Your 202 1 Preferred Drug List - Trinity Health
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Your 2021 Preferred Drug List
Effective January 1, 2021
For the most current list of covered medications or if you have questions:
Call the number on your member ID card.
Visit your plan’s website on your member ID card to:
• Find a participating retail pharmacy by ZIP code.
• Look up possible lower-cost medication alternatives.
• Compare medication pricing and options.
Premium StandardUnderstanding your preferred drug list
What is a preferred drug list?
A preferred drug list is a list of prescribed medications or About this preferred drug list
other pharmacy care products, services or supplies chosen Where differences between
for their safety, cost, and effectiveness. Medications are this preferred drug list and your
listed by categories or classes and are placed into cost benefit plan exist, the benefit plan
levels known as tiers. It includes both brand and generic documents rule. This may not be a
prescription medications. complete list of medications that are
covered by your plan. Please review
To create the list, OptumRx® is guided by the Pharmacy and
your benefit plan for full details.
Therapeutics Committee. This group of doctors, nurses, and
pharmacists reviews which medications will be covered, how
well the drugs work, and overall value. They also make sure
there are safe and covered options.
How do I use my preferred drug list?
You and your doctor can use the preferred drug list to help you choose the most cost-effective
prescription medications. This guide tells you if a medication is generic or brand, and if special rules
apply. Bring this list with you when you see your doctor. If your medication is not listed here, please
visit your plan’s website or call the number on your member ID card.
What are tiers?
Tiers are the different cost levels you pay for a medication. Each tier is assigned a cost, set by your
employer or plan sponsor. This is how much you will pay when you fill a prescription.
When does the preferred drug list change?
• Medications may move to a lower tier at any time.
• Medications may move to a higher tier when a generic equal becomes available.
• Medications may move to a higher tier or be excluded from coverage on January 1 or July 1
of each year.
When a medication changes tiers, you may have to pay a different amount for that medication.
Why are some medications excluded from coverage?
A medication may be excluded from coverage under your pharmacy benefit when it works the same
as or similar to another prescription or over-the-counter (OTC) medication.
What if I don’t agree with a decision about an excluded medication?
You or your authorized representative and your doctor can ask for a coverage request by calling the
number on your member ID card.
2Medication tips
What is the difference between brand-name and
generic medications? Over-the-counter medications
Generic medications contain the same active ingredients (what makes An over-the-counter (OTC)
the medication work) as brand-name medications, but they often cost medication may be the right
less. Once the patent for a brand-name medication ends, the FDA can treatment for some conditions.
approve a generic version with the same active ingredients. Talk to your doctor about OTC
options. Even though OTC
What if my doctor writes a brand-name prescription? medications may not be covered
If your doctor gives you a prescription for a brand-name by your pharmacy benefit,
medication, ask if a generic or lower-cost option could be right for they may cost less than a
you. Generic medications are usually your lowest-cost option. prescription medication.
What if I am taking a specialty medication?
Specialty medications are for rare or complex conditions and are usually higher-cost medications. Please
note, not all specialty medications are listed in the formulary. Our specialty pharmacy can provide most of
your specialty medications along with helpful programs and services.
3Reading your preferred drug list
The preferred drug list gives you choices so you and your doctor can decide your best course of
treatment. In this preferred drug list, brand-name medications are shown in UPPERCASE (for example,
CLOBEX). Generic medications are shown in lowercase (for example, clobetasol).
Tier information
Using lower tier or preferred medications can help you pay your lowest out-of-pocket cost. Your plan
may have multiple or no tiers. Please note: If you have a high-deductible plan, the tier cost levels will
apply once you meet your deductible.
Drug Tier Includes Helpful Tips
Tier 1 Lower-cost generics
$ Use Tier 1 drugs for the lowest out-of-pocket costs.
and some brand-name
Tier 2 Mid-range cost
$$ Use Tier 2 drugs instead of Tier 3 to help reduce your
preferred brand-name out-of-pocket costs.
Tier 3 $$$ Highest-cost Many Tier 3 drugs have lower-cost options in Tier 1 or 2.
non-preferred Ask your doctor if they could work for you.
Tier E
Excluded May not be covered or need prior authorization. Lower-cost
options are available and covered.
Tier 50% 50% Coinsurance 50% Coinsurance applies to infertility medications
Drug list information
In this drug list, some medications are noted with letters next to them to help you see which ones may
have coverage requirements or limits. Your benefit plan decides how these medications may be covered.
PA Prior Authorization – Your doctor is required to give OptumRx more information
to determine coverage.
QL Quantity Limit – Medication may be limited to a certain quantity.
SP Specialty Medication – Medication is designated as specialty.
ST Step Therapy – Must try lower-cost medication(s) before a higher-cost medication
can be covered.
4Table of Contents
Analgesics - Drugs for Pain.................................................................................................................................7
Analgesics - Drugs for Pain and Inflammation.................................................................................................... 7
Anesthetics..........................................................................................................................................................8
Anti-Addiction / Substance Abuse Treatment Agents......................................................................................... 8
Antibacterials.......................................................................................................................................................8
Anticoagulants.....................................................................................................................................................9
Anticonvulsants - Drugs for Seizures.................................................................................................................. 9
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia.............................................................. 10
Antidepressants.................................................................................................................................................10
Antiemetics - Drugs for Nausea and Vomiting.................................................................................................. 11
Antifungals.........................................................................................................................................................11
Antigout Agents................................................................................................................................................. 11
Antimigraine Agents.......................................................................................................................................... 11
Antineoplastics - Drugs for Cancer....................................................................................................................12
Antiparasitics..................................................................................................................................................... 12
Antiparkinson Agents........................................................................................................................................ 12
Antiplatelets.......................................................................................................................................................13
Antipsychotics - Drugs for Mood Disorders....................................................................................................... 13
Antivirals............................................................................................................................................................13
Anxiolytics - Drugs for Anxiety...........................................................................................................................14
Bipolar Agents - Drugs for Mood Disorders.......................................................................................................14
Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders..............................................14
Cardiovascular Agents - Drugs for Heart and Circulation Conditions............................................................... 14
Central Nervous System Agents - Drugs for Attention Deficit Disorder............................................................ 17
Central Nervous System Agents - Drugs for Multiple Sclerosis........................................................................ 17
Central Nervous System Agents - Miscellaneous............................................................................................. 18
Dental and Oral Agents - Drugs for Mouth and Throat Conditions....................................................................18
Dermatological Agents - Drugs for Skin Conditions.......................................................................................... 18
Diabetes - Antidiabetic Agents.......................................................................................................................... 20
Diabetes - Glucose Monitoring.......................................................................................................................... 20
Diabetes - Glycemic Agents.............................................................................................................................. 23
Diabetes - Insulins.............................................................................................................................................23
Electrolytes / Minerals / Metals / Vitamins.........................................................................................................24
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer................................................................................25
Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions.................................................26
Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment............................................. 26
Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions.......................................................26
Genitourinary Agents - Drugs for Prostate Conditions...................................................................................... 27
Hormonal Agents - Adrenal............................................................................................................................... 27
Hormonal Agents - Men's Health.......................................................................................................................27
Hormonal Agents - Osteoporosis...................................................................................................................... 27
Hormonal Agents - Pituitary.............................................................................................................................. 27
Hormonal Agents - Sex Hormones and Birth Control........................................................................................28
Hormonal Agents - Thyroid............................................................................................................................... 28
Immunological Agents - Drugs for Immune System Stimulation or Suppression.............................................. 29
Inflammatory Bowel Disease Agents.................................................................................................................30
Metabolic Bone Disease Agents - Drugs for Osteoporosis............................................................................... 30
Metabolic Bone Disease Agents - Other........................................................................................................... 30
Miscellaneous Therapeutic Agents................................................................................................................... 30
Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation...........................................................31
Ophthalmic Agents - Drugs for Glaucoma.........................................................................................................31
5Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions......................................................................... 32
Otic Agents - Drugs for Ear Conditions............................................................................................................. 32
Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold........................................................32
Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions................................... 32
Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis.................................................................... 34
Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension.................................................... 34
Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm...................................................................... 34
Sleep Disorder Agents...................................................................................................................................... 34
6Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Analgesics - Drugs hydromorphone hcl oral
for Pain 1 QL
tablet
acetaminophen- HYSINGLA ER 2 PA; QL
1 QL
codeine #2 KADIAN E
acetaminophen- LAZANDA E
1 QL
codeine #3
morphine sulfate er oral
acetaminophen- 1 PA; QL
1 QL tablet extended release
codeine #4
MS CONTIN E
acetaminophen-
codeine oral tablet 300- 1 QL NORCO E
15 mg, 300-60 mg NUCYNTA E
APADAZ E NUCYNTA ER E
apap-caff- OXYCODONE HCL ER E
dihydrocodeine oral 1 QL oxycodone hcl oral
capsule 1 QL
tablet
ARYMO ER E oxycodone-
BELBUCA 2 PA; QL acetaminophen oral
BENZHYDROCODON tablet 10-325 mg, 2.5- 1 QL
E 325 mg, 5-325 mg, 7.5-
E-ACETAMINOPHEN
325 mg
butalbital-apap-caffeine 1
OXYCONTIN 2 PA; QL
BUTRANS
TRANSDERMAL PERCOCET E
PATCH WEEKLY 10 ROXICODONE E
E
MCG/HR, 15 MCG/HR, SUBSYS E
20 MCG/HR, 5
MCG/HR TRAMADOL HCL ER
ORAL CAPSULE
CONZIP E EXTENDED RELEASE E
DILAUDID ORAL E 24 HOUR 100 MG, 200
DURAGESIC-100 E MG, 300 MG
DURAGESIC-12 E tramadol hcl oral tablet
1 QL
50 mg
DURAGESIC-25 E
TREZIX 3 QL
DURAGESIC-50 E
ULTRACET E
DURAGESIC-75 E
ULTRAM E
fentanyl 1 PA; QL
XTAMPZA ER 2 PA; QL
FENTANYL CITRATE
E ZOHYDRO ER E
BUCCAL TABLET
FENTORA E Analgesics - Drugs
for Pain and
FIORICET E Inflammation
FIORICET/CODEINE E ARTHROTEC E
hydrocodone- CAMBIA E
acetaminophen oral 1 QL
tablet CELEBREX E
celecoxib oral 1 QL
Effective Date: 1/1/21
7Drug Name Drug Tier Notes Drug Name Drug Tier Notes
DICLOFENAC E buprenorphine hcl
1 QL
diclofenac sodium oral 1 sublingual
diclofenac sodium buprenorphine hcl-
1 QL 1 QL
transdermal gel 1 % naloxone hcl
etodolac oral tablet 1 CHANTIX 3 QL
FLECTOR E CHANTIX
CONTINUING MONTH 3 QL
ibuprofen oral tablet PAK
400 mg, 600 mg, 800 1
mg CHANTIX STARTING
3 QL
MONTH PAK
indomethacin oral
1 NALOXONE HCL
capsule 25 mg, 50 mg
INJECTION
KETOROLAC E
SOLUTION AUTO-
TROMETHAMINE E INJECTOR
NASAL
naltrexone hcl oral 1
ketorolac tromethamine
1 QL NARCAN 2
oral
meloxicam oral 1 SUBOXONE E
MOBIC E ZUBSOLV 2 QL
nabumetone oral 1 Antibacterials
NALFON E ACTICLATE E
naproxen oral tablet 1 amoxicillin oral capsule 1
PENNSAID E amoxicillin oral
suspension 1
QMIIZ ODT E reconstituted
RELAFEN E amoxicillin oral tablet 1
RELAFEN DS E amoxicillin-potassium
SPRIX E clavulanate oral
1
VIMOVO E suspension
reconstituted
VOLTAREN E
amoxicillin-potassium
ZIPSOR E 1
clavulanate oral tablet
ZORVOLEX E azithromycin oral
Anesthetics suspension 1
lidocaine external patch reconstituted
1
5% azithromycin oral tablet 1
lidocaine-prilocaine cefdinir 1
1
external cream cefuroxime axetil 1
LIDODERM E cephalexin oral capsule 1
ZTLIDO E cephalexin oral
Anti-Addiction / suspension 1
Substance Abuse reconstituted
Treatment Agents ciprofloxacin hcl oral
1
BUNAVAIL 3 QL tablet 250 mg, 500 mg
Effective Date: 1/1/21
8Drug Name Drug Tier Notes Drug Name Drug Tier Notes
clarithromycin oral TARGADOX E
1
tablet XENLETA 3
clindamycin hcl oral 1 XEPI 3
CLINDESSE 3 XIMINO 3
DIFICID 3 Anticoagulants
DORYX E ELIQUIS 2 QL
DORYX MPC E enoxaparin sodium 1 SP; QL
doxycycline hyclate oral PRADAXA 2 QL
1
capsule
warfarin sodium oral 1
doxycycline hyclate oral
1 XARELTO 2 QL
tablet 100 mg, 20 mg
DOXYCYCLINE XARELTO STARTER
2 QL
HYCLATE ORAL PACK
E
TABLET DELAYED Anticonvulsants -
RELEASE 80 MG Drugs for Seizures
doxycycline BRIVIACT
3
monohydrate oral 1 INTRAVENOUS
capsule 100 mg, 50 mg BRIVIACT ORAL 3 ST
doxycycline carbamazepine oral
1 1
monohydrate oral tablet tablet
levofloxacin oral tablet 1 CARBATROL E
metronidazole oral DEPAKOTE E
1
tablet
DEPAKOTE ER E
metronidazole vaginal 1
DEPAKOTE
minocycline hcl oral E
1 SPRINKLES
capsule
DILANTIN INFATABS E
MINOLIRA E
DILANTIN ORAL
mupirocin external 1 E
CAPSULE 100 MG
nitrofurantoin DILANTIN ORAL
1 E
macrocrystal oral SUSPENSION
nitrofurantoin divalproex sodium er 1
monohydrate 1
macrocrystals divalproex sodium oral
1
tablet delayed release
NUZYRA ORAL 3
EPIDIOLEX 3 PA; SP
penicillin v potassium
1 FYCOMPA 3
oral tablet
SEYSARA 3 ST gabapentin oral
1
capsule
SILVADENE E
gabapentin oral tablet 1
SOLODYN E
KEPPRA ORAL E
SOLOSEC 3
KEPPRA XR E
sulfamethoxazole-
1 LAMICTAL E
trimethoprim oral tablet
Effective Date: 1/1/21
9Drug Name Drug Tier Notes Drug Name Drug Tier Notes
LAMICTAL ODT E Antidementia Agents
LAMICTAL STARTER E - Drugs for
Alzheimer's Disease
LAMICTAL XR ORAL and Dementia
TABLET EXTENDED E
RELEASE 24 HOUR donepezil hcl oral tablet
1
10 mg, 23 mg
lamotrigine er 1
memantine hcl oral
lamotrigine oral tablet 1 1
tablet 10 mg, 5 mg
levetiracetam oral NAMZARIC 2 QL
1
tablet
Antidepressants
NAYZILAM 3 QL
amitriptyline hcl oral 1
NEURONTIN E
BRISDELLE E
ONFI E
bupropion hcl er (sr) 1 QL
oxcarbazepine oral
1 bupropion hcl er (xl)
tablet
oral tablet extended
OXTELLAR XR E 1 QL
release 24 hour 150
QUDEXY XR E mg, 300 mg
SABRIL E BUPROPION HCL ER
SYMPAZAN 3 PA (XL) ORAL TABLET
E
EXTENDED RELEASE
TEGRETOL E 24 HOUR 450 MG
TEGRETOL-XR E bupropion hcl oral 1
TOPAMAX E CELEXA E
TOPAMAX SPRINKLE E citalopram
topiramate oral tablet 1 hydrobromide oral 1
TRILEPTAL E tablet
TROKENDI XR 3 ST CYMBALTA E
VALTOCO 10 MG desvenlafaxine
3 QL 1 QL
DOSE succinate er
VALTOCO 15 MG doxepin hcl oral
3 QL 1
DOSE capsule
VALTOCO 20 MG duloxetine hcl oral 1 QL
3 QL
DOSE EFFEXOR XR E
VALTOCO 5 MG escitalopram oxalate
3 QL 1
DOSE oral tablet
VIMPAT 3 fluoxetine hcl oral
1
XCOPRI 3 ST capsule
XCOPRI (250 MG fluoxetine hcl oral tablet 1
3 ST
DAILY DOSE) fluvoxamine maleate 1
XCOPRI (350 MG FORFIVO XL E
3 ST
DAILY DOSE) LEXAPRO E
ZONEGRAN E mirtazapine oral tablet 1
zonisamide oral 1
Effective Date: 1/1/21
10Drug Name Drug Tier Notes Drug Name Drug Tier Notes
nortriptyline hcl oral clotrimazole external
1 1
capsule cream
paroxetine hcl 1 clotrimazole-
PAXIL CR E betamethasone 1
external cream
PAXIL ORAL TABLET E
CRESEMBA ORAL 3
PRISTIQ E
fluconazole oral tablet 1
PROZAC E
GYNAZOLE-1 3
sertraline hcl oral tablet 1
JUBLIA E
trazodone hcl oral 1
KERYDIN 3 PA
TRINTELLIX 3 ST; QL
ketoconazole external
venlafaxine hcl 1 1
cream
venlafaxine hcl er oral ketoconazole external
capsule extended 1 1
shampoo
release 24 hour
nystatin external cream 1
venlafaxine hcl er oral
tablet extended release 1 nystatin mouth/throat 1
24 hour 225 mg terbinafine hcl oral 1 QL
VIIBRYD 3 QL terconazole vaginal
1
VIIBRYD STARTER cream
3 QL
PACK TOLSURA E
WELLBUTRIN SR E Antigout Agents
WELLBUTRIN XL E allopurinol oral 1
ZOLOFT E COLCHICINE ORAL
E
Antiemetics - Drugs CAPSULE
for Nausea and colchicine oral tablet 1
Vomiting COLCRYS E
meclizine hcl oral tablet 1 febuxostat 1 ST
metoclopramide hcl GLOPERBA E
1
oral tablet 10 mg
MITIGARE E
ondansetron hcl oral
1 Antimigraine Agents
tablet 4 mg, 8 mg
ondansetron odt 1 AIMOVIG 2 PA; QL
prochlorperazine AJOVY E
1
maleate oral eletriptan hydrobromide 1 QL
SANCUSO E EMGALITY 2 PA; QL
scopolamine 1 EMGALITY (300 MG
2 PA; QL
VARUBI (180 MG DOSE)
3 QL
DOSE) IMITREX E
Antifungals IMITREX STATDOSE
E
ciclopirox external REFILL
1
solution IMITREX STATDOSE
E
SYSTEM
Effective Date: 1/1/21
11Drug Name Drug Tier Notes Drug Name Drug Tier Notes
MAXALT E NUBEQA 3 PA; SP
MAXALT-MLT E OGIVRI E
NURTEC 2 PA; QL ONTRUZANT E
ONZETRA XSAIL E REVLIMID 2 PA; SP
RELPAX E RUBRACA 2 PA; SP
REYVOW E RUXIENCE 2 PA; SP
rizatriptan benzoate 1 QL SPRYCEL 2 PA; SP
sumatriptan succinate TABRECTA E
1 QL
oral tamoxifen citrate oral 1
TOSYMRA E TARGRETIN
3 PA
TREXIMET E EXTERNAL
UBRELVY 2 PA; QL TARGRETIN ORAL E
ZEMBRACE TAZVERIK E
E
SYMTOUCH temozolomide 1 PA; SP
ZOMIG ORAL E TRAZIMERA 2 PA; SP
ZOMIG ZMT E TREANDA E
Antineoplastics - TRUXIMA E
Drugs for Cancer
XTANDI 3 PA; SP
AFINITOR ORAL
TABLET 2.5 MG, 5 E YONSA E
MG, 7.5 MG ZEJULA 2 PA; SP
anastrozole oral 1 ZIRABEV 2 PA; SP
ARIMIDEX E ZYTIGA E
BELRAPZO E Antiparasitics
CABOMETYX 2 PA; SP ARAKODA 3
capecitabine 1 PA; SP EMVERM 2
DARZALEX FASPRO E hydroxychloroquine
1
ERLEADA E sulfate oral
GLEEVEC E NATROBA E
HERZUMA E PLAQUENIL E
IBRANCE ORAL Antiparkinson Agents
3 PA; SP
CAPSULE benztropine mesylate
1
IDHIFA 3 PA; SP; QL oral
imatinib mesylate 1 PA; SP carbidopa-levodopa
1
oral tablet
IMBRUVICA ORAL
3 PA; SP GOCOVRI E
TABLET
KANJINTI 2 PA; SP INBRIJA 3 PA; SP
letrozole oral 1 NOURIANZ 3 PA
LYNPARZA 2 PA; SP OSMOLEX ER E
MVASI 2 PA; SP
Effective Date: 1/1/21
12Drug Name Drug Tier Notes Drug Name Drug Tier Notes
pramipexole acyclovir oral tablet 1
1
dihydrochloride ATRIPLA E
ropinirole hcl 1 BARACLUDE ORAL
E
RYTARY 3 ST TABLET
Antiplatelets BIKTARVY 3
ASPIRIN- CIMDUO 2
E
OMEPRAZOLE DESCOVY E
BRILINTA 2 DOVATO 2
clopidogrel bisulfate entecavir 1 SP; QL
1
oral
EPCLUSA ORAL
PLAVIX E 2 PA; SP; QL
TABLET 400-100 MG
prasugrel hcl 1 GENVOYA 3
YOSPRALA E HARVONI 2 PA; SP; QL
Antipsychotics - JULUCA 2
Drugs for Mood
Disorders LEDIPASVIR-
E
SOFOSBUVIR
ABILIFY E
MAVYRET 2 PA; SP; QL
aripiprazole oral tablet 1 QL
ODEFSEY 3
ARISTADA 3
oseltamivir phosphate
ARISTADA INITIO 3 1 QL
oral
INVEGA SUSTENNA 3 PREZCOBIX 2
INVEGA TRINZA 3 SOFOSBUVIR-
E
LATUDA 3 QL VELPATASVIR
olanzapine oral tablet 1 QL SYMFI 2
PERSERIS 3 SYMFI LO 2
quetiapine fumarate 1 QL TAMIFLU E
quetiapine fumarate er 1 QL TEMIXYS E
REXULTI 3 QL TIVICAY 2
RISPERDAL E TRIUMEQ 2
risperidone oral tablet 1 QL TRUVADA E
SAPHRIS 2 QL valacyclovir hcl oral 1 QL
SECUADO E VALTREX E
SEROQUEL E VEMLIDY 3 SP
SEROQUEL XR E VOSEVI 2 PA; SP; QL
VRAYLAR 3 ST; QL XOFLUZA (40 MG
3 QL
ziprasidone hcl 1 QL DOSE)
ZYPREXA E XOFLUZA (80 MG
3 QL
DOSE)
Antivirals
ZOVIRAX EXTERNAL E
acyclovir oral capsule 1
Effective Date: 1/1/21
13Drug Name Drug Tier Notes Drug Name Drug Tier Notes
ZOVIRAX ORAL JIVI 3 SP
E
SUSPENSION MULPLETA 2 PA; SP
Anxiolytics - Drugs NEULASTA 3 PA; SP
for Anxiety
NEULASTA ONPRO 3 PA; SP
alprazolam oral tablet 1 QL
NEUPOGEN E
ATIVAN ORAL E
NIVESTYM 2 PA; SP
buspirone hcl oral 1
NOVOEIGHT 3 SP
clonazepam oral tablet 1 QL
NUWIQ 2 SP
diazepam oral tablet 1
PROCRIT E
hydroxyzine hcl oral
1 RETACRIT 2 PA; SP
tablet
hydroxyzine pamoate UDENYCA E
1
oral ULTOMIRIS
KLONOPIN E INTRAVENOUS
3 PA; SP
SOLUTION 300
lorazepam oral tablet 1 QL MG/30ML
triazolam 1 QL ZARXIO 2 PA; SP
VALIUM E ZIEXTENZO 3 PA; SP
XANAX E Cardiovascular
XANAX XR E Agents - Drugs for
Bipolar Agents - Heart and Circulation
Drugs for Mood Conditions
Disorders ALTACE E
lithium carbonate er 1 amiodarone hcl oral 1
lithium carbonate oral amlodipine besylate
1 1
capsule oral
Blood Products / amlodipine besylate-
1
Modifiers / Volume benazepril hcl
Expanders - Drugs for amlodipine besylate-
Bleeding Disorders 1
valsartan
ADYNOVATE 3 SP amlodipine-olmesartan 1
AFSTYLA ATACAND E
INTRAVENOUS KIT
1000 UNIT, 2000 UNIT, 3 SP atenolol oral 1
250 UNIT, 3000 UNIT, atenolol-chlorthalidone 1
500 UNIT atorvastatin calcium
1
ARANESP (ALBUMIN oral
2 PA; SP
FREE) AVAPRO E
ELOCTATE 3 SP AZOR E
EPOGEN E benazepril hcl oral 1
ESPEROCT E BENICAR E
FULPHILA E BENICAR HCT E
GRANIX E bisoprolol fumarate 1
Effective Date: 1/1/21
14Drug Name Drug Tier Notes Drug Name Drug Tier Notes
bisoprolol- EXFORGE E
1
hydrochlorothiazide EXFORGE HCT E
bumetanide oral 1 ezetimibe 1
BYSTOLIC 2 ezetimibe-simvastatin 1
candesartan cilexetil 1 fenofibrate micronized
CARDIZEM LA ORAL oral capsule 134 mg, 1
TABLET EXTENDED 200 mg, 67 mg
RELEASE 24 HOUR E fenofibrate oral tablet
180 MG, 240 MG, 300 145 mg, 160 mg, 48 1
MG, 360 MG, 420 MG mg, 54 mg
cartia xt 1 fenofibric acid oral
carvedilol 1 capsule delayed 1
CATAPRES-TTS-1 E release
CATAPRES-TTS-2 E flecainide acetate 1
CATAPRES-TTS-3 E furosemide oral tablet 1
chlorthalidone 1 gemfibrozil oral 1
clonidine hcl oral 1 guanfacine hcl 1
COLESTID E HEMANGEOL 3
COLESTID hydralazine hcl oral 1
E
FLAVORED hydrochlorothiazide
1
CONSENSI E oral
COREG E HYZAAR E
COREG CR E INDERAL LA E
CORLANOR 3 PA; QL INDERAL XL E
COZAAR E INNOPRAN XL E
CRESTOR E irbesartan 1
digoxin oral tablet 1 irbesartan-
1
hydrochlorothiazide
diltiazem hcl er coated
beads oral capsule isosorbide mononitrate
1 1
extended release 24 er
hour KAPSPARGO
E
dilt-xr 1 SPRINKLE
DIOVAN E KATERZIA E
DIOVAN HCT E labetalol hcl oral 1
doxazosin mesylate LASIX E
1
oral LESCOL XL E
DYAZIDE E LIPITOR E
EDARBI 3 ST lisinopril oral 1
EDARBYCLOR 3 ST lisinopril-
1
enalapril maleate oral 1 hydrochlorothiazide
ENTRESTO 2 QL LIVALO E
Effective Date: 1/1/21
15Drug Name Drug Tier Notes Drug Name Drug Tier Notes
losartan potassium oral 1 REPATHA 2 PA; SP; QL
losartan potassium-hctz 1 REPATHA
LOTREL E PUSHTRONEX 2 PA; SP; QL
SYSTEM
lovastatin 1
REPATHA
LOVAZA E 2 PA; SP; QL
SURECLICK
metoprolol succinate er 1 rosuvastatin calcium 1
metoprolol tartrate oral 1 simvastatin oral 1
MICARDIS E sotalol hcl oral 1
MICARDIS HCT E spironolactone oral 1
MULTAQ 3 TEKTURNA 2
NEXLETOL 2 PA; QL TEKTURNA HCT 2 ST
NEXLIZET 2 PA; QL telmisartan 1
NIASPAN E telmisartan-hctz 1
nifedipine er 1 TENORMIN E
nifedipine er osmotic TIKOSYN E
1
release
TOPROL XL E
nitroglycerin sublingual 1
torsemide 1
NITROSTAT E
triamterene-hctz 1
NORVASC E
TRIBENZOR E
olmesartan medoxomil
1 TRICOR E
oral
olmesartan medoxomil- valsartan 1
1
hctz valsartan-
1
olmesartan-amlodipine- hydrochlorothiazide
1
hctz VASCEPA 2 PA
omega-3-acid ethyl verapamil hcl er oral
1 PA
esters capsule extended
PRALUENT 2 PA; SP; QL release 24 hour 120 1
mg, 180 mg, 240 mg,
PRAVACHOL E 360 mg
pravastatin sodium 1 verapamil hcl er oral
1
prazosin hcl oral 1 tablet extended release
PRINIVIL E VYTORIN E
propranolol hcl er 1 WELCHOL E
propranolol hcl oral ZESTRIL E
1
tablet ZETIA E
QUESTRAN E ZOCOR ORAL
QUESTRAN LIGHT E TABLET 10 MG, 20 E
ramipril 1 MG, 40 MG, 80 MG
RANEXA E ZYPITAMAG E
ranolazine er 1
Effective Date: 1/1/21
16Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Central Nervous Central Nervous
System Agents - System Agents -
Drugs for Attention Drugs for Multiple
Deficit Disorder Sclerosis
ADDERALL E AMPYRA 3 PA; SP; QL
ADDERALL XR E AUBAGIO 3 PA; SP; QL
ADHANSIA XR E AVONEX PEN 2 PA; SP; QL
amphetamine- AVONEX PREFILLED 2 PA; SP; QL
1 PA
dextroamphetamine BAFIERTAM 2 PA; SP; QL
amphetamine- BETASERON 2 PA; SP; QL
1 PA
dextroamphetamine er
COPAXONE 2 PA; SP; QL
atomoxetine hcl 1
EXTAVIA E
CONCERTA E
GILENYA 3 PA; SP; QL
dexmethylphenidate hcl
1 PA glatiramer acetate 1 PA; SP; QL
er
dexmethylphenidate hcl MAVENCLAD (10
1 PA 3 PA; SP
oral tablet 10 mg, 5 mg TABS)
EVEKEO E MAVENCLAD (4
3 PA; SP
TABS)
EVEKEO ODT 3 PA
MAVENCLAD (5
FOCALIN E 3 PA; SP
TABS)
FOCALIN XR E MAVENCLAD (6
3 PA; SP
guanfacine hcl er 1 TABS)
INTUNIV E MAVENCLAD (7
3 PA; SP
JORNAY PM 3 PA TABS)
methylphenidate hcl er MAVENCLAD (8
3 PA; SP
(la) oral capsule TABS)
extended release 24 1 PA MAVENCLAD (9
3 PA; SP
hour 10 mg, 20 mg, 30 TABS)
mg, 40 mg MAYZENT 3 PA; SP; QL
methylphenidate hcl er PLEGRIDY E
1 PA
(xr)
PLEGRIDY STARTER
methylphenidate hcl er E
PACK
oral tablet extended 1 PA
release REBIF E
methylphenidate hcl REBIF REBIDOSE E
1 PA
oral tablet REBIF REBIDOSE
E
RITALIN E TITRATION PACK
RITALIN LA E REBIF TITRATION
E
PACK
STRATTERA E
TECFIDERA 2 PA; SP; QL
VYVANSE 2 PA
VUMERITY 2 PA; SP; QL
VUMERITY
2 PA; SP; QL
(STARTER)
Effective Date: 1/1/21
17Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Central Nervous BENZAMYCIN E
System Agents - betamethasone
Miscellaneous dipropionate external 1
ADIPEX-P E cream
AUSTEDO 3 PA; SP; QL CALCIPOTRIENE
E
CONTRAVE E EXTERNAL FOAM
GRALISE 3 ST; QL CAPEX E
HORIZANT 3 PA; QL claravis 1 PA
LYRICA E CLINDAGEL E
phentermine hcl oral clindamycin phosphate-
1 PA benzoyl peroxide 1
tablet
external gel 1-5 %
pregabalin oral capsule 1 QL
clindamycin phosphate
QSYMIA 3 PA 1
external lotion
SAXENDA 3 PA clindamycin phosphate
1
TEGSEDI 3 PA; SP external solution
TIGLUTIK 3 clindamycin phosphate
1
VYLEESI 3 PA; QL external swab
Dental and Oral clindamycin phosphate
1
Agents - Drugs for gel 1 % external
Mouth and Throat CLINDAMYCIN
Conditions PHOSPHATE GEL 1 % E
chlorhexidine gluconate EXTERNAL
1
mouth/throat clobetasol propionate
1
lidocaine viscous hcl 1 external cream
Dermatological clobetasol propionate
1
Agents - Drugs for external ointment
Skin Conditions clobetasol propionate
1
ABSORICA LD 3 PA external solution
ACANYA E CLOBEX E
ACZONE EXTERNAL CLOBEX SPRAY E
E
GEL 5 % CLODERM E
ACZONE EXTERNAL CORDRAN
2 E
GEL 7.5 % EXTERNAL TAPE
AKLIEF E DAPSONE EXTERNAL
E
ALA SCALP E GEL 7.5 %
AMZEEQ 3 DESONATE E
APEXICON E E DIFFERIN EXTERNAL
E
CREAM
AVITA E
DIFFERIN EXTERNAL
BENZACLIN E E
GEL 0.3 %
BENZACLIN WITH DIFFERIN EXTERNAL
E E
PUMP LOTION
Effective Date: 1/1/21
18Drug Name Drug Tier Notes Drug Name Drug Tier Notes
DUOBRII E PANDEL E
DUPIXENT PROPECIA E
SUBCUTANEOUS PSORCON E
2 PA; SP; QL
SOLUTION
PREFILLED SYRINGE QBREXZA 3 QL
ELIDEL E RETIN-A E
EPIDUO E RETIN-A MICRO GEL
E
0.04 %, 0.1 %
EPIDUO FORTE 3
RETIN-A MICRO
EUCRISA 2 ST PUMP EXTERNAL E
FINACEA EXTERNAL GEL 0.04 %, 0.1 %
3
FOAM RETIN-A MICRO
FINACEA EXTERNAL PUMP EXTERNAL 2 PA
3 ST
GEL GEL 0.06 %, 0.08 %
fluocinonide external RHOFADE 3
1
cream SERNIVO 3
FLUOROPLEX 3 SOOLANTRA 3
HALOBETASOL SORILUX E
PROPIONATE E
EXTERNAL FOAM TACLONEX
EXTERNAL E
HALOG EXTERNAL OINTMENT
E
CREAM
TACLONEX
HALOG EXTERNAL EXTERNAL 3 QL
E
OINTMENT SUSPENSION
hydrocortisone external tacrolimus external
1 1
cream 1 %, 2.5 % ointment
hydrocortisone external TAZORAC EXTERNAL
1 E
ointment 1 %, 2.5 % CREAM 0.1 %
IMIQUIMOD PUMP E TOPICORT SPRAY E
IMPOYZ E tretinoin external cream 1 PA
KENALOG EXTERNAL E triamcinolone acetonide
1
LEXETTE E external cream
METROGEL E triamcinolone acetonide
1
metronidazole external external ointment
1
cream TRIANEX E
metronidazole external ULTRAVATE E
1
gel VECTICAL E
MIRVASO 3 VELTIN E
mometasone furoate VERDESO E
1
external cream
ZIANA E
NORITATE E
ZYCLARA E
ONEXTON 3
ZYCLARA PUMP E
ORACEA E
Effective Date: 1/1/21
19Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Diabetes - NESINA E
Antidiabetic Agents ONGLYZA E
ADLYXIN E OSENI E
ADLYXIN STARTER OZEMPIC 2 ST; QL
E
PACK
pioglitazone hcl 1
ALOGLIPTIN
E QTERN E
BENZOATE
ALOGLIPTIN- RYBELSUS 2 ST; QL
E
METFORMIN HCL SEGLUROMET E
ALOGLIPTIN- SOLIQUA 2 ST; QL
E
PIOGLITAZONE STEGLATRO E
BYDUREON 2 ST; QL STEGLUJAN E
BYDUREON BCISE SYMLINPEN 120 3 PA
2 ST; QL
AUTOINJECTOR
SYMLINPEN 60 3 PA
BYETTA 10 MCG PEN 2 ST; QL
SYNJARDY 2 ST
BYETTA 5 MCG PEN 2 ST; QL
SYNJARDY XR 2 ST
FARXIGA 2 ST
TRADJENTA 2 ST
FORTAMET E
TRIJARDY XR 2 ST
glimepiride 1
TRULICITY
glipizide er 1 SUBCUTANEOUS
glipizide ir 1 SOLUTION PEN-
2 ST; QL
GLUMETZA E INJECTOR 0.75
MG/0.5ML, 1.5
glyburide oral 1 MG/0.5ML
GLYXAMBI 2 ST VICTOZA 2 ST; QL
INVOKAMET E XIGDUO XR 2 ST
INVOKAMET XR E Diabetes - Glucose
INVOKANA E Monitoring
JANUMET 2 ST ACCU-CHEK AVIVA
E
JANUMET XR 2 ST DEVICE
JANUVIA 2 ST ACCU-CHEK AVIVA
CONNECT KIT E
JARDIANCE 2 ST W/DEVICE
JENTADUETO 2 ST ACCU-CHEK AVIVA
E
JENTADUETO XR 2 ST PLUS KIT W/DEVICE
KAZANO E ACCU-CHEK
KOMBIGLYZE XR E COMPACT PLUS E
CARE KIT
metformin hcl er 1
ACCU-CHEK
metformin hcl er (mod) E COMPACT PLUS E
metformin hcl er (osm) E CONTROL
metformin hcl oral
1
tablet
Effective Date: 1/1/21
20Drug Name Drug Tier Notes Drug Name Drug Tier Notes
ACCU-CHEK CONTOUR TEST 2 QL
COMPACT PLUS E DIATHRIVE BLOOD
TEST STRIPS E
GLUCOSE METER
ACCU-CHEK DIATHRIVE BLOOD
FASTCLIX LANCET 2 E
GLUCOSE TEST
KIT
DIATHRIVE GLUCOSE
ACCU-CHEK GUIDE E
E CONTROL SOLN
KIT W/DEVICE
DIATHRIVE GLUCOSE
ACCU-CHEK GUIDE E
E TEST
CONTROL
DIATHRIVE+
ACCU-CHEK GUIDE E
E GLUCOSE MONITOR
KIT W/DEVICE
DIATHRIVE+
ACCU-CHEK NANO E
GLUCOSE TEST
SMARTVIEW KIT E
W/DEVICE EASY TRAK II BLOOD
E
GLUCOSE SYS
ACCU-CHEK
SMARTVIEW E EASY TRAK II
E
CONTROL CONTROL
ACCU-CHEK EASY TRAK II
E
SMARTVIEW TEST E GLUCOSE TEST
STRIPS EASYMAX 15 LEVEL
E
ACCU-CHEK 2-3 CONTROL
SOFTCLIX LANCET 2 EASYMAX CONTROL E
DEVICE KIT EASYMAX CONTROL
E
AGAMATRIX NORMAL/HIGH
E
CONTROL LEVEL 2 EMBRACE TALK
E
AGAMATRIX BLOOD GLUCOSE
E
CONTROL LEVEL 4 EMBRACE TALK
E
AGAMATRIX PRESTO GLUCOSE CONTROL
E
TEST EMBRACE TALK
E
ASSURE PLATINUM E GLUCOSE TEST
BIOTEL CARE BLOOD EMBRACE TALK
E
GLUCOSE SYST MONITORING E
BLOOD GLUCOSE SYSTEM
E
TEST EVENCARE PROVIEW
E
CARETOUCH GLUCOSE TEST
CONTROL SOL LEVEL E FORA 6 CONNECT E
2 FORA GTEL BLOOD
E
CARETOUCH TEST E GLUCOSE SYSTEM
CONTOUR CONTROL 2 FORA GTEL BLOOD
E
CONTOUR NEXT GLUCOSE TEST
2
CONTROL FORTISCARE
E
CONTOUR NEXT CONTROL
2 QL
TEST
Effective Date: 1/1/21
21Drug Name Drug Tier Notes Drug Name Drug Tier Notes
FORTISCARE GOJJI BLOOD TEST
E
GLUCOSE SYSTEM E STRIP/LANCETS
DEVICE GOJJI CONTROL E
FORTISCARE T1 HARMONY BLOOD
E E
GLUCOSE SYSTEM GLUCOSE TEST
FREESTYLE HW EMBRACE PRO
E E
FREEDOM LITE GLUCOSE METER
FREESTYLE HW EMBRACE PRO
E E
INSULINX SYSTEM GLUCOSE TEST
FREESTYLE HW EMBRACE TALK
E E
INSULINX TEST BLOOD GLUCOSE
FREESTYLE LIBRE 14 HW EMBRACE TALK
E E
DAY READER GLUCOSE TEST
FREESTYLE LIBRE 14 INFINITY BLOOD
E E
DAY SENSOR GLUCOSE TEST
FREESTYLE LIBRE 2 KROGER
E
READER SYSTM HEALTHPRO E
FREESTYLE LIBRE 2 GLUCOSE TEST
E
SENSOR SYSTM MICRODOT TEST E
FREESTYLE LIBRE ONE DROP BLOOD
E E
READER GLUCOSE MONITOR
FREESTYLE LIBRE ONE DROP TEST E
E
SENSOR SYSTEM
ONETOUCH ULTRA E
FREESTYLE LITE
E ONETOUCH ULTRA 2
TEST E
KIT W/DEVICE
FREESTYLE
PRECISION NEO E ONETOUCH ULTRA
E
TEST MINI KIT W/DEVICE
FREESTYLE TEST E ONETOUCH VERIO
E
KIT W/DEVICE
GLUCOCARD 01
E ONETOUCH VERIO
SENSOR PLUS
FLEX SYSTEM KIT E
GLUCOCARD W/DEVICE
E
EXPRESSION TEST
ONETOUCH VERIO IN
GLUCOCARD SHINE VITRO SOLUTION E
E
CONNEX HIGH
GLUCOCARD SHINE ONETOUCH VERIO
E E
EXPRESS TEST STRIPS
GLUCOCARD SHINE ONETOUCH VERIO IQ
E E
TEST SYSTEM
GLUCOCARD VITAL ONETOUCH VERIO
E E
TEST REFLECT
GOJJI BLOOD ONETOUCH VERIO
E
GLUCOSE TEST SYNC SYSTEM KIT E
W/DEVICE
Effective Date: 1/1/21
22Drug Name Drug Tier Notes Drug Name Drug Tier Notes
PRECISION LINK E TRUE METRIX PRO
E
PRECISION PCX BLOOD GLUCOSE
E
PLUS TEST TRUETRACK TEST E
PRECISION QID UNISTRIP CONTROL
E
MONITOR IN VITRO SOLUTION E
PRECISION QID TEST E LOW
PRECISION SOF- VIVAGUARD INO
E E
TACT MONITOR CONTROL SOLUTION
PRECISION SOF- VIVAGUARD INO
E E
TACT TEST GLUCOSE METER
PRECISION XTRA VIVAGUARD INO
E E
BLOOD GLUCOSE TEST STRIPS
PRECISION XTRA Diabetes - Glycemic
E Agents
DEVICE
PRECISION XTRA KIT E BAQSIMI ONE PACK 2
PRECISION XTRA BAQSIMI TWO PACK 2
E
MONITOR GLUCAGON
2
PRODIGY NO EMERGENCY KIT
CODING BLOOD E GVOKE PFS 2
GLUC Diabetes - Insulins
RELION BLOOD ADMELOG E
E
GLUCOSE TEST
ADMELOG
RELION PREMIER E
E SOLOSTAR
CLASSIC
APIDRA SOLOSTAR E
RELION PREMIER
E APIDRA VIAL E
TEST
RELION ULTIMA TEST E BASAGLAR KWIKPEN E
SURESTEP PRO BD AUTOSHIELD DUO
E 2
HIGH GLUCOSE PEN NEEDLES
SURESTEP PRO LOW BD ULTRA-FINE
E 2
GLUCOSE INSULIN SYRINGES
SURESTEP PRO BD ULTRA-FINE PEN
E 2
NORMAL GLUCOSE NEEDLES
TRUE FOCUS BLOOD BD VEO INSULIN SYR
E 2
GLUCOSE METER U/F 1/2UNIT
TRUE METRIX BLOOD FIASP E
E
GLUCOSE TEST FIASP FLEXTOUCH E
TRUE METRIX LEVEL FIASP PENFILL E
E
1 HUMALOG KWIKPEN 2
TRUE METRIX LEVEL HUMALOG MIX 50/50
E 2
2 KWIKPEN
TRUE METRIX LEVEL HUMALOG MIX 50/50
E 2
3 VIAL
Effective Date: 1/1/21
23Drug Name Drug Tier Notes Drug Name Drug Tier Notes
HUMALOG MIX 75/25 NOVOFINE PEN
2 2
KWIKPEN NEEDLE
HUMALOG MIX 75/25 NOVOFINE PLUS PEN
2 2
VIAL NEEDLE
HUMALOG U-100 NOVOLIN 70/30
2 E
JUNIOR KWIKPEN FLEXPEN
HUMALOG VIAL 2 NOVOLIN 70/30
E
HUMULIN 70/30 FLEXPEN RELION
2
KWIKPEN NOVOLIN 70/30
E
HUMULIN 70/30 VIAL 2 RELION
HUMULIN N KWIKPEN 2 NOVOLIN 70/30 VIAL E
HUMULIN N VIAL 2 NOVOLIN N FLEXPEN E
HUMULIN R U-500 NOVOLIN N FLEXPEN
2 E
KWIKPEN RELION
HUMULIN R U-500 NOVOLIN N RELION E
2
VIAL NOVOLIN N VIAL E
HUMULIN R VIAL 2 NOVOLIN R FLEXPEN E
INSULIN ASP PROT & NOVOLIN R FLEXPEN
E E
ASP FLEXPEN RELION
INSULIN ASPART E NOVOLIN R RELION E
INSULIN ASPART NOVOLIN R VIAL E
E
FLEXPEN NOVOLOG FLEXPEN E
INSULIN ASPART NOVOLOG MIX 70/30
E E
PENFILL FLEXPEN
INSULIN ASPART NOVOLOG MIX 70/30
E E
PROT & ASPART VIAL
INSULIN LISPRO E NOVOLOG PENFILL E
INSULIN LISPRO (1 NOVOLOG U-100 VIAL E
E
UNIT DIAL)
NOVOTWIST PEN
INSULIN LISPRO 2
E NEEDLE
JUNIOR KWIKPEN
TOUJEO MAX
INSULIN LISPRO 2
E SOLOSTAR
PROT & LISPRO
TOUJEO SOLOSTAR 2
LANTUS SOLOSTAR 2
TRESIBA E
LANTUS U-100 VIAL 2
TRESIBA
LEVEMIR U-100 E
E FLEXTOUCH
FLEXTOUCH
Electrolytes / Minerals
LEVEMIR U-100 VIAL E / Metals / Vitamins
NOVOFINE AZESCHEW
AUTOCOVER PEN 2 PRENATAL/POSTNAT E
NEEDLE AL
AZESCO E
Effective Date: 1/1/21
24Drug Name Drug Tier Notes Drug Name Drug Tier Notes
CARNITOR ORAL E sodium fluoride oral
1
CARNITOR SF E tablet chewable
CITRANATAL BLOOM E TRINAZ E
cyanocobalamin TRISTART ONE E
injection solution 1000 1 VELTASSA 3
mcg/ml VITAFOL FE+ E
CYANOCOBALAMIN VITAFOL-OB+DHA E
INJECTION
3 vitamin d
SOLUTION 2000
MCG/ML (ergocalciferol) oral
1
capsule 1.25 mg
ENBRACE HR E (50000 ut)
ergocalciferol oral VITATHELY WITH
1 E
capsule GINGER
folic acid oral tablet 1 WESTGEL DHA E
1
mg
ZALVIT E
klor-con m20 1
Gastrointestinal
K-TAB E Agents - Drugs for
LOKELMA 3 Acid Reflux and Ulcer
multivitamin/fluoride ACIPHEX E
oral tablet chewable 1 CARAFATE ORAL
0.25 mg, 0.5 mg, 1 mg E
TABLET
NASCOBAL 3 DEXILANT 2
NESTABS ONE E esomeprazole
potassium chloride crys magnesium oral
1 1
er capsule delayed
potassium chloride er 1 release
potassium citrate er 1 famotidine oral tablet
1
20 mg, 40 mg
PREGENNA E
lansoprazole oral
PRENARA E capsule delayed 1
PRENATE E release
PRENATE DHA E NEXIUM ORAL
PRENATE ELITE E CAPSULE DELAYED E
RELEASE
PRENATE ENHANCE E
omeprazole oral
PRENATE ESSENTIAL E capsule delayed 1
PRENATE MINI E release
PRENATE PIXIE E omeprazole-sodium
E
PRENATE RESTORE E bicarbonate
PRENATVITE pantoprazole sodium
E oral tablet delayed 1
COMPLETE
release
PRIMACARE E
PREVACID E
Effective Date: 1/1/21
25Drug Name Drug Tier Notes Drug Name Drug Tier Notes
PREVACID SOLUTAB E OSMOPREP E
PROTONIX ORAL PLENVU E
TABLET DELAYED E PYLERA 2
RELEASE
RELISTOR E
RABEPRAZOLE
SODIUM ORAL E SUPREP BOWEL
3
CAPSULE SPRINKLE PREP KIT
rabeprazole sodium SYMPROIC 2 ST; QL
oral tablet delayed 1 TRULANCE E
release VIBERZI 3 PA; QL
sucralfate oral tablet 1 ZELNORM 3 QL
ZEGERID E Genetic or Enzyme
Gastrointestinal Disorder - Drugs for
Agents - Drugs for Replacement,
Bowel, Intestine and Modification,
Stomach Conditions Treatment
AMITIZA E CERDELGA 3 PA; SP
CLENPIQ 3 CREON 2
dicyclomine hcl oral EXONDYS 51 E
1
capsule NITYR 3 PA; SP
dicyclomine hcl oral PANCREAZE E
1
tablet
PERTZYE E
diphenoxylate-atropine
1 STRENSIQ
oral tablet
SUBCUTANEOUS
gavilyte-g 1 SOLUTION 28 2 PA; SP
glycopyrrolate oral MG/0.7ML, 40 MG/ML,
1
tablet 1 mg, 2 mg 80 MG/0.8ML
GOLYTELY E VIOKACE E
hyoscyamine sulfate sl 1 VYONDYS 53 E
hyoscyamine sulfate ZENPEP 2
1
sublingual Genitourinary Agents
lactulose oral solution 1 - Drugs for Bladder,
LINZESS 2 ST; QL Genital and Kidney
Conditions
MOTEGRITY 3 ST; QL
AURYXIA 3
MOTOFEN E
CIALIS ORAL TABLET
MOVANTIK E E
2.5 MG, 5 MG
MOVIPREP E DEPEN TITRATABS 2 SP
NULYTELY LEMON- MYRBETRIQ 2
E
LIME
oxybutynin chloride er 1
NULYTELY WITH
E oxybutynin chloride oral
FLAVOR PACKS 1
tablet
OMECLAMOX-PAK 2
Effective Date: 1/1/21
26Drug Name Drug Tier Notes Drug Name Drug Tier Notes
phenazopyridine hcl RAYOS E
oral tablet 100 mg, 200 1 Hormonal Agents -
mg Men's Health
RENAGEL E ANDRODERM 2 PA
solifenacin succinate 1 ANDROGEL E
tadalafil oral tablet 2.5 ANDROGEL PUMP E
1 PA; QL
mg, 5 mg
AVEED E
tolterodine tartrate er 1
DEPO-
TOVIAZ 3 E
TESTOSTERONE
VELPHORO 3 FORTESTA E
VESICARE E JATENZO E
Genitourinary Agents NATESTO E
- Drugs for Prostate
Conditions TESTIM E
alfuzosin hcl er 1 TESTOPEL E
AVODART E testosterone cypionate
1 PA
intramuscular
dutasteride oral 1
testosterone
finasteride oral tablet 5 transdermal gel 1.62 %,
1
mg 10 mg/act (2%), 20.25
FLOMAX E mg/1.25gm (1.62%),
tamsulosin hcl 1 20.25 mg/act (1.62%), 1 PA
25 mg/2.5gm (1%),
terazosin hcl oral 40.5 mg/2.5gm
capsule 1 mg, 10 mg, 5 1 (1.62%), 50 mg/5gm
mg (1%)
Hormonal Agents - VOGELXO E
Adrenal
VOGELXO PUMP E
CORTEF E
XYOSTED 3 PA
dexamethasone oral
1 Hormonal Agents -
tablet
Osteoporosis
hydrocortisone oral 1
OSPHENA 3
KENALOG INJECTION
SUSPENSION 40 E Hormonal Agents -
MG/ML Pituitary
methylprednisolone ACTHAR 2 PA; SP
1
oral BYNFEZIA PEN E
prednisolone oral cabergoline 1
1
solution CETROTIDE E
prednisolone sodium FOLLISTIM AQ 50% PA
1
phosphate oral solution
ganirelix acetate 50% PA
prednisone oral tablet 1
GENOTROPIN E
prednisone oral tablet
1 GENOTROPIN
therapy pack E
MINIQUICK
Effective Date: 1/1/21
27Drug Name Drug Tier Notes Drug Name Drug Tier Notes
GONAL-F E ELESTRIN 3
GONAL-F RFF E ENDOMETRIN 2
GONAL-F RFF ESTRACE E
E
REDIJECT estradiol oral 1
HUMATROPE E estradiol transdermal 1
ISTURISA E estradiol vaginal 1
LUPRON DEPOT (1- ESTROGEL 3
MONTH)
2 PA; SP EVAMIST 3
INTRAMUSCULAR KIT
7.5 MG IMVEXXY
3
LUPRON DEPOT (3- MAINTENANCE PACK
MONTH) IMVEXXY STARTER
2 PA; SP 3
INTRAMUSCULAR KIT PACK
22.5 MG MAKENA 2 PA; SP
LUPRON DEPOT (4- medroxyprogesterone
MONTH) 1
2 PA; SP acetate oral
INTRAMUSCULAR KIT
30MG norethindrone acetate
1
oral
LUPRON DEPOT (6-
MONTH) PREMARIN ORAL 2
2 PA; SP
INTRAMUSCULAR KIT PREMARIN VAGINAL 2
45MG PREMPHASE 2
NOCDURNA 3 PREMPRO 2
OMNITROPE E progesterone
1
ORILISSA 50% micronized oral
SAIZEN E PROMETRIUM E
SAIZENPREP E VAGIFEM E
SANDOSTATIN E VIVELLE-DOT E
ZOMACTON E Hormonal Agents -
ZOMACTON (FOR Thyroid
E
ZOMA-JET 10) ARMOUR THYROID 3 ST
Hormonal Agents - CYTOMEL E
Sex Hormones and
euthyrox 1
Birth Control
levothyroxine sodium
BIJUVA 3 1
oral
CLIMARA E levoxyl 1
CLIMARA PRO 2 liothyronine sodium oral 1
DELESTROGEN methimazole oral 1
INTRAMUSCULAR OIL E
20 MG/ML, 40 MG/ML
DIVIGEL 3
dotti 1
DUAVEE 2
Effective Date: 1/1/21
28Drug Name Drug Tier Notes Drug Name Drug Tier Notes
NATURE-THROID ENBREL SURECLICK 3 PA; SP
ORAL TABLET 113.75 FIRAZYR 3 PA; SP; QL
MG, 130 MG, 146.25
MG, 16.25 MG, 195 HAEGARDA 3 PA; SP
3 ST
MG, 260 MG, 32.5 MG, HUMIRA 2 PA; SP
325 MG, 48.75 MG, 65 HUMIRA PEDIATRIC
MG, 81.25 MG, 97.5 2 PA; SP
CROHNS START
MG
HUMIRA PEN 2 PA; SP
np thyroid oral tablet 60
1 HUMIRA PEN-
mg 2 PA; SP
CD/UC/HS STARTER
SYNTHROID 3
HUMIRA PEN-
TIROSINT E PS/UV/ADOL HS 2 PA; SP
TIROSINT-SOL E START
Immunological INFLECTRA 2 PA; SP
Agents - Drugs for
leflunomide oral 1
Immune System
Stimulation or methotrexate oral 1
Suppression methotrexate sodium
1
ACTEMRA ACTPEN 3 PA; SP oral
ACTEMRA mycophenolate mofetil
3 PA; SP 1
SUBCUTANEOUS oral capsule
ASCENIV E mycophenolate mofetil
1
oral tablet
azathioprine oral 1
mycophenolate sodium 1
CIMZIA 2 PA; SP
OLUMIANT E
CIMZIA PREFILLED
2 PA; SP ORENCIA CLICKJECT 3 PA; SP
KIT
CIMZIA STARTER KIT 2 PA; SP ORENCIA
SUBCUTANEOUS
COSENTYX (300 MG SOLUTION 3 PA; SP
E
DOSE) PREFILLED SYRINGE
COSENTYX 150 125 MG/ML
E
MG/ML OTEZLA 2 PA; SP
COSENTYX PANZYGA E
SENSOREADY (300 E
MG) PROGRAF ORAL
3
CAPSULE
COSENTYX
E RASUVO 2 PA; QL
SENSOREADY PEN
CUTAQUIG E REMICADE E
cyclosporine modified RENFLEXIS 2 PA; SP
1
oral capsule RINVOQ 2 PA; SP
ENBREL MINI 3 PA; SP RUCONEST 3 PA; SP; QL
ENBREL SIMPONI 2 PA; SP
SUBCUTANEOUS SIMPONI ARIA 2 PA; SP
3 PA; SP
SOLUTION
PREFILLED SYRINGE sirolimus oral tablet 1
Effective Date: 1/1/21
29Drug Name Drug Tier Notes Drug Name Drug Tier Notes
SKYRIZI (150 MG PROLIA 2 PA; SP; QL
2 PA; SP
DOSE) RAYALDEE 3
STELARA TYMLOS 2 PA; SP
2 PA; SP
INTRAVENOUS
Metabolic Bone
STELARA Disease Agents -
2 PA; SP; QL
SUBCUTANEOUS Other
tacrolimus oral 1 calcitriol oral capsule 1
TAKHZYRO 3 PA; SP SENSIPAR E
TALTZ 3 PA; SP Miscellaneous
TREMFYA 2 PA; SP Therapeutic Agents
XELJANZ 2 PA; SP BOTOX 2 PA; SP
XELJANZ XR 2 PA; SP DUROLANE 2 PA; SP
XEMBIFY 3 PA; SP ENDARI 3 PA
Inflammatory Bowel EUFLEXXA 2 PA; SP
Disease Agents
FIRDAPSE E
APRISO 2 GEL-ONE E
ASACOL HD E GELSYN-3 2 PA; SP
CANASA E GENVISC 850 E
DELZICOL E HYALGAN E
DIPENTUM E HYMOVIS E
LIALDA E MONOVISC E
mesalamine oral tablet ORTHOVISC E
1
delayed release
OXBRYTA E
PENTASA 3
PALFORZIA (12 MG
PROCTOFOAM HC 2 E
DAILY DOSE)
sulfasalazine oral tablet 1 PALFORZIA (120 MG
E
UCERIS ORAL E DAILY DOSE)
UCERIS RECTAL 3 PALFORZIA (160 MG
E
Metabolic Bone DAILY DOSE)
Disease Agents - PALFORZIA (20 MG
E
Drugs for DAILY DOSE)
Osteoporosis PALFORZIA (200 MG
E
alendronate sodium DAILY DOSE)
1
oral tablet 10 mg, 5 mg PALFORZIA (240 MG
E
alendronate sodium DAILY DOSE)
oral tablet 35 mg, 70 1 QL PALFORZIA (3 MG
mg E
DAILY DOSE)
BINOSTO 3 QL PALFORZIA (300 MG
E
FORTEO 2 PA; SP MAINTENANCE)
ibandronate sodium PALFORZIA (300 MG
1 QL E
oral TITRATION)
Effective Date: 1/1/21
30Drug Name Drug Tier Notes Drug Name Drug Tier Notes
PALFORZIA (40 MG ofloxacin ophthalmic 1
E
DAILY DOSE) olopatadine hcl
1
PALFORZIA (6 MG ophthalmic
E
DAILY DOSE) PAZEO E
PALFORZIA (80 MG PRED FORTE E
E
DAILY DOSE)
prednisolone acetate
PALFORZIA INITIAL 1
E ophthalmic
ESCALATION
PROLENSA 2 QL
SODIUM
HYALURONATE E VIGAMOX E
INTRA-ARTICULAR ZERVIATE E
SUPARTZ FX E Ophthalmic Agents -
SYNVISC E Drugs for Glaucoma
SYNVISC ONE E ALPHAGAN P
OPHTHALMIC 2
TRILURON E SOLUTION 0.1 %
TRIVISC E ALPHAGAN P
VISCO-3 E OPHTHALMIC E
Ophthalmic Agents - SOLUTION 0.15 %
Drugs for Eye Allergy, AZOPT 2
Infection and BETIMOL 3
Inflammation
brimonidine tartrate
AZASITE 3 1
ophthalmic
BESIVANCE 3 COMBIGAN 2
BROMSITE E COSOPT E
ciprofloxacin hcl COSOPT PF E
1
ophthalmic
dorzolamide hcl-timolol
erythromycin 1
1 mal
ophthalmic
latanoprost ophthalmic 1
ILEVRO E
LUMIGAN 2 QL
INVELTYS 3
RHOPRESSA 3 QL
ketorolac tromethamine
1 ROCKLATAN 3 QL
ophthalmic
LOTEMAX SIMBRINZA 2
OPHTHALMIC E timolol maleate
1
SUSPENSION ophthalmic solution
LOTEMAX SM 3 TIMOPTIC E
MOXEZA 2 TIMOPTIC OCUDOSE E
moxifloxacin hcl (2x TIMOPTIC-XE E
1
day) VYZULTA E
moxifloxacin hcl XALATAN E
1
ophthalmic
ZIOPTAN E
NEVANAC E
Effective Date: 1/1/21
31Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Ophthalmic Agents - mometasone furoate
Drugs for 1 QL
nasal
Miscellaneous Eye NASONEX E
Conditions
NUCALA 2 PA; SP; QL
BEOVU E
OMNARIS 3 QL
CEQUA E
promethazine hcl oral
LATISSE E 1
tablet
polymyxin b- promethazine-codeine 1 PA; QL
1
trimethoprim
promethazine-dm 1
RESTASIS 2 PA
pseudoephedrine-
RESTASIS bromphen-dm oral 1
2 PA
MULTIDOSE syrup
TOBRADEX QNASL 3 QL
OPHTHALMIC E
SUSPENSION QNASL CHILDRENS 3 QL
tobramycin- XHANCE E
1
dexamethasone XOLAIR 2 PA; SP
XIIDRA 2 PA ZETONNA 3 QL
Otic Agents - Drugs Respiratory Tract /
for Ear Conditions Pulmonary Agents -
CIPRODEX 2 Drugs for Asthma and
Other Lung
neomycin-polymyxin-hc Conditions
1
otic suspension
ADVAIR DISKUS 2 QL
ofloxacin otic 1
ADVAIR HFA 2 QL
Respiratory Tract /
Pulmonary Agents - AIRDUO DIGIHALER E
Drugs for Allergies, AIRDUO RESPICLICK
Cough, Cold E
113/14
azelastine hcl nasal 1 QL AIRDUO RESPICLICK
E
benzonatate 1 232/14
CLARINEX-D 12 AIRDUO RESPICLICK
E E
HOUR 55/14
cyproheptadine hcl oral albuterol sulfate hfa
1 aerosol solution 108
tablet 1 QL
(90 base) mcg/act
DYMISTA 2 inhalation
FASENRA 2 PA; SP ALBUTEROL
FASENRA PEN 2 PA; SP SULFATE HFA
fluticasone propionate AEROSOL SOLUTION
1 E (Prasco)
nasal 108 (90 BASE)
MCG/ACT
hydrocodone polst- INHALATION
1 PA; QL
chlorphen polst er susp
ipratropium bromide
1
nasal
Effective Date: 1/1/21
32Drug Name Drug Tier Notes Drug Name Drug Tier Notes
albuterol sulfate EPIPEN 2-PAK 3
inhalation nebulization EPIPEN JR 2-PAK E
solution (2.5 mg/3ml) 1 QL
0.083%, 0.63 mg/3ml, FLOVENT DISKUS 2 QL
1.25 mg/3ml FLOVENT HFA 2 QL
albuterol sulfate fluticasone-salmeterol
inhalation nebulization inhalation aerosol
1
solution (5 mg/ml) powder breath
0.5%, 2.5 mg/0.5ml activated 100-50 1 QL
ALVESCO E mcg/dose, 250-50
mcg/dose, 500-50
ANORO ELLIPTA 2 QL mcg/dose
ARMONAIR INCRUSE ELLIPTA E
E
DIGIHALER
ipratropium-albuterol 1 QL
ARNUITY ELLIPTA 2 QL
LEVALBUTEROL HFA
ASMANEX (120 INHALATION
E E
METERED DOSES) AEROSOL 45
ASMANEX (14 MCG/ACT
E
METERED DOSES) LONHALA MAGNAIR
3 QL
ASMANEX (30 REFILL KIT
E
METERED DOSES) LONHALA MAGNAIR
3 QL
ASMANEX (60 STARTER KIT
E
METERED DOSES) montelukast sodium
1
ASMANEX (7 oral tablet
E
METERED DOSES) montelukast sodium
1
ASMANEX HFA E oral tablet chewable
ATROVENT HFA 3 QL PERFOROMIST 3 QL
AUVI-Q INJECTION PROAIR DIGIHALER E
SOLUTION AUTO- PROAIR HFA E
INJECTOR 0.15 E
MG/0.15ML, 0.3 PROAIR RESPICLICK E
MG/0.3ML PROVENTIL HFA E
BEVESPI PULMICORT
E 2 QL
AEROSPHERE FLEXHALER
BREO ELLIPTA 2 QL PULMICORT
E
budesonide inhalation 1 QL SUSPENSION
BUDESONIDE- QVAR REDIHALER E
FORMOTEROL E SEEBRI NEOHALER E
FUMARATE SEREVENT DISKUS 2 QL
COMBIVENT SINGULAIR E
2 QL
RESPIMAT
SPIRIVA
DUAKLIR PRESSAIR E 2 QL
HANDIHALER
DULERA E SPIRIVA RESPIMAT 2 QL
epinephrine injection STIOLTO RESPIMAT 2 QL
1
solution auto-injector
Effective Date: 1/1/21
33Drug Name Drug Tier Notes Drug Name Drug Tier Notes
STRIVERDI sildenafil citrate oral
2 QL 1 PA; SP; QL
RESPIMAT tablet 20 mg
SYMBICORT 2 QL TRACLEER 62.5 MG,
E
SYMJEPI 3 125 MG
TRELEGY ELLIPTA Skeletal Muscle
INHALATION Relaxants - Drugs for
AEROSOL POWDER 2 QL Muscle Pain and
BREATH ACTIVATED Spasm
100-62.5-25 MCG/INH AMRIX E
TUDORZA PRESSAIR E baclofen oral 1
UTIBRON NEOHALER E carisoprodol oral 1
VENTOLIN HFA E cyclobenzaprine hcl
1
wixela inhub 1 QL oral
XOPENEX HFA E LORZONE 3
YUPELRI 3 QL metaxalone 1
Respiratory Tract / methocarbamol oral 1
Pulmonary Agents - NORGESIC FORTE E
Drugs for Cystic ORPHENGESIC
Fibrosis E
FORTE
BETHKIS 2 SP OZOBAX E
KITABIS PAK E SKELAXIN E
PULMOZYME 2 PA; SP SOMA E
TOBI NEBULIZER E tizanidine hcl oral tablet 1
TOBI PODHALER 3 SP; QL VANADOM E
tobramycin nebulization ZANAFLEX E
solution 300 mg/5ml 1 SP
inhalation Sleep Disorder
Agents
TOBRAMYCIN
NEBULIZATION AMBIEN E
E
SOLUTION 300 AMBIEN CR E
MG/5ML INHALATION armodafinil 1 PA; QL
TRIKAFTA 3 PA; SP; QL eszopiclone 1 QL
Respiratory Tract / LUNESTA E
Pulmonary Agents -
Drugs for Pulmonary modafinil 1 PA; QL
Hypertension NUVIGIL E
ADCIRCA E PROVIGIL E
ADEMPAS 2 PA; SP; QL RESTORIL E
LETAIRIS E SILENOR 3 QL
OPSUMIT 2 PA; SP; QL SUNOSI 2 PA; QL
ORENITRAM 3 PA; SP temazepam 1 QL
REMODULIN E WAKIX 3 PA; QL; SP
Effective Date: 1/1/21
34Drug Name Drug Tier Notes
XYREM 3 PA; QL; SP
zolpidem tartrate er 1 QL
zolpidem tartrate oral 1 QL
Effective Date: 1/1/21
35Index of Drugs
ABILIFY.....................................13 AFSTYLA.................................. 14 APADAZ......................................7
ABSORICA LD..........................18 AGAMATRIX CONTROL apap-caff-dihydrocodeine........... 7
ACANYA................................... 18 LEVEL 2....................................21 APEXICON E............................ 18
ACCU-CHEK AVIVA AGAMATRIX CONTROL APIDRA SOLOSTAR................ 23
CONNECT KIT W/DEVICE.......20 LEVEL 4....................................21 APIDRA VIAL............................23
ACCU-CHEK AVIVA DEVICE...20 AGAMATRIX PRESTO TEST...21 APRISO.................................... 30
ACCU-CHEK AVIVA PLUS AIMOVIG...................................11 ARAKODA................................ 12
KIT W/DEVICE..........................20 AIRDUO DIGIHALER................32 ARANESP (ALBUMIN FREE)... 14
ACCU-CHEK COMPACT AIRDUO RESPICLICK 113/14..32 ARIMIDEX.................................12
PLUS CARE KIT....................... 20 AIRDUO RESPICLICK 232/14..32 aripiprazole............................... 13
ACCU-CHEK COMPACT AIRDUO RESPICLICK 55/14....32 ARISTADA................................ 13
PLUS CONTROL...................... 20 AJOVY...................................... 11 ARISTADA INITIO.................... 13
ACCU-CHEK COMPACT AKLIEF......................................18 armodafinil................................ 34
PLUS TEST STRIPS................ 21 ALA SCALP.............................. 18 ARMONAIR DIGIHALER.......... 33
ACCU-CHEK FASTCLIX albuterol sulfate.........................33 ARMOUR THYROID.................28
LANCET KIT............................. 21 albuterol sulfate hfa...................32 ARNUITY ELLIPTA...................33
ACCU-CHEK GUIDE ALBUTEROL SULFATE HFA... 32 ARTHROTEC..............................7
CONTROL................................ 21 alendronate sodium.................. 30 ARYMO ER.................................7
ACCU-CHEK GUIDE KIT alfuzosin hcl er.......................... 27 ASACOL HD............................. 30
W/DEVICE................................ 21 allopurinol..................................11 ASCENIV.................................. 29
ACCU-CHEK NANO ALOGLIPTIN BENZOATE........ 20 ASMANEX (120 METERED
SMARTVIEW KIT W/DEVICE...21 ALOGLIPTIN-METFORMIN DOSES).................................... 33
ACCU-CHEK SMARTVIEW HCL...........................................20 ASMANEX (14 METERED
CONTROL................................ 21 ALOGLIPTIN-PIOGLITAZONE. 20 DOSES).................................... 33
ACCU-CHEK SMARTVIEW ALPHAGAN P........................... 31 ASMANEX (30 METERED
TEST STRIPS...........................21 alprazolam................................ 14 DOSES).................................... 33
ACCU-CHEK SOFTCLIX ALTACE.................................... 14 ASMANEX (60 METERED
LANCET DEVICE KIT...............21 ALVESCO................................. 33 DOSES).................................... 33
acetaminophen-codeine..............7 AMBIEN.................................... 34 ASMANEX (7 METERED
acetaminophen-codeine #2.........7 AMBIEN CR.............................. 34 DOSES).................................... 33
acetaminophen-codeine #3.........7 amiodarone hcl......................... 14 ASMANEX HFA........................ 33
acetaminophen-codeine #4.........7 AMITIZA....................................26 ASPIRIN-OMEPRAZOLE......... 13
ACIPHEX.................................. 25 amitriptyline hcl......................... 10 ASSURE PLATINUM................ 21
ACTEMRA................................ 29 amlodipine besylate.................. 14 ATACAND.................................14
ACTEMRA ACTPEN.................29 amlodipine besylate-benazepril atenolol..................................... 14
ACTHAR................................... 27 hcl............................................. 14 atenolol-chlorthalidone..............14
ACTICLATE................................ 8 amlodipine besylate-valsartan.. 14 ATIVAN..................................... 14
acyclovir.................................... 13 amlodipine-olmesartan..............14 atomoxetine hcl.........................17
ACZONE................................... 18 amoxicillin................................... 8 atorvastatin calcium.................. 14
ADCIRCA..................................34 amoxicillin-potassium ATRIPLA................................... 13
ADDERALL............................... 17 clavulanate..................................8 ATROVENT HFA...................... 33
ADDERALL XR......................... 17 amphetamine- AUBAGIO..................................17
ADEMPAS................................ 34 dextroamphetamine.................. 17 AURYXIA.................................. 26
ADHANSIA XR..........................17 amphetamine- AUSTEDO.................................18
ADIPEX-P................................. 18 dextroamphetamine er.............. 17 AUVI-Q......................................33
ADLYXIN...................................20 AMPYRA...................................17 AVAPRO................................... 14
ADLYXIN STARTER PACK...... 20 AMRIX.......................................34 AVEED......................................27
ADMELOG................................ 23 AMZEEQ...................................18 AVITA........................................18
ADMELOG SOLOSTAR........... 23 anastrozole............................... 12 AVODART.................................27
ADVAIR DISKUS...................... 32 ANDRODERM.......................... 27 AVONEX PEN...........................17
ADVAIR HFA............................ 32 ANDROGEL..............................27 AVONEX PREFILLED.............. 17
ADYNOVATE............................14 ANDROGEL PUMP.................. 27 AZASITE................................... 31
AFINITOR................................. 12 ANORO ELLIPTA..................... 33 azathioprine.............................. 29
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