2023 Aetna Pharmacy Drug Guide Advanced Control Plan

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 prescription’s 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.

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

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.

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.

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.

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),

CRCo[email protected].

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).

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 plan’s 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

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)

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg NP

ELYXYB ORAL SOLUTION 120 MG/4.8ML (celecoxib

(migraine))

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

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)

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

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)

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

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

FIORICET ORAL CAPSULE 50-300-40 MG (butalbital-

apap-caffeine)

NSAIDS

CAMBIA ORAL PACKET 50 MG (diclofenac

potassium(migraine))

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

diclofenac sodium oral tablet delayed release 25 mg, 50 mg, 75

etodolac er oral tablet extended release 24 hour 400 mg, 500 mg,

600 mg

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)

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

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)

NAPROSYN ORAL SUSPENSION 125 MG/5ML

(naproxen)

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

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)

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)

diclofenac-misoprostol oral tablet delayed release 50-0.2 mg, 75-

0.2 mg

DUEXIS ORAL TABLET 800-26.6 MG (ibuprofen-

famotidine)

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

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

VIMOVO ORAL TABLET DELAYED RELEASE 375-20

MG, 500-20 MG (naproxen-esomeprazole)

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)

PA; QL (120 LOZENGES

per 25 DAYs)

APADAZ ORAL TABLET 4.08-325 MG, 6.12-325 MG,

8.16-325 MG (benzhydrocodone-acetaminophen)

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

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

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)

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

PA; QL (120 LOZENGES

per 25 DAYs)

fentanyl citrate buccal tablet 100 mcg, 200 mcg, 400 mcg, 600

mcg, 800 mcg

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

ST; QL (10 PATCHES per

25 DAYs)

FENTORA BUCCAL TABLET 100 MCG, 200 MCG, 400

MCG, 600 MCG, 800 MCG (fentanyl citrate)

FIORICET/CODEINE ORAL CAPSULE 50-300-40-30 MG

(butalbital-apap-caff-cod)

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

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

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

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

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

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

ST; QL (30 TABLETS per

25 DAYs)

hydromorphone hcl er oral tablet extended release 24 hour 32

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)

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

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

ST; QL (30 CAPSULES per

25 DAYs)

morphine sulfate er oral capsule extended release 24 hour 10 mg,

20 mg, 30 mg

ST; QL (60 CAPSULES per

25 days)

morphine sulfate er oral capsule extended release 24 hour 100

PG ST

morphine sulfate er oral capsule extended release 24 hour 50 mg,

60 mg, 80 mg

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

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)

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)

NUCYNTA ORAL TABLET 100 MG, 50 MG, 75 MG

(tapentadol hcl)

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

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

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

oxycodone-acetaminophen oral solution 10-300 mg/5ml, 5-325

mg/5ml

oxycodone-acetaminophen oral tablet 10-300 mg, 2.5-300 mg, 5-

300 mg, 7.5-300 mg

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)

oxymorphone hcl er oral tablet extended release 12 hour 10 mg,

15 mg, 20 mg, 30 mg, 40 mg, 5 mg, 7.5 mg

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)

PROLATE ORAL SOLUTION 10-300 MG/5ML

(oxycodone-acetaminophen)

PROLATE ORAL TABLET 10-300 MG, 5-300 MG, 7.5-300

MG (oxycodone-acetaminophen)

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

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

ROXYBOND ORAL TABLET ABUSE-DETERRENT 15

MG, 30 MG, 5 MG (oxycodone hcl)

SEGLENTIS ORAL TABLET 56-44 MG (celecoxib-tramadol

hcl)

SUBSYS SUBLINGUAL LIQUID 100 MCG, 1200 (600 X 2)

MCG, 1600 (800 X 2) MCG, 200 MCG, 400 MCG, 600

MCG, 800 MCG (fentanyl)

tramadol hcl (er biphasic) oral capsule extended release 24 hour

100 mg, 200 mg, 300 mg

tramadol hcl (er biphasic) oral tablet extended release 24 hour

100 mg

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

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)

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)

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

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

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)

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)

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))

HYALGAN INTRA-ARTICULAR SOLUTION 20

MG/2ML (sodium hyaluronate (viscosup))

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

HYALGAN INTRA-ARTICULAR SOLUTION

PREFILLED SYRINGE 20 MG/2ML (sodium hyaluronate

(viscosup))

HYMOVIS INTRA-ARTICULAR SOLUTION

PREFILLED SYRINGE 24 MG/3ML (hyaluronan)

MONOVISC INTRA-ARTICULAR SOLUTION

PREFILLED SYRINGE 88 MG/4ML (hyaluronan)

ORTHOVISC INTRA-ARTICULAR SOLUTION

PREFILLED SYRINGE 30 MG/2ML (hyaluronan)

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))

SYNVISC INTRA-ARTICULAR SOLUTION

PREFILLED SYRINGE 16 MG/2ML (hylan)

SYNVISC ONE INTRA-ARTICULAR SOLUTION

PREFILLED SYRINGE 48 MG/6ML (hylan)

TRILURON INTRA-ARTICULAR SOLUTION

PREFILLED SYRINGE 20 MG/2ML (sodium hyaluronate

(viscosup))

TRIVISC INTRA-ARTICULAR SOLUTION PREFILLED

SYRINGE 25 MG/2.5ML (sodium hyaluronate (viscosup))

VISCO-3 INTRA-ARTICULAR SOLUTION PREFILLED

SYRINGE 25 MG/2.5ML (sodium hyaluronate (viscosup))

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)

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

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)

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

tinidazole oral tablet 250 mg, 500 mg NP

ANTIFUNGALS - DRUGS TO TREAT FUNGAL

INFECTIONS

BREXAFEMME ORAL TABLET 150 MG (ibrexafungerp

citrate)

ST; QL (4 TABLETS per 7

DAYs)

CRESEMBA ORAL CAPSULE 186 MG (isavuconazonium

sulfate)

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)

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

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)

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)

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)

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

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)

QL (60 TABLETS per 30

DAYs)

ISENTRESS ORAL PACKET 100 MG (raltegravir

potassium)

QL (60 PACKETS per 30

days)

ISENTRESS ORAL TABLET 400 MG (raltegravir

potassium)

QL (120 TABLETS per 30

DAYs)

ISENTRESS ORAL TABLET CHEWABLE 100 MG, 25

MG (raltegravir potassium)

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

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)

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

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)

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)

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)

SUNLENCA SUBCUTANEOUS SOLUTION 463.5

MG/1.5ML (lenacapavir sodium)

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)

QL (60 TABLETS per 30

DAYs)

TIVICAY PD ORAL TABLET SOLUBLE 5 MG

(dolutegravir sodium)

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)

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)

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

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)

QL (30 TABLETS per 30

days)

BIKTARVY ORAL TABLET 50-200-25 MG (bictegravir-

emtricitab-tenofov)

QL (30 TABLETS per 30

DAYs)

CIMDUO ORAL TABLET 300-300 MG (lamivudine-

tenofovir)

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)

DELSTRIGO ORAL TABLET 100-300-300 MG (doravirin-

lamivudin-tenofov df)

DESCOVY ORAL TABLET 120-15 MG, 200-25 MG

(emtricitabine-tenofovir af)

QL (30 TABLETS per 30

DAYs)

DOVATO ORAL TABLET 50-300 MG (dolutegravir-

lamivudine)

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

QL (30 TABLETS per 30

DAYs)

emtricitabine-tenofovir df oral tablet 100-150 mg, 133-200 mg,

167-250 mg

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

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

EPZICOM ORAL TABLET 600-300 MG (abacavir sulfate-

lamivudine)

QL (30 TABLETS per 30

DAYs)

EVOTAZ ORAL TABLET 300-150 MG (atazanavir-

cobicistat)

QL (30 TABLETS per 30

DAYs)

GENVOYA ORAL TABLET 150-150-200-10 MG (elviteg-

cobic-emtricit-tenofaf)

QL (30 TABLETS per 30

DAYs)

JULUCA ORAL TABLET 50-25 MG (dolutegravir-

rilpivirine)

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)

QL (30 TABLETS per 30

DAYs)

PREZCOBIX ORAL TABLET 800-150 MG (darunavir-

cobicistat)

QL (30 TABLETS per 30

DAYs)

STRIBILD ORAL TABLET 150-150-200-300 MG (elviteg-

cobic-emtricit-tenofdf)

SYMFI LO ORAL TABLET 400-300-300 MG (efavirenz-

lamivudine-tenofovir)

QL (30 TABLETS per 30

days)

SYMFI ORAL TABLET 600-300-300 MG (efavirenz-

lamivudine-tenofovir)

QL (30 TABLETS per 30

days)

SYMTUZA ORAL TABLET 800-150-200-10 MG (darun-

cobic-emtricit-tenofaf)

QL (30 TABLETS per 30

days)

TRIUMEQ ORAL TABLET 600-50-300 MG (abacavir-

dolutegravir-lamivud)

QL (30 TABLETS per 30

DAYs)

TRIUMEQ PD ORAL TABLET SOLUBLE 60-5-30 MG

(abacavir-dolutegravir-lamivud)

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

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

TRIZIVIR ORAL TABLET 300-150-300 MG (abacavir-

lamivudine-zidovudine)

QL (60 TABLETS per 30

DAYs)

TRUVADA ORAL TABLET 100-150 MG, 133-200 MG,

167-250 MG, 200-300 MG (emtricitabine-tenofovir df)

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

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)

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)

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)

VEMLIDY ORAL TABLET 25 MG (tenofovir alafenamide

fumarate)

XERESE EXTERNAL CREAM 5-1 % (acyclovir-

hydrocortisone)

XOFLUZA (40 MG DOSE) ORAL TABLET THERAPY

PACK 1 X 40 MG (baloxavir marboxil)

XOFLUZA (80 MG DOSE) ORAL TABLET THERAPY

PACK 1 X 80 MG (baloxavir marboxil)

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

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

cefaclor oral suspension reconstituted 125 mg/5ml, 250 mg/5ml,

375 mg/5ml

cefadroxil oral capsule 500 mg PG

cefadroxil oral suspension reconstituted 250 mg/5ml, 500

mg/5ml

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

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

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)

SUPRAX ORAL TABLET CHEWABLE 100 MG, 200 MG

(cefixime)

ERYTHROMYCINS/MACROLIDES - DRUGS TO

TREAT INFECTIONS

azithromycin oral packet 1 gm PG

azithromycin oral suspension reconstituted 100 mg/5ml, 200

mg/5ml

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

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

clarithromycin oral suspension reconstituted 125 mg/5ml, 250

mg/5ml

clarithromycin oral tablet 250 mg, 500 mg PG

DIFICID ORAL SUSPENSION RECONSTITUTED 40

MG/ML (fidaxomicin)

DIFICID ORAL TABLET 200 MG (fidaxomicin) PB

E.E.S. GRANULES ORAL SUSPENSION

RECONSTITUTED 200 MG/5ML (erythromycin

ethylsuccinate)

ERYPED 200 ORAL SUSPENSION RECONSTITUTED

200 MG/5ML (erythromycin ethylsuccinate)

ERYPED 400 ORAL SUSPENSION RECONSTITUTED

400 MG/5ML (erythromycin ethylsuccinate)

erythromycin base (Ery-Tab Oral Tablet Delayed Release 250

Mg, 333 Mg, 500 Mg)

ERYTHROCIN STEARATE ORAL TABLET 250 MG

(erythromycin stearate)

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

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

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)

MAVYRET ORAL TABLET 100-40 MG (glecaprevir-

pibrentasvir)

PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML

(peginterferon alfa-2a)

PEGASYS SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 180 MCG/0.5ML (peginterferon alfa-2a)

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)

MISCELLANEOUS

ALINIA ORAL SUSPENSION RECONSTITUTED 100

MG/5ML (nitazoxanide)

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

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

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)

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)

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

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)

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

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

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

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

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

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)

DORYX ORAL TABLET DELAYED RELEASE 200 MG,

50 MG, 80 MG (doxycycline hyclate)

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

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

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

doxycycline monohydrate oral tablet 100 mg, 150 mg, 50 mg, 75

minocycline hcl er oral capsule extended release 24 hour 135 mg,

45 mg, 90 mg

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

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)

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)

SOLODYN ORAL TABLET EXTENDED RELEASE 24

HOUR 105 MG, 115 MG, 55 MG, 65 MG, 80 MG

(minocycline hcl)

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)

XIMINO ORAL CAPSULE EXTENDED RELEASE 24

HOUR 135 MG, 45 MG, 90 MG (minocycline hcl)

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

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)

PA; N7 (NPSP); QL (5

TABLETS per 28 days)

LONSURF ORAL TABLET 15-6.14 MG (trifluridine-

tipiracil)

PA; N7 (PSP); QL (100

TABLETS per 30 days)

LONSURF ORAL TABLET 20-8.19 MG (trifluridine-

tipiracil)

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

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

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)

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)

PA; N7 (NPSP); QL (21

CAPSULES per 28 days)

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 5

MG (lenalidomide)

PA; N7 (PSP); QL (28

CAPSULES per 28 days)

REVLIMID ORAL CAPSULE 20 MG, 25 MG

(lenalidomide)

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

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)

FIRMAGON SUBCUTANEOUS SOLUTION

RECONSTITUTED 80 MG (degarelix acetate)

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)

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))

LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT

30 MG (leuprolide acetate (4 month))

LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT

45 MG (leuprolide acetate (6 month))

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

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)

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)

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)

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

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)

PA; N7 (PSP); QL (30

TABLETS per 30 days)

CALQUENCE ORAL TABLET 100 MG (acalabrutinib

maleate)

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)

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)

PA; N7 (NPSP); QL (112

CAPSULES per 28 days)

COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MG

(cabozantinib s-malate)

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

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)

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)

PA; N7 (PSP); QL (21

CAPSULES per 28 days)

IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG

(palbociclib)

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)

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

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)

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)

PA; N7 (PSP); QL (63

TABLETS per 28 days)

KISQALI (400 MG DOSE) ORAL TABLET THERAPY

PACK 200 MG (ribociclib succinate)

PA; N7 (PSP); QL (63

TABLETS per 28 days)

KISQALI (600 MG DOSE) ORAL TABLET THERAPY

PACK 200 MG (ribociclib succinate)

PA; N7 (PSP); QL (63

TABLETS per 28 days)

KISQALI FEMARA (200 MG DOSE) ORAL TABLET

THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole)

PA; N7 (PSP); QL (49

TABLETS per 28 days)

KISQALI FEMARA (400 MG DOSE) ORAL TABLET

THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole)

PA; N7 (PSP); QL (70

TABLETS per 28 days)

KISQALI FEMARA (600 MG DOSE) ORAL TABLET

THERAPY PACK 200 & 2.5 MG (ribociclib-letrozole)

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)

PA; N7 (PSP); QL (30

CAPSULES per 30 days)

LENVIMA (12 MG DAILY DOSE) ORAL CAPSULE

THERAPY PACK 3 X 4 MG (lenvatinib mesylate)

PA; N7 (PSP); QL (90

CAPSULES per 30 days)

LENVIMA (14 MG DAILY DOSE) ORAL CAPSULE

THERAPY PACK 10 & 4 MG (lenvatinib mesylate)

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)

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

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

LENVIMA (20 MG DAILY DOSE) ORAL CAPSULE

THERAPY PACK 2 X 10 MG (lenvatinib mesylate)

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)

PA; N7 (PSP); QL (90

CAPSULES per 30 days)

LENVIMA (4 MG DAILY DOSE) ORAL CAPSULE

THERAPY PACK 4 MG (lenvatinib mesylate)

PA; N7 (PSP); QL (30

CAPSULES per 30 days)

LENVIMA (8 MG DAILY DOSE) ORAL CAPSULE

THERAPY PACK 2 X 4 MG (lenvatinib mesylate)

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)

PA; N7 (NPSP); QL (28

TABLETS per 28 days)

PIQRAY (250 MG DAILY DOSE) ORAL TABLET

THERAPY PACK 200 & 50 MG (alpelisib)

PA; N7 (NPSP); QL (56

TABLETS per 28 days)

PIQRAY (300 MG DAILY DOSE) ORAL TABLET

THERAPY PACK 2 X 150 MG (alpelisib)

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

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)

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)

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

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)

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)

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)

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

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)

PA; N7 (NPSP); QL (8

TABLETS per 28 days)

XPOVIO (40 MG ONCE WEEKLY) ORAL TABLET

THERAPY PACK 40 MG (selinexor)

PA; N7 (NPSP); QL (4

TABLETS per 28 days)

XPOVIO (40 MG TWICE WEEKLY) ORAL TABLET

THERAPY PACK 40 MG (selinexor)

PA; N7 (NPSP); QL (8

TABLETS per 28 days)

XPOVIO (60 MG ONCE WEEKLY) ORAL TABLET

THERAPY PACK 60 MG (selinexor)

PA; N7 (NPSP); QL (4

TABLETS per 28 days)

XPOVIO (60 MG TWICE WEEKLY) ORAL TABLET

THERAPY PACK 20 MG (selinexor)

PA; N7 (NPSP); QL (24

TABLETS per 28 days)

XPOVIO (80 MG ONCE WEEKLY) ORAL TABLET

THERAPY PACK 40 MG (selinexor)

PA; N7 (NPSP); QL (8

TABLETS per 28 days)

XPOVIO (80 MG TWICE WEEKLY) ORAL TABLET

THERAPY PACK 20 MG (selinexor)

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

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)

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

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)

quinapril-hydrochlorothiazide oral tablet 20-12.5 mg, 20-25 mg PG LGC

trandolapril-verapamil hcl er oral tablet extended release 1-240

ZESTORETIC ORAL TABLET 10-12.5 MG, 20-12.5 MG,

20-25 MG (lisinopril-hydrochlorothiazide)

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

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

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

ATACAND HCT ORAL TABLET 16-12.5 MG, 32-12.5

MG, 32-25 MG (candesartan cilexetil-hctz)

AZOR ORAL TABLET 10-20 MG, 10-40 MG, 5-20 MG, 5-

40 MG (amlodipine-olmesartan)

BENICAR HCT ORAL TABLET 20-12.5 MG, 40-12.5 MG,

40-25 MG (olmesartan medoxomil-hctz)

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

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

DIOVAN HCT ORAL TABLET 160-12.5 MG, 160-25 MG,

320-12.5 MG, 320-25 MG, 80-12.5 MG (valsartan-

hydrochlorothiazide)

EDARBYCLOR ORAL TABLET 40-12.5 MG, 40-25 MG

(azilsartan-chlorthalidone)

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)

EXFORGE ORAL TABLET 10-160 MG, 10-320 MG, 5-160

MG, 5-320 MG (amlodipine besylate-valsartan)

HYZAAR ORAL TABLET 100-12.5 MG, 100-25 MG, 50-

12.5 MG (losartan potassium-hctz)

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)

olmesartan medoxomil-hctz oral tablet 20-12.5 mg, 40-12.5 mg,

40-25 mg

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

telmisartan-amlodipine oral tablet 40-10 mg, 40-5 mg, 80-10

mg, 80-5 mg

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)

BENICAR ORAL TABLET 20 MG, 40 MG, 5 MG

(olmesartan medoxomil)

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

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

COZAAR ORAL TABLET 100 MG, 25 MG, 50 MG

(losartan potassium)

DIOVAN ORAL TABLET 160 MG, 320 MG, 40 MG, 80

MG (valsartan)

EDARBI ORAL TABLET 40 MG, 80 MG (azilsartan

medoxomil)

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)

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)

BETAPACE ORAL TABLET 120 MG, 160 MG, 80 MG

(sotalol hcl)

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)

propafenone hcl er oral capsule extended release 12 hour 225

mg, 325 mg, 425 mg

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

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)

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

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)

ATORVALIQ ORAL SUSPENSION 20 MG/5ML

(atorvastatin calcium)

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)

EZALLOR SPRINKLE ORAL CAPSULE SPRINKLE 10

MG, 20 MG, 40 MG, 5 MG (rosuvastatin calcium)

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)

LIPITOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG

(atorvastatin calcium)

LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG (pitavastatin

calcium)

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

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

ZYPITAMAG ORAL TABLET 2 MG, 4 MG (pitavastatin

magnesium)

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

ezetimibe-simvastatin oral tablet 10-10 mg, 10-20 mg, 10-40 mg,

10-80 mg

ROSZET ORAL TABLET 10-10 MG, 10-20 MG, 10-40 MG,

10-5 MG (ezetimibe-rosuvastatin)

ANTILIPEMICS, MISCELLANEOUS - DRUGS TO

TREAT HIGH CHOLESTEROL

JUXTAPID ORAL CAPSULE 10 MG, 20 MG, 30 MG, 5

MG (lomitapide mesylate)

niacin er (antihyperlipidemic) oral tablet extended release 1000

mg, 500 mg, 750 mg

NIACOR ORAL TABLET 500 MG (niacin

(antihyperlipidemic))

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)

omega-3-acid ethyl esters oral capsule 1 gm PG

VASCEPA ORAL CAPSULE 0.5 GM, 1 GM (icosapent

ethyl)

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)

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

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

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)

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

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)

INDERAL LA ORAL CAPSULE EXTENDED RELEASE

24 HOUR 120 MG, 160 MG, 60 MG, 80 MG (propranolol

hcl)

INDERAL XL ORAL CAPSULE EXTENDED RELEASE

24 HOUR 120 MG, 80 MG (propranolol hcl sr beads)

INNOPRAN XL ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 120 MG, 80 MG (propranolol hcl sr

beads)

KAPSPARGO SPRINKLE ORAL CAPSULE ER 24

HOUR SPRINKLE 100 MG, 200 MG, 25 MG, 50 MG

(metoprolol succinate)

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

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

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)

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

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)

CARDIZEM LA ORAL TABLET EXTENDED RELEASE

24 HOUR 120 MG, 180 MG, 240 MG, 300 MG, 360 MG, 420

MG (diltiazem hcl)

CARDIZEM ORAL TABLET 120 MG, 30 MG, 60 MG

(diltiazem hcl)

CONJUPRI ORAL TABLET 2.5 MG, 5 MG (levamlodipine

maleate)

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

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

diltiazem hcl er coated beads oral capsule extended release 24

hour 120 mg, 180 mg, 240 mg, 300 mg, 360 mg

diltiazem hcl er oral capsule extended release 12 hour 120 mg,

60 mg, 90 mg

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

felodipine er oral tablet extended release 24 hour 10 mg, 2.5 mg,

5 mg

isradipine oral capsule 2.5 mg, 5 mg PG

KATERZIA ORAL SUSPENSION 1 MG/ML (amlodipine

benzoate)

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)

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

nifedipine er osmotic release oral tablet extended release 24 hour

30 mg, 60 mg, 90 mg

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

NORLIQVA ORAL SOLUTION 1 MG/ML (amlodipine

besylate)

NORVASC ORAL TABLET 10 MG, 2.5 MG, 5 MG

(amlodipine besylate)

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

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

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)

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)

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

The formulary is updated annually in July

07/01/2023

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)

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)

CORLANOR ORAL TABLET 5 MG, 7.5 MG (ivabradine

hcl)

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103

MG (sacubitril-valsartan)

isosorb dinitrate-hydralazine oral tablet 20-37.5 mg PG

VERQUVO ORAL TABLET 10 MG, 2.5 MG, 5 MG

(vericiguat)

VYNDAMAX ORAL CAPSULE 61 MG (tafamidis) NPSP

PA; QL (30 CAPSULES per

30 days)

VYNDAQEL ORAL CAPSULE 20 MG (tafamidis

meglumine (cardiac))

MISCELLANEOUS

ASPRUZYO SPRINKLE ORAL PACKET 1000 MG, 500

MG (ranolazine)

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

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

DIBENZYLINE ORAL CAPSULE 10 MG

(phenoxybenzamine hcl)

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)

NORTHERA ORAL CAPSULE 100 MG, 200 MG, 300 MG

(droxidopa)

phenoxybenzamine hcl oral capsule 10 mg PG

ranolazine er oral tablet extended release 12 hour 1000 mg, 500

VECAMYL ORAL TABLET 2.5 MG (mecamylamine hcl) NP PA

NITRATES - DRUGS TO TREAT HEART CONDITIONS

GONITRO SUBLINGUAL PACKET 400 MCG

(nitroglycerin)

ISORDIL TITRADOSE ORAL TABLET 40 MG, 5 MG

(isosorbide dinitrate)

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

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

nitroglycerin translingual solution 0.4 mg/spray PG

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

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)

REVATIO INTRAVENOUS SOLUTION 10 MG/12.5ML

(sildenafil citrate)

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

REVATIO ORAL SUSPENSION RECONSTITUTED 10

MG/ML (sildenafil citrate)

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))

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)

TYVASO DPI TITRATION KIT INHALATION POWDER

112 X 16MCG & 84 X 32MCG, 16 & 32 & 48 MCG

(treprostinil)

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)

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

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

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)

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)

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

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

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)

QL (150 CAPSULES per 25

days)

LOREEV XR ORAL CAPSULE ER 24 HOUR SPRINKLE

3 MG (lorazepam)

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)

XANAX XR ORAL TABLET EXTENDED RELEASE 24

HOUR 0.5 MG, 1 MG, 2 MG, 3 MG (alprazolam)

ANTIDEMENTIA - DRUGS TO TREAT DEMENTIA AND

MEMORY LOSS

ADLARITY TRANSDERMAL PATCH WEEKLY 10

MG/DAY, 5 MG/DAY (donepezil hcl)

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

The formulary is updated annually in July

07/01/2023

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

galantamine hydrobromide er oral capsule extended release 24

hour 16 mg, 24 mg, 8 mg

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)

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

The formulary is updated annually in July

07/01/2023

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)

bupropion hcl er (sr) oral tablet extended release 12 hour 100

mg, 150 mg, 200 mg

bupropion hcl er (xl) oral tablet extended release 24 hour 150

mg, 300 mg

bupropion hcl er (xl) oral tablet extended release 24 hour 450

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)

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

The formulary is updated annually in July

07/01/2023

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

desvenlafaxine er oral tablet extended release 24 hour 100 mg,

50 mg

desvenlafaxine succinate er oral tablet extended release 24 hour

100 mg, 25 mg, 50 mg

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)

duloxetine hcl oral capsule delayed release particles 20 mg, 30

mg, 40 mg, 60 mg

EFFEXOR XR ORAL CAPSULE EXTENDED RELEASE

24 HOUR 150 MG, 37.5 MG, 75 MG (venlafaxine hcl)

escitalopram oxalate oral solution 5 mg/5ml PG

escitalopram oxalate oral tablet 10 mg, 20 mg, 5 mg PG

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

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)

FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR

THERAPY PACK 20 & 40 MG (levomilnacipran hcl)

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)

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

NP STX

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

NORPRAMIN ORAL TABLET 10 MG, 25 MG

(desipramine hcl)

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

paroxetine hcl er oral tablet extended release 24 hour 37.5 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

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)

PAXIL ORAL SUSPENSION 10 MG/5ML (paroxetine hcl) NF

PAXIL ORAL TABLET 10 MG, 20 MG, 30 MG, 40 MG

(paroxetine hcl)

PEXEVA ORAL TABLET 10 MG, 20 MG, 30 MG

(paroxetine mesylate)

phenelzine sulfate oral tablet 15 mg PG

PRISTIQ ORAL TABLET EXTENDED RELEASE 24

HOUR 100 MG, 25 MG, 50 MG (desvenlafaxine succinate)

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)

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

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

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

venlafaxine hcl er oral capsule extended release 24 hour 150 mg,

37.5 mg, 75 mg

venlafaxine hcl er oral tablet extended release 24 hour 150 mg,

37.5 mg, 75 mg

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

VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG

(vilazodone hcl)

VIIBRYD STARTER PACK ORAL KIT 10 & 20 MG

(vilazodone hcl)

vilazodone hcl oral tablet 10 mg, 20 mg, 40 mg NF

ZOLOFT ORAL CONCENTRATE 20 MG/ML (sertraline

hcl)

ZOLOFT ORAL TABLET 100 MG, 25 MG, 50 MG

(sertraline hcl)

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)

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

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)

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

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250

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

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)

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)

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)

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

pramipexole dihydrochloride oral tablet 0.125 mg, 0.25 mg, 0.5

mg, 0.75 mg, 1 mg, 1.5 mg

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

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

ropinirole hcl oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4

mg, 5 mg

RYTARY ORAL CAPSULE EXTENDED RELEASE

23.75-95 MG, 36.25-145 MG, 48.75-195 MG, 61.25-245 MG

(carbidopa-levodopa)

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)

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)

ZELAPAR ORAL TABLET DISPERSIBLE 1.25 MG

(selegiline hcl)

ANTIPSYCHOTICS - DRUGS TO TREAT PSYCHOSES

ABILIFY ASIMTUFII INTRAMUSCULAR PREFILLED

SYRINGE 720 MG/2.4ML, 960 MG/3.2ML (aripiprazole)

ABILIFY MAINTENA INTRAMUSCULAR PREFILLED

SYRINGE 300 MG, 400 MG (aripiprazole)

ABILIFY MAINTENA INTRAMUSCULAR

SUSPENSION RECONSTITUTED ER 300 MG, 400 MG

(aripiprazole)

ABILIFY ORAL TABLET 10 MG, 15 MG, 2 MG, 20 MG,

30 MG, 5 MG (aripiprazole)

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)

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

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)

asenapine maleate sublingual tablet sublingual 10 mg, 2.5 mg, 5

CAPLYTA ORAL CAPSULE 10.5 MG, 21 MG, 42 MG

(lumateperone tosylate)

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

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

FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4

MG, 6 MG, 8 MG (iloperidone)

FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 &

6 MG (iloperidone)

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)

GEODON ORAL CAPSULE 20 MG, 40 MG, 60 MG, 80

MG (ziprasidone hcl)

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)

INVEGA ORAL TABLET EXTENDED RELEASE 24

HOUR 1.5 MG, 3 MG, 9 MG (paliperidone)

PA; QL (30 TABLETS per

25 DAYs)

INVEGA ORAL TABLET EXTENDED RELEASE 24

HOUR 6 MG (paliperidone)

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)

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60

MG, 80 MG (lurasidone hcl)

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

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

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg PG

PERSERIS SUBCUTANEOUS PREFILLED SYRINGE

120 MG, 90 MG (risperidone)

quetiapine fumarate er oral tablet extended release 24 hour 150

mg, 200 mg, 300 mg, 400 mg, 50 mg

quetiapine fumarate oral tablet 100 mg, 200 mg, 25 mg, 300 mg,

400 mg, 50 mg

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)

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

SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10

MG, 2.5 MG, 5 MG (asenapine maleate)

SECUADO TRANSDERMAL PATCH 24 HOUR 3.8

MG/24HR, 5.7 MG/24HR, 7.6 MG/24HR (asenapine)

SEROQUEL XR ORAL TABLET EXTENDED RELEASE

24 HOUR 150 MG, 200 MG, 300 MG, 400 MG, 50 MG

(quetiapine fumarate)

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

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)

PA; QL (60 CAPSULES per

25 DAYs)

VRAYLAR ORAL CAPSULE 4.5 MG, 6 MG (cariprazine

hcl)

PA; QL (30 CAPSULES per

25 DAYs)

VRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3

MG (cariprazine hcl)

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)

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

carbamazepine er oral tablet extended release 12 hour 100 mg,

200 mg, 400 mg

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

QL (300 TABLETS per 25

days)

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

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)

DEPAKOTE ORAL TABLET DELAYED RELEASE 125

MG, 250 MG, 500 MG (divalproex sodium)

DEPAKOTE SPRINKLES ORAL CAPSULE DELAYED

RELEASE SPRINKLE 125 MG (divalproex sodium)

DIACOMIT ORAL CAPSULE 250 MG, 500 MG

(stiripentol)

DIACOMIT ORAL PACKET 250 MG, 500 MG (stiripentol) NF

DIASTAT ACUDIAL RECTAL GEL 10 MG, 20 MG

(diazepam)

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)

DILANTIN ORAL CAPSULE 100 MG, 30 MG (phenytoin

sodium extended)

DILANTIN ORAL SUSPENSION 125 MG/5ML (phenytoin) NF

divalproex sodium er oral tablet extended release 24 hour 250

mg, 500 mg

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)

EPIDIOLEX ORAL SOLUTION 100 MG/ML (cannabidiol) NPSP

PA; QL (800 ML per 30

days)

EPRONTIA ORAL SOLUTION 25 MG/ML (topiramate) NF

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

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)

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)

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)

KEPPRA XR ORAL TABLET EXTENDED RELEASE 24

HOUR 500 MG, 750 MG (levetiracetam)

KLONOPIN ORAL TABLET 0.5 MG, 1 MG, 2 MG

(clonazepam)

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)

LAMICTAL ODT ORAL TABLET DISPERSIBLE 100

MG, 200 MG, 25 MG, 50 MG (lamotrigine)

LAMICTAL ORAL TABLET 100 MG, 150 MG, 200 MG,

25 MG (lamotrigine)

LAMICTAL ORAL TABLET CHEWABLE 25 MG, 5 MG

(lamotrigine)

LAMICTAL STARTER ORAL KIT 35 X 25 MG, 42 X 25

MG & 7 X 100 MG, 84 X 25 MG & 14X100 MG (lamotrigine)

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

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)

LAMICTAL XR ORAL TABLET EXTENDED RELEASE

24 HOUR 100 MG, 200 MG, 25 MG, 250 MG, 300 MG, 50

MG (lamotrigine)

lamotrigine er oral tablet extended release 24 hour 100 mg, 200

mg, 25 mg, 250 mg, 300 mg, 50 mg

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

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

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)

LYRICA ORAL SOLUTION 20 MG/ML (pregabalin) NF

NAYZILAM NASAL SOLUTION 5 MG/0.1ML (midazolam

(anticonvulsant))

QL (10 SOLUTION per 25

days)

NEURONTIN ORAL CAPSULE 100 MG, 300 MG, 400

MG (gabapentin)

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

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

OXTELLAR XR ORAL TABLET EXTENDED RELEASE

24 HOUR 150 MG, 300 MG, 600 MG (oxcarbazepine)

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

phenytoin oral suspension 125 mg/5ml PG

phenytoin oral tablet chewable 50 mg PG

phenytoin sodium extended oral capsule 100 mg, 200 mg, 300

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)

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)

SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MG

(clobazam)

TEGRETOL ORAL SUSPENSION 100 MG/5ML

(carbamazepine)

TEGRETOL ORAL TABLET 200 MG (carbamazepine) NF

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

TEGRETOL-XR ORAL TABLET EXTENDED RELEASE

12 HOUR 100 MG, 200 MG, 400 MG (carbamazepine)

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

topiramate er oral capsule extended release 24 hour 100 mg, 200

mg, 25 mg, 50 mg

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)

TRILEPTAL ORAL TABLET 150 MG, 300 MG, 600 MG

(oxcarbazepine)

TROKENDI XR ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 100 MG, 200 MG, 25 MG, 50 MG

(topiramate)

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)

QL (10 BLISTER per 25

days)

VALTOCO 15 MG DOSE NASAL LIQUID THERAPY

PACK 7.5 MG/0.1ML (diazepam)

QL (10 BLISTER per 25

days)

VALTOCO 20 MG DOSE NASAL LIQUID THERAPY

PACK 10 MG/0.1ML (diazepam)

QL (10 BLISTER per 25

days)

VALTOCO 5 MG DOSE NASAL LIQUID 5 MG/0.1ML

(diazepam)

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

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50

MG (lacosamide)

XCOPRI (250 MG DAILY DOSE) ORAL TABLET

THERAPY PACK 100 & 150 MG (cenobamate)

XCOPRI (350 MG DAILY DOSE) ORAL TABLET

THERAPY PACK 150 & 200 MG (cenobamate)

XCOPRI ORAL TABLET 100 MG, 150 MG, 200 MG, 50

MG (cenobamate)

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)

ZONEGRAN ORAL CAPSULE 100 MG, 25 MG

(zonisamide)

ZONISADE ORAL SUSPENSION 100 MG/5ML

(zonisamide)

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)

ADDERALL XR ORAL CAPSULE EXTENDED

RELEASE 24 HOUR 10 MG, 15 MG, 20 MG, 25 MG, 30

MG, 5 MG (amphetamine-dextroamphetamine)

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)

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

QL (90 CAPSULES per 25

days)

amphetamine-dextroamphet er oral capsule extended release 24

hour 15 mg, 20 mg, 25 mg, 30 mg

QL (30 CAPSULES per 25

days)

amphetamine-dextroamphetamine oral tablet 10 mg PG

QL (90 TABLETS per 25

DAYs)

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

amphetamine-dextroamphetamine oral tablet 12.5 mg, 5 mg, 7.5

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)

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)

QL (30 CAPSULES per 25

days)

CONCERTA ORAL TABLET EXTENDED RELEASE 18

MG, 27 MG, 36 MG, 54 MG (methylphenidate hcl)

COTEMPLA XR-ODT ORAL TABLET EXTENDED

RELEASE DISPERSIBLE 17.3 MG, 25.9 MG, 8.6 MG

(methylphenidate)

DAYTRANA TRANSDERMAL PATCH 10 MG/9HR, 15

MG/9HR, 20 MG/9HR, 30 MG/9HR (methylphenidate)

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)

ST; QL (120 CAPSULES

per 25 days)

DEXEDRINE ORAL CAPSULE EXTENDED RELEASE

24 HOUR 15 MG (dextroamphetamine sulfate)

ST; QL (60 CAPSULES per

25 days)

dexmethylphenidate hcl er oral capsule extended release 24 hour

10 mg, 15 mg, 20 mg, 5 mg

QL (60 CAPSULES per 25

DAYs)

dexmethylphenidate hcl er oral capsule extended release 24 hour

25 mg, 30 mg, 40 mg

QL (30 CAPSULES per 25

DAYs)

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

dexmethylphenidate hcl er oral capsule extended release 24 hour

35 mg

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

QL (120 CAPSULES per 25

days)

dextroamphetamine sulfate er oral capsule extended release 24

hour 15 mg

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)

DYANAVEL XR ORAL TABLET CHEWABLE

EXTENDED RELEASE 10 MG, 15 MG, 20 MG, 5 MG

(amphetamine)

EVEKEO ODT ORAL TABLET DISPERSIBLE 10 MG, 15

MG, 20 MG, 5 MG (amphetamine sulfate)

EVEKEO ORAL TABLET 10 MG, 5 MG (amphetamine

sulfate)

FOCALIN ORAL TABLET 10 MG (dexmethylphenidate hcl) NP

QL (60 TABLETS per 25

DAYs)

FOCALIN ORAL TABLET 2.5 MG, 5 MG

(dexmethylphenidate hcl)

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)

guanfacine hcl er oral tablet extended release 24 hour 1 mg, 2

mg, 3 mg, 4 mg

INTUNIV ORAL TABLET EXTENDED RELEASE 24

HOUR 1 MG, 2 MG, 3 MG, 4 MG (guanfacine hcl)

JORNAY PM ORAL CAPSULE EXTENDED RELEASE

24 HOUR 100 MG, 20 MG, 40 MG, 60 MG, 80 MG

(methylphenidate hcl)

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

KAPVAY ORAL TABLET EXTENDED RELEASE 12

HOUR 0.1 MG (clonidine hcl)

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

QL (60 CAPSULES per 25

DAYs)

methylphenidate hcl er (cd) oral capsule extended release 40

mg, 50 mg, 60 mg

QL (30 CAPSULES per 25

DAYs)

methylphenidate hcl er (la) oral capsule extended release 24

hour 10 mg

QL (60 CAPSULES per 25

DAYs)

methylphenidate hcl er (la) oral capsule extended release 24

hour 20 mg, 30 mg

QL (60 CAPSULES per 25

days)

methylphenidate hcl er (la) oral capsule extended release 24

hour 40 mg, 60 mg

QL (30 CAPSULES per 25

days)

methylphenidate hcl er (osm) oral tablet extended release 18

mg, 27 mg, 36 mg

QL (60 TABLETS per 25

days)

methylphenidate hcl er (osm) oral tablet extended release 45

mg, 63 mg

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

QL (60 CAPSULES per 25

DAYs)

methylphenidate hcl er (xr) oral capsule extended release 24

hour 40 mg, 50 mg, 60 mg

QL (30 CAPSULES per 25

DAYs)

methylphenidate hcl er oral tablet extended release 10 mg, 20

QL (90 TABLETS per 25

DAYs)

methylphenidate hcl er oral tablet extended release 24 hour 18

mg, 27 mg, 36 mg, 54 mg

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

The formulary is updated annually in July

07/01/2023

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

MYDAYIS ORAL CAPSULE EXTENDED RELEASE 24

HOUR 12.5 MG, 25 MG, 37.5 MG, 50 MG (amphetamine-

dextroamphetamine)

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)

QL (90 CAPSULES per 25

days)

QUILLICHEW ER ORAL TABLET CHEWABLE

EXTENDED RELEASE 20 MG, 30 MG, 40 MG

(methylphenidate hcl)

QUILLIVANT XR ORAL SUSPENSION

RECONSTITUTED ER 25 MG/5ML (methylphenidate hcl)

RELEXXII ORAL TABLET EXTENDED RELEASE 45

MG, 63 MG, 72 MG (methylphenidate hcl)

RITALIN LA ORAL CAPSULE EXTENDED RELEASE

24 HOUR 10 MG, 20 MG, 30 MG (methylphenidate hcl)

QL (60 CAPSULES per 25

DAYs)

RITALIN LA ORAL CAPSULE EXTENDED RELEASE

24 HOUR 40 MG (methylphenidate hcl)

QL (30 CAPSULES per 25

DAYs)

RITALIN ORAL TABLET 10 MG, 5 MG (methylphenidate

hcl)

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)

QL (120 CAPSULES per 25

DAYs)

STRATTERA ORAL CAPSULE 100 MG, 60 MG, 80 MG

(atomoxetine hcl)

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

The formulary is updated annually in July

07/01/2023

Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG

(lisdexamfetamine dimesylate)

QL (60 CAPSULES per 25

DAYs)

VYVANSE ORAL CAPSULE 40 MG, 50 MG, 60 MG, 70

MG (lisdexamfetamine dimesylate)

QL (30 CAPSULES per 25

DAYs)

VYVANSE ORAL TABLET CHEWABLE 10 MG, 20 MG,

30 MG (lisdexamfetamine dimesylate)

QL (60 TABLETS per 25

DAYs)

VYVANSE ORAL TABLET CHEWABLE 40 MG, 50 MG,

60 MG (lisdexamfetamine dimesylate)

QL (30 TABLETS per 25

DAYs)

XELSTRYM TRANSDERMAL PATCH 13.5 MG/9HR, 18

MG/9HR, 4.5 MG/9HR, 9 MG/9HR (dextroamphetamine)

dextroamphetamine sulfate (Zenzedi Oral Tablet 15 Mg, 20

Mg)

QL (60 TABLETS per 25

days)

ZENZEDI ORAL TABLET 2.5 MG, 7.5 MG

(dextroamphetamine sulfate)

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)

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)

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)

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

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)

midazolam hcl oral syrup 2 mg/ml NP

quazepam oral tablet 15 mg NF

QUVIVIQ ORAL TABLET 25 MG, 50 MG (daridorexant

hcl)

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)

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

The formulary is updated annually in July

07/01/2023

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)

MIGRAINE - DRUGS TO TREAT SEVERE HEADACHES

AIMOVIG SUBCUTANEOUS SOLUTION AUTO-

INJECTOR 140 MG/ML, 70 MG/ML (erenumab-aooe)

ST; QL (1 SYRINGE per 25

days)

AJOVY SUBCUTANEOUS SOLUTION AUTO-

INJECTOR 225 MG/1.5ML (fremanezumab-vfrm)

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)

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)

ST; QL (2 syringes first

month, then 1 syringe per 25

days)

EMGALITY SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 120 MG/ML (galcanezumab-gnlm)

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

The formulary is updated annually in July

07/01/2023

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)

ST; QL (12 TABLETS per

25 DAYs)

IMITREX STATDOSE REFILL SUBCUTANEOUS

SOLUTION CARTRIDGE 4 MG/0.5ML (sumatriptan

succinate)

ST; QL (18 SYRINGES per

25 DAYs)

IMITREX STATDOSE REFILL SUBCUTANEOUS

SOLUTION CARTRIDGE 6 MG/0.5ML (sumatriptan

succinate)

ST; QL (12 CARTRIDGES

per 25 days)

IMITREX STATDOSE SYSTEM SUBCUTANEOUS

SOLUTION AUTO-INJECTOR 4 MG/0.5ML (sumatriptan

succinate)

ST; QL (18 SYRINGES per

25 DAYs)

IMITREX STATDOSE SYSTEM SUBCUTANEOUS

SOLUTION AUTO-INJECTOR 6 MG/0.5ML (sumatriptan

succinate)

ST; QL (12 INJECTIONS

per 25 days)

MAXALT ORAL TABLET 10 MG (rizatriptan benzoate) NF

MAXALT-MLT ORAL TABLET DISPERSIBLE 10 MG

(rizatriptan benzoate)

MIGERGOT RECTAL SUPPOSITORY 2-100 MG

(ergotamine-caffeine)

MIGRANAL NASAL SOLUTION 4 MG/ML

(dihydroergotamine mesylate)

naratriptan hcl oral tablet 1 mg, 2.5 mg PG

QL (12 TABLETS per 25

DAYs)

NURTEC ORAL TABLET DISPERSIBLE 75 MG

(rimegepant sulfate)

ST; QL (16 TABLETS per

25 days)

ONZETRA XSAIL NASAL EXHALER POWDER 11

MG/NOSEPC (sumatriptan succinate)

ST; QL (8 POUCHES per

25 days)

QULIPTA ORAL TABLET 10 MG, 30 MG, 60 MG

(atogepant)

ST; QL (30 TABLETS per

25 days)

RELPAX ORAL TABLET 20 MG, 40 MG (eletriptan

hydrobromide)

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

The formulary is updated annually in July

07/01/2023

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

QL (18 SYRINGES per 25

days)

sumatriptan succinate refill subcutaneous solution cartridge 6

mg/0.5ml

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)

TRUDHESA NASAL AEROSOL SOLUTION 0.725

MG/ACT (dihydroergotamine mesylate hfa)

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)

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

The formulary is updated annually in July

07/01/2023

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

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)

MESTINON ORAL TABLET 60 MG (pyridostigmine

bromide)

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)

riluzole oral tablet 50 mg PG

SKYCLARYS ORAL CAPSULE 50 MG (omaveloxolone) NF

TIGLUTIK ORAL SUSPENSION 50 MG/10ML (riluzole) NF

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

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)

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)

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

The formulary is updated annually in July

07/01/2023

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)

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)

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)

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

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)

2023 Pharmacy Drug Guide - Advanced Control Plan - Aetna Student Health

The formulary is updated annually in July

07/01/2023

100

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)

TECFIDERA ORAL 120 & 240 MG (dimethyl fumarate) NF

TECFIDERA ORAL CAPSULE DELAYED RELEASE 120

MG, 240 MG (dimethyl fumarate)

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)

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)

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

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)

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)

orphenadrine-aspirin-caffeine oral tablet 25-385-30 mg NF

orphenadrine-aspirin-caffeine (Orphengesic Forte Oral Tablet

50-770-60 Mg)

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)

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

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)

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)

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)

QL (30 TABLETS per 25

DAYs)

ZUBSOLV SUBLINGUAL TABLET SUBLINGUAL 8.6-

2.1 MG (buprenorphine hcl-naloxone hcl)

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)

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))

ST; QL (150 TABLETS per

25 days)

GRALISE ORAL TABLET 450 MG (gabapentin (once-

daily))

ST; QL (90 TABLETS per

25 DAYs)

GRALISE ORAL TABLET 600 MG (gabapentin (once-

daily))

ST; QL (90 TABLETS per

25 days)

GRALISE ORAL TABLET 750 MG, 900 MG (gabapentin

(once-daily))

ST; QL (60 TABLETS per

25 DAYs)

HORIZANT ORAL TABLET EXTENDED RELEASE 300

MG, 600 MG (gabapentin enacarbil)

LYRICA CR ORAL TABLET EXTENDED RELEASE 24

HOUR 165 MG, 330 MG, 82.5 MG (pregabalin)

pregabalin er oral tablet extended release 24 hour 165 mg, 330

mg, 82.5 mg

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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)

NUEDEXTA ORAL CAPSULE 20-10 MG

(dextromethorphan-quinidine)

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)

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Coverage Requirements and

Limits

SMOKING DETERRENTS

bupropion hcl er (smoking det) oral tablet extended release 12

hour 150 mg

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

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)

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)

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)

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Limits

ANDROGENS

TLANDO ORAL CAPSULE 112.5 MG (testosterone

undecanoate)

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)

AVEED INTRAMUSCULAR SOLUTION 750 MG/3ML

(testosterone undecanoate)

NPSP PA

FORTESTA TRANSDERMAL GEL 10 MG/ACT (2%)

(testosterone)

JATENZO ORAL CAPSULE 158 MG, 198 MG, 237 MG

(testosterone undecanoate)

NP PA

KYZATREX ORAL CAPSULE 100 MG, 150 MG, 200 MG

(testosterone undecanoate)

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)

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%)

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)

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Limits

VOGELXO TRANSDERMAL GEL 50 MG/5GM (1%)

(testosterone)

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)

metformin hcl er (mod) oral tablet extended release 24 hour

1000 mg, 500 mg

metformin hcl er (osm) oral tablet extended release 24 hour

1000 mg, 500 mg

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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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)

NESINA ORAL TABLET 12.5 MG, 25 MG, 6.25 MG

(alogliptin benzoate)

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)

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

JANUMET ORAL TABLET 50-1000 MG, 50-500 MG

(sitagliptin-metformin hcl)

JANUMET XR ORAL TABLET EXTENDED RELEASE

24 HOUR 100-1000 MG, 50-1000 MG, 50-500 MG

(sitagliptin-metformin hcl)

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)

KOMBIGLYZE XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 2.5-1000 MG, 5-1000 MG, 5-500 MG

(saxagliptin-metformin)

OSENI ORAL TABLET 12.5-30 MG, 25-15 MG, 25-30 MG,

25-45 MG (alogliptin-pioglitazone)

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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Limits

ANTIDIABETICS, INCRETIN MIMETIC AGENTS

BYDUREON BCISE SUBCUTANEOUS AUTO-

INJECTOR 2 MG/0.85ML (exenatide)

BYETTA 10 MCG PEN SUBCUTANEOUS SOLUTION

PEN-INJECTOR 10 MCG/0.04ML (exenatide)

BYETTA 5 MCG PEN SUBCUTANEOUS SOLUTION

PEN-INJECTOR 5 MCG/0.02ML (exenatide)

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)

OZEMPIC (0.25 OR 0.5 MG/DOSE) SUBCUTANEOUS

SOLUTION PEN-INJECTOR 2 MG/3ML (semaglutide)

PA; QL (1 PEN per 28

DAYs)

OZEMPIC (1 MG/DOSE) SUBCUTANEOUS SOLUTION

PEN-INJECTOR 4 MG/3ML (semaglutide)

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)

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)

PA; QL (4 PENS per 21

DAYs)

VICTOZA SUBCUTANEOUS SOLUTION PEN-

INJECTOR 18 MG/3ML (liraglutide)

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)

ADMELOG SOLOSTAR SUBCUTANEOUS SOLUTION

PEN-INJECTOR 100 UNIT/ML (insulin lispro)

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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)

APIDRA INJECTION SOLUTION 100 UNIT/ML (insulin

glulisine)

APIDRA SOLOSTAR SUBCUTANEOUS SOLUTION

PEN-INJECTOR 100 UNIT/ML (insulin glulisine)

BASAGLAR KWIKPEN SUBCUTANEOUS SOLUTION

PEN-INJECTOR 100 UNIT/ML (insulin glargine)

BASAGLAR TEMPO PEN SUBCUTANEOUS

SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin

glargine)

FIASP FLEXTOUCH SUBCUTANEOUS SOLUTION

PEN-INJECTOR 100 UNIT/ML (insulin aspart

(w/niacinamide))

FIASP INJECTION SOLUTION 100 UNIT/ML (insulin

aspart (w/niacinamide))

FIASP PENFILL SUBCUTANEOUS SOLUTION

CARTRIDGE 100 UNIT/ML (insulin aspart (w/niacinamide))

HUMALOG INJECTION SOLUTION 100 UNIT/ML

(insulin lispro)

HUMALOG JUNIOR KWIKPEN SUBCUTANEOUS

SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin lispro)

HUMALOG KWIKPEN SUBCUTANEOUS SOLUTION

PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin

lispro)

HUMALOG MIX 50/50 KWIKPEN SUBCUTANEOUS

SUSPENSION PEN-INJECTOR (50-50) 100 UNIT/ML

(insulin lispro prot & lispro)

HUMALOG MIX 50/50 SUBCUTANEOUS SUSPENSION

(50-50) 100 UNIT/ML (insulin lispro prot & lispro)

HUMALOG MIX 75/25 KWIKPEN SUBCUTANEOUS

SUSPENSION PEN-INJECTOR (75-25) 100 UNIT/ML

(insulin lispro prot & lispro)

HUMALOG MIX 75/25 SUBCUTANEOUS SUSPENSION

(75-25) 100 UNIT/ML (insulin lispro prot & lispro)

HUMALOG SUBCUTANEOUS SOLUTION

CARTRIDGE 100 UNIT/ML (insulin lispro)

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Limits

HUMALOG TEMPO PEN SUBCUTANEOUS SOLUTION

PEN-INJECTOR 100 UNIT/ML (insulin lispro)

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS

SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

(insulin nph isophane & regular)

HUMULIN 70/30 SUBCUTANEOUS SUSPENSION (70-

30) 100 UNIT/ML (insulin nph isophane & regular)

HUMULIN N KWIKPEN SUBCUTANEOUS

SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph

human (isophane))

HUMULIN N SUBCUTANEOUS SUSPENSION 100

UNIT/ML (insulin nph human (isophane))

HUMULIN R INJECTION SOLUTION 100 UNIT/ML

(insulin regular human)

HUMULIN R U-500 (CONCENTRATED)

SUBCUTANEOUS SOLUTION 500 UNIT/ML (insulin

regular human)

HUMULIN R U-500 KWIKPEN SUBCUTANEOUS

SOLUTION PEN-INJECTOR 500 UNIT/ML (insulin regular

human)

insulin asp prot & asp flexpen subcutaneous suspension pen-

injector (70-30) 100 unit/ml

insulin aspart flexpen subcutaneous solution pen-injector 100

unit/ml

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

insulin degludec flextouch subcutaneous solution pen-injector

100 unit/ml, 200 unit/ml

insulin degludec subcutaneous solution 100 unit/ml NF

insulin glargine solostar subcutaneous solution pen-injector 100

unit/ml

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

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Coverage Requirements and

Limits

insulin lispro (1 unit dial) subcutaneous solution pen-injector

100 unit/ml

insulin lispro injection solution 100 unit/ml NF

insulin lispro junior kwikpen subcutaneous solution pen-injector

100 unit/ml

insulin lispro prot & lispro subcutaneous suspension pen-injector

(75-25) 100 unit/ml

LANTUS SOLOSTAR SUBCUTANEOUS SOLUTION

PEN-INJECTOR 100 UNIT/ML (insulin glargine)

LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML

(insulin glargine)

LEVEMIR FLEXPEN SUBCUTANEOUS SOLUTION

PEN-INJECTOR 100 UNIT/ML (insulin detemir)

LEVEMIR SUBCUTANEOUS SOLUTION 100 UNIT/ML

(insulin detemir)

LYUMJEV INJECTION SOLUTION 100 UNIT/ML (insulin

lispro-aabc)

LYUMJEV KWIKPEN SUBCUTANEOUS SOLUTION

PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin

lispro-aabc)

LYUMJEV TEMPO PEN SUBCUTANEOUS SOLUTION

PEN-INJECTOR 100 UNIT/ML (insulin lispro-aabc)

MYXREDLIN INTRAVENOUS SOLUTION 100-0.9

UT/100ML-% (insulin regular(human) in nacl)

NOVOLIN 70/30 FLEXPEN RELION SUBCUTANEOUS

SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

(insulin nph isophane & regular)

NOVOLIN 70/30 FLEXPEN SUBCUTANEOUS

SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

(insulin nph isophane & regular)

NOVOLIN 70/30 RELION SUBCUTANEOUS

SUSPENSION (70-30) 100 UNIT/ML (insulin nph isophane &

regular)

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION (70-30)

100 UNIT/ML (insulin nph isophane & regular)

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Limits

NOVOLIN N FLEXPEN RELION SUBCUTANEOUS

SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph

human (isophane))

NOVOLIN N FLEXPEN SUBCUTANEOUS

SUSPENSION PEN-INJECTOR 100 UNIT/ML (insulin nph

human (isophane))

NOVOLIN N RELION SUBCUTANEOUS SUSPENSION

100 UNIT/ML (insulin nph human (isophane))

NOVOLIN N SUBCUTANEOUS SUSPENSION 100

UNIT/ML (insulin nph human (isophane))

NOVOLIN R FLEXPEN INJECTION SOLUTION PEN-

INJECTOR 100 UNIT/ML (insulin regular human)

NOVOLIN R FLEXPEN RELION INJECTION

SOLUTION PEN-INJECTOR 100 UNIT/ML (insulin regular

human)

NOVOLIN R INJECTION SOLUTION 100 UNIT/ML

(insulin regular human)

NOVOLIN R RELION INJECTION SOLUTION 100

UNIT/ML (insulin regular human)

NOVOLOG 70/30 FLEXPEN RELION SUBCUTANEOUS

SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

(insulin aspart prot & aspart)

NOVOLOG FLEXPEN SUBCUTANEOUS SOLUTION

PEN-INJECTOR 100 UNIT/ML (insulin aspart)

NOVOLOG INJECTION SOLUTION 100 UNIT/ML

(insulin aspart)

NOVOLOG MIX 70/30 FLEXPEN SUBCUTANEOUS

SUSPENSION PEN-INJECTOR (70-30) 100 UNIT/ML

(insulin aspart prot & aspart)

NOVOLOG MIX 70/30 SUBCUTANEOUS SUSPENSION

(70-30) 100 UNIT/ML (insulin aspart prot & aspart)

NOVOLOG PENFILL SUBCUTANEOUS SOLUTION

CARTRIDGE 100 UNIT/ML (insulin aspart)

REZVOGLAR KWIKPEN SUBCUTANEOUS SOLUTION

PEN-INJECTOR 100 UNIT/ML (insulin glargine-aglr)

SEMGLEE (YFGN) SUBCUTANEOUS SOLUTION 100

UNIT/ML (insulin glargine-yfgn)

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Coverage Requirements and

Limits

SEMGLEE (YFGN) SUBCUTANEOUS SOLUTION PEN-

INJECTOR 100 UNIT/ML (insulin glargine-yfgn)

TOUJEO MAX SOLOSTAR SUBCUTANEOUS

SOLUTION PEN-INJECTOR 300 UNIT/ML (insulin

glargine)

TOUJEO SOLOSTAR SUBCUTANEOUS SOLUTION

PEN-INJECTOR 300 UNIT/ML (insulin glargine)

TRESIBA FLEXTOUCH SUBCUTANEOUS SOLUTION

PEN-INJECTOR 100 UNIT/ML, 200 UNIT/ML (insulin

degludec)

TRESIBA SUBCUTANEOUS SOLUTION 100 UNIT/ML

(insulin degludec)

ANTIDIABETICS, INSULIN SENSITIZER

ACTOS ORAL TABLET 15 MG, 30 MG, 45 MG

(pioglitazone hcl)

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)

INVOKAMET XR ORAL TABLET EXTENDED

RELEASE 24 HOUR 150-1000 MG, 150-500 MG, 50-1000

MG, 50-500 MG (canagliflozin-metformin hcl)

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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)

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)

STEGLUJAN ORAL TABLET 15-100 MG, 5-100 MG

(ertugliflozin-sitagliptin)

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)

JARDIANCE ORAL TABLET 10 MG, 25 MG

(empagliflozin)

PB ST

STEGLATRO ORAL TABLET 15 MG, 5 MG (ertugliflozin

l-pyroglutamicac)

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

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

PG LGC

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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)

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

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)

ST; QL (4 TABLETS per 21

days)

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Coverage Requirements and

Limits

BINOSTO ORAL TABLET EFFERVESCENT 70 MG

(alendronate sodium)

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)

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

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)

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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Limits

CARNITOR SF ORAL SOLUTION 1 GM/10ML

(levocarnitine)

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)

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)

EXJADE ORAL TABLET SOLUBLE 125 MG, 250 MG,

500 MG (deferasirox)

FERRIPROX ORAL SOLUTION 100 MG/ML (deferiprone) NF

FERRIPROX ORAL TABLET 1000 MG, 500 MG

(deferiprone)

FERRIPROX TWICE-A-DAY ORAL TABLET 1000 MG

(deferiprone)

JADENU ORAL TABLET 180 MG, 360 MG, 90 MG

(deferasirox)

JADENU SPRINKLE ORAL PACKET 180 MG, 360 MG,

90 MG (deferasirox)

LOKELMA ORAL PACKET 10 GM, 5 GM (sodium

zirconium cyclosilicate)

penicillamine oral capsule 250 mg PSP PA

penicillamine oral tablet 250 mg PG PA

sodium polystyrene sulfonate oral powder PG

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Limits

SPS ORAL SUSPENSION 15 GM/60ML (sodium polystyrene

sulfonate)

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)

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)

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)

norethin ace-eth estrad-fe (Blisovi 24 Fe Oral Tablet 1-20 Mg-

Mcg(24))

CE N7 (PG)

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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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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)

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)

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

N7 (PG); QL (4 ML per 300

days)

medroxyprogesterone acetate intramuscular suspension prefilled

syringe 150 mg/ml

N7 (PG); QL (4 ML per 300

days)

MINASTRIN 24 FE ORAL TABLET CHEWABLE 1-20

MG-MCG(24) (norethin ace-eth estrad-fe)

MIRENA (52 MG) INTRAUTERINE INTRAUTERINE

DEVICE 20 MCG/DAY (levonorgestrel)

N7 (PB); QL (1

INTRAUTERINE

DEVICE per 300 Days)

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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)

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)

N7 (NP); QL (1

DIAPHRAGM per 300

days)

PARAGARD INTRAUTERINE COPPER

INTRAUTERINE INTRAUTERINE DEVICE (copper)

N7 (NP); QL (1

INTRAUTERINE

DEVICE per 300 days)

QUARTETTE ORAL TABLET 42-21-21-7 DAYS

(levonorgest-eth estrad 91-day)

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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)

SEASONIQUE ORAL TABLET 0.15-0.03 &0.01 MG

(levonorgest-eth estrad 91-day)

SKYLA INTRAUTERINE INTRAUTERINE DEVICE

13.5 MG (levonorgestrel)

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)

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)

N7 (NP); QL (1

DIAPHRAGM per 300

days)

WIDE-SEAL DIAPHRAGM 65 VAGINAL DIAPHRAGM

2 % (diaphragm wide seal)

N7 (NP); QL (1

DIAPHRAGM per 300

days)

WIDE-SEAL DIAPHRAGM 70 VAGINAL DIAPHRAGM

2 % (diaphragm wide seal)

N7 (NP); QL (1

DIAPHRAGM per 300

days)

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Limits

WIDE-SEAL DIAPHRAGM 75 VAGINAL DIAPHRAGM

2 % (diaphragm wide seal)

N7 (NP); QL (1

DIAPHRAGM per 300

days)

WIDE-SEAL DIAPHRAGM 80 VAGINAL DIAPHRAGM

2 % (diaphragm wide seal)

N7 (NP); QL (1

DIAPHRAGM per 300

days)

WIDE-SEAL DIAPHRAGM 85 VAGINAL DIAPHRAGM

2 % (diaphragm wide seal)

N7 (NP); QL (1

DIAPHRAGM per 300

days)

WIDE-SEAL DIAPHRAGM 90 VAGINAL DIAPHRAGM

2 % (diaphragm wide seal)

N7 (NP); QL (1

DIAPHRAGM per 300

days)

WIDE-SEAL DIAPHRAGM 95 VAGINAL DIAPHRAGM

2 % (diaphragm wide seal)

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)

YAZ ORAL TABLET 3-0.02 MG (drospirenone-ethinyl

estradiol)

CORTISOL SYNTHESIS INHIBITORS

ISTURISA ORAL TABLET 1 MG, 10 MG, 5 MG

(osilodrostat phosphate)

RECORLEV ORAL TABLET 150 MG (levoketoconazole) NF

DIABETIC SUPPLIES

ACCU-CHEK AVIVA PLUS IN VITRO STRIP (glucose

blood)

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)

QL (150 TEST STRIPS per

25 days)

ACCU-CHEK SOFTCLIX LANCETS (lancets) NP

ACCUTREND GLUCOSE IN VITRO STRIP (glucose

blood)

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Limits

ADVANCE INTUITION TEST IN VITRO STRIP (glucose

blood)

ADVANCE MICRO-DRAW TEST IN VITRO STRIP

(glucose blood)

ADVOCATE REDI-CODE IN VITRO STRIP (glucose

blood)

ADVOCATE REDI-CODE+ TEST IN VITRO STRIP

(glucose blood)

ADVOCATE TEST IN VITRO STRIP (glucose blood) NF

AGAMATRIX AMP TEST IN VITRO STRIP (glucose

blood)

AGAMATRIX JAZZ TEST IN VITRO STRIP (glucose

blood)

AGAMATRIX KEYNOTE TEST IN VITRO STRIP

(glucose blood)

AGAMATRIX PRESTO TEST IN VITRO STRIP (glucose

blood)

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)

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)

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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Coverage Requirements and

Limits

BD PEN NEEDLE MICRO U/F 32G X 6 MM (insulin pen

needle)

N8 (BD syringes and needles

are the only preferred

options)

BD PEN NEEDLE MINI U/F 31G X 5 MM (insulin pen

needle)

N8 (BD syringes and needles

are the only preferred

options)

BD PEN NEEDLE NANO 2ND GEN 32G X 4 MM (insulin

pen needle)

N8 (BD syringes and needles

are the only preferred

options)

BD PEN NEEDLE NANO U/F 32G X 4 MM (insulin pen

needle)

N8 (BD syringes and needles

are the only preferred

options)

BD PEN NEEDLE ORIGINAL U/F 29G X 12.7MM (insulin

pen needle)

N8 (BD syringes and needles

are the only preferred

options)

BD PEN NEEDLE SHORT U/F 31G X 8 MM (insulin pen

needle)

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)

CARETOUCH TEST IN VITRO STRIP (glucose blood) NF

CLEVER CHEK AUTO-CODE TEST IN VITRO STRIP

(glucose blood)

CLEVER CHEK AUTO-CODE VOICE IN VITRO STRIP

(glucose blood)

CLEVER CHEK TEST IN VITRO STRIP (glucose blood) NF

CLEVER CHOICE AUTO-CODE TEST IN VITRO STRIP

(glucose blood)

CLEVER CHOICE MICRO TEST IN VITRO STRIP

(glucose blood)

CLEVER CHOICE NO CODING IN VITRO STRIP

(glucose blood)

CLEVER CHOICE TALK SYSTEM IN VITRO STRIP

(glucose blood)

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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)

CVS ADVANCED GLUCOSE TEST IN VITRO STRIP

(glucose blood)

D-CARE BLOOD GLUCOSE IN VITRO STRIP (glucose

blood)

DEXCOM G6 RECEIVER DEVICE (continuous blood gluc

receiver)

DEXCOM G6 SENSOR (continuous blood gluc sensor) PB

QL (3 SENSORS per 25

days)

DEXCOM G6 TRANSMITTER (continuous blood gluc

transmit)

DEXCOM G7 RECEIVER DEVICE (continuous blood gluc

receiver)

DEXCOM G7 SENSOR (continuous blood gluc sensor) PB

QL (3 SENSORS per 25

days)

DIATHRIVE GLUCOSE TEST IN VITRO STRIP (glucose

blood)

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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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)

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)

EMBRACE EVO BLOOD GLUCOSE TEST IN VITRO

STRIP (glucose blood)

EMBRACE PRO GLUCOSE TEST IN VITRO STRIP

(glucose blood)

EMBRACE TALK GLUCOSE TEST IN VITRO STRIP

(glucose blood)

ENLITE GLUCOSE SENSOR (continuous blood gluc sensor) NF

eq blood glucose test in vitro strip NF

EVERSENSE SENSOR/HOLDER (continuous blood gluc

sensor)

EVERSENSE SMART TRANSMITTER (continuous blood

gluc transmit)

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Coverage Requirements and

Limits

EVOLUTION AUTOCODE IN VITRO STRIP (glucose

blood)

FIFTY50 GLUCOSE TEST 2.0 IN VITRO STRIP (glucose

blood)

FINGERSTIX LANCETS (lancets) NP

FORA 6 CONNECT IN VITRO STRIP (glucose blood) NF

FORA BLOOD GLUCOSE TEST IN VITRO STRIP

(glucose blood)

FORA D15G BLOOD GLUCOSE TEST IN VITRO STRIP

(glucose blood)

FORA D20 BLOOD GLUCOSE TEST IN VITRO STRIP

(glucose blood)

FORA D40/G31 BLOOD GLUCOSE IN VITRO STRIP

(glucose blood)

FORA G20 BLOOD GLUCOSE TEST IN VITRO STRIP

(glucose blood)

FORA G30/PREM V10 GLUCOSE TEST IN VITRO STRIP

(glucose blood)

FORA GD20 TEST IN VITRO STRIP (glucose blood) NF

FORA GD50 BLOOD GLUCOSE TEST IN VITRO STRIP

(glucose blood)

FORA GTEL BLOOD GLUCOSE TEST IN VITRO STRIP

(glucose blood)

FORA TN'G ADVANCE PRO IN VITRO STRIP (glucose

blood)

FORA TN'G/TN'G VOICE IN VITRO STRIP (glucose

blood)

FORA V10 BLOOD GLUCOSE TEST IN VITRO STRIP

(glucose blood)

FORA V12 BLOOD GLUCOSE TEST IN VITRO STRIP

(glucose blood)

FORA V20 BLOOD GLUCOSE TEST IN VITRO STRIP

(glucose blood)

FORA V30A BLOOD GLUCOSE TEST IN VITRO STRIP

(glucose blood)

FORACARE GD40 TEST IN VITRO STRIP (glucose blood) NF

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Coverage Requirements and

Limits

FORACARE PREMIUM V10 TEST IN VITRO STRIP

(glucose blood)

FORACARE TEST N GO TEST IN VITRO STRIP (glucose

blood)

FORTISCARE TEST IN VITRO STRIP (glucose blood) NF

FREESTYLE INSULINX TEST IN VITRO STRIP (glucose

blood)

FREESTYLE LANCETS (lancets) NP

FREESTYLE LIBRE 14 DAY SENSOR (continuous blood

gluc sensor)

FREESTYLE LIBRE 2 SENSOR (continuous blood gluc

sensor)

freestyle libre 3 sensor NF

FREESTYLE LIBRE READER DEVICE (continuous blood

gluc receiver)

FREESTYLE LITE TEST IN VITRO STRIP (glucose blood) NF

FREESTYLE PRECISION NEO TEST IN VITRO STRIP

(glucose blood)

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)

GLUCOCARD 01 SENSOR PLUS IN VITRO STRIP

(glucose blood)

GLUCOCARD EXPRESSION TEST IN VITRO STRIP

(glucose blood)

GLUCOCARD SHINE TEST IN VITRO STRIP (glucose

blood)

GLUCOCARD VITAL TEST IN VITRO STRIP (glucose

blood)

GLUCOCARD X-SENSOR IN VITRO STRIP (glucose

blood)

GLUCOCOM TEST IN VITRO STRIP (glucose blood) NF

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Coverage Requirements and

Limits

GLUCONAVII BLOOD GLUCOSE TEST IN VITRO

STRIP (glucose blood)

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)

goodsense blood glucose in vitro strip NF

GUARDIAN LINK 3 TRANSMITTER (continuous blood

gluc transmit)

GUARDIAN REAL-TIME REPLACE PED DEVICE

(continuous blood gluc receiver)

GUARDIAN SENSOR (3) (continuous blood gluc sensor) NF

guardian sensor 3 NF

HW EMBRACE PRO GLUCOSE TEST IN VITRO STRIP

(glucose blood)

HW EMBRACE TALK GLUCOSE TEST IN VITRO

STRIP (glucose blood)

IGLUCOSE TEST STRIPS IN VITRO STRIP (glucose

blood)

IN TOUCH BLOOD GLUCOSE TEST IN VITRO STRIP

(glucose blood)

INFINITY BLOOD GLUCOSE TEST IN VITRO STRIP

(glucose blood)

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)

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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Coverage Requirements and

Limits

MEIJER TRUETEST TEST IN VITRO STRIP (glucose

blood)

MEIJER TRUETRACK TEST IN VITRO STRIP (glucose

blood)

MICRODOT TEST IN VITRO STRIP (glucose blood) NF

MICROLET LANCETS (lancets) NP

MYGLUCOHEALTH TEST IN VITRO STRIP (glucose

blood)

NEUTEK 2TEK TEST IN VITRO STRIP (glucose blood) NF

NOVA MAX GLUCOSE TEST IN VITRO STRIP (glucose

blood)

OMNIPOD 5 G6 INTRO (GEN 5) KIT (insulin disposable

pump)

OMNIPOD 5 G6 POD (GEN 5) (insulin disposable pump) PB

OMNIPOD CLASSIC PODS (GEN 3) (insulin disposable

pump)

OMNIPOD DASH INTRO (GEN 4) KIT (insulin disposable

pump)

OMNIPOD DASH PDM (GEN 4) KIT (insulin disposable

pump)

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)

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)

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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)

PRECISION THINS GP LANCETS (lancets) NP

PRECISION XTRA BLOOD GLUCOSE IN VITRO STRIP

(glucose blood)

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)

PTS PANELS EGLU TEST IN VITRO STRIP (glucose

blood)

QUICKTEK TEST IN VITRO STRIP (glucose blood) NF

QUINTET AC BLOOD GLUCOSE TEST IN VITRO

STRIP (glucose blood)

QUINTET BLOOD GLUCOSE TEST IN VITRO STRIP

(glucose blood)

REFUAH PLUS BLOOD GLUCOSE TEST IN VITRO

STRIP (glucose blood)

RELION BLOOD GLUCOSE TEST IN VITRO STRIP

(glucose blood)

RELION CONFIRM/MICRO TEST IN VITRO STRIP

(glucose blood)

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)

RIGHTEST GS300 BLOOD GLUCOSE IN VITRO STRIP

(glucose blood)

RIGHTEST GS550 BLOOD GLUCOSE IN VITRO STRIP

(glucose blood)

sapscare twist top lancets NP

SIMPLE DIAGNOSTICS LANCING DEV (lancet devices) NP

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Limits

SMART SENSE PREMIUM TEST IN VITRO STRIP

(glucose blood)

SMARTEST BLOOD GLUCOSE TEST IN VITRO STRIP

(glucose blood)

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)

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)

BUPHENYL ORAL TABLET 500 MG (sodium

phenylbutyrate)

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Limits

CARBAGLU ORAL TABLET SOLUBLE 200 MG

(carglumic acid)

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)

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)

KUVAN ORAL TABLET 100 MG (sapropterin

dihydrochloride)

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)

PHEBURANE ORAL PELLET 483 MG/GM (sodium

phenylbutyrate)

NPSP PA; QL (672 G per 30 days)

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Limits

RAVICTI ORAL LIQUID 1.1 GM/ML (glycerol

phenylbutyrate)

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)

estradiol-norethindrone acet (Amabelz Oral Tablet 0.5-0.1 Mg,

1-0.5 Mg)

ANGELIQ ORAL TABLET 0.25-0.5 MG, 0.5-1 MG

(drospirenone-estradiol)

BIJUVA ORAL CAPSULE 1-100 MG (estradiol-

progesterone)

CLIMARA PRO TRANSDERMAL PATCH WEEKLY

0.045-0.015 MG/DAY (estradiol-levonorgestrel)

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)

COMBIPATCH TRANSDERMAL PATCH TWICE

WEEKLY 0.05-0.14 MG/DAY, 0.05-0.25 MG/DAY

(estradiol-norethindrone acet)

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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)

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)

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

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

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

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)

EVAMIST TRANSDERMAL SOLUTION 1.53

MG/SPRAY (estradiol)

norethindrone-eth estradiol (Fyavolv Oral Tablet 0.5-2.5 Mg-

Mcg, 1-5 Mg-Mcg)

IMVEXXY MAINTENANCE PACK VAGINAL INSERT

10 MCG, 4 MCG (estradiol)

IMVEXXY STARTER PACK VAGINAL INSERT 10

MCG, 4 MCG (estradiol)

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)

MENOSTAR TRANSDERMAL PATCH WEEKLY 14

MCG/24HR (estradiol)

estradiol-norethindrone acet (Mimvey Oral Tablet 1-0.5 Mg) PG

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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)

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)

PREMARIN ORAL TABLET 0.3 MG, 0.45 MG, 0.625 MG,

0.9 MG, 1.25 MG (estrogens conjugated)

PREMARIN VAGINAL CREAM 0.625 MG/GM (estrogens,

conjugated)

PREMPHASE ORAL TABLET 0.625-5 MG (conj estrog-

medroxyprogest ace)

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)

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)

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

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)

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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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)

OVIDREL SUBCUTANEOUS INJECTABLE 250

MCG/0.5ML (choriogonadotropin alfa)

PSP PA; SPC

PREGNYL INTRAMUSCULAR SOLUTION

RECONSTITUTED 10000 UNIT (chorionic gonadotropin)

GLUCOCORTICOIDS - DRUGS TO TREAT

INFLAMMATORY RESPONSE

ALKINDI SPRINKLE ORAL CAPSULE SPRINKLE 0.5

MG, 1 MG, 2 MG, 5 MG (hydrocortisone)

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

dexamethasone oral tablet therapy pack 1.5 mg (21), 1.5 mg

(35), 1.5 mg (51)

DXEVO 11-DAY ORAL TABLET THERAPY PACK 1.5

MG (dexamethasone)

EMFLAZA ORAL SUSPENSION 22.75 MG/ML

(deflazacort)

EMFLAZA ORAL TABLET 18 MG, 30 MG, 36 MG, 6 MG

(deflazacort)

fludrocortisone acetate oral tablet 0.1 mg PG

HEMADY ORAL TABLET 20 MG (dexamethasone) NF

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dexamethasone (Hidex 6-Day Oral Tablet Therapy Pack 1.5

Mg (21))

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

prednisolone sodium phosphate oral solution 15 mg/5ml, 25

mg/5ml, 6.7 (5 base) mg/5ml

prednisolone sodium phosphate oral tablet dispersible 10 mg, 15

mg, 30 mg

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)

RAYOS ORAL TABLET DELAYED RELEASE 1 MG, 2

MG, 5 MG (prednisone)

TAPERDEX 12-DAY ORAL TABLET THERAPY PACK

1.5 MG (49) (dexamethasone)

dexamethasone (Taperdex 6-Day Oral Tablet Therapy Pack

1.5 Mg, 1.5 Mg (21))

TAPERDEX 7-DAY ORAL TABLET THERAPY PACK

1.5 MG (27) (dexamethasone)

GLUCOSE ELEVATING AGENTS - DRUGS TO TREAT

LOW BLOOD SUGAR

BAQSIMI ONE PACK NASAL POWDER 3 MG/DOSE

(glucagon)

BAQSIMI TWO PACK NASAL POWDER 3 MG/DOSE

(glucagon)

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Limits

BD GLUCOSE ORAL TABLET CHEWABLE 5 GM

(dextrose (diabetic use))

diazoxide oral suspension 50 mg/ml PG

GLUCAGEN HYPOKIT INJECTION SOLUTION

RECONSTITUTED 1 MG (glucagon hcl (rdna))

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)

GVOKE HYPOPEN 2-PACK SUBCUTANEOUS

SOLUTION AUTO-INJECTOR 0.5 MG/0.1ML, 1

MG/0.2ML (glucagon)

GVOKE KIT SUBCUTANEOUS SOLUTION 1 MG/0.2ML

(glucagon)

GVOKE PFS SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 0.5 MG/0.1ML, 1 MG/0.2ML (glucagon)

ZEGALOGUE SUBCUTANEOUS SOLUTION AUTO-

INJECTOR 0.6 MG/0.6ML (dasiglucagon hcl)

ZEGALOGUE SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 0.6 MG/0.6ML (dasiglucagon hcl)

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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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)

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)

NUTROPIN AQ NUSPIN 20 SUBCUTANEOUS

SOLUTION PEN-INJECTOR 20 MG/2ML (somatropin)

NUTROPIN AQ NUSPIN 5 SUBCUTANEOUS

SOLUTION PEN-INJECTOR 5 MG/2ML (somatropin)

OMNITROPE SUBCUTANEOUS SOLUTION

CARTRIDGE 10 MG/1.5ML, 5 MG/1.5ML (somatropin)

OMNITROPE SUBCUTANEOUS SOLUTION

RECONSTITUTED 5.8 MG (somatropin)

SAIZEN INJECTION SOLUTION RECONSTITUTED 5

MG, 8.8 MG (somatropin (non-refrigerated))

SAIZENPREP INJECTION SOLUTION

RECONSTITUTED 8.8 MG (somatropin (non-refrigerated))

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)

ZOMACTON SUBCUTANEOUS SOLUTION

RECONSTITUTED 10 MG, 5 MG (somatropin)

ZORBTIVE SUBCUTANEOUS SOLUTION

RECONSTITUTED 8.8 MG (somatropin (non-refrigerated))

NPSP PA

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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)

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)

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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JYNARQUE ORAL TABLET THERAPY PACK 15 MG,

30 & 15 MG, 45 & 15 MG, 60 & 30 MG, 90 & 30 MG

(tolvaptan)

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)

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

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)

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)

calcium acetate (phos binder) oral capsule 667 mg PG

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FOSRENOL ORAL PACKET 1000 MG, 750 MG

(lanthanum carbonate)

FOSRENOL ORAL TABLET CHEWABLE 1000 MG, 500

MG, 750 MG (lanthanum carbonate)

lanthanum carbonate oral tablet chewable 1000 mg, 500 mg, 750

RENVELA ORAL PACKET 0.8 GM, 2.4 GM (sevelamer

carbonate)

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)

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)

THYROID AGENTS - DRUGS TO REGULATE

THYROID LEVELS

ADTHYZA ORAL TABLET 130 MG, 16.25 MG, 32.5 MG,

65 MG, 97.5 MG (thyroid)

CYTOMEL ORAL TABLET 25 MCG, 5 MCG, 50 MCG

(liothyronine sodium)

ERMEZA ORAL SOLUTION 150 MCG/5ML (levothyroxine

sodium)

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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

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

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)

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)

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)

VASOPRESSINS - DRUGS TO REGULATE PITUITARY

HORMONES

DDAVP ORAL TABLET 0.1 MG, 0.2 MG (desmopressin

acetate)

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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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)

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)

MYTESI ORAL TABLET DELAYED RELEASE 125 MG

(crofelemer)

ANTIEMETICS - DRUGS FOR NAUSEA AND

VOMITING

AKYNZEO ORAL CAPSULE 300-0.5 MG (netupitant-

palonosetron)

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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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)

EMEND TRI-PACK ORAL CAPSULE 80 & 125 MG

(aprepitant)

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)

SANCUSO TRANSDERMAL PATCH 3.1 MG/24HR

(granisetron)

QL (2 PATCHES per 21

days)

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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)

trimethobenzamide hcl oral capsule 300 mg PG

VARUBI (180 MG DOSE) ORAL TABLET THERAPY

PACK 2 X 90 MG (rolapitant hcl)

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)

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)

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)

DELZICOL ORAL CAPSULE DELAYED RELEASE 400

MG (mesalamine)

DIPENTUM ORAL CAPSULE 250 MG (olsalazine sodium) NP PA

LIALDA ORAL TABLET DELAYED RELEASE 1.2 GM

(mesalamine)

mesalamine er oral capsule extended release 24 hour 0.375 gm PG

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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)

PENTASA ORAL CAPSULE EXTENDED RELEASE 250

MG, 500 MG (mesalamine)

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)

UCERIS RECTAL FOAM 2 MG/ACT (budesonide) NF

IRRITABLE BOWEL SYNDROME WITH

CONSTIPATION

AMITIZA ORAL CAPSULE 24 MCG, 8 MCG

(lubiprostone)

IBSRELA ORAL TABLET 50 MG (tenapanor hcl) NF

LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG

(linaclotide)

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)

N7 (PB); N8 ($0 copay for

members age 45 through

75); AL (Min 45 Years and

Max 75 Years)

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Coverage Requirements and

Limits

enulose oral solution 10 gm/15ml PG

GAVILYTE-C ORAL SOLUTION RECONSTITUTED 240

GM (peg 3350-kcl-nabcb-nacl-nasulf)

peg 3350-kcl-nabcb-nacl-nasulf (Gavilyte-G Oral Solution

Reconstituted 236 Gm)

GOLYTELY ORAL SOLUTION RECONSTITUTED 236

GM (peg 3350-kcl-nabcb-nacl-nasulf)

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)

na sulfate-k sulfate-mg sulf oral solution 17.5-3.13-1.6

gm/177ml

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)

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)

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)

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)

SUTAB ORAL TABLET 1479-225-188 MG (sodium sulfate-

mag sulfate-kcl)

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)

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Limits

BYLVAY ORAL CAPSULE 1200 MCG, 400 MCG

(odevixibat)

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)

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)

MOVANTIK ORAL TABLET 12.5 MG, 25 MG (naloxegol

oxalate)

OCALIVA ORAL TABLET 10 MG, 5 MG (obeticholic acid) NPSP

PA; QL (30 TABLETS per

30 days)

RELISTOR ORAL TABLET 150 MG (methylnaltrexone

bromide)

RELISTOR SUBCUTANEOUS SOLUTION 12 MG/0.6ML,

8 MG/0.4ML (methylnaltrexone bromide)

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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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))

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))

PERTZYE ORAL CAPSULE DELAYED RELEASE

PARTICLES 16000-57500 UNIT, 24000-86250 UNIT, 4000-

14375 UNIT, 8000-28750 UNIT (pancrelipase (lip-prot-amyl))

VIOKACE ORAL TABLET 10440-39150 UNIT, 20880-

78300 UNIT (pancrelipase (lip-prot-amyl))

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))

PROTON PUMP INHIBITORS - DRUGS FOR ULCERS

AND STOMACH ACID

ACIPHEX ORAL TABLET DELAYED RELEASE 20 MG

(rabeprazole sodium)

DEXILANT ORAL CAPSULE DELAYED RELEASE 30

MG, 60 MG (dexlansoprazole)

dexlansoprazole oral capsule delayed release 30 mg, 60 mg NF

esomeprazole magnesium oral capsule delayed release 20 mg, 40

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)

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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Coverage Requirements and

Limits

NEXIUM 24HR ORAL TABLET DELAYED RELEASE 20

MG (esomeprazole magnesium)

Select OTC; QL (90 tablets

per 365 days)

NEXIUM ORAL CAPSULE DELAYED RELEASE 40 MG

(esomeprazole magnesium)

NEXIUM ORAL PACKET 10 MG, 2.5 MG, 20 MG, 40

MG, 5 MG (esomeprazole magnesium)

omeprazole magnesium oral capsule delayed release 20.6 (20

base) mg

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

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)

PREVACID SOLUTAB ORAL TABLET DELAYED

RELEASE DISPERSIBLE 30 MG (lansoprazole)

PRILOSEC ORAL PACKET 10 MG, 2.5 MG (omeprazole

magnesium)

PRILOSEC OTC ORAL TABLET DELAYED RELEASE

20 MG (omeprazole magnesium)

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)

qc lansoprazole oral capsule delayed release 15 mg PG

Select OTC; QL (90

CAPSULES per 365 DAYs)

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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)

ZEGERID ORAL PACKET 20-1680 MG, 40-1680 MG

(omeprazole-sodium bicarbonate)

RECTAL, CORTICOSTEROIDS

hydrocortisone (perianal) external cream 2.5 % PG

PROCTOCORT EXTERNAL CREAM 1 % (hydrocortisone) NF

PROCTOFOAM HC EXTERNAL FOAM 1-1 %

(hydrocortisone ace-pramoxine)

hydrocortisone (Proctozone-Hc External Cream 2.5 %) PG

ULCER THERAPY COMBINATIONS

amoxicill-clarithro-lansopraz oral therapy pack 500 & 500 & 30

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)

TALICIA ORAL CAPSULE DELAYED RELEASE 250-

12.5-10 MG (amoxicill-rifabutin-omeprazole)

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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Coverage Requirements and

Limits

JALYN ORAL CAPSULE 0.5-0.4 MG (dutasteride-

tamsulosin hcl)

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)

CONTRACEPTIVES - PRODUCTS FOR BIRTH

CONTROL

ENCARE VAGINAL SUPPOSITORY 100 MG (nonoxynol-

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))

SPC ; QL (6 KITS per 25

days)

CAVERJECT INTRACAVERNOSAL SOLUTION

RECONSTITUTED 40 MCG (alprostadil (vasodilator))

SPC ; QL (6 VIALS per 25

days)

CIALIS ORAL TABLET 10 MG, 2.5 MG, 20 MG, 5 MG

(tadalafil)

EDEX INTRACAVERNOSAL KIT 10 MCG, 20 MCG, 40

MCG (alprostadil (vasodilator))

SPC ; QL (6 VIALS per 25

days)

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Coverage Requirements and

Limits

MUSE URETHRAL PELLET 1000 MCG, 250 MCG, 500

MCG (alprostadil (vasodilator))

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

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)

super quad-mix intracavernosal solution reconstituted 150-20-

0.2-2 mg

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)

ESTROGENS - DRUGS TO REGULATE FEMALE

HORMONES

FEMRING VAGINAL RING 0.05 MG/24HR, 0.1

MG/24HR (estradiol acetate)

MISCELLANEOUS

bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg PG

ELMIRON ORAL CAPSULE 100 MG (pentosan polysulfate

sodium)

FILSPARI ORAL TABLET 200 MG, 400 MG (sparsentan) NF

LITHOSTAT ORAL TABLET 250 MG (acetohydroxamic

acid)

pot & sod cit-cit ac oral solution 550-500-334 mg/5ml PG

N8 (Listing does not include

certain NDCs)

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Coverage Requirements and

Limits

potassium citrate er oral tablet extended release 10 meq (1080

mg), 15 meq (1620 mg), 5 meq (540 mg)

PROCYSBI ORAL CAPSULE DELAYED RELEASE 25

MG, 75 MG (cysteamine bitartrate)

PROCYSBI ORAL PACKET 300 MG, 75 MG (cysteamine

bitartrate)

TARPEYO ORAL CAPSULE DELAYED RELEASE 4 MG

(budesonide)

THIOLA EC ORAL TABLET DELAYED RELEASE 100

MG, 300 MG (tiopronin)

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)

URINARY ANTISPASMODICS - DRUGS TO TREAT

URINARY INCONTINENCE

darifenacin hydrobromide er oral tablet extended release 24

hour 15 mg, 7.5 mg

DETROL LA ORAL CAPSULE EXTENDED RELEASE

24 HOUR 2 MG, 4 MG (tolterodine tartrate)

DITROPAN XL ORAL TABLET EXTENDED RELEASE

24 HOUR 5 MG (oxybutynin chloride)

ST; QL (30 TABLETS per

25 days)

fesoterodine fumarate er oral tablet extended release 24 hour 4

mg, 8 mg

flavoxate hcl oral tablet 100 mg PG

GELNIQUE TRANSDERMAL GEL 10 % (oxybutynin

chloride)

GEMTESA ORAL TABLET 75 MG (vibegron) PB

ST; QL (30 TABLETS per

25 days)

MYRBETRIQ ORAL SUSPENSION RECONSTITUTED

ER 8 MG/ML (mirabegron)

MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24

HOUR 25 MG, 50 MG (mirabegron)

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Coverage Requirements and

Limits

oxybutynin chloride er oral tablet extended release 24 hour 10

mg, 15 mg, 5 mg

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

tolterodine tartrate oral tablet 1 mg, 2 mg PG

TOVIAZ ORAL TABLET EXTENDED RELEASE 24

HOUR 4 MG, 8 MG (fesoterodine fumarate)

trospium chloride er oral capsule extended release 24 hour 60

trospium chloride oral tablet 20 mg PG

VESICARE ORAL TABLET 10 MG, 5 MG (solifenacin

succinate)

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)

ELIQUIS ORAL TABLET 2.5 MG, 5 MG (apixaban) PB

enoxaparin sodium injection solution 300 mg/3ml PG

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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

fondaparinux sodium subcutaneous solution 10 mg/0.8ml, 2.5

mg/0.5ml, 5 mg/0.4ml, 7.5 mg/0.6ml

FRAGMIN SUBCUTANEOUS SOLUTION 10000

UNIT/4ML, 95000 UNIT/3.8ML (dalteparin sodium)

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)

heparin sodium (porcine) injection solution 1000 unit/ml, 10000

unit/ml, 20000 unit/ml, 5000 unit/ml

heparin sodium (porcine) pf injection solution 5000 unit/0.5ml PG

PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG

(dabigatran etexilate mesylate)

PRADAXA ORAL PACKET 110 MG, 150 MG, 20 MG, 30

MG, 40 MG, 50 MG (dabigatran etexilate mesylate)

SAVAYSA ORAL TABLET 15 MG, 30 MG, 60 MG

(edoxaban tosylate)

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)

XARELTO ORAL TABLET 10 MG, 15 MG, 2.5 MG, 20

MG (rivaroxaban)

XARELTO STARTER PACK ORAL TABLET THERAPY

PACK 15 & 20 MG (rivaroxaban)

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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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)

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))

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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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)

FULPHILA SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 6 MG/0.6ML (pegfilgrastim-jmdb)

FYLNETRA SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 6 MG/0.6ML (pegfilgrastim-pbbk)

GRANIX SUBCUTANEOUS SOLUTION 300 MCG/ML,

480 MCG/1.6ML (tbo-filgrastim)

GRANIX SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML (tbo-

filgrastim)

LEUKINE INJECTION SOLUTION RECONSTITUTED

250 MCG (sargramostim)

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)

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)

NEULASTA SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 6 MG/0.6ML (pegfilgrastim)

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480

MCG/1.6ML (filgrastim)

NEUPOGEN INJECTION SOLUTION PREFILLED

SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML (filgrastim)

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)

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NYVEPRIA SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 6 MG/0.6ML (pegfilgrastim-apgf)

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)

releuko injection solution 480 mcg/1.6ml NF

releuko subcutaneous solution prefilled syringe 300 mcg/0.5ml,

480 mcg/0.8ml

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)

STIMUFEND SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 6 MG/0.6ML (pegfilgrastim-fpgk)

UDENYCA SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 6 MG/0.6ML (pegfilgrastim-cbqv)

ZARXIO INJECTION SOLUTION PREFILLED

SYRINGE 300 MCG/0.5ML, 480 MCG/0.8ML (filgrastim-

sndz)

ZIEXTENZO SUBCUTANEOUS SOLUTION

PREFILLED SYRINGE 6 MG/0.6ML (pegfilgrastim-bmez)

PSP

PA; QL (2 INJECTIONS

per 28 days)

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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)

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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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))

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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))

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

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)

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)

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)

TAVALISSE ORAL TABLET 100 MG, 150 MG

(fostamatinib disodium)

PSP

PA; QL (60 TABLETS per

30 days)

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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

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)

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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VITAMINS - VITAMINS AND SUPPLEMENTS

NASCOBAL NASAL SOLUTION 500 MCG/0.1ML

(cyanocobalamin)

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)

PALFORZIA (120 MG DAILY DOSE) ORAL 20 MG & 100

MG (peanut powder-dnfp)

PALFORZIA (160 MG DAILY DOSE) ORAL 3 X 20 MG &

100 MG (peanut powder-dnfp)

PALFORZIA (20 MG DAILY DOSE) ORAL 20 MG

(peanut powder-dnfp)

PALFORZIA (200 MG DAILY DOSE) ORAL 2 X 100 MG

(peanut powder-dnfp)

PALFORZIA (240 MG DAILY DOSE) ORAL 2 X 20 MG &

2 X 100 MG (peanut powder-dnfp)

PALFORZIA (3 MG DAILY DOSE) ORAL 3 X 1 MG

(peanut powder-dnfp)

PALFORZIA (300 MG MAINTENANCE) ORAL PACKET

300 MG (peanut powder-dnfp)

PALFORZIA (300 MG TITRATION) ORAL PACKET 300

MG (peanut powder-dnfp)

PALFORZIA (40 MG DAILY DOSE) ORAL 2 X 20 MG

(peanut powder-dnfp)

PALFORZIA (6 MG DAILY DOSE) ORAL 6 X 1 MG

(peanut powder-dnfp)

PALFORZIA (80 MG DAILY DOSE) ORAL 4 X 20 MG

(peanut powder-dnfp)

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PALFORZIA INITIAL ESCALATION ORAL 0.5 & 1 & 1.5

& 3 & 6 MG (peanut powder-dnfp)

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)

AVSOLA INTRAVENOUS SOLUTION

RECONSTITUTED 100 MG (infliximab-axxq)

ENTYVIO INTRAVENOUS SOLUTION

RECONSTITUTED 300 MG (vedolizumab)

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)

infliximab intravenous solution reconstituted 100 mg NF

ORENCIA INTRAVENOUS SOLUTION

RECONSTITUTED 250 MG (abatacept)

REMICADE INTRAVENOUS SOLUTION

RECONSTITUTED 100 MG (infliximab)

PSP

PA; QL (5 VIALS per 42

days)

RENFLEXIS INTRAVENOUS SOLUTION

RECONSTITUTED 100 MG (infliximab-abda)

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)

ACTEMRA SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 162 MG/0.9ML (tocilizumab)

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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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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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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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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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)

OLUMIANT ORAL TABLET 1 MG, 2 MG, 4 MG

(baricitinib)

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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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)

SIMPONI SUBCUTANEOUS SOLUTION AUTO-

INJECTOR 100 MG/ML, 50 MG/0.5ML (golimumab)

SIMPONI SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 100 MG/ML, 50 MG/0.5ML (golimumab)

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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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))

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))

HEREDITARY ANGIOEDEMA

BERINERT INTRAVENOUS KIT 500 UNIT (c1 esterase

inhibitor (human))

CINRYZE INTRAVENOUS SOLUTION

RECONSTITUTED 500 UNIT (c1 esterase inhibitor

(human))

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Coverage Requirements and

Limits

FIRAZYR SUBCUTANEOUS SOLUTION PREFILLED

SYRINGE 30 MG/3ML (icatibant acetate)

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)

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))

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)

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)

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)

IMMUNOMODULATORS

ACTIMMUNE SUBCUTANEOUS SOLUTION 2000000

UNIT/0.5ML (interferon gamma-1b)

NPSP PA

ARCALYST SUBCUTANEOUS SOLUTION

RECONSTITUTED 220 MG (rilonacept)

JOENJA ORAL TABLET 70 MG (leniolisib phosphate) NF

IMMUNOSUPPRESSANTS

ATGAM INTRAVENOUS INJECTABLE 50 MG/ML

(lymphocyte,anti-thymo imm glob)

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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Limits

CELLCEPT INTRAVENOUS INTRAVENOUS

SOLUTION RECONSTITUTED 500 MG (mycophenolate

mofetil hcl)

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

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)

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)

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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))

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)

potassium chloride crys er (Klor-Con M10 Oral Tablet

Extended Release 10 Meq)

potassium chloride crys er (Klor-Con M15 Oral Tablet

Extended Release 15 Meq)

potassium chloride crys er (Klor-Con M20 Oral Tablet

Extended Release 20 Meq)

potassium chloride (Klor-Con Oral Packet 20 Meq) NP

potassium chloride (Klor-Con Oral Tablet Extended Release 8

Meq)

N8 (Listing does not include

certain NDCs)

potassium chloride crys er oral tablet extended release 10 meq,

20 meq

potassium chloride er oral capsule extended release 10 meq, 8

meq

potassium chloride er oral tablet extended release 10 meq, 20

meq

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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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

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)

azesco oral tablet 13-1 mg NF

CITRANATAL 90 DHA ORAL 90-1 & 300 MG (prenat w/o

a-fecbgl-dss-fa-dha)

CITRANATAL ASSURE ORAL 35-1 & 300 MG (prenat w/o

a-fecbgl-dss-fa-dha)

CITRANATAL B-CALM ORAL 20-1 MG & 2 X 25 MG

(prenat w/o a fecbnfeglu-fa &b6)

CITRANATAL BLOOM ORAL TABLET 90-1 MG

(prenatal-dss-fecb-fegl-fa)

CITRANATAL DHA ORAL 27-1 & 250 MG (prenat w/o a-

fecbgl-dss-fa-dha)

CITRANATAL HARMONY ORAL CAPSULE 27-1-260

MG (prenat-fefmcb-dss-fa-dha w/o a)

CITRANATAL MEDLEY ORAL CAPSULE 27-1-200 MG

(prenat-fecb-fefum-fa-dha w/o a)

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)

DUET DHA 400 ORAL 25-1 & 400 MG (prenat-fepoly-fered-

fa-omega 3)

DUET DHA BALANCED ORAL 25-1 & 267 MG (prenat-

fepoly-fered-fa-omega 3)

ENBRACE HR ORAL CAPSULE (prenat vit-fe gly cys-fa-

omega)

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Coverage Requirements and

Limits

FOLIVANE-OB ORAL CAPSULE 85-1 MG (prenat w/o a

vit-fefum-fepo-fa)

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)

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)

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)

NESTABS ONE ORAL CAPSULE 38-1-225 MG (prenat-fe-

methylfol-dha w/o a)

NESTABS ORAL TABLET 32-1 MG (prenat-fe bisgly-fa-w/o

vit a)

OB COMPLETE ONE ORAL CAPSULE 50-1-476 MG

(prenat-fecbn-feaspgl-fa-fish)

OB COMPLETE ORAL TABLET 50-1.25 MG (prenatal vit-

iron carbonyl-fa)

OB COMPLETE PETITE ORAL CAPSULE 35-5-1-200 MG

(prenat-fecbn-feaspgl-fa-omega)

OB COMPLETE PREMIER ORAL TABLET 30-20-1 MG

(prenatal-fe cbn-fe asp gly-fa)

OB COMPLETE/DHA ORAL CAPSULE 30-10-1-200 MG

(prenat-fecbn-feaspgl-fa-omega)

OBSTETRIX DHA ORAL 29-1 & 387 MG (prenatal-fecbn-

fa-dss-omega 3)

OBSTETRIX ONE ORAL CAPSULE 38-1-225 MG (prenat-

fe-methyl-dss-dha w/o a)

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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)

PRENATE AM ORAL TABLET 1 MG (prenatal ca-b6-b12-

fa-ginger)

PRENATE DHA ORAL CAPSULE 18-0.6-0.4-300 MG

(prenat-feasp-meth-fa-dha w/o a)

PRENATE ELITE ORAL TABLET 20-0.6-0.4 MG

(prenatal-feaspgly-methylfol-fa)

PRENATE ENHANCE ORAL CAPSULE 28-0.6-0.4-400

MG (prenat w/o a-fe-methfol-fa-dha)

PRENATE MINI ORAL CAPSULE 18-0.6-0.4-350 MG

(prenat-fecbn-feasp-meth-fa-dha)

PRENATE ORAL TABLET CHEWABLE 0.6-0.4 MG

(prenat mv-min-methylfolate-fa)

PRENATE PIXIE ORAL CAPSULE 10-0.6-0.4-200 MG

(prenat-feasp-meth-fa-dha w/o a)

PRENATE RESTORE ORAL CAPSULE 27-0.6-0.4-400

MG (prenat w/o a-fe-methfol-fa-dha)

prenatvite plus oral tablet 1 mg NF

PRIMACARE ORAL CAPSULE 30-1-470 MG (pren-fe-

meth-fa-omeg w/o a)

PROVIDA OB ORAL CAPSULE 20-20-1.25 MG (prenat w/o

a vit-fefum-fepo-fa)

SELECT-OB ORAL TABLET CHEWABLE 29-0.6-0.4 MG

(prenat vit-fepoly-methylfol-fa)

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SELECT-OB ORAL TABLET CHEWABLE 29-1 MG

(prenatal vit-fe psac cmplx-fa)

SELECT-OB+DHA ORAL 29-1 & 250 MG (prenatal vit-

fepoly-fa-dha)

TARON-C DHA ORAL CAPSULE 35-1 MG (prenat-fefum-

fepo-fa-omega 3)

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)

VINATE ONE ORAL TABLET 60-1 MG (prenatal vit-fe

fumarate-fa)

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)

VITAFOL GUMMIES ORAL TABLET CHEWABLE 3.33-

0.333-34.8 MG (prenatal vit-fe phos-fa-omega)

VITAFOL STRIPS ORAL FILM 1 MG (prenatal-b6-b12-d3-

folic acid)

VITAFOL ULTRA ORAL CAPSULE 29-0.6-0.4-200 MG

(prenat-fe poly-methfol-fa-dha)

VITAFOL-NANO ORAL TABLET 18-0.6-0.4 MG (prenatal-

fe fum-methf-fa w/o a)

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)

VITAFOL-ONE ORAL CAPSULE 29-1-200 MG (prenatal

vit-fepoly-fa-dha)

VITAMEDMD REDICHEW RX ORAL TABLET

CHEWABLE 1.4 MG (prenat-b2-b6-b12-d3-fa)

VITAPEARL ORAL CAPSULE EXTENDED RELEASE

30-1.4-200 MG (prenat-fefum-fered-fa-dha w/oa)

VIVA DHA ORAL CAPSULE 28-1-200 MG (prenatal vit-fe

fum-fa-omega)

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

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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)

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)

FLORIVA ORAL LIQUID 0.25-400 MG-UNIT/ML (sodium

fluoride-vitamin d)

FLORIVA ORAL TABLET CHEWABLE 0.25 MG, 0.5

MG, 1 MG (ped multiple vit-minerals-fl)

folbee plus oral tablet PG

FOLGARD OS ORAL TABLET 500-1.1 MG (multiple vit-

min-calcium-fa)

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)

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)

POLY-VI-FLOR/IRON ORAL SUSPENSION 0.25-7

MG/ML (ped multivitamins-fl-iron)

POLY-VI-FLOR/IRON ORAL TABLET CHEWABLE 0.5-

10 MG (ped multivitamins-fl-iron)

QUFLORA FE ORAL TABLET CHEWABLE 0.25 MG

(multi vit-min-fluoride-fe-fa)

QUFLORA FE PEDIATRIC ORAL LIQUID 0.25-9.5

MG/ML (ped multivitamins-fl-iron)

QUFLORA GUMMIES ORAL TABLET CHEWABLE

0.125 MG (pediatric multivitamins-fl)

RENATABS WITH IRON ORAL 1 & 100 MG (b complex-c-

biotin-e-fa-fe cbn)

reno caps oral capsule 1 mg PG Select OTC

TRIFERIC HEMODIALYSIS PACKET 272 MG (ferric

pyrophosphate citrate)

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)

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)

ANTIGLAUCOMA - DRUGS TO TREAT GLAUCOMA

ALPHAGAN P OPHTHALMIC SOLUTION 0.1 %, 0.15 %

(brimonidine tartrate)

AZOPT OPHTHALMIC SUSPENSION 1 % (brinzolamide) NF

betaxolol hcl ophthalmic solution 0.5 % PG

BETIMOL OPHTHALMIC SOLUTION 0.25 %, 0.5 %

(timolol hemihydrate)

BETOPTIC-S OPHTHALMIC SUSPENSION 0.25 %

(betaxolol hcl)

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)

COSOPT PF OPHTHALMIC SOLUTION 2-0.5 %

(dorzolamide hcl-timolol mal)

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)

latanoprost ophthalmic solution 0.005 % PG

levobunolol hcl ophthalmic solution 0.5 % PG

LUMIGAN OPHTHALMIC SOLUTION 0.01 %

(bimatoprost)

pilocarpine hcl ophthalmic solution 1 %, 2 %, 4 % PG

RHOPRESSA OPHTHALMIC SOLUTION 0.02 %

(netarsudil dimesylate)

ROCKLATAN OPHTHALMIC SOLUTION 0.02-0.005 %

(netarsudil-latanoprost)

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Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

SIMBRINZA OPHTHALMIC SUSPENSION 1-0.2 %

(brinzolamide-brimonidine)

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 %)

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)

TRAVATAN Z OPHTHALMIC SOLUTION 0.004 %

(travoprost)

travoprost (bak free) ophthalmic solution 0.004 % PG

VYZULTA OPHTHALMIC SOLUTION 0.024 %

(latanoprostene bunod)

XELPROS OPHTHALMIC EMULSION 0.005 %

(latanoprost)

ZIOPTAN OPHTHALMIC SOLUTION 0.0015 %

(tafluprost)

ANTI-INFECTIVE/ANTI-INFLAMMATORY - DRUGS

TO TREAT INFECTIONS AND INFLAMMATION

neomycin-polymyxin-dexameth ophthalmic ointment 3.5-10000-

0.1

neomycin-polymyxin-dexameth ophthalmic suspension 3.5-

10000-0.1

sulfacetamide-prednisolone ophthalmic solution 10-0.23 % PG

TOBRADEX OPHTHALMIC OINTMENT 0.3-0.1 %

(tobramycin-dexamethasone)

TOBRADEX OPHTHALMIC SUSPENSION 0.3-0.1 %

(tobramycin-dexamethasone)

TOBRADEX ST OPHTHALMIC SUSPENSION 0.3-0.05 %

(tobramycin-dexamethasone)

tobramycin-dexamethasone ophthalmic suspension 0.3-0.1 % PG

ZYLET OPHTHALMIC SUSPENSION 0.5-0.3 %

(loteprednol-tobramycin)

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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)

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)

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-%

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)

ANTI-INFLAMMATORIES - DRUGS TO TREAT

INFLAMMATION

ACUVAIL OPHTHALMIC SOLUTION 0.45 % (ketorolac

tromethamine)

ALREX OPHTHALMIC SUSPENSION 0.2 % (loteprednol

etabonate)

bromfenac sodium (once-daily) ophthalmic solution 0.09 % NP

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Coverage Requirements and

Limits

BROMSITE OPHTHALMIC SOLUTION 0.075 %

(bromfenac sodium)

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)

PA; QL (2 BOTTLES per 90

days)

FLAREX OPHTHALMIC SUSPENSION 0.1 %

(fluorometholone acetate)

fluorometholone ophthalmic suspension 0.1 % PG

flurbiprofen sodium ophthalmic solution 0.03 % PG

FML FORTE OPHTHALMIC SUSPENSION 0.25 %

(fluorometholone)

FML LIQUIFILM OPHTHALMIC SUSPENSION 0.1 %

(fluorometholone)

ILEVRO OPHTHALMIC SUSPENSION 0.3 % (nepafenac) NF

INVELTYS OPHTHALMIC SUSPENSION 1 % (loteprednol

etabonate)

ketorolac tromethamine ophthalmic solution 0.4 % NP

ketorolac tromethamine ophthalmic solution 0.5 % PG

LOTEMAX OPHTHALMIC GEL 0.5 % (loteprednol

etabonate)

LOTEMAX OPHTHALMIC OINTMENT 0.5 % (loteprednol

etabonate)

LOTEMAX OPHTHALMIC SUSPENSION 0.5 %

(loteprednol etabonate)

LOTEMAX SM OPHTHALMIC GEL 0.38 % (loteprednol

etabonate)

loteprednol etabonate ophthalmic gel 0.5 % NF

loteprednol etabonate ophthalmic suspension 0.5 % PG

MAXIDEX OPHTHALMIC SUSPENSION 0.1 %

(dexamethasone)

NEVANAC OPHTHALMIC SUSPENSION 0.1 %

(nepafenac)

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Coverage Requirements and

Limits

PRED FORTE OPHTHALMIC SUSPENSION 1 %

(prednisolone acetate)

PRED MILD OPHTHALMIC SUSPENSION 0.12 %

(prednisolone acetate)

prednisolone acetate ophthalmic suspension 1 % PG

PROLENSA OPHTHALMIC SOLUTION 0.07 %

(bromfenac sodium)

DRY EYE DISEASE

CEQUA OPHTHALMIC SOLUTION 0.09 % (cyclosporine) NF

cyclosporine ophthalmic emulsion 0.05 % NF

RESTASIS MULTIDOSE OPHTHALMIC EMULSION

0.05 % (cyclosporine)

RESTASIS OPHTHALMIC EMULSION 0.05 %

(cyclosporine)

XIIDRA OPHTHALMIC SOLUTION 5 % (lifitegrast) PB

MISCELLANEOUS

atropine sulfate ophthalmic solution 1 % PG

CYSTADROPS OPHTHALMIC SOLUTION 0.37 %

(cysteamine hcl)

CYSTARAN OPHTHALMIC SOLUTION 0.44 %

(cysteamine hcl)

NPSP

PA; QL (4 BOTTLES per 28

days)

LACRISERT OPHTHALMIC INSERT 5 MG (artificial tear

insert)

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)

UPNEEQ OPHTHALMIC SOLUTION 0.1 %

(oxymetazoline hcl)

VERKAZIA OPHTHALMIC EMULSION 0.1 %

(cyclosporine)

VISUDYNE INTRAVENOUS SOLUTION

RECONSTITUTED 15 MG (verteporfin)

NPSP PA

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Limits

RETINAL DISORDERS

BYOOVIZ INTRAVITREAL SOLUTION 0.5 MG/0.05ML

(ranibizumab-nuna)

CIMERLI INTRAVITREAL SOLUTION 0.3 MG/0.05ML,

0.5 MG/0.05ML (ranibizumab-eqrn)

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)

GLASSIA INTRAVENOUS SOLUTION 1000 MG/50ML

(alpha1-proteinase inhibitor)

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)

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

QL (4 SOLUTION AUTO-

INJECTOR per 25 days)

EPINEPHRINESNAP-V INJECTION KIT 1 MG/ML

(epinephrine)

EPIPEN 2-PAK INJECTION SOLUTION AUTO-

INJECTOR 0.3 MG/0.3ML (epinephrine)

QL (4 INJECTIONS per 25

DAYs)

EPIPEN JR 2-PAK INJECTION SOLUTION AUTO-

INJECTOR 0.15 MG/0.3ML (epinephrine)

QL (4 INJECTIONS per 25

DAYs)

SYMJEPI INJECTION SOLUTION PREFILLED

SYRINGE 0.15 MG/0.3ML, 0.3 MG/0.3ML (epinephrine)

ANTICHOLINERGIC/BETA AGONIST

COMBINATIONS - DRUGS TO TREAT COPD

AIRDUO RESPICLICK 113/14 INHALATION AEROSOL

POWDER BREATH ACTIVATED 113-14 MCG/ACT

(fluticasone-salmeterol)

AIRDUO RESPICLICK 232/14 INHALATION AEROSOL

POWDER BREATH ACTIVATED 232-14 MCG/ACT

(fluticasone-salmeterol)

AIRDUO RESPICLICK 55/14 INHALATION AEROSOL

POWDER BREATH ACTIVATED 55-14 MCG/ACT

(fluticasone-salmeterol)

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)

BREZTRI AEROSPHERE INHALATION AEROSOL 160-

9-4.8 MCG/ACT (budeson-glycopyrrol-formoterol)

QL (1 PACKAGE per 25

days)

COMBIVENT RESPIMAT INHALATION AEROSOL

SOLUTION 20-100 MCG/ACT (ipratropium-albuterol)

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

ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg/3ml PG

QL (6 BOXES per 25

DAYs)

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Coverage Requirements and

Limits

STIOLTO RESPIMAT INHALATION AEROSOL

SOLUTION 2.5-2.5 MCG/ACT (tiotropium bromide-

olodaterol)

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)

INCRUSE ELLIPTA INHALATION AEROSOL POWDER

BREATH ACTIVATED 62.5 MCG/ACT (umeclidinium

bromide)

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)

LONHALA MAGNAIR STARTER KIT INHALATION

SOLUTION 25 MCG/ML (glycopyrrolate)

SPIRIVA HANDIHALER INHALATION CAPSULE 18

MCG (tiotropium bromide monohydrate)

QL (1 PACKAGE per 25

DAYs)

SPIRIVA RESPIMAT INHALATION AEROSOL

SOLUTION 1.25 MCG/ACT (tiotropium bromide

monohydrate)

QL (1 PACKAGE per 25

DAYs)

SPIRIVA RESPIMAT INHALATION AEROSOL

SOLUTION 2.5 MCG/ACT (tiotropium bromide

monohydrate)

QL (1 PACKAGE per 25

days)

TUDORZA PRESSAIR INHALATION AEROSOL

POWDER BREATH ACTIVATED 400 MCG/ACT

(aclidinium bromide)

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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Coverage Requirements and

Limits

DYMISTA NASAL SUSPENSION 137-50 MCG/ACT

(azelastine-fluticasone)

RYALTRIS NASAL SUSPENSION 665-25 MCG/ACT

(olopatadine-mometasone)

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)

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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Limits

BETA AGONISTS - DRUGS TO TREAT ASTHMA AND

COPD

albuterol sulfate hfa inhalation aerosol solution 108 (90 base)

mcg/act

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

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

BROVANA INHALATION NEBULIZATION SOLUTION

15 MCG/2ML (arformoterol tartrate)

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))

PROAIR RESPICLICK INHALATION AEROSOL

POWDER BREATH ACTIVATED 108 (90 BASE)

MCG/ACT (albuterol sulfate)

PROVENTIL HFA INHALATION AEROSOL SOLUTION

108 (90 BASE) MCG/ACT (albuterol sulfate)

SEREVENT DISKUS INHALATION AEROSOL

POWDER BREATH ACTIVATED 50 MCG/ACT

(salmeterol xinafoate)

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Limits

STRIVERDI RESPIMAT INHALATION AEROSOL

SOLUTION 2.5 MCG/ACT (olodaterol hcl)

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)

XOPENEX HFA INHALATION AEROSOL 45 MCG/ACT

(levalbuterol tartrate)

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)

HYCODAN ORAL TABLET 5-1.5 MG (hydrocodone bit-

homatrop mbr)

hydrocod poli-chlorphe poli er oral suspension extended release

10-8 mg/5ml

hydrocodone bit-homatrop mbr oral solution 5-1.5 mg/5ml PG QL (30 ML per 1 day)

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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

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

PG Select OTC

TUXARIN ER ORAL TABLET EXTENDED RELEASE

12 HOUR 54.3-8 MG (chlorpheniramine-codeine)

TUZISTRA XR ORAL SUSPENSION EXTENDED

RELEASE 14.7-2.8 MG/5ML (codeine polst-chlorphen polst)

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)

BRONCHITOL INHALATION CAPSULE 40 MG

(mannitol (cystic fibrosis))

CAYSTON INHALATION SOLUTION

RECONSTITUTED 75 MG (aztreonam lysine)

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)

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)

TOBI PODHALER INHALATION CAPSULE 28 MG

(tobramycin)

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)

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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Coverage Requirements and

Limits

MISCELLANEOUS

acetylcysteine inhalation solution 10 %, 20 % PG

DALIRESP ORAL TABLET 250 MCG, 500 MCG

(roflumilast)

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)

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)

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)

Select OTC; QL (1

PACKAGE per 25 DAYs)

OMNARIS NASAL SUSPENSION 50 MCG/ACT

(ciclesonide)

QNASL CHILDRENS NASAL AEROSOL SOLUTION 40

MCG/ACT (beclomethasone diprop (nasal))

QNASL NASAL AEROSOL SOLUTION 80 MCG/ACT

(beclomethasone diprop (nasal))

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)

PA; QL (2 PACKAGES per

25 days)

ZETONNA NASAL AEROSOL SOLUTION 37 MCG/ACT

(ciclesonide)

PULMONARY FIBROSIS AGENTS

ESBRIET ORAL CAPSULE 267 MG (pirfenidone) NF

ESBRIET ORAL TABLET 267 MG, 801 MG (pirfenidone) NF

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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)

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)

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Limits

ARMONAIR DIGIHALER INHALATION AEROSOL

POWDER BREATH ACTIVATED 113 MCG/ACT, 232

MCG/ACT, 55 MCG/ACT (fluticasone propionate(sensor))

ARNUITY ELLIPTA INHALATION AEROSOL

POWDER BREATH ACTIVATED 100 MCG/ACT, 200

MCG/ACT, 50 MCG/ACT (fluticasone furoate)

ASMANEX (120 METERED DOSES) INHALATION

AEROSOL POWDER BREATH ACTIVATED 220

MCG/ACT (mometasone furoate)

ASMANEX (30 METERED DOSES) INHALATION

AEROSOL POWDER BREATH ACTIVATED 110

MCG/ACT, 220 MCG/ACT (mometasone furoate)

ASMANEX (60 METERED DOSES) INHALATION

AEROSOL POWDER BREATH ACTIVATED 220

MCG/ACT (mometasone furoate)

ASMANEX HFA INHALATION AEROSOL 100

MCG/ACT, 200 MCG/ACT, 50 MCG/ACT (mometasone

furoate)

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))

FLOVENT HFA INHALATION AEROSOL 110

MCG/ACT, 220 MCG/ACT, 44 MCG/ACT (fluticasone

propionate hfa)

fluticasone propionate hfa inhalation aerosol 110 mcg/act, 220

mcg/act, 44 mcg/act

PULMICORT FLEXHALER INHALATION AEROSOL

POWDER BREATH ACTIVATED 180 MCG/ACT

(budesonide)

QL (2 AEROSOL

POWDER BREATH

ACTIVATED per 25 days)

PULMICORT FLEXHALER INHALATION AEROSOL

POWDER BREATH ACTIVATED 90 MCG/ACT

(budesonide)

QL (3 AEROSOL

POWDER BREATH

ACTIVATED per 25 days)

PULMICORT INHALATION SUSPENSION 0.25

MG/2ML, 0.5 MG/2ML, 1 MG/2ML (budesonide)

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Coverage Requirements and

Limits

QVAR REDIHALER INHALATION AEROSOL BREATH

ACTIVATED 40 MCG/ACT, 80 MCG/ACT (beclomethasone

diprop hfa)

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)

QL (1 INHALER per 25

days)

ADVAIR HFA INHALATION AEROSOL 115-21

MCG/ACT, 230-21 MCG/ACT, 45-21 MCG/ACT

(fluticasone-salmeterol)

AIRDUO DIGIHALER INHALATION AEROSOL

POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-

14 MCG/ACT, 55-14 MCG/ACT (fluticasone-

salmeterol(sensor))

BREO ELLIPTA INHALATION AEROSOL POWDER

BREATH ACTIVATED 100-25 MCG/ACT, 200-25

MCG/ACT (fluticasone furoate-vilanterol)

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

DUAKLIR PRESSAIR INHALATION AEROSOL

POWDER BREATH ACTIVATED 400-12 MCG/ACT

(aclidinium br-formoterol fum)

DULERA INHALATION AEROSOL 100-5 MCG/ACT,

200-5 MCG/ACT, 50-5 MCG/ACT (mometasone furo-

formoterol fum)

fluticasone furoate-vilanterol inhalation aerosol powder breath

activated 100-25 mcg/act, 200-25 mcg/act

fluticasone-salmeterol inhalation aerosol 115-21 mcg/act, 230-

21 mcg/act, 45-21 mcg/act

fluticasone-salmeterol inhalation aerosol powder breath

activated 100-50 mcg/act, 250-50 mcg/act, 500-50 mcg/act

SYMBICORT INHALATION AEROSOL 160-4.5

MCG/ACT, 80-4.5 MCG/ACT (budesonide-formoterol

fumarate)

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)

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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)

theophylline er oral tablet extended release 12 hour 300 mg, 450

theophylline er oral tablet extended release 24 hour 400 mg, 600

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)

ABSORICA ORAL CAPSULE 10 MG, 20 MG, 25 MG, 30

MG, 35 MG, 40 MG (isotretinoin)

ACANYA EXTERNAL GEL 1.2-2.5 % (clindamycin phos-

benzoyl perox)

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)

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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)

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

NP PA

KLARON EXTERNAL LOTION 10 % (sulfacetamide

sodium (acne))

NP ST

ONEXTON EXTERNAL GEL 1.2-3.75 % (clindamycin phos-

benzoyl perox)

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)

VELTIN EXTERNAL GEL 1.2-0.025 % (clindamycin-

tretinoin)

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)

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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)

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)

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)

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)

luliconazole external cream 1 % NF

LUZU EXTERNAL CREAM 1 % (luliconazole) NF

miconazole-zinc oxide-petrolat external ointment 0.25-15-81.35

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)

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)

VTAMA EXTERNAL CREAM 1 % (tapinarof) NF

WYNZORA EXTERNAL CREAM 0.005-0.064 %

(calcipotriene-betameth diprop)

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)

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

CAPEX EXTERNAL SHAMPOO 0.01 % (fluocinolone

acetonide)

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)

PA; QL (180 ML per 25

DAYs)

CLOBEX EXTERNAL SHAMPOO 0.05 % (clobetasol

propionate)

PA; QL (180 ML per 25

DAYs)

CLOBEX SPRAY EXTERNAL LIQUID 0.05 % (clobetasol

propionate)

clocortolone pivalate external cream 0.1 % NF

CLODERM EXTERNAL CREAM 0.1 % (clocortolone

pivalate)

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)

DERMA-SMOOTHE/FS BODY EXTERNAL OIL 0.01 %

(fluocinolone acetonide)

PA; QL (180 ML per 25

DAYs)

DERMA-SMOOTHE/FS SCALP EXTERNAL OIL 0.01 %

(fluocinolone acetonide)

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)

PA; QL (180 GRAMS per

25 days)

DUOBRII EXTERNAL LOTION 0.01-0.045 % (halobetasol

prop-tazarotene)

ENSTILAR EXTERNAL FOAM 0.005-0.064 %

(calcipotriene-betameth diprop)

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)

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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)

IMPOYZ EXTERNAL CREAM 0.025 % (clobetasol

propionate)

KENALOG EXTERNAL AEROSOL SOLUTION 0.147

MG/GM (triamcinolone acetonide)

LEXETTE EXTERNAL FOAM 0.05 % (halobetasol

propionate)

LOCOID EXTERNAL LOTION 0.1 % (hydrocortisone

butyrate)

PA; QL (180 ML per 25

DAYs)

LOCOID LIPOCREAM EXTERNAL CREAM 0.1 %

(hydrocortisone butyr lipo base)

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)

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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)

PANDEL EXTERNAL CREAM 0.1 % (hydrocortisone

probutate)

PA; QL (180 GM per 25

DAYs)

SERNIVO EXTERNAL EMULSION 0.05 % (betamethasone

dipropionate)

PA; STX; QL (120 ML per

25 DAYs)

SYNALAR EXTERNAL CREAM 0.025 % (fluocinolone

acetonide)

PA; QL (180 GM per 25

DAYs)

SYNALAR EXTERNAL OINTMENT 0.025 % (fluocinolone

acetonide)

PA; QL (180 GM per 25

DAYs)

SYNALAR EXTERNAL SOLUTION 0.01 % (fluocinolone

acetonide)

PA; QL (180 ML per 25

DAYs)

TACLONEX EXTERNAL OINTMENT 0.005-0.064 %

(calcipotriene-betameth diprop)

TACLONEX EXTERNAL SUSPENSION 0.005-0.064 %

(calcipotriene-betameth diprop)

TEXACORT EXTERNAL SOLUTION 2.5 %

(hydrocortisone)

PA; QL (180 ML per 25

DAYs)

TOPICORT EXTERNAL CREAM 0.05 %, 0.25 %

(desoximetasone)

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)

PA; QL (180 GM per 25

DAYs)

TOPICORT SPRAY EXTERNAL LIQUID 0.25 %

(desoximetasone)

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)

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Prescription Drug Name Drug Tier

Coverage Requirements and

Limits

ULTRAVATE EXTERNAL LOTION 0.05 % (halobetasol

propionate)

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)

SX1 MEDICATED POST-OPERATIVE EXTERNAL KIT

2 % (lidocaine hcl & post-op system)

SYNERA EXTERNAL PATCH 70-70 MG (lidocaine-

tetracaine)

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)

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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)

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)

penciclovir external cream 1 % NF

PENNSAID EXTERNAL SOLUTION 2 % (diclofenac

sodium)

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

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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)

RHOFADE EXTERNAL CREAM 1 % (oxymetazoline hcl) NF

SOOLANTRA EXTERNAL CREAM 1 % (ivermectin) PB

ZILXI EXTERNAL FOAM 1.5 % (minocycline hcl

micronized)

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)

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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)

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)

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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