PPHP Part D 1-Tier CY20



Abilify MyCiteXE "Abilify MyCite"ABILIFY MYCITE ORAL TABLET 10 MG, 15 MG, 20 MG, 30 MGQuantity Limit: 30 EA Per 30 DaysABILIFY MYCITE ORAL TABLET 2 MG, 5 MGQuantity Limit: 60 EA Per 30 DaysAbiraterone AcetateXE "Abiraterone Acetate"abiraterone acetate oral tablet 250 mgQuantity Limit: 120 EA Per 30 DaysAdefovir DipivoxilXE "Adefovir Dipivoxil"adefovir dipivoxil oral tablet 10 mgQuantity Limit: 30 EA Per 30 DaysAdempasXE "Adempas"ADEMPAS ORAL TABLET 0.5 MG, 1 MG, 1.5 MG, 2 MG, 2.5 MGQuantity Limit: 90 EA Per 30 DaysAfinitor DisperzXE "Afinitor Disperz"AFINITOR DISPERZ ORAL TABLET SOLUBLE 2 MG, 3 MGQuantity Limit: 30 EA Per 30 DaysAFINITOR DISPERZ ORAL TABLET SOLUBLE 5 MGQuantity Limit: 60 EA Per 30 DaysAfinitorXE "Afinitor"AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MGQuantity Limit: 30 EA Per 30 DaysAlbuterol Sulfate HFAXE "Albuterol Sulfate HFA"albuterol sulfate hfa inhalation aerosol solution 108 (90 base) mcg/actQuantity Limit: 17 GM Per 30 DaysAliniaXE "Alinia"ALINIA ORAL SUSPENSION RECONSTITUTED 100 MG/5MLQuantity Limit: 180 ML Per 30 DaysALINIA ORAL TABLET 500 MGQuantity Limit: 6 EA Per 30 DaysAlmotriptan MalateXE "Almotriptan Malate"almotriptan malate oral tablet 12.5 mg, 6.25 mgQuantity Limit: 12 EA Per 30 DaysAlunbrigXE "Alunbrig"ALUNBRIG ORAL TABLET 180 MGQuantity Limit: 30 EA Per 30 DaysALUNBRIG ORAL TABLET 30 MGQuantity Limit: 180 EA Per 30 DaysALUNBRIG ORAL TABLET 90 MGQuantity Limit: 60 EA Per 30 DaysALUNBRIG ORAL TABLET THERAPY PACK 90 & 180 MGQuantity Limit: 30 EA Per 30 DaysAmbrisentanXE "Ambrisentan"ambrisentan oral tablet 10 mg, 5 mgQuantity Limit: 30 EA Per 30 DaysApokynXE "Apokyn"APOKYN SUBCUTANEOUS SOLUTION CARTRIDGE 30 MG/3MLQuantity Limit: 60 ML Per 30 DaysAprepitantXE "Aprepitant"aprepitant oral capsule 125 mg, 40 mg, 80 mgQuantity Limit: 8 EA Per 30 Daysaprepitant oral capsule 80 & 125 mgQuantity Limit: 12 EA Per 30 DaysAptiomXE "Aptiom"APTIOM ORAL TABLET 200 MG, 400 MGQuantity Limit: 30 EA Per 30 DaysAPTIOM ORAL TABLET 600 MGQuantity Limit: 60 EA Per 30 DaysAPTIOM ORAL TABLET 800 MGQuantity Limit: 45 EA Per 30 DaysARIPiprazoleXE "ARIPiprazole"aripiprazole oral solution 1 mg/mlQuantity Limit: 750 ML Per 30 Daysaripiprazole oral tablet 10 mg, 15 mg, 20 mg, 30 mgQuantity Limit: 30 EA Per 30 Daysaripiprazole oral tablet 2 mg, 5 mgQuantity Limit: 60 EA Per 30 Daysaripiprazole oral tablet dispersible 10 mg, 15 mgQuantity Limit: 60 EA Per 30 DaysArmodafinilXE "Armodafinil"armodafinil oral tablet 150 mg, 200 mg, 250 mg, 50 mgQuantity Limit: 30 EA Per 30 DaysAscomp-CodeineXE "Ascomp-Codeine"ASCOMP-CODEINE ORAL CAPSULE 50-325-40-30 MGQuantity Limit: 180 EA Per 30 DaysAtomoxetine HClXE "Atomoxetine HCl"atomoxetine hcl oral capsule 10 mg, 18 mg, 25 mg, 40 mgQuantity Limit: 60 EA Per 30 Daysatomoxetine hcl oral capsule 100 mg, 60 mg, 80 mgQuantity Limit: 30 EA Per 30 DaysAustedoXE "Austedo"AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MGQuantity Limit: 120 EA Per 30 DaysBanzelXE "Banzel"BANZEL ORAL SUSPENSION 40 MG/MLQuantity Limit: 2400 ML Per 30 DaysBANZEL ORAL TABLET 200 MG, 400 MGQuantity Limit: 240 EA Per 30 DaysBaracludeXE "Baraclude"BARACLUDE ORAL SOLUTION 0.05 MG/MLQuantity Limit: 600 ML Per 30 DaysBelsomraXE "Belsomra"BELSOMRA ORAL TABLET 10 MG, 15 MG, 20 MG, 5 MGQuantity Limit: 30 EA Per 30 DaysBicalutamideXE "Bicalutamide"bicalutamide oral tablet 50 mgQuantity Limit: 30 EA Per 30 DaysBimatoprostXE "Bimatoprost"bimatoprost ophthalmic solution 0.03 %Quantity Limit: 5 ML Per 25 DaysBosentanXE "Bosentan"bosentan oral tablet 125 mg, 62.5 mgQuantity Limit: 60 EA Per 30 DaysBosulifXE "Bosulif"BOSULIF ORAL TABLET 100 MGQuantity Limit: 120 EA Per 30 DaysBOSULIF ORAL TABLET 400 MG, 500 MGQuantity Limit: 30 EA Per 30 DaysBriviactXE "Briviact"BRIVIACT ORAL SOLUTION 10 MG/MLQuantity Limit: 600 ML Per 30 DaysBRIVIACT ORAL TABLET 10 MG, 100 MG, 25 MG, 50 MG, 75 MGQuantity Limit: 60 EA Per 30 DaysBupapXE "Bupap"BUPAP ORAL TABLET 50-300 MGQuantity Limit: 180 EA Per 30 DaysButalbital-AcetaminophenXE "Butalbital-Acetaminophen"butalbital-acetaminophen oral tablet 50-325 mgQuantity Limit: 180 EA Per 30 DaysButalbital-APAP-Caff-CodXE "Butalbital-APAP-Caff-Cod"butalbital-apap-caff-cod oral capsule 50-325-40-30 mgQuantity Limit: 180 EA Per 30 DaysButalbital-APAP-CaffeineXE "Butalbital-APAP-Caffeine"butalbital-apap-caffeine oral capsule 50-300-40 mgQuantity Limit: 180 EA Per 30 Daysbutalbital-apap-caffeine oral tablet 50-325-40 mgQuantity Limit: 180 EA Per 30 DaysButalbital-ASA-Caff-CodeineXE "Butalbital-ASA-Caff-Codeine"butalbital-asa-caff-codeine oral capsule 50-325-40-30 mgQuantity Limit: 180 EA Per 30 DaysButalbital-Aspirin-CaffeineXE "Butalbital-Aspirin-Caffeine"butalbital-aspirin-caffeine oral capsule 50-325-40 mgQuantity Limit: 180 EA Per 30 DaysCalquenceXE "Calquence"CALQUENCE ORAL CAPSULE 100 MGQuantity Limit: 60 EA Per 30 DaysCaprelsaXE "Caprelsa"CAPRELSA ORAL TABLET 100 MGQuantity Limit: 60 EA Per 30 DaysCAPRELSA ORAL TABLET 300 MGQuantity Limit: 30 EA Per 30 DaysCelecoxibXE "Celecoxib"celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mgQuantity Limit: 60 EA Per 30 DaysCinacalcet HClXE "Cinacalcet HCl"cinacalcet hcl oral tablet 30 mg, 90 mgQuantity Limit: 120 EA Per 30 Dayscinacalcet hcl oral tablet 60 mgQuantity Limit: 150 EA Per 30 DaysCloBAZamXE "CloBAZam"clobazam oral tablet 10 mg, 20 mgQuantity Limit: 60 EA Per 30 DaysCometriq (100 mg Daily Dose)XE "Cometriq (100 mg Daily Dose)"COMETRIQ (100 MG DAILY DOSE) ORAL KIT 1 X 80 & 1 X 20 MGQuantity Limit: 60 EA Per 30 DaysCometriq (140 mg Daily Dose)XE "Cometriq (140 mg Daily Dose)"COMETRIQ (140 MG DAILY DOSE) ORAL KIT 1 X 80 & 3 X 20 MGQuantity Limit: 120 EA Per 30 DaysCometriq (60 mg Daily Dose)XE "Cometriq (60 mg Daily Dose)"COMETRIQ (60 MG DAILY DOSE) ORAL KIT 20 MGQuantity Limit: 90 EA Per 30 DaysCopiktraXE "Copiktra"COPIKTRA ORAL CAPSULE 15 MG, 25 MGQuantity Limit: 60 EA Per 30 DaysCorlanorXE "Corlanor"CORLANOR ORAL SOLUTION 5 MG/5MLQuantity Limit: 450 ML Per 30 DaysCORLANOR ORAL TABLET 5 MG, 7.5 MGQuantity Limit: 60 EA Per 30 DaysCystaranXE "Cystaran"CYSTARAN OPHTHALMIC SOLUTION 0.44 %Quantity Limit: 60 ML Per 30 DaysDalfampridine ERXE "Dalfampridine ER"dalfampridine er oral tablet extended release 12 hour 10 mgQuantity Limit: 60 EA Per 30 DaysDexilantXE "Dexilant"DEXILANT ORAL CAPSULE DELAYED RELEASE 30 MG, 60 MGQuantity Limit: 30 EA Per 30 DaysDiclofenac SodiumXE "Diclofenac Sodium"diclofenac sodium transdermal gel 1 %Quantity Limit: 1000 GM Per 30 Daysdiclofenac sodium transdermal gel 3 %Quantity Limit: 300 GM Per 365 Daysdiclofenac sodium transdermal solution 1.5 %Quantity Limit: 450 ML Per 30 DaysDigitekXE "Digitek"DIGITEK ORAL TABLET 125 MCGQuantity Limit: 30 EA Per 30 DaysDigoxXE "Digox"DIGOX ORAL TABLET 125 MCGQuantity Limit: 30 EA Per 30 DaysDigoxinXE "Digoxin"digoxin oral tablet 125 mcgQuantity Limit: 30 EA Per 30 DaysDihydroergotamine MesylateXE "Dihydroergotamine Mesylate"dihydroergotamine mesylate nasal solution 4 mg/mlQuantity Limit: 24 ML Per 28 DaysDrizalma SprinkleXE "Drizalma Sprinkle"DRIZALMA SPRINKLE ORAL CAPSULE DELAYED RELEASE SPRINKLE 20 MG, 30 MG, 40 MG, 60 MGQuantity Limit: 60 EA Per 30 DaysDronabinolXE "Dronabinol"dronabinol oral capsule 10 mg, 2.5 mg, 5 mgQuantity Limit: 60 EA Per 30 DaysEletriptan HydrobromideXE "Eletriptan Hydrobromide"eletriptan hydrobromide oral tablet 20 mg, 40 mgQuantity Limit: 12 EA Per 30 DaysEmsamXE "Emsam"EMSAM TRANSDERMAL PATCH 24 HOUR 12 MG/24HR, 6 MG/24HR, 9 MG/24HRQuantity Limit: 30 EA Per 30 DaysEndariXE "Endari"ENDARI ORAL PACKET 5 GMQuantity Limit: 180 EA Per 30 DaysEntecavirXE "Entecavir"entecavir oral tablet 0.5 mg, 1 mgQuantity Limit: 30 EA Per 30 DaysEntrestoXE "Entresto"ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MGQuantity Limit: 60 EA Per 30 DaysEPINEPHrineXE "EPINEPHrine"epinephrine injection solution auto-injector 0.15 mg/0.3ml, 0.3 mg/0.3mlQuantity Limit: 2 EA Per 30 DaysErgotamine-CaffeineXE "Ergotamine-Caffeine"ergotamine-caffeine oral tablet 1-100 mgQuantity Limit: 40 EA Per 28 DaysErleadaXE "Erleada"ERLEADA ORAL TABLET 60 MGQuantity Limit: 120 EA Per 30 DaysErlotinib HClXE "Erlotinib HCl"erlotinib hcl oral tablet 100 mg, 150 mgQuantity Limit: 30 EA Per 30 Dayserlotinib hcl oral tablet 25 mgQuantity Limit: 90 EA Per 30 DaysExemestaneXE "Exemestane"exemestane oral tablet 25 mgQuantity Limit: 60 EA Per 30 DaysFanaptXE "Fanapt"FANAPT ORAL TABLET 1 MG, 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MGQuantity Limit: 60 EA Per 30 DaysFanapt Titration PackXE "Fanapt Titration Pack"FANAPT TITRATION PACK ORAL TABLET 1 & 2 & 4 & 6 MGQuantity Limit: 8 EA Per 180 DaysFentaNYL CitrateXE "FentaNYL Citrate"fentanyl citrate buccal lozenge on a handle 1200 mcg, 1600 mcg, 200 mcg, 400 mcg, 600 mcg, 800 mcgQuantity Limit: 180 EA Per 30 DaysFentaNYLXE "FentaNYL"fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 37.5 mcg/hr, 50 mcg/hr, 62.5 mcg/hr, 75 mcg/hr, 87.5 mcg/hrQuantity Limit: 10 EA Per 30 DaysFetzimaXE "Fetzima"FETZIMA ORAL CAPSULE EXTENDED RELEASE 24 HOUR 120 MG, 20 MG, 40 MG, 80 MGQuantity Limit: 30 EA Per 30 DaysFetzima TitrationXE "Fetzima Titration"FETZIMA TITRATION ORAL CAPSULE ER 24 HOUR THERAPY PACK 20 & 40 MGQuantity Limit: 56 EA Per 365 DaysFirdapseXE "Firdapse"FIRDAPSE ORAL TABLET 10 MGQuantity Limit: 240 EA Per 30 DaysFlurazepam HClXE "Flurazepam HCl"flurazepam hcl oral capsule 15 mgQuantity Limit: 60 EA Per 30 Daysflurazepam hcl oral capsule 30 mgQuantity Limit: 30 EA Per 30 DaysForteoXE "Forteo"FORTEO SUBCUTANEOUS SOLUTION 600 MCG/2.4MLQuantity Limit: 2.4 ML Per 28 DaysGocovriXE "Gocovri"GOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR 137 MGQuantity Limit: 60 EA Per 30 DaysGOCOVRI ORAL CAPSULE EXTENDED RELEASE 24 HOUR 68.5 MGQuantity Limit: 30 EA Per 30 DaysGranisetron HClXE "Granisetron HCl"granisetron hcl oral tablet 1 mgQuantity Limit: 60 EA Per 30 DaysIclusigXE "Iclusig"ICLUSIG ORAL TABLET 15 MGQuantity Limit: 60 EA Per 30 DaysICLUSIG ORAL TABLET 45 MGQuantity Limit: 30 EA Per 30 DaysIDHIFAXE "IDHIFA"IDHIFA ORAL TABLET 100 MGQuantity Limit: 30 EA Per 30 DaysIDHIFA ORAL TABLET 50 MGQuantity Limit: 60 EA Per 30 DaysImatinib MesylateXE "Imatinib Mesylate"imatinib mesylate oral tablet 100 mgQuantity Limit: 180 EA Per 30 Daysimatinib mesylate oral tablet 400 mgQuantity Limit: 60 EA Per 30 DaysInlytaXE "Inlyta"INLYTA ORAL TABLET 1 MGQuantity Limit: 180 EA Per 30 DaysINLYTA ORAL TABLET 5 MGQuantity Limit: 60 EA Per 30 DaysJakafiXE "Jakafi"JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MGQuantity Limit: 60 EA Per 30 DaysJanumetXE "Janumet"JANUMET ORAL TABLET 50-1000 MG, 50-500 MGQuantity Limit: 60 EA Per 30 DaysJanumet XRXE "Janumet XR"JANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 100-1000 MGQuantity Limit: 30 EA Per 30 DaysJANUMET XR ORAL TABLET EXTENDED RELEASE 24 HOUR 50-1000 MG, 50-500 MGQuantity Limit: 60 EA Per 30 DaysJanuviaXE "Januvia"JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MGQuantity Limit: 30 EA Per 30 DaysKorlymXE "Korlym"KORLYM ORAL TABLET 300 MGQuantity Limit: 120 EA Per 30 DaysLatanoprostXE "Latanoprost"latanoprost ophthalmic solution 0.005 %Quantity Limit: 2.5 ML Per 20 DaysLatudaXE "Latuda"LATUDA ORAL TABLET 120 MG, 20 MG, 40 MGQuantity Limit: 30 EA Per 30 DaysLATUDA ORAL TABLET 60 MG, 80 MGQuantity Limit: 60 EA Per 30 DaysLevalbuterol TartrateXE "Levalbuterol Tartrate"levalbuterol tartrate inhalation aerosol 45 mcg/actQuantity Limit: 30 GM Per 30 DaysLidocaineXE "Lidocaine"lidocaine external ointment 5 %Quantity Limit: 50 GM Per 30 Dayslidocaine external patch 5 %Quantity Limit: 90 EA Per 30 DaysLidocaine HClXE "Lidocaine HCl"lidocaine hcl external solution 4 %Quantity Limit: 50 ML Per 30 DaysLidocaine HCl Urethral/MucosalXE "Lidocaine HCl Urethral/Mucosal"lidocaine hcl urethral/mucosal external gel 2 %Quantity Limit: 30 ML Per 30 DaysLidocaine-PrilocaineXE "Lidocaine-Prilocaine"lidocaine-prilocaine external cream 2.5-2.5 %Quantity Limit: 30 GM Per 30 DaysLinezolidXE "Linezolid"linezolid oral tablet 600 mgQuantity Limit: 60 EA Per 30 DaysLumiganXE "Lumigan"LUMIGAN OPHTHALMIC SOLUTION 0.01 %Quantity Limit: 2.5 ML Per 20 DaysLyricaXE "Lyrica"LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 50 MG, 75 MGQuantity Limit: 120 EA Per 30 DaysLYRICA ORAL CAPSULE 300 MGQuantity Limit: 60 EA Per 30 DaysLYRICA ORAL SOLUTION 20 MG/MLQuantity Limit: 900 ML Per 30 DaysModafinilXE "Modafinil"modafinil oral tablet 100 mg, 200 mgQuantity Limit: 30 EA Per 30 DaysMonurolXE "Monurol"MONUROL ORAL PACKET 3 GMQuantity Limit: 2 EA Per 30 DaysNaratriptan HClXE "Naratriptan HCl"naratriptan hcl oral tablet 1 mg, 2.5 mgQuantity Limit: 12 EA Per 30 DaysNerlynxXE "Nerlynx"NERLYNX ORAL TABLET 40 MGQuantity Limit: 180 EA Per 30 DaysNexAVARXE "NexAVAR"NEXAVAR ORAL TABLET 200 MGQuantity Limit: 120 EA Per 30 DaysNilutamideXE "Nilutamide"nilutamide oral tablet 150 mgQuantity Limit: 60 EA Per 30 DaysNubeqaXE "Nubeqa"NUBEQA ORAL TABLET 300 MGQuantity Limit: 120 EA Per 30 DaysOLANZapineXE "OLANZapine"olanzapine oral tablet 10 mg, 15 mg, 2.5 mg, 20 mg, 5 mg, 7.5 mgQuantity Limit: 30 EA Per 30 Daysolanzapine oral tablet dispersible 10 mg, 15 mg, 20 mg, 5 mgQuantity Limit: 30 EA Per 30 DaysOndansetron HClXE "Ondansetron HCl"ondansetron hcl oral solution 4 mg/5mlQuantity Limit: 450 ML Per 30 Daysondansetron hcl oral tablet 24 mgQuantity Limit: 30 EA Per 30 Daysondansetron hcl oral tablet 4 mgQuantity Limit: 120 EA Per 30 Daysondansetron hcl oral tablet 8 mgQuantity Limit: 60 EA Per 30 DaysOndansetronXE "Ondansetron"ondansetron oral tablet dispersible 4 mgQuantity Limit: 120 EA Per 30 Daysondansetron oral tablet dispersible 8 mgQuantity Limit: 60 EA Per 30 DaysOpsumitXE "Opsumit"OPSUMIT ORAL TABLET 10 MGQuantity Limit: 30 EA Per 30 DaysOxtellar XRXE "Oxtellar XR"OXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 150 MGQuantity Limit: 480 EA Per 30 DaysOXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 300 MGQuantity Limit: 240 EA Per 30 DaysOXTELLAR XR ORAL TABLET EXTENDED RELEASE 24 HOUR 600 MGQuantity Limit: 120 EA Per 30 DaysPaliperidone ERXE "Paliperidone ER"paliperidone er oral tablet extended release 24 hour 1.5 mg, 3 mg, 6 mgQuantity Limit: 60 EA Per 30 Dayspaliperidone er oral tablet extended release 24 hour 9 mgQuantity Limit: 30 EA Per 30 DaysPaxilXE "Paxil"PAXIL ORAL SUSPENSION 10 MG/5MLQuantity Limit: 900 ML Per 30 DaysPregabalinXE "Pregabalin"pregabalin oral capsule 100 mg, 150 mg, 200 mg, 225 mg, 25 mg, 50 mg, 75 mgQuantity Limit: 120 EA Per 30 Dayspregabalin oral capsule 300 mgQuantity Limit: 60 EA Per 30 Dayspregabalin oral solution 20 mg/mlQuantity Limit: 900 ML Per 30 DaysProAir HFAXE "ProAir HFA"PROAIR HFA INHALATION AEROSOL SOLUTION 108 (90 BASE) MCG/ACTQuantity Limit: 17 GM Per 30 DaysProAir RespiClickXE "ProAir RespiClick"PROAIR RESPICLICK INHALATION AEROSOL POWDER BREATH ACTIVATED 108 (90 BASE) MCG/ACTQuantity Limit: 2 EA Per 30 DaysPromactaXE "Promacta"PROMACTA ORAL PACKET 12.5 MGQuantity Limit: 360 EA Per 30 DaysPROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MGQuantity Limit: 30 EA Per 30 DaysRasagiline MesylateXE "Rasagiline Mesylate"rasagiline mesylate oral tablet 0.5 mg, 1 mgQuantity Limit: 30 EA Per 30 DaysRestasisXE "Restasis"RESTASIS OPHTHALMIC EMULSION 0.05 %Quantity Limit: 60 EA Per 30 DaysRexultiXE "Rexulti"REXULTI ORAL TABLET 0.25 MG, 0.5 MG, 1 MG, 2 MG, 3 MG, 4 MGQuantity Limit: 30 EA Per 30 DaysRivastigmineXE "Rivastigmine"rivastigmine transdermal patch 24 hour 13.3 mg/24hr, 4.6 mg/24hr, 9.5 mg/24hrQuantity Limit: 30 EA Per 30 DaysRizatriptan BenzoateXE "Rizatriptan Benzoate"rizatriptan benzoate oral tablet 10 mg, 5 mgQuantity Limit: 12 EA Per 30 Daysrizatriptan benzoate oral tablet dispersible 10 mg, 5 mgQuantity Limit: 12 EA Per 30 DaysRydaptXE "Rydapt"RYDAPT ORAL CAPSULE 25 MGQuantity Limit: 240 EA Per 30 DaysSaphrisXE "Saphris"SAPHRIS SUBLINGUAL TABLET SUBLINGUAL 10 MG, 2.5 MG, 5 MGQuantity Limit: 60 EA Per 30 DaysSavellaXE "Savella"SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MGQuantity Limit: 60 EA Per 30 DaysSavella Titration PackXE "Savella Titration Pack"SAVELLA TITRATION PACK ORAL 12.5 & 25 & 50 MGQuantity Limit: 110 EA Per 365 DaysSigniforXE "Signifor"SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML, 0.6 MG/ML, 0.9 MG/MLQuantity Limit: 60 ML Per 30 DaysSildenafil CitrateXE "Sildenafil Citrate"sildenafil citrate oral tablet 20 mgQuantity Limit: 90 EA Per 30 DaysSilenorXE "Silenor"SILENOR ORAL TABLET 3 MG, 6 MGQuantity Limit: 30 EA Per 30 DaysSoliquaXE "Soliqua"SOLIQUA SUBCUTANEOUS SOLUTION PEN-INJECTOR 100-33 UNT-MCG/MLQuantity Limit: 18 ML Per 30 DaysSpritamXE "Spritam"SPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 1000 MGQuantity Limit: 90 EA Per 30 DaysSPRITAM ORAL TABLET DISINTEGRATING SOLUBLE 250 MG, 500 MG, 750 MGQuantity Limit: 120 EA Per 30 DaysSprycelXE "Sprycel"SPRYCEL ORAL TABLET 100 MG, 50 MG, 70 MG, 80 MGQuantity Limit: 60 EA Per 30 DaysSPRYCEL ORAL TABLET 140 MGQuantity Limit: 30 EA Per 30 DaysSPRYCEL ORAL TABLET 20 MGQuantity Limit: 90 EA Per 30 DaysSUMAtriptan SuccinateXE "SUMAtriptan Succinate"sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mgQuantity Limit: 12 EA Per 30 DaysSymlinPen 120XE "SymlinPen 120"SYMLINPEN 120 SUBCUTANEOUS SOLUTION PEN-INJECTOR 2700 MCG/2.7MLQuantity Limit: 10.8 ML Per 28 DaysSymlinPen 60XE "SymlinPen 60"SYMLINPEN 60 SUBCUTANEOUS SOLUTION PEN-INJECTOR 1500 MCG/1.5MLQuantity Limit: 10.8 ML Per 28 DaysSympazanXE "Sympazan"SYMPAZAN ORAL FILM 10 MG, 20 MG, 5 MGQuantity Limit: 60 EA Per 30 DaysTargretinXE "Targretin"TARGRETIN EXTERNAL GEL 1 %Quantity Limit: 60 GM Per 30 DaysTasignaXE "Tasigna"TASIGNA ORAL CAPSULE 150 MG, 200 MG, 50 MGQuantity Limit: 120 EA Per 30 DaysTavalisseXE "Tavalisse"TAVALISSE ORAL TABLET 100 MG, 150 MGQuantity Limit: 60 EA Per 30 DaysTegsediXE "Tegsedi"TEGSEDI SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 284 MG/1.5MLQuantity Limit: 6 ML Per 28 DaysTemazepamXE "Temazepam"temazepam oral capsule 15 mg, 22.5 mg, 30 mgQuantity Limit: 30 EA Per 30 Daystemazepam oral capsule 7.5 mgQuantity Limit: 120 EA Per 30 DaysTenconXE "Tencon"TENCON ORAL TABLET 50-325 MGQuantity Limit: 180 EA Per 30 DaysTetrabenazineXE "Tetrabenazine"tetrabenazine oral tablet 12.5 mgQuantity Limit: 90 EA Per 30 Daystetrabenazine oral tablet 25 mgQuantity Limit: 120 EA Per 30 DaysTobramycinXE "Tobramycin"tobramycin inhalation nebulization solution 300 mg/5mlQuantity Limit: 280 ML Per 42 DaysToremifene CitrateXE "Toremifene Citrate"toremifene citrate oral tablet 60 mgQuantity Limit: 30 EA Per 30 DaysTracleerXE "Tracleer"TRACLEER ORAL TABLET SOLUBLE 32 MGQuantity Limit: 120 EA Per 30 DaystraMADol HClXE "traMADol HCl"tramadol hcl oral tablet 50 mgQuantity Limit: 240 EA Per 30 DaysTramadol-AcetaminophenXE "Tramadol-Acetaminophen"tramadol-acetaminophen oral tablet 37.5-325 mgQuantity Limit: 240 EA Per 30 DaysTravatan ZXE "Travatan Z"TRAVATAN Z OPHTHALMIC SOLUTION 0.004 %Quantity Limit: 2.5 ML Per 20 DaysTrintellixXE "Trintellix"TRINTELLIX ORAL TABLET 10 MG, 20 MG, 5 MGQuantity Limit: 30 EA Per 30 DaysTrokendi XRXE "Trokendi XR"TROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 25 MG, 50 MGQuantity Limit: 120 EA Per 30 DaysTROKENDI XR ORAL CAPSULE EXTENDED RELEASE 24 HOUR 200 MGQuantity Limit: 60 EA Per 30 DaysTykerbXE "Tykerb"TYKERB ORAL TABLET 250 MGQuantity Limit: 150 EA Per 30 DaysUptraviXE "Uptravi"UPTRAVI ORAL TABLET 1000 MCG, 1200 MCG, 1400 MCG, 1600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCGQuantity Limit: 60 EA Per 30 DaysUPTRAVI ORAL TABLET THERAPY PACK 200 & 800 MCGQuantity Limit: 400 EA Per 365 DaysValchlorXE "Valchlor"VALCHLOR EXTERNAL GEL 0.016 %Quantity Limit: 60 GM Per 30 DaysVarubiXE "Varubi"VARUBI ORAL TABLET 90 MGQuantity Limit: 8 EA Per 30 DaysViibrydXE "Viibryd"VIIBRYD ORAL TABLET 10 MG, 20 MG, 40 MGQuantity Limit: 30 EA Per 30 DaysViibryd Starter PackXE "Viibryd Starter Pack"VIIBRYD STARTER PACK ORAL KIT 10 & 20 MGQuantity Limit: 30 EA Per 30 DaysVimpatXE "Vimpat"VIMPAT ORAL SOLUTION 10 MG/MLQuantity Limit: 1200 ML Per 30 DaysVIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MGQuantity Limit: 60 EA Per 30 DaysVizimproXE "Vizimpro"VIZIMPRO ORAL TABLET 15 MG, 30 MG, 45 MGQuantity Limit: 30 EA Per 30 DaysVoriconazoleXE "Voriconazole"voriconazole oral suspension reconstituted 40 mg/mlQuantity Limit: 300 ML Per 30 Daysvoriconazole oral tablet 200 mg, 50 mgQuantity Limit: 120 EA Per 30 DaysVotrientXE "Votrient"VOTRIENT ORAL TABLET 200 MGQuantity Limit: 120 EA Per 30 DaysVraylarXE "Vraylar"VRAYLAR ORAL CAPSULE 1.5 MGQuantity Limit: 120 EA Per 30 DaysVRAYLAR ORAL CAPSULE 3 MGQuantity Limit: 60 EA Per 30 DaysVRAYLAR ORAL CAPSULE 4.5 MG, 6 MGQuantity Limit: 30 EA Per 30 DaysVRAYLAR ORAL CAPSULE THERAPY PACK 1.5 & 3 MGQuantity Limit: 14 EA Per 365 DaysVyndamaxXE "Vyndamax"VYNDAMAX ORAL CAPSULE 61 MGQuantity Limit: 30 EA Per 30 DaysVyzultaXE "Vyzulta"VYZULTA OPHTHALMIC SOLUTION 0.024 %Quantity Limit: 2.5 ML Per 20 DaysXalkoriXE "Xalkori"XALKORI ORAL CAPSULE 200 MG, 250 MGQuantity Limit: 60 EA Per 30 DaysXgevaXE "Xgeva"XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7MLQuantity Limit: 1.7 ML Per 28 DaysXolairXE "Xolair"XOLAIR SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 150 MG/ML, 75 MG/0.5MLQuantity Limit: 6 ML Per 28 DaysXOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED 150 MGQuantity Limit: 6 EA Per 28 DaysXtandiXE "Xtandi"XTANDI ORAL CAPSULE 40 MGQuantity Limit: 120 EA Per 30 DaysXultophyXE "Xultophy"XULTOPHY SUBCUTANEOUS SOLUTION PEN-INJECTOR 100-3.6 UNIT-MG/MLQuantity Limit: 15 ML Per 30 DaysXyremXE "Xyrem"XYREM ORAL SOLUTION 500 MG/MLQuantity Limit: 540 ML Per 30 DaysYonsaXE "Yonsa"YONSA ORAL TABLET 125 MGQuantity Limit: 120 EA Per 30 DaysZaleplonXE "Zaleplon"zaleplon oral capsule 5 mgQuantity Limit: 30 EA Per 30 DaysZejulaXE "Zejula"ZEJULA ORAL CAPSULE 100 MGQuantity Limit: 90 EA Per 30 DaysZelborafXE "Zelboraf"ZELBORAF ORAL TABLET 240 MGQuantity Limit: 240 EA Per 30 DaysZioptanXE "Zioptan"ZIOPTAN OPHTHALMIC SOLUTION 0.0015 %Quantity Limit: 30 EA Per 30 DaysZiprasidone HClXE "Ziprasidone HCl"ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mgQuantity Limit: 60 EA Per 30 DaysZolinzaXE "Zolinza"ZOLINZA ORAL CAPSULE 100 MGQuantity Limit: 120 EA Per 30 DaysZOLMitriptanXE "ZOLMitriptan"zolmitriptan oral tablet 2.5 mg, 5 mgQuantity Limit: 12 EA Per 30 Dayszolmitriptan oral tablet dispersible 2.5 mg, 5 mgQuantity Limit: 12 EA Per 30 DaysZolpidem Tartrate ERXE "Zolpidem Tartrate ER"zolpidem tartrate er oral tablet extended release 12.5 mg, 6.25 mgQuantity Limit: 30 EA Per 30 DaysZolpidem TartrateXE "Zolpidem Tartrate"zolpidem tartrate oral tablet 10 mg, 5 mgQuantity Limit: 30 EA Per 30 DaysZydeligXE "Zydelig"ZYDELIG ORAL TABLET 100 MGQuantity Limit: 90 EA Per 30 DaysZYDELIG ORAL TABLET 150 MGQuantity Limit: 60 EA Per 30 DaysZytigaXE "Zytiga"ZYTIGA ORAL TABLET 500 MGQuantity Limit: 120 EA Per 30 DaysAlphabetical ListingINDEX INDEX \e "" \c "2" \h "A" \z "1033" AAbilify MyCite1Abiraterone Acetate1Adefovir Dipivoxil1Adempas1Afinitor1Afinitor Disperz1Albuterol Sulfate HFA2Alinia2Almotriptan Malate2Alunbrig2Ambrisentan2Apokyn2Aprepitant3Aptiom3ARIPiprazole3Armodafinil3Ascomp-Codeine4Atomoxetine HCl4Austedo4BBanzel4Baraclude4Belsomra4Bicalutamide5Bimatoprost5Bosentan5Bosulif5Briviact5Bupap5Butalbital-Acetaminophen6Butalbital-APAP-Caff-Cod6Butalbital-APAP-Caffeine6Butalbital-ASA-Caff-Codeine6Butalbital-Aspirin-Caffeine6CCalquence6Caprelsa7Celecoxib7Cinacalcet HCl7CloBAZam7Cometriq (100 mg Daily Dose)7Cometriq (140 mg Daily Dose)7Cometriq (60 mg Daily Dose)8Copiktra8Corlanor8Cystaran8DDalfampridine ER8Dexilant8Diclofenac Sodium9Digitek9Digox9Digoxin9Dihydroergotamine Mesylate9Drizalma Sprinkle9Dronabinol10EEletriptan Hydrobromide10Emsam10Endari10Entecavir10Entresto10EPINEPHrine11Ergotamine-Caffeine11Erleada11Erlotinib HCl11Exemestane11FFanapt11Fanapt Titration Pack11FentaNYL12FentaNYL Citrate12Fetzima12Fetzima Titration12Firdapse12Flurazepam HCl12Forteo13GGocovri13Granisetron HCl13IIclusig13IDHIFA13Imatinib Mesylate14Inlyta14JJakafi14Janumet14Janumet XR14Januvia15KKorlym15LLatanoprost15Latuda15Levalbuterol Tartrate15Lidocaine16Lidocaine HCl16Lidocaine HCl Urethral/Mucosal16Lidocaine-Prilocaine16Linezolid16Lumigan16Lyrica16MModafinil17Monurol17NNaratriptan HCl17Nerlynx17NexAVAR17Nilutamide17Nubeqa18OOLANZapine18Ondansetron18Ondansetron HCl18Opsumit19Oxtellar XR19PPaliperidone ER19Paxil19Pregabalin19ProAir HFA20ProAir RespiClick20Promacta20RRasagiline Mesylate20Restasis20Rexulti21Rivastigmine21Rizatriptan Benzoate21Rydapt21SSaphris21Savella21Savella Titration Pack22Signifor22Sildenafil Citrate22Silenor22Soliqua22Spritam22Sprycel23SUMAtriptan Succinate23SymlinPen 12023SymlinPen 6023Sympazan23TTargretin24Tasigna24Tavalisse24Tegsedi24Temazepam24Tencon24Tetrabenazine25Tobramycin25Toremifene Citrate25Tracleer25traMADol HCl25Tramadol-Acetaminophen25Travatan Z26Trintellix26Trokendi XR26Tykerb26UUptravi26VValchlor27Varubi27Viibryd27Viibryd Starter Pack27Vimpat27Vizimpro27Voriconazole27Votrient28Vraylar28Vyndamax28Vyzulta28XXalkori28Xgeva29Xolair29Xtandi29Xultophy29Xyrem29YYonsa29ZZaleplon30Zejula30Zelboraf30Zioptan30Ziprasidone HCl30Zolinza30ZOLMitriptan31Zolpidem Tartrate31Zolpidem Tartrate ER31Zydelig31Zytiga31 ................
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