| 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® |
|
