z6500 Drug List

FEP 5 Tier Rx Drug Formulary (607) Standard Option 1022
Effective October 1, 2022 v2
The FEP formulary includes the preferred drug list which is comprised of Tier 1, generics and Tier 2, preferred brand-name drugs. Also
included in the formulary are Tier 3, non-preferred brand-name drugs, Tier 4, preferred specialty drugs and Tier 5, non-preferred specialty
drugs.
Ask your physician if there is a generic drug available to treat your condition. If there is no generic drug available, ask your physician to
prescribe a preferred brand-name drug.
The preferred brand-name drugs within our formulary are listed to identify medicines that are clinically appropriate and cost-effective.
Click on the category name in the Table of Contents below to go directly to that page
INTRODUCTION ........................................................................................................................................................................................................................ 5
PREFACE ................................................................................................................................................................................................................................... 5
EXCLUDED DRUGS .................................................................................................................................................................................................................. 6
PRIOR APPROVAL ................................................................................................................................................................................................................... 6
QUANTITY LIMITATIONS ......................................................................................................................................................................................................... 6
PHARMACY AND MEDICAL POLICY COMMITTEE ................................................................................................................................................................ 6
PRODUCT SELECTION CRITERIA .......................................................................................................................................................................................... 6
FORMULARY PRODUCT DESCRIPTIONS .............................................................................................................................................................................. 7
GENERIC SUBSTITUTION ........................................................................................................................................................................................................ 7
DRUG EFFICACY STUDY IMPLEMENTATION DRUGS ......................................................................................................................................................... 8
EDITOR ...................................................................................................................................................................................................................................... 8
NOTICE ...................................................................................................................................................................................................................................... 8
LEGEND ..................................................................................................................................................................................................................................... 8
ANALGESICS .......................................................................................................................................................................................................................... 10
ANALGESICS, OTHER .................................................................................................................................................................................................. 10
COX-2 INHIBITORS ....................................................................................................................................................................................................... 10
GOUT ............................................................................................................................................................................................................................. 10
NSAIDs........................................................................................................................................................................................................................... 10
NSAIDs, COMBINATIONS ............................................................................................................................................................................................. 10
NSAIDs, TOPICAL ......................................................................................................................................................................................................... 10
OPIOID ANALGESICS ................................................................................................................................................................................................... 10
NON-OPIOID ANALGESICS ......................................................................................................................................................................................... 11
VISCOSUPPLEMENTS ................................................................................................................................................................................................. 11
ANTI-INFECTIVES ................................................................................................................................................................................................................... 12
ANTIBACTERIALS ......................................................................................................................................................................................................... 12
ANTIFUNGALS .............................................................................................................................................................................................................. 13
ANTIMALARIALS ........................................................................................................................................................................................................... 14
ANTIRETROVIRAL AGENTS ........................................................................................................................................................................................ 14
ANTITUBERCULAR AGENTS ....................................................................................................................................................................................... 15
ANTIVIRALS .................................................................................................................................................................................................................. 15
MISCELLANEOUS ......................................................................................................................................................................................................... 16
ANTINEOPLASTIC AGENTS .................................................................................................................................................................................................. 17
ALKYLATING AGENTS ................................................................................................................................................................................................. 17
ANTIMETABOLITES ...................................................................................................................................................................................................... 17
HORMONAL ANTINEOPLASTIC AGENTS .................................................................................................................................................................. 18
IMMUNOMODULATORS ............................................................................................................................................................................................... 18
KINASE INHIBITORS .................................................................................................................................................................................................... 18
MULTIPLE MYELOMA ................................................................................................................................................................................................... 20
TOPOISOMERASE INHIBITORS .................................................................................................................................................................................. 20
MISCELLANEOUS ......................................................................................................................................................................................................... 20
CARDIOVASCULAR ................................................................................................................................................................................................................ 22
ACE INHIBITORS .......................................................................................................................................................................................................... 22
ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS .......................................................................................................................... 22
ACE INHIBITOR/DIURETIC COMBINATIONS .............................................................................................................................................................. 23
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ADRENOLYTICS, CENTRAL ........................................................................................................................................................................................ 23
ALDOSTERONE RECEPTOR ANTAGONISTS ............................................................................................................................................................ 23
ALPHA BLOCKERS ....................................................................................................................................................................................................... 23
ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS ............................................................................................................ 23
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS ........................................................................... 23
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS ......................................................... 23
ANTIARRHYTHMICS ..................................................................................................................................................................................................... 23
ANTILIPEMICS .............................................................................................................................................................................................................. 24
BETA-BLOCKERS ......................................................................................................................................................................................................... 25
BETA-BLOCKER/DIURETIC COMBINATIONS ............................................................................................................................................................ 25
CALCIUM CHANNEL BLOCKERS ................................................................................................................................................................................ 25
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS .............................................................................................................................. 26
DIGITALIS GLYCOSIDES ............................................................................................................................................................................................. 26
DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS ......................................................................................................................................... 26
DIURETICS .................................................................................................................................................................................................................... 26
HEART FAILURE ........................................................................................................................................................................................................... 26
NITRATES...................................................................................................................................................................................................................... 26
PULMONARY ARTERIAL HYPERTENSION ................................................................................................................................................................ 27
MISCELLANEOUS ......................................................................................................................................................................................................... 27
CENTRAL NERVOUS SYSTEM .............................................................................................................................................................................................. 27
ANTIANXIETY ................................................................................................................................................................................................................ 27
ANTICONVULSANTS .................................................................................................................................................................................................... 28
ANTIDEMENTIA............................................................................................................................................................................................................. 29
ANTIDEPRESSANTS .................................................................................................................................................................................................... 29
ANTIPARKINSONIAN AGENTS .................................................................................................................................................................................... 30
ANTIPSYCHOTICS ........................................................................................................................................................................................................ 31
ATTENTION DEFICIT HYPERACTIVITY DISORDER .................................................................................................................................................. 31
FIBROMYALGIA ............................................................................................................................................................................................................ 32
HYPNOTICS .................................................................................................................................................................................................................. 32
MIGRAINE...................................................................................................................................................................................................................... 33
MOOD STABILIZERS .................................................................................................................................................................................................... 33
MOVEMENT DISORDERS ............................................................................................................................................................................................ 33
MULTIPLE SCLEROSIS ................................................................................................................................................................................................ 33
MUSCULOSKELETAL THERAPY AGENTS ................................................................................................................................................................. 34
MYASTHENIA GRAVIS ................................................................................................................................................................................................. 34
NARCOLEPSY/CATAPLEXY ........................................................................................................................................................................................ 34
PSYCHOTHERAPEUTIC-MISCELLANEOUS ............................................................................................................................................................... 34
MISCELLANEOUS ......................................................................................................................................................................................................... 35
ENDOCRINE AND METABOLIC ............................................................................................................................................................................................. 35
ANDROGENS ................................................................................................................................................................................................................ 35
ANTIDIABETICS ............................................................................................................................................................................................................ 36
CALCIUM RECEPTOR AGONISTS .............................................................................................................................................................................. 39
CALCIUM REGULATORS ............................................................................................................................................................................................. 39
CARNITINE DEFICIENCY AGENTS ............................................................................................................................................................................. 39
CONTRACEPTIVES ...................................................................................................................................................................................................... 39
DIABETIC KIDNEY DISEASE........................................................................................................................................................................................ 41
ENDOMETRIOSIS ......................................................................................................................................................................................................... 41
FERTILITY REGULATORS ........................................................................................................................................................................................... 41
GAUCHER DISEASE ..................................................................................................................................................................................................... 41
GLUCOCORTICOIDS .................................................................................................................................................................................................... 41
GLUCOSE ELEVATING AGENTS................................................................................................................................................................................. 41
HEREDITARY TYROSINEMIA TYPE 1 AGENTS ......................................................................................................................................................... 42
HUMAN GROWTH HORMONES .................................................................................................................................................................................. 42
HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS ................................................................................................................................... 42
INSULIN-LIKE GROWTH FACTOR-1 AGENTS ............................................................................................................................................................ 42
MENOPAUSAL SYMPTOM AGENTS ........................................................................................................................................................................... 42
PHENYLKETONURIA TREATMENT AGENTS ............................................................................................................................................................. 43
PHOSPHATE BINDER AGENTS................................................................................................................................................................................... 43
POTASSIUM-REMOVING AGENTS ............................................................................................................................................................................. 43
PROGESTINS ................................................................................................................................................................................................................ 43
SELECTIVE ESTROGEN RECEPTOR MODULATORS ............................................................................................................................................... 43
THYROID AGENTS ....................................................................................................................................................................................................... 44
UREA CYCLE DISORDERS .......................................................................................................................................................................................... 44
UTERINE FIBROIDS ..................................................................................................................................................................................................... 44
VASOPRESSINS ........................................................................................................................................................................................................... 44
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MISCELLANEOUS ......................................................................................................................................................................................................... 44
GASTROINTESTINAL ............................................................................................................................................................................................................. 45
ANTIDIARRHEALS ........................................................................................................................................................................................................ 45
ANTIEMETICS ............................................................................................................................................................................................................... 45
ANTISPASMODICS ....................................................................................................................................................................................................... 46
CHOLELITHOLYTICS .................................................................................................................................................................................................... 46
H2 RECEPTOR ANTAGONISTS .................................................................................................................................................................................... 46
INFLAMMATORY BOWEL DISEASE ............................................................................................................................................................................ 46
IRRITABLE BOWEL SYNDROME ................................................................................................................................................................................. 46
LAXATIVES .................................................................................................................................................................................................................... 46
OPIOID-INDUCED CONSTIPATION ............................................................................................................................................................................. 47
PANCREATIC ENZYMES .............................................................................................................................................................................................. 47
PROSTAGLANDINS ...................................................................................................................................................................................................... 47
PROTON PUMP INHIBITORS ....................................................................................................................................................................................... 47
SALIVA STIMULANTS ................................................................................................................................................................................................... 47
STEROIDS, RECTAL ..................................................................................................................................................................................................... 47
ULCER THERAPY COMBINATIONS ............................................................................................................................................................................ 47
MISCELLANEOUS ......................................................................................................................................................................................................... 47
GENITOURINARY .................................................................................................................................................................................................................... 48
BENIGN PROSTATIC HYPERPLASIA .......................................................................................................................................................................... 48
URINARY ANTISPASMODICS ...................................................................................................................................................................................... 48
VAGINAL ANTI-INFECTIVES ........................................................................................................................................................................................ 48
MISCELLANEOUS ......................................................................................................................................................................................................... 48
HEMATOLOGIC ....................................................................................................................................................................................................................... 49
ANTICOAGULANTS ...................................................................................................................................................................................................... 49
HEMATOPOIETIC GROWTH FACTORS ...................................................................................................................................................................... 49
HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS .......................................................................................... 49
IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS........................................................................................................................................ 50
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS .......................................................................................................................... 50
PLATELET AGGREGATION INHIBITORS .................................................................................................................................................................... 50
PLATELET SYNTHESIS INHIBITORS .......................................................................................................................................................................... 50
SICKLE CELL DISEASE ................................................................................................................................................................................................ 50
STEM CELL MOBILIZERS ............................................................................................................................................................................................ 51
THROMBOCYTOPENIA AGENTS ................................................................................................................................................................................ 51
MISCELLANEOUS ......................................................................................................................................................................................................... 51
IMMUNOLOGIC AGENTS ....................................................................................................................................................................................................... 51
ALLERGENIC EXTRACTS ............................................................................................................................................................................................ 51
AUTOIMMUNE AGENTS ............................................................................................................................................................................................... 51
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs) ................................................................................................................................... 52
HEREDITARY ANGIOEDEMA AGENTS ....................................................................................................................................................................... 52
IMMUNE GLOBULINS ................................................................................................................................................................................................... 52
IMMUNOMODULATORS ............................................................................................................................................................................................... 53
IMMUNOSUPPRESSANTS ........................................................................................................................................................................................... 53
NUTRITIONAL/SUPPLEMENTS ............................................................................................................................................................................................. 53
ELECTROLYTES ........................................................................................................................................................................................................... 53
VITAMINS AND MINERALS .......................................................................................................................................................................................... 54
MISCELLANEOUS ......................................................................................................................................................................................................... 54
RESPIRATORY ........................................................................................................................................................................................................................ 54
ALPHA-1 ANTITRYPSIN DEFICIENCY AGENTS ......................................................................................................................................................... 54
ANAPHYLAXIS TREATMENT AGENTS ....................................................................................................................................................................... 54
ANTICHOLINERGICS .................................................................................................................................................................................................... 54
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ............................................................................................................................................. 55
ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS ......................................................................................................... 55
ANTIHISTAMINES, LOW SEDATING ........................................................................................................................................................................... 55
ANTIHISTAMINES, NONSEDATING............................................................................................................................................................................. 55
ANTIHISTAMINES, SEDATING..................................................................................................................................................................................... 55
ANTIHISTAMINE/DECONGESTANT COMBINATIONS ............................................................................................................................................... 55
ANTITUSSIVES ............................................................................................................................................................................................................. 55
ANTITUSSIVE COMBINATIONS ................................................................................................................................................................................... 55
BETA AGONISTS .......................................................................................................................................................................................................... 55
CYSTIC FIBROSIS ........................................................................................................................................................................................................ 56
LEUKOTRIENE MODULATORS ................................................................................................................................................................................... 56
MAST CELL STABILIZERS ........................................................................................................................................................................................... 56
NASAL ANTIHISTAMINES ............................................................................................................................................................................................ 56
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NASAL STEROIDS/COMBINATIONS ........................................................................................................................................................................... 56
PHOSPHODIESTERASE-4 INHIBITORS...................................................................................................................................................................... 56
PULMONARY FIBROSIS AGENTS ............................................................................................................................................................................... 56
SEVERE ASTHMA AGENTS ......................................................................................................................................................................................... 57
STEROID/BETA AGONIST COMBINATIONS ............................................................................................................................................................... 57
STEROID INHALANTS .................................................................................................................................................................................................. 57
XANTHINES ................................................................................................................................................................................................................... 57
MISCELLANEOUS ......................................................................................................................................................................................................... 57
TOPICAL .................................................................................................................................................................................................................................. 57
DERMATOLOGY ........................................................................................................................................................................................................... 57
MOUTH/THROAT/DENTAL AGENTS ........................................................................................................................................................................... 61
OPHTHALMIC ................................................................................................................................................................................................................ 61
OTIC ............................................................................................................................................................................................................................... 64
WEBSITES ............................................................................................................................................................................................................................... 65
2022 FEP EXCLUDED DRUG LIST STANDARD OPTION CHART ....................................................................................................................................... 67
INDEX ....................................................................................................................................................................................................................................... 72
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The Retail and Mail Service Prescription Drug Program cannot refill a controlled substance until 80% of the prescription has been used.
Call us at 1-800-624-5060 or visit our website www.fepblue.org if you have any questions about dispensing limits.
INTRODUCTION
FEP is pleased to provide the 2022 FEP 5 Tier Rx Drug Formulary as a useful reference for drug product selection. The drugs on
the FEP 5 Tier Rx Drug Formulary have been reviewed by the FEP Pharmacy and Medical Policy Committee and FEP
physicians and pharmacists and found appropriate for preferred status.
All the information in the FEP 5 Tier Rx Drug Formulary is provided as a reference for drug therapy selection. Specific drug
selection for an individual patient rests solely with the prescriber.
National guidelines can be found on the National Guideline Clearinghouse site at https://www.ahrq.gov/gam/, on the websites
listed under each therapeutic class and on the sites listed in the WEBSITES section of this publication.
PREFACE
The formulary is organized by sections, which refer to either a drug class or disease state. Unless exceptions are noted, all
dosage forms and strengths of the drug cited are included in the formulary.
The FEP 5 Tier Rx Drug Formulary is an open formulary, but FEP may impose restrictions or not reimburse for specific drug
products or types of products. For example, drugs and supplies for weight loss are excluded from the pharmacy benefit. In
addition, over-the-counter (OTC) products, with the exception of insulin and diabetes monitoring products, are generally not
included in the pharmacy benefit. Some OTC products are listed in the formulary for informational purposes only.
The formulary is separated by Tiers in the following manner:
Tier 1 Tier 2 Tier 3 Tier 4 Tier 5

generic drugs preferred brand- non-preferred brand- preferred specialty non-preferred
name drugs name drugs and all drugs specialty drugs
compounded
medications
Standard Option $7.50 copayment 30% coinsurance 50% coinsurance 30% coinsurance 30% coinsurance
Preferred Retail for a 0 to 30-day Limit*: one 30-day Limit*: one 30-day
Pharmacy supply supply fill at retail supply fill at retail
($22.50 copayment
for a 31 to 90-day
supply)
Medicare Part B $5 copayment for a

Primary 0 to 30-day supply
($15 copayment for a
31 to 90-day supply)
Standard Option 45% of average wholesale price plus any difference between our allowance and the billed amount
Non-Preferred
Retail Pharmacy
Standard Option $15 copay $90 copay $125 copay
Mail Pharmacy
Medicare Part B $10 copay

Standard Option $65 for a 0 to 30- $85 for a 0 to 30-
Specialty Drug day supply day supply
Pharmacy Program
$185 for 31 to 90- $240 for 31 to 90-
day supply day supply
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* First fill of specialty medications is limited to a 30-day supply at retail. All subsequent fills must be through the Specialty Drug
Pharmacy Program. A 90-day supply fill of a specialty medication may only be obtained through the Specialty Drug Pharmacy
Program once a member has received three 30-day supply fills of that medication.
Drug products shown in boldface type indicate generic availability.
All drugs that are preferred are noted in their respective tiers of the drug lists throughout this formulary. Drugs may be reviewed
by the FEP Pharmacy and Medical Policy Committee and designated non-preferred. FEP may designate certain drugs as non-
preferred, typically if the cost-effectiveness is less than other similar drugs.
EXCLUDED DRUGS
Select medications are covered on the Standard Option drug benefit plan. These excluded medications have available covered
options in the same therapeutic class. For a full listing of these excluded medications please see the EXCLUDED DRUG LIST
STANDARD OPTION CHART located before the INDEX in this document.
Patients taking an excluded medication should expect to pay the full cost of the prescription.
PRIOR APPROVAL
Prior approval (PA) is required for certain drugs before FEP will cover them. The prescribing physician may request PA by calling
toll-free 1-877-727-3784. The list of prior approval medications is subject to change. For a current list of medications that require
prior approval please see our Prior Approval web page.
QUANTITY LIMITATIONS
Quantity limitations (QL) have been established for some of the medications covered by FEP. Requests for quantities greater
than allowed can be submitted to the Prior Approval program by the prescribing physician by calling toll-free
1-877-727-3784. The list of medications that have quantity limitations is subject to change. For a current list of medications with
quantity limitations please see our Prior Approval web page.
PHARMACY AND MEDICAL POLICY COMMITTEE

The role of the FEP Pharmacy and Medical Policy Committee includes evaluating new medications, and making
recommendations for the designation of preferred or non-preferred status on the FEP 5 Tier Rx Drug Formulary. The FEP
Pharmacy and Medical Policy Committee is made up of physicians and pharmacists who are not employees or agents of, nor
have financial interest in FEP.
PRODUCT SELECTION CRITERIA

The FEP Pharmacy and Medical Policy Committee will consider U.S. Food and Drug Administration (FDA) approved drugs for
preferred status designation. The evaluation includes a literature review; expert opinion may also be sought. Formal reviews are
prepared that typically address the following information:
• Safety
• Efficacy
• Comparison studies
• Drug interactions
• Approved indications
• Formulation and administration
• Adverse effects
• Contraindications
• Pharmacokinetics
• Patient compliance considerations
• Medical outcome and pharmacoeconomic studies
When a new drug is considered for preferred status, an attempt will be made to examine the drug relative to similar drugs
currently preferred. In addition, entire therapeutic classes are periodically reviewed. The class review process may result in a
6
designation of non-preferred status to drug(s) in a particular therapeutic class, in an effort to continually promote the most
clinically useful and cost-effective agents.
Drugs evaluated by the Pharmacy and Medical Policy Committee and not classified as preferred receive a non-preferred
designation in the FEP 5 Tier Rx Drug Formulary. This designation indicates the Pharmacy and Medical Policy Committee's
belief that the drug offers no important clinical or cost advantage over comparable preferred drugs, or that there is currently
insufficient information to determine its appropriate clinical role, or that questions remain regarding safety and effectiveness. In
an open formulary environment, non-preferred drugs are covered under FEP's pharmacy benefit. However, there may be
additional costs incurred by the patient to receive a non-preferred medication. Physicians are encouraged to prescribe preferred
drugs.
All the information in the FEP 5 Tier Rx Drug Formulary is provided as a reference for drug therapy selection. The final choice of
a specific drug selection for an individual patient rests solely with the prescriber.
FORMULARY PRODUCT DESCRIPTIONS

To assist in understanding which specific strengths and dosage forms are preferred, examples are noted below. The
general principles shown in the examples can usually be extended to other entries in the book. Any exceptions are noted.
Preferred products include all strengths and dosage forms of the cited brand-name product.
sevelamer carbonate Renvela
Oral powder packets, tabs and all strengths of Renvela would be included in this listing.
When a strength or dosage form is specified, only the specified strength and dosage form is preferred. Other
strengths/dosage forms of the reference product are not.
meloxicam tabs
The tablets of meloxicam are preferred. From this entry, the capsules cannot be assumed to be on the list unless
there is a specific entry.
Extended-release and delayed-release products require their own entry.

sitagliptin/metformin Janumet
The immediate-release product listing of Janumet alone would not include the extended-release product Janumet XR.
sitagliptin/metformin ext-rel Janumet XR

A separate entry for Janumet XR confirms that the extended-release product is on the formulary.
Dosage forms will be consistent with the category and use where listed.
nystatin
The above nystatin entry listed in the TOPICAL/DERMATOLOGY section is limited to the topical dosage forms. From this
entry the oral formulations cannot be assumed to be on the list unless there is an entry for this product in the ANTI-
INFECTIVES section of the formulary.
GENERIC SUBSTITUTION
Generic substitution is a pharmacy action whereby a generic version is dispensed rather than a prescribed brand-name product.
Boldface type indicates generic availability. However, not all strengths or dosage forms of the generic name in boldface type
may be generically available. In addition, boldface type may indicate that the brand name cited is a generic. Examples of the
latter include Levoxyl and Trivora.
One way to reduce out-of-pocket cost is by requesting a generic drug. Generic drugs are usually priced lower than their brand-
name equivalents. Prescription generic drugs are:
• Approved by the FDA for safety and effectiveness, and are manufactured under the same strict standards that apply to
brand-name drugs.
• Tested in humans to assure the generic is absorbed into the bloodstream in a similar rate and to the same extent as
the brand-name drug. Generics may be different from the brand in size, color, and inactive ingredients, but this does
not alter their effectiveness or ability to be absorbed just like the brand-name drug.
• Manufactured in the same strength and dosage form as the brand-name drugs.
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When a generic drug is substituted for a brand-name drug, you can expect the generic to produce the same clinical effect and
safety profile as the brand-name drug.
DRUG EFFICACY STUDY IMPLEMENTATION DRUGS

Drugs first marketed between 1938 and 1962 were approved as safe but required no showing of effectiveness for FDA approval.
Since 1962, all new drugs are required to be both safe and effective before they can be marketed. The legislation that resulted in
this change also applies retroactively to all drugs approved as safe from 1938-1962. The Drug Efficacy Study Implementation
(DESI) program was established by the FDA to review the effectiveness of these pre-1962 drugs for their labeled indications, and
a determination of fully effective was made for most of these products and they remain in the marketplace. A few DESI products
remain classified as "less than fully effective" while awaiting final administrative disposition. Also classified as DESI are many
products listed as identical, similar, or related to actual DESI products.
EDITOR
Your comments and suggestions regarding this FEP 5 Tier Rx Drug Formulary are encouraged. Your input is vital to this
formulary's continued success. All responses will be reviewed and considered. Please send your comments to:
FEP Rx Drug Formulary - MC 145

P.O. Box 52115
Phoenix, AZ 85072-2115
NOTICE
The information contained in this FEP 5 Tier Rx Drug Formulary and its appendices is provided by FEP, solely for the
convenience of medical providers. FEP does not warrant or assure accuracy of such information nor is it intended to be
comprehensive in nature. The FEP 5 Tier Rx Drug Formulary is not a complete list of all covered medications. This FEP 5 Tier
Rx Drug Formulary is not intended to be a substitute for the knowledge, expertise, skill and judgment of the medical provider in
his or her choice of prescription drugs. FEP assumes no responsibility for the actions or omissions of any medical provider based
upon reliance, in whole or in part, on the information contained herein. The medical provider should consult the drug
manufacturer's product literature or standard references for more detailed information.
The information contained in this document is proprietary. The information may not be copied in whole or in part without the
written permission of FEP. ©2022. All rights reserved.
This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of
pharmaceutical manufacturers not affiliated with FEP.
If viewing this formulary via Internet, please be advised that the formulary is updated periodically and changes may
appear prior to their effective date.
LEGEND
† Generic contraceptives are covered at no charge to qualifying members
‡ Medication is covered at no charge to the member
d DESI drug
OTC Over the counter
PA Prior Approval
PA/ST Prior Approval with Step Therapy
QL Quantity Limitations - quantity allowed before prior approval is required. Quantity limits apply for
both brands and generics
ST Step Therapy - indicates the requirement for previous use of one or more drugs before coverage is
provided for the targeted drug
boldface Indicates generic availability; boldface may not apply to every strength or dosage form under the
listed generic name
delayed-rel Delayed-release (also known as enteric-coated), refer to the reference brand listed for clarification
ext-rel Extended-release (also known as sustained-release), refer to the reference brand listed for
clarification
8
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ANALGESICS
Practice guidelines of pain management are available at:
https://www.asahq.org
ANALGESICS, OTHER
Treatment recommendations for osteoarthritis are available at:
https://www.rheumatology.org
acetaminophen inj Tier 1 OFIRMEV Tier 3
COX-2 INHIBITORS
QL celecoxib Tier 1 CELEBREX Tier 3
PA celecoxib oral solution ELYXYB Tier 3
GOUT
allopurinol Tier 1 ZYLOPRIM Tier 3
colchicine Tier 1 COLCRYS Tier 3
colchicine Tier 1 MITIGARE Tier 3
PA febuxostat Tier 1 ULORIC Tier 3
probenecid Tier 1
PA pegloticase KRYSTEXXA Tier 5
NSAIDs
diclofenac sodium delayed/ext-rel Tier 1
diflunisal Tier 1
etodolac Tier 1
etodolac ext-rel Tier 1
flurbiprofen Tier 1
ibuprofen Tier 1
indomethacin (except caps 20 mg, 40 mg) Tier 1
indomethacin ext-rel Tier 1
ketoprofen Tier 1
ketoprofen ext-rel Tier 1
ketorolac Tier 1
meloxicam tabs Tier 1
nabumetone Tier 1
naproxen Tier 1 NAPROSYN Tier 3
naproxen sodium Tier 1
oxaprozin Tier 1 DAYPRO Tier 3
piroxicam Tier 1 FELDENE Tier 3
sulindac Tier 1
ibuprofen inj CALDOLOR Tier 2
PA ketorolac tromethamine nasal spray SPRIX Tier 3
NSAIDs, COMBINATIONS
diclofenac sodium delayed-rel/misoprostol Tier 1 ARTHROTEC Tier 3
NSAIDs, TOPICAL
QL diclofenac sodium gel 1% Tier 1
diclofenac sodium soln (except 2% soln) Tier 1
diclofenac epolamine patch LICART Tier 3
diclofenac epolamine patch FLECTOR Tier 3
OPIOID ANALGESICS
Practice Guidelines for Cancer Pain Management (includes WHO analgesic ladder) are available at:
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https://www.nccn.org
Opioid guidelines in the management of chronic non-malignant pain are available at:
https://www.asipp.org/ASIPP-Guidelines.html
QL buprenorphine transdermal Tier 1 BUTRANS Tier 3

QL butalbital/acetaminophen/caffeine/codeine Tier 1 FIORICET w/CODEINE Tier 3
QL butalbital/aspirin/caffeine/codeine Tier 1
QL butorphanol nasal spray Tier 1
QL codeine/acetaminophen Tier 1
PA fentanyl citrate buccal Tier 1 FENTORA Tier 3
QL fentanyl transdermal Tier 1 DURAGESIC Tier 3
PA fentanyl transmucosal lozenge Tier 1 ACTIQ Tier 3
PA hydrocodone ext-rel caps Tier 1
QL hydrocodone/acetaminophen Tier 1
QL hydromorphone Tier 1 DILAUDID Tier 3
QL hydromorphone ext-rel Tier 1
QL methadone Tier 1
QL morphine Tier 1
QL morphine ext-rel Tier 1
QL morphine ext-rel Tier 1 MS CONTIN Tier 3
QL morphine supp Tier 1
QL oxycodone Tier 1 ROXICODONE Tier 3
QL oxycodone concentrate 20 mg/mL Tier 1
QL oxycodone soln Tier 1
QL oxycodone/acetaminophen 5/325 Tier 1 PERCOCET Tier 3
QL oxymorphone Tier 1 OPANA Tier 3
QL tramadol (except 100 mg tabs) Tier 1 ULTRAM Tier 3
QL tramadol ext-rel Tier 1 ULTRAM ER Tier 3
QL tramadol/acetaminophen Tier 1
QL morphine/naltrexone ext-rel EMBEDA Tier 2
QL oxycodone ext-rel XTAMPZA ER Tier 2
QL tapentadol NUCYNTA Tier 2
QL tapentadol ext-rel NUCYNTA ER Tier 2
QL buprenorphine BELBUCA Tier 3
PA celecoxib/tramadol tabs SEGLENTIS Tier 3
PA fentanyl sublingual spray SUBSYS Tier 3
PA hydrocodone ext-rel tabs HYSINGLA ER Tier 3
QL morphine ext-rel MORPHABOND Tier 3
QL oxycodone ext-rel OXYCONTIN Tier 3
QL tramadol oral solution QDOLO Tier 3
NON-OPIOID ANALGESICS
QL butalbital/acetaminophen Tier 1
QL butalbital/acetaminophen/caffeine Tier 1 FIORICET Tier 3
QL butalbital/aspirin/caffeine Tier 1 FIORINAL Tier 3
ziconotide PRIALT Tier 4
VISCOSUPPLEMENTS
PA sodium hyaluronate GEL-ONE Tier 4
PA sodium hyaluronate GELSYN-3 Tier 4
PA sodium hyaluronate HYALGAN Tier 4
PA sodium hyaluronate SUPARTZ FX Tier 4
PA high molecular weight hyaluronan HYMOVIS Tier 5
PA high molecular weight hyaluronan ORTHOVISC Tier 5
PA hyaluronate sodium TRIVISC Tier 5
11
PA hylan G-F 20 SYNVISC Tier 5
PA hylan G-F 20 SYNVISC-ONE Tier 5
PA sodium hyaluronate DUROLANE Tier 5
PA sodium hyaluronate EUFLEXXA Tier 5
PA sodium hyaluronate MONOVISC Tier 5
ANTI-INFECTIVES
Practice guidelines and statements developed and endorsed by the Infectious Diseases Society of America are available at:
https://www.idsociety.org
Hepatitis: CDC recommendations on the treatment of hepatitis are available at:

https://www.cdc.gov/hepatitis/Resources/
Guidelines for the management of chronic hepatitis by the American Association for the Study of Liver Disease are available at:
https://www.aasld.org
HIV/AIDS: Guidelines for the treatment of HIV patients by the U.S. Department of Health and Human Services are available at:
https://www.aidsinfo.nih.gov
Infective Endocarditis: American Heart Association recommendations for the prevention of bacterial endocarditis are available at:
https://professional.heart.org
Influenza: Recommendations of the Advisory Committee on Immunization Practices are available at:
https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/flu.html
International Travel: CDC recommendations for international travel are available at:
https://wwwnc.cdc.gov/travel
Respiratory Tract Infection/Antibiotic Use/Community Acquired Pneumonia/Other: Principles of appropriate antibiotic use for
treatment of nonspecific upper respiratory tract infection in adults are available at:
https://www.cdc.gov/pneumonia/management-prevention-guidelines.html
Sexually Transmitted Diseases: CDC Sexually Transmitted Diseases Guidelines are available at:
https://www.cdc.gov/std/treatment/default.htm
ANTIBACTERIALS
Cephalosporins
First Generation
cephalexin Tier 1
Second Generation
cefaclor Tier 1
cefoxitin Tier 1
cefprozil Tier 1
cefuroxime axetil Tier 1
Third Generation
cefdinir Tier 1
cefixime caps, susp 100 mg/5 mL, 200 mg/5 mL Tier 1 SUPRAX Tier 2
QL cefotaxime Tier 1
cefpodoxime Tier 1
ceftazidime Tier 1
QL ceftriaxone Tier 1 ROCEPHIN Tier 3
Fourth Generation
cefepime Tier 1
12
Fifth Generation
ceftaroline fosamil TEFLARO Tier 2
Erythromycins/Macrolides
azithromycin Tier 1 ZITHROMAX Tier 3
clarithromycin Tier 1
clarithromycin ext-rel Tier 1
erythromycin delayed-rel Tier 1
erythromycin delayed-rel - Ery-tab Tier 1
erythromycin ethylsuccinate Tier 1 ERYPED Tier 3
erythromycin stearate Tier 1
fidaxomicin DIFICID Tier 2
Fluoroquinolones
ciprofloxacin Tier 1 CIPRO Tier 3
levofloxacin Tier 1 LEVAQUIN Tier 3
ofloxacin Tier 1
Penicillins
amoxicillin, except film-coated tabs Tier 1
amoxicillin/clavulanate Tier 1 AUGMENTIN Tier 3
amoxicillin/clavulanate ext-rel Tier 1
amoxicillin/clavulanate susp 600 mg Tier 1
ampicillin Tier 1
ampicillin sodium/sulbactam sodium Tier 1 UNASYN Tier 3
dicloxacillin Tier 1
penicillin VK Tier 1
piperacillin/tazobactam Tier 1 ZOSYN Tier 3
Tetracyclines
doxycycline hyclate Tier 1 VIBRAMYCIN Tier 3
doxycycline hyclate delayed-rel tabs Tier 1 DORYX/MPC Tier 3
doxycycline monohydrate Tier 1
minocycline Tier 1 MINOCIN Tier 3
minocycline ext-rel Tier 1 SOLODYN Tier 3
tetracycline Tier 1
QL omadacycline NUZYRA Tier 3
sarecycline SEYSARA Tier 3
Miscellaneous
QL lefamulin XENLETA Tier 3
QL rifamycin delayed-rel AEMCOLO Tier 3
ANTIFUNGALS
clotrimazole troches Tier 1
fluconazole Tier 1 DIFLUCAN Tier 3
griseofulvin microsize Tier 1
griseofulvin ultramicrosize Tier 1
PA itraconazole Tier 1 SPORANOX Tier 3
PA ketoconazole tabs Tier 1
micafungin Tier 1
nystatin Tier 1
PA posaconazole delayed-rel tabs Tier 1 NOXAFIL tabs Tier 3
terbinafine tabs Tier 1
QL voriconazole Tier 1 VFEND Tier 3
13
amphotericin B lipid complex inj ABELCET Tier 2
amphotericin B liposome inj AMBISOME Tier 2
anidulafungin ERAXIS Tier 2
PA posaconazole susp NOXAFIL susp Tier 2
PA ibrexafungerp tabs BREXAFEMME Tier 3
PA isavuconazonium CRESEMBA Tier 3
ANTIMALARIALS
atovaquone/proguanil Tier 1 MALARONE Tier 3
chloroquine Tier 1
mefloquine Tier 1
primaquine Tier 1
PA pyrimethamine Tier 1 DARAPRIM Tier 3
artemether/lumefantrine COARTEM Tier 2
tafenoquine ARAKODA Tier 3
tafenoquine KRINTAFEL Tier 3
ANTIRETROVIRAL AGENTS
Antiretroviral Adjuvants
cobicistat TYBOST Tier 2
Antiretroviral Combinations
abacavir/lamivudine Tier 1 EPZICOM Tier 3
abacavir/lamivudine/zidovudine Tier 1 TRIZIVIR Tier 3
efavirenz/emtricitabine/tenofovir disoproxil fumarate Tier 1
efavirenz/lamivudine/tenofovir disoproxil fumarate Tier 1 SYMFI Tier 3
efavirenz/lamivudine/tenofovir disoproxil fumarate Tier 1 SYMFI LO Tier 3
emtricitabine/tenofovir disoproxil fumarate Tier 1 TRUVADA Tier 3
lamivudine/zidovudine Tier 1 COMBIVIR Tier 3
abacavir/dolutegravir/lamivudine TRIUMEQ Tier 2
atazanavir/cobicistat EVOTAZ Tier 2
bictegravir/emtricitabine/tenofovir alafenamide BIKTARVY Tier 2
darunavir/cobicistat PREZCOBIX Tier 2
darunavir/cobicistat/emtricitabine/tenofovir alafenamide SYMTUZA Tier 2
dolutegravir/lamivudine DOVATO Tier 2
doravirine/lamivudine/tenofovir disoproxil fumarate DELSTRIGO Tier 2
elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide GENVOYA Tier 2
elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate STRIBILD Tier 2
emtricitabine/rilpivirine/tenofovir alafenamide ODEFSEY Tier 2
emtricitabine/rilpivirine/tenofovir disoproxil fumarate COMPLERA Tier 2
emtricitabine/tenofovir alafenamide DESCOVY Tier 2
dolutegravir/rilpivirine JULUCA Tier 3
lamivudine/tenofovir disoproxil fumarate CIMDUO Tier 3
Chemokine Receptor Antagonists

maraviroc Tier 1 SELZENTRY Tier 2
Fusion Inhibitors
enfuvirtide FUZEON Tier 4
Gp120-Directed Attachment Inhibitors

fostemsavir ext-rel RUKOBIA Tier 2
Integrase Inhibitors
dolutegravir TIVICAY Tier 2
raltegravir ISENTRESS Tier 2
14
Monoclonal Antibody
PA ibalizumab-uiyk TROGARZO Tier 4
Non-nucleoside Reverse Transcriptase Inhibitors

efavirenz Tier 1 SUSTIVA Tier 3
etravirine tabs 100 mg, 200 mg Tier 1 INTELENCE TABS 100 mg, 200 Tier 3
mg
nevirapine Tier 1
nevirapine ext-rel Tier 1
etravirine INTELENCE tabs 25 mg Tier 2
rilpivirine EDURANT Tier 2
doravirine PIFELTRO Tier 3
Nucleoside Reverse Transcriptase Inhibitors

abacavir Tier 1 ZIAGEN Tier 3
abacavir soln Tier 1 ZIAGEN soln Tier 3
emtricitabine caps Tier 1 EMTRIVA Tier 2
lamivudine Tier 1 EPIVIR Tier 3
stavudine Tier 1
zidovudine Tier 1 RETROVIR Tier 3
Nucleotide Reverse Transcriptase Inhibitors

tenofovir disoproxil fumarate tabs 300 mg Tier 1 VIREAD Tier 2
Protease Inhibitors
atazanavir caps Tier 1 REYATAZ Tier 3
fosamprenavir Tier 1 LEXIVA Tier 3
lopinavir/ritonavir Tier 1 KALETRA Tier 3
ritonavir tabs Tier 1 NORVIR Tier 2
darunavir PREZISTA Tier 2
nelfinavir VIRACEPT Tier 2
tipranavir APTIVUS Tier 2
ANTITUBERCULAR AGENTS
ethambutol Tier 1 MYAMBUTOL Tier 3
isoniazid Tier 1
pyrazinamide Tier 1
rifampin Tier 1
pretomanid tabs PRETOMANID Tier 2
rifampin/isoniazid/pyrazinamide RIFATER Tier 2
rifapentine PRIFTIN Tier 2
bedaquiline SIRTURO Tier 3
ANTIVIRALS
Cytomegalovirus Agents
cidofovir Tier 1 VISTIDE Tier 3
PA valganciclovir Tier 1 VALCYTE Tier 3
ganciclovir inj Tier 4
PA maribavir LIVTENCITY Tier 3
cytomegalovirus immune globulin CYTOGAM Tier 4
PA letermovir PREVYMIS Tier 4
Hepatitis Agents
Hepatitis B
lamivudine Tier 1 EPIVIR-HBV Tier 3
15
PA, * adefovir dipivoxil Tier 4 HEPSERA Tier 5
PA, * entecavir tabs Tier 4 BARACLUDE Tier 5
entecavir soln BARACLUDE soln Tier 4
telbivudine TYZEKA Tier 4
tenofovir alafenamide VEMLIDY Tier 4
* Brand requires prior approval
Hepatitis C
PA ledipasvir/sofosbuvir Tier 4 HARVONI Tier 4
PA ribavirin caps Tier 4
PA ribavirin caps - Ribasphere Tier 4
PA ribavirin tabs Tier 4
PA sofosbuvir/velpatasvir Tier 4 EPCLUSA Tier 4
PA glecaprevir/pibrentasvir MAVYRET Tier 4
PA sofosbuvir SOVALDI Tier 4
PA sofosbuvir/velpatasvir/voxilaprevir VOSEVI Tier 4
PA elbasvir/grazoprevir ZEPATIER Tier 5
Herpes Agents
acyclovir caps, susp, tabs Tier 1 ZOVIRAX Tier 3
famciclovir Tier 1
valacyclovir Tier 1 VALTREX Tier 3
Influenza Agents
QL oseltamivir Tier 1 TAMIFLU Tier 3
rimantadine Tier 1
QL zanamivir RELENZA Tier 2
QL baloxavir XOFLUZA Tier 3
Respiratory Syncytial Virus Agents

PA palivizumab SYNAGIS Tier 4
MISCELLANEOUS
PA albendazole Tier 1
atovaquone Tier 1 MEPRON Tier 3
aztreonam Tier 1 AZACTAM Tier 3
clindamycin Tier 1 CLEOCIN Tier 3
QL dapsone Tier 1 ACZONE Tier 3
daptomycin 500 mg Tier 1 CUBICIN Tier 3
ertapenem Tier 1 INVANZ Tier 3
imipenem/cilastatin Tier 1 PRIMAXIN Tier 3
QL linezolid Tier 1 ZYVOX Tier 3
meropenem Tier 1
methenamine hippurate, prophylaxis Tier 1
metronidazole tabs Tier 1 FLAGYL Tier 3
nitazoxanide tabs Tier 1 ALINIA Tier 2
nitrofurantoin ext-rel Tier 1 MACROBID Tier 3
nitrofurantoin macrocrystals Tier 1 MACRODANTIN Tier 3
rifabutin Tier 1 MYCOBUTIN Tier 3
sulfamethoxazole/trimethoprim Tier 1
sulfamethoxazole/trimethoprim DS Tier 1
tigecycline Tier 1 TYGACIL Tier 3
tinidazole Tier 1
trimethoprim Tier 1
16
vancomycin caps Tier 1 VANCOCIN Tier 3
PA mebendazole EMVERM Tier 2
miltefosine IMPAVIDO Tier 2
QL rifaximin XIFAXAN Tier 2
vancomycin oral soln FIRVANQ Tier 2
nifurtimox LAMPIT Tier 3
secnidazole SOLOSEC Tier 3
QL tedizolid SIVEXTRO Tier 3
telavancin VIBATIV Tier 3
ANTINEOPLASTIC AGENTS
Clinical practice guidelines in oncology are available at:
https://www.asco.org
https://www.nccn.org
ALKYLATING AGENTS
busulfan Tier 1 BUSULFEX Tier 2
ifosfamide/mesna Tier 1
carmustine Tier 4 BICNU Tier 5
cyclophosphamide caps Tier 4 CYCLOPHOSPHAMIDE Tier 4
CAPSULES
cyclophosphamide inj Tier 4
dacarbazine Tier 4
melphalan inj Tier 4 ALKERAN inj Tier 5
melphalan tabs Tier 4 ALKERAN tabs Tier 5
PA, * temozolomide caps Tier 4 TEMODAR caps Tier 5
thiotepa Tier 4 TEPADINA Tier 5
busulfan MYLERAN Tier 2
chlorambucil LEUKERAN Tier 2
lomustine GLEOSTINE Tier 2
PA mechlorethamine gel VALCHLOR Tier 4
streptozocin ZANOSAR Tier 4
PA trabectedin YONDELIS Tier 4
PA bendamustine BELRAPZO Tier 5
PA bendamustine TREANDA Tier 5
PA lurbinectedin ZEPZELCA Tier 5
temozolomide inj TEMODAR inj Tier 5
* Brand TEMODAR caps requires prior approval
ANTIMETABOLITES
mercaptopurine Tier 1
PA, * capecitabine Tier 4 XELODA Tier 5
cladribine Tier 4
clofarabine Tier 4 CLOLAR Tier 5
cytarabine Tier 4
floxuridine Tier 4
fludarabine Tier 4
fluorouracil inj Tier 4
gemcitabine inj Tier 4 GEMCITABINE Tier 4
thioguanine TABLOID Tier 2
pentostatin NIPENT Tier 4
pralatrexate FOLOTYN Tier 4
rasburicase ELITEK Tier 4
PA azacitidine ONUREG Tier 5
17
mercaptopurine susp PURIXAN Tier 5
* Brand XELODA requires prior approval
HORMONAL ANTINEOPLASTIC AGENTS

Antiandrogens
bicalutamide Tier 1 CASODEX Tier 3
flutamide Tier 1
PA nilutamide Tier 1 NILANDRON Tier 3
PA abiraterone Tier 4 ZYTIGA Tier 5
PA enzalutamide XTANDI Tier 4
PA abiraterone YONSA Tier 5
PA apalutamide ERLEADA Tier 5
PA darolutamide NUBEQA Tier 5
Antiestrogens
tamoxifen Tier 1
toremifene Tier 1 FARESTON Tier 3
PA, * fulvestrant Tier 4 FASLODEX Tier 5
*Brand FASLODEX requires prior approval
Aromatase Inhibitors
anastrozole Tier 1 ARIMIDEX Tier 3
exemestane Tier 1 AROMASIN Tier 3
letrozole Tier 1 FEMARA Tier 3
Gonadotropin-Releasing Hormone (GnRH) Antagonists

PA degarelix acetate FIRMAGON Tier 4
PA relugolix ORGOVYX Tier 5
Luteinizing Hormone-Releasing Hormone (LHRH) Agonists

PA leuprolide acetate Tier 4
PA goserelin acetate ZOLADEX Tier 4
PA leuprolide acetate ELIGARD Tier 4
PA leuprolide acetate LUPRON DEPOT Tier 4
PA triptorelin pamoate TRELSTAR Tier 4
PA triptorelin pamoate TRELSTAR DEPOT Tier 4
PA triptorelin pamoate TRELSTAR LA Tier 4
PA leuprolide acetate FENSOLVI Tier 5
Progestins
megestrol acetate Tier 1
IMMUNOMODULATORS
PA pembrolizumab KEYTRUDA Tier 4
PA nivolumab-relatlimab-rmbw OPDUALAG Tier 5
PA pomalidomide POMALYST Tier 5
KINASE INHIBITORS
PA erlotinib Tier 4
PA everolimus Tier 4 AFINITOR Tier 5
PA everolimus tabs for oral suspension Tier 4 AFINITOR DISPERZ Tier 5
PA imatinib mesylate Tier 4 GLEEVEC Tier 5
PA lapatinib Tier 4 TYKERB Tier 5
PA sorafenib Tier 4 NEXAVAR Tier 5
18
PA sunitinib Tier 4 SUTENT Tier 5
temsirolimus Tier 4 TORISEL Tier 5
PA abemaciclib VERZENIO Tier 4
PA acalabrutinib CALQUENCE Tier 4
PA afatinib GILOTRIF Tier 4
PA alpelisib PIQRAY Tier 4
PA axitinib INLYTA Tier 4
PA bosutinib BOSULIF Tier 4
PA cabozantinib CABOMETYX Tier 4
PA cabozantinib COMETRIQ Tier 4
PA capmatinib TABRECTA Tier 4
PA ceritinib ZYKADIA Tier 4
PA cobimetinib COTELLIC Tier 4
PA crizotinib XALKORI Tier 4
PA dabrafenib TAFINLAR Tier 4
PA dasatinib SPRYCEL Tier 4
PA entrectinib ROZLYTREK Tier 4
PA erdafitinib BALVERSA Tier 4
PA ibrutinib IMBRUVICA Tier 4
PA idelalisib ZYDELIG Tier 4
PA larotrectinib VITRAKVI Tier 4
PA lenvatinib LENVIMA Tier 4
PA midostaurin RYDAPT Tier 4
PA palbociclib IBRANCE Tier 4
PA pazopanib VOTRIENT Tier 4
PA pexidartinib TURALIO Tier 4
PA ponatinib ICLUSIG Tier 4
PA regorafenib STIVARGA Tier 4
PA ribociclib KISQALI Tier 4
PA ribociclib + letrozole KISQALI FEMARA CO-PACK Tier 4
PA ruxolitinib JAKAFI Tier 4
PA selpercatinib RETEVMO Tier 4
PA selumetinib KOSELUGO Tier 4
PA trametinib MEKINIST Tier 4
PA vandetanib CAPRELSA Tier 4
PA vemurafenib ZELBORAF Tier 4
PA alectinib ALECENSA Tier 5
PA alpelisib VIJOICE Tier 5
PA asciminib hcl SCEMBLIX Tier 5
PA avapritinib AYVAKIT Tier 5
PA binimetinib MEKTOVI Tier 5
PA brigatinib ALUNBRIG Tier 5
PA dacomitinib VIZIMPRO Tier 5
PA duvelisib COPIKTRA Tier 5
PA encorafenib BRAFTOVI Tier 5
PA fedratinib INREBIC Tier 5
PA gefitinib IRESSA Tier 5
PA gilteritinib XOSPATA Tier 5
PA lorlatinib LORBRENA Tier 5
PA neratinib NERLYNX Tier 5
PA nilotinib TASIGNA Tier 5
PA osimertinib TAGRISSO Tier 5
PA pacritinib VONJO Tier 5
PA pemigatinib PEMAZYRE Tier 5
PA pralsetinib GAVRETO Tier 5
PA ripretinib QINLOCK Tier 5
19
PA tazemetostat TAZVERIK Tier 5
PA tepotinib TEPMETKO Tier 5
PA tivozanib FOTIVDA Tier 5
PA tucatinib TUKYSA Tier 5
PA zanubrutinib BRUKINSA Tier 5
MULTIPLE MYELOMA
Immunomodulators
PA lenalidomide Tier 4 REVLIMID Tier 4
PA thalidomide THALOMID Tier 4
PA isatuximab-irfc SARCLISA Tier 5
Proteasome Inhibitors
PA bortezomib Tier 4 VELCADE Tier 5
PA ixazomib NINLARO Tier 4
TOPOISOMERASE INHIBITORS
topotecan inj Tier 4 HYCAMTIN inj Tier 5
topotecan HYCAMTIN Tier 4
PA irinotecan liposome inj ONIVYDE Tier 5
MISCELLANEOUS
hydroxyurea Tier 1 HYDREA Tier 3
leucovorin calcium Tier 1
amifostine Tier 4 ETHYOL Tier 5
arsenic trioxide Tier 4 TRISENOX Tier 5
azacitidine Tier 4 VIDAZA Tier 5
PA bexarotene caps Tier 4 TARGRETIN caps Tier 5
PA bexarotene gel Tier 4 TARGRETIN gel Tier 5
bleomycin sulfate Tier 4
carboplatin Tier 4
cisplatin Tier 4
dactinomycin Tier 4 COSMEGEN Tier 5
daunorubicin Tier 4
decitabine Tier 4 DACOGEN Tier 5
dexrazoxane Tier 4
dexrazoxane Tier 4 TOTECT Tier 5
docetaxel Tier 4
doxorubicin Tier 4 ADRIAMYCIN Tier 5
doxorubicin liposomal Tier 4 DOXIL Tier 5
etoposide Tier 4
idarubicin Tier 4 IDAMYCIN PFS Tier 5
ifosfamide Tier 4 IFEX Tier 5
irinotecan Tier 4 CAMPTOSAR Tier 5
levoleucovorin calcium Tier 4
mesna inj Tier 4 MESNEX inj Tier 5
mitomycin Tier 4
mitoxantrone Tier 4
nelarabine Tier 4 ARRANON Tier 5
oxaliplatin Tier 4
paclitaxel Tier 4
paclitaxel protein-bound particles Tier 4 ABRAXANE Tier 5
PA romidepsin Tier 4 ISTODAX Tier 5
valrubicin Tier 4 VALSTAR Tier 5
vinblastine Tier 4
vincristine Tier 4
20
vinorelbine Tier 4
PA mitotane LYSODREN Tier 2
PA ado-trastuzumab emtansine KADCYLA Tier 4
aldesleukin PROLEUKIN Tier 4
asparaginase ELSPAR Tier 4
PA atezolizumab TECENTRIQ Tier 4
BCG live vaccine TICE BCG Tier 4
PA belinostat BELEODAQ Tier 4
PA bendamustine BENDEKA Tier 4
PA bevacizumab-awwb MVASI Tier 4
PA bevacizumab-bvzr ZIRABEV Tier 4
PA blinatumomab BLINCYTO Tier 4
PA brentuximab vedotin ADCETRIS Tier 4
PA cabazitaxel JEVTANA Tier 4
PA cetuximab ERBITUX Tier 4
PA daratumumab DARZALEX Tier 4
PA decitabine-cedazuridine INQOVI Tier 4
PA elotuzumab EMPLICITI Tier 4
PA eribulin HALAVEN Tier 4
etoposide phosphate ETOPOPHOS Tier 4
glucarpidase VORAXAZE Tier 4
PA ipilimumab YERVOY Tier 4
ixabepilone IXEMPRA Tier 4
mesna tabs 400 mg MESNEX Tier 4
PA necitumumab PORTRAZZA Tier 4
PA niraparib ZEJULA Tier 4
PA nivolumab OPDIVO Tier 4
PA obinutuzumab GAZYVA Tier 4
PA ofatumumab ARZERRA Tier 4
PA olaparib LYNPARZA Tier 4
PA omacetaxine mepesuccinate SYNRIBO Tier 4
PA panitumumab VECTIBIX Tier 4
PA pertuzumab PERJETA Tier 4
PA pertuzumab/trastuzumab/hyaluronidase-zzxf PHESGO Tier 4
procarbazine MATULANE Tier 4
PA rituximab-abbs TRUXIMA Tier 4
PA rituximab-arrx RIABNI Tier 4
PA rituximab-pvvr RUXIENCE Tier 4
PA rucaparib RUBRACA Tier 4
PA talazoparib TALZENNA Tier 4
PA talimogene laherparepvec IMLYGIC Tier 4
PA trastuzumab-anns KANJINTI Tier 4
PA trastuzumab-dkst OGIVRI Tier 4
PA trastuzumab-dttb ONTRUZANT Tier 4
PA trastuzumab-pkrb HERZUMA Tier 4
PA trastuzumab-qyyp TRAZIMERA Tier 4
PA venetoclax VENCLEXTA Tier 4
PA vismodegib ERIVEDGE Tier 4
PA vorinostat ZOLINZA Tier 4
PA ziv-aflibercept ZALTRAP Tier 4
PA avelumab BAVENCIO Tier 5
PA bevacizumab AVASTIN Tier 5
PA carfilzomib KYPROLIS Tier 5
PA daratumumab/hyaluronidase-fihj DARZALEX FASPRO Tier 5
PA durvalumab IMFINZI Tier 5
PA enasidenib IDHIFA Tier 5
21
PA enfortumab vedotin-ejfv PADCEV Tier 5
epirubicin ELLENCE Tier 5
PA fam-trastuzumab deruxtecan-nxki ENHERTU Tier 5
PA gemtuzumab ozogamicin MYLOTARG Tier 5
PA glasdegib DAURISMO Tier 5
PA hydroxyurea SIKLOS Tier 5
PA inotuzumab ozogamicin BESPONSA Tier 5
PA ivosidenib TIBSOVO Tier 5
levoleucovorin KHAPZORY Tier 5
PA melphalan EVOMELA Tier 5
PA mogamulizumab-kpkc POTELIGEO Tier 5
PA moxetumomab pasudotox-tdfk LUMOXITI Tier 5
PA panobinostat FARYDAK Tier 5
PA ramucirumab CYRAMZA Tier 5
PA rituximab RITUXAN Tier 5
PA rituximab/hyaluronidase human RITUXAN HYCELA Tier 5
PA sacituzumab govitecan-hziy TRODELVY Tier 5
PA selinexor XPOVIO Tier 5
PA sonidegib ODOMZO Tier 5
PA trastuzumab HERCEPTIN Tier 5
PA trastuzumab/hyaluronidase-oysk HERCEPTIN HYLECTA Tier 5
PA trifluridine/tipiracil LONSURF Tier 5
CARDIOVASCULAR
The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure is available
at:
https://jamanetwork.com/journals/jama/fullarticle/1791497
Guidelines for the evaluation and management of cardiovascular diseases in adults are available at:
https://www.acc.org
ACE INHIBITORS
Guidelines for the use of ACE inhibitors are available at:
https://professional.diabetes.org
https://www.acc.org
benazepril Tier 1 LOTENSIN Tier 3

enalapril Tier 1 VASOTEC Tier 3
enalapril oral soln Tier 1 EPANED Tier 3
fosinopril Tier 1
lisinopril Tier 1
lisinopril Tier 1 ZESTRIL Tier 3
perindopril Tier 1
quinapril Tier 1 ACCUPRIL Tier 3
ramipril Tier 1 ALTACE Tier 3
trandolapril Tier 1
lisinopril oral soln QBRELIS Tier 3
ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS

benazepril/amlodipine Tier 1 LOTREL Tier 3
trandolapril/verapamil ext-rel Tier 1
perindopril arginine/amlodipine PRESTALIA Tier 3
22
ACE INHIBITOR/DIURETIC COMBINATIONS
benazepril/hydrochlorothiazide Tier 1 LOTENSIN HCT Tier 3
enalapril/hydrochlorothiazide Tier 1 VASERETIC Tier 3
fosinopril/hydrochlorothiazide Tier 1
lisinopril/hydrochlorothiazide Tier 1 ZESTORETIC Tier 3
quinapril/hydrochlorothiazide Tier 1 ACCURETIC Tier 3
ADRENOLYTICS, CENTRAL
clonidine Tier 1
clonidine transdermal Tier 1 CATAPRES-TTS Tier 3
ALDOSTERONE RECEPTOR ANTAGONISTS

eplerenone Tier 1 INSPRA Tier 3
spironolactone Tier 1 ALDACTONE Tier 3
ALPHA BLOCKERS
Guidelines for the use of alpha blockers in various patient populations are available at:
doxazosin Tier 1 CARDURA Tier 3

prazosin Tier 1 MINIPRESS Tier 3
terazosin Tier 1
ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS

Guidelines for the use of angiotensin II receptor antagonists in various patient populations are available at:
candesartan Tier 1 ATACAND Tier 3

candesartan/hydrochlorothiazide Tier 1 ATACAND HCT Tier 3
irbesartan Tier 1 AVAPRO Tier 3
irbesartan/hydrochlorothiazide Tier 1 AVALIDE Tier 3
losartan Tier 1 COZAAR Tier 3
losartan/hydrochlorothiazide Tier 1 HYZAAR Tier 3
olmesartan Tier 1 BENICAR Tier 3
olmesartan/hydrochlorothiazide Tier 1 BENICAR HCT Tier 3
telmisartan Tier 1 MICARDIS Tier 3
telmisartan/hydrochlorothiazide Tier 1 MICARDIS HCT Tier 3
valsartan Tier 1 DIOVAN Tier 3
valsartan/hydrochlorothiazide Tier 1 DIOVAN HCT Tier 3
azilsartan EDARBI Tier 3
azilsartan/chlorthalidone EDARBYCLOR Tier 3
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS

amlodipine/olmesartan Tier 1 AZOR Tier 3
amlodipine/telmisartan Tier 1
amlodipine/valsartan Tier 1 EXFORGE Tier 3
ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS

amlodipine/valsartan/hydrochlorothiazide EXFORGE HCT Tier 3
olmesartan/amlodipine/hydrochlorothiazide Tier 1 TRIBENZOR Tier 3
ANTIARRHYTHMICS
Guidelines for the use of antiarrhythmics and cardiac glycosides in various patient populations are available at:
https://www.acc.org
23
amiodarone Tier 1
disopyramide Tier 1 NORPACE Tier 3
flecainide Tier 1
mexiletine Tier 1
propafenone ext-rel Tier 1 RYTHMOL SR Tier 3
quinidine gluconate ext-rel Tier 1
sotalol Tier 1
sotalol AF Tier 1
PA, * dofetilide Tier 4 TIKOSYN Tier 5
disopyramide ext-rel NORPACE CR Tier 2
dronedarone MULTAQ Tier 2
* Brand TIKOSYN requires prior approval
ANTILIPEMICS
The 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol
is available at:
https://www.ahajournals.org/doi/10.1161/CIR.0000000000000625
ACL Inhibitor/Combinations
PA bempedoic acid NEXLETOL Tier 3
PA bempedoic acid/ezetimibe NEXLIZET Tier 3
Bile Acid Resins

cholestyramine pkt Tier 1 QUESTRAN/QUESTRAN LIGHT Tier 3
colesevelam Tier 1 WELCHOL Tier 3
colestipol Tier 1 COLESTID Tier 3
Cholesterol Absorption Inhibitors

ezetimibe Tier 1 ZETIA Tier 3
Fibrates
fenofibrate Tier 1 ANTARA Tier 3
fenofibrate Tier 1 LIPOFEN Tier 3
fenofibrate Tier 1 TRICOR Tier 3
fenofibric acid delayed-rel Tier 1 TRILIPIX Tier 3
gemfibrozil Tier 1 LOPID Tier 3
HMG-CoA Reductase Inhibitors/Combinations

‡, * atorvastatin Tier 1 LIPITOR Tier 3
ezetimibe/simvastatin Tier 1 VYTORIN Tier 3
‡, * fluvastatin Tier 1
‡, * fluvastatin ext-rel Tier 1 LESCOL XL Tier 3
‡, * lovastatin Tier 1
‡, * pravastatin Tier 1
‡, * rosuvastatin Tier 1 CRESTOR Tier 3
‡, * simvastatin Tier 1 ZOCOR Tier 3
ezetimibe/rosuvastatin ROSZET Tier 3
ezetimibe/rosuvastatin tabs EZETIMIBE/ROSUVASTATIN tabs Tier 3
pitavastatin LIVALO Tier 3
rosuvastatin capsules EZALLOR SPRINKLE Tier 3
* Generic cholesterol-lowering statin drugs are covered at no charge to the member at a preferred retail pharmacy or for Standard Option
members and for Basic Option members with primary Medicare Part B, through the Mail Service Prescription Drug Program.
Microsomal Triglyceride Transfer Protein Inhibitors

PA lomitapide JUXTAPID Tier 4
24
Niacins
niacin ext-rel Tier 1 NIASPAN Tier 3
Omega-3 Fatty Acids

icosapent ethyl caps 1 gm Tier 1 VASCEPA Tier 2
omega-3 acid ethyl esters Tier 1 LOVAZA Tier 3
PCSK9 Inhibitors
PA evolocumab REPATHA Tier 2
PA alirocumab PRALUENT Tier 3
BETA-BLOCKERS
Guidelines for the use of beta-blockers and beta-blocker combinations in various patient populations are available at:
https://www.acc.org
acebutolol Tier 1
atenolol Tier 1 TENORMIN Tier 3
carvedilol Tier 1 COREG Tier 3
carvedilol phosphate ext-rel Tier 1 COREG CR Tier 3
esmolol Tier 1 BREVIBLOC Tier 3
metoprolol succinate ext-rel Tier 1 TOPROL-XL Tier 3
metoprolol tartrate Tier 1 LOPRESSOR Tier 3
nebivolol Tier 1 BYSTOLIC Tier 3
pindolol Tier 1
propranolol Tier 1
propranolol ext-rel Tier 1 INDERAL LA Tier 3
metoprolol succinate ext-rel KAPSPARGO Tier 3
propranolol ext-rel INNOPRAN XL Tier 3
BETA-BLOCKER/DIURETIC COMBINATIONS
Guidelines for the use of beta-blockers and diuretic combinations in various patient populations are available at:
https://www.acc.org
atenolol/chlorthalidone Tier 1
bisoprolol/hydrochlorothiazide Tier 1 ZIAC Tier 3
metoprolol/hydrochlorothiazide Tier 1
CALCIUM CHANNEL BLOCKERS

Dihydropyridines
amlodipine tabs Tier 1 NORVASC Tier 3
felodipine ext-rel Tier 1
nicardipine Tier 1
nifedipine ext-rel Tier 1
nifedipine ext-rel Tier 1 PROCARDIA XL Tier 3
nimodipine Tier 1 NIMOTOP Tier 3
nisoldipine ext-rel Tier 1 SULAR Tier 3
amlodipine benzoate oral susp KATERZIA Tier 3
Nondihydropyridines
diltiazem Tier 1 CARDIZEM Tier 3
diltiazem ext-rel Tier 1 CARDIZEM CD Tier 3
diltiazem ext-rel Tier 1 TIAZAC Tier 3
verapamil Tier 1
25
verapamil ext-rel Tier 1 CALAN SR Tier 3
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS

amlodipine/atorvastatin Tier 1 CADUET Tier 3
DIGITALIS GLYCOSIDES
digoxin Tier 1 LANOXIN Tier 2
DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS

aliskiren Tier 1 TEKTURNA Tier 3
aliskiren/hydrochlorothiazide TEKTURNA HCT Tier 2
DIURETICS
Carbonic Anhydrase Inhibitors
acetazolamide Tier 1
acetazolamide ext-rel Tier 1
methazolamide Tier 1
PA dichlorphenamide KEVEYIS Tier 3
Diuretic Combinations
amiloride/hydrochlorothiazide Tier 1
spironolactone/hydrochlorothiazide Tier 1 ALDACTAZIDE Tier 3
triamterene/hydrochlorothiazide Tier 1
triamterene/hydrochlorothiazide Tier 1 MAXZIDE Tier 3
triamterene/hydrochlorothiazide 37.5/25 Tier 1 MAXZIDE-25 Tier 3
triamterene/hydrochlorothiazide 50/25 Tier 1
Loop Diuretics
bumetanide Tier 1
ethacrynic acid Tier 1 EDECRIN Tier 3
furosemide Tier 1 LASIX Tier 3
torsemide Tier 1
torsemide SOAANZ Tier 3
Potassium-sparing Diuretics
amiloride Tier 1
Thiazides and Thiazide-like Diuretics

chlorthalidone Tier 1
hydrochlorothiazide Tier 1
indapamide Tier 1
metolazone Tier 1
HEART FAILURE
isosorbide dinitrate/hydralazine Tier 1 BIDIL Tier 3
PA ivabradine CORLANOR Tier 3
PA sacubitril/valsartan ENTRESTO Tier 3
PA vericiguat VERQUVO Tier 3
PA tafamidis VYNDAMAX Tier 4
PA tafamidis meglumine VYNDAQEL Tier 4
NITRATES
Oral
isosorbide dinitrate oral Tier 1 ISORDIL Tier 3
isosorbide mononitrate Tier 1
isosorbide mononitrate ext-rel Tier 1
26
Sublingual/Translingual
nitroglycerin lingual spray Tier 1 NITROLINGUAL Tier 3
nitroglycerin sublingual Tier 1 NITROSTAT Tier 3
nitroglycerin sublingual aerosol NITROMIST Tier 3
nitroglycerin sublingual powder GONITRO Tier 3
Transdermal
nitroglycerin transdermal Tier 1
nitroglycerin transdermal Tier 1 NITRO-DUR Tier 3
nitroglycerin ointment NITRO-BID Tier 3
PULMONARY ARTERIAL HYPERTENSION

Endothelin Receptor Antagonists
PA ambrisentan Tier 4 LETAIRIS Tier 5
PA bosentan Tier 4 TRACLEER Tier 5
PA macitentan OPSUMIT Tier 4
Phosphodiesterase Inhibitors
PA sildenafil Tier 4 REVATIO Tier 5
PA tadalafil tabs 20 mg Tier 4 ADCIRCA Tier 5
PA tadalafil tabs 20 mg - Alyq Tier 4
Prostacyclin Receptor Agonists

PA selexipag UPTRAVI Tier 5
Prostaglandin Vasodilators
PA epoprostenol Tier 4 VELETRI Tier 5
PA epoprostenol sodium Tier 4 FLOLAN Tier 5
PA treprostinil Tier 4 REMODULIN Tier 5
PA iloprost VENTAVIS Tier 4
PA treprostinil ext-rel ORENITRAM Tier 4
PA treprostinil TYVASO Tier 5
PA treprostinil inhalation powder TYVASO DPI POWDER Tier 5
Soluble Guanylate Cyclase Stimulators

PA riociguat ADEMPAS Tier 5
MISCELLANEOUS
hydralazine Tier 1
midodrine Tier 1
minoxidil tabs Tier 1
ranolazine ext-rel Tier 1 RANEXA Tier 3
PA droxidopa Tier 4 NORTHERA Tier 5
mecamylamine VECAMYL Tier 3
PA mavacamten CAMZYOS Tier 5
CENTRAL NERVOUS SYSTEM

Practice guidelines for psychiatric disorders are available at:
https://www.psychiatry.org
ANTIANXIETY
Benzodiazepines
alprazolam Tier 1 XANAX Tier 3
alprazolam ext-rel Tier 1 XANAX XR Tier 3
chlordiazepoxide Tier 1
27
clonazepam Tier 1 KLONOPIN Tier 3
clorazepate Tier 1 TRANXENE T-TAB Tier 3
diazepam Tier 1 VALIUM Tier 3
lorazepam Tier 1 ATIVAN Tier 3
oxazepam Tier 1
Miscellaneous
buspirone Tier 1
clomipramine Tier 1 ANAFRANIL Tier 3
fluvoxamine Tier 1
fluvoxamine ext-rel Tier 1
hydroxyzine HCl Tier 1
hydroxyzine pamoate Tier 1 VISTARIL Tier 3
ANTICONVULSANTS
Practice guidelines for the treatment of epilepsy are available at:
https://www.aan.com
carbamazepine Tier 1 TEGRETOL Tier 3

carbamazepine ext-rel Tier 1 CARBATROL Tier 3
carbamazepine ext-rel Tier 1 TEGRETOL-XR Tier 3
clobazam Tier 1 ONFI Tier 3
diazepam rectal gel Tier 1 DIASTAT Tier 3
divalproex sodium delayed-rel Tier 1 DEPAKOTE Tier 3
divalproex sodium ext-rel Tier 1 DEPAKOTE ER Tier 3
divalproex sodium sprinkle caps Tier 1 DEPAKOTE SPRINKLE Tier 3
ethosuximide Tier 1 ZARONTIN Tier 3
felbamate Tier 1 FELBATOL Tier 3
QL gabapentin Tier 1 NEURONTIN Tier 3
lacosamide Tier 1 VIMPAT Tier 3
lamotrigine Tier 1 LAMICTAL Tier 3
lamotrigine ext-rel Tier 1 LAMICTAL XR Tier 3
lamotrigine orally disintegrating tabs Tier 1 LAMICTAL ODT Tier 3
levetiracetam Tier 1 KEPPRA Tier 3
levetiracetam ext-rel Tier 1 KEPPRA XR Tier 3
oxcarbazepine Tier 1 TRILEPTAL Tier 3
phenobarbital Tier 1
phenytoin Tier 1 DILANTIN INFATABS Tier 3
phenytoin sodium extended Tier 1 DILANTIN Tier 3
primidone Tier 1 MYSOLINE Tier 3
rufinamide Tier 1 BANZEL Tier 3
tiagabine Tier 1 GABITRIL Tier 3
topiramate Tier 1 TOPAMAX Tier 3
topiramate ext-rel Tier 1 QUDEXY XR Tier 3
valproic acid Tier 1
zonisamide Tier 1 ZONEGRAN Tier 3
PA vigabatrin Tier 4 SABRIL Tier 5
PA vigabatrin powder - Vigadrone Tier 4
brivaracetam BRIVIACT Tier 3
PA cenobamate XCOPRI Tier 3
PA diazepam nasal spray VALTOCO Tier 3
eslicarbazepine APTIOM Tier 3
levetiracetam ext-rel tabs ELEPSIA XR Tier 3
PA midazolam nasal spray NAYZILAM Tier 3
oxcarbazepine ext-rel OXTELLAR XR Tier 3
perampanel FYCOMPA Tier 3
28
topiramate ext-rel TROKENDI XR Tier 3
PA cannabidiol EPIDIOLEX Tier 5
PA fenfluramine FINTEPLA Tier 5
PA ganaxolone suspension ZTALMY Tier 5
PA stiripentol DIACOMIT Tier 5
ANTIDEMENTIA
Practice guidelines for the management of dementia are available at:
https://www.aan.com
donepezil Tier 1 ARICEPT Tier 3

donepezil orally disintegrating tabs Tier 1
galantamine Tier 1
galantamine ext-rel Tier 1 RAZADYNE ER Tier 3
memantine soln Tier 1
memantine tabs Tier 1 NAMENDA tabs Tier 3
rivastigmine Tier 1
rivastigmine transdermal Tier 1 EXELON PATCH Tier 3
ANTIDEPRESSANTS
Although these agents are primarily indicated for depression, some of these are also approved for other indications, including bipolar
disorder, obsessive-compulsive disorder, panic disorder and premenstrual dysphoric disorder.
Guidelines for the evaluation and management of bipolar and depressive disorders are available at:
Monoamine Oxidase Inhibitors (MAOIs)

phenelzine Tier 1 NARDIL Tier 3
tranylcypromine Tier 1 PARNATE Tier 3
isocarboxazid MARPLAN Tier 3
selegiline transdermal EMSAM Tier 3
Selective Serotonin Reuptake Inhibitors (SSRIs)

citalopram tabs Tier 1 CELEXA Tier 3
escitalopram Tier 1 LEXAPRO Tier 3
fluoxetine Tier 1
fluoxetine Tier 1 PROZAC Tier 3
fluoxetine delayed-rel Tier 1
paroxetine HCl Tier 1 PAXIL Tier 3
paroxetine HCl ext-rel Tier 1 PAXIL CR Tier 3
sertraline tabs Tier 1 ZOLOFT Tier 3
vilazodone Tier 1 VIIBRYD Tier 3
citalopram caps CITALOPRAM caps Tier 3
duloxetine delayed-release sprinkle capsule DRIZALMA SPRINKLE Tier 3
paroxetine mesylate PEXEVA Tier 3
sertraline caps SERTRALINE caps Tier 3
vortioxetine TRINTELLIX Tier 3
Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

desvenlafaxine ext-rel Tier 1 PRISTIQ Tier 3
duloxetine delayed-rel Tier 1 CYMBALTA Tier 3
venlafaxine hcl Tier 1
venlafaxine hcl ext-rel Tier 1 EFFEXOR XR Tier 3
venlafaxine hcl ext-rel tabs Tier 1
levomilnacipran ext-rel FETZIMA Tier 3
venlafaxine besylate ext-rel tabs VENLAFAXINE BESYLATE EXT- Tier 3
29
REL TABS
Tricyclic Antidepressants (TCAs)

amitriptyline Tier 1
desipramine Tier 1 NORPRAMIN Tier 3
doxepin Tier 1
imipramine HCl Tier 1
imipramine pamoate Tier 1
nortriptyline Tier 1 PAMELOR Tier 3
protriptyline Tier 1
Miscellaneous Agents
amitriptyline/perphenazine Tier 1
bupropion Tier 1
bupropion ext-rel Tier 1 FORFIVO XL Tier 3
bupropion ext-rel Tier 1 WELLBUTRIN SR Tier 3
bupropion ext-rel Tier 1 WELLBUTRIN XL Tier 3
mirtazapine Tier 1 REMERON Tier 3
nefazodone Tier 1
trazodone Tier 1
bupropion ext-rel APLENZIN Tier 3
PA esketamine nasal solution SPRAVATO Tier 3
ANTIPARKINSONIAN AGENTS
Practice guidelines for the diagnosis and treatment of Parkinson's disease are available at:
https://www.aan.com
amantadine, except tabs Tier 1

benztropine Tier 1
bromocriptine Tier 1 PARLODEL Tier 3
carbidopa/levodopa Tier 1 SINEMET Tier 3
carbidopa/levodopa ext-rel Tier 1
carbidopa/levodopa/entacapone Tier 1 STALEVO Tier 3
diphenhydramine Tier 1
entacapone Tier 1 COMTAN Tier 3
pramipexole Tier 1
pramipexole ext-rel Tier 1 MIRAPEX ER Tier 3
rasagiline Tier 1 AZILECT Tier 3
ropinirole Tier 1
ropinirole ext-rel Tier 1
selegiline caps Tier 1
tolcapone Tier 1
trihexyphenidyl Tier 1
PA apomorphine Tier 4 APOKYN Tier 4
rotigotine transdermal NEUPRO Tier 2
selegiline orally disintegrating tabs ZELAPAR Tier 2
PA amantadine ext-rel GOCOVRI Tier 3
PA amantadine ext-rel OSMOLEX ER Tier 3
PA apomorphine KYNMOBI Tier 3
carbidopa/levodopa enteral susp DUOPA Tier 3
carbidopa/levodopa ext-rel RYTARY Tier 3
opicapone ONGENTYS Tier 3
safinamide XADAGO Tier 3
PA istradefylline NOURIANZ Tier 5
PA levodopa inhalation powder INBRIJA Tier 5
30
ANTIPSYCHOTICS
Atypicals
aripiprazole Tier 1 ABILIFY Tier 3
aripiprazole orally disintegrating tabs Tier 1
asenapine Tier 1 SAPHRIS Tier 3
clozapine Tier 1 CLOZARIL Tier 3
clozapine orally disintegrating tabs Tier 1
olanzapine Tier 1 ZYPREXA/ZYPREXA ZYDIS Tier 3
olanzapine/fluoxetine Tier 1
paliperidone ext-rel Tier 1 INVEGA Tier 3
quetiapine Tier 1 SEROQUEL Tier 3
quetiapine ext-rel Tier 1 SEROQUEL XR Tier 3
risperidone Tier 1 RISPERDAL Tier 3
risperidone orally disintegrating tabs Tier 1 RISPERDAL M-TABS Tier 3
ziprasidone Tier 1 GEODON Tier 3
paliperidone palmitate ext-rel inj INVEGA SUSTENNA Tier 2
risperidone long-acting inj RISPERDAL CONSTA Tier 2
aripiprazole ext-rel inj ABILIFY MAINTENA Tier 3
aripiprazole lauroxil ext-rel inj ARISTADA Tier 3
PA aripiprazole tab with sensor ABILIFY MYCITE Tier 3
asenapine transdermal SECUADO Tier 3
brexpiprazole REXULTI Tier 3
cariprazine VRAYLAR Tier 3
iloperidone FANAPT Tier 3
lumateperone CAPLYTA Tier 3
lurasidone LATUDA Tier 3
PA olanzapine pamoate ext-rel inj ZYPREXA RELPREVV Tier 3
PA olanzapine-samidorphan LYBALVI Tier 3
paliperidone palmitate ext-rel inj INVEGA HAFYERA Tier 3
paliperidone palmitate ext-rel inj INVEGA TRINZA Tier 3
risperidone ext-rel inj PERSERIS Tier 3
Miscellaneous
fluphenazine Tier 1
haloperidol Tier 1
haloperidol decanoate inj Tier 1 HALDOL DECANOATE 100 Tier 3
haloperidol lactate inj Tier 1
loxapine Tier 1
perphenazine Tier 1
thioridazine Tier 1
thiothixene Tier 1
trifluoperazine Tier 1
PA pimavanserin NUPLAZID Tier 5
ATTENTION DEFICIT HYPERACTIVITY DISORDER

Guidelines for the evaluation and management of attention deficit disorder are available at:
https://www.aacap.org
https://www.aap.org
PA amphetamine sulfate Tier 1 EVEKEO Tier 3

PA amphetamine/dextroamphetamine mixed salts Tier 1 ADDERALL Tier 3
PA amphetamine/dextroamphetamine mixed salts ext-rel Tier 1 ADDERALL XR Tier 3
atomoxetine Tier 1 STRATTERA Tier 3
clonidine ext-rel Tier 1 KAPVAY Tier 3
PA dexmethylphenidate Tier 1 FOCALIN Tier 3
PA dexmethylphenidate ext-rel Tier 1 FOCALIN XR Tier 3
31
PA dextroamphetamine Tier 1
PA dextroamphetamine Tier 1 ZENZEDI Tier 1
PA dextroamphetamine ext-rel Tier 1 DEXEDRINE SPANSULE Tier 3
PA dextroamphetamine soln - Procentra Tier 1
guanfacine ext-rel Tier 1 INTUNIV Tier 3
PA methamphetamine Tier 1
PA methylphenidate Tier 1 METHYLIN Tier 3
PA methylphenidate Tier 1 RITALIN Tier 3
PA methylphenidate ext-rel Tier 1 CONCERTA Tier 3
PA methylphenidate ext-rel Tier 1 RITALIN LA Tier 3
PA methylphenidate ext-rel (except methylphenidate tab ER Tier 1
osmotic release 72 mg)
PA methylphenidate ext-rel caps Tier 1 APTENSIO XR Tier 3
PA methylphenidate transdermal Tier 1 DAYTRANA Tier 3
PA amphetamine/dextroamphetamine mixed salts ext-rel MYDAYIS Tier 2
PA lisdexamfetamine VYVANSE Tier 2
PA methylphenidate ext-rel caps ADHANSIA XR Tier 3
PA methylphenidate ext-rel caps (PM) JORNAY PM Tier 3
PA methylphenidate ext-rel chewable tabs QUILLICHEW ER Tier 3
PA methylphenidate ext-rel susp QUILLIVANT XR Tier 3
PA serdexmethylphenidate-dexmethylphenidate AZSTARYS Tier 3
PA viloxazine ext-rel caps QELBREE Tier 3
FIBROMYALGIA
QL pregabalin Tier 1 LYRICA Tier 3
QL milnacipran SAVELLA Tier 3
HYPNOTICS
Practice parameters for the treatment of sleep disorders and clinical guidelines for the evaluation and management of chronic insomnia in
adults are available at:
https://aasm.org
Benzodiazepines
QL estazolam Tier 1
QL flurazepam Tier 1
QL quazepam Tier 1
QL temazepam Tier 1 RESTORIL Tier 3
Nonbenzodiazepines
QL eszopiclone Tier 1 LUNESTA Tier 3
QL ramelteon Tier 1 ROZEREM Tier 3
QL zaleplon Tier 1
QL zolpidem Tier 1 AMBIEN Tier 3
QL zolpidem ext-rel Tier 1 AMBIEN CR Tier 3
QL zolpidem sublingual Tier 1
QL lemborexant DAYVIGO Tier 3
QL suvorexant BELSOMRA Tier 3
QL zolpidem spray ZOLPIMIST Tier 3
QL zolpidem sublingual EDLUAR Tier 3
PA tasimelteon HETLIOZ Tier 4
Tricyclics
doxepin Tier 1 SILENOR Tier 3
32
MIGRAINE
Guidelines for prevention and management of migraine headaches are available at:
https://www.aan.com
Calcitonin Gene-Related Peptide Receptor Antagonist

PA atogepant QULIPTA Tier 3
PA rimegepant NURTEC ODT Tier 3
Ergotamine Derivatives
dihydroergotamine inj Tier 1 D.H.E. 45 Tier 3
PA dihydroergotamine spray Tier 1 MIGRANAL Tier 3
ergotamine/caffeine supp Tier 1
ergotamine/caffeine tabs Tier 1
Monoclonal Antibodies
PA erenumab-aooe AIMOVIG Tier 2
PA galcanezumab-gnlm 100 mg/mL EMGALITY 100 mg/mL Tier 2
PA galcanezumab-gnlm 120 mg/mL EMGALITY 120 mg/mL Tier 2
PA eptinezumab-jjmr VYEPTI Tier 5
Selective Serotonin Agonists

QL almotriptan Tier 1
QL eletriptan Tier 1 RELPAX Tier 3
QL frovatriptan Tier 1 FROVA Tier 3
QL naratriptan Tier 1 AMERGE Tier 3
QL rizatriptan Tier 1 MAXALT/MAXALT-MLT Tier 3
QL sumatriptan Tier 1 IMITREX Tier 3
QL zolmitriptan Tier 1 ZOMIG/ZOMIG-ZMT Tier 3
QL zolmitriptan nasal spray Tier 1 ZOMIG Tier 3
QL sumatriptan nasal powder ONZETRA XSAIL Tier 3
QL sumatriptan nasal spray TOSYMRA Tier 3
Selective Serotonin Agonist/Nonsteroidal Anti-inflammatory Drug (NSAID) Combinations

QL sumatriptan/naproxen sodium TREXIMET Tier 3
MOOD STABILIZERS
lithium carbonate Tier 1
lithium carbonate ext-rel tabs 300 mg Tier 1 LITHOBID Tier 3
lithium carbonate ext-rel tabs 450 mg Tier 1
carbamazepine EQUETRO Tier 3
MOVEMENT DISORDERS
PA tetrabenazine Tier 4 XENAZINE Tier 5
PA deutetrabenazine AUSTEDO Tier 5
MULTIPLE SCLEROSIS
Practice guidelines for multiple sclerosis are available at:
https://www.aan.com
PA dalfampridine ext-rel Tier 4

PA dimethyl fumarate delayed-rel Tier 4
PA glatiramer Tier 4 Tier 5
PA glatiramer - Glatopa Tier 4
PA fingolimod GILENYA Tier 4
PA interferon beta-1a AVONEX Tier 4
PA interferon beta-1a REBIF Tier 4
33
PA interferon beta-1a REBIF REBIDOSE Tier 4
PA interferon beta-1b BETASERON Tier 4
PA natalizumab TYSABRI Tier 4
PA ocrelizumab OCREVUS Tier 4
PA ozanimod ZEPOSIA Tier 4
PA peginterferon beta-1a PLEGRIDY Tier 4
PA peginterferon beta-1a PLEGRIDY PEN Tier 4
PA siponimod MAYZENT Tier 4
PA teriflunomide AUBAGIO Tier 4
PA alemtuzumab LEMTRADA Tier 5
PA cladribine MAVENCLAD Tier 5
PA diroximel fumarate delayed-rel VUMERITY Tier 5
PA interferon beta-1b EXTAVIA Tier 5
PA monomethyl fumarate BAFIERTAM Tier 5
PA ofatumumab KESIMPTA Tier 5
PA ponesimod PONVORY Tier 5
MUSCULOSKELETAL THERAPY AGENTS

baclofen Tier 1
baclofen intrathecal (10 mg/20 mL, 40 mg/20 mL) Tier 1 LIORESAL INTRATHECAL Tier 2
PA baclofen oral solution Tier 1 OZOBAX Tier 3
cyclobenzaprine Tier 1
dantrolene Tier 1 DANTRIUM Tier 3
PA baclofen FLEQSUVY Tier 3
PA baclofen LYVISPAH Tier 3
MYASTHENIA GRAVIS
pyridostigmine Tier 1 MESTINON Tier 3
pyridostigmine ext-rel tabs 180 mg Tier 1 MESTINON TIMESPAN Tier 3
NARCOLEPSY/CATAPLEXY
PA armodafinil Tier 1 NUVIGIL Tier 3
PA modafinil Tier 1 PROVIGIL Tier 3
PA sodium oxybate XYREM Tier 2
PA calcium, magnesium, potassium, and sodium oxybates XYWAV Tier 3
PA solriamfetol SUNOSI Tier 3
PA pitolisant WAKIX Tier 5
PSYCHOTHERAPEUTIC-MISCELLANEOUS
Alcohol Deterrents
acamprosate calcium Tier 1
disulfiram Tier 1
naltrexone Tier 1
naltrexone microspheres VIVITROL Tier 4
Opioid Antagonists
naloxone inj Tier 1
naloxone nasal spray Tier 1 NARCAN Tier 1
naloxone nasal spray KLOXXADO Tier 3
naloxone prefilled syringe ZIMHI Tier 3
Partial Opioid Agonists

QL buprenorphine Tier 1
PA buprenorphine ext-rel inj SUBLOCADE Tier 5
34
Partial Opioid Agonist/Opioid Antagonist Combinations
QL buprenorphine/naloxone sublingual film Tier 1 SUBOXONE FILM Tier 3
QL buprenorphine/naloxone sublingual tabs Tier 1
QL buprenorphine/naloxone sublingual tabs ZUBSOLV Tier 2
Pseudobulbar Affect
PA dextromethorphan/quinidine NUEDEXTA Tier 2
Smoking Deterrents
Treating Tobacco Use and Dependence: 2008 Update-Clinical Practice Guideline is available at:
https://www.ahrq.gov/professionals/clinicians-providers/guidelines-recommendations/tobacco/index.html
bupropion ext-rel Tier 1

varenicline Tier 1
nicotine nasal spray NICOTROL NASAL SPRAY Tier 2
nicotine inhaler system NICOTROL INHALER Tier 3
MISCELLANEOUS
Amyotrophic Lateral Sclerosis
riluzole Tier 1 RILUTEK Tier 3
PA riluzole EXSERVAN Tier 3
riluzole TIGLUTIK Tier 3
PA edaravone RADICAVA Tier 5
PA edaravone oral susp RADICAVA ORS Tier 5
Botulinum Toxins
PA abobotulinumtoxinA DYSPORT Tier 4
PA incobotulinumtoxinA XEOMIN Tier 4
PA onabotulinumtoxinA BOTOX Tier 4
PA rimabotulinumtoxinB MYOBLOC Tier 4
Duchenne Muscular Dystrophy

PA casimersen AMONDYS 45 Tier 5
PA deflazacort EMFLAZA Tier 5
PA eteplirsen EXONDYS 51 Tier 5
PA golodirsen VYONDYS 53 Tier 5
PA viltolarsen VILTEPSO Tier 5
Lambert-Eaton Myasthenic Syndrome

PA amifampridine FIRDAPSE Tier 4
Spinal Muscular Atrophy

PA risdiplam EVRYSDI Tier 5
Tardive Dyskinesia
PA valbenazine INGREZZA Tier 5
ENDOCRINE AND METABOLIC

ANDROGENS
Clinical practice guidelines for the treatment of hypogonadism are available at:
https://www.aace.com
PA testosterone cypionate Tier 1

PA testosterone enanthate Tier 1
PA testosterone gel Tier 1 ANDROGEL Tier 3
PA testosterone gel Tier 1 FORTESTA Tier 3
35
PA testosterone gel Tier 1 TESTIM Tier 3
PA testosterone gel Tier 1 VOGELXO Tier 3
PA testosterone soln Tier 1
PA testosterone transdermal ANDRODERM Tier 2
PA testosterone buccal STRIANT Tier 3
PA testosterone enanthate auto-injector XYOSTED Tier 3
PA testosterone nasal gel NATESTO Tier 3
PA testosterone undecanoate capsule JATENZO Tier 3
PA testosterone undecanoate inj AVEED Tier 4
PA testosterone pellets TESTOPEL Tier 5
ANTIDIABETICS
Guidelines of treatment and management of diabetes are available at:
Alpha-glucosidase Inhibitors
acarbose Tier 1 PRECOSE Tier 3
miglitol Tier 1
Amylin Analogs
pramlintide SYMLINPEN Tier 2
Biguanides
metformin (does not include 625 mg tabs) Tier 1
* metformin ext-rel Tier 1
PA metformin oral soln Tier 1 RIOMET IR Tier 3
* Generic versions of FORTAMET and GLUMETZA (metformin ext-rel tabs) require PA
Biguanide/Sulfonylurea Combinations
glipizide/metformin Tier 1
glyburide/metformin Tier 1
Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

alogliptin Tier 1
sitagliptin phosphate JANUVIA Tier 2
Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations

alogliptin/metformin Tier 1
sitagliptin/metformin JANUMET Tier 2
sitagliptin/metformin ext-rel JANUMET XR Tier 2
Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Insulin Sensitizer Combinations

alogliptin/pioglitazone Tier 1
Incretin Mimetic Agents

dulaglutide TRULICITY Tier 2
liraglutide VICTOZA Tier 2
semaglutide OZEMPIC Tier 2
semaglutide RYBELSUS Tier 2
Incretin Mimetic Agent/Insulin Combinations

PA liraglutide/insulin degludec XULTOPHY Tier 3
PA lixisenatide/insulin glargine SOLIQUA Tier 3
36
Insulins
insulin aspart FIASP Tier 2
insulin aspart FIASP FLEXTOUCH Tier 2
insulin aspart INSULIN ASPART Tier 2
insulin aspart NOVOLOG Tier 2
insulin aspart protamine 70%/insulin aspart 30% INSULIN ASPART PROTAMINE Tier 2
70%/INSULIN ASPART 30%
insulin aspart protamine 70%/insulin aspart 30% NOVOLOG MIX 70/30 Tier 2
insulin degludec TRESIBA Tier 2
insulin detemir LEVEMIR Tier 2
insulin glargine BASAGLAR Tier 2
insulin glargine LANTUS Tier 2
insulin glargine TOUJEO Tier 2
OTC insulin human HUMULIN R Tier 2
insulin human HUMULIN R U-500 Tier 2
OTC insulin human NOVOLIN R Tier 2
OTC insulin isophane human HUMULIN N Tier 2
OTC insulin isophane human NOVOLIN N Tier 2
OTC insulin isophane human 70%/regular 30% HUMULIN 70/30 Tier 2
OTC insulin isophane human 70%/regular 30% NOVOLIN 70/30 Tier 2
insulin lispro HUMALOG Tier 2
insulin lispro INSULIN LISPRO Tier 2
insulin lispro protamine/insulin lispro HUMALOG MIX Tier 2
insulin lispro protamine/insulin lispro INSULIN LISPRO Tier 2
PROTAMINE/INSULIN LISPRO
insulin glulisine APIDRA Tier 3
PA insulin human inhalation powder AFREZZA Tier 3
insulin lispro ADMELOG Tier 3
insulin lispro ADMELOG SOLOSTAR Tier 3
insulin lispro-aabc LYUMJEV/KWIKPEN Tier 3
Insulin Sensitizers
pioglitazone Tier 1 ACTOS Tier 3
Insulin Sensitizer/Biguanide Combinations

pioglitazone/metformin Tier 1 ACTOPLUS MET Tier 3
pioglitazone/metformin ext-rel ACTOPLUS MET XR Tier 3
Insulin Sensitizer/Sulfonylurea Combinations

pioglitazone/glimepiride Tier 1 DUETACT Tier 3
Meglitinides
nateglinide Tier 1
repaglinide Tier 1
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors

ST dapagliflozin FARXIGA Tier 2
ST empagliflozin JARDIANCE Tier 2
PA/ST canagliflozin INVOKANA Tier 3
PA/ST ertugliflozin STEGLATRO Tier 3
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitor/Biguanide Combinations

ST dapagliflozin/metformin ext-rel XIGDUO XR Tier 2
ST empagliflozin/metformin SYNJARDY Tier 2
ST empagliflozin/metformin ext-rel SYNJARDY XR Tier 2
PA/ST canagliflozin/metformin INVOKAMET Tier 3
37
PA/ST canagliflozin/metformin ext-rel INVOKAMET XR Tier 3
PA/ST ertugliflozin/metformin SEGLUROMET Tier 3
Sodium-Glucose Co-Transporter 2 Inhibitor/Dipeptidyl Peptidase-4 Inhibitor Combinations

ST dapagliflozin/saxagliptin QTERN Tier 2
ST empagliflozin/linagliptin GLYXAMBI Tier 2
PA/ST ertugliflozin/sitagliptin STEGLUJAN Tier 3
Sodium Glucose Co-Transporter 2 Inhibitor/Dipeptidyl Peptidase-4 (DPP-4) Inhibitor/Biguanide Combinations

PA/ST empagliflozin/linagliptin/metformin extended-release TRIJARDY XR Tier 3
Sulfonylureas
glimepiride Tier 1 AMARYL Tier 3
glipizide Tier 1
glipizide ext-rel Tier 1 GLUCOTROL XL Tier 3
glyburide Tier 1
glyburide, micronized Tier 1 GLYNASE Tier 3
Supplies
PA blood glucose continuous monitoring receivers, sensors, FREESTYLE LIBRE / Tier 2
transmitters FREESTYLE LIBRE 2
CONTINUOUS GLUCOSE
MONITORING SYST
OTC blood glucose meters and kits ACCU-CHEK METERS AND KITS Tier 2
OTC blood glucose meters and kits ONETOUCH METERS AND KITS Tier 2
OTC blood glucose test strips ACCU-CHEK TEST STRIPS Tier 2
OTC blood glucose test strips ONETOUCH TEST STRIPS Tier 2
PA insulin infusion disposable pump kit V-GO INSULIN INFUSION Tier 2
DISPOSABLE PUMP
PA insulin patch CEQUR SIMPLICITY Tier 2
OTC insulin pen needles NOVOFINE PEN NEEDLES Tier 2
OTC insulin syringes, needles BD INSULIN SYRINGES AND Tier 2
NEEDLES
OTC lancet device ACCU-CHEK FASTCLIX LANCET Tier 2
DEVICE
OTC lancet device SOFTCLIX LANCET DEVICE Tier 2
OTC lancet device SOFTTOUCH LANCET DEVICE Tier 2
OTC lancets ACCU-CHEK FASTCLIX Tier 2
LANCETS
OTC lancets ONETOUCH LANCETS Tier 2
OTC lancets SOFTCLIX LANCETS Tier 2
OTC lancets SOFTTOUCH LANCETS Tier 2
OTC urine test strips CHEMSTRIP K URINE KETONE Tier 2
STRIPS
OTC urine test strips CHEMSTRIP UGK URINE Tier 2
GLUCOSE/KETONE STRIPS
OTC urine test strips CHEMSTRIP UG URINE Tier 2
GLUCOSE STRIPS
PA blood glucose continuous monitoring receivers, sensors, DEXCOM CONTINUOUS Tier 3
transmitters GLUCOSE MONITORING
SYSTEM
PA insulin infusion disposable pump kit OMNIPOD 5 G6 INSULIN Tier 3
INFUSION DISPOSABLE PUMP
PA insulin infusion disposable pump kit OMNIPOD DASH INSULIN Tier 3
INFUSION DISPOSABLE PUMP
38
CALCIUM RECEPTOR AGONISTS
PA cinacalcet Tier 4 SENSIPAR Tier 5
PA etelcalcetide PARSABIV Tier 5
CALCIUM REGULATORS
Guidelines of treatment and management of osteoporosis are available at:
https://www.aace.com
https://www.nof.org
Bisphosphonates
alendronate Tier 1 FOSAMAX Tier 3
ibandronate Tier 1 BONIVA Tier 3
risedronate Tier 1 ACTONEL Tier 3
risedronate delayed-rel Tier 1 ATELVIA Tier 3
pamidronate Tier 4
zoledronic acid 4 mg/100 mL Tier 4
PA, * zoledronic acid 5 mg/100 mL Tier 4 RECLAST Tier 5
alendronate/vitamin D3 FOSAMAX PLUS D Tier 3
* Brand RECLAST requires prior approval
Calcitonins
calcitonin-salmon inj Tier 1 MIACALCIN inj Tier 3
calcitonin-salmon spray Tier 1 MIACALCIN Tier 3
Parathyroid Hormones
PA teriparatide FORTEO Tier 4
PA abaloparatide TYMLOS Tier 5
PA parathyroid hormone (recombinant) NATPARA Tier 5
Miscellaneous
PA denosumab PROLIA Tier 4
PA denosumab XGEVA Tier 4
PA romosozumab-aqqg EVENITY Tier 5
CARNITINE DEFICIENCY AGENTS

levocarnitine Tier 1 CARNITOR Tier 3
CONTRACEPTIVES
EE = ethinyl estradiol
Monophasic
20 mcg Estrogen
† drospirenone/EE 3/20 Tier 1 YAZ Tier 3
† levonorgestrel/EE 0.1/20 Tier 1
† norethindrone acetate/EE 1/20 Tier 1
† norethindrone acetate/EE 1/20 and iron Tier 1
† norethindrone acetate/EE 1/20 and iron Tier 1 TAYTULLA Tier 3
30 mcg Estrogen
† desogestrel/EE 0.15/30 Tier 1
† drospirenone/EE 3/30 Tier 1 YASMIN Tier 3
† drospirenone/EE/levomefolate 3/30 and levomefolate Tier 1 SAFYRAL Tier 3
† levonorgestrel/EE 0.15/30 Tier 1
† levonorgestrel/EE 0.15/30 - Levora Tier 1
† norethindrone acetate/EE 1.5/30 Tier 1
39
† norethindrone acetate/EE 1.5/30 and iron Tier 1
† norgestrel/EE 0.3/30 - Cryselle Tier 1
† norgestrel/EE 0.3/30 - Low-Ogestrel Tier 1
35 mcg Estrogen
† ethynodiol diacetate/EE 1/35 - Zovia 1/35 Tier 1
† norethindrone/EE 0.4/35 Tier 1
† norethindrone/EE 0.5/35 Tier 1
† norethindrone/EE 1/35 Tier 1
† norgestimate/EE 0.25/35 Tier 1
50 mcg Estrogen
† ethynodiol diacetate/EE 1/50 Tier 1
† norgestrel/EE 0.5/50 Tier 1
Miscellaneous
drospirenone/estetrol NEXTSTELLIS Tier 3
Biphasic
† desogestrel/EE Tier 1 MIRCETTE Tier 3
norethindrone acetate/EE 1/10 and EE 10 and iron LO LOESTRIN FE Tier 2
Triphasic
† desogestrel/EE Tier 1
† levonorgestrel/EE - Trivora Tier 1
† norethindrone acetate/EE and iron Tier 1
† norethindrone/EE Tier 1
† norgestimate/EE Tier 1
levonorgestrel/EE TYBLUME Tier 3
Four Phase
estradiol valerate and dienogest/estradiol valerate NATAZIA Tier 3
Extended Cycle
† levonorgestrel/EE 0.1/20 and EE 10 Tier 1 LOSEASONIQUE Tier 3
† levonorgestrel/EE 0.15/30 - Jolessa Tier 1
† levonorgestrel/EE 0.15/30 and EE 10 Tier 1 SEASONIQUE Tier 3
Continuous
† levonorgestrel/EE 0.09/20 - Amethyst Tier 1
Progestin Only
† norethindrone Tier 1
drospirenone SLYND Tier 3
Implant
‡ etonogestrel implant NEXPLANON Tier 4
Injectable
† medroxyprogesterone acetate 150 mg/mL Tier 1 DEPO-PROVERA Tier 3
Intrauterine Devices
‡ intrauterine copper contraceptive PARAGARD T 380A Tier 2
‡ levonorgestrel-releasing IUD KYLEENA Tier 4
‡ levonorgestrel-releasing IUD MIRENA Tier 4
‡ levonorgestrel-releasing IUD SKYLA Tier 4
40
levonorgestrel-releasing IUD LILETTA Tier 5
Transdermal
† norelgestromin/EE Tier 1
ethinyl estradiol/levonorgestrel TWIRLA Tier 3
Vaginal
†, * etonogestrel/EE - EluRyng Tier 1 NUVARING Tier 3
lactic acid/citric acid/potassium bitartrate gel PHEXXI Tier 3
segesterone acetate/EE ring ANNOVERA Tier 3
* Generic versions are covered at no charge to qualifying members
DIABETIC KIDNEY DISEASE

PA finerenone KERENDIA Tier 3
ENDOMETRIOSIS
danazol Tier 1
PA nafarelin SYNAREL Tier 2
PA elagolix ORILISSA Tier 3
FERTILITY REGULATORS
PA clomiphene Tier 1
PA chorionic gonadotropin Tier 4
PA ganirelix acetate inj Tier 4 GANIRELIX ACETATE Tier 4
PA gonadorelin LUTREPULSE Tier 2
PA cetrorelix CETROTIDE Tier 4
PA choriogonadotropin alfa OVIDREL Tier 4
PA chorionic gonadotropin NOVAREL Tier 4
PA chorionic gonadotropin PREGNYL Tier 4
PA follitropin beta FOLLISTIM AQ Tier 4
PA menotropins MENOPUR Tier 4
PA follitropin alfa GONAL-F Tier 5
PA follitropin alfa GONAL-F RFF Tier 5
GAUCHER DISEASE
PA eliglustat CERDELGA Tier 4
PA imiglucerase CEREZYME Tier 4
GLUCOCORTICOIDS
dexamethasone Tier 1
fludrocortisone Tier 1
hydrocortisone Tier 1 CORTEF Tier 3
methylprednisolone Tier 1 MEDROL Tier 3
prednisolone Tier 1
prednisolone sodium phosphate Tier 1
prednisolone sodium phosphate orally disintegrating tabs Tier 1 ORAPRED ODT Tier 3
prednisolone syrup Tier 1
prednisone Tier 1
PA dexamethasone HEMADY Tier 3
hydrocortisone ALKINDI SPRINKLE CAPS Tier 3
PA prednisone delayed-rel RAYOS Tier 3
GLUCOSE ELEVATING AGENTS

diazoxide Tier 1 PROGLYCEM Tier 3
glucagon, human recombinant (KIT) Tier 1 GLUCAGON EMERGENCY KIT Tier 3
41
glucagon nasal powder BAQSIMI Tier 2
glucagon subcutaneous soln GVOKE Tier 2
glucagon, human recombinant GLUCAGEN Tier 2
dasiglucagon ZEGALOGUE Tier 3
HEREDITARY TYROSINEMIA TYPE 1 AGENTS

nitisinone Tier 4 ORFADIN Tier 4
nitisinone NITYR Tier 5
HUMAN GROWTH HORMONES

Guidelines for use of growth hormone are available at:
https://www.aace.com/publications/guidelines
PA somatropin NORDITROPIN Tier 4

PA, * somatropin SEROSTIM Tier 4
PA, ** somatropin ZORBTIVE Tier 4
PA lonapegsomatropin-tcgd SKYTROFA Tier 5
PA somatropin GENOTROPIN Tier 5
PA somatropin HUMATROPE Tier 5
PA somatropin NUTROPIN AQ Tier 5
PA somatropin NUTROPIN AQ NUSPIN Tier 5
PA somatropin OMNITROPE Tier 5
PA somatropin SAIZEN Tier 5
PA somatropin ZOMACTON Tier 5
* Indicated for AIDS wasting only

** Indicated only for the treatment of Short Bowel Syndrome in patients receiving specialized nutritional support
HYPERPARATHYROID TREATMENT, VITAMIN D ANALOGS

calcitriol (1,25-D3) Tier 1 ROCALTROL Tier 3
doxercalciferol Tier 1
paricalcitol Tier 1 ZEMPLAR Tier 3
calcifediol ext-rel RAYALDEE Tier 3
INSULIN-LIKE GROWTH FACTOR-1 AGENTS

PA mecasermin INCRELEX Tier 4
MENOPAUSAL SYMPTOM AGENTS

Guidelines of treatment and management of hormone therapy and menopause are available at:
https://www.menopause.org
https://www.aace.com/files/menopause.pdf
Injectable
estradiol valerate Tier 1 DELESTROGEN Tier 2
Oral
EE/norethindrone acetate Tier 1
EE/norethindrone acetate - Jinteli Tier 1
estradiol Tier 1 ESTRACE Tier 3
estradiol/norethindrone acetate Tier 1 ACTIVELLA Tier 3
estrogens, esterified/methyltestosterone Tier 1
estrogens, conjugated PREMARIN Tier 2
estrogens, conjugated/medroxyprogesterone PREMPHASE Tier 2
estrogens, conjugated/medroxyprogesterone PREMPRO Tier 2
conjugated estrogens/bazedoxifene DUAVEE Tier 3
drospirenone/estradiol ANGELIQ Tier 3
42
estradiol/norgestimate PREFEST Tier 3
estradiol/progesterone BIJUVA Tier 3
Transdermal
estradiol Tier 1 CLIMARA Tier 3
estradiol Tier 1 MINIVELLE Tier 3
estradiol Tier 1 VIVELLE-DOT Tier 3
estradiol transdermal spray EVAMIST Tier 2
estradiol/levonorgestrel CLIMARA PRO Tier 2
estradiol ALORA Tier 3
estradiol transdermal gel DIVIGEL Tier 3
estradiol transdermal gel ESTROGEL Tier 3
estradiol/norethindrone acetate COMBIPATCH Tier 3
Vaginal
estradiol vaginal crm Tier 1 ESTRACE Tier 3
estradiol vaginal tabs- YUVAFEM Tier 1 VAGIFEM Tier 3
estradiol vaginal ring ESTRING Tier 2
estrogens, conjugated crm PREMARIN crm Tier 2
estradiol vaginal inserts IMVEXXY Tier 3
estradiol vaginal ring FEMRING Tier 3
PHENYLKETONURIA TREATMENT AGENTS

PA sapropterin Tier 4 KUVAN Tier 5
PA pegvaliase-pqpz PALYNZIQ Tier 5
PHOSPHATE BINDER AGENTS

calcium acetate Tier 1
lanthanum carbonate chew tabs Tier 1 FOSRENOL CHEWABLE Tier 3
TABLETS
sevelamer carbonate Tier 1 RENVELA Tier 3
sevelamer HCl Tier 1 RENAGEL Tier 3
ferric citrate AURYXIA Tier 2
lanthanum oral powder FOSRENOL ORAL POWDER Tier 2
sucroferric oxyhydroxide VELPHORO Tier 3
POTASSIUM-REMOVING AGENTS
sodium polystyrene sulfonate Tier 1
PA patiromer VELTASSA Tier 3
PA sodium zirconium cyclosilicate LOKELMA Tier 3
PROGESTINS
Injectable
hydroxyprogesterone caproate Tier 4 MAKENA Tier 5
Oral
medroxyprogesterone acetate Tier 1 PROVERA Tier 3
megestrol acetate susp Tier 1
norethindrone acetate Tier 1 AYGESTIN Tier 3
PA progesterone, micronized Tier 1 PROMETRIUM Tier 3
Vaginal
PA progesterone vaginal inserts ENDOMETRIN Tier 2
SELECTIVE ESTROGEN RECEPTOR MODULATORS

raloxifene Tier 1 EVISTA Tier 3
43
ospemifene OSPHENA Tier 3
THYROID AGENTS
Antithyroid Agents
methimazole Tier 1
propylthiouracil Tier 1
Thyroid Supplements
levothyroxine Tier 1 SYNTHROID Tier 2
levothyroxine Tier 1 TIROSINT Tier 3
levothyroxine - Levoxyl Tier 1
liothyronine Tier 1 CYTOMEL Tier 3
levothyroxine THYQUIDITY Tier 3
thyroid ARMOUR THYROID Tier 3
UREA CYCLE DISORDERS

PA sodium phenylbutyrate Tier 4 BUPHENYL Tier 5
UTERINE FIBROIDS
PA elagolix sodium/estradiol/norethindrone acetate ORIAHNN Tier 3
PA relugolix/estradiol/norethindrone acetate MYFEMBREE Tier 3
VASOPRESSINS
desmopressin spray, tabs Tier 1 DDAVP Tier 3
MISCELLANEOUS
acetylcysteine Tier 1 ACETADOTE Tier 3
methylergonovine Tier 1
trientine Tier 1 SYPRINE Tier 3
betaine anhydrous Tier 4 CYSTADANE Tier 5
PA carglumic acid Tier 4 CARBAGLU Tier 5
corticotropin powder Tier 4
PA lanreotide acetate Tier 4 SOMATULINE DEPOT Tier 4
PA miglustat Tier 4 ZAVESCA Tier 5
PA, * octreotide acetate Tier 4 SANDOSTATIN Tier 5
PA tolvaptan Tier 4 SAMSCA Tier 4
hydroxocobalamin CYANOKIT Tier 2
prasterone vaginal inserts INTRAROSA Tier 3
PA uridine triacetate XURIDEN Tier 3
PA agalsidase beta FABRAZYME Tier 4
PA alglucosidase alfa LUMIZYME Tier 4
PA asfotase alfa STRENSIQ Tier 4
PA burosumab-twza CRYSVITA Tier 4
cysteamine CYSTAGON Tier 4
PA cysteamine delayed-rel PROCYSBI Tier 4
PA elosulfase alfa VIMIZIM Tier 4
PA galsulfase NAGLAZYME Tier 4
PA glycerol phenylbutyrate RAVICTI Tier 4
PA histrelin acetate SUPPRELIN LA Tier 4
PA idursulfase ELAPRASE Tier 4
PA laronidase ALDURAZYME Tier 4
PA leuprolide acetate LUPRON DEPOT-PED Tier 4
PA lonafarnib ZOKINVY Tier 4
PA mifepristone KORLYM Tier 4
PA octreotide acetate SANDOSTATIN LAR Tier 4
PA pasireotide SIGNIFOR Tier 4
44
pegvisomant SOMAVERT Tier 4
PA sebelipase alfa KANUMA Tier 4
PA tesamorelin EGRIFTA Tier 4
thyrotropin alfa THYROGEN Tier 4
PA tolvaptan JYNARQUE Tier 4
PA vestronidase alfa-vjbk MEPSEVII Tier 4
PA vosoritide VOXZOGO Tier 4
PA budesonide delayed-rel caps TARPEYO Tier 5
PA corticotropin ACTHAR Tier 5
PA elapegademase-lvlr REVCOVI Tier 5
PA inotersen TEGSEDI Tier 5
PA metreleptin MYALEPT Tier 5
PA migalastat GALAFOLD Tier 5
PA octreotide MYCAPSSA Tier 5
PA osilodrostat phosphate ISTURISA Tier 5
PA taliglucerase alfa ELELYSO Tier 5
PA triptorelin pamoate TRIPTODUR Tier 5
PA velaglucerase alfa VPRIV Tier 5
* Brand SANDOSTATIN requires prior approval
GASTROINTESTINAL
Guidelines for the treatment and management of various gastrointestinal diseases/conditions are available at:
https://gi.org
https://www.gastro.org
ANTIDIARRHEALS
diphenoxylate/atropine Tier 1 LOMOTIL Tier 3
loperamide Tier 1
PA crofelemer delayed-rel MYTESI Tier 3
ANTIEMETICS
QL aprepitant caps Tier 1 EMEND Tier 3
PA doxylamine/pyridoxine delayed-rel Tier 1 DICLEGIS Tier 3
QL dronabinol Tier 1 MARINOL Tier 3
granisetron Tier 1
meclizine Tier 1
metoclopramide Tier 1 REGLAN Tier 3
QL ondansetron Tier 1
QL ondansetron orally disintegrating tabs Tier 1
PA palonosetron Tier 1
prochlorperazine Tier 1
promethazine Tier 1
scopolamine transdermal Tier 1 TRANSDERM SCOP Tier 3
trimethobenzamide Tier 1
QL granisetron transdermal SANCUSO Tier 2
QL rolapitant VARUBI Tier 2
QL aprepitant CINVANTI Tier 3
QL aprepitant susp EMEND Tier 3
PA doxylamine/pyridoxine ext-rel BONJESTA Tier 3
PA granisetron ext-rel inj SUSTOL Tier 3
metoclopramide nasal spray GIMOTI Tier 3
QL netupitant/palonosetron AKYNZEO Tier 3
45
ANTISPASMODICS
d atropine/hyoscyamine/scopolamine/phenobarbital Tier 1
chlordiazepoxide/clidinium Tier 1
dicyclomine Tier 1
d hyoscyamine sulfate Tier 1 LEVSIN Tier 3
d hyoscyamine sulfate ext-rel Tier 1 LEVBID Tier 3
CHOLELITHOLYTICS
ursodiol Tier 1
ursodiol Tier 1 URSO Tier 3
ursodiol Tier 1 URSO FORTE Tier 3
H2 RECEPTOR ANTAGONISTS
cimetidine Tier 1
* famotidine Tier 1
nizatidine Tier 1
* Except OTC available versions like 10 mg and 20 mg
INFLAMMATORY BOWEL DISEASE

Injectable Agents
PA vedolizumab ENTYVIO Tier 5
Oral Agents
balsalazide Tier 1
budesonide delayed-rel caps Tier 1
mesalamine delayed-rel caps Tier 1 DELZICOL Tier 3
mesalamine delayed-rel tabs Tier 1 ASACOL HD Tier 3
mesalamine delayed-rel tabs Tier 1 LIALDA Tier 3
mesalamine ext-rel caps Tier 1 APRISO Tier 3
mesalamine ext-rel caps Tier 1 PENTASA Tier 2
sulfasalazine Tier 1 AZULFIDINE Tier 3
sulfasalazine delayed-rel Tier 1 AZULFIDINE EN-TABS Tier 3
budesonide ext-rel caps ORTIKOS Tier 3
olsalazine DIPENTUM Tier 3
Rectal Agents
hydrocortisone enema Tier 1
mesalamine rectal susp Tier 1 ROWASA Tier 3
mesalamine supp Tier 1 CANASA Tier 3
hydrocortisone acetate foam CORTIFOAM Tier 2
IRRITABLE BOWEL SYNDROME

Irritable Bowel Syndrome with Constipation
PA lubiprostone Tier 1 AMITIZA Tier 3
PA linaclotide LINZESS Tier 2
PA prucalopride MOTEGRITY Tier 3
PA tegaserod maleate ZELNORM Tier 3
PA tenapanor IBSRELA Tier 3
Irritable Bowel Syndrome with Diarrhea

alosetron Tier 1 LOTRONEX Tier 3
PA eluxadoline VIBERZI Tier 3
LAXATIVES
lactulose soln Tier 1
46
peg 3350/electrolytes Tier 1
peg 3350/electrolytes Tier 1 GOLYTELY Tier 3
peg 3350/electrolytes Tier 1 MOVIPREP Tier 3
sodium sulfate/potassium sulfate/magnesium sulfate SUPREP Tier 2
lactulose KRISTALOSE pak Tier 3
peg 3350/electrolytes PLENVU Tier 3
sodium phosphates OSMOPREP Tier 3
sodium picosulfate/magnesium oxide/citric acid CLENPIQ Tier 3
sodium picosulfate/magnesium oxide/citric acid PREPOPIK Tier 3
sodium sulfate/magnesium sulfate/potassium chloride SUTAB Tier 3
OPIOID-INDUCED CONSTIPATION
PA naloxegol MOVANTIK Tier 2
PA methylnaltrexone RELISTOR Tier 3
PANCREATIC ENZYMES
pancrelipase VIOKACE Tier 2
pancrelipase delayed-rel CREON Tier 2
pancrelipase delayed-rel ZENPEP Tier 2
pancrelipase delayed-rel PANCREAZE Tier 3
PROSTAGLANDINS
misoprostol Tier 1 CYTOTEC Tier 3
PROTON PUMP INHIBITORS

QL dexlansoprazole delayed-rel Tier 1 DEXILANT Tier 3
QL esomeprazole magnesium delayed-rel Tier 1
QL lansoprazole delayed-rel Tier 1
omeprazole delayed-rel Tier 1
QL omeprazole/sodium bicarbonate Tier 1
QL pantoprazole delayed-rel Tier 1
QL rabeprazole delayed-rel (except rabeprazole capsule sprinkle Tier 1
delayed-rel)
SALIVA STIMULANTS
cevimeline Tier 1 EVOXAC Tier 3
pilocarpine tabs Tier 1 SALAGEN Tier 3
STEROIDS, RECTAL
d hydrocortisone acetate/pramoxine foam EPIFOAM Tier 2
d hydrocortisone acetate/pramoxine foam PROCTOFOAM-HC Tier 2
ULCER THERAPY COMBINATIONS

QL lansoprazole + amoxicillin + clarithromycin Tier 1
QL bismuth subsalicylate + metronidazole + tetracycline PYLERA Tier 2
QL amoxicillin/rifabutin/omeprazole TALICIA Tier 3
MISCELLANEOUS
alvimopan Tier 1 ENTEREG Tier 3
cromolyn sodium Tier 1 GASTROCROM Tier 3
glycopyrrolate oral solution Tier 1 CUVPOSA Tier 3
sucralfate Tier 1
QL dronabinol solution SYNDROS Tier 3
nitroglycerin rectal oint 0.4% RECTIV Tier 3
PA plecanatide TRULANCE Tier 3
dextranomer/sodium hyaluronate SOLESTA Tier 4
47
PA palifermin KEPIVANCE Tier 4
PA teduglutide GATTEX Tier 4
PA cholic acid CHOLBAM Tier 5
PA givosiran GIVLAARI Tier 5
PA maralixibat LIVMARLI Tier 5
PA obeticholic acid OCALIVA Tier 5
PA telotristat XERMELO Tier 5
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
Guidelines for the management of BPH are available at:
https://www.auanet.org/guidelines
alfuzosin ext-rel Tier 1

dutasteride Tier 1 AVODART Tier 3
dutasteride/tamsulosin Tier 1 JALYN Tier 3
finasteride Tier 1 PROSCAR Tier 3
silodosin Tier 1 RAPAFLO Tier 3
PA tadalafil 2.5 mg, 5 mg Tier 1 CIALIS Tier 3
tamsulosin Tier 1 FLOMAX Tier 3
URINARY ANTISPASMODICS
darifenacin ext-rel Tier 1
fesoterodine ext-rel Tier 1 TOVIAZ Tier 3
oxybutynin Tier 1
oxybutynin ext-rel Tier 1 DITROPAN XL Tier 3
solifenacin Tier 1
tolterodine Tier 1
tolterodine ext-rel Tier 1
trospium Tier 1
trospium ext-rel Tier 1
mirabegron ext-rel MYRBETRIQ Tier 2
oxybutynin gel GELNIQUE Tier 3
solifenacin VESICARE LS Tier 3
vibegron GEMTESA Tier 3
VAGINAL ANTI-INFECTIVES
metronidazole vaginal Tier 1
terconazole crm Tier 1
terconazole supp 80 mg Tier 1
clindamycin supp CLEOCIN vaginal supp Tier 2
clindamycin vaginal cream CLINDESSE Tier 2
MISCELLANEOUS
bethanechol Tier 1
phenazopyridine Tier 1 PYRIDIUM Tier 3
potassium citrate ext-rel Tier 1 UROCIT-K Tier 3
PA tiopronin Tier 1 THIOLA Tier 3
pentosan polysulfate sodium ELMIRON Tier 2
PA tiopronin delayed-rel THIOLA EC Tier 3
48
HEMATOLOGIC
ANTICOAGULANTS
CHEST guidelines are available at:
https://www.chestnet.org/Guidelines-and-Resources/CHEST-Guideline-Topic-Areas/Pulmonary-Vascular
Injectable
enoxaparin Tier 1 LOVENOX Tier 3
dalteparin FRAGMIN Tier 2
Oral
warfarin Tier 1
apixaban ELIQUIS Tier 2
rivaroxaban XARELTO Tier 2
Synthetic Heparinoid-like Agents

fondaparinux Tier 1 ARIXTRA Tier 3
HEMATOPOIETIC GROWTH FACTORS

Guidelines for the management of neutropenia are available at:
Guidelines for the management of anemia associated with chronic kidney disease are available at:
https://www.kidney.org/professionals/guidelines#guidelines
PA darbepoetin alfa ARANESP Tier 4

PA epoetin alfa-epbx RETACRIT Tier 4
PA filgrastim-aafi NIVESTYM Tier 4
PA filgrastim-sndz ZARXIO Tier 4
PA pegfilgrastim-apgf NYVEPRIA Tier 4
PA pegfilgrastim-ayow RELEUKO Tier 4
PA pegfilgrastim-bmez ZIEXTENZO Tier 4
PA pegfilgrastim-cbqv UDENYCA Tier 4
PA pegfilgrastim-jmdb FULPHILA Tier 4
PA tbo-filgrastim GRANIX Tier 4
PA epoetin alfa EPOGEN Tier 5
PA epoetin alfa PROCRIT Tier 5
PA filgrastim NEUPOGEN Tier 5
PA methoxy polyethylene glycol/epoetin beta MIRCERA Tier 5
PA pegfilgrastim NEULASTA Tier 5
PA sargramostim LEUKINE Tier 5
HEMOPHILIA, VON WILLEBRAND DISEASE AND RELATED BLEEDING DISORDERS

Guidelines of treatment and management of hemophilia are available at:
https://www.hemophilia.org
AHF, human/VWF, human HUMATE-P Tier 4

antihemophilic factor ALPHANATE Tier 4
antihemophilic factor HEMOFIL M Tier 4
antihemophilic factor KOATE-DVI Tier 4
antihemophilic factor recombinant, Fc fusion protein ELOCTATE Tier 4
antihemophilic factor, recombinant ADVATE Tier 4
antihemophilic factor, recombinant AFSTYLA Tier 4
antihemophilic factor, recombinant KOGENATE FS Tier 4
antihemophilic factor, recombinant KOVALTRY Tier 4
antihemophilic factor, recombinant NOVOEIGHT Tier 4
antihemophilic factor, recombinant RECOMBINATE Tier 4
49
antihemophilic factor, recombinant XYNTHA Tier 4
antihemophilic factor, recombinant XYNTHA SOLOFUSE Tier 4
anti-inhibitor coagulant complex FEIBA VH IMMUNO Tier 4
coagulation factor IX (recombinant), glycopegylated REBINYN Tier 4
coagulation factor IX, recombinant IDELVION Tier 4
coagulation factor IX, recombinant IXINITY Tier 4
coagulation factor VIIa NOVOSEVEN RT Tier 4
coagulation factor X, human COAGADEX Tier 4
desmopressin spray STIMATE Tier 4
emicizumab-kxwh HEMLIBRA Tier 4
factor IX concentrate ALPHANINE SD Tier 4
factor IX concentrate BENEFIX Tier 4
factor IX concentrate PROFILNINE Tier 4
factor IX concentrate RIXUBIS Tier 4
factor IX recombinant, Fc fusion protein ALPROLIX Tier 4
factor XIII A-subunit recombinant TRETTEN Tier 4
factor XIII concentrate CORIFACT Tier 4
fibrinogen RIASTAP Tier 4
human coagulation factor VIII (rDNA) simoctocog alfa NUWIQ Tier 4
von Willebrand factor, recombinant VONVENDI Tier 4
VWF, human/factor VIII complex WILATE Tier 4
antihemophilic factor (recombinant) pegylated ADYNOVATE Tier 5
antihemophilic factor (recombinant) pegylated-aucl JIVI Tier 5
antihemophilic factor (recombinant) porcine sequence OBIZUR Tier 5
antihemophilic factor (recombinant), glycopegylated-exei ESPEROCT Tier 5
coagulation factor VIIa-jncw SEVENFACT Tier 5
fibrinogen FIBRYGA Tier 5
IDIOPATHIC THROMBOCYTOPENIC PURPURA AGENTS

PA eltrombopag PROMACTA Tier 4
PA romiplostim NPLATE Tier 4
PA fostamatinib TAVALISSE Tier 5
PAROXYSMAL NOCTURNAL HEMOGLOBINURIA (PNH) AGENTS

PA eculizumab SOLIRIS Tier 4
PA ravulizumab-cwvz ULTOMIRIS Tier 5
PLATELET AGGREGATION INHIBITORS

clopidogrel Tier 1 PLAVIX Tier 3
dipyridamole Tier 1
dipyridamole ext-rel/aspirin Tier 1
prasugrel Tier 1 EFFIENT Tier 3
PA aspirin ext-rel DURLAZA Tier 3
cangrelor KENGREAL Tier 3
ticagrelor BRILINTA Tier 3
tirofiban inj AGGRASTAT Tier 3
vorapaxar ZONTIVITY Tier 3
PLATELET SYNTHESIS INHIBITORS

anagrelide Tier 1 AGRYLIN Tier 3
SICKLE CELL DISEASE

PA crizanlizumab-tmca ADAKVEO Tier 4
PA voxelotor OXBRYTA Tier 4
50
STEM CELL MOBILIZERS
PA plerixafor MOZOBIL Tier 4
THROMBOCYTOPENIA AGENTS
QL lusutrombopag MULPLETA Tier 5
MISCELLANEOUS
aminocaproic acid Tier 1 AMICAR Tier 3
cilostazol Tier 1
pentoxifylline ext-rel Tier 1
tranexamic acid Tier 1 CYKLOKAPRON inj Tier 3
tranexamic acid Tier 1 LYSTEDA Tier 3
PA deferasirox Tier 4 EXJADE Tier 5
PA deferasirox Tier 4 JADENU Tier 5
PA deferiprone Tier 4 FERRIPROX Tier 4
deferoxamine Tier 4 DESFERAL Tier 5
alteplase CATHFLO ACTIVASE Tier 2
PA luspatercept-aamt REBLOZYL Tier 4
PA protein C concentrate, human CEPROTIN Tier 4
PA avatrombopag DOPTELET Tier 5
PA L-glutamine oral powder ENDARI Tier 5
PA mitapivat PYRUKYND Tier 5
PA ropeginterferon alfa-2b-njft BESREMI Tier 5
PA sutimlimab-jome ENJAYMO Tier 5
IMMUNOLOGIC AGENTS
Guidelines for the management of rheumatic diseases are available at:
https://www.rheumatology.org
ALLERGENIC EXTRACTS
PA grass mixed pollen allergen extract ORALAIR Tier 5
PA peanut allergen-dfnp PALFORZIA Tier 5
AUTOIMMUNE AGENTS
PA adalimumab HUMIRA Tier 4
PA apremilast OTEZLA Tier 4
PA etanercept ENBREL Tier 4
PA etanercept ENBREL SURECLICK Tier 4
PA golimumab SIMPONI 100 mg Tier 4
PA guselkumab TREMFYA Tier 4
PA ixekizumab TALTZ Tier 4
PA risankizumab-rzaa SKYRIZI Tier 4
PA tocilizumab ACTEMRA Tier 4
PA tofacitinib XELJANZ Tier 4
PA tofacitinib ext-rel XELJANZ XR Tier 4
PA upadacitinib RINVOQ ER Tier 4
PA ustekinumab STELARA Tier 4
PA ustekinumab STELARA SUBCUTANEOUS Tier 4
PA abatacept ORENCIA Tier 5
PA anakinra KINERET Tier 5
PA baricitinib OLUMIANT Tier 5
PA brodalumab SILIQ Tier 5
PA certolizumab pegol CIMZIA Tier 5
PA golimumab SIMPONI 50 mg Tier 5
PA, * infliximab REMICADE
51
PA, * infliximab-abda RENFLEXIS
PA, * infliximab-axxq AVSOLA
PA, * infliximab-dyyb INFLECTRA
PA sarilumab KEVZARA Tier 5
PA satralizumab-mwge ENSPRYNG Tier 5
PA secukinumab COSENTYX Tier 5
PA tildrakizumab-asmn ILUMYA Tier 5
* Medical Benefit only drug
DISEASE-MODIFYING ANTIRHEUMATIC DRUGS (DMARDs)

hydroxychloroquine Tier 1 PLAQUENIL Tier 3
leflunomide Tier 1 ARAVA Tier 3
methotrexate inj Tier 1
methotrexate oral Tier 1
penicillamine tabs Tier 1 DEPEN Tier 3
auranofin RIDAURA Tier 3
PA methotrexate auto-injector RASUVO Tier 3
PA methotrexate inj OTREXUP Tier 3
PA methotrexate prefilled syringe REDITREX Tier 3
HEREDITARY ANGIOEDEMA AGENTS

PA icatibant Tier 4 FIRAZYR Tier 5
PA C1 esterase inhibitor BERINERT Tier 4
PA C1 esterase inhibitor CINRYZE Tier 4
PA ecallantide KALBITOR Tier 4
PA berotralstat ORLADEYO Tier 5
PA C1 esterase inhibitor HAEGARDA Tier 5
PA C1 esterase inhibitor, recombinant RUCONEST Tier 5
PA lanadelumab-flyo TAKHZYRO Tier 5
IMMUNE GLOBULINS
hepatitis B immune globulin HEPAGAM B Tier 4
hepatitis B immune globulin HYPERHEP B S-D Tier 4
hepatitis B immune globulin NABI-HB Tier 4
PA immune globulin (human)-ifas PANZYGA Tier 4
PA immune globulin, gamma GAMASTAN Tier 4
PA immune globulin, gamma GAMUNEX-C Tier 4
PA immune globulin, gamma (IGG) GAMMAKED Tier 4
PA immune globulin, gamma (IGG) GAMMAPLEX Tier 4
PA immune globulin, intravenous BIVIGAM Tier 4
PA immune globulin, intravenous FLEBOGAMMA Tier 4
PA immune globulin, intravenous GAMMAGARD LIQUID Tier 4
PA immune globulin, intravenous GAMMAGARD S-D Tier 4
PA immune globulin, intravenous OCTAGAM Tier 4
PA immune globulin, intravenous PRIVIGEN Tier 4
PA immune globulin, subcutaneous HIZENTRA Tier 4
PA immune globulin/hyaluronidase HYQVIA Tier 4
Rho (D) immune globulin HYPERRHO S-D Tier 4
Rho (D) immune globulin MICRHOGAM Tier 4
Rho (D) immune globulin MICRHOGAM PLUS Tier 4
Rho (D) immune globulin RHOGAM Tier 4
Rho (D) immune globulin RHOGAM PLUS Tier 4
Rho (D) immune globulin RHOPHYLAC Tier 4
Rho (D) immune globulin WINRHO SDF Tier 4
varicella zoster immune globulin VARIZIG Tier 4
52
PA immune globulin (human)-klhw XEMBIFY Tier 5
PA immune globulin (human)-slra ASCENIV Tier 5
PA immune globulin, subcutaneous CUVITRU Tier 5
PA immune globulin-hipp CUTAQUIG Tier 5
IMMUNOMODULATORS
CDC recommendations on the treatment of hepatitis are available at:
https://www.cdc.gov/hepatitis/Resources/
Guidelines for the management of hepatitis are available at:

https://www.aasld.org
Interferons
PA interferon alfa-2b INTRON A Tier 4
PA interferon gamma-1b, recombinant ACTIMMUNE Tier 4
PA peginterferon alfa-2a PEGASYS Tier 4
Miscellaneous
bezlotoxumab ZINPLAVA Tier 3
PA canakinumab ILARIS Tier 4
PA rilonacept ARCALYST Tier 4
IMMUNOSUPPRESSANTS
Antimetabolites
azathioprine Tier 1 IMURAN Tier 3
mycophenolate mofetil Tier 1 CELLCEPT Tier 3
mycophenolate sodium delayed-rel Tier 1 MYFORTIC Tier 3
Calcineurin Inhibitors
cyclosporine Tier 1 SANDIMMUNE Tier 3
cyclosporine, modified Tier 1 NEORAL Tier 3
tacrolimus Tier 1 PROGRAF Tier 3
tacrolimus ext-rel ASTAGRAF XL Tier 2
tacrolimus ext-rel ENVARSUS XR Tier 3
PA voclosporin LUPKYNIS Tier 5
Rapamycin Derivatives
sirolimus Tier 1 RAPAMUNE Tier 3
PA, * everolimus Tier 4 ZORTRESS Tier 5
* Prior approval required for brand ZORTRESS only
Miscellaneous
belatacept NULOJIX Tier 4
PA belimumab BENLYSTA Tier 4
PA avacopan TAVNEOS Tier 5
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES
Potassium
potassium chloride ext-rel Tier 1
potassium chloride liquid Tier 1
potassium chloride powder Tier 1
53
VITAMINS AND MINERALS
Folic Acid Agents
folic acid Tier 1
Prenatal Vitamins
prenatal vitamins/folic acid DUET DHA Tier 2
prenatal vitamins/folic acid PRENATE ELITE Tier 2
prenatal vitamins/folic acid VITAFOL-OB Tier 3
Miscellaneous
cyanocobalamin inj Tier 1
ergocalciferol (D2) Tier 1
ferumoxytol inj Tier 1 FERAHEME Tier 3
phytonadione Tier 1 MEPHYTON Tier 3
sodium ferric gluconate inj Tier 1 FERRLECIT Tier 3
cyanocobalamin spray NASCOBAL Tier 2
iron sucrose inj VENOFER Tier 2
zinc acetate GALZIN Tier 2
ferric carboxymaltose inj INJECTAFER Tier 3
ferric derisomaltose inj MONOFERRIC Tier 3
ferric maltol ACCRUFER Tier 3
MISCELLANEOUS
PA triheptanoin DOJOLVI Tier 5
RESPIRATORY
Guidelines to the management, prevention, or treatment of COPD and asthma are available at:
https://www.aaaai.org
https://ginasthma.org
https://goldcopd.org
https://www.nhlbi.nih.gov
The Allergy Report and guidelines for allergy-related conditions are available at:
https://www.aaaai.org
ALPHA-1 ANTITRYPSIN DEFICIENCY AGENTS

PA alpha-1 proteinase inhibitor ARALAST NP Tier 4
PA alpha-1 proteinase inhibitor GLASSIA Tier 4
PA alpha-1 proteinase inhibitor PROLASTIN-C Tier 4
PA alpha-1 proteinase inhibitor ZEMAIRA Tier 4
ANAPHYLAXIS TREATMENT AGENTS

epinephrine auto-injector 0.15 mg Tier 1 EPIPEN JR. Tier 3
epinephrine auto-injector 0.30 mg Tier 1 EPIPEN Tier 3
epinephrine inj (0.15 mg and 0.30 mg) SYMJEPI Tier 2
ANTICHOLINERGICS
ipratropium soln Tier 1
ipratropium, CFC-free aerosol ATROVENT HFA Tier 2
tiotropium SPIRIVA Tier 2
tiotropium SPIRIVA RESPIMAT Tier 2
aclidinium bromide TUDORZA PRESSAIR Tier 3
glycopyrrolate inhalation solution LONHALA MAGNAIR Tier 3
revefenacin inhalation solution YUPELRI Tier 3
umeclidinium bromide INCRUSE ELLIPTA Tier 3
54
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
Short Acting
ipratropium/albuterol soln Tier 1
ipratropium/albuterol, CFC-free aerosol COMBIVENT RESPIMAT Tier 3
Long Acting
tiotropium/olodaterol STIOLTO RESPIMAT Tier 2
umeclidinium/vilanterol ANORO ELLIPTA Tier 2
aclidinium bromide/formoterol fumarate DUAKLIR PRESSAIR Tier 3
glycopyrrolate/formoterol BEVESPI AEROSPHERE Tier 3
ANTICHOLINERGIC/BETA AGONIST/STEROID INHALANT COMBINATIONS

fluticasone/umeclidinium/vilanterol TRELEGY ELLIPTA Tier 2
budesonide/glycopyrrolate/formoterol BREZTRI AEROSPHERE Tier 3
ANTIHISTAMINES, LOW SEDATING

levocetirizine Tier 1
ANTIHISTAMINES, NONSEDATING
desloratadine Tier 1 CLARINEX Tier 3
ANTIHISTAMINES, SEDATING
cyproheptadine Tier 1
diphenhydramine Tier 1
hydroxyzine HCl Tier 1
hydroxyzine pamoate Tier 1 VISTARIL Tier 3
promethazine Tier 1
ANTIHISTAMINE/DECONGESTANT COMBINATIONS
desloratadine/pseudoephedrine ext-rel CLARINEX-D Tier 3
ANTITUSSIVES
Clinical practice guidelines are available at:
https://journal.chestnet.org/article/S0012-3692(15)52856-0/pdf
benzonatate Tier 1
ANTITUSSIVE COMBINATIONS
Opioid
QL codeine/promethazine Tier 1
QL codeine/promethazine/phenylephrine Tier 1
QL hydrocodone/homatropine Tier 1
BETA AGONISTS
Inhalants
Short Acting
albuterol soln Tier 1
albuterol sulfate, CFC-free aerosol Tier 1 PROAIR HFA Tier 3
albuterol sulfate, CFC-free aerosol Tier 1 PROVENTIL HFA Tier 3
albuterol sulfate, CFC-free aerosol Tier 1 VENTOLIN HFA Tier 3
levalbuterol inhalation soln Tier 1 XOPENEX SOLUTION Tier 3
levalbuterol nebulizer soln concentrate Tier 1 XOPENEX CONCENTRATE Tier 3
levalbuterol tartrate, CFC-free aerosol Tier 1 XOPENEX HFA Tier 3
albuterol sulfate aerosol powder breath-activated PROAIR RESPICLICK Tier 2
albuterol sulfate aerosol powder 108mcg/actuation with sensor PROAIR DIGIHALER Tier 3
55
Long Acting
Hand-held Active Inhalation
salmeterol xinafoate SEREVENT DISKUS Tier 2
formoterol inhalation caps FORADIL Tier 3
olodaterol, CFC-free aerosol STRIVERDI RESPIMAT Tier 3
Nebulized Passive Inhalation

arformoterol soln Tier 1 BROVANA Tier 3
formoterol inhalation soln Tier 1 PERFOROMIST Tier 3
Oral Agents
albuterol Tier 1
terbutaline Tier 1
CYSTIC FIBROSIS
tobramycin inhalation soln Tier 4 BETHKIS Tier 5
tobramycin inhalation soln Tier 4 KITABIS PAK Tier 5
tobramycin inhalation soln Tier 4 TOBI Tier 5
aztreonam lysine inhalation soln CAYSTON Tier 4
PA dornase alfa PULMOZYME Tier 4
PA elexacaftor/tezacaftor/ivacaftor + ivacaftor TRIKAFTA Tier 4
PA ivacaftor KALYDECO Tier 4
PA lumacaftor/ivacaftor ORKAMBI Tier 4
PA tezacaftor/ivacaftor + ivacaftor SYMDEKO Tier 4
tobramycin inhalation powder TOBI PODHALER Tier 4
PA amikacin liposome inhalation susp ARIKAYCE Tier 5
PA mannitol inhalation powder BRONCHITOL Tier 5
LEUKOTRIENE MODULATORS
montelukast Tier 1 SINGULAIR Tier 3
zafirlukast Tier 1 ACCOLATE Tier 3
zileuton ZYFLO Tier 2
MAST CELL STABILIZERS

cromolyn soln Tier 1
NASAL ANTIHISTAMINES
azelastine spray Tier 1
olopatadine spray Tier 1 PATANASE Tier 3
NASAL STEROIDS/COMBINATIONS
azelastine/fluticasone nasal spray Tier 1 DYMISTA Tier 3
flunisolide spray Tier 1
fluticasone spray Tier 1
mometasone spray Tier 1
ciclesonide spray OMNARIS Tier 2
fluticasone furoate spray VERAMYST Tier 2
beclomethasone spray BECONASE AQ Tier 3
PA fluticasone propionate XHANCE Tier 3
PHOSPHODIESTERASE-4 INHIBITORS
roflumilast DALIRESP Tier 3
PULMONARY FIBROSIS AGENTS

PA pirfenidone tabs Tier 4 ESBRIET tabs Tier 5
PA nintedanib OFEV Tier 4
56
PA pirfenidone 267mg caps ESBRIET 267mg caps Tier 4
SEVERE ASTHMA AGENTS

PA omalizumab XOLAIR Tier 4
PA mepolizumab NUCALA Tier 5
STEROID/BETA AGONIST COMBINATIONS

budesonide/formoterol Tier 1 SYMBICORT Tier 3
fluticasone/salmeterol Tier 1 ADVAIR Tier 3
fluticasone/salmeterol Tier 1 AIRDUO RESPICLICK Tier 3
fluticasone/salmeterol, CFC-free aerosol ADVAIR HFA Tier 2
fluticasone/vilanterol BREO ELLIPTA Tier 2
mometasone/formoterol DULERA Tier 2
fluticasone/salmeterol AIRDUO DIGIHALER Tier 3
STEROID INHALANTS
budesonide inhalation suspension Tier 1 PULMICORT RESPULES Tier 3
beclomethasone breath-activated aerosol QVAR REDIHALER Tier 2
beclomethasone, CFC-free aerosol QVAR Tier 2
budesonide PULMICORT FLEXHALER Tier 2
fluticasone ARNUITY ELLIPTA Tier 2
fluticasone FLOVENT Tier 2
fluticasone, CFC-free aerosol FLOVENT HFA Tier 2
ciclesonide ALVESCO Tier 3
fluticasone propionate ARMONAIR DIGIHALER Tier 3
mometasone ASMANEX Tier 3
mometasone, CFC-free aerosol ASMANEX HFA Tier 3
XANTHINES
caffeine citrate Tier 1 CAFCIT Tier 3
theophylline ext-rel tabs Tier 1
theophylline ext-rel caps THEO-24 Tier 2
theophylline liquid ELIXOPHYLLIN Tier 2
MISCELLANEOUS
ipratropium nasal spray Tier 1
PA benralizumab FASENRA Tier 5
PA reslizumab inj CINQAIR Tier 5
TOPICAL
DERMATOLOGY
Acne
Guidelines for the care and treatment of acne vulgaris are available at:
https://www.aad.org/practicecenter/quality/clinical-guidelines
Oral
isotretinoin Tier 1
PA, * isotretinoin Tier 1 ABSORICA Tier 3
minocycline ext-rel caps Tier 1 XIMINO Tier 3
* Brand ABSORICA requires PA
Topical
PA adapalene crm, gel Tier 1 DIFFERIN Tier 3
PA adapalene/benzoyl peroxide Tier 1 EPIDUO Tier 3
PA adapalene/benzoyl peroxide Tier 1 EPIDUO FORTE Tier 3
57
benzoyl peroxide Tier 1 BENZAC AC Tier 3
QL clindamycin gel, lotion, soln Tier 1 CLEOCIN T Tier 3
clindamycin swabs Tier 1
clindamycin/benzoyl peroxide Tier 1
clindamycin/benzoyl peroxide Tier 1 ACANYA Tier 3
PA clindamycin/tretinoin Tier 1 VELTIN Tier 3
PA clindamycin/tretinoin Tier 1 ZIANA Tier 3
QL erythromycin gel 2% Tier 1 ERYGEL Tier 3
QL erythromycin soln Tier 1
erythromycin/benzoyl peroxide Tier 1 BENZAMYCIN Tier 3
QL, * sulfacetamide sodium Tier 1
PA tazarotene crm 0.1% Tier 1 TAZORAC Tier 3
PA tretinoin Tier 1 ATRALIN Tier 3
PA tretinoin Tier 1 RETIN-A Tier 3
PA tretinoin gel microsphere Tier 1 RETIN-A MICRO Tier 3
azelaic acid AZELEX Tier 3
PA clascoterone WINLEVI Tier 3
clindamycin/benzoyl peroxide ONEXTON Tier 3
QL minocycline hcl micronized foam AMZEEQ Tier 3
PA tazarotene crm 0.05%, gel 0.05%, 0.1% TAZORAC Tier 3
PA tazarotene foam 0.1% FABIOR Tier 3
PA tazarotene lotion 0.045% ARAZLO Tier 3
PA trifarotene cream 0.005% AKLIEF Tier 3
* generic for OVACE and OVACE PLUS
Actinic Keratosis
PA diclofenac sodium 3% gel Tier 1
fluorouracil Tier 1 CARAC Tier 3
fluorouracil Tier 1 EFUDEX Tier 3
PA aminolevulinic acid gel 10% AMELUZ Tier 3
PA aminolevulinic acid soln LEVULAN KERASTICK Tier 3
fluorouracil FLUOROPLEX Tier 3
PA tirbanibulin KLISYRI Tier 3
Antibiotics
QL gentamicin crm Tier 1
mafenide acetate packets 5% Tier 1 SULFAMYLON Tier 3
QL mupirocin Tier 1
silver sulfadiazine Tier 1 SILVADENE Tier 3
retapamulin ALTABAX Tier 2
PA ozenoxacin XEPI Tier 3
Antifungals
QL ciclopirox Tier 1 LOPROX Tier 3
QL clotrimazole Tier 1
QL clotrimazole/betamethasone Tier 1
QL econazole Tier 1
QL ketoconazole Tier 1
PA luliconazole Tier 1 LUZU Tier 3
QL miconazole nitrate/zinc oxide Tier 1 VUSION Tier 3
QL naftifine Tier 1 NAFTIN (EXCEPT 2% GEL) Tier 3
QL nystatin Tier 1
PA oxiconazole crm Tier 1 OXISTAT Tier 3
PA sulconazole Tier 1 EXELDERM Tier 3
PA tavaborole sol 5% Tier 1 KERYDIN Tier 3
58
QL naftifine gel 2% NAFTIN GEL 2% Tier 2
butenafine MENTAX Tier 3
PA econazole foam ECOZA Tier 3
PA efinaconazole JUBLIA Tier 3
PA sertaconazole ERTACZO Tier 3
Antipsoriatics
Guidelines of care for the management and treatment of psoriasis with topical therapies are available at:
https://www.aad.org
Oral
acitretin Tier 1
methoxsalen oral Tier 1
Topical
QL betamethasone dipropionate/calcipotriene oint, susp Tier 1
QL calcipotriene Tier 1 DOVONEX Tier 3
QL, * calcipotriene foam Tier 1 SORILUX Tier 3
calcitriol oint Tier 1 VECTICAL Tier 3
PA calcipotriene/betamethasone dipropionate cream WYNZORA Tier 3
QL calcipotriene/betamethasone foam ENSTILAR Tier 3
PA halobetasol propionate/tazarotene DUOBRII Tier 3
* Does not include NDC 73308-0357-60
Antiseborrheics
QL ketoconazole shampoo 2% Tier 1 NIZORAL SHAMPOO Tier 3
Atopic Dermatitis
Guidelines for the treatment of atopic dermatitis are available at:
https://www.aad.org/practicecenter/quality/clinical-guidelines
Injectable
PA dupilumab DUPIXENT Tier 5
PA tralokinumab-ldrm ADBRY Tier 5
Oral
PA abrocitinib CIBINQO Tier 5
Topical
pimecrolimus Tier 1 ELIDEL Tier 3
tacrolimus Tier 1 PROTOPIC Tier 3
PA crisaborole oint EUCRISA Tier 3
PA ruxolitinib OPZELURA Tier 3
Corticosteroids
Low Potency
QL alclometasone crm, oint 0.05% Tier 1
QL desonide crm 0.05% Tier 1 DESOWEN Tier 3
QL desonide gel 0.05% Tier 1
QL desonide lotion, oint 0.05% Tier 1
QL fluocinolone acetonide soln 0.01% Tier 1
QL hydrocortisone crm 2.5% Tier 1
QL desonide foam 0.05% VERDESO Tier 2
QL fluocinolone shampoo 0.01% CAPEX Tier 3
pramoxine/hydrocortisone PRAMOSONE Tier 3
59
Medium Potency
QL betamethasone dipropionate crm, lotion 0.05% Tier 1
QL betamethasone valerate crm, lotion, oint 0.1% Tier 1
QL clocortolone pivalate crm 0.1% Tier 1 CLODERM Tier 3
QL desoximetasone crm, oint 0.05% Tier 1
QL fluocinolone acetonide crm, oint 0.025% Tier 1 SYNALAR Tier 3
QL fluocinolone acetonide oil 0.01% Tier 1 DERMA-SMOOTHE/FS Tier 3
QL flurandrenolide crm, lotion, oint 0.05% Tier 1 CORDRAN crm, lotion, oint Tier 3
QL fluticasone propionate crm 0.05%, oint 0.005% Tier 1
QL fluticasone propionate lotion 0.05% Tier 1
QL hydrocortisone butyrate crm 0.1% Tier 1 LOCOID LIPOCREAM Tier 3
QL hydrocortisone butyrate crm, lotion, oint, soln 0.1% Tier 1
QL hydrocortisone valerate crm, oint 0.2% Tier 1
QL mometasone crm, lotion, oint 0.1% Tier 1
QL triamcinolone acetonide crm, lotion 0.025% Tier 1
QL triamcinolone acetonide crm, lotion, oint 0.1% Tier 1
QL flurandrenolide tape CORDRAN TAPE Tier 2
QL betamethasone dipropionate spray 0.05% SERNIVO Tier 3
QL hydrocortisone probutate crm 0.1% PANDEL Tier 3
High Potency
QL amcinonide crm, lotion, oint 0.1% Tier 1
QL betamethasone dipropionate augmented crm 0.05% Tier 1
QL desoximetasone crm, oint, spray 0.25%, gel 0.05% Tier 1 TOPICORT Tier 3
QL diflorasone diacetate crm 0.05% Tier 1
QL fluocinonide crm, gel, oint, soln 0.05% Tier 1
QL triamcinolone acetonide crm 0.5% Tier 1
QL triamcinolone acetonide topical spray Tier 1 KENALOG SPRAY Tier 3
QL diflorasone diacetate emollient crm 0.05% APEXICON E Tier 3
QL halcinonide crm, oint, soln 0.1% HALOG Tier 3
Very High Potency

QL betamethasone dipropionate augmented gel, lotion 0.05% Tier 1
QL betamethasone dipropionate augmented oint 0.05% Tier 1 DIPROLENE oint 0.05% Tier 3
QL betamethasone dipropionate oint 0.05% Tier 1
QL clobetasol propionate crm, gel, oint, soln 0.05% Tier 1 TEMOVATE Tier 3
QL clobetasol propionate lotion, shampoo, spray 0.05% Tier 1 CLOBEX Tier 3
QL diflorasone diacetate oint 0.05% Tier 1
QL fluocinonide crm 0.1% Tier 1
QL halobetasol propionate crm, oint 0.05% Tier 1 ULTRAVATE Tier 3
QL clobetasol propionate lotion IMPEKLO Tier 3
Emollients
ammonium lactate 12% Tier 1
Local Analgesics
QL lidocaine patch Tier 1 LIDODERM Tier 3
PA capsaicin 8% patch QUTENZA Tier 3
Local Anesthetics
QL lidocaine Tier 1
QL lidocaine/prilocaine Tier 1
Rosacea
PA azelaic acid gel Tier 1 FINACEA Tier 3
60
doxycycline monohydrate delayed-rel caps Tier 1 ORACEA Tier 3
PA ivermectin crm 1% Tier 1 SOOLANTRA Tier 3
QL metronidazole crm 0.75% Tier 1 METROCREAM Tier 3
QL metronidazole gel 0.75% Tier 1
metronidazole gel 1% Tier 1 METROGEL Tier 3
metronidazole lotion 0.75% Tier 1 METROLOTION Tier 3
PA brimonidine topical gel MIRVASO Tier 3
PA metronidazole crm NORITATE Tier 3
QL minocycline foam ZILXI Tier 3
PA oxymetazoline crm 1% RHOFADE Tier 3
Scabicides and Pediculicides

ivermectin Tier 1
lindane Tier 1
permethrin 5% Tier 1
spinosad Tier 1 NATROBA Tier 3
Miscellaneous Skin and Mucous Membrane

acyclovir Tier 1 ZOVIRAX Tier 3
QL doxepin crm Tier 1 ZONALON Tier 3
d, PA hydrocortisone/aloe polysaccharide/iodoquinol Tier 1
d, PA hydrocortisone/iodoquinol Tier 1
PA imiquimod Tier 1
PA imiquimod crm 3.75% Tier 1 ZYCLARA Tier 2
podofilox Tier 1 CONDYLOX Tier 3
alitretinoin PANRETIN Tier 2
PA becaplermin REGRANEX Tier 2
absorbable fibrin sealant TACHOSIL Tier 3
PA glycopyrronium pads QBREXZA Tier 3
penciclovir DENAVIR Tier 3
PA collagenase clostridium histolyticum XIAFLEX Tier 4
PA interferon alfa-n3 ALFERON N Tier 4
MOUTH/THROAT/DENTAL AGENTS
Anesthetics - Topical Oral
lidocaine viscous Tier 1
Steroids - Mouth/Throat
triamcinolone paste Tier 1
Miscellaneous
sodium fluoride Tier 1 PREVIDENT Tier 3
OPHTHALMIC
Preferred Practice Pattern Guidelines for the treatment of various ophthalmic conditions are available at:
https://one.aao.org
Antiallergics
bepotastine Tier 1 BEPREVE Tier 3
cromolyn sodium Tier 1
epinastine Tier 1
olopatadine Tier 1
phenylephrine Tier 1
alcaftadine LASTACAFT Tier 3
lodoxamide ALOMIDE Tier 3
61
Antifungals
natamycin NATACYN Tier 2
Anti-infectives
bacitracin Tier 1
ciprofloxacin Tier 1 CILOXAN Tier 3
erythromycin Tier 1
levofloxacin Tier 1
moxifloxacin Tier 1
moxifloxacin Tier 1 VIGAMOX Tier 3
neomycin/polymyxin B/gramicidin Tier 1
ofloxacin Tier 1 OCUFLOX Tier 3
polymyxin B/bacitracin Tier 1
polymyxin B/trimethoprim Tier 1 POLYTRIM Tier 3
sulfacetamide soln 10% Tier 1 BLEPH-10 Tier 3
tobramycin Tier 1 TOBREX Tier 3
azithromycin AZASITE Tier 2
besifloxacin BESIVANCE Tier 2
Anti-infective/Anti-inflammatory Combinations
neomycin/dexamethasone Tier 1
neomycin/polymyxin B/dexamethasone Tier 1 MAXITROL Tier 3
neomycin/polymyxin B/hydrocortisone susp Tier 1
sulfacetamide/prednisolone phosphate 10%/0.25% Tier 1
tobramycin/dexamethasone susp 0.3%/0.1% Tier 1 TOBRADEX SUSPENSION Tier 3
tobramycin/dexamethasone oint 0.3%/0.1% TOBRADEX OINTMENT Tier 2
tobramycin/loteprednol ZYLET Tier 2
gentamicin/prednisolone acetate PRED-G Tier 3
sulfacetamide/prednisolone acetate oint 10%/0.2% BLEPHAMIDE SOP Tier 3
Anti-inflammatories
Nonsteroidal
bromfenac sodium Tier 1
diclofenac sodium Tier 1
flurbiprofen Tier 1
ketorolac 0.5% Tier 1 ACULAR Tier 3
bromfenac 0.075% BROMSITE Tier 3
bromfenac sodium 0.07% PROLENSA Tier 3
ketorolac 0.45% ACUVAIL Tier 3
nepafenac NEVANAC Tier 3
nepafenac 0.3% ILEVRO Tier 3
Steroidal
dexamethasone sodium phosphate Tier 1
difluprednate Tier 1 DUREZOL Tier 3
fluorometholone Tier 1 FML Tier 3
loteprednol 0.5% gel, susp Tier 1 LOTEMAX Gel, Susp Tier 3
prednisolone acetate 1% Tier 1 PRED FORTE Tier 3
prednisolone phosphate 1% Tier 1
loteprednol LOTEMAX SM Tier 2
loteprednol 0.2% ALREX Tier 2
loteprednol oint LOTEMAX Oint Tier 2
prednisolone acetate 0.12% PRED MILD Tier 2
rimexolone VEXOL Tier 2
dexamethasone MAXIDEX Tier 3
fluorometholone acetate FLAREX Tier 3
62
loteprednol 1.0% INVELTYS Tier 3
Antivirals
trifluridine Tier 1
ganciclovir ZIRGAN Tier 2
Beta-blockers
Nonselective
carteolol Tier 1
levobunolol Tier 1
timolol maleate Tier 1 ISTALOL Tier 3
timolol maleate Tier 1 TIMOPTIC Tier 3
timolol maleate gel Tier 1 TIMOPTIC-XE Tier 3
timolol hemihydrate BETIMOL Tier 3
Selective
betaxolol BETOPTIC S Tier 3
Carbonic Anhydrase Inhibitors

Topical
brinzolamide Tier 1 AZOPT Tier 3
dorzolamide Tier 1 TRUSOPT Tier 3
Carbonic Anhydrase Inhibitor/Beta-blocker Combinations

dorzolamide/timolol maleate Tier 1 COSOPT Tier 3
Carbonic Anhydrase Inhibitor/Sympathomimetic Combinations

brinzolamide/brimonidine SIMBRINZA Tier 2
Dry Eye Disease

PA cyclosporine, emulsion Tier 1 RESTASIS Tier 3
PA lifitegrast XIIDRA Tier 2
PA cyclosporine eye solution CEQUA Tier 3
PA loteprednol etabonate EYSUVIS Tier 3
PA varenicline nasal solution TYRVAYA Tier 3
Mydriatics
atropine sulfate soln Tier 1
cyclopentolate Tier 1 CYCLOGYL Tier 3
scopolamine ISOPTO HYOSCINE Tier 2
Neurotrophic Keratitis
PA cenegermin-bkbj OXERVATE Tier 4
Parasympathomimetics
pilocarpine PILOPINE HS GEL Tier 3
Prostaglandins
latanoprost Tier 1 XALATAN Tier 3
travoprost Tier 1 TRAVATAN Z Tier 3
bimatoprost 0.01% LUMIGAN Tier 2
latanoprost ophthalmic emulsion XELPROS Tier 3
latanoprostene bunod VYZULTA Tier 3
tafluprost ZIOPTAN Tier 3
63
Retinal Disorders
PA aflibercept EYLEA Tier 4
PA ranibizumab LUCENTIS Tier 4
PA brolucizumab-dbll BEOVU Tier 5
Rho Kinase Inhibitors

netarsudil RHOPRESSA Tier 3
Rho Kinase Inhibitor/Prostaglandin Combinations

netarsudil/latanoprost ROCKLATAN Tier 3
Sympathomimetics
brimonidine 0.15% Tier 1 ALPHAGAN P 0.15% Tier 3
brimonidine 0.2% Tier 1
brimonidine 0.1% ALPHAGAN P 0.1% Tier 2
Sympathomimetic/Beta-blocker Combinations
brimonidine/timolol Tier 1 COMBIGAN Tier 3
Miscellaneous
naphazoline Tier 1
PA oxymetazoline opth soln UPNEEQ Tier 3
cysteamine CYSTARAN Tier 4
verteporfin VISUDYNE Tier 4
cysteamine CYSTADROPS Tier 5
PA teprotumumab-trbw for IV soln TEPEZZA Tier 5
OTIC
Clinical practice guidelines for the treatment of otitis media are available at:
https://www.aap.org
Anti-infectives
acetic acid Tier 1
ciprofloxacin otic Tier 1 CETRAXAL Tier 3
ofloxacin otic Tier 1
Anti-infective/Anti-inflammatory Combinations
acetic acid/hydrocortisone Tier 1
ciprofloxacin/dexamethasone Tier 1 CIPRODEX Tier 3
neomycin/polymyxin B/hydrocortisone Tier 1
ciprofloxacin/hydrocortisone CIPRO HC OTIC Tier 2
Miscellaneous
fluocinolone acetonide Tier 1 DERMOTIC Tier 3
triethanolamine polypeptide oleate CERUMENEX Tier 3
64
WEBSITES
Agency for Healthcare Research and Quality American Congress of Obstetricians and
https://www.ahrq.gov Gynecologists
https://www.acog.org
Alzheimer's Association
https://www.alz.org American Diabetes Association
http://www.diabetes.org
American Academy of Allergy, Asthma and
Immunology American Gastroenterological Association
https://www.aaaai.org https://www.gastro.org
American Academy of Child & Adolescent Psychiatry American Headache Society Committee for Headache
https://www.aacap.org Education
https://americanheadachesociety.org
American Academy of Dermatology
https://www.aad.org American Heart Association
American Academy of Neurology
https://www.aan.com American Lung Association
https://www.lung.org
American Academy of Ophthalmology
https://www.aao.org American Medical Association
https://www.ama-assn.org
American Academy of Pediatrics
https://www.aap.org American Psychiatric Association
American Association for the Study of Liver Disease
https://www.aasld.org American Society of Anesthesiologists
American Association of Clinical Endocrinologists
https://www.aace.com American Society of Clinical Oncology
American Association of Diabetes Educators
https://www.diabeteseducator.org American Society of Interventional Pain Physicians
https://www.asipp.org
American Cancer Society
https://www.cancer.org American Urological Association
https://www.auanet.org
American College of Allergy, Asthma and Immunology
https://www.acaai.org Centers for Disease Control and Prevention
https://www.cdc.gov
American College of Cardiology
https://www.acc.org Centers for Disease Control and Prevention
Guideline topics: AIDS
American College of Chest Physicians https://www.cdc.gov/hiv/default.html
https://www.chestnet.org
Centers for Disease Control and Prevention
American College of Gastroenterology Guideline topics: Sexually Transmitted Diseases
https://gi.org https://www.cdc.gov/std/treatment/default.htm
American College of Physicians CVS Caremark

https://www.acponline.org https://www.caremark.com
American College of Rheumatology The Food and Drug Administration

https://www.rheumatology.org https://www.fda.gov
65
Global Initiative for Asthma http://www.nfid.org
https://ginasthma.org
National Guideline Clearinghouse
Infectious Diseases Society of America https://www.ahrq.gov
https://www.idsociety.org
National Heart, Lung and Blood Institute
Institute for Safe Medication Practices https://www.nhlbi.nih.gov
https://www.ismp.org
National Institutes of Health
Johns Hopkins AIDS Service https://www.nih.gov
https://www.thebody.com/content/art12096.html
National Kidney Foundation
Juvenile Diabetes Research Foundation International https://www.kidney.org
https://www.jdrf.org
National Osteoporosis Foundation
MedWatch https://www.nof.org
https://www.fda.gov/Safety/MedWatch/default.htm
North American Menopause Society
National Agricultural Library https://www.menopause.org
https://www.nal.usda.gov
United States Department of Health and Human
National Cancer Institute Services
https://www.cancer.gov/about-cancer https://www.hhs.gov
National Comprehensive Cancer Network World Health Organization

https://www.nccn.org https://www.who.int
National Foundation for Infectious Diseases
66
2022 FEP EXCLUDED DRUG LIST STANDARD OPTION CHART
These listed drugs are not covered under Standard Option. If you use any of these Excluded Drugs, you will need to pay the full cost of the
drug(s).
If you are using one of these non-covered drugs, ask your doctor for one of the covered generic or brand name options.
CATEGORY* DRUGS NOT COVERED IN COVERED OPTIONS**

DRUG CLASS* 2022 FOR STANDARD OPTION
ACNE MINOLIRA azithromycin, doxycycline (except 20 mg),
ORAL ANTIBIOTICS minocycline, minocycline ext-rel,
sulfamethoxazole/trimethoprim, MINOCIN,
SOLODYN, VIBRAMYCIN, ZITHROMAX
ACNE adapalene pad, adapalene soln 0.1% adapalene crm, adapalene gel, DIFFERIN
TOPICAL
ABSORICA LD isotretinoin, ABSORICA
ALLERGIES carbinoxamine 6 mg, RYVENT desloratadine, levocetirizine (Rx), montelukast,

ANTIHISTAMINES zafirlukast, ACCOLATE, CLARINEX, CLARINEX-
D, SINGULAIR
ANAPHYLAXIS TREATMENT AUVI-Q epinephrine injection/auto-injector (0.15 mg, 0.30
mg), EPIPEN, EPIPEN JR., SYMJEPI
ANTICOAGULANTS PRADAXA, SAVAYSA warfarin, ELIQUIS, XARELTO
ANTIDIARRHEALS opium tincture diphenoxylate/atropine, loperamide
ANTIFUNGALS TOLSURA fluconazole, itraconazole, ketoconazole,
posaconazole delayed-rel tabs, voriconazole,
DIFLUCAN, NOXAFIL susp, NOXAFIL tabs,
SPORANOX, VFEND
ANTI-INFLAMMATORIES diclofenac potassium cap, diclofenac diclofenac DR/ER (except diclofenac potassium
NONSTEROIDAL ANTI-INFLAMMATORIES sodium soln 2%, fenoprofen cap 200 cap), diclofenac gel/soln (except soln 2%),
(NSAIDs) mg, indomethacin caps (20 mg, 40 etodolac/ER, flurbiprofen, ibuprofen,
mg), meloxicam caps (5 mg, 10 indomethacin/ER (except indomethacin caps 20
mg), naproxen sodium ext-rel mg, 40 mg), ketoprofen/ER, meloxicam tabs,
tablets, CAMBIA, FENORTHO, nabumetone, naproxen, oxaprozin, piroxicam,
INDOCIN SUSP, NAPRELAN, sulindac
PENNSAID 2%, QMIIZ, RELAFEN
DS, TIVORBEX, VIVLODEX,
ZIPSOR, ZORVOLEX
ANTI-INFLAMMATORIES ibuprofen/famotidine tabs, diclofenac/misoprostol, esomeprazole
NONSTEROIDAL ANTI-INFLAMMATORIES naproxen/esomeprazole magnesium magnesium delayed-rel, famotidine, ibuprofen,
(NSAIDs) COMBINATIONS tabs DR, DUEXIS, VIMOVO naproxen
CONSENSI celecoxib, CELEBREX, AND amlodipine tabs,
NORVASC
ANTIRHEUMATICS penicillamine caps, CUPRIMINE azathioprine, hydroxychloroquine, leflunomide,

methotrexate, penicillamine tabs, DEPEN
ANTISPASMODICS LIBRAX clidinium/chlordiazepoxide, dicyclomine,
hyoscyamine
DONNATAL atropine/hyoscyamine/scopolamine/phenobarbital
67
ANXIETY DISORDERS LOREEV XR alprazolam/ext-rel, chlordiazepoxide,
BENZODIAZEPINES clonazepam, clorazepate, diazepam, lorazepam,
oxazepam, ATIVAN, KLONOPIN, TRANXENE T-
TAB, VALIUM, XANAX/XR
ASTHMA zileuton ext-rel, ZYFLO CR montelukast, zafirlukast, ACCOLATE,
LEUKOTRIENE MODULATORS SINGULAIR, ZYFLO
BENIGN PROSTATIC HYPERPLASIA (BPH) UROXATRAL alfuzosin ext-rel, dutasteride,
dutasteride/tamsulosin, finasteride, silodosin,
tadalafil (2.5mg, 5mg), tamsulosin, AVODART,
CIALIS (2.5mg, 5mg), JALYN, PROSCAR,
RAPAFLO, FLOMAX
BLADDER AGENTS DETROL, DETROL LA, ENABLEX, darifenacin ext-rel, oxybutynin, oxybutynin ext-rel,
OXYTROL, VESICARE solifenacin, tolterodine, tolterodine ext-rel,
trospium, trospium ext-rel, DITROPAN XL,
GELNIQUE, GEMTESA, MYRBETRIQ, TOVIAZ,
VESICARE LS
CARDIOVASCULAR BETAPACE, BETAPACE AF sotalol, sotalol AF
ANTIARRHYTHMICS
CARDIOVASCULAR aspirin/omeprazole delayed-rel tabs, aspirin*** and esomeprazole magnesium
HEART YOSPRALA delayed-rel, lansoprazole, omeprazole,
pantoprazole, rabeprazole (except rabeprazole
capsule sprinkle delayed-rel)
CENTRAL NERVOUS SYSTEM SYMBYAX olanzapine/fluoxetine
ANTIDEPRESSANT COMBINATIONS
CENTRAL NERVOUS SYSTEM methylphenidate tab ER osmotic amphetamine/dextroamphetamine mixed
MISCELLANEOUS release 72 mg, ADZENYS XR-ODT, salts/ER, amphetamine sulfate,
COTEMPLA XR-ODT, DESOXYN, dexmethylphenidate/ER, dextroamphetamine/ER,
DYANAVEL XR, EVEKEO ODT, methylphenidate/ER (except methylphenidate tab
RELEXXII ER osmotic release 72 mg), ADDERALL,
ADDERALL XR, ADHANSIA XR, APTENSIO XR,
AZSTARYS, CONCERTA, DAYTRANA,
DEXEDRINE, EVEKEO, FOCALIN, FOCALIN
XR, JORNAY PM, METHYLIN, MYDAYIS,
PROCENTRA, QUILLICHEW ER, QUILLIVANT
XR, RITALIN, RITALIN LA, VYVANSE, ZENZEDI
COTRICOSTEROIDS DEXABLISS, DXEVO 11-DAY, dexamethasone, fludrocortisone, hydrocortisone,
ORAL MILLIPRED methylprednisolone, prednisolone, prednisone,
CORTEF, MEDROL, ORAPRED ODT, RAYOS
DERMATOLOGY ALCOTRIN-A, LOTRISONE*, ciclopirox, clotrimazole,
ANTIFUNGAL XOLEGEL clotrimazole/betamethasone, econazole,
hydrocortisone/iodoquinol,
hydrocortisone/iodoquinol/aloe, ketoconazole,
luliconazole, miconazole nitrate/zinc oxide,
naftifine, nystatin, oxiconazole crm, sulconazole,
tavaborole sol 5%, ECOZA, ERTACZO,
EXELDERM, JUBLIA, KERYDIN, LOPROX,
LUZU, MENTAX, NAFTIN, OXISTAT, VUSION
DERMATOLOGY halobetasol propionate topical foam, betamethasone dipropionate (crm, lotion, oint),
CORTICOSTEROIDS triamcinolone oint 0.05%, BRYHALI, betamethasone dipropionate augmented (crm,
LEXETTE, NOVACORT, lotion, gel, oint), clobetasol propionate,
OLUX/OLUX-E, PSORCON, diflorasone diacetate, fluocinonide (crm, gel, oint,
68
TRIANEX, VANOS soln), halobetasol propionate crm, triamcinolone
acetonide (except triamcinolone oint 0.05%),
APEXICON E, CLOBEX, DIPROLENE, HALOG,
KENALOG SPRAY, SERNIVO, TEMOVATE,
TOPICORT, ULTRAVATE
DERMATOLOGY XERESE acyclovir, hydrocortisone
MISCELLANEOUS
VEREGEN imiquimod, ZYCLARA
EXTINA ketoconazole foam 2%
OVACE, OVACE PLUS sulfacetamide sodium
DERMATOLOGY SORIATANE, TACLONEX acitretin, betamethasone

PSORIASIS dipropionate/calcipotriene (oint, susp), calcitriol,
methoxsalen, DOVONEX, DUOBRII, ENSTILAR,
SORILUX, VECTICAL, WYNZORA
DIABETES JENTADUETO, JENTADUETO XR, alogliptin, alogliptin/metformin,
DIPEPTIDYL PEPTIDASE-4 (DPP-4) KAZANO, KOMBIGLYZE XR, alogliptin/pioglitazone, JANUMET, JANUMET
INHIBITORS/COMBINATIONS NESINA, ONGLYZA, OSENI, XR, JANUVIA
TRADJENTA
DIABETES ADLYXIN, BYDUREON, OZEMPIC, RYBELSUS, TRULICITY, VICTOZA
INCRETIN MIMETIC AGENTS BYDUREON BCISE, BYETTA
DIABETES insulin glargine-yfgn, SEMGLEE BASAGLAR, LANTUS, LEVEMIR, TOUJEO,
INSULINS TRESIBA
DIABETES metformin 625mg tab, GLUMETZA, metformin (does not include 625mg tabs),
METFORMIN RIOMET ER metformin ext-rel, metformin oral soln, RIOMET
IR
DIABETES CYCLOSET alogliptin, alogliptin/metformin,
OTHER alogliptin/pioglitazone, bromocriptine mesylate,
glimepiride, glipizide, glyburide,
glyburide/metformin, pioglitazone, repaglinide
H2 RECEPTOR ANTAGONISTS PEPCID cimetidine, famotidine 40mg, nizatidine
HIGH BLOOD PRESSURE DUTOPROL metoprolol succinate ext-rel, hydrochlorothiazide
BETA-BLOCKERS/COMBINATIONS
HIGH CHOLESTEROL FENOGLIDE fenofibrate, fenofibric acid del-rel, gemfibrozil,
FIBRATES ANTARA, LIPOFEN, LOPID, TRICOR,
TRIPLEX
HIGH CHOLESTEROL simvastatin susp, ALTOPREV, atorvastatin, ezetimibe/simvastatin, fluvastatin,
STATINS FLOLIPID, ZYPITAMAG fluvastatin ext-rel, lovastatin, pravastatin,
rosuvastatin, simvastatin, CRESTOR, EZALLOR
SPRINKLE, EZETIMIBE/ROSUVASTATIN tabs,
LESCOL XL, LIPITOR, LIVALO, ROSZET,
VYTORIN, ZOCOR
INFLUENZA AGENTS FLUMADINE oseltamivir, rimantadine, RELENZA, TAMIFLU,
XOFLUZA
LAXATIVES LACTULOSE PAK 10MG, PCP 100 lactulose solution, PEG 3350/electrolytes,
CLENPIQ, GOLYTELY, KRISTALOSE,
69
MOVIPREP, OSMOPREP, PLENVU,
PREPOPIK, SUPREP
MIGRAINE AGENTS AJOVY AIMOVIG, EMGALITY 120 mg/mL, QULIPTA,
CALCITONIN GENE-RELATED PEPTIDE VYEPTI
(CGRP) INHIBITORS
UBRELVY NURTEC ODT
MIGRAINE AGENTS CAFERGOT dihydroergotamine nasal spray/inj,

ERGOTAMINE DERIVATIVES ergotamine/caffeine tabs, D.H.E. 45, MIGRANAL
MIGRAINE AGENTS REYVOW almotriptan, eletriptan, frovatriptan, naratriptan,
SELECTIVE SEROTONIN AGONISTS rizatriptan, sumatriptan, zolmitriptan, AMERGE,
FROVA, IMITREX, MAXALT, MAXALT-MLT,
ONZETRA XSAIL, RELPAX, TOSYMRA,
ZOMIG, ZOMIG-ZMT
MOVEMENT DISORDERS TASMAR amantadine, apomorphine, benztropine,
bromocriptine, carbidopa/levodopa, entacapone,
pramipexole, rasagiline, ropinirole/ER, selegiline,
tolcapone, APOKYN, AZILECT, COMTAN,
DUOPA, GOCOVRI, KYNMOBI, MIRAPEX XR,
NEUPRO, OSMOLEX ER, PARLODEL,
RYTARY, SINEMET, STALEVO, XADAGO,
ZELAPAR
MULTIPLE SCLEROSIS AMPYRA dalfampridine ER
COPAXONE glatiramer, glatopa
TECFIDERA dimethyl fumarate delayed-rel
MUSCULOSKELETAL THERAPY AGENTS cyclobenzaprine ext-rel, AMRIX baclofen, cyclobenzaprine
chlorzoxazone tab (250mg, 375mg, chlorzoxazone tab 500mg

750mg), LORZONE
orphenadrine/aspirin/caffeine tabs, aspirin***, caffeine§, baclofen, cyclobenzaprine
ORPHENGESIC FORTE
NAUSEA AND VOMITING THERAPY ANZEMET, ZUPLENZ granisetron, ondansetron, palonosetron,
(5HT-3 BLOCKER) promethazine, SANCUSO
OPHTHALMOLOGY BACIGUENT bacitracin ophthalmic
ANTI-INFECTIVES
OPHTHALMOLOGY atropine sulfate eye ointment atropine ophthalmic solution, cyclopentolate
MISCELLANEOUS ophthalmic solution
VUITY Members advised to discuss suitable therapeutic
alternatives with prescriber
PAIN MEDICATIONS pregabalin ext-rel tabs, GRALISE, gabapentin, pregabalin (does not include ext-rel
NEUROPATHIC PAIN HORIZANT, LYRICA CR tabs), LYRICA, NEURONTIN
PAIN MEDICATIONS benzhydrocodone/acetaminophen, codeine/acetaminophen,
OPIOIDS hydrocodone-acetaminophen sol 10- hydrocodone/acetaminophen,
325 mg/15 mL, oxycodone/acetaminophen (except 2.5 mg - 300,
oxycodone/acetaminophen tab (2.5 5 mg - 300 mg, 10 mg - 300 mg tabs),
mg - 300 mg, 5 mg - 300 mg, 10 mg tramadol/acetaminophen, ENDOCET, LORTAB,
70
- 300 mg), APADAZ, NALOCET, PERCOCET
PRIMLEV, PROLATE
LAZANDA fentanyl buccal, fentanyl sublingual, fentanyl
transmucosal, ACTIQ, FENTORA, SUBSYS
levorphanol hydromorphone, morphine, oxycodone, tramadol

(except 100mg tab), DILAUDID, NUCYNTA,
OPANA, ROXICODONE
tramadol 100 mg tabs, CONZIP tramadol (except 100 mg tabs), tramadol ext-rel,
tramadol/acetaminophen, ULTRAM, ULTRAM
ER
PAIN MEDICATIONS ZTLIDO lidocaine cream, lidocaine gel, lidocaine lotion,
TOPICAL lidocaine ointment, lidocaine patch 5%,
LIDODERM PATCH, QUTENZA PATCH
PROTON PUMP INHIBITORS esomeprazole strontium, rabeprazole dexlansoprazole delayed-rel, esomeprazole
capsule sprinkle delayed-rel, magnesium delayed-rel, lansoprazole delayed-
ACIPHEX, FIRST-LANSOPRAZOLE, rel, omeprazole delayed-rel, omeprazole/sodium
FIRST-OMEPRAZOLE, NEXIUM, bicarbonate, pantoprazole delayed-rel,
PREVACID, PREVACID SOLUTAB, rabeprazole (except rabeprazole capsule sprinkle
PRILOSEC, PROTONIX, ZEGERID delayed-rel), DEXILANT
SLEEP AGENTS DORAL, SECONAL doxepin, estazolam, eszopiclone, flurazepam,
quazepam, ramelteon, temazepam, triazolam,
zaleplon, zolpidem/ER, AMBIEN/CR,
BELSOMRA, DAYVIGO, EDLUAR, LUNESTA,
RESTORIL, ROZEREM, SILENOR, ZOLPIMIST
ULCERATIVE COLITIS COLAZAL balsalazide, mesalamine delayed-rel (caps, tabs),
mesalamine ext-rel caps, sulfasalazine,
sulfasalazine delayed, rel, ASACOL HD,
APRISO, AZULFIDINE, DELZICOL, DIPENTIUM,
LIALDA, PENTASA
ULCER THERAPY CARAFATE sucralfate
MISCELLANEOUS
* This list shows uses for which the drug is prescribed. Some drugs are prescribed for more than one condition.
** For more covered options, consult 2022 Standard Option formulary.
*** Multiple strengths of aspirin are covered for men age 45 through 79 and women age 50 through 79. Low-dose aspirin (81 mg per day)
for female members at risk for preeclampsia.
§ Denotes over-the-counter (OTC) availability only, and not covered through the prescription benefit.
71
INDEX
ADBRY, 59
A ADCETRIS, 21
abacavir, 15
ADCIRCA, 27
abacavir soln, 15
ADDERALL, 31
abacavir/dolutegravir/lamivudine, 14
ADDERALL XR, 31
abacavir/lamivudine, 14
adefovir dipivoxil, 16
abacavir/lamivudine/zidovudine, 14
ADEMPAS, 27
abaloparatide, 39
ADHANSIA XR, 32
abatacept, 51
ADMELOG, 37
ABELCET, 14
ADMELOG SOLOSTAR, 37
abemaciclib, 19
ado-trastuzumab emtansine, 21
ABILIFY, 31
ADRIAMYCIN, 20
ABILIFY MAINTENA, 31
ADVAIR, 57
ABILIFY MYCITE, 31
ADVAIR HFA, 57
abiraterone, 18
ADVATE, 49
abobotulinumtoxinA, 35
ADYNOVATE, 50
ABRAXANE, 20
AEMCOLO, 13
abrocitinib, 59
afatinib, 19
absorbable fibrin sealant, 61
AFINITOR, 18
ABSORICA, 57
AFINITOR DISPERZ, 18
acalabrutinib, 19
aflibercept, 64
acamprosate calcium, 34
AFREZZA, 37
ACANYA, 58
AFSTYLA, 49
acarbose, 36
agalsidase beta, 44
ACCOLATE, 56
AGGRASTAT, 50
ACCRUFER, 54
AGRYLIN, 50
ACCU-CHEK FASTCLIX LANCET DEVICE, 38
AHF, human/VWF, human, 49
ACCU-CHEK FASTCLIX LANCETS, 38
AIMOVIG, 33
ACCU-CHEK METERS AND KITS, 38
AIRDUO DIGIHALER, 57
ACCU-CHEK TEST STRIPS, 38
AIRDUO RESPICLICK, 57
ACCUPRIL, 22
AKLIEF, 58
ACCURETIC, 23
AKYNZEO, 45
acebutolol, 25
albendazole, 16
ACETADOTE, 44
albuterol, 56
acetaminophen inj, 10
albuterol soln, 55
acetazolamide, 26
albuterol sulfate aerosol powder 108mcg/actuation with sensor, 55
acetazolamide ext-rel, 26
albuterol sulfate aerosol powder breath-activated, 55
acetic acid, 64
albuterol sulfate, CFC-free aerosol, 55
acetic acid/hydrocortisone, 64
alcaftadine, 61
acetylcysteine, 44
alclometasone crm, oint 0.05%, 59
acitretin, 59
ALDACTAZIDE, 26
aclidinium bromide, 54
ALDACTONE, 23
aclidinium bromide/formoterol fumarate, 55
aldesleukin, 21
ACTEMRA, 51
ALDURAZYME, 44
ACTHAR, 45
ALECENSA, 19
ACTIMMUNE, 53
alectinib, 19
ACTIQ, 11
alemtuzumab, 34
ACTIVELLA, 42
alendronate, 39
ACTONEL, 39
alendronate/vitamin D3, 39
ACTOPLUS MET, 37
ALFERON N, 61
ACTOPLUS MET XR, 37
alfuzosin ext-rel, 48
ACTOS, 37
alglucosidase alfa, 44
ACULAR, 62
ALINIA, 16
ACUVAIL, 62
alirocumab, 25
acyclovir, 61
aliskiren, 26
acyclovir caps, susp, tabs, 16
aliskiren/hydrochlorothiazide, 26
ACZONE, 16
alitretinoin, 61
ADAKVEO, 50
ALKERAN inj, 17
adalimumab, 51
ALKERAN tabs, 17
adapalene crm, gel, 57
ALKINDI SPRINKLE CAPS, 41
adapalene/benzoyl peroxide, 57
allopurinol, 10
72
almotriptan, 33 amphotericin B liposome inj, 14
alogliptin, 36 ampicillin, 13
alogliptin/metformin, 36 ampicillin sodium/sulbactam sodium, 13
alogliptin/pioglitazone, 36 AMZEEQ, 58
ALOMIDE, 61 ANAFRANIL, 28
ALORA, 43 anagrelide, 50
alosetron, 46 anakinra, 51
alpelisib, 19 anastrozole, 18
alpha-1 proteinase inhibitor, 54 ANDRODERM, 36
ALPHAGAN P 0.1%, 64 ANDROGEL, 35
ALPHAGAN P 0.15%, 64 ANGELIQ, 42
ALPHANATE, 49 anidulafungin, 14
ALPHANINE SD, 50 ANNOVERA, 41
alprazolam, 27 ANORO ELLIPTA, 55
alprazolam ext-rel, 27 ANTARA, 24
ALPROLIX, 50 antihemophilic factor, 49
ALREX, 62 antihemophilic factor (recombinant) pegylated, 50
ALTABAX, 58 antihemophilic factor (recombinant) pegylated-aucl, 50
ALTACE, 22 antihemophilic factor (recombinant) porcine sequence, 50
alteplase, 51 antihemophilic factor (recombinant), glycopegylated-exei, 50
ALUNBRIG, 19 antihemophilic factor recombinant, Fc fusion protein, 49
ALVESCO, 57 antihemophilic factor, recombinant, 49, 50
alvimopan, 47 anti-inhibitor coagulant complex, 50
amantadine ext-rel, 30 apalutamide, 18
amantadine, except tabs, 30 APEXICON E, 60
AMARYL, 38 APIDRA, 37
AMBIEN, 32 apixaban, 49
AMBIEN CR, 32 APLENZIN, 30
AMBISOME, 14 APOKYN, 30
ambrisentan, 27 apomorphine, 30
amcinonide crm, lotion, oint 0.1%, 60 apremilast, 51
AMELUZ, 58 aprepitant, 45
AMERGE, 33 aprepitant caps, 45
AMICAR, 51 aprepitant susp, 45
amifampridine, 35 APRISO, 46
amifostine, 20 APTENSIO XR, 32
amikacin liposome inhalation susp, 56 APTIOM, 28
amiloride, 26 APTIVUS, 15
amiloride/hydrochlorothiazide, 26 ARAKODA, 14
aminocaproic acid, 51 ARALAST NP, 54
aminolevulinic acid gel 10%, 58 ARANESP, 49
aminolevulinic acid soln, 58 ARAVA, 52
amiodarone, 24 ARAZLO, 58
AMITIZA, 46 ARCALYST, 53
amitriptyline, 30 arformoterol soln, 56
amitriptyline/perphenazine, 30 ARICEPT, 29
amlodipine benzoate oral susp, 25 ARIKAYCE, 56
amlodipine tabs, 25 ARIMIDEX, 18
amlodipine/atorvastatin, 26 aripiprazole, 31
amlodipine/olmesartan, 23 aripiprazole ext-rel inj, 31
amlodipine/telmisartan, 23 aripiprazole lauroxil ext-rel inj, 31
amlodipine/valsartan, 23 aripiprazole orally disintegrating tabs, 31
amlodipine/valsartan/hydrochlorothiazide, 23 aripiprazole tab with sensor, 31
ammonium lactate 12%, 60 ARISTADA, 31
AMONDYS 45, 35 ARIXTRA, 49
amoxicillin, except film-coated tabs, 13 armodafinil, 34
amoxicillin/clavulanate, 13 ARMONAIR DIGIHALER, 57
amoxicillin/clavulanate ext-rel, 13 ARMOUR THYROID, 44
amoxicillin/clavulanate susp 600 mg, 13 ARNUITY ELLIPTA, 57
amoxicillin/rifabutin/omeprazole, 47 AROMASIN, 18
amphetamine sulfate, 31 ARRANON, 20
amphetamine/dextroamphetamine mixed salts, 31 arsenic trioxide, 20
amphetamine/dextroamphetamine mixed salts ext-rel, 31, 32 artemether/lumefantrine, 14
amphotericin B lipid complex inj, 14 ARTHROTEC, 10
73
ARZERRA, 21 AZSTARYS, 32
ASACOL HD, 46 aztreonam, 16
ASCENIV, 53 aztreonam lysine inhalation soln, 56
asciminib hcl, 19 AZULFIDINE, 46
asenapine, 31 AZULFIDINE EN-TABS, 46
asenapine transdermal, 31
asfotase alfa, 44
B
bacitracin, 62
ASMANEX, 57
baclofen, 34
ASMANEX HFA, 57
baclofen intrathecal (10 mg/20 mL, 40 mg/20 mL), 34
asparaginase, 21
baclofen oral solution, 34
aspirin ext-rel, 50
BAFIERTAM, 34
ASTAGRAF XL, 53
baloxavir, 16
ATACAND, 23
balsalazide, 46
ATACAND HCT, 23
BALVERSA, 19
atazanavir caps, 15
BANZEL, 28
atazanavir/cobicistat, 14
BAQSIMI, 42
ATELVIA, 39
BARACLUDE, 16
atenolol, 25
BARACLUDE soln, 16
atenolol/chlorthalidone, 25
baricitinib, 51
atezolizumab, 21
BASAGLAR, 37
ATIVAN, 28
BAVENCIO, 21
atogepant, 33
BCG live vaccine, 21
atomoxetine, 31
BD INSULIN SYRINGES AND NEEDLES, 38
atorvastatin, 24
becaplermin, 61
atovaquone, 16
beclomethasone breath-activated aerosol, 57
atovaquone/proguanil, 14
beclomethasone spray, 56
ATRALIN, 58
beclomethasone, CFC-free aerosol, 57
atropine sulfate soln, 63
BECONASE AQ, 56
atropine/hyoscyamine/scopolamine/phenobarbital, 46
bedaquiline, 15
ATROVENT HFA, 54
belatacept, 53
AUBAGIO, 34
BELBUCA, 11
AUGMENTIN, 13
BELEODAQ, 21
auranofin, 52
belimumab, 53
AURYXIA, 43
belinostat, 21
AUSTEDO, 33
BELRAPZO, 17
avacopan, 53
BELSOMRA, 32
AVALIDE, 23
bempedoic acid, 24
avapritinib, 19
bempedoic acid/ezetimibe, 24
AVAPRO, 23
benazepril, 22
AVASTIN, 21
benazepril/amlodipine, 22
avatrombopag, 51
benazepril/hydrochlorothiazide, 23
AVEED, 36
bendamustine, 17, 21
avelumab, 21
BENDEKA, 21
AVODART, 48
BENEFIX, 50
AVONEX, 33
BENICAR, 23
AVSOLA, 52
BENICAR HCT, 23
axitinib, 19
BENLYSTA, 53
AYGESTIN, 43
benralizumab, 57
AYVAKIT, 19
BENZAC AC, 58
azacitidine, 17, 20
BENZAMYCIN, 58
AZACTAM, 16
benzonatate, 55
AZASITE, 62
benzoyl peroxide, 58
azathioprine, 53
benztropine, 30
azelaic acid, 58
BEOVU, 64
azelaic acid gel, 60
bepotastine, 61
azelastine spray, 56
BEPREVE, 61
azelastine/fluticasone nasal spray, 56
BERINERT, 52
AZELEX, 58
berotralstat, 52
AZILECT, 30
besifloxacin, 62
azilsartan, 23
BESIVANCE, 62
azilsartan/chlorthalidone, 23
BESPONSA, 22
azithromycin, 13, 62
BESREMI, 51
AZOPT, 63
betaine anhydrous, 44
AZOR, 23
74
betamethasone dipropionate augmented crm 0.05%, 60 brivaracetam, 28
betamethasone dipropionate augmented gel, lotion 0.05%, 60 BRIVIACT, 28
betamethasone dipropionate augmented oint 0.05%, 60 brodalumab, 51
betamethasone dipropionate crm, lotion 0.05%, 60 brolucizumab-dbll, 64
betamethasone dipropionate oint 0.05%, 60 bromfenac 0.075%, 62
betamethasone dipropionate spray 0.05%, 60 bromfenac sodium, 62
betamethasone dipropionate/calcipotriene oint, susp, 59 bromfenac sodium 0.07%, 62
betamethasone valerate crm, lotion, oint 0.1%, 60 bromocriptine, 30
BETASERON, 34 BROMSITE, 62
betaxolol, 63 BRONCHITOL, 56
bethanechol, 48 BROVANA, 56
BETHKIS, 56 BRUKINSA, 20
BETIMOL, 63 budesonide, 57
BETOPTIC S, 63 budesonide delayed-rel caps, 45, 46
bevacizumab, 21 budesonide ext-rel caps, 46
bevacizumab-awwb, 21 budesonide inhalation suspension, 57
bevacizumab-bvzr, 21 budesonide/formoterol, 57
BEVESPI AEROSPHERE, 55 budesonide/glycopyrrolate/formoterol, 55
bexarotene caps, 20 bumetanide, 26
bexarotene gel, 20 BUPHENYL, 44
bezlotoxumab, 53 buprenorphine, 11, 34
bicalutamide, 18 buprenorphine ext-rel inj, 34
BICNU, 17 buprenorphine transdermal, 11
bictegravir/emtricitabine/tenofovir alafenamide, 14 buprenorphine/naloxone sublingual film, 35
BIDIL, 26 buprenorphine/naloxone sublingual tabs, 35
BIJUVA, 43 bupropion, 30
BIKTARVY, 14 bupropion ext-rel, 30, 35
bimatoprost 0.01%, 63 burosumab-twza, 44
binimetinib, 19 buspirone, 28
bismuth subsalicylate + metronidazole + tetracycline, 47 busulfan, 17
bisoprolol/hydrochlorothiazide, 25 BUSULFEX, 17
BIVIGAM, 52 butalbital/acetaminophen, 11
bleomycin sulfate, 20 butalbital/acetaminophen/caffeine, 11
BLEPH-10, 62 butalbital/acetaminophen/caffeine/codeine, 11
BLEPHAMIDE SOP, 62 butalbital/aspirin/caffeine, 11
blinatumomab, 21 butalbital/aspirin/caffeine/codeine, 11
BLINCYTO, 21 butenafine, 59
blood glucose continuous monitoring receivers, sensors, transmitters, butorphanol nasal spray, 11
38 BUTRANS, 11
blood glucose meters and kits, 38 BYSTOLIC, 25
blood glucose test strips, 38
BONIVA, 39
C
C1 esterase inhibitor, 52
BONJESTA, 45
C1 esterase inhibitor, recombinant, 52
bortezomib, 20
cabazitaxel, 21
bosentan, 27
CABOMETYX, 19
BOSULIF, 19
cabozantinib, 19
bosutinib, 19
CADUET, 26
BOTOX, 35
CAFCIT, 57
BRAFTOVI, 19
caffeine citrate, 57
brentuximab vedotin, 21
CALAN SR, 26
BREO ELLIPTA, 57
calcifediol ext-rel, 42
BREVIBLOC, 25
calcipotriene, 59
BREXAFEMME, 14
calcipotriene foam, 59
brexpiprazole, 31
calcipotriene/betamethasone dipropionate cream, 59
BREZTRI AEROSPHERE, 55
calcipotriene/betamethasone foam, 59
brigatinib, 19
calcitonin-salmon inj, 39
BRILINTA, 50
calcitonin-salmon spray, 39
brimonidine 0.1%, 64
calcitriol (1,25-D3), 42
calcitriol oint, 59
calcium acetate, 43
brimonidine topical gel, 61
calcium, magnesium, potassium, and sodium oxybates, 34
brimonidine/timolol, 64
CALDOLOR, 10
brinzolamide, 63
CALQUENCE, 19
brinzolamide/brimonidine, 63
75
CAMPTOSAR, 20 CEPROTIN, 51
CAMZYOS, 27 CEQUA, 63
canagliflozin, 37 CEQUR SIMPLICITY, 38
canagliflozin/metformin, 37 CERDELGA, 41
canagliflozin/metformin ext-rel, 38 CEREZYME, 41
canakinumab, 53 ceritinib, 19
CANASA, 46 certolizumab pegol, 51
candesartan, 23 CERUMENEX, 64
candesartan/hydrochlorothiazide, 23 CETRAXAL, 64
cangrelor, 50 cetrorelix, 41
cannabidiol, 29 CETROTIDE, 41
capecitabine, 17 cetuximab, 21
CAPEX, 59 cevimeline, 47
CAPLYTA, 31 CHEMSTRIP K URINE KETONE STRIPS, 38
capmatinib, 19 CHEMSTRIP UG URINE GLUCOSE STRIPS, 38
CAPRELSA, 19 CHEMSTRIP UGK URINE GLUCOSE/KETONE STRIPS, 38
capsaicin 8% patch, 60 chlorambucil, 17
CARAC, 58 chlordiazepoxide, 27
CARBAGLU, 44 chlordiazepoxide/clidinium, 46
carbamazepine, 28, 33 chloroquine, 14
carbamazepine ext-rel, 28 chlorthalidone, 26
CARBATROL, 28 CHOLBAM, 48
carbidopa/levodopa, 30 cholestyramine pkt, 24
carbidopa/levodopa enteral susp, 30 cholic acid, 48
carbidopa/levodopa ext-rel, 30 choriogonadotropin alfa, 41
carbidopa/levodopa/entacapone, 30 chorionic gonadotropin, 41
carboplatin, 20 CIALIS, 48
CARDIZEM, 25 CIBINQO, 59
CARDIZEM CD, 25 ciclesonide, 57
CARDURA, 23 ciclesonide spray, 56
carfilzomib, 21 ciclopirox, 58
carglumic acid, 44 cidofovir, 15
cariprazine, 31 cilostazol, 51
carmustine, 17 CILOXAN, 62
CARNITOR, 39 CIMDUO, 14
carteolol, 63 cimetidine, 46
carvedilol, 25 CIMZIA, 51
carvedilol phosphate ext-rel, 25 cinacalcet, 39
casimersen, 35 CINQAIR, 57
CASODEX, 18 CINRYZE, 52
CATAPRES-TTS, 23 CINVANTI, 45
CATHFLO ACTIVASE, 51 CIPRO, 13
CAYSTON, 56 CIPRO HC OTIC, 64
cefaclor, 12 CIPRODEX, 64
cefdinir, 12 ciprofloxacin, 13, 62
cefepime, 12 ciprofloxacin otic, 64
cefixime caps, susp 100 mg/5 mL, 200 mg/5 mL, 12 ciprofloxacin/dexamethasone, 64
cefotaxime, 12 ciprofloxacin/hydrocortisone, 64
cefoxitin, 12 cisplatin, 20
cefpodoxime, 12 citalopram caps, 29
cefprozil, 12 CITALOPRAM caps, 29
ceftaroline fosamil, 13 citalopram tabs, 29
ceftazidime, 12 cladribine, 17, 34
ceftriaxone, 12 CLARINEX, 55
cefuroxime axetil, 12 CLARINEX-D, 55
CELEBREX, 10 clarithromycin, 13
celecoxib, 10 clarithromycin ext-rel, 13
celecoxib oral solution, 10 clascoterone, 58
celecoxib/tramadol tabs, 11 CLENPIQ, 47
CELEXA, 29 CLEOCIN, 16
CELLCEPT, 53 CLEOCIN T, 58
cenegermin-bkbj, 63 CLEOCIN vaginal supp, 48
cenobamate, 28 CLIMARA, 43
cephalexin, 12 CLIMARA PRO, 43
76
clindamycin, 16 CORIFACT, 50
clindamycin gel, lotion, soln, 58 CORLANOR, 26
clindamycin supp, 48 CORTEF, 41
clindamycin swabs, 58 corticotropin, 45
clindamycin vaginal cream, 48 corticotropin powder, 44
clindamycin/benzoyl peroxide, 58 CORTIFOAM, 46
clindamycin/tretinoin, 58 COSENTYX, 52
CLINDESSE, 48 COSMEGEN, 20
clobazam, 28 COSOPT, 63
clobetasol propionate crm, gel, oint, soln 0.05%, 60 COTELLIC, 19
clobetasol propionate lotion, 60 COZAAR, 23
clobetasol propionate lotion, shampoo, spray 0.05%, 60 CREON, 47
CLOBEX, 60 CRESEMBA, 14
clocortolone pivalate crm 0.1%, 60 CRESTOR, 24
CLODERM, 60 crisaborole oint, 59
clofarabine, 17 crizanlizumab-tmca, 50
CLOLAR, 17 crizotinib, 19
clomiphene, 41 crofelemer delayed-rel, 45
clomipramine, 28 cromolyn sodium, 47, 61
clonazepam, 28 cromolyn soln, 56
clonidine, 23 CRYSVITA, 44
clonidine ext-rel, 31 CUBICIN, 16
clonidine transdermal, 23 CUTAQUIG, 53
clopidogrel, 50 CUVITRU, 53
clorazepate, 28 CUVPOSA, 47
clotrimazole, 58 cyanocobalamin inj, 54
clotrimazole troches, 13 cyanocobalamin spray, 54
clotrimazole/betamethasone, 58 CYANOKIT, 44
clozapine, 31 cyclobenzaprine, 34
clozapine orally disintegrating tabs, 31 CYCLOGYL, 63
CLOZARIL, 31 cyclopentolate, 63
COAGADEX, 50 cyclophosphamide caps, 17
coagulation factor IX (recombinant), glycopegylated, 50 CYCLOPHOSPHAMIDE CAPSULES, 17
coagulation factor IX, recombinant, 50 cyclophosphamide inj, 17
coagulation factor VIIa, 50 cyclosporine, 53
coagulation factor VIIa-jncw, 50 cyclosporine eye solution, 63
coagulation factor X, human, 50 cyclosporine, emulsion, 63
COARTEM, 14 cyclosporine, modified, 53
cobicistat, 14 CYKLOKAPRON inj, 51
cobimetinib, 19 CYMBALTA, 29
codeine/acetaminophen, 11 cyproheptadine, 55
codeine/promethazine, 55 CYRAMZA, 22
codeine/promethazine/phenylephrine, 55 CYSTADANE, 44
colchicine, 10 CYSTADROPS, 64
COLCRYS, 10 CYSTAGON, 44
colesevelam, 24 CYSTARAN, 64
COLESTID, 24 cysteamine, 44, 64
colestipol, 24 cysteamine delayed-rel, 44
collagenase clostridium histolyticum, 61 cytarabine, 17
COMBIGAN, 64 CYTOGAM, 15
COMBIPATCH, 43 cytomegalovirus immune globulin, 15
COMBIVENT RESPIMAT, 55 CYTOMEL, 44
COMBIVIR, 14 CYTOTEC, 47
COMETRIQ, 19
COMPLERA, 14
D
D.H.E. 45, 33
COMTAN, 30
dabrafenib, 19
CONCERTA, 32
dacarbazine, 17
CONDYLOX, 61
DACOGEN, 20
conjugated estrogens/bazedoxifene, 42
dacomitinib, 19
COPIKTRA, 19
dactinomycin, 20
CORDRAN crm, lotion, oint, 60
dalfampridine ext-rel, 33
CORDRAN TAPE, 60
DALIRESP, 56
COREG, 25
dalteparin, 49
COREG CR, 25
77
danazol, 41 dexamethasone, 41, 62
DANTRIUM, 34 dexamethasone sodium phosphate, 62
dantrolene, 34 DEXCOM CONTINUOUS GLUCOSE MONITORING SYSTEM, 38
dapagliflozin, 37 DEXEDRINE SPANSULE, 32
dapagliflozin/metformin ext-rel, 37 DEXILANT, 47
dapagliflozin/saxagliptin, 38 dexlansoprazole delayed-rel, 47
dapsone, 16 dexmethylphenidate, 31
daptomycin 500 mg, 16 dexmethylphenidate ext-rel, 31
DARAPRIM, 14 dexrazoxane, 20
daratumumab, 21 dextranomer/sodium hyaluronate, 47
daratumumab/hyaluronidase-fihj, 21 dextroamphetamine, 32
darbepoetin alfa, 49 dextroamphetamine ext-rel, 32
darifenacin ext-rel, 48 dextroamphetamine soln - Procentra, 32
darolutamide, 18 dextromethorphan/quinidine, 35
darunavir, 15 DIACOMIT, 29
darunavir/cobicistat, 14 DIASTAT, 28
darunavir/cobicistat/emtricitabine/tenofovir alafenamide, 14 diazepam, 28
DARZALEX, 21 diazepam nasal spray, 28
DARZALEX FASPRO, 21 diazepam rectal gel, 28
dasatinib, 19 diazoxide, 41
dasiglucagon, 42 dichlorphenamide, 26
daunorubicin, 20 DICLEGIS, 45
DAURISMO, 22 diclofenac epolamine patch, 10
DAYPRO, 10 diclofenac sodium, 62
DAYTRANA, 32 diclofenac sodium 3% gel, 58
DAYVIGO, 32 diclofenac sodium delayed/ext-rel, 10
DDAVP, 44 diclofenac sodium delayed-rel/misoprostol, 10
decitabine, 20 diclofenac sodium gel 1%, 10
decitabine-cedazuridine, 21 diclofenac sodium soln (except 2% soln), 10
deferasirox, 51 dicloxacillin, 13
deferiprone, 51 dicyclomine, 46
deferoxamine, 51 DIFFERIN, 57
deflazacort, 35 DIFICID, 13
degarelix acetate, 18 diflorasone diacetate crm 0.05%, 60
DELESTROGEN, 42 diflorasone diacetate emollient crm 0.05%, 60
DELSTRIGO, 14 diflorasone diacetate oint 0.05%, 60
DELZICOL, 46 DIFLUCAN, 13
DENAVIR, 61 diflunisal, 10
denosumab, 39 difluprednate, 62
DEPAKOTE, 28 digoxin, 26
DEPAKOTE ER, 28 dihydroergotamine inj, 33
DEPAKOTE SPRINKLE, 28 dihydroergotamine spray, 33
DEPEN, 52 DILANTIN, 28
DEPO-PROVERA, 40 DILANTIN INFATABS, 28
DERMA-SMOOTHE/FS, 60 DILAUDID, 11
DERMOTIC, 64 diltiazem, 25
DESCOVY, 14 diltiazem ext-rel, 25
DESFERAL, 51 dimethyl fumarate delayed-rel, 33
desipramine, 30 DIOVAN, 23
desloratadine, 55 DIOVAN HCT, 23
desloratadine/pseudoephedrine ext-rel, 55 DIPENTUM, 46
desmopressin spray, 50 diphenhydramine, 30, 55
desmopressin spray, tabs, 44 diphenoxylate/atropine, 45
desogestrel/EE, 40 DIPROLENE oint 0.05%, 60
desogestrel/EE 0.15/30, 39 dipyridamole, 50
desonide crm 0.05%, 59 dipyridamole ext-rel/aspirin, 50
desonide foam 0.05%, 59 diroximel fumarate delayed-rel, 34
desonide gel 0.05%, 59 disopyramide, 24
desonide lotion, oint 0.05%, 59 disopyramide ext-rel, 24
DESOWEN, 59 disulfiram, 34
desoximetasone crm, oint 0.05%, 60 DITROPAN XL, 48
desoximetasone crm, oint, spray 0.25%, gel 0.05%, 60 divalproex sodium delayed-rel, 28
desvenlafaxine ext-rel, 29 divalproex sodium ext-rel, 28
deutetrabenazine, 33 divalproex sodium sprinkle caps, 28
78
DIVIGEL, 43 E
docetaxel, 20 ecallantide, 52
dofetilide, 24 econazole, 58
DOJOLVI, 54 econazole foam, 59
dolutegravir, 14 ECOZA, 59
dolutegravir/lamivudine, 14 eculizumab, 50
dolutegravir/rilpivirine, 14 edaravone, 35
donepezil, 29 edaravone oral susp, 35
donepezil orally disintegrating tabs, 29 EDARBI, 23
DOPTELET, 51 EDARBYCLOR, 23
doravirine, 15 EDECRIN, 26
doravirine/lamivudine/tenofovir disoproxil fumarate, 14 EDLUAR, 32
dornase alfa, 56 EDURANT, 15
DORYX/MPC, 13 EE/norethindrone acetate, 42
dorzolamide, 63 EE/norethindrone acetate - Jinteli, 42
dorzolamide/timolol maleate, 63 efavirenz, 15
DOVATO, 14 efavirenz/emtricitabine/tenofovir disoproxil fumarate, 14
DOVONEX, 59 efavirenz/lamivudine/tenofovir disoproxil fumarate, 14
doxazosin, 23 EFFEXOR XR, 29
doxepin, 30, 32 EFFIENT, 50
doxepin crm, 61 efinaconazole, 59
doxercalciferol, 42 EFUDEX, 58
DOXIL, 20 EGRIFTA, 45
doxorubicin, 20 elagolix, 41
doxorubicin liposomal, 20 elagolix sodium/estradiol/norethindrone acetate, 44
doxycycline hyclate, 13 elapegademase-lvlr, 45
doxycycline hyclate delayed-rel tabs, 13 ELAPRASE, 44
doxycycline monohydrate, 13 elbasvir/grazoprevir, 16
doxycycline monohydrate delayed-rel caps, 61 ELELYSO, 45
doxylamine/pyridoxine delayed-rel, 45 ELEPSIA XR, 28
doxylamine/pyridoxine ext-rel, 45 eletriptan, 33
DRIZALMA SPRINKLE, 29 elexacaftor/tezacaftor/ivacaftor + ivacaftor, 56
dronabinol, 45 ELIDEL, 59
dronabinol solution, 47 ELIGARD, 18
dronedarone, 24 eliglustat, 41
drospirenone, 40 ELIQUIS, 49
drospirenone/EE 3/20, 39 ELITEK, 17
drospirenone/EE 3/30, 39 ELIXOPHYLLIN, 57
drospirenone/EE/levomefolate 3/30 and levomefolate, 39 ELLENCE, 22
drospirenone/estetrol, 40 ELMIRON, 48
drospirenone/estradiol, 42 ELOCTATE, 49
droxidopa, 27 elosulfase alfa, 44
DUAKLIR PRESSAIR, 55 elotuzumab, 21
DUAVEE, 42 ELSPAR, 21
DUET DHA, 54 eltrombopag, 50
DUETACT, 37 eluxadoline, 46
dulaglutide, 36 elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, 14
DULERA, 57 elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate, 14
duloxetine delayed-rel, 29 ELYXYB, 10
duloxetine delayed-release sprinkle capsule, 29 EMBEDA, 11
DUOBRII, 59 EMEND, 45
DUOPA, 30 EMFLAZA, 35
dupilumab, 59 EMGALITY 100 mg/mL, 33
DUPIXENT, 59 EMGALITY 120 mg/mL, 33
DURAGESIC, 11 emicizumab-kxwh, 50
DUREZOL, 62 empagliflozin, 37
DURLAZA, 50 empagliflozin/linagliptin, 38
DUROLANE, 12 empagliflozin/linagliptin/metformin extended-release, 38
durvalumab, 21 empagliflozin/metformin, 37
dutasteride, 48 empagliflozin/metformin ext-rel, 37
dutasteride/tamsulosin, 48 EMPLICITI, 21
duvelisib, 19 EMSAM, 29
DYMISTA, 56 emtricitabine caps, 15
DYSPORT, 35
79
emtricitabine/rilpivirine/tenofovir alafenamide, 14 ERLEADA, 18
emtricitabine/rilpivirine/tenofovir disoproxil fumarate, 14 erlotinib, 18
emtricitabine/tenofovir alafenamide, 14 ERTACZO, 59
emtricitabine/tenofovir disoproxil fumarate, 14 ertapenem, 16
EMTRIVA, 15 ertugliflozin, 37
EMVERM, 17 ertugliflozin/metformin, 38
enalapril, 22 ertugliflozin/sitagliptin, 38
enalapril oral soln, 22 ERYGEL, 58
enalapril/hydrochlorothiazide, 23 ERYPED, 13
enasidenib, 21 erythromycin, 62
ENBREL, 51 erythromycin delayed-rel, 13
ENBREL SURECLICK, 51 erythromycin delayed-rel - Ery-tab, 13
encorafenib, 19 erythromycin ethylsuccinate, 13
ENDARI, 51 erythromycin gel 2%, 58
ENDOMETRIN, 43 erythromycin soln, 58
enfortumab vedotin-ejfv, 22 erythromycin stearate, 13
enfuvirtide, 14 erythromycin/benzoyl peroxide, 58
ENHERTU, 22 ESBRIET 267mg caps, 57
ENJAYMO, 51 ESBRIET tabs, 56
enoxaparin, 49 escitalopram, 29
ENSPRYNG, 52 esketamine nasal solution, 30
ENSTILAR, 59 eslicarbazepine, 28
entacapone, 30 esmolol, 25
entecavir soln, 16 esomeprazole magnesium delayed-rel, 47
entecavir tabs, 16 ESPEROCT, 50
ENTEREG, 47 estazolam, 32
entrectinib, 19 ESTRACE, 42, 43
ENTRESTO, 26 estradiol, 42, 43
ENTYVIO, 46 estradiol transdermal gel, 43
ENVARSUS XR, 53 estradiol transdermal spray, 43
enzalutamide, 18 estradiol vaginal crm, 43
EPANED, 22 estradiol vaginal inserts, 43
EPCLUSA, 16 estradiol vaginal ring, 43
EPIDIOLEX, 29 estradiol vaginal tabs- YUVAFEM, 43
EPIDUO, 57 estradiol valerate, 42
EPIDUO FORTE, 57 estradiol valerate and dienogest/estradiol valerate, 40
EPIFOAM, 47 estradiol/levonorgestrel, 43
epinastine, 61 estradiol/norethindrone acetate, 42, 43
epinephrine auto-injector 0.15 mg, 54 estradiol/norgestimate, 43
epinephrine auto-injector 0.30 mg, 54 estradiol/progesterone, 43
epinephrine inj (0.15 mg and 0.30 mg), 54 ESTRING, 43
EPIPEN, 54 ESTROGEL, 43
EPIPEN JR., 54 estrogens, conjugated, 42
epirubicin, 22 estrogens, conjugated crm, 43
EPIVIR, 15 estrogens, conjugated/medroxyprogesterone, 42
EPIVIR-HBV, 15 estrogens, esterified/methyltestosterone, 42
eplerenone, 23 eszopiclone, 32
epoetin alfa, 49 etanercept, 51
epoetin alfa-epbx, 49 etelcalcetide, 39
EPOGEN, 49 eteplirsen, 35
epoprostenol, 27 ethacrynic acid, 26
epoprostenol sodium, 27 ethambutol, 15
eptinezumab-jjmr, 33 ethinyl estradiol/levonorgestrel, 41
EPZICOM, 14 ethosuximide, 28
EQUETRO, 33 ethynodiol diacetate/EE 1/35 - Zovia 1/35, 40
ERAXIS, 14 ethynodiol diacetate/EE 1/50, 40
ERBITUX, 21 ETHYOL, 20
erdafitinib, 19 etodolac, 10
erenumab-aooe, 33 etodolac ext-rel, 10
ergocalciferol (D2), 54 etonogestrel implant, 40
ergotamine/caffeine supp, 33 etonogestrel/EE - EluRyng, 41
ergotamine/caffeine tabs, 33 ETOPOPHOS, 21
eribulin, 21 etoposide, 20
ERIVEDGE, 21 etoposide phosphate, 21
80
etravirine, 15 fentanyl transdermal, 11
etravirine tabs 100 mg, 200 mg, 15 fentanyl transmucosal lozenge, 11
EUCRISA, 59 FENTORA, 11
EUFLEXXA, 12 FERAHEME, 54
EVAMIST, 43 ferric carboxymaltose inj, 54
EVEKEO, 31 ferric citrate, 43
EVENITY, 39 ferric derisomaltose inj, 54
everolimus, 18, 53 ferric maltol, 54
everolimus tabs for oral suspension, 18 FERRIPROX, 51
EVISTA, 43 FERRLECIT, 54
evolocumab, 25 ferumoxytol inj, 54
EVOMELA, 22 fesoterodine ext-rel, 48
EVOTAZ, 14 FETZIMA, 29
EVOXAC, 47 FIASP, 37
EVRYSDI, 35 FIASP FLEXTOUCH, 37
EXELDERM, 58 fibrinogen, 50
EXELON PATCH, 29 FIBRYGA, 50
exemestane, 18 fidaxomicin, 13
EXFORGE, 23 filgrastim, 49
EXFORGE HCT, 23 filgrastim-aafi, 49
EXJADE, 51 filgrastim-sndz, 49
EXONDYS 51, 35 FINACEA, 60
EXSERVAN, 35 finasteride, 48
EXTAVIA, 34 finerenone, 41
EYLEA, 64 fingolimod, 33
EYSUVIS, 63 FINTEPLA, 29
EZALLOR SPRINKLE, 24 FIORICET, 11
ezetimibe, 24 FIORICET w/CODEINE, 11
ezetimibe/rosuvastatin, 24 FIORINAL, 11
ezetimibe/rosuvastatin tabs, 24 FIRAZYR, 52
EZETIMIBE/ROSUVASTATIN tabs, 24 FIRDAPSE, 35
ezetimibe/simvastatin, 24 FIRMAGON, 18
FIRVANQ, 17
F FLAGYL, 16
FABIOR, 58
FLAREX, 62
FABRAZYME, 44
FLEBOGAMMA, 52
factor IX concentrate, 50
flecainide, 24
factor IX recombinant, Fc fusion protein, 50
FLECTOR, 10
factor XIII A-subunit recombinant, 50
FLEQSUVY, 34
factor XIII concentrate, 50
FLOLAN, 27
famciclovir, 16
FLOMAX, 48
famotidine, 46
FLOVENT, 57
fam-trastuzumab deruxtecan-nxki, 22
FLOVENT HFA, 57
FANAPT, 31
floxuridine, 17
FARESTON, 18
fluconazole, 13
FARXIGA, 37
fludarabine, 17
FARYDAK, 22
fludrocortisone, 41
FASENRA, 57
flunisolide spray, 56
FASLODEX, 18
fluocinolone acetonide, 64
febuxostat, 10
fluocinolone acetonide crm, oint 0.025%, 60
fedratinib, 19
fluocinolone acetonide oil 0.01%, 60
FEIBA VH IMMUNO, 50
fluocinolone acetonide soln 0.01%, 59
felbamate, 28
fluocinolone shampoo 0.01%, 59
FELBATOL, 28
fluocinonide crm 0.1%, 60
FELDENE, 10
fluocinonide crm, gel, oint, soln 0.05%, 60
felodipine ext-rel, 25
fluorometholone, 62
FEMARA, 18
fluorometholone acetate, 62
FEMRING, 43
FLUOROPLEX, 58
fenfluramine, 29
fluorouracil, 58
fenofibrate, 24
fluorouracil inj, 17
fenofibric acid delayed-rel, 24
fluoxetine, 29
FENSOLVI, 18
fluoxetine delayed-rel, 29
fentanyl citrate buccal, 11
fluphenazine, 31
fentanyl sublingual spray, 11
flurandrenolide crm, lotion, oint 0.05%, 60
81
flurandrenolide tape, 60 GALZIN, 54
flurazepam, 32 GAMASTAN, 52
flurbiprofen, 10, 62 GAMMAGARD LIQUID, 52
flutamide, 18 GAMMAGARD S-D, 52
fluticasone, 57 GAMMAKED, 52
fluticasone furoate spray, 56 GAMMAPLEX, 52
fluticasone propionate, 56, 57 GAMUNEX-C, 52
fluticasone propionate crm 0.05%, oint 0.005%, 60 ganaxolone suspension, 29
fluticasone propionate lotion 0.05%, 60 ganciclovir, 63
fluticasone spray, 56 ganciclovir inj, 15
fluticasone, CFC-free aerosol, 57 GANIRELIX ACETATE, 41
fluticasone/salmeterol, 57 ganirelix acetate inj, 41
fluticasone/salmeterol, CFC-free aerosol, 57 GASTROCROM, 47
fluticasone/umeclidinium/vilanterol, 55 GATTEX, 48
fluticasone/vilanterol, 57 GAVRETO, 19
fluvastatin, 24 GAZYVA, 21
fluvastatin ext-rel, 24 gefitinib, 19
fluvoxamine, 28 GELNIQUE, 48
fluvoxamine ext-rel, 28 GEL-ONE, 11
FML, 62 GELSYN-3, 11
FOCALIN, 31 GEMCITABINE, 17
FOCALIN XR, 31 gemcitabine inj, 17
folic acid, 54 gemfibrozil, 24
FOLLISTIM AQ, 41 GEMTESA, 48
follitropin alfa, 41 gemtuzumab ozogamicin, 22
follitropin beta, 41 GENOTROPIN, 42
FOLOTYN, 17 gentamicin crm, 58
fondaparinux, 49 gentamicin/prednisolone acetate, 62
FORADIL, 56 GENVOYA, 14
FORFIVO XL, 30 GEODON, 31
formoterol inhalation caps, 56 GILENYA, 33
formoterol inhalation soln, 56 GILOTRIF, 19
FORTEO, 39 gilteritinib, 19
FORTESTA, 35 GIMOTI, 45
FOSAMAX, 39 GIVLAARI, 48
FOSAMAX PLUS D, 39 givosiran, 48
fosamprenavir, 15 glasdegib, 22
fosinopril, 22 GLASSIA, 54
fosinopril/hydrochlorothiazide, 23 glatiramer, 33
FOSRENOL CHEWABLE TABLETS, 43 glatiramer - Glatopa, 33
FOSRENOL ORAL POWDER, 43 glecaprevir/pibrentasvir, 16
fostamatinib, 50 GLEEVEC, 18
fostemsavir ext-rel, 14 GLEOSTINE, 17
FOTIVDA, 20 glimepiride, 38
FRAGMIN, 49 glipizide, 38
FREESTYLE LIBRE / FREESTYLE LIBRE 2 CONTINUOUS glipizide ext-rel, 38
GLUCOSE MONITORING SYST, 38 glipizide/metformin, 36
FROVA, 33 GLUCAGEN, 42
frovatriptan, 33 GLUCAGON EMERGENCY KIT, 41
FULPHILA, 49 glucagon nasal powder, 42
fulvestrant, 18 glucagon subcutaneous soln, 42
furosemide, 26 glucagon, human recombinant, 42
FUZEON, 14 glucagon, human recombinant (KIT), 41
FYCOMPA, 28 glucarpidase, 21
GLUCOTROL XL, 38
G glyburide, 38
gabapentin, 28
glyburide, micronized, 38
GABITRIL, 28
glyburide/metformin, 36
GALAFOLD, 45
glycerol phenylbutyrate, 44
galantamine, 29
glycopyrrolate inhalation solution, 54
galantamine ext-rel, 29
glycopyrrolate oral solution, 47
galcanezumab-gnlm 100 mg/mL, 33
glycopyrrolate/formoterol, 55
galcanezumab-gnlm 120 mg/mL, 33
glycopyrronium pads, 61
galsulfase, 44
GLYNASE, 38
82
GLYXAMBI, 38 hydrocodone ext-rel tabs, 11
GOCOVRI, 30 hydrocodone/acetaminophen, 11
golimumab, 51 hydrocodone/homatropine, 55
golodirsen, 35 hydrocortisone, 41
GOLYTELY, 47 hydrocortisone acetate foam, 46
gonadorelin, 41 hydrocortisone acetate/pramoxine foam, 47
GONAL-F, 41 hydrocortisone butyrate crm 0.1%, 60
GONAL-F RFF, 41 hydrocortisone butyrate crm, lotion, oint, soln 0.1%, 60
GONITRO, 27 hydrocortisone crm 2.5%, 59
goserelin acetate, 18 hydrocortisone enema, 46
granisetron, 45 hydrocortisone probutate crm 0.1%, 60
granisetron ext-rel inj, 45 hydrocortisone valerate crm, oint 0.2%, 60
granisetron transdermal, 45 hydrocortisone/aloe polysaccharide/iodoquinol, 61
GRANIX, 49 hydrocortisone/iodoquinol, 61
grass mixed pollen allergen extract, 51 hydromorphone, 11
griseofulvin microsize, 13 hydromorphone ext-rel, 11
griseofulvin ultramicrosize, 13 hydroxocobalamin, 44
guanfacine ext-rel, 32 hydroxychloroquine, 52
guselkumab, 51 hydroxyprogesterone caproate, 43
GVOKE, 42 hydroxyurea, 20, 22
hydroxyzine HCl, 28, 55
H hydroxyzine pamoate, 28, 55
HAEGARDA, 52
hylan G-F 20, 12
HALAVEN, 21
HYMOVIS, 11
halcinonide crm, oint, soln 0.1%, 60
hyoscyamine sulfate, 46
HALDOL DECANOATE 100, 31
hyoscyamine sulfate ext-rel, 46
halobetasol propionate crm, oint 0.05%, 60
HYPERHEP B S-D, 52
halobetasol propionate/tazarotene, 59
HYPERRHO S-D, 52
HALOG, 60
HYQVIA, 52
haloperidol, 31
HYSINGLA ER, 11
haloperidol decanoate inj, 31
HYZAAR, 23
haloperidol lactate inj, 31
HARVONI, 16 I
HEMADY, 41 ibalizumab-uiyk, 15
HEMLIBRA, 50 ibandronate, 39
HEMOFIL M, 49 IBRANCE, 19
HEPAGAM B, 52 ibrexafungerp tabs, 14
hepatitis B immune globulin, 52 ibrutinib, 19
HEPSERA, 16 IBSRELA, 46
HERCEPTIN, 22 ibuprofen, 10
HERCEPTIN HYLECTA, 22 ibuprofen inj, 10
HERZUMA, 21 icatibant, 52
HETLIOZ, 32 ICLUSIG, 19
high molecular weight hyaluronan, 11 icosapent ethyl caps 1 gm, 25
histrelin acetate, 44 IDAMYCIN PFS, 20
HIZENTRA, 52 idarubicin, 20
HUMALOG, 37 idelalisib, 19
HUMALOG MIX, 37 IDELVION, 50
human coagulation factor VIII (rDNA) simoctocog alfa, 50 IDHIFA, 21
HUMATE-P, 49 idursulfase, 44
HUMATROPE, 42 IFEX, 20
HUMIRA, 51 ifosfamide, 20
HUMULIN 70/30, 37 ifosfamide/mesna, 17
HUMULIN N, 37 ILARIS, 53
HUMULIN R, 37 ILEVRO, 62
HUMULIN R U-500, 37 iloperidone, 31
HYALGAN, 11 iloprost, 27
hyaluronate sodium, 11 ILUMYA, 52
HYCAMTIN, 20 imatinib mesylate, 18
HYCAMTIN inj, 20 IMBRUVICA, 19
hydralazine, 27 IMFINZI, 21
HYDREA, 20 imiglucerase, 41
hydrochlorothiazide, 26 imipenem/cilastatin, 16
hydrocodone ext-rel caps, 11 imipramine HCl, 30
83
imipramine pamoate, 30 interferon alfa-n3, 61
imiquimod, 61 interferon beta-1a, 33, 34
imiquimod crm 3.75%, 61 interferon beta-1b, 34
IMITREX, 33 interferon gamma-1b, recombinant, 53
IMLYGIC, 21 INTRAROSA, 44
immune globulin (human)-ifas, 52 intrauterine copper contraceptive, 40
immune globulin (human)-klhw, 53 INTRON A, 53
immune globulin (human)-slra, 53 INTUNIV, 32
immune globulin, gamma, 52 INVANZ, 16
immune globulin, gamma (IGG), 52 INVEGA, 31
immune globulin, intravenous, 52 INVEGA HAFYERA, 31
immune globulin, subcutaneous, 52, 53 INVEGA SUSTENNA, 31
immune globulin/hyaluronidase, 52 INVEGA TRINZA, 31
immune globulin-hipp, 53 INVELTYS, 63
IMPAVIDO, 17 INVOKAMET, 37
IMPEKLO, 60 INVOKAMET XR, 38
IMURAN, 53 INVOKANA, 37
IMVEXXY, 43 ipilimumab, 21
INBRIJA, 30 ipratropium nasal spray, 57
incobotulinumtoxinA, 35 ipratropium soln, 54
INCRELEX, 42 ipratropium, CFC-free aerosol, 54
INCRUSE ELLIPTA, 54 ipratropium/albuterol soln, 55
indapamide, 26 ipratropium/albuterol, CFC-free aerosol, 55
INDERAL LA, 25 irbesartan, 23
indomethacin (except caps 20 mg, 40 mg), 10 irbesartan/hydrochlorothiazide, 23
indomethacin ext-rel, 10 IRESSA, 19
INFLECTRA, 52 irinotecan, 20
infliximab, 51 irinotecan liposome inj, 20
infliximab-abda, 52 iron sucrose inj, 54
infliximab-axxq, 52 isatuximab-irfc, 20
infliximab-dyyb, 52 isavuconazonium, 14
INGREZZA, 35 ISENTRESS, 14
INJECTAFER, 54 isocarboxazid, 29
INLYTA, 19 isoniazid, 15
INNOPRAN XL, 25 ISOPTO HYOSCINE, 63
inotersen, 45 ISORDIL, 26
inotuzumab ozogamicin, 22 isosorbide dinitrate oral, 26
INQOVI, 21 isosorbide dinitrate/hydralazine, 26
INREBIC, 19 isosorbide mononitrate, 26
INSPRA, 23 isosorbide mononitrate ext-rel, 26
insulin aspart, 37 isotretinoin, 57
INSULIN ASPART, 37 ISTALOL, 63
insulin aspart protamine 70%/insulin aspart 30%, 37 ISTODAX, 20
INSULIN ASPART PROTAMINE 70%/INSULIN ASPART 30%, 37 istradefylline, 30
insulin degludec, 37 ISTURISA, 45
insulin detemir, 37 itraconazole, 13
insulin glargine, 37 ivabradine, 26
insulin glulisine, 37 ivacaftor, 56
insulin human, 37 ivermectin, 61
insulin human inhalation powder, 37 ivermectin crm 1%, 61
insulin infusion disposable pump kit, 38 ivosidenib, 22
insulin isophane human, 37 ixabepilone, 21
insulin isophane human 70%/regular 30%, 37 ixazomib, 20
insulin lispro, 37 ixekizumab, 51
INSULIN LISPRO, 37 IXEMPRA, 21
insulin lispro protamine/insulin lispro, 37 IXINITY, 50
INSULIN LISPRO PROTAMINE/INSULIN LISPRO, 37
insulin lispro-aabc, 37
J
JADENU, 51
insulin patch, 38
JAKAFI, 19
insulin pen needles, 38
JALYN, 48
insulin syringes, needles, 38
JANUMET, 36
INTELENCE TABS 100 mg, 200 mg, 15
JANUMET XR, 36
INTELENCE tabs 25 mg, 15
JANUVIA, 36
interferon alfa-2b, 53
84
JARDIANCE, 37 lactulose, 47
JATENZO, 36 lactulose soln, 46
JEVTANA, 21 LAMICTAL, 28
JIVI, 50 LAMICTAL ODT, 28
JORNAY PM, 32 LAMICTAL XR, 28
JUBLIA, 59 lamivudine, 15
JULUCA, 14 lamivudine/tenofovir disoproxil fumarate, 14
JUXTAPID, 24 lamivudine/zidovudine, 14
JYNARQUE, 45 lamotrigine, 28
lamotrigine ext-rel, 28
K
lamotrigine orally disintegrating tabs, 28
KADCYLA, 21
LAMPIT, 17
KALBITOR, 52
lanadelumab-flyo, 52
KALETRA, 15
lancet device, 38
KALYDECO, 56
lancets, 38
KANJINTI, 21
LANOXIN, 26
KANUMA, 45
lanreotide acetate, 44
KAPSPARGO, 25
lansoprazole + amoxicillin + clarithromycin, 47
KAPVAY, 31
lansoprazole delayed-rel, 47
KATERZIA, 25
lanthanum carbonate chew tabs, 43
KENALOG SPRAY, 60
lanthanum oral powder, 43
KENGREAL, 50
LANTUS, 37
KEPIVANCE, 48
lapatinib, 18
KEPPRA, 28
laronidase, 44
KEPPRA XR, 28
larotrectinib, 19
KERENDIA, 41
LASIX, 26
KERYDIN, 58
LASTACAFT, 61
KESIMPTA, 34
latanoprost, 63
ketoconazole, 58
latanoprost ophthalmic emulsion, 63
ketoconazole shampoo 2%, 59
latanoprostene bunod, 63
ketoconazole tabs, 13
LATUDA, 31
ketoprofen, 10
ledipasvir/sofosbuvir, 16
ketoprofen ext-rel, 10
lefamulin, 13
ketorolac, 10
leflunomide, 52
ketorolac 0.45%, 62
lemborexant, 32
ketorolac 0.5%, 62
LEMTRADA, 34
ketorolac tromethamine nasal spray, 10
lenalidomide, 20
KEVEYIS, 26
lenvatinib, 19
KEVZARA, 52
LENVIMA, 19
KEYTRUDA, 18
LESCOL XL, 24
KHAPZORY, 22
LETAIRIS, 27
KINERET, 51
letermovir, 15
KISQALI, 19
letrozole, 18
KISQALI FEMARA CO-PACK, 19
leucovorin calcium, 20
KITABIS PAK, 56
LEUKERAN, 17
KLISYRI, 58
LEUKINE, 49
KLONOPIN, 28
leuprolide acetate, 18, 44
KLOXXADO, 34
levalbuterol inhalation soln, 55
KOATE-DVI, 49
levalbuterol nebulizer soln concentrate, 55
KOGENATE FS, 49
levalbuterol tartrate, CFC-free aerosol, 55
KORLYM, 44
LEVAQUIN, 13
KOSELUGO, 19
LEVBID, 46
KOVALTRY, 49
LEVEMIR, 37
KRINTAFEL, 14
levetiracetam, 28
KRISTALOSE pak, 47
levetiracetam ext-rel, 28
KRYSTEXXA, 10
levetiracetam ext-rel tabs, 28
KUVAN, 43
levobunolol, 63
KYLEENA, 40
levocarnitine, 39
KYNMOBI, 30
levocetirizine, 55
KYPROLIS, 21
levodopa inhalation powder, 30
L levofloxacin, 13, 62
lacosamide, 28 levoleucovorin, 22
lactic acid/citric acid/potassium bitartrate gel, 41 levoleucovorin calcium, 20
levomilnacipran ext-rel, 29
85
levonorgestrel/EE, 40 lorazepam, 28
levonorgestrel/EE - Trivora, 40 LORBRENA, 19
levonorgestrel/EE 0.09/20 - Amethyst, 40 lorlatinib, 19
levonorgestrel/EE 0.1/20, 39 losartan, 23
levonorgestrel/EE 0.1/20 and EE 10, 40 losartan/hydrochlorothiazide, 23
levonorgestrel/EE 0.15/30, 39 LOSEASONIQUE, 40
levonorgestrel/EE 0.15/30 - Jolessa, 40 LOTEMAX Gel, Susp, 62
levonorgestrel/EE 0.15/30 - Levora, 39 LOTEMAX Oint, 62
levonorgestrel/EE 0.15/30 and EE 10, 40 LOTEMAX SM, 62
levonorgestrel-releasing IUD, 40, 41 LOTENSIN, 22
levothyroxine, 44 LOTENSIN HCT, 23
levothyroxine - Levoxyl, 44 loteprednol, 62
LEVSIN, 46 loteprednol 0.2%, 62
LEVULAN KERASTICK, 58 loteprednol 0.5% gel, susp, 62
LEXAPRO, 29 loteprednol 1.0%, 63
LEXIVA, 15 loteprednol etabonate, 63
L-glutamine oral powder, 51 loteprednol oint, 62
LIALDA, 46 LOTREL, 22
LICART, 10 LOTRONEX, 46
lidocaine, 60 lovastatin, 24
lidocaine patch, 60 LOVAZA, 25
lidocaine viscous, 61 LOVENOX, 49
lidocaine/prilocaine, 60 loxapine, 31
LIDODERM, 60 lubiprostone, 46
lifitegrast, 63 LUCENTIS, 64
LILETTA, 41 luliconazole, 58
linaclotide, 46 lumacaftor/ivacaftor, 56
lindane, 61 lumateperone, 31
linezolid, 16 LUMIGAN, 63
LINZESS, 46 LUMIZYME, 44
LIORESAL INTRATHECAL, 34 LUMOXITI, 22
liothyronine, 44 LUNESTA, 32
LIPITOR, 24 LUPKYNIS, 53
LIPOFEN, 24 LUPRON DEPOT, 18
liraglutide, 36 LUPRON DEPOT-PED, 44
liraglutide/insulin degludec, 36 lurasidone, 31
lisdexamfetamine, 32 lurbinectedin, 17
lisinopril, 22 luspatercept-aamt, 51
lisinopril oral soln, 22 lusutrombopag, 51
lisinopril/hydrochlorothiazide, 23 LUTREPULSE, 41
lithium carbonate, 33 LUZU, 58
lithium carbonate ext-rel tabs 300 mg, 33 LYBALVI, 31
lithium carbonate ext-rel tabs 450 mg, 33 LYNPARZA, 21
LITHOBID, 33 LYRICA, 32
LIVALO, 24 LYSODREN, 21
LIVMARLI, 48 LYSTEDA, 51
LIVTENCITY, 15 LYUMJEV/KWIKPEN, 37
lixisenatide/insulin glargine, 36 LYVISPAH, 34
LO LOESTRIN FE, 40
LOCOID LIPOCREAM, 60
M
macitentan, 27
lodoxamide, 61
MACROBID, 16
LOKELMA, 43
MACRODANTIN, 16
lomitapide, 24
mafenide acetate packets 5%, 58
LOMOTIL, 45
MAKENA, 43
lomustine, 17
MALARONE, 14
lonafarnib, 44
mannitol inhalation powder, 56
lonapegsomatropin-tcgd, 42
maralixibat, 48
LONHALA MAGNAIR, 54
maraviroc, 14
LONSURF, 22
maribavir, 15
loperamide, 45
MARINOL, 45
LOPID, 24
MARPLAN, 29
lopinavir/ritonavir, 15
MATULANE, 21
LOPRESSOR, 25
mavacamten, 27
LOPROX, 58
86
MAVENCLAD, 34 methylnaltrexone, 47
MAVYRET, 16 methylphenidate, 32
MAXALT/MAXALT-MLT, 33 methylphenidate ext-rel, 32
MAXIDEX, 62 methylphenidate ext-rel (except methylphenidate tab ER osmotic
MAXITROL, 62 release 72 mg), 32
MAXZIDE, 26 methylphenidate ext-rel caps, 32
MAXZIDE-25, 26 methylphenidate ext-rel caps (PM), 32
MAYZENT, 34 methylphenidate ext-rel chewable tabs, 32
mebendazole, 17 methylphenidate ext-rel susp, 32
mecamylamine, 27 methylphenidate transdermal, 32
mecasermin, 42 methylprednisolone, 41
mechlorethamine gel, 17 metoclopramide, 45
meclizine, 45 metoclopramide nasal spray, 45
MEDROL, 41 metolazone, 26
medroxyprogesterone acetate, 43 metoprolol succinate ext-rel, 25
medroxyprogesterone acetate 150 mg/mL, 40 metoprolol tartrate, 25
mefloquine, 14 metoprolol/hydrochlorothiazide, 25
megestrol acetate, 18 metreleptin, 45
megestrol acetate susp, 43 METROCREAM, 61
MEKINIST, 19 METROGEL, 61
MEKTOVI, 19 METROLOTION, 61
meloxicam tabs, 10 metronidazole crm, 61
melphalan, 22 metronidazole crm 0.75%, 61
melphalan inj, 17 metronidazole gel 0.75%, 61
melphalan tabs, 17 metronidazole gel 1%, 61
memantine soln, 29 metronidazole lotion 0.75%, 61
memantine tabs, 29 metronidazole tabs, 16
MENOPUR, 41 metronidazole vaginal, 48
menotropins, 41 mexiletine, 24
MENTAX, 59 MIACALCIN, 39
MEPHYTON, 54 MIACALCIN inj, 39
mepolizumab, 57 micafungin, 13
MEPRON, 16 MICARDIS, 23
MEPSEVII, 45 MICARDIS HCT, 23
mercaptopurine, 17 miconazole nitrate/zinc oxide, 58
mercaptopurine susp, 18 MICRHOGAM, 52
meropenem, 16 MICRHOGAM PLUS, 52
mesalamine delayed-rel caps, 46 midazolam nasal spray, 28
mesalamine delayed-rel tabs, 46 midodrine, 27
mesalamine ext-rel caps, 46 midostaurin, 19
mesalamine rectal susp, 46 mifepristone, 44
mesalamine supp, 46 migalastat, 45
mesna inj, 20 miglitol, 36
mesna tabs 400 mg, 21 miglustat, 44
MESNEX, 21 MIGRANAL, 33
MESNEX inj, 20 milnacipran, 32
MESTINON, 34 miltefosine, 17
MESTINON TIMESPAN, 34 MINIPRESS, 23
metformin (does not include 625 mg tabs), 36 MINIVELLE, 43
metformin ext-rel, 36 MINOCIN, 13
metformin oral soln, 36 minocycline, 13
methadone, 11 minocycline ext-rel, 13
methamphetamine, 32 minocycline ext-rel caps, 57
methazolamide, 26 minocycline foam, 61
methenamine hippurate, prophylaxis, 16 minocycline hcl micronized foam, 58
methimazole, 44 minoxidil tabs, 27
methotrexate auto-injector, 52 mirabegron ext-rel, 48
methotrexate inj, 52 MIRAPEX ER, 30
methotrexate oral, 52 MIRCERA, 49
methotrexate prefilled syringe, 52 MIRCETTE, 40
methoxsalen oral, 59 MIRENA, 40
methoxy polyethylene glycol/epoetin beta, 49 mirtazapine, 30
methylergonovine, 44 MIRVASO, 61
METHYLIN, 32 misoprostol, 47
87
mitapivat, 51 naphazoline, 64
MITIGARE, 10 NAPROSYN, 10
mitomycin, 20 naproxen, 10
mitotane, 21 naproxen sodium, 10
mitoxantrone, 20 naratriptan, 33
modafinil, 34 NARCAN, 34
mogamulizumab-kpkc, 22 NARDIL, 29
mometasone, 57 NASCOBAL, 54
mometasone crm, lotion, oint 0.1%, 60 NATACYN, 62
mometasone spray, 56 natalizumab, 34
mometasone, CFC-free aerosol, 57 natamycin, 62
mometasone/formoterol, 57 NATAZIA, 40
MONOFERRIC, 54 nateglinide, 37
monomethyl fumarate, 34 NATESTO, 36
MONOVISC, 12 NATPARA, 39
montelukast, 56 NATROBA, 61
MORPHABOND, 11 NAYZILAM, 28
morphine, 11 nebivolol, 25
morphine ext-rel, 11 necitumumab, 21
morphine supp, 11 nefazodone, 30
morphine/naltrexone ext-rel, 11 nelarabine, 20
MOTEGRITY, 46 nelfinavir, 15
MOVANTIK, 47 neomycin/dexamethasone, 62
MOVIPREP, 47 neomycin/polymyxin B/dexamethasone, 62
moxetumomab pasudotox-tdfk, 22 neomycin/polymyxin B/gramicidin, 62
moxifloxacin, 62 neomycin/polymyxin B/hydrocortisone, 64
MOZOBIL, 51 neomycin/polymyxin B/hydrocortisone susp, 62
MS CONTIN, 11 NEORAL, 53
MULPLETA, 51 nepafenac, 62
MULTAQ, 24 nepafenac 0.3%, 62
mupirocin, 58 neratinib, 19
MVASI, 21 NERLYNX, 19
MYALEPT, 45 netarsudil, 64
MYAMBUTOL, 15 netarsudil/latanoprost, 64
MYCAPSSA, 45 netupitant/palonosetron, 45
MYCOBUTIN, 16 NEULASTA, 49
mycophenolate mofetil, 53 NEUPOGEN, 49
mycophenolate sodium delayed-rel, 53 NEUPRO, 30
MYDAYIS, 32 NEURONTIN, 28
MYFEMBREE, 44 NEVANAC, 62
MYFORTIC, 53 nevirapine, 15
MYLERAN, 17 nevirapine ext-rel, 15
MYLOTARG, 22 NEXAVAR, 18
MYOBLOC, 35 NEXLETOL, 24
MYRBETRIQ, 48 NEXLIZET, 24
MYSOLINE, 28 NEXPLANON, 40
MYTESI, 45 NEXTSTELLIS, 40
niacin ext-rel, 25
N NIASPAN, 25
NABI-HB, 52
nicardipine, 25
nabumetone, 10
nicotine inhaler system, 35
nafarelin, 41
nicotine nasal spray, 35
naftifine, 58
NICOTROL INHALER, 35
naftifine gel 2%, 59
NICOTROL NASAL SPRAY, 35
NAFTIN (EXCEPT 2% GEL), 58
nifedipine ext-rel, 25
NAFTIN GEL 2%, 59
nifurtimox, 17
NAGLAZYME, 44
NILANDRON, 18
naloxegol, 47
nilotinib, 19
naloxone inj, 34
nilutamide, 18
naloxone nasal spray, 34
nimodipine, 25
naloxone prefilled syringe, 34
NIMOTOP, 25
naltrexone, 34
NINLARO, 20
naltrexone microspheres, 34
nintedanib, 56
NAMENDA tabs, 29
NIPENT, 17
88
niraparib, 21 NUBEQA, 18
nisoldipine ext-rel, 25 NUCALA, 57
nitazoxanide tabs, 16 NUCYNTA, 11
nitisinone, 42 NUCYNTA ER, 11
NITRO-BID, 27 NUEDEXTA, 35
NITRO-DUR, 27 NULOJIX, 53
nitrofurantoin ext-rel, 16 NUPLAZID, 31
nitrofurantoin macrocrystals, 16 NURTEC ODT, 33
nitroglycerin lingual spray, 27 NUTROPIN AQ, 42
nitroglycerin ointment, 27 NUTROPIN AQ NUSPIN, 42
nitroglycerin rectal oint 0.4%, 47 NUVARING, 41
nitroglycerin sublingual, 27 NUVIGIL, 34
nitroglycerin sublingual aerosol, 27 NUWIQ, 50
nitroglycerin sublingual powder, 27 NUZYRA, 13
nitroglycerin transdermal, 27 nystatin, 13, 58
NITROLINGUAL, 27 NYVEPRIA, 49
NITROMIST, 27
NITROSTAT, 27
O
obeticholic acid, 48
NITYR, 42
obinutuzumab, 21
NIVESTYM, 49
OBIZUR, 50
nivolumab, 21
OCALIVA, 48
nivolumab-relatlimab-rmbw, 18
ocrelizumab, 34
nizatidine, 46
OCREVUS, 34
NIZORAL SHAMPOO, 59
OCTAGAM, 52
NORDITROPIN, 42
octreotide, 45
norelgestromin/EE, 41
octreotide acetate, 44
norethindrone, 40
OCUFLOX, 62
norethindrone acetate, 43
ODEFSEY, 14
norethindrone acetate/EE 1.5/30, 39
ODOMZO, 22
norethindrone acetate/EE 1.5/30 and iron, 40
ofatumumab, 21, 34
norethindrone acetate/EE 1/10 and EE 10 and iron, 40
OFEV, 56
norethindrone acetate/EE 1/20, 39
OFIRMEV, 10
norethindrone acetate/EE 1/20 and iron, 39
ofloxacin, 13, 62
norethindrone acetate/EE and iron, 40
ofloxacin otic, 64
norethindrone/EE, 40
OGIVRI, 21
norethindrone/EE 0.4/35, 40
olanzapine, 31
norethindrone/EE 0.5/35, 40
olanzapine pamoate ext-rel inj, 31
norethindrone/EE 1/35, 40
olanzapine/fluoxetine, 31
norgestimate/EE, 40
olanzapine-samidorphan, 31
norgestimate/EE 0.25/35, 40
olaparib, 21
norgestrel/EE 0.3/30 - Cryselle, 40
olmesartan, 23
norgestrel/EE 0.3/30 - Low-Ogestrel, 40
olmesartan/amlodipine/hydrochlorothiazide, 23
norgestrel/EE 0.5/50, 40
olmesartan/hydrochlorothiazide, 23
NORITATE, 61
olodaterol, CFC-free aerosol, 56
NORPACE, 24
olopatadine, 61
NORPACE CR, 24
olopatadine spray, 56
NORPRAMIN, 30
olsalazine, 46
NORTHERA, 27
OLUMIANT, 51
nortriptyline, 30
omacetaxine mepesuccinate, 21
NORVASC, 25
omadacycline, 13
NORVIR, 15
omalizumab, 57
NOURIANZ, 30
omega-3 acid ethyl esters, 25
NOVAREL, 41
omeprazole delayed-rel, 47
NOVOEIGHT, 49
omeprazole/sodium bicarbonate, 47
NOVOFINE PEN NEEDLES, 38
OMNARIS, 56
NOVOLIN 70/30, 37
OMNIPOD 5 G6 INSULIN INFUSION DISPOSABLE PUMP, 38
NOVOLIN N, 37
OMNIPOD DASH INSULIN INFUSION DISPOSABLE PUMP, 38
NOVOLIN R, 37
OMNITROPE, 42
NOVOLOG, 37
onabotulinumtoxinA, 35
NOVOLOG MIX 70/30, 37
ondansetron, 45
NOVOSEVEN RT, 50
ondansetron orally disintegrating tabs, 45
NOXAFIL susp, 14
ONETOUCH LANCETS, 38
NOXAFIL tabs, 13
ONETOUCH METERS AND KITS, 38
NPLATE, 50
89
ONETOUCH TEST STRIPS, 38 P
ONEXTON, 58 paclitaxel, 20
ONFI, 28 paclitaxel protein-bound particles, 20
ONGENTYS, 30 pacritinib, 19
ONIVYDE, 20 PADCEV, 22
ONTRUZANT, 21 palbociclib, 19
ONUREG, 17 PALFORZIA, 51
ONZETRA XSAIL, 33 palifermin, 48
OPANA, 11 paliperidone ext-rel, 31
OPDIVO, 21 paliperidone palmitate ext-rel inj, 31
OPDUALAG, 18 palivizumab, 16
opicapone, 30 palonosetron, 45
OPSUMIT, 27 PALYNZIQ, 43
OPZELURA, 59 PAMELOR, 30
ORACEA, 61 pamidronate, 39
ORALAIR, 51 PANCREAZE, 47
ORAPRED ODT, 41 pancrelipase, 47
ORENCIA, 51 pancrelipase delayed-rel, 47
ORENITRAM, 27 PANDEL, 60
ORFADIN, 42 panitumumab, 21
ORGOVYX, 18 panobinostat, 22
ORIAHNN, 44 PANRETIN, 61
ORILISSA, 41 pantoprazole delayed-rel, 47
ORKAMBI, 56 PANZYGA, 52
ORLADEYO, 52 PARAGARD T 380A, 40
ORTHOVISC, 11 parathyroid hormone (recombinant), 39
ORTIKOS, 46 paricalcitol, 42
oseltamivir, 16 PARLODEL, 30
osilodrostat phosphate, 45 PARNATE, 29
osimertinib, 19 paroxetine HCl, 29
OSMOLEX ER, 30 paroxetine HCl ext-rel, 29
OSMOPREP, 47 paroxetine mesylate, 29
ospemifene, 44 PARSABIV, 39
OSPHENA, 44 pasireotide, 44
OTEZLA, 51 PATANASE, 56
OTREXUP, 52 patiromer, 43
OVIDREL, 41 PAXIL, 29
oxaliplatin, 20 PAXIL CR, 29
oxaprozin, 10 pazopanib, 19
oxazepam, 28 peanut allergen-dfnp, 51
OXBRYTA, 50 peg 3350/electrolytes, 47
oxcarbazepine, 28 PEGASYS, 53
oxcarbazepine ext-rel, 28 pegfilgrastim, 49
OXERVATE, 63 pegfilgrastim-apgf, 49
oxiconazole crm, 58 pegfilgrastim-ayow, 49
OXISTAT, 58 pegfilgrastim-bmez, 49
OXTELLAR XR, 28 pegfilgrastim-cbqv, 49
oxybutynin, 48 pegfilgrastim-jmdb, 49
oxybutynin ext-rel, 48 peginterferon alfa-2a, 53
oxybutynin gel, 48 peginterferon beta-1a, 34
oxycodone, 11 pegloticase, 10
oxycodone concentrate 20 mg/mL, 11 pegvaliase-pqpz, 43
oxycodone ext-rel, 11 pegvisomant, 45
oxycodone soln, 11 PEMAZYRE, 19
oxycodone/acetaminophen 5/325, 11 pembrolizumab, 18
OXYCONTIN, 11 pemigatinib, 19
oxymetazoline crm 1%, 61 penciclovir, 61
oxymetazoline opth soln, 64 penicillamine tabs, 52
oxymorphone, 11 penicillin VK, 13
ozanimod, 34 PENTASA, 46
OZEMPIC, 36 pentosan polysulfate sodium, 48
ozenoxacin, 58 pentostatin, 17
OZOBAX, 34 pentoxifylline ext-rel, 51
90
perampanel, 28 pralatrexate, 17
PERCOCET, 11 pralsetinib, 19
PERFOROMIST, 56 PRALUENT, 25
perindopril, 22 pramipexole, 30
perindopril arginine/amlodipine, 22 pramipexole ext-rel, 30
PERJETA, 21 pramlintide, 36
permethrin 5%, 61 PRAMOSONE, 59
perphenazine, 31 pramoxine/hydrocortisone, 59
PERSERIS, 31 prasterone vaginal inserts, 44
pertuzumab, 21 prasugrel, 50
pertuzumab/trastuzumab/hyaluronidase-zzxf, 21 pravastatin, 24
PEXEVA, 29 prazosin, 23
pexidartinib, 19 PRECOSE, 36
phenazopyridine, 48 PRED FORTE, 62
phenelzine, 29 PRED MILD, 62
phenobarbital, 28 PRED-G, 62
phenylephrine, 61 prednisolone, 41
phenytoin, 28 prednisolone acetate 0.12%, 62
phenytoin sodium extended, 28 prednisolone acetate 1%, 62
PHESGO, 21 prednisolone phosphate 1%, 62
PHEXXI, 41 prednisolone sodium phosphate, 41
phytonadione, 54 prednisolone sodium phosphate orally disintegrating tabs, 41
PIFELTRO, 15 prednisolone syrup, 41
pilocarpine, 63 prednisone, 41
pilocarpine tabs, 47 prednisone delayed-rel, 41
PILOPINE HS GEL, 63 PREFEST, 43
pimavanserin, 31 pregabalin, 32
pimecrolimus, 59 PREGNYL, 41
pindolol, 25 PREMARIN, 42
pioglitazone, 37 PREMARIN crm, 43
pioglitazone/glimepiride, 37 PREMPHASE, 42
pioglitazone/metformin, 37 PREMPRO, 42
pioglitazone/metformin ext-rel, 37 prenatal vitamins/folic acid, 54
piperacillin/tazobactam, 13 PRENATE ELITE, 54
PIQRAY, 19 PREPOPIK, 47
pirfenidone 267mg caps, 57 PRESTALIA, 22
pirfenidone tabs, 56 PRETOMANID, 15
piroxicam, 10 pretomanid tabs, 15
pitavastatin, 24 PREVIDENT, 61
pitolisant, 34 PREVYMIS, 15
PLAQUENIL, 52 PREZCOBIX, 14
PLAVIX, 50 PREZISTA, 15
plecanatide, 47 PRIALT, 11
PLEGRIDY, 34 PRIFTIN, 15
PLEGRIDY PEN, 34 primaquine, 14
PLENVU, 47 PRIMAXIN, 16
plerixafor, 51 primidone, 28
podofilox, 61 PRISTIQ, 29
polymyxin B/bacitracin, 62 PRIVIGEN, 52
polymyxin B/trimethoprim, 62 PROAIR DIGIHALER, 55
POLYTRIM, 62 PROAIR HFA, 55
pomalidomide, 18 PROAIR RESPICLICK, 55
POMALYST, 18 probenecid, 10
ponatinib, 19 procarbazine, 21
ponesimod, 34 PROCARDIA XL, 25
PONVORY, 34 prochlorperazine, 45
PORTRAZZA, 21 PROCRIT, 49
posaconazole delayed-rel tabs, 13 PROCTOFOAM-HC, 47
posaconazole susp, 14 PROCYSBI, 44
potassium chloride ext-rel, 53 PROFILNINE, 50
potassium chloride liquid, 53 progesterone vaginal inserts, 43
potassium chloride powder, 53 progesterone, micronized, 43
potassium citrate ext-rel, 48 PROGLYCEM, 41
POTELIGEO, 22 PROGRAF, 53
91
PROLASTIN-C, 54 RANEXA, 27
PROLENSA, 62 ranibizumab, 64
PROLEUKIN, 21 ranolazine ext-rel, 27
PROLIA, 39 RAPAFLO, 48
PROMACTA, 50 RAPAMUNE, 53
promethazine, 45, 55 rasagiline, 30
PROMETRIUM, 43 rasburicase, 17
propafenone ext-rel, 24 RASUVO, 52
propranolol, 25 RAVICTI, 44
propranolol ext-rel, 25 ravulizumab-cwvz, 50
propylthiouracil, 44 RAYALDEE, 42
PROSCAR, 48 RAYOS, 41
protein C concentrate, human, 51 RAZADYNE ER, 29
PROTOPIC, 59 REBIF, 33
protriptyline, 30 REBIF REBIDOSE, 34
PROVENTIL HFA, 55 REBINYN, 50
PROVERA, 43 REBLOZYL, 51
PROVIGIL, 34 RECLAST, 39
PROZAC, 29 RECOMBINATE, 49
prucalopride, 46 RECTIV, 47
PULMICORT FLEXHALER, 57 REDITREX, 52
PULMICORT RESPULES, 57 REGLAN, 45
PULMOZYME, 56 regorafenib, 19
PURIXAN, 18 REGRANEX, 61
PYLERA, 47 RELENZA, 16
pyrazinamide, 15 RELEUKO, 49
PYRIDIUM, 48 RELISTOR, 47
pyridostigmine, 34 RELPAX, 33
pyridostigmine ext-rel tabs 180 mg, 34 relugolix, 18
pyrimethamine, 14 relugolix/estradiol/norethindrone acetate, 44
PYRUKYND, 51 REMERON, 30
REMICADE, 51
Q REMODULIN, 27
QBRELIS, 22
RENAGEL, 43
QBREXZA, 61
RENFLEXIS, 52
QDOLO, 11
RENVELA, 43
QELBREE, 32
repaglinide, 37
QINLOCK, 19
REPATHA, 25
QTERN, 38
reslizumab inj, 57
quazepam, 32
RESTASIS, 63
QUDEXY XR, 28
RESTORIL, 32
QUESTRAN/QUESTRAN LIGHT, 24
RETACRIT, 49
quetiapine, 31
retapamulin, 58
quetiapine ext-rel, 31
RETEVMO, 19
QUILLICHEW ER, 32
RETIN-A, 58
QUILLIVANT XR, 32
RETIN-A MICRO, 58
quinapril, 22
RETROVIR, 15
quinapril/hydrochlorothiazide, 23
REVATIO, 27
quinidine gluconate ext-rel, 24
REVCOVI, 45
QULIPTA, 33
revefenacin inhalation solution, 54
QUTENZA, 60
REVLIMID, 20
QVAR, 57
REXULTI, 31
QVAR REDIHALER, 57
REYATAZ, 15
R Rho (D) immune globulin, 52
rabeprazole delayed-rel (except rabeprazole capsule sprinkle delayed- RHOFADE, 61
rel), 47 RHOGAM, 52
RADICAVA, 35 RHOGAM PLUS, 52
RADICAVA ORS, 35 RHOPHYLAC, 52
raloxifene, 43 RHOPRESSA, 64
raltegravir, 14 RIABNI, 21
ramelteon, 32 RIASTAP, 50
ramipril, 22 ribavirin caps, 16
ramucirumab, 22 ribavirin caps - Ribasphere, 16
ribavirin tabs, 16
92
ribociclib, 19 ROXICODONE, 11
ribociclib + letrozole, 19 ROZEREM, 32
RIDAURA, 52 ROZLYTREK, 19
rifabutin, 16 RUBRACA, 21
rifampin, 15 rucaparib, 21
rifampin/isoniazid/pyrazinamide, 15 RUCONEST, 52
rifamycin delayed-rel, 13 rufinamide, 28
rifapentine, 15 RUKOBIA, 14
RIFATER, 15 RUXIENCE, 21
rifaximin, 17 ruxolitinib, 19, 59
rilonacept, 53 RYBELSUS, 36
rilpivirine, 15 RYDAPT, 19
RILUTEK, 35 RYTARY, 30
riluzole, 35 RYTHMOL SR, 24
rimabotulinumtoxinB, 35
rimantadine, 16
S
SABRIL, 28
rimegepant, 33
sacituzumab govitecan-hziy, 22
rimexolone, 62
sacubitril/valsartan, 26
RINVOQ ER, 51
safinamide, 30
riociguat, 27
SAFYRAL, 39
RIOMET IR, 36
SAIZEN, 42
ripretinib, 19
SALAGEN, 47
risankizumab-rzaa, 51
salmeterol xinafoate, 56
risdiplam, 35
SAMSCA, 44
risedronate, 39
SANCUSO, 45
risedronate delayed-rel, 39
SANDIMMUNE, 53
RISPERDAL, 31
SANDOSTATIN, 44
RISPERDAL CONSTA, 31
SANDOSTATIN LAR, 44
RISPERDAL M-TABS, 31
SAPHRIS, 31
risperidone, 31
sapropterin, 43
risperidone ext-rel inj, 31
SARCLISA, 20
risperidone long-acting inj, 31
sarecycline, 13
risperidone orally disintegrating tabs, 31
sargramostim, 49
RITALIN, 32
sarilumab, 52
RITALIN LA, 32
satralizumab-mwge, 52
ritonavir tabs, 15
SAVELLA, 32
RITUXAN, 22
SCEMBLIX, 19
RITUXAN HYCELA, 22
scopolamine, 63
rituximab, 22
scopolamine transdermal, 45
rituximab/hyaluronidase human, 22
SEASONIQUE, 40
rituximab-abbs, 21
sebelipase alfa, 45
rituximab-arrx, 21
secnidazole, 17
rituximab-pvvr, 21
SECUADO, 31
rivaroxaban, 49
secukinumab, 52
rivastigmine, 29
segesterone acetate/EE ring, 41
rivastigmine transdermal, 29
SEGLENTIS, 11
RIXUBIS, 50
SEGLUROMET, 38
rizatriptan, 33
selegiline caps, 30
ROCALTROL, 42
selegiline orally disintegrating tabs, 30
ROCEPHIN, 12
selegiline transdermal, 29
ROCKLATAN, 64
selexipag, 27
roflumilast, 56
selinexor, 22
rolapitant, 45
selpercatinib, 19
romidepsin, 20
selumetinib, 19
romiplostim, 50
SELZENTRY, 14
romosozumab-aqqg, 39
semaglutide, 36
ropeginterferon alfa-2b-njft, 51
SENSIPAR, 39
ropinirole, 30
serdexmethylphenidate-dexmethylphenidate, 32
ropinirole ext-rel, 30
SEREVENT DISKUS, 56
rosuvastatin, 24
SERNIVO, 60
rosuvastatin capsules, 24
SEROQUEL, 31
ROSZET, 24
SEROQUEL XR, 31
rotigotine transdermal, 30
SEROSTIM, 42
ROWASA, 46
93
sertaconazole, 59 sorafenib, 18
sertraline caps, 29 SORILUX, 59
SERTRALINE caps, 29 sotalol, 24
sertraline tabs, 29 sotalol AF, 24
sevelamer carbonate, 43 SOVALDI, 16
sevelamer HCl, 43 spinosad, 61
SEVENFACT, 50 SPIRIVA, 54
SEYSARA, 13 SPIRIVA RESPIMAT, 54
SIGNIFOR, 44 spironolactone, 23
SIKLOS, 22 spironolactone/hydrochlorothiazide, 26
sildenafil, 27 SPORANOX, 13
SILENOR, 32 SPRAVATO, 30
SILIQ, 51 SPRIX, 10
silodosin, 48 SPRYCEL, 19
SILVADENE, 58 STALEVO, 30
silver sulfadiazine, 58 stavudine, 15
SIMBRINZA, 63 STEGLATRO, 37
SIMPONI 100 mg, 51 STEGLUJAN, 38
SIMPONI 50 mg, 51 STELARA, 51
simvastatin, 24 STELARA SUBCUTANEOUS, 51
SINEMET, 30 STIMATE, 50
SINGULAIR, 56 STIOLTO RESPIMAT, 55
siponimod, 34 stiripentol, 29
sirolimus, 53 STIVARGA, 19
SIRTURO, 15 STRATTERA, 31
sitagliptin phosphate, 36 STRENSIQ, 44
sitagliptin/metformin, 36 streptozocin, 17
sitagliptin/metformin ext-rel, 36 STRIANT, 36
SIVEXTRO, 17 STRIBILD, 14
SKYLA, 40 STRIVERDI RESPIMAT, 56
SKYRIZI, 51 SUBLOCADE, 34
SKYTROFA, 42 SUBOXONE FILM, 35
SLYND, 40 SUBSYS, 11
SOAANZ, 26 sucralfate, 47
sodium ferric gluconate inj, 54 sucroferric oxyhydroxide, 43
sodium fluoride, 61 SULAR, 25
sodium hyaluronate, 11, 12 sulconazole, 58
sodium oxybate, 34 sulfacetamide sodium, 58
sodium phenylbutyrate, 44 sulfacetamide soln 10%, 62
sodium phosphates, 47 sulfacetamide/prednisolone acetate oint 10%/0.2%, 62
sodium picosulfate/magnesium oxide/citric acid, 47 sulfacetamide/prednisolone phosphate 10%/0.25%, 62
sodium polystyrene sulfonate, 43 sulfamethoxazole/trimethoprim, 16
sodium sulfate/magnesium sulfate/potassium chloride, 47 sulfamethoxazole/trimethoprim DS, 16
sodium sulfate/potassium sulfate/magnesium sulfate, 47 SULFAMYLON, 58
sodium zirconium cyclosilicate, 43 sulfasalazine, 46
sofosbuvir, 16 sulfasalazine delayed-rel, 46
sofosbuvir/velpatasvir, 16 sulindac, 10
sofosbuvir/velpatasvir/voxilaprevir, 16 sumatriptan, 33
SOFTCLIX LANCET DEVICE, 38 sumatriptan nasal powder, 33
SOFTCLIX LANCETS, 38 sumatriptan nasal spray, 33
SOFTTOUCH LANCET DEVICE, 38 sumatriptan/naproxen sodium, 33
SOFTTOUCH LANCETS, 38 sunitinib, 19
SOLESTA, 47 SUNOSI, 34
solifenacin, 48 SUPARTZ FX, 11
SOLIQUA, 36 SUPPRELIN LA, 44
SOLIRIS, 50 SUPRAX, 12
SOLODYN, 13 SUPREP, 47
SOLOSEC, 17 SUSTIVA, 15
solriamfetol, 34 SUSTOL, 45
somatropin, 42 SUTAB, 47
SOMATULINE DEPOT, 44 SUTENT, 19
SOMAVERT, 45 sutimlimab-jome, 51
sonidegib, 22 suvorexant, 32
SOOLANTRA, 61 SYMBICORT, 57
94
SYMDEKO, 56 teduglutide, 48
SYMFI, 14 TEFLARO, 13
SYMFI LO, 14 tegaserod maleate, 46
SYMJEPI, 54 TEGRETOL, 28
SYMLINPEN, 36 TEGRETOL-XR, 28
SYMTUZA, 14 TEGSEDI, 45
SYNAGIS, 16 TEKTURNA, 26
SYNALAR, 60 TEKTURNA HCT, 26
SYNAREL, 41 telavancin, 17
SYNDROS, 47 telbivudine, 16
SYNJARDY, 37 telmisartan, 23
SYNJARDY XR, 37 telmisartan/hydrochlorothiazide, 23
SYNRIBO, 21 telotristat, 48
SYNTHROID, 44 temazepam, 32
SYNVISC, 12 TEMODAR caps, 17
SYNVISC-ONE, 12 TEMODAR inj, 17
SYPRINE, 44 TEMOVATE, 60
temozolomide caps, 17
T
temozolomide inj, 17
TABLOID, 17
temsirolimus, 19
TABRECTA, 19
tenapanor, 46
TACHOSIL, 61
tenofovir alafenamide, 16
tacrolimus, 53, 59
tenofovir disoproxil fumarate tabs 300 mg, 15
tacrolimus ext-rel, 53
TENORMIN, 25
tadalafil 2.5 mg, 5 mg, 48
TEPADINA, 17
tadalafil tabs 20 mg, 27
TEPEZZA, 64
tadalafil tabs 20 mg - Alyq, 27
TEPMETKO, 20
tafamidis, 26
tepotinib, 20
tafamidis meglumine, 26
teprotumumab-trbw for IV soln, 64
tafenoquine, 14
terazosin, 23
TAFINLAR, 19
terbinafine tabs, 13
tafluprost, 63
terbutaline, 56
TAGRISSO, 19
terconazole crm, 48
TAKHZYRO, 52
terconazole supp 80 mg, 48
talazoparib, 21
teriflunomide, 34
TALICIA, 47
teriparatide, 39
taliglucerase alfa, 45
tesamorelin, 45
talimogene laherparepvec, 21
TESTIM, 36
TALTZ, 51
TESTOPEL, 36
TALZENNA, 21
testosterone buccal, 36
TAMIFLU, 16
testosterone cypionate, 35
tamoxifen, 18
testosterone enanthate, 35
tamsulosin, 48
testosterone enanthate auto-injector, 36
tapentadol, 11
testosterone gel, 35, 36
tapentadol ext-rel, 11
testosterone nasal gel, 36
TARGRETIN caps, 20
testosterone pellets, 36
TARGRETIN gel, 20
testosterone soln, 36
TARPEYO, 45
testosterone transdermal, 36
TASIGNA, 19
testosterone undecanoate capsule, 36
tasimelteon, 32
testosterone undecanoate inj, 36
tavaborole sol 5%, 58
tetrabenazine, 33
TAVALISSE, 50
tetracycline, 13
TAVNEOS, 53
tezacaftor/ivacaftor + ivacaftor, 56
TAYTULLA, 39
thalidomide, 20
tazarotene crm 0.05%, gel 0.05%, 0.1%, 58
THALOMID, 20
tazarotene crm 0.1%, 58
THEO-24, 57
tazarotene foam 0.1%, 58
theophylline ext-rel caps, 57
tazarotene lotion 0.045%, 58
theophylline ext-rel tabs, 57
tazemetostat, 20
theophylline liquid, 57
TAZORAC, 58
thioguanine, 17
TAZVERIK, 20
THIOLA, 48
tbo-filgrastim, 49
THIOLA EC, 48
TECENTRIQ, 21
thioridazine, 31
tedizolid, 17
thiotepa, 17
95
thiothixene, 31 tralokinumab-ldrm, 59
THYQUIDITY, 44 tramadol (except 100 mg tabs), 11
THYROGEN, 45 tramadol ext-rel, 11
thyroid, 44 tramadol oral solution, 11
thyrotropin alfa, 45 tramadol/acetaminophen, 11
tiagabine, 28 trametinib, 19
TIAZAC, 25 trandolapril, 22
TIBSOVO, 22 trandolapril/verapamil ext-rel, 22
ticagrelor, 50 tranexamic acid, 51
TICE BCG, 21 TRANSDERM SCOP, 45
tigecycline, 16 TRANXENE T-TAB, 28
TIGLUTIK, 35 tranylcypromine, 29
TIKOSYN, 24 trastuzumab, 22
tildrakizumab-asmn, 52 trastuzumab/hyaluronidase-oysk, 22
timolol hemihydrate, 63 trastuzumab-anns, 21
timolol maleate, 63 trastuzumab-dkst, 21
timolol maleate gel, 63 trastuzumab-dttb, 21
TIMOPTIC, 63 trastuzumab-pkrb, 21
TIMOPTIC-XE, 63 trastuzumab-qyyp, 21
tinidazole, 16 TRAVATAN Z, 63
tiopronin, 48 travoprost, 63
tiopronin delayed-rel, 48 TRAZIMERA, 21
tiotropium, 54 trazodone, 30
tiotropium/olodaterol, 55 TREANDA, 17
tipranavir, 15 TRELEGY ELLIPTA, 55
tirbanibulin, 58 TRELSTAR, 18
tirofiban inj, 50 TRELSTAR DEPOT, 18
TIROSINT, 44 TRELSTAR LA, 18
TIVICAY, 14 TREMFYA, 51
tivozanib, 20 treprostinil, 27
TOBI, 56 treprostinil ext-rel, 27
TOBI PODHALER, 56 treprostinil inhalation powder, 27
TOBRADEX OINTMENT, 62 TRESIBA, 37
TOBRADEX SUSPENSION, 62 tretinoin, 58
tobramycin, 62 tretinoin gel microsphere, 58
tobramycin inhalation powder, 56 TRETTEN, 50
tobramycin inhalation soln, 56 TREXIMET, 33
tobramycin/dexamethasone oint 0.3%/0.1%, 62 triamcinolone acetonide crm 0.5%, 60
tobramycin/dexamethasone susp 0.3%/0.1%, 62 triamcinolone acetonide crm, lotion 0.025%, 60
tobramycin/loteprednol, 62 triamcinolone acetonide crm, lotion, oint 0.1%, 60
TOBREX, 62 triamcinolone acetonide topical spray, 60
tocilizumab, 51 triamcinolone paste, 61
tofacitinib, 51 triamterene/hydrochlorothiazide, 26
tofacitinib ext-rel, 51 triamterene/hydrochlorothiazide 37.5/25, 26
tolcapone, 30 triamterene/hydrochlorothiazide 50/25, 26
tolterodine, 48 TRIBENZOR, 23
tolterodine ext-rel, 48 TRICOR, 24
tolvaptan, 44, 45 trientine, 44
TOPAMAX, 28 triethanolamine polypeptide oleate, 64
TOPICORT, 60 trifarotene cream 0.005%, 58
topiramate, 28 trifluoperazine, 31
topiramate ext-rel, 28, 29 trifluridine, 63
topotecan, 20 trifluridine/tipiracil, 22
topotecan inj, 20 triheptanoin, 54
TOPROL-XL, 25 trihexyphenidyl, 30
toremifene, 18 TRIJARDY XR, 38
TORISEL, 19 TRIKAFTA, 56
torsemide, 26 TRILEPTAL, 28
TOSYMRA, 33 TRILIPIX, 24
TOTECT, 20 trimethobenzamide, 45
TOUJEO, 37 trimethoprim, 16
TOVIAZ, 48 TRINTELLIX, 29
trabectedin, 17 TRIPTODUR, 45
TRACLEER, 27 triptorelin pamoate, 18, 45
96
TRISENOX, 20 VALTOCO, 28
TRIUMEQ, 14 VALTREX, 16
TRIVISC, 11 VANCOCIN, 17
TRIZIVIR, 14 vancomycin caps, 17
TRODELVY, 22 vancomycin oral soln, 17
TROGARZO, 15 vandetanib, 19
TROKENDI XR, 29 varenicline, 35
trospium, 48 varenicline nasal solution, 63
trospium ext-rel, 48 varicella zoster immune globulin, 52
TRULANCE, 47 VARIZIG, 52
TRULICITY, 36 VARUBI, 45
TRUSOPT, 63 VASCEPA, 25
TRUVADA, 14 VASERETIC, 23
TRUXIMA, 21 VASOTEC, 22
tucatinib, 20 VECAMYL, 27
TUDORZA PRESSAIR, 54 VECTIBIX, 21
TUKYSA, 20 VECTICAL, 59
TURALIO, 19 vedolizumab, 46
TWIRLA, 41 velaglucerase alfa, 45
TYBLUME, 40 VELCADE, 20
TYBOST, 14 VELETRI, 27
TYGACIL, 16 VELPHORO, 43
TYKERB, 18 VELTASSA, 43
TYMLOS, 39 VELTIN, 58
TYRVAYA, 63 VEMLIDY, 16
TYSABRI, 34 vemurafenib, 19
TYVASO, 27 VENCLEXTA, 21
TYVASO DPI POWDER, 27 venetoclax, 21
TYZEKA, 16 venlafaxine besylate ext-rel tabs, 29
VENLAFAXINE BESYLATE EXT-REL TABS, 29
U venlafaxine hcl, 29
UDENYCA, 49
venlafaxine hcl ext-rel, 29
ULORIC, 10
venlafaxine hcl ext-rel tabs, 29
ULTOMIRIS, 50
VENOFER, 54
ULTRAM, 11
VENTAVIS, 27
ULTRAM ER, 11
VENTOLIN HFA, 55
ULTRAVATE, 60
VERAMYST, 56
umeclidinium bromide, 54
verapamil, 25
umeclidinium/vilanterol, 55
verapamil ext-rel, 26
UNASYN, 13
VERDESO, 59
upadacitinib, 51
vericiguat, 26
UPNEEQ, 64
VERQUVO, 26
UPTRAVI, 27
verteporfin, 64
uridine triacetate, 44
VERZENIO, 19
urine test strips, 38
VESICARE LS, 48
UROCIT-K, 48
vestronidase alfa-vjbk, 45
URSO, 46
VEXOL, 62
URSO FORTE, 46
VFEND, 13
ursodiol, 46
V-GO INSULIN INFUSION DISPOSABLE PUMP, 38
ustekinumab, 51
VIBATIV, 17
V vibegron, 48
VAGIFEM, 43 VIBERZI, 46
valacyclovir, 16 VIBRAMYCIN, 13
valbenazine, 35 VICTOZA, 36
VALCHLOR, 17 VIDAZA, 20
VALCYTE, 15 vigabatrin, 28
valganciclovir, 15 vigabatrin powder - Vigadrone, 28
VALIUM, 28 VIGAMOX, 62
valproic acid, 28 VIIBRYD, 29
valrubicin, 20 VIJOICE, 19
valsartan, 23 vilazodone, 29
valsartan/hydrochlorothiazide, 23 viloxazine ext-rel caps, 32
VALSTAR, 20 VILTEPSO, 35
viltolarsen, 35
97
VIMIZIM, 44 XELJANZ, 51
VIMPAT, 28 XELJANZ XR, 51
vinblastine, 20 XELODA, 17
vincristine, 20 XELPROS, 63
vinorelbine, 21 XEMBIFY, 53
VIOKACE, 47 XENAZINE, 33
VIRACEPT, 15 XENLETA, 13
VIREAD, 15 XEOMIN, 35
vismodegib, 21 XEPI, 58
VISTARIL, 28, 55 XERMELO, 48
VISTIDE, 15 XGEVA, 39
VISUDYNE, 64 XHANCE, 56
VITAFOL-OB, 54 XIAFLEX, 61
VITRAKVI, 19 XIFAXAN, 17
VIVELLE-DOT, 43 XIGDUO XR, 37
VIVITROL, 34 XIIDRA, 63
VIZIMPRO, 19 XIMINO, 57
voclosporin, 53 XOFLUZA, 16
VOGELXO, 36 XOLAIR, 57
von Willebrand factor, recombinant, 50 XOPENEX CONCENTRATE, 55
VONJO, 19 XOPENEX HFA, 55
VONVENDI, 50 XOPENEX SOLUTION, 55
vorapaxar, 50 XOSPATA, 19
VORAXAZE, 21 XPOVIO, 22
voriconazole, 13 XTAMPZA ER, 11
vorinostat, 21 XTANDI, 18
vortioxetine, 29 XULTOPHY, 36
VOSEVI, 16 XURIDEN, 44
vosoritide, 45 XYNTHA, 50
VOTRIENT, 19 XYNTHA SOLOFUSE, 50
voxelotor, 50 XYOSTED, 36
VOXZOGO, 45 XYREM, 34
VPRIV, 45 XYWAV, 34
VRAYLAR, 31
VUMERITY, 34
Y
YASMIN, 39
VUSION, 58
YAZ, 39
VWF, human/factor VIII complex, 50
YERVOY, 21
VYEPTI, 33
YONDELIS, 17
VYNDAMAX, 26
YONSA, 18
VYNDAQEL, 26
YUPELRI, 54
VYONDYS 53, 35
VYTORIN, 24 Z
VYVANSE, 32 zafirlukast, 56
VYZULTA, 63 zaleplon, 32
ZALTRAP, 21
W
zanamivir, 16
WAKIX, 34
ZANOSAR, 17
warfarin, 49
zanubrutinib, 20
WELCHOL, 24
ZARONTIN, 28
WELLBUTRIN SR, 30
ZARXIO, 49
WELLBUTRIN XL, 30
ZAVESCA, 44
WILATE, 50
ZEGALOGUE, 42
WINLEVI, 58
ZEJULA, 21
WINRHO SDF, 52
ZELAPAR, 30
WYNZORA, 59
ZELBORAF, 19
X ZELNORM, 46
XADAGO, 30 ZEMAIRA, 54
XALATAN, 63 ZEMPLAR, 42
XALKORI, 19 ZENPEP, 47
XANAX, 27 ZENZEDI, 32
XANAX XR, 27 ZEPATIER, 16
XARELTO, 49 ZEPOSIA, 34
XCOPRI, 28 ZEPZELCA, 17
98
ZESTORETIC, 23 ZOLOFT, 29
ZESTRIL, 22 zolpidem, 32
ZETIA, 24 zolpidem ext-rel, 32
ZIAC, 25 zolpidem spray, 32
ZIAGEN, 15 zolpidem sublingual, 32
ZIAGEN soln, 15 ZOLPIMIST, 32
ZIANA, 58 ZOMACTON, 42
ziconotide, 11 ZOMIG, 33
zidovudine, 15 ZOMIG/ZOMIG-ZMT, 33
ZIEXTENZO, 49 ZONALON, 61
zileuton, 56 ZONEGRAN, 28
ZILXI, 61 zonisamide, 28
ZIMHI, 34 ZONTIVITY, 50
zinc acetate, 54 ZORBTIVE, 42
ZINPLAVA, 53 ZORTRESS, 53
ZIOPTAN, 63 ZOSYN, 13
ziprasidone, 31 ZOVIRAX, 16, 61
ZIRABEV, 21 ZTALMY, 29
ZIRGAN, 63 ZUBSOLV, 35
ZITHROMAX, 13 ZYCLARA, 61
ziv-aflibercept, 21 ZYDELIG, 19
ZOCOR, 24 ZYFLO, 56
ZOKINVY, 44 ZYKADIA, 19
ZOLADEX, 18 ZYLET, 62
zoledronic acid 4 mg/100 mL, 39 ZYLOPRIM, 10
zoledronic acid 5 mg/100 mL, 39 ZYPREXA RELPREVV, 31
ZOLINZA, 21 ZYPREXA/ZYPREXA ZYDIS, 31
zolmitriptan, 33 ZYTIGA, 18
zolmitriptan nasal spray, 33 ZYVOX, 16
99

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FEP 5 Tier Rx Drug Formulary (607) Standard Option 1022

Effective October 1, 2022 v2

The formulary is separated by Tiers in the following manner:

Tier 1 Tier 2 Tier 3 Tier 4 Tier 5

Medicare Part B $5 copayment for a

Medicare Part B $10 copay

Drug products shown in boldface type indicate generic availability.

PHARMACY AND MEDICAL POLICY COMMITTEE

PRODUCT SELECTION CRITERIA

FORMULARY PRODUCT DESCRIPTIONS

Extended-release and delayed-release products require their own entry.

sitagliptin/metformin ext-rel Janumet XR

DRUG EFFICACY STUDY IMPLEMENTATION DRUGS

FEP Rx Drug Formulary - MC 145

acetaminophen inj Tier 1 OFIRMEV Tier 3

QL buprenorphine transdermal Tier 1 BUTRANS Tier 3

Hepatitis: CDC recommendations on the treatment of hepatitis are available at:

Chemokine Receptor Antagonists

Gp120-Directed Attachment Inhibitors

Non-nucleoside Reverse Transcriptase Inhibitors

Nucleoside Reverse Transcriptase Inhibitors

Nucleotide Reverse Transcriptase Inhibitors

* Brand requires prior approval

Respiratory Syncytial Virus Agents

* Brand TEMODAR caps requires prior approval

* Brand XELODA requires prior approval

HORMONAL ANTINEOPLASTIC AGENTS

*Brand FASLODEX requires prior approval

Gonadotropin-Releasing Hormone (GnRH) Antagonists

Luteinizing Hormone-Releasing Hormone (LHRH) Agonists

benazepril Tier 1 LOTENSIN Tier 3

ACE INHIBITOR/CALCIUM CHANNEL BLOCKER COMBINATIONS

ALDOSTERONE RECEPTOR ANTAGONISTS

doxazosin Tier 1 CARDURA Tier 3

ANGIOTENSIN II RECEPTOR ANTAGONISTS/DIURETIC COMBINATIONS

candesartan Tier 1 ATACAND Tier 3

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER COMBINATIONS

ANGIOTENSIN II RECEPTOR ANTAGONIST/CALCIUM CHANNEL BLOCKER/DIURETIC COMBINATIONS

* Brand TIKOSYN requires prior approval

Bile Acid Resins

Cholesterol Absorption Inhibitors

HMG-CoA Reductase Inhibitors/Combinations

Microsomal Triglyceride Transfer Protein Inhibitors

Omega-3 Fatty Acids

CALCIUM CHANNEL BLOCKERS

CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS

DIRECT RENIN INHIBITORS/DIURETIC COMBINATIONS

Thiazides and Thiazide-like Diuretics

PULMONARY ARTERIAL HYPERTENSION

Prostacyclin Receptor Agonists

Soluble Guanylate Cyclase Stimulators

CENTRAL NERVOUS SYSTEM

carbamazepine Tier 1 TEGRETOL Tier 3

donepezil Tier 1 ARICEPT Tier 3

Monoamine Oxidase Inhibitors (MAOIs)

Selective Serotonin Reuptake Inhibitors (SSRIs)

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

Tricyclic Antidepressants (TCAs)