230 N. Main St. Dayton, OH 45402 | 833-230-2005 | Ca reSou rcePASSE.comCareSourcePASSE.com Asunto: Resumen de cambios al Formulario/a la Autorizacin previa en vigor desde el JULY 1, 2023 Su atencin mdica es nuestra prioridad. Po ello le escribimos para informarle que el July 1, 2023 , habr cambios en la Lista de medicamentos preferidos (PDL) de Medicaid de Arkansas o en la administracin de product os que no estn en la PDL de Medicaid de Arkansas de parte de CareSource PASSE. Una PDL es una lista de medicamentos preferidos. RESUMEN DE CAMBIOS A LA PDL DE MEDICAID DE MEDICAID EN VIGOR A PARTIR DEL JULY 1, 2023 :LOS SIGUIENTES MEDICAMENTOS SE INCL UIRN COMO PREFERIDOS EN LA PDL APARTIR DEL JULY 1, 2023 . Nombre del producto Dosis Notas Baqsimi nasal spray 3mg Preferred without prior authorization Clonidine extended release tablet (Generic for Kapvay ) 0.1mg Preferred with prior authorization Took effect 3/24/2023 EpiPen auto-injector 0.3mg/0.3mL Preferred without prior authorization EpiPen Jr auto-injector 0.15mg/0.3mL Preferred without prior authorization Fensolvi syringe ki t 45mg Preferred with prior authorization Finasteride tablet (Generic for Proscar ) 5mg Preferred with prior authorization Gvoke syringe, auto-injector All Preferred without prior authorization Insulin Aspart mix pen, vial (Generic for Novolog Mix) All Preferred rapid/intermediate acting combination insulin alongside brand Novolog Mix Took effect 5/15/2023 Insulin Aspart cartridge, vial, Flex Pen (Generic for Novolog) All Preferred rapid acting insulin alongside brand Novolog Took effect 5/15/2023 Ketorolac vial All Preferred with criteria Took effect 4/11/2023 Lamotrigine tablet (Generic for Lamictal ) 25mg, 100mg, 150mg, 200mg Extended release or ODT preparations are not preferred Took effect 5/15/2023 Lupaneta kit 3.75-5mg Preferred with criteria Lupron Depot kit 3.75 mg, 7.5mg, 11.25, mg-3month Preferred with criteria Lupron Depot-Ped kit 7.5mg, 11.25, mg, 15mg, 11.25-3 month kit, 30mg-3 month kit, Preferred with prior authorization CareSourcePASSE.com 45mg-6month kit Proglycem oral suspension 5mg/mL Preferred without prior authorization Riluzole tablet ( Generic for Rilutek ) 50mg Prior authorization is not required Quantity limit of 62 tablets per 31 days Synarel spray 2mg/mL Preferred with prior authorization LOS SIGUIENTES MEDICAMENTOS SE INCLUIRN COMO NO PREFERIDOS EN LA PDL A PARTIR DEL JULY 1, 2023 .Nombre del producto Dosis NotasChlordiazepoxide-Clidinium capsule (Generic for Librax ) 5mg-2.5mg Not paid for by the Arkansas PASSE Medicaid program Covaryx Half Strength tablet 0.625mg – 1.25mg Not paid for by the Arkansas PASSE Medicaid program Covaryx tablet 1.25-2.5mg Not paid for by the Arkansas PASSE Medicaid program Diazoxide suspension (generic for Proglycem) 5mg/mL Prior authorization is r equired Brand name Proglycem is preferred without prior authorization ED-Spaz oral disintegrating tablet 0.125mg Not paid for by the Arkansas PASSE Medicaid program EEMT Double Strength tablet 1.25mg – 2.5mg Not paid for by the Arkansas PASSE Medicaid program EEMT Half Strength tablet 0.625mg – 1.25mg Not paid for by the Arkansas PASSE Medicaid program Epinephrine auto-injector (Generic for EpiPen and EpiPen Jr) All Prior authorization is required Brand name EpiPen / EpiPen Jr are preferred without prior authorization Estrogen-Methyltestosterone Full Strength tablet 1.25mg – 2.5mg Not paid for by the Arkansas PASSE Medicaid program Estrogen-Methyltestosterone Half Strength tablet 0.625mg – 1.25mg Not paid for by the Arkansas PASSE Medicaid program Glucagon Emergency Kit 1mg Prior authorization is required Lamictal tablet 25mg, 100mg, 150mg, 200mg Generic lamotrigine tablet is preferred Took effect 5/15/2023 Latuda tablet All Generic lurasidone remains preferred with criteria Took effect 5/19/2023 Nitro-Time extended release capsule 2.5mg, 6.5mg Not paid for by the Arkansas PASSE Medicaid program Triptodur vial 22.5mg – 6month Prior authorization is required CareSourcePASSE.com LOS SIGUIENTES MEDICAMENTOS TIENEN CAMBIOS EN LA AUTORIZACIN PREVIA/CRITERIOS DE AUTORIZACIN PREVIA EN LA PDL EN VIGOR A PARTIR DEL JULY 1, 2023 .Nombre del producto Dosis NotasAmitiza capsule All Prior authorization is required if under 18 years of age Camcevi syringe 42mg Medical benefit review to determine if treatment is essential for prostate cancer diagnosis Eligard syringe kit 7.5 mg, 22.5 mg-3 month , 30 mg-4 month, and 45 mg-6 month Medical benefit review to determine if treatment is essential for prostate cancer diagnosis Gabapentin solution (Generic for Neurontin ) All Prior authorization is not required if under 7 years of age or if you have had a medical condition called NPO (nothing by mouth) and it was billed as a diagnosis within the past year Took effect 4/17/2023 Lupron Depot syringe kit 22.5 mg-3 month, 30 mg-4 month, 45mg-6 month Medical benefit review to determine if treatment is essential for prostate cancer diagnosis Lupron 2 week kit 1mg/0.2mL Medical benefit review to determine if treatment is essential for prostate cancer diagnosis Sublocade syringe All Now accepted on the pharmacy benefit in addition to the medical benefit Took effect 5/22/2023 Trelstar vial 3.75 mg, 11.25 mg, 22.5 mg Medical benefit review to determine if treatment is essential for prostate cancer diagnosis RESUMEN DE CAMBIOS A LOS PRODUCTOS QUE NO ESTN EN LA PDL DE MEDICAID DE ARKANSAS EN VIGOR A PARTIR DEL JULY 1, 2023 :LOS SIGUIENTES MEDICAMENTOS TIENEN CAMBIOS EN LA AUTORIZACIN PREVIA/CRITERIOS DE AUTORIZACIN PREVIA EN VIGOR A PARTIR DEL JULY 1, 2023 .Nombre del producto Dosis Notas Afinitor tablet All No longer preferred by Arkansas PASSE Medicaid program Took ef fect 3/1/2023 CareSourcePASSE.com Briumvi vial 150mg/6mL Medical benefit review to determine if treatment is essential Dartisla orally disintegrating tablet 1.7mg New criteria Quantity limit of 124 tablets per 31 days Exservan film 50mg New criteria Quantity limit of 62 films per 31 days Ferrlecit vial 62.5mg/5mL Medical benefit review to determine if treatment is essential Preferred with prior authorization Trial of Ferrlecit, Infed or Venofer is required before a non – preferred iron injection product is approved Filspari tablet 200mg, 400mg New criteria Quantity limit of 31 tablets per 31 days Glycate tablet 1.5mg New criteria Hemgenix kit All Medical benefit review to determine if treatment is essential Infed vial 100mg/2mL Medical benefit review to determine if treatment is essential Preferred with prior authorization Trial of Ferrlecit, Infed or Venofer is required before a non – preferred iron injection product is approved Jaypirca tablet 50mg, 100mg New criteria Quantity limit of 31 tablets per 31 days of 50mg and 62 tablets per 31 days of 100mg Kalydeco granule packet, tablet All Updated criteria Kevzara pen, syringe All New criteria for polymyalgia rheumatica Krazati tablet 200mg New criteria Quantity limit of 180 tablets per 30 days Leqembi vial All Medical benefit review to determine if treatment is essential Nalmefene vial 2mg/2mL Medical benefit review to determine if treatment is essential Orkambi granule packet, tablet All Updated criteria CareSourcePASSE.com Orserdu tablet 86mg, 345mg New criteria Quantity limit of 93 tablets per 31 days of 86mg and 31 tablets per 31 days of 345mg Radicava oral suspension 105mg/5mL New criteria Quantity limit of o ne 50 mL or 70mL bottle per 28 days Rebyota rectal suspension 500mL Medical benefit review to determine if treatment is essential Relyvrio powder in packet 3gm-1gm New criteria Quantity limit of 62 powder packets per 31 days Sunlenca t ablet 300mg New criteria Quantity limit of 1 oral tablet pack per year (qty 4 or 5 depending on regimen chosen) Sunlenca vial 463.5mg/1.5mL New criteria Quantity limit of 1 injection kit (2 vials) every 6 months Symdeko tablet All Updated criteria Tiglutik oral suspension 50mg/10mL New criteria Quantity limit of 620 mL per 31 days Trikafta tablet All Updated criteria Tzield vial 2mg/2mL Medical benefit review to determine if treatment is essential Venofer vial 200mg/10mL Medical benefit review to determine if treatment is essential Preferred with prior authorization Trial of Ferrlecit, Infed or Venofer is required before a non – preferred iron injection product is approved Qu debe hacer?Primero, hable con la persona que le receta. Hay distintas formas en que usted y la persona que receta pueden encontrar informacin sobre medicamentos: Puede busca r en nuestro sitio web, en CareSourcePASSE.com . En la pginaAfiliados, vaya a Herramientas y Recursos y haga clic en Encontrar mis medicamentos con receta. CareSourcePASSE.com Ollame al Departamento de Servicios para Afiliados, al 1-833-230-2005 (TDD/TTY: 711). Estamos aqu para ayudarle. El Departamento de Servicios para Afiliados a CareSource PASSE est abierto de lunes a viernes, de 8 a. m. a 5 p. m. hora del centro.Atentamente,CareSource PASSEAR-PAS-M-1135300-SP-V.6 Aprobado por DHS: 3/18 /2022
P.O. Box 8738, Dayton, OH 45401-8738 | CareSource.comAsunto: Resumen de cambios en la PDL vigentes a partir del July 1, 2023Estimado(a) afiliado(a) a CareSource:Su atencin mdica es nuestra prioridad. Por ello le escribimos para informarle que laLista de Medicamentos Preferidos (Preferred Drug List, PDL) de CareSource cambiar el July 1, 2023 . Una PDL es una lista de medicamentos preferidos.LOS SIGUIENTES MEDICAMENTOS TIENEN UN CAMBIO DE ESTADO A PARTIRDEL July 1, 2023 .Nombre de Marca Nombre Genrico Dosis Notas Si Corresponde Estrogen – Methyltestoster one Estrogen – Methyltestosterone 0.625 mg-1.25 mg tablet Not a covered product Hydrocortisone-Pramoxine Hydrocortisone – Pramoxine 2.5 % -1 % cream Not a covered productHyosyne Hyoscyamine Sulfate 0.125 mg /mL drops and 125 mcg /5 mL elixir Not a covered product Oscimin Hyoscyamine Sulfate 0.125 mg tablet Not a covered product Pyridium Phenazopyridine 100 mg and 200 mg tablet Not a covered produc t Urea Urea 40% cream Not a covered product Qu debe hacer?Primero, hable con la persona que le receta. Es posible que haya otros medicamentos en la PDL de CareSource que puede tomar en su lugar. Hay algunas formas para que usted o la persona que le receta puedan encontrar los medicamentos: Puede buscar en nuestro sitio web: CareSource.com . En la pgina de "Afiliados", vaya a "Herramientas y recursos" y haga clic en Encontrar mis medicamentos con receta”. Obien, llame a nuestro Departamento de Servicios para Afiliados al 1-844-607-2829 (TTY: 1-800-743-3333 o 711). Estamos aqu para ayudarle. El Departamento de Servicios para Afiliados est abierto de lunes a viernes, de 8 a. m. a 8 p. m. hora del este. Atentamente,CareSource RxInnovationsRR2022-IN-MMED-1895-SP-V.2 ; Primer Uso: 1/17/2023 ; Aprobado por OMPP: 1/17/2023
Formulario de reclamos para afiliados A.INFORMACIN DEL SUSCRIPTOR 1a.ID de afiliado 2a.Plan de salud 3a N. de telfono: ( ) 4a.Apellido: 5a.Primer 6a.I nic. del 2. nombre: nombre: 7a . Fecha de nacimiento/ / 8a.Direccinparticular: 9a.Ciudad : 10a.Estado: 11a.Cdigo postal:B.INFORMACIN DEL PACIENTE C.INFORMACIN SOBRE ACCIDENTES (si corresponde)1c. Accidente 2c.Fecha en que ocurri TrabajoAuto Otro el accidente: / /3c.Cmo ocurri el accidente?D. OTRO SEGURO 1d.El paciente tiene cobertura de otro plan de seguro?SNo Si es S, complete lo siguiente:2d.Nombre de la persona 3d.Fecha de nacimiento que cuenta con otro seguro:/ /4d.Identificacin del afiliado : 5d.Nombre de la otra compaa de seguros:6d.Nmero de 7d.Nombre del pliza: empleador: 8d.TODA PERSONA QUE A SABIENDAS PRESENTE UNA DECLARACIN DE RECLAMO QUE CONTENGA CUALQUIER TIPO DE INTERPRETACIN ERRNEA DE INFORMACIN ENGAOSA, FALSA OINCOMPLETA SER CONSIDERADA CULPABLE DE UN DELITO PENADO POR LEY YESTAR SUJETA A SANCIONES CIVILES. CERTIFICO QUE LA INFORMACIN SUMINISTRADA ES VERDADERA YCORRECTA. Firma del afiliado o del padre/madre/tutor: Fecha:E.ASIGNACIN DE BENEFICIOS 1e.Firme a continuacin solo si desea que CareSource le pague los beneficios directamente al proveedor de servicios mdicos. Firma del afiliado o padre/madre/tutor:Fecha: PAUTAS PARA PRESENTAR RECLAMOS ACareSourceUse clip, no grapas, para adjuntar todas las facturas al formulario completo y enviar todo por correo a CareSource a la direccin provista a continuacin.Asegrese de que todas las facturas indiquen un cdigo de diagnst ico, cdigo de procedimiento, fecha y costo del servicio.Proporcione una copia del formulario UB92 o del formulario HCFA1500 (este formulario puede proporcionrselo su proveedor de servicios).Incluya su N. de afiliado en todos los documentos y enve todos los reclamos a CareSource puntualmente.Enve los reclamos a: P.O. Box 8730, Dayton, OH 45401-8730Este formulario no puede ser utilizado para reclamos de farmacias IN-MMED-2864a-SP, First Use: 5/25/2023 OMPP Approved: 5/25/20231b. Identificacin de afiliado del paciente :2b. Apellido: 3b.Primer 4b.I nic. del 2. nombre: nombre: 6b.Direccin particular: 7b.Ciudad : 8b.Estado: 9b.Cdigo postal : 10b. Sexo: MF 11b.Relacin con 12b.Estudiante a tiempo completo: 13b.Nombre de la escuela: el suscriptor: SNo Servicios dentales Todos los dems servicios5b . Fecha de nacimiento/ / ENGLISH-Language assistance services, free of charge, are available to you. Call: 1-844-607-2829 (TTY: 1-800-743-3333 or 711).SPANISH-Servicios gratuitos de asistencia lingstica, sin cargo, disponibles para usted. Llame al: 1-844-607-2829 (TTY: 1-800-743-3333 or 711).NEPALI – : 1-844-607-2829(TTY: 1-800-743-3333 or 711). KOREAN – . : 1-844-607-2829 (TTY: 1-800-743-3333 or 711). FRENCH-Services daide linguistique offerts sans frais. Composez le 1-844-607-2829 (TTY: 1-800-743-3333 or 711). GERMAN-Es stehen Ihnen kostenlose Sprachassistenzdienste zur Verfgung. Anrufen unter: 1-844-607-2829 (TTY: 1-800-743-3333 or 711).SIMPLIFIED CHINESE-1 – 844-607-2829 (TTY: 1-800-743-3333 or 711).TELUGU – , . : 1-844-607-2829 (TTY: 1-800-743-3333 or 711). BURMESE – : 1-844-607-2829 (TTY: 1-800-743-3333 or 711). .- ARABIC: 1-844-607-2829:( 1-800-743-3333 711.)URDU – AVISO DE NO DISCRIMINACIN CareSource cumple con las leyes federales y estatales vigentes sobre derechos civiles. No discriminamos, ni excluimos a las personas, ni las tratamos de forma distinta debido a la edad, el gnero, la identidad de gnero, el color, la raza, una discapacidad, el origen nacional, el origen tnico, el estado civil, la preferenc ia sexual, la orientacin sexual, la afiliacin religiosa, el estado de salud o el estado de asistencia pblica. CareSource ofrece ayuda y servicios gratuitos a personas con discapacidades o aquellas personas cuya lengua materna no es el ingls. Podemos ob tener intrpretes de lengua de seas o de otros idiomas para que puedan comunicarse con nosotros o sus proveedores de manera efectiva. Tambin hay materiales impresos gratuitos disponibles en letra grande, braille o audio. Si necesita alguno de estos servi cios, llame a Servicios para Afiliados al nmero que se encuentra en su tarjeta de identificacin de CareSource. : 1-8 44-6 07-2829 (TTY: 1-8 00-743-3333 or 711).PENNSYLVANIA DUTCH-Mir kenne dich Hilf griege mit Deitsch, unni as es dich ennich eppes koschte zellt. Ruf 1-8 44-607-2829 (TTY: 1-8 00-743-3333 or 711) uff. RUSSIAN – . : 1-8 44-6 07-2829 (TTY: 1-8 00-743-3333 or 711).TAGALOG-May mga serbisyong tulong sa wika, na walang bayad, na magagamit mo. Tumawag sa: 1-8 44-6 07-2829 (TTY: 1-8 00-743-3333 or 711).VIETNAMESE-Dch v h tr ngn ng min ph dnh cho bn. Gi: 1-8 44-607-2829 (TTY: 1-8 00-743-3333 or 711). GUJARATI – :. 1-8 44-6 07-2829 (TTY: 1-8 00-743-3333or 711) .PORTUGUESE-Servios lingusticos gratuitos disponveis para voc. Ligue para: 1-844-607-2829 (TTY: 1-800-7 43-3333 or 711). MARSHALLESE-Jerbal in jiba ikijen kajin, ejelok onean, ej bellok an eok. Kurlok: 1-844-6 07-2829 (TTY: 1-8 00-743-3333 or 711). Correo postal : CareSource, Attn: Civil Rights Coordinator P.O. Box 1947, Dayton, Ohio 45401 Correo electrnico : CivilRightsCoordinator@CareSource.com Telfono : 1-844-539-1732Fax : 1-8 44-417-6 254 Tambin puede presentar una queja ante la Oficina de Derechos Civiles del Departamento de Salud y Servicios Humanos de EE. UU. Correo postal : U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F HHH Building Washington, D.C. 20201 Telfo no: 1-800-3 68-1019 (TTY: 1-8 00-537-7697) En lnea : ocrportal.hhs.gov/ocr/portal/lobby.jsf Los formularios de queja estn disponibles en: www.hhs.gov/ocr/office/file/index.html. Puede presentar una queja si considera que no le hemos brindado estos servicios o que discriminamos en su contra de cualquier otra manera. 2022 CareSource. Todos los derechos reservados. RR2022-IN-MED-M-15 68661-SP | Primer uso: 12/4/2022Aprobado por OMPP: 12/4/2022
Quiroprctico Sala de emergencias clnicas de salud rurales (RHC) Hospital (pacientes internados y ambulatorios) Proveedores de atencin primaria, como mdicos, obstetras/gineclogos, asistentes mdicos y enfermeros profesionales Telesalud (visita mdica virtual por telfono o en lnea) Especialistas (podiatra, neurlogo, onclogo, etc.) Servicios de atencin de urgencia Atencin preventiva y pruebas de deteccin Prueba de deteccin de aneurisma de aorta abdominal Pruebas y tratamiento de alergias Visita anual de bienestar Evaluacin de trastornos del espectro autista Control de la presin arterial Prueba de deteccin de cncer de mama (mamografa) Prueba de deteccin de cncer de cuello de tero y vaginal (prueba de Papanicolau) Control del colesterol Prueba de deteccin de cncer colorrectal Prueba de deteccin de la diabetes Exmenes auditivos Pruebas de deteccin de hepatitis A, By C Prueba de deteccin de VIH Inmunizaciones (vacunas) Prueba de deteccin de cncer de pulmn Asesora nutricional Control de obesidad/IMC y asesoramiento diettico Exmenes fsicos Prueba de deteccin de cncer de prstata Exmenes fsicos para deportes Prueba de deteccin y asesoramiento sobre ITS/ETS Prueba de deteccin y asesoramiento para dejar de fumar y consumir tabaco Exmenes de la vista Prueba de deteccin peridica temprana, diagnstico y tratamiento (para menores de 21 aos) Evaluacin integral de la salud y del desarrollo Educacin sobre la salud Examen de la audicin Inmunizaciones (vacunas) Anlisis de laboratorio Prueba de deteccin de plomo en la sangre Evaluacin nutricional Examen de la vista Atencin mdica domiciliaria Asistente de enfermera Servicios de cuidados paliativos a domicilio Terapia de infusin Servicios de cuidados personales Fisioterapia Atencin de enfermera privada Servicios domiciliarios y basados en la comunidad Equipo de adaptacin Servicios diurnos de rehabilitacin para adultos Asistencia conductual Servicios de relevo para cuidadores Servicios de apoyo para nios y jvenes Servicios de transicin comunitaria (CTS) Servicios de consulta Intervencin en crisis Relevo de emergencia Asociados de apoyo parala familia Intervencin en crisis mvil Servicios del Programa de hospitalizacin parcial (PHP) Apoyo de pares Asesoramiento farmacolgico por parte de enfermero/a registrado/a Programa residencial de reinsercin en la comunidad Suministros mdicos especializados Desintoxicacin por abuso de sustancias (observacional) Empleo asistido Vivienda asistida Desarrollo asistido de habilidades para la vida Servicios de apoyo complementario (SSS) Comunidades teraputicas Hogares de acogida con cuidados teraputicos En CareSource PASSE, nos preocupamos por usted. Sabemos que la salud y el bienestar implican ms que solo una excelente atencin mdica. Por ese motivo, contiene todos los servicios y la atencin cubiertos que usted tiene * ? V H O D S D U D S R Q H U O R V E H Q H F L R V D V X V H U Y L F L R ( Q V X P D Q X D O G H O D O L D G R sobre los servicios y la atencin cubiertos en esta lista. Vea el manual CareSourcePASSE. com en la pestaa de planes. Es posible que se necesite una autorizacin previa para algunos estos servicios. Autorizacin previa D O J X Q R V G H H V W R V E H Q H F L R V W H Q J D Q necesidad mdica. GUA RPIDA DE BENEFICIOS ambulatorios (en el centro, profesionales, de diagnstico) Quimioterapia/radioterapia Dilisis Estudios mediante imgenes (tomografa computarizada (TC)/exploracin por tomografa por emisin de positrones (PET)/imgenes por resonancia magntica (MRI) Terapia de infusin Servicios de observacin Centro de servicios mdicos para pacientes ambulatorios Procedimientos, anlisis de laboratorio y pruebas de diagnstico en el hospital para pacientes ambulatorios Ciruga en el hospital como paciente ambulatorio y centro quirrgico ambulatorio (ASC) Servicios de salud mental para pacientes ambulatorios Tratamiento por abuso de sustancias en pacientes ambulatorios Radiografas y diagnstico por imgenes Servicios de centros para pacientes hospitalizados Servicios en centros de cuidados paliativos Servicios hospitalarios para pacientes internados Servicios hospitalarios de rehabilitacin para pacientes internados Servicios de mdicos para pacientes internados Ciruga como paciente internado Atencin de relevo para pacientes internados Centros de atencin intermedia Atencin aguda a largo plazo (LTAC) Centro de tratamiento residencial psiquitrico (PRTF) Enfermera especializada Manejo de afecciones de salud Terapia de anlisis del comportamiento aplicado (ABA) Intervencin teraputica clnica Terapia por inhalacin Control del dolor medial/facetario implantadas las articulaciones sacroilacas mdula espinal (SCS)desencadenantes Servicios de terapia y del lenguaje)Equipo mdico permanente y suministros Implantes cocleares y bateras Suministros para la diabetes Nutricin enteral/parenteral y suministros Anteojos Suministros para la incontinencia Oxgeno y suministros relacionados Aparatos ortopdicos y prtesis Silla de ruedas y andadores Cuidado de heridas Servicios de salud conductual (servicios de salud mental y para trastornos por abuso de sustancias) Tratamiento conductual adaptativo Psicoterapia familiar (asesoramiento sobre salud conductual de pareja/familiar) Asesoramiento farmacolgico grupal Psicoterapia grupal Asesoramiento farmacolgico individual Psicoterapia individual (asesoramiento sobre salud conductual individual) Evaluacin diagnstica psiquitrica (diagnstico de salud mental) Evaluacin diagnstica psiquitrica con servicios mdicos (evaluacin psiquitrica) Servicios de rehabilitacin psicosocial Desintoxicacin por abuso de sustancias Farmacia y medicamentos Medicamentos con receta de marca y genricos Programa de restriccin de proveedores Programa de gestin de terapia de medicamentos (MTM) Suministros para desechar medicamentos Planificacin familiar y Anticoncepcin Clases sobre lactancia Exmenes de Servicios de tratamientos de la infertilidad(solo diagnstico) Servicios hospitalarios de maternidad/parto para pacientes internados Clases de Lamaze o cursos de actualizacin Educacin parental Visitas prenatales y posparto al proveedor y visitas domiciliarias Visitas de beb sano Servicios quirrgicos Ciruga baritrica Ciruga por blefaroplastia Ciruga esttica Ciruga reconstructiva Llame a Servicios para Afiliados al 1-833-230-2005 (TDD/TTY: 711) si tiene alguna pregunta o si quiere obtener ms informacin sobre esta lista. Nuestro horario de atencin b S b P K R U D F H Q W U D O 6 X F R R U G L Q D G R U ayudarle a entender esta lista.
Healthy Indiana Plan (HIP) Plus, HIP State Plan Plus Vigencia 2/1/2026CareSource Healthy Indiana Plan (HIP) Plus, HIP State Plan Plus 1/1/2026 INTRODUCCIN Esta es la Lista de medicamentos preferidos (Preferred Drug List, PDL) de Medicaid de CareSource de 2026. Esta lista puede ayudar a los proveedores a seleccionar los productos m is adecuados y de menor costo. Todos los medicamentos de Medicaid de Indiana est in cubiertos por CareSource. Esta es solo una lista de medicamentos preferidos. Estos medicamentos han sido revisados por el Comit de Farmacia y Teraputica (Pharmacy and Therapeutics, P&T) de CareSource. La lista se encuentra actualizada al momento de la revisin. No prometemos la exactitud de los datos. Tampoco pretende ser una lista completa. No sustituye la habilidad y el criterio del proveedor. Es solo una gua de referencia. Los proveedores son totalmente responsables de todas las opciones de medicamentos. La lista est i su Meta a regulaciones estatales. Esto puede incluir: ODVUHJXODFLRQHVVREUHHOXVRGHPHGLFDPHQWRVJHQpULFRV ODVOLVWDVGHVXVWDQFLDVFRQWURODGDV ODSUHIHUHQFLDSRUODPDUFD ORVPHGLFDPHQWRVJHQpULFRVREOLJDWRULRVFXDQGRFRUUHVSRQGD RWUDVQRUPDWLYDV 1RVRPRVUHVSRQVDEOHVGHODVDFFLRQHVGHQLQJ~QSURYHHGRU/RVSURYHHGRUHVGHEHQFRQVXOWDUODVUHIHUHQFLDVHVWiQGDUGHOIDEULFDQWHGHPHGLFDPHQWRVPREFACIO La lista est ordenada por secciones. Cada seccin se divide por clase de medicamento teraputico, segn el mtodo de accin. Los productos se mencionan por nombre genrico. El nombre de marca tambin figura en la lista. Esto es solo a fines informativos. A menos que se trate de un caso especial, se incluye la dosis, la presentacin y la concentracin del medicamento. COMIT DE FARMACIA YTERAPUTICA (P&T) Las terapias farmacolgicas seguras y eficaces son aprobadas por un Comit nacional de farmacia y teraputica (Pharmacy and Therapeutics, P&T). Est compuesto por: los directores mdicos del plan;el personal de farmacia;la comunidad mdica. Healthy Indiana Plan (HIP) Plus, HIP State Plan Plus Vigencia 2/1/2026 DESCRIPCIONES DE LOS PRODUCTOS INCLUIDOS EN LA LISTA DE MEDICAMENTOS Una determinada concentracin, dosificacin u otra formulacin solo estar cubierta si aparece en la lista. Las versiones no incluidas no estn cubiertas. Las formas inyectables del producto son un ejemplo. Los productos de liberacin prolongada y retardada tienen su propio listado. Se mencionan las excepciones que pueden existir. Pregabalina Lyrica Todas las concentraciones de Lyrica estn incluidas en esta lista. Colestipol, comprimidos Colestid El nombre genrico aparece en la lista. Las presentaciones en paquetes o grnulos orales no estn incluidas; tienen su propia entrada. Metformina Glucophage La entrada correspondiente a la presentacin de liberacin inmediata no incluye el producto de liberacin prolongada. Metformina ext-rel Glucophage XR Existe una segunda entrada que muestra la versin de liberacin prolongada. La dosis se indica en la seccin correspondiente al medicamento. Neomicina/polimixina B/hidrocortisona Cortisporin Cortisporin solo figura en la lista de TICOS. Esta seccin incluye nicamente la solucin y la suspensin. La crema no est incluida en esta lista. Se encuentra en la seccin de DERMATOLOGA. SUSTITUCIN POR MEDICAMENTOS GENRICOS Un producto genrico puede reemplazar a uno de marca. La farmacia se encarga de realizar este cambio. Cuando un medicamento de marca tiene una versin genrica, deja de ser preferido. En su lugar, se cubre el genrico. La lista est sujeta a las leyes estatales sobre sustitucin por genricos. Los medicamentos genricos con frecuencia tienen un precio ms bajo que los medicamentos de marca. Se deben usar primero si cumplen con todas las normas. Los medicamentos genricos: Cuentan con la aprobacin de la FDA de EE. UU. por su seguridad y eficacia. Se fabrican bajo los mismos estndares que los medicamentos de marca.Estn probados en humanos. Deben absorberse a la misma velocidad que los medicamentos de marca. Pueden diferir en tamao, color e ingredientes inactivos.Se fabrican con la misma concentracin y dosificacin que los medicamentos de marca.Tienen el mismo efecto y ofrecen el mismo nivel de seguridad que los medicamentos de marca.DISEO DEL PLAN La lista muestra un plan del formulario de diseo cerrado. Estos medicamentos estn cubiertos por el plan como se muestra. Algunos medicamentos estn cubiertos solo si se cumplen ciertos requisitos previos. Esto puede incluir: Healthy Indiana Plan (HIP) Plus, HIP State Plan Plus Vigencia 2/1/2026 oterapia escalonada;o autorizacin previa (Prior authorization, PA);o lmites de cantidad del medicamento.Se revisarn las solicitudes de medicamentos que no cumplan con los estndares. Si un medicamento no aparece en la lista, puede solicitar una excepcin para su cobertura. Tambin se evaluarn las solicitudes basadas en la necesidad mdica. Estas se analizan conforme a los pasos de autorizacin previa (PA) o criterios para medicamentos fuera del formulario. LMITES DE CANTIDAD Los afiliados al plan HIP Plus pueden surtir los medicamentos de mantenimiento. Esto incluye a los suministros de hasta 90 das, ya sea en una farmacia o por pedido por correo. Para los afiliados a Hoosier Healthwise y HIP Basic, la cantidad mxima permitida es un suministro para 90 das. HIP PLUS HIP Plus es el plan recomendado para todos los afiliados a HIP. Tiene la mejor cobertura. Tambin incluye atencin oftalmolgica y odontolgica. Su costo mensual, tambin llamado su contribucin a la cuenta POWER, se basa en los ingresos. No pagar ningn otro costo, salvo que vaya a la sala de emergencias para obtener servicios que no se consideran de emergencia. HIP Plus cubre todos los beneficios de salud exigidos por la ley federal. Tambin incluye ms visitas anuales a terapeutas como servicios de fisioterapia, terapia del habla y ocupacional en comparacin con el programa HIP Basic. Cubre, adems, ciruga bari trica y tratamientos para trastornos de la articulacin temporomandibular (Temporomandibular Joint Disorders, TMJ). PLAN HIP STATE PLUS El plan HIP State Plus ofrece beneficios que se adaptan mejor a su situacin. Usted recibir estos beneficios por un costo mensual bajo. Esto se denomina una contribucin a la cuenta POWER. HIP Plus y HIP State Plus pueden costar menos dado que NO tiene que hacer pagos cuando visita al mdico, surte una receta o va al hospital. Si tiene el plan HIP Plus o HIP State Plus y NO realiza su contribucin a la Cuenta POWER, sus beneficios costarn ms cuando reciba atencin. AVISO Los datos de esta lista son privados. La informacin no se puede copiar en su totalidad o en parte sin una autorizacin por escrito. 2025. Todos los derechos reservados. Esta lista contiene medicamentos con receta de marca que son marcas comerciales o marcas registradas. CareSource no controla a las organizaciones mencionadas. CareSource no se responsabiliza por la exactitud del contenido. Estas referencias no constituyen recomendaciones por parte de CareSource. Nota: Esta lista se actualiza peridicamente. Es posible que los cambios aparezcan antes de su fecha de entrada en vigencia. List of Abbreviations 1: P referred generic product 2: Preferred brand product ACA: Affordable Care Act AR: Age Restriction. For certain drugs, the drug may be covered for members in a certain age range without a prior authorization. O TC: Over-the-Counter. An OTC drug is a non-prescription drug. P A: Prior Authorization. The Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval before you fill your prescriptions. If you dont get approval, we may not cover the drug. Q L: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover. S T: Step Therapy. In some cases, the Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug Bboth treat your medical condition, we may not cover Drug Bunless you try Drug A first. If Drug A does not work for you, we will then cover Drug B. 2 Indiana Medicaid Preferred Drug List T able of Contents ANALGESICS ……………………………………………………………………………………………………………………….. 3 ANESTHETICS ……………………………………………………………………………………………………………………… 5 ANTIALLERGY ………………………………………………………………………………………………………………………. 5 ANTIARTHRITICS ………………………………………………………………………………………………………………….. 5 ANTIASTHMATICS ………………………………………………………………………………………………………………… 6 ANTIBIOTICS ………………………………………………………………………………………………………………………… 7 ANTICOAGULANTS ……………………………………………………………………………………………………………… 10 ANTIDOTES ………………………………………………………………………………………………………………………… 10 ANTIFUNGALS ……………………………………………………………………………………………………………………. 11 ANTIHISTAMINE AND DECONGESTANT COMBINATION ……………………………………………………….. 11 ANTIHISTAMINES ……………………………………………………………………………………………………………….. 11 ANTIHYPERGLYCEMICS ……………………………………………………………………………………………………… 12 ANTIINFECTIVES/MISCELLANEOUS …………………………………………………………………………………….. 13 ANTIINFLAM.TUMOR NECROSIS FACTOR INHIBITING AGENTS ……………………………………………. 13 ANTINEOPLASTICS …………………………………………………………………………………………………………….. 14 ANTI-OBESITY DRUGS ……………………………………………………………………………………………………….. 15 ANTIPARASITICS ………………………………………………………………………………………………………………… 15 ANTIPARKINSON DRUGS ……………………………………………………………………………………………………. 15 ANTIPLATELET DRUGS ………………………………………………………………………………………………………. 16 ANTIVIRALS ……………………………………………………………………………………………………………………….. 16 AUTONOMIC DRUGS ………………………………………………………………………………………………………….. 17 BIOLOGICALS …………………………………………………………………………………………………………………….. 18 B LOOD ……………………………………………………………………………………………………………………………….. 19 CARDIAC DRUGS ……………………………………………………………………………………………………………….. 19 CARDIOVASCULAR …………………………………………………………………………………………………………….. 20 CNS DRUGS ……………………………………………………………………………………………………………………….. 22 COLONY STIMULATING FACTORS ………………………………………………………………………………………. 25 CONTRACEPTIVES ……………………………………………………………………………………………………………… 25 COUGH/COLD PREPARATIONS …………………………………………………………………………………………… 29 DIURETICS …………………………………………………………………………………………………………………………. 29 EENT PREPS ………………………………………………………………………………………………………………………. 29 ELECT/CALORIC/H2O ………………………………………………………………………………………………………….. 30 GASTROINTESTINAL …………………………………………………………………………………………………………… 33 HORMONES ………………………….. …………………………………………………………………………………………… 35 IMMUNOSUPPRESSANTS ……………………………………………………………………………………………………. 38 MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG ……………………………………………… 38 MUSCLE RELAXANTS …………………………………………………………………………………………………………. 40 PRE-NATAL VITAMINS …………………………………………………………………………………………………………. 40 PSYCHOTHERAPEUTIC DRUGS ………………………………………………………………………………………….. 41 SEDATIVE/HYPNOTICS ……………………………………………………………………………………………………….. 48 SKIN PREPS ……………………………………………………………………………………………………………………….. 48 SMOKING DETERRENTS …………………………………………………………………………………………………….. 50 THYROID PREPS ………………………………………………………………………………………………………………… 50 U NCLASSIFIED DRUG PRODUCTS ………………………………………………………………………………………. 51 VITAMINS …………………………………………………………………………………………………………………………… 53 INDIANA MEDICAID | Effective 02/01/2026 3 CURRENT AS OF 2/1/2026 Drug Name Tier Restrictions / Limits ANALGESICS acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 300 mg-30 mg /12.5 ml 1 PA acetaminophen-codeine oral solution 120-12 mg/5 ml 1 PA;QL ( 3 ML per 1 day); ARacetaminophen-codeine oral tablet 1 PA; QL (3 EA per 1 day); AR AIMOVIG AUTOINJECTOR 2 QL (140 ML per 22 days) AJOVY AUTOINJECTOR 2 PA; ST; QL (1.5 ML per 22 days) AJOVY SYRINGE 2 PA; ST; QL (1.5 ML per 22 days) ASCOMP WITH CODEINE 1 PA; ST; AR buprenorphine hcl injection 1 PA; ST butalbital-acetaminop – caf-cod oral capsule 50-300-40-30 mg 1 PA; ST; QL (3EA per 1 day)butalbital-acetaminop-caf-cod oral capsule 50-325-40-30 mg 1 PA; ST; QL (3 EA per 1 day); AR butalbital – acetaminophen oral tablet 50-325 mg 1 QL( 48 EA per 25 days)butalbital-acetaminophen-caff oral capsule 50-325-40 mg 1 QL( 48 EA per 25 days)butalbital-acetaminophen-caff oral tablet 1 QL( 48 EA per 25 days)butalbital-aspirin-caffeine oral capsule 1 QL (48 EA per 30 days) butorphanol injection 1 PA; ST; AR butorphanol nasal 1 PA; ST; QL (2.5 ML per 30 days); AR Drug Name Tier Restrictions / Limits BUTRANS 2 PA; QL (4 EA per 28 days) codeine sulfate 1 PA; ST; AR codeine-butalbital-asa – caff 1 PA; ST; AR diclofenac potassium oral tablet 1 diflunisal 1 dihydroergotamine injection 1 DURAMORPH (PF) 1 PA ELMIRON 2 ELYXYB 2 PA; ST; QL (120 ML per 1 day) EMGALITY PEN 2 PA; ST; QL (240 ML per 22 days); AR EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 120 MG/ML 2 PA; ST; QL (240 ML per 22 days); AR ENDOCET 1 PA; QL (3 EA per 1 day) ergotamine-caffeine 1 fentanyl 1 PA; QL (10 EA per 22 days) hydrocodone – acetaminophen oral solution 7.5-325 mg/15 ml 1 PA; QL (3 ML per 1 day) hydrocodone – acetaminophen oral tablet 10-300 mg, 10-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg 1 PA; QL (3 EA per 1 day) hydrocodone-ibuprofen 1 PA hydromorphone (pf) injection solution 1 mg/ml, 4 mg/ml 2 PA hydromorphone (pf) injection solution 10 mg/ml, 2 mg/ml 1 PA INDIANA MEDICAID | Effective 02/01/2026 4Drug Name Tier Restrictions / Limits hydromorphone (pf) injection syringe 0.5 mg/0.5 ml, 1 mg/ml 1 PA hydromorphone injection solution 1 PA hydromorphone injection syringe 0.25 mg/0.5 ml, 0.5 mg/0.5 ml 2 PA hydromorphone injection syringe 1 mg/ml, 2 mg/ml, 4 mg/ml 1 PA hydromorphone oral liquid 1 PA hydromorphone oral tablet 1 PA hydromorphone rectal 1 PA ketorolac oral 1 QL (20 EA per 30 days) levorphanol tartrate 1 PA meperidine 1 PA meperidine (pf) 1 PA MIGERGOT 1 morphine (pf) injection 1 PA morphine (pf) intravenous patient control.analgesia soln 1 PA morphine concentrate oral solution 1 PA morphine concentrate oral syringe 10 mg/0.5 ml 2 PA morphine concentrate oral syringe 20 mg/ml 1 PA morphine injection solution 10 mg/ml, 2 mg/ml, 4 mg/ml, 5 mg/ml 2 PA morphine injection solution 8 mg/ml 1 morphine injection syringe 2 mg/ml 2 PA Drug Name Tier Restrictions / Limits morphine injection syringe 4 mg/ml 1 PA morphine intravenous solution 10 mg/ml, 4 mg/ml, 50 mg/ml 1 PA morphine intravenous solution 8 mg/ml 2 PA morphine intravenous syringe 1 PA morphine oral solution 1 PA morphine oral tablet 1 PA morphine oral tablet extended release 1 PA; QL (3 EA per 1 day) morphine rectal 1 PA nalbuphine 1 PA NUCYNTA 2 PA; QL (6 EA per 1 day) NUCYNTA ER 2 PA; QL (2 EA per 1 day) NURTEC ODT 2 PA; ST; AR oxycodone oral capsule 1 PA oxycodone oral concentrate 1 PA oxycodone oral solution 1 PA oxycodone oral tablet 1 PA oxycodone – acetaminophen oral tablet 1 PA pentazocine-naloxone 1 PA QULIPTA 2 PA; ST; QL (30 EA per 28 days); AR rizatriptan oral tablet 1 QL (12 EA per 22 days) rizatriptan oral tablet,disintegrating 1 QL (12 EA per 30 days) sumatriptan 1 QL (6 EA per 22 days) sumatriptan succinate oral 1 QL (9 EA per 22 days) sumatriptan succinate subcutaneous 1 QL (1 ML per 22 days) 5 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits TENCON 1 QL (48 EA per 25 days) tramadol oral tablet 100 mg 2 PA; ST; QL (400 MG per 1 day) tramadol oral tablet 25 mg 2 PA; ST tramadol oral tablet 50 mg 1 PA; ST; QL (400 MG per 1 day); AR tramadol oral tablet 75 mg 1 PA tramadol-acetaminophen 1 PA; ST; QL (3 EA per 1 day); AR UBRELVY 2 PA; ST; QL (10 EA per 20 days); AR ANESTHETICS DERMACINRX LIDOCAN 1 GLYDO 1 QL (1 ML per 1 day) lidocaine hcl mucous membrane jelly 1 lidocaine hcl mucous membrane jelly in applicator 1 QL (1 ML per 1 day) lidocaine hcl mucous membrane solution 2 % 1 lidocaine hcl mucous membrane solution 4 % (40 mg/ml) 1 PA; QL (50 ML per 30 days) lidocaine topical adhesive patch,medicated 5 % 1 QL (3 Boxes per 22 days) LIDOCAINE VISCOUS 1 QL (100 ML per 25 days) lidocaine-prilocaine topical cream 1 QL (1 GM per 1 day) LIDOCAN III 1 LIDOCAN IV 1 LIDOCAN V 1 Drug Name Tier Restrictions / Limits LIDODERM 2 QL (3 EA per 30 days) midazolam (pf) injection solution 1 midazolam (pf) injection syringe 2 mg/2 ml (1 mg/ml) 1 midazolam (pf) injection syringe 5 mg/ml 1 PA midazolam injection 1 midazolam intravenous syringe 150 mg/30 ml (5 mg/ml) 2 phenazopyridine oral tablet 100 mg, 200 mg 1 TRIDACAINE II 1 TRIDACAINE III 1 ZTLIDO 2 ST; QL (3 EA per 30 days) ANTIALLERGY cromolyn oral 1 PA ANTIARTHRITICS allopurinol oral tablet 100 mg, 300 mg 1 CELEBREX 2 colchicine oral tablet 1 QL (2 EA per 1 day) diclofenac sodium oral 1 etodolac 1 febuxostat 1 ST flurbiprofen 1 IBU 1 ibuprofen oral tablet 400 mg, 600 mg, 800 mg 1 INDOCIN 2 indomethacin oral capsule 1 indomethacin oral capsule, extended release 1 indomethacin rectal suppository 50 mg 1 INDIANA MEDICAID | Effective 02/01/2026 6Drug Name Tier Restrictions / Limits ketoprofen oral capsule 50 mg, 75 mg 1 ketoprofen oral capsule,ext rel. pellets 24 hr 1 KINERET 2 PA; QL (28 ML per 28 days) leflunomide 1 meclofenamate 1 meloxicam oral tablet 1 nabumetone 1 naproxen oral tablet 1 naproxen oral tablet,delayed release (dr/ec) 1 naproxen sodium oral tablet 275 mg, 550 mg 1 OLUMIANT ORAL TABLET 1 MG 2 PA OLUMIANT ORAL TABLET 2 MG, 4 MG 2 PA; QL (1 EA per 1 day) ORENCIA (WITH MALTOSE) 2 PA; QL (4 EA per 22 days) ORENCIA CLICKJECT 2 PA; QL (4 ML per 22 days) ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML 2 PA; QL (4 ML per 22 days) ORENCIA SUBCUTANEOUS SYRINGE 50 MG/0.4 ML, 87.5 MG/0.7 ML 2 PA OTEZLA ORAL TABLET 30 MG 2 PA; QL (2 EA per 1 day) OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4) -20 MG (4) -30 MG (47) 2 PA; QL (55 EA per 22 days) OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4) -20 MG (4) -30 MG(19) 2 oxaprozin oral tablet 1 Drug Name Tier Restrictions / Limits penicillamine oral capsule 1 piroxicam 1 probenecid 1 RINVOQ 2 PA; QL (1 EA per 1 day) RINVOQ LQ 2 sulindac 1 ULORIC 2 XELJANZ ORAL SOLUTION 2 PA; ST XELJANZ ORAL TABLET 10 MG 2 PA; QL (30 EA per 30 days) XELJANZ ORAL TABLET 5 MG 2 PA; QL (60 EA per 22 days) XELJANZ XR 2 PA; QL (30 EA per 22 days) ANTIASTHMATICS ADVAIR DISKUS 2 QL (1 EA per 22 days) ADVAIR HFA 2 QL (1 EA per 22 days) albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %) 1 QL (375 ML per 30 days) albuterol sulfate inhalation solution for nebulization 2.5 mg/0.5 ml 1 QL (2 EA per 1 day) albuterol sulfate inhalation solution for nebulization 5 mg/ml 1 QL (2 ML per 1 day) albuterol sulfate oral syrup 1 albuterol sulfate oral tablet extended release 12 hr 1 ANORO ELLIPTA 2 ST; QL (1 EA per 30 days) ARNUITY ELLIPTA 2 QL (1 EA per 30 days) 7 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits ASMANEX HFA 2 QL (1 GM per 30 days) ASMANEX TWISTHALER 2 QL (1 EA per 22 days) ATROVENT HFA 2 QL (2 GM per 30 days) budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml 1 ST; QL (120 ML per 30 days); AR budesonide inhalation suspension for nebulization 1 mg/2 ml 1 ST; QL (60 ML per 30 days); AR COMBIVENT RESPIMAT 2 QL (2 GM per 30 days) cromolyn inhalation 1 QL (8 ML per 1 day) DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 50-5 MCG/ACTUATION 2 ST; QL (2 Inhalers per 30 days) DULERA INHALATION HFA AEROSOL INHALER 200-5 MCG/ACTUATION 2 QL (1 Inhaler per 30 days) FASENRA 2 PA; ST FASENRA PEN 2 PA; ST fluticasone propionate inhalation blister with device 2 fluticasone propionate inhalation hfa aerosol inhaler 2 QL (1 GM per 22 days) INCRUSE ELLIPTA 2 QL (1 EA per 30 days) ipratropium bromide inhalation 1 QL (2 Boxes per 30 days) ipratropium-albuterol 1 QL (3 Boxes per 30 days) montelukast oral tablet 1 montelukast oral tablet,chewable 1 Drug Name Tier Restrictions / Limits NUCALA SUBCUTANEOUS AUTO-INJECTOR 2 PA; ST NUCALA SUBCUTANEOUS RECON SOLN 2 PA NUCALA SUBCUTANEOUS SYRINGE 2 PA; ST PROAIR RESPICLICK 2 ST; QL (4 EA per 72 days) PULMICORT FLEXHALER 2 QVAR REDIHALER 2 roflumilast oral tablet 250 mcg 1 ST roflumilast oral tablet 500 mcg 1 ST; QL (1 EA per 1 day) SEREVENT DISKUS 2 QL (2 EA per 1 day) SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION 2 PA; QL (1 GM per 30 days) SPIRIVA RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION 2 QL (1 GM per 30 days) SPIRIVA WITH HANDIHALER 2 QL (1 Inhaler per 30 days) SYMBICORT 2 ST; QL (2 EA per 30 days) THEO-24 2 theophylline 1 TRELEGY ELLIPTA 2 PA; ST; QL (1 EA per 28 days) VENTOLIN HFA 2 XOLAIR 2 PA; ST XOPENEX HFA 2 ST ANTIBIOTICS amoxicillin 1 amoxicillin-pot clavulanate 1 ampicillin 1 INDIANA MEDICAID | Effective 02/01/2026 8Drug Name Tier Restrictions / Limits AVAR 1 AVAR-E 2 azithromycin oral packet 1 azithromycin oral suspension for reconstitution 1 azithromycin oral tablet 250 mg 1 QL (6 EA per 30 days) azithromycin oral tablet 500 mg 1 QL (7 EA per 30 days) azithromycin oral tablet 600 mg 1 QL (1 EA per 1 day) bacitracin-polymyxin b 1 BESIVANCE 2 BICILLIN L-A 2 CAYSTON 2 PA; QL (84 ML per 28 days) cefaclor oral capsule 1 cefaclor oral tablet extended release 12 hr 1 cefadroxil 1 cefdinir 1 cefpodoxime 1 cefprozil 1 cefuroxime axetil 1 CENTANY 2 QL (22 GM per 30 days) cephalexin oral capsule 250 mg, 500 mg 1 cephalexin oral suspension for reconstitution 1 cephalexin oral tablet 1 CILOXAN 2 CIPRO HC 2 PA ciprofloxacin hcl ophthalmic (eye) 1 ciprofloxacin hcl oral 1 ciprofloxacin – dexamethasone 1 clarithromycin 1 Drug Name Tier Restrictions / Limits CLEOCIN VAGINAL CREAM 2 CLINDACIN ETZ TOPICAL SWAB 1 ST CLINDACIN P 1 ST clindamycin hcl 1 clindamycin palmitate hcl 1 CLINDAMYCIN PEDIATRIC 1 clindamycin phosphate topical gel 1 ST clindamycin phosphate topical gel, once daily 1 ST clindamycin phosphate topical lotion 1 ST clindamycin phosphate topical solution 1 ST CORTISPORIN-TC 2 dapsone oral 1 dicloxacillin 1 doxycycline hyclate oral capsule 1 doxycycline hyclate oral tablet 100 mg 1 doxycycline monohydrate oral capsule 100 mg, 50 mg 1 doxycycline monohydrate oral suspension for reconstitution 1 doxycycline monohydrate oral tablet 50 mg, 75 mg 1 erythromycin ethylsuccinate oral suspension for reconstitution 1 ST erythromycin ophthalmic (eye) 1 erythromycin oral capsule,delayed release(dr/ec) 1 9 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits erythromycin with ethanol 1 ST erythromycin-benzoyl peroxide 1 ST ethambutol 1 fidaxomicin 1 PA FIRVANQ 2 PA gentamicin 1 isoniazid oral 1 levofloxacin oral tablet 1 methenamine hippurate 1 methenamine mandelate 1 methen-sod phos-meth blue-hyos 1 metronidazole oral capsule 1 metronidazole oral tablet 250 mg, 500 mg 1 metronidazole vaginal gel 0.75 % (37.5mg/5 gram) 1 QL (70 GM per 30 days) minocycline oral capsule 1 MONDOXYNE NL ORAL CAPSULE 100 MG 1 MORGIDOX 1 moxifloxacin ophthalmic (eye) drops 1 PA; ST; AR moxifloxacin ophthalmic (eye) drops, viscous 1 AR moxifloxacin oral 1 mupirocin 1 QL (22 GM per 30 days) neomycin 1 neomycin-polymyxin b- dexameth 1 neomycin-polymyxin-gramicidin 1 neomycin-polymyxin-hc otic (ear) 1 Drug Name Tier Restrictions / Limits nitrofurantoin macrocrystal 1 nitrofurantoin monohyd/m-cryst 1 nitrofurantoin oral suspension 25 mg/5 ml 1 NUVESSA 2 ofloxacin ophthalmic (eye) 1 QL (10 ML per 30 days) ofloxacin otic (ear) 1 OTOVEL 2 penicillin v potassium 1 POLYCIN 1 polymyxin b sulf – trimethoprim 1 pretomanid 2 PRIFTIN 2 PA; AR pyrazinamide 1 rifabutin 1 rifampin oral 1 silver sulfadiazine 1 SIRTURO 2 AR SOLOSEC 2 SSD 1 sulfacetamide sodium ophthalmic (eye) drops 1 sulfacetamide sodium – sulfur topical lotion 1 sulfacetamide sodium – sulfur topical suspension 10-5 % 1 sulfacetamide – prednisolone 1 SULFACLEANSE 8-4 1 ST sulfadiazine 1 sulfamethoxazole – trimethoprim oral 1 SULFATRIM 1 SUMAXIN TS 2 ST tetracycline oral capsule 1 THALOMID 2 PA INDIANA MEDICAID | Effective 02/01/2026 10Drug Name Tier Restrictions / Limits TOBRADEX 2 TOBRADEX ST 2 tobramycin in 0.225 % nacl 1 QL (10 ML per 1 day) tobramycin ophthalmic (eye) 1 tobramycin sulfate injection solution 40 mg/ml 1 PA tobramycin with nebulizer 2 QL (10 ML per 1 day) tobramycin-dexamethasone 1 trimethoprim 1 URELLE 2 URETRON D-S 1 URYL 1 vancomycin oral recon soln 1 PA XIFAXAN ORAL TABLET 200 MG 2 PA; QL (9 EA per 28 days) XIFAXAN ORAL TABLET 550 MG 2 PA; QL (2 EA per 1 day) ZYLET 2 ANTICOAGULANTS ELIQUIS DVT-PE TREAT 30D START 2 QL (1 Pack per 90 days) ELIQUIS ORAL TABLET 2.5 MG 2 QL (2 EA per 1 day) ELIQUIS ORAL TABLET 5 MG 2 QL (4 EA per 1 day) ELIQUIS ORAL TABLET FOR SUSPENSION 2 ST; QL (16 EA per 1 day) ELIQUIS SPRINKLE 2 ST; QL (2 EA per 1 day) enoxaparin 1 fondaparinux 1 QL (1 ML per 1 day) FRAGMIN SUBCUTANEOUS SOLUTION 25,000 ANTI-XA UNIT/ML 2 PA Drug Name Tier Restrictions / Limits FRAGMIN SUBCUTANEOUS SYRINGE 2 PA HEP FLUSH-10 (PF) 1 heparin (porcine) 1 heparin lock flush (porcine) 1 HEPARIN LOCKFLUSH(PORCIN E)(PF) 1 heparin, porcine (pf) injection solution 1 heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml 1 heparin, porcine (pf) injection syringe 5,000 unit/ml 2 heparin, porcine (pf) intravenous 1 JANTOVEN 1 warfarin 1 XARELTO DVT-PE TREAT 30D START 2 QL (1 EA per 90 days) XARELTO ORAL SUSPENSION FOR RECONSTITUTION 2 ST; QL (20 ML per 1 day); AR XARELTO ORAL TABLET 10 MG, 20 MG 2 QL (1 EA per 1 day) XARELTO ORAL TABLET 15 MG 2 XARELTO ORAL TABLET 2.5 MG 2 QL (2 EA per 1 day) ANTIDOTES KLOXXADO 2 QL (2 EA per 30 days) nalmefene 2 naloxone injection solution 1 QL (2 ML per 30 days) naloxone injection syringe 1 naltrexone 1 11 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits OPVEE 2 QL (2 EA per 30 days) RELISTOR SUBCUTANEOUS 2 PA REXTOVY 2 ZIMHI 2 ANTIFUNGALS CICLODAN 1 ciclopirox topical cream 1 ciclopirox topical solution 1 clotrimazole mucous membrane 1 clotrimazole-betamethasone topical cream 1 QL (45 GM per 30 days) clotrimazole-betamethasone topical lotion 1 EXELDERM 2 fluconazole oral suspension for reconstitution 1 fluconazole oral tablet 100 mg, 200 mg 1 fluconazole oral tablet 150 mg 1 QL (4 EA per 30 days) fluconazole oral tablet 50 mg 1 QL (3 EA per 30 days) griseofulvin microsize 1 griseofulvin ultramicrosize oral tablet 125 mg, 250 mg 1 itraconazole oral capsule 1 QL (4 EA per 1 day) JUBLIA 2 ketoconazole oral 1 ketoconazole topical cream 1 QL (2 GM per 1 day) ketoconazole topical shampoo 1 QL (4 ML per 1 day) KLAYESTA 1 Drug Name Tier Restrictions / Limits NYAMYC 1 QL (2 GM per 1 day) nystatin oral 1 nystatin topical cream 1 nystatin topical ointment 1 nystatin topical powder 1 QL (2 GM per 1 day) nystatin-triamcinolone 1 NYSTOP 1 QL (2 GM per 1 day) terbinafine hcl oral 1 QL (1 EA per 1 day) terconazole vaginal cream 1 ANTIHISTAMINE AND DECONGESTANT COMBINATION PROMETHAZINE VC 1 promethazine – phenylephrine 1 ANTIHISTAMINES azelastine ophthalmic (eye) 1 BEPREVE 2 clemastine oral tablet 1 cyproheptadine 1 hydroxyzine hcl intramuscular 1 hydroxyzine hcl oral solution 10 mg/5 ml 1 QL (100 ML per 1 day) hydroxyzine hcl oral tablet 10 mg, 25 mg 1 QL (4 EA per 1 day) hydroxyzine hcl oral tablet 50 mg 1 QL (8 EA per 1 day) hydroxyzine pamoate 1 QL (4 EA per 1 day) levocetirizine oral solution 1 ST; QL (10 ML per 1 day); AR promethazine oral 1 INDIANA MEDICAID | Effective 02/01/2026 12Drug Name Tier Restrictions / Limits ANTIHYPERGLYCEMICS acarbose 1 FARXIGA 2 FIASP FLEXTOUCH U- 100 INSULIN 2 FIASP PENFILL U-100 INSULIN 2 FIASP PUMPCART 2 FIASP U-100 INSULIN 2 glimepiride oral tablet 1 mg, 2 mg, 4 mg 1 glipizide oral tablet 10 mg, 5 mg 1 glipizide oral tablet 2.5 mg 2 glipizide oral tablet extended release 24hr 1 glipizide-metformin 1 glyburide micronized oral tablet 1.5 mg 1 QL (8 EA per 1 day) glyburide micronized oral tablet 3 mg 1 glyburide micronized oral tablet 6 mg 1 QL (2 EA per 1 day) glyburide oral tablet 1.25 mg 1 QL (16 EA per 1 day) glyburide oral tablet 2.5 mg 1 QL (8 EA per 1 day) glyburide oral tablet 5 mg 1 QL (4 EA per 1 day) glyburide-metformin oral tablet 1.25-250 mg 1 QL (260 EA per 30 days) glyburide-metformin oral tablet 2.5-500 mg, 5-500 mg 1 QL (5 EA per 1 day) GLYXAMBI 2 HUMALOG MIX 50-50 KWIKPEN 2 QL (45 ML per 25 days) HUMALOG U-100 INSULIN SUBCUTANEOUS CARTRIDGE 2 QL (1 ML per 1 day) Drug Name Tier Restrictions / Limits HUMALOG U-100 INSULIN SUBCUTANEOUS SOLUTION 2 HUMULIN RU-500 (CONC) KWIKPEN 2 QL (40 ML per 25 days) insulin asp prt-insulin aspart subcutaneous insulin pen 1 insulin asp prt-insulin aspart subcutaneous solution 1 QL (40 ML per 25 days) insulin aspart u-100 2 QL (1 ML per 1 day) insulin lispro protamin – lispro 1 insulin lispro subcutaneous insulin pen 1 QL (1 ML per 1 day) insulin lispro subcutaneous insulin pen, half-unit 1 QL (1 ML per 1 day) JANUVIA 2 ST JARDIANCE 2 QL (30 EA per 28 days) JENTADUETO 2 ST JENTADUETO XR 2 ST KAZANO 2 ST LANTUS SOLOSTAR U-100 INSULIN 2 QL (1 ML per 1 day) LANTUS U-100 INSULIN 2 liraglutide 1 metformin oral tablet 1,000 mg, 500 mg, 850 mg 1 metformin oral tablet 625 mg 2 metformin oral tablet extended release 24 hr 1 NOVOLOG FLEXPEN U-100 INSULIN 2 PA; QL (1 ML per 1 day) NOVOLOG MIX 70-30 U-100 INSULN 2 QL (40 ML per 25 days) 13 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits NOVOLOG MIX 70 – 30FLEXPEN U-100 2 QL (1 ML per 1 day) NOVOLOG PENFILL U- 100 INSULIN 2 QL (1 ML per 1 day) NOVOLOG U-100 INSULIN ASPART 2 QL (1 ML per 1 day) OZEMPIC 2 PA; QL (3 ML per 22 days); AR pioglitazone 1 QL (1 EA per 1 day) repaglinide 1 sitagliptin-metformin oral tablet, er multiphase 24 hr 1 ST SOLIQUA 100/33 2 PA; ST; QL (0.6 ML per 1 day); AR SYNJARDY 2 TRADJENTA 2 ST TRESIBA FLEXTOUCH U-100 2 QL (1 ML per 1 day) TRESIBA FLEXTOUCH U-200 2 QL (1 ML per 1 day) TRESIBA U-100 INSULIN 2 QL (40 ML per 25 days) TRULICITY 2 PA; ST; QL (2 ML per 30 days); AR VICTOZA 2-PAK 2 PA; ST; QL (1.8 MG per 1 day); AR VICTOZA 3-PAK 2 PA; ST; QL (1.8 MG per 1 day); AR XIGDUO XR 2 ANTIINFECTIVES/MISCELLANEOUS atovaquone 1 atovaquone-proguanil 1 QL (12 EA per 180 days) benznidazole 2 Drug Name Tier Restrictions / Limits chloroquine phosphate 1 QL (10 EA per 180 days) COARTEM 2 QL (24 EA per 180 days) EMVERM 2 hydroxychloroquine 1 ivermectin oral tablet 3 mg 1 QL (20 EA per 90 days) KRINTAFEL 2 mefloquine 1 QL (6 EA per 180 days) praziquantel 1 primaquine 1 QL (28 EA per 14 days) pyrimethamine 1 ANTIINFLAM. TUMOR NECROSIS FACTOR INHIBITING AGENTS adalimumab-adaz subcutaneous pen injector 1 adalimumab-adaz subcutaneous syringe 10 mg/0.1 ml 1 PA adalimumab-adaz subcutaneous syringe 20 mg/0.2 ml, 40 mg/0.4 ml 1 ENBREL MINI 2 PA; QL (4 ML per 28 days) ENBREL SUBCUTANEOUS SOLUTION 2 PA; QL (4 ML per 22 days) ENBREL SUBCUTANEOUS SYRINGE 2 PA; QL (4 ML per 28 days) ENBREL SURECLICK 2 PA; QL (4 ML per 30 days) HADLIMA 2 PA HADLIMA PUSHTOUCH 2 PA HADLIMA(CF) 2 PA INDIANA MEDICAID | Effective 02/01/2026 14Drug Name Tier Restrictions / Limits HADLIMA(CF) PUSHTOUCH 2 PA SIMPONI SUBCUTANEOUS PEN INJECTOR 100 MG/ML 2 PA; QL (1 ML per 22 days) SIMPONI SUBCUTANEOUS PEN INJECTOR 50 MG/0.5 ML 2 PA; QL (0.5 ML per 22 days) SIMPONI SUBCUTANEOUS SYRINGE 100 MG/ML 2 PA; QL (1 ML per 22 days) SIMPONI SUBCUTANEOUS SYRINGE 50 MG/0.5 ML 2 PA; QL (0.5 ML per 22 days) ZYMFENTRA 2 PA ANTINEOPLASTICS abiraterone 1 PA ACTIMMUNE 2 PA AFINITOR 2 PA anastrozole 1 bexarotene oral 1 PA bexarotene topical 1 PA; QL (60 GM per 28 days) bicalutamide 1 capecitabine 1 PA COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1) 2 PA diclofenac sodium topical gel 3 % 1 PA EFUDEX 2 ELIGARD 2 ELIGARD (3 MONTH) 2 ELIGARD (4 MONTH) 2 ELIGARD (6 MONTH) 2 ERIVEDGE 2 PA erlotinib 1 PA etoposide oral 1 Drug Name Tier Restrictions / Limits everolimus (antineoplastic) oral tablet 10 mg 1 PA everolimus (antineoplastic) oral tablet for suspension 1 PA exemestane 1 FARYDAK 2 PA fluorouracil topical cream 5 % 1 fluorouracil topical solution 1 GILOTRIF 2 PA HYCAMTIN 2 PA hydroxyurea 1 IBRANCE 2 PA ICLUSIG 2 PA imatinib 1 PA IMBRUVICA ORAL CAPSULE 2 PA; QL (1 EA per 1 day) IMBRUVICA ORAL TABLET 2 PA; QL (1 EA per 1 day) INLYTA 2 PA JAKAFI 2 PA; QL (2 EA per 1 day) lapatinib 1 PA LENVIMA 2 PA letrozole 1 PA LEUKERAN 2 PA leuprolide subcutaneous kit 1 LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 22.5 MG 2 LUPRON DEPOT (4 MONTH) 2 LUPRON DEPOT (6 MONTH) 2 LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 7.5 MG 2 15 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits LYSODREN 2 MATULANE 2 megestrol oral tablet 1 MEKINIST ORAL TABLET 2 PA mercaptopurine oral tablet 1 methotrexate sodium 1 methotrexate sodium (pf) injection solution 1 MYLERAN 2 PA ONTRUZANT 2 PANRETIN 2 PA pazopanib oral tablet 200 mg 1 POMALYST 2 PA REVLIMID 2 PA romidepsin intravenous recon soln 2 PA sorafenib 1 PA SPRYCEL 2 PA sunitinib malate 1 PA TABLOID 2 PA TAFINLAR ORAL CAPSULE 2 PA tamoxifen 1 TASIGNA 2 PA temozolomide 1 PA toremifene 1 TRAZIMERA 2 TRELSTAR 2 tretinoin (antineoplastic) 1 TREXALL 2 VALCHLOR 2 PA; QL (2 GM per 1 day) VOTRIENT 2 PA XTANDI ORAL CAPSULE 2 PA ZELBORAF 2 PA ZOLADEX 2 Drug Name Tier Restrictions / Limits ZOLINZA 2 PA INCRETINMIMETICS ZEPBOUND SUBCUTANEOUS PEN INJECTOR 2 PA ZEPBOUND SUBCUTANEOUS SOLUTION 10 MG/0.5 ML, 2.5 MG/0.5 ML, 5 MG/0.5 ML, 7.5 MG/0.5 ML 2 PA ANTIPARASITICS ALINIA ORAL SUSPENSION FOR RECONSTITUTION 2 PA; QL (18 ML per 1 day) nitazoxanide 1 PA; QL (20 EA per 30 days) permethrin 1 QL (1 GM per 30 per fills) spinosad 2 QL (1 ML per 30 per fills) ULESFIA 2 ST; QL (227 GM per 30 days) ANTIPARKINSON DRUGS amantadine hcl 1 benztropine 1 bromocriptine 1 carbidopa-levodopa oral tablet 1 carbidopa-levodopa oral tablet extended release 1 carbidopa-levodopa oral tablet,disintegrating 1 carbidopa-levodopa-entacapone 1 entacapone 1 pramipexole oral tablet 1 ropinirole oral tablet 1 selegiline hcl 1 trihexyphenidyl 1 INDIANA MEDICAID | Effective 02/01/2026 16Drug Name Tier Restrictions / Limits ZELAPAR 2 ANTIPLATELET DRUGS anagrelide 1 aspirin-dipyridamole 1 BRILINTA 2 QL (2 EA per 1 day) cilostazol 1 clopidogrel 1 dipyridamole oral 1 prasugrel hcl 1 ANTIVIRALS abacavir 1 abacavir-lamivudine 1 acyclovir oral capsule 1 acyclovir oral suspension 200 mg/5 ml 1 acyclovir oral tablet 1 acyclovir topical cream 1 ST; QL (5 GM per 30 days) adefovir 1 PA APTIVUS 2 atazanavir 1 BARACLUDE ORAL SOLUTION 2 PA BIKTARVY ORAL TABLET 30-120-15 MG 2 BIKTARVY ORAL TABLET 50-200-25 MG 2 QL (1 EA per 1 day) COMPLERA 2 darunavir 1 DELSTRIGO 2 DESCOVY 2 PA DOVATO 2 QL (1 EA per 1 day) EDURANT 2 efavirenz 1 efavirenz-emtricitabin – tenofov 1 Drug Name Tier Restrictions / Limits efavirenz-lamivu – tenofov disop oral tablet 400-300-300 mg 1 emtricitabine 1 emtricitabine-tenofovir (tdf) 1 EMTRIVA 2 entecavir 1 PA etravirine 1 EVOTAZ 2 fosamprenavir 1 GENVOYA 2 ISENTRESS 2 ISENTRESS HD 2 JULUCA 2 QL (1 EA per 1 day) lamivudine oral solution 1 lamivudine oral tablet 100 mg 1 PA lamivudine oral tablet 150 mg, 300 mg 1 lamivudine-zidovudine 1 ledipasvir-sofosbuvir 1 PA lopinavir-ritonavir 1 maraviroc oral tablet 150 mg 1 PA; QL (2 EA per 1 day) maraviroc oral tablet 300 mg 1 PA; QL (4 EA per 1 day) nevirapine 1 NORVIR ORAL POWDER IN PACKET 2 QL (6 EA per 180 days) ODEFSEY 2 oseltamivir oral capsule 30 mg 1 QL (40 EA per 365 days) oseltamivir oral capsule 45 mg, 75 mg 1 QL (20 EA per 365 days) oseltamivir oral suspension for reconstitution 1 QL (360 ML per 365 days) 17 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits PAXLOVID ORAL TABLETS,DOSE PACK 150 MG (10) – 100 MG (10), 300 MG (150 MG X 2)-100 MG 2 QL (1 pack per 30 days) penciclovir 1 PIFELTRO 2 PREZCOBIX ORAL TABLET 800-150 MG-MG 2 PREZISTA ORAL SUSPENSION 2 QL (1 ML per 1 day) PREZISTA ORAL TABLET 150 MG, 75 MG 2 RELENZA DISKHALER 2 QL (40 EA per 365 days) ritonavir 1 SELZENTRY ORAL SOLUTION 2 PA; QL (1840 ML per 30 days) sofosbuvir-velpatasvir 1 PA STRIBILD 2 SYMTUZA 2 QL (1 EA per 1 day) tenofovir disoproxil fumarate 1 TIVICAY 2 trifluridine 1 TRIUMEQ 2 PA valacyclovir 1 ST valganciclovir 1 VEREGEN 2 PA VIRACEPT 2 VIREAD 2 XERESE 2 QL (1 EA per 90 days) zidovudine 1 ZIRGAN 2 PA Drug Name Tier Restrictions / Limits AUTONOMIC DRUGS amphetamine sulfate oral tablet 10 mg 1 PA; ST; QL (6 EA per 1 day); AR amphetamine sulfate oral tablet 5 mg 1 PA; ST; QL (2 EA per 1 day); AR bethanechol chloride 1 dextroamphetamine sulfate oral capsule, extended release 10 mg, 15 mg, 5 mg 1 QL (2 EA per 1 day); AR dextroamphetamine sulfate oral capsule, extended release 10 mg, 15 mg, 5 mg 1 PA; ST; QL (2 EA per 1 day); AR dextroamphetamine sulfate oral solution 1 ST; QL (40 ML per 1 day); AR dextroamphetamine sulfate oral tablet 10 mg 1 QL (4 EA per 1 day); AR dextroamphetamine sulfate oral tablet 10 mg 1 PA; ST; QL (4 EA per 1 day); AR dextroamphetamine sulfate oral tablet 15 mg, 2.5 mg, 20 mg, 30 mg, 5 mg, 7.5 mg 1 QL (2 EA per 1 day); AR dextroamphetamine sulfate oral tablet 15 mg, 2.5 mg, 20 mg, 30 mg, 5 mg, 7.5 mg 1 PA; ST; QL (2 EA per 1 day); AR dextroamphetamine-amphetamine oral capsule, er triphasic 24 hr 12.5 mg, 25 mg, 37.5 mg, 50 mg 1 PA; ST; QL (1 EA per 1 day); AR dextroamphetamine – amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 5 mg 1 PA; ST; QL (1 EA per 1 day); AR INDIANA MEDICAID | Effective 02/01/2026 18Drug Name Tier Restrictions / Limits dextroamphetamine – amphetamine oral capsule,extended release 24hr 20 mg, 25 mg, 30 mg 1 PA; ST; QL (2 EA per 1 day); AR dextroamphetamine-amphetamine oral tablet 1 PA; ST; QL (3 EA per 1 day); AR donepezil 1 QL (1 EA per 1 day) DYANAVEL XR ORAL SUSPEN, IR-ER, BIPHASIC 24HR 2 PA; ST; QL (8 ML per 1 day); AR DYANAVEL XR ORAL TABLET, IR-ER, BIPHASIC 24HR 2 PA; ST; QL (1 EA per 1 day); AR epinephrine injection auto-injector 0.15 mg/0.15 ml 2 QL (4 EA per 365 days) epinephrine injection auto-injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml 1 QL (4 EA per 365 days) galantamine oral capsule,ext rel. pellets 24 hr 1 QL (1 EA per 1 day) galantamine oral solution 1 ST; QL (6 ML per 1 day) galantamine oral tablet 1 QL (2 EA per 1 day) MESTINON ORAL TABLET 2 MESTINON TIMESPAN 2 methamphetamine 1 PA; ST; AR midodrine 1 pilocarpine hcl oral 1 pyridostigmine bromide oral syrup 1 pyridostigmine bromide oral tablet 60 mg 1 pyridostigmine bromide oral tablet extended release 180 mg 1 rivastigmine 1 QL (1 EA per 1 day) Drug Name Tier Restrictions /Limits rivastigmine tartrate 1 QL (2 EA per 1 day) BIOLOGICALS ACTHIB (PF) 2 ADACEL(TDAP ADOLESN/ADULT)(PF) 2 AREXVY (PF) 2 BEXSERO 2 BOOSTRIX TDAP 2 CAPVAXIVE 2 DAPTACEL (DTAP PEDIATRIC) (PF) 2 ENGERIX-B (PF) 2 ENGERIX-B PEDIATRIC (PF) 2 GARDASIL 9 (PF) 2 GRASTEK 2 PA; AR HAVRIX (PF) 2 HEPLISAV-B (PF) 2 HIBERIX (PF) 2 INFANRIX (DTAP) (PF) 2 IPOL 2 JYNNEOS (PF) 2 KINRIX (PF) 2 M-M-R II (PF) 2 MRESVIA (PF) 2 PALFORZIA (LEVEL 1) 2 PA; AR PALFORZIA (LEVEL 2) 2 PA; AR PALFORZIA (LEVEL 3) 2 PA; AR PALFORZIA (LEVEL 4) 2 PA; AR PALFORZIA (LEVEL 5) 2 PA; AR PALFORZIA (LEVEL 6) 2 PA; AR PALFORZIA (LEVEL 7) 2 PA; AR PALFORZIA (LEVEL 8) 2 PA; AR PALFORZIA (LEVEL 9) 2 PA; AR PALFORZIA (LEVEL 10) 2 PA; AR PALFORZIA (LEVEL 11 UP-DOSE) 2 PA; QL (1 EA per 28 days); AR 19 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits PALFORZIA INITIAL (4- 17 YRS) 2 PA; AR PALFORZIA LEVEL 11 MAINTENANCE 2 PA; QL (1 EA per 28 days); AR PALYNZIQ 2 PA PEDIARIX (PF) 2 PEDVAX HIB (PF) 2 PENBRAYA (PF) 2 PENTACEL ACTHIB COMPONENT (PF) 2 PNEUMOVAX-23 2 PROQUAD (PF) 2 QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 2 RAGWITEK 2 PA RECOMBIVAX HB (PF) INTRAMUSCULAR SUSPENSION 40 MCG/ML, 5 MCG/0.5 ML 2 RECOMBIVAX HB (PF) INTRAMUSCULAR SYRINGE 2 RHOGAM ULTRA – FILTERED PLUS 2 TAKHZYRO 2 QL (2 EA per 28 days); AR TENIVAC (PF) 2 TRUMENBA 2 TWINRIX (PF) 2 VAQTA (PF) 2 VARIVAX (PF) 2 VARIZIG 2 VAXNEUVANCE (PF) 2 BLOOD aminocaproic acid oral 1 DROXIA 2 PA EMPAVELI 2 PA; QL (8 ML per 28 days); AR Drug Name Tier Restrictions / Limits ENDARI ORAL POWDER IN PACKET 5 GRAM 2 PA ENDARI ORAL POWDER IN PACKET 5 GRAM 2 PA; AR pentoxifylline 1 tranexamic acid oral 1 ST CARDIAC DRUGS amiodarone oral 1 amlodipine 1 CARDIZEM LA 2 CARTIA XT 1 CORLANOR ORAL SOLUTION 2 PA; ST DIGITEK 1 digoxin oral solution 1 digoxin oral tablet 125 mcg (0.125 mg), 250 mcg (0.25 mg) 1 diltiazem hcl intravenous solution 1 diltiazem hcl oral 1 DILT-XR 1 disopyramide phosphate 1 dofetilide 1 felodipine 1 flecainide 1 ISORDIL TITRADOSE 2 isosorbide dinitrate 1 isosorbide mononitrate 1 ivabradine 1 PA; ST LANOXIN ORAL TABLET 125 MCG (0.125 MG), 250 MCG (0.25 MG) 2 nifedipine 1 nimodipine oral capsule 1 NITRO-BID 1 NITRO-DUR 2 INDIANA MEDICAID | Effective 02/01/2026 20Drug Name Tier Restrictions / Limits nitroglycerin oral 1 nitroglycerin sublingual 1 nitroglycerin transdermal patch 24 hour 1 nitroglycerin translingual 1 NITRO-TIME 1 NORLIQVA 2 PA; ST NORPACE CR 2 PACERONE ORAL TABLET 200 MG 1 propafenone 1 ranolazine 1 TIADYLT ER 1 verapamil oral capsule,ext rel. pellets 24 hr 1 verapamil oral tablet 120 mg, 80 mg 1 verapamil oral tablet 40 mg 1 QL (12 EA per 1 day) verapamil oral tablet extended release 1 CARDIOVASCULAR acebutolol oral capsule 200 mg 1 QL (6 EA per 1 day) acebutolol oral capsule 400 mg 1 QL (3 EA per 1 day) aliskiren 1 ALYQ 1 PA amlodipine-benazepril 1 QL (30 EA per 22 days) atenolol 1 atenolol-chlorthalidone 1 ATORVALIQ 2 atorvastatin 1 benazepril 1 benazepril – hydrochlorothiazide 1 bisoprolol fumarate oral tablet 10 mg, 5 mg 1 Drug Name Tier Restrictions / Limits bisoprolol – hydrochlorothiazide 1 bosentan oral tablet 1 PA captopril – hydrochlorothiazide 1 carvedilol 1 cholestyramine (with sugar) oral powder 1 CHOLESTYRAMINE LIGHT ORAL POWDER 1 clonidine hcl oral tablet 0.1 mg 1 PA; ST; QL (24 EA per 1 day); AR clonidine hcl oral tablet 0.2 mg 1 PA; ST; QL (12 EA per 1 day); AR clonidine hcl oral tablet 0.3 mg 1 PA; ST; QL (8 EA per 1 day); AR clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr 1 ST; QL (4 EA per 28 days) clonidine transdermal patch weekly 0.3 mg/24 hr 1 ST; QL (8 EA per 28 days) colesevelam 1 doxazosin 1 EDARBI 2 QL (1 EA per 1 day) EDARBYCLOR 2 enalapril maleate oral tablet 1 enalapril – hydrochlorothiazide 1 ENTRESTO 2 PA; ST ergoloid 1 QL (3 EA per 1 day) ezetimibe 1 ezetimibe-simvastatin 1 ST fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg 1 21 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits fenofibrate nanocrystallized 1 fenofibrate oral tablet 160 mg, 54 mg 1 fosinopril 1 gemfibrozil 1 guanfacine oral tablet 1 PA; ST hydralazine oral 1 irbesartan 1 QL (1 EA per 1 day) labetalol oral tablet 100 mg, 200 mg, 300 mg 1 lisinopril 1 lisinopril-hydrochlorothiazide 1 losartan oral tablet 100 mg 1 QL (1 EA per 1 day) losartan oral tablet 25 mg, 50 mg 1 QL (2 EA per 1 day) losartan – hydrochlorothiazide 1 lovastatin 1 methyldopa 1 methyldopa – hydrochlorothiazide 1 metoprolol succinate 1 metoprolol tartrate oral tablet 100 mg, 25 mg, 37.5 mg, 50 mg, 75 mg 1 metyrosine 1 PA minoxidil oral 1 nadolol 1 nebivolol 1 olmesartan oral tablet 20 mg, 40 mg 1 QL (1 EA per 1 day) olmesartan oral tablet 5 mg 1 QL (3 EA per 1 day) PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML 2 PA; ST; QL (2 ML per 22 days) Drug Name Tier Restrictions / Limits PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 75 MG/ML 2 PA; ST; QL (4 ML per 22 days) pravastatin 1 prazosin 1 PREVALITE 1 propranolol 1 propranolol – hydrochlorothiazid 1 PROSTIN VR PEDIATRIC 2 quinapril – hydrochlorothiazide 1 ramipril 1 REMODULIN INJECTION SOLUTION 1 MG/ML, 10 MG/ML, 2.5 MG/ML, 5 MG/ML 2 PA REPATHA PUSHTRONEX 2 PA; ST; QL (3.5 ML per 28 days) REPATHA SURECLICK 2 PA; ST; QL (2 ML per 28 days) REPATHA SYRINGE 2 PA; ST; QL (2 ML per 28 days) rosuvastatin 1 sacubitril-valsartan 1 PA sildenafil (pulm.hypertension) intravenous 1 PA; QL (60 ML per 1 day) sildenafil (pulm.hypertension) oral suspension for reconstitution 1 PA; ST; QL (60 ML per 1 day) sildenafil (pulm.hypertension) oral tablet 1 PA; QL (60 EA per 1 day) simvastatin 1 SOTALOL AF 1 sotalol oral 1 tadalafil (pulm. hypertension) 1 PA; QL (2 EA per 1 day) INDIANA MEDICAID | Effective 02/01/2026 22Drug Name Tier Restrictions / Limits TADLIQ 2 PA; QL (40 ML per 1 day) telmisartan 1 QL (1 EA per 1 day) terazosin 1 TRACLEER ORAL TABLET FOR SUSPENSION 2 PA treprostinil sodium 1 PA valsartan oral tablet 160 mg, 40 mg, 80 mg 1 PA; QL (2 EA per 1 day) valsartan oral tablet 320 mg 1 PA; QL (1 EA per 1 day) valsartan – hydrochlorothiazide 1 VELETRI 1 PA CNS DRUGS AMPYRA 2 PA AUSTEDO 2 PA; ST; QL (4 EA per 1 day) AUSTEDO XR ORAL TABLET EXTENDED RELEASE 24 HR 12 MG, 24 MG, 6 MG 2 PA; ST; AR AUSTEDO XR ORAL TABLET EXTENDED RELEASE 24 HR 18 MG, 30 MG, 36 MG, 42 MG, 48 MG 2 PA; ST AUSTEDO XR TITRATION KT(WK1-4) 2 PA; ST AVONEX INTRAMUSCULAR PEN INJECTOR KIT 2 PA; QL (4 EA per 28 days) AVONEX INTRAMUSCULAR SYRINGE 2 PA; QL (2 ML per 28 days) AVONEX INTRAMUSCULAR SYRINGE KIT 2 PA; QL (4 EA per 28 days) BETASERON SUBCUTANEOUS KIT 2 PA; QL (14 EA per 22 days) BRIUMVI 2 PA caffeine citrate oral 1 AR Drug Name Tier Restrictions / Limits carbamazepine 1 CARBATROL 2 CELONTIN 2 clobazam oral suspension 1 QL (32 ML per 1 day) clobazam oral tablet 10 mg 1 QL (8 EA per 1 day) clobazam oral tablet 20 mg 1 QL (4 EA per 1 day) clonazepam 1 PA; QL (3 EA per 1 day) COPAXONE 2 PA dalfampridine 1 PA; QL (2 EA per 1 day) DEPAKOTE SPRINKLES 2 PA diazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg, 5-7.5-10 mg 1 QL (10 doses per 30 days) diazepam rectal kit 12.5-15-17.5-20 mg, 2.5 mg, 5-7.5-10 mg 1 QL (10 EA per 30 days) DILANTIN 2 DILANTIN EXTENDED 2 DILANTIN INFATABS 2 DILANTIN-125 2 dimethyl fumarate 1 PA; QL (2 EA per 1 day) divalproex 1 EMGALITY SYRINGE SUBCUTANEOUS SYRINGE 300 MG/3 ML (100 MG/ML X 3) 2 PA; ST; QL (300 ML per 22 days); AR EPRONTIA 2 PA; QL (16 ML per 1 day) ethosuximide 1 felbamate oral suspension 1 PA FELBATOL 2 fingolimod 1 PA; QL (1 EA per 1 day) fosphenytoin 1 23 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits gabapentin oral capsule 100 mg, 400 mg 1 QL (6 EA per 1 day) gabapentin oral capsule 300 mg 1 QL (9 EA per 1 day) gabapentin oral tablet 600 mg 1 QL (6 EA per 1 day) gabapentin oral tablet 800 mg 1 QL (4 EA per 1 day) GILENYA ORAL CAPSULE 0.25 MG 2 PA; QL (1 EA per 1 day) GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 300 MG, 450 MG 2 PA; QL (1 EA per 1 day) GRALISE ORAL TABLET EXTENDED RELEASE 24 HR 600 MG, 750 MG, 900 MG 2 PA; QL (2 EA per 1 day) GRALISE ORAL TABLET, EXT REL 24HR DOSE PACK 2 PA; QL (1 Pack per 90 days) INGREZZA 2 PA; ST; QL (30 EA per 22 days) INGREZZA INITIATION PK(TARDIV) 2 PA; ST; QL (28 EA per 22 days) INGREZZA SPRINKLE 2 PA KESIMPTA PEN 2 PA lacosamide oral tablet 1 ST LAMICTAL ODT STARTER (BLUE) 2 LAMICTAL ODT STARTER (GREEN) 2 LAMICTAL ODT STARTER (ORANGE) 2 LAMICTAL STARTER (BLUE) KIT 2 LAMICTAL STARTER (GREEN) KIT 2 LAMICTAL STARTER (ORANGE) KIT 2 Drug Name Tier Restrictions / Limits LAMICTAL XR ORAL TABLET EXTENDED RELEASE 24HR 250 MG, 300 MG, 50 MG 2 PA LAMICTAL XR STARTER (BLUE) 2 LAMICTAL XR STARTER (GREEN) 2 LAMICTAL XR STARTER (ORANGE) 2 lamotrigine oral tablet 1 lamotrigine oral tablet extended release 24hr 1 lamotrigine oral tablet, chewable dispersible 1 lamotrigine oral tablet,disintegrating 1 levetiracetam intravenous 1 levetiracetam oral solution 1 QL (30 ML per 1 day) levetiracetam oral tablet 1,000 mg 1 QL (3 EA per 1 day) levetiracetam oral tablet 250 mg 1 QL (2 EA per 1 day) levetiracetam oral tablet 500 mg 1 QL (6 EA per 1 day) levetiracetam oral tablet 750 mg 1 QL (4 EA per 1 day) levetiracetam oral tablet extended release 24 hr 500 mg 1 QL (2 EA per 1 day) levetiracetam oral tablet extended release 24 hr 750 mg 1 QL (4 EA per 1 day) LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 25 MG, 50 MG, 75 MG 2 QL (3 EA per 1 day) LYRICA ORAL CAPSULE 225 MG, 300 MG 2 QL (2 EA per 1 day) LYRICA ORAL SOLUTION 2 QL (30 ML per 1 day) INDIANA MEDICAID | Effective 02/01/2026 24Drug Name Tier Restrictions / Limits memantine oral capsule,sprinkle,er 24hr 1 QL (1 EA per 1 day) memantine oral solution 1 QL (10 ML per 1 day) memantine oral tablet 1 QL (2 EA per 1 day) memantine oral tablets,dose pack 2 QL (1 Pak per 90 days) NAYZILAM 2 QL (10 EA per 30 days) NEURONTIN ORAL CAPSULE 100 MG, 400 MG 2 QL (6 EA per 1 day) NEURONTIN ORAL CAPSULE 300 MG 2 QL (9 EA per 1 day) NEURONTIN ORAL SOLUTION 2 QL (72 ML per 1 day) NEURONTIN ORAL TABLET 600 MG 2 QL (6 EA per 1 day) NEURONTIN ORAL TABLET 800 MG 2 QL (4 EA per 1 day) NUEDEXTA 2 PA OCREVUS ZUNOVO 2 PA oxcarbazepine oral suspension 1 oxcarbazepine oral tablet 1 OXTELLAR XR 2 PHENYTEK 2 phenytoin 1 phenytoin sodium 1 phenytoin sodium extended 1 pregabalin oral capsule 100 mg, 150 mg, 200 mg, 25 mg, 50 mg, 75 mg 1 QL (3 EA per 1 day) pregabalin oral capsule 225 mg, 300 mg 1 QL (2 EA per 1 day) primidone oral tablet 125 mg 2 primidone oral tablet 250 mg, 50 mg 1 Drug Name Tier Restrictions / Limits REBIF (WITH ALBUMIN) 2 PA; QL (6 ML per 28 days) REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML 2 PA REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6) 2 PA; QL (4.2 ML per 28 days) REBIF TITRATION PACK 2 PA riluzole 1 PA ROWEEPRA 1 QL (6 EA per 1 day) TASCENSO ODT 2 PA; ST; QL (1 EA per 1 day) TEGRETOL 2 TEGRETOL XR 2 teriflunomide 1 PA tetrabenazine 1 PA; ST tiagabine 1 topiramate oral capsule, sprinkle 15 mg, 25 mg 1 topiramate oral capsule,sprinkle,er 24hr 1 ST; QL (2 EA per 1 day) topiramate oral tablet 1 TROKENDI XR 2 QL (2 EA per 1 day) valproate sodium 1 valproic acid 1 valproic acid (as sodium salt) 1 VALTOCO NASAL SPRAY,NON-AEROSOL 10 MG/SPRAY (0.1 ML), 15 MG/2 SPRAY (7.5/0.1ML X 2), 20 MG/2 SPRAY (10MG/0.1ML X2), 5 MG/SPRAY (0.1 ML) 2 QL (10 Doses per 30 days) 25 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits VALTOCO NASAL SPRAY,NON-AEROSOL 10 MG/SPRAY (0.1 ML), 15 MG/2 SPRAY (7.5/0.1ML X 2), 20 MG/2 SPRAY (10MG/0.1ML X2), 5 MG/SPRAY (0.1 ML) 2 QL (10 EA per 30 days) ZEPOSIA 2 PA; QL (30 EA per 22 days) ZEPOSIA STARTER KIT (28-DAY) 2 PA ZEPOSIA STARTER PACK (7-DAY) 2 PA; QL (1 Dose pack per 77 days) zonisamide oral capsule 100 mg 1 ST; QL (2 EA per 1 day) zonisamide oral capsule 25 mg, 50 mg 1 ST; QL (1 EA per 1 day) COLONY STIMULATING FACTORS ARANESP (IN POLYSORBATE) 2 PA EPOGEN INJECTION SOLUTION 10,000 UNIT/ML 2 PA; QL (32 ML per 28 days) EPOGEN INJECTION SOLUTION 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML 2 PA FYLNETRA 2 NEUPOGEN 2 PROMACTA ORAL TABLET 12.5 MG 2 PA; QL (90 EA per 28 days) PROMACTA ORAL TABLET 25 MG 2 PA; QL (30 EA per 28 days) PROMACTA ORAL TABLET 50 MG, 75 MG 2 PA; QL (60 EA per 28 days) RELEUKO 2 Drug Name Tier Restrictions / Limits RETACRIT INJECTION SOLUTION 10,000 UNIT/ML 2 PA; QL (24 ML per 22 days) RETACRIT INJECTION SOLUTION 2,000 UNIT/ML 2 PA; QL (120 ML per 22 days) RETACRIT INJECTION SOLUTION 20,000 UNIT/2 ML, 20,000 UNIT/ML 2 PA RETACRIT INJECTION SOLUTION 3,000 UNIT/ML 2 PA; QL (80 ML per 22 days) RETACRIT INJECTION SOLUTION 4,000 UNIT/ML 2 PA; QL (60 ML per 22 days) RETACRIT INJECTION SOLUTION 40,000 UNIT/ML 2 PA; QL (6 ML per 22 days) CONTRACEPTIVES AFIRMELLE 1 ALTAVERA (28) 1 ALYACEN 1/35 (28) 1 ALYACEN 7/7/7 (28) 1 AMETHIA 1 QL (1 EA per 1 day) AMETHYST (28) 1 ANNOVERA 2 APRI 1 ARANELLE (28) 1 ASHLYNA 1 QL (1 EA per 1 day) AUBRA 1 AUBRA EQ 1 AUROVELA 1.5/30 (21) 1 AUROVELA 1/20 (21) 1 AUROVELA 24 FE 1 AUROVELA FE 1.5/30 (28) 1 AUROVELA FE 1-20 (28) 1 AVIANE 1 INDIANA MEDICAID | Effective 02/01/2026 26Drug Name Tier Restrictions / Limits AYUNA 1 AZURETTE (28) 1 BALCOLTRA 2 BALZIVA (28) 1 BEYAZ 2 PA BLISOVI 24 FE 1 BLISOVI FE 1.5/30 (28) 1 BLISOVI FE 1/20 (28) 1 BRIELLYN 1 CAMILA 1 CAMRESE 1 QL (1 EA per 1 day) CAMRESE LO 1 QL (1 EA per 1 day) CAYA CONTOURED 2 QL (2 EA per 365 days) CAZIANT (28) 1 CHARLOTTE 24 FE 1 CHATEAL EQ (28) 1 CRYSELLE (28) 1 CYRED 1 CYRED EQ 1 DASETTA 1/35 (28) 1 DASETTA 7/7/7 (28) 1 DAYSEE 1 QL (1 EA per 1 day) DEBLITANE 1 DEPO-SUBQ PROVERA 104 2 desog – e.estradiol/e.estradiol 1 DOLISHALE 1 drospirenone – e.estradiol-lm.fa oral tablet 3-0.02-0.451 mg (24) (4) 1 PA drospirenone – e.estradiol-lm.fa oral tablet 3-0.03-0.451 mg (21) (7) 1 Drug Name Tier Restrictions / Limits drospirenone-ethinyl estradiol 1 ELINEST 1 ELLA 2 QL (6 EA per 365 days) ELURYNG 1 EMZAHH 1 ENILLORING 1 ENPRESSE 1 ENSKYCE 1 ERRIN 1 ESTARYLLA 1 ethynodiol diac-eth estradiol 1 etonogestrel-ethinyl estradiol 1 FALMINA (28) 1 FEMCAP 2 QL (2 EA per 365 days) FINZALA 1 GEMMILY 1 HAILEY 1 HAILEY 24 FE 1 HAILEY FE 1.5/30 (28) 1 HAILEY FE 1/20 (28) 1 HALOETTE 1 HEATHER 1 ICLEVIA 1 INCASSIA 1 ISIBLOOM 1 JAIMIESS 1 JASMIEL (28) 1 JENCYCLA 1 JOLESSA 1 QL (1 EA per 1 day) JOYEAUX 1 JULEBER 1 JUNEL 1.5/30 (21) 1 JUNEL 1/20 (21) 1 27 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits JUNEL FE 1.5/30 (28) 1 JUNEL FE 1/20 (28) 1 JUNEL FE 24 1 KAITLIB FE 1 KALLIGA 1 KARIVA (28) 1 KELNOR 1/35 (28) 1 KURVELO (28) 1 KYLEENA 2 lnorgest/e.estradiol – e.estrad 1 QL (1 EA per 1 day) LARIN 1.5/30 (21) 1 LARIN 1/20 (21) 1 LARIN 24 FE 1 LARIN FE 1.5/30 (28) 1 LARIN FE 1/20 (28) 1 LESSINA 1 LEVONEST (28) 1 levonorgest – eth.estradiol-iron 1 levonorgestrel-ethinyl estrad oral tablet 1 levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 1 QL (1 EA per 1 day) levonorg-eth estrad triphasic 1 LILETTA 2 LO LOESTRIN FE 2 LOESTRIN 1.5/30 (21) 2 PA LOESTRIN 1/20 (21) 2 PA LOESTRIN FE 1.5/30 (28-DAY) 2 PA LOESTRIN FE 1/20 (28-DAY) 2 PA LOJAIMIESS 1 LORYNA (28) 1 LOW-OGESTREL (28) 1 LO-ZUMANDIMINE (28) 1 LUTERA (28) 1 Drug Name Tier Restrictions / Limits LYLEQ 1 LYZA 1 MARLISSA (28) 1 medroxyprogesterone intramuscular 1 QL (1 ML per 67 days) MIBELAS 24 FE 1 MICROGESTIN 1.5/30 (21) 1 MICROGESTIN 1/20 (21) 1 MICROGESTIN FE 1.5/30 (28) 1 MICROGESTIN FE 1/20 (28) 1 MILI 1 MIRENA 2 MONO-LINYAH 1 NATAZIA 2 NECON 0.5/35 (28) 1 NEXPLANON 2 NEXTSTELLIS 2 QL (28 EA per 22 days) NIKKI (28) 1 NORA-BE 1 noreth-ethinyl estradiol-iron 1 norethindrone (contraceptive) 1 norethindrone ac-eth estradiol oral tablet 1-20 mg-mcg, 1.5-30 mg-mcg 1 norethindrone-e.estradiol-iron 1 norgestimate-ethinyl estradiol 1 NORTREL 0.5/35 (28) 1 NORTREL 1/35 (21) 1 NORTREL 1/35 (28) 1 NORTREL 7/7/7 (28) 1 NUVARING 2 PA INDIANA MEDICAID | Effective 02/01/2026 28Drug Name Tier Restrictions / Limits NYLIA 1/35 (28) 1 NYLIA 7/7/7 (28) 1 OCELLA 1 PARAGARD T 380A 2 PARAGARD T380A (SINGLE HAND) 2 PHILITH 1 PIMTREA (28) 1 PORTIA 28 1 RECLIPSEN (28) 1 RIVELSA 1 SAFYRAL 2 PA SETLAKIN 1 QL (1 EA per 1 day) SHAROBEL 1 SIMLIYA (28) 1 SIMPESSE 1 QL (1 EA per 1 day) SKYLA 2 SLYND 2 SPRINTEC (28) 1 SRONYX 1 SYEDA 1 TARINA 24 FE 1 TARINA FE 1/20 (28) 1 TARINA FE 1-20 EQ (28) 1 TAYTULLA 2 PA TILIA FE 1 TRI-ESTARYLLA 1 TRI-LEGEST FE 1 TRI-LINYAH 1 TRI-LO-ESTARYLLA 1 TRI-LO-MARZIA 1 TRI-LO-MILI 1 TRI-LO-SPRINTEC 1 TRI-MILI 1 TRI-SPRINTEC (28) 1 TRI-VYLIBRA 1 Drug Name Tier Restrictions / Limits TRI-VYLIBRA LO 1 TULANA 1 TURQOZ (28) 1 TWIRLA 2 QL (3 EA per 22 days) TYBLUME 2 TYDEMY 1 VELIVET TRIPHASIC REGIMEN (28) 1 VESTURA (28) 1 VIENVA 1 VIORELE (28) 1 VOLNEA (28) 1 VYFEMLA (28) 1 VYLIBRA 1 WERA (28) 1 WIDE-SEAL DIAPHRAGM 60 2 WIDE-SEAL DIAPHRAGM 65 2 WIDE-SEAL DIAPHRAGM 70 2 WIDE-SEAL DIAPHRAGM 75 2 WIDE-SEAL DIAPHRAGM 80 2 WIDE-SEAL DIAPHRAGM 85 2 WIDE-SEAL DIAPHRAGM 90 2 WIDE-SEAL DIAPHRAGM 95 2 WYMZYA FE 1 XULANE 1 YASMIN (28) 2 PA YAZ (28) 2 PA ZARAH 1 ZOVIA 1-35 (28) 1 ZUMANDIMINE (28) 1 29 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits COUGH/COLD PREPARATIONS benzonatate 1 QL (4 EA per 1 day) BROMFED DM 2 brompheniramine-pseudoeph-dm 1 hydrocodone – homatropine oral solution 5-1.5 mg/5 ml 1 PA; ST; QL (6 OZ per 1 RX); AR hydrocodone – homatropine oral solution 5-1.5 mg/5 ml (5 ml) 1 PA; ST hydrocodone-homatropine oral tablet 1 PA; ST; QL (36 RX per 30 RXs); AR HYDROMET 1 PA; ST; QL (180 ML per 1 per fill); AR promethazine-codeine 1 PA; ST; QL (180 per fill per 30 days) promethazine-dm 1 DIURETICS acetazolamide 1 amiloride 1 amiloride – hydrochlorothiazide 1 bumetanide oral 1 chlorthalidone 1 DIURIL 2 eplerenone 1 furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml) 1furosemide oral tablet 1 hydrochlorothiazide 1 indapamide 1 methazolamide 1 metolazone 1 Drug Name Tier Restrictions / Limits spironolactone oral tablet 1 spironolacton – hydrochlorothiaz 1 tolvaptan 1 PA torsemide 1 triamterene – hydrochlorothiazid oral capsule 1 triamterene – hydrochlorothiazid oral tablet 37.5-25 mg 1 QL (1 EA per 1 day) triamterene – hydrochlorothiazid oral tablet 75-50 mg 1 EENT PREPS acetic acid otic (ear) 1 ALPHAGAN P 2 ALREX 2 ALTACAINE 1 PA apraclonidine 1 atropine ophthalmic (eye) drops 1 % 1 azelastine nasal spray,non-aerosol 137 mcg (0.1 %) 1 azelastine-fluticasone 1 PA AZOPT 2 BETOPTIC S 2 brimonidine ophthalmic (eye) drops 0.2 % 1 carteolol 1 COMBIGAN 2 cromolyn ophthalmic (eye) 1 CYCLOGYL OPHTHALMIC (EYE) DROPS 1 %, 2 % 2 cyclopentolate 1 DERMOTIC OIL 2 INDIANA MEDICAID | Effective 02/01/2026 30Drug Name Tier Restrictions / Limits dexamethasone sodium phosphate ophthalmic (eye) 1 diclofenac sodium ophthalmic (eye) 1 dorzolamide 1 dorzolamide (pf) 2 dorzolamide-timolol 1 dorzolamide-timolol (pf) 1 DUREZOL 2 DYMISTA 2 FLAREX 2 fluocinolone acetonide oil 1 flurbiprofen sodium 1 FML LIQUIFILM 2 HOMATROPAIRE 1 IOPIDINE 2 ipratropium bromide nasal 1 ISOPTO ATROPINE 2 ketorolac ophthalmic (eye) drops 0.4 % 1 QL (5 ML per 30 days) ketorolac ophthalmic (eye) drops 0.5 % 1 latanoprost 1 levobunolol 1 LOTEMAX OPHTHALMIC (EYE) DROPS,GEL 2 PA LOTEMAX OPHTHALMIC (EYE) OINTMENT 2 loteprednol etabonate ophthalmic (eye) drops,suspension 0.5 % 1 LUMIGAN 2 NEVANAC 2 OMNARIS 2 OXERVATE 2 PA Drug Name Tier Restrictions / Limits phenylephrine hcl ophthalmic (eye) 1 pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 % 1 PRED MILD 2 prednisolone acetate 1 prednisolone acetate (pf) 2 prednisolone sodium phosphate ophthalmic (eye) 1 PROLENSA 2 RESTASIS 2 PA; ST; QL (2 EA per 1 day) RHOPRESSA 2 ROCKLATAN 2 SIMBRINZA 2 ST tetracaine hcl 1 PA tetracaine hcl (pf) ophthalmic (eye) 2 PA timolol maleate (pf) 1 timolol maleate ophthalmic (eye) drops 1 timolol maleate ophthalmic (eye) drops, once daily 1 TRAVATAN Z 2 tropicamide 1 XIIDRA 2 PA; ST; QL (60 EA per 30 days) ELECT/CALORIC/H2O arginine (l-arginine) oral capsule 2 arginine (l-arginine) oral powder 2 arginine (l-arginine) oral powder in packet 500 mg 2 arginine (l-arginine) oral tablet 1 31 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits arginine hcl (l-arginine) 2 BAQSIMI 2 QL (2 EA per 365 days) CAL-CITRATE 2 CALCIUM 500 1 CALCIUM 500 + DORAL TABLET 500 MG-5 MCG (200 UNIT) 1 CALCIUM 500 + DORAL TABLET,CHEWABLE 1 CALCIUM 600 + D(3) 1 CALCIUM 600 WITH VITAMIN D3 1 calcium acetate 1 calcium acetate(phosphat bind) 1 calcium carbonate oral tablet 500 mg calcium (1,250 mg) 1 calcium carbonate oral tablet,chewable 500 mg calcium (1,250 mg) 1 calcium carbonate-vit d3-min 1 calcium carbonate-vitamin d3 oral capsule 600 mg-10 mcg (400 unit) 1 calcium carbonate – vitamin d3 oral capsule 600 mg-12.5 mcg (500 unit), 600 mg-25 mcg (1,000 unit), 600 mg-62.5 mcg (2,500 unit) 2 calcium carbonate-vitamin d3 oral tablet 1,000 mg-20 mcg (800 unit) 2 Drug Name Tier Restrictions / Limits calcium carbonate – vitamin d3 oral tablet 250 mg-3.125 mcg (125 unit), 500 mg-15 mcg (600 unit), 500 mg-3.125 mcg (125 unit), 500 mg-5 mcg (200 unit), 600 mg-10 mcg (400 unit), 600 mg-20 mcg (800 unit), 600 mg-5 mcg (200 unit) 1 calcium carbonate – vitamin d3 oral tablet,chewable 500 mg-10 mcg (400 unit) 1 calcium carbonate-vitamin d3 oral tablet,chewable 500 mg-2.5 mcg (100 unit) 2 CALCIUM CITRATE + D 1 calcium citrate-vitamin d3 oral liquid 1 calcium citrate-vitamin d3 oral tablet 1 CALCIUM WITH VITAMIN D 1 CAL-QUICK 2 CALTRATE 600 PLUS D 2 CALTRATE WITH VITAMIN D3 2 CITRACAL + D MAXIMUM 2 CITRACAL REGULAR 2 CITRACAL-D3 PETITES 2 DENTA 5000 PLUS 1 DEX4 GLUCOSE ORAL TABLET,CHEWABLE 1 DEX4 GLUCOSE POUCH PACK 1 DEX4 GLUCOSE QUICK DISSOLVE 1 dextrose oral gel 1 INDIANA MEDICAID | Effective 02/01/2026 32Drug Name Tier Restrictions / Limits EFFER-K ORAL TABLET, EFFERVESCENT 25 MEQ 1 FEOSOL ORAL TABLET 325 MG (65 MG IRON) 1 FEROSUL 1 FERREX 150 1 FERRIC X-150 1 FERRO-TIME 1 ferrous sulfate oral drops 1 ferrous sulfate oral elixir 1 ferrous sulfate oral solution 1 ferrous sulfate oral tablet 1 ferrous sulfate oral tablet,delayed release (dr/ec) 1 FE-VITE ORAL DROPS 1 fluoride (sodium) dental cream 1 GLUCOSE GEL 1 glucose oral tablet,chewable 4 gram 1 GLUTOSE-5 1 GVOKE 2 GVOKE HYPOPEN 1- PACK 2 GVOKE HYPOPEN 2- PACK 2 GVOKE PFS 1-PACK SYRINGE 2 GVOKE PFS 2-PACK SYRINGE 2 IFEREX 150 1 IRON (FERROUS SULFATE) 1 IRON ORAL TABLET 1 Drug Name Tier Restrictions / Limits KIONEX (WITH SORBITOL) 1 KLOR-CON 10 1 KLOR-CON 8 1 KLOR-CON M10 1 KLOR-CON M15 1 KLOR-CON M20 1 L-ARGININE(ALPHA – KETOGLUTARAT) 2 LIQUID CALCIUM WITH VITAMIN D 2 LOKELMA 2 MAGNEBIND 300 2 QL (300 EA per 30 days) MAGNEBIND 400 2 magnesium oxide oral tablet 400 mg magnesium 1 MGO 1 MYFERON 150 1 NOVAFERRUM YUMMY PEDIATRIC 2 PA ONEVITE CALCIUM-D3 ORAL TABLET 500 MG-5 MCG (200 UNIT) 1 OYSCO 500/D 1 OYSTER SHELL + D3 1 OYSTER SHELL CALCIUM 1 OYSTER SHELL CALCIUM 500 1 OYSTER SHELL CALCIUM-VIT D3 ORAL TABLET 250 MG-3.125 MCG (125 UNIT) 2 OYSTER SHELL CALCIUM-VIT D3 ORAL TABLET 500 MG-5 MCG (200 UNIT) 1 PEDIA IRON ORAL DROPS 1 POLY-IRON 1 33 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits polysaccharide iron complex 1 potassium chloride oral capsule, extended release 1 potassium chloride oral liquid 1 potassium chloride oral packet 20 meq 1 potassium chloride oral tablet extended release 10 meq, 20 meq, 8 meq 1 potassium chloride oral tablet,er particles/crystals 1 potassium citrate oral tablet extended release 1 potassium iodide oral solution 1 PURE L-CITRULLINE ORAL CAPSULE 2 RENVELA 2 sevelamer hcl oral tablet 800 mg 1 SF 5000 PLUS 1 SODIUM FLUORIDE 5000 PLUS 1 sodium polystyrene sulfonate oral powder 1 SPS (WITH SORBITOL) 1 VELTASSA ORAL POWDER IN PACKET 16.8 GRAM, 8.4 GRAM 2 ZEGALOGUE AUTOINJECTOR 2 ZEGALOGUE SYRINGE 2 ZINC (WITH A AND C) LOZENGES 2 zinc sulfate oral capsule 1 ZINC-220 1 Drug Name Tier Restrictions / Limits GASTROINTESTINAL alosetron 1 PA ANALPRAM-HC RECTAL 2 ANALPRAM-HC SINGLES 2 aprepitant oral capsule 40 mg 1 QL (6 EA per 1 Fill) aprepitant oral capsule 80 mg 1 PA; QL (6 EA per 1 Fill) aprepitant oral capsule,dose pack 1 QL (2 packs per 1 Rx) balsalazide 1 chlordiazepoxide – clidinium 1 CHOLBAM 2 PA cimetidine oral tablet 300 mg, 400 mg, 800 mg 1 QL (60 EA per 30 days) COMPRO 1 CONSTULOSE 1 CREON 2 DAILY FIBER (PSYLLIUM-ASPART) 2 DAILY FIBER (PSYLLIUM-SUCROSE) ORAL POWDER 3 GRAM/7 GRAM 2 DEXILANT 2 QL (1 EA per 1 day) DICLEGIS 2 dicyclomine oral capsule 1 dicyclomine oral solution 1 dicyclomine oral tablet 20 mg 1 DIPENTUM 2 diphenoxylate-atropine 1 ED-SPAZ 1 INDIANA MEDICAID | Effective 02/01/2026 34Drug Name Tier Restrictions / Limits ENULOSE 1 esomeprazole magnesium oral capsule,delayed release(dr/ec) 40 mg 1 QL (1 EA per 1 day) famotidine oral tablet 40 mg 1 QL (60 EA per 30 days) FIBER (WITH ASPARTAME) ORAL POWDER 3 GRAM/5.8 GRAM 2 FIBER THERAPY (PSYLLIUM-SUCRO) 2 fosaprepitant 1 QL (2 Vials per 1 Fill) GAVILYTE-C 1 GAVILYTE-G 1 GAVILYTE-N 1 GENERLAC 1 GERI-MUCIL (ASPARTAME) 2 GERI-MUCIL (SUGAR) 2 glycopyrrolate oral solution 1 PA glycopyrrolate oral tablet 1 hydrocortisone – pramoxine rectal cream 1 hyoscyamine sulfate oral 1 hyoscyamine sulfate sublingual 1 HYOSYNE 1 icosapent ethyl 1 QL (4 EA per 1 day); AR KONSYL (SUGAR) 2 KRISTALOSE 2 lactulose oral packet 10 gram 1 lactulose oral solution 1 lansoprazole oral capsule,delayed release(dr/ec) 30 mg 1 ST; QL (1 EA per 1 day) Drug Name Tier Restrictions / Limits lidocaine hcl – hydrocortison ac rectal cream 1 PA; QL (98 GM per 30 days) LINZESS 2 ST LITHOSTAT 2 PA loperamide oral capsule 1 QL (12 EA per 14 days) lubiprostone 1 ST mesalamine oral capsule (with del rel tablets) 1 mesalamine oral capsule,extended release 24hr 1 mesalamine oral tablet,delayed release (dr/ec) 1 mesalamine rectal 1 mesalamine with cleansing wipe 1 META APPETITE CTRL (ASPARTAME) 2 METAMUCIL (WITH SUGAR) ORAL POWDER 3 GRAM/7 GRAM 2 METAMUCIL FREE (WITH SUGAR) 2 methscopolamine 1 metoclopramide hcl oral 1 misoprostol 1 MOTEGRITY 2 ST MYTESI 2 PA NEXIUM PACKET 2 PA; QL (1 EA per 1 day) nizatidine 1 QL (60 EA per 30 days) NULEV 2 omega 3-dha-epa-fish oil oral capsule 1,200 (144-216) mg, 200-300-1,000 mg 2 35 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits omega-3 acid ethyl esters 1 omeprazole oral capsule,delayed release(dr/ec) 10 mg, 40 mg 1 QL (2 EA per 1 day) omeprazole oral capsule,delayed release(dr/ec) 20 mg 1 QL (4 EA per 1 day) ondansetron hcl (pf) 1 ondansetron hcl intravenous 1 ondansetron hcl oral solution 1 QL (1 Bottle per 1 Fill) ondansetron hcl oral tablet 1 QL (90 EA per 30 days) ondansetron oral tablet,disintegrating 16 mg 2 ondansetron oral tablet,disintegrating 4 mg, 8 mg 1 QL (90 EA per 30 days) opium tincture 1 PA OSCIMIN 1 OSCIMIN SL 1 PANCREAZE 2 pantoprazole oral tablet,delayed release (dr/ec) 1 QL (2 EA per 1 day) peg 3350-electrolytes 1 peg-electrolyte soln 1 PENTASA 2 PHEBURANE 2 PA; QL (7 Bottles per 28 days) PROBIOTIC 4X 1 prochlorperazine edisylate injection solution 10 mg/2 ml (5 mg/ml) 1 PA prochlorperazine edisylate injection solution 5 mg/ml 1 Drug Name Tier Restrictions / Limits prochlorperazine maleate 1 PA promethazine rectal 1 PROMETHEGAN 1 PROTONIX ORAL GRANULES DR FOR SUSP IN PACKET 2 PA; ST; QL (1 EA per 1 day) psyllium husk (with sugar) 1 PYLERA 2 RECTIV 2 REGULOID (ASPARTAME) 2 REGULOID (PSYLLIUM HUSK) ORAL POWDER 2 REGULOID (PSYLLIUM HUSK-SUCRO) 2 ROBINUL 2 ROBINUL FORTE 2 senna leaf extract 2 SENNA ORAL SYRUP 176 MG/5 ML 2 SFROWASA 2 sodium phenylbutyrate 1 PA SUCRAID 2 PA sucralfate oral suspension 1 PA; ST; AR sucralfate oral tablet 1 sulfasalazine 1 SYMAX-SL 1 SYMAX-SR 1 trimethobenzamide 1 ursodiol 1 VOQUEZNA TRIPLE PAK 2 ZENPEP 2 HORMONES ANDROGEL 2 PA; QL (150 GM per 30 days) INDIANA MEDICAID | Effective 02/01/2026 36Drug Name Tier Restrictions / Limits ANGELIQ 2 budesonide oral capsule,delayed,extend. release 1 cabergoline 1 calcitonin (salmon) nasal 1 CHILDREN'S SLEEP (MELATONIN) ORAL LIQUID 2 CLIMARA PRO 2 ST COMBIPATCH 2 CORTIFOAM 2 cortisone 1 COVARYX 1 COVARYX H.S. 1 deflazacort oral tablet 1 PA DEPO-ESTRADIOL 2 DEPO – TESTOSTERONE 2 PA desmopressin nasal spray with pump 1 desmopressin oral 1 DEXAMETHASONE INTENSOL 1 dexamethasone oral elixir 1 dexamethasone oral solution 1 dexamethasone oral tablet 1 DEXONTO 2 EEMT 1 EEMT HS 1 EMFLAZA ORAL SUSPENSION 2 PA; QL (117 ML per 30 days); AR EMFLAZA ORAL TABLET 18 MG 2 PA; QL (30 EA per 30 days); AR Drug Name Tier Restrictions / Limits EMFLAZA ORAL TABLET 30 MG, 36 MG 2 PA; QL (90 EA per 30 days); AR EMFLAZA ORAL TABLET 6 MG 2 PA; QL (60 EA per 30 days); AR estradiol oral 1 estradiol transdermal gel in metered-dose pump 1 estradiol transdermal patch weekly 1 estradiol valerate 1 estradiol-norethindrone acet 1 ESTRING 2 estrogens-methyltestosterone 1 EVAMIST 2 FENSOLVI 2 fludrocortisone 1 FYAVOLV 1 GENOTROPIN 2 PA; ST GENOTROPIN MINIQUICK 2 PA; ST hydrocortisone oral 1 hydrocortisone rectal 1 JINTELI 1 KIDS MELATONIN 1 LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG 2 LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG 2 LUPRON DEPOT-PED 2 LUPRON DEPOT-PED (3 MONTH) 2 MEDROL (PAK) 2 37 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits MEDROL ORAL TABLET 16 MG, 4 MG, 8 MG 2 medroxyprogesterone oral 1 melatonin oral capsule 2 melatonin oral drops 2 PA melatonin oral liquid 2.5 mg/10 ml 2 melatonin oral liquid 5 mg/15 ml 1 melatonin oral tablet 1 mg, 10 mg, 3 mg, 5 mg 1 melatonin oral tablet 12 mg 2 melatonin oral tablet,chewable 2.5 mg, 5 mg 2 melatonin oral tablet,disintegrating 1 mg 2 melatonin-lemon balm leaf extr 2 melatonin-pyridoxine hcl (b6) oral tablet 1-10 mg, 3-10 mg 1MENEST 2 methylergonovine oral 1 methylprednisolone 1 MIMVEY 1 MINIVELLE 2 MYFEMBREE 2 PA; QL (1 EA per 1 day) NORDITROPIN FLEXPRO 2 PA; ST norethindrone acetate 1 ORIAHNN 2 PA; ST; QL (2 EA per 1 day) ORILISSA ORAL TABLET 150 MG 2 PA; ST; QL (1 EA per 1 day) ORILISSA ORAL TABLET 200 MG 2 PA; ST; QL (2 EA per 1 day) Drug Name Tier Restrictions / Limits prednisolone oral solution 1 prednisolone sodium phosphate oral solution 15 mg/5 ml (3 mg/ml), 15 mg/5 ml (5 ml), 5 mg base/5 ml (6.7 mg/5 ml) 1 PREDNISONE INTENSOL 1 prednisone oral solution 1 prednisone oral tablet 1 prednisone oral tablets,dose pack 1 PREMARIN 2 PREMPRO 2 progesterone 1 progesterone micronized oral 1 PROVERA 2 SEROSTIM 2 PA; ST; QL (30 EA per 22 days) SKYTROFA SUBCUTANEOUS CARTRIDGE 11 MG, 13.3 MG, 3 MG, 3.6 MG, 4.3 MG, 5.2 MG, 6.3 MG, 7.6 MG, 9.1 MG 2 PA; ST SUPPRELIN LA 2 SYNAREL 2 TESTIM 2 PA; ST; QL (60 EA per 30 days); AR testosterone transdermal gel in metered-dose pump 12.5 mg/ 1.25 gram (1 %) 1 PA; ST; QL (300 GM per 22 days) testosterone transdermal gel in metered-dose pump 20.25 mg/1.25 gram (1.62 %) 1 PA; ST; QL (150 GM per 22 days); AR INDIANA MEDICAID | Effective 02/01/2026 38Drug Name Tier Restrictions / Limits testosterone transdermal gel in packet 1 % (25 mg/2.5gram) 1 PA; ST; QL (30 GM per 30 days); AR testosterone transdermal gel in packet 1 % (50 mg/5 gram) 1 PA; QL (60 GM per 30 days); AR TRIPTODUR 2 VAGIFEM 2 VITAJOY MELATONIN 2 VIVELLE-DOT 2 IMMUNOSUPPRESSANTS ACTEMRA ACTPEN 2 PA ACTEMRA INTRAVENOUS 2 PA; ST ACTEMRA SUBCUTANEOUS 2 PA; ST; QL (3.6 ML per 22 days) azathioprine oral tablet 50 mg 1 cyclosporine modified 1 cyclosporine oral 1 DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 200 MG/1.14 ML 2 PA; ST; QL (2.28 ML per 22 days) DUPIXENT PEN SUBCUTANEOUS PEN INJECTOR 300 MG/2 ML 2 PA; ST; QL (4 ML per 22 days) DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 200 MG/1.14 ML 2 PA; ST; QL (2.28 ML per 22 days) DUPIXENT SYRINGE SUBCUTANEOUS SYRINGE 300 MG/2 ML 2 PA; ST; QL (4 ML per 22 days) ENSPRYNG 2 PA; QL (1 ML per 28 days); AR Drug Name Tier Restrictions / Limits everolimus (immunosuppressive) 1 GENGRAF 1 KEVZARA SUBCUTANEOUS PEN INJECTOR 2 PA KEVZARA SUBCUTANEOUS SYRINGE 2 PA; QL (2.28 ML per 22 days) mycophenolate mofetil 1 mycophenolate sodium 1 NEORAL 2 pimecrolimus 1 PA; ST; QL (100 GM per 25 days) PYZCHIVA 2 PA PYZCHIVA AUTOINJECTOR 2 PA SANDIMMUNE ORAL 2 SELARSDI 2 PA sirolimus 1 tacrolimus oral capsule 1 tacrolimus topical 1 PA; ST TYENNE 2 PA TYENNE AUTOINJECTOR 2 PA MISCELLANEOUS MEDICAL SUPPLIES, DEVICES, NON-DRUG ACE AEROSOL CLOUD ENHANCER 2 QL (2 EA per 365 days) AEROCHAMBER MINI 2 QL (2 EA per 365 days) AEROCHAMBER MV 2 QL (2 EA per 365 days) AEROCHAMBER PLUS FLOW-VU 2 QL (2 EA per 365 days) AEROCHAMBER PLUS ZSTAT 2 QL (2 EA per 365 days) 39 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits AEROCHAMBER PLUS ZSTAT MD MSK 2 QL (2 EA per 365 days) AEROCHAMBER PLUS ZSTAT SM MSK 2 QL (2 EA per 365 days) AEROCHAMBER Z – STAT PLUS-FLW SG 2 QL (2 EA per 365 days) AEROTRACH PLUS 2 QL (2 EA per 365 days) AEROVENT PLUS 2 QL (2 EA per 365 days) BD ECLIPSE LUER – LOK NEEDLE 30 X 1/2 " 2 BD PRECISIONGLIDE NEEDLE 27 GAUGE X 3/8" 2 BD SAFETYGLIDE ALLERGIST TRAY SYRINGE 1 ML 27 X 1/2" 2 BREATHERITE MDI SPACER 2 QL (2 EA per 365 days) BREATHERITE VALVED MDI CHAMBER 2 QL (2 EA per 365 days) BREATHERITE VALVED MDI SPACER 2 QL (2 EA per 365 days) CLEVER CHOICE CHAMBER-LRG MASK 2 QL (2 EA per 365 days) CLEVER CHOICE CHAMBER-MED MASK 2 QL (2 EA per 365 days) CLEVER CHOICE CHAMBER-SM MASK 2 QL (2 EA per 365 days) COMPACT SPACE CHAMBER 2 QL (2 EA per 365 days) DEXCOM G6 RECEIVER 2 QL (1 EA per 1 LIFETIME) DEXCOM G6 SENSOR 2 QL (3 EA per 28 days) DEXCOM G6 TRANSMITTER 2 QL (1 EA per 90 days) DEXCOM G7 RECEIVER 2 QL (1 EA per 1 Year) Drug Name Tier Restrictions / Limits DEXCOM G7 SENSOR 2 QL (3 EA per 28 days) EASIVENT HOLDING CHAMBER 2 QL (2 EA per 365 days) EASYPOINT NEEDLE NEEDLE 25 GAUGE X 1 1/2" 2 ECLIPSE NEEDLE NEEDLE 23 GAUGE X 1", 25 GAUGE X 5/8" 2 FLEXICHAMBER 2 QL (2 EA per 365 days) FLEXICHAMBER-LG CHILD MASK 2 QL (2 EA per 365 days) FLEXICHAMBER-SM ADULT MASK 2 QL (2 EA per 365 days) FLEXICHAMBER-SM CHILD MASK 2 QL (2 EA per 365 days) insulin syringe-needle u-100 syringe 1 ml 27gauge x 1/2", 1/2 ml 27 gauge x 1/2" 2 QL (400 EA per 30 days) INSUPEN PEN NEEDLE NEEDLE 32 GAUGE X 1/4" 2 LITE TOUCH-MEDIUM MASK 2 QL (2 EA per 365 days) LITEAIRE MDI CHAMBER 2 QL (2 EA per 365 days) LITETOUCH-LARGE MASK 2 QL (2 EA per 365 days) LITETOUCH-SMALL MASK 2 QL (2 EA per 365 days) MAGELLAN INSULIN SAFETY SYRNG 2 QL (400 EA per 30 days) MAGELLAN SYRINGE SYRINGE 0.3 ML 30 X 5/16", 0.5 ML 30 GAUGE X 5/16" 2 QL (400 EA per 30 days) MICROCHAMBER 2 QL (2 EA per 365 days) MINI WRIGHT PEAK FLOW METER 2 QL (1 EA per 365 days) MINIMED INSTINCT SENSOR 2 INDIANA MEDICAID | Effective 02/01/2026 40Drug Name Tier Restrictions / Limits MONOJECT INSULIN SAFETY SYRING SYRINGE 0.3 ML 30 GAUGE X 5/16", 0.5 ML 29 GAUGE X 1/2", 0.5 ML 30 GAUGE X 5/16" 2 QL (400 EA per 30 days) MONOJECT MAGELLAN SAFETY SYRNG SYRINGE 3 ML 20 GAUGE X 1" 2 MONOJECT SAFETY SYRINGES SYRINGE 3 ML 22 GAUGE X 1 1/2" 2 MONOJECT SYRINGE SYRINGE 1/2 ML 28 GAUGE 2 QL (400 EA per 30 days) OPTICHAMBER ADULT MASK-LARGE 2 QL (2 EA per 365 days) OPTICHAMBER DIAMOND LG MASK 2 QL (2 EA per 365 days) OPTICHAMBER DIAMOND VHC 2 QL (2 EA per 365 days) OPTICHAMBER DIAMOND-MED MSK 2 QL (2 EA per 365 days) OPTICHAMBER DIAMOND-SML MASK 2 QL (2 EA per 365 days) PEN NEEDLE NEEDLE 30 GAUGE X 5/16" 2 QL (400 EA per 30 days) POCKET CHAMBER 2 QL (2 EA per 365 days) PROCARE SPACER WITH ADULT MASK 2 QL (2 EA per 365 days) PROCARE SPACER WITH CHILD MASK 2 QL (2 EA per 365 days) PROCHAMBER 2 QL (2 EA per 365 days) RITEFLO AEROCHAMBER 2 QL (2 EA per 365 days) SILICONE MASK – INFANT 2 QL (2 EA per 365 days) SIMPLERA SENSOR 2 SIMPLERA SYNC SENSOR 2 SPACE CHAMBER 2 Drug Name Tier Restrictions / Limits SPACE CHAMBER WITH LARGE MASK 2 SPACE CHAMBER WITH MEDIUM MASK 2 SPACE CHAMBER WITH SMALL MASK 2 TRUZONE PEAK FLOW METER 2 QL (1 EA per 365 days) TUBERCULIN SYRINGE SYRINGE 1 ML 25 GAUGE X 1" 2 ULTICARE SYRINGE 1 ML 25 GAUGE X 5/8" 2 VORTEX HOLDING CHAMBER 2 QL (2 EA per 365 days) MUSCLE RELAXANTS baclofen oral tablet 10 mg, 20 mg, 5 mg 1 baclofen oral tablet 15 mg 2 chlorzoxazone 1 cyclobenzaprine oral tablet 1 methocarbamol injection 1 methocarbamol oral tablet 500 mg, 750 mg 1 orphenadrine citrate 1 tizanidine oral tablet 1 PRE-NATAL VITAMINS CADEAU DHA 2 CLASSIC PRENATAL 1 COMPLETENATE 1 KOSHER PRENATAL PLUS IRON 2 KPN 2 MINI PRENATAL 2 M-NATAL PLUS 1 ONE A DAY WOMEN'S PRENATAL DHA 2 41 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits ONE-A-DAY PRENATAL-1 2 pnv no.95-ferrous fumarate-fa 1 PRENATABS FA 1 PRENATABS RX 1 PRENATAL + DHA ORAL COMBO PACK 28 MG IRON-975 MCG-200 MG 1 PRENATAL + DHA ORAL COMBO PACK 28 MG IRON-800 MCG-200 MG 2 PRENATAL 19 ORAL TABLET,CHEWABLE 2 PRENATAL COMPLETE 1 PRENATAL FORMULA 2 PRENATAL MULTI 2 PRENATAL MULTI – DHA (ALGAL OIL) 1 PA PRENATAL MULTI – DHA(WITH VIT K) 2 PA PRENATAL MULTIVITAMINS 1 PRENATAL ONE DAILY 1 PRENATAL ORAL TABLET 28 MG IRON-800 MCG 1 PRENATAL ORAL TABLET 28-800 MG-MCG 2 PRENATAL PLUS 1 PRENATAL PLUS (CALCIUM CARB) 1 PRENATAL TABLET 1 prenatal vit no.179-iron – folic 1 PRENATAL VITAMIN ORAL TABLET 27 MG IRON-0.8 MG 1 Drug Name Tier Restrictions / Limits PRENATAL VITAMIN PLUS LOW IRON 1 PRENATAL VITAMIN WITH MINERALS 1 prenatal vit-iron fum – folic ac 1 SE-NATAL 19 CHEWABLE 1 SIMILAC PRENATAL 2 THERANATAL COMPLETE 2 PA THERANATAL ONE 2 THERANATAL ORAL TABLET 2 THRIVITE RX 2 TRICARE 2 TRINATAL RX 1 1 WOMEN'S PRENATAL PLUS DHA 2 PSYCHOTHERAPEUTIC DRUGS ABILIFY ASIMTUFII INTRAMUSCULAR SUSPENSION,EXTEN DED REL SYRING 720 MG/2.4 ML 2 PA; ST; QL (1 ML per 56 days); AR ABILIFY ASIMTUFII INTRAMUSCULAR SUSPENSION,EXTEN DED REL SYRING 960 MG/3.2 ML 2 PA; ST; QL (1 EA per 56 days); AR ABILIFY MAINTENA 2 PA; ST; QL (1 EA per 28 days) ALPRAZOLAM INTENSOL 1 PA; QL (4 ML per 1 day) alprazolam oral tablet 1 PA; QL (4 EA per 1 day) alprazolam oral tablet extended release 24 hr 1 PA; QL (1 EA per 1 day) alprazolam oral tablet,disintegrating 1 PA; QL (4 EA per 1 day) amitriptyline oral tablet 10 mg 1 QL (4 EA per 1 day) INDIANA MEDICAID | Effective 02/01/2026 42Drug Name Tier Restrictions / Limits amitriptyline oral tablet 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 1 QL (3 EA per 1 day) amitriptyline – chlordiazepoxide 1 PA amoxapine oral tablet 100 mg, 50 mg 1 QL (4 EA per 1 day) amoxapine oral tablet 150 mg, 25 mg 1 QL (2 EA per 1 day) APLENZIN 2 ST; QL (1 EA per 1 day) aripiprazole oral solution 1 PA; ST; QL (30 ML per 1 day); AR aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 30 mg 1 PA; ST; QL (1 EA per 1 day); AR aripiprazole oral tablet 20 mg 1 PA; ST; QL (2 EA per 1 day); AR aripiprazole oral tablet 5 mg 1 PA; ST; QL (1.5 EA per 1 day); AR aripiprazole oral tablet,disintegrating 1 PA; ST; QL (2 EA per 1 day); AR ARISTADA INITIO 2 PA; QL (2.4 ML per 180 days); AR ARISTADA INTRAMUSCULAR SUSPENSION,EXTEN DED REL SYRING 1,064 MG/3.9 ML 2 PA; QL (1 ML per 56 days); AR ARISTADA INTRAMUSCULAR SUSPENSION,EXTEN DED REL SYRING 441 MG/1.6 ML, 662 MG/2.4 ML, 882 MG/3.2 ML 2 PA; QL (1 ML per 28 days); AR armodafinil oral tablet 150 mg, 200 mg, 250 mg 1 PA; ST; QL (1 EA per 1 day); AR armodafinil oral tablet 50 mg 1 PA; ST; QL (2 EA per 1 day); AR Drug Name Tier Restrictions / Limits asenapine maleate 1 PA; QL (2 EA per 1 day); AR atomoxetine oral capsule 10 mg, 18 mg, 25 mg, 40 mg 1 ST; QL (2 EA per 1 day) atomoxetine oral capsule 100 mg, 60 mg, 80 mg 1 ST; QL (1 EA per 1 day) AUVELITY 2 QL (2 EA per 1 day); AR AZSTARYS 2 PA; ST; QL (1 EA per 1 day); AR bupropion hcl oral tablet 1 ST; QL (4 EA per 1 day) bupropion hcl oral tablet extended release 24 hr 150 mg, 300 mg 1 ST; QL (1 EA per 1 day) bupropion hcl oral tablet sustained-release 12 hr 1 ST; QL (2 EA per 1 day) buspirone oral tablet 10 mg 1 QL (4 EA per 1 day) buspirone oral tablet 15 mg, 5 mg, 7.5 mg 1 QL (3 EA per 1 day) buspirone oral tablet 30 mg 1 QL (2 EA per 1 day) CAPLYTA 2 PA; QL (1 EA per 1 day); AR chlordiazepoxide hcl 1 PA; QL (4 EA per 1 day) chlorpromazine injection 1 PA chlorpromazine oral concentrate 100 mg/ml 1 PA; QL (8 ML per 1 day) chlorpromazine oral concentrate 30 mg/ml 1 PA; QL (26.7 ML per 1 day) chlorpromazine oral tablet 1 PA; QL (4 EA per 1 day) citalopram oral solution 1 PA; ST; QL (20 ML per 1 day) citalopram oral tablet 10 mg, 20 mg 1 PA; QL (1.5 EA per 1 day) citalopram oral tablet 40 mg 1 PA; QL (1 EA per 1 day) 43 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits clomipramine oral capsule 25 mg 1 QL (2 EA per 1 day) clomipramine oral capsule 50 mg 1 QL (5 EA per 1 day) clomipramine oral capsule 75 mg 1 QL (3 EA per 1 day) clonidine hcl oral tablet extended release 12 hr 1 PA; ST; QL (4 EA per 1 day) clorazepate dipotassium 1 PA; QL (4 EA per 1 day) clozapine oral tablet 100 mg 1 PA; QL (6 EA per 1 day); AR clozapine oral tablet 200 mg, 25 mg, 50 mg 1 PA; QL (3 EA per 1 day); AR clozapine oral tablet,disintegrating 100 mg 1 ST; QL (6 EA per 1 day); AR clozapine oral tablet,disintegrating 12.5 mg, 150 mg, 200 mg, 25 mg 1 ST; QL (3 EA per 1 day); AR DAYTRANA 2 PA; ST; QL (1 EA per 1 day); AR desipramine oral tablet 10 mg 1 QL (4 EA per 1 day) desipramine oral tablet 100 mg 1 QL (3 EA per 1 day) desipramine oral tablet 150 mg, 25 mg, 50 mg, 75 mg 1 QL (2 EA per 1 day) desvenlafaxine oral tablet extended release 24 hr 100 mg 2 PA; QL (2 EA per 1 day) desvenlafaxine oral tablet extended release 24 hr 50 mg 2 PA; QL (1 EA per 1 day) desvenlafaxine succinate oral tablet extended release 24 hr 100 mg 1 PA; QL (2 EA per 1 day) desvenlafaxine succinate oral tablet extended release 24 hr 25 mg, 50 mg 1 PA; QL (1 EA per 1 day) Drug Name Tier Restrictions / Limits dexmethylphenidate oral capsule,er biphasic 50-50 1 PA; ST; QL (1 EA per 1 day); AR dexmethylphenidate oral tablet 10 mg 1 PA; ST; QL (4 EA per 1 day); AR dexmethylphenidate oral tablet 2.5 mg, 5 mg 1 PA; ST; QL (2 EA per 1 day); AR diazepam injection 1 PA DIAZEPAM INTENSOL 1 PA; QL (8 ML per 1 day) diazepam oral concentrate 1 PA; QL (8 ML per 1 day) diazepam oral solution 1 PA; QL (8 ML per 1 day) diazepam oral tablet 1 PA; QL (4 EA per 1 day) doxepin oral capsule 10 mg 1 QL (4 EA per 1 day) doxepin oral capsule 100 mg, 150 mg, 25 mg, 50 mg, 75 mg 1 QL (2 EA per 1 day) doxepin oral concentrate 1 QL (30 ML per 1 day) droperidol 1 duloxetine 1 PA; QL (2 EA per 1 day) EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 100 MG 2 QL (4 EA per 1 day) EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 200 MG 2 QL (8 EA per 1 day) EQUETRO ORAL CAPSULE, ER MULTIPHASE 12 HR 300 MG 2 QL (5 EA per 1 day) INDIANA MEDICAID | Effective 02/01/2026 44Drug Name Tier Restrictions / Limits ERZOFRI INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML 2 PA; QL (1 EA per 28 days); AR ERZOFRI INTRAMUSCULAR SYRINGE 351 MG/2.25 ML 2 PA; QL (1 EA per 180 days); AR escitalopram oxalate oral solution 1 PA; ST; QL (20 ML per 1 day) escitalopram oxalate oral tablet 10 mg, 20 mg 1 PA; QL (1.5 EA per 1 day) escitalopram oxalate oral tablet 5 mg 1 PA; QL (1 EA per 1 day) FETZIMA ORAL CAPSULE,EXT REL 24HR DOSE PACK 20 MG (2)- 40 MG (26) 2 PA; QL (1 EA per 1 day) FETZIMA ORAL CAPSULE,EXTENDED RELEASE 24 HR 2 PA; QL (1 EA per 1 day) fluoxetine oral capsule 10 mg 1 PA; QL (1 EA per 1 day) fluoxetine oral capsule 20 mg 1 PA; QL (4 EA per 1 day) fluoxetine oral capsule 40 mg 1 PA; QL (2 EA per 1 day) fluoxetine oral capsule,delayed release(dr/ec) 1 PA; QL (4 EA per 28 days) fluoxetine oral solution 1 PA; ST; QL (20 ML per 1 day) fluoxetine oral tablet 10 mg 1 PA; QL (1.5 EA per 1 day) fluoxetine oral tablet 20 mg 1 PA; QL (4 EA per 1 day) fluoxetine oral tablet 60 mg 1 PA; QL (1 EA per 1 day) fluphenazine decanoate 1 PA; AR fluphenazine hcl injection 1 PA; AR fluphenazine hcl oral concentrate 1 PA; AR Drug Name Tier Restrictions / Limits fluphenazine hcl oral elixir 1 PA; AR fluphenazine hcl oral tablet 1 PA; QL (4 EA per 1 day); AR fluvoxamine oral tablet 100 mg 1 PA; QL (3 EA per 1 day) fluvoxamine oral tablet 25 mg, 50 mg 1 PA; QL (1 EA per 1 day) guanfacine oral tablet extended release 24 hr 1 PA; ST; QL (1 EA per 1 day) haloperidol 1 PA; QL (3 EA per 1 day); AR haloperidol decanoate 1 PA; AR haloperidol lactate 1 PA; AR imipramine hcl oral tablet 10 mg 1 QL (2 EA per 1 day) imipramine hcl oral tablet 25 mg 1 QL (1 EA per 1 day) imipramine hcl oral tablet 50 mg 1 QL (6 EA per 1 day) imipramine pamoate oral capsule 100 mg 1 QL (3 EA per 1 day) imipramine pamoate oral capsule 125 mg, 150 mg 1 QL (2 EA per 1 day) imipramine pamoate oral capsule 75 mg 1 QL (1 EA per 1 day) INVEGA HAFYERA 2 PA; QL (1 ML per 180 days) INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 39 MG/0.25 ML, 78 MG/0.5 ML 2 PA; QL (1 ML per 28 days) INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 234 MG/1.5 ML 2 PA; QL (2 ML per 28 days) INVEGA TRINZA INTRAMUSCULAR SYRINGE 273 MG/0.88 ML 2 PA; QL (1 ML per 90 days) 45 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits INVEGA TRINZA INTRAMUSCULAR SYRINGE 410 MG/1.32 ML, 546 MG/1.75 ML 2 PA; QL (2 ML per 90 days) INVEGA TRINZA INTRAMUSCULAR SYRINGE 819 MG/2.63 ML 2 PA; QL (3 ML per 90 days) JORNAY PM 2 ST; QL (1 EA per 1 day); AR lithium carbonate 1 lithium citrate 1 ST LORAZEPAM INTENSOL 1 PA lorazepam oral concentrate 1 PA lorazepam oral tablet 1 PA; QL (4 EA per 1 day) loxapine succinate 1 PA; QL (4 EA per 1 day); AR lurasidone oral tablet 120 mg, 20 mg, 40 mg, 60 mg 1 PA; QL (1 EA per 1 day); AR lurasidone oral tablet 80 mg 1 PA; QL (2 EA per 1 day); AR LYBALVI 2 PA; QL (30 EA per 28 days) methylphenidate hcl oral cap,er sprinkle,biphasic 40-60 1 PA; ST; QL (1 EA per 1 day); AR methylphenidate hcl oral capsule, er biphasic 30-70 1 PA; ST; QL (1 EA per 1 day); AR methylphenidate hcl oral capsule,er biphasic 50-50 10 mg, 20 mg, 40mg, 60 mg 1 PA; ST; QL (1 EA per 1 day); AR methylphenidate hcl oral capsule,er biphasic 50-50 30 mg 1 PA; ST; QL (2 EA per 1 day); AR methylphenidate hcl oral solution 10 mg/5 ml 1 PA; ST; QL (30 ML per 1 day); AR Drug Name Tier Restrictions / Limits methylphenidate hcl oral solution 5 mg/5 ml 1 PA; ST; QL (60 ML per 1 day); AR methylphenidate hcl oral tablet 1 PA; ST; QL (3 EA per 1 day); AR methylphenidate hcl oral tablet extended release 1 PA; ST; QL (3 EA per 1 day); AR methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg 1 PA; ST; QL (1 EA per 1 day); AR methylphenidate hcl oral tablet extended release 24hr 36 mg, 54 mg 1 PA; ST; QL (2 EA per 1 day); AR methylphenidate hcl oral tablet extended release 24hr 45 mg, 63 mg 2 PA; ST; AR methylphenidate hcl oral tablet extended release 24hr 72 mg 2 PA; ST; QL (1 EA per 1 day); AR methylphenidate hcl oral tablet,chewable 1 PA; ST; QL (3 EA per 1 day); AR mirtazapine 1 QL (1 EA per 1 day) modafinil oral tablet 100 mg 1 PA; QL (1 EA per 1 day); AR modafinil oral tablet 200 mg 1 PA; QL (2 EA per 1 day); AR molindone oral tablet 10 mg, 5 mg 1 PA; QL (4 EA per 1 day); AR molindone oral tablet 25 mg 1 PA; QL (9 EA per 1 day); AR nefazodone 1 QL (2 EA per 1 day) nortriptyline oral capsule 10 mg, 25 mg 1 QL (4 EA per 1 day) nortriptyline oral capsule 50 mg 1 QL (3 EA per 1 day) nortriptyline oral capsule 75 mg 1 QL (2 EA per 1 day) INDIANA MEDICAID | Effective 02/01/2026 46Drug Name Tier Restrictions / Limits nortriptyline oral solution 1 ST; QL (20 ML per 1 day) olanzapine intramuscular 1 PA; AR olanzapine oral tablet 10 mg, 15 mg 1 PA; QL (2 EA per 1 day); AR olanzapine oral tablet 2.5 mg, 5 mg, 7.5 mg 1 PA; QL (1 EA per 1 day); AR olanzapine oral tablet 20 mg 1 PA; QL (3 EA per 1 day); AR olanzapine oral tablet,disintegrating 10 mg, 15 mg 1 PA; QL (2 EA per 1 day); AR olanzapine oral tablet,disintegrating 20 mg 1 PA; QL (3 EA per 1 day); AR olanzapine oral tablet,disintegrating 5 mg 1 PA; QL (1 EA per 1 day); AR olanzapine-fluoxetine 1 PA; QL (1 EA per 1 day); AR oxazepam 1 PA; QL (4 EA per 1 day) paliperidone oral tablet extended release 24hr 1.5 mg, 3 mg, 9 mg 1 PA; ST; QL (1 EA per 1 day); AR paliperidone oral tablet extended release 24hr 6 mg 1 PA; ST; QL (2 EA per 1 day); AR PAMELOR ORAL CAPSULE 10 MG, 25 MG 2 PA; QL (4 EA per 1 day) PAMELOR ORAL CAPSULE 50 MG 2 PA; QL (3 EA per 1 day) PAMELOR ORAL CAPSULE 75 MG 2 PA; QL (2 EA per 1 day) paroxetine hcl oral suspension 1 ST; QL (40 ML per 1 day); AR paroxetine hcl oral tablet 10 mg 1 PA; QL (1.5 EA per 1 day); AR paroxetine hcl oral tablet 20 mg 1 PA; QL (1 EA per 1 day); AR paroxetine hcl oral tablet 30 mg, 40 mg 1 PA; QL (2 EA per 1 day); AR Drug Name Tier Restrictions / Limits paroxetine hcl oral tablet extended release 24 hr 12.5 mg, 25 mg 1 PA; QL (1 EA per 1 day); AR paroxetine hcl oral tablet extended release 24 hr 37.5 mg 1 QL (2 EA per 1 day); AR perphenazine 1 PA; QL (4 EA per 1 day); AR perphenazine – amitriptyline 1 PA; AR protriptyline 1 QL (4 EA per 1 day) QELBREE ORAL CAPSULE,EXTENDED RELEASE 24HR 100 MG 2 ST; QL (1 EA per 1 day); AR QELBREE ORAL CAPSULE,EXTENDED RELEASE 24HR 150 MG 2 ST; QL (2 EA per 1 day); AR QELBREE ORAL CAPSULE,EXTENDED RELEASE 24HR 200 MG 2 ST; QL (3 EA per 1 day); AR quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg 1 PA; QL (3 EA per 1 day); AR quetiapine oral tablet 150 mg 2 PA; QL (2 EA per 1 day); AR quetiapine oral tablet 300 mg, 400 mg 1 PA; QL (4 EA per 1 day); AR quetiapine oral tablet extended release 24 hr 150 mg, 200 mg 1 PA; QL (1 EA per 1 day); AR quetiapine oral tablet extended release 24 hr 300 mg 1 PA; QL (3 EA per 1 day); AR quetiapine oral tablet extended release 24 hr 400 mg 1 PA; QL (4 EA per 1 day); AR quetiapine oral tablet extended release 24 hr 50 mg 1 PA; QL (2 EA per 1 day); AR 47 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits QUILLICHEW ER ORAL TABLET,CHEW,IR-ER.BIPHASIC24HR 20 MG, 40 MG 2 PA; ST; QL (1 EA per 1 day); AR QUILLICHEW ER ORAL TABLET,CHEW,IR-ER.BIPHASIC24HR 30 MG 2 PA; ST; QL (2 EA per 1 day); AR QUILLIVANT XR 2 PA; ST; QL (12 ML per 1 day); AR REXULTI ORAL TABLET 2 PA; QL (1 EA per 1 day); AR RISPERDAL CONSTA 2 PA; QL (2 EA per 28 days) risperidone oral solution 1 ST; QL (8 ML per 1 day); AR risperidone oral tablet 1 PA; QL (2 EA per 1 day); AR risperidone oral tablet,disintegrating 0.25 mg, 1 mg, 2 mg, 3 mg, 4 mg 1 ST; QL (2 EA per 1 day); AR risperidone oral tablet,disintegrating 0.5 mg 1 PA; ST; QL (2 EA per 1 day); AR sertraline oral concentrate 1 ST; QL (10 ML per 1 day) sertraline oral tablet 100 mg 1 QL (3 EA per 1 day) sertraline oral tablet 25 mg, 50 mg 1 QL (2 EA per 1 day) thioridazine 1 PA; QL (4 EA per 1 day); AR thiothixene 1 PA; QL (3 EA per 1 day); AR trazodone oral tablet 100 mg, 150 mg 1 QL (3 EA per 1 day) trazodone oral tablet 300 mg, 50 mg 1 QL (2 EA per 1 day) trifluoperazine oral tablet 1 mg, 2 mg, 5 mg 1 PA; QL (2 EA per 1 day); AR Drug Name Tier Restrictions / Limits trifluoperazine oral tablet 10 mg 1 PA; QL (4 EA per 1 day); AR TRINTELLIX 2 QL (1 EA per 1 day) UZEDY 2 PA; ST; QL (1 EA per 28 days); AR venlafaxine besylate 2 PA; QL (2 EA per 1 day) venlafaxine oral capsule,extended release 24hr 150 mg 1 PA; QL (2 EA per 1 day) venlafaxine oral capsule,extended release 24hr 37.5 mg 1 PA; QL (1 EA per 1 day) venlafaxine oral capsule,extended release 24hr 75 mg 1 PA; QL (3 EA per 1 day) venlafaxine oral tablet 1 PA; QL (3 EA per 1 day) venlafaxine oral tablet extended release 24hr 150 mg 1 PA; QL (2 EA per 1 day) venlafaxine oral tablet extended release 24hr 225 mg, 37.5 mg 1 PA; QL (1 EA per 1 day) venlafaxine oral tablet extended release 24hr 75 mg 1 PA; QL (3 EA per 1 day) vilazodone 1 QL (1 EA per 1 day) VRAYLAR ORAL CAPSULE 1.5 MG 2 PA; ST; QL (2 EA per 1 day); AR VRAYLAR ORAL CAPSULE 3 MG, 4.5 MG, 6 MG 2 PA; ST; QL (1 EA per 1 day); AR VYVANSE ORAL CAPSULE 2 QL (1 EA per 1 day); AR VYVANSE ORAL TABLET,CHEWABLE 2 ST; QL (1 EA per 1 day); AR ziprasidone hcl oral capsule 20 mg, 40 mg 1 PA; ST; QL (2 EA per 1 day); AR INDIANA MEDICAID | Effective 02/01/2026 48Drug Name Tier Restrictions / Limits ziprasidone hcl oral capsule 60 mg, 80 mg 1 PA; ST; QL (3 EA per 1 day); AR ziprasidone mesylate 1 PA; ST; AR ZURZUVAE ORAL CAPSULE 20 MG, 25 MG 2 PA; QL (28 EA per 365 days); AR ZURZUVAE ORAL CAPSULE 30 MG 2 PA; QL (14 EA per 365 days); AR ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 300 MG 2 PA; ST; QL (2 EA per 28 days); AR ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 405 MG 2 PA; ST; QL (1 EA per 28 days); AR SEDATIVE/HYPNOTICS BELSOMRA 2 ST; QL (1 EA per 1 day); AR doxepin oral tablet 1 QL (1 EA per 1 day) estazolam 1 PA; QL (1 EA per 1 day) eszopiclone 1 QL (1 EA per 1 day) lorazepam injection 1 PA LUMRYZ 2 LUNESTA 2 PA; QL (1 EA per 1 day) midazolam oral syrup 10 mg/5 ml (2 mg/ml) 2 midazolam oral syrup 2 mg/ml 1 pentobarbital sodium 1 phenobarbital 1 phenobarbital sodium 1 ramelteon 1 QL (1 EA per 1 day) Drug Name Tier Restrictions / Limits temazepam 1 PA; QL (1 EA per 1 day) triazolam 1 PA; QL (1 EA per 1 day) zaleplon 1 QL (2 EA per 1 day) zolpidem oral tablet 1 QL (1 EA per 1 day) zolpidem oral tablet,ext release multiphase 1 QL (1 EA per 1 day) SKIN PREPS ACCUTANE 1 acitretin 1 PA ALA-CORT 1 alclometasone topical cream 1 alclometasone topical ointment 1 QL (2 GM per 1 day) AMNESTEEM ORAL CAPSULE 10 MG, 20 MG, 40 MG 1 ST; AR AZELEX 2 betamethasone dipropionate topical cream 1 betamethasone dipropionate topical lotion 1 betamethasone dipropionate topical ointment 1 PA betamethasone valerate topical cream 1 betamethasone valerate topical lotion 1 betamethasone valerate topical ointment 1 betamethasone, augmented topical cream 1 betamethasone, augmented topical lotion 1 49 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits betamethasone, augmented topical ointment 1 calcipotriene scalp 1 QL (2 ML per 1 day) calcipotriene topical cream 1 QL (4 GM per 1 day) CLARAVIS 1 ST; AR clindamycin-benzoyl peroxide topical gel 1 ST clindamycin-benzoyl peroxide topical gel with pump 1-5 % 1 ST clobetasol scalp 1 PA clobetasol topical cream 0.05 % 1 PA clobetasol topical gel 1 PA clobetasol topical ointment 1 clobetasol topical shampoo 1 PA; QL (118 ML per 30 days) clobetasol-emollient topical cream 1 CLODAN 1 PA; QL (118 ML per 30 days) desonide topical cream 1 desonide topical ointment 1 desoximetasone topical cream 0.25 % 1 desoximetasone topical ointment 0.05 % 1 QL (4 GM per 1 day) DIFFERIN TOPICAL CREAM 2 PA DIFFERIN TOPICAL GEL WITH PUMP 2 PA; ST DIFFERIN TOPICAL LOTION 2 diflorasone 1 PA; QL (2 GM per 1 day) ENSTILAR 2 Drug Name Tier Restrictions / Limits EPIDUO FORTE 2 PA EUCRISA 2 PA FINACEA 2 ST fluocinolone and shower cap 1 QL (1 ML per 28 days) fluocinolone topical cream 1 QL (2 GM per 1 day) fluocinolone topical oil 1 fluocinolone topical ointment 1 QL (2 GM per 1 day) fluocinolone topical solution 1 QL (4 ML per 1 day) fluocinonide topical cream 1 PA fluocinonide topical gel 1 PA; QL (2 GM per 1 day) fluocinonide topical ointment 1 PA; QL (2 GM per 1 day) fluocinonide topical solution 1 QL (4 ML per 1 day) FLUOCINONIDE-E 1 fluocinonide-emollient 1 fluticasone propionate topical cream 1 QL (2 GM per 1 day) fluticasone propionate topical ointment 1 QL (2 GM per 1 day) hydrocortisone butyrate topical ointment 1 hydrocortisone butyrate topical solution 1 QL (2 ML per 1 day) hydrocortisone topical cream 2.5 % 1 hydrocortisone topical cream with perineal applicator 1 hydrocortisone topical lotion 2 %, 2.5 % 1 hydrocortisone topical ointment 2.5 % 1 hydrocortisone valerate topical cream 1 lidocaine hcl – hydrocortison ac topical 1 PA; QL (29 GM per 30 days) INDIANA MEDICAID | Effective 02/01/2026 50Drug Name Tier Restrictions / Limits METROCREAM 2 METROLOTION 2 metronidazole topical cream 1 AR metronidazole topical gel 1 AR metronidazole topical lotion 1 AR mometasone topical 1 NEUAC 1 ST OPZELURA 2 PA; QL (360 GM per 1 Year) podofilox topical solution 1 QL (1 ML per 28 days) PROCTO-MED HC 1 PROCTOSOL HC 1 PROCTOZONE-HC 1 ROSADAN TOPICAL CREAM 1 ROSADAN TOPICAL GEL 1 SANTYL 2 QL (60 GM per 28 days) selenium sulfide topical lotion 1 sulfacetamide sodium topical cleanser, gel 1 ST sulfacetamide sodium topical shampoo 10 % 1 TACLONEX 2 TALTZ AUTOINJECTOR 2 PA; QL (1 ML per 22 days) TALTZ AUTOINJECTOR (2 PACK) 2 PA; QL (2 ML per 2 days) TALTZ AUTOINJECTOR (3 PACK) 2 PA; QL (3 ML per 22 days) TALTZ SYRINGE SUBCUTANEOUS SYRINGE 80 MG/ML 2 PA tazarotene topical cream 0.1 % 1 Drug Name Tier Restrictions / Limits tretinoin topical cream 1 QL (45 GM per 30 days); AR tretinoin topical gel 0.01 %, 0.025 % 1 ST; QL (45 GM per 30 days); AR triamcinolone acetonide topical cream 1 QL (454 GM per 30 days) triamcinolone acetonide topical lotion 1 triamcinolone acetonide topical ointment 0.025 %, 0.1 %, 0.5 % 1 QL (454 GM per 30 days) TRI-CHLOR 1 TRIDERM 1 QL (454 GM per 30 days) urea topical cream 39 %, 40 %, 41 %, 45 %, 47 %, 50 % 1 urea topical lotion 40 % 2 VECTICAL 2 VTAMA 2 ZENATANE 1 ST; AR SMOKING DETERRENTS bupropion hcl (smoking deter) 1 ST; QL (1 EA per 1 day) CHANTIX CONTINUING MONTH BOX 2 AR CHANTIX ORAL TABLET 0.5 MG 2 CHANTIX ORAL TABLET 1 MG 2 AR CHANTIX STARTING MONTH BOX 2 PA; AR varenicline tartrate oral tablet 1 ST; AR varenicline tartrate oral tablets,dose pack 1 ST; QL (1 Pack per 90 days); AR THYROID PREPS ARMOUR THYROID 2 EUTHYROX 1 51 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits levothyroxine oral tablet 1 LEVOXYL 1 liothyronine oral 1 methimazole 1 NP THYROID 1 propylthiouracil 1 SYNTHROID 2 thyroid (pork) 1 UNITHROID 1 UNCLASSIFIED DRUG PRODUCTS acamprosate 1 ADBRY 2 PA; ST alendronate oral tablet 1 alfuzosin 1 arginine (l-arginine) (bulk) crystals 2 BASE, PCCA SYRUP VEHICLE 2 BRIXADI 2 PA; AR buprenorphine hcl sublingual 1 QL (24 MG per 1 day) buprenorphine – naloxone sublingual tablet 1 QL (24 MG per 1 day) CARBAGLU 2 PA CHEMET 2 chloral hydrate (bulk) 2 chlorhexidine gluconate mucous membrane 1 cinacalcet 1 cpd vehicle susp.sugar – free 12 2 deferasirox oral tablet, dispersible 1 PA disulfiram 1 doxycycline hyclate oral tablet 20 mg 1 dutasteride 1 fesoterodine 1 Drug Name Tier Restrictions / Limits finasteride oral tablet 5 mg 1 FLAVOR BLEND 2 IN 1 2 FLAVOR PLUS 2 FLAVOR SWEET 2 FLAVOR SWEET-SF 2 fluphenazine decanoate (bulk) liquid 2 PA; AR fluphenazine decanoate (bulk) oil 2 PA FORTEO 2 PA; ST; QL (2.4 ML per 22 days) GALZIN 2 PA HYPER-SAL 2 ibandronate oral 1 icatibant 1 PA leucovorin calcium oral 1 levocarnitine (with sugar) 1 levocarnitine oral solution 100 mg/ml 1 MEGAVITE 2 megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml) 1 megestrol oral suspension 625 mg/5 ml (125 mg/ml) 1 PA MESNEX ORAL 2 miglustat 1 PA; QL (90 EA per 28 days) MX-SOL 2 MX-SOL BLEND 2 MX-SOL BLEND SF 2 MX-SOL SF 2 MX-SOL SUSPEND 2 MYRBETRIQ ORAL TABLET EXTENDED RELEASE 24 HR 2 INDIANA MEDICAID | Effective 02/01/2026 52Drug Name Tier Restrictions / Limits NEBUSAL INHALATION SOLUTION FOR NEBULIZATION 3 % 1 nitisinone 1 PA OFEV ORAL CAPSULE 100 MG 2 PA; QL (3 EA per 1 day) OFEV ORAL CAPSULE 150 MG 2 PA; QL (2 EA per 1 day) ONE DAILY WOMEN’S METABOLISM 2 ORA-BLEND 2 ORA-BLEND SF 2 ORAL MIX 2 ORAL MIX SF 2 ORAL SUSPEND 2 ORAL SYRUP 2 ORAL SYRUP SF 2 ORALONE 1 ORA-PLUS 2 ORA-SWEET 1 ORA-SWEET SF 2 ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG 2 ORFADIN ORAL CAPSULE 20 MG 2 PA ORFADIN ORAL SUSPENSION 2 PA ORLADEYO 2 QL (28 EA per 28 days); AR oxybutynin chloride oral syrup 1 oxybutynin chloride oral tablet 2.5 mg 2 oxybutynin chloride oral tablet 5 mg 1 oxybutynin chloride oral tablet extended release 24hr 1 OXYTROL 2 Drug Name Tier Restrictions / Limits paricalcitol oral capsule 4 mcg 1 ST PAROEX ORAL RINSE 1 paroxetine mesylate(menop.sym) 1 PA PCCA-PLUS BASE 2 PERIOGARD 1 PHYTOMULTI 2 pirfenidone oral capsule 1 PA pirfenidone oral tablet 267 mg, 801 mg 1 PA PULMOSAL 1 PULMOZYME 2 PA; QL (2.5 ML per 1 day) raloxifene 1 risedronate oral tablet 1 PA; ST sapropterin 1 PA SAVELLA ORAL TABLET 2 PA SAVELLA ORAL TABLETS,DOSE PACK 2 PA; QL (1 Pak per 90 days) selegiline hcl (bulk) 2 SENSIPAR 2 simple syrup 1 sodium chloride inhalation solution for nebulization 0.9 %, 3 %, 7 % 1 sodium chloride inhalation solution for nebulization 10 % 1 QL (4 ML per 1 day) sodium phenylbutyrate (bulk) 1 solifenacin 1 SOMAVERT 2 PA; QL (30 Vials per 30 days); AR STRENSIQ 2 PA 53 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 100 MG/0.5 ML 2 PA; QL (100 mg per 30 days); AR SUBLOCADE SUBCUTANEOUS SOLUTION, EXTENDED REL SYRINGE 300 MG/1.5 ML 2 PA; QL (300 mg per 30 days); AR SUBOXONE SUBLINGUAL FILM 12-3 MG 2 PA; ST; QL (24 mg per 1 day); AR SUBOXONE SUBLINGUAL FILM 2-0.5 MG 2 PA; ST; QL (24 MG per 1 day); AR SUBOXONE SUBLINGUAL FILM 4-1 MG, 8-2 MG 2 ST; QL (24 mg per 1 day); AR SUSPENDRX ANHYDROUS SWEETENED 2 SUSPENDRX ANHYDROUS UNSWEET 2 SWEET-SF 2 SYRPALTA VEHICLE 1 SYRSPEND SF LIQUID 2 SYRUP VEHICLE SF 2 tamsulosin 1 TEZSPIRE 2 PA; ST THIOLA EC 2 tolterodine 1 triamcinolone acetonide dental 1 TYBOST 2 VERSA FREE 2 VERSA PLUS 2 VIVITROL 2 QL (1 EA per 30 days) VYNDAMAX 2 PA; QL (1 EA per 1 day) Drug Name Tier Restrictions / Limits ZUBSOLV 2 ST; QL (17.2 MG per 1 day); AR VITAMINS A THRU Z 1 A THRU ZADVANCED FORMULA 1 A THRU ZHIGH POTENCY 1 A THRU ZMEN'S ULTIMATE 2 A THRU ZSELECT 50PLUS FORMULA 1 A THRU ZSELECT ORAL TABLET , 500-300-250 MCG 1 A THRU ZSELECT WOMEN'S 1 ABC COMPLETE SENIOR WOMEN'S 2 ACTIVNUTRIENTS CHEWABLE 2 ADEK GUMMIES PLUS ZINC 2 ADULT MULTIVITAMIN GUMMIES ORAL TABLET,CHEWABLE 200 MCG 2 ADULT ONE DAILY GUMMIES 2 ADULTS 50 PLUS 1 ADULTS' DAILY FORMULA 2 ADULTS MULTIVITAMIN 2 ADVANCED MULTI EA 2 ALIVE MAX POTENCY 2 ALIVE PREMIUM PRENATAL 2 ALIVE WOMEN 50 PLS ULT POTENCY 2 ALIVE WOMEN'S 50 PLUS COMPLETE 2 INDIANA MEDICAID | Effective 02/01/2026 54Drug Name Tier Restrictions / Limits ALIVE WOMEN'S 50 PLUS GUMMY 2 ALIVE WOMEN'S ENERGY 2 ALIVE WOMEN'S GUMMY VITAMIN 2 ALIVE WOMEN'S ULTRA POTENCY 2 AMLADEX 2 ANIMAL CHEWS 1 APATATE FORTE 1 AQUA-E 2 AQUASOL A 2 ascorbic acid (vitamin c) oral tablet 1 B COMPLEX 2 BABY DDROPS 2 BABY VITAMIN D3 2 BABY'S SUPER DAILY D3 2 BACMIN 2 BARIATRIC MULTIVITAMINS ORAL CAPSULE 45 MG IRON-800 MCG-120 MCG 2 BIO-35, GLUTEN FREE 2 BIOCEL (WITH LUTEIN) 1 BIO-D-MULSION 2 biotin oral capsule 5 mg 1 CCOMPLEX 1 C-1000 1 C-1000 WITH RO SE HIPS 1 C-500 ORAL TABLET 1 CALCIDOL 1 calcitriol oral 1 CENTRAVITES 1 CENTRAVITES 50 PLUS 1 Drug Name Tier Restrictions / Limits CENTRAVITES ADULTS 2 CENTRUM ADULT 50 FRESH-FRUITY 2 CENTRUM CHEWABLES 2 CENTRUM COMPLETE 2 CENTRUM KIDS (VIT D3, VIT K) 2 CENTRUM MEN 2 CENTRUM ORAL LIQUID 9 MG IRON/15 ML 2 CENTRUM ORAL TABLET 1 CENTRUM SILVER ORAL TABLET,CHEWABLE 2 CENTRUM SPECIALIST HEART 2 CENTRUM ULTRA MEN'S 2 CENTRUM WOMEN 1 CENTURY 1 CENTURY MATURE 1 CEROVITE JR 1 CEROVITE SENIOR 1 CERTA PLUS 1 CERTAVITE SENIOR 1 CERTAVITE – ANTIOXIDANT 1 CHILD CHEWABLE VITAMN COMPLETE 2 CHILD COMPLETE MULTIVITAMIN 2 CHILD MULTIVITAMIN PLUS IRON 2 CHILDREN MULTIVITAMIN 2 CHILDREN'S CHEW MULTIVITAMIN 1 55 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits CHILDREN'S CHEWABLE COMPLETE 2 CHILDREN'S CHEWABLE MULTIVITMN 1 CHILDREN'S CHEWABLE VITAMIN 2 CHILDREN'S CHEWABLES 1 CHILDREN'S CHEWABLES EXTRA C 1 CHILDREN'S MULTI – VIT GUMMIES 2 CHILDREN'S MULTIVITAMIN 2 CHILDREN'S MULTIVITAMIN GUMMY 2 cholecalciferol (vitamin d3) oral capsule 1,250 mcg (50,000 unit), 10 mcg (400 unit), 125 mcg (5,000 unit), 25 mcg (1,000 unit), 50 mcg (2,000 unit) 1 cholecalciferol (vitamin d3) oral capsule 62.5 mcg (2,500 unit) 2 cholecalciferol (vitamin d3) oral drops 10 mcg/drop (400 unit/drop) 2 cholecalciferol (vitamin d3) oral drops 10 mcg/ml (400 unit/ml) 1 cholecalciferol (vitamin d3) oral tablet 1,250 mcg (50,000 unit), 10 mcg (400 unit), 125 mcg (5,000 unit), 25 mcg (1,000 unit), 50 mcg (2,000 unit) 1 Drug Name Tier Restrictions / Limits cholecalciferol (vitamin d3) oral tablet,chewable 10 mcg (400 unit), 25 mcg (1,000 unit) 1 COMPLETE MULTIVITAMIN-MINERAL ORAL LIQUID 2 COMPLETE MULTIVITAMIN-MINERAL ORAL TABLET 1 COMPLETE MV ADULT 50 PLUS 1 CORVITA 1 CORVITE 2 CORVITE FREE 2 cyanocobalamin (vitamin b-12) injection 1 cyanocobalamin (vitamin b-12) oral capsule 1,000 mcg 2 cyanocobalamin (vitamin b-12) oral liquid 2 cyanocobalamin (vitamin b-12) oral tablet 1,000 mcg 1 cyanocobalamin (vitamin b-12) sublingual tablet 1,000 mcg 1 D3-2000 1 D3-5000 1 DAILY GUMMIES 2 DAILY MULTIPLE FOR WOMEN 2 DAILY MULTIVITAMIN 2 DAILY MULTI-VITAMIN 1 DAILY MULTIVITAMIN WITH IRON 1 DAILY VALUE 1 DAILY VITAMIN FORMULA 1 INDIANA MEDICAID | Effective 02/01/2026 56Drug Name Tier Restrictions / Limits DAILY VITAMIN FORMULA-IRON 1 DAILY VITAMIN WITH IRON 1 DAILY VITES/IRON 1 DAILY-VITE 1 DAILY-VITE (WITH FOLIC ACID) 1 DAYAVITE 2 DECARA ORAL CAPSULE 1,250 MCG (50,000 UNIT) 1 DECUBI VITE 2 DEKAS BARIATRIC 2 DEKAS PLUS (FOLIC ACID) 2 DEKAS PLUS LIQUID 2 DELTA D3 1 DERMACINRX FOLIFLEX 2 DERMACINRX FOLITIN-Z 2 DERMACINRX MULTITAM 2 DERMACINRX VENEXA 2 DERMACINRX VENEXA FE 2 DERMACINRX VENTRIXYL 2 DERMACINRX VENTRIXYL FE 2 DERMACINRX VITRAMYN 2 DERMACINRX VITRANOL 2 DERMACINRX VITRANOL FE 2 DERMACINRX VITREXATE 2 DERMACINRX VITREXATE FE 2 Drug Name Tier Restrictions / Limits DERMACINRX ZINTREXYL-C 2 DIABETES HEALTH FORMULA 2 DIALYVITE SUPREME D 2 DIALYVITE VITAMIN D 1 D-VI-SOL 1 E-200 1 ELDERTONIC 2 ENDUR-ACIN 1 ENDUR-C WITH ROSE HIPS ORAL TABLET EXTENDED RELEASE 1,000 MG 1 ENDUR-VM IRON – FREE 2 ENDUR-VM WITH IRON 2 ergocalciferol (vitamin d2) oral capsule 1,250 mcg (50,000 unit) 1 ergocalciferol (vitamin d2) oral capsule 50 mcg (2,000 unit) 2 ergocalciferol (vitamin d2) oral drops 1 ergocalciferol (vitamin d2) oral tablet 10 mcg (400 unit) 1 ergocalciferol (vitamin d2) oral tablet 50 mcg (2,000 unit) 2 ESSENTIA 1 ESSENTIAL MAN 2 ESSENTIAL MAN 50 PLUS 2 FLINTSTONES COMPLETE 2 FLINTSTONES COMPLETE (FE SULF) 2 FLINTSTONES GUMMIES 2 57 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits FLINTSTONES GUMMIES OMEGA-3 2 FLINTSTONES MULTI – VIT GUMMIES 2 FLINTSTONES PLUS CALCIUM 2 FLINTSTONES SOUR GUMMIES 2 FLINTSTONES TAB CHEW 2 FLINTSTONES WITH IRON 2 FLINTSTONES/EXTRA CORAL TABLET,CHEWABLE 100 MCG 2 FOLAGENT DHA 2 FOLAMAX 2 FOLAMED DHA 2 FORTAVIT 2 FREEDAVITE 2 GUMMI BEAR MULTIVITAMIN 1 GUMMY DINOS 2 HIGH POTENCY MULTIVIT (W-IRON) 1 HONEY BEARS MULTIVITAMIN 1 INFANT-TODDLER MULTIVITAMIN 2 INFANT-TODDLER MULTIVIT-IRON 1 JUST 4 KIDZ MULTIVIT-PROBIOTIC 2 KIDS' GUMMY 2 K-PAX IMMUNE SUPPORT 2 levomefolate calcium 1 PA LIQUID B-12 1 LITTLE ANIMALS 1 lmefol ca-acetyl-meb12 – algal 2 PA Drug Name Tier Restrictions / Limits LYSIPLEX PLUS ORAL LIQUID 1 MEGA MULTI FOR WOMEN 1 MEGA MULTIVITAMIN FOR MEN 1 MEN 50 PLUS ADVANCED ONE DAILY 2 MEN'S 50 PLUS DAILY FORMULA 2 MEN'S 50 PLUS MULTIVITAMIN 2 MEN'S DAILY 2 MEN'S DAILY FORMULA 2 MEN'S DAILY GUMMIES 2 MEN'S MULTIVITAMIN GUMMIES ORAL TABLET,CHEWABLE 200 MCG 2 MEN'S ONE DAILY 2 MILLTRIUM SENIOR 1 MONOCAPS 2 MULTI COMPLETE WITH IRON 1 MULTI FOR HER 50 PLUS ORAL CAPSULE 2 MULTI FOR HER ORAL CAPSULE 2 MULTI FOR HER ORAL TABLET 1 MULTI PRO 2 MULTI VITAMIN 2 MULTIPLE VITAMIN – MINERALS 1 MULTIPLE VITAMINS 1 multivit with min-folic acid oral tablet 1 multivit,calc,min-fa-k1-lycop 2 multivitamin 1 INDIANA MEDICAID | Effective 02/01/2026 58Drug Name Tier Restrictions / Limits MULTIVITAMIN 50 PLUS 1 MULTIVITAMIN GUMMIES 2 MULTI-VITAMIN HP/MINERALS 1 multivitamin with iron 1 MULTIVITAMIN WOMEN 50 PLUS 1 MULTI-VITE ORAL LIQUID 9 MG IRON/15 ML 2 multivit-min-ferrous fumarate 2 multivit-min-ferrous gluconate oral liquid 9 mg iron/ 15 ml (15 ml) 2 multivit-min-folic acid – lutein 2 multivit-min-iron fum – folic ac 1 MVW COMPLETE FORMUL MULTIVIT 2 MVW COMPLETE FORMULATION D3000 2 MVW COMPLETE FORMULATION D5000 2 MY-VITALIFE 1 NEOVITE 2 niacin oral tablet 100 mg, 250 mg, 50 mg 1 niacinamide oral tablet 500 mg 1 NOVAFERRUM YUM PEDIATR MV-IRON 2 NOVAMV MMM PEDIATRIC MULTIVIT 2 ONE DAILY 1 ONE DAILY CALCIUM/IRON 1 ONE DAILY COMPLETE ORAL TABLET 18-0.4 MG 1 Drug Name Tier Restrictions / Limits ONE DAILY ESSENTIAL ORAL TABLET , 400 MCG 1 ONE DAILY ESSENTIAL ORAL TABLET 0.5 MG 2 ONE DAILY FOR MEN 1 ONE DAILY FOR MEN 50 PLUS ADV 1 ONE DAILY FOR WOMEN 1 ONE DAILY HEALTHY WEIGHT 2 ONE DAILY MAXIMUM ORAL TABLET 18-0.4 MG 1 ONE DAILY MEN'S 50 PLUS MEMORY 1 ONE DAILY MEN'S 50 PLUS W-D3 2 ONE DAILY MEN'S HEALTH 2 ONE DAILY MULTI-VIT W-MINERAL 1 ONE DAILY MULTIVITAMIN 1 ONE DAILY MULTIVITAMIN-IRON 2 ONE DAILY MULTIVIT – IRON(FOLIC) 1 ONE DAILY PLUS IRON 1 ONE DAILY WOMEN 50 PLUS 1 ONE DAILY WOMEN 50 PLUS(VIT K) 2 ONE DAILY WOMENS 50 PLUS 1 ONE DAILY WOMEN'S HEALTH 1 ONE DAILY WOMEN'S ORAL TABLET 18 MG IRON-400 MCG-25 MCG 2 59 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits ONE-A-DAY ENERGY 2 ONE-A-DAY ESSENTIAL 1 ONE-A-DAY KID'S 2 ONE-A-DAY MEN VITACRAVES 2 ONE-A-DAY MENOPAUSE FORMULA 2 ONE-A-DAY MEN'S 50 PLUS 2 ONE-A-DAY MEN'S COMPLETE 2 ONE-A-DAY MEN'S MULTIVITAMIN 2 ONE-A-DAY PROACTIVE 65 PLUS 2 ONE-A-DAY TEEN ADVANTAGE 1 ONE-A-DAY TEEN HER VITACRAVES 2 ONE-A-DAY TEEN HIM VITACRAVES 2 ONE-A-DAY VITACRAVES 2 ONE-A-DAY VITACRAVES IMMUNITY 2 ONE-A-DAY WEIGHTSMART 2 ONE-A-DAY WOMEN VITACRAVES 2 ONE-A-DAY WOMEN'S 50 PLUS 2 ONE-A-DAY WOMEN'S ACTIVE 2 ONE-A-DAY WOMENS FORMULA 2 ONE-A-DAY WOMEN'S HEALTHY SKIN 2 ONE-A-DAY WOMEN'S PETITES 2 ONE-DAILY MULTI 2 Drug Name Tier Restrictions / Limits ONEVITE(WITH LUTEIN) 2 OPTIMAL D3 1 OPURITY MULTIVITAMIN 2 pedi multivit no.194-iron sulf 2 PEDIA D-VITE ORAL DROPS 1 PEDIA POLY-VITE WITH IRON ORAL DROPS 2 PEDIATRIC D-VITE 1 pediatric multivitamin no.171 2 PEDIATRIC POLY – VITE 2 PEDIATRIC POLY – VITE WITH IRON 2 phytonadione (vitamin k1) oral tablet 5 mg 1 PA; QL (15 EA per 28 days) POLY-VI-SOL ORAL DROPS 2 POLY-VI-SOL WITH IRON 2 POLY-VITA DROPS 2 POLY-VITA WITH IRON 2 PROCERV HP 2 PROFOLA 2 PRORENAL QD 2 PROTECT CARDIO AF 2 PROTECT PLUS SO 2 pyridoxine (vitamin b6) oral tablet 100 mg, 50 mg 1 QUINTABS 2 QUINTABS-M 2 QUINTABS-M IRON FREE 1 REMEDIENT 2 REQ49 PLUS 2 INDIANA MEDICAID | Effective 02/01/2026 60Drug Name Tier Restrictions / Limits riboflavin (vitamin b2) oral tablet 100 mg 1 SCOOBY-DOO ONE A DAY KIDS 2 SENIOR TABS 1 SENTRY 1 SENTRY SENIOR 1 SLO-NIACIN ORAL TABLET EXTENDED RELEASE 500 MG 1 SOLO 2 SPECTRAVITE ADULT 1 SPECTRAVITE ADULT 50 PLUS 1 SPECTRAVITE ADULT 50 PLUS(LUT) 2 SPECTRAVITE ADVANCED FORMULA 1 SPECTRAVITE MEN'S 1 SPECTRAVITE WOMEN 1 SPECTRAVITE WOMEN 50 PLUS 1 STRESS BWITH ZINC 1 STRESS FORMULA 1 STRESS FORMULA WITH ZINC 1 STROVITE ONE 2 SUPER MULTIPLE – LOW IRON 2 SUPER THERA VITE M 1 SUPPORT 1 TAB-A-VITE 1 TAB-A-VITE MULTIVITAMIN W-IRON ORAL TABLET 15 MG IRON-400 MCG 1 THERA 1 THERA-D 1 THERAGRAN-M PREMIER 50 PLUS 2 Drug Name Tier Restrictions / Limits THERALOGIX COMPANION 1 THERA-M ORAL TABLET 19 MG IRON-400 MCG 2 THERA-M ORAL TABLET 27-0.4 MG, 9 MG IRON-400 MCG 1 THERAMILL FORTE 2 THERAPEUTIC-M 1 THERA-TABS 1 THERATRUM COMPLETE 50 PLUS/LUT 1 THERATRUM COMPLETE 50 PLUS-LYC 1 THERATRUM COMPLETE WITH LUTEIN 1 THEREMS MULTIVITAMIN 1 thiamine hcl (vitamin b1) oral tablet 1 thiamine mononitrate (vit b1) oral tablet 100 mg 1 TRI-VI-SOL 2 UDAMIN SP 2 ULTRA FREEDA 2 V-C FORTE 1 VIC-FORTE 1 VITABEX PLUS 2 VITACEL (WITH LUTEIN) 1 VITAJOY DAILY D 1 VITALEE 1 VITALETS 1 vitamin a oral capsule 3,000 mcg (10,000 unit) 1 vitamin a palmitate oral capsule 2 61 INDIANA MEDICAID | Effective 02/01/2026 Drug Name Tier Restrictions / Limits vitamin a palmitate oral tablet 3,000 mcg (10,000 unit) 2 VITAMIN B-1 1 VITAMIN B-1 (MONONITRATE) 1 VITAMIN B-12 ORAL TABLET 1,000 MCG 1 VITAMIN B-2 ORAL TABLET 100 MG, 50 MG 1 VITAMIN B-6 ORAL TABLET 100 MG, 250 MG, 50 MG 1 VITAMIN CORAL TABLET 1,000 MG, 250 MG, 500 MG 1 VITAMIN CORAL TABLET EXTENDED RELEASE 1,000 MG 1 VITAMIN CWITH ROSE HIPS ORAL TABLET 1 VITAMIN CWITH ROSE HIPS ORAL TABLET EXTENDED RELEASE 1,000 MG 1 VITAMIN D2 1 VITAMIN D3 1 vitamin e (dl, acetate) oral capsule 180 mg (400 unit), 45 mg (100 unit), 90 mg (200 unit) 1 vitamin e (dl, acetate) oral drops 22.5 mg (50 unit)/ml 1 vitamin e (dl, acetate) oral drops 45 mg/0.25ml 100 unit/0.25ml 2 vitamin e acetate 1 vitamin e mixed oral capsule 400 unit 1 vitamin e oral capsule 268 mg (400 unit) 1 Drug Name Tier Restrictions / Limits VITAMINS A-D-E SELENIUM 2 VITREXYL 2 VITREXYL PLUS IRON 2 WEEKLY-D 1 WOMEN'S 50 PLUS ADVANCED 2 WOMEN'S 50 PLUS DAILY FORMULA 2 WOMEN'S 50 PLUS MULTIVITAMIN 2 WOMEN'S DAILY FORMULA 2 WOMENS DAILY GUMMIES 2 WOMEN'S MULTIVITAMIN 2 WOMEN'S MULTIVITAMIN GUMMIES ORAL TABLET,CHEWABLE 200 MCG 2 WOMEN'S ONE DAILY ORAL TABLET 18 MG IRON-400 MCG-500 MG CA 2 XYZBAC 2 YELETS 1 ZINC WITH VITAMINS A AND C 1 ZOO FRIENDS 2 ZYVIT 2 INDIANA MEDICAID | Effective 02/01/2026 62Medical Benefit Drug Name Tier Restrictions / Limits CINRYZE 2 AR FERRLECIT 2 FULPHILA 2 QL (1.2 ML per 22 days) INFED 2 infliximab 2 PA OCREVUS 2 PA; QL (20 ML per 153 days) octreotide acetate 1 PA RITUXAN 2 PA SIMPONI ARIA 2 PA TYSABRI 2 PA VENOFER 2 63 Index A THRU Z ……………………………. 53 A THRU ZADVANCED FORMULA …………………………… 53 A THRU ZHIGH POTENCY …… 53 A THRU ZMEN'S ULTIMATE …. 53 A THRU ZSELECT ……………….. 53 A THRU ZSELECT 50PLUS FORMULA …………………………… 53 A THRU ZSELECT WOMEN'S. 53 abacavir ………………………………. 16 abacavir-lamivudine ……………….. 16 ABC COMPLETE SENIOR WOMEN'S ……………………………. 53 ABILIFY ASIMTUFII ………………. 41 ABILIFY MAINTENA ……………… 41 abiraterone …………………………… 14 acamprosate ………………………… 51 acarbose ……………………………… 12 ACCUTANE …………………………. 48 ACE AEROSOL CLOUD ENHANCER …………………………. 38 acebutolol ……………………………. 20 acetaminophen-codeine …………… 3 acetazolamide ………………………. 29 acetic acid ……………………………. 29 acitretin ……………………………….. 48 ACTEMRA …………………………… 38 ACTEMRA ACTPEN ……………… 38 ACTHIB (PF) ………………………… 18 ACTIMMUNE ……………………….. 14 ACTIVNUTRIENTS CHEWABLE …………………………. 53 acyclovir ………………………………. 16 ADACEL(TDAP ADOLESN/ADULT)(PF) …………. 18 adalimumab-adaz ………………….. 13 ADBRY ……………………………….. 51 adefovir ……………………………….. 16 ADEK GUMMIES PLUS ZINC …. 53 ADULT MULTIVITAMIN GUMMIES ……………………………. 53 ADULT ONE DAILY GUMMIES. 53 ADULTS 50 PLUS …………………. 53 ADULTS' DAILY FORMULA ……. 53 ADULTS MULTIVITAMIN ……….. 53 ADVAIR DISKUS ……………………. 6 ADVAIR HFA …………………………. 6 ADVANCED MULTI EA ………….. 53 AEROCHAMBER MINI …………… 38 AEROCHAMBER MV …………….. 38 AEROCHAMBER PLUS FLOW-VU ……………………………. 38 AEROCHAMBER PLUS Z STAT ………………………………….. 38 AEROCHAMBERPLUS ZSTAT MD MSK ……………………… 39 AEROCHAMBER PLUS ZSTAT SM MSK ……………………… 39 AEROCHAMBER Z-STAT PLUS-FLW SG ……………………… 39 AEROTRACH PLUS ………………. 39 AEROVENT PLUS ………………… 39 AFINITOR ……………………………. 14 AFIRMELLE …………………………. 25 AIMOVIG AUTOINJECTOR ……… 3 AJOVY AUTOINJECTOR …………. 3 AJOVY SYRINGE …………………… 3 ALA-CORT …………………………… 48 albuterol sulfate ………………………. 6 alclometasone ………………………. 48 alendronate ………………………….. 51 alfuzosin ………………………………. 51 ALINIA ………………………………… 15 aliskiren ……………………………….. 20 ALIVE MAX POTENCY ………….. 53 ALIVE PREMIUM PRENATAL … 53 ALIVE WOMEN 50 PLS ULT POTENCY ……………………………. 53 ALIVE WOMEN'S 50 PLUS COMPLETE …………………………. 53 ALIVE WOMEN'S 50 PLUS GUMMY ………………………………. 54 ALIVE WOMEN'S ENERGY ……. 54 ALIVE WOMEN'S GUMMY VITAMIN ……………………………… 54 ALIVE WOMEN'S ULTRA POTENCY ……………………………. 54 allopurinol ………………………………. 5 alosetron ……………………………… 33 ALPHAGAN P ………………………. 29 alprazolam …………………………… 41 ALPRAZOLAM INTENSOL ……… 41 ALREX ………………………………… 29 ALTACAINE …………………………. 29 ALTAVERA (28) ……………………. 25ALYACEN 1/35 (28) ………………. 25 ALYACEN 7/7/7 (28) ……………… 25 ALYQ ………………………………….. 20 amantadine hcl ……………………… 15 AMETHIA …………………………….. 25 AMETHYST (28) …………………… 25 amiloride ……………………………… 29 amiloride-hydrochlorothiazide29 aminocaproic acid …………………. 19 amiodarone ………………………….. 19 amitriptyline …………………….. 41, 42 amitriptyline-chlordiazepoxide 42 AMLADEX ……………………………. 54 amlodipine …………………………….19 amlodipine-benazepril ……………..20 AMNESTEEM ………………………..48 amoxapine …………………………….42 amoxicillin ……………………………… 7 amoxicillin-pot clavulanate ……….. 7 amphetamine sulfate ………………17 ampicillin ………………………………. 7 AMPYRA ………………………………22 anagrelide …………………………….16 ANALPRAM-HC …………………….33 ANALPRAM-HC SINGLES ………33 anastrozole …………………………… 14 ANDROGEL ………………………….35 ANGELIQ ……………………………..36 ANIMAL CHEWS ……………………54 ANNOVERA ………………………….25 ANORO ELLIPTA …………………… 6 APATATE FORTE ………………….54 APLENZIN …………………………….42 apraclonidine …………………………29 aprepitant ……………………………..33 APRI …………………………………….25 APTIVUS ………………………………16 AQUA-E ……………………………….54 AQUASOL A …………………………54 ARANELLE (28) …………………….25 ARANESP(INPOLYSORBATE) ……………………25 AREXVY (PF) ………………………..18 arginine (l-arginine) …………………30 arginine (l-arginine) (bulk) ………..51 arginine hcl (l-arginine) ……………31 aripiprazole …………………………… 42 ARISTADA …………………………… 42 ARISTADA INITIO ………………….42 armodafinil …………………………….42 ARMOUR THYROID ………………50 ARNUITY ELLIPTA ………………… 6 ASCOMP WITH CODEINE ……… 3 ascorbic acid (vitamin c) ………….54 asenapine maleate …………………42 ASHLYNA …………………………….25 ASMANEX HFA ……………………… 7 ASMANEX TWISTHALER ……….. 7 aspirin-dipyridamole ………………..16 atazanavir ……………………………..16 atenolol …………………………………20 atenolol-chlorthalidone …………….20 atomoxetine …………………………..42 ATORVALIQ ………………………….20 atorvastatin …………………………… 20 atovaquone …………………………..13 atovaquone-proguanil ……………..13 64 atropine ……………………………….. 29 ATROVENT HFA ……………………. 7 AUBRA ……………………………….. 25 AUBRA EQ ………………………….. 25 AUROVELA 1.5/30 (21) ………….. 25 AUROVELA 1/20 (21) ……………. 25 AUROVELA 24 FE ………………… 25 AUROVELA FE 1.5/30 (28) …….. 25 AUROVELA FE 1-20 (28) ……….. 25 AUSTEDO …………………………… 22 AUSTEDO XR ……………………… 22 AUSTEDO XR TITRATION KT(WK1-4) …………………………… 22 AUVELITY …………………………… 42 AVAR ……………………………………. 8 AVAR-E ………………………………… 8 AVIANE ……………………………….. 25 AVONEX ……………………………… 22 AYUNA ……………………………….. 26 azathioprine …………………………. 38 azelastine ……………………….. 11, 29 azelastine-fluticasone …………….. 29 AZELEX ………………………………. 48 azithromycin …………………………… 8 AZOPT ………………………………… 29 AZSTARYS ………………………….. 42 AZURETTE (28) ……………………. 26 BCOMPLEX ………………………… 54 BABY DDROPS ……………………. 54 BABY VITAMIN D3 ……………….. 54 BABY'S SUPER DAILY D3 …….. 54 bacitracin-polymyxin b ……………… 8 baclofen ………………………………. 40 BACMIN ………………………………. 54 BALCOLTRA ………………………… 26 balsalazide …………………………… 33 BALZIVA (28) ……………………….. 26 BAQSIMI ……………………………… 31 BARACLUDE ……………………….. 16 BARIATRIC MULTIVITAMINS …. 54 BASE, PCCA SYRUP VEHICLE …………………………….. 51 BD ECLIPSE LUER-LOK ……….. 39 BD PRECISIONGLIDE …………… 39 BD SAFETYGLIDE ALLERGIST TRAY ………………… 39 BELSOMRA …………………………. 48 benazepril ……………………………. 20 benazepril-hydrochlorothiazide20 benznidazole ………………………… 13 benzonatate …………………………. 29 benztropine ………………………….. 15 BEPREVE ……………………………. 11 BESIVANCE ………………………….. 8 betamethasone dipropionate …… 48 betamethasone valerate …………. 48 betamethasone, augmented 48, 49 BETASERON ……………………….. 22 bethanechol chloride ……………… 17 BETOPTIC S ………………………… 29 bexarotene …………………………… 14 BEXSERO ……………………………. 18 BEYAZ ………………………………… 26 bicalutamide …………………………. 14 BICILLIN L-A ………………………….. 8 BIKTARVY …………………………… 16 BIO-35, GLUTEN FREE …………. 54 BIOCEL (WITH LUTEIN) ………… 54 BIO-D -MULSION …………………… 54 biotin …………………………………… 54 bisoprolol fumarate ………………… 20 bisoprolol-hydrochlorothiazide 20 BLISOVI 24 FE ……………………… 26 BLISOVI FE 1.5/30 (28) …………. 26 BLISOVI FE 1/20 (28) ……………. 26 BOOSTRIX TDAP …………………. 18 bosentan ……………………………… 20 BREATHERITE MDI SPACER … 39 BREATHERITE VALVED MDI CHAMBER …………………………… 39 BREATHERITE VALVED MDI SPACER ……………………………… 39 BRIELLYN ……………………………. 26 BRILINTA …………………………….. 16 brimonidine …………………………… 29 BRIUMVI ……………………………… 22 BRIXADI ………………………………. 51 BROMFED DM …………………….. 29 bromocriptine ……………………….. 15brompheniramine-pseudoeph-dm ………………………………………. 29 budesonide ………………………. 7, 36 bumetanide ………………………….. 29 buprenorphine hcl ………………. 3, 51 buprenorphine-naloxone …………. 51 bupropion hcl ………………………… 42 bupropion hcl (smoking deter) 50 buspirone …………………………….. 42 butalbital-acetaminop-caf-cod ……. 3 butalbital-acetaminophen ………….. 3 butalbital-acetaminophen-caff ……. 3 butalbital-aspirin-caffeine ………….. 3 butorphanol ……………………………. 3 BUTRANS ……………………………… 3 CCOMPLEX ………………………… 54 C-1000 ………………………………… 54 C-1000 WITH ROSE HIPS ……… 54 C-500 ………………………………….. 54 cabergoline …………………………… 36 CADEAU DHA ………………………. 40 caffeine citrate ………………………. 22 CALCIDOL …………………………… 54 calcipotriene ………………………….49 calcitonin (salmon) ………………….36 CAL-CITRATE ……………………….31 calcitriol ……………………………….. 54 CALCIUM 500 ……………………….31 CALCIUM 500 + D ………………….31 CALCIUM 600 + D(3) ……………..31 CALCIUM 600 WITH VITAMIN D3 ……………………………………….31 calcium acetate ……………………..31 calcium acetate(phosphat bind) . 31 calcium carbonate ………………….31 calcium carbonate-vit d3-min ……31 calcium carbonate-vitamin d3 …..31 CALCIUM CITRATE + D …………31 calcium citrate-vitamin d3 ………..31CALCIUM WITH VITAMIN D ……31 CAL-QUICK …………………………..31 CALTRATE 600 PLUS D …………31 CALTRATE WITH VITAMIN D3 . 31 CAMILA ………………………………..26 CAMRESE …………………………… 26 CAMRESE LO ……………………….26 capecitabine ………………………….14 CAPLYTA ……………………………..42 captopril-hydrochlorothiazide ……20 CAPVAXIVE ………………………….18 CARBAGLU ………………………….51 carbamazepine ………………………22 CARBATROL ………………………..22 carbidopa-levodopa ………………..15 carbidopa-levodopa-entacapone …………………………..15 CARDIZEM LA ………………………19 carteolol ………………………………..29 CARTIA XT …………………………..19 carvedilol ………………………………20 CAYA CONTOURED ………………26 CAYSTON …………………………….. 8 CAZIANT (28)………………………..26 cefaclor ………………………………….. 8 cefadroxil ……………………………….. 8 cefdinir ………………………………….. 8 cefpodoxime …………………………… 8 cefprozil …………………………………. 8 cefuroxime axetil……………………… 8 CELEBREX …………………………… 5 CELONTIN …………………………… 22 CENTANY …………………………….. 8 CENTRAVITES …………………….. 54 CENTRAVITES 50 PLUS ……….. 54 CENTRAVITES ADULTS ……….. 54 CENTRUM …………………………… 5465 CENTRUM ADULT 50 FRESH-FRUITY ……………………………….. 54 CENTRUM CHEWABLES ………. 54 CENTRUM COMPLETE …………. 54 CENTRUM KIDS (VIT D3, VIT K) ……………………………………….. 54 CENTRUM MEN …………………… 54 CENTRUM SILVER ………………. 54 CENTRUM SPECIALISTHEART ……………………………….. 54 CENTRUM ULTRA MEN'S ……… 54 CENTRUM WOMEN ……………… 54 CENTURY …………………………… 54 CENTURY MATURE ……………… 54 cephalexin ……………………………… 8 CEROVITE JR ……………………… 54 CEROVITE SENIOR ……………… 54 CERTA PLUS ……………………….. 54 CERTAVITE SENIOR ……………. 54 CERTAVITE-ANTIOXIDANT …… 54 CHANTIX …………………………….. 50 CHANTIX CONTINUING MONTH BOX ……………………….. 50 CHANTIX STARTING MONTH BOX ……………………………………. 50 CHARLOTTE 24 FE ………………. 26 CHATEAL EQ (28) ………………… 26 CHEMET ……………………………… 51 CHILD CHEWABLE VITAMN COMPLETE …………………………. 54 CHILD COMPLETE MULTIVITAMIN …………………….. 54 CHILD MULTIVITAMIN PLUS IRON …………………………………… 54 CHILDREN MULTIVITAMIN ……. 54 CHILDREN'S CHEW MULTIVITAMIN …………………….. 54 CHILDREN'S CHEWABLE COMPLETE …………………………. 55 CHILDREN'S CHEWABLE MULTIVITMN ……………………….. 55 CHILDREN'S CHEWABLE VITAMIN ……………………………… 55 CHILDREN'S CHEWABLES ……. 55 CHILDREN'S CHEWABLES EXTRA C …………………………….. 55 CHILDREN'S MULTI-VIT GUMMIES ……………………………. 55 CHILDREN'S MULTIVITAMIN …. 55 CHILDREN'S MULTIVITAMIN GUMMY ………………………………. 55 CHILDREN'S SLEEP (MELATONIN) ………………………. 36 chloral hydrate (bulk) ……………… 51 chlordiazepoxide hcl ………………. 42chlordiazepoxide-clidinium ………. 33 chlorhexidine gluconate ………….. 51 chloroquine phosphate …………… 13 chlorpromazine ……………………… 42 chlorthalidone ……………………….. 29 chlorzoxazone ………………………. 40 CHOLBAM …………………………… 33 cholecalciferol (vitamin d3) ……… 55 cholestyramine (with sugar) …….. 20 CHOLESTYRAMINE LIGHT ……. 20 CICLODAN ………………………….. 11 ciclopirox ……………………………… 11 cilostazol ……………………………… 16 CILOXAN ………………………………. 8 cimetidine …………………………….. 33 cinacalcet …………………………….. 51 CINRYZE …………………………….. 62 CIPRO HC …………………………….. 8 ciprofloxacin hcl ………………………. 8 ciprofloxacin-dexamethasone ……. 8 citalopram ……………………………. 42 CITRACAL + DMAXIMUM ……… 31 CITRACAL REGULAR …………… 31 CITRACAL-D3 PETITES ………… 31 CLARAVIS …………………………… 49 clarithromycin …………………………. 8 CLASSIC PRENATAL ……………. 40 clemastine ……………………………. 11 CLEOCIN ………………………………. 8 CLEVER CHOICE CHAMBER-LRG MASK ………………………….. 39 CLEVER CHOICE CHAMBER-MED MASK ………………………….. 39 CLEVER CHOICE CHAMBER-SM MASK ……………………………. 39 CLIMARA PRO ……………………… 36 CLINDACIN ETZ …………………….. 8 CLINDACIN P ………………………… 8 clindamycin hcl ……………………….. 8 clindamycin palmitate hcl ………….. 8 CLINDAMYCIN PEDIATRIC ……… 8 clindamycin phosphate …………….. 8 clindamycin-benzoyl peroxide 49 clobazam ……………………………… 22clobetasol …………………………….. 49 clobetasol-emollient ……………….. 49 CLODAN ……………………………… 49 clomipramine ………………………… 43 clonazepam ………………………….. 22 clonidine ………………………………. 20 clonidine hcl ……………………. 20, 43 clopidogrel ……………………………. 16 clorazepate dipotassium …………. 43 clotrimazole ………………………….. 11 clotrimazole-betamethasone ……. 11 clozapine……………………………… 43 COARTEM …………………………… 13 codeine sulfate ………………………. 3 codeine-butalbital-asa-caff ……….. 3 colchicine ……………………………… 5 colesevelam ………………………….20 COMBIGAN …………………………..29 COMBIPATCH ………………………36 COMBIVENT RESPIMAT ………… 7 COMETRIQ …………………………..14 COMPACT SPACE CHAMBER. 39 COMPLERA ………………………….16 COMPLETE MULTIVITAMIN-MINERAL ……………………………..55 COMPLETE MV ADULT 50 PLUS ……………………………………55 COMPLETENATE ………………….40 COMPRO ……………………………..33 CONSTULOSE ………………………33 COPAXONE ………………………….22 CORLANOR ………………………….19 CORTIFOAM ………………………… 36 cortisone ………………………………. 36 CORTISPORIN-TC ………………… 8 CORVITA …………………………….. 55 CORVITE …………………………….. 55 CORVITE FREE ……………………. 55 COVARYX …………………………….36 COVARYX H.S. ……………………..36 cpd vehicle susp.sugar-free 12 51 CREON ………………………………..33 cromolyn ……………………….. 5, 7, 29 CRYSELLE (28) ……………………. 26 cyanocobalamin (vitamin b-12) 55 cyclobenzaprine ……………………..40 CYCLOGYL …………………………..29cyclopentolate………………………..29 cyclosporine ………………………….38 cyclosporine modified ……………..38 cyproheptadine ………………………11 CYRED ………………………………..26 CYRED EQ …………………………..26 D3-2000 ……………………………….55 D3-5000 ……………………………….55 DAILY FIBER (PSYLLIUM-ASPART) ………………………………33 DAILY FIBER (PSYLLIUM-SUCROSE) …………………………..33 DAILY GUMMIES …………………..55 DAILY MULTIPLE FORWOMEN ……………………………….55 DAILY MULTIVITAMIN ……………55 DAILY MULTI-VITAMIN …………..55 DAILY MULTIVITAMIN WITH IRON ……………………………………5566 DAILY VALUE ………………………. 55 DAILY VITAMIN FORMULA ……. 55 DAILY VITAMIN FORMULA-IRON …………………………………… 56 DAILY VITAMIN WITH IRON ….. 56 DAILY VITES/IRON ……………….. 56 DAILY-VITE …………………………. 56 DAILY-VITE (WITH FOLICACID) ………………………………….. 56 dalfampridine ……………………….. 22 dapsone ………………………………… 8 DAPTACEL (DTAP PEDIATRIC) (PF) ………………….. 18 darunavir ……………………………… 16 DASETTA 1/35 (28) ………………. 26 DASETTA 7/7/7 (28) ……………… 26 DAYAVITE …………………………… 56 DAYSEE ……………………………… 26 DAYTRANA …………………………. 43 DEBLITANE …………………………. 26 DECARA ……………………………… 56 DECUBI VITE ……………………….. 56 deferasirox …………………………… 51 deflazacort …………………………… 36 DEKAS BARIATRIC ………………. 56 DEKAS PLUS (FOLIC ACID) …… 56 DEKAS PLUS LIQUID ……………. 56 DELSTRIGO ………………………… 16 DELTA D3 ……………………………. 56 DENTA 5000 PLUS ……………….. 31 DEPAKOTE SPRINKLES ……….. 22 DEPO-ESTRADIOL ………………. 36 DEPO-SUBQ PROVERA 104 …. 26 DEPO-TESTOSTERONE ……….. 36 DERMACINRX FOLIFLEX ……… 56 DERMACINRX FOLITIN-Z ……… 56 DERMACINRX LIDOCAN ………… 5 DERMACINRX MULTITAM …….. 56 DERMACINRX VENEXA ………… 56 DERMACINRX VENEXA FE …… 56 DERMACINRX VENTRIXYL …… 56 DERMACINRX VENTRIXYL FE.56 DERMACINRX VITRAMYN …….. 56 DERMACINRX VITRANOL …….. 56 DERMACINRX VITRANOL FE 56 DERMACINRX VITREXATE……. 56 DERMACINRX VITREXATE FE.56 DERMACINRX ZINTREXYL-C 56 DERMOTIC OIL ……………………. 29 DESCOVY …………………………… 16 desipramine …………………………. 43 desmopressin ……………………….. 36 desog-e.estradiol/e.estradiol ……. 26 desonide ……………………………… 49 desoximetasone ……………………. 49 desvenlafaxine……………………… 43 desvenlafaxine succinate………… 43 DEX4 GLUCOSE ………………….. 31 DEX4GLUCOSE POUCHPACK ………………………………….. 31 DEX4 GLUCOSE QUICK DISSOLVE …………………………… 31 dexamethasone …………………….. 36 DEXAMETHASONE INTENSOL …………………………… 36 dexamethasone sodium phosphate ……………………………. 30 DEXCOM G6 RECEIVER ……….. 39 DEXCOM G6 SENSOR ………….. 39 DEXCOM G6 TRANSMITTER …. 39 DEXCOM G7 RECEIVER ……….. 39 DEXCOM G7 SENSOR ………….. 39 DEXILANT …………………………… 33 dexmethylphenidate ………………. 43 DEXONTO …………………………… 36 dextroamphetamine sulfate …….. 17 dextroamphetamine-amphetamine ………………….. 17, 18 dextrose ………………………………. 31 DIABETES HEALTHFORMULA …………………………… 56 DIALYVITE SUPREME D ……….. 56 DIALYVITE VITAMIN D ………….. 56 diazepam ……………………….. 22, 43 DIAZEPAM INTENSOL ………….. 43 DICLEGIS ……………………………. 33 diclofenac potassium ……………….. 3 diclofenac sodium …………. 5, 14, 30 dicloxacillin …………………………….. 8 dicyclomine ………………………….. 33 DIFFERIN ……………………………. 49 diflorasone ……………………………. 49 diflunisal ………………………………… 3 DIGITEK ………………………………. 19 digoxin ………………………………… 19 dihydroergotamine …………………… 3 DILANTIN …………………………….. 22 DILANTIN EXTENDED …………… 22 DILANTIN INFATABS …………….. 22 DILANTIN-125 ………………………. 22 diltiazem hcl …………………………. 19 DILT-XR ………………………………. 19 dimethyl fumarate ………………….. 22 DIPENTUM ………………………….. 33 diphenoxylate-atropine …………… 33 dipyridamole …………………………. 16 disopyramide phosphate ………… 19 disulfiram ……………………………… 51 DIURIL ………………………………… 29 divalproex …………………………….. 22 dofetilide……………………………….19 DOLISHALE ………………………….26 donepezil ………………………………18 dorzolamide …………………………..30 dorzolamide (pf) ……………………..30 dorzolamide-timolol …………………30 dorzolamide-timolol (pf) …………..30 DOVATO ………………………………16 doxazosin ……………………………..20 doxepin ………………………….. 43, 48 doxycycline hyclate …………….. 8, 51 doxycycline monohydrate ………… 8 droperidol ……………………………..43 drospirenone-e.estradiol-lm.fa 26 drospirenone-ethinyl estradiol 26 DROXIA ……………………………….19 DULERA ………………………………. 7 duloxetine ……………………………..43 DUPIXENT PEN …………………….38 DUPIXENT SYRINGE …………….38 DURAMORPH (PF) ………………… 3 DUREZOL …………………………….30 dutasteride…………………………….51 D-VI-SOL ………………………………56 DYANAVEL XR ……………………..18DYMISTA ……………………………..30 E-200 …………………………………..56 EASIVENTHOLDINGCHAMBER …………………………… 39 EASYPOINT NEEDLE…………….39 ECLIPSE NEEDLE …………………39 EDARBI ………………………………..20 EDARBYCLOR ………………………20 ED-SPAZ ………………………………33 EDURANT …………………………….16 EEMT …………………………………..36 EEMT HS ……………………………..36 efavirenz ……………………………….16 efavirenz-emtricitabin-tenofov 16 efavirenz-lamivu-tenofov disop 16 EFFER-K ………………………………32 EFUDEX ………………………………14 ELDERTONIC ……………………….56 ELIGARD ……………………………..14 ELIGARD (3 MONTH) …………….14 ELIGARD (4 MONTH) …………….14 ELIGARD (6 MONTH) …………….14 ELINEST ………………………………26 ELIQUIS ……………………………….10 ELIQUIS DVT-PE TREAT 30D START …………………………………10 ELIQUIS SPRINKLE ……………….10 ELLA ……………………………………26 ELMIRON ……………………………… 3 ELURYNG …………………………….2667 ELYXYB ………………………………… 3 EMFLAZA ……………………………. 36 EMGALITY PEN …………………….. 3 EMGALITY SYRINGE ………… 3, 22 EMPAVELI …………………………… 19 emtricitabine …………………………. 16 emtricitabine-tenofovir (tdf) ……… 16 EMTRIVA …………………………….. 16 EMVERM …………………………….. 13 EMZAHH ……………………………… 26 enalapril maleate …………………… 20 enalapril-hydrochlorothiazide …… 20 ENBREL ……………………………… 13 ENBREL MINI ………………………. 13 ENBREL SURECLICK …………… 13 ENDARI ………………………………. 19 ENDOCET …………………………….. 3 ENDUR-ACIN ……………………….. 56 ENDUR-CWITH ROSE HIPS …. 56 ENDUR-VM IRON-FREE ……….. 56 ENDUR-VM WITH IRON ………… 56 ENGERIX-B (PF) ………………….. 18 ENGERIX-B PEDIATRIC (PF) … 18 ENILLORING ……………………….. 26 enoxaparin …………………………… 10 ENPRESSE …………………………. 26 ENSKYCE ……………………………. 26 ENSPRYNG …………………………. 38 ENSTILAR …………………………… 49 entacapone ………………………….. 15 entecavir ……………………………… 16 ENTRESTO …………………………. 20 ENULOSE ……………………………. 34 EPIDUO FORTE …………………… 49 epinephrine ………………………….. 18 eplerenone …………………………… 29 EPOGEN …………………………….. 25 EPRONTIA ………………………….. 22 EQUETRO …………………………… 43 ergocalciferol (vitamin d2) ………. 56 ergoloid ……………………………….. 20 ergotamine-caffeine …………………. 3 ERIVEDGE ………………………….. 14 erlotinib ……………………………….. 14 ERRIN ………………………………… 26 erythromycin ………………………….. 8 erythromycin ethylsuccinate ……… 8 erythromycin with ethanol …………. 9 erythromycin-benzoyl peroxide 9 ERZOFRI …………………………….. 44 escitalopram oxalate ……………… 44 esomeprazole magnesium ……… 34 ESSENTIA …………………………… 56 ESSENTIAL MAN …………………. 56 ESSENTIAL MAN 50 PLUS ……. 56 ESTARYLLA………………………… 26 estazolam …………………………….. 48 estradiol ………………………………. 36 estradiol valerate …………………… 36 estradiol-norethindrone acet ……. 36 ESTRING …………………………….. 36 estrogens-methyltestosterone 36 eszopiclone ………………………….. 48 ethambutol …………………………….. 9 ethosuximide ………………………… 22 ethynodiol diac-eth estradiol ……. 26 etodolac ………………………………… 5 etonogestrel-ethinyl estradiol …… 26 etoposide …………………………….. 14 etravirine ……………………………… 16 EUCRISA …………………………….. 49 EUTHYROX …………………………. 50 EVAMIST …………………………….. 36 everolimus (antineoplastic) ……… 14 everolimus (immunosuppressive) …………….. 38 EVOTAZ ……………………………… 16 EXELDERM …………………………. 11 exemestane………………………….. 14 ezetimibe ……………………………… 20 ezetimibe-simvastatin …………….. 20 FALMINA (28) ………………………. 26 famotidine ……………………………. 34 FARXIGA …………………………….. 12 FARYDAK ……………………………. 14 FASENRA ……………………………… 7FASENRA PEN ………………………. 7 febuxostat ……………………………… 5 felbamate …………………………….. 22 FELBATOL …………………………… 22 felodipine ……………………………… 19 FEMCAP ……………………………… 26 fenofibrate ……………………………. 21 fenofibrate micronized ……………. 20 fenofibrate nanocrystallized …….. 21 FENSOLVI …………………………… 36 fentanyl …………………………………. 3 FEOSOL ……………………………… 32 FEROSUL ……………………………. 32 FERREX 150 ………………………… 32 FERRIC X-150 ……………………… 32 FERRLECIT …………………………. 62 FERRO-TIME ……………………….. 32 ferrous sulfate ………………………. 32 fesoterodine …………………………. 51 FETZIMA ……………………………… 44 FE-VITE ………………………………. 32 FIASP FLEXTOUCH U-100 INSULIN ………………………………. 12 FIASP PENFILLU-100INSULIN ……………………………….12 FIASP PUMPCART ………………..12 FIASP U-100 INSULIN ……………12 FIBER (WITH ASPARTAME) …..34 FIBER THERAPY (PSYLLIUM-SUCRO) ……………………………….34 fidaxomicin ……………………………. 9 FINACEA ………………………………49 finasteride ……………………………..51 fingolimod ……………………………..22 FINZALA ………………………………26 FIRVANQ ……………………………… 9 FLAREX ……………………………….30 FLAVOR BLEND 2 IN 1 ………….. 51 FLAVOR PLUS ………………………51 FLAVOR SWEET …………………..51 FLAVOR SWEET-SF ……………..51 flecainide ………………………………19 FLEXICHAMBER ……………………39 FLEXICHAMBER-LG CHILD MASK …………………………………..39 FLEXICHAMBER-SM ADULT MASK …………………………………..39 FLEXICHAMBER-SM CHILD MASK …………………………………..39 FLINTSTONES COMPLETE ……56 FLINTSTONES COMPLETE (FE SULF) …………………………….56 FLINTSTONES GUMMIES ………56 FLINTSTONES GUMMIES OMEGA-3 ……………………………..57 FLINTSTONES MULTI-VIT GUMMIES …………………………….57 FLINTSTONES PLUS CALCIUM ……………………………..57 FLINTSTONES SOURGUMMIES …………………………….57 FLINTSTONES TAB CHEW …….57 FLINTSTONES WITH IRON …….57 FLINTSTONES/EXTRA C ……….57 fluconazole …………………………… 11 fludrocortisone ……………………….36 fluocinolone …………………………..49 fluocinolone acetonide oil …………30 fluocinolone and shower cap ……49 fluocinonide …………………………..49 FLUOCINONIDE-E …………………49 fluocinonide-emollient ……………..49 fluoride (sodium) …………………….32 fluorouracil …………………………….14 fluoxetine ………………………………44 fluphenazine decanoate …………..44 fluphenazine decanoate (bulk) 51 fluphenazine hcl ……………………..4468 flurbiprofen …………………………….. 5 flurbiprofen sodium ………………… 30 fluticasone propionate ………… 7, 49 fluvoxamine ………………………….. 44 FML LIQUIFILM ……………………. 30 FOLAGENT DHA ………………….. 57 FOLAMAX ……………………………. 57 FOLAMED DHA ……………………. 57 fondaparinux ………………………… 10 FORTAVIT …………………………… 57 FORTEO ……………………………… 51 fosamprenavir ………………………. 16 fosaprepitant ………………………… 34 fosinopril ……………………………… 21 fosphenytoin …………………………. 22 FRAGMIN ……………………………. 10 FREEDAVITE ………………………. 57 FULPHILA ……………………………. 62 furosemide …………………………… 29 FYAVOLV ……………………………. 36 FYLNETRA ………………………….. 25 gabapentin …………………………… 23 galantamine …………………………. 18 GALZIN ……………………………….. 51 GARDASIL 9 (PF) …………………. 18 GAVILYTE-C ……………………….. 34 GAVILYTE-G ……………………….. 34 GAVILYTE-N ……………………….. 34 gemfibrozil ……………………………. 21 GEMMILY ……………………………. 26 GENERLAC …………………………. 34 GENGRAF …………………………… 38 GENOTROPIN ……………………… 36 GENOTROPIN MINIQUICK ……. 36 gentamicin ……………………………… 9 GENVOYA …………………………… 16 GERI-MUCIL (ASPARTAME) ….. 34 GERI-MUCIL (SUGAR) ………….. 34 GILENYA …………………………….. 23 GILOTRIF ……………………………. 14 glimepiride ……………………………. 12 glipizide ……………………………….. 12 glipizide-metformin ………………… 12 glucose ……………………………….. 32 GLUCOSE GEL ……………………. 32 GLUTOSE-5 ………………………… 32 glyburide ……………………………… 12 glyburide micronized ……………… 12 glyburide-metformin ……………….. 12 glycopyrrolate ……………………….. 34 GLYDO …………………………………. 5 GLYXAMBI ………………………….. 12 GRALISE …………………………….. 23 GRASTEK ……………………………. 18 griseofulvin microsize …………….. 11 griseofulvin ultramicrosize ………. 11 guanfacine ……………………… 21, 44 GUMMI BEAR MULTIVITAMIN 57 GUMMY DINOS ……………………. 57 GVOKE ……………………………….. 32 GVOKE HYPOPEN 1-PACK …… 32 GVOKE HYPOPEN 2-PACK …… 32 GVOKEPFS 1-PACKSYRINGE …………………………….. 32 GVOKE PFS 2-PACKSYRINGE …………………………….. 32 HADLIMA …………………………….. 13 HADLIMA PUSHTOUCH ………… 13 HADLIMA(CF) ………………………. 13 HADLIMA(CF) PUSHTOUCH ….. 14 HAILEY ……………………………….. 26 HAILEY 24 FE ………………………. 26 HAILEY FE 1.5/30 (28) …………… 26 HAILEY FE 1/20 (28) ……………… 26 HALOETTE ………………………….. 26 haloperidol ……………………………. 44 haloperidol decanoate ……………. 44 haloperidol lactate …………………. 44 HAVRIX (PF) ………………………… 18 HEATHER ……………………………. 26 HEP FLUSH-10 (PF) ……………… 10 heparin (porcine) …………………… 10 heparin lock flush (porcine) ……… 10 HEPARIN LOCKFLUSH(PORCINE)(PF) ….. 10 heparin, porcine (pf) ………………. 10 HEPLISAV-B (PF) …………………. 18 HIBERIX (PF) ……………………….. 18 HIGH POTENCY MULTIVIT (W-IRON) …………………………….. 57 HOMATROPAIRE …………………. 30 HONEY BEARSMULTIVITAMIN …………………….. 57 HUMALOG MIX 50-50KWIKPEN ……………………………. 12 HUMALOG U-100 INSULIN …….. 12 HUMULIN RU-500 (CONC) KWIKPEN ……………………………. 12 HYCAMTIN ………………………….. 14 hydralazine …………………………… 21 hydrochlorothiazide ……………….. 29 hydrocodone-acetaminophen …….. 3 hydrocodone-homatropine ………. 29 hydrocodone-ibuprofen …………….. 3 hydrocortisone …………………. 36, 49 hydrocortisone butyrate ………….. 49 hydrocortisone valerate ………….. 49 hydrocortisone-pramoxine ………. 34 HYDROMET ………………………… 29 hydromorphone ………………………. 4 hydromorphone (pf) ……………… 3, 4 hydroxychloroquine …………………13 hydroxyurea …………………………..14 hydroxyzine hcl ………………………11 hydroxyzine pamoate ……………..11 hyoscyamine sulfate ……………….34 HYOSYNE …………………………….34 HYPER-SAL ………………………….51 ibandronate …………………………..51 IBRANCE ……………………………..14 IBU ………………………………………. 5 ibuprofen ………………………………. 5 icatibant ………………………………..51 ICLEVIA ……………………………….26 ICLUSIG ……………………………….14 icosapent ethyl ………………………34 IFEREX 150 ………………………….32 imatinib …………………………………14 IMBRUVICA ………………………….14 imipramine hcl ……………………….44 imipramine pamoate ……………….44 INCASSIA …………………………….26 INCRUSE ELLIPTA ………………… 7 indapamide …………………………… 29INDOCIN ………………………………. 5 indomethacin …………………………. 5 INFANRIX (DTAP) (PF) …………..18 INFANT-TODDLER MULTIVITAMIN ……………………..57 INFANT-TODDLER MULTIVIT-IRON ……………………………………57 INFED ………………………………….62 infliximab ………………………………62 INGREZZA …………………………… 23 INGREZZA INITIATION PK(TARDIV) ………………………….23 INGREZZA SPRINKLE ……………23 INLYTA ………………………………..14 insulin asp prt-insulin aspart …….12 insulin aspart u-100 ………………..12 insulin lispro ………………………….12 insulin lispro protamin-lispro …….12 insulin syringe-needle u-100 …….39 INSUPEN PEN NEEDLE …………39 INVEGA HAFYERA ………………..44 INVEGA SUSTENNA ……………..44 INVEGA TRINZA ……………… 44, 45 IOPIDINE ……………………………..30 IPOL …………………………………….18 ipratropium bromide ……………. 7, 30 ipratropium-albuterol ……………….. 7 irbesartan ……………………………..21 IRON ……………………………………32 IRON (FERROUS SULFATE) …..32 ISENTRESS ………………………….16 69 ISENTRESS HD …………………… 16 ISIBLOOM …………………………… 26 isoniazid ………………………………… 9 ISOPTO ATROPINE ……………… 30 ISORDIL TITRADOSE …………… 19 isosorbide dinitrate ………………… 19 isosorbide mononitrate …………… 19 itraconazole ………………………….. 11 ivabradine ……………………………. 19 ivermectin …………………………….. 13 JAIMIESS ……………………………. 26 JAKAFI ……………………………….. 14 JANTOVEN ………………………….. 10 JANUVIA ……………………………… 12 JARDIANCE …………………………. 12 JASMIEL (28) ……………………….. 26 JENCYCLA ………………………….. 26 JENTADUETO ……………………… 12 JENTADUETO XR ………………… 12 JINTELI ……………………………….. 36 JOLESSA …………………………….. 26 JORNAY PM ………………………… 45 JOYEAUX ……………………………. 26 JUBLIA ……………………………….. 11 JULEBER …………………………….. 26 JULUCA ………………………………. 16 JUNEL 1.5/30 (21) ………………… 26 JUNEL 1/20 (21) …………………… 26 JUNEL FE 1.5/30 (28) ……………. 27 JUNEL FE 1/20 (28) ………………. 27 JUNEL FE 24 ……………………….. 27 JUST 4 KIDZ MULTIVIT-PROBIOTIC …………………………. 57 JYNNEOS (PF) …………………….. 18 KAITLIB FE ………………………….. 27 KALLIGA ……………………………… 27 KARIVA (28) ………………………… 27 KAZANO ……………………………… 12 KELNOR 1/35 (28) ………………… 27 KESIMPTA PEN …………………… 23 ketoconazole ………………………… 11 ketoprofen ……………………………… 6 ketorolac ………………………….. 4, 30 KEVZARA ……………………………. 38 KIDS' GUMMY ……………………… 57 KIDS MELATONIN ………………… 36 KINERET ………………………………. 6 KINRIX (PF) …………………………. 18 KIONEX (WITH SORBITOL) …… 32 KLAYESTA ………………………….. 11 KLOR-CON 10 ……………………… 32 KLOR-CON 8 ……………………….. 32 KLOR-CON M10 …………………… 32 KLOR-CON M15 …………………… 32 KLOR-CON M20 …………………… 32 KLOXXADO…………………………. 10 KONSYL (SUGAR) ………………… 34 KOSHER PRENATAL PLUS IRON …………………………………… 40 K-PAX IMMUNE SUPPORT ……. 57 KPN ……………………………………. 40 KRINTAFEL …………………………. 13 KRISTALOSE ……………………….. 34 KURVELO (28) ……………………… 27 KYLEENA ……………………………. 27 l norgest/e.estradiol-e.estrad …… 27 labetalol ……………………………….. 21 lacosamide …………………………… 23 lactulose ………………………………. 34 LAMICTAL ODT STARTER (BLUE) ………………………………… 23 LAMICTAL ODT STARTER (GREEN) ……………………………… 23 LAMICTAL ODT STARTER (ORANGE) …………………………… 23 LAMICTAL STARTER (BLUE) KIT ……………………………………… 23 LAMICTAL STARTER (GREEN) KIT ……………………….. 23 LAMICTAL STARTER (ORANGE) KIT ……………………… 23 LAMICTAL XR ………………………. 23 LAMICTAL XR STARTER(BLUE) ………………………………… 23 LAMICTAL XR STARTER (GREEN) ……………………………… 23 LAMICTAL XR STARTER (ORANGE) …………………………… 23 lamivudine ……………………………. 16 lamivudine-zidovudine ……………. 16 lamotrigine ……………………………. 23 LANOXIN …………………………….. 19 lansoprazole …………………………. 34 LANTUS SOLOSTAR U-100 INSULIN ………………………………. 12 LANTUS U-100 INSULIN………… 12 lapatinib ……………………………….. 14 L-ARGININE(ALPHA-KETOGLUTARAT) ………………… 32 LARIN 1.5/30 (21) …………………. 27 LARIN 1/20 (21) ……………………. 27 LARIN 24 FE ………………………… 27 LARIN FE 1.5/30 (28) …………….. 27 LARIN FE 1/20 (28) ……………….. 27 latanoprost …………………………… 30 ledipasvir-sofosbuvir ………………. 16 leflunomide …………………………….. 6 LENVIMA …………………………….. 14 LESSINA ……………………………… 27 letrozole ………………………………. 14 leucovorin calcium …………………. 51 LEUKERAN …………………………..14 leuprolide ………………………………14 levetiracetam …………………………23 levobunolol …………………………… 30 levocarnitine …………………………. 51 levocarnitine (with sugar) ………… 51 levocetirizine ………………………….11 levofloxacin ……………………………. 9 levomefolate calcium ……………… 57 LEVONEST (28) …………………….27 levonorgest-eth.estradiol-iron ……27 levonorgestrel-ethinyl estrad …….27 levonorg-eth estrad triphasic …….27 levorphanol tartrate …………………. 4 levothyroxine ………………………… 51 LEVOXYL …………………………….. 51 lidocaine ……………………………….. 5 lidocaine hcl …………………………… 5 lidocaine hcl-hydrocortison ac . …………………………………….. 34, 49 LIDOCAINE VISCOUS ……………. 5 lidocaine-prilocaine ………………….. 5 LIDOCAN III …………………………… 5 LIDOCAN IV …………………………… 5 LIDOCAN V ……………………………. 5 LIDODERM ……………………………. 5 LILETTA ………………………………. 27 LINZESS ……………………………… 34 liothyronine …………………………… 51 LIQUID B-12 …………………………. 57 LIQUID CALCIUM WITH VITAMIN D …………………………… 32 liraglutide ………………………………12 lisinopril ………………………………..21 lisinopril-hydrochlorothiazide …….21 LITE TOUCH-MEDIUM MASK …. 39 LITEAIRE MDI CHAMBER ……… 39 LITETOUCH-LARGE MASK ……. 39 LITETOUCH-SMALL MASK …….. 39 lithium carbonate …………………… 45 lithium citrate ………………………… 45 LITHOSTAT ………………………….34 LITTLE ANIMALS ………………….. 57 lmefol ca-acetyl-meb12-algal …… 57 LO LOESTRIN FE ………………….27 LOESTRIN 1.5/30 (21) ……………27 LOESTRIN 1/20 (21) ………………27 LOESTRIN FE 1.5/30 (28-DAY).27 LOESTRIN FE 1/20 (28-DAY) ….27 LOJAIMIESS …………………………27 LOKELMA …………………………….32 loperamide …………………………… 34 lopinavir-ritonavir ……………………16 lorazepam ………………………. 45, 48 70 LORAZEPAM INTENSOL ………. 45 LORYNA (28) ……………………….. 27 losartan ……………………………….. 21 losartan-hydrochlorothiazide ……. 21 LOTEMAX ……………………………. 30 loteprednol etabonate …………….. 30 lovastatin ……………………………… 21 LOW-OGESTREL (28) …………… 27 loxapine succinate …………………. 45 LO-ZUMANDIMINE (28) …………. 27 lubiprostone …………………………. 34 LUMIGAN ……………………………. 30 LUMRYZ ……………………………… 48 LUNESTA ……………………………. 48 LUPRON DEPOT …………….. 14, 36 LUPRON DEPOT (3 MONTH) . ……………………………………. 14, 36 LUPRON DEPOT (4 MONTH) …. 14 LUPRON DEPOT (6 MONTH) …. 14 LUPRON DEPOT-PED ………….. 36 LUPRON DEPOT-PED (3 MONTH) ……………………………… 36 lurasidone ……………………………. 45 LUTERA (28) ………………………… 27 LYBALVI ……………………………… 45 LYLEQ ………………………………… 27 LYRICA ……………………………….. 23 LYSIPLEX PLUS …………………… 57 LYSODREN …………………………. 15 LYZA …………………………………… 27 MAGELLAN INSULIN SAFETY SYRNG ……………………………….. 39 MAGELLAN SYRINGE …………… 39 MAGNEBIND 300 …………………. 32 MAGNEBIND 400 …………………. 32 magnesium oxide ………………….. 32 maraviroc …………………………….. 16 MARLISSA (28) …………………….. 27 MATULANE …………………………. 15 meclofenamate ……………………….. 6 MEDROL …………………………….. 37 MEDROL (PAK) ……………………. 36 medroxyprogesterone ……….. 27, 37 mefloquine …………………………… 13 MEGA MULTI FOR WOMEN ….. 57 MEGA MULTIVITAMIN FOR MEN ……………………………………. 57 MEGAVITE ………………………….. 51 megestrol ……………………….. 15, 51 MEKINIST ……………………………. 15 melatonin …………………………….. 37 melatonin-lemon balm leaf extr 37 melatonin-pyridoxine hcl (b6) …… 37 meloxicam ……………………………… 6 memantine …………………………… 24 MEN50 PLUS ADVANCED ONE DAILY ………………………….. 57 MENEST ……………………………… 37 MEN'S 50 PLUS DAILY FORMULA …………………………… 57 MEN'S50 PLUSMULTIVITAMIN …………………….. 57 MEN'S DAILY ……………………….. 57 MEN'S DAILY FORMULA ……….. 57 MEN'S DAILY GUMMIES ……….. 57 MEN'S MULTIVITAMINGUMMIES ……………………………. 57 MEN'S ONE DAILY ……………….. 57 meperidine …………………………….. 4 meperidine (pf) ……………………….. 4 mercaptopurine …………………….. 15 mesalamine ………………………….. 34 mesalamine with cleansing wipe ……………………………………. 34 MESNEX ……………………………… 51 MESTINON ………………………….. 18 MESTINON TIMESPAN …………. 18 META APPETITE CTRL (ASPARTAME) ……………………… 34 METAMUCIL (WITH SUGAR) …. 34 METAMUCIL FREE (WITH SUGAR) ………………………………. 34 metformin …………………………….. 12 methamphetamine …………………. 18 methazolamide ……………………… 29 methenamine hippurate ……………. 9 methenamine mandelate ………….. 9 methen-sod phos-meth blue-hyos ……………………………………… 9 methimazole …………………………. 51 methocarbamol……………………… 40 methotrexate sodium ……………… 15 methotrexate sodium (pf) ………… 15 methscopolamine ………………….. 34 methyldopa ………………………….. 21 methyldopa-hydrochlorothiazide 21 methylergonovine ………………….. 37 methylphenidate hcl ……………….. 45 methylprednisolone ……………….. 37 metoclopramide hcl ……………….. 34 metolazone ………………………….. 29 metoprolol succinate ………………. 21 metoprolol tartrate …………………. 21 METROCREAM ……………………. 50 METROLOTION ……………………. 50 metronidazole ……………………. 9, 50 metyrosine …………………………… 21 MGO …………………………………… 32 MIBELAS 24 FE ……………………. 27 MICROCHAMBER ………………… 39 MICROGESTIN1.5/30 (21) ……..27 MICROGESTIN 1/20 (21) ………..27 MICROGESTIN FE 1.5/30 (28)27 MICROGESTIN FE 1/20 (28) …..27 midazolam ………………………… 5, 48 midazolam (pf) ……………………….. 5 midodrine ……………………………..18 MIGERGOT …………………………… 4 miglustat ……………………………….51 MILI ……………………………………..27 MILLTRIUM SENIOR ……………..57 MIMVEY ……………………………….37 MINI PRENATAL ……………………40 MINI WRIGHT PEAK FLOW METER ………………………………..39 MINIMED INSTINCT SENSOR39 MINIVELLE …………………………..37 minocycline ……………………………. 9 minoxidil ……………………………….21 MIRENA ……………………………….27 mirtazapine …………………………… 45 misoprostol …………………………… 34 M-M -R II (PF) ………………………..18 M-NATAL PLUS …………………….40 modafinil ……………………………….45 molindone ……………………………..45mometasone………………………….50 MONDOXYNE NL ………………….. 9 MONOCAPS …………………………57 MONOJECT INSULIN SAFETY SYRING ……………………………….40 MONOJECT MAGELLAN SAFETY SYRNG …………………..40 MONOJECT SAFETYSYRINGES …………………………… 40 MONOJECT SYRINGE …………..40 MONO-LINYAH ……………………..27 montelukast …………………………… 7 MORGIDOX ………………………….. 9 morphine ………………………………. 4 morphine (pf) …………………………. 4 morphine concentrate ……………… 4 MOTEGRITY …………………………34 moxifloxacin …………………………… 9 MRESVIA (PF) ………………………18 MULTI COMPLETE WITHIRON ……………………………………57 MULTI FOR HER …………………..57 MULTI FOR HER 50 PLUS ……..57 MULTI PRO …………………………..57 MULTI VITAMIN …………………….57 MULTIPLEVITAMIN-MINERALS …………………………… 57 MULTIPLE VITAMINS …………….57 multivit with min-folic acid ………..5771 multivit,calc,min-fa-k1-lycop …….. 57 multivitamin ………………………….. 57 MULTIVITAMIN 50 PLUS ……….. 58 MULTIVITAMIN GUMMIES …….. 58 MULTI-VITAMIN HP/MINERALS ……………………… 58 multivitamin with iron ……………… 58 MULTIVITAMIN WOMEN 50 PLUS ………………………………….. 58 MULTI-VITE …………………………. 58 multivit-min-ferrous fumarate …… 58 multivit-min-ferrous gluconate 58 multivit-min-folic acid-lutein …….. 58 multivit-min-iron fum-folic ac ……. 58 mupirocin ………………………………. 9 MVW COMPLETE FORMUL MULTIVIT ……………………………. 58 MVW COMPLETE FORMULATION D3000 …………. 58 MVW COMPLETE FORMULATION D5000 …………. 58 MX-SOL ………………………………. 51 MX-SOL BLEND …………………… 51 MX-SOL BLEND SF ………………. 51 MX-SOL SF …………………………. 51 MX-SOL SUSPEND ………………. 51 mycophenolate mofetil …………… 38 mycophenolate sodium ………….. 38 MYFEMBREE ………………………. 37 MYFERON 150 …………………….. 32 MYLERAN …………………………… 15 MYRBETRIQ ………………………… 51 MYTESI ………………………………. 34 MY-VITALIFE ……………………….. 58 nabumetone …………………………… 6 nadolol ………………………………… 21 nalbuphine …………………………….. 4 nalmefene ……………………………. 10 naloxone ……………………………… 10 naltrexone ……………………………. 10 naproxen ……………………………….. 6 naproxen sodium …………………….. 6 NATAZIA ……………………………… 27 NAYZILAM …………………………… 24 nebivolol ………………………………. 21 NEBUSAL ……………………………. 52 NECON 0.5/35 (28) ……………….. 27 nefazodone ………………………….. 45 neomycin ………………………………. 9 neomycin-polymyxin b-dexameth ………………………………. 9 neomycin-polymyxin-gramicidin 9 neomycin-polymyxin-hc ……………. 9 NEORAL ……………………………… 38 NEOVITE …………………………….. 58 NEUAC……………………………….. 50 NEUPOGEN ………………………… 25 NEURONTIN ………………………… 24 NEVANAC ……………………………. 30 nevirapine ……………………………. 16 NEXIUM PACKET …………………. 34 NEXPLANON ……………………….. 27 NEXTSTELLIS ……………………… 27 niacin ………………………………….. 58 niacinamide ………………………….. 58 nifedipine ……………………………… 19 NIKKI (28) ……………………………. 27 nimodipine ……………………………. 19 nitazoxanide …………………………. 15 nitisinone ……………………………… 52 NITRO-BID …………………………… 19 NITRO-DUR …………………………. 19 nitrofurantoin ………………………….. 9 nitrofurantoin macrocrystal ……….. 9 nitrofurantoin monohyd/m-cryst 9 nitroglycerin ………………………….. 20 NITRO-TIME ………………………… 20 nizatidine ……………………………… 34 NORA-BE …………………………….. 27 NORDITROPIN FLEXPRO……… 37 noreth-ethinyl estradiol-iron …….. 27 norethindrone (contraceptive)27 norethindrone acetate …………….. 37 norethindrone ac-eth estradiol 27 norethindrone-e.estradiol-iron 27 norgestimate-ethinyl estradiol27NORLIQVA ………………………….. 20 NORPACE CR ……………………… 20 NORTREL 0.5/35 (28) ……………. 27 NORTREL 1/35 (21) ………………. 27 NORTREL 1/35 (28) ………………. 27 NORTREL 7/7/7 (28) ……………… 27 nortriptyline ……………………… 45, 46 NORVIR ………………………………. 16 NOVAFERRUM YUM PEDIATR MV-IRON ………………. 58 NOVAFERRUM YUMMY PEDIATRIC ………………………….. 32 NOVAMV MMM PEDIATRIC MULTIVIT …………………………….. 58 NOVOLOG FLEXPEN U-100 INSULIN ………………………………. 12 NOVOLOG MIX 70-30 U-100 INSULN ……………………………….. 12 NOVOLOG MIX 70-30FLEXPEN U-100 ……………….. 13 NOVOLOG PENFILL U-100 INSULIN ………………………………. 13 NOVOLOG U-100 INSULIN ASPART ……………………………… 13 NPTHYROID ………………………..51 NUCALA ………………………………. 7 NUCYNTA …………………………….. 4 NUCYNTA ER ……………………….. 4 NUEDEXTA …………………………..24 NULEV …………………………………34 NURTEC ODT ……………………….. 4 NUVARING …………………………..27 NUVESSA …………………………….. 9 NYAMYC ………………………………11 NYLIA 1/35 (28) ……………………..28 NYLIA 7/7/7 (28) …………………….28 nystatin …………………………………11 nystatin-triamcinolone ……………..11 NYSTOP ………………………………11 OCELLA ……………………………….28 OCREVUS …………………………… 62 OCREVUS ZUNOVO ……………..24 octreotide acetate …………………..62 ODEFSEY …………………………….16 OFEV …………………………………..52 ofloxacin ……………………………….. 9 olanzapine …………………………….46 olanzapine-fluoxetine ………………46 olmesartan …………………………… 21OLUMIANT ……………………………. 6 omega 3-dha-epa-fish oil …………34 omega-3 acid ethyl esters ………..35 omeprazole …………………………..35 OMNARIS …………………………….30 ondansetron ………………………….35 ondansetron hcl ……………………..35 ondansetron hcl (pf) ………………..35 ONE A DAY WOMEN'S PRENATAL DHA ……………………40 ONE DAILY …………………………..58 ONE DAILY CALCIUM/IRON……58 ONE DAILY COMPLETE …………58 ONE DAILY ESSENTIAL …………58 ONE DAILY FOR MEN ……………58 ONE DAILY FOR MEN 50 PLUS ADV …………………………… 58 ONE DAILY FOR WOMEN ………58 ONEDAILY HEALTHYWEIGHT ……………………………….58 ONE DAILY MAXIMUM …………..58 ONE DAILY MEN'S 50 PLUS MEMORY ……………………………..58 ONE DAILY MEN'S 50 PLUS W-D3 ……………………………………58 ONE DAILY MEN'S HEALTH …..58 ONE DAILY MULTI-VIT W-MINERAL ……………………………..58 ONE DAILY MULTIVITAMIN ……58 72 ONE DAILY MULTIVITAMIN-IRON …………………………………… 58 ONE DAILY MULTIVIT-IRON(FOLIC) ……………………….. 58 ONE DAILY PLUS IRON ………… 58 ONE DAILY WOMEN 50 PLUS 58 ONE DAILY WOMEN 50 PLUS(VIT K) ………………………… 58 ONE DAILY WOMEN'S ………….. 58 ONE DAILY WOMENS 50 PLUS ………………………………….. 58 ONEDAILY WOMEN'SHEALTH ………………………………. 58 ONE DAILY WOMEN'S METABOLISM ……………………… 52 ONE-A -DAY ENERGY …………… 59 ONE-A -DAY ESSENTIAL ……….. 59 ONE-A -DAY KID'S ………………… 59 ONE-A -DAY MENVITACRAVES ………………………. 59 ONE-A -DAY MENOPAUSE FORMULA …………………………… 59 ONE-A -DAY MEN'S 50 PLUS …. 59 ONE-A -DAY MEN'SCOMPLETE …………………………. 59 ONE-A -DAY MEN'S MULTIVITAMIN …………………….. 59 ONE-A -DAY PRENATAL-1 …….. 41 ONE-A -DAY PROACTIVE 65 PLUS ………………………………….. 59 ONE-A -DAY TEENADVANTAGE ……………………….. 59 ONE-A -DAY TEEN HER VITACRAVES ………………………. 59 ONE-A -DAY TEEN HIM VITACRAVES ………………………. 59 ONE-A -DAY VITACRAVES …….. 59 ONE-A -DAY VITACRAVES IMMUNITY …………………………… 59 ONE-A -DAY WEIGHTSMART …. 59 ONE-A -DAY WOMEN VITACRAVES ………………………. 59 ONE-A -DAY WOMEN'S 50PLUS ………………………………….. 59 ONE-A -DAY WOMEN'SACTIVE ……………………………….. 59 ONE-A -DAY WOMENS FORMULA …………………………… 59 ONE-A -DAY WOMEN'S HEALTHY SKIN ……………………. 59 ONE-A -DAYWOMEN'SPETITES ……………………………… 59 ONE-DAILY MULTI ……………….. 59 ONEVITE CALCIUM-D3 …………. 32 ONEVITE(WITH LUTEIN) ………. 59 ONTRUZANT……………………….. 15 opium tincture ……………………….. 35 OPTICHAMBER ADULT MASK-LARGE ………………………. 40 OPTICHAMBER DIAMOND LG MASK ………………………………….. 40 OPTICHAMBER DIAMONDVHC ……………………………………. 40 OPTICHAMBER DIAMOND-MED MSK ……………………………. 40 OPTICHAMBER DIAMOND-SML MASK …………………………… 40 OPTIMAL D3 ………………………… 59 OPURITY MULTIVITAMIN ……… 59 OPVEE ……………………………….. 11 OPZELURA ………………………….. 50 ORA-BLEND ………………………… 52 ORA-BLEND SF ……………………. 52 ORAL MIX ……………………………. 52 ORAL MIX SF ………………………. 52 ORAL SUSPEND ………………….. 52 ORAL SYRUP ………………………. 52 ORAL SYRUP SF ………………….. 52 ORALONE …………………………… 52 ORA-PLUS …………………………… 52 ORA-SWEET ……………………….. 52 ORA-SWEET SF …………………… 52 ORENCIA ………………………………. 6 ORENCIA (WITH MALTOSE) ……. 6 ORENCIA CLICKJECT …………….. 6 ORFADIN …………………………….. 52 ORIAHNN ……………………………. 37 ORILISSA ……………………………. 37 ORLADEYO …………………………. 52 orphenadrine citrate ………………. 40 OSCIMIN ……………………………… 35 OSCIMIN SL ………………………… 35 oseltamivir ……………………………. 16 OTEZLA ………………………………… 6 OTEZLA STARTER ………………… 6 OTOVEL ……………………………….. 9 oxaprozin ………………………………. 6 oxazepam ……………………………. 46 oxcarbazepine ………………………. 24 OXERVATE …………………………. 30 OXTELLAR XR …………………….. 24 oxybutynin chloride ………………… 52 oxycodone ……………………………… 4 oxycodone-acetaminophen ……….. 4 OXYTROL ……………………………. 52 OYSCO 500/D ……………………… 32 OYSTER SHELL + D3 ……………. 32 OYSTER SHELL CALCIUM ……. 32 OYSTER SHELL CALCIUM 500 ……………………………………… 32 OYSTERSHELL CALCIUM-VIT D3 ………………………………….32 OZEMPIC ……………………………..13 PACERONE ………………………….20 PALFORZIA (LEVEL 1) ………….18 PALFORZIA (LEVEL 2) ………….18 PALFORZIA (LEVEL 3) ………….18 PALFORZIA (LEVEL 4) ………….18 PALFORZIA (LEVEL 5) ………….18 PALFORZIA (LEVEL 6) ………….18 PALFORZIA (LEVEL 7) ………….18 PALFORZIA (LEVEL 8) ………….18 PALFORZIA (LEVEL 9) ………….18 PALFORZIA (LEVEL 10) …………18 PALFORZIA (LEVEL 11 UP-DOSE) ………………………………….18 PALFORZIAINITIAL (4-17YRS) ……………………………………19 PALFORZIA LEVEL 11 MAINTENANCE …………………….19 paliperidone …………………………..46 PALYNZIQ …………………………… 19 PAMELOR …………………………….46 PANCREAZE ………………………..35 PANRETIN …………………………… 15 pantoprazole ………………………….35 PARAGARD T 380A ……………….28 PARAGARD T380A (SINGLE HAND) …………………………………. 28 paricalcitol …………………………….52 PAROEX ORAL RINSE …………..52 paroxetine hcl ………………………..46 paroxetine mesylate(menop.sym) ……………..52 PAXLOVID …………………………… 17 pazopanib ……………………………..15 PCCA-PLUS BASE ………………..52 pedi multivit no.194-iron sulf …….59 PEDIA D-VITE ……………………….59 PEDIA IRON …………………………32 PEDIA POLY-VITE WITH IRON.59 PEDIARIX (PF) ………………………19 PEDIATRIC D-VITE………………..59 pediatric multivitamin no.171 ……59 PEDIATRIC POLY-VITE ………….59 PEDIATRIC POLY-VITE WITH IRON …………………………………… 59 PEDVAX HIB (PF) ………………….19 peg 3350-electrolytes ……………..35 peg-electrolyte soln…………………35 PEN NEEDLE ………………………..40 PENBRAYA (PF) ……………………19 penciclovir …………………………….17 penicillamine ………………………….. 6 penicillin v potassium ………………. 973 PENTACEL ACTHIB COMPONENT (PF) ……………….. 19 PENTASA ……………………………. 35 pentazocine-naloxone ……………… 4 pentobarbital sodium ……………… 48 pentoxifylline ………………………… 19 PERIOGARD ……………………….. 52 permethrin ……………………………. 15 perphenazine ……………………….. 46 perphenazine-amitriptyline ………. 46 PHEBURANE ……………………….. 35 phenazopyridine ……………………… 5 phenobarbital ……………………….. 48 phenobarbital sodium …………….. 48 phenylephrine hcl ………………….. 30 PHENYTEK ………………………….. 24 phenytoin …………………………….. 24 phenytoin sodium ………………….. 24 phenytoin sodium extended …….. 24 PHILITH ………………………………. 28 PHYTOMULTI ………………………. 52 phytonadione (vitamin k1) ………. 59 PIFELTRO …………………………… 17 pilocarpine hcl …………………. 18, 30 pimecrolimus ………………………… 38 PIMTREA (28) ………………………. 28 pioglitazone ………………………….. 13 pirfenidone …………………………… 52 piroxicam ………………………………. 6 PNEUMOVAX-23 ………………….. 19 pnv no.95-ferrous fumarate-fa 41 POCKET CHAMBER …………….. 40 podofilox ……………………………… 50 POLYCIN ………………………………. 9 POLY-IRON …………………………. 32 polymyxin b sulf-trimethoprim ……. 9 polysaccharide iron complex …… 33 POLY-VI-SOL ………………………. 59 POLY-VI-SOL WITH IRON ……… 59 POLY-VITA DROPS ……………… 59 POLY-VITA WITH IRON ………… 59 POMALYST …………………………. 15 PORTIA 28 ………………………….. 28 potassium chloride ………………… 33 potassium citrate …………………… 33 potassium iodide …………………… 33 PRALUENT PEN …………………… 21 pramipexole …………………………. 15 prasugrel hcl ………………………… 16 pravastatin …………………………… 21 praziquantel …………………………. 13 prazosin ………………………………. 21 PRED MILD …………………………. 30 prednisolone ………………………… 37 prednisolone acetate ……………… 30 prednisolone acetate (pf) ………… 30 prednisolone sodium phosphate . …………………………………….. 30, 37 prednisone …………………………… 37 PREDNISONE INTENSOL ……… 37 pregabalin ……………………………. 24 PREMARIN ………………………….. 37 PREMPRO …………………………… 37 PRENATABS FA …………………… 41 PRENATABS RX …………………… 41 PRENATAL ………………………….. 41 PRENATAL + DHA ………………… 41 PRENATAL 19 ……………………… 41 PRENATAL COMPLETE ………… 41 PRENATAL FORMULA ………….. 41 PRENATAL MULTI ………………… 41 PRENATAL MULTI-DHA (ALGAL OIL) ………………………… 41 PRENATAL MULTI-DHA(WITH VIT K) ………………………………….. 41 PRENATAL MULTIVITAMINS …. 41 PRENATAL ONE DAILY ………… 41 PRENATAL PLUS …………………. 41 PRENATAL PLUS (CALCIUM CARB) …………………………………. 41 PRENATAL TABLET ……………… 41 prenatal vit no.179-iron-folic ……. 41 PRENATAL VITAMIN …………….. 41 PRENATAL VITAMIN PLUS LOW IRON …………………………… 41 PRENATAL VITAMIN WITH MINERALS …………………………… 41 prenatal vit-iron fum-folic ac ……. 41 pretomanid …………………………….. 9 PREVALITE …………………………. 21 PREZCOBIX ………………………… 17 PREZISTA …………………………… 17 PRIFTIN ………………………………… 9 primaquine …………………………… 13 primidone …………………………….. 24 PROAIR RESPICLICK …………….. 7 probenecid …………………………….. 6 PROBIOTIC 4X …………………….. 35 PROCARE SPACER WITH ADULT MASK ………………………. 40 PROCARE SPACER WITH CHILD MASK ……………………….. 40 PROCERV HP ……………………… 59 PROCHAMBER ……………………. 40 prochlorperazine edisylate ………. 35 prochlorperazine maleate ……….. 35 PROCTO-MED HC ……………….. 50 PROCTOSOL HC …………………. 50 PROCTOZONE-HC ………………. 50 PROFOLA ……………………………. 59 progesterone …………………………37 progesterone micronized …………37 PROLENSA …………………………..30 PROMACTA ………………………….25 promethazine …………………… 11, 35 PROMETHAZINE VC ……………..11 promethazine-codeine …………….29 promethazine-dm ……………………29 promethazine-phenylephrine …….11 PROMETHEGAN …………………..35 propafenone ………………………….20 propranolol …………………………… 21 propranolol-hydrochlorothiazid 21 propylthiouracil ………………………51 PROQUAD (PF) …………………….19 PRORENAL QD …………………….59 PROSTIN VR PEDIATRIC ……….21 PROTECT CARDIO AF …………..59 PROTECT PLUS SO ………………59 PROTONIX …………………………..35 protriptyline …………………………… 46 PROVERA …………………………….37 psyllium husk (with sugar) ………..35 PULMICORT FLEXHALER ………. 7 PULMOSAL …………………………..52 PULMOZYME ………………………..52 PURE L-CITRULLINE ……………..33 PYLERA ……………………………….35 pyrazinamide …………………………. 9 pyridostigmine bromide ……………18 pyridoxine (vitamin b6) …………….59 pyrimethamine ……………………….13 PYZCHIVA …………………………… 38 PYZCHIVA AUTOINJECTOR …..38 QELBREE …………………………….46 QUADRACEL (PF) …………………19 quetiapine ……………………………..46 QUILLICHEW ER …………………..47 QUILLIVANT XR ……………………47 quinapril-hydrochlorothiazide ……21 QUINTABS …………………………… 59 QUINTABS-M ………………………..59 QUINTABS-M IRON FREE………59 QULIPTA ………………………………. 4 QVAR REDIHALER ………………… 7 RAGWITEK …………………………..19 raloxifene ………………………………52 ramelteon ……………………………..48 ramipril …………………………………21 ranolazine ……………………………..20 REBIF (WITH ALBUMIN) ………..24 REBIF REBIDOSE …………………24 REBIF TITRATION PACK ……….24 RECLIPSEN (28) ……………………28 RECOMBIVAX HB (PF) …………..19 74 RECTIV……………………………….. 35 REGULOID (ASPARTAME) ……. 35 REGULOID (PSYLLIUM HUSK) 35 REGULOID (PSYLLIUM HUSK-SUCRO) ………………………………. 35 RELENZA DISKHALER …………. 17 RELEUKO ……………………………. 25 RELISTOR …………………………… 11 REMEDIENT ………………………… 59 REMODULIN ……………………….. 21 RENVELA ……………………………. 33 repaglinide …………………………… 13 REPATHA PUSHTRONEX ……… 21 REPATHA SURECLICK …………. 21 REPATHA SYRINGE …………….. 21 REQ49 PLUS ……………………….. 59 RESTASIS …………………………… 30 RETACRIT …………………………… 25 REVLIMID ……………………………. 15 REXTOVY ……………………………. 11 REXULTI ……………………………… 47 RHOGAM ULTRA-FILTERED PLUS ………………………………….. 19 RHOPRESSA ………………………. 30 riboflavin (vitamin b2) …………….. 60 rifabutin …………………………………. 9 rifampin …………………………………. 9 riluzole ………………………………… 24 RINVOQ ………………………………… 6 RINVOQ LQ …………………………… 6 risedronate …………………………… 52 RISPERDAL CONSTA …………… 47 risperidone …………………………… 47 RITEFLO AEROCHAMBER ……. 40 ritonavir ……………………………….. 17 RITUXAN …………………………….. 62 rivastigmine ………………………….. 18 rivastigmine tartrate ……………….. 18 RIVELSA ……………………………… 28 rizatriptan ………………………………. 4 ROBINUL …………………………….. 35 ROBINUL FORTE …………………. 35 ROCKLATAN ……………………….. 30 roflumilast ………………………………. 7 romidepsin …………………………… 15 ropinirole ……………………………… 15 ROSADAN …………………………… 50 rosuvastatin ………………………….. 21 ROWEEPRA ………………………… 24 sacubitril-valsartan ………………… 21 SAFYRAL ……………………………. 28 SANDIMMUNE …………………….. 38 SANTYL ………………………………. 50 sapropterin …………………………… 52 SAVELLA …………………………….. 52 SCOOBY-DOO ONE A DAY KIDS …………………………………… 60 SELARSDI …………………………… 38 selegiline hcl …………………………. 15 selegiline hcl (bulk) ………………… 52 selenium sulfide ……………………. 50 SELZENTRY ………………………… 17 SE-NATAL 19 CHEWABLE …….. 41 SENIOR TABS ……………………… 60 SENNA ……………………………….. 35 senna leaf extract ………………….. 35 SENSIPAR …………………………… 52 SENTRY ……………………………… 60 SENTRY SENIOR …………………. 60 SEREVENT DISKUS ……………….. 7 SEROSTIM ………………………….. 37 sertraline ……………………………… 47 SETLAKIN ……………………………. 28 sevelamer hcl ……………………….. 33 SF 5000 PLUS ……………………… 33 SFROWASA ………………………… 35 SHAROBEL …………………………. 28 sildenafil (pulm.hypertension) ….. 21 SILICONE MASK-INFANT ……. 40 silver sulfadiazine ……………………. 9 SIMBRINZA …………………………. 30 SIMILAC PRENATAL …………….. 41 SIMLIYA (28) ……………………….. 28 SIMPESSE …………………………… 28 simple syrup …………………………. 52 SIMPLERA SENSOR …………….. 40 SIMPLERA SYNC SENSOR …… 40 SIMPONI ……………………………… 14 SIMPONI ARIA ……………………… 62 simvastatin …………………………… 21 sirolimus ………………………………. 38 SIRTURO ………………………………. 9 sitagliptin-metformin ……………….. 13 SKYLA ………………………………… 28 SKYTROFA ………………………….. 37 SLO-NIACIN …………………………. 60 SLYND ………………………………… 28 sodium chloride …………………….. 52 SODIUM FLUORIDE 5000PLUS ………………………………….. 33 sodium phenylbutyrate ……………. 35 sodium phenylbutyrate (bulk) …… 52 sodium polystyrene sulfonate ….. 33 sofosbuvir-velpatasvir …………….. 17 solifenacin ……………………………. 52 SOLIQUA 100/33 ………………….. 13 SOLO ………………………………….. 60 SOLOSEC ……………………………… 9 SOMAVERT …………………………. 52 sorafenib ……………………………… 15 sotalol…………………………………..21 SOTALOL AF ………………………..21 SPACE CHAMBER ………………..40 SPACE CHAMBER WITH LARGE MASK ……………………….40 SPACE CHAMBER WITH MEDIUM MASK …………………….40 SPACE CHAMBER WITH SMALL MASK ……………………….40 SPECTRAVITE ADULT …………..60 SPECTRAVITE ADULT 50PLUS ……………………………………60 SPECTRAVITE ADULT 50 PLUS(LUT) …………………………… 60 SPECTRAVITE ADVANCED FORMULA …………………………….60 SPECTRAVITE MEN'S …………..60 SPECTRAVITE WOMEN ………..60 SPECTRAVITE WOMEN 50 PLUS …………………………………… 60 spinosad ……………………………….15 SPIRIVA RESPIMAT ………………. 7 SPIRIVA WITH HANDIHALER …. 7 spironolactone ……………………….29 spironolacton-hydrochlorothiaz 29 SPRINTEC (28) ……………………..28 SPRYCEL …………………………….15 SPS (WITH SORBITOL) ………….33SRONYX ………………………………28 SSD ……………………………………… 9 STRENSIQ …………………………… 52 STRESS BWITH ZINC …………..60 STRESS FORMULA ………………60 STRESSFORMULA WITHZINC …………………………………….60 STRIBILD ……………………………..17 STROVITE ONE …………………….60 SUBLOCADE ………………………..53 SUBOXONE ………………………….53 SUCRAID ……………………………..35 sucralfate ………………………………35 sulfacetamide sodium …………. 9, 50 sulfacetamide sodium-sulfur …….. 9 sulfacetamide-prednisolone ……… 9 SULFACLEANSE 8-4 ……………… 9 sulfadiazine …………………………… 9 sulfamethoxazole-trimethoprim 9 sulfasalazine ………………………….35 SULFATRIM ………………………….. 9 sulindac ………………………………… 6 sumatriptan……………………………. 4 sumatriptan succinate ……………… 4 SUMAXIN TS ………………………… 9 sunitinib malate ……………………..1575 SUPER MULTIPLE-LOW IRON …………………………………… 60 SUPER THERA VITE M …………. 60 SUPPORT …………………………… 60 SUPPRELIN LA ……………………. 37 SUSPENDRX ANHYDROUS SWEETENED ………………………. 53 SUSPENDRX ANHYDROUS UNSWEET …………………………… 53 SWEET-SF ………………………….. 53 SYEDA ……………………………….. 28 SYMAX-SL …………………………… 35 SYMAX-SR ………………………….. 35 SYMBICORT ………………………….. 7 SYMTUZA ……………………………. 17 SYNAREL ……………………………. 37 SYNJARDY ………………………….. 13 SYNTHROID ………………………… 51 SYRPALTA VEHICLE ……………. 53 SYRSPEND SF LIQUID …………. 53 SYRUP VEHICLE SF …………….. 53 TAB-A-VITE …………………………. 60 TAB-A-VITE MULTIVITAMIN W-IRON ………………………………. 60 TABLOID …………………………….. 15 TACLONEX ………………………….. 50 tacrolimus …………………………….. 38 tadalafil (pulm. hypertension) …… 21 TADLIQ ……………………………….. 22 TAFINLAR …………………………… 15 TAKHZYRO …………………………. 19 TALTZ AUTOINJECTOR ……….. 50 TALTZ AUTOINJECTOR (2 PACK) …………………………………. 50 TALTZ AUTOINJECTOR (3 PACK) …………………………………. 50 TALTZ SYRINGE ………………….. 50 tamoxifen …………………………….. 15 tamsulosin ……………………………. 53 TARINA 24 FE ……………………… 28 TARINA FE 1/20 (28) …………….. 28 TARINA FE 1-20 EQ (28) ……….. 28 TASCENSO ODT ………………….. 24 TASIGNA …………………………….. 15 TAYTULLA …………………………… 28 tazarotene ……………………………. 50 TEGRETOL ………………………….. 24 TEGRETOL XR…………………….. 24 telmisartan …………………………… 22 temazepam ………………………….. 48 temozolomide ……………………….. 15 TENCON ……………………………….. 5 TENIVAC (PF) ……………………… 19 tenofovir disoproxil fumarate……. 17 terazosin ……………………………… 22 terbinafine hcl ……………………….. 11 terconazole …………………………… 11 teriflunomide …………………………. 24 TESTIM ……………………………….. 37 testosterone ……………………. 37, 38 tetrabenazine ……………………….. 24 tetracaine hcl ………………………… 30 tetracaine hcl (pf) …………………… 30 tetracycline …………………………….. 9 TEZSPIRE …………………………… 53 THALOMID ……………………………. 9 THEO-24 ……………………………….. 7 theophylline ……………………………. 7 THERA ………………………………… 60 THERA-D …………………………….. 60 THERAGRAN-MPREMIER 50 PLUS ………………………………….. 60 THERALOGIX COMPANION ….. 60 THERA-M …………………………….. 60 THERAMILL FORTE ……………… 60 THERANATAL ……………………… 41 THERANATAL COMPLETE ……. 41 THERANATAL ONE ………………. 41 THERAPEUTIC-M …………………. 60 THERA-TABS ………………………. 60 THERATRUM COMPLETE 50 PLUS/LUT ……………………………. 60 THERATRUM COMPLETE 50 PLUS-LYC …………………………… 60 THERATRUM COMPLETE WITH LUTEIN ………………………. 60 THEREMS MULTIVITAMIN …….. 60 thiamine hcl (vitamin b1) …………. 60 thiamine mononitrate (vit b1) …… 60 THIOLA EC ………………………….. 53 thioridazine …………………………… 47 thiothixene ……………………………. 47 THRIVITE RX ……………………….. 41 thyroid (pork) ………………………… 51 TIADYLT ER ………………………… 20 tiagabine ……………………………… 24 TILIA FE ………………………………. 28 timolol maleate ……………………… 30 timolol maleate (pf) ………………… 30 TIVICAY ………………………………. 17 tizanidine ……………………………… 40 TOBRADEX …………………………. 10 TOBRADEX ST …………………….. 10 tobramycin …………………………… 10 tobramycin in 0.225 % nacl ……… 10 tobramycin sulfate …………………. 10 tobramycin with nebulizer ……….. 10 tobramycin-dexamethasone …….. 10 tolterodine ……………………………. 53 tolvaptan ……………………………… 29 topiramate …………………………….24 toremifene …………………………….15 torsemide ……………………………..29 TRACLEER …………………………..22 TRADJENTA …………………………13 tramadol ……………………………….. 5 tramadol-acetaminophen …………. 5 tranexamic acid ……………………..19 TRAVATAN Z ………………………..30 TRAZIMERA ………………………….15 trazodone ……………………………..47 TRELEGY ELLIPTA ……………….. 7 TRELSTAR …………………………..15 treprostinil sodium ………………….22 TRESIBA FLEXTOUCH U-100 13 TRESIBA FLEXTOUCH U-200 13 TRESIBA U-100 INSULIN ……….13 tretinoin ………………………………..50 tretinoin (antineoplastic) …………..15 TREXALL ……………………………..15 triamcinolone acetonide …….. 50, 53 triamterene-hydrochlorothiazid 29 triazolam ……………………………….48 TRICARE ……………………………..41 TRI-CHLOR …………………………..50 TRIDACAINE II ………………………. 5 TRIDACAINE III ……………………… 5 TRIDERM ……………………………..50 TRI-ESTARYLLA ……………………28 trifluoperazine ………………………..47 trifluridine ………………………………17 trihexyphenidyl ……………………….15 TRI-LEGEST FE…………………….28 TRI-LINYAH ………………………….28 TRI-LO-ESTARYLLA ………………28 TRI-LO-MARZIA …………………….28 TRI-LO-MILI ………………………….28 TRI-LO-SPRINTEC ………………..28 trimethobenzamide …………………35 trimethoprim ………………………….10 TRI-MILI ……………………………….28 TRINATAL RX 1 …………………….41 TRINTELLIX ………………………….47 TRIPTODUR …………………………38 TRI-SPRINTEC (28) ……………….28 TRIUMEQ ……………………………..17 TRI-VI-SOL …………………………..60 TRI-VYLIBRA ………………………..28 TRI-VYLIBRA LO …………………..28 TROKENDI XR ………………………24 tropicamide …………………………… 30 TRULICITY …………………………… 13 TRUMENBA ………………………….19 TRUZONE PEAK FLOW METER ………………………………..4076 TUBERCULIN SYRINGE ……….. 40 TULANA ………………………………. 28 TURQOZ (28) ………………………. 28 TWINRIX (PF) ………………………. 19 TWIRLA ………………………………. 28 TYBLUME ……………………………. 28 TYBOST ……………………………… 53 TYDEMY ……………………………… 28 TYENNE ……………………………… 38 TYENNE AUTOINJECTOR …….. 38 TYSABRI …………………………….. 62 UBRELVY ……………………………… 5 UDAMIN SP …………………………. 60 ULESFIA ……………………………… 15 ULORIC ………………………………… 6 ULTICARE …………………………… 40 ULTRA FREEDA …………………… 60 UNITHROID …………………………. 51 urea ……………………………………. 50 URELLE ………………………………. 10 URETRON D-S …………………….. 10 ursodiol ……………………………….. 35 URYL ………………………………….. 10 UZEDY ……………………………….. 47 VAGIFEM …………………………….. 38 valacyclovir ………………………….. 17 VALCHLOR …………………………. 15 valganciclovir ………………………… 17 valproate sodium …………………… 24 valproic acid …………………………. 24 valproic acid (as sodium salt) ….. 24 valsartan ……………………………… 22 valsartan-hydrochlorothiazide 22 VALTOCO ………………………. 24, 25 vancomycin ………………………….. 10 VAQTA (PF) …………………………. 19 varenicline tartrate …………………. 50 VARIVAX (PF) ……………………… 19 VARIZIG ……………………………… 19 VAXNEUVANCE (PF) ……………. 19 V-C FORTE …………………………. 60 VECTICAL …………………………… 50 VELETRI ……………………………… 22VELIVET TRIPHASIC REGIMEN (28) ……………………… 28 VELTASSA ………………………….. 33 venlafaxine …………………………… 47 venlafaxine besylate ………………. 47 VENOFER …………………………… 62 VENTOLIN HFA ……………………… 7 verapamil …………………………….. 20 VEREGEN …………………………… 17 VERSA FREE ………………………. 53 VERSA PLUS……………………….. 53 VESTURA (28) ……………………… 28 VIC-FORTE ………………………….. 60 VICTOZA 2-PAK …………………… 13 VICTOZA 3-PAK …………………… 13 VIENVA ……………………………….. 28 vilazodone ……………………………. 47 VIORELE (28) ………………………. 28 VIRACEPT …………………………… 17 VIREAD ………………………………. 17 VITABEX PLUS …………………….. 60 VITACEL (WITH LUTEIN) ………. 60 VITAJOY DAILY D ………………… 60 VITAJOY MELATONIN ………….. 38 VITALEE ……………………………… 60 VITALETS ……………………………. 60 vitamin a ………………………………. 60 vitamin a palmitate …………… 60, 61 VITAMIN B-1 ………………………… 61 VITAMIN B-1(MONONITRATE) …………………. 61 VITAMIN B-12 ………………………. 61 VITAMIN B-2 ………………………… 61 VITAMIN B-6 ………………………… 61 VITAMIN C …………………………… 61 VITAMIN CWITH ROSE HIPS 61 VITAMIN D2 …………………………. 61 VITAMIN D3 …………………………. 61 vitamin e ………………………………. 61 vitamin e (dl, acetate) …………….. 61 vitamin e acetate …………………… 61 vitamin e mixed …………………….. 61 VITAMINS A-D -E SELENIUM ….. 61 VITREXYL ……………………………. 61 VITREXYL PLUS IRON ………….. 61 VIVELLE-DOT ………………………. 38 VIVITROL …………………………….. 53 VOLNEA (28) ……………………….. 28 VOQUEZNA TRIPLE PAK ………. 35 VORTEXHOLDINGCHAMBER …………………………… 40 VOTRIENT …………………………… 15 VRAYLAR ……………………………. 47 VTAMA ……………………………….. 50 VYFEMLA (28) ……………………… 28 VYLIBRA ……………………………… 28 VYNDAMAX …………………………. 53 VYVANSE ……………………………. 47 warfarin ……………………………….. 10 WEEKLY-D ………………………….. 61 WERA (28) …………………………… 28 WIDE-SEAL DIAPHRAGM 60 …. 28 WIDE-SEAL DIAPHRAGM 65 …. 28 WIDE-SEAL DIAPHRAGM 70 …. 28 WIDE-SEAL DIAPHRAGM 75 …. 28 WIDE-SEAL DIAPHRAGM 80 …. 28 WIDE-SEAL DIAPHRAGM 85 …. 28 WIDE-SEAL DIAPHRAGM 90 ….28 WIDE-SEAL DIAPHRAGM 95 ….28 WOMEN'S 50 PLUS ADVANCED ………………………….61 WOMEN'S 50 PLUS DAILY FORMULA …………………………….61 WOMEN'S 50 PLUS MULTIVITAMIN ……………………..61 WOMEN'S DAILY FORMULA ….61 WOMENS DAILY GUMMIES ……61 WOMEN'S MULTIVITAMIN ……..61 WOMEN'S MULTIVITAMIN GUMMIES …………………………….61 WOMEN'S ONE DAILY …………..61 WOMEN'S PRENATAL PLUS DHA …………………………………….41 WYMZYA FE …………………………28 XARELTO …………………………….10 XARELTO DVT-PE TREAT 30D START …………………………..10 XELJANZ ……………………………… 6 XELJANZ XR …………………………. 6 XERESE ………………………………17 XIFAXAN ………………………………10 XIGDUO XR ………………………….13 XIIDRA …………………………………30 XOLAIR ………………………………… 7 XOPENEX HFA ……………………… 7 XTANDI ………………………………..15 XULANE ……………………………….28 XYZBAC ……………………………….61 YASMIN (28) …………………………28 YAZ (28) ……………………………….28 YELETS ……………………………….61 zaleplon ………………………………..48 ZARAH …………………………………28 ZEGALOGUE AUTOINJECTOR ……………………33 ZEGALOGUE SYRINGE …………33 ZELAPAR ……………………………..16 ZELBORAF …………………………..15 ZENATANE …………………………..50 ZENPEP ……………………………….35 ZEPBOUND ………………………….15 ZEPOSIA ………………………………25 ZEPOSIA STARTER KIT (28-DAY) …………………………………… 25 ZEPOSIA STARTER PACK (7-DAY) …………………………………… 25 zidovudine …………………………….17 ZIMHI …………………………………..11 ZINC (WITH A AND C) LOZENGES …………………………..33 zinc sulfate …………………………… 33 77 ZINC WITH VITAMINS A AND C ………………………………………… 61 ZINC-220 …………………………….. 33 ziprasidone hcl ………………… 47, 48 ziprasidone mesylate ……………… 48 ZIRGAN ………………………………. 17 ZOLADEX ……………………………. 15 ZOLINZA ……………………………… 15 zolpidem ……………………………… 48 zonisamide …………………………… 25 ZOO FRIENDS …………………….. 61 ZOVIA 1-35 (28) ……………………. 28 ZTLIDO …………………………………. 5 ZUBSOLV ……………………………. 53 ZUMANDIMINE (28) ………………. 28 ZURZUVAE ………………………….. 48 ZYLET ………………………………… 10 ZYMFENTRA ……………………….. 14 ZYPREXA RELPREVV ………….. 48 ZYVIT …………………………………. 61 Healthy Indiana Plan (HIP) Plus, HIP State Plan Plus Vigencia 2/1/2026 IN-MED-M-3083119-SPA-V.2; Primer uso: 1/14/2026 Aprobado por OMPP: 1/14/2026
Transporte mdico que no se considera de emergencia Los afiliados al Paquete A de todos nuestros programas HIP y HHW cuentan con beneficios de transporte, incluida una opcin para reembolso de millas. Todos los afiliados al Paquete A de HIP y HHW pueden tener acceso a una cantidad ilimitada de traslados que no se consideran de emergencia para visitas de atencin mdica cubiertas durante el ao, sin necesidad de solicitar autorizaciones previas. Adems, los afiliados al Paquete A de HIP y HHW tienen acceso a transporte que no se considera de emergencia.Sus amigos y familiares pueden obtener un reembolso por transportarlo. Debe inscribirse primero a los Programas de cobertura de salud de Indiana (Indiana Health Coverage Programs, IHCP) en www.in.gov/medicaid/members/540.htm. Los formularios se encuentran en el sitio web. Una vez que los formularios estn completos, comunquese con CareSource para programar el viaje.Solicite el transporte al menos dos das laborales antes de su cita. Puede llamar hasta 30 das antes de la visita para solicitar el transporte (45 a 90 das para rdenes permanentes). Solo se puede proporcionar transporte para una visita urgente si hay un conductor disponible. El proveedor deber verificar que la visita es urgente.Deber proporcionar esta informacin cuando solicite un transporte:Por dnde deben pasar a buscarlo.Su nombre y el lugar de su cita.Cualquier necesidad especfica que tenga. Esto incluye una silla de ruedas, el tamao y peso de la silla de ruedas, oxgeno o, si lo necesita, ayuda para entrar y salir del consultorio del proveedor.Tambin debe programar el transporte de su acompaante, si lo tiene.Solo debe solicitar el servicio de transporte si no tiene otra forma de trasladarse hasta el lugar. Si tiene otras formas de llegar a donde se encuentra su proveedor, debe usar estas primero. Es posible que se le solicite que use el transporte pblico si el viaje est en la ruta de un transporte pblico. Recibir pases para cubrir los costos. Si no puede tomar el transporte pblico, llame a Servicios para Afiliados para solicitar un Formulario de restriccin de uso de transporte pblico. Usted y su proveedor pueden explicar en el formulario por qu no puede usar el transporte pblico. Si cree que un conductor est infringiendo la ley en cualquier forma o que usted se encuentra en peligro, llame a la polica. Llame a Servicios para Afiliados para informar lo sucedido una vez que llegue a su destino a salvo. Cmo hacer que su viaje sea un xitoHay ciertas cosas que debe saber o que puede hacer para que su viaje sea un xito.Si no puede asistir o si se modifica la cita, llame a Servicios para Afiliados lo antes posible. Est listo cuando el conductor llegue al lugar a la hora programada. El conductor podr esperar nicamente 10 minutos. Despus de los 10 minutos, se ir y se considerar que usted no se present. Tal vez deba compartir el viaje con otras personas. Debe usar el cinturn de seguridad.El abuso verbal o fsico, no seguir las instrucciones del conductor o infringir las reglas puede impedir que obtenga transporte en el futuro.No puede fumar ni usar vapeadores en el vehculo.No coma ni beba durante el viaje.No participe de ninguna actividad ilegal ni viaje ebrio.Si tiene programado un viaje de regreso, llame a Servicios para Afiliados cuando haya finalizado su cita. El conductor tiene una hora para regresar y buscarlo. Llame al nmero de Servicios para Afiliados que se encuentra en el reverso de su tarjeta de identificacin de afiliado si tiene alguna pregunta. RR2022-IN-MED-M-132482-SP; Primer uso: 2/10/2023 Aprobado por OMPP: 2/10/2023 2022 CareSource. Todos los derechos reservados.
MEDICAID Recompensas en su camino hacia la recuperacin Una buena salud incluye a la persona en su totalidad, su cuerpo y su mente.Dado que alcanzar un buen estado de salud y mantenerse saludable puede ser todo un desafo, CareSource lo recompensar por las acciones que realice para mejorar su salud. Si est afiliado a Healthy Indiana Plan (HIP) y recibe tratamiento debido a un trastorno por abuso de sustancias (Substance Use Disorder, SUD) a travs de los programas intensivos para pacientes ambulatorios (Intensive Outpatient Program, IOP), puede ganar recompensas!1 Obtenga una recompensa de $10 por cada sesin de IOP dentro de la red y un mximo de $100.* 2 Haga un seguimiento de sus recompensas en su cuenta My CareSource . Ingrese a My CareSource.com y haga clic en el cono MyHealth (Mi salud) debajo de My Plan (Mi plan). Si no tiene una cuenta de My CareSource, visite My.CareSource.com y regstrese para tener una. Sus recompensas se agregarn a su cuenta MyHealth Rewards una vez que CareSource obtenga la confirmacin de cada una de sus sesiones de IOP. 3 Puede usar sus recompensas para obtener tarjetas de r egalo de diversas tiendas minoristas, como TJ Maxx , Home Goods , Old Navy , Panera , iTunes y mucho ms. Tambin puede guardar las recompensas, ya que se acumulan con el tiempo. Cmo ganar recompensasPuede ganar recompensas cuando toma medidas de atencin preventiva. Gane hasta $300 por ao cuando complete actividades elegibles como exmenes fsicos, exmenes odontolgicos, vacunas antigripales y ms. Si tiene una enfermedad crnica, puede ganar ms recompensas.Puede encontrar todas las recompensas a las que puede acceder en MyHealth. Si tiene pr eguntas sobre las recompensas de MyHealth, llame a Servicios para Afiliados al 1-844-607-2829 (TTY: 1-800-743-3333 o 711). Recompensas IOP Gane hasta $100 por asistir a sesiones de IOP aprobadas*. Los grupos de IOP forman parte del total de $300 que se pueden ganar entre todos los programas de incentivo. Para ganar recompensas por asistir a las sesiones de IOP debido a un SUD, su r egistro mdico debe incluir un diagnstico de SUD.Recompensas de Administracin de la AtencinCareSource tiene un departamento de Administracin de la Atencin que puede brindar educacin, apoyo e informacin sobre sus necesidades de salud, as como tambin sobre los beneficios del programa de recompensas. Participe en el programa de Administracin de la Atencin de CareSource para ganar hasta $60 por ao como parte del total de $300 que puede ganar con todos los programas de incentivo. Llame hoy al 1-844-607-2831 para inscribirse! Gane hasta $ 30Complete la evaluacin de necesidades de salud (Health Needs Screening, HNS).** Inicie sesin en My CareSource, haga clic en la pestaa Salud y luego en el enlace a la evaluacin de salud.Visite el kiosco de Pursuant Health en la farmacia de W almart de su localidad.Por telfono, llamando al 1-833-230-2011. Obien, puede completar la HNS impr esa que se incluye en su correo de nuevo afiliado. Necesita ayuda para adicciones?Llame a la Lnea directa contra las adicciones de CareSource: 1-833-674-6437 si necesita ayuda para encontrar un especialista en abuso de sustancias. No necesita una derivacin de un mdico para recibir tratamiento como paciente ambulatorio. CareSource desea que est en el camino hacia la recuperacin.Est en crisis? Llame al 9-8-8, que es la Lnea directa de Pr evencin contra el suicidio y crisis de salud mental para comunicarse con un consejero de crisis. Puede llamar las 24 horas del da, los 7 das de la semana. Tambin puede llamar a la lnea de crisis de BH al 1-833-227-3464 o (TTY: 1-800-743-3333 o 711) y hablar con un profesional con licencia capacitado en salud conductual. Estamos aqu para ayudarle cuando atraviese una crisis de salud mental o por consumo de sustancias.Tenga en cuenta:*$10 por grupo de IOP al que asista, con lo que puede sumar un total de $100 por ao calendario. Las recompensas basadas en los reclamos se registran una vez que los proveedores envan los reclamos y CareSource los procesa. A veces pueden pasar hasta cuatro semanas para que pueda visualizar las recompensas por estas actividades en su cuenta.** Para ganar $30 por completar la HNS, debe hacerlo en un plazo de 90 das desde que se afilia a CareSource.2022 CareSource. Todos los derechos reservados. RR2022-IN-MMED-2347b-SP; Primer uso: 1/24/2023Aprobado por OMPP: 1/24/2023
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