You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
Drug Name Drug Tier RequirementsLimits
tarina 24 fe oral tablet 1 mg-20 mcg (24)75 mg (4)
(norethindrone-eestradiol-iron)
2
tarina fe 1-20 eq (28) oral tablet 1 mg-20 mcg (21)75 mg (7)
(norethindrone-eestradiol-iron)
1 GC
tri femynor oral tablet0180215025 mg-35 mcg (28)
(norgestimate-ethinyl estradiol)
2
tri-estarylla oral tablet0180215025 mg-35 mcg (28)
(norgestimate-ethinyl estradiol)
1 GC
tri-legest fe oral tablet 1-20(5)1-30(7) 1mg-35mcg (9)
2
tri-linyah oral tablet 0180215025 mg-35 mcg (28)
(norgestimate-ethinyl estradiol)
2
tri-lo-estarylla oral tablet0180215025 mg-25 mcg
(norgestimate-ethinyl estradiol)
1 GC
tri-lo-marzia oral tablet0180215025 mg-25 mcg
(norgestimate-ethinyl estradiol)
1 GC
tri-lo-mili oral tablet 0180215025 mg-25 mcg
(norgestimate-ethinyl estradiol)
1 GC
tri-lo-sprintec oral tablet0180215025 mg-25 mcg
(norgestimate-ethinyl estradiol)
2
tri-mili oral tablet 0180215025 mg-35 mcg (28)
(norgestimate-ethinyl estradiol)
2
tri-nymyo oral tablet0180215025 mg-35 mcg (28)
(norgestimate-ethinyl estradiol)
2
tri-previfem (28) oral tablet0180215025 mg-35 mcg (28)
(norgestimate-ethinyl estradiol)
1 GC
tri-sprintec (28) oral tablet0180215025 mg-35 mcg (28)
(norgestimate-ethinyl estradiol)
2
trivora (28) oral tablet 50-30 (6)75-40 (5)125-30(10)
(levonorg-eth estrad triphasic)
2
tri-vylibra lo oral tablet0180215025 mg-25 mcg
(norgestimate-ethinyl estradiol)
1 GC
tri-vylibra oral tablet0180215025 mg-35 mcg (28)
(norgestimate-ethinyl estradiol)
2
tulana oral tablet 035 mg (norethindrone (contraceptive))
1 GC
tyblume oral tabletchewable 01 mg- 20 mcg
2
velivet triphasic regimen (28) oral tablet 0112515-25 mg-mcg
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
102
Drug Name Drug Tier RequirementsLimits
vestura (28) oral tablet 3-002 mg (drospirenone-ethinyl estradiol)
2
vienva oral tablet 01-20 mg-mcg (levonorgestrel-ethinyl estrad)
2
viorele (28) oral tablet 015-002 mgx21 001 mg x 5
(desog-eestradioleestradiol)
2
volnea (28) oral tablet 015-002 mgx21 001 mg x 5
(desog-eestradioleestradiol)
2
vyfemla (28) oral tablet 04-35 mg-mcg
2
vylibra oral tablet 025-35 mg-mcg (norgestimate-ethinyl estradiol)
2
wera (28) oral tablet 05-35 mg-mcg
2
xulane transdermal patch weekly150-35 mcg24 hr
2 QL (3 per 28 days)
zafemy transdermal patch weekly150-35 mcg24 hr
2 QL (3 per 28 days)
zarah oral tablet 3-003 mg (drospirenone-ethinyl estradiol)
2
zovia 1-35 (28) oral tablet 1-35 mg-mcg
(ethynodiol diac-eth estradiol)
2
zovia 1-35e tablet outer 1-35 mg-mcg
(ethynodiol diac-eth estradiol)
2
zumandimine (28) oral tablet 3-003 mg
(drospirenone-ethinyl estradiol)
2
Dental And Oral AgentsDental And Oral Agentscevimeline oral capsule 30 mg (Evoxac) 2
chlorhexidine gluconate mucous membrane mouthwash 012
(Paroex Oral Rinse) 1 GC
denta 5000 plus dental cream 11 (fluoride (sodium)) 1 GC
dentagel dental gel 11 (fluoride (sodium)) 1 GC
fluoride (sodium) dental solution02
(PreviDent) 1 GC
oralone dental paste 01 (triamcinolone acetonide)
2
paroex oral rinse mucous membrane mouthwash 012
(chlorhexidine gluconate)
1 GC
periogard mucous membrane mouthwash 012
(chlorhexidine gluconate)
1 GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
103
Drug Name Drug Tier RequirementsLimits
pilocarpine hcl oral tablet 5 mg 75 mg
(Salagen (pilocarpine)) 2
sf 5000 plus dental cream 11 (fluoride (sodium)) 1 GC
sodium fluoride-pot nitrate dental paste 11-5
(Fluoridex Sensitivity Relief)
1 GC
triamcinolone acetonide dental paste01
(Oralone) 2
Dermatological AgentsDermatological Agents Otheraccutane oral capsule 10 mg 20 mg 30 mg 40 mg
(isotretinoin) 2
acitretin oral capsule 10 mg 175 mg 25 mg
2
acyclovir topical cream 5 (Zovirax) 2 QL (5 per 4 days)
acyclovir topical ointment 5 (Zovirax) 2 QL (30 per 30 days)
ALCOHOL 70 SWABS (Alcohol Pads) 1 GC
ALCOHOL PADS TOPICAL PADS MEDICATED
(alcohol swabs) 1 GC
ALCOHOL PREP SWABS TOPICAL PADS MEDICATED
(alcohol swabs) 1 GC
ammonium lactate topical cream 12
2
ammonium lactate topical lotion 12
(Skin Treatment) 2
BD SINGLE USE SWAB (alcohol swabs) 1 GC
calcipotriene scalp solution 0005 2 QL (120 per 30 days)
calcipotriene topical cream 0005 (Dovonex) 2 QL (120 per 30 days)
calcipotriene topical ointment 0005
2 QL (120 per 30 days)
CARETOUCH ALCOHOL 70 PREP PAD
(alcohol swabs) 1 GC
CURITY ALCOHOL PREPS 2 PLYMEDIUM
(alcohol swabs) 1 GC
DENAVIR TOPICAL CREAM 1
5 NM NDS
EASY COMFORT ALCOHOL 70 PAD
(alcohol swabs) 1 GC
EASY TOUCH ALCOHOL 70 PADS GAMMA-STERILIZED
(alcohol swabs) 1 GC
fluorouracil topical cream 05 (Carac) 5 NM NDS
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
104
Drug Name Drug Tier RequirementsLimits
fluorouracil topical cream 5 (Efudex) 2
fluorouracil topical solution 2 5
2
HEB INCONTROL ALCOHOL 70 PADS
(alcohol swabs) 1 GC
imiquimod topical cream in packet 5
(Aldara) 2 QL (24 per 30 days)
IV ANTISEPTIC WIPES (alcohol swabs) 1 GC
KENDALL ALCOHOL 70 PREP PAD
(alcohol swabs) 1 GC
methoxsalen oral capsuleliqd-filledrapid rel 10 mg
5 NM NDS
PANRETIN TOPICAL GEL 01
5 NM NDS QL (180 per 30 days)
podofilox topical solution 05 2
PRO COMFORT ALCOHOL 70 PADS
(alcohol swabs) 1 GC
PURE COMFORT ALCOHOL 70 PADS
(alcohol swabs) 1 GC
RA ISOPROPYL ALCOHOL 70 WIPES
(alcohol swabs) 1 GC
REGRANEX TOPICAL GEL 001
5 PA NM NDS QL (30 per 30 days)
SANTYL TOPICAL OINTMENT 250 UNITGRAM
4 QL (180 per 30 days)
SURE COMFORT ALCOHOL PREP PADS
(alcohol swabs) 1 GC
SURE-PREP ALCOHOL PREP PADS
(alcohol swabs) 1 GC
TRUE COMFORT ALCOHOL 70 PADS
(alcohol swabs) 1 GC
TRUE COMFORT PRO ALCOHOL PADS
(alcohol swabs) 1 GC
ULTILET ALCOHOL STERL SWAB
(alcohol swabs) 1 GC
VALCHLOR TOPICAL GEL 0016
5 NM NDS
VEREGEN TOPICAL OINTMENT 15
5 NM NDS
WEBCOL ALCOHOL PREPS 20SLARGE
(alcohol swabs) 1 GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
105
Drug Name Drug Tier RequirementsLimits
zenatane oral capsule 10 mg 20 mg 30 mg 40 mg
(isotretinoin) 2
Dermatological Antibacterialsclindamycin phosphate topical foam1
(Evoclin) 2 QL (100 per 30 days)
clindamycin phosphate topical solution 1
(Cleocin T) 2 QL (180 per 30 days)
clindamycin phosphate topical swab1
(Clindacin ETZ) 2
clindamycin-benzoyl peroxide topical gel 12 (1 base) -5
(Neuac) 2
clindamycin-benzoyl peroxide topical gel 1-5
(Benzaclin) 2
ery pads topical swab 2 (erythromycin with ethanol)
2
erythromycin with ethanol topical gel 2
(Erygel) 2 QL (180 per 30 days)
erythromycin with ethanol topical solution 2
2 QL (180 per 30 days)
erythromycin-benzoyl peroxide topical gel 3-5
(Benzamycin) 2
gentamicin topical cream 01 2 QL (120 per 30 days)
gentamicin topical ointment 01 2 QL (120 per 30 days)
metronidazole topical cream 075 (Rosadan) 2
metronidazole topical gel 075 (Rosadan) 2
metronidazole topical gel 1 (Metrogel) 2
metronidazole topical lotion 075 (MetroLotion) 2
mupirocin topical ointment 2 (Centany) 1 GC QL (220 per 30 days)
neomycin-polymyxin b gu irrigation solution 40 mg-200000 unitml
2
rosadan topical cream 075 (metronidazole) 2
selenium sulfide topical lotion 25 2
silver sulfadiazine topical cream 1 (SSD) 2
ssd topical cream 1 (silver sulfadiazine) 4
sulfacetamide sodium (acne) topical suspension 10
(Klaron) 2
Dermatological Anti-Inflammatory Agentsala-cort topical cream 1 (hydrocortisone) 1 GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
106
Drug Name Drug Tier RequirementsLimits
ala-scalp topical lotion 2 2
alclometasone topical cream 005 2
alclometasone topical ointment 005
2
betamethasone dipropionate topical cream 005
2
betamethasone dipropionate topical lotion 005
2
betamethasone dipropionate topical ointment 005
2
betamethasone valerate topical cream 01
2
betamethasone valerate topical foam012
(Luxiq) 2
betamethasone valerate topical lotion 01
2
betamethasone valerate topical ointment 01
2
betamethasone augmented topical cream 005
2
betamethasone augmented topical gel 005
2
betamethasone augmented topical lotion 005
2
betamethasone augmented topical ointment 005
(Diprolene (augmented))
2
clobetasol scalp solution 005 2
clobetasol topical cream 005 2
clobetasol topical foam 005 (Olux) 2
clobetasol topical gel 005 2
clobetasol topical lotion 005 (Clobex) 2
clobetasol topical ointment 005 (Temovate) 2
clobetasol topical shampoo 005 (Clobex) 2
clobetasol-emollient topical cream005
2
clobetasol-emollient topical foam005
(Olux-E) 2
desonide topical cream 005 (DesOwen) 2
desonide topical lotion 005 (DesOwen) 2
desonide topical ointment 005 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
107
Drug Name Drug Tier RequirementsLimits
desoximetasone topical cream 005 025
(Topicort) 2 QL (120 per 30 days)
desoximetasone topical gel 005 (Topicort) 2 QL (120 per 30 days)
desoximetasone topical ointment005 025
(Topicort) 2 QL (120 per 30 days)
diflorasone topical ointment 005 2 QL (180 per 30 days)
EUCRISA TOPICAL OINTMENT 2
3
fluocinolone topical cream 001 2
fluocinolone topical cream 0025 (Synalar) 2
fluocinolone topical ointment 0025
(Synalar) 2
fluocinonide topical cream 005 2
fluocinonide topical gel 005 2
fluocinonide topical ointment 005 2
fluocinonide topical solution 005 2
fluocinonide-e topical cream 005 (fluocinonide-emollient)
2
fluticasone propionate topical cream005
2
fluticasone propionate topical ointment 0005
2
halobetasol propionate topical cream 005
2
halobetasol propionate topical ointment 005
2
hydrocortisone 25 cream 25 1 GC
hydrocortisone butyrate topical cream 01
2 QL (120 per 30 days)
hydrocortisone butyrate topical lotion 01
(Locoid) 2 QL (236 per 30 days)
hydrocortisone butyrate topical ointment 01
2 QL (120 per 30 days)
hydrocortisone butyrate topical solution 01
2 QL (120 per 30 days)
hydrocortisone topical cream 1 (Ala-Cort) 1 GC
hydrocortisone topical cream with perineal applicator 25
(Procto-Med HC) 1 GC
hydrocortisone topical lotion 25 2
hydrocortisone topical ointment 1 (Anti-Itch (HC)) 1 GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
108
Drug Name Drug Tier RequirementsLimits
hydrocortisone topical ointment 25
1 GC
hydrocortisone valerate topical cream 02
2
hydrocortisone valerate topical ointment 02
2
mometasone topical cream 01 2
mometasone topical ointment 01 2
mometasone topical solution 01 2
pimecrolimus topical cream 1 (Elidel) 2 QL (100 per 30 days)
prednicarbate topical ointment 01
2
procto-med hc topical cream with perineal applicator 25
(hydrocortisone) 2
procto-pak topical cream with perineal applicator 1
(hydrocortisone) 2
proctosol hc topical cream with perineal applicator 25
(hydrocortisone) 2
proctozone-hc topical cream with perineal applicator 25
(hydrocortisone) 2
tacrolimus topical ointment 003 01
(Protopic) 2 QL (100 per 30 days)
triamcinolone acetonide topical cream 0025
1 GC
triamcinolone acetonide topical cream 01 05
(Triderm) 1 GC
triamcinolone acetonide topical lotion 0025 01
2
triamcinolone acetonide topical ointment 0025
1 GC
triamcinolone acetonide topical ointment 005
(Trianex) 2
triamcinolone acetonide topical ointment 01 05
2
Dermatological Retinoidsadapalene topical cream 01 (Differin) 2
adapalene topical gel 01 (Differin) 2
ALTRENO TOPICAL LOTION 005
4 PA
tazarotene topical cream 01 (Tazorac) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
109
Drug Name Drug Tier RequirementsLimits
TAZORAC TOPICAL CREAM 005
4
tretinoin topical cream 0025 (Avita) 2 PA
tretinoin topical cream 005 01
(Retin-A) 2 PA
tretinoin topical gel 001 (Retin-A) 2 PA
tretinoin topical gel 0025 (Avita) 2 PA
tretinoin topical gel 005 (Atralin) 2 PAScabicides And Pediculicidesmalathion topical lotion 05 (Ovide) 2
permethrin topical cream 5 (Elimite) 2
DevicesDevices1ST TIER UNIFINE PENTP 5MM 31G 31 GAUGE X 316
(pen needle diabetic) 2
1ST TIER UNIFINE PNTIP 4MM 32G 32 GAUGE X 532
(pen needle diabetic) 2
1ST TIER UNIFINE PNTIP 6MM 31G 31 GAUGE X 14
(pen needle diabetic) 2
1ST TIER UNIFINE PNTIP 8MM 31G STRLSINGLE-USESHRT 31 GAUGE X 516
(pen needle diabetic) 2
1ST TIER UNIFINE PNTP 29GX12 29 GAUGE X 12
(pen needle diabetic) 2
1ST TIER UNIFINE PNTP 31GX316 31 GAUGE X 316
(pen needle diabetic) 2
1ST TIER UNIFINE PNTP 32GX532 32 GAUGE X 532
(pen needle diabetic) 2
ABOUTTIME PEN NEEDLE 30G X 8MM 30 GAUGE X 516
(pen needle diabetic) 2
ABOUTTIME PEN NEEDLE 31G X 5MM 31 GAUGE X 316
(pen needle diabetic) 2
ABOUTTIME PEN NEEDLE 31G X 8MM 31 GAUGE X 516
(pen needle diabetic) 2
ABOUTTIME PEN NEEDLE 32G X 4MM 32 GAUGE X 532
(pen needle diabetic) 2
ADVOCATE INS 03 ML 30GX516 03 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
110
Drug Name Drug Tier RequirementsLimits
ADVOCATE INS 03 ML 31GX516 03 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
ADVOCATE INS 05 ML 30GX516 05 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
ADVOCATE INS 05 ML 31GX516 05 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
ADVOCATE INS 1 ML 31GX516 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
ADVOCATE INS SYR 03 ML 29GX12 03 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
ADVOCATE INS SYR 05 ML 29GX12 05 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
ADVOCATE INS SYR 1 ML 29GX12 1 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
ADVOCATE INS SYR 1 ML 30GX516 1 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
ADVOCATE PEN NDL 127MM 29G 29 GAUGE X 12
(pen needle diabetic) 2
ADVOCATE PEN NEEDLE 4MM 33G 33 GAUGE X 532
(pen needle diabetic) 2
ADVOCATE PEN NEEDLES 5MM 31G 31 GAUGE X 316
(pen needle diabetic) 2
ADVOCATE PEN NEEDLES 8MM 31G 31 GAUGE X 516
(pen needle diabetic) 2
ASSURE ID DUO-SHIELD 30GX316 30 GAUGE X 316
2
ASSURE ID DUO-SHIELD 30GX516 30 GAUGE X 516
2
ASSURE ID INSULIN SAFETY SYRINGE 1 ML 29 GAUGE X 12
2
ASSURE ID PEN NEEDLE 30GX316 30 GAUGE X 316
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
111
Drug Name Drug Tier RequirementsLimits
ASSURE ID PEN NEEDLE 30GX516 30 GAUGE X 516
2
ASSURE ID PEN NEEDLE 31GX316 31 GAUGE X 316
2
ASSURE ID SYR 05 ML 29GX12 (RX) 05 ML 29 GAUGE X 12
2
ASSURE ID SYR 05 ML 31GX1564 05 ML 31 GAUGE X 1564
2
ASSURE ID SYR 1 ML 31GX1564 1 ML 31 GAUGE X 1564
2
BD AUTOSHIELD DUO NDL 5MMX30G 30 GAUGE X 316
2
BD ECLIPSE 30GX12 SYRINGE 1 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
BD INS SYR 03 ML 8MMX31G(12) 03 ML 31 GAUGE X 516
2
BD INS SYRINGE 12 ML 6MMX31G (ONLY FOR 500 UNITML INSULIN) 12 ML 31 GAUGE X 1564
2
BD INS SYRN UF 1 ML 127MMX30G NOT FOR RETAIL SALE 1 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
BD INSULIN SYR 05 ML 29GX12 05 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
BD INSULIN SYR 1 ML 25GX1 1 ML 25 X 1
2
BD INSULIN SYR 1 ML 25GX58 1 ML 25 GAUGE X 58
(insulin syringe-needle u-100)
2
BD INSULIN SYR 1 ML 26GX12 1 ML 26 X 12
2
BD INSULIN SYR 1 ML 27GX58 MICRO-FINE 1 ML 27 GAUGE X 58
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
112
Drug Name Drug Tier RequirementsLimits
BD INSULIN SYR 1 ML 28GX12 (OTC) 1 ML 28 GAUGE X 12
(Comfort EZ Insulin Syringe)
2
BD INSULIN SYRINGE 1 ML WO NEEDLE 1 ML
(insulin syringe needleless)
2
BD LUER-LOK SYRINGE 1 ML 1 ML
(BD Insulin Syringe Slip Tip)
2
BD NANO 2 GEN PEN NDL 32GX4MM 32 GAUGE X 532
(pen needle diabetic) 2
BD SAFETGLD INS 03 ML 13MMX29G 03 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
BD SAFETGLD INS 03 ML 8MMX31G 03 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
BD SAFETGLD INS 05 ML 13MMX29G 05 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
BD SAFETGLD INS 05 ML 8MMX30G 05 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
BD SAFETYGLD INS 1 ML 13MMX29G 1 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
BD SAFETYGLID INS 1 ML 6MMX31G 1 ML 31 GAUGE X 1564
2
BD SAFETYGLIDE SYRINGE 27GX58 1 ML 27 GAUGE X 58
2
BD SAFTYGLD INS 03 ML 6MMX31G 03 ML 31 GAUGE X 1564
2
BD SAFTYGLD INS 05 ML 6MMX31G 05 ML 31 GAUGE X 1564
2
BD UF MICRO PEN NEEDLE 6MMX32G 32 GAUGE X 14
(pen needle diabetic) 2
BD UF MINI PEN NEEDLE 5MMX31G 31 GAUGE X 316
(pen needle diabetic) 2
BD UF NANO PEN NEEDLE 4MMX32G 32 GAUGE X 532
(pen needle diabetic) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
113
Drug Name Drug Tier RequirementsLimits
BD UF ORIG PEN NDL 127MMX29G 29 GAUGE X 12
(pen needle diabetic) 2
BD UF SHORT PEN NEEDLE 8MMX31G 31 GAUGE X 516
(pen needle diabetic) 2
BD VEO INS 03 ML 6MMX31G (12) 03 ML 31 GAUGE X 1564
2
BD VEO INS SYRING 1 ML 6MMX31G 1 ML 31 GAUGE X 1564
(insulin syringe-needle u-100)
2
BD VEO INS SYRN 03 ML 6MMX31G 03 ML 31 GAUGE X 1564
(insulin syringe-needle u-100)
2
BD VEO INS SYRN 05 ML 6MMX31G 12 ML 31 GAUGE X 1564
(insulin syringe-needle u-100)
2
BORDERED GAUZE 2X2 2 X 2
(gauze bandage) 1 GC
CAREFINE PEN NEEDLE 127MM 29G 29 GAUGE X 12
(pen needle diabetic) 2
CAREFINE PEN NEEDLE 4MM 32G 32 GAUGE X 532
(pen needle diabetic) 2
CAREFINE PEN NEEDLE 5MM 32G 32 GAUGE X 316
(pen needle diabetic) 2
CAREFINE PEN NEEDLE 6MM 31G 31 GAUGE X 14
(pen needle diabetic) 2
CAREFINE PEN NEEDLE 8MM 30G 30 GAUGE X 516
(pen needle diabetic) 2
CAREFINE PEN NEEDLES 6MM 32G 32 GAUGE X 14
(pen needle diabetic) 2
CAREFINE PEN NEEDLES 8MM 31G 31 GAUGE X 516
(pen needle diabetic) 2
CAREONE SYR 03 ML 31GX516 SHORT HRI 03 ML 31 GAUGE X 516
(Advocate Syringes) 2
CARETOUCH PEN NEEDLE 29G 12MM 29 GAUGE X 12
(pen needle diabetic) 2
CARETOUCH PEN NEEDLE 31GX14 31 GAUGE X 14
(pen needle diabetic) 2
CARETOUCH PEN NEEDLE 31GX316 31 GAUGE X 316
(pen needle diabetic) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
114
Drug Name Drug Tier RequirementsLimits
CARETOUCH PEN NEEDLE 31GX516 31 GAUGE X 516
(pen needle diabetic) 2
CARETOUCH PEN NEEDLE 32GX316 32 GAUGE X 316
(pen needle diabetic) 2
CARETOUCH PEN NEEDLE 32GX532 32 GAUGE X 532
(pen needle diabetic) 2
CARETOUCH SYR 03 ML 31GX516 03 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
CARETOUCH SYR 05 ML 30GX516 05 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
CARETOUCH SYR 05 ML 31GX516 05 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
CARETOUCH SYR 1 ML 28GX516 1 ML 28 X 516
2
CARETOUCH SYR 1 ML 29GX516 1 ML 29 GAUGE X 516
2
CARETOUCH SYR 1 ML 30GX516 1 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
CARETOUCH SYR 1 ML 31GX516 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
CLICKFINE 31G X 516 NEEDLES 8MM UNIVERSAL 31 GAUGE X 516
(pen needle diabetic) 2
CLICKFINE PEN NEEDLE 32GX532 32GX4MM STERILE 32 GAUGE X 532
(pen needle diabetic) 2
CLICKFINE UNIVERSAL 31G X 14 6MM STORE BRAND 31 GAUGE X 14
(pen needle diabetic) 2
COMFORT EZ INS 03 ML 30GX12 03 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
COMFORT EZ INS 03 ML 30GX516 03 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
115
Drug Name Drug Tier RequirementsLimits
COMFORT EZ INS 1 ML 31GX516 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
COMFORT EZ INSULIN SYR 03 ML 03 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
COMFORT EZ INSULIN SYR 05 ML 05 ML 30 GAUGE X 516 05 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
COMFORT EZ PEN NEEDLE 12MM 29G 29 GAUGE X 12
(pen needle diabetic) 2
COMFORT EZ PEN NEEDLES 4MM 32G SINGLE USE MICRO 32 GAUGE X 532
(pen needle diabetic) 2
COMFORT EZ PEN NEEDLES 4MM 33G SINGLE USEMICROHRI 33 GAUGE X 532
(pen needle diabetic) 2
COMFORT EZ PEN NEEDLES 5MM 31G LATEX-FREE MINI 31 GAUGE X 316
(pen needle diabetic) 2
COMFORT EZ PEN NEEDLES 5MM 32G SINGLE USEMINIHRI 32 GAUGE X 316
(pen needle diabetic) 2
COMFORT EZ PEN NEEDLES 5MM 33G 33 GAUGE X 316
2
COMFORT EZ PEN NEEDLES 6MM 31G LATEX-FREE 31 GAUGE X 14
(pen needle diabetic) 2
COMFORT EZ PEN NEEDLES 6MM 32G SINGLE USE HRI 32 GAUGE X 14
(pen needle diabetic) 2
COMFORT EZ PEN NEEDLES 6MM 33G 33 GAUGE X 14
2
COMFORT EZ PEN NEEDLES 8MM 31G LATEX-FREE SHORT 31 GAUGE X 516
(pen needle diabetic) 2
COMFORT EZ PEN NEEDLES 8MM 32G 32 GAUGE X 516
2
COMFORT EZ PEN NEEDLES 8MM 33G 33 GAUGE X 516
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
116
Drug Name Drug Tier RequirementsLimits
COMFORT EZ SYR 03 ML 29GX12 03 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
COMFORT EZ SYR 05 ML 28GX12 12 ML 28 GAUGE X 12
(insulin syringe-needle u-100)
2
COMFORT EZ SYR 05 ML 29GX12 05 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
COMFORT EZ SYR 05 ML 30GX12 05 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
COMFORT EZ SYR 1 ML 28GX12 1 ML 28 GAUGE X 12
(insulin syringe-needle u-100)
2
COMFORT EZ SYR 1 ML 29GX12 1 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
COMFORT EZ SYR 1 ML 30GX12 1 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
COMFORT EZ SYR 1 ML 30GX516 1 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
COMFORT POINT PEN NDL 31GX13 31 GAUGE X 13
2
COMFORT POINT PEN NDL 31GX16 31 GAUGE X 16
2
COMFORT TOUCH PEN NDL 31G 4MM 31 GAUGE X 532
2
COMFORT TOUCH PEN NDL 31G 5MM 31 GAUGE X 316
(pen needle diabetic) 2
COMFORT TOUCH PEN NDL 31G 6MM 31 GAUGE X 14
(pen needle diabetic) 2
COMFORT TOUCH PEN NDL 31G 8MM 31 GAUGE X 516
(pen needle diabetic) 2
COMFORT TOUCH PEN NDL 32G 4MM 32 GAUGE X 532
(pen needle diabetic) 2
COMFORT TOUCH PEN NDL 32G 5MM 32 GAUGE X 316
(pen needle diabetic) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
117
Drug Name Drug Tier RequirementsLimits
COMFORT TOUCH PEN NDL 32G 6MM 32 GAUGE X 14
(pen needle diabetic) 2
COMFORT TOUCH PEN NDL 32G 8MM 32 GAUGE X 516
2
COMFORT TOUCH PEN NDL 33G 6MM 33 GAUGE X 14
2
COMFORT TOUCH PEN NDL 33GX4MM 33 GAUGE X 532
(pen needle diabetic) 2
COMFORT TOUCH PEN NDL 33GX5MM 33 GAUGE X 316
2
CURAD GAUZE PADS 2 X 2 2 X 2
(gauze bandage) 1 GC
CURITY GAUZE SPONGES (12 PLY)-200BAG 2 X 2
1 GC
CURITY GUAZE PADS 1S(12 PLY) 2 X 2
(gauze bandage) 1 GC
DERMACEA 2X2 GAUZE 12 PLY USP TYPE VII 2 X 2
(gauze bandage) 1 GC
DERMACEA GAUZE 2X2 SPONGE 8 PLY LATEX-FREE 2 X 2
1 GC
DERMACEA NON-WOVEN 2X2 SPNGE 2 X 2
1 GC
DROPLET 05 ML 29GX125MM(12) 05 ML 29 GAUGE X 12
2
DROPLET 05 ML 30GX125MM(12) 05 ML 30 GAUGE X 12
2
DROPLET INS 03 ML 29GX125MM 03 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
DROPLET INS 03 ML 30GX125MM 03 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
DROPLET INS 05 ML 30GX6MM(12) 05ML 30 GAUGE X 1564
2
DROPLET INS 05 ML 30GX8MM(12) 05 ML 30 GAUGE X 516
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
118
Drug Name Drug Tier RequirementsLimits
DROPLET INS 05 ML 31GX6MM(12) 05 ML 31 GAUGE X 1564
2
DROPLET INS 05 ML 31GX8MM(12) 05 ML 31 GAUGE X 516
2
DROPLET INS SYR 03 ML 30GX6MM 03 ML 30 GAUGE X 1564
2
DROPLET INS SYR 03 ML 30GX8MM 03 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
DROPLET INS SYR 03 ML 31GX6MM 03 ML 31 GAUGE X 1564
(insulin syringe-needle u-100)
2
DROPLET INS SYR 03 ML 31GX8MM 03 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
DROPLET INS SYR 1 ML 29GX125MM 1 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
DROPLET INS SYR 1 ML 30GX125MM 1 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
DROPLET INS SYR 1 ML 30GX6MM 1 ML 30 GAUGE X 1564
2
DROPLET INS SYR 1 ML 30GX8MM 1 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
DROPLET INS SYR 1 ML 31GX6MM 1 ML 31 GAUGE X 1564
(insulin syringe-needle u-100)
2
DROPLET INS SYR 1 ML 31GX8MM 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
DROPLET MICRON 34G X 964 34 GAUGE X 964
2
DROPLET PEN NEEDLE 29GX12 29 GAUGE X 12
(pen needle diabetic) 2
DROPLET PEN NEEDLE 29GX38 29 GAUGE X 38
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
119
Drug Name Drug Tier RequirementsLimits
DROPLET PEN NEEDLE 30GX516 30 GAUGE X 516
(pen needle diabetic) 2
DROPLET PEN NEEDLE 31GX14 31 GAUGE X 14
(pen needle diabetic) 2
DROPLET PEN NEEDLE 31GX316 31 GAUGE X 316
(pen needle diabetic) 2
DROPLET PEN NEEDLE 31GX516 31 GAUGE X 516
(pen needle diabetic) 2
DROPLET PEN NEEDLE 32GX14 32 GAUGE X 14
(pen needle diabetic) 2
DROPLET PEN NEEDLE 32GX316 32 GAUGE X 316
(pen needle diabetic) 2
DROPLET PEN NEEDLE 32GX516 32 GAUGE X 516
2
DROPLET PEN NEEDLE 32GX532 32 GAUGE X 532
(pen needle diabetic) 2
DROPSAFE PEN NEEDLE 31GX14 31 GAUGE X 14
2
DROPSAFE PEN NEEDLE 31GX516 31 GAUGE X 516
2
DRUG MART ULTRA COMFORT SYR 03 ML 29 GAUGE X 12 03 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
DRUG MART ULTRA COMFORT SYR 05ML 05 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
DRUG MART ULTRA COMFORT SYR 1ML 1 ML 29 GAUGE X 12 1 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
EASY COMFORT 03 ML SYRINGE 03 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
EASY COMFORT 05 ML 30GX12 05 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
EASY COMFORT 05 ML 31GX516 05 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
120
Drug Name Drug Tier RequirementsLimits
EASY COMFORT 05 ML 32GX516 12 ML 32 GAUGE X 516
2
EASY COMFORT 05 ML SYRINGE 05 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
EASY COMFORT 1 ML 31GX516 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
EASY COMFORT 1 ML 32GX516 1 ML 32 GAUGE X 516
2
EASY COMFORT INSULIN 1 ML SYR 1 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
EASY COMFORT PEN NDL 31GX14 31 GAUGE X 14
(pen needle diabetic) 2
EASY COMFORT PEN NDL 31GX316 31 GAUGE X 316
(pen needle diabetic) 2
EASY COMFORT PEN NDL 31GX516 31 GAUGE X 516
(pen needle diabetic) 2
EASY COMFORT PEN NDL 32GX532 32 GAUGE X 532
(pen needle diabetic) 2
EASY COMFORT PEN NDL 33G 4MM 33 GAUGE X 532
(pen needle diabetic) 2
EASY COMFORT PEN NDL 33G 5MM 33 GAUGE X 316
2
EASY COMFORT PEN NDL 33G 6MM 33 GAUGE X 14
2
EASY COMFORT SYR 1 ML 30GX12 1 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
EASY GLIDE INS 03 ML 31GX6MM 03 ML 31 GAUGE X 1564
(insulin syringe-needle u-100)
2
EASY GLIDE INS 05 ML 31GX6MM 12 ML 31 GAUGE X 1564
(insulin syringe-needle u-100)
2
EASY GLIDE INS 1 ML 31GX6MM 1 ML 31 GAUGE X 1564
(insulin syringe-needle u-100)
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
121
Drug Name Drug Tier RequirementsLimits
EASY GLIDE PEN NEEDLE 4MM 33G 33 GAUGE X 532
(pen needle diabetic) 2
EASY TOUCH 03 ML SYR 30GX12 03 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
EASY TOUCH 05 ML SYR 27GX12 12 ML 27 GAUGE X 12
(insulin syringe-needle u-100)
2
EASY TOUCH 05 ML SYR 29GX12 05 ML 29 GAUGE X 12
2
EASY TOUCH 05 ML SYR 30GX12 05 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
EASY TOUCH 05 ML SYR 30GX516 05 ML 30 GAUGE X 516
2
EASY TOUCH 1 ML SYR 27GX12 1 ML 27 GAUGE X 12
(insulin syringe-needle u-100)
2
EASY TOUCH 1 ML SYR 29GX12 1 ML 29 GAUGE X 12
2
EASY TOUCH 1 ML SYR 30GX12 1 ML 30 GAUGE X 12
2
EASY TOUCH FLIPLOK 1 ML 27GX05 1 ML 27 GAUGE X 12
2
EASY TOUCH INSULIN 1 ML 29GX12 1 ML 29 GAUGE X 12
2
EASY TOUCH INSULIN 1 ML 30GX12 1 ML 30 GAUGE X 12
2
EASY TOUCH INSULIN SYR 03 ML 03 ML 30 GAUGE X 516 03 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
EASY TOUCH INSULIN SYR 05 ML 05 ML 30 GAUGE X 516 05 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
EASY TOUCH INSULIN SYR 1 ML 1 ML 30 GAUGE X 516 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
122
Drug Name Drug Tier RequirementsLimits
EASY TOUCH INSULIN SYR 1 ML RETRACTABLE 1 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
EASY TOUCH INSULN 1 ML 29GX12 1 ML 29 GAUGE X 12
2
EASY TOUCH INSULN 1 ML 30GX12 1 ML 30 GAUGE X 12
2
EASY TOUCH INSULN 1 ML 30GX516 1 ML 30 GAUGE X 516
2
EASY TOUCH INSULN 1 ML 30GX516 1 ML 30 GAUGE X 516
2
EASY TOUCH INSULN 1 ML 31GX516 1 ML 31 GAUGE X 516
2
EASY TOUCH INSULN 1 ML 31GX516 1 ML 31 GAUGE X 516
2
EASY TOUCH LUER LOK INSUL 1 ML 1 ML
(insulin syringe needleless)
2
EASY TOUCH PEN NEEDLE 29GX12 29 GAUGE X 12
(pen needle diabetic) 2
EASY TOUCH PEN NEEDLE 30GX516 30 GAUGE X 516
(pen needle diabetic) 2
EASY TOUCH PEN NEEDLE 31GX14 31 GAUGE X 14
(pen needle diabetic) 2
EASY TOUCH PEN NEEDLE 31GX316 31 GAUGE X 316
(pen needle diabetic) 2
EASY TOUCH PEN NEEDLE 31GX516 31 GAUGE X 516
(pen needle diabetic) 2
EASY TOUCH PEN NEEDLE 32GX14 32 GAUGE X 14
(pen needle diabetic) 2
EASY TOUCH PEN NEEDLE 32GX316 32 GAUGE X 316
(pen needle diabetic) 2
EASY TOUCH PEN NEEDLE 32GX532 32 GAUGE X 532
(pen needle diabetic) 2
EASY TOUCH SAF PEN NDL 29G 5MM 29 GAUGE X 316
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
123
Drug Name Drug Tier RequirementsLimits
EASY TOUCH SAF PEN NDL 29G 8MM 29 GAUGE X 516
2
EASY TOUCH SAF PEN NDL 30G 5MM 30 GAUGE X 316
2
EASY TOUCH SAF PEN NDL 30G 8MM 30 GAUGE X 516
2
EASY TOUCH SYR 05 ML 28G 127MM 12 ML 28 GAUGE X 12
(insulin syringe-needle u-100)
2
EASY TOUCH SYR 05 ML 29G 127MM 05 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
EASY TOUCH SYR 1 ML 27G 16MM 1 ML 27 GAUGE X 58
2
EASY TOUCH SYR 1 ML 28G 127MM 1 ML 28 GAUGE X 12
(insulin syringe-needle u-100)
2
EASY TOUCH SYR 1 ML 29G 127MM 1 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
EASY TOUCH UNI-SLIP SYR 1 ML 1 ML
(insulin syringe needleless)
2
EASYTOUCH SAF PEN NDL 30G 6MM 30 GAUGE X 14
2
EQL INSULIN 03 ML SYRINGE SHORT NEEDLE 03 ML 30
(Ultra Comfort Insulin Syringe)
2
EQL INSULIN 05 ML SYRINGE SHORT NEEDLE 12 ML 30 GAUGE
(Lite Touch Insulin Syringe)
2
EQL INSULIN 1 ML SYRINGE SHORT NEEDLE 1 ML 30 GAUGE X 716
(Lite Touch Insulin Syringe)
2
EXEL INSULIN SYRINGE 27G-1 ML 1 ML 27 GAUGE X 12
(insulin syringe-needle u-100)
2
FIFTY50 INS 05 ML 31GX516 SHORT NEEDLE 05 ML 31 GAUGE X 516
(Advocate Syringes) 2
FIFTY50 INS SYR 1 ML 31GX516 SHORT NEEDLE 1 ML 31 GAUGE X 516
(Advocate Syringes) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
124
Drug Name Drug Tier RequirementsLimits
FIFTY50 PEN 31G X 316 NEEDLE (OTC) 31 GAUGE X 316
(pen needle diabetic) 2
FIFTY50 PEN NEEDLE 32G X 14 32 GAUGE X 14
(BD Ultra-Fine Micro Pen Needle)
2
FP INSULIN 1 ML SYRINGE 1 ML 28 GAUGE
(Lite Touch Insulin Syringe)
2
FREESTYLE PREC 05 ML 30GX516 05 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
FREESTYLE PREC 05 ML 31GX516 05 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
FREESTYLE PREC 1 ML 30GX516 1 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
FREESTYLE PREC 1 ML 31GX516 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
GAUZE PAD TOPICAL BANDAGE 2 X 2
(gauze bandage) 1 GC
GNP ULT C 03 ML 29GX12 (12) 03 ML 29 GAUGE X 12
2
GNP ULTRA COMFORT 05 ML SYR 12 ML 29 12 ML 30 GAUGE
(insulin syringe-needle u-100)
2
GNP ULTRA COMFORT 1 ML SYRINGE 1 ML 28 GAUGE 1 ML 30 GAUGE X 716
(insulin syringe-needle u-100)
2
GNP ULTRA COMFORT 1 ML SYRINGE 1 ML 29 GAUGE
2
GNP ULTRA COMFORT 310 ML SYR 03 ML 30
(insulin syringe-needle u-100)
2
HEALTHWISE INS 03 ML 30GX516 03 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
HEALTHWISE INS 03 ML 31GX516 03 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
125
Drug Name Drug Tier RequirementsLimits
HEALTHWISE INS 05 ML 30GX516 05 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
HEALTHWISE INS 05 ML 31GX516 05 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
HEALTHWISE INS 1 ML 30GX516 1 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
HEALTHWISE INS 1 ML 31GX516 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
HEALTHWISE PEN NEEDLE 31G 5MM 31 GAUGE X 316
(pen needle diabetic) 2
HEALTHWISE PEN NEEDLE 31G 8MM 31 GAUGE X 516
(pen needle diabetic) 2
HEALTHWISE PEN NEEDLE 32G 4MM 32 GAUGE X 532
(pen needle diabetic) 2
HEALTHY ACCENTS PENTIP 4MM 32G 32 GAUGE X 532
(pen needle diabetic) 2
HEALTHY ACCENTS PENTIP 5MM 31G 31 GAUGE X 316
(pen needle diabetic) 2
HEALTHY ACCENTS PENTIP 6MM 31G 31 GAUGE X 14
(pen needle diabetic) 2
HEALTHY ACCENTS PENTIP 8MM 31G 31 GAUGE X 516
(pen needle diabetic) 2
HEALTHY ACCENTS PENTP 12MM 29G 29 GAUGE X 12
2
INCONTROL PEN NEEDLE 12MM 29G 29 GAUGE X 12
(pen needle diabetic) 2
INCONTROL PEN NEEDLE 4MM 32G 32 GAUGE X 532
(pen needle diabetic) 2
INCONTROL PEN NEEDLE 5MM 31G 31 GAUGE X 316
(pen needle diabetic) 2
INCONTROL PEN NEEDLE 6MM 31G 31 GAUGE X 14
(pen needle diabetic) 2
INCONTROL PEN NEEDLE 8MM 31G 31 GAUGE X 516
(pen needle diabetic) 2
INSULIN SYR 03 ML 30GX516 03 ML 30 GAUGE X 516
(Advocate Syringes) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
126
Drug Name Drug Tier RequirementsLimits
INSULIN SYR 03 ML 31GX14(12) 03 ML 31 GAUGE X 14
(UltiCare Insuln Syr(half unit))
2
INSULIN SYRIN 03 ML 30GX12 SHORT NEEDLE 03 ML 30 GAUGE X 12
(Comfort EZ Insulin Syringe)
2
INSULIN SYRIN 05 ML 28GX12 12 ML 28 GAUGE X 12
(Comfort EZ Insulin Syringe)
2
INSULIN SYRIN 05 ML 30GX12 SHORT NEEDLE (OTC) 05 ML 30 GAUGE X 12
(Comfort EZ Insulin Syringe)
2
INSULIN SYRIN 05 ML 30GX516 SHORT NEEDLE (OTC) 05 ML 30 GAUGE X 516
(Advocate Syringes) 2
INSULIN SYRING 05 ML 27GX12 12 ML 27 GAUGE X 12
(Easy Touch Insulin Syringe)
2
INSULIN SYRINGE 03 ML 03 ML 29 GAUGE
(insulin syringe-needle u-100)
2
INSULIN SYRINGE 03 ML 31GX14 03 ML 31 GAUGE X 14
(Sure Comfort Insulin Syringe)
2
INSULIN SYRINGE 05 ML 12 ML 29
(insulin syringe-needle u-100)
2
INSULIN SYRINGE 05 ML 31GX14 12 ML 31 GAUGE X 14
(Sure Comfort Insulin Syringe)
2
INSULIN SYRINGE 1 ML 1 ML 29 GAUGE
2
INSULIN SYRINGE 1 ML 30GX12 (RX) 1 ML 30 GAUGE X 12
(BD Eclipse Luer-Lok) 2
INSULIN SYRINGE 1 ML 30GX516 SHORT NEEDLE (OTC) 1 ML 30 GAUGE X 516
(Advocate Syringes) 2
INSULIN SYRINGE 1 ML 31GX14 1 ML 31 GAUGE X 14
(Sure Comfort Insulin Syringe)
2
INSULIN SYRINGE-NEEDLE U-100 SYRINGE 03 ML 29 GAUGE
(Ultilet Insulin Syringe) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
127
Drug Name Drug Tier RequirementsLimits
INSULIN SYRINGE-NEEDLE U-100 SYRINGE 1 ML 29 GAUGE X 12
(Advocate Syringes) 2
INSULIN SYRINGE-NEEDLE U-100 SYRINGE 12 ML 28 GAUGE
(Lite Touch Insulin Syringe)
2
INSUPEN 30G ULTRAFIN NEEDLE 30 GAUGE X 516
(pen needle diabetic) 2
INSUPEN 31G ULTRAFIN NEEDLE 31 GAUGE X 14 31 GAUGE X 516
(pen needle diabetic) 2
INSUPEN 32G 6MM PEN NEEDLE 32 GAUGE X 14
(pen needle diabetic) 2
INSUPEN 32G 8MM PEN NEEDLE 32 GAUGE X 516
2
INSUPEN PEN NEEDLE 29GX12MM 29 GAUGE X 12
(pen needle diabetic) 2
INSUPEN PEN NEEDLE 31GX316 31 GAUGE X 316
(pen needle diabetic) 2
INSUPEN PEN NEEDLE 32GX4MM 32 GAUGE X 532
(pen needle diabetic) 2
INSUPEN PEN NEEDLE 33GX4MM 33 GAUGE X 532
(pen needle diabetic) 2
KRO PEN NEEDLE 4MM X 33G 33 GAUGE X 532
(Advocate Pen Needle) 2
LISCO SPONGES 100BAG 2 X 2
1 GC
LITE TOUCH 31GX14 PEN NEEDLE 31 GAUGE X 14
(pen needle diabetic) 2
LITE TOUCH INSULIN 05 ML SYR 12 ML 28 GAUGE 12 ML 29 12 ML 30 GAUGE
(insulin syringe-needle u-100)
2
LITE TOUCH INSULIN 1 ML SYR 1 ML 28 GAUGE 1 ML 30 GAUGE X 716
(insulin syringe-needle u-100)
2
LITE TOUCH INSULIN 1 ML SYR 1 ML 29 GAUGE
2
LITE TOUCH INSULIN SYR 1 ML 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
LITE TOUCH PEN NEEDLE 29G 29 GAUGE X 12
(pen needle diabetic) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
128
Drug Name Drug Tier RequirementsLimits
LITE TOUCH PEN NEEDLE 31G 31 GAUGE X 316 31 GAUGE X 516
(pen needle diabetic) 2
LITETOUCH INS 03 ML 29GX12 03 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
LITETOUCH INS 03 ML 30GX516 03 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
LITETOUCH INS 03 ML 31GX516 03 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
LITETOUCH INS 05 ML 31GX516 05 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
LITETOUCH SYR 05 ML 28GX12 12 ML 28 GAUGE X 12
(insulin syringe-needle u-100)
2
LITETOUCH SYR 05 ML 29GX12 05 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
LITETOUCH SYR 05 ML 30GX516 05 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
LITETOUCH SYRIN 1 ML 28GX12 1 ML 28 GAUGE X 12
(insulin syringe-needle u-100)
2
LITETOUCH SYRIN 1 ML 29GX12 1 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
LITETOUCH SYRIN 1 ML 30GX516 1 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
MAGELLAN INSUL SYRINGE 03 ML 03 ML 30 X 516
2
MAGELLAN INSUL SYRINGE 05 ML 05 ML 30 GAUGE X 516
2
MAGELLAN INSULIN SYR 03 ML 03 ML 29 X 12
2
MAGELLAN INSULIN SYR 05 ML 05 ML 29 GAUGE X 12
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
129
Drug Name Drug Tier RequirementsLimits
MAGELLAN INSULIN SYRINGE 1 ML 1 ML 29 GAUGE X 12 1 ML 30 GAUGE X 516
2
MAXICOMFORT II PEN NDL 31GX6MM 31 GAUGE X 14
(pen needle diabetic) 2
MAXICOMFORT INS 05 ML 27GX12 12 ML 27 GAUGE X 12
(insulin syringe-needle u-100)
2
MAXI-COMFORT INS 05 ML 28G 12 ML 28 GAUGE X 12
(insulin syringe-needle u-100)
2
MAXICOMFORT INS 1 ML 27GX12 1 ML 27 GAUGE X 12
(insulin syringe-needle u-100)
2
MAXI-COMFORT INS 1 ML 28GX12 1 ML 28 GAUGE X 12
(insulin syringe-needle u-100)
2
MAXICOMFORT PEN NDL 29G X 5MM 29 GAUGE X 316
2
MAXICOMFORT PEN NDL 29G X 8MM 29 GAUGE X 516
2
MICRODOT PEN NEEDLE 31GX6MM 31 GAUGE X 14
(pen needle diabetic) 2
MICRODOT PEN NEEDLE 32GX4MM 32 GAUGE X 532
(pen needle diabetic) 2
MICRODOT PEN NEEDLE 33GX4MM 33 GAUGE X 532
(pen needle diabetic) 2
MINI ULTRA-THIN II PEN NDL 31G LATEX-FREESTERILE 31 GAUGE X 316
(pen needle diabetic) 2
MONOJECT 05 ML SYRN 28GX12 12 ML 28 GAUGE
(insulin syringe-needle u-100)
2
MONOJECT 1 ML SYRN 27X12 1 ML 27 GAUGE X 12
(insulin syringe-needle u-100)
2
MONOJECT 1 ML SYRN 28GX12 (OTC) 1 ML 28 GAUGE X 12
(insulin syringe-needle u-100)
2
MONOJECT INSUL SYR U100 (OTC) 03 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
130
Drug Name Drug Tier RequirementsLimits
MONOJECT INSUL SYR U100 5ML29GX12 (OTC) 05 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
MONOJECT INSUL SYR U100 05 ML CONVERTS TO 29G (OTC) 12 ML 28 GAUGE X 12
(insulin syringe-needle u-100)
2
MONOJECT INSUL SYR U100 1 ML 1 ML 25 GAUGE X 58
(insulin syringe-needle u-100)
2
MONOJECT INSUL SYR U100 1 ML 3S 29GX12 (OTC) 1 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
MONOJECT INSUL SYR U100 1 ML WO NEEDLE (OTC) 1 ML
(insulin syringes (disposable))
2
MONOJECT INSULIN SYR 03 ML (OTC) 03 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
MONOJECT INSULIN SYR 03 ML 03 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
MONOJECT INSULIN SYR 05 ML (OTC) 05 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
MONOJECT INSULIN SYR 05 ML 05 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
MONOJECT INSULIN SYR 1 ML 3S (OTC) 1 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
MONOJECT INSULIN SYR U-100 05 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
MONOJECT INSULIN SYR U-100 29 GAUGE X 12
2
MONOJECT SYRINGE 03 ML 03 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
MONOJECT SYRINGE 05 ML 05 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
MONOJECT SYRINGE 1 ML 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
NOVOFINE 30 NEEDLE 30 GAUGE X 13
2
NOVOFINE 32G NEEDLES 32 GAUGE X 14
(pen needle diabetic) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
131
Drug Name Drug Tier RequirementsLimits
NOVOFINE PLUS PEN NDL 32GX16 32 GAUGE X 16
2
NOVOTWIST NEEDLE 32G 5MM 32 GAUGE X 15
2
OMNIPOD DASH 5 PACK POD SUBCUTANEOUS CARTRIDGE
3
OMNIPOD DASH PDM KIT 3 QL (1 per 365 days)
OMNIPOD INSULIN MANAGEMENT
3 QL (1 per 365 days)
OMNIPOD INSULIN REFILL SUBCUTANEOUS CARTRIDGE
3
PC UNIFINE PENTIPS 8MM NEEDLE SHORT 31 GAUGE X 516
(pen needle diabetic) 2
PEN NEEDLE 30G X 516 30 GAUGE X 516
(pen needle diabetic) 2
PEN NEEDLE 30G X 8MM 30 GAUGE X 516
(AboutTime Pen Needle)
2
PEN NEEDLE 32G X 316 32 GAUGE X 316
(CareFine Pen Needle) 2
PEN NEEDLE 32G X 532 4MM 32 GAUGE X 532
(1st Tier Unifine Pentips)
2
PEN NEEDLE DIABETIC NEEDLE 29 GAUGE X 12
(1st Tier Unifine Pentips Plus)
2
PEN NEEDLES 12MM 29G 29GX12MMSTRL 29 GAUGE X 12
(pen needle diabetic) 2
PEN NEEDLES 4MM 32G 32 GAUGE X 532
(pen needle diabetic) 2
PEN NEEDLES 6MM 31G 31GX6MM STRL 31 GAUGE X 14
(1st Tier Unifine Pentips)
2
PEN NEEDLES 8MM 31G 31GX8MMSTRLSHORT (OTC) 31 GAUGE X 516
(pen needle diabetic) 2
PENTIPS PEN NEEDLE 29GX12 29 GAUGE X 12
(pen needle diabetic) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
132
Drug Name Drug Tier RequirementsLimits
PENTIPS PEN NEEDLE 31GX316 MINI 5MM 31 GAUGE X 316
(pen needle diabetic) 2
PENTIPS PEN NEEDLE 31GX516 SHORT 8MM 31 GAUGE X 516
(pen needle diabetic) 2
PENTIPS PEN NEEDLE 32GX532 4MM 32 GAUGE X 532
(pen needle diabetic) 2
PENTIPS PEN NEEDLE 6MM 31G 31 GAUGE X 14
(pen needle diabetic) 2
PIP PEN NEEDLE 31G X 5MM 31 GAUGE X 316
(pen needle diabetic) 2
PIP PEN NEEDLE 32G X 4MM 32 GAUGE X 532
(pen needle diabetic) 2
PREVENT PEN NEEDLE 31GX14 31 GAUGE X 14
2
PREVENT PEN NEEDLE 31GX516 31 GAUGE X 516
2
PRO COMFORT 05 ML 30GX12 05 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
PRO COMFORT 05 ML 30GX516 05 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
PRO COMFORT 05 ML 31GX516 05 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
PRO COMFORT 1 ML 30GX12 1 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
PRO COMFORT 1 ML 30GX516 1 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
PRO COMFORT 1 ML 31GX516 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
PRO COMFORT PEN NDL 31GX516 31 GAUGE X 516
(pen needle diabetic) 2
PRO COMFORT PEN NDL 32G X 14 32 GAUGE X 14
(pen needle diabetic) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
133
Drug Name Drug Tier RequirementsLimits
PRO COMFORT PEN NDL 4MM 32G 32 GAUGE X 532
(pen needle diabetic) 2
PRO COMFORT PEN NDL 5MM 32G 32 GAUGE X 316
(pen needle diabetic) 2
PRODIGY INS SYR 1 ML 28GX12 1 ML 28 GAUGE X 12
(insulin syringe-needle u-100)
2
PRODIGY SYRNG 05 ML 31GX516 05 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
PRODIGY SYRNGE 03 ML 31GX516 03 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
PURE COMFORT PEN NDL 32G 4MM 32 GAUGE X 532
(pen needle diabetic) 2
PURE COMFORT PEN NDL 32G 5MM 32 GAUGE X 316
(pen needle diabetic) 2
PURE COMFORT PEN NDL 32G 6MM 32 GAUGE X 14
(pen needle diabetic) 2
PURE COMFORT PEN NDL 32G 8MM 32 GAUGE X 516
2
RELI ON 31G X 14 NEEDLES 31 GAUGE X 14
(pen needle diabetic) 2
RELION INS SYR 03 ML 31GX6MM 03 ML 31 GAUGE X 1564
(BD Veo Insulin Syringe UF)
2
RELION INS SYR 05 ML 31GX6MM 12 ML 31 GAUGE X 1564
(BD Veo Insulin Syringe UF)
2
RELION INS SYR 1 ML 31GX1564 1 ML 31 GAUGE X 1564
(BD Veo Insulin Syringe UF)
2
RELI-ON INSULIN 05 ML SYR 12 ML 29
(Lite Touch Insulin Syringe)
2
RELI-ON INSULIN 1 ML SYR 1 ML 29 GAUGE X 716
2
RELION MINI PEN 31G X 14 NDL 31 GAUGE X 14
(pen needle diabetic) 2
RELION PEN NEEDLE 31G 6MM 31 GAUGE X 1564
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
134
Drug Name Drug Tier RequirementsLimits
RELION PEN NEEDLES 32GX532 32 GAUGE X 532
(pen needle diabetic) 2
SAFESNAP INS SYR UNITS-100 03 ML 30GX51610X10LF 03 ML 30 GAUGE X 516
2
SAFESNAP INS SYR UNITS-100 05 ML 29GX1210X10LF 05 ML 29 GAUGE X 12
2
SAFESNAP INS SYR UNITS-100 05 ML 30GX51610X10LF 05 ML 30 GAUGE X 516
2
SAFESNAP INS SYR UNITS-100 1 ML 28GX1210X10LF 1 ML 28 GAUGE X 12
2
SAFESNAP INS SYR UNITS-100 1 ML 29GX1210X10LF 1 ML 29 GAUGE X 12
2
SAFETY PEN NEEDLE 5MM X 31G 31 GAUGE X 316
2
SECURESAFE PEN NDL 30GX516 OUTER 30 GAUGE X 516
2
SM STERILE PADS 2 X 2 2X2 STERILE 2 X 2
(gauze bandage) 1 GC
SM ULT CFT 03 ML 31GX516(12) 03 ML 31 GAUGE X 516
2
SURE CMFT SFTY PEN NDL 31G 6MM 31 GAUGE X 14
2
SURE CMFT SFTY PEN NDL 32G 4MM 32 GAUGE X 532
2
NEEDLES INSULIN DISP SAFETY
(insulin syringe-needle u-100)
2
SURE COMFORT 05 ML SYRINGE 05 ML 30 GAUGE X 12 05 ML 30 GAUGE X 516 05 ML 31 GAUGE X 516 12 ML 28 GAUGE X 12
(insulin syringe-needle u-100)
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
135
Drug Name Drug Tier RequirementsLimits
SURE COMFORT 1 ML SYRINGE 1 ML 28 GAUGE X 12 1 ML 29 GAUGE X 12 1 ML 30 GAUGE X 12 1 ML 30 GAUGE X 516 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
SURE COMFORT 310 ML SYRINGE 03 ML 29 GAUGE X 12 03 ML 30 GAUGE X 12 03 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
SURE COMFORT 310 ML SYRINGE INSULIN SYRINGE 03 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
SURE COMFORT 30G PEN NEEDLE 30 GAUGE X 516
(pen needle diabetic) 2
SURE COMFORT 31G PEN NEEDLE 31 GAUGE X 516
(pen needle diabetic) 2
SURE COMFORT INS 03 ML 31GX14 03 ML 31 GAUGE X 14
(insulin syringe-needle u-100)
2
SURE COMFORT INS 05 ML 31GX14 12 ML 31 GAUGE X 14
(insulin syringe-needle u-100)
2
SURE COMFORT INS 1 ML 31GX14 1 ML 31 GAUGE X 14
(insulin syringe-needle u-100)
2
SURE COMFORT PEN NDL 29GX12 127MM 29 GAUGE X 12
(pen needle diabetic) 2
SURE COMFORT PEN NDL 31GX316 31 GAUGE X 316
(pen needle diabetic) 2
SURE COMFORT PEN NDL 32GX14 32 GAUGE X 14
(pen needle diabetic) 2
SURE COMFORT PEN NDL 32GX532 32 GAUGE X 532
(pen needle diabetic) 2
SURE-FINE PEN NEEDLES 127MM 29 GAUGE X 12
(pen needle diabetic) 2
SURE-FINE PEN NEEDLES 5MM 31 GAUGE X 316
(pen needle diabetic) 2
SURE-FINE PEN NEEDLES 8MM 31 GAUGE X 516
(pen needle diabetic) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
136
Drug Name Drug Tier RequirementsLimits
SURE-JECT INSU SYR U100 03 ML 03 ML 29 GAUGE X 12 03 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
SURE-JECT INSU SYR U100 05 ML 05 ML 29 GAUGE X 12 05 ML 30 GAUGE X 516 12 ML 28 GAUGE X 12
(insulin syringe-needle u-100)
2
SURE-JECT INSU SYR U100 1 ML 1 ML 28 GAUGE X 12
(insulin syringe-needle u-100)
2
SURE-JECT INSUL SYR U100 1 ML 1 ML 29 GAUGE X 12 1 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
SURE-JECT INSULIN SYRINGE 1 ML 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
TECHLITE 03 ML 29GX12MM (12) 03 ML 29 GAUGE X 12
2
TECHLITE 03 ML 30GX12MM (12) 03 ML 30 GAUGE X 12
2
TECHLITE 03 ML 30GX8MM (12) 03 ML 30 GAUGE X 516
2
TECHLITE 03 ML 31GX6MM (12) 03 ML 31 GAUGE X 1564
2
TECHLITE 03 ML 31GX8MM (12) 03 ML 31 GAUGE X 516
2
TECHLITE 05 ML 29GX12MM (12) 05 ML 29 GAUGE X 12
2
TECHLITE 05 ML 30GX12MM (12) 05 ML 30 GAUGE X 12
2
TECHLITE 05 ML 30GX8MM (12) 05 ML 30 GAUGE X 516
2
TECHLITE 05 ML 31GX6MM (12) 05 ML 31 GAUGE X 1564
2
TECHLITE 05 ML 31GX8MM (12) 05 ML 31 GAUGE X 516
2
TECHLITE INS SYR 1 ML 29GX12MM 1 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
TECHLITE INS SYR 1 ML 30GX12MM 1 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
137
Drug Name Drug Tier RequirementsLimits
TECHLITE INS SYR 1 ML 30GX8MM 1 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
TECHLITE INS SYR 1 ML 31GX6MM 1 ML 31 GAUGE X 1564
(insulin syringe-needle u-100)
2
TECHLITE INS SYR 1 ML 31GX8MM 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
TECHLITE PEN NEEDLE 29GX12 29 GAUGE X 12
(pen needle diabetic) 2
TECHLITE PEN NEEDLE 29GX38 29 GAUGE X 38
2
TECHLITE PEN NEEDLE 31GX14 31 GAUGE X 14
(pen needle diabetic) 2
TECHLITE PEN NEEDLE 31GX316 31 GAUGE X 316
(pen needle diabetic) 2
TECHLITE PEN NEEDLE 31GX516 31 GAUGE X 516
(pen needle diabetic) 2
TECHLITE PEN NEEDLE 32GX14 32 GAUGE X 14
(pen needle diabetic) 2
TECHLITE PEN NEEDLE 32GX516 32 GAUGE X 516
2
TECHLITE PEN NEEDLE 32GX532 32 GAUGE X 532
(pen needle diabetic) 2
TERUMO INS SYR 03 ML 29GX12 03 ML 29 GAUGE X 12
(Advocate Syringes) 2
TERUMO INS SYRINGE U100-1 ML 1 ML 27 GAUGE X 12 1 ML 28 GAUGE X 12 1 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
TERUMO INS SYRINGE U100-1 ML 1 ML 30 GAUGE X 38
(Thinpro Insulin Syringe)
2
TERUMO INS SYRINGE U100-12 ML 12 ML 30 X 38
(insulin syringe-needle u-100)
2
TERUMO INS SYRINGE U100-13 ML 03 ML 30 X 38
(insulin syringe-needle u-100)
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
138
Drug Name Drug Tier RequirementsLimits
TERUMO INS SYRNG U100-12 ML 05 ML 29 GAUGE X 12 12 ML 27 GAUGE X 12 12 ML 28 GAUGE X 12
(insulin syringe-needle u-100)
2
THINPRO INS SYRIN U100-03 ML 03 ML 29 GAUGE X 12 03 ML 30 X 38
(insulin syringe-needle u-100)
2
THINPRO INS SYRIN U100-03 ML 03 ML 31 X 38
2
THINPRO INS SYRIN U100-05 ML 05 ML 29 GAUGE X 12 12 ML 28 GAUGE X 12 12 ML 30 X 38
(insulin syringe-needle u-100)
2
THINPRO INS SYRIN U100-05 ML 05 ML 31 X 38
2
THINPRO INS SYRIN U100-1 ML 1 ML 28 GAUGE X 12 1 ML 29 GAUGE X 12 1 ML 30 GAUGE X 38
(insulin syringe-needle u-100)
2
THINPRO INS SYRIN U100-1 ML 1 ML 31 X 38
2
TOPCARE CLICKFINE 31G X 14 31 GAUGE X 14
(pen needle diabetic) 2
TOPCARE CLICKFINE 31G X 516 31 GAUGE X 516
(pen needle diabetic) 2
TOPCARE ULTRA COMFORT SYRINGE 03 ML 29 GAUGE X 12 03 ML 30 GAUGE X 516 03 ML 31 GAUGE X 516 05 ML 29 GAUGE X 12 05 ML 30 GAUGE X 516 05 ML 31 GAUGE X 516 1 ML 29 GAUGE X 12 1 ML 30 GAUGE X 516 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
TRUE CMFRT PRO 05 ML 30G 516 05 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
TRUE CMFRT PRO 05 ML 31G 516 05 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
TRUE CMFRT PRO 05 ML 32G 516 12 ML 32 GAUGE X 516
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
139
Drug Name Drug Tier RequirementsLimits
TRUE COMFORT 05 ML 31GX516 05 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
TRUE COMFORT 1 ML 31GX516 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
TRUE COMFORT PEN NDL 31G 8MM 31 GAUGE X 516
(pen needle diabetic) 2
TRUE COMFORT PEN NDL 31GX5MM 31 GAUGE X 316
(pen needle diabetic) 2
TRUE COMFORT PEN NDL 31GX6MM 31 GAUGE X 14
(pen needle diabetic) 2
TRUE COMFORT PEN NDL 32G 5MM 32 GAUGE X 316
(pen needle diabetic) 2
TRUE COMFORT PEN NDL 32GX4MM 32 GAUGE X 532
(pen needle diabetic) 2
TRUE COMFORT PRO 1 ML 30G 12 1 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
TRUE COMFORT PRO 1 ML 30G 516 1 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
TRUE COMFORT PRO 1 ML 31G 516 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
TRUE COMFORT PRO 1 ML 32G 516 1 ML 32 GAUGE X 516
2
TRUE COMFRT PRO 05 ML 30G 12 05 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
TRUEPLUS PEN NEEDLE 29GX12 29 GAUGE X 12
(pen needle diabetic) 2
TRUEPLUS PEN NEEDLE 31G X 14 31 GAUGE X 14
(pen needle diabetic) 2
TRUEPLUS PEN NEEDLE 31GX316 31 GAUGE X 316
(pen needle diabetic) 2
TRUEPLUS PEN NEEDLE 31GX516 31 GAUGE X 516
(pen needle diabetic) 2
TRUEPLUS PEN NEEDLE 32GX532 32 GAUGE X 532
(pen needle diabetic) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
140
Drug Name Drug Tier RequirementsLimits
TRUEPLUS SYR 03 ML 29GX12 03 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
TRUEPLUS SYR 03 ML 30GX516 03 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
TRUEPLUS SYR 03 ML 31GX516 03 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
TRUEPLUS SYR 05 ML 28GX12 12 ML 28 GAUGE X 12
(insulin syringe-needle u-100)
2
TRUEPLUS SYR 05 ML 29GX12 05 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
TRUEPLUS SYR 05 ML 30GX516 05 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
TRUEPLUS SYR 05 ML 31GX516 05 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
TRUEPLUS SYR 1 ML 28GX12 1 ML 28 GAUGE X 12
(insulin syringe-needle u-100)
2
TRUEPLUS SYR 1 ML 29GX12 1 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
TRUEPLUS SYR 1 ML 30GX516 1 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
TRUEPLUS SYR 1 ML 31GX516 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
ULT CFT 03 ML 30GX516 (12) 03 ML 30 GAUGE X 516
2
ULTICAR INS 03 ML 31GX14(12) 03 ML 31 GAUGE X 14
(insulin syrndl u100 half mark)
2
ULTICARE INS 03 ML 31GX14 03 ML 31 GAUGE X 14
(insulin syringe-needle u-100)
2
ULTICARE INS 05 ML 31GX14 12 ML 31 GAUGE X 14
(insulin syringe-needle u-100)
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
141
Drug Name Drug Tier RequirementsLimits
ULTICARE INS 1 ML 31GX14 1 ML 31 GAUGE X 14
(insulin syringe-needle u-100)
2
ULTICARE INS SYR 1 ML 30GX12 30GX12 1 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
ULTICARE PEN NEEDLE 31GX316 31 GAUGE X 316
(pen needle diabetic) 2
ULTICARE PEN NEEDLE 6MM 31G 31 GAUGE X 14
(pen needle diabetic) 2
ULTICARE PEN NEEDLE 8MM 31G 31 GAUGE X 516
(pen needle diabetic) 2
ULTICARE PEN NEEDLES 12MM 29G 29 GAUGE X 12
(pen needle diabetic) 2
ULTICARE PEN NEEDLES 4MM 32G MICRO 32GX4MM 32 GAUGE X 532
(pen needle diabetic) 2
ULTICARE PEN NEEDLES 6MM 32G 32 GAUGE X 14
(pen needle diabetic) 2
ULTICARE SAFE PEN NDL 5MM 30G 30 GAUGE X 316
2
ULTICARE SAFE PEN NDL 8MM 30G 30 GAUGE X 516
2
ULTICARE SAFETY 05 ML 29GX12 LATEXFREE (RX) 05 ML 29 GAUGE X 12
(Advocate Syringes) 2
ULTICARE SYR 03 ML 30GX12 LATEX FREE 03 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
ULTICARE SYR 03 ML 31GX516 LATEX FREESHORT NDL 03 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
ULTICARE SYR 05 ML 30GX12 LATEX FREE 05 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
ULTICARE SYR 05 ML 31GX516 LATEX FREESHORT NDL 05 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
142
Drug Name Drug Tier RequirementsLimits
ULTICARE SYR 1 ML 31GX516 LATEX FREESHORT NDL 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
ULTIGUARD SAFE 1 ML 30G 127MM 1 ML 30 X 12
2
ULTIGUARD SAFE PACK 29G 127MM 29 GAUGE X 12
2
ULTIGUARD SAFE PACK 32G 4MM 32 GAUGE X 532
2
ULTIGUARD SAFE03 ML 30G 127MM 03 ML 30 X 12
2
ULTIGUARD SAFE05 ML 30G 127MM 12 ML 30 X 12
2
ULTIGUARD SAFEPACK 1 ML 31G 8MM 1 ML 31 X 516
2
ULTIGUARD SAFEPACK 31G 5MM 31 GAUGE X 316
2
ULTIGUARD SAFEPACK 31G 6MM 31 GAUGE X 14
2
ULTIGUARD SAFEPACK 31G 8MM 31 GAUGE X 516
2
ULTIGUARD SAFEPACK 32G 6MM 32 GAUGE X 14
2
ULTIGUARD SAFEPK 03 ML 31G 8MM 03 ML 31 X 516
2
ULTIGUARD SAFEPK 05 ML 31G 8MM 12 ML 31 X 516
2
ULTILET INSULIN SYRINGE 03 ML 03 ML 29 GAUGE X 12 03 ML 30 GAUGE X 516 03 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
ULTILET INSULIN SYRINGE 05 ML 05 ML 29 GAUGE X 12 05 ML 30 GAUGE X 516 05 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
ULTILET INSULIN SYRINGE 1 ML 1 ML 29 GAUGE X 12 1 ML 30 GAUGE X 516 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
143
Drug Name Drug Tier RequirementsLimits
ULTILET PEN NEEDLE 29 GAUGE
2
ULTILET PEN NEEDLE 4MM 32G 32 GAUGE X 532
(pen needle diabetic) 2
ULTRA COMFORT 03 ML SYRINGE 03 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
ULTRA COMFORT 05 ML 28GX12 CONVERTS TO 29G 12 ML 28 GAUGE X 12
(insulin syringe-needle u-100)
2
ULTRA COMFORT 05 ML 29GX12 05 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
ULTRA COMFORT 05 ML SYRINGE 12 ML 28 GAUGE
(insulin syringe-needle u-100)
2
ULTRA COMFORT 1 ML 31GX516 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
ULTRA COMFORT 1 ML SYRINGE 1 ML 28 GAUGE X 12
(insulin syringe-needle u-100)
2
ULTRA FLO 03 ML 30G 12 (12) 03 ML 30 GAUGE X 12
2
ULTRA FLO 03 ML 30G 516(12) 03 ML 30 GAUGE X 516
2
ULTRA FLO 03 ML 31G 516(12) 03 ML 31 GAUGE X 516
2
ULTRA FLO PEN NEEDLE 31G 5MM 31 GAUGE X 316
(pen needle diabetic) 2
ULTRA FLO PEN NEEDLE 31G 8MM 31 GAUGE X 516
(pen needle diabetic) 2
ULTRA FLO PEN NEEDLE 32G 4MM 32 GAUGE X 532
(pen needle diabetic) 2
ULTRA FLO PEN NEEDLE 33G 4MM 33 GAUGE X 532
(pen needle diabetic) 2
ULTRA FLO PEN NEEDLES 12MM 29G 29 GAUGE X 12
(pen needle diabetic) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
144
Drug Name Drug Tier RequirementsLimits
ULTRA FLO SYR 03 ML 29GX12 03 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
ULTRA FLO SYR 03 ML 30G 516 03 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
ULTRA FLO SYR 03 ML 31G 516 03 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
ULTRA FLO SYR 05 ML 29G 12 05 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
ULTRA THIN PEN NDL 32G X 4MM 32 GAUGE X 532
(pen needle diabetic) 2
ULTRACARE INS 03 ML 30GX516 03 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
ULTRACARE INS 03 ML 31GX516 03 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
ULTRACARE INS 05 ML 30GX12 05 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
ULTRACARE INS 05 ML 30GX516 05 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
ULTRACARE INS 05 ML 31GX516 05 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
ULTRACARE INS 1 ML 30G X 516 1 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
ULTRACARE INS 1 ML 30GX12 1 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
ULTRACARE INS 1 ML 31G X 516 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
ULTRACARE PEN NEEDLE 31GX14 31 GAUGE X 14
(pen needle diabetic) 2
ULTRACARE PEN NEEDLE 31GX316 31 GAUGE X 316
(pen needle diabetic) 2
ULTRACARE PEN NEEDLE 31GX516 31 GAUGE X 516
(pen needle diabetic) 2
ULTRACARE PEN NEEDLE 32GX14 32 GAUGE X 14
(pen needle diabetic) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
145
Drug Name Drug Tier RequirementsLimits
ULTRACARE PEN NEEDLE 32GX316 32 GAUGE X 316
(pen needle diabetic) 2
ULTRACARE PEN NEEDLE 32GX532 32 GAUGE X 532
(pen needle diabetic) 2
ULTRACARE PEN NEEDLE 33GX532 33 GAUGE X 532
(pen needle diabetic) 2
ULTRA-THIN II 1 ML 31GX516 1 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
ULTRA-THIN II INS 03 ML 29G 03 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
ULTRA-THIN II INS 03 ML 30G 03 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
ULTRA-THIN II INS 03 ML 31G 03 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
ULTRA-THIN II INS 05 ML 29G 05 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
ULTRA-THIN II INS 05 ML 30G 05 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
ULTRA-THIN II INS 05 ML 31G 05 ML 31 GAUGE X 516
(insulin syringe-needle u-100)
2
ULTRA-THIN II INS SYR 1 ML 29G 1 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
ULTRA-THIN II INS SYR 1 ML 30G 1 ML 30 GAUGE X 516
(insulin syringe-needle u-100)
2
ULTRA-THIN II PEN NDL 29GX12 29 GAUGE X 12
(pen needle diabetic) 2
ULTRA-THIN II PEN NDL 31GX516 31 GAUGE X 516
(pen needle diabetic) 2
UNIFINE PEN NEEDLE 32G 4MM 32 GAUGE X 532
(pen needle diabetic) 2
UNIFINE PENTIPS 12MM 29G 29GX12MM STRL 29 GAUGE X 12
(pen needle diabetic) 2
UNIFINE PENTIPS 31GX316 31GX5MMSTRLMINI 31 GAUGE X 316
(pen needle diabetic) 2
UNIFINE PENTIPS 32GX14 32 GAUGE X 14
(pen needle diabetic) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
146
Drug Name Drug Tier RequirementsLimits
UNIFINE PENTIPS 32GX532 32GX4MM STRL NANO 32 GAUGE X 532
(pen needle diabetic) 2
UNIFINE PENTIPS 33GX532 33 GAUGE X 532
(pen needle diabetic) 2
UNIFINE PENTIPS 6MM 31G 31 GAUGE X 14
(pen needle diabetic) 2
UNIFINE PENTIPS MAX 30GX316 30 GAUGE X 316
2
UNIFINE PENTIPS NEEDLES 29G 29 GAUGE
2
UNIFINE PENTIPS PLUS 29GX12 12MM 29 GAUGE X 12
(pen needle diabetic) 2
UNIFINE PENTIPS PLUS 30GX316 30 GAUGE X 316
2
UNIFINE PENTIPS PLUS 31GX14 ULTRA SHORT 6MM 31 GAUGE X 14
(pen needle diabetic) 2
UNIFINE PENTIPS PLUS 31GX316 MINI 31 GAUGE X 316
(pen needle diabetic) 2
UNIFINE PENTIPS PLUS 31GX516 SHORT 31 GAUGE X 516
(pen needle diabetic) 2
UNIFINE PENTIPS PLUS 32GX532 32 GAUGE X 532
(pen needle diabetic) 2
UNIFINE PENTIPS PLUS 33GX532 33 GAUGE X 532
(pen needle diabetic) 2
UNIFINE SAFECONTROL 30GX316 30 GAUGE X 316
2
UNIFINE SAFECONTROL 30GX516 30 GAUGE X 516
2
VANISHPOINT 05 ML 30GX12 SY LATEX-FREE OUTER 05 ML 30 GAUGE X 12
(insulin syringe-needle u-100)
2
VANISHPOINT INS 1 ML 30GX316 1 ML 30 GAUGE X 316
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
147
Drug Name Drug Tier RequirementsLimits
VANISHPOINT U-100 29X12 SYR 1 ML 29 GAUGE X 12
(insulin syringe-needle u-100)
2
VERIFINE PEN NEEDLE 31G X 6MM 31 GAUGE X 14
(pen needle diabetic) 2
VERIFINE PEN NEEDLE 31G X 8MM 31 GAUGE X 516
(pen needle diabetic) 2
VERIFINE PEN NEEDLE 32G X 4MM 32 GAUGE X 532
(pen needle diabetic) 2
VERIFINE PEN NEEDLE 32G X 5MM 32 GAUGE X 316
(pen needle diabetic) 2
VERSALON ALL PURPOSE SPONGE 25SN-STERILE3PLY 2 X 2
1 GC
V-GO 20 DEVICE 3
V-GO 30 DEVICE 3
V-GO 40 DEVICE 3
Enzyme ReplacementModifiersEnzyme ReplacementModifiersALDURAZYME INTRAVENOUS SOLUTION 29 MG5 ML
5 NM NDS
CERDELGA ORAL CAPSULE 84 MG
5 PA NM NDS
CEREZYME INTRAVENOUS RECON SOLN 400 UNIT
5 NM NDS
CREON ORAL CAPSULEDELAYED RELEASE(DREC) 12000-38000 -60000 UNIT 24000-76000 -120000 UNIT 3000-9500- 15000 UNIT 36000-114000- 180000 UNIT 6000-19000 -30000 UNIT
3
ELAPRASE INTRAVENOUS SOLUTION 6 MG3 ML
5 NM NDS
ELITEK INTRAVENOUS RECON SOLN 15 MG 75 MG
5 NM NDS
FABRAZYME INTRAVENOUS RECON SOLN 35 MG 5 MG
5 PA NM NDS
GALAFOLD ORAL CAPSULE 123 MG
5 PA NM NDS QL (14 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
148
Drug Name Drug Tier RequirementsLimits
KANUMA INTRAVENOUS SOLUTION 2 MGML
5 PA NM NDS
KRYSTEXXA INTRAVENOUS SOLUTION 8 MGML
5 PA BvD NM NDS
MEPSEVII INTRAVENOUS SOLUTION 2 MGML
5 PA NM NDS
miglustat oral capsule 100 mg (Zavesca) 5 PA NM NDS QL (90 per 30 days)
NAGLAZYME INTRAVENOUS SOLUTION 5 MG5 ML
5 NM NDS
nitisinone oral capsule 10 mg 2 mg 5 mg
(Orfadin) 5 PA NM NDS
NITYR ORAL TABLET 10 MG 2 MG 5 MG
5 PA NM NDS
ORFADIN ORAL CAPSULE 20 MG
5 PA NM NDS
ORFADIN ORAL SUSPENSION 4 MGML
5 PA NM NDS
PALYNZIQ SUBCUTANEOUS SYRINGE 10 MG05 ML 25 MG05 ML 20 MGML
5 PA NM NDS
PULMOZYME INHALATION SOLUTION 1 MGML
5 PA BvD NM NDS
REVCOVI INTRAMUSCULAR SOLUTION 24 MG15 ML (16 MGML)
5 PA NM NDS
sapropterin oral tabletsoluble 100 mg
(Kuvan) 5 NM NDS
STRENSIQ SUBCUTANEOUS SOLUTION 18 MG045 ML 28 MG07 ML 40 MGML 80 MG08 ML
5 PA NM LA NDS
VIMIZIM INTRAVENOUS SOLUTION 5 MG5 ML (1 MGML)
5 PA NM NDS
VPRIV INTRAVENOUS RECON SOLN 400 UNIT
5 NM NDS
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
149
Drug Name Drug Tier RequirementsLimits
ZENPEP ORAL CAPSULEDELAYED RELEASE(DREC) 10000-32000 -42000 UNIT 15000-47000 -63000 UNIT 20000-63000- 84000 UNIT 25000-79000- 105000 UNIT 3000-10000 -14000-UNIT 40000-126000- 168000 UNIT 5000-17000- 24000 UNIT
3
Eye Ear Nose Throat AgentsEye Ear Nose Throat Agents Miscellaneousalcaine ophthalmic (eye) drops 05
(proparacaine) 2
apraclonidine ophthalmic (eye) drops 05
2
atropine ophthalmic (eye) drops 1
(Isopto Atropine) 4
azelastine nasal aerosolspray 137 mcg (01 )
2 QL (30 per 25 days)
azelastine nasal spraynon-aerosol2055 mcg (015 )
2 QL (30 per 25 days)
azelastine ophthalmic (eye) drops005
2
bepotastine besilate ophthalmic (eye) drops 15
(Bepreve) 2 ST
cromolyn ophthalmic (eye) drops 4
2
cyclopentolate ophthalmic (eye) drops 05 1 2
(Cyclogyl) 2
CYSTADROPS OPHTHALMIC (EYE) DROPS 037
5 PA NM NDS QL (20 per 28 days)
CYSTARAN OPHTHALMIC (EYE) DROPS 044
5 PA NM NDS QL (60 per 28 days)
epinastine ophthalmic (eye) drops005
2
ipratropium bromide nasal spraynon-aerosol 21 mcg (003 )
2 QL (30 per 28 days)
ipratropium bromide nasal spraynon-aerosol 42 mcg (006 )
2 QL (15 per 10 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
150
Drug Name Drug Tier RequirementsLimits
olopatadine nasal spraynon-aerosol06
(Patanase) 2 QL (305 per 30 days)
olopatadine ophthalmic (eye) drops01
(Eye Allergy Itch-Redness Rlf)
2
olopatadine ophthalmic (eye) drops02
(Eye Allergy Itch Relief)
2
proparacaine ophthalmic (eye) drops 05
(Alcaine) 2
TEPEZZA INTRAVENOUS RECON SOLN 500 MG
5 PA NM NDS
Eye Ear Nose Throat Anti-Infectives Agentsacetic acid otic (ear) solution 2 2
bacitracin ophthalmic (eye) ointment 500 unitgram
2
bacitracin-polymyxin b ophthalmic (eye) ointment 500-10000 unitgram
(Polycin) 2
bleph-10 ophthalmic (eye) drops 10
(sulfacetamide sodium) 2
ciprofloxacin hcl ophthalmic (eye) drops 03
(Ciloxan) 2
ciprofloxacin-dexamethasone otic (ear) dropssuspension 03-01
(Ciprodex) 2 QL (75 per 7 days)
erythromycin ophthalmic (eye) ointment 5 mggram (05 )
2 QL (35 per 4 days)
gatifloxacin ophthalmic (eye) drops05
(Zymaxid) 2
gentak ophthalmic (eye) ointment03 (3 mggram)
(gentamicin) 2
gentamicin ophthalmic (eye) drops03
1 GC
hydrocortisone-acetic acid otic (ear) drops 1-2
2
levofloxacin ophthalmic (eye) drops05
2
moxifloxacin ophthalmic (eye) drops 05
(Vigamox) 2
NATACYN OPHTHALMIC (EYE) DROPSSUSPENSION 5
4
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
151
Drug Name Drug Tier RequirementsLimits
neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1
(Neo-Polycin HC) 2
neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg
(Neo-Polycin) 2
neomycin-polymyxin b-dexameth ophthalmic (eye) dropssuspension35mgml-10000 unitml-01
(Maxitrol) 2
neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 35 mgg-10000 unitg-01
(Maxitrol) 2
neomycin-polymyxin-gramicidin ophthalmic (eye) drops 175 mg-10000 unit-0025mgml
2
neomycin-polymyxin-hc ophthalmic (eye) dropssuspension 35-10000-10 mg-unit-mgml
2
neomycin-polymyxin-hc otic (ear) dropssuspension 35-10000-1 mgml-unitml-
2
neomycin-polymyxin-hc otic (ear) solution 35-10000-1 mgml-unitml-
2
neo-polycin hc ophthalmic (eye) ointment 35-400-10000 mg-unitg-1
(neomycin-bacitracin-poly-hc)
2
neo-polycin ophthalmic (eye) ointment 35-400-10000 mg-unit-unitg
(neomycin-bacitracin-polymyxin)
2
ofloxacin ophthalmic (eye) drops03
(Ocuflox) 2
ofloxacin otic (ear) drops 03 2
polycin ophthalmic (eye) ointment500-10000 unitgram
(bacitracin-polymyxin b)
2
polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10000 unit- 1 mgml
(Polytrim) 1 GC
sulfacetamide sodium ophthalmic (eye) drops 10
(Bleph-10) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
152
Drug Name Drug Tier RequirementsLimits
sulfacetamide sodium ophthalmic (eye) ointment 10
2
sulfacetamide-prednisolone ophthalmic (eye) drops 10 -023 (025 )
2
tobramycin ophthalmic (eye) drops03
(Tobrex) 2
tobramycin-dexamethasone ophthalmic (eye) dropssuspension03-01
(TobraDex) 2
trifluridine ophthalmic (eye) drops1
2
ZIRGAN OPHTHALMIC (EYE) GEL 015
4
ZYLET OPHTHALMIC (EYE) DROPSSUSPENSION 03-05
3
Eye Ear Nose Throat Anti-Inflammatory AgentsALREX OPHTHALMIC (EYE) DROPSSUSPENSION 02
3 ST
bromfenac ophthalmic (eye) drops009
2
BROMSITE OPHTHALMIC (EYE) DROPS 0075
3
dexamethasone sodium phosphate ophthalmic (eye) drops 01
2
diclofenac sodium ophthalmic (eye) drops 01
2
difluprednate ophthalmic (eye) drops 005
(Durezol) 2
DUREZOL OPHTHALMIC (EYE) DROPS 005
(difluprednate) 3
EYSUVIS OPHTHALMIC (EYE) DROPSSUSPENSION 025
3 QL (83 per 14 days)
flunisolide nasal spraynon-aerosol25 mcg (0025 )
2 QL (50 per 25 days)
fluocinolone acetonide oil otic (ear) drops 001
(DermOtic Oil) 2
fluorometholone ophthalmic (eye) dropssuspension 01
(FML Liquifilm) 4
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
153
Drug Name Drug Tier RequirementsLimits
flurbiprofen sodium ophthalmic (eye) drops 003
2
fluticasone propionate nasal spraysuspension 50 mcgactuation
(24 Hour Allergy Relief)
1 GC QL (16 per 30 days)
ILEVRO OPHTHALMIC (EYE) DROPSSUSPENSION 03
3
INVELTYS OPHTHALMIC (EYE) DROPSSUSPENSION 1
3
ketorolac ophthalmic (eye) drops05
(Acular) 2 QL (10 per 25 days)
LOTEMAX OPHTHALMIC (EYE) OINTMENT 05
3
LOTEMAX SM OPHTHALMIC (EYE) DROPSGEL 038
3
loteprednol etabonate ophthalmic (eye) dropsgel 05
(Lotemax) 2
loteprednol etabonate ophthalmic (eye) dropssuspension 05
(Lotemax) 2
mometasone nasal spraynon-aerosol50 mcgactuation
(Nasonex) 2 QL (34 per 30 days)
prednisolone acetate ophthalmic (eye) dropssuspension 1
(Pred Forte) 4
prednisolone sodium phosphate ophthalmic (eye) drops 1
2
PROLENSA OPHTHALMIC (EYE) DROPS 007
3
RESTASIS MULTIDOSE 005 EYE PF 005
3 QL (60 per 30 days)
RESTASIS OPHTHALMIC (EYE) DROPPERETTE 005
3 QL (60 per 30 days)
XHANCE NASAL AEROSOL BREATH ACTIVATED 93 MCGACTUATION
3 ST QL (32 per 30 days)
XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5
3 QL (60 per 30 days)
Gastrointestinal AgentsAntiulcer Agents And Acid Suppressantsamoxicil-clarithromy-lansopraz oral combo pack 500-500-30 mg
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
154
Drug Name Drug Tier RequirementsLimits
cimetidine hcl oral solution 300 mg5 ml
2
cimetidine oral tablet 200 mg (Acid Reducer (cimetidine))
2
cimetidine oral tablet 300 mg 400 mg 800 mg
2
esomeprazole magnesium oral capsuledelayed release(drec) 20 mg
(Nexium) 2 QL (30 per 30 days)
esomeprazole magnesium oral capsuledelayed release(drec) 40 mg
(Nexium) 2 QL (60 per 30 days)
esomeprazole sodium intravenous recon soln 20 mg
2
esomeprazole sodium intravenous recon soln 40 mg
(Nexium IV) 2
famotidine (pf) intravenous solution20 mg2 ml
1 GC
famotidine (pf)-nacl (iso-os) intravenous piggyback 20 mg50 ml
2
famotidine intravenous solution 10 mgml
2
famotidine oral suspension 40 mg5 ml (8 mgml)
2
famotidine oral tablet 20 mg (Acid Controller) 1 GC
famotidine oral tablet 40 mg (Pepcid) 1 GC
lansoprazole oral capsuledelayed release(drec) 15 mg
(Prevacid 24Hr) 2 QL (30 per 30 days)
lansoprazole oral capsuledelayed release(drec) 30 mg
(Prevacid) 2 QL (60 per 30 days)
misoprostol oral tablet 100 mcg 200 mcg
(Cytotec) 2
nizatidine oral capsule 150 mg 300 mg
2
nizatidine oral solution 150 mg10 ml
2
omeprazole oral capsuledelayed release(drec) 10 mg 40 mg
1 GC
omeprazole oral capsuledelayed release(drec) 20 mg
1 GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
155
Drug Name Drug Tier RequirementsLimits
omeprazole-sodium bicarbonate oral capsule 20-11 mg-gram 40-11 mg-gram
(Zegerid) 2 ST QL (30 per 30 days)
pantoprazole intravenous recon soln40 mg
(Protonix) 2
pantoprazole oral tabletdelayed release (drec) 20 mg
(Protonix) 1 GC QL (30 per 30 days)
pantoprazole oral tabletdelayed release (drec) 40 mg
(Protonix) 1 GC QL (60 per 30 days)
rabeprazole oral tabletdelayed release (drec) 20 mg
(AcipHex) 2 QL (30 per 30 days)
sucralfate oral tablet 1 gram (Carafate) 2Gastrointestinal Agents OtherCARBAGLU ORAL TABLET DISPERSIBLE 200 MG
5 NM NDS
constulose oral solution 10 gram15 ml
(lactulose) 2
cromolyn oral concentrate 100 mg5 ml
(Gastrocrom) 2
dicyclomine oral capsule 10 mg 2
dicyclomine oral solution 10 mg5 ml 2
dicyclomine oral tablet 20 mg 2
diphenoxylate-atropine oral liquid25-0025 mg5 ml
2
diphenoxylate-atropine oral tablet25-0025 mg
(Lomotil) 2
enulose oral solution 10 gram15 ml (lactulose) 2
GATTEX 30-VIAL SUBCUTANEOUS KIT 5 MG
5 PA NM NDS
generlac oral solution 10 gram15 ml (lactulose) 2
glycopyrrolate oral tablet 1 mg 2 mg
2
kionex (with sorbitol) oral suspension 15-193 gram60 ml
2
lactulose oral solution 10 gram15 ml
(Constulose) 2
LINZESS ORAL CAPSULE 145 MCG 290 MCG 72 MCG
3 QL (30 per 30 days)
LOKELMA ORAL POWDER IN PACKET 10 GRAM
3 QL (34 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
156
Drug Name Drug Tier RequirementsLimits
LOKELMA ORAL POWDER IN PACKET 5 GRAM
3 QL (30 per 30 days)
loperamide oral capsule 2 mg (Anti-Diarrheal (loperamide))
2
lubiprostone oral capsule 24 mcg 8 mcg
(Amitiza) 3 QL (60 per 30 days)
methscopolamine oral tablet 25 mg 5 mg
2
metoclopramide hcl injection solution 5 mgml
2
metoclopramide hcl injection syringe5 mgml
2
metoclopramide hcl oral solution 5 mg5 ml
2
metoclopramide hcl oral tablet 10 mg 5 mg
(Reglan) 1 GC
MOVANTIK ORAL TABLET 125 MG 25 MG
3 QL (30 per 30 days)
OCALIVA ORAL TABLET 10 MG 5 MG
5 PA NM NDS QL (30 per 30 days)
propantheline oral tablet 15 mg 2
RAVICTI ORAL LIQUID 11 GRAMML
5 PA NM NDS
RELISTOR ORAL TABLET 150 MG
5 PA NM NDS QL (90 per 30 days)
RELISTOR SUBCUTANEOUS SOLUTION 12 MG06 ML
5 PA NM NDS QL (168 per 28 days)
RELISTOR SUBCUTANEOUS SYRINGE 12 MG06 ML
5 PA NM NDS QL (168 per 28 days)
RELISTOR SUBCUTANEOUS SYRINGE 8 MG04 ML
5 PA NM NDS QL (112 per 28 days)
sodium phenylbutyrate oral tablet500 mg
(Buphenyl) 5 NM NDS
sodium polystyrene (sorb free) oral suspension 15 gram60 ml
2
sodium polystyrene sulfonate oral powder
2
sps (with sorbitol) oral suspension15-20 gram60 ml
2
ursodiol oral capsule 300 mg 2
ursodiol oral tablet 250 mg (URSO 250) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
157
Drug Name Drug Tier RequirementsLimits
ursodiol oral tablet 500 mg (URSO Forte) 2
XERMELO ORAL TABLET 250 MG
5 PA NM NDS QL (90 per 30 days)
LaxativesCLENPIQ ORAL SOLUTION 10 MG-35 GRAM -12 GRAM160 ML
3
gavilyte-c oral recon soln 240-2272-672 -584 gram
(peg 3350-electrolytes) 2
gavilyte-g oral recon soln 236-2274-674 -586 gram
(peg 3350-electrolytes) 2
gavilyte-n oral recon soln 420 gram (peg-electrolyte soln) 2
SUPREP BOWEL PREP KIT ORAL RECON SOLN 175-313-16 GRAM
3
trilyte with flavor packets oral recon soln 420 gram
(peg-electrolyte soln) 2
Phosphate Binderscalcium acetate(phosphat bind) oral capsule 667 mg
2
calcium acetate(phosphat bind) oral tablet 667 mg
2
lanthanum oral tabletchewable1000 mg 500 mg 750 mg
(Fosrenol) 5 NM NDS
PHOSLYRA ORAL SOLUTION 667 MG (169 MG CALCIUM)5 ML
4
sevelamer carbonate oral powder in packet 08 gram 24 gram
(Renvela) 5 NM NDS
sevelamer carbonate oral tablet 800 mg
(Renvela) 2
sevelamer hcl oral tablet 400 mg 2
sevelamer hcl oral tablet 800 mg (Renagel) 2
VELPHORO ORAL TABLETCHEWABLE 500 MG
3
Genitourinary AgentsAntispasmodics Urinarybethanechol chloride oral tablet 10 mg 25 mg 5 mg 50 mg
2
flavoxate oral tablet 100 mg 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
158
Drug Name Drug Tier RequirementsLimits
MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 25 MG 50 MG
3
oxybutynin chloride oral syrup 5 mg5 ml
2
oxybutynin chloride oral tablet 5 mg 2
oxybutynin chloride oral tablet extended release 24hr 10 mg 5 mg
(Ditropan XL) 2
oxybutynin chloride oral tablet extended release 24hr 15 mg
2
tolterodine oral capsuleextended release 24hr 2 mg 4 mg
(Detrol LA) 2
tolterodine oral tablet 1 mg 2 mg (Detrol) 2
TOVIAZ ORAL TABLET EXTENDED RELEASE 24 HR 4 MG 8 MG
3
trospium oral capsuleextended release 24hr 60 mg
2
trospium oral tablet 20 mg 2Genitourinary Agents Miscellaneousalfuzosin oral tablet extended release 24 hr 10 mg
(Uroxatral) 1 GC QL (30 per 30 days)
dutasteride oral capsule 05 mg (Avodart) 2
dutasteride-tamsulosin oral capsule er multiphase 24 hr 05-04 mg
(Jalyn) 2
finasteride oral tablet 5 mg (Proscar) 1 GC
tamsulosin oral capsule 04 mg (Flomax) 1 GC
terazosin oral capsule 1 mg 10 mg 2 mg 5 mg
1 GC
THIOLA EC ORAL TABLETDELAYED RELEASE (DREC) 100 MG 300 MG
5 PA NM NDS
tiopronin oral tablet 100 mg (Thiola) 5 NM NDS
Heavy Metal AntagonistsHeavy Metal Antagonistsclovique oral capsule 250 mg (trientine) 5 PA NM NDS QL
(240 per 30 days)
deferasirox oral granules in packet180 mg 360 mg 90 mg
(Jadenu Sprinkle) 5 PA NM NDS
deferasirox oral tablet 180 mg 360 mg
(Jadenu) 5 PA NM NDS
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
159
Drug Name Drug Tier RequirementsLimits
deferasirox oral tablet 90 mg (Jadenu) 2 PA
deferasirox oral tablet dispersible125 mg
(Exjade) 2 PA
deferasirox oral tablet dispersible250 mg 500 mg
(Exjade) 5 PA NM NDS
deferiprone oral tablet 500 mg (Ferriprox) 5 PA NM NDS
deferoxamine injection recon soln 2 gram
2 PA
deferoxamine injection recon soln500 mg
(Desferal) 2 PA
FERRIPROX 1000 MG TAB(2XDAY) 1000 MG
5 PA NM NDS
FERRIPROX ORAL SOLUTION 100 MGML
5 PA NM NDS
FERRIPROX ORAL TABLET 1000 MG
5 PA NM NDS
penicillamine oral capsule 250 mg (Cuprimine) 5 PA NM NDS
penicillamine oral tablet 250 mg (Depen Titratabs) 5 PA NM NDS
trientine oral capsule 250 mg (Syprine) 5 PA NM NDS QL (240 per 30 days)
Hormonal Agents StimulantReplacementModifyingAndrogensANADROL-50 ORAL TABLET 50 MG
5 PA NM NDS
danazol oral capsule 100 mg 200 mg 50 mg
2
oxandrolone oral tablet 10 mg 25 mg
(Oxandrin) 2
testosterone cypionate intramuscular oil 100 mgml 200 mgml
(Depo-Testosterone) 2 PA
testosterone cypionate intramuscular oil 200 mgml (1 ml)
2 PA
testosterone enanthate intramuscular oil 200 mgml
2 PA QL (5 per 28 days)
testosterone transdermal gel in metered-dose pump 125 mg 125 gram (1 )
(Vogelxo) 2 PA QL (300 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
160
Drug Name Drug Tier RequirementsLimits
testosterone transdermal gel in metered-dose pump 2025 mg125 gram (162 )
(AndroGel) 2 PA QL (150 per 30 days)
testosterone transdermal gel in packet 1 (25 mg25gram) 1 (50 mg5 gram)
(AndroGel) 2 PA QL (300 per 30 days)
testosterone transdermal solution in metered pump wapp 30 mgactuation (15 ml)
2 PA QL (180 per 30 days)
XYOSTED SUBCUTANEOUS AUTO-INJECTOR 100 MG05 ML 50 MG05 ML 75 MG05 ML
3 PA QL (2 per 28 days)
Estrogens And Antiestrogensamabelz oral tablet 05-01 mg 1-05 mg
(estradiol-norethindrone acet)
2
dotti transdermal patch semiweekly0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
(estradiol) 2 QL (8 per 28 days)
DUAVEE ORAL TABLET 045-20 MG
3
estradiol oral tablet 05 mg 1 mg 2 mg
(Estrace) 1 GC
estradiol transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
(Dotti) 2 QL (8 per 28 days)
estradiol transdermal patch weekly0025 mg24 hr 00375 mg24 hr 005 mg24 hr 006 mg24 hr 0075 mg24 hr 01 mg24 hr
(Climara) 2 QL (4 per 28 days)
estradiol vaginal cream 001 (01 mggram)
(Estrace) 2
estradiol vaginal tablet 10 mcg (Yuvafem) 2 QL (18 per 28 days)
estradiol valerate intramuscular oil20 mgml 40 mgml
(Delestrogen) 2
estradiol-norethindrone acet oral tablet 05-01 mg
(Amabelz) 2
FEMRING VAGINAL RING 005 MG24 HR 01 MG24 HR
4 QL (1 per 84 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
161
Drug Name Drug Tier RequirementsLimits
fyavolv oral tablet 05-25 mg-mcg 1-5 mg-mcg
(norethindrone ac-eth estradiol)
2
jinteli oral tablet 1-5 mg-mcg (norethindrone ac-eth estradiol)
2
lyllana transdermal patch semiweekly 0025 mg24 hr 00375 mg24 hr 005 mg24 hr 0075 mg24 hr 01 mg24 hr
(estradiol) 2 QL (8 per 28 days)
mimvey oral tablet 1-05 mg (estradiol-norethindrone acet)
2
norethindrone ac-eth estradiol oral tablet 05-25 mg-mcg 1-5 mg-mcg
(Fyavolv) 2
PREMARIN INJECTION RECON SOLN 25 MG
3
PREMARIN ORAL TABLET 03 MG 045 MG 09 MG
3
PREMARIN ORAL TABLET 0625 MG 125 MG
(conjugated estrogens) 3
PREMARIN VAGINAL CREAM 0625 MGGRAM
3
PREMPHASE ORAL TABLET 0625 MG (14) 0625MG-5MG(14)
3
PREMPRO ORAL TABLET 03-15 MG 045-15 MG 0625-25 MG 0625-5 MG
3
raloxifene oral tablet 60 mg (Evista) 2
yuvafem vaginal tablet 10 mcg (estradiol) 2 QL (18 per 28 days)GlucocorticoidsMineralocorticoidsa-hydrocort injection recon soln 100 mg
2
betamethasone acetsod phos injection suspension 6 mgml
(Celestone Soluspan) 2
dexamethasone 05 mg5 ml liq 05 mg5 ml
2
dexamethasone oral elixir 05 mg5 ml
2
dexamethasone oral tablet 05 mg 075 mg 4 mg 6 mg
(Decadron) 2
dexamethasone oral tablet 1 mg 15 mg 2 mg
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
162
Drug Name Drug Tier RequirementsLimits
dexamethasone sodium phos (pf) injection solution 10 mgml
1 GC
dexamethasone sodium phos (pf) injection syringe 10 mgml
1 GC
dexamethasone sodium phosphate injection solution 10 mgml 4 mgml
1 GC
dexamethasone sodium phosphate injection syringe 4 mgml
1 GC
EMFLAZA ORAL SUSPENSION 2275 MGML
5 PA NM NDS QL (91 per 28 days)
EMFLAZA ORAL TABLET 18 MG
5 PA NM NDS QL (30 per 30 days)
EMFLAZA ORAL TABLET 30 MG 36 MG 6 MG
5 PA NM NDS QL (60 per 30 days)
fludrocortisone oral tablet 01 mg 2
HEMADY ORAL TABLET 20 MG
4
hydrocortisone oral tablet 10 mg 20 mg 5 mg
(Cortef) 2
methylprednisolone acetate injection suspension 40 mgml 80 mgml
(Depo-Medrol) 2
methylprednisolone oral tablet 16 mg 32 mg 4 mg 8 mg
(Medrol) 2
methylprednisolone oral tabletsdose pack 4 mg
(Medrol (Pak)) 2
methylprednisolone sodium succ injection recon soln 125 mg 40 mg
2
methylprednisolone sodium succ intravenous recon soln 1000 mg 500 mg
(Solu-Medrol) 2
prednisolone 15 mg5 ml soln af df15 mg5 ml (3 mgml)
2 PA BvD
prednisolone oral solution 15 mg5 ml
2 PA BvD
prednisolone sodium phosphate oral solution 25 mg5 ml (5 mgml)
2 PA BvD
prednisolone sodium phosphate oral solution 5 mg base5 ml (67 mg5 ml)
(Pediapred) 2 PA BvD
prednisone oral solution 5 mg5 ml 2 PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
163
Drug Name Drug Tier RequirementsLimits
prednisone oral tablet 1 mg 10 mg 25 mg 20 mg 5 mg 50 mg
1 PA BvD GC
prednisone oral tabletsdose pack 10 mg 10 mg (48 pack) 5 mg 5 mg (48 pack)
2
SOLU-CORTEF ACT-O-VIAL (PF) INJECTION RECON SOLN 1000 MG8 ML 100 MG2 ML 250 MG2 ML 500 MG4 ML
4
triamcinolone acetonide injection suspension 40 mgml
(Kenalog) 2
PituitaryACTHAR INJECTION GEL 80 UNITML
5 PA NM NDS QL (35 per 28 days)
BYNFEZIA SUBCUTANEOUS PEN INJECTOR 2500 MCGML
5 NM NDS
desmopressin injection solution 4 mcgml
(DDAVP) 2
desmopressin nasal spray with pump10 mcgspray (01 ml)
2
desmopressin oral tablet 01 mg 02 mg
(DDAVP) 2
EGRIFTA SUBCUTANEOUS RECON SOLN 2 MG
5 PA NM NDS QL (30 per 30 days)
EGRIFTA SV SUBCUTANEOUS RECON SOLN 2 MG
5 PA NM NDS QL (30 per 30 days)
INCRELEX SUBCUTANEOUS SOLUTION 10 MGML
5 NM NDS
LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 1125 MG
5 NM NDS
LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 375 MG 75 MG
5 NM NDS
LUPRON DEPOT-PED (3 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG
5 NM NDS
LUPRON DEPOT-PED INTRAMUSCULAR KIT 1125 MG 15 MG
5 NM NDS
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
164
Drug Name Drug Tier RequirementsLimits
MYCAPSSA ORAL CAPSULEDELAYED RELEASE(DREC) 20 MG
5 PA NM NDS QL (120 per 30 days)
NORDITROPIN FLEXPRO SUBCUTANEOUS PEN INJECTOR 10 MG15 ML (67 MGML) 15 MG15 ML (10 MGML) 30 MG3 ML (10 MGML) 5 MG15 ML (33 MGML)
5 PA NM NDS
octreotide acetate injection solution1000 mcgml 200 mcgml
2
octreotide acetate injection solution100 mcgml 50 mcgml 500 mcgml
(Sandostatin) 2
octreotide acetate injection syringe100 mcgml (1 ml) 50 mcgml (1 ml) 500 mcgml (1 ml)
2
ORGOVYX ORAL TABLET 120 MG
5 PA NSO NM NDS
ORILISSA ORAL TABLET 150 MG
5 PA NM NDS QL (28 per 28 days)
ORILISSA ORAL TABLET 200 MG
5 PA NM NDS QL (56 per 28 days)
SANDOSTATIN LAR DEPOT INTRAMUSCULAR SUSPENSIONEXTENDED REL RECON 10 MG 20 MG 30 MG
5 NM NDS
SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG 5 MG 6 MG
5 PA NM NDS
SIGNIFOR SUBCUTANEOUS SOLUTION 03 MGML (1 ML) 06 MGML (1 ML) 09 MGML (1 ML)
5 PA NM NDS QL (60 per 30 days)
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG05 ML
5 PA NSO NM NDS QL (05 per 28 days)
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 60 MG02 ML
5 PA NSO NM NDS QL (02 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
165
Drug Name Drug Tier RequirementsLimits
SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 90 MG03 ML
5 PA NSO NM NDS QL (03 per 28 days)
SOMAVERT SUBCUTANEOUS RECON SOLN 10 MG 15 MG 20 MG 25 MG 30 MG
5 PA NM NDS
SUPPRELIN LA IMPLANT KIT 50 MG (65 MCGDAY)
5 NM NDS QL (1 per 360 days)
SYNAREL NASAL SPRAYNON-AEROSOL 2 MGML
5 NM NDS
TRIPTODUR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 225 MG
5 NM NDS QL (1 per 168 days)
ZORBTIVE SUBCUTANEOUS RECON SOLN 88 MG
5 PA NM NDS
Progestinshydroxyprogesterone cap(ppres) intramuscular oil 250 mgml
(Makena) 5 NM NDS
medroxyprogesterone intramuscular suspension 150 mgml
(Depo-Provera) 2 QL (1 per 84 days)
medroxyprogesterone intramuscular syringe 150 mgml
(Depo-Provera) 2 QL (1 per 84 days)
medroxyprogesterone oral tablet 10 mg 25 mg 5 mg
(Provera) 1 GC
megestrol oral suspension 400 mg10 ml (40 mgml)
2
norethindrone acetate oral tablet 5 mg
(Aygestin) 2
progesterone intramuscular oil 50 mgml
2
progesterone micronized oral capsule 100 mg 200 mg
(Prometrium) 2
Thyroid And Antithyroid Agentslevothyroxine oral tablet 100 mcg 112 mcg 125 mcg 137 mcg 150 mcg 175 mcg 200 mcg 25 mcg 50 mcg 75 mcg 88 mcg
(Euthyrox) 1 GC
levothyroxine oral tablet 300 mcg (Levo-T) 1 GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
166
Drug Name Drug Tier RequirementsLimits
liothyronine oral tablet 25 mcg 5 mcg 50 mcg
(Cytomel) 2
methimazole oral tablet 10 mg 5 mg 1 GC
propylthiouracil oral tablet 50 mg 2
Immunological AgentsImmunological AgentsACTEMRA ACTPEN SUBCUTANEOUS PEN INJECTOR 162 MG09 ML
5 PA NM NDS
ACTEMRA INTRAVENOUS SOLUTION 200 MG10 ML (20 MGML) 400 MG20 ML (20 MGML) 80 MG4 ML (20 MGML)
5 PA NM NDS
ACTEMRA SUBCUTANEOUS SYRINGE 162 MG09 ML
5 PA NM NDS
ARCALYST SUBCUTANEOUS RECON SOLN 220 MG
5 NM NDS
AVSOLA INTRAVENOUS RECON SOLN 100 MG
5 PA NM NDS
azathioprine oral tablet 50 mg (Imuran) 2 PA BvD
azathioprine sodium injection recon soln 100 mg
2 PA BvD
BENLYSTA INTRAVENOUS RECON SOLN 120 MG 400 MG
5 PA NM NDS
BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MGML
5 PA NM NDS QL (8 per 28 days)
BENLYSTA SUBCUTANEOUS SYRINGE 200 MGML
5 PA NM NDS QL (8 per 28 days)
CIMZIA POWDER FOR RECONST SUBCUTANEOUS KIT 400 MG (200 MG X 2 VIALS)
5 PA NM NDS
CIMZIA SUBCUTANEOUS SYRINGE KIT 400 MG2 ML (200 MGML X 2)
5 PA NM NDS
COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MGML
5 PA NM NDS
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
167
Drug Name Drug Tier RequirementsLimits
COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MGML
5 PA NM NDS
COSENTYX SUBCUTANEOUS SYRINGE 75 MG05 ML
5 PA NM NDS
cyclosporine intravenous solution250 mg5 ml
(Sandimmune) 2 PA BvD
cyclosporine modified oral capsule100 mg 25 mg
(Gengraf) 2 PA BvD
cyclosporine modified oral capsule50 mg
2 PA BvD
cyclosporine modified oral solution100 mgml
(Gengraf) 2 PA BvD
cyclosporine oral capsule 100 mg 25 mg
(Sandimmune) 2 PA BvD
DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 100 MG067 ML
5 PA NM NDS
ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MGML (1 ML)
5 PA NM NDS
ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)
5 PA NM NDS
ENBREL SUBCUTANEOUS SOLUTION 25 MG05 ML
5 PA NM NDS
ENBREL SUBCUTANEOUS SYRINGE 25 MG05 ML (05) 50 MGML (1 ML)
5 PA NM NDS
ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MGML (1 ML)
5 PA NM NDS
everolimus (immunosuppressive) oral tablet 025 mg
(Zortress) 2 PA BvD
everolimus (immunosuppressive) oral tablet 05 mg 075 mg
(Zortress) 5 PA BvD NM NDS
FLEBOGAMMA DIF INTRAVENOUS SOLUTION 10 5
5 PA BvD NM NDS
GAMIFANT INTRAVENOUS SOLUTION 5 MGML
5 PA NM NDS
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
168
Drug Name Drug Tier RequirementsLimits
GAMMAGARD LIQUID INJECTION SOLUTION 10
5 PA BvD NM NDS
GAMMAGARD S-D (IGA lt 1 MCGML) INTRAVENOUS RECON SOLN 10 GRAM 5 GRAM
5 PA BvD NM NDS
GAMMAPLEX (WITH SORBITOL) INTRAVENOUS SOLUTION 5
5 PA BvD NM NDS
GAMMAPLEX INTRAVENOUS SOLUTION 10 10 (100 ML) 10 (200 ML)
5 PA BvD NM NDS
GAMUNEX-C INJECTION SOLUTION 1 GRAM10 ML (10 ) 10 GRAM100 ML (10 ) 25 GRAM25 ML (10 ) 20 GRAM200 ML (10 ) 40 GRAM400 ML (10 ) 5 GRAM50 ML (10 )
5 PA BvD NM NDS
gengraf oral capsule 100 mg 25 mg (cyclosporine modified) 2 PA BvD
gengraf oral solution 100 mgml (cyclosporine modified) 2 PA BvD
HUMIRA PEN CROHNS-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
5 PA NM NDS
HUMIRA PEN PSOR-UVEITS-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
5 PA NM NDS
HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG08 ML
5 PA NM NDS
HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG08 ML
5 PA NM NDS
HUMIRA(CF) PEDI CROHNS STARTER SUBCUTANEOUS SYRINGE KIT 80 MG08 ML 80 MG08 ML-40 MG04 ML
5 PA NM NDS
HUMIRA(CF) PEN CROHNS-UC-HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML
5 PA NM NDS
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
169
Drug Name Drug Tier RequirementsLimits
HUMIRA(CF) PEN PEDIATRIC UC SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML
5 PA NM NDS
HUMIRA(CF) PEN PSOR-UV-ADOL HS SUBCUTANEOUS PEN INJECTOR KIT 80 MG08 ML-40 MG04 ML
5 PA NM NDS
HUMIRA(CF) PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG04 ML 80 MG08 ML
5 PA NM NDS
HUMIRA(CF) SUBCUTANEOUS SYRINGE KIT 10 MG01 ML 20 MG02 ML 40 MG04 ML
5 PA NM NDS
HYQVIA SUBCUTANEOUS SOLUTION 10 GRAM 100 ML (10 ) 25 GRAM 25 ML (10 ) 20 GRAM 200 ML (10 ) 30 GRAM 300 ML (10 ) 5 GRAM 50 ML (10 )
5 PA BvD NM NDS
ILARIS (PF) SUBCUTANEOUS RECON SOLN 150 MGML
5 PA NM NDS
ILARIS (PF) SUBCUTANEOUS SOLUTION 150 MGML
5 PA NM NDS
ILUMYA SUBCUTANEOUS SYRINGE 100 MGML
5 PA NM NDS
INFLECTRA INTRAVENOUS RECON SOLN 100 MG
5 PA NM NDS
KEVZARA SUBCUTANEOUS PEN INJECTOR 150 MG114 ML 200 MG114 ML
5 PA NM NDS
KEVZARA SUBCUTANEOUS SYRINGE 150 MG114 ML 200 MG114 ML
5 PA NM NDS
KINERET SUBCUTANEOUS SYRINGE 100 MG067 ML
5 PA NM NDS
leflunomide oral tablet 10 mg 20 mg (Arava) 2
mycophenolate mofetil (hcl) intravenous recon soln 500 mg
(CellCept Intravenous) 2 PA BvD
mycophenolate mofetil oral capsule250 mg
(CellCept) 2 PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
170
Drug Name Drug Tier RequirementsLimits
mycophenolate mofetil oral suspension for reconstitution 200 mgml
(CellCept) 5 PA BvD NM NDS
mycophenolate mofetil oral tablet500 mg
(CellCept) 2 PA BvD
NULOJIX INTRAVENOUS RECON SOLN 250 MG
5 PA BvD NM NDS
OCTAGAM INTRAVENOUS SOLUTION 10 5
5 PA BvD NM NDS
OLUMIANT ORAL TABLET 1 MG 2 MG
5 PA NM NDS
ORENCIA (WITH MALTOSE) INTRAVENOUS RECON SOLN 250 MG
5 PA NM NDS
ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MGML
5 PA NM NDS
ORENCIA SUBCUTANEOUS SYRINGE 125 MGML 50 MG04 ML 875 MG07 ML
5 PA NM NDS
OTEZLA ORAL TABLET 30 MG 5 PA NM NDS
OTEZLA STARTER ORAL TABLETSDOSE PACK 10 MG (4)-20 MG (4)-30 MG (47) 10 MG (4)-20 MG (4)-30 MG(19)
5 PA NM NDS
PRIVIGEN INTRAVENOUS SOLUTION 10
5 PA BvD NM NDS
PROGRAF INTRAVENOUS SOLUTION 5 MGML
4 PA BvD
PROGRAF ORAL GRANULES IN PACKET 02 MG 1 MG
4 PA BvD ST
RASUVO (PF) SUBCUTANEOUS AUTO-INJECTOR 10 MG02 ML 125 MG025 ML 15 MG03 ML 175 MG035 ML 20 MG04 ML 225 MG045 ML 25 MG05 ML 30 MG06 ML 75 MG015 ML
3
REMICADE INTRAVENOUS RECON SOLN 100 MG
(infliximab) 5 PA NM NDS
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
171
Drug Name Drug Tier RequirementsLimits
RENFLEXIS INTRAVENOUS RECON SOLN 100 MG
5 PA NM NDS
REZUROCK ORAL TABLET 200 MG
5 PA NSO NM NDS
RIDAURA ORAL CAPSULE 3 MG
5 NM NDS
RINVOQ ORAL TABLET EXTENDED RELEASE 24 HR 15 MG
5 PA NM NDS
sirolimus oral solution 1 mgml (Rapamune) 5 PA BvD NM NDS
sirolimus oral tablet 05 mg 1 mg (Rapamune) 2 PA BvD
sirolimus oral tablet 2 mg (Rapamune) 5 PA BvD NM NDS
SKYRIZI SUBCUTANEOUS PEN INJECTOR 150 MGML
5 PA NM NDS
SKYRIZI SUBCUTANEOUS SYRINGE 150 MGML 75 MG083 ML
5 PA NM NDS
SKYRIZI SUBCUTANEOUS SYRINGE KIT 150MG166ML(75 MG083 ML X2)
5 PA NM NDS
STELARA INTRAVENOUS SOLUTION 130 MG26 ML
5 PA NM NDS
STELARA SUBCUTANEOUS SOLUTION 45 MG05 ML
5 PA NM NDS
STELARA SUBCUTANEOUS SYRINGE 45 MG05 ML 90 MGML
5 PA NM NDS
tacrolimus oral capsule 05 mg 1 mg 5 mg
(Prograf) 2 PA BvD
TALTZ AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 80 MGML
5 PA NM NDS
TALTZ SYRINGE (2 PACK) SUBCUTANEOUS SYRINGE 80 MGML
5 PA NM NDS
TALTZ SYRINGE (3 PACK) SUBCUTANEOUS SYRINGE 80 MGML
5 PA NM NDS
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
172
Drug Name Drug Tier RequirementsLimits
TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MGML
5 PA NM NDS
TREMFYA SUBCUTANEOUS AUTO-INJECTOR 100 MGML
5 PA NM NDS
TREMFYA SUBCUTANEOUS SYRINGE 100 MGML
5 PA NM NDS
TYSABRI INTRAVENOUS SOLUTION 300 MG15 ML
5 PA NM LA NDS
XELJANZ ORAL SOLUTION 1 MGML
5 PA NM NDS
XELJANZ ORAL TABLET 10 MG 5 MG
5 PA NM NDS
XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG 22 MG
5 PA NM NDS
ZORTRESS ORAL TABLET 1 MG
(everolimus (immunosuppressive))
5 PA BvD NM NDS
VaccinesACTHIB (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
3
ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SUSPENSION 2 LF-(25-5-3-5 MCG)-5LF05 ML
3
ADACEL(TDAP ADOLESNADULT)(PF) INTRAMUSCULAR SYRINGE 2 LF-(25-5-3-5 MCG)-5LF05 ML
3
BCG VACCINE LIVE (PF) PERCUTANEOUS SUSPENSION FOR RECONSTITUTION 50 MG
3
BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG05 ML
3
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
173
Drug Name Drug Tier RequirementsLimits
BOOSTRIX TDAP INTRAMUSCULAR SUSPENSION 25-8-5 LF-MCG-LF05ML
3
BOOSTRIX TDAP INTRAMUSCULAR SYRINGE 25-8-5 LF-MCG-LF05ML
3
DAPTACEL (DTAP PEDIATRIC) (PF) INTRAMUSCULAR SUSPENSION 15-10-5 LF-MCG-LF05ML
3
DENGVAXIA (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP45-6 CCID5005 ML
3 QL (3 per 365 days)
ENGERIX-B (PF) INTRAMUSCULAR SUSPENSION 20 MCGML
3 PA BvD
ENGERIX-B (PF) INTRAMUSCULAR SYRINGE 20 MCGML
3 PA BvD
ENGERIX-B PEDIATRIC (PF) INTRAMUSCULAR SYRINGE 10 MCG05 ML
3 PA BvD
GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 05 ML
3 QL (15 per 365 days)
GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 05 ML
3 QL (15 per 365 days)
HAVRIX (PF) INTRAMUSCULAR SYRINGE 1440 ELISA UNITML 720 ELISA UNIT05 ML
3
HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG05 ML
3
IMOVAX RABIES VACCINE (PF) INTRAMUSCULAR RECON SOLN 25 UNIT
3 PA BvD
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
174
Drug Name Drug Tier RequirementsLimits
INFANRIX (DTAP) (PF) INTRAMUSCULAR SUSPENSION 25-58-10 LF-MCG-LF05ML
3
INFANRIX (DTAP) (PF) INTRAMUSCULAR SYRINGE 25-58-10 LF-MCG-LF05ML
3
IPOL INJECTION SUSPENSION 40-8-32 UNIT05 ML
3
IXIARO (PF) INTRAMUSCULAR SYRINGE 6 MCG05 ML
3
KINRIX (PF) INTRAMUSCULAR SUSPENSION 25 LF-58 MCG-10 LF05 ML
3
KINRIX (PF) INTRAMUSCULAR SYRINGE 25 LF-58 MCG-10 LF05 ML
3
MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG05 ML
3
MENQUADFI (PF) INTRAMUSCULAR SOLUTION 10 MCG05 ML
3
MENVEO A-C-Y-W-135-DIP (PF) INTRAMUSCULAR KIT 10-5 MCG05 ML
3
M-M-R II (PF) SUBCUTANEOUS RECON SOLN 1000-12500 TCID5005 ML
3
PEDIARIX (PF) INTRAMUSCULAR SYRINGE 10 MCG-25LF-25 MCG-10LF05 ML
3
PEDVAX HIB (PF) INTRAMUSCULAR SOLUTION 75 MCG05 ML
3
PENTACEL (PF) INTRAMUSCULAR KIT 15 LF UNIT-20 MCG-5 LF05 ML
3
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
175
Drug Name Drug Tier RequirementsLimits
PROQUAD (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP3-43-3- 399 TCID5005
3
QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT05ML
3
RABAVERT (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 25 UNIT
3 PA BvD
RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 10 MCGML 40 MCGML 5 MCG05 ML
3 PA BvD
RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 10 MCGML 5 MCG05 ML
3 PA BvD
ROTARIX ORAL SUSPENSION FOR RECONSTITUTION 10EXP6 CCID50ML
3
ROTATEQ VACCINE ORAL SOLUTION 2 ML
3
SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG05 ML
3 QL (2 per 365 days)
TDVAX INTRAMUSCULAR SUSPENSION 2-2 LF UNIT05 ML
(tetanus-diphtheria toxoids-td)
3
TENIVAC (PF) INTRAMUSCULAR SUSPENSION 5 LF UNIT- 2 LF UNIT05ML
3
TENIVAC (PF) INTRAMUSCULAR SYRINGE 5-2 LF UNIT05 ML
3
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
176
Drug Name Drug Tier RequirementsLimits
TETANUSDIPHTHERIA TOX PED(PF) INTRAMUSCULAR SUSPENSION 5-25 LF UNIT05 ML
3
TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG05 ML
3
TWINRIX (PF) INTRAMUSCULAR SYRINGE 720 ELISA UNIT- 20 MCGML
3
TYPHIM VI INTRAMUSCULAR SOLUTION 25 MCG05 ML
3
TYPHIM VI INTRAMUSCULAR SYRINGE 25 MCG05 ML
(typhoid vi polysacch vaccine)
3
VAQTA (PF) INTRAMUSCULAR SUSPENSION 25 UNIT05 ML 50 UNITML
3
VAQTA (PF) INTRAMUSCULAR SYRINGE 25 UNIT05 ML 50 UNITML
3
VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1350 UNIT05 ML
3 QL (2 per 365 days)
YF-VAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10 EXP474 UNIT05 ML
3
ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19400 UNIT065 ML
3 QL (1 per 365 days)
Inflammatory Bowel Disease AgentsInflammatory Bowel Disease Agentsalosetron oral tablet 05 mg (Lotronex) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
177
Drug Name Drug Tier RequirementsLimits
alosetron oral tablet 1 mg (Lotronex) 5 NM NDS
balsalazide oral capsule 750 mg (Colazal) 2
budesonide oral capsuledelayedextendrelease 3 mg
(Entocort EC) 2
DIPENTUM ORAL CAPSULE 250 MG
5 ST NM NDS
hydrocortisone rectal enema 100 mg60 ml
(Cortenema) 4
mesalamine oral capsule (with del rel tablets) 400 mg
(Delzicol) 2
mesalamine oral capsuleextended release 24hr 0375 gram
(Apriso) 2
mesalamine oral tabletdelayed release (drec) 12 gram
(Lialda) 2
mesalamine oral tabletdelayed release (drec) 800 mg
(Asacol HD) 2
mesalamine rectal suppository 1000 mg
(Canasa) 2
sulfasalazine oral tablet 500 mg (Azulfidine) 2
sulfasalazine oral tabletdelayed release (drec) 500 mg
(Azulfidine EN-tabs) 4
UCERIS RECTAL FOAM 2 MGACTUATION
3
Metabolic Bone Disease AgentsMetabolic Bone Disease Agentsalendronate oral solution 70 mg75 ml
2 QL (300 per 28 days)
alendronate oral tablet 10 mg 5 mg 1 GC QL (30 per 30 days)
alendronate oral tablet 35 mg 1 GC QL (4 per 28 days)
alendronate oral tablet 70 mg (Fosamax) 1 GC QL (4 per 28 days)
calcitonin (salmon) injection solution 200 unitml
(Miacalcin) 5 NM NDS
calcitonin (salmon) nasal spraynon-aerosol 200 unitactuation
2 QL (37 per 28 days)
calcitriol intravenous solution 1 mcgml
2
calcitriol oral capsule 025 mcg 05 mcg
(Rocaltrol) 2
calcitriol oral solution 1 mcgml (Rocaltrol) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
178
Drug Name Drug Tier RequirementsLimits
cinacalcet oral tablet 30 mg (Sensipar) 2 QL (60 per 30 days)
cinacalcet oral tablet 60 mg (Sensipar) 5 NM NDS QL (60 per 30 days)
cinacalcet oral tablet 90 mg (Sensipar) 5 NM NDS QL (120 per 30 days)
doxercalciferol oral capsule 05 mcg 1 mcg 25 mcg
2
EVENITY SUBCUTANEOUS SYRINGE 105 MG117 ML 210MG234ML ( 105MG117MLX2)
5 PA NM NDS QL (234 per 30 days)
ibandronate intravenous solution 3 mg3 ml
2 QL (3 per 84 days)
ibandronate intravenous syringe 3 mg3 ml
2 QL (3 per 84 days)
ibandronate oral tablet 150 mg (Boniva) 2 QL (1 per 28 days)
NATPARA SUBCUTANEOUS CARTRIDGE 100 MCGDOSE 25 MCGDOSE 50 MCGDOSE 75 MCGDOSE
5 PA NM NDS QL (2 per 28 days)
pamidronate intravenous recon soln30 mg 90 mg
2
pamidronate intravenous solution 30 mg10 ml (3 mgml) 60 mg10 ml (6 mgml) 90 mg10 ml (9 mgml)
2
paricalcitol oral capsule 1 mcg 2 mcg
(Zemplar) 2
paricalcitol oral capsule 4 mcg 2
PROLIA SUBCUTANEOUS SYRINGE 60 MGML
3 QL (1 per 180 days)
RAYALDEE ORAL CAPSULEEXTENDED RELEASE 24 HR 30 MCG
3 QL (60 per 30 days)
risedronate oral tablet 150 mg (Actonel) 2 QL (1 per 28 days)
risedronate oral tablet 30 mg 5 mg 2 QL (30 per 30 days)
risedronate oral tablet 35 mg (Actonel) 2 QL (4 per 28 days)
risedronate oral tablet 35 mg (12 pack) 35 mg (4 pack)
2 QL (4 per 28 days)
risedronate oral tabletdelayed release (drec) 35 mg
(Atelvia) 2 QL (4 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
179
Drug Name Drug Tier RequirementsLimits
TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3120 MCG156 ML)
3 PA QL (156 per 30 days)
XGEVA SUBCUTANEOUS SOLUTION 120 MG17 ML (70 MGML)
5 PA NM NDS
zoledronic acid intravenous recon soln 4 mg
2
zoledronic acid intravenous solution4 mg5 ml
2
zoledronic acid-mannitol-water intravenous piggyback 5 mg100 ml
(Reclast) 2 QL (100 per 300 days)
Miscellaneous Therapeutic AgentsMiscellaneous Therapeutic AgentsACTIMMUNE SUBCUTANEOUS SOLUTION 100 MCG05 ML
5 PA NM NDS
buspirone oral tablet 10 mg 15 mg 30 mg 5 mg 75 mg
2
CYSTADANE ORAL POWDER 1 GRAM17 ML
5 NM NDS
dexrazoxane hcl intravenous recon soln 250 mg 500 mg
5 NM NDS
diazoxide oral suspension 50 mgml (Proglycem) 2
ELMIRON ORAL CAPSULE 100 MG
4 QL (90 per 30 days)
ENDARI ORAL POWDER IN PACKET 5 GRAM
5 PA NM NDS QL (180 per 30 days)
EVRYSDI ORAL RECON SOLN 075 MGML
5 PA NM NDS
EXONDYS-51 INTRAVENOUS SOLUTION 50 MGML
5 PA NM LA NDS
fomepizole intravenous solution 1 gramml
5 NM NDS
GVOKE HYPOPEN 2-PACK SUBCUTANEOUS AUTO-INJECTOR 05 MG01 ML 1 MG02 ML
3
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
180
Drug Name Drug Tier RequirementsLimits
GVOKE PFS 1-PACK SYRINGE SUBCUTANEOUS SYRINGE 05 MG01 ML 1 MG02 ML
3
hydroxyzine pamoate oral capsule100 mg
2
hydroxyzine pamoate oral capsule25 mg 50 mg
(Vistaril) 1 GC
KEVEYIS ORAL TABLET 50 MG
5 PA NM NDS QL (120 per 30 days)
leucovorin calcium injection recon soln 100 mg 200 mg 350 mg 50 mg 500 mg
2
leucovorin calcium injection solution10 mgml
2
leucovorin calcium oral tablet 10 mg 15 mg 25 mg 5 mg
2
levocarnitine (with sugar) oral solution 100 mgml
(Carnitor) 2
levocarnitine oral tablet 330 mg (Carnitor) 4
levoleucovorin calcium intravenous recon soln 50 mg
(Fusilev) 5 NM NDS
mesna intravenous solution 100 mgml
(Mesnex) 2
MESNEX ORAL TABLET 400 MG
5 NM NDS
OXLUMO SUBCUTANEOUS SOLUTION 945 MG05 ML
5 PA NM NDS
pyridostigmine bromide oral syrup60 mg5 ml
(Mestinon) 2
pyridostigmine bromide oral tablet30 mg
2
pyridostigmine bromide oral tablet60 mg
(Mestinon) 2
pyridostigmine bromide oral tablet extended release 180 mg
(Mestinon Timespan) 2
RECTIV RECTAL OINTMENT 04 (WW)
4 QL (30 per 30 days)
TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG2 ML (150 MGML)
5 PA NM NDS QL (4 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
181
Drug Name Drug Tier RequirementsLimits
THALOMID ORAL CAPSULE 100 MG 150 MG 200 MG 50 MG
5 PA NSO NM NDS QL (60 per 30 days)
TOTECT INTRAVENOUS RECON SOLN 500 MG
5 NM NDS
TYBOST ORAL TABLET 150 MG
4 QL (30 per 30 days)
VISTOGARD ORAL GRANULES IN PACKET 10 GRAM
5 NM NDS QL (24 per 14 days)
XURIDEN ORAL GRANULES IN PACKET 2 GRAM
5 PA NM NDS QL (120 per 30 days)
Ophthalmic AgentsAntiglaucoma Agentsacetazolamide oral capsule extended release 500 mg
2
acetazolamide oral tablet 125 mg 250 mg
2
acetazolamide sodium injection recon soln 500 mg
2
ALPHAGAN P OPHTHALMIC (EYE) DROPS 01
3
AZOPT OPHTHALMIC (EYE) DROPSSUSPENSION 1
(brinzolamide) 2
betaxolol ophthalmic (eye) drops05
2
bimatoprost ophthalmic (eye) drops003
2 QL (25 per 25 days)
brimonidine ophthalmic (eye) drops015
(Alphagan P) 4
brimonidine ophthalmic (eye) drops02
1 GC
carteolol ophthalmic (eye) drops 1
2
COMBIGAN OPHTHALMIC (EYE) DROPS 02-05
3
dorzolamide ophthalmic (eye) drops2
(Trusopt) 2
dorzolamide-timolol ophthalmic (eye) drops 223-68 mgml
(Cosopt) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
182
Drug Name Drug Tier RequirementsLimits
latanoprost ophthalmic (eye) drops0005
(Xalatan) 1 GC QL (25 per 25 days)
levobunolol ophthalmic (eye) drops05
1 GC
LUMIGAN OPHTHALMIC (EYE) DROPS 001
3 QL (25 per 25 days)
methazolamide oral tablet 25 mg 50 mg
2
metipranolol ophthalmic (eye) drops 03
2
pilocarpine hcl ophthalmic (eye) drops 1 2
(Isopto Carpine) 2
pilocarpine hcl ophthalmic (eye) drops 4
2
RHOPRESSA OPHTHALMIC (EYE) DROPS 002
3 QL (25 per 25 days)
ROCKLATAN OPHTHALMIC (EYE) DROPS 002-0005
3 QL (25 per 25 days)
SIMBRINZA OPHTHALMIC (EYE) DROPSSUSPENSION 1-02
3
timolol maleate ophthalmic (eye) drops 025 05
(Timoptic) 1 GC
timolol maleate ophthalmic (eye) gel forming solution 025 05
(Timoptic-XE) 4
travoprost ophthalmic (eye) drops0004
(Travatan Z) 2 QL (25 per 25 days)
VYZULTA OPHTHALMIC (EYE) DROPS 0024
4 QL (5 per 30 days)
XELPROS OPHTHALMIC (EYE) DROPS EMULSION 0005
4 ST QL (25 per 25 days)
ZIOPTAN (PF) OPHTHALMIC (EYE) DROPPERETTE 00015
4 QL (30 per 30 days)
Replacement PreparationsReplacement Preparationscalcium chloride intravenous syringe100 mgml (10 )
2
d5 and 09 sodium chloride intravenous parenteral solution
4
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
183
Drug Name Drug Tier RequirementsLimits
d5 -045 sodium chloride intravenous parenteral solution
4
ISOLYTE S IV SOLUTION-EXCEL SINGLE USE
4
ISOLYTE S PH 74 INTRAVENOUS PARENTERAL SOLUTION
4
ISOLYTE-P IN 5 DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5
4
klor-con m10 oral tableter particlescrystals 10 meq
(potassium chloride) 2
klor-con m15 oral tableter particlescrystals 15 meq
(potassium chloride) 2
klor-con m20 oral tableter particlescrystals 20 meq
(potassium chloride) 2
magnesium sulfate in d5w intravenous piggyback 1 gram100 ml
2
magnesium sulfate in water intravenous parenteral solution 20 gram500 ml (4 ) 40 gram1000 ml (4 )
2 PA BvD
magnesium sulfate in water intravenous piggyback 2 gram50 ml (4 ) 4 gram100 ml (4 ) 4 gram50 ml (8 )
2 PA BvD
magnesium sulfate injection syringe4 meqml
2 PA BvD
NORMOSOL-M IN 5 DEXTROSE INTRAVENOUS PARENTERAL SOLUTION
4
PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION
4
PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION
4
potassium chloride intravenous solution 2 meqml
1 PA BvD GC
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
184
Drug Name Drug Tier RequirementsLimits
potassium chloride intravenous solution 2 meqml (20 ml)
2 PA BvD
potassium chloride oral capsule extended release 10 meq 8 meq
2
potassium chloride oral liquid 20 meq15 ml 40 meq15 ml
2
potassium chloride oral tablet extended release 10 meq 20 meq 8 meq
(K-Tab) 2
potassium chloride oral tableter particlescrystals 10 meq
(Klor-Con M10) 2
potassium chloride oral tableter particlescrystals 15 meq
(Klor-Con M15) 2
potassium chloride oral tableter particlescrystals 20 meq
(Klor-Con M20) 2
potassium chloride-045 nacl intravenous parenteral solution 20 meql
2
potassium citrate oral tablet extended release 10 meq (1080 mg)
(Urocit-K 10) 2
potassium citrate oral tablet extended release 15 meq
(Urocit-K 15) 2
potassium citrate oral tablet extended release 5 meq (540 mg)
(Urocit-K 5) 2
sodium chloride 045 intravenous parenteral solution 045
2
sodium chloride 09 intravenous parenteral solution
2
sodium chloride 09 intravenous piggyback
2
sodium chloride 09 solution viaflex single use
4
Respiratory Tract AgentsAnti-Inflammatories Inhaled CorticosteroidsADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCGDOSE 250-50 MCGDOSE 500-50 MCGDOSE
(fluticasone propion-salmeterol)
2 QL (60 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
185
Drug Name Drug Tier RequirementsLimits
ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCGACTUATION 230-21 MCGACTUATION 45-21 MCGACTUATION
3 QL (12 per 30 days)
ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 200 MCGACTUATION 50 MCGACTUATION
3 QL (30 per 30 days)
BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCGDOSE 200-25 MCGDOSE
3 QL (60 per 30 days)
budesonide inhalation suspension for nebulization 025 mg2 ml 05 mg2 ml
(Pulmicort) 2 PA BvD QL (120 per 30 days)
budesonide inhalation suspension for nebulization 1 mg2 ml
(Pulmicort) 2 PA BvD QL (60 per 30 days)
FLOVENT 100 MCG DISKUS 100 MCGACTUATION
3 QL (60 per 30 days)
FLOVENT 250 MCG DISKUS 250 MCGACTUATION
3 QL (120 per 30 days)
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCGACTUATION 50 MCGACTUATION
3 QL (60 per 30 days)
FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCGACTUATION
3 QL (120 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCGACTUATION
3 QL (12 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCGACTUATION
3 QL (24 per 30 days)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCGACTUATION
3 QL (212 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
186
Drug Name Drug Tier RequirementsLimits
SYMBICORT INHALATION HFA AEROSOL INHALER 160-45 MCGACTUATION 80-45 MCGACTUATION
(budesonide-formoterol)
3 QL (306 per 30 days)
Antileukotrienesmontelukast oral tablet 10 mg (Singulair) 1 GC
montelukast oral tabletchewable 4 mg 5 mg
(Singulair) 1 GC
zafirlukast oral tablet 10 mg 20 mg (Accolate) 2Bronchodilatorsalbuterol 5 mgml solution 5 mgml 2 PA BvD QL (120 per
30 days)
albuterol sulfate inhalation hfa aerosol inhaler 90 mcgactuation
(ProAir HFA) 2 QL (17 per 30 days)
albuterol sulfate inhalation hfa aerosol inhaler 90 mcgactuation (nda020503)
2 QL (134 per 30 days)
albuterol sulfate inhalation hfa aerosol inhaler 90 mcgactuation (nda020983)
4 QL (36 per 30 days)
albuterol sulfate inhalation solution for nebulization 063 mg3 ml 125 mg3 ml 25 mg 3 ml (0083 )
2 PA BvD QL (360 per 30 days)
albuterol sulfate inhalation solution for nebulization 25 mg05 ml
2 PA BvD QL (120 per 30 days)
albuterol sulfate oral syrup 2 mg5 ml
2
albuterol sulfate oral tablet 2 mg 4 mg
2
albuterol sulfate oral tablet extended release 12 hr 4 mg 8 mg
2
ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 625-25 MCGACTUATION
3 QL (60 per 30 days)
ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCGACTUATION
4 QL (258 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
187
Drug Name Drug Tier RequirementsLimits
BREZTRI AEROSPHERE INHALATION HFA AEROSOL INHALER 160-9-48 MCGACTUATION
3 QL (107 per 30 days)
COMBIVENT RESPIMAT INHALATION MIST 20-100 MCGACTUATION
3 QL (8 per 30 days)
elixophyllin oral elixir 80 mg15 ml (theophylline) 2
ipratropium bromide inhalation solution 002
2 PA BvD QL (3125 per 30 days)
ipratropium-albuterol inhalation solution for nebulization 05 mg-3 mg(25 mg base)3 ml
2 PA BvD QL (540 per 30 days)
metaproterenol oral syrup 10 mg5 ml
1 GC
PROAIR RESPICLICK INHALATION AEROSOL POWDR BREATH ACTIVATED 90 MCGACTUATION
4 QL (2 per 30 days)
SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCGDOSE
3 QL (60 per 30 days)
SPIRIVA RESPIMAT INHALATION MIST 125 MCGACTUATION 25 MCGACTUATION
3 QL (4 per 30 days)
SPIRIVA WITH HANDIHALER INHALATION CAPSULE WINHALATION DEVICE 18 MCG
3 QL (30 per 30 days)
STIOLTO RESPIMAT INHALATION MIST 25-25 MCGACTUATION
3 QL (4 per 30 days)
terbutaline oral tablet 25 mg 5 mg 2
terbutaline subcutaneous solution 1 mgml
5 NM NDS
theophylline oral solution 80 mg15 ml
2
theophylline oral tablet extended release 12 hr 300 mg 450 mg
2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
188
Drug Name Drug Tier RequirementsLimits
theophylline oral tablet extended release 24 hr 400 mg 600 mg
2
TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-625-25 MCG 200-625-25 MCG
3 QL (60 per 30 days)
Respiratory Tract Agents Otheracetylcysteine intravenous solution200 mgml (20 )
(Acetadote) 2
acetylcysteine solution 100 mgml (10 ) 200 mgml (20 )
2 PA BvD
BRONCHITOL INHALATION CAPSULE WINHALATION DEVICE 40 MG
5 NM NDS QL (560 per 28 days)
CINQAIR INTRAVENOUS SOLUTION 10 MGML
5 PA NM NDS
cromolyn inhalation solution for nebulization 20 mg2 ml
2 PA BvD
DALIRESP ORAL TABLET 250 MCG
3 QL (28 per 28 days)
DALIRESP ORAL TABLET 500 MCG
3 QL (30 per 30 days)
ESBRIET ORAL CAPSULE 267 MG
5 PA NM NDS QL (270 per 30 days)
ESBRIET ORAL TABLET 267 MG
5 PA NM NDS QL (270 per 30 days)
ESBRIET ORAL TABLET 801 MG
5 PA NM NDS QL (90 per 30 days)
FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MGML
5 PA NM NDS QL (1 per 28 days)
FASENRA SUBCUTANEOUS SYRINGE 30 MGML
5 PA NM NDS QL (1 per 28 days)
KALYDECO ORAL GRANULES IN PACKET 25 MG 50 MG 75 MG
5 PA NM NDS QL (56 per 28 days)
KALYDECO ORAL TABLET 150 MG
5 PA NM NDS QL (56 per 28 days)
NUCALA SUBCUTANEOUS AUTO-INJECTOR 100 MGML
5 PA NM LA NDS QL (3 per 28 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
189
Drug Name Drug Tier RequirementsLimits
NUCALA SUBCUTANEOUS RECON SOLN 100 MG
5 PA NM LA NDS QL (3 per 28 days)
NUCALA SUBCUTANEOUS SYRINGE 100 MGML
5 PA NM LA NDS QL (3 per 28 days)
OFEV ORAL CAPSULE 100 MG 150 MG
5 PA NM NDS QL (60 per 30 days)
ORKAMBI ORAL GRANULES IN PACKET 100-125 MG 150-188 MG
5 PA NM NDS QL (56 per 28 days)
ORKAMBI ORAL TABLET 100-125 MG 200-125 MG
5 PA NM NDS QL (120 per 30 days)
PROLASTIN C 1000 MG20 ML VL PRICEONE MGLFSUV 1000 MG (+-)20 ML
5 PA BvD NM NDS
PROLASTIN-C INTRAVENOUS RECON SOLN 1000 MG
5 PA BvD NM NDS
SYMDEKO ORAL TABLETS SEQUENTIAL 100-150 MG (D) 150 MG (N) 50-75 MG (D) 75 MG (N)
5 PA NM NDS QL (56 per 28 days)
TRIKAFTA ORAL TABLETS SEQUENTIAL 100-50-75 MG(D) 150 MG (N) 50-25-375 MG (D)75 MG (N)
5 PA NM NDS QL (84 per 28 days)
XOLAIR SUBCUTANEOUS RECON SOLN 150 MG
5 PA NM NDS
XOLAIR SUBCUTANEOUS SYRINGE 150 MGML 75 MG05 ML
5 PA NM NDS
Skeletal Muscle RelaxantsSkeletal Muscle Relaxantsbaclofen oral tablet 10 mg 20 mg 5 mg
2
chlorzoxazone oral tablet 250 mg 5 NM NDS QL (120 per 30 days)
chlorzoxazone oral tablet 500 mg 2
cyclobenzaprine oral tablet 10 mg 5 mg
1 GC
dantrolene oral capsule 100 mg 2
dantrolene oral capsule 25 mg 50 mg
(Dantrium) 2
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
190
Drug Name Drug Tier RequirementsLimits
methocarbamol oral tablet 500 mg 750 mg
2
revonto intravenous recon soln 20 mg
(dantrolene) 2
tizanidine oral tablet 2 mg 2
tizanidine oral tablet 4 mg (Zanaflex) 2
Sleep Disorder AgentsSleep Disorder Agentsarmodafinil oral tablet 150 mg 200 mg 250 mg 50 mg
(Nuvigil) 2 PA QL (30 per 30 days)
BELSOMRA ORAL TABLET 10 MG 15 MG 20 MG 5 MG
3 QL (30 per 30 days)
eszopiclone oral tablet 1 mg 2 mg 3 mg
(Lunesta) 2 QL (30 per 30 days)
HETLIOZ LQ ORAL SUSPENSION 4 MGML
5 PA NM NDS QL (150 per 30 days)
HETLIOZ ORAL CAPSULE 20 MG
5 PA NM NDS QL (30 per 30 days)
SUNOSI ORAL TABLET 150 MG 75 MG
4 PA QL (30 per 30 days)
XYREM ORAL SOLUTION 500 MGML
5 PA NM LA NDS QL (540 per 30 days)
zaleplon oral capsule 10 mg 5 mg 2 QL (30 per 30 days)
zolpidem oral tablet 10 mg 5 mg (Ambien) 1 GC QL (30 per 30 days)
zolpidem oral tabletext release multiphase 125 mg 625 mg
(Ambien CR) 2 QL (30 per 30 days)
Vasodilating AgentsVasodilating AgentsADEMPAS ORAL TABLET 05 MG 1 MG 15 MG 2 MG 25 MG
5 PA NM NDS QL (90 per 30 days)
alyq oral tablet 20 mg (tadalafil (pulm hypertension))
2 PA QL (60 per 30 days)
ambrisentan oral tablet 10 mg 5 mg (Letairis) 5 PA NM NDS QL (30 per 30 days)
epoprostenol (glycine) intravenous recon soln 05 mg 15 mg
(Flolan) 5 PA NM NDS
OPSUMIT ORAL TABLET 10 MG
5 PA NM NDS QL (30 per 30 days)
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
191
Drug Name Drug Tier RequirementsLimits
sildenafil (pulmhypertension) intravenous solution 10 mg125 ml
(Revatio) 5 PA NM NDS QL (375 per 1 day)
sildenafil (pulmhypertension) oral tablet 20 mg
(Revatio) 2 PA QL (90 per 30 days)
sildenafil oral tablet 100 mg 25 mg 50 mg
(Viagra) 2 EX CB (6 EA per 30 days)
tadalafil (pulm hypertension) oral tablet 20 mg
(Alyq) 2 PA QL (60 per 30 days)
tadalafil oral tablet 25 mg 5 mg (Cialis) 2 PA QL (30 per 30 days)
TRACLEER ORAL TABLET 125 MG 625 MG
(bosentan) 5 PA NM LA NDS QL (60 per 30 days)
TRACLEER ORAL TABLET FOR SUSPENSION 32 MG
5 PA NM NDS QL (112 per 28 days)
treprostinil sodium injection solution1 mgml 10 mgml 25 mgml 5 mgml
(Remodulin) 5 PA NM NDS
TYVASO INHALATION SOLUTION FOR NEBULIZATION 174 MG29 ML (06 MGML)
5 PA NM NDS
UPTRAVI INTRAVENOUS RECON SOLN 1800 MCG
5 PA NM NDS QL (60 per 30 days)
UPTRAVI ORAL TABLET 1000 MCG 1200 MCG 1400 MCG 1600 MCG 400 MCG 600 MCG 800 MCG
5 PA NM NDS QL (60 per 30 days)
UPTRAVI ORAL TABLET 200 MCG
5 PA NM NDS QL (240 per 30 days)
UPTRAVI ORAL TABLETSDOSE PACK 200 MCG (140)- 800 MCG (60)
5 PA NM NDS
You can find information on what the symbols and abbreviations in this table mean by going to the introduction pages of this document
192
INDEX
1ST TIER UNIFINE PENTIPS 1101ST TIER UNIFINE PENTIPS PLUS110abacavir 66abacavir-lamivudine 66abacavir-lamivudine-zidovudine 66ABELCET 51abiraterone 20ABOUTTIME PEN NEEDLE 110ABRAXANE21acamprosate 9acarbose 46accutane 104acebutolol 82acetaminophen-codeine 3acetazolamide 182acetazolamide sodium 182acetic acid 151acetylcysteine 189acitretin 104ACTEMRA 167ACTEMRA ACTPEN167ACTHAR 164ACTHIB (PF) 173ACTIMMUNE 180acyclovir 71 104acyclovir sodium 71ADACEL(TDAP ADOLESNADULT)(PF) 173ADAKVEO 75adapalene 109ADCETRIS 21adefovir 71ADEMPAS 191adriamycin 21
adrucil 21ADVAIR DISKUS 185ADVAIR HFA 186ADVOCATE PEN NEEDLE 111ADVOCATE SYRINGES 110 111AFINITOR21AFINITOR DISPERZ 21afirmelle 95a-hydrocort 162AIMOVIG AUTOINJECTOR 54AKYNZEO (FOSNETUPITANT)56AKYNZEO (NETUPITANT) 56ala-cort 106ala-scalp 107albendazole 57albuterol sulfate 187alcaine 150alclometasone 107ALCOHOL PADS 104ALCOHOL PREP PADS 105ALCOHOL PREP SWABS 104ALCOHOL SWABS 104ALCOHOL WIPES 105ALDURAZYME148ALECENSA 21alendronate 178alfuzosin 159ALIMTA 21ALIQOPA21aliskiren 90allopurinol 53alosetron 177 178ALPHAGAN P182
alprazolam 11ALREX153altavera (28) 95ALTRENO 109ALUNBRIG21alyacen 135 (28) 95alyacen 777 (28) 95alyq 191amabelz 161amantadine hcl 58AMBISOME51ambrisentan 191amethia 95amiloride 86amiloride-hydrochlorothiazide 86AMINOSYN II 15 76AMINOSYN-PF 7 (SULFITE-FREE)76amiodarone 81amitriptyline 43amitriptyline-chlordiazepoxide 43amlodipine 86amlodipine-atorvastatin 88amlodipine-benazepril 86amlodipine-olmesartan 86amlodipine-valsartan 86amlodipine-valsartan-hcthiazid 86ammonium lactate 104amoxapine 43amoxicil-clarithromy-lansopraz 154amoxicillin 17amoxicillin-pot clavulanate 17 18amphotericin b 51ampicillin 18ampicillin sodium 18ampicillin-sulbactam 18ANADROL-50 160
I-1
anagrelide 75anastrozole 21ANORO ELLIPTA 187APOKYN 58apraclonidine 150aprepitant 56apri 95APTIOM37APTIVUS 66APTIVUS (WITH VITAMIN E) 66aranelle (28) 95ARCALYST 167aripiprazole 60 61ARISTADA61ARISTADA INITIO 61armodafinil 191ARNUITY ELLIPTA 186arsenic trioxide 21ascomp with codeine 3asenapine maleate 61ashlyna 95ASPARLAS21aspirin-dipyridamole 75ASSURE ID DUO-SHIELD 111ASSURE ID INSULIN SAFETY111 112ASSURE ID PEN NEEDLE 111 112atazanavir 66atenolol 82atenolol-chlorthalidone 82atomoxetine 91atorvastatin 88atovaquone 57atovaquone-proguanil 58atropine 150ATROVENT HFA 187AUBAGIO91aubra eq 95
aurovela 1530 (21) 95aurovela 120 (21) 95aurovela 24 fe 95aurovela fe 1530 (28) 95aurovela fe 1-20 (28) 95AUSTEDO 91AVASTIN21aviane 95AVONEX 91AVSOLA 167ayuna 95AYVAKIT21azacitidine 22azathioprine 167azathioprine sodium 167azelastine 150azithromycin 16AZOPT 182aztreonam 17azurette (28) 95bacitracin 13 151bacitracin-polymyxin b 151baclofen 190balsalazide 178BALVERSA 22balziva (28) 96BAVENCIO22BAXDELA 19BCG VACCINE LIVE (PF) 173BD ALCOHOL SWABS104BD AUTOSHIELD DUO PEN NEEDLE112BD ECLIPSE LUER-LOK112BD INSULIN SYRINGE112BD INSULIN SYRINGE (HALF UNIT) 112BD INSULIN SYRINGE SLIP TIP 113BD INSULIN SYRINGE U-500112
BD INSULIN SYRINGE ULTRA-FINE112BD NANO 2ND GEN PEN NEEDLE 113BD SAFETYGLIDE INSULIN SYRINGE112 113BD SAFETYGLIDE SYRINGE 113BD ULTRA-FINE MICRO PEN NEEDLE113BD ULTRA-FINE MINI PEN NEEDLE113BD ULTRA-FINE NANO PEN NEEDLE113BD ULTRA-FINE ORIG PEN NEEDLE114BD ULTRA-FINE SHORT PEN NEEDLE114BD VEO INSULIN SYR (HALF UNIT) 114BD VEO INSULIN SYRINGE UF 114bekyree (28) 96BELEODAQ22BELSOMRA191benazepril 80benazepril-hydrochlorothiazide 80BENDEKA22BENLYSTA167benztropine 58 59bepotastine besilate 150BESPONSA 22betamethasone acetsod phos 162betamethasone dipropionate 107betamethasone valerate 107betamethasone augmented 107BETASERON91betaxolol 82 182bethanechol chloride 158bexarotene 22
I-2
BEXSERO 173bicalutamide 22BICILLIN L-A 18BIDIL 90BIKTARVY 66bimatoprost 182bisoprolol fumarate 82bisoprolol-hydrochlorothiazide 82BLENREP 22bleomycin 22bleph-10 151BLINCYTO22blisovi 24 fe 96blisovi fe 1530 (28) 96blisovi fe 120 (28) 96BOOSTRIX TDAP174BORDERED GAUZE 114BORTEZOMIB 22BOSULIF 22BRAFTOVI 22BREO ELLIPTA 186BREZTRI AEROSPHERE 188briellyn 96BRILINTA 75brimonidine 182BRIVIACT 37bromfenac 153bromocriptine 59BROMSITE 153BRONCHITOL 189BRUKINSA 22budesonide 178 186bumetanide 86buprenorphine 3buprenorphine hcl 3 9buprenorphine-naloxone 10bupropion hcl 43bupropion hcl (smoking deter) 10buspirone 180butalbital-acetaminop-caf-cod 3
butalbital-acetaminophen 3butalbital-acetaminophen-caff 3butalbital-aspirin-caffeine 3butorphanol 3BYNFEZIA 164BYSTOLIC82CABENUVA 66cabergoline 59CABLIVI 75CABOMETYX 22caffeine citrate 91calcipotriene 104calcitonin (salmon) 178calcitriol 178calcium acetate(phosphat bind) 158calcium chloride 183CALQUENCE22camila 96candesartan 79candesartan-hydrochlorothiazid 79CAPLYTA61CAPRELSA23captopril 80captopril-hydrochlorothiazide 80CARBAGLU 156carbamazepine 38carbidopa 59carbidopa-levodopa 59carbidopa-levodopa-entacapone 59carbinoxamine maleate 53carboplatin 23CAREFINE PEN NEEDLE 114CARETOUCH ALCOHOL PREP PAD 104CARETOUCH INSULIN SYRINGE 115
CARETOUCH PEN NEEDLE114 115CAROSPIR 90carteolol 182cartia xt 83carvedilol 82caspofungin 51CAYSTON 17caziant (28) 96cefaclor 14cefadroxil 14cefazolin 14cefdinir 14 15cefepime 15cefixime 15cefotaxime 15cefoxitin 15cefoxitin in dextrose iso-osm 15cefpodoxime 15cefprozil 15ceftazidime 15ceftriaxone 15cefuroxime axetil 15cefuroxime sodium 15celecoxib 6CELONTIN38cephalexin 15 16CERDELGA 148CEREZYME 148cevimeline 103CHANTIX10CHANTIX CONTINUING MONTH BOX10CHANTIX STARTING MONTH BOX10chateal eq (28) 96chloramphenicol sod succinate 13chlordiazepoxide hcl 11chlorhexidine gluconate 103chloroquine phosphate 58
I-3
chlorothiazide sodium 87chlorpromazine 61chlorthalidone 87chlorzoxazone 190cholestyramine (with sugar) 88cholestyramine light 88ciclopirox 51cidofovir 71cilostazol 76CIMDUO 66cimetidine 155cimetidine hcl 155CIMZIA167CIMZIA POWDER FOR RECONST167cinacalcet 179CINQAIR 189CINRYZE 73ciprofloxacin 19ciprofloxacin hcl 19 151ciprofloxacin in 5 dextrose 19ciprofloxacin-dexamethasone 151citalopram 43cladribine 23clarithromycin 16clemastine 53CLENPIQ 158CLICKFINE PEN NEEDLE 115clindamycin hcl 13clindamycin in 5 dextrose 13clindamycin pediatric 13clindamycin phosphate 13 54 106clindamycin-benzoyl peroxide 106CLINIMIX 5D15W SULFITE FREE76CLINIMIX 425D10W SULF FREE76CLINIMIX 425D5W SULFIT FREE 76
CLINIMIX 5-D20W(SULFITE-FREE) 76CLINIMIX 6-D5W (SULFITE-FREE)76CLINIMIX 8-D10W(SULFITE-FREE) 76CLINIMIX 8-D14W(SULFITE-FREE) 77CLINIMIX E 275D5W SULF FREE77CLINIMIX E 425D10W SUL FREE 77CLINIMIX E 425D5W SULF FREE77CLINIMIX E 5D15W SULFIT FREE 77CLINIMIX E 5D20W SULFIT FREE 77CLINIMIX E 8-D10W SULFITEFREE 77CLINIMIX E 8-D14W SULFITEFREE 77clobazam 38clobetasol 107clobetasol-emollient 107clofarabine 23clomipramine 43clonazepam 11clonidine 78clonidine hcl 78 91clopidogrel 76clorazepate dipotassium 11clotrimazole 51clotrimazole-betamethasone 51clovique 159clozapine 61COARTEM 58codeine sulfate 3codeine-butalbital-asa-caff 3colchicine 53
colesevelam 88colestipol 88colistin (colistimethate na) 13COMBIGAN 182COMBIVENT RESPIMAT188COMETRIQ23COMFORT EZ INSULIN SYRINGE115 116 117COMFORT EZ PEN NEEDLES 116COMFORT TOUCH PEN NEEDLE117 118COMPLERA 66compro 56constulose 156COPAXONE 91COPIKTRA23CORLANOR85COSENTYX 168COSENTYX (2 SYRINGES) 167COSENTYX PEN (2 PENS) 168COTELLIC23CREON 148CRIXIVAN 66cromolyn 150 156 189cryselle (28) 96CURAD GAUZE PAD 118CURITY ALCOHOL SWABS 104CURITY GAUZE 118cyclafem 135 (28) 96cyclafem 777 (28) 96cyclobenzaprine 190cyclopentolate 150cyclophosphamide 23CYCLOPHOSPHAMIDE23cyclosporine 168cyclosporine modified 168cyproheptadine 53
I-4
CYRAMZA23cyred eq 96CYSTADANE 180CYSTADROPS 150CYSTARAN150d5 and 09 sodium chloride 183d5 -045 sodium chloride 184dalfampridine 91DALIRESP189danazol 160dantrolene 190DANYELZA 23dapsone 55DAPTACEL (DTAP PEDIATRIC) (PF) 174daptomycin 13DARZALEX 23DARZALEX FASPRO 23dasetta 135 (28) 96dasetta 777 (28) 96DAURISMO 23daysee 96deblitane 96decitabine 24deferasirox 159 160deferiprone 160deferoxamine 160DELSTRIGO 66demeclocycline 19DENAVIR104DENGVAXIA (PF)174denta 5000 plus 103dentagel 103DERMACEA 118DERMACEA NON-WOVEN118DESCOVY 66desipramine 43desmopressin 164
desog-eestradioleestradiol 96desogestrel-ethinyl estradiol 96desonide 107desoximetasone 108desvenlafaxine succinate 44dexamethasone 162dexamethasone sodium phos (pf) 163dexamethasone sodium phosphate 153 163dexmethylphenidate 91dexrazoxane hcl 180dextroamphetamine 91dextroamphetamine-amphetamine 92dextrose 10 in water (d10w) 77dextrose 5 in water (d5w) 77DIACOMIT38diazepam 11 38diazoxide 180diclofenac epolamine 6diclofenac potassium 7diclofenac sodium 7 153diclofenac-misoprostol 7dicloxacillin 18dicyclomine 156didanosine 66DIFICID16diflorasone 108diflunisal 7difluprednate 153digitek 85digox 85digoxin 85dihydroergotamine 54DILANTIN 38diltiazem hcl 84dilt-xr 84dimenhydrinate 56dimethyl fumarate 92
DIPENTUM178diphenhydramine hcl 53diphenoxylate-atropine 156dipyridamole 76disopyramide phosphate 81disulfiram 10divalproex 38docetaxel 24dofetilide 81donepezil 42DOPTELET (10 TAB PACK) 73DOPTELET (15 TAB PACK) 73DOPTELET (30 TAB PACK) 73dorzolamide 182dorzolamide-timolol 182dotti 161DOVATO 66doxazosin 78doxepin 44doxercalciferol 179doxorubicin 24doxorubicin peg-liposomal 24doxy-100 19doxycycline hyclate 20doxycycline monohydrate 20DRIZALMA SPRINKLE 44dronabinol 56droperidol 56DROPLET INSULIN SYR(HALF UNIT)118 119DROPLET INSULIN SYRINGE 118 119DROPLET MICRON PEN NEEDLE 119DROPLET PEN NEEDLE 119 120DROPSAFE PEN NEEDLE 120drospirenone-ethinyl estradiol96 97DROXIA 75
I-5
droxidopa 78DUAVEE161duloxetine 44DUPIXENT SYRINGE 168DUREZOL 153dutasteride 159dutasteride-tamsulosin 159EASY COMFORT ALCOHOL PAD 104EASY COMFORT INSULIN SYRINGE120 121EASY COMFORT PEN NEEDLES 121EASY GLIDE INSULIN SYRINGE 121EASY GLIDE PEN NEEDLE 122EASY TOUCH 123EASY TOUCH ALCOHOL PREP PADS 104EASY TOUCH FLIPLOCK INSULIN123EASY TOUCH FLIPLOCK SYRINGE 122EASY TOUCH INSULIN SAFETY SYR 122EASY TOUCH INSULIN SYRINGE122 123 124EASY TOUCH LUER LOCK INSULIN123EASY TOUCH PEN NEEDLE 123EASY TOUCH SAFETY PEN NEEDLE 123 124EASY TOUCH SHEATHLOCK INSULIN 122 123EASY TOUCH UNI-SLIP 124econazole 51EDARBI 79
EDARBYCLOR79EDURANT 67efavirenz 67efavirenz-emtricitabin-tenofov 67efavirenz-lamivu-tenofov disop 67EGRIFTA164EGRIFTA SV 164ELAPRASE 148ELIGARD24ELIGARD (3 MONTH)24ELIGARD (4 MONTH)24ELIGARD (6 MONTH)24elinest 97ELIQUIS 72ELIQUIS DVT-PE TREAT 30D START72ELITEK148elixophyllin 188ELLA97ELMIRON 180eluryng 97EMCYT 24EMEND 56EMFLAZA 163EMGALITY PEN 54EMGALITY SYRINGE 54emoquette 97EMPLICITI24EMSAM 44emtricitabine 67emtricitabine-tenofovir (tdf) 67EMTRIVA67enalapril maleate 80enalaprilat 80enalapril-hydrochlorothiazide 80ENBREL 168ENBREL MINI 168ENBREL SURECLICK168ENDARI180endocet 3 4
ENGERIX-B (PF) 174ENGERIX-B PEDIATRIC (PF) 174ENHERTU24enoxaparin 72enpresse 97enskyce 97ENSPRYNG 92entacapone 59entecavir 71ENTRESTO 79enulose 156EPANED 80EPCLUSA 70EPIDIOLEX38epinastine 150epinephrine 85epitol 38EPIVIR HBV67eplerenone 90epoprostenol (glycine) 191eprosartan 79ERBITUX 24ergoloid 42ERIVEDGE24ERLEADA 24erlotinib 24errin 97ertapenem 17ery pads 106erythromycin 16 151erythromycin ethylsuccinate 16erythromycin with ethanol 106erythromycin-benzoyl peroxide 106ESBRIET 189escitalopram oxalate 44esomeprazole magnesium 155esomeprazole sodium 155estarylla 97
I-6
estazolam 11estradiol 161estradiol valerate 161estradiol-norethindrone acet 161eszopiclone 191ethambutol 55ethosuximide 38 39ethynodiol diac-eth estradiol 97etodolac 7etonogestrel-ethinyl estradiol 97ETOPOPHOS 25etoposide 25etravirine 67EUCRISA108EVENITY179everolimus (antineoplastic) 25everolimus (immunosuppressive) 168EVOTAZ 67EVRYSDI180EXEL INSULIN124exemestane 25EXKIVITY25EXONDYS-51 180EYSUVIS153EZALLOR SPRINKLE 88ezetimibe 88ezetimibe-simvastatin 88FABRAZYME 148falmina (28) 97famciclovir 71famotidine 155famotidine (pf) 155famotidine (pf)-nacl (iso-os) 155FANAPT 62FARXIGA46FARYDAK 25FASENRA189FASENRA PEN 189febuxostat 53
felbamate 39felodipine 86FEMRING 161femynor 97fenofibrate 88fenofibrate micronized 88fenofibrate nanocrystallized 88fenofibric acid (choline) 88fenoprofen 7fentanyl 4fentanyl citrate 4FERRIPROX 160FERRIPROX (2 TIMES A DAY) 160FETZIMA 44FIASP FLEXTOUCH U-100 INSULIN48FIASP PENFILL U-100 INSULIN48FIASP U-100 INSULIN48finasteride 159FINTEPLA39FIRVANQ13flavoxate 158FLEBOGAMMA DIF168flecainide 81FLOVENT DISKUS 186FLOVENT HFA186floxuridine 25fluconazole 51fluconazole in nacl (iso-osm) 51flucytosine 51fludrocortisone 163flumazenil 92flunisolide 153fluocinolone 108fluocinolone acetonide oil 153fluocinonide 108fluocinonide-e 108fluoride (sodium) 103
fluorometholone 153fluorouracil 25 104 105fluoxetine 44fluphenazine decanoate 62fluphenazine hcl 62flurazepam 11 12flurbiprofen 7flurbiprofen sodium 154flutamide 25fluticasone propionate 108 154fluvastatin 89fluvoxamine 44fomepizole 180fondaparinux 72 73fosamprenavir 67fosaprepitant 56foscarnet 70fosinopril 80fosinopril-hydrochlorothiazide 81fosphenytoin 39FOTIVDA 25FREESTYLE PRECISION125FULPHILA 73fulvestrant 25furosemide 87FUZEON67fyavolv 162FYCOMPA 39gabapentin 39GALAFOLD 148galantamine 42GAMIFANT 168GAMMAGARD LIQUID 169GAMMAGARD S-D (IGA lt 1 MCGML)169GAMMAPLEX 169GAMMAPLEX (WITH SORBITOL)169GAMUNEX-C 169ganciclovir sodium 72
I-7
GARDASIL 9 (PF)174gatifloxacin 151GATTEX 30-VIAL156GAUZE PAD 125gavilyte-c 158gavilyte-g 158gavilyte-n 158GAVRETO25GAZYVA 25gemcitabine 25gemfibrozil 89generlac 156gengraf 169gentak 151gentamicin 12 106 151gentamicin sulfate (ped) (pf) 12gentamicin sulfate (pf) 12GENVOYA 67GILENYA92GILOTRIF 25GIVLAARI 75glatiramer 92glatopa 92glimepiride 50glipizide 50glipizide-metformin 50glyburide 51glyburide micronized 50glyburide-metformin 51glycopyrrolate 156glydo 9granisetron (pf) 56granisetron hcl 56 57GRANIX 74griseofulvin microsize 52griseofulvin ultramicrosize 52guanfacine 78 92GVOKE HYPOPEN 2-PACK 180
GVOKE PFS 1-PACK SYRINGE 181HAEGARDA 74hailey 97hailey 24 fe 97hailey fe 1530 (28) 97hailey fe 120 (28) 97halobetasol propionate 108haloperidol 62haloperidol decanoate 62haloperidol lactate 62HARVONI70 71HAVRIX (PF) 174HEALTHWISE INSULIN SYRINGE 125 126HEALTHWISE PEN NEEDLE 126HEALTHY ACCENTS UNIFINE PENTIP126heather 97HEMADY 163heparin (porcine) 73heparin porcine (pf) 73HEPATAMINE 878HERCEPTIN 26HERCEPTIN HYLECTA26HERZUMA26HETLIOZ 191HETLIOZ LQ191HIBERIX (PF)174HUMIRA 169HUMIRA PEN169HUMIRA PEN CROHNS-UC-HS START169HUMIRA PEN PSOR-UVEITS-ADOL HS169HUMIRA(CF)170HUMIRA(CF) PEDI CROHNS STARTER169HUMIRA(CF) PEN 170
HUMIRA(CF) PEN CROHNS-UC-HS 169HUMIRA(CF) PEN PEDIATRIC UC 170HUMIRA(CF) PEN PSOR-UV-ADOL HS 170HUMULIN R U-500 (CONC) INSULIN 48HUMULIN R U-500 (CONC) KWIKPEN49hydralazine 85hydrochlorothiazide 87hydrocodone-acetaminophen 4hydrocodone-ibuprofen 4hydrocortisone 108 109 163 178hydrocortisone butyrate 108hydrocortisone valerate 109hydrocortisone-acetic acid 151hydromorphone 4hydromorphone (pf) 4hydroxychloroquine 58hydroxyprogesterone cap(ppres) 166hydroxyurea 26hydroxyzine hcl 53hydroxyzine pamoate 181HYQVIA170ibandronate 179IBRANCE 26ibu 7ibuprofen 7ibuprofen-famotidine 7icatibant 85iclevia 97ICLUSIG 26IDHIFA26ifosfamide 26ILARIS (PF) 170ILEVRO 154ILUMYA170
I-8
imatinib 26IMBRUVICA 26IMFINZI 26imipenem-cilastatin 17imipramine hcl 44imipramine pamoate 45imiquimod 105IMLYGIC26IMOVAX RABIES VACCINE (PF) 174IMPAVIDO58INBRIJA 59incassia 97INCONTROL ALCOHOL PADS 105INCONTROL PEN NEEDLE 126INCRELEX 164indapamide 87indomethacin 7 8INFANRIX (DTAP) (PF) 175INFLECTRA170INFUGEM27INLYTA 27INQOVI27INREBIC27INSULIN SYRNDL U100 HALF MARK 127INSULIN SYRINGE 113INSULIN SYRINGE MICROFINE 112INSULIN SYRINGE NEEDLELESS 113INSULIN SYRINGE-NEEDLE U-100113 114 124 125 126 127 128 134 138 142INSUPEN128INTELENCE67INTRALIPID78
INTRON A71introvale 98INVEGA HAFYERA 62INVEGA SUSTENNA 62 63INVEGA TRINZA63INVELTYS154INVIRASE 67IPOL 175ipratropium bromide 150 188ipratropium-albuterol 188irbesartan 79irbesartan-hydrochlorothiazide 79IRESSA 27irinotecan 27ISENTRESS 67ISENTRESS HD 67isibloom 98ISOLYTE S PH 74184ISOLYTE-P IN 5 DEXTROSE 184ISOLYTE-S 184isoniazid 55isosorbide dinitrate 90isosorbide mononitrate 90isradipine 86itraconazole 52IV PREP WIPES105ivermectin 58IXEMPRA27IXIARO (PF)175jaimiess 98JAKAFI27jantoven 73JARDIANCE 46jasmiel (28) 98JEMPERLI27jencycla 98JENTADUETO46JENTADUETO XR46 47jinteli 162
juleber 98JULUCA 68junel 1530 (21) 98junel 120 (21) 98junel fe 1530 (28) 98junel fe 120 (28) 98junel fe 24 98JUXTAPID89JYNARQUE 87kalliga 98KALYDECO 189KANJINTI 27KANUMA149kariva (28) 98KATERZIA86kelnor 135 (28) 98kelnor 1-50 (28) 98KESIMPTA PEN 92ketoconazole 52ketoprofen 8ketorolac 8 154KEVEYIS 181KEVZARA 170KEYTRUDA 27KINERET 170KINRIX (PF) 175kionex (with sorbitol) 156KISQALI 28KISQALI FEMARA CO-PACK27 28klor-con m10 184klor-con m15 184klor-con m20 184KLOXXADO 10KORLYM 47KOSELUGO 28KRINTAFEL 58KRYSTEXXA 149kurvelo (28) 98KYNMOBI59
I-9
KYPROLIS 28l norgesteestradiol-eestrad 98labetalol 82lactulose 156lamivudine 68lamivudine-zidovudine 68lamotrigine 39 40lansoprazole 155lanthanum 158LANTUS SOLOSTAR U-100 INSULIN49LANTUS U-100 INSULIN 49lapatinib 28larin 1530 (21) 98larin 120 (21) 99larin 24 fe 99larin fe 1530 (28) 99larin fe 120 (28) 99larissia 99latanoprost 183LATUDA 63LAZANDA 4leflunomide 170LENVIMA 28lessina 99letrozole 28leucovorin calcium 181LEUKERAN28LEUKINE 74leuprolide 28levetiracetam 40levobunolol 183levocarnitine 181levocarnitine (with sugar) 181levocetirizine 53 54levofloxacin 19 151levofloxacin in d5w 19levoleucovorin calcium 181levonest (28) 99levonorgestrel-ethinyl estrad 99
levonorg-eth estrad triphasic 99levora-28 99levothyroxine 166LEXIVA 68LIBTAYO28lidocaine 9lidocaine (pf) 9 81lidocaine hcl 9lidocaine viscous 9lidocaine-prilocaine 9lillow (28) 99linezolid 13linezolid in dextrose 5 13linezolid-09 sodium chloride 13LINZESS 156liothyronine 167LISCO128lisinopril 81lisinopril-hydrochlorothiazide 81LITE TOUCH INSULIN PEN NEEDLES 128 129LITE TOUCH INSULIN SYRINGE 128 129lithium carbonate 92 93LIVALO 89lojaimiess 99LOKELMA 156 157LONSURF 28loperamide 157lopinavir-ritonavir 68lorazepam 12lorazepam intensol 12LORBRENA 28loryna (28) 99losartan 79losartan-hydrochlorothiazide 79LOTEMAX154LOTEMAX SM 154loteprednol etabonate 154lovastatin 89
low-ogestrel (28) 99loxapine succinate 63lo-zumandimine (28) 99lubiprostone 157LUCEMYRA 10LUMAKRAS 29LUMIGAN183LUMOXITI29LUPRON DEPOT164LUPRON DEPOT (3 MONTH) 29 164LUPRON DEPOT (4 MONTH)29LUPRON DEPOT (6 MONTH)29LUPRON DEPOT-PED164LUPRON DEPOT-PED (3 MONTH)164lutera (28) 99LYBALVI63lyleq 99lyllana 162LYNPARZA 29LYSODREN 29lyza 100MAGELLAN INSULIN SAFETY SYRNG129 130MAGELLAN SYRINGE129magnesium sulfate 184magnesium sulfate in d5w 184magnesium sulfate in water 184malathion 110maprotiline 45marlissa (28) 100MARPLAN 45MARQIBO 29MATULANE 29matzim la 84MAVENCLAD (10 TABLET PACK) 93
I-10
MAVENCLAD (4 TABLET PACK) 93MAVENCLAD (5 TABLET PACK) 93MAVENCLAD (6 TABLET PACK) 93MAVENCLAD (7 TABLET PACK) 93MAVENCLAD (8 TABLET PACK) 93MAVENCLAD (9 TABLET PACK) 93MAVYRET 71MAXICOMFORT II PEN NEEDLE 130MAXICOMFORT INSULIN SYRINGE 130MAXI-COMFORT INSULIN SYRINGE 130MAXICOMFORT SAFETY PEN NEEDLE130MAYZENT 93MAYZENT STARTER PACK 93meclizine 57medroxyprogesterone 166mefenamic acid 8mefloquine 58megestrol 29 166MEKINIST 29MEKTOVI 29meloxicam 8melphalan hcl 29memantine 43MENACTRA (PF) 175MENQUADFI (PF) 175MENVEO A-C-Y-W-135-DIP (PF) 175MEPSEVII149mercaptopurine 29
meropenem 17meropenem-09 sodium chloride 17mesalamine 178mesna 181MESNEX181metadate er 93metaproterenol 188metformin 47methadone 4 5methadose 5methazolamide 183methenamine hippurate 13methimazole 167methocarbamol 191methotrexate sodium 29methotrexate sodium (pf) 29methoxsalen 105methscopolamine 157methyldopa 78methylphenidate hcl 93 94methylprednisolone 163methylprednisolone acetate 163methylprednisolone sodium succ 163metipranolol 183metoclopramide hcl 157metolazone 87metoprolol succinate 83metoprolol ta-hydrochlorothiaz 83metoprolol tartrate 83metronidazole 14 54 106metronidazole in nacl (iso-os) 14metyrosine 85mexiletine 81miconazole-3 52MICRODOT INSULIN PEN NEEDLE 130microgestin fe 120 (28) 100midazolam 12
midodrine 79miglitol 47miglustat 149mili 100mimvey 162MINI ULTRA-THIN II 130minitran 90minocycline 20minoxidil 90mirtazapine 45misoprostol 155MITIGARE53mitoxantrone 30M-M-R II (PF)175moexipril 81molindone 63mometasone 109 154mondoxyne nl 20MONJUVI30MONOJECT INSULIN SAFETY SYRING131MONOJECT INSULIN SYRINGE 130 131MONOJECT SYRINGE 130MONOJECT ULTRA COMFORT INSULIN 144mono-linyah 100montelukast 187morphine 5MORPHINE 5morphine concentrate 5MOVANTIK 157moxifloxacin 19 151MOZOBIL74MULPLETA 74MULTAQ81mupirocin 106MVASI 30MYCAPSSA 165mycophenolate mofetil 170 171
I-11
mycophenolate mofetil (hcl) 170MYLOTARG 30MYRBETRIQ 159nabumetone 8nadolol 83nafcillin 18nafcillin in dextrose iso-osm 18NAGLAZYME149naloxone 10naltrexone 10NAMZARIC 43naproxen 8naproxen-esomeprazole 8naratriptan 54NARCAN10NATACYN 151nateglinide 47NATPARA 179NAYZILAM 40nebivolol 83necon 0535 (28) 100nefazodone 45neomycin 12neomycin-bacitracin-poly-hc 152neomycin-bacitracin-polymyxin 152neomycin-polymyxin b gu 106neomycin-polymyxin b-dexameth 152neomycin-polymyxin-gramicidin 152neomycin-polymyxin-hc 152neo-polycin 152neo-polycin hc 152NEPHRAMINE 54 78NERLYNX 30NEULASTA74NEUPRO60nevirapine 68NEXAVAR 30
NEXLETOL 89NEXLIZET 89niacin 89niacor 89nicardipine 86NICOTROL 10nifedipine 86nikki (28) 100nilutamide 30NINLARO30nitazoxanide 58nitisinone 149nitrofurantoin macrocrystal 14nitrofurantoin monohydm-cryst 14nitroglycerin 90NITYR149NIVESTYM 74nizatidine 155NORDITROPIN FLEXPRO 165norethindrone (contraceptive) 100norethindrone acetate 166norethindrone ac-eth estradiol 100 162norethindrone-eestradiol-iron 100norgestimate-ethinyl estradiol 100norlyda 100NORMOSOL-M IN 5 DEXTROSE 184nortrel 0535 (28) 100nortrel 135 (21) 100nortrel 135 (28) 101nortrel 777 (28) 101nortriptyline 45NORVIR 68NOVOFINE 30131NOVOFINE 32131NOVOFINE PLUS132
NOVOLIN 7030 U-100 INSULIN49NOVOLIN 70-30 FLEXPEN U-100 49NOVOLIN N FLEXPEN49NOVOLIN N NPH U-100 INSULIN49NOVOLIN R FLEXPEN 49NOVOLIN R REGULAR U-100 INSULN49NOVOLOG FLEXPEN U-100 INSULIN 49NOVOLOG MIX 70-30 U-100 INSULN49NOVOLOG MIX 70-30FLEXPEN U-10049NOVOLOG PENFILL U-100 INSULIN50NOVOLOG U-100 INSULIN ASPART50NOVOTWIST132NOXAFIL 52NPLATE74NUBEQA 30NUCALA189 190NULOJIX171NUPLAZID 63NUTRILIPID78nyamyc 52nylia 777 (28) 101nymyo 101nystatin 52nystatin-triamcinolone 52nystop 52NYVEPRIA74OCALIVA 157OCTAGAM171octreotide acetate 165ODEFSEY68ODOMZO 30
I-12
OFEV190ofloxacin 152OGIVRI30olanzapine 64olmesartan 79olmesartan-amlodipin-hcthiazid 79olmesartan-hydrochlorothiazide 79olopatadine 151OLUMIANT 171omega-3 acid ethyl esters 89omeprazole 155omeprazole-sodium bicarbonate 156OMNIPOD VGO132OMNIPOD DASH PDM KIT 132OMNIPOD INSULIN MANAGEMENT132OMNIPOD INSULIN REFILL 132ONCASPAR30ondansetron 57ondansetron hcl 57ondansetron hcl (pf) 57ONGENTYS 60ONIVYDE30ONTRUZANT 30ONUREG30OPDIVO 30OPSUMIT 191oralone 103ORENCIA 171ORENCIA (WITH MALTOSE) 171ORENCIA CLICKJECT171ORFADIN149ORGOVYX 165ORILISSA 165
ORKAMBI 190ORLADEYO74orsythia 101oseltamivir 70OSMOLEX ER60OTEZLA171OTEZLA STARTER171oxaliplatin 30oxandrolone 160oxazepam 12oxcarbazepine 40OXLUMO 181OXTELLAR XR 40oxybutynin chloride 159oxycodone 5oxycodone-acetaminophen 5 6oxycodone-aspirin 6OXYCONTIN6oxymorphone 6OZEMPIC 47pacerone 81 82paclitaxel 30PADCEV 31paliperidone 64PALYNZIQ 149pamidronate 179PANRETIN105pantoprazole 156paricalcitol 179paroex oral rinse 103paromomycin 58paroxetine hcl 45PAXIL 45PEDIARIX (PF) 175PEDVAX HIB (PF) 175PEGASYS71PEGINTRON71PEMAZYRE 31PEN NEEDLE125 132 134
PEN NEEDLE DIABETIC117 125 128 132 134penicillamine 160penicillin g potassium 18penicillin g procaine 18penicillin v potassium 18PENNSAID8PENTACEL (PF) 175pentamidine 58PENTIPS132 133pentoxifylline 76PEPAXTO 31perindopril erbumine 81periogard 103PERJETA 31permethrin 110perphenazine 64perphenazine-amitriptyline 45PERSERIS64pfizerpen-g 18phenelzine 45phenobarbital 40phenylephrine hcl 79phenytoin 40phenytoin sodium 40 41phenytoin sodium extended 40PHESGO 31philith 101PHOSLYRA 158PIFELTRO68pilocarpine hcl 104 183pimecrolimus 109pimozide 64pimtrea (28) 101pindolol 83pioglitazone 47PIP PEN NEEDLE133piperacillin-tazobactam 18PIQRAY 31pirmella 101
I-13
piroxicam 8PLASMA-LYTE 148 184PLASMA-LYTE A184PLEGRIDY94podofilox 105POLIVY31polycin 152polymyxin b sulfate 14polymyxin b sulf-trimethoprim152POMALYST31portia 28 101PORTRAZZA 31posaconazole 52potassium chloride 184 185potassium chloride-045 nacl 185potassium citrate 185PRALUENT PEN 89pramipexole 60prasugrel 76pravastatin 89prazosin 79prednicarbate 109prednisolone 163prednisolone acetate 154prednisolone sodium phosphate 154 163prednisone 163 164pregabalin 41PREMARIN162PREMPHASE 162PREMPRO 162PRETOMANID 55prevalite 89PREVENT DROPSAFE PEN NEEDLE133previfem 101PREVYMIS70PREZCOBIX68PREZISTA 68
PRIFTIN 55PRIMAQUINE 58primidone 41PRIVIGEN 171PRO COMFORT ALCOHOL PADS 105PRO COMFORT INSULIN SYRINGE 133PRO COMFORT PEN NEEDLE133 134PROAIR RESPICLICK 188probenecid 53probenecid-colchicine 53procainamide 82PROCALAMINE 378prochlorperazine 57prochlorperazine edisylate 57prochlorperazine maleate 57procto-med hc 109procto-pak 109proctosol hc 109proctozone-hc 109PRODIGY INSULIN SYRINGE 134progesterone 166progesterone micronized 166PROGRAF 171PROLASTIN-C 190PROLENSA 154PROLEUKIN31PROLIA179PROMACTA 74 75promethazine 54 57promethegan 57propafenone 82propantheline 157proparacaine 151propranolol 83propranolol-hydrochlorothiazid 83propylthiouracil 167
PROQUAD (PF) 176PROSOL 20 78protamine 75protriptyline 45PULMOZYME149PURE COMFORT ALCOHOL PADS 105PURE COMFORT PEN NEEDLE 134PURIXAN31pyrazinamide 55pyridostigmine bromide 181pyrimethamine 58QBRELIS 81QINLOCK31QUADRACEL (PF) 176quetiapine 64quinapril 81quinapril-hydrochlorothiazide 81quinidine gluconate 82quinidine sulfate 82quinine sulfate 58RABAVERT (PF)176rabeprazole 156RADICAVA94raloxifene 162ramipril 81ranolazine 85rasagiline 60RASUVO (PF)171RAVICTI157RAYALDEE 179reclipsen (28) 101RECOMBIVAX HB (PF) 176RECTIV181REGRANEX105RELENZA DISKHALER 70RELION NEEDLES 134RELION PEN NEEDLES135RELISTOR157
I-14
REMICADE171RENFLEXIS 172repaglinide 47repaglinide-metformin 47REPATHA PUSHTRONEX89REPATHA SURECLICK89REPATHA SYRINGE89RESTASIS 154RESTASIS MULTIDOSE154RETACRIT 75RETEVMO31RETROVIR68REVCOVI149REVLIMID 31revonto 191REXULTI 64REYATAZ 69REZUROCK 172RHOPRESSA 183RIABNI 32ribavirin 72RIDAURA 172rifabutin 55rifampin 55 56riluzole 94rimantadine 70RINVOQ172risedronate 179RISPERDAL CONSTA 64risperidone 65ritonavir 69RITUXAN32RITUXAN HYCELA 32rivastigmine 43rivastigmine tartrate 43rizatriptan 54ROCKLATAN 183ropinirole 60rosadan 106rosuvastatin 90
ROTARIX 176ROTATEQ VACCINE176ROZLYTREK32RUBRACA 32rufinamide 41RUKOBIA69RUXIENCE 32RYBELSUS47RYBREVANT32RYDAPT32SAFESNAP INSULIN SYRINGE 135SAFETY PEN NEEDLE135sajazir 85SANDOSTATIN LAR DEPOT 165SANTYL 105sapropterin 149SARCLISA32SAVELLA 94SCEMBLIX 32scopolamine base 57SECUADO 65SECURESAFE PEN NEEDLE 135selegiline hcl 60selenium sulfide 106SELZENTRY 69SEREVENT DISKUS 188SEROSTIM 165sertraline 45setlakin 101sevelamer carbonate 158sevelamer hcl 158sf 5000 plus 104sharobel 101SHINGRIX (PF) 176SIGNIFOR 165SIKLOS 75sildenafil 192
sildenafil (pulmhypertension) 192silver sulfadiazine 106SIMBRINZA 183simliya (28) 101simpesse 101simvastatin 90sirolimus 172SIRTURO56SKYRIZI 172SLYND101sodium chloride 045 185sodium chloride 09 185sodium fluoride-pot nitrate 104sodium phenylbutyrate 157sodium polystyrene (sorb free) 157sodium polystyrene sulfonate 157SOLIQUA 10033 50SOLTAMOX 32SOLU-CORTEF ACT-O-VIAL (PF)164SOMATULINE DEPOT 165 166SOMAVERT 166sorine 83sotalol 83sotalol af 83SPIRIVA RESPIMAT188SPIRIVA WITH HANDIHALER 188spironolactone 87spironolacton-hydrochlorothiaz 87SPRAVATO 45sprintec (28) 101SPRITAM41SPRYCEL 32sps (with sorbitol) 157sronyx 101ssd 106stavudine 69
I-15
STELARA 172STERILE PADS 135STIOLTO RESPIMAT188STIVARGA32STRENSIQ 149streptomycin 12STRIBILD69SUBLOCADE 10subvenite 41sucralfate 156sulfacetamide sodium 152 153sulfacetamide sodium (acne) 106sulfacetamide-prednisolone 153sulfadiazine 19sulfamethoxazole-trimethoprim 19sulfasalazine 178sulindac 9sumatriptan 55sumatriptan succinate 55sunitinib 32SUNOSI191SUPPRELIN LA 166SUPREP BOWEL PREP KIT 158SURE COMFORT ALCOHOL PREP PADS 105SURE COMFORT INS SYR U-100135SURE COMFORT INSULIN SYRINGE135 136SURE COMFORT PEN NEEDLE 136SURE COMFORT SAFETY PEN NEEDLE135SURE-FINE PEN NEEDLES 136SURE-JECT INSULIN SYRINGE 137
SURE-PREP ALCOHOL PREP PADS 105syeda 101SYLVANT32SYMBICORT 187SYMDEKO 190SYMJEPI85SYMLINPEN 120 47SYMLINPEN 60 48SYMPAZAN 41SYMTUZA69SYNAGIS70SYNAREL166SYNDROS 57SYNERCID14SYNJARDY48SYNJARDY XR 48SYNRIBO32TABLOID 32TABRECTA 33tacrolimus 109 172tadalafil 192tadalafil (pulm hypertension) 192TAFINLAR33TAGRISSO 33TAKHZYRO181TALTZ AUTOINJECTOR 172TALTZ SYRINGE173TALTZ SYRINGE (2 PACK) 172TALTZ SYRINGE (3 PACK) 172TALZENNA 33tamoxifen 33tamsulosin 159TARGRETIN33tarina 24 fe 102tarina fe 1-20 eq (28) 102TASIGNA 33TAVALISSE75
tazarotene 109TAZORAC 110taztia xt 84TAZVERIK33TDVAX 176TECENTRIQ 33TECHLITE INSULIN SYRINGE 137 138TECHLITE INSULN SYR(HALF UNIT) 137TECHLITE PEN NEEDLE 138TEFLARO16telmisartan 79telmisartan-amlodipine 80telmisartan-hydrochlorothiazid 80temazepam 12TEMIXYS 69TEMODAR33temsirolimus 33tencon 6TENIVAC (PF)176tenofovir disoproxil fumarate 69TEPEZZA151TEPMETKO 33terazosin 159terbinafine hcl 52terbutaline 188terconazole 54TERUMO INSULIN SYRINGE 138 139testosterone 160 161testosterone cypionate 160testosterone enanthate 160TETANUSDIPHTHERIA TOX PED(PF) 177tetrabenazine 94tetracycline 20THALOMID 182theophylline 188 189
I-16
THINPRO INSULIN SYRINGE 139THIOLA EC 159thioridazine 65thiotepa 33thiothixene 65tiadylt er 84tiagabine 41TIBSOVO 33TICE BCG 33tigecycline 20timolol maleate 83 183tinidazole 58tiopronin 159TIVDAK33TIVICAY69TIVICAY PD69tizanidine 191TOBI PODHALER 12tobramycin 13 153tobramycin in 0225 nacl 13tobramycin sulfate 13tobramycin-dexamethasone 153tolmetin 9tolterodine 159TOPCARE CLICKFINE 139TOPCARE ULTRA COMFORT 139topiramate 41toposar 33topotecan 34toremifene 34torsemide 87TOTECT182TOUJEO MAX U-300 SOLOSTAR50TOUJEO SOLOSTAR U-300 INSULIN50TOVIAZ 159TRACLEER 192
TRADJENTA 48tramadol 6tramadol-acetaminophen 6trandolapril 81tranexamic acid 75tranylcypromine 46TRAVASOL 10 78travoprost 183TRAZIMERA 34trazodone 46TREANDA 34TRECATOR56TRELEGY ELLIPTA 189TRELSTAR34TREMFYA173treprostinil sodium 192tretinoin 110tretinoin (antineoplastic) 34tri femynor 102triamcinolone acetonide104 109 164triamterene-hydrochlorothiazid 87triazolam 12trientine 160tri-estarylla 102trifluoperazine 65trifluridine 153trihexyphenidyl 60TRIKAFTA190tri-legest fe 102tri-linyah 102tri-lo-estarylla 102tri-lo-marzia 102tri-lo-mili 102tri-lo-sprintec 102trilyte with flavor packets 158trimethoprim 14tri-mili 102trimipramine 46TRINTELLIX 46
tri-nymyo 102tri-previfem (28) 102TRIPTODUR 166tri-sprintec (28) 102TRIUMEQ 69trivora (28) 102tri-vylibra 102tri-vylibra lo 102TRODELVY 34TROGARZO69TROPHAMINE 10 78trospium 159TRUE COMFORT ALCOHOL PADS 105TRUE COMFORT INSULIN SYRINGE 140TRUE COMFORT PEN NEEDLE 140TRUE COMFORT PRO ALCOHOL PADS 105TRUE COMFORT PRO INS SYRINGE 139 140TRUEPLUS INSULIN 141TRUEPLUS PEN NEEDLE 140TRULICITY 48TRUMENBA 177TRUSELTIQ 34TRUXIMA34TUKYSA34tulana 102TURALIO 34TWINRIX (PF) 177tyblume 102TYBOST 182TYMLOS180TYPHIM VI177TYSABRI 173TYVASO 192UBRELVY 55UCERIS178
I-17
UDENYCA 75UKONIQ34ULTICARE142 143ULTICARE INSULIN SYRINGE 141 142ULTICARE INSULN SYR(HALF UNIT) 141ULTICARE PEN NEEDLE 142ULTICARE SAFETY PEN NEEDLE 142ULTIGUARD SAFEPACK-INSULIN SYR 143ULTIGUARD SAFEPACK-PEN NEEDLE143ULTILET ALCOHOL SWAB 105ULTILET INSULIN SYRINGE 127 143ULTILET PEN NEEDLE144ULTRA CMFT INS SYR (HALF UNIT) 125 135 141ULTRA COMFORT INSULIN SYRINGE120 125 144ULTRA FLO INSUL SYR(HALF UNIT) 144ULTRA FLO INSULIN SYRINGE 145ULTRA FLO PEN NEEDLE 144ULTRA THIN PEN NEEDLE 145ULTRACARE INSULIN SYRINGE 145ULTRACARE PEN NEEDLE145 146ULTRA-THIN II (SHORT) INS SYR 146ULTRA-THIN II (SHORT) PEN NDL 146
ULTRA-THIN II INS PEN NEEDLES 146ULTRA-THIN II INSULIN SYRINGE 146UNIFINE PEN NEEDLE146UNIFINE PENTIPS132 146 147UNIFINE PENTIPS MAXFLOW 147UNIFINE PENTIPS PLUS147UNIFINE PENTIPS PLUS MAXFLOW 147UNIFINE SAFECONTROL147UNITUXIN35UPTRAVI192ursodiol 157 158valacyclovir 72VALCHLOR 105valganciclovir 72valproate sodium 41valproic acid 41valproic acid (as sodium salt) 41valrubicin 35valsartan 80valsartan-hydrochlorothiazide 80VALTOCO 41vancomycin 14VANISHPOINT INSULIN SYRINGE 147VANISHPOINT SYRINGE 147 148VAQTA (PF) 177varenicline 11VARIVAX (PF) 177VASCEPA 90VECTIBIX35VEKLURY72VELCADE 35velivet triphasic regimen (28) 102VELPHORO158
VEMLIDY 69VENCLEXTA 35VENCLEXTA STARTING PACK 35venlafaxine 46verapamil 84VEREGEN 105VERIFINE PEN NEEDLE148VERSACLOZ65VERSALON 148VERZENIO35vestura (28) 103V-GO 20148V-GO 30148V-GO 40148vicodin hp 6VICTOZA48vienva 103vigabatrin 41 42vigadrone 42VIIBRYD 46VIMIZIM 149VIMPAT42vinblastine 35vincasar pfs 35vincristine 35vinorelbine 35viorele (28) 103VIRACEPT 69VIREAD69VISTOGARD 182VITRAKVI35VIZIMPRO 35VOCABRIA 70volnea (28) 103voriconazole 52 53VOSEVI 71VOTRIENT35VPRIV 149VRAYLAR65
I-18
VUMERITY95vyfemla (28) 103vylibra 103VYNDAMAX 85VYNDAQEL86VYXEOS 36VYZULTA 183warfarin 73WEBCOL105WELIREG36wera (28) 103XADAGO60XALKORI36XARELTO 73XARELTO DVT-PE TREAT 30D START73XATMEP36XCOPRI 42XCOPRI MAINTENANCE PACK 42XCOPRI TITRATION PACK 42XELJANZ 173XELJANZ XR173XELPROS 183XERMELO158XGEVA 180XHANCE 154XIFAXAN14XIGDUO XR 48XIIDRA154XOFLUZA 70XOLAIR190XOSPATA36XPOVIO 36XTAMPZA ER 6XTANDI 36xulane 103XULTOPHY 10036 50XURIDEN 182
XYOSTED161XYREM191YERVOY36YF-VAX (PF) 177YONDELIS36YONSA 37yuvafem 162zafemy 103zafirlukast 187zaleplon 191ZALTRAP37zarah 103ZARXIO75zebutal 6ZEJULA 37ZELBORAF 37zenatane 106ZENPEP 150ZEPZELCA 37zidovudine 70ZIEXTENZO75ZIOPTAN (PF)183ziprasidone hcl 65ziprasidone mesylate 65ZIRABEV37ZIRGAN153ZOLADEX 37zoledronic acid 180zoledronic acid-mannitol-water 180ZOLINZA 37zolmitriptan 55zolpidem 191zonisamide 42ZORBTIVE166ZORTRESS 173ZOSTAVAX (PF) 177zovia 135e (28) 103zovia 1-35 (28) 103ZTLIDO 9
ZULRESSO46zumandimine (28) 103ZYDELIG 37ZYKADIA37ZYLET 153ZYNLONTA 37ZYPREXA RELPREVV 65 66ZYTIGA 37
I-19
This formulary was updated on 10052021 For more recent information or other questions please contact Essence Healthcare Customer Service at 1-855-996-8422 (TTY 711) from 8 am to 8 pm You may reach a messaging service on weekends from April 1 through September 30 and holidays Please leave a message and your call will be returned the next business day
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