Quantity Limits Farm Bureau Select Health Plan Date Effective: January 1, 2022 Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 1 ABACAVIR SULFATE/LAMIVUDINE ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE ACTEMRA ADEMPAS AFINITOR AIMOVIG AKYNZEO ALBUTEROL SULFATE ALBUTEROL SULFATE HFA Abacavir Sulfate/lamivudine Quantity Limit: 30 EA Per 30 Days Abacavir Sulfate/lamivudine/zidovudine Quantity Limit: 60 EA Per 30 Days Actemra INJ 162MG/0.9ML Quantity Limit: 3.60 ML Per 28 Days Adempas Quantity Limit: 90 EA Per 30 Days Afinitor TABS 10MG Quantity Limit: 30 EA Per 30 Days Aimovig INJ 140MG/ML Quantity Limit: 1 ML Per 30 Days Aimovig INJ 70MG/ML Quantity Limit: 2 ML Per 30 Days Akynzeo CAPS Quantity Limit: 2 EA Per 30 Days Albuterol Sulfate NEBU 0.083% Quantity Limit: 525 ML Per 30 Days Albuterol Sulfate NEBU 2.5MG/0.5ML Quantity Limit: 100 EA Per 30 Days Albuterol Sulfate Hfa Quantity Limit: 13.40 GM Per 30 Days Albuterol Sulfate Hfa Quantity Limit: 17 GM Per 30 Days Albuterol Sulfate Hfa Quantity Limit: 48 GM Per 30 Days
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Quantity Limits
Farm Bureau Select Health Plan
Date Effective: January 1, 2022
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 1
ABACAVIR SULFATE/LAMIVUDINE
ABACAVIR SULFATE/LAMIVUDINE/ZIDOVUDINE
ACTEMRA
ADEMPAS
AFINITOR
AIMOVIG
AKYNZEO
ALBUTEROL SULFATE
ALBUTEROL SULFATE HFA
Abacavir Sulfate/lamivudine Quantity Limit: 30 EA Per 30 Days
Abacavir Sulfate/lamivudine/zidovudine Quantity Limit: 60 EA Per 30 Days
Actemra INJ 162MG/0.9ML Quantity Limit: 3.60 ML Per 28 Days
Adempas Quantity Limit: 90 EA Per 30 Days
Afinitor TABS 10MG Quantity Limit: 30 EA Per 30 Days
Aimovig INJ 140MG/ML Quantity Limit: 1 ML Per 30 Days
Aimovig INJ 70MG/ML Quantity Limit: 2 ML Per 30 Days
Akynzeo CAPS Quantity Limit: 2 EA Per 30 Days
Albuterol Sulfate NEBU 0.083% Quantity Limit: 525 ML Per 30 Days
Albuterol Sulfate NEBU 2.5MG/0.5ML Quantity Limit: 100 EA Per 30 Days
Albuterol Sulfate Hfa Quantity Limit: 13.40 GM Per 30 Days
Albuterol Sulfate Hfa Quantity Limit: 17 GM Per 30 Days
Albuterol Sulfate Hfa Quantity Limit: 48 GM Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 2
ALENDRONATE SODIUM
ALPRAZOLAM
ALUNBRIG
ALYQ
AMBRISENTAN
AMPHETAMINE/DEXTROAMPHETAMINE
ANORO ELLIPTA
Alendronate Sodium TABS 70MG Quantity Limit: 4 EA Per 28 Days
Alprazolam TABS 0.25MG, 0.5MG, 1MG Quantity Limit: 120 EA Per 30 Days
Alprazolam TABS 2MG Quantity Limit: 150 EA Per 30 Days
Alunbrig TABS 180MG, 90MG Quantity Limit: 30 EA Per 30 Days
Alunbrig TABS 30MG Quantity Limit: 120 EA Per 30 Days
Alunbrig TBPK Quantity Limit: 60 EA Per 365 Days
Alyq Quantity Limit: 60 EA Per 30 Days
Ambrisentan Quantity Limit: 30 EA Per 30 Days
Amphetamine/dextroamphetamine CP24 Quantity Limit: 30 EA Per 30 Days
Amphetamine/dextroamphetamine TABS Quantity Limit: 90 EA Per 30 Days
Anoro Ellipta Quantity Limit: 60 EA Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 3
APREPITANT
ARIPIPRAZOLE
ARIPIPRAZOLE ODT
ARMODAFINIL
ARNUITY ELLIPTA
ASENAPINE MALEATE SL
ASMANEX HFA
ASMANEX TWISTHALER 120 METERED DOSES
Aprepitant CAPS 0 Quantity Limit: 6 EA Per 30 Days
Aprepitant CAPS 125MG Quantity Limit: 2 EA Per 30 Days
Aprepitant CAPS 40MG Quantity Limit: 1 EA Per 30 Days
Aprepitant CAPS 80MG Quantity Limit: 8 EA Per 30 Days
Aripiprazole SOLN Quantity Limit: 750 ML Per 30 Days
Aripiprazole TABS Quantity Limit: 30 EA Per 30 Days
Aripiprazole Odt Quantity Limit: 60 EA Per 30 Days
Armodafinil TABS 150MG, 200MG, 250MG Quantity Limit: 30 EA Per 30 Days
Armodafinil TABS 50MG Quantity Limit: 60 EA Per 30 Days
Arnuity Ellipta Quantity Limit: 30 EA Per 30 Days
Asenapine Maleate Sl Quantity Limit: 60 EA Per 30 Days
Asmanex Hfa Quantity Limit: 13 GM Per 30 Days
Asmanex Twisthaler 120 Metered Doses Quantity Limit: 1 EA Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 4
ASMANEX TWISTHALER 14 METERED DOSES
ASMANEX TWISTHALER 30 METERED DOSES
ASMANEX TWISTHALER 60 METERED DOSES
ASMANEX TWISTHALER 7 METERED DOSES
ATOMOXETINE
ATOMOXETINE HYDROCHLORIDE
ATROVENT HFA
AUSTEDO
AYVAKIT
AZELASTINE HCL
Asmanex Twisthaler 14 Metered Doses Quantity Limit: 1 EA Per 30 Days
Asmanex Twisthaler 30 Metered Doses Quantity Limit: 1 EA Per 30 Days
Asmanex Twisthaler 60 Metered Doses Quantity Limit: 1 EA Per 30 Days
Asmanex Twisthaler 7 Metered Doses Quantity Limit: 1 EA Per 30 Days
Atomoxetine CAPS 10MG Quantity Limit: 60 EA Per 30 Days
Atomoxetine CAPS 40MG, 60MG, 80MG Quantity Limit: 30 EA Per 30 Days
Atomoxetine Hydrochloride CAPS 100MG, 18MG,
25MG
Quantity Limit: 30 EA Per 30 Days
Atrovent Hfa Quantity Limit: 25.80 GM Per 30 Days
Austedo Quantity Limit: 120 EA Per 30 Days
Ayvakit Quantity Limit: 30 EA Per 30 Days
Azelastine Hcl NASAL SOLN 0.15% Quantity Limit: 60 ML Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 5
AZELASTINE HYDROCHLORIDE
AZELASTINE HYDROCHLORIDE/FLUTICASONE PROPIONATE
BAFIERTAM
BARACLUDE
BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2"
B-D INSULIN SYRINGE ULTRAFINE II/0.3ML/31G X 5/16"
BD INSULIN SYRINGE ULTRA-FINE/0.5ML/30G X 12.7MM
BD INSULIN SYRINGE ULTRA-FINE/1ML/31G X 8MM
BD INSULIN SYRINGE/1ML/29G X 12.7MM
BD PEN NEEDLE/ORIGINAL/ULTRA-FINE/29G X 12.7MM
Azelastine Hydrochloride SOLN 0.1% Quantity Limit: 60 ML Per 30 Days
Azelastine Hydrochloride/fluticasone Propionate Quantity Limit: 23 GM Per 30 Days
Bafiertam Quantity Limit: 120 EA Per 30 Days
Baraclude SOLN Quantity Limit: 600 ML Per 30 Days
Bd Insulin Syringe Safetyglide/1ml/29g X 1/2" Quantity Limit: 200 EA Per 30 Days
B-d Insulin Syringe Ultrafine Ii/0.3ml/31g X 5/16" Quantity Limit: 200 EA Per 30 Days
Bd Insulin Syringe Ultra-fine/0.5ml/30g X 12.7mm Quantity Limit: 200 EA Per 30 Days
Bd Insulin Syringe Ultra-fine/1ml/31g X 8mm Quantity Limit: 200 EA Per 30 Days
Bd Insulin Syringe/1ml/29g X 12.7mm Quantity Limit: 200 EA Per 30 Days
Bd Pen Needle/original/ultra-fine/29g X 12.7mm Quantity Limit: 200 EA Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 6
BD VEO INSULIN SYRINGE ULTRA-AFINE/0.3ML/31G X 6MM
BELSOMRA
BETASERON
BIKTARVY
BIMATOPROST
BREO ELLIPTA
BREZTRI AEROSPHERE
BUDESONIDE
BUPRENORPHINE HCL/NALOXONE HCL
Bd Veo Insulin Syringe Ultra-afine/0.3ml/31g X
6mm
Quantity Limit: 200 EA Per 30 Days
Belsomra Quantity Limit: 30 EA Per 30 Days
Betaseron Quantity Limit: 15 EA Per 30 Days
Biktarvy Quantity Limit: 30 EA Per 30 Days
Bimatoprost SOLN Quantity Limit: 5 ML Per 30 Days
Breo Ellipta Quantity Limit: 60 EA Per 30 Days
Breztri Aerosphere Quantity Limit: 23.60 GM Per 28 Days
Budesonide SUSP Quantity Limit: 120 ML Per 30 Days
Buprenorphine Hcl/naloxone Hcl SUBL 2MG;
0.5MG
Quantity Limit: 360 EA Per 30 Days
Buprenorphine Hcl/naloxone Hcl SUBL 8MG;
2MG
Quantity Limit: 90 EA Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 7
BUPRENORPHINE HYDROCHLORIDE/NALOXONE HYDROCHLORIDE
BUPROPION HYDROCHLORIDE ER (SR)
BUPROPION HYDROCHLORIDE ER (XL)
BYDUREON BCISE
BYDUREON PEN
CABLIVI
CALCIPOTRIENE
Buprenorphine Hydrochloride/naloxone
Hydrochloride FILM 12MG; 3MG, 4MG; 1MG
Quantity Limit: 60 EA Per 30 Days
Buprenorphine Hydrochloride/naloxone
Hydrochloride FILM 2MG; 0.5MG, 8MG; 2MG
Quantity Limit: 90 EA Per 30 Days
Buprenorphine Hydrochloride/naloxone
Hydrochloride SUBL 2MG; 0.5MG
Quantity Limit: 360 EA Per 30 Days
Bupropion Hydrochloride Er (sr) TB12 100MG Quantity Limit: 90 EA Per 30 Days
Bupropion Hydrochloride Er (sr) TB12 150MG,
200MG
Quantity Limit: 60 EA Per 30 Days
Bupropion Hydrochloride Er (xl) TB24 150MG Quantity Limit: 90 EA Per 30 Days
Bupropion Hydrochloride Er (xl) TB24 300MG Quantity Limit: 30 EA Per 30 Days
Bydureon Bcise Quantity Limit: 3.40 ML Per 28 Days
Bydureon Pen Quantity Limit: 4 EA Per 28 Days
Cablivi Quantity Limit: 30 EA Per 30 Days
Calcipotriene CREA Quantity Limit: 120 GM Per 30 Days
Calcipotriene OINT Quantity Limit: 120 GM Per 30 Days
Calcipotriene SOLN Quantity Limit: 60 ML Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 8
CALCITONIN-SALMON
CAPLYTA
CAPRELSA
CELECOXIB
CHANTIX
CHANTIX CONTINUING MONTH PAK
CHANTIX STARTING MONTH PAK
CIMDUO
CLONAZEPAM
Calcitonin-salmon SOLN Quantity Limit: 3.70 ML Per 30 Days
Caplyta Quantity Limit: 30 EA Per 30 Days
Caprelsa TABS 100MG Quantity Limit: 60 EA Per 30 Days
Celecoxib CAPS Quantity Limit: 60 EA Per 30 Days
Chantix TABS 0.5MG, 1MG Quantity Limit: 504 EA Per 365 Days
Chantix Continuing Month Pak Quantity Limit: 504 EA Per 365 Days
Chantix Starting Month Pak Quantity Limit: 504 EA Per 365 Days
Cimduo Quantity Limit: 30 EA Per 30 Days
Clonazepam TABS 0.5MG, 1MG Quantity Limit: 90 EA Per 30 Days
Clonazepam TABS 2MG Quantity Limit: 300 EA Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 9
CLONAZEPAM ODT
CLORAZEPATE DIPOTASSIUM
CLOZAPINE
CLOZAPINE ODT
COMBIVENT RESPIMAT
COMPLERA
CORLANOR
Clonazepam Odt TBDP 0.125MG, 0.25MG,
0.5MG, 1MG
Quantity Limit: 90 EA Per 30 Days
Clonazepam Odt TBDP 2MG Quantity Limit: 300 EA Per 30 Days
Clorazepate Dipotassium TABS 15MG Quantity Limit: 180 EA Per 30 Days
Clorazepate Dipotassium TABS 3.75MG Quantity Limit: 720 EA Per 30 Days
Clorazepate Dipotassium TABS 7.5MG Quantity Limit: 360 EA Per 30 Days
Clozapine TABS 100MG, 25MG Quantity Limit: 270 EA Per 30 Days
Clozapine TABS 200MG Quantity Limit: 120 EA Per 30 Days
Clozapine TABS 50MG Quantity Limit: 180 EA Per 30 Days
Clozapine Odt TBDP 100MG, 25MG Quantity Limit: 270 EA Per 30 Days
Clozapine Odt TBDP 12.5MG Quantity Limit: 90 EA Per 30 Days
Clozapine Odt TBDP 150MG Quantity Limit: 180 EA Per 30 Days
Clozapine Odt TBDP 200MG Quantity Limit: 120 EA Per 30 Days
Combivent Respimat Quantity Limit: 8 GM Per 30 Days
Complera Quantity Limit: 30 EA Per 30 Days
Corlanor TABS Quantity Limit: 60 EA Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 10
CYSTARAN
DALFAMPRIDINE ER
DELSTRIGO
DEPO-PROVERA
DESCOVY
DESVENLAFAXINE ER
DEXTROAMPHETAMINE SULFATE
DIAZEPAM
Cystaran Quantity Limit: 60 ML Per 28 Days
Dalfampridine Er Quantity Limit: 60 EA Per 30 Days
Delstrigo Quantity Limit: 30 EA Per 30 Days
Depo-provera INJ 400MG/ML Quantity Limit: 10 ML Per 28 Days
Descovy Quantity Limit: 30 EA Per 30 Days
Desvenlafaxine Er TB24 100MG Quantity Limit: 120 EA Per 30 Days
Desvenlafaxine Er TB24 25MG, 50MG Quantity Limit: 30 EA Per 30 Days
Dextroamphetamine Sulfate TABS 10MG Quantity Limit: 180 EA Per 30 Days
Dextroamphetamine Sulfate TABS 5MG Quantity Limit: 90 EA Per 30 Days
Diazepam TABS 10MG Quantity Limit: 120 EA Per 30 Days
Diazepam TABS 2MG Quantity Limit: 300 EA Per 30 Days
Diazepam TABS 5MG Quantity Limit: 240 EA Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 11
DICLOFENAC SODIUM
DIHYDROERGOTAMINE MESYLATE
DIMETHYL FUMARATE
DIMETHYL FUMARATE STARTERPACK
DOVATO
DRIZALMA SPRINKLE
DRONABINOL
DULERA
DULOXETINE HCL
Diclofenac Sodium GEL 1% Quantity Limit: 1000 GM Per 30 Days
Diclofenac Sodium GEL 3% Quantity Limit: 300 GM Per 30 Days
Dihydroergotamine Mesylate NASAL SOLN Quantity Limit: 8 ML Per 30 Days
Dimethyl Fumarate CPDR Quantity Limit: 60 EA Per 30 Days
Dimethyl Fumarate Starterpack MISC 0 Quantity Limit: 120 EA Per 365 Days
Dovato Quantity Limit: 30 EA Per 30 Days
Drizalma Sprinkle CSDR 20MG, 60MG Quantity Limit: 60 EA Per 30 Days
Drizalma Sprinkle CSDR 30MG, 40MG Quantity Limit: 90 EA Per 30 Days
Dronabinol Quantity Limit: 60 EA Per 30 Days
Dulera AERO 5MCG/ACT; 100MCG/ACT,
5MCG/ACT; 200MCG/ACT
Quantity Limit: 17.60 GM Per 30 Days
Dulera AERO 5MCG/ACT; 50MCG/ACT Quantity Limit: 13 GM Per 30 Days
Duloxetine Hcl CPEP 30MG Quantity Limit: 90 EA Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 12
DULOXETINE HYDROCHLORIDE
DUPIXENT
EFAVIRENZ/EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE
EFAVIRENZ/LAMIVUDINE/TENOFOVIR DISOPROXIL FUMARATE
ELIQUIS
ELIQUIS STARTER PACK
EMGALITY
EMSAM
EMTRICITABINE/TENOFOVIR DISOPROXIL
Duloxetine Hydrochloride CPEP 20MG, 60MG Quantity Limit: 60 EA Per 30 Days
Dupixent Quantity Limit: 4.56 ML Per 28 Days
Dupixent Quantity Limit: 8 ML Per 28 Days
Efavirenz/emtricitabine/tenofovir Disoproxil
Fumarate
Quantity Limit: 30 EA Per 30 Days
Efavirenz/lamivudine/tenofovir Disoproxil
Fumarate
Quantity Limit: 30 EA Per 30 Days
Eliquis TABS 2.5MG Quantity Limit: 60 EA Per 30 Days
Eliquis TABS 5MG Quantity Limit: 90 EA Per 30 Days
Eliquis Starter Pack Quantity Limit: 148 EA Per 365 Days
Emgality Quantity Limit: 1 ML Per 30 Days
Emgality INJ 100MG/ML Quantity Limit: 3 ML Per 30 Days
Emsam Quantity Limit: 30 EA Per 30 Days
Emtricitabine/tenofovir Disoproxil Quantity Limit: 30 EA Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 13
EMTRICITABINE/TENOFOVIR DISOPROXIL FUMARATE
ENOXAPARIN SODIUM
ENTECAVIR
ENTRESTO
ESOMEPRAZOLE MAGNESIUM
ESTRING
EVEROLIMUS
EVOTAZ
Emtricitabine/tenofovir Disoproxil Fumarate Quantity Limit: 30 EA Per 30 Days
Enoxaparin Sodium INJ 100MG/ML, 150MG/ML Quantity Limit: 35 ML Per 90 Days
Enoxaparin Sodium INJ 120MG/0.8ML,
80MG/0.8ML
Quantity Limit: 28 ML Per 90 Days
Enoxaparin Sodium INJ 300MG/3ML Quantity Limit: 105 ML Per 90 Days
Enoxaparin Sodium INJ 30MG/0.3ML Quantity Limit: 10.50 ML Per 90 Days
Enoxaparin Sodium INJ 40MG/0.4ML Quantity Limit: 14 ML Per 90 Days
Enoxaparin Sodium INJ 60MG/0.6ML Quantity Limit: 21 ML Per 90 Days
Entecavir Quantity Limit: 30 EA Per 30 Days
Entresto Quantity Limit: 60 EA Per 30 Days
Esomeprazole Magnesium CPDR Quantity Limit: 60 EA Per 30 Days
Estring Quantity Limit: 1 EA Per 90 Days
Everolimus TABS 10MG, 2.5MG, 5MG, 7.5MG Quantity Limit: 30 EA Per 30 Days
Evotaz Quantity Limit: 30 EA Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 14
EVRYSDI
FANAPT
FANAPT TITRATION PACK
FETZIMA
FETZIMA TITRATION PACK
FIRMAGON
FLOVENT DISKUS
FLOVENT HFA
FLUOCINONIDE
Evrysdi Quantity Limit: 240 ML Per 30 Days
Fanapt Quantity Limit: 60 EA Per 30 Days
Fanapt Titration Pack Quantity Limit: 8 EA Per 180 Days
Fetzima Quantity Limit: 30 EA Per 30 Days
Fetzima Titration Pack Quantity Limit: 56 EA Per 365 Days
Firmagon INJ 120MG/VIAL Quantity Limit: 4 EA Per 365 Days
Firmagon INJ 80MG Quantity Limit: 1 EA Per 28 Days
Flovent Diskus AEPB 100MCG/BLIST,
50MCG/BLIST
Quantity Limit: 60 EA Per 30 Days
Flovent Diskus AEPB 250MCG/BLIST Quantity Limit: 240 EA Per 30 Days
Flovent Hfa AERO 110MCG/ACT, 220MCG/ACT Quantity Limit: 24 GM Per 30 Days
Flovent Hfa AERO 44MCG/ACT Quantity Limit: 21.20 GM Per 30 Days
Fluocinonide CREA 0.1% Quantity Limit: 120 GM Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 15
FLUTICASONE PROPIONATE/SALMETEROL DISKUS
FONDAPARINUX SODIUM
FORMOTEROL FUMARATE
GABAPENTIN
GALAFOLD
GENVOYA
GILENYA
GILOTRIF
Fluticasone Propionate/salmeterol Diskus Quantity Limit: 60 EA Per 30 Days
Fondaparinux Sodium INJ 10MG/0.8ML Quantity Limit: 28 ML Per 90 Days
Fondaparinux Sodium INJ 2.5MG/0.5ML Quantity Limit: 17.50 ML Per 90 Days
Fondaparinux Sodium INJ 5MG/0.4ML Quantity Limit: 14 ML Per 90 Days
Fondaparinux Sodium INJ 7.5MG/0.6ML Quantity Limit: 21 ML Per 90 Days
Formoterol Fumarate NEBU Quantity Limit: 120 ML Per 30 Days
Gabapentin CAPS 100MG, 300MG Quantity Limit: 360 EA Per 30 Days
Gabapentin CAPS 400MG Quantity Limit: 270 EA Per 30 Days
Gabapentin SOLN 250MG/5ML Quantity Limit: 2160 ML Per 30 Days
Gabapentin TABS 600MG Quantity Limit: 180 EA Per 30 Days
Gabapentin TABS 800MG Quantity Limit: 150 EA Per 30 Days
Galafold Quantity Limit: 14 EA Per 28 Days
Genvoya Quantity Limit: 30 EA Per 30 Days
Gilenya Quantity Limit: 30 EA Per 30 Days
Gilotrif Quantity Limit: 30 EA Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 16
GLATIRAMER ACETATE
GLYDO
HYDROCORTISONE VALERATE
IBANDRONATE SODIUM
ICLUSIG
IDHIFA
IPRATROPIUM BROMIDE
IPRATROPIUM BROMIDE/ALBUTEROL SULFATE
JAKAFI
JULUCA
Glatiramer Acetate INJ 20MG/ML Quantity Limit: 30 ML Per 30 Days
Glatiramer Acetate INJ 40MG/ML Quantity Limit: 12 ML Per 28 Days
Glydo Quantity Limit: 30 ML Per 30 Days
Hydrocortisone Valerate CREA Quantity Limit: 60 GM Per 30 Days
Ibandronate Sodium TABS Quantity Limit: 1 EA Per 28 Days
Iclusig TABS 10MG, 15MG Quantity Limit: 30 EA Per 30 Days
Idhifa Quantity Limit: 30 EA Per 30 Days
Ipratropium Bromide INHALATION SOLN 0.02% Quantity Limit: 312.50 ML Per 30 Days
Ipratropium Bromide/albuterol Sulfate Quantity Limit: 540 ML Per 30 Days
Jakafi TABS 10MG Quantity Limit: 60 EA Per 30 Days
Juluca Quantity Limit: 30 EA Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 17
JUXTAPID
KESIMPTA
KETOROLAC TROMETHAMINE
KORLYM
KYNMOBI
KYNMOBI TITRATION KIT
LAMIVUDINE/ZIDOVUDINE
LANSOPRAZOLE
LATUDA
LEVALBUTEROL TARTRATE HFA
Juxtapid CAPS 10MG, 40MG, 5MG, 60MG Quantity Limit: 30 EA Per 30 Days
Juxtapid CAPS 20MG, 30MG Quantity Limit: 60 EA Per 30 Days
Kesimpta Quantity Limit: 0.40 ML Per 28 Days
Ketorolac Tromethamine TABS Quantity Limit: 20 EA Per 30 Days
Korlym Quantity Limit: 120 EA Per 30 Days
Kynmobi Quantity Limit: 150 EA Per 30 Days
Kynmobi Titration Kit Quantity Limit: 20 EA Per 365 Days
Lamivudine/zidovudine Quantity Limit: 60 EA Per 30 Days
Lansoprazole CPDR Quantity Limit: 60 EA Per 30 Days
Latuda TABS 120MG, 20MG, 40MG, 60MG Quantity Limit: 30 EA Per 30 Days
Latuda TABS 80MG Quantity Limit: 60 EA Per 30 Days
Levalbuterol Tartrate Hfa Quantity Limit: 30 GM Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 18
LIDOCAINE
LIDOCAINE HCL
LIDOCAINE HCL JELLY
LIDOCAINE/PRILOCAINE
LIDOCAINE-PRILOCAINE-CREAM BASE
LINEZOLID
LINZESS
LORAZEPAM
LOTEMAX SM
Lidocaine OINT 5% Quantity Limit: 150 GM Per 30 Days
Lidocaine Hcl PRSY Quantity Limit: 30 ML Per 30 Days
Lidocaine Hcl Jelly PRSY Quantity Limit: 30 ML Per 30 Days
Lidocaine/prilocaine CREA Quantity Limit: 30 GM Per 30 Days
Lidocaine-prilocaine-cream Base CREA 2.5%;
2.5%
Quantity Limit: 30 GM Per 30 Days
Linezolid SUSR Quantity Limit: 1800 ML Per 28 Days
Linezolid TABS Quantity Limit: 56 EA Per 28 Days
Linzess Quantity Limit: 30 EA Per 30 Days
Lorazepam TABS 0.5MG, 1MG Quantity Limit: 90 EA Per 30 Days
Lorazepam TABS 2MG Quantity Limit: 150 EA Per 30 Days
Lotemax Sm Quantity Limit: 20 GM Per 365 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 19
LOTEPREDNOL ETABONATE
LUBIPROSTONE
LUMIGAN
LUPRON DEPOT (1-MONTH)
LUPRON DEPOT (3-MONTH)
LUPRON DEPOT (4-MONTH)
LUPRON DEPOT (6-MONTH)
LYBALVI
MAVYRET
MEDROXYPROGESTERONE ACETATE
MEMANTINE HYDROCHLORIDE ER
Loteprednol Etabonate GEL Quantity Limit: 20 GM Per 365 Days
Lubiprostone Quantity Limit: 60 EA Per 30 Days
Lumigan Quantity Limit: 2.50 ML Per 25 Days
Lupron Depot (1-month) Quantity Limit: 1 EA Per 28 Days
Lupron Depot (3-month) Quantity Limit: 1 EA Per 84 Days
Lupron Depot (4-month) Quantity Limit: 1 EA Per 112 Days
Lupron Depot (6-month) Quantity Limit: 1 EA Per 168 Days
Lybalvi Quantity Limit: 30 EA Per 30 Days
Mavyret Quantity Limit: 336 EA Per 365 Days
Medroxyprogesterone Acetate INJ Quantity Limit: 1 ML Per 90 Days
Memantine Hydrochloride Er Quantity Limit: 30 EA Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 20
METHYLPHENIDATE HYDROCHLORIDE
MODAFINIL
MOMETASONE FUROATE
MOTEGRITY
NAMZARIC
NARATRIPTAN HCL
NATPARA
NAYZILAM
NERLYNX
NICOTROL NS
Methylphenidate Hydrochloride TABS Quantity Limit: 90 EA Per 30 Days
Modafinil Quantity Limit: 30 EA Per 30 Days
Mometasone Furoate SUSP Quantity Limit: 34 GM Per 30 Days
Motegrity Quantity Limit: 30 EA Per 30 Days
Namzaric C4PK Quantity Limit: 56 EA Per 365 Days
Namzaric CP24 Quantity Limit: 30 EA Per 30 Days
Naratriptan Hcl Quantity Limit: 9 EA Per 30 Days
Natpara Quantity Limit: 2 EA Per 28 Days
Nayzilam Quantity Limit: 10 EA Per 30 Days
Nerlynx Quantity Limit: 180 EA Per 30 Days
Nicotrol Ns Quantity Limit: 360 ML Per 365 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 21
ODEFSEY
OLANZAPINE
OLANZAPINE ODT
OMEPRAZOLE
OMEPRAZOLE DR
OMNIPOD 5 PACK
OMNIPOD DASH 5 PACK
OMNIPOD DASH SYSTEM
OMNIPOD STARTER KIT
ONDANSETRON HCL
OPSUMIT
Odefsey Quantity Limit: 30 EA Per 30 Days
Olanzapine TABS Quantity Limit: 30 EA Per 30 Days
Olanzapine Odt Quantity Limit: 30 EA Per 30 Days
Omeprazole CPDR Quantity Limit: 60 EA Per 30 Days
Omeprazole Dr CPDR 10MG Quantity Limit: 60 EA Per 30 Days
Omnipod 5 Pack Quantity Limit: 30 EA Per 30 Days
Omnipod Dash 5 Pack Quantity Limit: 30 EA Per 30 Days
Omnipod Dash System Quantity Limit: 1 EA Per 365 Days
Omnipod Starter Kit Quantity Limit: 1 EA Per 365 Days
Ondansetron Hcl SOLN Quantity Limit: 450 ML Per 30 Days
Opsumit Quantity Limit: 30 EA Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 22
ORENCIA CLICKJECT
ORKAMBI
OSELTAMIVIR PHOSPHATE
OSPHENA
OXANDROLONE
OZEMPIC
PALIPERIDONE ER
Orencia Clickject Quantity Limit: 4 ML Per 28 Days
Orkambi PACK Quantity Limit: 56 EA Per 28 Days
Orkambi TABS Quantity Limit: 112 EA Per 28 Days
Oseltamivir Phosphate CAPS 30MG Quantity Limit: 168 EA Per 365 Days
Oseltamivir Phosphate CAPS 45MG Quantity Limit: 84 EA Per 365 Days
Oseltamivir Phosphate CAPS 75MG Quantity Limit: 110 EA Per 365 Days
Oseltamivir Phosphate SUSR Quantity Limit: 1080 ML Per 365 Days
Osphena Quantity Limit: 30 EA Per 30 Days
Oxandrolone TABS 10MG Quantity Limit: 60 EA Per 30 Days
Oxandrolone TABS 2.5MG Quantity Limit: 240 EA Per 30 Days
Ozempic Quantity Limit: 3 ML Per 28 Days
Ozempic INJ 2MG/1.5ML Quantity Limit: 1.50 ML Per 28 Days
Paliperidone Er TB24 1.5MG, 3MG, 9MG Quantity Limit: 30 EA Per 30 Days
Paliperidone Er TB24 6MG Quantity Limit: 60 EA Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 23
PANTOPRAZOLE SODIUM
PANTOPRAZOLE SODIUM DR
PEMAZYRE
PERFOROMIST
PREGABALIN
PREZCOBIX
PROAIR HFA
PROAIR RESPICLICK
PROLENSA
Pantoprazole Sodium TBEC Quantity Limit: 60 EA Per 30 Days
Pantoprazole Sodium Dr TBEC 40MG Quantity Limit: 60 EA Per 30 Days
Pemazyre Quantity Limit: 30 EA Per 30 Days
Perforomist Quantity Limit: 120 ML Per 30 Days
Pregabalin CAPS 100MG, 150MG, 200MG,
225MG, 25MG, 50MG, 75MG
Quantity Limit: 90 EA Per 30 Days
Pregabalin CAPS 300MG Quantity Limit: 60 EA Per 30 Days
Pregabalin SOLN Quantity Limit: 900 ML Per 30 Days
Prezcobix Quantity Limit: 30 EA Per 30 Days
Proair Hfa Quantity Limit: 17 GM Per 30 Days
Proair Respiclick Quantity Limit: 2 EA Per 30 Days
Prolensa Quantity Limit: 12 ML Per 365 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 24
PROLIA
QUETIAPINE FUMARATE
QUETIAPINE FUMARATE ER
QVAR REDIHALER
RABEPRAZOLE SODIUM
RAMELTEON
RELISTOR
REPATHA
Prolia Quantity Limit: 2 ML Per 365 Days
Quetiapine Fumarate TABS 100MG, 200MG,
25MG, 50MG
Quantity Limit: 90 EA Per 30 Days
Quetiapine Fumarate TABS 300MG, 400MG Quantity Limit: 60 EA Per 30 Days
Quetiapine Fumarate Er TB24 150MG, 300MG,
400MG, 50MG
Quantity Limit: 60 EA Per 30 Days
Quetiapine Fumarate Er TB24 200MG Quantity Limit: 90 EA Per 30 Days
Qvar Redihaler Quantity Limit: 21.20 GM Per 30 Days
Rabeprazole Sodium Quantity Limit: 60 EA Per 30 Days
Ramelteon Quantity Limit: 30 EA Per 30 Days
Relistor INJ 12MG/0.6ML Quantity Limit: 18 ML Per 30 Days
Relistor INJ 8MG/0.4ML Quantity Limit: 12 ML Per 30 Days
Relistor TABS Quantity Limit: 90 EA Per 30 Days
Repatha Quantity Limit: 3 ML Per 28 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 25
REPATHA PUSHTRONEX SYSTEM
REPATHA SURECLICK
REXULTI
REZUROCK
RHOPRESSA
RISPERIDONE
RISPERIDONE ODT
RIZATRIPTAN BENZOATE
RIZATRIPTAN BENZOATE ODT
ROCKLATAN
Repatha Pushtronex System Quantity Limit: 3.50 ML Per 28 Days
Repatha Sureclick Quantity Limit: 3 ML Per 28 Days
Rexulti Quantity Limit: 30 EA Per 30 Days
Rezurock Quantity Limit: 60 EA Per 30 Days
Rhopressa Quantity Limit: 2.50 ML Per 25 Days
Risperidone SOLN Quantity Limit: 240 ML Per 30 Days
Risperidone TABS Quantity Limit: 60 EA Per 30 Days
Risperidone Odt Quantity Limit: 60 EA Per 30 Days
Rizatriptan Benzoate Quantity Limit: 18 EA Per 30 Days
Rizatriptan Benzoate Odt Quantity Limit: 18 EA Per 30 Days
Rocklatan Quantity Limit: 2.50 ML Per 25 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 26
RYBELSUS
SAVELLA
SAVELLA TITRATION PACK
SECUADO
SEREVENT DISKUS
SIGNIFOR
SILDENAFIL CITRATE
SOFOSBUVIR/VELPATASVIR
SPIRIVA HANDIHALER
SPIRIVA RESPIMAT
Rybelsus TABS 14MG, 7MG Quantity Limit: 30 EA Per 30 Days
Rybelsus TABS 3MG Quantity Limit: 60 EA Per 365 Days
Savella Quantity Limit: 60 EA Per 30 Days
Savella Titration Pack Quantity Limit: 110 EA Per 365 Days
Secuado Quantity Limit: 30 EA Per 30 Days
Serevent Diskus Quantity Limit: 60 EA Per 30 Days
Signifor Quantity Limit: 60 ML Per 30 Days
Sildenafil Citrate TABS 20MG Quantity Limit: 90 EA Per 30 Days
Sofosbuvir/velpatasvir Quantity Limit: 84 EA Per 365 Days
Spiriva Handihaler Quantity Limit: 30 EA Per 30 Days
Spiriva Respimat AERS 1.25MCG/ACT Quantity Limit: 8 GM Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 27
STIOLTO RESPIMAT
STRIBILD
SUMATRIPTAN
SUMATRIPTAN SUCCINATE
SUMATRIPTAN SUCCINATE REFILL
SUPPRELIN LA
SYMBICORT
SYMTUZA
TABRECTA
TADALAFIL
Stiolto Respimat Quantity Limit: 24 GM Per 30 Days
Stribild Quantity Limit: 30 EA Per 30 Days
Sumatriptan SOLN Quantity Limit: 12 EA Per 30 Days
Sumatriptan Succinate INJ Quantity Limit: 5 ML Per 30 Days
Sumatriptan Succinate TABS Quantity Limit: 9 EA Per 30 Days
Sumatriptan Succinate Refill Quantity Limit: 5 ML Per 30 Days
Supprelin La Quantity Limit: 1 EA Per 365 Days
Symbicort AERO 160MCG/ACT; 4.5MCG/ACT Quantity Limit: 12 GM Per 30 Days
Symbicort AERO 80MCG/ACT; 4.5MCG/ACT Quantity Limit: 13.80 GM Per 30 Days
Symtuza Quantity Limit: 30 EA Per 30 Days
Tabrecta Quantity Limit: 120 EA Per 30 Days
Tadalafil TABS 20MG Quantity Limit: 60 EA Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 28
TAGRISSO
TEMAZEPAM
TEMIXYS
TERBINAFINE HCL
TRELEGY ELLIPTA
TRELSTAR MIXJECT
TRIKAFTA
TRINTELLIX
TRIPTODUR
TRIUMEQ
Tagrisso TABS 40MG Quantity Limit: 30 EA Per 30 Days
Temazepam CAPS 15MG, 30MG Quantity Limit: 30 EA Per 30 Days
Temixys Quantity Limit: 30 EA Per 30 Days
Terbinafine Hcl TABS Quantity Limit: 84 EA Per 180 Days
Trelegy Ellipta Quantity Limit: 60 EA Per 30 Days
Trelstar Mixject INJ 11.25MG Quantity Limit: 1 EA Per 84 Days
Trelstar Mixject INJ 22.5MG Quantity Limit: 1 EA Per 168 Days
Trikafta TBPK 50MG; 0; 25MG Quantity Limit: 84 EA Per 28 Days
Trintellix Quantity Limit: 30 EA Per 30 Days
Triptodur Quantity Limit: 1 EA Per 168 Days
Triumeq Quantity Limit: 30 EA Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 29
TRULICITY
UBRELVY
VALACYCLOVIR HCL
VALACYCLOVIR HYDROCHLORIDE
VALTOCO
VANCOMYCIN HYDROCHLORIDE
VARENICLINE TARTRATE
VENTAVIS
VERSACLOZ
VICTOZA
Trulicity Quantity Limit: 2 ML Per 28 Days
Ubrelvy Quantity Limit: 16 EA Per 30 Days
Valacyclovir Hcl TABS 1GM Quantity Limit: 120 EA Per 30 Days
Valacyclovir Hydrochloride TABS 500MG Quantity Limit: 120 EA Per 30 Days
Valtoco Quantity Limit: 10 EA Per 30 Days
Vancomycin Hydrochloride CAPS 125MG Quantity Limit: 120 EA Per 30 Days
Vancomycin Hydrochloride CAPS 250MG Quantity Limit: 240 EA Per 30 Days
Varenicline Tartrate Quantity Limit: 504 EA Per 365 Days
Ventavis Quantity Limit: 270 ML Per 30 Days
Versacloz Quantity Limit: 540 ML Per 30 Days
Victoza Quantity Limit: 9 ML Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 30
VIIBRYD
VIIBRYD STARTER PACK
VOSEVI
VRAYLAR
VYNDAMAX
VYNDAQEL
VYZULTA
WIXELA INHUB
XARELTO
XARELTO STARTER PACK
Viibryd TABS Quantity Limit: 30 EA Per 30 Days
Viibryd Starter Pack Quantity Limit: 60 EA Per 365 Days
Vosevi Quantity Limit: 84 EA Per 365 Days
Vraylar CAPS Quantity Limit: 30 EA Per 30 Days
Vraylar CPPK Quantity Limit: 14 EA Per 365 Days
Vyndamax Quantity Limit: 30 EA Per 30 Days
Vyndaqel Quantity Limit: 120 EA Per 30 Days
Vyzulta Quantity Limit: 5 ML Per 25 Days
Wixela Inhub Quantity Limit: 60 EA Per 30 Days
Xarelto TABS 10MG, 20MG Quantity Limit: 30 EA Per 30 Days
Xarelto TABS 15MG, 2.5MG Quantity Limit: 60 EA Per 30 Days
Xarelto Starter Pack Quantity Limit: 102 EA Per 365 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 31
XERMELO
XIIDRA
XOFLUZA
XYREM
ZALEPLON
ZIPRASIDONE HCL
ZIPRASIDONE MESYLATE
ZOKINVY
ZOLADEX
Xermelo Quantity Limit: 90 EA Per 30 Days
Xiidra Quantity Limit: 60 EA Per 30 Days
Xofluza TBPK 20MG, 40MG Quantity Limit: 4 EA Per 365 Days
Xofluza TBPK 80MG Quantity Limit: 2 EA Per 365 Days
Xyrem Quantity Limit: 540 ML Per 30 Days
Zaleplon CAPS 10MG Quantity Limit: 60 EA Per 30 Days
Zaleplon CAPS 5MG Quantity Limit: 30 EA Per 30 Days
Ziprasidone Hcl Quantity Limit: 60 EA Per 30 Days
Ziprasidone Mesylate Quantity Limit: 60 EA Per 30 Days
Zokinvy Quantity Limit: 120 EA Per 30 Days
Zoladex INJ 3.6MG Quantity Limit: 1 EA Per 28 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 32
ZOLMITRIPTAN
ZOLPIDEM TARTRATE
Zolmitriptan TABS Quantity Limit: 12 EA Per 30 Days
Zolpidem Tartrate TABS Quantity Limit: 30 EA Per 30 Days
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 33
INDEX
A
Abacavir Sulfate/lamivudine ................................. 1
Abacavir Sulfate/lamivudine/zidovudine .............. 1
Actemra ................................................................. 1
Adempas ................................................................ 1
Afinitor .................................................................. 1
Aimovig ................................................................. 1
Akynzeo ................................................................ 1
Albuterol Sulfate ................................................... 1
Albuterol Sulfate Hfa ............................................ 1
Alendronate Sodium .............................................. 2
Alprazolam ............................................................ 2
Alunbrig ................................................................ 2
Alyq ....................................................................... 2
Ambrisentan .......................................................... 2
Amphetamine/dextroamphetamine ....................... 2
Anoro Ellipta ......................................................... 2
Aprepitanth ........................................................ 2, 3
Aripiprazole ........................................................... 3
Aripiprazole Odt .................................................... 3
Armodafinil ........................................................... 3
Arnuity Ellipta ....................................................... 3
Asenapine Maleate Sl ............................................ 3
Asmanex Hfa ......................................................... 3
Asmanex Twisthaler 120 Metered Doses.............. 3
Asmanex Twisthaler 14 Metered Doses................ 3
Asmanex Twisthaler 30 Metered Doses................ 3
Asmanex Twisthaler 60 Metered Doses................ 4
Asmanex Twisthaler 7 Metered Doses.................. 4
Atomoxetine .......................................................... 4
Atomoxetine Hydrochloride .................................. 4
Atrovent Hfa .......................................................... 4
Austedo ................................................................. 4
Ayvakit .................................................................. 4
Azelastine Hcl ....................................................... 4
Azelastine Hydrochloride ...................................... 4
Azelastine Hydrochloride/fluticasone Propionate . 4
B
Bafiertam ............................................................... 5
Baraclude ............................................................... 5
Bd Insulin Syringe Safetyglide/1ml/29g X 1/2 ..... 5
B-d Insulin Syringe Ultrafine Ii/0.3ml/31g X 5/16 5
Bd Insulin Syringe Ultra-fine/0.5ml/30g X
12.7mm .............................................................. 5
Bd Insulin Syringe Ultra-fine/1ml/31g X 8mm ..... 5
Bd Insulin Syringe/1ml/29g X 12.7mm ................. 5
Bd Pen Needle/original/ultra-fine/29g X 12.7mm . 5
Bd Veo Insulin Syringe Ultra-afine/0.3ml/31g X
6mm ................................................................... 5
Belsomra ................................................................ 5
Betaseron................................................................ 6
Biktarvy.................................................................. 6
Bimatoprost ............................................................ 6
Breo Ellipta ............................................................ 6
Breztri Aerosphere ................................................. 6
Budesonide ............................................................. 6
Buprenorphine Hcl/naloxone Hcl .......................... 6
Buprenorphine Hydrochloride/naloxone
Hydrochloride .................................................... 6
Bupropion Hydrochloride Er (sr) ........................... 7
Bupropion Hydrochloride Er (xl)........................... 7
Bydureon Bcise ...................................................... 7
Bydureon Pen ......................................................... 7
C
Cablivi .................................................................... 7
Calcipotriene .......................................................... 7
Calcitonin-salmon .................................................. 7
Caplyta ................................................................... 7
Caprelsa.................................................................. 7
Celecoxib ............................................................... 8
Chantix ................................................................... 8
Chantix Continuing Month Pak ............................. 8
Chantix Starting Month Pak ................................... 8
Cimduo ................................................................... 8
Clonazepam............................................................ 8
Clonazepam Odt..................................................... 8
Clorazepate Dipotassium ....................................... 8
Clozapine ............................................................... 9
Clozapine Odt ........................................................ 9
Combivent Respimat .............................................. 9
Complera ................................................................ 9
Corlanor ................................................................. 9
Cystaran ................................................................. 9
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 34
D
Dalfampridine Er ................................................... 9
Delstrigo ................................................................ 9
Depo-provera ....................................................... 10
Descovy ............................................................... 10
Desvenlafaxine Er ............................................... 10
Dextroamphetamine Sulfate ................................ 10
Diazepam ............................................................. 10
Diclofenac Sodium .............................................. 10
Dihydroergotamine Mesylate .............................. 10
Dimethyl Fumarate .............................................. 10
Dimethyl Fumarate Starterpack .......................... 11
Dovato ................................................................. 11
Drizalma Sprinkle ............................................... 11
Dronabinol ........................................................... 11
Dulera .................................................................. 11
Duloxetine Hcl .................................................... 11
Duloxetine Hydrochloride ................................... 11
Dupixent .............................................................. 11
E
Efavirenz/emtricitabine/tenofovir Disoproxil
Fumarate .......................................................... 11
Efavirenz/lamivudine/tenofovir Disoproxil
Fumarate .......................................................... 12
Eliquis ................................................................. 12
Eliquis Starter Pack ............................................. 12
Emgality .............................................................. 12
Emsam ................................................................. 12
Emtricitabine/tenofovir Disoproxil ..................... 12
Emtricitabine/tenofovir Disoproxil Fumarate ..... 12
Enoxaparin Sodium ....................................... 12, 13
Entecavir.............................................................. 13
Entresto................................................................ 13
Esomeprazole Magnesium .................................. 13
Estring ................................................................. 13
Everolimus .......................................................... 13
Evotaz .................................................................. 13
Evrysdi ................................................................ 13
F
Fanapt .................................................................. 13
Fanapt Titration Pack .......................................... 13
Fetzima ................................................................ 13
Fetzima Titration Pack ........................................ 14
Firmagon ............................................................. 14
Flovent Diskus .................................................... 14
Flovent Hfa .......................................................... 14
Fluocinonide ........................................................ 14
Fluticasone Propionate/salmeterol Diskus .......... 14
Fondaparinux Sodium ......................................... 14
Formoterol Fumarate ........................................... 14
G
Gabapentin ........................................................... 15
Galafold................................................................ 15
Genvoya ............................................................... 15
Gilenya ................................................................. 15
Gilotrif.................................................................. 15
Glatiramer Acetate ............................................... 15
Glydo.................................................................... 15
H
Hydrocortisone Valerate ...................................... 15
I
Ibandronate Sodium ............................................. 16
Iclusig ................................................................... 16
Idhifa .................................................................... 16
Ipratropium Bromide ........................................... 16
Ipratropium Bromide/albuterol Sulfate ................ 16
J
Jakafi .................................................................... 16
Juluca ................................................................... 16
Juxtapid ................................................................ 16
K
Kesimpta .............................................................. 16
Ketorolac Tromethamine ..................................... 16
Korlym ................................................................. 17
Kynmobi .............................................................. 17
Kynmobi Titration Kit ......................................... 17
L
Lamivudine/zidovudine ....................................... 17
Lansoprazole ........................................................ 17
Latuda .................................................................. 17
Levalbuterol Tartrate Hfa .................................... 17
Lidocaine.............................................................. 17
Lidocaine Hcl ....................................................... 17
Lidocaine Hcl Jelly .............................................. 17
Lidocaine/prilocaine ............................................ 18
Lidocaine-prilocaine-cream Base ........................ 18
Linezolid .............................................................. 18
Linzess ................................................................. 18
Lorazepam ............................................................ 18
Lotemax Sm ......................................................... 18
Loteprednol Etabonate ......................................... 18
Lubiprostone ........................................................ 18
Lumigan ............................................................... 18
Lupron Depot (1-month) ...................................... 18
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 35
Lupron Depot (3-month) ..................................... 19
Lupron Depot (4-month) ..................................... 19
Lupron Depot (6-month) ..................................... 19
Lybalvi ................................................................ 19
M
Mavyret ............................................................... 19
Medroxyprogesterone Acetate ............................ 19
Memantine Hydrochloride Er ............................. 19
Methylphenidate Hydrochloride ......................... 19
Modafinil ............................................................. 19
Mometasone Furoate ........................................... 19
Motegrity ............................................................. 20
N
Namzaric ............................................................. 20
Naratriptan Hcl .................................................... 20
Natpara ................................................................ 20
Nayzilam ............................................................. 20
Nerlynx ................................................................ 20
Nicotrol Ns .......................................................... 20
O
Odefsey................................................................ 20
Olanzapine ........................................................... 20
Olanzapine Odt .................................................... 20
Omeprazole ......................................................... 21
Omeprazole Dr .................................................... 21
Omnipod 5 Pack .................................................. 21
Omnipod Dash 5 Pack ......................................... 21
Omnipod Dash System ........................................ 21
Omnipod Starter Kit ............................................ 21
Ondansetron Hcl .................................................. 21
Opsumit ............................................................... 21
Orencia Clickject ................................................. 21
Orkambi ............................................................... 21
Oseltamivir Phosphate......................................... 22
Osphena ............................................................... 22
Oxandrolone ........................................................ 22
Ozempic .............................................................. 22
P
Paliperidone Er .................................................... 22
Pantoprazole Sodium........................................... 22
Pantoprazole Sodium Dr ..................................... 22
Pemazyre ............................................................. 22
Perforomist .......................................................... 23
Pregabalin ............................................................ 23
Prezcobix ............................................................. 23
Proair Hfa ............................................................ 23
Proair Respiclick ................................................. 23
Prolensa ................................................................ 23
Prolia .................................................................... 23
Q
Quetiapine Fumarate ............................................ 23
Quetiapine Fumarate Er ................................. 23, 24
Qvar Redihaler ..................................................... 24
R
Rabeprazole Sodium ............................................ 24
Ramelteon ............................................................ 24
Relistor ................................................................. 24
Repatha ................................................................ 24
Repatha Pushtronex System ................................. 24
Repatha Sureclick ................................................ 24
Rexulti .................................................................. 24
Rezurock .............................................................. 24
Rhopressa ............................................................. 25
Risperidone .......................................................... 25
Risperidone Odt ................................................... 25
Rizatriptan Benzoate ............................................ 25
Rizatriptan Benzoate Odt ..................................... 25
Rocklatan ............................................................. 25
Rybelsus ............................................................... 25
S
Savella .................................................................. 25
Savella Titration Pack .......................................... 25
Secuado ................................................................ 25
Serevent Diskus ................................................... 26
Signifor ................................................................ 26
Sildenafil Citrate .................................................. 26
Sofosbuvir/velpatasvir ......................................... 26
Spiriva Handihaler ............................................... 26
Spiriva Respimat .................................................. 26
Stiolto Respimat ................................................... 26
Stribild.................................................................. 26
Sumatriptan .......................................................... 26
Sumatriptan Succinate ......................................... 26
Sumatriptan Succinate Refill ............................... 27
Supprelin La ......................................................... 27
Symbicort ............................................................. 27
Symtuza................................................................ 27
T
Tabrecta ................................................................ 27
Tadalafil ............................................................... 27
Tagrisso ................................................................ 27
Temazepam .......................................................... 27
Temixys................................................................ 27
Terbinafine Hcl .................................................... 27
Formulary ID 22327 Effective Date: 01/01/2022 Last Updated: October 2021 36
Trelegy Ellipta ..................................................... 28
Trelstar Mixject ................................................... 28
Trikafta ................................................................ 28
Trintellix .............................................................. 28
Triptodur.............................................................. 28
Triumeq ............................................................... 28
Trulicity ............................................................... 28
U
Ubrelvy ................................................................ 28
V
Valacyclovir Hcl ................................................. 28
Valacyclovir Hydrochloride ................................ 28
Valtoco ................................................................ 29
Vancomycin Hydrochloride ................................ 29
Varenicline Tartrate............................................. 29
Ventavis ............................................................... 29
Versacloz ............................................................. 29
Victoza ................................................................ 29
Viibryd ................................................................ 29
Viibryd Starter Pack ............................................ 29
Vosevi ................................................................. 29
Vraylar ................................................................. 29
Vyndamax ............................................................ 30
Vyndaqel .............................................................. 30
Vyzulta ................................................................. 30
W
Wixela Inhub ........................................................ 30
X
Xarelto.................................................................. 30
Xarelto Starter Pack ............................................. 30
Xermelo................................................................ 30
Xiidra ................................................................... 30
Xofluza ................................................................. 30
Xyrem .................................................................. 30
Z
Zaleplon ............................................................... 31
Ziprasidone Hcl .................................................... 31
Ziprasidone Mesylate ........................................... 31
Zokinvy ................................................................ 31
Zoladex ................................................................ 31
Zolmitriptan ......................................................... 31
Zolpidem Tartrate ................................................ 31
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