| Drug Name |
|
Quantity Limit |
| Analgesics |
|
|
| Analgesics, Miscellaneous |
|
|
| acetaminophen-codeine oral solution 120-12 mg/5 ml |
|
QL (4500 per 30 days) |
| acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg |
|
QL (360 per 30 days) |
| acetaminophen-codeine oral tablet 300-60 mg |
|
QL (180 per 30 days) |
| butalbital-acetaminophen-caff oral tablet 50-325-40 mg |
(Esgic) |
QL (180 per 30 days); |
| butalbital-aspirin-caffeine oral capsule 50-325-40 mg |
|
QL (180 per 30 days); |
| butalbital-aspirin-caffeine oral tablet 50-325-40 mg |
|
QL (180 per 30 days); |
| codeine sulfate oral tablet 30 mg, 60 mg |
|
QL (180 per 30 days) |
| endocet oral tablet 10-325 mg |
(oxycodone-acetaminophen) |
QL (180 per 30 days) |
| endocet oral tablet 2.5-325 mg, 5-325 mg |
(oxycodone-acetaminophen) |
QL (360 per 30 days) |
| endocet oral tablet 7.5-325 mg |
(oxycodone-acetaminophen) |
QL (240 per 30 days) |
| fentanyl citrate buccal lozenge on a handle 1,200 mcg, 1,600 mcg, 400 mcg, 600 mcg, 800 mcg |
(Actiq) |
QL (120 per 30 days) |
| fentanyl citrate buccal lozenge on a handle 200 mcg |
(Actiq) |
QL (120 per 30 days) |
| fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 50 mcg/hr, 75 mcg/hr |
|
QL (10 per 30 days) |
| fentanyl transdermal patch 72 hour 25 mcg/hr |
|
QL (10 per 30 days) |
| hydrocodone-acetaminophen oral solution 7.5-325 mg/15 ml |
|
QL (2700 per 30 days) |
| hydrocodone-acetaminophen oral tablet 10-325 mg, 7.5-325 mg |
|
QL (180 per 30 days) |
| hydrocodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg |
|
QL (240 per 30 days) |
| hydrocodone-ibuprofen oral tablet 7.5-200 mg |
|
QL (150 per 30 days) |
| hydromorphone oral liquid 1 mg/ml |
(Dilaudid) |
QL (1200 per 30 days) |
| hydromorphone oral tablet 2 mg, 4 mg, 8 mg |
(Dilaudid) |
QL (180 per 30 days) |
| LAZANDA NASAL SPRAY,NON-AEROSOL 100 MCG/SPRAY, 300 MCG/SPRAY, 400 MCG/SPRAY |
|
QL (30 per 30 days) |
| methadone injection solution 10 mg/ml |
|
QL (120 per 30 days) |
| methadone oral solution 10 mg/5 ml |
|
QL (600 per 30 days) |
| methadone oral solution 5 mg/5 ml |
|
QL (1200 per 30 days) |
| methadone oral tablet 10 mg |
|
QL (120 per 30 days) |
| methadone oral tablet 5 mg |
|
QL (180 per 30 days) |
| methadose oral tablet,soluble 40 mg |
(methadone) |
QL (30 per 30 days) |
| morphine concentrate oral solution 100 mg/5 ml (20 mg/ml) |
|
QL (180 per 30 days) |
| morphine oral solution 10 mg/5 ml |
|
QL (700 per 30 days) |
| morphine oral solution 20 mg/5 ml (4 mg/ml) |
|
QL (300 per 30 days) |
| MORPHINE ORAL TABLET 15 MG |
|
QL (180 per 30 days) |
| MORPHINE ORAL TABLET 30 MG |
|
QL (120 per 30 days) |
| morphine oral tablet extended release 100 mg, 200 mg, 60 mg |
(MS Contin) |
QL (60 per 30 days) |
| morphine oral tablet extended release 15 mg, 30 mg |
(MS Contin) |
QL (90 per 30 days) |
| oxycodone oral solution 5 mg/5 ml |
|
QL (1300 per 30 days) |
| oxycodone oral tablet 10 mg |
|
QL (180 per 30 days) |
| oxycodone oral tablet 15 mg, 30 mg |
(Roxicodone) |
QL (120 per 30 days) |
| oxycodone oral tablet 20 mg |
|
QL (120 per 30 days) |
| oxycodone oral tablet 5 mg |
(Roxicodone) |
QL (180 per 30 days) |
| oxycodone oral tablet,oral only,ext.rel.12 hr 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, 80 mg |
(OxyContin) |
QL (60 per 30 days) |
| oxycodone-acetaminophen oral tablet 10-325 mg |
(Endocet) |
QL (180 per 30 days) |
| oxycodone-acetaminophen oral tablet 2.5-325 mg, 5-325 mg |
(Endocet) |
QL (360 per 30 days) |
| oxycodone-acetaminophen oral tablet 7.5-325 mg |
(Endocet) |
QL (240 per 30 days) |
| oxycodone-aspirin oral tablet 4.8355-325 mg |
|
QL (360 per 30 days) |
| OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG, 80 MG |
(oxycodone) |
QL (60 per 30 days) |
| tramadol oral tablet 50 mg |
(Ultram) |
QL (240 per 30 days) |
| tramadol-acetaminophen oral tablet 37.5-325 mg |
(Ultracet) |
QL (300 per 30 days) |
| XTAMPZA ER ORAL CAP,SPRINKL,ER12HR(DONT CRUSH) 13.5 MG, 18 MG, 9 MG |
|
QL (60 per 30 days) |
| XTAMPZA ER ORAL CAP,SPRINKL,ER12HR(DONT CRUSH) 27 MG |
|
QL (120 per 30 days) |
| XTAMPZA ER ORAL CAP,SPRINKL,ER12HR(DONT CRUSH) 36 MG |
|
QL (240 per 30 days) |
| Nonsteroidal Anti-Inflammatory Agents |
|
|
| celecoxib oral capsule 100 mg, 200 mg, 50 mg |
(Celebrex) |
QL (60 per 30 days) |
| diclofenac epolamine transdermal patch 12 hour 1.3 % |
(Flector) |
QL (60 per 30 days) |
| diclofenac potassium oral tablet 50 mg |
(Cataflam) |
QL (120 per 30 days) |
| diclofenac sodium oral tablet extended release 24 hr 100 mg |
|
QL (60 per 30 days) |
| diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg |
|
QL (150 per 30 days) |
| diclofenac sodium oral tablet,delayed release (dr/ec) 50 mg |
|
QL (120 per 30 days) |
| diclofenac sodium oral tablet,delayed release (dr/ec) 75 mg |
|
QL (60 per 30 days) |
| diclofenac sodium topical drops 1.5 % |
|
QL (300 per 30 days) |
| diclofenac sodium topical gel 1 % |
(Arthritis Pain (diclofenac)) |
QL (1000 per 30 days) |
| diclofenac sodium topical gel 3 % |
|
QL (100 per 28 days) |
| indomethacin oral capsule 25 mg |
|
QL (240 per 30 days); |
| indomethacin oral capsule 50 mg |
|
QL (120 per 30 days); |
| ketorolac oral tablet 10 mg |
|
QL (20 per 30 days); |
| PENNSAID TOPICAL SOLUTION IN METERED-DOSE PUMP 20 MG/GRAM /ACTUATION(2 %) |
|
QL (224 per 28 days) |
| Anesthetics |
|
|
| Local Anesthetics |
|
|
| glydo mucous membrane jelly in applicator 2 % |
(lidocaine hcl) |
QL (30 per 30 days) |
| lidocaine hcl mucous membrane jelly 2 % |
|
QL (30 per 30 days) |
| lidocaine topical adhesive patch,medicated 5 % |
(Lidoderm) |
QL (90 per 30 days) |
| lidocaine topical ointment 5 % |
|
QL (90 per 30 days) |
| lidocaine-prilocaine topical cream 2.5-2.5 % |
|
QL (30 per 30 days) |
| ZTLIDO TOPICAL ADHESIVE PATCH,MEDICATED 1.8 % |
|
QL (90 per 30 days) |
| Anti-Addiction/Substance Abuse Treatment Agents |
|
|
| Anti-Addiction/Substance Abuse Treatment Agents |
|
|
| buprenorphine hcl sublingual tablet 2 mg, 8 mg |
|
QL (90 per 30 days) |
| buprenorphine-naloxone sublingual film 12-3 mg |
(Suboxone) |
QL (60 per 30 days) |
| buprenorphine-naloxone sublingual film 2-0.5 mg, 4-1 mg, 8-2 mg |
(Suboxone) |
QL (90 per 30 days) |
| buprenorphine-naloxone sublingual tablet 2-0.5 mg, 8-2 mg |
|
QL (90 per 30 days) |
| CHANTIX CONTINUING MONTH BOX ORAL TABLET 1 MG |
(varenicline) |
QL (336 per 365 days) |
| KLOXXADO NASAL SPRAY,NON-AEROSOL 8 MG/ACTUATION |
|
QL (4 per 30 days) |
| LUCEMYRA ORAL TABLET 0.18 MG |
|
QL (228 per 14 days) |
| naloxone nasal spray,non-aerosol 4 mg/actuation |
(Narcan) |
QL (4 per 30 days) |
| NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION |
(naloxone) |
QL (4 per 30 days) |
| NICOTROL INHALATION CARTRIDGE 10 MG |
|
QL (1008 per 90 days) |
| SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 100 MG/0.5 ML |
|
QL (0.5 per 30 days) |
| SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 300 MG/1.5 ML |
|
QL (1.5 per 30 days) |
| varenicline oral tablet 0.5 mg, 1 mg |
|
QL (336 per 365 days) |
| Antianxiety Agents |
|
|
| Benzodiazepines |
|
|
| alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg |
(Xanax) |
QL (120 per 30 days) |
| alprazolam oral tablet 2 mg |
(Xanax) |
QL (150 per 30 days) |
| chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg |
|
QL (120 per 30 days) |
| clonazepam oral tablet 0.5 mg, 1 mg |
(Klonopin) |
QL (90 per 30 days) |
| clonazepam oral tablet 2 mg |
(Klonopin) |
QL (300 per 30 days) |
| clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg |
|
QL (90 per 30 days) |
| clonazepam oral tablet,disintegrating 2 mg |
|
QL (300 per 30 days) |
| clorazepate dipotassium oral tablet 15 mg, 3.75 mg |
|
QL (180 per 30 days) |
| clorazepate dipotassium oral tablet 7.5 mg |
(Tranxene T-Tab) |
QL (180 per 30 days) |
| diazepam injection solution 5 mg/ml |
|
QL (10 per 28 days) |
| diazepam injection syringe 5 mg/ml |
|
QL (10 per 28 days) |
| diazepam oral concentrate 5 mg/ml |
(Diazepam Intensol) |
QL (1200 per 30 days) |
| diazepam oral solution 5 mg/5 ml (1 mg/ml) |
|
QL (1200 per 30 days) |
| diazepam oral tablet 10 mg, 2 mg, 5 mg |
(Valium) |
QL (120 per 30 days) |
| lorazepam injection solution 2 mg/ml, 4 mg/ml |
(Ativan) |
QL (2 per 30 days) |
| lorazepam injection syringe 2 mg/ml, 4 mg/ml |
|
QL (2 per 30 days) |
| lorazepam oral tablet 0.5 mg, 1 mg |
(Ativan) |
QL (90 per 30 days) |
| lorazepam oral tablet 2 mg |
(Ativan) |
QL (150 per 30 days) |
| temazepam oral capsule 15 mg, 30 mg |
(Restoril) |
QL (30 per 30 days) |
| Antibacterials |
|
|
| Aminoglycosides |
|
|
| TOBI PODHALER INHALATION CAPSULE, W/INHALATION DEVICE 28 MG |
|
QL (224 per 28 days) |
| Antibacterials, Miscellaneous |
|
|
| nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg |
(Macrodantin) |
QL (120 per 30 days) |
| nitrofurantoin macrocrystal oral capsule 25 mg |
(Macrodantin) |
QL (120 per 30 days) |
| nitrofurantoin monohyd/m-cryst oral capsule 100 mg |
(Macrobid) |
QL (60 per 30 days) |
| vancomycin oral capsule 125 mg |
(Vancocin) |
QL (56 per 14 days) |
| vancomycin oral capsule 250 mg |
(Vancocin) |
QL (112 per 14 days) |
| XIFAXAN ORAL TABLET 200 MG |
|
QL (9 per 30 days) |
| XIFAXAN ORAL TABLET 550 MG |
|
QL (90 per 30 days) |
| Macrolides |
|
|
| DIFICID ORAL SUSPENSION FOR RECONSTITUTION 40 MG/ML |
|
QL (136 per 10 days) |
| DIFICID ORAL TABLET 200 MG |
|
QL (20 per 10 days) |
| Quinolones |
|
|
| BAXDELA ORAL TABLET 450 MG |
|
QL (28 per 14 days) |
| Tetracyclines |
|
|
| doxycycline monohydrate oral capsule 100 mg |
(Mondoxyne NL) |
QL (60 per 30 days) |
| doxycycline monohydrate oral capsule 50 mg |
(Monodox) |
QL (60 per 30 days) |
| doxycycline monohydrate oral tablet 100 mg |
(Avidoxy) |
QL (60 per 30 days) |
| doxycycline monohydrate oral tablet 50 mg |
|
QL (60 per 30 days) |
| mondoxyne nl oral capsule 100 mg |
(doxycycline monohydrate) |
QL (60 per 30 days) |
| Anticancer Agents |
|
|
| Anticancer Agents |
|
|
| abiraterone oral tablet 250 mg, 500 mg |
(Zytiga) |
QL (120 per 30 days) |
| ALECENSA ORAL CAPSULE 150 MG |
|
QL (240 per 30 days) |
| ALIQOPA INTRAVENOUS RECON SOLN 60 MG |
|
QL (3 per 28 days) |
| ALUNBRIG ORAL TABLET 180 MG, 90 MG |
|
QL (30 per 30 days) |
| ALUNBRIG ORAL TABLET 30 MG |
|
QL (120 per 30 days) |
| AYVAKIT ORAL TABLET 100 MG, 200 MG, 25 MG, 300 MG, 50 MG |
|
QL (30 per 30 days) |
| BALVERSA ORAL TABLET 3 MG |
|
QL (84 per 28 days) |
| BALVERSA ORAL TABLET 4 MG |
|
QL (56 per 28 days) |
| BALVERSA ORAL TABLET 5 MG |
|
QL (28 per 28 days) |
| BOSULIF ORAL TABLET 100 MG |
|
QL (90 per 30 days) |
| BOSULIF ORAL TABLET 400 MG, 500 MG |
|
QL (30 per 30 days) |
| BRAFTOVI ORAL CAPSULE 75 MG |
|
QL (180 per 30 days) |
| BRUKINSA ORAL CAPSULE 80 MG |
|
QL (120 per 30 days) |
| CABOMETYX ORAL TABLET 20 MG, 60 MG |
|
QL (30 per 30 days) |
| CABOMETYX ORAL TABLET 40 MG |
|
QL (60 per 30 days) |
| CALQUENCE ORAL CAPSULE 100 MG |
|
QL (60 per 30 days) |
| CAPRELSA ORAL TABLET 100 MG |
(vandetanib) |
QL (60 per 30 days) |
| CAPRELSA ORAL TABLET 300 MG |
(vandetanib) |
QL (30 per 30 days) |
| COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY) |
|
QL (112 per 28 days) |
| COPIKTRA ORAL CAPSULE 15 MG, 25 MG |
|
QL (56 per 28 days) |
| COTELLIC ORAL TABLET 20 MG |
|
QL (63 per 28 days) |
| DANYELZA INTRAVENOUS SOLUTION 4 MG/ML |
|
QL (120 per 28 days) |
| DAURISMO ORAL TABLET 100 MG |
|
QL (30 per 30 days) |
| DAURISMO ORAL TABLET 25 MG |
|
QL (60 per 30 days) |
| ERIVEDGE ORAL CAPSULE 150 MG |
|
QL (30 per 30 days) |
| ERLEADA ORAL TABLET 60 MG |
|
QL (120 per 30 days) |
| erlotinib oral tablet 100 mg, 25 mg |
(Tarceva) |
QL (60 per 30 days) |
| erlotinib oral tablet 150 mg |
(Tarceva) |
QL (90 per 30 days) |
| everolimus (antineoplastic) oral tablet 10 mg |
(Afinitor) |
QL (56 per 28 days) |
| everolimus (antineoplastic) oral tablet 2.5 mg, 5 mg, 7.5 mg |
(Afinitor) |
QL (28 per 28 days) |
| everolimus (antineoplastic) oral tablet for suspension 2 mg, 3 mg, 5 mg |
(Afinitor Disperz) |
QL (112 per 28 days) |
| EXKIVITY ORAL CAPSULE 40 MG |
|
QL (120 per 30 days) |
| FOTIVDA ORAL CAPSULE 0.89 MG, 1.34 MG |
|
QL (21 per 28 days) |
| GAVRETO ORAL CAPSULE 100 MG |
|
QL (120 per 30 days) |
| GILOTRIF ORAL TABLET 20 MG, 30 MG, 40 MG |
|
QL (30 per 30 days) |
| HERCEPTIN HYLECTA SUBCUTANEOUS SOLUTION 600 MG-10,000 UNIT/5 ML |
|
QL (5 per 21 days) |
| IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG |
|
QL (21 per 28 days) |
| IBRANCE ORAL TABLET 100 MG, 125 MG, 75 MG |
|
QL (21 per 28 days) |
| ICLUSIG ORAL TABLET 10 MG, 15 MG, 30 MG, 45 MG |
|
QL (30 per 30 days) |
| IDHIFA ORAL TABLET 100 MG, 50 MG |
|
QL (30 per 30 days) |
| imatinib oral tablet 100 mg |
(Gleevec) |
QL (180 per 30 days) |
| imatinib oral tablet 400 mg |
(Gleevec) |
QL (60 per 30 days) |
| IMBRUVICA ORAL CAPSULE 140 MG |
|
QL (120 per 30 days) |
| IMBRUVICA ORAL CAPSULE 70 MG |
|
QL (28 per 28 days) |
| IMBRUVICA ORAL TABLET 140 MG, 280 MG, 420 MG, 560 MG |
|
QL (28 per 28 days) |
| IMLYGIC INJECTION SUSPENSION 10EXP6 (1 MILLION) PFU/ML |
|
QL (4 per 365 days) |
| IMLYGIC INJECTION SUSPENSION 10EXP8 (100 MILLION) PFU/ML |
|
QL (8 per 28 days) |
| INLYTA ORAL TABLET 1 MG |
|
QL (180 per 30 days) |
| INLYTA ORAL TABLET 5 MG |
|
QL (120 per 30 days) |
| INQOVI ORAL TABLET 35-100 MG |
|
QL (5 per 28 days) |
| INREBIC ORAL CAPSULE 100 MG |
|
QL (120 per 30 days) |
| IRESSA ORAL TABLET 250 MG |
|
QL (60 per 30 days) |
| JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG |
|
QL (60 per 30 days) |
| KEYTRUDA INTRAVENOUS SOLUTION 25 MG/ML |
|
QL (8 per 21 days) |
| KISQALI FEMARA CO-PACK ORAL TABLET 200 MG/DAY(200 MG X 1)-2.5 MG |
|
QL (49 per 28 days) |
| KISQALI FEMARA CO-PACK ORAL TABLET 400 MG/DAY(200 MG X 2)-2.5 MG |
|
QL (70 per 28 days) |
| KISQALI FEMARA CO-PACK ORAL TABLET 600 MG/DAY(200 MG X 3)-2.5 MG |
|
QL (91 per 28 days) |
| KISQALI ORAL TABLET 200 MG/DAY (200 MG X 1) |
|
QL (21 per 28 days) |
| KISQALI ORAL TABLET 400 MG/DAY (200 MG X 2) |
|
QL (42 per 28 days) |
| KISQALI ORAL TABLET 600 MG/DAY (200 MG X 3) |
|
QL (63 per 28 days) |
| KOSELUGO ORAL CAPSULE 10 MG |
|
QL (300 per 30 days) |
| KOSELUGO ORAL CAPSULE 25 MG |
|
QL (120 per 30 days) |
| LIBTAYO INTRAVENOUS SOLUTION 50 MG/ML |
|
QL (7 per 21 days) |
| LONSURF ORAL TABLET 15-6.14 MG |
|
QL (100 per 28 days) |
| LONSURF ORAL TABLET 20-8.19 MG |
|
QL (80 per 28 days) |
| LORBRENA ORAL TABLET 100 MG |
|
QL (30 per 30 days) |
| LORBRENA ORAL TABLET 25 MG |
|
QL (90 per 30 days) |
| LUMAKRAS ORAL TABLET 120 MG |
|
QL (240 per 30 days) |
| LYNPARZA ORAL TABLET 100 MG, 150 MG |
|
QL (120 per 30 days) |
| MEKINIST ORAL TABLET 0.5 MG |
|
QL (90 per 30 days) |
| MEKINIST ORAL TABLET 2 MG |
|
QL (30 per 30 days) |
| MEKTOVI ORAL TABLET 15 MG |
|
QL (180 per 30 days) |
| NERLYNX ORAL TABLET 40 MG |
|
QL (180 per 30 days) |
| NEXAVAR ORAL TABLET 200 MG |
|
QL (120 per 30 days) |
| NINLARO ORAL CAPSULE 2.3 MG, 3 MG, 4 MG |
|
QL (3 per 28 days) |
| NUBEQA ORAL TABLET 300 MG |
|
QL (120 per 30 days) |
| ONUREG ORAL TABLET 200 MG, 300 MG |
|
QL (14 per 28 days) |
| PEMAZYRE ORAL TABLET 13.5 MG, 4.5 MG, 9 MG |
|
QL (14 per 21 days) |
| PEPAXTO INTRAVENOUS RECON SOLN 20 MG |
|
QL (2 per 28 days) |
| PHESGO SUBCUTANEOUS SOLUTION 1,200 MG-600MG- 30000 UNIT/15ML |
|
QL (15 per 21 days) |
| PHESGO SUBCUTANEOUS SOLUTION 600 MG-600 MG- 20000 UNIT/10ML |
|
QL (10 per 21 days) |
| PIQRAY ORAL TABLET 200 MG/DAY (200 MG X 1) |
|
QL (28 per 28 days) |
| PIQRAY ORAL TABLET 250 MG/DAY (200 MG X1-50 MG X1), 300 MG/DAY (150 MG X 2) |
|
QL (56 per 28 days) |
| POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG |
|
QL (21 per 28 days) |
| PORTRAZZA INTRAVENOUS SOLUTION 800 MG/50 ML (16 MG/ML) |
|
QL (100 per 21 days) |
| QINLOCK ORAL TABLET 50 MG |
|
QL (90 per 30 days) |
| RETEVMO ORAL CAPSULE 40 MG |
|
QL (180 per 30 days) |
| RETEVMO ORAL CAPSULE 80 MG |
|
QL (120 per 30 days) |
| REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG |
|
QL (28 per 28 days) |
| ROZLYTREK ORAL CAPSULE 100 MG |
|
QL (180 per 30 days) |
| ROZLYTREK ORAL CAPSULE 200 MG |
|
QL (90 per 30 days) |
| RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG |
|
QL (120 per 30 days) |
| RYDAPT ORAL CAPSULE 25 MG |
|
QL (224 per 28 days) |
| SPRYCEL ORAL TABLET 100 MG, 140 MG, 50 MG, 70 MG, 80 MG |
|
QL (30 per 30 days) |
| SPRYCEL ORAL TABLET 20 MG |
|
QL (90 per 30 days) |
| STIVARGA ORAL TABLET 40 MG |
|
QL (84 per 28 days) |
| sunitinib oral capsule 12.5 mg, 25 mg, 37.5 mg, 50 mg |
(Sutent) |
QL (30 per 30 days) |
| TABRECTA ORAL TABLET 150 MG, 200 MG |
|
QL (120 per 30 days) |
| TAFINLAR ORAL CAPSULE 50 MG, 75 MG |
|
QL (120 per 30 days) |
| TAGRISSO ORAL TABLET 40 MG, 80 MG |
|
QL (30 per 30 days) |
| TALZENNA ORAL CAPSULE 0.25 MG |
|
QL (90 per 30 days) |
| TALZENNA ORAL CAPSULE 1 MG |
|
QL (30 per 30 days) |
| TASIGNA ORAL CAPSULE 150 MG, 200 MG |
|
QL (112 per 28 days) |
| TASIGNA ORAL CAPSULE 50 MG |
|
QL (120 per 30 days) |
| TAZVERIK ORAL TABLET 200 MG |
|
QL (240 per 30 days) |
| TEPMETKO ORAL TABLET 225 MG |
|
QL (60 per 30 days) |
| TIBSOVO ORAL TABLET 250 MG |
|
QL (60 per 30 days) |
| TIVDAK INTRAVENOUS RECON SOLN 40 MG |
|
QL (5 per 21 days) |
| TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 11.25 MG |
|
QL (1 per 84 days) |
| TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG |
|
QL (1 per 168 days) |
| TRELSTAR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 3.75 MG |
|
QL (1 per 28 days) |
| TUKYSA ORAL TABLET 150 MG |
|
QL (120 per 30 days) |
| TUKYSA ORAL TABLET 50 MG |
|
QL (300 per 30 days) |
| TURALIO ORAL CAPSULE 200 MG |
|
QL (120 per 30 days) |
| UKONIQ ORAL TABLET 200 MG |
|
QL (120 per 30 days) |
| VENCLEXTA ORAL TABLET 10 MG |
|
QL (60 per 30 days) |
| VENCLEXTA ORAL TABLET 100 MG |
|
QL (180 per 30 days) |
| VENCLEXTA ORAL TABLET 50 MG |
|
QL (30 per 30 days) |
| VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG |
|
NDS |
| VERZENIO ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG |
|
QL (56 per 28 days) |
| VITRAKVI ORAL CAPSULE 100 MG |
|
QL (60 per 30 days) |
| VITRAKVI ORAL CAPSULE 25 MG |
|
QL (180 per 30 days) |
| VITRAKVI ORAL SOLUTION 20 MG/ML |
|
QL (300 per 30 days) |
| VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MG |
|
QL (30 per 30 days) |
| VOTRIENT ORAL TABLET 200 MG |
|
QL (120 per 30 days) |
| WELIREG ORAL TABLET 40 MG |
|
QL (90 per 30 days) |
| XALKORI ORAL CAPSULE 200 MG, 250 MG |
|
QL (120 per 30 days) |
| XOSPATA ORAL TABLET 40 MG |
|
QL (90 per 30 days) |
| XPOVIO ORAL TABLET 100 MG/WEEK (20 MG X 5) |
|
QL (20 per 28 days) |
| XPOVIO ORAL TABLET 100 MG/WEEK (50 MG X 2), 40 MG/WEEK (20 MG X 2), 40MG TWICE WEEK (40 MG X 2), 80 MG/WEEK (40 MG X 2) |
|
QL (8 per 28 days) |
| XPOVIO ORAL TABLET 40 MG/WEEK (40 MG X 1), 60 MG/WEEK (60 MG X 1) |
|
QL (4 per 28 days) |
| XPOVIO ORAL TABLET 40MG TWICE WEEK (80 MG/WEEK), 80 MG/WEEK (20 MG X 4) |
|
QL (16 per 28 days) |
| XPOVIO ORAL TABLET 60 MG/WEEK (20 MG X 3) |
|
QL (12 per 28 days) |
| XPOVIO ORAL TABLET 60MG TWICE WEEK (120 MG/WEEK) |
|
QL (24 per 28 days) |
| XPOVIO ORAL TABLET 80MG TWICE WEEK (160 MG/WEEK) |
|
QL (32 per 28 days) |
| XTANDI ORAL CAPSULE 40 MG |
|
QL (120 per 30 days) |
| XTANDI ORAL TABLET 40 MG |
|
QL (120 per 30 days) |
| XTANDI ORAL TABLET 80 MG |
|
QL (60 per 30 days) |
| YONSA ORAL TABLET 125 MG |
|
QL (120 per 30 days) |
| ZEJULA ORAL CAPSULE 100 MG |
|
QL (90 per 30 days) |
| ZELBORAF ORAL TABLET 240 MG |
|
QL (240 per 30 days) |
| ZOLADEX SUBCUTANEOUS IMPLANT 10.8 MG |
|
QL (1 per 84 days) |
| ZOLADEX SUBCUTANEOUS IMPLANT 3.6 MG |
|
QL (1 per 28 days) |
| ZYDELIG ORAL TABLET 100 MG, 150 MG |
|
QL (60 per 30 days) |
| ZYKADIA ORAL TABLET 150 MG |
|
QL (84 per 28 days) |
| ZYTIGA ORAL TABLET 250 MG, 500 MG |
(abiraterone) |
QL (120 per 30 days) |
| Anticonvulsants |
|
|
| Anticonvulsants |
|
|
| APTIOM ORAL TABLET 200 MG, 400 MG |
|
QL (30 per 30 days) |
| APTIOM ORAL TABLET 600 MG, 800 MG |
|
QL (60 per 30 days) |
| BRIVIACT INTRAVENOUS SOLUTION 50 MG/5 ML |
|
QL (80 per 30 days) |
| BRIVIACT ORAL SOLUTION 10 MG/ML |
|
QL (600 per 30 days) |
| BRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MG |
|
QL (60 per 30 days) |
| clobazam oral suspension 2.5 mg/ml |
(Onfi) |
QL (480 per 30 days) |
| clobazam oral tablet 10 mg, 20 mg |
(Onfi) |
QL (60 per 30 days) |
| DIACOMIT ORAL CAPSULE 250 MG |
|
QL (360 per 30 days) |
| DIACOMIT ORAL CAPSULE 500 MG |
|
QL (180 per 30 days) |
| DIACOMIT ORAL POWDER IN PACKET 250 MG |
|
QL (360 per 30 days) |
| DIACOMIT ORAL POWDER IN PACKET 500 MG |
|
QL (180 per 30 days) |
| EPRONTIA ORAL SOLUTION 25 MG/ML |
|
QL (480 per 30 days) |
| FYCOMPA ORAL SUSPENSION 0.5 MG/ML |
|
QL (720 per 30 days) |
| FYCOMPA ORAL TABLET 10 MG, 12 MG, 8 MG |
|
QL (30 per 30 days) |
| FYCOMPA ORAL TABLET 2 MG |
|
QL (30 per 30 days) |
| FYCOMPA ORAL TABLET 4 MG, 6 MG |
|
QL (60 per 30 days) |
| gabapentin oral capsule 100 mg, 300 mg |
(Neurontin) |
QL (360 per 30 days) |
| gabapentin oral capsule 400 mg |
(Neurontin) |
QL (270 per 30 days) |
| gabapentin oral solution 250 mg/5 ml |
(Neurontin) |
QL (2160 per 30 days) |
| gabapentin oral tablet 600 mg |
(Neurontin) |
QL (180 per 30 days) |
| gabapentin oral tablet 800 mg |
(Neurontin) |
QL (120 per 30 days) |
| NAYZILAM NASAL SPRAY,NON-AEROSOL 5 MG/SPRAY (0.1 ML) |
|
QL (10 per 30 days) |
| pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 mg, 75 mg |
(Lyrica) |
QL (90 per 30 days) |
| pregabalin oral capsule 225 mg, 300 mg |
(Lyrica) |
QL (60 per 30 days) |
| pregabalin oral solution 20 mg/ml |
(Lyrica) |
QL (900 per 30 days) |
| SPRITAM ORAL TABLET FOR SUSPENSION 1,000 MG |
|
QL (60 per 30 days) |
| SPRITAM ORAL TABLET FOR SUSPENSION 250 MG, 500 MG, 750 MG |
|
QL (120 per 30 days) |
| SYMPAZAN ORAL FILM 10 MG, 20 MG |
|
QL (60 per 30 days) |
| SYMPAZAN ORAL FILM 5 MG |
|
QL (60 per 30 days) |
| vigabatrin oral powder in packet 500 mg |
(Vigadrone) |
QL (180 per 30 days) |
| vigabatrin oral tablet 500 mg |
(Sabril) |
QL (180 per 30 days) |
| vigadrone oral powder in packet 500 mg |
(vigabatrin) |
QL (180 per 30 days) |
| VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML |
|
QL (200 per 5 days) |
| VIMPAT ORAL SOLUTION 10 MG/ML |
|
QL (1200 per 30 days) |
| VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG |
|
QL (60 per 30 days) |
| XCOPRI MAINTENANCE PACK ORAL TABLET 250 MG/DAY (200 MG X1-50 MG X1), 250MG/DAY(150 MG X1-100MG X1), 350 MG/DAY (200 MG X1-150MG X1) |
|
QL (56 per 28 days) |
| XCOPRI ORAL TABLET 100 MG, 50 MG |
|
QL (30 per 30 days) |
| XCOPRI ORAL TABLET 150 MG, 200 MG |
|
QL (60 per 30 days) |
| Antidementia Agents |
|
|
| Antidementia Agents |
|
|
| donepezil oral tablet 10 mg, 5 mg |
(Aricept) |
QL (30 per 30 days) |
| donepezil oral tablet,disintegrating 10 mg, 5 mg |
|
QL (30 per 30 days) |
| galantamine oral capsule,ext rel. pellets 24 hr 16 mg, 24 mg, 8 mg |
(Razadyne ER) |
QL (30 per 30 days) |
| galantamine oral solution 4 mg/ml |
|
QL (200 per 30 days) |
| galantamine oral tablet 12 mg, 4 mg, 8 mg |
|
QL (60 per 30 days) |
| memantine oral capsule,sprinkle,er 24hr 14 mg, 21 mg, 28 mg, 7 mg |
(Namenda XR) |
QL (30 per 30 days) |
| memantine oral solution 2 mg/ml |
|
QL (300 per 30 days) |
| memantine oral tablet 10 mg, 5 mg |
(Namenda) |
QL (60 per 30 days) |
| NAMZARIC ORAL CAPSULE,SPRINKLE,ER 24HR 14-10 MG, 21-10 MG, 28-10 MG, 7-10 MG |
|
QL (30 per 30 days) |
| rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg |
|
QL (60 per 30 days) |
| rivastigmine transdermal patch 24 hour 13.3 mg/24 hour, 4.6 mg/24 hour, 9.5 mg/24 hour |
(Exelon Patch) |
QL (30 per 30 days) |
| Antidepressants |
|
|
| Antidepressants |
|
|
| citalopram oral solution 10 mg/5 ml |
|
QL (600 per 30 days) |
| citalopram oral tablet 10 mg, 20 mg, 40 mg |
(Celexa) |
QL (30 per 30 days) |
| desvenlafaxine succinate oral tablet extended release 24 hr 100 mg, 25 mg, 50 mg |
(Pristiq) |
QL (30 per 30 days) |
| DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 20 MG, 30 MG, 60 MG |
|
QL (60 per 30 days) |
| DRIZALMA SPRINKLE ORAL CAPSULE, DELAYED REL SPRINKLE 40 MG |
|
QL (30 per 30 days) |
| duloxetine oral capsule,delayed release(dr/ec) 20 mg, 30 mg, 60 mg |
(Cymbalta) |
QL (60 per 30 days) |
| EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24 HR, 6 MG/24 HR, 9 MG/24 HR |
|
QL (30 per 30 days) |
| FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 120 MG, 20 MG, 40 MG, 80 MG |
|
QL (30 per 30 days) |
| TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MG |
|
QL (30 per 30 days) |
| venlafaxine oral capsule,extended release 24hr 150 mg |
(Effexor XR) |
QL (30 per 30 days) |
| venlafaxine oral capsule,extended release 24hr 37.5 mg, 75 mg |
(Effexor XR) |
QL (90 per 30 days) |
| VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MG |
|
QL (30 per 30 days) |
| Antidiabetic Agents |
|
|
| Antidiabetic Agents, Miscellaneous |
|
|
| acarbose oral tablet 100 mg, 25 mg, 50 mg |
(Precose) |
QL (90 per 30 days) |
| FARXIGA ORAL TABLET 10 MG, 5 MG |
|
QL (30 per 30 days) |
| GLYXAMBI ORAL TABLET 10-5 MG, 25-5 MG |
|
QL (30 per 30 days) |
| JARDIANCE ORAL TABLET 10 MG, 25 MG |
|
QL (30 per 30 days) |
| JENTADUETO ORAL TABLET 2.5-1,000 MG, 2.5-500 MG, 2.5-850 MG |
|
QL (60 per 30 days) |
| JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG |
|
QL (60 per 30 days) |
| JENTADUETO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 5-1,000 MG |
|
QL (30 per 30 days) |
| KORLYM ORAL TABLET 300 MG |
|
QL (112 per 28 days) |
| metformin oral tablet 1,000 mg |
|
QL (75 per 30 days) |
| metformin oral tablet 500 mg |
|
QL (150 per 30 days) |
| metformin oral tablet 850 mg |
|
QL (90 per 30 days) |
| metformin oral tablet extended release 24 hr 500 mg |
|
QL (120 per 30 days) |
| metformin oral tablet extended release 24 hr 750 mg |
|
QL (60 per 30 days) |
| OZEMPIC SUBCUTANEOUS PEN INJECTOR 0.25 MG OR 0.5 MG(2 MG/1.5 ML) |
|
QL (1.5 per 28 days) |
| OZEMPIC SUBCUTANEOUS PEN INJECTOR 1 MG/DOSE (2 MG/1.5 ML), 1 MG/DOSE (4 MG/3 ML) |
|
QL (3 per 28 days) |
| pioglitazone oral tablet 15 mg, 30 mg, 45 mg |
(Actos) |
QL (30 per 30 days) |
| repaglinide oral tablet 0.5 mg, 1 mg |
|
QL (120 per 30 days) |
| repaglinide oral tablet 2 mg |
|
QL (240 per 30 days) |
| RYBELSUS ORAL TABLET 14 MG, 3 MG, 7 MG |
|
QL (30 per 30 days) |
| SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML |
|
QL (10.8 per 28 days) |
| SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML |
|
QL (10.8 per 28 days) |
| SYNJARDY ORAL TABLET 12.5-1,000 MG, 12.5-500 MG, 5-1,000 MG, 5-500 MG |
|
QL (60 per 30 days) |
| SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 25-1,000 MG |
|
QL (30 per 30 days) |
| SYNJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 12.5-1,000 MG, 5-1,000 MG |
|
QL (60 per 30 days) |
| TRADJENTA ORAL TABLET 5 MG |
|
QL (30 per 30 days) |
| TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-5-1,000 MG, 25-5-1,000 MG |
|
QL (30 per 30 days) |
| TRIJARDY XR ORAL TABLET, IR - ER, BIPHASIC 24HR 12.5-2.5-1,000 MG, 5-2.5-1,000 MG |
|
QL (60 per 30 days) |
| TRULICITY SUBCUTANEOUS PEN INJECTOR 0.75 MG/0.5 ML, 1.5 MG/0.5 ML, 3 MG/0.5 ML, 4.5 MG/0.5 ML |
|
QL (2 per 28 days) |
| VICTOZA SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML) |
|
QL (9 per 30 days) |
| XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 10-1,000 MG, 10-500 MG |
|
QL (30 per 30 days) |
| XIGDUO XR ORAL TABLET, IR - ER, BIPHASIC 24HR 2.5-1,000 MG, 5-1,000 MG, 5-500 MG |
|
QL (60 per 30 days) |
| Insulins |
|
|
| FIASP FLEXTOUCH U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) |
|
SI;QL (30 per 28 days) |
| FIASP PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML (3 ML) |
|
SI;QL (30 per 28 days) |
| FIASP U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML |
|
SI;QL (40 per 28 days) |
| HUMULIN R U-500 (CONC) INSULIN SUBCUTANEOUS SOLUTION 500 UNIT/ML |
|
SI;QL (40 per 28 days) |
| HUMULIN R U-500 (CONC) KWIKPEN SUBCUTANEOUS INSULIN PEN 500 UNIT/ML (3 ML) |
|
SI;QL (24 per 28 days) |
| LANTUS SOLOSTAR U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) |
|
SI;QL (30 per 28 days) |
| LANTUS U-100 INSULIN SUBCUTANEOUS SOLUTION 100 UNIT/ML |
(insulin glargine) |
SI;QL (40 per 28 days) |
| NOVOLIN 70/30 U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30) |
|
SI;QL (40 per 28 days) |
| NOVOLIN 70-30 FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) |
|
SI;QL (30 per 28 days) |
| NOVOLIN N FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) |
|
SI;QL (30 per 28 days) |
| NOVOLIN N NPH U-100 INSULIN SUBCUTANEOUS SUSPENSION 100 UNIT/ML |
|
SI;QL (40 per 28 days) |
| NOVOLIN R FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) |
|
SI;QL (30 per 28 days) |
| NOVOLIN R REGULAR U-100 INSULN INJECTION SOLUTION 100 UNIT/ML |
|
SI;QL (40 per 28 days) |
| NOVOLOG FLEXPEN U-100 INSULIN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML) |
(insulin aspart u-100) |
SI;QL (30 per 28 days) |
| NOVOLOG MIX 70-30 U-100 INSULN SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30) |
(insulin asp prt-insulin aspart) |
SI;QL (40 per 28 days) |
| NOVOLOG MIX 70-30FLEXPEN U-100 SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30) |
(insulin asp prt-insulin aspart) |
SI;QL (30 per 28 days) |
| NOVOLOG PENFILL U-100 INSULIN SUBCUTANEOUS CARTRIDGE 100 UNIT/ML |
(insulin aspart u-100) |
SI;QL (30 per 28 days) |
| NOVOLOG U-100 INSULIN ASPART SUBCUTANEOUS SOLUTION 100 UNIT/ML |
(insulin aspart u-100) |
SI;QL (40 per 28 days) |
| SOLIQUA 100/33 SUBCUTANEOUS INSULIN PEN 100 UNIT-33 MCG/ML |
|
QL (30 per 30 days) |
| TOUJEO MAX U-300 SOLOSTAR SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (3 ML) |
|
SI;QL (18 per 28 days) |
| TOUJEO SOLOSTAR U-300 INSULIN SUBCUTANEOUS INSULIN PEN 300 UNIT/ML (1.5 ML) |
|
SI;QL (13.5 per 28 days) |
| XULTOPHY 100/3.6 SUBCUTANEOUS INSULIN PEN 100 UNIT-3.6 MG /ML (3 ML) |
|
QL (15 per 28 days) |
| Sulfonylureas |
|
|
| glimepiride oral tablet 1 mg, 2 mg |
(Amaryl) |
QL (30 per 30 days) |
| glimepiride oral tablet 4 mg |
(Amaryl) |
QL (60 per 30 days) |
| glipizide oral tablet 10 mg |
(Glucotrol) |
QL (120 per 30 days) |
| glipizide oral tablet 5 mg |
|
QL (60 per 30 days) |
| glipizide oral tablet extended release 24hr 10 mg |
(Glucotrol XL) |
QL (60 per 30 days) |
| glipizide oral tablet extended release 24hr 2.5 mg, 5 mg |
(Glucotrol XL) |
QL (30 per 30 days) |
| glipizide-metformin oral tablet 2.5-250 mg |
|
QL (240 per 30 days) |
| glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg |
|
QL (120 per 30 days) |
| Antifungals |
|
|
| Antifungals |
|
|
| ciclopirox topical cream 0.77 % |
(Ciclodan) |
QL (180 per 30 days) |
| ciclopirox topical solution 8 % |
(Ciclodan) |
QL (19.8 per 30 days) |
| clotrimazole-betamethasone topical cream 1-0.05 % |
|
QL (90 per 30 days) |
| econazole topical cream 1 % |
|
QL (170 per 30 days) |
| ketoconazole topical cream 2 % |
|
QL (180 per 30 days) |
| ketoconazole topical shampoo 2 % |
|
QL (360 per 30 days) |
| nyamyc topical powder 100,000 unit/gram |
(nystatin) |
QL (60 per 30 days) |
| nystatin oral suspension 100,000 unit/ml |
|
QL (900 per 30 days) |
| nystatin topical cream 100,000 unit/gram |
|
QL (60 per 30 days) |
| nystatin topical ointment 100,000 unit/gram |
|
QL (60 per 30 days) |
| nystatin topical powder 100,000 unit/gram |
(Nyamyc) |
QL (60 per 30 days) |
| nystop topical powder 100,000 unit/gram |
(nystatin) |
QL (60 per 30 days) |
| Antigout Agents |
|
|
| Antigout Agents, Other |
|
|
| colchicine oral tablet 0.6 mg |
(Colcrys) |
QL (120 per 30 days) |
| febuxostat oral tablet 40 mg, 80 mg |
(Uloric) |
QL (30 per 30 days) |
| MITIGARE ORAL CAPSULE 0.6 MG |
(colchicine) |
QL (60 per 30 days) |
| Antimigraine Agents |
|
|
| Antimigraine Agents |
|
|
| AIMOVIG AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 140 MG/ML, 70 MG/ML |
|
QL (1 per 30 days) |
| AJOVY AUTOINJECTOR SUBCUTANEOUS AUTO-INJECTOR 225 MG/1.5 ML |
|
QL (1.5 per 30 days) |
| AJOVY SYRINGE SUBCUTANEOUS SYRINGE 225 MG/1.5 ML |
|
QL (1.5 per 30 days) |
| dihydroergotamine injection solution 1 mg/ml |
(D.H.E.45) |
QL (24 per 28 days) |
| dihydroergotamine nasal spray,non-aerosol 0.5 mg/pump act. (4 mg/ml) |
(Migranal) |
QL (8 per 28 days) |
| EMGALITY PEN SUBCUTANEOUS PEN INJECTOR 120 MG/ML |
|
QL (2 per 30 days) |
| EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MG/ML |
|
QL (2 per 30 days) |
| EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 300 MG/3 ML (100 MG/ML X 3) |
|
QL (3 per 30 days) |
| NURTEC ODT ORAL TABLET,DISINTEGRATING 75 MG |
|
QL (18 per 30 days) |
| rizatriptan oral tablet 10 mg |
(Maxalt) |
QL (12 per 30 days) |
| rizatriptan oral tablet 5 mg |
|
QL (12 per 30 days) |
| rizatriptan oral tablet,disintegrating 10 mg |
(Maxalt-MLT) |
QL (12 per 30 days) |
| rizatriptan oral tablet,disintegrating 5 mg |
|
QL (12 per 30 days) |
| sumatriptan nasal spray,non-aerosol 20 mg/actuation |
(Imitrex) |
QL (12 per 30 days) |
| sumatriptan nasal spray,non-aerosol 5 mg/actuation |
(Imitrex) |
QL (18 per 30 days) |
| sumatriptan succinate oral tablet 100 mg |
(Imitrex) |
QL (9 per 30 days) |
| sumatriptan succinate oral tablet 25 mg, 50 mg |
(Imitrex) |
QL (18 per 30 days) |
| sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml |
(Imitrex STATdose Refill) |
QL (4 per 28 days) |
| sumatriptan succinate subcutaneous cartridge 6 mg/0.5 ml |
(Imitrex STATdose Refill) |
QL (4 per 28 days) |
| sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml |
(Imitrex STATdose Pen) |
QL (4 per 28 days) |
| sumatriptan succinate subcutaneous solution 6 mg/0.5 ml |
(Imitrex) |
QL (4 per 28 days) |
| sumatriptan succinate subcutaneous syringe 6 mg/0.5 ml |
|
QL (4 per 28 days) |
| UBRELVY ORAL TABLET 100 MG, 50 MG |
|
QL (16 per 30 days) |
| Antimycobacterials |
|
|
| Antimycobacterials |
|
|
| PRETOMANID ORAL TABLET 200 MG |
|
QL (30 per 30 days) |
| Antinausea Agents |
|
|
| Antinausea Agents |
|
|
| aprepitant oral capsule 125 mg |
|
QL (2 per 28 days) |
| aprepitant oral capsule 40 mg |
|
QL (1 per 28 days) |
| aprepitant oral capsule 80 mg |
(Emend) |
QL (4 per 28 days) |
| aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2) |
(Emend) |
QL (6 per 28 days) |
| dronabinol oral capsule 10 mg, 2.5 mg, 5 mg |
(Marinol) |
QL (60 per 30 days) |
| EMEND ORAL SUSPENSION FOR RECONSTITUTION 125 MG (25 MG/ ML FINAL CONC.) |
|
QL (6 per 28 days) |
| fosaprepitant intravenous recon soln 150 mg |
(Emend (fosaprepitant)) |
QL (2 per 28 days) |
| scopolamine base transdermal patch 3 day 1 mg over 3 days |
(Transderm-Scop) |
QL (10 per 30 days); |
| Antiparasite Agents |
|
|
| Antiparasite Agents |
|
|
| chloroquine phosphate oral tablet 250 mg |
|
QL (50 per 30 days) |
| chloroquine phosphate oral tablet 500 mg |
|
QL (25 per 30 days) |
| hydroxychloroquine oral tablet 200 mg |
(Plaquenil) |
QL (90 per 30 days) |
| IMPAVIDO ORAL CAPSULE 50 MG |
|
QL (84 per 28 days) |
| quinine sulfate oral capsule 324 mg |
(Qualaquin) |
QL (42 per 7 days) |
| Antiparkinsonian Agents |
|
|
| Antiparkinsonian Agents |
|
|
| APOKYN SUBCUTANEOUS CARTRIDGE 10 MG/ML |
|
QL (60 per 30 days) |
| INBRIJA INHALATION CAPSULE, W/INHALATION DEVICE 42 MG |
|
QL (300 per 30 days) |
| KYNMOBI SUBLINGUAL FILM 10 MG, 15 MG, 20 MG, 25 MG, 30 MG |
|
QL (150 per 30 days) |
| NEUPRO TRANSDERMAL PATCH 24 HOUR 1 MG/24 HOUR, 2 MG/24 HOUR, 3 MG/24 HOUR, 4 MG/24 HOUR, 6 MG/24 HOUR, 8 MG/24 HOUR |
|
QL (30 per 30 days) |
| OSMOLEX ER ORAL TABLET, IR - ER, BIPHASIC 24HR 129 MG, 193 MG, 258 MG |
|
QL (30 per 30 days) |
| OSMOLEX ER ORAL TABLET, IR - ER, BIPHASIC 24HR 322 MG/DAY(129 MG X1-193MG X1) |
|
QL (60 per 30 days) |
| XADAGO ORAL TABLET 100 MG |
|
QL (30 per 30 days) |
| XADAGO ORAL TABLET 50 MG |
|
QL (30 per 30 days) |
| Antipsychotic Agents |
|
|
| Antipsychotic Agents |
|
|
| aripiprazole oral solution 1 mg/ml |
|
QL (900 per 30 days) |
| aripiprazole oral tablet 10 mg, 15 mg, 20 mg, 30 mg, 5 mg |
(Abilify) |
QL (30 per 30 days) |
| aripiprazole oral tablet 2 mg |
(Abilify) |
QL (60 per 30 days) |
| aripiprazole oral tablet,disintegrating 10 mg |
|
QL (90 per 30 days) |
| aripiprazole oral tablet,disintegrating 15 mg |
|
QL (60 per 30 days) |
| ARISTADA INITIO INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 675 MG/2.4 ML |
|
QL (4.8 per 365 days) |
| ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 1,064 MG/3.9 ML |
|
QL (3.9 per 56 days) |
| ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 441 MG/1.6 ML |
|
QL (1.6 per 28 days) |
| ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 662 MG/2.4 ML |
|
QL (2.4 per 28 days) |
| ARISTADA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 882 MG/3.2 ML |
|
QL (3.2 per 28 days) |
| asenapine maleate sublingual tablet 10 mg, 2.5 mg, 5 mg |
(Saphris) |
QL (60 per 30 days) |
| CAPLYTA ORAL CAPSULE 42 MG |
|
QL (30 per 30 days) |
| clozapine oral tablet 100 mg |
(Clozaril) |
QL (270 per 30 days) |
| clozapine oral tablet 200 mg |
(Clozaril) |
QL (135 per 30 days) |
| clozapine oral tablet 25 mg |
(Clozaril) |
QL (90 per 30 days) |
| clozapine oral tablet 50 mg |
(Clozaril) |
QL (90 per 30 days) |
| clozapine oral tablet,disintegrating 100 mg, 12.5 mg, 25 mg |
|
QL (90 per 30 days) |
| clozapine oral tablet,disintegrating 150 mg |
|
QL (180 per 30 days) |
| clozapine oral tablet,disintegrating 200 mg |
|
QL (120 per 30 days) |
| FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG |
|
QL (60 per 30 days) |
| INVEGA HAFYERA INTRAMUSCULAR SYRINGE 1,092 MG/3.5 ML |
|
QL (3.5 per 180 days) |
| INVEGA HAFYERA INTRAMUSCULAR SYRINGE 1,560 MG/5 ML |
|
QL (5 per 180 days) |
| INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML |
|
QL (0.75 per 28 days) |
| INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 156 MG/ML |
|
QL (1 per 28 days) |
| INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML |
|
QL (1.5 per 28 days) |
| INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 39 MG/0.25 ML |
|
QL (0.25 per 28 days) |
| INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 78 MG/0.5 ML |
|
QL (0.5 per 28 days) |
| INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.88 ML |
|
QL (0.88 per 84 days) |
| INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.32 ML |
|
QL (1.32 per 84 days) |
| INVEGA TRINZA INTRAMUSCULAR SYRINGE 546 MG/1.75 ML |
|
QL (1.75 per 84 days) |
| INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.63 ML |
|
QL (2.63 per 84 days) |
| LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG |
|
QL (30 per 30 days) |
| LATUDA ORAL TABLET 80 MG |
|
QL (60 per 30 days) |
| LYBALVI ORAL TABLET 10-10 MG, 15-10 MG, 20-10 MG, 5-10 MG |
|
QL (30 per 30 days) |
| molindone oral tablet 10 mg |
|
QL (240 per 30 days) |
| molindone oral tablet 25 mg |
|
QL (270 per 30 days) |
| molindone oral tablet 5 mg |
|
QL (120 per 30 days) |
| NUPLAZID ORAL CAPSULE 34 MG |
|
QL (30 per 30 days) |
| NUPLAZID ORAL TABLET 10 MG |
|
QL (30 per 30 days) |
| olanzapine intramuscular recon soln 10 mg |
(Zyprexa) |
QL (30 per 30 days) |
| olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mg |
(Zyprexa) |
QL (30 per 30 days) |
| olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5 mg |
(Zyprexa Zydis) |
QL (30 per 30 days) |
| paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg |
(Invega) |
QL (30 per 30 days) |
| paliperidone oral tablet extended release 24hr 6 mg |
(Invega) |
QL (60 per 30 days) |
| PERSERIS ABDOMINAL SUBCUTANEOUS SUSPENSION,EXTENDED REL SYRING 120 MG, 90 MG |
|
QL (1 per 30 days) |
| quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg |
(Seroquel) |
QL (90 per 30 days) |
| quetiapine oral tablet 300 mg, 400 mg |
(Seroquel) |
QL (60 per 30 days) |
| REXULTI ORAL TABLET 0.25 MG |
|
QL (120 per 30 days) |
| REXULTI ORAL TABLET 0.5 MG |
|
QL (60 per 30 days) |
| REXULTI ORAL TABLET 1 MG, 2 MG, 3 MG, 4 MG |
|
QL (30 per 30 days) |
| RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 12.5 MG/2 ML, 25 MG/2 ML |
|
QL (2 per 28 days) |
| RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 37.5 MG/2 ML, 50 MG/2 ML |
|
QL (2 per 28 days) |
| risperidone oral solution 1 mg/ml |
(Risperdal) |
QL (480 per 30 days) |
| risperidone oral tablet 0.25 mg |
|
QL (60 per 30 days) |
| risperidone oral tablet 0.5 mg, 1 mg, 2 mg, 3 mg |
(Risperdal) |
QL (60 per 30 days) |
| risperidone oral tablet 4 mg |
(Risperdal) |
QL (120 per 30 days) |
| risperidone oral tablet,disintegrating 0.25 mg, 0.5 mg, 1 mg, 2 mg |
|
QL (60 per 30 days) |
| risperidone oral tablet,disintegrating 3 mg, 4 mg |
|
QL (120 per 30 days) |
| SECUADO TRANSDERMAL PATCH 24 HOUR 3.8 MG/24 HOUR, 5.7 MG/24 HOUR, 7.6 MG/24 HOUR |
|
QL (30 per 30 days) |
| VERSACLOZ ORAL SUSPENSION 50 MG/ML |
|
QL (540 per 30 days) |
| VRAYLAR ORAL CAPSULE 1.5 MG, 3 MG, 4.5 MG, 6 MG |
|
QL (30 per 30 days) |
| ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg |
(Geodon) |
QL (60 per 30 days) |
| ziprasidone mesylate intramuscular recon soln 20 mg/ml (final conc.) |
(Geodon) |
QL (6 per 28 days) |
| ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG |
|
QL (2 per 28 days) |
| ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 300 MG |
|
QL (2 per 28 days) |
| ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG |
|
QL (1 per 28 days) |
| Antivirals (Systemic) |
|
|
| Antiretrovirals |
|
|
| APRETUDE INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE 600 MG/3 ML (200 MG/ML) |
|
QL (24 per 365 days) |
| lopinavir-ritonavir oral solution 400-100 mg/5 ml |
(Kaletra) |
QL (480 per 30 days) |
| lopinavir-ritonavir oral tablet 100-25 mg |
(Kaletra) |
QL (300 per 30 days) |
| lopinavir-ritonavir oral tablet 200-50 mg |
(Kaletra) |
QL (120 per 30 days) |
| VEMLIDY ORAL TABLET 25 MG |
|
QL (30 per 30 days) |
| Antivirals, Miscellaneous |
|
|
| oseltamivir oral capsule 30 mg |
(Tamiflu) |
QL (84 per 180 days) |
| oseltamivir oral capsule 45 mg |
(Tamiflu) |
QL (48 per 180 days) |
| oseltamivir oral capsule 75 mg |
(Tamiflu) |
QL (42 per 180 days) |
| oseltamivir oral suspension for reconstitution 6 mg/ml |
(Tamiflu) |
QL (540 per 180 days) |
| PAXLOVID (EUA) ORAL TABLET 300 MG (150 MG X 2)-100 MG |
|
QL (30 per 5 days) |
| PREVYMIS INTRAVENOUS SOLUTION 240 MG/12 ML |
|
QL (336 per 28 days) |
| PREVYMIS INTRAVENOUS SOLUTION 480 MG/24 ML |
|
QL (672 per 28 days) |
| PREVYMIS ORAL TABLET 240 MG, 480 MG |
|
QL (28 per 28 days) |
| RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION |
|
QL (60 per 180 days) |
| XOFLUZA ORAL TABLET 20 MG, 40 MG |
|
QL (4 per 180 days) |
| XOFLUZA ORAL TABLET 80 MG |
|
QL (2 per 180 days) |
| Hcv Antivirals |
|
|
| EPCLUSA ORAL PELLETS IN PACKET 150-37.5 MG |
|
QL (28 per 28 days) |
| EPCLUSA ORAL PELLETS IN PACKET 200-50 MG |
|
QL (56 per 28 days) |
| EPCLUSA ORAL TABLET 200-50 MG |
|
QL (28 per 28 days) |
| EPCLUSA ORAL TABLET 400-100 MG |
(sofosbuvir-velpatasvir) |
QL (28 per 28 days) |
| HARVONI ORAL PELLETS IN PACKET 33.75-150 MG |
|
QL (28 per 28 days) |
| HARVONI ORAL PELLETS IN PACKET 45-200 MG |
|
QL (56 per 28 days) |
| HARVONI ORAL TABLET 45-200 MG |
|
QL (28 per 28 days) |
| HARVONI ORAL TABLET 90-400 MG |
(ledipasvir-sofosbuvir) |
QL (28 per 28 days) |
| VOSEVI ORAL TABLET 400-100-100 MG |
|
QL (28 per 28 days) |
| Nucleosides And Nucleotides |
|
|
| molnupiravir oral capsule 200 mg |
|
QL (40 per 5 days) |
| Blood Products/Modifiers/Volume Expanders |
|
|
| Anticoagulants |
|
|
| ELIQUIS ORAL TABLET 2.5 MG |
|
QL (60 per 30 days) |
| ELIQUIS ORAL TABLET 5 MG |
|
QL (74 per 30 days) |
| enoxaparin subcutaneous solution 300 mg/3 ml |
(Lovenox) |
QL (30 per 30 days) |
| enoxaparin subcutaneous syringe 100 mg/ml, 150 mg/ml |
(Lovenox) |
QL (60 per 30 days) |
| enoxaparin subcutaneous syringe 120 mg/0.8 ml, 80 mg/0.8 ml |
(Lovenox) |
QL (48 per 30 days) |
| enoxaparin subcutaneous syringe 30 mg/0.3 ml |
(Lovenox) |
QL (18 per 30 days) |
| enoxaparin subcutaneous syringe 40 mg/0.4 ml |
(Lovenox) |
QL (24 per 30 days) |
| enoxaparin subcutaneous syringe 60 mg/0.6 ml |
(Lovenox) |
QL (36 per 30 days) |
| fondaparinux subcutaneous syringe 10 mg/0.8 ml |
(Arixtra) |
QL (24 per 30 days) |
| fondaparinux subcutaneous syringe 2.5 mg/0.5 ml |
(Arixtra) |
QL (15 per 30 days) |
| fondaparinux subcutaneous syringe 5 mg/0.4 ml |
(Arixtra) |
QL (12 per 30 days) |
| fondaparinux subcutaneous syringe 7.5 mg/0.6 ml |
(Arixtra) |
QL (18 per 30 days) |
| XARELTO ORAL TABLET 10 MG, 20 MG |
|
QL (30 per 30 days) |
| XARELTO ORAL TABLET 15 MG, 2.5 MG |
|
QL (60 per 30 days) |
| Blood Formation Modifiers |
|
|
| CINRYZE INTRAVENOUS RECON SOLN 500 UNIT (5 ML) |
|
QL (20 per 30 days) |
| DOPTELET (10 TAB PACK) ORAL TABLET 20 MG |
|
QL (60 per 30 days) |
| DOPTELET (15 TAB PACK) ORAL TABLET 20 MG |
|
QL (60 per 30 days) |
| DOPTELET (30 TAB PACK) ORAL TABLET 20 MG |
|
QL (60 per 30 days) |
| HAEGARDA SUBCUTANEOUS RECON SOLN 2,000 UNIT |
|
QL (30 per 30 days) |
| HAEGARDA SUBCUTANEOUS RECON SOLN 3,000 UNIT |
|
QL (20 per 30 days) |
| MULPLETA ORAL TABLET 3 MG |
|
QL (7 per 7 days) |
| ORLADEYO ORAL CAPSULE 110 MG, 150 MG |
|
QL (30 per 30 days) |
| PROMACTA ORAL POWDER IN PACKET 12.5 MG |
|
QL (90 per 30 days) |
| PROMACTA ORAL POWDER IN PACKET 25 MG |
|
QL (180 per 30 days) |
| PROMACTA ORAL TABLET 12.5 MG |
|
QL (90 per 30 days) |
| PROMACTA ORAL TABLET 25 MG |
|
QL (30 per 30 days) |
| PROMACTA ORAL TABLET 50 MG, 75 MG |
|
QL (60 per 30 days) |
| RETACRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML |
|
QL (12 per 28 days) |
| RETACRIT INJECTION SOLUTION 40,000 UNIT/ML |
|
QL (4 per 28 days) |
| Hematologic Agents, Miscellaneous |
|
|
| CABLIVI INJECTION KIT 11 MG |
|
QL (30 per 30 days) |
| TAVALISSE ORAL TABLET 100 MG, 150 MG |
|
QL (60 per 30 days) |
| tranexamic acid oral tablet 650 mg |
(Lysteda) |
QL (30 per 30 days) |
| Platelet-Aggregation Inhibitors |
|
|
| aspirin-dipyridamole oral capsule, er multiphase 12 hr 25-200 mg |
|
QL (60 per 30 days) |
| prasugrel oral tablet 10 mg, 5 mg |
(Effient) |
QL (30 per 30 days) |
| Cardiovascular Agents |
|
|
| Alpha-Adrenergic Agents |
|
|
| clonidine transdermal patch weekly 0.1 mg/24 hr |
(Catapres-TTS-1) |
QL (4 per 28 days) |
| clonidine transdermal patch weekly 0.2 mg/24 hr |
(Catapres-TTS-2) |
QL (4 per 28 days) |
| clonidine transdermal patch weekly 0.3 mg/24 hr |
(Catapres-TTS-3) |
QL (8 per 28 days) |
| droxidopa oral capsule 100 mg, 200 mg, 300 mg |
(Northera) |
QL (180 per 30 days) |
| Angiotensin Ii Receptor Antagonists |
|
|
| ENTRESTO ORAL TABLET 24-26 MG |
|
QL (180 per 30 days) |
| ENTRESTO ORAL TABLET 49-51 MG, 97-103 MG |
|
QL (60 per 30 days) |
| Cardiovascular Agents, Miscellaneous |
|
|
| CORLANOR ORAL SOLUTION 5 MG/5 ML |
|
QL (600 per 30 days) |
| CORLANOR ORAL TABLET 5 MG, 7.5 MG |
|
QL (60 per 30 days) |
| epinephrine injection auto-injector 0.15 mg/0.3 ml |
(EpiPen Jr) |
QL (4 per 30 days) |
| epinephrine injection auto-injector 0.3 mg/0.3 ml |
(Auvi-Q) |
QL (4 per 30 days) |
| icatibant subcutaneous syringe 30 mg/3 ml |
(Sajazir) |
QL (18 per 30 days) |
| ranolazine oral tablet extended release 12 hr 1,000 mg |
(Ranexa) |
QL (60 per 30 days) |
| ranolazine oral tablet extended release 12 hr 500 mg |
(Ranexa) |
QL (120 per 30 days) |
| sajazir subcutaneous syringe 30 mg/3 ml |
(icatibant) |
QL (18 per 30 days) |
| VYNDAMAX ORAL CAPSULE 61 MG |
|
QL (30 per 30 days) |
| VYNDAQEL ORAL CAPSULE 20 MG |
|
QL (120 per 30 days) |
| Diuretics |
|
|
| JYNARQUE ORAL TABLET 15 MG, 30 MG |
|
QL (120 per 30 days) |
| JYNARQUE ORAL TABLETS, SEQUENTIAL 15 MG (AM)/ 15 MG (PM), 30 MG (AM)/ 15 MG (PM), 45 MG (AM)/ 15 MG (PM), 60 MG (AM)/ 30 MG (PM), 90 MG (AM)/ 30 MG (PM) |
|
QL (56 per 28 days) |
| Dyslipidemics |
|
|
| atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg |
(Lipitor) |
QL (30 per 30 days) |
| ezetimibe oral tablet 10 mg |
(Zetia) |
QL (30 per 30 days) |
| JUXTAPID ORAL CAPSULE 10 MG, 30 MG, 40 MG, 60 MG |
|
QL (30 per 30 days) |
| JUXTAPID ORAL CAPSULE 20 MG |
|
QL (90 per 30 days) |
| JUXTAPID ORAL CAPSULE 5 MG |
|
QL (45 per 30 days) |
| LIVALO ORAL TABLET 1 MG, 2 MG, 4 MG |
|
QL (30 per 30 days) |
| NEXLETOL ORAL TABLET 180 MG |
|
QL (30 per 30 days) |
| NEXLIZET ORAL TABLET 180-10 MG |
|
QL (30 per 30 days) |
| omega-3 acid ethyl esters oral capsule 1 gram |
(Lovaza) |
QL (120 per 30 days) |
| PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML |
|
QL (2 per 28 days) |
| pravastatin oral tablet 20 mg, 40 mg |
|
QL (30 per 30 days) |
| prevalite oral powder in packet 4 gram |
(cholestyramine-aspartame) |
|
| REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML |
|
QL (7 per 28 days) |
| REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML |
|
QL (6 per 28 days) |
| REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MG/ML |
|
QL (6 per 28 days) |
| rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg |
(Crestor) |
QL (30 per 30 days) |
| simvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg |
(Zocor) |
QL (30 per 30 days) |
| simvastatin oral tablet 5 mg |
|
QL (30 per 30 days) |
| VASCEPA ORAL CAPSULE 0.5 GRAM |
|
QL (240 per 30 days) |
| VASCEPA ORAL CAPSULE 1 GRAM |
(icosapent ethyl) |
QL (120 per 30 days) |
| Central Nervous System Agents |
|
|
| Central Nervous System Agents |
|
|
| atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg |
(Strattera) |
QL (60 per 30 days) |
| atomoxetine oral capsule 100 mg, 60 mg, 80 mg |
(Strattera) |
QL (30 per 30 days) |
| AUBAGIO ORAL TABLET 14 MG, 7 MG |
|
QL (30 per 30 days) |
| AUSTEDO ORAL TABLET 12 MG, 9 MG |
|
QL (120 per 30 days) |
| AUSTEDO ORAL TABLET 6 MG |
|
QL (60 per 30 days) |
| AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML |
|
QL (1 per 28 days) |
| AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML |
|
QL (1 per 28 days) |
| BETASERON SUBCUTANEOUS KIT 0.3 MG |
|
QL (15 per 30 days) |
| COPAXONE SUBCUTANEOUS SYRINGE 20 MG/ML |
(glatiramer) |
QL (30 per 30 days) |
| COPAXONE SUBCUTANEOUS SYRINGE 40 MG/ML |
(glatiramer) |
QL (12 per 28 days) |
| dalfampridine oral tablet extended release 12 hr 10 mg |
(Ampyra) |
QL (60 per 30 days) |
| dexmethylphenidate oral tablet 10 mg, 2.5 mg |
(Focalin) |
QL (60 per 30 days) |
| dexmethylphenidate oral tablet 5 mg |
(Focalin) |
QL (60 per 30 days) |
| dextroamphetamine oral tablet 10 mg |
(Zenzedi) |
QL (180 per 30 days) |
| dextroamphetamine oral tablet 15 mg, 5 mg |
(Zenzedi) |
QL (90 per 30 days) |
| dextroamphetamine oral tablet 20 mg, 30 mg |
(Zenzedi) |
QL (60 per 30 days) |
| dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg |
(Adderall XR) |
QL (30 per 30 days) |
| dextroamphetamine-amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg |
(Adderall XR) |
QL (60 per 30 days) |
| dextroamphetamine-amphetamine oral tablet 10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg |
(Adderall) |
QL (60 per 30 days) |
| dimethyl fumarate oral capsule,delayed release(dr/ec) 120 mg |
(Tecfidera) |
QL (14 per 7 days) |
| dimethyl fumarate oral capsule,delayed release(dr/ec) 240 mg |
(Tecfidera) |
QL (60 per 30 days) |
| GILENYA ORAL CAPSULE 0.25 MG, 0.5 MG |
|
QL (30 per 30 days) |
| glatiramer subcutaneous syringe 20 mg/ml |
(Copaxone) |
QL (30 per 30 days) |
| glatiramer subcutaneous syringe 40 mg/ml |
(Copaxone) |
QL (12 per 28 days) |
| glatopa subcutaneous syringe 20 mg/ml |
(glatiramer) |
QL (30 per 30 days) |
| glatopa subcutaneous syringe 40 mg/ml |
(glatiramer) |
QL (12 per 28 days) |
| guanfacine oral tablet extended release 24 hr 1 mg, 2 mg, 3 mg, 4 mg |
(Intuniv ER) |
QL (30 per 30 days) |
| KESIMPTA PEN SUBCUTANEOUS PEN INJECTOR 20 MG/0.4 ML |
|
QL (1.2 per 28 days) |
| MAYZENT ORAL TABLET 0.25 MG |
|
QL (112 per 28 days) |
| MAYZENT ORAL TABLET 2 MG |
|
QL (30 per 30 days) |
| methylphenidate hcl oral capsule, er biphasic 30-70 10 mg, 20 mg, 40 mg, 50 mg, 60 mg |
|
QL (30 per 30 days) |
| methylphenidate hcl oral capsule, er biphasic 30-70 30 mg |
|
QL (60 per 30 days) |
| methylphenidate hcl oral capsule,er biphasic 50-50 10 mg, 20 mg, 40 mg |
(Ritalin LA) |
QL (30 per 30 days) |
| methylphenidate hcl oral capsule,er biphasic 50-50 30 mg |
(Ritalin LA) |
QL (60 per 30 days) |
| methylphenidate hcl oral capsule,er biphasic 50-50 60 mg |
|
QL (30 per 30 days) |
| methylphenidate hcl oral solution 10 mg/5 ml, 5 mg/5 ml |
(Methylin) |
QL (900 per 30 days) |
| methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg |
(Ritalin) |
QL (90 per 30 days) |
| PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML |
|
QL (1 per 28 days) |
| PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML |
|
QL (1 per 28 days) |
| RADICAVA INTRAVENOUS SOLUTION 30 MG/100 ML |
|
QL (2800 per 28 days) |
| riluzole oral tablet 50 mg |
(Rilutek) |
QL (60 per 30 days) |
| SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG |
|
QL (60 per 30 days) |
| tetrabenazine oral tablet 12.5 mg, 25 mg |
(Xenazine) |
QL (112 per 28 days) |
| VUMERITY ORAL CAPSULE,DELAYED RELEASE(DR/EC) 231 MG |
|
QL (120 per 30 days) |
| Contraceptives |
|
|
| Contraceptives |
|
|
| amethia oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) |
(l norgest/e.estradiol-e.estrad) |
QL (91 per 84 days) |
| ashlyna oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) |
(l norgest/e.estradiol-e.estrad) |
QL (91 per 84 days) |
| daysee oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) |
(l norgest/e.estradiol-e.estrad) |
QL (91 per 84 days) |
| ELLA ORAL TABLET 30 MG |
|
QL (6 per 365 days) |
| eluryng vaginal ring 0.12-0.015 mg/24 hr |
(etonogestrel-ethinyl estradiol) |
QL (1 per 28 days) |
| etonogestrel-ethinyl estradiol vaginal ring 0.12-0.015 mg/24 hr |
(EluRyng) |
QL (1 per 28 days) |
| iclevia oral tablets,dose pack,3 month 0.15 mg-30 mcg (91) |
(levonorgestrel-ethinyl estrad) |
QL (91 per 84 days) |
| introvale oral tablets,dose pack,3 month 0.15 mg-30 mcg (91) |
(levonorgestrel-ethinyl estrad) |
QL (91 per 84 days) |
| jaimiess oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) |
(l norgest/e.estradiol-e.estrad) |
QL (91 per 84 days) |
| l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) |
(LoJaimiess) |
QL (91 per 84 days) |
| l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) |
(Amethia) |
QL (91 per 84 days) |
| levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg (91) |
(Iclevia) |
QL (91 per 84 days) |
| lojaimiess oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7) |
(l norgest/e.estradiol-e.estrad) |
QL (91 per 84 days) |
| setlakin oral tablets,dose pack,3 month 0.15 mg-30 mcg (91) |
(levonorgestrel-ethinyl estrad) |
QL (91 per 84 days) |
| simpesse oral tablets,dose pack,3 month 0.15 mg-30 mcg (84)/10 mcg (7) |
(l norgest/e.estradiol-e.estrad) |
QL (91 per 84 days) |
| xulane transdermal patch weekly 150-35 mcg/24 hr |
|
QL (3 per 28 days) |
| zafemy transdermal patch weekly 150-35 mcg/24 hr |
|
QL (3 per 28 days) |
| Dermatological Agents |
|
|
| Dermatological Agents, Other |
|
|
| acyclovir topical ointment 5 % |
(Zovirax) |
QL (30 per 30 days) |
| calcipotriene scalp solution 0.005 % |
|
QL (120 per 30 days) |
| calcipotriene topical cream 0.005 % |
(Dovonex) |
QL (120 per 30 days) |
| imiquimod topical cream in packet 5 % |
(Aldara) |
QL (24 per 30 days) |
| PANRETIN TOPICAL GEL 0.1 % |
|
QL (180 per 30 days) |
| SANTYL TOPICAL OINTMENT 250 UNIT/GRAM |
|
QL (180 per 30 days) |
| Dermatological Antibacterials |
|
|
| clindamycin phosphate topical solution 1 % |
(Cleocin T) |
QL (180 per 30 days) |
| erythromycin with ethanol topical gel 2 % |
(Erygel) |
QL (180 per 30 days) |
| erythromycin with ethanol topical solution 2 % |
|
QL (180 per 30 days) |
| gentamicin topical cream 0.1 % |
|
QL (120 per 30 days) |
| gentamicin topical ointment 0.1 % |
|
QL (120 per 30 days) |
| mupirocin topical ointment 2 % |
(Centany) |
QL (220 per 30 days) |
| Dermatological Anti-Inflammatory Agents |
|
|
| desoximetasone topical cream 0.25 % |
(Topicort) |
QL (120 per 30 days) |
| pimecrolimus topical cream 1 % |
(Elidel) |
QL (100 per 30 days) |
| tacrolimus topical ointment 0.03 %, 0.1 % |
(Protopic) |
QL (100 per 30 days) |
| Devices |
|
|
| Devices |
|
|
| OMNIPOD DASH PDM KIT |
|
QL (1 per 365 days) |
| OMNIPOD INSULIN MANAGEMENT |
|
QL (1 per 365 days) |
| Enzyme Replacement/Modifiers |
|
|
| Enzyme Replacement/Modifiers |
|
|
| GALAFOLD ORAL CAPSULE 123 MG |
|
QL (14 per 28 days) |
| miglustat oral capsule 100 mg |
(Zavesca) |
QL (90 per 30 days) |
| Eye, Ear, Nose, Throat Agents |
|
|
| Eye, Ear, Nose, Throat Agents, Miscellaneous |
|
|
| azelastine nasal aerosol,spray 137 mcg (0.1 %) |
|
QL (30 per 25 days) |
| CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 % |
|
QL (60 per 28 days) |
| ipratropium bromide nasal spray,non-aerosol 21 mcg (0.03 %) |
|
QL (30 per 28 days) |
| ipratropium bromide nasal spray,non-aerosol 42 mcg (0.06 %) |
|
QL (15 per 10 days) |
| Eye, Ear, Nose, Throat Anti-Infectives Agents |
|
|
| ciprofloxacin-dexamethasone otic (ear) drops,suspension 0.3-0.1 % |
(Ciprodex) |
QL (7.5 per 7 days) |
| erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %) |
|
QL (3.5 per 4 days) |
| Eye, Ear, Nose, Throat Anti-Inflammatory Agents |
|
|
| EYSUVIS OPHTHALMIC (EYE) DROPS,SUSPENSION 0.25 % |
|
QL (8.3 per 14 days) |
| flunisolide nasal spray,non-aerosol 25 mcg (0.025 %) |
|
QL (50 per 25 days) |
| fluticasone propionate nasal spray,suspension 50 mcg/actuation |
(24 Hour Allergy Relief) |
QL (16 per 30 days) |
| ketorolac ophthalmic (eye) drops 0.5 % |
(Acular) |
QL (10 per 25 days) |
| mometasone nasal spray,non-aerosol 50 mcg/actuation |
|
QL (34 per 30 days) |
| RESTASIS MULTIDOSE OPHTHALMIC (EYE) DROPS 0.05 % |
|
QL (60 per 30 days) |
| RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 % |
|
QL (60 per 30 days) |
| XHANCE NASAL AEROSOL BREATH ACTIVATED 93 MCG/ACTUATION |
|
QL (32 per 30 days) |
| XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5 % |
|
QL (60 per 30 days) |
| Gastrointestinal Agents |
|
|
| Antiulcer Agents And Acid Suppressants |
|
|
| esomeprazole magnesium oral capsule,delayed release(dr/ec) 20 mg |
(Nexium) |
QL (30 per 30 days) |
| esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg |
(Nexium) |
QL (60 per 30 days) |
| lansoprazole oral capsule,delayed release(dr/ec) 15 mg |
(Prevacid 24Hr) |
QL (30 per 30 days) |
| lansoprazole oral capsule,delayed release(dr/ec) 30 mg |
(Prevacid) |
QL (60 per 30 days) |
| omeprazole-sodium bicarbonate oral capsule 20-1.1 mg-gram, 40-1.1 mg-gram |
(Zegerid) |
QL (30 per 30 days) |
| pantoprazole oral tablet,delayed release (dr/ec) 20 mg |
(Protonix) |
QL (30 per 30 days) |
| pantoprazole oral tablet,delayed release (dr/ec) 40 mg |
(Protonix) |
QL (60 per 30 days) |
| rabeprazole oral tablet,delayed release (dr/ec) 20 mg |
(AcipHex) |
QL (30 per 30 days) |
| Gastrointestinal Agents, Other |
|
|
| LINZESS ORAL CAPSULE 145 MCG, 290 MCG, 72 MCG |
|
QL (30 per 30 days) |
| LOKELMA ORAL POWDER IN PACKET 10 GRAM |
|
QL (34 per 30 days) |
| LOKELMA ORAL POWDER IN PACKET 5 GRAM |
|
QL (30 per 30 days) |
| lubiprostone oral capsule 24 mcg, 8 mcg |
(Amitiza) |
QL (60 per 30 days) |
| MOVANTIK ORAL TABLET 12.5 MG, 25 MG |
|
QL (30 per 30 days) |
| OCALIVA ORAL TABLET 10 MG, 5 MG |
|
QL (30 per 30 days) |
| XERMELO ORAL TABLET 250 MG |
|
QL (90 per 30 days) |
| Genitourinary Agents |
|
|
| Genitourinary Agents, Miscellaneous |
|
|
| alfuzosin oral tablet extended release 24 hr 10 mg |
(Uroxatral) |
QL (30 per 30 days) |
| Heavy Metal Antagonists |
|
|
| Heavy Metal Antagonists |
|
|
| clovique oral capsule 250 mg |
(trientine) |
QL (240 per 30 days) |
| trientine oral capsule 250 mg |
(Syprine) |
QL (240 per 30 days) |
| Hormonal Agents, Stimulant/Replacement/Modifying |
|
|
| Androgens |
|
|
| testosterone enanthate intramuscular oil 200 mg/ml |
|
QL (5 per 28 days) |
| testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %) |
(Vogelxo) |
QL (300 per 30 days) |
| testosterone transdermal gel in metered-dose pump 20.25 mg/1.25 gram (1.62 %) |
(AndroGel) |
QL (150 per 30 days) |
| testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram) |
(AndroGel) |
QL (300 per 30 days) |
| testosterone transdermal solution in metered pump w/app 30 mg/actuation (1.5 ml) |
|
QL (180 per 30 days) |
| XYOSTED SUBCUTANEOUS AUTO-INJECTOR 100 MG/0.5 ML, 50 MG/0.5 ML, 75 MG/0.5 ML |
|
QL (2 per 28 days) |
| Estrogens And Antiestrogens |
|
|
| dotti transdermal patch semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr |
(estradiol) |
QL (8 per 28 days); |
| estradiol transdermal patch semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr |
(Dotti) |
QL (8 per 28 days); |
| estradiol transdermal patch weekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.06 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr |
(Climara) |
QL (4 per 28 days); |
| estradiol vaginal tablet 10 mcg |
(Yuvafem) |
QL (18 per 28 days) |
| FEMRING VAGINAL RING 0.05 MG/24 HR, 0.1 MG/24 HR |
|
QL (1 per 84 days) |
| lyllana transdermal patch semiweekly 0.025 mg/24 hr, 0.0375 mg/24 hr, 0.05 mg/24 hr, 0.075 mg/24 hr, 0.1 mg/24 hr |
(estradiol) |
QL (8 per 28 days); |
| yuvafem vaginal tablet 10 mcg |
(estradiol) |
QL (18 per 28 days) |
| Glucocorticoids/Mineralocorticoids |
|
|
| EMFLAZA ORAL SUSPENSION 22.75 MG/ML |
|
QL (91 per 28 days) |
| EMFLAZA ORAL TABLET 18 MG |
|
QL (30 per 30 days) |
| EMFLAZA ORAL TABLET 30 MG, 36 MG, 6 MG |
|
QL (60 per 30 days) |
| Pituitary |
|
|
| ACTHAR INJECTION GEL 80 UNIT/ML |
|
QL (35 per 28 days) |
| CORTROPHIN GEL INJECTION GEL 80 UNIT/ML |
|
QL (35 per 28 days) |
| EGRIFTA SUBCUTANEOUS RECON SOLN 2 MG |
|
QL (30 per 30 days) |
| EGRIFTA SV SUBCUTANEOUS RECON SOLN 2 MG |
|
QL (30 per 30 days) |
| ORILISSA ORAL TABLET 150 MG |
|
QL (28 per 28 days) |
| ORILISSA ORAL TABLET 200 MG |
|
QL (56 per 28 days) |
| SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML) |
|
QL (60 per 30 days) |
| SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML |
(lanreotide) |
QL (0.5 per 28 days) |
| SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 60 MG/0.2 ML |
|
QL (0.2 per 28 days) |
| SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 90 MG/0.3 ML |
|
QL (0.3 per 28 days) |
| SUPPRELIN LA IMPLANT KIT 50 MG (65 MCG/DAY) |
|
QL (1 per 360 days) |
| TRIPTODUR INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 22.5 MG |
|
QL (1 per 168 days) |
| Progestins |
|
|
| medroxyprogesterone intramuscular suspension 150 mg/ml |
(Depo-Provera) |
QL (1 per 84 days) |
| medroxyprogesterone intramuscular syringe 150 mg/ml |
(Depo-Provera) |
QL (1 per 84 days) |
| Immunological Agents |
|
|
| Immunological Agents |
|
|
| BENLYSTA SUBCUTANEOUS AUTO-INJECTOR 200 MG/ML |
|
QL (8 per 28 days) |
| BENLYSTA SUBCUTANEOUS SYRINGE 200 MG/ML |
|
QL (8 per 28 days) |
| BESREMI SUBCUTANEOUS SYRINGE 500 MCG/ML |
|
QL (2 per 28 days) |
| Vaccines |
|
|
| DENGVAXIA (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 10EXP4.5-6 CCID50/0.5 ML |
|
QL (3 per 365 days) |
| GARDASIL 9 (PF) INTRAMUSCULAR SUSPENSION 0.5 ML |
|
QL (1.5 per 365 days) |
| GARDASIL 9 (PF) INTRAMUSCULAR SYRINGE 0.5 ML |
|
QL (1.5 per 365 days) |
| SHINGRIX (PF) INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 50 MCG/0.5 ML |
|
QL (2 per 365 days) |
| VARIVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 1,350 UNIT/0.5 ML |
|
QL (2 per 365 days) |
| Metabolic Bone Disease Agents |
|
|
| Metabolic Bone Disease Agents |
|
|
| alendronate oral tablet 10 mg, 5 mg |
|
QL (30 per 30 days) |
| alendronate oral tablet 35 mg |
|
QL (4 per 28 days) |
| alendronate oral tablet 70 mg |
(Fosamax) |
QL (4 per 28 days) |
| calcitonin (salmon) nasal spray,non-aerosol 200 unit/actuation |
|
QL (3.7 per 28 days) |
| cinacalcet oral tablet 30 mg |
(Sensipar) |
QL (60 per 30 days) |
| cinacalcet oral tablet 60 mg |
(Sensipar) |
QL (60 per 30 days) |
| cinacalcet oral tablet 90 mg |
(Sensipar) |
QL (120 per 30 days) |
| EVENITY SUBCUTANEOUS SYRINGE 105 MG/1.17 ML, 210MG/2.34ML ( 105MG/1.17MLX2) |
|
QL (2.34 per 30 days) |
| ibandronate intravenous solution 3 mg/3 ml |
|
QL (3 per 84 days) |
| ibandronate intravenous syringe 3 mg/3 ml |
|
QL (3 per 84 days) |
| ibandronate oral tablet 150 mg |
(Boniva) |
QL (1 per 28 days) |
| NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE |
|
QL (2 per 28 days) |
| PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML |
|
QL (1 per 180 days) |
| RAYALDEE ORAL CAPSULE,EXTENDED RELEASE 24 HR 30 MCG |
|
QL (60 per 30 days) |
| risedronate oral tablet 150 mg |
(Actonel) |
QL (1 per 28 days) |
| risedronate oral tablet 30 mg, 5 mg |
|
QL (30 per 30 days) |
| risedronate oral tablet 35 mg |
(Actonel) |
QL (4 per 28 days) |
| risedronate oral tablet 35 mg (12 pack), 35 mg (4 pack) |
|
QL (4 per 28 days) |
| risedronate oral tablet,delayed release (dr/ec) 35 mg |
(Atelvia) |
QL (4 per 28 days) |
| TYMLOS SUBCUTANEOUS PEN INJECTOR 80 MCG (3,120 MCG/1.56 ML) |
|
QL (1.56 per 30 days) |
| zoledronic acid-mannitol-water intravenous piggyback 5 mg/100 ml |
(Reclast) |
QL (100 per 300 days) |
| Miscellaneous Therapeutic Agents |
|
|
| Miscellaneous Therapeutic Agents |
|
|
| ELMIRON ORAL CAPSULE 100 MG |
|
QL (90 per 30 days) |
| KEVEYIS ORAL TABLET 50 MG |
|
QL (120 per 30 days) |
| RECTIV RECTAL OINTMENT 0.4 % (W/W) |
|
QL (30 per 30 days) |
| TAKHZYRO SUBCUTANEOUS SOLUTION 300 MG/2 ML (150 MG/ML) |
|
QL (4 per 28 days) |
| THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG |
|
QL (60 per 30 days) |
| TYBOST ORAL TABLET 150 MG |
|
QL (30 per 30 days) |
| VISTOGARD ORAL GRANULES IN PACKET 10 GRAM |
|
QL (24 per 14 days) |
| XURIDEN ORAL GRANULES IN PACKET 2 GRAM |
|
QL (120 per 30 days) |
| Ophthalmic Agents |
|
|
| Antiglaucoma Agents |
|
|
| latanoprost ophthalmic (eye) drops 0.005 % |
(Xalatan) |
QL (2.5 per 25 days) |
| LUMIGAN OPHTHALMIC (EYE) DROPS 0.01 % |
|
QL (2.5 per 25 days) |
| RHOPRESSA OPHTHALMIC (EYE) DROPS 0.02 % |
|
QL (2.5 per 25 days) |
| ROCKLATAN OPHTHALMIC (EYE) DROPS 0.02-0.005 % |
|
QL (2.5 per 25 days) |
| travoprost ophthalmic (eye) drops 0.004 % |
(Travatan Z) |
QL (2.5 per 25 days) |
| Respiratory Tract Agents |
|
|
| Anti-Inflammatories, Inhaled Corticosteroids |
|
|
| ADVAIR DISKUS INHALATION BLISTER WITH DEVICE 100-50 MCG/DOSE, 250-50 MCG/DOSE, 500-50 MCG/DOSE |
(fluticasone propion-salmeterol) |
QL (60 per 30 days) |
| ADVAIR HFA INHALATION HFA AEROSOL INHALER 115-21 MCG/ACTUATION, 230-21 MCG/ACTUATION, 45-21 MCG/ACTUATION |
|
QL (12 per 30 days) |
| ARNUITY ELLIPTA INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 200 MCG/ACTUATION, 50 MCG/ACTUATION |
|
QL (30 per 30 days) |
| BREO ELLIPTA INHALATION BLISTER WITH DEVICE 100-25 MCG/DOSE, 200-25 MCG/DOSE |
|
QL (60 per 30 days) |
| budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml |
(Pulmicort) |
QL (120 per 30 days) |
| budesonide inhalation suspension for nebulization 1 mg/2 ml |
(Pulmicort) |
QL (60 per 30 days) |
| FLOVENT 100 MCG DISKUS 100 MCG/ACTUATION |
|
QL (60 per 30 days) |
| FLOVENT 250 MCG DISKUS 250 MCG/ACTUATION |
|
QL (120 per 30 days) |
| FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 50 MCG/ACTUATION |
|
QL (60 per 30 days) |
| FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 250 MCG/ACTUATION |
|
QL (120 per 30 days) |
| FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION |
|
QL (12 per 30 days) |
| FLOVENT HFA INHALATION HFA AEROSOL INHALER 220 MCG/ACTUATION |
|
QL (24 per 30 days) |
| FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION |
|
QL (21.2 per 30 days) |
| SYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION |
(budesonide-formoterol) |
QL (30.6 per 30 days) |
| Bronchodilators |
|
|
| albuterol 5 mg/ml solution 5 mg/ml |
|
QL (120 per 30 days) |
| albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation |
(ProAir HFA) |
QL (17 per 30 days) |
| albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (nda020503) |
|
QL (13.4 per 30 days) |
| albuterol sulfate inhalation hfa aerosol inhaler 90 mcg/actuation (nda020983) |
|
QL (36 per 30 days) |
| albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %) |
|
QL (360 per 30 days) |
| albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml |
|
QL (120 per 30 days) |
| ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION |
|
QL (60 per 30 days) |
| ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION |
|
QL (25.8 per 28 days) |
| BREZTRI AEROSPHERE INHALATION HFA AEROSOL INHALER 160-9-4.8 MCG/ACTUATION |
|
QL (10.7 per 30 days) |
| COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION |
|
QL (8 per 30 days) |
| ipratropium bromide inhalation solution 0.02 % |
|
QL (312.5 per 30 days) |
| ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml |
|
QL (540 per 30 days) |
| SEREVENT DISKUS INHALATION BLISTER WITH DEVICE 50 MCG/DOSE |
|
QL (60 per 30 days) |
| SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION |
|
QL (4 per 30 days) |
| SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG |
|
QL (30 per 30 days) |
| STIOLTO RESPIMAT INHALATION MIST 2.5-2.5 MCG/ACTUATION |
|
QL (4 per 30 days) |
| STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION |
|
QL (4 per 28 days) |
| TRELEGY ELLIPTA INHALATION BLISTER WITH DEVICE 100-62.5-25 MCG, 200-62.5-25 MCG |
|
QL (60 per 30 days) |
| Respiratory Tract Agents, Other |
|
|
| BRONCHITOL INHALATION CAPSULE, W/INHALATION DEVICE 40 MG |
|
QL (560 per 28 days) |
| DALIRESP ORAL TABLET 250 MCG |
|
QL (28 per 28 days) |
| DALIRESP ORAL TABLET 500 MCG |
|
QL (30 per 30 days) |
| ESBRIET ORAL CAPSULE 267 MG |
|
QL (270 per 30 days) |
| ESBRIET ORAL TABLET 267 MG |
|
QL (270 per 30 days) |
| ESBRIET ORAL TABLET 801 MG |
|
QL (90 per 30 days) |
| FASENRA PEN SUBCUTANEOUS AUTO-INJECTOR 30 MG/ML |
|
QL (1 per 28 days) |
| FASENRA SUBCUTANEOUS SYRINGE 30 MG/ML |
|
QL (1 per 28 days) |
| KALYDECO ORAL GRANULES IN PACKET 25 MG, 50 MG, 75 MG |
|
QL (56 per 28 days) |
| KALYDECO ORAL TABLET 150 MG |
|
QL (56 per 28 days) |
| NUCALA SUBCUTANEOUS AUTO-INJECTOR 100 MG/ML |
|
QL (3 per 28 days) |
| NUCALA SUBCUTANEOUS RECON SOLN 100 MG |
|
QL (3 per 28 days) |
| NUCALA SUBCUTANEOUS SYRINGE 100 MG/ML |
|
QL (3 per 28 days) |
| OFEV ORAL CAPSULE 100 MG, 150 MG |
|
QL (60 per 30 days) |
| ORKAMBI ORAL GRANULES IN PACKET 100-125 MG, 150-188 MG |
|
QL (56 per 28 days) |
| ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG |
|
QL (120 per 30 days) |
| SYMDEKO ORAL TABLETS, SEQUENTIAL 100-150 MG (D)/ 150 MG (N), 50-75 MG (D)/ 75 MG (N) |
|
QL (56 per 28 days) |
| TRIKAFTA ORAL TABLETS, SEQUENTIAL 100-50-75 MG(D) /150 MG (N), 50-25-37.5 MG (D)/75 MG (N) |
|
QL (84 per 28 days) |
| Skeletal Muscle Relaxants |
|
|
| Skeletal Muscle Relaxants |
|
|
| chlorzoxazone oral tablet 250 mg |
|
QL (120 per 30 days); |
| Sleep Disorder Agents |
|
|
| Sleep Disorder Agents |
|
|
| armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mg |
(Nuvigil) |
QL (30 per 30 days) |
| BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MG |
|
QL (30 per 30 days) |
| eszopiclone oral tablet 1 mg, 2 mg, 3 mg |
(Lunesta) |
QL (30 per 30 days) |
| HETLIOZ LQ ORAL SUSPENSION 4 MG/ML |
|
QL (150 per 30 days) |
| HETLIOZ ORAL CAPSULE 20 MG |
|
QL (30 per 30 days) |
| SUNOSI ORAL TABLET 150 MG, 75 MG |
|
QL (30 per 30 days) |
| XYREM ORAL SOLUTION 500 MG/ML |
|
QL (540 per 30 days) |
| zaleplon oral capsule 10 mg, 5 mg |
|
QL (30 per 30 days) |
| zolpidem oral tablet 10 mg, 5 mg |
(Ambien) |
QL (30 per 30 days) |
| Vasodilating Agents |
|
|
| Vasodilating Agents |
|
|
| ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MG |
|
QL (90 per 30 days) |
| alyq oral tablet 20 mg |
(tadalafil (pulm. hypertension)) |
QL (60 per 30 days) |
| ambrisentan oral tablet 10 mg, 5 mg |
(Letairis) |
QL (30 per 30 days) |
| OPSUMIT ORAL TABLET 10 MG |
|
QL (30 per 30 days) |
| sildenafil (pulm.hypertension) intravenous solution 10 mg/12.5 ml |
(Revatio) |
QL (37.5 per 1 day) |
| sildenafil (pulm.hypertension) oral tablet 20 mg |
(Revatio) |
QL (90 per 30 days) |
| tadalafil (pulm. hypertension) oral tablet 20 mg |
(Alyq) |
QL (60 per 30 days) |
| TRACLEER ORAL TABLET 125 MG, 62.5 MG |
(bosentan) |
QL (60 per 30 days) |
| TRACLEER ORAL TABLET FOR SUSPENSION 32 MG |
|
QL (112 per 28 days) |
| UPTRAVI INTRAVENOUS RECON SOLN 1,800 MCG |
|
QL (60 per 30 days) |
| UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 400 MCG, 600 MCG, 800 MCG |
|
QL (60 per 30 days) |
| UPTRAVI ORAL TABLET 200 MCG |
|
QL (240 per 30 days) |
| Last Updated 2/22/2022 |