Contra Costa Health Plan (CCHP) Medi-Cal & Commercial Hmo Formulary

Contra Costa Health Plan (CCHP)
MEDI-CAL & COMMERCIAL HMO

Formulary
Last updated: August 1, 2021

Note: The CCHP formulary is subject to change, and all previous versions are no longer in effect.
o To access the electronic version of the CCHP formulary on the health plan’s website, please go to the
following web address: https://cchealth.org/healthplan/pdf/pdl.pdf
o To access the CCHP interactive formulary search tool, please go to the following web address:
https://formularynavigator.com/Search.aspx?siteID=MMRREQ3QBC
o To access plan-specific coverage information including cost sharing information, member handbook, and
other important materials such as your Evidence of Coverage (EOC) documents, please go to the
following web address:
https://cchealth.org/healthplan/member-publications.php
Table of Contents:
Informational Section (ENGLISH) i-xi
Sección Informativa (ESPAÑOL) a-m
Antihistamine Drugs - Drugs For Allergy 1
Anti-Infective Agents - Drugs For Infections 4
Antineoplastic Agents - Drugs For Cancer 15
Antitoxins,Immune Glob,Toxoids,Vaccines - Drugs For The Immune System 19
Autonomic Drugs - Drugs For The Nervous System 22
Blood Formation, Coagulation, Thrombosis - Drugs For The Blood 28
Cardiovascular Drugs - Drugs For The Heart 31
Central Nervous System Agents - Drugs For The Nervous System 49
Contraceptives (E.G. Foams, Devices) - Drugs For Women 65
Devices - Medical Supplies And Durable Medical Equipment 67
Diagnostic Agents 68
Electrolytic, Caloric, And Water Balance 68
Enzymes 73
Eye, Ear, Nose And Throat (Eent) Preps 73
Gastrointestinal Drugs 78
Gastrointestinal Drugs - Drugs For The Stomach 79
Gold Compounds 83
Heavy Metal Antagonists - Drugs To Reduce Iron 83
Hormones And Synthetic Substitutes - Hormones 84
Local Anesthetics (Parenteral) - Drugs For Numbing 95
Miscellaneous Therapeutic Agents 95
Oxytocics - Drugs For Women 100
Pharmaceutical Aids 101
Respiratory Tract Agents - Drugs For The Lungs 101
Skin And Mucous Membrane Agents - Drugs For The Skin 109
Smooth Muscle Relaxants - Drugs To Relax Muscles 119
Vitamins 120
Index of Prescription Drugs 125
Frequently Asked Questions
What is the CCHP formulary?
The CCHP formulary (also known as the CCHP preferred drug list, or PDL) includes
drugs used to treat common diseases or health problems. This formulary applies only
to outpatient drugs and self-administered drugs – it does not apply to medications used
in the inpatient setting or in medical offices.
The formulary is a continually reviewed and revised list of preferred medications based
on safety, efficacy, and cost-effectiveness. It is updated on a monthly basis and is
effective the first of every month. Updates are based on input from a team of doctors
and pharmacists that meet regularly to decide which drugs should be included. These
updates may include, but are not limited to the following: (i) removal or addition of drugs
and/or dosage forms. (ii) changes in tier placement of a drug (iii) changes to utilization
management restrictions (such as quantity limits, step therapy, etc.). Updated
documents are available online at: https://www.cchealth.org.
How do I use the CCHP formulary?

The list of formulary drugs begins on Page 1. To locate a drug on the formulary, simply
look for the name of the drug in the index at the end of this booklet - the index lists all of
the drugs on the formulary, including brand name and generic name. Once you have
located the name of the drug in the index, you will see the page number where you can
find more information about your drug listed next to it.
Instead of using the index, the formulary can also be searched by using ctrl+F to find a
specific medication by brand name, generic name, or therapeutic class.
A mobile-enabled version of the CCHP formulary is also available using the ePocrates
application. After you have downloaded the application to your mobile device, simply
choose the “Contra Costa Health Plan Medi-Cal” formulary to display the formulary
status of drugs within the application. If you have any questions about the installation or
use of the Epocrates application, please contact Epocrates Customer Support at
(800)230-2150 or goldsupport@epocrates.com.
The presence of a prescription drug on the CCHP formulary does not guarantee that a
member will be prescribed that medication by his or her prescribing provider for a
particular medical condition. The absence of a drug on the CCHP means that the drug
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is not on the formulary, and will require prior authorization to be covered (specific
information about the CCHP prior authorization process is located below in the section
titled “What if the drug that I need isn’t listed on the CCHP formulary?”)
How are drugs listed on the formulary?
Drugs are listed alphabetically by brand and generic name within the therapeutic
category and class to which they belong. Brand name drugs will appear in all CAPITAL
letters, with the generic name listed in parentheses after the brand name in all bold and
italicized lowercase letters. If a generic drug is available, it will be listed separately
from the brand name drug, and will always be listed in bold and italicized lowercase
letters. If a generic equivalent of a brand name drug is not available, then the generic
drug will not be listed separately from the brand name drug. In situations where an FDA
approved generic equivalent is available, brand names are listed for reference purposes
only, and do not denote coverage for the brand, unless specifically noted.
An example listing from the CCHP formulary is below:
What if the drug that I need isn’t listed on the CCHP formulary?
If your drug isn’t listed on the CCHP formulary you can ask your doctor if there is a
different drug on the formulary that will work the same way. If your doctor decides that
you need a drug that is not on the formulary, they can ask CCHP to make an exception
through the prior authorization process. All prior authorization requests will be
evaluated by a health plan clinician (pharmacist or medical doctor) based upon CCHP
prior authorization criteria that is approved by the CCHP Pharmacy and Therapeutics
(P&T) committee. In instances where specific criteria do not exist, FDA indications,
peer reviewed literature, other plan criteria, national treatment guidelines (such as
IDSA, NCCN, AACE, etc.), and other medical compendia will be used for evaluation.
Exceptions can be made for a variety of different reasons:
 Your doctor can ask CCHP to cover a drug that is listed on the formulary as
requiring a prior authorization (PA): these drugs require approval prior to being
dispensed at a network pharmacy. Each request will be reviewed by a health plan
clinician, and if the request does not meet the guidelines established by the plan it
will not be approved, and alternative therapy may be recommended.
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 Your doctor can ask CCHP to cover a drug that isn’t listed on the formulary: any
drug not found on this list is considered non-formulary. Coverage for non-formulary
agents may be requested by the prescriber. Each request will be reviewed by a
health plan clinician, and approval will be given if a documented medical need exists
and if there isn’t an alternate agent on the formulary.
 Your doctor can ask CCHP to make an exception to limits on a drug. For example, if
a drug has a limit of 1 tablet per day, your doctor can ask us to cover more. If
quantities exceeding the limit are necessary, an exception to coverage may be
requested by the prescriber. Each request will be reviewed by a health plan
clinician, and approval will be given if a documented medical need exists without
compromising safety.
 Your doctor can ask CCHP to make an exception to Step Therapy (ST)
requirements: these drugs require one or more first step drugs to be tried before
progressing to the second step drug (for example, if Drug A and Drug B both treat
your health condition, CCHP may not cover Drug B unless you try Drug A first). If
there is a medical need to use a second step drug without trying a first step drug, an
exception to coverage may be requested by the prescriber. Each request will be
reviewed by a health plan clinician, and approval will be given if a documented
medical need exists. If you have already tried and failed the preferred drug(s), or if
you are already taking a drug that is subject to step therapy when you switch to
CCHP, you will not have to try the preferred drugs again. Your doctor can simply
request an approval through the plan for continuation of therapy.
To start the CCHP prior authorization process or to ask for an exception, your doctor
must fax a prior authorization request to CCHP at 1-866-428-7369 for urgent requests,
or 1-866-205-8014 for standard requests. Your doctor may also be able to submit the
request electronically to CCHP using the electronic medical record. If the request is
approved, you will be able to get your medication filled at a pharmacy that works with
CCHP. If we deny the request we will send you and your doctor a letter and will tell you
how to file an appeal or a grievance. An “appeal” is when you want a decision to be
reviewed again by the health plan (usually with additional information), and a
“grievance” is a complaint or concern regarding the health plan.
CCHP will make a decision to deny or approve all prior authorization and exception
requests within 24 hours of receiving the request. If CCHP fails to respond to a prior
authorization or step therapy request within 72 hours of receiving a non-urgent request
or 24 hours of receiving a request based on exigent circumstances, the request shall be
deemed approved.
CCHP will provide coverage pursuant to a non-urgent request for the duration of the
prescription, including refills. CCHP will provide coverage, including refills, pursuant to
a request based on exigent circumstances for the duration of the exigency.
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If you would like to download the CCHP prior authorization form, it is available at:
https://cchealth.org/healthplan/pdf/performrx_medication_prior_auth_form.pdf
What if I need my medication urgently – do pharmacies have the ability to fill

emergency supplies of medication?
Yes. To ensure that CCHP members have access to a sufficient supply of medications
in emergency situations, CCHP has established an Emergency Supply Policy that
allows pharmacists to use their clinical judgement to override claims that deny at the
point of sale. When a pharmacist determines that a medication is medically necessary,
they may enter an authorization code that allows them to fill a 5-day emergency supply
of medication for any CCHP member. CCHP promotes the use of the Emergency
Supply Policy through point-of-sale messaging.
Instead of using the 5-day Emergency Supply Policy, pharmacies may also choose to
call the PerformRx provider call center at 877-234-4269 – representatives are available
24 hours per day, 365 days per year. Staff at the call center have the ability to override
prescriptions based on guidance provided by CCHP.
What if I’m a new CCHP member?
If you are a new CCHP member you may be taking drugs that are not on our formulary,
or you may be taking drugs that are on our formulary but have limits. If possible, you
should talk to your doctor to see if you can change to a preferred drug on the CCHP
formulary. If you cannot switch to a preferred drug, then your doctor will need to ask
CCHP for an exception to cover a drug you have been taking (known as continuation of
therapy). See the section above titled “What if the drug that I need isn’t listed on the
CCHP formulary?” for more information.
Does CCHP cover generic and brand name medications?
CCHP covers brand and generic drugs, but when a generic drug is available CCHP
requires that it be used. All drugs that become available generically are subject to
review by the CCHP Pharmacy & Therapeutics committee.
A prescriber may request a brand name product in lieu of an approved generic if the
prescriber determines that there is a documented medical need for the brand
equivalent. This type of request for coverage may be made through the CCHP prior
authorization process described above in the section titled “What if the drug that I need
isn’t listed on the CCHP formulary.”
Are there drugs that are excluded from coverage?

The CCHP Medi-Cal formulary is very similar to the California Medi-Cal List of Contract
Drugs. The following types of drugs are generally not a covered benefit for Medi-Cal
members (please note that this list is subject to change):
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 Erectile or sexual dysfunction drugs
 Drugs used for cosmetic reasons or hair growth
 Drugs that are considered experimental, or that are being used in an experimental
manner
 Drugs used to treat infertility
 Drugs specifically listed as “not covered” on the formulary
 Foreign drugs or drugs not approved by the United States Food & Drug
Administration (FDA)
If CCHP’s coverage is amended to exclude a drug that we have been covering and
providing to you under your current coverage, we will continue to provide the drug if a
plan physician continues to prescribe the drug for the same condition and for a use
approved by the Food and Drug Administration.
Some drugs are carved-out by the Department of Health Care Services. This means
that these drugs are covered by the Medi-Cal Fee-for-Service program for Medi-Cal
members, not by CCHP. The following types of drugs are carved-out:
 Antipsychotic medications
 HIV/AIDS medications
 Select alcohol, heroin detoxification, and dependency treatment drugs
 Select drugs to treat hemophilia
Can I go to any pharmacy for my medication?

No, members must use a pharmacy that is in the CCHP network. To find a network
pharmacy, visit the CCHP website or call the health plan directly to have one of our
member services or pharmacy staff help you locate a pharmacy near you (see section
below titled “How do I find a pharmacy?”).
How do I find a pharmacy?

To find a pharmacy near you, visit the CCHP website at https://cchealth.org/healthplan/.
Once you have navigated to the CCHP website, follow the directions below:
(1) Scroll down and click on the “Search Doctors/Clinics/Pharmacies in My Area” button
(2) Click on the red “Begin Your Search Here” button (a new window will pop up)
(3) Click on the “Facility” tab, and choose “Pharmacy” as the facility type
(4) Choose how you want to search (by zip code, distance, etc.)
(5) Click “Find a Facility” - results will immediately show up (as a map and a list)
Be sure to show your CCHP Member ID card when you fill your prescriptions at the
pharmacy.
Note: some medications are subject to limited distribution by the U.S. Food and Drug
Administration. These types of drugs are called “specialty medications” because they
require special handling, provider coordination, or special education that may not be
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provided at your local pharmacy. CCHP has a contract with Walgreens to provide these
types of medications. If you have specific questions about these types of drugs please
contact the CCHP pharmacy unit directly.
What drugs are covered by CCHP?
You can get the following drugs and other items when they are prescribed by your
doctor and are medically necessary:
 Prescription drugs listed on the CCHP formulary

 Non-prescription drugs or over-the-counter drugs (such as cough/cold syrups, cough
drops or aspirin) listed on the CCHP formulary
 Formulary diabetic supplies: insulin, insulin syringes, glucose test strips, lancets and
lancet puncture devices, pen delivery systems, and blood glucose monitors
 FDA-approved birth control and contraceptives listed on the CCHP formulary
 Emergency contraception
 Epi-Pens, peak flow meters and spacers
Are intravenous (IV) and injectable drugs covered by CCHP?
Yes, the CCHP formulary lists certain injectable products that are covered as a
pharmacy benefit. CCHP also covers most other intravenous medications through the
medical benefit. Medications that are generally covered through the medical benefit are
those that are given in a doctor’s office, clinic, or hospital setting. Requests for
coverage of a medication through the medical benefit should be directed to the CCHP
Utilization Management Department by downloading the medical referral form at
https://cchealth.org/healthplan/providers/ and faxing to (925) 313-6058 for routine
requests or (925) 313-6458 for urgent requests.
Coverage of intravenous and injectable drugs through the pharmacy benefit are outlined
below:
 Simple intravenous solutions: simple intravenous solutions are typically used for
hydration therapy. Included are commercially available (non-compounded) solutions
such as Normal Saline, Dextrose (up to 10% in Water) and Lactated Ringer’s
Solution; commercially prepared solutions of potassium chloride in such solutions
are also included in this definition. Simple intravenous solutions should be billed
using the product’s National Drug Code (NDC) number.
 Parenteral nutrition solutions (TPN or hyperalimentation): restricted to dispensing
within 10 days following inpatient discharge from an acute care hospital, when (IV)
therapy with the same product was started before discharge. There is a maximum of
10 days supply per dispensing within this 10-day period. (Parenteral nutrition
solutions are intravenously or intra-arterially administered nutritional products that
typically are suspensions or solutions of amino acids or protein, dextrose, lipids,
electrolytes, vitamin &/or mineral supplements and trace elements.) Adjuncts to
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parenteral nutrition are other drugs which are physically mixed into a parenteral
nutrition solution at any time prior to administration. Bill for these products as part of
the parenteral nutrition billing. Note: Non-compounded products must be billed
using the product’s NDC number. Compounded solutions must be billed as a
compound claim.
 Separately administered intravenous lipids: restricted to dispensing within 10 days
following inpatient discharge from an acute care hospital, when (IV) therapy with the
same product was started before discharge. There is a maximum of 10 days supply
per dispensing within this10-day period. Intravenous lipid solutions or suspensions
that are administered separately from parenteral nutrition solutions (that is, are not
physically mixed into the parenteral nutrition solution container) should be billed
using the product’s NDC number.
 Intravenous solutions of unlisted antibiotics: restricted to dispensing within 10 days
following inpatient discharge from an acute care hospital, when IV therapy with the
same antibiotic was started before discharge. There is a maximum of 10 days supply
per dispensing within the 10-day period. Note: Non-compounded products must be
billed using the product’s NDC number. Compounded solutions must be billed as a
compound claim.
 Intravenous solutions of other unlisted drugs: restricted to dispensing within 10 days
following inpatient discharge from an acute care hospital, when IV therapy with the
same drug was started before discharge. There is a maximum of 10 days supply per
dispensing within the10-day period. Note: Non-compounded products must be
billed using the product’s NDC number. Compounded solutions must be billed as a
compound claim.
How Much I Will Pay for My Drugs?

For all CCHP Medi-Cal members, you do not have to pay for covered services;
medications are available with no copay.
CCHP commercial members (plans such as commercial plan A, plan B, IHSS, etc.) may
have small copays for their medications. Please see your plan materials to determine if
you have a copay.
Can providers make suggestions to CCHP to improve the formulary?

Absolutely. The formulary is a tool to promote cost-effective prescription drug use.
CCHP has made every attempt to create a document that meets all therapeutic needs,
however the art of medicine makes this a formidable task. CCHP welcomes the
participation of physicians, pharmacists, and ancillary medical providers in this
dynamic process. Physicians and pharmacists are highly encouraged to direct any
suggestions or comments to CCHP via e-mail at:
cchp_pharmacy_director@hsd.cccounty.us.
What if I need more information?
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For more information about your pharmacy benefits, please review your Evidence of
Coverage documents or call CCHP directly to discuss. CCHP member services
department and pharmacy department staff are available to answer questions Monday
through Friday from 8:00am to 5:00pm Pacific Time at the phone numbers listed below:
CCHP Member Services Department: (877) 661-6230 x2
CCHP Pharmacy Department: (877) 661-6230 x3
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Definitions & Abbreviations:
There are a number of terms that are used in this document that Contra Costa Health
Plan wants to make sure that you understand. Below are some definitions and
abbreviations:
“Brand name drug” is a drug that is marketed under a proprietary, trademark protected
name. The brand name drug is listed in all CAPITAL letters.
“Coinsurance” is a percentage of the cost of a covered health care benefit that an

enrollee pays after the enrollee has paid the deductible, if a deductible applies to the
health care benefit, such as the prescription drug benefit.
“Copayment” is a fixed dollar amount that an enrollee pays for a covered health care
benefit after the enrollee has paid the deductible, if a deductible applies to the health
care benefit, such as the prescription drug benefit.
“Deductible” is the amount an enrollee pays for covered health care benefits before
the enrollee's health plan begins payment for all or part of the cost of the health care
benefit under the terms of the policy.
“Drug Tier” is a group of prescription drugs that corresponds to a specified cost

sharing tier in the health plan's prescription drug coverage. The tier in which a
prescription drug is placed determines the enrollee's portion of the cost for the drug.
“Enrollee” is a person enrolled in a health plan who is entitled to receive services from
the plan. All references to enrollees in this formulary template shall also include
subscribers as defined in this section below.
“Exception request” is a request for coverage of a prescription drug. If an enrollee, his

or her designee, or prescribing healthcare provider submits an exception request for
coverage of a prescription drug, the health plan must cover the prescription drug when
the drug is determined to be medically necessary to treat the enrollee's condition.
“Exigent circumstances” are when an enrollee is suffering from a health condition that
may seriously jeopardize the enrollee's life, health, or ability to regain maximum
function, or when an enrollee is undergoing a current course of treatment using a non-
formulary drug.
“Formulary” is the complete list of drugs preferred for use and eligible for coverage
under a health plan product, and includes all drugs covered under the outpatient
prescription drug benefit of the health plan product. Formulary is also known as a
prescription drug list,
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“Generic drug” is the same drug as its brand name equivalent in dosage, safety,
strength, how it is taken, quality,
performance, and intended use. A generic drug is listed in bold and italicized
lowercase letters.
“Nonformulary drug” is a prescription drug that is not listed on the health plan's
formulary.
“Out-of-pocket cost” are copayments, coinsurance, and the applicable deductible,

plus all costs for health care services that are not covered by the health plan.
“Prescribing provider” is a health care provider authorized to write a prescription to

treat a medical condition for a health plan enrollee.
“Prescription” is an oral, written, or electronic order by a prescribing provider for a

specific enrollee that contains the name of the prescription drug, the quantity of the
prescribed drug, the date of issue, the name and contact information of the prescribing
provider, the signature of the prescribing provider if the prescription is in writing, and if
requested by the enrollee, the medical condition or purpose for which the drug is being
prescribed.
“Prescription drug” is a drug that is prescribed by the enrollee's prescribing provider

and requires a prescription under
applicable law.
“Prior Authorization” is a health plan's requirement that the enrollee or the enrollee's
prescribing provider obtain the health plan's authorization for a prescription drug before
the health plan will cover the drug. The health plan shall grant a prior authorization
when it is medically necessary for the enrollee to obtain the drug.
“Step therapy” is a process specifying the sequence in which different prescription

drugs for a given medical condition and medically appropriate for a particular patient are
prescribed. The health plan may require the enrollee to try one or more drugs to treat
the enrollee's medical condition before the health plan will cover a particular drug for the
condition pursuant to a step therapy request. If the enrollee's prescribing provider
submits a request for step therapy exception, the health plans shall make exceptions to
step therapy when the criteria is met.
“Subscriber” means the person who is responsible for payment to a plan or whose
employment or other status, except for family dependency, is the basis for eligibility for
membership in the plan.
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Additional abbreviations and terms used on the CCHP formulary document are
explained below:
Abbreviation Term What it means
AL Age Limit Some drugs are only covered for certain ages.
NF Non-Formulary These drugs are not covered on the Drug List.
If your doctor feels you need a drug that is not
covered, he or she can ask us to make an
exception.
PA Prior Authorization Your doctor must ask for approval from CCHP
before some drugs will be covered.
QL Quantity Limit Some drugs are only covered for a certain
amount.
SCO State Carve-Out These drugs are carved out by the Department
of Health Care Services. This means these
drugs are covered by the Medi-Cal Fee-for-
Service program and must be billed to the
State by the pharmacy.
ST Step Therapy In some cases, you must first try certain drugs
before CalViva Health covers another drug for
your medical condition.
For example, if Drug A and Drug B both treat

your health condition, CCHP may not cover
Drug B unless you try Drug A first.
The CCHP formulary uses a 3 tier structure – the tiers are explained below:
Abbreviation Term What it means
T1 Tier 1 Tier 1 medications are preferred on the CCHP
formulary and are available without restriction
or prior authorization.
T2 Tier 2 Tier 2 medications are preferred on the CCHP
formulary and are available without prior
authorization, BUT may have certain
restrictions such as quantity limits, step
therapy, etc. (the specific restrictions are
listed on the CCHP formulary).
T3 Tier 3 Tier 3 medications are non-preferred. These
medications require prior authorization.
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Plan de Salud de Contra Costa CCHP)
ORGANIZACIÓN DE ADMINISTRACIÓN
DE SALUD (HMO) COMERCIAL Y DE
MEDI-CAL
Formulario
Última actualización: 1 de agosto de 2021

Nota: El formulario del CCHP está sujeto a cambios, y todas las versiones anteriores ya no están
vigentes.
o Para acceder a la versión electrónica del formulario del CCHP en el sitio web del plan de salud, visite la
siguiente dirección web: https://cchealth.org/healthplan/pdf/pdl.pdf
o Para acceder a la herramienta de búsqueda del formulario interactivo del CCHP, visite la siguiente
dirección web: https://formularynavigator.com/Search.aspx?siteID=MMRREQ3QBC
o Para acceder a la información de cobertura específica del plan que incluye información de costos
compartidos, manual para miembros y otros materiales importantes como los documentos de su
Evidencia de cobertura (EOC), visite la siguiente dirección web:
https://cchealth.org/healthplan/member-publications.php
Preguntas frecuentes
¿Qué es el formulario del CCHP?
El formulario del CCHP (también conocido como la lista de medicamentos preferidos
del CCHP, o PDL) incluye medicamentos utilizados para tratar enfermedades o
problemas de salud comunes. Este formulario aplica solo a los medicamentos para
pacientes en consulta externa y medicamentos autoadministrados, no aplica a
medicamentos utilizados en el entorno de pacientes internados o en consultorios
médicos.
El formulario es una lista de medicamentos preferidos examinada y revisada

continuamente en función de la seguridad, eficacia y rentabilidad. Se actualiza
mensualmente y es efectiva el primer día de cada mes. Las actualizaciones se basan
en comentarios de un grupo de médicos y farmacéuticos que se reúnen regularmente
para decidir qué medicamentos deben incluirse. Estas actualizaciones pueden incluir,
entre otros, lo siguiente: (i) eliminación o adición de medicamentos o formas
farmacéuticas, (ii) cambios en la colocación de nivel de un medicamento, (iii) cambios
en las restricciones de administración de utilización (como límites de cantidad,
tratamiento escalonado, etc.). Los documentos actualizados están disponibles en línea
en: https://www.cchealth.org.
¿Cómo uso el formulario del CCHP?

La lista de medicamentos de formulario comienza en la Página 1. Para ubicar un
medicamento en el formulario, simplemente busque el nombre del medicamento en el
índice al final de este folleto. El índice enumera todos los medicamentos en el
formulario, incluidos los medicamentos de marca y los medicamentos genéricos. Una
vez que haya ubicado el nombre del medicamento en el índice, verá el número de
página en donde puede encontrar más información sobre el medicamento indicado
junto a este.
En lugar de usar el índice, también se puede buscar en el formulario usando ctrl+F para
encontrar un medicamento específico por marca, nombre genérico o clase terapéutica.
Una versión para teléfonos celulares del formulario del CCHP también está disponible
usando la aplicación ePocrates. Después de que haya descargado la aplicación a su
dispositivo móvil, simplemente elija el formulario “Plan de Salud de Contra Costa Medi-
Cal” para mostrar el estado de formulario de los medicamentos en la aplicación. Si
tiene alguna pregunta sobre la instalación o uso de la aplicación Epocrates,
comuníquese con atención al cliente de Epocrates al (800)230-2150 o
goldsupport@epocrates.com.
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La presencia de un medicamento que requiere receta en el formulario del CCHP no
garantiza que el proveedor que emite recetas le recete a un miembro ese medicamento
para una afección médica particular.
Si un medicamento no está en el formulario del CCHP, requerirá una autorización

previa para que esté cubierto (la información específica sobre el proceso de
autorización previa del CCHP se encuentra a continuación en la sección titulada “¿Qué
sucede si el medicamento que necesito no está en el formulario del CCHP?”)
¿Cómo se indican los medicamentos en el formulario?
Los medicamentos están indicados alfabéticamente por marca y nombre genérico en la

categoría terapéutica y clase a la que pertenecen. Los medicamentos de marca
aparecerán en MAYÚSCULAS, con el nombre genérico indicado en paréntesis después
de la marca todo escrito en letra minúscula negrita y cursiva. Si el medicamento
genérico está disponible, se indicará de forma separada del medicamento de marca y
siempre se indicará en letra minúscula negrita y cursiva. Si un genérico equivalente
de un medicamento de marca no está disponible, el medicamento genérico no estará
indicado de forma separada del medicamento de marca. En situaciones en las que un
equivalente genérico aprobado por la Administración de Alimentos y Medicamentos
(Food & Drug Administration, FDA) está disponible, las marcas se indican con fines de
referencia únicamente, y no denotan cobertura para la marca, a menos que se indique
específicamente.
Una lista de ejemplo del formulario del CCHP se encuentra a continuación:
¿Qué sucede si el medicamento que necesito no está indicado en el formulario del

CCHP?
Si su medicamento no figura en el formulario del CCHP, puede preguntarle a su médico
si hay un medicamento diferente en el formulario que funcione de la misma manera. Si
su médico decide que necesita un medicamento que no está en el formulario, puede
pedirle al CCHP que haga una excepción a través del proceso de autorización previa.
Todas las solicitudes de autorización previa serán evaluadas por un médico del plan de
salud (farmacéutico o médico) según los criterios de autorización previa del CCHP
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aprobados por el comité de Farmacia y Terapéutica (P&T) del CCHP. En los casos en
que no existan criterios específicos, se utilizarán para la evaluación indicaciones de la
FDA, literatura revisada por pares, otros criterios del plan, pautas nacionales de
tratamiento (como IDSA, NCCN, AACE, etc.) y otros compendios médicos. Se pueden
hacer excepciones por una variedad de motivos diferentes:
 Su médico puede pedirle al CCHP que cubra un medicamento que figura en el

formulario que requiere una autorización previa (PA): estos medicamentos requieren
aprobación antes de ser despachados en una farmacia de la red. Cada solicitud
será revisada por un médico del plan de salud, y si la solicitud no cumple con las
pautas establecidas por el plan, no será aprobada, y se puede recomendar una
terapia alternativa.
 Su médico puede pedirle al CCHP que cubra un medicamento que no figura en el
formulario: cualquier medicamento que no se encuentre en esta lista se considera
no incluido en el formulario. La persona que emite la receta puede solicitar
cobertura para agentes que no figuran en el formulario. Cada solicitud será revisada
por un médico del plan de salud y se aprobará si existe una necesidad médica
documentada y si no hay un agente alternativo en el formulario.
 Su médico puede pedirle al CCHP que haga una excepción a los límites de un
medicamento. Por ejemplo, si un medicamento tiene un límite de 1 tableta por día,
su médico puede pedirnos que cubramos más. Si se necesitan cantidades que
exceden el límite, la persona que emite la receta puede solicitar una excepción a la
cobertura. Cada solicitud será revisada por un médico del plan de salud y se
aprobará si existe una necesidad médica documentada sin comprometer la
seguridad.
 Su médico puede pedirle al CCHP que haga una excepción a los requisitos de
tratamiento escalonado (ST): estos medicamentos requieren que se prueben uno o
más medicamentos de primer paso antes de pasar al medicamento de segundo
paso (por ejemplo, si el medicamento A y el medicamento B tratan su afección de
salud, el CCHP puede no cubrir el medicamento B a menos que primero pruebe el
medicamento A). Si existe una necesidad médica de usar un medicamento de
segundo paso sin probar un medicamento de primer paso, la persona que emite la
receta puede solicitar una excepción a la cobertura. Cada solicitud será revisada por
un médico del plan de salud y se aprobará si existe una necesidad médica
documentada. Si ya probó el medicamento preferido y este falló, o si ya está
tomando un medicamento sujeto a tratamiento escalonado cuando se cambia al
CCHP, no tendrá que probar los medicamentos preferidos nuevamente. Su médico
simplemente puede solicitar una aprobación a través del plan para la continuación
del tratamiento.
Para comenzar el proceso de autorización previa del CCHP o para solicitar una
excepción, su médico debe enviar por fax una solicitud de autorización previa al CCHP
al 1-866-428-7369 para solicitudes urgentes, o 1-866-205-8014 para solicitudes
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estándar. Su médico también puede enviar la solicitud electrónicamente al CCHP
utilizando la historia clínica electrónica. Si se aprueba la solicitud, podrá surtir su
medicamento en una farmacia que trabaje con el CCHP. Si denegamos la solicitud, le
enviaremos una carta a usted y a su médico y le diremos cómo presentar una
apelación o una queja formal. Una "apelación" es cuando desea que el plan de salud
revise nuevamente una decisión (generalmente con información adicional), y una
"queja formal" es una queja o inquietud relacionada con el plan de salud.
El CCHP tomará la decisión de denegar o aprobar todas las solicitudes de autorización

previa y de excepción dentro de las 24 horas posteriores a la recepción de la solicitud.
Si el CCHP no responde a una autorización previa o solicitud de tratamiento
escalonado dentro de las 72 horas de haber recibido una solicitud no urgente o 24
horas después de recibir una solicitud basada en circunstancias exigentes, la solicitud
se considerará aprobada.
El CCHP proporcionará cobertura de conformidad con una solicitud no urgente por la

duración de la receta, incluidos los resurtidos. El CCHP proporcionará cobertura,
incluidos los resurtidos, de conformidad con una solicitud basada en circunstancias
exigentes por la duración de la exigencia.
Si desea descargar el formulario de autorización previa del CCHP, está disponible en:
https://cchealth.org/healthplan/pdf/performrx_medication_prior_auth_form.pdf
¿Qué sucede si necesito mi medicamento con urgencia? ¿Las farmacias tienen la

capacidad de surtir suministros de medicamentos de emergencia?
Sí. Para garantizar que los miembros del CCHP tengan acceso a un suministro
suficiente de medicamentos en situaciones de emergencia, el CCHP ha establecido
una Política de suministros de emergencia que permite a los farmacéuticos utilizar su
criterio clínico para anular los reclamos que rechazan en el punto de venta. Cuando un
farmacéutico determina que un medicamento es médicamente necesario, puede
ingresar un código de autorización que le permita surtir un suministro de medicamentos
de emergencia para 5 días para cualquier miembro del CCHP. El CCHP promueve el
uso de la Política de suministros de emergencia a través de mensajes en el punto de
venta.
En lugar de utilizar la Política de suministros de emergencia para 5 días, las farmacias
también pueden optar por llamar al centro de llamadas del proveedor de PerformRx al
877-234-4269; los representantes están disponibles las 24 horas del día, los 365 días
del año. El personal del centro de llamadas tiene la capacidad de anular las recetas en
función de la orientación proporcionada por el CCHP.
¿Qué sucede si soy un miembro nuevo del CCHP?
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Si es un miembro nuevo del CCHP, puede estar tomando medicamentos que no están
en nuestro formulario, o puede estar tomando medicamentos que están en nuestro
formulario, pero que tienen límites. Si es posible, debe hablar con su médico para ver si
puede cambiar a un medicamento preferido en el formulario del CCHP. Si no puede
cambiarse a un medicamento preferido, entonces su médico deberá solicitarle al CCHP
una excepción para cubrir un medicamento que ha estado tomando (conocido como
continuación del tratamiento). Consulte la sección anterior titulada "¿Qué sucede si el
medicamento que necesito no figura en el formulario del CCHP?" para obtener más
información.
¿El CCHP cubre medicamentos genéricos y de marca?
El CCHP cubre medicamentos de marca y genéricos, pero cuando hay un

medicamento genérico disponible, el CCHP requiere que se use. Todos los
medicamentos que están disponibles genéricamente están sujetos a revisión por parte
del comité de Farmacia y Terapéutica del CCHP.
Una persona que emite una receta puede solicitar un producto de marca en lugar de un
genérico aprobado si determina que existe una necesidad médica documentada del
equivalente de marca. Este tipo de solicitud de cobertura se puede realizar a través del
proceso de autorización previa del CCHP descrito anteriormente en la sección titulada
"¿Qué sucede si el medicamento que necesito no está indicado en el formulario del
CCHP?"
¿Hay medicamentos que están excluidos de la cobertura?

El formulario de Medi-Cal del CCHP es muy similar a la Lista de Medicamentos con
Contrato de Medi-Cal de California. Los siguientes tipos de medicamentos
generalmente no son un beneficio cubierto para los miembros de Medi-Cal (tenga en
cuenta que esta lista está sujeta a cambios):
 Medicamentos para la disfunción eréctil o sexual
 Medicamentos utilizados por razones estéticas o crecimiento del cabello
 Medicamentos que se consideran experimentales, o que se usan de manera
experimental
 Medicamentos utilizados para tratar la infertilidad
 Medicamentos específicamente enumerados como "no cubiertos" en el formulario
 Medicamentos extranjeros o medicamentos no aprobados por la Administración de
Alimentos y Medicamentos de los Estados Unidos (FDA)
Si se modifica la cobertura del CCHP para excluir un medicamento que hemos estado
cubriendo y proporcionándole bajo su cobertura actual, continuaremos proporcionándole
el medicamento si un médico del plan continúa recetándolo para la misma afección y
para un uso aprobado por la Administración de Alimentos y Medicamentos.
Algunos medicamentos están excluidos por el Departamento de Servicios de Atención

Médica. Esto significa que estos medicamentos están cubiertos por el programa de
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pago por servicio de Medi-Cal para miembros de Medi-Cal, no por el CCHP. Los
siguientes tipos de medicamentos están excluidos:
 Medicamentos antipsicóticos
 Medicamentos para el VIH/sida
 Medicamentos exclusivos para el tratamiento de desintoxicación y dependencia del
alcohol y heroína
 Medicamentos exclusivos para tratar la hemofilia
¿Puedo ir a cualquier farmacia por mi medicamento?

No, los miembros deben usar una farmacia que esté en la red del CCHP. Para
encontrar una farmacia de la red, visite el sitio web del CCHP o llame al plan de salud
directamente para que uno de los miembros del personal de servicios para miembros o
de farmacia le ayuden a ubicar una farmacia cercana (consulte la sección a
continuación titulada “¿Cómo encuentro una farmacia?”).
¿Cómo encuentro una farmacia?

Para encontrar una farmacia cercana, visite el sitio web del CCHP en
https://cchealth.org/healthplan/. Una vez que haya navegado al sitio web del CCHP,
siga las instrucciones a continuación:
(1) Desplácese hacia abajo y haga clic en el botón "Buscar médicos/clínicas/farmacias

en mi área" (Search Doctors/Clinics/Pharmacies in My Area)
(2) Haga clic en el botón rojo "Comenzar aquí" (Begin Your Search Here) (se abrirá una
nueva ventana)
(3) Haga clic en la pestaña "Instalaciones" (Facility) y elija "Farmacia" (Pharmacy) como
tipo de instalación
(4) Elija cómo desea buscar (por código postal, distancia, etc.)
(5) Haga clic en "Buscar una instalación" (Find a Facility): los resultados aparecerán
inmediatamente (como un mapa y una lista)
Asegúrese de mostrar su tarjeta de identificación de miembro del CCHP cuando surta

sus recetas en la farmacia.
Nota: algunos medicamentos están sujetos a una distribución limitada por parte de la
Administración de Alimentos y Medicamentos de EE. UU. Estos tipos de medicamentos
se denominan "medicamentos de especialidad" porque requieren un manejo especial,
coordinación de proveedores o instrucciones especiales que es posible que su farmacia
local no le proporcione. El CCHP tiene un contrato con Walgreens para proporcionar
este tipo de medicamentos. Si tiene preguntas específicas sobre este tipo de
medicamentos, comuníquese directamente con la unidad de farmacia del CCHP.
¿Qué medicamentos están cubiertos por el CCHP?
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Usted puede obtener los siguientes medicamentos y otros artículos cuando los haya
recetado su médico y sean médicamente necesarios:
 Medicamentos recetados que figuran en el formulario del CCHP

 Medicamentos sin receta o medicamentos de venta libre (como jarabes para la
tos/resfrío, pastillas para la tos o aspirina) mencionados en el formulario del CCHP
 Suministros para diabéticos del formulario: insulina, jeringas de insulina, tiras
reactivas de glucosa, lancetas y dispositivos de punción de lancetas, sistemas de
administración de plumas y monitores de glucosa en sangre
 Anticonceptivos aprobados por la FDA que figuran en el formulario del CCHP
 Anticoncepción de emergencia
 Epipens, medidores de flujo máximo y espaciadores
¿Los medicamentos intravenosos (IV) e inyectables están cubiertos por el CCHP?
Sí, el formulario del CCHP enumera ciertos productos inyectables que están cubiertos
como un beneficio de farmacia. El CCHP también cubre la mayoría de los demás
medicamentos intravenosos a través del beneficio médico. Los medicamentos que
generalmente están cubiertos a través del beneficio médico son aquellos que se
administran en el consultorio de un médico, clínica u hospital. Las solicitudes de
cobertura de un medicamento a través del beneficio médico deben dirigirse al
Departamento de Administración de Utilización del CCHP descargando el formulario de
referencia médica en https://cchealth.org/healthplan/providers/ y enviando un fax al
(925) 313-6058 para solicitudes de rutina o (925) 313-6458 para solicitudes urgentes.
La cobertura de medicamentos intravenosos e inyectables a través del beneficio de

farmacia se detalla a continuación:
 Soluciones intravenosas simples: las soluciones intravenosas simples normalmente

se usan para la terapia de hidratación. Se incluyen soluciones comercialmente
disponibles (no compuestas) como solución salina normal, dextrosa (hasta 10% en
agua) y solución de ringer lactato; las soluciones de cloruro de potasio preparadas
comercialmente en tales soluciones también se incluyen en esta definición. Las
soluciones intravenosas simples se deben facturar utilizando el número del Código
Nacional de Medicamentos (National Drug Code, NDC) del producto.
 Soluciones de nutrición parenteral (TPN o hiperalimentación): restringidas para
dispensar dentro de los 10 días posteriores al alta hospitalaria de un hospital de
cuidados agudos, cuando se inició la terapia (IV) con el mismo producto antes del
alta. Hay un suministro máximo para 10 días por dispensación dentro de este
período de 10 días. (Las soluciones de nutrición parenteral son productos
nutricionales administrados por vía intravenosa o intraarterial que suelen ser
suspensiones o soluciones de aminoácidos o proteínas, dextrosa, lípidos,
electrolitos, suplementos vitamínicos y/o minerales y oligoelementos). Los
complementos a la nutrición parenteral son otros medicamentos que se mezclan
físicamente con una solución de nutrición parenteral en cualquier momento antes de
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la administración. Facture estos productos como parte de la facturación de nutrición
parenteral. Nota: Los productos no compuestos deben facturarse utilizando el
número NDC del producto. Las soluciones compuestas deben facturarse como un
reclamo compuesto.
 Lípidos intravenosos administrados por separado: restringidos para ser dispensados
dentro de los 10 días posteriores al alta hospitalaria de un hospital de cuidados
agudos, cuando la terapia (IV) con el mismo producto se haya iniciado antes del
alta. Hay un suministro máximo para 10 días por dispensación dentro de este
período de 10 días. Las soluciones o suspensiones de lípidos intravenosos que se
administran por separado de las soluciones de nutrición parenteral (es decir, no se
mezclan físicamente en el recipiente de la solución de nutrición parenteral) deben
facturarse utilizando el número NDC del producto.
 Soluciones intravenosas de antibióticos no incluidos en la lista: restringidas para ser
dispensadas dentro de los 10 días posteriores al alta hospitalaria de un hospital de
cuidados agudos, cuando la terapia IV con el mismo antibiótico se haya iniciado
antes del alta. Hay un suministro máximo para 10 días por dispensación dentro del
período de 10 días. Nota: Los productos no compuestos deben facturarse utilizando
el número NDC del producto. Las soluciones compuestas deben facturarse como un
reclamo compuesto.
 Soluciones intravenosas de otros medicamentos no indicados en la lista:
restringidas para ser dispensadas dentro de los 10 días posteriores al alta
hospitalaria de un hospital de cuidados agudos, cuando la terapia IV con el mismo
medicamento se haya iniciado antes del alta. Hay un suministro máximo para 10
días por dispensación dentro del período de 10 días. Nota: Los productos no
compuestos deben facturarse utilizando el número NDC del producto. Las
soluciones compuestas deben facturarse como un reclamo compuesto.
¿Cuánto pagaré por mis medicamentos?

Los miembros de Medi-Cal del CCHP no tienen que pagar los servicios cubiertos; los
medicamentos están disponibles sin copago.
Los miembros comerciales del CCHP (con planes como el plan comercial A, el plan B,
IHSS, etc.) pueden tener que pagar pequeños copagos por sus medicamentos.
Consulte los materiales de su plan para determinar si tiene un copago.
¿Los proveedores pueden hacer sugerencias al CCHP para mejorar el formulario?

Por supuesto que sí. El formulario es una herramienta para promover el uso rentable
de medicamentos recetados. El CCHP ha hecho todo lo posible para crear un
documento que satisfaga todas las necesidades terapéuticas; sin embargo, el arte de
la medicina hace que esta sea una tarea formidable. El CCHP agradece la
participación de médicos, farmacéuticos y proveedores de servicios médicos
auxiliares en este proceso dinámico. Se alienta a los médicos y farmacéuticos a dirigir
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cualquier sugerencia o comentario al CCHP por correo electrónico a:
cchp_pharmacy_director@hsd.cccounty.us.
¿Qué puedo hacer si necesito más información?

Para obtener más información sobre sus beneficios de farmacia, revise los documentos
de su Evidencia de cobertura o llame al CCHP directamente para hablar sobre ellos. El
departamento de servicios para miembros del CCHP y el personal del departamento de
farmacia están disponibles para responder preguntas de lunes a viernes de 8 a.m. a
5 p.m., hora del Pacífico, en los números de teléfono que se detallan a continuación:
Departamento de Servicios a Miembros del CCHP: (877) 661-6230 x2
Departamento de Farmacia del CCHP: (877) 661-6230 x3
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Definiciones y abreviaturas:
En este documento, se usan varios términos que el Plan de Salud Contra Costa quiere
asegurarse de que usted entienda. A continuación se presentan algunas definiciones y
abreviaturas:
“Medicamento de marca” es un medicamento que se comercializa bajo un nombre

patentado y protegido por marca registrada. El medicamento de marca aparece en
todas las letras en MAYÚSCULAS.
“Coseguro” es un porcentaje del costo de un beneficio de atención médica cubierto

que un afiliado paga después de que haya pagado el deducible, si se aplica un
deducible al beneficio de atención médica, como el beneficio de medicamentos
recetados.
“Copago” es un monto fijo en dólares que un afiliado paga por un beneficio de

atención médica cubierto después de que haya pagado el deducible, si se aplica un
deducible al beneficio de atención médica, como el beneficio de medicamentos
recetados.
“Deducible” es el monto que un afiliado paga por los beneficios de atención médica
cubiertos antes de que el plan de salud del afiliado comience a pagar la totalidad o
parte del costo del beneficio de atención médica según los términos de la póliza.
“Nivel de medicamento” es un grupo de medicamentos recetados que corresponde a

un nivel de costo compartido especificado en la cobertura de medicamentos recetados
del plan de salud. El nivel en el que se coloca un medicamento recetado determina la
parte del costo del medicamento para el afiliado.
“Afiliado” es una persona inscrita en un plan de salud que tiene derecho a recibir
servicios del plan. Todas las referencias a los afiliados en esta plantilla del formulario
también incluirán suscriptores como se define en esta sección a continuación.
“Solicitud de excepción” es una solicitud de cobertura de un medicamento recetado.

Si un afiliado, su persona designada o el proveedor de atención médica que emite la
receta presenta una solicitud de excepción para la cobertura de un medicamento
recetado, el plan de salud debe cubrir el medicamento recetado cuando se determina
que el medicamento es médicamente necesario para tratar la afección del afiliado.
“Circunstancias exigentes” se producen cuando un afiliado sufre una afección de

salud que puede poner en grave peligro la vida, la salud o la capacidad del afiliado de
recuperar su función máxima, o cuando un afiliado se somete a un tratamiento actual
con un medicamento que no figura en el formulario.
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“Formulario” es la lista completa de medicamentos preferidos para su uso y elegibles
para la cobertura de un producto del plan de salud, e incluye todos los medicamentos
cubiertos bajo el beneficio de medicamentos recetados para pacientes ambulatorios del
producto del plan de salud. El formulario también se conoce como una lista de
medicamentos recetados,
“Medicamento genérico” es el mismo medicamento que su equivalente de marca en

dosis, seguridad, concentración, cómo se toma, calidad,
rendimiento y uso previsto. Un medicamento genérico aparece en letra minúscula
negrita y cursiva.
“Medicamento que no figura en el formulario” es un medicamento recetado que no

figura en el formulario del plan de salud.
“Costo de bolsillo” son copagos, coseguros y el deducible aplicable, más todos los
costos por servicios de atención médica que no están cubiertos por el plan de salud.
“Proveedor que emite la receta” es un proveedor de atención médica autorizado para

emitir una receta médica para tratar una afección médica de un afiliado al plan de
salud.
“Receta” es una orden oral, escrita o electrónica de un proveedor que emite recetas
para un afiliado específico que contiene el nombre del medicamento recetado, la
cantidad del medicamento recetado, la fecha de emisión, el nombre y la información de
contacto del proveedor que receta, la firma del proveedor que emite recetas si la receta
es por escrito, y si la persona inscrita lo solicita, la afección médica o el propósito para
el cual se receta el medicamento.
“Medicamento recetado” es un medicamento recetado por el proveedor del afiliado

que emite recetas y requiere una receta en virtud de
la ley aplicable.
“Autorización previa” es un requisito del plan de salud de que el afiliado o el

proveedor del afiliado que emite recetas obtenga la autorización del plan de salud para
un medicamento recetado antes de que el plan de salud cubra el medicamento. El plan
de salud otorgará una autorización previa cuando sea médicamente necesario que el
afiliado obtenga el medicamento.
“Tratamiento escalonado” es un proceso que especifica la secuencia en la que se

recetan diferentes medicamentos recetados para una afección médica determinada y
médicamente apropiados para un paciente en particular. El plan de salud puede
requerir que el afiliado pruebe uno o más medicamentos para tratar la afección médica
del afiliado antes de que el plan de salud cubra un medicamento en particular para la
afección de conformidad con una solicitud de tratamiento escalonado. Si el proveedor
que emite recetas al afiliado presenta una solicitud de excepción de tratamiento
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escalonado, los planes de salud harán excepciones al tratamiento escalonado cuando
se cumplan los criterios.
“Suscriptor” es la persona responsable del pago de un plan o cuyo empleo u otra

circunstancia, excepto la dependencia familiar, es la base para la elegibilidad para la
membresía en el plan.
A continuación se explican abreviaturas y términos adicionales utilizados en el

documento del formulario del CCHP:
Abreviatura Término Qué significa
AL Límite de edad Algunos medicamentos solo están cubiertos
para ciertas edades.
NF No figura en el Estos medicamentos no están cubiertos en la
formulario Lista de medicamentos. Si su médico
considera que necesita un medicamento que
no está cubierto, puede solicitarnos que
hagamos una excepción.
PA Autorización previa Su médico debe solicitar la aprobación del
CCHP antes de que se cubran algunos
medicamentos.
QL Límite de cantidad Algunos medicamentos solo están cubiertos
para ciertas cantidades.
SCO Exclusión estatal Estos medicamentos están excluidos por el
Departamento de Servicios de Atención
Médica. Esto significa que estos medicamentos
están cubiertos por el programa de tarifa por
servicio de Medi-Cal y deben ser facturados al
estado por la farmacia.
ST Tratamiento En algunos casos, primero debe probar ciertos
escalonado medicamentos antes de que CalViva Health
cubra otro medicamento para su afección
médica.
Por ejemplo, si el Medicamento A y el

Medicamento B tratan su afección de salud, es
posible que el CCHP no cubra el Medicamento
B a menos que pruebe el Medicamento A
primero.
El formulario del CCHP utiliza una estructura de 3 niveles; los niveles se explican a
continuación:
Abreviatura Término Qué significa
l
T1 Nivel 1 Los medicamentos de nivel 1 se prefieren en
el formulario del CCHP y están disponibles sin
restricción o autorización previa.
T2 Nivel 2 Los medicamentos de nivel 2 se prefieren en
el formulario del CCHP y están disponibles sin
autorización previa, PERO pueden tener
ciertas restricciones, como límites de cantidad,
tratamiento escalonado, etc. (las restricciones
específicas se enumeran en el formulario del
CCHP).
T3 Nivel 3 Los medicamentos de nivel 3 no son
preferidos. Estos medicamentos requieren
autorización previa.
m
397 CCHP 08/01/2021
Contra Costa Health Plan Formulary
Informational Section .............................................................................................................................................. 2
Antihistamine Drugs - Drugs For Allergy ....................................................................................................... 1
Anti-Infective Agents - Drugs For Infections ................................................................................................. 4
Antineoplastic Agents - Drugs For Cancer .................................................................................................. 17
Antitoxins,Immune Glob,Toxoids,Vaccines - Drugs For The Immune System .................................. 22
Autonomic Drugs - Drugs For The Nervous System................................................................................. 25
Blood Formation, Coagulation, Thrombosis - Drugs For The Blood .................................................... 32
Cardiovascular Drugs - Drugs For The Heart .............................................................................................. 37
Central Nervous System Agents - Drugs For The Nervous System ..................................................... 58
Devices - Medical Supplies And Durable Medical Equipment ................................................................ 78
Diagnostic Agents .............................................................................................................................................. 81
Electrolytic, Caloric, And Water Balance ..................................................................................................... 81
Enzymes ................................................................................................................................................................ 87
Eye, Ear, Nose And Throat (Eent) Preps. ..................................................................................................... 87
Gastrointestinal Drugs ...................................................................................................................................... 93
Gastrointestinal Drugs - Drugs For The Stomach ..................................................................................... 94
Gold Compounds ................................................................................................................................................ 99
Heavy Metal Antagonists - Drugs To Reduce Iron ..................................................................................... 99
Hormones And Synthetic Substitutes - Hormones ................................................................................... 99
Local Anesthetics (Parenteral) - Drugs For Numbing ............................................................................. 114
Miscellaneous Therapeutic Agents .............................................................................................................. 114
Nonhormonal Contraceptives - Drugs For Women ................................................................................. 121
Oxytocics - Drugs For Women ...................................................................................................................... 122
Pharmaceutical Aids ........................................................................................................................................ 122
Respiratory Tract Agents - Drugs For The Lungs .................................................................................... 123
Skin And Mucous Membrane Agents - Drugs For The Skin .................................................................. 133
Smooth Muscle Relaxants - Drugs To Relax Muscles ............................................................................ 146
Vitamins ............................................................................................................................................................... 147
TOC-1
Informational Section
2
CURRENT AS OF 08/01/2021
Drug Tier Coverage Requirements and

SCO = State Carve Out Limits
T1 = Preferred Medication AL = Age Limit
T2 = Preferred Medication with PA = Prior Authorization
bold italics = Generic drugs Restriction QL = Quantity Limit
UPPERCASE = Brand name T3 = Non-Preferred Medication - SCO = State Carve Out
drugs Prior Authorization is Required ST = Step Therapy
Coverage
Prescription Drug Name Drug Tier Requirements and
Limits
Antihistamine Drugs - Drugs For Allergy
Ethanolamine Derivatives - Drugs For Allergy
CHILDREN'S ALLERGY (DIPHENHYD) ORAL
T2
TABLET,CHEWABLE (diphenhydramine HCl)
clemastine oral tablet 2.68 mg T1
dimenhydrinate injection solution T3 PA
diphenhydramine HCl injection solution 50 mg/mL T2 QL (1 EA per 30 days)
diphenhydramine HCl injection syringe T2 QL (1 EA per 30 days)
diphenhydramine HCl oral capsule T2
diphenhydramine HCl oral elixir T2
diphenhydramine HCl oral liquid T2
diphenhydramine HCl oral tablet 25 mg T2
SLEEP AID (DIPHENHYDRAMINE) ORAL CAPSULE 50
T2
MG (diphenhydramine HCl)
SLEEP AID (DIPHENHYDRAMINE) ORAL TABLET
T2
(diphenhydramine HCl)
WAL-SOM (DOXYLAMINE) (doxylamine succinate) T2
First Gen. Antihist. Derivatives, Misc. - Drugs For Allergy
cyproheptadine T1
First Generation Antihistamines - Drugs For Allergy
carbinoxamine maleate oral tablet 4 mg T1
T2
chlorpheniramine maleate oral tablet T2
chlorpheniramine maleate oral tablet extended release T2
PA = Prior Authorization; ST = Step Therapy; QL= Quantity Limits; AL = Age Limits; SCO = State
Carve Out; T1 = Preferred Medication; T2 = Preferred Medication with Restriction; T3 =Non-Preferred
Medication - Prior Authorization is Required; QY = Quantity; DY =Days; DS = Days Supply; EA = Each;
GM = Gram; FL = Fill; ML = Milliliter; MIN =Minimum; MAX = Maximum
1
Coverage
Limits
cyproheptadine T1
T2
T2
Phenothiazine Derivatives - Drugs For Allergy
promethazine HCl (Phenadoz Rectal Suppository 25 Mg) T1
promethazine injection solution 25 mg/mL T2 QL (1 EA per 30 days)
promethazine injection solution 50 mg/mL T1
promethazine oral T1
promethazine rectal suppository 12.5 mg, 50 mg T1
phenylephrine HCl/promethazine HCl (Promethazine Vc) T1
QL (240 ML per 30 days); AL
promethazine-phenyleph-codeine T2
(Min 18 Years)
Piperazine Derivatives - Drugs For Allergy
hydroxyzine HCl intramuscular T2 QL (1 EA per 30 days)
hydroxyzine HCl oral solution 10 mg/5 mL T1
hydroxyzine HCl oral tablet T1
2
Coverage
Limits
hydroxyzine pamoate T1
meclizine oral tablet 12.5 mg T2
meclizine oral tablet 25 mg T1
meclizine oral tablet,chewable T2
Propylamine Derivatives - Drugs For Allergy
chlorpheniramine-phenyleph-DM T3 PA
ED A-HIST DM ORAL LIQUID (chlorpheniramine
T2
maleate/phenylephrine HCl/dextromethorphan)
LOHIST - D (chlorpheniramine
T1
maleate/pseudoephedrine HCl)
PEDIATRIC COUGH AND COLD ORAL LIQUID 1-15-5
MG/5 ML (chlorpheniramine T2
maleate/pseudoephedrine/dextromethorphan)
RESCON-DM (chlorpheniramine
T2
SCOT-TUSSIN DM (chlorpheniramine
T2
maleate/dextromethorphan HBr)
Second Generation Antihistamines - Drugs For Allergy
ALAVERT (loratadine) T2
ALAVERT D-12 ALLERGY-SINUS
T2
(loratadine/pseudoephedrine sulfate)
cetirizine oral solution 1 mg/mL T2
cetirizine oral tablet T2
cetirizine oral tablet,chewable T2
cetirizine-pseudoephedrine T2
CHILDREN'S ALLERGY RELIEF(FEX) (fexofenadine HCl) T2 ST
3
Coverage
Limits
fexofenadine oral tablet 180 mg, 60 mg T2 ST
fexofenadine-pseudoephedrine T2 ST
levocetirizine oral tablet T2
loratadine oral solution T2
loratadine oral tablet T2
LORATADINE-D ORAL TABLET EXTENDED RELEASE 24
T2
HR (loratadine/pseudoephedrine sulfate)
WAL-FEX D 24 HOUR (fexofenadine
T2 ST
HCl/pseudoephedrine HCl)
Anti-Infective Agents - Drugs For Infections
1St Generation Cephalosporin Antibiotics - Antibiotics
cephalexin oral capsule 250 mg, 500 mg T1
cephalexin oral capsule 750 mg T3 PA
cephalexin oral suspension for reconstitution T1
cephalexin oral tablet T3 PA
2Nd Generation Cephalosporin Antibiotics - Antibiotics
cefaclor oral capsule T1
cefaclor oral suspension for reconstitution 125 mg/5
T1
mL, 250 mg/5 mL, 375 mg/5 mL
cefaclor oral tablet extended release 12 hr T3 PA
cefuroxime axetil oral suspension for reconstitution 125
T1
mg/5 mL
cefuroxime axetil oral tablet T1
3Rd Generation Cephalosporin Antibiotics - Antibiotics
cefdinir oral capsule T2 QL (20 QY per 10 DYs)
cefdinir oral suspension for reconstitution 125 mg/5 mL T2 QL (200 QY per 10 DYs)
cefdinir oral suspension for reconstitution 250 mg/5 mL T2 QL (100 QY per 10 DYs)
4
Coverage
Limits
cefixime oral suspension for reconstitution 100 mg/5
T2 PA; ST
mL
cefpodoxime oral suspension for reconstitution T2 QL (2 Fills per 180 DYs)
cefpodoxime oral tablet T2 QL (4 EA per 1 DY)
SUPRAX ORAL CAPSULE (cefixime) T2 QL (1 Tablet per 30 days)
SUPRAX ORAL SUSPENSION FOR RECONSTITUTION
T2 PA
200 MG/5 ML (cefixime)
Adamantane Antivirals - Drugs For Viral Infections
amantadine HCl T2 SCO
Allylamine Antifungals - Drugs For Fungus
terbinafine HCl oral T1
Amebicides - Drugs For The Mouth And Throat
metronidazole oral T1
Aminoglycoside Antibiotics - Antibiotics
gentamicin injection solution 20 mg/2 mL T2 QL (1 EA per 30 days)
neomycin T1
streptomycin T2 QL (1 EA per 30 days)
tobramycin sulfate injection solution 10 mg/mL T2 QL (1 EA per 30 days)
Aminopenicillin Antibiotics - Antibiotics
amoxicillin oral capsule T1
amoxicillin oral suspension for reconstitution T1
amoxicillin oral tablet T1
amoxicillin oral tablet,chewable 125 mg, 250 mg T1
amoxicillin-pot clavulanate oral suspension for
T1
reconstitution 200-28.5 mg/5 mL
5
Coverage
Limits
T2 QL (14 QY per 1 Fill)
reconstitution 250-62.5 mg/5 mL
T2 QL (14 DS per 1 Fill)
reconstitution 400-57 mg/5 mL
amoxicillin-pot clavulanate oral tablet T2 QL (14 DS per 1 Fill)
amoxicillin-pot clavulanate oral tablet extended release
T2 QL (14 QY per 1 Fill)
12 hr
amoxicillin-pot clavulanate oral tablet,chewable T2 QL (14 DS per 1 Fill)
ampicillin oral capsule T1
AUGMENTIN ORAL SUSPENSION FOR
RECONSTITUTION 125-31.25 MG/5 ML T2 QL (14 DS per 1 Fill)
(amoxicillin/potassium clavulanate)
Anthelmintics - Drugs For Parasites
EMVERM (mebendazole) T2 QL (6 EA per 3 days)
ivermectin oral T2 QL (30 EA per 365 days)
REESE'S PINWORM MEDICINE (pyrantel pamoate) T2
Antifungals, Miscellaneous - Drugs For Fungus
griseofulvin microsize T1
griseofulvin ultramicrosize T1
SSKI (potassium iodide) T1
Antimalarials - Drugs For The Mouth And Throat
atovaquone-proguanil oral tablet 250-100 mg T2 QL (180 EA per 365 days)
atovaquone-proguanil oral tablet 62.5-25 mg T2 QL (540 EA per 365 days)
chloroquine phosphate T1
DARAPRIM (pyrimethamine) T1
hydroxychloroquine T1
mefloquine T1
6
Coverage
Limits
primaquine T1
quinidine gluconate oral T1
quinidine sulfate oral tablet T1
quinine sulfate T3 PA
Antimycobacterials, Miscellaneous - Antibiotics
dapsone oral T1
Antiprotozoals, Miscellaneous - Drugs For The Mouth And Throat
atovaquone T3 PA
dapsone oral T1
metronidazole oral T1
PENTAM (pentamidine isethionate) T2 QL (1 EA per 30 days)
Antituberculosis Agents - Antibiotics
CAPASTAT (capreomycin sulfate) T3 PA
ciprofloxacin T1
ciprofloxacin HCl oral T1
clarithromycin oral suspension for reconstitution T3 PA
clarithromycin oral tablet T1
clarithromycin oral tablet extended release 24 hr T3 PA
ethambutol T1
isoniazid T1
levofloxacin oral solution T3 PA
levofloxacin oral tablet T2 QL (30 QY per 30 DYs)
moxifloxacin oral T2 QL (21 QY per 21 DYs)
pyrazinamide T1
rifabutin T1
rifampin T1
7
Coverage
Limits
streptomycin T2 QL (1 EA per 30 days)
TRECATOR (ethionamide) T1
Antivirals, Miscellaneous - Drugs For Viral Infections
foscarnet T2 QL (0.5 ML per 30 days)
Azole Antifungals - Drugs For Fungus
fluconazole oral suspension for reconstitution T1
fluconazole oral tablet 100 mg, 150 mg, 200 mg T1
itraconazole oral capsule T3 PA
SPORANOX ORAL SOLUTION (itraconazole) T3 PA
Erythromycin Antibiotics - Antibiotics
erythromycin ethylsuccinate (E.E.S. 400 Oral Tablet) T1
erythromycin stearate (Erythrocin (As Stearate) Oral
T1
Tablet 250 Mg)
erythromycin ethylsuccinate oral suspension for
T1
reconstitution 400 mg/5 mL
erythromycin ethylsuccinate oral tablet T1
erythromycin oral T1
Glycopeptide Antibiotics - Antibiotics
FIRVANQ ORAL RECON SOLN 25 MG/ML (vancomycin
T1
HCl)
vancomycin intravenous recon soln 1,000 mg, 10 gram,
T1
500 mg
vancomycin intravenous recon soln 5 gram T1
vancomycin oral capsule T1
vancomycin oral recon soln T1
Hcv Polymerase Inhibitor Antivirals - Drugs For Viral Infections
8
Coverage
Limits
sofosbuvir-velpatasvir T3 PA
VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) T3 PA
Hcv Protease Inhibitor Antivirals - Drugs For Viral Infections
MAVYRET (glecaprevir/pibrentasvir) T2 PA
ZEPATIER (elbasvir/grazoprevir) T3 PA
Hcv Replication Complex Inhibitors - Drugs For Viral Infections
MAVYRET (glecaprevir/pibrentasvir) T2 PA
sofosbuvir-velpatasvir T3 PA
VOSEVI (sofosbuvir/velpatasvir/voxilaprevir) T3 PA
ZEPATIER (elbasvir/grazoprevir) T3 PA
Hiv Entry And Fusion Inhibitors - Drugs For Viral Infections
FUZEON SUBCUTANEOUS RECON SOLN (enfuvirtide) T2 SCO
RUKOBIA (fostemsavir tromethamine) T3 PA
SELZENTRY ORAL TABLET 150 MG, 300 MG (maraviroc) T2 PA; SCO
TROGARZO (ibalizumab-uiyk) T2 SCO
Hiv Integrase Inhibitor Antiretrovirals - Drugs For Viral Infections
BIKTARVY (bictegravir sodium/emtricitabine/tenofovir
T2 SCO
alafenamide fumar)
CABENUVA (cabotegravir/rilpivirine) T2 SCO
DOVATO (dolutegravir sodium/lamivudine) T2 SCO
GENVOYA
(elvitegravir/cobicistat/emtricitabine/tenofovir T2 SCO
alafenamide)
ISENTRESS HD (raltegravir potassium) T2 SCO
ISENTRESS ORAL TABLET (raltegravir potassium) T2 SCO
ISENTRESS ORAL TABLET,CHEWABLE (raltegravir
T2 SCO
potassium)
9
Coverage
Limits
JULUCA (dolutegravir sodium/rilpivirine HCl) T2 SCO
STRIBILD (elvitegravir/cobicistat/emtricitabine/tenofovir
T2 SCO
disoproxil)
TIVICAY (dolutegravir sodium) T2 SCO
TIVICAY PD (dolutegravir sodium) T2
TRIUMEQ (abacavir sulfate/dolutegravir
T2 SCO
sodium/lamivudine)
Hiv Nonnucleoside Rev.Transcrip. Inhib. - Drugs For Viral Infections
COMPLERA (emtricitabine/rilpivirine HCl/tenofovir
T2 SCO
disoproxil fumarate)
DELSTRIGO (doravirine/lamivudine/tenofovir disoproxil
T2 SCO
fumarate)
EDURANT (rilpivirine HCl) T2 SCO
efavirenz-emtricitabin-tenofov T2 SCO
efavirenz-lamivu-tenofov disop T2 SCO
etravirine T2 SCO
INTELENCE ORAL TABLET 25 MG (etravirine) T2 SCO
JULUCA (dolutegravir sodium/rilpivirine HCl) T2 SCO
nevirapine T2 SCO
ODEFSEY (emtricitabine/rilpivirine HCl/tenofovir
T2 SCO
alafenamide fumarate)
PIFELTRO (doravirine) T2 SCO
SUSTIVA (efavirenz) T2 SCO
Hiv Nucleoside, Nucleotide Rt Inhibitors - Drugs For Viral Infections
abacavir oral tablet T2 SCO
abacavir-lamivudine T2 SCO
abacavir-lamivudine-zidovudine T2 SCO
10
Coverage
Limits
BIKTARVY (bictegravir sodium/emtricitabine/tenofovir
T2 SCO
alafenamide fumar)
CIMDUO (lamivudine/tenofovir disoproxil fumarate) T2 SCO
COMPLERA (emtricitabine/rilpivirine HCl/tenofovir
T2 SCO
disoproxil fumarate)
DELSTRIGO (doravirine/lamivudine/tenofovir disoproxil
T2 SCO
fumarate)
DESCOVY (emtricitabine/tenofovir alafenamide
T2 SCO
fumarate)
didanosine oral capsule,delayed release(DR/EC) 250
T1
mg, 400 mg
DOVATO (dolutegravir sodium/lamivudine) T2 SCO
efavirenz-emtricitabin-tenofov T2 SCO
efavirenz-lamivu-tenofov disop T2 SCO
emtricitabine T2 SCO
emtricitabine-tenofovir (TDF) T2 SCO
EMTRIVA ORAL SOLUTION (emtricitabine) T2 SCO
EPIVIR HBV ORAL SOLUTION (lamivudine) T3 PA; SCO
GENVOYA
(elvitegravir/cobicistat/emtricitabine/tenofovir T2 SCO
alafenamide)
lamivudine oral solution T2 SCO
lamivudine oral tablet 100 mg T2 PA; SCO
lamivudine oral tablet 150 mg, 300 mg T2 SCO
lamivudine-zidovudine T2 SCO
ODEFSEY (emtricitabine/rilpivirine HCl/tenofovir
T2 SCO
alafenamide fumarate)
stavudine oral capsule T2 SCO
11
Coverage
Limits
STRIBILD (elvitegravir/cobicistat/emtricitabine/tenofovir
T2 SCO
disoproxil)
SYMTUZA (darunavir
T2 SCO
eth/cobicistat/emtricitabine/tenofovir alafenamide)
TRIUMEQ (abacavir sulfate/dolutegravir
T2 SCO
sodium/lamivudine)
TRUVADA ORAL TABLET 100-150 MG, 133-200 MG, 167-
T2
250 MG (emtricitabine/tenofovir disoproxil fumarate)
VIREAD (tenofovir disoproxil fumarate) T2 SCO
ZIAGEN ORAL SOLUTION (abacavir sulfate) T2 SCO
zidovudine oral capsule T1
zidovudine oral tablet T1
Hiv Protease Inhibitor Antiretrovirals - Drugs For Viral Infections
APTIVUS (tipranavir) T2 SCO
atazanavir oral capsule 150 mg, 300 mg T2 SCO
atazanavir oral capsule 200 mg T2
EVOTAZ (atazanavir sulfate/cobicistat) T2 SCO
fosamprenavir T2 SCO
INVIRASE ORAL TABLET (saquinavir mesylate) T2 SCO
LEXIVA ORAL SUSPENSION (fosamprenavir calcium) T2 SCO
lopinavir-ritonavir T2 SCO
NORVIR ORAL CAPSULE (ritonavir) T2 SCO
NORVIR ORAL POWDER IN PACKET (ritonavir) T2 SCO
NORVIR ORAL SOLUTION (ritonavir) T2 SCO
PREZISTA ORAL SUSPENSION (darunavir ethanolate) T2 SCO
PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800
T2 SCO
MG (darunavir ethanolate)
12
Coverage
Limits
REYATAZ ORAL POWDER IN PACKET (atazanavir
T2 SCO
sulfate)
ritonavir T2 SCO
SYMTUZA (darunavir
T2 SCO
VIRACEPT ORAL TABLET (nelfinavir mesylate) T2 SCO
Interferon Antivirals - Drugs For Viral Infections
INTRON A INJECTION RECON SOLN (interferon alfa-
T2 PA
2b,recomb.)
INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML
T3 PA
(interferon alfa-2b,recomb.)
T2 QL (0.5 ML per 30 days)
PEGASYS SUBCUTANEOUS SOLUTION (peginterferon
alfa-2a)
Lincomycin Antibiotics - Antibiotics
clindamycin HCl T1
clindamycin palmitate HCl (Clindamycin Pediatric) T1 AL (Max 12 Years)
clindamycin phosphate injection T3 PA
Macrolide Antibiotics - Antibiotics
erythromycin ethylsuccinate (E.E.S. 400 Oral Tablet) T1
erythromycin stearate (Erythrocin (As Stearate) Oral
T1
Tablet 250 Mg)
erythromycin ethylsuccinate oral suspension for
T1
reconstitution 400 mg/5 mL
erythromycin ethylsuccinate oral tablet T1
erythromycin oral T1
Natural Penicillin Antibiotics - Antibiotics
13
Coverage
Limits
BICILLIN C-R INTRAMUSCULAR SYRINGE 1,200,000
UNIT/ 2 ML(900K/300K) (penicillin G T2 QL (1 EA per 30 days)
benzathine/penicillin G procaine)
BICILLIN L-A INTRAMUSCULAR SYRINGE 600,000
T2 QL (1 EA per 30 days)
UNIT/ML (penicillin G benzathine)
penicillin G potassium T2 QL (1 EA per 30 days)
penicillin G sodium T2 QL (1 EA per 30 days)
penicillin V potassium T1
Neuraminidase Inhibitor Antivirals - Drugs For Viral Infections
oseltamivir oral capsule T2 QL (10 EA per 180 days)
oseltamivir oral suspension for reconstitution T2 QL (120 ML per 180 days)
Nucleoside And Nucleotide Antivirals - Drugs For Viral Infections
acyclovir oral capsule T1
acyclovir oral suspension 200 mg/5 mL T1
acyclovir oral tablet T1
adefovir T3 PA
BARACLUDE ORAL SOLUTION (entecavir) T3 PA
cidofovir T2 QL (0.5 ML per 30 days)
entecavir oral tablet 0.5 mg T3 PA; QL (90 EA per 90 days)
entecavir oral tablet 1 mg T3 PA; QL (30 EA per 30 days)
ganciclovir sodium intravenous recon soln T2 QL (1 EA per 30 days)
ribavirin oral capsule T1
ribavirin oral tablet 200 mg T1
SYMTUZA (darunavir
T2 SCO
valacyclovir T1
valganciclovir oral tablet T3 PA
14
Coverage
Limits
VEMLIDY (tenofovir alafenamide) T3 PA; SCO
Other Macrolide Antibiotics - Antibiotics
azithromycin oral packet T1
azithromycin oral suspension for reconstitution 100
T2 QL (30 EA per 90 DYs)
mg/5 mL
azithromycin oral suspension for reconstitution 200
T2 QL (60 EA per 90 DYs)
mg/5 mL
azithromycin oral tablet 250 mg T2 QL (12 EA per 90 DYs)
azithromycin oral tablet 500 mg T2 QL (6 EA per 90 DYs)
azithromycin oral tablet 600 mg T1
clarithromycin oral suspension for reconstitution T3 PA
clarithromycin oral tablet T1
clarithromycin oral tablet extended release 24 hr T3 PA
Oxazolidinone Antibiotics - Antibiotics
linezolid oral tablet T3 PA
ZYVOX ORAL SUSPENSION FOR RECONSTITUTION
T3 PA
(linezolid)
Penicillinase-Resistant Penicillins - Antibiotics
dicloxacillin T1
Polyene Antifungals - Drugs For Fungus
amphotericin B T2 QL (1 EA per 30 days)
nystatin oral suspension T1
nystatin oral tablet T1
Polymyxin Antibiotics - Antibiotics
colistin (colistimethate Na) T3 PA
polymyxin B sulfate T1
15
Coverage
Limits
Quinolone Antibiotics - Antibiotics
ciprofloxacin T1
ciprofloxacin HCl oral T1
levofloxacin oral solution T3 PA
levofloxacin oral tablet T2 QL (30 QY per 30 DYs)
moxifloxacin oral T2 QL (21 QY per 21 DYs)
ofloxacin oral tablet 300 mg, 400 mg T3 PA
Rifamycin Antibiotics - Antibiotics
rifabutin T1
rifampin T1
XIFAXAN (rifaximin) T3 PA
Sulfonamide Antibiotics (Systemic) - Antibiotics
sulfadiazine T1
sulfamethoxazole-trimethoprim T1
sulfasalazine T1
SULFATRIM (sulfamethoxazole/trimethoprim) T1
Tetracycline Antibiotics - Antibiotics
demeclocycline T3 PA
doxycycline hyclate (Doxy-100) T3 PA
doxycycline hyclate oral capsule T1
doxycycline hyclate oral tablet 100 mg T1
doxycycline monohydrate oral capsule 100 mg, 50 mg T1
doxycycline monohydrate oral tablet 100 mg, 50 mg T1
minocycline oral capsule 100 mg, 50 mg T2 QL (60 QY per 30 DYs)
QL (60 QY per 30 DYs); AL
minocycline oral capsule 75 mg T2
(Max 30 Years)
16
Coverage
Limits
minocycline oral tablet T3 PA; AL (Max 30 Years)
tetracycline T1
VIBRAMYCIN ORAL SYRUP (doxycycline calcium) T3 PA
Urinary Anti-Infectives - Drugs For The Urinary System
methenamine hippurate T1
methenamine mandelate T1
MONUROL (fosfomycin tromethamine) T1
nitrofurantoin T1
nitrofurantoin macrocrystal T1
nitrofurantoin monohyd/m-cryst T1
PRIMSOL (trimethoprim) T1
trimethoprim T1
URETRON D-S ORAL TABLET 81.6-10.8-40.8 MG
(methenamine/methylene blue/sod T1
phos/p.salicylate/hyoscyamine)
Antineoplastic Agents - Drugs For Cancer
Antineoplastic Agents - Drugs For Cancer
ALIMTA INTRAVENOUS RECON SOLN 500 MG
(pemetrexed disodium)
ALKERAN (melphalan) T3 PA
anastrozole T1
ARRANON (nelarabine) T2 QL (0.5 ML per 30 days)
ARZERRA INTRAVENOUS SOLUTION 100 MG/5 ML
(ofatumumab)
AVASTIN (bevacizumab) T2 QL (0.5 ML per 30 days)
BAVENCIO (avelumab) T2 QL (0.5 ML per 30 days)
BENDEKA (bendamustine HCl) T2 QL (0.5 ML per 30 days)
17
Coverage
Limits
bicalutamide T1
BICNU (carmustine) T2 QL (1 EA per 30 days)
bleomycin injection recon soln 15 unit T2 QL (1 EA per 30 days)
capecitabine T3 PA
carboplatin intravenous recon soln T2 QL (1 EA per 30 DYs)
cisplatin intravenous solution T2 QL (1 EA per 30 days)
cladribine T2 QL (0.5 ML per 30 days)
cyclophosphamide intravenous recon soln T2 QL (1 EA per 30 days)
CYRAMZA (ramucirumab) T2 QL (0.5 ML per 30 days)
cytarabine (PF) injection solution 20 mg/mL T2 QL (0.5 ML per 30 days)
dacarbazine T2 QL (1 EA per 30 days)
DARZALEX (daratumumab) T2 QL (0.5 ML per 30 days)
daunorubicin intravenous solution T2 QL (0.5 ML per 30 days)
decitabine T2 QL (1 EA per 30 days)
docetaxel intravenous solution 20 mg/mL (1 mL) T2 QL (0.5 ML per 30 days)
doxorubicin intravenous recon soln T2 QL (1 EA per 30 days)
doxorubicin intravenous solution 2 mg/mL T2 QL (1 EA per 30 days)
DROXIA (hydroxyurea) T1
EMCYT (estramustine phosphate sodium) T1
EMPLICITI INTRAVENOUS RECON SOLN 300 MG
(elotuzumab)
epirubicin intravenous solution 200 mg/100 mL T2 QL (0.5 ML per 30 days)
ERBITUX INTRAVENOUS SOLUTION 100 MG/50 ML
(cetuximab)
erlotinib oral tablet 100 mg, 150 mg T3 PA
erlotinib oral tablet 25 mg T3
ETOPOPHOS (etoposide phosphate) T2 QL (1 EA per 30 days)
18
Coverage
Limits
etoposide T1
exemestane T1
FARESTON (toremifene citrate) T1
FASLODEX (fulvestrant) T2 QL (0.5 ML per 30 days)
FIRMAGON KIT W DILUENT SYRINGE SUBCUTANEOUS
RECON SOLN 80 MG (degarelix acetate)
floxuridine T2 QL (1 EA per 30 days)
fludarabine intravenous recon soln T2 QL (1 EA per 30 days)
FLUOROPLEX (fluorouracil) T1
fluorouracil intravenous solution 500 mg/10 mL T2 QL (0.5 ML per 30 days)
fluorouracil topical cream 5 % T1
fluorouracil topical solution T1
flutamide T1
GAZYVA (obinutuzumab) T2 QL (0.5 ML per 30 days)
gemcitabine intravenous recon soln 200 mg T2 QL (1 EA per 30 days)
GLEOSTINE ORAL CAPSULE 10 MG, 100 MG, 40 MG
T1
(lomustine)
HALAVEN (eribulin mesylate) T2 QL (0.5 ML per 30 days)
hydroxyurea T1
ifosfamide intravenous recon soln 3 gram T2 QL (1 EA per 30 days)
imatinib T3 PA
IMFINZI (durvalumab) T2 QL (0.5 ML per 30 days)
T2 PA
2b,recomb.)
T3 PA
19
Coverage
Limits
irinotecan intravenous solution 100 mg/5 mL T2 QL (0.5 ML per 30 days)
IXEMPRA INTRAVENOUS RECON SOLN 15 MG
(ixabepilone)
JEVTANA (cabazitaxel) T2 QL (0.5 ML per 30 days)
KEYTRUDA INTRAVENOUS SOLUTION
(pembrolizumab)
letrozole T1
LEUKERAN (chlorambucil) T3 PA
LUPRON DEPOT (3 MONTH) (leuprolide acetate) T3 PA
LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75
T3 PA
MG (leuprolide acetate)
LUPRON DEPOT-PED (leuprolide acetate) T3 PA
LYSODREN (mitotane) T1
MATULANE (procarbazine HCl) T3 PA
megestrol oral suspension 400 mg/10 mL (40 mg/mL) T1
megestrol oral tablet T1
mercaptopurine T1
methotrexate sodium T1
methotrexate sodium (PF) T1
mitomycin intravenous T2 QL (1 EA per 30 DYs)
mitoxantrone T2 QL (0.5 ML per 30 days)
MYLERAN (busulfan) T3 PA
20
Coverage
Limits
NEXAVAR (sorafenib tosylate) T3 PA
nilutamide T1
NIPENT (pentostatin) T2 QL (1 EA per 30 days)
ONCASPAR (pegaspargase) T2 QL (0.5 ML per 30 days)
OPDIVO INTRAVENOUS SOLUTION 40 MG/4 ML
(nivolumab)
oxaliplatin intravenous solution 50 mg/10 mL (5 mg/mL) T2 QL (0.5 ML per 30 days)
paclitaxel T2 QL (0.5 ML per 30 days)
PERJETA (pertuzumab) T2 QL (0.5 ML per 30 days)
PHOTOFRIN (porfimer sodium) T2 QL (1 EA per 30 days)
PORTRAZZA (necitumumab) T2 QL (0.5 ML per 30 days)
PROLEUKIN (aldesleukin) T2 QL (1 EA per 30 days)
REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG
T3 PA
(lenalidomide)
RITUXAN (rituximab) T2 QL (0.5 ML per 30 days)
SPRYCEL ORAL TABLET 100 MG, 20 MG, 50 MG, 70 MG
T3 PA
(dasatinib)
SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 50 MG
T3 PA
(sunitinib malate)
SYNRIBO (omacetaxine mepesuccinate) T2 QL (1 EA per 30 days)
TABLOID (thioguanine) T1
tamoxifen T1
TASIGNA ORAL CAPSULE 200 MG (nilotinib HCl) T3 PA
TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML
(60 MG/ML) (atezolizumab)
TEMODAR INTRAVENOUS (temozolomide) T2 QL (1 EA per 30 days)
temozolomide T3 PA
21
Coverage
Limits
teniposide T2 QL (0.5 ML per 30 days)
thiotepa injection recon soln 15 mg T2 QL (1 EA per 30 days)
topotecan intravenous solution 4 mg/4 mL (1 mg/mL) T2 QL (0.5 ML per 30 days)
TORISEL (temsirolimus) T2 QL (0.5 ML per 30 days)
TRELSTAR INTRAMUSCULAR SUSPENSION FOR
RECONSTITUTION 11.25 MG (triptorelin pamoate)
TYKERB (lapatinib ditosylate) T3 PA
VECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (20
MG/ML) (panitumumab)
VELCADE (bortezomib) T2 QL (1 EA per 30 days)
vinblastine intravenous solution T2 QL (1 EA per 30 days)
vincristine intravenous solution 1 mg/mL T2 QL (1 EA per 30 days)
vinorelbine intravenous solution 50 mg/5 mL T2 QL (0.5 ML per 30 days)
YERVOY INTRAVENOUS SOLUTION 50 MG/10 ML (5
MG/ML) (ipilimumab)
YONDELIS (trabectedin) T2 QL (1 EA per 30 days)
ZALTRAP INTRAVENOUS SOLUTION 100 MG/4 ML (25
MG/ML) (ziv-aflibercept)
ZANOSAR (streptozocin) T2 QL (1 EA per 30 days)
ZOLINZA (vorinostat) T3 PA
Antitoxins,Immune Glob,Toxoids,Vaccines - Drugs For The Immune System
Antitoxins And Immune Globulins - Organ Transplant
RHOGAM ULTRA-FILTERED PLUS (Rho(D) immune
T2
globulin)
Toxoids - Vaccines
ADACEL(TDAP ADOLESN/ADULT)(PF) QL (0.5 ML per 1 Fill); AL
T2
(diphtheria,pertussis(acellular),tetanus vaccine/PF) (Min 19 Years)
22
Coverage
Limits
BOOSTRIX TDAP QL (0.5 ML per 1 Fill); AL
T2
(diphtheria,pertussis(acellular),tetanus vaccine) (Min 19 Years)
TENIVAC (PF) (tetanus and diphtheria toxoids, QL (0.5 ML per 1 Fill); AL
T2
adsorbed, adult/PF) (Min 19 Years)
Vaccines - Vaccines
ACTHIB (PF) (Haemophilus b conjugate vaccine(tetanus QL (0.5 ml per 1 Fill); AL
T2
toxoid conjugate)/PF) (Min 19 Years)
BEXSERO (meningococcal group B vaccine, 4- QL (0.5 ML per 1 Fill); AL
T2
component) (Min 19 Years)
ENGERIX-B (PF) (hepatitis B virus vaccine QL (1 ML per 1 Fill); AL (Min
T2
recombinant/PF) 19 Years)
QL (0.5 ML per 1 Fill); AL
GARDASIL 9 (PF) (human papillomavirus vaccine, 9-
T2 (Min 19 Years and Max 45
valent/PF)
Years)
HAVRIX (PF) INTRAMUSCULAR SUSPENSION 1,440 QL (1 ML per 1 Fill); AL (Min
T2
ELISA UNIT/ML (hepatitis A virus vaccine/PF) 19 Years)
HAVRIX (PF) INTRAMUSCULAR SYRINGE (hepatitis A QL (1 ML per 1 Fill); AL (Min
T2
virus vaccine/PF) 19 Years)
HEPLISAV-B (PF) INTRAMUSCULAR SYRINGE (hepatitis QL (0.5 ML per 1 Fill); AL
T2
B vaccine recombinant/vaccine adjuvant CpG 1018/PF) (Min 19 Years)
HIBERIX (PF) (Haemophilus b conjugate QL (0.5 ml per 1 Fill); AL
T2
vaccine(tetanus toxoid conjugate)/PF) (Min 19 Years)
IMOVAX RABIES VACCINE (PF) (rabies vaccine, human QL (1 ml per 1 Fill); AL (Min
T2
diploid cell/PF) 19 Years)
IXIARO (PF) (Japanese encephalitis vaccine/PF) T3 PA
MENACTRA (PF) INTRAMUSCULAR SOLUTION
(meningococcalvaccine A,C,Y,W-135,diphtheria toxoid T2
(Min 19 Years)
conj/PF)
MENQUADFI (PF) (meningococcal vaccine A,C,Y and W- QL (0.5 ML per 1 Fill); AL
T2
135,conj tetanus toxoid/PF) (Min 19 Years)
23
Coverage
Limits
MENVEO A-C-Y-W-135-DIP (PF) (meningococcalvaccine QL (0.5 EA per 1 Fill); AL
T2
A,C,Y,W-135,diphtheria toxoid conj/PF) (Min 19 Years)
M-M-R II (PF) (measles, mumps, and rubella vaccine QL (0.5 ml per 1 Fill); AL
T2
live/PF) (Min 19 Years)
PENTACEL ACTHIB COMPONENT (PF) (Haemophilus B QL (0.5 ml per 1 Fill); AL
T2
polysacc conj-tetanus tox,component 2 of 2/PF) (Min 19 Years)
PNEUMOVAX-23 (pneumococcal 23-valent QL (0.5 ML per 1 Fill); AL
T2
polysaccharide vaccine) (Min 19 Years)
PREVNAR 13 (PF) (pneumococcal 13-valent conjugate QL (0.5 ML per 1 Fill); AL
T2
vaccine (Diphtheria crm)/PF) (Min 19 Years)
RABAVERT (PF) (rabies vaccine, purified chicken QL (1 ml per 1 Fill); AL (Min
T2
embryo cell (PCEC)/PF) 19 Years)
RECOMBIVAX HB (PF) (hepatitis B virus vaccine QL (1 ML per 1 Fill); AL (Min
T2
recombinant/PF) 19 Years)
SHINGRIX (PF) (varicella-zoster virus glycoprotein
T2 AL (Min 50 Years)
E,rec/AS01B adjuvant/PF)
TRUMENBA (Neisseria meningitidis group B, lipidated QL (0.5 ML per 1 Fill); AL
T2
fHBP recombinant) (Min 19 Years)
TWINRIX (PF) INTRAMUSCULAR SYRINGE (hepatitis A QL (1 ML per 1 Fill); AL (Min
T2
virus and hepatitis B virus vaccine/PF) 19 Years)
TYPHIM VI (typhoid vaccine VI capsular QL (1 ML per 365 days); AL
T2
polysaccharide) (Min 18 Years)
VAQTA (PF) (hepatitis A virus vaccine/PF) T2
(Min 19 Years)
QL (1 EA per 1 Fill); AL (Min
VARIVAX (PF) (varicella virus vaccine live/PF) T2
19 Years)
YF-VAX (PF) (yellow fever vaccine live/PF) T3 PA
QL (1 Fill per 1 Lifetime); AL
ZOSTAVAX (PF) (zoster vaccine live/PF) T2
(Min 60 Years)
24
Coverage
Limits
Autonomic Drugs - Drugs For The Nervous System
Alpha- And Beta-Adrenergic Agonists - Drugs For Heart And Lungs
T2
bupivacaine-epinephrine T3 PA
bupivacaine-epinephrine (PF) injection solution 0.5 %-
T3 PA
1:200,000
CHILDREN'S SILFEDRINE (pseudoephedrine HCl) T2
ephedrine sulfate injection solution T3 PA
epinephrine injection auto-injector 0.15 mg/0.3 mL T2 QL (4 EA per 180 days)
epinephrine injection auto-injector 0.3 mg/0.3 mL T2 QL (4 EA per 6 monthss)
epinephrine injection solution T2 QL (1 EA per 30 days)
epinephrine injection syringe 0.1 mg/mL T2 QL (1 EA per 30 days)
LEVOPHED (BITARTRATE) (norepinephrine bitartrate) T3 PA
lidocaine-epinephrine injection solution 0.5 %-1:200,000 T3 PA
lidocaine-epinephrine injection solution 1 %-1:100,000,
T1
2 %-1:100,000
T1
T2
MUCUS D ORAL TABLET EXTENDED RELEASE 12 HR
T2
60-600 MG (guaifenesin/pseudoephedrine HCl)
MUCUS RELIEF D (PSEUDOEPHED) ORAL TABLET
EXTENDED RELEASE 12 HR 120-1,200 MG T2
(guaifenesin/pseudoephedrine HCl)
25
Coverage
Limits
PEDIA RELIEF INFANT NASAL (pseudoephedrine HCl) T2
pseudoephedrine HCl oral tablet T2
T2
SUDOGEST 12-HOUR (pseudoephedrine HCl) T2
SYMJEPI (epinephrine) T2 QL (4 EA per 180 days)
TUSNEL NEW FORMULA ORAL TABLET
(guaifenesin/dextromethorphan HBr/pseudoephedrine T3 PA
HCl)
T2 ST
XYLOCAINE-MPF/EPINEPHRINE (lidocaine
T1
HCl/epinephrine/PF)
Alpha-Adrenergic Agonists - Drugs For Heart And Lungs
clonidine T1
clonidine HCl oral tablet T1
T2
methyldopa T1
methyldopa-hydrochlorothiazide oral tablet 250-15 mg T1
methyldopa-hydrochlorothiazide oral tablet 250-25 mg T3 PA
methyldopate T1
phenylephrine HCl injection T2 QL (1 EA per 30 days)
26
Coverage
Limits
(Min 18 Years)
ROBAFEN CF (PHENYLEPHRINE)
T2
(guaifenesin/dextromethorphan HBr/phenylephrine)
Antimuscarinics/Antispasmodics - Drugs For Parkinson
ANORO ELLIPTA (umeclidinium bromide/vilanterol
T1
trifenatate)
atropine injection solution T1
atropine injection syringe 0.05 mg/mL, 0.1 mg/mL T1
ATROVENT HFA (ipratropium bromide) T1
BENTYL INTRAMUSCULAR (dicyclomine HCl) T1
BREZTRI AEROSPHERE
T3 PA
(budesonide/glycopyrrolate/formoterol fumarate)
chlordiazepoxide-clidinium T1
COMBIVENT RESPIMAT (ipratropium bromide/albuterol
T1
sulfate)
dicyclomine intramuscular T3 PA
dicyclomine oral capsule T1
dicyclomine oral solution T3 PA
dicyclomine oral tablet T1
diphenoxylate-atropine T1
glycopyrrolate injection T2 QL (0.5 ML per 30 days)
glycopyrrolate oral tablet 1 mg, 2 mg T1
hydrocodone-homatropine oral syrup 5-1.5 mg/5 mL T2 AL (Min 18 Years)
hyoscyamine sulfate oral T1
hyoscyamine sulfate sublingual T1
INCRUSE ELLIPTA (umeclidinium bromide) T2 QL (30 EA per 30 DYs)
27
Coverage
Limits
ipratropium bromide inhalation T1
ipratropium-albuterol T1
phenobarb-hyoscy-atropine-scop oral elixir 16.2-0.1037
T1
-0.0194 mg/5 mL
phenobarb-hyoscy-atropine-scop oral tablet T1
SPIRIVA RESPIMAT (tiotropium bromide) T2 QL (4 GM per 30 days)
SPIRIVA WITH HANDIHALER (tiotropium bromide) T1
STIOLTO RESPIMAT (tiotropium bromide/olodaterol
T1
HCl)
TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE
100-62.5-25 MCG (fluticasone furoate/umeclidinium T3 PA
bromide/vilanterol trifenat)
Antiparkinsonian Agents - Drugs For Parkinson
benztropine oral T2 SCO
trihexyphenidyl oral tablet T2 SCO
Autonomic Drugs, Miscellaneous - Drugs For The Nervous System
CHANTIX (varenicline tartrate) T2 QL (180 DS per 365 days)
CHANTIX CONTINUING MONTH BOX (varenicline
T2 QL (180 DS per 365 days)
tartrate)
CHANTIX STARTING MONTH BOX (varenicline tartrate) T2 QL (180 DS per 365 days)
nicotine (polacrilex) buccal gum T2 QL (340 QY per 30 DYs)
nicotine (polacrilex) buccal lozenge T2 QL (324 QY per 30 DYs)
nicotine transdermal patch 24 hour 14 mg/24 hr, 21
mg/24 hr, 7 mg/24 hr
NICOTROL (nicotine) T3 PA
NICOTROL NS (nicotine) T3 PA
Centrally Acting Skeletal Muscle Relaxnt - Drugs For Relaxing Muscles
28
Coverage
Limits
chlorzoxazone oral tablet 500 mg T1
cyclobenzaprine oral tablet 10 mg, 5 mg T1
methocarbamol T1
tizanidine oral tablet 2 mg T2 QL (540 QY per 30 DYs)
tizanidine oral tablet 4 mg T2 QL (270 QY per 30 DYs)
Direct-Acting Skeletal Muscle Relaxants - Drugs For Relaxing Muscles
dantrolene oral T1
Gaba-Derivative Skeletal Muscle Relaxant - Drugs For Relaxing Muscles
baclofen oral tablet 10 mg, 20 mg T1
baclofen oral tablet 5 mg T2 QL (90 EA per 30 days)
Non-Sel. Beta-Adrenergic Blocking Agents - Drugs For The Heart
carvedilol T1
labetalol intravenous solution T1
labetalol oral T1
nadolol T1
pindolol T3 PA
propranolol intravenous T2 QL (0.5 ML per 30 days)
propranolol oral T1
propranolol-hydrochlorothiazid T1
sotalol HCl (Sotalol Af) T1
sotalol oral T1
timolol maleate oral T3 PA
Non-Sel.Alpha-1-Adrenergic Blocking Agts - Drugs For The Heart
doxazosin T1
prazosin T1
terazosin T1
29
Coverage
Limits
Non-Sel.Alpha-Adrenergic Blocking Agents - Drugs For The Heart
ergoloid T3
ergotamine-caffeine T1
MIGERGOT (ergotamine tartrate/caffeine) T1
phenoxybenzamine T3 PA
Parasympathomimetic (Cholinergic Agents) - Drugs For Bladder Incontinence
ARICEPT ORAL TABLET 23 MG (donepezil HCl) T3 PA
bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg T1
bethanechol chloride oral tablet 50 mg T3 PA
cevimeline T1
donepezil oral tablet 10 mg, 5 mg T1
donepezil oral tablet,disintegrating T1
MESTINON ORAL SYRUP (pyridostigmine bromide) T1
MESTINON TIMESPAN (pyridostigmine bromide) T1
pilocarpine HCl oral tablet 5 mg T1
pyridostigmine bromide oral tablet 60 mg T1
REGONOL (pyridostigmine bromide) T2 QL (1 EA per 30 days)
rivastigmine transdermal patch 24 hour 4.6 mg/24 hour,
T3 PA
9.5 mg/24 hour
Selective Alpha-1-Adrenergic Block.Agent - Drugs For The Heart
alfuzosin T1
carvedilol T1
labetalol oral T1
tamsulosin T1
Selective Beta-1-Adrenergic Agonists - Drugs For Heart And Lungs
30
Coverage
Limits
dopamine in 5 % dextrose intravenous solution 800
T3 PA
mg/250 mL (3,200 mcg/mL)
dopamine intravenous solution 800 mg/5 mL (160
T3 PA
mg/mL)
Selective Beta-2-Adrenergic Agonists - Drugs For Heart And Lungs
ADVAIR HFA (fluticasone propionate/salmeterol
T1
xinafoate)
albuterol sulfate inhalation HFA aerosol inhaler T2 QL (2 QY per 30 days)
albuterol sulfate inhalation solution for nebulization 2.5
T1
mg /3 mL (0.083 %), 5 mg/mL
albuterol sulfate oral T1
T1
trifenatate)
BREO ELLIPTA (fluticasone furoate/vilanterol
T3 PA
trifenatate)
BREZTRI AEROSPHERE
T3 PA
budesonide-formoterol T2 QL (10.2 GM per 30 days)
T1
sulfate)
DULERA (mometasone furoate/formoterol fumarate) T1
fluticasone propion-salmeterol inhalation blister with
T1
device
levalbuterol HCl T3 PA
levalbuterol tartrate T3 PA
metaproterenol oral syrup T1
SEREVENT DISKUS (salmeterol xinafoate) T1
31
Coverage
Limits
T1
HCl)
terbutaline oral T1
fluticasone propionate/salmeterol xinafoate (Wixela
T1
Inhub)
Selective Beta-Adrenergic Blocking Agent - Drugs For The Heart
acebutolol T1
atenolol T1
atenolol-chlorthalidone T1
bisoprolol fumarate T1
bisoprolol-hydrochlorothiazide T1
esmolol intravenous solution T3 PA
metoprolol succinate T1
metoprolol tartrate intravenous solution T2 QL (1 EA per 30 DYs)
metoprolol tartrate oral tablet 100 mg, 50 mg T1
metoprolol tartrate oral tablet 25 mg T1
Skeletal Muscle Relaxants, Miscellaneous - Drugs For Relaxing Muscles
orphenadrine citrate injection T2 QL (1 EA per 30 days)
Blood Formation, Coagulation, Thrombosis - Drugs For The Blood
Coumarin Derivatives - Drugs To Prevent Blood Clots
warfarin sodium (Jantoven) T1
warfarin T1
Direct Factor Xa Inhibitors - Drugs To Prevent Blood Clots
32
Coverage
Limits
ELIQUIS (apixaban) T2 QL (60 EA per 30 days)
ELIQUIS DVT-PE TREAT 30D START (apixaban) T2 QL (74 EA per 30 days)
XARELTO DVT-PE TREAT 30D START (rivaroxaban) T2 QL (51 EA per 30 days)
XARELTO ORAL TABLET 10 MG, 20 MG (rivaroxaban) T2 QL (30 EA per 30 days)
XARELTO ORAL TABLET 15 MG (rivaroxaban) T2 QL (42 EA per 21 days)
XARELTO ORAL TABLET 2.5 MG (rivaroxaban) T2 QL (60 EA per 30 days)
Hematopoietic Agents - Drugs For Anemia
EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000
T3 PA
UNIT/ML, 4,000 UNIT/ML (epoetin alfa)
FULPHILA (pegfilgrastim-jmdb) T3 PA
GRANIX SUBCUTANEOUS SYRINGE (tbo-filgrastim) T3 PA
NIVESTYM SUBCUTANEOUS (filgrastim-aafi) T3 PA
RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000
UNIT/ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 T3 PA
UNIT/ML, 40,000 UNIT/ML (epoetin alfa-epbx)
UDENYCA (pegfilgrastim-cbqv) T3 PA
Hemorrheologic Agents - Drugs For Blood Flow
pentoxifylline T1
Hemostatics - Drugs To Prevent Bleeding
AMICAR ORAL TABLET (aminocaproic acid) T3 PA
aminocaproic acid intravenous T2 QL (1 EA per 30 days)
aminocaproic acid oral solution T3 PA
desmopressin injection T3 PA
desmopressin nasal spray,non-aerosol T3 PA
desmopressin oral T2 AL (Min 6 Years)
tranexamic acid oral T3 PA
33
Coverage
Limits
Heparins - Drugs To Prevent Blood Clots
enoxaparin subcutaneous solution T3 PA
enoxaparin subcutaneous syringe 100 mg/mL, 150
T2 QL (40 ML per 180 days)
mg/mL
enoxaparin subcutaneous syringe 120 mg/0.8 mL, 80
mg/0.8 mL
enoxaparin subcutaneous syringe 30 mg/0.3 mL T2 QL (12 ML per 180 days)
heparin (porcine) injection solution T2 QL (1 EA per 30 days)
heparin (porcine) injection syringe 5,000 unit/mL T2 QL (1 EA per 30 days)
heparin flush(porcine)-0.9NaCl T2 QL (1 EA per 30 days)
heparin lock flush (porcine) intravenous solution 100
unit/mL
HEPARIN LOCK FLUSH INTRAVENOUS SOLUTION
(heparin sodium,porcine)
heparin, porcine (PF) injection syringe 5,000 unit/0.5 mL T2 QL (1 EA per 30 days)
Iron Preparations - Vitamins And Minerals
FEOSOL ORAL TABLET 45 MG (iron,carbonyl) T2
ferrous gluconate oral tablet 324 mg (37.5 mg iron), 324
T2
mg (38 mg iron)
ferrous sulfate oral drops T2
ferrous sulfate oral elixir T1
ferrous sulfate oral tablet 325 mg (65 mg iron) T2
ferrous sulfate oral tablet,delayed release (DR/EC) 325
T1
mg (65 mg iron)
FOLITAB (ferrous sulfate/ascorbic acid/folic acid) T1
34
Coverage
Limits
GERITOL TONIC WITH FERREX 18
(thiamine/riboflavin/niacin/pant T1
acid/B6/iron/methion/choline)
HEMOCYTE-F (ferrous fumarate/folic acid) T1
INFED (iron dextran complex) T2 QL (1 EA per 30 DYs)
KOSHER PRENATAL PLUS IRON (prenatal vitamins
T3 PA
no.108/iron,carbonyl/folic acid)
OB COMPLETE PETITE (prenatal no56/iron
T3 PA
carbonyl,asparto glycinate/folic acid/dha)
polysaccharide iron complex T1
PRENATAL + DHA ORAL COMBO PACK 28 MG IRON-800
MCG-200 MG (prenatal vit with calcium 95/ferrous T2 QL (1 EA per 1 day)
fumarate/folic acid/dha)
PRENATAL PLUS (CALCIUM CARB) (prenatal vits with AL (Min 13 Years and Max
T2
calcium no.72/ferrous fumarate/folic acid) 45 Years)
PRENATE DHA (FERR ASP GLYCIN) (prenatal vitamins
T3 PA
no.78/iron asparto glycin/folate no.1/dha)
PRENATE ENHANCE (prenatal vitamins no.68/iron
T3 PA
fumarate/folate no.6/dha)
PRENATE MINI (FERR ASP GLYCIN) (prenatal vits
T3 PA
no.87/iron carb-asp.glycinate/folate no.1/dha)
PRENATE PIXIE (prenatal vitamins no.85/iron asparto
T3 PA
glycin/folate no.1/dha)
PRIMACARE (prenatal vits no.118/iron asparto
T3 PA
glycinate/folate no.6/dha)
SELECT-OB + DHA (prenatal vitamins no.33/iron
T3 PA
polysach complex/folic acid/dha)
VITAMED MD ONE RX (prenatal vits no.25/ferrous
T3 PA
fumarate/folate comb. no.6/dha)
35
Coverage
Limits
Platelet-Aggregation Inhibitors - Drugs To Prevent Blood Clots
aspirin oral tablet T2
aspirin oral tablet,chewable T2
aspirin oral tablet,delayed release (DR/EC) 325 mg, 500
T2
mg, 650 mg, 81 mg
aspirin rectal T2
aspirin-dipyridamole T1
BAYER ADVANCED 500 MG TABLET T1
BAYER ADVANCED ORAL TABLET 500 MG (aspirin) T1
BRILINTA ORAL TABLET 60 MG (ticagrelor) T3 PA
BRILINTA ORAL TABLET 90 MG (ticagrelor) T2 QL (60 EA per 30 days)
butalbital-aspirin-caffeine oral capsule T1
cilostazol T1
clopidogrel oral tablet 300 mg T2 QL (2 EA per 30 days)
clopidogrel oral tablet 75 mg T1
dipyridamole oral T1
prasugrel T2 QL (30 EA per 30 days)
Platelet-Reducing Agents - Drugs To Prevent Blood Clots
anagrelide oral capsule 0.5 mg T1
Thrombolytic Agents - Drugs To Prevent Blood Clots
T2
mg, 650 mg, 81 mg
aspirin rectal T2
36
Coverage
Limits
Cardiovascular Drugs - Drugs For The Heart
Alpha-Adrenergic Blocking Agents - Drugs For High Blood Pressure
carvedilol T1
doxazosin T1
labetalol oral T1
prazosin T1
terazosin T1
Alpha-Adrenergic Blocking Agt.(Hypoten) - Drugs For High Blood Pressure &
Angina
doxazosin T1
labetalol oral T1
prazosin T1
terazosin T1
Angiotensin Ii Receptor Antagon.(Hypotn) - Drugs For High Blood Pressure &
Angina
irbesartan T1
irbesartan-hydrochlorothiazide T1
losartan T1
losartan-hydrochlorothiazide T1
MICARDIS (telmisartan) T3 PA
MICARDIS HCT (telmisartan/hydrochlorothiazide) T3 PA
olmesartan T1
olmesartan-hydrochlorothiazide T1
telmisartan T1
37
Coverage
Limits
valsartan T1
valsartan-hydrochlorothiazide T1
Angiotensin Ii Receptor Antagonists - Drugs For The Heart
ENTRESTO (sacubitril/valsartan) T2 QL (60 EA per 30 days)
irbesartan T1
losartan T1
MICARDIS (telmisartan) T3 PA
olmesartan T1
telmisartan T1
valsartan T1
Angiotensin-Convert.Enzyme Inhib(Hypotn) - Drugs For High Blood Pressure &
Angina
amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg,
T1
5-10 mg, 5-20 mg, 5-40 mg
benazepril T1
benazepril-hydrochlorothiazide oral tablet 10-12.5 mg,
T1
20-12.5 mg, 5-6.25 mg
captopril T1
captopril-hydrochlorothiazide T2 PA
enalapril maleate T1
enalapril-hydrochlorothiazide oral tablet 10-25 mg T1
38
Coverage
Limits
fosinopril T1
lisinopril T1
lisinopril-hydrochlorothiazide T1
quinapril T1
quinapril-hydrochlorothiazide T1
ramipril T1
trandolapril T1
Angiotensin-Converting Enzyme Inhibitors - Drugs For The Heart
T1
5-10 mg, 5-20 mg, 5-40 mg
benazepril T1
T1
20-12.5 mg, 5-6.25 mg
captopril T1
enalapril maleate T1
fosinopril T1
lisinopril T1
quinapril T1
ramipril T1
trandolapril T1
Antiarrhythmics, Miscellaneous - Drugs For Angina
digoxin (Digox) T1
39
Coverage
Limits
digoxin injection solution T1
digoxin injection syringe T2 QL (1 EA per 30 days)
digoxin oral solution 50 mcg/mL (0.05 mg/mL) T1
digoxin oral tablet T1
LANOXIN PEDIATRIC (digoxin) T1
Antilipemic Agents, Miscellaneous - Drugs For Cholesterol
omega-3 acid ethyl esters (Lovaza) T2 ST
NEXLETOL (bempedoic acid) T3 PA
NEXLIZET (bempedoic acid/ezetimibe) T3 PA
niacin oral capsule, extended release 125 mg, 250 mg,
T2
500 mg
niacin oral tablet T2
niacin oral tablet extended release T2
niacin oral tablet extended release 24 hr T3 PA
omega 3-dha-epa-fish oil oral capsule 300-1,000 mg T1
omega 3-dha-epa-fish oil oral capsule,delayed
T1
release(DR/EC) 300 mg (120 mg- 180mg)-1,000 mg
omega 3-dha-epa-fish oil oral capsule,delayed
T1
release(DR/EC) 300-1,000 mg
omega-3 fatty acids oral capsule T1
omega-3 fatty acids-fish oil oral capsule 300-1,000 mg T1
Beta-Adrenergic Blocking Agents - Drugs For Abnormal Heart Rhythms
acebutolol T1
atenolol T1
40
Coverage
Limits
carvedilol T1
labetalol oral T1
LEVATOL (penbutolol sulfate) T3 PA
nadolol T1
pindolol T3 PA
propranolol oral T1
sotalol oral T1
Beta-Adrenergic Blocking Agt.(Hypoten) - Drugs For High Blood Pressure &
Angina
acebutolol T1
atenolol T1
41
Coverage
Limits
labetalol oral T1
nadolol T1
pindolol T3 PA
propranolol oral T1
sotalol oral T1
Bile Acid Sequestrants - Drugs For Cholesterol
cholestyramine (with sugar) T1
cholestyramine/aspartame (Cholestyramine Light Oral
T1
Powder In Packet)
colestipol T1
cholestyramine/aspartame (Prevalite) T1
Calcium-Channel Block.Agt,Misc(Hypoten) - Drugs For High Blood Pressure &
Angina
CARDIZEM LA ORAL TABLET EXTENDED RELEASE 24
T3 PA
HR 120 MG (diltiazem HCl)
diltiazem HCl (Cartia Xt) T1
diltiazem HCl oral capsule,ext.rel 24h degradable T1
diltiazem HCl oral capsule,extended release 12 hr T2 ST
42
Coverage
Limits
diltiazem HCl oral capsule,extended release 24 hr T1
diltiazem HCl oral capsule,extended release 24hr 120
T1
mg, 180 mg, 240 mg, 300 mg
T3 PA
mg
diltiazem HCl oral tablet T1
diltiazem HCl oral tablet extended release 24 hr T3 PA
DILT-XR (diltiazem HCl) T1
diltiazem HCl (Matzim La) T3 PA
diltiazem HCl (Taztia Xt Oral Capsule,Extended Release
T1
24 Hr 120 Mg, 180 Mg, 240 Mg, 360 Mg)
T2 PA
24 Hr 300 Mg)
verapamil intravenous T1
verapamil oral capsule,ext rel. pellets 24 hr 120 mg, 180
T1
mg, 240 mg
verapamil oral capsule,ext rel. pellets 24 hr 360 mg T3 PA
verapamil oral tablet T1
verapamil oral tablet extended release T1
Calcium-Channel Blocking Agents - Drugs For High Blood Pressure & Angina
amlodipine T1
amlodipine-atorvastatin oral tablet 10-10 mg, 10-20 mg,
T3 PA
10-40 mg, 10-80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg
T1
5-10 mg, 5-20 mg, 5-40 mg
T3 PA
43
Coverage
Limits
T1
mg, 180 mg, 240 mg, 300 mg
T3 PA
mg
felodipine T1
isradipine T2 ST
nicardipine oral T3 PA
nifedipine oral capsule T3 PA
nifedipine oral tablet extended release T1
nifedipine oral tablet extended release 24hr T1
nimodipine T3 PA
T1
24 Hr 120 Mg, 180 Mg, 240 Mg, 360 Mg)
T2 PA
24 Hr 300 Mg)
T1
mg, 240 mg
44
Coverage
Limits
Calcium-Channel Blocking Agents(Hypoten) - Drugs For High Blood Pressure &
Angina
T3 PA
T1
mg, 180 mg, 240 mg, 300 mg
T3 PA
mg
T1
24 Hr 120 Mg, 180 Mg, 240 Mg, 360 Mg)
T2 PA
24 Hr 300 Mg)
T1
mg, 240 mg
45
Coverage
Limits
Calcium-Channel Blocking Agents, Misc. - Drugs For High Blood Pressure &
Angina
T3 PA
T1
mg, 180 mg, 240 mg, 300 mg
T3 PA
mg
T1
24 Hr 120 Mg, 180 Mg, 240 Mg, 360 Mg)
T2 PA
24 Hr 300 Mg)
T1
mg, 240 mg
Carbonic Anhydrase Inhibitors(Hypoten) - Drugs For High Blood Pressure &
Angina
46
Coverage
Limits
acetazolamide T1
Cardiotonic Agents - Drugs For Angina
digoxin (Digox) T1
digoxin injection solution T1
digoxin injection syringe T2 QL (1 EA per 30 days)
digoxin oral solution 50 mcg/mL (0.05 mg/mL) T1
digoxin oral tablet T1
dopamine in 5 % dextrose intravenous solution 800
T3 PA
mg/250 mL (3,200 mcg/mL)
dopamine intravenous solution 800 mg/5 mL (160
T3 PA
mg/mL)
LANOXIN PEDIATRIC (digoxin) T1
Central Alpha-Agonists - Drugs For High Blood Pressure & Angina
clonidine T1
clonidine HCl oral tablet T1
guanfacine T1
methyldopa T1
methyldopate T1
Cholesterol Absorption Inhibitors - Drugs For Cholesterol
ezetimibe T2 ST
NEXLIZET (bempedoic acid/ezetimibe) T3 PA
Class Ia Antiarrhythmics - Drugs For Angina
disopyramide phosphate oral capsule T1
NORPACE CR (disopyramide phosphate) T1
47
Coverage
Limits
procainamide injection solution 100 mg/mL T2 QL (0.5 ML per 30 days)
procainamide injection solution 500 mg/mL T1
quinidine gluconate oral T1
quinidine sulfate oral tablet T1
Class Ib Antiarrhythmics - Drugs For Angina
DILANTIN (phenytoin sodium extended) T1
mexiletine T1
phenytoin oral suspension 125 mg/5 mL T1
phenytoin oral tablet,chewable T1
phenytoin sodium T1
phenytoin sodium extended T1
Class Ic Antiarrhythmics - Drugs For Angina
flecainide T1
propafenone T1
Class Ii Antiarrhythmics - Drugs For Angina
acebutolol T1
atenolol T1
carvedilol T1
labetalol oral T1
48
Coverage
Limits
nadolol T1
pindolol T3 PA
propranolol oral T1
sotalol oral T1
Class Iii Antiarrhythmics - Drugs For Angina
amiodarone oral T1
dofetilide oral capsule 250 mcg, 500 mcg T1
MULTAQ (dronedarone HCl) T3 PA
sotalol oral T1
TIKOSYN ORAL CAPSULE 125 MCG (dofetilide) T1
Class Iv Antiarrhythmics - Drugs For Angina
T3 PA
T1
mg, 180 mg, 240 mg, 300 mg
49
Coverage
Limits
T3 PA
mg
T1
mg, 240 mg
Dihydropyridines - Drugs For High Blood Pressure & Angina
amlodipine T1
T3 PA
10-40 mg, 10-80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg
T1
5-10 mg, 5-20 mg, 5-40 mg
felodipine T1
isradipine T2 ST
nimodipine T3 PA
Dihydropyridines (Antihypertensive) - Drugs For High Blood Pressure & Angina
amlodipine T1
50
Coverage
Limits
T3 PA
10-40 mg, 10-80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg
T1
5-10 mg, 5-20 mg, 5-40 mg
felodipine T1
isradipine T2 ST
nimodipine T3 PA
Direct Vasodilators - Drugs For High Blood Pressure & Angina
hydralazine T1
minoxidil oral T1
Diuretics, Miscellaneous (Hypotensive) - Drugs For High Blood Pressure &
Angina
theophylline in dextrose 5 % intravenous parenteral
solution 200 mg/100 mL
theophylline oral elixir T1
theophylline oral tablet extended release 12 hr 300 mg,
T1
450 mg
theophylline oral tablet extended release 24 hr T1
Fibric Acid Derivatives - Drugs For Cholesterol
fenofibrate micronized oral capsule 134 mg T1
fenofibrate micronized oral capsule 200 mg, 67 mg T2 ST
fenofibrate nanocrystallized oral tablet 145 mg, 48 mg T1
fenofibrate oral tablet 160 mg, 54 mg T1
51
Coverage
Limits
gemfibrozil T1
Hmg-Coa Reductase Inhibitors - Drugs For Cholesterol
T3 PA
10-40 mg, 10-80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg
atorvastatin T1
fluvastatin oral capsule T3 PA
fluvastatin oral tablet extended release 24 hr T2 PA
lovastatin T1
pravastatin T2 QL (30 EA per 30 days)
rosuvastatin T2 QL (30 EA per 30 days)
simvastatin oral tablet T1
Hypotensive Agents, Miscellaneous - Drugs For High Blood Pressure & Angina
acebutolol T1
amlodipine T1
T1
5-10 mg, 5-20 mg, 5-40 mg
carvedilol T1
doxazosin T1
felodipine T1
isradipine T2 ST
nimodipine T3 PA
phenoxybenzamine T3 PA
52
Coverage
Limits
pindolol T3 PA
propranolol oral T1
sotalol oral T1
terazosin T1
Loop Diuretics (Hypotensive Agents) - Drugs For High Blood Pressure & Angina
bumetanide T1
EDECRIN (ethacrynic acid) T1
ethacrynate sodium T1
furosemide injection T2 QL (1 EA per 30 days)
furosemide oral solution 10 mg/mL T2 QL (1 EA per 30 days)
furosemide oral solution 40 mg/5 mL (8 mg/mL) T1
furosemide oral tablet T1
torsemide oral T1
Mineralocorticoid (Aldosterone) Antagnts - Drugs For The Heart
ALDACTAZIDE ORAL TABLET 50-50 MG
T3 PA
(spironolactone/hydrochlorothiazide)
spironolactone T1
spironolacton-hydrochlorothiaz T1
Mineralocorticoid(Aldoster.)Antag(Hypot) - Drugs For High Blood Pressure &
Angina
T3 PA
spironolactone T1
53
Coverage
Limits
Nitrates And Nitrites - Drugs For The Heart
DILATRATE-SR (isosorbide dinitrate) T1
isosorbide dinitrate oral T1
isosorbide mononitrate T1
nitroglycerin (Nitro-Bid) T1
nitroglycerin oral T1
nitroglycerin sublingual T1
nitroglycerin transdermal patch 24 hour T1
Osmotic Diuretics (Hypotensive Agents) - Drugs For High Blood Pressure &
Angina
mannitol 10 % T2 QL (1 EA per 30 days)
mannitol 25 % intravenous solution T2 QL (1 EA per 30 days)
Pcsk9 Inhibitors - Drugs For Cholesterol
REPATHA PUSHTRONEX (evolocumab) T3 PA
REPATHA SURECLICK (evolocumab) T3 PA
REPATHA SYRINGE (evolocumab) T3 PA
Phosphodiesterase Type 5 Inhibitors - Drugs For The Heart
CIALIS (tadalafil) T3 PA; QL (3 QY per 30 DYs)
cilostazol T1
LEVITRA ORAL TABLET 10 MG (vardenafil HCl) T3 PA; QL (3 QY per 30 DYs)
sildenafil (pulm.hypertension) oral tablet T3 PA
tadalafil (pulm. hypertension) T3 PA
VIAGRA (sildenafil citrate) T3 PA; QL (3 QY per 30 DYs)
54
Coverage
Limits
Potassium-Sparing Diuretics (Hypoten) - Drugs For High Blood Pressure &
Angina
T3 PA
amiloride T1
amiloride-hydrochlorothiazide T1
DYRENIUM (triamterene) T3 PA
spironolactone T1
triamterene-hydrochlorothiazid oral capsule 37.5-25 mg T1
triamterene-hydrochlorothiazid oral tablet T1
Renin-Angioten.-Aldost. Sys. Inhib, Misc - Drugs For The Heart
ENTRESTO (sacubitril/valsartan) T2 QL (60 EA per 30 days)
Thiazide Diuretics(Hypotensive Agents) - Drugs For High Blood Pressure &
Angina
T3 PA
T1
20-12.5 mg, 5-6.25 mg
chlorothiazide oral tablet 500 mg T1
DIURIL (chlorothiazide) T1
hydrochlorothiazide oral capsule T1
hydrochlorothiazide oral tablet 25 mg, 50 mg T1
55
Coverage
Limits
Thiazide-Like Diuretics(Hypotensive Agt) - Drugs For High Blood Pressure &
Angina
chlorthalidone oral tablet 25 mg, 50 mg T1
indapamide T1
metolazone T1
Vasodilating Agents, Miscellaneous - Drugs For The Heart
amlodipine T1
T3 PA
10-40 mg, 10-80 mg, 5-10 mg, 5-20 mg, 5-40 mg, 5-80 mg
T1
5-10 mg, 5-20 mg, 5-40 mg
56
Coverage
Limits
T3 PA
CAVERJECT IMPULSE (alprostadil) T3 PA
CAVERJECT INTRACAVERNOSAL RECON SOLN
T3 PA
(alprostadil)
T1
mg, 180 mg, 240 mg, 300 mg
T3 PA
mg
dipyridamole oral T1
felodipine T1
isradipine T2 ST
MUSE INTRA-URETHRAL SUPPOSITORY 1,000 MCG,
T3 PA
250 MCG (alprostadil)
nimodipine T3 PA
57
Coverage
Limits
T1
24 Hr 120 Mg, 180 Mg, 240 Mg, 360 Mg)
T2 PA
24 Hr 300 Mg)
VENTAVIS INHALATION SOLUTION FOR NEBULIZATION
T3 PA
20 MCG/ML (iloprost tromethamine)
T1
mg, 240 mg
VERQUVO (vericiguat) T3 PA
Central Nervous System Agents - Drugs For The Nervous System
Adamantanes (Cns) - Drugs For Parkinson
amantadine HCl T2 SCO
Amphetamine Derivatives - Drugs For The Nervous System
QSYMIA (phentermine HCl/topiramate) T3 PA
Amphetamines - Drugs For The Nervous System
QL (30 EA per 30 days); AL
dextroamphetamine oral capsule, extended release T2
(Max 18 Years)
dextroamphetamine oral tablet T2
(Max 18 Years)
dextroamphetamine-amphetamine oral QL (30 QY per 30 DYs); AL
T2
capsule,extended release 24hr (Max 18 Years)
dextroamphetamine-amphetamine oral tablet 10 mg, QL (60 EA per 30 days); AL
T2
12.5 mg, 15 mg, 20 mg, 5 mg, 7.5 mg (Max 18 Years)
58
Coverage
Limits
dextroamphetamine-amphetamine oral tablet 30 mg T2
(Max 18 Years)
methamphetamine T3 PA
VYVANSE ORAL CAPSULE (lisdexamfetamine
T3 PA
dimesylate)
Analgesics And Antipyretics, Misc. - Drugs For Pain
acetaminophen oral elixir T2
acetaminophen oral liquid 500 mg/5 mL T2
acetaminophen rectal T2
acetaminophen-codeine oral solution 120-12 mg/5 mL T1
acetaminophen-codeine oral solution 240 mg-24 mg /10
T1
mL (10 mL)
acetaminophen-codeine oral tablet T1
butalbital-acetaminop-caf-cod oral capsule 50-325-40-30
T3 PA
mg
butalbital-acetaminophen-caff oral capsule 50-325-40
T1
mg
butalbital-acetaminophen-caff oral tablet 50-325-40 mg T1
oxycodone HCl/acetaminophen (Endocet Oral Tablet 5-
T1
325 Mg)
FEVERALL RECTAL SUPPOSITORY 325 MG, 80 MG
T2
(acetaminophen)
gabapentin oral capsule T1
gabapentin oral solution 250 mg/5 mL T1
gabapentin oral tablet 600 mg, 800 mg T1
hydrocodone-acetaminophen oral solution 7.5-325
T1
mg/15 mL
59
Coverage
Limits
hydrocodone-acetaminophen oral tablet 10-325 mg, 5-
T1
325 mg, 7.5-325 mg
INFANT'S NON-ASPIRIN ORAL DROPS (acetaminophen) T2
isometh-dichloral-acetaminophn T3 PA
MAPAP (ACETAMINOPHEN) ORAL CAPSULE
T2
(acetaminophen)
MAPAP (ACETAMINOPHEN) ORAL LIQUID 500 MG/15
T2
ML (acetaminophen)
MAPAP ARTHRITIS PAIN (acetaminophen) T2
oxycodone-acetaminophen oral tablet 10-325 mg T2 QL (30 tablets per 1 fill)
oxycodone-acetaminophen oral tablet 5-325 mg T1
pregabalin oral capsule T1
pregabalin oral solution T2 ST
tramadol-acetaminophen T1
Anorexigenic Agents, Miscellaneous - Drugs For The Nervous System
CONTRAVE (naltrexone HCl/bupropion HCl) T3 PA
Anticholinergic Agents (Cns) - Drugs For Parkinson
benztropine oral T2 SCO
trihexyphenidyl oral tablet T2 SCO
Anticonvulsants, Miscellaneous - Drugs For Seizures
carbamazepine oral capsule, ER multiphase 12 hr T1
carbamazepine oral suspension 100 mg/5 mL T1
carbamazepine oral tablet T1
carbamazepine oral tablet extended release 12 hr T1
carbamazepine oral tablet,chewable T1
60
Coverage
Limits
divalproex T1
EPIDIOLEX (cannabidiol (CBD)) T3 PA
felbamate T3 PA
gabapentin oral capsule T1
gabapentin oral solution 250 mg/5 mL T1
gabapentin oral tablet 600 mg, 800 mg T1
GABITRIL ORAL TABLET 12 MG, 16 MG (tiagabine HCl) T1
lamotrigine oral tablet T1
lamotrigine oral tablet, chewable dispersible T1
levetiracetam oral solution T1
levetiracetam oral tablet T1
oxcarbazepine T1
rufinamide oral tablet T3 PA
tiagabine oral tablet 2 mg, 4 mg T1
topiramate oral capsule, sprinkle T1
topiramate oral tablet T1
valproic acid T1
valproic acid (as sodium salt) oral solution T1
VIMPAT ORAL SOLUTION (lacosamide) T3 PA
VIMPAT ORAL TABLET (lacosamide) T3 PA
zonisamide T1
Antidepressants, Miscellaneous - Drugs For Depression & Psychosis
bupropion HCl (smoking deter) T2 QL (60 EA per 30 days)
61
Coverage
Limits
bupropion HCl oral tablet T1
bupropion HCl oral tablet extended release 24 hr 150
T1
mg, 300 mg
bupropion HCl oral tablet sustained-release 12 hr 100
T1
mg, 200 mg
bupropion HCl oral tablet sustained-release 12 hr 150
T2 QL (60 QY per 30 DYs)
mg
mirtazapine oral tablet T1
mirtazapine oral tablet,disintegrating 15 mg, 30 mg T1
mirtazapine oral tablet,disintegrating 45 mg T3 PA
Antimanic Agents - Drugs For Personality Disorder
aripiprazole oral tablet T2 SCO
carbamazepine oral capsule, ER multiphase 12 hr T1
carbamazepine oral suspension 100 mg/5 mL T1
carbamazepine oral tablet T1
carbamazepine oral tablet extended release 12 hr T1
carbamazepine oral tablet,chewable T1
divalproex T1
lamotrigine oral tablet T1
lamotrigine oral tablet, chewable dispersible T1
lithium carbonate T2 SCO
lithium citrate oral solution 8 mEq/5 mL T2 SCO
olanzapine oral tablet T2 SCO
olanzapine oral tablet,disintegrating T3 PA; SCO
quetiapine T2 SCO
risperidone oral solution T2 SCO
risperidone oral tablet T2 SCO
62
Coverage
Limits
risperidone oral tablet,disintegrating T2 SCO
valproic acid T1
ziprasidone HCl T2 SCO
ZYPREXA ZYDIS (olanzapine) T3 PA; SCO
Antimigraine Agents, Miscellaneous - Migraine Treatment
AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-
T3 PA
INJECTOR 70 MG/ML (erenumab-aooe)
AJOVY SYRINGE (fremanezumab-vfrm) T3 PA
T2
mg, 650 mg, 81 mg
aspirin rectal T2
codeine phosphate/butalbital/aspirin/caffeine (Butalbital
T3 PA
Compound W/Codeine)
T3 PA
mg
T1
mg
divalproex T1
EMGALITY PEN (galcanezumab-gnlm) T3 PA
EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120
T3 PA
MG/ML (galcanezumab-gnlm)
ergotamine-caffeine T1
63
Coverage
Limits
MIGERGOT (ergotamine tartrate/caffeine) T1
propranolol oral T1
valproic acid T1
Antipsychotics, Miscellaneous - Drugs For Depression & Psychosis
loxapine succinate T2 SCO
pimozide T2 SCO
Anxiolytics,Sedatives,And Hypnotics,Misc - Drugs For Anxiety & Sleep Disorder
AMBIEN CR (zolpidem tartrate) T3 PA
BELSOMRA (suvorexant) T3 PA
buspirone oral tablet 30 mg, 5 mg, 7.5 mg T1
droperidol injection solution T1
eszopiclone T1
hydroxyzine HCl intramuscular T2 QL (1 EA per 30 days)
hydroxyzine HCl oral solution 10 mg/5 mL T1
hydroxyzine HCl oral tablet T1
hydroxyzine pamoate T1
promethazine HCl (Phenadoz Rectal Suppository 25 Mg) T1
promethazine rectal suppository 12.5 mg, 50 mg T1
ROZEREM (ramelteon) T3 PA
64
Coverage
Limits
T2
T2
zaleplon T1
zolpidem oral tablet T2 QL (30 QY per 30 DYs)
zolpidem oral tablet,ext release multiphase T3 PA
Atypical Antipsychotics - Drugs For Depression & Psychosis
aripiprazole oral tablet T2 SCO
clozapine oral tablet T2 SCO
olanzapine oral tablet T2 SCO
olanzapine oral tablet,disintegrating T3 PA; SCO
quetiapine T2 SCO
REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3
T3 PA; SCO
MG (brexpiprazole)
risperidone oral solution T2 SCO
risperidone oral tablet T2 SCO
risperidone oral tablet,disintegrating T2 SCO
ziprasidone HCl T2 SCO
ZYPREXA ZYDIS (olanzapine) T3 PA; SCO
Barbiturates (Anticonvulsants) - Drugs For Seizures
T1
-0.0194 mg/5 mL
phenobarbital T1
primidone T1
65
Coverage
Limits
Barbiturates (Anxiolytic, Sedative/Hyp) - Drugs For Anxiety & Sleep Disorder
T3 PA
Compound W/Codeine)
T3 PA
mg
T1
mg
T1
-0.0194 mg/5 mL
phenobarbital oral elixir T1
phenobarbital oral tablet 100 mg, 16.2 mg, 32.4 mg, 64.8
T1
mg, 97.2 mg
phenobarbital oral tablet 15 mg, 60 mg T1
Benzodiazepines (Anticonvulsants) - Drugs For Seizures
clobazam oral tablet T2 QL (60 EA per 30 DYs)
clonazepam T1
clorazepate dipotassium T1
diazepam (Diazepam Intensol) T1
diazepam oral solution T1
diazepam oral tablet T1
lorazepam oral concentrate T1
lorazepam oral tablet T1
Benzodiazepines (Anxiolytic,Sedativ/Hyp) - Drugs For Anxiety & Sleep Disorder
ALPRAZOLAM INTENSOL (alprazolam) T1
66
Coverage
Limits
alprazolam oral tablet T1
alprazolam oral tablet,disintegrating T3 PA
chlordiazepoxide HCl T1
chlordiazepoxide-clidinium T1
clobazam oral tablet T2 QL (60 EA per 30 DYs)
clonazepam T1
clorazepate dipotassium T1
diazepam (Diazepam Intensol) T1
diazepam oral solution T1
diazepam oral tablet T1
flurazepam T1
lorazepam oral concentrate T1
lorazepam oral tablet T1
oxazepam T3 PA
temazepam oral capsule 15 mg, 30 mg T1
temazepam oral capsule 22.5 mg, 7.5 mg T3 PA
triazolam T1
Butyrophenones - Drugs For Depression & Psychosis
haloperidol T2 SCO
haloperidol decanoate T2 SCO
haloperidol lactate injection T2 SCO
haloperidol lactate oral T2 SCO
Calcitonin Gene-Related Peptide Antag. - Migraine Treatment
AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-
T3 PA
INJECTOR 70 MG/ML (erenumab-aooe)
AJOVY SYRINGE (fremanezumab-vfrm) T3 PA
67
Coverage
Limits
EMGALITY PEN (galcanezumab-gnlm) T3 PA
EMGALITY SYRINGE (galcanezumab-gnlm) T3 PA
NURTEC ODT (rimegepant sulfate) T3 PA
UBRELVY (ubrogepant) T3 PA
Catechol-O-Methyltransferase(Comt)Inhib. - Drugs For Parkinson
entacapone T2 QL (120 EA per 30 days)
Central Nervous System Agents, Misc. - Drugs For Attention Deficit Disorder
acamprosate T2 SCO
atomoxetine T3 PA
AUSTEDO (deutetrabenazine) T3 PA
guanfacine T1
INGREZZA ORAL CAPSULE 40 MG, 80 MG (valbenazine
T3 PA
tosylate)
memantine oral tablet T1
memantine oral tablets,dose pack T1
QELBREE (viloxazine HCl) T3 PA
riluzole T1
Cyclooxygenase-2 (Cox-2) Inhibitors - Drugs For Pain
celecoxib oral capsule 100 mg, 200 mg T1
celecoxib oral capsule 400 mg, 50 mg T3 PA
Dopamine Precursors - Drugs For Parkinson
carbidopa-levodopa oral tablet T1
carbidopa-levodopa oral tablet extended release T1
Ergot-Deriv. Dopamine Receptor Agonists - Drugs For Parkinson
bromocriptine T1
cabergoline T1
68
Coverage
Limits
Fibromyalgia Agents - Drugs For Nerve Pain
duloxetine oral capsule,delayed release(DR/EC) 20 mg,
30 mg, 60 mg
duloxetine oral capsule,delayed release(DR/EC) 40 mg T3 PA
SAVELLA ORAL TABLET (milnacipran HCl) T3 PA
Hydantoins - Drugs For Seizures
DILANTIN (phenytoin sodium extended) T1
phenytoin oral suspension 125 mg/5 mL T1
phenytoin oral tablet,chewable T1
phenytoin sodium T1
phenytoin sodium extended T1
Monoamine Oxidase B Inhibitors - Drugs For Parkinson
selegiline HCl T1
Monoamine Oxidase Inhibitors - Drugs For Depression & Psychosis
selegiline HCl T1
Nonergot-Deriv.Dopamine Receptor Agonist - Drugs For Parkinson
pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 1 mg T1
ropinirole oral tablet T1
Opiate Agonists - Drugs For Pain
acetaminophen-codeine oral solution 120-12 mg/5 mL T1
acetaminophen-codeine oral solution 240 mg-24 mg /10
T1
mL (10 mL)
acetaminophen-codeine oral tablet T1
69
Coverage
Limits
T3 PA
Compound W/Codeine)
T3 PA
mg
codeine sulfate oral tablet T1
DEMEROL INJECTION SOLUTION 50 MG/ML
T2 PA
(meperidine HCl)
oxycodone HCl/acetaminophen (Endocet Oral Tablet 5-
T1
325 Mg)
fentanyl transdermal patch 72 hour 100 mcg/hr, 12
T3 PA; QL (10 QY per 30 DYs)
mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
hydrocodone-acetaminophen oral solution 7.5-325
T1
mg/15 mL
hydrocodone-acetaminophen oral tablet 10-325 mg, 5-
T1
325 mg, 7.5-325 mg
hydromorphone injection solution 2 mg/mL T1
hydromorphone injection syringe 1 mg/mL, 2 mg/mL, 4
T1
mg/mL
hydromorphone oral liquid T1
hydromorphone oral tablet T1
hydromorphone rectal T1
levorphanol tartrate oral tablet 2 mg T3 PA
meperidine injection cartridge T1
meperidine oral solution T3 PA
meperidine oral tablet 50 mg T3 PA
methadone injection solution T1
methadone oral concentrate T1
70
Coverage
Limits
methadone oral solution T1
methadone oral tablet T1
morphine concentrate oral solution T1
morphine injection solution 8 mg/mL T2 QL (1 EA per 30 days)
morphine injection syringe 10 mg/mL, 2 mg/mL, 4
mg/mL, 8 mg/mL
morphine oral solution T1
morphine oral tablet T1
morphine oral tablet extended release T1
morphine rectal T1
oxycodone oral concentrate T3 PA
oxycodone oral solution T3 PA
oxycodone oral tablet 15 mg, 30 mg T3 PA
oxycodone oral tablet 5 mg T2 QL (10 EA per 5 days)
oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15
T3 PA
mg, 20 mg, 40 mg, 60 mg, 80 mg
oxycodone oral tablet,oral only,ext.rel.12 hr 30 mg T2 PA
oxycodone-acetaminophen oral tablet 10-325 mg T2 QL (30 tablets per 1 fill)
oxycodone-acetaminophen oral tablet 5-325 mg T1
oxycodone-aspirin T3 PA
promethazine-codeine T2
(Min 18 Years)
(Min 18 Years)
ROXICODONE ORAL TABLET 15 MG, 30 MG (oxycodone
T3 PA
HCl)
tramadol oral tablet 50 mg T1
71
Coverage
Limits
Opiate Antagonists - Drugs For Overdose Or Poisoning
SCO; QL (2 QY per 180
naloxone injection syringe 1 mg/mL T2
DYs)
naltrexone T2 SCO
NARCAN NASAL SPRAY,NON-AEROSOL 4 SCO; QL (2 EA per 180
T2
MG/ACTUATION (naloxone HCl) days)
Opiate Partial Agonists - Drugs For Pain
buprenorphine T3 PA; SCO
buprenorphine HCl sublingual T2 SCO
buprenorphine-naloxone sublingual film 2-0.5 mg, 8-2
T2 SCO
mg
buprenorphine-naloxone sublingual tablet T2 SCO
nalbuphine T1
pentazocine-naloxone T3 PA
SUBOXONE SUBLINGUAL FILM 12-3 MG, 4-1 MG
T3 PA; SCO
(buprenorphine HCl/naloxone HCl)
Other Nonsteroidal Anti-Inflam. Agents - Drugs For Pain
CHILDREN'S IBUPROFEN (ibuprofen) T2
diclofenac potassium T1
diclofenac sodium oral T1
diclofenac sodium topical gel 1 % T2 QL (200 GM per 30 days)
diclofenac-misoprostol T3 PA
diflunisal T1
etodolac T1
fenoprofen oral capsule 200 mg T3 PA
fenoprofen oral tablet T3 PA
72
Coverage
Limits
flurbiprofen oral tablet 100 mg T3 PA
ibuprofen oral tablet 400 mg, 600 mg, 800 mg T1
INDOCIN ORAL (indomethacin) T1
indomethacin oral T1
ketoprofen oral capsule 50 mg, 75 mg T3 PA
ketorolac oral T3 PA
meclofenamate T3 PA
meloxicam T1
nabumetone T1
naproxen oral suspension T1
naproxen oral tablet T1
naproxen sodium oral tablet 275 mg, 550 mg T1
oxaprozin T2 QL (270 EA per 90 days)
piroxicam T1
sulindac T1
tolmetin T3 PA
TREXIMET ORAL TABLET 85-500 MG (sumatriptan
T3 PA
succinate/naproxen sodium)
Phenothiazines - Drugs For Depression & Psychosis
chlorpromazine oral T2 SCO
fluphenazine decanoate T2 SCO
fluphenazine HCl injection T2 SCO
fluphenazine HCl oral tablet T2 SCO
perphenazine T2 SCO
prochlorperazine T1
prochlorperazine Edisylate injection solution 5 mg/mL T2 QL (1 EA per 30 days)
73
Coverage
Limits
prochlorperazine maleate T1
thioridazine T2 SCO
trifluoperazine T2 SCO
Respiratory And Cns Stimulants - Drugs For The Nervous System
T3 PA
Compound W/Codeine)
T3 PA
mg
T1
mg
dexmethylphenidate oral capsule,ER biphasic 50-50 10 QL (60 EA per 30 days); AL
T2
mg, 5 mg (Max 18 Years)
dexmethylphenidate oral capsule,ER biphasic 50-50 15 QL (30 EA per 30 days); AL
T2
dexmethylphenidate oral tablet T2
(Max 18 Years)
doxapram T3 PA
methylphenidate HCl oral capsule, ER biphasic 30-70 T2
(Max 18 Years)
methylphenidate HCl oral capsule,ER biphasic 50-50 10 QL (30 EA per 30 DYs); AL
T2
mg (Max 18 Years)
methylphenidate HCl oral capsule,ER biphasic 50-50 20 QL (30 QY per 30 DYs); AL
T2
methylphenidate HCl oral capsule,ER biphasic 50-50 30 QL (60 EA per 30 days); AL
T2
mg (Max 18 Years)
methylphenidate HCl oral capsule,ER biphasic 50-50 60 QL (30 EA per 30 days); AL
T2
mg (Max 18 Years)
74
Coverage
Limits
methylphenidate HCl oral solution T2
(Max 18 Years)
methylphenidate HCl oral tablet 10 mg, 5 mg T2
(Max 18 Years)
methylphenidate HCl oral tablet 20 mg T2
(Max 18 Years)
methylphenidate HCl oral tablet extended release T2
(Max 18 Years)
methylphenidate HCl oral tablet extended release 24hr QL (30 QY per 30 DYs); AL
T2
18 mg, 27 mg, 54 mg (Max 18 Years)
methylphenidate HCl oral tablet extended release 24hr QL (60 QY per 30 DYs); AL
T2
36 mg (Max 18 Years)
methylphenidate HCl oral tablet extended release 24hr QL (30 EA per 30 days); AL
T2
72 mg (Max 18 Years)
methylphenidate HCl oral tablet,chewable T2
(Max 18 Years)
Salicylates - Drugs For Pain
T2
mg, 650 mg, 81 mg
aspirin rectal T2
T3 PA
Compound W/Codeine)
choline,magnesium salicylate T3
oxycodone-aspirin T3 PA
75
Coverage
Limits
salsalate T1
Sel.Serotonin,Norepi Reuptake Inhibitor - Drugs For Depression & Psychosis
duloxetine oral capsule,delayed release(DR/EC) 20 mg,
30 mg, 60 mg
duloxetine oral capsule,delayed release(DR/EC) 40 mg T3 PA
SAVELLA ORAL TABLET (milnacipran HCl) T3 PA
venlafaxine oral capsule,extended release 24hr T1
venlafaxine oral tablet T1
Selective Serotonin Agonists - Migraine Treatment
almotriptan malate T3 PA; QL (12 QY per 30 days)
ALSUMA (sumatriptan succinate) T3 PA
FROVA (frovatriptan succinate) T3 PA; QL (12 QY per 30 DYs)
frovatriptan T3 PA; QL (12 QY per 30 days)
IMITREX NASAL (sumatriptan) T3 PA
IMITREX STATDOSE PEN (sumatriptan succinate) T3 PA
IMITREX STATDOSE REFILL (sumatriptan succinate) T3 PA
IMITREX SUBCUTANEOUS (sumatriptan succinate) T3 PA
naratriptan T2 ST; QL (12 QY per 30 days)
RELPAX (eletriptan hydrobromide) T3 PA; QL (12 QY per 30 DYs)
rizatriptan oral tablet T2 QL (12 QY per 30 days)
rizatriptan oral tablet,disintegrating T2 QL (12 EA per 30 days)
sumatriptan T3 PA
sumatriptan succinate oral tablet 100 mg, 50 mg T2 QL (18 QY per 30 DYs)
sumatriptan succinate oral tablet 25 mg T2 QL (12 QY per 30 DYs)
sumatriptan succinate subcutaneous cartridge T3 PA
sumatriptan succinate subcutaneous pen injector T3 PA
76
Coverage
Limits
sumatriptan succinate subcutaneous solution T3 PA
TREXIMET ORAL TABLET 85-500 MG (sumatriptan
T3 PA
succinate/naproxen sodium)
zolmitriptan oral tablet 2.5 mg T3 PA; QL (12 QY per 30 days)
zolmitriptan oral tablet 5 mg T3 PA; QL (12 QY per 30 DYs)
zolmitriptan oral tablet,disintegrating T3 PA; QL (12 QY per 30 DYs)
ZOMIG NASAL SPRAY,NON-AEROSOL 5 MG
T3 PA
(zolmitriptan)
ZOMIG ORAL (zolmitriptan) T3 PA; QL (12 QY per 30 DYs)
ZOMIG ZMT (zolmitriptan) T3 PA; QL (12 QY per 30 DYs)
Selective-Serotonin Reuptake Inhibitors - Drugs For Depression & Psychosis
citalopram oral solution T2 QL (900 ML per 30 days)
citalopram oral tablet T1
escitalopram oxalate T1
fluoxetine oral capsule T1
fluoxetine oral capsule,delayed release(DR/EC) T3 PA
fluoxetine oral solution T1
fluvoxamine oral tablet T1
paroxetine HCl oral tablet T1
paroxetine HCl oral tablet extended release 24 hr T3 PA
PEXEVA (paroxetine mesylate) T3 PA
sertraline T1
Serotonin Modulators - Drugs For Depression & Psychosis
nefazodone T1
trazodone T1
TRINTELLIX (vortioxetine hydrobromide) T3 PA
77
Coverage
Limits
VIIBRYD ORAL TABLET (vilazodone HCl) T3 PA
VIIBRYD ORAL TABLETS,DOSE PACK 10 MG (7)- 20 MG
T3 PA
(23) (vilazodone HCl)
Succinimides - Drugs For Seizures
ethosuximide T1
Thioxanthenes - Drugs For Depression & Psychosis
thiothixene oral capsule 1 mg, 10 mg, 2 mg T2 SCO
Tricyclics, Other Norepi-Ru Inhibitors - Drugs For Depression & Psychosis
amitriptyline T1
clomipramine T1
desipramine T1
doxepin oral capsule 10 mg, 100 mg, 25 mg, 50 mg, 75
T1
mg
doxepin oral concentrate T1
imipramine HCl T1
imipramine pamoate T3 PA
nortriptyline oral capsule T1
protriptyline T3 PA
Vesicular Monoamine Transport2 Inhibitor - Drugs For The Nervous System
AUSTEDO (deutetrabenazine) T3 PA
INGREZZA ORAL CAPSULE 40 MG, 80 MG (valbenazine
T3 PA
tosylate)
Wakefulness-Promoting Agents - Drugs For The Nervous System
modafinil T3 PA
Devices - Medical Supplies And Durable Medical Equipment
Devices - Medical Supplies And Durable Medical Equipment
78
Coverage
Limits
ADVOCATE BLOOD PRESSURE MONITR (blood
T1
pressure test kit-large)
BD ULTRA-FINE NANO PEN NEEDLE (pen needle,
T2
diabetic)
blood pressure kit-extra large kit T3
BLOOD PRESSURE MONITOR KIT ACCUFIT XL,UA-789 T3 PA
blood pressure test kit-large T1
blood pressure test kit-medium T2 QL (1 EA per 5 yearss)
CARETOUCH BP MONITOR (blood pressure test kit-
T1
large)
CLEVER CHOICE BP MONITOR (blood pressure test kit-
T1
large)
DUROLANE (hyaluronate sodium, stabilized) T2
FEMCAP (cervical cap) T1
FORA TEST N'GO BP SYSTEM (blood pressure test kit-
T1
large)
FREESTYLE LIBRE 14 DAY READER (flash glucose
T3 PA
scanning reader)
FREESTYLE LIBRE 14 DAY SENSOR (flash glucose
T3 PA
sensor)
FREESTYLE LIBRE 2 SENSOR (flash glucose sensor) T3 PA
heparin flush(porcine)-0.9NaCl T2 QL (1 EA per 30 days)
heparin lock flush (porcine) intravenous solution 100
unit/mL
HEPARIN LOCK FLUSH INTRAVENOUS SOLUTION
(heparin sodium,porcine)
HYALGAN INTRA-ARTICULAR SYRINGE (hyaluronate
T2
sodium)
79
Coverage
Limits
HYPER-SAL INHALATION SOLUTION FOR
T1
NEBULIZATION 3.5 % (sodium chloride for inhalation)
lancets T1
OPTICHAMBER ADULT MASK-LARGE (inhaler, assist
T1
devices, accessories)
OPTICHAMBER DIAMOND LG MASK (inhaler,assist
device with large mask)
OPTICHAMBER DIAMOND VHC (inhaler, assist devices) T2 QL (2 QY per 365 DYs)
OPTICHAMBER DIAMOND-MED MSK (inhaler,assist
device with medium mask)
OPTICHAMBER DIAMOND-SML MASK (inhaler,assist
device with small mask)
PROCARE BLOOD PRESSURE MONITOR (blood
T1
pressure test kit-large)
PROCHAMBER (inhaler, assist devices) T1
SELF-TAKING BLOOD PRESSURE (blood pressure test
T1
kit-large)
sodium chloride inhalation solution for nebulization 0.9
T2
%
sodium chloride inhalation solution for nebulization 3 % T1
SURELIFE ARM BP MONITOR (blood pressure test kit-
T1
large)
SURELIFE TALKING ARM BP MONITR (blood pressure
T1
test kit-large)
TRUE METRIX AIR GLUCOSE METER (blood-glucose
meter)
TRUE METRIX GLUCOSE METER (blood-glucose meter) T2 QL (1 EA per 365 days)
TRUETRACK SMART SYSTEM KIT (blood-glucose
T2
meter)
80
Coverage
Limits
Diagnostic Agents
Diabetes Mellitus
TRUE METRIX GLUCOSE TEST STRIP (blood sugar
T2
diagnostic)
TRUETRACK TEST (blood sugar diagnostic) T2
Kidney Function
Electrolytic, Caloric, And Water Balance
Acidifying Agents
K-PHOS NO 2 (sodium
phosphate,monobasic/potassium T1
phosphate,monobasic)
K-PHOS ORIGINAL (potassium phosphate,monobasic) T1
PHOSPHA 250 NEUTRAL (sodium
phosphate,dibasic/pot phos,monob/sod phosphate T1
mono)
Alkalinizing Agents
ORACIT (citric acid/sodium citrate) T1
potassium citrate oral tablet extended release 5 mEq
T1
(540 mg)
sodium bicarbonate intravenous syringe 4.2 % (0.5
mEq/mL), 7.5 % (0.9 mEq/mL), 8.4 % (1 mEq/mL)
THAM (tromethamine) T2 QL (1 EA per 30 days)
Ammonia Detoxicants
81
Coverage
Limits
lactulose (Constulose) T1
lactulose (Generlac) T1
lactulose (Kristalose) T1
lactulose oral solution T1
Carbonic Anhydrase Inhibitors - Drugs For Water Balance
acetazolamide T1
Diuretics, Miscellaneous - Drugs For Water Balance
theophylline anhydrous (Elixophyllin Oral Elixir 80 Mg/15
T1
Ml)
T1
450 mg
theophylline oral tablet extended release 24 hr 600 mg T1
Irrigating Solutions
acetic acid irrigation T1
glycine urologic solution T3 PA
Ringer's irrigation T2 QL (1 EA per 30 days)
sodium chloride irrigation T1
sorbitol-mannitol T2 QL (1 EA per 30 days)
water for irrigation, sterile T1
Loop Diuretics - Drugs For Water Balance
bumetanide T1
EDECRIN (ethacrynic acid) T1
ethacrynate sodium T1
82
Coverage
Limits
furosemide injection T2 QL (1 EA per 30 days)
furosemide oral solution 10 mg/mL T2 QL (1 EA per 30 days)
furosemide oral solution 40 mg/5 mL (8 mg/mL) T1
furosemide oral tablet T1
torsemide oral T1
Osmotic Diuretics - Drugs For Water Balance
sorbitol-mannitol T2 QL (1 EA per 30 days)
Phosphate-Removing Agents
calcium acetate(phosphat bind) T1
lanthanum T3 PA
RENAGEL ORAL TABLET 800 MG (sevelamer HCl) T3 PA
sevelamer carbonate oral powder in packet T3 PA
sevelamer carbonate oral tablet T2 ST
Potassium-Removing Agents
LOKELMA (sodium zirconium cyclosilicate) T2 QL (34 EA per 30 days)
sodium polystyrene sulfonate oral powder T1
VELTASSA (patiromer calcium sorbitex) T2 ST; QL (30 EA per 30 days)
Potassium-Sparing Diuretics - Drugs For Water Balance
T3 PA
amiloride T1
83
Coverage
Limits
DYRENIUM (triamterene) T3 PA
spironolactone T1
Replacement Preparations
ANTACID EXTRA-STRENGTH ORAL
TABLET,CHEWABLE 168 MG CALCIUM (420 MG) T2
(calcium carbonate)
CALCIUM 500 ORAL TABLET,CHEWABLE (calcium
T1
carbonate)
CALCIUM ANTACID ORAL TABLET,CHEWABLE 300 MG
T2
(750 MG) (calcium carbonate)
CALCIUM ANTACID ULTRA MAX ST (calcium carbonate) T2
calcium carbonate oral suspension T1
calcium carbonate oral tablet 260 mg calcium (648 mg) T2
calcium carbonate oral tablet 600 mg calcium (1,500
T1
mg), 650 mg calcium (1,625 mg)
calcium carbonate oral tablet,chewable 200 mg calcium
T2
(500 mg)
calcium carbonate-vitamin D3 oral tablet 1,000 mg(2,500
T1
mg)-800 unit
calcium carbonate-vitamin D3 oral tablet 250-125 mg-
unit, 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 T1
unit, 600 mg(1,500mg) -800 unit
calcium lactate oral tablet 650 mg T2
dextrose 5 %-lactated ringers T1
84
Coverage
Limits
FLINTSTONES PLUS CALCIUM (calcium
T1
carbonate/multivitamin)
HYPER-SAL INHALATION SOLUTION FOR
T1
NEBULIZATION 3.5 % (sodium chloride for inhalation)
ORALYTE (electrolytes/dextrose) T2
OYSTER SHELL CALCIUM 500 (calcium carbonate) T2
OYSTER SHELL CALCIUM-VIT D2 ORAL TABLET 250
(625)-125 MG-UNIT (calcium carbonate/ergocalciferol T1
(vitamin D2))
potassium acetate intravenous solution 2 mEq/mL T2 QL (1 EA per 30 days)
potassium chloride oral capsule, extended release 8
T1
mEq
potassium chloride oral liquid T1
potassium chloride oral packet T3 PA
potassium chloride oral tablet extended release T1
potassium chloride oral tablet,ER particles/crystals T1
potassium chloride-D5-0.2%NaCl intravenous
parenteral solution 30 mEq/L
potassium chloride-D5-0.9%NaCl intravenous
parenteral solution 40 mEq/L
potassium phosphate m-/d-basic intravenous solution 3
mmol/mL
T2
sodium acetate T2 QL (1 EA per 30 days)
sodium chloride 5 % T2 QL (1 EA per 30 days)
sodium chloride inhalation solution for nebulization 0.9
T2
%
85
Coverage
Limits
sodium chloride inhalation solution for nebulization 10
T1
%, 3 %
sodium chloride intravenous parenteral solution 4
T1
mEq/mL
zinc chloride T1
zinc sulfate intravenous solution 1 mg/mL, 5 mg/mL T1
Thiazide Diuretics - Drugs For Water Balance
T3 PA
T1
20-12.5 mg, 5-6.25 mg
hydrochlorothiazide oral capsule T1
hydrochlorothiazide oral tablet 25 mg, 50 mg T1
86
Coverage
Limits
Thiazide-Like Diuretics - Drugs For Water Balance
chlorthalidone oral tablet 25 mg, 50 mg T1
indapamide T1
metolazone T1
Uricosuric Agents
probenecid T1
probenecid-colchicine T1
Enzymes
Enzymes
AMPHADASE (hyaluronidase) T3 PA
PULMOZYME (dornase alfa) T3 PA
Eye, Ear, Nose And Throat (Eent) Preps.
Alpha-Adrenergic Agonists (Eent) - Drugs For The Eye
ALPHAGAN P OPHTHALMIC (EYE) DROPS 0.1 %
T3 PA
(brimonidine tartrate)
brimonidine ophthalmic (eye) drops 0.15 % T3 PA
brimonidine ophthalmic (eye) drops 0.2 % T1
Antiallergic Agents - Drugs For Allergy
ALLERGY EYE (KETOTIFEN) (ketotifen fumarate) T2 QL (10 ML per 30 DYs)
ALOCRIL (nedocromil sodium) T3 PA; QL (1 QY per 30 DYs)
ALOMIDE (lodoxamide tromethamine) T3 PA; QL (1 QY per 30 DYs)
87
Coverage
Limits
azelastine nasal T1
azelastine ophthalmic (eye) T2 QL (1 QY per 30 DYs)
cromolyn ophthalmic (eye) T2 QL (1 QY per 30 DYs)
epinastine T3 PA; QL (1 QY per 30 DYs)
ketotifen fumarate T2 QL (10 ML per 30 days)
olopatadine ophthalmic (eye) drops 0.1 % T2 QL (5 ML per 25 days)
olopatadine ophthalmic (eye) drops 0.2 % T3 PA; QL (2.5 ML per 25 days)
Antibacterials (Eent) - Drugs For Infections
bacitracin ophthalmic (eye) T1
bacitracin-polymyxin B ophthalmic (eye) T1
BLEPHAMIDE (sulfacetamide sodium/prednisolone
T1
acetate)
sulfacetamide sodium/prednisolone acetate
T1
(Blephamide S.O.P.)
CIPRO HC (ciprofloxacin HCl/hydrocortisone) T1
CIPRODEX (ciprofloxacin HCl/dexamethasone) T1
ciprofloxacin HCl ophthalmic (eye) T1
erythromycin ophthalmic (eye) T1
gentamicin sulfate (Gentak Ophthalmic (Eye) Ointment) T1
gentamicin ophthalmic (eye) drops T1
moxifloxacin ophthalmic (eye) drops T1
neomycin-bacitracin-poly-HC T1
neomycin-bacitracin-polymyxin T1
neomycin-polymyxin B-dexameth T1
neomycin-polymyxin-gramicidin T1
neomycin-polymyxin-HC T1
88
Coverage
Limits
ofloxacin ophthalmic (eye) T1
ofloxacin otic (ear) T1
polymyxin B sulf-trimethoprim T1
PRED-G (gentamicin sulfate/prednisolone acetate) T1
PRED-G S.O.P. (gentamicin sulfate/prednisolone
T1
acetate)
sulfacetamide sodium ophthalmic (eye) T1
sulfacetamide-prednisolone T1
TOBRADEX OPHTHALMIC (EYE) OINTMENT
T1
(tobramycin/dexamethasone)
tobramycin ophthalmic (eye) T1
tobramycin-dexamethasone T1
TOBREX OPHTHALMIC (EYE) OINTMENT (tobramycin) T1
Antifungals (Eent) - Drugs For Infections
NATACYN (natamycin) T1
Antiglaucoma Agents, Miscellaneous - Drugs For The Eye
RHOPRESSA (netarsudil mesylate) T3 PA
Antivirals (Eent) - Drugs For Infections
trifluridine T1
Beta-Adrenergic Blocking Agents (Eent) - Drugs For The Eye
betaxolol ophthalmic (eye) T3 PA
BETIMOL (timolol) T1
BETOPTIC S (betaxolol HCl) T3 PA
dorzolamide-timolol T1
levobunolol ophthalmic (eye) drops 0.5 % T1
metipranolol T1
89
Coverage
Limits
timolol maleate ophthalmic (eye) drops T1
timolol maleate ophthalmic (eye) gel forming solution T1
Carbonic Anhydrase Inhibitors (Eent) - Drugs For The Eye
acetazolamide T1
AZOPT (brinzolamide) T3 PA
dorzolamide T1
dorzolamide-timolol T1
methazolamide T3 PA
Corticosteroids (Eent) - Drugs For Inflammation
ALLERGY RELIEF (FLUTICASONE) (fluticasone
T2 QL (1 QY per 30 days)
propionate)
BECONASE AQ (beclomethasone dipropionate) T3 PA
budesonide nasal T2 QL (8.43 ML per 30 days)
CIPRO HC (ciprofloxacin HCl/hydrocortisone) T1
CIPRODEX (ciprofloxacin HCl/dexamethasone) T1
dexamethasone sodium phosphate ophthalmic (eye) T1
DUREZOL (difluprednate) T2 ST; QL (5 ML per 30 days)
FLAREX (fluorometholone acetate) T1
FLONASE SENSIMIST (fluticasone furoate) T2 QL (9.1 ML per 30 days)
flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) T3 PA; QL (1 QY per 30 DYs)
fluorometholone T1
fluticasone propionate nasal T2 QL (1 QY per 30 DYs)
FML FORTE (fluorometholone) T1
FML S.O.P. (fluorometholone) T1
hydrocortisone-acetic acid T1
90
Coverage
Limits
loteprednol etabonate ophthalmic (eye)
T1
drops,suspension
MAXIDEX (dexamethasone) T1
mometasone nasal T3 PA
NASAL ALLERGY (triamcinolone acetonide) T2 QL (1 qy per 30 days)
NASONEX (mometasone furoate) T3 PA
neomycin-bacitracin-poly-HC T1
neomycin-polymyxin B-dexameth T1
neomycin-polymyxin-HC ophthalmic (eye) T1
OMNARIS (ciclesonide) T3 PA
PRED MILD (prednisolone acetate) T1
PRED-G (gentamicin sulfate/prednisolone acetate) T1
PRED-G S.O.P. (gentamicin sulfate/prednisolone
T1
acetate)
prednisolone acetate T1
prednisolone sodium phosphate ophthalmic (eye) T1
QNASL (beclomethasone dipropionate) T3 PA
RHINOCORT ALLERGY (budesonide) T2 QL (8.43 ML per 30 days)
TOBRADEX OPHTHALMIC (EYE) OINTMENT
T1
(tobramycin/dexamethasone)
tobramycin-dexamethasone T1
triamcinolone acetonide nasal T2 QL (1 QY per 30 days)
ZETONNA (ciclesonide) T3 PA
Eent Anti-Infectives, Miscellaneous - Drugs For Infections
acetic acid otic (ear) T1
chlorhexidine gluconate mucous membrane T1
hydrocortisone-acetic acid T1
91
Coverage
Limits
Eent Drugs, Miscellaneous
ARTIFICIAL TEARS (POLYVIN ALC) (polyvinyl alcohol) T2 QL (30 ML per 30 days)
ENUCLENE (tyloxapol) T2
GONIOVISC (hypromellose) T1
IOPIDINE OPHTHALMIC (EYE) DROPPERETTE
T1
(apraclonidine HCl)
ipratropium bromide nasal T1
LUBRICANT EYE (PG-PEG 400) (propylene
glycol/polyethylene glycol 400)
LUBRICANT EYE DROPS OPHTHALMIC (EYE) DROPS
0.5 % (carboxymethylcellulose sodium)
LUBRICANT EYE OPHTHALMIC (EYE) OINTMENT 57.3-
T2 QL (7 GM per 30 days)
42.5 % (mineral oil/petrolatum,white)
MURO 128 OPHTHALMIC (EYE) DROPS 2 % (sodium
T2
chloride)
polyvinyl alcohol T2 QL (30 ML per 30 days)
REFRESH LIQUIGEL (carboxymethylcellulose sodium) T2 QL (30 ML per 30 days)
REFRESH P.M. (mineral oil/petrolatum,white) T2 QL (7 GM per 30 days)
REFRESH TEARS (carboxymethylcellulose sodium) T2 QL (30 ML per 30 days)
RESTORE TEARS (carboxymethylcellulose sodium) T2 QL (30 ML per 30 days)
sodium chloride ophthalmic (eye) T2
SYSTANE NIGHTTIME (mineral oil/petrolatum,white) T2 QL (7 GM per 30 days)
ULTRA FRESH (carboxymethylcellulose sodium) T2 QL (30 ML per 30 days)
Eent Nonsteroidal Anti-Inflam. Agents - Drugs For Inflammation
diclofenac sodium ophthalmic (eye) T1
flurbiprofen sodium T3 PA
ketorolac ophthalmic (eye) T1
92
Coverage
Limits
Local Anesthetics (Eent) - Drugs For Numbing
lidocaine HCl mucous membrane jelly T1
lidocaine HCl mucous membrane solution 4 % (40
T3 PA
mg/mL)
lidocaine HCl (Lidocaine Viscous) T1
proparacaine T1
tetracaine HCl T1
Miotics - Drugs For The Eye
pilocarpine HCl ophthalmic (eye) drops 1 %, 2 %, 4 % T1
Mydriatics - Drugs For The Eye
atropine ophthalmic (eye) drops T1
atropine ophthalmic (eye) ointment T1
cyclopentolate T1
HOMATROPAIRE (homatropine Hbr) T1
tropicamide T1
Prostaglandin Analogs - Drugs For The Eye
bimatoprost ophthalmic (eye) T3 PA
latanoprost T1
LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 %
T3 PA
(bimatoprost)
travoprost T3 PA
Rho Kinase Inhibitors - Drugs For The Eye
RHOPRESSA (netarsudil mesylate) T3 PA
Vasoconstrictors
phenylephrine HCl ophthalmic (eye) drops 2.5 % T1
Gastrointestinal Drugs
93
Coverage
Limits
Antacids And Adsorbents
ACID GONE ANTACID E.STRENGTH (magnesium
T2
carbonate/aluminum hydroxide)
ADVANCED ANTACID-ANTIGAS ORAL SUSPENSION
200-200-20 MG/5 ML (magnesium hydroxide/aluminum T2
hydroxide/simethicone)
aluminum hydroxide gel oral suspension 320 mg/5 mL T2
ANTACID SUPREME (calcium carbonate/magnesium
T1
hydroxide)
ANTACID-SIMETHICONE (magnesium
T2
hydroxide/aluminum hydroxide/simethicone)
CALCIUM ANTACID ORAL TABLET,CHEWABLE 300 MG
T2
(750 MG) (calcium carbonate)
CALCIUM ANTACID ULTRA MAX ST (calcium carbonate) T2
calcium carbonate oral tablet 260 mg calcium (648 mg) T2
calcium carbonate oral tablet,chewable 200 mg calcium
T2
(500 mg)
GAVISCON ORAL TABLET,CHEWABLE (magnesium
T2
trisilicate/aluminum hydrox/sod bicarb/alginic ac)
MAALOX MAXIMUM STRENGTH (magnesium
T2
magnesium oxide oral tablet 400 mg (241.3 mg
T2
magnesium)
MINTOX PLUS (magnesium hydroxide/aluminum
T2
PINK BISMUTH ORAL TABLET,CHEWABLE (bismuth
T2
subsalicylate)
Gastrointestinal Drugs - Drugs For The Stomach
5-Ht3 Receptor Antagonists - Drugs For Vomiting And Nausea
94
Coverage
Limits
ALOXI (palonosetron HCl) T2 QL (0.5 ML per 30 days)
granisetron HCl oral T2 ST; QL (12 QY per 30 DYs)
ondansetron T1
ondansetron HCl oral solution T1
ondansetron HCl oral tablet 4 mg, 8 mg T1
Antidiarrhea Agents - Drugs For Diarrhea
loperamide oral capsule T1
loperamide oral tablet T1
PINK BISMUTH ORAL TABLET,CHEWABLE (bismuth
T2
subsalicylate)
Antiemetics, Miscellaneous - Drugs For Vomiting And Nausea
dronabinol T3 PA
Antiflatulents - Drugs For Gas
ADVANCED ANTACID-ANTIGAS ORAL SUSPENSION
200-200-20 MG/5 ML (magnesium hydroxide/aluminum T2
ANTACID-SIMETHICONE (magnesium
T2
MAALOX MAXIMUM STRENGTH (magnesium
T2
MINTOX PLUS (magnesium hydroxide/aluminum
T2
simethicone oral capsule 125 mg T1
simethicone oral tablet,chewable T1
Antihistamines (Gi Drugs) - Drugs For Vomiting And Nausea
95
Coverage
Limits
meclizine oral tablet 12.5 mg T2
meclizine oral tablet 25 mg T1
meclizine oral tablet,chewable T2
prochlorperazine T1
prochlorperazine Edisylate injection solution 5 mg/mL T2 QL (1 EA per 30 days)
prochlorperazine maleate T1
trimethobenzamide oral T1
Anti-Inflammatory Agents (Gi Drugs) - Drugs For Inflammation
alosetron T1
balsalazide T1
mesalamine oral capsule (with del rel tablets) T1
mesalamine oral tablet,delayed release (DR/EC) T1
mesalamine rectal T1
PENTASA (mesalamine) T1
sulfasalazine T1
Cathartics And Laxatives - Drugs For Constipation
bisacodyl T2
DIOCTO ORAL SYRUP (docusate sodium) T2
docusate sodium oral capsule T2
docusate sodium oral liquid T2
docusate sodium oral tablet T1
DOCUSOL (docusate sodium) T2
magnesium citrate oral solution T2
PEDIA-LAX STOOL SOFTENER (docusate sodium) T1
peg 3350-electrolytes oral recon soln 236-22.74-6.74 -
T1
5.86 gram
96
Coverage
Limits
PEG-3350 WITH FLAVOR PACKS (sodium
T1
chloride/sodium bicarbonate/potassium chloride/peg)
polyethylene glycol 3350 oral powder T2
SENNA ORAL TABLET (sennosides) T1
SENNA-S (sennosides/docusate sodium) T2
sorbitol solution 70 % T1
STOOL SOFTENER ORAL CAPSULE 50 MG (docusate
T1
sodium)
SUPREP BOWEL PREP KIT (sodium sulfate/potassium
T1
sulfate/magnesium sulfate)
Cholelitholytic Agents - Drugs For The Stomach
ursodiol oral capsule T1
Digestants - Drugs For The Stomach
CREON (lipase/protease/amylase) T1
ZENPEP ORAL CAPSULE,DELAYED RELEASE(DR/EC)
10,000-32,000 -42,000 UNIT, 15,000-47,000 -63,000 UNIT,
20,000-63,000- 84,000 UNIT, 25,000-79,000- 105,000
T1
UNIT, 3,000-10,000 -14,000-UNIT, 40,000-126,000-
168,000 UNIT, 5,000-17,000- 24,000 UNIT
(lipase/protease/amylase)
Gi Drugs, Miscellaneous - Drugs For The Stomach
ENTYVIO (vedolizumab) T3 PA
HUMIRA PEN (adalimumab) T3 PA
HUMIRA PEN CROHNS-UC-HS START (adalimumab) T3 PA
HUMIRA PEN PSOR-UVEITS-ADOL HS (adalimumab) T3 PA
HUMIRA SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML
T3 PA
(adalimumab)
INFLECTRA (infliximab-dyyb) T3 PA
97
Coverage
Limits
REMICADE (infliximab) T3 PA
RENFLEXIS (infliximab-abda) T3 PA
Histamine H2-Antagonists - Drugs For Ulcers And Stomach Acid
ACID REDUCER (FAMOTIDINE) ORAL TABLET 10 MG
T2
(famotidine)
cimetidine HCl oral T1
cimetidine oral tablet 300 mg, 400 mg, 800 mg T1
famotidine intravenous solution T3 PA
famotidine oral suspension T1
famotidine oral tablet 20 mg, 40 mg T1
Neurokinin-1 Receptor Antagonists - Drugs For Vomiting And Nausea
aprepitant T1
Prokinetic Agents - Drugs For The Stomach
metoclopramide HCl injection solution T1
metoclopramide HCl oral solution T1
metoclopramide HCl oral tablet T1
Prostaglandins - Drugs For Ulcers And Stomach Acid
diclofenac-misoprostol T3 PA
misoprostol T1
Protectants - Drugs For Ulcers And Stomach Acid
sucralfate T1
Proton-Pump Inhibitors - Drugs For Ulcers And Stomach Acid
DEXILANT (dexlansoprazole) T3 PA
esomeprazole magnesium oral capsule,delayed
T3 PA
release(DR/EC)
lansoprazole oral capsule,delayed release(DR/EC) T1
98
Coverage
Limits
lansoprazole oral tablet,disintegrat, delay rel 15 mg T3 PA; AL (Max 9 Years)
NEXIUM (esomeprazole magnesium) T3 PA
NEXIUM PACKET ORAL GRANULES DR FOR SUSP IN
PACKET 10 MG, 20 MG, 40 MG (esomeprazole T3 PA
magnesium)
omeprazole oral capsule,delayed release(DR/EC) 10 mg,
T1
20 mg
omeprazole-sodium bicarbonate oral capsule T3 PA
pantoprazole oral tablet,delayed release (DR/EC) T1
PREVACID 24HR (lansoprazole) T1
PRILOSEC ORAL SUSP,DELAYED RELEASE FOR
T3 PA
RECON (omeprazole magnesium)
rabeprazole oral tablet,delayed release (DR/EC) T1
ZEGERID ORAL CAPSULE (omeprazole/sodium
T3 PA
bicarbonate)
ZEGERID ORAL PACKET 40-1,680 MG
T3 PA
(omeprazole/sodium bicarbonate)
ZEGERID OTC (omeprazole/sodium bicarbonate) T3 PA
Gold Compounds
Gold Compounds
RIDAURA (auranofin) T1
Heavy Metal Antagonists - Drugs To Reduce Iron
Heavy Metal Antagonists - Drugs To Reduce Iron
CHEMET (succimer) T1
Hormones And Synthetic Substitutes - Hormones
Adrenals - Hormones
99
Coverage
Limits
T1
xinafoate)
ARISTOSPAN INTRA-ARTICULAR (triamcinolone
T3 PA
hexacetonide)
ARISTOSPAN INTRALESIONAL (triamcinolone
T3 PA
hexacetonide)
ARNUITY ELLIPTA (fluticasone furoate) T1
ASMANEX HFA (mometasone furoate) T1
ASMANEX TWISTHALER INHALATION AEROSOL
POWDR BREATH ACTIVATED 110 MCG/ ACTUATION
(30), 220 MCG/ ACTUATION (120), 220 MCG/ T2 QL (1 EA per 30 days)
ACTUATION (14), 220 MCG/ ACTUATION (30), 220 MCG/
ACTUATION (60) (mometasone furoate)
T3 PA
trifenatate)
BREZTRI AEROSPHERE
T3 PA
budesonide inhalation suspension for nebulization 0.25
mg/2 mL
T2 QL (120 ML per 30 DYs)
mg/2 mL
budesonide inhalation suspension for nebulization 1
mg/2 mL
budesonide oral capsule,delayed,extend.release T2 QL (90 EA per 30 days)
DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML
(methylprednisolone acetate)
DEXAMETHASONE INTENSOL (dexamethasone) T1
dexamethasone oral elixir T1
100
Coverage
Limits
dexamethasone oral solution T1
dexamethasone oral tablet T1
dexamethasone sodium phosphate injection solution T1
FLOVENT DISKUS (fluticasone propionate) T1
FLOVENT HFA INHALATION HFA AEROSOL INHALER
110 MCG/ACTUATION, 220 MCG/ACTUATION T2 QL (12 GM per 30 days)
(fluticasone propionate)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 44
T2 QL (10.6 GM per 30 days)
MCG/ACTUATION (fluticasone propionate)
fludrocortisone T1
T1
device
hydrocortisone oral T1
MEDROL ORAL TABLET 2 MG (methylprednisolone) T1
methylprednisolone acetate T1
methylprednisolone oral tablet 16 mg, 32 mg, 8 mg T1
methylprednisolone oral tablets,dose pack T1
methylprednisolone sodium succ injection recon soln
125 mg
methylprednisolone sodium succ intravenous recon
soln 1,000 mg
MILLIPRED ORAL TABLET (prednisolone) T1
prednisolone oral solution 15 mg/5 mL T1
prednisolone sodium phosphate oral solution 15 mg/5
T1
mL (3 mg/mL)
PREDNISONE INTENSOL (prednisone) T1
prednisone oral solution T1
101
Coverage
Limits
prednisone oral tablet T1
PULMICORT FLEXHALER (budesonide) T3 PA
QVAR REDIHALER (beclomethasone dipropionate) T1
SOLU-CORTEF (hydrocortisone sod succinate) T2 QL (1 EA per 30 days)
SOLU-MEDROL INTRAVENOUS RECON SOLN 2 GRAM,
500 MG (methylprednisolone sodium succinate)
triamcinolone acetonide injection T2 QL (1 EA per 30 days)
UCERIS (budesonide) T3 PA
T1
Inhub)
Alpha-Glucosidase Inhibitors - Drugs For Diabetes
acarbose T1
miglitol T2 ST
Amylinomimetics - Drugs For Diabetes
SYMLINPEN 120 (pramlintide acetate) T3 PA
SYMLINPEN 60 (pramlintide acetate) T3 PA
Androgens - Hormones
ANDRODERM (testosterone) T3 PA
ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25
T3 PA
MG/2.5GRAM), 1 % (50 MG/5 GRAM) (testosterone)
estrogens-methyltestosterone T1
METHITEST (methyltestosterone) T3 PA
oxandrolone oral tablet 2.5 mg T3 PA
testosterone cypionate intramuscular oil 200 mg/mL T2 QL (4 ML per 28 days)
102
Coverage
Limits
testosterone enanthate T1
testosterone transdermal gel in packet 1 % (25
T3 PA
mg/2.5gram), 1 % (50 mg/5 gram)
Antiestrogens - Drugs For Women
anastrozole T1
exemestane T1
letrozole T1
Antigonadtropins - Hormones
ORILISSA (elagolix sodium) T3 PA
Antihypoglycemic Agents, Miscellaneous - Hormones
PROGLYCEM (diazoxide) T3 PA
Antiparathyroid Agents - Drugs For Bones
calcitonin (salmon) injection T2 QL (0.5 ML per 30 days)
calcitonin (salmon) nasal T1
Antithyroid Agents - Drugs For The Thyroid
methimazole oral tablet 10 mg, 5 mg T1
propylthiouracil T1
Biguanides - Drugs For Diabetes
alogliptin-metformin T2 ST; QL (60 EA per 30 days)
glipizide-metformin T1
glyburide-metformin oral tablet 2.5-500 mg, 5-500 mg T1
INVOKAMET (canagliflozin/metformin HCl) T2 ST
JANUMET (sitagliptin phosphate/metformin HCl) T2 ST
103
Coverage
Limits
metformin oral tablet T1
metformin oral tablet extended release 24 hr T1
SYNJARDY (empagliflozin/metformin HCl) T2 ST
Contraceptives - Drugs For Women
desogestrel-ethinyl estradiol (Apri) T1
norethindrone-ethinyl estradiol (Aranelle (28)) T1
levonorgestrel/ethinyl estradiol (Aviane) T1
norethindrone-ethinyl estradiol (Balziva (28)) T1
norethindrone (Camila) T1
norgestrel-ethinyl estradiol (Cryselle (28)) T1
drospirenone-e.estradiol-lm.FA oral tablet 3-0.02-0.451
T1
mg (24) (4)
drospirenone-ethinyl estradiol oral tablet 3-0.02 mg T1
ELLA (ulipristal acetate) T1
levonorgestrel/ethinyl estradiol (Enpresse) T1
norethindrone (Errin) T1
ESTROSTEP FE-28 (norethindrone acetate-ethinyl
T1
estradiol/ferrous fumarate)
etonogestrel-ethinyl estradiol T1
norethindrone acetate-ethinyl estradiol (Junel 1.5/30
T1
(21))
norethindrone acetate-ethinyl estradiol (Junel 1/20 (21)) T1
norethindrone acetate-ethinyl estradiol/ferrous
T1
fumarate (Junel Fe 1.5/30 (28))
T1
fumarate (Junel Fe 1/20 (28))
104
Coverage
Limits
desogestrel-ethinyl estradiol/ethinyl estradiol (Kariva
T1
(28))
ethynodiol diacetate-ethinyl estradiol (Kelnor 1/35 (28)) T1
L norgest/e.estradiol-e.estrad T1
LEENA 28 (norethindrone-ethinyl estradiol) T1
levonorgestrel/ethinyl estradiol (Lessina) T1
levonorgestrel-ethinyl estrad oral tablet 90-20 mcg (28) T1
levonorgestrel-ethinyl estrad oral tablets,dose pack,3
T1
month
levonorgestrel/ethinyl estradiol (Levora-28) T1
LO LOESTRIN FE (norethindrone acetate-ethinyl
T1
estradiol/ferrous fumarate)
norgestrel-ethinyl estradiol (Low-Ogestrel (28)) T1
levonorgestrel/ethinyl estradiol (Lutera (28)) T1
norethindrone acetate-ethinyl estradiol (Microgestin
T1
1.5/30 (21))
norethindrone acetate-ethinyl estradiol (Microgestin 1/20
T1
(21))
T1
fumarate (Microgestin Fe 1.5/30 (28))
T1
fumarate (Microgestin Fe 1/20 (28))
MY WAY (levonorgestrel) T1
NATAZIA (estradiol valerate/dienogest) T1
norethindrone-ethinyl estradiol (Necon 0.5/35 (28)) T1
NORA-BE (norethindrone) T1
noreth-ethinyl estradiol-iron T1
norethindrone-e.estradiol-iron oral tablet,chewable T1
105
Coverage
Limits
norgestimate-ethinyl estradiol oral tablet 0.18/0.215/0.25
T1
mg-35 mcg (28)
norethindrone-ethinyl estradiol (Nortrel 0.5/35 (28)) T1
NORTREL 1/35 (21) (norethindrone-ethinyl estradiol) T1
norethindrone-ethinyl estradiol (Nortrel 1/35 (28)) T1
norethindrone-ethinyl estradiol (Nortrel 7/7/7 (28)) T1
OCELLA (ethinyl estradiol/drospirenone) T1
PLAN B ONE-STEP (levonorgestrel) T1
levonorgestrel/ethinyl estradiol (Portia 28) T1
desogestrel-ethinyl estradiol (Reclipsen (28)) T1
SAFYRAL (drospirenone/ethinyl estradiol/levomefolate
T1
calcium)
norgestimate-ethinyl estradiol (Sprintec (28)) T1
levonorgestrel/ethinyl estradiol (Sronyx) T1
levonorgestrel/ethinyl estradiol (Trivora (28)) T1
desogestrel-ethinyl estradiol (Velivet Triphasic Regimen
T1
(28))
XULANE (norelgestromin/ethinyl estradiol) T1
ethynodiol diacetate-ethinyl estradiol (Zovia 1/35E (28)) T1
Dipeptidyl Peptidase-4(Dpp-4) Inhibitors - Drugs For Diabetes
alogliptin T2 ST; QL (30 EA per 30 days)
alogliptin-metformin T2 ST; QL (60 EA per 30 days)
JANUMET (sitagliptin phosphate/metformin HCl) T2 ST
JANUVIA (sitagliptin phosphate) T2 ST
Estrogen Agonist-Antagonists - Drugs For Women
FARESTON (toremifene citrate) T1
raloxifene T1
106
Coverage
Limits
tamoxifen T1
Estrogens - Drugs For Women
CLIMARA PRO (estradiol/levonorgestrel) T3 PA
COMBIPATCH (estradiol/norethindrone acetate) T2 ST
estradiol oral T1
estradiol transdermal patch semiweekly T2 QL (8 EA per 28 days)
estradiol transdermal patch weekly T1
estradiol vaginal cream T1
estradiol valerate intramuscular oil 20 mg/mL, 40
T3 PA
mg/mL
ESTRING (estradiol) T3 PA
ESTROGEL (estradiol) T1
estrogens-methyltestosterone T1
FEMRING (estradiol acetate) T3 PA
MENEST (estrogens,esterified) T1
MENOSTAR (estradiol) T3 PA
PREMARIN (estrogens, conjugated) T1
PREMPHASE (estrogens,
T1
conjugated/medroxyprogesterone acetate)
PREMPRO (estrogens,
T1
conjugated/medroxyprogesterone acetate)
estradiol (Yuvafem) T1
Glycogenolytic Agents - Hormones
BAQSIMI (glucagon) T1
glucagon (Glucagon Emergency Kit (Human)) T1
Gonadotropins - Hormones
107
Coverage
Limits
T3 PA
NOVAREL (chorionic gonadotropin, human) T3 PA
TRELSTAR INTRAMUSCULAR SUSPENSION FOR
RECONSTITUTION 11.25 MG (triptorelin pamoate)
Gonadotropins And Antigonadotropins - Hormones
T3 PA
NOVAREL (chorionic gonadotropin, human) T3 PA
Incretin Mimetics - Drugs For Diabetes
BYETTA (exenatide) T3 PA
OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG
T2 ST; QL (1.5 ML per 28 days)
OR 0.5 MG(2 MG/1.5 ML) (semaglutide)
OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MG/DOSE
T2 ST; QL (3 ML per 28 days)
(2 MG/1.5 ML), 1 MG/DOSE (4 MG/3 ML) (semaglutide)
RYBELSUS (semaglutide) T2 ST; QL (30 EA per 30 days)
TRULICITY (dulaglutide) T2 ST
VICTOZA 2-PAK (liraglutide) T2 ST; QL (9 ML per 30 days)
108
Coverage
Limits
VICTOZA 3-PAK (liraglutide) T2 ST; QL (9 ML per 30 days)
Insulins - Drugs For Diabetes
APIDRA SOLOSTAR U-100 INSULIN (insulin glulisine) T2 QL (30 QY per 30 DYs)
APIDRA U-100 INSULIN (insulin glulisine) T2 QL (30 ML per 30 DYs)
HUMALOG MIX 50-50 INSULN U-100 (insulin lispro
protamine and insulin lispro)
HUMALOG MIX 50-50 KWIKPEN (insulin lispro
HUMALOG MIX 75-25(U-100)INSULN (insulin lispro
HUMALOG U-100 INSULIN SUBCUTANEOUS
CARTRIDGE (insulin lispro)
HUMULIN 70/30 U-100 INSULIN (insulin NPH human
isophane/insulin regular, human)
HUMULIN N NPH U-100 INSULIN (insulin NPH human
isophane)
HUMULIN R REGULAR U-100 INSULN (insulin regular,
human)
insulin asp prt-insulin aspart T2 QL (30 ML per 30 DYs)
PA; ST; QL (30 ML per 30
insulin aspart U-100 subcutaneous cartridge T3
DYs)
insulin aspart U-100 subcutaneous insulin pen T2 QL (30 ML per 30 days)
insulin aspart U-100 subcutaneous solution T2 QL (30 ML per 30 days)
insulin lispro protamin-lispro T2 QL (30 ML per 30 days)
insulin lispro subcutaneous insulin pen T2 QL (30 ML per 30 days)
insulin lispro subcutaneous solution T2 QL (30 ML per 30 days)
LANTUS SOLOSTAR U-100 INSULIN (insulin
glargine,human recombinant analog)
109
Coverage
Limits
LANTUS U-100 INSULIN (insulin glargine,human
recombinant analog)
LEVEMIR FLEXTOUCH U-100 INSULN (insulin detemir) T2 QL (2 QY per 30 days)
LEVEMIR U-100 INSULIN (insulin detemir) T2 QL (3 QY per 30 DYs)
NOVOLIN 70/30 U-100 INSULIN (insulin NPH human
NOVOLIN N NPH U-100 INSULIN (insulin NPH human
isophane)
NOVOLIN R REGULAR U-100 INSULN (insulin regular,
human)
Intermediate-Acting Insulins - Drugs For Diabetes
HUMULIN N NPH U-100 INSULIN (insulin NPH human
isophane)
NOVOLIN N NPH U-100 INSULIN (insulin NPH human
isophane)
110
Coverage
Limits
Long-Acting Insulins - Drugs For Diabetes
LANTUS SOLOSTAR U-100 INSULIN (insulin
glargine,human recombinant analog)
LANTUS U-100 INSULIN (insulin glargine,human
recombinant analog)
LEVEMIR FLEXTOUCH U-100 INSULN (insulin detemir) T2 QL (2 QY per 30 days)
LEVEMIR U-100 INSULIN (insulin detemir) T2 QL (3 QY per 30 DYs)
Meglitinides - Drugs For Diabetes
nateglinide T2 ST
repaglinide T2 ST
Parathyroid And Antiparathyroid Agents - Drugs For Bones
Pituitary - Hormones
desmopressin injection T3 PA
desmopressin nasal spray,non-aerosol T3 PA
desmopressin oral T2 AL (Min 6 Years)
HUMATROPE INJECTION RECON SOLN (somatropin) T2 QL (1 EA per 30 days)
vasopressin T2 QL (1 EA per 30 days)
Progestins - Drugs For Women
COMBIPATCH (estradiol/norethindrone acetate) T2 ST
DEPO-SUBQ PROVERA 104 (medroxyprogesterone
T1
acetate)
medroxyprogesterone T1
megestrol oral suspension 400 mg/10 mL (40 mg/mL) T1
megestrol oral tablet T1
111
Coverage
Limits
norethindrone acetate T1
progesterone micronized T2 QL (30 EA per 30 days)
Rapid-Acting Insulins - Drugs For Diabetes
APIDRA SOLOSTAR U-100 INSULIN (insulin glulisine) T2 QL (30 QY per 30 DYs)
APIDRA U-100 INSULIN (insulin glulisine) T2 QL (30 ML per 30 DYs)
HUMALOG U-100 INSULIN SUBCUTANEOUS
CARTRIDGE (insulin lispro)
PA; ST; QL (30 ML per 30
insulin aspart U-100 subcutaneous cartridge T3
DYs)
insulin aspart U-100 subcutaneous insulin pen T2 QL (30 ML per 30 days)
insulin aspart U-100 subcutaneous solution T2 QL (30 ML per 30 days)
insulin lispro subcutaneous insulin pen T2 QL (30 ML per 30 days)
insulin lispro subcutaneous solution T2 QL (30 ML per 30 days)
Short-Acting Insulins - Drugs For Diabetes
HUMULIN R REGULAR U-100 INSULN (insulin regular,
human)
112
Coverage
Limits
NOVOLIN R REGULAR U-100 INSULN (insulin regular,
human)
Sodium-Gluc Cotransport 2 (Sglt2) Inhib - Drugs For Diabetes
FARXIGA (dapagliflozin propanediol) T2 QL (30 EA per 30 days)
INVOKAMET (canagliflozin/metformin HCl) T2 ST
INVOKANA (canagliflozin) T2 ST
JARDIANCE (empagliflozin) T2 ST
SYNJARDY (empagliflozin/metformin HCl) T2 ST
Sulfonylureas - Drugs For Diabetes
glimepiride T1
glipizide T1
glipizide-metformin T1
glyburide micronized T1
glyburide oral tablet 1.25 mg, 2.5 mg T1
glyburide-metformin oral tablet 2.5-500 mg, 5-500 mg T1
Thiazolidinediones - Drugs For Diabetes
pioglitazone T1
Thyroid Agents - Drugs For The Thyroid
ARMOUR THYROID ORAL TABLET 120 MG, 240 MG, 300
T1
MG (thyroid,pork)
levothyroxine intravenous recon soln 200 mcg, 500 mcg T3 PA
levothyroxine oral tablet T1
liothyronine oral T1
NP THYROID ORAL TABLET 15 MG, 30 MG, 60 MG, 90
T1
MG (thyroid,pork)
UNITHROID ORAL TABLET 100 MCG, 112 MCG
T3 PA
(levothyroxine sodium)
113
Coverage
Limits
UNITHROID ORAL TABLET 125 MCG, 150 MCG, 175
MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 T1
MCG (levothyroxine sodium)
Local Anesthetics (Parenteral) - Drugs For Numbing
Local Anesthetics (Parenteral) - Drugs For Numbing
bupivacaine HCl T1
bupivacaine-epinephrine T3 PA
bupivacaine-epinephrine (PF) injection solution 0.5 %-
T3 PA
1:200,000
lidocaine HCl injection solution 10 mg/mL (1 %) T3 PA
lidocaine HCl injection solution 20 mg/mL (2 %), 5
T1
mg/mL (0.5 %)
lidocaine-epinephrine injection solution 0.5 %-1:200,000 T3 PA
lidocaine-epinephrine injection solution 1 %-1:100,000,
T1
2 %-1:100,000
mepivacaine HCl (Polocaine Injection Solution) T3 PA
XYLOCAINE-MPF/EPINEPHRINE (lidocaine
T1
HCl/epinephrine/PF)
Miscellaneous Therapeutic Agents
5-Alpha-Reductase Inhibitors
finasteride oral tablet 5 mg T1
Alcohol Deterrents - Drugs For Alcohol Dependence
disulfiram T2 SCO
naltrexone T2 SCO
Antidotes - Drugs For Overdose Or Poisoning
BAQSIMI (glucagon) T1
CHEMET (succimer) T1
114
Coverage
Limits
GLUCAGEN HYPOKIT (glucagon) T1
glucagon (Glucagon Emergency Kit (Human)) T1
lanthanum T3 PA
leucovorin calcium injection recon soln 50 mg T2 QL (1 EA per 30 days)
leucovorin calcium oral tablet 5 mg T1
MEPHYTON (phytonadione (vit K1)) T1
SCO; QL (2 QY per 180
naloxone injection syringe 1 mg/mL T2
DYs)
NARCAN NASAL SPRAY,NON-AEROSOL 4 SCO; QL (2 EA per 180
T2
MG/ACTUATION (naloxone HCl) days)
phytonadione (vitamin K1) injection syringe T2 QL (1 EA per 30 days)
RENAGEL ORAL TABLET 800 MG (sevelamer HCl) T3 PA
sevelamer carbonate oral powder in packet T3 PA
sevelamer carbonate oral tablet T2 ST
phytonadione (vit K1) (Vitamin K) T1
phytonadione (vit K1) (Vitamin K1 Injection) T1
Antigout Agents - Drugs For Gout
allopurinol T1
colchicine oral capsule T2 QL (15 EA per 30 DYs)
colchicine oral tablet T2 QL (15 EA per 30 days)
INDOCIN ORAL (indomethacin) T1
indomethacin oral T1
naproxen oral suspension T1
naproxen oral tablet T1
naproxen sodium oral tablet 275 mg, 550 mg T1
115
Coverage
Limits
probenecid T1
probenecid-colchicine T1
Bone Resorption Inhibitors - Drugs For Bone Loss
alendronate oral tablet 10 mg, 35 mg, 5 mg, 70 mg T1
etidronate disodium oral tablet 200 mg T3 PA
ibandronate oral T2 QL (1 EA per 30 days)
PROLIA (denosumab) T3 PA
raloxifene T1
XGEVA (denosumab) T3 PA
zoledronic acid intravenous solution T2 QL (0.5 ML per 30 days)
Cariostatic Agents - Vitamins And Fluoride
fluoride (sodium) dental solution T1
fluoride (sodium) oral drops T1
fluoride (sodium) oral tablet,chewable T1
PREVIDENT 5000 DRY MOUTH (fluoride (sodium)) T1
PREVIDENT DENTAL GEL (fluoride (sodium)) T1
SF (fluoride (sodium)) T1
TRI-VITAMIN WITH FLUORIDE (pediatric multivit with
T1
A,C,D3 no.21/sodium fluoride)
Disease-Modifying Antirheumatic Agents - Drugs For Arthritis
azathioprine T1
cyclosporine modified T1
cyclosporine oral capsule T1
ENBREL MINI (etanercept) T3 PA
116
Coverage
Limits
ENBREL SUBCUTANEOUS SOLUTION (etanercept) T3 PA
ENBREL SUBCUTANEOUS SYRINGE 50 MG/ML (1 ML)
T3 PA
(etanercept)
ENBREL SURECLICK (etanercept) T3 PA
cyclosporine, modified (Gengraf Oral Capsule 100 Mg, 25
T1
Mg)
cyclosporine, modified (Gengraf Oral Solution) T1
T3 PA
(adalimumab)
leflunomide T1
OTEZLA (apremilast) T3 PA
OTEZLA STARTER (apremilast) T3 PA
SANDIMMUNE ORAL SOLUTION (cyclosporine) T1
sulfasalazine T1
Gonadotropin-Releasing Hormone Antagnts - Hormones
117
Coverage
Limits
Immunomodulatory Agents - Drugs For The Immune System
AVONEX INTRAMUSCULAR PEN INJECTOR KIT
T1
(interferon beta-1a)
AVONEX INTRAMUSCULAR SYRINGE KIT (interferon
T1
beta-1a)
azathioprine T1
BETASERON SUBCUTANEOUS KIT (interferon beta-1b) T1
dimethyl fumarate T3 PA
T3 PA
(etanercept)
ENTYVIO (vedolizumab) T3 PA
EXTAVIA (interferon beta-1b) T1
T1
Mg)
GILENYA ORAL CAPSULE 0.5 MG (fingolimod HCl) T3 PA
glatiramer T1
glatiramer acetate (Glatopa) T1
118
Coverage
Limits
T3 PA
(adalimumab)
T2 PA
2b,recomb.)
T3 PA
leflunomide T1
PROLEUKIN (aldesleukin) T2 QL (1 EA per 30 days)
REBIF (WITH ALBUMIN) (interferon beta-1a/albumin
T1
human)
REBIF TITRATION PACK (interferon beta-1a/albumin
T1
human)
REVLIMID ORAL CAPSULE 10 MG, 15 MG, 25 MG, 5 MG
T3 PA
(lenalidomide)
sulfasalazine T1
THALOMID (thalidomide) T3 PA
119
Coverage
Limits
Immunosuppressive Agents - Drugs For Transplant
azathioprine T1
cyclophosphamide intravenous recon soln T2 QL (1 EA per 30 days)
T1
Mg)
mercaptopurine T1
mycophenolate mofetil T1
mycophenolate sodium T1
pimecrolimus T3 PA
RAPAMUNE ORAL SOLUTION (sirolimus) T1
RAPAMUNE ORAL TABLET 2 MG (sirolimus) T1
sirolimus oral tablet 0.5 mg, 1 mg T1
tacrolimus oral T1
Other Miscellaneous Therapeutic Agents
acetylcysteine T1
DEMSER (metyrosine) T1
EVOTAZ (atazanavir sulfate/cobicistat) T2 SCO
levocarnitine oral tablet T1
120
Coverage
Limits
SYMTUZA (darunavir
T2 SCO
Protective Agents
ELMIRON (pentosan polysulfate sodium) T1
MESNEX ORAL (mesna) T1
Nonhormonal Contraceptives - Drugs For Women
Nonhormonal Contraceptives - Drugs For Women
CAYA CONTOURED (diaphragms, contoured) T1
DUREX AVANTI BARE REAL FEEL (condoms, non-latex,
T2
lubricated)
FANTASY CONDOM (condoms, latex, lubricated) T2
FC2 FEMALE CONDOM (condoms, female) T2
FEMCAP (cervical cap) T1
GYNOL II (nonoxynol 9) T2
KIMONO CONDOMS(NON-LUBRICATED) (condoms,
T2
latex, non-lubricated)
KIMONO MAXX CONDOMS (condoms, latex, non-
T2
lubricated)
KIMONO MICROTHIN AQUA LUBE CON (condoms,
T2
latex, lubricated)
KIMONO MICROTHIN CONDOMS (condoms, latex, non-
T2
lubricated)
KIMONO MICROTHIN LARGE CONDOMS (condoms,
T2
latex, lubricated)
KIMONO TEXTURED CONDOMS (condoms, latex,
T2
lubricated)
TODAY CONTRACEPTIVE SPONGE (nonoxynol 9) T2
TRUSTEX LATEX CONDOM (condoms, latex, lubricated) T2
121
Coverage
Limits
TRUSTEX LUBRICATED CONDOMS (condoms, latex,
T2
lubricated)
TRUSTEX NON-LUB CONDOMS (condoms, latex, non-
T2
lubricated)
TRUSTEX-RIA LUB/SPERMICIDE (condoms, latex,
T2
lubricated)
TRUSTEX-RIA LUBRICATED CONDOMS (condoms,
T2
latex, lubricated)
TRUSTEX-RIA NON-LUB CONDOMS (condoms, latex,
T2
non-lubricated)
VAGINAL CONTRACEPTIVE FOAM (nonoxynol 9) T2
VCF CONTRACEPTIVE FILM (nonoxynol 9) T2
VCF CONTRACEPTIVE GEL (nonoxynol 9) T2
WIDE-SEAL DIAPHRAGM 60 (diaphragms, wide seal) T1
Oxytocics - Drugs For Women
Oxytocics - Drugs For Women
methylergonovine maleate (Methergine) T2 QL (4 EA per 1 day)
methylergonovine injection T1
oxytocin injection solution T2 QL (1 EA per 30 days)
Pharmaceutical Aids
122
Coverage
Limits
Pharmaceutical Aids
water for injection,sterile (Sterile Water For Injection) T1
water for inject, bacteriostat T1
water for injection, sterile injection solution T1
water for injection, sterile intravenous T1
Respiratory Tract Agents - Drugs For The Lungs
Alpha And Beta Adrenergic Agonist(Respr) - Drugs For Asthma/Copd
T2
CHILDREN'S SILFEDRINE (pseudoephedrine HCl) T2
ephedrine sulfate injection solution T3 PA
epinephrine injection auto-injector 0.15 mg/0.3 mL T2 QL (4 EA per 180 days)
epinephrine injection auto-injector 0.3 mg/0.3 mL T2 QL (4 EA per 6 monthss)
epinephrine injection solution T2 QL (1 EA per 30 days)
epinephrine injection syringe 0.1 mg/mL T2 QL (1 EA per 30 days)
T1
T2
T2
PEDIA RELIEF INFANT NASAL (pseudoephedrine HCl) T2
123
Coverage
Limits
pseudoephedrine HCl oral tablet T2
T2
SUDOGEST 12-HOUR (pseudoephedrine HCl) T2
SYMJEPI (epinephrine) T2 QL (4 EA per 180 days)
HCl)
T2 ST
Anticholinergic Agents (Respir.Tract) - Drugs For Asthma/Copd
T1
trifenatate)
atropine injection solution T1
atropine injection syringe 0.05 mg/mL, 0.1 mg/mL T1
ATROVENT HFA (ipratropium bromide) T1
BREZTRI AEROSPHERE
T3 PA
T1
sulfate)
INCRUSE ELLIPTA (umeclidinium bromide) T2 QL (30 EA per 30 DYs)
ipratropium bromide inhalation T1
SPIRIVA RESPIMAT (tiotropium bromide) T2 QL (4 GM per 30 days)
124
Coverage
Limits
SPIRIVA WITH HANDIHALER (tiotropium bromide) T1
T1
HCl)
Anti-Inflammatory Agents (Respiratory) - Drugs For Inflammation
NUCALA SUBCUTANEOUS RECON SOLN
T3 PA
(mepolizumab)
Antitussives - Drugs For Cough And Cold
benzonatate oral capsule 100 mg T1
codeine sulfate oral tablet 30 mg, 60 mg T1
T2
MUCUS DM (guaifenesin/dextromethorphan HBr) T2
NEO-TUSS (guaifenesin/dextromethorphan HBr) T2
(Min 18 Years)
promethazine-DM T1
(Min 18 Years)
T2
125
Coverage
Limits
T2
T2
HCl)
WAL-TUSSIN MAX STRENGTH COUGH
T2
(dextromethorphan HBr)
Expectorants - Drugs For The Lungs
guaifenesin oral liquid T2
guaifenesin oral tablet 200 mg T1
T2
MUCUS DM (guaifenesin/dextromethorphan HBr) T2
MUCUS RELIEF ORAL TABLET 400 MG (guaifenesin) T2
NEO-TUSS (guaifenesin/dextromethorphan HBr) T2
T2
HCl)
First Generation Antihist.(Respir Tract) - Drugs For Allergy
T2
126
Coverage
Limits
cyproheptadine T1
T2
T1
(Min 18 Years)
promethazine-DM T1
(Min 18 Years)
127
Coverage
Limits
T2
T2
T2
T2
Interleukin Antagonists - Drugs For Inflammation
DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 300
T3 PA
MG/2 ML (dupilumab)
DUPIXENT SYRINGE (dupilumab) T3 PA
FASENRA (benralizumab) T3 PA
FASENRA PEN (benralizumab) T3 PA
NUCALA (mepolizumab) T3 PA
Leukotriene Modifiers - Drugs For Inflammation
montelukast oral granules in packet T3 PA
montelukast oral tablet T1
montelukast oral tablet,chewable T1
SINGULAIR ORAL GRANULES IN PACKET (montelukast
T3 PA
sodium)
zafirlukast T3 PA
zileuton T3 PA
ZYFLO (zileuton) T3 PA
Mast-Cell Stabilizers - Drugs For Inflammation
ALOCRIL (nedocromil sodium) T3 PA; QL (1 QY per 30 DYs)
128
Coverage
Limits
cromolyn inhalation T1
cromolyn ophthalmic (eye) T2 QL (1 QY per 30 DYs)
Mucolytic Agents - Drugs For The Lungs
acetylcysteine T1
PULMOZYME (dornase alfa) T3 PA
Nasal Preparations (Steroids) - Drugs For Inflammation
ALLERGY RELIEF (FLUTICASONE) (fluticasone
T2 QL (1 QY per 30 days)
propionate)
BECONASE AQ (beclomethasone dipropionate) T3 PA
budesonide nasal T2 QL (8.43 ML per 30 days)
FLONASE SENSIMIST (fluticasone furoate) T2 QL (9.1 ML per 30 days)
flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) T3 PA; QL (1 QY per 30 DYs)
fluticasone propionate nasal T2 QL (1 QY per 30 DYs)
mometasone nasal T3 PA
NASAL ALLERGY (triamcinolone acetonide) T2 QL (1 qy per 30 days)
NASONEX (mometasone furoate) T3 PA
OMNARIS (ciclesonide) T3 PA
QNASL (beclomethasone dipropionate) T3 PA
RHINOCORT ALLERGY (budesonide) T2 QL (8.43 ML per 30 days)
triamcinolone acetonide nasal T2 QL (1 QY per 30 days)
ZETONNA (ciclesonide) T3 PA
Orally Inhaled Preparations (Steroids) - Drugs For Inflammation
T1
xinafoate)
ARNUITY ELLIPTA (fluticasone furoate) T1
ASMANEX HFA (mometasone furoate) T1
129
Coverage
Limits
ASMANEX TWISTHALER INHALATION AEROSOL
POWDR BREATH ACTIVATED 110 MCG/ ACTUATION
(30), 220 MCG/ ACTUATION (120), 220 MCG/ T2 QL (1 EA per 30 days)
ACTUATION (14), 220 MCG/ ACTUATION (30), 220 MCG/
ACTUATION (60) (mometasone furoate)
T3 PA
trifenatate)
BREZTRI AEROSPHERE
T3 PA
mg/2 mL
mg/2 mL
budesonide inhalation suspension for nebulization 1
mg/2 mL
FLOVENT DISKUS (fluticasone propionate) T1
FLOVENT HFA INHALATION HFA AEROSOL INHALER
110 MCG/ACTUATION, 220 MCG/ACTUATION T2 QL (12 GM per 30 days)
(fluticasone propionate)
FLOVENT HFA INHALATION HFA AEROSOL INHALER 44
T2 QL (10.6 GM per 30 days)
MCG/ACTUATION (fluticasone propionate)
T1
device
PULMICORT FLEXHALER (budesonide) T3 PA
QVAR REDIHALER (beclomethasone dipropionate) T1
130
Coverage
Limits
T1
Inhub)
Phosphodiesterase Type 4 Inhibitors - Drugs For The Lungs
DALIRESP (roflumilast) T3 PA
Respiratory Tract Agents, Miscellaneous - Drugs For The Lungs
XOLAIR (omalizumab) T3 PA
Second Generation Antihist(Respir Tract) - Drugs For Allergy
ALAVERT (loratadine) T2
T2
cetirizine oral solution 1 mg/mL T2
cetirizine oral tablet T2
cetirizine oral tablet,chewable T2
CHILDREN'S ALLERGY RELIEF(FEX) (fexofenadine HCl) T2 ST
fexofenadine oral tablet 180 mg, 60 mg T2 ST
levocetirizine oral tablet T2
loratadine oral solution T2
loratadine oral tablet T2
T2
T2 ST
Select.Beta-2-Adrenergic Agonist(Respir) - Drugs For Asthma/Copd
T1
xinafoate)
131
Coverage
Limits
albuterol sulfate inhalation HFA aerosol inhaler T2 QL (2 QY per 30 days)
albuterol sulfate inhalation solution for nebulization 2.5
T1
mg /3 mL (0.083 %), 5 mg/mL
albuterol sulfate oral T1
T1
trifenatate)
T3 PA
trifenatate)
BREZTRI AEROSPHERE
T3 PA
T1
sulfate)
T1
device
levalbuterol HCl T3 PA
levalbuterol tartrate T3 PA
metaproterenol oral syrup T1
SEREVENT DISKUS (salmeterol xinafoate) T1
T1
HCl)
terbutaline oral T1
T1
Inhub)
132
Coverage
Limits
Vasodilating Agents (Respiratory Tract) - Drugs For The Lungs
sildenafil (pulm.hypertension) oral tablet T3 PA
tadalafil (pulm. hypertension) T3 PA
VENTAVIS INHALATION SOLUTION FOR NEBULIZATION
T3 PA
20 MCG/ML (iloprost tromethamine)
Xanthine Derivatives - Drugs For Asthma/Copd
T1
Ml)
T1
450 mg
Skin And Mucous Membrane Agents - Drugs For The Skin
Allylamines (Skin And Mucous Membrane) - Drugs For The Skin
naftifine topical cream 1 % T1
terbinafine HCl topical T1
Antibacterials (Skin, Mucous Membrane) - Drugs For The Skin
bacitracin topical ointment T2
bacitracin zinc T2
BENZAMYCIN (erythromycin base/benzoyl peroxide) T3 PA
CLEOCIN VAGINAL SUPPOSITORY (clindamycin
T3 PA
phosphate)
clindamycin phosphate topical gel T1
clindamycin phosphate topical gel, once daily T1
clindamycin phosphate topical lotion T1
133
Coverage
Limits
clindamycin phosphate topical solution T1
clindamycin phosphate topical swab T1
clindamycin phosphate vaginal T1
clindamycin-benzoyl peroxide topical gel 1-5 % T3 PA
ERY PADS (erythromycin base in ethanol) T3 PA
erythromycin with ethanol topical gel T1
erythromycin with ethanol topical solution T1
erythromycin-benzoyl peroxide T3 PA
gentamicin topical T1
metronidazole topical cream T2 QL (45 GM per 30 days)
metronidazole topical gel T2 QL (45 GM per 30 days)
metronidazole topical gel with pump T3 PA
metronidazole vaginal T1
mupirocin T1
neomycin-polymyxin B GU T1
NORITATE (metronidazole) T3 PA
Antifulgals (Skin, Mucous Membrane),Misc - Drugs For The Skin
EXODERM (sodium thiosulfate/salicylic acid) T1
gentian violet T2
Anti-Inflammatory Agents (Skin, Mucous) - Drugs For The Skin
alclometasone T3 PA
amcinonide topical cream T3 PA
amcinonide topical lotion T3 PA
APEXICON E (diflorasone diacetate/emollient base) T3 PA
betamethasone dipropionate T1
betamethasone valerate topical cream T1
134
Coverage
Limits
betamethasone valerate topical lotion T1
betamethasone valerate topical ointment T1
betamethasone, augmented topical cream T1
betamethasone, augmented topical gel T1
betamethasone, augmented topical lotion T3 PA
betamethasone, augmented topical ointment T3 PA
clobetasol scalp T1
clobetasol topical cream T1
clobetasol topical foam T1
clobetasol topical gel T1
clobetasol topical lotion T1
clobetasol topical ointment T1
clobetasol-emollient topical cream T1
clotrimazole-betamethasone T1
CORDRAN TAPE LARGE ROLL (flurandrenolide) T3 PA
CORDRAN TOPICAL CREAM 0.05 % (flurandrenolide) T3 PA
CORDRAN TOPICAL LOTION (flurandrenolide) T3 PA
CORDRAN TOPICAL OINTMENT (flurandrenolide) T3 PA
CORTIFOAM (hydrocortisone acetate) T1
CORTISONE COOLING (hydrocortisone) T1
desonide topical cream T1
desonide topical lotion T3 PA
desonide topical ointment T1
desoximetasone topical cream T3 PA
desoximetasone topical gel T3 PA
desoximetasone topical ointment 0.25 % T3 PA
135
Coverage
Limits
diflorasone topical ointment T3 PA
fluocinolone T1
fluocinolone and shower cap T1
fluocinonide T1
fluocinonide/emollient base (Fluocinonide-E) T1
fluticasone propionate topical cream T1
fluticasone propionate topical lotion T3 PA
fluticasone propionate topical ointment T1
halobetasol propionate topical cream T1
halobetasol propionate topical ointment T1
HALOG TOPICAL CREAM (halcinonide) T3 PA
HALOG TOPICAL OINTMENT (halcinonide) T3 PA
hydrocortisone acetate rectal suppository 30 mg T1
hydrocortisone acetate topical cream T2
hydrocortisone butyrate topical cream T3 PA
hydrocortisone butyrate topical ointment T3 PA
hydrocortisone butyrate topical solution T3 PA
hydrocortisone rectal T1
hydrocortisone topical cream T2
hydrocortisone topical cream with perineal applicator 1
T1
%
hydrocortisone topical lotion 1 % T2
hydrocortisone topical lotion 2.5 % T1
hydrocortisone topical ointment 0.5 %, 1 % T2
hydrocortisone topical ointment 2.5 % T1
hydrocortisone valerate T3 PA
136
Coverage
Limits
hydrocortisone-aloe vera topical cream 0.5 % T1
hydrocortisone-aloe vera topical cream 1 % T2
hydrocortisone-pramoxine rectal cream 1-1 %, 2.5-1 % T1
hydrocortisone-pramoxine topical T1
lidocaine HCl-hydrocortison ac topical T2
mometasone topical T1
PANDEL (hydrocortisone probutate) T3 PA
PRAMOSONE TOPICAL CREAM 1-1 % (hydrocortisone
T1
acetate/pramoxine HCl)
PRAMOSONE TOPICAL OINTMENT (hydrocortisone
T1
prednicarbate T3 PA
hydrocortisone (Proctozone-Hc) T1
SCALACORT (hydrocortisone) T3
SCALP RELIEF TOPICAL SOLUTION (hydrocortisone) T1
SCALPICIN ANTI-ITCH (hydrocortisone) T1
triamcinolone acetonide dental T1
triamcinolone acetonide topical aerosol T3 PA
triamcinolone acetonide topical cream T1
triamcinolone acetonide topical lotion T1
triamcinolone acetonide topical ointment 0.025 %, 0.1
T1
%, 0.5 %
triamcinolone acetonide (Trianex) T3 PA
Antipruritics And Local Anesthetics - Drugs For The Skin
CALACLEAR (pramoxine HCl/camphor/zinc acetate) T2
CALAGESIC (pramoxine HCl/calamine) T2
137
Coverage
Limits
lidocaine HCl topical cream 3 % T2 QL (85 GM per 30 days)
LIDOCAINE PLUS (lidocaine HCl) T2 QL (60 GM per 30 days)
lidocaine topical adhesive patch,medicated 5 % T3 PA
lidocaine topical cream 4 % T2 QL (60 GM per 30 days)
lidocaine topical ointment T2 QL (60 GM per 30 days)
lidocaine-prilocaine topical cream T2 QL (60 GM per 30 days)
phenazopyridine oral tablet 100 mg, 200 mg T1
T1
T1
Antivirals (Skin And Mucous Membrane) - Drugs For The Skin
ABREVA (docosanol) T2
acyclovir topical T3 PA
Astringents - Drugs For The Skin
DRYSOL (aluminum chloride) T1
XERAC AC (aluminum chloride) T1
Azoles (Skin And Mucous Membrane) - Drugs For The Skin
ANTIFUNGAL CREAM (MICONAZOLE) (miconazole
T2
nitrate)
clotrimazole mucous membrane T1
clotrimazole topical T1
clotrimazole vaginal cream T2
138
Coverage
Limits
econazole T1
FUNGI CURE (clotrimazole) T2
JUBLIA (efinaconazole) T3 PA
ketoconazole topical cream T1
ketoconazole topical shampoo T1
LOTRIMIN AF (miconazole nitrate) T2
LOTRIMIN AF POWDER (miconazole nitrate) T2
miconazole nitrate vaginal cream T2
miconazole nitrate vaginal suppository T2
MICONAZOLE-3 VAGINAL KIT (miconazole nitrate) T2
MICONAZOLE-3 VAGINAL SUPPOSITORY (miconazole
T1
nitrate)
NIZORAL A-D (ketoconazole) T1
terconazole vaginal cream T2
terconazole vaginal suppository T3 PA
tioconazole T1
Basic Lotions And Liniments - Drugs For The Skin
calamine T2
calamine-zinc oxide T2
Cell Stimulants And Proliferants - Drugs For The Skin
REGRANEX (becaplermin) T3 PA
tretinoin microspheres topical gel T2 AL (Max 30 Years)
tretinoin microspheres topical gel with pump 0.04 % T2 AL (Max 30 Years)
tretinoin microspheres topical gel with pump 0.1 % T2
tretinoin topical cream T2 AL (Max 30 Years)
tretinoin topical gel 0.01 %, 0.025 % T2 AL (Max 30 Years)
139
Coverage
Limits
Corticosteroids (Skin, Mucous Membrane) - Drugs For The Skin
alclometasone T3 PA
amcinonide topical cream T3 PA
amcinonide topical lotion T3 PA
APEXICON E (diflorasone diacetate/emollient base) T3 PA
betamethasone dipropionate T1
betamethasone valerate topical cream T1
betamethasone valerate topical lotion T1
betamethasone valerate topical ointment T1
betamethasone, augmented topical cream T1
betamethasone, augmented topical gel T1
betamethasone, augmented topical lotion T3 PA
betamethasone, augmented topical ointment T3 PA
clobetasol scalp T1
clobetasol topical cream T1
clobetasol topical foam T1
clobetasol topical gel T1
clobetasol topical lotion T1
clobetasol topical ointment T1
clobetasol-emollient topical cream T1
CORDRAN TAPE LARGE ROLL (flurandrenolide) T3 PA
CORDRAN TOPICAL CREAM 0.05 % (flurandrenolide) T3 PA
CORDRAN TOPICAL LOTION (flurandrenolide) T3 PA
CORDRAN TOPICAL OINTMENT (flurandrenolide) T3 PA
CORTIFOAM (hydrocortisone acetate) T1
140
Coverage
Limits
CORTISONE COOLING (hydrocortisone) T1
desonide topical cream T1
desonide topical lotion T3 PA
desonide topical ointment T1
desoximetasone topical cream T3 PA
desoximetasone topical gel T3 PA
desoximetasone topical ointment 0.25 % T3 PA
diflorasone topical ointment T3 PA
fluocinolone T1
fluocinolone and shower cap T1
fluocinonide T1
fluocinonide/emollient base (Fluocinonide-E) T1
fluticasone propionate topical cream T1
fluticasone propionate topical lotion T3 PA
fluticasone propionate topical ointment T1
halobetasol propionate topical cream T1
halobetasol propionate topical ointment T1
HALOG TOPICAL CREAM (halcinonide) T3 PA
HALOG TOPICAL OINTMENT (halcinonide) T3 PA
hydrocortisone acetate rectal suppository 30 mg T1
hydrocortisone acetate topical cream T2
hydrocortisone butyrate topical cream T3 PA
hydrocortisone butyrate topical ointment T3 PA
hydrocortisone butyrate topical solution T3 PA
hydrocortisone rectal T1
hydrocortisone topical cream T2
141
Coverage
Limits
hydrocortisone topical cream with perineal applicator 1
T1
%
hydrocortisone topical lotion 1 % T2
hydrocortisone topical lotion 2.5 % T1
hydrocortisone topical ointment 0.5 %, 1 % T2
hydrocortisone topical ointment 2.5 % T1
hydrocortisone valerate T3 PA
hydrocortisone-aloe vera topical cream 0.5 % T1
hydrocortisone-aloe vera topical cream 1 % T2
hydrocortisone-iodoquinol T1
mometasone topical T1
PANDEL (hydrocortisone probutate) T3 PA
T1
T1
prednicarbate T3 PA
hydrocortisone (Proctozone-Hc) T1
SCALACORT (hydrocortisone) T3
SCALP RELIEF TOPICAL SOLUTION (hydrocortisone) T1
SCALPICIN ANTI-ITCH (hydrocortisone) T1
triamcinolone acetonide dental T1
triamcinolone acetonide topical aerosol T3 PA
triamcinolone acetonide topical cream T1
142
Coverage
Limits
triamcinolone acetonide topical lotion T1
triamcinolone acetonide topical ointment 0.025 %, 0.1
T1
%, 0.5 %
triamcinolone acetonide (Trianex) T3 PA
Hydroxypyridones (Skin, Mucous Membrane) - Drugs For The Skin
ciclopirox T1
Keratolytic Agents - Drugs For The Skin
ACNE CLEANSING BAR (benzoyl peroxide) T2
ACNE MEDICATION TOPICAL LOTION 5 % (benzoyl
T1
peroxide)
benzoyl peroxide topical cleanser 10 %, 5 % T1
benzoyl peroxide topical gel 10 %, 2.5 %, 5 % T1
clindamycin-benzoyl peroxide topical gel 1-5 % T3 PA
salicylic acid topical cream T1
salicylic acid topical lotion T1
salicylic acid topical shampoo T1
silver nitrate topical solution 10 % T3 PA
sodium hydroxide (bulk) solution 10 % T2 QL (1 EA per 30 days)
sulfacetamide sodium-sulfur topical cream 10-5 % (w/w) T1
sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v),
T1
10-5 % (w/w)
sulfacetamide sod-sulfur-urea topical cleanser T1
TARGETED ACNE SPOT TREATMENT (benzoyl
T1
peroxide)
urea topical cream 20 % T1
urea topical cream 40 % T3 PA
Keratoplastic Agents - Drugs For The Skin
143
Coverage
Limits
IONIL T (coal tar) T2
X-SEB T PLUS (coal tar) T2
Local Anti-Infectives, Miscellaneous - Drugs For The Skin
hydrocortisone-iodoquinol T1
selenium sulfide topical lotion T1
selenium sulfide topical shampoo 2.25 % T1
silver sulfadiazine T1
SSD (silver sulfadiazine) T1
sulfacetamide sodium-sulfur topical cream 10-5 % (w/w) T1
sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v) T1
sulfacetamide sod-sulfur-urea topical cleanser T1
Nonsteroidal Anti-Inflammat.Agents(Skin) - Drugs For The Skin
Polyenes (Skin And Mucous Membrane) - Drugs For The Skin
nystatin topical T1
nystatin-triamcinolone T1
Scabicides And Pediculicides - Drugs For The Skin
EURAX TOPICAL CREAM (crotamiton) T2
ivermectin topical lotion T3 PA
lindane topical shampoo T3 PA
malathion T3 PA
permethrin topical cream T1
Skin And Mucous Membrane Agents, Misc. - Drugs For The Skin
acitretin oral capsule 10 mg, 25 mg T1
QL (15 GM per 30 days); AL
adapalene topical gel 0.1 % T2
(Max 40 Years)
144
Coverage
Limits
azelaic acid T3 PA
calcipotriene scalp T3 PA
calcipotriene topical cream T3 PA
calcipotriene topical ointment T3 PA
capsaicin topical cream 0.025 %, 0.1 % T1
isotretinoin (Claravis) T3 PA
CONDYLOX TOPICAL GEL (podofilox) T2 QL (2 QY per 28 DYs)
COSENTYX (2 SYRINGES) (secukinumab) T3 PA
COSENTYX PEN (secukinumab) T3 PA
COSENTYX PEN (2 PENS) (secukinumab) T3 PA
COSENTYX SUBCUTANEOUS SYRINGE 150 MG/ML
T3 PA
(secukinumab)
DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 300
T3 PA
MG/2 ML (dupilumab)
DUPIXENT SYRINGE (dupilumab) T3 PA
T3 PA
(etanercept)
FINACEA TOPICAL FOAM (azelaic acid) T3 PA
FLUOROPLEX (fluorouracil) T1
fluorouracil topical cream 5 % T1
fluorouracil topical solution T1
145
Coverage
Limits
T3 PA
(adalimumab)
imiquimod topical cream in packet 5 % T1
pimecrolimus T3 PA
podofilox T2 QL (2 QY per 28 DYs)
REGRANEX (becaplermin) T3 PA
SANTYL (collagenase Clostridium histolyticum) T1
tacrolimus topical T2 QL (30 GM per 30 days)
tazarotene topical cream T1
TAZORAC TOPICAL CREAM 0.05 % (tazarotene) T1
TAZORAC TOPICAL GEL (tazarotene) T1
Thiocarbamates(Skin And Mucous Membrane) - Drugs For The Skin
ANTIFUNGAL (TOLNAFTATE) TOPICAL POWDER
T2
(tolnaftate)
LAMISIL AF TOPICAL POWDER (tolnaftate) T2
tolnaftate topical aerosol powder T2
tolnaftate topical cream T2
Smooth Muscle Relaxants - Drugs To Relax Muscles
Antimuscarinics - Drugs For The Urinary System
darifenacin oral tablet extended release 24 hr 7.5 mg T3 PA
146
Coverage
Limits
flavoxate T3 PA
oxybutynin chloride T1
tolterodine T2 ST
trospium oral tablet T3 PA
Respiratory Smooth Muscle Relaxants - Drugs For Lungs
T1
Ml)
T1
450 mg
Selective Beta-3-Adrenergic Agonists - Drugs For The Urinary System
MYRBETRIQ (mirabegron) T3 PA
Vitamins
Multivitamin Preparations
CENTRAVITES (folic acid/multivit,calcium,iron,other
T2
mins/lycopene/lutein)
COMPLETE SENIOR ORAL TABLET (multivitamin with
T1
iron and other minerals)
T3 PA
multivitamin oral tablet T2
MULTI-VITAMINS WITH IRON (multivitamin with iron and
T1
other minerals)
T3 PA
147
Coverage
Limits
PEDIA TRI-VITE (vitamin A palmitate/ascorbic
T1
acid/cholecalciferol (vit D3))
T2
T3 PA
T3 PA
T3 PA
T3 PA
T3 PA
T3 PA
STRESS FORMULA (multivitamin,stress formula) T1
TRI-VI-SOL (vitamin A palmitate/ascorbic
T1
T1
T3 PA
Vitamin A
T1
148
Coverage
Limits
T1
T1
Vitamin B Complex
B-complex with vitamin C oral tablet T1
cyanocobalamin (vitamin B-12) injection T2 QL (4 ML per 28 days)
cyanocobalamin (vitamin B-12) oral tablet 1,000 mcg T2
DIALYVITE 800 ORAL TABLET (folic acid/vitamin B
T1
complex and vitamin C)
folic acid injection T3 PA
folic acid oral tablet 1 mg T1
GERITOL TONIC WITH FERREX 18
(thiamine/riboflavin/niacin/pant T1
acid/B6/iron/methion/choline)
hydroxocobalamin T3 PA
T3 PA
niacinamide oral tablet 500 mg T3 PA
T3 PA
T2
T3 PA
149
Coverage
Limits
T3 PA
T3 PA
T3 PA
T3 PA
pyridoxine (vitamin B6) injection T1
pyridoxine (vitamin B6) oral tablet 50 mg, 500 mg T2
RENA-VITE (folic acid/vitamin B complex and vitamin C) T1
riboflavin (vitamin B2) oral tablet 100 mg T1
riboflavin (vitamin B2) oral tablet 400 mg T1
T3 PA
thiamine HCl (vitamin B1) injection T2 QL (1 EA per 30 days)
thiamine mononitrate (vit B1) T2
T3 PA
VITAMIN B COMPLEX WITH C (B-complex with vitamin
T1
C)
VITAMIN B-12 ORAL TABLET 1,000 MCG, 100 MCG, 250
T2
MCG, 500 MCG (cyanocobalamin (vitamin B-12))
VITAMIN B-12 ORAL TABLET 50 MCG (cyanocobalamin
T1
(vitamin B-12))
VITAMIN B-12 ORAL TABLET EXTENDED RELEASE
T1
1,000 MCG (cyanocobalamin (vitamin B-12))
VITAMIN B-12 ORAL TABLET EXTENDED RELEASE
T2
2,000 MCG (cyanocobalamin (vitamin B-12))
150
Coverage
Limits
VITAMIN B-6 ORAL TABLET 100 MG, 25 MG, 250 MG
T2
(pyridoxine HCl (vitamin B6))
Vitamin C
DIALYVITE 800 ORAL TABLET (folic acid/vitamin B
T1
complex and vitamin C)
T1
RENA-VITE (folic acid/vitamin B complex and vitamin C) T1
T1
T1
Vitamin D
CALCIDOL (ergocalciferol (vitamin D2)) T2
calcitriol oral T1
calcium carbonate-vitamin D3 oral tablet 1,000 mg(2,500
T1
mg)-800 unit
calcium carbonate-vitamin D3 oral tablet 250-125 mg-
unit, 600 mg(1,500mg) -200 unit, 600 mg(1,500mg) -400 T1
unit, 600 mg(1,500mg) -800 unit
cholecalciferol (vitamin D3) oral capsule 1,250 mcg
T2
(50,000 unit)
cholecalciferol (vitamin D3) oral drops 10 mcg/mL (400
unit/mL)
cholecalciferol (vitamin D3) oral drops 125 mcg/mL
T2
(5,000 unit/mL)
cholecalciferol (vitamin D3) oral tablet 50 mcg (2,000
T2
unit)
151
Coverage
Limits
ergocalciferol (vitamin D2) oral capsule 1,250 mcg
T1
(50,000 unit)
KIDS VITAMIN D3 (cholecalciferol (vitamin D3)) T2
T1
T1
T1
VITAMIN D3 ORAL CAPSULE 10 MCG (400 UNIT), 25
MCG (1,000 UNIT), 50 MCG (2,000 UNIT) (cholecalciferol T2
(vitamin D3))
VITAMIN D3 ORAL TABLET 10 MCG (400 UNIT), 25 MCG
T2
(1,000 UNIT) (cholecalciferol (vitamin D3))
VITAMIN D3 ORAL TABLET,CHEWABLE 25 MCG (1,000
T2
UNIT) (cholecalciferol (vitamin D3))
Vitamin K Activity
MEPHYTON (phytonadione (vit K1)) T1
phytonadione (vitamin K1) injection syringe T2 QL (1 EA per 30 days)
phytonadione (vit K1) (Vitamin K) T1
phytonadione (vit K1) (Vitamin K1 Injection) T1
152
Contra Costa Health Plan Formulary
A ALLERGY EYE ANTACID-SIMETHICONE 94,

abacavir ............................. 10 (KETOTIFEN) .................87 95
abacavir-lamivudine .......... 10 ALLERGY RELIEF ANTIFUNGAL
abacavir-lamivudine- (FLUTICASONE) ....90, 129 (TOLNAFTATE) ........... 146
zidovudine ..................... 10 allopurinol.........................115 ANTIFUNGAL CREAM
ABREVA .......................... 138 almotriptan malate .............76 (MICONAZOLE) ........... 138
acamprosate ..................... 68 ALOCRIL....................87, 128 APEXICON E........... 134, 140
acarbose ......................... 102 alogliptin ...........................106 APIDRA SOLOSTAR U-100
acebutolol .. 32, 40, 41, 48, 52 alogliptin-metformin..103, 106 INSULIN ............... 109, 112
acetaminophen .................. 59 ALOMIDE ...........................87 APIDRA U-100 INSULIN 109,
acetaminophen-codeine ... 59, alosetron ............................96 112
69 ALOXI ................................95 aprepitant........................... 98
acetazolamide ....... 47, 82, 90 ALPHAGAN P ....................87 Apri .................................. 104
acetic acid ................... 82, 91 alprazolam .........................67 APTIVUS ........................... 12
acetylcysteine .......... 120, 129 ALPRAZOLAM INTENSOL 66 Aranelle (28) .................... 104
ACID GONE ANTACID ALSUMA ............................76 ARICEPT ........................... 30
E.STRENGTH................ 94 aluminum hydroxide gel .....94 aripiprazole .................. 62, 65
ACID REDUCER amantadine HCl .............5, 58 ARISTOSPAN INTRA-
(FAMOTIDINE) .............. 98 AMBIEN CR .......................64 ARTICULAR................. 100
acitretin ............................ 144 amcinonide...............134, 140 ARISTOSPAN
ACNE CLEANSING BAR 143 AMICAR .............................33 INTRALESIONAL......... 100
ACNE MEDICATION ....... 143 amiloride ......................55, 83 ARMOUR THYROID ....... 113
ACTHIB (PF) ..................... 23 amiloride-hydrochlorothiazide ARNUITY ELLIPTA . 100, 129
acyclovir .................... 14, 138 ...........................55, 83, 86 ARRANON......................... 17
ADACEL(TDAP aminocaproic acid ..............33 ARTIFICIAL TEARS
ADOLESN/ADULT)(PF). 22 amiodarone ........................49 (POLYVIN ALC) ............. 92
adapalene ....................... 144 amitriptyline ........................78 ARZERRA ......................... 17
adefovir ............................. 14 amlodipine........43, 50, 52, 56 ASMANEX HFA ....... 100, 129
ADVAIR HFA .... 31, 100, 129, amlodipine-atorvastatin .....43, ASMANEX TWISTHALER
131 50, 51, 52, 56 ............................. 100, 130
ADVANCED ANTACID- amlodipine-benazepril .38, 39, aspirin .................... 36, 63, 75
ANTIGAS ................. 94, 95 43, 50, 51, 52, 56 aspirin-dipyridamole ... 36, 56,
ADVOCATE BLOOD amoxicillin ............................5 75
PRESSURE MONITR .... 79 amoxicillin-pot clavulanate ..5, atazanavir .......................... 12
AIMOVIG AUTOINJECTOR 6 atenolol ............ 32, 40, 41, 48
................................. 63, 67 AMPHADASE ....................87 atenolol-chlorthalidone 32, 40,
AJOVY SYRINGE ....... 63, 67 amphotericin B ...................15 41, 48, 56, 87
ALAVERT .................... 3, 131 ampicillin ..............................6 atomoxetine ....................... 68
ALAVERT D-12 ALLERGY- anagrelide ..........................36 atorvastatin ........................ 52
SINUS ........ 3, 25, 123, 131 anastrozole ................17, 103 atovaquone .......................... 7
albuterol sulfate ......... 31, 132 ANDRODERM .................102 atovaquone-proguanil .......... 6
alclometasone ......... 134, 140 ANDROGEL .....................102 atropine................ 27, 93, 124
ALDACTAZIDE 53, 55, 83, 86 ANORO ELLIPTA .......27, 31, ATROVENT HFA ....... 27, 124
alendronate ..................... 116 124, 132 AUGMENTIN ....................... 6
alfuzosin ............................ 30 ANTACID EXTRA- AUSTEDO ................... 68, 78
ALIMTA ............................. 17 STRENGTH....................84 AVASTIN ........................... 17
ALKERAN ......................... 17 ANTACID SUPREME ........94 Aviane.............................. 104
AVONEX.......................... 118
153
azathioprine ..... 116, 118, 120 bisacodyl ............................96 C
azelaic acid ..................... 145 bisoprolol fumarate .....32, 40, CABENUVA ......................... 9
azelastine .......................... 88 41, 48 cabergoline ........................ 68
azithromycin ...................... 15 bisoprolol- CALACLEAR ................... 137
AZOPT .............................. 90 hydrochlorothiazide .32, 40, CALAGESIC .................... 137
B 41, 48, 55, 86 calamine .......................... 139
bacitracin ................... 88, 133 bleomycin ...........................18 calamine-zinc oxide ......... 139
bacitracin zinc ................. 133 BLEPHAMIDE ....................88 CALCIDOL....................... 151
bacitracin-polymyxin B ...... 88 Blephamide S.O.P. ............88 calcipotriene .................... 145
baclofen ............................. 29 blood pressure kit-extra large calcitonin (salmon).. 103, 111,
balsalazide ........................ 96 .......................................79 116
Balziva (28) ..................... 104 blood pressure test kit-large calcitriol............................ 151
BAQSIMI ................. 107, 114 .......................................79 CALCIUM 500 ................... 84
BARACLUDE .................... 14 blood pressure test kit- calcium acetate(phosphat
BAVENCIO ........................ 17 medium...........................79 bind) ............................... 83
Bayer Advanced ................ 36 BOOSTRIX TDAP ..............23 CALCIUM ANTACID.... 84, 94
BAYER ADVANCED ......... 36 BREO ELLIPTA 31, 100, 130, CALCIUM ANTACID ULTRA
B-complex with vitamin C 149 132 MAX ST.................... 84, 94
BD ULTRA-FINE NANO PEN BREZTRI AEROSPHERE.27, calcium carbonate ....... 84, 94
NEEDLE ........................ 79 31, 100, 124, 130, 132 calcium carbonate-vitamin D3
BECONASE AQ ........ 90, 129 BRILINTA ...........................36 ............................... 84, 151
BELSOMRA ...................... 64 brimonidine ........................87 calcium lactate ................... 84
benazepril .................... 38, 39 bromocriptine .....................68 Camila ............................. 104
benazepril- budesonide 90, 100, 129, 130 CAPASTAT.......................... 7
hydrochlorothiazide 38, 39, budesonide-formoterol ......31, capecitabine ...................... 18
55, 86 100, 130, 132 capsaicin.......................... 145
BENDEKA ......................... 17 bumetanide ..................53, 82 captopril ....................... 38, 39
BENTYL ............................ 27 bupivacaine HCl ...............114 captopril-hydrochlorothiazide
BENZAMYCIN ................. 133 bupivacaine-epinephrine ...25, ..................... 38, 39, 55, 86
benzonatate .................... 125 114 carbamazepine ............ 60, 62
benzoyl peroxide ............. 143 bupivacaine-epinephrine (PF) carbidopa-levodopa ........... 68
benztropine ................. 28, 60 ...............................25, 114 carbinoxamine maleate ....... 1
betamethasone dipropionate buprenorphine ....................72 carboplatin ......................... 18
............................. 134, 140 buprenorphine HCl .............72 CARDIZEM LA 42, 43, 45, 46,
betamethasone valerate . 134, buprenorphine-naloxone ....72 49, 57
135, 140 bupropion HCl ....................62 CARETOUCH BP MONITOR
betamethasone, augmented bupropion HCl (smoking ....................................... 79
............................. 135, 140 deter) ..............................61 Cartia Xt.... 42, 43, 45, 46, 49,
BETASERON .................. 118 buspirone ...........................64 57
betaxolol ............................ 89 Butalbital Compound carvedilol .. 29, 30, 37, 41, 48,
bethanechol chloride ......... 30 W/Codeine...63, 66, 70, 74, 52
BETIMOL........................... 89 75 CAVERJECT ..................... 57
BETOPTIC S ..................... 89 butalbital-acetaminop-caf-cod CAVERJECT IMPULSE .... 57
BEXSERO ......................... 23 .............. 59, 63, 66, 70, 74 CAYA CONTOURED....... 121
bicalutamide ...................... 18 butalbital-acetaminophen-caff cefaclor ................................ 4
BICILLIN C-R .................... 14 .....................59, 63, 66, 74 cefdinir ................................. 4
BICILLIN L-A ..................... 14 butalbital-aspirin-caffeine ..36, cefixime ............................... 5
BICNU ............................... 18 63, 66, 74, 75 cefpodoxime ........................ 5
BIKTARVY..................... 9, 11 BYETTA ...........................108 cefuroxime axetil.................. 4
bimatoprost ....................... 93 celecoxib............................ 68
154
CENTRAVITES ............... 147 cisplatin ..............................18 COSENTYX (2 SYRINGES)
cephalexin ........................... 4 citalopram ..........................77 ..................................... 145
cetirizine ...................... 3, 131 cladribine............................18 COSENTYX PEN ............ 145
cetirizine-pseudoephedrine 3, Claravis ............................145 COSENTYX PEN (2 PENS)
25, 123, 131 clarithromycin .................7, 15 ..................................... 145
cevimeline ......................... 30 clemastine ................1, 2, 127 CREON.............................. 97
CHANTIX........................... 28 CLEOCIN .........................133 cromolyn .................... 88, 129
CHANTIX CONTINUING CLEVER CHOICE BP Cryselle (28) .................... 104
MONTH BOX ................. 28 MONITOR ......................79 cyanocobalamin (vitamin B-
CHANTIX STARTING CLIMARA PRO ................107 12) ................................ 149
MONTH BOX ................. 28 clindamycin HCl .................13 cyclobenzaprine................. 29
CHEMET ................... 99, 114 Clindamycin Pediatric ........13 cyclopentolate.................... 93
CHILDREN'S ALLERGY clindamycin phosphate .....13, cyclophosphamide ..... 18, 120
(DIPHENHYD) ......... 1, 126 133, 134 cyclosporine..... 116, 118, 120
CHILDREN'S ALLERGY clindamycin-benzoyl peroxide cyclosporine modified ..... 116,
RELIEF(FEX) ........... 3, 131 .............................134, 143 118, 120
CHILDREN'S IBUPROFEN72 clobazam......................66, 67 cyproheptadine ........ 1, 2, 127
CHILDREN'S SILFEDRINE clobetasol .................135, 140 CYRAMZA ......................... 18
............................... 25, 123 clobetasol-emollient .135, 140 cytarabine (PF) .................. 18
chlordiazepoxide HCl ........ 67 clomipramine......................78 D
chlordiazepoxide-clidinium 27, clonazepam..................66, 67 dacarbazine ....................... 18
67 clonidine .......................26, 47 DALIRESP ....................... 131
chlorhexidine gluconate .... 91 clonidine HCl ................26, 47 dantrolene.......................... 29
chloroquine phosphate ........ 6 clopidogrel..........................36 dapsone ............................... 7
chlorothiazide .................... 55 clorazepate dipotassium ...66, DARAPRIM.......................... 6
chlorpheniramine maleate .. 1, 67 darifenacin ....................... 146
3, 127 clotrimazole ......................138 DARZALEX........................ 18
chlorpheniramine-phenyleph- clotrimazole-betamethasone daunorubicin ...................... 18
DM ............. 3, 26, 125, 127 .................... 135, 138, 140 decitabine .......................... 18
chlorpromazine .................. 73 clozapine ............................65 DELSTRIGO ................ 10, 11
chlorthalidone .............. 56, 87 codeine sulfate ...........70, 125 demeclocycline .................. 16
chlorzoxazone ................... 29 colchicine .........................115 DEMEROL ......................... 70
cholecalciferol (vitamin D3) colestipol ............................42 DEMSER ......................... 120
..................................... 151 colistin (colistimethate Na) .15 DEPO-MEDROL .............. 100
cholestyramine (with sugar) COMBIPATCH .........107, 111 DEPO-SUBQ PROVERA 104
....................................... 42 COMBIVENT RESPIMAT .27, ..................................... 111
Cholestyramine Light ........ 42 31, 124, 132 DESCOVY ......................... 11
choline,magnesium salicylate COMPLERA .................10, 11 desipramine ....................... 78
....................................... 75 COMPLETE SENIOR ......147 desmopressin ............ 33, 111
CIALIS ............................... 54 CONDYLOX .....................145 desonide .................. 135, 141
ciclopirox ......................... 143 Constulose .........................82 desoximetasone ...... 135, 141
cidofovir ............................. 14 CONTRAVE .......................60 dexamethasone ....... 100, 101
cilostazol ..................... 36, 54 CORDRAN ...............135, 140 DEXAMETHASONE
CIMDUO ............................ 11 CORDRAN TAPE LARGE INTENSOL ................... 100
cimetidine .......................... 98 ROLL ....................135, 140 dexamethasone sodium
cimetidine HCl ................... 98 CORTIFOAM ...........135, 140 phosphate .............. 90, 101
CIPRO HC ................... 88, 90 CORTISONE COOLING .135, DEXILANT ......................... 98
CIPRODEX.................. 88, 90 141 dexmethylphenidate .......... 74
ciprofloxacin .................. 7, 16 COSENTYX .....................145 dextroamphetamine ........... 58
ciprofloxacin HCl ..... 7, 16, 88
155
dextroamphetamine- doxorubicin.........................18 enalapril-hydrochlorothiazide
amphetamine ........... 58, 59 Doxy-100............................16 ..................... 38, 39, 55, 86
dextrose 5 %-lactated ringers doxycycline hyclate ............16 ENBREL .......... 117, 118, 145
....................................... 84 doxycycline monohydrate ..16 ENBREL MINI.. 116, 118, 145
DIALYVITE 800 ....... 149, 151 dronabinol ..........................95 ENBREL SURECLICK.... 117,
diazepam ..................... 66, 67 droperidol ...........................64 118, 145
Diazepam Intensol ...... 66, 67 drospirenone-e.estradiol- Endocet ....................... 59, 70
diclofenac potassium ......... 72 lm.FA ............................104 ENGERIX-B (PF) ............... 23
diclofenac sodium ...... 72, 92, drospirenone-ethinyl estradiol enoxaparin ......................... 34
144, 145 .....................................104 Enpresse ......................... 104
diclofenac-misoprostol 72, 98 DROXIA .............................18 entacapone ........................ 68
dicloxacillin ........................ 15 DRYSOL ..........................138 entecavir ............................ 14
dicyclomine ....................... 27 DULERA ... 31, 101, 130, 132 ENTRESTO ................. 38, 55
didanosine ......................... 11 duloxetine.....................69, 76 ENTYVIO ................... 97, 118
diflorasone ............... 136, 141 DUPIXENT PEN ......128, 145 ENUCLENE ....................... 92
diflunisal ............................ 72 DUPIXENT SYRINGE.....128, ephedrine sulfate ....... 25, 123
Digox ........................... 39, 47 145 EPIDIOLEX........................ 61
digoxin ......................... 40, 47 DUREX AVANTI BARE epinastine .......................... 88
DILANTIN .................... 48, 69 REAL FEEL ..................121 epinephrine ................ 25, 123
DILATRATE-SR ................ 54 DUREZOL ..........................90 epirubicin ........................... 18
diltiazem HCl .. 42, 43, 44, 45, DUROLANE .......................79 EPIVIR HBV ...................... 11
46, 49, 50, 57 DYRENIUM ..................55, 84 EPOGEN ........................... 33
DILT-XR ... 43, 44, 45, 46, 50, E ERBITUX ........................... 18
57 E.E.S. 400 ......................8, 13 ergocalciferol (vitamin D2)
dimenhydrinate .. 1, 2, 95, 127 econazole.........................139 ..................................... 152
dimethyl fumarate ............ 118 ED A-HIST DM......3, 26, 125, ergoloid .............................. 30
DIOCTO ............................ 96 127 ergotamine-caffeine ..... 30, 63
diphenhydramine HCl ..... 1, 2, EDECRIN .....................53, 82 erlotinib .............................. 18
127 EDURANT..........................10 Errin ................................. 104
diphenoxylate-atropine27, 95, efavirenz-emtricitabin-tenofov ERY PADS ...................... 134
124 .................................10, 11 Erythrocin (As Stearate) 8, 13
dipyridamole ................ 36, 57 efavirenz-lamivu-tenofov erythromycin ............ 8, 13, 88
disopyramide phosphate ... 47 disop .........................10, 11 erythromycin ethylsuccinate8,
disulfiram ......................... 114 ELIQUIS .............................33 13
DIURIL............................... 55 ELIQUIS DVT-PE TREAT erythromycin with ethanol 134
divalproex .............. 61, 62, 63 30D START ....................33 erythromycin-benzoyl
docetaxel ........................... 18 Elixophyllin .........82, 133, 147 peroxide ....................... 134
docusate sodium ............... 96 ELLA ................................104 escitalopram oxalate.......... 77
DOCUSOL......................... 96 ELMIRON.........................121 esmolol .................. 32, 41, 48
dofetilide ............................ 49 EMCYT ..............................18 esomeprazole magnesium 98
donepezil ........................... 30 EMGALITY PEN ..........63, 68 estradiol ........................... 107
dopamine .................... 31, 47 EMGALITY SYRINGE..63, 68 estradiol valerate ............. 107
dopamine in 5 % dextrose 31, EMPLICITI .........................18 ESTRING......................... 107
47 emtricitabine.......................11 ESTROGEL ..................... 107
dorzolamide ....................... 90 emtricitabine-tenofovir (TDF) estrogens-methyltestosterone
dorzolamide-timolol ..... 89, 90 .......................................11 ............................. 102, 107
DOVATO ....................... 9, 11 EMTRIVA ...........................11 ESTROSTEP FE-28 ........ 104
doxapram .......................... 74 EMVERM .............................6 eszopiclone........................ 64
doxazosin .............. 29, 37, 52 enalapril maleate..........38, 39 ethacrynate sodium ..... 53, 82
doxepin .............................. 78 ethambutol ........................... 7
156
ethosuximide ..................... 78 FLINTSTONES PLUS frovatriptan......................... 76
etidronate disodium ......... 116 CALCIUM .......................85 FULPHILA ......................... 33
etodolac ............................. 72 FLONASE SENSIMIST .....90, FUNGI CURE .................. 139
etonogestrel-ethinyl estradiol 129 furosemide ................... 53, 83
..................................... 104 FLOVENT DISKUS ..101, 130 FUZEON .............................. 9
ETOPOPHOS.................... 18 FLOVENT HFA ........101, 130 G
etoposide ........................... 19 floxuridine...........................19 gabapentin ................... 59, 61
etravirine ........................... 10 fluconazole ...........................8 GABITRIL .......................... 61
EURAX ............................ 144 fludarabine .........................19 ganciclovir sodium ............. 14
EVOTAZ .................... 12, 120 fludrocortisone .................101 GARDASIL 9 (PF) ............. 23
exemestane ............... 19, 103 flunisolide ...................90, 129 GAVISCON........................ 94
EXODERM ...................... 134 fluocinolone ..............136, 141 GAZYVA ............................ 19
EXTAVIA ......................... 118 fluocinolone and shower cap gemcitabine ....................... 19
ezetimibe ........................... 47 .............................136, 141 gemfibrozil ......................... 52
F fluocinonide ..............136, 141 Generlac ............................ 82
famotidine .......................... 98 Fluocinonide-E .........136, 141 Gengraf............ 117, 118, 120
FANTASY CONDOM ...... 121 fluoride (sodium) ..............116 Gentak ............................... 88
FARESTON ............... 19, 106 fluorometholone .................90 gentamicin ............. 5, 88, 134
FARXIGA......................... 113 FLUOROPLEX ...........19, 145 gentian violet ................... 134
FASENRA ....................... 128 fluorouracil .................19, 145 GENVOYA ..................... 9, 11
FASENRA PEN ............... 128 fluoxetine............................77 GERITOL TONIC WITH
FASLODEX ....................... 19 fluphenazine decanoate .....73 FERREX 18 ........... 35, 149
FC2 FEMALE CONDOM . 121 fluphenazine HCl................73 GILENYA ......................... 118
felbamate .......................... 61 flurazepam .........................67 glatiramer......................... 118
felodipine ... 44, 50, 51, 52, 57 flurbiprofen .........................73 Glatopa ............................ 118
FEMCAP ................... 79, 121 flurbiprofen sodium ............92 GLEOSTINE ...................... 19
FEMRING ........................ 107 flutamide ............................19 glimepiride ....................... 113
fenofibrate ......................... 51 fluticasone propionate .......90, glipizide............................ 113
fenofibrate micronized ....... 51 129, 136, 141 glipizide-metformin .. 103, 113
fenofibrate nanocrystallized fluticasone propion- GLUCAGEN HYPOKIT.... 115
....................................... 51 salmeterol ......31, 101, 130, Glucagon Emergency Kit
fenoprofen ......................... 72 132 (Human) ............... 107, 115
fentanyl .............................. 70 fluvastatin ...........................52 glyburide .......................... 113
FEOSOL ............................ 34 fluvoxamine ........................77 glyburide micronized........ 113
ferrous gluconate .............. 34 FML FORTE.......................90 glyburide-metformin . 103, 113
ferrous sulfate ................... 34 FML S.O.P. ........................90 glycine urologic solution .... 82
FEVERALL ........................ 59 folic acid ...........................149 glycopyrrolate .................... 27
fexofenadine ................ 4, 131 FOLITAB ............................34 GONIOVISC ...................... 92
fexofenadine- FORA TEST N'GO BP granisetron HCl.................. 95
pseudoephedrine ...... 4, 25, SYSTEM.........................79 GRANIX ............................. 33
123, 131 fosamprenavir ....................12 griseofulvin microsize .......... 6
FINACEA ......................... 145 foscarnet ..............................8 griseofulvin ultramicrosize ... 6
finasteride ........................ 114 fosinopril.............................39 guaifenesin ...................... 126
FIRMAGON KIT W DILUENT FREESTYLE LIBRE 14 DAY guanfacine ................... 47, 68
SYRINGE....... 19, 103, 117 READER ........................79 GYNOL II ......................... 121
FIRVANQ ............................ 8 FREESTYLE LIBRE 14 DAY H
FLAREX ............................ 90 SENSOR ........................79 HALAVEN .......................... 19
flavoxate .......................... 147 FREESTYLE LIBRE 2 halobetasol propionate ... 136,
flecainide ........................... 48 SENSOR ........................79 141
FROVA...............................76 HALOG .................... 136, 141
157
haloperidol ......................... 67 hydrocortisone 101, 136, 141, insulin asp prt-insulin aspart
haloperidol decanoate ....... 67 142 ..................... 109, 110, 112
haloperidol lactate ............. 67 hydrocortisone acetate....136, insulin aspart U-100. 109, 112
HAVRIX (PF) ..................... 23 141 insulin lispro ............. 109, 112
HEMOCYTE-F................... 35 hydrocortisone butyrate ..136, insulin lispro protamin-lispro
heparin (porcine) ............... 34 141 ..................... 109, 110, 112
heparin flush(porcine)- hydrocortisone valerate...136, INTELENCE ...................... 10
0.9NaCl .................... 34, 79 142 INTRON A ..... 13, 19, 20, 119
HEPARIN LOCK FLUSH .. 34, hydrocortisone-acetic acid 90, INVIRASE .......................... 12
79 91 INVOKAMET ........... 103, 113
heparin lock flush (porcine) hydrocortisone-aloe vera 137, INVOKANA ...................... 113
................................. 34, 79 142 IONIL T ............................ 144
heparin, porcine (PF) ........ 34 hydrocortisone-iodoquinol IOPIDINE ........................... 92
HEPLISAV-B (PF) ............. 23 .............................142, 144 ipratropium bromide.... 28, 92,
HIBERIX (PF) .................... 23 hydrocortisone-pramoxine 124
HOMATROPAIRE ............. 93 .................... 137, 138, 142 ipratropium-albuterol... 28, 31,
HUMALOG MIX 50-50 hydromorphone ..................70 124, 132
INSULN U-100 .... 109, 110, hydroxocobalamin ............149 irbesartan..................... 37, 38
112 hydroxychloroquine .....6, 117, irbesartan-
HUMALOG MIX 50-50 119 hydrochlorothiazide . 37, 38,
KWIKPEN .... 109, 110, 112 hydroxyurea .......................19 56, 86
HUMALOG MIX 75-25 hydroxyzine HCl .............2, 64 irinotecan ........................... 20
KWIKPEN .................... 110 hydroxyzine pamoate .....3, 64 ISENTRESS ........................ 9
HUMALOG MIX 75-25(U- hyoscyamine sulfate ..........27 ISENTRESS HD .................. 9
100)INSULN 109, 110, 112 HYPER-SAL.................80, 85 isometh-dichloral-
HUMALOG U-100 INSULIN I acetaminophn ................ 60
............................. 109, 112 ibandronate ......................116 isoniazid............................... 7
HUMATROPE ................. 111 ibuprofen ............................73 isosorbide dinitrate ............ 54
HUMIRA .... 97, 117, 119, 146 ifosfamide...........................19 isosorbide mononitrate ...... 54
HUMIRA PEN ... 97, 117, 118, imatinib...............................19 isradipine ... 44, 50, 51, 52, 57
145 IMFINZI ..............................19 itraconazole ......................... 8
HUMIRA PEN CROHNS-UC- imipramine HCl ..................78 ivermectin .................... 6, 144
HS START .... 97, 117, 118, imipramine pamoate ..........78 IXEMPRA .......................... 20
145 imiquimod.........................146 IXIARO (PF) ...................... 23
HUMIRA PEN PSOR- IMITREX ............................76 J
UVEITS-ADOL HS 97, 117, IMITREX STATDOSE PEN76 Jantoven ............................ 32
118, 146 IMITREX STATDOSE JANUMET................ 103, 106
HUMULIN 70/30 U-100 REFILL ...........................76 JANUVIA ......................... 106
INSULIN....... 109, 110, 112 IMOVAX RABIES VACCINE JARDIANCE .................... 113
HUMULIN N NPH U-100 (PF) ................................23 JEVTANA .......................... 20
INSULIN............... 109, 110 INCRUSE ELLIPTA ...27, 124 JUBLIA ............................ 139
HUMULIN R REGULAR U- indapamide ..................56, 87 JULUCA............................. 10
100 INSULN ........ 109, 112 INDOCIN ....................73, 115 Junel 1.5/30 (21).............. 104
HYALGAN ......................... 79 indomethacin..............73, 115 Junel 1/20 (21)................. 104
hydralazine ........................ 51 INFANT'S NON-ASPIRIN ..60 Junel Fe 1.5/30 (28) ........ 104
hydrochlorothiazide ..... 55, 86 INFED ................................35 Junel Fe 1/20 (28) ........... 104
hydrocodone-acetaminophen INFLECTRA ......97, 117, 119, K
........................... 59, 60, 70 146 Kariva (28) ....................... 105
hydrocodone-homatropine 27, INGREZZA ...................68, 78 Kelnor 1/35 (28) ............... 105
70, 125 ketoconazole ................... 139
158
ketoprofen ......................... 73 LEVEMIR FLEXTOUCH U- Lovaza ............................... 40
ketorolac ...................... 73, 92 100 INSULN .........110, 111 Low-Ogestrel (28) ............ 105
ketotifen fumarate ............. 88 LEVEMIR U-100 INSULIN loxapine succinate ............. 64
KEYTRUDA ....................... 20 .............................110, 111 LUBRICANT EYE .............. 92
KIDS VITAMIN D3 ........... 152 levetiracetam......................61 LUBRICANT EYE (PG-PEG
KIMONO CONDOMS(NON- LEVITRA ............................54 400) ................................ 92
LUBRICATED) ............. 121 levobunolol .........................89 LUBRICANT EYE DROPS 92
KIMONO MAXX CONDOMS levocarnitine .....................120 LUMIGAN .......................... 93
..................................... 121 levocetirizine ................4, 131 LUPRON DEPOT ...... 20, 108
KIMONO MICROTHIN AQUA levofloxacin ....................7, 16 LUPRON DEPOT (3
LUBE CON .................. 121 levonorgestrel-ethinyl estrad MONTH)................. 20, 108
KIMONO MICROTHIN .....................................105 LUPRON DEPOT (4
CONDOMS .................. 121 LEVOPHED (BITARTRATE) MONTH)................. 20, 108
KIMONO MICROTHIN .......................................25 LUPRON DEPOT-PED..... 20,
LARGE CONDOMS ..... 121 Levora-28 .........................105 108
KIMONO TEXTURED levorphanol tartrate ............70 Lutera (28) ....................... 105
CONDOMS .................. 121 levothyroxine ....................113 LYSODREN ....................... 20
KOSHER PRENATAL PLUS LEXIVA ..............................12 M
IRON .............. 35, 147, 149 lidocaine ...........................138 MAALOX MAXIMUM
K-PHOS NO 2 ................... 81 lidocaine HCl ......93, 114, 138 STRENGTH ............. 94, 95
K-PHOS ORIGINAL .......... 81 lidocaine HCl-hydrocortison magnesium citrate ............. 96
Kristalose .......................... 82 ac................. 137, 138, 142 magnesium oxide .............. 94
L LIDOCAINE PLUS ...........138 malathion ......................... 144
L norgest/e.estradiol-e.estrad Lidocaine Viscous ..............93 mannitol 10 % ........ 54, 81, 83
..................................... 105 lidocaine-epinephrine .25, 114 mannitol 20 % ........ 54, 81, 83
labetalol29, 30, 37, 41, 42, 48 lidocaine-prilocaine ..........138 mannitol 25 % ........ 54, 81, 83
lactulose ............................ 82 lindane .............................144 mannitol 5 % .......... 54, 81, 83
LAMISIL AF ..................... 146 linezolid ..............................15 MAPAP (ACETAMINOPHEN)
lamivudine ......................... 11 liothyronine.......................113 ....................................... 60
lamivudine-zidovudine ....... 11 lisinopril ..............................39 MAPAP ARTHRITIS PAIN. 60
lamotrigine ................... 61, 62 lisinopril-hydrochlorothiazide MATULANE ....................... 20
lancets ............................... 80 ...........................39, 56, 86 Matzim La . 43, 44, 45, 46, 50,
LANOXIN PEDIATRIC 40, 47 lithium carbonate................62 57
lansoprazole ................ 98, 99 lithium citrate ......................62 MAVYRET ........................... 9
lanthanum ................. 83, 115 LO LOESTRIN FE............105 MAXIDEX .......................... 91
LANTUS SOLOSTAR U-100 LOHIST - D ... 3, 25, 123, 127 meclizine........................ 3, 96
INSULIN............... 109, 111 LOKELMA ..........................83 meclofenamate .................. 73
LANTUS U-100 INSULIN 110, loperamide .........................95 MEDROL ......................... 101
111 lopinavir-ritonavir................12 medroxyprogesterone...... 111
latanoprost ........................ 93 loratadine .....................4, 131 mefloquine ........................... 6
LEENA 28 ....................... 105 LORATADINE-D ...4, 25, 123, megestrol ................... 20, 111
leflunomide .............. 117, 119 131 meloxicam ......................... 73
Lessina ............................ 105 lorazepam ....................66, 67 memantine ......................... 68
letrozole ..................... 20, 103 losartan ........................37, 38 MENACTRA (PF) .............. 23
leucovorin calcium ........... 115 losartan-hydrochlorothiazide MENEST.......................... 107
LEUKERAN ....................... 20 .....................37, 38, 56, 86 MENOSTAR .................... 107
levalbuterol HCl ......... 31, 132 loteprednol etabonate ........91 MENQUADFI (PF) ............. 23
levalbuterol tartrate ... 31, 132 LOTRIMIN AF ..................139 MENVEO A-C-Y-W-135-DIP
LEVATOL .......................... 41 LOTRIMIN AF POWDER .139 (PF) ................................ 24
lovastatin ............................52 meperidine ......................... 70
159
MEPHYTON ............ 115, 152 Microgestin Fe 1.5/30 (28) NARCAN ................... 72, 115
mercaptopurine ......... 20, 120 .....................................105 NASAL ALLERGY ..... 91, 129
mesalamine ....................... 96 Microgestin Fe 1/20 (28) ..105 NASONEX ................. 91, 129
MESNEX ......................... 121 MIGERGOT .................30, 64 NATACYN ......................... 89
MESTINON ....................... 30 miglitol ..............................102 NATAZIA ......................... 105
MESTINON TIMESPAN .... 30 MILLIPRED ......................101 nateglinide ....................... 111
metaproterenol .......... 31, 132 minocycline ..................16, 17 Necon 0.5/35 (28) ............ 105
metformin ........................ 104 minoxidil .............................51 nefazodone ........................ 77
methadone .................. 70, 71 MINTOX PLUS.............94, 95 neomycin ............................. 5
methamphetamine ............ 59 mirtazapine ........................62 neomycin-bacitracin-poly-HC
methazolamide .................. 90 misoprostol.........................98 ................................. 88, 91
methenamine hippurate .... 17 mitomycin ...........................20 neomycin-bacitracin-
methenamine mandelate ... 17 mitoxantrone ......................20 polymyxin ....................... 88
Methergine ...................... 122 M-M-R II (PF) .....................24 neomycin-polymyxin B GU
methimazole .................... 103 modafinil.............................78 ..................................... 134
METHITEST .................... 102 mometasone .....91, 129, 137, neomycin-polymyxin B-
methocarbamol ................. 29 142 dexameth ................. 88, 91
methotrexate sodium 20, 117, montelukast......................128 neomycin-polymyxin-
119, 120 MONUROL.........................17 gramicidin....................... 88
methotrexate sodium (PF) 20, morphine ............................71 neomycin-polymyxin-HC... 88,
117, 119, 120 morphine concentrate ........71 91
methyldopa .................. 26, 47 moxifloxacin .............7, 16, 88 NEO-TUSS .............. 125, 126
methyldopa- MUCUS D ..........25, 123, 126 nevirapine .......................... 10
hydrochlorothiazide 26, 47, MUCUS DM .............125, 126 NEXAVAR ......................... 21
56, 86 MUCUS RELIEF ..............126 NEXIUM............................. 99
methyldopate ............... 26, 47 MUCUS RELIEF D NEXIUM PACKET ............. 99
methylergonovine ............ 122 (PSEUDOEPHED) 25, 123, NEXLETOL ........................ 40
methylphenidate HCl ... 74, 75 126 NEXLIZET ................... 40, 47
methylprednisolone ......... 101 MULTAQ ............................49 niacin ................................. 40
methylprednisolone acetate multivitamin ......................147 niacinamide ..................... 149
..................................... 101 MULTI-VITAMINS WITH nicardipine . 44, 50, 51, 52, 57
methylprednisolone sodium IRON ............................147 nicotine .............................. 28
succ ............................. 101 mupirocin .........................134 nicotine (polacrilex)............ 28
metipranolol ....................... 89 MURO 128 .........................92 NICOTROL ........................ 28
metoclopramide HCl .......... 98 MUSE.................................57 NICOTROL NS .................. 28
metolazone .................. 56, 87 MY WAY ..........................105 nifedipine ... 44, 50, 51, 52, 57
metoprolol succinate .. 32, 41, mycophenolate mofetil .....120 nilutamide .......................... 21
42, 48 mycophenolate sodium ....120 nimodipine . 44, 50, 51, 52, 57
metoprolol tartrate 32, 41, 42, MYLERAN..........................20 NIPENT ............................. 21
48, 49 MYRBETRIQ....................147 Nitro-Bid............................. 54
metronidazole .......... 5, 7, 134 N nitrofurantoin...................... 17
mexiletine .......................... 48 nabumetone .......................73 nitrofurantoin macrocrystal 17
MICARDIS ................... 37, 38 nadolol .............29, 41, 42, 49 nitrofurantoin monohyd/m-
MICARDIS HCT ... 37, 38, 56, naftifine ............................133 cryst ............................... 17
86 nalbuphine .........................72 nitroglycerin ....................... 54
miconazole nitrate ........... 139 naloxone ....................72, 115 NIVESTYM ........................ 33
MICONAZOLE-3 ............. 139 naltrexone ..................72, 114 NIZORAL A-D .................. 139
Microgestin 1.5/30 (21) ... 105 naproxen ....................73, 115 NORA-BE ........................ 105
Microgestin 1/20 (21) ...... 105 naproxen sodium .......73, 115 noreth-ethinyl estradiol-iron
naratriptan ..........................76 ..................................... 105
160
norethindrone acetate ..... 112 OPTICHAMBER DIAMOND penicillin G sodium ............ 14
norethindrone-e.estradiol-iron LG MASK .......................80 penicillin V potassium ........ 14
..................................... 105 OPTICHAMBER DIAMOND PENTACEL ACTHIB
norgestimate-ethinyl estradiol VHC ................................80 COMPONENT (PF)........ 24
..................................... 106 OPTICHAMBER DIAMOND- PENTAM.............................. 7
NORITATE ...................... 134 MED MSK.......................80 PENTASA .......................... 96
NORPACE CR .................. 47 OPTICHAMBER DIAMOND- pentazocine-naloxone ....... 72
Nortrel 0.5/35 (28) ........... 106 SML MASK .....................80 pentoxifylline ...................... 33
NORTREL 1/35 (21) ........ 106 ORACIT .............................81 PERJETA .......................... 21
Nortrel 1/35 (28) .............. 106 ORALYTE ..........................85 permethrin ....................... 144
Nortrel 7/7/7 (28) ............. 106 ORILISSA ........................103 perphenazine ..................... 73
nortriptyline ........................ 78 orphenadrine citrate ...........32 PEXEVA ............................ 77
NORVIR ............................ 12 oseltamivir ..........................14 Phenadoz ...................... 2, 64
NOVAREL ....................... 108 OTEZLA .......... 117, 119, 146 phenazopyridine .............. 138
NOVOLIN 70/30 U-100 OTEZLA STARTER 117, 119, phenobarb-hyoscy-atropine-
INSULIN............... 110, 112 146 scop ................... 28, 65, 66
NOVOLIN N NPH U-100 oxaliplatin ...........................21 phenobarbital ............... 65, 66
INSULIN....................... 110 oxandrolone .....................102 phenoxybenzamine ..... 30, 52
NOVOLIN R REGULAR U- oxaprozin ...........................73 phenylephrine HCl ....... 26, 93
100 INSULN ........ 110, 113 oxazepam ..........................67 phenytoin ..................... 48, 69
NP THYROID .................. 113 oxcarbazepine....................61 phenytoin sodium ........ 48, 69
NUCALA .................. 125, 128 oxybutynin chloride ..........147 phenytoin sodium extended
NURTEC ODT ................... 68 oxycodone..........................71 ................................. 48, 69
nystatin ...................... 15, 144 oxycodone-acetaminophen PHOSPHA 250 NEUTRAL 81
nystatin-triamcinolone ..... 144 .................................60, 71 PHOTOFRIN ..................... 21
O oxycodone-aspirin ........71, 75 phytonadione (vitamin K1)
OB COMPLETE PETITE .. 35, oxytocin ............................122 ............................. 115, 152
147, 149 OYSTER SHELL CALCIUM PIFELTRO ......................... 10
OCELLA .......................... 106 500 .................................85 pilocarpine HCl ............ 30, 93
ODEFSEY ................... 10, 11 OYSTER SHELL CALCIUM- pimecrolimus ........... 120, 146
ofloxacin ...................... 16, 89 VIT D2 ............................85 pimozide ............................ 64
olanzapine ................... 62, 65 OZEMPIC.........................108 pindolol ...... 29, 41, 42, 49, 53
olmesartan .................. 37, 38 P PINK BISMUTH ........... 94, 95
olmesartan- paclitaxel ............................21 pioglitazone ..................... 113
hydrochlorothiazide 37, 38, PANDEL...................137, 142 piroxicam ........................... 73
56, 86 pantoprazole ......................99 PLAN B ONE-STEP ........ 106
olopatadine ........................ 88 paroxetine HCl ...................77 PNEUMOVAX-23 .............. 24
omega 3-dha-epa-fish oil .. 40 PEDIA RELIEF INFANT podofilox .......................... 146
omega-3 fatty acids ........... 40 NASAL....................26, 123 Polocaine ......................... 114
omega-3 fatty acids-fish oil 40 PEDIA TRI-VITE .....148, 151, polyethylene glycol 3350 ... 97
omeprazole ....................... 99 152 polymyxin B sulfate............ 15
omeprazole-sodium PEDIA-LAX STOOL polymyxin B sulf-trimethoprim
bicarbonate .................... 99 SOFTENER ....................96 ....................................... 89
OMNARIS.................. 91, 129 PEDIATRIC COUGH AND polysaccharide iron complex
ONCASPAR ...................... 21 COLD 3, 26, 124, 125, 127 ....................................... 35
ondansetron ...................... 95 peg 3350-electrolytes.........96 polyvinyl alcohol ................ 92
ondansetron HCl ............... 95 PEG-3350 WITH FLAVOR Portia 28 .......................... 106
OPDIVO ............................ 21 PACKS ...........................97 PORTRAZZA ..................... 21
OPTICHAMBER ADULT PEGASYS ..........................13 potassium acetate ............. 85
MASK-LARGE ............... 80 penicillin G potassium ........14 potassium chloride............. 85
161
potassium chloride-D5- PRIMSOL ...........................17 quinine sulfate ..................... 7
0.2%NaCl ...................... 85 probenecid .................87, 116 QVAR REDIHALER . 102, 130
potassium chloride-D5- probenecid-colchicine 87, 116 R
0.9%NaCl ...................... 85 procainamide .....................48 RABAVERT (PF) ............... 24
potassium citrate ............... 81 PROCARE BLOOD rabeprazole........................ 99
potassium phosphate m-/d- PRESSURE MONITOR..80 raloxifene ................. 106, 116
basic .............................. 85 PROCHAMBER .................80 ramipril ............................... 39
pramipexole ....................... 69 prochlorperazine ..........73, 96 RAPAMUNE .................... 120
PRAMOSONE . 137, 138, 142 prochlorperazine Edisylate73, REBIF (WITH ALBUMIN) 119
prasugrel ........................... 36 96 REBIF TITRATION PACK119
pravastatin ......................... 52 prochlorperazine maleate .74, Reclipsen (28) ................. 106
prazosin ....................... 29, 37 96 RECOMBIVAX HB (PF)..... 24
PRED MILD ....................... 91 Proctozone-Hc .........137, 142 REESE'S PINWORM
PRED-G ...................... 89, 91 progesterone micronized .112 MEDICINE ....................... 6
PRED-G S.O.P. ........... 89, 91 PROGLYCEM ..................103 REFRESH LIQUIGEL ........ 92
prednicarbate .......... 137, 142 PROLEUKIN ..............21, 119 REFRESH P.M. ................. 92
prednisolone .................... 101 PROLIA ............................116 REFRESH TEARS ............ 92
prednisolone acetate ......... 91 promethazine .........2, 64, 127 REGONOL......................... 30
prednisolone sodium Promethazine Vc....2, 26, 127 REGRANEX ............ 139, 146
phosphate .............. 91, 101 promethazine-codeine ......71, RELPAX ............................ 76
prednisone .............. 101, 102 125, 127 REMICADE....... 98, 117, 119,
PREDNISONE INTENSOL promethazine-DM ....125, 127 120, 146
..................................... 101 promethazine-phenyleph- RENAGEL ................. 83, 115
pregabalin ............. 60, 61, 69 codeine 2, 27, 71, 125, 127 RENA-VITE ............. 150, 151
PREMARIN ..................... 107 propafenone .......................48 RENFLEXIS...... 98, 117, 119,
PREMPHASE .................. 107 proparacaine ......................93 146
PREMPRO ...................... 107 propranolol 29, 41, 42, 49, 53, repaglinide ....................... 111
PRENATAL + DHA... 35, 148, 64 REPATHA PUSHTRONEX 54
149 propranolol- REPATHA SURECLICK .... 54
PRENATAL PLUS hydrochlorothiazid ...29, 41, REPATHA SYRINGE ........ 54
(CALCIUM CARB) .. 35, 85, 42, 49, 56, 86 RESCON-DM 3, 26, 124, 125,
148, 149 propylthiouracil .................103 128
PRENATE DHA (FERR ASP protriptyline ........................78 RESTORE TEARS ............ 92
GLYCIN) ........ 35, 148, 149 pseudoephedrine HCl 26, 124 RETACRIT......................... 33
PRENATE ENHANCE ...... 35, PULMICORT FLEXHALER REVLIMID.................. 21, 119
148, 150 .............................102, 130 REXULTI ........................... 65
PRENATE MINI (FERR ASP PULMOZYME ............87, 129 REYATAZ .......................... 13
GLYCIN) ........ 35, 148, 150 pyrazinamide........................7 RHINOCORT ALLERGY .. 91,
PRENATE PIXIE 35, 148, 150 pyridostigmine bromide ......30 129
PREVACID 24HR .............. 99 pyridoxine (vitamin B6) ....150 RHOGAM ULTRA-
Prevalite ............................ 42 Q FILTERED PLUS ........... 22
PREVIDENT .................... 116 QELBREE ..........................68 RHOPRESSA .............. 89, 93
PREVIDENT 5000 DRY QNASL .......................91, 129 ribavirin .............................. 14
MOUTH........................ 116 QSYMIA .................58, 60, 61 riboflavin (vitamin B2) ...... 150
PREVNAR 13 (PF) ............ 24 quetiapine ....................62, 65 RIDAURA .......... 99, 117, 119
PREZISTA ......................... 12 quinapril .............................39 rifabutin .......................... 7, 16
PRILOSEC ........................ 99 quinapril-hydrochlorothiazide rifampin .......................... 7, 16
PRIMACARE ..... 35, 148, 150 ...........................39, 56, 86 riluzole ............................... 68
primaquine .......................... 7 quinidine gluconate ........7, 48 Ringer's ............................. 82
primidone .......................... 65 quinidine sulfate .............7, 48 risperidone ............. 62, 63, 65
162
ritonavir.............................. 13 SLEEP AID sulfacetamide-prednisolone
RITUXAN........................... 21 (DIPHENHYDRAMINE) ...1, ....................................... 89
rivastigmine ....................... 30 2, 65, 128 sulfadiazine........................ 16
rizatriptan .......................... 76 sodium acetate...................85 sulfamethoxazole-
ROBAFEN CF sodium bicarbonate............81 trimethoprim ................... 16
(PHENYLEPHRINE) ..... 27, sodium chloride .....80, 82, 85, sulfasalazine 16, 96, 117, 119
126 86, 92 SULFATRIM ...................... 16
ropinirole ........................... 69 sodium chloride 5 %...........85 sulindac ............................. 73
rosuvastatin ....................... 52 sodium hydroxide (bulk) ...143 sumatriptan ........................ 76
ROXICODONE .................. 71 sodium polystyrene sulfonate sumatriptan succinate.. 76, 77
ROZEREM ........................ 64 .......................................83 SUPRAX .............................. 5
rufinamide ......................... 61 sofosbuvir-velpatasvir ..........9 SUPREP BOWEL PREP KIT
RUKOBIA ............................ 9 SOLU-CORTEF ...............102 ....................................... 97
RYBELSUS ..................... 108 SOLU-MEDROL...............102 SURELIFE ARM BP
S sorbitol ...............................97 MONITOR ...................... 80
SAFYRAL ........................ 106 sorbitol-mannitol...........82, 83 SURELIFE TALKING ARM
salicylic acid .................... 143 sotalol........ 29, 41, 42, 49, 53 BP MONITR ................... 80
salsalate ............................ 76 Sotalol Af... 29, 41, 42, 49, 53 SUSTIVA ........................... 10
SANDIMMUNE 117, 119, 120 SPIRIVA RESPIMAT .28, 124 SUTENT ............................ 21
SANTYL .......................... 146 SPIRIVA WITH SYMJEPI ................... 26, 124
SAVELLA .................... 69, 76 HANDIHALER ........28, 125 SYMLINPEN 120 ............. 102
SCALACORT .......... 137, 142 spironolactone........53, 55, 84 SYMLINPEN 60 ............... 102
SCALP RELIEF ....... 137, 142 spironolacton- SYMTUZA ..... 12, 13, 14, 121
SCALPICIN ANTI-ITCH.. 137, hydrochlorothiaz 53, 54, 55, SYNJARDY ............. 104, 113
142 56, 84, 86 SYNRIBO .......................... 21
SCOT-TUSSIN DM .... 3, 126, SPORANOX.........................8 SYSTANE NIGHTTIME ..... 92
128 Sprintec (28) ....................106 T
SELECT-OB + DHA . 35, 148, SPRYCEL ..........................21 TABLOID ........................... 21
150 Sronyx ..............................106 tacrolimus ................ 120, 146
selegiline HCl .................... 69 SSD..................................144 tadalafil (pulm. hypertension)
selenium sulfide .............. 144 SSKI ............ 6, 103, 115, 126 ............................... 54, 133
SELF-TAKING BLOOD stavudine............................11 tamoxifen ................... 21, 107
PRESSURE ................... 80 Sterile Water For Injection tamsulosin ......................... 30
SELZENTRY ....................... 9 .....................................123 TARGETED ACNE SPOT
SENNA .............................. 97 STIOLTO RESPIMAT .28, 32, TREATMENT ............... 143
SENNA-S .......................... 97 125, 132 TASIGNA ........................... 21
SEREVENT DISKUS. 31, 132 STOOL SOFTENER ..........97 tazarotene........................ 146
sertraline ........................... 77 streptomycin.....................5, 8 TAZORAC ....................... 146
sevelamer carbonate . 83, 115 STRESS FORMULA ........148 Taztia Xt .... 43, 44, 45, 46, 58
SF .................................... 116 STRIBILD .....................10, 12 TECENTRIQ ...................... 21
SHINGRIX (PF) ................. 24 SUBOXONE.......................72 telmisartan ................... 37, 38
sildenafil (pulm.hypertension) sucralfate ...........................98 temazepam ........................ 67
............................... 54, 133 SUDOGEST 12-HOUR .....26, TEMODAR......................... 21
silver nitrate ..................... 143 124 temozolomide .................... 21
silver sulfadiazine ............ 144 sulfacetamide sodium ........89 teniposide .......................... 22
simethicone ....................... 95 sulfacetamide sodium-sulfur TENIVAC (PF) ................... 23
simvastatin ........................ 52 .............................143, 144 terazosin ................ 29, 37, 53
SINGULAIR ..................... 128 sulfacetamide sod-sulfur-urea terbinafine HCl ............. 5, 133
sirolimus .......................... 120 .............................143, 144 terbutaline .................. 32, 132
terconazole ...................... 139
163
testosterone .................... 103 tretinoin ............................139 TRUVADA ......................... 12
testosterone cypionate .... 102 tretinoin microspheres......139 TUSNEL NEW FORMULA 26,
testosterone enanthate ... 103 TREXIMET ...................73, 77 124, 126
tetracaine HCl ................... 93 triamcinolone acetonide ....91, TWINRIX (PF) ................... 24
tetracycline ........................ 17 102, 129, 137, 142, 143 TYKERB ............................ 22
THALOMID ...................... 119 triamterene- TYPHIM VI......................... 24
THAM ................................ 81 hydrochlorothiazid ...55, 56, U
theophylline . 51, 82, 133, 147 84, 87 UBRELVY .......................... 68
theophylline in dextrose 5 % Trianex .....................137, 143 UCERIS ........................... 102
................. 51, 82, 133, 147 triazolam ............................67 UDENYCA ......................... 33
thiamine HCl (vitamin B1) 150 trifluoperazine ....................74 ULTRA FRESH.................. 92
thiamine mononitrate (vit B1) trifluridine ...........................89 UNITHROID............. 113, 114
..................................... 150 trihexyphenidyl .............28, 60 urea ................................. 143
thioridazine ........................ 74 trimethobenzamide ............96 URETRON D-S.................. 17
thiotepa ............................. 22 trimethoprim .......................17 ursodiol .............................. 97
thiothixene ......................... 78 TRINTELLIX.......................77 V
tiagabine ............................ 61 TRIUMEQ ....................10, 12 VAGINAL CONTRACEPTIVE
TIKOSYN........................... 49 TRI-VI-SOL .... 148, 149, 151, FOAM........................... 122
timolol maleate 29, 41, 42, 49, 152 valacyclovir ........................ 14
53, 64, 90 TRI-VITAMIN WITH valganciclovir ..................... 14
tioconazole ...................... 139 FLUORIDE . 116, 148, 149, valproic acid........... 61, 63, 64
TIVICAY ............................ 10 151, 152 valproic acid (as sodium salt)
TIVICAY PD ...................... 10 Trivora (28) ......................106 ........................... 61, 63, 64
tizanidine ........................... 29 TROGARZO.........................9 valsartan ............................ 38
TOBRADEX................. 89, 91 tropicamide ........................93 valsartan-hydrochlorothiazide
tobramycin ......................... 89 trospium ...........................147 ........................... 38, 56, 87
tobramycin sulfate ............... 5 TRUE METRIX AIR vancomycin.......................... 8
tobramycin-dexamethasone GLUCOSE METER ........80 VAQTA (PF) ...................... 24
................................. 89, 91 TRUE METRIX GLUCOSE VARIVAX (PF) ................... 24
TOBREX............................ 89 METER ...........................80 vasopressin ..................... 111
TODAY CONTRACEPTIVE TRUE METRIX GLUCOSE VCF CONTRACEPTIVE
SPONGE ..................... 121 TEST STRIP...................81 FILM ............................. 122
tolmetin .............................. 73 TRUETRACK SMART VCF CONTRACEPTIVE GEL
tolnaftate ......................... 146 SYSTEM.........................80 ..................................... 122
tolterodine ....................... 147 TRUETRACK TEST ...........81 VECTIBIX .......................... 22
topiramate ......................... 61 TRULICITY ......................108 VELCADE .......................... 22
topotecan .......................... 22 TRUMENBA .......................24 Velivet Triphasic Regimen
TORISEL ........................... 22 TRUSTEX LATEX CONDOM (28)............................... 106
torsemide .................... 53, 83 .....................................121 VELTASSA ........................ 83
tramadol ............................ 71 TRUSTEX LUBRICATED VEMLIDY ........................... 15
tramadol-acetaminophen . 60, CONDOMS...................122 venlafaxine ........................ 76
64, 72 TRUSTEX NON-LUB VENTAVIS ................. 58, 133
trandolapril ........................ 39 CONDOMS...................122 verapamil .. 43, 44, 45, 46, 50,
tranexamic acid ................. 33 TRUSTEX-RIA 58
travoprost .......................... 93 LUB/SPERMICIDE .......122 VERQUVO......................... 58
trazodone .......................... 77 TRUSTEX-RIA VIAGRA ............................. 54
TRECATOR......................... 8 LUBRICATED CONDOMS VIBRAMYCIN .................... 17
TRELEGY ELLIPTA ... 28, 32, .....................................122 VICTOZA 2-PAK.............. 108
102, 125, 130, 132 TRUSTEX-RIA NON-LUB VICTOZA 3-PAK.............. 109
TRELSTAR................ 22, 108 CONDOMS...................122 VIIBRYD ............................ 78
164
VIMPAT ............................. 61 WIDE-SEAL DIAPHRAGM YF-VAX (PF)...................... 24
vinblastine ......................... 22 65 .................................122 YONDELIS ........................ 22
vincristine .......................... 22 WIDE-SEAL DIAPHRAGM Yuvafem .......................... 107
vinorelbine ......................... 22 70 .................................122 Z
VIRACEPT ........................ 13 WIDE-SEAL DIAPHRAGM zafirlukast ........................ 128
VIREAD ............................. 12 75 .................................122 zaleplon ............................. 65
VITAMED MD ONE RX .... 35, WIDE-SEAL DIAPHRAGM ZALTRAP .......................... 22
148, 150 80 .................................122 ZANOSAR ......................... 22
VITAMIN B COMPLEX WITH WIDE-SEAL DIAPHRAGM ZEGERID........................... 99
C .................................. 150 85 .................................122 ZEGERID OTC .................. 99
VITAMIN B-12 ................. 150 WIDE-SEAL DIAPHRAGM ZENPEP ............................ 97
VITAMIN B-6 ................... 151 90 .................................122 ZEPATIER ........................... 9
VITAMIN D3 .................... 152 WIDE-SEAL DIAPHRAGM ZETONNA ................. 91, 129
Vitamin K ................. 115, 152 95 .................................122 ZIAGEN ............................. 12
Vitamin K1 ............... 115, 152 Wixela Inhub .....32, 102, 131, zidovudine ......................... 12
VOSEVI ............................... 9 132 zileuton ............................ 128
VYVANSE ......................... 59 X zinc chloride....................... 86
W XARELTO ..........................33 zinc sulfate......................... 86
WAL-FEX D 24 HOUR . 4, 26, XARELTO DVT-PE TREAT ziprasidone HCl ........... 63, 65
124, 131 30D START ....................33 zoledronic acid................. 116
WAL-SOM (DOXYLAMINE) 1, XERAC AC.......................138 ZOLINZA ........................... 22
2, 65, 128 XGEVA.............................116 zolmitriptan ........................ 77
WAL-TUSSIN MAX XIFAXAN............................16 zolpidem ............................ 65
STRENGTH COUGH... 126 XOLAIR ............................131 ZOMIG ............................... 77
warfarin.............................. 32 X-SEB T PLUS.................144 ZOMIG ZMT ...................... 77
water for inject, bacteriostat XULANE...........................106 zonisamide ........................ 61
..................................... 123 XYLOCAINE- ZOSTAVAX (PF) ............... 24
water for injection, sterile 123 MPF/EPINEPHRINE .....26, Zovia 1/35E (28) .............. 106
water for irrigation, sterile .. 82 114 ZYFLO ............................. 128
WIDE-SEAL DIAPHRAGM Y ZYPREXA ZYDIS ........ 63, 65
60 ................................. 122 YERVOY ............................22 ZYVOX .............................. 15
165

Contra Costa Health Plan (CCHP) Medi-Cal & Commercial Hmo Formulary

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Contra Costa Health Plan (CCHP) Medi-Cal & Commercial Hmo Formulary

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Contra Costa Health Plan (CCHP)

MEDI-CAL & COMMERCIAL HMO

Last updated: August 1, 2021

How do I use the CCHP formulary?

How are drugs listed on the formulary?

An example listing from the CCHP formulary is below:

What if I need my medication urgently – do pharmacies have the ability to fill

Does CCHP cover generic and brand name medications?

Are there drugs that are excluded from coverage?

Can I go to any pharmacy for my medication?

How do I find a pharmacy?

What drugs are covered by CCHP?

 Prescription drugs listed on the CCHP formulary

Are intravenous (IV) and injectable drugs covered by CCHP?

How Much I Will Pay for My Drugs?

Can providers make suggestions to CCHP to improve the formulary?

What if I need more information?

“Coinsurance” is a percentage of the cost of a covered health care benefit that an

“Drug Tier” is a group of prescription drugs that corresponds to a specified cost

“Exception request” is a request for coverage of a prescription drug. If an enrollee, his

“Out-of-pocket cost” are copayments, coinsurance, and the applicable deductible,

“Prescribing provider” is a health care provider authorized to write a prescription to

“Prescription” is an oral, written, or electronic order by a prescribing provider for a

“Prescription drug” is a drug that is prescribed by the enrollee's prescribing provider

“Step therapy” is a process specifying the sequence in which different prescription

For example, if Drug A and Drug B both treat

Última actualización: 1 de agosto de 2021

El formulario es una lista de medicamentos preferidos examinada y revisada

¿Cómo uso el formulario del CCHP?

Si un medicamento no está en el formulario del CCHP, requerirá una autorización

¿Cómo se indican los medicamentos en el formulario?

Los medicamentos están indicados alfabéticamente por marca y nombre genérico en la

Una lista de ejemplo del formulario del CCHP se encuentra a continuación:

¿Qué sucede si el medicamento que necesito no está indicado en el formulario del

 Su médico puede pedirle al CCHP que cubra un medicamento que figura en el

El CCHP tomará la decisión de denegar o aprobar todas las solicitudes de autorización

El CCHP proporcionará cobertura de conformidad con una solicitud no urgente por la

¿Qué sucede si necesito mi medicamento con urgencia? ¿Las farmacias tienen la

¿El CCHP cubre medicamentos genéricos y de marca?

El CCHP cubre medicamentos de marca y genéricos, pero cuando hay un

¿Hay medicamentos que están excluidos de la cobertura?

Algunos medicamentos están excluidos por el Departamento de Servicios de Atención

¿Puedo ir a cualquier farmacia por mi medicamento?

¿Cómo encuentro una farmacia?

(1) Desplácese hacia abajo y haga clic en el botón "Buscar médicos/clínicas/farmacias

Asegúrese de mostrar su tarjeta de identificación de miembro del CCHP cuando surta

¿Qué medicamentos están cubiertos por el CCHP?

 Medicamentos recetados que figuran en el formulario del CCHP

¿Los medicamentos intravenosos (IV) e inyectables están cubiertos por el CCHP?

La cobertura de medicamentos intravenosos e inyectables a través del beneficio de

 Soluciones intravenosas simples: las soluciones intravenosas simples normalmente

¿Cuánto pagaré por mis medicamentos?

¿Los proveedores pueden hacer sugerencias al CCHP para mejorar el formulario?

¿Qué puedo hacer si necesito más información?

“Medicamento de marca” es un medicamento que se comercializa bajo un nombre

“Coseguro” es un porcentaje del costo de un beneficio de atención médica cubierto

“Copago” es un monto fijo en dólares que un afiliado paga por un beneficio de

“Nivel de medicamento” es un grupo de medicamentos recetados que corresponde a

“Solicitud de excepción” es una solicitud de cobertura de un medicamento recetado.

“Circunstancias exigentes” se producen cuando un afiliado sufre una afección de

“Medicamento genérico” es el mismo medicamento que su equivalente de marca en

“Medicamento que no figura en el formulario” es un medicamento recetado que no