BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

BMC HealthNet Plan Drug List – Employer Choice & Commonwealth Choice (Updated 11/01/2012) 

The BMC HealthNet Plan (Plan) Drug Formulary includes prescribed drugs and devices covered and excluded by the Plan. Restrictions may apply. The Drug Formulary is 

subject to change with notification. All newly approved drugs require prior authorization until reviewed by the Plan and a coverage determination is made. The Drug 

Formulary is also subject to the Plan’s mandatory generic program. For further detail on the Pharmacy Program, please visit the pharmacy page at bmchp.org. 

For further questions, please contact the Plan or the Pharmacy Benefits Manager at: Employer Choice & Commonwealth Choice Members: 1‐877‐492‐6967 

Providers: 1‐888‐566‐0008 

Pharmacy Benefit Manager – Catamaran 1‐866‐795‐0049 (Phone) | 1‐866‐795‐8834 (Fax) 

Drug Name Drug Category Drug Type Coverage Tier Quantity Limits Specialty Product 

8‐MOP CAP 10MG PIGMENTING AGENTS BRAND Covered TIER 3 

ABACAVIR TAB 300MG 

NUCLEOSIDE,NUCLEOTIDE 

REV.TRNSCRIP.INHIB GENERIC Covered TIER 1 

ABELCET INJ 5MG/ML POLYENES BRAND Covered TIER 3 

ABILIFY SOL 1MG/ML ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 2 QL 

ABILIFY TAB 10MG ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 2 QL 






ABILIFY DISC TAB 10MG ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 2 QL 

ABILIFY DISC TAB 15MG ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 2 QL 

ABLAVAR INJ 244MG/ML DIAGNOSTIC AGENTS BRAND Excluded TIER 99 

ABRAXANE INJ 100MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

ABSTRAL SUB 100MCG OPIATE AGONISTS BRAND Covered TIER 3 



Key: Brand‐O = Brand with AB‐rated generic equivalent. Coverage Detail: PA=Prior Authorization Required, SP= Restricted to specialty pharmacy, QL= Quantity Limit, 

MO= Mail order eligible after one prescription fill at retail 

1




ACANYA GEL 1.2‐2.5% 

ANTIBACTERIALS (SKIN & MUCOUS 

MEMBRANE) BRAND Covered TIER 2 

ACARBOSE TAB 100MG ALPHA‐GLUCOSIDASE INHIBITORS GENERIC Covered TIER 1 



ACCOLATE TAB 10MG LEUKOTRIENE MODIFIERS Brand‐O PA TIER 3 

ACCOLATE TAB 20MG LEUKOTRIENE MODIFIERS Brand‐O PA TIER 3 

ACCU‐CHEK KIT SPIRIT DEVICES BRAND Covered TIER 3 

ACCU‐CHEK MIS ADAPTER DEVICES BRAND Covered TIER 3 

ACCU‐CHEK MIS BATTERY DEVICES BRAND Covered TIER 3 

ACCUNEB NEB 0.63MG/3 

SELECTIVE BETA‐2‐ADRENERGIC 

AGONISTS Brand‐O PA TIER 3 QL 

ACCUNEB NEB 1.25MG/3 



ACCUPRIL TAB 10MG 

ANGIOTENSIN‐CONVERTING ENZYME 

INHIBITORS Brand‐O PA TIER 3 










ACCURETIC TAB 10‐12.5 



ACCURETIC TAB 20‐12.5 





2

ACCURETIC TAB 20‐25MG 



ACD FORMULA SOL A ANTICOAGULANTS, MISCELLANEOUS GENERIC Covered TIER 1 

ACD FORMULA SOL B ANTICOAGULANTS, MISCELLANEOUS GENERIC Covered TIER 1 

ACD/FLUORIDE DRO 0.25MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

ACD‐A SOL ANTICOAGULANTS, MISCELLANEOUS BRAND Covered TIER 3 

ACE ACD/ALUM SOL 2% OTIC EENT DRUGS, MISCELLANEOUS GENERIC Covered TIER 1 

ACE AERO CLD MIS ENHANCER DEVICES BRAND Excluded TIER 99 

ACEBUTOLOL CAP 200MG 

BETA‐ADRENERGIC BLOCKING 

AGENTS GENERIC Covered TIER 1 

ACEBUTOLOL CAP 400MG 



ACEON TAB 2MG 



ACEON TAB 4MG 



ACEON TAB 8MG 



ACETADOTE INJ 200MG/ML ANTIDOTES BRAND Covered TIER 3 

ACETASOL HC SOL OTIC CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

ACETAZOLAMID CAP 500MG ER 

CARBONIC ANHYDRASE INHIBITORS 

(EENT) GENERIC Covered TIER 1 

ACETAZOLAMID INJ 500MG 



ACETAZOLAMID TAB 125MG 





3

ACETAZOLAMID TAB 250MG 



ACETIC ACID SOL 0.25%IRR IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

ACETIC ACID SOL 2% OTIC EENT DRUGS, MISCELLANEOUS GENERIC Covered TIER 1 

ACETYLCYST SOL 10% ANTIDOTES GENERIC Covered TIER 1 

ACETYLCYST SOL 20% ANTIDOTES GENERIC Covered TIER 1 

ACID JELLY GEL VAG/APPL 

LOCAL ANTI‐INFECTIVES, 

MISCELLANEOUS GENERIC Covered TIER 1 

ACIPHEX TAB 20MG PROTON‐PUMP INHIBITORS BRAND Covered TIER 3 QL 

ACLARO EMU DEPIGMENTING AGENTS BRAND Excluded TIER 99 

ACLARO PD EMU 4% DEPIGMENTING AGENTS BRAND Excluded TIER 99 

ACLOVATE CRE 0.05% 

ANTI‐INFLAMMATORY AGENTS (SKIN 

& MUCOUS) Brand‐O PA TIER 3 

DISEASE‐MODIFYING 

ACTEMRA INJ 200/10ML 

ANTIRHEUMATIC AGENTS BRAND PA TIER 3 SP 

ACTEMRA INJ 400/20ML 



ACTEMRA INJ 80MG/4ML 



ACTHAR HP INJ 80UNIT PITUITARY BRAND Covered TIER 2 SP 

ACTHIB INJ VACCINES BRAND Covered TIER 3 

ACTHREL INJ 100MCG PITUITARY FUNCTION BRAND Covered TIER 3 

ACTICIN CRE 5% SCABICIDES AND PEDICULICIDES GENERIC Covered TIER 1 

ACTIFOAM MIS 12.7X8.9 HEMOSTATICS BRAND Excluded TIER 99 

ACTIFOAM MIS 7X5X0.6 HEMOSTATICS BRAND Excluded TIER 99 

ACTIGALL CAP 300MG CHOLELITHOLYTIC AGENTS Brand‐O PA TIER 3 

ACTIMMUNE INJ 2MU/0.5 BIOLOGIC RESPONSE MODIFIERS BRAND Covered TIER 2 SP 

ACTIQ LOZ 1200MCG OPIATE AGONISTS Brand‐O PA TIER 3 QL 





4




ACTIVASE INJ 100MG THROMBOLYTIC AGENTS BRAND Covered TIER 3 

ACTIVASE INJ 50MG THROMBOLYTIC AGENTS BRAND Covered TIER 3 

ACTIVELLA TAB 0.5‐0.1 ESTROGENS Brand‐O PA TIER 3 

ACTIVELLA TAB 1‐0.5MG ESTROGENS Brand‐O PA TIER 3 

ACTIVITY PCH MIS DEVICES BRAND Excluded TIER 99 

ACTONEL TAB 150MG BONE RESORPTION INHIBITORS BRAND Covered TIER 3 




ACTOPLUS MET TAB 15‐500MG THIAZOLIDINEDIONES Brand‐O PA TIER 3 

ACTOPLUS MET TAB 15‐850MG THIAZOLIDINEDIONES Brand‐O PA TIER 3 

ACTOPLUS MET TAB XR THIAZOLIDINEDIONES BRAND Covered TIER 3 

ACTOS TAB 15MG THIAZOLIDINEDIONES Brand‐O PA TIER 3 



ACUFLEX TAB ETHANOLAMINE DERIVATIVES BRAND Covered TIER 3 

ACULAR SOL 0.5% OP 

EENT NONSTEROIDAL ANTI‐INFLAM. 

AGENTS Brand‐O PA TIER 3 

ACULAR LS SOL 0.4% 



ACUNOL TAB 600MG 

OTHER MISCELLANEOUS 

THERAPEUTIC AGENTS BRAND Excluded TIER 99 

ACUVAIL SOL 0.45% 


AGENTS BRAND Covered TIER 3 

ACYCLOVIR CAP 200MG NUCLEOSIDES AND NUCLEOTIDES GENERIC Covered TIER 1 

ACYCLOVIR SUS 200/5ML NUCLEOSIDES AND NUCLEOTIDES GENERIC Covered TIER 1 

ACYCLOVIR TAB 400MG NUCLEOSIDES AND NUCLEOTIDES GENERIC Covered TIER 1 



5

ACYCLOVIR TAB 800MG NUCLEOSIDES AND NUCLEOTIDES GENERIC Covered TIER 1 

ACYCLOVIR NA INJ 1000MG NUCLEOSIDES AND NUCLEOTIDES GENERIC Covered TIER 1 

ACYCLOVIR NA INJ 500MG NUCLEOSIDES AND NUCLEOTIDES GENERIC Covered TIER 1 

ACYCLOVIR NA INJ 50MG/ML NUCLEOSIDES AND NUCLEOTIDES GENERIC Covered TIER 1 

ACZONE GEL 5% 

SKIN AND MUCOUS MEMBRANE 

AGENTS, MISC. BRAND Covered TIER 2 

ADACEL INJ TOXOIDS BRAND Excluded TIER 99 

ADAGEN INJ 250/ML ENZYMES BRAND Covered TIER 2 SP 

ADALAT CC TAB 30MG ER DIHYDROPYRIDINES Brand‐O PA TIER 3 



ADAPALENE CRE 0.1% 


AGENTS, MISC. GENERIC Covered TIER 1 

ADAPALENE GEL 0.1% 



ADCETRIS INJ 50MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

ADCIRCA TAB 20MG 

PHOSPHODIESTERASE TYPE 5 

INHIBITORS BRAND PA TIER 3 SP 

ADDERALL TAB 10MG AMPHETAMINES Brand‐O PA TIER 3 QL 

ADDERALL TAB 12.5MG AMPHETAMINES Brand‐O PA TIER 3 QL 





ADDERALL TAB 7.5MG AMPHETAMINES Brand‐O PA TIER 3 QL 

ADDERALL XR CAP 10MG AMPHETAMINES Brand‐O PA TIER 3 QL 







6


ADENOCARD INJ 12MG/4ML CLASS IV ANTIARRHYTHMICS Brand‐O PA TIER 3 

ADENOCARD INJ 3MG/ML CLASS IV ANTIARRHYTHMICS Brand‐O PA TIER 3 

ADENOCARD INJ 6MG/2ML CLASS IV ANTIARRHYTHMICS Brand‐O PA TIER 3 

ADENOSCAN INJ 3MG/ML CARDIAC FUNCTION BRAND Covered TIER 3 

ADENOSINE INJ 12MG/4ML CLASS IV ANTIARRHYTHMICS GENERIC Covered TIER 1 

ADENOSINE INJ 3MG/ML CLASS IV ANTIARRHYTHMICS GENERIC Covered TIER 1 

ADENOSINE INJ 6MG/2ML CLASS IV ANTIARRHYTHMICS GENERIC Covered TIER 1 

ADIPEX‐P CAP 37.5MG 

ANOREX.,RESPIR.,CEREBRAL 

STIMULANTS,MISC Brand‐O PA TIER 99 

ADIPEX‐P TAB 37.5MG 



ADJ ONE BOTL MIS TUBING DEVICES BRAND Excluded TIER 99 

ADOXA CAP 150MG TETRACYCLINES Brand‐O PA TIER 3 

ADOXA TAB 100MG TETRACYCLINES Brand‐O PA TIER 3 



ADOXA PAK 1/ TAB 100MG TETRACYCLINES Brand‐O PA TIER 3 



ADRENAL C TAB FORMULA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

ADRENALIN INJ 1MG/ML 

ALPHA‐ AND BETA‐ADRENERGIC 

AGONISTS Brand‐O PA TIER 3 

ADRENALIN SOL 1:1000 VASOCONSTRICTORS BRAND Covered TIER 3 

ADREVIEW INJ PHEOCHROMOCYTOMA BRAND Covered TIER 3 

ADRIAMYC INJ 50MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

ADRIAMYCIN INJ 10MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

ADRIAMYCIN INJ 20MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

ADRIAMYCIN INJ 2MG/ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

ADRUCIL INJ 50MG/ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 



7

ADULT MASK MIS DEVICES GENERIC Excluded TIER 99 

ADULT MASK MIS LARGE DEVICES GENERIC Excluded TIER 99 

ADVAIR DISKU AER 100/50 


AGONISTS BRAND Covered TIER 3 QL 







ADVAIR HFA AER 115/21 









ADVANCED MIS AM/PM MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

ADVATE INJ 1000UNIT HEMOSTATICS BRAND Covered TIER 2 SP 







ADVICOR TAB 1000‐20 HMG‐COA REDUCTASE INHIBITORS BRAND Covered TIER 3 

ADVICOR TAB 1000‐40 HMG‐COA REDUCTASE INHIBITORS BRAND Covered TIER 3 

ADVICOR TAB 500‐20MG HMG‐COA REDUCTASE INHIBITORS BRAND Covered TIER 3 

ADVICOR TAB 750‐20MG HMG‐COA REDUCTASE INHIBITORS BRAND Covered TIER 3 



8

AERCHMBR PLS MIS LRG MASK DEVICES BRAND Excluded TIER 99 

AERCHMBR PLS MIS MASK DEVICES BRAND Excluded TIER 99 

AERCHMBR PLS MIS SM MASK DEVICES BRAND Excluded TIER 99 

AERCHMBR Z‐ MIS STAT PLS DEVICES BRAND Excluded TIER 99 

AERO OTIC HC SOL CORTICOSTEROIDS (EENT) GENERIC Excluded TIER 99 

AEROCHAMBER KIT ACTION DEVICES BRAND Excluded TIER 99 

AEROCHAMBER MIS CHAMBER DEVICES BRAND Excluded TIER 99 

AEROCHAMBER MIS FLOSIGNA DEVICES BRAND Excluded TIER 99 

AEROCHAMBER MIS MAX/MASK DEVICES BRAND Excluded TIER 99 

AEROCHAMBER MIS MV DEVICES BRAND Excluded TIER 99 

AEROCHAMBER MIS PLUS DEVICES BRAND Excluded TIER 99 

AEROECLIPSE MIS II NEB DEVICES BRAND Excluded TIER 99 

AEROHIST TAB 8‐2.5MG PROPYLAMINE DERIVATIVES BRAND Covered TIER 3 

AEROKID SYP PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

AEROSOL MASK MIS ADULT DEVICES GENERIC Excluded TIER 99 

AEROSOL MASK MIS PED DEVICES GENERIC Excluded TIER 99 

AEROTRC PLUS MIS DEVICES BRAND Excluded TIER 99 

AFEDITAB TAB 30MG CR DIHYDROPYRIDINES GENERIC Covered TIER 1 

AFEDITAB TAB 60MG CR DIHYDROPYRIDINES GENERIC Covered TIER 1 

AFINITOR TAB 10MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 QL SP 

AFINITOR TAB 2.5MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 QL SP 

AFINITOR TAB 5MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 QL SP 

AFINITOR TAB 7.5MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 QL SP 

AFLURIA INJ 2009‐10 VACCINES BRAND Covered TIER 3 



AFLURIA INJ PF 10‐11 VACCINES BRAND Covered TIER 3 





9

AGGRASTAT INJ 25MG/500 PLATELET‐AGGREGATION INHIBITORS BRAND Covered TIER 3 

AGGRENOX CAP 25‐200MG PLATELET‐AGGREGATION INHIBITORS BRAND Covered TIER 2 

AGRIFLU INJ 2010‐11 VACCINES BRAND Covered TIER 3 

AGRYLIN CAP 0.5MG PLATELET‐REDUCING AGENTS Brand‐O PA TIER 3 

AHIST TAB 12MG PROPYLAMINE DERIVATIVES BRAND Covered TIER 3 

A‐HYDROCORT INJ 100MG ADRENALS GENERIC Covered TIER 1 

AIR TUBE MIS /PLUGS DEVICES GENERIC Excluded TIER 99 

AIR WATCH MIS MONITOR DEVICES GENERIC Excluded TIER 99 

AIRACOF SYP ANTITUSSIVES GENERIC Covered TIER 1 

AIRAVITE TAB VITAMIN B COMPLEX GENERIC Covered TIER 1 

AIRIAL MIS COMPACT DEVICES BRAND Excluded TIER 99 

AIRIAL MIS VOYAGER DEVICES BRAND Excluded TIER 99 

AIRIAL COMP MIS COMPRESS DEVICES BRAND Excluded TIER 99 

AIRIAL PEDIA MIS BUILDING DEVICES BRAND Excluded TIER 99 

AIRIAL PEDIA MIS DUCK DEVICES BRAND Excluded TIER 99 

AIRIAL PEDIA MIS FIRE ENG DEVICES BRAND Excluded TIER 99 

AIRIAL PEDIA MIS PANDA DEVICES BRAND Excluded TIER 99 

AIRIAL PEDIA MIS PENGUIN DEVICES BRAND Excluded TIER 99 

AIRS DISPOSA KIT NEBULIZE DEVICES BRAND Excluded TIER 99 

AK‐CON SOL 0.1% OP VASOCONSTRICTORS GENERIC Covered TIER 1 

AK‐FLUOR INJ 10% OP OCULAR DISORDERS GENERIC Covered TIER 1 

AKNE‐MYCIN OIN 2% 



AKORN BALANC SOL SALT OP EENT DRUGS, MISCELLANEOUS GENERIC Covered TIER 1 

AK‐PENTOLATE SOL 1% OP MYDRIATICS GENERIC Covered TIER 1 

AK‐POLY‐BAC OIN OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

AKTEN GEL 3.5% LOCAL ANESTHETICS (EENT) BRAND Covered TIER 3 



10

ALA CORT CRE 1% 


& MUCOUS) GENERIC Covered TIER 1 

ALA QUIN CRE 3‐0.5% 

ANTIFULGALS(SKIN & MUCOUS 

MEMBRANE),MISC BRAND Excluded TIER 99 

ALA SCALP LOT 2% 



ALAGESIC CAP 

ANALGESICS AND ANTIPYRETICS, 

MISC. GENERIC Covered TIER 1 

ALAGESIC LQ SOL 


MISC. BRAND Covered TIER 3 

ALA‐HIST TAB 6‐25MG PROPYLAMINE DERIVATIVES BRAND Covered TIER 3 

ALAHIST AC LIQ 7.5‐10 ANTITUSSIVES BRAND Excluded TIER 99 

ALA‐HIST D TAB 6‐25‐20 PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

ALAHIST DHC LIQ 7.5‐3 ANTITUSSIVES BRAND Excluded TIER 99 

ALAMAST DRO 0.1% ANTIALLERGIC AGENTS BRAND Covered TIER 3 

ALBA‐DERM CRE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

ALBAFORT INJ IRON PREPARATIONS BRAND Covered TIER 3 

ALBATUSSIN CAP ANTITUSSIVES BRAND Excluded TIER 99 

ALBATUSSIN LIQ NN ANTITUSSIVES GENERIC Covered TIER 1 

Excluded TIER 99 

ALBENZA TAB 200MG ANTHELMINTICS BRAND Covered TIER 2 

ALBUKED 25 INJ 25% BLOOD DERIVATIVES GENERIC Covered TIER 1 

ALBUKED 5 INJ 5% BLOOD DERIVATIVES GENERIC Covered TIER 1 

ALBUMIN HUM INJ 25% BLOOD DERIVATIVES GENERIC Covered TIER 1 

ALBUMIN HUM INJ 5% BLOOD DERIVATIVES GENERIC Covered TIER 1 

ALBUMINAR‐25 INJ 25% BLOOD DERIVATIVES GENERIC Covered TIER 1 

ALBUMINAR‐5 INJ 5% BLOOD DERIVATIVES GENERIC Covered TIER 1 

ALBUMIN‐ZLB INJ BLOOD DERIVATIVES GENERIC Covered TIER 1 

ALBUMIN‐ZLB SOL 25% BLOOD DERIVATIVES GENERIC Covered TIER 1 

ALBURX INJ 5% BLOOD DERIVATIVES GENERIC Covered TIER 1 



11

ALBUTEIN INJ 25% BLOOD DERIVATIVES GENERIC Covered TIER 1 

ALBUTEIN INJ 5% BLOOD DERIVATIVES GENERIC Covered TIER 1 

ALBUTEROL NEB 0.083% 


AGONISTS GENERIC Covered TIER 1 QL 

ALBUTEROL NEB 0.5% 



ALBUTEROL NEB 0.63MG/3 



ALBUTEROL NEB 1.25MG/3 



ALBUTEROL SYP 2MG/5ML 


AGONISTS GENERIC Covered TIER 1 

ALBUTEROL TAB 2MG 



ALBUTEROL TAB 4MG 



ALBUTEROL TAB 4MG ER 



ALBUTEROL TAB 8MG ER 



ALCAINE SOL 0.5% OP LOCAL ANESTHETICS (EENT) Brand‐O PA TIER 3 

ALCLOMETASON CRE 0.05% 



ALCLOMETASON OIN 0.05% 



ALCOHOL INJ 95% CALORIC AGENTS GENERIC Covered TIER 1 

ALCOHOL INJ 98% CALORIC AGENTS GENERIC Covered TIER 1 

ALCOHOL SOL REGENT 


MISCELLANEOUS GENERIC Excluded TIER 99 



12

ALCORTIN A GEL 


MISCELLANEOUS BRAND Excluded TIER 99 

ALDACTAZIDE TAB 25/25 

MINERALOCORTICOID 

(ALDOSTERONE) ANTAGNTS Brand‐O PA TIER 3 

ALDACTAZIDE TAB 50/50 


(ALDOSTERONE) ANTAGNTS BRAND Covered TIER 3 

ALDACTONE TAB 100MG 









ALDARA CRE 5% 


AGENTS, MISC. Brand‐O PA TIER 3 QL 

ALDURAZYME INJ 2.9MG/5M ENZYMES BRAND Covered TIER 2 SP 

ALENAZE‐D LIQ PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

ALENAZE‐D NR LIQ PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

ALENDRONATE TAB 10MG BONE RESORPTION INHIBITORS GENERIC Covered TIER 1 





ALFENTA INJ 500/ML OPIATE AGONISTS Brand‐O PA TIER 3 

ALFENTANIL INJ 500/ML OPIATE AGONISTS GENERIC Covered TIER 1 

ALFERON N INJ 5MU/ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

SELECTIVE ALPHA‐1‐ADRENERGIC 

ALFUZOSIN TAB 10MG 

BLOCK.AGENT GENERIC Covered TIER 1 QL 

ALICLEN SHA 6% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

ALI‐FLEX TAB 50‐500MG ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1 

ALIMTA INJ 100MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 



13

ALIMTA INJ 500MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

ALINIA SUS 100MG/5M ANTIPROTOZOALS, MISCELLANEOUS BRAND Covered TIER 2 

ALINIA TAB 500MG ANTIPROTOZOALS, MISCELLANEOUS BRAND Covered TIER 2 

ALKERAN INJ 50MG ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

ALKERAN TAB 2MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

ALLERGIST KIT 0.5/26G DEVICES BRAND Excluded TIER 99 

ALLERGIST KIT 0.5/28G DEVICES BRAND Excluded TIER 99 

ALLERGIST KIT 1MLX26G DEVICES BRAND Excluded TIER 99 



ALLERSCRIPT MIS TABLETS PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

ALLERX MIS PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

ALLERX DF MIS PROPYLAMINE DERIVATIVES Brand‐O PA TIER 3 

ALLERX DF 30 MIS PROPYLAMINE DERIVATIVES Brand‐O PA TIER 3 

ALLERX PE MIS PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

ALLERX‐D TAB 120/2.5 



ALLFEN CD TAB 400‐10MG ANTITUSSIVES BRAND Excluded TIER 99 

ALLFEN CDX LIQ ANTITUSSIVES BRAND Excluded TIER 99 

ALLFEN CDX TAB 400‐20MG ANTITUSSIVES BRAND Excluded TIER 99 

ALLOPURINOL INJ 500MG ANTIGOUT AGENTS GENERIC Covered TIER 1 

ALLOPURINOL TAB 100MG ANTIGOUT AGENTS GENERIC Covered TIER 1 

ALLOPURINOL TAB 300MG ANTIGOUT AGENTS GENERIC Covered TIER 1 

ALMOND OIL LIQ BITTER PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

ALOCRIL SOL 2% ANTIALLERGIC AGENTS BRAND Covered TIER 3 

ALODOX KIT 20MG TETRACYCLINES BRAND Covered TIER 3 

ALOMIDE SOL 0.1% OP ANTIALLERGIC AGENTS BRAND Covered TIER 3 

ALOPRIM INJ 500MG ANTIGOUT AGENTS Brand‐O PA TIER 3 



14

ALOQUIN GEL 1.25‐1% 


MEMBRANE),MISC BRAND Covered TIER 3 

ALORA DIS 0.025MG ESTROGENS BRAND Covered TIER 3 




ALOXI INJ 0.25MG/5 5‐HT3 RECEPTOR ANTAGONISTS BRAND Covered TIER 3 

ALPAIN TAB ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1 

ALPHAGAN P SOL 0.1% 

ALPHA‐ADRENERGIC AGONISTS 

(EENT) BRAND Covered TIER 2 

ALPHAGAN P SOL 0.15% 


(EENT) Brand‐O PA TIER 3 

ALPHANATE INJ VWF/HUM HEMOSTATICS BRAND PA TIER 2 SP 

ALPHANINE SD INJ 1000UNIT HEMOSTATICS BRAND PA TIER 2 SP 



ALPHAQUIN HP CRE 4% DEPIGMENTING AGENTS GENERIC Excluded TIER 99 

ALPHATREX GEL 0.05% 



ALPRAZOLAM CON 1 MG/ML 

BENZODIAZEPINES 

(ANXIOLYTIC,SEDATIV/HYP) BRAND Covered TIER 3 

ALPRAZOLAM TAB 0.25 ODT 


(ANXIOLYTIC,SEDATIV/HYP) GENERIC Covered TIER 1 

ALPRAZOLAM TAB 0.25MG 



ALPRAZOLAM TAB 0.5MG 



ALPRAZOLAM TAB 0.5MG ER 





15

ALPRAZOLAM TAB 0.5MG OD 



ALPRAZOLAM TAB 1MG 



ALPRAZOLAM TAB 1MG ER 



ALPRAZOLAM TAB 1MG ODT 



ALPRAZOLAM TAB 2MG 






ALPRAZOLAM TAB 2MG ODT 






ALPRAZOLAM TAB XR 0.5MG 



ALPRAZOLAM TAB XR 1MG 









ALPROSTADIL INJ 500MCG 

VASODILATING AGENTS, 


ALREX SUS 0.2% CORTICOSTEROIDS (EENT) BRAND Covered TIER 2 

ALSUMA INJ 6MG/0.5 SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 3 QL 

ALTABAX OIN 1% 





16

ALTACAINE SOL 0.5% OP LOCAL ANESTHETICS (EENT) GENERIC Covered TIER 1 

ALTACE CAP 1.25MG 



ALTACE CAP 10MG 



ALTACE CAP 2.5MG 



ALTACE CAP 5MG 



ALTAFLUOR SOL 0.25‐0.4 OCULAR DISORDERS GENERIC Covered TIER 1 

ALTAFRIN SOL 10% OP VASOCONSTRICTORS GENERIC Covered TIER 1 

ALTAFRIN SOL 2.5% OP VASOCONSTRICTORS GENERIC Covered TIER 1 

ALTAVERA TAB CONTRACEPTIVES GENERIC Covered TIER 1 

ALTOPREV TAB 20MG ER HMG‐COA REDUCTASE INHIBITORS BRAND Covered TIER 2 



ALUMINUM SOL ACETATE ASTRINGENTS GENERIC Covered TIER 1 

ALUMINUM CL CRY ASTRINGENTS GENERIC Excluded TIER 99 

ALUMINUM CL CRY HEXAHYDR ASTRINGENTS GENERIC Excluded TIER 99 

ALUVEA CRE 39% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

ALVESCO AER 160MCG ADRENALS BRAND Covered TIER 2 

ALVESCO AER 80MCG ADRENALS BRAND Covered TIER 2 

ALYACEN TAB 1/35 CONTRACEPTIVES GENERIC Covered TIER 1 

ALYACEN TAB 7/7/7 CONTRACEPTIVES GENERIC Covered TIER 1 

ALZ‐NAC TAB VITAMIN B COMPLEX BRAND Excluded TIER 99 

AMANTADINE CAP 100MG ADAMANTANES (CNS) GENERIC Covered TIER 1 

AMANTADINE SYP 50MG/5ML ADAMANTANES (CNS) GENERIC Covered TIER 1 



17

AMANTADINE TAB 100MG ADAMANTANES (CNS) GENERIC Covered TIER 1 

AMARYL TAB 1MG SULFONYLUREAS Brand‐O PA TIER 3 



AMBIEN TAB 10MG 

ANXIOLYTICS, SEDATIVES & 

HYPNOTICS,MISC. Brand‐O PA TIER 3 QL 

AMBIEN TAB 5MG 



AMBIEN CR TAB 12.5MG 



AMBIEN CR TAB 6.25MG 



AMBIFED CD TAB ANTITUSSIVES BRAND Excluded TIER 99 

AMBIFED CDX TAB ANTITUSSIVES BRAND Excluded TIER 99 

AMBIFED‐G TAB CDX ANTITUSSIVES BRAND Excluded TIER 99 

AMBIFED‐G CD TAB ANTITUSSIVES BRAND Excluded TIER 99 

AMBISOME INJ 50MG POLYENES BRAND Covered TIER 3 

AMCINONIDE CRE 0.1% 



AMCINONIDE LOT 0.1% 



AMCINONIDE OIN 0.1% 



AMD FOAM PAD 2"X2" DEVICES BRAND Covered TIER 3 

AMD FOAM PAD 3.5"X3" DEVICES BRAND Covered TIER 3 





AMERGE TAB 1MG SELECTIVE SEROTONIN AGONISTS Brand‐O PA TIER 3 QL 



18

AMERGE TAB 2.5MG SELECTIVE SEROTONIN AGONISTS Brand‐O PA TIER 3 QL 

A‐METHAPRED INJ 125MG ADRENALS GENERIC Covered TIER 1 

A‐METHAPRED INJ 40MG ADRENALS GENERIC Covered TIER 1 

AMETHIA TAB CONTRACEPTIVES GENERIC Covered TIER 1 

AMETHIA LO TAB CONTRACEPTIVES GENERIC Covered TIER 1 

AMETHYST TAB 90‐20MCG CONTRACEPTIVES GENERIC Covered TIER 1 


AMEVIVE INJ 15MG 

AGENTS, MISC. BRAND PA TIER 3 SP 

AMICAR SYP 25% HEMOSTATICS Brand‐O PA TIER 3 

AMICAR TAB 1000MG HEMOSTATICS BRAND Covered TIER 3 

AMICAR TAB 500MG HEMOSTATICS Brand‐O PA TIER 3 

AMIDATE INJ 2MG/ML 

GENERAL ANESTHETICS, 

MISCELLANEOUS Brand‐O PA TIER 3 

AMIFOSTINE INJ 500MG PROTECTIVE AGENTS GENERIC Covered TIER 1 SP 

AMIKACIN INJ 100/2ML AMINOGLYCOSIDES GENERIC Covered TIER 1 SP 

AMIKACIN INJ 1GM/4ML AMINOGLYCOSIDES GENERIC Covered TIER 1 SP 

AMIKACIN INJ 500/2ML AMINOGLYCOSIDES GENERIC Covered TIER 1 SP 

AMILOR/HCTZ TAB 5‐50 POTASSIUM‐SPARING DIURETICS GENERIC Covered TIER 1 

AMILORIDE TAB 5MG POTASSIUM‐SPARING DIURETICS GENERIC Covered TIER 1 

AMINO ACIDS INJ 15% CALORIC AGENTS GENERIC Covered TIER 1 

AMINOAC ACID SOL 1.5% IRR IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

AMINOBEZ POT POW VITAMIN B COMPLEX GENERIC Excluded TIER 99 

AMINOCAPR AC INJ 250MG/ML HEMOSTATICS GENERIC Covered TIER 1 

AMINOCAPR AC SYP 25% HEMOSTATICS GENERIC Covered TIER 1 

AMINOCAPR AC TAB 1000MG HEMOSTATICS GENERIC Covered TIER 1 

AMINOCAPR AC TAB 500MG HEMOSTATICS GENERIC Covered TIER 1 

AMINOHIPPURA INJ 20% KIDNEY FUNCTION GENERIC Covered TIER 1 

AMINOPHYLLIN INJ 25MG/ML 

RESPIRATORY SMOOTH MUSCLE 

RELAXANTS GENERIC Covered TIER 1 



19

AMINOPHYLLIN TAB 100MG 



AMINOPHYLLIN TAB 200MG 



AMINOSYN INJ 10% CALORIC AGENTS BRAND Covered TIER 3 

AMINOSYN INJ 3.5% CALORIC AGENTS BRAND Covered TIER 3 

AMINOSYN INJ 7% CALORIC AGENTS BRAND Covered TIER 3 

AMINOSYN INJ 8.5% CALORIC AGENTS BRAND Covered TIER 3 

AMINOSYN INJ 8.5/LYTE CALORIC AGENTS GENERIC Covered TIER 1 

AMINOSYN 7% INJ /LYTES CALORIC AGENTS BRAND Covered TIER 3 

AMINOSYN II INJ 10% CALORIC AGENTS BRAND Covered TIER 3 

AMINOSYN II INJ 15% CALORIC AGENTS Brand‐O PA TIER 3 

AMINOSYN II INJ 4.25/D25 CALORIC AGENTS BRAND Covered TIER 3 

AMINOSYN II INJ 5/D25 CALORIC AGENTS BRAND Covered TIER 3 

AMINOSYN II INJ 7% CALORIC AGENTS BRAND Covered TIER 3 

AMINOSYN II INJ 8.5% CALORIC AGENTS BRAND Covered TIER 3 

AMINOSYN II INJ 8.5/LYTE CALORIC AGENTS GENERIC Covered TIER 1 

AMINOSYN M INJ 3.5% CALORIC AGENTS BRAND Covered TIER 3 

AMINOSYN‐HBC INJ 7% CALORIC AGENTS BRAND Covered TIER 3 

AMINOSYN‐HF INJ 8% CALORIC AGENTS GENERIC Covered TIER 1 

AMINOSYN‐PF INJ 10% CALORIC AGENTS BRAND Covered TIER 3 

AMINOSYN‐PF INJ 7% CALORIC AGENTS BRAND Covered TIER 3 

AMINOSYN‐RF INJ 5.2% CALORIC AGENTS BRAND Covered TIER 3 

AMIODARONE INJ 150MG/3M CLASS III ANTIARRHYTHMICS GENERIC Covered TIER 1 

AMIODARONE INJ 50MG/ML CLASS III ANTIARRHYTHMICS GENERIC Covered TIER 1 

AMIODARONE TAB 200MG CLASS III ANTIARRHYTHMICS GENERIC Covered TIER 1 

AMIODARONE TAB 400MG CLASS III ANTIARRHYTHMICS GENERIC Covered TIER 1 

AMITIZA CAP 24MCG GI DRUGS, MISCELLANEOUS BRAND PA TIER 2 

AMITIZA CAP 8MCG GI DRUGS, MISCELLANEOUS BRAND PA TIER 2 



20

AMITRIPTYLIN TAB 100MG 

TRYCYCLICS & OTHER NOREPINEPH.‐ 

RU INHIB GENERIC Covered TIER 1 
















AMLOD/ATORVA TAB 10‐10MG DIHYDROPYRIDINES GENERIC Covered TIER 1 




AMLOD/ATORVA TAB 2.5‐10MG DIHYDROPYRIDINES GENERIC Covered TIER 1 







AMLOD/BENAZP CAP 10‐20MG DIHYDROPYRIDINES GENERIC Covered TIER 1 


AMLOD/BENAZP CAP 2.5‐10MG DIHYDROPYRIDINES GENERIC Covered TIER 1 




AMLODIPINE TAB 10MG DIHYDROPYRIDINES GENERIC Covered TIER 1 



21

AMLODIPINE TAB 2.5MG DIHYDROPYRIDINES GENERIC Covered TIER 1 

AMLODIPINE TAB 5MG DIHYDROPYRIDINES GENERIC Covered TIER 1 

AMMON MOLYBD INJ 25MCG/ML REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

AMMONIUM CHL INJ 5MEQ/ML ACIDIFYING AGENTS GENERIC Covered TIER 1 

AMMONIUM LAC CRE 12% BASIC LOTIONS AND LINIMENTS GENERIC Covered TIER 1 

AMMONUL INJ 10% AMMONIA DETOXICANTS BRAND Covered TIER 3 

AMNESTEEM CAP 10MG 









AMOX/K CLAV CHW 200MG AMINOPENICILLINS GENERIC Covered TIER 1 

AMOX/K CLAV CHW 400MG AMINOPENICILLINS GENERIC Covered TIER 1 

AMOX/K CLAV SUS 200/5ML AMINOPENICILLINS GENERIC Covered TIER 1 




AMOX/K CLAV TAB 250MG AMINOPENICILLINS GENERIC Covered TIER 1 



AMOXAPINE TAB 100MG 












AMOXICILLIN CAP 250MG AMINOPENICILLINS GENERIC Covered TIER 1 



22

AMOXICILLIN CAP 500MG AMINOPENICILLINS GENERIC Covered TIER 1 

AMOXICILLIN CHW 125MG AMINOPENICILLINS GENERIC Covered TIER 1 

AMOXICILLIN CHW 250MG AMINOPENICILLINS GENERIC Covered TIER 1 

AMOXICILLIN SUS 125/5ML AMINOPENICILLINS GENERIC Covered TIER 1 




AMOXICILLIN TAB 500MG AMINOPENICILLINS GENERIC Covered TIER 1 

AMOXICILLIN TAB 875MG AMINOPENICILLINS GENERIC Covered TIER 1 

AMOX‐POT CLA TAB ER AMINOPENICILLINS GENERIC Covered TIER 1 

AMPHADASE INJ 150/ML ENZYMES BRAND Covered TIER 3 

AMPHETAMINE CAP 10MG ER AMPHETAMINES GENERIC Covered TIER 1 QL 






AMPHETAMINE TAB 10MG AMPHETAMINES GENERIC Covered TIER 1 QL 

AMPHETAMINE TAB 12.5MG AMPHETAMINES GENERIC Covered TIER 1 QL 





AMPHETAMINE TAB 7.5MG AMPHETAMINES GENERIC Covered TIER 1 QL 

AMPHOTEC INJ 100MG POLYENES BRAND Covered TIER 3 

AMPHOTEC INJ 50MG POLYENES BRAND Covered TIER 3 

AMPHOTERICIN INJ 50MG POLYENES GENERIC Covered TIER 1 

AMPICILLIN CAP 250MG AMINOPENICILLINS GENERIC Covered TIER 1 

AMPICILLIN CAP 500MG AMINOPENICILLINS GENERIC Covered TIER 1 

AMPICILLIN INJ 10GM AMINOPENICILLINS GENERIC Covered TIER 1 



23

AMPICILLIN INJ 125MG AMINOPENICILLINS GENERIC Covered TIER 1 





AMPICILLIN SUS 125/5ML AMINOPENICILLINS GENERIC Covered TIER 1 

AMPICILLIN SUS 250/5ML AMINOPENICILLINS GENERIC Covered TIER 1 

AMP‐SULBACTA INJ 1.5GM AMINOPENICILLINS GENERIC Covered TIER 1 

AMP‐SULBACTA INJ 1‐0.5GM AMINOPENICILLINS GENERIC Covered TIER 1 

AMP‐SULBACTA INJ 10‐5GM AMINOPENICILLINS GENERIC Covered TIER 1 

AMP‐SULBACTA INJ 15GM AMINOPENICILLINS GENERIC Covered TIER 1 

AMP‐SULBACTA INJ 2‐1GM AMINOPENICILLINS GENERIC Covered TIER 1 

AMP‐SULBACTA INJ 3GM AMINOPENICILLINS GENERIC Covered TIER 1 

AMPYRA TAB 10MG 


THERAPEUTIC AGENTS BRAND PA TIER 3 QL SP 

AMRIX CAP 15MG 

CENTRALLY ACTING SKELETAL 

MUSCLE RELAXNT BRAND Covered TIER 3 

AMRIX CAP 30MG 



AMTURNIDE150 TAB ‐5‐12.5 RENIN INHIBITORS BRAND Covered TIER 2 


AMTURNIDE300 TAB ‐10‐25MG RENIN INHIBITORS BRAND Covered TIER 2 


AMTURNIDE300 TAB ‐5‐25MG RENIN INHIBITORS BRAND Covered TIER 2 

AMVISC INJ 12MG/ML EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 3 

AMVISC PLUS INJ 16MG/ML EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 3 

AMYL NITRITE INH 0.3ML NITRATES AND NITRITES GENERIC Covered TIER 1 

AMYTAL SOD INJ 500MG 

BARBITURATES (ANXIOLYTIC, 

SEDATIVE/HYP) BRAND Covered TIER 3 

AMYVID INJ RADIOACTIVE AGENTS BRAND Covered TIER 3 



24

ANABAR TAB 



ANACAINE OIN 

ANTIPRURITICS AND LOCAL 

ANESTHETICS BRAND Covered TIER 3 

ANADROL‐50 TAB 50MG ANDROGENS BRAND PA TIER 3 

ANAFRANIL CAP 25MG 


RU INHIB Brand‐O PA TIER 3 







ANAGRELIDE CAP 0.5MG PLATELET‐REDUCING AGENTS GENERIC Covered TIER 1 

ANAGRELIDE CAP 1MG PLATELET‐REDUCING AGENTS GENERIC Covered TIER 1 

ANALPRAM KIT ADVANCED 



ANALPRAM E KIT 


ANESTHETICS Brand‐O PA TIER 99 

ANALPRAM‐HC CRE 1‐1% 



ANALPRAM‐HC CRE 1‐2.5% 



ANALPRAM‐HC CRE SINGLES 



TIER 99 

ANALPRAM‐HC LOT 2.5% 



ANAMANTLE HC CRE 



ANAMANTLE HC KIT 





25

ANAPROX TAB 275MG 

OTHER NONSTEROIDAL ANTI‐ 

INFLAM. AGENTS Brand‐O PA TIER 3 

ANAPROX DS TAB 550MG 



ANASCORP INJ SERUMS BRAND Covered TIER 3 

ANASPAZ TAB 0.125MG 

ANTIMUSCARINICS/ANTISPASMODIC 

S Brand‐O PA TIER 3 

ANASTROZOLE TAB 1MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

ANCOBON CAP 250MG PYRIMIDINES Brand‐O PA TIER 3 

ANCOBON CAP 500MG PYRIMIDINES Brand‐O PA TIER 3 

ANDRODERM DIS 2.5MG/24 ANDROGENS BRAND Covered TIER 2 

ANDRODERM DIS 2MG/24HR ANDROGENS BRAND Covered TIER 2 



ANDROGEL GEL 1%(25MG) ANDROGENS BRAND Covered TIER 2 

ANDROGEL GEL 1%(50MG) ANDROGENS BRAND Covered TIER 2 

ANDROGEL GEL 1.62% ANDROGENS BRAND Covered TIER 2 

ANDROGEL GEL PUMP 1% ANDROGENS BRAND Covered TIER 2 

ANDROID CAP 10MG ANDROGENS BRAND Covered TIER 3 

ANDROXY TAB 10MG ANDROGENS BRAND Covered TIER 2 

ANECTINE INJ 20MG/ML 

NEUROMUSCULAR BLOCKING 


ANESTH NEEDL MIS 23X1‐3/8 DEVICES GENERIC Excluded TIER 99 

ANGEL WING MIS 19GX3/4" DEVICES BRAND Excluded TIER 99 




ANGEL WING MIS TRANSFER DEVICES BRAND Excluded TIER 99 

ANGEL WING MIS TUBE HLD DEVICES BRAND Excluded TIER 99 

ANGELIQ TAB 0.25‐0.5 ESTROGENS BRAND Covered TIER 3 



26

ANGELIQ TAB 0.5‐1MG ESTROGENS BRAND Covered TIER 3 

ANGIOMAX INJ 250MG DIRECT THROMBIN INHIBITORS BRAND Covered TIER 3 

ANHYDROUS GEL BASE PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

ANHYDROUS OIN BASE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

ANIMI‐3 CAP VITAMIN B COMPLEX Brand‐O PA TIER 3 

ANIMI‐3 CAP VIT D VITAMIN B COMPLEX BRAND Covered TIER 3 

ANISE EXTRAC LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

ANISE FLAVOR OIL PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

ANOLOR 300 CAP 



ANTABUSE TAB 250MG ALCOHOL DETERRENTS Brand‐O PA TIER 3 

ANTABUSE TAB 500MG ALCOHOL DETERRENTS Brand‐O PA TIER 3 

ANTARA CAP 130MG FIBRIC ACID DERIVATIVES BRAND Covered TIER 2 QL 

ANTARA CAP 43MG FIBRIC ACID DERIVATIVES BRAND Covered TIER 2 QL 

ANTICOAG CPD SOL ANTICOAGULANTS, MISCELLANEOUS BRAND Covered TIER 3 

ANTICOAGULNT SOL SOD CITR ANTICOAGULANTS, MISCELLANEOUS GENERIC Covered TIER 1 

ANTIPY/BENZO DRO OTIC LOCAL ANESTHETICS (EENT) GENERIC Covered TIER 1 

ANTIPY/BENZO SOL 14‐54MG LOCAL ANESTHETICS (EENT) GENERIC Covered TIER 1 

ANTIPY/BENZO SOL OTIC LOCAL ANESTHETICS (EENT) GENERIC Covered TIER 1 

ANTIVENIN KIT LAT MACT SERUMS GENERIC Covered TIER 1 

ANTIVENIN MI KIT SERUMS GENERIC Covered TIER 1 

ANTIVERT TAB 12.5MG ANTIHISTAMINES (GI DRUGS) Brand‐O PA TIER 3 

ANTIVERT TAB 25MG ANTIHISTAMINES (GI DRUGS) Brand‐O PA TIER 3 

ANTIVERT TAB 50MG ANTIHISTAMINES (GI DRUGS) BRAND Covered TIER 3 

ANTIZOL INJ 1GM/ML ANTIDOTES Brand‐O PA TIER 3 

ANUCORT‐HC SUP 25MG 


& MUCOUS) GENERIC Excluded TIER 99 



27

ANUSOL‐HC CRE 2.5% 



ANUSOL‐HC SUP 25MG 



ANZEMET INJ 20MG/ML 5‐HT3 RECEPTOR ANTAGONISTS BRAND Covered TIER 3 

ANZEMET TAB 100MG 5‐HT3 RECEPTOR ANTAGONISTS BRAND Covered TIER 2 QL 

ANZEMET TAB 50MG 5‐HT3 RECEPTOR ANTAGONISTS BRAND Covered TIER 2 QL 

APAP/CAFF/DI TAB HYDROCOD OPIATE AGONISTS GENERIC Covered TIER 1 

APAP/CODEINE SOL 120‐12/5 OPIATE AGONISTS GENERIC Covered TIER 1 

APAP/CODEINE TAB 300‐15MG OPIATE AGONISTS GENERIC Covered TIER 1 



APEXICON OIN 0.05% 



APEXICON E CRE 0.05% 



APHTHASOL PST 5% EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 3 

APIDRA INJ SOLOSTAR INSULINS BRAND Covered TIER 2 

APIDRA INJ U‐100 INSULINS BRAND Covered TIER 2 

APLENZIN TAB 174MG ANTIDEPRESSANTS, MISCELLANEOUS BRAND Covered TIER 3 QL 




APLIGRAF MIS 


APLISOL INJ 5/0.1ML TUBERCULOSIS BRAND Covered TIER 3 

APOKYN INJ 

NONERGOT‐DERIV.DOPAMINE 

RECEPTOR AGONIST BRAND Covered TIER 2 



28

APOKYN INJ 10MG/ML 



APPBUTAMONE PAK ANTIDEPRESSANTS, MISCELLANEOUS BRAND Covered TIER 3 

APPBUTAMONE PAK ‐D ANTIDEPRESSANTS, MISCELLANEOUS BRAND Covered TIER 3 

APPFORMIN PAK BIGUANIDES BRAND Covered TIER 3 

APPFORMIN‐D PAK BIGUANIDES BRAND Covered TIER 3 

APPLE FLAVOR LIQ PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

APPTRIM CAP CALORIC AGENTS BRAND Excluded TIER 99 

APPTRIM LIFE CAP BARIATRC CALORIC AGENTS BRAND Excluded TIER 99 

APPTRIM LIFE CAP OBESITY CALORIC AGENTS BRAND Excluded TIER 99 

APPTRIM‐D CAP CALORIC AGENTS BRAND Excluded TIER 99 

APRACLONIDIN SOL 0.5% OP EENT DRUGS, MISCELLANEOUS GENERIC Covered TIER 1 

APRI TAB CONTRACEPTIVES GENERIC Covered TIER 1 

APRICOT LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

APRISO CAP 0.375GM 

ANTI‐INFLAMMATORY AGENTS (GI 

DRUGS) BRAND Covered TIER 2 

APTIVUS CAP 250MG HIV PROTEASE INHIBITORS BRAND Covered TIER 2 

APTIVUS SOL HIV PROTEASE INHIBITORS BRAND Covered TIER 2 

AP‐ZEL TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

AQUA GLYC HC KIT SCLP/BDY 


& MUCOUS) BRAND Covered TIER 3 

AQUAFLO MIS 3" 



AQUAFLO MIS 4.75" 



AQUA‐SEAL MIS UNIT DEVICES BRAND Excluded TIER 99 

AQUASOL A INJ 50000/ML VITAMIN A BRAND Covered TIER 3 

AQUORAL AER EENT DRUGS, MISCELLANEOUS GENERIC Covered TIER 1 



29

ARALAST NP INJ 1000MG 

RESPIRATORY TRACT AGENTS, 

MISCELLANEOUS BRAND Covered TIER 2 SP 










ARALEN TAB 500MG ANTIMALARIALS Brand‐O PA TIER 3 QL 

ARANELLE TAB CONTRACEPTIVES GENERIC Covered TIER 1 

ARANESP INJ 100MCG HEMATOPOIETIC AGENTS BRAND PA TIER 2 SP 








ARAVA TAB 10MG 


ANTIRHEUMATIC AGENTS Brand‐O PA TIER 3 

ARAVA TAB 20MG 


ANTIRHEUMATIC AGENTS Brand‐O PA TIER 3 

ARBINOXA LIQ 4MG/5ML ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1 

ARBINOXA TAB 4MG ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1 

ARCALYST INJ 220MG 



ARCAPTA CAP 75MCG 



AREDIA INJ 30MG BONE RESORPTION INHIBITORS Brand‐O PA TIER 3 SP 

ARESTIN MIS 1MG ANTIBACTERIALS (EENT) BRAND Covered TIER 3 



30

ARGATROBAN INJ 100MG/ML DIRECT THROMBIN INHIBITORS GENERIC Covered TIER 1 

ARGATROBAN INJ 125/125 DIRECT THROMBIN INHIBITORS GENERIC Covered TIER 1 

ARGATROBAN INJ 50MG/50M DIRECT THROMBIN INHIBITORS GENERIC Covered TIER 1 

ARGENTUM‐D20 INJ 


THERAPEUTIC AGENTS GENERIC Excluded TIER 99 

ARGYLE PLUG MIS INFUSION DEVICES BRAND Excluded TIER 99 

ARICEPT TAB 10MG 

PARASYMPATHOMIMETIC 

(CHOLINERGIC AGENTS) Brand‐O PA TIER 3 



(CHOLINERGIC AGENTS) BRAND Covered TIER 2 




ARICEPT ODT TAB 10MG 



ARICEPT ODT TAB 5MG 



ARIDOL KIT RESPIRATORY FUNCTION BRAND Covered TIER 3 

ARIMIDEX TAB 1MG ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 

ARISTOSPAN INJ 20MG/ML ADRENALS BRAND Covered TIER 3 

ARISTOSPAN INJ 5MG/ML ADRENALS BRAND Covered TIER 3 

ARIXTRA SOL 10/0.8 DIRECT FACTOR XA INHIBITORS Brand‐O PA TIER 3 

ARIXTRA SOL 2.5/0.5 DIRECT FACTOR XA INHIBITORS Brand‐O PA TIER 3 



ARMOUR THYRO TAB 120MG THYROID AGENTS BRAND Covered TIER 3 





ARMOUR THYRO TAB 30MG THYROID AGENTS Brand‐O PA TIER 3 



31



ARNICA TIN FLOWER 



AROMASIN TAB 25MG ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 

ARRANON INJ 5MG/ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

ARTHROTEC 50 TAB 


INFLAM. AGENTS BRAND Covered TIER 3 

ARTHROTEC 75 TAB 



ARTISS SOL 10ML 









ARZERRA CON 100/50ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

ARZERRA CON 100/5ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

ARZOL SILVER MIS NITR APP 

EENT ANTI‐INFECTIVES, 


ASACOL TAB 400MG DR 



ASACOL HD TAB 800MG 



ASCLERA INJ 0.5% SCLEROSING AGENTS BRAND Covered TIER 3 

ASCLERA INJ 1% SCLEROSING AGENTS BRAND Covered TIER 3 

ASCOMP/COD CAP 30MG OPIATE AGONISTS GENERIC Covered TIER 1 

ASCOR L 500 INJ 500MG/ML VITAMIN C GENERIC Covered TIER 1 

ASCOR L NC INJ 500MG/ML VITAMIN C GENERIC Covered TIER 1 

ASCORBIC ACD INJ 500MG/ML VITAMIN C GENERIC Covered TIER 1 



32

ASMALPRED SOL 15MG/5ML ADRENALS GENERIC Covered TIER 1 

ASMALPRED SOL PLUS ADRENALS GENERIC Covered TIER 1 

ASMANEX 120 AER 220MCG ADRENALS BRAND Covered TIER 2 






ASPARTAME POW SALT AND SUGAR SUBSTITUTES BRAND Excluded TIER 99 

ASPERGILLUS INJ 1:500 DIAGNOSTIC AGENTS GENERIC Excluded TIER 99 

ASSEMBLY MIS FIXTURE DEVICES BRAND Excluded TIER 99 

ASTELIN NASA SPR 137MCG ANTIALLERGIC AGENTS Brand‐O PA TIER 2 

ASTEPRO SPR 0.15% ANTIALLERGIC AGENTS BRAND Covered TIER 2 

ASTHMA CNTRL KIT DEVICES GENERIC Excluded TIER 99 

ASTHMA RX TAB 



ASTHMAPACK KIT II DEVICES BRAND Excluded TIER 99 

ASTHMAPACK KIT III DEVICES BRAND Excluded TIER 99 

ASTHMAPACK I KIT DEVICES BRAND Excluded TIER 99 

ASTRAMORPH INJ 10/10ML OPIATE AGONISTS GENERIC Covered TIER 1 

ASTRAMORPH INJ 1MG/2ML OPIATE AGONISTS GENERIC Covered TIER 1 

ASTRAMORPH INJ 2MG/2ML OPIATE AGONISTS GENERIC Covered TIER 1 

ASTRINGYN SOL 259MG/GM HEMOSTATICS BRAND Covered TIER 3 

ATABEX TAB PRENATAL MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

ATABEX EC TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

ATACAND TAB 16MG 

ANGIOTENSIN II RECEPTOR 

ANTAGONISTS BRAND Covered TIER 2 






33







ATACAND HCT TAB 16‐12.5 



ATACAND HCT TAB 32‐12.5 



ATACAND HCT TAB 32‐25MG 



ATELVIA TAB BONE RESORPTION INHIBITORS BRAND Covered TIER 3 

ATENOL/CHLOR TAB 100‐25MG 



ATENOL/CHLOR TAB 50‐25MG 



ATENOLOL TAB 100MG 









ATGAM INJ 250MG IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 3 SP 

ATIVAN INJ 2MG/ML 


(ANXIOLYTIC,SEDATIV/HYP) Brand‐O PA TIER 3 SP 

ATIVAN INJ 4MG/ML 


(ANXIOLYTIC,SEDATIV/HYP) Brand‐O PA TIER 3 SP 

ATIVAN TAB 0.5MG 


(ANXIOLYTIC,SEDATIV/HYP) Brand‐O PA TIER 3 

ATIVAN TAB 1MG 





34

ATIVAN TAB 2MG 

ATOPICLAIR CRE 



BASIC OINTMENTS AND 

PROTECTANTS BRAND Covered TIER 3 

ATORVASTATIN TAB 10MG HMG‐COA REDUCTASE INHIBITORS GENERIC Covered TIER 1 




ATOVAQ/PROGU TAB 250‐100 ANTIMALARIALS GENERIC Covered TIER 1 

ATOVAQ/PROGU TAB 62.5‐25 ANTIMALARIALS GENERIC Covered TIER 1 

ATRACURIUM INJ 10MG/ML 



ATRALIN GEL 0.05% 

CELL STIMULANTS AND 

PROLIFERANTS BRAND Covered TIER 2 

ATRAPRO GEL HYDROGEL 



ATRAPRO DERM SPR 



ATRIPLA TAB ANTIRETROVIRALS, MISCELLANEOUS BRAND Covered TIER 2 


ATROPEN INJ 0.25MG 

S BRAND Covered TIER 3 

ATROPEN INJ 0.5MG 



ATROPEN INJ 1MG 





35

ATROPEN INJ 2MG 



ATROPIN‐CARE SOL 1% OP MYDRIATICS GENERIC Covered TIER 1 

ATROPINE SUL INJ 0.05MG/1 


S GENERIC Covered TIER 1 

ATROPINE SUL INJ 0.1MG/ML 



ATROPINE SUL INJ 0.4/0.5 



ATROPINE SUL INJ 0.4MG/ML 



ATROPINE SUL INJ 1MG/ML 



ATROPINE SUL OIN 1% OP MYDRIATICS GENERIC Covered TIER 1 

ATROPINE SUL SOL 1% OP MYDRIATICS GENERIC Covered TIER 1 

ATROPINUM SUB COMPOSIT 



ATROVENT HFA AER 17MCG 


S BRAND Covered TIER 2 QL 

ATROVENT NAS SOL 0.03% 



ATROVENT NAS SOL 0.06% 



ATRYN INJ 1750 ANTICOAGULANTS, MISCELLANEOUS BRAND Covered TIER 3 

ATUSS DS SUS ANTITUSSIVES Brand‐O PA TIER 99 

AUBAGIO TAB 14MG 


THERAPEUTIC AGENTS BRAND Covered TIER 3 

AUBAGIO TAB 7MG 





36

AUG BETAMET CRE 0.05% 



AUG BETAMET GEL 0.05% 



AUG BETAMET LOT 0.05% 



AUG BETAMET OIN 0.05% 



AUGMENTIN SUS 125/5ML AMINOPENICILLINS BRAND Covered TIER 2 

AUGMENTIN SUS 250/5ML AMINOPENICILLINS Brand‐O PA TIER 3 

AUGMENTIN SUS ES‐600 AMINOPENICILLINS Brand‐O PA TIER 3 

AUGMENTIN TAB 500MG AMINOPENICILLINS Brand‐O PA TIER 3 

AUGMENTIN TAB 875MG AMINOPENICILLINS Brand‐O PA TIER 3 

AUGMENTIN XR TAB 12HR AMINOPENICILLINS Brand‐O PA TIER 3 

AURALGAN SOL 1.4‐5.5% LOCAL ANESTHETICS (EENT) Brand‐O PA TIER 3 

AURAX SOL 1.4‐5.5% LOCAL ANESTHETICS (EENT) GENERIC Covered TIER 1 

AURODEX SOL OTIC LOCAL ANESTHETICS (EENT) GENERIC Covered TIER 1 

AURSTAT KIT 

EMOLLIENTS, DEMULCENTS, AND 


AURUM LIQ 12X 



AURUMHEEL DRO 



AUTOSHIELD MIS 30GX3/16 DEVICES BRAND Excluded TIER 99 

AUTOTRANSFUS MIS ACC UNT DEVICES BRAND Excluded TIER 99 

AVAGE CRE 0.1% 


AGENTS, MISC. BRAND Excluded TIER 99 

AVAILNEX CHW 750MG 





37

AVALIDE TAB 150‐12.5 


ANTAGONISTS Brand‐O PA TIER 3 

AVALIDE TAB 300‐12.5 



AVALIDE TAB 300‐25MG 



AVANDAMET TAB 2‐1000MG THIAZOLIDINEDIONES BRAND Covered TIER 2 




AVANDARYL TAB 4‐1MG THIAZOLIDINEDIONES BRAND Covered TIER 2 





AVANDIA TAB 2MG THIAZOLIDINEDIONES BRAND Covered TIER 2 



AVAPRO TAB 150MG 









AVAR CLEANSE EMU 10‐5% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

AVAR LS LIQ 10‐2% KERATOLYTIC AGENTS BRAND Covered TIER 3 

AVAR‐E EMOLL CRE 10‐5% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

AVAR‐E GREEN CRE 10‐5% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

AVAR‐E LS CRE 10‐2% KERATOLYTIC AGENTS BRAND Covered TIER 3 

AVASTIN INJ ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 



38

AVC CRE 15% 


MISCELLANEOUS BRAND Covered TIER 2 

AVELOX INJ QUINOLONES BRAND Covered TIER 2 

AVELOX TAB 400MG QUINOLONES BRAND Covered TIER 2 

AVELOX ABC TAB 400MG QUINOLONES BRAND Covered TIER 2 

AVIANE TAB CONTRACEPTIVES GENERIC Covered TIER 1 

AVIDOXY TAB 100MG TETRACYCLINES GENERIC Covered TIER 1 

AVIDOXY DK KIT TETRACYCLINES BRAND Covered TIER 3 

AVINZA CAP 120MG OPIATE AGONISTS BRAND Covered TIER 2 QL 






AVITA CRE 0.025% 


PROLIFERANTS GENERIC Covered TIER 1 

AVITA GEL 0.025% 



AVITENE PAD 35X35MM HEMOSTATICS BRAND Excluded TIER 99 



AVITENE SYRG MIS 1GM HEMOSTATICS BRAND Excluded TIER 99 

AVO CREAM EMU 



AVODART CAP 0.5MG 5‐ALPHA‐REDUCTASE INHIBITORS BRAND Covered TIER 2 QL 

AVONEX KIT 30MCG BIOLOGIC RESPONSE MODIFIERS BRAND Covered TIER 2 SP 

AVONEX PEN KIT 30MCG BIOLOGIC RESPONSE MODIFIERS BRAND Covered TIER 2 SP 

AVONEX PREFL KIT 30MCG BIOLOGIC RESPONSE MODIFIERS BRAND Covered TIER 2 SP 

AVOSTARTGRIP MIS DEVICES BRAND Excluded TIER 99 

AXERT TAB 12.5MG SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 3 QL 



39

AXERT TAB 6.25MG SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 3 QL 

AXID CAP 150MG HISTAMINE H2‐ANTAGONISTS Brand‐O PA TIER 3 

AXID CAP 300MG HISTAMINE H2‐ANTAGONISTS Brand‐O PA TIER 3 

AXID SOL 15MG/ML HISTAMINE H2‐ANTAGONISTS Brand‐O PA TIER 2 

AXIRON SOL 30MG/ACT ANDROGENS BRAND Covered TIER 2 

AXONA POW CALORIC AGENTS BRAND Excluded TIER 99 

AYGESTIN TAB 5MG PROGESTINS Brand‐O PA TIER 3 

AZ CREAM CRE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

AZACTAM INJ 1GM MONOBACTAMS Brand‐O PA TIER 3 

AZACTAM INJ 2GM MONOBACTAMS Brand‐O PA TIER 3 

AZACTAM/DEX INJ 1GM MONOBACTAMS BRAND Covered TIER 3 

AZACTAM/DEX INJ 2GM MONOBACTAMS BRAND Covered TIER 3 

AZASAN TAB 100MG IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 2 

AZASAN TAB 75 MG IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 2 

AZASITE SOL 1% ANTIBACTERIALS (EENT) BRAND Covered TIER 3 

AZATHIOPRINE INJ 100MG IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1 

AZATHIOPRINE TAB 50MG IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1 

AZELASTINE DRO 0.05% ANTIALLERGIC AGENTS GENERIC Covered TIER 1 

AZELASTINE SPR 0.1% ANTIALLERGIC AGENTS GENERIC Covered TIER 1 

AZELEX CRE 20% 



AZILECT TAB 0.5MG MONOAMINE OXIDASE B INHIBITORS BRAND Covered TIER 2 

AZILECT TAB 1MG MONOAMINE OXIDASE B INHIBITORS BRAND Covered TIER 2 

AZITHROMYCIN INJ 2.5GM OTHER MACROLIDES GENERIC Covered TIER 1 

AZITHROMYCIN INJ 500MG OTHER MACROLIDES GENERIC Covered TIER 1 

AZITHROMYCIN POW 1GM PAK OTHER MACROLIDES GENERIC Covered TIER 1 

AZITHROMYCIN SUS 100/5ML OTHER MACROLIDES GENERIC Covered TIER 1 

AZITHROMYCIN SUS 200/5ML OTHER MACROLIDES GENERIC Covered TIER 1 



40

AZITHROMYCIN TAB 250MG OTHER MACROLIDES GENERIC Covered TIER 1 



AZOPT SUS 1% OP 



AZOR TAB 10‐20MG DIHYDROPYRIDINES BRAND Covered TIER 2 




AZTREONAM INJ 1GM MONOBACTAMS GENERIC Covered TIER 1 

AZTREONAM INJ 2GM MONOBACTAMS GENERIC Covered TIER 1 

AZULFIDINE TAB 500MG SULFONAMIDES (SYSTEMIC) Brand‐O PA TIER 3 

AZULFIDINE TAB 500MG EN SULFONAMIDES (SYSTEMIC) Brand‐O PA TIER 3 

AZURETTE TAB 28 DAY CONTRACEPTIVES GENERIC Covered TIER 1 

B6 FOLIC ACD CAP VITAMIN B COMPLEX GENERIC Covered TIER 1 

BACIIM INJ 50000UNT BACITRACINS GENERIC Covered TIER 1 

BACIT/POLYMY OIN OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

BACITRACIN INJ 50000UNT BACITRACINS GENERIC Covered TIER 1 

BACITRACIN OIN OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

BACLOFEN TAB 10MG 

GABA‐DERIVATIVE SKELETAL MUSCLE 

RELAXANT GENERIC Covered TIER 1 

BACLOFEN TAB 20MG 



BACMIN TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

BACON FLAVOR LIQ PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

BACTER WATER INJ BENZ ALC PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

BACTER WATER INJ PARABENS PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

BACTOCILL INJ DEX 1GM 

PENICILLINASE‐RESISTANT 

PENICILLINS BRAND Covered TIER 3 



41

BACTOCILL INJ DEX 2GM 



BACTRIM TAB 400‐80MG SULFONAMIDES (SYSTEMIC) Brand‐O PA TIER 3 

BACTRIM DS TAB 800‐160 SULFONAMIDES (SYSTEMIC) Brand‐O PA TIER 3 

BACTROBAN CRE 2% 



BACTROBAN OIN 2% 


MEMBRANE) Brand‐O PA TIER 3 

BACTROBAN OIN NASAL 2% 



BAL IN OIL INJ 100MG/ML HEAVY METAL ANTAGONISTS BRAND Covered TIER 3 

BAL SALT SOL OP EENT DRUGS, MISCELLANEOUS GENERIC Covered TIER 1 

BALACALL DM SYP 5‐2‐10MG ANTITUSSIVES GENERIC Covered TIER 1 

BALANCED SAL SOL OP EENT DRUGS, MISCELLANEOUS GENERIC Covered TIER 1 

BAL‐CARE MIS DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

BAL‐CARE DHA MIS ESSNTIAL MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

BALSALAZIDE CAP 750MG 


DRUGS) GENERIC Covered TIER 1 

BALZIVA TAB CONTRACEPTIVES GENERIC Covered TIER 1 

BANANA LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

BANANA CREME LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

BANZEL SUS 40MG/ML 

ANTICONVULSANTS, 

MISCELLANEOUS BRAND Covered TIER 3 QL 

BANZEL TAB 200MG 



BANZEL TAB 400MG 



BARACLUDE SOL .05MG/ML NUCLEOSIDES AND NUCLEOTIDES BRAND Covered TIER 2 

BARACLUDE TAB 0.5MG NUCLEOSIDES AND NUCLEOTIDES BRAND Covered TIER 2 

BARACLUDE TAB 1MG NUCLEOSIDES AND NUCLEOTIDES BRAND Covered TIER 2 



42

BARD URETHR MIS CATH 16" DEVICES BRAND Excluded TIER 99 

BAR‐TEST TAB 650MG ROENTGENOGRAPHY BRAND Covered TIER 3 

BASE C PEG LIQ 300 CATHARTICS AND LAXATIVES GENERIC Excluded TIER 99 

BASE W301 CRE PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

BASE X MIS PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

BASIC BIOPSY KIT 20GX1.5" LOCAL ANESTHETICS (PARENTERAL) BRAND Covered TIER 3 

BAYCADRON ELX 0.5/5ML ADRENALS GENERIC Covered TIER 1 

B‐COMPLEX INJ VITAMIN B COMPLEX GENERIC Covered TIER 1 

B‐COMPLEX INJ 100 VITAMIN B COMPLEX GENERIC Covered TIER 1 

BD ECLIPSE MIS 18GX1.5" DEVICES BRAND Excluded TIER 99 

BD ECLIPSE MIS 22GX1" DEVICES BRAND Excluded TIER 99 

BD ECLIPSE MIS 23GX1" DEVICES BRAND Excluded TIER 99 

BD FIL NEED MIS 5 MICRON DEVICES GENERIC Excluded TIER 99 

BD NEXIVA MIS 18GX1.25 DEVICES BRAND Excluded TIER 99 


BD NEXIVA MIS 20GX1" DEVICES BRAND Excluded TIER 99 



BD NEXIVA MIS 22GX1" DEVICES BRAND Excluded TIER 99 



BD POSIFLUSH INJ 0.9% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

BD SAF‐T‐INT KIT 22GX0.75 DEVICES BRAND Excluded TIER 99 

BD SAF‐T‐INT KIT 24GX0.75 DEVICES BRAND Excluded TIER 99 

BEBULIN INJ 200‐1200 HEMOSTATICS BRAND PA TIER 3 SP 

BEBULIN VH INJ 200‐1200 HEMOSTATICS BRAND PA TIER 3 SP 

BECONASE AQ SUS 0.042% CORTICOSTEROIDS (EENT) BRAND Covered TIER 3 

BEE VENOM INJ 1300MCG 





43

BEE VENOM INJ 550MCG 



BEES WAX MIS WHITE PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

BELLA ALK/PB TAB 16.2MG 


S GENERIC Excluded TIER 99 

BELLA/OPIUM SUP 16.2‐30 



BELLA/OPIUM SUP 16.2‐60 



BELLADONNA TIN 30/100ML 



BENAZEP/HCTZ TAB 10‐12.5 


INHIBITORS GENERIC Covered TIER 1 




BENAZEP/HCTZ TAB 20‐25MG 






BENAZEPRIL TAB 10MG 












BENEFIX INJ 1000UNIT HEMOSTATICS BRAND PA TIER 2 SP 





44



BENICAR TAB 20MG 









BENICAR HCT TAB 20‐12.5 



BENICAR HCT TAB 40‐12.5 



BENICAR HCT TAB 40‐25MG 



BENLYSTA INJ 120MG IMMUNOSUPPRESSIVE AGENTS BRAND PA TIER 3 

BENLYSTA INJ 400MG IMMUNOSUPPRESSIVE AGENTS BRAND PA TIER 3 

BENSAL HP OIN 



BENTYL CAP 10MG 



BENTYL INJ 10MG/ML 



BENTYL SYP 10MG/5ML 



BENTYL TAB 20MG 



BENZAC AC LIQ 5% WASH 



BENZAC W LIQ 5% WASH 





45

BENZACLIN GEL 1‐5% 



BENZACLIN GEL 1‐5%PUMP 



BENZALDEHYDE ELX PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

BENZALKONIUM SOL 17% 



BENZALKONIUM SOL 50% 



BENZALKONIUM SOL NF 



BENZAMYCIN GEL 



BENZAMYCIN GEL PAK 



BENZEFOAM AER 5.3% 



BENZEFOAM AER 9.8% 



BENZEPRO AER 5.3% 



BENZEPRO SC AER 9.8% 



BENZIQ GEL 5.25% 



BENZIQ LS GEL 2.75% 



BENZIQ WASH LIQ 5.25% 



BENZONATATE CAP 100MG ANTITUSSIVES GENERIC Covered TIER 1 



46

BENZONATATE CAP 200MG ANTITUSSIVES GENERIC Covered TIER 1 

BENZOYL PER AER 5.3% 



BENZOYL PER GEL 10% 



BENZOYL PER GEL 2.5% 



BENZOYL PER LIQ 10% WASH 



BENZOYL PER LIQ 2.5%WASH 









BENZOYL PER LOT 3% 












BENZOYL PER PAD 3% 











47

BENZOYL PERO AER 9.8% 



BENZOYL PERO KIT ACNE PCK 



BENZPHETAMIN TAB 50MG AMPHETAMINES GENERIC Excluded TIER 99 

BENZTROPINE INJ 1MG/ML ANTICHOLINERGIC AGENTS (CNS) GENERIC Covered TIER 1 

BENZTROPINE TAB 0.5MG ANTICHOLINERGIC AGENTS (CNS) GENERIC Covered TIER 1 

BENZTROPINE TAB 1MG ANTIPARKINSONIAN AGENTS GENERIC Covered TIER 1 

BENZTROPINE TAB 2MG ANTICHOLINERGIC AGENTS (CNS) GENERIC Covered TIER 1 

BEPREVE DRO 1.5% ANTIALLERGIC AGENTS BRAND Covered TIER 3 

BERINERT INJ 500UNIT COMPLEMENT INHIBITORS BRAND PA TIER 3 SP 

BESIVANCE SUS 0.6% ANTIBACTERIALS (EENT) BRAND Covered TIER 2 

BETADINE SOL 5% OP 



BETAGAN SOL 0.5% OP 


AGENTS (EENT) Brand‐O PA TIER 3 

BETAMETH DIP CRE 0.05% 



BETAMETH DIP LOT 0.05% 



BETAMETH DIP OIN 0.05% 



BETAMETH VAL CRE 0.1% 



BETAMETH VAL LOT 0.1% 



BETAMETH VAL OIN 0.1% 



BETAPACE TAB 120MG 





48







BETAPACE AF TAB 120MG 









BETA‐PHOS/AC INJ 3‐3MG/ML ADRENALS GENERIC Covered TIER 1 

BETASERON INJ 0.3MG BIOLOGIC RESPONSE MODIFIERS BRAND Covered TIER 3 SP 

BETAXOLOL SOL 0.5% OP 


AGENTS (EENT) GENERIC Covered TIER 1 

BETAXOLOL TAB 10MG 



BETAXOLOL TAB 20MG 



BETHANECHOL TAB 10MG 


(CHOLINERGIC AGENTS) GENERIC Covered TIER 1 










BETIMOL SOL 0.25% 


AGENTS (EENT) BRAND Covered TIER 3 

BETIMOL SOL 0.5% 





49

BETOPTIC‐S SUS 0.25% OP 



BEXXAR CON 14MG/ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

BEXXAR 131 I INJ 0.61/ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 

BEXXAR 131 I INJ 5.6MCI/M ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 

BEYAZ TAB CONTRACEPTIVES BRAND Covered TIER 2 

BIAFINE EMU 



BIAXIN SUS 250/5ML OTHER MACROLIDES Brand‐O PA TIER 3 

BIAXIN TAB 250MG OTHER MACROLIDES Brand‐O PA TIER 3 

BIAXIN TAB 500MG OTHER MACROLIDES Brand‐O PA TIER 3 

BIAXIN XL TAB 500MG OTHER MACROLIDES Brand‐O PA TIER 3 

BIAXIN XL TAB PAC 500 OTHER MACROLIDES Brand‐O PA TIER 3 

BICALUTAMIDE TAB 50MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

BICILLIN C‐R INJ 1200000 NATURAL PENICILLINS BRAND Covered TIER 3 

BICILLIN C‐R INJ 900/300 NATURAL PENICILLINS BRAND Covered TIER 3 

BICILLIN L‐A INJ 1200000 NATURAL PENICILLINS BRAND Covered TIER 3 



BICNU INJ 100MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

BIDHIST‐D TAB 6‐45MG PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

BIDIL TAB NITRATES AND NITRITES BRAND Covered TIER 2 

BIFERARX TAB IRON PREPARATIONS BRAND Covered TIER 3 

BILTRICIDE TAB 600MG ANTHELMINTICS BRAND Covered TIER 2 

BINOSTO TAB 70MG BONE RESORPTION INHIBITORS BRAND Covered TIER 3 

BIO GLO TES 1MG OP OCULAR DISORDERS GENERIC Covered TIER 1 

BIOCEL TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

BIOGESIC TAB 30‐500MG ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1 

BIONECT CRE 0.2% 





50

BIONECT GEL 0.2% 



BIONECT SPR 0.2% 



BIOPEPTIDE CRE BASE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

BIOREGESIC TAB 50‐650MG ETHANOLAMINE DERIVATIVES BRAND Covered TIER 3 

BIO‐STATIN CAP 1000000 POLYENES BRAND Covered TIER 3 

BIO‐STATIN CAP 500000 POLYENES BRAND Covered TIER 3 

BIOTHRAX INJ VACCINES BRAND Covered TIER 3 

BIOTUSS LIQ ANTITUSSIVES GENERIC Covered TIER 1 

BIOTUSS LIQ PEDIATRC ANTITUSSIVES GENERIC Covered TIER 1 

BISOPRL/HCTZ TAB 10/6.25 



BISOPRL/HCTZ TAB 2.5/6.25 



BISOPRL/HCTZ TAB 5‐6.25MG 



BISOPROL FUM TAB 10MG 



BISOPROL FUM TAB 5MG 



BITTER STOP LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

BLACK WALNUT LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

BLACKBERRY LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

BLADE HANDLE MIS 3L DEVICES GENERIC Excluded TIER 99 

BLADE HANDLE MIS 3LA DEVICES GENERIC Excluded TIER 99 

BLADE HANDLE MIS 3S DEVICES BRAND Excluded TIER 99 

BLADE HANDLE MIS 4 DEVICES GENERIC Excluded TIER 99 

BLADE HANDLE MIS 4L DEVICES GENERIC Excluded TIER 99 

BLADE HANDLE MIS 4S DEVICES BRAND Excluded TIER 99 



51






BLEOMYCIN INJ 15UNIT ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

BLEOMYCIN INJ 30UNIT ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

BLEPH‐10 SOL 10% OP ANTIBACTERIALS (EENT) Brand‐O PA TIER 3 

BLEPHAMIDE OIN S.O.P. CORTICOSTEROIDS (EENT) BRAND Covered TIER 2 

BLEPHAMIDE SUS OP CORTICOSTEROIDS (EENT) BRAND Covered TIER 3 

BLUEBERRY LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

BLUESTAR MIS DEVICES BRAND Covered TIER 3 

BLUNT FILTER MIS CANNULA DEVICES BRAND Excluded TIER 99 

BLUNT NEEDLE MIS 15GX1.5" DEVICES BRAND Excluded TIER 99 



BLUNT NEEDLE MIS 18GX1" DEVICES BRAND Excluded TIER 99 






BLUNTITE MIS CLIP DEVICES BRAND Excluded TIER 99 

B‐NEXA TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

BOLUS FEEDIN MIS SET DEVICES BRAND Excluded TIER 99 

BONE MARROW KIT 16G LOCAL ANESTHETICS (PARENTERAL) BRAND Covered TIER 3 

BONE MARROW KIT 16GX2" LOCAL ANESTHETICS (PARENTERAL) BRAND Covered TIER 3 



52

BONE MARROW KIT BIOPSY LOCAL ANESTHETICS (PARENTERAL) BRAND Covered TIER 3 

BONIVA TAB 150MG BONE RESORPTION INHIBITORS Brand‐O PA TIER 3 

BONTRIL PDM TAB 35MG 



BONTRIL SR CAP 105MG 



BOOSTRIX INJ TOXOIDS BRAND Excluded TIER 99 

BORIC ACID GRA 



GENERIC Covered TIER 1 

BOSULIF TAB 100MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 

BOSULIF TAB 500MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 

BOTOX INJ 100UNIT 


THERAPEUTIC AGENTS BRAND PA TIER 3 SP 

BOTOX INJ 200UNIT 



BOTOX COSMET INJ 100UNIT 



BOTOX COSMET INJ 50UNIT 



BOTTLE SINGL MIS 2000ML DEVICES BRAND Excluded TIER 99 

BP 10‐1 EMU KERATOLYTIC AGENTS GENERIC Covered TIER 1 

BP CLEANSER LIQ 4.25% 



BP CLEANSING EMU 10‐4% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

BP FOLINATAL TAB PLUS B MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

BP MULTINATL CHW PLUS MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

BP MULTINATL TAB PLUS MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

BP POLY‐650 TAB ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1 



53

BP VIT 3 CAP VITAMIN B COMPLEX GENERIC Covered TIER 1 

BP WASH LIQ 2.5% 



BP WASH LIQ 5.25% 



BP WASH LIQ 7% 



B‐PLEX TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

B‐PLEX PLUS TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

BPM TAB 6MG PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

BPM PSEUDO TAB 6‐45MG PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

BPO GEL 4% 



BPO GEL 8% 



BPO CLOTHS MIS 3% 









BPO CREAMY KIT 8% WASH 



BRAVELLE INJ 75UNIT GONADOTROPINS BRAND PA TIER 2 SP 

BREATHERITE MIS DEVICES BRAND Excluded TIER 99 

BREATHERITE MIS LG MASK DEVICES BRAND Excluded TIER 99 

BREATHERITE MIS MDI CHMB DEVICES BRAND Excluded TIER 99 

BREATHERITE MIS MED MASK DEVICES BRAND Excluded TIER 99 

BREATHERITE MIS SM MASK DEVICES BRAND Excluded TIER 99 

BREATHERITE MIS SPACER DEVICES BRAND Excluded TIER 99 



54

BREATHERITE MIS W/MASK DEVICES BRAND Excluded TIER 99 

BREVIBLOC INJ 10MG/ML 



BREVIBLOC SOL 



BREVIBLOC SOL 10MG/ML 



BREVICON TAB 0.5/35 CONTRACEPTIVES Brand‐O PA TIER 3 

BREVITAL SOD INJ 2.5GM 

BARBITURATES (GENERAL 

ANESTHETICS) BRAND Covered TIER 3 

BREVITAL SOD INJ 500MG 



BRIELLYN TAB CONTRACEPTIVES GENERIC Covered TIER 1 

BRILINTA TAB 90MG PLATELET‐AGGREGATION INHIBITORS BRAND Covered TIER 2 


BRIMONIDINE SOL 0.15% 


BRIMONIDINE SOL 0.2% OP 



BROMATAN SUS PLUS ANTITUSSIVES GENERIC Covered TIER 1 

BROMAX TAB 11MG PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

BROMDAY SOL 0.09% 



BROMFED DM SYP ANTITUSSIVES GENERIC Covered TIER 1 

BROMFENAC SOL 0.09% 



BROMHIST‐DM SYP PED ANTITUSSIVES GENERIC Excluded TIER 99 

BROMHIST‐PDX SYP ANTITUSSIVES GENERIC Excluded TIER 99 

BROMOCRIPTIN CAP 5MG 

ERGOT‐DERIV. DOPAMINE RECEPTOR 




55

BROMOCRIPTIN TAB 2.5MG 



BROMPHENIRAM CHW 12MG PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

BROMSPIRO LIQ 2MG/5ML PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

BRONCOMAR‐1 ELX 


RELAXANTS BRAND Covered TIER 3 

BRONCOPECTOL SYP ANTITUSSIVES BRAND Excluded TIER 99 

BRONDIL LIQ 



BROVANA NEB 15MCG 


AGONISTS BRAND Covered TIER 3 

BSS SOL OP EENT DRUGS, MISCELLANEOUS GENERIC Covered TIER 1 

BSS PLUS SOL OP EENT DRUGS, MISCELLANEOUS Brand‐O PA TIER 3 

BUBBLE GUM LIQ CONCENTR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

BUBBLE GUM LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

BUCALSEP SOL 



BUCALSEP SPR 



BUDEPRION TAB 100MG SR ANTIDEPRESSANTS, MISCELLANEOUS GENERIC Covered TIER 1 QL 

BUDEPRION TAB 150MG SR ANTIDEPRESSANTS, MISCELLANEOUS GENERIC Covered TIER 1 QL 

BUDEPRION XL TAB 150MG ANTIDEPRESSANTS, MISCELLANEOUS GENERIC Covered TIER 1 QL 

BUDEPRION XL TAB 300MG ANTIDEPRESSANTS, MISCELLANEOUS GENERIC Covered TIER 1 QL 

BUDESONIDE CAP 3MG/24HR ADRENALS GENERIC Covered TIER 1 

BUDESONIDE SUS 0.25MG/2 ADRENALS GENERIC Covered TIER 1 QL 

BUDESONIDE SUS 0.5MG/2 ADRENALS GENERIC Covered TIER 1 QL 



56

BUMETANIDE INJ 0.25/ML LOOP DIURETICS GENERIC Covered TIER 1 

BUMETANIDE TAB 0.5MG LOOP DIURETICS GENERIC Covered TIER 1 

BUMETANIDE TAB 1MG LOOP DIURETICS GENERIC Covered TIER 1 

BUMETANIDE TAB 2MG LOOP DIURETICS GENERIC Covered TIER 1 

BUMINATE INJ 25% BLOOD DERIVATIVES GENERIC Covered TIER 1 

BUMINATE INJ 5% BLOOD DERIVATIVES GENERIC Covered TIER 1 

BUPAP TAB 50‐650MG 



BUPHENYL POW AMMONIA DETOXICANTS BRAND Covered TIER 2 

BUPHENYL TAB 500MG AMMONIA DETOXICANTS BRAND Covered TIER 2 

BUPIVACAINE INJ 0.25% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 



BUPIVACAINE INJ SPINAL LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

BUPIVACAINE/ INJ EPI 0.25 LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

BUPIVACAINE/ INJ EPI 0.5% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

BUPRENEX INJ 0.3MG/ML OPIATE PARTIAL AGONISTS Brand‐O PA TIER 3 

BUPRENORPHIN INJ 0.3MG/ML OPIATE PARTIAL AGONISTS GENERIC PA TIER 1 

BUPRENORPHIN SUB 2MG OPIATE PARTIAL AGONISTS GENERIC PA TIER 1 QL 

BUPRENORPHIN SUB 8MG OPIATE PARTIAL AGONISTS GENERIC PA TIER 1 QL 

BUPROBAN TAB 150MG ANTIDEPRESSANTS, MISCELLANEOUS GENERIC Covered TIER 1 

BUPROPION TAB 100MG ANTIDEPRESSANTS, MISCELLANEOUS GENERIC Covered TIER 1 QL 



57

BUPROPION TAB 100MG ER ANTIDEPRESSANTS, MISCELLANEOUS GENERIC Covered TIER 1 QL 

BUPROPION TAB 100MG SR ANTIDEPRESSANTS, MISCELLANEOUS GENERIC Covered TIER 1 QL 

BUPROPION TAB 150MG ANTIDEPRESSANTS, MISCELLANEOUS GENERIC Covered TIER 1 





BUPROPION TAB 75MG ANTIDEPRESSANTS, MISCELLANEOUS GENERIC Covered TIER 1 QL 

BUPROPN HCL TAB 150MG XL ANTIDEPRESSANTS, MISCELLANEOUS GENERIC Covered TIER 1 QL 

BUPROPN HCL TAB 300MG XL ANTIDEPRESSANTS, MISCELLANEOUS GENERIC Covered TIER 1 QL 

BURETTE SET MIS 100ML DEVICES BRAND Excluded TIER 99 

BUSPIRONE TAB 10MG 


HYPNOTICS,MISC. GENERIC Covered TIER 1 












58

BUSPIRONE TAB 7.5MG 



BUSULFEX INJ 6MG/ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

BUT/APAP/CAF CAP 



BUT/APAP/CAF CAP CODEINE OPIATE AGONISTS GENERIC Covered TIER 1 

BUT/APAP/CAF TAB 



BUT/ASA/CAF/ CAP COD 30MG OPIATE AGONISTS GENERIC Covered TIER 1 

BUT/ASA/CAFF CAP SALICYLATES GENERIC Covered TIER 1 

BUT/ASA/CAFF TAB SALICYLATES GENERIC Covered TIER 1 

BUTAL/APAP TAB 50‐325MG 



BUTALBITAL TAB CPD SALICYLATES GENERIC Covered TIER 1 

BUTISOL SOD ELX 30MG/5ML 



BUTISOL SOD TAB 30MG 



BUTISOL SOD TAB 50MG 



BUTORPHANOL INJ 1MG/ML OPIATE PARTIAL AGONISTS GENERIC Covered TIER 1 

BUTORPHANOL INJ 2MG/ML OPIATE PARTIAL AGONISTS GENERIC Covered TIER 1 

BUTORPHANOL SOL 10MG/ML OPIATE PARTIAL AGONISTS GENERIC Covered TIER 1 QL 

BUTRANS DIS 10MCG/HR OPIATE PARTIAL AGONISTS BRAND PA TIER 2 



BUTTER LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

BUTTER RUM LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

BUTTERSCOTCH LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

BXN MOUTHWSH SUS POLYENES BRAND Covered TIER 3 



59

BYDUREON INJ INCRETIN MIMETICS BRAND PA TIER 2 

BYETTA INJ 10MCG INCRETIN MIMETICS BRAND PA TIER 2 

BYETTA INJ 5MCG INCRETIN MIMETICS BRAND PA TIER 2 

BYSTOLIC TAB 10MG 



BYSTOLIC TAB 2.5MG 









CA CHLORIDE GRA ANHYDR REPLACEMENT PREPARATIONS GENERIC Excluded TIER 99 

CABERGOLINE TAB 0.5MG 



CACTUS LIQ COMPOSIT 



CA‐DTPA SOL 1000MG HEAVY METAL ANTAGONISTS GENERIC Covered TIER 1 

CADUET TAB 10‐10MG DIHYDROPYRIDINES BRAND Covered TIER 3 




CADUET TAB 2.5‐10MG DIHYDROPYRIDINES BRAND Covered TIER 3 







CAFCIT INJ 60MG/3ML 





60

CAFCIT SOL 60MG/3ML 

CAFERGOT TAB 1‐100MG 

CAFFEINE CIT INJ 20MG/ML 

CAFFEINE CIT INJ 60MG/3ML 

CAFFEINE CIT SOL 20MG/ML 

CAFFEINE CIT SOL 60MG/3ML 

CAFFEINE/SOD INJ BENZOATE 

CAFGESIC CAP 

CAFGESIC TAB 

CALAFOL RX TAB 

CALAN TAB 120MG 

CALAN TAB 80MG 

CALAN SR TAB 120MG 





ANTIMIGRAINE AGENTS, 



STIMULANTS,MISC GENERIC Covered TIER 1 















CALCIUM‐CHANNEL BLOCKING 

AGENTS, MISC. Brand‐O PA TIER 3 











61

CALC ACETATE CAP 667MG REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

CALC ACETATE TAB 667MG REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

CALC CHLORID GRA DIHYDRAT REPLACEMENT PREPARATIONS GENERIC Excluded TIER 99 

CALC FOLINAT INJ 100/10ML ANTIDOTES GENERIC Covered TIER 1 SP 

CALC FOLINAT INJ 300/30ML ANTIDOTES GENERIC Covered TIER 1 SP 

CALCIFOL WAF REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

CALCIFOLIC‐D WAF REPLACEMENT PREPARATIONS Brand‐O PA TIER 3 

CALCIJEX INJ 1MCG/ML VITAMIN D Brand‐O PA TIER 3 

CALCIPOTRIEN CRE 0.005% 



CALCIPOTRIEN OIN 0.005% 



CALCIPOTRIEN SOL 0.005% 



CALCITONIN SPR 200/ACT PARATHYROID GENERIC Covered TIER 1 

CALCITRENE OIN 0.005% 



CALCITRIOL CAP 0.25MCG VITAMIN D GENERIC Covered TIER 1 

CALCITRIOL CAP 0.5MCG VITAMIN D GENERIC Covered TIER 1 

CALCITRIOL INJ 1MCG/ML VITAMIN D GENERIC Covered TIER 1 

CALCITRIOL OIN 3MCG/GM 



CALCITRIOL SOL 1MCG/ML VITAMIN D GENERIC Covered TIER 1 

CALCIUM CL INJ 10% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

CALCIUM DISO INJ 500/2.5M HEAVY METAL ANTAGONISTS GENERIC Covered TIER 1 

CALCIUM GLUC INJ 10% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

CALCIUM‐FA WAF PLUS D REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

CALDOLOR INJ 400/4ML 





62

CALDOLOR INJ 800/8ML 



CAMBIA POW 50MG 



CAMILA TAB 0.35MG CONTRACEPTIVES GENERIC Covered TIER 1 

CAMPATH INJ 30MG/ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

CAMPHOR GUM GUM BLOCKS 


ANESTHETICS GENERIC Excluded TIER 99 

CAMPRAL TAB 333MG 

CENTRAL NERVOUS SYSTEM AGENTS, 


CAMPTOSAR INJ 100/5ML ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

CAMPTOSAR INJ 300/15ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

CAMPTOSAR INJ 40MG/2ML ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

CAMRESE TAB CONTRACEPTIVES GENERIC Covered TIER 1 

CAMRESE LO TAB CONTRACEPTIVES GENERIC Covered TIER 1 

CANASA SUP 1000MG 



CANCIDAS INJ 50MG ECHINOCANDINS BRAND Covered TIER 3 

CANCIDAS INJ 70MG ECHINOCANDINS BRAND Covered TIER 3 

CANDIN INJ DRUG HYPERSENSITIVITY BRAND Covered TIER 3 

CANTIL TAB 25MG 



CAP POSILOK CAP #0 PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 




CAPACET CAP 



CAPASTAT SUL INJ 1GM ANTITUBERCULOSIS AGENTS BRAND Covered TIER 3 



63

CAPEX SHA 0.01% 



CAPHOSOL SOL EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 3 

CAPITAL/COD SUS 120‐12/5 OPIATE AGONISTS BRAND Covered TIER 3 

CAPRELSA TAB 100MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

CAPRELSA TAB 300MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

CAPSULE #1 CAP DRCAPS PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

CAPSULE CONI CAP ‐SN #000 PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

CAPSULE CONI CAP ‐SNAP #1 PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 




CAPSULE LOCK CAP #0 CLEAR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 



CAPTOPR/HCTZ TAB 25‐15MG 












CAPTOPRIL TAB 100MG 



CAPTOPRIL TAB 12.5MG 








64




CARAC CRE 0.5% 



CARAFATE SUS 1GM/10ML PROTECTANTS BRAND Covered TIER 2 

CARAFATE TAB 1GM PROTECTANTS Brand‐O PA TIER 3 

CARB/LEVO TAB 10‐100MG DOPAMINE PRECURSORS GENERIC Covered TIER 1 



CARB/LEVO 50 TAB /ENTACAP DOPAMINE PRECURSORS GENERIC Covered TIER 1 

CARB/LEVO 75 TAB /ENTACAP DOPAMINE PRECURSORS GENERIC Covered TIER 1 

CARB/LEVO ER TAB 25‐100MG DOPAMINE PRECURSORS GENERIC Covered TIER 1 

CARB/LEVO ER TAB 50‐200MG DOPAMINE PRECURSORS GENERIC Covered TIER 1 

CARB/LEVO SR TAB 25‐100MG DOPAMINE PRECURSORS GENERIC Covered TIER 1 

CARB/LEVO SR TAB 50‐200MG DOPAMINE PRECURSORS GENERIC Covered TIER 1 

CARB/LEVO100 TAB /ENTACAP DOPAMINE PRECURSORS GENERIC Covered TIER 1 




CARBAGLU TAB 200MG AMMONIA DETOXICANTS BRAND Covered TIER 2 

CARBAMAZEPIN CAP 100MG ER 









CARBAMAZEPIN CHW 100MG 



CARBAMAZEPIN SUS 100/5ML 





65

CARBAMAZEPIN TAB 200MG 



CARBAMAZEPIN TAB 200MG ER 



CARBAMAZEPIN TAB 400MG ER 



CARBAPHEN 12 LIQ ANTITUSSIVES BRAND Excluded TIER 99 

CARBAPHEN 12 SUS PED ANTITUSSIVES BRAND Excluded TIER 99 

CARBATROL CAP 100MG 









CARBATUSS SYP ANTITUSSIVES BRAND Excluded TIER 99 

CARBATUSS‐12 SUS ANTITUSSIVES BRAND Excluded TIER 99 

CARBATUSS‐CL LIQ ANTITUSSIVES BRAND Excluded TIER 99 

CARBA‐XP LIQ ANTITUSSIVES BRAND Excluded TIER 99 

CARBINOXAMIN LIQ 4MG/5ML ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1 

CARBINOXAMIN TAB 4MG ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1 

CARBOCAINE INJ 1% LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 

CARBOCAINE INJ 1% PF LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 

CARBOCAINE INJ 1.5% PF LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 

CARBOCAINE INJ 2% LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 

CARBOCAINE INJ 2% PF LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 



66

CARBOGEL GEL 940 PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

CARBOHOL GEL 940 PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

CARBOMER GEL AQUEOUS PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

CARBOMER GEL HYDROALC PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

CARBOPLATIN INJ 150/15ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

CARBOPLATIN INJ 150MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 


CARBOPLATIN INJ 50MG/5ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 


CARDENE I.V. INJ 2.5MG/ML DIHYDROPYRIDINES Brand‐O PA TIER 3 

CARDENE IV INJ 40/200ML DIHYDROPYRIDINES BRAND Covered TIER 3 

CARDENE IV SOL 20/200ML DIHYDROPYRIDINES BRAND Covered TIER 3 

CARDENE SR CAP 30MG DIHYDROPYRIDINES BRAND Covered TIER 3 



CARDIOPLEGIC SOL REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

CARDIOTEK‐RX TAB VITAMIN B COMPLEX BRAND Covered TIER 3 

CARDIOVID CAP PLUS 



CARDIZEM TAB 120MG 












CARDIZEM CD CAP 120MG/24 





67





CARDIZEM LA TAB 120MG 



CARDIZEM LA TAB 300MG/24 


CARDIZEM LA TAB 420MG/24 

CARDURA TAB 1MG 




CARDURA XL TAB 4MG 





















ALPHA‐ADRENERGIC BLOCKING 









AGENTS BRAND Covered TIER 3 QL 



68

CARDURA XL TAB 8MG 


AGENTS BRAND Covered TIER 3 QL 

CARIMUNE NF INJ 12GM SERUMS GENERIC PA TIER 1 SP 




CARISOPR/ASA TAB 200‐325 

MUSCLE RELAXNT GENERIC Covered TIER 1 QL 

CARISOPRODOL TAB 250MG 



CARISOPRODOL TAB 350MG 



CARISOPRODOL TAB ASA/COD 


MUSCLE RELAXNT GENERIC Covered TIER 1 

CARMOL‐HC CRE 1% 



CARNITOR INJ 1GM/5ML 


THERAPEUTIC AGENTS Brand‐O PA TIER 3 

CARNITOR SOL 1GM/10ML 



CARNITOR TAB 330MG 



CARNITOR SF SOL 1GM/10ML 



CAROMEGA TAB MULTIVITAMIN PREPARATIONS Brand‐O PA TIER 3 

CARTEOLOL SOL 1% OP 



CARTIA XT CAP 120/24HR 








69







CARTICEL IMP 



CARTRIDGE MIS 3.15ML DEVICES BRAND Covered TIER 3 

CARTRIDGE MIS 3ML DEVICES GENERIC Covered TIER 1 

CARTRIDGE MIS IR 1000 DEVICES GENERIC Covered TIER 1 

CARTRIDGE MIS IR 1200 DEVICES GENERIC Covered TIER 1 

CARTRIDGE MIS PUMP DEVICES GENERIC Covered TIER 1 

CARVEDILOL TAB 12.5MG 



CARVEDILOL TAB 25MG 









CASCARA EXT SAGRADA CATHARTICS AND LAXATIVES GENERIC Covered TIER 1 

CASCARA SAGR EXT CATHARTICS AND LAXATIVES GENERIC Covered TIER 1 

CASCARA SAGR EXT AROMATIC CATHARTICS AND LAXATIVES GENERIC Covered TIER 1 

CASODEX TAB 50MG ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 

CAT HAIR INJ EXTRACT 



CATAFLAM TAB 50MG 



CATAPRES TAB 0.1MG CENTRAL ALPHA‐AGONISTS Brand‐O PA TIER 3 





70

CATAPRES‐TTS DIS 0.1/24HR CENTRAL ALPHA‐AGONISTS Brand‐O PA TIER 3 



CATH TRAY KIT DEVICES BRAND Excluded TIER 99 

CATH TRAY KIT 14FR DEVICES BRAND Excluded TIER 99 

CATH TRAY KIT 14FR‐5ML DEVICES BRAND Excluded TIER 99 



CATH TRAY KIT UNIVERSL DEVICES BRAND Excluded TIER 99 

CATHETER KIT INSERT DEVICES BRAND Excluded TIER 99 

CATHETER MIS 14FR‐5ML DEVICES BRAND Excluded TIER 99 

CATHETER MIS 16FR‐5ML DEVICES BRAND Excluded TIER 99 

CATHETER MIS 30FR‐30 DEVICES BRAND Excluded TIER 99 

CATHFLO ACTI INJ VASE THROMBOLYTIC AGENTS BRAND Covered TIER 3 

CAVAN TAB PRENATAL MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

CAVAN ONE CAP OMEGA MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

CAVAN‐ALPHA KIT MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

CAVAN‐EC SOD MIS DHA MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

CAVAN‐FOLATE MIS DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

CAVAN‐FOLATE TAB OB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

CAVAREST GEL 1.1% CARIOSTATIC AGENTS GENERIC Covered TIER 1 

CAVERJECT INJ 20MCG 



CAVERJECT INJ 40MCG 



CAVERJECT KIT 10MCG 



CAVERJECT KIT 20MCG 



CAVIAR FLAVO LIQ NATURAL PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 



71

CAVIRINSE SOL 0.2% CARIOSTATIC AGENTS GENERIC Covered TIER 1 

CAYSTON INH 75MG MONOBACTAMS BRAND Covered TIER 2 

CAZIANT PAK CONTRACEPTIVES GENERIC Covered TIER 1 

CDP/AMITRIP TAB 10‐25MG 



CDP/AMITRIP TAB 5‐12.5MG 



CEDAX CAP 400MG 

THIRD GENERATION 

CEPHALOSPORINS BRAND Covered TIER 3 

CEDAX SUS 180/5ML 



CEDAX SUS 90MG/5ML 



CEENU CAP 100MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 



CEFACLOR CAP 250MG 

SECOND GENERATION 

CEPHALOSPORINS GENERIC Covered TIER 1 

CEFACLOR CAP 500MG 



CEFACLOR ER TAB 500MG 



CEFADROXIL CAP 500MG 

FIRST GENERATION 


CEFADROXIL SUS 250/5ML 



CEFADROXIL SUS 500/5ML 



CEFADROXIL TAB 1GM 





72

CEFAZOL/DEX SOL 1GM 

CEFAZOL/DEX SOL 2GM 

CEFAZOLIN INJ 100GM 



CEFAZOLIN INJ 1GM/50ML 



CEFAZOLIN INJ 500MG 

CEFDINIR CAP 300MG 

CEFDINIR SUS 125/5ML 

CEFDINIR SUS 250/5ML 

CEFDITOREN TAB 200MG 

CEFDITOREN TAB 400MG 

CEFEPIME INJ 1GM 





























FOURTH GENERATION 




73

CEFEPIME INJ 2GM 

FOURTH GENERATION 


CEFOTAXIME INJ 10GM 












CEFOTAXIME INJ 500MG 



CEFOTET/DEX INJ 1‐3.58% CEPHAMYCINS GENERIC Covered TIER 1 

CEFOTET/DEX INJ 2‐2.08% CEPHAMYCINS GENERIC Covered TIER 1 

CEFOTETAN INJ 10G CEPHAMYCINS GENERIC Covered TIER 1 

CEFOTETAN INJ 1GM/10ML CEPHAMYCINS GENERIC Covered TIER 1 

CEFOTETAN INJ 2GM/20ML CEPHAMYCINS GENERIC Covered TIER 1 

CEFOXITIN INJ 10GM CEPHAMYCINS GENERIC Covered TIER 1 



CEFPODO PROX SUS 100/5ML 



CEFPODO PROX SUS 50MG/5ML 



CEFPODOXIME TAB 100MG 



CEFPODOXIME TAB 200MG 



CEFPROZIL SUS 125/5ML 





74

CEFPROZIL SUS 250/5ML 

CEFPROZIL TAB 250MG 

CEFPROZIL TAB 500MG 

CEFTAZIDIME INJ 100GM 



CEFTAZIDIME INJ 500MG 


CEFTAZIDIME/ SOL D5W 1GM 

CEFTAZIDIME/ SOL D5W 2GM 

CEFTIN SUS 125/5ML 

CEFTIN SUS 250/5ML 

CEFTIN TAB 250MG 

CEFTIN TAB 500MG 

CEFTRIAX/DEX INJ 1GM 






















CEPHALOSPORINS Brand‐O PA TIER 2 











75

CEFTRIAX/DEX INJ 2GM 

CEFTRIAXONE INJ 10GM 


CEFTRIAXONE INJ 250MG 


CEFTRIAXONE INJ 500MG 

CEFTRIAXONE/ INJ DEX 1GM 

CEFTRIAXONE/ INJ DEX 2GM 

CEFUROX/DEXT INJ 1.5GM 

CEFUROX/DEXT INJ 750MG 

CEFUROXIME INJ 1.5GM 

CEFUROXIME INJ 225GM 

CEFUROXIME INJ 7.5GM 

CEFUROXIME INJ 750MG 

CEFUROXIME INJ 75GM 

































76

CEFUROXIME SUS 125/5ML 



CEFUROXIME TAB 250MG 



CEFUROXIME TAB 500MG 



CELEBREX CAP 100MG 

CYCLOOXYGENASE‐2 (COX‐2) 

INHIBITORS BRAND Covered TIER 2 QL 










CELESTONE INJ SOLUSPAN ADRENALS Brand‐O PA TIER 3 

CELESTONE SOL 0.6MG/5 ADRENALS BRAND Covered TIER 3 

CELEXA TAB 10MG 

SELECTIVE‐SEROTONIN REUPTAKE 

INHIBITORS Brand‐O PA TIER 3 QL 







CELLCEPT CAP 250MG IMMUNOSUPPRESSIVE AGENTS Brand‐O PA TIER 3 

CELLCEPT SUS 200MG/ML IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 2 

CELLCEPT TAB 500MG IMMUNOSUPPRESSIVE AGENTS Brand‐O PA TIER 3 

CELLCEPT IV INJ 500MG IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 3 

CELLUGEL SOL 2% EENT DRUGS, MISCELLANEOUS Brand‐O PA TIER 99 

CELONTIN CAP 300MG SUCCINIMIDES BRAND Covered TIER 2 

CEM‐UREA SOL 45% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

CENESTIN TAB 0.3MG ESTROGENS BRAND Covered TIER 2 



77





CENFOL TAB VITAMIN B COMPLEX BRAND Covered TIER 3 

CENHIST CHW 6‐15MG PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

CENOLATE INJ 500MG/ML VITAMIN C GENERIC Covered TIER 1 

CENTANY OIN 2% 


MEMBRANE) GENERIC Covered TIER 1 

CENTANY AT KIT 2% 



CENTERGY DRO 1‐2MG/ML PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

CENTERGY DM DRO ANTITUSSIVES GENERIC Covered TIER 1 

CENTRATEX CAP IRON PREPARATIONS BRAND Covered TIER 3 

CEPHADYN TAB 50‐650MG 



CEPHALEXIN CAP 250MG 



CEPHALEXIN CAP 500MG 



CEPHALEXIN SUS 125/5ML 



CEPHALEXIN SUS 250/5ML 



CEPHALEXIN TAB 250MG 



CEPHALEXIN TAB 500MG 



CEPROTIN INJ 1000UNIT ANTICOAGULANTS, MISCELLANEOUS BRAND Covered TIER 3 



78

CEPROTIN INJ 500 UNIT ANTICOAGULANTS, MISCELLANEOUS BRAND Covered TIER 3 


CERECOMP INJ 


CEREDASE INJ 80UNT/ML ENZYMES BRAND Covered TIER 3 SP 

CEREFOLIN TAB VITAMIN B COMPLEX BRAND Excluded TIER 99 

CEREFOLIN TAB NAC VITAMIN B COMPLEX BRAND Excluded TIER 99 

CERETEC INJ DIAGNOSTIC AGENTS BRAND Excluded TIER 99 

CEREZYME INJ 200UNIT ENZYMES BRAND Covered TIER 2 SP 

CEREZYME INJ 400UNIT ENZYMES BRAND Covered TIER 2 SP 

CERISA WASH EMU 10‐1% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

CERON‐DM SYP ANTITUSSIVES GENERIC Covered TIER 1 

CEROVEL GEL 40% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

CEROVEL LOT 40% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

CERUBIDINE INJ 20MG ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

CERVARIX INJ VACCINES BRAND PA TIER 3 

CERVIDIL VAG MIS 10MG INS OXYTOCICS BRAND Covered TIER 3 

CESAMET CAP 1MG ANTIEMETICS, MISCELLANEOUS BRAND Covered TIER 3 

CESIA PAK CONTRACEPTIVES GENERIC Covered TIER 1 

CESINEX SUS CALORIC AGENTS BRAND Excluded TIER 99 

CETIRIZINE SYP 5MG/5ML 


ANTIHISTAMINES GENERIC Covered TIER 1 

CETRAXAL SOL 0.2% ANTIBACTERIALS (EENT) BRAND Covered TIER 3 

CETROTIDE KIT 0.25MG 

GONADOTROPIN‐RELEASING 

HORMONE ANTAGNTS BRAND Covered TIER 2 SP 

CETROTIDE KIT 3MG 


HORMONE ANTAGNTS BRAND Covered TIER 2 SP 

CETYL ALCOHO MIS PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

CETYLCIDE‐G CON 





79

CEVIMELINE CAP 30MG 



CGMS MIS SOFTWARE DEVICES BRAND Covered TIER 3 

CGMS CABLE MIS DEVICES BRAND Covered TIER 3 

CGMS SYSTEM MIS GOLD DEVICES BRAND Covered TIER 3 

CGU WC LIQ ANTITUSSIVES Brand‐O PA TIER 99 

CHANTIX PAK 0.5& 1MG 

AUTONOMIC DRUGS, 


CHANTIX PAK 1MG 



CHANTIX TAB 0.5MG 



CHANTIX TAB 1MG 



CHCK FLAVOR LIQ OIL SOLU PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

CHCK FLAVOR LIQ WTR MISC PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

CHEESECAKE LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

CHELIDONIUM LIQ COMPOUND 



CHEMET CAP 100MG HEAVY METAL ANTAGONISTS BRAND Covered TIER 2 

CHEMOSAFETY KIT SPILL DEVICES BRAND Excluded TIER 99 

CHEMSIL K‐12 PST PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

CHEMSIL K‐51 GEL PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

CHENODAL TAB 250MG CHOLELITHOLYTIC AGENTS BRAND Covered TIER 3 

CHERRY LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

CHERRY SYP PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

CHIRHOSTIM SOL 16MCG PANCREATIC FUNCTION BRAND Covered TIER 3 

CHLORAL CRY HYDRATE 


HYPNOTICS,MISC. GENERIC Excluded TIER 99 



80

CHLORAL HYDR SYP 500/5ML 



CHLORAMPHEN INJ 1GM CHLORAMPHENICOL GENERIC Covered TIER 1 

CHLORD/CLIDI CAP 5‐2.5MG 



CHLORDEX GP SYP ANTITUSSIVES GENERIC Excluded TIER 99 

CHLORDIAZEP CAP 10MG 









CHLORHEX DIG SOL 20% 



CHLORHEX GLU SOL 0.12% 



CHLORHEX GLU SOL 20% 



CHLORHEXIDIN CON FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

CHLOR‐MES D SYP LIQUID PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

CHLOR‐MES JR CAP 4‐20MG PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

CHLOROMAG INJ 20% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

CHLOROPROC INJ 2% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

CHLOROPROC INJ 3% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

CHLOROQUINE TAB 250MG ANTIMALARIALS GENERIC Covered TIER 1 QL 

CHLOROQUINE TAB 500MG ANTIMALARIALS GENERIC Covered TIER 1 QL 

CHLOROTHIAZ INJ 500MG THIAZIDE DIURETICS GENERIC Covered TIER 1 

CHLOROTHIAZ TAB 250MG THIAZIDE DIURETICS GENERIC Covered TIER 1 



81

CHLOROTHIAZ TAB 500MG THIAZIDE DIURETICS GENERIC Covered TIER 1 

CHLORPROMAZ INJ 25MG/ML PHENOTHIAZINES GENERIC Covered TIER 1 

CHLORPROMAZ TAB 100MG PHENOTHIAZINES GENERIC Covered TIER 1 





CHLORPROPAM TAB 100MG SULFONYLUREAS GENERIC Covered TIER 1 

CHLORPROPAM TAB 250MG SULFONYLUREAS GENERIC Covered TIER 1 

CHLORTETRACY CRY HCL TETRACYCLINES GENERIC Excluded TIER 99 

CHLORTHALID TAB 100MG THIAZIDE‐LIKE DIURETICS GENERIC Excluded TIER 99 

CHLORTHALID TAB 25MG THIAZIDE‐LIKE DIURETICS GENERIC Covered TIER 1 

CHLORTHALID TAB 50MG THIAZIDE‐LIKE DIURETICS GENERIC Covered TIER 1 

CHLORZOXAZON TAB 500MG 



CHO MAG TRIS LIQ 500/5ML SALICYLATES GENERIC Covered TIER 1 

CHO MAG TRIS TAB 1000MG SALICYLATES GENERIC Covered TIER 1 



CHOC HAZELNT LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

CHOCOLATE LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

CHOLESTYRAM POW 4GM BILE ACID SEQUESTRANTS GENERIC Covered TIER 1 

CHOLESTYRAM POW 4GM LITE BILE ACID SEQUESTRANTS GENERIC Covered TIER 1 

CHOLETEC INJ DIAGNOSTIC AGENTS BRAND Excluded TIER 99 

CHOLINE BIT CRY FCC LIPOTROPIC AGENTS GENERIC Excluded TIER 99 

CHOLOGRAFIN INJ 52% ROENTGENOGRAPHY BRAND Covered TIER 3 

CHOR GONADOT INJ 10000UNT GONADOTROPINS GENERIC PA TIER 1 SP 

CHROMIUM CL INJ 4MCG/ML REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

CHRYSADERM CRE DAY PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

CHRYSADERM CRE NIGHT PHARMACEUTICAL AIDS BRAND Excluded TIER 99 



82

CIALIS TAB 10MG 

CIALIS TAB 2.5MG 


CICLODAN CRE 0.77% 

CICLODAN SOL 8% 

CICLODAN CRE KIT 0.77% 

CICLODAN SOL KIT 8% 

CICLOPIROX CRE 0.77% 

CICLOPIROX GEL 0.77% 

CICLOPIROX KIT 8% 

CICLOPIROX SHA 1% 

CICLOPIROX SOL 8% 

CICLOPIROX SUS 0.77% 


INHIBITORS BRAND Excluded TIER 99 





HYDROXYPYRIDONES(SKIN & 

MUCOUS MEMBRANE) GENERIC Covered TIER 1 




MUCOUS MEMBRANE) BRAND Covered TIER 3 


MUCOUS MEMBRANE) Brand‐O PA TIER 3 













CILOSTAZOL TAB 100MG PLATELET‐AGGREGATION INHIBITORS GENERIC Covered TIER 1 

CILOSTAZOL TAB 50MG PLATELET‐AGGREGATION INHIBITORS GENERIC Covered TIER 1 



83

CILOXAN OIN 0.3% OP ANTIBACTERIALS (EENT) BRAND Covered TIER 2 

CILOXAN SOL 0.3% OP ANTIBACTERIALS (EENT) Brand‐O PA TIER 3 

CIMETIDINE INJ 150MG/ML HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

CIMETIDINE SOL 300/5ML HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

CIMETIDINE TAB 300MG HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 



CIMZIA KIT 



CIMZIA KIT 200MG/ML 


ANTIRHEUMATIC AGENTS BRAND PA TIER 3 QL SP 

CIMZIA KIT STARTER 



CINNAMON OIL FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

CINRYZE SOL 500 UNIT COMPLEMENT INHIBITORS BRAND PA TIER 3 QL SP 

CIPRO TAB 250MG QUINOLONES Brand‐O PA TIER 3 

CIPRO TAB 500MG QUINOLONES Brand‐O PA TIER 3 

CIPRO (10%) SUS 500MG/5 QUINOLONES BRAND Covered TIER 2 

CIPRO (5%) SUS 250MG/5 QUINOLONES BRAND Covered TIER 2 

CIPRO HC SUS OTIC CORTICOSTEROIDS (EENT) BRAND Covered TIER 3 

CIPRO I.V. INJ 200MG QUINOLONES Brand‐O PA TIER 3 

CIPRO I.V. INJ 400MG QUINOLONES Brand‐O PA TIER 3 

CIPRODEX SUS 0.3‐0.1% CORTICOSTEROIDS (EENT) BRAND Covered TIER 2 

CIPROFLOXACN INJ 200MG QUINOLONES GENERIC Covered TIER 1 

CIPROFLOXACN INJ 400MG QUINOLONES GENERIC Covered TIER 1 

CIPROFLOXACN SOL 0.2% ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

CIPROFLOXACN SOL 0.3% OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

CIPROFLOXACN TAB 1000MG QUINOLONES GENERIC Covered TIER 1 





84


CIPROFLOXACN TAB 500MG ER QUINOLONES GENERIC Covered TIER 1 


CISATRACURIU INJ 10MG/ML 



CISATRACURIU INJ 2MG/ML 



CISPLATIN INJ 100MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

CISPLATIN INJ 1MG/ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 


CISPLATIN INJ 50/50ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 


CITALOPRAM SOL 10MG/5ML 




CITALOPRAM TAB 10MG 

INHIBITORS GENERIC Covered TIER 1 QL 







CITRANATAL CAP HARMONY MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

CITRANATAL MIS 90 DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

CITRANATAL MIS B‐CALM MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

CITRANATAL PAK ASSURE MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

CITRANATAL PAK DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

CITRANATAL TAB RX MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

CITRIC ACID/ SOL SOD CITR ALKALINIZING AGENTS GENERIC Covered TIER 1 

CITROLITH TAB ALKALINIZING AGENTS BRAND Covered TIER 3 

CLADRIBINE INJ 1MG/ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 



85

CLAFORAN INJ 10GM 









CLAFORAN INJ 500MG 



CLAFORAN/D5W INJ 1GM 



CLAFORAN/D5W INJ 2GM 



CLARAVIS CAP 10MG 












CLARIFOAM EF AER 10‐5% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

CLARINEX SYP 0.5MG/ML 


ANTIHISTAMINES BRAND Covered TIER 2 

CLARINEX TAB 5MG 


ANTIHISTAMINES Brand‐O PA TIER 3 

CLARINEX RDT TAB 2.5MG 



CLARINEX RDT TAB 5MG 



CLARIS WASH EMU 10‐4% KERATOLYTIC AGENTS GENERIC Covered TIER 1 



86

CLARITHROMYC SUS 125/5ML OTHER MACROLIDES GENERIC Covered TIER 1 

CLARITHROMYC SUS 250/5ML OTHER MACROLIDES GENERIC Covered TIER 1 

CLARITHROMYC TAB 250MG OTHER MACROLIDES GENERIC Covered TIER 1 

CLARITHROMYC TAB 500MG OTHER MACROLIDES GENERIC Covered TIER 1 

CLARITHROMYC TAB 500MG ER OTHER MACROLIDES GENERIC Covered TIER 1 

CLEARPLEX X GEL 10% 



CLEMASTINE SYP 0.5/5ML ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1 

CLEMASTINE TAB 2.68MG ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1 

CLENIA CRE 10‐5% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

CLENIA EMU FOAMING KERATOLYTIC AGENTS GENERIC Covered TIER 1 

CLEOCIN CAP 150MG LINCOMYCINS Brand‐O PA TIER 3 



CLEOCIN CRE 2% VAG 



CLEOCIN INJ 600MG LINCOMYCINS BRAND Covered TIER 3 

CLEOCIN INJ 900MG LINCOMYCINS BRAND Covered TIER 3 

CLEOCIN SUP 100MG 



CLEOCIN PED SOL 75MG/5ML LINCOMYCINS Brand‐O PA TIER 3 

CLEOCIN PHOS INJ 300MG LINCOMYCINS Brand‐O PA TIER 3 SP 



CLEOCIN PHOS INJ 9GM LINCOMYCINS Brand‐O PA TIER 3 SP 

CLEOCIN/D5W INJ 300MG LINCOMYCINS BRAND Covered TIER 3 

CLEOCIN‐T GEL 1% 



CLEOCIN‐T LOT 1% 





87

CLEOCIN‐T PAD 1% 



CLEOCIN‐T SOL 1% 



CLEVIPREX EMU 0.5MG/ML DIHYDROPYRIDINES BRAND Covered TIER 3 

CLIMARA DIS 0.025MG ESTROGENS Brand‐O PA TIER 2 






CLIMARA PRO DIS WEEKLY ESTROGENS BRAND Covered TIER 3 

CLINDACIN KIT PAC 1% 



CLINDACIN‐P PAD 1% 



CLINDAGEL GEL 1% 



CLINDAMAX GEL 1% 



CLINDAMAX LOT 10MG/ML 



CLINDAMY/BEN GEL 1.2‐5% 



CLINDAMY/BEN GEL 1‐5% 



CLINDAMYCIN AER 1% 



CLINDAMYCIN CAP 150MG LINCOMYCINS GENERIC Covered TIER 1 




88


CLINDAMYCIN CRE 2% VAG 



CLINDAMYCIN GEL 1% 



CLINDAMYCIN INJ 150MG/ML LINCOMYCINS GENERIC Covered TIER 1 SP 

CLINDAMYCIN INJ 300/2ML LINCOMYCINS GENERIC Covered TIER 1 SP 

CLINDAMYCIN INJ 300MG LINCOMYCINS GENERIC Covered TIER 1 SP 




CLINDAMYCIN INJ 9000/60 LINCOMYCINS GENERIC Covered TIER 1 SP 


CLINDAMYCIN LOT 1% 



CLINDAMYCIN LOT 10MG/ML 



CLINDAMYCIN PAD 1% 



CLINDAMYCIN SOL 1% 



CLINDAMYCIN SOL 75MG/5ML LINCOMYCINS GENERIC Covered TIER 1 

CLINDAREACH KIT 1% 



CLINICAL PRD MIS PUMP ADP DEVICES BRAND Excluded TIER 99 

CLINIMIX INJ 2.75/D5W CALORIC AGENTS BRAND Covered TIER 3 

CLINIMIX INJ 4.25/D10 CALORIC AGENTS BRAND Covered TIER 3 






89



CLINIMIX INJ 4.25/D5W CALORIC AGENTS BRAND Covered TIER 3 

CLINIMIX INJ 5%/D15W CALORIC AGENTS BRAND Covered TIER 3 



CLINIMIX E INJ 2.75/D10 CALORIC AGENTS BRAND Covered TIER 3 

CLINIMIX E INJ 2.75/D5W CALORIC AGENTS BRAND Covered TIER 3 




CLINIMIX E INJ 4.25/D5W CALORIC AGENTS BRAND Covered TIER 3 

CLINIMIX E INJ 5%/D15W CALORIC AGENTS BRAND Covered TIER 3 



CLINISOL SF INJ 15% CALORIC AGENTS GENERIC Covered TIER 1 

CLINORIL TAB 200MG 



CLINPRO 5000 PST 1.1% CARIOSTATIC AGENTS GENERIC Covered TIER 1 

CLOBETA KIT CREAM 



CLOBETA KIT OINTMENT 



CLOBETASOL AER 0.05% 



CLOBETASOL CRE 0.05% 



CLOBETASOL GEL 0.05% 





90

CLOBETASOL LOT 0.05% 



CLOBETASOL OIN 0.05% 



CLOBETASOL SHA 0.05% 



CLOBETASOL SOL 0.05% 



CLOBETASOL E CRE 0.05% 



CLOBEX LOT 0.05% 



CLOBEX SHA 0.05% 



CLOBEX SPR 0.05% 



CLODERM CRE 0.1% 



CLODERM CRE 0.1% PMP 



CLOLAR INJ 1MG/ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

CLOMID TAB 50MG ESTROGEN AGONIST‐ANTAGONISTS Brand‐O PA TIER 3 SP 

CLOMIPHENE TAB 50MG ESTROGEN AGONIST‐ANTAGONISTS GENERIC PA TIER 1 SP 

CLOMIPRAMINE CAP 25MG 








91




CLONAZEP ODT TAB 0.125MG 


(ANTICONVULSANTS) GENERIC Covered TIER 1 







CLONAZEP ODT TAB 1MG 



CLONAZEP ODT TAB 2MG 



CLONAZEPAM TAB 0.5MG 



CLONAZEPAM TAB 1MG 



CLONAZEPAM TAB 2MG 



CLONIDINE DIS 0.1/24HR CENTRAL ALPHA‐AGONISTS GENERIC Covered TIER 1 



CLONIDINE INJ CENTRAL ALPHA‐AGONISTS GENERIC Covered TIER 1 

CLONIDINE TAB 0.1MG CENTRAL ALPHA‐AGONISTS GENERIC Covered TIER 1 



CLOPIDOGREL TAB 300MG PLATELET‐AGGREGATION INHIBITORS GENERIC Covered TIER 1 

CLOPIDOGREL TAB 75MG PLATELET‐AGGREGATION INHIBITORS GENERIC Covered TIER 1 



92

CLORAZ DIPOT TAB 15MG 



CLORAZ DIPOT TAB 3.75MG 



CLORAZ DIPOT TAB 7.5MG 



CLORPRES TAB 0.1‐15MG CENTRAL ALPHA‐AGONISTS BRAND Covered TIER 3 



CLOTRIM/BETA CRE 1‐0.05% 

AZOLES (SKIN & MUCOUS 


CLOTRIM/BETA CRE DIPROP 



CLOTRIM/BETA LOT DIPROP 



CLOTRIMAZOLE CRY 


MEMBRANE) GENERIC Excluded TIER 99 

CLOTRIMAZOLE LOZ 10MG 



CLOTRIMAZOLE SOL 1% 



CLOTRIMAZOLE TRO 10MG 



CLOZAPINE TAB 100/ODT ATYPICAL ANTIPSYCHOTICS GENERIC Covered TIER 1 

CLOZAPINE TAB 100MG ATYPICAL ANTIPSYCHOTICS GENERIC Covered TIER 1 

CLOZAPINE TAB 12.5/ODT ATYPICAL ANTIPSYCHOTICS GENERIC Covered TIER 1 



CLOZAPINE TAB 25MG ODT ATYPICAL ANTIPSYCHOTICS GENERIC Covered TIER 1 




93

CLOZARIL TAB 100MG ATYPICAL ANTIPSYCHOTICS Brand‐O PA TIER 2 

CLOZARIL TAB 25MG ATYPICAL ANTIPSYCHOTICS Brand‐O PA TIER 2 

CNL8 NAIL KIT 



CO MONITOR KIT DEVICES GENERIC Excluded TIER 99 

CO MONITOR MIS DEVICES GENERIC Excluded TIER 99 

CO MONITOR MIS T PIECES DEVICES GENERIC Excluded TIER 99 

COAL TAR OIN 1% KERATOPLASTIC AGENTS GENERIC Covered TIER 1 

COAL TAR SOL 20% KERATOPLASTIC AGENTS GENERIC Covered TIER 1 

COARTEM TAB 20‐120MG ANTIMALARIALS BRAND Covered TIER 2 

COCAINE HCL SOL 10% LOCAL ANESTHETICS (EENT) GENERIC Covered TIER 1 

COCAINE HCL SOL 4% LOCAL ANESTHETICS (EENT) GENERIC Covered TIER 1 

COCET TAB 650‐30MG OPIATE AGONISTS BRAND Covered TIER 3 

COCET PLUS TAB 650‐60MG OPIATE AGONISTS BRAND Covered TIER 3 

COCOA BUTTER MIS BASIC LOTIONS AND LINIMENTS GENERIC Excluded TIER 99 

COCONUT LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

COD LIVER OIL MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

CODEINE PHOS INJ 30MG/2ML OPIATE AGONISTS GENERIC Covered TIER 1 

CODEINE PHOS INJ 60MG/2ML OPIATE AGONISTS GENERIC Covered TIER 1 

CODEINE SULF SOL 30MG/5ML OPIATE AGONISTS GENERIC Covered TIER 1 

CODEINE SULF TAB 15MG OPIATE AGONISTS GENERIC Covered TIER 1 



COENZYME INJ COMPOSIT 



COFFEE LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

COGENTIN INJ 1MG/ML ANTICHOLINERGIC AGENTS (CNS) Brand‐O PA TIER 3 

CO‐GESIC TAB 5‐500MG OPIATE AGONISTS GENERIC Covered TIER 1 

COLA FLAVOR LIQ PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 



94

COLAZAL CAP 750MG 


DRUGS) Brand‐O PA TIER 3 

COLCHICINE TAB 0.6MG ANTIGOUT AGENTS GENERIC Covered TIER 1 

COLCRYS TAB 0.6MG ANTIGOUT AGENTS BRAND Covered TIER 2 

COLD CRE PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

COLDEC DM SYP ANTITUSSIVES GENERIC Covered TIER 1 

COLESTID GRA 5GM BILE ACID SEQUESTRANTS Brand‐O PA TIER 3 

COLESTID POW 5GM BILE ACID SEQUESTRANTS Brand‐O PA TIER 3 

COLESTID TAB 1GM BILE ACID SEQUESTRANTS Brand‐O PA TIER 3 

COLESTID FLA GRA 5/7.5GM BILE ACID SEQUESTRANTS Brand‐O PA TIER 3 

COLESTID FLA GRA 5GM BILE ACID SEQUESTRANTS Brand‐O PA TIER 3 

COLESTIPOL GRA 5GM BILE ACID SEQUESTRANTS GENERIC Covered TIER 1 

COLESTIPOL TAB 1GM BILE ACID SEQUESTRANTS GENERIC Covered TIER 1 

COLIDROPS DRO 0.125/ML 



COLISTIMETH INJ 150MG POLYMYXINS GENERIC Covered TIER 1 

COLLODION LIQ PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

COLOCORT ENE 100MG 



COLY‐MYCIN M INJ 150MG POLYMYXINS Brand‐O PA TIER 3 

COLY‐MYCIN S SUS OTIC CORTICOSTEROIDS (EENT) BRAND Covered TIER 3 

COLYTE/FLAVR SOL PACKS CATHARTICS AND LAXATIVES BRAND Covered TIER 2 

Brand‐O PA TIER 3 

COMBIGAN SOL 0.2/0.5% 



COMBIPATCH DIS .05/.14 ESTROGENS BRAND Covered TIER 2 

COMBIPATCH DIS .05/.25 ESTROGENS BRAND Covered TIER 2 

COMBIVENT AER 





95

COMBIVENT AER RESPIMAT 



COMBIVIR TAB 150‐300 


REV.TRNSCRIP.INHIB Brand‐O PA TIER 3 

COMFORT SET MIS 23"/17MM DEVICES BRAND Covered TIER 3 



COMFORT SHRT MIS 23"/13MM DEVICES BRAND Covered TIER 3 



COMP AIR MIS COMP/NEB DEVICES BRAND Excluded TIER 99 

COMP AIR MIS ELITE DEVICES BRAND Excluded TIER 99 

COMPLERA TAB 

NONNUCLEOSIDE 

REV.TRANSCRIPTASE INHIB. BRAND Covered TIER 2 

COMPLETE NAT PAK DHA MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

COMPLETENATE CHW MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

COMPLETE‐RF TAB PRENATAL MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

COMPOUND 347 LIQ INHALATION ANESTHETICS GENERIC Covered TIER 1 

COMPRESSION MIS PANTYHSE DEVICES GENERIC Excluded TIER 99 

COMPRESSION MIS THIGH DEVICES GENERIC Excluded TIER 99 

COMPRO SUP 25MG PHENOTHIAZINES GENERIC Covered TIER 1 

COMTAN TAB 200MG 

CATECHOL‐O‐ 

METHYLTRANSFERASE(COMT)INHIB. BRAND Covered TIER 3 

COMVAX INJ VACCINES BRAND Covered TIER 3 

CO‐NATAL FA TAB 29‐1MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

CONCENTRATE CRE PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

CONCEPT DHA CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

CONCEPT OB CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

CONCEPTION KIT DEVICES GENERIC Excluded TIER 99 



96

CONCERTA TAB 18MG 


STIMULANTS,MISC BRAND Covered TIER 3 QL 










CONDYLOX GEL 0.5% 



CONDYLOX SOL 0.5% 



CONFIRM NOW MIS DETECTOR DEVICES BRAND Excluded TIER 99 

CONNECT TUBE MIS 3/16"X6' DEVICES BRAND Excluded TIER 99 

CONNECTOR MIS LUER LOC DEVICES BRAND Excluded TIER 99 

CONNECTOR MIS Y‐SITE DEVICES BRAND Excluded TIER 99 

CONRAY INJ 60% ROENTGENOGRAPHY BRAND Covered TIER 3 

CONRAY 30 INJ 30% ROENTGENOGRAPHY BRAND Covered TIER 3 

CONRAY 43 INJ 43% ROENTGENOGRAPHY BRAND Covered TIER 3 

CONSTULOSE SOL 10GM/15 AMMONIA DETOXICANTS GENERIC Covered TIER 1 

CONTINUOUS MIS FEED SET DEVICES BRAND Excluded TIER 99 

CONTROLRX CRE 1.1% CARIOSTATIC AGENTS GENERIC Covered TIER 1 

CONTROLRX PST 1.1% CARIOSTATIC AGENTS GENERIC Covered TIER 1 

CONVERSION MIS BABY SZ1 DEVICES BRAND Excluded TIER 99 



CONZIP CAP 100MG OPIATE AGONISTS BRAND Covered TIER 3 



COPAXONE KIT 20MG/ML BIOLOGIC RESPONSE MODIFIERS BRAND Covered TIER 2 SP 



97

COPD TAB 200‐200 



COPEGUS TAB 200MG NUCLEOSIDES AND NUCLEOTIDES Brand‐O PA TIER 3 SP 

COPPER SULF INJ 0.4MG/ML REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

COR COMPOSIT LIQ 



CORDARONE TAB 200MG CLASS III ANTIARRHYTHMICS Brand‐O PA TIER 3 

CORDRAN LOT 0.05% 



CORDRAN 24X3 TAP 4MCG/CM 



CORDRAN 80X3 TAP 4MCG/CM 



CORDRAN SP CRE 0.05% 



COREG TAB 12.5MG 



COREG TAB 25MG 









COREG CR CAP 10MG 











98




CORENATE‐DHA MIS MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

CORGARD TAB 20MG 









CORIANDER OIL PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

CORIFACT KIT HEMOSTATICS BRAND PA TIER 2 SP 

CORLOPAM INJ 10MG/ML DIRECT VASODILATORS Brand‐O PA TIER 3 

CORMAX OIN 0.05% 



CORMAX SOL 0.05% 



CORMAX SCALP SOL 0.05% 



CORTALO GEL 2% 



CORTANE‐B DRO AQ OTIC CORTICOSTEROIDS (EENT) Brand‐O PA TIER 99 

CORTANE‐B DRO OTIC CORTICOSTEROIDS (EENT) Brand‐O PA TIER 99 

CORTANE‐B LOT 


& MUCOUS) BRAND Excluded TIER 99 

CORTEF TAB 10MG ADRENALS Brand‐O PA TIER 3 



CORTENEMA ENE 100MG 



CORTIC‐ND DRO CORTICOSTEROIDS (EENT) GENERIC Excluded TIER 99 



99

CORTIFOAM AER 90MG 



CORTISONE AC TAB 25MG ADRENALS GENERIC Covered TIER 1 

CORTISPORIN CRE 0.5% 



CORTISPORIN OIN 1% 



CORTISPORIN SOL 1% OTIC CORTICOSTEROIDS (EENT) Brand‐O PA TIER 3 

CORTISPORIN SUS ‐TC OTIC CORTICOSTEROIDS (EENT) BRAND Covered TIER 3 

CORTOMYCIN SUS 1% OTIC CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

CORTROSYN INJ 0.25MG ADRENOCORTICAL INSUFFICIENCY Brand‐O PA TIER 3 

CORVERT INJ 1MG/10ML CLASS III ANTIARRHYTHMICS Brand‐O PA TIER 3 

CORVITA TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

CORVITA 150 TAB IRON PREPARATIONS GENERIC Covered TIER 1 

CORVITE TAB MULTIVITAMIN PREPARATIONS Brand‐O PA TIER 3 

CORVITE 150 TAB IRON PREPARATIONS Brand‐O PA TIER 3 

CORVITE FE TAB IRON PREPARATIONS BRAND Covered TIER 3 

CORVITE FREE TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

CORZALL LIQ 20‐30MG ANTITUSSIVES BRAND Excluded TIER 99 

CORZALL PLUS LIQ ANTITUSSIVES BRAND Excluded TIER 99 

CORZALL‐PE LIQ ANTITUSSIVES BRAND Excluded TIER 99 

CORZIDE TAB 40‐5MG 



CORZIDE TAB 80‐5MG 



COSMEGEN INJ 0.5MG ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

COSOPT SOL 2‐0.5%OP 





100

COSOPT PF SOL 



COSYNTROPIN INJ 0.25MG ADRENOCORTICAL INSUFFICIENCY GENERIC Covered TIER 1 

COTAB A TAB 4‐10MG ANTITUSSIVES BRAND Excluded TIER 99 

COTAB AX TAB 4‐20MG ANTITUSSIVES BRAND Excluded TIER 99 

COTABFLU TAB 20‐4‐500 ANTITUSSIVES BRAND Excluded TIER 99 

COTTON CANDY LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

COUMADIN INJ 5 MG COUMARIN DERIVATIVES BRAND Covered TIER 3 

COUMADIN TAB 10MG COUMARIN DERIVATIVES Brand‐O PA TIER 3 


COUMADIN TAB 2.5MG COUMARIN DERIVATIVES Brand‐O PA TIER 3 






COUMADIN TAB 7.5MG COUMARIN DERIVATIVES Brand‐O PA TIER 3 

COVARYX TAB ESTROGENS GENERIC Excluded TIER 99 

COVARYX HS TAB ESTROGENS GENERIC Excluded TIER 99 

COVERA‐HS TAB 180MG 



COVERA‐HS TAB 240MG 



COZAAR TAB 100MG 











101

CPB WC LIQ ANTITUSSIVES BRAND Excluded TIER 99 

CRALONIN DRO 



CRALONIN LIQ 



CRAN‐RASPBER LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

CREME DE MNT LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

CREME DEMENT LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

CREON CAP 12000UNT DIGESTANTS BRAND Covered TIER 2 

CREON CAP 24000UNT DIGESTANTS BRAND Covered TIER 2 

CREON CAP 3000UNIT DIGESTANTS BRAND Covered TIER 2 

CREON CAP 6000UNIT DIGESTANTS BRAND Covered TIER 2 

CRESTOR TAB 10MG HMG‐COA REDUCTASE INHIBITORS BRAND Covered TIER 2 




CRESYLATE SOL 25% OTIC ANTIBACTERIALS (EENT) BRAND Covered TIER 3 

CRINONE GEL 4% VAG PROGESTINS BRAND PA TIER 2 SP 

CRINONE GEL 8% VAG PROGESTINS BRAND PA TIER 2 SP 

CRIXIVAN CAP 100MG HIV PROTEASE INHIBITORS BRAND Covered TIER 2 



CRNATAL PAK MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

CROFAB INJ SERUMS BRAND Covered TIER 3 

CROMOLYN SOD CON 100/5ML MAST‐CELL STABILIZERS GENERIC Covered TIER 1 

CROMOLYN SOD NEB 20MG/2ML MAST‐CELL STABILIZERS GENERIC Covered TIER 1 



102

CROMOLYN SOD SOL 4% OP ANTIALLERGIC AGENTS GENERIC Covered TIER 1 

CRYSELLE‐28 TAB 28 TABS CONTRACEPTIVES GENERIC Covered TIER 1 

C‐TAN D PLUS SUS PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

CUBICIN SOL 500MG CYCLIC LIPOPEPTIDES BRAND Covered TIER 3 

CUPRIC CHLOR INJ 0.4MG/ML REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

CUPRIC SULF GRA PENTAHYD REPLACEMENT PREPARATIONS GENERIC Excluded TIER 99 

CUPRIMINE CAP 250MG HEAVY METAL ANTAGONISTS BRAND Covered TIER 2 

CURAFIL HYDR PAD 1"X36" 












CURAFIL WOUN GEL DRESSING 



CURAFOAM PAD 4"X5" DEVICES BRAND Covered TIER 3 

CURAFOAM PAD 6"X8" DEVICES BRAND Covered TIER 3 

CURAGEL HYDR PAD 2"X3" 

















103

CURAGEL HYDR PAD 8.5"X9.5 

CURASORB MIS 12" ROPE 

CURASORB MIS 12"X24" 





CURASORB MIS 4"X5.5" 



CURASORB PLS MIS 4"X4" 

CURASORB ZN MIS 12" ROPE 

CURASORB ZN PAD 2"X2" 



































104

CURI‐STRIP MIS 1/2"X4" DEVICES BRAND Covered TIER 3 

CURI‐STRIP MIS 1/4"X1.5 DEVICES BRAND Covered TIER 3 




CURITY AMD PAD 2"X2" DEVICES BRAND Covered TIER 3 

CURITY AMD PAD 4"X4" DEVICES BRAND Covered TIER 3 

CURITY CATH KIT 14FRENCH DEVICES BRAND Excluded TIER 99 

CURITY FOLEY KIT 16FR‐5ML DEVICES BRAND Excluded TIER 99 

CURITY HYPER MIS 1/2"X15' 



CURITY NACL PAD 6"X6‐3/4 



CURITY SALIN SOL 0.9% IRR IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

CURITY SPONG MIS STICKS 



CURITY WET PAD 8"X4" 



CUROSURF SUS 80MG/ML PULMONARY SURFACTANTS BRAND Covered TIER 3 

CUST LIPOTHN GEL 110 PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

CUST LIPOTHN GEL 133 PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

CUTIS COMPOS INJ 



CUTIVATE CRE 0.05% 



CUTIVATE LOT 0.05% 



CUTIVATE OIN 0.005% 





105

CUVPOSA SOL 1MG/5ML 



CYANIDE ANTI KIT PKG UNIT HEAVY METAL ANTAGONISTS GENERIC Covered TIER 1 

CYANOCOBALAM CRY VITAMIN B COMPLEX GENERIC Excluded TIER 99 

CYANOCOBALAM INJ 1000MCG VITAMIN B COMPLEX GENERIC Covered TIER 1 

CYANOKIT INJ 5GM ANTIDOTES BRAND Covered TIER 3 

CYCLAFEM TAB 1/35 CONTRACEPTIVES GENERIC Covered TIER 1 

CYCLAFEM TAB 7/7/7 CONTRACEPTIVES GENERIC Covered TIER 1 

CYCLESSA PAK CONTRACEPTIVES Brand‐O PA TIER 3 

CYCLOBENZAPR CAP 15MG ER 



CYCLOBENZAPR CAP 30MG ER 



CYCLOBENZAPR CRE 20MG/GM 



CYCLOBENZAPR KIT COMFORT 



CYCLOBENZAPR TAB 10MG 



CYCLOBENZAPR TAB 5MG 



CYCLOBENZAPR TAB 7.5MG 



CYCLOGYL SOL 0.5% OP MYDRIATICS BRAND Covered TIER 3 

CYCLOGYL SOL 1% OP MYDRIATICS Brand‐O PA TIER 3 

CYCLOGYL SOL 2% OP MYDRIATICS Brand‐O PA TIER 3 

CYCLOMYDRIL SOL OP MYDRIATICS BRAND Covered TIER 3 

CYCLOPENTOL SOL 1% OP MYDRIATICS GENERIC Covered TIER 1 

CYCLOPENTOL SOL 2% OP MYDRIATICS GENERIC Covered TIER 1 

CYCLOPHOSPH INJ 1GM ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 



106

CYCLOPHOSPH INJ 2GM ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

CYCLOPHOSPH INJ 500MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

CYCLOPHOSPH TAB 25MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

CYCLOPHOSPH TAB 50MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

CYCLOSERINE CAP 250MG ANTITUBERCULOSIS AGENTS GENERIC Covered TIER 1 

ANTIDIABETIC AGENTS, 

CYCLOSET TAB 0.8MG 

MISCELLANEOUS BRAND PA TIER 3 QL 

CYCLOSPORINE CAP 100MG IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1 

CYCLOSPORINE CAP 100MG MD IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1 

CYCLOSPORINE CAP 25MG IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1 

CYCLOSPORINE CAP 25MG MOD IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1 

CYCLOSPORINE CAP 50MG MOD IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1 

CYCLOSPORINE INJ 50MG/ML IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1 

CYCLOSPORINE SOL MODIFIED IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1 

CYKLOKAPRON INJ 100MG/ML HEMOSTATICS Brand‐O PA TIER 3 

CYLATE SOL 1% OP MYDRIATICS GENERIC Covered TIER 1 

CYMBALTA CAP 20MG 

SEL. SEROTONIN & NOREPI 

REUPTAKE INHIBTR BRAND Covered TIER 2 QL 







CYOTIC DRO CORTICOSTEROIDS (EENT) GENERIC Excluded TIER 99 

CYPROHEPTAD SYP 2MG/5ML 

FIRST GEN. ANTIHIST. DERIVATIVES, 


CYPROHEPTAD TAB 4MG 




CYSTADANE POW 

THERAPEUTIC AGENTS BRAND Covered TIER 2 SP 



107

CYSTAGON CAP 150MG 



CYSTAGON CAP 50MG 



CYSTEINE HCL INJ 50MG/ML CALORIC AGENTS GENERIC Covered TIER 1 

CYSTO‐CONRAY INJ II 17.2% ROENTGENOGRAPHY BRAND Covered TIER 3 

CYSTOGRAFIN INJ 30% ROENTGENOGRAPHY BRAND Covered TIER 3 

CYSTOGRAFIN‐ INJ DILUTE ROENTGENOGRAPHY BRAND Covered TIER 3 

CYSVIEW INJ 100MG DIAGNOSTIC AGENTS BRAND Excluded TIER 99 

CYTARABINE INJ 100MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

CYTARABINE INJ 100MG/ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

CYTARABINE INJ 1GM ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

CYTARABINE INJ 20MG/ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

CYTARABINE INJ 500MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

CYTOGAM INJ SERUMS BRAND Covered TIER 3 SP 

CYTOMEL TAB 25MCG THYROID AGENTS Brand‐O PA TIER 3 



CYTOTEC TAB 100MCG PROSTAGLANDINS Brand‐O PA TIER 3 

CYTOTEC TAB 200MCG PROSTAGLANDINS Brand‐O PA TIER 3 

CYTOVENE INJ 500MG NUCLEOSIDES AND NUCLEOTIDES Brand‐O PA TIER 3 

CYTRA K GRA CRYSTALS ALKALINIZING AGENTS GENERIC Covered TIER 1 

CYTRA‐2 SOL ALKALINIZING AGENTS GENERIC Covered TIER 1 

CYTRA‐3 SYP ALKALINIZING AGENTS GENERIC Covered TIER 1 

CYTRA‐K SOL ALKALINIZING AGENTS GENERIC Covered TIER 1 

D.H.E. 45 INJ 1MG/ML 

NON‐SEL.ALPHA‐ADRENERGIC 

BLOCKING AGENTS Brand‐O PA TIER 3 

D10W/NACL INJ 0.2% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 





108


D2.5W/NACL INJ 0.45% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

D5W/LR INJ REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

D5W/LYTES INJ #48 REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 







D5W/RINGERS INJ REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

DACARBAZINE INJ 100MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

DACARBAZINE INJ 200MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

DACEX‐DM SYP ANTITUSSIVES GENERIC Covered TIER 1 

DACOGEN INJ 50MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

DACTINOMYCIN INJ 0.5MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

DALIRESP TAB 500MCG 


INHIBITORS BRAND PA TIER 3 

DALLERGY CHW PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

DALLERGY SYP PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

DALLERGY TAB PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

DALLERGY TAB ER PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

DALLERGY DM SYP ANTITUSSIVES Brand‐O PA TIER 99 

DALLERGY JR CAP 4‐20MG PROPYLAMINE DERIVATIVES Brand‐O PA TIER 99 

DALLERGY PE SYP PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

DALLERGY PE TAB PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

DALLERGY PSE TAB PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

DALLERGY‐JR SUS PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

DANAZOL CAP 100MG ANDROGENS GENERIC Covered TIER 1 




109


DANTRIUM CAP 100MG 

DIRECT‐ACTING SKELETAL MUSCLE 

RELAXANTS Brand‐O PA TIER 3 







DANTRIUM IV INJ 20MG 



DANTROLENE CAP 100MG 









DAPSONE TAB 100MG 

ANTIMYCOBACTERIALS, 


DAPSONE TAB 25MG 

ANTIMYCOBACTERIALS, 


DAPTACEL INJ TOXOIDS BRAND Excluded TIER 99 

DARAPRIM TAB 25MG ANTIMALARIALS BRAND Covered TIER 2 

DASETTA TAB 1/35 CONTRACEPTIVES GENERIC Covered TIER 1 

DASETTA TAB 7/7/7 CONTRACEPTIVES GENERIC Covered TIER 1 

DATSCAN SOL DIAGNOSTIC AGENTS BRAND Excluded TIER 99 

DAUNORUBICIN INJ 20MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

DAUNORUBICIN INJ 5MG/ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

DAUNOXOME INJ 2MG/ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

DAYPRO TAB 600MG 





110

DAYTRANA DIS 10MG/9HR 












DDAVP INJ 4MCG/ML PITUITARY Brand‐O PA TIER 3 

DDAVP SOL 0.01% PITUITARY Brand‐O PA TIER 3 

DDAVP SPR 0.01% PITUITARY Brand‐O PA TIER 3 

DDAVP TAB 0.1MG PITUITARY Brand‐O PA TIER 3 

DDAVP TAB 0.2MG PITUITARY Brand‐O PA TIER 3 

DEBACTEROL SOL 30‐50% EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 3 

DECARA CAP 25000 IU VITAMIN D BRAND Covered TIER 3 

DECAVAC INJ 5‐2LF TOXOIDS GENERIC Excluded TIER 99 

DE‐CHLOR DM LIQ LIQUID ANTITUSSIVES GENERIC Covered TIER 1 

DE‐CHLOR DR SYP LIQUID ANTITUSSIVES GENERIC Covered TIER 1 

DECON‐A ELX 2‐5MG/5M PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

DECON‐G DRO 2‐1‐40MG EXPECTORANTS BRAND Excluded TIER 99 

DEFEROXAMINE INJ 2GM HEAVY METAL ANTAGONISTS GENERIC Covered TIER 1 SP 

DEFEROXAMINE INJ 500MG HEAVY METAL ANTAGONISTS GENERIC Covered TIER 1 SP 

DEFINITY SUS 1.1MG/ML DIAGNOSTIC AGENTS BRAND Excluded TIER 99 

DEHISTINE SYP PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

DELATESTRYL INJ 200MG/ML ANDROGENS Brand‐O PA TIER 3 

DELESTROGEN INJ 10MG/ML ESTROGENS Brand‐O PA TIER 3 



DELFLEX‐LC/ SOL 1.5% DEX IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

DELFLEX‐LC/ SOL 2.5% DEX IRRIGATING SOLUTIONS GENERIC Covered TIER 1 



111

DELFLEX‐LC/ SOL 4.25 DEX IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

DELFLEX‐LM SOL 1.5% DEX IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

DELFLEX‐LM SOL 2.5% DEX IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

DELFLEX‐LM/ SOL 4.25 DEX IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

DELFLEX‐SM/ SOL 1.5% DEX IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

DELFLEX‐SM/ SOL 2.5% DEX IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

DELFLEX‐SM/ SOL 4.25 DEX IRRIGATING SOLUTIONS BRAND Covered TIER 3 

DELOS LIQ 3.5% 



DELOS LOT 3.5% 



DELTEC COZMO MIS INL PUMP DEVICES BRAND Covered TIER 3 

DELTUSS DMX LIQ ANTITUSSIVES BRAND Excluded TIER 99 

DEMADEX TAB 100MG LOOP DIURETICS Brand‐O PA TIER 3 




DEMECLOCYCL TAB 150MG TETRACYCLINES GENERIC Covered TIER 1 

DEMECLOCYCL TAB 300MG TETRACYCLINES GENERIC Covered TIER 1 

DEMEROL INJ 100/2ML OPIATE AGONISTS BRAND Covered TIER 3 

DEMEROL INJ 100MG/ML OPIATE AGONISTS Brand‐O PA TIER 3 

DEMEROL INJ 25MG/0.5 OPIATE AGONISTS BRAND Covered TIER 3 



DEMEROL INJ 75MG/1.5 OPIATE AGONISTS BRAND Covered TIER 3 

DEMEROL INJ 75MG/ML OPIATE AGONISTS BRAND Covered TIER 3 

DEMEROL TAB 100MG OPIATE AGONISTS Brand‐O PA TIER 3 

DEMEROL TAB 50MG OPIATE AGONISTS Brand‐O PA TIER 3 

DEMSER CAP 250MG 





112

DENAVIR CRE 1% 

ANTIVIRALS (SKIN & MUCOUS 


DENTA 5000 CRE PLUS CARIOSTATIC AGENTS GENERIC Covered TIER 1 

DENTA 5000 CRE PLUS 2PK CARIOSTATIC AGENTS GENERIC Covered TIER 1 

DENTAGEL GEL 1.1% CARIOSTATIC AGENTS GENERIC Covered TIER 1 

DENTAL NEEDL MIS 25GX21MM DEVICES GENERIC Excluded TIER 99 







DEPACON INJ 100MG/ML 



DEPADE TAB 50MG OPIATE ANTAGONISTS GENERIC Covered TIER 1 

DEPAKENE CAP 250MG 



DEPAKENE SYP 250/5ML 



DEPAKOTE TAB 125MG DR 









DEPAKOTE ER TAB 250MG 



DEPAKOTE ER TAB 500MG 





113

DEPAKOTE SPR CAP 125MG 



DEPEN TITRA TAB 250MG HEAVY METAL ANTAGONISTS BRAND Covered TIER 3 

DEPLIN TAB 15MG 



DEPLIN TAB 7.5MG 



DEPOCYT INJ 50MG/5ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

DEPODUR INJ 10MG/ML OPIATE AGONISTS BRAND Covered TIER 3 

DEPODUR INJ 15/1.5ML OPIATE AGONISTS BRAND Covered TIER 3 

DEPO‐ESTRADI INJ 5MG/ML ESTROGENS BRAND Covered TIER 3 

DEPO‐MEDROL INJ 20MG/ML ADRENALS BRAND Covered TIER 3 

DEPO‐MEDROL INJ 40MG/ML ADRENALS Brand‐O PA TIER 3 

DEPO‐MEDROL INJ 80MG/ML ADRENALS Brand‐O PA TIER 3 

DEPO‐PROVERA INJ 150MG/ML PROGESTINS Brand‐O PA TIER 3 

DEPO‐PROVERA INJ 400/ML PROGESTINS BRAND Covered TIER 2 SP 

DEPO‐SQ PROV INJ 104 PROGESTINS BRAND Covered TIER 3 

DEPO‐TESTOST INJ 100MG/ML ANDROGENS Brand‐O PA TIER 3 

DEPO‐TESTOST INJ 200MG/ML ANDROGENS Brand‐O PA TIER 3 

DERMAGRAFT MIS 



DERMA‐SMOOTH OIL /FS BODY 



DERMA‐SMOOTH OIL /FS SCLP 



DERMATODORON LIQ 



DERMATOP CRE 0.1% 





114

DERMATOP OIN 0.1% 



DERMAZENE CRE 1% 



DERMOTIC OIL 0.01% CORTICOSTEROIDS (EENT) Brand‐O PA TIER 3 

DESFERAL INJ 2GM HEAVY METAL ANTAGONISTS Brand‐O PA TIER 3 SP 

DESFERAL INJ 500MG HEAVY METAL ANTAGONISTS Brand‐O PA TIER 3 SP 

DESIPRAMINE TAB 100MG 


















DESLORATADIN TAB 5MG 



DESMOPRESSIN INJ 4MCG/ML PITUITARY GENERIC Covered TIER 1 

DESMOPRESSIN SOL 0.01% PITUITARY GENERIC Covered TIER 1 

DESMOPRESSIN SPR 0.01% PITUITARY GENERIC Covered TIER 1 

DESMOPRESSIN TAB 0.1MG PITUITARY GENERIC Covered TIER 1 

DESMOPRESSIN TAB 0.2MG PITUITARY GENERIC Covered TIER 1 

DESOGEN‐28 TAB CONTRACEPTIVES Brand‐O PA TIER 3 

DESONATE GEL 0.05% 





115

DESONIDE CRE 0.05% 

DESONIDE LOT 0.05% 

DESONIDE OIN 0.05% 

DESONIL KIT 0.05% 

DESONIL PLUS KIT CREAM 

DESONIL PLUS KIT OINTMENT 

DESOWEN CRE 0.05% 

DESOWEN LOT 0.05% 

DESOWEN OIN 0.05% 

DESOWEN CRM KIT 0.05% 

DESOWEN LOT KIT 0.05% 

DESOWEN OINT KIT 0.05% 

DESOXIMETAS CRE 0.05% 

DESOXIMETAS CRE 0.25% 

DESOXIMETAS GEL 0.05% 

































116

DESOXIMETAS OIN 0.05% 



DESOXIMETAS OIN 0.25% 



DESOXYN TAB 5MG AMPHETAMINES Brand‐O PA TIER 3 

DESPEC‐EXP SYP ANTITUSSIVES GENERIC Covered TIER 1 

DESPEC‐PDC LIQ ANTITUSSIVES BRAND Excluded TIER 99 

DESQUAM‐X LIQ 10% WASH 



DESQUAM‐X LIQ 5% WASH 



DETROL TAB 1MG 

GENITOURINARY SMOOTH MUSCLE 


DETROL TAB 2MG 



DETROL LA CAP 2MG 


RELAXANTS BRAND Covered TIER 2 QL 

DETROL LA CAP 4MG 



DEXAMETH PHO INJ 10MG/ML ADRENALS GENERIC Covered TIER 1 

DEXAMETH PHO INJ 4MG/ML ADRENALS GENERIC Covered TIER 1 

DEXAMETH PHO SOL 0.1% OP CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

DEXAMETHASON CON 1MG/ML ADRENALS BRAND Covered TIER 3 

DEXAMETHASON ELX 0.5/5ML ADRENALS GENERIC Covered TIER 1 

DEXAMETHASON SOL 0.5/5ML ADRENALS GENERIC Covered TIER 1 

DEXAMETHASON TAB 0.5MG ADRENALS GENERIC Covered TIER 1 



DEXAMETHASON TAB 1MG ADRENALS GENERIC Covered TIER 1 




117



DEXCHLORPHEN SYP 2MG/5ML PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

DEXCHLORPHEN TAB 4MG CR PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

DEXEDRINE CAP 10MG CR AMPHETAMINES Brand‐O PA TIER 3 QL 



DEXFERRUM INJ 50MG/ML IRON PREPARATIONS GENERIC Covered TIER 1 SP 

DEXILANT CAP 30MG DR PROTON‐PUMP INHIBITORS BRAND Covered TIER 3 QL 

DEXILANT CAP 60MG DR PROTON‐PUMP INHIBITORS BRAND Covered TIER 3 QL 

DEXMETHYLPH TAB 10MG 


STIMULANTS,MISC GENERIC Covered TIER 1 QL 

DEXMETHYLPH TAB 2.5MG 



DEXMETHYLPH TAB 5MG 



DEXPAK PAK 10 DAY ADRENALS BRAND Covered TIER 3 



DEXPANTHENOL INJ 250MG/ML VITAMIN B COMPLEX GENERIC Covered TIER 1 

DEXRAZOXANE INJ 250MG PROTECTIVE AGENTS GENERIC Covered TIER 1 SP 

DEXRAZOXANE INJ 500MG PROTECTIVE AGENTS GENERIC Covered TIER 1 

DEXTRAN 70 INJ 6% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

DEXTRAN HM INJ 32% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

DEXTROAMPHET CAP 10MG ER AMPHETAMINES GENERIC Covered TIER 1 QL 



DEXTROAMPHET TAB 10MG AMPHETAMINES GENERIC Covered TIER 1 QL 

DEXTROAMPHET TAB 5MG AMPHETAMINES GENERIC Covered TIER 1 QL 

DEXTROSE INJ 10% CALORIC AGENTS GENERIC Covered TIER 1 SP 



118

DEXTROSE INJ 2.5% CALORIC AGENTS GENERIC Covered TIER 1 SP 






CARDIAC FUNCTION BRAND Covered TIER 3 

DEXTROSE INJ 5% PGBK CALORIC AGENTS GENERIC Covered TIER 1 SP 



DEX‐TUSS LIQ 300‐10/5 ANTITUSSIVES GENERIC Covered TIER 1 

DG 200 TAB 200‐200 



DIAB GEL 



DIAB F.D.G. GEL 



DIABETA TAB 1.25MG SULFONYLUREAS BRAND Covered TIER 3 

DIABETA TAB 2.5MG SULFONYLUREAS BRAND Covered TIER 3 

DIABETA TAB 5MG SULFONYLUREAS BRAND Covered TIER 3 

DIAGNOSTIC KIT DIAGNOSTIC AGENTS GENERIC Excluded TIER 99 

DIALYVITE TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

DIALYVITE TAB 3000 MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

DIALYVITE TAB 5000 MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

DIALYVITE TAB SUPREM D MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

DIALYVITE/ TAB ZINC MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

DIAMOX SEQUE CAP 500MG CR 



DIANEAL SOL LOW CALC IRRIGATING SOLUTIONS BRAND Covered TIER 3 

DIANEAL PD‐2 SOL 1.5% DEX IRRIGATING SOLUTIONS BRAND Covered TIER 3 



119

DIANEAL PD‐2 SOL 2.5% DEX IRRIGATING SOLUTIONS BRAND Covered TIER 3 

DIANEAL PD‐2 SOL 4.25%DEX IRRIGATING SOLUTIONS BRAND Covered TIER 3 

DIASTAT ACDL GEL 12.5‐20 



DIASTAT ACDL GEL 5‐10MG 



DIASTAT PED GEL 2.5M GEL 



DIATX ZN TAB MULTIVITAMIN PREPARATIONS Brand‐O PA TIER 3 

DIAZEPAM CON 5MG/ML 



DIAZEPAM GEL 10MG 



DIAZEPAM GEL 2.5MG 



DIAZEPAM GEL 20MG 



DIAZEPAM INJ 10MG/2ML 



DIAZEPAM INJ 5MG/ML 



DIAZEPAM SOL 1MG/ML 



DIAZEPAM TAB 10MG 











120

DIBENZYLINE CAP 10MG 

DICLOFEN POT TAB 50MG 

DICLOFENAC SOL 0.1% OP 

DICLOFENAC TAB 100MG ER 

DICLOFENAC TAB 100MG XR 

DICLOFENAC TAB 25MG DR 



DICLOXACILL CAP 250MG 

DICLOXACILL CAP 500MG 

DICYCLOMINE CAP 10MG 

DICYCLOMINE SOL 10MG/5ML 

DICYCLOMINE TAB 20MG 

DIDANOSINE CAP 125MG 



BLOCKING AGENTS BRAND Covered TIER 2 


INFLAM. AGENTS GENERIC Covered TIER 1 














PENICILLINS GENERIC Covered TIER 1 















121







DIDREX TAB 50MG AMPHETAMINES Brand‐O PA TIER 99 

DIDRONEL TAB 400MG BONE RESORPTION INHIBITORS Brand‐O PA TIER 3 

DIETHYLPROP TAB 25MG 


STIMULANTS,MISC GENERIC Excluded TIER 99 

DIETHYLPROP TAB 75MG ER 



DIFFERIN CRE 0.1% 



DIFFERIN GEL 0.1% 



DIFFERIN GEL 0.3% 



DIFFERIN LOT 0.1% 



DIFICID TAB 200MG OTHER MACROLIDES BRAND PA TIER 2 QL 

DIFIL‐G 400 TAB 



DIFIL‐G FORT LIQ 100‐100 



DIFLORASONE CRE 0.05% 



DIFLORASONE OIN 0.05% 



DIFLUCAN SUS 10MG/ML AZOLES Brand‐O PA TIER 3 

DIFLUCAN SUS 40MG/ML AZOLES Brand‐O PA TIER 3 

DIFLUCAN TAB 100MG AZOLES Brand‐O PA TIER 3 



122




DIFLUNISAL TAB 500MG 



DIGESTODORON LIQ 



DIGEX NF CAP 



DIGIBAR 190 SUS ROENTGENOGRAPHY BRAND Covered TIER 3 

DIGIFAB INJ 40MG SERUMS BRAND Covered TIER 3 

DIGOXIN INJ 0.25MG/1 CARDIOTONIC AGENTS GENERIC Covered TIER 1 

DIGOXIN SOL 50MCG/ML CARDIOTONIC AGENTS GENERIC Covered TIER 1 

DIGOXIN TAB 0.125MG CARDIOTONIC AGENTS GENERIC Covered TIER 1 

DIGOXIN TAB 0.25MG CARDIOTONIC AGENTS GENERIC Covered TIER 1 

DIHYDRO‐CP SYP ANTITUSSIVES GENERIC Covered TIER 1 

DIHYDROERGOT CRY MESYLATE 


BLOCKING AGENTS GENERIC Excluded TIER 99 

DIHYDROERGOT INJ 1MG/ML 


BLOCKING AGENTS GENERIC Covered TIER 1 

DIHYDRO‐PE SYP ANTITUSSIVES GENERIC Covered TIER 1 

DILACOR XR CAP 240MG/24 



DILANTIN CAP 100MG HYDANTOINS Brand‐O PA TIER 3 

DILANTIN CAP 30MG HYDANTOINS BRAND Covered TIER 2 

DILANTIN CHW 50MG HYDANTOINS BRAND Covered TIER 2 

DILANTIN‐125 SUS 125/5ML HYDANTOINS Brand‐O PA TIER 3 

DILATRATE SR CAP 40MG NITRATES AND NITRITES BRAND Covered TIER 2 

DILAUDID INJ 1MG/ML OPIATE AGONISTS Brand‐O PA TIER 3 




123


DILAUDID TAB 2MG OPIATE AGONISTS Brand‐O PA TIER 3 



DILAUDID‐5 LIQ 1MG/ML OPIATE AGONISTS Brand‐O PA TIER 3 

DILAUDID‐HP INJ 10MG/ML OPIATE AGONISTS Brand‐O PA TIER 3 

DILAUDID‐HP INJ 250MG OPIATE AGONISTS BRAND Covered TIER 3 

DILEX‐G 200 SYP 



DILEX‐G 400 TAB 



DILT‐CD CAP 120MG 












DILTIAZEM CAP 120MG CD 



DILTIAZEM CAP 120MG ER 



DILTIAZEM CAP 120MG/24 











124














DILTIAZEM INJ 100MG 

DILTIAZEM INJ 125/25ML 

































125

DILTIAZEM INJ 25MG/5ML 



DILTIAZEM INJ 50/10ML 



DILTIAZEM TAB 120MG 












DILT‐XR CAP 120MG 









DILTZAC CAP 120MG/24 















DIMENHYDRIN INJ 50MG/ML ANTIHISTAMINES (GI DRUGS) GENERIC Covered TIER 1 



126

DIOVAN TAB 160MG 












DIOVAN HCT TAB 160‐12.5 



DIOVAN HCT TAB 160‐25MG 



DIOVAN HCT TAB 320‐12.5 



DIOVAN HCT TAB 320‐25MG 



DIOVAN HCT TAB 80/12.5 



DIP/TET PED INJ 25‐5LFU TOXOIDS GENERIC Excluded TIER 99 

DIP/TET PED INJ 6.7‐5LF TOXOIDS GENERIC Excluded TIER 99 

DIPENTUM CAP 250MG 



DIPHEN/ATROP LIQ 2.5/5 ANTIDIARRHEA AGENTS GENERIC Covered TIER 1 

DIPHEN/ATROP TAB 2.5MG ANTIDIARRHEA AGENTS GENERIC Covered TIER 1 

DIPHENHYDRAM ELX 12.5/5ML ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1 

DIPHENHYDRAM INJ 50MG/ML ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1 

DIPRIVAN INJ 10MG/ML 



DIPROLENE LOT 0.05% 





127

DIPROLENE OIN 0.05% 



DIPROLENE AF CRE 0.05% 



DIPYRIDAMOLE INJ 5MG/ML 



DIPYRIDAMOLE TAB 25MG 









DISCOVISC SOL EENT DRUGS, MISCELLANEOUS BRAND Excluded TIER 99 

DISCUS INJ COMPOSIT 



DISCUS LIQ COMPOSIT 



DISCUS SUB COMPOSIT 



DISOPYRAMIDE CAP 100MG CLASS IA ANTIARRHYTHMICS GENERIC Covered TIER 1 

DISOPYRAMIDE CAP 150MG CLASS IA ANTIARRHYTHMICS GENERIC Covered TIER 1 

DISPENSER MIS MEGAPUMP DEVICES BRAND Excluded TIER 99 

DISULFIRAM TAB 250MG ALCOHOL DETERRENTS GENERIC Covered TIER 1 

DISULFIRAM TAB 500MG ALCOHOL DETERRENTS GENERIC Covered TIER 1 

DITROPAN XL TAB 10MG 











128

DIURIL SUS 250/5ML THIAZIDE DIURETICS BRAND Covered TIER 3 

DIVALPROEX CAP 125MG 



DIVALPROEX TAB 125MG DR 






DIVALPROEX TAB 250MG ER 






DIVALPROEX TAB 500MG ER 



DIVIGEL GEL 0.25MG ESTROGENS BRAND Covered TIER 2 

DIVIGEL GEL 0.5MG ESTROGENS BRAND Covered TIER 2 

DIVIGEL GEL 1MG/GM ESTROGENS BRAND Covered TIER 2 

DIVISTA CAP VITAMIN B COMPLEX BRAND Covered TIER 3 

DM/CPM/PE DRO ANTITUSSIVES GENERIC Covered TIER 1 

DM/PE/CPM DRO ANTITUSSIVES GENERIC Covered TIER 1 

DM‐PE‐CHLOR DRO ANTITUSSIVES GENERIC Covered TIER 1 

DMSA KIT KIDNEY FUNCTION BRAND Covered TIER 3 

DOBELLS SOL MOUTHWASHES AND GARGLES GENERIC Covered TIER 1 

DOBUTAM/D5W INJ 1MG/ML 









DOBUTAMINE INJ 250MG 





129

DOBUTAMINE INJ 500MG 



DOCEFREZ INJ 20MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

DOCEFREZ INJ 80MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

DOCETAXEL INJ 160/16ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

DOCETAXEL INJ 160/8ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

DOCETAXEL INJ 20/0.5ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

DOCETAXEL INJ 20MG/2ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

DOCETAXEL INJ 20MG/ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 




DOLGIC PLUS TAB 



DOLOGESIC LIQ 30‐500MG ETHANOLAMINE DERIVATIVES BRAND Covered TIER 3 

DOLOGESIC TAB 30‐500MG ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1 

DOLOMITE GRA REPLACEMENT PREPARATIONS GENERIC Excluded TIER 99 

DOLOPHINE TAB 10MG OPIATE AGONISTS Brand‐O PA TIER 3 

DOLOPHINE TAB 5MG OPIATE AGONISTS Brand‐O PA TIER 3 

DOLOREX TAB 50‐500MG ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1 

DONATUSS DC SYP ANTITUSSIVES BRAND Excluded TIER 99 

DONATUSS XP SUS ANTITUSSIVES BRAND Excluded TIER 99 

DONATUSSIN SUS DM ANTITUSSIVES BRAND Excluded TIER 99 

DONATUSSIN SYP ANTITUSSIVES BRAND Excluded TIER 99 

DONATUSSIN SYP DM ANTITUSSIVES Brand‐O PA TIER 99 

DONEPEZIL TAB 10MG 



DONEPEZIL TAB 10MG ODT 





130

DONEPEZIL TAB 5MG 



DONEPEZIL TAB 5MG ODT 



DONNATAL ELX 



DONNATAL TAB 



DONNATAL TAB EXTENTAB 


S BRAND Excluded TIER 99 

DOPAMINE INJ 160MG/ML 









DOPAMINE/D5W INJ 0.8MG/ML 





AGONISTS GENERIC Covered TIER 1 SP 




DOPRAM INJ 20MG/ML 


STIMULANTS,MISC Brand‐O PA TIER 3 SP 

DORAL TAB 15MG 



DORIBAX INJ 250MG CARBAPENEMS BRAND Covered TIER 3 

DORIBAX INJ 500MG CARBAPENEMS BRAND Covered TIER 3 

DORYX TAB 100MG TETRACYCLINES Brand‐O PA TIER 3 

DORYX TAB 150MG TETRACYCLINES BRAND Covered TIER 3 



131

DORZOL/TIMOL SOL 2‐0.5%OP 



DORZOLAMIDE SOL 2% OP 



DOVER TRAY KIT 14FR‐5ML DEVICES BRAND Excluded TIER 99 



DOVER URETH MIS 10FR DEVICES BRAND Excluded TIER 99 

DOVONEX CRE 0.005% 



DOVONX SCALP SOL 0.005% 



DOW CORNING LIQ 9011 PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

DOXAPRAM HCL INJ 20MG/ML 


STIMULANTS,MISC GENERIC Covered TIER 1 SP 

DOXAZOSIN TAB 1MG 












DOXEPIN HCL CAP 100MG 











132










DOXEPIN HCL CON 10MG/ML 



DOXIL INJ 2MG/ML ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

DOXORUBICIN INJ 10MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 


DOXORUBICIN INJ 2MG/ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 


DOXYCYC MONO CAP 100MG TETRACYCLINES GENERIC Covered TIER 1 

DOXYCYC MONO CAP 50MG TETRACYCLINES GENERIC Covered TIER 1 

DOXYCYC MONO TAB 100MG TETRACYCLINES GENERIC Covered TIER 1 




DOXYCYCL HYC CAP 100MG TETRACYCLINES GENERIC Covered TIER 1 

DOXYCYCL HYC CAP 50MG TETRACYCLINES GENERIC Covered TIER 1 

DOXYCYCL HYC INJ 100MG TETRACYCLINES GENERIC Covered TIER 1 

DOXYCYCL HYC TAB 100MG TETRACYCLINES GENERIC Covered TIER 1 



DOXYCYCLINE CAP 150MG TETRACYCLINES GENERIC Covered TIER 1 

DOXYCYCLINE CAP 75MG TETRACYCLINES GENERIC Covered TIER 1 

DOXYCYCLINE TAB 20MG TETRACYCLINES GENERIC Covered TIER 1 

DOXYTEX LIQ ETHANOLAMINE DERIVATIVES BRAND Covered TIER 3 

DRAINAGE BAG MIS DEVICES BRAND Excluded TIER 99 



133

DRAINAGE BAG MIS 2000ML DEVICES BRAND Excluded TIER 99 

DRAX IMAGE KIT DTPA KIDNEY FUNCTION BRAND Covered TIER 3 

DRCAPS CLEAR CAP SIZE 1 PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

DRIHEP PLUS KIT 100UNIT DEVICES BRAND Covered TIER 3 

DRIHEP SYRNG KIT 100UNIT DEVICES BRAND Covered TIER 3 

DRISDOL CAP 50000UNT VITAMIN D Brand‐O PA TIER 3 

DRITHO‐CREME CRE HP 1% 



DRITHO‐SCALP CRE 0.5% 



DRONABINOL CAP 10MG ANTIEMETICS, MISCELLANEOUS GENERIC Covered TIER 1 QL 

DRONABINOL CAP 2.5MG ANTIEMETICS, MISCELLANEOUS GENERIC Covered TIER 1 QL 

DRONABINOL CAP 5MG ANTIEMETICS, MISCELLANEOUS GENERIC Covered TIER 1 QL 

DROPERIDOL INJ 2.5MG/ML 



DROXIA CAP 200MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 



DRYMAX SYP PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

DRYSOL SOL 20% ASTRINGENTS Brand‐O PA TIER 3 

DUAC GEL 1.2‐5% 



DUAL THORACI MIS DRAIN DEVICES BRAND Excluded TIER 99 

DUET DHA MIS 25‐1‐400 MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

DUET DHA MIS 25‐1‐430 MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

DUET DHA MIS BALANCED MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

DUET DHA EC MIS 25‐1‐400 MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

DUET DHA EC MIS 25‐1‐430 MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

DUETACT TAB 30‐2MG THIAZOLIDINEDIONES BRAND Covered TIER 2 

DUETACT TAB 30‐4MG THIAZOLIDINEDIONES BRAND Covered TIER 2 



134

DUEXIS TAB 800‐26.6 



DULERA AER 100‐5MCG ADRENALS BRAND Covered TIER 3 QL 

DULERA AER 200‐5MCG ADRENALS BRAND Covered TIER 3 QL 

DUOCAINE INJ LOCAL ANESTHETICS (PARENTERAL) BRAND Covered TIER 3 

DUODOTE INJ ANTIDOTES BRAND Covered TIER 3 

DUONEB SOL 



DUOVISC KIT 0.35/0.4 EENT DRUGS, MISCELLANEOUS BRAND Excluded TIER 99 

DUOVISC KIT 0.5/0.55 EENT DRUGS, MISCELLANEOUS BRAND Excluded TIER 99 

DURABAC CAP 


MISC. Brand‐O PA TIER 3 

DURABAC TAB FORTE 



DURACLON INJ CENTRAL ALPHA‐AGONISTS Brand‐O PA TIER 3 

DURAFLU TAB ANTITUSSIVES BRAND Excluded TIER 99 

DURAGESIC DIS 100MCG/H OPIATE AGONISTS Brand‐O PA TIER 3 QL 

DURAGESIC DIS 12MCG/HR OPIATE AGONISTS Brand‐O PA TIER 3 QL 




DURAMORPH INJ 0.5MG/ML OPIATE AGONISTS GENERIC Covered TIER 1 

DURAMORPH INJ 1MG/ML OPIATE AGONISTS GENERIC Covered TIER 1 

DURASAF MINI KIT SPIN/EPI DEVICES BRAND Excluded TIER 99 

DURASAFE SET KIT SPIN/EPI DEVICES BRAND Excluded TIER 99 

DURASAL SOL 26% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

DURAXIN CAP 



DUREZOL EMU 0.05% CORTICOSTEROIDS (EENT) BRAND Covered TIER 2 



135

DUTOPROL TAB 100‐12.5 









DYAZIDE CAP 37.5‐25 POTASSIUM‐SPARING DIURETICS Brand‐O PA TIER 3 

DYFLEX‐G TAB 200‐200 



DY‐G LIQ 100‐100 



DYLIX ELX 100/15ML 



DYMISTA SPR 137‐50 ANTIALLERGIC AGENTS BRAND Covered TIER 3 

DYNACIN TAB 100MG TETRACYCLINES Brand‐O PA TIER 3 



DYNACIRC CR TAB 10MG DIHYDROPYRIDINES BRAND Covered TIER 3 

DYNACIRC CR TAB 5MG DIHYDROPYRIDINES BRAND Covered TIER 3 

DYPHYLLIN GG TAB 200‐200 



DYPHYLLIN‐GG ELX 100‐100 



DYRENIUM CAP 100MG POTASSIUM‐SPARING DIURETICS BRAND Covered TIER 3 

DYRENIUM CAP 50MG POTASSIUM‐SPARING DIURETICS BRAND Covered TIER 3 

DYSPORT INJ 300UNIT 



DYSPORT INJ 500UNIT 



DYTUSS SYP 12.5/5ML ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1 



136

E.E.S. 400 TAB 400MG ERYTHROMYCINS GENERIC Covered TIER 1 

E.E.S. GRAN SUS 200/5ML ERYTHROMYCINS BRAND Covered TIER 3 

E.S.P. SUS 200‐600 ERYTHROMYCINS GENERIC Covered TIER 1 

EARPOPPER MIS MID EAR DEVICES GENERIC Excluded TIER 99 

EASIVENT MIS DEVICES BRAND Excluded TIER 99 

EASIVENT MIS MASK LG DEVICES BRAND Excluded TIER 99 

EASIVENT MIS MASK SM DEVICES BRAND Excluded TIER 99 

EASIVENT MIS MASK MED DEVICES BRAND Excluded TIER 99 

EASYGEL GEL 0.4% CARIOSTATIC AGENTS GENERIC Covered TIER 1 

EASYGEL GEL 0.4%CHRY CARIOSTATIC AGENTS GENERIC Covered TIER 1 

EASYGEL GEL 0.4%CITR CARIOSTATIC AGENTS GENERIC Covered TIER 1 

EASYGEL GEL 0.4%MINT CARIOSTATIC AGENTS GENERIC Covered TIER 1 

ECHINACEA LIQ COMPOSIT 



ECHINACEA SUB COMPOSIT 



ECLIPSE NDL MIS 21GX1" DEVICES BRAND Excluded TIER 99 

EC‐NAPROSYN TAB 375MG 



EC‐NAPROSYN TAB 500MG 



ECONAZOLE CRE 1% 



ECZEMOL TAB 



ED BACLOFEN TAB 10MG 



ED CHLORPED SUS 2MG/ML PROPYLAMINE DERIVATIVES BRAND Covered TIER 3 

ED CHLORPED SUS D PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

ED CYTE F TAB IRON PREPARATIONS GENERIC Covered TIER 1 



137

ED DM CHW ANTITUSSIVES BRAND Excluded TIER 99 

ED‐A‐HIST DM LIQ ANTITUSSIVES GENERIC Covered TIER 1 

EDARBI TAB 40MG 



EDARBI TAB 80MG 



EDARBYCLOR TAB 40‐12.5 



EDARBYCLOR TAB 40‐25MG 



ED‐BRON G SYP 



ED‐CHLOR‐TAN TAB 8MG PROPYLAMINE DERIVATIVES BRAND Covered TIER 3 

EDECRIN TAB 25MG LOOP DIURETICS BRAND Covered TIER 3 

EDEX KIT 10MCG 









ED‐FLEX CAP 



EDLUAR SUB 10MG 


HYPNOTICS,MISC. BRAND Covered TIER 3 QL 

EDLUAR SUB 5MG 



ED‐SPAZ TAB 0.125MG 



EDURANT TAB 25MG 

NONNUCLEOSIDE 




138

EEMT TAB ESTROGENS GENERIC Excluded TIER 99 

EEMT HS TAB ESTROGENS GENERIC Excluded TIER 99 

EES/SULFISOX SUS 200‐600 ERYTHROMYCINS GENERIC Covered TIER 1 

EFFER‐K TAB 10MEQ REPLACEMENT PREPARATIONS BRAND Covered TIER 2 

EFFER‐K TAB 20MEQ REPLACEMENT PREPARATIONS BRAND Covered TIER 2 

EFFER‐K TAB 25MEQ EF REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

EFFEXOR XR CAP 150MG 


REUPTAKE INHIBTR Brand‐O PA TIER 3 QL 

EFFEXOR XR CAP 37.5MG 



EFFEXOR XR CAP 75MG 



EFFIENT TAB 10MG PLATELET‐AGGREGATION INHIBITORS BRAND Covered TIER 2 

EFFIENT TAB 5MG PLATELET‐AGGREGATION INHIBITORS BRAND Covered TIER 2 

EFLOW SCF MIS AEROSOL DEVICES BRAND Excluded TIER 99 

EFLOW SCF MIS NEBULIZR DEVICES BRAND Excluded TIER 99 

EFUDEX CRE 5% 



EGGNOG LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

EGRIFTA INJ 1MG SOMATOTROPIN AGONISTS BRAND PA TIER 3 QL SP 

EGRIFTA SOL 2MG SOMATOTROPIN AGONISTS BRAND PA TIER 3 

ELAPRASE INJ 6MG/3ML ENZYMES BRAND Covered TIER 2 SP 

ELDEPRYL CAP 5MG MONOAMINE OXIDASE B INHIBITORS Brand‐O PA TIER 3 

ELDOPAQUE CRE 4% FORTE DEPIGMENTING AGENTS Brand‐O PA TIER 99 

ELDOQUIN CRE 4% FORTE DEPIGMENTING AGENTS Brand‐O PA TIER 99 

ELELYSO INJ 200UNIT ENZYMES BRAND Covered TIER 3 

ELESTAT DRO 0.05% ANTIALLERGIC AGENTS Brand‐O PA TIER 3 



139

ELESTRIN GEL 0.06% ESTROGENS BRAND Covered TIER 3 

ELETONE CRE 



ELIDEL CRE 1% 


AGENTS, MISC. BRAND Covered TIER 2 QL 

ELIGARD INJ 22.5MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

ELIGARD INJ 30MG ANTINEOPLASTIC AGENTS BRAND PA TIER 3 SP 

ELIGARD INJ 45MG ANTINEOPLASTIC AGENTS BRAND PA TIER 3 SP 

ELIGARD INJ 7.5MG ANTINEOPLASTIC AGENTS BRAND PA TIER 3 SP 

ELIMITE CRE 5% SCABICIDES AND PEDICULICIDES Brand‐O PA TIER 3 

ELINEST TAB CONTRACEPTIVES GENERIC Covered TIER 1 

ELIPHOS TAB 667MG REPLACEMENT PREPARATIONS Brand‐O PA TIER 3 

ELITE DC AUT MIS ADAPTER DEVICES BRAND Excluded TIER 99 

ELITE OB CAP W/DHA MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

ELITE SYSTEM MIS NEBULIZR DEVICES BRAND Excluded TIER 99 

ELITEK INJ 1.5MG ENZYMES BRAND Covered TIER 3 SP 

ELITEK INJ 7.5MG ENZYMES BRAND Covered TIER 3 SP 

ELITE‐OB TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

ELITE‐OB 400 CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

ELIXOPHYLLIN ELX 80/15ML 



ELLA TAB 30MG CONTRACEPTIVES BRAND Covered TIER 2 

ELLENCE INJ 2MG/ML ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

ELLIOTTS B INJ REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

ELMIRON CAP 100MG 



ELOCON CRE 0.1% 



ELOCON LOT 0.1% 





140

ELOCON OIN 0.1% 



ELOXATIN INJ 100MG ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

ELOXATIN INJ 200MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

ELOXATIN INJ 50MG ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

ELSPAR INJ 10000UNT ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

EMADINE SOL 0.05% OP ANTIALLERGIC AGENTS BRAND Covered TIER 3 

EMCYT CAP 140MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

EMEND CAP 125MG ANTIEMETICS, MISCELLANEOUS BRAND Covered TIER 2 QL 



EMEND PAK 80 & 125 ANTIEMETICS, MISCELLANEOUS BRAND Covered TIER 2 QL 

EMEND SOL 150MG ANTIEMETICS, MISCELLANEOUS BRAND Covered TIER 3 

EMJOI TENS MIS DEVICES BRAND Excluded TIER 99 

EMLA CRE 



EMOLLIENT CRE PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

EMOQUETTE TAB CONTRACEPTIVES GENERIC Covered TIER 1 

EMSAM DIS 12MG/24H MONOAMINE OXIDASE B INHIBITORS BRAND Covered TIER 3 

EMSAM DIS 6MG/24HR MONOAMINE OXIDASE B INHIBITORS BRAND Covered TIER 3 

EMSAM DIS 9MG/24HR MONOAMINE OXIDASE B INHIBITORS BRAND Covered TIER 3 


EMTRIVA CAP 200MG 

REV.TRNSCRIP.INHIB BRAND Covered TIER 2 

EMTRIVA SOL 10MG/ML 



EMULGADE CM LIQ PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

EMULSIFIX LIQ 205 BASE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 



141

EMULSIFYING MIS WAX 


PROTECTANTS GENERIC Excluded TIER 99 

EMULSION LIQ CONCENTR PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

EMULSION SB EMU 



ENABLEX TAB 15MG 



ENABLEX TAB 7.5MG 



ENALAPR/HCTZ TAB 10‐25MG 



ENALAPR/HCTZ TAB 5‐12.5MG 



ENALAPRIL TAB 10MG 



ENALAPRIL TAB 2.5MG 









ENALAPRILAT INJ 1.25/ML 



ENBREL INJ 25/0.5ML 



ENBREL INJ 25MG 



ENBREL INJ 50MG/ML 





142

ENBREL SRCLK INJ 50MG/ML 



ENDO AVITENE MIS 10MM DIA HEMOSTATICS BRAND Excluded TIER 99 

ENDO AVITENE MIS 5MM DIA HEMOSTATICS BRAND Excluded TIER 99 

ENDOCET TAB 10‐325MG OPIATE AGONISTS GENERIC Covered TIER 1 QL 



ENDOCET TAB 7.5‐325M OPIATE AGONISTS GENERIC Covered TIER 1 QL 

ENDOCET TAB 7.5‐500M OPIATE AGONISTS GENERIC Covered TIER 1 QL 

ENDODAN TAB OPIATE AGONISTS GENERIC Covered TIER 1 QL 

ENDOMETRIN SUP 100MG PROGESTINS BRAND PA TIER 2 SP 

ENDRATE INJ 150MG/ML HEAVY METAL ANTAGONISTS BRAND Covered TIER 3 

ENG TOFFEE LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

ENGERIX‐B INJ 10/0.5ML VACCINES BRAND Covered TIER 3 

ENGERIX‐B INJ 20MCG/ML VACCINES BRAND Covered TIER 3 

ENGYSTOL INJ 



ENJUVIA TAB 0.3MG ESTROGENS BRAND Covered TIER 2 





ENLON INJ 150/15ML MYASTHENIA GRAVIS BRAND Covered TIER 3 

ENLON‐PLUS INJ 10‐0.14 



ENLYTE CAP CALORIC AGENTS BRAND Excluded TIER 99 

ENOXAPARIN INJ 100MG/ML HEPARINS GENERIC Covered TIER 1 

ENOXAPARIN INJ 120/0.8 HEPARINS GENERIC Covered TIER 1 

ENOXAPARIN INJ 150MG/ML HEPARINS GENERIC Covered TIER 1 

ENOXAPARIN INJ 30/0.3ML HEPARINS GENERIC Covered TIER 1 



143

ENOXAPARIN INJ 300/3ML HEPARINS GENERIC Covered TIER 1 




ENPRESSE‐28 TAB CONTRACEPTIVES GENERIC Covered TIER 1 

ENTACAPONE TAB 200MG 


METHYLTRANSFERASE(COMT)INHIB. GENERIC Covered TIER 1 

ENTENSION ST MIS 4 FOOT DEVICES BRAND Excluded TIER 99 

ENTERAL PUMP MIS JOEY DEVICES BRAND Excluded TIER 99 

ENTEREG CAP 12MG GI DRUGS, MISCELLANEOUS BRAND Covered TIER 3 

ENTERO VU POW 13% ROENTGENOGRAPHY BRAND Covered TIER 3 

ENTERO VU SUS 13% ROENTGENOGRAPHY BRAND Covered TIER 3 

ENTERO VU SUS 24% ROENTGENOGRAPHY BRAND Covered TIER 3 

ENTOCORT EC CAP 3MG/24HR ADRENALS Brand‐O PA TIER 3 

ENTRE‐B SUS 6‐10MG/5 PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

ENULOSE SOL 10GM/15 AMMONIA DETOXICANTS GENERIC Covered TIER 1 

EOVIST INJ DIAGNOSTIC AGENTS BRAND Excluded TIER 99 

EPHEDRINE SU INJ 50MG/ML 



EPICERAM EMU 



EPIDRIN CAP 



EPIDUO GEL 0.1‐2.5% 



EPIDUR NEEDL MIS 18GX2.5" DEVICES BRAND Excluded TIER 99 

EPIDURAL KIT 17GX3.5" DEVICES BRAND Excluded TIER 99 

EPIDURAL KIT 18GX3.5" DEVICES BRAND Excluded TIER 99 

EPIFLUR CHW 0.25MG F CARIOSTATIC AGENTS GENERIC Covered TIER 1 



144

EPIFLUR CHW 0.5MG F CARIOSTATIC AGENTS GENERIC Covered TIER 1 

EPIFLUR CHW 1MG F CARIOSTATIC AGENTS GENERIC Covered TIER 1 

EPIFOAM AER 1% 



EPIKLOR POW 20MEQ REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

EPIKLOR/25 POW 25MEQ REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

EPINASTINE DRO 0.05% ANTIALLERGIC AGENTS GENERIC Covered TIER 1 

EPINEPHRINE INJ 0.15MG 



EPINEPHRINE INJ 0.1MG/ML 



EPINEPHRINE INJ 0.3MG 



EPINEPHRINE INJ 1MG/ML 



EPIPEN INJ 0.3MG 



EPIPEN 2‐PAK INJ 0.3MG 



EPIPEN‐JR INJ 0.15MG 



EPIPEN‐JR INJ 2‐PAK 



EPIQUIN MICR CRE 4% DEPIGMENTING AGENTS Brand‐O PA TIER 99 

EPIQUIN MICR CRE 4% PUMP DEPIGMENTING AGENTS Brand‐O PA TIER 99 

EPIRUBICIN INJ 200MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

EPIRUBICIN INJ 50/25ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

EPIRUBICIN INJ 50MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

EPISIL LIQ 





145

EPITOL TAB 200MG 



EPIVIR SOL 10MG/ML 



EPIVIR TAB 150MG 



EPIVIR TAB 300MG 



EPIVIR HBV SOL 5MG/ML 



EPIVIR HBV TAB 100MG 



EPLERENONE TAB 25MG 


(ALDOSTERONE) ANTAGNTS GENERIC Covered TIER 1 

EPLERENONE TAB 50MG 



EPOGEN INJ 10000/ML HEMATOPOIETIC AGENTS BRAND PA TIER 3 SP 





EPOPROSTENOL INJ 0.5MG 


MISCELLANEOUS GENERIC PA TIER 1 SP 

EPOPROSTENOL INJ 1.5MG 


MISCELLANEOUS GENERIC PA TIER 1 SP 

EPROSART MES TAB 600MG 


ANTAGONISTS GENERIC Covered TIER 1 

EPZICOM TAB 





146

EQUAGESIC TAB 200‐325 


HYPNOTICS,MISC. BRAND Covered TIER 3 

EQUETRO CAP 100MG 









ERAXIS INJ 100MG ECHINOCANDINS BRAND Covered TIER 3 

ERAXIS INJ 50MG ECHINOCANDINS BRAND Covered TIER 3 

ERBITUX INJ 100MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

ERBITUX INJ 200MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

ERECAID KIT CLASSIC DEVICES BRAND Excluded TIER 99 

ERECAID KIT ESTEEM DEVICES BRAND Excluded TIER 99 

ERGOCALCIFER CAP 50000UNT VITAMIN D GENERIC Covered TIER 1 

ERGOLOID MES TAB 1MG ORAL 



ERGOMAR SUB 2MG 


BLOCKING AGENTS BRAND Covered TIER 2 

ERGOTAM/CAFF TAB 1/100 



ERIVEDGE CAP 150MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

EROS‐CTD MIS DEVICES BRAND Excluded TIER 99 

ERRIN TAB 0.35MG CONTRACEPTIVES GENERIC Covered TIER 1 

ERTACZO CRE 2% 



ERWINAZE INJ 10000UNT ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 

ERY PAD 2% 



ERYPED SUS 200/5ML ERYTHROMYCINS BRAND Covered TIER 3 



147

ERYPED SUS 400/5ML ERYTHROMYCINS BRAND Covered TIER 3 

ERYSIDORON LIQ #1 



ERYSIDORON TAB #2 



ERY‐TAB TAB 250MG EC ERYTHROMYCINS BRAND Covered TIER 3 



ERYTHROCIN INJ 1000MG ERYTHROMYCINS BRAND Covered TIER 3 

ERYTHROCIN INJ 500MG ERYTHROMYCINS BRAND Covered TIER 3 


ERYTHROCIN TAB 250MG ERYTHROMYCINS BRAND Covered TIER 3 


ERYTHROM ETH TAB 400MG ERYTHROMYCINS GENERIC Covered TIER 1 

ERYTHROMYCIN CAP 250MG EC ERYTHROMYCINS GENERIC Covered TIER 1 

ERYTHROMYCIN GEL /BENZOYL 



ERYTHROMYCIN GEL 2% 



ERYTHROMYCIN OIN OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

ERYTHROMYCIN PAD 2% 



ERYTHROMYCIN SOL 2% 



ERYTHROMYCIN TAB 250MG BS ERYTHROMYCINS GENERIC Covered TIER 1 

ERYTHROMYCIN TAB 500MG BS ERYTHROMYCINS GENERIC Covered TIER 1 

ESCAVITE CHW MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

ESCITALOPRAM SOL 5MG/5ML 





148

ESCITALOPRAM TAB 10MG 









ESGIC CAP 



ESGIC TAB 



ESGIC‐PLUS CAP 



ESGIC‐PLUS TAB 



ESMOLOL HCL INJ 100MG/10 



ESMOLOL HCL INJ 10MG/ML 



ESOPHO‐CAT CRE 3% ROENTGENOGRAPHY BRAND Covered TIER 3 

ESSIAN TAB ESTROGENS GENERIC Excluded TIER 99 

ESSIAN H.S. TAB ESTROGENS GENERIC Excluded TIER 99 

EST ESTROGEN TAB MTEST ESTROGENS GENERIC Excluded TIER 99 

EST ESTROGEN TAB MTEST DS ESTROGENS GENERIC Excluded TIER 99 

EST ESTROGEN TAB MTEST HS ESTROGENS GENERIC Excluded TIER 99 

ESTAZOLAM TAB 1MG 



ESTAZOLAM TAB 2MG 



ESTRA/NORETH TAB 0.5‐0.1 ESTROGENS GENERIC Covered TIER 1 

ESTRA/NORETH TAB 1‐0.5MG ESTROGENS GENERIC Covered TIER 1 



149

ESTRACE TAB 0.5MG ESTROGENS Brand‐O PA TIER 3 

ESTRACE TAB 1MG ESTROGENS Brand‐O PA TIER 3 

ESTRACE TAB 2MG ESTROGENS Brand‐O PA TIER 3 

ESTRACE VAG CRE 0.1MG/GM ESTROGENS BRAND Covered TIER 2 

ESTRAD VAL INJ 10MG/ML ESTROGENS GENERIC Covered TIER 1 

ESTRAD VAL INJ 200MG/5 ESTROGENS GENERIC Covered TIER 1 



ESTRADERM DIS 0.05MG ESTROGENS BRAND Covered TIER 3 

ESTRADERM DIS 0.1MG ESTROGENS BRAND Covered TIER 3 

ESTRADIOL DIS 0.025MG ESTROGENS GENERIC Covered TIER 1 






ESTRADIOL TAB 0.5MG ESTROGENS GENERIC Covered TIER 1 

ESTRADIOL TAB 1MG ESTROGENS GENERIC Covered TIER 1 

ESTRADIOL TAB 2MG ESTROGENS GENERIC Covered TIER 1 

ESTRASORB EMU ESTROGENS BRAND Covered TIER 3 

ESTRING MIS 2MG ESTROGENS BRAND Covered TIER 2 

ESTROGEL GEL ESTROGENS BRAND Covered TIER 3 

ESTRONE CRY USP ESTROGENS GENERIC Excluded TIER 99 

ESTROPIPATE TAB 0.75MG ESTROGENS GENERIC Covered TIER 1 

ESTROPIPATE TAB 1.5MG ESTROGENS GENERIC Covered TIER 1 

ESTROPIPATE TAB 3MG ESTROGENS GENERIC Covered TIER 1 

ESTROSTEP FE TAB CONTRACEPTIVES Brand‐O PA TIER 3 

ETHAMBUTOL TAB 100MG ANTITUBERCULOSIS AGENTS GENERIC Covered TIER 1 

ETHAMBUTOL TAB 400MG ANTITUBERCULOSIS AGENTS GENERIC Covered TIER 1 

ETHAMOLIN INJ 5% SCLEROSING AGENTS BRAND Covered TIER 3 



150

ETHOSUXIMIDE CAP 250MG SUCCINIMIDES GENERIC Covered TIER 1 

ETHOSUXIMIDE SOL 250/5ML SUCCINIMIDES GENERIC Covered TIER 1 

ETHRANE INH INHALATION ANESTHETICS Brand‐O PA TIER 3 

ETHYL ACETAT SOL PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

ETHYL ALCOHO SOL 100% 



ETHYL CHLOR AER FINE PIN 


ANESTHETICS GENERIC Covered TIER 1 

ETHYL CHLOR AER FN STRM 



ETHYL CHLOR AER MED JET 



ETHYL CHLOR AER MED STRM 



ETHYL CHLOR AER MIST 



ETHYL CHLOR AER SPRAY 



ETHYOL INJ 500MG PROTECTIVE AGENTS Brand‐O PA TIER 3 SP 

ETIDRON DISD TAB 200MG BONE RESORPTION INHIBITORS GENERIC Covered TIER 1 

ETIDRON DISD TAB 400MG BONE RESORPTION INHIBITORS GENERIC Covered TIER 1 

ETODOLAC CAP 200MG 



ETODOLAC CAP 300MG 



ETODOLAC TAB 400MG 



ETODOLAC TAB 500MG 





151

ETODOLAC ER TAB 400MG 









ETOMIDATE INJ 2MG/ML 



ETOPOPHOS INJ 100MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

ETOPOSIDE CAP 50MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

ETOPOSIDE INJ 20MG/ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

EUCALYPTOL LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

EUCALYPTUS OIL BASIC LOTIONS AND LINIMENTS GENERIC Covered TIER 1 

EUCALYPTUS OIL FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

EUFLEXXA INJ 10MG/ML 



EUGENOL LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

EURAX CRE 10% SCABICIDES AND PEDICULICIDES BRAND Covered TIER 2 

EURAX LOT 10% SCABICIDES AND PEDICULICIDES BRAND Covered TIER 2 

EVAMIST SPR 1.53MG ESTROGENS BRAND Covered TIER 2 

EVICEL KIT 2ML 



EVICEL KIT 5ML 



EVISTA TAB 60MG ESTROGEN AGONIST‐ANTAGONISTS BRAND Covered TIER 2 

EVITHROM SOL 800‐1200 HEMOSTATICS BRAND Covered TIER 3 

EVOCLIN AER 1% 





152

EVOXAC CAP 30MG 



EXACTACAIN AER 



EXACTUSS LIQ ANTITUSSIVES BRAND Excluded TIER 99 

EXALGO TAB 12MG OPIATE AGONISTS BRAND Covered TIER 3 QL 


EXALGO TAB 32MG OPIATE AGONISTS BRAND Covered TIER 3 


EXALL LIQ 10‐100MG ANTITUSSIVES BRAND Excluded TIER 99 

EXALL‐D LIQ ANTITUSSIVES BRAND Excluded TIER 99 

EXEFEN‐IR TAB 60‐400MG EXPECTORANTS GENERIC Covered TIER 1 

EXELDERM CRE 1% 



EXELDERM SOL 1% 



EXELON CAP 1.5MG 



EXELON CAP 3MG 



EXELON CAP 4.5MG 



EXELON CAP 6MG 



EXELON DIS 13.3/24 



EXELON DIS 4.6MG/24 



EXELON DIS 9.5MG/24 





153

EXELON SOL 2MG/ML 



EXEMESTANE TAB 25MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

EXFORGE TAB 10‐160MG DIHYDROPYRIDINES BRAND Covered TIER 2 




EXFORGEH/10‐ TAB 160‐12.5 DIHYDROPYRIDINES BRAND Covered TIER 2 

EXFORGEH/10‐ TAB 160‐25 DIHYDROPYRIDINES BRAND Covered TIER 2 


EXFORGEH/5‐ TAB 160‐12.5 DIHYDROPYRIDINES BRAND Covered TIER 2 


EXJADE TAB 125MG HEAVY METAL ANTAGONISTS BRAND PA TIER 3 



EXODERM LOT 25‐1% 


MEMBRANE),MISC GENERIC Covered TIER 1 

EXOTIC‐HC DRO OTIC CORTICOSTEROIDS (EENT) GENERIC Excluded TIER 99 

EXPAREL INJ 1.3% LOCAL ANESTHETICS (PARENTERAL) BRAND Covered TIER 3 

EXPECTUSS LIQ 20‐75MG/ ANTITUSSIVES GENERIC Covered TIER 1 

EXTAVIA INJ 0.3MG BIOLOGIC RESPONSE MODIFIERS BRAND Covered TIER 3 SP 

EXTENDER CAP MIS 1ML/3ML DEVICES BRAND Excluded TIER 99 

EXTENSION MIS SET DEVICES BRAND Excluded TIER 99 

EXTINA AER 2% 



EXTRANEAL SOL IRRIGATING SOLUTIONS BRAND Covered TIER 3 

EYLEA INJ 2/0.05ML EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 3 

E‐Z SPACER MIS DEVICES BRAND Excluded TIER 99 

E‐Z SPACER MIS BODY GRD DEVICES BRAND Excluded TIER 99 



154

E‐Z‐CAT DRY PAK ROENTGENOGRAPHY BRAND Covered TIER 3 

E‐Z‐DISK TAB 700MG ROENTGENOGRAPHY BRAND Covered TIER 3 

E‐Z‐DOSE ENE ROENTGENOGRAPHY BRAND Covered TIER 3 

E‐Z‐HD SUS 98% ROENTGENOGRAPHY BRAND Covered TIER 3 

E‐Z‐PAQUE SUS 60% ROENTGENOGRAPHY BRAND Covered TIER 3 

E‐Z‐PAQUE SUS 96% ROENTGENOGRAPHY BRAND Covered TIER 3 

E‐Z‐PASTE CRE 60% ROENTGENOGRAPHY BRAND Covered TIER 3 

FA‐B6‐B12 TAB VITAMIN B COMPLEX GENERIC Covered TIER 1 

FABB TAB VITAMIN B COMPLEX GENERIC Covered TIER 1 

FABRAZYME INJ 35MG ENZYMES BRAND Covered TIER 2 SP 

FABRAZYME INJ 5MG ENZYMES BRAND Covered TIER 2 SP 

FACTIVE TAB 320MG QUINOLONES BRAND Covered TIER 3 

FALMINA TAB CONTRACEPTIVES GENERIC Covered TIER 1 

FAMCICLOVIR TAB 125MG NUCLEOSIDES AND NUCLEOTIDES GENERIC Covered TIER 1 



FAMOTIDINE INJ 10MG/ML HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

FAMOTIDINE INJ 200/20ML HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

FAMOTIDINE INJ 20MG/2ML HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

FAMOTIDINE INJ 20MG/50M HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

FAMOTIDINE INJ 40MG/4ML HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

FAMOTIDINE SUS 40MG/5ML HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

FAMOTIDINE TAB 20MG HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

FAMOTIDINE TAB 40MG HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

FAMVIR TAB 125MG NUCLEOSIDES AND NUCLEOTIDES Brand‐O PA TIER 3 



FANAPT PAK ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 3 

FANAPT TAB 10MG ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 3 QL 




155






FARESTON TAB 60MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 

FASLODEX INJ 250MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

FAZACLO TAB 100MG ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 3 

FAZACLO TAB 12.5MG ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 3 




FE C PLUS TAB IRON PREPARATIONS GENERIC Covered TIER 1 

FEED/IRRIGAT MIS KIT DEVICES BRAND Excluded TIER 99 

FEEDING SET MIS 5FR 16" DEVICES BRAND Excluded TIER 99 

FEEDING SET MIS 8FR 16" DEVICES BRAND Excluded TIER 99 

FEEDING TUBE MIS 10FR 42" DEVICES BRAND Excluded TIER 99 






FEEDING TUBE MIS 3.5FR12" DEVICES BRAND Excluded TIER 99 










156







FEEDING TUBE MIS 9FR/16FR DEVICES BRAND Excluded TIER 99 

FEEDING TUBE MIS SYSTEM DEVICES BRAND Excluded TIER 99 

FEIBA NF INJ HEMOSTATICS BRAND PA TIER 3 SP 

FEIBA VH INJ IMMUNO HEMOSTATICS BRAND PA TIER 3 SP 

GENERIC PA TIER 1 SP 

FELBAMATE SUS 600/5ML 



FELBAMATE TAB 400MG 



FELBAMATE TAB 600MG 



FELBATOL SUS 600/5ML 



FELBATOL TAB 400MG 



FELBATOL TAB 600MG 



FELDENE CAP 10MG 



FELDENE CAP 20MG 



FELODIPINE TAB 10MG ER DIHYDROPYRIDINES GENERIC Covered TIER 1 

FELODIPINE TAB 2.5MG ER DIHYDROPYRIDINES GENERIC Covered TIER 1 

FELODIPINE TAB 5MG ER DIHYDROPYRIDINES GENERIC Covered TIER 1 



157

FEM PH GEL 



FEMARA TAB 2.5MG ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 

FEMCAP MIS 22MM 

CONTRACEPTIVES (E.G. FOAMS, 

DEVICES) BRAND Covered TIER 3 







FEMCON FE CHW CONTRACEPTIVES Brand‐O PA TIER 3 

FEMHRT TAB 0.5‐2.5 ESTROGENS BRAND Covered TIER 3 

FEMHRT 1/5 TAB ESTROGENS Brand‐O PA TIER 3 

FEMRING MIS 0.05/24H ESTROGENS BRAND Covered TIER 3 

FEMRING MIS 0.1MG/24 ESTROGENS BRAND Covered TIER 3 

FEMTRACE TAB 0.45MG ESTROGENS BRAND Covered TIER 3 



FENOFIBRATE CAP 134MG FIBRIC ACID DERIVATIVES GENERIC Covered TIER 1 QL 



FENOFIBRATE TAB 160MG FIBRIC ACID DERIVATIVES GENERIC Covered TIER 1 QL 

FENOFIBRATE TAB 54MG FIBRIC ACID DERIVATIVES GENERIC Covered TIER 1 QL 

FENOFIBRIC TAB 105MG FIBRIC ACID DERIVATIVES GENERIC Covered TIER 1 QL 

FENOFIBRIC TAB 35MG FIBRIC ACID DERIVATIVES GENERIC Covered TIER 1 QL 

FENOGLIDE TAB 120MG FIBRIC ACID DERIVATIVES BRAND Covered TIER 2 QL 

FENOGLIDE TAB 40MG FIBRIC ACID DERIVATIVES BRAND Covered TIER 2 QL 

FENOLDOPAM INJ 10MG/ML DIRECT VASODILATORS GENERIC Covered TIER 1 

FENOLDOPAM INJ 20MG/2ML DIRECT VASODILATORS GENERIC Covered TIER 1 

FENOPROFEN TAB 600MG 





158

FENTANYL DIS 100MCG/H OPIATE AGONISTS GENERIC Covered TIER 1 QL 

FENTANYL DIS 12MCG/HR OPIATE AGONISTS GENERIC Covered TIER 1 QL 




FENTANYL CIT INJ 0.05MG/1 OPIATE AGONISTS GENERIC Covered TIER 1 

FENTANYL CIT INJ 1000MCG OPIATE AGONISTS GENERIC Covered TIER 1 




FENTANYL OT LOZ 1200MCG OPIATE AGONISTS GENERIC Covered TIER 1 QL 






FENTORA TAB 100MCG OPIATE AGONISTS BRAND Covered TIER 2 QL 





FERAHEME INJ 510/17ML IRON PREPARATIONS BRAND Covered TIER 3 

FERGUSN CATH MIS 28FR DEVICES BRAND Excluded TIER 99 



FERIDEX I.V. INJ 11.2MF F ROENTGENOGRAPHY BRAND Covered TIER 3 

FEROCON CAP IRON PREPARATIONS GENERIC Covered TIER 1 

FEROTRIN CAP IRON PREPARATIONS GENERIC Covered TIER 1 

FEROTRINSIC CAP IRON PREPARATIONS GENERIC Covered TIER 1 

FERRALET 90 TAB IRON PREPARATIONS BRAND Covered TIER 3 



159

FERRAPLUS 90 TAB IRON PREPARATIONS GENERIC Covered TIER 1 

FERREX 150 CAP FORTE IRON PREPARATIONS GENERIC Covered TIER 1 

FERREX 150 CAP FORTE PL IRON PREPARATIONS GENERIC Covered TIER 1 

FERREX 28 TAB IRON PREPARATIONS GENERIC Covered TIER 1 

FERRIC GLUCO INJ 12.5MG/M IRON PREPARATIONS GENERIC Covered TIER 1 

FERRIPROX TAB 500MG HEAVY METAL ANTAGONISTS BRAND PA TIER 3 

FERRLECIT INJ 12.5MG/M IRON PREPARATIONS Brand‐O PA TIER 3 

FERROCITE TAB PLUS IRON PREPARATIONS GENERIC Covered TIER 1 

FERROGELS FO CAP FORTE IRON PREPARATIONS GENERIC Covered TIER 1 

FERRO‐PLEX TAB IRON PREPARATIONS BRAND Covered TIER 3 

FERROTRIN CAP IRON PREPARATIONS BRAND Covered TIER 3 

FETRIN CAP IRON PREPARATIONS BRAND Covered TIER 3 

FEXMID TAB 7.5MG 


MUSCLE RELAXNT Brand‐O PA TIER 3 

FEXOFEN/PSE TAB 60‐120MG 



FEXOFENADINE TAB 180MG 









FIBRICOR TAB 105MG FIBRIC ACID DERIVATIVES BRAND Covered TIER 3 QL 

FIBRICOR TAB 35MG FIBRIC ACID DERIVATIVES BRAND Covered TIER 3 QL 

FILTER AIR MIS PP DEVICES GENERIC Excluded TIER 99 

FILTER ASPIR MIS 18GX3" DEVICES BRAND Excluded TIER 99 

FILTER CONN MIS 5 MICRON DEVICES BRAND Excluded TIER 99 

FILTER NEEDL MIS 18GX1" DEVICES BRAND Excluded TIER 99 

FILTER NEEDL MIS 20GX1.5" DEVICES BRAND Excluded TIER 99 



160

FINACEA GEL 15% 



FINACEA PLUS KIT 



FINASTERIDE TAB 5MG 5‐ALPHA‐REDUCTASE INHIBITORS GENERIC Covered TIER 1 QL 

FINGER GRIP MIS EXTENDER DEVICES BRAND Excluded TIER 99 

FIORICET TAB 



FIORICET/COD CAP OPIATE AGONISTS Brand‐O PA TIER 3 

FIORINAL CAP SALICYLATES Brand‐O PA TIER 3 

FIORINAL/COD CAP 30MG OPIATE AGONISTS Brand‐O PA TIER 3 

FIRAZYR INJ 30MG/3ML COMPLEMENT INHIBITORS BRAND PA TIER 3 SP 

FIRMAGON INJ 120MG ANTINEOPLASTIC AGENTS BRAND PA TIER 2 


FIRMAGON INJ 80MG ANTINEOPLASTIC AGENTS BRAND PA TIER 2 


FIRST DUKES SUS MOUTHWSH POLYENES BRAND Covered TIER 3 

FIRST‐MARYS SUS MOUTHWSH POLYENES BRAND Covered TIER 3 

FIRST‐MOUTHW SUS BLM 



FIRST‐OMEPRA SUS 2MG/ML PROTON‐PUMP INHIBITORS BRAND Covered TIER 3 

FIRST‐TESTOS CRE MC 2% ANDROGENS BRAND Covered TIER 3 

FIRST‐TESTOS OIN 2% ANDROGENS BRAND Covered TIER 3 

FISH FLAVOR LIQ PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

FLAGYL CAP 375MG ANTIPROTOZOALS, MISCELLANEOUS Brand‐O PA TIER 3 

FLAGYL TAB 250MG ANTIPROTOZOALS, MISCELLANEOUS Brand‐O PA TIER 3 

FLAGYL TAB 500MG ANTIPROTOZOALS, MISCELLANEOUS Brand‐O PA TIER 3 



161

FLAGYL ER TAB 750MG ANTIPROTOZOALS, MISCELLANEOUS BRAND Covered TIER 3 

FLAREX SUS 0.1% OP CORTICOSTEROIDS (EENT) BRAND Covered TIER 3 

FLAVOR BLEND SUS PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

FLAVOR PLUS LIQ PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

FLAVOR SWEET LIQ S/F PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

FLAVOR SWEET SYP PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

FLAVOXATE TAB 100MG 



FLEBOGAMMA INJ 10% SERUMS BRAND PA TIER 3 SP 

FLEBOGAMMA INJ 5% SERUMS GENERIC PA TIER 1 SP 

FLEBOGAMMA INJ DIF 5% SERUMS BRAND PA TIER 3 SP 

FLECAINIDE TAB 100MG CLASS IC ANTIARRHYTHMICS GENERIC Covered TIER 1 




FLECTOR DIS 1.3% 


FLEXBUMIN INJ 25% BLOOD DERIVATIVES GENERIC Covered TIER 1 

FLEXERIL TAB 10MG 



FLEXERIL TAB 5MG 



FLEXI‐SEAL MIS FMS DEVICES BRAND Excluded TIER 99 

FLEXLINK MIS PLS/10MM DEVICES BRAND Covered TIER 3 

FLEXLINK MIS PLUS/6MM DEVICES BRAND Covered TIER 3 

FLEXLINK MIS PLUS/8MM DEVICES BRAND Covered TIER 3 

FLEXTRA CAP ETHANOLAMINE DERIVATIVES BRAND Covered TIER 3 

FLEXTRA DS TAB 50‐500MG ETHANOLAMINE DERIVATIVES Brand‐O PA TIER 3 

FLEXTRA‐650 TAB ETHANOLAMINE DERIVATIVES Brand‐O PA TIER 3 



162

FLOLAN INJ 0.5MG 


MISCELLANEOUS Brand‐O PA TIER 2 SP 

FLOLAN INJ 1.5MG 


MISCELLANEOUS Brand‐O PA TIER 2 SP 

FLOMAX CAP 0.4MG 


BLOCK.AGENT Brand‐O PA TIER 3 

FLONASE SPR 0.05% CORTICOSTEROIDS (EENT) Brand‐O PA TIER 3 

FLO‐PRED SUS ADRENALS BRAND Covered TIER 3 

FLOVENT DISK AER 100MCG ADRENALS BRAND Covered TIER 2 QL 



FLOVENT HFA AER 110MCG ADRENALS BRAND Covered TIER 2 QL 



FLOXURIDINE INJ 0.5GM ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

FLUARIX INJ PF 10‐11 VACCINES BRAND Covered TIER 3 



FLUCAINE SOL 0.25‐0.5 OCULAR DISORDERS GENERIC Covered TIER 1 

FLUCONAZOLE SUS 10MG/ML AZOLES GENERIC Covered TIER 1 

FLUCONAZOLE SUS 40MG/ML AZOLES GENERIC Covered TIER 1 

FLUCONAZOLE TAB 100MG AZOLES GENERIC Covered TIER 1 




FLUCONAZOLE/ INJ DEX 200 AZOLES GENERIC Covered TIER 1 

FLUCONAZOLE/ INJ DEX 400 AZOLES GENERIC Covered TIER 1 

FLUCONAZOLE/ INJ NACL 100 AZOLES GENERIC Covered TIER 1 





163

FLUCYTOSINE CAP 250MG PYRIMIDINES GENERIC Covered TIER 1 

FLUCYTOSINE CAP 500MG PYRIMIDINES GENERIC Covered TIER 1 

FLUDARA INJ 50MG ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

FLUDARABINE INJ 50MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

FLUDARABINE INJ 50MG/2ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

FLUDROCORT TAB 0.1MG ADRENALS GENERIC Covered TIER 1 

FLULAVAL INJ 2010‐11 VACCINES BRAND Covered TIER 3 



FLUMADINE TAB 100MG ADAMANTANES Brand‐O PA TIER 3 

FLUMAZENIL INJ 0.1MG/ML 



FLUMAZENIL INJ 0.5MG/5 



FLUMAZENIL INJ 1MG/10ML 



FLUMIST NASA LIQ 2010‐11 VACCINES BRAND Covered TIER 3 



FLUNISOLIDE SPR 0.025% CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

FLUNISOLIDE SPR 29MCG CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

FLUOCIN ACET CRE 0.01% 



FLUOCIN ACET CRE 0.025% 



FLUOCIN ACET OIL 0.01% CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

FLUOCIN ACET OIL BODY 



FLUOCIN ACET OIL SCALP 





164

FLUOCIN ACET OIN 0.025% 



FLUOCIN ACET SOL 0.01% 



FLUOCINONIDE CRE 0.05% 



FLUOCINONIDE CRE ‐E 0.05% 



FLUOCINONIDE GEL 0.05% 



FLUOCINONIDE OIN 0.05% 



FLUOCINONIDE SOL 0.05% 



FLUORABON DRO CARIOSTATIC AGENTS BRAND Covered TIER 2 

FLUORACAINE SOL OP OCULAR DISORDERS Brand‐O PA TIER 3 

FLUOR‐A‐DAY CHW 0.25MG F CARIOSTATIC AGENTS BRAND Covered TIER 2 

FLUOR‐A‐DAY CHW 0.5MG F CARIOSTATIC AGENTS BRAND Covered TIER 2 

FLUOR‐A‐DAY CHW 1MG F CARIOSTATIC AGENTS BRAND Covered TIER 3 

FLUOR‐A‐DAY DRO 0.125MG CARIOSTATIC AGENTS GENERIC Covered TIER 1 

FLUORE‐BENOX SOL 0.25‐0.4 OCULAR DISORDERS GENERIC Covered TIER 1 

FLUORESCEIN INJ 10% OP OCULAR DISORDERS GENERIC Covered TIER 1 

FLUORESCEIN INJ 25% OP OCULAR DISORDERS GENERIC Covered TIER 1 

FLUORESCEIN/ SOL PROPARAC OCULAR DISORDERS GENERIC Covered TIER 1 

FLUORESCITE INJ 10% OP OCULAR DISORDERS Brand‐O PA TIER 3 

FLUORETS TES 1MG OP OCULAR DISORDERS GENERIC Covered TIER 1 

FLUORIDE CHW 0.25MG F CARIOSTATIC AGENTS GENERIC Covered TIER 1 

FLUORIDE CHW 0.5MG F CARIOSTATIC AGENTS GENERIC Covered TIER 1 

FLUORIDE CHW 1MG F CARIOSTATIC AGENTS GENERIC Covered TIER 1 

FLUORIDEX GEL 1.1% CARIOSTATIC AGENTS GENERIC Covered TIER 1 



165

FLUORIDEX GEL SENSITIV DENTAL AGENTS BRAND Covered TIER 3 

FLUORIDEX GEL WHITENIN CARIOSTATIC AGENTS GENERIC Covered TIER 1 

FLUORIDEX DD PST SENSITIV DENTAL AGENTS GENERIC Covered TIER 1 

FLUOR‐I‐STRI TES 1MG OP OCULAR DISORDERS GENERIC Covered TIER 1 

FLUORITAB CHW 0.25MG F CARIOSTATIC AGENTS GENERIC Covered TIER 1 

FLUORITAB CHW 0.5MG F CARIOSTATIC AGENTS GENERIC Covered TIER 1 

FLUORITAB CHW 1MG F CARIOSTATIC AGENTS GENERIC Covered TIER 1 

FLUORITAB CHW 2.2MG CARIOSTATIC AGENTS GENERIC Covered TIER 1 

FLUORITAB DRO 0.125MG CARIOSTATIC AGENTS GENERIC Covered TIER 1 

FLUOROMETHOL SUS 0.1% OP CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

FLUOR‐OP SUS 0.1% OP CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

FLUOROPLEX CRE 1% 



FLUOROURACIL CRE 5% 



FLUOROURACIL DRO 2% 



FLUOROURACIL DRO 5% 



FLUOROURACIL INJ 1GM/20ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

FLUOROURACIL INJ 2.5G/50M ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

FLUOROURACIL INJ 500MG/10 ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

FLUOROURACIL INJ 50MG/ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

FLUOROURACIL INJ 5GM/100M ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

FLUOROURACIL SOL 2% 



FLUOROURACIL SOL 5% 



FLUOXETINE CAP 10MG 





166

FLUOXETINE CAP 10MG SELECTIVE‐SEROTONIN REUPTAKE GENERIC Covered TIER 1 QL 




QL 




FLUOXETINE CAP 90MG DR 



FLUOXETINE SOL 20MG/5ML 



FLUOXETINE TAB 10MG 









FLUPHENAZ DE INJ 25MG/ML PHENOTHIAZINES GENERIC Covered TIER 1 

FLUPHENAZINE CON 5MG/ML PHENOTHIAZINES GENERIC Covered TIER 1 

FLUPHENAZINE ELX 2.5/5ML PHENOTHIAZINES GENERIC Covered TIER 1 

FLUPHENAZINE INJ 2.5MG/ML PHENOTHIAZINES GENERIC Covered TIER 1 

FLUPHENAZINE TAB 10MG PHENOTHIAZINES GENERIC Covered TIER 1 


FLUPHENAZINE TAB 2.5MG PHENOTHIAZINES GENERIC Covered TIER 1 


FLURA‐DROPS DRO 0.125MG CARIOSTATIC AGENTS GENERIC Covered TIER 1 

FLURA‐DROPS DRO 0.25MG F CARIOSTATIC AGENTS GENERIC Covered TIER 1 

FLURA‐SAFE SOL OCULAR DISORDERS BRAND Covered TIER 3 

FLURAZEPAM CAP 15MG 





167

FLURAZEPAM CAP 30MG 



FLURBIPROFEN SOL 0.03% OP 



FLURBIPROFEN TAB 100MG 



FLURBIPROFEN TAB 50MG 



FLURESS SOL OP OCULAR DISORDERS Brand‐O PA TIER 3 

FLUROX SOL OP OCULAR DISORDERS GENERIC Covered TIER 1 

FLUTAMIDE CAP 125MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

FLUTICASONE CRE 0.05% 



FLUTICASONE LOT 0.05% 



FLUTICASONE OIN 0.005% 



FLUTICASONE SPR 50MCG CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

FLUTTER MIS DEVICES GENERIC Excluded TIER 99 

FLUVASTATIN CAP 20MG HMG‐COA REDUCTASE INHIBITORS GENERIC Covered TIER 1 

FLUVASTATIN CAP 40MG HMG‐COA REDUCTASE INHIBITORS GENERIC Covered TIER 1 

FLUVIRIN INJ 2010‐11 VACCINES BRAND Covered TIER 3 



FLUVIRIN INJ PF 11‐12 VACCINES BRAND Covered TIER 3 

FLUVIRIN INJ PF 12‐13 VACCINES BRAND Covered TIER 3 

FLUVOXAMINE TAB 100MG 





168







FLUZONE INJ INTRADRM VACCINES BRAND Covered TIER 3 

FLUZONE INJ PF 10‐11 VACCINES BRAND Covered TIER 3 



FLUZONE HD INJ PF 10‐11 VACCINES BRAND Covered TIER 3 



FLUZONE PED/ INJ PF 10‐11 VACCINES BRAND Covered TIER 3 



FLUZONE SPLT INJ 2010‐11 VACCINES BRAND Covered TIER 3 



FML OIN 0.1% OP CORTICOSTEROIDS (EENT) BRAND Covered TIER 2 

FML FORTE SUS 0.25% OP CORTICOSTEROIDS (EENT) BRAND Covered TIER 3 

FML LIQUIFLM SUS 0.1% OP CORTICOSTEROIDS (EENT) Brand‐O PA TIER 3 

FOAM RING MIS 2" DEVICES GENERIC Excluded TIER 99 

FOCALIN TAB 10MG 


STIMULANTS,MISC Brand‐O PA TIER 3 QL 

FOCALIN TAB 2.5MG 



FOCALIN TAB 5MG 



FOCALIN XR CAP 10MG 





169






















FOLASTIN TAB VITAMIN B COMPLEX GENERIC Excluded TIER 99 

FOLBECAL TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

FOLBEE TAB VITAMIN B COMPLEX GENERIC Covered TIER 1 

FOLBEE AR TAB VITAMIN B COMPLEX BRAND Covered TIER 3 

FOLBEE PLUS TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

FOLBEE PLUS TAB CZ MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

FOLBIC TAB VITAMIN B COMPLEX GENERIC Excluded TIER 99 

FOLCAL DHA CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

FOLCAPS CAP OMEGA 3 MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

FOLCAPS TAB VITAMIN B COMPLEX GENERIC Covered TIER 1 

FOLEY CATH KIT 14FRENCH DEVICES BRAND Excluded TIER 99 



FOLEY TRAY KIT 14FR‐5ML DEVICES BRAND Excluded TIER 99 





170

FOLEY TRAY KIT 5ML DEVICES BRAND Excluded TIER 99 

FOLGARD OS TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

FOLGARD RX TAB VITAMIN B COMPLEX Brand‐O PA TIER 3 

FOLIC ACID INJ 5MG/ML VITAMIN B COMPLEX GENERIC Covered TIER 1 

FOLIC ACID TAB VITAMIN B COMPLEX GENERIC Excluded TIER 99 

FOLIC ACID TAB 1MG VITAMIN B COMPLEX GENERIC Covered TIER 1 

FOLITAB TAB IRON PREPARATIONS GENERIC Covered TIER 1 

FOLIVANE‐EC PAK CA DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

FOLIVANE‐F CAP IRON PREPARATIONS BRAND Covered TIER 3 

FOLIVANE‐OB CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

FOLIVANE‐PLS CAP IRON PREPARATIONS BRAND Covered TIER 3 

FOLIVANE‐PRX CAP DHA NF MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

FOLLISTIM AQ INJ 150UNIT GONADOTROPINS BRAND PA TIER 2 SP 





FOLOTYN INJ 20MG/ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

FOLOTYN INJ 40MG/2ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

FOLPACE RX TAB VITAMIN B COMPLEX BRAND Covered TIER 3 

FOLPLEX 2.2 TAB VITAMIN B COMPLEX GENERIC Covered TIER 1 

FOLTRATE TAB VITAMIN B COMPLEX BRAND Covered TIER 2 

FOLTRIN CAP IRON PREPARATIONS GENERIC Covered TIER 1 

FOLTX TAB VITAMIN B COMPLEX Brand‐O PA TIER 99 

FOMEPIZOLE INJ 1.5GM ANTIDOTES GENERIC Covered TIER 1 

FOMEPIZOLE INJ 1GM/ML ANTIDOTES GENERIC Covered TIER 1 

FONDAPARINUX SOL 10/0.8 DIRECT FACTOR XA INHIBITORS GENERIC Covered TIER 1 

FONDAPARINUX SOL 2.5/0.5 DIRECT FACTOR XA INHIBITORS GENERIC Covered TIER 1 





171

FOOD COLOR LIQ BLUE PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

FOOD COLOR LIQ GREEN PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

FOOD COLOR LIQ PINK PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

FOOD COLOR LIQ RED PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

FOOD COLOR LIQ WHITE PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

FOOD COLOR LIQ YELLOW PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

FORADIL CAP AEROLIZE 



FORANE SOL INHALATION ANESTHETICS Brand‐O PA TIER 3 

FORFIVO XL TAB 450MG ANTIDEPRESSANTS, MISCELLANEOUS BRAND Covered TIER 3 

DISINFECTANTS (FOR NON‐ 

FORMADON SOL 

DERMATOLOGIC USE) GENERIC Covered TIER 1 

FORMALDEHYDE SOL 10% 



FORMA‐RAY SOL 20% 



FORTAMET TAB 1000MG BIGUANIDES Brand‐O PA TIER 3 

FORTAMET TAB 500MG BIGUANIDES Brand‐O PA TIER 3 

FORTAVIT CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

FORTAZ INJ 1GM 






FORTAZ INJ 500MG 






FORTEO SOL 600/2.4 PARATHYROID BRAND PA TIER 2 SP 

FORTESTA GEL 10MG/ACT ANDROGENS BRAND Covered TIER 2 



172

FORTICAL SPR 200/ACT PARATHYROID GENERIC Covered TIER 1 

FOSAMAX TAB 10MG BONE RESORPTION INHIBITORS Brand‐O PA TIER 3 





FOSAMAX + D TAB 70‐2800 BONE RESORPTION INHIBITORS BRAND Covered TIER 3 

FOSAMAX + D TAB 70‐5600 BONE RESORPTION INHIBITORS BRAND Covered TIER 3 

FOSCARNET INJ 24MG/ML ANTIVIRALS, MISCELLANEOUS GENERIC Covered TIER 1 

FOSCAVIR INJ 24MG/ML ANTIVIRALS, MISCELLANEOUS BRAND Covered TIER 3 

FOSINOP/HCTZ TAB 10/12.5 



FOSINOP/HCTZ TAB 20/12.5 



FOSINOPRIL TAB 10MG 









FOSPHENYTOIN INJ 100/2ML HYDANTOINS GENERIC Covered TIER 1 

FOSPHENYTOIN INJ 500/10ML HYDANTOINS GENERIC Covered TIER 1 

FOSRENOL CHW 1000MG PHOSPHATE‐REMOVING AGENTS BRAND Covered TIER 2 



FOSTEUM CAP 



FOVEX CAP CALORIC AGENTS BRAND Excluded TIER 99 

FRAGMIN INJ 10000/ML HEPARINS BRAND Covered TIER 2 

FRAGMIN INJ 12500UNT HEPARINS BRAND Covered TIER 2 



173



FRAGMIN INJ 2500/0.2 HEPARINS BRAND Covered TIER 2 

FRAGMIN INJ 25000/ML HEPARINS BRAND Covered TIER 2 



FREAMINE HBC INJ 6.9% CALORIC AGENTS BRAND Covered TIER 3 

FREAMINE III INJ 10% CALORIC AGENTS BRAND Covered TIER 3 

FREAMINE III INJ 3% CALORIC AGENTS BRAND Covered TIER 3 

FREAMINE III INJ 8.5% CALORIC AGENTS GENERIC Covered TIER 1 

FREESTYLE KIT SENSOR DEVICES BRAND Covered TIER 3 

FRENADOL TAB 



FROVA TAB 2.5MG SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 2 QL 

FRST‐HYDRCRT GEL 10% 



FRUCTOSE GRA CALORIC AGENTS GENERIC Excluded TIER 99 

FUL‐GLO TES 0.6MG OP OCULAR DISORDERS BRAND Covered TIER 3 

FUL‐GLO TES 1MG OP OCULAR DISORDERS GENERIC Covered TIER 1 

FULL KIT NEB MIS SET DEVICES BRAND Excluded TIER 99 

FUMATINIC CAP IRON PREPARATIONS BRAND Covered TIER 3 

FURADANTIN SUS 25MG/5ML URINARY ANTI‐INFECTIVES Brand‐O PA TIER 3 

FUROSEMIDE INJ 10MG/ML LOOP DIURETICS GENERIC Covered TIER 1 

FUROSEMIDE SOL 10MG/ML LOOP DIURETICS GENERIC Covered TIER 1 

FUROSEMIDE SOL 8MG/ML LOOP DIURETICS GENERIC Covered TIER 1 

FUROSEMIDE TAB 20MG LOOP DIURETICS GENERIC Covered TIER 1 



FUSILEV INJ 50MG ANTIDOTES BRAND Covered TIER 3 SP 



174

FUZEON INJ 90MG HIV ENTRY AND FUSION INHIBITORS BRAND Covered TIER 3 

FUZEON KIT HIV ENTRY AND FUSION INHIBITORS BRAND Covered TIER 2 SP 

G/P TAB 1200‐75 EXPECTORANTS GENERIC Covered TIER 1 

G4 PLATINUM KIT RECEIVER DEVICES BRAND Covered TIER 3 

G4 SENSOR KIT DEVICES BRAND Covered TIER 3 

GABADONE CAP CALORIC AGENTS BRAND Excluded TIER 99 

GABAPENTIN CAP 100MG 









GABAPENTIN SOL 250/5ML 



GABAPENTIN TAB 600MG 



GABAPENTIN TAB 800MG 



GABAVALE‐5 PAK 



GABAZOLAMINE PAK 



GABAZOLAMINE PAK 0.5MG 



GABAZOLPIDEM PAK 5MG 



GABITIDINE PAK HISTAMINE H2‐ANTAGONISTS BRAND Covered TIER 3 



175

GABITRIL TAB 12MG 












GABLOFEN INJ 10000/20 


RELAXANT BRAND Covered TIER 3 SP 







GABLOFEN INJ 50MCG/ML 



GABOXETINE PAK 


INHIBITORS BRAND Covered TIER 3 

GADAVIST INJ 1MMOL/ML ROENTGENOGRAPHY BRAND Covered TIER 3 

GALANTAMINE CAP 16MG ER 









GALANTAMINE SOL 4MG/ML 



GALANTAMINE TAB 12MG 





176







GALIUM‐HEEL INJ 



GALZIN CAP 25MG REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

GALZIN CAP 50MG REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

GAMASTAN S/D INJ SERUMS GENERIC PA TIER 1 SP 

GAMMAGARD INJ 10GM/100 SERUMS GENERIC Covered TIER 1 SP 

GAMMAGARD INJ 1GM/10ML SERUMS GENERIC Covered TIER 1 SP 

GAMMAGARD INJ 2.5GM/25 SERUMS GENERIC Covered TIER 1 SP 

GAMMAGARD INJ 20GM/200 SERUMS GENERIC Covered TIER 1 SP 

GAMMAGARD INJ 30GM/300 SERUMS BRAND Covered TIER 2 SP 

GAMMAGARD INJ 5GM/50ML SERUMS GENERIC Covered TIER 1 SP 

GAMMAGARD SD INJ 10GM HU SERUMS BRAND PA TIER 3 SP 

GAMMAGARD SD INJ 2.5GM HU SERUMS GENERIC PA TIER 1 SP 

GAMMAGARD SD INJ 5GM HU SERUMS BRAND PA TIER 3 SP 

GAMMAKED INJ 10GM/100 SERUMS BRAND Covered TIER 3 SP 

GAMMAKED INJ 1GM/10ML SERUMS BRAND Covered TIER 3 SP 

GAMMAKED INJ 2.5GM/25 SERUMS BRAND Covered TIER 3 SP 

GAMMAKED INJ 20GM/200 SERUMS BRAND Covered TIER 3 SP 

GAMMAKED INJ 5GM/50ML SERUMS BRAND Covered TIER 3 SP 

GAMMAPLEX INJ 10GM SERUMS BRAND PA TIER 3 SP 

GAMMAPLEX INJ 2.5GM SERUMS BRAND PA TIER 3 SP 

GAMMAPLEX INJ 5GM SERUMS BRAND PA TIER 3 SP 

GAMUNEX INJ 10% SERUMS BRAND PA TIER 2 SP 

GAMUNEX‐C INJ 10GM/100 SERUMS BRAND Covered TIER 3 SP 

GAMUNEX‐C INJ 1GM/10ML SERUMS BRAND Covered TIER 3 SP 

GAMUNEX‐C INJ 2.5GM/25 SERUMS BRAND Covered TIER 3 SP 



177

GAMUNEX‐C INJ 20GM/200 SERUMS BRAND Covered TIER 3 SP 

GAMUNEX‐C INJ 5GM/50ML SERUMS BRAND Covered TIER 3 SP 

GANCICLOVIR INJ 500MG NUCLEOSIDES AND NUCLEOTIDES GENERIC Covered TIER 1 

GANIDIN‐NR LIQ 100/5ML EXPECTORANTS GENERIC Covered TIER 1 

GANIRELIX AC INJ 


HORMONE ANTAGNTS GENERIC PA TIER 1 SP 

GANITE INJ 25MG/ML BONE RESORPTION INHIBITORS BRAND Covered TIER 3 

GANI‐TUSS DM LIQ 100‐10/5 ANTITUSSIVES GENERIC Covered TIER 1 

GANI‐TUSS NR LIQ 100‐10/5 ANTITUSSIVES GENERIC Covered TIER 1 

GARAMYCIN OIN 0.3% OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

GARAMYCIN SOL 0.3% OP ANTIBACTERIALS (EENT) Brand‐O PA TIER 3 

GARDASIL INJ VACCINES BRAND PA TIER 3 

GASTRINEX NF CAP 



GASTROCROM CON 100/5ML MAST‐CELL STABILIZERS Brand‐O PA TIER 3 

GASTROGRAFIN SOL ROENTGENOGRAPHY Brand‐O PA TIER 3 

GASTROMARK SUS 175MCG ROENTGENOGRAPHY BRAND Covered TIER 3 

GASTROS TUBE MIS 12FRENCH DEVICES BRAND Excluded TIER 99 






GAVILYTE‐C SOL CATHARTICS AND LAXATIVES GENERIC Covered TIER 1 

GAVILYTE‐G SOL CATHARTICS AND LAXATIVES GENERIC Covered TIER 1 

GAVILYTE‐N SOL FLAV PK CATHARTICS AND LAXATIVES GENERIC Covered TIER 1 

GEBAUERS SPR AER /STRETCH 



GELATIN EMPT CAP LOCKING PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 



178

GELCLAIR GEL 



GELFILM MIS ENVELOPE HEMOSTATICS BRAND Excluded TIER 99 

GELFILM MIS OP HEMOSTATICS BRAND Covered TIER 3 

GELFOAM MIS DENTAL 4 HEMOSTATICS BRAND Excluded TIER 99 

GELFOAM MIS SPON COM HEMOSTATICS BRAND Excluded TIER 99 

GELFOAM MIS SPONG 50 HEMOSTATICS BRAND Excluded TIER 99 

GELFOAM MIS SPONG100 HEMOSTATICS BRAND Excluded TIER 99 

GELFOAM MIS SPONG200 HEMOSTATICS BRAND Excluded TIER 99 

GELFOAM POW HEMOSTATICS BRAND Excluded TIER 99 

GELFOAM SPNG MIS 12‐7MM HEMOSTATICS BRAND Excluded TIER 99 

GEL‐KAM CON 0.63% CARIOSTATIC AGENTS Brand‐O PA TIER 3 

GELNIQUE GEL 10% 



GELNIQUE GEL 3% 



GEMCITABINE INJ 1GM ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

SP 

GEMCITABINE INJ 200MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

SP 

GEMCITABINE INJ 2GM ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

GEMFIBROZIL TAB 600MG FIBRIC ACID DERIVATIVES GENERIC Covered TIER 1 

GEMZAR INJ 1GM ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

GEMZAR INJ 200MG ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

GENADUR LIQ 



GENERESS FE CHW CONTRACEPTIVES BRAND Covered TIER 3 

GENERLAC SOL 10GM/15 AMMONIA DETOXICANTS GENERIC Covered TIER 1 

GENEXA LA CAP 30‐400MG EXPECTORANTS GENERIC Covered TIER 1 

GENGRAF CAP 100MG IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1 



179

GENGRAF CAP 25MG IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1 

GENGRAF SOL 100MG/ML IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1 

GENOTROPIN INJ 0.2MG SOMATOTROPIN AGONISTS BRAND PA TIER 3 SP 








GENOTROPIN INJ 12MG SOMATOTROPIN AGONISTS BRAND PA TIER 3 SP 




GENTAK OIN 0.3% OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

GENTAK SOL 0.3% OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

GENTAM/NACL INJ 0.9MG/ML AMINOGLYCOSIDES GENERIC Covered TIER 1 

GENTAM/NACL INJ 1.4MG/ML AMINOGLYCOSIDES GENERIC Covered TIER 1 

GENTAM/NACL INJ 100MG AMINOGLYCOSIDES GENERIC Covered TIER 1 

GENTAM/NACL INJ 100MG PB AMINOGLYCOSIDES GENERIC Covered TIER 1 






GENTAMICIN CRE 0.1% 



GENTAMICIN INJ 10MG/ML AMINOGLYCOSIDES GENERIC Covered TIER 1 

GENTAMICIN INJ 40MG/ML AMINOGLYCOSIDES GENERIC Covered TIER 1 



180

GENTAMICIN OIN 0.1% 



GENTAMICIN OIN 0.3% OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

GENTAMICIN SOL 0.3% OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

GENTEX 30 LIQ ANTITUSSIVES Brand‐O PA TIER 99 

GENTEX ADE TAB 28‐1MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

GENTEX LQ SYP ANTITUSSIVES GENERIC Covered TIER 1 

GEODON CAP 20MG ATYPICAL ANTIPSYCHOTICS Brand‐O PA TIER 3 QL 




GEODON INJ 20MG ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 3 QL 

GESTICARE PAK DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

GESTICARE TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

GFN1200/DM60 TAB ANTITUSSIVES GENERIC Covered TIER 1 

GFN550/PSE60 TAB EXPECTORANTS GENERIC Covered TIER 1 

GG/PE SYP EXPECTORANTS GENERIC Covered TIER 1 

GIANVI TAB 3‐0.02MG CONTRACEPTIVES GENERIC Covered TIER 1 

GIENTRI PORT MIS DEVICES BRAND Excluded TIER 99 

GILDESS FE TAB 1.5/30 CONTRACEPTIVES GENERIC Covered TIER 1 

GILDESS FE TAB 1/20 CONTRACEPTIVES GENERIC Covered TIER 1 

GILENYA CAP 0.5MG BIOLOGIC RESPONSE MODIFIERS BRAND PA TIER 3 QL 

GILPHEX TR TAB 10‐388MG EXPECTORANTS BRAND Excluded TIER 99 

GILTUSS LIQ ANTITUSSIVES BRAND Excluded TIER 99 

GILTUSS LIQ PED‐C ANTITUSSIVES BRAND Excluded TIER 99 

GILTUSS PED LIQ ANTITUSSIVES BRAND Excluded TIER 99 

GILTUSS TR CAP 7‐14‐288 ANTITUSSIVES GENERIC Covered TIER 1 

GILTUSS TR TAB ANTITUSSIVES BRAND Excluded TIER 99 


GLASSIA INJ 




181

GLEEVEC TAB 100MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 QL SP 

GLEEVEC TAB 400MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 QL SP 

GLIADEL WAF 7.7MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 

GLIMEPIRIDE TAB 1MG SULFONYLUREAS GENERIC Covered TIER 1 



GLIP/METFORM TAB 2.5‐250M SULFONYLUREAS GENERIC Covered TIER 1 

GLIP/METFORM TAB 2.5‐500M SULFONYLUREAS GENERIC Covered TIER 1 

GLIP/METFORM TAB 5‐500MG SULFONYLUREAS GENERIC Covered TIER 1 

GLIPIZIDE TAB 10MG SULFONYLUREAS GENERIC Covered TIER 1 

GLIPIZIDE TAB 5MG SULFONYLUREAS GENERIC Covered TIER 1 

GLIPIZIDE ER TAB 10MG SULFONYLUREAS GENERIC Covered TIER 1 

GLIPIZIDE ER TAB 2.5MG SULFONYLUREAS GENERIC Covered TIER 1 

GLIPIZIDE ER TAB 5MG SULFONYLUREAS GENERIC Covered TIER 1 

GLIPIZIDE XL TAB 10MG SULFONYLUREAS GENERIC Covered TIER 1 

GLIPIZIDE XL TAB 2.5MG SULFONYLUREAS GENERIC Covered TIER 1 

GLIPIZIDE XL TAB 5MG SULFONYLUREAS GENERIC Covered TIER 1 

GLOFIL‐125 INJ 0.1% ROENTGENOGRAPHY BRAND Covered TIER 3 

GLONOIN DRO HOMACCOR 



GLUCAGEN INJ 1MG GLYCOGENOLYTIC AGENTS BRAND Covered TIER 3 

GLUCAGEN INJ HYPOKIT GLYCOGENOLYTIC AGENTS BRAND Covered TIER 3 

GLUCAGON KIT 1MG GLYCOGENOLYTIC AGENTS BRAND Covered TIER 2 

GLUCOPHAGE TAB 1000MG BIGUANIDES Brand‐O PA TIER 3 



GLUCOPHAGE TAB XR 500MG BIGUANIDES Brand‐O PA TIER 3 

GLUCOPHAGE TAB XR 750MG BIGUANIDES Brand‐O PA TIER 3 

GLUCOPRO SYR MIS RES 3ML DEVICES BRAND Covered TIER 3 

GLUCOTROL TAB 10MG SULFONYLUREAS Brand‐O PA TIER 3 



182

GLUCOTROL TAB 5MG SULFONYLUREAS Brand‐O PA TIER 3 

GLUCOTROL XL TAB 10MG SULFONYLUREAS Brand‐O PA TIER 3 

GLUCOTROL XL TAB 2.5MG SULFONYLUREAS Brand‐O PA TIER 3 

GLUCOTROL XL TAB 5MG SULFONYLUREAS Brand‐O PA TIER 3 

GLUCOVANCE TAB 1.25‐250 SULFONYLUREAS Brand‐O PA TIER 3 

GLUCOVANCE TAB 2.5‐500 SULFONYLUREAS Brand‐O PA TIER 3 

GLUCOVANCE TAB 5‐500MG SULFONYLUREAS Brand‐O PA TIER 3 

GLUMETZA TAB 1000MG BIGUANIDES BRAND PA TIER 3 

GLUMETZA TAB 500MG BIGUANIDES BRAND PA TIER 3 

GLUTATHIONE CRY REDUCED CALORIC AGENTS GENERIC Excluded TIER 99 

GLUTATHIONE POW CALORIC AGENTS GENERIC Excluded TIER 99 

GLUTATHIONE POW REDUCED CALORIC AGENTS GENERIC Excluded TIER 99 

GLYB/METFORM TAB 1.25‐250 SULFONYLUREAS GENERIC Covered TIER 1 

GLYB/METFORM TAB 2.5‐500 SULFONYLUREAS GENERIC Covered TIER 1 

GLYB/METFORM TAB 5‐500MG SULFONYLUREAS GENERIC Covered TIER 1 

GLYBURID MCR TAB 1.5MG SULFONYLUREAS GENERIC Covered TIER 1 

GLYBURID MCR TAB 3MG SULFONYLUREAS GENERIC Covered TIER 1 

GLYBURID MCR TAB 6MG SULFONYLUREAS GENERIC Covered TIER 1 

GLYBURIDE TAB 1.25MG SULFONYLUREAS GENERIC Covered TIER 1 

GLYBURIDE TAB 2.5MG SULFONYLUREAS GENERIC Covered TIER 1 

GLYBURIDE TAB 5MG SULFONYLUREAS GENERIC Covered TIER 1 

GLYCINE SOL 1.5% IRR IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

GLYCOPYRROL INJ 0.2MG/ML 



GLYCOPYRROL TAB 1MG 



GLYCOPYRROL TAB 2MG 



GLYCRON TAB 1.5MG SULFONYLUREAS GENERIC Covered TIER 1 

GLYCRON TAB 3MG SULFONYLUREAS GENERIC Covered TIER 1 



183

GLYCRON TAB 4.5MG SULFONYLUREAS BRAND Covered TIER 3 

GLYCRON TAB 6MG SULFONYLUREAS GENERIC Covered TIER 1 

GLYNASE TAB 1.5MG SULFONYLUREAS Brand‐O PA TIER 3 

GLYNASE TAB 3MG SULFONYLUREAS Brand‐O PA TIER 3 

GLYNASE TAB 6MG SULFONYLUREAS Brand‐O PA TIER 3 

GLYOXAL INJ COMPOSIT 



GLYSET TAB 100MG ALPHA‐GLUCOSIDASE INHIBITORS BRAND Covered TIER 3 



GOLYTELY SOL CATHARTICS AND LAXATIVES Brand‐O PA TIER 2 

GOLYTELY SOL PINEAPPL CATHARTICS AND LAXATIVES Brand‐O PA TIER 2 

GONAL‐F INJ 1050UNIT GONADOTROPINS BRAND PA TIER 3 SP 

GONAL‐F INJ 450UNIT GONADOTROPINS BRAND PA TIER 3 SP 

GONAL‐F RFF INJ 300 GONADOTROPINS BRAND PA TIER 3 SP 


GONAL‐F RFF INJ 75UNIT GONADOTROPINS BRAND PA TIER 3 SP 


GORDOFILM SOL KERATOLYTIC AGENTS BRAND Covered TIER 3 

GORDONS UREA OIN 40% KERATOLYTIC AGENTS BRAND Covered TIER 3 

GRAFCO SILVR MIS NIT APPL 



GRAFIX CORE MIS 2CMX2CM 



GRAFIX CORE MIS 5CMX5CM 



GRAFIX PRIME MIS 2CMX2CM 



GRAFIX PRIME MIS 5CMX5CM 





184

GRAFIX PRIME MIS 7.5X15CM 



GRALISE TAB 300MG 


MISC. BRAND Covered TIER 3 QL 

GRALISE TAB 600MG 



GRALISE STAR MIS 300/600 



GRANISETRON INJ 0.1MG/ML 5‐HT3 RECEPTOR ANTAGONISTS GENERIC Covered TIER 1 

GRANISETRON INJ 1MG/ML 5‐HT3 RECEPTOR ANTAGONISTS GENERIC Covered TIER 1 

GRANISETRON INJ 4MG/4ML 5‐HT3 RECEPTOR ANTAGONISTS GENERIC Covered TIER 1 

GRANISETRON TAB 1MG 5‐HT3 RECEPTOR ANTAGONISTS GENERIC Covered TIER 1 QL 

GRANISOL SOL 2MG/10ML 5‐HT3 RECEPTOR ANTAGONISTS BRAND Covered TIER 3 QL 

GRANULEX AER 



GRAPEFRUIT OIL FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

GRIFULVIN V TAB 500MG ANTIFUNGALS, MISCELLANEOUS BRAND Covered TIER 3 

GRIPP‐HEEL INJ 



GRISEOFULVIN SUS 125/5ML ANTIFUNGALS, MISCELLANEOUS GENERIC Covered TIER 1 

GRIS‐PEG TAB 125MG ANTIFUNGALS, MISCELLANEOUS BRAND Covered TIER 3 

GRIS‐PEG TAB 250MG ANTIFUNGALS, MISCELLANEOUS BRAND Covered TIER 3 

GUANABENZ TAB 4MG CENTRAL ALPHA‐AGONISTS GENERIC Covered TIER 1 

GUANFACINE TAB 1MG CENTRAL ALPHA‐AGONISTS GENERIC Covered TIER 1 

GUANFACINE TAB 2MG CENTRAL ALPHA‐AGONISTS GENERIC Covered TIER 1 

GUANIDINE TAB 125MG 



GUARDIAN MIS TRANSMTR DEVICES BRAND Covered TIER 3 

GUARDIAN RT KIT DEVICES BRAND Covered TIER 3 

GUARDIAN RT KIT STARTER DEVICES BRAND Covered TIER 3 



185

GUARDIAN RT KIT SYST PED DEVICES BRAND Covered TIER 3 

GUARDIAN RT KIT SYSTEM DEVICES BRAND Covered TIER 3 

GUARDIAN RT MIS CHARGER DEVICES BRAND Covered TIER 3 

GUARDIAN RT MIS REPL PED DEVICES BRAND Covered TIER 3 

GUARDIAN RT MIS REPLACE DEVICES BRAND Covered TIER 3 

GUARDIAN RT MIS SOFTWARE DEVICES BRAND Covered TIER 3 

GUARDIAN RT MIS SYSTEM DEVICES BRAND Covered TIER 3 

GUARDIAN RT MIS TST PLUG DEVICES BRAND Covered TIER 3 

GUAVA FLAVOR LIQ PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

GUMMY TROCHE GEL GELATIN PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

HALAC KIT 



HALAVEN INJ 1MG/2ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

HALCION TAB 0.25MG 



HALDOL INJ 5MG/ML BUTYROPHENONES Brand‐O PA TIER 3 

HALDOL DECAN INJ 100MG/ML BUTYROPHENONES Brand‐O PA TIER 3 

HALDOL DECAN INJ 50MG/ML BUTYROPHENONES Brand‐O PA TIER 3 

HALFLYTELY KIT FLAV PKS CATHARTICS AND LAXATIVES BRAND Covered TIER 2 

HALOBETASOL CRE 0.05% 



HALOBETASOL OIN 0.05% 



HALOG CRE 0.1% 



HALOG OIN 0.1% 



HALONATE KIT 





186

HALONATE PAC KIT 



HALOPER DEC INJ 100MG/ML BUTYROPHENONES GENERIC Covered TIER 1 

HALOPER DEC INJ 50MG/ML BUTYROPHENONES GENERIC Covered TIER 1 

HALOPER LAC INJ 5MG/ML BUTYROPHENONES GENERIC Covered TIER 1 

HALOPERIDOL CON 2MG/ML BUTYROPHENONES GENERIC Covered TIER 1 

HALOPERIDOL TAB 0.5MG BUTYROPHENONES GENERIC Covered TIER 1 

HALOPERIDOL TAB 10MG BUTYROPHENONES GENERIC Covered TIER 1 





HALOTIN CRE 1% 



HAM FLAVOR LIQ PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

HAVRIX INJ 1440UNIT VACCINES BRAND Covered TIER 3 

HAVRIX INJ 720UNIT VACCINES BRAND Covered TIER 3 

HC AC/ALOE GEL 2% 



HC BUTYRATE CRE 0.1% 



HC BUTYRATE OIN 0.1% 



HC BUTYRATE SOL 0.1% 



HC PRAMOXINE CRE 1‐1% 



Excluded TIER 99 

HC PRAMOXINE CRE 1‐2.5% 





187

HC PRAMOXINE CRE 2.5‐1% 



HC VALERATE CRE 0.2% 



HC VALERATE OIN 0.2% 



HC/ACET ACID SOL OTIC CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

HDC DM SYP ANTITUSSIVES GENERIC Covered TIER 1 

HEALON INJ 10MG/ML EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 3 

HEALON GV INJ 14MG/ML EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 3 

HEALON5 INJ 23MG/ML EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 3 

HEALTHY LIV MIS COMPRESS DEVICES BRAND Excluded TIER 99 

HEATHER TAB 0.35MG CONTRACEPTIVES GENERIC Covered TIER 1 

HECORIA CAP 0.5MG IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1 

HECORIA CAP 1MG IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1 

HECORIA CAP 5MG IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1 

HECTOROL CAP 0.5MCG VITAMIN D BRAND Covered TIER 2 

HECTOROL CAP 1MCG VITAMIN D BRAND Covered TIER 2 

HECTOROL CAP 2.5MCG VITAMIN D BRAND Covered TIER 2 

HECTOROL INJ 2MCG/ML VITAMIN D BRAND Covered TIER 3 

HECTOROL INJ 4MCG/2ML VITAMIN D BRAND Covered TIER 3 

HELIDAC MIS 

ANTIULCER AGENTS & ACID 

SUPPRESS., MISC BRAND Covered TIER 3 

HELISTAT MIS 5MM HEMOSTATICS BRAND Excluded TIER 99 

HELIXATE FS INJ 1000UNIT HEMOSTATICS BRAND PA TIER 2 SP 





HELIXATE FS SOL 1000UNIT HEMOSTATICS BRAND PA TIER 2 SP 



188



HEMABATE INJ 250MCG OXYTOCICS BRAND Covered TIER 3 

HEMATINIC PL TAB VIT/MIN IRON PREPARATIONS GENERIC Covered TIER 1 

HEMATINIC/FA TAB IRON PREPARATIONS GENERIC Covered TIER 1 

HEMATOGEN CAP IRON PREPARATIONS GENERIC Covered TIER 1 

HEMATOGEN CAP FORTE IRON PREPARATIONS GENERIC Covered TIER 1 

HEMATOGEN FA CAP IRON PREPARATIONS GENERIC Covered TIER 1 

HEMATRON‐AF TAB IRON PREPARATIONS Brand‐O PA TIER 3 

HEMENATAL OB MIS + DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

HEMENATAL OB TAB 28‐6‐1MG MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

HEMETAB TAB IRON PREPARATIONS BRAND Covered TIER 3 

HEMOCYTE TAB ‐PLUS IRON PREPARATIONS GENERIC Covered TIER 1 

HEMOCYTE PLS CAP IRON PREPARATIONS BRAND Covered TIER 3 

HEMOCYTE‐F ELX IRON PREPARATIONS BRAND Covered TIER 3 

HEMOCYTE‐F TAB IRON PREPARATIONS GENERIC Covered TIER 1 

HEMOFIL M INJ 220‐400 HEMOSTATICS BRAND PA TIER 2 SP 

HEMOFIL M INJ 401‐800 HEMOSTATICS BRAND PA TIER 2 SP 

HEMOFIL M SOL 501‐2000 HEMOSTATICS BRAND PA TIER 3 SP 

HEMOFIL M SOL 801‐1500 HEMOSTATICS BRAND PA TIER 3 SP 

HEMRIL‐30 SUP 30MG 



HEP FLUSH‐10 INJ 10UNT/ML HEPARINS GENERIC Covered TIER 1 

HEP SOD/D5W INJ 100/ML HEPARINS GENERIC Covered TIER 1 

HEP SOD/D5W INJ 20000UNT HEPARINS GENERIC Covered TIER 1 

HEP SOD/D5W INJ 25000UNT HEPARINS GENERIC Covered TIER 1 

HEP SOD/D5W INJ 50UNT/ML HEPARINS GENERIC Covered TIER 1 

HEP SOD/NACL INJ 1000UNIT HEPARINS GENERIC Covered TIER 1 

HEP SOD/NACL INJ 12500UNT HEPARINS GENERIC Covered TIER 1 

HEP SOD/NACL INJ 2000UNIT HEPARINS GENERIC Covered TIER 1 



189

HEP SOD/NACL INJ 25000UNT HEPARINS GENERIC Covered TIER 1 

HEP SOD/NACL INJ 2UNIT/ML HEPARINS GENERIC Covered TIER 1 

HEPAGAM B INJ SERUMS BRAND Covered TIER 3 SP 

GENERIC Covered TIER 1 SP 

HEPAR INJ COMPOSIT 



HEPARIN LOCK INJ 100/ML HEPARINS GENERIC Covered TIER 1 

HEPARIN LOCK INJ 10UNT/ML HEPARINS GENERIC Covered TIER 1 

HEPARIN LOCK INJ 1UNIT/ML HEPARINS GENERIC Covered TIER 1 

HEPARIN LOCK INJ 2UNIT/ML HEPARINS GENERIC Covered TIER 1 

HEPARIN LOCK KIT 100/ML HEPARINS GENERIC Covered TIER 1 

HEPARIN LOCK KIT 10UNT/ML HEPARINS GENERIC Covered TIER 1 

HEPARIN SOD INJ 1000/ML HEPARINS GENERIC Covered TIER 1 





HEPARIN SOD INJ 5000/0.5 HEPARINS GENERIC Covered TIER 1 


HEPATAMINE SOL 8% CALORIC AGENTS GENERIC Covered TIER 1 

HEPATASOL INJ 8% CALORIC AGENTS GENERIC Covered TIER 1 

HEPSERA TAB 10MG NUCLEOSIDES AND NUCLEOTIDES BRAND Covered TIER 2 

HERCEPTIN INJ 440MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

HESPAN INJ 6%/NACL REPLACEMENT PREPARATIONS Brand‐O PA TIER 3 

HETASTARCH INJ 6%/NACL REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

HEXALEN CAP 50MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

HEXTEND SOL 6% REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

HIBERIX SOL 10‐25MCG VACCINES BRAND Covered TIER 3 

HIPREX TAB 1GM URINARY ANTI‐INFECTIVES Brand‐O PA TIER 3 

HISTATROL INJ 0.275/ML PHEOCHROMOCYTOMA BRAND Covered TIER 3 



190

HISTOACRYL LIQ DEVICES BRAND Excluded TIER 99 

HIZENTRA INJ 1GM/5ML SERUMS BRAND PA TIER 2 SP 



HOMATROPAIRE SOL 5% OP MYDRIATICS GENERIC Covered TIER 1 

HOMATROPINE SOL 5% OP MYDRIATICS GENERIC Covered TIER 1 

HONEY BEE INJ 1000MCG 


THERAPEUTIC AGENTS GENERIC Covered TIER 1 

HONEY BEE KIT 100MCG 



HONEY FLAVOR LIQ PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

HOREHOUND LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 


HORIZANT TAB 600MG 


HORMEEL LIQ 



HORNET VENOM INJ 1300MCG 



HORNET VENOM INJ 550MCG 



HPR AER 



HPR PLUS AER 



HPR PLUS CRE 



HPR PLUS MB KIT HYDROGEL 



HRT BASE CRE PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

HRT BASE CRE BOTANICA PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 



191

HRT BASE CRE HEAVY PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

HRT BASE CRE SUPREME PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

HRT BASE CRE WOMEN PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

HRT BASE GEL FOR MEN PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

HRT NATURAL CRE BASE PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

HRT NATURAL LOT BASE PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

HSA DILUENT SOL STERILE BLOOD DERIVATIVES GENERIC Excluded TIER 99 

HUMALOG INJ 100/ML INSULINS BRAND Covered TIER 2 

HUMALOG KWIK INJ 100/ML INSULINS BRAND Covered TIER 2 

HUMALOG MIX INJ 50/50 INSULINS BRAND Covered TIER 2 

HUMALOG MIX INJ 50/50KWP INSULINS BRAND Covered TIER 2 

HUMALOG MIX INJ 75/25KWP INSULINS BRAND Covered TIER 2 

HUMALOG MIX SUS 75/25 INSULINS BRAND Covered TIER 2 

HUMAPEN MIS LUXURA DEVICES BRAND Excluded TIER 99 

HUMAPEN MIS MEMOIR DEVICES BRAND Excluded TIER 99 

HUMATE‐P INJ 600UNIT HEMOSTATICS BRAND PA TIER 2 SP 

HUMATE‐P SOL 1200UNIT HEMOSTATICS BRAND PA TIER 2 SP 



HUMATROPE INJ 12MG SOMATOTROPIN AGONISTS BRAND PA TIER 3 SP 




HUMIRA KIT 20MG/0.4 



HUMIRA KIT 40MG/0.8 



HUMIRA PEN KIT 40MG/0.8 





192

HUMIRA PEN KIT CROHNS 



HUMIRA PEN KIT PSORIASI 



HUMULIN R INJ U‐500 INSULINS BRAND Covered TIER 2 

HYALGAN INJ 20MG/2ML 



HYALURONATE GEL 0.2% BASIC LOTIONS AND LINIMENTS GENERIC Covered TIER 1 

HYCAMTIN CAP 0.25MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

HYCAMTIN CAP 1MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

HYCAMTIN INJ 4MG ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

HYCET SOL 7.5‐325 OPIATE AGONISTS Brand‐O PA TIER 3 

HYD POLST‐CH LIQ LOR POLS ANTITUSSIVES GENERIC Covered TIER 1 

HYDRALAZINE INJ 20MG/ML DIRECT VASODILATORS GENERIC Covered TIER 1 

HYDRALAZINE TAB 100MG DIRECT VASODILATORS GENERIC Covered TIER 1 




HYDREA CAP 500MG ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 

HYDRO 35 AER KERATOLYTIC AGENTS Brand‐O PA TIER 3 

HYDRO 40 AER FOAM KERATOLYTIC AGENTS Brand‐O PA TIER 3 


HYDROCHLORIC INJ 1:500 DIGESTANTS GENERIC Covered TIER 1 

HYDROCHLOROT CAP 12.5MG THIAZIDE DIURETICS GENERIC Covered TIER 1 

HYDROCHLOROT TAB 12.5MG THIAZIDE DIURETICS GENERIC Covered TIER 1 

HYDROCHLOROT TAB 25MG THIAZIDE DIURETICS GENERIC Covered TIER 1 

HYDROCHLOROT TAB 50MG THIAZIDE DIURETICS GENERIC Covered TIER 1 

HYDROCO/APAP SOL 10‐325MG OPIATE AGONISTS GENERIC Covered TIER 1 

HYDROCO/APAP SOL 7.5‐325 OPIATE AGONISTS GENERIC Covered TIER 1 

HYDROCO/APAP SOL 7.5‐500 OPIATE AGONISTS GENERIC Covered TIER 1 



193

HYDROCO/APAP TAB 10‐300MG OPIATE AGONISTS GENERIC Covered TIER 1 






HYDROCO/APAP TAB 2.5‐325 OPIATE AGONISTS GENERIC Covered TIER 1 










HYDROCOD/HOM SYP 5‐1.5/5 ANTITUSSIVES GENERIC Covered TIER 1 

HYDROCOD/IBU TAB 10‐200MG OPIATE AGONISTS GENERIC Covered TIER 1 

HYDROCOD/IBU TAB 2.5‐200 OPIATE AGONISTS GENERIC Covered TIER 1 

HYDROCOD/IBU TAB 5‐200MG OPIATE AGONISTS GENERIC Covered TIER 1 

HYDROCOD/IBU TAB 7.5‐200 OPIATE AGONISTS GENERIC Covered TIER 1 

HYDROCODONE CRY BITARTRA OPIATE AGONISTS GENERIC Excluded TIER 99 

HYDROCODONE/ TAB HOMATROP ANTITUSSIVES GENERIC Covered TIER 1 

HYDROCORT CRE 1% 



HYDROCORT CRE 2.5% 



HYDROCORT ENE 100MG 





194

HYDROCORT LOT 2.5% 



HYDROCORT OIN 1% 



HYDROCORT OIN 2.5% 



HYDROCORT TAB 10MG ADRENALS GENERIC Covered TIER 1 



HYDROCORT AC SUP 25MG 



HYDROCORT AC SUP 30MG 



HYDROCORT/ CRE IODOQUIN 



HYDROCORT/ KIT PRAMOXIN 



HYDROCORT/AB OIN 1% 



HYDROFERA PAD 4"X4" 



HYDROGEL GEL PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

HYDROGEN PER SOL 35% FCC 



HYDROGESIC CAP 5‐500MG OPIATE AGONISTS GENERIC Covered TIER 1 

HYDRO‐IODOQU GEL 2‐1 



HYDROMET SYP 5‐1.5/5 ANTITUSSIVES GENERIC Covered TIER 1 

HYDROMORPHON INJ 10MG/ML OPIATE AGONISTS GENERIC Covered TIER 1 




195



HYDROMORPHON INJ 500/50ML OPIATE AGONISTS GENERIC Covered TIER 1 

HYDROMORPHON INJ 50MG/5ML OPIATE AGONISTS GENERIC Covered TIER 1 

HYDROMORPHON LIQ 1MG/ML OPIATE AGONISTS GENERIC Covered TIER 1 

HYDROMORPHON SUP 3MG OPIATE AGONISTS GENERIC Covered TIER 1 

HYDROMORPHON TAB 2MG OPIATE AGONISTS GENERIC Covered TIER 1 



HYDROQUINONE CRE 4% DEPIGMENTING AGENTS GENERIC Excluded TIER 99 

HYDROQUINONE CRE 4% TR DEPIGMENTING AGENTS GENERIC Excluded TIER 99 

HYDROQUINONE CRE 4%/SUNS DEPIGMENTING AGENTS GENERIC Excluded TIER 99 

HYDROQUINONE EMU 4% DEPIGMENTING AGENTS GENERIC Excluded TIER 99 

HYDROQUINONE GEL 4%/SUNS DEPIGMENTING AGENTS GENERIC Excluded TIER 99 

HYDROXOCOBAL INJ 1000MCG VITAMIN B COMPLEX GENERIC Covered TIER 1 

HYDROXYCHLOR TAB 200MG ANTIMALARIALS GENERIC Covered TIER 1 

HYDROXYUREA CAP 500MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

HYDROXYZ HCL INJ 25MG/ML 



HYDROXYZ HCL INJ 50MG/ML 



HYDROXYZ HCL SOL 10MG/5ML 



HYDROXYZ HCL SYP 10MG/5ML 



HYDROXYZ HCL TAB 10MG 








196




HYDROXYZ PAM CAP 100MG 









HYGEL GEL 0.2% BASIC LOTIONS AND LINIMENTS GENERIC Covered TIER 1 

HYLASE WOUND GEL 



HYLATOPC PLS KIT /AURSTAT 



HYLATOPIC AER 



HYLATOPIC AER PLUS 



HYLATOPIC CRE PLUS 



HYLENEX INJ 150 UNIT ENZYMES BRAND Covered TIER 3 

HYLIRA GEL 0.2% BASIC LOTIONS AND LINIMENTS Brand‐O PA TIER 3 

HYLIRA LOT 0.1% BASIC LOTIONS AND LINIMENTS BRAND Covered TIER 3 

HYOMAX TAB 0.125MG 



HYOMAX‐DT TAB 



HYOMAX‐FT TAB 0.125MG 



HYOMAX‐SL SUB 0.125MG 





197

HYOMAX‐SR TAB 0.375MG 



HYOPHEN TAB URINARY ANTI‐INFECTIVES GENERIC Covered TIER 1 

HYOSCYAMINE DRO 0.125/ML 



HYOSCYAMINE ELX 0.125/5 



HYOSCYAMINE SUB 0.125MG 



HYOSCYAMINE TAB 0.125MG 



HYOSCYAMINE TAB 0.375 ER 



HYOSCYAMINE TAB 0.375 SR 



HYOSYNE DRO 0.125/ML 



HYOSYNE ELX 0.125/5 



HYPERCARE SOL 20% ASTRINGENTS GENERIC Covered TIER 1 

HYPERHEP B INJ S/D SERUMS BRAND Covered TIER 3 SP 

HYPERLYTE‐CR INJ REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

HYPERRAB S/D INJ 150/ML SERUMS BRAND Covered TIER 3 SP 

HYPERRHO S/D INJ 300MCG SERUMS BRAND Covered TIER 3 SP 

HYPERRHO S/D INJ 50MCG SERUMS GENERIC Covered TIER 1 SP 

HYPERSAL NEB 3.5% MUCOLYTIC AGENTS BRAND Excluded TIER 99 

HYPERSAL NEB 7% MUCOLYTIC AGENTS Brand‐O PA TIER 99 

HYPER‐SAL NEB 7% MUCOLYTIC AGENTS Brand‐O PA TIER 99 

HYPERTENEVID PAK 12.5MG 





198

HYPERTENIPIN PAK 2.5MG DIHYDROPYRIDINES BRAND Covered TIER 3 

HYPERTENSA CAP CALORIC AGENTS BRAND Excluded TIER 99 

HYPERTENSOLO PAK 



HYPERTET S/D INJ 250/ML SERUMS BRAND Covered TIER 3 SP 

HYPO NEEDLE MIS 14GX1" DEVICES BRAND Excluded TIER 99 

HYPO NEEDLE MIS 14GX1.5" DEVICES BRAND Excluded TIER 99 



HYPO NEEDLE MIS 16GX3/4" DEVICES BRAND Excluded TIER 99 


HYPO NEEDLE MIS 19GX1.25 DEVICES BRAND Excluded TIER 99 




HYPO NEEDLE MIS 25GX1.25 DEVICES BRAND Excluded TIER 99 




HYPOCHLORITE SOL SODIUM 



HYSKON SOL IRRIGATING SOLUTIONS BRAND Covered TIER 3 

HYZAAR TAB 100‐12.5 



HYZAAR TAB 100‐25 



HYZAAR TAB 50‐12.5 



IBANDRONATE TAB 150MG BONE RESORPTION INHIBITORS GENERIC Covered TIER 1 

IBUDONE TAB 10‐200MG OPIATE AGONISTS Brand‐O PA TIER 3 



199

IBUDONE TAB 5‐200MG OPIATE AGONISTS GENERIC Covered TIER 1 

IBUPROFEN KIT COMFORT 



IBUPROFEN TAB 400MG 









IBUTILIDE INJ 1MG/10ML CLASS III ANTIARRHYTHMICS GENERIC Covered TIER 1 

IC 400 KIT 400MG 



IC 800 KIT 800MG 



IC GREEN INJ 25MG CARDIAC FUNCTION Brand‐O PA TIER 3 

ICAR‐C PLUS CAP SR IRON PREPARATIONS BRAND Covered TIER 3 

ICAR‐C PLUS TAB IRON PREPARATIONS Brand‐O PA TIER 3 

IDAMYCIN PFS INJ 10/10ML ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

IDAMYCIN PFS INJ 20/20ML ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

IDAMYCIN PFS INJ 5MG/5ML ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

IDARUBICIN INJ 10/10ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

IDARUBICIN INJ 20/20ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

IDARUBICIN INJ 5MG/5ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

IFEREX 150 CAP FORTE IRON PREPARATIONS GENERIC Covered TIER 1 

IFEX INJ 1GM ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

IFEX INJ 3GM ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

IFOSFAMIDE INJ 1GM ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

IFOSFAMIDE INJ 1GM/20ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

IFOSFAMIDE INJ 3GM ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

IFOSFAMIDE INJ 3GM/60ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 



200

IFOSFAMIDE KIT MESNA ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

ILARIS INJ 180MG 


MISC. BRAND PA TIER 3 QL SP 

ILOTYCIN OIN OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

IMDUR TAB 120MG ER NITRATES AND NITRITES Brand‐O PA TIER 3 



IMIPENEM/CIL INJ 250MG CARBAPENEMS GENERIC Covered TIER 1 

IMIPENEM/CIL INJ 500MG CARBAPENEMS GENERIC Covered TIER 1 

IMIPRAM HCL TAB 10MG 









IMIPRAM PAM CAP 100MG 












IMIQUIMOD CRE 5% 


AGENTS, MISC. GENERIC Covered TIER 1 QL 

IMITREX INJ 4MG/0.5 SELECTIVE SEROTONIN AGONISTS Brand‐O PA TIER 3 QL 

IMITREX INJ 6MG/0.5 SELECTIVE SEROTONIN AGONISTS Brand‐O PA TIER 3 QL 

IMITREX SPR 20MG/ACT SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 3 QL 

IMITREX SPR 5MG/ACT SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 3 QL 

IMITREX TAB 100MG SELECTIVE SEROTONIN AGONISTS Brand‐O PA TIER 3 QL 



201



IMOGAM RABIE INJ 150/ML SERUMS GENERIC Covered TIER 1 SP 

IMOVAX RABIE INJ 2.5/ML VACCINES BRAND Covered TIER 3 

IMPLANON IMP 68MG CONTRACEPTIVES BRAND Covered TIER 3 

IMURAN TAB 50MG IMMUNOSUPPRESSIVE AGENTS Brand‐O PA TIER 3 

INATAL ADV TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

INATAL GT TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

INATAL ULTRA TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

IN‐CHK DIAL MIS TRAINER DEVICES BRAND Excluded TIER 99 

IN‐CHK FLOW MIS METER DEVICES BRAND Excluded TIER 99 

INCISION/ KIT DRAINAGE DEVICES BRAND Covered TIER 3 

INCIVEK TAB 375MG HCV PROTEASE INHIBITORS BRAND PA TIER 2 SP 

INCRELEX INJ 40MG/4ML SOMATOTROPIN AGONISTS BRAND PA TIER 3 SP 

INDAMIX DM SUS ANTITUSSIVES GENERIC Covered TIER 1 

INDAPAMIDE TAB 1.25MG THIAZIDE‐LIKE DIURETICS GENERIC Covered TIER 1 

INDAPAMIDE TAB 2.5MG THIAZIDE‐LIKE DIURETICS GENERIC Covered TIER 1 

INDERAL LA CAP 120MG 












INDICLOR INJ 



INDIGO CARMI INJ 8MG/ML KIDNEY FUNCTION GENERIC Covered TIER 1 

INDIUM IN111 INJ DTPA 





202

INDIUM IN111 INJ OXYQUINO DIAGNOSTIC AGENTS GENERIC Excluded TIER 99 

INDOCIN SUP 50MG 



INDOCIN SUS 25MG/5ML 



INDOCIN IV INJ 1MG 



INDOCYANINE INJ 25MG CARDIAC FUNCTION GENERIC Covered TIER 1 

INDOMETHACIN CAP 25MG 



INDOMETHACIN CAP 50MG 



INDOMETHACIN CAP 75MG ER 



INDOMETHACIN INJ 1MG 



INFANRIX INJ TOXOIDS BRAND Excluded TIER 99 

INFASURF SUS 35MG/ML PULMONARY SURFACTANTS BRAND Covered TIER 3 

INFED INJ 50MG/ML IRON PREPARATIONS GENERIC Covered TIER 1 SP 

INFERGEN INJ 15MCG INTERFERONS BRAND PA TIER 3 SP 

INFERGEN INJ 9MCG INTERFERONS BRAND PA TIER 3 SP 

INFLUENZA A INJ PF09H1N1 VACCINES GENERIC Covered TIER 1 

INFLUENZA A SPR 09 H1N1 VACCINES GENERIC Covered TIER 1 

INFUMORPH INJ 10MG/ML OPIATE AGONISTS BRAND Covered TIER 3 


INFUMORPH INJ 25MG/ML OPIATE AGONISTS BRAND Covered TIER 3 


INFUS NEEDLE MIS 15GX2" DEVICES GENERIC Excluded TIER 99 

INFUSION MIS ADAPTER DEVICES BRAND Excluded TIER 99 

INFUSION MIS CLAMP DEVICES BRAND Excluded TIER 99 



203

INFUSION SET MIS 23" DEVICES BRAND Covered TIER 3 

GENERIC Excluded TIER 99 

INFUSION SET MIS 23" 10MM DEVICES GENERIC Excluded TIER 99 

INFUSION SET MIS 23" 6MM DEVICES BRAND Covered TIER 3 




INFUSION SET MIS 23" COMF DEVICES GENERIC Excluded TIER 99 

INFUSION SET MIS 23"/COMF DEVICES GENERIC Excluded TIER 99 

INFUSION SET MIS 23"COMFO DEVICES GENERIC Excluded TIER 99 





INFUSION SET MIS 24"/9MM DEVICES GENERIC Excluded TIER 99 










INFUSION SET MIS 43" 10MM DEVICES GENERIC Excluded TIER 99 




INFUSION SET MIS 43"/COMF DEVICES GENERIC Excluded TIER 99 

INFUSION SET MIS 43"COMFO DEVICES GENERIC Excluded TIER 99 



204

INFUSION SET MIS CATH 23" DEVICES GENERIC Covered TIER 1 



INFUVITE INJ MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

INFUVITE INJ ADULT MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

INFUVITE INJ PEDIATRI MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

INJECTOR MIS LUER LOC DEVICES BRAND Excluded TIER 99 

INJECTOR CAP MIS PHASEAL DEVICES BRAND Excluded TIER 99 

INLYTA TAB 1MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 

INLYTA TAB 5MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 

INNOPRAN XL CAP 120MG 



INNOPRAN XL CAP 80MG 



INOVA KIT 4% 



INOVA KIT 8% 



INOVA 4/1 KIT ACNE CON 



INOVA 8/2 KIT ACNE CON 



INPERSOL/DEX SOL 1.5% IRRIGATING SOLUTIONS GENERIC Covered TIER 1 



INPERSOL‐LM/ SOL 1.5% DEX IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

INPERSOL‐LM/ SOL 2.5% DEX IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

INPERSOL‐LM/ SOL 4.25 DEX IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

INSERTION KIT 16FRENCH DEVICES BRAND Excluded TIER 99 

INSERTION KIT 18FRENCH DEVICES BRAND Excluded TIER 99 



205

INSPIRATION MIS ELITE DEVICES BRAND Excluded TIER 99 

INSPIRATION MIS NEBULIZR DEVICES BRAND Excluded TIER 99 

INSPIREASE MIS DD SYST DEVICES BRAND Excluded TIER 99 

INSPRA TAB 25MG 



INSPRA TAB 50MG 



INSTAT PAD 2.5X5.1 HEMOSTATICS BRAND Excluded TIER 99 

INSTAT PAD 7.6X10.2 HEMOSTATICS BRAND Excluded TIER 99 

INSUFLON MIS 25GX0.71 DEVICES BRAND Excluded TIER 99 

INSULIN PUMP KIT IR2020 DEVICES GENERIC Covered TIER 1 

INSULIN PUMP MIS AMIGO DEVICES BRAND Covered TIER 3 

INSULIN PUMP MIS PEDIATRI DEVICES BRAND Covered TIER 3 

INSULIN PUMP MIS PROGRAM DEVICES BRAND Covered TIER 3 

INSYTE AUTOG MIS 14GX1.75 DEVICES BRAND Excluded TIER 99 

INSYTE AUTOG MIS 18GX1.16 DEVICES BRAND Excluded TIER 99 

INSYTE AUTOG MIS 22GX1" DEVICES BRAND Excluded TIER 99 

INSYTE AUTOG MIS 24GX3/4" DEVICES BRAND Excluded TIER 99 

INTEGRA F CAP IRON PREPARATIONS BRAND Covered TIER 3 

INTEGRA PLUS CAP IRON PREPARATIONS BRAND Covered TIER 3 

INTEGRILIN INJ 0.75MG/1 PLATELET‐AGGREGATION INHIBITORS BRAND Covered TIER 3 

INTEGRILIN INJ 2MG/ML PLATELET‐AGGREGATION INHIBITORS BRAND Covered TIER 3 

NONNUCLEOSIDE 

INTELENCE TAB 100MG 



NONNUCLEOSIDE 



NONNUCLEOSIDE 




206

INTERCED TC7 PAD 1.5"X2" 



INTERCED TC7 PAD 3"X4" 



INTERMEZZO SUB 1.75MG 



INTERMEZZO SUB 3.5MG 



INTERMITTENT MIS 14FR40CM DEVICES BRAND Excluded TIER 99 

INTRALIPID INJ 20% CALORIC AGENTS GENERIC Covered TIER 1 

INTRALIPID INJ 30% CALORIC AGENTS Brand‐O PA TIER 3 

INTRO NEEDLE MIS 18GX1.25 DEVICES BRAND Excluded TIER 99 

INTROL SOL 75% EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 3 

INTRON‐A INJ 10MU ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 




INTROVALE TAB CONTRACEPTIVES GENERIC Covered TIER 1 


INTUNIV TAB 1MG 











INULIN INJ 100MG/ML KIDNEY FUNCTION GENERIC Covered TIER 1 

INVANZ INJ 1GM CARBAPENEMS BRAND Covered TIER 3 

INVEGA TAB 1.5MG ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 3 

INVEGA TAB 3MG ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 3 QL 



207



INVEGA SUST INJ 117/0.75 ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 3 

INVEGA SUST INJ 156MG/ML ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 3 



INVEGA SUST INJ 78/0.5ML ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 3 

INVIRASE CAP 200MG HIV PROTEASE INHIBITORS BRAND Covered TIER 2 

INVIRASE TAB 500MG HIV PROTEASE INHIBITORS BRAND Covered TIER 2 

IODINE SOL STRONG EXPECTORANTS GENERIC Covered TIER 1 

IODINE TIN 2% MILD 



IODINE TIN STRONG 



IODOFLEX PAD PAD 



IODOPEN INJ 100MCG THYROID FUNCTION BRAND Covered TIER 3 

IODOSORB GEL 



IODOSORB GEL 0.9% 



IONOSOL‐B/ INJ D5W REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

IONOSOL‐MB INJ /D5W REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

IOPIDINE SOL 0.5% OP EENT DRUGS, MISCELLANEOUS Brand‐O PA TIER 3 

IOPIDINE SOL 1% OP EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 3 

IPOL INJ INACTIVE VACCINES BRAND Covered TIER 3 

I‐PORT MIS 6MM DEVICES BRAND Excluded TIER 99 

I‐PORT MIS 9MM DEVICES BRAND Excluded TIER 99 

IPRATROPIUM SOL 0.02%INH 





208

IPRATROPIUM SPR 0.03% 



IPRATROPIUM SPR 0.06% 



IPRATROPIUM/ SOL ALBUTER 



IPRIVASK INJ 15MG DIRECT THROMBIN INHIBITORS BRAND PA TIER 3 

IQUIX SOL 1.5% ANTIBACTERIALS (EENT) BRAND Covered TIER 3 

IRBESAR/HCTZ TAB 150‐12.5 



IRBESAR/HCTZ TAB 300‐12.5 



IRBESARTAN TAB 150MG 









IRESSA TAB 250MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 QL SP 

IRINOTECAN INJ 100/5ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

IRINOTECAN INJ 40MG/2ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

IRINOTECAN INJ 500MG/25 ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

IRON OXIDE PST BLACK PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

IRON OXIDE PST RED PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

IRON OXIDE PST YELLOW PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

IROSPAN 24/6 MIS IRON PREPARATIONS BRAND Covered TIER 3 

IRRIGAT SYRG MIS 50ML BUL DEVICES BRAND Excluded TIER 99 

ISCAR MALI INJ 5MG/ML 



ISENTRESS CHW 100MG INTEGRASE INHIBITORS BRAND Covered TIER 2 



209

ISENTRESS CHW 25MG INTEGRASE INHIBITORS BRAND Covered TIER 2 

ISENTRESS TAB 400MG INTEGRASE INHIBITORS BRAND Covered TIER 2 

ISO ATROPINE SOL 1% OP MYDRIATICS Brand‐O PA TIER 3 

ISO CARBACHO SOL 1.5% OP MIOTICS BRAND Covered TIER 2 

ISO CARBACHO SOL 3% OP MIOTICS BRAND Covered TIER 2 

ISO HOMATROP SOL 2% OP MYDRIATICS BRAND Covered TIER 3 

ISO HOMATROP SOL 5% OP MYDRIATICS Brand‐O PA TIER 3 

ISO HYOSCINE SOL 0.25% OP MYDRIATICS BRAND Covered TIER 3 

ISOCHRON TAB 40MG CR NITRATES AND NITRITES GENERIC Covered TIER 1 

ISODITRATE TAB 40MG ER NITRATES AND NITRITES GENERIC Covered TIER 1 

ISOFLURANE SOL INHALATION ANESTHETICS GENERIC Covered TIER 1 

ISOLYTE‐H INJ /D5W REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

ISOLYTE‐M INJ /D5W REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

ISOLYTE‐P INJ /D5W REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

ISOLYTE‐S INJ REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

ISOLYTE‐S INJ /D5W REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

ISOLYTE‐S INJ PH 7.4 REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

ISOMETH/APAP CAP DICHLOR 



ISOMETH/CAFF TAB /APAP 



ISONARIF CAP ANTITUBERCULOSIS AGENTS GENERIC Covered TIER 1 

ISONIAZID INJ 100MG/ML ANTITUBERCULOSIS AGENTS GENERIC Covered TIER 1 

ISONIAZID SYP 50MG/5ML ANTITUBERCULOSIS AGENTS GENERIC Covered TIER 1 

ISONIAZID TAB 100MG ANTITUBERCULOSIS AGENTS GENERIC Covered TIER 1 

ISONIAZID TAB 300MG ANTITUBERCULOSIS AGENTS GENERIC Covered TIER 1 

ISOPTIN SR TAB 120MG 








210




ISOPTO CARP SOL 1% OP MIOTICS Brand‐O PA TIER 3 



ISORDIL TAB 40MG NITRATES AND NITRITES BRAND Covered TIER 3 

ISORDIL TAB 5MG NITRATES AND NITRITES Brand‐O PA TIER 3 

ISOSORB DIN SUB 2.5MG NITRATES AND NITRITES GENERIC Covered TIER 1 

ISOSORB DIN SUB 5MG NITRATES AND NITRITES GENERIC Covered TIER 1 

ISOSORB DIN TAB 10MG NITRATES AND NITRITES GENERIC Covered TIER 1 



ISOSORB DIN TAB 40MG ER NITRATES AND NITRITES GENERIC Covered TIER 1 


ISOSORB MONO TAB 10MG NITRATES AND NITRITES GENERIC Covered TIER 1 

ISOSORB MONO TAB 120MG ER NITRATES AND NITRITES GENERIC Covered TIER 1 

ISOSORB MONO TAB 20MG NITRATES AND NITRITES GENERIC Covered TIER 1 



ISOSULFAN INJ BLUE 1% DIAGNOSTIC AGENTS GENERIC Excluded TIER 99 

ISOVUE‐200 INJ 41% ROENTGENOGRAPHY BRAND Covered TIER 3 


ISOVUE‐250 INJ 51%MLTPK ROENTGENOGRAPHY BRAND Covered TIER 3 





ISOVUE‐M 200 INJ 41% ROENTGENOGRAPHY BRAND Covered TIER 3 

ISOVUE‐M 300 INJ 61% ROENTGENOGRAPHY BRAND Covered TIER 3 



211

ISOXSUPRINE TAB 10MG 



ISRADIPINE CAP 2.5MG DIHYDROPYRIDINES GENERIC Covered TIER 1 

ISRADIPINE CAP 5MG DIHYDROPYRIDINES GENERIC Covered TIER 1 

ISTALOL SOL 0.5% OP 




ISTODAX INJ 10MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

ISUPREL INJ 0.2MG/ML 

NON‐SELECTIVE BETA‐ADRENERGIC 


ITRACONAZOLE CAP 100MG AZOLES GENERIC Covered TIER 1 QL 

IV BAG HANGR MIS PHASEAL DEVICES BRAND Excluded TIER 99 

IXEMPRA KIT INJ 15MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

IXEMPRA KIT INJ 45MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

IXIARO INJ VACCINES BRAND Covered TIER 3 

JAKAFI TAB 10MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 





JALYN CAP 5‐ALPHA‐REDUCTASE INHIBITORS BRAND Covered TIER 2 QL 

JANTOVEN TAB 10MG COUMARIN DERIVATIVES GENERIC Covered TIER 1 


JANTOVEN TAB 2.5MG COUMARIN DERIVATIVES GENERIC Covered TIER 1 






JANTOVEN TAB 7.5MG COUMARIN DERIVATIVES GENERIC Covered TIER 1 



212

JANUMET TAB 50‐1000 

DIPEPTIDYL PEPTIDASE‐4(DPP‐4) 


JANUMET TAB 50‐500MG 



JANUMET XR TAB 100‐1000 



JANUMET XR TAB 50‐1000 



JANUMET XR TAB 50‐500MG 



JANUVIA TAB 100MG 









JAY‐PHYL SYP 



J‐COF DHC LIQ ANTITUSSIVES BRAND Excluded TIER 99 

JENTADUETO TAB 2.5‐1000 









JEVANTIQUE TAB 1MG‐5MCG ESTROGENS GENERIC Covered TIER 1 

JE‐VAX INJ VACCINES BRAND Covered TIER 3 

JEVTANA INJ 60/1.5ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

JINTELI TAB 1MG‐5MCG ESTROGENS GENERIC Covered TIER 1 

J‐MAX DHC LIQ ANTITUSSIVES BRAND Excluded TIER 99 



213

JOLESSA TAB CONTRACEPTIVES GENERIC Covered TIER 1 

JOLIVETTE TAB 0.35MG CONTRACEPTIVES GENERIC Covered TIER 1 

J‐TAN D CHW 2.2‐1.58 PROPYLAMINE DERIVATIVES Brand‐O PA TIER 99 

J‐TAN D SUS PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

J‐TAN D SR TAB 6‐30MG PROPYLAMINE DERIVATIVES Brand‐O PA TIER 99 

J‐TIP KIT KIT ADAPTERS DEVICES BRAND Excluded TIER 99 

JUNEL 1.5/30 TAB CONTRACEPTIVES GENERIC Covered TIER 1 

JUNEL 1/20 TAB CONTRACEPTIVES GENERIC Covered TIER 1 

JUNEL FE TAB 1.5/30 CONTRACEPTIVES GENERIC Covered TIER 1 

JUNEL FE TAB 1/20 CONTRACEPTIVES GENERIC Covered TIER 1 

JUVISYNC TAB 100‐10MG 


















K CITRATE SOL CITR ACD ALKALINIZING AGENTS GENERIC Covered TIER 1 

KADIAN CAP 100MG CR OPIATE AGONISTS Brand‐O PA TIER 3 QL 

KADIAN CAP 10MG CR OPIATE AGONISTS BRAND Covered TIER 3 QL 

KADIAN CAP 130MG CR OPIATE AGONISTS BRAND Covered TIER 3 


KADIAN CAP 200MG CR OPIATE AGONISTS BRAND Covered TIER 3 QL 





214






KAHLUA LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

KALBITOR INJ 10MG/ML COMPLEMENT INHIBITORS BRAND PA TIER 3 

KALETRA SOL HIV PROTEASE INHIBITORS BRAND Covered TIER 2 

KALETRA TAB 100‐25MG HIV PROTEASE INHIBITORS BRAND Covered TIER 2 

KALETRA TAB 200‐50MG HIV PROTEASE INHIBITORS BRAND Covered TIER 2 

KALYDECO TAB 150MG 



KANAMYCIN INJ 333MG/ML AMINOGLYCOSIDES GENERIC Covered TIER 1 

KANG EXTENSN MIS Y‐SITE DEVICES BRAND Excluded TIER 99 

KANGAROO KIT 12FR/0.8 DEVICES BRAND Excluded TIER 99 




KANGAROO KIT 12FR/1CM DEVICES BRAND Excluded TIER 99 














215

































216













KANGAROO MIS IRRIGATI DEVICES BRAND Excluded TIER 99 

KAPVAY MIS 0.1&0.2 CENTRAL ALPHA‐AGONISTS BRAND Covered TIER 3 

KAPVAY TAB 0.1 MG CENTRAL ALPHA‐AGONISTS BRAND Covered TIER 3 QL 

KARAYA GUM CATHARTICS AND LAXATIVES GENERIC Excluded TIER 99 

KARIDIUM DRO 0.125MG CARIOSTATIC AGENTS GENERIC Covered TIER 1 

KARIGEL GEL 0.5% CARIOSTATIC AGENTS GENERIC Covered TIER 1 

KARIGEL‐N GEL 1.1% CARIOSTATIC AGENTS GENERIC Covered TIER 1 

KARIVA TAB 28 DAY CONTRACEPTIVES GENERIC Covered TIER 1 

KCL IN NACL INJ REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

KCL/D5W INJ 0.15% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 SP 



KCL/D5W/LR INJ 0.15% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 SP 

KCL/D5W/LR INJ 0.3% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 SP 

KCL/D5W/NACL INJ .075/.2% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 SP 

KCL/D5W/NACL INJ .075/.45 REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 SP 

KCL/D5W/NACL INJ .15‐.45% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 SP 




217




KCL/D5W/NACL INJ 0.15/0.2 REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 SP 


KCL/D5W/NACL INJ 0.3/0.2% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 SP 


KCL/D5W/NACL INJ 0.3/0.9% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 SP 

KCL/NACL INJ 0.15‐0.9 REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

KCL/NACL INJ 0.3‐0.9 REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

KEDBUMIN INJ 25% BLOOD DERIVATIVES GENERIC Covered TIER 1 

K‐EFFERVESCE TAB 25MEQ EF REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

KEFLEX CAP 250MG 









KELNOR TAB 1/35 CONTRACEPTIVES GENERIC Covered TIER 1 

KENALOG AER SPRAY 



KENALOG‐10 INJ 10MG/ML ADRENALS BRAND Covered TIER 3 

KENALOG‐40 INJ 40MG/ML ADRENALS BRAND Covered TIER 3 

KENGUARD MIS DRAINAGE DEVICES BRAND Excluded TIER 99 

KEPIVANCE INJ 6.25MG 


PROLIFERANTS BRAND Covered TIER 2 SP 

KEPPRA INJ 500/5ML 



KEPPRA SOL 100MG/ML 





218

KEPPRA TAB 1000MG 












KEPPRA XR TAB 500MG 


MISCELLANEOUS Brand‐O PA TIER 3 QL 

KEPPRA XR TAB 750MG 



KERAFOAM AER 30% KERATOLYTIC AGENTS BRAND Covered TIER 3 

KERAFOAM 42 AER 42% KERATOLYTIC AGENTS BRAND Covered TIER 3 

KERALYT GEL 6% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

KERALYT KIT SCALP 6% KERATOLYTIC AGENTS BRAND Covered TIER 3 

KERLONE TAB 10MG 



KERLONE TAB 20MG 



KEROL EMU 50% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

KEROL SUS 50% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

KEROL AD EMU 45% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

KERR TRIPLE MIS DYE SWAB 



KETALAR INJ 100MG/ML 








219




KETAMINE INJ 100MG/ML 









KETEK TAB 300MG KETOLIDES BRAND Covered TIER 3 

KETEK TAB 400MG KETOLIDES BRAND Covered TIER 3 

KETOCON KIT 



KETOCONAZOLE AER 2% 



KETOCONAZOLE CRE 2% 



KETOCONAZOLE SHA 2% 



KETOCONAZOLE TAB 200MG AZOLES GENERIC Covered TIER 1 

KETODAN AER 2% 



KETODAN KIT 2% 



KETOPROFEN CAP 200MG ER 



KETOPROFEN CAP 50MG 



KETOPROFEN CAP 75MG 





220

KETOROLAC INJ 15MG/ML 



KETOROLAC INJ 30MG/ML 



KETOROLAC INJ 60MG/2ML 



KETOROLAC SOL 0.4% 



KETOROLAC SOL 0.5% 



KETOROLAC TAB 10MG 



KGS‐PE LIQ 5MG‐75MG EXPECTORANTS GENERIC Covered TIER 1 

KINERET INJ 



KINEVAC INJ 5MCG GALLBLADDER FUNCTION BRAND Covered TIER 3 

KINLYTIC INJ 250000 THROMBOLYTIC AGENTS BRAND Covered TIER 3 

KINRIX INJ TOXOIDS BRAND Excluded TIER 99 

KIONEX SUS 15GM/60 POTASSIUM‐REMOVING AGENTS GENERIC Covered TIER 1 

KLARON LOT 10% 



KLATSKIN BIO MIS 16X4" DEVICES BRAND Excluded TIER 99 

KLONOPIN TAB 0.5MG 


(ANTICONVULSANTS) Brand‐O PA TIER 3 

KLONOPIN TAB 1MG 



KLONOPIN TAB 2MG 



K‐LOR POW 20MEQ REPLACEMENT PREPARATIONS Brand‐O PA TIER 3 

KLOR‐CON POW 20MEQ REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 



221

KLOR‐CON 10 TAB 10MEQ ER REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

KLOR‐CON 8 TAB 8MEQ ER REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

KLOR‐CON M10 TAB 10MEQ ER REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

KLOR‐CON M15 TAB REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

KLOR‐CON M20 TAB 20MEQ ER REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

KLOR‐CON/EF TAB 25MEQ FR REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

KLOR‐CON‐25 POW 25MEQ REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

KNEE LENGTH MIS MED/REG DEVICES BRAND Excluded TIER 99 

KOATE‐DVI INJ 1000UNIT HEMOSTATICS BRAND PA TIER 2 SP 



KOGENATE FS INJ 1000/BS HEMOSTATICS BRAND PA TIER 2 SP 

KOGENATE FS INJ 1000UNIT HEMOSTATICS BRAND PA TIER 2 SP 









KOMBIGLYZE TAB 2.5‐1000 



KOMBIGLYZE TAB 5‐1000MG 



KOMBIGLYZE TAB 5‐500MG 



KORLYM TAB 300MG 

ANTIDIABETIC AGENTS, 


K‐PHOS TAB REPLACEMENT PREPARATIONS BRAND Covered TIER 3 



222

K‐PHOS TAB MF ACIDIFYING AGENTS BRAND Covered TIER 3 

K‐PHOS TAB NEUTRAL REPLACEMENT PREPARATIONS Brand‐O PA TIER 3 

K‐PHOS TAB NO 2 ACIDIFYING AGENTS BRAND Covered TIER 3 

K‐PRIME TAB 25MEQ EF REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

KRIS‐ESTER LIQ 236 PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

KRISGEL 100 GEL PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

KRISTALOSE PAK 10GM AMMONIA DETOXICANTS BRAND Covered TIER 2 

KRISTALOSE PAK 20GM AMMONIA DETOXICANTS BRAND Covered TIER 2 

KRYSTEXXA INJ 8MG/ML ANTIGOUT AGENTS BRAND PA TIER 2 SP 

K‐TABS TAB 10MEQ CR REPLACEMENT PREPARATIONS Brand‐O PA TIER 3 

KUVAN TAB 100MG 



K‐VESCENT POW 20MEQ REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

K‐VESCENT TAB 25MEQ EF REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

KYPROLIS SOL 60MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 

LABETALOL INJ 5MG/ML 



LABETALOL TAB 100MG 









LACERATION KIT DEVICES BRAND Covered TIER 3 

LAC‐HYDRIN CRE 12% BASIC LOTIONS AND LINIMENTS Brand‐O PA TIER 3 

LAC‐HYDRIN LOT 12% BASIC LOTIONS AND LINIMENTS Brand‐O PA TIER 3 

LACLOTION LOT 12% BASIC LOTIONS AND LINIMENTS GENERIC Covered TIER 1 

LACRISERT MIS 5MG OP EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 2 

LACTATED RIN INJ REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

LACTATED RIN SOL IRRIGAT IRRIGATING SOLUTIONS GENERIC Covered TIER 1 



223

LACTIC ACID CRE /VIT E BASIC OILS AND OTHER SOLVENTS GENERIC Covered TIER 1 

LACTIC ACID CRE E BASIC OILS AND OTHER SOLVENTS GENERIC Covered TIER 1 

LACTIC ACID LOT 10% BASIC LOTIONS AND LINIMENTS GENERIC Covered TIER 1 

LACTOCAL‐F TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

LACTULOSE SOL 10GM/15 AMMONIA DETOXICANTS GENERIC Covered TIER 1 

LACTULOSE SOL 20GM/30 AMMONIA DETOXICANTS GENERIC Covered TIER 1 

LAGESIC TAB 66‐600MG ETHANOLAMINE DERIVATIVES Brand‐O PA TIER 3 

LAMICTAL CHW 25MG 









LAMICTAL KIT START 35 









LAMICTAL TAB 100MG 














224

LAMICTAL ODT TAB 100MG 












LAMICTAL XR TAB 100MG 


















LAMISIL GRA 125MG ALLYLAMINES BRAND Covered TIER 3 QL 

LAMISIL GRA 187.5MG ALLYLAMINES BRAND Covered TIER 3 QL 

LAMISIL SPR 1% 

ALLYLAMINES (SKIN & MUCOUS 


LAMISIL TAB 250MG ALLYLAMINES Brand‐O PA TIER 3 QL 

LAMIVUD/ZIDO TAB 150‐300 



LAMIVUDINE TAB 150MG 





225

LAMIVUDINE TAB 300MG 



LAMOTRIGINE CHW 25MG 



LAMOTRIGINE CHW 5MG 



LAMOTRIGINE TAB 100MG 


MISCELLANEOUS GENERIC Covered TIER 1 QL 










LANOLIN OIL 



LANOLIN OIN ALCOHOL 



LANOLIN/UREA OIN BASE 



LANOXIN INJ 0.1MG/ML CARDIOTONIC AGENTS BRAND Covered TIER 3 

LANOXIN INJ 0.25MG/1 CARDIOTONIC AGENTS Brand‐O PA TIER 3 

LANOXIN TAB 0.125MG CARDIOTONIC AGENTS Brand‐O PA TIER 3 

LANOXIN TAB 0.25MG CARDIOTONIC AGENTS Brand‐O PA TIER 3 

LANSOPRAZOLE CAP 15MG DR PROTON‐PUMP INHIBITORS GENERIC Covered TIER 1 QL 

LANSOPRAZOLE CAP 30MG DR PROTON‐PUMP INHIBITORS GENERIC Covered TIER 1 QL 

LANSOPRAZOLE SUS 3MG/ML PROTON‐PUMP INHIBITORS BRAND Covered TIER 3 

LANSOPRAZOLE TAB 15MG ODT PROTON‐PUMP INHIBITORS GENERIC Covered TIER 1 QL 

LANSOPRAZOLE TAB 30MG ODT PROTON‐PUMP INHIBITORS GENERIC Covered TIER 1 QL 

LANTUS INJ 100/ML INSULINS BRAND Covered TIER 2 



226

LANTUS INJ SOLOSTAR INSULINS BRAND Covered TIER 2 

LARTUS LIQ ANTITUSSIVES BRAND Excluded TIER 99 

LASIX TAB 20MG LOOP DIURETICS Brand‐O PA TIER 3 



LASTACAFT SOL 0.25% ANTIALLERGIC AGENTS BRAND Covered TIER 3 

LATANOPROST SOL 0.005% PROSTAGLANDIN ANALOGS GENERIC Covered TIER 1 

LATISSE SOL 0.03% 



LATRIX SUS 50% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

LATRIX XM EMU 45% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

LATUDA TAB 120MG ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 2 




LAVOCLEN‐4 KIT ACNE WSH 



LAVOCLEN‐4 LIQ CREM WSH 



LAVOCLEN‐8 KIT ACNE WSH 



LAVOCLEN‐8 LIQ CREM WSH 



LAZANDA SPR 100MCG OPIATE AGONISTS BRAND Covered TIER 3 

LAZANDA SPR 400MCG OPIATE AGONISTS BRAND Covered TIER 3 

LAZERFORMALY SOL 10% 



L‐CYSTEINE INJ 50MG/ML CALORIC AGENTS GENERIC Covered TIER 1 

LECITHIN GEL PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

LECITHIN GRA LIPOTROPIC AGENTS GENERIC Covered TIER 1 



227

LEENA TAB CONTRACEPTIVES GENERIC Covered TIER 1 

LEFLUNOMIDE TAB 10MG 


ANTIRHEUMATIC AGENTS GENERIC Covered TIER 1 

LEFLUNOMIDE TAB 20MG 


ANTIRHEUMATIC AGENTS GENERIC Covered TIER 1 

LEFT VENTRIC MIS CATHETER DEVICES BRAND Excluded TIER 99 

LEMOHIST CAP PLUS EXPECTORANTS BRAND Excluded TIER 99 

LEMON LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

LEMON EXTRAC LIQ PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

LEMON FLAVOR OIL PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

LEMONADE OIL FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

LESCOL CAP 20MG HMG‐COA REDUCTASE INHIBITORS Brand‐O PA TIER 3 

LESCOL CAP 40MG HMG‐COA REDUCTASE INHIBITORS Brand‐O PA TIER 3 

LESCOL XL TAB 80MG HMG‐COA REDUCTASE INHIBITORS BRAND Covered TIER 3 

LESSINA‐28 TAB CONTRACEPTIVES GENERIC Covered TIER 1 

LETAIRIS TAB 10MG 


MISCELLANEOUS BRAND PA TIER 2 SP 

LETAIRIS TAB 5MG 



LETROZOLE TAB 2.5MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

LEUCOVOR CA INJ 100MG ANTIDOTES GENERIC Covered TIER 1 SP 

LEUCOVOR CA INJ 10MG/ML ANTIDOTES GENERIC Covered TIER 1 SP 




LEUCOVOR CA TAB 10MG ANTIDOTES GENERIC Covered TIER 1 




228



LEUCOVORIN INJ CALCIUM ANTIDOTES GENERIC Covered TIER 1 SP 

LEUKERAN TAB 2MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

LEUKINE INJ 250MCG HEMATOPOIETIC AGENTS BRAND Covered TIER 2 

LEUKINE INJ 500 MCG HEMATOPOIETIC AGENTS BRAND Covered TIER 2 

LEUPROLIDE INJ 1MG/0.2 ANTINEOPLASTIC AGENTS GENERIC PA TIER 1 SP 

LEUSTATIN INJ 1MG/ML ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

LEVACET TAB SALICYLATES BRAND Covered TIER 3 


LEVALBUTEROL NEB 0.31MG 





LEVALBUTEROL NEB 1.25/0.5 






LEVAQUIN INJ 25MG/ML QUINOLONES Brand‐O PA TIER 3 

LEVAQUIN SOL 25MG/ML QUINOLONES Brand‐O PA TIER 3 

LEVAQUIN TAB 250MG QUINOLONES Brand‐O PA TIER 3 



LEVAQUIN/D5W INJ 250/50ML QUINOLONES Brand‐O PA TIER 3 

LEVAQUIN/D5W INJ 500/100M QUINOLONES Brand‐O PA TIER 3 

LEVAQUIN/D5W INJ 750/150 QUINOLONES Brand‐O PA TIER 3 

LEVATOL TAB 20MG 



LEVBID TAB 0.375 ER 



LEVEMIR INJ INSULINS BRAND Covered TIER 2 



229

LEVEMIR INJ FLEXPEN INSULINS BRAND Covered TIER 2 

LEVETIRACETA INJ 10MG/ML 









LEVETIRACETA SOL 100MG/ML 



LEVETIRACETA SOL 500/5ML 



LEVETIRACETA TAB 1000MG 









LEVETIRACETA TAB 500MG ER 






LEVETIRACETA TAB 750MG ER 



LEVETIRACETM INJ 500/5ML 



LEVITRA TAB 10MG 



LEVITRA TAB 2.5MG 





230







LEVOBUNOLOL SOL 0.25% OP 



LEVOBUNOLOL SOL 0.5% OP 



LEVOCARNITIN INJ 200MG/ML 



LEVOCARNITIN SOL 1GM/10ML 



LEVOCARNITIN TAB 330MG 



LEVOCETIRIZI SOL 2.5/5ML 



LEVOCETIRIZI TAB DHCL 5MG 



LEVOFLOX/D5W INJ 250/50ML QUINOLONES GENERIC Covered TIER 1 

LEVOFLOX/D5W INJ 500/100M QUINOLONES GENERIC Covered TIER 1 

LEVOFLOX/D5W INJ 750/150 QUINOLONES GENERIC Covered TIER 1 

LEVOFLOXACIN INJ 25MG/ML QUINOLONES GENERIC Covered TIER 1 

LEVOFLOXACIN SOL 0.5% ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

LEVOFLOXACIN SOL 25MG/ML QUINOLONES GENERIC Covered TIER 1 

LEVOFLOXACIN TAB 250MG QUINOLONES GENERIC Covered TIER 1 



LEVOMEFOLATE CAP DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 2 

LEVOMEFOLATE MIS MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

LEVONEST TAB CONTRACEPTIVES GENERIC Covered TIER 1 



231

LEVONOR/ETHI TAB ESTRADIO CONTRACEPTIVES GENERIC Covered TIER 1 

LEVONORGESTR TAB 0.75MG CONTRACEPTIVES GENERIC Covered TIER 1 

LEVOPHED INJ 1MG/ML 




LEVORA‐28 TAB 0.15/30 CONTRACEPTIVES GENERIC Covered TIER 1 

LEVORPHANOL TAB 2MG OPIATE AGONISTS GENERIC Covered TIER 1 

LEVOTHROID TAB 100MCG THYROID AGENTS GENERIC Covered TIER 1 












LEVOTHYROXIN INJ 100MCG THYROID AGENTS GENERIC Covered TIER 1 



LEVOTHYROXIN TAB 100MCG THYROID AGENTS GENERIC Covered TIER 1 










232





LEVOXYL TAB 100MCG THYROID AGENTS GENERIC Covered TIER 1 











LEVSIN INJ 0.5MG/ML 



LEVSIN TAB 0.125MG 



LEVSIN/SL SUB 0.125MG 



LEVULAN KERA SOL 20% 



LEXAPRO SOL 5MG/5ML 



LEXAPRO TAB 10MG 








233




LEXISCAN INJ 0.4MG CARDIAC FUNCTION BRAND Covered TIER 3 

LEXIVA SUS 50MG/ML HIV PROTEASE INHIBITORS BRAND Covered TIER 2 

LEXIVA TAB 700MG HIV PROTEASE INHIBITORS BRAND Covered TIER 2 

L‐GLUTAMINE CRY FCC CALORIC AGENTS GENERIC Excluded TIER 99 

L‐HISTIDINE CRY MONOHYDR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

LIALDA TAB 1.2GM 



LIBRAX CAP 5‐2.5MG 



LICORICE LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

LIDAMANTLE CRE HC3‐0.5% 



LIDAZONE CRE 



LIDO/DEXTROS INJ 5‐7.5% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

LIDO/EPI INJ 0.5% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

LIDO/EPI INJ 1.5% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

LIDO/EPI INJ 2% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

LIDO/EPI 1%‐ INJ 1:100000 LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

LIDO/PRILOCN CRE 2.5‐2.5% 



LIDO/PRILOCN KIT 2.5‐2.5% 





234

LIDOCAIN/D5W INJ 4MG/ML CLASS IB ANTIARRHYTHMICS GENERIC Covered TIER 1 

LIDOCAIN/D5W INJ 8MG/ML CLASS IB ANTIARRHYTHMICS GENERIC Covered TIER 1 

LIDOCAINE CRE 3% 



LIDOCAINE GEL 2% 



LIDOCAINE GEL 2% JELLY 



LIDOCAINE INJ 0.5% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

LIDOCAINE INJ 1% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

LIDOCAINE INJ 1.5% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

LIDOCAINE INJ 10MG/ML CLASS IB ANTIARRHYTHMICS GENERIC Covered TIER 1 


LIDOCAINE INJ 20MG/ML CLASS IB ANTIARRHYTHMICS GENERIC Covered TIER 1 


LIDOCAINE LOT 3% 



LIDOCAINE OIN 5% 



LIDOCAINE SOL 2% VISC LOCAL ANESTHETICS (EENT) GENERIC Covered TIER 1 

LIDOCAINE SOL 4% 



LIDOCAINE/HC CRE 3%‐0.5% 





235

LIDOCAINE/HC KIT 2‐2% 



LIDOCAINE/HC KIT 3%‐0.5% 



LIDOCAINE/HC KIT 3%‐1% 



LIDOCAINE/HC KIT 3‐2.5% 



LIDODERM DIS 5% 



LIDO‐HYDRO GEL 2.8‐0.55 



LIDOVIR OIN 4‐4% 



LIMBREL CAP 250MG 



LIMBREL CAP 500MG 



LIMBREL250 CAP 250‐50MG 









LIME FLAVOR OIL PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

LINCOCIN INJ 300MG/ML LINCOMYCINS BRAND Covered TIER 3 

LINDANE LOT 1% SCABICIDES AND PEDICULICIDES GENERIC Covered TIER 1 

LINDANE SHA 1% SCABICIDES AND PEDICULICIDES GENERIC Covered TIER 1 

LINZESS CAP 145MCG GI DRUGS, MISCELLANEOUS BRAND Covered TIER 3 

LINZESS CAP 290MCG GI DRUGS, MISCELLANEOUS BRAND Covered TIER 3 



236

LIORESAL INT INJ 0.05MG/1 



LIORESAL INT INJ 10MG/20 



LIORESAL INT INJ 10MG/5ML 



LIORESAL INT INJ 40MG/20 



LIOTHYRONINE INJ 10MCG/ML THYROID AGENTS GENERIC Covered TIER 1 

LIOTHYRONINE TAB 25MCG THYROID AGENTS GENERIC Covered TIER 1 



LIPITOR TAB 10MG HMG‐COA REDUCTASE INHIBITORS Brand‐O PA TIER 3 




LIPMAX SOL LIPOTROPIC AGENTS BRAND Excluded TIER 99 

LIPO CREAM CRE BASE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

LIPOBASE CRE HEAVY PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

LIPOBASE CRE REGULAR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

LIPODERM HMW GEL PCCA PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

LIPODOX INJ 2MG/ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

LIPODOX 50 INJ 2MG/ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

LIPOFEN CAP 150MG FIBRIC ACID DERIVATIVES BRAND Covered TIER 2 QL 

LIPOFEN CAP 50MG FIBRIC ACID DERIVATIVES BRAND Covered TIER 2 QL 

LIPOPEN CRE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 



237

LIPOPEN CRE PLUS PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

LIPOSYN II INJ 10% CALORIC AGENTS Brand‐O PA TIER 3 

LIPOSYN II INJ 20% CALORIC AGENTS Brand‐O PA TIER 3 

LIPOSYN III INJ 10% CALORIC AGENTS Brand‐O PA TIER 3 

LIPOSYN III INJ 20% CALORIC AGENTS Brand‐O PA TIER 3 

LIPOSYN III INJ 30% CALORIC AGENTS GENERIC Covered TIER 1 

LIQUICET SOL 10‐500MG OPIATE AGONISTS BRAND Covered TIER 3 

LIQUIGEL LIQ COMPLEX PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

LIQUIHEP KIT 500UNIT DEVICES BRAND Covered TIER 3 

LIQUIHEP II KIT 500UNIT DEVICES BRAND Covered TIER 3 

LISINOP/HCTZ TAB 10‐12.5 



LISINOP/HCTZ TAB 20‐12.5 



LISINOP/HCTZ TAB 20‐25MG 



LISINOPRIL TAB 10MG 



LISINOPRIL TAB 2.5MG 















LISSAMINE GR TES 1.5MG OCULAR DISORDERS GENERIC Covered TIER 1 

LISTER‐V CAP CALORIC AGENTS BRAND Excluded TIER 99 



238

LITEAIRE MIS DEVICES BRAND Excluded TIER 99 

LITETOUCH MIS MASK LG DEVICES BRAND Excluded TIER 99 

LITETOUCH MIS MASK MD DEVICES BRAND Excluded TIER 99 

LITETOUCH MIS MASK SM DEVICES BRAND Excluded TIER 99 

LITH HEPARIN KIT 100UNIT DEVICES GENERIC Covered TIER 1 

LITH HEPARIN KIT 500UNIT DEVICES BRAND Covered TIER 3 

LITH HEPARIN KIT 70UNIT DEVICES GENERIC Covered TIER 1 

LITHIUM CARB CAP 150MG ANTIMANIC AGENTS GENERIC Covered TIER 1 



LITHIUM CARB TAB 300MG ANTIMANIC AGENTS GENERIC Covered TIER 1 

LITHIUM CARB TAB 300MG ER ANTIMANIC AGENTS GENERIC Covered TIER 1 

LITHIUM CARB TAB 450MG ER ANTIMANIC AGENTS GENERIC Covered TIER 1 

LITHIUM CITR SOL 8MEQ/5ML ANTIMANIC AGENTS GENERIC Covered TIER 1 

LITHOBID TAB 300MG CR ANTIMANIC AGENTS Brand‐O PA TIER 3 

LITHOSTAT TAB 250MG AMMONIA DETOXICANTS BRAND Covered TIER 3 

LIVALO TAB 1MG HMG‐COA REDUCTASE INHIBITORS BRAND Covered TIER 3 



LIVER FLAVOR LIQ PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

LLX EXTENSIO MIS NEEDLE DEVICES BRAND Excluded TIER 99 

LMD 10%/D5W INJ REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

LMD 10%/NACL INJ 0.9% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

L‐METHYL‐ TAB B6‐B12 VITAMIN B COMPLEX GENERIC Excluded TIER 99 

L‐METHYLFOLA CAP PNV DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 2 

L‐METHYLFOLA TAB 15MG 





239

L‐METHYLFOLA TAB 7.5MG 



L‐METHYL‐MC TAB VITAMIN B COMPLEX BRAND Excluded TIER 99 

LO LOESTRIN TAB CONTRACEPTIVES BRAND Covered TIER 2 

LO/OVRAL‐28 TAB CONTRACEPTIVES Brand‐O PA TIER 3 

LOCOID CRE 0.1% 



LOCOID LOT 0.1% 



LOCOID OIN 0.1% 



LOCOID SOL 0.1% 



LOCOID LIPO CRE 0.1% 



LODOSYN TAB 25MG DOPAMINE PRECURSORS BRAND Covered TIER 2 

LODRANE 12D TAB 6‐45MG PROPYLAMINE DERIVATIVES Brand‐O PA TIER 99 

LODRANE 24 CAP PROPYLAMINE DERIVATIVES BRAND Covered TIER 3 

LODRANE 24D CAP 12‐90MG PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

LOESTRIN TAB 1/20‐21 CONTRACEPTIVES Brand‐O PA TIER 3 

LOESTRIN 21 TAB 1.5/30 CONTRACEPTIVES Brand‐O PA TIER 3 

LOESTRIN 24 TAB FE CONTRACEPTIVES BRAND Covered TIER 2 

LOESTRIN FE TAB 1.5/30 CONTRACEPTIVES Brand‐O PA TIER 3 

LOESTRIN FE TAB 1/20 CONTRACEPTIVES Brand‐O PA TIER 3 

LOFENE TAB 2.5MG ANTIDIARRHEA AGENTS GENERIC Covered TIER 1 

LOFIBRA CAP 134MG FIBRIC ACID DERIVATIVES Brand‐O PA TIER 3 QL 



LOFIBRA TAB 160MG FIBRIC ACID DERIVATIVES Brand‐O PA TIER 3 QL 

LOFIBRA TAB 54MG FIBRIC ACID DERIVATIVES Brand‐O PA TIER 3 QL 



240

LOHIST‐12 TAB 12 HOUR PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

LOHIST‐12D TAB 6‐45MG PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

LOKARA LOT 0.05% 



LOMOTIL TAB 2.5MG ANTIDIARRHEA AGENTS Brand‐O PA TIER 3 

LONOX TAB 2.5MG ANTIDIARRHEA AGENTS GENERIC Covered TIER 1 

LOPERAMIDE CAP 2MG ANTIDIARRHEA AGENTS GENERIC Covered TIER 1 

LOPID TAB 600MG FIBRIC ACID DERIVATIVES Brand‐O PA TIER 3 

LOPRESS HCT TAB 100‐25MG 



LOPRESS HCT TAB 50‐25MG 



LOPRESSOR INJ 5MG/5ML 



LOPRESSOR TAB 100MG 



LOPRESSOR TAB 50MG 



LOPROX GEL 0.77% 



LOPROX SHA 1% 



LORAZEPAM CON 2MG/ML 




LORAZEPAM INJ 2MG/ML 


(ANXIOLYTIC,SEDATIV/HYP) GENERIC Covered TIER 1 SP 

LORAZEPAM INJ 4MG/ML 


(ANXIOLYTIC,SEDATIV/HYP) GENERIC Covered TIER 1 SP 



241

LORAZEPAM TAB 0.5MG 



LORAZEPAM TAB 1MG 



LORAZEPAM TAB 2MG 



LORCET TAB 10‐650MG OPIATE AGONISTS Brand‐O PA TIER 3 

LORCET PLUS TAB 7.5‐650 OPIATE AGONISTS Brand‐O PA TIER 3 

LORTAB ELX 7.5‐500 OPIATE AGONISTS Brand‐O PA TIER 3 

LORTAB TAB 10‐500MG OPIATE AGONISTS Brand‐O PA TIER 3 

LORTAB TAB 5‐500MG OPIATE AGONISTS Brand‐O PA TIER 3 

LORTAB TAB 7.5‐500 OPIATE AGONISTS Brand‐O PA TIER 3 

LORYNA TAB 3‐0.02MG CONTRACEPTIVES GENERIC Covered TIER 1 

LORZONE TAB 375MG 



LORZONE TAB 750MG 



LOSARTAN POT TAB 100MG 









LOSARTAN/HCT TAB 100‐12.5 



LOSARTAN/HCT TAB 100‐25 



LOSARTAN/HCT TAB 50‐12.5 



LOSEASONIQUE TAB CONTRACEPTIVES Brand‐O PA TIER 3 



242

LOTEMAX OIN 0.5% CORTICOSTEROIDS (EENT) BRAND Covered TIER 3 

LOTEMAX SUS 0.5% CORTICOSTEROIDS (EENT) BRAND Covered TIER 2 

LOTENSIN TAB 10MG 









LOTENSIN HCT TAB 10‐12.5 



LOTENSIN HCT TAB 20‐12.5 



LOTENSIN HCT TAB 20‐25MG 



LOTREL CAP 10‐20MG DIHYDROPYRIDINES Brand‐O PA TIER 3 


LOTREL CAP 2.5‐10MG DIHYDROPYRIDINES Brand‐O PA TIER 3 




LOTRISONE CRE 



LOTRONEX TAB 0.5MG 



LOTRONEX TAB 1MG 



LOVASTATIN TAB 10MG HMG‐COA REDUCTASE INHIBITORS GENERIC Covered TIER 1 




243


LOVAZA CAP 1GM 

ANTILIPEMIC AGENTS, 

MISCELLANEOUS BRAND PA TIER 2 

LOVENOX INJ 100MG/ML HEPARINS Brand‐O PA TIER 3 

LOVENOX INJ 120/0.8 HEPARINS Brand‐O PA TIER 3 

LOVENOX INJ 150MG/ML HEPARINS Brand‐O PA TIER 3 

LOVENOX INJ 30/0.3ML HEPARINS Brand‐O PA TIER 3 

LOVENOX INJ 300/3ML HEPARINS Brand‐O PA TIER 3 




LOW‐OGESTREL TAB CONTRACEPTIVES GENERIC Covered TIER 1 

LOXAPINE CAP 10MG ANTIPSYCHOTICS, MISCELLANEOUS GENERIC Covered TIER 1 




LOXITANE CAP 10MG ANTIPSYCHOTICS, MISCELLANEOUS Brand‐O PA TIER 3 




LOZI‐FLUR LOZ 1MG F CARIOSTATIC AGENTS GENERIC Covered TIER 1 



244

LTA 360 KIT SOL 4% LOCAL ANESTHETICS (EENT) Brand‐O PA TIER 3 

L‐THREONINE CRY CALORIC AGENTS GENERIC Excluded TIER 99 

LUBRAJEL NP GEL PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

LUCENTIS SOL 0.3MG EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 2 SP 

LUCENTIS SOL 0.5MG EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 2 SP 

LUDENT CHW 0.25MG F CARIOSTATIC AGENTS GENERIC Covered TIER 1 

LUDENT CHW 0.5MG F CARIOSTATIC AGENTS GENERIC Covered TIER 1 

LUDENT CHW 1MG F CARIOSTATIC AGENTS GENERIC Covered TIER 1 

LUFYLLIN TAB 200MG 



LUFYLLIN TAB 400MG 



LUFYLLIN‐GG ELX 100‐100 



LUKAID GLA EMU 1GM/ML CALORIC AGENTS BRAND Excluded TIER 99 

LUMBAR KIT PUNCTURE DEVICES BRAND Excluded TIER 99 

LUMIGAN SOL 0.01% PROSTAGLANDIN ANALOGS BRAND Covered TIER 2 

LUMIGAN SOL 0.03% PROSTAGLANDIN ANALOGS BRAND Covered TIER 2 

LUMINAL INJ 130MG/ML 


SEDATIVE/HYP) Brand‐O PA TIER 3 

LUMINAL INJ 60MG/ML 



LUMINEB II MIS NEBULIZR DEVICES BRAND Excluded TIER 99 

LUMIZYME INJ 50MG ENZYMES BRAND Covered TIER 2 SP 


LUNESTA TAB 1MG 










245

LUNGLAID EMU 1GM/ML CALORIC AGENTS BRAND Excluded TIER 99 

LUPR DEP‐PED INJ 11.25MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

PA TIER 2 SP 

LUPR DEP‐PED INJ 15MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

LUPR DEP‐PED INJ 30MG ANTINEOPLASTIC AGENTS BRAND PA TIER 2 SP 

LUPR DEP‐PED INJ 7.5MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

LUPRON DEPOT INJ 11.25MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

LUPRON DEPOT INJ 22.5MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

LUPRON DEPOT INJ 3.75MG ANTINEOPLASTIC AGENTS BRAND PA TIER 2 SP 

LUPRON DEPOT INJ 30MG ANTINEOPLASTIC AGENTS BRAND PA TIER 2 SP 

LUPRON DEPOT INJ 45MG ANTINEOPLASTIC AGENTS BRAND PA TIER 2 SP 

LUPRON DEPOT INJ 7.5MG ANTINEOPLASTIC AGENTS BRAND PA TIER 2 SP 

LURIDE CHW 0.25MG F CARIOSTATIC AGENTS Brand‐O PA TIER 2 

LURIDE CHW 0.5MG F CARIOSTATIC AGENTS Brand‐O PA TIER 2 

LURIDE CHW 1MG F CARIOSTATIC AGENTS Brand‐O PA TIER 3 

LURIDE DRO 0.5MG/ML CARIOSTATIC AGENTS Brand‐O PA TIER 2 

LUSEDRA INJ 



LUSONAL LIQ ALPHA‐ADRENERGIC AGONISTS BRAND Covered TIER 3 

LUSTRA CRE 4% DEPIGMENTING AGENTS Brand‐O PA TIER 99 

LUSTRA‐AF CRE 4% DEPIGMENTING AGENTS Brand‐O PA TIER 99 

LUSTRA‐ULTRA CRE 4% DEPIGMENTING AGENTS Brand‐O PA TIER 99 

LUTERA TAB CONTRACEPTIVES GENERIC Covered TIER 1 

LUVERIS INJ 75UNIT GONADOTROPINS BRAND PA TIER 3 SP 


LUVOX CR CAP 100MG 


LUVOX CR CAP 150MG 



LUXIQ AER 0.12% 





246

L‐VALINE CRY CALORIC AGENTS GENERIC Excluded TIER 99 

LYBREL TAB 90‐20MCG CONTRACEPTIVES Brand‐O PA TIER 3 

LYCELLE GEL SCABICIDES AND PEDICULICIDES BRAND Covered TIER 3 

LYMPHAZURIN INJ 1% DIAGNOSTIC AGENTS Brand‐O Excluded TIER 99 

LYMPHOMYOSOT INJ 



LYMPHOMYSOT INJ 



LYRICA CAP 100MG 
























LYRICA SOL 20MG/ML 



LYSIPLEX TAB PLUS MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

LYSODREN TAB 500MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

LYSTEDA TAB 650MG HEMOSTATICS BRAND PA TIER 2 



247

LYTENSOPRIL PAK 



LYTENSOPRIL PAK ‐90 



M.V.I PEDIAT INJ MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

M.V.I. ADULT INJ MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

M.V.I‐12 W/O INJ VIT K MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

MACNATAL CN CAP DHA MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MACROBID CAP 100MG URINARY ANTI‐INFECTIVES Brand‐O PA TIER 3 

MACRODANTIN CAP 100MG URINARY ANTI‐INFECTIVES Brand‐O PA TIER 3 

MACRODANTIN CAP 25MG URINARY ANTI‐INFECTIVES BRAND Covered TIER 3 

MACRODANTIN CAP 50MG URINARY ANTI‐INFECTIVES Brand‐O PA TIER 3 

MACUGEN INJ EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 3 SP 

MACUTEK TAB CALORIC AGENTS BRAND Excluded TIER 99 

MAG CARB GRA REPLACEMENT PREPARATIONS GENERIC Excluded TIER 99 

MAGN CHLORID CRY HEXAHYDR REPLACEMENT PREPARATIONS GENERIC Excluded TIER 99 

MAGN CHLORID MIS FLAKES REPLACEMENT PREPARATIONS GENERIC Excluded TIER 99 

MAGNACET TAB 10‐400MG OPIATE AGONISTS BRAND Covered TIER 3 QL 

MAGNACET TAB 5‐400MG OPIATE AGONISTS BRAND Covered TIER 3 QL 

MAGNACET TAB 7.5‐400 OPIATE AGONISTS BRAND Covered TIER 3 QL 

MAGNEBIND TAB 400 REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

MAGNESIUM CL INJ 20% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

MAGNESIUM SU INJ 40MG/ML 



MAGNESIUM SU INJ 50% 



MAGNESIUM SU INJ 80MG/ML 



MAGNEVIST INJ 46.9% DIAGNOSTIC AGENTS BRAND Excluded TIER 99 

MAKENA INJ 250MG/ML PROGESTINS BRAND PA TIER 2 QL 



248

MALARONE TAB 250‐100 ANTIMALARIALS Brand‐O PA TIER 3 

MALARONE TAB 62.5‐25 ANTIMALARIALS BRAND Covered TIER 3 

MALATHION LOT 0.5% SCABICIDES AND PEDICULICIDES GENERIC Covered TIER 1 

MANGANESE CL INJ 0.1MG/ML REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

MANGANESE SU INJ 0.1MG/ML REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

MANNITOL INJ 10% OSMOTIC DIURETICS GENERIC Covered TIER 1 





MAPLE FLAVOR LIQ PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

MAPROTILINE TAB 25MG 









MARCAINE INJ 0.25% LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 



MARCAINE INJ SPINAL LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 

MARCAINE/EPI INJ 0.25% LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 

MARCAINE/EPI INJ 0.5% LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 

MARGARITA LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 



249

MARGESIC CAP 



MARINOL CAP 10MG ANTIEMETICS, MISCELLANEOUS Brand‐O PA TIER 3 QL 

MARINOL CAP 2.5MG ANTIEMETICS, MISCELLANEOUS Brand‐O PA TIER 3 QL 

MARINOL CAP 5MG ANTIEMETICS, MISCELLANEOUS Brand‐O PA TIER 3 QL 

MARLISSA TAB 0.15/30 CONTRACEPTIVES GENERIC Covered TIER 1 

MARNATAL‐F CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

MARNATAL‐F MIS PLUS DUO MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

MARPLAN TAB 10MG MONOAMINE OXIDASE INHIBITORS BRAND Covered TIER 3 

MARSHMALLOW LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

MARTEN‐TAB TAB 50‐325MG 



MARTINIC CAP IRON PREPARATIONS GENERIC Covered TIER 1 

MATULANE CAP 50MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

MATZIM LA TAB 180MG/24 















MAVIK TAB 1MG 



MAVIK TAB 2MG 





250

MAVIK TAB 4MG 



MAXAIR AUTOH AER 200MCG 



MAXALT TAB 10MG SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 2 QL 

MAXALT TAB 5MG SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 2 QL 

MAXALT‐MLT TAB 10MG SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 2 QL 

MAXALT‐MLT TAB 5MG SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 2 QL 

MAXARON TAB FORTE IRON PREPARATIONS BRAND Covered TIER 3 

MAXARON FORT CAP IRON PREPARATIONS BRAND Covered TIER 3 

MAXIBAR SUS 210% ROENTGENOGRAPHY BRAND Covered TIER 3 

MAXIDEX SUS 0.1% OP CORTICOSTEROIDS (EENT) BRAND Covered TIER 3 

MAXIDONE TAB 10‐750MG OPIATE AGONISTS Brand‐O PA TIER 3 

MAXIFED CD TAB ANTITUSSIVES BRAND Excluded TIER 99 

MAXIFED CDX TAB ANTITUSSIVES BRAND Excluded TIER 99 

MAXIFED‐G TAB CDX ANTITUSSIVES BRAND Excluded TIER 99 

MAXIFED‐G CD TAB ANTITUSSIVES BRAND Excluded TIER 99 

MAXIFLU CD TAB ANTITUSSIVES BRAND Excluded TIER 99 

MAXIFLU CDX TAB ANTITUSSIVES BRAND Excluded TIER 99 

MAXINATE TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

MAXIPHEN CD TAB ANTITUSSIVES BRAND Excluded TIER 99 

MAXIPHEN CDX TAB ANTITUSSIVES BRAND Excluded TIER 99 

MAXITROL OIN 0.1% OP CORTICOSTEROIDS (EENT) Brand‐O PA TIER 3 

MAXITROL SUS 0.1% OP CORTICOSTEROIDS (EENT) Brand‐O PA TIER 3 

MAXZIDE TAB 75‐50 POTASSIUM‐SPARING DIURETICS Brand‐O PA TIER 3 

MAXZIDE‐25 TAB POTASSIUM‐SPARING DIURETICS Brand‐O PA TIER 3 

MB HYDROGEL KIT 



MD‐76 R INJ ROENTGENOGRAPHY BRAND Covered TIER 3 

MD‐GASTROVIE SOL 66‐10% ROENTGENOGRAPHY GENERIC Covered TIER 1 



251

MDP KIT MULTIDOS DIAGNOSTIC AGENTS BRAND Excluded TIER 99 

MEBENDAZOLE CHW 100MG ANTHELMINTICS GENERIC Covered TIER 1 

MECLOFEN SOD CAP 100MG 



MECLOFEN SOD CAP 50MG 



MEDIBASE C LIQ CATHARTICS AND LAXATIVES GENERIC Excluded TIER 99 

MEDICAL LEG MIS WAIST HI DEVICES GENERIC Excluded TIER 99 

MEDIDERM CRE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

MEDIHOL BASE GEL 



MEDIHONEY PAD 2"X2" 



MEDIHONEY PAD 4"X5" 



MEDROL PAK 4MG ADRENALS Brand‐O PA TIER 3 

MEDROL TAB 16MG ADRENALS Brand‐O PA TIER 3 

MEDROL TAB 2MG ADRENALS BRAND Covered TIER 3 




MEDROX‐RX OIN BASIC LOTIONS AND LINIMENTS BRAND Covered TIER 3 

MEDROXYPR AC INJ 150MG/ML PROGESTINS GENERIC Covered TIER 1 

MEDROXYPR AC TAB 10MG PROGESTINS GENERIC Covered TIER 1 QL 

MEDROXYPR AC TAB 2.5MG PROGESTINS GENERIC Covered TIER 1 QL 

MEDROXYPR AC TAB 5MG PROGESTINS GENERIC Covered TIER 1 QL 

MEFENAM ACID CAP 250MG 



MEFLOQUINE TAB 250MG ANTIMALARIALS GENERIC Covered TIER 1 

MEFOXIN INJ 1GM/50ML CEPHAMYCINS BRAND Covered TIER 3 



252

MEFOXIN INJ 2GM/50ML CEPHAMYCINS BRAND Covered TIER 3 

MEGA‐C/A PLU INJ 500MG/ML VITAMIN C GENERIC Covered TIER 1 

MEGACE ES SUS 625/5ML PROGESTINS BRAND Covered TIER 3 

MEGACE ORAL SUS 40MG/ML ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 

MEGESTROL AC SUS 400MG/10 ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

MEGESTROL AC SUS 40MG/ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

MEGESTROL AC TAB 20MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

MEGESTROL AC TAB 40MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

MELILOTUS DRO HOMACCOR 



MELILOTUS LIQ HOMACCOR 



MELOXICAM KIT COMFORT 



MELOXICAM SUS 7.5/5ML 



MELOXICAM TAB 15MG 



MELOXICAM TAB 7.5MG 



MELPAQUE HP CRE 4% DEPIGMENTING AGENTS GENERIC Excluded TIER 99 

MELPHALAN INJ 50MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

MELQUIN 3 SOL 3% DEPIGMENTING AGENTS GENERIC Excluded TIER 99 

MELQUIN HP CRE 4% DEPIGMENTING AGENTS GENERIC Excluded TIER 99 

MEMBRANEBLUE SOL 0.15% OCULAR DISORDERS BRAND Excluded TIER 99 

MENACTRA INJ VACCINES BRAND Covered TIER 3 

MENEST TAB 0.3MG ESTROGENS BRAND Covered TIER 3 






253

MENHIBRIX INJ VACCINES BRAND Covered TIER 3 

MENOMUNE INJ A/C/Y/W VACCINES BRAND Covered TIER 3 

MENOPUR INJ 75UNIT GONADOTROPINS BRAND PA TIER 2 SP 

MENOSTAR DIS 14MCG ESTROGENS BRAND Covered TIER 3 

MENTAX CRE 1% 

BENZYLAMINES (SKIN & MUCOUS 


MENTHOL LIQ EUCALYPT PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

MENVEO INJ VACCINES BRAND Covered TIER 3 

MEPERIDINE INJ 100MG/ML OPIATE AGONISTS GENERIC Covered TIER 1 




MEPERIDINE SOL 50MG/5ML OPIATE AGONISTS GENERIC Covered TIER 1 

MEPERIDINE TAB 100MG OPIATE AGONISTS GENERIC Covered TIER 1 

MEPERIDINE TAB 50MG OPIATE AGONISTS GENERIC Covered TIER 1 

MEPERITAB TAB 100MG OPIATE AGONISTS GENERIC Covered TIER 1 

MEPERITAB TAB 50MG OPIATE AGONISTS GENERIC Covered TIER 1 

MEPHYTON TAB 5MG VITAMIN K ACTIVITY BRAND Covered TIER 2 

MEPIVACAINE INJ 3% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

MEPROBAMATE TAB 200MG 



MEPROBAMATE TAB 400MG 



MEPRON SUS ANTIPROTOZOALS, MISCELLANEOUS BRAND Covered TIER 2 

MERCAPTOPUR TAB 50MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

MEROPENEM INJ 1GM CARBAPENEMS GENERIC Covered TIER 1 

MEROPENEM INJ 500MG CARBAPENEMS GENERIC Covered TIER 1 

MERREM INJ 1GM CARBAPENEMS Brand‐O PA TIER 3 



254

MERREM INJ 500MG CARBAPENEMS Brand‐O PA TIER 3 

MESALAMINE ENE 4GM 



MESALAMINE KIT 4GM 



MESNA INJ 1GM PROTECTIVE AGENTS GENERIC Covered TIER 1 SP 

MESNEX INJ 1GM PROTECTIVE AGENTS Brand‐O PA TIER 3 SP 

MESNEX TAB 400MG PROTECTIVE AGENTS BRAND Covered TIER 2 

MESTINON SYP 60MG/5ML 



MESTINON TAB 60MG 



MESTINON TAB TIMESPAN 




METADATE TAB 20MG ER 


METADATE CD CAP 10MG 


















METAGLIP TAB 2.5‐250M SULFONYLUREAS Brand‐O PA TIER 3 

METANX TAB VITAMIN B COMPLEX BRAND Excluded TIER 99 



255

METAPROTEREN SYP 10MG/5ML 



METAPROTEREN TAB 10MG 



METAPROTEREN TAB 20MG 



METASTRON INJ 



METAXALONE TAB 800MG 



METER BUFFER SOL PH 10 PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 



METFORMIN TAB 1000MG BIGUANIDES GENERIC Covered TIER 1 


METFORMIN TAB 500MG ER BIGUANIDES GENERIC Covered TIER 1 

PA TIER 1 

METFORMIN TAB 750MG ER BIGUANIDES GENERIC Covered TIER 1 


METFORMIN ER TAB 1000MG BIGUANIDES GENERIC PA TIER 1 

METHACHOLINE CRY CHLORIDE DIAGNOSTIC AGENTS GENERIC Excluded TIER 99 

METHADONE CON 10MG/ML OPIATE AGONISTS Brand‐O PA TIER 3 


METHADONE INJ 10MG/ML OPIATE AGONISTS GENERIC Covered TIER 1 

METHADONE SOL 10MG/5ML OPIATE AGONISTS GENERIC Covered TIER 1 

METHADONE SOL 5MG/5ML OPIATE AGONISTS GENERIC Covered TIER 1 

METHADONE TAB 10MG OPIATE AGONISTS GENERIC Covered TIER 1 



METHADOSE CON 10MG/ML OPIATE AGONISTS GENERIC Covered TIER 1 



256

METHADOSE TAB 10MG OPIATE AGONISTS GENERIC Covered TIER 1 

METHADOSE TAB 40MG OPIATE AGONISTS GENERIC Covered TIER 1 

METHADOSE SF CON 10MG/ML OPIATE AGONISTS GENERIC Covered TIER 1 

METHAMPHETAM TAB 5MG AMPHETAMINES GENERIC Covered TIER 1 

METHAZOLAMID TAB 25MG 



METHAZOLAMID TAB 50MG 



METHENAM HIP TAB 1GM URINARY ANTI‐INFECTIVES GENERIC Covered TIER 1 

METHENAM MAN TAB 1000MG URINARY ANTI‐INFECTIVES GENERIC Covered TIER 1 

METHENAM MAN TAB 1GM URINARY ANTI‐INFECTIVES GENERIC Covered TIER 1 

METHENAM MAN TAB 500MG URINARY ANTI‐INFECTIVES GENERIC Covered TIER 1 

METHERGINE INJ 0.2MG/ML OXYTOCICS Brand‐O PA TIER 3 

METHERGINE TAB 0.2MG OXYTOCICS Brand‐O PA TIER 3 

METHIMAZOLE TAB 10MG ANTITHYROID AGENTS GENERIC Covered TIER 1 

METHIMAZOLE TAB 5MG ANTITHYROID AGENTS GENERIC Covered TIER 1 

METHITEST TAB 10MG ANDROGENS BRAND Covered TIER 2 

METHOCARBAM TAB 500MG 



METHOCARBAM TAB 750MG 



METHOTREXATE INJ 100/4ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

METHOTREXATE INJ 1GM ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

METHOTREXATE INJ 1GM/40ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

METHOTREXATE INJ 200/8ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

METHOTREXATE INJ 250MG/10 ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

METHOTREXATE INJ 25MG/ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

METHOTREXATE INJ 50MG/2ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

METHOTREXATE TAB 2.5MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

METHOXSALEN CRY USP/NF PIGMENTING AGENTS GENERIC Excluded TIER 99 



257

METHSCOPOLAM TAB 2.5MG 



METHSCOPOLAM TAB 5MG 



METHYCLOTHIA TAB 5MG THIAZIDE DIURETICS GENERIC Covered TIER 1 

METHYL SALIC LIQ BASIC LOTIONS AND LINIMENTS GENERIC Covered TIER 1 

METHYLD/HCTZ TAB 250/15 CENTRAL ALPHA‐AGONISTS GENERIC Covered TIER 1 

METHYLD/HCTZ TAB 250/25 CENTRAL ALPHA‐AGONISTS GENERIC Covered TIER 1 

METHYLDOPA TAB 250MG CENTRAL ALPHA‐AGONISTS GENERIC Covered TIER 1 

METHYLDOPA TAB 500MG CENTRAL ALPHA‐AGONISTS GENERIC Covered TIER 1 

METHYLDOPATE INJ 250/5ML CENTRAL ALPHA‐AGONISTS GENERIC Covered TIER 1 

METHYLENE BL INJ 1% ANTIDOTES GENERIC Covered TIER 1 

METHYLERGON INJ 0.2MG/ML OXYTOCICS GENERIC Covered TIER 1 

METHYLERGON TAB 0.2MG OXYTOCICS GENERIC Covered TIER 1 

METHYLFOL/ME TAB ‐CBL/NAC VITAMIN B COMPLEX GENERIC Excluded TIER 99 

METHYLFOL/ME TAB ‐CBL/P5P VITAMIN B COMPLEX GENERIC Excluded TIER 99 

METHYLIN CHW 10MG 



METHYLIN CHW 2.5MG 



METHYLIN CHW 5MG 



METHYLIN SOL 10MG/5ML 



METHYLIN SOL 5MG/5ML 



METHYLIN TAB 10MG 



METHYLIN TAB 10MG ER 





258


METHYLIN TAB 20MG ER 


METHYLPHENID CAP 10MG 


METHYLPHENID CAP 20MG ER 







METHYLPHENID SOL 10MG/5ML 

METHYLPHENID SOL 5MG/5ML 

METHYLPHENID TAB 10MG 

































259

METHYLPHENID TAB 10MG ER 












METHYLPHENID TAB 20MG SR 















METHYLPR ACE INJ 40MG/ML ADRENALS GENERIC Covered TIER 1 

METHYLPR ACE INJ 80MG/ML ADRENALS GENERIC Covered TIER 1 

METHYLPR SS INJ 1000MG ADRENALS GENERIC Covered TIER 1 


METHYLPR SS INJ 1GM ADRENALS GENERIC Covered TIER 1 



METHYLPRED PAK 4MG ADRENALS GENERIC Covered TIER 1 

METHYLPRED TAB 16MG ADRENALS GENERIC Covered TIER 1 






260

METIPRANOLOL SOL 0.3% 



METIPRANOLOL SOL 0.3% OPH 



METOCLOPRAM INJ 5MG/ML PROKINETIC AGENTS GENERIC Covered TIER 1 

METOCLOPRAM SOL 10/10ML PROKINETIC AGENTS GENERIC Covered TIER 1 

METOCLOPRAM SOL 5MG/5ML PROKINETIC AGENTS GENERIC Covered TIER 1 

METOCLOPRAM TAB 10MG PROKINETIC AGENTS GENERIC Covered TIER 1 

METOCLOPRAM TAB 5MG PROKINETIC AGENTS GENERIC Covered TIER 1 

METOLAZONE TAB 10MG THIAZIDE‐LIKE DIURETICS GENERIC Covered TIER 1 

METOLAZONE TAB 2.5MG THIAZIDE‐LIKE DIURETICS GENERIC Covered TIER 1 

METOLAZONE TAB 5MG THIAZIDE‐LIKE DIURETICS GENERIC Covered TIER 1 

METOPIRONE CAP 250MG PITUITARY FUNCTION BRAND Covered TIER 3 

METOPRL/HCTZ TAB 100‐25MG 









METOPROL TAR TAB 100MG 









METOPROLOL INJ 1MG/ML 



METOPROLOL INJ 5MG/5ML 





261

METOPROLOL TAB 100MG ER 












METOZOLV ODT TAB 10MG PROKINETIC AGENTS BRAND Covered TIER 3 QL 

METOZOLV ODT TAB 5MG PROKINETIC AGENTS BRAND Covered TIER 3 QL 

METRO IV INJ 5MG/ML ANTIPROTOZOALS, MISCELLANEOUS BRAND Covered TIER 3 

METROCREAM CRE 0.75% 



METROGEL GEL 1% 



METROGEL‐VAG GEL 0.75% 



METROLOTION LOT 0.75% 



METRON/NACL INJ 500MG ANTIPROTOZOALS, MISCELLANEOUS GENERIC Covered TIER 1 

METRONIDAZOL CAP 375MG ANTIPROTOZOALS, MISCELLANEOUS GENERIC Covered TIER 1 

METRONIDAZOL CRE 0.75% 



METRONIDAZOL GEL 0.75% 



METRONIDAZOL GEL 0.75%VAG 





262

METRONIDAZOL LOT 0.75% 



METRONIDAZOL TAB 250MG ANTIPROTOZOALS, MISCELLANEOUS GENERIC Covered TIER 1 

METRONIDAZOL TAB 500MG ANTIPROTOZOALS, MISCELLANEOUS GENERIC Covered TIER 1 


METVIXIA CRE 16.8% 


MEVACOR TAB 20MG HMG‐COA REDUCTASE INHIBITORS Brand‐O PA TIER 3 

MEVACOR TAB 40MG HMG‐COA REDUCTASE INHIBITORS Brand‐O PA TIER 3 

MEXAR WASH LIQ 10% 



MEXILETINE CAP 150MG CLASS IB ANTIARRHYTHMICS GENERIC Covered TIER 1 



MG SO4/D5W INJ 10MG/ML REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

MG SO4/D5W INJ 20MG/ML REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

MI PASTE PST DENTAL AGENTS BRAND Covered TIER 3 

MI PLUS PST DENTAL AGENTS BRAND Covered TIER 3 

MIACALCIN INJ 200/ML PARATHYROID BRAND Covered TIER 3 

MIACALCIN SPR 200/ACT PARATHYROID Brand‐O PA TIER 3 

MICARDIS TAB 20MG 











263

MICARDIS HCT TAB 40/12.5 



MICARDIS HCT TAB 80/12.5 



MICARDIS HCT TAB 80‐25MG 



MICONAZOLE 3 KIT COMBO PK 



MICONAZOLE 3 SUP 200MG 



MICRHOGAM PL INJ 50MCG SERUMS BRAND Covered TIER 3 SP 

MICRO AIR MIS NEBULIZR DEVICES BRAND Excluded TIER 99 

MICRO PLUS MIS NEBULIZR DEVICES BRAND Excluded TIER 99 

MICROCHAMBER MIS DEVICES BRAND Excluded TIER 99 

MICROELITE MIS COMP/NEB DEVICES BRAND Excluded TIER 99 

MICROGESTIN TAB 1.5/30 CONTRACEPTIVES GENERIC Covered TIER 1 

MICROGESTIN TAB 1/20 CONTRACEPTIVES GENERIC Covered TIER 1 

MICROGESTIN TAB FE 1/20 CONTRACEPTIVES GENERIC Covered TIER 1 

MICROGESTIN TAB FE1.5/30 CONTRACEPTIVES GENERIC Covered TIER 1 

MICRO‐K CAP 10MEQ CR REPLACEMENT PREPARATIONS Brand‐O PA TIER 3 

MICRO‐K CAP 8MEQ CR REPLACEMENT PREPARATIONS Brand‐O PA TIER 3 

MICROLIPID EMU 50% CALORIC AGENTS BRAND Covered TIER 3 

MICROSPACER MIS DEVICES BRAND Excluded TIER 99 

MICROZIDE CAP 12.5MG THIAZIDE DIURETICS Brand‐O PA TIER 3 

MIDAMOR TAB 5MG POTASSIUM‐SPARING DIURETICS Brand‐O PA TIER 3 

MIDAZOLAM INJ 10MG/10 



MIDAZOLAM INJ 10MG/2ML 





264

MIDAZOLAM INJ 1MG/ML 









MIDAZOLAM INJ 50MG/10 






MIDAZOLAM INJ 5MG/ML 



MIDAZOLAM SYP 2MG/ML 



MIDODRINE TAB 10MG ALPHA‐ADRENERGIC AGONISTS GENERIC Covered TIER 1 

MIDODRINE TAB 2.5MG ALPHA‐ADRENERGIC AGONISTS GENERIC Covered TIER 1 

MIDODRINE TAB 5MG ALPHA‐ADRENERGIC AGONISTS GENERIC Covered TIER 1 

MIFEPREX TAB 200MG OXYTOCICS BRAND Covered TIER 3 

MIGERGOT SUP 2/100 



MIGRAGESIC CAP IDA 



MIGRAL TAB 130MG 



MIGRALAM CAP 



MIGRANAL SPR 4MG/ML 


BLOCKING AGENTS BRAND Covered TIER 3 QL 

MILLEX‐FG MIS 0.2UM DEVICES BRAND Excluded TIER 99 

MILLIPRED SOL 10MG/5ML ADRENALS BRAND Covered TIER 3 



265

MILLIPRED TAB 5MG ADRENALS BRAND Covered TIER 3 

MILLIPRED DP PAK 5MG ADRENALS BRAND Covered TIER 3 

MILRINONE INJ 1MG/ML CARDIOTONIC AGENTS GENERIC Covered TIER 1 

MILRINONE INJ DW5 CARDIOTONIC AGENTS GENERIC Covered TIER 1 

MIMVEY TAB 1‐0.5MG ESTROGENS GENERIC Covered TIER 1 

MIMYX CRE 



MINI COMPRES MIS NEBULIZR DEVICES BRAND Excluded TIER 99 

MINI PLUS MIS NEBULIZR DEVICES BRAND Excluded TIER 99 

MINIELITE MIS BATTERY DEVICES BRAND Excluded TIER 99 

MINIELITE MIS COMP/NEB DEVICES BRAND Excluded TIER 99 

MINILINK RT KIT REPLACE DEVICES BRAND Covered TIER 3 

MINIMED PUMP MIS RES 3ML DEVICES BRAND Covered TIER 3 

MINIPRESS CAP 1MG 









MINIRIN SPR NASAL PITUITARY GENERIC Covered TIER 1 

MINITRAN DIS 0.1MG/HR NITRATES AND NITRITES GENERIC Covered TIER 1 




MINOCIN CAP 100MG TETRACYCLINES Brand‐O PA TIER 3 

MINOCIN CAP 50MG TETRACYCLINES Brand‐O PA TIER 3 

MINOCIN INJ 100MG TETRACYCLINES BRAND Covered TIER 3 

MINOCIN KIT 100MG TETRACYCLINES BRAND Covered TIER 3 

MINOCIN KIT 50MG TETRACYCLINES BRAND Covered TIER 3 

MINOCYCLINE CAP 100MG TETRACYCLINES GENERIC Covered TIER 1 



266



MINOCYCLINE TAB 100MG TETRACYCLINES GENERIC Covered TIER 1 

MINOCYCLINE TAB 135MG ER 











MINOXIDIL TAB 10MG DIRECT VASODILATORS GENERIC Covered TIER 1 

MINOXIDIL TAB 2.5MG DIRECT VASODILATORS GENERIC Covered TIER 1 

MINT CHOCOLA LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

MIO INF SET MIS 18"/6MM DEVICES BRAND Covered TIER 3 




MIOCHOL‐E SOL 1:100 MIOTICS BRAND Covered TIER 3 

MI‐OMEGA NF CAP VITAMIN B COMPLEX GENERIC Covered TIER 1 

MIOSTAT INJ 0.01% OP MIOTICS BRAND Covered TIER 3 

MIRAPEX TAB 0.125MG 


RECEPTOR AGONIST Brand‐O PA TIER 3 












267




MIRAPEX TAB 1MG 



MIRAPEX ER TAB 0.375MG 


RECEPTOR AGONIST BRAND Covered TIER 2 QL 













MIRAPEX ER TAB 3MG 






MIRCETTE TAB 28 DAY CONTRACEPTIVES Brand‐O PA TIER 3 

MIRENA IUD SYSTEM CONTRACEPTIVES BRAND Covered TIER 3 

MIRTAZAPINE TAB 15MG ANTIDEPRESSANTS, MISCELLANEOUS GENERIC Covered TIER 1 QL 

MIRTAZAPINE TAB 15MG ODT ANTIDEPRESSANTS, MISCELLANEOUS GENERIC Covered TIER 1 QL 






268


MIRTAZAPINE TAB 7.5MG ANTIDEPRESSANTS, MISCELLANEOUS GENERIC Covered TIER 1 QL 

MISOPROSTOL TAB 100MCG PROSTAGLANDINS GENERIC Covered TIER 1 

MISOPROSTOL TAB 200MCG PROSTAGLANDINS GENERIC Covered TIER 1 

MISTERNEB MIS NEBULIZE DEVICES BRAND Excluded TIER 99 

MITOMYCIN INJ 20MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 



MITOSOL KIT 0.2MG ANTIBACTERIALS (EENT) BRAND Covered TIER 3 

MITOXANTRON INJ 2MG/ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

MIXED VESPID INJ 1650MCG 



MIXED VESPID INJ 3900MCG 



MIXED VESPID KIT 3000MCG 



MIXED VESPID KIT 300MCG 



M‐M‐R II INJ LIVE VACCINES BRAND Covered TIER 3 

MOBIC SUS 7.5/5ML 



MOBIC TAB 15MG 



MOBIC TAB 7.5MG 




MODAFINIL TAB 100MG 

STIMULANTS,MISC GENERIC PA TIER 1 QL 



269

MODAFINIL TAB 200MG 


STIMULANTS,MISC GENERIC PA TIER 1 QL 

MODICON TAB 0.5/35 CONTRACEPTIVES Brand‐O PA TIER 3 

MOEXIPR/HCTZ TAB 15‐12.5 



MOEXIPR/HCTZ TAB 15‐25MG 



MOEXIPR/HCTZ TAB 7.5‐12.5 



MOEXIPRIL TAB 15MG 



MOEXIPRIL TAB 7.5MG 



MOMETASONE CRE 0.1% 



MOMETASONE OIN 0.1% 



MOMETASONE SOL 0.1% 



MOMEXIN KIT 



MOMORDICA DRO COMPOSIT 



MOMORDICA LIQ COMPOSIT 



MONOCHLOROAC CRY ACID KERATOLYTIC AGENTS GENERIC Excluded TIER 99 

MONOCLATE‐P INJ 1000UNIT HEMOSTATICS BRAND PA TIER 2 SP 






270

MONODOX CAP 100MG TETRACYCLINES Brand‐O PA TIER 3 



MONOJECT INJ PREFILL REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

MONOJECT MIS 20GX1" DEVICES BRAND Excluded TIER 99 

MONOJECT MIS 20GX1.5 DEVICES BRAND Excluded TIER 99 





MONOJECT MIS CANNULA DEVICES BRAND Excluded TIER 99 

MONOJECT MIS HOLDER DEVICES BRAND Excluded TIER 99 

MONOJECT MIS TIP CAPS DEVICES BRAND Excluded TIER 99 

MONOJECT LS MIS CANN/BLN DEVICES BRAND Excluded TIER 99 

MONOJECT LUE MIS ADAPTER DEVICES BRAND Excluded TIER 99 

MONOKET TAB 10MG NITRATES AND NITRITES Brand‐O PA TIER 3 

MONOKET TAB 20MG NITRATES AND NITRITES Brand‐O PA TIER 3 

MONONESSA TAB CONTRACEPTIVES GENERIC Covered TIER 1 

MONONINE INJ 1000UNIT HEMOSTATICS BRAND PA TIER 2 SP 



MONSELS FERR SOL SUBSULF HEMOSTATICS BRAND Excluded TIER 99 

MONTELUKAST CHW 4MG LEUKOTRIENE MODIFIERS GENERIC Covered TIER 1 

MONTELUKAST CHW 5MG LEUKOTRIENE MODIFIERS GENERIC Covered TIER 1 

MONTELUKAST GRA 4MG LEUKOTRIENE MODIFIERS GENERIC Covered TIER 1 

MONTELUKAST TAB 10MG LEUKOTRIENE MODIFIERS GENERIC Covered TIER 1 

MONUROL PAK GRANULES URINARY ANTI‐INFECTIVES BRAND Covered TIER 3 

MORGIDOX CAP 1X100MG TETRACYCLINES GENERIC Covered TIER 1 

MORGIDOX CAP 2X100MG TETRACYCLINES GENERIC Covered TIER 1 

MORGIDOX KIT 1X100MG TETRACYCLINES BRAND Covered TIER 3 



271

MORGIDOX KIT 2X100MG TETRACYCLINES BRAND Covered TIER 3 

MORPHINE SUL CAP 100MG ER OPIATE AGONISTS GENERIC Covered TIER 1 QL 






MORPHINE SUL INJ 0.5MG/ML OPIATE AGONISTS GENERIC Covered TIER 1 

MORPHINE SUL INJ 10/0.7ML OPIATE AGONISTS GENERIC Covered TIER 1 

MORPHINE SUL INJ 10MG/ML OPIATE AGONISTS GENERIC Covered TIER 1 

MORPHINE SUL INJ 150/30ML OPIATE AGONISTS GENERIC Covered TIER 1 









MORPHINE SUL SOL 100/5ML OPIATE AGONISTS GENERIC Covered TIER 1 

MORPHINE SUL SOL 10MG/5ML OPIATE AGONISTS GENERIC Covered TIER 1 

MORPHINE SUL SOL 20MG/5ML OPIATE AGONISTS GENERIC Covered TIER 1 

MORPHINE SUL SOL 20MG/ML OPIATE AGONISTS GENERIC Covered TIER 1 

MORPHINE SUL SUP 10MG OPIATE AGONISTS GENERIC Covered TIER 1 




MORPHINE SUL TAB 100MG ER OPIATE AGONISTS GENERIC Covered TIER 1 

MORPHINE SUL TAB 15MG OPIATE AGONISTS GENERIC Covered TIER 1 




272


MORPHINE SUL TAB 30MG OPIATE AGONISTS GENERIC Covered TIER 1 



MORPHINE/D5W INJ 1MG/ML OPIATE AGONISTS GENERIC Covered TIER 1 

MORRHUAT SOD INJ 5% SCLEROSING AGENTS GENERIC Covered TIER 1 

MOTOFEN TAB ANTIDIARRHEA AGENTS BRAND Covered TIER 2 

MOUTHPIECE MIS DISP LOW DEVICES GENERIC Excluded TIER 99 

MOUTHPIECE MIS DISP UNI DEVICES GENERIC Excluded TIER 99 

MOUTHPIECE MIS DISPOSAB DEVICES GENERIC Excluded TIER 99 

MOVIPREP SOL CATHARTICS AND LAXATIVES BRAND Covered TIER 3 

MOXATAG TAB 775MG AMINOPENICILLINS BRAND Covered TIER 3 

MOXEZA SOL 0.5% ANTIBACTERIALS (EENT) BRAND Covered TIER 2 

MOZOBIL INJ HEMATOPOIETIC AGENTS BRAND PA TIER 2 SP 

MS CONTIN TAB 100MG CR OPIATE AGONISTS Brand‐O PA TIER 3 





MST 600 TAB SALICYLATES GENERIC Covered TIER 1 

MTEST HS/EST TAB ESTROGEN ESTROGENS GENERIC Excluded TIER 99 

MTEST/EST TAB ESTROGEN ESTROGENS GENERIC Excluded TIER 99 

MUCOSA INJ COMPOSIT 



MUCOTROL WAF 



MUGARD LIQ 



MULTAQ TAB 400MG CLASS III ANTIARRHYTHMICS BRAND Covered TIER 2 

MULTIBASE CRE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 



273

MULTICHEW CHW MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

MULTI‐DRAW MIS 20GX1" DEVICES GENERIC Excluded TIER 99 



MULTIGEN TAB IRON PREPARATIONS GENERIC Covered TIER 1 

MULTIGEN TAB FOLIC IRON PREPARATIONS GENERIC Covered TIER 1 

MULTIGEN PLS TAB IRON PREPARATIONS GENERIC Covered TIER 1 

MULTIHANCE SOL ROENTGENOGRAPHY BRAND Covered TIER 3 

MULTITRACE‐4 INJ REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 SP 

MULTITRACE‐4 INJ CONC REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 SP 

MULTITRACE‐4 INJ NEONATAL REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 SP 

MULTITRACE‐4 INJ PED REPLACEMENT PREPARATIONS BRAND Covered TIER 3 SP 

MULTITRACE‐5 INJ REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

MULTITRACE‐5 INJ CONC REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

MULTITRACE‐5 INJ REGULAR REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

MULTI‐VIT/FE DRO /FL 0.25 MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MULTIVIT/FL CHW 0.25MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MULTIVIT/FL CHW 0.5MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MULTIVIT/FL CHW 1MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MULTI‐VIT/FL CHW 0.25MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MULTI‐VIT/FL CHW 0.5MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MULTI‐VIT/FL CHW 1MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MULTI‐VIT/FL DRO /FE 0.25 MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MULTI‐VIT/FL DRO 0.25MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MULTI‐VIT/FL DRO 0.5MG/ML MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MULT‐VIT/FL CHW 0.5MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MUPIROCIN OIN 2% 



MURI‐LUBE OIL CATHARTICS AND LAXATIVES BRAND Excluded TIER 99 



274

MUSE SUP 1000MCG 












MUSTARGEN INJ 10MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

MVC‐FLUORIDE CHW 0.25MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MVC‐FLUORIDE CHW 0.5MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MVC‐FLUORIDE CHW 1MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

M‐VIT TAB 27‐1MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MYAMBUTOL TAB 100MG ANTITUBERCULOSIS AGENTS Brand‐O PA TIER 3 

MYAMBUTOL TAB 400MG ANTITUBERCULOSIS AGENTS Brand‐O PA TIER 3 

MYCAMINE INJ 100MG ECHINOCANDINS BRAND Covered TIER 3 

MYCAMINE INJ 50MG ECHINOCANDINS BRAND Covered TIER 3 

MYCI‐GC SOL 100‐10/5 ANTITUSSIVES GENERIC Covered TIER 1 

MYCOBUTIN CAP 150MG ANTITUBERCULOSIS AGENTS BRAND Covered TIER 2 

MYCOPHENOLAT CAP 250MG IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1 

MYCOPHENOLAT TAB 500MG IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1 

MYDFRIN SOL 2.5% OP VASOCONSTRICTORS Brand‐O PA TIER 3 

MYDRAL SOL 0.5% OP MYDRIATICS GENERIC Covered TIER 1 

MYDRAL SOL 1% OP MYDRIATICS GENERIC Covered TIER 1 

MYDRIACYL SOL 1% OP MYDRIATICS Brand‐O PA TIER 3 

MYFERON 150 CAP FORTE IRON PREPARATIONS GENERIC Covered TIER 1 

MYFORTIC TAB 180MG IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 3 

MYFORTIC TAB 360MG IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 3 

MYHIST‐PD LIQ PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

MYKIDZ IRON SUS FL MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 



275

MYLERAN TAB 2MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

MYNATAL CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

MYNATAL TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MYNATAL TAB ADVANCE MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MYNATAL PLUS TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MYNATAL‐Z TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MYNATE 90 TAB PLUS MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MYNEPHROCAPS CAP MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

MYOBLOC INJ 10000/2 



MYOBLOC INJ 2500/0.5 



MYOBLOC INJ 5000/ML 



MYOCHRYSINE INJ 50MG/ML GOLD COMPOUNDS Brand‐O PA TIER 3 

MYORISAN CAP 10MG 









MYOVIEW KIT CARDIAC FUNCTION BRAND Covered TIER 3 

MYOXIN SUS OTIC LOCAL ANESTHETICS (EENT) GENERIC Covered TIER 1 

MYOZYME INJ 50MG ENZYMES BRAND Covered TIER 2 SP 

MYRBETRIQ TAB 25MG 



MYRBETRIQ TAB 50MG 



MYSOLINE TAB 250MG BARBITURATES (ANTICONVULSANTS) Brand‐O PA TIER 3 



276

MYSOLINE TAB 50MG BARBITURATES (ANTICONVULSANTS) Brand‐O PA TIER 3 


MYTELASE TAB 10MG 


MYTUSSIN AC SYP 100‐10/5 ANTITUSSIVES GENERIC Covered TIER 1 

MYZILRA TAB CONTRACEPTIVES GENERIC Covered TIER 1 

NABI‐HB INJ SERUMS GENERIC Covered TIER 1 SP 

NABUMETONE TAB 500MG 



NABUMETONE TAB 750MG 



N‐ACETYL‐L‐ CAP CYSTEINE CALORIC AGENTS GENERIC Covered TIER 1 

NACL/BACT INJ 0.9%BENZ REPLACEMENT PREPARATIONS GENERIC Excluded TIER 99 

NADOLOL TAB 20MG 









NADOLOL/BEND TAB 40‐5MG 



NADOLOL/BEND TAB 80‐5MG 



NAFCILLIN INJ 10GM 


PENICILLINS GENERIC Covered TIER 1 SP 







NAFRINSE CHW 1MG F CARIOSTATIC AGENTS GENERIC Covered TIER 1 



277

NAFRINSE DRO 0.125MG CARIOSTATIC AGENTS GENERIC Covered TIER 1 

NAFRINSE SOL DAILY DENTAL AGENTS BRAND Covered TIER 3 

NAFRINSE DLY SOL /NEUTRAL CARIOSTATIC AGENTS BRAND Covered TIER 3 

NAFRINSE WK SOL 0.2% CARIOSTATIC AGENTS BRAND Covered TIER 3 

NAFTIN CRE 1% 



NAFTIN CRE 2% 



NAFTIN GEL 1% 



NAGLAZYME INJ 1MG/ML ENZYMES BRAND Covered TIER 2 SP 

NALBUPHINE INJ 10MG/ML OPIATE PARTIAL AGONISTS GENERIC Covered TIER 1 

NALBUPHINE INJ 20MG/ML OPIATE PARTIAL AGONISTS GENERIC Covered TIER 1 

NALFON CAP 200MG 



NALFON CAP 400MG 



NALLPEN/DEX INJ 1GM/50ML 



NALLPEN/DEX INJ 2GM/100 



NALOXONE INJ 0.4MG/ML OPIATE ANTAGONISTS GENERIC Covered TIER 1 

NALOXONE INJ 1MG/ML OPIATE ANTAGONISTS GENERIC Covered TIER 1 

NALTREXONE TAB 50MG OPIATE ANTAGONISTS GENERIC Covered TIER 1 

NAMENDA SOL 10MG/5ML 



NAMENDA TAB 10MG 



NAMENDA TAB 5‐10MG 





278

NAMENDA TAB 5MG 

NAPRELAN PAK 

NAPRELAN TAB 375MG CR 



NAPRO CRE 15% 

NAPRODERM CRE 15% 

NAPROSYN SUS 125/5ML 

NAPROSYN TAB 250MG 



NAPROXEN KIT COMFORT 

NAPROXEN SUS 125/5ML 

NAPROXEN TAB 250MG 


































279




NAPROXEN DR TAB 375MG 



NAPROXEN DR TAB 500MG 



NAPROXEN SOD TAB 275MG 



NAPROXEN SOD TAB 550MG 



NARATRIPTAN TAB 1MG SELECTIVE SEROTONIN AGONISTS GENERIC Covered TIER 1 QL 

NARATRIPTAN TAB 2.5MG SELECTIVE SEROTONIN AGONISTS GENERIC Covered TIER 1 QL 

NARDIL TAB 15MG MONOAMINE OXIDASE INHIBITORS Brand‐O PA TIER 3 

NARIZ LIQ 7.5‐200 EXPECTORANTS Brand‐O PA TIER 99 

NAROPIN INJ 10MG/ML LOCAL ANESTHETICS (PARENTERAL) BRAND Covered TIER 3 



NAROPIN INJ 7.5MG/ML LOCAL ANESTHETICS (PARENTERAL) BRAND Covered TIER 3 

NASACORT AQ AER 55MCG/AC CORTICOSTEROIDS (EENT) Brand‐O PA TIER 3 

NASCOBAL SPR 500MCG VITAMIN B COMPLEX BRAND Covered TIER 3 

NASOHIST DRO 1‐2MG/ML PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

NASOHIST DM DRO ANTITUSSIVES Brand‐O PA TIER 99 

NASONEB NSL MIS REPLACEM DEVICES BRAND Excluded TIER 99 

NASONEB NSL MIS STARTER DEVICES BRAND Excluded TIER 99 

NASONEX SPR 50MCG/AC CORTICOSTEROIDS (EENT) BRAND Covered TIER 2 



280

NASOTUSS LIQ ANTITUSSIVES BRAND Excluded TIER 99 

NATA KOMPLET TAB 25‐1MG MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

NATACHEW CHW MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

NATACREAM CRE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

NATACYN SUS 5% OP ANTIFUNGALS (EENT) BRAND Covered TIER 2 

NATAFORT TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

NATALVIT TAB 75‐1MG MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

NATAZIA TAB CONTRACEPTIVES BRAND Covered TIER 2 

NATEGLINIDE TAB 120MG MEGLITINIDES GENERIC Covered TIER 1 

NATEGLINIDE TAB 60MG MEGLITINIDES GENERIC Covered TIER 1 

NATELLE ONE CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

NATELLE‐EZ TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

NATRECOR INJ 1.5MG 



NATROBA SUS 0.9% SCABICIDES AND PEDICULICIDES BRAND Covered TIER 3 

NATURE THROI TAB 162.5MG THYROID AGENTS BRAND Covered TIER 3 

NATURE‐THROI TAB 113.75MG THYROID AGENTS BRAND Covered TIER 3 

NATURE‐THROI TAB 130MG THYROID AGENTS GENERIC Covered TIER 1 


NATURE‐THROI TAB 16.25MG THYROID AGENTS GENERIC Covered TIER 1 


NATURE‐THROI TAB 260MG THYROID AGENTS BRAND Covered TIER 3 

NATURE‐THROI TAB 32.5MG THYROID AGENTS GENERIC Covered TIER 1 

NATURE‐THROI TAB 325MG THYROID AGENTS BRAND Covered TIER 3 





NAVANE CAP 10MG THIOXANTHENES Brand‐O PA TIER 3 

NAVANE CAP 20MG THIOXANTHENES BRAND Covered TIER 3 



281

NAVANE CAP 2MG THIOXANTHENES Brand‐O PA TIER 3 

NAVA‐SC CRE 4% DEPIGMENTING AGENTS GENERIC Excluded TIER 99 

NAVELBINE INJ 10MG/ML ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

NAVELBINE INJ 50MG/5ML ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

NEBULIZER KIT DEVICES GENERIC Excluded TIER 99 

NEBULIZER KIT CMPRESS DEVICES GENERIC Excluded TIER 99 

NEBULIZER KIT MASK DEVICES GENERIC Excluded TIER 99 

NEBULIZER KIT SAMI DEVICES BRAND Excluded TIER 99 

NEBULIZER MIS CMPRESSR DEVICES BRAND Excluded TIER 99 

NEBULIZER MIS COMPRESS DEVICES GENERIC Excluded TIER 99 

NEBULIZER MIS POCKET DEVICES BRAND Excluded TIER 99 

NEBULIZER MIS ULTRASNC DEVICES BRAND Excluded TIER 99 

NEBULIZER MIS ULTRASON DEVICES GENERIC Excluded TIER 99 

NEBUPENT INH 300MG ANTIPROTOZOALS, MISCELLANEOUS BRAND Covered TIER 2 

NEBUSAL NEB 6% MUCOLYTIC AGENTS BRAND Excluded TIER 99 

NECON TAB 0.5/35 CONTRACEPTIVES GENERIC Covered TIER 1 

NECON TAB 1/35‐28 CONTRACEPTIVES GENERIC Covered TIER 1 



NECON 7/7/7 TAB 28 DAY CONTRACEPTIVES GENERIC Covered TIER 1 

NEEDLE MIS 18GX1" DEVICES GENERIC Excluded TIER 99 

NEEDLE‐FREE KIT A DEVICES BRAND Excluded TIER 99 

NEEDLE‐FREE KIT B DEVICES BRAND Excluded TIER 99 

NEEDLE‐FREE KIT C DEVICES BRAND Excluded TIER 99 

NEEVO PAK MULTIVITAMIN PREPARATIONS BRAND Covered TIER 2 

NEEVO DHA CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 2 

NEFAZODONE TAB 100MG SEROTONIN MODULATORS GENERIC Covered TIER 1 





282



NEMBUTAL INJ 50MG/ML 



NEMBUTAL SOD INJ 50MG/ML 



NEO DM SUS ANTITUSSIVES BRAND Excluded TIER 99 

NEO/BAC/POLY OIN OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

NEO/POLY GU SOL 40/ML IR 



NEO/POLY/BAC OIN /HC 1%OP CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

NEO/POLY/DEX OIN 0.1% OP CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

NEO/POLY/DEX SUS 0.1% OP CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

NEO/POLY/GRA SOL OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

NEO/POLY/HC SOL 1% OTIC CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

NEO/POLY/HC SUS 1% OTIC CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

NEO/POLY/HC SUS OP CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

NEOBENZ MICR CRE 3.5% 









NEOBENZ MICR KIT PLUS PK 



NEOBENZ MICR LIQ 7% WASH 



NEO‐FRADIN SOL 125/5ML AMINOGLYCOSIDES BRAND Covered TIER 3 

NEOFRIN SOL 10% OP VASOCONSTRICTORS GENERIC Covered TIER 1 

NEOFRIN SOL 2.5% OP VASOCONSTRICTORS GENERIC Covered TIER 1 



283

NEOMYCIN TAB 500MG AMINOGLYCOSIDES GENERIC Covered TIER 1 

NEO‐POLYCIN OIN OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

NEOPROFEN SOL 10MG/ML 



NEORAL CAP 100MG IMMUNOSUPPRESSIVE AGENTS Brand‐O PA TIER 2 

NEORAL CAP 25MG IMMUNOSUPPRESSIVE AGENTS Brand‐O PA TIER 2 

NEORAL SOL 100MG/ML IMMUNOSUPPRESSIVE AGENTS Brand‐O PA TIER 2 

NEOSALUS AER 



NEOSALUS CRE 



NEOSALUS CRE 180 PACK 



NEOSALUS LOT BASIC LOTIONS AND LINIMENTS BRAND Covered TIER 3 

NEOSPORIN SOL OP ANTIBACTERIALS (EENT) Brand‐O PA TIER 3 

NEOSPORIN GU SOL 40/ML IR 



NEOSTIG METH INJ 0.5MG/ML 



NEOSTIG METH INJ 1MG/ML 



NEO‐SYNEPHRI INJ 10MG/ML ALPHA‐ADRENERGIC AGONISTS Brand‐O PA TIER 3 

NEOTIC DRO LOCAL ANESTHETICS (EENT) Brand‐O PA TIER 3 

NEOTUSS PLUS LIQ ANTITUSSIVES BRAND Excluded TIER 99 

NEOTUSS‐D LIQ ANTITUSSIVES BRAND Excluded TIER 99 

NEPHPLEX RX TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

NEPHRAMINE INJ 5.4% CALORIC AGENTS BRAND Covered TIER 3 

NEPHROCAPS CAP MULTIVITAMIN PREPARATIONS Brand‐O PA TIER 3 

NEPHROCAPS TAB QT MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

NEPHRON FA TAB IRON PREPARATIONS BRAND Covered TIER 3 



284

NEPHRONEX TAB 1MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

NEPHRO‐VITE TAB RX MULTIVITAMIN PREPARATIONS Brand‐O PA TIER 3 

NEPTAZANE TAB 25MG 



NEPTAZANE TAB 50MG 



NESACAINE INJ 1% LOCAL ANESTHETICS (PARENTERAL) BRAND Covered TIER 3 

NESACAINE INJ 2% LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 

NESACAINE INJ ‐MPF 2% LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 

NESACAINE INJ ‐MPF 3% LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 

NESTABS TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

NESTABS DHA PAK MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

NEULASTA INJ 6MG/0.6M HEMATOPOIETIC AGENTS BRAND Covered TIER 2 SP 

NEUMEGA INJ 5MG HEMATOPOIETIC AGENTS BRAND Covered TIER 2 

NEUPOGEN INJ 300/0.5 HEMATOPOIETIC AGENTS BRAND Covered TIER 2 SP 

NEUPOGEN INJ 300MCG HEMATOPOIETIC AGENTS BRAND Covered TIER 2 SP 

NEUPOGEN INJ 480/0.8 HEMATOPOIETIC AGENTS BRAND Covered TIER 2 SP 

NEUPOGEN INJ 480MCG HEMATOPOIETIC AGENTS BRAND Covered TIER 2 SP 

NEUPRO DIS 1MG/24HR 














285







NEURALGO INJ RHEUM 



NEURIN‐SL SUB VITAMIN B COMPLEX BRAND Covered TIER 3 

NEURODEP SOL MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

NEURONTIN CAP 100MG 









NEURONTIN SOL 250/5ML 



NEURONTIN TAB 600MG 



NEURONTIN TAB 800MG 



NEUT INJ 4% ALKALINIZING AGENTS BRAND Covered TIER 3 

NEUTRAGARD GEL 1.1% CARIOSTATIC AGENTS GENERIC Covered TIER 1 

NEUTRAHIST DRO 0.8‐9MG PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

NEUTRASAL POW EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 3 

NEUTREXIN INJ 25MG ANTIPROTOZOALS, MISCELLANEOUS BRAND Covered TIER 3 

NEVANAC SUS 0.1% 



NEVIRAPINE SUS 50MG/5ML 

NONNUCLEOSIDE 

REV.TRANSCRIPTASE INHIB. GENERIC Covered TIER 1 



286

NEVIRAPINE TAB 200MG 

NONNUCLEOSIDE 

REV.TRANSCRIPTASE INHIB. GENERIC Covered TIER 1 

NEXA PLUS CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

NEXA SELECT CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

NEXAVAR TAB 200MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 QL SP 

NEXAVIR INJ 



NEXICLON XR SUS 0.09/ML CENTRAL ALPHA‐AGONISTS BRAND Covered TIER 3 

NEXICLON XR TAB 0.17MG CENTRAL ALPHA‐AGONISTS BRAND Covered TIER 3 

NEXIUM CAP 20MG PROTON‐PUMP INHIBITORS BRAND Covered TIER 2 QL 

NEXIUM CAP 40MG PROTON‐PUMP INHIBITORS BRAND Covered TIER 2 QL 

NEXIUM GRA 10MG DR PROTON‐PUMP INHIBITORS BRAND Covered TIER 2 QL 

NEXIUM GRA 2.5MG DR PROTON‐PUMP INHIBITORS BRAND Covered TIER 2 



NEXIUM GRA 5MG DR PROTON‐PUMP INHIBITORS BRAND Covered TIER 2 

NEXIUM I.V. INJ 20MG PROTON‐PUMP INHIBITORS BRAND Covered TIER 3 

NEXIUM I.V. INJ 40MG PROTON‐PUMP INHIBITORS BRAND Covered TIER 3 

NEXPLANON IMP 68MG CONTRACEPTIVES BRAND Covered TIER 3 

NEXT CHOICE TAB 0.75MG CONTRACEPTIVES GENERIC Covered TIER 1 

NEXT CHOICE TAB 1.5MG CONTRACEPTIVES GENERIC Covered TIER 1 

NEXTERONE INJ CLASS III ANTIARRHYTHMICS BRAND Covered TIER 3 

NIACIN POW USP/NF VITAMIN B COMPLEX GENERIC Covered TIER 1 

NIACOR TAB 500MG VITAMIN B COMPLEX GENERIC Covered TIER 1 

NIASPAN TAB 1000 ER 



NIASPAN TAB 500MG ER 



NIASPAN TAB 750MG ER 





287

NICARDIPINE CAP 20MG DIHYDROPYRIDINES GENERIC Covered TIER 1 

NICARDIPINE CAP 30MG DIHYDROPYRIDINES GENERIC Covered TIER 1 

NICARDIPINE INJ 25/10ML DIHYDROPYRIDINES GENERIC Covered TIER 1 

NICAZEL TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

NICOMIDE TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

NICOTINAMIDE TAB ZN/CU/FA MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

NICOTROL INH 



NICOTROL NS SPR 10MG/ML 



NIFEDIAC CC TAB 30MG ER DIHYDROPYRIDINES GENERIC Covered TIER 1 



NIFEDICAL XL TAB 30MG DIHYDROPYRIDINES GENERIC Covered TIER 1 

NIFEDICAL XL TAB 60MG DIHYDROPYRIDINES GENERIC Covered TIER 1 

NIFEDIPINE CAP 10MG DIHYDROPYRIDINES GENERIC Covered TIER 1 

NIFEDIPINE CAP 20MG DIHYDROPYRIDINES GENERIC Covered TIER 1 

NIFEDIPINE TAB 30MG ER DIHYDROPYRIDINES GENERIC Covered TIER 1 



NILANDRON TAB 150MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 

NIMBEX INJ 10MG/ML 



NIMBEX INJ 2MG/ML 



NIMODIPINE CAP 30MG DIHYDROPYRIDINES GENERIC Covered TIER 1 

NIMOTOP CAP 30MG DIHYDROPYRIDINES Brand‐O PA TIER 3 

NIPENT INJ 10MG ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

NIRAVAM TAB 0.25MG 





288

NIRAVAM TAB 0.5MG 



NIRAVAM TAB 1MG 



NIRAVAM TAB 2MG 



NIRON KOMPLE TAB 30‐1MG IRON PREPARATIONS BRAND Covered TIER 3 

NISOLDIPINE TAB 17MG ER DIHYDROPYRIDINES GENERIC Covered TIER 1 

NISOLDIPINE TAB 20MG DIHYDROPYRIDINES GENERIC Covered TIER 1 

NISOLDIPINE TAB 25.5MG DIHYDROPYRIDINES GENERIC Covered TIER 1 


NISOLDIPINE TAB 34MG ER DIHYDROPYRIDINES GENERIC Covered TIER 1 


NISOLDIPINE TAB 8.5MG ER DIHYDROPYRIDINES GENERIC Covered TIER 1 

NITHIODOTE KIT HEAVY METAL ANTAGONISTS BRAND Covered TIER 3 

NITRO‐BID OIN 2% NITRATES AND NITRITES BRAND Covered TIER 2 

NITRO‐DUR DIS 0.1MG/HR NITRATES AND NITRITES Brand‐O PA TIER 2 


NITRO‐DUR DIS 0.3MG/HR NITRATES AND NITRITES BRAND Covered TIER 2 



NITRO‐DUR DIS 0.8MG/HR NITRATES AND NITRITES BRAND Covered TIER 2 

NITROFUR MAC CAP 100MG URINARY ANTI‐INFECTIVES GENERIC Covered TIER 1 

NITROFUR MAC CAP 50MG URINARY ANTI‐INFECTIVES GENERIC Covered TIER 1 

NITROFURANTN CAP 100MG URINARY ANTI‐INFECTIVES GENERIC Covered TIER 1 

NITROFURANTN SUS 25MG/5ML URINARY ANTI‐INFECTIVES GENERIC Covered TIER 1 

NITROGLY/D5W INJ NITRATES AND NITRITES GENERIC Covered TIER 1 

NITROGLY/D5W INJ 100MG NITRATES AND NITRITES GENERIC Covered TIER 1 





289


NITROGLYCER CAP 2.5MG ER NITRATES AND NITRITES GENERIC Excluded TIER 99 

NITROGLYCER CAP 6.5MG ER NITRATES AND NITRITES GENERIC Excluded TIER 99 

NITROGLYCER CAP 9MG ER NITRATES AND NITRITES GENERIC Excluded TIER 99 

NITROGLYCER DIS 0.1MG/HR NITRATES AND NITRITES GENERIC Covered TIER 1 




NITROGLYCER INJ 5MG/ML NITRATES AND NITRITES GENERIC Covered TIER 1 

NITROGLYCERI DIS 0.6MG/HR NITRATES AND NITRITES GENERIC Covered TIER 1 

NITROGLYCRN SPR LINGUAL NITRATES AND NITRITES GENERIC Covered TIER 1 

NITROLINGUAL SPR PUMPSPRA NITRATES AND NITRITES BRAND Covered TIER 2 

NITROMIST AER 400MCG NITRATES AND NITRITES BRAND Covered TIER 3 

NITROPRESS INJ 25MG/ML DIRECT VASODILATORS BRAND Covered TIER 3 

NITROSTAT SUB 0.3MG NITRATES AND NITRITES BRAND Covered TIER 2 



NITRO‐TIME CAP 2.5MG CR NITRATES AND NITRITES GENERIC Excluded TIER 99 

NITRO‐TIME CAP 6.5MG CR NITRATES AND NITRITES GENERIC Excluded TIER 99 

NITRO‐TIME CAP 9MG CR NITRATES AND NITRITES GENERIC Excluded TIER 99 

NIZATIDINE CAP 150MG HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

NIZATIDINE CAP 300MG HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

NIZATIDINE SOL 15MG/ML HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

NIZORAL SHA 2% 



NOCLOT‐50 SOL ACD‐A ANTICOAGULANTS, MISCELLANEOUS GENERIC Covered TIER 1 


NODOLOR CAP 


NOHIST TAB 8‐20MG PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 



290

NOHIST DMX TAB ANTITUSSIVES GENERIC Covered TIER 1 

NON GELATIN CAP EMPTY PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

NORA‐BE TAB 0.35MG CONTRACEPTIVES GENERIC Covered TIER 1 

NORCO TAB 10‐325MG OPIATE AGONISTS Brand‐O PA TIER 3 

NORCO TAB 5‐325MG OPIATE AGONISTS Brand‐O PA TIER 3 

NORCO TAB 7.5‐325 OPIATE AGONISTS Brand‐O PA TIER 3 

NORDETTE‐28 TAB CONTRACEPTIVES Brand‐O PA TIER 3 

NORDIPEN 5 MIS DEVICE DEVICES BRAND Excluded TIER 99 

NORDITROPIN INJ 10/1.5ML SOMATOTROPIN AGONISTS BRAND PA TIER 2 SP 


NORDITROPIN INJ 30/3ML SOMATOTROPIN AGONISTS BRAND PA TIER 2 SP 


NOREL SD SYP PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

NOREL SR TAB 


MISC. BRAND Excluded TIER 99 

NOREPINEPHR INJ 1MG/ML 



NORETHIN ACE TAB 5MG PROGESTINS GENERIC Covered TIER 1 

NORETHINDRON TAB 0.35MG CONTRACEPTIVES GENERIC Covered TIER 1 

NORFLEX INJ 30MG/ML 

SKELETAL MUSCLE RELAXANTS, 


NORGEST/ETH TAB ESTRAD CONTRACEPTIVES GENERIC Covered TIER 1 

NORGEST/ETHI TAB 0.25/35 CONTRACEPTIVES GENERIC Covered TIER 1 

NORGEST/ETHI TAB ESTRADIO CONTRACEPTIVES GENERIC Covered TIER 1 

NORINYL TAB 1+35‐28 CONTRACEPTIVES Brand‐O PA TIER 3 

NORINYL TAB 1+50‐28 CONTRACEPTIVES BRAND Covered TIER 3 

NORITATE CRE 1% 



NORMAL SALIN INJ 0.9% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

NORML SALINE INJ FLUSH REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 



291

NORML SALINE INJ IV FLUSH REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

NORMOSOL ‐M INJ /D5W REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

NORMOSOL ‐R INJ REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

NORMOSOL ‐R INJ /D5W REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

NORMOSOL‐R INJ PH 7.4 REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

NOROXIN TAB 400MG QUINOLONES BRAND Covered TIER 2 

NORPACE CAP 100MG CLASS IA ANTIARRHYTHMICS Brand‐O PA TIER 3 

NORPACE CAP 100MG CR CLASS IA ANTIARRHYTHMICS BRAND Covered TIER 3 

NORPACE CAP 150MG CLASS IA ANTIARRHYTHMICS Brand‐O PA TIER 3 

NORPACE CAP 150MG CR CLASS IA ANTIARRHYTHMICS BRAND Covered TIER 3 

NORPRAMIN TAB 100MG 


















NOR‐QD TAB 0.35MG CONTRACEPTIVES Brand‐O PA TIER 3 

NORTREL (21) TAB 1/35 CONTRACEPTIVES GENERIC Covered TIER 1 

NORTREL (28) TAB 1/35 CONTRACEPTIVES GENERIC Covered TIER 1 

NORTREL 28 TAB 0.5/35 CONTRACEPTIVES GENERIC Covered TIER 1 

NORTREL7/7/7 TAB 28 DAYS CONTRACEPTIVES GENERIC Covered TIER 1 

NORTRIPTYLIN CAP 10MG 





292










NORTRIPTYLIN SOL 10MG/5ML 



NORTUSS‐DE DRO ANTITUSSIVES GENERIC Covered TIER 1 

NORTUSS‐EX LIQ 200‐20/5 ANTITUSSIVES GENERIC Covered TIER 1 

NORVASC TAB 10MG DIHYDROPYRIDINES Brand‐O PA TIER 3 

NORVASC TAB 2.5MG DIHYDROPYRIDINES Brand‐O PA TIER 3 

NORVASC TAB 5MG DIHYDROPYRIDINES Brand‐O PA TIER 3 

NORVIR CAP 100MG HIV PROTEASE INHIBITORS BRAND Covered TIER 2 

NORVIR SOL 80MG/ML HIV PROTEASE INHIBITORS BRAND Covered TIER 2 

NORVIR TAB 100MG HIV PROTEASE INHIBITORS BRAND Covered TIER 2 

NOTUSS‐AC LIQ 2‐10MG/5 ANTITUSSIVES Brand‐O PA TIER 99 

NOTUSS‐PE LIQ ANTITUSSIVES BRAND Excluded TIER 99 

NOVACORT GEL 



NOVAFERRUM SOL IRON PREPARATIONS BRAND Covered TIER 3 

NOVAGESIC TAB 30‐500MG ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1 

NOVANTRONE INJ 2MG/ML ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 SP 

NOVAREL INJ 10000UNT GONADOTROPINS GENERIC PA TIER 1 SP 

NOVOLOG INJ 100/ML INSULINS BRAND Covered TIER 2 

NOVOLOG INJ FLEXPEN INSULINS BRAND Covered TIER 2 

NOVOLOG INJ PENFILL INSULINS BRAND Covered TIER 2 

NOVOLOG MIX INJ 70/30 INSULINS BRAND Covered TIER 2 

NOVOLOG MIX INJ FLEXPEN INSULINS BRAND Covered TIER 2 

NOVOSEVEN INJ 2400MCG HEMOSTATICS BRAND PA TIER 2 SP 



293

NOVOSEVEN RT INJ 1MG HEMOSTATICS BRAND PA TIER 2 SP 




NOXAFIL SUS 40MG/ML AZOLES BRAND PA TIER 3 

NP THYROID TAB 30MG THYROID AGENTS GENERIC Covered TIER 1 



NPLATE INJ 250MCG HEMATOPOIETIC AGENTS BRAND PA TIER 2 SP 

NPLATE INJ 500MCG HEMATOPOIETIC AGENTS BRAND PA TIER 2 SP 

NUCORT LOT 2% 



NUCYNTA TAB 100MG OPIATE AGONISTS BRAND Covered TIER 2 QL 



NUCYNTA ER TAB 100MG OPIATE AGONISTS BRAND Covered TIER 2 





NUEDEXTA CAP 20‐10MG 



NUFOL TAB VITAMIN B COMPLEX GENERIC Covered TIER 1 

NULECIT INJ 12.5MG/M IRON PREPARATIONS GENERIC Covered TIER 1 

NULEV TAB 0.125MG 



NULOJIX INJ 250MG IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 3 

NULYTELY SOL FLAV PKS CATHARTICS AND LAXATIVES Brand‐O PA TIER 2 

NUMOISYN LIQ EENT DRUGS, MISCELLANEOUS GENERIC Covered TIER 1 

NUMOISYN LOZ EENT DRUGS, MISCELLANEOUS Brand‐O PA TIER 3 



294

NUOX GEL 6‐3% 



NUQUIN HP CRE 4% DEPIGMENTING AGENTS GENERIC Excluded TIER 99 

NUQUIN HP GEL 4% DEPIGMENTING AGENTS GENERIC Excluded TIER 99 

NUTRESTORE PAK 5GM GI DRUGS, MISCELLANEOUS BRAND Covered TIER 3 

NUTRICAP TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

NUTRIDOX KIT TETRACYCLINES BRAND Covered TIER 3 

NUTRIFAC ZX TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

NUTRILYTE INJ REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

NUTRILYTE II INJ REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

NUTRIPORT KIT 20FR/2.5 DEVICES BRAND Excluded TIER 99 




NUTRIPORT KIT 20FR/4CM DEVICES BRAND Excluded TIER 99 















NUTRI‐TAB OB MIS + DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 



295

NUTRI‐TAB OB TAB 32‐1MG MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

NUTRIVIT LIQ 800‐15‐1 MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

NUTROPIN INJ 10MG SOMATOTROPIN AGONISTS BRAND PA TIER 2 SP 

NUTROPIN AQ INJ 10MG/2ML SOMATOTROPIN AGONISTS BRAND PA TIER 2 SP 

NUTROPIN AQ INJ 20MG/2ML SOMATOTROPIN AGONISTS BRAND PA TIER 2 SP 

NUTROPIN AQ INJ NUSPIN 5 SOMATOTROPIN AGONISTS BRAND PA TIER 2 SP 

NUVAIL SOL 16% 



NUVARING MIS CONTRACEPTIVES BRAND Covered TIER 2 


NUVIGIL TAB 150MG 

STIMULANTS,MISC BRAND PA TIER 3 QL 







NUZOLE CRE 2% 



NUZON GEL 2% 



NYSTAT/TRIAM CRE 



NYSTAT/TRIAM OIN 



NYSTATIN CRE 100000 

POLYENES (SKIN & MUCOUS 


NYSTATIN OIN 100000 



NYSTATIN POW POLYENES GENERIC Excluded TIER 99 

NYSTATIN POW 10BU POLYENES GENERIC Excluded TIER 99 

NYSTATIN POW 150MU POLYENES GENERIC Excluded TIER 99 



296






NYSTATIN POW DOMESTIC POLYENES GENERIC Excluded TIER 99 

NYSTATIN SUS 100000 POLYENES GENERIC Covered TIER 1 

NYSTATIN TAB 500000 POLYENES GENERIC Covered TIER 1 

NYSTATIN VAG TAB 100000 



OASIS BURN MIS 7X20CM 



OASIS ULTRA MIS TRI MESH 



OASIS WOUND MIS 3X3.5CM 



OASIS WOUND MIS 3X7CM 









OB COMPLETE CAP 400 MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

OB COMPLETE CAP ONE MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

OB COMPLETE CAP PETITE MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

OB COMPLETE CAP WITH DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

OB COMPLETE CHW MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

OB COMPLETE TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

OB COMPLETE TAB PREMIER MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

OB COMPLETE/ CAP DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 



297

OB‐NATAL ONE CAP 20‐7‐1MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

OB‐NATAL ONE CAP 27‐1MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

OBSTETRIX PAK DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

OBSTETRIX EC TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

O‐CAL TAB PRENATAL MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

O‐CAL FA TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

OCCLUSADERM GEL PCCA PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

OCELLA TAB 3‐0.03MG CONTRACEPTIVES GENERIC Covered TIER 1 

OCTAGAM INJ 10GM SERUMS BRAND PA TIER 3 SP 


OCTAGAM INJ 2.5GM SERUMS BRAND PA TIER 3 SP 



OCTREOSCAN KIT 



OCTREOTIDE INJ 1000MCG 












OCTREOTIDE INJ 50MCG/ML 



OCUCOAT SOL 2% OP EENT DRUGS, MISCELLANEOUS GENERIC Excluded TIER 99 

OCUDOX KIT TETRACYCLINES BRAND Covered TIER 3 

OCUFEN SOL 0.03% OP 



OCUFLOX DRO 0.3% OP ANTIBACTERIALS (EENT) Brand‐O PA TIER 3 



298

OFFICE SAFET KIT 3.2QT DEVICES BRAND Excluded TIER 99 

OFIRMEV INJ 10MG/ML 



OFLOXACIN DRO 0.3% OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

OFLOXACIN DRO 0.3%OTIC ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

OFLOXACIN TAB 200MG QUINOLONES GENERIC Covered TIER 1 



OFORTA TAB 10MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

OGESTREL TAB CONTRACEPTIVES GENERIC Covered TIER 1 

OINTMENT BAS OIN EMULSIFY PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 


OLANZA/FLUOX CAP 12‐25MG INHIBITORS GENERIC Covered TIER 1 QL 

OLANZA/FLUOX CAP 12‐50MG 









OLANZAPINE INJ 10MG ATYPICAL ANTIPSYCHOTICS GENERIC Covered TIER 1 QL 

OLANZAPINE TAB 10MG ATYPICAL ANTIPSYCHOTICS GENERIC Covered TIER 1 QL 

OLANZAPINE TAB 10MG ODT ATYPICAL ANTIPSYCHOTICS GENERIC Covered TIER 1 QL 



OLANZAPINE TAB 2.5MG ATYPICAL ANTIPSYCHOTICS GENERIC Covered TIER 1 QL 





OLANZAPINE TAB 7.5MG ATYPICAL ANTIPSYCHOTICS GENERIC Covered TIER 1 QL 



299

OLEABASE OIN PLASTICI PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

OLEIC ACID LIQ 



OLEPTRO TAB 24HR150 SEROTONIN MODULATORS BRAND Covered TIER 3 QL 

OLEPTRO TAB 24HR300 SEROTONIN MODULATORS BRAND Covered TIER 3 QL 

OLUX AER 0.05% 



OLUX‐E AER 0.05% 



OMECLAMOX‐ MIS PAK PROTON‐PUMP INHIBITORS BRAND Covered TIER 3 

OMEPRA/BICAR CAP 20‐1100 PROTON‐PUMP INHIBITORS GENERIC Covered TIER 1 QL 

OMEPRA/BICAR CAP 40‐1100 PROTON‐PUMP INHIBITORS GENERIC Covered TIER 1 QL 

OMEPRAZOLE CAP 10MG PROTON‐PUMP INHIBITORS GENERIC Covered TIER 1 QL 



OMNARIS SPR CORTICOSTEROIDS (EENT) BRAND Covered TIER 3 

OMNIFLEX DPR 



OMNIPAQUE INJ 180MG/ML ROENTGENOGRAPHY BRAND Covered TIER 3 




OMNIPOD KIT STARTER DEVICES BRAND Covered TIER 3 

OMNIPOD MIS DEVICES BRAND Covered TIER 3 

OMNIPRED SUS 1% OP CORTICOSTEROIDS (EENT) Brand‐O PA TIER 3 

OMNISCAN INJ /NACL DIAGNOSTIC AGENTS BRAND Excluded TIER 99 

OMNISCAN INJ 287MG/ML DIAGNOSTIC AGENTS BRAND Excluded TIER 99 

OMNITROPE INJ 10/1.5ML SOMATOTROPIN AGONISTS BRAND PA TIER 3 SP 

OMNITROPE INJ 5.8MG SOMATOTROPIN AGONISTS BRAND PA TIER 3 SP 

OMNITROPE INJ 5/1.5ML SOMATOTROPIN AGONISTS BRAND PA TIER 3 SP 



300

OMNITROPE 5 MIS DEVICE DEVICES BRAND Excluded TIER 99 

OMONTYS INJ 10MG/ML HEMATOPOIETIC AGENTS BRAND Covered TIER 3 SP 

OMONTYS INJ 20MG/2ML HEMATOPOIETIC AGENTS BRAND Covered TIER 3 SP 

ONCASPAR INJ 750/ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

ONDANSETRON INJ 32/50ML 5‐HT3 RECEPTOR ANTAGONISTS GENERIC Covered TIER 1 SP 

ONDANSETRON INJ 40/20ML 5‐HT3 RECEPTOR ANTAGONISTS GENERIC Covered TIER 1 

ONDANSETRON INJ 4MG/2ML 5‐HT3 RECEPTOR ANTAGONISTS GENERIC Covered TIER 1 

ONDANSETRON SOL 32MG/50M 5‐HT3 RECEPTOR ANTAGONISTS GENERIC Covered TIER 1 

ONDANSETRON SOL 4MG/5ML 5‐HT3 RECEPTOR ANTAGONISTS GENERIC Covered TIER 1 QL 

ONDANSETRON TAB 24MG 5‐HT3 RECEPTOR ANTAGONISTS GENERIC Covered TIER 1 QL 


ONDANSETRON TAB 4MG ODT 5‐HT3 RECEPTOR ANTAGONISTS GENERIC Covered TIER 1 QL 


ONDANSETRON TAB 8MG ODT 5‐HT3 RECEPTOR ANTAGONISTS GENERIC Covered TIER 1 QL 

ONE FLOW KIT SPIROMTR DEVICES BRAND Excluded TIER 99 

ONE FLOW MIS SPIROMTR DEVICES BRAND Excluded TIER 99 

ONETOUCH PNG KIT INS PUMP DEVICES BRAND Covered TIER 3 

ONFI TAB 10MG 


(ANTICONVULSANTS) BRAND Covered TIER 3 

ONFI TAB 20MG 



ONFI TAB 5MG 



ONGLYZA TAB 2.5MG 



ONGLYZA TAB 5MG 



ONSOLIS MIS 1200MCG OPIATE AGONISTS BRAND Covered TIER 3 QL 

ONSOLIS MIS 200MCG OPIATE AGONISTS BRAND Covered TIER 3 QL 

ONSOLIS MIS 400MCG OPIATE AGONISTS BRAND Covered TIER 3 



301



ONTAK INJ 150/ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

OPANA TAB 10MG OPIATE AGONISTS Brand‐O PA TIER 3 

OPANA TAB 5MG OPIATE AGONISTS Brand‐O PA TIER 3 

OPANA ER TAB 10MG OPIATE AGONISTS BRAND Covered TIER 3 

QL 


QL 


QL 


QL 


QL 

OPIUM TIN 1% ANTIDIARRHEA AGENTS GENERIC Covered TIER 1 

OPTASE GEL 



OPTICHAMBER MIS ADV LRG DEVICES BRAND Excluded TIER 99 

OPTICHAMBER MIS ADV MED DEVICES BRAND Excluded TIER 99 

OPTICHAMBER MIS ADVANTAG DEVICES BRAND Excluded TIER 99 

OPTICHAMBER MIS DIA LG DEVICES BRAND Excluded TIER 99 

OPTICHAMBER MIS DIA MD DEVICES BRAND Excluded TIER 99 

OPTICHAMBER MIS DIA SM DEVICES BRAND Excluded TIER 99 

OPTICHAMBER MIS DIAMOND DEVICES BRAND Excluded TIER 99 

OPTIHALER MIS DEVICES BRAND Excluded TIER 99 

OPTIMARK INJ 330.9MG DIAGNOSTIC AGENTS BRAND Excluded TIER 99 

OPTIONHOME MIS NEBULIZR DEVICES BRAND Excluded TIER 99 

OPTIPRANOLOL SOL 0.3% OP 





302

OPTIRAY 160 INJ 34% ROENTGENOGRAPHY BRAND Covered TIER 3 





OPTISON INJ DIAGNOSTIC AGENTS BRAND Excluded TIER 99 

OPTIVAR DRO 0.05% ANTIALLERGIC AGENTS Brand‐O PA TIER 3 

ORACEA CAP 40MG 



ORACIT SOL ALKALINIZING AGENTS BRAND Covered TIER 3 

ORAL SYRINGE MIS 6ML DEVICES BRAND Excluded TIER 99 

ORALONE PST 0.1% 



ORAMAGICRX SUS 



ORAMORPH SR TAB 100MG OPIATE AGONISTS BRAND Covered TIER 3 




ORANGE LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

ORANGE CREAM LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

ORANGE OIL LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

ORAP TAB 1MG ANTIPSYCHOTICS, MISCELLANEOUS BRAND Covered TIER 2 

ORAP TAB 2MG ANTIPSYCHOTICS, MISCELLANEOUS BRAND Covered TIER 2 

ORAPRED SOL 15MG/5ML ADRENALS Brand‐O PA TIER 3 

ORAPRED ODT TAB 10MG ADRENALS BRAND Covered TIER 3 





303

ORAVIG TAB 50MG 


MEMBRANE) BRAND Covered TIER 3 QL 

ORAXYL CAP 20MG TETRACYCLINES BRAND Covered TIER 3 

ORBIVAN CAP 



ORBIVAN CF TAB 50‐300MG 



ORENCIA INJ 125MG/ML 


ANTIRHEUMATIC AGENTS BRAND PA TIER 3 QL 

ORENCIA INJ 250MG 



ORFADIN CAP 10MG 









ORGANIDIN NR TAB 200MG EXPECTORANTS GENERIC Covered TIER 1 

ORPH/ASA/CAF TAB SALICYLATES GENERIC Covered TIER 1 

ORPHEN CPD TAB DS SALICYLATES GENERIC Covered TIER 1 

ORPHENADRINE INJ 30MG/ML 



ORPHENADRINE TAB 100MG ER 



ORSYTHIA TAB CONTRACEPTIVES GENERIC Covered TIER 1 

ORTHO COIL DPR KIT 100 








304




ORTHO EVRA DIS WEEK CONTRACEPTIVES BRAND Covered TIER 3 

ORTHO FIT MIS ALL‐FLEX DEVICES BRAND Excluded TIER 99 

ORTHO FLAT DPR KIT 55 



























ORTHO FLEX DPR 65MM 














305

ORTHO MICRON TAB 0.35MG CONTRACEPTIVES Brand‐O PA TIER 3 

ORTHO TRI‐ TAB CYCLEN CONTRACEPTIVES Brand‐O PA TIER 3 

ORTHO TRI‐ TAB CYCLN LO CONTRACEPTIVES BRAND Covered TIER 3 

ORTHO‐CEPT TAB 28 CONTRACEPTIVES Brand‐O PA TIER 3 

ORTHOCLONE INJ OKT3 IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 3 

ORTHO‐CS 250 INJ 250MG/ML VITAMIN C GENERIC Covered TIER 1 

ORTHO‐CYCLEN TAB 0.25/35 CONTRACEPTIVES Brand‐O PA TIER 3 

ORTHO‐EST TAB 0.625 ESTROGENS GENERIC Covered TIER 1 

ORTHO‐EST TAB 1.25 ESTROGENS GENERIC Covered TIER 1 

ORTHO‐NOVUM TAB 1/35‐28 CONTRACEPTIVES Brand‐O PA TIER 3 

ORTHO‐NOVUM TAB 7/7/7‐28 CONTRACEPTIVES Brand‐O PA TIER 3 

ORTHOVISC INJ 15MG/ML 



OSCIMIN SUB 0.125MG 



OSCIMIN TAB 0.125MG 



OSCIMIN SR TAB 0.375MG 



OSCION CLNSR LOT 6% 



OSCION CLNSR LOT 9% 



OSGOOD BIOPS MIS DEVICES BRAND Excluded TIER 99 

OSGOOD BIOPS MIS 18GX1" DEVICES BRAND Excluded TIER 99 

OSMITROL INJ 10% OSMOTIC DIURETICS GENERIC Covered TIER 1 



OSMITROL VFX INJ 20% OSMOTIC DIURETICS GENERIC Covered TIER 1 

OSMOPREP TAB 1.5GM CATHARTICS AND LAXATIVES BRAND Covered TIER 3 



306

OTIC CARE DRO LOCAL ANESTHETICS (EENT) GENERIC Covered TIER 1 

OTICIN DRO 1‐0.1% LOCAL ANESTHETICS (EENT) GENERIC Covered TIER 1 

OTICIN HC DRO CORTICOSTEROIDS (EENT) Brand‐O PA TIER 99 

OTO‐END 10 SOL CORTICOSTEROIDS (EENT) GENERIC Excluded TIER 99 

OTOMAR SOL OTIC CORTICOSTEROIDS (EENT) GENERIC Excluded TIER 99 

OTOMAX‐HC DRO CORTICOSTEROIDS (EENT) GENERIC Excluded TIER 99 

OTOZIN DRO LOCAL ANESTHETICS (EENT) GENERIC Covered TIER 1 

OVACE PLUS CRE 10% 



OVACE PLUS GEL 10% WASH 



OVACE PLUS SHA 10% 



OVACE WASH LIQ 10% 



OVCON 50 TAB 28 CONTRACEPTIVES BRAND Covered TIER 3 

OVCON‐35 TAB CONTRACEPTIVES Brand‐O PA TIER 3 

OVIDE LOT 0.5% SCABICIDES AND PEDICULICIDES Brand‐O PA TIER 3 

OVIDREL INJ GONADOTROPINS BRAND PA TIER 2 SP 

OXACILLIN INJ 10GM 









OXALIPLATIN INJ 100MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

OXALIPLATIN INJ 50MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

OXANDRIN TAB 10MG ANDROGENS Brand‐O PA TIER 3 

OXANDRIN TAB 2.5MG ANDROGENS Brand‐O PA TIER 3 

OXANDROLONE TAB 10MG ANDROGENS GENERIC PA TIER 1 



307

OXANDROLONE TAB 2.5MG ANDROGENS GENERIC PA TIER 1 

OXAPROZIN TAB 600MG 



OXAZEPAM CAP 10MG 









OXCARBAZEPIN SUS 300MG/5M 



OXCARBAZEPIN TAB 150MG 









OXECTA TAB 5MG OPIATE AGONISTS BRAND Covered TIER 3 

OXECTA TAB 7.5MG OPIATE AGONISTS BRAND Covered TIER 3 

OXISTAT CRE 1% 



OXISTAT LOT 1% 



OXSORALEN LOT 1% PIGMENTING AGENTS BRAND Excluded TIER 99 

OXSORALEN‐UL CAP 10MG PIGMENTING AGENTS BRAND Covered TIER 2 

OXYBUTYNIN SYP 5MG/5ML 



OXYBUTYNIN TAB 10MG ER 





308




OXYBUTYNIN TAB 5MG 






OXYCEL COTTN PAD 2"X1"X1" 



OXYCEL GAUZE PAD 18"X2" 



OXYCEL GAUZE PAD 3"X3" 



OXYCEL GAUZE PAD 36"X1/2" 



OXYCEL GAUZE PAD 5"X1/2" 



OXYCOD/APAP CAP 5‐500MG OPIATE AGONISTS GENERIC Covered TIER 1 QL 

OXYCOD/APAP TAB 10‐325MG OPIATE AGONISTS GENERIC Covered TIER 1 QL 


OXYCOD/APAP TAB 2.5‐325 OPIATE AGONISTS GENERIC Covered TIER 1 QL 




OXYCOD/ASA TAB OPIATE AGONISTS GENERIC Covered TIER 1 QL 

OXYCOD/IBU TAB 5‐400MG OPIATE AGONISTS GENERIC Covered TIER 1 QL 

OXYCODONE CAP 5MG OPIATE AGONISTS GENERIC Covered TIER 1 

OXYCODONE CON 20MG/ML OPIATE AGONISTS GENERIC Covered TIER 1 

OXYCODONE SOL 5MG/5ML OPIATE AGONISTS GENERIC Covered TIER 1 

OXYCODONE TAB 10MG OPIATE AGONISTS GENERIC Covered TIER 1 




309




OXYCONTIN TAB 10MG CR OPIATE AGONISTS BRAND Covered TIER 2 QL 







OXYMORPHONE TAB 15MG ER OPIATE AGONISTS GENERIC Covered TIER 1 QL 

OXYMORPHONE TAB 7.5MG ER OPIATE AGONISTS GENERIC Covered TIER 1 QL 

OXYMORPHONE TAB HCL 10MG OPIATE AGONISTS GENERIC Covered TIER 1 

OXYMORPHONE TAB HCL 5MG OPIATE AGONISTS GENERIC Covered TIER 1 

OXYTOCIN INJ 10UNT/ML OXYTOCICS GENERIC Covered TIER 1 

OXYTROL DIS 3.9MG/24 



OZURDEX IMP 0.7MG CORTICOSTEROIDS (EENT) BRAND Covered TIER 2 

P CHLOR DM DRO ANTITUSSIVES GENERIC Covered TIER 1 

PACERONE TAB 100MG CLASS III ANTIARRHYTHMICS BRAND Covered TIER 2 

PACERONE TAB 200MG CLASS III ANTIARRHYTHMICS GENERIC Covered TIER 1 

PACERONE TAB 400MG CLASS III ANTIARRHYTHMICS Brand‐O PA TIER 3 

PACLITAXEL INJ 100MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

PACLITAXEL INJ 150/25ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

PACLITAXEL INJ 300/50ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

PACLITAXEL INJ 30MG/5ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

PACNEX HP PAD 7% 



PACNEX LP PAD 4.25% 





310

PACNEX MX LIQ 4.25% 



PACNEX WASH LIQ 7% 



PAIN EASE AER MD STRM 



PAIN EASE AER MIST 



PAIRE OB MIS MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PALGIC LIQ 4MG/5ML ETHANOLAMINE DERIVATIVES Brand‐O PA TIER 3 

PALGIC TAB 4MG ETHANOLAMINE DERIVATIVES Brand‐O PA TIER 3 

PAMELOR CAP 10MG 












PAMIDRONATE INJ 30/10ML BONE RESORPTION INHIBITORS GENERIC Covered TIER 1 

PAMIDRONATE INJ 30MG BONE RESORPTION INHIBITORS GENERIC Covered TIER 1 SP 

PAMIDRONATE INJ 6MG/ML BONE RESORPTION INHIBITORS GENERIC Covered TIER 1 

PAMIDRONATE INJ 90/10ML BONE RESORPTION INHIBITORS GENERIC Covered TIER 1 

PAMIDRONATE INJ 90MG BONE RESORPTION INHIBITORS GENERIC Covered TIER 1 SP 

PAMINE TAB 2.5MG 



PAMINE FORTE TAB 5MG 



PAMINE FQ KIT 





311

PANATUSS DXP LIQ ANTITUSSIVES BRAND Excluded TIER 99 

PANCREAZE CAP 10500UNT DIGESTANTS BRAND Covered TIER 3 



PANCREAZE CAP 4200UNIT DIGESTANTS BRAND Covered TIER 3 

PANCRELIPASE CAP 5000UNIT DIGESTANTS GENERIC Covered TIER 1 

PANCURONIUM INJ 1MG/ML 



PANCURONIUM INJ 2MG/ML 



PANDEL CRE 0.1% 



PANHEMATIN INJ 313MG BLOOD DERIVATIVES BRAND Covered TIER 3 

PANRETIN GEL 0.1% 



PANTOPRAZOLE TAB 20MG PROTON‐PUMP INHIBITORS GENERIC Covered TIER 1 QL 

PANTOPRAZOLE TAB 40MG PROTON‐PUMP INHIBITORS GENERIC Covered TIER 1 QL 

PAPAVERINE INJ 30MG/ML 



PAPAVERINE SOL 30MG/ML 



PARADIGM KIT LINK DEVICES BRAND Covered TIER 3 

PARADIGM MIS UPGRADE DEVICES BRAND Covered TIER 3 

PARADIGM QR MIS POLY 24" DEVICES BRAND Covered TIER 3 

PARADIGM QR MIS POLY 42" DEVICES BRAND Covered TIER 3 

PARADIGM REA MIS TRANSMIT DEVICES BRAND Covered TIER 3 

PARADIGM RES MIS 1.76ML DEVICES BRAND Covered TIER 3 

PARADIGM RES MIS 3ML DEVICES BRAND Covered TIER 3 

PARADIGM SOF MIS ‐SET 24" DEVICES BRAND Covered TIER 3 

PARADIGM SOF MIS ‐SET 42" DEVICES BRAND Covered TIER 3 



312

PARAFON FORT TAB DSC 



PARAGARD IUD T380A 



PARALDEHYDE LIQ 


HYPNOTICS,MISC. GENERIC Excluded TIER 99 

PARALLEL Y MIS CON ADLT DEVICES BRAND Excluded TIER 99 

PARCAINE SOL 0.5% OP LOCAL ANESTHETICS (EENT) GENERIC Covered TIER 1 

PARCOPA TAB 10‐100MG DOPAMINE PRECURSORS Brand‐O PA TIER 3 



PAREGORIC TIN 2MG/5ML ANTIDIARRHEA AGENTS GENERIC Covered TIER 1 

PAREMYD SOL 1‐0.25% OCULAR DISORDERS BRAND Covered TIER 3 

PARI BABY MIS SIZE 0 DEVICES BRAND Excluded TIER 99 



PARI EXPIRAT MIS FILTER DEVICES BRAND Excluded TIER 99 

PARI LC MIS SPRINT DEVICES BRAND Excluded TIER 99 

PARI LC D MIS NEBULIZR DEVICES BRAND Excluded TIER 99 

PARI LC PLUS KIT PED DEVICES BRAND Excluded TIER 99 

PARI LC PLUS MIS DEVICES BRAND Excluded TIER 99 

PARI LC PLUS MIS NEBULIZR DEVICES BRAND Excluded TIER 99 

PARI LC STAR MIS DEVICES BRAND Excluded TIER 99 

PARI LC STAR MIS NEBULIZR DEVICES BRAND Excluded TIER 99 

PARI MANUAL MIS INTERRUP DEVICES BRAND Excluded TIER 99 

PARI MASK MIS SIZE 3 DEVICES BRAND Excluded TIER 99 

PARI PLASTIC MIS MASK DEVICES BRAND Excluded TIER 99 

PARI PLASTIC MIS MASK PED DEVICES BRAND Excluded TIER 99 

PARI PRONEB MIS ULTRA II DEVICES BRAND Excluded TIER 99 

PARI SINUS MIS AERO SYS DEVICES BRAND Excluded TIER 99 



313

PARI TREK S KIT COMBO DEVICES BRAND Excluded TIER 99 

PARI TREK S KIT POWER DEVICES BRAND Excluded TIER 99 

PARI TREK S MIS DEVICES BRAND Excluded TIER 99 

PARLODEL CAP 5MG 



PARLODEL TAB 2.5MG 



PARNATE TAB 10MG MONOAMINE OXIDASE INHIBITORS Brand‐O PA TIER 3 

PAROMOMYCIN CAP 250MG AMEBICIDES GENERIC Covered TIER 1 

PAROXETIN ER TAB 12.5MG 



PAROXETIN ER TAB 37.5MG 



PAROXETINE SUS 10MG/5ML 



PAROXETINE TAB 10MG 






PAROXETINE TAB 25MG ER 









PASER GRA 4GM ANTITUBERCULOSIS AGENTS BRAND Covered TIER 3 

PATADAY SOL 0.2% ANTIALLERGIC AGENTS BRAND Covered TIER 2 

PATANASE SPR 0.6% ANTIALLERGIC AGENTS BRAND Covered TIER 3 

PATANOL SOL 0.1% OP ANTIALLERGIC AGENTS BRAND Covered TIER 2 



314

PATROL PUMP MIS 40MM CAP DEVICES BRAND Excluded TIER 99 

PAXIL SUS 10MG/5ML 



PAXIL TAB 10MG 












PAXIL CR TAB 12.5MG 



PAXIL CR TAB 25MG 



PAXIL CR TAB 37.5MG 



PCA INJECTOR MIS DEVICES GENERIC Excluded TIER 99 

PCCA ACACIA SYP BASE CALORIC AGENTS BRAND Excluded TIER 99 

PCCA ALADERM CRE BASE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA BASE MIS TRSDRML PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA COBASE OIN #1 PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA COSMETI CRE HRT BASE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA CUSTOM CRE LIPO‐MAX PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA FIXED LIQ OIL BASE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA GELATIN OIN BASE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA LECITHI SOL ISOPROPY LIPOTROPIC AGENTS BRAND Excluded TIER 99 

PCCA LIPODER CRE BASE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA LIPOSOM CRE DEHYDRAT PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA LIPOSOM CRE DRY PHARMACEUTICAL AIDS BRAND Excluded TIER 99 



315

PCCA LIPOSOM CRE NORMAL PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA LIPOSOM CRE OILY PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA LIPOSOM CRE PROBLEM PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA LIPOSOM CRE SENSITIV PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA MVC CRE BASE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA PLASTIC OIN BASE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA PLURONI GEL F127 20% PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA PLURONI GEL F127 30% PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA SWEET SYP ‐SF PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA SYRUP SYP VEHICLE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA VANISH CRE BASE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA VANISHI CRE LIGHT PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA VANPEN CRE BASE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCCA‐PLUS SUS PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PCE TAB 333MG EC ERYTHROMYCINS BRAND Covered TIER 3 

PCE TAB 500MG EC ERYTHROMYCINS BRAND Covered TIER 3 

PE/GUAIFENES DRO 1.5‐20MG EXPECTORANTS GENERIC Covered TIER 1 

PEACH FLAVOR LIQ PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

PEANUT BUTTR LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

PEDIADERM AF KIT COMPLETE 



PEDIADERM HC KIT 



PEDIADERM TA KIT 



PEDIAPRED SOL 6.7/5ML ADRENALS Brand‐O PA TIER 3 

PEDIARIX INJ 0.5ML VACCINES BRAND Excluded TIER 99 

PEDIATEX TD LIQ PROPYLAMINE DERIVATIVES Brand‐O PA TIER 99 

PEDIATEX TDM SUS ANTITUSSIVES BRAND Excluded TIER 99 

PEDIATRIC MIS MASK DEVICES GENERIC Excluded TIER 99 



316

PEDIPIROX‐4 KIT NAIL 



PEDI‐TUBE MIS 20" DEVICES BRAND Excluded TIER 99 

PEDI‐TUBE MIS 36" DEVICES BRAND Excluded TIER 99 

PEDVAX HIB INJ VACCINES BRAND Covered TIER 3 

PEG OIN BASE L PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

PEG 3350 SOL ELECTROL CATHARTICS AND LAXATIVES GENERIC Covered TIER 1 

PEG 400 LIQ CATHARTICS AND LAXATIVES GENERIC Excluded TIER 99 

PEG ENTERAL MIS CONNECTR DEVICES BRAND Excluded TIER 99 

PEG‐3350 SOL ELECTROL CATHARTICS AND LAXATIVES GENERIC Covered TIER 1 

PEG‐3350/KCL SOL /SODIUM CATHARTICS AND LAXATIVES GENERIC Covered TIER 1 

PEGANONE TAB 250MG HYDANTOINS BRAND Covered TIER 2 

PEGASYS INJ INTERFERONS BRAND PA TIER 2 SP 

PEGASYS INJ 180MCG/M INTERFERONS BRAND PA TIER 2 SP 

PEGASYS INJ PROCLICK INTERFERONS BRAND PA TIER 2 SP 

PEGASYS KIT INTERFERONS BRAND PA TIER 2 SP 

PEG‐INTRON KIT 120 RP INTERFERONS BRAND PA TIER 2 SP 

PEG‐INTRON KIT 120MCG INTERFERONS BRAND PA TIER 2 SP 

PEG‐INTRON KIT 150 RP INTERFERONS BRAND PA TIER 2 SP 



PEG‐INTRON KIT 50MCG RP INTERFERONS BRAND PA TIER 2 SP 


PEG‐INTRON KIT 80MCG RP INTERFERONS BRAND PA TIER 2 SP 

PE‐GUAI DRO 1.5‐20MG EXPECTORANTS GENERIC Covered TIER 1 

PELVIC MUSCL MIS TRAINER DEVICES GENERIC Excluded TIER 99 

PEN G PROC INJ 600000 NATURAL PENICILLINS GENERIC Covered TIER 1 

PEN G SOD INJ 5000000 NATURAL PENICILLINS GENERIC Covered TIER 1 

PENCREAM CRE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PENDERM CRE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 



317

PENICILL GK/ INJ DEX 1MU NATURAL PENICILLINS GENERIC Covered TIER 1 



PENICILLN GK INJ 20MU NATURAL PENICILLINS GENERIC Covered TIER 1 

PENICILLN GK INJ 5MU NATURAL PENICILLINS GENERIC Covered TIER 1 

PENICILLN VK SOL 125/5ML NATURAL PENICILLINS GENERIC Covered TIER 1 

PENICILLN VK SOL 250/5ML NATURAL PENICILLINS GENERIC Covered TIER 1 

PENICILLN VK TAB 250MG NATURAL PENICILLINS GENERIC Covered TIER 1 

PENICILLN VK TAB 500MG NATURAL PENICILLINS GENERIC Covered TIER 1 

PENLAC SOL 8% 



PENNSAID SOL 1.5% 



PENTA/APAP TAB 25‐650MG OPIATE PARTIAL AGONISTS GENERIC Covered TIER 1 

PENTACEL INJ VACCINES BRAND Excluded TIER 99 

PENTAM 300 INJ 300MG ANTIPROTOZOALS, MISCELLANEOUS BRAND Covered TIER 3 

PENTASA CAP 250MG CR 



PENTASA CAP 500MG CR 



PENTAZ/NALOX TAB 50‐0.5MG OPIATE PARTIAL AGONISTS GENERIC Covered TIER 1 

PENTOPAK TAB 400MG CR HEMORRHEOLOGIC AGENTS GENERIC Covered TIER 1 

PENTOSTATIN INJ 10MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

PENTOTHAL INJ 1GM 



PENTOTHAL INJ 250MG 








318




PENTOXIFYLLI TAB 400MG ER HEMORRHEOLOGIC AGENTS GENERIC Covered TIER 1 

PEPCID SUS 40MG/5ML HISTAMINE H2‐ANTAGONISTS Brand‐O PA TIER 3 

PEPCID TAB 20MG HISTAMINE H2‐ANTAGONISTS Brand‐O PA TIER 3 

PEPCID TAB 40MG HISTAMINE H2‐ANTAGONISTS Brand‐O PA TIER 3 

PEPPERMINT OIL FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

PERCOCET TAB 10‐325MG OPIATE AGONISTS Brand‐O PA TIER 3 QL 


PERCOCET TAB 2.5‐325 OPIATE AGONISTS Brand‐O PA TIER 3 QL 


PERCOCET TAB 7.5‐325M OPIATE AGONISTS Brand‐O PA TIER 3 QL 

PERCOCET TAB 7.5‐500 OPIATE AGONISTS Brand‐O PA TIER 3 QL 

PERCODAN TAB OPIATE AGONISTS Brand‐O PA TIER 3 QL 

PERCURA CAP CALORIC AGENTS BRAND Excluded TIER 99 

PERFOROMIST NEB 20MCG 



PERIDEX SOL 0.12% 



PERINDOPRIL TAB 2MG 









PERIO MED CON 0.63% CARIOSTATIC AGENTS GENERIC Covered TIER 1 

PERIOGARD SOL 0.12% 



PERJETA INJ 420/14ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 

PERMETHRIN CRE 5% SCABICIDES AND PEDICULICIDES GENERIC Covered TIER 1 



319

PERPHEN/AMIT TAB 2‐10MG 















PERPHENAZINE TAB 16MG PHENOTHIAZINES GENERIC Covered TIER 1 




PERSANTINE TAB 25MG 









PERTZYE CAP DIGESTANTS BRAND Covered TIER 3 

PETROLATUM OIN WHITE 



PETROLATUM OIN YELLOW 



PEXEVA TAB 10MG 








320







PFIZERPEN‐G INJ 20MU NATURAL PENICILLINS Brand‐O PA TIER 3 

PFIZERPEN‐G INJ 5MU NATURAL PENICILLINS GENERIC Covered TIER 1 

PFLEX MIS DEVICES BRAND Excluded TIER 99 

PFT FILTER KIT 1000 DEVICES BRAND Excluded TIER 99 





PFT FILTER MIS 1000 DEVICES BRAND Excluded TIER 99 







PHARM SYRNG MIS TRAY 1ML DEVICES BRAND Excluded TIER 99 

PHARM TRAY MIS 12ML/LL DEVICES BRAND Excluded TIER 99 





PHARM TRAY MIS 6ML DEVICES BRAND Excluded TIER 99 

PHARMABASE CRE COSMETIC PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PHARMABASE CRE HEAVY PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PHENADOZ SUP 12.5MG PHENOTHIAZINE DERIVATIVES GENERIC Covered TIER 1 

PHENADOZ SUP 25MG PHENOTHIAZINE DERIVATIVES GENERIC Covered TIER 1 



321

PHENA‐PLUS TAB PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

PHENA‐S LIQ PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

PHENAZO TAB 200MG 



PHENAZOPYRID TAB 100MG 



PHENAZOPYRID TAB 200MG 



PHENAZOPYRID TAB PLUS 



PHENDIMETRAZ CAP 105MG ER 



PHENDIMETRAZ TAB 35MG 



PHENELZINE TAB 15MG MONOAMINE OXIDASE INHIBITORS GENERIC Covered TIER 1 

PHENER FORT SYP 25MG/5ML ANTIHISTAMINE DRUGS BRAND Covered TIER 3 

PHENERGAN INJ 25MG/ML PHENOTHIAZINE DERIVATIVES Brand‐O PA TIER 3 

PHENERGAN INJ 50MG/ML PHENOTHIAZINE DERIVATIVES Brand‐O PA TIER 3 

PHENFLU CD TAB ANTITUSSIVES BRAND Excluded TIER 99 

PHENFLU CDX TAB ANTITUSSIVES BRAND Excluded TIER 99 

PHENOBARB ELX 20MG/5ML 


SEDATIVE/HYP) GENERIC Covered TIER 1 

PHENOBARB INJ 130MG/ML 



PHENOBARB INJ 65MG/ML 



PHENOBARB SOL 20MG/5ML 





322

PHENOBARB TAB 100MG 


PHENOBARB TAB 16.2MG 






PHENOL CRY 

PHENOL LIQ 

PHENOL LIQ 89% 

PHENTERMINE CAP 15MG 

PHENTERMINE CAP 30MG 

PHENTERMINE CAP 37.5MG 

PHENTERMINE TAB 37.5MG 

































323

PHENTOL MESY INJ 5MG 



PHENTOLAMINE INJ MESYLATE 



PHENYLEPHRIN CRY ALPHA‐ADRENERGIC AGONISTS GENERIC Excluded TIER 99 

PHENYLEPHRIN INJ 10MG/ML ALPHA‐ADRENERGIC AGONISTS GENERIC Covered TIER 1 

PHENYLEPHRIN SOL 10% OP VASOCONSTRICTORS GENERIC Covered TIER 1 

PHENYLEPHRIN SOL 2.5% OP VASOCONSTRICTORS GENERIC Covered TIER 1 

PHENYTEK CAP 200MG HYDANTOINS Brand‐O PA TIER 3 

PHENYTEK CAP 300MG HYDANTOINS Brand‐O PA TIER 3 

PHENYTOIN INJ 50MG/ML HYDANTOINS GENERIC Covered TIER 1 SP 

PHENYTOIN SUS 125/5ML HYDANTOINS GENERIC Covered TIER 1 

PHENYTOIN EX CAP 100MG HYDANTOINS GENERIC Covered TIER 1 



PHILITH TAB 0.4‐35 CONTRACEPTIVES GENERIC Covered TIER 1 

PHISOHEX LIQ 3% 



PHOS‐FLUR GEL 1.1% CARIOSTATIC AGENTS GENERIC Covered TIER 1 

PHOSLO CAP 667MG REPLACEMENT PREPARATIONS Brand‐O PA TIER 2 

PHOSLYRA SOL REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

PHOSPHA 250 TAB NEUTRAL REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

PHOSPHASAL TAB URINARY ANTI‐INFECTIVES GENERIC Covered TIER 1 

PHOSPHOLINE SOL 0.125%OP MIOTICS BRAND Covered TIER 2 

PHOTOFRIN INJ 75MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

PHRENILIN CAP FORTE 



PHYSIOLYTE SOL IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

PHYSIOSOL SOL IRRIGAT IRRIGATING SOLUTIONS BRAND Covered TIER 3 




324

PHYSOS SALIC INJ 1MG/ML 



PHYTONADIONE INJ 1MG/0.5 VITAMIN K ACTIVITY GENERIC Covered TIER 1 

PICATO GEL 0.015% 



PICATO GEL 0.05% 



PILLOW MASK MIS ADULT DEVICES GENERIC Excluded TIER 99 

PILLOW MASK MIS CHILD DEVICES GENERIC Excluded TIER 99 

PILLOW MASK MIS PEDIATRI DEVICES GENERIC Excluded TIER 99 

PILOCARPINE SOL 1% OP MIOTICS GENERIC Covered TIER 1 



PILOCARPINE TAB 5MG 



PILOCARPINE TAB 7.5MG 



PILOPINE HS GEL 4% OP MIOTICS BRAND Covered TIER 2 

PINA COLADA LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

PINDOLOL TAB 10MG 



PINDOLOL TAB 5MG 



PINEAPPLE LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

PINNACAINE DRO 20% OTIC LOCAL ANESTHETICS (EENT) BRAND Covered TIER 3 

PIOGLITA/MET TAB 15‐500MG THIAZOLIDINEDIONES GENERIC Covered TIER 1 

PIOGLITA/MET TAB 15‐850MG THIAZOLIDINEDIONES GENERIC Covered TIER 1 

PIOGLITAZONE TAB 15MG THIAZOLIDINEDIONES GENERIC Covered TIER 1 





325

PIPER/TAZOBA INJ 2‐0.25GM EXTENDED‐SPECTRUM PENICILLINS GENERIC Covered TIER 1 

PIPER/TAZOBA INJ 3‐0.375G EXTENDED‐SPECTRUM PENICILLINS GENERIC Covered TIER 1 



PIPETTING MIS 10ML DEVICES BRAND Excluded TIER 99 




PIROXICAM CAP 10MG 



PIROXICAM CAP 20MG 



PITOCIN INJ 10UNT/ML OXYTOCICS Brand‐O PA TIER 3 

PITRESSIN INJ 20UNT/ML PITUITARY Brand‐O PA TIER 3 

PIZZA FLAVOR LIQ PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

PLACEBO #00 CAP PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

PLACENTA INJ COMPOSIT 



PLAN B TAB 0.75MG CONTRACEPTIVES Brand‐O PA TIER 3 

PLAN B TAB 1.5MG CONTRACEPTIVES Brand‐O PA TIER 3 

PLAQUENIL TAB 200MG ANTIMALARIALS Brand‐O PA TIER 3 

PLASBUMIN‐25 INJ 25% BLOOD DERIVATIVES GENERIC Covered TIER 1 

PLASBUMIN‐5 INJ 5% BLOOD DERIVATIVES GENERIC Covered TIER 1 

PLASMA‐LYTE INJ ‐148 REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

PLASMA‐LYTE INJ 56/D5W REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

PLASMA‐LYTE INJ ‐A REPLACEMENT PREPARATIONS BRAND Covered TIER 3 



326

PLASMANATE INJ 5% BLOOD DERIVATIVES BRAND Covered TIER 3 

PLAVIX TAB 300MG PLATELET‐AGGREGATION INHIBITORS Brand‐O PA TIER 3 

PLAVIX TAB 75MG PLATELET‐AGGREGATION INHIBITORS Brand‐O PA TIER 3 

PLEGISOL SOL REPLACEMENT PREPARATIONS Brand‐O PA TIER 3 

PLETAL TAB 100MG PLATELET‐AGGREGATION INHIBITORS Brand‐O PA TIER 3 

PLETAL TAB 50MG PLATELET‐AGGREGATION INHIBITORS Brand‐O PA TIER 3 

PLEXION CLNS EMU 10‐5% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

PLEXION CLTH MIS 10‐5% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

PLEXION SCT CRE 10‐5% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

PLO GEL MEDIFLO PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

PLO MEDIFLO KIT KIT PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PLO TRANSDER CRE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PLURONIC GEL F127 20% PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PLURONIC GEL F127 30% PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PLURONIC L64 LIQ CATHARTICS AND LAXATIVES BRAND Excluded TIER 99 

PNEUMODORON LIQ 



PNEUMOTHORX KIT TRAY 8FR LOCAL ANESTHETICS (PARENTERAL) BRAND Covered TIER 3 

PNEUMOVAX 23 INJ 25/0.5 VACCINES BRAND Covered TIER 3 


PNV OB+DHA PAK MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PNV‐DHA CAP MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

PNV‐DHA CAP DOCUSATE MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PNV‐OMEGA CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PNV‐SELECT TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 



327

PNV‐TOTAL CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

POCKET CHAMB MIS DEVICES GENERIC Excluded TIER 99 

POCKET SPACE MIS DEVICES GENERIC Excluded TIER 99 

PODOCON SOL 25% 



PODOFILOX SOL 0.5% 



POLIBAR SUS 100% ROENTGENOGRAPHY BRAND Covered TIER 3 

POLIBAR ACB KIT 96% ROENTGENOGRAPHY BRAND Covered TIER 3 

POLIBAR PLUS SUS 105% ROENTGENOGRAPHY BRAND Covered TIER 3 

POLOCAINE INJ 1% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

POLOCAINE INJ 2% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

POLOCAINE INJ ‐MPF 1% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

POLOCAINE INJ MPF 1.5% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

POLOCAINE INJ ‐MPF 2% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

POLY GLYCOL GRA 3350 CATHARTICS AND LAXATIVES GENERIC Excluded TIER 99 

POLY GLYCOL LIQ 1450 CATHARTICS AND LAXATIVES GENERIC Excluded TIER 99 

POLY HIST LIQ DHC ANTITUSSIVES BRAND Excluded TIER 99 

POLY HIST NC LIQ ANTITUSSIVES BRAND Excluded TIER 99 

POLY HIST PD LIQ PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

POLYCIN B OIN OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

POLYCITRA‐K POW CRYSTALS ALKALINIZING AGENTS Brand‐O PA TIER 3 

POLY‐DEX OIN 0.1% OP CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

POLYETH GLYC OIN 8000 CATHARTICS AND LAXATIVES GENERIC Excluded TIER 99 

POLYETH GLYC POW 3350 NF CATHARTICS AND LAXATIVES GENERIC Covered TIER 1 



328

POLYETHYLENE LIQ GLYCOL CATHARTICS AND LAXATIVES GENERIC Excluded TIER 99 

POLYFIN 24" MIS INFUSION DEVICES BRAND Covered TIER 3 

POLYFIN 42" MIS INFUSION DEVICES BRAND Covered TIER 3 

POLYFIN 42" MIS QR INFUS DEVICES BRAND Covered TIER 3 

POLYFIN 60" MIS TUBING DEVICES BRAND Covered TIER 3 

POLYGLYCOL MIS TROCHE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

POLY‐IRON CAP 150 FORT IRON PREPARATIONS GENERIC Covered TIER 1 

POLYMYXIN B INJ 500000 POLYMYXINS GENERIC Covered TIER 1 

POLYMYXIN B/ SOL TRIMETHP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

POLYPEG OIN BASE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

POLYPEG SUP MIS BASE 



POLY‐PRED SUS OP CORTICOSTEROIDS (EENT) BRAND Covered TIER 3 

POLYSACCHARI CAP IRON IRON PREPARATIONS GENERIC Covered TIER 1 

POLYTRIM SOL OP ANTIBACTERIALS (EENT) Brand‐O PA TIER 3 

POLY‐TUSSIN LIQ DHC ANTITUSSIVES BRAND Excluded TIER 99 

POLY‐TUSSIN SYP EX ANTITUSSIVES BRAND Excluded TIER 99 

POLY‐VI‐FLOR CHW 0.25MG MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

POLY‐VI‐FLOR CHW 0.5MG MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

POLY‐VI‐FLOR CHW 1MG MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

POLY‐VI‐FLOR CHW W/IRON MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

POLY‐VI‐FLOR SUS /IRON MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

POLY‐VI‐FLOR SUS 0.25/ML MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

POLY‐VIT/FE DRO /FL 0.25 MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

POLY‐VIT/FE DRO /FL 0.5 MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

POLYVIT/FL DRO 0.5MG/ML MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

POLY‐VIT/FL DRO 0.25MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

PONSTEL CAP 250MG 





329

PONTOCAINE INJ 1% LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 

PONTOCAINE INJ 20MG LOCAL ANESTHETICS (PARENTERAL) BRAND Covered TIER 3 

PONTOCAINE SOL 2% 



PORTIA‐28 TAB CONTRACEPTIVES GENERIC Covered TIER 1 

POT ACETATE INJ 2MEQ/ML REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

POT ACETATE INJ 4MEQ/ML REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

POT BICARBON GRA REPLACEMENT PREPARATIONS GENERIC Excluded TIER 99 

POT BICARBON TAB 25MEQ EF REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

POT CHLORIDE CAP 10MEQ ER REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

POT CHLORIDE CAP 8MEQ ER REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

POT CHLORIDE GRA REPLACEMENT PREPARATIONS GENERIC Excluded TIER 99 

POT CHLORIDE INJ 10MEQ REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 


POT CHLORIDE INJ 2MEQ/ML REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 



POT CHLORIDE LIQ 10% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

POT CHLORIDE LIQ 20% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

POT CHLORIDE LIQ 20% SF REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

POT CHLORIDE SOL 10% SF REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

POT CHLORIDE TAB 10MEQ CR REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

POT CHLORIDE TAB 10MEQ ER REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

POT CHLORIDE TAB 25MEQ EF REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

POT CHLORIDE TAB 8MEQ ER REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

POT CHLORIDE TAB 8MEQ SR REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

POT CITRATE GRA MONOHYDR REPLACEMENT PREPARATIONS GENERIC Excluded TIER 99 

POT CITRATE TAB 1080MG ALKALINIZING AGENTS GENERIC Covered TIER 1 



330

POT CITRATE TAB 540MG ALKALINIZING AGENTS GENERIC Covered TIER 1 

POT CL MICRO TAB 10MEQ CR REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

POT CL MICRO TAB 10MEQ ER REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

POT CL MICRO TAB 20MEQ ER REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

POT PERMANGT CRY PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

POT PHOSPHAT CRY MONOBASI REPLACEMENT PREPARATIONS GENERIC Excluded TIER 99 

POT PHOSPHAT GRA DIBASIC REPLACEMENT PREPARATIONS GENERIC Excluded TIER 99 

POT PHOSPHAT INJ 3MM/ML REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

POT/CHLORIDE TAB 25MEQ EF REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

POTABA CAP 500MG VITAMIN B COMPLEX BRAND Excluded TIER 99 

POTABA TAB 500MG VITAMIN B COMPLEX BRAND Excluded TIER 99 

POTASSIUM GRA SORBATE PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

POTASSIUM TAB 25MEQ EF REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

POTIGA TAB 200MG 












PR BENZOYL LIQ 7% WASH 



PR CREAM KIT 



PR NATAL 400 PAK MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

PR NATAL 400 PAK EC MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

PR NATAL 430 PAK MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

PR NATAL 430 PAK EC MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

PRACAMAC OIL BASE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 



331

PRACASIL TM‐ CRE PLUS PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

PRADAXA CAP 150MG DIRECT THROMBIN INHIBITORS BRAND PA TIER 2 QL 

PRADAXA CAP 75MG DIRECT THROMBIN INHIBITORS BRAND PA TIER 2 QL 

PRALIDOXIME INJ 600/2ML ANTIDOTES GENERIC Covered TIER 1 

PRALINES/CRM LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

PRAMCORT CRE 1‐1% 



PRAM‐HCA KIT 2.35‐1% 



PRAMIPEXOLE TAB 0.125MG 


RECEPTOR AGONIST GENERIC Covered TIER 1 













PRAMIPEXOLE TAB 1MG 



PRAMOSONE CRE 1% 



PRAMOSONE CRE 1‐2.5% 



PRAMOSONE LOT 1% 



PRAMOSONE LOT 2.5% 





332

PRAMOSONE OIN 1% 



PRAMOSONE OIN 2.5% 



PRAMOSONE E CRE 1‐2.5% 



PRAMOTIC DRO 1‐0.1% LOCAL ANESTHETICS (EENT) Brand‐O PA TIER 3 

PRAMOX GEL 1% 



PRAMOXINE‐HC DRO AQ OTIC CORTICOSTEROIDS (EENT) GENERIC Excluded TIER 99 

PRANDIMET TAB 1‐500MG MEGLITINIDES BRAND Covered TIER 3 

PRANDIMET TAB 2‐500MG MEGLITINIDES BRAND Covered TIER 3 

PRANDIN TAB 0.5MG MEGLITINIDES BRAND Covered TIER 2 

PRANDIN TAB 1MG MEGLITINIDES BRAND Covered TIER 2 

PRANDIN TAB 2MG MEGLITINIDES BRAND Covered TIER 2 

PRASCION EMU KERATOLYTIC AGENTS GENERIC Covered TIER 1 

PRASCION FC PAD 10‐5% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

PRASCION RA CRE 10‐5% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

PRAVACHOL TAB 10MG HMG‐COA REDUCTASE INHIBITORS Brand‐O PA TIER 3 




PRAVASTATIN TAB 10MG HMG‐COA REDUCTASE INHIBITORS GENERIC Covered TIER 1 




333



PRAZOLAMINE PAK 



PRAZOSIN HCL CAP 1MG 









PRECEDEX INJ 100MCG 



PRECOSE TAB 100MG ALPHA‐GLUCOSIDASE INHIBITORS Brand‐O PA TIER 3 



PRED FORTE SUS 1% OP CORTICOSTEROIDS (EENT) Brand‐O PA TIER 3 

PRED MILD SUS 0.12% OP CORTICOSTEROIDS (EENT) BRAND Covered TIER 2 

PRED SOD PHO SOL 1% OP CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

PRED SOD PHO SOL 5MG/5ML ADRENALS GENERIC Covered TIER 1 

PRED SOD PHO SOL 6.7/5ML ADRENALS GENERIC Covered TIER 1 

PRED‐G SUS OP CORTICOSTEROIDS (EENT) BRAND Covered TIER 3 

PRED‐G S.O.P OIN OP CORTICOSTEROIDS (EENT) BRAND Covered TIER 3 

PREDNICARBAT CRE 0.1% 



PREDNICARBAT OIN 0.1% 



PREDNISOLONE SOL 15MG/5ML ADRENALS GENERIC Covered TIER 1 

PREDNISOLONE SOL 25MG/5ML ADRENALS GENERIC Covered TIER 1 



334

PREDNISOLONE SUS 1% OP CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

PREDNISONE CON 5MG/ML ADRENALS BRAND Covered TIER 3 

PREDNISONE PAK 10MG ADRENALS GENERIC Covered TIER 1 

PREDNISONE PAK 5MG ADRENALS GENERIC Covered TIER 1 

PREDNISONE SOL 5MG/5ML ADRENALS GENERIC Covered TIER 1 

PREDNISONE TAB 10MG ADRENALS GENERIC Covered TIER 1 


PREDNISONE TAB 2.5MG ADRENALS GENERIC Covered TIER 1 




PREFERA OB MIS + DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 2 

PREFERA OB TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 2 

PREFERAOB CAP ONE MULTIVITAMIN PREPARATIONS BRAND Covered TIER 2 

PREFEST TAB ESTROGENS BRAND Covered TIER 3 

PRE‐FOLIC TAB 1‐100MG VITAMIN B COMPLEX BRAND Covered TIER 3 

PREGNYL INJ 10000UNT GONADOTROPINS GENERIC PA TIER 1 SP 

PRELONE SYP 15MG/5ML ADRENALS Brand‐O PA TIER 3 

PREMARIN INJ 25MG ESTROGENS BRAND Covered TIER 3 

PREMARIN TAB 0.3MG ESTROGENS BRAND Covered TIER 2 





PREMARIN VAG CRE 0.625MG ESTROGENS BRAND Covered TIER 3 

PREMASOL SOL 10% CALORIC AGENTS BRAND Covered TIER 3 

PREMASOL SOL 6% CALORIC AGENTS GENERIC Covered TIER 1 

PREMPHASE TAB ESTROGENS BRAND Covered TIER 2 

PREMPRO TAB .625‐2.5 ESTROGENS BRAND Covered TIER 2 

PREMPRO TAB 0.3‐1.5 ESTROGENS BRAND Covered TIER 2 



335

PREMPRO TAB 0.45‐1.5 ESTROGENS BRAND Covered TIER 2 

PREMPRO TAB 0.625‐5 ESTROGENS BRAND Covered TIER 2 

PRENA1 CAP QUATREFO MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PRENA1 CHW QUATREFO MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PRENA1 PLUS MIS QUATREFO MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PRENAFIRST TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

PRENAISSANCE CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PRENAISSANCE CAP BALANCE MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PRENAISSANCE CAP PLUS MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

PRENAISSANCE MIS HARMONY MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PRENAISSANCE TAB NEXT MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PRENAPLUS TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

PRENATA CHW 29‐1MG MULTIVITAMIN PREPARATIONS BRAND Covered TIER 2 

PRENATABS TAB OBN MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

PRENATABS FA TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

PRENATABS RX TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

PRENATAL TAB LOW IRON MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 


PRENATAL TAB PLUS MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 


PRENATAL TAB PLUS/FE MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

PRENATAL 19 CHW TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

PRENATAL 19 TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

PRENATAL AD TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

PRENATAL VIT TAB PLUS MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PRENATAL‐U CAP MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

PRENATE CAP ESSENTIL MULTIVITAMIN PREPARATIONS BRAND Covered TIER 2 

PRENATE TAB ELITE MULTIVITAMIN PREPARATIONS BRAND Covered TIER 2 

PRENATE DHA CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 2 

PRENATE ELIT TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 2 



336

PRENATE MINI CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PRENEXA CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PRENTIF MIS 22MM 












PRENTIF MIS FITTING 



PRE‐PEN INJ DRUG HYPERSENSITIVITY BRAND Covered TIER 3 

PREPIDIL GEL 0.5MG/3G OXYTOCICS BRAND Covered TIER 3 

PREPOPIK PAK CATHARTICS AND LAXATIVES BRAND Covered TIER 3 

PREQUE 10 TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PREVACID CAP 15MG DR PROTON‐PUMP INHIBITORS Brand‐O PA TIER 3 QL 

PREVACID CAP 30MG DR PROTON‐PUMP INHIBITORS Brand‐O PA TIER 3 QL 

PREVACID TAB 15MG STB PROTON‐PUMP INHIBITORS BRAND Covered TIER 3 QL 

PREVACID TAB 30MG STB PROTON‐PUMP INHIBITORS BRAND Covered TIER 3 QL 

PREVALITE POW 4GM BILE ACID SEQUESTRANTS GENERIC Covered TIER 1 

PREVALITE POW 4GM PK BILE ACID SEQUESTRANTS GENERIC Covered TIER 1 

PREVIDENT CRE 5000 PLS CARIOSTATIC AGENTS Brand‐O PA TIER 3 

PREVIDENT GEL 1.1% BER CARIOSTATIC AGENTS Brand‐O PA TIER 3 

PREVIDENT GEL 1.1% CHR CARIOSTATIC AGENTS Brand‐O PA TIER 3 

PREVIDENT GEL 1.1% MIN CARIOSTATIC AGENTS Brand‐O PA TIER 3 

PREVIDENT PST 1.1% CARIOSTATIC AGENTS Brand‐O PA TIER 3 

PREVIDENT PST 5000 BST CARIOSTATIC AGENTS Brand‐O PA TIER 3 

PREVIDENT PST 5000 SEN DENTAL AGENTS Brand‐O PA TIER 3 

PREVIDENT SOL RINSE CARIOSTATIC AGENTS Brand‐O PA TIER 3 



337

PREVIFEM TAB CONTRACEPTIVES GENERIC Covered TIER 1 

PREVNAR 13 INJ VACCINES BRAND Covered TIER 3 

PREVPAC MIS PROTON‐PUMP INHIBITORS BRAND Covered TIER 3 

PREZISTA TAB 150MG HIV PROTEASE INHIBITORS BRAND Covered TIER 2 




PRIALT INJ 100MCG 



PRIALT INJ 25MCG/ML 



PRIALT INJ 500MCG 



PRIFTIN TAB 150MG ANTITUBERCULOSIS AGENTS BRAND Covered TIER 3 

PRILOSEC CAP 10MG PROTON‐PUMP INHIBITORS Brand‐O PA TIER 3 QL 



PRILOSEC POW 10MG PROTON‐PUMP INHIBITORS BRAND Covered TIER 3 QL 

PRILOSEC POW 2.5MG PROTON‐PUMP INHIBITORS BRAND Covered TIER 3 QL 

PRIMABELLA MIS DEVICES BRAND Excluded TIER 99 

PRIMAQUINE TAB 26.3MG ANTIMALARIALS GENERIC Covered TIER 1 

PRIMAXIN IV INJ 250MG CARBAPENEMS Brand‐O PA TIER 3 

PRIMAXIN IV INJ 500MG CARBAPENEMS Brand‐O PA TIER 3 

PRIMEAIRE MIS CHAMBER DEVICES BRAND Excluded TIER 99 

PRIMIDONE TAB 250MG BARBITURATES (ANTICONVULSANTS) GENERIC Covered TIER 1 

PRIMIDONE TAB 50MG BARBITURATES (ANTICONVULSANTS) GENERIC Covered TIER 1 

PRIMLEV TAB 10‐300MG OPIATE AGONISTS BRAND Covered TIER 3 QL 

PRIMLEV TAB 5‐300MG OPIATE AGONISTS BRAND Covered TIER 3 QL 



338

PRIMLEV TAB 7.5‐300 OPIATE AGONISTS BRAND Covered TIER 3 QL 

PRIMSOL SOL 50MG/5ML URINARY ANTI‐INFECTIVES BRAND Covered TIER 3 

PRINIVIL TAB 10MG 









PRINZIDE TAB 10‐12.5 



PRINZIDE TAB 20‐12.5 



PRISMASOL SOL 0/0/1.2 REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

PRISMASOL SOL 0/2.5 REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

PRISMASOL SOL 2/0 REPLACEMENT PREPARATIONS BRAND Covered TIER 3 


PRISMASOL SOL 4/0/1.2 REPLACEMENT PREPARATIONS BRAND Covered TIER 3 


PRISMASOL SOL B22GK2/0 REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

PRISMASOL SOL B22GK4/0 REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

PRISTIQ TAB 100MG 



PRISTIQ TAB 50MG 



PRIVIGEN INJ 10GRAMS SERUMS BRAND PA TIER 2 SP 

PRIVIGEN INJ 20GRAMS SERUMS BRAND PA TIER 2 SP 

PRIVIGEN INJ 5 GRAMS SERUMS BRAND PA TIER 2 SP 


PROAIR HFA AER 


PROBARIMIN CHW QT CALORIC AGENTS BRAND Excluded TIER 99 



339

PROBEN/COLCH TAB 500‐0.5 URICOSURIC AGENTS GENERIC Covered TIER 1 

PROBENECID TAB 500MG URICOSURIC AGENTS GENERIC Covered TIER 1 

PROCAINAMIDE INJ 100MG/ML CLASS IA ANTIARRHYTHMICS GENERIC Covered TIER 1 

PROCAINAMIDE INJ 500MG/ML CLASS IA ANTIARRHYTHMICS GENERIC Covered TIER 1 

PROCAINE HCL CRY LOCAL ANESTHETICS (PARENTERAL) GENERIC Excluded TIER 99 

PROCALAMINE INJ 3% CALORIC AGENTS BRAND Covered TIER 3 

PROCARDIA CAP 10MG DIHYDROPYRIDINES Brand‐O PA TIER 3 

PROCARDIA XL TAB 30MG CR DIHYDROPYRIDINES Brand‐O PA TIER 3 



PROCENTRA SOL 5MG/5ML AMPHETAMINES BRAND Covered TIER 3 

PROCHLORPER INJ 5MG/ML PHENOTHIAZINES GENERIC Covered TIER 1 

PROCHLORPER SUP 25MG PHENOTHIAZINES GENERIC Covered TIER 1 

PROCHLORPER TAB 10MG PHENOTHIAZINES GENERIC Covered TIER 1 

PROCHLORPER TAB 5MG PHENOTHIAZINES GENERIC Covered TIER 1 

PRO‐CLEAR CAP 200‐9MG ANTITUSSIVES Brand‐O PA TIER 99 

PROCORT CRE 



PROCRIT INJ 10000/ML HEMATOPOIETIC AGENTS BRAND PA TIER 2 SP 






PROCTOCORT CRE 1% 



PROCTOCORT SUP 30MG 





340

PROCTOCREAM CRE HC 2.5% 



PROCTOFOAM AER HC 1% 



PROCTO‐PAK CRE 1% 



PROCTOSOL HC CRE 2.5% 



PROCTOZONE CRE ‐HC 2.5% 



PRODRIN TAB 



PROFERRIN‐ TAB FORTE IRON PREPARATIONS BRAND Covered TIER 3 

PROFILNINE INJ 1000UNIT HEMOSTATICS BRAND PA TIER 3 SP 



PROGESTERONE CAP 100MG PROGESTINS GENERIC Covered TIER 1 

PROGESTERONE CAP 200MG PROGESTINS GENERIC Covered TIER 1 

PROGESTERONE INJ 50MG/ML PROGESTINS GENERIC Covered TIER 1 

PROGESTERONE SUP VGS 100 PROGESTINS BRAND PA TIER 3 





PROGLYCEM SUS 50MG/ML DIRECT VASODILATORS BRAND Covered TIER 3 

PROGRAF CAP 0.5MG IMMUNOSUPPRESSIVE AGENTS Brand‐O PA TIER 3 

PROGRAF CAP 1MG IMMUNOSUPPRESSIVE AGENTS Brand‐O PA TIER 3 

PROGRAF CAP 5MG IMMUNOSUPPRESSIVE AGENTS Brand‐O PA TIER 3 

PROGRAF INJ 5MG/ML IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 3 SP 

PROHANCE INJ 279.3/ML DIAGNOSTIC AGENTS BRAND Excluded TIER 99 



341

PROHIST CD LIQ ANTITUSSIVES BRAND Excluded TIER 99 

PROHIST CF LIQ ANTITUSSIVES BRAND Excluded TIER 99 

PROHIST LQ LIQ PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

PROLASTIN INJ 1000MG 



PROLASTIN INJ 500MG 



PROLASTIN‐C INJ 1000MG 



PROLEUKIN INJ 22MU ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

PROLIA SOL 60MG/ML BONE RESORPTION INHIBITORS BRAND PA TIER 3 QL SP 

PROMACET TAB 50‐650MG 



PROMACTA TAB 12.5MG HEMATOPOIETIC AGENTS BRAND PA TIER 2 SP 

PROMACTA TAB 25MG HEMATOPOIETIC AGENTS BRAND PA TIER 2 SP 



PROMAR CAP IRON PREPARATIONS BRAND Covered TIER 3 

PROMETH VC SYP 6.25‐5/5 PHENOTHIAZINE DERIVATIVES GENERIC Covered TIER 1 

PROMETH VC SYP PLAIN PHENOTHIAZINE DERIVATIVES GENERIC Covered TIER 1 

PROMETH VC/ SYP CODEINE ANTITUSSIVES GENERIC Covered TIER 1 

PROMETH/COD SYP 6.25‐10 ANTITUSSIVES GENERIC Covered TIER 1 

PROMETHAZINE INJ 25MG/ML PHENOTHIAZINE DERIVATIVES GENERIC Covered TIER 1 

PROMETHAZINE INJ 50MG/ML PHENOTHIAZINE DERIVATIVES GENERIC Covered TIER 1 

PROMETHAZINE SOL 6.25/5ML PHENOTHIAZINE DERIVATIVES GENERIC Covered TIER 1 

PROMETHAZINE SUP 12.5MG PHENOTHIAZINE DERIVATIVES GENERIC Covered TIER 1 

PROMETHAZINE SUP 25MG PHENOTHIAZINE DERIVATIVES GENERIC Covered TIER 1 

PROMETHAZINE SYP 6.25/5ML PHENOTHIAZINE DERIVATIVES GENERIC Covered TIER 1 

PROMETHAZINE SYP DM ANTITUSSIVES GENERIC Covered TIER 1 

PROMETHAZINE TAB 12.5MG PHENOTHIAZINE DERIVATIVES GENERIC Covered TIER 1 



342

PROMETHAZINE TAB 25MG PHENOTHIAZINE DERIVATIVES GENERIC Covered TIER 1 

PROMETHAZINE TAB 50MG PHENOTHIAZINE DERIVATIVES GENERIC Covered TIER 1 

PROMETHEGAN SUP 12.5MG PHENOTHIAZINE DERIVATIVES GENERIC Covered TIER 1 

PROMETHEGAN SUP 25MG PHENOTHIAZINE DERIVATIVES GENERIC Covered TIER 1 

PROMETHEGAN SUP 50MG PHENOTHIAZINE DERIVATIVES GENERIC Covered TIER 1 

PROMETRIUM CAP 100MG PROGESTINS Brand‐O PA TIER 3 

PROMETRIUM CAP 200MG PROGESTINS Brand‐O PA TIER 3 

PROMISEB CRE KERATOLYTIC AGENTS BRAND Covered TIER 3 

PROMISEB KIT COMPLETE KERATOLYTIC AGENTS BRAND Covered TIER 3 

PRONEB ULTRA MIS II/LCD DEVICES BRAND Excluded TIER 99 

PRONEB ULTRA MIS II/PED DEVICES BRAND Excluded TIER 99 

PRONEB ULTRA MIS LC PLUS DEVICES BRAND Excluded TIER 99 

PRONEB ULTRA MIS LC SPRNT DEVICES BRAND Excluded TIER 99 

PRONEB ULTRA MIS LC STAR DEVICES BRAND Excluded TIER 99 

PROPAFENONE CAP 225MG ER CLASS IC ANTIARRHYTHMICS GENERIC Covered TIER 1 

PROPAFENONE CAP 325MG ER CLASS IC ANTIARRHYTHMICS GENERIC Covered TIER 1 

PROPAFENONE CAP 425MG SR CLASS IC ANTIARRHYTHMICS GENERIC Covered TIER 1 

PROPAFENONE TAB 150MG CLASS IC ANTIARRHYTHMICS GENERIC Covered TIER 1 



PROPANTHELIN TAB 15MG 



PROPARACAINE SOL 0.5% OP LOCAL ANESTHETICS (EENT) GENERIC Covered TIER 1 

PROPECIA TAB 1MG 



PROP‐FLUORE SOL 0.5‐0.25 OCULAR DISORDERS GENERIC Covered TIER 1 

PROPOFOL INJ 10MG/ML 



PROPOVEN INJ 10MG/ML 





343

PROPRAN/HCTZ TAB 40/25 



PROPRAN/HCTZ TAB 80/25 



PROPRANOLOL CAP 120MG ER 












PROPRANOLOL INJ 1MG/ML 



PROPRANOLOL SOL 20MG/5ML 



PROPRANOLOL SOL 40MG/5ML 



PROPRANOLOL TAB 10MG 















PROPYLENE GL SOL USP EENT DRUGS, MISCELLANEOUS GENERIC Excluded TIER 99 

PROPYLTHIOUR TAB 50MG ANTITHYROID AGENTS GENERIC Covered TIER 1 



344

PROQUAD INJ VACCINES BRAND Covered TIER 3 

PROSCAR TAB 5MG 5‐ALPHA‐REDUCTASE INHIBITORS Brand‐O PA TIER 3 QL 

PROSED/DS TAB URINARY ANTI‐INFECTIVES Brand‐O PA TIER 3 

PROSOL INJ 20% CALORIC AGENTS BRAND Covered TIER 3 

PROSTASCINT KIT 



PROSTIGMIN INJ 0.5MG/ML 



PROSTIGMIN TAB 15MG 



PROSTIN E2 SUP 20MG OXYTOCICS BRAND Covered TIER 3 

PROSTIN VR INJ 500MCG 



PROTAMINE SU SOL 10MG/ML ANTIHEPARIN AGENTS GENERIC Covered TIER 1 

PROTECT CAP CARDIO MULTIVITAMIN PREPARATIONS BRAND Excluded TIER 99 

PROTECT PLUS CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PROTECT PLUS CAP NR MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PROTECT PLUS LIQ MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PROTECTBONE WAF MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PROTECTIRON TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PROTECTNATAL TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PROTECTOR 14 MIS PHASEAL DEVICES BRAND Excluded TIER 99 




PROTEOLIN TAB CALORIC AGENTS BRAND Excluded TIER 99 

PROTID TAB CR PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

PROTONIX INJ 40MG PROTON‐PUMP INHIBITORS BRAND Covered TIER 3 

PROTONIX PAK PROTON‐PUMP INHIBITORS BRAND Covered TIER 3 QL 

PROTONIX TAB 20MG PROTON‐PUMP INHIBITORS Brand‐O PA TIER 3 QL 



345

PROTONIX TAB 40MG PROTON‐PUMP INHIBITORS Brand‐O PA TIER 3 QL 

PROTOPAM CHL INJ 1GM ANTIDOTES BRAND Covered TIER 3 

PROTOPIC OIN 0.03% 



PROTOPIC OIN 0.1% 



PROTRIPTYLIN TAB 10MG 



PROTRIPTYLIN TAB 5MG 



PROVENGE INJ CELLULAR THERAPY BRAND Covered TIER 3 

PROVENT MIS STARTER DEVICES BRAND Excluded TIER 99 

PROVENT HR MIS DEVICES BRAND Excluded TIER 99 

PROVENT SR MIS DEVICES BRAND Excluded TIER 99 

PROVENTIL AER HFA 



PROVERA TAB 10MG PROGESTINS Brand‐O PA TIER 3 QL 

PROVERA TAB 2.5MG PROGESTINS Brand‐O PA TIER 3 QL 

PROVERA TAB 5MG PROGESTINS Brand‐O PA TIER 3 QL 

PROVIGIL TAB 100MG 



PROVIGIL TAB 200MG 



PROVISC INJ 1% EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 3 

PROVOCHOLINE SOL 100MG DIAGNOSTIC AGENTS BRAND Excluded TIER 99 

PROZAC CAP 10MG 








346




PROZAC WEEKL CAP 90MG 



PRUCLAIR CRE 



PRUDOXIN CRE 5% 



PRUMYX CRE 



PRUTECT EMU 


AGENTS, MISC. GENERIC Excluded TIER 99 

PRVDNT 5000 PST ENAML PR DENTAL AGENTS Brand‐O PA TIER 3 

PRYFLEX TAB 



PSEUDOEPHEDR CRY HCL 


AGONISTS GENERIC Excluded TIER 99 

PSORINOHEEL DRO 



PSORINOHEEL LIQ 



PSORIZIDE TAB FORTE 



PSORIZIDE TAB ULTRA 



PUDEND/LOCAL KIT 1% LIDO LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

PUDEND/LOCAL KIT BLOCK DEVICES GENERIC Excluded TIER 99 

PULMARI‐GP LIQ 20‐100MG ANTITUSSIVES GENERIC Covered TIER 1 

PULMICORT INH 180MCG ADRENALS BRAND Covered TIER 2 QL 



347

PULMICORT INH 90MCG ADRENALS BRAND Covered TIER 2 QL 

PULMICORT SUS 0.25MG/2 ADRENALS Brand‐O PA TIER 3 QL 

PULMICORT SUS 0.5MG/2 ADRENALS Brand‐O PA TIER 3 QL 

PULMICORT SUS 1MG/2ML ADRENALS BRAND Covered TIER 2 QL 

PULMO‐AIDE MIS LT NEBUL DEVICES BRAND Excluded TIER 99 

PULMO‐AIDE MIS NEBULIZE DEVICES BRAND Excluded TIER 99 

PULMO‐AIDE MIS TRAVELER DEVICES BRAND Excluded TIER 99 

PULMOMATE/ MIS NEBULIZR DEVICES BRAND Excluded TIER 99 

PULMONA CAP CALORIC AGENTS BRAND Excluded TIER 99 

PULMOPHYLLIN PAK 



PULMOZYME SOL 1MG/ML MUCOLYTIC AGENTS BRAND Covered TIER 2 SP 

PULSATILLA INJ COMPOSIT 



PUMP SET MIS 100ML DEVICES BRAND Excluded TIER 99 

PUMP SET MIS 500ML DEVICES BRAND Excluded TIER 99 

PUMP SET EXT MIS TUBING DEVICES BRAND Excluded TIER 99 

PUMPKIN LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

PUREFE CAP PLUS IRON PREPARATIONS BRAND Covered TIER 3 

PUREFE OB CAP PLUS MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

PUREVIT DUAL CAP FE PLUS IRON PREPARATIONS GENERIC Covered TIER 1 

PURINETHOL TAB 50MG ANTINEOPLASTIC AGENTS Brand‐O PA TIER 3 

PYLERA CAP 

ANTIULCER AGENTS & ACID 

SUPPRESS., MISC BRAND Covered TIER 2 

PYRAZINAMIDE TAB 500MG ANTITUBERCULOSIS AGENTS GENERIC Covered TIER 1 

PYRIDIUM TAB 100MG 



PYRIDIUM TAB 200MG 





348

PYRIDOSTIGM TAB 60MG 



PYRIDOXINE INJ 100MG/ML VITAMIN B COMPLEX GENERIC Covered TIER 1 

PYRILAMINE CRY USP NF ETHYLENEDIAMINE DERIVATIVES GENERIC Excluded TIER 99 

PYROGALL ACD OIN KERATOLYTIC AGENTS GENERIC Covered TIER 1 

Q4 ORAL CLEA KIT SYSTEM DENTAL AGENTS BRAND Covered TIER 3 

QNAPRIL/HCTZ TAB 10‐12.5 



QNAPRIL/HCTZ TAB 20‐12.5 



QNAPRIL/HCTZ TAB 20‐25MG 



QNASL AER 80MCG CORTICOSTEROIDS (EENT) BRAND Covered TIER 3 

QSYMIA CAP 11.25‐69 


STIMULANTS,MISC BRAND Excluded TIER 99 

QSYMIA CAP 15‐92MG 



QSYMIA CAP 3.75‐23 



QSYMIA CAP 7.5‐46MG 



QUADRAMET INJ RADIOACTIVE AGENTS BRAND Covered TIER 3 

QUADRAPAX ELX 



QUAKE MIS DEVICES BRAND Excluded TIER 99 

QUALAQUIN CAP 324MG ANTIMALARIALS GENERIC Covered TIER 1 

QUAL‐TUSSIN DRO PED EXPECTORANTS GENERIC Excluded TIER 99 

QUASENSE TAB CONTRACEPTIVES GENERIC Covered TIER 1 

QUELICIN INJ ‐1000 





349

QUELICIN INJ 20MG/ML 



QUESTRAN POW 4GM BILE ACID SEQUESTRANTS Brand‐O PA TIER 3 

QUESTRAN POW 4GM LITE BILE ACID SEQUESTRANTS Brand‐O PA TIER 3 

QUETIAPINE TAB 100MG ATYPICAL ANTIPSYCHOTICS GENERIC Covered TIER 1 QL 






QUICK‐SET MIS 18"/6MM DEVICES BRAND Covered TIER 3 







QUINAPRIL TAB 10MG 












QUINIDINE GL INJ 80MG/ML CLASS IA ANTIARRHYTHMICS GENERIC Covered TIER 1 

QUINIDINE GL TAB 324MG CR CLASS IA ANTIARRHYTHMICS GENERIC Covered TIER 1 

QUINIDINE GL TAB 324MG ER CLASS IA ANTIARRHYTHMICS GENERIC Covered TIER 1 

QUINIDINE SU TAB 200MG CLASS IA ANTIARRHYTHMICS GENERIC Covered TIER 1 

QUINIDINE SU TAB 300MG CLASS IA ANTIARRHYTHMICS GENERIC Covered TIER 1 



350

QUINIDINE SU TAB 300MG ER CLASS IA ANTIARRHYTHMICS GENERIC Covered TIER 1 

QUININE SULF CAP 324MG ANTIMALARIALS GENERIC Covered TIER 1 

QUINZYME TAB 90MG 



QUIXIN SOL 0.5% ANTIBACTERIALS (EENT) Brand‐O PA TIER 3 

QUTENZA KIT 8% 1‐PCH 


AGENTS, MISC. BRAND PA TIER 3 QL 

QUTENZA KIT 8% 2‐PCH 


AGENTS, MISC. BRAND PA TIER 3 QL 

QV‐ALLERGY SYP PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

QVAR AER 40MCG ADRENALS BRAND Covered TIER 2 QL 

QVAR AER 80MCG ADRENALS BRAND Covered TIER 2 QL 

RA RENEWAL GEL 10% 



RABAVERT INJ VACCINES BRAND Covered TIER 3 

RADIAGEL GEL 



RADIAPLEXRX GEL 



RADIGEL GEL 



RAMIPRIL CAP 1.25MG 



RAMIPRIL CAP 10MG 



RAMIPRIL CAP 2.5MG 



RAMIPRIL CAP 5MG 





351

RANEXA TAB 1000MG CARDIAC DRUGS, MISCELLANEOUS BRAND PA TIER 2 

RANEXA TAB 500MG CARDIAC DRUGS, MISCELLANEOUS BRAND PA TIER 2 

RANITIDINE CAP 150MG HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

RANITIDINE CAP 300MG HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

RANITIDINE INJ 150/6ML HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

RANITIDINE INJ 25MG/ML HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

RANITIDINE INJ 50MG/2ML HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

RANITIDINE SYP 150/10ML HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

RANITIDINE SYP 15MG/ML HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

RANITIDINE SYP 75MG/5ML HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

RANITIDINE TAB 150MG HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

RANITIDINE TAB 300MG HISTAMINE H2‐ANTAGONISTS GENERIC Covered TIER 1 

RAPAFLO CAP 4MG 


BLOCK.AGENT BRAND Covered TIER 2 QL 

RAPAFLO CAP 8MG 


BLOCK.AGENT BRAND Covered TIER 2 QL 

RAPAMUNE SOL 1MG/ML IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 2 

RAPAMUNE TAB 0.5MG IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 2 

RAPAMUNE TAB 1MG IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 2 

RAPAMUNE TAB 2MG IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 2 

RAPID‐D INF MIS 24"/10MM DEVICES BRAND Covered TIER 3 










352


RAPPORT RLS KIT DEVICES BRAND Excluded TIER 99 

RAPPORT VTD KIT DEVICES BRAND Excluded TIER 99 

RASPBERRY CON FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

RASPBERRY SYP 



RAUWOLFIA LIQ COMPOSIT 



RAUWOLFIA SUB COMPOSIT 



RAYOS TAB 1MG ADRENALS BRAND Covered TIER 3 



RAZADYNE SOL 4MG/ML 



RAZADYNE TAB 12MG 









RAZADYNE ER CAP 16MG 









READI‐CAT SUS 1.3% ROENTGENOGRAPHY BRAND Covered TIER 3 

READI‐CAT 2 SUS 2.1% ROENTGENOGRAPHY BRAND Covered TIER 3 

READI‐CAT 2 SUS APPLE ROENTGENOGRAPHY BRAND Covered TIER 3 



353

READI‐CAT 2 SUS BANANA ROENTGENOGRAPHY BRAND Covered TIER 3 

READI‐CAT 2 SUS BERRY ROENTGENOGRAPHY BRAND Covered TIER 3 

READI‐CAT 2 SUS MOCHACCI ROENTGENOGRAPHY BRAND Covered TIER 3 

READI‐CAT 2 SUS VANILLA ROENTGENOGRAPHY BRAND Covered TIER 3 

REAL‐TIME KIT DEVICES BRAND Covered TIER 3 

REAPHIRM CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

REBETOL CAP 200MG NUCLEOSIDES AND NUCLEOTIDES Brand‐O PA TIER 3 SP 

REBETOL SOL 40MG/ML NUCLEOSIDES AND NUCLEOTIDES BRAND Covered TIER 3 SP 

REBIF INJ 22/0.5 BIOLOGIC RESPONSE MODIFIERS BRAND Covered TIER 2 SP 

REBIF INJ 44/0.5 BIOLOGIC RESPONSE MODIFIERS BRAND Covered TIER 2 SP 

REBIF TITRTN SOL PACK BIOLOGIC RESPONSE MODIFIERS BRAND Covered TIER 2 SP 

RECLIPSEN TAB CONTRACEPTIVES GENERIC Covered TIER 1 

RECOMBINATE INJ HEMOSTATICS BRAND PA TIER 2 SP 

RECOMBINATE INJ 220‐400 HEMOSTATICS BRAND PA TIER 2 SP 



RECOMBIVA HB INJ 10MCG/ML VACCINES BRAND Covered TIER 3 

RECOMBIVA HB INJ 5MCG/0.5 VACCINES BRAND Covered TIER 3 

RECOMBIVA‐HB INJ 40MCG/ML VACCINES BRAND Covered TIER 3 

RECOTHROM SOL 20000UNT HEMOSTATICS BRAND Covered TIER 3 

RECOTHROM SOL 5000UNIT HEMOSTATICS BRAND Covered TIER 3 

RECTACORT‐HC SUP 25MG 



RECTIV OIN 0.4% 



REDICHEW CHW RX MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

REFACTO INJ 500UNIT HEMOSTATICS BRAND PA TIER 2 SP 

REFISSA CRE 0.05% 


PROLIFERANTS BRAND Excluded TIER 99 

REFLUDAN INJ 50MG DIRECT THROMBIN INHIBITORS BRAND Covered TIER 3 



354

REGENECARE GEL 



REGIMEX TAB 25MG AMPHETAMINES BRAND Excluded TIER 99 

REGLAN INJ 5MG/ML PROKINETIC AGENTS Brand‐O PA TIER 3 

REGLAN TAB 10MG PROKINETIC AGENTS Brand‐O PA TIER 3 

REGLAN TAB 5MG PROKINETIC AGENTS Brand‐O PA TIER 3 

REGONOL INJ 5MG/ML 




REGRANEX GEL 0.01% 



REJUVESOL SOL 



RELACON‐DM LIQ NR ANTITUSSIVES GENERIC Covered TIER 1 

RELAGARD GEL 



RELAGESIC LIQ 5‐160MG ETHANOLAMINE DERIVATIVES BRAND Covered TIER 3 

RELAGESIC TAB 50‐650MG ETHANOLAMINE DERIVATIVES BRAND Covered TIER 3 

RELAMINE TAB 



RELASIN DM LIQ ANTITUSSIVES GENERIC Covered TIER 1 

RELCOF CPM TAB 8‐2.5MG PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

RELCOF DN MIS PSE PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

RELCOF DN PE MIS PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

RELCOF PE TAB PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

RELCOF PSE TAB PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

RELENZA MIS DISKHALE NEURAMINIDASE INHIBITORS BRAND Covered TIER 2 QL 

RELERA TAB PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

RELHIST CHW PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

RELISTOR INJ 12/0.6ML GI DRUGS, MISCELLANEOUS BRAND PA TIER 2 QL 



355

RELISTOR INJ 8/0.4ML GI DRUGS, MISCELLANEOUS BRAND PA TIER 2 

RELISTOR KIT 12/0.6ML GI DRUGS, MISCELLANEOUS BRAND PA TIER 2 QL 

RELNATE DHA CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

RELPAX TAB 20MG SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 2 QL 

RELPAX TAB 40MG SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 2 QL 

REMERGENT HQ CRE 4% DEPIGMENTING AGENTS GENERIC Excluded TIER 99 

REMERON TAB 15MG ANTIDEPRESSANTS, MISCELLANEOUS Brand‐O PA TIER 3 QL 



REMERON SLTB TAB 15MG ANTIDEPRESSANTS, MISCELLANEOUS Brand‐O PA TIER 3 QL 



REMESENSE MIS DENTAL AGENTS BRAND Covered TIER 3 

REMEVEN CRE 50% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

REMICADE INJ 100MG 



REMODULIN INJ 10MG/ML 






REMODULIN INJ 2.5MG/ML 








356

RENACIDIN SOL IRR IRRIGATING SOLUTIONS BRAND Covered TIER 3 

RENAGEL TAB 400MG PHOSPHATE‐REMOVING AGENTS BRAND Covered TIER 3 

RENAGEL TAB 800MG PHOSPHATE‐REMOVING AGENTS BRAND Covered TIER 3 

RENAL CAP SOFTGEL MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

RENALPREN CAP MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

RENASTART POW CALORIC AGENTS BRAND Excluded TIER 99 

RENATABS MIS IRON IRON PREPARATIONS BRAND Covered TIER 3 

RENATABS TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

RENA‐VITE RX TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

RENAX TAB 2.5MG MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

RENAX 5.5 TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

RENEEL SUB 



RENO CAP MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

RENOVA CRE 0.02% 



RENOVA PUMP CRE 0.02% 



RENVELA PAK 0.8GM PHOSPHATE‐REMOVING AGENTS BRAND Covered TIER 3 

RENVELA PAK 2.4GM PHOSPHATE‐REMOVING AGENTS BRAND Covered TIER 3 

RENVELA TAB 800MG PHOSPHATE‐REMOVING AGENTS BRAND Covered TIER 2 

REOPRO INJ 2MG/ML PLATELET‐AGGREGATION INHIBITORS BRAND Covered TIER 3 


REPAN TAB 


REPLACEMENT MIS FILTER DEVICES GENERIC Excluded TIER 99 

REPREXAIN TAB 10‐200MG OPIATE AGONISTS GENERIC Covered TIER 1 

REPREXAIN TAB 2.5‐200 OPIATE AGONISTS BRAND Covered TIER 3 

REPREXAIN TAB 5‐200MG OPIATE AGONISTS Brand‐O PA TIER 3 

REPRONEX INJ 75UNIT GONADOTROPINS BRAND PA TIER 2 SP 



357

REQ 49+ TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

REQUIP TAB 0.25MG 



REQUIP TAB 0.5MG 



REQUIP TAB 1MG 















REQUIP XL TAB 12MG 


RECEPTOR AGONIST Brand‐O PA TIER 3 QL 













RESCON TAB PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

RESCON‐JR TAB PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 


RESCON‐MX TAB PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 



358

RESCRIPTOR TAB 100 MG 

NONNUCLEOSIDE 


RESCRIPTOR TAB 200MG 

NONNUCLEOSIDE 


RESECTISOL SOL 5% IRRIGATING SOLUTIONS BRAND Covered TIER 3 

RESERPINE TAB 0.1MG 

PERIPHERAL ADRENERGIC 


RESERPINE TAB 0.25MG 

PERIPHERAL ADRENERGIC 


RESERVIOR MIS 3ML DEVICES GENERIC Covered TIER 1 

RESPA‐A.R. TAB PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

RESPA‐BR TAB 11MG PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

RESPERAL‐DM DRO 12‐1‐5MG ANTITUSSIVES GENERIC Covered TIER 1 

RESPERATE KIT 1.0 DEVICES BRAND Excluded TIER 99 

RESPERATE KIT 1.1 DEVICES BRAND Excluded TIER 99 

RESPIVENT MIS DF 30 PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

RESPIVENT DF MIS PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

RESPIVENT‐D TAB 



RESTASIS EMU 0.05% 

EENT ANTI‐INFLAMMATORY AGENTS, 


RESTORE SILV PAD 2"X2" 






RESTORE SILV PAD 4"X4.75" 








359




RESTORIL CAP 15MG 



RESTORIL CAP 22.5MG 



RESTORIL CAP 30MG 



RESTORIL CAP 7.5MG 



RETAVASE INJ THROMBOLYTIC AGENTS BRAND Covered TIER 3 

RETAVASE INJ HALF‐KIT THROMBOLYTIC AGENTS BRAND Covered TIER 3 

RETIN‐A CRE 0.025% 


PROLIFERANTS Brand‐O PA TIER 3 







RETIN‐A GEL 0.01% 



RETIN‐A GEL 0.025% 



RETIN‐A MICR GEL 0.04% 



RETIN‐A MICR GEL 0.04%PMP 



RETIN‐A MICR GEL 0.1% 



RETIN‐A MICR GEL 0.1%PUMP 





360

RETISERT IMP 0.59MG CORTICOSTEROIDS (EENT) BRAND Covered TIER 2 

RETROVIR CAP 100MG 



RETROVIR INJ 10MG/ML 



RETROVIR SYP 50MG/5ML 



RETROVIR TAB 300MG 



REVATIO INJ 



REVATIO TAB 20MG 



REVIA TAB 50MG OPIATE ANTAGONISTS Brand‐O PA TIER 3 

REVINA OIN 



REVLIMID CAP 10MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 QL SP 


REVLIMID CAP 2.5MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 



REVONTO INJ 20MG 



REYATAZ CAP 100MG HIV PROTEASE INHIBITORS BRAND Covered TIER 2 




REZIRA SOL 60‐5/5ML ANTITUSSIVES BRAND Excluded TIER 99 

REZYST CHW 250MG ANTIDIARRHEA AGENTS BRAND Covered TIER 3 

REZYST IM CHW ANTIDIARRHEA AGENTS BRAND Covered TIER 3 



361

R‐GENE 10 INJ 10% PITUITARY FUNCTION BRAND Covered TIER 3 

RHEUMADORON LIQ 102A 



RHEUMATREX TAB 2.5MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 

RHINOCORT SUS AQUA CORTICOSTEROIDS (EENT) BRAND Covered TIER 2 

RHINOFLEX TAB 50‐500MG ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1 

RHINOFLEX TAB 50‐650MG ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1 

RHOGAM PLUS INJ 300MCG SERUMS BRAND Covered TIER 3 SP 

RHOPHYLAC INJ 1500/2ML SERUMS BRAND Covered TIER 3 SP 

RIASTAP SOL 1GM HEMOSTATICS BRAND Covered TIER 3 SP 

RIBAPAK MIS 600/DAY NUCLEOSIDES AND NUCLEOTIDES BRAND PA TIER 2 SP 

RIBAPAK PAK 1000/DAY NUCLEOSIDES AND NUCLEOTIDES BRAND PA TIER 3 SP 

RIBAPAK PAK 1200/DAY NUCLEOSIDES AND NUCLEOTIDES GENERIC PA TIER 1 SP 

RIBAPAK PAK 800/DAY NUCLEOSIDES AND NUCLEOTIDES GENERIC PA TIER 1 SP 

RIBASPHERE CAP 200MG NUCLEOSIDES AND NUCLEOTIDES GENERIC Covered TIER 1 SP 

RIBASPHERE TAB 200MG NUCLEOSIDES AND NUCLEOTIDES GENERIC Covered TIER 1 SP 

RIBASPHERE TAB 400MG NUCLEOSIDES AND NUCLEOTIDES GENERIC PA TIER 1 SP 

RIBASPHERE TAB 600MG NUCLEOSIDES AND NUCLEOTIDES GENERIC PA TIER 1 SP 

RIBATAB PAK 1000/DAY NUCLEOSIDES AND NUCLEOTIDES GENERIC PA TIER 1 SP 

RIBATAB TAB 1200/DAY NUCLEOSIDES AND NUCLEOTIDES GENERIC PA TIER 1 SP 

RIBATAB TAB 800/DAY NUCLEOSIDES AND NUCLEOTIDES GENERIC PA TIER 1 SP 

RIBAVIRIN CAP 200MG NUCLEOSIDES AND NUCLEOTIDES GENERIC Covered TIER 1 SP 

RIBAVIRIN TAB 200MG NUCLEOSIDES AND NUCLEOTIDES GENERIC Covered TIER 1 SP 

RIDAURA CAP 3MG GOLD COMPOUNDS BRAND Covered TIER 2 

RIFADIN CAP 150MG ANTITUBERCULOSIS AGENTS Brand‐O PA TIER 3 

RIFADIN CAP 300MG ANTITUBERCULOSIS AGENTS Brand‐O PA TIER 3 

RIFADIN INJ 600 MG ANTITUBERCULOSIS AGENTS Brand‐O PA TIER 3 

RIFAMATE CAP ANTITUBERCULOSIS AGENTS Brand‐O PA TIER 3 

RIFAMPIN CAP 150MG ANTITUBERCULOSIS AGENTS GENERIC Covered TIER 1 

RIFAMPIN CAP 300MG ANTITUBERCULOSIS AGENTS GENERIC Covered TIER 1 



362

RIFAMPIN INJ 600 MG ANTITUBERCULOSIS AGENTS GENERIC Covered TIER 1 

RIFATER TAB ANTITUBERCULOSIS AGENTS BRAND Covered TIER 3 

RILUTEK TAB 50MG 



RIMANTADINE TAB 100MG ADAMANTANES GENERIC Covered TIER 1 

RIMANTALIST PAK ADAMANTANES BRAND Covered TIER 3 SP 

RIMSO‐50 SOL 50% 



RINATE SUS PEDI PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

RINGERS INJ REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

RINGERS IRR SOL IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

RINNOVI NAIL KIT SYSTEM KERATOLYTIC AGENTS BRAND Covered TIER 3 

RIOMET SOL BIGUANIDES BRAND Covered TIER 2 

RISPERDAL INJ 12.5MG ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 3 QL 

RISPERDAL INJ 25MG ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 3 QL 

RISPERDAL INJ 37.5MG ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 3 QL 

RISPERDAL INJ 50MG ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 3 QL 

RISPERDAL SOL 1MG/ML ATYPICAL ANTIPSYCHOTICS Brand‐O PA TIER 3 QL 

RISPERDAL TAB 0.25MG ATYPICAL ANTIPSYCHOTICS Brand‐O PA TIER 3 QL 

RISPERDAL TAB 0.5MG ATYPICAL ANTIPSYCHOTICS Brand‐O PA TIER 3 QL 

RISPERDAL TAB 1MG ATYPICAL ANTIPSYCHOTICS Brand‐O PA TIER 3 QL 




RISPERDAL M TAB 0.5MG ATYPICAL ANTIPSYCHOTICS Brand‐O PA TIER 3 QL 

RISPERDAL M TAB 1MG ATYPICAL ANTIPSYCHOTICS Brand‐O PA TIER 3 QL 




RISPERIDONE SOL 1MG/ML ATYPICAL ANTIPSYCHOTICS GENERIC Covered TIER 1 QL 



363

RISPERIDONE TAB 0.25 ODT ATYPICAL ANTIPSYCHOTICS GENERIC Covered TIER 1 

RISPERIDONE TAB 0.25MG ATYPICAL ANTIPSYCHOTICS GENERIC Covered TIER 1 QL 

RISPERIDONE TAB 0.5MG ATYPICAL ANTIPSYCHOTICS GENERIC Covered TIER 1 QL 

RISPERIDONE TAB 0.5MG OD ATYPICAL ANTIPSYCHOTICS GENERIC Covered TIER 1 QL 

RISPERIDONE TAB 1MG ATYPICAL ANTIPSYCHOTICS GENERIC Covered TIER 1 QL 

RISPERIDONE TAB 1MG ODT ATYPICAL ANTIPSYCHOTICS GENERIC Covered TIER 1 QL 







RITALIN TAB 10MG 






RITALIN TAB 20MG SR 






RITALIN LA CAP 10MG 












RITEFLO MIS DEVICES BRAND Excluded TIER 99 

RITUXAN INJ 100MG ANTINEOPLASTIC AGENTS BRAND PA TIER 2 SP 



364

RITUXAN INJ 500MG ANTINEOPLASTIC AGENTS BRAND PA TIER 2 SP 

RIVASTIGMINE CAP 1.5MG 



RIVASTIGMINE CAP 3MG 



RIVASTIGMINE CAP 4.5MG 



RIVASTIGMINE CAP 6MG 



ROBAFEN AC SYP 100‐10/5 ANTITUSSIVES GENERIC Covered TIER 1 

ROBAXIN INJ 100MG/ML 



ROBAXIN TAB 500MG 



ROBAXIN‐750 TAB 750MG 



ROBINUL INJ 0.2MG/ML 



ROBINUL TAB 1MG 



ROBINUL FORT TAB 2MG 



ROCALTROL CAP 0.25MCG VITAMIN D Brand‐O PA TIER 3 

ROCALTROL CAP 0.5MCG VITAMIN D Brand‐O PA TIER 3 

ROCALTROL SOL 1MCG/ML VITAMIN D Brand‐O PA TIER 3 

ROCEPHIN INJ 1GM 



ROCEPHIN INJ 500MG 





365

ROCURONIUM INJ 100MG/10 



ROCURONIUM INJ 10MG/ML 



ROCURONIUM INJ 50MG/5ML 



ROMAZICON INJ 0.1MG/ML 



ROMILAR AC SOL 100‐10/5 ANTITUSSIVES GENERIC Covered TIER 1 

ROMYCIN OIN OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

ROPINIROLE TAB 0.25MG 



ROPINIROLE TAB 0.5MG 



ROPINIROLE TAB 12MG ER 


RECEPTOR AGONIST GENERIC Covered TIER 1 QL 

ROPINIROLE TAB 1MG 























366







ROSADAN CRE 0.75% 



ROSADAN GEL 0.75% 



ROSADAN KIT 0.75% 



ROSANIL EMU CLEANSER KERATOLYTIC AGENTS GENERIC Covered TIER 1 

ROSANIL KIT KERATOLYTIC AGENTS BRAND Covered TIER 3 

ROSE GLO TES 1.5MG OCULAR DISORDERS BRAND Covered TIER 3 

ROSENTHAL MIS DEVICES BRAND Excluded TIER 99 

ROTARIX SUS VACCINES BRAND Covered TIER 3 

ROTATEQ SUS VACCINES BRAND Covered TIER 3 

ROWASA KIT 4GM 


DRUGS) Brand‐O PA TIER 3 

ROXICET SOL 5‐325/5 OPIATE AGONISTS BRAND Covered TIER 3 

ROXICET TAB 5‐325MG OPIATE AGONISTS GENERIC Covered TIER 1 QL 

ROXICET TAB 5‐500MG OPIATE AGONISTS BRAND Covered TIER 3 QL 

ROXICODONE TAB 15MG OPIATE AGONISTS Brand‐O PA TIER 3 



ROZEREM TAB 8MG 



RT ANG CATH MIS 16FR/20" DEVICES BRAND Excluded TIER 99 






367




R‐TANNA SUS PEDI PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

R‐TANNA TAB 9‐25MG PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

RU‐HIST TAB FORTE PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

RU‐TUSS TAB PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

RU‐TUSS DM SYP ANTITUSSIVES BRAND Excluded TIER 99 


RYBIX ODT TAB 50MG OPIATE AGONISTS BRAND Covered TIER 3 

RYNA‐12 TAB 60‐25MG ETHYLENEDIAMINE DERIVATIVES BRAND Excluded TIER 99 

RYNA‐12X TAB EXPECTORANTS BRAND Excluded TIER 99 

RYNATAN TAB 9‐25MG PROPYLAMINE DERIVATIVES Brand‐O PA TIER 99 

RYNATAN PED SUS PROPYLAMINE DERIVATIVES Brand‐O PA TIER 99 

RYNATAN PEDI CHW 4.5‐5MG PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

RYNATUSS TAB ANTITUSSIVES BRAND Excluded TIER 99 

RYNEZE LIQ PROPYLAMINE DERIVATIVES BRAND Covered TIER 3 

RYTHMOL TAB 150MG CLASS IC ANTIARRHYTHMICS Brand‐O PA TIER 3 

RYTHMOL TAB 225MG CLASS IC ANTIARRHYTHMICS Brand‐O PA TIER 3 

RYTHMOL SR CAP 225MG CLASS IC ANTIARRHYTHMICS Brand‐O PA TIER 3 



RYZOLT TAB 100MG OPIATE AGONISTS Brand‐O PA TIER 3 



SABRIL POW 500MG 



SABRIL TAB 500MG 



SAFETY PEG MIS KIT 16FR DEVICES BRAND Excluded TIER 99 



368

SAFETY PEG MIS KIT 20FR DEVICES BRAND Excluded TIER 99 

SAFETYGLIDE MIS 21GX1.5" DEVICES BRAND Excluded TIER 99 

SAFTY NEEDLE MIS 18GX1" DEVICES BRAND Excluded TIER 99 

SAFTY NEEDLE MIS 18GX1.5" DEVICES BRAND Excluded TIER 99 







SAFTY NEEDLE MIS 21GX5/8" DEVICES BRAND Excluded TIER 99 







SAFYRAL TAB CONTRACEPTIVES BRAND Covered TIER 2 

SAIZEN INJ 5MG SOMATOTROPIN AGONISTS BRAND PA TIER 3 SP 

SAIZEN INJ 8.8MG SOMATOTROPIN AGONISTS BRAND PA TIER 3 SP 

SALACYN CRE 6% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SALACYN LOT 6% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SALAGEN TAB 5MG 



SALAGEN TAB 7.5MG 



SALEM SUMP MIS 10FR DEVICES BRAND Excluded TIER 99 






369


SALEX SHA 6% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

SALEX CREAM KIT 6% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

SALEX LOTION KIT 6% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

SALICEPT SOL 



SALICEPT SUS 



SALICYLIC AER 6% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SALICYLIC CRY ACID KERATOLYTIC AGENTS GENERIC Excluded TIER 99 

SALICYLIC AC AER 6% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SALICYLIC AC CRE 6% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SALICYLIC AC GEL 6% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SALICYLIC AC KIT 6% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SALICYLIC AC KIT 6% CREAM KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SALICYLIC AC KIT 6% LOTN KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SALICYLIC AC LIQ 26% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SALICYLIC AC LIQ 27.5% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SALICYLIC AC LOT 6% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SALICYLIC AC SHA 6% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SALINE FLUSH INJ 0.9% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

SALINE/PHENO SOL REPLACEMENT PREPARATIONS GENERIC Excluded TIER 99 

SALKERA AER 6% KERATOLYTIC AGENTS BRAND Covered TIER 3 

SALSALATE TAB 500MG SALICYLATES GENERIC Covered TIER 1 

SALSALATE TAB 750MG SALICYLATES GENERIC Covered TIER 1 

SALT STABLE CRE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

SAL‐TROPINE TAB 0.4MG 



SALVAX AER 6% KERATOLYTIC AGENTS Brand‐O PA TIER 3 




370

SALVAX DUO KIT PLUS KERATOLYTIC AGENTS BRAND Covered TIER 3 

SAMSCA TAB 15MG VASOPRESSIN ANTAGONISTS BRAND PA TIER 2 QL 

SAMSCA TAB 30MG VASOPRESSIN ANTAGONISTS BRAND PA TIER 2 QL 

SANCTURA TAB 20MG 



SANCTURA XR CAP 60MG 



SANCUSO DIS 3.1MG 5‐HT3 RECEPTOR ANTAGONISTS BRAND Covered TIER 2 QL 

SANDIMMUNE CAP 100MG IMMUNOSUPPRESSIVE AGENTS Brand‐O PA TIER 2 

SANDIMMUNE CAP 25MG IMMUNOSUPPRESSIVE AGENTS Brand‐O PA TIER 2 

SANDIMMUNE INJ 50MG/ML IMMUNOSUPPRESSIVE AGENTS Brand‐O PA TIER 3 

SANDIMMUNE SOL 100MG/ML IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 2 

SANDOSTATIN INJ 1000MCG 












SANDOSTATIN INJ 50MCG/ML 



SANDOSTATIN KIT LAR 10MG 









SANTYL OIN 250/GM 





371

SAPHRIS SUB 10MG ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 3 QL 

SAPHRIS SUB 5MG ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 3 QL 

SARAFEM TAB 10MG 



SARAFEM TAB 20MG 



SARAPIN INJ 



SARSAPARILLA LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

SASH KIT 100/ML HEPARINS GENERIC Covered TIER 1 

SASH KIT 10UNT/ML HEPARINS GENERIC Covered TIER 1 

SAVELLA MIS TITR PAK FIBROMYALGIA AGENTS BRAND Covered TIER 3 QL 

SAVELLA TAB 100MG FIBROMYALGIA AGENTS BRAND Covered TIER 2 QL 

SAVELLA TAB 12.5MG FIBROMYALGIA AGENTS BRAND Covered TIER 2 QL 



SCALACORT LOT 2% 



SCALACORT DK KIT 



SCALPEL/BLAD MIS SIZE 12 DEVICES GENERIC Excluded TIER 99 

SCALPEL/BLAD MIS SIZE 12B DEVICES GENERIC Excluded TIER 99 




SCALPEL/BLAD MIS SIZE 25T DEVICES GENERIC Excluded TIER 99 

SCLEROMATE INJ 5% SCLEROSING AGENTS GENERIC Covered TIER 1 

SCLEROSOL AER INTRAPLE SCLEROSING AGENTS BRAND Covered TIER 3 

SCOPACE TAB 0.4MG ANTIEMETICS, MISCELLANEOUS BRAND Covered TIER 3 



372

SCOPOLAMINE INJ 0.4MG/ML 



SE 10‐5 SS CRE 10‐5% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SE BPO 7‐5.5 KIT WASH KIT 



SE BPO CLOTH MIS 3% 









SE BPO WASH LIQ 7% 



SEASONALE TAB CONTRACEPTIVES Brand‐O PA TIER 3 

SEASONIQUE TAB CONTRACEPTIVES Brand‐O PA TIER 3 

SEB‐PREV LIQ WASH 



SEB‐PREV LOT 10% 



SE‐CARE CHW MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

SE‐CARE TAB CONCEIVE MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

SECONAL CAP 100MG 



SECONDARY MIS SET/DRIP DEVICES BRAND Excluded TIER 99 

SECREFLO INJ 16MCG PANCREATIC FUNCTION BRAND Covered TIER 3 

SECTRAL CAP 200MG 



SECTRAL CAP 400MG 





373

SEDAPAP TAB 50‐650MG 



SE‐DONNA ELX PB HYOS 



SELECT‐OB CHW MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

SELECT‐OB+ PAK DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

SELEGILINE CAP 5MG MONOAMINE OXIDASE B INHIBITORS GENERIC Covered TIER 1 

SELEGILINE TAB 5MG MONOAMINE OXIDASE B INHIBITORS GENERIC Covered TIER 1 

SELENIUM INJ 40MCG/ML REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

SELENIUM SUL LOT 2.5% 



SELENIUM SUL SHA 2.25% 



SELENIUM SUL SHA 2.5% 



SELSUN SHA 2.5% 



SELZENTRY TAB 150MG HIV ENTRY AND FUSION INHIBITORS BRAND PA TIER 2 

SELZENTRY TAB 300MG HIV ENTRY AND FUSION INHIBITORS BRAND PA TIER 2 

SEMPREX‐D CAP 8‐60MG 


ANTIHISTAMINES BRAND Excluded TIER 99 

SE‐NATAL 19 CHW MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

SE‐NATAL 19 TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

SE‐NATAL 90 TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

SE‐NATAL ONE TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

SENETONIC LIQ MULTIVITAMIN PREPARATIONS Brand‐O PA TIER 3 



374

SENILEZOL ELX IRON PREPARATIONS GENERIC Covered TIER 1 

SENNA LEAVES MIS CATHARTICS AND LAXATIVES GENERIC Covered TIER 1 

SENOPHYLLINE PAK 



SENSIPAR TAB 30MG 









SENSORCAINE INJ 0.25% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

SENSORCAINE INJ 0.5% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

SENSORCAINE INJ MPF 0.5% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

SENSORCAINE INJ MPF SPIN LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

SENSORCAINE INJ ‐MPF/EPI LOCAL ANESTHETICS (PARENTERAL) BRAND Covered TIER 3 


SENSORCAINE INJ MPF0.25% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

SENSORCAINE INJ MPF0.75% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

SENSORCAINE/ INJ EPI 0.25 LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

SENSORCAINE/ INJ EPI 0.5% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

SENTRA AM CAP CALORIC AGENTS BRAND Excluded TIER 99 



375

SENTRA PM CAP CALORIC AGENTS BRAND Excluded TIER 99 

SENTRADINE PAK HISTAMINE H2‐ANTAGONISTS BRAND Covered TIER 3 

SENTRAFLOX PAK AM‐10 



SENTRALOPRAM PAK AM‐10 



SENTRAMODAFI PAK AM‐100 


STIMULANTS,MISC BRAND Covered TIER 3 

SENTRAVIL PM PAK ‐25 


RU INHIB BRAND Covered TIER 3 

SENTRAZOLAM PAK AM 0.25 



SENTRAZOLPID PAK PM‐5 



SENTROXATINE PAK 



SEPINEO P600 LIQ PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

SE‐PLETE DHA CAP MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

SEPTRA DS TAB 800‐160 SULFONAMIDES (SYSTEMIC) Brand‐O PA TIER 3 

SERADEX LIQ ANTITUSSIVES Brand‐O PA TIER 99 

SEREVENT DIS AER 50MCG 



SEROMYCIN CAP 250MG ANTITUBERCULOSIS AGENTS BRAND Covered TIER 2 

SEROPHENE TAB 50MG ESTROGEN AGONIST‐ANTAGONISTS GENERIC PA TIER 1 SP 

SEROQUEL TAB 100MG ATYPICAL ANTIPSYCHOTICS Brand‐O PA TIER 3 QL 







376


SEROQUEL XR TAB 150MG ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 2 QL 





SEROSTIM INJ 4MG SOMATOTROPIN AGONISTS BRAND PA TIER 3 SP 



SERTRALINE CON 20MG/ML 




SERTRALINE TAB 100MG 








SE‐TAN DHA CAP MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

SE‐TAN PLUS CAP IRON PREPARATIONS GENERIC Covered TIER 1 

SETON ET‐EC PAK MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

SETONET PAK MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

SEVEN PLUS KIT STARTER DEVICES BRAND Covered TIER 3 

SEVEN PLUS MIS RECEIVER DEVICES BRAND Covered TIER 3 

SEVEN PLUS MIS TRANSMIT DEVICES BRAND Covered TIER 3 

SEVEN SYSTEM MIS SENSOR DEVICES BRAND Covered TIER 3 

SEVOFLURANE SOL INHALATION ANESTHETICS GENERIC Covered TIER 1 

SF GEL 1.1% CARIOSTATIC AGENTS GENERIC Covered TIER 1 

SF 5000 PLUS CRE 1.1% CARIOSTATIC AGENTS GENERIC Covered TIER 1 

SFROWASA ENE 4GM 





377

SHARPS CONT MIS 1.1QT DEVICES BRAND Excluded TIER 99 

SHARPS CONT MIS 4QT DEVICES BRAND Excluded TIER 99 

SHEA BUTTER MIS BASIC LOTIONS AND LINIMENTS GENERIC Excluded TIER 99 

SHEA BUTTER MIS ORGANIC BASIC LOTIONS AND LINIMENTS GENERIC Excluded TIER 99 

SHELLGEL SOL EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 3 

SHOHLS SOL MODIFIED ALKALINIZING AGENTS Brand‐O PA TIER 3 

SHRIMP LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

SIDEROL LIQ MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

SIDEROL TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

SIDESTREAM KIT NEBULIZE DEVICES BRAND Excluded TIER 99 

SIDESTREAM MIS MASK DEVICES BRAND Excluded TIER 99 

SIDESTREAM MIS NEBULIZR DEVICES BRAND Excluded TIER 99 

SIDESTREAM MIS PLUS DEVICES BRAND Excluded TIER 99 

SIL MEDIASTN MIS CATHETER DEVICES BRAND Excluded TIER 99 

SIL RT ANGLE MIS THOR CTH DEVICES BRAND Excluded TIER 99 

SIL STR THOR MIS CATHETER DEVICES BRAND Excluded TIER 99 

SILENOR TAB 3MG 


RU INHIB BRAND Covered TIER 2 QL 

SILENOR TAB 6MG 


RU INHIB BRAND Covered TIER 2 QL 

SILHOUETTE MIS 13MM DEVICES BRAND Covered TIER 3 

SILHOUETTE MIS 17MM DEVICES BRAND Covered TIER 3 

SILHOUETTE MIS 18"/13MM DEVICES BRAND Covered TIER 3 

SILHOUETTE MIS 23" SET DEVICES BRAND Covered TIER 3 

SILHOUETTE MIS 32"/17MM DEVICES BRAND Covered TIER 3 

SILHOUETTE MIS 43" SET DEVICES BRAND Covered TIER 3 

SILHOUETTE MIS COMBO DEVICES BRAND Covered TIER 3 

SILHOUETTE MIS FULL SET DEVICES BRAND Covered TIER 3 

SILICONE MSK MIS ADULT DEVICES GENERIC Excluded TIER 99 

SILICONE MSK MIS INFANT DEVICES GENERIC Excluded TIER 99 



378

SILICONE MSK MIS PED DEVICES GENERIC Excluded TIER 99 

SILVADENE CRE 1% 



SILVASORB GEL 



SILVER CRY NITRATE 



SILVER NITRA OIN 10% 



SILVER NITRA SOL 0.5% 



SILVER NITRA SOL 10% 









SILVER SULFA CRE 1% 



SILVRSTAT GEL DRESSING 



SIMCOR TAB 1000‐20 HMG‐COA REDUCTASE INHIBITORS BRAND Covered TIER 2 

SIMCOR TAB 1000‐40 HMG‐COA REDUCTASE INHIBITORS BRAND Covered TIER 2 

SIMCOR TAB 500‐20MG HMG‐COA REDUCTASE INHIBITORS BRAND Covered TIER 2 




379


SIMETYL ELX 



SIMPLE SYP PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

SIMPLGEL 30 GEL PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

SIMPONI INJ 50MG 



SIMUC‐GP TAB 25‐1200 EXPECTORANTS GENERIC Covered TIER 1 

SIMULECT INJ 10MG IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 3 SP 

SIMULECT INJ 20MG IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 3 SP 

SIMVASTATIN TAB 10MG HMG‐COA REDUCTASE INHIBITORS GENERIC Covered TIER 1 





SINA‐12X TAB 25‐200MG EXPECTORANTS BRAND Excluded TIER 99 

SINEMET TAB 10‐100MG DOPAMINE PRECURSORS Brand‐O PA TIER 3 



SINEMET CR TAB 25‐100MG DOPAMINE PRECURSORS Brand‐O PA TIER 3 

SINEMET CR TAB 50‐200MG DOPAMINE PRECURSORS Brand‐O PA TIER 3 

SINGULAIR CHW 4MG LEUKOTRIENE MODIFIERS Brand‐O PA TIER 3 

SINGULAIR CHW 5MG LEUKOTRIENE MODIFIERS Brand‐O PA TIER 3 

SINGULAIR GRA 4MG LEUKOTRIENE MODIFIERS Brand‐O PA TIER 3 



380

SINGULAIR TAB 10MG LEUKOTRIENE MODIFIERS Brand‐O PA TIER 3 

SINOGRAFIN INJ ROENTGENOGRAPHY BRAND Covered TIER 3 

SINUSTAR MIS NEBULIZE DEVICES BRAND Excluded TIER 99 

SINUSTAR MIS SYSTEM DEVICES BRAND Excluded TIER 99 

SITZMARKS CAP ROENTGENOGRAPHY BRAND Covered TIER 3 

SKELAXIN TAB 800MG 



SKELID TAB 200MG BONE RESORPTION INHIBITORS BRAND Covered TIER 3 

SKIN BLEACH CRE 4% DEPIGMENTING AGENTS GENERIC Excluded TIER 99 

SKIN BLEACH CRE SUNSCREE DEPIGMENTING AGENTS GENERIC Excluded TIER 99 

SKIN SCRUB KIT PACK 



SKIN SCRUB KIT PACK WET 



SKIN SCRUB KIT TRAY DRY DEVICES BRAND Covered TIER 3 

SKIN SCRUB KIT TRAY WET 



SKLICE LOT 0.5% ANTHELMINTICS BRAND Covered TIER 3 

SLEEVE COVER MIS UNIVERSA DEVICES GENERIC Excluded TIER 99 

SMARTIP SYR MIS /CANNULA DEVICES BRAND Excluded TIER 99 

SMZ/TMP DS TAB 800‐160 SULFONAMIDES (SYSTEMIC) GENERIC Covered TIER 1 

SMZ‐TMP INJ 400‐80/5 SULFONAMIDES (SYSTEMIC) GENERIC Covered TIER 1 

SMZ‐TMP SUS SULFONAMIDES (SYSTEMIC) GENERIC Covered TIER 1 

SMZ‐TMP SUS 200‐40/5 SULFONAMIDES (SYSTEMIC) GENERIC Covered TIER 1 

SMZ‐TMP TAB 400‐80MG SULFONAMIDES (SYSTEMIC) GENERIC Covered TIER 1 

SOD ACETATE CRY ANHYDR ALKALINIZING AGENTS GENERIC Excluded TIER 99 

SOD ACETATE INJ 2MEQ/ML ALKALINIZING AGENTS GENERIC Covered TIER 1 

SOD ACETATE INJ 4MEQ/ML ALKALINIZING AGENTS GENERIC Covered TIER 1 

SOD ASCORBAT GRA VITAMIN C GENERIC Excluded TIER 99 

SOD ASCORBAT GRA USP VITAMIN C GENERIC Excluded TIER 99 



381

SOD ASCORBAT GRA USP NF VITAMIN C GENERIC Excluded TIER 99 

SOD BICARB INJ 4.2% ALKALINIZING AGENTS GENERIC Covered TIER 1 



SOD CHLORIDE INJ 0.45% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 


SOD CHLORIDE INJ 0.9%BACT REPLACEMENT PREPARATIONS GENERIC Excluded TIER 99 

SOD CHLORIDE INJ 2.5/ML REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 


SOD CHLORIDE INJ 3% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

SOD CHLORIDE INJ 4MEQ/ML REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

SOD CHLORIDE INJ 5% REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

SOD CITRATE CRY PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

SOD DIURIL INJ 500MG THIAZIDE DIURETICS Brand‐O PA TIER 3 

SOD EDECRIN INJ 50MG LOOP DIURETICS BRAND Covered TIER 3 

SOD FLUORIDE CHW 0.25MG F CARIOSTATIC AGENTS GENERIC Covered TIER 1 

SOD FLUORIDE CHW 0.5MG F CARIOSTATIC AGENTS GENERIC Covered TIER 1 

SOD FLUORIDE CHW 1.1MG CARIOSTATIC AGENTS GENERIC Covered TIER 1 

SOD FLUORIDE CHW 1MG F CARIOSTATIC AGENTS GENERIC Covered TIER 1 

SOD FLUORIDE CHW 2.2MG CARIOSTATIC AGENTS GENERIC Covered TIER 1 

SOD FLUORIDE DRO 0.5MG/ML CARIOSTATIC AGENTS GENERIC Covered TIER 1 

SOD FLUORIDE SOL 0.2%MINT CARIOSTATIC AGENTS GENERIC Covered TIER 1 

SOD FLUORIDE TAB 0.5MG F CARIOSTATIC AGENTS GENERIC Covered TIER 1 

SOD FLUORIDE TAB 1MG F CARIOSTATIC AGENTS GENERIC Covered TIER 1 

SOD HYPOCHLR SOL 5% 



SOD LACTATE INJ 1/6M ALKALINIZING AGENTS GENERIC Covered TIER 1 

SOD LACTATE INJ 5MEQ/ML ALKALINIZING AGENTS GENERIC Covered TIER 1 

SOD NITRITE INJ 30MG/ML HEAVY METAL ANTAGONISTS GENERIC Covered TIER 1 

SOD PHOSPHAT INJ 3MM/ML REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 



382

SOD POLY SUL SUS 15GM/60 POTASSIUM‐REMOVING AGENTS GENERIC Covered TIER 1 

SOD SACCHARI GRA USP SALT AND SUGAR SUBSTITUTES GENERIC Covered TIER 1 

SOD SALICYLA CRY USP SALICYLATES GENERIC Excluded TIER 99 

SOD SALICYLA CRY USP NF SALICYLATES GENERIC Excluded TIER 99 

SOD SUL/SULF AER 10‐5% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SOD SUL/SULF CRE 10‐5% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SOD SUL/SULF EMU 10‐5% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SOD SUL/SULF GEL 10‐5% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SOD SUL/SULF LIQ 9‐4.5% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SOD SUL/SULF LIQ WASH KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SOD SUL/SULF LOT 10‐5% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SOD SUL/SULF PAD 10‐4% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SOD SUL/SULF PAD 10‐5% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SOD SUL/SULF SUS 10‐5% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SOD SUL/SULF SUS 8‐4% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SOD SULFACET PAD 10% 



SOD SULFACET SOL 10% OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

SOD THIOSULF INJ 10% HEAVY METAL ANTAGONISTS GENERIC Covered TIER 1 

SOD THIOSULF INJ 25% HEAVY METAL ANTAGONISTS GENERIC Covered TIER 1 

SODIUM ACETA GRA ALKALINIZING AGENTS GENERIC Excluded TIER 99 

SODIUM ACETA GRA USP ALKALINIZING AGENTS GENERIC Excluded TIER 99 

SODIUM CHLOR INJ 0.9% CARDIAC FUNCTION BRAND Covered TIER 3 

SODIUM CHLOR NEB 10% MUCOLYTIC AGENTS GENERIC Covered TIER 1 



SODIUM CHLOR SOL 0.9% IRR IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

SODIUM CITRA GRA ALKALINIZING AGENTS GENERIC Covered TIER 1 

SODIUM IODID CAP I‐123 THYROID FUNCTION GENERIC Covered TIER 1 



383

SODIUM SULFA LIQ 10% WASH 



SOF‐SENSOR MIS DEVICES BRAND Covered TIER 3 

SOF‐SET 24" KIT INFUSION DEVICES BRAND Covered TIER 3 

SOF‐SET 24" KIT MICRO QR DEVICES BRAND Covered TIER 3 

SOF‐SET 24" KIT ULTIM QR DEVICES BRAND Covered TIER 3 

SOF‐SET 42" KIT INFUSION DEVICES BRAND Covered TIER 3 

SOF‐SET 42" KIT MICRO QR DEVICES BRAND Covered TIER 3 

SOF‐SET 42" KIT ULTIM QR DEVICES BRAND Covered TIER 3 

SOJOURN SOL INHALATION ANESTHETICS GENERIC Covered TIER 1 

SOLARAZE GEL 3% W/W 



SOLESTA INJ 50‐15ML 



SOLIA TAB CONTRACEPTIVES GENERIC Covered TIER 1 

SOLIRIS INJ 10MG/ML COMPLEMENT INHIBITORS BRAND Covered TIER 2 SP 

SOLODYN TAB 105MG 























384




SOLTAMOX SOL 10MG/5ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 

SOLU‐CORTEF INJ 1000MG ADRENALS BRAND Covered TIER 3 

SOLU‐CORTEF INJ 100MG ADRENALS Brand‐O PA TIER 3 



SOLU‐MEDROL INJ 125MG ADRENALS Brand‐O PA TIER 3 

SOLU‐MEDROL INJ 1GM ADRENALS Brand‐O PA TIER 3 

SOLU‐MEDROL INJ 2GM ADRENALS BRAND Covered TIER 3 



SOMA TAB 250MG 


MUSCLE RELAXNT BRAND Covered TIER 3 QL 

SOMA TAB 350MG 


MUSCLE RELAXNT Brand‐O PA TIER 3 QL 


SOMATULINE INJ 120/.5ML 


SOMATULINE INJ 60/0.2ML 



SOMATULINE INJ 90/0.3ML 



SOMAVERT INJ 10MG SOMATOTROPIN ANTAGONISTS BRAND Covered TIER 2 SP 



SOMNOTE CAP 500MG 



SONAFINE EMU 





385

SONATA CAP 10MG 



SONATA CAP 5MG 



SORBITOL MIS LOLLIPOP CATHARTICS AND LAXATIVES BRAND Excluded TIER 99 

SORBITOL SOL CATHARTICS AND LAXATIVES GENERIC Excluded TIER 99 

SORBITOL SOL 3% IRR IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

SORBITOL SOL 3.3% IRR IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

SORBITOL‐MAN SOL IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

SORIATANE CAP 10MG 



SORIATANE CAP 17.5MG 



SORIATANE CAP 25MG 



SORILUX AER 0.005% 



SORINE TAB 120MG 












SOTALOL AF TAB 120MG 








386




SOTALOL HCL INJ 150/10ML 



SOTALOL HCL TAB 120MG 












SOTRADECOL INJ 1% SCLEROSING AGENTS BRAND Covered TIER 3 

SOTRADECOL INJ 3% SCLEROSING AGENTS BRAND Covered TIER 3 

SOTRET CAP 10MG 









SPASCUPREEL INJ 



SPEARMINT OIL FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

SPECTRACEF TAB 200MG 



SPECTRACEF TAB 400MG 



SPECTRAGEL GEL 





387

SPEED GEL GEL TRAUMA 



SPEED GEL RX GEL 



SPG SUPPOSI‐ MIS BASE 



SPINAL NEEDL MIS 25GX2.5" DEVICES BRAND Excluded TIER 99 

SPINAL/EPIDU KIT CL CATH LOCAL ANESTHETICS (PARENTERAL) BRAND Covered TIER 3 

SPINAL/EPIDU KIT OPN CATH LOCAL ANESTHETICS (PARENTERAL) BRAND Covered TIER 3 

SPINOSAD SUS 0.9% SCABICIDES AND PEDICULICIDES GENERIC Covered TIER 1 

SPIRA‐WASH GEL BASE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

SPIRIVA CAP HANDIHLR 


S BRAND Covered TIER 2 QL 

SPIRO PD MIS DEVICES BRAND Excluded TIER 99 

SPIRONO/HCTZ TAB 25/25 



SPIRONOLACT TAB 100MG 









SPORANOX CAP 100MG AZOLES Brand‐O PA TIER 3 QL 

SPORANOX CAP PULSEPAK AZOLES Brand‐O PA TIER 3 QL 

SPORANOX SOL 10MG/ML AZOLES BRAND Covered TIER 2 

SPRINTEC 28 TAB 28 DAY CONTRACEPTIVES GENERIC Covered TIER 1 

SPRIX SPR 15.75MG 


INFLAM. AGENTS BRAND Covered TIER 3 QL 



388

SPRYCEL TAB 100MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 QL SP 

SPRYCEL TAB 140MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 




SPRYCEL TAB 80MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

SPS SUS 15GM/60 POTASSIUM‐REMOVING AGENTS GENERIC Covered TIER 1 

SRONYX TAB CONTRACEPTIVES GENERIC Covered TIER 1 

SSD CRE 1% 



SSD AF CRE 1% 



SSKI SOL 1GM/ML ANTITHYROID AGENTS BRAND Covered TIER 3 

SSS 10‐4 AER 10‐4% KERATOLYTIC AGENTS BRAND Covered TIER 3 

STAFLEX TAB 55‐500MG ETHANOLAMINE DERIVATIVES Brand‐O PA TIER 3 

STAGESIC CAP 5‐500MG OPIATE AGONISTS GENERIC Covered TIER 1 

STAHIST TAB PROPYLAMINE DERIVATIVES Brand‐O PA TIER 99 

STALEVO 100 TAB DOPAMINE PRECURSORS BRAND Covered TIER 3 






STAN FLUORID CON 0.63% CARIOSTATIC AGENTS GENERIC Covered TIER 1 

STAPHAGE LYS INJ 



STARLIX TAB 120MG MEGLITINIDES Brand‐O PA TIER 3 

STARLIX TAB 60MG MEGLITINIDES Brand‐O PA TIER 3 

STAVUDINE CAP 15MG 





389










STAVUDINE SOL 1MG/ML 



STAVZOR CAP 125MG 









STAXYN TAB 10MG 



STEARIC ACID MIS PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

STEARYL MIS ALCOHOL BASIC LOTIONS AND LINIMENTS GENERIC Excluded TIER 99 

STELARA INJ 45MG/0.5 


AGENTS, MISC. BRAND PA TIER 3 QL SP 

STELARA INJ 90MG/ML 


AGENTS, MISC. BRAND PA TIER 3 QL SP 

STERIL TALC SUS 5GM SCLEROSING AGENTS BRAND Covered TIER 3 

STERIL WATER INJ PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

STERIL WATER SOL IRRIG IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

STERILE DILU SOL FLOLAN PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

STERYMINE GEL 



STIMATE SOL 1.5MG/ML PITUITARY BRAND Covered TIER 2 

STIVARGA TAB 40MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 



390

STOPCOCK MIS 1‐WAY DEVICES BRAND Excluded TIER 99 



STOPCOCK DBL MIS 3‐WAY DEVICES BRAND Excluded TIER 99 

STR CATHETER MIS 12FR/20" DEVICES BRAND Excluded TIER 99 








STRATTERA CAP 100MG 





















STRAWBERRY LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

STRAZEPAM PAK 



STREPTOMYCIN INJ 1GM AMINOGLYCOSIDES GENERIC Covered TIER 1 



391

STRIANT MIS 30MG ANDROGENS BRAND Covered TIER 3 

STRIBILD TAB INTEGRASE INHIBITORS BRAND Covered TIER 3 

STROMECTOL TAB 3MG ANTHELMINTICS BRAND Covered TIER 2 

STROVITE TAB MULTIVITAMIN PREPARATIONS Brand‐O PA TIER 3 

STROVITE TAB ADVANCE MULTIVITAMIN PREPARATIONS Brand‐O PA TIER 3 

STROVITE FOR SYP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

STROVITE FOR TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

STROVITE ONE TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

STROVITE PLU TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

STRUMEEL DRO FORTE 



STRUMEEL SUB 



SUBLIMAZE INJ 0.05MG/1 OPIATE AGONISTS Brand‐O PA TIER 3 

SUBOXONE MIS 2‐0.5MG OPIATE PARTIAL AGONISTS BRAND PA TIER 2 QL 

SUBOXONE MIS 8‐2MG OPIATE PARTIAL AGONISTS BRAND PA TIER 2 QL 

SUBOXONE SUB 2‐0.5MG OPIATE PARTIAL AGONISTS BRAND Covered TIER 3 QL 

SUBOXONE SUB 8‐2MG OPIATE PARTIAL AGONISTS BRAND Covered TIER 3 QL 

SUBSYS SPR 100MCG OPIATE AGONISTS BRAND Covered TIER 3 







SUBUTEX SUB 2MG OPIATE PARTIAL AGONISTS Brand‐O PA TIER 3 QL 

SUBUTEX SUB 8MG OPIATE PARTIAL AGONISTS Brand‐O PA TIER 3 QL 

SUCRAID SOL 8500/ML ENZYMES BRAND Covered TIER 3 

SUCRALFATE TAB 1GM PROTECTANTS GENERIC Covered TIER 1 

SUDAHIST TAB 12‐120MG PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 



392

SUDATEX‐DM TAB ANTITUSSIVES GENERIC Covered TIER 1 

SUFENTA INJ 50MCG/ML OPIATE AGONISTS Brand‐O PA TIER 3 

SUFENTANIL INJ 100/2ML OPIATE AGONISTS GENERIC Covered TIER 1 

SUFENTANIL INJ 250/5ML OPIATE AGONISTS GENERIC Covered TIER 1 

SUFENTANIL INJ 50MCG/ML OPIATE AGONISTS GENERIC Covered TIER 1 

SULAR TAB 17MG DIHYDROPYRIDINES Brand‐O PA TIER 3 

SULAR TAB 25.5MG DIHYDROPYRIDINES Brand‐O PA TIER 3 

SULAR TAB 34MG DIHYDROPYRIDINES Brand‐O PA TIER 3 

SULAR TAB 8.5MG DIHYDROPYRIDINES Brand‐O PA TIER 3 

SULF LIME SOL USP SCABICIDES AND PEDICULICIDES GENERIC Covered TIER 1 

SULF/PRED NA SOL OP CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

SULFACET SOD OIN 10% OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

SULFACET SOD SOL 10% OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

SULFACETAMID LOT 10% 



SULFACETAMID SUS 10% 



SULFACLEANSE SUS 8‐4% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SULFADIAZINE TAB 500MG SULFONAMIDES (SYSTEMIC) GENERIC Covered TIER 1 

SULFAMYLON CRE 85MG/GM 



SULFAMYLON PAK 5% 



SULFASALAZIN TAB 500MG SULFONAMIDES (SYSTEMIC) GENERIC Covered TIER 1 

SULFASALAZIN TAB 500MG DR SULFONAMIDES (SYSTEMIC) GENERIC Covered TIER 1 

SULFAZINE TAB 500MG SULFONAMIDES (SYSTEMIC) GENERIC Covered TIER 1 

SULFAZINE EC TAB 500MG SULFONAMIDES (SYSTEMIC) GENERIC Covered TIER 1 

SULFISOXIZOL CRY SULFONAMIDES (SYSTEMIC) GENERIC Excluded TIER 99 

SULFISOXIZOL CRY USP NF SULFONAMIDES (SYSTEMIC) GENERIC Excluded TIER 99 

SULFOAM SHA 2% KERATOLYTIC AGENTS BRAND Covered TIER 3 



393

SULINDAC TAB 150MG 



SULINDAC TAB 200MG 



SUMADAN KIT KERATOLYTIC AGENTS BRAND Covered TIER 3 

SUMADAN WASH LIQ 9‐4.5% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

SUMATRIPTAN INJ 4MG/0.5 SELECTIVE SEROTONIN AGONISTS GENERIC Covered TIER 1 QL 

SUMATRIPTAN INJ 6MG/0.5 SELECTIVE SEROTONIN AGONISTS GENERIC Covered TIER 1 QL 

SUMATRIPTAN SPR 20MG/ACT SELECTIVE SEROTONIN AGONISTS GENERIC Covered TIER 1 QL 

SUMATRIPTAN SPR 5MG/ACT SELECTIVE SEROTONIN AGONISTS GENERIC Covered TIER 1 QL 

SUMATRIPTAN TAB 100MG SELECTIVE SEROTONIN AGONISTS GENERIC Covered TIER 1 QL 



SUMAVEL DOSE INJ 6MG/0.5 SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 3 

SUMAXIN PAD 10‐4% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

SUMAXIN CP KIT KERATOLYTIC AGENTS BRAND Covered TIER 3 

SUMAXIN TS SUS 8‐4% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

SUMAXIN WASH LIQ 9‐4% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

SUMP DRAIN MIS 16FR/12" DEVICES BRAND Excluded TIER 99 






SUPARTZ INJ 25/2.5ML 



SUPERVITE LIQ MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

SUPERVITE EC TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

SUPHERA CRE 10‐5% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

SUPPORT LIQ MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 



394

SUPPORT‐500 CAP MULTIVITAMIN PREPARATIONS BRAND Excluded TIER 99 

SUPPOSIBLEND MIS 



SUPPOSISTRIP MIS 1.4GM DEVICES BRAND Excluded TIER 99 

SUPPOSISTRIP MIS 1.9GM DEVICES GENERIC Excluded TIER 99 

SUPPOSITORY MIS 1.46GM DEVICES GENERIC Excluded TIER 99 

SUPPOSITORY MIS 2.25GM DEVICES GENERIC Excluded TIER 99 

SUPPRELIN LA KIT 50MG ANTINEOPLASTIC AGENTS BRAND PA TIER 2 QL SP 

SUPRANE INH INHALATION ANESTHETICS BRAND Covered TIER 3 

SUPRANE SOL INHALATION ANESTHETICS BRAND Covered TIER 3 

SUPRAX CHW 100MG 



SUPRAX CHW 200MG 



SUPRAX SUS 100/5ML 



SUPRAX SUS 200/5ML 



SUPRAX TAB 400MG 



SUPRENZA TAB 15MG 



SUPRENZA TAB 30MG 



SUPREP BOWEL SOL PREP CATHARTICS AND LAXATIVES BRAND Covered TIER 2 

SURE‐T MIS 23"/6MM DEVICES BRAND Covered TIER 3 

SURE‐T MIS 23"/8MM DEVICES BRAND Covered TIER 3 

SURE‐T INFUS MIS SET 18" DEVICES BRAND Excluded TIER 99 





395

SURG BLADES MIS SIZE 10A DEVICES BRAND Excluded TIER 99 

SURG BLADES MIS SIZE 12 DEVICES BRAND Excluded TIER 99 

SURG BLADES MIS SIZE 12B DEVICES BRAND Excluded TIER 99 

SURG BLADES MIS SIZE 15C DEVICES BRAND Excluded TIER 99 





SURGICEL PAD 0.5"X2" 



SURGICEL PAD 1"X 1" 



SURGICEL PAD 1"X2" 



SURGICEL PAD 1"X3.5" 


























396

SURGIFOAM MIS 12‐7MM HEMOSTATICS BRAND Excluded TIER 99 

SURGIFOAM MIS SIZE 100 HEMOSTATICS BRAND Excluded TIER 99 

SURGUARD2 MIS 18GX1" DEVICES BRAND Excluded TIER 99 

SURGUARD2 MIS 18GX1.5" DEVICES BRAND Excluded TIER 99 












SURGUARD2 MIS 25GX5/8" DEVICES BRAND Excluded TIER 99 




SURMONTIL CAP 100MG 









SURVANTA INH PULMONARY SURFACTANTS BRAND Covered TIER 3 

SUSTIVA CAP 200MG 

NONNUCLEOSIDE 


SUSTIVA CAP 50MG 

NONNUCLEOSIDE 




397

SUSTIVA TAB 600MG 

NONNUCLEOSIDE 


SUTAN‐DM SUS ANTITUSSIVES GENERIC Covered TIER 1 

SUTENT CAP 12.5MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 QL SP 

SUTENT CAP 25MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 QL SP 

SUTENT CAP 50MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 QL SP 

SUTTAR‐2 SYP ANTITUSSIVES Brand‐O PA TIER 99 

SUTTAR‐SF SYP ANTITUSSIVES Brand‐O PA TIER 99 

SWEETNESS LIQ ENHANCER PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

SYEDA TAB 3‐0.03MG CONTRACEPTIVES GENERIC Covered TIER 1 

SYLATRON KIT 296MCG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 



SYMAX DUOTAB TAB 



SYMAX FASTAB TAB 0.125MG 



SYMAX‐SL SUB 0.125MG 



SYMAX‐SR TAB 0.375MG 



SYMBICORT AER 160‐4.5 ADRENALS BRAND Covered TIER 3 QL 

SYMBICORT AER 80‐4.5 ADRENALS BRAND Covered TIER 3 QL 

SYMBYAX CAP 12‐25MG 











398







SYMLIN INJ 600MCG AMYLINOMIMETICS BRAND Covered TIER 2 

SYMLINPEN 60 INJ 1000MCG AMYLINOMIMETICS BRAND Covered TIER 2 

SYMLNPEN 120 INJ 1000MCG AMYLINOMIMETICS BRAND Covered TIER 2 

SYNAGEX CAP 1.25MG MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

SYNAGIS INJ 100MG/ML MONOCLONAL ANTIBODIES BRAND PA TIER 2 QL SP 

SYNAGIS INJ 50MG MONOCLONAL ANTIBODIES BRAND PA TIER 2 QL SP 

SYNALAR SOL 0.01% 



SYNALAR TS KIT 0.01% 



SYNALGOS‐DC CAP OPIATE AGONISTS BRAND Covered TIER 3 

SYNAREL SOL 2MG/ML GONADOTROPINS BRAND Covered TIER 2 SP 

SYNATEK CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

SYNERA DIS 70‐70MG 



SYNERCID INJ 500MG STREPTOGRAMINS BRAND Covered TIER 3 

SYNTHROID TAB 100MCG THYROID AGENTS Brand‐O PA TIER 2 












399



SYNVISC INJ 8MG/ML 



SYNVISC ONE INJ 8MG/ML 



SYPRINE CAP 250MG HEAVY METAL ANTAGONISTS BRAND Covered TIER 3 

SYRINGE FILT MIS 25MM DEVICES BRAND Excluded TIER 99 

SYRINGE TRAY MIS PHASEAL DEVICES BRAND Excluded TIER 99 

SYRNG BARREL MIS 1.5OZ DEVICES GENERIC Excluded TIER 99 

SYRNG BARREL MIS 1OZ DEVICES GENERIC Excluded TIER 99 




SYRPALTA SYP PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

SYRPALTA SYP CLEAR PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

SYZYGIUM DRO COMPOSIT 



T.E.D. MIS LG/LONG DEVICES BRAND Excluded TIER 99 

T.E.D. MIS LG/REG DEVICES BRAND Excluded TIER 99 

T.E.D. MIS LG/SHORT DEVICES BRAND Excluded TIER 99 

T.E.D. MIS MD/SHORT DEVICES BRAND Excluded TIER 99 

T.E.D. MIS MED/LONG DEVICES BRAND Excluded TIER 99 

T.E.D. MIS MED/REG DEVICES BRAND Excluded TIER 99 

T.E.D. MIS MED‐LONG DEVICES BRAND Excluded TIER 99 

T.E.D. MIS SM/LONG DEVICES BRAND Excluded TIER 99 

T.E.D. MIS SM/REG DEVICES BRAND Excluded TIER 99 

T.E.D. MIS SM/SHORT DEVICES BRAND Excluded TIER 99 

T.E.D. MIS XL/LONG DEVICES BRAND Excluded TIER 99 

T.E.D. MIS XL/REG DEVICES BRAND Excluded TIER 99 



400

T.E.D. MIS XSM/LONG DEVICES BRAND Excluded TIER 99 

T.E.D. MIS X‐SM/REG DEVICES BRAND Excluded TIER 99 

T.R.U.E. TES DIAGNOSTIC AGENTS BRAND Excluded TIER 99 

TABLOID TAB 40MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

TACHOSIL PAD 



TACLONEX OIN 



TACLONEX SUS SCALP 



TACROLIMUS CAP 0.5MG IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1 

TACROLIMUS CAP 1MG IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1 

TACROLIMUS CAP 5MG IMMUNOSUPPRESSIVE AGENTS GENERIC Covered TIER 1 

TAGITOL V SUS 40% ROENTGENOGRAPHY BRAND Covered TIER 3 

TALWIN INJ 30MG/ML OPIATE PARTIAL AGONISTS BRAND Covered TIER 3 

TAMBOCOR TAB 100MG CLASS IC ANTIARRHYTHMICS Brand‐O PA TIER 3 



TAMIFLU CAP 30MG NEURAMINIDASE INHIBITORS BRAND Covered TIER 2 QL 



TAMIFLU SUS 12MG/ML NEURAMINIDASE INHIBITORS BRAND Covered TIER 2 QL 

TAMIFLU SUS 6MG/ML NEURAMINIDASE INHIBITORS BRAND Covered TIER 2 QL 

TAMOXIFEN TAB 10MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

TAMOXIFEN TAB 20MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

TAMSULOSIN CAP 0.4MG 


BLOCK.AGENT GENERIC Covered TIER 1 

TANDEM DHA CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TANDEM F CAP IRON PREPARATIONS GENERIC Covered TIER 1 

TANDEM OB CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 



401

TANDEM PLUS CAP IRON PREPARATIONS Brand‐O PA TIER 3 

TANGERINE OIL FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

TANNIHIST‐12 SUS 4‐30MG/5 ANTITUSSIVES GENERIC Covered TIER 1 

TAPAZOLE TAB 10MG ANTITHYROID AGENTS Brand‐O PA TIER 3 

TAPAZOLE TAB 5MG ANTITHYROID AGENTS Brand‐O PA TIER 3 

TARCEVA TAB 100MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 QL SP 



TARGRETIN CAP 75MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

TARGRETIN GEL 1% 


AGENTS, MISC. BRAND Covered TIER 3 SP 

TARKA TAB 1‐240 CR 












TARON GRA CRYSTALS ALKALINIZING AGENTS GENERIC Covered TIER 1 

TARON EC PAK CALCIUM MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

TARON FORTE CAP IRON PREPARATIONS BRAND Covered TIER 3 

TARON‐BC MIS MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TARON‐C DHA CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TARON‐DUO EC PAK MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TARON‐EC CAL TAB 28‐1MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

TARON‐PREX CAP MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

TASIGNA CAP 150MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 QL SP 

TASIGNA CAP 200MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 QL SP 



402

TASMAR TAB 100MG 


METHYLTRANSFERASE(COMT)INHIB. BRAND Covered TIER 3 

TAURINE LIQ CALORIC AGENTS GENERIC Excluded TIER 99 

TAXOTERE INJ 20/0.5ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

TAXOTERE INJ 20MG/ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

TAXOTERE INJ 80MG/2ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

TAXOTERE INJ 80MG/4ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

TAZICEF INJ 1GM 



TAZICEF INJ 1GM/50ML 









TAZORAC CRE 0.05% 



TAZORAC CRE 0.1% 



TAZORAC GEL 0.05% 



TAZORAC GEL 0.1% 



TAZTIA XT CAP 120MG/24 











403







TB SYRINGE MIS 0.5/28G DEVICES BRAND Excluded TIER 99 

TBC AER 



TEABERRY OIL FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

TEARS AGAIN CAP HYDRATE 



TEFLARO INJ 400MG 

FIFTH GENERATION 


TEFLARO INJ 600MG 

FIFTH GENERATION 


TEGADERM AG PAD 2"X2" 












TEGRETOL CHW 100MG 



TEGRETOL SUS 100/5ML 



TEGRETOL TAB 200MG 



TEGRETOL XR TAB 100MG 





404







TEKAMLO TAB 150‐10MG RENIN INHIBITORS BRAND Covered TIER 2 




TEKRAL TAB ETHANOLAMINE DERIVATIVES BRAND Excluded TIER 99 

TEKTURNA TAB 150MG RENIN INHIBITORS BRAND Covered TIER 2 

TEKTURNA TAB 300MG RENIN INHIBITORS BRAND Covered TIER 2 

TEKTURNA HCT TAB 150‐12.5 RENIN INHIBITORS BRAND Covered TIER 2 

TEKTURNA HCT TAB 150‐25MG RENIN INHIBITORS BRAND Covered TIER 2 

TEKTURNA HCT TAB 300‐12.5 RENIN INHIBITORS BRAND Covered TIER 2 

TEKTURNA HCT TAB 300‐25MG RENIN INHIBITORS BRAND Covered TIER 2 

TEMAZEPAM CAP 15MG 



TEMAZEPAM CAP 22.5MG 



TEMAZEPAM CAP 30MG 



TEMAZEPAM CAP 7.5MG 



TEMODAR CAP 100MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 






TEMODAR INJ 100MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 



405

TEMOVATE CRE 0.05% 



TEMOVATE GEL 0.05% 



TEMOVATE OIN 0.05% 



TEMOVATE SOL 0.05% 



TEMOVATE E CRE 0.05%EML 



TENCON TAB 50‐650MG 



TENDER 1 KIT 31" DEVICES BRAND Excluded TIER 99 


TENDER 1 KIT INFUSION DEVICES BRAND Excluded TIER 99 



TENEX TAB 1MG CENTRAL ALPHA‐AGONISTS Brand‐O PA TIER 3 

TENEX TAB 2MG CENTRAL ALPHA‐AGONISTS Brand‐O PA TIER 3 

TENIVAC INJ 5‐2LF TOXOIDS BRAND Excluded TIER 99 

TENORETIC TAB 100 



TENORETIC TAB 50 



TENORMIN TAB 100MG 











406

TEQUILA SUNR LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

TERAZOL 3 CRE 0.8% 



TERAZOL 3 SUP 80MG 



TERAZOL 7 CRE 0.4% 



TERAZOSIN CAP 10MG 












TERBINAFINE TAB 250MG ALLYLAMINES GENERIC Covered TIER 1 QL 

TERBINEX KIT ALLYLAMINES BRAND Covered TIER 3 

TERBUTALINE INJ 1MG/ML 



TERBUTALINE TAB 2.5MG 



TERBUTALINE TAB 5MG 



TERCONAZOLE CRE 0.4% 



TERCONAZOLE CRE 0.8% 



TERCONAZOLE SUP 80MG 



TERRELL SOL INHALATION ANESTHETICS GENERIC Covered TIER 1 



407

TERSI FOAM AER 2.25% 



TESSALON CAP 200MG ANTITUSSIVES Brand‐O PA TIER 99 

TESSALON PER CAP 100MG ANTITUSSIVES Brand‐O PA TIER 99 

TESTIM GEL 1%(50MG) ANDROGENS BRAND Covered TIER 3 

TESTOPEL MIS PELLETS ANDROGENS BRAND Covered TIER 3 

TESTOST CYP INJ 100MG/ML ANDROGENS GENERIC Covered TIER 1 

TESTOST CYP INJ 200MG/ML ANDROGENS GENERIC Covered TIER 1 

TESTOST ENAN INJ 200MG/ML ANDROGENS GENERIC Covered TIER 1 

TESTRED CAP 10MG ANDROGENS BRAND Covered TIER 3 

TET/DIP TOX INJ 2‐2 LF TOXOIDS GENERIC Excluded TIER 99 

TETANUS TOX INJ 5LF ADS TOXOIDS GENERIC Excluded TIER 99 

TETCAINE SOL 0.5% OP LOCAL ANESTHETICS (EENT) GENERIC Covered TIER 1 

TETRACAINE INJ 1% LOCAL ANESTHETICS (PARENTERAL) GENERIC Covered TIER 1 

TETRACAINE SOL 0.5% OP LOCAL ANESTHETICS (EENT) GENERIC Covered TIER 1 

TETRACYCLINE CAP 250MG TETRACYCLINES GENERIC Covered TIER 1 

TETRACYCLINE CAP 500MG TETRACYCLINES GENERIC Covered TIER 1 

TETRAVISC SOL 0.5% OP LOCAL ANESTHETICS (EENT) GENERIC Covered TIER 1 

TETRAVISC SOL FORTE LOCAL ANESTHETICS (EENT) GENERIC Covered TIER 1 

TETRIX KIT 



TEVETEN TAB 400MG 



TEVETEN TAB 600MG 



TEVETEN HCT TAB 600‐12.5 



TEVETEN HCT TAB 600‐25MG 





408

TEV‐TROPIN INJ 5MG SOMATOTROPIN AGONISTS BRAND PA TIER 3 SP 

TEXACORT SOL 2.5% 



TEXAS CATH MIS MALE DEVICES BRAND Excluded TIER 99 

TGQ 15DM/5PE SYP H/2CPM ANTITUSSIVES GENERIC Covered TIER 1 

TGQ 30/ SYP 150/15 ANTITUSSIVES GENERIC Covered TIER 1 

TGQ 30/PSE/3 SYP BRM/15DM ANTITUSSIVES GENERIC Covered TIER 1 

TGQ 50PSE/3 SYP BRM/30DM ANTITUSSIVES GENERIC Covered TIER 1 

TGQ 7.5PEH/4 LIQ BRM/15DM ANTITUSSIVES GENERIC Covered TIER 1 

THALAMUS SUB COMPOSIT 



THALITONE TAB 15MG THIAZIDE‐LIKE DIURETICS BRAND Covered TIER 3 

THALLOUS CL INJ TL 201 CARDIAC FUNCTION GENERIC Covered TIER 1 

THALOMID CAP 100MG BIOLOGIC RESPONSE MODIFIERS BRAND Covered TIER 2 QL SP 




THAM INJ 30MEQ ALKALINIZING AGENTS BRAND Covered TIER 3 

THEO‐24 CAP 100MG CR 









THEO‐24 CAP 400MG ER 



THEOCHRON TAB 100MG CR 








409


THEOPHYL/D5W INJ 0.8MG/ML 



THEOPHYLLINE SOL 80/15ML 

THEOPHYLLINE TAB 100MG CR 

THEOPHYLLINE TAB 100MG ER 

THEOPHYLLINE TAB 200MG CR 






THERABENZAPR PAK ‐60 

THERABENZAPR PAK ‐90 

































410

THERABENZAPR PAK ‐90‐5 



THERACODEINE PAK ‐300 OPIATE AGONISTS BRAND Covered TIER 3 

THERACODOPHE PAK ‐750 OPIATE AGONISTS BRAND Covered TIER 3 

THERACODOPHN PAK ‐325 OPIATE AGONISTS BRAND Covered TIER 3 

THERACODOPHN PAK ‐650 OPIATE AGONISTS BRAND Covered TIER 3 

THERACODOPHN PAK ‐LOW‐90 OPIATE AGONISTS BRAND Covered TIER 3 

THERACYS INJ VACCINES BRAND Covered TIER 3 SP 

THERAFELDAMI PAK 



THERA‐FLUR‐N DRO 1.1% CARIOSTATIC AGENTS Brand‐O PA TIER 3 

THERAMINE CAP CALORIC AGENTS BRAND Excluded TIER 99 

THERAPENTIN PAK ‐60 



THERAPENTIN PAK ‐90 



THERAPROFEN PAK ‐60 



THERAPROFEN PAK 800MG 



THERAPROFEN PAK ‐90 



THERAPROXEN PAK 



THERAPROXEN PAK 500MG 



THERAPROXEN PAK ‐60 



THERAPROXEN PAK ‐90 





411

THERATRAMADO PAK ‐60 OPIATE AGONISTS BRAND Covered TIER 3 

THERATRAMADO PAK ‐90 OPIATE AGONISTS BRAND Covered TIER 3 

THERMAZENE CRE 1% 



THEROBEC TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

THI AORTIC MIS CANNULA DEVICES BRAND Excluded TIER 99 

THIAMINE HCL INJ 100MG/ML VITAMIN B COMPLEX GENERIC Covered TIER 1 

THINSET MIS 23"/6MM DEVICES BRAND Covered TIER 3 




THINSET SYR MIS RES 1.8 DEVICES BRAND Covered TIER 3 

THINSET SYR MIS RES 3ML DEVICES BRAND Covered TIER 3 

THIOLA TAB 100MG 



THIORIDAZINE TAB 100MG PHENOTHIAZINES GENERIC Covered TIER 1 




THIOSULFATE CRY SODIUM 


MEMBRANE),MISC GENERIC Excluded TIER 99 

THIOTEPA INJ 15MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

THIOTHIXENE CAP 10MG THIOXANTHENES GENERIC Covered TIER 1 




THORACENTESI KIT 16GX3.5" DEVICES BRAND Excluded TIER 99 

THORACENTESI KIT 17GX6" DEVICES BRAND Excluded TIER 99 

THORA‐SEAL MIS III CHMB DEVICES BRAND Excluded TIER 99 

THORA‐SEAL MIS III SYST DEVICES BRAND Excluded TIER 99 



412

THORA‐SEAL MIS III UNIT DEVICES BRAND Excluded TIER 99 

THRESHOLD MIS IMT DEVICES BRAND Excluded TIER 99 

THRESHOLD MIS PEP DEVICES BRAND Excluded TIER 99 

THROMBAT III INJ 1000UNIT ANTICOAGULANTS, MISCELLANEOUS BRAND Covered TIER 3 

THROMBAT III INJ 500UNIT ANTICOAGULANTS, MISCELLANEOUS BRAND Covered TIER 3 

THROMBI‐GEL PAD 10 HEMOSTATICS BRAND Excluded TIER 99 



THROMBIN KIT 5000UNIT HEMOSTATICS BRAND Covered TIER 3 

THROMBIN‐JMI KIT 20000UNT HEMOSTATICS BRAND Covered TIER 3 

THROMBIN‐JMI KIT 5000UNIT HEMOSTATICS BRAND Covered TIER 3 

THROMBIN‐JMI SOL 20000UNT HEMOSTATICS BRAND Covered TIER 3 

THROMBIN‐JMI SOL 5000UNIT HEMOSTATICS BRAND Covered TIER 3 

THROMBI‐PAD PAD 3"X3" HEMOSTATICS BRAND Excluded TIER 99 

THROMBOGEN KIT 10000UNT HEMOSTATICS BRAND Covered TIER 3 

THROMBOGEN SOL 10000UNT HEMOSTATICS BRAND Covered TIER 3 

THROMBOGEN SOL 1000UNIT HEMOSTATICS BRAND Covered TIER 3 

THYMOGLOBULN INJ 25MG IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 3 SP 

THYREL TRH INJ 0.5MG/ML DIAGNOSTIC AGENTS BRAND Excluded TIER 99 

THYREOIDEA LIQ COMPOSIT 



THYREOIDEA SUB COMPOSIT 



THYROGEN INJ 1.1MG THYROID FUNCTION BRAND Covered TIER 3 SP 

THYROLAR‐1 TAB 60MG THYROID AGENTS BRAND Covered TIER 3 

THYROLAR‐1/2 TAB 30MG THYROID AGENTS BRAND Covered TIER 3 

THYROLAR‐1/4 TAB 15MG THYROID AGENTS BRAND Covered TIER 3 




413


TIAGABINE TAB 2MG 



TIAGABINE TAB 4MG 



TIAZAC CAP 120MG/24 


















TICE BCG INJ VACCINES BRAND Covered TIER 3 SP 

TICLOPIDINE TAB 250MG PLATELET‐AGGREGATION INHIBITORS GENERIC Covered TIER 1 

TIGAN CAP 300MG ANTIHISTAMINES (GI DRUGS) Brand‐O PA TIER 3 

TIGAN INJ 100MG/ML ANTIHISTAMINES (GI DRUGS) Brand‐O PA TIER 3 

TIKOSYN CAP 125MCG CLASS III ANTIARRHYTHMICS BRAND Covered TIER 2 SP 



TILIA FE TAB CONTRACEPTIVES GENERIC Covered TIER 1 

TIMENTIN INJ 3.1GM EXTENDED‐SPECTRUM PENICILLINS BRAND Covered TIER 3 

TIMENTIN INJ 31GM EXTENDED‐SPECTRUM PENICILLINS BRAND Covered TIER 3 



414

TIMOLOL GEL SOL 0.25% OP 

TIMOLOL GEL SOL 0.5% OP 

TIMOLOL MAL SOL 0.25% OP 

TIMOLOL MAL SOL 0.5% OP 

TIMOLOL MAL TAB 10MG 



TIMOPTIC SOL 0.25% OP 

TIMOPTIC SOL 0.5% OP 

TIMOPTIC OCU SOL 0.25% OP 

TIMOPTIC OCU SOL 0.5% OP 

TIMOPTIC‐XE SOL 0.25% OP 

TIMOPTIC‐XE SOL 0.5% OP 



























TINDAMAX TAB 250MG ANTIPROTOZOALS, MISCELLANEOUS Brand‐O PA TIER 3 

TINDAMAX TAB 500MG ANTIPROTOZOALS, MISCELLANEOUS Brand‐O PA TIER 3 



415

TINIDAZOLE TAB 250MG ANTIPROTOZOALS, MISCELLANEOUS GENERIC Covered TIER 1 

TINIDAZOLE TAB 500MG ANTIPROTOZOALS, MISCELLANEOUS GENERIC Covered TIER 1 

TIP CAPS MIS DEVICES GENERIC Excluded TIER 99 

TIROSINT CAP 100MCG THYROID AGENTS BRAND Covered TIER 3 










TISSEEL KIT 



TISSEEL SOL 



TIS‐U‐SOL SOL IRRIGATING SOLUTIONS GENERIC Covered TIER 1 

TITUS NEEDLE MIS 18X1‐1/4 DEVICES GENERIC Excluded TIER 99 

TIZANIDINE CAP 2MG 









TIZANIDINE KIT COMFORT 





416

TIZANIDINE TAB 2MG 



TIZANIDINE TAB 4MG 



TL BPO MX LIQ 4.25% 



TL GARD RX TAB VITAMIN B COMPLEX GENERIC Covered TIER 1 

TL G‐FOL OS TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TL HYDROQUIN CRE 4% DEPIGMENTING AGENTS GENERIC Excluded TIER 99 

TL ICON CAP IRON PREPARATIONS GENERIC Covered TIER 1 

TL NICOTINAM TAB IDE MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

TL UREA LOT 45% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

TL‐ASSURE CAP ONE MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TL‐ASSURE+ MIS DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TL‐CERMIDE EMU 



TL‐DEX DM LIQ ANTITUSSIVES GENERIC Covered TIER 1 

TL‐FLUORIVIT CHW MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TL‐FOL 500 TAB IRON PREPARATIONS GENERIC Covered TIER 1 

TL‐HEM 150 TAB IRON PREPARATIONS GENERIC Covered TIER 1 

TL‐HIST CD LIQ ANTITUSSIVES GENERIC Covered TIER 1 

TL‐HIST CM LIQ ANTITUSSIVES GENERIC Covered TIER 1 

TL‐SELECT CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TNKASE KIT 50MG THROMBOLYTIC AGENTS BRAND Covered TIER 3 

TOBI NEB 300/5ML AMINOGLYCOSIDES BRAND Covered TIER 2 SP 

TOBRA/DEXAME SUS 0.3‐0.1% CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

TOBRA/NACL INJ 60/0.9 AMINOGLYCOSIDES GENERIC Covered TIER 1 

TOBRA/NACL INJ 80/0.9 AMINOGLYCOSIDES GENERIC Covered TIER 1 

TOBRADEX OIN 0.3‐0.1% CORTICOSTEROIDS (EENT) BRAND Covered TIER 2 

TOBRADEX SUS 0.3‐0.1% CORTICOSTEROIDS (EENT) Brand‐O PA TIER 3 



417

TOBRADEX ST SUS 0.3‐0.05 CORTICOSTEROIDS (EENT) BRAND Covered TIER 2 

TOBRAMYCIN INJ 1.2/30ML AMINOGLYCOSIDES GENERIC Covered TIER 1 

TOBRAMYCIN INJ 1.2GM AMINOGLYCOSIDES GENERIC Covered TIER 1 

TOBRAMYCIN INJ 10MG/ML AMINOGLYCOSIDES GENERIC Covered TIER 1 

TOBRAMYCIN INJ 40MG/ML AMINOGLYCOSIDES GENERIC Covered TIER 1 

TOBRAMYCIN INJ 80MG/2ML AMINOGLYCOSIDES GENERIC Covered TIER 1 

TOBRAMYCIN SOL 0.3% OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

TOBRASOL SOL 0.3% OP ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

TOBREX OIN 0.3% OP ANTIBACTERIALS (EENT) BRAND Covered TIER 2 

TOBREX SOL 0.3% OP ANTIBACTERIALS (EENT) Brand‐O PA TIER 3 

TOFRANIL TAB 10MG 









TOFRANIL‐PM CAP 100MG 












TOLAZAMIDE TAB 250MG SULFONYLUREAS GENERIC Covered TIER 1 

TOLAZAMIDE TAB 500MG SULFONYLUREAS GENERIC Covered TIER 1 

TOLBUTAMIDE TAB 500MG SULFONYLUREAS GENERIC Covered TIER 1 

TOLMETIN SOD CAP 400MG 





418

TOLMETIN SOD TAB 200MG 



TOLMETIN SOD TAB 600MG 



TOLTERODINE TAB 1MG 



TOLTERODINE TAB 2MG 



TOMMY GEL GEL PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

TONSIL NEEDL MIS 23GX1/2" DEVICES GENERIC Excluded TIER 99 

TONSIL NEEDL MIS 23GX3/4" DEVICES GENERIC Excluded TIER 99 

TOOMEY SYRIN MIS 70ML DEVICES GENERIC Excluded TIER 99 

TOPAMAX TAB 100MG 












TOPAMAX SPR CAP 15MG 



TOPAMAX SPR CAP 25MG 



TOPEX TOPCAL SPR ANESTHET 



TOPI‐CLICK MIS BLUE DEVICES BRAND Excluded TIER 99 

TOPI‐CLICK MIS GREEN DEVICES BRAND Excluded TIER 99 

TOPI‐CLICK MIS PINK DEVICES BRAND Excluded TIER 99 

TOPI‐CLICK MIS PURPLE DEVICES BRAND Excluded TIER 99 



419

TOPI‐CLICK MIS RED DEVICES BRAND Excluded TIER 99 

TOPI‐CLICK MIS SILVER DEVICES BRAND Excluded TIER 99 

TOPI‐CLICK MIS WHITE DEVICES BRAND Excluded TIER 99 

TOPICORT CRE 0.05% 



TOPICORT CRE 0.25% 



TOPICORT GEL 0.05% 



TOPICORT OIN 0.05% 



TOPICORT OIN 0.25% 



TOPIRAGEN TAB 100MG 












TOPIRAMATE CAP 15MG 



TOPIRAMATE CAP 25MG 



TOPIRAMATE TAB 100MG 








420







TOPOSAR INJ 100/5ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

TOPOSAR INJ 1GM/50ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

TOPOSAR INJ 500/25ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

TOPOTECAN INJ 4MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

TOPOTECAN INJ 4MG/4ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

TOPROL XL TAB 100MG 












TORISEL SOL 25MG/ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

TORSEMIDE INJ 20MG/2ML LOOP DIURETICS GENERIC Covered TIER 1 

TORSEMIDE INJ 50MG/5ML LOOP DIURETICS GENERIC Covered TIER 1 

TORSEMIDE TAB 100MG LOOP DIURETICS GENERIC Covered TIER 1 




TOTECT INJ 500MG PROTECTIVE AGENTS BRAND Covered TIER 3 

TOVIAZ TAB 4MG 



TOVIAZ TAB 8MG 



TOZAL CAP CALORIC AGENTS BRAND Excluded TIER 99 



421

TPN ELECTROL INJ REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

TPN ELECTROL INJ II REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

TRACE ELEM 4 INJ PED REPLACEMENT PREPARATIONS BRAND Covered TIER 3 SP 

TRACE METALS INJ REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 SP 

TRACLEER TAB 125MG 



TRACLEER TAB 62.5MG 



TRADJENTA TAB 5MG 



TRAGACANTH MIS RIBBON PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

TRAMADL/APAP TAB 37.5‐325 OPIATE AGONISTS GENERIC Covered TIER 1 

TRAMADOL HCL CAP 150MG ER OPIATE AGONISTS GENERIC Covered TIER 1 

TRAMADOL HCL TAB 100MG ER OPIATE AGONISTS GENERIC Covered TIER 1 



TRAMADOL HCL TAB 50MG OPIATE AGONISTS GENERIC Covered TIER 1 

TRANDATE TAB 100MG 









TRANDO/VERAP TAB 1‐240 CR 











422




TRANDOLAPRIL TAB 1MG 









TRANEXAMIC INJ ACID HEMOSTATICS GENERIC PA TIER 1 

TRANSDERMAL CRE PAIN BAS PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

TRANSDERMAL DIS 2" X 3" PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

TRANSDERM‐SC DIS 1.5MG ANTIEMETICS, MISCELLANEOUS BRAND Covered TIER 2 

TRANSFER NDL MIS 20G DEVICES BRAND Excluded TIER 99 

TRANSMITTER MIS G4 DEVICES BRAND Covered TIER 3 

TRANXENE T TAB 15MG 



TRANXENE T TAB 3.75MG 



TRANXENE T TAB 7.5MG 



TRANYLCYPROM TAB 10MG MONOAMINE OXIDASE INHIBITORS GENERIC Covered TIER 1 

TRANZGEL GEL 



TRASYLOL INJ 10000/ML HEMOSTATICS BRAND Covered TIER 3 

TRAUMANIL GEL 



TRAUMEEL INJ 



TRAVASOL INJ 10% CALORIC AGENTS BRAND Covered TIER 3 



423

TRAVATAN Z DRO 0.004% PROSTAGLANDIN ANALOGS BRAND Covered TIER 2 

TRAVEL‐AIRE MIS COMPRES DEVICES BRAND Excluded TIER 99 

TRAZAMINE PAK SEROTONIN MODULATORS BRAND Covered TIER 3 

TRAZODONE TAB 100MG SEROTONIN MODULATORS GENERIC Covered TIER 1 




TREAGAN OTIC DRO LOCAL ANESTHETICS (EENT) Brand‐O PA TIER 3 

TREANDA INJ 100MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

TREANDA INJ 25MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

TRECATOR TAB 250MG ANTITUBERCULOSIS AGENTS BRAND Covered TIER 3 

TRELSTAR DEP INJ 3.75MG ANTINEOPLASTIC AGENTS BRAND PA TIER 3 SP 

TRELSTAR LA INJ 11.25MG ANTINEOPLASTIC AGENTS BRAND PA TIER 3 SP 

TRELSTAR MIX INJ 22.5MG ANTINEOPLASTIC AGENTS BRAND PA TIER 3 SP 

TRENTAL TAB 400MG CR HEMORRHEOLOGIC AGENTS Brand‐O PA TIER 3 

TREPADICLOFE PAK 25MG 



TREPADONE CAP CALORIC AGENTS BRAND Excluded TIER 99 

TREPOXEN PAK 250MG 



TREPOXICAM PAK 7.5MG 



TRETINOIN CAP 10MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

TRETINOIN CRE 0.025% 











424

TRETINOIN GEL 0.01% 



TRETINOIN GEL 0.025% 



TRETINOIN EM CRE 0.05% 


PROLIFERANTS GENERIC Excluded TIER 99 

TRETIN‐X CRE 0.0375% 



TRETIN‐X CRE KIT 0.025% 









TRETIN‐X GEL KIT 0.01% 



TRETIN‐X GEL KIT 0.025% 



TREXALL TAB 10MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 



TREXALL TAB 7.5MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

TREXBROM LIQ ANTITUSSIVES GENERIC Covered TIER 1 

TREXIMET TAB 85‐500MG SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 2 QL 

TREZIX CAP OPIATE AGONISTS GENERIC Covered TIER 1 

TRI PRENATAL CAP DHA ONE MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TRI RX TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

TRIADVANCE TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

TRIAMCIN/ORA PST 0.1% 





425

TRIAMCINOLON CRE 0.025% 









TRIAMCINOLON LOT 0.025% 



TRIAMCINOLON LOT 0.1% 



TRIAMCINOLON OIN 0.025% 












TRIAMCINOLON PST 0.1% 



TRIAMCINOLON SPR 55MCG/AC CORTICOSTEROIDS (EENT) GENERIC Covered TIER 1 

TRIAMT/HCTZ CAP 37.5‐25 POTASSIUM‐SPARING DIURETICS GENERIC Covered TIER 1 

TRIAMT/HCTZ TAB 37.5‐25 POTASSIUM‐SPARING DIURETICS GENERIC Covered TIER 1 

TRIAMT/HCTZ TAB 75‐50MG POTASSIUM‐SPARING DIURETICS GENERIC Covered TIER 1 

TRIANEX OIN 0.05% 



TRIAZ PAD 3% 



TRIAZ PAD 6% 





426

TRIAZ PAD 9% 



TRIAZ CLEANS LOT 3% 









TRIAZ CLOTHS MIS 3% 









TRIAZOLAM TAB 0.125MG 



TRIAZOLAM TAB 0.25MG 



TRIBENZOR20‐ TAB 5‐12.5MG DIHYDROPYRIDINES BRAND Covered TIER 2 

TRIBENZOR40‐ TAB 10‐12.5 DIHYDROPYRIDINES BRAND Covered TIER 2 

TRIBENZOR40‐ TAB 10‐25MG DIHYDROPYRIDINES BRAND Covered TIER 2 

TRIBENZOR40‐ TAB 5‐12.5MG DIHYDROPYRIDINES BRAND Covered TIER 2 

TRIBENZOR40‐ TAB 5‐25MG DIHYDROPYRIDINES BRAND Covered TIER 2 

TRICARE TAB PRENATAL MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

TRICARE DHA CAP 301 MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TRI‐CHLOR LIQ 80% 



TRICHOPHYTON INJ 1:200 TRICHINOSIS GENERIC Covered TIER 1 

TRICHOPHYTON INJ 1:500 TRICHINOSIS BRAND Covered TIER 3 



427

TRICITRASOL CON ANTICOAGULANTS, MISCELLANEOUS BRAND Covered TIER 3 

TRICITRATES SOL ALKALINIZING AGENTS GENERIC Covered TIER 1 

TRICON CAP IRON PREPARATIONS GENERIC Covered TIER 1 

TRICOR TAB 145MG FIBRIC ACID DERIVATIVES BRAND Covered TIER 2 QL 

TRICOR TAB 48MG FIBRIC ACID DERIVATIVES BRAND Covered TIER 2 QL 

TRIDERM CRE 0.1% 



TRIESENCE INJ 40MG/ML CORTICOSTEROIDS (EENT) BRAND Covered TIER 3 

TRIFLUOPERAZ TAB 10MG PHENOTHIAZINES GENERIC Covered TIER 1 




TRIFLURIDINE SOL 1% OP ANTIVIRALS (EENT) GENERIC Covered TIER 1 

TRIGELS‐F CAP FORTE IRON PREPARATIONS GENERIC Covered TIER 1 

TRIGLIDE TAB 160MG FIBRIC ACID DERIVATIVES BRAND Covered TIER 2 QL 

TRIGLIDE TAB 50MG FIBRIC ACID DERIVATIVES BRAND Covered TIER 2 QL 

TRIHEXYPHEN ELX 0.4MG/ML ANTICHOLINERGIC AGENTS (CNS) GENERIC Covered TIER 1 

TRIHEXYPHEN TAB 2MG ANTICHOLINERGIC AGENTS (CNS) GENERIC Covered TIER 1 

TRIHEXYPHEN TAB 5MG ANTICHOLINERGIC AGENTS (CNS) GENERIC Covered TIER 1 

TRIHIBIT KIT P/F TOXOIDS BRAND Excluded TIER 99 

TRI‐LEGEST TAB FE CONTRACEPTIVES GENERIC Covered TIER 1 

TRILEPTAL SUS 300MG/5M 



TRILEPTAL TAB 150MG 











428

TRILIPIX CAP 135MG FIBRIC ACID DERIVATIVES BRAND Covered TIER 2 QL 

TRILIPIX CAP 45MG FIBRIC ACID DERIVATIVES BRAND Covered TIER 2 QL 

TRI‐LUMA CRE DEPIGMENTING AGENTS BRAND Excluded TIER 99 

TRILYTE SOL CATHARTICS AND LAXATIVES GENERIC Covered TIER 1 

TRIMESIS RX TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

TRIMETHOBENZ CAP 300MG ANTIHISTAMINES (GI DRUGS) GENERIC Covered TIER 1 

TRIMETHOBENZ INJ 100MG/ML ANTIHISTAMINES (GI DRUGS) GENERIC Covered TIER 1 

TRIMETHOPRIM SOL POLYMYXN ANTIBACTERIALS (EENT) GENERIC Covered TIER 1 

TRIMETHOPRIM TAB 100MG URINARY ANTI‐INFECTIVES GENERIC Covered TIER 1 

TRIMIPRAMINE CAP 100MG 









TRINATAL TAB ULTRA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TRINATAL GT TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TRINATAL RX TAB 1 MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

TRINATE TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

TRINESSA TAB CONTRACEPTIVES GENERIC Covered TIER 1 

TRI‐NORINYL TAB 28 CONTRACEPTIVES Brand‐O PA TIER 3 

TRIOSTAT INJ 10MCG/ML THYROID AGENTS Brand‐O PA TIER 3 

TRIOXIN SUS OTIC LOCAL ANESTHETICS (EENT) Brand‐O PA TIER 3 

TRIPEDIA SUS P/F TOXOIDS BRAND Excluded TIER 99 

TRIPHROCAPS CAP MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

TRIPLE DYE LIQ 



TRI‐PREVIFEM TAB CONTRACEPTIVES GENERIC Covered TIER 1 

TRISENOX SOL 10MG/10M ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

TRISPEC DMX DRO PEDIATRC ANTITUSSIVES BRAND Excluded TIER 99 



429

TRISPEC DMX LIQ ANTITUSSIVES BRAND Excluded TIER 99 

TRISPEC PSE DRO PEDIATRC ANTITUSSIVES BRAND Excluded TIER 99 

TRISPEC PSE LIQ ANTITUSSIVES BRAND Excluded TIER 99 

TRI‐SPRINTEC TAB CONTRACEPTIVES GENERIC Covered TIER 1 

TRITUSS SYP ANTITUSSIVES BRAND Excluded TIER 99 

TRIVEEN‐DUO PAK DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TRIVEEN‐ONE CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TRIVEEN‐PRX CAP RNF MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TRIVEEN‐TEN TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TRIVEEN‐U CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TRI‐VI‐FLOR SUS 0.25/ML MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TRI‐VI‐FLOR SUS 0.5MG/ML MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TRI‐VIT/FE DRO /FL 0.25 MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

TRI‐VIT/FL DRO 0.25MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

TRI‐VIT/FL DRO 0.5MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

TRI‐VIT/FLUO DRO 0.25MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

TRI‐VIT/FLUO DRO 0.5MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

TRI‐VITA/FL DRO 0.25MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

TRIVORA‐28 TAB CONTRACEPTIVES GENERIC Covered TIER 1 

TRI‐ZEL TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

TRIZIVIR TAB 



TROCAR CATH MIS 10FR/9" DEVICES BRAND Excluded TIER 99 










430

TROCHE MOLD MIS 30 CAVIT DEVICES BRAND Excluded TIER 99 

TROLAMINE LIQ PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

TROLAMINE LIQ 99% PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

TROPAZONE CRE 



TROPAZONE LOT BASIC LOTIONS AND LINIMENTS BRAND Covered TIER 3 

TROPHAMINE INJ 10% CALORIC AGENTS BRAND Covered TIER 3 

TROPHAMINE INJ 6% CALORIC AGENTS Brand‐O PA TIER 3 

TROPICAMIDE SOL 0.5% OP MYDRIATICS GENERIC Covered TIER 1 

TROPICAMIDE SOL 1% OP MYDRIATICS GENERIC Covered TIER 1 

TROSPIUM CHL CAP 60MG ER 



TROSPIUM CL TAB 20MG 



TRUSOPT SOL 2% OP 



TRUST NATAL PAK DHA MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

TRUVADA TAB 



TRUZONE PEAK MIS FLOW MTR DEVICES BRAND Excluded TIER 99 

TRYPTOPHAN CAP 500MG 



TUBERSOL INJ 5/0.1ML TUBERCULOSIS BRAND Covered TIER 3 

TUBING EXT MIS SET DEVICES BRAND Excluded TIER 99 

TUDORZA PRES AER 400/ACT 



TURPENTINE SOL SPIRITS BASIC LOTIONS AND LINIMENTS GENERIC Covered TIER 1 

TUSNEL CAP EXPECTORANTS BRAND Excluded TIER 99 

TUSNEL PED‐C SYP ANTITUSSIVES BRAND Excluded TIER 99 

TUSSAFED EX LIQ ANTITUSSIVES GENERIC Covered TIER 1 



431

TUSSI PRES‐B LIQ EXPECTORANTS GENERIC Excluded TIER 99 

TUSSI‐12 TAB 5‐60MG ANTITUSSIVES BRAND Excluded TIER 99 

TUSSI‐12 S SUS 4‐30MG/5 ANTITUSSIVES Brand‐O PA TIER 99 

TUSSI‐12D TAB 10‐40‐60 ANTITUSSIVES BRAND Excluded TIER 99 

TUSSI‐12D S SUS ANTITUSSIVES BRAND Excluded TIER 99 

TUSSICAPS CAP 10‐8MG ANTITUSSIVES BRAND Excluded TIER 99 

TUSSICAPS CAP 5‐4MG ANTITUSSIVES BRAND Excluded TIER 99 

TUSSIGON TAB 5MG ANTITUSSIVES GENERIC Covered TIER 1 

TUSSIONEX SUS EXT‐REL ANTITUSSIVES Brand‐O PA TIER 99 

TUSSO‐C LIQ 200‐10MG ANTITUSSIVES BRAND Excluded TIER 99 

TUSSO‐DMR CAP 7‐14‐288 ANTITUSSIVES BRAND Excluded TIER 99 

TUSSO‐ZMR CAP 8‐200MG ANTITUSSIVES BRAND Excluded TIER 99 

TUSSO‐ZR SYP 7.5‐150 ANTITUSSIVES BRAND Excluded TIER 99 

TUTTI FRUTTI LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

TUTTI‐FRUTTI LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

TWINJECT INJ 0.15MG 



TWINJECT INJ 0.3MG 



TWINRIX INJ VACCINES BRAND Covered TIER 3 

TWO BOTTLE MIS SNGL DRN DEVICES BRAND Excluded TIER 99 

TWO BOTTLE MIS TUBING DEVICES BRAND Excluded TIER 99 

TWYNSTA TAB 40‐10MG DIHYDROPYRIDINES BRAND Covered TIER 2 




TYGACIL INJ 50MG GLYCYLCYCLINES BRAND Covered TIER 3 

TYKERB TAB 250MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 QL SP 

TYLENOL/COD TAB #3 OPIATE AGONISTS Brand‐O PA TIER 3 

TYLENOL/COD TAB #4 OPIATE AGONISTS Brand‐O PA TIER 3 



432

TYLOX CAP 5‐500MG OPIATE AGONISTS Brand‐O PA TIER 3 QL 

TYPHIM VI INJ VACCINES BRAND Covered TIER 3 

TYSABRI INJ BIOLOGIC RESPONSE MODIFIERS BRAND Covered TIER 3 SP 

TYVASO SOL 0.6MG/ML 



TYVASO REFIL SOL 0.6MG/ML 



TYVASO START SOL 0.6MG/ML 



TYZEKA TAB 600MG NUCLEOSIDES AND NUCLEOTIDES BRAND Covered TIER 3 

TYZINE SOL 0.1% VASOCONSTRICTORS BRAND Covered TIER 3 

TYZINE PED DRO 0.05% VASOCONSTRICTORS BRAND Covered TIER 3 

UBICHINON INJ COMPOSIT 



U‐CORT CRE 1% 



UDAMIN TAB MULTIVITAMIN PREPARATIONS BRAND Excluded TIER 99 

UDAMIN SP TAB MULTIVITAMIN PREPARATIONS BRAND Excluded TIER 99 

U‐KERA E CRE 40% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

ULESFIA LOT 5% SCABICIDES AND PEDICULICIDES BRAND Covered TIER 2 

ULORIC TAB 40MG ANTIGOUT AGENTS BRAND Covered TIER 2 

ULORIC TAB 80MG ANTIGOUT AGENTS BRAND Covered TIER 2 

ULTANE SOL INHALATION ANESTHETICS Brand‐O PA TIER 3 

ULTEC PRO PAD 4"X4" 











433




ULTIMATE OB MIS DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

ULTIMATECARE CAP ONE MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

ULTIMATECARE CAP ONE NF MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

ULTIMATECARE MIS ADVANTAG MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

ULTIMATECARE MIS COMBO MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

ULTIVA INJ 1MG OPIATE AGONISTS BRAND Covered TIER 3 



ULTRA TABS TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

ULTRABAG/ SOL DIANEAL IRRIGATING SOLUTIONS BRAND Covered TIER 3 

ULTRABAG/PD2 SOL DIANEAL IRRIGATING SOLUTIONS BRAND Covered TIER 3 

ULTRACET TAB 37.5‐325 OPIATE AGONISTS Brand‐O PA TIER 3 

ULTRADERM CRE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

ULTRAFLEX II MIS 31"/8MM DEVICES BRAND Covered TIER 3 

ULTRAFOAM MIS 2X6.25X7 HEMOSTATICS BRAND Excluded TIER 99 



ULTRAFOAM MIS 8X25X1 HEMOSTATICS BRAND Excluded TIER 99 


ULTRAM TAB 50MG OPIATE AGONISTS Brand‐O PA TIER 3 

ULTRAM ER TAB 100MG OPIATE AGONISTS Brand‐O PA TIER 3 



ULTRAVATE CRE 0.05% 



ULTRAVATE KIT 





434

ULTRAVATE KIT PAC 



ULTRAVATE OIN 0.05% 



ULTRAVATE X KIT 0.05‐10% 



ULTRAVIST INJ 150MG/ML ROENTGENOGRAPHY BRAND Covered TIER 3 




UMECTA EMU KERATOLYTIC AGENTS BRAND Covered TIER 3 

UMECTA SUS 40% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

UMECTA MOUSS AER 40% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

UMECTA NAIL SUS FILM KERATOLYTIC AGENTS Brand‐O PA TIER 3 

UMECTA PD EMU 40‐0.3% KERATOLYTIC AGENTS BRAND Covered TIER 3 

UMECTA PD SUS 40‐0.3% KERATOLYTIC AGENTS BRAND Covered TIER 3 

UNASYN INJ 1.5GM AMINOPENICILLINS Brand‐O PA TIER 3 

UNASYN INJ 1.5GM PB AMINOPENICILLINS Brand‐O PA TIER 3 

UNASYN INJ 15GM AMINOPENICILLINS Brand‐O PA TIER 3 

UNASYN INJ 3GM AMINOPENICILLINS Brand‐O PA TIER 3 

UNASYN INJ 3GM PB AMINOPENICILLINS Brand‐O PA TIER 3 

UNGUATOR MIS 36MM DEVICES BRAND Excluded TIER 99 

UNGUATOR MIS 57MM DEVICES BRAND Excluded TIER 99 

UNGUATOR 1MM MIS VARIONOZ DEVICES BRAND Excluded TIER 99 

UNGUATOR 4MM MIS VARIONOZ DEVICES BRAND Excluded TIER 99 

UNGUATOR AIR MIS 300/390 DEVICES BRAND Excluded TIER 99 

UNGUATOR AIR MIS 500/600 DEVICES BRAND Excluded TIER 99 

UNGUATOR JAR MIS 100/140 DEVICES BRAND Excluded TIER 99 





435




UNGUTOR 50 MIS 43MM DEVICES BRAND Excluded TIER 99 

UNIRETIC TAB 15‐12.5 



UNIRETIC TAB 15‐25MG 



UNIRETIC TAB 7.5‐12.5 



UNITH DIRECT TAB 100MCG THYROID AGENTS GENERIC Covered TIER 1 











UNITHROID TAB 100MCG THYROID AGENTS GENERIC Covered TIER 1 











436




UNIVASC TAB 15MG 



UNIVASC TAB 7.5MG 



UNIVERSAL GEL WATER 



UNIVERSAL MIS PUMP ADP DEVICES BRAND Excluded TIER 99 

UNIVERT TAB 32MG ANTIHISTAMINES (GI DRUGS) GENERIC Covered TIER 1 

UR N‐C TAB URINARY ANTI‐INFECTIVES GENERIC Covered TIER 1 

URAMAXIN AER 20% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

URAMAXIN CRE 45% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

URAMAXIN GEL 45% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

URAMAXIN LOT 45% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

URAMAXIN GT KIT 45% KERATOLYTIC AGENTS BRAND Covered TIER 3 

URAMAXIN GT SOL 45% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

UREA CRE 39% KERATOLYTIC AGENTS GENERIC Covered TIER 1 




UREA EMU 50% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

UREA GEL 40% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

UREA LOT 40% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

UREA LOT 45% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

UREA OIN 50% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

UREA SUS 50% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

UREA 40% SUS NAIL KERATOLYTIC AGENTS GENERIC Covered TIER 1 

UREA HYDRATI AER 35% KERATOLYTIC AGENTS GENERIC Covered TIER 1 



437

UREA NAIL GEL 45% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

UREA NAIL KIT KERATOLYTIC AGENTS GENERIC Covered TIER 1 

UREA NAIL MIS 50% KERATOLYTIC AGENTS BRAND Covered TIER 3 

UREA TOPICAL SUS 40% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

UREA‐C40 LOT 40% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

URECHOLINE TAB 10MG 












URELIEF PLUS TAB 



URELLE TAB URINARY ANTI‐INFECTIVES BRAND Covered TIER 3 

URETHR CATH MIS 14FRENCH DEVICES BRAND Excluded TIER 99 

URETRON D/S TAB URINARY ANTI‐INFECTIVES BRAND Covered TIER 3 


UREX TAB 1GM URINARY ANTI‐INFECTIVES Brand‐O PA TIER 3 

URIBEL CAP 118MG URINARY ANTI‐INFECTIVES BRAND Covered TIER 3 

URI‐CLEANSE TAB RX 



URI‐CONTROL TAB RX 



URIN D/S TAB URINARY ANTI‐INFECTIVES GENERIC Covered TIER 1 

URINE METER MIS KIDS DEVICES BRAND Excluded TIER 99 

UROCIT‐K 10 TAB ALKALINIZING AGENTS Brand‐O PA TIER 3 

UROCIT‐K 15 TAB ALKALINIZING AGENTS BRAND Covered TIER 2 

UROCIT‐K 5 TAB ALKALINIZING AGENTS Brand‐O PA TIER 3 



438

UROGESIC‐ TAB BLUE URINARY ANTI‐INFECTIVES Brand‐O PA TIER 3 

UROQID #2 TAB URINARY ANTI‐INFECTIVES BRAND Covered TIER 3 

UROSEX TAB MULTIVITAMIN PREPARATIONS GENERIC Excluded TIER 99 

UROXATRAL TAB 10MG 


BLOCK.AGENT Brand‐O PA TIER 3 QL 

URSO 250 TAB 250MG CHOLELITHOLYTIC AGENTS Brand‐O PA TIER 3 

URSO FORTE TAB 500MG CHOLELITHOLYTIC AGENTS Brand‐O PA TIER 3 

URSODIOL CAP 300MG CHOLELITHOLYTIC AGENTS GENERIC Covered TIER 1 

URSODIOL TAB 250MG CHOLELITHOLYTIC AGENTS GENERIC Covered TIER 1 

URSODIOL TAB 500MG CHOLELITHOLYTIC AGENTS GENERIC Covered TIER 1 

URYL TAB URINARY ANTI‐INFECTIVES GENERIC Covered TIER 1 

USTELL CAP URINARY ANTI‐INFECTIVES GENERIC Covered TIER 1 

UTA CAP 120MG URINARY ANTI‐INFECTIVES GENERIC Covered TIER 1 

UTICAP CAP URINARY ANTI‐INFECTIVES GENERIC Covered TIER 1 

UTIRA‐C TAB URINARY ANTI‐INFECTIVES GENERIC Covered TIER 1 

UTRONA‐C TAB URINARY ANTI‐INFECTIVES GENERIC Covered TIER 1 

UVADEX INJ 20MCG/ML PIGMENTING AGENTS BRAND Covered TIER 3 SP 

VAGIFEM TAB 10MCG ESTROGENS BRAND Covered TIER 2 

VAGINAL APPL MIS SUPPOSIT DEVICES GENERIC Excluded TIER 99 

VAGINAL PREP KIT PACK 



VAGINAL PREP KIT TRAY 



VALACYCLOVIR TAB 1GM NUCLEOSIDES AND NUCLEOTIDES GENERIC Covered TIER 1 

VALACYCLOVIR TAB 500MG NUCLEOSIDES AND NUCLEOTIDES GENERIC Covered TIER 1 

VALCYTE SOL 50MG/ML NUCLEOSIDES AND NUCLEOTIDES BRAND Covered TIER 3 

VALCYTE TAB 450MG NUCLEOSIDES AND NUCLEOTIDES BRAND Covered TIER 2 

VALERIAN EXT ROOT 





439

VALIUM TAB 10MG 









VALPROATE INJ 100MG/ML 



VALPROATE INJ 500/5ML 



VALPROIC ACD CAP 250MG 



VALPROIC ACD SOL 250/5ML 



VALPROIC ACD SYP 250/5ML 



VALSART/HCTZ TAB 160‐12.5 



VALSART/HCTZ TAB 160‐25MG 






VALSART/HCTZ TAB 320‐25MG 






VALSTAR SOL 40MG/ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

VALTREX TAB 1GM NUCLEOSIDES AND NUCLEOTIDES Brand‐O PA TIER 3 

VALTREX TAB 500MG NUCLEOSIDES AND NUCLEOTIDES Brand‐O PA TIER 3 

VALTURNA TAB 150‐160 RENIN INHIBITORS BRAND Covered TIER 2 



440

VALTURNA TAB 300‐320 RENIN INHIBITORS BRAND Covered TIER 2 

VALVD HOLDNG MIS CHAMBER DEVICES BRAND Excluded TIER 99 

VANCOCIN HCL CAP 125MG GLYCOPEPTIDES Brand‐O PA TIER 3 

VANCOCIN HCL CAP 250MG GLYCOPEPTIDES Brand‐O PA TIER 3 

VANCOMYC/DEX INJ 1GM GLYCOPEPTIDES GENERIC Covered TIER 1 

VANCOMYC/DEX INJ 500MG GLYCOPEPTIDES GENERIC Covered TIER 1 

VANCOMYC/DEX INJ 750MG GLYCOPEPTIDES GENERIC Covered TIER 1 

VANCOMYCIN CAP 125MG GLYCOPEPTIDES GENERIC Covered TIER 1 

VANCOMYCIN CAP 250MG GLYCOPEPTIDES GENERIC Covered TIER 1 

VANCOMYCIN INJ 1 GM GLYCOPEPTIDES GENERIC Covered TIER 1 

VANCOMYCIN INJ 1000MG GLYCOPEPTIDES GENERIC Covered TIER 1 

VANCOMYCIN INJ 10GM GLYCOPEPTIDES GENERIC Covered TIER 1 


VANCOMYCIN INJ 5GM GLYCOPEPTIDES GENERIC Covered TIER 1 


VANDAZOLE GEL 0.75% 



VANDETANIB TAB 100MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

VANDETANIB TAB 300MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 

VANILLA LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

VANILLA EXTR LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

VANIQA CRE 13.9% 



VANISHING CRE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

VANISHING CRE BASE II PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

VANISH‐PEN CRE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

VANOS CRE 0.1% 



VANOXIDE HC KIT 





441

VANOXIDE‐HC LOT 5‐0.5% 



VANTAS KIT 50MG ANTINEOPLASTIC AGENTS BRAND PA TIER 2 SP 

VAPRISOL INJ VASOPRESSIN ANTAGONISTS BRAND Covered TIER 3 

VAQTA INJ 25/0.5ML VACCINES BRAND Covered TIER 3 

VAQTA INJ 50UNT/ML VACCINES BRAND Covered TIER 3 

VARIBAR PST PUDDING ROENTGENOGRAPHY BRAND Covered TIER 3 

VARIBAR HONE SUS 40% ROENTGENOGRAPHY BRAND Covered TIER 3 

VARIBAR NECT SUS 40% ROENTGENOGRAPHY BRAND Covered TIER 3 

VARIBAR THIN SUS HONEY ROENTGENOGRAPHY BRAND Covered TIER 3 

VARIBAR THIN SUS LIQUID ROENTGENOGRAPHY BRAND Covered TIER 3 

VARIVAX INJ VACCINES BRAND Covered TIER 3 

VASCAZEN CAP 1GM 



VASCULERA TAB CALORIC AGENTS BRAND Excluded TIER 99 

VASERETIC TAB 10‐25MG 



VASOLEX OIN 



VASOPRESSIN INJ 10/0.5ML PITUITARY GENERIC Covered TIER 1 

VASOPRESSIN INJ 20UNT/ML PITUITARY GENERIC Covered TIER 1 

VASOTEC TAB 10MG 



VASOTEC TAB 2.5MG 











442

VAYACOG CAP 



VAYARIN CAP 



VAYAROL CAP 



VAZOBID SUS 6‐10MG/5 PROPYLAMINE DERIVATIVES Brand‐O PA TIER 99 

VAZOL LIQ 2MG/5ML PROPYLAMINE DERIVATIVES BRAND Covered TIER 3 

VAZOTAB CHW PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

VAZOTAN SUS ANTITUSSIVES BRAND Excluded TIER 99 

V‐C FORTE CAP MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

V‐COF SUS ANTITUSSIVES GENERIC Covered TIER 1 

VECTIBIX INJ 100MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

VECTIBIX INJ 400MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

VECTICAL OIN 3MCG/GM 



VECURONIUM INJ 10MG 



VECURONIUM INJ 20MG 



VELCADE INJ 3.5MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

VELETRI INJ 0.5MG 



VELETRI INJ 1.5MG 




VELIVET PAK CONTRACEPTIVES GENERIC Covered TIER 1 

VELTIN GEL 



VEMAVITE‐ CAP PRX 2 MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 



443

VENA‐BAL MIS DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VENATAL COMP MIS DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VENATAL‐FA TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VENELEX OIN 



VENLAFAXINE CAP 150MG ER 


REUPTAKE INHIBTR GENERIC Covered TIER 1 QL 

VENLAFAXINE CAP 37.5MG 



VENLAFAXINE CAP 75MG ER 



VENLAFAXINE TAB 100MG 



VENLAFAXINE TAB 150MG ER 









VENLAFAXINE TAB 37.5 ER 



VENLAFAXINE TAB 37.5MG 












VENOFER INJ 20MG/ML IRON PREPARATIONS BRAND Covered TIER 3 



444

VENOMIL KIT HONEYBEE 



VENOMIL KIT WASP 



VENOMIL KIT WHT HORN 



VENOMIL KIT YEL HORN 



VENOMIL KIT YEL JACK 



VENOMIL MIX INJ VESPID 



VENTAVIS SOL 10MCG/ML 



VENTAVIS SOL 20MCG/ML 




VENTOLIN HFA AER 


VERAMYST SPR 27.5MCG CORTICOSTEROIDS (EENT) BRAND Covered TIER 2 

VERAPAMIL CAP 100MG ER 






VERAPAMIL CAP 120MG SR 











445






VERAPAMIL INJ 2.5MG/ML 

VERAPAMIL TAB 120MG 

VERAPAMIL TAB 120MG ER 

VERAPAMIL TAB 120MG SR 







































446

VERDESO AER 0.05% 



VEREGEN OIN 15% 



VERELAN CAP 120MG SR 



VERELAN CAP 180MG 









VERELAN PM CAP 100MG 









VERIPRED 20 SOL 20MG/5ML ADRENALS BRAND Covered TIER 3 

VERSABASE AER PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

VERSABASE CRE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

VERSABASE GEL PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

VERSABASE LIQ TRANSDML PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

VERSABASE LOT PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

VERSABASE SHA PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

VERSAFREE SYP PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

VERSAPLUS SYP PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

VERSAPRO CRE PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

VERSAPRO GEL PHARMACEUTICAL AIDS BRAND Excluded TIER 99 



447

VERSICLEAR LOT 



VERTIGOHEEL DRO 



VERTIGOHEEL LIQ 



VERTIGOHEEL SUB 



VESICARE TAB 10MG 



VESICARE TAB 5MG 



VESTURA TAB 3‐0.02MG CONTRACEPTIVES GENERIC Covered TIER 1 

VEXOL SUS 1% OP CORTICOSTEROIDS (EENT) BRAND Covered TIER 3 

VFEND SUS 40MG/ML AZOLES BRAND Covered TIER 3 

VFEND TAB 200MG AZOLES Brand‐O PA TIER 3 QL 

VFEND TAB 50MG AZOLES Brand‐O PA TIER 3 QL 

VFEND IV INJ 200MG AZOLES Brand‐O PA TIER 3 

V‐GO 20 KIT DEVICES BRAND Covered TIER 2 



V‐HIST SUS 6‐10MG/5 PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

VIAGRA TAB 100MG 









VIASPAN SOL 





448

VIBATIV INJ 250MG GLYCOPEPTIDES BRAND Covered TIER 3 

VIBATIV INJ 750MG GLYCOPEPTIDES BRAND Covered TIER 3 

VIBRAMYCIN CAP 100MG TETRACYCLINES Brand‐O PA TIER 3 

VIBRAMYCIN SUS 25MG/5ML TETRACYCLINES BRAND Covered TIER 2 

VIBRAMYCIN SYP 50MG/5ML TETRACYCLINES BRAND Covered TIER 3 

VICAP FORTE CAP MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

VIC‐FORTE CAP MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

VICODIN TAB 5‐300MG OPIATE AGONISTS GENERIC Covered TIER 1 

VICODIN TAB 5‐500MG OPIATE AGONISTS Brand‐O PA TIER 3 

VICODIN ES TAB 7.5‐300 OPIATE AGONISTS GENERIC Covered TIER 1 

VICODIN ES TAB 7.5‐750 OPIATE AGONISTS Brand‐O PA TIER 3 

VICODIN HP TAB 10‐300MG OPIATE AGONISTS GENERIC Covered TIER 1 

VICODIN HP TAB 10‐660MG OPIATE AGONISTS GENERIC Covered TIER 1 

VICOPROFEN TAB 7.5‐200 OPIATE AGONISTS Brand‐O PA TIER 3 

VICTOZA INJ 18MG/3ML INCRETIN MIMETICS BRAND PA TIER 2 

VICTRELIS CAP 200MG HCV PROTEASE INHIBITORS BRAND PA TIER 2 SP 

VIDAZA INJ 100MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

VIDEX SOL 2GM 



VIDEX SOL 4GM 



VIDEX EC CAP 125MG 












VIGAMOX DRO 0.5% ANTIBACTERIALS (EENT) BRAND Covered TIER 2 



449

VIIBRYD KIT SEROTONIN MODULATORS BRAND Covered TIER 2 

VIIBRYD TAB 10MG SEROTONIN MODULATORS BRAND Covered TIER 2 QL 



VIMOVO TAB 375‐20MG 



VIMOVO TAB 500‐20MG 



VIMPAT INJ 200MG/20 



VIMPAT SOL 10MG/ML 



VIMPAT TAB 100MG 












VINACAL TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VINATE AZ TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

VINATE AZ EX TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 2 

VINATE C TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

VINATE CAL TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VINATE CARE CHW MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

VINATE GT TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

VINATE IC CAP MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

VINATE II TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

VINATE M TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 



450

VINATE ONE TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

VINATE PN TAB CARE MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

VINATE ULTRA TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

VINBLASTINE INJ 10MG ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

VINBLASTINE INJ 1MG/ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

VINCASAR PFS INJ 1MG/ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

VINCRISTINE INJ 1MG/ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

VINORELBINE INJ 10MG/ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

VINORELBINE INJ 50MG/5ML ANTINEOPLASTIC AGENTS GENERIC Covered TIER 1 SP 

VIOKACE TAB DIGESTANTS BRAND Covered TIER 3 

VIORELE TAB CONTRACEPTIVES GENERIC Covered TIER 1 

VIOS MIS SYSTEM DEVICES BRAND Excluded TIER 99 

VIOS LC MIS SPRINT DEVICES BRAND Excluded TIER 99 

VIOS LC PLUS MIS DEVICES BRAND Excluded TIER 99 

VIOS LC PLUS MIS DELUXE DEVICES BRAND Excluded TIER 99 

VIOS LC PLUS MIS PEDIATRC DEVICES BRAND Excluded TIER 99 

VIRACEPT POW 50MG/GM HIV PROTEASE INHIBITORS BRAND Covered TIER 2 

VIRACEPT TAB 250MG HIV PROTEASE INHIBITORS BRAND Covered TIER 2 

VIRACEPT TAB 625MG HIV PROTEASE INHIBITORS BRAND Covered TIER 2 

VIRAMUNE SUS 50MG/5ML 

NONNUCLEOSIDE 


VIRAMUNE TAB 200MG 

NONNUCLEOSIDE 

REV.TRANSCRIPTASE INHIB. Brand‐O PA TIER 3 

VIRAMUNE XR TAB 

NONNUCLEOSIDE 


VIRASAL LIQ 27.5% KERATOLYTIC AGENTS Brand‐O PA TIER 3 

VIRAZOLE INH 6GM NUCLEOSIDES AND NUCLEOTIDES BRAND Covered TIER 3 

VIREAD POW 40MG/GM 





451

VIREAD TAB 150MG 












VIRILEX CAP CALORIC AGENTS BRAND Excluded TIER 99 

VIROPTIC SOL 1% OP ANTIVIRALS (EENT) Brand‐O PA TIER 3 

VIRT‐BAL DHA MIS MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VIRT‐BAL DHA MIS PLUS MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VIRTI‐SULF CRE 10‐5% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

VIRT‐PN TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VIRT‐PN DHA CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VIRT‐SELECT CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VISCOAT SOL EENT DRUGS, MISCELLANEOUS BRAND Excluded TIER 99 

VISICOL TAB 1.5GM CATHARTICS AND LAXATIVES BRAND Covered TIER 3 

VISIONBLUE SOL 0.06% OCULAR DISORDERS BRAND Excluded TIER 99 

VISIPAQUE INJ 270MG/ML ROENTGENOGRAPHY BRAND Covered TIER 3 

VISIPAQUE INJ 320MG/ML ROENTGENOGRAPHY BRAND Covered TIER 3 

VISTARIL CAP 25MG 


HYPNOTICS,MISC. Brand‐O PA TIER 3 

VISTARIL CAP 50MG 


HYPNOTICS,MISC. Brand‐O PA TIER 3 

VISTIDE INJ 75MG/ML NUCLEOSIDES AND NUCLEOTIDES BRAND Covered TIER 3 

VISUDYNE INJ 15MG EENT DRUGS, MISCELLANEOUS BRAND Covered TIER 3 SP 

VIT B‐COMPLX INJ 100 VITAMIN B COMPLEX GENERIC Covered TIER 1 

VITA S FORTE TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

VITACEL TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 



452

VITACIRC‐B TAB VITAMIN B COMPLEX BRAND Excluded TIER 99 

VITAFOL SYP IRON PREPARATIONS BRAND Covered TIER 3 

VITAFOL TAB IRON PREPARATIONS Brand‐O PA TIER 3 

VITAFOL‐OB PAK +DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VITAFOL‐OB TAB 65‐1MG MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

VITAFOL‐ONE CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VITAFOL‐PLUS CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VITAFOL‐PN TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VITAJECT INJ MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VITAL‐D RX TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VITAMAX PED DRO MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VITAMEDMD CAP ONE RX MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VITAMEDMD MIS PLUS RX MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VITAMIN C INJ 222MG/ML VITAMIN C GENERIC Covered TIER 1 

VITAMIN D CAP 50000UNT VITAMIN D GENERIC Covered TIER 1 

VITAMIN K1 INJ 10MG/ML VITAMIN K ACTIVITY GENERIC Covered TIER 1 

VITAMIN K1 INJ 1MG/0.5 VITAMIN K ACTIVITY GENERIC Covered TIER 1 

VITAMN FORTE CAP MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

VITA‐PREN TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VITA‐RESPA TAB VITAMIN B COMPLEX BRAND Excluded TIER 99 

VITAROCA PLU TAB MULTIVITAMIN PREPARATIONS Brand‐O PA TIER 3 

VITASPIRE TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

VITAZOL CRE 0.75% 



VITRASE INJ 200/ML ENZYMES BRAND Covered TIER 3 

VITRASERT IMP 4.5MG ANTIVIRALS (EENT) BRAND Covered TIER 3 

VIVA CT CHW 28‐1MG MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VIVA DHA CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VIVACTIL TAB 10MG 





453

VIVACTIL TAB 5MG 



VIVELLE‐DOT DIS 0.025MG ESTROGENS BRAND Covered TIER 2 





VIVITROL INJ 380MG OPIATE ANTAGONISTS BRAND PA TIER 2 SP 

VIVOTIF BERN CAP EC VACCINES BRAND Covered TIER 3 

VIXONE DISP MIS NEBULIZR DEVICES BRAND Excluded TIER 99 

V‐NATAL TAB 32‐1MG MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

V‐NATAL DHA MIS MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VOL‐CARE RX TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

VOL‐NATE TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VOL‐PLUS TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VOL‐TAB RX TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 


VOLTAREN GEL 1% 


VOLTAREN SOL 0.1% OP 



VOLTAREN‐XR TAB 100MG 



VOLUMEN SUS 0.1% ROENTGENOGRAPHY BRAND Covered TIER 3 

VOLUVEN INJ 6%/NACL REPLACEMENT PREPARATIONS BRAND Covered TIER 3 

VORAXAZE INJ 1000UNIT ANTIDOTES BRAND Covered TIER 3 

VORICONAZOLE INJ 200MG AZOLES GENERIC Covered TIER 1 

VORICONAZOLE TAB 200MG AZOLES GENERIC PA TIER 1 QL 

VORICONAZOLE TAB 50MG AZOLES GENERIC PA TIER 1 QL 

VORTEX VALVE MIS CHAMBER DEVICES BRAND Excluded TIER 99 

VORTEX/MASK MIS CHILDS DEVICES BRAND Excluded TIER 99 



454

VORTEX/MASK MIS TODDLER DEVICES BRAND Excluded TIER 99 

VOSOL SOL 2% OTIC EENT DRUGS, MISCELLANEOUS Brand‐O PA TIER 3 

VOSOL HC SOL OTIC CORTICOSTEROIDS (EENT) Brand‐O PA TIER 3 

VOSPIRE ER TAB 4MG 



VOSPIRE ER TAB 8MG 



VOTRIENT TAB 200MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 QL SP 

VP‐CH‐PNV CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VP‐ERA OB PAK PLUS MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VP‐GGR‐B6 TAB PRENATAL MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VP‐GSTN CAP 



VP‐PNV‐DHA CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

VP‐PRECIP CAP 



VPRIV INJ 400UNIT ENZYMES BRAND Covered TIER 2 

VP‐ZEL TAB MULTIVITAMIN PREPARATIONS GENERIC Covered TIER 1 

VSL#3 DS PAK ANTIDIARRHEA AGENTS BRAND Covered TIER 3 

VUMON INJ 50MG/5ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

VUSION OIN 



VYTORIN TAB 10‐10MG HMG‐COA REDUCTASE INHIBITORS BRAND Covered TIER 2 






455

VYVANSE CAP 20MG AMPHETAMINES BRAND Covered TIER 2 QL 






WARFARIN TAB 10MG COUMARIN DERIVATIVES GENERIC Covered TIER 1 


WARFARIN TAB 2.5MG COUMARIN DERIVATIVES GENERIC Covered TIER 1 






WARFARIN TAB 7.5MG COUMARIN DERIVATIVES GENERIC Covered TIER 1 

WASP VENOM INJ 1000MCG 









WASP VENOM KIT 100MCG 



WATCHHALER MIS DEVICES BRAND Excluded TIER 99 

WATERMELON LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

WELCHOL PAK 3.75GM BILE ACID SEQUESTRANTS BRAND Covered TIER 2 

WELCHOL TAB 625MG BILE ACID SEQUESTRANTS BRAND Covered TIER 2 

WELLBUTRIN TAB 100MG ANTIDEPRESSANTS, MISCELLANEOUS Brand‐O PA TIER 3 QL 



456

WELLBUTRIN TAB 100MG SR ANTIDEPRESSANTS, MISCELLANEOUS Brand‐O PA TIER 3 QL 



WELLBUTRIN TAB 75MG ANTIDEPRESSANTS, MISCELLANEOUS Brand‐O PA TIER 3 QL 

WELLBUTRIN TAB XL 150MG ANTIDEPRESSANTS, MISCELLANEOUS Brand‐O PA TIER 3 QL 

WELLBUTRIN TAB XL 300MG ANTIDEPRESSANTS, MISCELLANEOUS Brand‐O PA TIER 3 QL 

WERA TAB 0.5/35 CONTRACEPTIVES GENERIC Covered TIER 1 

WESTCORT OIN 0.2% 



WESTHROID TAB 113.75MG THYROID AGENTS BRAND Covered TIER 3 

WESTHROID TAB 130MG THYROID AGENTS GENERIC Covered TIER 1 




WESTHROID TAB 195MG THYROID AGENTS BRAND Covered TIER 3 


WESTHROID TAB 32.5MG THYROID AGENTS GENERIC Covered TIER 1 



WESTHROID TAB 65MG THYROID AGENTS GENERIC Covered TIER 1 



WHEAT GERM OIL VITAMIN E GENERIC Covered TIER 1 

WHEY PROTEIN POW CALORIC AGENTS GENERIC Covered TIER 1 



457

WHITE HORNET KIT 100MCG 



WHITE HORNET SOL 1000MCG 



WHITE WAX MIS PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

WIDE‐SEAL DPR KIT 60 
























WILATE INJ HEMOSTATICS BRAND PA TIER 2 SP 

WILD CHERRY LIQ FLAVOR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

WILEY BASIC OIN BHRT PHARMACEUTICAL AIDS BRAND Excluded TIER 99 

WINDMILL MIS TRAINER DEVICES BRAND Excluded TIER 99 

WINGED GRIP MIS SPONGE 



WINRHO SDF INJ 15000UNT SERUMS BRAND Covered TIER 3 SP 

WINRHO SDF INJ 1500UNIT SERUMS BRAND Covered TIER 3 SP 




458


WITEPSOL H15 MIS BASE F PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

WYMZYA FE CHW 0.4MG‐35 CONTRACEPTIVES GENERIC Covered TIER 1 

XALATAN SOL 0.005% PROSTAGLANDIN ANALOGS Brand‐O PA TIER 3 

XALKORI CAP 200MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

XALKORI CAP 250MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

XANAX TAB 0.25MG 



XANAX TAB 0.5MG 



XANAX TAB 1MG 



XANAX TAB 2MG 



XANAX XR TAB 0.5MG 



XANAX XR TAB 1MG 









XARELTO TAB 10MG DIRECT FACTOR XA INHIBITORS BRAND PA TIER 3 QL 



XCLAIR CRE 



XELODA TAB 150MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 

XELODA TAB 500MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 SP 



459

XENADERM OIN 



XENAZINE TAB 12.5MG 



XENAZINE TAB 25MG 



XENICAL CAP 120MG GI DRUGS, MISCELLANEOUS BRAND Excluded TIER 99 

XEOMIN INJ 100UNIT 



XEOMIN INJ 50 UNIT 



XERAC‐AC SOL 6.25% ASTRINGENTS BRAND Covered TIER 3 

XERESE CRE 5‐1% 



XEROFORM MIS DRESSING DEVICES BRAND Covered TIER 3 

XEROFORM MIS OVERWRAP DEVICES BRAND Covered TIER 3 

XEROFORM PET MIS OVERWRAP DEVICES BRAND Covered TIER 3 

XEROFORM PET MIS ROLL DEVICES BRAND Covered TIER 3 

XEROFORM PET PAD 1"X8" DEVICES BRAND Covered TIER 3 




XGEVA INJ BONE RESORPTION INHIBITORS BRAND PA TIER 2 QL SP 

XIAFLEX INJ 0.9MG ENZYMES BRAND PA TIER 2 SP 

XIBROM SOL 0.09% 



XIFAXAN TAB 200MG RIFAMYCINS BRAND PA TIER 3 QL 

XIFAXAN TAB 550MG RIFAMYCINS BRAND PA TIER 2 QL 

XIGRIS INJ 20MG 





460

XIGRIS INJ 5MG 



XODOL TAB 10‐300MG OPIATE AGONISTS Brand‐O PA TIER 3 

XODOL TAB 5‐300MG OPIATE AGONISTS Brand‐O PA TIER 3 

XODOL TAB 7.5‐300 OPIATE AGONISTS Brand‐O PA TIER 3 

XOLAIR SOL 150MG 



XOLEGEL GEL 2% 



XOLEGEL KIT COREPAK 



XOLEGEL DUO/ KIT HEAD&SHD 



XOLEGEL DUO/ KIT XOLEX 



XOLOX TAB 10‐500MG OPIATE AGONISTS BRAND Covered TIER 3 QL 

XOPENEX NEB 0.31MG 



XOPENEX NEB 0.63MG 



XOPENEX NEB 1.25/3ML 



XOPENEX CONC NEB 1.25/0.5 



XOPENEX HFA AER 



XROFORM PET MIS OVERWRAP DEVICES BRAND Covered TIER 3 

XTANDI CAP 40MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 

X‐VIATE CRE 40% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

X‐VIATE GEL 40% KERATOLYTIC AGENTS GENERIC Covered TIER 1 



461

X‐VIATE LOT 40% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

XYLO/EPI INJ 0.5% LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 

XYLO/EPI INJ 2% LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 

XYLO/EPI 1%‐ INJ 1:100000 LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 


XYLOCAINE GEL 2% 


XYLOCAINE INJ 0.5% LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 

XYLOCAINE INJ 1% LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 

XYLOCAINE INJ 2% LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 

XYLOCAINE INJ MPF 0.5% LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 

XYLOCAINE INJ ‐MPF 1% LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 

XYLOCAINE INJ MPF 1.5% LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 




XYLOCAINE SOL 4% 


XYLO‐MPF/EPI INJ 1% LOCAL ANESTHETICS (PARENTERAL) BRAND Covered TIER 3 



462

XYLO‐MPF/EPI INJ 1.5% LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 

XYLO‐MPF/EPI INJ 2% LOCAL ANESTHETICS (PARENTERAL) Brand‐O PA TIER 3 

XYNTHA INJ 1000UNIT HEMOSTATICS BRAND PA TIER 2 SP 





XYNTHA SOLOF INJ 500UNIT HEMOSTATICS BRAND PA TIER 2 SP 

XYNTHA SOLOF KIT 250UNIT HEMOSTATICS BRAND PA TIER 2 SP 

XYREM SOL 500MG/ML 



XYZAL SOL 



XYZAL TAB 5MG 



YASMIN 28 TAB 3‐0.03MG CONTRACEPTIVES Brand‐O PA TIER 3 

YAZ TAB 3‐0.02MG CONTRACEPTIVES Brand‐O PA TIER 2 

YELLOW HORN INJ 550MCG 



YELLOW HORNT KIT 100MCG 



YELLOW HORNT SOL 1000MCG 



YELLOW JACK INJ 1300MCG 



YELLOW JACK INJ 550MCG 





463

YELLOW JACKT KIT 100MCG 



YELLOW JACKT SOL 1000MCG 



YERVOY INJ 200MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

YERVOY INJ 50MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

YF‐VAX INJ VACCINES GENERIC Covered TIER 1 

YIELD NON‐AD PAD 2"X3" DEVICES BRAND Covered TIER 3 

YIELD NON‐AD PAD 3"X4" DEVICES BRAND Covered TIER 3 

YODOXIN TAB 210MG AMEBICIDES BRAND Covered TIER 2 

YODOXIN TAB 650MG AMEBICIDES BRAND Covered TIER 2 

ZACARE KIT KIT 4% 



ZACARE KIT KIT 8% 



ZACLIR LOT 4% 



ZACLIR LOT 8% 



ZAFIRLUKAST TAB 10MG LEUKOTRIENE MODIFIERS GENERIC Covered TIER 1 

ZAFIRLUKAST TAB 20MG LEUKOTRIENE MODIFIERS GENERIC Covered TIER 1 

ZALEPLON CAP 10MG 


HYPNOTICS,MISC. GENERIC Covered TIER 1 QL 

ZALEPLON CAP 5MG 



ZALTRAP INJ 100/4ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 

ZALTRAP INJ 200/8ML ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 

ZAMICET SOL 10‐325MG OPIATE AGONISTS BRAND Covered TIER 3 

ZANAFLEX CAP 2MG 





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ZANAFLEX TAB 4MG 



ZANOSAR INJ 1GM ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

ZANTAC INJ 25MG/ML HISTAMINE H2‐ANTAGONISTS Brand‐O PA TIER 3 

ZANTAC INJ 50/50ML HISTAMINE H2‐ANTAGONISTS BRAND Covered TIER 3 

ZANTAC SYP 15MG/ML HISTAMINE H2‐ANTAGONISTS Brand‐O PA TIER 3 

ZANTAC TAB 150MG HISTAMINE H2‐ANTAGONISTS Brand‐O PA TIER 3 

ZANTAC TAB 25MG EF HISTAMINE H2‐ANTAGONISTS BRAND Covered TIER 3 

ZANTAC TAB 300MG HISTAMINE H2‐ANTAGONISTS Brand‐O PA TIER 3 

ZARAH TAB CONTRACEPTIVES GENERIC Covered TIER 1 

ZARONTIN CAP 250MG SUCCINIMIDES Brand‐O PA TIER 3 

ZARONTIN SOL 250/5ML SUCCINIMIDES Brand‐O PA TIER 3 

ZAROXOLYN TAB 2.5MG THIAZIDE‐LIKE DIURETICS Brand‐O PA TIER 3 

ZAROXOLYN TAB 5MG THIAZIDE‐LIKE DIURETICS Brand‐O PA TIER 3 

ZATEAN‐CH CAP MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

ZATEAN‐PN CAP DHA MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

ZATEAN‐PN CAP PLUS MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

ZATEAN‐PN TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

ZAVESCA CAP 100MG 



ZAZOLE CRE 0.4% 



ZAZOLE CRE 0.8% 



ZAZOLE SUP 80MG 





465

Z‐COF I SUS ANTITUSSIVES BRAND Excluded TIER 99 

Z‐DEX SYP ANTITUSSIVES GENERIC Covered TIER 1 

Z‐DEX 12D TAB ANTITUSSIVES GENERIC Covered TIER 1 

ZEBETA TAB 10MG 



ZEBETA TAB 5MG 



ZEBUTAL CAP 



ZEEL INJ 



ZEGERID CAP 20‐1100 PROTON‐PUMP INHIBITORS Brand‐O PA TIER 3 QL 

ZEGERID CAP 40‐1100 PROTON‐PUMP INHIBITORS Brand‐O PA TIER 3 QL 

ZEGERID POW 20‐1680 PROTON‐PUMP INHIBITORS BRAND Covered TIER 3 QL 

ZEGERID POW 40‐1680 PROTON‐PUMP INHIBITORS BRAND Covered TIER 3 QL 

ZELAPAR TAB 1.25MG MONOAMINE OXIDASE B INHIBITORS BRAND Covered TIER 3 

ZELBORAF TAB 240MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

ZEMAIRA INJ 1000MG 



ZEMA‐PAK PAK 10 DAY ADRENALS GENERIC Covered TIER 1 



ZEMPLAR CAP 1MCG VITAMIN D BRAND Covered TIER 2 



ZEMPLAR INJ 2MCG/ML VITAMIN D BRAND Covered TIER 3 

ZEMPLAR INJ 5MCG/ML VITAMIN D BRAND Covered TIER 3 

ZEMURON INJ 10MG/ML 





466

ZENCHENT TAB CONTRACEPTIVES GENERIC Covered TIER 1 

ZENCHENT FE CHW 0.4MG‐35 CONTRACEPTIVES GENERIC Covered TIER 1 

ZENCIA LIQ 9‐4% KERATOLYTIC AGENTS GENERIC Covered TIER 1 

ZENIEVA CRE 



ZENPEP CAP 10000UNT DIGESTANTS BRAND Covered TIER 2 




ZENPEP CAP 3000UNIT DIGESTANTS BRAND Covered TIER 2 

ZENPEP CAP 5000UNIT DIGESTANTS BRAND Covered TIER 2 

ZEOSA CHW CONTRACEPTIVES GENERIC Covered TIER 1 

ZERIT CAP 15MG 












ZERIT SOL 1MG/ML 



ZESTORETIC TAB 10‐12.5 



ZESTORETIC TAB 20‐12.5 



ZESTORETIC TAB 20‐25MG 



ZESTRIL TAB 10MG 





467

ZESTRIL TAB 2.5MG 















ZETIA TAB 10MG 

CHOLESTEROL ABSORPTION 


ZETONNA AER 37MCG CORTICOSTEROIDS (EENT) BRAND Covered TIER 3 

ZEVALIN KIT IN‐111 ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 SP 

ZEVALIN KIT Y‐90 ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 

ZEWA TENS MIS 502 DEVICES BRAND Excluded TIER 99 

ZEWA TENS MIS 504 DEVICES BRAND Excluded TIER 99 

ZFLEX TAB ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1 

ZGESIC TAB 66‐600MG ETHANOLAMINE DERIVATIVES GENERIC Covered TIER 1 

ZIAC TAB 10/6.25 



ZIAC TAB 2.5/6.25 



ZIAC TAB 5‐6.25MG 



ZIAGEN SOL 20MG/ML 



ZIAGEN TAB 300MG 





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ZIANA GEL 



ZIDOVUDINE CAP 100MG 



ZIDOVUDINE SYP 50MG/5ML 



ZIDOVUDINE TAB 300MG 



ZINACEF INJ 1.5GM 



ZINACEF INJ 7.5GM 



ZINACEF INJ 750MG 



ZINACEF/D5W INJ 750MG PB 



ZINACEF/H20 INJ 1.5GM PB 



ZINC ACETATE CRY REPLACEMENT PREPARATIONS GENERIC Excluded TIER 99 

ZINC ACETATE CRY USP PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

ZINC SULFATE GRA HEPTAHYR PHARMACEUTICAL AIDS GENERIC Excluded TIER 99 

ZINC SULFATE GRA USP/NF REPLACEMENT PREPARATIONS GENERIC Excluded TIER 99 

ZINC SULFATE INJ 1MG/ML REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

ZINC SULFATE INJ 5MG/ML REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

ZINC TRACE INJ 1MG/ML REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

ZINCATE CAP 220MG REPLACEMENT PREPARATIONS GENERIC Covered TIER 1 

ZINECARD INJ 250MG PROTECTIVE AGENTS Brand‐O PA TIER 3 SP 

ZINECARD INJ 500MG PROTECTIVE AGENTS Brand‐O PA TIER 3 

ZINGIBER TAB MULTIVITAMIN PREPARATIONS BRAND Covered TIER 3 

ZINOTIC DRO LOCAL ANESTHETICS (EENT) BRAND Covered TIER 3 



469

ZINOTIC ES DRO LOCAL ANESTHETICS (EENT) BRAND Covered TIER 3 

ZIOPTAN DRO 0.0015% PROSTAGLANDIN ANALOGS BRAND Covered TIER 3 

ZIPRASIDONE CAP 20MG ATYPICAL ANTIPSYCHOTICS GENERIC Covered TIER 1 QL 




ZIPSOR CAP 25MG 



ZIRGAN GEL 0.15% ANTIVIRALS (EENT) BRAND Covered TIER 3 

ZITHRANOL SHA 1% 



ZITHRANOL‐RR CRE 1.2% 



ZITHROMAX INJ 500MG OTHER MACROLIDES Brand‐O PA TIER 3 

ZITHROMAX POW 1GM PAK OTHER MACROLIDES BRAND Covered TIER 3 

ZITHROMAX SUS 100/5ML OTHER MACROLIDES Brand‐O PA TIER 3 

ZITHROMAX SUS 200/5ML OTHER MACROLIDES Brand‐O PA TIER 3 

ZITHROMAX TAB 250MG OTHER MACROLIDES Brand‐O PA TIER 3 



ZITHROMAX TAB TRI‐PAK OTHER MACROLIDES Brand‐O PA TIER 3 

ZITHROMAX TAB Z‐PAK OTHER MACROLIDES Brand‐O PA TIER 3 

ZMAX SUS 2GM OTHER MACROLIDES BRAND Covered TIER 3 

ZN‐DTPA SOL 1000MG HEAVY METAL ANTAGONISTS GENERIC Covered TIER 1 

ZOCOR TAB 10MG HMG‐COA REDUCTASE INHIBITORS Brand‐O PA TIER 3 





470



ZOFRAN INJ 40/20ML 5‐HT3 RECEPTOR ANTAGONISTS Brand‐O PA TIER 3 

ZOFRAN SOL 4MG/5ML 5‐HT3 RECEPTOR ANTAGONISTS Brand‐O PA TIER 3 QL 

ZOFRAN TAB 4MG 5‐HT3 RECEPTOR ANTAGONISTS Brand‐O PA TIER 3 QL 

ZOFRAN TAB 4MG ODT 5‐HT3 RECEPTOR ANTAGONISTS Brand‐O PA TIER 3 QL 

ZOFRAN TAB 8MG 5‐HT3 RECEPTOR ANTAGONISTS Brand‐O PA TIER 3 QL 

ZOFRAN TAB 8MG ODT 5‐HT3 RECEPTOR ANTAGONISTS Brand‐O PA TIER 3 QL 

ZOLADEX IMP 10.8MG ANTINEOPLASTIC AGENTS BRAND PA TIER 2 SP 

ZOLADEX IMP 3.6MG ANTINEOPLASTIC AGENTS BRAND PA TIER 2 SP 

ZOLINZA CAP 100MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 3 QL SP 

ZOLOFT CON 20MG/ML 



ZOLOFT TAB 100MG 









ZOLPIDEM TAB 10MG 



ZOLPIDEM TAB 5MG 



ZOLPIDEM ER TAB 12.5MG 



ZOLPIDEM ER TAB 6.25MG 





471

ZOLPIMIST SPR 5MG 



ZOLVIT SOL 10‐300MG OPIATE AGONISTS BRAND Covered TIER 3 

ZOMETA INJ 4MG/5ML BONE RESORPTION INHIBITORS BRAND Covered TIER 3 SP 

ZOMIG SPR 5MG SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 2 

ZOMIG TAB 2.5MG SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 2 QL 

ZOMIG TAB 5MG SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 2 QL 

ZOMIG ZMT TAB 2.5 MG SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 2 QL 

ZOMIG ZMT TAB 5MG SELECTIVE SEROTONIN AGONISTS BRAND Covered TIER 2 QL 

ZONALON CRE 5% 



ZONATUSS CAP 150MG ANTITUSSIVES BRAND Excluded TIER 99 

ZONEGRAN CAP 100MG 



ZONEGRAN CAP 25MG 



ZONISAMIDE CAP 100MG 









ZORBTIVE INJ 8.8MG SOMATOTROPIN AGONISTS BRAND PA TIER 3 SP 

ZORTRESS TAB 0.25MG IMMUNOSUPPRESSIVE AGENTS BRAND Covered TIER 3 



ZOSTAVAX INJ VACCINES BRAND Covered TIER 3 

ZOSYN INJ 2‐0.25GM EXTENDED‐SPECTRUM PENICILLINS Brand‐O PA TIER 3 



472

ZOSYN INJ 3‐0.375G EXTENDED‐SPECTRUM PENICILLINS Brand‐O PA TIER 3 



ZOSYN SOL 2‐0.25GM EXTENDED‐SPECTRUM PENICILLINS BRAND Covered TIER 3 

ZOSYN SOL 3‐0.375G EXTENDED‐SPECTRUM PENICILLINS BRAND Covered TIER 3 

ZOSYN SOL 4‐0.50GM EXTENDED‐SPECTRUM PENICILLINS BRAND Covered TIER 3 

ZOTEX SYP ANTITUSSIVES Brand‐O PA TIER 99 

ZOTEX PE TAB PROPYLAMINE DERIVATIVES BRAND Excluded TIER 99 

ZOTEX PED DRO ANTITUSSIVES Brand‐O PA TIER 99 

ZOTEX‐12D TAB ANTITUSSIVES GENERIC Covered TIER 1 

ZOTEX‐C SYP ANTITUSSIVES BRAND Excluded TIER 99 

ZOTEX‐D SYP ANTITUSSIVES BRAND Excluded TIER 99 

ZOTEX‐DM SYP ANTITUSSIVES BRAND Excluded TIER 99 

ZOTEX‐EX TAB ANTITUSSIVES BRAND Excluded TIER 99 

ZOTEX‐G SYP ANTITUSSIVES BRAND Excluded TIER 99 

ZOTEX‐GP TAB EXPECTORANTS BRAND Excluded TIER 99 

ZOTEX‐PE TAB 6‐30MG PROPYLAMINE DERIVATIVES GENERIC Covered TIER 1 

ZOVIA 1/35E TAB CONTRACEPTIVES GENERIC Covered TIER 1 

ZOVIA 1/50E TAB CONTRACEPTIVES GENERIC Covered TIER 1 

ZOVIRAX CAP 200MG NUCLEOSIDES AND NUCLEOTIDES Brand‐O PA TIER 3 

ZOVIRAX CRE 5% 



ZOVIRAX OIN 5% 





473

ZOVIRAX SUS 200/5ML NUCLEOSIDES AND NUCLEOTIDES Brand‐O PA TIER 3 

ZOVIRAX TAB 400MG NUCLEOSIDES AND NUCLEOTIDES Brand‐O PA TIER 3 

ZOVIRAX TAB 800MG NUCLEOSIDES AND NUCLEOTIDES Brand‐O PA TIER 3 

Z‐PRAM KIT 2.35‐1% 



Z‐TUSS DM LIQ ANTITUSSIVES GENERIC Covered TIER 1 

ZUPLENZ MIS 4MG 5‐HT3 RECEPTOR ANTAGONISTS BRAND Covered TIER 3 QL 

ZUPLENZ MIS 8MG 5‐HT3 RECEPTOR ANTAGONISTS BRAND Covered TIER 3 QL 

ZUTRIPRO LIQ ANTITUSSIVES BRAND Excluded TIER 99 

ZYBAN TAB 150MG SR ANTIDEPRESSANTS, MISCELLANEOUS Brand‐O PA TIER 2 


ZYCLARA CRE 3.75% 


ZYCLARA PUMP CRE 2.5% 



ZYCLARA PUMP CRE 3.75% 



ZYDONE TAB 10‐400MG OPIATE AGONISTS BRAND Covered TIER 3 

ZYDONE TAB 5‐400MG OPIATE AGONISTS BRAND Covered TIER 3 

ZYDONE TAB 7.5‐400 OPIATE AGONISTS BRAND Covered TIER 3 

ZYFLO TAB 600MG LEUKOTRIENE MODIFIERS BRAND Covered TIER 3 

ZYFLO CR TAB 600MG LEUKOTRIENE MODIFIERS BRAND Covered TIER 3 

ZYLET SUS 0.5‐0.3% CORTICOSTEROIDS (EENT) BRAND Covered TIER 2 

ZYLOPRIM TAB 100MG ANTIGOUT AGENTS Brand‐O PA TIER 3 

ZYLOPRIM TAB 300MG ANTIGOUT AGENTS Brand‐O PA TIER 3 

ZYMAXID SOL 0.5% ANTIBACTERIALS (EENT) BRAND Covered TIER 2 

ZYPRAM CRE 2.35‐1% 



ZYPREXA INJ 10MG ATYPICAL ANTIPSYCHOTICS Brand‐O PA TIER 3 QL 

ZYPREXA TAB 10MG ATYPICAL ANTIPSYCHOTICS Brand‐O PA TIER 3 QL 



474


ZYPREXA TAB 2.5MG ATYPICAL ANTIPSYCHOTICS Brand‐O PA TIER 3 QL 



ZYPREXA TAB 7.5MG ATYPICAL ANTIPSYCHOTICS Brand‐O PA TIER 3 QL 

ZYPREXA RELP INJ 210MG ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 3 



ZYPREXA ZYDI TAB 10MG ATYPICAL ANTIPSYCHOTICS Brand‐O PA TIER 3 QL 




ZYTAZE CAP 25‐500 REPLACEMENT PREPARATIONS BRAND Excluded TIER 99 

ZYTIGA TAB 250MG ANTINEOPLASTIC AGENTS BRAND Covered TIER 2 

ZYVOX SOL 2MG/ML OXAZOLIDINONES BRAND PA TIER 3 

ZYVOX SUS 100MG/5M OXAZOLIDINONES BRAND PA TIER 2 QL 

ZYVOX TAB 600MG OXAZOLIDINONES BRAND PA TIER 2 QL 

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ABILIFY INJ 9.75MG ATYPICAL ANTIPSYCHOTICS BRAND Covered TIER 2 QL 

BONIVA INJ 3MG/3ML BONE RESORPTION INHIBITORS BRAND Covered TIER 3 QL SP 



INHIBITORS BRAND PA TIER 2 QL 

CLARINEX‐D TAB 2.5‐120 



CLARINEX‐D TAB 5‐240MG 



LAMICTAL ODT KIT 



LAMICTAL XR KIT 





475

OPANA INJ 1MG/ML OPIATE AGONISTS BRAND Covered TIER 3 

RECLAST INJ 5/100ML BONE RESORPTION INHIBITORS BRAND Covered TIER 3 QL 

ZOMETA INJ 4MG/100 BONE RESORPTION INHIBITORS BRAND Covered TIER 3 



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BMC Formularies by drug class 11.1.12.xlsx - BMC HealthNet Plan

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