abatacept for polyarticular juvenile idiopathic arthritis |
Orencia® |
|
abatacept for rheumatoid arthritis |
Orencia® |
|
abobotulinumtoxinA |
Dysport Therapeutic™ |
|
acamprosate |
Campral® |
|
acetaminophen 500 mg |
Tylenol 500 mg® |
|
aclidinium |
Tudorza™ Genuair™ |
|
aclidinium-formoterol |
Duaklir™ Genuair® |
|
adalimumab |
Amgevita®, Hadlima®, Hulio®, Humira®, Hyrimoz®, Idacio® |
|
alemtuzumab |
Lemtrada® |
|
alendronate 10/70 mg |
Fosamax® 10 mg / 70 mg |
|
alendronate with vitamin D 10/70 mg |
Fosavance® 70 mg / 5600 IU |
|
alendronate 40 mg |
Fosamax® 40 mg |
|
alitretinoin |
Toctino® |
|
ambrisentan |
Volibris® |
|
apixaban for atrial fibrillation |
Eliquis® |
|
apixaban for the treatment of deep vein thrombosis (DVT) or pulmonary embolism (PE) |
Eliquis® |
Yes |
apixaban for venous thromboembolism |
Eliquis® |
|
apomorphine |
Movapo™, Kynmobi® |
|
aprepitant |
Emend® |
|
aripiprazole (Plan G) |
Abilify® |
|
aripiprazole monohydrate |
Abilify Maintena® |
|
asenapine |
Saphris™ |
|
atomoxetine |
Strattera® |
|
aztreonam |
Cayston™ |
|
baclofen intrathecal |
Lioresal® Intrathecal |
|
benazepril (RDP - ACE Inhibitor Drugs) |
Lotensin® |
|
benzydamine |
Tantum® |
|
benralizumab |
Fasenra® |
|
bosentan |
Tracleer® |
|
botulinum neurotoxin type A, free from complexing proteins, also known as incobotulinumtoxinA |
Xeomin® |
|
botulinum neurotoxin type A, with complexing proteins, also known as onabotulinumtoxinA |
Botox® |
|
brexpiprazole (Plan G) |
Rexulti® |
|
brivaracetam |
Brivlera® |
|
budesonide capsules |
Entocort Capsules® |
|
budesonide enema |
Entocort Enema® |
|
budesonide-formoterol |
Symbicort® |
|
budesonide nebules |
Pulmicort® |
|
buprenorphine |
Sublocade™ |
|
bupropion (Plan G) |
Wellbutrin® SR and XL, Zyban® |
Yes |
candesartan |
Atacand®, Atacand Plus® |
Yes |
captopril (RDP - ACE Inhibitor Drugs) |
Capoten® |
|
carvedilol |
Coreg® |
Yes |
celecoxib |
Celebrex® |
|
certolizumab for the treatment of ankylosing spondylitis |
Cimzia® |
|
certolizumab for the treatment of psoriatic arthritis |
Cimzia® |
|
certolizumab for the treatment of rheumatoid arthritis |
Cimzia® |
|
chlorambucil |
Leukeran® |
|
chloroquine |
Aralen® |
|
ciclopirox 1% |
Loprox® |
|
cilazapril with/without HCTZ (RDP - ACE Inhibitor Drugs) |
Inhibace®, Inhibace Plus® |
|
cimetidine - prescription strength (RDP - H2 Blocker Drugs) |
Tagamet® |
|
ciprofloxacin ophthalmic |
Ciloxan® |
|
cladribine |
Mavenclad® |
|
clioquinol topical |
Locacorten Vioform, Vioform Hydrocortisone |
|
clobazam (Plan G) |
Frisium® |
|
clotrimazole |
Canesten Topical® |
|
codeine sustained release |
Codeine Contin® |
|
continuous glucose monitor |
Dexcom G6® |
|
cyclosporine |
Neoral® |
|
cyproterone (Plan G) |
Androcur® |
|
cysteamine ophthalmic solution |
Cystadrops® |
|
dabigatran |
Pradaxa® |
|
dalteparin |
Fragmin® |
|
dapagliflozin |
Forxiga® |
Yes |
deferasirox |
Exjade® |
|
deferiprone |
Ferriprox® |
|
denosumab |
Prolia® |
|
desmopressin oral |
DDAVP Tablets®, DDAVP Melt® |
|
dextroamphetamine-amphetamine |
Adderall XR® |
|
diclofenac IR/SR |
Voltaren®, Arthrotec® |
|
diclofenac IR with misoprostol |
Arthrotec® |
|
dienogest |
Visanne® |
|
diflunisal |
Dolobid® |
|
dimethyl fumarate |
Tecfidera™ |
|
diphenoxylate HCI-atropine sulfate |
Lomotil® |
|
dipyridamole-acetylsalicylic acid |
Aggrenox® |
|
donepezil |
Aricept® |
|
dorzolamide-timolol preservative free |
Cosopt non-preserved® |
|
dronedarone |
Multaq® |
|
duloxetine |
generics |
|
dutasteride |
Avodart® |
|
edaravone |
Radicava™ |
|
empagliflozin and empagliflozin-metformin |
Jardiance®, Synjardy® |
|
enalapril without HCTZ (RDP - ACE Inhibitor Drugs) |
Vasotec® |
|
enalapril with HCTZ (RDP - ACE Inhibitor Drugs) |
Vasotec Plus® |
|
enoxaparin |
Inclunox®, Inclunox® HP, Noromby®, Noromby® HP, Redesca®, Redesca® HP |
|
entacapone |
Comtan® |
|
entacapone/levodopa/carbidopa combination tablet |
Stalevo® |
|
entecavir |
Baraclude® |
|
epoprostenol |
Caripul®, Flolan® |
|
eprosartan with/without HCTZ (RDP - ARB Drugs and LCD) |
Teventen®, Teveten Plus® |
|
eslicarbazepine acetate |
Aptiom™ |
|
esomeprazole (RDP - PPI Drugs and LCD) |
Nexium® |
|
estradiol patches |
Climara®, Estalis®, Estalis-Sequi®, Estracomb®, Estraderm®, Estradot®, Oesclim®, Vivelle® |
|
estradiol transdermal gel |
Divigel®, Estrogel® |
|
etanercept |
Enbrel®, Brenzys™, Erelzi™ |
|
evolocumab |
Repatha™ |
|
ezetimibe |
Ezetrol®, generics |
|
famotidine (RDP - H2 Blocker Drugs) |
Pepcid® |
|
febuxostat |
Uloric® |
|
felodipine (RDP - Calcium Channel Blockers) |
Plendil®, Renedil® |
|
fentanyl patch |
Duragesic® |
|
fentanyl tablet |
Fentora® |
|
fidaxomicin |
Dificid® |
|
filgrastim |
Grastofil®, Nivestym® |
|
finasteride |
Proscar® |
|
fingolimod |
generics, Gilenya® (partial benefit) |
|
fluconazole oral solids |
Diflucan® |
|
flurbiprofen |
Ansaid®, Froben® |
|
fluticasone furoate-umeclidinium-vilanterol |
Trelegy® Ellipta® |
|
fluticasone furoate-vilanterol |
Breo® Ellipta® |
|
fluticasone propionate-salmeterol |
Advair® |
|
fluvastatin (RDP - Statin Drugs) |
Lescol® |
|
formoterol |
Foradil®, Oxeze® Turbuhaler® |
|
fosinopril (RDP - ACE Inhibitor Drugs) |
Monopril® |
|
fremanezumab |
Ajovy® |
|
gabapentin (Plan G) |
Neurontin® |
|
galantamine |
Reminyl® |
|
glatiramer acetate |
Glatect™, Copaxone® |
|
glecaprevir-pibrentasvir |
Maviret™ |
|
gliclazide |
Diamicron® |
Yes |
glycopyrronium |
Seebri® Breezhaler® |
|
golimumab |
Simponi® |
|
goserelin |
Zoladex® |
|
granisetron |
Kytril® |
|
glycerol phenylbutyrate |
Ravicti® |
|
glycopyrronium-indacaterol |
Ultibro® Breezhaler® |
|
hydromorphone controlled release |
Hydromorph Contin® |
|
hydromorphone injection |
Hydromorphone HP 50 |
|
hydroxyurea |
Hydrea® |
|
hydroxyzine (Plan G) |
Atarax® |
|
icatibant |
Firazyr® |
|
indacaterol |
Onbrez® Breezhaler® |
|
indacaterol-glycopyrronium-mometasone furoate |
Enerzair® Breezhaler® |
|
indacaterol-mometasone furoate |
Atectura® Breezhaler® |
|
indapamide |
Lozide® |
|
indomethacin |
Indocid® |
|
infliximab |
Avsola®, Inflectra™, Renflexis™, Remicade® |
|
insulin detemir |
Levemir®, Levemir® FlexTouch® |
|
insulin glargine |
Basaglar™ |
|
interferon alfa |
Intron A® |
|
interferon beta-1a |
Avonex®, Rebif® |
|
interferon beta-1b |
Betaseron®, Extavia® |
|
ipratropium nebules |
Atrovent® |
|
ipratropium and salbutamol combination nebules |
Combivent® UDV |
|
irbesartan with/without HCTZ (RDP - ARB Drugs and LCD) |
Avapro®, Avalide® |
|
iron isomaltoside |
Monoferric® |
|
iron sucrose |
Venofer® |
|
isavuconazole |
Cresemba® |
|
itraconazole |
Sporanox® |
|
ivabradine |
Lancora™ |
|
ixekizumab |
Taltz™ |
|
ketoconazole 2% cream |
Nizoral® |
|
ketoprofen enteric-coated |
Orudis E® |
|
ketoprofen SR |
Orudis® |
|
lacosamide tablets |
Vimpat® |
|
lactulose |
Laxilose® |
|
lamivudine |
Heptovir® |
|
lansoprazole 15 mg or 30 mg (RDP - PPI Drugs and LCD) |
Prevacid® |
|
ledipasvir-sofosbuvir |
Harvoni™ |
|
letermovir |
Prevymis™ |
|
leuprolide (Plan G) |
Lupron® |
|
levetiracetam |
Keppra® |
|
levodopa-carbidopa |
Duodopa® |
|
linagliptin and linagliptin-metformin |
Trajenta™, Jentadueto™ |
|
linezolid 600 mg tablet |
Zyvoxam® |
|
lisdexamfetamine |
Vyvanse® |
|
lisinopril with or without HCTZ (RDP - ACE Inhibitor Drugs) |
Prinivil®, Zestril®, Zestoretic® |
|
loperamide |
Imodium® |
|
losartan |
Cozaar®, Hyzaar® |
Yes |
lovastatin (RDP - Statin Drugs) |
Mevacor® |
|
meloxicam |
Mobicox® |
|
mepolizumab |
Nucala® |
|
mercaptopurine |
Purinethol® |
|
methotrexate pre-filled syringes |
PharmaScience |
|
methylphenidate extended-release |
Concerta® |
|
miconazole 2% topical |
Micatin Cream® |
|
miconazole topical |
Monistat Derm Cream® |
|
modafinil |
Alertec® |
|
mometasone-formoterol |
Zenhale™ |
|
mometasone nasal spray |
Nasonex® |
|
mycophenolate mofetil |
CellCept® |
|
nabumetone |
Relafen® |
|
nadroparin |
Fraxiparine® |
|
naltrexone |
ReVia® |
|
naproxen enteric-coated (RDP - NSAIDs) |
Naprosyn EC® |
|
naproxen SR (RDP - NSAIDs) |
Naprosyn® |
|
natalizumab |
Tysabri® |
|
netupitant-palonosetron |
Akynzeo® |
|
nifedipine (RDP - Calcium Channel Blockers) |
Adalat® |
|
nintedanib |
Ofev® |
|
nirmatrelvir/ritonavir (Plan Z or ZE) |
Paxlovid® |
N/A |
nitisinone |
Orfadin® |
|
nizatidine (RDP - H2 Blocker Drugs) |
Axid® |
|
obeticholic acid |
Ocaliva® |
|
ocrelizumab |
Ocrevus® |
|
ocriplasmin |
Jetrea® |
|
ofloxacin ophthalmic drops |
Ocuflox® |
|
olanzapine (Plan G) |
Zyprexa®, Zyprexa Zydis® |
|
olmesartan |
Olmetec®, Olmetec Plus® |
|
oseltamivir |
Tamiflu® |
|
omeprazole 20 mg (RDP - PPI Drugs and LCD) |
Losec® 20 mg |
|
ondansetron |
Zofran® |
|
paliperidone palmitate injection (Plan G) |
Invenga Sustenna®, Invega Trinza® |
|
pamidronate |
Aredia® |
|
pantoprazole magnesium RDP - PPI Drugs and LCD |
Tecta® |
Yes |
pantoprazole sodium 40 mg (RDP - PPI Drugs and LCD) |
Pantoloc® 40 mg |
|
pentazocine |
Talwin® |
|
perampanel |
Fycompa™ |
|
perindopril (RDP - ACE Inhibitor Drugs) |
Coversyl® |
|
pimecrolimus cream |
Elidel® Cream |
|
pioglitazone |
Actos® |
|
pirfenidone |
Esbriet® |
|
piroxicam capsule |
Feldene® |
|
pramipexole |
Mirapex® |
|
pravastatin (RDP - Statin Drugs) |
Pravachol® |
|
propranolol hydrochloride |
Hemangiol® |
|
prostaglandin compounded injection |
Prostaglandin® |
|
quinapril with HCTZ (RDP - ACE Inhibitor Drugs) |
Accuretic® |
|
rabeprazole (RDP - PPI DrugsLCD) |
Pariet® |
Yes |
raloxifene |
Evista® |
|
ribavirin |
Ibavyr™ |
|
rifaximin |
Zaxine® |
|
risedronate 30 mg |
Actonel® 30 mg |
|
risedronate 5/35 mg |
Actonel® 5 / 35 mg |
|
risperidone microspheres |
Risperdal Consta® |
|
rituximab |
Rituxan®, Truxima™, Riximyo™ and Ruxience™ |
|
risankizumab |
Skyrizi™ |
|
rivaroxaban for atrial fibrillation |
Xarelto® |
|
rivaroxaban for concomitant coronary artery disease and peripheral artery disease |
Xarelto® |
|
rivaroxaban for prophylaxis of venous thromboembolism |
Xarelto® |
|
rivaroxaban for the treatment of venous thromboembolic events (DVT or PE) |
Xarelto® |
Yes |
rivastigmine |
Exelon® |
|
ropinirole |
ReQuip® |
|
rotigotine |
Neupro® |
|
rufinamide |
Banzel® |
|
sacubitril-valsartan |
Entresto™ |
|
salbutamol nebules |
Ventolin® |
|
salmeterol |
Serevent® |
|
sarilumab |
Kevzara® |
|
saxagliptin and saxagliptin-metformin |
Onglyza®, Komboglyze™ |
|
secukinumab |
Cosentyx® |
|
selexipag |
Uptravi® |
|
semaglutide |
Ozempic® |
|
sildenafil |
Viagra® |
|
simvastatin (RDP - Statin Drugs) |
Zocor® |
|
siponimod |
Mayzent® |
|
sodium cromoglycate nebules |
Intal® nebules |
|
sodium phenylbutyrate |
Pheburane® |
|
sofosbuvir |
Sovaldi® |
|
sofosbuvir-velpatasvir |
Epclusa® |
|
sofosbuvir-velpatasvir-voxilaprevir |
Vosevi™ |
|
solifenacin |
generics only |
|
somatropin |
Genotropin®, Humatrope®, Norditriopin Nordiflex®, Nutropin AQ®, Omnitrope®, Saizen® |
|
stiripentol |
Diacomit™ |
|
sulindac |
Clinoril® |
|
sumatriptan injection |
Imitrex® Injection |
|
supportive care for cancer treatment |
Grastofil(R) pre-filled syringe |
|
tacrolimus ointment |
Protopic® Ointment |
|
tadalafil 20 mg |
Adcirca® |
|
telmisartan without HCTZ (RDP - ARB Drugs and LCD) |
Micardis® |
Yes |
telmisartan with HCTZ (RDP - ARB Drugs and LCD) |
Micardis Plus® |
Yes |
telmisartan + amlodipine combination (RDP - ARB Drugs and LCD) |
Twynsta® |
Yes |
tenofovir |
Viread® |
|
tenoxicam |
Mobiflex® |
|
terbinafine tablets |
Lamisil® tablets |
|
teriflunomide |
Aubagio™ |
|
testosterone cypionate |
Depo-testosterone® |
|
testosterone enanthate |
Delatestryl® |
|
tiaprofenic acid regular release |
Surgam® |
|
ticagrelor |
Brilinta® |
|
ticlopidine |
Ticlid® |
|
tinzaparin |
Innohep® |
|
tiotropium |
Spiriva® Handihaler® |
|
tiotropium-olodaterol |
Inspiolto® Respimat® |
|
tizanidine |
Zanaflex® |
|
tobramycin |
Tobi®, Tobi® Podhaler® |
|
tocilizumab for the treatment of giant cell arteritis |
Actemra® |
|
tocilizumab for the treatment of active polyarticular juvenile idiopathic arthritis |
Actemra® |
|
tocilizumab for the treatment of active systemic juvenile idiopathic arthritis |
Actemra® |
|
tocilizumab for the treatment of rheumatoid arthritis |
Actemra® |
|
tofacitinib for the treatment of rheumatoid arthritis |
Xeljanz® |
|
tofacitinib for the treatment of ulcerative colitis |
Xeljanz® |
|
trandolapril (RDP - ACE Inhibitor Drugs) |
Mavik® |
|
treprostinil |
Remodulin® |
|
tretinoin topical |
Rejuva-A Cream®, Retin-A Cream®, Stieva-A Cream®, Vitamin A Acid Cream® |
|
trientine |
Mar-Trientine |
|
umeclidinium-vilanterol |
Anoro® Ellipta® |
|
ustekinumab |
Stelara® |
|
valganciclovir |
Valcyte® |
|
valsartan (RDP - ARB DrugsLCD) |
Diovan®, Diovan HCT® |
Yes |
vancomycin oral |
Vancocin® |
Yes |
varenicline (Plan G) |
Champix® |
|
vedolizumab |
Entyvio® |
|
voriconazole |
Vfend® |
|
vortioxetine |
Trintellix™ |
|
zanamivir |
Relenza® |
|
ziprasidone (Plan G) |
Zeldox® |
|
zoledronic acid |
Aclasta™ |
|
zopiclone (Plan G) |
Imovane® |
|