD
GLUCOSE TEST................. 135
RELION
CONFIRM/MICRO TEST...135
RELION PRIME TEST....... 135
RELION ULTIMA TEST.... 135
RELISTOR...........................154
RELPAX.................................95
RELTONE............................154
RELYVRIO............................97
REMICADE.........................171
REMODULIN....................... 66
RENATABS WITH IRON...189
RENFLEXIS........................ 171
reno caps................................189
RENVELA............................147
repaglinide............................. 116
REPATHA............................. 59
REPATHA PUSHTRONEX
SYSTEM.................................59
REPATHA SURECLICK......59
RESTASIS............................ 194
RESTASIS MULTIDOSE....194
RESTORIL.............................93
RETACRIT.......................... 165
RETEVMO....................... 49, 50
RETIN-A.............................. 210
RETIN-A MICRO................210
RETIN-A MICRO PUMP....210
RETROVIR............................30
REVATIO......................... 66, 67
REVLIMID............................ 43
REXULTI...............................80
REYATAZ........................30, 31
REYVOW...............................95
REZLIDHIA.......................... 52
REZUROCK........................ 182
239
REZVOGLAR KWIKPEN.. 115
RHOFADE...........................221
RHOGAM ULTRA-
FILTERED PLUS................ 181
RHOPHYLAC......................181
RHOPRESSA....................... 190
RIASTAP..............................163
ribavirin................................... 38
rifabutin...................................34
rifampin................................... 34
RIGHTEST GS100 BLOOD
GLUCOSE............................135
RIGHTEST GS300 BLOOD
GLUCOSE............................135
RIGHTEST GS550 BLOOD
GLUCOSE............................135
riluzole.....................................97
rimantadine hcl........................ 35
RINVOQ....................... 175, 176
RIOMET...............................109
risedronate sodium..................119
risperidone............................... 80
RITALIN................................91
RITALIN LA......................... 91
ritonavir...................................31
rivastigmine..............................70
rivastigmine tartrate.................70
Rivelsa...................................125
rixubis....................................168
rizatriptan benzoate..................96
ROBINUL............................ 149
ROBINUL-FORTE..............149
ROCKLATAN..................... 190
roflumilast..............................204
ROLVEDON........................ 165
ropinirole hcl............................78
ropinirole hcl er........................78
rosuvastatin calcium.................58
ROSZET................................. 59
ROWASA............................. 152
ROXICODONE..................... 23
ROXYBOND......................... 24
ROZEREM.............................93
ROZLYTREK........................50
RUBRACA.............................52
RUCONEST.........................179
rufinamide................................85
RUKOBIA..............................31
RYALTRIS...........................198
RYBELSUS.......................... 111
RYCLORA...........................199
RYDAPT................................50
RYTARY................................78
RYVENT.............................. 199
SABRIL.................................. 85
SAFYRAL............................125
SAIZEN................................ 144
SAIZENPREP...................... 144
SAMSCA.............................. 146
SANCUSO............................150
SANDIMMUNE.................. 182
SANDOSTATIN.................. 107
SANDOSTATIN LAR
DEPOT................................. 107
SANTYL...............................220
SAPHRIS................................80
sapropterin dihydrochloride.... 138
sapscare twist top lancets........135
SAVAYSA............................ 162
SAVELLA.............................. 92
SAVELLA TITRATION
PACK..................................... 92
SAXENDA........................... 118
SCEMBLIX............................ 50
scopolamine............................151
SEASONIQUE..................... 125
SECUADO............................. 80
SEGLENTIS...........................24
SEGLUROMET................... 117
SELECT-OB..................186, 187
SELECT-OB+DHA..............187
selegiline hcl.............................78
SELZENTRY......................... 31
SEMGLEE (YFGN)......115, 116
SENSIPAR........................... 119
SEREVENT DISKUS.......... 200
SERNIVO............................. 218
SEROQUEL XR.....................80
SEROSTIM...........................144
sertraline hcl............................ 75
sevelamer carbonate............... 147
sevelamer hcl..........................147
SEVENFACT....................... 163
SEYSARA.............................. 41
SFROWASA.........................152
SHUR-SEAL
CONTRACEPTIVE............. 158
SIGNIFOR........................... 146
SIGNIFOR LAR.................. 146
SIKLOS.................................169
sildenafil citrate................ 67, 159
SILENOR............................... 93
SILIQ.................................... 176
silodosin................................. 158
silver sulfadiazine................... 211
SIMBRINZA........................ 191
SIMPLE DIAGNOSTICS
LANCING DEV...................135
SIMPONI..............................176
SIMPONI ARIA...................171
SIMULECT.......................... 182
simvastatin...............................58
SINEMET...............................78
SINGULAIR........................ 203
sirolimus.................................183
SIRTURO...............................34
SITAVIG................................ 35
SIVEXTRO.............................39
SKYCLARYS.........................97
SKYLA................................. 125
SKYRIZI.............................. 176
SKYRIZI PEN......................176
SKYTROFA.........................144
SLYND.................................125
sm loratadine..........................199
sm loratadine allergy relief..... 199
sm loratadine d 12hr............... 202
SMART SENSE PREMIUM
TEST.....................................136
SMARTEST BLOOD
GLUCOSE TEST................. 136
SOAANZ................................ 64
sodium chloride...................... 204
sodium fluoride.......................184
sodium oxybate...................... 103
sodium phenylbutyrate............138
sodium polystyrene sulfonate.. 120
sofosbuvir-velpatasvir............... 38
solifenacin succinate............... 161
SOLIQUA.............................111
SOLODYN............................. 41
SOLOSEC...............................39
SOLUS V2 TEST.................. 136
SOMA...................................102
SOMATULINE DEPOT...... 107
SOMAVERT.........................107
SOOLANTRA...................... 221
sorafenib tosylate..................... 50
SORILUX.............................213
sotalol hcl...........................56, 57
240
sotalol hcl (af).........................56
SOTYKTU............................213
SOVALDI...............................38
spinosad................................. 221
SPIRIVA HANDIHALER...197
SPIRIVA RESPIMAT.......... 197
spironolactone..........................64
spironolactone-hctz.................. 64
SPORANOX...........................28
SPRAVATO (56 MG DOSE). 75
SPRAVATO (84 MG DOSE). 75
SPRITAM...............................85
SPRIX.....................................17
SPRYCEL...............................50
SPS........................................ 121
Ssd.........................................211
stavudine..................................31
STEGLATRO.......................117
STEGLUJAN....................... 117
STELARA.....................176, 177
STENDRA............................159
sterile water for irrigation.......195
STIMUFEND.......................165
STIOLTO RESPIMAT.........197
STIVARGA............................ 50
STRATTERA.........................91
STRENSIQ........................... 138
STRIBILD.............................. 33
STRIVERDI RESPIMAT.... 201
SUBLOCADE........................ 25
SUBOXONE.........................103
SUBSYS..................................24
SUCRAID............................ 154
sucralfate............................... 154
sulconazole nitrate.......... 212, 213
sulfacetamide sodium..............192
sulfacetamide sodium (acne).. 210
sulfacetamide-prednisolone..... 191
sulfadiazine.............................. 27
sulfamethoxazole-trimethoprim 27
sulfasalazine...........................152
sulindac....................................17
sumatriptan..............................96
sumatriptan succinate...............96
sumatriptan succinate refill.......96
sumatriptan-naproxen sodium...96
sunitinib malate........................50
SUNLENCA...........................31
SUNOSI................................103
SUPARTZ FX........................ 26
super quad-mix.......................159
super thin lancets....................136
SUPRAX................................ 36
SUPREME TEST................. 136
SUPREP BOWEL PREP KIT
...............................................153
SUSTIVA................................31
SUTAB..................................153
SUTENT.................................50
SX1 MEDICATED POST-
OPERATIVE........................ 219
SYMBICORT....................... 207
SYMDEKO.......................... 203
SYMFI....................................33
SYMFI LO..............................33
SYMJEPI.............................. 196
SYMLINPEN 120.................109
SYMLINPEN 60...................109
SYMPAZAN.......................... 85
SYMPROIC..........................154
SYMTUZA.............................33
SYNAGIS............................. 183
SYNALAR........................... 218
SYNAREL............................145
SYNDROS............................151
SYNERA.............................. 219
SYNJARDY......................... 117
SYNJARDY XR...................117
SYNOJOYNT.........................26
SYNRIBO...............................52
SYNVISC................................26
SYNVISC ONE...................... 26
SYPRINE............................. 121
TABLOID...............................42
TABRECTA........................... 50
TACLONEX.........................218
tacrolimus.......................183, 220
tadalafil..................................159
tadalafil (pah)......................... 67
TADLIQ................................. 67
TAFINLAR............................50
tafluprost (pf)........................191
TAGRISSO.............................50
TAKHZYRO........................179
TALICIA.............................. 157
TALTZ..................................177
TALZENNA...........................52
TAMIFLU..............................35
tamoxifen citrate......................45
tamsulosin hcl.........................158
TAPERDEX 12-DAY...........142
Taperdex 6-Day.....................142
TAPERDEX 7-DAY............ 142
TARCEVA............................. 50
Targadox.................................41
TARGRETIN................. 52, 220
TARON-C DHA...................187
TARPEYO............................160
TASCENSO ODT.................101
TASIGNA...............................50
tasimelteon...............................93
tavaborole.............................. 213
TAVALISSE......................... 168
TAVNEOS............................169
TAYTULLA.........................125
tazarotene.......................210, 213
TAZORAC........................... 213
TAZVERIK............................52
TECFIDERA........................101
TEGRETOL........................... 85
TEGRETOL-XR.................... 86
TEGSEDI............................. 147
TEKTURNA HCT.................63
telmisartan...............................56
telmisartan-amlodipine.............55
telmisartan-hctz....................... 55
temazepam...............................93
temozolomide........................... 42
tenofovir disoproxil fumarate....31
TEPMETKO...........................50
terazosin hcl.............................54
terbinafine hcl.......................... 28
terbutaline sulfate...................201
terconazole.............................161
teriflunomide..........................101
teriparatide (recombinant).....146
TESTIM................................108
testosterone............................ 108
testosterone cypionate............ 108
testosterone enanthate............ 108
tetrabenazine............................98
tetracycline hcl.........................41
TEXACORT.........................218
TEZSPIRE............................205
THALITONE......................... 64
THALOMID.......................... 43
THEO-24...............................208
theophylline............................208
theophylline er........................208
THIOLA............................... 160
241
THIOLA EC......................... 160
thioridazine hcl.........................81
thiothixene............................... 81
THYMOGLOBULIN...........183
THYQUIDITY.....................148
tiagabine hcl.............................86
TIBSOVO............................... 52
TIGLUTIK.............................97
TIKOSYN...............................57
Tilia Fe.................................. 125
timolol maleate................. 61, 191
timolol maleate (once-daily).. 191
Timolol Maleate Ocudose......191
timolol maleate pf...................191
TIMOPTIC OCUDOSE....... 191
tinidazole................................. 27
tiopronin................................ 160
TIROSINT............................148
TIROSINT-SOL................... 148
TIVICAY................................31
TIVICAY PD..........................31
tizanidine hcl...................102, 103
TLANDO..............................108
TOBI..................................... 203
TOBI PODHALER.............. 203
TOBRADEX.........................191
TOBRADEX ST................... 191
tobramycin......................192, 203
tobramycin-dexamethasone.... 191
TODAY SPONGE................158
tolcapone..................................78
tolsura......................................28
tolterodine tartrate................. 161
tolterodine tartrate er............. 161
tolvaptan................................ 146
TOPICORT...........................218
TOPICORT SPRAY.............218
topiramate............................... 86
topiramate er............................86
TOPROL XL.......................... 61
toremifene citrate..................... 45
torsemide................................. 64
TOSYMRA.............................96
TOUJEO MAX SOLOSTAR116
TOUJEO SOLOSTAR..........116
Tovet..................................... 218
TOVIAZ................................161
TRACLEER........................... 67
TRADJENTA.......................110
tramadol hcl.............................24
tramadol hcl (er biphasic)........24
tramadol hcl er.........................24
tramadol-acetaminophen.......... 24
trandolapril.............................. 54
trandolapril-verapamil hcl er.... 53
tranexamic acid......................169
TRANSDERM-SCOP.......... 151
tranylcypromine sulfate............ 75
TRAVATAN Z.....................191
travoprost (bak free)..............191
trazodone hcl............................75
TRELEGY ELLIPTA...........197
TRELSTAR MIXJECT..........45
TREMFYA...........................177
treprostinil............................... 67
TRESIBA..............................116
TRESIBA FLEXTOUCH.....116
tretinoin............................52, 210
tretinoin microsphere..............210
TRETTEN............................ 163
TREXALL..............................42
TREXIMET............................96
triamcinolone acetonide
................................204, 218, 222
triamterene...............................64
triamterene-hctz.......................64
triazolam..................................93
TRICOR................................. 58
TRIDESILON...................... 218
trientine hcl............................ 121
TRIFERIC............................189
trifluoperazine hcl.................... 81
trifluridine..............................192
trihexyphenidyl hcl...................78
TRIJARDY XR....................110
TRIKAFTA..........................203
Tri-Legest Fe......................... 125
TRILEPTAL...........................86
Tri-Lo-Sprintec......................125
TRILURON........................... 26
trimethobenzamide hcl............151
trimipramine maleate............... 76
TRINATE.............................187
TRINTELLIX........................ 76
TRIPTODUR....................... 145
tristart dha............................. 187
TRIUMEQ............................. 33
TRIUMEQ PD....................... 33
tri-vi-floro.............................. 189
TRIVISC.................................26
TRIZIVIR...............................34
TROKENDI XR.................... 86
tropicamide............................ 194
trospium chloride....................161
trospium chloride er................161
TRUDHESA.......................... 96
true focus blood glucose strip.. 136
TRUE METRIX BLOOD
GLUCOSE TEST................. 136
TRUEPLUS LANCETS 26G136
TRUEPLUS LANCETS 30G136
TRUEPLUS SAFETY
LANCETS 28G.....................136
TRUETEST TEST................136
TRUETRACK TEST........... 136
TRULICITY.........................111
TRUVADA............................ 34
TUDORZA PRESSAIR....... 197
TUKYSA................................50
TURALIO.............................. 51
TUXARIN ER......................202
TUZISTRA XR.................... 202
TWIRLA...............................125
TWYNEO............................. 210
TYBLUME...........................125
TYBOST................................. 31
TYKERB................................ 51
TYMLOS.............................. 146
TYRVAYA...........................194
TYSABRI............................. 101
TYVASO.................................67
TYVASO DPI
MAINTENANCE KIT.......... 67
TYVASO DPI TITRATION
KIT......................................... 67
TYVASO REFILL................. 67
TYVASO STARTER..............67
UBRELVY............................. 96
UCERIS................................152
UDENYCA.......................... 165
ULORIC.................................15
ULTRAVATE...................... 219
UNISTRIP1 GENERIC....... 136
UPNEEQ.............................. 194
UPTRAVI...............................67
UROXATRAL..................... 158
ursodiol.................................. 154
VAGIFEM............................140
valacyclovir hcl.........................35
VALCHLOR.........................220
242
VALCYTE..............................35
valganciclovir hcl......................35
VALIUM................................ 86
valproic acid.............................86
valsartan.................................. 56
valsartan-hydrochlorothiazide...55
VALTOCO 10 MG DOSE......86
VALTOCO 15 MG DOSE......86
VALTOCO 20 MG DOSE......86
VALTOCO 5 MG DOSE........86
VALTREX..............................35
VANCOCIN........................... 39
vancomycin hcl.........................39
VANOS.................................219
vardenafil hcl..........................159
varenicline tartrate................. 107
VARIZIG..............................181
VARUBI (180 MG DOSE)... 151
VASCEPA.............................. 59
VCF VAGINAL
CONTRACEPTIVE............. 158
VECAMYL.............................65
VECTICAL...........................213
VELETRI............................... 68
VELIVET..............................125
VELPHORO.........................147
VELTASSA...........................121
VELTIN................................210
VEMLIDY..............................35
VENCLEXTA...................42, 43
VENCLEXTA STARTING
PACK..................................... 43
venlafaxine besylate er............. 76
venlafaxine hcl......................... 76
venlafaxine hcl er..................... 76
VENOFER............................189
VENTAVIS.............................68
VENTOLIN HFA.................201
verapamil hcl............................63
verapamil hcl er.................. 62, 63
verasens blood glucose test......136
VERDESO............................219
VEREGEN........................... 220
VERKAZIA..........................194
VERQUVO.............................64
VERSACLOZ.........................81
VERZENIO............................51
VESICARE...........................161
V-GO 20................................136
V-GO 30................................136
V-GO 40................................136
VIAGRA...............................159
VIBERZI...............................152
VIBRAMYCIN...................... 41
VICTOZA.............................111
vigabatrin.................................86
Vigadrone................................86
VIIBRYD................................76
VIIBRYD STARTER PACK.76
VIJOICE............................... 146
vilazodone hcl...........................76
VIMIZIM..............................138
VIMOVO................................ 18
VIMPAT........................... 86, 87
VINATE II............................187
VINATE ONE...................... 187
VIOKACE............................ 155
VIRACEPT.............................31
VIREAD.................................31
virt-pn dha..............................187
VISCO-3..................................26
VISTOGARD......................... 52
VISUDYNE..........................194
VITAFOL FE+.....................187
VITAFOL GUMMIES.........187
VITAFOL STRIPS............... 187
VITAFOL ULTRA...............187
VITAFOL-NANO................ 187
VITAFOL-OB.......................187
VITAFOL-OB+DHA........... 187
VITAFOL-ONE....................187
VITAMEDMD REDICHEW
RX.........................................187
vitamin d (ergocalciferol).......189
VITAPEARL........................ 187
VITRAKVI.............................51
VIVA DHA...........................187
VIVELLE-DOT.................... 140
VIVITROL............................104
VIVJOA.................................. 28
VIZIMPRO.............................51
VOGELXO........................... 109
VOGELXO PUMP............... 108
VONJO................................... 51
VONVENDI......................... 163
voriconazole............................. 28
VOSEVI.................................. 38
VOTRIENT............................51
VOXZOGO...........................143
VPRIV...................................138
VRAYLAR.............................81
VTAMA................................213
VUMERITY.........................101
VUSION............................... 213
VYLEESI..............................105
VYNDAMAX........................ 64
VYNDAQEL..........................64
VYVANSE..............................92
VYZULTA............................191
WAKIX.................................103
warfarin sodium......................162
WEGOVY.............................118
WELIREG..............................52
wescap-c dha.......................... 187
westgel dha.............................187
WIDE-SEAL DIAPHRAGM
60...........................................125
WIDE-SEAL DIAPHRAGM
65...........................................125
WIDE-SEAL DIAPHRAGM
70...........................................125
WIDE-SEAL DIAPHRAGM
75...........................................126
WIDE-SEAL DIAPHRAGM
80...........................................126
WIDE-SEAL DIAPHRAGM
85...........................................126
WIDE-SEAL DIAPHRAGM
90...........................................126
WIDE-SEAL DIAPHRAGM
95...........................................126
WILATE............................... 163
WINLEVI............................. 210
WINRHO SDF..................... 181
Wixela Inhub.........................207
WYNZORA..........................213
XADAGO...............................78
XALKORI..............................51
XANAX..................................69
XANAX XR........................... 69
XARELTO............................162
XARELTO STARTER
PACK....................................162
XATMEP................................42
XCOPRI................................. 87
XCOPRI (250 MG DAILY
DOSE).....................................87
XCOPRI (350 MG DAILY
DOSE).....................................87
XELJANZ..................... 177, 178
243
XELJANZ XR......................178
XELODA................................42
XELPROS.............................191
XELSTRYM...........................92
XEMBIFY............................ 181
XENAZINE............................98
XENICAL.............................118
XEOMIN.............................. 103
XEPI..................................... 211
XERESE................................. 35
XERMELO...........................154
XGEVA.................................146
XHANCE............................. 204
XIFAXAN........................ 39, 40
XIGDUO XR........................117
XIIDRA................................194
XIMINO.................................41
XOFLUZA (40 MG DOSE)... 35
XOFLUZA (80 MG DOSE)... 35
XOLAIR............................... 205
XOPENEX HFA.................. 201
XOSPATA.............................. 51
XPOVIO (100 MG ONCE
WEEKLY).............................. 52
XPOVIO (40 MG ONCE
WEEKLY).............................. 52
XPOVIO (40 MG TWICE
WEEKLY).............................. 52
XPOVIO (60 MG ONCE
WEEKLY).............................. 52
XPOVIO (60 MG TWICE
WEEKLY).............................. 52
XPOVIO (80 MG ONCE
WEEKLY).............................. 52
XPOVIO (80 MG TWICE
WEEKLY).............................. 52
XTAMPZA ER.......................24
XTANDI.................................45
Xulane...................................126
XULTOPHY.........................111
XURIDEN............................146
XYNTHA............................. 167
XYNTHA SOLOFUSE........ 167
XYOSTED............................109
XYREM................................103
XYWAV................................103
XYZAL ALLERGY 24HR...199
YASMIN 28..........................126
YAZ...................................... 126
YONSA...................................45
YOSPRALA......................... 169
YUPELRI............................. 197
Yuvafem................................140
ZADITOR............................ 189
zafirlukast..............................203
zaleplon....................................93
zalvit...................................... 188
ZARXIO............................... 165
ZAVESCA............................ 138
ZEGALOGUE......................143
ZEGERID.............................157
ZEJULA................................. 52
ZELAPAR.............................. 78
ZELBORAF........................... 51
ZEMAIRA............................195
ZEMBRACE SYMTOUCH...96
Zenatane................................210
ZENPEP............................... 155
Zenzedi....................................92
ZENZEDI...............................92
ZEPATIER.............................38
ZEPOSIA.............................. 101
ZEPOSIA 7-DAY STARTER
PACK....................................101
ZEPOSIA STARTER KIT... 101
ZERVIATE...........................190
ZESTORETIC........................ 53
ZETIA.....................................57
ZETONNA........................... 204
ZIAGEN.................................32
ZIANA..................................210
zidovudine................................ 32
ZIEXTENZO........................165
zileuton er.............................. 203
ZILXI....................................221
ZIMHI.................................. 104
ZIOPTAN............................. 191
ziprasidone hcl..........................81
ziprasidone mesylate.................81
ZIPSOR.................................. 17
ZIRGAN...............................192
ZOKINVY............................ 146
zoledronic acid....................... 119
ZOLINZA...............................53
zolmitriptan............................. 96
ZOLOFT.................................76
zolpidem tartrate......................94
zolpidem tartrate er..................93
ZOLPIMIST........................... 94
ZOMACTON........................144
ZOMIG...................................97
ZONALON...........................213
ZONEGRAN..........................87
ZONISADE............................ 87
zonisamide............................... 87
ZONTIVITY.........................169
ZORBTIVE...........................144
ZORVOLEX...........................17
ZORYVE.............................. 213
ZOVIRAX............................ 220
ZTALMY............................... 87
ZTLIDO................................219
ZUBSOLV.....................103, 104
ZYCLARA........................... 211
ZYCLARA PUMP............... 211
ZYDELIG.............................. 51
ZYFLO................................. 203
ZYKADIA..............................51
ZYLET..................................191
ZYMAXID........................... 192
ZYPITAMAG........................ 59
ZYRTEC ALLERGY...........199
ZYRTEC CHILDRENS
ALLERGY........................... 199
ZYRTEC-D ALLERGY &
CONGESTION.....................202
ZYTIGA................................. 45
ZYVOX...................................40
244