Your 2021 Premium Standard Formulary - My Hamilton
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Your 2021 Premium Standard Formulary
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.Understanding your formulary
What is a formulary?
A formulary is a list of prescribed medications or other About this formulary
pharmacy care products, services or supplies chosen Where differences between
for their safety, cost, and effectiveness. Medications are this formulary and your benefit
listed by categories or classes and are placed into cost plan exist, the benefit plan
levels known as tiers. It includes both brand and generic documents rule. This may not be
prescription medications. a complete list of medications
that are covered by your plan.
To create the list, OptumRx® is guided by the Pharmacy and
Please review your benefit plan
Therapeutics Committee. This group of doctors, nurses, and
for full details.
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 formulary?
You and your doctor can use the formulary 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 formulary 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 An over-the-counter (OTC)
(offer the same effect) as brand-name medications, but they medication may be the right
often cost less. Once the patent for a brand-name medication treatment option for some
ends, the FDA can approve a generic version with the same conditions. Talk to your doctor
active ingredients. about OTC options. Even though
OTC medications may not be
What if my doctor writes a brand-name prescription? covered by your pharmacy
If your doctor gives you a prescription for a brand-name benefit, they may cost less
medication, ask if a generic or lower-cost option could be right than a prescription medication.
for you. Generic medications are usually your lowest-cost option.
What if I am taking a specialty medication?
Specialty medications are used to treat complex conditions. These high-cost medications may
be injected, infused or taken by mouth. 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. Call 1-855-427-4682 and have your prescriptions delivered right to your
home or doctor’s office.
3Reading your formulary
The formulary gives you choices so you and your doctor can decide your best course of treatment.
In this formulary, 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.
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.
M Authorized generic or cobranded product
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 tep Therapy – Must try lower-cost medication(s) before a higher-cost medication
S
can be covered.
3P Tier 3 preferred
4Table of Contents
Analgesics - Drugs for Pain.................................................................................................................................7
Analgesics - Drugs for Pain and Inflammation.................................................................................................... 8
Anesthetics..........................................................................................................................................................8
Anti-Addiction / Substance Abuse Treatment Agents......................................................................................... 8
Antibacterials.......................................................................................................................................................8
Anticoagulants.....................................................................................................................................................9
Anticonvulsants - Drugs for Seizures................................................................................................................ 10
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia.............................................................. 11
Antidepressants.................................................................................................................................................11
Antiemetics - Drugs for Nausea and Vomiting.................................................................................................. 11
Antifungals.........................................................................................................................................................12
Antigout Agents................................................................................................................................................. 12
Antimigraine Agents.......................................................................................................................................... 12
Antineoplastics - Drugs for Cancer....................................................................................................................12
Antiparasitics..................................................................................................................................................... 13
Antiparkinson Agents........................................................................................................................................ 13
Antiplatelets.......................................................................................................................................................13
Antipsychotics - Drugs for Mood Disorders....................................................................................................... 13
Antivirals............................................................................................................................................................14
Anxiolytics - Drugs for Anxiety...........................................................................................................................14
Bipolar Agents - Drugs for Mood Disorders.......................................................................................................15
Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders..............................................15
Cardiovascular Agents - Drugs for Heart and Circulation Conditions............................................................... 15
Central Nervous System Agents - Drugs for Attention Deficit Disorder........................................................... 18
Central Nervous System Agents - Drugs for Multiple Sclerosis........................................................................ 18
Central Nervous System Agents - Miscellaneous............................................................................................. 19
Dental and Oral Agents - Drugs for Mouth and Throat Conditions....................................................................19
Dermatological Agents - Drugs for Skin Conditions.......................................................................................... 19
Diabetes - Antidiabetic Agents.......................................................................................................................... 21
Diabetes - Glucose Monitoring.......................................................................................................................... 22
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.................................................25
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............................................................................................................................... 30
Immunological Agents - Drugs for Immune System Stimulation or Suppression.............................................. 30
Inflammatory Bowel Disease Agents.................................................................................................................31
Metabolic Bone Disease Agents - Drugs for Osteoporosis............................................................................... 31
Metabolic Bone Disease Agents - Other........................................................................................................... 32
Miscellaneous Therapeutic Agents................................................................................................................... 32
Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation...........................................................32
Ophthalmic Agents - Drugs for Glaucoma.........................................................................................................33
5Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions......................................................................... 33
Otic Agents - Drugs for Ear Conditions............................................................................................................. 34
Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold........................................................34
Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions................................... 34
Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis.................................................................... 36
Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension.................................................... 36
Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm...................................................................... 36
Sleep Disorder Agents...................................................................................................................................... 36
6Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Analgesics - Drugs FIORICET/CODEINE E
for Pain hydrocodone-
acetaminophen- acetaminophen oral 1 QL
1 QL
codeine #2 tablet
acetaminophen- hydromorphone hcl oral
1 QL 1 QL
codeine #3 tablet
acetaminophen- HYSINGLA ER 2 PA; QL
1 QL
codeine #4 KADIAN E
acetaminophen- LAZANDA E
codeine oral tablet 300- 1 QL
15 mg, 300-60 mg morphine sulfate er oral
1 PA; QL
tablet extended release
APADAZ E
MS CONTIN E
apap-caff-
dihydrocodeine oral 1 QL NORCO E
capsule NUCYNTA E
ARYMO ER E NUCYNTA ER E
BELBUCA 2 PA; QL OXYCODONE HCL ER E M
BENZHYDROCODON oxycodone hcl oral
E 1 QL
E-ACETAMINOPHEN tablet
butalbital-apap-caffeine 1 oxycodone-
1 QL
BUTRANS acetaminophen
TRANSDERMAL OXYCONTIN 2 PA; QL
PATCH WEEKLY 10 PERCOCET E
E
MCG/HR, 15 MCG/HR,
20 MCG/HR, 5 ROXICODONE E
MCG/HR SUBSYS E
CONZIP E TRAMADOL HCL ER
DILAUDID ORAL E ORAL CAPSULE
EXTENDED RELEASE E M
DURAGESIC-100 E 24 HOUR 100 MG, 200
DURAGESIC-12 E MG, 300 MG
DURAGESIC-25 E tramadol hcl oral tablet
1 QL
DURAGESIC-50 E 50 mg
DURAGESIC-75 E TREZIX 3 QL
fentanyl 1 PA; QL ULTRACET E
FENTANYL CITRATE ULTRAM E
E M
BUCCAL TABLET XTAMPZA ER 2 PA; QL
FENTORA E ZOHYDRO ER E
FIORICET E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
7Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Analgesics - Drugs Anesthetics
for Pain and lidocaine external patch 1
Inflammation
lidocaine-prilocaine
ARTHROTEC E 1
external cream
CAMBIA E LIDODERM E
CELEBREX E ZTLIDO E
celecoxib oral 1 QL Anti-Addiction /
diclofenac sodium oral 1 Substance Abuse
diclofenac sodium Treatment Agents
1 QL
transdermal gel 1 % BUNAVAIL 3 QL
DUEXIS E buprenorphine hcl
1 QL
etodolac oral tablet 1 sublingual
FLECTOR E buprenorphine hcl-
1 QL
naloxone hcl
ibuprofen oral tablet 1
CHANTIX 3 QL
INDOMETHACIN
ORAL CAPSULE 20 3 ST CHANTIX
MG CONTINUING MONTH 3 QL
PAK
indomethacin oral
1 CHANTIX STARTING
capsule 25 mg, 50 mg 3 QL
MONTH PAK
ketorolac tromethamine
1 QL EVZIO E
oral
meloxicam oral 1 NALOXONE HCL
INJECTION
MOBIC E E
SOLUTION AUTO-
nabumetone oral 1 INJECTOR
NALFON E naltrexone hcl oral 1
NAPRELAN 3 NARCAN 2
naproxen oral tablet 1 SUBOXONE E
PENNSAID E ZUBSOLV 2 QL
QMIIZ ODT E Antibacterials
RELAFEN DS E ACTICLATE E
SPRIX E amoxicillin oral capsule 1
VIMOVO E amoxicillin oral
VOLTAREN E suspension 1
reconstituted
ZIPSOR E
amoxicillin oral tablet 1
ZORVOLEX E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
8Drug Name Drug Tier Notes Drug Name Drug Tier Notes
amoxicillin-potassium metronidazole oral
1
clavulanate oral tablet
1
suspension metronidazole vaginal 1
reconstituted
minocycline hcl oral
amoxicillin-potassium 1
1 capsule
clavulanate oral tablet
MINOLIRA E
azithromycin oral
suspension 1 mupirocin external 1
reconstituted nitrofurantoin
1
azithromycin oral tablet 1 macrocrystal oral
cefdinir 1 nitrofurantoin
monohydrate 1
cefuroxime axetil 1 macrocrystals
cephalexin oral capsule 1 NUZYRA ORAL 3
cephalexin oral penicillin v potassium
suspension 1 1
oral tablet
reconstituted
SEYSARA 3 ST
ciprofloxacin hcl oral
1 SILVADENE E
tablet 250 mg, 500 mg
clarithromycin oral SOLODYN E
1
tablet SOLOSEC 3
clindamycin hcl oral 1 sulfamethoxazole-
1
CLINDESSE 3 trimethoprim oral tablet
DIFICID 3 TARGADOX E
DORYX MPC E XENLETA 3
DORYX ORAL XEPI 3
TABLET DELAYED XIMINO 3
E
RELEASE 200 MG, 50 Anticoagulants
MG
ELIQUIS 2 QL
doxycycline hyclate oral
1 ELIQUIS DVT/PE
capsule 2 QL
STARTER PACK
doxycycline hyclate oral
1 enoxaparin sodium 1 SP; QL
tablet
doxycycline PRADAXA 2 QL
monohydrate oral 1 warfarin sodium oral 1
capsule XARELTO 2 QL
doxycycline XARELTO STARTER
1 2 QL
monohydrate oral tablet PACK
levofloxacin oral tablet 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
9Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Anticonvulsants - NAYZILAM 3 QL
Drugs for Seizures NEURONTIN E
BRIVIACT ONFI E
3
INTRAVENOUS
oxcarbazepine oral
BRIVIACT ORAL 3 ST 1
tablet
carbamazepine oral OXTELLAR XR E
1
tablet
QUDEXY XR E
CARBATROL E
SABRIL E SP
DEPAKOTE E
SYMPAZAN 3 PA
DEPAKOTE ER E
TEGRETOL E
DEPAKOTE
E TEGRETOL-XR E
SPRINKLES
DILANTIN INFATABS E TOPAMAX E
DILANTIN ORAL TOPAMAX SPRINKLE E
E
CAPSULE 100 MG topiramate oral tablet 1
DILANTIN ORAL TRILEPTAL E
E
SUSPENSION TROKENDI XR 3 ST
divalproex sodium er 1 VALTOCO 10 MG
3 QL
divalproex sodium oral DOSE
1
tablet delayed release VALTOCO 15 MG
3 QL
EPIDIOLEX 3 PA; SP DOSE
FYCOMPA 3 VALTOCO 20 MG
3 QL
gabapentin oral DOSE
1
capsule VALTOCO 5 MG
3 QL
gabapentin oral tablet 1 DOSE
KEPPRA ORAL E VIMPAT 3
KEPPRA XR E XCOPRI 3 ST
LAMICTAL E XCOPRI (250 MG
3 ST
DAILY DOSE)
LAMICTAL ODT E
XCOPRI (350 MG
LAMICTAL STARTER E 3 ST
DAILY DOSE)
LAMICTAL XR ORAL ZONEGRAN E
TABLET EXTENDED E
RELEASE 24 HOUR zonisamide oral 1
lamotrigine er 1
lamotrigine oral tablet 1
levetiracetam oral
1
tablet
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
10Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Antidementia Agents fluvoxamine maleate 1
- Drugs for FORFIVO XL E
Alzheimer's Disease
and Dementia LEXAPRO E
donepezil hcl oral tablet mirtazapine oral tablet 1
1
10 mg, 23 mg nortriptyline hcl oral
1
memantine hcl oral capsule
1
tablet 10 mg, 5 mg paroxetine hcl 1
NAMZARIC 2 QL PAXIL CR E
Antidepressants PAXIL ORAL TABLET E
amitriptyline hcl oral 1 PRISTIQ E
BRISDELLE E PROZAC E
bupropion hcl er (sr) 1 QL sertraline hcl oral tablet 1
bupropion hcl er (xl) trazodone hcl oral 1
oral tablet extended TRINTELLIX 3 ST; QL
1 QL
release 24 hour 150
mg, 300 mg venlafaxine hcl 1
BUPROPION HCL ER venlafaxine hcl er 1
(XL) ORAL TABLET VIIBRYD 3 QL
E M
EXTENDED RELEASE VIIBRYD STARTER
24 HOUR 450 MG 3 QL
PACK
bupropion hcl oral 1 WELLBUTRIN SR E
CELEXA E WELLBUTRIN XL E
citalopram ZOLOFT E
hydrobromide oral 1
tablet Antiemetics - Drugs
for Nausea and
CYMBALTA E Vomiting
desvenlafaxine meclizine hcl oral tablet 1
1 QL
succinate er
metoclopramide hcl
doxepin hcl oral 1
1 oral tablet 10 mg
capsule
ondansetron hcl oral
duloxetine hcl oral 1 QL 1
tablet 4 mg, 8 mg
EFFEXOR XR E ondansetron odt 1
escitalopram oxalate prochlorperazine
1 1
oral tablet maleate oral
fluoxetine hcl oral SANCUSO E
1
capsule
scopolamine 1
fluoxetine hcl oral tablet 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
11Drug Name Drug Tier Notes Drug Name Drug Tier Notes
VARUBI (180 MG AJOVY E
3 QL
DOSE) eletriptan hydrobromide 1 QL
Antifungals EMGALITY 2 PA; QL
ciclopirox external EMGALITY (300 MG
1 2 PA; QL
solution DOSE)
clotrimazole external IMITREX E
1
cream
IMITREX STATDOSE
clotrimazole- E
REFILL
betamethasone 1
external cream IMITREX STATDOSE
E
SYSTEM
CRESEMBA ORAL 3
MAXALT E
fluconazole oral tablet 1
MAXALT-MLT E
GYNAZOLE-1 3
NURTEC 2 PA; QL
JUBLIA E
ONZETRA XSAIL E
KERYDIN 3 PA
RELPAX E
ketoconazole external
1 REYVOW E
cream
ketoconazole external rizatriptan benzoate 1 QL
1
shampoo sumatriptan succinate
1 QL
nystatin external cream 1 oral
nystatin mouth/throat 1 TOSYMRA E
terbinafine hcl oral 1 QL TREXIMET E
terconazole vaginal UBRELVY 2 PA; QL
1
cream ZEMBRACE
E
TOLSURA E SYMTOUCH
Antigout Agents ZOMIG ORAL E
allopurinol oral 1 ZOMIG ZMT E
COLCHICINE ORAL Antineoplastics -
E Drugs for Cancer
CAPSULE
colchicine oral tablet 1 AFINITOR ORAL
TABLET 2.5 MG, 5 E SP
COLCRYS E MG, 7.5 MG
febuxostat 1 ST anastrozole oral 1
GLOPERBA E ARIMIDEX E
MITIGARE E BELRAPZO E SP
Antimigraine Agents BENDAMUSTINE HCL E SP
AIMOVIG 2 PA; QL CABOMETYX 2 PA; SP
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
12Drug Name Drug Tier Notes Drug Name Drug Tier Notes
capecitabine 1 PA; SP EMVERM 2
ERLEADA E SP hydroxychloroquine
1
GLEEVEC E SP sulfate oral
IBRANCE ORAL NATROBA E
3 PA; SP
CAPSULE PLAQUENIL E
IDHIFA 3 PA; SP; QL Antiparkinson Agents
imatinib mesylate 1 PA; SP benztropine mesylate
1
IMBRUVICA ORAL oral
3 PA; SP
TABLET carbidopa-levodopa
1
KANJINTI 2 PA; SP oral tablet
letrozole oral 1 GOCOVRI E
LYNPARZA 2 PA; SP INBRIJA 3 PA; SP
MVASI 2 PA; SP NOURIANZ 3 PA
NUBEQA 3 PA; SP OSMOLEX ER E
OGIVRI E SP pramipexole
1
dihydrochloride
REVLIMID 2 PA; SP
ropinirole hcl 1
RUBRACA 2 PA; SP
RYTARY 3 ST
RUXIENCE 2 PA; SP
Antiplatelets
SPRYCEL 2 PA; SP
ASPIRIN-
tamoxifen citrate oral 1 E M
OMEPRAZOLE
TARGRETIN BRILINTA 2
3 PA; SP
EXTERNAL
clopidogrel bisulfate
TARGRETIN ORAL E SP 1
oral
TAZVERIK E SP PLAVIX E
temozolomide 1 PA; SP prasugrel hcl 1
TRAZIMERA 2 PA; SP YOSPRALA E
TREANDA E SP Antipsychotics -
TRUXIMA E SP Drugs for Mood
Disorders
XTANDI 3 PA; SP
YONSA E SP ABILIFY E
ZEJULA 2 PA; SP aripiprazole oral tablet 1 QL
ZIRABEV 2 PA; SP ARISTADA 3
ZYTIGA E SP ARISTADA INITIO 3
Antiparasitics INVEGA SUSTENNA 3
ARAKODA 3 INVEGA TRINZA 3
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
13Drug Name Drug Tier Notes Drug Name Drug Tier Notes
LATUDA 3 QL oseltamivir phosphate
1 QL
olanzapine oral tablet 1 QL oral
PERSERIS 3 PREZCOBIX 2
quetiapine fumarate 1 QL SOFOSBUVIR-
E M; SP
VELPATASVIR
quetiapine fumarate er 1 QL
SYMFI 2
REXULTI 3 QL
SYMFI LO 2
RISPERDAL E
TAMIFLU E
risperidone oral tablet 1 QL
TEMIXYS E
SAPHRIS 2 QL
TIVICAY 2
SECUADO E
TRIUMEQ 2
SEROQUEL E
TRUVADA E
SEROQUEL XR E
valacyclovir hcl oral 1 QL
VRAYLAR 3 ST; QL
VALTREX E
ziprasidone hcl 1 QL
VEMLIDY 3 SP
ZYPREXA E
VOSEVI 2 PA; SP; QL
Antivirals
XOFLUZA (40 MG
acyclovir oral capsule 1 3 QL
DOSE)
acyclovir oral tablet 1 XOFLUZA (80 MG
3 QL
ATRIPLA E DOSE)
BARACLUDE ORAL ZOVIRAX EXTERNAL E
E SP
TABLET ZOVIRAX ORAL
E
BIKTARVY 3 SUSPENSION
CIMDUO 2 Anxiolytics - Drugs
for Anxiety
DESCOVY E
DOVATO 2 alprazolam oral tablet 1 QL
entecavir 1 SP; QL ATIVAN ORAL E
EPCLUSA 2 PA; SP; QL buspirone hcl oral 1
GENVOYA 3 clonazepam oral tablet 1 QL
HARVONI 2 PA; SP; QL diazepam oral tablet 1
JULUCA 2 hydroxyzine hcl oral
1
tablet
LEDIPASVIR-
E M; SP hydroxyzine pamoate
SOFOSBUVIR 1
oral
MAVYRET 2 PA; SP; QL
KLONOPIN E
ODEFSEY 3
lorazepam oral tablet 1 QL
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
14Drug Name Drug Tier Notes Drug Name Drug Tier Notes
triazolam 1 QL UDENYCA E SP
VALIUM E ULTOMIRIS 3 PA; SP
XANAX E ZARXIO 2 PA; SP
XANAX XR E ZIEXTENZO 3 PA; SP
Bipolar Agents - Cardiovascular
Drugs for Mood Agents - Drugs for
Disorders Heart and Circulation
lithium carbonate er 1 Conditions
lithium carbonate oral ALTACE E
1
capsule amiodarone hcl oral 1
Blood Products / amlodipine besylate
1
Modifiers / Volume oral
Expanders - Drugs for amlodipine besylate-
Bleeding Disorders 1
benazepril hcl
ADYNOVATE 3 SP amlodipine besylate-
1
AFSTYLA valsartan
INTRAVENOUS KIT amlodipine-olmesartan 1
1000 UNIT, 2000 UNIT, 3 SP
250 UNIT, 3000 UNIT, ATACAND E
500 UNIT atenolol oral 1
ARANESP (ALBUMIN atenolol-chlorthalidone 1
2 PA; SP
FREE) atorvastatin calcium
1
ELOCTATE 3 SP oral
EPOGEN E SP AVAPRO E
ESPEROCT E SP AZOR E
FULPHILA E SP benazepril hcl oral 1
GRANIX E SP BENICAR E
JIVI 3 SP BENICAR HCT E
MULPLETA 2 PA; SP bisoprolol fumarate 1
NEULASTA 3 PA; SP bisoprolol-
1
NEULASTA ONPRO 3 PA; SP hydrochlorothiazide
NEUPOGEN E SP bumetanide oral 1
NIVESTYM 2 PA; SP BYSTOLIC 2
NOVOEIGHT 3 SP candesartan cilexetil 1
NUWIQ 3 SP
PROCRIT E SP
RETACRIT 2 PA; SP
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
15Drug Name Drug Tier Notes Drug Name Drug Tier Notes
CARDIZEM LA ORAL EXFORGE E
TABLET EXTENDED EXFORGE HCT E
RELEASE 24 HOUR E
180 MG, 240 MG, 300 ezetimibe 1
MG, 360 MG, 420 MG ezetimibe-simvastatin 1
cartia xt 1 fenofibrate micronized
carvedilol 1 oral capsule 134 mg, 1
200 mg, 67 mg
CATAPRES-TTS-1 E
fenofibrate oral tablet 1
CATAPRES-TTS-2 E
fenofibric acid oral
CATAPRES-TTS-3 E capsule delayed 1
chlorthalidone 1 release
clonidine hcl oral 1 flecainide acetate 1
COLESTID E furosemide oral tablet 1
COLESTID gemfibrozil oral 1
E
FLAVORED guanfacine hcl 1
CONSENSI E HEMANGEOL 3
COREG E hydralazine hcl oral 1
COREG CR E hydrochlorothiazide
1
CORLANOR 3 PA; QL oral
COZAAR E HYZAAR E
CRESTOR E INDERAL LA E
digoxin oral tablet 1 INDERAL XL E
diltiazem hcl er coated INNOPRAN XL E
beads oral capsule irbesartan 1
1
extended release 24
hour irbesartan-
1
hydrochlorothiazide
dilt-xr 1
isosorbide mononitrate
DIOVAN E 1
er
DIOVAN HCT E KAPSPARGO
E
doxazosin mesylate SPRINKLE
1
oral KATERZIA E
DYAZIDE E labetalol hcl oral 1
EDARBI 3 ST LASIX E
EDARBYCLOR 3 ST LESCOL XL E
enalapril maleate oral 1 LIPITOR E
ENTRESTO 2 QL lisinopril oral 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
16Drug Name Drug Tier Notes Drug Name Drug Tier Notes
lisinopril- propranolol hcl er 1
1
hydrochlorothiazide propranolol hcl oral
1
LIVALO E tablet
losartan potassium oral 1 QUESTRAN E
losartan potassium-hctz 1 QUESTRAN LIGHT E
LOTREL E ramipril 1
lovastatin 1 RANEXA E
LOVAZA E ranolazine er 1
metoprolol succinate er 1 REPATHA 2 PA; QL
metoprolol tartrate oral 1 REPATHA
MICARDIS E PUSHTRONEX 2 PA; QL
SYSTEM
MICARDIS HCT E
REPATHA
MULTAQ 3 2 PA; QL
SURECLICK
nadolol oral 1 rosuvastatin calcium 1
NEXLETOL 2 PA; QL simvastatin oral 1
NEXLIZET 2 PA; QL sotalol hcl oral 1
NIASPAN E spironolactone oral 1
nifedipine er 1 TEKTURNA 2
nifedipine er osmotic TEKTURNA HCT 2 ST
1
release
telmisartan 1
nitroglycerin sublingual 1
telmisartan-hctz 1
NITROSTAT E
TENORMIN E
NORVASC E
TIKOSYN E
olmesartan medoxomil
1 TOPROL XL E
oral
olmesartan medoxomil- torsemide 1
1
hctz triamterene-hctz 1
olmesartan-amlodipine- TRIBENZOR E
1
hctz TRICOR E
omega-3-acid ethyl valsartan 1
1 PA
esters
valsartan-
PRALUENT 2 PA; QL 1
hydrochlorothiazide
PRAVACHOL E VASCEPA 2 PA
pravastatin sodium 1
prazosin hcl oral 1
PRINIVIL E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
17Drug Name Drug Tier Notes Drug Name Drug Tier Notes
verapamil hcl er oral JORNAY PM 3 PA; ST; QL
capsule extended methylphenidate hcl er
release 24 hour 120 1 (la) oral capsule
mg, 180 mg, 240 mg, extended release 24 1 PA; QL
360 mg hour 10 mg, 20 mg, 30
verapamil hcl er oral mg, 40 mg
1
tablet extended release METHYLPHENIDATE
3 PA; ST; QL
VYTORIN E HCL ER (XR)
WELCHOL E methylphenidate hcl er
ZESTRIL E oral tablet extended 1 PA; QL
release
ZETIA E
methylphenidate hcl
ZOCOR ORAL 1 PA; QL
oral tablet
TABLET 10 MG, 20 E
MG, 40 MG, 80 MG RITALIN E
ZYPITAMAG E RITALIN LA E
Central Nervous STRATTERA E
System Agents - VYVANSE 2 PA; QL
Drugs for Attention Central Nervous
Deficit Disorder System Agents -
ADDERALL E Drugs for Multiple
ADDERALL XR E Sclerosis
ADHANSIA XR E AMPYRA 3 PA; SP; QL
amphetamine- AUBAGIO 3 PA; SP; QL
1 PA; QL
dextroamphetamine AVONEX PEN 2 PA; SP; QL
amphetamine- AVONEX PREFILLED 2 PA; SP; QL
1 PA; QL
dextroamphetamine er BAFIERTAM 2 PA; SP; QL
atomoxetine hcl 1 QL BETASERON 2 PA; SP; QL
CONCERTA E COPAXONE 2 PA; SP; QL
dexmethylphenidate hcl EXTAVIA E SP
1 PA; QL
er
PA; 3P; SP;
dexmethylphenidate hcl GILENYA 3
1 PA; QL QL
oral tablet 10 mg, 5 mg
glatiramer acetate 1 PA; SP; QL
EVEKEO E
MAVENCLAD (10
EVEKEO ODT 3 PA; QL 3 PA; 3P; SP
TABS)
FOCALIN E MAVENCLAD (4
3 PA; 3P; SP
FOCALIN XR E TABS)
guanfacine hcl er 1 MAVENCLAD (5
3 PA; 3P; SP
INTUNIV E TABS)
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
18Drug Name Drug Tier Notes Drug Name Drug Tier Notes
MAVENCLAD (6 SAXENDA 3 PA
3 PA; 3P; SP
TABS) TEGSEDI 3 PA; SP
MAVENCLAD (7 TIGLUTIK 3 PA; SP; QL
3 PA; 3P; SP
TABS)
VYLEESI 3 PA; QL
MAVENCLAD (8
3 PA; 3P; SP Dental and Oral
TABS)
Agents - Drugs for
MAVENCLAD (9 Mouth and Throat
3 PA; 3P; SP
TABS) Conditions
PA; 3P; SP; chlorhexidine gluconate
MAYZENT 3 1
QL mouth/throat
PLEGRIDY E SP lidocaine viscous hcl 1
PLEGRIDY STARTER Dermatological
E SP
PACK Agents - Drugs for
REBIF E SP Skin Conditions
REBIF REBIDOSE E SP ABSORICA 3 PA
REBIF REBIDOSE ABSORICA LD 3 PA
E SP
TITRATION PACK ACANYA E
REBIF TITRATION ACZONE EXTERNAL
E SP E
PACK GEL 5 %
TECFIDERA 2 PA; SP; QL ACZONE EXTERNAL
2
VUMERITY 2 PA; SP; QL GEL 7.5 %
VUMERITY AKLIEF E
2 PA; SP; QL
(STARTER) ALA SCALP E
Central Nervous AMZEEQ 3
System Agents -
Miscellaneous APEXICON E E
ADDYI 3 PA; QL AVITA E
ADIPEX-P E BENZACLIN E
AUSTEDO 3 PA; SP; QL BENZACLIN WITH
E
PUMP
CONTRAVE E
BENZAMYCIN E
GRALISE 3 ST; QL
betamethasone
HORIZANT 3 PA; QL dipropionate external 1
LYRICA E cream
phentermine hcl oral BRYHALI 3
1 PA
tablet CALCIPOTRIENE
E M
pregabalin oral capsule 1 QL EXTERNAL FOAM
QSYMIA 3 PA CAPEX E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
19Drug Name Drug Tier Notes Drug Name Drug Tier Notes
claravis 1 PA ELIDEL E
CLINDAGEL E ENSTILAR 3 QL
clindamycin phosphate- EPIDUO E
benzoyl peroxide 1 EPIDUO FORTE 3
external gel 1-5 %
EUCRISA 2 ST
clindamycin phosphate
1 FINACEA EXTERNAL
external lotion 3
FOAM
clindamycin phosphate
1 FINACEA EXTERNAL
external solution 3 ST
GEL
clindamycin phosphate
1 fluocinonide external
external swab 1
cream
CLINDAMYCIN
PHOSPHATE GEL 1 % E M FLUOROPLEX 3
EXTERNAL HALOBETASOL
clindamycin phosphate PROPIONATE E M
1 EXTERNAL FOAM
gel 1 % external
clobetasol propionate HALOG EXTERNAL
1 E
external cream CREAM
clobetasol propionate HALOG EXTERNAL
1 E
external ointment OINTMENT
clobetasol propionate hydrocortisone external
1 1
external solution cream
CLOBEX E hydrocortisone external
1
ointment
CLOBEX SPRAY E
IMIQUIMOD PUMP
CLODERM E CREAM 3.75 % E
CORDRAN EXTERNAL
E
EXTERNAL TAPE IMIQUIMOD PUMP
DESONATE E CREAM 3.75 % E M
DIFFERIN EXTERNAL EXTERNAL
E
CREAM IMPOYZ E
DIFFERIN EXTERNAL KENALOG EXTERNAL E
E
GEL 0.3 % LEXETTE E
DIFFERIN EXTERNAL METROGEL E
E
LOTION
metronidazole external
DUOBRII E 1
cream
DUPIXENT metronidazole external
SUBCUTANEOUS 1
2 PA; SP; QL gel
SOLUTION
PREFILLED SYRINGE MIRVASO 3
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
20Drug Name Drug Tier Notes Drug Name Drug Tier Notes
mometasone furoate TRIANEX E
1
external cream ULTRAVATE E
NORITATE E VECTICAL E
ONEXTON 3 VELTIN E
ORACEA E VERDESO E
PANDEL E ZIANA E
PROPECIA E ZYCLARA E
PSORCON E ZYCLARA PUMP E
QBREXZA 3 QL Diabetes -
RETIN-A E Antidiabetic Agents
RETIN-A MICRO GEL ADLYXIN E
E
0.04 %, 0.1 % ADLYXIN STARTER
E
RETIN-A MICRO PACK
PUMP EXTERNAL E ALOGLIPTIN
GEL 0.04 %, 0.1 % E M
BENZOATE
RETIN-A MICRO ALOGLIPTIN-
PUMP EXTERNAL 2 PA E M
METFORMIN HCL
GEL 0.06 %, 0.08 %
ALOGLIPTIN-
RHOFADE 3 E M
PIOGLITAZONE
SERNIVO 3 BYDUREON 2 ST; QL
SOOLANTRA 3 BYDUREON BCISE
2 ST; QL
SORILUX E AUTOINJECTOR
TACLONEX BYETTA 10 MCG PEN 2 ST; QL
EXTERNAL E BYETTA 5 MCG PEN 2 ST; QL
OINTMENT
FARXIGA 2 ST
TACLONEX
EXTERNAL 3 QL FORTAMET E
SUSPENSION glimepiride 1
tacrolimus external glipizide er 1
1
ointment glipizide ir 1
TAZORAC EXTERNAL GLUMETZA E
E
CREAM 0.1 %
glyburide oral 1
TOPICORT SPRAY E
GLYXAMBI 2 ST
tretinoin external cream 1 PA
INVOKAMET E
triamcinolone acetonide
1 INVOKAMET XR E
external cream
triamcinolone acetonide INVOKANA E
1
external ointment JANUMET 2 ST
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
21Drug Name Drug Tier Notes Drug Name Drug Tier Notes
JANUMET XR 2 ST Diabetes - Glucose
JANUVIA 2 ST Monitoring
JARDIANCE 2 ST ACCU-CHEK
FASTCLIX LANCET 2
JENTADUETO 2 ST KIT
JENTADUETO XR 2 ST ACCU-CHEK GUIDE
E
KAZANO E TEST STRIPS
KOMBIGLYZE XR E ACCU-CHEK GUIDE
E
metformin hcl er 1 KIT W/DEVICE
metformin hcl er (mod) E ACCU-CHEK
SOFTCLIX LANCET 2
metformin hcl er (osm) E DEVICE KIT
metformin hcl oral CONTOUR MONITOR 2
1
tablet
CONTOUR CONTROL 2
NESINA E
CONTOUR NEXT
ONGLYZA E 2
CONTROL
OSENI E CONTOUR NEXT
2
OZEMPIC 2 ST; QL MONITOR
pioglitazone hcl 1 CONTOUR NEXT
2 QL
QTERN E TEST
RYBELSUS 2 ST; QL CONTOUR TEST 2 QL
SEGLUROMET E DEXCOM G4 / G5 / G6
RECEIVER,
SOLIQUA 2 ST; QL TRANSMITTER,
STEGLATRO E SENSOR (INCLUDING 2
STEGLUJAN E PLATINUM,
PLATINUM
SYMLINPEN 120 3 PA PEDIATRIC)
SYMLINPEN 60 3 PA DEXCOM G4 / G5 / G6
SYNJARDY 2 ST RECEIVER,
SYNJARDY XR 2 ST TRANSMITTER,
SENSOR (INCLUDING 2
TRADJENTA 2 ST PLATINUM,
TRIJARDY XR 2 ST PLATINUM
TRULICITY 2 ST; QL PEDIATRIC) DEVICE
VICTOZA 2 ST; QL FREESTYLE LIBRE 14
E
DAY READER
XIGDUO XR 2 ST
FREESTYLE LIBRE 14
E
DAY SENSOR
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
22Drug Name Drug Tier Notes Drug Name Drug Tier Notes
FREESTYLE LIBRE 2 BD VEO INSULIN SYR
E 2
READER SYSTM U/F 1/2UNIT
FREESTYLE LIBRE 2 FIASP E
E
SENSOR SYSTM FIASP FLEXTOUCH E
FREESTYLE LIBRE FIASP PENFILL E
E
READER
HUMALOG KWIKPEN 2
FREESTYLE LIBRE
E HUMALOG MIX 50/50
SENSOR SYSTEM 2
KWIKPEN
ONETOUCH ULTRA E
HUMALOG MIX 50/50
ONETOUCH VERIO 2
E VIAL
TEST STRIPS
HUMALOG MIX 75/25
V-GO 20 2 2
KWIKPEN
V-GO 30 2 HUMALOG MIX 75/25
2
V-GO 40 2 VIAL
Diabetes - Glycemic HUMALOG U-100
Agents 2
JUNIOR KWIKPEN
BAQSIMI ONE PACK 2 HUMALOG VIAL 2
BAQSIMI TWO PACK 2 HUMULIN 70/30
2
GLUCAGON KWIKPEN
2 Made by Lilly
EMERGENCY KIT HUMULIN 70/30 VIAL 2
GLUCAGON Made by HUMULIN N KWIKPEN 2
2
EMERGENCY KIT Fresenius HUMULIN N VIAL 2
GVOKE PFS 2 HUMULIN R U-500
2
Diabetes - Insulins KWIKPEN
ADMELOG E HUMULIN R U-500
2
ADMELOG VIAL
E
SOLOSTAR HUMULIN R VIAL 2
APIDRA SOLOSTAR E INSULIN ASP PROT &
E M
APIDRA VIAL E ASP FLEXPEN
BASAGLAR KWIKPEN E INSULIN ASPART E M
BD AUTOSHIELD DUO INSULIN ASPART
2 E M
PEN NEEDLES FLEXPEN
BD ULTRA-FINE INSULIN ASPART
2 E M
INSULIN SYRINGES PENFILL
BD ULTRA-FINE PEN INSULIN ASPART
2 E M
NEEDLES PROT & ASPART
INSULIN LISPRO E M
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
23Drug Name Drug Tier Notes Drug Name Drug Tier Notes
INSULIN LISPRO (1 NOVOLOG MIX 70/30
E M E
UNIT DIAL) VIAL
INSULIN LISPRO NOVOLOG PENFILL E
E M
JUNIOR KWIKPEN NOVOLOG U-100 VIAL E
INSULIN LISPRO NOVOTWIST PEN
E M 2
PROT & LISPRO NEEDLE
LANTUS SOLOSTAR 2 TOUJEO MAX
2
LANTUS U-100 VIAL 2 SOLOSTAR
LEVEMIR U-100 TOUJEO SOLOSTAR 2
E
FLEXTOUCH TRESIBA E
LEVEMIR U-100 VIAL E TRESIBA
E
NOVOFINE FLEXTOUCH
AUTOCOVER PEN 2 Electrolytes / Minerals
NEEDLE / Metals / Vitamins
NOVOFINE PEN AZESCO E
2
NEEDLE
CARNITOR ORAL E
NOVOFINE PLUS PEN
2 CARNITOR SF E
NEEDLE
NOVOLIN 70/30 cyanocobalamin
E injection solution 1000 1
FLEXPEN
mcg/ml
NOVOLIN 70/30
E ergocalciferol oral
FLEXPEN RELION 1
capsule
NOVOLIN 70/30
E folic acid oral tablet 1
RELION
NOVOLIN 70/30 VIAL E klor-con m20 1
NOVOLIN N FLEXPEN E K-TAB E
NOVOLIN N FLEXPEN LOKELMA 3
E
RELION multivitamin/fluoride
NOVOLIN N RELION E oral tablet chewable 1
0.25 mg, 0.5 mg, 1 mg
NOVOLIN N VIAL E
NASCOBAL 3
NOVOLIN R FLEXPEN E
potassium chloride crys
NOVOLIN R FLEXPEN 1
E er
RELION
potassium chloride er 1
NOVOLIN R RELION E
potassium citrate er 1
NOVOLIN R VIAL E
PREGENNA E
NOVOLOG FLEXPEN E
PRENATE DHA E
NOVOLOG MIX 70/30
E PRENATE ELITE E
FLEXPEN
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
24Drug Name Drug Tier Notes Drug Name Drug Tier Notes
PRENATE ENHANCE E omeprazole oral
PRENATE ESSENTIAL E capsule delayed 1 QL
release
PRENATE MINI E
omeprazole-sodium
PRENATE PIXIE E E
bicarbonate
PRENATE RESTORE E pantoprazole sodium
sodium fluoride oral oral tablet delayed 1 QL
1
tablet chewable release
TRINAZ E PREVACID E
VELTASSA 3 PREVACID SOLUTAB E
VITAFOL FE+ E PROTONIX ORAL
VITAFOL-OB+DHA E TABLET DELAYED E
RELEASE
vitamin d
(ergocalciferol) oral RABEPRAZOLE
1 SODIUM ORAL E M
capsule 1.25 mg
(50000 ut) CAPSULE SPRINKLE
VITATHELY WITH rabeprazole sodium
E oral tablet delayed 1 QL
GINGER
release
ZALVIT E
sucralfate oral tablet 1
Gastrointestinal
Agents - Drugs for ZEGERID E
Acid Reflux and Ulcer Gastrointestinal
Agents - Drugs for
ACIPHEX E
Bowel, Intestine and
CARAFATE ORAL Stomach Conditions
E
TABLET
AMITIZA E
DEXILANT 2 QL
CLENPIQ 3
esomeprazole
magnesium oral dicyclomine hcl oral
1 QL 1
capsule delayed capsule
release dicyclomine hcl oral
1
famotidine oral tablet 1 tablet
lansoprazole oral diphenoxylate-atropine
1
capsule delayed 1 QL oral tablet
release gavilyte-g 1
NEXIUM ORAL glycopyrrolate oral
1
CAPSULE DELAYED E tablet 1 mg, 2 mg
RELEASE GLYCOPYRROLATE
3
ORAL TABLET 1.5 MG
GOLYTELY E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
25Drug Name Drug Tier Notes Drug Name Drug Tier Notes
hyoscyamine sulfate sl 1 STRENSIQ
hyoscyamine sulfate SUBCUTANEOUS
1 SOLUTION 28 2 PA; SP
sublingual
MG/0.7ML, 40 MG/ML,
lactulose oral solution 1 80 MG/0.8ML
LINZESS 2 ST; QL VIOKACE E
MOTEGRITY 3 ST; QL VYONDYS 53 E SP
MOTOFEN E ZENPEP 2
MOVANTIK E Genitourinary Agents
MOVIPREP E - Drugs for Bladder,
Genital and Kidney
NULYTELY WITH
E Conditions
FLAVOR PACKS
OMECLAMOX-PAK 2 AURYXIA 3
OSMOPREP E CIALIS E
PLENVU E DEPEN TITRATABS 2 SP
PYLERA 2 LEVITRA E
RELISTOR E MYRBETRIQ 2
SUPREP BOWEL oxybutynin chloride er 1
3
PREP KIT oxybutynin chloride oral
1
SYMPROIC 2 ST; QL tablet
TRULANCE E phenazopyridine hcl
oral tablet 100 mg, 200 1
VIBERZI 3 PA; QL mg
ZELNORM 3 PA; QL RENAGEL E
Genetic or Enzyme sildenafil citrate oral
Disorder - Drugs for tablet 100 mg, 25 mg, 1 QL
Replacement, 50 mg
Modification,
Treatment solifenacin succinate 1
CERDELGA 3 PA; SP STAXYN E
CREON 2 STENDRA E
EXONDYS 51 E SP tadalafil oral 1 QL
NITYR 3 PA; SP tolterodine tartrate er 1
PANCREAZE E TOVIAZ 3
PERTZYE E VELPHORO 3
VESICARE E
VIAGRA E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
26Drug Name Drug Tier Notes Drug Name Drug Tier Notes
Genitourinary Agents ANDROGEL E
- Drugs for Prostate ANDROGEL PUMP E
Conditions
AVEED E
alfuzosin hcl er 1
DEPO-
AVODART E E
TESTOSTERONE
dutasteride oral 1 FORTESTA E
finasteride oral tablet 5 JATENZO E
1
mg
NATESTO E
FLOMAX E
TESTIM E
tamsulosin hcl 1
TESTOPEL E
terazosin hcl oral
capsule 1 mg, 10 mg, 5 1 testosterone cypionate
1 PA
mg intramuscular
Hormonal Agents - testosterone
Adrenal transdermal gel 1.62 %,
10 mg/act (2%), 20.25
CORTEF E mg/1.25gm (1.62%),
dexamethasone oral 20.25 mg/act (1.62%), 1 PA
1
tablet 25 mg/2.5gm (1%),
hydrocortisone oral 1 40.5 mg/2.5gm
(1.62%), 50 mg/5gm
KENALOG INJECTION (1%)
SUSPENSION 40 E
MG/ML VOGELXO E
methylprednisolone VOGELXO PUMP E
1
oral XYOSTED 3 PA
prednisolone oral Hormonal Agents -
1 Osteoporosis
solution
prednisolone sodium OSPHENA 3
1
phosphate oral solution Hormonal Agents -
prednisone oral tablet 1 Pituitary
prednisone oral tablet ACTHAR 2 PA; SP
1
therapy pack cabergoline 1
RAYOS E CETROTIDE E SP
TAPERDEX 12-DAY 3 FOLLISTIM AQ 2 PA; SP
TAPERDEX 6-DAY 3 ganirelix acetate
TAPERDEX 7-DAY 3 solution prefilled
1 PA; SP
Hormonal Agents - syringe 250 mcg/0.5ml
Men's Health subcutaneous
ANDRODERM 2 PA
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
27Drug Name Drug Tier Notes Drug Name Drug Tier Notes
ganirelix acetate SAIZEN E SP
PA; Made by
solution prefilled SAIZENPREP E SP
1 Organon/Merc
syringe 250 mcg/0.5ml
k; SP SANDOSTATIN E SP
subcutaneous
GENOTROPIN E SP ZOMACTON E SP
GENOTROPIN ZOMACTON (FOR
E SP E SP
MINIQUICK ZOMA-JET 10)
GONAL-F E SP Hormonal Agents -
Sex Hormones and
GONAL-F RFF E SP Birth Control
GONAL-F RFF ANNOVERA E
E SP
REDIJECT
apri 1
HUMATROPE E SP
aviane 1
LUPRON DEPOT (1-
MONTH) BEYAZ E
2 PA; SP
INTRAMUSCULAR KIT BIJUVA 3
7.5 MG blisovi 24 fe 1
LUPRON DEPOT (3- blisovi fe 1.5/30 1
MONTH)
2 PA; SP blisovi fe 1/20 1
INTRAMUSCULAR KIT
22.5 MG CLIMARA E
LUPRON DEPOT (4- CLIMARA PRO 2
MONTH) cryselle-28 1
2 PA; SP
INTRAMUSCULAR KIT
30MG DELESTROGEN
INTRAMUSCULAR OIL E
LUPRON DEPOT (6- 20 MG/ML, 40 MG/ML
MONTH)
2 PA; SP DIVIGEL 3
INTRAMUSCULAR KIT
45MG dotti 1
NOCDURNA 3 drospirenone-ethinyl
1
NORDITROPIN estradiol
2 PA; SP
FLEXPRO DUAVEE 2
NUTROPIN AQ ELESTRIN 3
2 PA; SP
NUSPIN 10 eluryng 1
NUTROPIN AQ ENDOMETRIN 2
2 PA; SP
NUSPIN 20
enskyce 1
NUTROPIN AQ
2 PA; SP estarylla 1
NUSPIN 5
OMNITROPE E SP ESTRACE E
ORILISSA 2 PA; QL estradiol oral 1
estradiol transdermal 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
28Drug Name Drug Tier Notes Drug Name Drug Tier Notes
estradiol vaginal 1 LOESTRIN FE 1/20 E
ESTROGEL 3 low-ogestrel 1
etonogestrel-ethinyl MAKENA 2 PA; SP
1
estradiol medroxyprogesterone
1 QL
EVAMIST 3 acetate intramuscular
femynor 1 medroxyprogesterone
1
GENERESS FE E acetate oral
gianvi 1 microgestin fe 1/20 1
IMVEXXY MINASTRIN 24 FE E
3
MAINTENANCE PACK MIRENA (52 MG) 3
IMVEXXY STARTER mono-linyah 1
3
PACK NATAZIA 2
isibloom 1 nikki 1
junel 1.5/30 1 norethindrone acetate
1
junel 1/20 1 oral
junel fe 1.5/30 1 norethindrone acet-
1
junel fe 1/20 1 ethinyl est
junel fe 24 1 norethindrone oral 1
kariva 1 norgestimate-ethinyl
1
estradiol triphasic
kurvelo 1
nortrel 1/35 (21) 1
larin fe 1/20 1
nortrel 1/35 (28) 1
larissia 1
NUVARING 3
lessina 1
ORTHO MICRONOR E
levonorgest-eth est &
1 QL PREMARIN ORAL 2
eth est
levonorgest-eth estrad PREMARIN VAGINAL 2
91-day oral tablet 0.15- PREMPHASE 2
1 QL
0.03 &0.01 mg, 0.15- PREMPRO 2
0.03 mg
progesterone
levonorgestrel-ethinyl 1
micronized oral
estrad oral tablet 0.1-20
1 PROMETRIUM E
mg-mcg, 0.15-30 mg-
mcg SAFYRAL E
LO LOESTRIN FE E SEASONIQUE E
LOESTRIN 1.5/30 (21) E SLYND E
LOESTRIN 1/20 (21) E sprintec 28 1
LOESTRIN FE 1.5/30 E sronyx 1
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
29Drug Name Drug Tier Notes Drug Name Drug Tier Notes
syeda 1 Immunological
TAYTULLA 3 Agents - Drugs for
Immune System
tri femynor 1 Stimulation or
tri-lo-marzia 1 Suppression
tri-lo-sprintec 1 ACTEMRA ACTPEN 3 PA; 3P; SP
tri-previfem 1 ACTEMRA
3 PA; 3P; SP
tri-sprintec 1 SUBCUTANEOUS
VAGIFEM E ASCENIV E SP
vienva 1 azathioprine oral 1
viorele 1 CIMZIA 2 PA; SP
VIVELLE-DOT E CIMZIA PREFILLED
2 PA; SP
KIT
xulane 1
CIMZIA STARTER KIT 2 PA; SP
YASMIN 28 E
COSENTYX (300 MG
YAZ E E SP
DOSE)
Hormonal Agents - COSENTYX 150
Thyroid E SP
MG/ML
ARMOUR THYROID 3 ST COSENTYX
CYTOMEL E SENSOREADY (300 E SP
euthyrox 1 MG)
levothyroxine sodium COSENTYX
1 E SP
oral SENSOREADY PEN
levoxyl 1 CUTAQUIG E SP
liothyronine sodium oral 1 cyclosporine modified
1 SP
oral capsule
methimazole oral 1
ENBREL MINI 3 PA; SP
NATURE-THROID
ORAL TABLET 113.75 ENBREL
MG, 130 MG, 146.25 SUBCUTANEOUS
3 PA; SP
MG, 16.25 MG, 195 SOLUTION
3 ST PREFILLED SYRINGE
MG, 260 MG, 32.5 MG,
325 MG, 48.75 MG, 65 ENBREL SURECLICK 3 PA; SP
MG, 81.25 MG, 97.5 FIRAZYR 3 PA; SP; QL
MG
HAEGARDA 3 PA; SP
np thyroid oral tablet 60
1 HUMIRA 2 PA; SP
mg
SYNTHROID E HUMIRA PEDIATRIC
2 PA; SP
CROHNS START
TIROSINT E
HUMIRA PEN 2 PA; SP
TIROSINT-SOL E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
30Drug Name Drug Tier Notes Drug Name Drug Tier Notes
HUMIRA PEN- STELARA
2 PA; SP 2 PA; SP
CD/UC/HS STARTER INTRAVENOUS
HUMIRA PEN- STELARA
2 PA; SP; QL
PS/UV/ADOL HS 2 PA; SP SUBCUTANEOUS
START tacrolimus oral 1 SP
INFLECTRA 2 PA; SP TAKHZYRO 3 PA; SP
leflunomide oral 1 TALTZ 3 PA; 3P; SP
methotrexate oral 1 TREMFYA 2 PA; SP
methotrexate sodium XELJANZ 2 PA; SP
1
oral
XELJANZ XR 2 PA; SP
mycophenolate mofetil
1 SP XEMBIFY 3 PA; SP
oral capsule
mycophenolate mofetil Inflammatory Bowel
1 SP Disease Agents
oral tablet
mycophenolate sodium 1 SP APRISO 2
OLUMIANT E SP ASACOL HD E
ORENCIA CLICKJECT 3 PA; 3P; SP CANASA E
ORENCIA DELZICOL E
SUBCUTANEOUS DIPENTUM E
SOLUTION 3 PA; 3P; SP LIALDA E
PREFILLED SYRINGE
125 MG/ML mesalamine oral tablet
1
delayed release
OTEZLA 2 PA; SP
PENTASA 3
PANZYGA E SP
PROCTOFOAM HC 2
PROGRAF ORAL
3 SP sulfasalazine oral tablet 1
CAPSULE
RASUVO 2 PA; QL UCERIS ORAL E
REMICADE E SP UCERIS RECTAL 3
RENFLEXIS 2 PA; SP Metabolic Bone
Disease Agents -
RINVOQ 2 PA; SP Drugs for
RUCONEST 3 PA; SP; QL Osteoporosis
SIMPONI 2 PA; SP alendronate sodium
1
SIMPONI ARIA 2 PA; SP oral tablet 10 mg, 5 mg
sirolimus oral tablet 1 SP alendronate sodium
oral tablet 35 mg, 70 1 QL
SKYRIZI (150 MG mg
2 PA; SP
DOSE)
BINOSTO 3 QL
FORTEO 2 PA; SP
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
31Drug Name Drug Tier Notes Drug Name Drug Tier Notes
ibandronate sodium PALFORZIA (240 MG
1 QL E SP
oral DAILY DOSE)
PROLIA 2 PA; SP; QL PALFORZIA (3 MG
E SP
RAYALDEE 3 DAILY DOSE)
TYMLOS 2 PA; SP PALFORZIA (300 MG
E SP
MAINTENANCE)
Metabolic Bone
Disease Agents - PALFORZIA (300 MG
E SP
Other TITRATION)
calcitriol oral capsule 1 PALFORZIA (40 MG
E SP
DAILY DOSE)
SENSIPAR E
PALFORZIA (6 MG
Miscellaneous E SP
DAILY DOSE)
Therapeutic Agents
PALFORZIA (80 MG
PA; Non- E SP
BOTOX 2 DAILY DOSE)
Cosmetic; SP
PALFORZIA INITIAL
DUROLANE 2 PA; SP E SP
ESCALATION
ENDARI 3 PA SODIUM
EUFLEXXA 2 PA; SP HYALURONATE E SP
FIRDAPSE E SP INTRA-ARTICULAR
GEL-ONE E SP SUPARTZ FX E SP
GELSYN-3 2 PA; SP SYNVISC E SP
GENVISC 850 E SP SYNVISC ONE E SP
HYALGAN E SP TRILURON E SP
HYMOVIS E SP TRIVISC E SP
MONOVISC E SP VISCO-3 E SP
Ophthalmic Agents -
ORTHOVISC E SP
Drugs for Eye Allergy,
OXBRYTA E SP Infection and
PALFORZIA (12 MG Inflammation
E SP
DAILY DOSE) AZASITE 3
PALFORZIA (120 MG BESIVANCE 3
E SP
DAILY DOSE)
BROMSITE E
PALFORZIA (160 MG
E SP ciprofloxacin hcl
DAILY DOSE) 1
ophthalmic
PALFORZIA (20 MG
E SP erythromycin
DAILY DOSE) 1
ophthalmic
PALFORZIA (200 MG
E SP ILEVRO E
DAILY DOSE)
INVELTYS 3
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
32Drug Name Drug Tier Notes Drug Name Drug Tier Notes
ketorolac tromethamine BETIMOL 3
1
ophthalmic brimonidine tartrate
1
LOTEMAX ophthalmic
3 QL
OPHTHALMIC GEL COMBIGAN 2
LOTEMAX COSOPT E
OPHTHALMIC 3 QL
OINTMENT COSOPT PF E
LOTEMAX dorzolamide hcl-timolol
1
OPHTHALMIC E mal
SUSPENSION latanoprost ophthalmic 1
LOTEMAX SM 3 LUMIGAN 2 QL
MOXEZA 2 RHOPRESSA 3 QL
MOXIFLOXACIN HCL ROCKLATAN 3 QL
INTRAOCULAR 3 SIMBRINZA 2
SOLUTION
timolol maleate
moxifloxacin hcl 1
1 ophthalmic solution
ophthalmic
TIMOPTIC E
NEVANAC E
TIMOPTIC OCUDOSE E
ofloxacin ophthalmic 1
TIMOPTIC-XE E
olopatadine hcl
1 VYZULTA E
ophthalmic
PATADAY XALATAN E
OPHTHALMIC 3 ZIOPTAN E
SOLUTION 0.2 % Ophthalmic Agents -
PAZEO E Drugs for
PRED FORTE E Miscellaneous Eye
Conditions
prednisolone acetate
1 BEOVU E SP
ophthalmic
PROLENSA 2 QL CEQUA E
VIGAMOX E LATISSE E
Ophthalmic Agents - polymyxin b-
1
Drugs for Glaucoma trimethoprim
ALPHAGAN P RESTASIS 2 PA
OPHTHALMIC 2 RESTASIS
2 PA
SOLUTION 0.1 % MULTIDOSE
ALPHAGAN P TOBRADEX
OPHTHALMIC E OPHTHALMIC E
SOLUTION 0.15 % SUSPENSION
AZOPT 2
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
33Drug Name Drug Tier Notes Drug Name Drug Tier Notes
tobramycin- NUCALA 2 PA; SP; QL
1
dexamethasone OMNARIS 3 QL
XIIDRA 2 PA promethazine hcl oral
Otic Agents - Drugs 1
tablet
for Ear Conditions promethazine-codeine 1 PA; QL
CIPRODEX 2 promethazine-dm 1
neomycin-polymyxin-hc pseudoephedrine-
1
otic suspension bromphen-dm oral 1
ofloxacin otic 1 syrup
OTOVEL 3 QNASL 3 QL
Respiratory Tract / QNASL CHILDRENS 3 QL
Pulmonary Agents - XHANCE E
Drugs for Allergies,
Cough, Cold XOLAIR 2 PA; SP
azelastine hcl nasal 1 QL ZETONNA 3 QL
benzonatate 1 Respiratory Tract /
Pulmonary Agents -
cetirizine hcl oral Drugs for Asthma and
1
solution Other Lung
CLARINEX E Conditions
CLARINEX-D 12 ADVAIR DISKUS 2 QL
E
HOUR ADVAIR HFA 2 QL
cyproheptadine hcl oral AIRDUO RESPICLICK
1 E
tablet 113/14
DYMISTA 2 QL AIRDUO RESPICLICK
E
FASENRA 2 PA; SP 232/14
FASENRA PEN 2 PA; SP AIRDUO RESPICLICK
E
fluticasone propionate 55/14
1
nasal albuterol sulfate hfa
hydrocodone polst- aerosol solution 108
1 PA; QL 1 QL
chlorphen polst er susp (90 base) mcg/act
inhalation
ipratropium bromide
1 ALBUTEROL
nasal
SULFATE HFA
levocetirizine AEROSOL SOLUTION
dihydrochloride oral 1 E M
108 (90 BASE)
tablet MCG/ACT
mometasone furoate INHALATION
1 QL
nasal albuterol sulfate
1 QL
NASONEX E inhalation
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
34Drug Name Drug Tier Notes Drug Name Drug Tier Notes
ALVESCO E fluticasone-salmeterol
ANORO ELLIPTA 2 QL inhalation aerosol
powder breath
ARNUITY ELLIPTA 2 QL activated 100-50 1 QL
ASMANEX (120 mcg/dose, 250-50
E
METERED DOSES) mcg/dose, 500-50
ASMANEX (14 mcg/dose
E
METERED DOSES) INCRUSE ELLIPTA E
ASMANEX (30 ipratropium-albuterol 1 QL
E
METERED DOSES) LEVALBUTEROL HFA
ASMANEX (60 INHALATION
E E M
METERED DOSES) AEROSOL 45
ASMANEX (7 MCG/ACT
E
METERED DOSES) LONHALA MAGNAIR
3 QL
ASMANEX HFA E REFILL KIT
ATROVENT HFA 3 QL LONHALA MAGNAIR
3 QL
STARTER KIT
AUVI-Q INJECTION
SOLUTION AUTO- montelukast sodium
1
INJECTOR 0.15 E oral tablet
MG/0.15ML, 0.3 montelukast sodium
1
MG/0.3ML oral tablet chewable
BEVESPI PERFOROMIST 3 QL
E
AEROSPHERE PROAIR DIGIHALER E
BREO ELLIPTA 2 QL PROAIR HFA E
budesonide inhalation 1 QL PROAIR RESPICLICK E
BUDESONIDE- PROVENTIL HFA E
FORMOTEROL E M
FUMARATE PULMICORT
2 QL
FLEXHALER
COMBIVENT
2 QL PULMICORT
RESPIMAT E
SUSPENSION
DUAKLIR PRESSAIR E
QVAR REDIHALER E
DULERA E
SEEBRI NEOHALER E
epinephrine injection
1 SEREVENT DISKUS 2 QL
solution auto-injector
EPIPEN 2-PAK 3 ST SINGULAIR E
EPIPEN JR 2-PAK E SPIRIVA
2 QL
HANDIHALER
FLOVENT DISKUS 2 QL
SPIRIVA RESPIMAT 2 QL
FLOVENT HFA 2 QL
STIOLTO RESPIMAT 2 QL
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
35Drug Name Drug Tier Notes Drug Name Drug Tier Notes
STRIVERDI REMODULIN E SP
2 QL
RESPIMAT sildenafil citrate oral
1 PA; SP; QL
SYMBICORT 2 QL tablet 20 mg
SYMJEPI 3 TRACLEER 62.5 MG,
E SP
TRELEGY ELLIPTA 2 QL 125 MG
TUDORZA PRESSAIR E Skeletal Muscle
Relaxants - Drugs for
UTIBRON NEOHALER E Muscle Pain and
VENTOLIN HFA E Spasm
wixela inhub 1 QL AMRIX E
XOPENEX HFA E baclofen oral 1
YUPELRI 3 QL carisoprodol oral 1
Respiratory Tract / cyclobenzaprine hcl
1
Pulmonary Agents - oral
Drugs for Cystic LORZONE 3
Fibrosis
metaxalone 1
BETHKIS 2 SP
methocarbamol oral 1
KITABIS PAK E SP
NORGESIC FORTE E
PULMOZYME 2 PA; SP
ORPHENGESIC
TOBI NEBULIZER E SP E
FORTE
TOBI PODHALER 3 SP; QL OZOBAX E
tobramycin nebulization SKELAXIN E
solution 300 mg/5ml 1 SP
inhalation SOMA E
TOBRAMYCIN tizanidine hcl oral tablet 1
NEBULIZATION VANADOM E
E M; SP
SOLUTION 300 ZANAFLEX E
MG/5ML INHALATION
Sleep Disorder
TRIKAFTA 3 PA; SP; QL Agents
Respiratory Tract / AMBIEN E
Pulmonary Agents -
Drugs for Pulmonary AMBIEN CR E
Hypertension armodafinil 1 PA; QL
ADCIRCA E SP eszopiclone 1 QL
ADEMPAS 2 PA; SP; QL LUNESTA E
LETAIRIS E SP modafinil 1 PA; QL
OPSUMIT 2 PA; SP; QL NUVIGIL E
ORENITRAM 3 PA; SP PROVIGIL E
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
36Drug Name Drug Tier Notes
RESTORIL E
SILENOR 3 QL
SUNOSI 2 PA; QL
temazepam 1 QL
WAKIX 3 PA; SP; QL
XYREM 3 PA; SP; QL
zolpidem tartrate er 1 QL
zolpidem tartrate oral 1 QL
For more information regarding the tiers and designations in this drug list, please see the Reading your
formulary section of this booklet.
37Index of Drugs
ABILIFY.....................................13 ALOGLIPTIN-PIOGLITAZONE. 21 ASMANEX (14 METERED
ABSORICA............................... 19 ALPHAGAN P........................... 33 DOSES).................................... 35
ABSORICA LD..........................19 alprazolam................................ 14 ASMANEX (30 METERED
ACANYA................................... 19 ALTACE.................................... 15 DOSES).................................... 35
ACCU-CHEK FASTCLIX ALVESCO................................. 35 ASMANEX (60 METERED
LANCET KIT............................. 22 AMBIEN.................................... 36 DOSES).................................... 35
ACCU-CHEK GUIDE KIT AMBIEN CR.............................. 36 ASMANEX (7 METERED
W/DEVICE................................ 22 amiodarone hcl......................... 15 DOSES).................................... 35
ACCU-CHEK SOFTCLIX AMITIZA....................................25 ASMANEX HFA........................ 35
LANCET DEVICE KIT...............22 amitriptyline hcl......................... 11 ASPIRIN-OMEPRAZOLE......... 13
acetaminophen-codeine..............7 amlodipine besylate.................. 15 ATACAND.................................15
acetaminophen-codeine #2.........7 amlodipine besylate-benazepril atenolol..................................... 15
acetaminophen-codeine #3.........7 hcl............................................. 15 atenolol-chlorthalidone..............15
acetaminophen-codeine #4.........7 amlodipine besylate-valsartan.. 15 ATIVAN..................................... 14
ACIPHEX.................................. 25 amlodipine-olmesartan..............15 atomoxetine hcl.........................18
ACTEMRA................................ 30 amoxicillin................................... 8 atorvastatin calcium.................. 15
ACTEMRA ACTPEN.................30 amoxicillin-potassium ATRIPLA................................... 14
ACTHAR................................... 27 clavulanate..................................9 ATROVENT HFA...................... 35
ACTICLATE................................ 8 amphetamine- AUBAGIO..................................18
acyclovir.................................... 14 dextroamphetamine.................. 18 AURYXIA.................................. 26
ACZONE................................... 19 amphetamine- AUSTEDO.................................19
ADCIRCA..................................36 dextroamphetamine er.............. 18 AUVI-Q......................................35
ADDERALL............................... 18 AMPYRA...................................18 AVAPRO................................... 15
ADDERALL XR......................... 18 AMRIX.......................................36 AVEED......................................27
ADDYI....................................... 19 AMZEEQ...................................19 aviane....................................... 28
ADEMPAS................................ 36 anastrozole............................... 12 AVITA........................................19
ADHANSIA XR..........................18 ANDRODERM.......................... 27 AVODART.................................27
ADIPEX-P................................. 19 ANDROGEL..............................27 AVONEX PEN...........................18
ADLYXIN...................................21 ANDROGEL PUMP.................. 27 AVONEX PREFILLED.............. 18
ADLYXIN STARTER PACK...... 21 ANNOVERA..............................28 AZASITE................................... 32
ADMELOG................................ 23 ANORO ELLIPTA..................... 35 azathioprine.............................. 30
ADMELOG SOLOSTAR........... 23 APADAZ......................................7 azelastine hcl............................ 34
ADVAIR DISKUS...................... 34 apap-caff-dihydrocodeine........... 7 AZESCO................................... 24
ADVAIR HFA............................ 34 APEXICON E............................ 19 azithromycin................................9
ADYNOVATE............................15 APIDRA SOLOSTAR................ 23 AZOPT...................................... 33
AFINITOR................................. 12 APIDRA VIAL............................23 AZOR........................................ 15
AFSTYLA.................................. 15 apri............................................ 28 baclofen.................................... 36
AIMOVIG...................................12 APRISO.................................... 31 BAFIERTAM............................. 18
AIRDUO RESPICLICK 113/14..34 ARAKODA................................ 13 BAQSIMI ONE PACK............... 23
AIRDUO RESPICLICK 232/14..34 ARANESP (ALBUMIN FREE)... 15 BAQSIMI TWO PACK...............23
AIRDUO RESPICLICK 55/14....34 ARIMIDEX.................................12 BARACLUDE............................ 14
AJOVY...................................... 12 aripiprazole............................... 13 BASAGLAR KWIKPEN............. 23
AKLIEF......................................19 ARISTADA................................ 13 BD AUTOSHIELD DUO PEN
ALA SCALP.............................. 19 ARISTADA INITIO.................... 13 NEEDLES................................. 23
albuterol sulfate.........................34 armodafinil................................ 36 BD ULTRA-FINE INSULIN
albuterol sulfate hfa...................34 ARMOUR THYROID.................30 SYRINGES............................... 23
ALBUTEROL SULFATE HFA... 34 ARNUITY ELLIPTA...................35 BD ULTRA-FINE PEN
alendronate sodium.................. 31 ARTHROTEC..............................8 NEEDLES................................. 23
alfuzosin hcl er.......................... 27 ARYMO ER.................................7 BD VEO INSULIN SYR U/F
allopurinol..................................12 ASACOL HD............................. 31 1/2UNIT.....................................23
ALOGLIPTIN BENZOATE........ 21 ASCENIV.................................. 30 BELBUCA................................... 7
ALOGLIPTIN-METFORMIN ASMANEX (120 METERED BELRAPZO...............................12
HCL...........................................21 DOSES).................................... 35 benazepril hcl............................15
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