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2018 Prescription Drug List

Effective January 1, 2018

Ambetter.SuperiorHealthPlan.com

 
Formulary Introduction
 
SUMMARY OF FORMULARY BENEFITS
 
The information in this document is designed to help you understand the prescription drug benefits offered under this plan
and to compare these benefits to those offered by other plans. Information contained in this summary is designed to help you
compare both the value and scope of formulary benefits.
 
HOW TO FIND INFORMATION ON THE COST OF PRESCRIPTION DRUGS
To find the cost of your prescription please visit https://ambetter.superiorhealthplan.com/resources/pharmacy-resources.html.
In the Drug Cost Tool please select the plan in which you are participating (planning to participate) and enter medications
that you are taking. The tool will provide you an approximate cost of your prescriptions, excluding any deductible or
maximum out of pocket requirements. The tool uses median cost for generic prescriptions and actual allowed cost for
branded products. If the total medication cost is less than the co-pay that you would pay for that Tier you will be responsible
only for the lesser of amount.
 
 
 
FORMULARY BY HEALTH BENEFIT PLAN
 
Plan Formulary Summary of Benefits and Coverage
Ambetter Secure Care 1 (2018) with 3 Standard Formulary https://ambetter.superiorhealthplan.com/20
Free PCP Visits 18-brochures.html?plan=SecureCare
Ambetter Balanced Care 1 (2018) Standard Formulary https://ambetter.superiorhealthplan.com/20
18-brochures.html?plan=BalancedCare
Ambetter Balanced Care 2 (2018) Standard Formulary https://ambetter.superiorhealthplan.com/20
18-brochures.html?plan=BalancedCare
Ambetter Balanced Care 10 (2018) Standard Formulary https://ambetter.superiorhealthplan.com/20
18-brochures.html?plan=BalancedCare
Ambetter Balanced Care 3 (2018) Standard Formulary https://ambetter.superiorhealthplan.com/20
18-brochures.html?plan=BalancedCare
Ambetter Balanced Care 4 (2018) Standard Formulary https://ambetter.superiorhealthplan.com/20
18-brochures.html?plan=BalancedCare
Ambetter Balanced Care 12 (2018) Standard Formulary https://ambetter.superiorhealthplan.com/20
18-brochures.html?plan=BalancedCare
Ambetter Balanced Care 5 (2018) Standard Formulary https://ambetter.superiorhealthplan.com/20
18-brochures.html?plan=BalancedCare
Ambetter Essential Care 1 (2018) Standard Formulary https://ambetter.superiorhealthplan.com/20
18-brochures.html?plan=EssentialCare
Ambetter Balanced Care 1 (2018) + Standard Formulary https://ambetter.superiorhealthplan.com/20
Vision 18-brochures.html?plan=BalancedCare
Ambetter Balanced Care 2 (2018) + Standard Formulary https://ambetter.superiorhealthplan.com/20
Vision 18-brochures.html?plan=BalancedCare
Ambetter Balanced Care 10 (2018) + Standard Formulary https://ambetter.superiorhealthplan.com/20
Vision 18-brochures.html?plan=BalancedCare
Ambetter Balanced Care 3 (2018) + Standard Formulary https://ambetter.superiorhealthplan.com/20
Vision 18-brochures.html?plan=BalancedCare
Ambetter Essential Care 1 (2018) + Standard Formulary https://ambetter.superiorhealthplan.com/20
Vision 18-brochures.html?plan=EssentialCare
DRUG BY COST-SHARING TIER

 
Tier Percent of drugs in each
cost-sharing tier:
0 6%
1 84%
2 2%
3 3%
4 5%
 
 
HOW PRESCRIPTION DRUGS ARE COVERED UNDER THE PLAN
 
A) FORMULARY COMPOSITION:
a. Ambetter formulary is guided by the principle of offering widest possible access to drugs at the lowest cost.
With that in mind, we start with the Affordable Care Act mandated benchmark. We then review the formulary
for addition of other clinically necessary and appropriate drugs. Ambetter’s formulary is considered a closed
formulary. This means that any drug not found in the formulary requires prior authorization. To make sure
that our members always have access to appropriate drugs, we review and update our formulary on a
monthly basis.
 
B) RIGHT TO APPEAL
a. If we deny your request for Prior Authorization you have 180 days from being denied coverage for a drug to
file an appeal, and your appeal will be resolved within 30 days. In the event that your appeal is successful,
non-specialty non-formulary drugs will be covered at your Tier 3 cost-share (co-pay or co-insurance) and
specialty non-formulary drugs will be covered at your Tier 4 cost-share (co-pay or co-insurance). Please
consult your individual Summary of Benefits and Coverage for additional information on your cost-share. All
other provisions of your benefit, such as deductibles and maximum out of pockets, apply to formulary and
non-formulary drugs that have been provided through an appeal.
 
C) CONTINUATION OF COVERAGE
a. Ambetter does not make changes to our formulary requiring a continuation of coverage. However, if a
formulary change is made requiring a continuation of coverage, you would have the right to continue taking
the drug at the coverage level or tier at which the drug was covered at the beginning of the plan year until
your plan is renewed.
 
D) OFF-LABEL DRUG USE
a. We provide coverage for off-label drug use. Off-label use indicates medication use that has not been FDA
approved for that condition. Coverage of a product under off-label use policy requires that the following must
be true:
i. Use must be diagnosis specific as defined by ICD-10 code AND
ii. Off-label use must be supported by one major multi-site study or three smaller studies published in
a reputable medical journal, peer reviewed specialty medical journal, or listed in reputable
compendia.
 
E) COST SHARING
a. Cost sharing is your monetary participation in your care. You will need to know few items to determine the
cost-share you are responsible for. Knowing the following items will help you estimate the cost you’ll be
responsible for at any given time: how much of your deductible you have already paid, how much deductible
remains, what drug you are prescribed, and your maximum out of pocket allowance. All those items, with the
exception of the tier, can be obtained from the Summary of Benefits and Coverage (see links above). To
obtain the tier for your drug please consult the Formulary. To determine your cost share please follow those
steps:
i. Determine the tier that the drug/product you are filling is listed under by consulting the Formulary.
ii. Once you have determined the tier, utilize the Summary of Benefits and Coverage (SBC) document
to determine what cost-share will apply to your selected drug/product.
iii. If you have not met your deductible, you will be responsible for the full cost of the drug until you
meet your deductible.
iv. If you have met your deductible, but not the Maximum Out of Pocket, you will be charged a copay
for drugs that are assigned a copay under your SBC and co-insurance for drugs that are assigned
a co-insurance under your SBC. Generally, you will pay one (1) co-pay for each 30 day supply of
medication. Two co-pays will be charged for 2 month supply and three co-pays for 3 month supply
of your medication, respectively.
v. To determine the cost for co-insurance drugs/products, please utilize our online drug search tool.
Please see section: “HOW TO FIND INFORMATION ON THE COST OF PRESCRIPTION
DRUGS” above.

b. Please be aware that pharmacy claims will only process if you present your prescription to an in-network
pharmacy. Out-of-network claims will not be covered. To find an in-network-pharmacy close to you please
consult our Find a Provider tool available on our website under Pharmacy Resources.

c. Your cost share for maintenance medications obtained through either Mail Order or at retail pharmacies
participating in our Extended Day Supply retail network will be calculated based on the day supply that you
obtain. For up to 30 day supply you will be charged one (1) copay or co-insurance, 31 to 60 day supply you
will be responsible for two (2) copays or co-insurance and for day supply greater than 60 but less than 91 you
will be charged three (3) copays or co-insurance.

F) MEDICAL MANAGEMENT REQUIREMENTS


a. Prior Authorization (PA) – Drugs that have PA indication on the Formulary require Prior Authorization. You or
your provider have to request an authorization from us to use this drug/product prior to be able to fill a
prescription for the drug/product.
b. Step Therapy (ST) – Drugs that have ST indication on the Formulary require that you try and fail other
formulary products before you can obtain the drug/product. When your provider does not feel that trying
another product is appropriate your provider or you can submit a regular Prior Authorization request to obtain
the Step Therapy drug/product.
c. Quantity Limit (QL) – Drugs that have QL indication on the Formulary are limited to the quantity indicated.
Those quantity limits are based on the FDA approved maximum doses. If your provider would like to request
exception to those limits he/she may submit a Prior Authorization request. All request requested for quantity
limit exemptions will be processed under our Off-Label policy.
d. Non-Formulary Drugs – Drugs not found on this formulary are considered non-formulary drugs. To obtain
non-formulary drugs your provider would have to submit a regular Prior Authorization request. All request for
Non-Formulary Drugs will be reviewed under our Non-Formulary Drug Request Policy.

STANDARD FORMULARY

The Ambetter from Superior Health Plan Formulary, or Preferred Drug List, is a guide to available brand and
generic drugs that are approved by the Food and Drug Administration (FDA) and covered through your
prescription drug benefit. Generic drugs have the same active ingredients as their brand name counterparts
and should be considered the first line of treatment. The FDA requires generics to be safe and work the same
as brand name drugs. If there is no generic available, there may be more than one brand name drug to treat a
condition. Preferred brand name drugs are listed on Tier 2 to help identify brand drugs that are clinically
appropriate, safe, and cost-effective treatment options, if a generic medication on the formulary is not
suitable for your condition.

Drug List Key:


Brand name drugs are listed in CAPS and generic drugs are
lower case. Drugs are covered under different copay tiers
depending on your benefit:

Tier 0 - No copayment for those drugs that are used for prevention and are mandated by Affordable Care
Act. Select oral contraceptives, vitamin D, folic acid for women of child bearing age, over-the-counter (OTC)
aspirin, and smoking cessation products may be covered under this tier. Certain age or gender limits apply.

Tier 1 - Lowest copayment for those drugs that offer the greatest value compared to other drugs used to
treat similar conditions. Select over-the-counter (OTC), generic or brand name drugs may be covered under
this tier.

Tier 2 - Medium copayment covers brand name drugs that are generally more affordable, or may be
preferred compared to other drugs to treat the same conditions.

Tier 3 - Highest copayment covers higher cost brand name drugs. This tier may also cover non-specialty
drugs that are not on the Preferred Drug List but approval has been granted for coverage.

Tier 4 - Coverage for this tier is for “specialty” drugs used to treat complex, chronic conditions that may
require special handling, storage or clinical management. For members who do not have a four Tier plan,
these drugs may be covered under Tier 3.
Formulary Abbreviations:

Abbreviation Term What it means

AL Age Limit Some drugs are only covered for certain ages.

QL Quantity Limit Some drugs are only covered for a certain amount.

Your doctor must ask for approval from Ambetter before


PA Prior Authorization
some drugs will be covered.

In some cases, you must first try certain drugs before


Ambetter covers another drug for your medical condition.
ST Step Therapy For example, if Drug A and Drug B both treat your
medical condition, Ambetter may not cover Drug B
unless you try Drug A first.
This product is not covered unless you or your provider
NF Non-formulary request an exception. Alternative medications are listed
next to non-covered product

These drugs are made in both prescription form and


RX/OTC Prescription and OTC
Over-the-counter (OTC) form.
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ADHD/ANTI-NARCOLEPSY/ANTI- amphetamine- QL(2 ea daily)
OBESITY/ANOREXIANTS - Drugs to Treat dextroamphetamine cp24
ADHD, Sleep and Eating Disorders 5mg-5mg-5mg-5mg, 1
7.5mg-7.5mg-7.5mg-
Amphetamines 7.5mg, 6.25mg-6.25mg-
ADDERALL TABS 5MG- QL(3 ea daily) 6.25mg-6.25mg
5MG-5MG-5MG, 2.5MG- amphetamine- QL(3 ea daily)
2.5MG-2.5MG-2.5MG, dextroamphetamine tabs
1.25MG-1.25MG-1.25MG- 5mg-5mg-5mg-5mg,
1.25MG, 3.75MG-3.75MG- 2.5mg-2.5mg-2.5mg-
3.75MG-3.75MG, NF 2.5mg, 1.25mg-1.25mg-
1.875MG-1.875MG- 1.25mg-1.25mg, 3.75mg- 1
1.875MG-1.875MG, 3.75mg-3.75mg-3.75mg,
3.125MG-3.125MG- 1.875mg-1.875mg-
3.125MG-3.125MG (Use 1.875mg-1.875mg,
Amphetamine- 3.125mg-3.125mg-
Dextroamphetamine) 3.125mg-3.125mg
ADDERALL TABS 7.5MG- amphetamine-
7.5MG-7.5MG-7.5MG (Use NF dextroamphetamine tabs 1
Amphetamine- 7.5mg-7.5mg-7.5mg-7.5mg
Dextroamphetamine)
QL(5 ea daily);
ADDERALL XR CP24 QL(1 ea daily) DESOXYN TABS (Use 3 AL; At least 6
2.5MG-2.5MG-2.5MG- Methamphetamine HCl) yrs old
2.5MG, 1.25MG-1.25MG- NF
1.25MG-1.25MG (Use DEXEDRINE CP24 10 MG, QL(4 ea daily)
Amphetamine- 15 MG (Use NF
Dextroamphetamine) Dextroamphetamine
Sulfate)
ADDERALL XR CP24
3.75MG-3.75MG-3.75MG- DEXEDRINE CP24 5 MG
3.75MG (Use NF (Use Dextroamphetamine NF
Amphetamine- Sulfate)
Dextroamphetamine) dextroamphetamine sulfate 1 QL(4 ea daily)
ADDERALL XR CP24 QL(2 ea daily) cp24 10 mg, 15 mg
5MG-5MG-5MG-5MG, dextroamphetamine sulfate 1
7.5MG-7.5MG-7.5MG- cp24 5 mg
7.5MG, 6.25MG-6.25MG- NF dextroamphetamine sulfate QL(4 ea daily)
6.25MG-6.25MG (Use 1
tabs 5 mg, 10 mg
Amphetamine- QL(5 ea daily);
Dextroamphetamine) methamphetamine hcl tabs 3 AL; At least 6
amphetamine- QL(1 ea daily) yrs old
dextroamphetamine cp24 VYVANSE CAPS 10 MG, ST; QL(1 ea
2.5mg-2.5mg-2.5mg- 1 20 MG, 30 MG, 40 MG, 50 2 daily)
2.5mg, 1.25mg-1.25mg- MG, 60 MG, 70 MG
1.25mg-1.25mg
amphetamine- Anorexiants Non-Amphetamine
dextroamphetamine cp24 ADIPEX-P CAPS (Use NF PA
1 Phentermine HCl)
3.75mg-3.75mg-3.75mg-
3.75mg phendimetrazine tartrate 1 PA
tabs

Ambetter Formulary Updated April 01, 2018

1
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
phentermine hcl caps 15 1 PA FOCALIN TABS (Use
QL(2 ea daily);
mg, 30 mg, 37.5 mg Dexmethylphenidate HCl) NF AL; At least 6
yrs old
Anti-Obesity Agents
PA FOCALIN XR CP24 (Use NF QL(1 ea daily)
BELVIQ TABS 3 Dexmethylphenidate HCl)
PA QL(1 ea daily);
CONTRAVE TB12 3 METADATE CD CPCR NF AL; At least 6
(Use Methylphenidate HCl) yrs old
Attention-Deficit/Hyperactivity Disorder (ADHD)
METHYLIN SOLN 5 QL(30 ml
QL(2 ea daily); MG/5ML, 10 MG/5ML (Use NF daily); AL; At
atomoxetine hcl caps 10 1 AL; At least 6
mg, 18 mg, 25 mg, 40 mg Methylphenidate HCl) least 6 yrs old
yrs old
methylphenidate hcl cp24 1 AL; At least 6
QL(1 ea daily); 20 mg, 40 mg yrs old
atomoxetine hcl caps 60 1 AL; At least 6
mg, 80 mg, 100 mg yrs old QL(3 ea daily);
methylphenidate hcl cp24 1 AL; At least 6
30 mg yrs old
clonidine hcl (adhd) tb12 1
QL(1 ea daily); methylphenidate hcl cpcr QL(1 ea daily);
guanfacine hcl (adhd) tb24 1 AL; At least 6 10 mg, 20 mg, 30 mg, 40 1 AL; At least 6
yrs old mg, 50 mg, 60 mg yrs old
QL(1 ea daily); QL(1 ea daily);
INTUNIV TB24 (Use METHYLPHENIDATE HCL 1 AL; At least 6
NF AL; At least 6 ER TB24 18 MG, 27 MG
Guanfacine HCl (ADHD)) yrs old yrs old
KAPVAY TB12 (Use QL(2 ea daily);
NF METHYLPHENIDATE HCL 1 AL; At least 6
Clonidine HCl (ADHD)) ER TB24 36 MG, 54 MG yrs old
STRATTERA CAPS 10 QL(2 ea daily);
MG, 18 MG, 25 MG, 40 MG NF AL; At least 6 QL(1 ea daily);
METHYLPHENIDATE HCL 2 AL; At least 6
(Use Atomoxetine HCl) yrs old ER TBCR 18 MG yrs old
STRATTERA CAPS 60 QL(1 ea daily);
MG, 80 MG, 100 MG (Use NF AL; At least 6 QL(30 ml
methylphenidate hcl soln 5 1 daily); AL; At
Atomoxetine HCl) yrs old mg/5ml, 10 mg/5ml least 6 yrs old
Stimulants - Misc. QL(5 ea daily);
PA; QL(1 ea methylphenidate hcl tabs 1 AL; At least 6
armodafinil tabs 1 daily); AL; At 10 mg, 20 mg yrs old
least 17 yrs old QL(6 ea daily);
CONCERTA TBCR 18 MG, QL(1 ea daily); methylphenidate hcl tabs 5 1 AL; At least 6
27 MG (Use NF AL; At least 6 mg yrs old
Methylphenidate HCl) yrs old QL(3 ea daily);
CONCERTA TBCR 36 MG, QL(2 ea daily); methylphenidate hcl tbcr 10 1 AL; At least 6
54 MG (Use NF AL; At least 6 mg, 20 mg yrs old
Methylphenidate HCl) yrs old QL(1 ea daily);
dexmethylphenidate hcl QL(1 ea daily) methylphenidate hcl tbcr 18 1 AL; At least 6
cp24 5 mg, 10 mg, 15 mg, mg, 27 mg yrs old
1
20 mg, 25 mg, 30 mg, 35 QL(2 ea daily);
mg, 40 mg methylphenidate hcl tbcr 36 1 AL; At least 6
QL(2 ea daily); mg, 54 mg yrs old
dexmethylphenidate hcl 1 AL; At least 6
tabs 5 mg, 10 mg, 2.5 mg yrs old
Ambetter Formulary Updated April 01, 2018

2
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
PA; QL(1 ea GENTAMICIN
modafinil tabs 100 mg 1 daily); AL; At SULFATE/0.9% SODIUM
least 16 yrs old CHLORIDE SOLN 0.9%- 1
PA; QL(2 ea 0.9MG/ML, 0.9%-
modafinil tabs 200 mg 1 daily); AL; At 1.4MG/ML
least 16 yrs old KITABIS PAK NEBU 4 PA
NUVIGIL TABS (Use PA; QL(1 ea
NF daily); AL; At neomycin sulfate tabs 1
Armodafinil) least 17 yrs old
PA; QL(1 ea paromomycin sulfate caps 1
PROVIGIL TABS 100 MG NF daily); AL; At
(Use Modafinil) least 16 yrs old STREPTOMYCIN 3
SULFATE SOLR
PA; QL(2 ea
PROVIGIL TABS 200 MG NF daily); AL; At TOBI NEBU (Use PA
(Use Modafinil) 4
least 16 yrs old Tobramycin)
RITALIN LA CP24 20 MG, AL; At least 6 tobramycin nebu 4 PA
40 MG (Use NF yrs old
Methylphenidate HCl) TOBRAMYCIN NEBU 4 PA
QL(3 ea daily);
RITALIN LA CP24 30 MG NF AL; At least 6 TOBRAMYCIN SULFATE
(Use Methylphenidate HCl) 1
yrs old SOLN 10 MG/ML
RITALIN TABS 10 MG, 20 QL(5 ea daily); tobramycin sulfate soln 40 1
MG (Use Methylphenidate NF AL; At least 6 mg/ml, 80 mg/2ml
HCl) yrs old ANALGESICS - ANTI-INFLAMMATORY - Drugs
QL(6 ea daily); to Treat Pain, Swelling, Muscle and Joint
RITALIN TABS 5 MG (Use NF AL; At least 6 Conditions
Methylphenidate HCl) yrs old Anti-TNF-alpha - Monoclonal Antibodies
ALLERGENIC EXTRACTS/BIOLOGICALS MISC HUMIRA PEDIATRIC PA; SP
CROHNS DISEASE 4
Allergenic Extracts STARTER PACK PSKT
GRASTEK SUBL 3 PA HUMIRA PEN PNKT 4 PA; SP
Biologicals Misc HUMIRA PEN-CROHNS 4 PA; SP
PA; SP DISEASESTARTER PNKT
ADAGEN SOLN 4 HUMIRA PEN-PSORIASIS PA; SP
4
STARTER PNKT
AMINOGLYCOSIDES - Drugs to Treat Bacterial
Infections PA; QL(0.0571
HUMIRA PSKT 20 4 ea daily,30
Aminoglycosides MG/0.4ML days retail,30
amikacin sulfate soln 1 days mail); SP
HUMIRA PSKT 40 4 PA; SP
gentamicin in saline soln 1 MG/0.8ML
SIMPONI SOAJ 100 4 PA; SP
gentamicin sulfate soln ij 1 MG/ML
40 mg/ml
gentamicin sulfate soln iv 1
10 mg/ml

Ambetter Formulary Updated April 01, 2018

3
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
PA; QL(0.0179 ARTHROTEC 75 TBEC
SIMPONI SOAJ 50 4 ml daily,30 (Use Diclofenac w/ NF
MG/0.5ML days retail,30 Misoprostol)
days mail); SP CELEBREX CAPS (Use NF PA
PA; QL(0.357 Celecoxib)
SIMPONI SOSY 100 4 ml daily,30 PA
MG/ML days retail,30 celecoxib caps 1
days mail); SP CHILDRENS ADVIL SUSP
SIMPONI SOSY 50 NF RX/OTC
4 PA; SP (Use Ibuprofen)
MG/0.5ML CHILDRENS MOTRIN NF RX/OTC
Antirheumatic - Enzyme Inhibitors SUSP (Use Ibuprofen)
PA; QL(2 ea DAYPRO TABS (Use NF
daily,30 days Oxaprozin)
XELJANZ TABS 4
retail,30 days
mail); SP diclofenac potassium tabs 1
Antirheumatic Antimetabolites diclofenac sodium tb24 or 1
100 mg
PA; QL(1.714
ea daily,30 diclofenac sodium tbec or 1
RHEUMATREX TABS 4
days retail,30 25 mg, 50 mg, 75 mg
days mail); SP diclofenac w/ misoprostol 1
tbec
Gold Compounds
EC-NAPROSYN TBEC 500 NF
RIDAURA CAPS 3 QL(3 ea daily) MG (Use Naproxen)
etodolac caps 200 mg, 300 1
Interleukin-1 Blockers mg
PA; QL(0.286 etodolac tabs 400 mg, 500
ea daily,30 1
ARCALYST SOLR 4 mg
days retail,30
days mail); SP FELDENE CAPS (Use NF
Piroxicam)
Interleukin-1 Receptor Antagonist (IL-1Ra) fenoprofen calcium tabs ST; QL(4 ea
1
KINERET SOSY 4 PA; SP 600 mg daily)

Interleukin-6 Receptor Inhibitors flurbiprofen tabs 1


ACTEMRA SOLN IV 80 PA; SP ibuprofen susp 100 mg/5ml 1 RX/OTC
MG/4ML, 200 MG/10ML, 4
400 MG/20ML ibuprofen tabs 400 mg, 600 1
PA; QL(0.129 mg, 800 mg
ACTEMRA SOSY SC 162 4 ml daily,30 indomethacin caps 1
MG/0.9ML days retail,30
days mail); SP
indomethacin cpcr 1
Nonsteroidal Anti-inflammatory Agents (NSAIDs)
ketoprofen caps 50 mg, 75 1
ANAPROX DS TABS (Use NF mg
Naproxen Sodium)
ketorolac tromethamine 1 QL(0.667 ea
ARTHROTEC 50 TBEC tabs or 10 mg daily)
(Use Diclofenac w/ NF
Misoprostol) LODINE TABS (Use NF
Etodolac)
Ambetter Formulary Updated April 01, 2018

4
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
MECLOFENAMATE 1 ARAVA TABS (Use NF QL(1 ea daily)
SODIUM CAPS 50 MG Leflunomide)
ST; QL(6 ea leflunomide tabs 1 QL(1 ea daily)
mefenamic acid caps 1
daily)
meloxicam tabs 1 QL(1 ea daily) Selective Costimulation Modulators
ORENCIA SOLR IV 250 4 PA; SP
MOBIC SUSP 7.5 MG/5ML 1 MG
PA; QL(0.143
MOBIC TABS 15 MG, 7.5 NF QL(1 ea daily) ORENCIA SOSY SC 125
MG (Use Meloxicam) 4 ml daily,30
MG/ML days retail,30
nabumetone tabs 1 days mail); SP
ORENCIA SOSY SC 50 4 PA; QL(0.143
NAPROSYN SUSP 125 1 PA MG/0.4ML, 87.5 MG/0.7ML ml daily)
MG/5ML (Use Naproxen)
NAPROSYN TABS 500 Soluble Tumor Necrosis Factor Receptor Agents
NF PA; QL(30
MG (Use Naproxen)
naproxen sodium tabs 550 ENBREL MINI SOCT 4 days retail,30
1 days mail)
mg
NAPROXEN SUSP 125 PA PA; QL(0.286
1
MG/5ML ENBREL SOLR 25 MG 4 ea daily,30
days retail,30
naproxen susp 125 mg/5ml 1 PA days mail); SP
PA; QL(0.146
naproxen tabs 250 mg, 375 ENBREL SOSY 25
mg, 500 mg 1 4 ml daily,30
MG/0.5ML days retail,30
naproxen tbec 500 mg 1 days mail); SP
PA; QL(0.28 ml
oxaprozin tabs 1 ENBREL SOSY 50 MG/ML 4 daily,30 days
retail,30 days
piroxicam caps 1 mail); SP
PONSTEL CAPS (Use PA; QL(0.14 ml
NF ST; QL(6 ea ENBREL SURECLICK
Mefenamic Acid) daily) 4 daily,30 days
SOAJ retail,30 days
sulindac tabs 1 mail); SP
TOLMETIN SODIUM ANALGESICS - NonNarcotic - Drugs to Treat
1 Pain, Muscle and Joint Conditions
CAPS 400 MG
tolmetin sodium caps 400 Analgesic Combinations
1
mg butalbital-acetaminophen 1
TOLMETIN SODIUM TABS tabs 325mg-50mg
1
200 MG, 600 MG butalbital-acetaminophen- 1
Phosphodiesterase 4 (PDE4) Inhibitors caffeine caps
butalbital-acetaminophen-
OTEZLA TABS 4 PA caffeine tabs 1
PA butalbital-aspirin-caffeine 1
OTEZLA TBPK 4 caps
Pyrimidine Synthesis Inhibitors

Ambetter Formulary Updated April 01, 2018

5
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ESGIC TABS (Use DILAUDID LIQD OR 1
Butalbital-Acetaminophen- NF MG/ML (Use NF
Caffeine) Hydromorphone HCl)
FIORICET CAPS (Use DILAUDID TABS OR 2 QL(8 ea daily)
Butalbital-Acetaminophen- NF MG, 4 MG, 8 MG (Use NF
Caffeine) Hydromorphone HCl)
FIORINAL CAPS (Use NF DILAUDID-HP SOLN (Use NF
Butalbital-Aspirin-Caffeine) Hydromorphone HCl)
Salicylates DOLOPHINE TABS 10 MG NF QL(10 ea daily)
AL; At least 45 (Use Methadone HCl)
aspirin chew or 81 mg 0 yrs old - Up to DOLOPHINE TABS 5 MG NF QL(4 ea daily)
79 yrs old (Use Methadone HCl)
AL; At least 45 DURAGESIC PT72 (Use NF QL(0.34 ea
ASPIRIN LOW DOSE Fentanyl) daily)
0 yrs old - Up to
TABS 79 yrs old
EMBEDA CPCR 3 PA; QL(2 ea
AL; At least 45 daily)
aspirin tabs or 325 mg 0 yrs old - Up to EXALGO T24A 32 MG
79 yrs old 2 PA; QL(1 ea
(Use Hydromorphone HCl) daily)
AL; At least 45 EXALGO T24A 8 MG, 12 PA; QL(2 ea
aspirin tbec or 81 mg 0 yrs old - Up to MG, 16 MG (Use NF daily)
79 yrs old Hydromorphone HCl)
diflunisal tabs 1 fentanyl citrate lpop bu 200 PA; QL(4 ea
mcg, 400 mcg, 600 mcg, 1 daily)
DISALCID TABS (Use 800 mcg, 1200 mcg, 1600
NF mcg
Salsalate)
salsalate tabs 1 fentanyl pt72 12 mcg/hr, 25 QL(0.34 ea
mcg/hr, 50 mcg/hr, 75 1 daily)
ANALGESICS - OPIOID - Drugs to Treat Pain, mcg/hr, 100 mcg/hr
Muscle and Joint Conditions hydromorphone hcl liqd or 1
1 mg/ml
Opioid Agonists
hydromorphone hcl soln ij
ACTIQ LPOP (Use NF PA; QL(4 ea 10 mg/ml, 50 mg/5ml, 500 1
Fentanyl Citrate) daily) mg/50ml
codeine sulfate tabs 15 mg, 1 hydromorphone hcl t24a or PA; QL(1 ea
30 mg, 60 mg 1
32 mg daily)
CODEINE SULFATE TABS hydromorphone hcl t24a or PA; QL(2 ea
15 MG, 30 MG, 60 MG 1 1
8mg, 8 mg, 12 mg, 16 mg daily)
(Use Codeine Sulfate)
hydromorphone hcl tabs or 1 QL(8 ea daily)
DEMEROL SOLN IJ 25 2 mg, 4 mg, 8 mg
MG/ML, 50 MG/ML, 100 NF
MG/ML (Use Meperidine KADIAN CP24 20 MG, 30 PA; QL(2 ea
HCl) MG, 50 MG, 60 MG, 80 NF daily)
MG, 100 MG (Use
DEMEROL TABS OR 50 QL(6 ea daily) Morphine Sulfate)
MG, 100 MG (Use NF
Meperidine HCl) LEVORPHANOL 1
TARTRATE TABS

Ambetter Formulary Updated April 01, 2018

6
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
meperidine hcl soln ij 25 morphine sulfate tbcr or 15 QL(2 ea daily)
mg/ml, 50 mg/ml, 100 1 mg, 30 mg, 60 mg, 100 mg, 1
mg/ml 200 mg
MEPERIDINE HCL SOLN 1 QL(500 ml per MS CONTIN TBCR (Use NF QL(2 ea daily)
OR 50 MG/5ML fill retail) Morphine Sulfate)
meperidine hcl tabs or 50 1 QL(6 ea daily)
NUCYNTA ER TB12 2 PA; QL(2 ea
mg, 100 mg daily)
methadone hcl conc or 10 1 QL(10 ml daily)
NUCYNTA TABS 2 PA; QL(6 ea
mg/ml daily)
methadone hcl soln ij 10 1 OPANA TABS OR 5 MG, PA; QL(12 ea
mg/ml 10 MG (Use Oxymorphone NF daily)
METHADONE HCL SOLN HCl)
IJ 10 MG/ML (Use 1 OXYCODONE HCL ER 2 PA; QL(2 ea
Methadone HCl) T12A daily)
methadone hcl soln or 10 1 QL(50 ml daily) oxycodone hcl tabs 5 mg, QL(12 ea daily)
mg/5ml 10 mg, 15 mg, 20 mg, 30 1
METHADONE HCL SOLN QL(50 ml daily) mg
OR 10 MG/5ML (Use 1 2 PA; QL(2 ea
OXYCONTIN T12A
Methadone HCl) daily)
methadone hcl soln or 5 1 QL(100 ml oxymorphone hcl tabs 5 1 PA; QL(12 ea
mg/5ml daily) mg, 10 mg daily)
METHADONE HCL SOLN QL(100 ml oxymorphone hcl tb12 40 3 PA; QL(4 ea
OR 5 MG/5ML (Use 1 daily) mg daily)
Methadone HCl) oxymorphone hcl tb12 5 PA; QL(2 ea
methadone hcl tabs or 10 1 QL(10 ea daily) mg, 10 mg, 15 mg, 20 mg, 3 daily)
mg 30 mg, 7.5 mg
methadone hcl tabs or 5 1 QL(4 ea daily) OXYMORPHONE PA; QL(4 ea
mg HYDROCHLORIDE ER 3 daily)
methadone hcl tbso or 40 QL(2 ea daily) TB12 40 MG
1
mg OXYMORPHONE PA; QL(2 ea
METHADOSE CONC (Use QL(10 ml daily) HYDROCHLORIDE ER daily)
1 TB12 5 MG, 10 MG, 15 3
Methadone HCl)
MG, 20 MG, 30 MG, 7.5
METHADOSE SUGAR- QL(10 ml daily) MG
FREE CONC (Use 1
Methadone HCl) ROXICODONE TABS (Use NF QL(12 ea daily)
Oxycodone HCl)
morphine sulfate cp24 or PA; QL(2 ea
20 mg, 30 mg, 50 mg, 60 1 daily) tramadol hcl tabs 50 mg 1 QL(8 ea daily)
mg, 80 mg, 100 mg
morphine sulfate soln ij 0.5 tramadol hcl tb24 100 mg, 1 QL(1 ea daily)
1 200 mg, 300 mg
mg/ml, 1 mg/ml
morphine sulfate soln or 10 QL(100 ml ULTRAM ER TB24 (Use NF QL(1 ea daily)
1 Tramadol HCl)
mg/5ml daily)
morphine sulfate soln or 20 QL(50 ml daily) ULTRAM TABS (Use NF QL(8 ea daily)
1 Tramadol HCl)
mg/5ml
MORPHINE SULFATE QL(6 ea daily) PA; QL(2 ea
1 ZOHYDRO ER C12A 3
TABS OR 15 MG, 30 MG daily)
Opioid Combinations
Ambetter Formulary Updated April 01, 2018

7
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
acetaminophen w/ codeine 1 QL(75 ml daily) hydrocodone-ibuprofen PA
soln 120mg/5ml-12mg/5ml tabs 200mg-5mg, 200mg- 1
acetaminophen w/ codeine 10mg
1 QL(13 ea daily)
tabs 300mg-15mg hydrocodone-ibuprofen 1 QL(5 ea daily)
acetaminophen w/ codeine tabs 200mg-7.5mg
1 QL(12 ea daily)
tabs 300mg-30mg IBUDONE TABS (Use NF PA
acetaminophen w/ codeine Hydrocodone-Ibuprofen)
1 QL(6 ea daily)
tabs 300mg-60mg LORTAB ELIX 2
ACETAMINOPHEN/CAFFE
INE/DIHYDROCODEINE 1 NORCO TABS (Use QL(12 ea daily)
CAPS Hydrocodone- NF
butalbital-acetaminophen- Acetaminophen)
caffeine w/ codeine caps 1 oxycodone w/ QL(12 ea daily)
300mg-50mg-40mg-30mg acetaminophen tabs 5mg- 1
butalbital-acetaminophen- QL(6 ea daily) 325mg, 10mg-325mg,
caffeine w/ codeine caps 1 7.5mg-325mg
325mg-50mg-40mg-30mg OXYCODONE/ACETAMIN 2
butalbital-aspirin-caffeine OPHEN SOLN
1 QL(6 ea daily) OXYCODONE/IBUPROFE QL(1 ea daily)
w/cod caps 1
FIORICET/CODEINE N TABS
CAPS (Use Butalbital- PERCOCET TABS 5MG- QL(12 ea daily)
NF 325MG, 10MG-325MG,
Acetaminophen-Caffeine
w/ Codeine) 7.5MG-325MG (Use NF
FIORINAL/CODEINE #3 QL(6 ea daily) Oxycodone w/
CAPS (Use Butalbital- NF Acetaminophen)
Aspirin-Caffeine w/Cod) REPREXAIN TABS (Use NF PA
HYCET SOLN (Use QL(180 ml Hydrocodone-Ibuprofen)
Hydrocodone- NF daily) tramadol-acetaminophen 1 QL(8 ea daily)
Acetaminophen) tabs
hydrocodone- TREZIX CAPS 3 PA
acetaminophen soln 1
10mg/15ml-325mg/15ml TYLENOL/CODEINE #3 QL(12 ea daily)
hydrocodone- QL(180 ml TABS (Use Acetaminophen NF
acetaminophen soln daily) w/ Codeine)
2.5mg/5ml-108mg/5ml, 1 TYLENOL/CODEINE #4 QL(6 ea daily)
5mg/10ml-217mg/10ml, TABS (Use Acetaminophen NF
7.5mg/15ml-325mg/15ml w/ Codeine)
hydrocodone- ULTRACET TABS (Use NF QL(8 ea daily)
acetaminophen tabs 1 Tramadol-Acetaminophen)
2.5mg-325mg VICOPROFEN TABS (Use NF QL(5 ea daily)
hydrocodone- QL(13 ea daily) Hydrocodone-Ibuprofen)
acetaminophen tabs 5mg- 1 XODOL TABS (Use QL(13 ea daily)
300mg, 10mg-300mg, Hydrocodone- NF
7.5mg-300mg Acetaminophen)
hydrocodone- QL(12 ea daily) Opioid Partial Agonists
acetaminophen tabs 5mg- 1
325mg, 10mg-325mg, BUNAVAIL FILM 3 PA
7.5mg-325mg
Ambetter Formulary Updated April 01, 2018

8
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
BUPRENEX SOLN (Use NF METHITEST TABS 3
Buprenorphine HCl)
buprenorphine hcl soln ij 1 testosterone cypionate soln 1
0.3 mg/ml
buprenorphine hcl subl sl 2 PA; QL(3 ea testosterone enanthate 1
1 soln
mg, 8 mg daily)
buprenorphine hcl- PA; QL(3 ea ANORECTAL AGENTS - Rectal Drugs to Treat
3 Pain, Swelling and Itching
naloxone hcl dihydrate subl daily)
PA; QL(0.143 Intrarectal Steroids
BUPRENORPHINE PTWK 3
ea daily) CORTENEMA ENEM (Use
butorphanol tartrate soln ij 1 Hydrocortisone NF
2 mg/ml (Intrarectal))
butorphanol tartrate soln na 1 PA hydrocortisone (intrarectal)
10 mg/ml 1
enem
PA; QL(0.143 UCERIS FOAM RE 2
BUTRANS PTWK 3
ea daily) 4 PA
MG/ACT
nalbuphine hcl soln 1 QL(8 ml daily) Rectal Steroids
pentazocine w/ naloxone ANUSOL-HC CREA (Use NF
tabs 1 Hydrocortisone (Rectal))
SUBOXONE FILM 4MG- PA; QL(3 ea hydrocortisone (rectal) crea 1
3
1MG, 2MG-0.5MG daily)
hydrocortisone acetate 1
SUBOXONE FILM 8MG- 3 PA; QL(2 ea (rectal) supp
2MG, 12MG-3MG daily)
PROCTOCORT CREA
TALWIN SOLN 3 (Use Hydrocortisone NF
(Rectal))
ANDROGENS-ANABOLIC - Drugs to Regulate PROCTOCORT SUPP
Hormones (Use Hydrocortisone NF
Anabolic Steroids Acetate (Rectal))
ANADROL-50 TABS 3 Vasodilating Agents

OXANDRIN TABS (Use RECTIV OINT 3


NF
Oxandrolone)
ANTHELMINTICS - Drugs to Treat Worm
oxandrolone tabs 1 Infections
Anthelmintics
Androgens
PA; QL(1 ea ALBENZA TABS 3
ANDRODERM PT24 2
daily)
BILTRICIDE TABS 3
ANDROXY TABS 3
EMVERM CHEW 1
danazol caps 1
DEPO-TESTOSTERONE ivermectin tabs 1
SOLN (Use Testosterone NF STROMECTOL TABS (Use
Cypionate) NF
Ivermectin)

Ambetter Formulary Updated April 01, 2018

9
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ANTI-INFECTIVE AGENTS - MISC. - Drugs to sulfamethoxazole- 1
Treat Bacterial Infections trimethoprim soln
Anti-infective Agents - Misc.
sulfamethoxazole- 1
trimethoprim susp
AZACTAM SOLR (Use
Aztreonam) NF sulfamethoxazole- 1
trimethoprim tabs
AZACTAMIN ISO-
OSMOTIC DEXTROSE 3 Antiprotozoal Agents
SOLN ALINIA SUSR 2
aztreonam solr 1
ALINIA TABS 2
bacitracin solr im 50000 3
unit atovaquone susp or 1
PA; QL(3 ml
daily,30 days MEPRON SUSP (Use NF
CAYSTON SOLR 4
retail,30 days Atovaquone)
mail); SP Carbapenems
FLAGYL TABS 250 MG,
500 MG (Use NF imipenem-cilastatin solr 1
Metronidazole)
INVANZ SOLR IJ 3
metronidazole tabs or 250 1
mg, 500 mg meropenem solr 1
NEBUPENT SOLR 3 MERREM SOLR (Use NF
Meropenem)
PENTAM 300 SOLR 3
PRIMAXIN IV ADD-
trimethoprim tabs 1 VANTAGE SOLR (Use NF
Imipenem-Cilastatin)
QL(4 ea PRIMAXIN IV SOLR (Use
VANCOCIN HCL CAPS NF daily,40 ea per NF
(Use Vancomycin HCl) Imipenem-Cilastatin)
fill retail)
Chloramphenicols
QL(4 ea
vancomycin hcl caps or 1 daily,40 ea per CHLORAMPHENICOL PA; SP
125 mg, 250 mg fill retail) SODIUM SUCCINATE 4
SOLR
vancomycin hcl solr iv 10 1
gm, 500 mg, 1000 mg Cyclic Lipopeptides
CUBICIN RF SOLR (Use NF
VIBATIV SOLR 750 MG 3 Daptomycin)
PA; AL; At least CUBICIN SOLR (Use
XIFAXAN TABS 3 NF
12 yrs old Daptomycin)
Anti-infective Misc. - Combinations daptomycin solr 1
BACTRIM DS TABS (Use
Sulfamethoxazole- NF Glycylcyclines
Trimethoprim)
tigecycline solr 1
BACTRIM TABS (Use
Sulfamethoxazole- NF TIGECYCLINE SOLR 3
Trimethoprim)

Ambetter Formulary Updated April 01, 2018

10
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
TYGACIL SOLR (Use 3 linezolid susr or 100 1
Tigecycline) mg/5ml
Ketolides PA; QL(2 ea
daily,14 days
QL(2 ea linezolid tabs or 600 mg 1
retail,14 days
KETEK TABS 3 daily,20 ea per mail)
fill retail)
SIVEXTRO TABS OR 3 PA
Leprostatics
dapsone tabs 3 ZYVOX SUSR OR 100 NF
MG/5ML (Use Linezolid)
Lincosamides PA; QL(2 ea
CLEOCIN CAPS OR 75 ZYVOX TABS OR 600 MG NF daily,14 days
MG, 150 MG, 300 MG (Use NF (Use Linezolid) retail,14 days
Clindamycin HCl) mail)
CLEOCIN PEDIATRIC Polymyxins
GRANULES SOLR (Use NF
Clindamycin Palmitate polymyxin b sulfate solr 1
Hydrochloride)
ANTIANGINAL AGENTS - Drugs to Treat Chest
CLEOCIN PHOSPHATE Pain
SOLN IJ 300 MG/2ML, 600
MG/4ML, 900 MG/6ML NF Antianginals-Other
(Use Clindamycin
Phosphate) RANEXA TB12 1000 MG 2
CLEOCIN PHOSPHATE RANEXA TB12 500 MG 2 QL(3 ea daily)
SOLN IV 300 MG/2ML 1
(Use Clindamycin Nitrates
Phosphate) ISORDIL TITRADOSE
CLEOCIN PHOSPHATE TABS 5 MG (Use NF
SOLN IV 600 MG/4ML, 900 NF Isosorbide Dinitrate)
MG/6ML (Use Clindamycin ISOSORBIDE DINITRATE
Phosphate) ER TBCR
1
clindamycin hcl caps 1
isosorbide dinitrate tabs 1
clindamycin palmitate 1
hydrochloride solr isosorbide mononitrate tabs 1
clindamycin phosphate isosorbide mononitrate
soln ij 150 mg/ml, 300 1
1 tb24
mg/2ml, 600 mg/4ml, 900
mg/6ml, 9000 mg/60ml NITRO-BID OINT 3
clindamycin phosphate NITRO-DUR PT24 0.1
soln iv 150 mg/ml, 300 1 MG/HR, 0.2 MG/HR, 0.4
mg/2ml, 600 mg/4ml, 900 2
MG/HR, 0.6 MG/HR (Use
mg/6ml Nitroglycerin)
LINCOCIN SOLN (Use NF nitroglycerin cpcr or 9 mg, QL(4 ea daily)
Lincomycin HCl) 1
2.5 mg, 6.5 mg
lincomycin hcl soln 1 nitroglycerin pt24 td 0.1
mg/hr, 0.2 mg/hr, 0.4 1
Oxazolidinones mg/hr, 0.6 mg/hr
Ambetter Formulary Updated April 01, 2018

11
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
NITROGLYCERIN SOLN 1 diazepam tabs or 2 mg, 5 1 QL(4 ea daily)
IV 5 MG/ML mg, 10 mg
nitroglycerin subl sl 0.3 mg, 1 lorazepam conc or 2 mg/ml 1
0.4 mg, 0.6 mg
NITROSTAT SUBL (Use lorazepam tabs or 0.5 mg, 1 QL(3 ea daily)
2 2 mg
Nitroglycerin)
lorazepam tabs or 1 mg 1 QL(4 ea daily)
ANTIANXIETY AGENTS - Drugs to Treat Anxiety
Antianxiety Agents - Misc. oxazepam caps 1
buspirone hcl tabs 10 mg, 1 TRANXENE T TABS (Use
15 mg, 30 mg, 7.5 mg NF
Clorazepate Dipotassium)
buspirone hcl tabs 5 mg QL(6 ea daily) VALIUM TABS (Use
1 NF QL(4 ea daily)
Diazepam)
hydroxyzine hcl soln im 50 1
mg/ml XANAX TABS (Use NF QL(4 ea daily)
Alprazolam)
hydroxyzine hcl syrp or 10 1
mg/5ml XANAX XR TB24 (Use NF
Alprazolam)
hydroxyzine hcl tabs or 10 1
mg, 25 mg, 50 mg ANTIARRHYTHMICS - Drugs to treat abnormal
HYDROXYZINE heart rhythms
1
PAMOATE CAPS 100 MG Antiarrhythmics Type I-A
hydroxyzine pamoate caps 1 disopyramide phosphate
25 mg, 50 mg 1
caps
meprobamate tabs 1 NORPACE CAPS (Use NF
Disopyramide Phosphate)
VISTARIL CAPS (Use NF procainamide hcl soln 500
Hydroxyzine Pamoate) 1
mg/ml
Benzodiazepines QUINIDINE SULFATE ER 1
alprazolam tabs 0.25 mg, QL(4 ea daily) TBCR
1
0.5 mg, 1 mg, 2 mg QUINIDINE SULFATE 1
alprazolam tb24 0.5 mg, 1 TABS
1
mg, 2 mg, 3 mg Antiarrhythmics Type I-B
alprazolam tbdp 0.25 mg, 1
0.5 mg, 1 mg, 2 mg mexiletine hcl caps 1
ATIVAN TABS OR 0.5 MG, NF QL(3 ea daily) Antiarrhythmics Type I-C
2 MG (Use Lorazepam)
ATIVAN TABS OR 1 MG flecainide acetate tabs 1
NF QL(4 ea daily)
(Use Lorazepam)
propafenone hcl cp12 1
chlordiazepoxide hcl caps 1
clorazepate dipotassium propafenone hcl tabs 1
1
tabs RYTHMOL SR CP12 (Use NF
diazepam conc or 5 mg/ml 1 Propafenone HCl)
RYTHMOL TABS (Use NF
DIAZEPAM SOLN OR 1 1 Propafenone HCl)
MG/ML

Ambetter Formulary Updated April 01, 2018

12
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
Antiarrhythmics Type III SINGULAIR CHEW 4 MG, QL(1 ea daily)
amiodarone hcl soln iv 50 5 MG (Use Montelukast NF
mg/ml, 150 mg/3ml 1 Sodium)
amiodarone hcl tabs or 100 SINGULAIR PACK 4 MG NF PA; QL(1 ea
mg, 200 mg, 400 mg 1 (Use Montelukast Sodium) daily)
SINGULAIR TABS 10 MG NF QL(1 ea daily)
dofetilide caps 1 (Use Montelukast Sodium)
zafirlukast tabs 1 QL(2 ea daily)
MULTAQ TABS 3
TIKOSYN CAPS (Use zileuton tb12 1 QL(4 ea daily)
NF
Dofetilide)
ZYFLO CR TB12 (Use 3 QL(4 ea daily)
ANTIASTHMATIC AND BRONCHODILATOR Zileuton)
AGENTS - Drugs to Treat Lung Conditions
Selective Phosphodiesterase 4 (PDE4) Inhibitors
Anti-Inflammatory Agents
QL(8 ml daily) DALIRESP TABS 3
cromolyn sodium nebu 1
Steroid Inhalants
Antiasthmatic - Monoclonal Antibodies
ALVESCO AERS 3 PA
PA; QL(0.214
XOLAIR SOLR 4 ea daily,30 ASMANEX TWISTHALER
days retail,30 120 METERED DOSES 2
days mail); SP AEPB
Bronchodilators - Anticholinergics ASMANEX TWISTHALER
QL(0.067 gm 14 METERED DOSES 2
ATROVENT HFA AERS 3 AEPB
daily)
ASMANEX TWISTHALER
INCRUSE ELLIPTA AEPB 2 30 METERED DOSES 2
QL(15 ml daily) AEPB
ipratropium bromide soln 1
ASMANEX TWISTHALER
SPIRIVA HANDIHALER QL(1 ea daily) 60 METERED DOSES 2
2 AEPB
CAPS
SPIRIVA RESPIMAT ASMANEX TWISTHALER
2 7 METERED DOSES 2
AERS
TUDORZA PRESSAIR AEPB
3 budesonide (inhalation) PA; QL(4 ml
AEPB 1
susp daily)
Leukotriene Modulators
ACCOLATE TABS (Use FLOVENT DISKUS AEPB 3
NF QL(2 ea daily)
Zafirlukast)
montelukast sodium chew QL(1 ea daily) FLOVENT HFA AERO 3
1
4 mg, 5 mg PULMICORT FLEXHALER
montelukast sodium pack 4 PA; QL(1 ea 2
1 AEPB
mg daily) PULMICORT SUSP (Use
montelukast sodium tabs QL(1 ea daily) NF PA; QL(4 ml
1 Budesonide (Inhalation)) daily)
10 mg
QVAR AERS 2

Ambetter Formulary Updated April 01, 2018

13
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
QVAR REDIHALER AERB 2 1 rtl pack lmt
PROAIR HFA AERS 2 per fill,2 rtl
Sympathomimetics MAX fill,30 rtl
day(s) supply,
ADVAIR DISKUS AEPB 2 1 rtl pack lmt
ADVAIR HFA AERO 2 PROVENTIL HFA AERS 2 per fill,2 rtl
MAX fill,30 rtl
albuterol sulfate nebu in day(s) supply,
1 SEREVENT DISKUS
0.5 % 2
albuterol sulfate nebu in QL(15 ml daily) AEPB
0.63 mg/3ml, 0.083 %, 1.25 1 STRIVERDI RESPIMAT 3 PA
mg/3ml AERS
albuterol sulfate syrp or 2 1 SYMBICORT AERO 2
mg/5ml
albuterol sulfate tabs or 2 1 terbutaline sulfate soln 1
mg, 4 mg
albuterol sulfate tb12 or 4 terbutaline sulfate tabs 1
1
mg, 8 mg UTIBRON NEOHALER PA; QL(2 ea
PA 3
ANORO ELLIPTA AEPB 3 CAPS daily)
1 rtl pack lmt
ARCAPTA NEOHALER 2 PA per fill,2 rtl
CAPS VENTOLIN HFA AERS 2
MAX fill,30 rtl
BREO ELLIPTA AEPB 2 day(s) supply,
VOSPIRE ER TB12 (Use NF
PA; QL(4 ml Albuterol Sulfate)
BROVANA NEBU 3
daily)
XOPENEX PA
epinephrine hcl soln 1 1 CONCENTRATE NEBU NF
mg/ml (Use Levalbuterol HCl)
ipratropium-albuterol soln 1 QL(18 ml daily) PA; Limit 2
levalbuterol hcl nebu 0.31 PA; QL(12 ml XOPENEX HFA AERO 3 inhalers per
month;QL(1 gm
mg/3ml, 0.63 mg/3ml, 1.25 1 daily) daily)
mg/3ml
XOPENEX NEBU (Use NF PA; QL(12 ml
levalbuterol hcl nebu 1.25 1 PA Levalbuterol HCl) daily)
mg/0.5ml
Xanthines
PA; Limit 2
LEVALBUTEROL 3 inhalers per aminophylline soln 1
TARTRATE HFA AERO month;QL(1 gm
daily) ELIXOPHYLLIN ELIX 1
METAPROTERENOL
SULFATE SYRP OR 10 1 theophylline tb12 100 mg, 1
MG/5ML 200 mg, 300 mg, 450 mg
METAPROTERENOL theophylline tb24 400 mg, 1
SULFATE TABS OR 10 1 600 mg
MG, 20 MG ANTICOAGULANTS - Blood Thinners
Coumarin Anticoagulants

Ambetter Formulary Updated April 01, 2018

14
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
COUMADIN TABS (Use 2 QL(5 ml per 30
Warfarin Sodium) fondaparinux sodium soln 4 days retail,5 ml
2.5 mg/0.5ml, 7.5 mg/0.6ml per 30 days
warfarin sodium tabs 1 mail); SP
Direct Factor Xa Inhibitors QL(4 ml per 30
fondaparinux sodium soln 5 4 days retail,4 ml
ELIQUIS STARTER PACK 2 QL(2.47 ea mg/0.4ml per 30 days
TABS daily) mail); SP
QL(2.47 ea FRAGMIN SOLN 10000 PA; SP
ELIQUIS TABS 2
daily) UNIT/ML, 2500
XARELTO TABS 10 MG, 2 QL(1 ea daily) UNIT/0.2ML, 5000
20 MG UNIT/0.2ML, 7500 4
QL(2 ea daily) UNIT/0.3ML, 12500
XARELTO TABS 15 MG 2 UNIT/0.5ML, 15000
Heparins And Heparinoid-Like Agents UNIT/0.6ML, 18000
UNT/0.72ML
QL(7 ml per 30
ARIXTRA SOLN 10 heparin sod (porcine) in
MG/0.8ML (Use NF days retail,7 ml d5w soln 1
per 30 days
Fondaparinux Sodium) mail); SP heparin sodium (porcine)
ARIXTRA SOLN 2.5 QL(5 ml per 30 soln 5000 unit/ml, 10000 1
MG/0.5ML, 7.5 MG/0.6ML unit/ml, 20000 unit/ml
NF days retail,5 ml HEPARIN SODIUM/NACL
(Use Fondaparinux per 30 days 1
Sodium) mail); SP 0.45% SOLN
QL(4 ml per 30 LOVENOX SOLN IJ 300 QL(6 ml daily)
ARIXTRA SOLN 5 MG/3ML (Use Enoxaparin NF
MG/0.4ML (Use NF days retail,4 ml Sodium)
per 30 days
Fondaparinux Sodium) mail); SP LOVENOX SOLN SC 100 QL(2 ml daily)
enoxaparin sodium soln ij MG/ML, 150 MG/ML (Use NF
4 QL(6 ml daily) Enoxaparin Sodium)
300 mg/3ml
enoxaparin sodium soln sc QL(2 ml daily) QL(0.6 ml
4 LOVENOX SOLN SC 30
100 mg/ml, 150 mg/ml MG/0.3ML (Use NF daily,30 days
QL(0.6 ml retail,30 days
Enoxaparin Sodium) mail); SP
enoxaparin sodium soln sc 4 daily,30 days
30 mg/0.3ml retail,30 days LOVENOX SOLN SC 40 QL(0.8 ml
mail); SP MG/0.4ML (Use NF daily,30 day(s)
QL(0.8 ml Enoxaparin Sodium) limit); SP
enoxaparin sodium soln sc 4 daily,30 day(s) LOVENOX SOLN SC 60 QL(1.2 ml
40 mg/0.4ml limit); SP MG/0.6ML (Use NF daily,30 day(s)
QL(1.2 ml Enoxaparin Sodium) limit); SP
enoxaparin sodium soln sc 4 daily,30 day(s) LOVENOX SOLN SC 80 QL(1.6 ml
60 mg/0.6ml limit); SP MG/0.8ML, 120 MG/0.8ML NF daily)
enoxaparin sodium soln sc QL(1.6 ml (Use Enoxaparin Sodium)
4
80 mg/0.8ml, 120 mg/0.8ml daily) Thrombin Inhibitors
QL(7 ml per 30 PRADAXA CAPS 75 MG, QL(2 ea daily)
fondaparinux sodium soln days retail,7 ml 2
4 150 MG
10 mg/0.8ml per 30 days
mail); SP ANTICONVULSANTS - Drugs to Treat Seizures

Ambetter Formulary Updated April 01, 2018

15
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
AMPA Glutamate Receptor Antagonists carbamazepine tb12 200 1 QL(6 ea daily)
FYCOMPA TABS 2 MG, 4 PA
mg
MG, 6 MG, 8 MG, 10 MG, 3 CARBATROL CP12 100 NF
12 MG MG (Use Carbamazepine)
Anticonvulsants - Benzodiazepines CARBATROL CP12 200 NF QL(6 ea daily)
MG (Use Carbamazepine)
clonazepam tabs 0.5 mg, 1 1
mg, 2 mg CARBATROL CP12 300 NF QL(4 ea daily)
MG (Use Carbamazepine)
DIASTAT ACUDIAL GEL 3 gabapentin caps 100 mg, 1
300 mg, 400 mg
DIASTAT PEDIATRIC GEL 3 gabapentin soln 250 QL(60 ml daily)
1
DIAZEPAM GEL RE 10 mg/5ml, 300 mg/6ml
3 gabapentin tabs 600 mg,
MG, 20 MG, 2.5 MG 1
DIAZEPAM RECTAL GEL 800 mg
3 KEPPRA SOLN IV 500 QL(30 ml daily)
GEL
KLONOPIN TABS (Use MG/5ML (Use NF
NF Levetiracetam)
Clonazepam)
PA; QL(16 ml KEPPRA SOLN OR 100 QL(30 ml daily)
ONFI SUSP 2.5 MG/ML 3 MG/ML (Use NF
daily)
Levetiracetam)
PA; QL(2 ea
ONFI TABS 10 MG, 20 MG 3 KEPPRA TABS OR 1000
daily) NF QL(3 ea daily)
MG (Use Levetiracetam)
Anticonvulsants - Misc. KEPPRA TABS OR 250 QL(4 ea daily)
ST; QL(2 ea MG, 750 MG (Use NF
APTIOM TABS 3
daily) Levetiracetam)
PA; QL(80 ml KEPPRA TABS OR 500
BANZEL SUSP 40 MG/ML 2
daily) NF QL(6 ea daily)
MG (Use Levetiracetam)
PA; QL(2 ea KEPPRA XR TB24 (Use
BANZEL TABS 200 MG 2
daily) NF QL(4 ea daily)
Levetiracetam)
PA; QL(8 ea LAMICTAL CHEWABLE
BANZEL TABS 400 MG 2
daily) DISPERSIBLE CHEW (Use NF
carbamazepine chew 100 Lamotrigine)
1
mg LAMICTAL ODT TBDP 25 QL(1 ea daily)
3
carbamazepine cp12 100 MG (Use Lamotrigine)
1
mg LAMICTAL ODT TBDP 50 QL(1 ea daily)
carbamazepine cp12 200 QL(6 ea daily) MG, 100 MG, 200 MG (Use NF
1 Lamotrigine)
mg
carbamazepine cp12 300 QL(4 ea daily) LAMICTAL TABS (Use NF
1 Lamotrigine)
mg
carbamazepine susp 100 lamotrigine chew 5 mg, 25 1
1 mg
mg/5ml
carbamazepine tabs 200 lamotrigine tabs 25 mg, 1
1 100 mg, 150 mg, 200 mg
mg
carbamazepine tb12 100 QL(4 ea daily) lamotrigine tbdp 25 mg 3 QL(1 ea daily)
1
mg, 400 mg

Ambetter Formulary Updated April 01, 2018

16
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
lamotrigine tbdp 50 mg, 1 QL(1 ea daily) TEGRETOL-XR TB12 100 QL(4 ea daily)
100 mg, 200 mg MG, 400 MG (Use NF
levetiracetam soln iv 500 QL(30 ml daily) Carbamazepine)
1
mg/5ml TEGRETOL-XR TB12 200 NF QL(6 ea daily)
levetiracetam soln or 100 QL(30 ml daily) MG (Use Carbamazepine)
1
mg/ml, 500 mg/5ml TOPAMAX SPRINKLE QL(6 ea daily)
levetiracetam tabs or 1000 QL(3 ea daily) CPSP 15 MG (Use NF
1 Topiramate)
mg
levetiracetam tabs or 250 QL(4 ea daily) TOPAMAX SPRINKLE QL(8 ea daily)
1 CPSP 25 MG (Use NF
mg, 750 mg
Topiramate)
levetiracetam tabs or 500 1 QL(6 ea daily)
mg TOPAMAX TABS 100 MG NF QL(4 ea daily)
(Use Topiramate)
levetiracetam tb24 or 500 1 QL(4 ea daily)
mg, 750 mg TOPAMAX TABS 200 MG NF QL(2 ea daily)
(Use Topiramate)
LYRICA CAPS 225 MG, 2 PA; QL(2 ea
300 MG daily) TOPAMAX TABS 25 MG, NF QL(6 ea daily)
50 MG (Use Topiramate)
LYRICA CAPS 25 MG, 50 PA; QL(3 ea
MG, 75 MG, 100 MG, 150 2 daily) topiramate cpsp 15 mg 1 QL(6 ea daily)
MG, 200 MG
QL(30 ml daily) topiramate cpsp 25 mg 1 QL(8 ea daily)
LYRICA SOLN 20 MG/ML 2
MYSOLINE TABS (Use topiramate tabs 100 mg 1 QL(4 ea daily)
NF
Primidone)
topiramate tabs 200 mg 1 QL(2 ea daily)
NEURONTIN CAPS 100
MG, 300 MG, 400 MG (Use NF topiramate tabs 25 mg, 50 QL(6 ea daily)
Gabapentin) 1
mg
NEURONTIN SOLN 250 NF QL(60 ml daily) TRILEPTAL SUSP 300 QL(40 ml daily)
MG/5ML (Use Gabapentin) MG/5ML (Use NF
NEURONTIN TABS 600 Oxcarbazepine)
MG, 800 MG (Use NF TRILEPTAL TABS 150 QL(3 ea daily)
Gabapentin) MG, 300 MG (Use NF
oxcarbazepine susp 60 1 QL(40 ml daily) Oxcarbazepine)
mg/ml, 300 mg/5ml TRILEPTAL TABS 600 MG
oxcarbazepine tabs 150 QL(3 ea daily) NF QL(4 ea daily)
1 (Use Oxcarbazepine)
mg, 300 mg VIMPAT SOLN IV 200 QL(40 ml daily)
oxcarbazepine tabs 600 QL(4 ea daily) 3
1 MG/20ML
mg VIMPAT SOLN OR 10 PA; QL(40 ml
PA; QL(3 ea 3
POTIGA TABS 3 MG/ML daily)
daily) VIMPAT TABS OR 50 MG, 3 PA; QL(2 ea
primidone tabs 1 100 MG, 150 MG, 200 MG daily)
ZONEGRAN CAPS (Use NF QL(6 ea daily)
TEGRETOL SUSP (Use 2 Zonisamide)
Carbamazepine)
zonisamide caps 1 QL(6 ea daily)
TEGRETOL TABS (Use 2
Carbamazepine)
Carbamates

Ambetter Formulary Updated April 01, 2018

17
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
felbamate susp 600 1 QL(30 ml daily) PHENYTEK CAPS (Use
mg/5ml Phenytoin Sodium 2
QL(9 ea daily) Extended)
felbamate tabs 400 mg 1
phenytoin chew 1
felbamate tabs 600 mg 1 QL(6 ea daily)
phenytoin sodium extended 1
FELBATOL SUSP 600 caps
NF QL(30 ml daily)
MG/5ML (Use Felbamate)
phenytoin sodium soln 1
FELBATOL TABS 400 MG NF QL(9 ea daily)
(Use Felbamate) phenytoin susp 1
FELBATOL TABS 600 MG NF QL(6 ea daily)
(Use Felbamate) Succinimides
GABA Modulators CELONTIN CAPS 3 QL(4 ea daily)
GABITRIL TABS 2 MG, 4 NF
MG (Use Tiagabine HCl) ethosuximide caps 250 mg 1 QL(6 ea daily)
PA; QL(6 ea ethosuximide soln 250 QL(30 ml daily)
SABRIL PACK (Use daily,30 days 1
4 mg/5ml
Vigabatrin) retail,30 days
mail); SP ZARONTIN CAPS 250 MG 2 QL(6 ea daily)
(Use Ethosuximide)
PA; QL(6 ea
daily,30 days ZARONTIN SOLN 250 QL(30 ml daily)
SABRIL TABS 4 MG/5ML (Use NF
retail,30 days
mail); SP Ethosuximide)
tiagabine hcl tabs 2 mg, 4 Valproic Acid
1
mg DEPACON SOLN (Use NF
PA; QL(6 ea Valproate Sodium)
daily,30 days DEPAKENE CAPS (Use
vigabatrin pack 4
retail,30 days NF
Valproic Acid)
mail); SP DEPAKENE SOLN (Use NF
Hydantoins Valproate Sodium)
CEREBYX SOLN (Use DEPAKOTE ER TB24 (Use NF
NF Divalproex Sodium)
Fosphenytoin Sodium)
DILANTIN CAPS 100 MG DEPAKOTE TBEC (Use NF
(Use Phenytoin Sodium 2 Divalproex Sodium)
Extended) divalproex sodium tb24 250 1
DILANTIN CAPS 30 MG 2 mg, 500 mg
divalproex sodium tbec 125 1
DILANTIN INFATABS 2 mg, 250 mg, 500 mg
CHEW (Use Phenytoin)
DILANTIN-125 SUSP (Use valproate sodium soln 1
2
Phenytoin)
valproic acid caps 1
fosphenytoin sodium soln 1
ANTIDEPRESSANTS - Drugs to Treat Depression
PEGANONE TABS 3
Alpha-2 Receptor Antagonists (Tetracyclics)

Ambetter Formulary Updated April 01, 2018

18
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
mirtazapine tabs 15 mg 1 QL(3 ea daily) WELLBUTRIN SR TB12 QL(2 ea daily)
200 MG (Use Bupropion NF
QL(1.5 ea HCl)
mirtazapine tabs 30 mg 1
daily) WELLBUTRIN TABS (Use NF QL(3 ea daily)
mirtazapine tabs 45 mg, QL(1 ea daily) Bupropion HCl)
1
7.5 mg WELLBUTRIN XL TB24 QL(3 ea daily)
mirtazapine tbdp 15 mg 1 QL(3 ea daily) 150 MG (Use Bupropion NF
HCl)
QL(1.5 ea WELLBUTRIN XL TB24 QL(1 ea daily)
mirtazapine tbdp 30 mg 1
daily) 300 MG (Use Bupropion NF
HCl)
mirtazapine tbdp 45 mg 1
Monoamine Oxidase Inhibitors (MAOIs)
REMERON SOLTAB TBDP NF QL(3 ea daily)
15 MG (Use Mirtazapine) EMSAM PT24 3 QL(1 ea daily)
REMERON SOLTAB TBDP NF QL(1.5 ea QL(6 ea daily)
30 MG (Use Mirtazapine) daily) MARPLAN TABS 2
REMERON SOLTAB TBDP NF NARDIL TABS (Use
45 MG (Use Mirtazapine) NF
Phenelzine Sulfate)
REMERON TABS 15 MG NF QL(3 ea daily) PARNATE TABS (Use
(Use Mirtazapine) NF
Tranylcypromine Sulfate)
REMERON TABS 30 MG NF QL(1.5 ea
(Use Mirtazapine) daily) phenelzine sulfate tabs 1
REMERON TABS 45 MG tranylcypromine sulfate
NF QL(1 ea daily) tabs 1
(Use Mirtazapine)
Antidepressants - Misc. Selective Serotonin Reuptake Inhibitors (SSRIs)
bupropion hcl tabs 75 mg, QL(3 ea daily) CELEXA TABS 10 MG QL(4 ea daily)
1 (Use Citalopram NF
100 mg
QL(4 ea daily) Hydrobromide)
bupropion hcl tb12 100 mg 1
CELEXA TABS 20 MG QL(2 ea daily)
QL(3 ea daily) (Use Citalopram NF
bupropion hcl tb12 150 mg 1 Hydrobromide)
bupropion hcl tb12 200 mg 1 QL(2 ea daily) CELEXA TABS 40 MG QL(1 ea daily)
(Use Citalopram NF
bupropion hcl tb24 150 mg 1 QL(3 ea daily) Hydrobromide)
citalopram hydrobromide 1 QL(20 ml daily)
bupropion hcl tb24 300 mg 1 QL(1 ea daily) soln 10 mg/5ml
citalopram hydrobromide 1 QL(4 ea daily)
MAPROTILINE HCL TABS 3 tabs 10 mg
WELLBUTRIN SR TB12 QL(4 ea daily) citalopram hydrobromide 1 QL(2 ea daily)
100 MG (Use Bupropion NF tabs 20 mg
HCl) citalopram hydrobromide 1 QL(1 ea daily)
WELLBUTRIN SR TB12 QL(3 ea daily) tabs 40 mg
150 MG (Use Bupropion NF escitalopram oxalate soln 5 1 QL(20 ml daily)
HCl) mg/5ml
escitalopram oxalate tabs 1 QL(2 ea daily)
10 mg

Ambetter Formulary Updated April 01, 2018

19
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
escitalopram oxalate tabs 1 QL(1 ea daily) paroxetine hcl tb24 25 mg, 1 QL(2 ea daily)
20 mg 37.5 mg
escitalopram oxalate tabs 5 1 QL(4 ea daily) PAXIL CR TB24 12.5 MG NF QL(1 ea daily)
mg (Use Paroxetine HCl)
fluoxetine hcl caps 10 mg 1 QL(1 ea daily) PAXIL CR TB24 25 MG, QL(2 ea daily)
37.5 MG (Use Paroxetine NF
fluoxetine hcl caps 20 mg 1 QL(3 ea daily) HCl)
PAXIL SUSP 10 MG/5ML 3 QL(30 ml daily)
fluoxetine hcl caps 40 mg 1 QL(2 ea daily)
PAXIL TABS 10 MG (Use NF QL(6 ea daily)
fluoxetine hcl cpdr 90 mg 1 Paroxetine HCl)
PAXIL TABS 20 MG (Use NF QL(3 ea daily)
fluoxetine hcl soln 20 1 QL(20 ml daily) Paroxetine HCl)
mg/5ml
PAXIL TABS 30 MG (Use NF QL(2 ea daily)
fluoxetine hcl tabs 10 mg, 1 QL(1 ea daily) Paroxetine HCl)
60 mg
PAXIL TABS 40 MG (Use NF QL(1 ea daily)
fluoxetine hcl tabs 20 mg 1 QL(3 ea daily) Paroxetine HCl)
PROZAC CAPS 10 MG NF QL(1 ea daily)
FLUOXETINE HCL TABS 1 QL(1 ea daily) (Use Fluoxetine HCl)
60 MG
PROZAC CAPS 20 MG NF QL(3 ea daily)
FLUOXETINE HCL TABS QL(1 ea daily) (Use Fluoxetine HCl)
60 MG (Use Fluoxetine 1
HCl) PROZAC CAPS 40 MG NF QL(2 ea daily)
(Use Fluoxetine HCl)
fluvoxamine maleate tabs 1 QL(3 ea daily)
100 mg PROZAC WEEKLY CPDR NF
(Use Fluoxetine HCl)
fluvoxamine maleate tabs 1 QL(2 ea daily)
25 mg, 50 mg sertraline hcl conc 20 1 QL(10 ml daily)
mg/ml
LEXAPRO SOLN 5 QL(20 ml daily)
MG/5ML (Use NF sertraline hcl tabs 100 mg 1 QL(2 ea daily)
Escitalopram Oxalate)
LEXAPRO TABS 10 MG sertraline hcl tabs 25 mg, QL(4 ea daily)
NF QL(2 ea daily) 50 mg 1
(Use Escitalopram Oxalate)
LEXAPRO TABS 20 MG ZOLOFT CONC 20 MG/ML NF QL(10 ml daily)
NF QL(1 ea daily) (Use Sertraline HCl)
(Use Escitalopram Oxalate)
LEXAPRO TABS 5 MG ZOLOFT TABS 100 MG NF QL(2 ea daily)
NF QL(4 ea daily) (Use Sertraline HCl)
(Use Escitalopram Oxalate)
QL(6 ea daily) ZOLOFT TABS 25 MG, 50 NF QL(4 ea daily)
paroxetine hcl tabs 10 mg 1 MG (Use Sertraline HCl)
paroxetine hcl tabs 20 mg 1 QL(3 ea daily) Serotonin Modulators
PA; QL(1 ea
QL(2 ea daily) BRINTELLIX TABS 3
paroxetine hcl tabs 30 mg 1 daily)
NEFAZODONE HCL TABS 3
paroxetine hcl tabs 40 mg 1 QL(1 ea daily) 100 MG, 150 MG, 200 MG
paroxetine hcl tb24 12.5 QL(1 ea daily) nefazodone hcl tabs 50 mg, 3
1 250 mg
mg
trazodone hcl tabs 1

Ambetter Formulary Updated April 01, 2018

20
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
TRINTELLIX TABS 3 PA; QL(1 ea VENLAFAXINE HCL ER QL(1 ea daily)
daily) TB24 75 MG, 37.5 MG 3
VIIBRYD STARTER PACK (Use Venlafaxine HCl)
2 PA
KIT venlafaxine hcl tabs 25 mg, QL(3 ea daily)
50 mg, 75 mg, 100 mg, 1
VIIBRYD TABS 2 PA; QL(1 ea 37.5 mg
daily)
venlafaxine hcl tb24 150 1 QL(2 ea daily)
Serotonin-Norepinephrine Reuptake Inhibitors mg
CYMBALTA CPEP (Use NF QL(2 ea daily) venlafaxine hcl tb24 225 ST; QL(1 ea
Duloxetine HCl) mg 1
daily)
desvenlafaxine succinate 1 QL(4 ea daily) venlafaxine hcl tb24 75 mg, QL(1 ea daily)
tb24 100 mg 37.5 mg 1
desvenlafaxine succinate 1 QL(1 ea daily)
tb24 25 mg, 50 mg Tricyclic Agents
duloxetine hcl cpep 20 mg, 1 QL(2 ea daily) amitriptyline hcl tabs 1
30 mg, 60 mg
DULOXETINE HCL CPEP AMOXAPINE TABS 3
1
40 MG
ANAFRANIL CAPS (Use NF PA
EFFEXOR XR CP24 150 NF QL(2 ea daily) Clomipramine HCl)
MG (Use Venlafaxine HCl)
clomipramine hcl caps 1 PA
EFFEXOR XR CP24 37.5 NF QL(4 ea daily)
MG (Use Venlafaxine HCl)
EFFEXOR XR CP24 75 desipramine hcl tabs 1
NF QL(5 ea daily)
MG (Use Venlafaxine HCl)
doxepin hcl caps 1
FETZIMA CP24 3 PA
doxepin hcl conc 1
FETZIMA TITRATION 3 PA
PACK C4PK ELAVIL TABS (Use NF
PRISTIQ TB24 100 MG QL(4 ea daily) Amitriptyline HCl)
(Use Desvenlafaxine NF imipramine hcl tabs 1
Succinate)
PRISTIQ TB24 25 MG, 50 QL(1 ea daily) imipramine pamoate caps 1
MG (Use Desvenlafaxine NF
Succinate) NORPRAMIN TABS (Use NF
venlafaxine hcl cp24 150 QL(2 ea daily) Desipramine HCl)
1 nortriptyline hcl caps 10
mg 1
venlafaxine hcl cp24 37.5 QL(4 ea daily) mg, 25 mg, 50 mg, 75 mg
1 NORTRIPTYLINE HCL
mg 1
QL(5 ea daily) SOLN 10 MG/5ML
venlafaxine hcl cp24 75 mg 1
PAMELOR CAPS (Use NF
VENLAFAXINE HCL ER QL(2 ea daily) Nortriptyline HCl)
TB24 150 MG (Use 1
Venlafaxine HCl) protriptyline hcl tabs 1
VENLAFAXINE HCL ER ST; QL(1 ea SURMONTIL CAPS (Use NF
1 Trimipramine Maleate)
TB24 225 MG daily)
TOFRANIL TABS (Use NF
Imipramine HCl)

Ambetter Formulary Updated April 01, 2018

21
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
trimipramine maleate caps 1 pioglitazone hcl-glimepiride 1 QL(1 ea daily)
tabs
ANTIDIABETICS - Drugs to Regulate Blood Sugar pioglitazone hcl-metformin 1 QL(2 ea daily)
hcl tabs
Alpha-Glucosidase Inhibitors REPAGLINIDE/METFORM QL(2 ea daily)
QL(3 ea daily) IN HYDROCHLORIDE 1
acarbose tabs 1 TABS
GLYSET TABS (Use NF SYNJARDY TABS 3 PA
Miglitol)
XIGDUO XR TB24 5MG- PA
miglitol tabs 1 500MG, 10MG-500MG, 3
PRECOSE TABS (Use 5MG-1000MG, 10MG-
NF QL(3 ea daily) 1000MG
Acarbose)
Antidiabetic - Amylin Analogs Biguanides
PA; QL(0.36 ml GLUCOPHAGE TABS QL(2.5 ea
SYMLINPEN 120 SOPN 2 1000 MG (Use Metformin NF daily)
daily)
PA; QL(0.2 ml HCl)
SYMLINPEN 60 SOPN 2 GLUCOPHAGE TABS 500
daily) NF QL(5 ea daily)
MG (Use Metformin HCl)
Antidiabetic Combinations
GLUCOPHAGE TABS 850 NF QL(3 ea daily)
ACTOPLUS MET TABS QL(2 ea daily) MG (Use Metformin HCl)
(Use Pioglitazone HCl- NF
Metformin HCl) GLUCOPHAGE XR TB24 NF
(Use Metformin HCl)
DUETACT TABS (Use QL(1 ea daily)
Pioglitazone HCl- NF metformin hcl tabs 1000 1 QL(2.5 ea
Glimepiride) mg daily)
glipizide-metformin hcl tabs QL(2 ea daily) metformin hcl tabs 500 mg 1 QL(5 ea daily)
2.5mg-250mg, 2.5mg- 1
500mg metformin hcl tabs 850 mg 1 QL(3 ea daily)
glipizide-metformin hcl tabs 1 QL(4 ea daily) metformin hcl tb24 500 mg,
5mg-500mg 1
750 mg
GLUCOVANCE TABS QL(2 ea daily)
2.5MG-500MG (Use NF Diabetic Other
Glyburide-Metformin) GLUCAGEN HYPOKIT 3 QL(0.035 ea
GLUCOVANCE TABS QL(4 ea daily) SOLR daily)
5MG-500MG (Use NF GLUCAGON 3 QL(0.035 ea
Glyburide-Metformin) EMERGENCY KIT KIT daily)
glyburide-metformin tabs QL(2 ea daily) PROGLYCEM SUSP 3
2.5mg-500mg, 1.25mg- 1
250mg Dipeptidyl Peptidase-4 (DPP-4) Inhibitors
glyburide-metformin tabs QL(4 ea daily)
5mg-500mg 1 ALOGLIPTIN TABS 3 PA; QL(1 ea
daily)
PA
GLYXAMBI TABS 3 JANUVIA TABS 2 QL(1 ea daily)
INVOKAMET TABS 3 PA PA; QL(1 ea
NESINA TABS 3
daily)

Ambetter Formulary Updated April 01, 2018

22
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ONGLYZA TABS 3 QL(1 ea daily) HUMALOG MIX 75/25 3
SUSP
TRADJENTA TABS 2 QL(1 ea daily)
HUMALOG SOCT 3
Dopamine Receptor Agonists - Antidiabetic HUMALOG SOLN 3
CYCLOSET TABS 3 QL(6 ea daily) HUMULIN 70/30 KWIKPEN 3
SUPN
Incretin Mimetic Agents (GLP-1 Receptor
BYETTA SOPN 10 HUMULIN 70/30 SUSP 3
2 PA; QL(0.04 ml
MCG/0.04ML daily)
HUMULIN N KWIKPEN 3
BYETTA SOPN 5 2 PA; QL(0.08 ml SUPN
MCG/0.02ML daily)
HUMULIN N SUSP 3
TANZEUM PEN 3 PA
PA HUMULIN R SOLN 3
TRULICITY SOPN 3
HUMULIN R U-500 3
PA; QL(0.3 ml (CONCENTRATED) SOLN
VICTOZA SOPN 2
daily)
LEVEMIR FLEXTOUCH 2
Insulin Sensitizing Agents SOPN
ACTOS TABS (Use NF QL(1 ea daily) LEVEMIR SOLN 2
Pioglitazone HCl)
QL(1 ea daily) NOVOLIN 70/30 RELION 2
AVANDIA TABS 3 SUSP
pioglitazone hcl tabs 1 QL(1 ea daily) NOVOLIN 70/30 SUSP 2
Insulin NOVOLIN N RELION 2
SUSP
APIDRA SOLN 3
NOVOLIN N SUSP 2
APIDRA SOLOSTAR 3
SOPN NOVOLIN R RELION 2
BASAGLAR KWIKPEN SOLN
2
SOPN NOVOLIN R SOLN 2
FIASP FLEXTOUCH 2
SOPN NOVOLOG FLEXPEN 2
SOPN
FIASP SOLN 2 NOVOLOG MIX 70/30
HUMALOG JUNIOR PREFILLED FLEXPEN 2
3 SUPN
KWIKPEN SOPN
HUMALOG KWIKPEN NOVOLOG MIX 70/30 2
3 SUSP
SOPN 100 UNIT/ML
HUMALOG MIX 50/50 NOVOLOG PENFILL 2
3 SOCT
KWIKPEN SUPN
HUMALOG MIX 50/50 NOVOLOG SOLN 2
3
SUSP
HUMALOG MIX 75/25 Meglitinide Analogues
3
KWIKPEN SUPN

Ambetter Formulary Updated April 01, 2018

23
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
nateglinide tabs 1 QL(3 ea daily) TOLBUTAMIDE TABS 1 QL(6 ea daily)
PRANDIN TABS 0.5 MG, 1 NF QL(4 ea daily)
MG (Use Repaglinide) ANTIDIARRHEALS - Drugs to Treat Diarrhea
PRANDIN TABS 2 MG NF QL(8 ea daily) Antiperistaltic Agents
(Use Repaglinide) diphenoxylate w/ atropine
repaglinide tabs 0.5 mg, 1 QL(4 ea daily) 1
1 tabs
mg DIPHENOXYLATE/ATROP
QL(8 ea daily) 1
repaglinide tabs 2 mg 1 INE LIQD
IMODIUM A-D CAPS 2 MG NF RX/OTC
STARLIX TABS (Use NF QL(3 ea daily) (Use Loperamide HCl)
Nateglinide) LOMOTIL TABS (Use NF
Sodium-Glucose Co-Transporter 2 (SGLT2) Diphenoxylate w/ Atropine)
FARXIGA TABS 3 PA loperamide hcl caps 2 mg 1 RX/OTC

PA; QL(1 ea MOTOFEN TABS 3


INVOKANA TABS 3
daily)
JARDIANCE TABS 3 PA ANTIDOTES AND SPECIFIC ANTAGONISTS
Sulfonylureas Antidotes - Chelating Agents
AMARYL TABS 1 MG, 2 NF QL(4 ea daily) CHEMET CAPS 3
MG (Use Glimepiride)
AMARYL TABS 4 MG (Use PA; SP
NF QL(2 ea daily) EXJADE TBSO 4
Glimepiride)
FERRIPROX TABS 500 3
CHLORPROPAMIDE 1 QL(3 ea daily) MG
TABS 100 MG
JADENU SPRINKLE PACK 4 PA
glimepiride tabs 1 mg, 2 1 QL(4 ea daily)
mg
JADENU TABS 4 PA; SP
glimepiride tabs 4 mg 1 QL(2 ea daily)
Antidotes and Specific Antagonists
glipizide tabs 5 mg, 10 mg 1 QL(4 ea daily)
VISTOGARD PACK 4 PA
glipizide tb24 5 mg, 10 mg, 1 QL(2 ea daily)
2.5 mg Opioid Antagonists
GLUCOTROL TABS (Use naloxone hcl soln 0.4
NF QL(4 ea daily) mg/ml 1
Glipizide)
GLUCOTROL XL TB24 NF QL(2 ea daily) naltrexone hcl tabs 1
(Use Glipizide)
QL(4 ea daily) NARCAN LIQD 3 PA
glyburide micronized tabs 1

glyburide tabs 1 QL(4 ea daily) ANTIEMETICS - Drugs to Treat Nausea and


Vomiting
GLYNASE TABS (Use NF QL(4 ea daily) 5-HT3 Receptor Antagonists
Glyburide Micronized)
QL(4 ea daily) ALOXI SOLN 3
TOLAZAMIDE TABS 1

Ambetter Formulary Updated April 01, 2018

24
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ANZEMET SOLN IV 20 3 CESAMET CAPS 3
MG/ML
ANZEMET TABS OR 50 3 PA; QL(0.167 dronabinol caps 1
MG, 100 MG ea daily)
granisetron hcl soln iv 0.1 MARINOL CAPS (Use NF
1 Dronabinol)
mg/ml, 1 mg/ml
granisetron hcl tabs or 1 QL(0.34 ea Substance P/Neurokinin 1 (NK1) Receptor
1
mg daily) aprepitant caps 40 mg, 125 1 PA; QL(0.067
ondansetron hcl soln ij 4 mg ea daily)
1
mg/2ml
aprepitant caps 80 mg 1 PA; QL(0.134
ondansetron hcl soln or 4 QL(3.34 ml ea daily)
1
mg/5ml daily) EMEND CAPS OR 40 MG, NF PA; QL(0.067
ondansetron hcl tabs or 24 QL(0.143 ea 125 MG (Use Aprepitant) ea daily)
1
mg daily) EMEND CAPS OR 80 MG NF PA; QL(0.134
ondansetron hcl tabs or 4 QL(1 ea daily) (Use Aprepitant) ea daily)
1
mg, 8 mg
VARUBI TABS OR 90 MG 3 PA
ondansetron tbdp 4 mg 1 QL(1 ea daily)
ANTIFUNGALS - Drugs to Treat Fungal Infections
ondansetron tbdp 8 mg 1
Antifungal - Glucan Synthesis Inhibitors
ZOFRAN ODT TBDP 4 MG NF QL(1 ea daily) CANCIDAS SOLR (Use
(Use Ondansetron) 3
Caspofungin Acetate)
ZOFRAN ODT TBDP 8 MG NF CASPOFUNGIN ACETATE 3
(Use Ondansetron) SOLR 50 MG, 70 MG
ZOFRAN SOLN 4 MG/5ML NF QL(3.34 ml caspofungin acetate solr 50 1
(Use Ondansetron HCl) daily) mg, 70 mg
ZOFRAN TABS 4 MG, 8 QL(1 ea daily)
MG (Use Ondansetron NF ERAXIS SOLR 3
HCl)
MYCAMINE SOLR 3
Antiemetics - Anticholinergic
meclizine hcl tabs 25 mg, 1 RX/OTC Antifungals
12.5 mg
ABELCET SUSP 3
QL(0.34 ea
scopolamine pt72 1
daily) AMBISOME SUSR 3
TIGAN CAPS OR 300 MG
(Use Trimethobenzamide NF AMPHOTEC SUSR 50 MG 3
HCl)
QL(0.34 ea AMPHOTERICIN B SOLR 3
TRANSDERM-SCOP PT72 2
daily)
ANCOBON CAPS (Use
TRANSDERM-SCOP PT72 2 QL(0.34 ea Flucytosine) NF
(Use Scopolamine) daily)
trimethobenzamide hcl flucytosine caps 1
1
caps
GRIS-PEG TABS (Use NF
Antiemetics - Miscellaneous Griseofulvin Ultramicrosize)
AKYNZEO CAPS 3 PA griseofulvin microsize susp AL; At least 2
1
125 mg/5ml yrs old
Ambetter Formulary Updated April 01, 2018

25
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
griseofulvin microsize tabs 1 clemastine fumarate tabs 1
500 mg 2.68 mg
griseofulvin ultramicrosize 1 diphenhydramine hcl caps 1 RX/OTC
tabs or 50 mg
LAMISIL TABS 250 MG NF QL(1 ea daily) diphenhydramine hcl elix or 1 RX/OTC
(Use Terbinafine HCl) 12.5 mg/5ml
nystatin tabs 1 diphenhydramine hcl soln ij 1
50 mg/ml
terbinafine hcl tabs 1 QL(1 ea daily) Antihistamines - Non-Sedating
ALLEGRA ALLERGY QL(30 ml daily)
Imidazole-Related Antifungals CHILDRENS SUSP 30
CRESEMBA CAPS OR 1
3 PA MG/5ML (Use
186 MG Fexofenadine HCl)
DIFLUCAN SUSR (Use NF ALLEGRA ALLERGY QL(2 ea daily)
Fluconazole) 1
CHILDRENS TBDP 30 MG
DIFLUCAN TABS (Use NF ALLEGRA ALLERGY QL(1 ea daily)
Fluconazole) TABS 180 MG (Use 1
Fexofenadine HCl)
fluconazole susr 1
ALLEGRA ALLERGY QL(2 ea daily)
fluconazole tabs 1 TABS 60 MG (Use 1
Fexofenadine HCl)
PA; QL(4 ea QL(1 ea daily)
itraconazole caps 1
daily) cetirizine hcl caps 10 mg 1

ketoconazole tabs 1 cetirizine hcl chew 5 mg, 10 1 QL(1 ea daily)


mg
NOXAFIL SUSP OR 40 3 QL(20 ml daily) cetirizine hcl soln 1 mg/ml, QL(10 ml
MG/ML 1
5 mg/5ml daily); RX/OTC
SPORANOX CAPS 100 NF PA; QL(4 ea cetirizine hcl syrp 1 mg/ml, QL(10 ml
MG (Use Itraconazole) daily) 1
5 mg/5ml daily); RX/OTC
SPORANOX PULSEPAK NF PA; QL(4 ea cetirizine hcl tabs 5 mg, 10 QL(1 ea daily)
CAPS (Use Itraconazole) daily) 1
mg
SPORANOX SOLN 10 3 PA; QL(20 ml CLARINEX TABS 5 MG
MG/ML daily) NF QL(1 ea daily)
(Use Desloratadine)
VFEND TABS 50 MG, 200 NF QL(4 ea daily) CLARITIN ALLERGY
MG (Use Voriconazole) CHILDRENS SYRP (Use 1
voriconazole tabs or 50 QL(4 ea daily) Loratadine)
1
mg, 200 mg CLARITIN CAPS 10 MG 1
(Use Loratadine)
ANTIHISTAMINES - Drugs to Treat Allergies
CLARITIN CHEW 5 MG 1
Antihistamines - Ethanolamines
carbinoxamine maleate CLARITIN CHILDRENS 1
1 CHEW
soln 4 mg/5ml
carbinoxamine maleate CLARITIN REDITABS
1 TBDP 10 MG (Use 1
tabs 4 mg
Loratadine)
CLEMASTINE FUMARATE 1
TABS 2.68 MG

Ambetter Formulary Updated April 01, 2018

26
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
CLARITIN REDITABS 1 ZYRTEC ALLERGY TABS 1 QL(1 ea daily)
TBDP 5 MG (Use Cetirizine HCl)
CLARITIN SYRP 5 1 ZYRTEC CHILDRENS QL(10 ml
MG/5ML (Use Loratadine) ALLERGY SYRP (Use 1 daily); RX/OTC
CLARITIN TABS 10 MG Cetirizine HCl)
1
(Use Loratadine) Antihistamines - Phenothiazines
DESLORATADINE ODT 1 QL(1 ea daily) PHENERGAN SOLN (Use
TBDP 2.5 MG NF
Promethazine HCl)
desloratadine tabs 1 QL(1 ea daily)
promethazine hcl soln 1
fexofenadine hcl susp 30 1 QL(30 ml daily)
mg/5ml promethazine hcl supp 1
fexofenadine hcl tabs 180 1 QL(1 ea daily) promethazine hcl syrp 1
mg
fexofenadine hcl tabs 60 1 QL(2 ea daily) promethazine hcl tabs 1
mg
levocetirizine QL(10 ml Antihistamines - Piperidines
dihydrochloride soln 2.5 1 daily); RX/OTC
mg/5ml cyproheptadine hcl syrp 1
levocetirizine 1 QL(1 ea daily); cyproheptadine hcl tabs 1
dihydrochloride tabs 5 mg RX/OTC
loratadine caps 1 ANTIHYPERLIPIDEMICS - Drugs to Treat High
Cholesterol
loratadine soln 1 Antihyperlipidemics - Combinations

loratadine syrp 1 ezetimibe-simvastatin tabs 1 ST; QL(1 ea


daily)
VYTORIN TABS (Use 2 ST; QL(1 ea
loratadine tabs 1 Ezetimibe-Simvastatin) daily)
loratadine tbdp 1 Antihyperlipidemics - Misc.
LOVAZA CAPS (Use NF QL(4 ea daily)
XYZAL ALLERGY 24HR QL(10 ml Omega-3-acid Ethyl Esters)
CHILDRENS SOLN (Use NF daily); RX/OTC
Levocetirizine omega-3-acid ethyl esters 1 QL(4 ea daily)
Dihydrochloride) caps
XYZAL ALLERGY 24HR QL(1 ea daily); VASCEPA CAPS 1 GM 3 PA
TABS (Use Levocetirizine NF RX/OTC
Dihydrochloride) Bile Acid Sequestrants
XYZAL SOLN 2.5 MG/5ML QL(10 ml cholestyramine light pack 4 QL(6 ea daily)
(Use Levocetirizine NF daily); RX/OTC 1
gm
Dihydrochloride) cholestyramine light powd QL(24 gm
XYZAL TABS 5 MG (Use QL(1 ea daily); 1
4 gm/dose daily)
Levocetirizine NF RX/OTC QL(6 ea daily)
Dihydrochloride) cholestyramine pack 4 gm 1
ZYRTEC ALLERGY CAPS 1 QL(1 ea daily) cholestyramine powd 4 QL(25.2 gm
(Use Cetirizine HCl) 1
gm/dose daily)

Ambetter Formulary Updated April 01, 2018

27
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
COLESTID FLAVORED QL(6 gm daily) CRESTOR TABS (Use NF QL(1 ea daily)
GRAN 5 GM (Use NF Rosuvastatin Calcium)
Colestipol HCl) fluvastatin sodium caps 20 QL(1 ea daily)
3
COLESTID GRAN 5 GM NF QL(6 gm daily) mg
(Use Colestipol HCl) fluvastatin sodium caps 40 QL(2 ea daily)
3
COLESTID PACK 5 GM NF QL(6 ea daily) mg
(Use Colestipol HCl) LIPITOR TABS (Use NF QL(1 ea daily)
COLESTID TABS 1 GM NF QL(16 ea daily) Atorvastatin Calcium)
(Use Colestipol HCl) ST; QL(1 ea
QL(6 gm daily) LIVALO TABS 3
daily)
colestipol hcl gran 5 gm 1
$0 copay for
colestipol hcl pack 5 gm 1 QL(6 ea daily) generic only,
lovastatin tabs 10 mg, 20 1 age 40 to
QL(16 ea daily) mg 76;QL(1 ea
colestipol hcl tabs 1 gm 1
daily); PV
QUESTRAN LIGHT POWD NF QL(24 gm $0 copay for
(Use Cholestyramine Light) daily) generic only,
QUESTRAN PACK 4 GM NF QL(6 ea daily) lovastatin tabs 40 mg 1 age 40 to
(Use Cholestyramine) 76;QL(2 ea
QUESTRAN POWD 4 QL(25.2 gm daily); PV
GM/DOSE (Use NF daily) $0 copay for
Cholestyramine) generic only,
MEVACOR TABS (Use NF age 40 to
PA; QL(1 ea Lovastatin)
WELCHOL PACK 3.75 GM 2 76;QL(2 ea
daily)
daily); PV
WELCHOL TABS 625 MG 2 QL(7 ea daily)
PRAVACHOL TABS (Use NF QL(1 ea daily)
Pravastatin Sodium)
Fibric Acid Derivatives
pravastatin sodium tabs 1 QL(1 ea daily)
fenofibrate micronized caps 1 QL(1 ea daily)
67 mg, 134 mg, 200 mg
rosuvastatin calcium tabs 1 QL(1 ea daily)
fenofibrate tabs 48 mg, 54 1 QL(1 ea daily)
mg, 145 mg, 160 mg QL(1 ea daily)
simvastatin tabs 1
gemfibrozil tabs 1 QL(2 ea daily)
ZOCOR TABS (Use NF QL(1 ea daily)
LOFIBRA CAPS (Use NF QL(1 ea daily) Simvastatin)
Fenofibrate Micronized)
Intestinal Cholesterol Absorption Inhibitors
LOFIBRA TABS (Use NF QL(1 ea daily)
Fenofibrate) ezetimibe tabs 1 QL(1 ea daily)
LOPID TABS (Use NF QL(2 ea daily) ZETIA TABS (Use
Gemfibrozil) NF QL(1 ea daily)
Ezetimibe)
TRICOR TABS (Use NF QL(1 ea daily)
Fenofibrate) Nicotinic Acid Derivatives
niacin (antihyperlipidemic) 1 QL(2 ea daily)
HMG CoA Reductase Inhibitors tbcr
ST; QL(1 ea NIASPAN TBCR (Use QL(2 ea daily)
ALTOPREV TB24 3
daily) Niacin (Antihyperlipidemic)) NF
atorvastatin calcium tabs 1 QL(1 ea daily)
Proprotein Convertase Subtilisin/Kexin Type 9

Ambetter Formulary Updated April 01, 2018

28
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
PA; QL(0.0714 Agents for Pheochromocytoma
REPATHA SOSY 4 ml daily,30 DIBENZYLINE CAPS (Use
days retail,30 Phenoxybenzamine HCl) 3
days mail)
PA; QL(0.0714
phenoxybenzamine hcl 3
REPATHA SURECLICK
caps
4 ml daily,30
SOAJ days retail,30 Angiotensin II Receptor Antagonists
days mail) ATACAND TABS (Use NF QL(1 ea daily)
ANTIHYPERTENSIVES - Drugs to Treat High Candesartan Cilexetil)
Blood Pressure AVAPRO TABS (Use NF QL(1 ea daily)
ACE Inhibitors
Irbesartan)
ACCUPRIL TABS (Use BENICAR TABS (Use NF QL(1 ea daily)
Quinapril HCl) NF Olmesartan Medoxomil)
ACEON TABS (Use candesartan cilexetil tabs 1 QL(1 ea daily)
NF
Perindopril Erbumine)
COZAAR TABS (Use NF QL(1 ea daily)
ALTACE CAPS (Use NF Losartan Potassium)
Ramipril)
DIOVAN TABS (Use NF QL(1 ea daily)
benazepril hcl tabs 1 Valsartan)
ST; QL(1 ea
captopril tabs 1 EDARBI TABS 3
daily)
EPROSARTAN 1 QL(1 ea daily)
enalapril maleate tabs 1 MESYLATE TABS
irbesartan tabs 1 QL(1 ea daily)
fosinopril sodium tabs 1
losartan potassium tabs 1 QL(1 ea daily)
lisinopril tabs 1
LOTENSIN TABS (Use MICARDIS TABS (Use NF QL(1 ea daily)
NF Telmisartan)
Benazepril HCl)
MAVIK TABS (Use olmesartan medoxomil tabs 1 QL(1 ea daily)
NF
Trandolapril)
telmisartan tabs 1 QL(1 ea daily)
moexipril hcl tabs 1
valsartan tabs 1 QL(1 ea daily)
perindopril erbumine tabs 1
PRINIVIL TABS (Use Antiadrenergic Antihypertensives
NF
Lisinopril) CARDURA TABS (Use NF
quinapril hcl tabs 1 Doxazosin Mesylate)
CATAPRES TABS (Use NF QL(8 ea daily)
ramipril caps 1 Clonidine HCl)
CATAPRES-TTS-1 PTWK NF QL(0.15 ea
trandolapril tabs 1 (Use Clonidine HCl) daily)
VASOTEC TABS (Use CATAPRES-TTS-2 PTWK NF QL(0.15 ea
Enalapril Maleate) NF (Use Clonidine HCl) daily)
ZESTRIL TABS (Use CATAPRES-TTS-3 PTWK NF QL(0.15 ea
Lisinopril) NF (Use Clonidine HCl) daily)

Ambetter Formulary Updated April 01, 2018

29
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
clonidine hcl ptwk td 0.1 QL(0.15 ea AVALIDE TABS (Use
mg/24hr, 0.2 mg/24hr, 0.3 3 daily) Irbesartan- NF
mg/24hr Hydrochlorothiazide)
clonidine hcl tabs or 0.1 1 QL(8 ea daily) AZOR TABS (Use ST
mg, 0.2 mg, 0.3 mg Amlodipine Besylate- NF
Olmesartan Medoxomil)
doxazosin mesylate tabs 1
benazepril & 1
guanfacine hcl tabs 1 hydrochlorothiazide tabs
BENICAR HCT TABS (Use
methyldopa tabs 1 QL(6 ea daily) Olmesartan Medoxomil- NF
Hydrochlorothiazide)
METHYLDOPATE HCL 3 bisoprolol & QL(2 ea daily)
SOLN 1
hydrochlorothiazide tabs
MINIPRESS CAPS (Use NF QL(4 ea daily) candesartan cilexetil-
Prazosin HCl) 1
hydrochlorothiazide tabs
prazosin hcl caps 1 QL(4 ea daily) DIOVAN HCT TABS (Use
Valsartan- NF
RESERPINE TABS 1 PA Hydrochlorothiazide)
enalapril maleate & 1
TENEX TABS (Use NF hydrochlorothiazide tabs
Guanfacine HCl)
EXFORGE HCT TABS
terazosin hcl caps 1 (Use Amlodipine-Valsartan- NF
Hydrochlorothiazide)
Antihypertensive Combinations EXFORGE TABS (Use
ACCURETIC TABS 10MG- QL(3 ea daily) Amlodipine Besylate- NF
12.5MG (Use Quinapril- NF Valsartan)
Hydrochlorothiazide) fosinopril sodium &
ACCURETIC TABS 20MG- QL(4 ea daily) 1
hydrochlorothiazide tabs
12.5MG (Use Quinapril- NF HYZAAR TABS (Use QL(1 ea daily)
Hydrochlorothiazide) Losartan Potassium & NF
ACCURETIC TABS 20MG- QL(2 ea daily) Hydrochlorothiazide)
25MG (Use Quinapril- NF irbesartan-
Hydrochlorothiazide) 1
hydrochlorothiazide tabs
amlodipine besylate- 1 lisinopril &
benazepril hcl caps 1
hydrochlorothiazide tabs
amlodipine besylate- ST losartan potassium & QL(1 ea daily)
olmesartan medoxomil tabs 1 hydrochlorothiazide tabs 1
amlodipine besylate- 1 LOTENSIN HCT TABS
valsartan tabs (Use Benazepril & NF
amlodipine-valsartan- 1 Hydrochlorothiazide)
hydrochlorothiazide tabs LOTREL CAPS (Use
ATACAND HCT TABS Amlodipine Besylate- NF
(Use Candesartan Cilexetil- NF Benazepril HCl)
Hydrochlorothiazide) MICARDIS HCT TABS
atenolol & chlorthalidone 1 (Use Telmisartan- NF
tabs Hydrochlorothiazide)

Ambetter Formulary Updated April 01, 2018

30
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
olmesartan medoxomil- ST VECAMYL TABS 3 PA
amlodipine- 1
hydrochlorothiazide tabs Direct Renin Inhibitors
olmesartan medoxomil- 1 QL(1 ea daily)
hydrochlorothiazide tabs TEKTURNA TABS 2
quinapril- QL(3 ea daily) Selective Aldosterone Receptor Antagonists
hydrochlorothiazide tabs 1
10mg-12.5mg eplerenone tabs 1
quinapril- QL(4 ea daily) INSPRA TABS (Use
hydrochlorothiazide tabs 1 NF
Eplerenone)
20mg-12.5mg
quinapril- QL(2 ea daily) Vasodilators
hydrochlorothiazide tabs 1 hydralazine hcl soln 1
20mg-25mg
TARKA TBCR (Use hydralazine hcl tabs 1
Trandolapril-Verapamil NF
HCl) minoxidil tabs 1
telmisartan-amlodipine tabs 1 ANTIMALARIALS - Drugs to Treat Malaria
telmisartan- (Parasitic Infections)
1
hydrochlorothiazide tabs Antimalarial Combinations
TENORETIC 100 TABS atovaquone-proguanil hcl QL(12 ea per 3
(Use Atenolol & NF 1
tabs days retail)
Chlorthalidone)
QL(24 ea per
TENORETIC 50 TABS fill retail,24 ea
(Use Atenolol & NF per fill mail,72
Chlorthalidone) COARTEM TABS 2 ea per 144
trandolapril-verapamil hcl 1 days retail,72
tbcr ea per 144
TRIBENZOR TABS (Use ST days mail)
Olmesartan Medoxomil- MALARONE TABS (Use
Amlodipine- NF NF QL(12 ea per 3
Atovaquone-Proguanil HCl) days retail)
Hydrochlorothiazide)
Antimalarials
TWYNSTA TABS (Use NF
Telmisartan-Amlodipine) CHLOROQUINE
PHOSPHATE TABS 250 1
valsartan- 1 MG
hydrochlorothiazide tabs
chloroquine phosphate tabs 1
VASERETIC TABS (Use 500 mg
Enalapril Maleate & NF
Hydrochlorothiazide) PA; QL(3 ea
DARAPRIM TABS 3
daily)
ZESTORETIC TABS (Use
Lisinopril & NF hydroxychloroquine sulfate 1
Hydrochlorothiazide) tabs
ZIAC TABS (Use Bisoprolol NF QL(2 ea daily)
& Hydrochlorothiazide)
Antihypertensives - Misc.

Ambetter Formulary Updated April 01, 2018

31
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
QL(5 ea daily)1 RIFATER TABS 3 QL(6 ea daily)
rtl MAX fill,180
rtl day(s) Antimycobacterial Agents
mefloquine hcl tabs 1 supply,1 mail
MAX fill,180 CAPASTAT SULFATE 3
mail day(s) SOLR
supply, CYCLOSERINE CAPS 3 QL(4 ea daily)
QL(5 ea daily)1
rtl MAX fill,180 ethambutol hcl tabs 1
rtl day(s)
MEFLOQUINE HCL TABS 1 supply,1 mail ISONIAZID SOLN IJ 100 1
MAX fill,180 MG/ML
mail day(s) ISONIAZID SYRP OR 50
supply, 1
MG/5ML
PLAQUENIL TABS (Use isoniazid tabs or 100 mg,
Hydroxychloroquine 1
NF 300 mg
Sulfate) MYAMBUTOL TABS (Use
PRIMAQUINE NF
3 Ethambutol HCl)
PHOSPHATE TABS MYCOBUTIN CAPS (Use
PA; QL(84 NF PA
QUALAQUIN CAPS (Use Rifabutin)
NF days retail,84 QL(3 ea daily)
Quinine Sulfate) days mail) PASER PACK 3
PA; QL(84
quinine sulfate caps 1 days retail,84 PRIFTIN TABS 3
days mail)
pyrazinamide tabs 1
ANTIMYASTHENIC/CHOLINERGIC AGENTS PA
rifabutin caps 1
Antimyasthenic/Cholinergic Agents
RIFADIN CAPS (Use NF
GUANIDINE HCL TABS 2 Rifampin)
MESTINON SYRP 60 RIFADIN SOLR (Use NF
2 Rifampin)
MG/5ML
MESTINON TABS 60 MG rifampin caps 1
(Use Pyridostigmine NF
Bromide) rifampin solr 1
MESTINON TIMESPAN
TBCR (Use Pyridostigmine NF SIRTURO TABS 3 PA
Bromide)
TRECATOR TABS 3 QL(4 ea daily)
pyridostigmine bromide 1
tabs
ANTINEOPLASTICS AND ADJUNCTIVE
pyridostigmine bromide 1 THERAPIES - Drugs to Treat Cancer
tbcr
Alkylating Agents
ANTIMYCOBACTERIAL AGENTS - Drugs to
Treat Tuberculosis (Bacterial Infections) ALKERAN SOLR IV 50 MG NF
(Use Melphalan HCl)
Anti TB Combinations ALKERAN TABS OR 2 MG 2
RIFAMATE CAPS 3 (Use Melphalan)

Ambetter Formulary Updated April 01, 2018

32
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
BICNU SOLR 4 PA; SP TEPADINA SOLR 15 MG
PA; QL(30
NF days retail,30
(Use Thiotepa) days mail); SP
busulfan soln 4 PA; SP
PA; QL(30
BUSULFEX SOLN (Use 4 PA; SP thiotepa solr 4 days retail,30
Busulfan) days mail); SP
PA; SP TREANDA SOLR 25 MG,
carboplatin soln 50 mg/5ml 4 4 PA; SP
100 MG
cisplatin soln 100 4 PA; SP PA; SP
mg/100ml ZANOSAR SOLR 4
CYCLOPHOSPHAMIDE 4 PA; SP Antimetabolites
CAPS OR 25 MG, 50 MG
ALIMTA SOLR 500 MG 4 PA; SP
cyclophosphamide solr ij 1 4 PA; SP
gm, 2 gm, 500 mg PA; SP
PA; SP ARRANON SOLN 4
GLEOSTINE CAPS 10 MG 4
azacitidine susr 4 PA; SP
GLEOSTINE CAPS 40 MG, 4 PA
100 MG PA; SP
capecitabine tabs 4
HEXALEN CAPS 4 PA; SP
clofarabine soln 4 PA; SP
IFEX SOLR 1 GM (Use 4 PA; SP
Ifosfamide) CLOLAR SOLN (Use PA; SP
4
PA; SP Clofarabine)
ifosfamide soln 1 gm/20ml 4
cytarabine soln 4 PA; SP
ifosfamide solr 1 gm 4 PA; SP
DACOGEN SOLR (Use 4 PA; SP
LEUKERAN TABS 4 PA; SP Decitabine)
decitabine solr 4 PA; SP
melphalan hcl solr 1
DEPOCYT SUSP 4 PA; SP
melphalan tabs 1
FLOXURIDINE SOLR 4 PA; SP
MUSTARGEN SOLR 4 PA; SP
fludarabine phosphate soln 4 PA; SP
MYLERAN TABS 4 PA; SP
fludarabine phosphate solr 4 PA; SP
oxaliplatin soln 50 4 PA; SP
mg/10ml, 100 mg/20ml fluorouracil soln iv 500 PA; SP
4
TEMODAR CAPS OR 5 PA; SP mg/10ml
MG, 20 MG, 100 MG, 140 4 FOLOTYN SOLN 20 PA; SP
MG, 180 MG, 250 MG (Use 4
MG/ML
Temozolomide) gemcitabine hcl solr 2 gm, PA; SP
TEMODAR SOLR IV 100 PA; SP 4
4 200 mg
MG GEMZAR SOLR 200 MG PA; SP
PA; SP 4
temozolomide caps 4 (Use Gemcitabine HCl)
mercaptopurine tabs 1

Ambetter Formulary Updated April 01, 2018

33
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
METHOTREXATE SP PA; QL(1 ea
SODIUM SOLN IJ 250 1
ERIVEDGE CAPS 4 daily,30 days
MG/10ML retail,30 days
methotrexate sodium soln ij mail); SP
1
50 mg/2ml ODOMZO CAPS 4 PA; QL(1 ea
methotrexate sodium soln ij SP daily)
1
50 mg/2ml Antineoplastic - Hormonal and Related Agents
methotrexate sodium solr ij SP
1 gm 1 anastrozole tabs 1 QL(1 ea daily)
methotrexate sodium tabs SP ARIMIDEX TABS (Use
or 2.5 mg 1 NF QL(1 ea daily)
Anastrozole)
TABLOID TABS 4 PA; SP QL(1 ea
AROMASIN TABS (Use 4 daily,30 days
TREXALL TABS 4 PA; SP Exemestane) retail,30 days
mail); SP
VIDAZA SUSR (Use 4 PA; SP PA; QL(1 ea
Azacitidine) daily,30 days
bicalutamide tabs 4
retail,30 days
XELODA TABS (Use 4 PA; SP
Capecitabine) mail); SP
Antineoplastic - Angiogenesis Inhibitors PA; QL(1 ea
CASODEX TABS (Use 4 daily,30 days
AVASTIN SOLN 100 4 PA; SP Bicalutamide) retail,30 days
MG/4ML mail); SP
ZALTRAP SOLN 100 4 PA; SP PA; SP
MG/4ML ELIGARD KIT 22.5 MG 4
Antineoplastic - Antibodies ELIGARD KIT 30 MG 4 PA; SP
ADCETRIS SOLR 4 PA; SP
ELIGARD KIT 45 MG 4 PA; SP
ARZERRA CONC 4 PA; SP
PA; QL(0.0089
PA ea daily,30
CAMPATH SOLN 4 ELIGARD KIT 7.5 MG 4
days retail,30
PA; SP days mail); SP
ERBITUX SOLN 4 PA; SP
EMCYT CAPS 4
HERCEPTIN SOLR 440 4 PA; SP
MG QL(1 ea
PA; SP daily,30 days
PERJETA SOLN 4 exemestane tabs 4
retail,30 days
PA; SP mail); SP
RITUXAN SOLN 4
FARESTON TABS 2
VECTIBIX SOLN 100 4 PA; SP
MG/5ML PA; QL(0.357
PA; SP ml daily,30
YERVOY SOLN 4 FASLODEX SOLN 4
days retail,30
days mail); SP
Antineoplastic - Hedgehog Pathway Inhibitors FEMARA TABS (Use NF
Letrozole)

Ambetter Formulary Updated April 01, 2018

34
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
PA; QL(0.143 PA; QL(0.0119
FIRMAGON SOLR 4 ea daily,30 ZOLADEX IMPL 10.8 MG 4 ea daily,30
days retail,30 days retail,30
days mail); SP days mail); SP
PA; QL(6 ea PA; QL(0.0357
flutamide caps 4 daily,30 days ZOLADEX IMPL 3.6 MG 4 ea daily,30
retail,30 days days retail,30
mail); SP days mail); SP
letrozole tabs 1 PA; QL(2 ea
ZYTIGA TABS 250 MG 4 daily,30 days
leuprolide acetate kit 4 PA; SP retail,30 days
mail); SP
PA; QL(0.0357
LUPRON DEPOT (1- ea daily,30 ZYTIGA TABS 500 MG 4 PA; QL(2 ea
4 daily)
MONTH) KIT days retail,30
days mail); SP Antineoplastic - Immunomodulators

LUPRON DEPOT (3-


PA; QL(90 POMALYST CAPS 4 PA; QL(1 ea
4 days retail,90 daily)
MONTH) KIT days mail); SP Antineoplastic Antibiotics
PA; QL(0.1339 bleomycin sulfate solr 15 PA; SP
LUPRON DEPOT (4- ea daily,120 4
4 unit
MONTH) KIT days retail,120 COSMEGEN SOLR (Use PA; SP
days mail); SP 4
Dactinomycin)
PA; QL(0.0089 PA; SP
LUPRON DEPOT (6- ea daily,180 dactinomycin solr 4
4
MONTH) KIT days retail,180 PA; SP
days mail); SP daunorubicin hcl inj 4
LYSODREN TABS 4 PA; SP PA; SP
DAUNOXOME INJ 4
MEGACE ORAL SUSP NF DOXIL INJ (Use PA; SP
(Use Megestrol Acetate) Doxorubicin HCl 4
megestrol acetate susp 1 Liposomal)
doxorubicin hcl liposomal 4 PA; SP
megestrol acetate tabs 1 inj
doxorubicin hcl soln 2 4 PA; SP
NILANDRON TABS (Use NF QL(2 ea daily) mg/ml
Nilutamide)
DOXORUBICIN HCL 4 PA; SP
nilutamide tabs 1 QL(2 ea daily) SOLR 10 MG, 50 MG
ELLENCE SOLN 50 PA; QL(30
tamoxifen citrate tabs 0 MG/25ML (Use Epirubicin NF days retail,30
HCl) days mail); SP
TRELSTAR MIXJECT 4 PA; SP
SUSR PA; QL(30
epirubicin hcl soln 50 4 days retail,30
TRELSTAR SUSR 4 PA; SP mg/25ml days mail); SP
PA; QL(4 ea IDAMYCIN PFS SOLN 5 PA; QL(30
daily,30 days MG/5ML, 10 MG/10ML NF days retail,30
XTANDI CAPS 4 (Use Idarubicin HCl) days mail); SP
retail,30 days
mail); SP
Ambetter Formulary Updated April 01, 2018

35
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
PA; QL(30 PA; QL(2 ea
idarubicin hcl soln 5 4 days retail,30
mg/5ml, 10 mg/10ml imatinib mesylate tabs 4 daily,30 days
days mail); SP retail,30 days
mail); SP
mitomycin solr 20 mg 4 PA; SP
IMBRUVICA CAPS 4 PA; QL(3 ea
mitoxantrone hcl conc 4 PA; SP daily)
PA; QL(2 ea
PA; SP
VALSTAR SOLN 4 INLYTA TABS 4 daily,30 days
retail,30 days
Antineoplastic Enzyme Inhibitors mail); SP
PA; QL(1 ea ISTODAX (OVERFILL) 4 PA; SP
daily,30 days SOLR
AFINITOR TABS 4
retail,30 days ISTODAX SOLR 4 PA; SP
mail); SP
PA; QL(30 JAKAFI TABS 10 MG, 15 4 PA; SP
BORTEZOMIB SOLR 4 days retail,30 MG, 20 MG, 25 MG
days mail) PA; QL(2 ea
PA; QL(1 ea daily,30 days
JAKAFI TABS 5 MG 4
BOSULIF TABS 100 MG, daily,30 days retail,30 days
4 mail); SP
500 MG retail,30 days
mail); SP PA
KYPROLIS SOLR 60 MG 4
PA; QL(30
BOSULIF TABS 400 MG 4 days retail,30 LENVIMA 10 MG DAILY 4 PA; QL(1 ea
days mail) DOSE CPPK daily)
PA; QL(1 ea LENVIMA 14 MG DAILY 4 PA; QL(2 ea
daily,30 days DOSE CPPK daily)
CAPRELSA TABS 4
retail,30 days LENVIMA 20 MG DAILY PA; QL(2 ea
mail); SP 4
DOSE CPPK daily)
PA; QL(3 ea LENVIMA 24 MG DAILY PA; QL(3 ea
daily,30 days 4
COMETRIQ KIT 4 DOSE CPPK daily)
retail,30 days
mail); SP PA; QL(16 ea
LYNPARZA CAPS 4
daily)
PA; QL(4 ea
daily,30 days PA; QL(16 ea
COMETRIQ KIT LYNPARZA TABS 4
4
retail,30 days daily)
mail); SP PA; QL(4 ea
PA; QL(2 ea daily,30 days
NEXAVAR TABS 4
daily,30 days retail,30 days
COMETRIQ KIT 4 mail); SP
retail,30 days
mail); SP PA; QL(0.143
NINLARO CAPS 4
PA; QL(1 ea ea daily)
GILOTRIF TABS 4 PA; SP
daily) ROMIDEPSIN SOLR 4
PA; QL(2 ea
GLEEVEC TABS (Use daily,30 days PA; QL(1 ea
4 daily,30 days
Imatinib Mesylate) retail,30 days SPRYCEL TABS 4
mail); SP retail,30 days
mail); SP

Ambetter Formulary Updated April 01, 2018

36
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
PA; QL(4 ea ERWINAZE SOLR 4 PA; SP
STIVARGA TABS 4 daily,30 days
retail,30 days ONCASPAR SOLN 4 PA; SP
mail); SP
PA; QL(1 ea Antineoplastics Misc.
SUTENT CAPS 25 MG, 50 4 daily,30 days PA; SP
MG, 12.5 MG retail,30 days ACTIMMUNE SOLN 4
mail); SP PA; QL(30
TAFINLAR CAPS 4 PA; QL(4 ea bexarotene caps 4 days retail,30
daily) days mail); SP
PA; QL(1 ea PA; SP
dacarbazine solr 200 mg 4
TARCEVA TABS 4 daily,30 days
retail,30 days HYDREA CAPS (Use
mail); SP NF
Hydroxyurea)
PA; QL(4 ea
hydroxyurea caps 1
TASIGNA CAPS 4 daily,30 days
retail,30 days PA; SP
mail); SP INTRON A SOLR 18 MU 4
PA; QL(0.143 INTRON A W/DILUENT PA; SP
4
TORISEL SOLN 4 ml daily,30 SOLR 18 MU
days retail,30 PA; SP
days mail); SP MATULANE CAPS 4
PA; QL(6 ea PA; SP
NIPENT SOLR 4
TYKERB TABS 4 daily,30 days
retail,30 days PA; SP
mail); SP PHOTOFRIN SOLR 4
VELCADE SOLR 4 PA; SP PA; SP
PROLEUKIN SOLR 4
PA; QL(4 ea PA; SP
daily,30 days SYLATRON KIT 4
VOTRIENT TABS 4
retail,30 days PA; SP
mail); SP SYNRIBO SOLR 4
PA; QL(2 ea PA; QL(30
daily,30 days TARGRETIN CAPS OR 75
XALKORI CAPS 4 MG (Use Bexarotene)
4 days retail,30
retail,30 days days mail); SP
mail); SP tretinoin (chemotherapy)
PA; SP 1
ZELBORAF TABS 4 caps
TRISENOX SOLN 10 4 PA; SP
PA; QL(4 ea MG/10ML
daily,30 days
ZOLINZA CAPS 4 UVADEX SOLN 4 PA; SP
retail,30 days
mail); SP
PA; QL(2 ea Chemotherapy Adjuncts
ZYDELIG TABS 4 PA; SP
daily) KEPIVANCE SOLR 4
PA; QL(5 ea
ZYKADIA CAPS 4 Chemotherapy Rescue/Antidote Agents
daily)
Antineoplastic Enzymes

Ambetter Formulary Updated April 01, 2018

37
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
leucovorin calcium solr ij 50 vincristine sulfate soln 4 PA; SP
mg, 100 mg, 200 mg, 350 1
mg vinorelbine tartrate soln 10 PA; SP
4
LEUCOVORIN CALCIUM mg/ml
1
SOLR IJ 500 MG Topoisomerase I Inhibitors
LEUCOVORIN CALCIUM 1 CAMPTOSAR SOLN 40 PA; SP
TABS OR 10 MG, 15 MG MG/2ML, 100 MG/5ML 4
leucovorin calcium tabs or 1 (Use Irinotecan HCl)
5 mg, 25 mg HYCAMTIN CAPS OR 0.25 PA; SP
PA; SP 4
VORAXAZE SOLR 4 MG, 1 MG
HYCAMTIN SOLR IV 4 MG 4 PA; SP
Mitotic Inhibitors (Use Topotecan HCl)
ABRAXANE SUSR 4 PA; SP irinotecan hcl soln 4 PA; SP

DOCEFREZ SOLR 4 PA; SP topotecan hcl solr 4 mg 4 PA; SP

docetaxel conc 20 mg/ml 4 PA; SP ANTIPARKINSON AGENTS - Drugs to Treat


Parkinson's Disease
DOCETAXEL CONC 20 4 PA; SP
MG/ML, 20 MG/0.5ML Antiparkinson Adjuvants
DOCETAXEL SOLN 20 4 PA; SP carbidopa tabs 1
MG/2ML
LODOSYN TABS (Use NF
ETOPOPHOS SOLR 4 PA; SP Carbidopa)
ETOPOSIDE CAPS OR 50 PA; SP Antiparkinson Anticholinergics
4
MG
benztropine mesylate soln 1
etoposide soln iv 1 PA; SP
gm/50ml, 100 mg/5ml, 500 4 benztropine mesylate tabs 1
mg/25ml
PA; SP COGENTIN SOLN (Use NF
HALAVEN SOLN 4 Benztropine Mesylate)
IXEMPRA KIT SOLR 15 4 PA; SP trihexyphenidyl hcl elix 1
MG
JEVTANA SOLN 4 PA; SP trihexyphenidyl hcl tabs 1
NAVELBINE SOLN 10 PA; SP Antiparkinson COMT Inhibitors
MG/ML (Use Vinorelbine 4 COMTAN TABS (Use
Tartrate) NF QL(8 ea daily)
Entacapone)
paclitaxel conc 100 PA; SP
mg/16.7ml 4 entacapone tabs 1 QL(8 ea daily)
PACLITAXEL CONC 150 4 PA; SP TASMAR TABS (Use
MG/25ML 3
Tolcapone)
TAXOTERE CONC 20 PA; SP
MG/ML (Use Docetaxel)
4 tolcapone tabs 3

TENIPOSIDE SOLN 4 PA; SP Antiparkinson Dopaminergics


amantadine hcl caps 1

Ambetter Formulary Updated April 01, 2018

38
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
amantadine hcl syrp 1 ropinirole hydrochloride
tabs 0.25 mg, 0.5 mg, 1 1
amantadine hcl tabs 1 mg, 2 mg, 3 mg, 4 mg, 5
mg
bromocriptine mesylate 1 ropinirole hydrochloride ST; QL(1 ea
caps 1
tb24 2 mg, 4 mg, 6 mg daily)
bromocriptine mesylate 1 ropinirole hydrochloride ST; QL(2 ea
tabs 1
tb24 8 mg, 12 mg daily)
carbidopa-levodopa tabs 1 SINEMET CR TBCR (Use NF
Carbidopa-Levodopa)
carbidopa-levodopa tbcr 1 SINEMET TABS (Use NF
Carbidopa-Levodopa)
carbidopa-levodopa tbdp 1 STALEVO 100 TABS 1
CARBIDOPA/LEVODOPA/ 1
ENTACAPONE TABS STALEVO 125 TABS 1
MIRAPEX TABS 0.125 MG QL(4 ea daily)
(Use Pramipexole NF STALEVO 150 TABS 1
Dihydrochloride)
MIRAPEX TABS 0.25 MG, STALEVO 200 TABS 1
0.75 MG, 0.5 MG, 1 MG, NF
1.5 MG (Use Pramipexole STALEVO 50 TABS 1
Dihydrochloride)
STALEVO 75 TABS 1
NEUPRO PT24 2
Antiparkinson Monoamine Oxidase Inhibitors
PARLODEL CAPS 5 MG AZILECT TABS (Use NF PA; QL(1 ea
(Use Bromocriptine 1
Mesylate) Rasagiline Mesylate) daily)
PARLODEL TABS 2.5 MG ELDEPRYL CAPS (Use NF
(Use Bromocriptine NF Selegiline HCl)
Mesylate) rasagiline mesylate tabs 1 PA; QL(1 ea
daily)
pramipexole QL(4 ea daily)
dihydrochloride tabs 0.125 1 selegiline hcl caps 1
mg
pramipexole selegiline hcl tabs 1
dihydrochloride tabs 0.25 1
mg, 0.75 mg, 0.5 mg, 1 mg, ANTIPSYCHOTICS/ANTIMANIC AGENTS -
1.5 mg Drugs to Treat Mood Disorders
REQUIP TABS (Use NF Antimanic Agents
Ropinirole Hydrochloride) lithium carbonate caps 150
REQUIP XL TB24 2 MG, 4 ST; QL(1 ea 1
mg, 300 mg, 600 mg
MG, 6 MG (Use Ropinirole NF daily) LITHIUM CARBONATE
Hydrochloride) CAPS 150 MG, 600 MG 1
REQUIP XL TB24 8 MG, ST; QL(2 ea (Use Lithium Carbonate)
12 MG (Use Ropinirole NF daily) lithium carbonate tabs 300
Hydrochloride) 1
mg
lithium carbonate tbcr 300 1
mg, 450 mg
Ambetter Formulary Updated April 01, 2018

39
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
LITHIUM SOLN 1 risperidone tabs 0.25 mg, QL(4 ea daily)
0.5 mg, 1 mg, 2 mg, 3 mg, 1
LITHOBID TBCR (Use 4 mg
NF
Lithium Carbonate) risperidone tbdp 0.25 mg, QL(2 ea daily)
Antipsychotics - Misc. 0.5 mg, 1 mg, 2 mg, 3 mg, 1
4 mg
EQUETRO CP12 100 MG 3 QL(2 ea daily)
Butyrophenones
EQUETRO CP12 200 MG 3 QL(8 ea daily) HALDOL DECANOATE QL(0.036 ml
100 SOLN (Use NF daily)
EQUETRO CP12 300 MG 3 QL(4 ea daily) Haloperidol Decanoate)
HALDOL DECANOATE 50 QL(0.036 ml
GEODON CAPS OR 20 QL(2 ea daily); SOLN (Use Haloperidol NF daily)
MG, 40 MG, 60 MG, 80 MG NF AL; At least 18 Decanoate)
(Use Ziprasidone HCl) yrs old HALDOL SOLN (Use NF
LATUDA TABS 3 PA; QL(1 ea Haloperidol Lactate)
daily) QL(0.036 ml
QL(2 ea daily); haloperidol decanoate soln 1
daily)
ziprasidone hcl caps 1 AL; At least 18
yrs old haloperidol lactate conc 1
Benzisoxazoles haloperidol lactate soln 1
PA; QL(2 ea
FANAPT TABS 2
daily) haloperidol tabs 1
FANAPT TITRATION 2 PA
PACK TABS Dibenzapines
INVEGA TB24 3 MG, 9 QL(1 ea daily) CLOZAPINE ODT TBDP 1
MG, 1.5 MG (Use NF
Paliperidone) clozapine tabs 1
INVEGA TB24 6 MG (Use NF QL(2 ea daily)
Paliperidone) clozapine tbdp 1
paliperidone tb24 3 mg, 9 1 QL(1 ea daily)
mg, 1.5 mg CLOZARIL TABS (Use NF
Clozapine)
paliperidone tb24 6 mg 1 QL(2 ea daily)
FAZACLO TBDP 150 MG, 1
RISPERDAL CONSTA 200 MG, 12.5 MG
2 PA; QL(0.072 FAZACLO TBDP 25 MG,
SUSR ea daily) NF
RISPERDAL M-TAB TBDP 100 MG (Use Clozapine)
NF QL(2 ea daily)
(Use Risperidone) loxapine succinate caps 1
RISPERDAL SOLN 1 NF QL(8 ml daily)
MG/ML (Use Risperidone) QL(0.215 ea
olanzapine solr im 10 mg 1
daily)
RISPERDAL TABS 0.25 QL(4 ea daily)
MG, 0.5 MG, 1 MG, 2 MG, olanzapine tabs or 10 mg, 1 QL(2 ea daily)
NF 15 mg, 20 mg, 7.5 mg
3 MG, 4 MG (Use
Risperidone) olanzapine tabs or 5 mg, 1 QL(4 ea daily)
QL(8 ml daily) 2.5 mg
risperidone soln 1 mg/ml 1 olanzapine tbdp or 5 mg, 1
10 mg, 15 mg, 20 mg

Ambetter Formulary Updated April 01, 2018

40
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
quetiapine fumarate tabs QL(4 ea daily); chlorpromazine hcl tabs or
25 mg, 50 mg, 100 mg, 200 1 AL; At least 10 10 mg, 25 mg, 50 mg, 100 1
mg yrs old mg, 200 mg
QL(2 ea daily); FLUPHENAZINE HCL
quetiapine fumarate tabs 1 AL; At least 10 CONC OR 5 MG/ML
1
300 mg, 400 mg yrs old FLUPHENAZINE HCL 1
PA; QL(2 ea ELIX OR 2.5 MG/5ML
quetiapine fumarate tb24 1 daily); AL; At
300 mg, 400 mg FLUPHENAZINE HCL 1
least 10 yrs old SOLN IJ 2.5 MG/ML
PA; QL(1 ea fluphenazine hcl tabs or 1
quetiapine fumarate tb24 1 daily); AL; At 1
50 mg, 150 mg, 200 mg mg, 5 mg, 10 mg, 2.5 mg
least 10 yrs old
perphenazine tabs 1
SAPHRIS SUBL 2.5 MG 2
prochlorperazine maleate 1
SAPHRIS SUBL 5 MG, 10 2 PA; QL(2 ea tabs
MG daily)
SEROQUEL TABS 25 MG, QL(4 ea daily); prochlorperazine supp 1
50 MG, 100 MG, 200 MG NF AL; At least 10
(Use Quetiapine Fumarate) yrs old thioridazine hcl tabs 1
SEROQUEL TABS 300 QL(2 ea daily);
MG, 400 MG (Use NF AL; At least 10 trifluoperazine hcl tabs 1
Quetiapine Fumarate) yrs old Quinolinone Derivatives
SEROQUEL XR TB24 300 PA; QL(2 ea QL(1 ea daily);
MG (Use Quetiapine 2 daily); AL; At ABILIFY TABS (Use NF AL; At least 6
Fumarate) least 10 yrs old Aripiprazole) yrs old
SEROQUEL XR TB24 400 PA; QL(2 ea QL(30 ml
MG (Use Quetiapine NF daily); AL; At aripiprazole soln 1 mg/ml 3 daily); AL; At
Fumarate) least 10 yrs old least 6 yrs old
SEROQUEL XR TB24 50 PA; QL(1 ea aripiprazole tabs 2 mg, 5 QL(1 ea daily);
MG, 150 MG, 200 MG (Use 2 daily); AL; At mg, 10 mg, 15 mg, 20 mg, 1 AL; At least 6
Quetiapine Fumarate) least 10 yrs old 30 mg yrs old
ZYPREXA SOLR IM 10 QL(0.215 ea
MG (Use Olanzapine)
NF
daily) REXULTI TABS 3 PA
ZYPREXA TABS OR 10 QL(2 ea daily)
MG, 15 MG, 20 MG, 7.5 NF Thioxanthenes
MG (Use Olanzapine) thiothixene caps 1
ZYPREXA TABS OR 5 QL(4 ea daily)
MG, 2.5 MG (Use NF ANTIVIRALS - Drugs to Treat Viral Infections
Olanzapine)
ZYPREXA ZYDIS TBDP Antiretrovirals
NF abacavir sulfate soln 20
(Use Olanzapine) 1
mg/ml
Phenothiazines
QL(2 ea
CHLORPROMAZINE HCL abacavir sulfate tabs 300 daily,30 days
SOLN IJ 25 MG/ML, 50 3 1
mg retail,30 days
MG/2ML mail)

Ambetter Formulary Updated April 01, 2018

41
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
QL(1 ea QL(2 ea
abacavir sulfate-lamivudine 1 daily,30 days didanosine cpdr 200 mg 1 daily,30 days
tabs retail,30 days retail,30 days
mail) mail)
QL(2 ea QL(1 ea
abacavir sulfate- 1 daily,30 days didanosine cpdr 250 mg, 1 daily,30 days
lamivudine-zidovudine tabs retail,30 days 400 mg retail,30 days
mail) mail)
QL(4 ea QL(1 ea
APTIVUS CAPS 250 MG 2 daily,30 days EDURANT TABS 2 daily,30 days
retail,30 days retail,30 days
mail) mail)
QL(10 ml QL(2 ea
APTIVUS SOLN 100 2 daily,30 days efavirenz caps 200 mg 1 daily,30 days
MG/ML retail,30 days retail,30 days
mail) mail)
QL(2 ea QL(3 ea
atazanavir sulfate caps 150 1 daily,30 days efavirenz caps 50 mg 1 daily,30 days
mg, 200 mg retail,30 days retail,30 days
mail) mail)
QL(1 ea QL(1 ea
atazanavir sulfate caps 300 1 daily,30 days efavirenz tabs 600 mg 1 daily,30 days
mg retail,30 days retail,30 days
mail) mail)
QL(1 ea QL(1 ea
ATRIPLA TABS 3 daily,30 days EMTRIVA CAPS 200 MG 2 daily,30 days
retail,30 days retail,30 days
mail) mail)
QL(2 ea EMTRIVA SOLN 10 2
COMBIVIR TABS (Use NF daily,30 days MG/ML
Lamivudine-Zidovudine) retail,30 days QL(30 ml
mail) EPIVIR SOLN 10 MG/ML daily,30 days
3
QL(1 ea (Use Lamivudine) retail,30 days
COMPLERA TABS 3 daily,30 days mail)
retail,30 days QL(2 ea
mail) EPIVIR TABS 150 MG daily,30 days
3
QL(9 ea (Use Lamivudine) retail,30 days
CRIXIVAN CAPS 200 MG 2 daily,30 days mail)
retail,30 days QL(1 ea
mail) EPIVIR TABS 300 MG daily,30 days
3
QL(6 ea (Use Lamivudine) retail,30 days
2 daily,30 days mail)
CRIXIVAN CAPS 400 MG retail,30 days QL(1 ea
mail) EPZICOM TABS (Use daily,30 days
QL(1 ea
Abacavir Sulfate- 2
retail,30 days
Lamivudine) mail)
DESCOVY TABS 2 daily,30 days
retail,30 days
mail)

Ambetter Formulary Updated April 01, 2018

42
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
QL(4 ea QL(4 ea
fosamprenavir calcium tabs 1 daily,30 days
retail,30 days
KALETRA TABS 100MG-
25MG, 200MG-50MG
2 daily,30 days
retail,30 days
mail) mail)
PA; QL(30 QL(30 ml
FUZEON SOLR 4 days retail,30 1 daily,30 days
days mail); SP lamivudine soln 10 mg/ml retail,30 days
QL(1 ea mail)
GENVOYA TABS 3 daily,30 days QL(2 ea
retail,30 days lamivudine tabs 150 mg 1 daily,30 days
mail) retail,30 days
QL(4 ea mail)
INTELENCE TABS 100 2 daily,30 days QL(1 ea
MG retail,30 days lamivudine tabs 300 mg 1 daily,30 days
mail) retail,30 days
QL(2 ea mail)
INTELENCE TABS 200 2 daily,30 days QL(2 ea
MG retail,30 days lamivudine-zidovudine tabs 1 daily,30 days
mail) retail,30 days
QL(8 ea mail)
2 daily,30 days QL(56 ml
INTELENCE TABS 25 MG retail,30 days LEXIVA SUSP 50 MG/ML 2 daily,30 days
mail) retail,30 days
QL(10 ea mail)
2 daily,30 days QL(4 ea
INVIRASE CAPS 200 MG LEXIVA TABS 700 MG
retail,30 days (Use Fosamprenavir 2 daily,30 days
mail) retail,30 days
Calcium) mail)
QL(4 ea
2 daily,30 days QL(12.5 ml
INVIRASE TABS 500 MG retail,30 days lopinavir-ritonavir soln 1 daily,30 days
mail) retail,30 days
ISENTRESS CHEW 25 mail)
2
MG, 100 MG QL(40 ml
QL(2 ea NEVIRAPINE SUSP 50 1 daily,30 days
MG/5ML retail,30 days
ISENTRESS HD TABS 2 daily,30 days mail)
retail,30 days
mail) QL(2 ea
QL(2 ea nevirapine tabs 200 mg 1 daily,30 days
ISENTRESS TABS 400 retail,30 days
2 daily,30 days mail)
MG retail,30 days
mail) QL(3 ea
QL(30 days nevirapine tb24 100 mg 1 daily,30 days
JULUCA TABS 3 retail,30 days retail,30 days
mail) mail)
QL(12.5 ml QL(1 ea
KALETRA SOLN
400MG/5ML-100MG/5ML 2 daily,30 days nevirapine tb24 400 mg 1 daily,30 days
retail,30 days retail,30 days
(Use Lopinavir-Ritonavir) mail) mail)

Ambetter Formulary Updated April 01, 2018

43
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
QL(12 ea QL(2 ea
REYATAZ CAPS 150 MG,
NORVIR CAPS 100 MG 2 daily,30 days 200 MG (Use Atazanavir 2 daily,30 days
retail,30 days Sulfate) retail,30 days
mail) mail)
QL(15 ml QL(1 ea
NORVIR SOLN 80 MG/ML 2 daily,30 days REYATAZ CAPS 300 MG 2 daily,30 days
retail,30 days (Use Atazanavir Sulfate) retail,30 days
mail) mail)
QL(12 ea QL(12 ea
NORVIR TABS 100 MG 2 daily,30 days ritonavir tabs 1 daily,30 days
(Use Ritonavir) retail,30 days retail,30 days
mail) mail)
QL(1 ea SELZENTRY SOLN 20 2 QL(30 ml daily)
ODEFSEY TABS 3 daily,30 days MG/ML
retail,30 days QL(2 ea
mail) SELZENTRY TABS 150 daily,30 days
2
QL(12 ml MG retail,30 days
PREZISTA SUSP 100 2 daily,30 days mail)
MG/ML retail,30 days QL(4 ea
mail) SELZENTRY TABS 300 daily,30 days
2
QL(2 ea MG retail,30 days
PREZISTA TABS 75 MG, 2 daily,30 days mail)
150 MG, 600 MG retail,30 days QL(2 ea
mail) daily,30 days
QL(1 ea
stavudine caps 1
retail,30 days
2 daily,30 days mail)
PREZISTA TABS 800 MG retail,30 days QL(1 ea
mail) daily,30 days
STRIBILD TABS 3
QL(12 ea retail,30 days
RESCRIPTOR TABS 100 2 daily,30 days mail)
MG retail,30 days QL(2 ea
mail) SUSTIVA CAPS 200 MG daily,30 days
2
QL(6 ea (Use Efavirenz) retail,30 days
RESCRIPTOR TABS 200 2 daily,30 days mail)
MG retail,30 days QL(3 ea
mail) SUSTIVA CAPS 50 MG daily,30 days
2
QL(6 ea (Use Efavirenz) retail,30 days
RETROVIR CAPS 100 MG NF daily,30 days mail)
(Use Zidovudine) retail,30 days QL(1 ea
mail) SUSTIVA TABS 600 MG daily,30 days
2
RETROVIR IV INFUSION 1 (Use Efavirenz) retail,30 days
SOLN mail)
QL(60 ml tenofovir disoproxil 1
RETROVIR SYRP 50 NF daily,30 days fumarate tabs
MG/5ML (Use Zidovudine) retail,30 days QL(30 days
mail) TIVICAY TABS 10 MG, 25 3 retail,30 days
MG mail)

Ambetter Formulary Updated April 01, 2018

44
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
TIVICAY TABS 50 MG 3 QL(2 ea
VIRAMUNE TABS 200 MG NF daily,30 days
QL(1 ea (Use Nevirapine) retail,30 days
mail)
TRIUMEQ TABS 3 daily,30 days
retail,30 days QL(3 ea
mail) VIRAMUNE XR TB24 100 2 daily,30 days
QL(2 ea MG (Use Nevirapine) retail,30 days
TRIZIVIR TABS (Use mail)
Abacavir Sulfate- 2 daily,30 days
retail,30 days QL(1 ea
Lamivudine-Zidovudine) mail) VIRAMUNE XR TB24 400 2 daily,30 days
TRUVADA TABS 150MG- PA; QL(1 ea MG (Use Nevirapine) retail,30 days
100MG, 200MG-133MG, 2 daily,30 day(s) mail)
250MG-167MG limit)
VIREAD POWD 40 MG/GM 2
PA; QL(1 ea
TRUVADA TABS 300MG- 2 daily,30 days QL(1 ea
200MG retail,30 days VIREAD TABS 150 MG, 2 daily,30 days
mail) 200 MG, 250 MG retail,30 days
QL(1 ea mail)
TYBOST TABS 2 daily,30 days VIREAD TABS 300 MG
retail,30 days (Use Tenofovir Disoproxil 2
mail) Fumarate)
QL(2 ea VITEKTA TABS 3
VIDEX EC CPDR 125 MG 2 daily,30 days
retail,30 days QL(2 ea
mail) ZERIT CAPS 15 MG, 20
MG, 30 MG, 40 MG (Use NF daily,30 days
QL(2 ea retail,30 days
Stavudine) mail)
VIDEX EC CPDR 200 MG NF daily,30 days
(Use Didanosine) retail,30 days QL(80 ml
mail)
ZERIT SOLR 1 MG/ML 2 daily,30 days
QL(1 ea retail,30 days
VIDEX EC CPDR 250 MG, mail)
NF daily,30 days
400 MG (Use Didanosine) retail,30 days ZIAGEN SOLN 20 MG/ML
mail) 2
(Use Abacavir Sulfate)
VIDEXPEDIATRIC SOLR 2 QL(2 ea
ZIAGEN TABS 300 MG NF daily,30 days
QL(10 ea (Use Abacavir Sulfate) retail,30 days
daily,30 days mail)
VIRACEPT TABS 250 MG 2
retail,30 days QL(6 ea
mail)
zidovudine caps 100 mg 1 daily,30 days
QL(4 ea retail,30 days
daily,30 days mail)
VIRACEPT TABS 625 MG 2
retail,30 days QL(60 ml
mail)
zidovudine syrp 50 mg/5ml 1 daily,30 days
QL(40 ml retail,30 days
VIRAMUNE SUSP 50 1 daily,30 days mail)
MG/5ML retail,30 days QL(2 ea
mail)
zidovudine tabs 300 mg 1 daily,30 days
retail,30 days
mail)
Ambetter Formulary Updated April 01, 2018

45
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
CMV Agents PA; QL(1 ea
HEPSERA TABS (Use 4 daily,30 days
cidofovir soln 3 Adefovir Dipivoxil) retail,30 days
mail); SP
CYTOVENE SOLR (Use NF
Ganciclovir Sodium) QL(3 ea
ganciclovir sodium solr 1 lamivudine (hbv) tabs 1 daily,30 days
retail,30 days
mail); SP
VALCYTE TABS 450 MG NF PA; QL(4 ea
(Use Valganciclovir HCl) daily) MAVYRET TABS 4 PA; QL(3 ea
daily)
valganciclovir hcl tabs 450 1 PA; QL(4 ea
mg daily) MODERIBA 1200 DOSE 4 PA
PACK TABS
Hepatitis Agents MODERIBA 800 DOSE PA
PA; QL(1 ea 4
PACK TABS
adefovir dipivoxil tabs 4 daily,30 days PA; QL(0.143
retail,30 days PEG-INTRON REDIPEN
mail); SP 4 ea daily,30
KIT days retail,30
PA; QL(20 ml days mail); SP
BARACLUDE SOLN 0.05 4 daily,30 days PA; QL(0.143
MG/ML retail,30 days PEG-INTRON REDIPEN
mail); SP 4 ea daily,30
PAK 4 KIT days retail,30
PA; QL(1 ea days mail); SP
BARACLUDE TABS 0.5 4 daily,30 days PA; QL(0.0714
MG, 1 MG (Use Entecavir) retail,30 days PEGASYS PROCLICK
mail); SP 4 ml daily,30
SOLN days retail,30
COPEGUS TABS (Use NF PA; QL(7 ea days mail); SP
Ribavirin (Hepatitis C)) daily) PA; QL(0.0714
DAKLINZA TABS 30 MG, 4 PA; QL(1 ea
60 MG daily) PEGASYS SOLN 4 ml daily,30
days retail,30
PA; QL(1 ea days mail); SP
entecavir tabs 4 daily,30 days PA; QL(0.143
retail,30 days
mail); SP PEGINTRON KIT 4 ea daily,30
days retail,30
days mail); SP
EPCLUSA TABS 4 PA; QL(1 ea
daily) REBETOL CAPS 200 MG PA; QL(7 ea
PA; QL(60 ml (Use Ribavirin (Hepatitis NF daily)
EPIVIR HBV SOLN 5 C))
4 daily,30 days
MG/ML retail,30 days PA; QL(35 ml
mail); SP REBETOL SOLN 40 daily,30 days
4
QL(3 ea MG/ML retail,30 days
EPIVIR HBV TABS 100 mail); SP
MG (Use Lamivudine NF daily,30 days
retail,30 days RIBASPHERE RIBAPAK PA
(HBV)) mail); SP 4
TABS 400 MG, 600 MG
PA; QL(1 ea PA
RIBASPHERE TABS 4
HARVONI TABS 4 daily,30 days
retail,30 days PA; QL(7 ea
mail); SP ribavirin (hepatitis c) caps 1
daily)

Ambetter Formulary Updated April 01, 2018

46
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ribavirin (hepatitis c) tabs 1 PA; QL(7 ea oseltamivir phosphate caps 1 QL(0.34 ea
daily) 45 mg daily)
PA; QL(1 ea Limit 1 every 3
SOVALDI TABS 4 daily,30 days oseltamivir phosphate caps 1 months;QL(10
retail,30 days 75 mg ea per 90 days
mail); SP retail)
PA; QL(1 ea Limit 1 every 3
TYZEKA TABS 4 daily,30 days oseltamivir phosphate susr 1 months;QL(120
retail,30 days 6 mg/ml ml per 90 days
mail); SP retail)
Herpes Agents RELENZA DISKHALER 2
QL(1.67 ea AEPB
acyclovir caps 200 mg 1 rimantadine hydrochloride
daily) 1 QL(2 ea daily)
QL(13.34 ml tabs
acyclovir susp 200 mg/5ml 1
daily) TAMIFLU CAPS 30 MG QL(0.667 ea
(Use Oseltamivir NF daily)
acyclovir tabs 400 mg, 800 1 QL(5 ea daily)
Phosphate)
mg
famciclovir tabs 125 mg, QL(3 ea daily) TAMIFLU CAPS 45 MG QL(0.34 ea
250 mg 1 (Use Oseltamivir NF daily)
Phosphate)
famciclovir tabs 500 mg 1 QL(4 ea daily)
Limit 1 every 3
TAMIFLU CAPS 75 MG
FAMVIR TABS 125 MG, (Use Oseltamivir NF months;QL(10
NF QL(3 ea daily) Phosphate) ea per 90 days
250 MG (Use Famciclovir) retail)
FAMVIR TABS 500 MG NF QL(4 ea daily) Limit 1 every 3
(Use Famciclovir) TAMIFLU SUSR 6 MG/ML
valacyclovir hcl tabs 1 gm, QL(4 ea daily) (Use Oseltamivir NF months;QL(120
1 ml per 90 days
1000 mg Phosphate) retail)
valacyclovir hcl tabs 500 1 QL(2 ea daily) BETA BLOCKERS - Drugs to Treat High Blood
mg Pressure
VALTREX TABS 1 GM NF QL(4 ea daily)
(Use Valacyclovir HCl) Alpha-Beta Blockers
VALTREX TABS 500 MG NF QL(2 ea daily) carvedilol tabs 1
(Use Valacyclovir HCl)
COREG TABS (Use NF
ZOVIRAX CAPS OR 200 NF QL(1.67 ea Carvedilol)
MG (Use Acyclovir) daily)
ZOVIRAX SUSP OR 200 labetalol hcl soln 1
NF QL(13.34 ml
MG/5ML (Use Acyclovir) daily)
ZOVIRAX TABS OR 400 QL(5 ea daily) labetalol hcl tabs 1
MG, 800 MG (Use NF
Acyclovir) Beta Blockers Cardio-Selective
Influenza Agents acebutolol hcl caps 1
FLUMADINE TABS (Use QL(2 ea daily)
Rimantadine NF atenolol tabs 1
Hydrochloride)
betaxolol hcl tabs 1
oseltamivir phosphate caps 1 QL(0.667 ea
30 mg daily)

Ambetter Formulary Updated April 01, 2018

47
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
bisoprolol fumarate tabs 1 sotalol hcl tabs 240 mg 1

BYSTOLIC TABS 20 MG 2 PA; QL(2 ea sotalol hcl tabs 80 mg, 120 1 QL(2 ea daily)
daily) mg, 160 mg
BYSTOLIC TABS 5 MG, 10 2 PA; QL(1 ea TIMOLOL MALEATE TABS 1
MG, 2.5 MG daily)
LOPRESSOR TABS (Use NF CALCIUM CHANNEL BLOCKERS - Drugs to
Metoprolol Tartrate) Treat High Blood Pressure
metoprolol succinate tb24 1 Calcium Channel Blockers
ADALAT CC TB24 (Use
metoprolol tartrate soln iv 5 1 Nifedipine) NF
mg/5ml
metoprolol tartrate tabs or amlodipine besylate tabs 1
1
25 mg, 50 mg, 100 mg
CALAN SR TBCR (Use NF
SECTRAL CAPS (Use NF Verapamil HCl)
Acebutolol HCl)
CALAN TABS (Use NF
TENORMIN TABS (Use NF Verapamil HCl)
Atenolol)
CARDIZEM CD CP24 (Use
TOPROL XL TB24 (Use NF Diltiazem HCl Coated NF
Metoprolol Succinate) Beads)
ZEBETA TABS (Use NF CARDIZEM LA TB24 180
Bisoprolol Fumarate) MG, 240 MG, 300 MG, 360
Beta Blockers Non-Selective MG, 420 MG (Use NF
BETAPACE TABS (Use Diltiazem HCl Coated
NF QL(2 ea daily) Beads)
Sotalol HCl)
CORGARD TABS (Use CARDIZEM TABS (Use NF
Nadolol) NF Diltiazem HCl)
PA; QL(75 ml diltiazem hcl coated beads 1
HEMANGEOL SOLN 4 cp24
daily)
INDERAL LA CP24 (Use diltiazem hcl coated beads 1
Propranolol HCl) NF tb24
diltiazem hcl cp12 or 60 1
nadolol tabs 1 mg, 90 mg, 120 mg
diltiazem hcl cp24 or 120 1
pindolol tabs 1 mg, 180 mg, 240 mg
propranolol hcl cp24 or 60 diltiazem hcl extended
mg, 80 mg, 120 mg, 160 1 release beads cp24 120 1
mg mg, 180 mg, 240 mg, 300
propranolol hcl soln iv 1 mg, 360 mg
1 diltiazem hcl soln iv 50
mg/ml 1
PROPRANOLOL HCL mg/10ml
SOLN OR 20 MG/5ML, 40 1 DILTIAZEM HCL SOLR IV 1
MG/5ML 100 MG
propranolol hcl tabs or 10 diltiazem hcl tabs or 30 mg, 1
mg, 20 mg, 40 mg, 60 mg, 1 60 mg, 90 mg, 120 mg
80 mg
felodipine tb24 1

Ambetter Formulary Updated April 01, 2018

48
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
isradipine caps 1 digoxin tabs or 0.125 mg,
0.25 mg, 125 mcg, 250 1
nicardipine hcl caps 1 mcg
LANOXIN SOLN IJ 0.25 2
nicardipine hcl soln 1 MG/ML (Use Digoxin)
LANOXIN TABS OR 125
nifedipine caps 1 MCG, 250 MCG (Use 2
Digoxin)
nifedipine tb24 1 LANOXIN TABS OR 62.5 2
MCG, 187.5 MCG
nimodipine caps 1
CARDIOVASCULAR AGENTS - MISC. - Drugs to
NISOLDIPINE ER TB24 20 Treat Heart and Circulation Conditions
1
MG, 30 MG, 40 MG Cardiovascular Agents Misc. - Combinations
nisoldipine tb24 1 amlodipine besylate- 1 QL(1 ea daily)
atorvastatin calcium tabs
NORVASC TABS (Use NF
Amlodipine Besylate) BIDIL TABS 2
PROCARDIA CAPS (Use NF CADUET TABS (Use QL(1 ea daily)
Nifedipine) Amlodipine Besylate- NF
PROCARDIA XL TB24 NF Atorvastatin Calcium)
(Use Nifedipine) PA
ENTRESTO TABS 3
SULAR TB24 (Use NF
Nisoldipine) Impotence Agents
TIAZAC CP24 120 MG, PA; BPH
180 MG, 240 MG, 300 MG, CIALIS TABS 5 MG 3 Only;QL(1 ea
360 MG (Use Diltiazem NF daily)
HCl Extended Release
Beads) PA; QL(0.1334
sildenafil citrate tabs 1
ea daily)
verapamil hcl cp24 1 QL(0.134 ea
STENDRA TABS 3
daily)
verapamil hcl soln 1 VIAGRA TABS (Use PA; QL(0.1334
3
Sildenafil Citrate) ea daily)
verapamil hcl tabs 1
Prostaglandin Vasodilators
verapamil hcl tbcr 1 ORENITRAM TBCR 0.125 PA
MG, 0.25 MG, 1 MG, 2.5 3
VERELAN CP24 (Use NF MG
Verapamil HCl)
REMODULIN SOLN 4 PA; SP
VERELAN PM CP24 (Use NF
Verapamil HCl) PA; SP
VENTAVIS SOLN 4
CARDIOTONICS - Drugs to Treat Heart Failure
and Abnormal Heart Rhythm Pulmonary Hypertension - Endothelin Receptor
Cardiac Glycosides PA; QL(1 ea
digoxin soln ij 0.25 mg/ml 1 LETAIRIS TABS 4 daily,30 days
retail,30 days
DIGOXIN SOLN OR 0.05 mail); SP
1
MG/ML
Ambetter Formulary Updated April 01, 2018

49
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
OPSUMIT TABS 4 PA; QL(1 ea cefazolin sodium solr ij 1 1
daily) gm, 10 gm, 500 mg
PA; QL(2 ea CEFAZOLIN SODIUM 1
4 daily,30 days SOLR IJ 20 GM
TRACLEER TABS 125 MG retail,30 days cephalexin caps 250 mg,
mail); SP 1
500 mg, 750 mg
PA; QL(2 ea cephalexin susr 125
TRACLEER TABS 62.5 1
4 daily,30 days mg/5ml, 250 mg/5ml
MG retail,30 days
mail) CEPHALEXIN TABS 250 1
MG, 500 MG
PA; QL(2 ea
KEFLEX CAPS (Use
TRACLEER TBSO 32 MG 4 daily,30 days Cephalexin) NF
retail,30 days
mail) Cephalosporins - 2nd Generation
Pulmonary Hypertension - Phosphodiesterase cefaclor caps 250 mg, 500 1
PA; QL(2 ea mg
CEFACLOR SUSR 125
ADCIRCA TABS 4 daily,30 days MG/5ML, 250 MG/5ML, 1
retail,30 days
mail); SP 375 MG/5ML
REVATIO SOLN IV 10 PA; QL(37.5 ml CEFOTAN SOLR (Use NF
MG/12.5ML (Use Sildenafil Cefotetan Disodium)
4 daily,30 days
Citrate (Pulmonary retail,30 days cefotetan disodium solr 1
Hypertension)) mail); SP
PA; QL(3 ea CEFOTETAN SOLR 3
REVATIO TABS OR 20
MG (Use Sildenafil Citrate 4 daily,30 days cefoxitin sodium solr ij 10
retail,30 days
(Pulmonary Hypertension)) mail); SP gm 1
PA; QL(37.5 ml cefoxitin sodium solr iv 1
sildenafil citrate (pulmonary daily,30 days gm, 2 gm 1
hypertension) soln iv 10 4
retail,30 days
mg/12.5ml mail); SP cefprozil susr 1
PA; QL(3 ea cefprozil tabs 1
sildenafil citrate (pulmonary daily,30 days
hypertension) tabs or 20 4
retail,30 days
mg CEFTIN SUSR 125 1
mail); SP MG/5ML
Pulmonary Hypertension - Sol Guanylate Cyclase CEFTIN TABS 250 MG,
ADEMPAS TABS 0.5 MG, 500 MG (Use Cefuroxime NF
4 PA; QL(4 ea Axetil)
2 MG, 1.5 MG, 2.5 MG daily)
CEPHALOSPORINS - Drugs to Treat Bacterial cefuroxime axetil tabs 1
Infections cefuroxime sodium solr ij 1
Cephalosporins - 1st Generation 1.5 gm, 7.5 gm, 750 mg
cefadroxil caps 1 ZINACEF SOLR IJ 1.5 GM,
7.5 GM, 750 MG (Use NF
cefadroxil susr 1
Cefuroxime Sodium)
Cephalosporins - 3rd Generation
cefadroxil tabs 1

Ambetter Formulary Updated April 01, 2018

50
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
CEDAX CAPS 400 MG 1 CONTRACEPTIVES - Drugs to Prevent
Pregnancy
CEDAX SUSR 180 3
MG/5ML Combination Contraceptives - Oral
BEYAZ TABS (Use
cefdinir caps 1 Drospirenone-Ethinyl 0
Estradiol-Levomefolate
cefdinir susr 1 Calcium)
CEFDITOREN PIVOXIL BREVICON-28 TABS (Use
3 Norethindrone & Eth 0
TABS 200 MG
CEFDITOREN PIVOXIL Estradiol)
2 CYCLESSA TABS (Use
TABS 400 MG
ST Desogestrel-Ethinyl 0
cefixime susr 1 Estradiol (Triphasic))
cefotaxime sodium solr 1 DESOGEN TABS (Use
1 Desogestrel & Ethinyl 0
gm
Estradiol)
CEFOTAXIME SODIUM 1
SOLR 1 GM, 2 GM, 10 GM desogestrel & ethinyl 0
estradiol tabs
cefpodoxime proxetil susr 1 desogestrel-ethinyl 0
estradiol (biphasic) tabs
cefpodoxime proxetil tabs 1 desogestrel-ethinyl 0
ceftazidime solr ij 1 gm, 2 estradiol (triphasic) tabs
1
gm, 6 gm drospirenone-ethinyl 0
CEFTIBUTEN CAPS 400 estradiol tabs
1
MG drospirenone-ethinyl
CEFTIBUTEN SUSR 180 estradiol-levomefolate 0
3 calcium tabs
MG/5ML
ceftriaxone sodium solr ij 1 ESTROSTEP FE TABS
1 (Use Norethindrone
gm, 2 gm, 250 mg, 500 mg 0
FORTAZ SOLR IJ 1 GM, 2 Acetate-Ethinyl Estradiol-
GM, 6 GM (Use NF Fe)
Ceftazidime) ethynodiol diacet & eth 0
estrad tabs
SPECTRACEF TABS 2 FEMCON FE CHEW (Use
SUPRAX SUSR 100 ST Norethindrone & Ethinyl 0
MG/5ML, 200 MG/5ML NF Estradiol-Fe)
(Use Cefixime) GENERESS FE CHEW
(Use Norethindrone & 0
Cephalosporins - 4th Generation Ethinyl Estradiol-Fe)
cefepime hcl solr 1 levonorgestrel & eth 0
estradiol tabs
MAXIPIME SOLR IJ 1 GM, NF
2 GM (Use Cefepime HCl) levonorgestrel-eth estradiol 0
(triphasic) tabs
Cephalosporins - 5th Generation levonorgestrel-ethinyl 0
TEFLARO SOLR 3 estradiol (91-day) tabs

Ambetter Formulary Updated April 01, 2018

51
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
levonorgestrel-ethinyl 0 norethindrone-eth estradiol 0
estradiol (continuous) tabs (triphasic) tabs
LO LOESTRIN FE TABS 0 norgestimate-ethinyl 0
estradiol (triphasic) tabs
LOESTRIN 1.5/30-21 norgestimate-ethinyl
TABS (Use Norethindrone 0 0
estradiol tabs
Acet & Eth Estra) norgestrel & ethinyl
LOESTRIN 1/20-21 TABS 0
estradiol tabs
(Use Norethindrone Acet & 0 NORINYL 1+35 TABS (Use
Eth Estra) Norethindrone & Eth 0
LOESTRIN FE 1.5/30 Estradiol)
TABS (Use Norethin Acet & 0
Estrad-Fe) NORINYL 1+50 TABS 0
LOESTRIN FE 1/20 TABS
(Use Norethin Acet & 0 OGESTREL TABS 0
Estrad-Fe) ORTHO TRI-CYCLEN LO
LOSEASONIQUE TABS TABS (Use Norgestimate-
(Use Levonorgestrel- 0 0
Ethinyl Estradiol
Ethinyl Estradiol (91-Day)) (Triphasic))
MINASTRIN 24 FE CHEW ORTHO TRI-CYCLEN
(Use Norethin Acet & 0 TABS (Use Norgestimate-
Estrad-Fe) 0
Ethinyl Estradiol
MIRCETTE TABS (Use (Triphasic))
Desogestrel-Ethinyl 0 ORTHO-CYCLEN TABS
Estradiol (Biphasic)) (Use Norgestimate-Ethinyl 0
MODICON TABS (Use Estradiol)
Norethindrone & Eth 0 ORTHO-NOVUM 1/35
Estradiol) TABS (Use Norethindrone 0
& Eth Estradiol)
NATAZIA TABS 0
ORTHO-NOVUM 7/7/7
NECON 1/50-28 TABS 0 TABS (Use Norethindrone- 0
Eth Estradiol (Triphasic))
NECON 10/11-28 TABS 0 OVCON-35 TABS (Use
Norethindrone & Eth 0
norethin acet & estrad-fe 0 Estradiol)
chew SAFYRAL TABS (Use
norethin acet & estrad-fe 0 Drospirenone-Ethinyl
tabs 0
Estradiol-Levomefolate
norethindrone & eth Calcium)
0
estradiol tabs SEASONIQUE TABS (Use
norethindrone & ethinyl Levonorgestrel-Ethinyl 0
0 Estradiol (91-Day))
estradiol-fe chew
norethindrone acet & eth TRI-NORINYL 28 TABS
0 (Use Norethindrone-Eth 0
estra tabs
norethindrone acetate- Estradiol (Triphasic))
0 YASMIN 28 TABS (Use
ethinyl estradiol-fe tabs
Drospirenone-Ethinyl 0
Estradiol)
Ambetter Formulary Updated April 01, 2018

52
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
YAZ TABS (Use medroxyprogesterone QL(1 ml per 90
Drospirenone-Ethinyl 0 acetate (contraceptive) 0 days retail)
Estradiol) susp
Combination Contraceptives - Transdermal medroxyprogesterone QL(1 ml per 90
acetate (contraceptive) 0 days retail)
XULANE PTWK 0 susy
Combination Contraceptives - Vaginal Progestin Contraceptives - Oral
NOR-QD TABS (Use
NUVARING RING 0 Norethindrone 0
(Contraceptive))
Copper Contraceptives - IUD
norethindrone 0
PARAGARD (contraceptive) tabs
INTRAUTERINE COPPER 0
CONTRACEPTIVE T380A ORTHO MICRONOR
IUD TABS (Use Norethindrone 0
(Contraceptive))
Emergency Contraceptives
CORTICOSTEROIDS - Steroid Hormone Drugs to
ELLA TABS 0 Treat Systemic Swelling Conditions
levonorgestrel (emergency Glucocorticosteroids
0
oc) tabs budesonide cpep 1 PA
PLAN B ONE-STEP TABS
(Use Levonorgestrel 0 CORTEF TABS (Use NF
(Emergency OC)) Hydrocortisone)
Progestin Contraceptives - IUD CORTISONE ACETATE 1
TABS
KYLEENA IUD 0 DEPO-MEDROL SUSP 20 3
MG/ML
LILETTA IUD 0 DEPO-MEDROL SUSP 40
MG/ML, 80 MG/ML (Use NF
MIRENA IUD 0 Methylprednisolone
Acetate)
SKYLA IUD 0
dexamethasone elix 0.5 1
Progestin Contraceptives - Implants mg/5ml
DEXAMETHASONE 1
NEXPLANON IMPL 0 INTENSOL CONC
Progestin Contraceptives - Injectable dexamethasone sodium
phosphate soln ij 4 mg/ml, 1
DEPO-PROVERA QL(1 ml per 90 20 mg/5ml, 120 mg/30ml
CONTRACEPTIVE SUSP 0 days retail)
(Use Medroxyprogesterone DEXAMETHASONE SOLN 1
Acetate (Contraceptive)) 0.5 MG/5ML
DEPO-PROVERA QL(1 ml per 90 dexamethasone tabs 0.75
CONTRACEPTIVE SUSY mg, 0.5 mg, 4 mg, 6 mg, 1
NF days retail) 1.5 mg
(Use Medroxyprogesterone
Acetate (Contraceptive)) DEXAMETHASONE TABS 1
DEPO-SUBQ PROVERA 1 MG, 2 MG
0 ENTOCORT EC CPEP
104 SUSY NF PA
(Use Budesonide)

Ambetter Formulary Updated April 01, 2018

53
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
hydrocortisone tabs 1 PREDNISONE SOLN 5 1
MG/5ML
KENALOG-40 SUSP (Use 3 prednisone tabs 1 mg, 5
Triamcinolone Acetonide) 1
mg, 10 mg, 20 mg, 2.5 mg
MEDROL DOSEPAK TBPK NF PREDNISONE TABS 50
(Use Methylprednisolone) 1
MG
MEDROL TABS 2 MG 3 PREDNISONE TBPK 5 1
MG, 10 MG
MEDROL TABS 4 MG, 8 SOLU-CORTEF SOLR 250
MG, 16 MG, 32 MG (Use NF 3
MG
Methylprednisolone)
SOLU-MEDROL SOLR 2 3
methylprednisolone acetate 1 GM
susp
SOLU-MEDROL SOLR 40
methylprednisolone sod 1 MG, 125 MG, 1000 MG
succ solr NF
(Use Methylprednisolone
methylprednisolone tabs 1 Sod Succ)
SOLU-MEDROL SOLR 500 1
methylprednisolone tbpk 1 MG
triamcinolone acetonide 1
MILLIPRED DP TBPK 3 susp
MILLIPRED SOLN 10 VERIPRED 20 SOLN (Use
MG/5ML (Use Prednisolone Sodium NF
NF Phosphate)
Prednisolone Sodium
Phosphate) Mineralocorticoids
MILLIPRED TABS 5 MG 3 fludrocortisone acetate tabs 1
ORAPRED ODT TBDP COUGH/COLD/ALLERGY - Drugs to Treat
(Use Prednisolone Sodium 3 Cough, Cold and Allergy Symptoms
Phosphate)
PEDIAPRED SOLN (Use Antitussives
Prednisolone Sodium NF QL(6 ea
Phosphate) benzonatate caps 100 mg 1 daily,10 days
PREDNISOLONE SODIUM retail,10 days
PHOSPHATE SOLN OR 1 mail)
25 MG/5ML QL(3 ea
prednisolone sodium benzonatate caps 200 mg 1 daily,10 days
phosphate soln or 5 retail,10 days
mg/5ml, 10 mg/5ml, 15 1 mail)
mg/5ml, 20 mg/5ml, 6.7 QL(6 ea
mg/5ml TESSALON PERLES NF daily,10 days
prednisolone sodium CAPS (Use Benzonatate) retail,10 days
phosphate tbdp or 10 mg, 3 mail)
15 mg, 30 mg Cough/Cold/Allergy Combinations
prednisolone soln 1

prednisolone syrp 1

Ambetter Formulary Updated April 01, 2018

54
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ALLEGRA-D 12 HOUR QL(2 ea daily) HYPERSAL NEBU 7 %
ALLERGY & (Use Sodium Chloride NF
CONGESTION TB12 (Use NF (Inhalant))
Fexofenadine-
Pseudoephedrine) NEBUSAL NEBU 1
ALLEGRA-D 24 HOUR QL(1 ea daily) sodium chloride (inhalant)
ALLERGY & 1
nebu 7 %
CONGESTION TB24 (Use NF
Fexofenadine- Mucolytics
Pseudoephedrine) acetylcysteine soln 1
cetirizine-pseudoephedrine 1 QL(2 ea daily)
tb12 DERMATOLOGICALS - Drugs to Treat Skin
CLARITIN-D 12 HOUR QL(2 ea daily) Conditions
TB12 (Use Loratadine & 1 Acne Products
Pseudoephedrine) PA; AL; At least
CLARITIN-D 24 HOUR QL(1 ea daily) adapalene crea 0.1 % 1
12 yrs old
TB24 (Use Loratadine & 1 PA; AL; At least
Pseudoephedrine) adapalene gel 0.1 % 1 12 yrs old;
fexofenadine- QL(2 ea daily) RX/OTC
pseudoephedrine tb12 1
60mg-120mg adapalene gel 0.3 % 1 ST; AL; At least
12 yrs old
fexofenadine- QL(1 ea daily)
pseudoephedrine tb24 1 ADAPALENE LOTN 0.1 % 1 ST; AL; At least
12 yrs old
180mg-240mg
adapalene-benzoyl 1 ST; AL; At least
FLOWTUSS SOLN 2 peroxide gel 12 yrs old
loratadine & QL(2 ea daily) AZELEX CREA 3 ST; AL; At least
pseudoephedrine tb12 1 12 yrs old
5mg-120mg BENZACLIN GEL (Use PA; AL; At least
loratadine & QL(1 ea daily) Clindamycin Phosphate- NF 12 yrs old
pseudoephedrine tb24 Benzoyl Peroxide)
1 BENZACLIN WITH PUMP PA; AL; At least
10mg-240mg, 10mg-10mg-
240mg-240mg GEL (Use Clindamycin NF 12 yrs old
Phosphate-Benzoyl
OBREDON SOLN 2 Peroxide)
PA BENZAMYCIN GEL (Use PA; AL; At least
VITUZ SOLN 3 Benzoyl Peroxide- NF 12 yrs old
ZYRTEC-D QL(2 ea daily) Erythromycin)
ALLERGY/CONGESTION AL; At least 12
1 BENZEFOAM FOAM (Use NF yrs old;
TB12 (Use Cetirizine- Benzoyl Peroxide)
Pseudoephedrine) RX/OTC
Misc. Respiratory Inhalants BENZEFOAM ULTRA AL; At least 12
FOAM (Use Benzoyl NF yrs old
HYPER-SAL NEBU (Use Peroxide)
Sodium Chloride (Inhalant)) NF
BENZEFOAMULTRA AL; At least 12
HYPERSAL NEBU 3.5 % 1 FOAM (Use Benzoyl NF yrs old
Peroxide)

Ambetter Formulary Updated April 01, 2018

55
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
benzoyl peroxide foam 5.3 AL; At least 12 clindamycin phosphate- 1 PA; AL; At least
% 1 yrs old; benzoyl peroxide gel 12 yrs old
RX/OTC clindamycin phosphate- 1 ST; AL; At least
benzoyl peroxide foam 9.8 1 AL; At least 12 tretinoin gel 12 yrs old
% yrs old
CLINDAP-T CREA 3 PA; AL; At least
AL; At least 12 12 yrs old
benzoyl peroxide gel 10 % 1 yrs old; DESQUAM-X WASH LIQD AL; At least 12
RX/OTC 10 % (Use Benzoyl NF yrs old;
benzoyl peroxide gel 5 % 1 AL; At least 12 Peroxide) RX/OTC
yrs old DIFFERIN CREA 0.1 % NF PA; AL; At least
AL; At least 12 (Use Adapalene) 12 yrs old
benzoyl peroxide liqd 10 % 1 yrs old;
RX/OTC DIFFERIN GEL 0.1 % (Use NF PA; AL; At least
12 yrs old;
benzoyl peroxide liqd 4 %, Adapalene)
1 AL; At least 12 RX/OTC
7% yrs old DIFFERIN GEL 0.3 % (Use NF ST; AL; At least
AL; At least 12 Adapalene) 12 yrs old
benzoyl peroxide lotn 6 % 1 yrs old;
RX/OTC DIFFERIN LOTN 0.1 % 1 ST; AL; At least
12 yrs old
benzoyl peroxide- 1 PA; AL; At least DUAC GEL (Use PA; AL; At least
erythromycin gel 12 yrs old Clindamycin Phosphate- NF 12 yrs old
BP CLEANSING WASH 2 AL; At least 12 Benzoyl Peroxide
EMUL yrs old (Refrigerate))
CLEOCIN-T GEL (Use AL; At least 12 EPIDUO GEL (Use ST; AL; At least
Clindamycin Phosphate NF yrs old Adapalene-Benzoyl 3 12 yrs old
(Topical)) Peroxide)
CLEOCIN-T LOTN (Use AL; At least 12 erythromycin (acne aid) 1 AL; At least 12
Clindamycin Phosphate NF yrs old pads yrs old
(Topical)) erythromycin (acne aid) 1 AL; At least 12
CLEOCIN-T SOLN (Use AL; At least 12 soln yrs old
Clindamycin Phosphate NF yrs old EVOCLIN FOAM (Use PA; AL; At least
(Topical)) Clindamycin Phosphate NF 12 yrs old
CLEOCIN-T SWAB (Use AL; At least 12 (Topical))
Clindamycin Phosphate NF yrs old
(Topical)) isotretinoin caps 3 PA; AL; At least
12 yrs old
clindamycin phosphate 1 PA; AL; At least KLARON LOTN (Use AL; At least 12
(topical) foam 12 yrs old Sulfacetamide Sodium NF yrs old
clindamycin phosphate 1 AL; At least 12 (Acne))
(topical) gel yrs old PANOXYL-4 CREAMY AL; At least 12
clindamycin phosphate 1 AL; At least 12 WASH LIQD (Use Benzoyl NF yrs old
(topical) lotn yrs old Peroxide)
clindamycin phosphate 1 AL; At least 12 RETIN-A CREA (Use NF AL; At least 12
(topical) soln yrs old Tretinoin) yrs old
clindamycin phosphate 1 AL; At least 12 RETIN-A GEL (Use NF AL; At least 12
(topical) swab yrs old Tretinoin) yrs old
clindamycin phosphate- PA; AL; At least RETIN-A MICRO GEL 0.1 PA; AL; At least
benzoyl peroxide 1 12 yrs old % (Use Tretinoin NF 12 yrs old
(refrigerate) gel Microsphere)
Ambetter Formulary Updated April 01, 2018

56
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
RETIN-A MICRO PUMP PA; AL; At least CORTISPORIN CREA 2
GEL 0.1 % (Use Tretinoin NF 12 yrs old
Microsphere) CORTISPORIN OINT 2
sulfacetamide sodium 1 AL; At least 12
(acne) lotn yrs old gentamicin sulfate (topical) 1 QL(1 gm daily)
sulfacetamide sodium crea
1 AL; At least 12 gentamicin sulfate (topical)
(acne) susp yrs old 1
sulfacetamide sodium w/ oint
1 AL; At least 12 mupirocin calcium (topical)
sulfur crea 5%-10% yrs old 1
sulfacetamide sodium w/ crea
1 AL; At least 12
sulfur emul 5%-10% yrs old mupirocin oint 1
sulfacetamide sodium w/ 1 ST; AL; At least
sulfur liqd 4.5%-9% 12 yrs old NEO-SYNALAR CREA 3 PA
SUMADAN WASH LIQD ST; AL; At least
(Use Sulfacetamide NF 12 yrs old Antifungals - Topical
Sodium w/ Sulfur) butenafine hcl crea 1 RX/OTC
tretinoin crea 0.025 %, 0.05 1 AL; At least 12
%, 0.1 % yrs old ciclopirox gel 0.77 % 1
tretinoin gel 0.025 %, 0.01 1 AL; At least 12
% yrs old ciclopirox olamine crea 1
tretinoin microsphere gel 1 PA; AL; At least
0.1 % 12 yrs old ciclopirox olamine susp 1
TRISEON CREA 3 PA; AL; At least ciclopirox sham 1 % 1
12 yrs old
ZIANA GEL (Use ST; AL; At least ciclopirox soln 8 % 1
Clindamycin Phosphate- NF 12 yrs old
Tretinoin) RX/OTC
clotrimazole (topical) crea 1
Agents for External Genital and Perianal Warts
clotrimazole (topical) soln 1 RX/OTC
VEREGEN OINT 3
clotrimazole w/ 1
Anti-inflammatory Agents - Topical betamethasone crea
diclofenac sodium (topical) 1 QL(3.34 gm clotrimazole w/
gel 1 % daily) 1
betamethasone lotn
FLECTOR PTCH 3 PA; QL(2 ea econazole nitrate crea 1
daily)
VOLTAREN GEL (Use QL(3.34 gm ERTACZO CREA 3
Diclofenac Sodium NF daily)
(Topical))
EXELDERM CREA 3
Antibiotics - Topical
EXELDERM SOLN 3
ALTABAX OINT 2
JUBLIA SOLN 3 PA
BACTROBAN CREA (Use
Mupirocin Calcium NF
(Topical)) KERYDIN SOLN 3 PA
BACTROBAN OINT (Use NF
Mupirocin) ketoconazole (topical) crea 1

Ambetter Formulary Updated April 01, 2018

57
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ketoconazole (topical) 1 OXISTAT CREA (Use NF
sham Oxiconazole Nitrate)
LOPROX CREA 0.77 % NF OXISTAT LOTN 2
(Use Ciclopirox Olamine)
LOPROX SHAMPOO PENLAC NAIL LACQUER NF
NF SOLN (Use Ciclopirox)
SHAM (Use Ciclopirox)
LOPROX SUSP 0.77 % NF Antineoplastic or Premalignant Lesion Agents -
(Use Ciclopirox Olamine) diclofenac sodium (actinic
LOTRIMIN AF CREA 1 % RX/OTC 1 PA; QL(3.34
keratoses) gel gm daily)
(Use Clotrimazole NF EFUDEX CREA (Use
(Topical)) NF
Fluorouracil (Topical))
LOTRIMIN AF FOR HER RX/OTC
CREA (Use Clotrimazole NF fluorouracil (topical) crea 1
(Topical))
LOTRIMIN AF JOCK ITCH RX/OTC fluorouracil (topical) soln 1
CREA (Use Clotrimazole NF
(Topical)) PANRETIN GEL 3

LOTRIMIN ULTRA CREA 1 RX/OTC PICATO GEL 2


LOTRIMIN ULTRA CREA 1 RX/OTC SOLARAZE GEL (Use PA; QL(3.34
(Use Butenafine HCl) Diclofenac Sodium (Actinic NF gm daily)
LOTRISONE CREA (Use Keratoses))
Clotrimazole w/ NF TARGRETIN GEL EX 1 % 4 PA; SP
Betamethasone)
LUZU CREA 3 PA Antipruritics - Topical
DOXEPIN 3 PA
MENTAX CREA 1 RX/OTC HYDROCHLORIDE CREA
PRUDOXIN CREA 3 PA
naftifine hcl crea 1
ZONALON CREA 3 PA
NAFTIN CREA 2 % (Use NF
Naftifine HCl)
Antipsoriatics
NAFTIN GEL 1 % 3 PA; QL(4 ea
8-MOP CAPS 3
NIZORAL SHAM (Use daily)
NF acitretin caps 10 mg, 17.5 QL(1 ea daily)
Ketoconazole (Topical)) 1
mg
nystatin (topical) crea 1
acitretin caps 25 mg 1 QL(2 ea daily)
nystatin (topical) oint 1
calcipotriene crea 1 QL(4 gm daily)
nystatin (topical) powd 1
calcipotriene oint 1 QL(4 gm daily)
nystatin-triamcinolone crea 1
calcipotriene soln 1 QL(4 ml daily)
nystatin-triamcinolone oint 1
CALCITRIOL OINT EX 3 1
MCG/GM
oxiconazole nitrate crea 1

Ambetter Formulary Updated April 01, 2018

58
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
COSENTYX 4 PA SULFAMYLON CREA 85 3
SENSOREADY PEN SOAJ MG/GM
COSENTYX SOSY 4 PA SULFAMYLON PACK 5 % 3
(Use Mafenide Acetate)
DOVONEX CREA (Use NF QL(4 gm daily) Corticosteroids - Topical
Calcipotriene)
ACLOVATE CREA (Use
methoxsalen rapid caps 1 QL(4 ea daily) Alclometasone NF
Dipropionate)
OXSORALEN ULTRA QL(4 ea daily)
CAPS (Use Methoxsalen NF alclometasone dipropionate 1
Rapid) crea
SORIATANE CAPS 10 QL(1 ea daily) alclometasone dipropionate 1
MG, 17.5 MG (Use NF oint
Acitretin) AMCINONIDE CREA 1
SORIATANE CAPS 25 MG NF QL(2 ea daily)
(Use Acitretin) AMCINONIDE LOTN 3
STELARA SOSY SC 90 4 PA; SP
MG/ML, 45 MG/0.5ML AMCINONIDE OINT 3
tazarotene crea 1 betamethasone 1
dipropionate (topical) crea
TAZORAC CREA 0.05 % 2 betamethasone 1
dipropionate (topical) lotn
TAZORAC CREA 0.1 % 2
(Use Tazarotene) betamethasone 1
dipropionate (topical) oint
TAZORAC GEL 0.05 %, 2
0.1 % betamethasone
dipropionate augmented 1
VECTICAL OINT 1 crea
betamethasone
Antiseborrheic Products dipropionate augmented 1
selenium sulfide lotn 2.5 % 1 lotn
betamethasone
Antivirals - Topical dipropionate augmented 1
oint
acyclovir topical oint 1
betamethasone valerate 1
DENAVIR CREA 3 crea
betamethasone valerate 1
ZOVIRAX CREA EX 5 % 3 foam
betamethasone valerate 1
ZOVIRAX OINT EX 5 % NF lotn
(Use Acyclovir Topical)
betamethasone valerate 1
Burn Products oint
mafenide acetate pack 3 calcipotriene- ST
betamethasone 1
SILVADENE CREA (Use NF dipropionate oint
Silver Sulfadiazine) QL(3 gm daily)
clobetasol propionate crea 1
silver sulfadiazine crea 1

Ambetter Formulary Updated April 01, 2018

59
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
clobetasol propionate 1 QL(3 gm daily) desoximetasone crea 0.25 1
emollient base crea %
ST; QL(3 gm desoximetasone gel 0.05 % 1
clobetasol propionate foam 1
daily)
ST; QL(2 gm desoximetasone oint 0.25 1
clobetasol propionate gel 1
daily) %
QL(4 gm daily) DIFLORASONE 2
clobetasol propionate oint 1 DIACETATE CREA
QL(3.34 ml DIFLORASONE
clobetasol propionate soln 1
daily) DIACETATE OINT
1
CLOCORTOLONE 3 DIPROLENE AF CREA
PIVALATE CREA (Use Betamethasone NF
CLOCORTOLONE Dipropionate Augmented)
3
PIVALATE PUMP CREA DIPROLENE LOTN (Use
Betamethasone NF
CLODERM CREA 3 Dipropionate Augmented)
CLODERM PUMP CREA 3 DIPROLENE OINT (Use
Betamethasone NF
CORDRAN CREA 0.05 % Dipropionate Augmented)
NF
(Use Flurandrenolide) ELOCON CREA (Use NF
CORDRAN TAPE 4 Mometasone Furoate)
3
MCG/SQCM ELOCON OINT (Use NF
Mometasone Furoate)
CORDRAN TAPE TAPE 3
fluocinolone acetonide crea 1
CUTIVATE CREA (Use NF 0.025 %, 0.01 %
Fluticasone Propionate) fluocinolone acetonide oil
CUTIVATE LOTN (Use 1
NF 0.01 %
Fluticasone Propionate) fluocinolone acetonide oint
DERMA-SMOOTHE/FS 1
0.025 %
SCALP OIL (Use NF fluocinolone acetonide soln
Fluocinolone Acetonide) 1
0.01 %
DERMACINRX SILAPAK PA
KIT (Use Triamcinolone fluocinonide crea 0.05 % 1
NF
Acetonide-Dimethicone- fluocinonide emulsified
Silicone) 1
base crea
DERMATOP CREA (Use NF
Prednicarbate) fluocinonide gel 0.05 % 1
desonide crea 1 QL(4 gm daily)
fluocinonide oint 0.05 % 1
desonide lotn 1 QL(4 ml daily)
fluocinonide soln 0.05 % 1
desonide oint 1 QL(3 gm daily) QL(2 gm daily)
flurandrenolide crea 2
DESOWEN CREA (Use NF QL(4 gm daily) QL(2 ml daily)
Desonide) flurandrenolide lotn 2
DESOWEN LOTN (Use NF QL(4 ml daily) fluticasone propionate crea 1
Desonide) ex 0.05 %

Ambetter Formulary Updated April 01, 2018

60
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
fluticasone propionate lotn 1 MONISTAT SOOTHING RX/OTC
ex 0.05 % CARE ITCH RELIEF CREA NF
fluticasone propionate oint (Use Hydrocortisone
1 (Topical))
ex 0.005 %
halobetasol propionate OLUX FOAM (Use NF ST; QL(3 gm
1 Clobetasol Propionate) daily)
crea
halobetasol propionate oint 1 prednicarbate crea 1

HALOG CREA 3 PA PSORCON CREA 2


PA SYNALAR CREA (Use NF
HALOG OINT 3 Fluocinolone Acetonide)
hydrocortisone (topical) RX/OTC SYNALAR OINT (Use NF
1 Fluocinolone Acetonide)
crea 1%, 1 %
hydrocortisone (topical) SYNALAR SOLN (Use NF
1 Fluocinolone Acetonide)
crea 2.5 %
hydrocortisone (topical) TACLONEX OINT (Use ST
1 Calcipotriene-
lotn 2.5 % NF
hydrocortisone (topical) RX/OTC Betamethasone
1 Dipropionate)
oint 1 %
hydrocortisone (topical) TACLONEX SUSP 3 ST
1
oint 2.5 %
TEMOVATE CREA (Use NF QL(3 gm daily)
hydrocortisone butyrate 1 Clobetasol Propionate)
crea
TEMOVATE E CREA (Use QL(3 gm daily)
hydrocortisone butyrate 1 Clobetasol Propionate NF
oint Emollient Base)
hydrocortisone butyrate TEMOVATE GEL (Use
soln 1 NF ST; QL(2 gm
Clobetasol Propionate) daily)
hydrocortisone valerate TEMOVATE OINT (Use
crea 1 NF QL(4 gm daily)
Clobetasol Propionate)
hydrocortisone valerate TEMOVATE SOLN (Use
oint 1 NF QL(3.34 ml
Clobetasol Propionate) daily)
LOCOID CREA (Use NF TOPICORT CREA 0.25 %
Hydrocortisone Butyrate) NF
(Use Desoximetasone)
LOCOID OINT (Use NF TOPICORT GEL 0.05 %
Hydrocortisone Butyrate) NF
(Use Desoximetasone)
LOCOID SOLN (Use NF TOPICORT OINT 0.25 %
Hydrocortisone Butyrate) NF
(Use Desoximetasone)
LUXIQ FOAM (Use NF triamcinolone acetonide
Betamethasone Valerate) (topical) crea 0.025 %, 0.1 1
mometasone furoate crea 1 %, 0.5 %
triamcinolone acetonide
mometasone furoate oint 1 (topical) lotn 0.025 %, 0.1 1
%
mometasone furoate soln 1

Ambetter Formulary Updated April 01, 2018

61
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
triamcinolone acetonide Immunosuppressive Agents - Topical
(topical) oint 0.025 %, 0.1 1
%, 0.5 % ELIDEL CREA 2 PA; AL; At least
2 yrs old
triamcinolone acetonide- PA
PROTOPIC OINT (Use NF AL; At least 2
1
dimethicone-silicone kit Tacrolimus (Topical)) yrs old
TRIDESILON CREA (Use NF QL(4 gm daily)
Desonide) tacrolimus (topical) oint 1 AL; At least 2
yrs old
ULTRAVATE CREA (Use NF
Halobetasol Propionate) Keratolytic/Antimitotic Agents
ULTRAVATE OINT (Use CONDYLOX SOLN (Use NF
NF Podofilox)
Halobetasol Propionate)
WESTCORT OINT (Use NF podofilox soln 1
Hydrocortisone Valerate)
Eczema Agents Local Anesthetics - Topical
PA EMLA CREA (Use NF
DUPIXENT SOSY 4 Lidocaine-Prilocaine)
lidocaine hcl gel ex 2 % 1 RX/OTC
Emollients
LAC-HYDRIN CREA (Use RX/OTC
Lactic Acid (Ammonium NF lidocaine hcl soln ex 4 % 1
Lactate)) PA
LAC-HYDRIN LOTN (Use RX/OTC lidocaine ptch 5 % 1
Lactic Acid (Ammonium NF
Lactate)) lidocaine-prilocaine crea 1
LAC-HYDRIN TWELVE RX/OTC LIDODERM PTCH (Use
LOTN (Use Lactic Acid NF PA
NF Lidocaine)
(Ammonium Lactate))
SYNERA PTCH 3
lactic acid (ammonium 1 RX/OTC
lactate) crea 12 % XYLOCAINE SOLN EX 4 NF
lactic acid (ammonium RX/OTC % (Use Lidocaine HCl)
1
lactate) lotn 12 % Pigmenting-Depigmenting Agents
Enzymes - Topical OXSORALEN LOTN 2
SANTYL OINT 3
Rosacea Agents
Hair Growth Agents FINACEA GEL 2 PA
finasteride (alopecia) tabs 1
METROCREAM CREA
PROPECIA TABS (Use (Use Metronidazole NF
NF (Topical))
Finasteride (Alopecia))
Immunomodulating Agents - Topical METROGEL GEL (Use NF
Metronidazole (Topical))
QL(12 ea per
ALDARA CREA (Use NF fill retail,12 ea METROLOTION LOTN
Imiquimod) per fill mail) (Use Metronidazole NF
(Topical))
QL(12 ea per
imiquimod crea 1 fill retail,12 ea metronidazole (topical) 1
per fill mail) crea

Ambetter Formulary Updated April 01, 2018

62
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
metronidazole (topical) gel 1 CHEMSTRIP-K STRP 1

metronidazole (topical) lotn 1 KETOCARE STRP 1


PA; QL(1 gm KETONE TEST STRIPS
MIRVASO GEL 3 1
daily) STRP
Scabicides & Pediculicides KETOSTIX STRP 1
ELIMITE CREA (Use NF
Permethrin) NOVA MAX PLUS
KETONE TESTSTRIPS 1
EURAX CREA 3 STRP
PRECISION XTRA STRP 1
EURAX LOTN 3 VI
PTS PANELS KETONE 1
LINDANE LOTN 3 TEST STRP
LINDANE SHAM 3 RELION KETONE STRP 1
RELION KETONE TEST 1
lindane sham 3 STRIPS STRP
malathion lotn 1 Limit 100 per
TRUE METRIX BLOOD month;QL(3.34
GLUCOSETEST STRIPS 1
NATROBA SUSP 1 PA ea daily);
STRP RX/OTC
OVIDE LOTN (Use NF TRUE METRIX BLOOD QL(3.34 ea
Malathion) GLUCOSETEST STRIPS 1 daily); RX/OTC
STRP
permethrin crea ex 5 % 1
Limit 100 per
PA TRUE METRIX SELF
SKLICE LOTN 3 month;QL(3.34
MONITORING BLOOD 1
ea daily);
PA GLUCOSE STRIPS STRP
SPINOSAD SUSP 1 RX/OTC
Limit 100 per
TRUETEST BLOOD
ULESFIA LOTN 3 month;QL(3.34
GLUCOSE TEST STRIPS 1
ea daily);
STRP
Wound Care Products RX/OTC
Limit 100 per
REGRANEX GEL 3 TRUETEST BLOOD month;QL(3.34
1
GLUCOSE TEST STRP ea daily);
DIAGNOSTIC PRODUCTS RX/OTC
Diagnostic Drugs Limit 100 per
month;QL(3.34
GLUCAGEN DIAGNOSTIC QL(0.035 ea TRUETEST STRIPS STRP 1
3 ea daily);
SOLR daily) RX/OTC
Diagnostic Tests QL(3.34 ea
TRUETEST STRIPS STRP 1
CHEK-STIX COMBO PAK daily); RX/OTC
URINALYSIS CONTROL 1 Limit 100 per
STRP TRUETRACK BLOOD month;QL(3.34
1
CHEK-STIX CONTROL GLUCOSE TEST STRP ea daily);
1 RX/OTC
STRP

Ambetter Formulary Updated April 01, 2018

63
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
Limit 100 per amiloride & 1
TRUETRACK TEST STRP 1 month;QL(3.34 hydrochlorothiazide tabs
ea daily); DYAZIDE CAPS (Use
RX/OTC Triamterene & NF
TRUETRACK TEST STRP 1 QL(3.34 ea Hydrochlorothiazide)
daily); RX/OTC MAXZIDE TABS (Use
DIGESTIVE AIDS - Drugs to Treat Low Digestive Triamterene & NF
Enzymes Hydrochlorothiazide)
MAXZIDE-25 TABS (Use
Digestive Enzymes Triamterene & NF
CREON CPEP 2 Hydrochlorothiazide)
spironolactone & 1
PANCREAZE CPEP hydrochlorothiazide tabs
14200UNIT-4200UNIT-
24600UNIT, 35500UNIT- triamterene & 1
10500UNIT-61500UNIT, 2 hydrochlorothiazide caps
54700UNIT-21000UNIT- triamterene & 1
83900UNIT, 56800UNIT- hydrochlorothiazide tabs
16800UNIT-98400UNIT TRIAMTERENE/HYDROC 1
SUCRAID SOLN 3 HLOROTHIAZIDE CAPS
Loop Diuretics
ZENPEP CPEP 2 bumetanide soln ij 0.25 1
mg/ml
DIURETICS - Drugs to Treat Heart, Circulation
Conditions and Blood Pressure bumetanide tabs or 0.5 mg, 1 QL(5 ea daily)
1 mg, 2 mg
Carbonic Anhydrase Inhibitors BUMEX TABS (Use
acetazolamide cp12 500 QL(2 ea daily) NF QL(5 ea daily)
1 Bumetanide)
mg DEMADEX TABS (Use NF
acetazolamide sodium solr 1 Torsemide)
EDECRIN TABS (Use NF QL(16 ea daily)
acetazolamide tabs 125 mg 1 QL(8 ea daily) Ethacrynic Acid)
ethacrynic acid tabs 1 QL(16 ea daily)
acetazolamide tabs 250 mg 1 QL(4 ea daily)

DIAMOX CP12 (Use furosemide soln ij 10 mg/ml 1


NF QL(2 ea daily)
Acetazolamide)
furosemide soln or 10 1
KEVEYIS TABS 4 PA mg/ml
FUROSEMIDE SOLN OR 8 1
methazolamide tabs 1 QL(6 ea daily) MG/ML
NEPTAZANE TABS (Use furosemide tabs or 20 mg,
NF QL(6 ea daily) 40 mg, 80 mg 1
Methazolamide)
LASIX TABS (Use NF
Diuretic Combinations Furosemide)
ALDACTAZIDE TABS
25MG-25MG (Use torsemide tabs 1
NF
Spironolactone &
Hydrochlorothiazide) Potassium Sparing Diuretics

Ambetter Formulary Updated April 01, 2018

64
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ALDACTONE TABS (Use NF ATELVIA TBEC (Use NF PA
Spironolactone) Risedronate Sodium)
amiloride hcl tabs 1 BONIVA SOLN IV 3 PA; SP
MG/3ML (Use Ibandronate 4
DYRENIUM CAPS 3 QL(3 ea daily) Sodium)
BONIVA TABS OR 150 MG NF QL(0.036 ea
spironolactone tabs 1 (Use Ibandronate Sodium) daily)
calcitonin (salmon) soln 1
Thiazides and Thiazide-Like Diuretics
CHLOROTHIAZIDE TABS ETIDRONATE DISODIUM 1
1 TABS 200 MG
250 MG
PA; QL(0.08 ml
chlorothiazide tabs 500 mg 1
FORTEO SOLN 4 daily,30 days
retail,30 days
chlorthalidone tabs 1 mail); SP
hydrochlorothiazide caps 1 QL(2 ea daily) FOSAMAX PLUS D TABS 3 PA; QL(0.143
ea daily)
QL(2 ea daily) FOSAMAX TABS (Use
hydrochlorothiazide tabs 1 NF QL(0.143 ea
Alendronate Sodium) daily)
QL(1 ea daily) ibandronate sodium soln iv
indapamide tabs 1.25 mg 1 4 PA; SP
3 mg/3ml
indapamide tabs 2.5 mg 1 QL(2 ea daily)
ibandronate sodium tabs or 1 QL(0.036 ea
150 mg daily)
METHYCLOTHIAZIDE 1
TABS MIACALCIN SOLN NA 200
UNIT/ACT (Use Calcitonin NF
metolazone tabs 1 QL(2 ea daily) (Salmon))
MICROZIDE CAPS (Use pamidronate disodium soln PA; SP
NF QL(2 ea daily) 30 mg/10ml, 90 mg/10ml 4
Hydrochlorothiazide)
PAMIDRONATE PA; SP
ENDOCRINE AND METABOLIC AGENTS - DISODIUM SOLN 6 4
MISC. - Drugs to Treat Bone Disease and MG/ML
Regulate Hormones
pamidronate disodium solr 4 PA; SP
Bone Density Regulators 30 mg, 90 mg
ACTONEL TABS 150 MG NF PA; QL(0.036 PA; QL(180
(Use Risedronate Sodium) ea daily) PROLIA SOLN 4 days retail,180
ACTONEL TABS 35 MG days mail); SP
NF PA; QL(0.143
(Use Risedronate Sodium) ea daily) RECLAST SOLN (Use PA; SP
4
ACTONEL TABS 5 MG, 30 PA; QL(1 ea Zoledronic Acid)
MG (Use Risedronate NF daily) risedronate sodium tabs PA; QL(0.036
Sodium) 1
150 mg ea daily)
alendronate sodium tabs 1 QL(0.143 ea risedronate sodium tabs 35 PA; QL(0.143
35 mg, 70 mg daily) 1
mg ea daily)
ALENDRONATE SODIUM 1 QL(1 ea daily) risedronate sodium tabs 5 PA; QL(1 ea
TABS 40 MG 1
mg, 30 mg daily)
alendronate sodium tabs 5 1 QL(1 ea daily) risedronate sodium tbec 35 PA
mg, 10 mg 1
mg

Ambetter Formulary Updated April 01, 2018

65
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
PA; QL(30 HUMATROPE SOLR 4 PA; SP
TYMLOS SOPN 4 days retail,30
days mail) NORDITROPIN FLEXPRO PA; SP
SOLN 5 MG/1.5ML, 10 4
XGEVA SOLN 4 PA; SP MG/1.5ML, 15 MG/1.5ML
zoledronic acid conc 4 4 PA; SP NUTROPIN AQ NUSPIN 4 PA; SP
mg/5ml 10 SOLN
ZOLEDRONIC ACID SOLN 4 PA; SP OMNITROPE SOLN 5 4 PA; SP
4 MG/100ML MG/1.5ML, 10 MG/1.5ML
zoledronic acid soln 5 4 PA; SP SAIZEN CLICK.EASY 4 PA; SP
mg/100ml SOLR
ZOLEDRONIC ACID SOLR 4 PA; SP SAIZEN SOLR 4 PA; SP
4 MG
ZOMETA CONC 4 PA; SP SAIZENPREP PA; SP
MG/5ML (Use Zoledronic 4 RECONSTITUTIONKIT 4
Acid) SOLR
ZOMETA SOLN 4 PA; SP SEROSTIM SOLR 4 PA; SP
4
MG/100ML
ZOMACTON SOLR 4 PA; SP
Fertility Regulators
CHORIONIC 4 PA; SP PA; SP
GONADOTROPIN SOLR ZORBTIVE SOLR 4
NOVAREL SOLR 10000 4 PA; SP Hormone Receptor Modulators
UNIT
EVISTA TABS (Use NF QL(1 ea daily)
PREGNYL W/DILUENT PA; SP Raloxifene HCl)
BENZYLALCOHOL/NACL 4
SOLR OSPHENA TABS 3 PA
GnRH/LHRH Antagonists raloxifene hcl tabs 0 QL(1 ea daily)
CETROTIDE KIT 4 PA
Insulin-Like Growth Factors (Somatomedins)
GANIRELIX ACETATE PA
SOLN
4 INCRELEX SOLN 4 PA; SP
Growth Hormone Receptor Antagonists LHRH/GnRH Agonist Analog Pituitary
SOMAVERT SOLR 10 MG, 4 PA; SP
15 MG, 20 MG LUPANETA PACK KIT 4 PA
Growth Hormone Releasing Hormones (GHRH) LUPRON DEPOT-PED (1- 4 PA; SP
MONTH) KIT
EGRIFTA SOLR 4 PA LUPRON DEPOT-PED (3- PA; SP
4
MONTH) KIT 30 MG
Growth Hormones
SYNAREL SOLN 4 PA; SP
GENOTROPIN MINIQUICK 4 PA; SP
SOLR 0.2 MG
Metabolic Modifiers
GENOTROPIN SOLR 5 4 PA; SP
MG ALDURAZYME SOLN 4 PA; SP
HUMATROPE COMBO 4 PA; SP
PACK SOLR BUPHENYL POWD 3
GM/TSP (Use Sodium 3
Phenylbutyrate)
Ambetter Formulary Updated April 01, 2018

66
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
BUPHENYL TABS 500 MG 3 PA; QL(4 ea
SENSIPAR TABS 4 daily,30 days
BUPHENYL TABS 500 MG retail,30 days
(Use Sodium 3 mail); SP
Phenylbutyrate) sodium phenylbutyrate 3
calcitriol caps or 0.25 mcg, powd 3 gm/tsp
1
0.5 mcg sodium phenylbutyrate tabs 1
calcitriol soln iv 1 mcg/ml 1 500 mg
ZEMPLAR CAPS (Use NF
calcitriol soln or 1 mcg/ml 1 Paricalcitol)
ZEMPLAR SOLN (Use NF
CARBAGLU TABS 4 PA; SP Paricalcitol)
PA; SP Posterior Pituitary Hormones
CYSTADANE POWD 4
DDAVP SOLN IJ 4 PA
MCG/ML (Use NF
doxercalciferol caps 1 Desmopressin Acetate)
doxercalciferol soln 1 DDAVP SOLN NA 0.01 %
(Use Desmopressin NF
ELAPRASE SOLN 4 PA; SP Acetate Spray)
DDAVP TABS OR 0.1 MG QL(6 ea daily)
FABRAZYME SOLR 35 4 PA; SP (Use Desmopressin NF
MG Acetate)
HECTOROL CAPS OR 0.5 DDAVP TABS OR 0.2 MG QL(8 ea daily)
MCG, 1 MCG, 2.5 MCG NF (Use Desmopressin NF
(Use Doxercalciferol) Acetate)
HECTOROL SOLN IV 4 desmopressin acetate soln PA
MCG/2ML (Use NF 1
ij 4 mcg/ml
Doxercalciferol) desmopressin acetate
PA; SP 1
KUVAN TBSO 100 MG 4 spray refrigerated soln
desmopressin acetate 1
LUMIZYME SOLR 4 PA; SP spray soln
PA desmopressin acetate tabs 1 QL(6 ea daily)
MYALEPT SOLR 4 or 0.1 mg
PA; SP desmopressin acetate tabs 1 QL(8 ea daily)
NAGLAZYME SOLN 4 or 0.2 mg
ORFADIN CAPS 2 MG, 5 PA; SP STIMATE SOLN 4 PA; SP
4
MG, 10 MG
paricalcitol caps 1 Prolactin Inhibitors
cabergoline tabs 1
paricalcitol soln 1
Somatostatic Agents
ROCALTROL CAPS (Use NF
Calcitriol) octreotide acetate soln 4 PA; SP
ROCALTROL SOLN (Use NF SANDOSTATIN SOLN PA; SP
Calcitriol) (Use Octreotide Acetate)
4

Ambetter Formulary Updated April 01, 2018

67
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
SIGNIFOR SOLN 4 PA estradiol pttw 1
SOMATULINE DEPOT 4 PA; SP estradiol ptwk 1
SOLN
Vasopressin Receptor Antagonists estradiol tabs 1
PA; QL(2 ea
daily,30 days estradiol valerate oil 1
SAMSCA TABS 4
retail,30 days
mail); SP ESTROGEL GEL 3
ESTROGENS - Hormone Replacement/Modifying ESTROPIPATE TABS 1
Drugs
Estrogen Combinations EVAMIST SOLN 3
CLIMARA PRO PTWK 3 MENEST TABS 3
DUAVEE TABS 3 PA
MENOSTAR PTWK 3
FEMHRT LOW DOSE
TABS (Use Norethindrone NF MINIVELLE PTTW 3
Acetate-Ethinyl Estradiol)
norethindrone acetate- PREMARIN SOLR 2
1
ethinyl estradiol tabs
PREMARIN TABS 2
PREMPHASE TABS 2
VIVELLE-DOT PTTW (Use 3
PREMPRO TABS 2 Estradiol)
FLUOROQUINOLONES - Drugs to Treat Bacterial
Estrogens Infections
ALORA PTTW 3 Fluoroquinolones
CLIMARA PTWK (Use AVELOX ABC PACK TABS NF
NF (Use Moxifloxacin HCl)
Estradiol)
DELESTROGEN OIL 10 AVELOX SOLN IV 3
1 400MG/250ML-0.8%
MG/ML
DELESTROGEN OIL 20 AVELOX SOLN IV
MG/ML, 40 MG/ML (Use NF 400MG/250ML-0.8% (Use 3
Estradiol Valerate) Moxifloxacin HCl in Sodium
Chloride)
DEPO-ESTRADIOL OIL 3 AVELOX TABS OR 400 NF
MG (Use Moxifloxacin HCl)
DIVIGEL GEL 3 CIPRO SUSR 500 MG/5ML NF
(Use Ciprofloxacin)
ELESTRIN GEL 3
CIPRO TABS 250 MG, 500
ENJUVIA TABS 3 MG (Use Ciprofloxacin NF
HCl)
ESTRACE TABS OR 0.5 CIPRO XR TB24 (Use
MG, 1 MG, 2 MG (Use NF Ciprofloxacin-Ciprofloxacin NF
Estradiol) HCl)

Ambetter Formulary Updated April 01, 2018

68
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
CIPROFLOXACIN HCL 1 ursodiol tabs 1
TABS 100 MG
ciprofloxacin hcl tabs 250 1 Gastrointestinal Chloride Channel Activators
mg, 500 mg, 750 mg
ciprofloxacin in d5w soln AMITIZA CAPS 2 PA; QL(2 ea
3 daily)
200mg/100ml-5%
Gastrointestinal Stimulants
CIPROFLOXACIN SOLN 1
IV 400 MG/40ML metoclopramide hcl soln ij 1
5 mg/ml
ciprofloxacin susr or 250 1
mg/5ml, 500 mg/5ml QL(60 ml
metoclopramide hcl soln or 1 daily,84 days
ciprofloxacin-ciprofloxacin 1 5 mg/5ml, 10 mg/10ml retail,84 days
hcl tb24 mail)
FACTIVE TABS 3 metoclopramide hcl tabs or 1 QL(6 ea daily)
5 mg, 10 mg
LEVAQUIN TABS (Use REGLAN TABS (Use
Levofloxacin) NF NF QL(6 ea daily)
Metoclopramide HCl)
levofloxacin in d5w soln 1
500mg/100ml-5% Inflammatory Bowel Agents
levofloxacin soln iv 25 1 APRISO CP24 2 PA
mg/ml
ASACOL HD TBEC 2 QL(6 ea daily)
levofloxacin soln or 25 1
mg/ml
AZULFIDINE EN-TABS NF
levofloxacin tabs or 250 1 TBEC (Use Sulfasalazine)
mg, 500 mg, 750 mg
AZULFIDINE TABS (Use NF
moxifloxacin hcl in sodium 1 Sulfasalazine)
chloride soln
moxifloxacin hcl tabs or balsalazide disodium caps 1
1
400 mg
OFLOXACIN TABS 300 CANASA SUPP 2
1
MG PA; QL(0.0714
ofloxacin tabs 400 mg 1 ea daily,30
CIMZIA KIT 4
days retail,30
GASTROINTESTINAL AGENTS - MISC. - days mail); SP
Miscellaneous Gastrointestinal Drugs PA; QL(0.214
ea daily,30
Bile Acid Synthesis Disorder Agents CIMZIA STARTER KIT KIT 4
days retail,30
CHOLBAM CAPS 4 PA; SP days mail); SP
COLAZAL CAPS (Use NF
Gallstone Solubilizing Agents Balsalazide Disodium)
ACTIGALL CAPS (Use NF DIPENTUM CAPS 2
Ursodiol)
URSO 250 TABS (Use LIALDA TBEC (Use NF
NF Mesalamine)
Ursodiol)
URSO FORTE TABS (Use NF mesalamine enem re 4 gm 1
Ursodiol)
ursodiol caps 1 mesalamine tbec or 1.2 gm 1

Ambetter Formulary Updated April 01, 2018

69
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
mesalamine tbec or 800 1 QL(6 ea daily) RENVELA TABS (Use NF
mg Sevelamer Carbonate)
REMICADE SOLR 4 PA; SP sevelamer carbonate pack 1

sulfasalazine tabs 1 sevelamer carbonate tabs 1

sulfasalazine tbec 1 VELPHORO CHEW 3 PA

Intestinal Acidifiers GENITOURINARY AGENTS - MISCELLANEOUS


lactulose (encephalopathy) - Miscellaneous Drugs to Treat Reproductive
1 Organs and Urinary System
soln
Irritable Bowel Syndrome (IBS) Agents Alkalinizers
potassium citrate 1
alosetron hcl tabs 1 (alkalinizer) tbcr 1080 mg
LINZESS CAPS 145 MCG, PA SHOHLS SOLUTION RX/OTC
3 MODIFIED SOLN (Use
290 MCG NF
PA; QL(1 ea Sodium Citrate & Citric
LINZESS CAPS 72 MCG 3 Acid)
daily)
LOTRONEX TABS (Use sodium citrate & citric acid 1 RX/OTC
NF soln
Alosetron HCl)
UROCIT-K 10 TBCR (Use
Peripheral Opioid Receptor Antagonists Potassium Citrate 1
ENTEREG CAPS 3 (Alkalinizer))
RELISTOR SOLN SC 8 Cystinosis Agents
2 PA
MG/0.4ML, 12 MG/0.6ML CYSTAGON CAPS 3
Phosphate Binder Agents
Genitourinary Irrigants
calcium acetate (phosphate 1
binder) caps acetic acid soln 1
calcium acetate (phosphate 1 RX/OTC
binder) tabs glycine (gu irrigant) soln 1
ELIPHOS TABS (Use RX/OTC
Calcium Acetate NF RESECTISOL SOLN 1
(Phosphate Binder)) sodium chloride (gu
FOSRENOL CHEW 500 1
irrigant) soln
MG, 750 MG, 1000 MG 2 SORBITOL SOLN IR 3 %,
(Use Lanthanum 1
3.3 %
Carbonate)
SORBITOL-MANNITOL 1
lanthanum carbonate chew 1 SOLN
Interstitial Cystitis Agents
PHOSLYRA SOLN 2
ELMIRON CAPS 2
RENAGEL TABS 3
Prostatic Hypertrophy Agents
RENVELA PACK (Use NF QL(1 ea daily)
Sevelamer Carbonate) alfuzosin hcl tb24 1

Ambetter Formulary Updated April 01, 2018

70
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
AVODART CAPS (Use NF QL(1 ea daily) 4 PA; QL(9 ml
Dutasteride) FIRAZYR SOLN daily)
dutasteride caps 1 QL(1 ea daily) Hematorheologic Agents
pentoxifylline tbcr 1 QL(3 ea daily)
finasteride tabs 1
FLOMAX CAPS (Use Platelet Aggregation Inhibitors
NF AGGRENOX CP12 (Use
Tamsulosin HCl) NF PA; QL(2 ea
PROSCAR TABS (Use Aspirin-Dipyridamole) daily)
NF AGRYLIN CAPS (Use
Finasteride) NF
Anagrelide HCl)
RAPAFLO CAPS 2
anagrelide hcl caps 1
tamsulosin hcl caps 1
PA; QL(2 ea
aspirin-dipyridamole cp12 1
daily)
UROXATRAL TB24 (Use NF QL(1 ea daily)
Alfuzosin HCl) BRILINTA TABS 2
Urinary Analgesics
phenazopyridine hcl tabs cilostazol tabs 1
1
100 mg, 200 mg clopidogrel bisulfate tabs
PYRIDIUM TABS (Use 1
NF 300 mg
Phenazopyridine HCl) clopidogrel bisulfate tabs QL(1 ea daily)
1
GOUT AGENTS - Drugs to Treat Gout 75 mg

Gout Agent Combinations dipyridamole tabs 1


colchicine w/ probenecid 1 EFFIENT TABS (Use 2 QL(1 ea daily)
tabs Prasugrel HCl)
Gout Agents PERSANTINE TABS (Use NF
Dipyridamole)
allopurinol tabs 1 PLAVIX TABS 300 MG NF
QL(6 ea per fill (Use Clopidogrel Bisulfate)
COLCHICINE TABS 2 retail,6 ea per PLAVIX TABS 75 MG (Use NF QL(1 ea daily)
fill mail) Clopidogrel Bisulfate)
QL(6 ea per fill prasugrel hcl tabs 1 QL(1 ea daily)
COLCRYS TABS 2 retail,6 ea per
fill mail) REOPRO SOLN 3
PA; QL(1 ea
ULORIC TABS 3 PA
daily) ZONTIVITY TABS 3
ZYLOPRIM TABS (Use NF
Allopurinol) HEMATOPOIETIC AGENTS - Drugs to Treat
Blood Disorders
Uricosurics
Agents for Gaucher Disease
probenecid tabs 1
PA; QL(2 ea
CERDELGA CAPS 4
HEMATOLOGICAL AGENTS - MISC. - Drugs to daily)
Treat Blood Disorders CEREZYME SOLR 4 PA; SP
Bradykinin B2 Receptor Antagonists

Ambetter Formulary Updated April 01, 2018

71
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ELELYSO SOLR 4 PA; SP NPLATE SOLR 4 PA; SP

VPRIV SOLR 4 PA; SP PROCRIT SOLN 2000 PA; SP


UNIT/ML, 3000 UNIT/ML, 3
PA; QL(3 ea 4000 UNIT/ML, 10000
daily,30 days UNIT/ML, 20000 UNIT/ML
ZAVESCA CAPS 4
retail,30 days PROCRIT SOLN 40000 PA; SP
mail); SP 4
UNIT/ML
Agents for Sickle Cell Anemia PROMACTA TABS 4 PA; SP
DROXIA CAPS 3
Hematopoietic Mixtures
Cobalamins ferrous fumarate-folic acid 1 QL(1 ea daily)
cyanocobalamin soln ij QL(1 ml daily) tabs
1
1000 mcg/ml Iron
Folic Acid/Folates FER-IN-SOL SOLN (Use 0 AL; Up to 1 yrs
RX/OTC Ferrous Sulfate) old
folic acid tabs or 1 mg 0
ferrous sulfate soln or 15 0 AL; Up to 1 yrs
mg/ml old
folic acid tabs or 400 mcg 0
ferrous sulfate tabs or 65 0
Hematopoietic Growth Factors mg, 325 mg
ARANESP ALBUMIN SP ferrous sulfate tbec or 325 0
4 mg
FREE SOLN 25 MCG/ML
ARANESP ALBUMIN PA; SP Stem Cell Mobilizers
FREE SOLN 40 MCG/ML, 4 PA; SP
60 MCG/ML, 100 MCG/ML MOZOBIL SOLN 4
ARANESP ALBUMIN PA; SP HEMOSTATICS - Drugs to Stop Bleeding/Treat
FREE SOSY 500 MCG/ML, Blood Disorders
150 MCG/0.3ML, 200 4
MCG/0.4ML, 300 Hemostatics - Systemic
MCG/0.6ML CYKLOKAPRON SOLN 1
PA; SP (Use Tranexamic Acid)
EPOGEN SOLN 3
LYSTEDA TABS (Use NF
LEUKINE SOLR 4 PA; SP Tranexamic Acid)
MIRCERA SOSY 50 PA tranexamic acid soln 1
MCG/0.3ML, 75
MCG/0.3ML, 100 4 tranexamic acid tabs 1
MCG/0.3ML, 200
MCG/0.3ML HYPNOTICS/SEDATIVES/SLEEP DISORDER
AGENTS
NEULASTA ONPRO KIT 4 PA; SP
PSKT Barbiturate Hypnotics
NEULASTA SOSY 4 PA; SP phenobarbital elix 20 1
mg/5ml
NEUPOGEN SOLN 4 PA; SP phenobarbital soln 20 1
mg/5ml
NEUPOGEN SOSY 4 PA; SP PHENOBARBITAL TABS 1
15 MG, 30 MG, 100 MG
Ambetter Formulary Updated April 01, 2018

72
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
phenobarbital tabs 16.2 ST; QL(1 ea
mg, 32.4 mg, 64.8 mg, 97.2 1 ROZEREM TABS 3 daily); AL; At
mg least 18 yrs old
Non-Barbiturate Hypnotics LAXATIVES - Bowel Treatment Drugs
QL(1 ea daily);
AMBIEN TABS (Use NF AL; At least 18 Bulk Laxatives
Zolpidem Tartrate) yrs old calcium polycarbophil tabs 1
estazolam tabs 1 FIBERCON TABS (Use NF
ST; QL(1 ea Calcium Polycarbophil)
eszopiclone tabs 1 daily); AL; At Laxative Combinations
least 18 yrs old
GOLYTELY SOLR 236GM-
HALCION TABS (Use NF 22.74GM-5.86GM-2.97GM-
Triazolam) 6.74GM (Use PEG 3350- 0
ST; QL(1 ea KCl-Sod Bicarb-Sod
LUNESTA TABS (Use NF daily); AL; At
Eszopiclone) Chloride-Sod Sulfate)
least 18 yrs old
MOVIPREP SOLR 2
RESTORIL CAPS (Use NF QL(1 ea daily)
Temazepam) peg 3350-kcl-sod bicarb-
QL(2 ea daily); sod chloride-sod sulfate 0
SONATA CAPS 10 MG NF AL; At least 18 solr 236gm-22.74gm-
(Use Zaleplon) yrs old 5.86gm-2.97gm-6.74gm
QL(1 ea daily); PREPOPIK PACK 3
SONATA CAPS 5 MG (Use NF AL; At least 18
Zaleplon) yrs old SUPREP BOWEL PREP 0
KIT SOLN
temazepam caps 1 QL(1 ea daily)
Laxatives - Miscellaneous
TRIAZOLAM TABS 0.125 1
MG lactulose soln 1
triazolam tabs 0.25 mg 1 Saline Laxatives
QL(2 ea daily); OSMOPREP TABS 3
zaleplon caps 10 mg 1 AL; At least 18
yrs old Stimulant Laxatives
QL(1 ea daily); bisacodyl tbec or 5 mg 1
zaleplon caps 5 mg 1 AL; At least 18
yrs old DULCOLAX TBEC OR 5 NF
QL(1 ea daily); MG (Use Bisacodyl)
zolpidem tartrate tabs or 5 1 AL; At least 18
mg, 10 mg Surfactant Laxatives
yrs old COLACE CAPS (Use NF
Orexin Receptor Antagonists Docusate Sodium)
BELSOMRA TABS 3 PA docusate calcium caps 1
Selective Melatonin Receptor Agonists docusate sodium caps or 1
100 mg, 250 mg
HETLIOZ CAPS 3 PA
LOCAL ANESTHETICS-Parenteral - Drugs for
Numbing
Ambetter Formulary Updated April 01, 2018

73
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
Local Anesthetics - Amides QL(6 ea per fill
ZITHROMAX Z-PAK TABS NF retail,6 ea per
lidocaine hcl (local anesth.) 1 (Use Azithromycin) fill mail)
soln 0.5 %, 1 %, 2 %
XYLOCAINE SOLN IJ 0.5 Clarithromycin
%, 1 % (Use Lidocaine HCl NF BIAXIN SUSR (Use NF
(Local Anesth.)) Clarithromycin)
XYLOCAINE-MPF SOLN BIAXIN TABS (Use NF
0.5 %, 1 %, 2 % (Use NF Clarithromycin)
Lidocaine HCl (Local clarithromycin susr 125
Anesth.)) 1
mg/5ml, 250 mg/5ml
MACROLIDES - Drugs to Treat Bacterial clarithromycin tabs 250 mg,
Infections 1
500 mg
Azithromycin clarithromycin tb24 500 mg 1
AZITHROMYCIN PACK 1
OR 1 GM Erythromycins
azithromycin solr iv 500 mg 1 E.E.S. 400 TABS 3
azithromycin susr or 100 E.E.S. GRANULES SUSR
1 (Use Erythromycin NF
mg/5ml, 200 mg/5ml
QL(6 ea per fill Ethylsuccinate)
azithromycin tabs or 250 1 retail,6 ea per
mg ERY-TAB TBEC 3
fill mail)
QL(4 ea per fill ERYPED 200 SUSR (Use
azithromycin tabs or 500 1 retail,4 ea per Erythromycin NF
mg fill mail) Ethylsuccinate)
azithromycin tabs or 600 1 QL(0.286 ea ERYPED 400 SUSR 3
mg daily)
ZITHROMAX PACK OR 1 erythromycin base cpep 3
1
GM
ZITHROMAX SOLR IV 500 erythromycin base tabs 3
NF
MG (Use Azithromycin) erythromycin
ZITHROMAX SUSR OR ethylsuccinate susr 200 1
100 MG/5ML, 200 MG/5ML NF mg/5ml
(Use Azithromycin) ERYTHROMYCIN
ZITHROMAX TABS OR QL(6 ea per fill ETHYLSUCCINATE TABS 3
250 MG (Use NF retail,6 ea per 400 MG
Azithromycin) fill mail)
Fidaxomicin
ZITHROMAX TABS OR QL(4 ea per fill
500 MG (Use NF retail,4 ea per DIFICID TABS 2
Azithromycin) fill mail)
ZITHROMAX TABS OR QL(0.286 ea MEDICAL DEVICES AND SUPPLIES
600 MG (Use NF daily)
Azithromycin) Contraceptives
QL(4 ea per fill AIMSCO LUBRICATED 0 QL(2 ea daily)
ZITHROMAX TRI-PAK NF retail,4 ea per MISC
TABS (Use Azithromycin) fill mail)

Ambetter Formulary Updated April 01, 2018

74
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ATLAS COLORED QL(2 ea daily) KIMONO PLUS QL(2 ea daily)
LUBRICATEDCONDOM 0 SPERMICIDE 0
DEVI LUBRICATED MISC
ATLAS LUBRICATED 0 QL(2 ea daily) KIMONO PLUS QL(2 ea daily)
CONDOM DEVI SPERMICIDE/LUBRICATE 0
ATLAS LUBRICATED QL(2 ea daily) D MISC
CONDOM/SPERMICIDE 0 KIMONO PS LUBRICATED 0 QL(2 ea daily)
DEVI MISC
CAYA DPRH 0 KIMONO PS PLUS QL(2 ea daily)
SPERMICIDE/LUBRICATE 0
CLASS ACT LUBRICATED QL(2 ea daily) D MISC
0
MISC KIMONO SENSATION QL(2 ea daily)
0
DUREX EXTRA QL(2 ea daily) LUBRICATED MISC
0
SENSITIVE DEVI KIMONO SENSATION QL(2 ea daily)
ELEXA NATURAL FEEL QL(2 ea daily) PLUS SPERMICIDE 0
0 LUBRICATED MISC
MISC
ELEXA STIMULATING QL(2 ea daily) KIMONO SPECIAL DEVI 0 QL(2 ea daily)
0
MISC
ELEXA ULTRA SENSITIVE QL(2 ea daily) MAXX LUBRICATED MISC 0 QL(2 ea daily)
0
MISC
EXTRA SENSITIVE QL(2 ea daily) MAXX PLUS SPERMICIDE 0 QL(2 ea daily)
0 LUBRICATED MISC
SPERMICIDAL DEVI
FANTASY LUBRICATED QL(2 ea daily) OMNIFLEX DIAPHRAGM 0
0 DPRH
MISC
FANTASY QL(2 ea daily) PREMIUM CONDOMS 0 QL(2 ea daily)
LUBRICATED/SPERMICID 0 LUBRICATED MISC
E MISC REALITY LATEX QL(2 ea daily)
FC FEMALE CONDOM CONDOMS/LUBRICATED 0
0 MISC
MISC
FC2 FEMALE CONDOM REALITY LATEX/ULTRA 0 QL(2 ea daily)
0 TEXTURED DEVI
MISC
REALITY LATEX/ULTRA 0 QL(2 ea daily)
FEMCAP DEVI 0 THIN DEVI
HIGH SENSATION QL(2 ea daily) TROJAN EXTENDED QL(2 ea daily)
0 PLEASURE/LUBRICATED 0
SPERMICIDAL DEVI
DEVI
INTENSE SENSATION 0 QL(2 ea daily)
DEVI TROJAN MAGNUM MISC 0 QL(2 ea daily)
KAMELEON LUBRICATED 0 QL(2 ea daily)
MISC TROJAN MAGNUM WARM 0 QL(2 ea daily)
SENSATIONS DEVI
KIMONO COLORS DEVI 0 QL(2 ea daily)
TROJAN MAGNUM XL 0 QL(2 ea daily)
LUBRICATED DEVI
KIMONO LUBRICATED 0 QL(2 ea daily)
MISC TROJAN PLEASURE QL(2 ea daily)
MESH/SPERMICIDAL 0
KIMONO MICRO THIN QL(2 ea daily) DEVI
PLUS SPERMICIDE 0
LUBRICATED MISC TROJAN RIBBED 0 QL(2 ea daily)
W/SPERMICIDAL MISC

Ambetter Formulary Updated April 01, 2018

75
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
TROJAN SHARED QL(2 ea daily) TRUSTEX QL(2 ea daily)
SENSATION/LUBRICATE 0 LUBRICATED/SPERMICID 0
D DEVI E MISC
TROJAN SUPRAS 0 QL(2 ea daily) TRUSTEX NATURAL QL(2 ea daily)
SPERMICIDAL DEVI CONDOMS 0
TROJAN TWISTED QL(2 ea daily) +LUBE/LUBRICATED
0 MISC
PLEASURE DEVI
TROJAN ULTRA QL(2 ea daily) TRUSTEX WITH QL(2 ea daily)
PLEASURE/LUBRICATED 0 NONOXYNOL- 0
DEVI 9/RIBBED/STUDDED
MISC
TROJAN VERY QL(2 ea daily)
SENSITIVE LUBRICATED 0 TRUSTEX/RIA 0 QL(2 ea daily)
MISC LUBRICATED MISC
TROJAN VERY QL(2 ea daily) TRUSTEX/RIA QL(2 ea daily)
SENSITIVE SPERMICIDAL 0 LUBRICATED 0
LUBRICANT MISC SPERMICIDE MISC
TROJAN VERY THIN QL(2 ea daily) TRUSTEX/RIA QL(2 ea daily)
0 LUBRICATED/SPERMICID 0
LUBRICATED MISC
E MISC
TROJAN VERY THIN QL(2 ea daily)
SPERMICIDAL 0 ULTIMATE FEELING DEVI 0 QL(2 ea daily)
LUBRICANT MISC
TROJAN-ENZ LUBRICANT QL(2 ea daily) WIDE-SEAL SILICONE
0 DIAPHRAGM KIT 60 0
MISC
DPRH
TROJAN-ENZ 0 QL(2 ea daily)
LUBRICATED MISC WIDE-SEAL SILICONE
DIAPHRAGM KIT 65 0
TROJAN-ENZ 0 QL(2 ea daily) DPRH
W/SPERMICIDAL MISC
WIDE-SEAL SILICONE
TRUSTEX COLOR 0 QL(2 ea daily) DIAPHRAGM KIT 70 0
CONDOMS + LUBE MISC DPRH
TRUSTEX LUBRICATED 0 QL(2 ea daily) WIDE-SEAL SILICONE
EXTRALARGE MISC DIAPHRAGM KIT 75 0
TRUSTEX LUBRICATED QL(2 ea daily) DPRH
0
EXTRASTRENGTH MISC WIDE-SEAL SILICONE
TRUSTEX LUBRICATED QL(2 ea daily) DIAPHRAGM KIT 80 0
0 DPRH
MISC
TRUSTEX QL(2 ea daily) WIDE-SEAL SILICONE
LUBRICATED/RIBBED/ST 0 DIAPHRAGM KIT 85 0
UDDED MISC DPRH
TRUSTEX QL(2 ea daily) WIDE-SEAL SILICONE
LUBRICATED/SPERMICID 0 DIAPHRAGM KIT 90 0
E EXTRA LARGE MISC DPRH
TRUSTEX QL(2 ea daily) WIDE-SEAL SILICONE
LUBRICATED/SPERMICID DIAPHRAGM KIT 95 0
0 DPRH
E EXTRA STRENGTH
MISC
Diabetic Supplies

Ambetter Formulary Updated April 01, 2018

76
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
1ST CHOICE LANCETS 1 QL(6.6667 ea ADVOCATE LANCETS 1 QL(6.6667 ea
SUPERTHIN MISC daily) MISC daily)
1ST CHOICE LANCETS 1 QL(6.6667 ea ADVOCATE LANCING 1
THIN MISC daily) DEVICE MISC
1ST CHOICE LANCETS 1 QL(6.6667 ea ADVOCATE RAPID-SAFE 1
ULTRATHIN MISC daily) LANCING DEVICE MISC
1ST TIER UNILET QL(6.6667 ea ADVOCATE SAFETY 1 QL(6.6667 ea
COMFORTOUCH 1 daily) LANCETS 26G MISC daily)
LANCETS 28G MISC ADVOCATE SAFETY QL(6.6667 ea
1
1ST TIER UNILET QL(6.6667 ea LANCETS MISC daily)
COMFORTOUCH 1 daily) AGAMATRIX ULTRA-THIN QL(6.6667 ea
LANCETS 30G MISC 1
LANCETS 33G MISC daily)
ACCU-CHEK FASTCLIX 1 QL(6.6667 ea ALTERNATE SITE
LANCETS MISC daily) 1
LANCING DEVICE MISC
ACCU-CHEK MULTICLIX 1 QL(6.6667 ea AQUA LANCE
LANCETS MISC daily) ADJUSTABLE LANCING 1
ACCU-CHEK SAFE-T-PRO QL(6.6667 ea DEVICE DEVI
1
LANCETS MISC daily) ASSURE COMFORT QL(6.6667 ea
ACCU-CHEK SAFE-T-PRO QL(6.6667 ea LANCETS ULTRA THIN 1 daily)
1 28G MISC
PLUSLANCETS MISC daily)
ACCU-CHEK SOFT QL(6.6667 ea ASSURE COMFORT QL(6.6667 ea
1 LANCETS ULTRA THIN daily)
TOUCH LANCETS MISC daily) 1
ACCU-CHEK SOFTCLIX QL(6.6667 ea 30G MISC
1
LANCETS MISC daily) ASSURE HAEMOLANCE QL(6.6667 ea
ACTI-LANCE LANCETS QL(6.6667 ea PLUS HIGH FLOW 18G 1 daily)
1 MISC
28G MISC daily)
ACTI-LANCE LITE QL(6.6667 ea ASSURE HAEMOLANCE QL(6.6667 ea
SAFETY LANCETS 28G 1 daily) PLUS LOW FLOW 25G 1 daily)
MISC MISC
ACTI-LANCE SPECIAL QL(6.6667 ea ASSURE HAEMOLANCE QL(6.6667 ea
SAFETY LANCETS 17G 1 daily) PLUS MICRO FLOW 28G 1 daily)
MISC MISC
ACTI-LANCE SPECIAL QL(6.6667 ea ASSURE HAEMOLANCE QL(6.6667 ea
SAFETYLANCETS 17G 1 daily) PLUS NORMAL FLOW 1 daily)
MISC 21G MISC
ACTI-LANCE UNIVERSAL QL(6.6667 ea ASSURE HAEMOLANCE QL(6.6667 ea
SAFETY LANCETS 23G 1 daily) PLUS PEDIATRIC BLADE 1 daily)
MISC MISC
ACTIVE 1ST BLOOD QL(6.6667 ea ASSURE LANCE 1 QL(6.6667 ea
LANCETS30G/EASY 1 daily) LANCETS 21G MISC daily)
TWIST CAP MISC ASSURE LANCE 1 QL(6.6667 ea
ADJUSTABLE LANCING LANCETS MISC daily)
1 ASSURE LANCE PLUS QL(6.6667 ea
DEVICE MISC
ADVANCED MOBILE QL(6.6667 ea SAFETYLANCETS 25G 1 daily)
1 MISC
LANCET 30G MISC daily)
ADVOCATE LANCETS 1 QL(6.6667 ea
30G MISC daily)
Ambetter Formulary Updated April 01, 2018

77
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ASSURE LANCE PLUS QL(6.6667 ea CAREONE LANCET 1 QL(6.6667 ea
SAFETYLANCETS 30G 1 daily) ULTRA THIN MISC daily)
MISC CARETOUCH LANCING
QL(6.6667 ea DEVICEWITH EJECTOR 1
ASSURE LANCETS MISC 1
daily) MISC
QL(6.6667 ea CARETOUCH TWIST QL(6.6667 ea
AT LAST LANCETS MISC 1
LANCETS 28G MISC
1
daily)
daily)
AURORA LANCET SUPER 1 QL(6.6667 ea CARETOUCH TWIST 1 QL(6.6667 ea
THIN30G MISC daily) LANCETS 30G MISC daily)
AURORA LANCET THIN 1 QL(6.6667 ea CARETOUCH TWIST 1 QL(6.6667 ea
23G MISC daily) LANCETS 33G MISC daily)
AUTO-LANCET MINI MISC 1 CLEANLET LANCETS 28G 1 QL(6.6667 ea
MISC daily)
AUTO-LANCET MISC 1 CLEVER CHEK LANCETS 1 QL(6.6667 ea
ULTRATHIN 30G MISC daily)
AUTOLET IMPRESSION 1 CLEVER CHEK LANCETS QL(6.6667 ea
LANCING DEVICE MISC 1
ULTRATHIN MISC daily)
AUTOLET LANCING 1 CLEVER CHOICE QL(6.6667 ea
DEVICE MISC COMFORT EZLANCETS 1 daily)
AUTOLET MINI MISC 1 21G MISC
CLEVER CHOICE QL(6.6667 ea
AUTOLET PLUS MISC 1 COMFORT EZLANCETS 1 daily)
23G MISC
BAYER MICROLET 2 1 CLEVER CHOICE QL(6.6667 ea
LANCING DEVICE MISC COMFORT EZLANCETS 1 daily)
BAYER MICROLET 1 QL(6.6667 ea 28G MISC
LANCETS MISC daily)
BD LANCET DEVICE CLOSERCARE MISC 1
1
MISC COAGUCHEK LANCETS QL(6.6667 ea
BD LANCET ULTRAFINE QL(6.6667 ea 1
1 MISC daily)
30G MISC daily) COMFORT ASSURED QL(6.6667 ea
BD LANCET ULTRAFINE 1 QL(6.6667 ea LANCETS MICRO THIN 1 daily)
33G MISC daily) 33G MISC
BD MICROTAINER 1 QL(6.6667 ea COMFORT ASSURED QL(6.6667 ea
LANCETS MISC daily) LANCETS SUPER THIN 1 daily)
BULLSEYE MINI SAFETY QL(6.6667 ea 28G MISC
1
LANCETS MISC daily) COMFORT LANCETS QL(6.6667 ea
1
BULLSEYE SAFETY QL(6.6667 ea MISC daily)
1
LANCETS MISC daily) QL(6.6667 ea
CVS LANCETS 21G MISC 1
CARDIOCOM LANCING daily)
1
DEVICE MISC CVS LANCETS MICRO QL(6.6667 ea
1
CAREONE ADVANCED THIN 33G MISC daily)
1
LANCINGDEVICE MISC CVS LANCETS MICRO- QL(6.6667 ea
1
CAREONE LANCET THIN QL(6.6667 ea THIN 33G MISC daily)
1
MISC daily) CVS LANCETS ORIGINAL QL(6.6667 ea
1
MISC daily)

Ambetter Formulary Updated April 01, 2018

78
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
CVS LANCETS THIN 26G 1 QL(6.6667 ea 1 QL(6.6667 ea
MISC daily) E-Z JECT LANCETS MISC daily)
CVS LANCETS ULTRA 1 QL(6.6667 ea E-Z JECT LANCETS 1 QL(6.6667 ea
THIN 30G MISC daily) SUPER THIN 30G MISC daily)
CVS LANCETS ULTRA- 1 QL(6.6667 ea E-Z JECT LANCETS THIN 1 QL(6.6667 ea
THIN 30G MISC daily) 26G MISC daily)
CVS LANCING DEVICE 1 E-ZJECT LANCETS 1 QL(6.6667 ea
MISC MICRO-THIN 33G MISC daily)
CVS ULTRA THIN 1 QL(6.6667 ea EASY COMFORT QL(6.6667 ea
LANCETS MISC daily) LANCETS 30G/PULL TOP 1 daily)
DIASTAR EASY TEST II QL(6.6667 ea MISC
1
LANCETS 30G MISC daily) EASY COMFORT QL(6.6667 ea
DIASTAR EASY TEST QL(6.6667 ea LANCETS 30G/THIN TOP 1 daily)
1 MISC
LANCETS30G MISC daily)
DROPLET LANCETS QL(6.6667 ea EASY COMFORT 1 QL(6.6667 ea
1 LANCETS MISC daily)
ULTRA THIN 30G MISC daily)
DROPLET LANCING EASY MINI EJECT 1
1 LANCING DEVICE MISC
DEVICE MISC
DRUG MART EASY MINI LANCING 1
ADJUSTABLE LANCING 1 DEVICE MISC
DEVICE MISC EASY TOUCH LANCETS QL(6.6667 ea
DRUG MART LANCETS QL(6.6667 ea 21G/PRESSURE 1 daily)
1 ACTIVATED MISC
THIN MISC daily)
DRUG MART ON-THE-GO QL(6.6667 ea EASY TOUCH LANCETS QL(6.6667 ea
LANCETS GENTLE 30G 1 daily) 23G/PRESSURE 1 daily)
MISC ACTIVATED MISC
DRUG MART UNILET QL(6.6667 ea EASY TOUCH LANCETS QL(6.6667 ea
LANCETSSUPER THIN 1 daily) 26G/PRESSURE 1 daily)
30G MISC ACTIVATED MISC
DRUG MART UNILET QL(6.6667 ea EASY TOUCH LANCETS 1 QL(6.6667 ea
LANCETSULTRA THIN 1 daily) 26G/PULL-TOP MISC daily)
28G MISC EASY TOUCH LANCETS 1 QL(6.6667 ea
DRUG MART UNILET QL(6.6667 ea 26G/TWIST MISC daily)
MICRO THIN LANCETS 1 daily) EASY TOUCH LANCETS QL(6.6667 ea
33G MISC 28G/PRESSURE 1 daily)
DUANE READE LANCET QL(6.6667 ea ACTIVATED MISC
ALTERNATE SITE 26G 1 daily) EASY TOUCH LANCETS 1 QL(6.6667 ea
MISC 28G/PULL-TOP MISC daily)
DUANE READE LANCET 1 QL(6.6667 ea EASY TOUCH LANCETS 1 QL(6.6667 ea
SUPERTHIN 30G MISC daily) 28G/TWIST MISC daily)
DUANE READE LANCET 1 QL(6.6667 ea EASY TOUCH LANCETS QL(6.6667 ea
ULTRATHIN 28G MISC daily) 30G/BUTTON-ACTIVATED 1 daily)
E-Z JECT LANCETS 21G QL(6.6667 ea MISC
1
MISC daily) EASY TOUCH LANCETS QL(6.6667 ea
E-Z JECT LANCETS QL(6.6667 ea 30G/PRESSURE 1 daily)
1 ACTIVATED MISC
COLOR MISC daily)

Ambetter Formulary Updated April 01, 2018

79
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
EASY TOUCH LANCETS 1 QL(6.6667 ea EQL THIN LANCETS 26G 1 QL(6.6667 ea
30G/PULL-TOP MISC daily) MISC daily)
EASY TOUCH LANCETS 1 QL(6.6667 ea EZ SMART BLOOD QL(6.6667 ea
30G/TWIST MISC daily) GLUCOSE LANCETS 1 daily)
EASY TOUCH LANCETS QL(6.6667 ea MISC
32G/PRESSURE 1 daily) EZ-LETS LANCETS 21G 1 QL(6.6667 ea
ACTIVATED MISC MISC daily)
EASY TOUCH LANCETS 1 QL(6.6667 ea EZ-LETS LANCETS 23G 1 QL(6.6667 ea
32G/PULL-TOP MISC daily) MISC daily)
EASY TOUCH LANCETS 1 QL(6.6667 ea EZ-LETS LANCETS 26G QL(6.6667 ea
32G/TWIST MISC daily) 1
SUPER-SOFT MISC daily)
EASY TOUCH LANCETS 1 QL(6.6667 ea EZ-LETS LANCETS 28G 1 QL(6.6667 ea
33G/TWIST MISC daily) ULTRA-SOFT MISC daily)
EASY TOUCH LANCING 1 EZ-LETS LANCETS 30G 1 QL(6.6667 ea
DEVICE/EJECTOR MISC MISC daily)
EASY TOUCH SAFETY QL(6.6667 ea FIFTY50 LANCING
LANCETS21G/PRESSURE daily) 1
1 DEVICE MISC
ACTIVATED MISC FIFTY50 SAFETY SEAL QL(6.6667 ea
1
EASY TOUCH SAFETY QL(6.6667 ea LANCETS 30G MISC daily)
LANCETS23G/PRESSURE 1 daily) FIFTY50 SAFETY SEAL QL(6.6667 ea
ACTIVATED MISC 1
LANCETS 32G MISC daily)
EASY TOUCH SAFETY QL(6.6667 ea FIFTY50 UNILET QL(6.6667 ea
LANCETS26G/BUTTON 1 daily) 1
LANCETS 33G MISC daily)
ACTIVATED MISC
QL(6.6667 ea
EASY TOUCH SAFETY QL(6.6667 ea FINE 30 MISC 1
daily)
LANCETS26G/PRESSURE 1 daily)
ACTIVATED MISC FINGERSTIX LANCETS 1 QL(6.6667 ea
MISC daily)
EASY TOUCH SAFETY QL(6.6667 ea
LANCETS28G/BUTTON 1 daily) QL(6.6667 ea
FORA LANCETS MISC 1
ACTIVATED MISC daily)
EASY TOUCH SAFETY QL(6.6667 ea FORA LANCING DEVICE 1
LANCETS28G/PRESSURE 1 daily) MISC
ACTIVATED MISC FORA LANCING 1
EASY TWIST & CAP QL(6.6667 ea DEVICE/CLEARCAP MISC
1 FREDS PHARMACY
LANCETS MISC daily)
EASYTEST II LANCETS QL(6.6667 ea AUTOLET LANCING 1
1 DEVICE MISC
MISC daily)
EASYTEST LANCETS QL(6.6667 ea FREDS PHARMACY QL(6.6667 ea
1 UNILET LANCETS SUPER 1 daily)
MISC daily)
THIN 30G MISC
EMBRACE LANCETS 1 QL(6.6667 ea
ULTRA THIN 30G MISC daily) FREDS PHARMACY QL(6.6667 ea
UNILET LANCETS ULTRA 1 daily)
EQL COLOR LANCETS 1 QL(6.6667 ea THIN 28G MISC
21G MISC daily)
FREESTYLE LANCETS 1 QL(6.6667 ea
EQL COLOR LANCETS 1 QL(6.6667 ea MISC daily)
MICRO THIN 33G MISC daily)
FREESTYLE UNISTICK II 1 QL(6.6667 ea
EQL SUPER THIN 1 QL(6.6667 ea LANCETS MISC daily)
LANCETS 30G MISC daily)
Ambetter Formulary Updated April 01, 2018

80
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
GENTLE-LET GP 1 QL(6.6667 ea GNP MICRO THIN 1 QL(6.6667 ea
LANCETS MISC daily) LANCETS 33G MISC daily)
GENTLE-LET LANCETS QL(6.6667 ea GNP SUPER THIN 1 QL(6.6667 ea
GENERAL PURPOSE 1 daily) LANCETS/30G MISC daily)
STYLE/FINE POINT MISC GOODSENSE LANCETS 1 QL(6.6667 ea
GENTLE-LET LANCETS QL(6.6667 ea MICRO-THIN 33G MISC daily)
GENERAL PURPOSE daily) GOODSENSE LANCETS
STYLE/MEDIUM POINT
1 1 QL(6.6667 ea
ULTRA-THIN 30G MISC daily)
MISC
GOODSENSE LANCING 1
GENTLE-LET LANCETS QL(6.6667 ea DEVICE MISC
SAFETY STYLE/FINE 1 daily)
POINT MISC GOODSENSE QL(6.6667 ea
UNIVERSAL 1 MICRO 1 daily)
GENTLE-LET LANCETS QL(6.6667 ea THIN 33G MISC
SAFETY STYLE/MEDIUM 1 daily)
POINT MISC GOODSENSE QL(6.6667 ea
UNIVERSAL 1 MICRO- 1 daily)
GLOBAL INJECT EASE 1 QL(6.6667 ea THIN 33G MISC
LANCETS 28G MISC daily)
GOODSENSE QL(6.6667 ea
GLOBAL INJECT EASE 1 QL(6.6667 ea UNIVERSAL 1THIN 26G 1 daily)
LANCETS 30G MISC daily) MISC
GLOBAL LANCING 1 H-E-B INCONTROL
DEVICE MISC ADVANCEDLANCING 1
GLUCOCOM LANCETS 1 QL(6.6667 ea DEVICE MISC
28G MISC daily) H-E-B INCONTROL QL(6.6667 ea
GLUCOCOM LANCETS 1 QL(6.6667 ea LANCETS MICRO THIN 1 daily)
30G MISC daily) 33G MISC
GLUCOCOM LANCETS 1 QL(6.6667 ea H-E-B INCONTROL QL(6.6667 ea
33G MISC daily) LANCETS SUPER THIN 1 daily)
GLUCOLET 2 30G MISC
AUTOMATIC LANCING 1 H-E-B INCONTROL QL(6.6667 ea
DEVICE MISC LANCETS ULTRA THIN 1 daily)
GLUCOSOURCE LANCET 28G MISC
1
DEVICE MISC HAEMOLANCE LOW 1 QL(6.6667 ea
GLUCOSOURCE QL(6.6667 ea FLOW LANCETS MISC daily)
1
LANCETS MISC daily) QL(6.6667 ea
HAEMOLANCE MISC 1
QL(6.6667 ea daily)
GNP LANCETS 21G MISC 1
daily) HAEMOLANCE PLUS 1 QL(6.6667 ea
GNP LANCETS MICRO QL(6.6667 ea HIGH FLOW MISC daily)
1
THIN 33G MISC daily) HAEMOLANCE PLUS 1 QL(6.6667 ea
QL(6.6667 ea LOW FLOW MISC daily)
GNP LANCETS MISC 1
daily) HAEMOLANCE PLUS 1 QL(6.6667 ea
GNP LANCETS SUPER QL(6.6667 ea MAX FLOW MISC daily)
1
THIN 30G MISC daily) HAEMOLANCE PLUS 1 QL(6.6667 ea
GNP LANCETS THIN 26G QL(6.6667 ea MISC daily)
1
MISC daily) HAEMOLANCE PLUS 1 QL(6.6667 ea
GNP LANCETS THIN QL(6.6667 ea PEDIATRIC FLOW MISC daily)
1
MISC daily) HEALTH CARE LANCING 1
DEVICE MISC
Ambetter Formulary Updated April 01, 2018

81
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
HEALTHWISE LANCETS 1 QL(6.6667 ea 1 QL(6.6667 ea
30G MISC daily) LANCETS 30G MISC daily)
HEALTHWISE LANCING 1 LANCETS 30G TWIST 1 QL(6.6667 ea
PEN MISC TOP MISC daily)
HEALTHY ACCENTS LANCETS 30G/TWIST 1 QL(6.6667 ea
AUTOLET IMPRESSION 1 TOP MISC daily)
LANCING DEVICE MISC LANCETS 31G TWIST 1 QL(6.6667 ea
HEALTHY ACCENTS QL(6.6667 ea TOP MISC daily)
UNILET LANCETS SUPER 1 daily) LANCETS 33G QL(6.6667 ea
THIN 30G MISC UNIVERSAL DESIGN 1 daily)
QL(6.6667 ea MISC
HY-VEE LANCETS MISC 1
daily) LANCETS MICRO THIN 1 QL(6.6667 ea
HY-VEE THIN LANCETS 1 QL(6.6667 ea 33G MISC daily)
MISC daily) QL(6.6667 ea
IN TOUCH LANCING LANCETS MISC 1
1 daily)
DEVICE MISC LANCETS SAFETY SEAL QL(6.6667 ea
IN TOUCH STERILE QL(6.6667 ea 1
1 21G MISC daily)
LANCETS30G MISC daily) LANCETS SAFETY SEAL QL(6.6667 ea
QL(6.6667 ea 1
KINNEY LANCETS MISC 1 26G MISC daily)
daily) LANCETS SAFETY SEAL QL(6.6667 ea
KINNEY THIN LANCETS QL(6.6667 ea 1
1 28G MISC daily)
MISC daily) LANCETS SAFETY SEAL QL(6.6667 ea
KROGER LANCETS 21G QL(6.6667 ea 1
1 30G MISC daily)
MISC daily) LANCETS SUPER THIN QL(6.6667 ea
KROGER LANCETS QL(6.6667 ea 1
1 28G MISC daily)
MICRO THIN33G MISC daily) QL(6.6667 ea
QL(6.6667 ea LANCETS THIN MISC 1
KROGER LANCETS MISC 1 daily)
daily) LANCETS TWIST TOP QL(6.6667 ea
KROGER LANCETS QL(6.6667 ea 1
1 MISC daily)
SUPER THIN MISC daily) LANCETS ULTRA FINE QL(6.6667 ea
KROGER LANCETS THIN QL(6.6667 ea 1
1 MISC daily)
26G MISC daily) LANCETS ULTRA THIN QL(6.6667 ea
KROGER LANCETS THIN QL(6.6667 ea 1
1 30G MISC daily)
MISC daily) LANCETS ULTRA THIN QL(6.6667 ea
KROGER LANCETS QL(6.6667 ea 1
1 MISC daily)
ULTRATHIN30G MISC daily) LANCETSBULLSEYE QL(6.6667 ea
KROGER LANCING 1
1 SAFETY MISC daily)
DEVICE MISC LANCING DEVICE
LANCET DEVICE 1
1 ADJUSTABLE MISC
ADJUSTABLE MISC
LANCING DEVICE MISC 1
LANCET DEVICE WITH 1
EJECTOR MISC LANZO MISC 1
LANCETS 26G TWIST 1 QL(6.6667 ea
TOP MISC daily) LEADER ADVANCED 1
QL(6.6667 ea LANCING DEVICE MISC
LANCETS 28G MISC 1
daily)

Ambetter Formulary Updated April 01, 2018

82
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
LIBERTY MEDICAL 1 QL(6.6667 ea MEDISENSE THIN 1 QL(6.6667 ea
LANCETS 30G MISC daily) LANCETS MISC daily)
LIBERTY MINI LANCING 1 MEDLANCE PLUS EXTRA 1 QL(6.6667 ea
DEVICE MISC LANCETS 21G MISC daily)
LIFESCAN UNISTIK 2 QL(6.6667 ea MEDLANCE PLUS
DEEP PENETRATION daily) 1 QL(6.6667 ea
1 LANCETS LITE 25G MISC daily)
MISC MEDLANCE PLUS
LIFESCAN UNISTIK II QL(6.6667 ea 1 QL(6.6667 ea
1 LANCETS MISC daily)
LANCETS MISC daily) MEDLANCE PLUS LITE
LITE TOUCH LANCETS QL(6.6667 ea 1 QL(6.6667 ea
1 LANCETS 25G MISC daily)
MISC daily) MEDLANCE PLUS QL(6.6667 ea
LITE TOUCH LANCING 1 SPECIAL LANCETS 1 daily)
DEVICE MISC 0.8MM MISC
LITE TOUCH LANCING MEDLANCE PLUS
PEN MISC
1 1 QL(6.6667 ea
SUPERLITE 30G MISC daily)
LITETOUCH LANCETS 1 QL(6.6667 ea MEDLANCE PLUS QL(6.6667 ea
MICRO THIN 33G MISC daily) SUPERLITE 1 daily)
LIVE BETTER ADVANCED 30G/COMFORT MAX
1 MISC
LANCING DEVICE MISC
LIVE BETTER LANCET QL(6.6667 ea MEDLANCE PLUS QL(6.6667 ea
1 UNIVERSAL LANCETS 1 daily)
SUPERTHIN 30G MISC daily)
21G MISC
LIVE BETTER LANCET 1 QL(6.6667 ea
ULTRATHIN 28G MISC daily) MEDLANCE PLUS/LITE 1 QL(6.6667 ea
25G MISC daily)
LONGS LANCETS 1 QL(6.6667 ea
STANDARD MISC daily) MEDLANCE/EXTRA MISC 1 QL(6.6667 ea
daily)
LONGS LANCETS THIN 1 QL(6.6667 ea
MISC daily) MEDLANCE/LITE MISC 1 QL(6.6667 ea
daily)
LONGS LANCETS ULTRA 1 QL(6.6667 ea
THIN MISC daily) MEDLANCE/UNIVERSAL 1 QL(6.6667 ea
MISC daily)
MEDICHOICE PRE-SET QL(6.6667 ea
SAFETY LANCET DUAL 1 daily) MEIJER COLOR QL(6.6667 ea
USE MISC LANCETS UNIVERSAL 1 daily)
33G MISC
MEDICHOICE PRE-SET QL(6.6667 ea
SAFETY LANCET LOW 1 daily) MEIJER LANCETS MISC 1 QL(6.6667 ea
FLOW MISC daily)
MEDICHOICE PRE-SET QL(6.6667 ea MEIJER LANCETS THIN 1 QL(6.6667 ea
SAFETY LANCET 1 daily) MISC daily)
MEDIUM FLOW MISC MEIJER LANCETS 1 QL(6.6667 ea
MEDICHOICE PRE-SET QL(6.6667 ea UNIVERSAL21G MISC daily)
SAFETY LANCET daily) MEIJER LANCETS 1 QL(6.6667 ea
1
MODERATE FLOW MISC UNIVERSAL30G MISC daily)
MEDICHOICE SAFETY QL(6.6667 ea MEIJER LANCETS
LANCETEXTRA MISC
1
daily) 1 QL(6.6667 ea
UNIVERSAL33G MISC daily)
MEDICHOICE SAFETY QL(6.6667 ea MEIJER SUPER THIN
LANCETNORMAL MISC
1
daily) 1 QL(6.6667 ea
LANCETS MISC daily)

Ambetter Formulary Updated April 01, 2018

83
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
MICROLET LANCETS 1 QL(6.6667 ea ONETOUCH COMBO 1 QL(6.6667 ea
MISC daily) PACK MISC daily)
MICROLET NEXT MISC 1 ONETOUCH DELICA QL(6.6667 ea
LANCETS EXTRA FINE 1 daily)
MICROTAINER SAFETY QL(6.6667 ea 33G MISC
FLOW 1 daily) ONETOUCH DELICA QL(6.6667 ea
LANCET/STERILE/SINGL 1
LANCETS FINE 30G MISC daily)
E-USE MISC ONETOUCH DELICA
MINI LANCING DEVICE 1
1 LANCING DEVICE MISC
MISC ONETOUCH FINEPOINT QL(6.6667 ea
MM LANCING DEVICE 1
1 LANCETS MISC daily)
MISC ONETOUCH ULTRASOFT QL(6.6667 ea
MM TWIST LANCETS QL(6.6667 ea 1
1 LANCETS MISC daily)
MISC daily) PC LANCETS SUPER QL(6.6667 ea
MONOLET LANCETS QL(6.6667 ea 1
1 THIN 30G MISC daily)
MISC daily) PERFECT LANCETS 30G QL(6.6667 ea
MONOLET OPD LANCETS QL(6.6667 ea 1
1 MISC daily)
MISC daily) PERFECT PRESSURE QL(6.6667 ea
MONOLETTOR SAFETY 1 QL(6.6667 ea ACTIVATED SAFETY 1 daily)
LANCETS MISC daily) LANCETS 28G MISC
MULTI-LANCET DEVICE 1 PHARMACIST CHOICE QL(6.6667 ea
MISC ULTRA THIN LANCETS 1 daily)
MYGLUCOHEALTH MGH QL(6.6667 ea 28G MISC
SOFTLANCE LANCETS 1 daily) PHARMACIST CHOICE QL(6.6667 ea
30G MISC ULTRA THIN LANCETS 1 daily)
NETGROUP LANCETS QL(6.6667 ea 30G MISC
1
MISC daily) PHARMACIST CHOICE QL(6.6667 ea
NOVA SAFETY LANCETS QL(6.6667 ea ULTRA THIN LANCETS 1 daily)
1 31G MISC
23G MISC daily)
NOVA SAFETY LANCETS QL(6.6667 ea PHARMACIST CHOICE QL(6.6667 ea
1 ULTRA THIN LANCETS 1 daily)
28G MISC daily)
NOVA SUREFLEX QL(6.6667 ea 33G MISC
1 PHARMACIST CHOICE QL(6.6667 ea
LANCETS MISC daily)
NOVA SUREFLEX ULTRA THIN LANCETS 1 daily)
1 MISC
LANCING DEVICE MISC
QL(6.6667 ea PHARMACY COUNTER 1 QL(6.6667 ea
ON CALL LANCETS MISC 1 LANCETS MISC daily)
daily)
ON CALL LANCING PRECISION THIN 1 QL(6.6667 ea
1 LANCETS MISC daily)
DEVICE MISC
ON CALL PLUS LANCETS QL(6.6667 ea PRECISION THINS GP 1 QL(6.6667 ea
1 LANCET MISC daily)
MISC daily)
ON CALL PLUS LANCING PRECISION ULTRA 1 QL(6.6667 ea
1 LANCET MISC daily)
DEVICE MISC
ONETOUCH CLUB QL(6.6667 ea PREFERRED PLUS QL(6.6667 ea
LANCETS FINE POINT 1 daily) LANCETS COLORED 21G 1 daily)
MISC MISC

Ambetter Formulary Updated April 01, 2018

84
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
PREFERRED PLUS QL(6.6667 ea QC UNILET LANCETS 1 QL(6.6667 ea
LANCETS SUPER THIN 1 daily) 33G/MICRO THIN MISC daily)
30G MISC RA E-ZJECT COLOR QL(6.6667 ea
PREFERRED PLUS 1 QL(6.6667 ea LANCETSMICRO-THIN 1 daily)
LANCETS THIN 26G MISC daily) 33G MISC
PRESSURE ACTIVATED QL(6.6667 ea RA E-ZJECT LANCETS 1 QL(6.6667 ea
SAFETYLANCET 21G 1 daily) 28G MISC daily)
MISC RA E-ZJECT LANCETS QL(6.6667 ea
1
PRO COMFORT 1 QL(6.6667 ea THIN 26G MISC daily)
LANCETS 30G MISC daily) RA E-ZJECT LANCETS QL(6.6667 ea
1
PRO COMFORT 1 QL(6.6667 ea THIN 28G MISC daily)
LANCETS 31G MISC daily) RA E-ZJECT LANCETS QL(6.6667 ea
1
PRODIGY LANCING 1 ULTRATHIN 30G MISC daily)
DEVICE MISC RA LANCING DEVICE 1
PRODIGY PRESSURE QL(6.6667 ea MISC
ACTIVATED SAFETY 1 daily) READYLANCE SAFETY QL(6.6667 ea
LANCETS MISC LANCETS/21G/2.2MM 1 daily)
PRODIGY SAFETY 1 QL(6.6667 ea MISC
LANCETS MISC daily) READYLANCE SAFETY QL(6.6667 ea
PRODIGY TWIST TOP 1 QL(6.6667 ea LANCETS/23G/1.8MM 1 daily)
LANCETS MISC daily) MISC
PSS SELECT GP 1 QL(6.6667 ea READYLANCE SAFETY QL(6.6667 ea
LANCETS MISC daily) LANCETS/26G/1.8MM 1 daily)
PSS SELECT SAFETY QL(6.6667 ea MISC
1
LANCETS MISC daily) READYLANCE SAFETY QL(6.6667 ea
PUSH BUTTON SAFETY QL(6.6667 ea LANCETS/28G/1.8MM 1 daily)
1 MISC
LANCETS 21G MISC daily)
PUSH BUTTON SAFETY QL(6.6667 ea READYLANCE SAFETY QL(6.6667 ea
1 LANCETS/30G/1.6MM 1 daily)
LANCETS 28G MISC daily)
MISC
PX ADVANCED LANCING 1
DEVICE MISC QL(6.6667 ea
REALITY LANCETS MISC 1
daily)
PX LANCET AUTO 1
INJECTOR MISC REALITY TRIGGER 1 QL(6.6667 ea
LANCETS MISC daily)
PX LANCETS ULTRA 1 QL(6.6667 ea
THIN 28G MISC daily) RELION 2-IN-1 LANCING 1
DEVICE 25G MISC
PX LANCETS ULTRA 1 QL(6.6667 ea
THIN MISC daily) RELION 2-IN-1 LANCING 1
DEVICE 30G MISC
QC ADVANCED LANCING 1
DEVICE MISC RELION LANCETS 1 QL(6.6667 ea
MICRO-THIN33G MISC daily)
QC LANCETS SUPER 1 QL(6.6667 ea
THIN MISC daily) RELION LANCETS 1 QL(6.6667 ea
STANDARD 21G MISC daily)
QC LANCETS ULTRA 1 QL(6.6667 ea
THIN MISC daily) RELION LANCETS THIN 1 QL(6.6667 ea
26G MISC daily)
QC UNILET LANCETS 1 QL(6.6667 ea
28G/ULTRA THIN MISC daily) RELION LANCETS 1 QL(6.6667 ea
ULTRA-THIN30G MISC daily)

Ambetter Formulary Updated April 01, 2018

85
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
RELION LANCING SAPS HEALTH TWIST
DEVICE MISC
1 1 QL(6.6667 ea
TOP LANCETS 30G MISC daily)
RELION ULTRA THIN QL(6.6667 ea SAPSCARE TWIST TOP
LANCETS30G MISC
1
daily) 1 QL(6.6667 ea
LANCETS 30G MISC daily)
RELION ULTRA THIN QL(6.6667 ea
PLUS LANCETS 32G daily) SB LANCETS THIN MISC 1 QL(6.6667 ea
1 daily)
MISC SB LANCETS ULTRA
RELION ULTRA THIN QL(6.6667 ea 1 QL(6.6667 ea
THIN MISC daily)
PLUS LANCETS 33G 1 daily) SELECT-LITE LANCING
MISC 1
DEVICE MISC
REXALL LANCETS ULTRA 1 QL(6.6667 ea SHOPKO AUTOLET
THIN MISC daily) 1
LANCING DEVICE MISC
RIGHTEST GD500 1 SHOPKO ON-THE-GO QL(6.6667 ea
LANCING DEVICE MISC COMFORTLANCETS 30G 1 daily)
RIGHTEST GL300 1 QL(6.6667 ea MISC
LANCETS MISC daily) SHOPKO UNILET QL(6.6667 ea
SAFE-T-LANCE LOW 1 QL(6.6667 ea LANCETS SUPER THIN 1 daily)
FLOW 25G MISC daily) 30G MISC
SAFE-T-LANCE NORMAL 1 QL(6.6667 ea SHOPKO UNILET QL(6.6667 ea
FLOW21G MISC daily) LANCETS ULTRA THIN 1 daily)
SAFE-T-LANCE PLUS QL(6.6667 ea 28G MISC
SAFETYLANCET HIGH 1 daily) SIDE BUTTON SAFETY 1 QL(6.6667 ea
FLOW MISC LANCET21G MISC daily)
SAFE-T-LANCE PLUS QL(6.6667 ea SIMPLE DIAGNOSTICS 1
SAFETYLANCET LOW 1 daily) LANCING DEVICE MISC
FLOW MISC QL(6.6667 ea
SINGLE-LET MISC 1
SAFE-T-LANCE PLUS QL(6.6667 ea daily)
SAFETYLANCET 1 daily) SM MICRO THIN QL(6.6667 ea
NORMAL FLOW MISC 1
LANCETS 33G MISC daily)
SAFETY LANCET QL(6.6667 ea SM TRUEDRAW LANCING
21G/PRESSURE 1 daily) 1
DEVICE MISC
ACTIVATED MISC
SMART DIABETES
SAFETY LANCET QL(6.6667 ea VANTAGE LANCING 1
28G/PRESSURE 1 daily) DEVICE MISC
ACTIVATED MISC
SMART SENSE COLOR QL(6.6667 ea
SAFETY LANCETS 21G 1 QL(6.6667 ea LANCETS UNIVERSAL 1 daily)
MISC daily) 33G MISC
SAFETY LANCETS 28G 1 QL(6.6667 ea SMART SENSE QL(6.6667 ea
MISC daily) STANDARD LANCETS 1 daily)
QL(6.6667 ea UNIVERSAL 21G MISC
SAFETY LANCETS MISC 1
daily) SMART SENSE SUPER QL(6.6667 ea
SAFETY LET LANCETS 1 QL(6.6667 ea THIN LANCETS 1 daily)
MISC daily) UNIVERSAL 30G MISC
SAFETY SEAL LANCETS 1 QL(6.6667 ea SMART SENSE THIN QL(6.6667 ea
28G MISC daily) LANCETSUNIVERSAL 1 daily)
SAFETY SEAL LANCETS QL(6.6667 ea 26G MISC
1
30G MISC daily)
Ambetter Formulary Updated April 01, 2018

86
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
SMARTEST LANCETS 1 QL(6.6667 ea TGT ADVANCED 1
28G MISC daily) LANCING DEVICE MISC
SOLUS V2 LANCING 1 TGT LANCET 1 QL(6.6667 ea
DEVICE MISC ALTERNATE SITE MISC daily)
SOLUS V2 PRESSURE QL(6.6667 ea TGT LANCET MICRO 1 QL(6.6667 ea
ACTIVATED SAFETY 1 daily) THIN 33G MISC daily)
LANCETS 28G MISC TGT LANCET SUPER QL(6.6667 ea
1
SOLUS V2 TWIST 1 QL(6.6667 ea THIN 30G MISC daily)
LANCETS 30G MISC daily) TGT LANCET THIN 23G QL(6.6667 ea
1
QL(6.6667 ea MISC daily)
STERILANCE TL MISC 1
daily) TGT LANCET THIN 26G 1 QL(6.6667 ea
SUPER THIN LANCETS 1 QL(6.6667 ea MISC daily)
MISC daily) TGT LANCET ULTRA QL(6.6667 ea
1
SURE COMFORT 1 QL(6.6667 ea THIN 28G MISC daily)
LANCETS 18G MISC daily) TGT LANCET ULTRA QL(6.6667 ea
1
SURE COMFORT 1 QL(6.6667 ea THIN 30G MISC daily)
LANCETS 21G MISC daily) TGT LANCING DEVICE 1
SURE COMFORT 1 QL(6.6667 ea MISC
LANCETS 23G MISC daily) THINLETS GP LANCETS QL(6.6667 ea
1
SURE COMFORT 1 QL(6.6667 ea MISC daily)
LANCETS 28G MISC daily) QL(6.6667 ea
THINLETS LANCET MISC 1
SURE COMFORT 1 QL(6.6667 ea daily)
LANCETS 30G MISC daily) TODAYS HEALTH
SURE COMFORT 1 ADVANCED LANCING 1
LANCING PEN MISC DEVICE MISC
SURE-LANCE FLAT 1 QL(6.6667 ea TODAYS HEALTH SUPER 1 QL(6.6667 ea
LANCETS MISC daily) THINLANCETS 30G MISC daily)
SURE-LANCE LANCETS 1 QL(6.6667 ea TODAYS HEALTH ULTRA 1 QL(6.6667 ea
26G MISC daily) THINLANCETS 28G MISC daily)
SURE-LANCE THIN 1 QL(6.6667 ea TOPCARE LANCETS 1 QL(6.6667 ea
LANCETS 28G MISC daily) MICRO-THIN 33G MISC daily)
SURE-LANCE ULTRA 1 QL(6.6667 ea TRAVEL LANCETS 30G 1 QL(6.6667 ea
THIN LANCETS MISC daily) MISC daily)
SURE-PEN MISC 1 TRAVEL LANCETS 1 QL(6.6667 ea
ADVANCED 28G MISC daily)
SURE-TOUCH LANCETS 1 QL(6.6667 ea TRUE METRIX CONTROL
UNIVERSAL MISC daily) SOLUTION LEVEL 3 1
SURELITE LANCETS QL(6.6667 ea SOLN
1
MISC daily) TRUEDRAW LANCING 1
TECHLITE AST LANCETS QL(6.6667 ea DEVICE MISC
1
MISC daily) TRUEPLUS LANCETS QL(6.6667 ea
1
TECHLITE LANCETS 30G QL(6.6667 ea 26G MISC daily)
1
MISC daily) TRUEPLUS LANCETS QL(6.6667 ea
1
TECHLITE LANCETS QL(6.6667 ea 28G MISC daily)
1
MISC daily) TRUEPLUS LANCETS QL(6.6667 ea
1
28G SUPER THIN MISC daily)

Ambetter Formulary Updated April 01, 2018

87
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
TRUEPLUS LANCETS 1 QL(6.6667 ea UNILET G.P. SUPERLITE
30G MISC daily) 1 QL(6.6667 ea
LANCET MISC daily)
TRUEPLUS LANCETS 1 QL(6.6667 ea UNILET GP 28 ULTRA
30G ULTRA THIN MISC daily) 1 QL(6.6667 ea
THIN MISC daily)
TRUEPLUS LANCETS 1 QL(6.6667 ea
33G MICRO THIN MISC daily) UNILET LANCET MISC 1 QL(6.6667 ea
daily)
TRUEPLUS LANCETS 1 QL(6.6667 ea UNILET LANCETS
33G MISC daily) 1 QL(6.6667 ea
MICRO-THIN33G MISC daily)
TRUEPLUS SAFETY 1 QL(6.6667 ea UNILET LANCETS
LANCETS 28G MISC daily) 1 QL(6.6667 ea
SUPER-THIN30G MISC daily)
ULTI-LANCE AUTOMATIC/ UNILET LANCETS
CLEAR TIP MISC
1 1 QL(6.6667 ea
ULTRA-THIN 28G MISC daily)
ULTICARE THIN QL(6.6667 ea UNILET SUPERLITE
LANCETS 30G MISC
1
daily) 1 QL(6.6667 ea
LANCET MISC daily)
ULTILET CLASSIC QL(6.6667 ea
LANCETS MISC
1
daily) UNISTIK 3 GENTLE MISC 1 QL(6.6667 ea
daily)
ULTILET LANCETS 33G QL(6.6667 ea UNISTIK SAFETY
MISC
1
daily) 1 QL(6.6667 ea
LANCETS 28G MISC daily)
QL(6.6667 ea UNISTIK SAFETY
ULTILET LANCETS MISC 1
daily) 1 QL(6.6667 ea
LANCETS 30G MISC daily)
ULTILET SAFETY QL(6.6667 ea UNISTIK TOUCH SAFETY
LANCETS 21G X 2.2MM daily) 1 QL(6.6667 ea
1 LANCETS 21G MISC daily)
MISC UNISTIK TOUCH SAFETY
ULTILET SAFETY QL(6.6667 ea 1 QL(6.6667 ea
1 LANCETS 23G MISC daily)
LANCETS 23G MISC daily) UNISTIK TOUCH SAFETY
ULTRA THIN LANCETS QL(6.6667 ea 1 QL(6.6667 ea
1 LANCETS 28G MISC daily)
28G MISC daily) UNISTIK TOUCH SAFETY
ULTRA THIN LANCETS QL(6.6667 ea 1 QL(6.6667 ea
1 LANCETS 30G MISC daily)
30G MISC daily) UNIVERSAL 1 LANCETS
ULTRA-THIN II AUTO QL(6.6667 ea 1 QL(6.6667 ea
1 THIN26G MISC daily)
LANCET MISC daily) UNIVERSAL 1 LANCETS
ULTRA-THIN II LANCETS QL(6.6667 ea 1 QL(6.6667 ea
1 ULTRA THIN 30G MISC daily)
28G MISC daily) UNIVERSAL 1 QL(6.6667 ea
ULTRA-THIN II LANCETS 1 QL(6.6667 ea LANCETS/33G/MICRO- 1 daily)
30G MISC daily) THIN MISC
ULTRA-THIN II SAFETY QL(6.6667 ea VALUE PLUS LANCETS QL(6.6667 ea
AUTOLANCETS 26G daily) 1
1 STANDARD 21G MISC daily)
MISC VALUE PLUS LANCETS QL(6.6667 ea
UNILET COMFORTOUCH QL(6.6667 ea 1
1 SUPERTHIN 30G MISC daily)
LANCET MISC daily) VALUE PLUS LANCETS QL(6.6667 ea
QL(6.6667 ea 1
UNILET EXCELITE II MISC 1 THIN 26G MISC daily)
daily) VALUE PLUS LANCING
QL(6.6667 ea 1
UNILET EXCELITE MISC 1 DEVICE MISC
daily) VALUMARK LANCET QL(6.6667 ea
1
UNILET G.P. LANCET QL(6.6667 ea SUPER THIN 30G MISC daily)
1
MISC daily)

Ambetter Formulary Updated April 01, 2018

88
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
VALUMARK LANCET 1 QL(6.6667 ea 1ST TIER UNIFINE QL(5 ea daily);
ULTRA THIN 28G MISC daily) PENTIPSPLUS 31GX8MM 1 RX/OTC
VIDA MIA AUTOLET MISC
1
LANCINGDEVICE MISC 1ST TIER UNIFINE QL(5 ea daily);
VIDA MIA UNILET QL(6.6667 ea PENTIPSPLUS 32GX4MM 1 RX/OTC
LANCETS SUPER THIN 1 daily) MISC
30G MISC 1ST TIER UNIFINE QL(5 ea daily);
VIDA MIA UNILET QL(6.6667 ea PENTIPSPLUS/MINI/31GX 1 RX/OTC
LANCETS ULTRA THIN 1 daily) 5MM MISC
28G MISC 1ST TIER UNIFINE QL(5 ea daily);
VITALET PRO LANCETS QL(6.6667 ea PENTIPSPLUS/ORIGINAL/ 1 RX/OTC
1 29GX12MM MISC
MISC daily)
VITALET PRO PLUS QL(6.6667 ea 1ST TIER UNIFINE QL(5 ea daily)
1 PENTIPSPLUS/ULTRA 1
LANCETS MISC daily)
SHORT/31GX6MM MISC
QL(6.6667 ea
W&F LANCETS 26G MISC 1 ADVOCATE INSULIN PEN QL(5 ea daily)
daily)
NEEDLES 29GX12.7MM 1
W&F LANCETS 1 QL(6.6667 ea MISC
COLORED 21G MISC daily)
ADVOCATE INSULIN PEN QL(5 ea daily);
WALGREENS ADVANCED QL(6.6667 ea NEEDLES 31GX5MM 1 RX/OTC
TRAVELLANCETS 28G 1 daily) MISC
MISC
ADVOCATE INSULIN PEN QL(5 ea daily);
WALGREENS COMFORT QL(6.6667 ea NEEDLES 31GX8MM 1 RX/OTC
ASSUREDLANCETS 1 daily) MISC
MICRO THIN/33G MISC
ADVOCATE INSULIN QL(5 ea daily);
WALGREENS COMFORT QL(6.6667 ea SYRINGE/U- 1 RX/OTC
ASSUREDLANCETS 1 daily) 100/0.3ML/29GX1/2" MISC
SUPER THIN/28G MISC
ADVOCATE INSULIN QL(5 ea daily);
WALGREENS LANCETS QL(6.6667 ea SYRINGE/U-
MISC
1
daily) 1 RX/OTC
100/0.3ML/30GX5/16"
WALGREENS THIN 1 QL(6.6667 ea MISC
LANCETS MISC daily) ADVOCATE INSULIN QL(5 ea daily)
WALGREENS ULTRA 1 QL(6.6667 ea SYRINGE/U-
THIN LANCETS MISC daily) 1
100/0.3ML/31GX5/16"
Parenteral Therapy Supplies MISC
1ST TIER UNIFINE QL(5 ea daily); ADVOCATE INSULIN QL(5 ea daily);
PENTIPS/MINI/31GX5MM 1 RX/OTC SYRINGE/U- 1 RX/OTC
MISC 100/0.5ML/29GX1/2" MISC
1ST TIER UNIFINE QL(5 ea daily); ADVOCATE INSULIN QL(5 ea daily);
PENTIPS29GX12MM 1 RX/OTC SYRINGE/U- 1 RX/OTC
MISC 100/0.5ML/30GX5/16"
MISC
1ST TIER UNIFINE 1 QL(5 ea daily)
PENTIPS31GX6MM MISC ADVOCATE INSULIN QL(5 ea daily)
SYRINGE/U- 1
1ST TIER UNIFINE 1 QL(5 ea daily); 100/0.5ML/31GX5/16"
PENTIPS31GX8MM MISC RX/OTC MISC
1ST TIER UNIFINE 1 QL(5 ea daily);
PENTIPS32GX4MM MISC RX/OTC

Ambetter Formulary Updated April 01, 2018

89
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ADVOCATE INSULIN QL(5 ea daily); B-D INSULIN SYRINGE QL(5 ea daily)
SYRINGE/U- 1 RX/OTC ULTRAFINE/0.3ML/30G X 1
100/1ML/29GX1/2" MISC 1/2" MISC
ADVOCATE INSULIN QL(5 ea daily); B-D INSULIN SYRINGE QL(5 ea daily)
SYRINGE/U- 1 RX/OTC ULTRAFINE/0.5ML/30G X 1
100/1ML/30GX5/16" MISC 1/2" MISC
ADVOCATE INSULIN QL(5 ea daily) BD LO-DOSE INSULIN QL(5 ea daily);
SYRINGE/U- 1 SYRINGE MICROFINE 1 RX/OTC
100/1ML/31GX5/16" MISC IV/0.5ML/28G X 1/2" MISC
ANTI-STICK INSULIN QL(5 ea daily); BD AUTOSHIELD 29G X QL(5 ea daily)
SYRINGE/U- RX/OTC 1
1 5/16" MISC
100/0.5ML/28G X 1/2" BD INSULIN SYRINGE QL(5 ea daily);
MISC LUER-LOK/U-100/1ML 1 RX/OTC
ANTI-STICK INSULIN QL(5 ea daily); MISC
SYRINGE/U- 1 RX/OTC BD INSULIN SYRINGE QL(5 ea daily)
100/0.5ML/29G X 1/2" MICROFINE IV/U-
MISC 1
100/0.3ML/28G X 1/2"
ANTI-STICK INSULIN QL(5 ea daily); MISC
SYRINGE/U-100/1ML/29G 1 RX/OTC BD INSULIN SYRINGE QL(5 ea daily);
X 1/2" MISC MICROFINE IV/U- RX/OTC
ASSURE ID INSULIN QL(5 ea daily); 1
100/0.5ML/28G X 1/2"
SAFETYSYRINGE/U- 1 RX/OTC MISC
100/0.5ML/29G X 1/2" BD INSULIN SYRINGE QL(5 ea daily)
MISC MICROFINE IV/U- 1
ASSURE ID INSULIN QL(5 ea daily); 100/1ML/27G X 5/8" MISC
SAFETYSYRINGE/U- 1 RX/OTC BD INSULIN SYRINGE QL(5 ea daily);
100/1ML/29G X 1/2" MISC MICROFINE IV/U- 1 RX/OTC
AURORA PEN NEEDLES 1 QL(5 ea daily); 100/1ML/28G X 1/2" MISC
29GX12MM MISC RX/OTC BD INSULIN SYRINGE QL(5 ea daily)
AURORA PEN NEEDLES 1 QL(5 ea daily) MICROFINE/U-
31G X6MM MISC 1
100/0.3ML/28G X 1/2"
AURORA PEN NEEDLES QL(5 ea daily); MISC
1
31G X8MM MISC RX/OTC BD INSULIN SYRINGE QL(5 ea daily);
AURORA UNIFINE QL(5 ea daily); MICROFINE/U- 1 RX/OTC
1 100/0.5ML/28G X 1/2"
PENTIPS/32GX5/32" MISC RX/OTC
MISC
AURORA UNIFINE QL(5 ea daily);
PENTIPS/MINI/31GX3/16" 1 RX/OTC BD INSULIN SYRINGE QL(5 ea daily)
MISC MICROFINE/U- 1
100/1ML/27G X 5/8" MISC
B-D INSULIN SYRINGE QL(5 ea daily)
ULTRAFINE II/0.3ML/31G 1 BD INSULIN SYRINGE QL(5 ea daily);
X 5/16" MISC MICROFINE/U- 1 RX/OTC
100/1ML/28G X 1/2" MISC
B-D INSULIN SYRINGE QL(5 ea daily)
ULTRAFINE II/0.5ML/31G 1 BD INSULIN SYRINGE QL(5 ea daily);
X 5/16" MISC SAFETYGLIDE/0.5ML/29G 1 RX/OTC
X 1/2" MISC
B-D INSULIN SYRINGE QL(5 ea daily)
ULTRAFINE II/1ML/31G X 1 BD INSULIN SYRINGE QL(5 ea daily);
5/16" MISC SAFETYGLIDE/1ML/29G X 1 RX/OTC
1/2" MISC

Ambetter Formulary Updated April 01, 2018

90
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily);
SAFETYGLIDE/U- ULTRAFINE/U-
100/0.3ML/31G X 5/16"
1 1 RX/OTC
100/0.5ML/29G X 1/2"
MISC MISC
BD INSULIN SYRINGE 1 QL(5 ea daily); BD INSULIN SYRINGE QL(5 ea daily)
SLIP TIP/U-100/1ML MISC RX/OTC ULTRAFINE/U- 1
BD INSULIN SYRINGE QL(5 ea daily) 100/0.5ML/30G X 1/2"
ULTRAFINE HALF- MISC
1
UNIT/0.3ML/31G X 5/16" BD INSULIN SYRINGE QL(5 ea daily)
MISC ULTRAFINE/U- 1
BD INSULIN SYRINGE QL(5 ea daily) 100/0.5ML/31G X 5/16"
ULTRAFINE MISC
1
II/SHORT/0.5ML/31G X BD INSULIN SYRINGE QL(5 ea daily);
5/16" MISC ULTRAFINE/U- 1 RX/OTC
BD INSULIN SYRINGE QL(5 ea daily) 100/1ML/29G X 1/2" MISC
ULTRAFINE 1 BD INSULIN SYRINGE QL(5 ea daily)
II/SHORT/1ML/31G X 5/16" ULTRAFINE/U- 1
MISC 100/1ML/30G X 1/2" MISC
BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN SYRINGE QL(5 ea daily)
ULTRAFINE/0.3ML/30G X 1 ULTRAFINE/U-
1/2" MISC 1
100/1ML/31G X 15/64"
BD INSULIN SYRINGE QL(5 ea daily) MISC
ULTRAFINE/0.3ML/31G X 1 BD INSULIN SYRINGE QL(5 ea daily)
5/16" MISC ULTRAFINE/U- 1
BD INSULIN SYRINGE QL(5 ea daily) 100/1ML/31G X 5/16"
ULTRAFINE/0.5ML/30G X 1 MISC
1/2" MISC BD INSULIN QL(5 ea daily)
BD INSULIN SYRINGE QL(5 ea daily) SYRINGE/DETACHABLE 1
ULTRAFINE/0.5ML/31G X 1 NEEDLE/U-100/1ML/25G
5/16" MISC X 1" MISC
BD INSULIN SYRINGE QL(5 ea daily) BD INSULIN QL(5 ea daily)
ULTRAFINE/1ML/30G X 1 SYRINGE/DETACHABLE 1
1/2" MISC NEEDLE/U-100/1ML/25G
X 5/8" MISC
BD INSULIN SYRINGE QL(5 ea daily)
ULTRAFINE/1ML/31G X 1 BD INSULIN QL(5 ea daily)
5/16" MISC SYRINGE/DETACHABLE 1
NEEDLE/U-100/1ML/26G
BD INSULIN SYRINGE QL(5 ea daily); X 1/2" MISC
ULTRAFINE/U- 1 RX/OTC
100/0.3ML/29G X 1/2" BD INSULIN SYRINGE/U- QL(5 ea daily)
MISC 100/0.5ML/30G X 1/2" 1
MISC
BD INSULIN SYRINGE QL(5 ea daily)
ULTRAFINE/U- BD INSULIN SYRINGE/U- 1 QL(5 ea daily);
1 100/1ML/27G X 1/2" MISC RX/OTC
100/0.3ML/30G X 1/2"
MISC BD INSULIN SYRINGE/U- QL(5 ea daily);
1
BD INSULIN SYRINGE QL(5 ea daily) 100/1ML/28G X 1/2" MISC RX/OTC
ULTRAFINE/U- 1 BD INTEGRA INSULIN QL(5 ea daily);
100/0.3ML/31G X 5/16" SYRINGE/U-100/1ML/29G 1 RX/OTC
MISC X 1/2" MISC

Ambetter Formulary Updated April 01, 2018

91
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
BD INTEGRA QL(5 ea daily) CAREFINE PEN QL(5 ea daily);
SYRINGE/RETRACTING 1 NEEDLES 31GX8MM 1 RX/OTC
NEEDLE/1ML/25G X 1" MISC
MISC CAREFINE PEN QL(5 ea daily);
BD PEN QL(5 ea daily); NEEDLES 32GX5MM 1 RX/OTC
NEEDLE/MINI/ULTRAFINE 1 RX/OTC MISC
/31G X 3/16" MISC CAREFINE PEN QL(5 ea daily)
BD PEN QL(5 ea daily); NEEDLES 32GX6MM 1
NEEDLE/NANO/ULTRAFI 1 RX/OTC MISC
NE/32G X 4MM MISC CAREONE INSULIN QL(5 ea daily)
BD PEN QL(5 ea daily); SYRINGES/0.3ML/30G X 1
NEEDLE/SHORT/ULTRAFI 1 RX/OTC 1/2" MISC
NE/31G X 5/16" MISC CAREONE INSULIN QL(5 ea daily)
BD PEN QL(5 ea daily) SYRINGES/0.3ML/31G X 1
NEEDLE/ULTRAFINE/29G 1 5/16" MISC
X 12.7MM MISC CAREONE INSULIN QL(5 ea daily)
BD PEN QL(5 ea daily) SYRINGES/0.5ML/30G X 1
NEEDLE/ULTRAFINE/29G 1 1/2" MISC
X1/2" 12.7MM MISC CAREONE INSULIN QL(5 ea daily)
BD PEN NEEDLES QL(5 ea daily); SYRINGES/0.5ML/31G X 1
SHORT/ULTRAFINE/31G 1 RX/OTC 5/16" MISC
X 5/16" MISC CAREONE INSULIN QL(5 ea daily)
BD SAFETY-GLIDE QL(5 ea daily); SYRINGES/1ML/30G X 1
INSULIN 1 RX/OTC 1/2" MISC
SYRINGE/0.5ML/29G X CAREONE INSULIN QL(5 ea daily)
1/2" MISC SYRINGES/1ML/31GX5/16 1
BD SAFETY-LOK INSULIN QL(5 ea daily); " MISC
SYRINGE/PERM 1 RX/OTC CAREONE UNIFINE QL(5 ea daily);
NEEDLE/UF/1ML/29G X PENTIPS 29GX12MM 1 RX/OTC
1/2" MISC MISC
BD SAFETYGLIDE QL(5 ea daily); CAREONE UNIFINE QL(5 ea daily);
INSULIN RX/OTC 1
1 PENTIPS 31GX5MM MISC RX/OTC
SYSYRINGE/0.5ML/30G X
5/16" MISC CAREONE UNIFINE 1 QL(5 ea daily)
PENTIPS 31GX6MM MISC
BD ULTRA-FINE MICRO QL(5 ea daily)
PEN NEEDLES 6MM X 1 CAREONE UNIFINE 1 QL(5 ea daily);
32G MISC PENTIPS 31GX8MM MISC RX/OTC
CAREFINE PEN NEEDLE QL(5 ea daily); CAREONE UNIFINE QL(5 ea daily);
1 PENTIPS PEN NEEDLES 1 RX/OTC
32GX4MM MISC RX/OTC
32GX4MM MISC
CAREFINE PEN 1 QL(5 ea daily);
NEEDLES 29GX1/2" MISC RX/OTC CAREONE UNIFINE QL(5 ea daily);
PENTIPS PLUS PEN 1 RX/OTC
CAREFINE PEN QL(5 ea daily); NEEDLES 29GX12MM
NEEDLES 30GX5/16" 1 RX/OTC MISC
MISC
CAREONE UNIFINE QL(5 ea daily);
CAREFINE PEN QL(5 ea daily) PENTIPS PLUS PEN RX/OTC
NEEDLES 31GX6MM 1 1
NEEDLES 31GX5MM
MISC MISC

Ambetter Formulary Updated April 01, 2018

92
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
CAREONE UNIFINE QL(5 ea daily) CLEVER CHOICE QL(5 ea daily);
PENTIPS PLUS PEN COMFORT EZINSULIN
NEEDLES 31GX6MM
1 1 RX/OTC
SYRINGE/0.5ML/28G X
MISC 1/2" MISC
CAREONE UNIFINE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily);
PENTIPS PLUS PEN 1 RX/OTC COMFORT EZINSULIN RX/OTC
NEEDLES 31GX8MM 1
SYRINGE/0.5ML/29G X
MISC 1/2" MISC
CAREONE UNIFINE QL(5 ea daily); CLEVER CHOICE QL(5 ea daily)
PENTIPS PLUS PEN 1 RX/OTC COMFORT EZINSULIN
NEEDLES 32GX4MM 1
SYRINGE/0.5ML/30G X
MISC 1/2" MISC
CARETOUCH PEN QL(5 ea daily) CLEVER CHOICE QL(5 ea daily);
NEEDLES 31G X 6 MM 1 COMFORT EZINSULIN RX/OTC
MISC 1
SYRINGE/0.5ML/30G X
CARETOUCH PEN QL(5 ea daily); 5/16" MISC
NEEDLES 31GX 5MM 1 RX/OTC CLEVER CHOICE QL(5 ea daily)
MISC COMFORT EZINSULIN 1
CARETOUCH PEN QL(5 ea daily); SYRINGE/0.5ML/31G X
NEEDLES 31GX 8MM 1 RX/OTC 5/16" MISC
MISC CLEVER CHOICE QL(5 ea daily)
CARETOUCH PEN QL(5 ea daily); COMFORT EZINSULIN 1
NEEDLES 32GX 4MM 1 RX/OTC SYRINGE/1.0ML/30G X
MISC 1/2" MISC
CARETOUCH PEN QL(5 ea daily); CLEVER CHOICE QL(5 ea daily);
NEEDLES 32GX 5MM 1 RX/OTC COMFORT EZINSULIN 1 RX/OTC
MISC SYRINGE/1ML/28G X 1/2"
MISC
CLEVER CHOICE QL(5 ea daily);
COMFORT EZINSULIN RX/OTC CLEVER CHOICE QL(5 ea daily);
1 COMFORT EZINSULIN RX/OTC
PEN NEEDLES 31GX8MM 1
MISC SYRINGE/1ML/29G X 1/2"
MISC
CLEVER CHOICE QL(5 ea daily);
COMFORT EZINSULIN RX/OTC CLEVER CHOICE QL(5 ea daily);
1 COMFORT EZINSULIN RX/OTC
SYRINGE/0.3ML/29G X 1
1/2" MISC SYRINGE/1ML/30G X
5/16" MISC
CLEVER CHOICE QL(5 ea daily)
COMFORT EZINSULIN CLEVER CHOICE QL(5 ea daily)
1 COMFORT EZINSULIN
SYRINGE/0.3ML/30G X 1
1/2" MISC SYRINGE/U-
100/1ML/31GX5/16" MISC
CLEVER CHOICE QL(5 ea daily);
COMFORT EZINSULIN RX/OTC CLEVER CHOICE QL(5 ea daily);
1 COMFORT EZPEN RX/OTC
SYRINGE/0.3ML/30G X 1
5/16" MISC NEEDLES 29GX12MM
MISC
CLEVER CHOICE QL(5 ea daily)
COMFORT EZINSULIN CLEVER CHOICE QL(5 ea daily);
1 COMFORT EZPEN RX/OTC
SYRINGE/0.3ML/31G X 1
5/16" MISC NEEDLES 31GX5MM
MISC

Ambetter Formulary Updated April 01, 2018

93
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
CLEVER CHOICE QL(5 ea daily) COMFORT ASSIST QL(5 ea daily);
COMFORT EZPEN INSULIN
NEEDLES 31GX6MM
1 1 RX/OTC
SYRINGE/0.5ML/29G X
MISC 1/2" MISC
CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily);
COMFORT EZPEN 1 RX/OTC INSULIN RX/OTC
NEEDLES 31GX8MM 1
SYRINGE/0.5ML/30G X
MISC 5/16" MISC
CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily)
COMFORT EZPEN 1 RX/OTC INSULIN
NEEDLES 32GX4MM 1
SYRINGE/0.5ML/31G X
MISC 5/16" MISC
CLEVER CHOICE QL(5 ea daily); COMFORT ASSIST QL(5 ea daily);
COMFORT EZPEN 1 RX/OTC INSULIN RX/OTC
NEEDLES 32GX5MM 1
SYRINGE/1ML/29G X 1/2"
MISC MISC
CLEVER CHOICE QL(5 ea daily) COMFORT ASSIST QL(5 ea daily);
COMFORT EZPEN 1 INSULIN RX/OTC
NEEDLES 32GX6MM 1
SYRINGE/1ML/30G X
MISC 5/16" MISC
CLICKFINE PEN NEEDLE 1 QL(5 ea daily); COMFORT ASSIST QL(5 ea daily)
32GX5/32" MISC RX/OTC INSULIN 1
CLICKFINE PEN NEEDLE QL(5 ea daily) SYRINGE/1ML/31G X
UNIVERSAL/31GX1/4" 1 5/16" MISC
MISC DROPLET PEN NEEDLES QL(5 ea daily);
1
CLICKFINE PEN NEEDLE QL(5 ea daily); 29GX12MM MISC RX/OTC
UNIVERSAL/31GX5/16" 1 RX/OTC DROPLET PEN NEEDLES QL(5 ea daily);
MISC 1
31GX5MM MISC RX/OTC
CLICKFINE PEN 1 QL(5 ea daily) DROPLET PEN NEEDLES QL(5 ea daily)
NEEDLES/31GX1/4" MISC 1
31GX6MM MISC
CLICKFINE PEN QL(5 ea daily); DROPLET PEN NEEDLES QL(5 ea daily);
NEEDLES/31GX5/16" RX/OTC 1
1 31GX8MM MISC RX/OTC
MISC DROPLET PEN NEEDLES QL(5 ea daily)
CLICKFINE UNIVERSAL QL(5 ea daily); 1
32G X 1/4" MISC
PEN NEEDLES 31GX5/16" 1 RX/OTC DROPLET PEN NEEDLES QL(5 ea daily);
MISC 1
32G X 3/16" MISC RX/OTC
COMFORT ASSIST QL(5 ea daily); DROPLET PEN NEEDLES QL(5 ea daily);
INSULIN SYRINGE 1 RX/OTC 1
32G X 5/32" MISC RX/OTC
0.3ML/29G X 1/2" MISC
DROPLET PEN NEEDLES 1 QL(5 ea daily);
COMFORT ASSIST QL(5 ea daily); 32GX4MM MISC RX/OTC
INSULIN 1 RX/OTC
SYRINGE/0.3ML/30G X DROPLET PEN NEEDLES 1 QL(5 ea daily);
5/16" MISC 32GX5MM MISC RX/OTC
COMFORT ASSIST QL(5 ea daily) DROPLET PEN NEEDLES 1 QL(5 ea daily)
INSULIN 32GX6MM MISC
1 DRUG MART UNIFINE QL(5 ea daily);
SYRINGE/0.3ML/31G X 1
5/16" MISC PENTIPS 31GX5MM MISC RX/OTC

Ambetter Formulary Updated April 01, 2018

94
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
DRUG MART UNIFINE QL(5 ea daily); EASY COMFORT PEN
PENTIPS29G X 12MM 1 RX/OTC 1 QL(5 ea daily);
NEEDLES31GX3/16" MISC RX/OTC
MISC EASY COMFORT PEN
DRUG MART UNIFINE QL(5 ea daily) 1 QL(5 ea daily);
1 NEEDLES31GX5/16" MISC RX/OTC
PENTIPS31GX6MM MISC EASY COMFORT PEN
DRUG MART UNIFINE QL(5 ea daily); 1 QL(5 ea daily);
1 NEEDLES32GX5/32" MISC RX/OTC
PENTIPS31GX8MM MISC RX/OTC EASY TOUCH 32GX5MM
DRUG MART UNIFINE QL(5 ea daily); 1 QL(5 ea daily);
1 MISC RX/OTC
PENTIPS32GX4MM MISC RX/OTC EASY TOUCH 32GX6MM
DRUG MART UNIFINE QL(5 ea daily); 1 QL(5 ea daily)
MISC
PENTIPSPLUS 32GX4MM 1 RX/OTC EASY TOUCH FLIPLOCK QL(5 ea daily);
MISC SAFETY INSULIN
DUANE READE UNIFINE QL(5 ea daily); 1 RX/OTC
SYRINGE 1ML/29GX1/2"
PENTIPS 29G X 12MM 1 RX/OTC MISC
MISC EASY TOUCH FLIPLOCK QL(5 ea daily)
DUANE READE UNIFINE QL(5 ea daily) SAFETY INSULIN
PENTIPS 31G X 6MM 1
1 SYRINGE 1ML/30GX1/2"
ULTRA SHORT MISC MISC
DUANE READE UNIFINE QL(5 ea daily); EASY TOUCH FLIPLOCK QL(5 ea daily);
PENTIPS 31G X 8MM RX/OTC SAFETY INSULIN 1 RX/OTC
1
SHORT MISC SYRINGE 1ML/30GX5/16"
EASY COMFORT INSULIN QL(5 ea daily); MISC
SYRINGE/0.3ML/30G X 1 RX/OTC EASY TOUCH FLIPLOCK QL(5 ea daily)
5/16" MISC SAFETY INSULIN 1
EASY COMFORT INSULIN QL(5 ea daily); SYRINGE 1ML/31GX5/16"
SYRINGE/0.5ML/30G X 1 RX/OTC MISC
5/16" MISC EASY TOUCH INSULIN QL(5 ea daily);
EASY COMFORT INSULIN QL(5 ea daily) SYRINGE/0.3ML/30G X 1 RX/OTC
SYRINGE/0.5ML/31G X 1 5/16" MISC
5/16" MISC EASY TOUCH INSULIN QL(5 ea daily)
EASY COMFORT INSULIN QL(5 ea daily); SYRINGE/0.3ML/31G X 1
SYRINGE/1ML/30G X 1 RX/OTC 5/16" MISC
5/16" MISC EASY TOUCH INSULIN QL(5 ea daily);
EASY COMFORT INSULIN QL(5 ea daily) SYRINGE/0.5ML/29G X 1 RX/OTC
SYRINGE/1ML/31G X 1 1/2" MISC
5/16" MISC EASY TOUCH INSULIN QL(5 ea daily);
EASY COMFORT INSULIN QL(5 ea daily) SYRINGE/0.5ML/30G X 1 RX/OTC
SYRINGE/U- 5/16" MISC
1
100/0.5ML/30G X 1/2" EASY TOUCH INSULIN QL(5 ea daily);
MISC SYRINGE/1ML/30G X 1 RX/OTC
EASY COMFORT INSULIN QL(5 ea daily) 5/16" MISC
SYRINGE/U-100/1ML/30G 1 EASY TOUCH INSULIN QL(5 ea daily);
X 1/2" MISC SYRINGE/SAFETY/U- 1 RX/OTC
EASY COMFORT PEN QL(5 ea daily) 100/0.5ML/29G X 1/2"
1 MISC
NEEDLES31GX1/4" MISC

Ambetter Formulary Updated April 01, 2018

95
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH PEN
SYRINGE/SAFETY/U- 1 QL(5 ea daily);
1 RX/OTC NEEDLES 29GX1/2" MISC RX/OTC
100/0.5ML/30G X 5/16" EASY TOUCH PEN
MISC 1 QL(5 ea daily)
NEEDLES 31GX1/4" MISC
EASY TOUCH INSULIN QL(5 ea daily); EASY TOUCH PEN QL(5 ea daily);
SYRINGE/SAFETY/U- 1 RX/OTC NEEDLES 31GX5/16" 1 RX/OTC
100/1ML/29G X 1/2" MISC MISC
EASY TOUCH INSULIN QL(5 ea daily) EASY TOUCH PEN
SYRINGE/SAFETY/U- 1 1 QL(5 ea daily)
NEEDLES 32GX1/4" MISC
100/1ML/30G X 1/2" MISC
EASY TOUCH PEN QL(5 ea daily);
EASY TOUCH INSULIN QL(5 ea daily) NEEDLES 32GX3/16" 1 RX/OTC
SYRINGE/U- 1 MISC
100/0.3ML/30G X 1/2"
MISC EASY TOUCH PEN QL(5 ea daily);
NEEDLES 32GX5/32" 1 RX/OTC
EASY TOUCH INSULIN QL(5 ea daily) MISC
SYRINGE/U- 1
100/0.5ML/27G X 1/2" EASY TOUCH PEN QL(5 ea daily);
MISC NEEDLES/31G X 3/16" 1 RX/OTC
MISC
EASY TOUCH INSULIN QL(5 ea daily);
SYRINGE/U- RX/OTC EASY TOUCH QL(5 ea daily);
1 SHEATHLOCK SAFETY
100/0.5ML/28G X 1/2" 1 RX/OTC
MISC INSULIN SYRINGE
1ML/29GX1/2" MISC
EASY TOUCH INSULIN QL(5 ea daily)
SYRINGE/U- EASY TOUCH QL(5 ea daily);
1 SHEATHLOCK SAFETY
100/0.5ML/30G X 1/2" 1 RX/OTC
MISC INSULIN SYRINGE
1ML/30GX5/16" MISC
EASY TOUCH INSULIN QL(5 ea daily)
SYRINGE/U- EASY TOUCH QL(5 ea daily)
1 SHEATHLOCK SAFETY
100/0.5ML/31G X 5/16" 1
MISC INSULIN SYRINGE
1ML/31GX5/16" MISC
EASY TOUCH INSULIN QL(5 ea daily);
SYRINGE/U-100/1ML/27G 1 RX/OTC EASY TOUCH QL(5 ea daily)
X 1/2" MISC SHEATHLOCK SAFETY 1
SYRINGE 1ML/30GX1/2"
EASY TOUCH INSULIN QL(5 ea daily); MISC
SYRINGE/U-100/1ML/28G 1 RX/OTC
X 1/2" MISC ELITE-THIN INSULIN QL(5 ea daily)
SYRINGE/0.3ML/31G X 1
EASY TOUCH INSULIN QL(5 ea daily); 5/16" MISC
SYRINGE/U-100/1ML/29G 1 RX/OTC
X 1/2" MISC ELITE-THIN INSULIN QL(5 ea daily);
SYRINGE/0.5ML/29G X 1 RX/OTC
EASY TOUCH INSULIN QL(5 ea daily) 1/2" MISC
SYRINGE/U-100/1ML/30G 1
X 1/2" MISC ELITE-THIN INSULIN QL(5 ea daily);
SYRINGE/0.5ML/30G X 1 RX/OTC
EASY TOUCH INSULIN QL(5 ea daily) 5/16" MISC
SYRINGE/U-100/1ML/31G 1
X 5/16" MISC ELITE-THIN INSULIN QL(5 ea daily);
SYRINGE/1ML/30G X 1 RX/OTC
EASY TOUCH PEN QL(5 ea daily); 5/16" MISC
NEEDLE 30G X 5/16" 1 RX/OTC
MISC

Ambetter Formulary Updated April 01, 2018

96
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ELITE-THIN INSULIN QL(5 ea daily); EQL INSULIN QL(5 ea daily);
SYRINGE/U- 1 RX/OTC SYRINGE/U-
100/0.5ML/28G X 1/2" 1 RX/OTC
100/0.5ML/29G X 1/2"
MISC MISC
ELITE-THIN INSULIN QL(5 ea daily) EQL INSULIN QL(5 ea daily);
SYRINGE/U- 1 SYRINGE/U-100/1ML/29G 1 RX/OTC
100/0.5ML/31G X 5/16" X 1/2" MISC
MISC EQL SHORT PEN QL(5 ea daily);
ELITE-THIN INSULIN QL(5 ea daily); NEEDLES 31G X 8MM 1 RX/OTC
SYRINGE/U-100/1ML/28G 1 RX/OTC MISC
X 1/2" MISC EQL ULTRA COMFORT QL(5 ea daily)
ELITE-THIN INSULIN QL(5 ea daily); INSULINSYRINGE/0.3ML/ 1
SYRINGE/U-100/1ML/29G 1 RX/OTC 31G X 5/16" MISC
X 1/2" MISC EQL ULTRA COMFORT QL(5 ea daily);
ELITE-THIN INSULIN QL(5 ea daily) INSULINSYRINGE/1ML/30 1 RX/OTC
SYRINGE/U-100/1ML/31G 1 G X 5/16" MISC
X 5/16" MISC EQL ULTRA SHORT PEN QL(5 ea daily)
EQL INSULIN QL(5 ea daily); NEEDLES 31G X 6MM 1
SYRINGE/0.3ML/29G X 1 RX/OTC MISC
1/2" MISC EXEL COMFORT POINT QL(5 ea daily);
EQL INSULIN QL(5 ea daily); INSULIN PEN NEEDLES 1 RX/OTC
SYRINGE/0.3ML/30G X 1 RX/OTC 29G X 12MM MISC
5/16" MISC EXEL COMFORT POINT QL(5 ea daily)
EQL INSULIN QL(5 ea daily) INSULIN PEN NEEDLES 1
SYRINGE/0.3ML/31G X 1 31G X 6MM MISC
5/16" MISC EXEL COMFORT POINT QL(5 ea daily);
EQL INSULIN QL(5 ea daily); INSULIN PEN NEEDLES 1 RX/OTC
SYRINGE/0.5ML/29G X 1 RX/OTC 31G X 8MM MISC
1/2" MISC EXEL COMFORT POINT QL(5 ea daily);
EQL INSULIN QL(5 ea daily); INSULIN RX/OTC
SYRINGE/0.5ML/30G X RX/OTC 1
1 SYRINGE/0.3ML/29G X
5/16" MISC 1/2" MISC
EQL INSULIN QL(5 ea daily) EXEL COMFORT POINT QL(5 ea daily);
SYRINGE/0.5ML/31G X 1 INSULIN RX/OTC
5/16" MISC 1
SYRINGE/0.3ML/30G X
EQL INSULIN QL(5 ea daily); 5/16" MISC
SYRINGE/1ML/29G X 1/2" 1 RX/OTC EXEL COMFORT POINT QL(5 ea daily);
MISC INSULIN RX/OTC
1
EQL INSULIN QL(5 ea daily); SYRINGE/0.5ML/28G X
SYRINGE/1ML/30G X 1 RX/OTC 1/2" MISC
5/16" MISC EXEL COMFORT POINT QL(5 ea daily);
EQL INSULIN QL(5 ea daily) INSULIN 1 RX/OTC
SYRINGE/1ML/31G X 1 SYRINGE/0.5ML/29G X
5/16" MISC 1/2" MISC
EQL INSULIN QL(5 ea daily); EXEL COMFORT POINT QL(5 ea daily);
SYRINGE/U- RX/OTC INSULIN 1 RX/OTC
1 SYRINGE/0.5ML/30G X
100/0.3ML/29G X 1/2"
MISC 5/16" MISC

Ambetter Formulary Updated April 01, 2018

97
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
EXEL COMFORT POINT QL(5 ea daily); FREDS PHARMACY QL(5 ea daily);
INSULIN 1 RX/OTC UNIFINE PENTIPS PLUS 1 RX/OTC
SYRINGE/1ML/28G X 1/2" 31GX8MM MISC
MISC FREESTYLE PRECISION QL(5 ea daily);
EXEL COMFORT POINT QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC
INSULIN 1 RX/OTC 100/0.5ML/30G X 5/16"
SYRINGE/1ML/29G X 1/2" MISC
MISC FREESTYLE PRECISION QL(5 ea daily)
EXEL COMFORT POINT QL(5 ea daily); INSULIN SYRINGE/U- 1
INSULIN 1 RX/OTC 100/0.5ML/31G X 5/16"
SYRINGE/1ML/30G X MISC
5/16" MISC FREESTYLE PRECISION QL(5 ea daily)
FIFTY50 PEN NEEDLES 1 QL(5 ea daily); INSULIN SYRINGE/U- 1
31G X3/16" (5MM) MISC RX/OTC 100/1ML/31G X 5/16"
FIFTY50 PEN NEEDLES QL(5 ea daily); MISC
1
31G X5/16" (8MM) MISC RX/OTC FREESTYLE PRECISION QL(5 ea daily);
FIFTY50 PEN NEEDLES QL(5 ea daily); INSULIN SYRINGES/U- 1 RX/OTC
1 100/1ML/30G X 5/16"
31GX5MM MISC RX/OTC
MISC
FIFTY50 PEN QL(5 ea daily);
NEEDLES/31GX8MM 1 RX/OTC GLOBAL EASE INJECT QL(5 ea daily);
MISC PEN NEEDLES 1 RX/OTC
29GX12MM MISC
FIFTY50 PEN QL(5 ea daily);
NEEDLES/32GX4MM 1 RX/OTC GLOBAL EASE INJECT QL(5 ea daily);
MISC PEN NEEDLES 31GX8MM 1 RX/OTC
MISC
FIFTY50 PEN QL(5 ea daily)
NEEDLES/32GX6MM 1 GLOBAL EASE INJECT QL(5 ea daily);
MISC PEN NEEDLES 32GX4MM 1 RX/OTC
MISC
FIFTY50 SUPERIOR QL(5 ea daily)
COMFORTINSULIN GLOBAL EASE INJECT QL(5 ea daily);
1 PEN NEEEDLES 1 RX/OTC
SYRINGE/0.3ML/31G X
5/16" MISC 31GX5MM MISC
FIFTY50 SUPERIOR QL(5 ea daily) GLOBAL EASY GLIDE QL(5 ea daily)
COMFORTINSULIN INSULINSYRINGE/U- 1
1 100/0.3ML/31G X 5/16"
SYRINGE/0.5ML/31G X
5/16" MISC MISC
FIFTY50 SUPERIOR QL(5 ea daily) GLOBAL EASY GLIDE QL(5 ea daily);
COMFORTINSULIN PEN NEEDLES 32GX4MM 1 RX/OTC
1 MISC
SYRINGE/1ML/31G X
5/16" MISC GLOBAL INJECT EASE QL(5 ea daily);
FREDS PHARMACY QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC
UNIFINE PENTIPS PEN RX/OTC 100/0.3ML/29G X 1/2"
1 MISC
NEEDLES 32GX4MM
MISC GLOBAL INJECT EASE QL(5 ea daily)
FREDS PHARMACY QL(5 ea daily); INSULIN SYRINGE/U- 1
UNIFINE PENTIPS PLUS 1 RX/OTC 100/0.3ML/30G X 1/2"
31GX5MM MISC MISC

Ambetter Formulary Updated April 01, 2018

98
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
GLOBAL INJECT EASE QL(5 ea daily); GLOBAL INSULIN QL(5 ea daily)
INSULIN SYRINGE/U- 1 RX/OTC SYRINGE/U-
100/0.3ML/30G X 5/16" 1
100/0.3ML/30G X 1/2"
MISC MISC
GLOBAL INJECT EASE QL(5 ea daily) GLOBAL INSULIN QL(5 ea daily);
INSULIN SYRINGE/U- 1 SYRINGES/U- RX/OTC
100/0.3ML/31G X 5/16" 1
100/0.3ML/30GX5/16"
MISC MISC
GLOBAL INJECT EASE QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily)
INSULIN SYRINGE/U- 1 RX/OTC SYRINGE/U-
100/0.5ML/28G X 1/2" 1
100/0.3ML/30G X 1/2"
MISC MISC
GLOBAL INJECT EASE QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily);
INSULIN SYRINGE/U- 1 RX/OTC SYRINGE/U- RX/OTC
100/0.5ML/29G X 1/2" 1
100/0.3ML/30G X 5/16"
MISC MISC
GLOBAL INJECT EASE QL(5 ea daily) GLUCOPRO INSULIN QL(5 ea daily)
INSULIN SYRINGE/U- 1 SYRINGE/U-
100/0.5ML/30G X 1/2" 1
100/0.3ML/31G X 5/16"
MISC MISC
GLOBAL INJECT EASE QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily)
INSULIN SYRINGE/U- 1 RX/OTC SYRINGE/U-
100/0.5ML/30G X 5/16" 1
100/0.5ML/30G X 1/2"
MISC MISC
GLOBAL INJECT EASE QL(5 ea daily) GLUCOPRO INSULIN QL(5 ea daily);
INSULIN SYRINGE/U- 1 SYRINGE/U- RX/OTC
100/0.5ML/31G X 5/16" 1
100/0.5ML/30G X 5/16"
MISC MISC
GLOBAL INJECT EASE QL(5 ea daily); GLUCOPRO INSULIN QL(5 ea daily)
INSULIN SYRINGE/U- 1 RX/OTC SYRINGE/U-
100/1ML/28G X 1/2" MISC 1
100/0.5ML/31G X 5/16"
GLOBAL INJECT EASE QL(5 ea daily); MISC
INSULIN SYRINGE/U- 1 RX/OTC GLUCOPRO INSULIN QL(5 ea daily)
100/1ML/29G X 1/2" MISC SYRINGE/U-100/1ML/30G 1
GLOBAL INJECT EASE QL(5 ea daily) X 1/2" MISC
INSULIN SYRINGE/U- 1 GLUCOPRO INSULIN QL(5 ea daily);
100/1ML/30G X 1/2" MISC SYRINGE/U-100/1ML/30G 1 RX/OTC
GLOBAL INJECT EASE QL(5 ea daily); X 5/16" MISC
INSULIN SYRINGE/U- 1 RX/OTC GLUCOPRO INSULIN QL(5 ea daily)
100/1ML/30G X 5/16" SYRINGE/U-100/1ML/31G 1
MISC X 5/16" MISC
GLOBAL INJECT EASE QL(5 ea daily) GNP CLICKFINE PEN QL(5 ea daily);
INSULIN SYRINGE/U- 1 NEEDLEUNIVERSAL/31G 1 RX/OTC
100/1ML/31G X 5/16" X5/16" MISC
MISC GNP CLICKFINE QL(5 ea daily)
UNIVERSAL PEN 1
NEEDLES 31GX1/4" MISC

Ambetter Formulary Updated April 01, 2018

99
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
GNP CLICKFINE QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily)
UNIVERSAL PEN 1 RX/OTC INSULIN
NEEDLES 31GX5/16" 1
SYRINGE/0.3ML/31G X
MISC 5/16" SHORT MISC
GNP INSULIN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily);
SYRINGE/0.3ML/29G X 1 RX/OTC INSULIN RX/OTC
1/2" MISC 1
SYRINGE/0.5ML/28G X
GNP INSULIN QL(5 ea daily); 1/2" MISC
SYRINGE/0.3ML/30G X 1 RX/OTC GNP ULTRA COMFORT QL(5 ea daily);
5/16" MISC INSULIN RX/OTC
1
GNP INSULIN QL(5 ea daily) SYRINGE/0.5ML/29G X
SYRINGE/0.3ML/31G X 1 1/2" MISC
5/16" MISC GNP ULTRA COMFORT QL(5 ea daily);
GNP INSULIN QL(5 ea daily); INSULIN 1 RX/OTC
SYRINGE/0.5ML/28G X 1 RX/OTC SYRINGE/0.5ML/30G X
1/2" MISC 5/16" SHORT MISC
GNP INSULIN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily)
SYRINGE/0.5ML/29G X 1 RX/OTC INSULIN 1
1/2" MISC SYRINGE/0.5ML/31G X
5/16" SHORT MISC
GNP INSULIN QL(5 ea daily);
SYRINGE/0.5ML/30G X 1 RX/OTC GNP ULTRA COMFORT QL(5 ea daily);
5/16" MISC INSULIN 1 RX/OTC
SYRINGE/1ML/28G X 1/2"
GNP INSULIN QL(5 ea daily) MISC
SYRINGE/0.5ML/31G X 1
5/16" MISC GNP ULTRA COMFORT QL(5 ea daily);
INSULIN 1 RX/OTC
GNP INSULIN QL(5 ea daily); SYRINGE/1ML/29G X 1/2"
SYRINGE/1ML/28G X 1/2" 1 RX/OTC MISC
MISC
GNP ULTRA COMFORT QL(5 ea daily);
GNP INSULIN QL(5 ea daily); INSULIN RX/OTC
SYRINGE/1ML/29G X 1/2" 1 RX/OTC 1
SYRINGE/1ML/30G X
MISC 5/16" SHORT MISC
GNP INSULIN QL(5 ea daily); GNP ULTRA COMFORT QL(5 ea daily)
SYRINGE/1ML/30G X 1 RX/OTC INSULIN
5/16" MISC 1
SYRINGE/1ML/31G X
GNP INSULIN QL(5 ea daily) 5/16" SHORT MISC
SYRINGE/1ML/31G X 1 H-E-B IN CONTROL PEN QL(5 ea daily);
5/16" MISC NEEDLES 31GX5MM 1 RX/OTC
GNP ULTRA COMFORT QL(5 ea daily); MISC
INSULIN 1 RX/OTC H-E-B IN CONTROL PEN QL(5 ea daily)
SYRINGE/0.3ML/29G X NEEDLES 31GX6MM 1
1/2" MISC MISC
GNP ULTRA COMFORT QL(5 ea daily); H-E-B IN CONTROL PEN QL(5 ea daily);
INSULIN 1 RX/OTC NEEDLES 31GX8MM 1 RX/OTC
SYRINGE/0.3ML/30G X MISC
5/16" SHORT MISC
H-E-B IN CONTROL PEN QL(5 ea daily);
NEEDLES/NANO/32GX4M 1 RX/OTC
M MISC

Ambetter Formulary Updated April 01, 2018

100
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
H-E-B IN CONTROL QL(5 ea daily); INSULIN QL(5 ea daily);
UNIFINEPENTIPS PLUS 1 RX/OTC SYRINGE/0.3ML/30G X 1 RX/OTC
31GX5MM MISC 5/16" MISC
H-E-B IN CONTROL QL(5 ea daily); INSULIN QL(5 ea daily)
UNIFINEPENTIPS PLUS 1 RX/OTC SYRINGE/0.3ML/31G X 1
32GX4MM MISC 5/16" MISC
H-E-B INCONTROL PEN QL(5 ea daily); INSULIN QL(5 ea daily)
NEEDLES 29GX12MM 1 RX/OTC SYRINGE/0.5ML/27G X 1
MISC 1/2" MISC
HEALTHWISE MINI PEN QL(5 ea daily) INSULIN QL(5 ea daily);
NEEDLES 31GX6MM 1 SYRINGE/0.5ML/28G X 1 RX/OTC
MISC 1/2" MISC
HEALTHWISE PEN QL(5 ea daily); INSULIN QL(5 ea daily);
NEEDLES 29GX12MM 1 RX/OTC SYRINGE/0.5ML/29G X 1 RX/OTC
MISC 1/2" MISC
HEALTHWISE SHORT QL(5 ea daily); INSULIN QL(5 ea daily)
PEN NEEDLES 31GX8MM 1 RX/OTC SYRINGE/0.5ML/30G X 1
MISC 1/2" MISC
HEALTHWISE UNIFINE QL(5 ea daily); INSULIN QL(5 ea daily);
PENTIPS PEN NEEDLES 1 RX/OTC SYRINGE/0.5ML/30G X 1 RX/OTC
32GX4MM MISC 5/16" MISC
HEALTHY ACCENTS QL(5 ea daily); INSULIN QL(5 ea daily)
UNIFINE PENTIPS PEN 1 RX/OTC SYRINGE/0.5ML/31G X 1
NEEDLES 29GX12MM 5/16" MISC
MISC INSULIN QL(5 ea daily);
HEALTHY ACCENTS QL(5 ea daily); SYRINGE/1ML/28G X 1/2" 1 RX/OTC
UNIFINE PENTIPS PEN 1 RX/OTC MISC
NEEDLES 31GX5MM INSULIN QL(5 ea daily);
MISC SYRINGE/1ML/29G X 1/2" 1 RX/OTC
HEALTHY ACCENTS QL(5 ea daily) MISC
UNIFINE PENTIPS PEN 1 INSULIN QL(5 ea daily);
NEEDLES 31GX6MM SYRINGE/1ML/30G X 1 RX/OTC
MISC 5/16" MISC
HEALTHY ACCENTS QL(5 ea daily); INSULIN QL(5 ea daily)
UNIFINE PENTIPS PEN 1 RX/OTC SYRINGE/1ML/31G X 1
NEEDLES 31GX8MM 5/16" MISC
MISC
INSULIN SYRINGE/U- QL(5 ea daily);
HEALTHY ACCENTS QL(5 ea daily); 100/0.3ML/29G X 1/2" 1 RX/OTC
UNIFINE PENTIPS PEN 1 RX/OTC MISC
NEEDLES 32GX4MM
MISC INSULIN SYRINGE/U- QL(5 ea daily);
100/0.5ML/28G X 1/2" 1 RX/OTC
INSULIN QL(5 ea daily) MISC
SYRINGE/0.3ML/29G X 1" 1
MISC INSULIN SYRINGE/U- QL(5 ea daily);
100/0.5ML/29G X 1/2" 1 RX/OTC
INSULIN QL(5 ea daily); MISC
SYRINGE/0.3ML/29G X 1 RX/OTC
1/2" MISC INSULIN SYRINGE/U- 1 QL(5 ea daily);
100/1ML/28G X 1/2" MISC RX/OTC

Ambetter Formulary Updated April 01, 2018

101
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
INSULIN SYRINGE/U- 1 QL(5 ea daily); INSUPEN 31G X 5MM
100/1ML/29G X 1/2" MISC RX/OTC 1 QL(5 ea daily);
MISC RX/OTC
INSULIN SYRINGE/U- QL(5 ea daily); INSUPEN 31G X 8MM
100/1ML/30G X 5/16" 1 RX/OTC 1 QL(5 ea daily);
MISC RX/OTC
MISC INSUPEN 32G X 4MM
INSULIN SYRINGE/U- QL(5 ea daily) 1 QL(5 ea daily);
MISC RX/OTC
100/1ML/31G X 5/16" 1 INSUPEN PEN NEEDLES
MISC 1 QL(5 ea daily);
32G X4MM MISC RX/OTC
INSULIN QL(5 ea daily) INSUPEN SENSITIVE
SYRINGES/0.5ML/27GX1/ 1 1 QL(5 ea daily)
32GX6MM MISC
2" MISC
INSUPEN ULTRAFIN 1 QL(5 ea daily);
INSULIN QL(5 ea daily); 29GX12MM MISC RX/OTC
SYRINGES/0.5ML/28GX1/ 1 RX/OTC
2" MISC INSUPEN ULTRAFIN 1 QL(5 ea daily);
30GX8MM MISC RX/OTC
INSULIN QL(5 ea daily);
SYRINGES/0.5ML/29GX1/ 1 RX/OTC INSUPEN ULTRAFIN 1 QL(5 ea daily)
2" MISC 31GX6MM MISC
INSULIN QL(5 ea daily); INSUPEN ULTRAFIN 1 QL(5 ea daily);
SYRINGES/0.5ML/30GX5/ 1 RX/OTC 31GX8MM MISC RX/OTC
16" MISC KINRAY INSULIN QL(5 ea daily)
INSULIN QL(5 ea daily) SYRINGE PREFERRED 1
SYRINGES/0.5ML/31GX 1 PLUS/0.3ML/31G X 5/16"
5/16" MISC MISC
INSULIN QL(5 ea daily) KINRAY INSULIN QL(5 ea daily)
SYRINGES/0.5ML/31GX5/ 1 SYRINGE PREFERRED 1
16" MISC PLUS/0.5ML/31G X 5/16"
MISC
INSULIN QL(5 ea daily);
SYRINGES/1ML/27GX/1/2" 1 RX/OTC KINRAY INSULIN QL(5 ea daily)
MISC SYRINGE PREFERRED 1
PLUS/1ML/31G X 5/16"
INSULIN QL(5 ea daily); MISC
SYRINGES/1ML/27GX1/2" 1 RX/OTC
MISC KINRAY INSULIN QL(5 ea daily);
SYRINGE/0.5ML/29G X 1 RX/OTC
INSULIN QL(5 ea daily); 1/2" MISC
SYRINGES/1ML/28GX1/2" 1 RX/OTC
MISC KMART VALU PLUS QL(5 ea daily);
INSULIN 1 RX/OTC
INSULIN QL(5 ea daily); SYRINGE/1ML/29G MISC
SYRINGES/1ML/29GX1/2" 1 RX/OTC
MISC KMART VALU PLUS QL(5 ea daily);
INSULIN 1 RX/OTC
INSULIN QL(5 ea daily) SYRINGE/1ML/30G MISC
SYRINGES/1ML/30GX1/2" 1
MISC KROGER INSULIN QL(5 ea daily);
SYRINGE/0.3ML/29G X 1 RX/OTC
INSULIN QL(5 ea daily) 1/2" MISC
SYRINGES/1ML/31GX5/16 1
" MISC KROGER INSULIN QL(5 ea daily);
SYRINGE/0.3ML/30G X 1 RX/OTC
INSUPEN 29G X 12MM 1 QL(5 ea daily); 5/16" MISC
MISC RX/OTC

Ambetter Formulary Updated April 01, 2018

102
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
KROGER INSULIN QL(5 ea daily) LEADER INSULIN QL(5 ea daily)
SYRINGE/0.3ML/31G X 1 SYRINGE/0.5ML/31G X 1
5/16" MISC 5/16" MISC
KROGER INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily);
SYRINGE/0.5ML/29G X 1 RX/OTC SYRINGE/1ML/28G X 1/2" 1 RX/OTC
1/2" MISC MISC
KROGER INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily);
SYRINGE/0.5ML/30G X 1 RX/OTC SYRINGE/1ML/29G X 1/2" 1 RX/OTC
5/16" MISC MISC
KROGER INSULIN QL(5 ea daily) LEADER INSULIN QL(5 ea daily);
SYRINGE/0.5ML/31G X 1 SYRINGE/1ML/30G X 1 RX/OTC
5/16" MISC 5/16" MISC
KROGER INSULIN QL(5 ea daily); LEADER INSULIN QL(5 ea daily)
SYRINGE/1ML/29G X 1/2" 1 RX/OTC SYRINGE/1ML/31G X 1
MISC 5/16" MISC
KROGER INSULIN QL(5 ea daily); LEADER UNIFINE QL(5 ea daily);
SYRINGE/1ML/30G X 1 RX/OTC PENTIPS RX/OTC
5/16" MISC 1
PLUS/MINI/31GX3/16"
KROGER INSULIN QL(5 ea daily) MISC
SYRINGE/1ML/31G X 1 LEADER UNIFINE QL(5 ea daily);
5/16" MISC PENTIPS RX/OTC
1
KROGER PEN NEEDLES QL(5 ea daily); PLUS/SHORT/31GX5/16"
1 MISC
29G X12MM MISC RX/OTC
KROGER PEN NEEDLES QL(5 ea daily); LEADER UNIFINE QL(5 ea daily);
1 PENTIPS/MINI/31GX3/16" 1 RX/OTC
31G X8MM MISC RX/OTC
MISC
KROGER PEN NEEDLES 1 QL(5 ea daily)
31GX1/4" MISC LEADER UNIFINE QL(5 ea daily);
PENTIPS/NANO/32GX5/32 1 RX/OTC
LEADER INSULIN QL(5 ea daily); " MISC
SYRINGE/0.3ML/29G X 1 RX/OTC
1/2" MISC LEADER UNIFINE QL(5 ea daily);
PENTIPS/PLUS/32GX5/32" 1 RX/OTC
LEADER INSULIN QL(5 ea daily); MISC
SYRINGE/0.3ML/30G X 1 RX/OTC
5/16" MISC LITE TOUCH PEN QL(5 ea daily);
NEEDLES/31G X 3/16" 1 RX/OTC
LEADER INSULIN QL(5 ea daily) MISC
SYRINGE/0.3ML/31G X 1
5/16" MISC LITETOUCH INSULIN QL(5 ea daily);
SYRINGE/0.3ML/29G X 1 RX/OTC
LEADER INSULIN QL(5 ea daily); 1/2" MISC
SYRINGE/0.5ML/28G X 1 RX/OTC
1/2" MISC LITETOUCH INSULIN QL(5 ea daily);
SYRINGE/0.3ML/30G X 1 RX/OTC
LEADER INSULIN QL(5 ea daily); 5/16" MISC
SYRINGE/0.5ML/29G X 1 RX/OTC
1/2" MISC LITETOUCH INSULIN QL(5 ea daily)
SYRINGE/0.3ML/31G X 1
LEADER INSULIN QL(5 ea daily); 5/16" MISC
SYRINGE/0.5ML/30G X 1 RX/OTC
5/16" MISC LITETOUCH INSULIN QL(5 ea daily);
SYRINGE/0.5ML/30G X 1 RX/OTC
5/16" MISC

Ambetter Formulary Updated April 01, 2018

103
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
LITETOUCH INSULIN QL(5 ea daily) MAGELLAN INSULIN QL(5 ea daily);
SYRINGE/0.5ML/31G X SAFETY SYRINGE/U- 1 RX/OTC
1
5/16" MISC 100/0.3ML/30G X 5/16"
LITETOUCH INSULIN QL(5 ea daily); MISC
SYRINGE/1ML/30G X 1 RX/OTC MAGELLAN INSULIN QL(5 ea daily);
5/16" MISC SAFETY SYRINGE/U- RX/OTC
1
LITETOUCH INSULIN QL(5 ea daily); 100/0.5ML/29G X 1/2"
SYRINGE/U- RX/OTC MISC
1
100/0.5ML/28G X 1/2" MAGELLAN INSULIN QL(5 ea daily);
MISC SAFETY SYRINGE/U- RX/OTC
1
LITETOUCH INSULIN QL(5 ea daily); 100/0.5ML/30G X 5/16"
SYRINGE/U- RX/OTC MISC
1
100/0.5ML/29G X 1/2" MAGELLAN INSULIN QL(5 ea daily);
MISC SAFETY SYRINGE/U- 1 RX/OTC
LITETOUCH INSULIN QL(5 ea daily); 100/1ML/29G X 1/2" MISC
SYRINGE/U-100/1ML/28G 1 RX/OTC MAGELLAN INSULIN QL(5 ea daily);
X 1/2" MISC SAFETY SYRINGE/U- RX/OTC
1
LITETOUCH INSULIN QL(5 ea daily); 100/1ML/30G X 5/16"
SYRINGE/U-100/1ML/29G 1 RX/OTC MISC
X 1/2" MISC MARATHON MEDICAL QL(5 ea daily);
LITETOUCH INSULIN QL(5 ea daily) PENTIPS29GX12MM 1 RX/OTC
SYRINGE/U-100/1ML/31G 1 MISC
X 5/16" MISC MARATHON MEDICAL QL(5 ea daily);
1
LITETOUCH PEN QL(5 ea daily) PENTIPS31GX5MM MISC RX/OTC
NEEDLES 29GX12.7MM 1 MARATHON MEDICAL QL(5 ea daily);
MISC 1
PENTIPS31GX8MM MISC RX/OTC
LITETOUCH PEN QL(5 ea daily) MARATHON MEDICAL QL(5 ea daily);
NEEDLES 31G X 6MM 1
1 PENTIPS32GX4MM MISC RX/OTC
MISC MAXI-COMFORT INSULIN QL(5 ea daily);
LITETOUCH PEN QL(5 ea daily); SYRINGE/U- 1 RX/OTC
NEEDLES 31GX8MM 1 RX/OTC 100/0.5ML/28GX1/2" MISC
SHORT MISC MAXI-COMFORT INSULIN QL(5 ea daily);
LIVE BETTER PEN QL(5 ea daily); SYRINGE/U- 1 RX/OTC
NEEDLES 29G X 12MM 1 RX/OTC 100/1ML/28GX1/2" MISC
MISC MEDIC INSULIN QL(5 ea daily);
LIVE BETTER PEN QL(5 ea daily); SYRINGE/0.3ML/30G X 1 RX/OTC
NEEDLES 31G X 12MM 1 RX/OTC 5/16" MISC
MISC MEDIC INSULIN QL(5 ea daily);
LIVE BETTER PEN QL(5 ea daily) SYRINGE/0.5ML/30G X 1 RX/OTC
NEEDLES 31G X 6MM 1 5/16" MISC
MISC MEDICINE SHOPPE PEN QL(5 ea daily);
LONGS INSULIN QL(5 ea daily) NEEDLES 29G X 12MM 1 RX/OTC
SYRINGE/0.5ML/31G X 1 MISC
5/16" MISC MEDICINE SHOPPE PEN QL(5 ea daily)
MAGELLAN INSULIN QL(5 ea daily); NEEDLES 31G X 6MM 1
SAFETY SYRINGE/U- 1 RX/OTC MISC
100/0.3ML/29G X 1/2"
MISC

Ambetter Formulary Updated April 01, 2018

104
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
MEDICINE SHOPPE PEN QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily);
NEEDLES 31G X 8MM 1 RX/OTC SYRINGE/DETACH
MISC 1 RX/OTC
NEEDLE/1ML/27G X 1/2"
MEIJER PEN NEEDLES QL(5 ea daily); MISC
1
29G X12MM MISC RX/OTC MONOJECT INSULIN QL(5 ea daily);
MEIJER PEN NEEDLES QL(5 ea daily) SYRINGE/PERM 1 RX/OTC
1 NEEDLE/1ML/28G X 1/2"
31G X6MM MISC
MISC
MEIJER PEN NEEDLES 1 QL(5 ea daily);
31G X8MM MISC RX/OTC MONOJECT INSULIN QL(5 ea daily);
SYRINGE/PERM 1 RX/OTC
MM INSULIN SYRINGE/U- QL(5 ea daily); NEEDLE/U-100/0.5ML/28G
100/0.3ML/30G X 5/16" 1 RX/OTC X 1/2" MISC
MISC
MONOJECT INSULIN QL(5 ea daily);
MM INSULIN SYRINGE/U- QL(5 ea daily) SYRINGE/SAFETY/PERM RX/OTC
100/0.3ML/31G X 5/16" 1 1
NEEDLE/0.3ML/29G X 1/2"
MISC MISC
MM INSULIN SYRINGE/U- QL(5 ea daily); MONOJECT INSULIN QL(5 ea daily);
100/1/2ML/30G X 5/16" 1 RX/OTC SYRINGE/SAFETY/PERM RX/OTC
MISC 1
NEEDLE/0.3ML/29GX1/2"
MM INSULIN SYRINGE/U- QL(5 ea daily) MISC
100/1/2ML/31G X 5/16" 1 MONOJECT INSULIN QL(5 ea daily);
MISC SYRINGE/SAFETY/PERM RX/OTC
MM INSULIN SYRINGE/U- QL(5 ea daily); 1
NEEDLE/0.5ML/29G X 1/2"
100/1ML/30G X 5/16" 1 RX/OTC MISC
MISC MONOJECT INSULIN QL(5 ea daily);
MM INSULIN SYRINGE/U- QL(5 ea daily) SYRINGE/SAFETY/PERM RX/OTC
100/1ML/31G X 5/16" 1 1
NEEDLE/1ML/29G X 1/2"
MISC MISC
MM PEN NEEDLES 31G X 1 QL(5 ea daily) MONOJECT INSULIN QL(5 ea daily);
1/4" MISC SYRINGE/SOFTPACK/1M 1 RX/OTC
MM PEN NEEDLES 31G X QL(5 ea daily); L/27G X 1/2" MISC
1
3/16" MISC RX/OTC MONOJECT INSULIN QL(5 ea daily);
MM PEN NEEDLES 31G X QL(5 ea daily); SYRINGE/SOFTPACK/U- 1 RX/OTC
1 100/0.5ML/28G X 1/2"
5/16" MISC RX/OTC
MM PEN NEEDLES 32G X QL(5 ea daily); MISC
1 MONOJECT INSULIN QL(5 ea daily);
5/32" MISC RX/OTC
MONOJECT INSULIN QL(5 ea daily); SYRINGE/U- 1 RX/OTC
1 100/0.3ML/30G X 5/16"
SYRINGE/1ML MISC RX/OTC
MISC
MONOJECT INSULIN QL(5 ea daily)
SYRINGE/1ML/31G X 1 MONOJECT INSULIN QL(5 ea daily);
5/16" MISC SYRINGE/U- 1 RX/OTC
100/0.5ML/28G X 1/2"
MONOJECT INSULIN QL(5 ea daily) MISC
SYRINGE/DETACH 1
NEEDLE/1ML/25G X 5/8" MONOJECT INSULIN QL(5 ea daily);
MISC SYRINGE/U- 1 RX/OTC
100/0.5ML/30G X 5/16"
MISC

Ambetter Formulary Updated April 01, 2018

105
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
MONOJECT INSULIN QL(5 ea daily); MONOJECT ULTRA QL(5 ea daily);
SYRINGE/U-100/1ML/28G 1 RX/OTC COMFORT INSULIN
X 1/2" MISC 1 RX/OTC
SYRINGE/1ML/30G X
MONOJECT INSULIN QL(5 ea daily); 5/16" MISC
SYRINGE/U-100/1ML/30G 1 RX/OTC MOORE MED MONOJECT QL(5 ea daily);
X 5/16" MISC INSULIN SYRINGE/U- RX/OTC
1
MONOJECT INSULIN QL(5 ea daily); 100/0.5ML/28G X 1/2"
SYRINGEREGULAR LUER 1 RX/OTC MISC
TIP/SOFTPACK/1ML MISC MOORE MED MONOJECT QL(5 ea daily);
MONOJECT ULTRA QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC
COMFORT INSULIN 100/0.5ML/29G X 1/2"
1 RX/OTC MISC
SYRINGE/0.3ML/29G X
1/2" MISC MOORE MED MONOJECT QL(5 ea daily);
MONOJECT ULTRA QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC
COMFORT INSULIN 100/1ML/28G X 1/2" MISC
1 RX/OTC
SYRINGE/0.3ML/30G X MOORE MED MONOJECT QL(5 ea daily);
5/16" MISC INSULIN SYRINGE/U- 1 RX/OTC
MONOJECT ULTRA QL(5 ea daily) 100/1ML/29G X 1/2" MISC
COMFORT INSULIN 1 MS INSULIN QL(5 ea daily)
SYRINGE/0.3ML/31G X SYRINGE/0.3ML/31G X 1
5/16" MISC 5/16" MISC
MONOJECT ULTRA QL(5 ea daily); MS INSULIN QL(5 ea daily)
COMFORT INSULIN 1 RX/OTC SYRINGE/0.5ML/31G X 1
SYRINGE/0.5ML/28G X 5/16" MISC
1/2" MISC MS INSULIN QL(5 ea daily)
MONOJECT ULTRA QL(5 ea daily); SYRINGE/1ML/31G X 1
COMFORT INSULIN 1 RX/OTC 5/16" MISC
SYRINGE/0.5ML/29G X NOVOFINE 30GX8MM QL(5 ea daily);
1/2" MISC 1
MISC RX/OTC
MONOJECT ULTRA QL(5 ea daily); NOVOFINE 32GX6MM QL(5 ea daily)
COMFORT INSULIN 1
1 RX/OTC MISC
SYRINGE/0.5ML/30G X
5/16" MISC NOVOFINE AUTOCOVER 1 QL(5 ea daily);
30GX8MM MISC RX/OTC
MONOJECT ULTRA QL(5 ea daily)
COMFORT INSULIN NOVOFINE PLUS 1 QL(5 ea daily);
1 32GX4MM MISC RX/OTC
SYRINGE/0.5ML/31G X
5/16" MISC NOVOTWIST 30GX8MM 1 QL(5 ea daily);
MONOJECT ULTRA QL(5 ea daily); MISC RX/OTC
COMFORT INSULIN NOVOTWIST 32GX5MM QL(5 ea daily);
1 RX/OTC MISC
1
RX/OTC
SYRINGE/1ML/28G X 1/2"
MISC PC UNIFINE PENTIPS QL(5 ea daily);
1
MONOJECT ULTRA QL(5 ea daily); 29G X1/2" MISC RX/OTC
COMFORT INSULIN 1 RX/OTC PC UNIFINE PENTIPS QL(5 ea daily);
SYRINGE/1ML/29G X 1/2" 1
31G X5MM MINI MISC RX/OTC
MISC PC UNIFINE PENTIPS QL(5 ea daily)
31G X6MM ULTRA 1
SHORT MISC

Ambetter Formulary Updated April 01, 2018

106
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
PC UNIFINE PENTIPS 1 QL(5 ea daily); PENTIPS 31GX6MM MISC 1 QL(5 ea daily)
31G X8MM SHORT MISC RX/OTC
PEN NEEDLES 29G X QL(5 ea daily);
1 QL(5 ea daily); PENTIPS 31GX8MM MISC 1
RX/OTC
12MM MISC RX/OTC
PEN NEEDLES 29GX1/2" PENTIPS 32G X 4MM QL(5 ea daily);
1 QL(5 ea daily); MISC
1
RX/OTC
MISC RX/OTC
PEN NEEDLES 30GX5/16" QL(5 ea daily);
1 QL(5 ea daily); PENTIPS 32GX4MM MISC 1
RX/OTC
MISC RX/OTC
PEN NEEDLES 30GX8MM PRECISION SURE-DOSE QL(5 ea daily);
1 QL(5 ea daily); INSULIN RX/OTC
MISC RX/OTC 1
PEN NEEDLES 31G X 1/4" SYRINGE/0.3ML/30G X
1 QL(5 ea daily) 5/16" MISC
SHORT MISC
PEN NEEDLES 31G X PRECISION SURE-DOSE QL(5 ea daily);
1 QL(5 ea daily); INSULIN RX/OTC
3/16" MISC RX/OTC 1
SYRINGE/0.5ML/28G X
PEN NEEDLES 31G X 1 QL(5 ea daily); 1/2" MISC
5MM MISC RX/OTC
PRECISION SURE-DOSE QL(5 ea daily);
PEN NEEDLES 31G X 1 QL(5 ea daily) INSULIN RX/OTC
6MM MISC 1
SYRINGE/0.5ML/29G X
PEN NEEDLES 31G X 1/2" MISC
1 QL(5 ea daily);
8MM MISC RX/OTC PRECISION SURE-DOSE QL(5 ea daily)
PEN NEEDLES 31GX5/16" INSULIN
1 QL(5 ea daily); SYRINGE/0.5ML/30G X
1
MISC RX/OTC
3/8" MISC
PEN NEEDLES 31GX6MM 1 QL(5 ea daily)
(1/4") MISC PRECISION SURE-DOSE QL(5 ea daily);
PEN NEEDLES 31GX8MM INSULIN RX/OTC
1 QL(5 ea daily); SYRINGE/1ML/28G X 1/2"
1
(5/16") MISC RX/OTC
MISC
PEN NEEDLES 31GX8MM 1 QL(5 ea daily);
MISC RX/OTC PRECISION SURE-DOSE QL(5 ea daily);
PLUSINSULIN 1 RX/OTC
PEN NEEDLES 32G X 1 QL(5 ea daily); SYRINGE/0.3ML/29G X
4MM MISC RX/OTC 1/2" MISC
PEN NEEDLES 32G X 1 QL(5 ea daily); PRECISION SURE-DOSE QL(5 ea daily);
5MM MISC RX/OTC PLUSINSULIN RX/OTC
PEN NEEDLES 32G X 1
1 QL(5 ea daily) SYRINGE/1ML/29G X 1/2"
6MM MISC MISC
PEN NEEDLES 32GX4MM 1 QL(5 ea daily); PREFERRED PLUS QL(5 ea daily);
MISC RX/OTC INSULIN SYRINGE/U- RX/OTC
1
PENTIPS 29G X 12MM 100/0.3ML/29G X 1/2"
1 QL(5 ea daily); MISC
MISC RX/OTC
PENTIPS 29GX12MM PREFERRED PLUS QL(5 ea daily);
1 QL(5 ea daily); INSULIN SYRINGE/U- RX/OTC
MISC RX/OTC 1
PENTIPS 31G X 5MM 100/0.3ML/30G X 5/16"
1 QL(5 ea daily); MISC
MISC RX/OTC
PENTIPS 31G X 8MM PREFERRED PLUS QL(5 ea daily);
1 QL(5 ea daily); INSULIN SYRINGE/U- RX/OTC
MISC RX/OTC 1
100/0.5ML/28G X 1/2"
PENTIPS 31GX5MM MISC 1 QL(5 ea daily); MISC
RX/OTC
Ambetter Formulary Updated April 01, 2018

107
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
PREFERRED PLUS QL(5 ea daily); PRO COMFORT INSULIN QL(5 ea daily);
INSULIN SYRINGE/U- 1 RX/OTC SYRINGES/1ML/30G X 1 RX/OTC
100/0.5ML/29G X 1/2" 5/16" MISC
MISC PRO COMFORT INSULIN QL(5 ea daily)
PREFERRED PLUS QL(5 ea daily); SYRINGES/1ML/31G X 1
INSULIN SYRINGE/U- 1 RX/OTC 5/16" MISC
100/0.5ML/30G X 5/16" PRO COMFORT PEN QL(5 ea daily);
MISC NEEDLES/31G X 8MM 1 RX/OTC
PREFERRED PLUS QL(5 ea daily); MISC
INSULIN SYRINGE/U- 1 RX/OTC PRO COMFORT PEN QL(5 ea daily);
100/1ML/28G X 1/2" MISC NEEDLES/32G X 4MM 1 RX/OTC
PREFERRED PLUS QL(5 ea daily); MISC
INSULIN SYRINGE/U- 1 RX/OTC PRO COMFORT PEN QL(5 ea daily);
100/1ML/29G X 1/2" MISC NEEDLES/32G X 5MM 1 RX/OTC
PREFERRED PLUS QL(5 ea daily); MISC
INSULIN SYRINGE/U- 1 RX/OTC PRO COMFORT PEN QL(5 ea daily)
100/1ML/30G X 5/16" NEEDLES/32G X 6MM 1
MISC MISC
PREFERRED PLUS QL(5 ea daily); PRODIGY INSULIN QL(5 ea daily)
UNIFINE PENTIPS 29G X 1 RX/OTC SYRING/U-100/0.3ML/31G 1
12MM MISC X 5/16" MISC
PREFERRED PLUS QL(5 ea daily) PRODIGY INSULIN QL(5 ea daily)
UNIFINE PENTIPS 31G X 1 SYRINGE/1/2ML/31G X 1
6MM ULTRA SHORT 5/16" MISC
MISC
PRODIGY INSULIN QL(5 ea daily);
PREFERRED PLUS QL(5 ea daily); SYRINGE/1ML/28G X 1/2" 1 RX/OTC
UNIFINE PENTIPS 31G X 1 RX/OTC MISC
8MM SHORT MISC
PX EXTRA SHORT PEN QL(5 ea daily)
PREFERRED PLUS QL(5 ea daily); NEEDLES 31GX6MM 1
UNIFINE PENTIPS 1 RX/OTC MISC
32GX4MM MISC
PX INSULIN SYRINGE/U- QL(5 ea daily)
PREFERRED PLUS QL(5 ea daily); 100/0.3ML/30G X 1/2" 1
UNIFINE 1 RX/OTC MISC
PENTIPS/MINI/31GX5MM
MISC PX INSULIN SYRINGE/U- QL(5 ea daily)
100/0.3ML/31G X 5/16" 1
PRO COMFORT INSULIN QL(5 ea daily) MISC
SYRINGES/0.5ML/30G X 1
1/2" MISC PX INSULIN SYRINGE/U- QL(5 ea daily)
100/0.5ML/30G X 1/2" 1
PRO COMFORT INSULIN QL(5 ea daily); MISC
SYRINGES/0.5ML/30G X 1 RX/OTC
5/16" MISC PX INSULIN SYRINGE/U- QL(5 ea daily)
100/0.5ML/31G X 5/16" 1
PRO COMFORT INSULIN QL(5 ea daily) MISC
SYRINGES/0.5ML/31G X 1
5/16" MISC PX INSULIN SYRINGE/U- 1 QL(5 ea daily)
100/1ML/30G X 1/2" MISC
PRO COMFORT INSULIN QL(5 ea daily)
SYRINGES/1ML/30G X 1 PX INSULIN SYRINGE/U- QL(5 ea daily)
1/2" MISC 100/1ML/31G X 5/16" 1
MISC

Ambetter Formulary Updated April 01, 2018

108
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
PX MINI PEN NEEDLES 1 QL(5 ea daily); RELION INSULIN QL(5 ea daily)
31GX5MM MISC RX/OTC SYRINGE 1
PX PEN NEEDLE 1ML/31GX15/64" MISC
1 QL(5 ea daily);
29GX12MM MISC RX/OTC RELION INSULIN QL(5 ea daily);
PX PEN NEEDLE SYRINGE/U-00/1ML/29G X 1 RX/OTC
1 QL(5 ea daily); 1/2" MISC
31GX8MM MISC RX/OTC
PX SHORTLENGTH PEN QL(5 ea daily); RELION INSULIN QL(5 ea daily);
NEEDLES/31GX8MM 1 RX/OTC SYRINGE/U- 1 RX/OTC
MISC 100/0.3ML/29G X 1/2"
MISC
QC PEN NEEDLES 29G X 1 QL(5 ea daily);
12MM MISC RX/OTC RELION INSULIN QL(5 ea daily);
SYRINGE/U- 1 RX/OTC
QC PEN NEEDLES 31G X 1 QL(5 ea daily) 100/0.3ML/30G X 5/16"
6MM MISC MISC
QC PEN NEEDLES 31G X 1 QL(5 ea daily); RELION INSULIN QL(5 ea daily)
8MM MISC RX/OTC SYRINGE/U-
QC UNIFINE PENTIPS QL(5 ea daily); 1
1 100/0.3ML/31G X 5/16"
32GX4MM MISC RX/OTC MISC
RA INSULIN QL(5 ea daily); RELION INSULIN QL(5 ea daily);
SYRINGE/0.5ML/29G X 1 RX/OTC SYRINGE/U- RX/OTC
1/2" MISC 1
100/0.5ML/29G X 1/2"
RA INSULIN QL(5 ea daily); MISC
SYRINGE/1ML/29G X 1/2" 1 RX/OTC RELION INSULIN QL(5 ea daily);
MISC SYRINGE/U- RX/OTC
1
RA INSULIN SYRINGE/U- QL(5 ea daily); 100/0.5ML/30G X 5/16"
100/0.5ML/30G X 5/16" 1 RX/OTC MISC
MISC RELION INSULIN QL(5 ea daily)
RA INSULIN SYRINGE/U- QL(5 ea daily); SYRINGE/U- 1
100/1 ML/30G X 5/16" 1 RX/OTC 100/0.5ML/31G X 5/16"
MISC MISC
RA PEN NEEDLES 31G X QL(5 ea daily); RELION INSULIN QL(5 ea daily);
1 SYRINGE/U-100/1ML/30G 1 RX/OTC
5MM3/16" MISC RX/OTC
RA PEN NEEDLES 31G X QL(5 ea daily); X 5/16" MISC
1 RELION INSULIN QL(5 ea daily)
8MM5/16" MISC RX/OTC
REALITY INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/31G 1
SYRINGE/U- RX/OTC X 15/64" MISC
1 RELION INSULIN QL(5 ea daily)
100/0.5ML/28G X 1/2"
MISC SYRINGE/U-100/1ML/31G 1
REALITY INSULIN QL(5 ea daily); X 5/16" MISC
SYRINGE/U- RX/OTC RELION MINI PEN QL(5 ea daily)
1 NEEDLES 31GX6MM 1
100/0.5ML/29G X 1/2"
MISC MISC
REALITY INSULIN QL(5 ea daily); RELION PEN NEEDLES 1 QL(5 ea daily);
SYRINGE/U-100/1ML/28G 1 RX/OTC 29GX12MM MISC RX/OTC
X 1/2" MISC RELION PEN NEEDLES QL(5 ea daily)
1
REALITY INSULIN QL(5 ea daily); 31GX6MM MISC
SYRINGE/U-100/1ML/29G 1 RX/OTC RELION PEN NEEDLES QL(5 ea daily);
X 1/2" MISC 1
31GX8MM MISC RX/OTC

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109
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
RELION PEN NEEDLES 1 QL(5 ea daily); SB INSULIN SYRINGE/U- QL(5 ea daily);
32GX4MM MISC RX/OTC 100/1ML/30G X 5/16" 1 RX/OTC
RELION SHORT PEN MISC
1 QL(5 ea daily);
NEEDLES31GX8MM MISC RX/OTC SB INSULIN SYRINGE/U- QL(5 ea daily)
SAFESNAP INSULIN QL(5 ea daily); 100/1ML/31G X 5/16" 1
SYRINGE/0.3ML/30G X 1 RX/OTC MISC
5/16" MISC SCHNUCKS INSULIN QL(5 ea daily);
SAFESNAP INSULIN QL(5 ea daily); SYRINGEULTI-FINE/U- 1 RX/OTC
SYRINGE/0.5ML/29G X 1 RX/OTC 100/0.5ML/29G X 1/2"
1/2" MISC MISC
SAFESNAP INSULIN QL(5 ea daily); SCHNUCKS INSULIN QL(5 ea daily);
SYRINGE/0.5ML/30G X 1 RX/OTC SYRINGEULTI-FINE/U- 1 RX/OTC
5/16" MISC 100/0.5ML/30G X 5/16"
MISC
SAFESNAP INSULIN QL(5 ea daily);
SYRINGE/1ML/28G X 1/2" 1 RX/OTC SHOPKO UNIFINE QL(5 ea daily);
MISC PENTIPS PEN 1 RX/OTC
NEEDLES/MICRO/32GX4
SAFESNAP INSULIN QL(5 ea daily); MM MISC
SYRINGE/1ML/29G X 1/2" 1 RX/OTC
MISC SHOPKO UNIFINE QL(5 ea daily);
PENTIPS PEN 1 RX/OTC
SAFETY INSULIN QL(5 ea daily); NEEDLES/MINI/31GX5MM
SYRINGES 1 RX/OTC MISC
0.5ML/29GX1/2" MISC
SHOPKO UNIFINE QL(5 ea daily);
SAFETY INSULIN QL(5 ea daily); PENTIPS PEN RX/OTC
SYRINGES 1 RX/OTC 1
NEEDLES/ORIGINAL/29G
0.5ML/30GX5/16" MISC X12MM MISC
SAFETY INSULIN QL(5 ea daily); SHOPKO UNIFINE QL(5 ea daily);
SYRINGES 1ML/27GX1/2" 1 RX/OTC PENTIPS PEN RX/OTC
MISC 1
NEEDLES/SHORT/31GX8
SAFETY INSULIN QL(5 ea daily); MM MISC
SYRINGES 1ML/29GX1/2" 1 RX/OTC SHOPKO UNIFINE QL(5 ea daily);
MISC PENTIPS PLUS PEN RX/OTC
SAFETY INSULIN QL(5 ea daily) 1
NEEDLES/MICRO/REMOV
SYRINGES 1ML/30GX1/2" 1 R/32GX4MM MISC
MISC SHOPKO UNIFINE QL(5 ea daily);
SAFETY-GLIDE INSULIN QL(5 ea daily); PENTIPS PLUS PEN RX/OTC
SYRINGE/0.3ML/29G X 1 RX/OTC 1
NEEDLES/MINI/REMOVE
1/2" MISC R/31GX5MM MISC
SB INSULIN SYRINGE/U- QL(5 ea daily); SHOPKO UNIFINE QL(5 ea daily);
100/0.5ML/29G X 1/2" 1 RX/OTC PENTIPS PLUS PEN RX/OTC
MISC 1
NEEDLES/REMOVER/29G
SB INSULIN SYRINGE/U- QL(5 ea daily); X12MM MISC
100/0.5ML/30G X 5/16" 1 RX/OTC SHOPKO UNIFINE QL(5 ea daily);
MISC PENTIPS PLUS PEN RX/OTC
1
SB INSULIN SYRINGE/U- NEEDLES/SHORT/REMO
1 QL(5 ea daily); VR/31GX8MM MISC
100/1ML/29G X 1/2" MISC RX/OTC

Ambetter Formulary Updated April 01, 2018

110
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
SM INSULIN QL(5 ea daily) SURE COMFORT QL(5 ea daily);
SYRINGE/1ML/31G X 1 INSULIN SYRINGE/U- 1 RX/OTC
5/16" MISC 100/1ML/29G X 1/2" MISC
SURE COMFORT QL(5 ea daily); SURE COMFORT QL(5 ea daily)
INSULIN SYRINGE/U- 1 RX/OTC INSULIN SYRINGE/U- 1
100/0.3ML/29G X 1/2" 100/1ML/30G X 1/2" MISC
MISC SURE COMFORT QL(5 ea daily);
SURE COMFORT QL(5 ea daily) INSULIN SYRINGE/U- RX/OTC
INSULIN SYRINGE/U- 1
1 100/1ML/30G X 5/16"
100/0.3ML/30G X 1/2" MISC
MISC SURE COMFORT QL(5 ea daily)
SURE COMFORT QL(5 ea daily); INSULIN SYRINGE/U-
INSULIN SYRINGE/U- RX/OTC 1
1 100/1ML/31G X 5/16"
100/0.3ML/30G X 5/16" MISC
MISC SURE COMFORT PEN QL(5 ea daily)
SURE COMFORT QL(5 ea daily) NEEDLES29GX1/2" 1
INSULIN SYRINGE/U- 1 12.7MM MISC
100/0.3ML/31G X 5/16 SURE COMFORT PEN QL(5 ea daily);
MISC NEEDLES30GX5/16" 1 RX/OTC
SURE COMFORT QL(5 ea daily) SHORT MISC
INSULIN SYRINGE/U- 1 SURE COMFORT PEN QL(5 ea daily);
100/0.3ML/31G X 5/16" NEEDLES31GX3/16" 1 RX/OTC
MISC (5MM) MISC
SURE COMFORT QL(5 ea daily); SURE COMFORT PEN QL(5 ea daily);
INSULIN SYRINGE/U- 1 RX/OTC NEEDLES31GX5/16" 1 RX/OTC
100/0.5ML/28G X 1/2" (8MM) MISC
MISC
SURE COMFORT PEN 1 QL(5 ea daily);
SURE COMFORT QL(5 ea daily); NEEDLES32GX5/32" MISC RX/OTC
INSULIN SYRINGE/U- 1 RX/OTC
100/0.5ML/29G X 1/2" SURE COMFORT PEN 1 QL(5 ea daily)
MISC NEEDLES32GX6MM MISC
SURE COMFORT QL(5 ea daily) SURE-FINE PEN QL(5 ea daily)
INSULIN SYRINGE/U- NEEDLES 29GX1/2" 1
1 12.7MM MISC
100/0.5ML/30G X 1/2"
MISC SURE-FINE PEN QL(5 ea daily);
SURE COMFORT QL(5 ea daily); NEEDLES 31GX3/16" 5MM 1 RX/OTC
INSULIN SYRINGE/U- RX/OTC MISC
1 SURE-FINE PEN QL(5 ea daily);
100/0.5ML/30G X 5/16"
MISC NEEDLES 31GX5/16" 8MM 1 RX/OTC
SURE COMFORT QL(5 ea daily) MISC
INSULIN SYRINGE/U- SURE-JECT INSULIN QL(5 ea daily);
1 SYRINGE/U- RX/OTC
100/0.5ML/31G X 5/16 1
MISC 100/0.3ML/29G X 1/2"
SURE COMFORT QL(5 ea daily); MISC
INSULIN SYRINGE/U- 1 RX/OTC SURE-JECT INSULIN QL(5 ea daily);
100/1ML/28G X 1/2" MISC SYRINGE/U- 1 RX/OTC
100/0.3ML/30G X 5/16"
MISC

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111
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
SURE-JECT INSULIN QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily);
SYRINGE/U- SYRINGEU-
100/0.3ML/31G X 5/16"
1 1 RX/OTC
100/0.5ML/29G X 1/2"
MISC MISC
SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily)
SYRINGE/U- 1 RX/OTC SYRINGEU-
100/0.5ML/28G X 1/2" 1
100/0.5ML/30G X 1/2"
MISC MISC
SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily);
SYRINGE/U- 1 RX/OTC SYRINGEU- RX/OTC
100/0.5ML/29G X 1/2" 1
100/0.5ML/30G X 5/16"
MISC MISC
SURE-JECT INSULIN QL(5 ea daily); TECHLITE INSULIN QL(5 ea daily)
SYRINGE/U- 1 RX/OTC SYRINGEU-
100/0.5ML/30G X 5/16" 1
100/0.5ML/31G X 5/16"
MISC MISC
SURE-JECT INSULIN QL(5 ea daily) TECHLITE INSULIN QL(5 ea daily);
SYRINGE/U- 1 SYRINGEU-100/1ML/29G 1 RX/OTC
100/0.5ML/31G X 5/16" X 1/2" MISC
MISC TECHLITE INSULIN QL(5 ea daily)
SURE-JECT INSULIN QL(5 ea daily); SYRINGEU-100/1ML/30G 1
SYRINGE/U-100/1ML/28G 1 RX/OTC X 1/2" MISC
X 1/2" MISC TECHLITE INSULIN QL(5 ea daily);
SURE-JECT INSULIN QL(5 ea daily); SYRINGEU-100/1ML/30G 1 RX/OTC
SYRINGE/U-100/1ML/29G 1 RX/OTC X 5/16" MISC
X 1/2" MISC TECHLITE INSULIN QL(5 ea daily)
SURE-JECT INSULIN QL(5 ea daily); SYRINGEU-100/1ML/31G 1
SYRINGE/U-100/1ML/30G 1 RX/OTC X 15/64" MISC
X 5/16" MISC TECHLITE INSULIN QL(5 ea daily)
SURE-JECT INSULIN QL(5 ea daily) SYRINGEU-100/1ML/31G 1
SYRINGE/U-100/1ML/31G 1 X 5/16" MISC
X 5/16" MISC TECHLITE PEN NEEDLES QL(5 ea daily);
TECHLITE INSULIN QL(5 ea daily); 1
29GX 12 MM MISC RX/OTC
SYRINGEU- 1 RX/OTC TECHLITE PEN NEEDLES QL(5 ea daily);
100/0.3ML/29G X 1/2" 1
31GX 5MM MISC RX/OTC
MISC
TECHLITE PEN QL(5 ea daily);
TECHLITE INSULIN QL(5 ea daily) NEEDLES/31GX 5MM 1 RX/OTC
SYRINGEU- 1 MISC
100/0.3ML/30G X 1/2"
MISC TECHLITE PEN QL(5 ea daily)
NEEDLES/31GX 6 MM 1
TECHLITE INSULIN QL(5 ea daily); MISC
SYRINGEU- 1 RX/OTC
100/0.3ML/30G X 5/16" TECHLITE PEN QL(5 ea daily);
MISC NEEDLES/31GX 8MM 1 RX/OTC
MISC
TECHLITE INSULIN QL(5 ea daily)
SYRINGEU- TECHLITE PEN QL(5 ea daily);
1 NEEDLES/32GX 4MM 1 RX/OTC
100/0.3ML/31G X 5/16"
MISC MISC

Ambetter Formulary Updated April 01, 2018

112
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
TECHLITE PEN QL(5 ea daily) TOPCARE ULTRA QL(5 ea daily);
NEEDLES/32GX 6MM 1 COMFORT INSULIN RX/OTC
MISC SYRINGE/U- 1
TODAYS HEALTH MINI QL(5 ea daily) 100/0.5ML/29G X 1/2"
PEN NEEDLES 31G X 1/4" 1 MISC
MISC TOPCARE ULTRA QL(5 ea daily);
TODAYS HEALTH QL(5 ea daily); COMFORT INSULIN 1 RX/OTC
ORIGINAL PEN NEEDLES 1 RX/OTC SYRINGE/U-100/1ML/29G
29G X 1/2" MISC X 1/2" MISC
TODAYS HEALTH SHORT QL(5 ea daily); TOPCO INSULIN QL(5 ea daily);
PEN NEEDLES 31G X 1 RX/OTC SYRINGE/U- 1 RX/OTC
5/16" MISC 100/0.3ML/29G X 1/2"
MISC
TOPCARE CLICKFINE QL(5 ea daily)
UNIVERSAL PEN EEDLES 1 TOPCO INSULIN QL(5 ea daily);
31GX1/4" MISC SYRINGE/U- 1 RX/OTC
100/0.5ML/28G X 1/2"
TOPCARE CLICKFINE QL(5 ea daily); MISC
UNIVERSAL PEN EEDLES 1 RX/OTC
31GX5/16" MISC TOPCO INSULIN QL(5 ea daily);
SYRINGE/U- 1 RX/OTC
TOPCARE ULTRA QL(5 ea daily); 100/0.5ML/29G X 1/2"
COMFORT INSULIN 1 RX/OTC MISC
SYRINGE/0.3ML/30G X
5/16" MISC TOPCO INSULIN QL(5 ea daily);
SYRINGE/U-100/1ML/28G 1 RX/OTC
TOPCARE ULTRA QL(5 ea daily) X 1/2" MISC
COMFORT INSULIN 1
SYRINGE/0.3ML/31G X TOPCO INSULIN QL(5 ea daily);
5/16" MISC SYRINGE/U-100/1ML/29G 1 RX/OTC
X 1/2" MISC
TOPCARE ULTRA QL(5 ea daily);
COMFORT INSULIN RX/OTC TRUEPLUS INSULIN QL(5 ea daily);
1 SYRINGE/U- RX/OTC
SYRINGE/0.5ML/30G X 1
5/16" MISC 100/0.3ML/29G X 1/2"
MISC
TOPCARE ULTRA QL(5 ea daily)
COMFORT INSULIN TRUEPLUS INSULIN QL(5 ea daily);
1 SYRINGE/U- RX/OTC
SYRINGE/0.5ML/31G X 1
5/16" MISC 100/0.3ML/30G X 5/16"
MISC
TOPCARE ULTRA QL(5 ea daily);
COMFORT INSULIN RX/OTC TRUEPLUS INSULIN QL(5 ea daily)
1 SYRINGE/U-
SYRINGE/1ML/30G X 1
5/16" MISC 100/0.3ML/31G X 5/16"
MISC
TOPCARE ULTRA QL(5 ea daily)
COMFORT INSULIN TRUEPLUS INSULIN QL(5 ea daily);
1 SYRINGE/U- RX/OTC
SYRINGE/1ML/31G X 1
5/16" MISC 100/0.5ML/28G X 1/2"
MISC
TOPCARE ULTRA QL(5 ea daily);
COMFORT INSULIN RX/OTC TRUEPLUS INSULIN QL(5 ea daily);
SYRINGE/U- 1 SYRINGE/U- 1 RX/OTC
100/0.3ML/29G X 1/2" 100/0.5ML/29G X 1/2"
MISC MISC

Ambetter Formulary Updated April 01, 2018

113
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
TRUEPLUS INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily)
SYRINGE/U- 1 RX/OTC SYRINGE/0.3ML/30G X 1
100/0.5ML/30G X 5/16" 1/2" MISC
MISC ULTICARE INSULIN QL(5 ea daily);
TRUEPLUS INSULIN QL(5 ea daily) SYRINGE/0.3ML/30G X 1 RX/OTC
SYRINGE/U- 1 5/16" MISC
100/0.5ML/31G X 5/16" ULTICARE INSULIN QL(5 ea daily);
MISC SYRINGE/0.5ML/28G X 1 RX/OTC
TRUEPLUS INSULIN QL(5 ea daily); 1/2" MISC
SYRINGE/U-100/1ML/28G 1 RX/OTC ULTICARE INSULIN QL(5 ea daily);
X 1/2" MISC SYRINGE/0.5ML/29G X 1 RX/OTC
TRUEPLUS INSULIN QL(5 ea daily); 1/2" MISC
SYRINGE/U-100/1ML/29G 1 RX/OTC ULTICARE INSULIN QL(5 ea daily)
X 1/2" MISC SYRINGE/0.5ML/30G X 1
TRUEPLUS INSULIN QL(5 ea daily); 1/2" MISC
SYRINGE/U-100/1ML/30G 1 RX/OTC ULTICARE INSULIN QL(5 ea daily);
X 5/16" MISC SYRINGE/0.5ML/30G X 1 RX/OTC
TRUEPLUS INSULIN QL(5 ea daily) 5/16" MISC
SYRINGE/U-100/1ML/31G 1 ULTICARE INSULIN QL(5 ea daily);
X 5/16" MISC SYRINGE/1ML/28G X 1/2" 1 RX/OTC
TRUEPLUS PEN QL(5 ea daily); MISC
NEEDLES 29GX12MM 1 RX/OTC ULTICARE INSULIN QL(5 ea daily);
MISC SYRINGE/1ML/29G X 1/2" 1 RX/OTC
TRUEPLUS PEN QL(5 ea daily); MISC
NEEDLES 31GX5MM 1 RX/OTC ULTICARE INSULIN QL(5 ea daily)
MISC SYRINGE/1ML/30G X 1/2" 1
TRUEPLUS PEN QL(5 ea daily) MISC
NEEDLES 31GX6MM 1 ULTICARE INSULIN QL(5 ea daily);
MISC SYRINGE/1ML/30G X 1 RX/OTC
TRUEPLUS PEN QL(5 ea daily); 5/16" MISC
NEEDLES 31GX8MM 1 RX/OTC ULTICARE INSULIN QL(5 ea daily);
MISC SYRINGE/SHORT/0.3ML/3 1 RX/OTC
TRUEPLUS PEN QL(5 ea daily); 0G X 5/16" MISC
NEEDLES 32GX4MM 1 RX/OTC ULTICARE INSULIN QL(5 ea daily)
MISC SYRINGE/SHORT/0.3ML/3 1
ULTICARE INSULIN QL(5 ea daily); 1G X 5/16" MISC
SAFETY 1 RX/OTC ULTICARE INSULIN QL(5 ea daily);
SYRINGE/0.5ML/29G X SYRINGE/SHORT/0.5ML/3 1 RX/OTC
1/2" MISC 0G X 5/16" MISC
ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily)
SAFETY 1 RX/OTC SYRINGE/SHORT/0.5ML/3 1
SYRINGE/1ML/29G X 1/2" 1G X 5/16" MISC
MISC
ULTICARE INSULIN QL(5 ea daily);
ULTICARE INSULIN QL(5 ea daily); SYRINGE/SHORT/1ML/30 1 RX/OTC
SYRINGE/0.3ML/29G X 1 RX/OTC G X 5/16" MISC
1/2" MISC
ULTICARE INSULIN QL(5 ea daily)
SYRINGE/SHORT/1ML/31 1
G X 5/16" MISC
Ambetter Formulary Updated April 01, 2018

114
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ULTICARE INSULIN QL(5 ea daily); ULTICARE INSULIN QL(5 ea daily)
SYRINGE/U- 1 RX/OTC SYRINGEULTRAFINE U-
100/0.3ML/29G X 1/2" 1
100/0.5ML/31G X 5/16"
MISC MISC
ULTICARE INSULIN QL(5 ea daily) ULTICARE INSULIN QL(5 ea daily)
SYRINGE/U- 1 SYRINGEULTRAFINE U-
100/0.3ML/30G X 1/2" 1
100/1ML/31G X 5/16"
MISC MISC
ULTICARE INSULIN QL(5 ea daily); ULTICARE MICRO PEN QL(5 ea daily);
SYRINGE/U- 1 RX/OTC NEEDLES 31G X 8MM 1 RX/OTC
100/0.3ML/30G X 5/16" MISC
MISC ULTICARE MICRO PEN QL(5 ea daily);
ULTICARE INSULIN QL(5 ea daily) NEEDLES 32G X 4MM 1 RX/OTC
SYRINGE/U- 1 MISC
100/0.3ML/31G X 5/16" ULTICARE MICRO PEN QL(5 ea daily);
MISC NEEDLES/32G X 4MM 1 RX/OTC
ULTICARE INSULIN QL(5 ea daily); MISC
SYRINGE/U- 1 RX/OTC ULTICARE MINI PEN QL(5 ea daily)
100/0.5ML/29G X 1/2" NEEDLES 31GX6MM 1
MISC MISC
ULTICARE INSULIN QL(5 ea daily) ULTICARE MINI PEN QL(5 ea daily)
SYRINGE/U- 1 NEEDLES ULTI-FINE IV 1
100/0.5ML/30G X 1/2" MISC
MISC
ULTICARE MINI PEN QL(5 ea daily)
ULTICARE INSULIN QL(5 ea daily); NEEDLES/31G X 6MM 1
SYRINGE/U- 1 RX/OTC MISC
100/0.5ML/30G X 5/16"
MISC ULTICARE MINI PEN 1 QL(5 ea daily)
NEEDLES31GX6MM MISC
ULTICARE INSULIN QL(5 ea daily)
SYRINGE/U- ULTICARE ORIGINAL QL(5 ea daily);
1 PEN NEEDLES ULTI-FINE 1 RX/OTC
100/0.5ML/31G X 5/16"
MISC MISC
ULTICARE INSULIN QL(5 ea daily); ULTICARE PEN NEEDLES 1 QL(5 ea daily);
SYRINGE/U-100/1ML/29G 1 RX/OTC 31GX 5MM/MINI MISC RX/OTC
X 1/2" MISC ULTICARE PEN QL(5 ea daily)
ULTICARE INSULIN QL(5 ea daily) NEEDLES/29GX 12.7MM 1
SYRINGE/U-100/1ML/30G 1 MISC
X 1/2" MISC ULTICARE SHORT PEN QL(5 ea daily);
ULTICARE INSULIN QL(5 ea daily); NEEDLES 31GX8MM 1 RX/OTC
SYRINGE/U-100/1ML/30G 1 RX/OTC MISC
X 5/16" MISC ULTICARE SHORT PEN QL(5 ea daily);
ULTICARE INSULIN QL(5 ea daily) NEEDLES ULTI-FINE IV 1 RX/OTC
SYRINGE/U-100/1ML/31G 1 MISC
X 5/16" MISC ULTICARE SHORT PEN QL(5 ea daily);
ULTICARE INSULIN QL(5 ea daily) NEEDLES/31G X 8MM 1 RX/OTC
SYRINGEULTRAFINE U- MISC
1 ULTILET INSULIN QL(5 ea daily);
100/0.3ML/31G X 5/16"
MISC SYRINGE/0.3ML/30G X 1 RX/OTC
8MM MISC
Ambetter Formulary Updated April 01, 2018

115
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ULTILET INSULIN QL(5 ea daily) ULTILET PEN NEEDLE
SYRINGE/0.3ML/31G X 1 QL(5 ea daily);
1 32GX4MM MISC RX/OTC
8MM MISC ULTILET PEN NEEDLE
ULTILET INSULIN QL(5 ea daily); 1 QL(5 ea daily);
32GX4MM/SHORT MISC RX/OTC
SYRINGE/0.5ML/30G X 1 RX/OTC ULTILET SHORT PEN QL(5 ea daily);
8MM MISC NEEDLES 31GX5/16" 1 RX/OTC
ULTILET INSULIN QL(5 ea daily); MISC
SYRINGE/1ML/30G X 1 RX/OTC ULTILET SHORT PEN QL(5 ea daily);
8MM MISC 1
NEEDLES31GX3/16" MISC RX/OTC
ULTILET INSULIN QL(5 ea daily) ULTRA COMFORT QL(5 ea daily);
SYRINGE/1ML/31G X 1 INSULIN SYRINGE/U- RX/OTC
8MM MISC 1
100/0.3ML/30G X 5/16"
ULTILET INSULIN QL(5 ea daily) MISC
SYRINGE/SHORT/0.3ML/3 1 ULTRA-COMFORT QL(5 ea daily);
0G X 12.7MM MISC INSULIN SYRINGE/U- RX/OTC
ULTILET INSULIN QL(5 ea daily); 1
100/0.3ML/29G X 1/2"
SYRINGE/SHORT/0.3ML/3 1 RX/OTC MISC
0G X 5/16" MISC ULTRA-COMFORT QL(5 ea daily);
ULTILET INSULIN QL(5 ea daily) INSULIN SYRINGE/U- RX/OTC
SYRINGE/SHORT/0.3ML/3 1
1 100/0.3ML/30G X 5/16"
1G X 5/16" MISC MISC
ULTILET INSULIN QL(5 ea daily); ULTRA-COMFORT QL(5 ea daily)
SYRINGE/SHORT/0.5ML/3 1 RX/OTC INSULIN SYRINGE/U-
0G X 5/16" MISC 1
100/0.3ML/31G X 5/16"
ULTILET INSULIN QL(5 ea daily) MISC
SYRINGE/SHORT/0.5ML/3 1 ULTRA-COMFORT QL(5 ea daily);
1G X 5/16" MISC INSULIN SYRINGE/U- RX/OTC
1
ULTILET INSULIN QL(5 ea daily); 100/0.5ML/28G X 1/2"
SYRINGE/SHORT/1ML/30 1 RX/OTC MISC
G X 5/16" MISC ULTRA-COMFORT QL(5 ea daily);
ULTILET INSULIN QL(5 ea daily) INSULIN SYRINGE/U- 1 RX/OTC
SYRINGE/SHORT/1ML/31 1 100/0.5ML/29G X 1/2"
G X 5/16" MISC MISC
ULTILET INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily);
SYRINGE/U- INSULIN SYRINGE/U- 1 RX/OTC
1 100/0.5ML/30G X 5/16"
100/0.5ML/30G X 1/2"
MISC MISC
ULTILET INSULIN QL(5 ea daily) ULTRA-COMFORT QL(5 ea daily)
SYRINGE/U-100/1ML/30G 1 INSULIN SYRINGE/U- 1
X 1/2" MISC 100/0.5ML/31G X 5/16"
MISC
ULTILET PEN NEEDLE 1 QL(5 ea daily)
29GX12.7MM MISC ULTRA-COMFORT QL(5 ea daily);
INSULIN SYRINGE/U- 1 RX/OTC
ULTILET PEN NEEDLE 1 QL(5 ea daily); 100/1ML/28G X 1/2" MISC
31GX5MM MISC RX/OTC
ULTRA-COMFORT QL(5 ea daily);
ULTILET PEN NEEDLE 1 QL(5 ea daily); INSULIN SYRINGE/U- 1 RX/OTC
31GX8MM MISC RX/OTC 100/1ML/29G X 1/2" MISC

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116
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ULTRA-COMFORT QL(5 ea daily); UNIFINE PENTIPS
INSULIN SYRINGE/U- 1 QL(5 ea daily);
1 RX/OTC 29GX12MM MISC RX/OTC
100/1ML/30G X 5/16" UNIFINE PENTIPS 31G X
MISC 1 QL(5 ea daily);
3/16" MISC RX/OTC
ULTRA-COMFORT QL(5 ea daily) UNIFINE PENTIPS
INSULIN SYRINGE/U- 1 QL(5 ea daily);
1 31GX5MM MISC RX/OTC
100/1ML/31G X 5/16"
MISC UNIFINE PENTIPS 1 QL(5 ea daily)
31GX6MM MISC
ULTRA-THIN II INSULIN QL(5 ea daily);
SYRINGE SHORT/U- RX/OTC UNIFINE PENTIPS 1 QL(5 ea daily);
1 31GX8MM MISC RX/OTC
100/0.3ML/30GX5/16"
MISC UNIFINE PENTIPS 1 QL(5 ea daily);
ULTRA-THIN II INSULIN QL(5 ea daily) 32GX4MM MISC RX/OTC
SYRINGE SHORT/U- UNIFINE PENTIPS PLUS 1 QL(5 ea daily);
1 29GX12MM MISC RX/OTC
100/0.3ML/31GX5/16"
MISC UNIFINE PENTIPS PLUS QL(5 ea daily);
1
ULTRA-THIN II INSULIN QL(5 ea daily); 31GX5MM MISC RX/OTC
SYRINGE SHORT/U- 1 RX/OTC UNIFINE PENTIPS PLUS QL(5 ea daily)
100/0.5ML/30GX5/16" 1
31GX6MM MISC
MISC UNIFINE PENTIPS PLUS QL(5 ea daily);
ULTRA-THIN II INSULIN QL(5 ea daily) 1
31GX8MM MISC RX/OTC
SYRINGE SHORT/U- 1 UNIFINE PENTIPS PLUS QL(5 ea daily);
100/0.5ML/31GX5/16" 1
32GX4MM MISC RX/OTC
MISC
V-R MONOJECT INSULIN QL(5 ea daily);
ULTRA-THIN II INSULIN QL(5 ea daily); SYRINGE/U- RX/OTC
SYRINGE SHORT/U- 1 RX/OTC 1
100/0.3ML/29G X 1/2"
100/1ML/30GX5/16" MISC MISC
ULTRA-THIN II INSULIN QL(5 ea daily) V-R MONOJECT INSULIN QL(5 ea daily);
SYRINGE SHORT/U- 1 SYRINGE/U- RX/OTC
100/1ML/31GX5/16" MISC 1
100/0.5ML/28G X 1/2"
ULTRA-THIN II INSULIN QL(5 ea daily); MISC
SYRINGE/U- 1 RX/OTC V-R MONOJECT INSULIN QL(5 ea daily);
100/0.3ML/29GX1/2" MISC SYRINGE/U- RX/OTC
ULTRA-THIN II INSULIN QL(5 ea daily); 1
100/0.5ML/29G X 1/2"
SYRINGE/U- 1 RX/OTC MISC
100/0.5ML/29GX1/2" MISC V-R MONOJECT INSULIN QL(5 ea daily);
ULTRA-THIN II INSULIN QL(5 ea daily); SYRINGE/U-100/1ML/28G 1 RX/OTC
SYRINGE/U- 1 RX/OTC X 1/2" MISC
100/1ML/29GX1/2" MISC V-R MONOJECT INSULIN QL(5 ea daily);
ULTRA-THIN II MINI PEN QL(5 ea daily); SYRINGE/U-100/1ML/29G 1 RX/OTC
NEEEDLES/31GX3/16" 1 RX/OTC X 1/2" MISC
MISC VALUE HEALTH INSULIN QL(5 ea daily);
ULTRA-THIN II PEN 1 QL(5 ea daily) SYRINGE/U- RX/OTC
NEEDLES 29GX1/2" MISC 1
100/0.5ML/29G X 1/2"
ULTRA-THIN II PEN QL(5 ea daily); MISC
NEEDLES/SHORT/31GX5/ 1 RX/OTC VALUE HEALTH INSULIN QL(5 ea daily);
16" MISC SYRINGE/U-100/1ML/29G 1 RX/OTC
X 1/2" MISC

Ambetter Formulary Updated April 01, 2018

117
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
VALUMARK PEN QL(5 ea daily); WEGMANS UNIFINE QL(5 ea daily)
NEEDLES 29GX12MM 1 RX/OTC PENTIPS PLUS/ULTRA 1
MISC SHORT/31GX6MM MISC
VALUMARK PEN QL(5 ea daily) MIGRAINE PRODUCTS - Drugs to Treat Migraine
NEEDLES 31GX 6MM 1 Headaches
MISC
VALUMARK PEN QL(5 ea daily); Migraine Combinations
NEEDLES 31GX 8MM 1 RX/OTC CAFERGOT TABS (Use NF
MISC Ergotamine w/ Caffeine)
VANISHPOINT INSULIN QL(5 ea daily) ergotamine w/ caffeine tabs 1
SYRINGE/0.5ML/30G X 1
1/2" MISC Migraine Products
VANISHPOINT INSULIN QL(5 ea daily); D.H.E. 45 SOLN (Use
SYRINGE/0.5ML/30G X 1 RX/OTC Dihydroergotamine NF
5/16" MISC Mesylate)
VANISHPOINT INSULIN QL(5 ea daily); dihydroergotamine
SYRINGE/1ML/29G X 1/2" 1 RX/OTC 1
mesylate soln ij 1 mg/ml
MISC dihydroergotamine QL(0.267 ml
VANISHPOINT INSULIN QL(5 ea daily); 1
mesylate soln na 4 mg/ml daily)
SYRINGE/1ML/30G X 1 RX/OTC QL(0.667 ea
5/16" MISC ERGOMAR SUBL 3
daily)
VIDA MIA UNIFINE 1 QL(5 ea daily); MIGRANAL SOLN (Use QL(0.267 ml
PENTIPS32GX4MM MISC RX/OTC Dihydroergotamine 1 daily)
VIDA MIA UNIFINE QL(5 ea daily) Mesylate)
PENTIPSMINI 31GX6MM 1
MISC Serotonin Agonists
VIDA MIA UNIFINE QL(5 ea daily); ST; QL(0.4 ea
almotriptan malate tabs 3 daily); AL; At
PENTIPSORIGINAL 1 RX/OTC 12.5 mg
29GX12MM MISC least 12 yrs old
VIDA MIA UNIPFINE QL(5 ea daily); ST; QL(0.3 ea
almotriptan malate tabs 3 daily); AL; At
PENTIPSSHORT 1 RX/OTC 6.25 mg
31GX8MM MISC least 12 yrs old
VP INSULIN SYRINGE/U- QL(5 ea daily); AMERGE TABS (Use QL(0.3 ea
100/0.3ML/29G X 1/2" 1 RX/OTC NF daily); AL; At
Naratriptan HCl) least 18 yrs old
MISC
WEGMANS UNIFINE QL(5 ea daily); ST; QL(0.4 ea
AXERT TABS 12.5 MG 3 daily); AL; At
PENTIPS PLUS 32GX4MM 1 RX/OTC (Use Almotriptan Malate)
MISC least 12 yrs old
WEGMANS UNIFINE QL(5 ea daily); ST; QL(0.3 ea
AXERT TABS 6.25 MG 3 daily); AL; At
PENTIPS 1 RX/OTC (Use Almotriptan Malate)
PLUS/MINI/31GX5MM least 12 yrs old
MISC ST; QL(0.2 ea
eletriptan hydrobromide 1 daily); AL; At
WEGMANS UNIFINE QL(5 ea daily); tabs
PENTIPS RX/OTC least 18 yrs old
1 ST; QL(0.4 ea
PLUS/SHORT/31GX8MM FROVA TABS (Use
MISC NF daily); AL; At
Frovatriptan Succinate) least 18 yrs old

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118
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ST; QL(0.4 ea QL(0.2 ea
frovatriptan succinate tabs 1 daily); AL; At sumatriptan soln 1 daily); AL; At
least 18 yrs old least 18 yrs old
IMITREX SOLN NA 5 QL(0.2 ea QL(0.134 ml
MG/ACT, 20 MG/ACT (Use 1 daily); AL; At sumatriptan succinate soaj 1 daily); AL; At
Sumatriptan) least 18 yrs old sc 4 mg/0.5ml, 6 mg/0.5ml least 18 yrs old
IMITREX SOLN SC 6 QL(0.134 ml sumatriptan succinate soct QL(0.134 ml
MG/0.5ML (Use NF daily); AL; At
sc 4 mg/0.5ml, 6 mg/0.5ml 1 daily); AL; At
Sumatriptan Succinate) least 18 yrs old least 18 yrs old
IMITREX STATDOSE QL(0.134 ml sumatriptan succinate soln QL(0.134 ml
REFILL SOCT (Use NF daily); AL; At
sc 6 mg/0.5ml 1 daily); AL; At
Sumatriptan Succinate) least 18 yrs old least 18 yrs old
IMITREX STATDOSE QL(0.134 ml SUMATRIPTAN QL(0.134 ml
SYSTEM SOAJ (Use NF daily); AL; At SUCCINATE SOSY SC 6 1 daily); AL; At
Sumatriptan Succinate) least 18 yrs old MG/0.5ML least 18 yrs old
IMITREX TABS OR 25 MG, QL(0.3 ea QL(0.3 ea
50 MG, 100 MG (Use NF daily); AL; At sumatriptan succinate tabs 1 daily); AL; At
Sumatriptan Succinate) least 18 yrs old
or 25 mg, 50 mg, 100 mg least 18 yrs old
QL(0.6 ea ST; QL(0.3 ea
MAXALT TABS 10 MG NF daily); AL; At zolmitriptan tabs 1 daily); AL; At
(Use Rizatriptan Benzoate) least 6 yrs old least 12 yrs old
QL(0.4 ea ST; QL(0.3 ea
MAXALT TABS 5 MG (Use NF daily); AL; At zolmitriptan tbdp 1 daily); AL; At
Rizatriptan Benzoate) least 6 yrs old least 12 yrs old
MAXALT-MLT TBDP 10 QL(0.6 ea ZOMIG SOLN NA 5 MG, ST; QL(0.2 ea
MG (Use Rizatriptan NF daily); AL; At
2.5 MG
2 daily); AL; At
Benzoate) least 6 yrs old least 12 yrs old
QL(0.4 ea ST; QL(0.3 ea
MAXALT-MLT TBDP 5 MG NF daily); AL; At ZOMIG TABS OR 5 MG, NF daily); AL; At
(Use Rizatriptan Benzoate) least 6 yrs old 2.5 MG (Use Zolmitriptan) least 12 yrs old
QL(0.3 ea ZOMIG ZMT TBDP (Use ST; QL(0.3 ea
naratriptan hcl tabs 1 daily); AL; At
Zolmitriptan) NF daily); AL; At
least 18 yrs old least 12 yrs old
ST; QL(0.2 ea
RELPAX TABS (Use 3 daily); AL; At MINERALS & ELECTROLYTES
Eletriptan Hydrobromide) least 18 yrs old Bicarbonates
QL(0.6 ea
rizatriptan benzoate tabs 1 daily); AL; At sodium acetate soln 1
10 mg least 6 yrs old
Calcium
QL(0.4 ea
rizatriptan benzoate tabs 5 1 daily); AL; At calcium chloride (dihydrate)
mg 1
least 6 yrs old soln
QL(0.6 ea calcium gluconate soln iv 1
rizatriptan benzoate tbdp 1 daily); AL; At 10 %
10 mg least 6 yrs old Electrolyte Mixtures
QL(0.4 ea DEXTROSE
rizatriptan benzoate tbdp 5 1 daily); AL; At
mg 5%/ELECTROLYTE #48 1
least 6 yrs old VIAFLEX SOLN
Ambetter Formulary Updated April 01, 2018

119
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
dextrose in lactated ringers 1 SSKI SOLN 3 PA
soln
IONOSOL-B/DEXTROSE 1 Magnesium
5% SOLN magnesium sulfate soln ij
IONOSOL-MB/DEXTROSE 1
1 50 %
5% SOLN magnesium sulfate soln iv
ISOLYTE-P/DEXTROSE 1 2 gm/50ml, 4 gm/50ml, 4
5% SOLN 1
gm/100ml, 20 gm/500ml,
40 gm/1000ml
ISOLYTE-S SOLN 1
MAGNESIUM SULFATE
KCL 0.3%/D5W/NACL SOLN IV 2 GM/50ML, 4
1 GM/50ML, 4 GM/100ML,
0.9% SOLN 1
20 GM/500ML, 40
lactated ringer's soln 1 GM/1000ML (Use
NORMOSOL-M IN D5W Magnesium Sulfate)
1
SOLN Phosphate
NORMOSOL-R SOLN 1 POTASSIUM 1
PHOSPHATES SOLN
parenteral electrolytes conc 1 potassium phosphates soln 1
parenteral electrolytes soln 1 Potassium
K-TAB TBCR 10 MEQ (Use NF
PLASMA-LYTE A SOLN 1 Potassium Chloride)
PLASMA-LYTE-148 SOLN 1 K-TAB TBCR 8 MEQ 1
PLASMA-LYTE-56/D5W 1 KLOR-CON M15 TBCR 1
SOLN
potassium chloride in MICRO-K CPCR (Use NF
dextrose & sodium chloride 1 Potassium Chloride)
soln potassium acetate soln 2 1
potassium chloride in meq/ml
1 POTASSIUM ACETATE
dextrose soln
potassium chloride in nacl SOLN 2 MEQ/ML (Use NF
1 Potassium Acetate)
soln
POTASSIUM potassium bicarb & chloride 1
CHLORIDE/DEXTROSE 1 tbef
SOLN potassium bicarbonate tbef 1
POTASSIUM
CHLORIDE/DEXTROSE/L potassium chloride cpcr or 1
ACTATED RINGERS 8 meq, 10 meq
1
SOLN 28MEQ/L-24MEQ/L- POTASSIUM CHLORIDE
130MEQ/L-149MEQ/L- 1
ER TBCR 8 MEQ
3MEQ/L-5% potassium chloride
ringer's soln 1 microencapsulated crystals 1
er tbcr
Iodine Products potassium chloride pack or 1 PA
20 meq
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120
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
potassium chloride soln iv AZATHIOPRINE SOLR IJ 1
0.4 meq/ml, 2 meq/ml, 20 1 100 MG
meq/50ml, 10 meq/100ml
azathioprine tabs or 50 mg 1
POTASSIUM CHLORIDE 1
SOLN IV 10 MEQ/50ML CELLCEPT CAPS 250 MG
potassium chloride soln or (Use Mycophenolate NF
1 Mofetil)
10 %
potassium chloride tbcr or CELLCEPT
1 INTRAVENOUS SOLR
8 meq, 10 meq 3
(Use Mycophenolate
Sodium Mofetil HCl)
sodium chloride soln ij 2.5 1 CELLCEPT TABS 500 MG
meq/ml (Use Mycophenolate NF
sodium chloride soln iv Mofetil)
0.45 %, 0.9 %, 3 %, 5 %, 4 1
meq/ml cyclosporine caps 1

MISCELLANEOUS THERAPEUTIC CLASSES cyclosporine modified (for 1


microemulsion) caps
Chelating Agents cyclosporine modified (for 1
PA microemulsion) soln
CUPRIMINE CAPS 3
CYCLOSPORINE
DEPEN TITRATABS TABS 3 QL(8 ea daily) MODIFIED CAPS (Use 1
Cyclosporine Modified (For
PA; QL(8 ea Microemulsion))
SYPRINE CAPS (Use 4 daily,30 days
Trientine HCl) retail,30 days cyclosporine soln 1
mail); SP IMURAN TABS (Use NF
PA; QL(8 ea Azathioprine)
daily,30 days mycophenolate mofetil
trientine hcl caps 4
retail,30 days 1
caps 250 mg
mail); SP
mycophenolate mofetil hcl 3
Immunomodulators solr
QL(30 days mycophenolate mofetil tabs
REVLIMID CAPS 20 MG 4 retail,30 days 1
500 mg
mail) mycophenolate sodium
PA; QL(1 ea 1
REVLIMID CAPS 5 MG, 10 tbec
daily,30 days MYFORTIC TBEC (Use
MG, 15 MG, 25 MG, 2.5 4 2
retail,30 days Mycophenolate Sodium)
MG mail); SP
NEORAL CAPS (Use
PA; QL(3 ea Cyclosporine Modified (For NF
daily,30 days Microemulsion))
THALOMID CAPS 4
retail,30 days
mail); SP NEORAL SOLN (Use
Cyclosporine Modified (For NF
Immunosuppressive Agents Microemulsion))
ATGAM INJ 4 PA; SP NULOJIX SOLR 4 PA; SP

AZASAN TABS 3

Ambetter Formulary Updated April 01, 2018

121
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
PROGRAF CAPS OR 0.5 ULTRABAG/DIANEAL
MG, 5 MG (Use NF LOW CALCIUM/1.5% 1
Tacrolimus) DEXTROSE SOLN
PROGRAF CAPS OR 1 2 ULTRABAG/DIANEAL PD- 1
MG (Use Tacrolimus) 2/1.5% DEXTROSE SOLN
PROGRAF SOLN IV 5 2 Potassium Removing Agents
MG/ML KAYEXALATE POWD (Use
RAPAMUNE TABS 0.5 Sodium Polystyrene NF
MG, 1 MG, 2 MG (Use NF Sulfonate)
Sirolimus) sodium polystyrene
SANDIMMUNE CAPS OR 1
sulfonate powd or
25 MG, 100 MG (Use NF
Cyclosporine) sodium polystyrene
sulfonate susp or 15 1
SANDIMMUNE SOLN IV gm/60ml
50 MG/ML (Use NF
Cyclosporine) MOUTH/THROAT/DENTAL AGENTS
SIMULECT SOLR 3 Anesthetics Topical Oral
lidocaine hcl (mouth-throat) 1 QL(4 ml daily)
sirolimus tabs 1 soln
tacrolimus caps 1 LIDOCAINE HCL SOLN 1
MT 4 %
THYMOGLOBULIN SOLR 4 PA; SP Anti-infectives - Throat
PA; QL(20 ea clotrimazole lozg 1
daily,30 days
ZORTRESS TABS 4
retail,30 days clotrimazole troc 1
mail); SP
nystatin (mouth-throat) 1
Irrigation Solutions susp
irrigation solutions, 1 Antiseptics - Mouth/Throat
physiological soln
chlorhexidine gluconate 1
lactated ringer's (irrigation) 1 (mouth-throat) soln
soln
DEBACTEROL SOLN 2
ringer's irrigation soln 1
PERIDEX SOLN (Use
water for irrigation, sterile 1 Chlorhexidine Gluconate NF
soln (Mouth-Throat))
Peritoneal Dialysis Solutions Dental Products
DELFLEX-LC/1.5% 1 GEL-KAM ORAL CARE RX/OTC
DEXTROSE SOLN RINSE CONC (Use 0
DIANEAL LOW Stannous Fluoride)
CALCIUM/1.5%DEXTROS 1 stannous fluoride conc mt RX/OTC
E SOLN 0
0.63 %
DIANEAL PD-2/1.5% 1
DEXTROSE SOLN Steroids - Mouth/Throat
triamcinolone acetonide 1
(mouth) pste

Ambetter Formulary Updated April 01, 2018

122
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
Throat Products - Misc. DANTRIUM CAPS (Use NF QL(4 ea daily)
Dantrolene Sodium)
cevimeline hcl caps 1 dantrolene sodium caps or QL(4 ea daily)
1
EVOXAC CAPS (Use 25 mg, 50 mg, 100 mg
NF
Cevimeline HCl) NASAL AGENTS - SYSTEMIC AND TOPICAL -
pilocarpine hcl (oral) tabs 1 Drugs to treat the Nose or Sinus
Nasal Antiallergy
SALAGEN TABS (Use NF
Pilocarpine HCl (Oral)) ASTEPRO SOLN (Use NF
Azelastine HCl)
MUSCULOSKELETAL THERAPY AGENTS -
Drugs to Treat Spasms azelastine hcl soln 1
Central Muscle Relaxants olopatadine hcl (nasal) soln 1
baclofen tabs or 10 mg, 20 1
mg PATANASE SOLN (Use NF
Olopatadine HCl (Nasal))
carisoprodol tabs 1
Nasal Anticholinergics
CHLORZOXAZONE TABS 1 QL(6 ea daily) ATROVENT SOLN 0.03 % QL(1 ml daily)
500 MG (Use Ipratropium Bromide NF
cyclobenzaprine hcl tabs 1 QL(3 ea daily) (Nasal))
ATROVENT SOLN 0.06 %
FEXMID TABS (Use NF QL(3 ea daily) (Use Ipratropium Bromide NF
Cyclobenzaprine HCl) (Nasal))
metaxalone tabs 800 mg 1 QL(4 ea daily) ipratropium bromide (nasal) QL(1 ml daily)
1
soln 0.03 %
methocarbamol tabs or 500 1 ipratropium bromide (nasal)
mg, 750 mg 1
soln 0.06 %
orphenadrine citrate tb12 1 QL(2 ea daily)
or 100 mg Nasal Steroids
ROBAXIN TABS OR 500 budesonide (nasal) susp 1 RX/OTC
NF
MG (Use Methocarbamol)
FLONASE ALLERGY Limit 2 inhalers
ROBAXIN-750 TABS (Use NF per
Methocarbamol) RELIEF CHILDRENS NF month;QL(32
SKELAXIN TABS (Use SUSP (Use Fluticasone
NF QL(4 ea daily) Propionate (Nasal)) ml per 30 days
Metaxalone) retail); RX/OTC
SOMA TABS (Use NF Limit 2 inhalers
Carisoprodol) FLONASE ALLERGY
RELIEF SUSP (Use per
NF month;QL(32
tizanidine hcl caps 1 Fluticasone Propionate ml per 30 days
(Nasal)) retail); RX/OTC
tizanidine hcl tabs 1
FLUNISOLIDE SOLN 1
ZANAFLEX CAPS (Use NF
Tizanidine HCl) Limit 2 inhalers
ZANAFLEX TABS (Use per
NF fluticasone propionate 1 month;QL(32
Tizanidine HCl) (nasal) susp ml per 30 days
Direct Muscle Relaxants retail); RX/OTC

Ambetter Formulary Updated April 01, 2018

123
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
mometasone furoate 1 PA; QL(1.14 CLINIMIX
(nasal) susp gm daily) 4.25%/DEXTROSE 5% 3
NASACORT ALLERGY RX/OTC SOLN
24HR AERO (Use NF CLINIMIX 5%/DEXTROSE 3
Triamcinolone Acetonide 25% SOLN
(Nasal)) CLINIMIX E
NASACORT ALLERGY RX/OTC 5%/DEXTROSE 20% 3
24HR CHILDRENS AERO NF SOLN
(Use Triamcinolone
Acetonide (Nasal)) OPHTHALMIC AGENTS - Drugs to Treat the Eye
NASONEX SUSP (Use PA; QL(1.14 Artificial Tears and Lubricants
Mometasone Furoate NF gm daily)
(Nasal)) LACRISERT INST 3
RHINOCORT AQUA SUSP NF RX/OTC
(Use Budesonide (Nasal)) Beta-blockers - Ophthalmic
triamcinolone acetonide BETAGAN SOLN (Use
1 RX/OTC Levobunolol HCl) NF
(nasal) aero
Sympathomimetic Decongestants betaxolol hcl (ophth) soln 1
TYZINE PEDIATRIC 3
NASAL DROPS SOLN carteolol hcl (ophth) soln 1
NEUROMUSCULAR AGENTS - Drugs to COMBIGAN SOLN 2
Relax/Paralyze Muscles
COSOPT SOLN (Use
ALS Agents Dorzolamide HCl-Timolol NF
RILUTEK TABS (Use 3 Maleate)
Riluzole) dorzolamide hcl-timolol 1
riluzole tabs 3 maleate soln
levobunolol hcl soln 1
Neuromuscular Blocking Agent - Neurotoxins
BOTOX SOLR 3 PA METIPRANOLOL SOLN 1
PA timolol maleate (ophth) solg 1
DYSPORT SOLR 3 0.25 %, 0.5 %
XEOMIN SOLR 50 UNIT 3 PA timolol maleate (ophth) soln 1
0.25 %, 0.5 %
NUTRIENTS TIMOPTIC SOLN (Use NF
Timolol Maleate (Ophth))
Proteins TIMOPTIC-XE SOLG 0.25
CLINIMIX % (Use Timolol Maleate NF
2.75%/DEXTROSE 5% 3 (Ophth))
SOLN Cycloplegic Mydriatics
CLINIMIX MYDRIACYL SOLN (Use
4.25%/DEXTROSE 10% 3 NF
Tropicamide)
SOLN
CLINIMIX tropicamide soln 1
4.25%/DEXTROSE 25% 3
SOLN Miotics

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124
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ISOPTO CARPINE SOLN NF moxifloxacin hcl (ophth) 1
(Use Pilocarpine HCl) soln
PHOSPHOLINE IODIDE 3 NATACYN SUSP 2
SOLR
neomycin-bacitracin zn- 1
pilocarpine hcl soln 1 polymyxin oint
Ophthalmic Adrenergic Agents OCUFLOX SOLN (Use NF
ALPHAGAN P SOLN 0.15 Ofloxacin (Ophth))
% (Use Brimonidine NF ofloxacin (ophth) soln 1
Tartrate)
polymyxin b-trimethoprim 1
apraclonidine hcl soln 1 soln
POLYTRIM SOLN (Use NF
brimonidine tartrate soln 1 Polymyxin B-Trimethoprim)
IOPIDINE SOLN 0.5 % sulfacetamide sodium 1
NF (ophth) soln
(Use Apraclonidine HCl)
IOPIDINE SOLN 1 % 3 tobramycin (ophth) soln 1

SIMBRINZA SUSP 3 PA TOBREX SOLN (Use NF


Tobramycin (Ophth))
Ophthalmic Anti-infectives trifluridine soln 1
AZASITE SOLN 3 VIGAMOX SOLN (Use 2
BACITRACIN OINT OP Moxifloxacin HCl (Ophth))
3 VIROPTIC SOLN (Use
500 UNIT/GM NF
Trifluridine)
BESIVANCE SUSP 3
ZIRGAN GEL 2
BLEPH-10 SOLN (Use
Sulfacetamide Sodium NF ZYMAXID SOLN (Use NF
(Ophth)) Gatifloxacin (Ophth))
CILOXAN SOLN (Use NF Ophthalmic Decongestants
Ciprofloxacin HCl (Ophth)) NAPHAZOLINE HCL
ciprofloxacin hcl (ophth) 1
1 SOLN
soln
Ophthalmic Immunomodulators
erythromycin (ophth) oint 1 PA
RESTASIS EMUL 2
gatifloxacin (ophth) soln 1 RESTASIS MULTIDOSE PA
2
gentamicin sulfate (ophth) EMUL
1
oint Ophthalmic Local Anesthetics
gentamicin sulfate (ophth) 1 ALCAINE SOLN (Use
soln NF
Proparacaine HCl)
levofloxacin (ophth) soln 1 proparacaine hcl soln 1

MOXEZA SOLN 2 Ophthalmic Steroids


ALREX SUSP 2

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125
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
DEXAMETHASONE TOBRADEX OINT 3
SODIUM PHOSPHATE 1
SOLN OP 0.1 % TOBRADEX SUSP (Use
Tobramycin- NF
DUREZOL EMUL 2 Dexamethasone)
fluorometholone (ophth) 1 tobramycin- 1
susp dexamethasone susp
FML FORTE SUSP 3 VEXOL SUSP 3
FML LIQUIFILM SUSP Ophthalmics - Misc.
(Use Fluorometholone NF
ACULAR LS SOLN (Use
(Ophth)) Ketorolac Tromethamine NF
FML OINT 3 (Ophth))
ACULAR SOLN (Use
LOTEMAX GEL 2 Ketorolac Tromethamine NF
(Ophth))
LOTEMAX OINT 2
ALOCRIL SOLN 3
LOTEMAX SUSP 2
ALOMIDE SOLN 3
MAXIDEX SUSP 3
azelastine hcl (ophth) soln 1
MAXITROL OINT (Use
Neomycin-Polymy- NF AZOPT SUSP 2
Dexameth)
MAXITROL SUSP (Use BEPREVE SOLN 3
Neomycin-Polymy- NF
bromfenac sodium (ophth)
Dexameth) soln 1
neomycin-polymy- 1
dexameth oint BROMFENAC SOLN 1
neomycin-polymy- 1 cromolyn sodium (ophth)
dexameth susp 1
soln
NEOMYCIN/POLYMYXIN/ PA
HYDROCORTISONE 1 CYSTARAN SOLN 2
SUSP diclofenac sodium (ophth)
OMNIPRED SUSP (Use 1
soln
Prednisolone Acetate NF
(Ophth)) dorzolamide hcl soln 1
PRED FORTE SUSP (Use ELESTAT SOLN (Use
Prednisolone Acetate NF NF
Epinastine HCl (Ophth))
(Ophth))
EMADINE SOLN 3
PRED MILD SUSP 3
prednisolone acetate epinastine hcl (ophth) soln 1
1
(ophth) susp
flurbiprofen sodium soln 1
PREDNISOLONE SODIUM
PHOSPHATE SOLN OP 1 3 ST; QL(0.2 ml
% ILEVRO SUSP 3
daily)

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126
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
ketorolac tromethamine 1 FLOXIN OTIC SOLN (Use NF
(ophth) soln Ofloxacin (Otic))
ketotifen fumarate (ophth) 1 ofloxacin (otic) soln 1
soln
LASTACAFT SOLN 2 Otic Combinations

ST; QL(0.2 ml CIPRO HC SUSP 3


NEVANAC SUSP 3
daily) PA
CIPRODEX SUSP 2
OCUFEN SOLN (Use NF
Flurbiprofen Sodium)
COLY-MYCIN S SUSP 3
olopatadine hcl soln 1
CORTISPORIN-TC SUSP 3
PATADAY SOLN (Use NF
Olopatadine HCl) neomycin-polymyxin-hc 1
PATANOL SOLN (Use (otic) soln
NF neomycin-polymyxin-hc
Olopatadine HCl) 1
TRUSOPT SOLN (Use (otic) susp
NF PA; QL(0.5 ea
Dorzolamide HCl) OTOVEL SOLN 3
ZADITOR SOLN (Use daily)
Ketotifen Fumarate 1 Otic Steroids
(Ophth)) DERMOTIC OIL (Use
Prostaglandins - Ophthalmic Fluocinolone Acetonide NF
(Otic))
BIMATOPROST SOLN 3
fluocinolone acetonide 1
(otic) oil
latanoprost soln 1
hydrocortisone w/acetic 1
LUMIGAN SOLN 3 ST acid soln
PASSIVE IMMUNIZING AGENTS - Antibody
RESCULA SOLN 3 PA Drugs to Treat Low Immune System

TRAVATAN Z SOLN 2 Immune Serums


CUVITRU SOLN 1 PA; SP
XALATAN SOLN (Use NF GM/5ML, 2 GM/10ML, 4 4
Latanoprost) GM/20ML
ZIOPTAN SOLN 2 GAMMAGARD LIQUID 4 PA; SP
SOLN 1 GM/10ML
OTIC AGENTS - Drugs to Treat the Ear GAMMAGARD S/D IGA PA; SP
LESS THAN 1MCG/ML 4
Otic Agents - Miscellaneous SOLR
acetic acid (otic) soln 1 GAMMAKED SOLN 1 4 PA; SP
GM/10ML
Otic Anti-infectives GAMUNEX-C SOLN 1 4 PA; SP
GM/10ML
CETRAXAL SOLN 1
HIZENTRA SOLN 4 PA; SP
CIPROFLOXACIN SOLN 1
OT 0.2 % Passive Immunizing Agents - Combinations

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127
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
HYQVIA KIT 4 PA PFIZERPEN-G SOLR
5000000 UNIT (Use NF
Penicillin G Potassium)
PENICILLINS - Drugs to Treat Bacterial Infections
Penicillin Combinations
Aminopenicillins amoxicillin & pot
amoxicillin caps 250 mg, 1
1 clavulanate susr
500 mg amoxicillin & pot
AMOXICILLIN CHEW 125 1
1 clavulanate tabs
MG, 250 MG amoxicillin & pot
amoxicillin susr 125 1
clavulanate tb12
mg/5ml, 200 mg/5ml, 250 1 AMOXICILLIN/CLAVULAN
mg/5ml, 400 mg/5ml 1
ATE POTASSIUM CHEW
amoxicillin tabs 500 mg, 1 ampicillin & sulbactam
875 mg sodium solr ij 0.5gm-1gm, 1
ampicillin caps 250 mg, 1 1gm-2gm
500 mg ampicillin & sulbactam
ampicillin sodium solr ij 1 1
1 sodium solr iv 5gm-10gm
gm AUGMENTIN ES-600
ampicillin sodium solr iv 10 1 SUSR (Use Amoxicillin & NF
gm Pot Clavulanate)
AMPICILLIN SUSR 125 1 AUGMENTIN SUSR
MG/5ML, 250 MG/5ML 250MG/5ML-62.5MG/5ML NF
Natural Penicillins (Use Amoxicillin & Pot
Clavulanate)
PENICILLIN G
POTASSIUM IN ISO- AUGMENTIN TABS
OSMOTIC DEXTROSE 1 500MG-125MG, 875MG- NF
SOLN 40000UNIT/ML, 125MG (Use Amoxicillin &
60000UNIT/ML Pot Clavulanate)
penicillin g potassium solr AUGMENTIN XR TB12
1 (Use Amoxicillin & Pot NF
5000000 unit
Clavulanate)
PENICILLIN G PROCAINE 3
SUSP piperacillin sodium- 1
tazobactam sodium solr
PENICILLIN G SODIUM 3
SOLR PIPERACILLIN/TAZOBAC 1
TAM SOLR
penicillin v potassium solr 1
125 mg/5ml, 250 mg/5ml UNASYN SOLR (Use
Ampicillin & Sulbactam NF
PENICILLIN V Sodium)
POTASSIUM SOLR 250 1
MG/5ML ZOSYN SOLR 0.375GM-
3GM, 0.25GM-2GM,
penicillin v potassium tabs 1 0.5GM-4GM, 4.5GM-36GM NF
250 mg, 500 mg (Use Piperacillin Sodium-
PFIZERPEN SOLR Tazobactam Sodium)
5000000 UNIT (Use NF
Penicillin G Potassium) Penicillinase-Resistant Penicillins
dicloxacillin sodium caps 1

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128
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
nafcillin sodium solr ij 1 gm, 1 ARICEPT TABS 5 MG QL(1 ea daily)
10 gm (Use Donepezil NF
oxacillin sodium solr 1 gm, Hydrochloride)
1
10 gm donepezil hydrochloride 1 QL(2 ea daily)
tabs 10 mg
PROGESTINS - Hormone Replacement/Modifying
Drugs donepezil hydrochloride 1 QL(1 ea daily)
tabs 5 mg
Progestins donepezil hydrochloride QL(2 ea daily)
AYGESTIN TABS (Use 1
0 tbdp 10 mg
Norethindrone Acetate)
donepezil hydrochloride 1 QL(1 ea daily)
medroxyprogesterone 1 tbdp 5 mg
acetate tabs
EXELON CAPS OR 3 MG,
MEGACE ES SUSP (Use PA 6 MG, 1.5 MG, 4.5 MG NF
Megestrol Acetate 3 (Use Rivastigmine Tartrate)
(Appetite))
galantamine hydrobromide 1 QL(1 ea daily)
megestrol acetate 3 PA cp24 8 mg, 16 mg, 24 mg
(appetite) susp
GALANTAMINE QL(6 ml daily)
norethindrone acetate tabs 0 HYDROBROMIDE SOLN 4 1
MG/ML
progesterone micronized 1 galantamine hydrobromide QL(2 ea daily)
caps 1
tabs 4 mg, 8 mg, 12 mg
PROMETRIUM CAPS (Use NF
Progesterone Micronized) memantine hcl tabs 1
PROVERA TABS (Use QL(2 ea daily)
Medroxyprogesterone NF memantine hcl tabs 10 mg 1
Acetate) QL(1 ea daily)
memantine hcl tabs 5 mg 1
PSYCHOTHERAPEUTIC AND NEUROLOGICAL
AGENTS - MISC. - Drugs to Treat Mental and NAMENDA TABS 10 MG NF QL(2 ea daily)
Emotional Conditions (Use Memantine HCl)
Agents for Chemical Dependency NAMENDA TABS 5 MG NF QL(1 ea daily)
(Use Memantine HCl)
acamprosate calcium tbec 1 NAMENDA TITRATION
ANTABUSE TABS (Use PAK TABS (Use NF
NF Memantine HCl)
Disulfiram)
RAZADYNE ER CP24 (Use QL(1 ea daily)
disulfiram tabs 1 Galantamine NF
Hydrobromide)
Anti-Cataplectic Agents
RAZADYNE TABS (Use QL(2 ea daily)
PA; QL(18 ml Galantamine NF
daily,30 days Hydrobromide)
XYREM SOLN 4
retail,30 days
mail); SP rivastigmine tartrate caps 1
Antidementia Agents Combination Psychotherapeutics
ARICEPT TABS 10 MG QL(2 ea daily) PERPHENAZINE/AMITRIP
(Use Donepezil NF 1 QL(4 ea daily)
TYLINE TABS
Hydrochloride)
Fibromyalgia Agents

Ambetter Formulary Updated April 01, 2018

129
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
2 PA; QL(2 ea PA; QL(0.0357
SAVELLA TABS glatiramer acetate sosy 20
daily) 4 ml daily,30
SAVELLA TITRATION mg/ml days retail,30
2 PA days mail); SP
PACK MISC
PA; QL(0.429
Movement Disorder Drug Therapy glatiramer acetate sosy 40
PA; SP 4 ml daily,30
tetrabenazine tabs 4 mg/ml days retail,30
days mail); SP
XENAZINE TABS (Use PA; SP
Tetrabenazine) 4 PLEGRIDY SOPN 4 PA; QL(0.0357
ml daily)
Multiple Sclerosis Agents
PLEGRIDY SOSY 4 PA
PA; QL(2 ea
daily,30 days PLEGRIDY STARTER PA
AMPYRA TB12 4
PACK SOPN
4
retail,30 days
mail); SP PLEGRIDY STARTER PA; QL(0.0357
4
AUBAGIO TABS 3 PA PACK SOSY ml daily)
PA; QL(0.214
PA; QL(0.0714 ml daily,30
AVONEX KIT 30 ea daily,30 REBIF REBIDOSE SOAJ 4
4 days retail,30
MCG/VIAL days retail,30 days mail); SP
days mail); SP REBIF REBIDOSE PA; SP
PA; QL(0.0714 4
TITRATIONPACK SOAJ
ea daily,30 PA; QL(0.214
AVONEX PEN AJKT 4
days retail,30 ml daily,30
days mail); SP REBIF SOSY 4
days retail,30
PA; QL(0.0714 days mail); SP
AVONEX PSKT 30 4 ml daily,30 REBIF TITRATION PACK PA; SP
MCG/0.5ML days retail,30 4
SOSY
days mail); SP
TECFIDERA CPDR 120 4 PA; QL(4 ea
PA; QL(0.0357 MG daily)
ea daily,30
BETASERON KIT 4 TECFIDERA CPDR 240 PA; QL(2 ea
days retail,30 4
days mail); SP MG daily)
PA; QL(0.0357 TECFIDERA STARTER 4 PA
COPAXONE SOSY 20 ml daily,30 PACK MISC
MG/ML (Use Glatiramer 4
days retail,30
Acetate) PA; QL(0.536
days mail); SP ml daily,30
TYSABRI CONC 4
PA; QL(0.429 days retail,30
COPAXONE SOSY 40 ml daily,30 days mail); SP
MG/ML (Use Glatiramer 4
days retail,30
Acetate) QL(0.0357 ml
days mail); SP ZINBRYTA SOSY 4
daily)
PA; QL(0.0357 Premenstrual Dysphoric Disorder (PMDD) Agents
ea daily,30
EXTAVIA KIT FLUOXETINE CAPS 10 1 QL(1 ea daily)
4
days retail,30
days mail); SP MG
PA; QL(1 ea FLUOXETINE CAPS 20 1 QL(3 ea daily)
daily,30 days MG
GILENYA CAPS 4
retail,30 days Pseudobulbar Affect (PBA) Agents
mail); SP
Ambetter Formulary Updated April 01, 2018

130
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
NUEDEXTA CAPS 3 RESPIRATORY AGENTS - MISC. - Drugs to
Treat Lung Conditions
Psychotherapeutic and Neurological Agents - Alpha-Proteinase Inhibitor (Human)
ERGOLOID MESYLATES ARALAST NP SOLR 800
TABS
3 4 PA; SP
MG, 1000 MG
ORAP TABS (Use NF PROLASTIN-C SOLR 1000 4 PA; SP
Pimozide) MG
pimozide tabs 1 ZEMAIRA SOLR 4 PA; SP
Smoking Deterrents Cystic Fibrosis Agents
bupropion hcl (smoking 0 QL(2 ea daily) PA; QL(2 ea
deterrent) tb12 daily,30 days
CHANTIX CONTINUING QL(2 ea daily) KALYDECO TABS 150 MG 4
0 retail,30 days
MONTHPAK TABS mail); SP
CHANTIX STARTING 0 PA; QL(2.5 ml
MONTH PAK TABS daily,30 days
PULMOZYME SOLN 4
retail,30 days
CHANTIX TABS 0 QL(2 ea daily)
mail); SP
NICODERM CQ PT24 (Use 0 QL(1 ea daily) SULFONAMIDES - Drugs to Treat Bacterial
Nicotine) Infections
NICORETTE GUM (Use 0
Nicotine Polacrilex) Sulfonamides
NICORETTE LOZG (Use SULFADIAZINE TABS 1
0
Nicotine Polacrilex)
NICORETTE MINI LOZG TETRACYCLINES - Drugs to Treat Bacterial
0 Infections
(Use Nicotine Polacrilex)
NICORETTE STARTER Tetracyclines
KIT GUM (Use Nicotine 0 ADOXA PAK 1/100 TABS QL(2 ea daily)
Polacrilex) (Use Doxycycline NF
(Monohydrate))
nicotine polacrilex gum 0
ADOXA PAK 2/100 TABS QL(2 ea daily)
nicotine polacrilex lozg 0 (Use Doxycycline NF
(Monohydrate))
nicotine pt24 0 QL(1 ea daily) ADOXA TABS 100 MG QL(2 ea daily)
(Use Doxycycline NF
NICOTINE (Monohydrate))
TRANSDERMAL SYSTEM 0
KIT demeclocycline hcl tabs 1
NICOTROL INHALER 0 doxycycline (monohydrate) QL(2 ea daily)
INHA 1
caps 50 mg, 100 mg
NICOTROL NS SOLN 0 doxycycline (monohydrate) 1
caps 75 mg
ZYBAN TB12 (Use QL(2 ea daily) doxycycline (monohydrate) QL(2 ea daily)
Bupropion HCl (Smoking 0 1
tabs 100 mg
Deterrent))
doxycycline hyclate caps or 1 QL(2 ea daily)
50 mg, 100 mg

Ambetter Formulary Updated April 01, 2018

131
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
doxycycline hyclate solr iv 1 liothyronine sodium soln 1
100 mg
doxycycline hyclate tabs or 1 QL(2 ea daily) liothyronine sodium tabs 1
20 mg, 100 mg
MINOCIN CAPS OR 50 QL(3 ea daily) NATURE-THROID TABS 2
MG, 75 MG, 100 MG (Use NF 81.25 MG, 113.75 MG
Minocycline HCl) SYNTHROID TABS (Use 2
minocycline hcl caps 50 Levothyroxine Sodium)
1 QL(3 ea daily)
mg, 75 mg, 100 mg THYROLAR-1 TABS 3
minocycline hcl tabs 50 1 QL(3 ea daily)
mg, 75 mg, 100 mg THYROLAR-1/2 TABS 3
MONODOX CAPS 100 MG QL(2 ea daily)
(Use Doxycycline NF THYROLAR-1/4 TABS 3
(Monohydrate))
MONODOX CAPS 75 MG THYROLAR-2 TABS 3
(Use Doxycycline NF
(Monohydrate)) THYROLAR-3 TABS 3
tetracycline hcl caps 250 1 QL(8 ea daily) TRIOSTAT SOLN (Use
mg, 500 mg NF
Liothyronine Sodium)
TETRACYCLINE HCL QL(8 ea daily) WP THYROID TABS 81.25
CAPS 250 MG, 500 MG NF 2
MG, 113.75 MG
(Use Tetracycline HCl)
VIBRAMYCIN CAPS 100 QL(2 ea daily) TOXOIDS
MG (Use Doxycycline NF
Hyclate) Toxoid Combinations
THYROID AGENTS - Drugs to Regulate Thyroid ADACEL SUSP 0
Hormones
BOOSTRIX SUSP 0
Antithyroid Agents
methimazole tabs 1 ULCER DRUGS - Drugs to Treat Bowel, Intestine
and Stomach Conditions
propylthiouracil tabs 1 Antispasmodics
TAPAZOLE TABS (Use ATROPINE SULFATE 1
NF SOLN IJ 0.4 MG/ML
Methimazole)
atropine sulfate soln ij 1 1
Thyroid Hormones mg/ml
CYTOMEL TABS (Use NF ATROPINE SULFATE
Liothyronine Sodium) 1
SOSY IJ 0.25 MG/5ML
LEVOTHYROXINE BENTYL CAPS OR 10 MG
SODIUM SOLR IV 100 1 NF
(Use Dicyclomine HCl)
MCG, 500 MCG
BENTYL TABS OR 20 MG NF
levothyroxine sodium tabs (Use Dicyclomine HCl)
or 25 mcg, 50 mcg, 75
mcg, 88 mcg, 100 mcg, 1
CANTIL TABS 3
112 mcg, 125 mcg, 137
mcg, 150 mcg, 175 mcg, chlordiazepoxide hcl- 1
200 mcg, 300 mcg clidinium bromide caps

Ambetter Formulary Updated April 01, 2018

132
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
dicyclomine hcl caps or 10 1 NIZATIDINE SOLN 15 1 QL(20 ml daily)
mg MG/ML
dicyclomine hcl soln or 10 1 PEPCID AC MAXIMUM RX/OTC
mg/5ml STRENGTH TABS (Use NF
dicyclomine hcl tabs or 20 Famotidine)
1
mg PEPCID SUSR 40 MG/5ML NF QL(10 ml daily)
glycopyrrolate soln ij 4 (Use Famotidine)
1
mg/20ml PEPCID TABS 20 MG (Use NF RX/OTC
glycopyrrolate tabs or 1 Famotidine)
1
mg, 2 mg PEPCID TABS 40 MG (Use NF
LIBRAX CAPS (Use Famotidine)
Chlordiazepoxide HCl- NF ranitidine hcl caps or 150 1
Clidinium Bromide) mg, 300 mg
methscopolamine bromide 1 ranitidine hcl soln ij 150 1
tabs mg/6ml
PAMINE FORTE TABS ranitidine hcl syrp or 15 QL(40 ml daily)
(Use Methscopolamine NF mg/ml, 75 mg/5ml, 150 1
Bromide) mg/10ml
PAMINE TABS (Use NF ranitidine hcl tabs or 150 1 RX/OTC
Methscopolamine Bromide) mg
ROBINUL FORTE TABS NF ranitidine hcl tabs or 300 1
(Use Glycopyrrolate) mg
ROBINUL SOLN IJ 4 TAGAMET HB TABS (Use NF RX/OTC
MG/20ML (Use NF Cimetidine)
Glycopyrrolate) ZANTAC 150 MAXIMUM RX/OTC
ROBINUL TABS OR 1 MG NF STRENGTH TABS (Use NF
(Use Glycopyrrolate) Ranitidine HCl)
H-2 Antagonists ZANTAC TABS OR 150 NF RX/OTC
RX/OTC MG (Use Ranitidine HCl)
cimetidine tabs 200 mg 1 ZANTAC TABS OR 300 NF
cimetidine tabs 300 mg, MG (Use Ranitidine HCl)
1
400 mg, 800 mg Misc. Anti-Ulcer
FAMOTIDINE PREMIXED 1 CARAFATE SUSP 1 QL(40 ml daily)
SOLN 2
GM/10ML
famotidine soln iv 20 CARAFATE TABS 1 GM
mg/2ml, 40 mg/4ml, 200 1 NF QL(4 ea daily)
(Use Sucralfate)
mg/20ml QL(4 ea daily)
famotidine susr or 40 QL(10 ml daily) sucralfate tabs 1
1
mg/5ml
Proton Pump Inhibitors
famotidine tabs or 20 mg 1 RX/OTC ACIPHEX TBEC (Use NF QL(1 ea daily)
Rabeprazole Sodium)
famotidine tabs or 40 mg 1 QL(2 ea daily)
CVS OMEPRAZOLE TBEC 1
nizatidine caps 150 mg, 1
300 mg ST; QL(1 ea
DEXILANT CPDR 3
daily)

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133
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
EQ OMEPRAZOLE TBEC 1 QL(2 ea daily) PRILOSEC CPDR 20 MG NF QL(2 ea daily);
(Use Omeprazole) RX/OTC
QL(2 ea daily)
EQL OMEPRAZOLE TBEC 1 PRILOSEC OTC TBEC 1 QL(4 ea daily)
esomeprazole magnesium 1 QL(2 ea daily); PROTONIX TBEC OR 20 QL(1 ea daily)
cpdr 20 mg RX/OTC MG (Use Pantoprazole NF
esomeprazole magnesium QL(1 ea daily) Sodium)
3
cpdr 40 mg PROTONIX TBEC OR 40
GNP OMEPRAZOLE QL(2 ea daily) MG (Use Pantoprazole NF
1 Sodium)
TBEC
HM OMEPRAZOLE TBEC 1 QL(2 ea daily) PX OMEPRAZOLE TBEC 1 QL(2 ea daily)

KLS OMEPRAZOLE TBEC 1 QL(2 ea daily) RA OMEPRAZOLE TBEC 1 QL(2 ea daily)

QL(2 ea daily); rabeprazole sodium tbec 1 QL(1 ea daily)


lansoprazole cpdr 15 mg 1
RX/OTC
SB OMEPRAZOLE TBEC 1 QL(2 ea daily)
lansoprazole cpdr 30 mg 1
QL(2 ea daily) SM OMEPRAZOLE TBEC 1 QL(2 ea daily)
NEXIUM 24HR TBEC 1
NEXIUM CPDR 20 MG QL(2 ea daily); SW OMEPRAZOLE TBEC 1 QL(2 ea daily)
(Use Esomeprazole NF RX/OTC
Magnesium) TGT OMEPRAZOLE TBEC 1 QL(2 ea daily)
NEXIUM CPDR 40 MG QL(1 ea daily)
(Use Esomeprazole NF Ulcer Drugs - Prostaglandins
Magnesium) CYTOTEC TABS (Use NF QL(4 ea daily)
omeprazole cpdr 10 mg, 40 QL(2 ea daily) Misoprostol)
1
mg
misoprostol tabs 1 QL(4 ea daily)
QL(2 ea daily);
omeprazole cpdr 20 mg 1
RX/OTC Ulcer Therapy Combinations
omeprazole magnesium 1 QL(4 ea daily) omeprazole-sodium QL(1 ea daily);
cpdr bicarbonate caps 20mg- 1 RX/OTC
OMEPRAZOLE TBEC 20 QL(2 ea daily) 1100mg
1
MG ZEGERID CAPS 20MG- RX/OTC
pantoprazole sodium tbec QL(1 ea daily) 1100MG (Use Omeprazole- NF
1 Sodium Bicarbonate)
or 20 mg
pantoprazole sodium tbec 1 URINARY ANTI-INFECTIVES - Drugs to Treat
or 40 mg Bladder/Kidney Infections
PREVACID 24HR CPDR 1 QL(2 ea daily); Urinary Anti-infectives
(Use Lansoprazole) RX/OTC
FURADANTIN SUSP (Use NF
PREVACID CPDR 15 MG 1 QL(2 ea daily); Nitrofurantoin)
(Use Lansoprazole) RX/OTC
HIPREX TABS (Use NF
PREVACID CPDR 30 MG NF Methenamine Hippurate)
(Use Lansoprazole)
MACROBID CAPS (Use
PRILOSEC CPDR 10 MG, NF QL(2 ea daily) Nitrofurantoin Monohyd NF
40 MG (Use Omeprazole) Macro)

Ambetter Formulary Updated April 01, 2018

134
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
MACRODANTIN CAPS 50 MYRBETRIQ TB24 3 PA
MG, 100 MG (Use NF
Nitrofurantoin Urinary Antispasmodics - Cholinergic Agonists
Macrocrystal)
bethanechol chloride tabs 1
methenamine hippurate 1 25 mg
tabs
bethanechol chloride tabs 5 1 QL(4 ea daily)
MONUROL PACK 3 mg, 10 mg, 50 mg
URECHOLINE TABS 25
nitrofurantoin macrocrystal 1 MG (Use Bethanechol NF
caps 50 mg, 100 mg Chloride)
nitrofurantoin monohyd 1 URECHOLINE TABS 5 QL(4 ea daily)
macro caps MG, 10 MG, 50 MG (Use NF
nitrofurantoin susp 1 Bethanechol Chloride)
Urinary Antispasmodics - Direct Muscle Relaxants
URINARY ANTISPASMODICS - Drugs to Treat
Miscellaneous Bladder Spasms flavoxate hcl tabs 1
Urinary Antispasmodic - Antimuscarinics
darifenacin hydrobromide VACCINES
1 QL(1 ea daily)
tb24 Bacterial Vaccines
DETROL LA CP24 (Use NF QL(1 ea daily)
Tolterodine Tartrate) MENACTRA INJ 0
DETROL TABS (Use NF MENOMUNE-A/C/Y/W-135
Tolterodine Tartrate) 0
INJ
DITROPAN XL TB24 (Use NF
Oxybutynin Chloride) MENVEO SOLR 0
ENABLEX TB24 (Use 3 PA; QL(1 ea PNEUMOVAX 23 INJ 0
Darifenacin Hydrobromide) daily)
PNEUMOVAX 23/1 DOSE 0
oxybutynin chloride syrp 1 INJ
oxybutynin chloride tabs 1 PREVNAR 13 SUSP 0

oxybutynin chloride tb24 1 Viral Vaccines


tolterodine tartrate cp24 2 QL(1 ea daily) AFLURIA 2015-2016 SUSP 0
1
mg, 4 mg
tolterodine tartrate tabs 1 AFLURIA 2016-2017 SUSP 0
1
mg, 2 mg
AFLURIA 2017-2018 SUSP 0
PA; QL(1 ea
TOVIAZ TB24 3
daily) AFLURIA PF 2015-2016 0
trospium chloride cp24 60 QL(1 ea daily) SUSY
1
mg AFLURIA PF 2016-2017 0
trospium chloride tabs 20 SUSY
1
mg AFLURIA PF 2017-2018 0
PA; QL(1 ea SUSY
VESICARE TABS 2
daily) AFLURIA QUADRIVALENT 0
Urinary Antispasmodics - Beta-3 Adrenergic 2016-2017 SUSY

Ambetter Formulary Updated April 01, 2018

135
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
AFLURIA QUADRIVALENT 0 FLUVIRIN 2016-2017 0
2017-2018 SUSP SUSP
AFLURIA QUADRIVALENT 0 FLUVIRIN 2016-2017 0
2017-2018 SUSY SUSY
FLUARIX QUADRIVALENT 0 FLUVIRIN 2017-2018 0
2015-2016 SUSY SUSP
FLUARIX QUADRIVALENT 0 FLUVIRIN 2017-2018 0
2016-2017 SUSY SUSY
FLUARIX QUADRIVALENT 0 FLUZONE HIGH-DOSE PF 0
2017-2018 SUSY 2015-2016 SUSY
FLUBLOK PV FLUZONE HIGH-DOSE PF 0
QUADRIVALENT 2017- 0 2016-2017 SUSY
2018 SOSY FLUZONE HIGH-DOSE PF 0
FLUCELVAX 2015-2016 0 2017-2018 SUSY
SUSY FLUZONE
FLUCELVAX QUADRIVALENT 2015- 0
QUADRIVALENT 2016- 0 2016 SUSP
2017 SUSY FLUZONE
FLUCELVAX QUADRIVALENT 2015- 0
QUADRIVALENT 2017- 0 2016 SUSY
2018 SUSP FLUZONE
FLUCELVAX QUADRIVALENT 2016- 0
QUADRIVALENT 2017- 0 2017 SUSP
2018 SUSY FLUZONE
FLULAVAL QUADRIVALENT 2016- 0
QUADRIVALENT 2014- 0 2017 SUSY
2015 SUSY FLUZONE
FLULAVAL QUADRIVALENT 2017- 0
QUADRIVALENT 2015- 0 2018 SUSP
2016 SUSP FLUZONE
FLULAVAL QUADRIVALENT 2017- 0
QUADRIVALENT 2016- 0 2018 SUSY
2017 SUSP FLUZONE SPLIT 2015- 0
FLULAVAL 2016 SUSP
QUADRIVALENT 2016- 0 AL; At least 50
2017 SUSY ZOSTAVAX SUSR 0
yrs old
FLULAVAL
QUADRIVALENT 2017- 0 VAGINAL PRODUCTS - Drugs to Treat Vaginal
2018 SUSP Infections and Low Hormones
FLULAVAL Spermicides
QUADRIVALENT 2017- 0 SHUR-SEAL GEL 0
2018 SUSY
FLUVIRIN 2015-2016 0 TODAY SPONGE MISC 0
SUSP
FLUVIRIN 2015-2016 Vaginal Anti-infectives
0
SUSY

Ambetter Formulary Updated April 01, 2018

136
Drug Requirements/ Drug Requirements/
Drug Name Tier Limits Drug Name Tier Limits
CLEOCIN CREA VA 2 % midodrine hcl tabs 1
(Use Clindamycin NF
Phosphate Vaginal)
VITAMINS
clindamycin phosphate 1
vaginal crea Oil Soluble Vitamins
clotrimazole vaginal crea 1 1 cholecalciferol caps 50000
% 1
unit
GYNAZOLE-1 CREA 3 cholecalciferol tabs 400 0
unit
GYNE-LOTRIMIN CREA NF DRISDOL CAPS 50000
(Use Clotrimazole Vaginal) 0
UNIT (Use Ergocalciferol)
METROGEL-VAGINAL DRISDOL SOLN 8000
GEL (Use Metronidazole NF UNIT/ML (Use 1
Vaginal) Ergocalciferol)
metronidazole vaginal gel 1 ergocalciferol caps or 0
50000 unit
MICONAZOLE 3 SUPP 3 ergocalciferol soln or 8000 1
unit/ml
TERAZOL 3 CREA (Use NF
Terconazole Vaginal) VITAMIN D2 TABS 400 0 AL; At least 65
UNIT yrs old
TERAZOL 7 CREA (Use NF
Terconazole Vaginal) Water Soluble Vitamins
TERCONAZOLE CREA 1 niacin cpcr or 250 mg, 500 1
mg
terconazole vaginal crea 1 niacin tabs or 50 mg, 100 1
mg, 250 mg, 500 mg
terconazole vaginal supp 1 niacin tbcr or 250 mg, 500 1
mg, 750 mg
Vaginal Estrogens
NIACIN TR TBCR 1
ESTRACE CREA VA 0.1
MG/GM (Use Estradiol 3 niacinamide tabs or 100
Vaginal) 1
mg, 500 mg
estradiol vaginal crea 0.1 1 SLO-NIACIN TBCR (Use
mg/gm 1
Niacin)
FEMRING RING 3

PREMARIN CREA 2
VASOPRESSORS - Drugs to Treat Heart and
Circulation Conditions
Anaphylaxis Therapy Agents
ADRENACLICK SOAJ 0.3 2
MG/0.3ML
epinephrine (anaphylaxis) 2
soaj
Vasopressors

Ambetter Formulary Updated April 01, 2018

137
Index
1ST CHOICE LANCETS ACCU-CHEK SOFTCLIX ADDERALL 1
SUPERTHIN 77 LANCETS 77 ADDERALL XR 1
1ST CHOICE LANCETS THIN ACCUPRIL 29
77 adefovir dipivoxil 46
ACCURETIC 30
1ST CHOICE LANCETS ADEMPAS 50
ULTRATHIN 77 acebutolol hcl 47
ADIPEX-P 1
1ST TIER UNIFINE ACEON 29 ADJUSTABLE LANCING
PENTIPS/MINI/31GX5MM 89 acetaminophen w/ codeine 8 DEVICE 77
1ST TIER UNIFINE ACETAMINOPHEN/CAFFEINE
PENTIPS29GX12MM 89 ADOXA 131
/DIHYDROCODEINE 8 ADOXA PAK 1/100 131
1ST TIER UNIFINE
PENTIPS31GX6MM 89 acetazolamide 64
ADOXA PAK 2/100 131
1ST TIER UNIFINE acetazolamide sodium 64
ADRENACLICK 137
PENTIPS31GX8MM 89 acetic acid 70
1ST TIER UNIFINE ADVAIR DISKUS 14
acetic acid (otic) 127
PENTIPS32GX4MM 89 ADVAIR HFA 14
1ST TIER UNIFINE acetylcysteine 55 ADVANCED MOBILE LANCET
PENTIPSPLUS 31GX8MM 89 ACIPHEX 133 30G 77
1ST TIER UNIFINE acitretin 58 ADVOCATE INSULIN PEN
PENTIPSPLUS 32GX4MM 89 NEEDLES 29GX12.7MM 89
1ST TIER UNIFINE ACLOVATE 59
ADVOCATE INSULIN PEN
PENTIPSPLUS/MINI/31GX5MM ACTEMRA 4 NEEDLES 31GX5MM 89
89 ACTI-LANCE LANCETS ADVOCATE INSULIN PEN
1ST TIER UNIFINE 28G 77 NEEDLES 31GX8MM 89
PENTIPSPLUS/ORIGINAL/29GX ACTI-LANCE LITE SAFETY ADVOCATE INSULIN
12MM 89 LANCETS 28G 77 SYRINGE/U-
1ST TIER UNIFINE ACTI-LANCE SPECIAL 100/0.3ML/29GX1/2" 89
PENTIPSPLUS/ULTRA SAFETY LANCETS 17G 77 ADVOCATE INSULIN
SHORT/31GX6MM 89 ACTI-LANCE SPECIAL SYRINGE/U-
1ST TIER UNILET SAFETYLANCETS 17G 77 100/0.3ML/30GX5/16" 89
COMFORTOUCH LANCETS ACTI-LANCE UNIVERSAL ADVOCATE INSULIN
28G 77 SAFETY LANCETS 23G 77 SYRINGE/U-
1ST TIER UNILET ACTIGALL 69 100/0.3ML/31GX5/16" 89
COMFORTOUCH LANCETS ACTIMMUNE 37 ADVOCATE INSULIN
30G 77 SYRINGE/U-
ACTIQ 6
8-MOP 58 100/0.5ML/29GX1/2" 89
ACTIVE 1ST BLOOD ADVOCATE INSULIN
abacavir sulfate 41 LANCETS30G/EASY TWIST SYRINGE/U-
abacavir sulfate-lamivudine 42 CAP 77 100/0.5ML/30GX5/16" 89
abacavir sulfate-lamivudine- ACTONEL 65 ADVOCATE INSULIN
zidovudine 42 ACTOPLUS MET 22 SYRINGE/U-
ABELCET 25 ACTOS 23 100/0.5ML/31GX5/16" 89
ABILIFY 41 ADVOCATE INSULIN
ACULAR 126 SYRINGE/U-100/1ML/29GX1/2"
ABRAXANE 38 ACULAR LS 126 90
acamprosate calcium 129 acyclovir 47 ADVOCATE INSULIN
acarbose 22 acyclovir topical 59 SYRINGE/U-100/1ML/30GX5/16"
ACCOLATE 13 90
ADACEL 132 ADVOCATE INSULIN
ACCU-CHEK FASTCLIX
LANCETS 77 ADAGEN 3 SYRINGE/U-100/1ML/31GX5/16"
ACCU-CHEK MULTICLIX ADALAT CC 48 90
LANCETS 77 adapalene 55 ADVOCATE LANCETS 77
ACCU-CHEK SAFE-T-PRO ADVOCATE LANCETS 30G 77
LANCETS 77 ADAPALENE 55
adapalene-benzoyl ADVOCATE LANCING
ACCU-CHEK SAFE-T-PRO DEVICE 77
PLUSLANCETS 77 peroxide 55
ADVOCATE RAPID-SAFE
ACCU-CHEK SOFT TOUCH ADCETRIS 34 LANCING DEVICE 77
LANCETS 77 ADCIRCA 50

Index 1
ADVOCATE SAFETY ALOXI 24 ampicillin sodium 128
LANCETS 77 ALPHAGAN P 125 AMPYRA 130
ADVOCATE SAFETY LANCETS
26G 77 alprazolam 12 ANADROL-50 9
AFINITOR 36 ALREX 125 ANAFRANIL 21
AFLURIA 2015-2016 135 ALTABAX 57 anagrelide hcl 71
AFLURIA 2016-2017 135 ALTACE 29 ANAPROX DS 4
AFLURIA 2017-2018 135 ALTERNATE SITE LANCING anastrozole 34
DEVICE 77 ANCOBON 25
AFLURIA PF 2015-2016 135
ALTOPREV 28
AFLURIA PF 2016-2017 135 ANDRODERM 9
ALVESCO 13
AFLURIA PF 2017-2018 135 ANDROXY 9
amantadine hcl 38
AFLURIA QUADRIVALENT ANORO ELLIPTA 14
2016-2017 135 AMARYL 24
ANTABUSE 129
AFLURIA QUADRIVALENT AMBIEN 73 ANTI-STICK INSULIN
2017-2018 136 AMBISOME 25 SYRINGE/U-100/0.5ML/28G X
AGAMATRIX ULTRA-THIN 1/2" 90
LANCETS 33G 77 AMCINONIDE 59
AMERGE 118 ANTI-STICK INSULIN
AGGRENOX 71 SYRINGE/U-100/0.5ML/29G X
AGRYLIN 71 amikacin sulfate 3 1/2" 90
AIMSCO LUBRICATED 74 amiloride & ANTI-STICK INSULIN
hydrochlorothiazide 64 SYRINGE/U-100/1ML/29G X
AKYNZEO 25 amiloride hcl 65 1/2" 90
ALBENZA 9 aminophylline 14 ANUSOL-HC 9
albuterol sulfate 14 amiodarone hcl 13 ANZEMET 25
ALCAINE 125 AMITIZA 69 APIDRA 23
alclometasone dipropionate 59 amitriptyline hcl 21 APIDRA SOLOSTAR 23
ALDACTAZIDE 64 amlodipine besylate 48 apraclonidine hcl 125
ALDACTONE 65 amlodipine besylate- aprepitant 25
ALDARA 62 atorvastatin calcium 49 APRISO 69
ALDURAZYME 66 amlodipine besylate-benazepril
hcl 30 APTIOM 16
alendronate sodium 65 amlodipine besylate-olmesartan APTIVUS 42
ALENDRONATE SODIUM 65 medoxomil 30 AQUA LANCE ADJUSTABLE
alendronate sodium 65 amlodipine besylate- LANCING DEVICE 77
alfuzosin hcl 70 valsartan 30 ARALAST NP 131
amlodipine-valsartan-
ALIMTA 33 hydrochlorothiazide 30 ARANESP ALBUMIN FREE 72
ALINIA 10 AMOXAPINE 21 ARAVA 5
ALKERAN 32 amoxicillin 128 ARCALYST 4
ALLEGRA ALLERGY 26 AMOXICILLIN 128 ARCAPTA NEOHALER 14
ALLEGRA ALLERGY amoxicillin 128 ARICEPT 129
CHILDRENS 26 amoxicillin & pot ARIMIDEX 34
ALLEGRA-D 12 HOUR clavulanate 128
ALLERGY & CONGESTION 55 aripiprazole 41
AMOXICILLIN/CLAVULANATE ARIXTRA 15
ALLEGRA-D 24 HOUR POTASSIUM 128
ALLERGY & CONGESTION 55 amphetamine- armodafinil 2
allopurinol 71 dextroamphetamine 1 AROMASIN 34
almotriptan malate 118 AMPHOTEC 25 ARRANON 33
ALOCRIL 126 AMPHOTERICIN B 25 ARTHROTEC 50 4
ALOGLIPTIN 22 ampicillin 128 ARTHROTEC 75 4
ALOMIDE 126 AMPICILLIN 128 ARZERRA 34
ALORA 68 ampicillin & sulbactam ASACOL HD 69
alosetron hcl 70 sodium 128

Index 2
ASMANEX TWISTHALER 120 ATLAS LUBRICATED AZACTAM 10
METERED DOSES 13 CONDOM/SPERMICIDE 75 AZACTAMIN ISO-OSMOTIC
ASMANEX TWISTHALER 14 atomoxetine hcl 2 DEXTROSE 10
METERED DOSES 13 atorvastatin calcium 28 AZASAN 121
ASMANEX TWISTHALER 30
METERED DOSES 13 atovaquone 10 AZASITE 125
ASMANEX TWISTHALER 60 atovaquone-proguanil hcl 31 AZATHIOPRINE 121
METERED DOSES 13 ATRIPLA 42 azathioprine 121
ASMANEX TWISTHALER 7
METERED DOSES 13 ATROPINE SULFATE 132 azelastine hcl 123
aspirin 6 atropine sulfate 132 azelastine hcl (ophth) 126
ASPIRIN LOW DOSE 6 ATROPINE SULFATE 132 AZELEX 55
aspirin-dipyridamole 71 ATROVENT 123 AZILECT 39
ASSURE COMFORT LANCETS ATROVENT HFA 13 AZITHROMYCIN 74
ULTRA THIN 28G 77 AUBAGIO 130 azithromycin 74
ASSURE COMFORT LANCETS AUGMENTIN 128 AZOPT 126
ULTRA THIN 30G 77
ASSURE HAEMOLANCE PLUS AUGMENTIN ES-600 128 AZOR 30
HIGH FLOW 18G 77 AUGMENTIN XR 128 aztreonam 10
ASSURE HAEMOLANCE PLUS AURORA LANCET SUPER AZULFIDINE 69
LOW FLOW 25G 77 THIN30G 78
ASSURE HAEMOLANCE PLUS AZULFIDINE EN-TABS 69
AURORA LANCET THIN
MICRO FLOW 28G 77 23G 78 B-D INSULIN SYRINGE
ASSURE HAEMOLANCE PLUS AURORA PEN NEEDLES ULTRAFINE II/0.3ML/31G X
NORMAL FLOW 21G 77 29GX12MM 90 5/16" 90
ASSURE HAEMOLANCE PLUS AURORA PEN NEEDLES 31G B-D INSULIN SYRINGE
PEDIATRIC BLADE 77 X6MM 90 ULTRAFINE II/0.5ML/31G X
ASSURE ID INSULIN AURORA PEN NEEDLES 31G 5/16" 90
SAFETYSYRINGE/U- X8MM 90 B-D INSULIN SYRINGE
100/0.5ML/29G X 1/2" 90 AURORA UNIFINE ULTRAFINE II/1ML/31G X
ASSURE ID INSULIN PENTIPS/32GX5/32" 90 5/16" 90
SAFETYSYRINGE/U- AURORA UNIFINE B-D INSULIN SYRINGE
100/1ML/29G X 1/2" 90 PENTIPS/MINI/31GX3/16" ULTRAFINE/0.3ML/30G X
ASSURE LANCE LANCETS 77 90 1/2" 90
ASSURE LANCE LANCETS AUTO-LANCET 78 B-D INSULIN SYRINGE
21G 77 ULTRAFINE/0.5ML/30G X
AUTO-LANCET MINI 78 1/2" 90
ASSURE LANCE PLUS AUTOLET IMPRESSION
SAFETYLANCETS 25G 77 bacitracin 10
LANCING DEVICE 78
ASSURE LANCE PLUS AUTOLET LANCING BACITRACIN 125
SAFETYLANCETS 30G 78 DEVICE 78 baclofen 123
ASSURE LANCETS 78 AUTOLET MINI 78 BACTRIM 10
ASTEPRO 123 AUTOLET PLUS 78 BACTRIM DS 10
AT LAST LANCETS 78 AVALIDE 30 BACTROBAN 57
ATACAND 29 AVANDIA 23 balsalazide disodium 69
ATACAND HCT 30 AVAPRO 29 BANZEL 16
atazanavir sulfate 42 AVASTIN 34 BARACLUDE 46
ATELVIA 65 AVELOX 68 BASAGLAR KWIKPEN 23
atenolol 47 AVELOX ABC PACK 68 BAYER MICROLET 2 LANCING
atenolol & chlorthalidone 30 AVODART 71 DEVICE 78
ATGAM 121 BAYER MICROLET
AVONEX 130 LANCETS 78
ATIVAN 12 AVONEX PEN 130 BD LO-DOSE INSULIN
ATLAS COLORED SYRINGE MICROFINE
LUBRICATEDCONDOM 75 AXERT 118
IV/0.5ML/28G X 1/2" 90
ATLAS LUBRICATED AYGESTIN 129 BD AUTOSHIELD 29G X
CONDOM 75 azacitidine 33 5/16" 90

Index 3
BD INSULIN SYRINGE LUER- BD INSULIN SYRINGE BD INTEGRA
LOK/U-100/1ML 90 ULTRAFINE/1ML/30G X SYRINGE/RETRACTING
BD INSULIN SYRINGE 1/2" 91 NEEDLE/1ML/25G X 1" 92
MICROFINE IV/U- BD INSULIN SYRINGE BD LANCET DEVICE 78
100/0.3ML/28G X 1/2" 90 ULTRAFINE/1ML/31G X BD LANCET ULTRAFINE
BD INSULIN SYRINGE 5/16" 91 30G 78
MICROFINE IV/U- BD INSULIN SYRINGE BD LANCET ULTRAFINE
100/0.5ML/28G X 1/2" 90 ULTRAFINE/U-100/0.3ML/29G 33G 78
BD INSULIN SYRINGE X 1/2" 91 BD MICROTAINER
MICROFINE IV/U-100/1ML/27G BD INSULIN SYRINGE LANCETS 78
X 5/8" 90 ULTRAFINE/U-100/0.3ML/30G BD PEN
BD INSULIN SYRINGE X 1/2" 91 NEEDLE/MINI/ULTRAFINE/31G
MICROFINE IV/U-100/1ML/28G BD INSULIN SYRINGE X 3/16" 92
X 1/2" 90 ULTRAFINE/U-100/0.3ML/31G BD PEN
BD INSULIN SYRINGE X 5/16" 91 NEEDLE/NANO/ULTRAFINE/32
MICROFINE/U-100/0.3ML/28G X BD INSULIN SYRINGE G X 4MM 92
1/2" 90 ULTRAFINE/U-100/0.5ML/29G BD PEN
BD INSULIN SYRINGE X 1/2" 91 NEEDLE/SHORT/ULTRAFINE/31
MICROFINE/U-100/0.5ML/28G X BD INSULIN SYRINGE G X 5/16" 92
1/2" 90 ULTRAFINE/U-100/0.5ML/30G BD PEN
BD INSULIN SYRINGE X 1/2" 91 NEEDLE/ULTRAFINE/29G X
MICROFINE/U-100/1ML/27G X BD INSULIN SYRINGE 12.7MM 92
5/8" 90 ULTRAFINE/U-100/0.5ML/31G BD PEN
BD INSULIN SYRINGE X 5/16" 91 NEEDLE/ULTRAFINE/29GX1/2"
MICROFINE/U-100/1ML/28G X BD INSULIN SYRINGE 12.7MM 92
1/2" 90 ULTRAFINE/U-100/1ML/29G X BD PEN NEEDLES
BD INSULIN SYRINGE 1/2" 91 SHORT/ULTRAFINE/31G X
SAFETYGLIDE/0.5ML/29G X BD INSULIN SYRINGE 5/16" 92
1/2" 90 ULTRAFINE/U-100/1ML/30G X BD SAFETY-GLIDE INSULIN
BD INSULIN SYRINGE 1/2" 91 SYRINGE/0.5ML/29G X 1/2" 92
SAFETYGLIDE/1ML/29G X BD INSULIN SYRINGE BD SAFETY-LOK INSULIN
1/2" 90 ULTRAFINE/U-100/1ML/31G X SYRINGE/PERM
BD INSULIN SYRINGE 15/64" 91 NEEDLE/UF/1ML/29G X
SAFETYGLIDE/U- BD INSULIN SYRINGE 1/2" 92
100/0.3ML/31G X 5/16" 91 ULTRAFINE/U-100/1ML/31G X BD SAFETYGLIDE INSULIN
BD INSULIN SYRINGE SLIP 5/16" 91 SYSYRINGE/0.5ML/30G X
TIP/U-100/1ML 91 BD INSULIN 5/16" 92
BD INSULIN SYRINGE SYRINGE/DETACHABLE BD ULTRA-FINE MICRO PEN
ULTRAFINE HALF- NEEDLE/U-100/1ML/25G X NEEDLES 6MM X 32G 92
UNIT/0.3ML/31G X 5/16" 91 1" 91 BELSOMRA 73
BD INSULIN SYRINGE BD INSULIN
ULTRAFINE SYRINGE/DETACHABLE BELVIQ 2
II/SHORT/0.5ML/31G X NEEDLE/U-100/1ML/25G X benazepril &
5/16" 91 5/8" 91 hydrochlorothiazide 30
BD INSULIN SYRINGE BD INSULIN benazepril hcl 29
ULTRAFINE II/SHORT/1ML/31G SYRINGE/DETACHABLE BENICAR 29
X 5/16" 91 NEEDLE/U-100/1ML/26G X BENICAR HCT 30
BD INSULIN SYRINGE 1/2" 91
ULTRAFINE/0.3ML/30G X BD INSULIN SYRINGE/U- BENTYL 132
1/2" 91 100/0.5ML/30G X 1/2" 91 BENZACLIN 55
BD INSULIN SYRINGE BD INSULIN SYRINGE/U- BENZACLIN WITH PUMP 55
ULTRAFINE/0.3ML/31G X 100/1ML/27G X 1/2" 91
5/16" 91 BD INSULIN SYRINGE/U- BENZAMYCIN 55
BD INSULIN SYRINGE 100/1ML/28G X 1/2" 91 BENZEFOAM 55
ULTRAFINE/0.5ML/30G X BD INTEGRA INSULIN BENZEFOAM ULTRA 55
1/2" 91 SYRINGE/U-100/1ML/29G X BENZEFOAMULTRA 55
BD INSULIN SYRINGE 1/2" 91
ULTRAFINE/0.5ML/31G X benzonatate 54
5/16" 91 benzoyl peroxide 56

Index 4
benzoyl peroxide- BULLSEYE MINI SAFETY CAMPTOSAR 38
erythromycin 56 LANCETS 78 CANASA 69
benztropine mesylate 38 BULLSEYE SAFETY
LANCETS 78 CANCIDAS 25
BEPREVE 126
bumetanide 64 candesartan cilexetil 29
BESIVANCE 125 candesartan cilexetil-
BUMEX 64
BETAGAN 124 hydrochlorothiazide 30
betamethasone dipropionate BUNAVAIL 8
CANTIL 132
(topical) 59 BUPHENYL 66,67
CAPASTAT SULFATE 32
betamethasone dipropionate BUPRENEX 9
augmented 59 capecitabine 33
BUPRENORPHINE 9

betamethasone valerate 59 CAPRELSA 36

buprenorphine hcl 9

BETAPACE 48 captopril 29

buprenorphine hcl-naloxone hcl

BETASERON 130 dihydrate 9 CARAFATE 133

betaxolol hcl 47 bupropion hcl 19 CARBAGLU 67

betaxolol hcl (ophth) 124 bupropion hcl (smoking carbamazepine 16

bethanechol chloride 135 deterrent) 131


CARBATROL 16

buspirone hcl 12
carbidopa 38

bexarotene 37
busulfan 33
carbidopa-levodopa 39

BEYAZ 51
BUSULFEX 33
CARBIDOPA/LEVODOPA/ENTA
BIAXIN 74
butalbital-acetaminophen 5 CAPONE 39
bicalutamide 34
butalbital-acetaminophen- carbinoxamine maleate 26
BICNU 33 caffeine 5 carboplatin 33
BIDIL 49 butalbital-acetaminophen- CARDIOCOM LANCING
BILTRICIDE 9 caffeine w/ codeine 8 DEVICE 78
BIMATOPROST 127 butalbital-aspirin-caffeine 5 CARDIZEM 48
butalbital-aspirin-caffeine
bisacodyl 73 w/cod 8 CARDIZEM CD 48
bisoprolol & butenafine hcl 57 CARDIZEM LA 48
hydrochlorothiazide 30 CARDURA 29
bisoprolol fumarate 48 butorphanol tartrate 9
BUTRANS 9 CAREFINE PEN NEEDLE
bleomycin sulfate 35 32GX4MM 92
BLEPH-10 125 BYETTA 23 CAREFINE PEN NEEDLES
BONIVA 65 BYSTOLIC 48 29GX1/2" 92
cabergoline 67 CAREFINE PEN NEEDLES
BOOSTRIX 132 30GX5/16" 92
BORTEZOMIB 36 CADUET 49 CAREFINE PEN NEEDLES
BOSULIF 36 CAFERGOT 118 31GX6MM 92
CALAN 48 CAREFINE PEN NEEDLES
BOTOX 124 31GX8MM 92
BP CLEANSING WASH 56 CALAN SR 48
CAREFINE PEN NEEDLES
BREO ELLIPTA 14 calcipotriene 58 32GX5MM 92
calcipotriene-betamethasone CAREFINE PEN NEEDLES
BREVICON-28 51 dipropionate 59 32GX6MM 92
BRILINTA 71 calcitonin (salmon) 65 CAREONE ADVANCED
brimonidine tartrate 125 CALCITRIOL 58 LANCINGDEVICE 78
BRINTELLIX 20 CAREONE INSULIN
calcitriol 67 SYRINGES/0.3ML/30G X
BROMFENAC 126 calcium acetate (phosphate 1/2" 92
bromfenac sodium (ophth) 126 binder) 70 CAREONE INSULIN
bromocriptine mesylate 39 calcium chloride SYRINGES/0.3ML/31G X
(dihydrate) 119 5/16" 92
BROVANA 14 calcium gluconate 119 CAREONE INSULIN
budesonide 53 calcium polycarbophil 73 SYRINGES/0.5ML/30G X
budesonide (inhalation) 13 CAMPATH 34 1/2" 92
budesonide (nasal) 123

Index 5
CAREONE INSULIN CASPOFUNGIN cetirizine-pseudoephedrine 55
SYRINGES/0.5ML/31G X ACETATE 25 CETRAXAL 127
5/16" 92 caspofungin acetate 25
CAREONE INSULIN CETROTIDE 66
CATAPRES 29
SYRINGES/1ML/30G X 1/2" 92 cevimeline hcl 123
CAREONE INSULIN CATAPRES-TTS-1 29
CHANTIX 131
SYRINGES/1ML/31GX5/16" 92 CATAPRES-TTS-2 29 CHANTIX CONTINUING
CAREONE LANCET THIN 78 CATAPRES-TTS-3 29 MONTHPAK 131
CAREONE LANCET ULTRA CAYA 75 CHANTIX STARTING MONTH
THIN 78 PAK 131
CAREONE UNIFINE PENTIPS CAYSTON 10
CHEK-STIX COMBO PAK
29GX12MM 92 CEDAX 51 URINALYSIS CONTROL 63
CAREONE UNIFINE PENTIPS cefaclor 50 CHEK-STIX CONTROL 63
31GX5MM 92 CEFACLOR 50
CAREONE UNIFINE PENTIPS CHEMET 24
31GX6MM 92 cefadroxil 50 CHEMSTRIP-K 63
CAREONE UNIFINE PENTIPS cefazolin sodium 50 CHILDRENS ADVIL 4
31GX8MM 92 CEFAZOLIN SODIUM 50 CHILDRENS MOTRIN 4
CAREONE UNIFINE PENTIPS
PEN NEEDLES 32GX4MM 92 cefdinir 51 CHLORAMPHENICOL SODIUM
CAREONE UNIFINE PENTIPS CEFDITOREN PIVOXIL 51 SUCCINATE 10
PLUS PEN NEEDLES cefepime hcl 51 chlordiazepoxide hcl 12
29GX12MM 92 chlordiazepoxide hcl-clidinium
cefixime 51 bromide 132
CAREONE UNIFINE PENTIPS
PLUS PEN NEEDLES CEFOTAN 50 chlorhexidine gluconate (mouth-
31GX5MM 92 cefotaxime sodium 51 throat) 122
CAREONE UNIFINE PENTIPS CEFOTAXIME SODIUM 51 CHLOROQUINE
PLUS PEN NEEDLES PHOSPHATE 31
31GX6MM 93 CEFOTETAN 50 chloroquine phosphate 31
CAREONE UNIFINE PENTIPS cefotetan disodium 50 CHLOROTHIAZIDE 65
PLUS PEN NEEDLES cefoxitin sodium 50 chlorothiazide 65
31GX8MM 93 cefpodoxime proxetil 51
CAREONE UNIFINE PENTIPS CHLORPROMAZINE HCL 41
PLUS PEN NEEDLES cefprozil 50 chlorpromazine hcl 41
32GX4MM 93 ceftazidime 51 CHLORPROPAMIDE 24
CARETOUCH LANCING CEFTIBUTEN 51
DEVICEWITH EJECTOR 78 chlorthalidone 65
CARETOUCH PEN NEEDLES CEFTIN 50 CHLORZOXAZONE 123
31G X 6 MM 93 ceftriaxone sodium 51 CHOLBAM 69
CARETOUCH PEN NEEDLES cefuroxime axetil 50 cholecalciferol 137
31GX 5MM 93 cefuroxime sodium 50
CARETOUCH PEN NEEDLES cholestyramine 27
31GX 8MM 93 CELEBREX 4 cholestyramine light 27
CARETOUCH PEN NEEDLES celecoxib 4 CHORIONIC
32GX 4MM 93 CELEXA 19 GONADOTROPIN 66
CARETOUCH PEN NEEDLES CIALIS 49
32GX 5MM 93 CELLCEPT 121
CARETOUCH TWIST LANCETS CELLCEPT ciclopirox 57
28G 78 INTRAVENOUS 121 ciclopirox olamine 57
CARETOUCH TWIST LANCETS CELONTIN 18 cidofovir 46
30G 78 cephalexin 50 cilostazol 71
CARETOUCH TWIST LANCETS CEPHALEXIN 50
33G 78 CILOXAN 125
carisoprodol 123 CERDELGA 71 cimetidine 133
carteolol hcl (ophth) 124 CEREBYX 18 CIMZIA 69
carvedilol 47 CEREZYME 71 CIMZIA STARTER KIT 69
CASODEX 34 CESAMET 25 CIPRO 68
cetirizine hcl 26 CIPRO HC 127

Index 6
CIPRO XR 68
CLEVER CHOICE COMFORT
CLEVER CHOICE COMFORT

CIPRODEX 127
EZINSULIN
EZPEN NEEDLES

SYRINGE/0.5ML/28G X
32GX5MM 94

CIPROFLOXACIN 69
1/2" 93
CLEVER CHOICE COMFORT

ciprofloxacin 69
CLEVER CHOICE COMFORT
EZPEN NEEDLES

CIPROFLOXACIN 127
EZINSULIN
32GX6MM 94

SYRINGE/0.5ML/29G X
CLICKFINE PEN NEEDLE

CIPROFLOXACIN HCL 69
32GX5/32" 94

1/2" 93

ciprofloxacin hcl 69
CLEVER CHOICE COMFORT
CLICKFINE PEN NEEDLE

ciprofloxacin hcl (ophth) 125
EZINSULIN
UNIVERSAL/31GX1/4" 94

ciprofloxacin in d5w 69
SYRINGE/0.5ML/30G X
CLICKFINE PEN NEEDLE

1/2" 93
UNIVERSAL/31GX5/16" 94

ciprofloxacin-ciprofloxacin
CLICKFINE PEN

hcl 69
CLEVER CHOICE COMFORT

EZINSULIN
NEEDLES/31GX1/4" 94

cisplatin 33
SYRINGE/0.5ML/30G X
CLICKFINE PEN

citalopram hydrobromide 19
5/16" 93
NEEDLES/31GX5/16" 94

CLARINEX 26
CLEVER CHOICE COMFORT
CLICKFINE UNIVERSAL PEN

EZINSULIN
NEEDLES 31GX5/16" 94

clarithromycin 74

SYRINGE/0.5ML/31G X
CLIMARA 68

CLARITIN 26,27
5/16" 93
CLIMARA PRO 68

CLARITIN ALLERGY
CLEVER CHOICE COMFORT

CHILDRENS 26
clindamycin hcl 11

EZINSULIN

CLARITIN CHILDRENS 26
SYRINGE/1.0ML/30G X
clindamycin palmitate

1/2" 93
hydrochloride 11

CLARITIN REDITABS 26,27

CLEVER CHOICE COMFORT


clindamycin phosphate 11

CLARITIN-D 12 HOUR 55
clindamycin phosphate

EZINSULIN

CLARITIN-D 24 HOUR 55
SYRINGE/1ML/28G X 1/2" 93
(topical) 56

CLASS ACT LUBRICATED 75


CLEVER CHOICE COMFORT
clindamycin phosphate

CLEANLET LANCETS 28G 78


EZINSULIN
vaginal 137

SYRINGE/1ML/29G X 1/2" 93
clindamycin phosphate-benzoyl

CLEMASTINE FUMARATE 26
CLEVER CHOICE COMFORT
peroxide 56

clemastine fumarate 26
EZINSULIN
clindamycin phosphate-benzoyl

CLEOCIN 11,137
SYRINGE/1ML/30G X
peroxide (refrigerate) 56

CLEOCIN PEDIATRIC
5/16" 93
clindamycin phosphate-
GRANULES 11
CLEVER CHOICE COMFORT
tretinoin 56

CLEOCIN PHOSPHATE 11
EZINSULIN SYRINGE/U- CLINDAP-T 56

100/1ML/31GX5/16" 93
CLINIMIX 2.75%/DEXTROSE

CLEOCIN-T 56
CLEVER CHOICE COMFORT
5% 124

CLEVER CHEK LANCETS


EZLANCETS 21G 78
CLINIMIX 4.25%/DEXTROSE

ULTRATHIN 78
CLEVER CHOICE COMFORT
10% 124

CLEVER CHEK LANCETS


EZLANCETS 23G 78
CLINIMIX 4.25%/DEXTROSE

ULTRATHIN 30G 78
CLEVER CHOICE COMFORT
25% 124

CLEVER CHOICE COMFORT


EZLANCETS 28G 78
CLINIMIX 4.25%/DEXTROSE

EZINSULIN PEN NEEDLES


CLEVER CHOICE COMFORT
5% 124

31GX8MM 93
EZPEN NEEDLES
CLINIMIX 5%/DEXTROSE

CLEVER CHOICE COMFORT


29GX12MM 93
25% 124

EZINSULIN
CLEVER CHOICE COMFORT
CLINIMIX E 5%/DEXTROSE

SYRINGE/0.3ML/29G X 1/2" 93
EZPEN NEEDLES
20% 124

CLEVER CHOICE COMFORT


31GX5MM 93
clobetasol propionate 59

EZINSULIN
CLEVER CHOICE COMFORT
clobetasol propionate emollient

SYRINGE/0.3ML/30G X 1/2" 93
EZPEN NEEDLES
base 60

CLEVER CHOICE COMFORT


31GX6MM 94
CLOCORTOLONE

EZINSULIN
CLEVER CHOICE COMFORT
PIVALATE 60

SYRINGE/0.3ML/30G X
EZPEN NEEDLES
CLOCORTOLONE PIVALATE

5/16" 93
31GX8MM 94
PUMP 60

CLEVER CHOICE COMFORT


CLEVER CHOICE COMFORT

EZINSULIN
CLODERM 60

EZPEN NEEDLES

SYRINGE/0.3ML/31G X
32GX4MM 94
CLODERM PUMP 60

5/16" 93
clofarabine 33

Index 7

CLOLAR 33 COMFORT ASSIST INSULIN CVS LANCETS 21G 78

clomipramine hcl 21 SYRINGE/1ML/29G X 1/2" 94 CVS LANCETS MICRO THIN


COMFORT ASSIST INSULIN 33G 78
clonazepam 16 SYRINGE/1ML/30G X CVS LANCETS MICRO-THIN
clonidine hcl 30 5/16" 94 33G 78
clonidine hcl (adhd) 2 COMFORT ASSIST INSULIN CVS LANCETS ORIGINAL 78
SYRINGE/1ML/31G X
clopidogrel bisulfate 71 5/16" 94 CVS LANCETS THIN 26G 79
clorazepate dipotassium 12 COMFORT ASSURED CVS LANCETS ULTRA THIN
CLOSERCARE 78 LANCETS MICRO THIN 30G 79
33G 78 CVS LANCETS ULTRA-THIN
clotrimazole 122 30G 79
COMFORT ASSURED
clotrimazole (topical) 57 LANCETS SUPER THIN CVS LANCING DEVICE 79
clotrimazole vaginal 137 28G 78 CVS OMEPRAZOLE 133
clotrimazole w/ COMFORT LANCETS 78 CVS ULTRA THIN
betamethasone 57 COMPLERA 42 LANCETS 79
clozapine 40 cyanocobalamin 72
COMTAN 38
CLOZAPINE ODT 40 CYCLESSA 51
CONCERTA 2
CLOZARIL 40 cyclobenzaprine hcl 123
CONDYLOX 62
COAGUCHEK LANCETS 78 CYCLOPHOSPHAMIDE 33
CONTRAVE 2
COARTEM 31 cyclophosphamide 33
COPAXONE 130
codeine sulfate 6 CYCLOSERINE 32
COPEGUS 46
CODEINE SULFATE 6 CYCLOSET 23
CORDRAN 60
COGENTIN 38 cyclosporine 121
CORDRAN TAPE 60
COLACE 73 CYCLOSPORINE
COREG 47
COLAZAL 69 MODIFIED 121
CORGARD 48 cyclosporine modified (for
COLCHICINE 71
CORTEF 53 microemulsion) 121
colchicine w/ probenecid 71 CYKLOKAPRON 72
CORTENEMA 9
COLCRYS 71 CYMBALTA 21
CORTISONE ACETATE 53
COLESTID 28 cyproheptadine hcl 27
CORTISPORIN 57
COLESTID FLAVORED 28 CYSTADANE 67
CORTISPORIN-TC 127
colestipol hcl 28 CYSTAGON 70
COSENTYX 59
COLY-MYCIN S 127 COSENTYX SENSOREADY CYSTARAN 126
COMBIGAN 124 PEN 59 cytarabine 33
COMBIVIR 42 COSMEGEN 35 CYTOMEL 132
COMETRIQ 36 COSOPT 124 CYTOTEC 134
COMFORT ASSIST INSULIN COUMADIN 15
SYRINGE 0.3ML/29G X 1/2" 94 CYTOVENE 46
COZAAR 29 D.H.E. 45 118
COMFORT ASSIST INSULIN
SYRINGE/0.3ML/30G X CREON 64 dacarbazine 37
5/16" 94 CRESEMBA 26 DACOGEN 33
COMFORT ASSIST INSULIN CRESTOR 28
SYRINGE/0.3ML/31G X dactinomycin 35
CRIXIVAN 42 DAKLINZA 46
5/16" 94
COMFORT ASSIST INSULIN cromolyn sodium 13 DALIRESP 13
SYRINGE/0.5ML/29G X 1/2" 94 cromolyn sodium (ophth) 126 danazol 9
COMFORT ASSIST INSULIN CUBICIN 10
SYRINGE/0.5ML/30G X DANTRIUM 123
5/16" 94 CUBICIN RF 10 dantrolene sodium 123
COMFORT ASSIST INSULIN CUPRIMINE 121 dapsone 11
SYRINGE/0.5ML/31G X CUTIVATE 60
5/16" 94 daptomycin 10
CUVITRU 127 DARAPRIM 31

Index 8
darifenacin hydrobromide 135 DESOXYN 1 didanosine 42
daunorubicin hcl 35 DESQUAM-X WASH 56 DIFFERIN 56
DAUNOXOME 35 desvenlafaxine succinate 21 DIFICID 74
DAYPRO 4 DETROL 135 DIFLORASONE
DDAVP 67 DETROL LA 135 DIACETATE 60
DIFLUCAN 26
DEBACTEROL 122 dexamethasone 53
diflunisal 6
decitabine 33 DEXAMETHASONE 53
digoxin 49
DELESTROGEN 68 dexamethasone 53
DELFLEX-LC/1.5% DIGOXIN 49
DEXAMETHASONE 53
DEXTROSE 122 DEXAMETHASONE digoxin 49
DEMADEX 64 INTENSOL 53 dihydroergotamine
demeclocycline hcl 131 dexamethasone sodium mesylate 118
phosphate 53 DILANTIN 18
DEMEROL 6
DEXAMETHASONE SODIUM DILANTIN INFATABS 18
DENAVIR 59 PHOSPHATE 126 DILANTIN-125 18
DEPACON 18 DEXEDRINE 1
DILAUDID 6
DEPAKENE 18 DEXILANT 133
DILAUDID-HP 6
DEPAKOTE 18 dexmethylphenidate hcl 2
diltiazem hcl 48
DEPAKOTE ER 18 dextroamphetamine sulfate 1
DILTIAZEM HCL 48
DEPEN TITRATABS 121 DEXTROSE
5%/ELECTROLYTE #48 diltiazem hcl 48
DEPO-ESTRADIOL 68
VIAFLEX 119 diltiazem hcl coated beads 48
DEPO-MEDROL 53 dextrose in lactated diltiazem hcl extended release
DEPO-PROVERA ringers 120 beads 48
CONTRACEPTIVE 53 DIAMOX 64
DEPO-SUBQ PROVERA DIOVAN 29
104 53 DIANEAL LOW DIOVAN HCT 30
CALCIUM/1.5%DEXTROSE
DEPO-TESTOSTERONE 9 122 DIPENTUM 69
DEPOCYT 33 DIANEAL PD-2/1.5% diphenhydramine hcl 26
DERMA-SMOOTHE/FS DEXTROSE 122 diphenoxylate w/ atropine 24
SCALP 60 DIASTAR EASY TEST II DIPHENOXYLATE/ATROPINE
DERMACINRX SILAPAK 60 LANCETS 30G 79 24
DERMATOP 60 DIASTAR EASY TEST DIPROLENE 60
LANCETS30G 79
DERMOTIC 127 DIASTAT ACUDIAL 16 DIPROLENE AF 60
DESCOVY 42 DIASTAT PEDIATRIC 16 dipyridamole 71
desipramine hcl 21 diazepam 12 DISALCID 6
desloratadine 27 DIAZEPAM 12 disopyramide phosphate 12
DESLORATADINE ODT 27 diazepam 12 disulfiram 129
desmopressin acetate 67 DIAZEPAM 16 DITROPAN XL 135
desmopressin acetate spray 67 DIAZEPAM RECTAL GEL 16 divalproex sodium 18
desmopressin acetate spray DIVIGEL 68
refrigerated 67 DIBENZYLINE 29
diclofenac potassium 4 DOCEFREZ 38
DESOGEN 51
diclofenac sodium 4 docetaxel 38
desogestrel & ethinyl
estradiol 51 diclofenac sodium (actinic DOCETAXEL 38
desogestrel-ethinyl estradiol keratoses) 58 docusate calcium 73
(biphasic) 51 diclofenac sodium (ophth)126 docusate sodium 73
desogestrel-ethinyl estradiol diclofenac sodium (topical) 57
(triphasic) 51 dofetilide 13
desonide 60 diclofenac w/ misoprostol 4 DOLOPHINE 6
DESOWEN 60 dicloxacillin sodium 128 donepezil hydrochloride 129
desoximetasone 60 dicyclomine hcl 133 dorzolamide hcl 126

Index 9
dorzolamide hcl-timolol DRUG MART UNIFINE E.E.S. 400 74
maleate 124 PENTIPS31GX6MM 95 E.E.S. GRANULES 74
DOVONEX 59 DRUG MART UNIFINE
PENTIPS31GX8MM 95 EASY COMFORT INSULIN
doxazosin mesylate 30 SYRINGE/0.3ML/30G X
DRUG MART UNIFINE
doxepin hcl 21 PENTIPS32GX4MM 95 5/16" 95
DOXEPIN DRUG MART UNIFINE EASY COMFORT INSULIN
HYDROCHLORIDE 58 PENTIPSPLUS 32GX4MM 95 SYRINGE/0.5ML/30G X
doxercalciferol 67 DRUG MART UNILET 5/16" 95
LANCETSSUPER THIN EASY COMFORT INSULIN
DOXIL 35 SYRINGE/0.5ML/31G X
30G 79
doxorubicin hcl 35 DRUG MART UNILET 5/16" 95
DOXORUBICIN HCL 35 LANCETSULTRA THIN EASY COMFORT INSULIN
doxorubicin hcl liposomal 35 28G 79 SYRINGE/1ML/30G X 5/16" 95
DRUG MART UNILET MICRO EASY COMFORT INSULIN
doxycycline (monohydrate) 131 SYRINGE/1ML/31G X 5/16" 95
THIN LANCETS 33G 79
doxycycline hyclate 131,132 EASY COMFORT INSULIN
DUAC 56 SYRINGE/U-100/0.5ML/30G X
DRISDOL 137 DUANE READE LANCET 1/2" 95
dronabinol 25 ALTERNATE SITE 26G 79 EASY COMFORT INSULIN
DROPLET LANCETS ULTRA DUANE READE LANCET SYRINGE/U-100/1ML/30G X
THIN 30G 79 SUPERTHIN 30G 79 1/2" 95
DROPLET LANCING DUANE READE LANCET
ULTRATHIN 28G 79 EASY COMFORT LANCETS79
DEVICE 79 EASY COMFORT LANCETS
DROPLET PEN NEEDLES DUANE READE UNIFINE
29GX12MM 94 PENTIPS 29G X 12MM 95 30G/PULL TOP 79
DROPLET PEN NEEDLES DUANE READE UNIFINE EASY COMFORT LANCETS
31GX5MM 94 PENTIPS 31G X 6MM ULTRA 30G/THIN TOP 79
DROPLET PEN NEEDLES SHORT 95 EASY COMFORT PEN
31GX6MM 94 DUANE READE UNIFINE NEEDLES31GX1/4" 95
DROPLET PEN NEEDLES PENTIPS 31G X 8MM EASY COMFORT PEN
31GX8MM 94 SHORT 95 NEEDLES31GX3/16" 95
DROPLET PEN NEEDLES 32G EASY COMFORT PEN
DUAVEE 68 NEEDLES31GX5/16" 95
X 1/4" 94 DUETACT 22 EASY COMFORT PEN
DROPLET PEN NEEDLES 32G
X 3/16" 94 DULCOLAX 73 NEEDLES32GX5/32" 95
DROPLET PEN NEEDLES 32G duloxetine hcl 21 EASY MINI EJECT LANCING
X 5/32" 94 DEVICE 79
DULOXETINE HCL 21 EASY MINI LANCING
DROPLET PEN NEEDLES
32GX4MM 94 DUPIXENT 62 DEVICE 79
DROPLET PEN NEEDLES DURAGESIC 6 EASY TOUCH 32GX5MM 95
32GX5MM 94 DUREX EXTRA EASY TOUCH 32GX6MM 95
DROPLET PEN NEEDLES SENSITIVE 75 EASY TOUCH FLIPLOCK
32GX6MM 94 DUREZOL 126 SAFETY INSULIN SYRINGE
drospirenone-ethinyl dutasteride 71 1ML/29GX1/2" 95
estradiol 51 EASY TOUCH FLIPLOCK
drospirenone-ethinyl estradiol- DYAZIDE 64 SAFETY INSULIN SYRINGE
levomefolate calcium 51 DYRENIUM 65 1ML/30GX1/2" 95
DROXIA 72 DYSPORT 124 EASY TOUCH FLIPLOCK
DRUG MART ADJUSTABLE E-Z JECT LANCETS 79 SAFETY INSULIN SYRINGE
LANCING DEVICE 79 1ML/30GX5/16" 95
DRUG MART LANCETS E-Z JECT LANCETS 21G 79 EASY TOUCH FLIPLOCK
THIN 79 E-Z JECT LANCETS SAFETY INSULIN SYRINGE
DRUG MART ON-THE-GO COLOR 79 1ML/31GX5/16" 95
LANCETS GENTLE 30G 79 E-Z JECT LANCETS SUPER EASY TOUCH INSULIN
DRUG MART UNIFINE PENTIPS THIN 30G 79 SYRINGE/0.3ML/30G X
31GX5MM 94 E-Z JECT LANCETS THIN 5/16" 95
DRUG MART UNIFINE 26G 79 EASY TOUCH INSULIN
PENTIPS29G X 12MM 95 E-ZJECT LANCETS MICRO- SYRINGE/0.3ML/31G X
THIN 33G 79 5/16" 95

Index 10
EASY TOUCH INSULIN EASY TOUCH LANCETS EASY TOUCH SAFETY
SYRINGE/0.5ML/29G X 1/2" 95 26G/PULL-TOP 79 LANCETS26G/PRESSURE
EASY TOUCH INSULIN EASY TOUCH LANCETS ACTIVATED 80
SYRINGE/0.5ML/30G X 26G/TWIST 79 EASY TOUCH SAFETY
5/16" 95 EASY TOUCH LANCETS LANCETS28G/BUTTON
EASY TOUCH INSULIN 28G/PRESSURE ACTIVATED 80
SYRINGE/1ML/30G X 5/16" 95 ACTIVATED 79 EASY TOUCH SAFETY
EASY TOUCH INSULIN EASY TOUCH LANCETS LANCETS28G/PRESSURE
SYRINGE/SAFETY/U- 28G/PULL-TOP 79 ACTIVATED 80
100/0.5ML/29G X 1/2" 95 EASY TOUCH LANCETS EASY TOUCH SHEATHLOCK
EASY TOUCH INSULIN 28G/TWIST 79 SAFETY INSULIN SYRINGE
SYRINGE/SAFETY/U- EASY TOUCH LANCETS 1ML/29GX1/2" 96
100/0.5ML/30G X 5/16" 96 30G/BUTTON-ACTIVATED EASY TOUCH SHEATHLOCK
EASY TOUCH INSULIN 79 SAFETY INSULIN SYRINGE
SYRINGE/SAFETY/U- EASY TOUCH LANCETS 1ML/30GX5/16" 96
100/1ML/29G X 1/2" 96 30G/PRESSURE EASY TOUCH SHEATHLOCK
EASY TOUCH INSULIN ACTIVATED 79 SAFETY INSULIN SYRINGE
SYRINGE/SAFETY/U- EASY TOUCH LANCETS 1ML/31GX5/16" 96
100/1ML/30G X 1/2" 96 30G/PULL-TOP 80 EASY TOUCH SHEATHLOCK
EASY TOUCH INSULIN EASY TOUCH LANCETS SAFETY SYRINGE
SYRINGE/U-100/0.3ML/30G X 30G/TWIST 80 1ML/30GX1/2" 96
1/2" 96 EASY TOUCH LANCETS EASY TWIST & CAP
EASY TOUCH INSULIN 32G/PRESSURE LANCETS 80
SYRINGE/U-100/0.5ML/27G X ACTIVATED 80 EASYTEST II LANCETS 80
1/2" 96 EASY TOUCH LANCETS
32G/PULL-TOP 80 EASYTEST LANCETS 80
EASY TOUCH INSULIN
SYRINGE/U-100/0.5ML/28G X EASY TOUCH LANCETS EC-NAPROSYN 4
1/2" 96 32G/TWIST 80 econazole nitrate 57
EASY TOUCH INSULIN EASY TOUCH LANCETS EDARBI 29
SYRINGE/U-100/0.5ML/30G X 33G/TWIST 80
1/2" 96 EASY TOUCH LANCING EDECRIN 64
EASY TOUCH INSULIN DEVICE/EJECTOR 80 EDURANT 42
SYRINGE/U-100/0.5ML/31G X EASY TOUCH PEN NEEDLE efavirenz 42
5/16" 96 30G X 5/16" 96
EASY TOUCH PEN NEEDLES EFFEXOR XR 21
EASY TOUCH INSULIN
SYRINGE/U-100/1ML/27G X 29GX1/2" 96 EFFIENT 71
1/2" 96 EASY TOUCH PEN NEEDLES EFUDEX 58
EASY TOUCH INSULIN 31GX1/4" 96 EGRIFTA 66
SYRINGE/U-100/1ML/28G X EASY TOUCH PEN NEEDLES
31GX5/16" 96 ELAPRASE 67
1/2" 96
EASY TOUCH INSULIN EASY TOUCH PEN NEEDLES ELAVIL 21
SYRINGE/U-100/1ML/29G X 32GX1/4" 96 ELDEPRYL 39
1/2" 96 EASY TOUCH PEN NEEDLES
32GX3/16" 96 ELELYSO 72
EASY TOUCH INSULIN
SYRINGE/U-100/1ML/30G X EASY TOUCH PEN NEEDLES ELESTAT 126
1/2" 96 32GX5/32" 96 ELESTRIN 68
EASY TOUCH INSULIN EASY TOUCH PEN eletriptan hydrobromide 118
SYRINGE/U-100/1ML/31G X NEEDLES/31G X 3/16" 96
EASY TOUCH SAFETY ELEXA NATURAL FEEL 75
5/16" 96
EASY TOUCH LANCETS LANCETS21G/PRESSURE ELEXA STIMULATING 75
21G/PRESSURE ACTIVATED 80 ELEXA ULTRA SENSITIVE 75
ACTIVATED 79 EASY TOUCH SAFETY
LANCETS23G/PRESSURE ELIDEL 62
EASY TOUCH LANCETS
23G/PRESSURE ACTIVATED 80 ELIGARD 34
ACTIVATED 79 EASY TOUCH SAFETY ELIMITE 63
EASY TOUCH LANCETS LANCETS26G/BUTTON ELIPHOS 70
26G/PRESSURE ACTIVATED 80
ELIQUIS 15
ACTIVATED 79
ELIQUIS STARTER PACK 15

Index 11
ELITE-THIN INSULIN ENTOCORT EC 53 EQL SUPER THIN LANCETS
SYRINGE/0.3ML/31G X ENTRESTO 49 30G 80
5/16" 96 EQL THIN LANCETS 26G 80
ELITE-THIN INSULIN EPCLUSA 46
EQL ULTRA COMFORT
SYRINGE/0.5ML/29G X 1/2" 96 EPIDUO 56 INSULINSYRINGE/0.3ML/31G X
ELITE-THIN INSULIN epinastine hcl (ophth) 126 5/16" 97
SYRINGE/0.5ML/30G X EQL ULTRA COMFORT
5/16" 96 epinephrine (anaphylaxis)137
INSULINSYRINGE/1ML/30G X
ELITE-THIN INSULIN epinephrine hcl 14 5/16" 97
SYRINGE/1ML/30G X 5/16" 96 epirubicin hcl 35 EQL ULTRA SHORT PEN
ELITE-THIN INSULIN EPIVIR 42 NEEDLES 31G X 6MM 97
SYRINGE/U-100/0.5ML/28G X EQUETRO 40
1/2" 97 EPIVIR HBV 46
ELITE-THIN INSULIN eplerenone 31 ERAXIS 25
SYRINGE/U-100/0.5ML/31G X EPOGEN 72 ERBITUX 34
5/16" 97 EPROSARTAN ergocalciferol 137
ELITE-THIN INSULIN MESYLATE 29
SYRINGE/U-100/1ML/28G X ERGOLOID MESYLATES 131
EPZICOM 42 ERGOMAR 118
1/2" 97
ELITE-THIN INSULIN EQ OMEPRAZOLE 134 ergotamine w/ caffeine 118
SYRINGE/U-100/1ML/29G X EQL COLOR LANCETS ERIVEDGE 34
1/2" 97 21G 80
ELITE-THIN INSULIN EQL COLOR LANCETS ERTACZO 57
SYRINGE/U-100/1ML/31G X MICRO THIN 33G 80 ERWINAZE 37
5/16" 97 EQL INSULIN ERY-TAB 74
ELIXOPHYLLIN 14 SYRINGE/0.3ML/29G X
1/2" 97 ERYPED 200 74
ELLA 53 EQL INSULIN ERYPED 400 74
ELLENCE 35 SYRINGE/0.3ML/30G X erythromycin (acne aid) 56
ELMIRON 70 5/16" 97 erythromycin (ophth) 125
ELOCON 60 EQL INSULIN
SYRINGE/0.3ML/31G X erythromycin base 74
EMADINE 126 5/16" 97 erythromycin ethylsuccinate 74
EMBEDA 6 EQL INSULIN ERYTHROMYCIN
EMBRACE LANCETS ULTRA SYRINGE/0.5ML/29G X ETHYLSUCCINATE 74
THIN 30G 80 1/2" 97 escitalopram oxalate 19,20
EMCYT 34 EQL INSULIN
SYRINGE/0.5ML/30G X ESGIC 6
EMEND 25 esomeprazole magnesium 134
5/16" 97
EMLA 62 EQL INSULIN estazolam 73
EMSAM 19 SYRINGE/0.5ML/31G X ESTRACE 68,137
EMTRIVA 42 5/16" 97
EQL INSULIN estradiol 68
EMVERM 9 SYRINGE/1ML/29G X 1/2" 97 estradiol vaginal 137
ENABLEX 135 EQL INSULIN estradiol valerate 68
enalapril maleate 29 SYRINGE/1ML/30G X ESTROGEL 68
enalapril maleate & 5/16" 97
EQL INSULIN ESTROPIPATE 68
hydrochlorothiazide 30
ENBREL 5 SYRINGE/1ML/31G X ESTROSTEP FE 51
5/16" 97 eszopiclone 73
ENBREL MINI 5 EQL INSULIN SYRINGE/U-
ENBREL SURECLICK 5 100/0.3ML/29G X 1/2" 97 ethacrynic acid 64
ENJUVIA 68 EQL INSULIN SYRINGE/U- ethambutol hcl 32
100/0.5ML/29G X 1/2" 97 ethosuximide 18
enoxaparin sodium 15 EQL INSULIN SYRINGE/U- ethynodiol diacet & eth
entacapone 38 100/1ML/29G X 1/2" 97 estrad 51
entecavir 46 EQL OMEPRAZOLE 134 ETIDRONATE DISODIUM 65
ENTEREG 70 EQL SHORT PEN NEEDLES etodolac 4
31G X 8MM 97

Index 12
ETOPOPHOS 38 EZ-LETS LANCETS 23G 80 FEXMID 123
ETOPOSIDE 38 EZ-LETS LANCETS 26G fexofenadine hcl 27
etoposide 38 SUPER-SOFT 80 fexofenadine-pseudoephedrine
EZ-LETS LANCETS 28G 55
EURAX 63 ULTRA-SOFT 80 FIASP 23
EVAMIST 68 EZ-LETS LANCETS 30G 80
FIASP FLEXTOUCH 23
EVISTA 66 ezetimibe 28
FIBERCON 73
EVOCLIN 56 ezetimibe-simvastatin 27
FIFTY50 LANCING DEVICE 80
EVOXAC 123 FABRAZYME 67 FIFTY50 PEN NEEDLES 31G
EXALGO 6 FACTIVE 69 X3/16" (5MM) 98
EXEL COMFORT POINT famciclovir 47 FIFTY50 PEN NEEDLES 31G
INSULIN PEN NEEDLES 29G X X5/16" (8MM) 98
12MM 97 famotidine 133
FIFTY50 PEN NEEDLES
EXEL COMFORT POINT FAMOTIDINE 31GX5MM 98
INSULIN PEN NEEDLES 31G X PREMIXED 133 FIFTY50 PEN
6MM 97 FAMVIR 47 NEEDLES/31GX8MM 98
EXEL COMFORT POINT FANAPT 40 FIFTY50 PEN
INSULIN PEN NEEDLES 31G X FANAPT TITRATION NEEDLES/32GX4MM 98
8MM 97 PACK 40 FIFTY50 PEN
EXEL COMFORT POINT FANTASY LUBRICATED 75 NEEDLES/32GX6MM 98
INSULIN SYRINGE/0.3ML/29G X FANTASY FIFTY50 SAFETY SEAL
1/2" 97 LUBRICATED/SPERMICIDE LANCETS 30G 80
EXEL COMFORT POINT 75 FIFTY50 SAFETY SEAL
INSULIN SYRINGE/0.3ML/30G X LANCETS 32G 80
5/16" 97 FARESTON 34 FIFTY50 SUPERIOR
EXEL COMFORT POINT FARXIGA 24 COMFORTINSULIN
INSULIN SYRINGE/0.5ML/28G X FASLODEX 34 SYRINGE/0.3ML/31G X
1/2" 97 FAZACLO 40 5/16" 98
EXEL COMFORT POINT FIFTY50 SUPERIOR
INSULIN SYRINGE/0.5ML/29G X FC FEMALE CONDOM 75 COMFORTINSULIN
1/2" 97 FC2 FEMALE CONDOM 75 SYRINGE/0.5ML/31G X
EXEL COMFORT POINT felbamate 18 5/16" 98
INSULIN SYRINGE/0.5ML/30G X FIFTY50 SUPERIOR
5/16" 97 FELBATOL 18 COMFORTINSULIN
EXEL COMFORT POINT FELDENE 4 SYRINGE/1ML/31G X 5/16" 98
INSULIN SYRINGE/1ML/28G X felodipine 48 FIFTY50 UNILET LANCETS
1/2" 98 FEMARA 34 33G 80
EXEL COMFORT POINT FINACEA 62
INSULIN SYRINGE/1ML/29G X FEMCAP 75
FEMCON FE 51 finasteride 71
1/2" 98
EXEL COMFORT POINT FEMHRT LOW DOSE 68 finasteride (alopecia) 62
INSULIN SYRINGE/1ML/30G X FEMRING 137 FINE 30 80
5/16" 98 FINGERSTIX LANCETS 80
EXELDERM 57 fenofibrate 28
fenofibrate micronized 28 FIORICET 6
EXELON 129 FIORICET/CODEINE 8
exemestane 34 fenoprofen calcium 4
fentanyl 6 FIORINAL 6
EXFORGE 30 FIORINAL/CODEINE #3 8
EXFORGE HCT 30 fentanyl citrate 6
FER-IN-SOL 72 FIRAZYR 71
EXJADE 24 FIRMAGON 35
EXTAVIA 130 FERRIPROX 24
ferrous fumarate-folic acid 72 FLAGYL 10
EXTRA SENSITIVE
SPERMICIDAL 75 ferrous sulfate 72 flavoxate hcl 135
EZ SMART BLOOD GLUCOSE FETZIMA 21 flecainide acetate 12
LANCETS 80 FETZIMA TITRATION FLECTOR 57
EZ-LETS LANCETS 21G 80 PACK 21 FLOMAX 71

Index 13
FLONASE ALLERGY flutamide 35 FREDS PHARMACY UNIFINE
RELIEF 123 fluticasone propionate 60,61 PENTIPS PLUS 31GX5MM 98
FLONASE ALLERGY RELIEF FREDS PHARMACY UNIFINE
CHILDRENS 123 fluticasone propionate PENTIPS PLUS 31GX8MM 98
(nasal) 123 FREDS PHARMACY UNILET
FLOVENT DISKUS 13
fluvastatin sodium 28 LANCETS SUPER THIN
FLOVENT HFA 13
FLUVIRIN 2015-2016 136 30G 80
FLOWTUSS 55 FREDS PHARMACY UNILET
FLUVIRIN 2016-2017 136
FLOXIN OTIC 127 LANCETS ULTRA THIN
FLUVIRIN 2017-2018 136 28G 80
FLOXURIDINE 33
fluvoxamine maleate 20 FREESTYLE LANCETS 80
FLUARIX QUADRIVALENT
2015-2016 136 FLUZONE HIGH-DOSE PF FREESTYLE PRECISION
FLUARIX QUADRIVALENT 2015-2016 136 INSULIN SYRINGE/U-
2016-2017 136 FLUZONE HIGH-DOSE PF 100/0.5ML/30G X 5/16" 98
FLUARIX QUADRIVALENT 2016-2017 136 FREESTYLE PRECISION
2017-2018 136 FLUZONE HIGH-DOSE PF INSULIN SYRINGE/U-
FLUBLOK QUADRIVALENT 2017-2018 136 100/0.5ML/31G X 5/16" 98
2017-2018 136 FLUZONE QUADRIVALENT FREESTYLE PRECISION
2015-2016 136 INSULIN SYRINGE/U-
FLUCELVAX 2015-2016 136 FLUZONE QUADRIVALENT
FLUCELVAX QUADRIVALENT 100/1ML/31G X 5/16" 98
2016-2017 136 FREESTYLE PRECISION
2016-2017 136 FLUZONE QUADRIVALENT
FLUCELVAX QUADRIVALENT INSULIN SYRINGES/U-
2017-2018 136 100/1ML/30G X 5/16" 98
2017-2018 136 FLUZONE SPLIT 2015-
fluconazole 26 FREESTYLE UNISTICK II
2016 136 LANCETS 80
flucytosine 25 FML 126 FROVA 118
fludarabine phosphate 33 FML FORTE 126 frovatriptan succinate 119
fludrocortisone acetate 54 FML LIQUIFILM 126 FURADANTIN 134
FLULAVAL QUADRIVALENT FOCALIN 2
2014-2015 136 furosemide 64
FOCALIN XR 2 FUROSEMIDE 64
FLULAVAL QUADRIVALENT
2015-2016 136 folic acid 72 furosemide 64
FLULAVAL QUADRIVALENT FOLOTYN 33 FUZEON 43
2016-2017 136 fondaparinux sodium 15
FLULAVAL QUADRIVALENT FYCOMPA 16
2017-2018 136 FORA LANCETS 80 gabapentin 16
FLUMADINE 47 FORA LANCING DEVICE 80 GABITRIL 18
FLUNISOLIDE 123 FORA LANCING
DEVICE/CLEARCAP 80 galantamine hydrobromide 129
fluocinolone acetonide 60 FORTAZ 51 GALANTAMINE
fluocinolone acetonide HYDROBROMIDE 129
(otic) 127 FORTEO 65 galantamine hydrobromide 129
fluocinonide 60 FOSAMAX 65 GAMMAGARD LIQUID 127
fluocinonide emulsified base 60 FOSAMAX PLUS D 65 GAMMAGARD S/D IGA LESS
fluorometholone (ophth) 126 fosamprenavir calcium 43 THAN 1MCG/ML 127
fluorouracil 33 fosinopril sodium 29 GAMMAKED 127
fluorouracil (topical) 58 fosinopril sodium & GAMUNEX-C 127
hydrochlorothiazide 30 ganciclovir sodium 46
FLUOXETINE 130 fosphenytoin sodium 18
fluoxetine hcl 20 GANIRELIX ACETATE 66
FOSRENOL 70 gatifloxacin (ophth) 125
FLUOXETINE HCL 20 FRAGMIN 15 GEL-KAM ORAL CARE
FLUPHENAZINE HCL 41 FREDS PHARMACY RINSE 122
fluphenazine hcl 41 AUTOLET LANCING gemcitabine hcl 33
flurandrenolide 60 DEVICE 80
FREDS PHARMACY UNIFINE gemfibrozil 28
flurbiprofen 4 PENTIPS PEN NEEDLES GEMZAR 33
flurbiprofen sodium 126 32GX4MM 98 GENERESS FE 51

Index 14
GENOTROPIN 66 GLOBAL INJECT EASE GLUCOPHAGE 22

GENOTROPIN MINIQUICK 66
INSULIN SYRINGE/U- GLUCOPHAGE XR 22

100/0.3ML/31G X 5/16" 99
GLUCOPRO INSULIN

gentamicin in saline 3
GLOBAL INJECT EASE

gentamicin sulfate 3
INSULIN SYRINGE/U- SYRINGE/U-100/0.3ML/30G X

100/0.5ML/28G X 1/2" 99
1/2" 99

gentamicin sulfate (ophth) 125


GLUCOPRO INSULIN

GLOBAL INJECT EASE

gentamicin sulfate (topical) 57
INSULIN SYRINGE/U- SYRINGE/U-100/0.3ML/30G X

GENTAMICIN SULFATE/0.9%
100/0.5ML/29G X 1/2" 99
5/16" 99

SODIUM CHLORIDE 3
GLOBAL INJECT EASE
GLUCOPRO INSULIN

GENTLE-LET GP LANCETS 81
INSULIN SYRINGE/U- SYRINGE/U-100/0.3ML/31G X

GENTLE-LET LANCETS
100/0.5ML/30G X 1/2" 99
5/16" 99

GENERAL PURPOSE
GLOBAL INJECT EASE
GLUCOPRO INSULIN

STYLE/FINE POINT 81
INSULIN SYRINGE/U- SYRINGE/U-100/0.5ML/30G X

GENTLE-LET LANCETS
100/0.5ML/30G X 5/16" 99
1/2" 99

GENERAL PURPOSE
GLOBAL INJECT EASE
GLUCOPRO INSULIN

STYLE/MEDIUM POINT 81
INSULIN SYRINGE/U- SYRINGE/U-100/0.5ML/30G X

GENTLE-LET LANCETS
100/0.5ML/31G X 5/16" 99
5/16" 99

SAFETY STYLE/FINE
GLOBAL INJECT EASE
GLUCOPRO INSULIN

POINT 81
INSULIN SYRINGE/U- SYRINGE/U-100/0.5ML/31G X

GENTLE-LET LANCETS
100/1ML/28G X 1/2" 99
5/16" 99

SAFETY STYLE/MEDIUM
GLOBAL INJECT EASE
GLUCOPRO INSULIN

POINT 81
INSULIN SYRINGE/U- SYRINGE/U-100/1ML/30G X

GENVOYA 43
100/1ML/29G X 1/2" 99
1/2" 99

GLOBAL INJECT EASE


GLUCOPRO INSULIN

GEODON 40
SYRINGE/U-100/1ML/30G X

INSULIN SYRINGE/U-
GILENYA 130
100/1ML/30G X 1/2" 99
5/16" 99

GILOTRIF 36
GLOBAL INJECT EASE
GLUCOPRO INSULIN

INSULIN SYRINGE/U- SYRINGE/U-100/1ML/31G X

glatiramer acetate 130


5/16" 99

GLEEVEC 36
100/1ML/30G X 5/16" 99
GLUCOSOURCE LANCET

GLOBAL INJECT EASE

GLEOSTINE 33
INSULIN SYRINGE/U- DEVICE 81

glimepiride 24
100/1ML/31G X 5/16" 99
GLUCOSOURCE LANCETS 81

glipizide 24
GLOBAL INJECT EASE
GLUCOTROL 24

LANCETS 28G 81
GLUCOTROL XL 24

glipizide-metformin hcl 22
GLOBAL INJECT EASE

GLOBAL EASE INJECT PEN
LANCETS 30G 81
GLUCOVANCE 22

NEEDLES 29GX12MM 98
GLOBAL INSULIN
glyburide 24

GLOBAL EASE INJECT PEN


SYRINGE/U-100/0.3ML/30G X
glyburide micronized 24

NEEDLES 31GX8MM 98
1/2" 99

GLOBAL EASE INJECT PEN


glyburide-metformin 22

GLOBAL INSULIN

NEEDLES 32GX4MM 98
SYRINGES/U- glycine (gu irrigant) 70

GLOBAL EASE INJECT PEN


100/0.3ML/30GX5/16" 99
glycopyrrolate 133

NEEEDLES 31GX5MM 98
GLOBAL LANCING

GLOBAL EASY GLIDE
GLYNASE 24

DEVICE 81
GLYSET 22

INSULINSYRINGE/U- GLUCAGEN

100/0.3ML/31G X 5/16" 98
DIAGNOSTIC 63
GLYXAMBI 22

GLOBAL EASY GLIDE PEN


GLUCAGEN HYPOKIT 22
GNP CLICKFINE PEN
NEEDLES 32GX4MM 98
NEEDLEUNIVERSAL/31GX5/16"
GLOBAL INJECT EASE INSULIN
GLUCAGON EMERGENCY

KIT 22
99

SYRINGE/U-100/0.3ML/29G X
GNP CLICKFINE UNIVERSAL

1/2" 98
GLUCOCOM LANCETS

28G 81
PEN NEEDLES 31GX1/4" 99

GLOBAL INJECT EASE INSULIN


GNP CLICKFINE UNIVERSAL

SYRINGE/U-100/0.3ML/30G X
GLUCOCOM LANCETS

30G 81
PEN NEEDLES 31GX5/16" 100

1/2" 98
GNP INSULIN

GLOBAL INJECT EASE INSULIN
GLUCOCOM LANCETS

33G 81
SYRINGE/0.3ML/29G X

SYRINGE/U-100/0.3ML/30G X
1/2" 100

5/16" 99
GLUCOLET 2 AUTOMATIC

LANCING DEVICE 81

Index 15

GNP INSULIN
GNP ULTRA COMFORT
H-E-B INCONTROL

SYRINGE/0.3ML/30G X
INSULIN SYRINGE/0.5ML/30G
ADVANCEDLANCING

5/16" 100
X 5/16" SHORT 100
DEVICE 81

GNP INSULIN
GNP ULTRA COMFORT
H-E-B INCONTROL LANCETS

SYRINGE/0.3ML/31G X
INSULIN SYRINGE/0.5ML/31G
MICRO THIN 33G 81

5/16" 100
X 5/16" SHORT 100
H-E-B INCONTROL LANCETS

GNP INSULIN
GNP ULTRA COMFORT
SUPER THIN 30G 81

SYRINGE/0.5ML/28G X
INSULIN SYRINGE/1ML/28G X
H-E-B INCONTROL LANCETS

1/2" 100
1/2" 100
ULTRA THIN 28G 81

GNP INSULIN
GNP ULTRA COMFORT
H-E-B INCONTROL PEN

SYRINGE/0.5ML/29G X
INSULIN SYRINGE/1ML/29G X
NEEDLES 29GX12MM 101

1/2" 100
1/2" 100
HAEMOLANCE 81

GNP INSULIN
GNP ULTRA COMFORT
HAEMOLANCE LOW FLOW

SYRINGE/0.5ML/30G X
INSULIN SYRINGE/1ML/30G X
LANCETS 81

5/16" 100
5/16" SHORT 100
HAEMOLANCE PLUS 81

GNP INSULIN
GNP ULTRA COMFORT
HAEMOLANCE PLUS HIGH

SYRINGE/0.5ML/31G X
INSULIN SYRINGE/1ML/31G X
FLOW 81

5/16" 100
5/16" SHORT 100
HAEMOLANCE PLUS LOW

GNP INSULIN
GOLYTELY 73
FLOW 81

SYRINGE/1ML/28G X 1/2" 100


GOODSENSE LANCETS
HAEMOLANCE PLUS MAX

GNP INSULIN
MICRO-THIN 33G 81
FLOW 81

SYRINGE/1ML/29G X 1/2" 100


GOODSENSE LANCETS
HAEMOLANCE PLUS

GNP INSULIN
ULTRA-THIN 30G 81
PEDIATRIC FLOW 81

SYRINGE/1ML/30G X
GOODSENSE LANCING

5/16" 100
HALAVEN 38

DEVICE 81

GNP INSULIN
GOODSENSE UNIVERSAL 1
HALCION 73

SYRINGE/1ML/31G X
MICRO THIN 33G 81
HALDOL 40

5/16" 100
GOODSENSE UNIVERSAL 1
HALDOL DECANOATE 100 40

GNP LANCETS 81
MICRO-THIN 33G 81
HALDOL DECANOATE 50 40

GNP LANCETS 21G 81


GOODSENSE UNIVERSAL

1THIN 26G 81
halobetasol propionate 61

GNP LANCETS MICRO THIN



33G 81
granisetron hcl 25
HALOG 61

GNP LANCETS SUPER THIN


GRASTEK 3
haloperidol 40

30G 81
GRIS-PEG 25
haloperidol decanoate 40

GNP LANCETS THIN 81


griseofulvin microsize 25,26
haloperidol lactate 40

GNP LANCETS THIN 26G 81


griseofulvin ultramicrosize 26
HARVONI 46

GNP MICRO THIN LANCETS


HEALTH CARE LANCING

33G 81
guanfacine hcl 30

DEVICE 81

GNP OMEPRAZOLE 134


guanfacine hcl (adhd) 2
HEALTHWISE LANCETS

GNP SUPER THIN
GUANIDINE HCL 32
30G 82

LANCETS/30G 81
GYNAZOLE-1 137
HEALTHWISE LANCING

GNP ULTRA COMFORT
PEN 82

INSULIN SYRINGE/0.3ML/29G X
GYNE-LOTRIMIN 137

HEALTHWISE MINI PEN



1/2" 100
H-E-B IN CONTROL PEN
NEEDLES 31GX6MM 101

GNP ULTRA COMFORT


NEEDLES 31GX5MM 100
HEALTHWISE PEN NEEDLES

INSULIN SYRINGE/0.3ML/30G X
H-E-B IN CONTROL PEN
29GX12MM 101

5/16" SHORT 100


NEEDLES 31GX6MM 100
HEALTHWISE SHORT PEN

GNP ULTRA COMFORT
H-E-B IN CONTROL PEN
NEEDLES 31GX8MM 101

INSULIN SYRINGE/0.3ML/31G X
NEEDLES 31GX8MM 100
HEALTHWISE UNIFINE

5/16" SHORT 100
H-E-B IN CONTROL PEN
PENTIPS PEN NEEDLES

GNP ULTRA COMFORT
NEEDLES/NANO/32GX4MM
32GX4MM 101

INSULIN SYRINGE/0.5ML/28G X
100
HEALTHY ACCENTS AUTOLET

1/2" 100
H-E-B IN CONTROL
IMPRESSION LANCING

GNP ULTRA COMFORT
UNIFINEPENTIPS PLUS
DEVICE 82

INSULIN SYRINGE/0.5ML/29G X
31GX5MM 101
HEALTHY ACCENTS UNIFINE

1/2" 100
H-E-B IN CONTROL
PENTIPS PEN NEEDLES

UNIFINEPENTIPS PLUS
29GX12MM 101

32GX4MM 101

Index 16

HEALTHY ACCENTS UNIFINE HUMULIN N 23 imipramine pamoate 21


PENTIPS PEN NEEDLES HUMULIN N KWIKPEN 23 imiquimod 62
31GX5MM 101
HEALTHY ACCENTS UNIFINE HUMULIN R 23 IMITREX 119
PENTIPS PEN NEEDLES HUMULIN R U-500 IMITREX STATDOSE
31GX6MM 101 (CONCENTRATED) 23 REFILL 119
HEALTHY ACCENTS UNIFINE HY-VEE LANCETS 82 IMITREX STATDOSE
PENTIPS PEN NEEDLES HY-VEE THIN LANCETS 82 SYSTEM 119
31GX8MM 101 IMODIUM A-D 24
HEALTHY ACCENTS UNIFINE HYCAMTIN 38
IMURAN 121
PENTIPS PEN NEEDLES HYCET 8
IN TOUCH LANCING
32GX4MM 101 hydralazine hcl 31 DEVICE 82
HEALTHY ACCENTS UNILET HYDREA 37 IN TOUCH STERILE
LANCETS SUPER THIN LANCETS30G 82
30G 82 hydrochlorothiazide 65
hydrocodone- INCRELEX 66
HECTOROL 67
acetaminophen 8 INCRUSE ELLIPTA 13
HEMANGEOL 48 hydrocodone-ibuprofen 8 indapamide 65
heparin sod (porcine) in d5w 15 hydrocortisone 54 INDERAL LA 48
heparin sodium (porcine) 15 hydrocortisone (intrarectal) 9 indomethacin 4
HEPARIN SODIUM/NACL
0.45% 15 hydrocortisone (rectal) 9 INLYTA 36
HEPSERA 46 hydrocortisone (topical) 61 INSPRA 31
HERCEPTIN 34 hydrocortisone acetate INSULIN SYRINGE/0.3ML/29G X
(rectal) 9 1" 101
HETLIOZ 73 hydrocortisone butyrate 61 INSULIN SYRINGE/0.3ML/29G X
HEXALEN 33 hydrocortisone valerate 61 1/2" 101
HIGH SENSATION hydrocortisone w/acetic INSULIN SYRINGE/0.3ML/30G X
SPERMICIDAL 75 acid 127 5/16" 101
HIPREX 134 INSULIN SYRINGE/0.3ML/31G X
hydromorphone hcl 6 5/16" 101
HIZENTRA 127 hydroxychloroquine sulfate 31 INSULIN SYRINGE/0.5ML/27G X
HM OMEPRAZOLE 134 hydroxyurea 37 1/2" 101
HUMALOG 23 hydroxyzine hcl 12 INSULIN SYRINGE/0.5ML/28G X
HUMALOG JUNIOR 1/2" 101
HYDROXYZINE INSULIN SYRINGE/0.5ML/29G X
KWIKPEN 23 PAMOATE 12
HUMALOG KWIKPEN 23 1/2" 101
hydroxyzine pamoate 12 INSULIN SYRINGE/0.5ML/30G X
HUMALOG MIX 50/50 23 HYPER-SAL 55 1/2" 101
HUMALOG MIX 50/50 INSULIN SYRINGE/0.5ML/30G X
KWIKPEN 23 HYPERSAL 55
5/16" 101
HUMALOG MIX 75/25 23 HYQVIA 128 INSULIN SYRINGE/0.5ML/31G X
HUMALOG MIX 75/25 HYZAAR 30 5/16" 101
KWIKPEN 23 ibandronate sodium 65 INSULIN SYRINGE/1ML/28G X
HUMATROPE 66 IBUDONE 8 1/2" 101
HUMATROPE COMBO INSULIN SYRINGE/1ML/29G X
ibuprofen 4 1/2" 101
PACK 66
HUMIRA 3 IDAMYCIN PFS 35 INSULIN SYRINGE/1ML/30G X
idarubicin hcl 36 5/16" 101
HUMIRA PEDIATRIC CROHNS INSULIN SYRINGE/1ML/31G X
DISEASE STARTER PACK 3 IFEX 33 5/16" 101
HUMIRA PEN 3 ifosfamide 33 INSULIN SYRINGE/U-
HUMIRA PEN-CROHNS ILEVRO 126 100/0.3ML/29G X 1/2" 101
DISEASESTARTER 3 INSULIN SYRINGE/U-
HUMIRA PEN-PSORIASIS imatinib mesylate 36 100/0.5ML/28G X 1/2" 101
STARTER 3 IMBRUVICA 36 INSULIN SYRINGE/U-
HUMULIN 70/30 23 imipenem-cilastatin 10 100/0.5ML/29G X 1/2" 101
HUMULIN 70/30 KWIKPEN 23 imipramine hcl 21 INSULIN SYRINGE/U-
100/1ML/28G X 1/2" 101

Index 17
INSULIN SYRINGE/U- INTRON A W/DILUENT 37 JULUCA 43
100/1ML/29G X 1/2" 102 INTUNIV 2 K-TAB 120
INSULIN SYRINGE/U-
100/1ML/30G X 5/16" 102 INVANZ 10 KADIAN 6
INSULIN SYRINGE/U- INVEGA 40 KALETRA 43
100/1ML/31G X 5/16" 102 INVIRASE 43 KALYDECO 131
INSULIN
SYRINGES/0.5ML/27GX1/2" INVOKAMET 22 KAMELEON LUBRICATED 75
102 INVOKANA 24 KAPVAY 2
INSULIN IONOSOL-B/DEXTROSE KAYEXALATE 122
SYRINGES/0.5ML/28GX1/2" 5% 120 KCL 0.3%/D5W/NACL
102 IONOSOL-MB/DEXTROSE 0.9% 120
INSULIN 5% 120 KEFLEX 50
SYRINGES/0.5ML/29GX1/2" IOPIDINE 125
102 KENALOG-40 54
ipratropium bromide 13
INSULIN KEPIVANCE 37
ipratropium bromide
SYRINGES/0.5ML/30GX5/16" (nasal) 123 KEPPRA 16
102 KEPPRA XR 16
INSULIN ipratropium-albuterol 14
SYRINGES/0.5ML/31GX irbesartan 29 KERYDIN 57
5/16" 102 irbesartan-hydrochlorothiazide KETEK 11
INSULIN 30 KETOCARE 63
SYRINGES/0.5ML/31GX5/16" irinotecan hcl 38
102 ketoconazole 26
irrigation solutions,
INSULIN physiological 122 ketoconazole (topical) 57
SYRINGES/1ML/27GX/1/2" ISENTRESS 43 KETONE TEST STRIPS 63
102 ketoprofen 4
INSULIN ISENTRESS HD 43
SYRINGES/1ML/27GX1/2" 102 ISOLYTE-P/DEXTROSE ketorolac tromethamine 4
INSULIN 5% 120 ketorolac tromethamine
SYRINGES/1ML/28GX1/2" 102 ISOLYTE-S 120 (ophth) 127
INSULIN ISONIAZID 32 KETOSTIX 63
SYRINGES/1ML/29GX1/2" 102 ketotifen fumarate (ophth) 127
INSULIN isoniazid 32
SYRINGES/1ML/30GX1/2" 102 ISOPTO CARPINE 125 KEVEYIS 64
INSULIN ISORDIL TITRADOSE 11 KIMONO COLORS 75
SYRINGES/1ML/31GX5/16" isosorbide dinitrate 11 KIMONO LUBRICATED 75
102 ISOSORBIDE DINITRATE KIMONO MICRO THIN PLUS
INSUPEN 29G X 12MM 102 ER 11 SPERMICIDE LUBRICATED75
INSUPEN 31G X 5MM 102 isosorbide mononitrate 11 KIMONO PLUS SPERMICIDE
INSUPEN 31G X 8MM 102 LUBRICATED 75
isotretinoin 56 KIMONO PLUS
INSUPEN 32G X 4MM 102 isradipine 49 SPERMICIDE/LUBRICATED
INSUPEN PEN NEEDLES 32G ISTODAX 36 75
X4MM 102 KIMONO PS LUBRICATED 75
INSUPEN SENSITIVE ISTODAX (OVERFILL) 36
KIMONO PS PLUS
32GX6MM 102 itraconazole 26 SPERMICIDE/LUBRICATED
INSUPEN ULTRAFIN ivermectin 9 75
29GX12MM 102 KIMONO SENSATION
INSUPEN ULTRAFIN IXEMPRA KIT 38
JADENU 24 LUBRICATED 75
30GX8MM 102 KIMONO SENSATION PLUS
INSUPEN ULTRAFIN JADENU SPRINKLE 24 SPERMICIDE LUBRICATED75
31GX6MM 102 JAKAFI 36
INSUPEN ULTRAFIN KIMONO SPECIAL 75
31GX8MM 102 JANUVIA 22 KINERET 4
INTELENCE 43 JARDIANCE 24 KINNEY LANCETS 82
INTENSE SENSATION 75 JEVTANA 38 KINNEY THIN LANCETS 82
INTRON A 37 JUBLIA 57

Index 18
KINRAY INSULIN SYRINGE KROGER LANCETS LANCETS SAFETY SEAL
PREFERRED PLUS/0.3ML/31G ULTRATHIN30G 82 26G 82
X 5/16" 102 KROGER LANCING LANCETS SAFETY SEAL
KINRAY INSULIN SYRINGE DEVICE 82 28G 82
PREFERRED PLUS/0.5ML/31G KROGER PEN NEEDLES 29G LANCETS SAFETY SEAL
X 5/16" 102 X12MM 103 30G 82
KINRAY INSULIN SYRINGE KROGER PEN NEEDLES 31G LANCETS SUPER THIN
PREFERRED PLUS/1ML/31G X X8MM 103 28G 82
5/16" 102 KROGER PEN NEEDLES LANCETS THIN 82
KINRAY INSULIN 31GX1/4" 103 LANCETS TWIST TOP 82
SYRINGE/0.5ML/29G X KUVAN 67
1/2" 102 LANCETS ULTRA FINE 82
KYLEENA 53
KITABIS PAK 3 LANCETS ULTRA THIN 82
KYPROLIS 36 LANCETS ULTRA THIN
KLARON 56 labetalol hcl 47 30G 82
KLONOPIN 16 LAC-HYDRIN 62 LANCETSBULLSEYE
KLOR-CON M15 120 LAC-HYDRIN TWELVE 62 SAFETY 82
KLS OMEPRAZOLE 134 LANCING DEVICE 82
LACRISERT 124
KMART VALU PLUS INSULIN LANCING DEVICE
SYRINGE/1ML/29G 102 lactated ringer's 120 ADJUSTABLE 82
KMART VALU PLUS INSULIN lactated ringer's LANOXIN 49
SYRINGE/1ML/30G 102 (irrigation) 122
lactic acid (ammonium lansoprazole 134
KROGER INSULIN
SYRINGE/0.3ML/29G X lactate) 62 lanthanum carbonate 70
1/2" 102 lactulose 73 LANZO 82
KROGER INSULIN lactulose (encephalopathy) 70 LASIX 64
SYRINGE/0.3ML/30G X LAMICTAL 16 LASTACAFT 127
5/16" 102 LAMICTAL CHEWABLE
KROGER INSULIN latanoprost 127
SYRINGE/0.3ML/31G X DISPERSIBLE 16 LATUDA 40
5/16" 103 LAMICTAL ODT 16 LEADER ADVANCED LANCING
KROGER INSULIN LAMISIL 26 DEVICE 82
SYRINGE/0.5ML/29G X lamivudine 43 LEADER INSULIN
1/2" 103 lamivudine (hbv) 46 SYRINGE/0.3ML/29G X
KROGER INSULIN 1/2" 103
SYRINGE/0.5ML/30G X lamivudine-zidovudine 43 LEADER INSULIN
5/16" 103 lamotrigine 16,17 SYRINGE/0.3ML/30G X
KROGER INSULIN LANCET DEVICE 5/16" 103
SYRINGE/0.5ML/31G X ADJUSTABLE 82 LEADER INSULIN
5/16" 103 LANCET DEVICE WITH SYRINGE/0.3ML/31G X
KROGER INSULIN EJECTOR 82 5/16" 103
SYRINGE/1ML/29G X 1/2" 103 LANCETS 82 LEADER INSULIN
KROGER INSULIN LANCETS 26G TWIST SYRINGE/0.5ML/28G X
SYRINGE/1ML/30G X TOP 82 1/2" 103
5/16" 103 LEADER INSULIN
KROGER INSULIN LANCETS 28G 82
SYRINGE/0.5ML/29G X
SYRINGE/1ML/31G X LANCETS 30G 82 1/2" 103
5/16" 103 LANCETS 30G TWIST LEADER INSULIN
KROGER LANCETS 82 TOP 82 SYRINGE/0.5ML/30G X
KROGER LANCETS 21G 82 LANCETS 30G/TWIST 5/16" 103
TOP 82 LEADER INSULIN
KROGER LANCETS MICRO LANCETS 31G TWIST
THIN33G 82 SYRINGE/0.5ML/31G X
TOP 82 5/16" 103
KROGER LANCETS SUPER LANCETS 33G UNIVERSAL
THIN 82 LEADER INSULIN
DESIGN 82 SYRINGE/1ML/28G X 1/2" 103
KROGER LANCETS THIN 82 LANCETS MICRO THIN LEADER INSULIN
KROGER LANCETS THIN 33G 82 SYRINGE/1ML/29G X 1/2" 103
26G 82 LANCETS SAFETY SEAL
21G 82

Index 19
LEADER INSULIN levonorgestrel-ethinyl estradiol LITETOUCH INSULIN
SYRINGE/1ML/30G X (91-day) 51 SYRINGE/0.3ML/30G X
5/16" 103 levonorgestrel-ethinyl estradiol 5/16" 103
LEADER INSULIN (continuous) 52 LITETOUCH INSULIN
SYRINGE/1ML/31G X LEVORPHANOL SYRINGE/0.3ML/31G X
5/16" 103 TARTRATE 6 5/16" 103
LEADER UNIFINE PENTIPS LEVOTHYROXINE LITETOUCH INSULIN
PLUS/MINI/31GX3/16" 103 SODIUM 132 SYRINGE/0.5ML/30G X
LEADER UNIFINE PENTIPS levothyroxine sodium 132 5/16" 103
PLUS/SHORT/31GX5/16" 103 LEXAPRO 20 LITETOUCH INSULIN
LEADER UNIFINE SYRINGE/0.5ML/31G X
PENTIPS/MINI/31GX3/16" 103 LEXIVA 43 5/16" 104
LEADER UNIFINE LIALDA 69 LITETOUCH INSULIN
PENTIPS/NANO/32GX5/32" LIBERTY MEDICAL LANCETS SYRINGE/1ML/30G X
103 30G 83 5/16" 104
LEADER UNIFINE LIBERTY MINI LANCING LITETOUCH INSULIN
PENTIPS/PLUS/32GX5/32" DEVICE 83 SYRINGE/U-100/0.5ML/28G X
103 LIBRAX 133 1/2" 104
leflunomide 5 lidocaine 62 LITETOUCH INSULIN
LENVIMA 10 MG DAILY SYRINGE/U-100/0.5ML/29G X
lidocaine hcl 62 1/2" 104
DOSE 36
LENVIMA 14 MG DAILY LIDOCAINE HCL 122 LITETOUCH INSULIN
DOSE 36 lidocaine hcl (local SYRINGE/U-100/1ML/28G X
LENVIMA 20 MG DAILY anesth.) 74 1/2" 104
DOSE 36 lidocaine hcl (mouth- LITETOUCH INSULIN
LENVIMA 24 MG DAILY throat) 122 SYRINGE/U-100/1ML/29G X
DOSE 36 lidocaine-prilocaine 62 1/2" 104
LETAIRIS 49 LIDODERM 62 LITETOUCH INSULIN
SYRINGE/U-100/1ML/31G X
letrozole 35 LIFESCAN UNISTIK 2 DEEP 5/16" 104
leucovorin calcium 38 PENETRATION 83 LITETOUCH LANCETS MICRO
LIFESCAN UNISTIK II THIN 33G 83
LEUCOVORIN CALCIUM 38 LANCETS 83
leucovorin calcium 38 LITETOUCH PEN NEEDLES
LILETTA 53 29GX12.7MM 104
LEUKERAN 33 LINCOCIN 11 LITETOUCH PEN NEEDLES
LEUKINE 72 lincomycin hcl 11 31G X 6MM 104
leuprolide acetate 35 LITETOUCH PEN NEEDLES
LINDANE 63 31GX8MM SHORT 104
levalbuterol hcl 14 lindane 63 LITHIUM 40
LEVALBUTEROL TARTRATE linezolid 11
HFA 14 lithium carbonate 39
LEVAQUIN 69 LINZESS 70 LITHIUM CARBONATE 39
LEVEMIR 23 liothyronine sodium 132 lithium carbonate 39
LEVEMIR FLEXTOUCH 23 LIPITOR 28 LITHOBID 40
levetiracetam 17 lisinopril 29 LIVALO 28
lisinopril & LIVE BETTER ADVANCED
levobunolol hcl 124 hydrochlorothiazide 30 LANCING DEVICE 83
levocetirizine dihydrochloride27 LITE TOUCH LANCETS 83 LIVE BETTER LANCET
levofloxacin 69 LITE TOUCH LANCING SUPERTHIN 30G 83
levofloxacin (ophth) 125 DEVICE 83 LIVE BETTER LANCET
levofloxacin in d5w 69 LITE TOUCH LANCING ULTRATHIN 28G 83
PEN 83 LIVE BETTER PEN NEEDLES
levonorgestrel & eth LITE TOUCH PEN 29G X 12MM 104
estradiol 51 NEEDLES/31G X 3/16" 103 LIVE BETTER PEN NEEDLES
levonorgestrel (emergency LITETOUCH INSULIN 31G X 12MM 104
oc) 53 SYRINGE/0.3ML/29G X LIVE BETTER PEN NEEDLES
levonorgestrel-eth estradiol 1/2" 103 31G X 6MM 104
(triphasic) 51
LO LOESTRIN FE 52

Index 20
LOCOID 61 LUNESTA 73 MARINOL 25
LODINE 4 LUPANETA PACK 66 MARPLAN 19
LODOSYN 38 LUPRON DEPOT (1- MATULANE 37
LOESTRIN 1.5/30-21 52 MONTH) 35 MAVIK 29
LUPRON DEPOT (3-
LOESTRIN 1/20-21 52 MONTH) 35 MAVYRET 46
LOESTRIN FE 1.5/30 52 LUPRON DEPOT (4- MAXALT 119
LOESTRIN FE 1/20 52 MONTH) 35 MAXALT-MLT 119
LUPRON DEPOT (6- MAXI-COMFORT INSULIN
LOFIBRA 28 MONTH) 35
LOMOTIL 24 SYRINGE/U-
LUPRON DEPOT-PED (1- 100/0.5ML/28GX1/2" 104
LONGS INSULIN MONTH) 66 MAXI-COMFORT INSULIN
SYRINGE/0.5ML/31G X LUPRON DEPOT-PED (3- SYRINGE/U-100/1ML/28GX1/2"
5/16" 104 MONTH) 66 104
LONGS LANCETS LUXIQ 61
STANDARD 83 MAXIDEX 126
LUZU 58 MAXIPIME 51
LONGS LANCETS THIN 83
LYNPARZA 36 MAXITROL 126
LONGS LANCETS ULTRA
THIN 83 LYRICA 17 MAXX LUBRICATED 75
loperamide hcl 24 LYSODREN 35 MAXX PLUS SPERMICIDE
LOPID 28 LYSTEDA 72 LUBRICATED 75
lopinavir-ritonavir 43 MACROBID 134 MAXZIDE 64
LOPRESSOR 48 MACRODANTIN 135 MAXZIDE-25 64
LOPROX 58 mafenide acetate 59 meclizine hcl 25
LOPROX SHAMPOO 58 MAGELLAN INSULIN SAFETY MECLOFENAMATE SODIUM 5
SYRINGE/U-100/0.3ML/29G X MEDIC INSULIN
loratadine 27 1/2" 104 SYRINGE/0.3ML/30G X
loratadine & MAGELLAN INSULIN SAFETY 5/16" 104
pseudoephedrine 55 SYRINGE/U-100/0.3ML/30G X MEDIC INSULIN
lorazepam 12 5/16" 104 SYRINGE/0.5ML/30G X
LORTAB 8 MAGELLAN INSULIN SAFETY 5/16" 104
losartan potassium 29 SYRINGE/U-100/0.5ML/29G X MEDICHOICE PRE-SET
losartan potassium & 1/2" 104 SAFETY LANCET DUAL
MAGELLAN INSULIN SAFETY USE 83
hydrochlorothiazide 30 SYRINGE/U-100/0.5ML/30G X
LOSEASONIQUE 52 MEDICHOICE PRE-SET
5/16" 104 SAFETY LANCET LOW
LOTEMAX 126 MAGELLAN INSULIN SAFETY FLOW 83
LOTENSIN 29 SYRINGE/U-100/1ML/29G X MEDICHOICE PRE-SET
LOTENSIN HCT 30 1/2" 104 SAFETY LANCET MEDIUM
MAGELLAN INSULIN SAFETY FLOW 83
LOTREL 30 SYRINGE/U-100/1ML/30G X MEDICHOICE PRE-SET
LOTRIMIN AF 58 5/16" 104 SAFETY LANCET MODERATE
LOTRIMIN AF FOR HER 58 magnesium sulfate 120 FLOW 83
LOTRIMIN AF JOCK ITCH 58 MAGNESIUM SULFATE 120 MEDICHOICE SAFETY
MALARONE 31 LANCETEXTRA 83
LOTRIMIN ULTRA 58 MEDICHOICE SAFETY
LOTRISONE 58 malathion 63 LANCETNORMAL 83
LOTRONEX 70 MAPROTILINE HCL 19 MEDICINE SHOPPE PEN
MARATHON MEDICAL NEEDLES 29G X 12MM 104
lovastatin 28 MEDICINE SHOPPE PEN
PENTIPS29GX12MM 104
LOVAZA 27 MARATHON MEDICAL NEEDLES 31G X 6MM 104
LOVENOX 15 PENTIPS31GX5MM 104 MEDICINE SHOPPE PEN
loxapine succinate 40 MARATHON MEDICAL NEEDLES 31G X 8MM 105
PENTIPS31GX8MM 104 MEDISENSE THIN
LUMIGAN 127 MARATHON MEDICAL LANCETS 83
LUMIZYME 67 PENTIPS32GX4MM 104 MEDLANCE PLUS EXTRA
LANCETS 21G 83

Index 21
MEDLANCE PLUS MENACTRA 135 METHYLIN 2
LANCETS 83 MENEST 68 methylphenidate hcl 2
MEDLANCE PLUS LANCETS
LITE 25G 83 MENOMUNE-A/C/Y/W-135 METHYLPHENIDATE HCL
MEDLANCE PLUS LITE 135 ER 2
LANCETS 25G 83 MENOSTAR 68 methylprednisolone 54
MEDLANCE PLUS SPECIAL MENTAX 58 methylprednisolone acetate 54
LANCETS 0.8MM 83 MENVEO 135 methylprednisolone sod
MEDLANCE PLUS SUPERLITE succ 54
30G 83 meperidine hcl 7
METIPRANOLOL 124
MEDLANCE PLUS SUPERLITE MEPERIDINE HCL 7
30G/COMFORT MAX 83 metoclopramide hcl 69
meperidine hcl 7
MEDLANCE PLUS UNIVERSAL metolazone 65
meprobamate 12
LANCETS 21G 83 metoprolol succinate 48
MEDLANCE PLUS/LITE MEPRON 10
metoprolol tartrate 48
25G 83 mercaptopurine 33
MEDLANCE/EXTRA 83 METROCREAM 62
meropenem 10
MEDLANCE/LITE 83 METROGEL 62
MERREM 10
MEDLANCE/UNIVERSAL 83 METROGEL-VAGINAL 137
mesalamine 69,70
MEDROL 54 METROLOTION 62
MESTINON 32
MEDROL DOSEPAK 54 metronidazole 10
MESTINON TIMESPAN 32
medroxyprogesterone metronidazole (topical) 62
METADATE CD 2
acetate 129 METAPROTERENOL metronidazole vaginal 137
medroxyprogesterone acetate SULFATE 14 MEVACOR 28
(contraceptive) 53
metaxalone 123 mexiletine hcl 12
mefenamic acid 5
metformin hcl 22 MIACALCIN 65
mefloquine hcl 32
methadone hcl 7 MICARDIS 29
MEFLOQUINE HCL 32
METHADONE HCL 7 MICARDIS HCT 30
MEGACE ES 129
methadone hcl 7 MICONAZOLE 3 137
MEGACE ORAL 35
METHADONE HCL 7 MICRO-K 120
megestrol acetate 35
megestrol acetate methadone hcl 7 MICROLET LANCETS 84
(appetite) 129 METHADONE HCL 7 MICROLET NEXT 84
MEIJER COLOR LANCETS methadone hcl 7 MICROTAINER SAFETY FLOW
UNIVERSAL 33G 83 METHADOSE 7 LANCET/STERILE/SINGLE-USE
MEIJER LANCETS 83 84
METHADOSE SUGAR-
MEIJER LANCETS THIN 83 FREE 7 MICROZIDE 65
MEIJER LANCETS methamphetamine hcl 1 midodrine hcl 137
UNIVERSAL21G 83 methazolamide 64 miglitol 22
MEIJER LANCETS
UNIVERSAL30G 83 methenamine hippurate 135 MIGRANAL 118
MEIJER LANCETS methimazole 132 MILLIPRED 54
UNIVERSAL33G 83 METHITEST 9 MILLIPRED DP 54
MEIJER PEN NEEDLES 29G MINASTRIN 24 FE 52
X12MM 105 methocarbamol 123
MEIJER PEN NEEDLES 31G METHOTREXATE MINI LANCING DEVICE 84
X6MM 105 SODIUM 34 MINIPRESS 30
MEIJER PEN NEEDLES 31G methotrexate sodium 34 MINIVELLE 68
X8MM 105 methoxsalen rapid 59
MEIJER SUPER THIN MINOCIN 132
methscopolamine minocycline hcl 132
LANCETS 83 bromide 133
meloxicam 5 METHYCLOTHIAZIDE 65 minoxidil 31
melphalan 33 methyldopa 30 MIRAPEX 39
melphalan hcl 33 METHYLDOPATE HCL 30 MIRCERA 72
memantine hcl 129 MIRCETTE 52

Index 22
MIRENA 53 MONOJECT INSULIN MONOJECT ULTRA COMFORT
mirtazapine 19 SYRINGE/PERM INSULIN SYRINGE/0.5ML/28G X
NEEDLE/1ML/28G X 1/2" 105 1/2" 106
MIRVASO 63 MONOJECT INSULIN MONOJECT ULTRA COMFORT
misoprostol 134 SYRINGE/PERM NEEDLE/U- INSULIN SYRINGE/0.5ML/29G X
mitomycin 36 100/0.5ML/28G X 1/2" 105 1/2" 106
MONOJECT INSULIN MONOJECT ULTRA COMFORT
mitoxantrone hcl 36 SYRINGE/SAFETY/PERM INSULIN SYRINGE/0.5ML/30G X
MM INSULIN SYRINGE/U- NEEDLE/0.3ML/29G X 5/16" 106
100/0.3ML/30G X 5/16" 105 1/2" 105 MONOJECT ULTRA COMFORT
MM INSULIN SYRINGE/U- MONOJECT INSULIN INSULIN SYRINGE/0.5ML/31G X
100/0.3ML/31G X 5/16" 105 SYRINGE/SAFETY/PERM 5/16" 106
MM INSULIN SYRINGE/U- NEEDLE/0.3ML/29GX1/2" MONOJECT ULTRA COMFORT
100/1/2ML/30G X 5/16" 105 105 INSULIN SYRINGE/1ML/28G X
MM INSULIN SYRINGE/U- MONOJECT INSULIN 1/2" 106
100/1/2ML/31G X 5/16" 105 SYRINGE/SAFETY/PERM MONOJECT ULTRA COMFORT
MM INSULIN SYRINGE/U- NEEDLE/0.5ML/29G X INSULIN SYRINGE/1ML/29G X
100/1ML/30G X 5/16" 105 1/2" 105 1/2" 106
MM INSULIN SYRINGE/U- MONOJECT INSULIN MONOJECT ULTRA COMFORT
100/1ML/31G X 5/16" 105 SYRINGE/SAFETY/PERM INSULIN SYRINGE/1ML/30G X
MM LANCING DEVICE 84 NEEDLE/1ML/29G X 1/2" 105 5/16" 106
MM PEN NEEDLES 31G X MONOJECT INSULIN MONOLET LANCETS 84
1/4" 105 SYRINGE/SOFTPACK/1ML/27
MM PEN NEEDLES 31G X MONOLET OPD LANCETS 84
G X 1/2" 105 MONOLETTOR SAFETY
3/16" 105 MONOJECT INSULIN
MM PEN NEEDLES 31G X LANCETS 84
SYRINGE/SOFTPACK/U-
5/16" 105 100/0.5ML/28G X 1/2" 105 montelukast sodium 13
MM PEN NEEDLES 32G X MONOJECT INSULIN MONUROL 135
5/32" 105 SYRINGE/U-100/0.3ML/30G X MOORE MED MONOJECT
MM TWIST LANCETS 84 5/16" 105 INSULIN SYRINGE/U-
MOBIC 5 MONOJECT INSULIN 100/0.5ML/28G X 1/2" 106
modafinil 3 SYRINGE/U-100/0.5ML/28G X MOORE MED MONOJECT
MODERIBA 1200 DOSE 1/2" 105 INSULIN SYRINGE/U-
MONOJECT INSULIN 100/0.5ML/29G X 1/2" 106
PACK 46 SYRINGE/U-100/0.5ML/30G X MOORE MED MONOJECT
MODERIBA 800 DOSE
PACK 46 5/16" 105 INSULIN SYRINGE/U-
MONOJECT INSULIN 100/1ML/28G X 1/2" 106
MODICON 52 SYRINGE/U-100/1ML/28G X MOORE MED MONOJECT
moexipril hcl 29 1/2" 106 INSULIN SYRINGE/U-
mometasone furoate 61 MONOJECT INSULIN 100/1ML/29G X 1/2" 106
mometasone furoate SYRINGE/U-100/1ML/30G X morphine sulfate 7
(nasal) 124 5/16" 106 MORPHINE SULFATE 7
MONISTAT SOOTHING CARE MONOJECT INSULIN
SYRINGEREGULAR LUER morphine sulfate 7
ITCH RELIEF 61
MONODOX 132 TIP/SOFTPACK/1ML 106 MOTOFEN 24
MONOJECT ULTRA MOVIPREP 73
MONOJECT INSULIN COMFORT INSULIN
SYRINGE/1ML 105 SYRINGE/0.3ML/29G X MOXEZA 125
MONOJECT INSULIN moxifloxacin hcl 69
SYRINGE/1ML/31G X 1/2" 106
MONOJECT ULTRA moxifloxacin hcl (ophth) 125
5/16" 105 COMFORT INSULIN
MONOJECT INSULIN moxifloxacin hcl in sodium
SYRINGE/DETACH SYRINGE/0.3ML/30G X chloride 69
NEEDLE/1ML/25G X 5/8" 105 5/16" 106 MOZOBIL 72
MONOJECT INSULIN MONOJECT ULTRA
COMFORT INSULIN MS CONTIN 7
SYRINGE/DETACH MS INSULIN
NEEDLE/1ML/27G X 1/2" 105 SYRINGE/0.3ML/31G X
5/16" 106 SYRINGE/0.3ML/31G X
5/16" 106

Index 23
MS INSULIN NASONEX 124 NICORETTE STARTER
SYRINGE/0.5ML/31G X NATACYN 125 KIT 131
5/16" 106 nicotine 131
MS INSULIN SYRINGE/1ML/31G NATAZIA 52
nicotine polacrilex 131
X 5/16" 106 nateglinide 24
NICOTINE TRANSDERMAL
MULTAQ 13 NATROBA 63 SYSTEM 131
MULTI-LANCET DEVICE 84 NATURE-THROID 132 NICOTROL INHALER 131
mupirocin 57 NAVELBINE 38 NICOTROL NS 131
mupirocin calcium (topical) 57 NEBUPENT 10 nifedipine 49
MUSTARGEN 33 NEBUSAL 55 NILANDRON 35
MYALEPT 67 NECON 1/50-28 52 nilutamide 35
MYAMBUTOL 32 NECON 10/11-28 52 nimodipine 49
MYCAMINE 25 NEFAZODONE HCL 20 NINLARO 36
MYCOBUTIN 32 nefazodone hcl 20 NIPENT 37
mycophenolate mofetil 121 NEO-SYNALAR 57 nisoldipine 49
mycophenolate mofetil hcl 121 neomycin sulfate 3 NISOLDIPINE ER 49
mycophenolate sodium 121 neomycin-bacitracin zn- NITRO-BID 11
MYDRIACYL 124 polymyxin 125
neomycin-polymy- NITRO-DUR 11
MYFORTIC 121 dexameth 126 nitrofurantoin 135
MYGLUCOHEALTH MGH neomycin-polymyxin-hc nitrofurantoin macrocrystal 135
SOFTLANCE LANCETS (otic) 127 nitrofurantoin monohyd
30G 84 NEOMYCIN/POLYMYXIN/HYD macro 135
MYLERAN 33 ROCORTISONE 126 nitroglycerin 11
MYRBETRIQ 135 NEORAL 121
NITROGLYCERIN 12
MYSOLINE 17 NEPTAZANE 64
nitroglycerin 12
nabumetone 5 NESINA 22
NITROSTAT 12
nadolol 48 NETGROUP LANCETS 84
nizatidine 133
nafcillin sodium 129 NEULASTA 72
NIZATIDINE 133
naftifine hcl 58 NEULASTA ONPRO KIT 72
NIZORAL 58
NAFTIN 58 NEUPOGEN 72
NOR-QD 53
NAGLAZYME 67 NEUPRO 39
NORCO 8
nalbuphine hcl 9 NEURONTIN 17
NORDITROPIN FLEXPRO 66
naloxone hcl 24 NEVANAC 127
norethin acet & estrad-fe 52
naltrexone hcl 24 NEVIRAPINE 43
norethindrone & eth estradiol52
NAMENDA 129 nevirapine 43 norethindrone & ethinyl estradiol-
NAMENDA TITRATION NEXAVAR 36 fe 52
PAK 129 NEXIUM 134 norethindrone
NAPHAZOLINE HCL 125 NEXIUM 24HR 134 (contraceptive) 53
NAPROSYN 5 norethindrone acet & eth
NEXPLANON 53 estra 52
NAPROXEN 5 niacin 137 norethindrone acetate 129
naproxen 5 niacin (antihyperlipidemic) 28 norethindrone acetate-ethinyl
naproxen sodium 5 NIACIN TR 137 estradiol 68
naratriptan hcl 119 norethindrone acetate-ethinyl
niacinamide 137 estradiol-fe 52
NARCAN 24 NIASPAN 28 norethindrone-eth estradiol
NARDIL 19 nicardipine hcl 49 (triphasic) 52
NASACORT ALLERGY norgestimate-ethinyl
24HR 124 NICODERM CQ 131
estradiol 52
NASACORT ALLERGY 24HR NICORETTE 131 norgestimate-ethinyl estradiol
CHILDRENS 124 NICORETTE MINI 131 (triphasic) 52

Index 24
norgestrel & ethinyl estradiol 52 NUVIGIL 3 ONETOUCH DELICA LANCETS
NORINYL 1+35 52 nystatin 26 EXTRA FINE 33G 84
ONETOUCH DELICA LANCETS
NORINYL 1+50 52 nystatin (mouth-throat) 122 FINE 30G 84
NORMOSOL-M IN D5W 120 nystatin (topical) 58 ONETOUCH DELICA LANCING
NORMOSOL-R 120 nystatin-triamcinolone 58 DEVICE 84
ONETOUCH FINEPOINT
NORPACE 12 OBREDON 55 LANCETS 84
NORPRAMIN 21 octreotide acetate 67 ONETOUCH ULTRASOFT
nortriptyline hcl 21 OCUFEN 127 LANCETS 84
NORTRIPTYLINE HCL 21 OCUFLOX 125 ONFI 16
NORVASC 49 ODEFSEY 44 ONGLYZA 23
NORVIR 44 ODOMZO 34 OPANA 7
NOVA MAX PLUS KETONE OFLOXACIN 69 OPSUMIT 50
TESTSTRIPS 63 ofloxacin 69 ORAP 131
NOVA SAFETY LANCETS ORAPRED ODT 54
23G 84 ofloxacin (ophth) 125
NOVA SAFETY LANCETS ofloxacin (otic) 127 ORENCIA 5
28G 84 OGESTREL 52 ORENITRAM 49
NOVA SUREFLEX ORFADIN 67
LANCETS 84 olanzapine 40
NOVA SUREFLEX LANCING olmesartan medoxomil 29 orphenadrine citrate 123
DEVICE 84 olmesartan medoxomil- ORTHO MICRONOR 53
NOVAREL 66 amlodipine-hydrochlorothiazide ORTHO TRI-CYCLEN 52
NOVOFINE 30GX8MM 106 31 ORTHO TRI-CYCLEN LO 52
olmesartan medoxomil-
NOVOFINE 32GX6MM 106 hydrochlorothiazide 31 ORTHO-CYCLEN 52
NOVOFINE AUTOCOVER olopatadine hcl 127 ORTHO-NOVUM 1/35 52
30GX8MM 106 ORTHO-NOVUM 7/7/7 52
NOVOFINE PLUS olopatadine hcl (nasal) 123
32GX4MM 106 OLUX 61 oseltamivir phosphate 47
NOVOLIN 70/30 23 omega-3-acid ethyl esters 27 OSMOPREP 73
NOVOLIN 70/30 RELION 23 omeprazole 134 OSPHENA 66
NOVOLIN N 23 OMEPRAZOLE 134 OTEZLA 5
NOVOLIN N RELION 23 omeprazole magnesium 134 OTOVEL 127
NOVOLIN R 23 omeprazole-sodium OVCON-35 52
NOVOLIN R RELION 23 bicarbonate 134 OVIDE 63
OMNIFLEX DIAPHRAGM 75 oxacillin sodium 129
NOVOLOG 23
OMNIPRED 126 oxaliplatin 33
NOVOLOG FLEXPEN 23
OMNITROPE 66 OXANDRIN 9
NOVOLOG MIX 70/30 23
NOVOLOG MIX 70/30 ON CALL LANCETS 84 oxandrolone 9
PREFILLED FLEXPEN 23 ON CALL LANCING
DEVICE 84 oxaprozin 5
NOVOLOG PENFILL 23 oxazepam 12
ON CALL PLUS LANCETS84
NOVOTWIST 30GX8MM 106 oxcarbazepine 17
ON CALL PLUS LANCING
NOVOTWIST 32GX5MM 106 DEVICE 84 oxiconazole nitrate 58
NOXAFIL 26 ONCASPAR 37 OXISTAT 58
NPLATE 72 ondansetron 25 OXSORALEN 62
NUCYNTA 7 ondansetron hcl 25 OXSORALEN ULTRA 59
NUCYNTA ER 7 ONETOUCH CLUB LANCETS oxybutynin chloride 135
NUEDEXTA 131 FINE POINT 84
ONETOUCH COMBO oxycodone hcl 7
NULOJIX 121 PACK 84 OXYCODONE HCL ER 7
NUTROPIN AQ NUSPIN 10 66 oxycodone w/ acetaminophen 8
NUVARING 53

Index 25
OXYCODONE/ACETAMINOPHE PEG-INTRON REDIPEN PAK PENTIPS 31G X 5MM 107
N 8 4 46 PENTIPS 31G X 8MM 107
OXYCODONE/IBUPROFEN 8 PEGANONE 18
PENTIPS 31GX5MM 107
OXYCONTIN 7 PEGASYS 46
PENTIPS 31GX6MM 107
oxymorphone hcl 7 PEGASYS PROCLICK 46
PENTIPS 31GX8MM 107
OXYMORPHONE PEGINTRON 46
HYDROCHLORIDE ER 7 PENTIPS 32G X 4MM 107
PEN NEEDLES 29G X
paclitaxel 38 12MM 107 PENTIPS 32GX4MM 107
PACLITAXEL 38 PEN NEEDLES pentoxifylline 71
paliperidone 40 29GX1/2" 107 PEPCID 133
PEN NEEDLES PEPCID AC MAXIMUM
PAMELOR 21 30GX5/16" 107 STRENGTH 133
pamidronate disodium 65 PEN NEEDLES
30GX8MM 107 PERCOCET 8
PAMIDRONATE DISODIUM 65
PEN NEEDLES 31G X 1/4" PERFECT LANCETS 30G 84
pamidronate disodium 65 SHORT 107 PERFECT PRESSURE
PAMINE 133 PEN NEEDLES 31G X ACTIVATED SAFETY LANCETS
PAMINE FORTE 133 3/16" 107 28G 84
PANCREAZE 64 PEN NEEDLES 31G X PERIDEX 122
5MM 107 perindopril erbumine 29
PANOXYL-4 CREAMY PEN NEEDLES 31G X
WASH 56 6MM 107 PERJETA 34
PANRETIN 58 PEN NEEDLES 31G X permethrin 63
pantoprazole sodium 134 8MM 107 perphenazine 41
PARAGARD INTRAUTERINE PEN NEEDLES PERPHENAZINE/AMITRIPTYLIN
COPPER CONTRACEPTIVE 31GX5/16" 107 E 129
T380A 53 PEN NEEDLES 31GX6MM
(1/4") 107 PERSANTINE 71
parenteral electrolytes 120
PEN NEEDLES PFIZERPEN 128
paricalcitol 67 31GX8MM 107 PFIZERPEN-G 128
PARLODEL 39 PEN NEEDLES 31GX8MM PHARMACIST CHOICE ULTRA
PARNATE 19 (5/16") 107 THIN LANCETS 84
PEN NEEDLES 32G X PHARMACIST CHOICE ULTRA
paromomycin sulfate 3 4MM 107
paroxetine hcl 20 THIN LANCETS 28G 84
PEN NEEDLES 32G X PHARMACIST CHOICE ULTRA
PASER 32 5MM 107 THIN LANCETS 30G 84
PATADAY 127 PEN NEEDLES 32G X PHARMACIST CHOICE ULTRA
6MM 107 THIN LANCETS 31G 84
PATANASE 123 PEN NEEDLES PHARMACIST CHOICE ULTRA
PATANOL 127 32GX4MM 107 THIN LANCETS 33G 84
PAXIL 20 penicillin g potassium 128 PHARMACY COUNTER
PAXIL CR 20 PENICILLIN G POTASSIUM IN LANCETS 84
PC LANCETS SUPER THIN ISO-OSMOTIC phenazopyridine hcl 71
30G 84 DEXTROSE 128 phendimetrazine tartrate 1
PC UNIFINE PENTIPS 29G PENICILLIN G
PROCAINE 128 phenelzine sulfate 19
X1/2" 106
PC UNIFINE PENTIPS 31G PENICILLIN G SODIUM 128 PHENERGAN 27
X5MM MINI 106 penicillin v potassium 128 phenobarbital 72
PC UNIFINE PENTIPS 31G PENICILLIN V PHENOBARBITAL 72
X6MM ULTRA SHORT 106 POTASSIUM 128
PC UNIFINE PENTIPS 31G phenobarbital 73
penicillin v potassium 128 phenoxybenzamine hcl 29
X8MM SHORT 107
PEDIAPRED 54 PENLAC NAIL LACQUER 58 phentermine hcl 2
peg 3350-kcl-sod bicarb-sod PENTAM 300 10 PHENYTEK 18
chloride-sod sulfate 73 pentazocine w/ naloxone 9 phenytoin 18
PEG-INTRON REDIPEN 46 PENTIPS 29G X 12MM 107 phenytoin sodium 18
PENTIPS 29GX12MM 107

Index 26
phenytoin sodium extended 18 potassium chloride prednicarbate 61
PHOSLYRA 70 microencapsulated crystals prednisolone 54
er 120 prednisolone acetate
PHOSPHOLINE IODIDE 125 POTASSIUM
PHOTOFRIN 37 CHLORIDE/DEXTROSE 120 (ophth) 126
POTASSIUM PREDNISOLONE SODIUM
PICATO 58 PHOSPHATE 54
CHLORIDE/DEXTROSE/LACT prednisolone sodium
pilocarpine hcl 125 ATED RINGERS 120
pilocarpine hcl (oral) 123 potassium citrate phosphate 54
PREDNISOLONE SODIUM
pimozide 131 (alkalinizer) 70 PHOSPHATE 126
pindolol 48 POTASSIUM
PHOSPHATES 120 PREDNISONE 54
pioglitazone hcl 23 potassium phosphates 120 prednisone 54
pioglitazone hcl-glimepiride 22 POTIGA 17 PREDNISONE 54
pioglitazone hcl-metformin PREFERRED PLUS INSULIN
hcl 22 PRADAXA 15
pramipexole SYRINGE/U-100/0.3ML/29G X
piperacillin sodium-tazobactam 1/2" 107
sodium 128 dihydrochloride 39 PREFERRED PLUS INSULIN
PIPERACILLIN/TAZOBACTAM PRANDIN 24 SYRINGE/U-100/0.3ML/30G X
128 prasugrel hcl 71 5/16" 107
piroxicam 5 PRAVACHOL 28 PREFERRED PLUS INSULIN
PLAN B ONE-STEP 53 pravastatin sodium 28 SYRINGE/U-100/0.5ML/28G X
PLAQUENIL 32 1/2" 107
prazosin hcl 30 PREFERRED PLUS INSULIN
PLASMA-LYTE A 120 PRECISION SURE-DOSE SYRINGE/U-100/0.5ML/29G X
PLASMA-LYTE-148 120 INSULIN SYRINGE/0.3ML/30G 1/2" 108
PLASMA-LYTE-56/D5W 120 X 5/16" 107 PREFERRED PLUS INSULIN
PRECISION SURE-DOSE SYRINGE/U-100/0.5ML/30G X
PLAVIX 71 INSULIN SYRINGE/0.5ML/28G 5/16" 108
PLEGRIDY 130 X 1/2" 107 PREFERRED PLUS INSULIN
PLEGRIDY STARTER PRECISION SURE-DOSE SYRINGE/U-100/1ML/28G X
PACK 130 INSULIN SYRINGE/0.5ML/29G 1/2" 108
PNEUMOVAX 23 135 X 1/2" 107 PREFERRED PLUS INSULIN
PNEUMOVAX 23/1 DOSE 135 PRECISION SURE-DOSE SYRINGE/U-100/1ML/29G X
INSULIN SYRINGE/0.5ML/30G 1/2" 108
podofilox 62 X 3/8" 107 PREFERRED PLUS INSULIN
polymyxin b sulfate 11 PRECISION SURE-DOSE SYRINGE/U-100/1ML/30G X
polymyxin b-trimethoprim 125 INSULIN SYRINGE/1ML/28G X 5/16" 108
1/2" 107 PREFERRED PLUS LANCETS
POLYTRIM 125 PRECISION SURE-DOSE COLORED 21G 84
POMALYST 35 PLUSINSULIN PREFERRED PLUS LANCETS
PONSTEL 5 SYRINGE/0.3ML/29G X SUPER THIN 30G 85
potassium acetate 120 1/2" 107 PREFERRED PLUS LANCETS
PRECISION SURE-DOSE THIN 26G 85
POTASSIUM ACETATE 120 PLUSINSULIN PREFERRED PLUS UNIFINE
potassium bicarb & chloride120 SYRINGE/1ML/29G X PENTIPS 29G X 12MM 108
potassium bicarbonate 120 1/2" 107 PREFERRED PLUS UNIFINE
potassium chloride 120,121 PRECISION THIN PENTIPS 31G X 6MM ULTRA
LANCETS 84 SHORT 108
POTASSIUM CHLORIDE 121 PRECISION THINS GP PREFERRED PLUS UNIFINE
potassium chloride 121 LANCET 84 PENTIPS 31G X 8MM
POTASSIUM CHLORIDE PRECISION ULTRA SHORT 108
ER 120 LANCET 84 PREFERRED PLUS UNIFINE
potassium chloride in PRECISION XTRA 63 PENTIPS 32GX4MM 108
dextrose 120 PRECOSE 22 PREFERRED PLUS UNIFINE
potassium chloride in dextrose & PENTIPS/MINI/31GX5MM 108
sodium chloride 120 PRED FORTE 126 PREGNYL W/DILUENT
potassium chloride in nacl 120 PRED MILD 126 BENZYLALCOHOL/NACL 66

Index 27
PREMARIN 68 procainamide hcl 12 PRUDOXIN 58

PREMIUM CONDOMS PROCARDIA 49 PSORCON 61

LUBRICATED 75 PROCARDIA XL 49 PSS SELECT GP LANCETS 85


PREMPHASE 68 PSS SELECT SAFETY
prochlorperazine 41
PREMPRO 68 LANCETS 85
prochlorperazine maleate 41
PREPOPIK 73 PTS PANELS KETONE
PROCRIT 72 TEST 63
PRESSURE ACTIVATED
SAFETYLANCET 21G 85 PROCTOCORT 9 PULMICORT 13
PREVACID 134 PRODIGY INSULIN PULMICORT FLEXHALER 13
SYRING/U-100/0.3ML/31G X
PREVACID 24HR 134 5/16" 108 PULMOZYME 131
PREVNAR 13 135 PRODIGY INSULIN PUSH BUTTON SAFETY
PREZISTA 44 SYRINGE/1/2ML/31G X LANCETS 21G 85
5/16" 108 PUSH BUTTON SAFETY
PRIFTIN 32 LANCETS 28G 85
PRODIGY INSULIN
PRILOSEC 134 SYRINGE/1ML/28G X PX ADVANCED LANCING
PRILOSEC OTC 134 1/2" 108 DEVICE 85
PRODIGY LANCING PX EXTRA SHORT PEN
PRIMAQUINE PHOSPHATE 32 NEEDLES 31GX6MM 108
PRIMAXIN IV 10 DEVICE 85
PRODIGY PRESSURE PX INSULIN SYRINGE/U-
PRIMAXIN IV ADD- ACTIVATED SAFETY 100/0.3ML/30G X 1/2" 108
VANTAGE 10 LANCETS 85 PX INSULIN SYRINGE/U-
primidone 17 PRODIGY SAFETY 100/0.3ML/31G X 5/16" 108
PRINIVIL 29 LANCETS 85 PX INSULIN SYRINGE/U-
PRODIGY TWIST TOP 100/0.5ML/30G X 1/2" 108
PRISTIQ 21 PX INSULIN SYRINGE/U-
PRO COMFORT INSULIN LANCETS 85
100/0.5ML/31G X 5/16" 108
SYRINGES/0.5ML/30G X progesterone micronized 129 PX INSULIN SYRINGE/U-
1/2" 108 PROGLYCEM 22 100/1ML/30G X 1/2" 108
PRO COMFORT INSULIN PROGRAF 122 PX INSULIN SYRINGE/U-
SYRINGES/0.5ML/30G X PROLASTIN-C 131 100/1ML/31G X 5/16" 108
5/16" 108 PX LANCET AUTO
PRO COMFORT INSULIN PROLEUKIN 37 INJECTOR 85
SYRINGES/0.5ML/31G X PROLIA 65 PX LANCETS ULTRA THIN 85
5/16" 108 PROMACTA 72 PX LANCETS ULTRA THIN
PRO COMFORT INSULIN 28G 85
SYRINGES/1ML/30G X promethazine hcl 27
PX MINI PEN NEEDLES
1/2" 108 PROMETRIUM 129 31GX5MM 109
PRO COMFORT INSULIN propafenone hcl 12 PX OMEPRAZOLE 134
SYRINGES/1ML/30G X proparacaine hcl 125
5/16" 108 PX PEN NEEDLE
PRO COMFORT INSULIN PROPECIA 62 29GX12MM 109
SYRINGES/1ML/31G X propranolol hcl 48 PX PEN NEEDLE
5/16" 108 31GX8MM 109
PROPRANOLOL HCL 48 PX SHORTLENGTH PEN
PRO COMFORT LANCETS
30G 85 propranolol hcl 48 NEEDLES/31GX8MM 109
PRO COMFORT LANCETS propylthiouracil 132 pyrazinamide 32
31G 85 PROSCAR 71 PYRIDIUM 71
PRO COMFORT PEN PROTONIX 134 pyridostigmine bromide 32
NEEDLES/31G X 8MM 108 QC ADVANCED LANCING
PRO COMFORT PEN PROTOPIC 62
DEVICE 85
NEEDLES/32G X 4MM 108 protriptyline hcl 21
PRO COMFORT PEN QC LANCETS SUPER THIN 85
PROVENTIL HFA 14
NEEDLES/32G X 5MM 108 QC LANCETS ULTRA THIN 85
PRO COMFORT PEN PROVERA 129 QC PEN NEEDLES 29G X
NEEDLES/32G X 6MM 108 PROVIGIL 3 12MM 109
PROAIR HFA 14 PROZAC 20 QC PEN NEEDLES 31G X
probenecid 71 PROZAC WEEKLY 20 6MM 109

Index 28
QC PEN NEEDLES 31G X RAZADYNE ER 129 RELION INSULIN SYRINGE/U-
8MM 109 READYLANCE SAFETY 100/0.3ML/31G X 5/16" 109
QC UNIFINE PENTIPS LANCETS/21G/2.2MM 85 RELION INSULIN SYRINGE/U-
32GX4MM 109 READYLANCE SAFETY 100/0.5ML/29G X 1/2" 109
QC UNILET LANCETS LANCETS/23G/1.8MM 85 RELION INSULIN SYRINGE/U-
28G/ULTRA THIN 85 READYLANCE SAFETY 100/0.5ML/30G X 5/16" 109
QC UNILET LANCETS LANCETS/26G/1.8MM 85 RELION INSULIN SYRINGE/U-
33G/MICRO THIN 85 READYLANCE SAFETY 100/0.5ML/31G X 5/16" 109
QUALAQUIN 32 LANCETS/28G/1.8MM 85 RELION INSULIN SYRINGE/U-
QUESTRAN 28 READYLANCE SAFETY 100/1ML/30G X 5/16" 109
LANCETS/30G/1.6MM 85 RELION INSULIN SYRINGE/U-
QUESTRAN LIGHT 28 100/1ML/31G X 15/64" 109
REALITY INSULIN
quetiapine fumarate 41 SYRINGE/U-100/0.5ML/28G X RELION INSULIN SYRINGE/U-
quinapril hcl 29 1/2" 109 100/1ML/31G X 5/16" 109
quinapril-hydrochlorothiazide REALITY INSULIN RELION KETONE 63
31 SYRINGE/U-100/0.5ML/29G X RELION KETONE TEST
QUINIDINE SULFATE 12 1/2" 109 STRIPS 63
REALITY INSULIN RELION LANCETS MICRO-
QUINIDINE SULFATE ER 12 SYRINGE/U-100/1ML/28G X THIN33G 85
quinine sulfate 32 1/2" 109 RELION LANCETS STANDARD
QVAR 13 REALITY INSULIN 21G 85
QVAR REDIHALER 14 SYRINGE/U-100/1ML/29G X RELION LANCETS THIN
1/2" 109 26G 85
RA E-ZJECT COLOR RELION LANCETS ULTRA-
LANCETSMICRO-THIN 33G 85 REALITY LANCETS 85
REALITY LATEX THIN30G 85
RA E-ZJECT LANCETS 28G85 RELION LANCING DEVICE 86
RA E-ZJECT LANCETS THIN CONDOMS/LUBRICATED 75
REALITY LATEX/ULTRA RELION MINI PEN NEEDLES
26G 85 31GX6MM 109
RA E-ZJECT LANCETS THIN TEXTURED 75
REALITY LATEX/ULTRA RELION PEN NEEDLES
28G 85 29GX12MM 109
RA E-ZJECT LANCETS THIN 75
REALITY TRIGGER RELION PEN NEEDLES
ULTRATHIN 30G 85 31GX6MM 109
RA INSULIN LANCETS 85
REBETOL 46 RELION PEN NEEDLES
SYRINGE/0.5ML/29G X 31GX8MM 109
1/2" 109 REBIF 130 RELION PEN NEEDLES
RA INSULIN SYRINGE/1ML/29G REBIF REBIDOSE 130 32GX4MM 110
X 1/2" 109 REBIF REBIDOSE RELION SHORT PEN
RA INSULIN SYRINGE/U- TITRATIONPACK 130 NEEDLES31GX8MM 110
100/0.5ML/30G X 5/16" 109 REBIF TITRATION PACK130 RELION ULTRA THIN
RA INSULIN SYRINGE/U-100/1 LANCETS30G 86
ML/30G X 5/16" 109 RECLAST 65
RELION ULTRA THIN PLUS
RA LANCING DEVICE 85 RECTIV 9 LANCETS 32G 86
RA OMEPRAZOLE 134 REGLAN 69 RELION ULTRA THIN PLUS
RA PEN NEEDLES 31G X REGRANEX 63 LANCETS 33G 86
5MM3/16" 109 RELENZA DISKHALER 47 RELISTOR 70
RA PEN NEEDLES 31G X RELPAX 119
RELION 2-IN-1 LANCING
8MM5/16" 109 REMERON 19
DEVICE 25G 85
rabeprazole sodium 134 RELION 2-IN-1 LANCING REMERON SOLTAB 19
raloxifene hcl 66 DEVICE 30G 85
RELION INSULIN SYRINGE REMICADE 70
ramipril 29
1ML/31GX15/64" 109 REMODULIN 49
RANEXA 11 RELION INSULIN SYRINGE/U- RENAGEL 70
ranitidine hcl 133 00/1ML/29G X 1/2" 109 RENVELA 70
RAPAFLO 71 RELION INSULIN SYRINGE/U-
100/0.3ML/29G X 1/2" 109 REOPRO 71
RAPAMUNE 122
RELION INSULIN SYRINGE/U- repaglinide 24
rasagiline mesylate 39 100/0.3ML/30G X 5/16" 109 REPAGLINIDE/METFORMIN
RAZADYNE 129 HYDROCHLORIDE 22

Index 29
REPATHA 29 risperidone 40 SAFETY INSULIN SYRINGES
REPATHA SURECLICK 29 RITALIN 3 1ML/27GX1/2" 110
SAFETY INSULIN SYRINGES
REPREXAIN 8 RITALIN LA 3 1ML/29GX1/2" 110
REQUIP 39 ritonavir 44 SAFETY INSULIN SYRINGES
REQUIP XL 39 RITUXAN 34 1ML/30GX1/2" 110
SAFETY LANCET
RESCRIPTOR 44 rivastigmine tartrate 129 21G/PRESSURE
RESCULA 127 rizatriptan benzoate 119 ACTIVATED 86
RESECTISOL 70 ROBAXIN 123 SAFETY LANCET
RESERPINE 30 ROBAXIN-750 123 28G/PRESSURE
ACTIVATED 86
RESTASIS 125 ROBINUL 133 SAFETY LANCETS 86
RESTASIS MULTIDOSE 125 ROBINUL FORTE 133 SAFETY LANCETS 21G 86
RESTORIL 73 ROCALTROL 67 SAFETY LANCETS 28G 86
RETIN-A 56 ROMIDEPSIN 36 SAFETY LET LANCETS 86
RETIN-A MICRO 56 ropinirole hydrochloride 39 SAFETY SEAL LANCETS
RETIN-A MICRO PUMP 57 rosuvastatin calcium 28 28G 86
RETROVIR 44 ROXICODONE 7 SAFETY SEAL LANCETS
30G 86
RETROVIR IV INFUSION 44 ROZEREM 73 SAFETY-GLIDE INSULIN
REVATIO 50 RYTHMOL 12 SYRINGE/0.3ML/29G X
REVLIMID 121 RYTHMOL SR 12 1/2" 110
REXALL LANCETS ULTRA SABRIL 18 SAFYRAL 52
THIN 86 SAFE-T-LANCE LOW FLOW SAIZEN 66
REXULTI 41 25G 86 SAIZEN CLICK.EASY 66
REYATAZ 44 SAFE-T-LANCE NORMAL SAIZENPREP
RHEUMATREX 4 FLOW21G 86 RECONSTITUTIONKIT 66
SAFE-T-LANCE PLUS SALAGEN 123
RHINOCORT AQUA 124 SAFETYLANCET HIGH
RIBASPHERE 46 FLOW 86 salsalate 6
RIBASPHERE RIBAPAK 46 SAFE-T-LANCE PLUS SAMSCA 68
SAFETYLANCET LOW SANDIMMUNE 122
ribavirin (hepatitis c) 46 FLOW 86
RIDAURA 4 SAFE-T-LANCE PLUS SANDOSTATIN 67
rifabutin 32 SAFETYLANCET NORMAL SANTYL 62
RIFADIN 32 FLOW 86 SAPHRIS 41
SAFESNAP INSULIN SAPS HEALTH TWIST TOP
RIFAMATE 32 SYRINGE/0.3ML/30G X LANCETS 30G 86
rifampin 32 5/16" 110 SAPSCARE TWIST TOP
RIFATER 32 SAFESNAP INSULIN LANCETS 30G 86
RIGHTEST GD500 LANCING SYRINGE/0.5ML/29G X SAVELLA 130
DEVICE 86 1/2" 110 SAVELLA TITRATION
RIGHTEST GL300 SAFESNAP INSULIN
SYRINGE/0.5ML/30G X PACK 130
LANCETS 86 SB INSULIN SYRINGE/U-
RILUTEK 124 5/16" 110 100/0.5ML/29G X 1/2" 110
SAFESNAP INSULIN SB INSULIN SYRINGE/U-
riluzole 124 SYRINGE/1ML/28G X 100/0.5ML/30G X 5/16" 110
rimantadine hydrochloride 47 1/2" 110 SB INSULIN SYRINGE/U-
ringer's 120 SAFESNAP INSULIN 100/1ML/29G X 1/2" 110
SYRINGE/1ML/29G X SB INSULIN SYRINGE/U-
ringer's irrigation 122 1/2" 110
risedronate sodium 65 100/1ML/30G X 5/16" 110
SAFETY INSULIN SYRINGES SB INSULIN SYRINGE/U-
RISPERDAL 40 0.5ML/29GX1/2" 110 100/1ML/31G X 5/16" 110
RISPERDAL CONSTA 40 SAFETY INSULIN SYRINGES
0.5ML/30GX5/16" 110 SB LANCETS THIN 86
RISPERDAL M-TAB 40 SB LANCETS ULTRA THIN 86

Index 30
SB OMEPRAZOLE 134 SHOPKO UNIFINE PENTIPS SMART SENSE THIN
SCHNUCKS INSULIN PLUS PEN LANCETSUNIVERSAL 26G 86
SYRINGEULTI-FINE/U- NEEDLES/SHORT/REMOVR/3 SMARTEST LANCETS 28G 87
100/0.5ML/29G X 1/2" 110 1GX8MM 110 sodium acetate 119
SCHNUCKS INSULIN SHOPKO UNILET LANCETS
SUPER THIN 30G 86 sodium chloride 121
SYRINGEULTI-FINE/U-
100/0.5ML/30G X 5/16" 110 SHOPKO UNILET LANCETS sodium chloride (gu irrigant) 70
scopolamine 25 ULTRA THIN 28G 86 sodium chloride (inhalant) 55
SHUR-SEAL 136 sodium citrate & citric acid 70
SEASONIQUE 52
SIDE BUTTON SAFETY
SECTRAL 48 LANCET21G 86 sodium phenylbutyrate 67
SELECT-LITE LANCING SIGNIFOR 68 sodium polystyrene
DEVICE 86 sulfonate 122
sildenafil citrate 49 SOLARAZE 58
selegiline hcl 39
sildenafil citrate (pulmonary
selenium sulfide 59 hypertension) 50 SOLU-CORTEF 54
SELZENTRY 44 SILVADENE 59 SOLU-MEDROL 54
SENSIPAR 67 silver sulfadiazine 59 SOLUS V2 LANCING
DEVICE 87
SEREVENT DISKUS 14 SIMBRINZA 125 SOLUS V2 PRESSURE
SEROQUEL 41 SIMPLE DIAGNOSTICS ACTIVATED SAFETY LANCETS
SEROQUEL XR 41 LANCING DEVICE 86 28G 87
SEROSTIM 66 SIMPONI 3,4 SOLUS V2 TWIST LANCETS
SIMULECT 122 30G 87
sertraline hcl 20 SOMA 123
sevelamer carbonate 70 simvastatin 28
SINEMET 39 SOMATULINE DEPOT 68
SHOHLS SOLUTION
MODIFIED 70 SINEMET CR 39 SOMAVERT 66
SHOPKO AUTOLET LANCING SINGLE-LET 86 SONATA 73
DEVICE 86 SORBITOL 70
SHOPKO ON-THE-GO SINGULAIR 13
sirolimus 122 SORBITOL-MANNITOL 70
COMFORTLANCETS 30G 86
SHOPKO UNIFINE PENTIPS SIRTURO 32 SORIATANE 59
PEN SIVEXTRO 11 sotalol hcl 48
NEEDLES/MICRO/32GX4MM SOVALDI 47
110 SKELAXIN 123
SHOPKO UNIFINE PENTIPS SKLICE 63 SPECTRACEF 51
PEN NEEDLES/MINI/31GX5MM SKYLA 53 SPINOSAD 63
110 SLO-NIACIN 137 SPIRIVA HANDIHALER 13
SHOPKO UNIFINE PENTIPS SPIRIVA RESPIMAT 13
PEN SM INSULIN
NEEDLES/ORIGINAL/29GX12M SYRINGE/1ML/31G X spironolactone 65
M 110 5/16" 111 spironolactone &
SHOPKO UNIFINE PENTIPS SM MICRO THIN LANCETS hydrochlorothiazide 64
PEN 33G 86 SPORANOX 26
NEEDLES/SHORT/31GX8MM SM OMEPRAZOLE 134 SPORANOX PULSEPAK 26
110 SM TRUEDRAW LANCING
DEVICE 86 SPRYCEL 36
SHOPKO UNIFINE PENTIPS
PLUS PEN SMART DIABETES VANTAGE SSKI 120
NEEDLES/MICRO/REMOVR/32 LANCING DEVICE 86 STALEVO 100 39
GX4MM 110 SMART SENSE COLOR STALEVO 125 39
SHOPKO UNIFINE PENTIPS LANCETS UNIVERSAL
33G 86 STALEVO 150 39
PLUS PEN
NEEDLES/MINI/REMOVER/31G SMART SENSE STANDARD STALEVO 200 39
X5MM 110 LANCETS UNIVERSAL STALEVO 50 39
SHOPKO UNIFINE PENTIPS 21G 86 STALEVO 75 39
PLUS PEN SMART SENSE SUPER THIN
NEEDLES/REMOVER/29GX12M LANCETS UNIVERSAL stannous fluoride 122
M 110 30G 86 STARLIX 24

Index 31
stavudine 44 SURE COMFORT INSULIN SURE-FINE PEN NEEDLES
STELARA 59 SYRINGE/U-100/0.5ML/28G X 29GX1/2" 12.7MM 111
1/2" 111 SURE-FINE PEN NEEDLES
STENDRA 49 SURE COMFORT INSULIN 31GX3/16" 5MM 111
STERILANCE TL 87 SYRINGE/U-100/0.5ML/29G X SURE-FINE PEN NEEDLES
STIMATE 67 1/2" 111 31GX5/16" 8MM 111
SURE COMFORT INSULIN SURE-JECT INSULIN
STIVARGA 37 SYRINGE/U-100/0.5ML/30G X SYRINGE/U-100/0.3ML/29G X
STRATTERA 2 1/2" 111 1/2" 111
STREPTOMYCIN SULFATE 3 SURE COMFORT INSULIN SURE-JECT INSULIN
STRIBILD 44 SYRINGE/U-100/0.5ML/30G X SYRINGE/U-100/0.3ML/30G X
5/16" 111 5/16" 111
STRIVERDI RESPIMAT 14 SURE COMFORT INSULIN SURE-JECT INSULIN
STROMECTOL 9 SYRINGE/U-100/0.5ML/31G X SYRINGE/U-100/0.3ML/31G X
SUBOXONE 9 5/16 111 5/16" 112
SURE COMFORT INSULIN SURE-JECT INSULIN
SUCRAID 64 SYRINGE/U-100/0.5ML/28G X
SYRINGE/U-100/1ML/28G X
sucralfate 133 1/2" 111 1/2" 112
SULAR 49 SURE COMFORT INSULIN SURE-JECT INSULIN
sulfacetamide sodium (acne) 57 SYRINGE/U-100/1ML/29G X SYRINGE/U-100/0.5ML/29G X
sulfacetamide sodium 1/2" 111 1/2" 112
(ophth) 125 SURE COMFORT INSULIN SURE-JECT INSULIN
sulfacetamide sodium w/ SYRINGE/U-100/1ML/30G X SYRINGE/U-100/0.5ML/30G X
sulfur 57 1/2" 111 5/16" 112
SURE COMFORT INSULIN SURE-JECT INSULIN
SULFADIAZINE 131 SYRINGE/U-100/1ML/30G X SYRINGE/U-100/0.5ML/31G X
sulfamethoxazole-trimethoprim 5/16" 111 5/16" 112
10 SURE COMFORT INSULIN SURE-JECT INSULIN
SULFAMYLON 59 SYRINGE/U-100/1ML/31G X SYRINGE/U-100/1ML/28G X
sulfasalazine 70 5/16" 111 1/2" 112
sulindac 5 SURE COMFORT LANCETS SURE-JECT INSULIN
18G 87 SYRINGE/U-100/1ML/29G X
SUMADAN WASH 57 SURE COMFORT LANCETS 1/2" 112
sumatriptan 119 21G 87 SURE-JECT INSULIN
sumatriptan succinate 119 SURE COMFORT LANCETS SYRINGE/U-100/1ML/30G X
SUMATRIPTAN 23G 87 5/16" 112
SUCCINATE 119 SURE COMFORT LANCETS SURE-JECT INSULIN
sumatriptan succinate 119 28G 87 SYRINGE/U-100/1ML/31G X
SURE COMFORT LANCETS 5/16" 112
SUPER THIN LANCETS 87 30G 87 SURE-LANCE FLAT
SUPRAX 51 SURE COMFORT LANCING LANCETS 87
SUPREP BOWEL PREP KIT73 PEN 87 SURE-LANCE LANCETS
SURE COMFORT INSULIN SURE COMFORT PEN 26G 87
SYRINGE/U-100/0.3ML/29G X NEEDLES29GX1/2" SURE-LANCE THIN LANCETS
1/2" 111 12.7MM 111 28G 87
SURE COMFORT INSULIN SURE COMFORT PEN SURE-LANCE ULTRA THIN
SYRINGE/U-100/0.3ML/30G X NEEDLES30GX5/16" LANCETS 87
1/2" 111 SHORT 111 SURE-PEN 87
SURE COMFORT INSULIN SURE COMFORT PEN SURE-TOUCH LANCETS
SYRINGE/U-100/0.3ML/30G X NEEDLES31GX3/16" UNIVERSAL 87
5/16" 111 (5MM) 111 SURELITE LANCETS 87
SURE COMFORT INSULIN SURE COMFORT PEN
NEEDLES31GX5/16" SURMONTIL 21
SYRINGE/U-100/0.3ML/31G X SUSTIVA 44
5/16 111 (8MM) 111
SURE COMFORT INSULIN SURE COMFORT PEN SUTENT 37
SYRINGE/U-100/0.3ML/31G X NEEDLES32GX5/32" 111 SW OMEPRAZOLE 134
SURE COMFORT PEN
5/16" 111 NEEDLES32GX6MM 111 SYLATRON 37
SYMBICORT 14

Index 32
SYMLINPEN 120 22 TECHLITE INSULIN TERAZOL 7 137
SYMLINPEN 60 22 SYRINGEU-100/1ML/29G X terazosin hcl 30
1/2" 112
SYNALAR 61 TECHLITE INSULIN terbinafine hcl 26
SYNAREL 66 SYRINGEU-100/1ML/30G X terbutaline sulfate 14
SYNERA 62 1/2" 112 TERCONAZOLE 137
TECHLITE INSULIN
SYNJARDY 22 SYRINGEU-100/1ML/30G X terconazole vaginal 137
SYNRIBO 37 5/16" 112 TESSALON PERLES 54
SYNTHROID 132 TECHLITE INSULIN testosterone cypionate 9
SYPRINE 121 SYRINGEU-100/1ML/31G X testosterone enanthate 9
15/64" 112
TABLOID 34 TECHLITE INSULIN tetrabenazine 130
TACLONEX 61 SYRINGEU-100/1ML/31G X tetracycline hcl 132
tacrolimus 122 5/16" 112 TETRACYCLINE HCL 132
tacrolimus (topical) 62 TECHLITE LANCETS 87 TGT ADVANCED LANCING
TAFINLAR 37 TECHLITE LANCETS 30G 87 DEVICE 87
TECHLITE PEN NEEDLES TGT LANCET ALTERNATE
TAGAMET HB 133 SITE 87
29GX 12 MM 112
TALWIN 9 TECHLITE PEN NEEDLES TGT LANCET MICRO THIN
TAMIFLU 47 31GX 5MM 112 33G 87
TECHLITE PEN TGT LANCET SUPER THIN
tamoxifen citrate 35 30G 87
NEEDLES/31GX 5MM 112
tamsulosin hcl 71 TECHLITE PEN TGT LANCET THIN 23G 87
TANZEUM 23 NEEDLES/31GX 6 MM 112 TGT LANCET THIN 26G 87
TAPAZOLE 132 TECHLITE PEN TGT LANCET ULTRA THIN
TARCEVA 37 NEEDLES/31GX 8MM 112 28G 87
TECHLITE PEN TGT LANCET ULTRA THIN
TARGRETIN 37,58 NEEDLES/32GX 4MM 112 30G 87
TARKA 31 TECHLITE PEN TGT LANCING DEVICE 87
TASIGNA 37 NEEDLES/32GX 6MM 113
TEFLARO 51 TGT OMEPRAZOLE 134
TASMAR 38 THALOMID 121
TAXOTERE 38 TEGRETOL 17
TEGRETOL-XR 17 theophylline 14
tazarotene 59 THINLETS GP LANCETS 87
TAZORAC 59 TEKTURNA 31
telmisartan 29 THINLETS LANCET 87
TECFIDERA 130 thioridazine hcl 41
TECFIDERA STARTER telmisartan-amlodipine 31
PACK 130 telmisartan-hydrochlorothiazide thiotepa 33
TECHLITE AST LANCETS 87 31 thiothixene 41
TECHLITE INSULIN SYRINGEU- temazepam 73 THYMOGLOBULIN 122
100/0.3ML/29G X 1/2" 112 TEMODAR 33 THYROLAR-1 132
TECHLITE INSULIN SYRINGEU- TEMOVATE 61 THYROLAR-1/2 132
100/0.3ML/30G X 1/2" 112 TEMOVATE E 61
TECHLITE INSULIN SYRINGEU- THYROLAR-1/4 132
100/0.3ML/30G X 5/16" 112 temozolomide 33 THYROLAR-2 132
TECHLITE INSULIN SYRINGEU- TENEX 30 THYROLAR-3 132
100/0.3ML/31G X 5/16" 112 TENIPOSIDE 38
TECHLITE INSULIN SYRINGEU- tiagabine hcl 18
100/0.5ML/29G X 1/2" 112 tenofovir disoproxil TIAZAC 49
TECHLITE INSULIN SYRINGEU- fumarate 44
TIGAN 25
100/0.5ML/30G X 1/2" 112 TENORETIC 100 31
tigecycline 10
TECHLITE INSULIN SYRINGEU- TENORETIC 50 31
100/0.5ML/30G X 5/16" 112 TIGECYCLINE 10
TENORMIN 48
TECHLITE INSULIN SYRINGEU- TIKOSYN 13
100/0.5ML/31G X 5/16" 112 TEPADINA 33
TIMOLOL MALEATE 48
TERAZOL 3 137
timolol maleate (ophth) 124

Index 33
TIMOPTIC 124 TOPCARE ULTRA COMFORT TREANDA 33

TIMOPTIC-XE 124 INSULIN SYRINGE/0.5ML/30G


TRECATOR 32

X 5/16" 113

TIVICAY 44,45 TOPCARE ULTRA COMFORT


TRELSTAR 35

tizanidine hcl 123 INSULIN SYRINGE/0.5ML/31G TRELSTAR MIXJECT 35

TOBI 3 X 5/16" 113 tretinoin 57

TOPCARE ULTRA COMFORT

TOBRADEX 126 INSULIN SYRINGE/1ML/30G X


tretinoin (chemotherapy) 37

tobramycin 3 5/16" 113 tretinoin microsphere 57

TOBRAMYCIN 3 TOPCARE ULTRA COMFORT TREXALL 34

tobramycin (ophth) 125 INSULIN SYRINGE/1ML/31G X


TREZIX 8

5/16" 113

TOBRAMYCIN SULFATE 3 TOPCARE ULTRA COMFORT


TRI-NORINYL 28 52

tobramycin sulfate 3 INSULIN SYRINGE/U- triamcinolone acetonide 54


tobramycin- 100/0.3ML/29G X 1/2" 113 triamcinolone acetonide
dexamethasone 126 TOPCARE ULTRA COMFORT (mouth) 122
TOBREX 125 INSULIN SYRINGE/U- triamcinolone acetonide
TODAY SPONGE 136 100/0.5ML/29G X 1/2" 113 (nasal) 124
TOPCARE ULTRA COMFORT triamcinolone acetonide
TODAYS HEALTH ADVANCED INSULIN SYRINGE/U- (topical) 61
LANCING DEVICE 87 100/1ML/29G X 1/2" 113 triamcinolone acetonide-
TODAYS HEALTH MINI PEN TOPCO INSULIN SYRINGE/U- dimethicone-silicone 62
NEEDLES 31G X 1/4" 113 100/0.3ML/29G X 1/2" 113 triamterene &
TODAYS HEALTH ORIGINAL TOPCO INSULIN SYRINGE/U- hydrochlorothiazide 64
PEN NEEDLES 29G X 1/2" 113 100/0.5ML/28G X 1/2" 113 TRIAMTERENE/HYDROCHLOR
TODAYS HEALTH SHORT PEN TOPCO INSULIN SYRINGE/U- OTHIAZIDE 64
NEEDLES 31G X 5/16" 113 100/0.5ML/29G X 1/2" 113
TODAYS HEALTH SUPER TRIAZOLAM 73
TOPCO INSULIN SYRINGE/U- triazolam 73
THINLANCETS 30G 87 100/1ML/28G X 1/2" 113
TODAYS HEALTH ULTRA TOPCO INSULIN SYRINGE/U- TRIBENZOR 31
THINLANCETS 28G 87 100/1ML/29G X 1/2" 113 TRICOR 28
TOFRANIL 21 TOPICORT 61 TRIDESILON 62
TOLAZAMIDE 24 topiramate 17 trientine hcl 121
TOLBUTAMIDE 24 topotecan hcl 38 trifluoperazine hcl 41
tolcapone 38 TOPROL XL 48 trifluridine 125
TOLMETIN SODIUM 5 TORISEL 37 trihexyphenidyl hcl 38
tolmetin sodium 5 torsemide 64 TRILEPTAL 17
TOLMETIN SODIUM 5 TOVIAZ 135 trimethobenzamide hcl 25
tolterodine tartrate 135 TRACLEER 50 trimethoprim 10
TOPAMAX 17 TRADJENTA 23 trimipramine maleate 22
TOPAMAX SPRINKLE 17 tramadol hcl 7 TRINTELLIX 21
TOPCARE CLICKFINE
UNIVERSAL PEN EEDLES tramadol-acetaminophen 8 TRIOSTAT 132
31GX1/4" 113 trandolapril 29 TRISENOX 37
TOPCARE CLICKFINE trandolapril-verapamil hcl 31 TRISEON 57
UNIVERSAL PEN EEDLES tranexamic acid 72
31GX5/16" 113 TRIUMEQ 45
TOPCARE LANCETS MICRO- TRANSDERM-SCOP 25 TRIZIVIR 45
THIN 33G 87 TRANXENE T 12 TROJAN EXTENDED
TOPCARE ULTRA COMFORT tranylcypromine sulfate 19 PLEASURE/LUBRICATED 75
INSULIN SYRINGE/0.3ML/30G X TROJAN MAGNUM 75
5/16" 113 TRAVATAN Z 127
TROJAN MAGNUM WARM
TOPCARE ULTRA COMFORT TRAVEL LANCETS 30G 87 SENSATIONS 75
INSULIN SYRINGE/0.3ML/31G X TRAVEL LANCETS TROJAN MAGNUM XL
5/16" 113 ADVANCED 28G 87 LUBRICATED 75
trazodone hcl 20

Index 34
TROJAN PLEASURE TRUEPLUS INSULIN TRUSTEX
MESH/SPERMICIDAL 75 SYRINGE/U-100/1ML/28G X LUBRICATED/SPERMICIDE
TROJAN RIBBED 1/2" 114 76
W/SPERMICIDAL 75 TRUEPLUS INSULIN TRUSTEX
TROJAN SHARED SYRINGE/U-100/1ML/29G X LUBRICATED/SPERMICIDE
SENSATION/LUBRICATED 76 1/2" 114 EXTRA LARGE 76
TROJAN SUPRAS TRUEPLUS INSULIN TRUSTEX
SPERMICIDAL 76 SYRINGE/U-100/1ML/30G X LUBRICATED/SPERMICIDE
TROJAN TWISTED 5/16" 114 EXTRA STRENGTH 76
PLEASURE 76 TRUEPLUS INSULIN TRUSTEX NATURAL
TROJAN ULTRA SYRINGE/U-100/1ML/31G X CONDOMS
PLEASURE/LUBRICATED 76 5/16" 114 +LUBE/LUBRICATED 76
TROJAN VERY SENSITIVE TRUEPLUS LANCETS TRUSTEX WITH NONOXYNOL-
LUBRICATED 76 26G 87 9/RIBBED/STUDDED 76
TROJAN VERY SENSITIVE TRUEPLUS LANCETS TRUSTEX/RIA
SPERMICIDAL LUBRICANT 76 28G 87 LUBRICATED 76
TROJAN VERY THIN TRUEPLUS LANCETS 28G TRUSTEX/RIA LUBRICATED
LUBRICATED 76 SUPER THIN 87 SPERMICIDE 76
TROJAN VERY THIN TRUEPLUS LANCETS TRUSTEX/RIA
SPERMICIDAL LUBRICANT 76 30G 88 LUBRICATED/SPERMICIDE
TROJAN-ENZ LUBRICANT 76 TRUEPLUS LANCETS 30G 76
TROJAN-ENZ ULTRA THIN 88 TRUVADA 45
LUBRICATED 76 TRUEPLUS LANCETS TUDORZA PRESSAIR 13
TROJAN-ENZ 33G 88
W/SPERMICIDAL 76 TRUEPLUS LANCETS 33G TWYNSTA 31
tropicamide 124 MICRO THIN 88 TYBOST 45
TRUEPLUS PEN NEEDLES TYGACIL 11
trospium chloride 135 29GX12MM 114
TRUE METRIX BLOOD TRUEPLUS PEN NEEDLES TYKERB 37
GLUCOSETEST STRIPS 63 31GX5MM 114 TYLENOL/CODEINE #3 8
TRUE METRIX CONTROL TRUEPLUS PEN NEEDLES TYLENOL/CODEINE #4 8
SOLUTION LEVEL 3 87 31GX6MM 114
TRUE METRIX SELF TRUEPLUS PEN NEEDLES TYMLOS 66
MONITORING BLOOD 31GX8MM 114 TYSABRI 130
GLUCOSE STRIPS 63 TRUEPLUS PEN NEEDLES TYZEKA 47
TRUEDRAW LANCING 32GX4MM 114 TYZINE PEDIATRIC NASAL
DEVICE 87 TRUEPLUS SAFETY DROPS 124
TRUEPLUS INSULIN LANCETS 28G 88
SYRINGE/U-100/0.3ML/29G X UCERIS 9
TRUETEST BLOOD
1/2" 113 GLUCOSE TEST 63 ULESFIA 63
TRUEPLUS INSULIN TRUETEST BLOOD ULORIC 71
SYRINGE/U-100/0.3ML/30G X GLUCOSE TEST STRIPS 63 ULTI-LANCE AUTOMATIC/
5/16" 113 TRUETEST STRIPS 63 CLEAR TIP 88
TRUEPLUS INSULIN TRUETRACK BLOOD ULTICARE INSULIN SAFETY
SYRINGE/U-100/0.3ML/31G X GLUCOSE TEST 63 SYRINGE/0.5ML/29G X
5/16" 113 1/2" 114
TRUEPLUS INSULIN TRUETRACK TEST 64
ULTICARE INSULIN SAFETY
SYRINGE/U-100/0.5ML/28G X TRULICITY 23 SYRINGE/1ML/29G X 1/2" 114
1/2" 113 TRUSOPT 127 ULTICARE INSULIN
TRUEPLUS INSULIN TRUSTEX COLOR CONDOMS SYRINGE/0.3ML/29G X
SYRINGE/U-100/0.5ML/29G X + LUBE 76 1/2" 114
1/2" 113 TRUSTEX LUBRICATED 76 ULTICARE INSULIN
TRUEPLUS INSULIN TRUSTEX LUBRICATED SYRINGE/0.3ML/30G X
SYRINGE/U-100/0.5ML/30G X EXTRALARGE 76 1/2" 114
5/16" 114 TRUSTEX LUBRICATED ULTICARE INSULIN
TRUEPLUS INSULIN EXTRASTRENGTH 76 SYRINGE/0.3ML/30G X
SYRINGE/U-100/0.5ML/31G X TRUSTEX 5/16" 114
5/16" 114 LUBRICATED/RIBBED/STUDD
ED 76

Index 35
ULTICARE INSULIN ULTICARE INSULIN ULTILET INSULIN
SYRINGE/0.5ML/28G X SYRINGE/U-100/0.5ML/30G X SYRINGE/0.3ML/30G X
1/2" 114 5/16" 115 8MM 115
ULTICARE INSULIN ULTICARE INSULIN ULTILET INSULIN
SYRINGE/0.5ML/29G X SYRINGE/U-100/0.5ML/31G X SYRINGE/0.3ML/31G X
1/2" 114 5/16" 115 8MM 116
ULTICARE INSULIN ULTICARE INSULIN ULTILET INSULIN
SYRINGE/0.5ML/30G X SYRINGE/U-100/1ML/29G X SYRINGE/0.5ML/30G X
1/2" 114 1/2" 115 8MM 116
ULTICARE INSULIN ULTICARE INSULIN ULTILET INSULIN
SYRINGE/0.5ML/30G X SYRINGE/U-100/1ML/30G X SYRINGE/1ML/30G X 8MM116
5/16" 114 1/2" 115 ULTILET INSULIN
ULTICARE INSULIN ULTICARE INSULIN SYRINGE/1ML/31G X 8MM116
SYRINGE/1ML/28G X 1/2" 114 SYRINGE/U-100/1ML/30G X ULTILET INSULIN
ULTICARE INSULIN 5/16" 115 SYRINGE/SHORT/0.3ML/30G X
SYRINGE/1ML/29G X 1/2" 114 ULTICARE INSULIN 12.7MM 116
ULTICARE INSULIN SYRINGE/U-100/1ML/31G X ULTILET INSULIN
SYRINGE/1ML/30G X 1/2" 114 5/16" 115 SYRINGE/SHORT/0.3ML/30G X
ULTICARE INSULIN ULTICARE INSULIN 5/16" 116
SYRINGE/1ML/30G X SYRINGEULTRAFINE U- ULTILET INSULIN
5/16" 114 100/0.3ML/31G X 5/16" 115 SYRINGE/SHORT/0.3ML/31G X
ULTICARE INSULIN ULTICARE INSULIN 5/16" 116
SYRINGE/SHORT/0.3ML/30G X SYRINGEULTRAFINE U- ULTILET INSULIN
5/16" 114 100/0.5ML/31G X 5/16" 115 SYRINGE/SHORT/0.5ML/30G X
ULTICARE INSULIN ULTICARE INSULIN 5/16" 116
SYRINGE/SHORT/0.3ML/31G X SYRINGEULTRAFINE U- ULTILET INSULIN
5/16" 114 100/1ML/31G X 5/16" 115 SYRINGE/SHORT/0.5ML/31G X
ULTICARE INSULIN ULTICARE MICRO PEN 5/16" 116
SYRINGE/SHORT/0.5ML/30G X NEEDLES 31G X 8MM 115 ULTILET INSULIN
5/16" 114 ULTICARE MICRO PEN SYRINGE/SHORT/1ML/30G X
ULTICARE INSULIN NEEDLES 32G X 4MM 115 5/16" 116
SYRINGE/SHORT/0.5ML/31G X ULTICARE MICRO PEN ULTILET INSULIN
5/16" 114 NEEDLES/32G X 4MM 115 SYRINGE/SHORT/1ML/31G X
ULTICARE INSULIN ULTICARE MINI PEN 5/16" 116
SYRINGE/SHORT/1ML/30G X NEEDLES 31GX6MM 115 ULTILET INSULIN SYRINGE/U-
5/16" 114 ULTICARE MINI PEN 100/0.5ML/30G X 1/2" 116
ULTICARE INSULIN NEEDLES ULTI-FINE IV 115 ULTILET INSULIN SYRINGE/U-
SYRINGE/SHORT/1ML/31G X ULTICARE MINI PEN 100/1ML/30G X 1/2" 116
5/16" 114 NEEDLES/31G X 6MM 115 ULTILET LANCETS 88
ULTICARE INSULIN ULTICARE MINI PEN ULTILET LANCETS 33G 88
SYRINGE/U-100/0.3ML/29G X NEEDLES31GX6MM 115
ULTICARE ORIGINAL PEN ULTILET PEN NEEDLE
1/2" 115
ULTICARE INSULIN NEEDLES ULTI-FINE 115 29GX12.7MM 116
ULTICARE PEN NEEDLES ULTILET PEN NEEDLE
SYRINGE/U-100/0.3ML/30G X
31GX 5MM/MINI 115 31GX5MM 116
1/2" 115 ULTILET PEN NEEDLE
ULTICARE INSULIN ULTICARE PEN
NEEDLES/29GX 12.7MM 115 31GX8MM 116
SYRINGE/U-100/0.3ML/30G X ULTILET PEN NEEDLE
5/16" 115 ULTICARE SHORT PEN
NEEDLES 31GX8MM 115 32GX4MM 116
ULTICARE INSULIN ULTILET PEN NEEDLE
SYRINGE/U-100/0.3ML/31G X ULTICARE SHORT PEN
NEEDLES ULTI-FINE IV 115 32GX4MM/SHORT 116
5/16" 115 ULTILET SAFETY LANCETS
ULTICARE INSULIN ULTICARE SHORT PEN
NEEDLES/31G X 8MM 115 21G X 2.2MM 88
SYRINGE/U-100/0.5ML/29G X ULTILET SAFETY LANCETS
1/2" 115 ULTICARE THIN LANCETS
30G 88 23G 88
ULTICARE INSULIN ULTILET SHORT PEN
SYRINGE/U-100/0.5ML/30G X ULTILET CLASSIC
LANCETS 88 NEEDLES 31GX5/16" 116
1/2" 115 ULTILET SHORT PEN
NEEDLES31GX3/16" 116

Index 36
ULTIMATE FEELING 76 ULTRA-THIN II INSULIN UNILET COMFORTOUCH
ULTRA COMFORT INSULIN SYRINGE SHORT/U- LANCET 88
SYRINGE/U-100/0.3ML/30G X 100/1ML/31GX5/16" 117 UNILET EXCELITE 88
5/16" 116 ULTRA-THIN II INSULIN UNILET EXCELITE II 88
ULTRA THIN LANCETS SYRINGE/U-
100/0.3ML/29GX1/2" 117 UNILET G.P. LANCET 88
28G 88
ULTRA THIN LANCETS ULTRA-THIN II INSULIN UNILET G.P. SUPERLITE
30G 88 SYRINGE/U- LANCET 88
ULTRA-COMFORT INSULIN 100/0.5ML/29GX1/2" 117 UNILET GP 28 ULTRA THIN88
SYRINGE/U-100/0.3ML/29G X ULTRA-THIN II INSULIN UNILET LANCET 88
1/2" 116 SYRINGE/U- UNILET LANCETS MICRO-
ULTRA-COMFORT INSULIN 100/1ML/29GX1/2" 117 THIN33G 88
SYRINGE/U-100/0.3ML/30G X ULTRA-THIN II LANCETS UNILET LANCETS SUPER-
5/16" 116 28G 88 THIN30G 88
ULTRA-COMFORT INSULIN ULTRA-THIN II LANCETS UNILET LANCETS ULTRA-THIN
SYRINGE/U-100/0.3ML/31G X 30G 88 28G 88
5/16" 116 ULTRA-THIN II MINI PEN UNILET SUPERLITE
ULTRA-COMFORT INSULIN NEEEDLES/31GX3/16" 117 LANCET 88
SYRINGE/U-100/0.5ML/28G X ULTRA-THIN II PEN NEEDLES UNISTIK 3 GENTLE 88
1/2" 116 29GX1/2" 117
ULTRA-THIN II PEN UNISTIK SAFETY LANCETS
ULTRA-COMFORT INSULIN 28G 88
SYRINGE/U-100/0.5ML/29G X NEEDLES/SHORT/31GX5/16"
117 UNISTIK SAFETY LANCETS
1/2" 116 30G 88
ULTRA-COMFORT INSULIN ULTRA-THIN II SAFETY
AUTOLANCETS 26G 88 UNISTIK TOUCH SAFETY
SYRINGE/U-100/0.5ML/30G X LANCETS 21G 88
5/16" 116 ULTRABAG/DIANEAL LOW
CALCIUM/1.5% UNISTIK TOUCH SAFETY
ULTRA-COMFORT INSULIN LANCETS 23G 88
SYRINGE/U-100/0.5ML/31G X DEXTROSE 122
ULTRABAG/DIANEAL PD- UNISTIK TOUCH SAFETY
5/16" 116 LANCETS 28G 88
ULTRA-COMFORT INSULIN 2/1.5% DEXTROSE 122 UNISTIK TOUCH SAFETY
SYRINGE/U-100/1ML/28G X ULTRACET 8 LANCETS 30G 88
1/2" 116 ULTRAM 7 UNIVERSAL 1 LANCETS
ULTRA-COMFORT INSULIN ULTRAM ER 7 THIN26G 88
SYRINGE/U-100/1ML/29G X UNIVERSAL 1 LANCETS ULTRA
1/2" 116 ULTRAVATE 62
THIN 30G 88
ULTRA-COMFORT INSULIN UNASYN 128 UNIVERSAL 1
SYRINGE/U-100/1ML/30G X UNIFINE PENTIPS LANCETS/33G/MICRO-THIN
5/16" 117 29GX12MM 117 88
ULTRA-COMFORT INSULIN UNIFINE PENTIPS 31G X URECHOLINE 135
SYRINGE/U-100/1ML/31G X 3/16" 117
5/16" 117 UNIFINE PENTIPS UROCIT-K 10 70
ULTRA-THIN II AUTO 31GX5MM 117 UROXATRAL 71
LANCET 88 UNIFINE PENTIPS URSO 250 69
ULTRA-THIN II INSULIN 31GX6MM 117 URSO FORTE 69
SYRINGE SHORT/U- UNIFINE PENTIPS
100/0.3ML/30GX5/16" 117 31GX8MM 117 ursodiol 69
ULTRA-THIN II INSULIN UNIFINE PENTIPS UTIBRON NEOHALER 14
SYRINGE SHORT/U- 32GX4MM 117 UVADEX 37
100/0.3ML/31GX5/16" 117 UNIFINE PENTIPS PLUS V-R MONOJECT INSULIN
ULTRA-THIN II INSULIN 29GX12MM 117 SYRINGE/U-100/0.3ML/29G X
SYRINGE SHORT/U- UNIFINE PENTIPS PLUS 1/2" 117
100/0.5ML/30GX5/16" 117 31GX5MM 117 V-R MONOJECT INSULIN
ULTRA-THIN II INSULIN UNIFINE PENTIPS PLUS SYRINGE/U-100/0.5ML/28G X
SYRINGE SHORT/U- 31GX6MM 117 1/2" 117
100/0.5ML/31GX5/16" 117 UNIFINE PENTIPS PLUS V-R MONOJECT INSULIN
ULTRA-THIN II INSULIN 31GX8MM 117 SYRINGE/U-100/0.5ML/29G X
SYRINGE SHORT/U- UNIFINE PENTIPS PLUS
32GX4MM 117 1/2" 117
100/1ML/30GX5/16" 117

Index 37
V-R MONOJECT INSULIN VASCEPA 27 vinorelbine tartrate 38
SYRINGE/U-100/1ML/28G X VASERETIC 31 VIRACEPT 45
1/2" 117
V-R MONOJECT INSULIN VASOTEC 29 VIRAMUNE 45
SYRINGE/U-100/1ML/29G X VECAMYL 31 VIRAMUNE XR 45
1/2" 117 VECTIBIX 34 VIREAD 45
valacyclovir hcl 47 VECTICAL 59 VIROPTIC 125
VALCYTE 46 VELCADE 37 VISTARIL 12
valganciclovir hcl 46 VELPHORO 70 VISTOGARD 24
VALIUM 12 venlafaxine hcl 21 VITALET PRO LANCETS 89
valproate sodium 18 VENLAFAXINE HCL ER 21 VITALET PRO PLUS
valproic acid 18 VENTAVIS 49 LANCETS 89
valsartan 29 VITAMIN D2 137
VENTOLIN HFA 14
valsartan-hydrochlorothiazide VITEKTA 45
31 verapamil hcl 49
VITUZ 55
VALSTAR 36 VEREGEN 57
VIVELLE-DOT 68
VALTREX 47 VERELAN 49
VOLTAREN 57
VALUE HEALTH INSULIN VERELAN PM 49
SYRINGE/U-100/0.5ML/29G X VORAXAZE 38
VERIPRED 20 54
1/2" 117 voriconazole 26
VESICARE 135
VALUE HEALTH INSULIN VOSPIRE ER 14
SYRINGE/U-100/1ML/29G X VEXOL 126
VOTRIENT 37
1/2" 117 VFEND 26
VP INSULIN SYRINGE/U-
VALUE PLUS LANCETS VIAGRA 49 100/0.3ML/29G X 1/2" 118
STANDARD 21G 88 VIBATIV 10
VALUE PLUS LANCETS VPRIV 72
SUPERTHIN 30G 88 VIBRAMYCIN 132 VYTORIN 27
VALUE PLUS LANCETS THIN VICOPROFEN 8 VYVANSE 1
26G 88 VICTOZA 23 W&F LANCETS 26G 89
VALUE PLUS LANCING VIDA MIA AUTOLET
DEVICE 88 W&F LANCETS COLORED
VALUMARK LANCET SUPER LANCINGDEVICE 89 21G 89
VIDA MIA UNIFINE WALGREENS ADVANCED
THIN 30G 88 PENTIPS32GX4MM 118
VALUMARK LANCET ULTRA TRAVELLANCETS 28G 89
VIDA MIA UNIFINE WALGREENS COMFORT
THIN 28G 89 PENTIPSMINI 31GX6MM118
VALUMARK PEN NEEDLES ASSUREDLANCETS MICRO
VIDA MIA UNIFINE THIN/33G 89
29GX12MM 118 PENTIPSORIGINAL
VALUMARK PEN NEEDLES WALGREENS COMFORT
31GX 6MM 118 29GX12MM 118 ASSUREDLANCETS SUPER
VALUMARK PEN NEEDLES VIDA MIA UNILET LANCETS THIN/28G 89
31GX 8MM 118 SUPER THIN 30G 89 WALGREENS LANCETS 89
VIDA MIA UNILET LANCETS WALGREENS THIN
VANCOCIN HCL 10 ULTRA THIN 28G 89
vancomycin hcl 10 LANCETS 89
VIDA MIA UNIPFINE WALGREENS ULTRA THIN
VANISHPOINT INSULIN PENTIPSSHORT LANCETS 89
SYRINGE/0.5ML/30G X 31GX8MM 118
1/2" 118 warfarin sodium 15
VIDAZA 34
VANISHPOINT INSULIN water for irrigation, sterile 122
VIDEX EC 45
SYRINGE/0.5ML/30G X WEGMANS UNIFINE PENTIPS
5/16" 118 VIDEXPEDIATRIC 45 PLUS 32GX4MM 118
VANISHPOINT INSULIN vigabatrin 18 WEGMANS UNIFINE PENTIPS
SYRINGE/1ML/29G X 1/2" 118 VIGAMOX 125 PLUS/MINI/31GX5MM 118
VANISHPOINT INSULIN WEGMANS UNIFINE PENTIPS
SYRINGE/1ML/30G X VIIBRYD 21 PLUS/SHORT/31GX8MM 118
5/16" 118 VIIBRYD STARTER PACK 21 WEGMANS UNIFINE PENTIPS
VARUBI 25 VIMPAT 17 PLUS/ULTRA
vincristine sulfate 38 SHORT/31GX6MM 118

Index 38
WELCHOL 28 YERVOY 34 ZOLOFT 20
WELLBUTRIN 19 ZADITOR 127 zolpidem tartrate 73
WELLBUTRIN SR 19 zafirlukast 13 ZOMACTON 66
WELLBUTRIN XL 19 zaleplon 73 ZOMETA 66
WESTCORT 62 ZALTRAP 34 ZOMIG 119
WIDE-SEAL SILICONE ZANAFLEX 123 ZOMIG ZMT 119
DIAPHRAGM KIT 60 76 ZANOSAR 33 ZONALON 58
WIDE-SEAL SILICONE
DIAPHRAGM KIT 65 76 ZANTAC 133 ZONEGRAN 17
WIDE-SEAL SILICONE ZANTAC 150 MAXIMUM zonisamide 17
DIAPHRAGM KIT 70 76 STRENGTH 133 ZONTIVITY 71
WIDE-SEAL SILICONE ZARONTIN 18
DIAPHRAGM KIT 75 76 ZORBTIVE 66
ZAVESCA 72
WIDE-SEAL SILICONE ZORTRESS 122
DIAPHRAGM KIT 80 76 ZEBETA 48
ZOSTAVAX 136
WIDE-SEAL SILICONE ZEGERID 134
ZOSYN 128
DIAPHRAGM KIT 85 76 ZELBORAF 37
WIDE-SEAL SILICONE ZOVIRAX 47,59
ZEMAIRA 131
DIAPHRAGM KIT 90 76 ZYBAN 131
WIDE-SEAL SILICONE ZEMPLAR 67
ZYDELIG 37
DIAPHRAGM KIT 95 76 ZENPEP 64
ZYFLO CR 13
WP THYROID 132 ZERIT 45
ZYKADIA 37
XALATAN 127 ZESTORETIC 31
ZYLOPRIM 71
XALKORI 37 ZESTRIL 29
ZYMAXID 125
XANAX 12 ZETIA 28
ZYPREXA 41
XANAX XR 12 ZIAC 31
ZYPREXA ZYDIS 41
XARELTO 15 ZIAGEN 45
ZYRTEC ALLERGY 27
XELJANZ 4 ZIANA 57 ZYRTEC CHILDRENS
XELODA 34 zidovudine 45 ALLERGY 27
XENAZINE 130 zileuton 13 ZYRTEC-D
XEOMIN 124 ZINACEF 50 ALLERGY/CONGESTION 55
XGEVA 66 ZYTIGA 35
ZINBRYTA 130
XIFAXAN 10 ZYVOX 11
ZIOPTAN 127
XIGDUO XR 22 ziprasidone hcl 40
XODOL 8 ZIRGAN 125
XOLAIR 13 ZITHROMAX 74
XOPENEX 14 ZITHROMAX TRI-PAK 74
XOPENEX CONCENTRATE 14 ZITHROMAX Z-PAK 74
XOPENEX HFA 14 ZOCOR 28
XTANDI 35 ZOFRAN 25
XULANE 53 ZOFRAN ODT 25
XYLOCAINE 62,74 ZOHYDRO ER 7
XYLOCAINE-MPF 74 ZOLADEX 35
XYREM 129 zoledronic acid 66
XYZAL 27 ZOLEDRONIC ACID 66
XYZAL ALLERGY 24HR 27 zoledronic acid 66
XYZAL ALLERGY 24HR ZOLEDRONIC ACID 66
CHILDRENS 27
ZOLINZA 37
YASMIN 28 52
zolmitriptan 119
YAZ 53

Index 39
@
superior
FROM I healthplan.

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