HIX - Ohio 2024

KY-EXC-M-862577

MARKETPLACE PLAN

Ohio

Drug Formulary

2024

INTRODUCTION

We are pleased to provide the 2024 CareSource Drug Formulary. The Drug Formulary is a list

of the drugs covered by CareSource.

This document is divided into three parts:

1. The Introduction – Provides important facts about the CareSource prescription drug

benefit. This section explains terms, such as network pharmacy, prior authorizations,

quantity limits, step therapy, therapeutic interchange and exceptions.

2. The Drug Formulary – Lists the drugs we cover.

3. The Index – Lists all of the covered drugs in alphabetical order. You can find the Index in

the back of this document.

PRESCRIPTION DRUG COVERAGE DETAILS

Best Medical Practices

We want to make sure our members get the safest, most cost-effective drugs for their needs.

We use evidence-based guidelines to make sure our Formulary meets best medical practices.

Network Pharmacies

CareSource provides coverage for prescription drugs and some prescription medical supplies.

CareSource contracts with pharmacies in order to provide members with a full range of

prescription benefits. Members may choose and receive prescriptions from any pharmacy that

is contracted with CareSource. These are often referred to as network pharmacies. It is

important that members receive prescriptions from network pharmacies because prescriptions

received from non-network pharmacies are generally not reimbursable or covered by

CareSource, except as otherwise required by applicable federal and state law and your

Evidence of Coverage. Accordingly, members may be responsible for the entire amount

charged by a non-network pharmacy.

Network pharmacies can include local pharmacies, mail-order pharmacies or specialty

pharmacies. To find a network pharmacy, use our online Find a Pharmacy tool under “Quick

Links” at CareSource.com/marketplace.

CareSource may also cover drugs administered in the member’s home, such as medicines

given through a home health agency.

Cost Sharing

Members may pay part of the costs of some drugs and supplies. These cost-sharing

amounts are called deductibles, copays and/or coinsurance. For some drugs, members

may pay coinsurance. Coinsurance is a percent of a drug's cost.

The Drug Formulary shows drugs in different levels or tiers. Drugs are grouped into tiers

based on the amounts that members pay.

Tiered Medications

The CareSource Formulary has up to five levels or tiers, including tiers 0, 1, 2, 3, and 4.

general, the higher the cost-sharing tier number, the higher the cost for the drug. In

general, the copay amount increases as the tier number increases. All deductibles,

coinsurance and copay amounts paid count toward members’ maximum out of-pocket

amount.

To fi

nd tier levels for drugs, go to the drug list section of this document.

Prior Authorizations

CareSource may require health partners (doctors or other providers) to send us information

about why a drug or a certain amount is needed. This is called a prior authorization request.

CareSource must approve the request before a member can get the drug. The abbreviation

“PA” is used in the Drug Formulary to show that a prior authorization is needed.

Here are some reasons for a prior authorization:

• A gener

ic or alternative drug is available.

• The drug can be misused or abused.

• The drug

requires special handling, monitoring or is available from limited shipping

locations.

• There are other drugs that must be tried first.

ior Authorization Requests

Health partners may make prior authorization requests electronically or by phone or fax. Please

all the Provider Services telephone number for your state and follow the prompts, or fax to

the Medical Management provider fax number for your state.

We may not approve a prior authorization request for a drug. If we don't, we will send the

member information about how to appeal our decision.

Quant

ity Limits

Some drugs have limits on how much can be given to a member at one time. The abbreviation

“QL” is used in the Drug Formulary to show there is a quantity limit. Quantity limits are based on

the drug makers’ recommended dosing frequencies. Patient safety is also considered.

Therapy with opioid analgesics may have quantity limits based on drug makers' recommended

dosing frequencies and/or state regulations.

Step Therapy

Members may need to try one drug before taking another. This is called Step Therapy. A

member must first try one medicine on the Formulary before another Formulary drug would be

approved for use.

areSource will cover certain drugs only if Step Therapy is used. The abbreviation “ST” is used

in the Drug Formulary to show when Step Therapy is required.

Generic Substitution and Therapeutic Interchange

A pharmacy may provide a generic drug in place of a brand-name drug. This is called generic

substitution. Members and health partners can expect the generic to produce the same effect

and have the same safety profile as the brand-name drug. This is known as therapeutic

interchange.

eneric drugs usually cost less than their brand-name equivalents.

Note to Health Partners: Generic drugs should be considered the first line of prescribing, subject

to applicable rules.

rescription generic drugs are:

• A

pproved by the U.S. Food and Drug Administration for safety and effectiveness, and

are manufactured under the same strict standards that apply to brand-name drugs.

• Tes

ted in humans to assure the generic is absorbed into the bloodstream in a similar

rate and extent compared to the brand-name drug (bioequivalence). Generics may be

different from the brand in size, color and inactive ingredients, but this does not alter

their effectiveness or ability to be absorbed just like the brand-name drugs.

• M

anufactured in the same strength and dosage form as the brand-name drugs.

• In most instances, a brand-name drug for which a generic product becomes available

will become non-Formulary, with the generic product covered in its place, upon release

of the generic product onto the market. However, the Formulary document is subject to

state- specific regulations and rules regarding generic substitution and mandatory

generic rules apply where appropriate.

Choosing a brand name drug when there is a generic available may cost you more. When a

generic is available and you choose the brand name drug, you may be responsible to pay the

cost difference between the two in addition to your copay or coinsurance. Or you could be

responsible for the entire cost of the brand.

ell Us the Medical Reasons for Exceptions

Sometimes a member may have a drug allergy or intolerance or, a certain drug may not be

effective for a member. In these cases, the member or the member’s representative may ask

for an exception to a drug listed on the Drug Formulary. The member or member’s

representative may make the request online or by calling Member Services. The member

services telephone number for your state is listed on the back of the member ID card.

CareSource then contacts the appropriate health partner. CareSource may ask the health

partner to provide written clinical documentation about why the member needs an

exception. Health partners must provide this information.

Typically, our Drug Formulary includes more than one drug for treating a condition. These

edicines are called “alternative” drugs. CareSource will generally not approve the request

for an exception if an alternative drug would be just as effective as the drug requested and

would not cause other health problems.

Specialty Pharmacy

CareSource works with Accredo Pharmacy to supply specialty medications that health

part

ners may prescribe. Accredo Pharmacy can:

• Help members get prescriptions filled or moved to Accredo Pharmacy from another

pharmacy

• Deliver members’ specialty medicines to their homes, workplaces or their doctors'

offices

• Help members learn about their specialty medications and give them support from

pecially-trained health care professionals

For more information, call Accredo Pharmacy at 1-866-231-3520. Hours are Monday

through Friday from 8 a.m. to 11 p.m. Eastern Time (ET).

Mail

Order Medications

CareSource works with Express Scripts Pharmacy to supply prescription medicines to

mbers’ homes. This could change a member’s copay amount. Express Scripts Pharmacy

can:

• Help members get prescriptions filled or moved to Express Scripts Pharmacy from another

pharmacy

• Deliver prescriptions to members’ homes, workplaces or doctors' offices.

For more information, call CareSource Member Services at 1-833-230-2099 (TTY: 711). Hours

are Monday through Friday from 7 a.m. to 7 p.m. Eastern Time.

Members may also access the express-scripts.com website through the CareSource member

portal to manage prescription refills for their specialty and mail order medications and to check

coverage. To create an account on the CareSource member portal, go to mycaresource.com.

Medications Administered in the Health Partner Setting

Medications that are administered in a health partner setting will be billed to the health plan

under your medical benefit. Such settings include a physician office, hospital outpatient

department, clinic, dialysis center, or infusion center. Prior authorization requirements

exist for many injectable medicines.

Medication Therapy Management Program

CareSource offers a Medication Therapy Management (MTM) program for all members. MTM

services allow local pharmacists to work with doctors and other prescribers to enhance quality

of care, improve medication compliance, address medication needs, and provide health care to

patients in a cost-effective manner. Members and health partners may be contacted by a

pharmacist to discuss medications. We encourage members to talk with their pharmacists

about their medications. This can help members to get the best results from the medications

they are taking.

HOW TO USE THIS DOCUMENT

Go to the Index to look up a drug by name. Drugs are listed in alphabetical order. The Index

will show the page number on which the drug is found in the Drug Formulary. Turn to that page

number to get details about the drug.

Note to Health Partners: The CareSource Drug Formulary is organized by sections. Each

section is divided by therapeutic drug class, primarily defined by mechanism of action. Products

are listed by generic name with brand name for reference only. Unless the cited drug is

available as an injectable or an exception is specifically noted, generally, all applicable dosage

forms and strengths of the drug cited are included in the document.

ADDITIONAL INFORMATION FOR HEALTH PARTNERS

The drugs represented have been reviewed and approved by a Pharmacy, Therapeutics and

Technology (PT&T) Committee for inclusion. The document is reflective of current medical

practice as of the date of review.

The information contained in this document and its appendices is provided solely for the

convenience of medical providers. We do not warrant or assure accuracy of such information

nor is it intended to be comprehensive in nature. This document is not intended to be a

substitute for the knowledge, expertise, skill and judgment of the medical provider in his or her

choice of prescription drugs. All the information in the document is provided as a reference for

drug therapy selection. Specific drug selection for an individual patient rests solely with the

prescriber.

The document is subject to state-specific regulations and rules, including, but not limited to,

those regarding generic substitution, controlled substance schedules, preference for brands and

mandatory generics whenever applicable.

We assume no responsibility for the actions or omissions of any medical provider based upon

reliance, in whole or in part, on the information contained herein. The medical provider should

consult the drug manufacturer's product literature or standard references for more detailed

information.

National guidelines can be found on the National Guideline Clearinghouse site at

www.guideline.gov.

CARESOURCE ONLINE FORMULARY SEARCH TOOLS AVAILABLE

CareSource has easy-to-use online drug formulary tools that can help you save time by quickly

looking up medications to make sure they are covered by CareSource. Also, you can check for

generic alternatives, prior authorization requirements, and any restrictions or limits that may

apply. To start using the tool, visit CareSource.com, and visit the Pharmacy page of the

appropriate line of business, and select Formulary Search Tool. You can also find CareSource

policies on the CareSource.com Health Partner Policies page.

PHARMACY AND THERAPEUTICS (P&T) COMMITTEE

The services of a Pharmacy and Therapeutics (P&T) Committee are utilized to approve safe

and clinically effective drug therapies. The P&T Committee is a multi-disciplinary committee

whose voting members include physicians and pharmacists with many different specialties.

Voting members of the P&T Committee must disclose any financial relationship or conflicts of

interest with any pharmaceutical manufacturers. The CareSource Pharmacy & Therapeutics

(P&T) Committee also includes regional member demographics in its formulary

recommendations.

DRUG LIST PRODUCT DESCRIPTIONS

To assist in understanding which specific strengths and dosage forms on the document are

covered, we have provided examples below. The general principles shown in the examples can

usually be extended to other entries in the document.

When a strength, dosage or different formulation is specified, only that specific strength, dosage

or formulation may be covered. Other strengths/dosages/formulations, including injectable

dosage forms of the reference product, are not covered. Extended-release and delayed-release

products require their own entry.

metformin Glucophage

The immediate-release product listing of Glucophage alone would not include the extended-

release product Glucophage XR.

metformin ext-rel Glucophage XR

A separate entry for Glucophage XR confirms that the extended-release product is on the

document.

Dosage forms on the document will be consistent with the category and use where listed.

neomycin/polymyxin B/hydrocortisone Cortisporin

Since Cortisporin is listed only in the OTIC section, it is limited to the OTIC solution and

suspension. From this entry the topical cream cannot be assumed to be on the list unless

there is an entry for this product in the DERMATOLOGY section of the document.

PLAN DESIGN

The document represents a closed formulary plan design. The medications listed on the

document are covered by the plan as represented. Certain medications on the list are covered if

utilization management criteria are met (i.e., Step Therapy, Prior Authorization, Quantity Limits,

etc.); requests for use of such medications outside of their listed criteria will be reviewed for

medical necessity. If a medication is not listed on the document, a Formulary exception may be

requested for coverage. Medical necessity or Formulary exception requests will be reviewed

based on drug-specific prior authorization criteria or standard non-formulary prescription

request criteria.

NOTICE

This document contains references to brand-name prescription drugs that are trademarks

or registered trademarks of pharmaceutical manufacturers.

Please be advised that this document is updated periodically and changes may

appear prior to their effective date to allow for member notification.

While we make every effort to ensure that our Drug Formulary is up-to-date, this list may

have changed since printing. For the most up-to-date information, you must use the

“Find My Prescriptions” tool on CareSource.com/marketplace, or contact Member Services at

the toll-free telephone number on your ID card to confirm the accuracy of the information

in this copy of the Drug Formulary.

The information contained in this document is proprietary. The information may not be

copied in whole or in part without written permission.

List of Abbreviations

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.

OTC: Over-the-Counter. An OTC drug is a non-prescription drug.

PA: 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 don’t get approval, we may not cover the drug.

QL: Quantity Limit. For certain drugs, the Plan limits the amount of the drug that we will cover.

ST: 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 B both treat your medical condition, we may not cover Drug B unless you try Drug A

first. If Drug A does not work for you, we will then cover Drug B.

Ohio Marketplace 2024 Drug Formulary

Table of Contents

ANTIDOTE THERAPEUTICS............................................................................................................................... 11

ANTIHISTAMINE DRUGS.....................................................................................................................................11

ANTI-INFECTIVE AGENTS.................................................................................................................................. 12

ANTINEOPLASTIC AGENTS................................................................................................................................21

ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINES..........................................................................................23

AUTONOMIC DRUGS.......................................................................................................................................... 25

BLOOD FORMATION, COAGULATION, THROMBOSIS.....................................................................................29

CARDIOVASCULAR DRUGS...............................................................................................................................31

CENTRAL NERVOUS SYSTEM AGENTS........................................................................................................... 41

DENTAL AGENTS................................................................................................................................................ 56

DEVICES...............................................................................................................................................................57

DIAGNOSTIC AGENTS........................................................................................................................................ 73

ELECTROLYTIC, CALORIC, AND WATER BALANCE........................................................................................75

ENZYMES.............................................................................................................................................................78

EYE, EAR, NOSE AND THROAT (EENT) PREPS............................................................................................... 78

GASTROINTESTINAL DRUGS............................................................................................................................ 83

HEAVY METAL ANTAGONISTS.......................................................................................................................... 86

HORMONES AND SYNTHETIC SUBSTITUTES................................................................................................. 86

IMMUNOMODULATORY AGENTS (90:00)........................................................................................................101

MISCELLANEOUS THERAPEUTIC AGENTS....................................................................................................103

NONHORMONAL CONTRACEPTIVES..............................................................................................................105

OXYTOCICS....................................................................................................................................................... 106

PHARMACEUTICAL AIDS..................................................................................................................................106

RESPIRATORY TRACT AGENTS......................................................................................................................106

SKIN AND MUCOUS MEMBRANE AGENTS.....................................................................................................111

SMOOTH MUSCLE RELAXANTS...................................................................................................................... 120

VITAMINS........................................................................................................................................................... 120

CURRENT AS OF 7/1/2024

Drug Name Tier Restrictions/Limits

ANTIDOTE THERAPEUTICS

ALCOHOL DETERRENTS (91:02)

acamprosate Tier 1

disulfiram Tier 1

ANTIDOTE THERAPEUTICS

BAQSIMI Tier 2 PA

D-PENAMINE Tier 2 PA

ED-SPAZ Tier 1

GLUCAGON (HCL) EMERGENCY KIT Tier 2 QL (2 EA per 30 days)

GLUCAGON EMERGENCY KIT (HUMAN) Tier 1

hyoscyamine sulfate oral Tier 1

hyoscyamine sulfate sublingual Tier 1

HYOSYNE Tier 1

OSCIMIN Tier 1

OSCIMIN SL Tier 1

penicillamine Tier 1 PA

phytonadione (vitamin k1) injection solution 1

mg/0.5 ml

Tier 2

phytonadione (vitamin k1) injection solution 10

mg/ml

Tier 1

phytonadione (vitamin k1) oral tablet 5 mg Tier 1 QL (10 EA per 1 FILL)

potassium iodide oral solution Tier 1

SSKI Tier 2

SYMAX-SR Tier 1

CHEMOTHERAPY

ANTIDOTES/PROTECTANTS

ELMIRON Tier 2

leucovorin calcium oral Tier 1

ANTIHISTAMINE DRUGS

ETHANOLAMINE DERIVATIVES

clemastine oral tablet Tier 1

diphenhydramine hcl oral capsule 50 mg Tier 1

diphenhydramine hcl oral elixir Tier 1

FIRST GEN. ANTIHIST. DERIVATIVES, MISC.

cyproheptadine Tier 1

FIRST GENERATION ANTIHISTAMINES

carbinoxamine maleate oral liquid Tier 1

carbinoxamine maleate oral tablet 4 mg Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

carbinoxamine maleate oral tablet 6 mg Tier 1 ST

clemastine oral tablet Tier 1

cyproheptadine Tier 1

dexchlorpheniramine maleate Tier 1

diphenhydramine hcl oral capsule 50 mg Tier 1

diphenhydramine hcl oral elixir Tier 1

PHENOTHIAZINE DERIVATIVES

promethazine oral Tier 1

promethazine rectal Tier 1

PROMETHAZINE VC Tier 1

promethazine-dm Tier 1

PROMETHEGAN Tier 1

PIPERAZINE DERIVATIVES

hydroxyzine hcl oral solution 10 mg/5 ml Tier 1

hydroxyzine hcl oral tablet Tier 1

hydroxyzine pamoate Tier 1

meclizine oral tablet 12.5 mg, 25 mg Tier 1

PROPYLAMINE DERIVATIVES

dexchlorpheniramine maleate Tier 1

hydrocodone-chlorpheniramine Tier 1

RYDEX Tier 1

SECOND GENERATION ANTIHISTAMINES

cetirizine oral solution 1 mg/ml Tier 1

desloratadine oral tablet Tier 1 ST; QL (30 EA per 30 days)

levocetirizine oral solution Tier 1

levocetirizine oral tablet Tier 1 QL (30 EA per 30 days)

ANTI-INFECTIVE AGENTS

1ST GENERATION CEPHALOSPORIN

ANTIBIOTICS

cefadroxil Tier 1

cephalexin oral capsule 250 mg, 500 mg Tier 1

cephalexin oral suspension for reconstitution Tier 1

cephalexin oral tablet 250 mg Tier 1

2ND GENERATION CEPHALOSPORIN

ANTIBIOTICS

cefprozil Tier 1

cefuroxime axetil Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

3RD GENERATION CEPHALOSPORIN

ANTIBIOTICS

cefdinir Tier 1

ADAMANTANE ANTIVIRALS

amantadine hcl Tier 1

rimantadine Tier 1

ALLYLAMINE ANTIFUNGALS

terbinafine hcl oral Tier 1 QL (1 EA per 1 day)

AMEBICIDES

metronidazole oral Tier 1

AMINOGLYCOSIDE ANTIBIOTICS

neomycin Tier 1

tobramycin in 0.225 % nacl Tier 4 PA; QL (280 ML per 30 days)

tobramycin inhalation Tier 4 PA; QL (224 ML per 30 days)

tobramycin sulfate injection recon soln Tier 1 PA

tobramycin sulfate injection solution 40 mg/ml Tier 1 PA

tobramycin with nebulizer Tier 4 PA; QL (280 ML per 30 days)

AMINOPENICILLIN ANTIBIOTICS

amoxicil-clarithromy-lansopraz Tier 1 QL (112 EA per 30 days)

amoxicillin Tier 1

amoxicillin-pot clavulanate Tier 1

ampicillin Tier 1

ANTHELMINTICS

albendazole Tier 1 PA; QL (120 EA per 30 days)

EMVERM Tier 2 QL (6 EA per 30 days)

ivermectin oral Tier 1 QL (20 EA per 30 days)

praziquantel Tier 1

ANTIFUNGALS, MISCELLANEOUS

griseofulvin microsize Tier 1

griseofulvin ultramicrosize Tier 1

potassium iodide oral solution Tier 1

SSKI Tier 2

ANTILEPROSY AGENTS

dapsone Tier 1

ANTIMALARIALS

atovaquone-proguanil oral tablet 250-100 mg Tier 1 QL (60 EA per 180 days)

atovaquone-proguanil oral tablet 62.5-25 mg Tier 1 QL (180 EA per 180 days)

chloroquine phosphate Tier 1 QL (1000 EA per 1 day)

COARTEM Tier 2 QL (24 EA per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

doxycycline hyclate oral capsule Tier 1

doxycycline hyclate oral tablet 100 mg Tier 1

doxycycline monohydrate oral capsule 100 mg,

50 mg, 75 mg

Tier 1

doxycycline monohydrate oral capsule 150 mg Tier 1 ST

doxycycline monohydrate oral suspension for

reconstitution

Tier 1

doxycycline monohydrate oral tablet 100 mg, 50

Tier 1

hydroxychloroquine Tier 1

mefloquine Tier 1 QL (13 EA per 180 days)

primaquine Tier 1 QL (120 EA per 180 days)

pyrimethamine Tier 4 PA; QL (3 EA per 1 day)

quinidine sulfate Tier 1

quinine sulfate Tier 1 QL (42 EA per 30 days)

tetracycline Tier 1

ANTIPROTOZOALS, CRYPTOSPORIDIOSIS

nitazoxanide Tier 1 QL (14 EA per 30 days)

ANTIPROTOZOALS, MISCELLANEOUS

dapsone topical Tier 1

ANTIPROTOZOALS, P JIROVECII

PNEUMONIA

atovaquone Tier 1

pentamidine inhalation Tier 1 PA; QL (1 EA per 28 days)

ANTIPROTOZOALS,NITROIMIDAZOLE-

DERIVATIVE

tinidazole oral tablet 250 mg Tier 1 QL (40 EA per 23 days)

tinidazole oral tablet 500 mg Tier 1 QL (20 EA per 23 days)

ANTIRETROVIRALS, MISCELLANEOUS

TYBOST Tier 2

ANTITUBERCULOSIS AGENTS

CIPRO HC Tier 3

ciprofloxacin Tier 1

ciprofloxacin hcl oral Tier 1

clarithromycin Tier 1

cycloserine Tier 1

ethambutol Tier 1

isoniazid oral Tier 1

levofloxacin ophthalmic (eye) Tier 1

levofloxacin oral Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

PASER Tier 2 PA

pretomanid Tier 2 PA; QL (1 EA per 1 day)

PRIFTIN Tier 3

pyrazinamide Tier 1

rifabutin Tier 1

rifampin oral Tier 1

AZOLE ANTIFUNGALS

CRESEMBA INTRAVENOUS Tier 3 PA; QL (1 Vial per 1 day)

CRESEMBA ORAL CAPSULE 186 MG Tier 3 PA; QL (2 EA per 1 day)

CRESEMBA ORAL CAPSULE 74.5 MG Tier 3 PA; QL (5 EA per 1 day)

fluconazole oral suspension for reconstitution Tier 1

fluconazole oral tablet 100 mg, 200 mg, 50 mg Tier 1

fluconazole oral tablet 150 mg Tier 1 QL (2 EA per 30 days)

ketoconazole oral Tier 1

ketoconazole topical cream Tier 1 QL (60 GM per 21 days)

ketoconazole topical shampoo Tier 1 QL (120 ML per 21 days)

voriconazole oral Tier 1 PA

CORONAVIRUS (COVID-19)

PAXLOVID ORAL TABLETS,DOSE PACK 150-

100 MG

Tier 2 QL (30 EA per 180 days)

PAXLOVID ORAL TABLETS,DOSE PACK 300

MG (150 MG X 2)-100 MG

Tier 2 QL (30 Tabs per 180 days)

ENDONUCLEASE INHIBITORS

XOFLUZA ORAL TABLET 20 MG Tier 2

XOFLUZA ORAL TABLET 40 MG Tier 2 QL (4 EA per 365 days)

ERYTHROMYCIN ANTIBIOTICS

ERYTHROCIN (AS STEARATE) Tier 1

erythromycin ethylsuccinate Tier 1

erythromycin oral Tier 1

GLYCOPEPTIDE ANTIBIOTICS

FIRVANQ ORAL RECON SOLN 25 MG/ML Tier 2 PA; QL (300 ML per 30 days)

FIRVANQ ORAL RECON SOLN 50 MG/ML Tier 2 PA; QL (450 ML per 30 days)

vancomycin oral capsule 125 mg Tier 1 PA; QL (40 EA per 30 days)

vancomycin oral capsule 250 mg Tier 1 PA; QL (80 EA per 30 days)

vancomycin oral recon soln 25 mg/ml Tier 1 PA; QL (300 ML per 30 days)

vancomycin oral recon soln 50 mg/ml Tier 1 PA; QL (450 ML per 30 days)

HCV POLYMERASE INHIBITOR ANTIVIRALS

sofosbuvir-velpatasvir Tier 1 PA; QL (1 EA per 1 day)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

HCV PROTEASE INHIBITOR ANTIVIRALS

MAVYRET ORAL TABLET Tier 4 PA; QL (3 EA per 1 day)

ZEPATIER Tier 4 PA; QL (28 EA per 28 days)

HCV REPLICATION COMPLEX INHIBITORS

MAVYRET ORAL TABLET Tier 4 PA; QL (3 EA per 1 day)

sofosbuvir-velpatasvir Tier 1 PA; QL (1 EA per 1 day)

ZEPATIER Tier 4 PA; QL (28 EA per 28 days)

HIV ENTRY AND FUSION INHIBITORS

maraviroc oral tablet 150 mg Tier 1 QL (2 EA per 1 day)

maraviroc oral tablet 300 mg Tier 1 QL (4 EA per 1 day)

SELZENTRY ORAL SOLUTION Tier 2 QL (1840 ML per 30 days)

HIV INTEGRASE INHIBITOR

ANTIRETROVIRALS

BIKTARVY ORAL TABLET 30-120-15 MG Tier 2

BIKTARVY ORAL TABLET 50-200-25 MG Tier 2 QL (1 EA per 1 day)

DOVATO Tier 2 QL (1 EA per 1 day)

GENVOYA Tier 2 QL (1 EA per 1 day)

ISENTRESS ORAL POWDER IN PACKET Tier 2 QL (2 EA per 1 day)

ISENTRESS ORAL TABLET Tier 2 QL (4 EA per 1 day)

ISENTRESS ORAL TABLET,CHEWABLE Tier 2 QL (6 EA per 1 day)

JULUCA Tier 2 QL (1 EA per 1 day)

STRIBILD Tier 2 QL (1 EA per 1 day)

TRIUMEQ Tier 2 PA; QL (1 EA per 1 day)

HIV NONNUCLEOSIDE REV.TRANSCRIP.

INHIB.

COMPLERA Tier 2 QL (1 EA per 1 day)

DELSTRIGO Tier 2 QL (1 EA per 1 day)

efavirenz oral capsule Tier 1 QL (3 EA per 1 day)

efavirenz oral tablet Tier 1 QL (1 EA per 1 day)

efavirenz-lamivu-tenofov disop Tier 1

etravirine oral tablet 100 mg Tier 1 QL (4 EA per 1 day)

etravirine oral tablet 200 mg Tier 1 QL (2 EA per 1 day)

JULUCA Tier 2 QL (1 EA per 1 day)

nevirapine oral suspension Tier 1 QL (40 ML per 1 day)

nevirapine oral tablet Tier 1 QL (2 EA per 1 day)

nevirapine oral tablet extended release 24 hr 100

Tier 1 QL (3 EA per 1 day)

nevirapine oral tablet extended release 24 hr 400

Tier 1 QL (1 EA per 1 day)

ODEFSEY Tier 2 QL (1 EA per 1 day)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

PIFELTRO Tier 2 QL (1 EA per 1 day)

HIV NUCLEOSIDE, NUCLEOTIDE RT

INHIBITORS

abacavir oral solution Tier 1 QL (30 ML per 1 day)

abacavir oral tablet Tier 1 QL (2 EA per 1 day)

abacavir-lamivudine Tier 1 QL (1 EA per 1 day)

BIKTARVY ORAL TABLET 30-120-15 MG Tier 2

BIKTARVY ORAL TABLET 50-200-25 MG Tier 2 QL (1 EA per 1 day)

COMPLERA Tier 2 QL (1 EA per 1 day)

DELSTRIGO Tier 2 QL (1 EA per 1 day)

DESCOVY ORAL TABLET 120-15 MG Tier 2 ST; QL (30 Tablets per 30 days)

DESCOVY ORAL TABLET 200-25 MG Tier 2 ST; QL (1 Tablets per 1 day)

DOVATO Tier 2 QL (1 EA per 1 day)

efavirenz-lamivu-tenofov disop Tier 1

emtricitabine Tier 1 QL (1 EA per 1 day)

emtricitabine-tenofovir (tdf) Tier 1 QL (1 EA per 1 day)

EMTRIVA ORAL SOLUTION Tier 2 QL (680 ML per 30 days)

GENVOYA Tier 2 QL (1 EA per 1 day)

lamivudine oral solution Tier 1 QL (30 ML per 1 day)

lamivudine oral tablet 100 mg Tier 1

lamivudine oral tablet 150 mg Tier 1 QL (2 EA per 1 day)

lamivudine oral tablet 300 mg Tier 1 QL (1 EA per 1 day)

lamivudine-zidovudine Tier 1 QL (2 EA per 1 day)

ODEFSEY Tier 2 QL (1 EA per 1 day)

STRIBILD Tier 2 QL (1 EA per 1 day)

SYMTUZA Tier 2 QL (1 EA per 1 day)

tenofovir disoproxil fumarate Tier 1 QL (1 EA per 1 day)

TRIUMEQ Tier 2 PA; QL (1 EA per 1 day)

VIREAD ORAL POWDER Tier 2 QL (8 GM per 1 day)

VIREAD ORAL TABLET 150 MG, 200 MG, 250

Tier 2 QL (1 EA per 1 day)

HIV PROTEASE INHIBITOR

ANTIRETROVIRALS

APTIVUS Tier 2 QL (4 EA per 1 day)

atazanavir oral capsule 150 mg Tier 1 QL (1 EA per 1 day)

atazanavir oral capsule 200 mg Tier 1 QL (2 EA per 1 day)

atazanavir oral capsule 300 mg Tier 1

darunavir oral tablet 600 mg Tier 1 QL (2 EA per 1 day)

darunavir oral tablet 800 mg Tier 1 QL (1 EA per 1 day)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

EVOTAZ Tier 2 QL (1 EA per 1 day)

fosamprenavir Tier 1 QL (2 EA per 1 day)

lopinavir-ritonavir oral solution Tier 1 QL (13 ML per 1 day)

lopinavir-ritonavir oral tablet 100-25 mg Tier 1 QL (8 EA per 1 day)

lopinavir-ritonavir oral tablet 200-50 mg Tier 1 QL (4 EA per 1 day)

NORVIR ORAL POWDER IN PACKET Tier 2 QL (6 EA per 180 days)

PREZCOBIX Tier 2 QL (1 EA per 1 day)

PREZISTA ORAL SUSPENSION Tier 2 QL (1 ML per 1 day)

PREZISTA ORAL TABLET 150 MG Tier 2 QL (6 EA per 1 day)

PREZISTA ORAL TABLET 75 MG Tier 2 QL (10 EA per 1 day)

ritonavir Tier 1

SYMTUZA Tier 2 QL (1 EA per 1 day)

VIRACEPT ORAL TABLET 250 MG Tier 2 QL (10 EA per 1 day)

VIRACEPT ORAL TABLET 625 MG Tier 2 QL (4 EA per 1 day)

INTERFERON ANTIVIRALS

PEGASYS SUBCUTANEOUS SOLUTION Tier 4 PA; QL (4 ML per 28 days)

PEGASYS SUBCUTANEOUS SYRINGE Tier 4 PA; QL (2 ML per 28 days)

LINCOMYCIN ANTIBIOTICS

CLEOCIN VAGINAL SUPPOSITORY Tier 2

CLINDACIN ETZ TOPICAL SWAB Tier 1

clindamycin hcl Tier 1

clindamycin palmitate hcl Tier 1

CLINDAMYCIN PEDIATRIC Tier 1

clindamycin phosphate topical gel Tier 1 QL (120 GM per 30 days)

clindamycin phosphate topical gel, once daily Tier 1 QL (150 ML per 30 days)

clindamycin phosphate topical lotion Tier 1 QL (120 ML per 30 days)

clindamycin phosphate topical solution Tier 1 QL (120 ML per 30 days)

clindamycin phosphate vaginal Tier 1

clindamycin-benzoyl peroxide topical gel Tier 1

clindamycin-benzoyl peroxide topical gel with

pump 1-5 %, 1.2 %(1 % base) -3.75 %

Tier 1

clindamycin-tretinoin Tier 1

MONOBACTAM ANTIBIOTICS

CAYSTON Tier 4 PA; QL (84 ML per 30 days)

NATURAL PENICILLIN ANTIBIOTICS

penicillin v potassium Tier 1

NEURAMINIDASE INHIBITOR ANTIVIRALS

oseltamivir oral capsule 30 mg Tier 1 QL (40 EA per 365 days)

oseltamivir oral capsule 45 mg, 75 mg Tier 1 QL (20 EA per 365 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

oseltamivir oral suspension for reconstitution Tier 1 QL (360 ML per 365 days)

NITROIMIDAZOLE DERIVATIVE,

TRYPANOCIDAL

benznidazole Tier 2 QL (720 EA per 365 days)

NITROIMIDAZOLE DERIVATIVES, MISC

metronidazole oral Tier 1

metronidazole topical cream Tier 1 QL (45 GM per 30 days)

metronidazole topical gel 0.75 % Tier 1 QL (45 GM per 30 days)

metronidazole topical lotion Tier 1 QL (59 ML per 30 days)

metronidazole vaginal gel 0.75 % (37.5mg/5

gram)

Tier 1 QL (70 GM per 30 days)

ROSADAN TOPICAL CREAM Tier 1 QL (45 GM per 30 days)

ROSADAN TOPICAL GEL Tier 1 QL (45 GM per 30 days)

VANDAZOLE Tier 1 QL (70 GM per 30 days)

NUCLEOSIDE AND NUCLEOTIDE

ANTIVIRALS

acyclovir oral capsule Tier 1

acyclovir oral suspension 200 mg/5 ml Tier 1

acyclovir oral tablet Tier 1

acyclovir topical ointment Tier 1 ST; QL (30 GM per 30 days)

adefovir Tier 1

BARACLUDE ORAL SOLUTION Tier 2 PA

COMPLERA Tier 2 QL (1 EA per 1 day)

DESCOVY ORAL TABLET 120-15 MG Tier 2

DESCOVY ORAL TABLET 200-25 MG Tier 2 ST; QL (1 EA per 1 day)

emtricitabine-tenofovir (tdf) Tier 1 QL (1 EA per 1 day)

entecavir Tier 1 PA

famciclovir oral tablet 125 mg, 500 mg Tier 1 QL (21 EA per 30 days)

famciclovir oral tablet 250 mg Tier 1 QL (60 EA per 30 days)

LAGEVRIO (EUA) Tier 2 QL (40 EA per 180 days)

ODEFSEY Tier 2 QL (1 EA per 1 day)

ribavirin oral Tier 4

SYMTUZA Tier 2 QL (1 EA per 1 day)

valacyclovir Tier 1 QL (30 EA per 30 days)

OTHER MACROLIDE ANTIBIOTICS

amoxicil-clarithromy-lansopraz Tier 1 QL (112 EA per 30 days)

azithromycin oral Tier 1

clarithromycin Tier 1

DIFICID ORAL SUSPENSION FOR

RECONSTITUTION

Tier 2

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

DIFICID ORAL TABLET Tier 2 PA; QL (20 EA per 10 days)

OXAZOLIDINONE ANTIBIOTICS

linezolid Tier 1 PA

PENICILLINASE-RESISTANT PENICILLINS

dicloxacillin Tier 1

POLYENE ANTIFUNGALS

nystatin oral Tier 1

POLYMYXIN ANTIBIOTICS

polymyxin b sulf-trimethoprim Tier 1

PYRIMIDINE ANTIFUNGALS

flucytosine Tier 1

QUINOLONE ANTIBIOTICS

CIPRO HC Tier 3

ciprofloxacin Tier 1

ciprofloxacin hcl Tier 1

ciprofloxacin-dexamethasone Tier 1 ST

ciprofloxacin-fluocinolone Tier 2

levofloxacin ophthalmic (eye) Tier 1

levofloxacin oral Tier 1

ofloxacin ophthalmic (eye) Tier 1 QL (10 ML per 30 days)

ofloxacin oral Tier 1 QL (2 EA per 1 day)

ofloxacin otic (ear) Tier 1

RIFAMYCIN ANTIBIOTICS

PRIFTIN Tier 3

rifabutin Tier 1

rifampin oral Tier 1

XIFAXAN ORAL TABLET 200 MG Tier 2 PA; QL (9 EA per 30 days)

XIFAXAN ORAL TABLET 550 MG Tier 2 PA; QL (60 EA per 30 days)

SULFONAMIDE ANTIBIOTICS (SYSTEMIC)

sulfadiazine Tier 1

sulfamethoxazole-trimethoprim oral Tier 1

sulfasalazine Tier 1

SULFATRIM Tier 1

TETRACYCLINE ANTIBIOTICS

demeclocycline Tier 1 PA

doxycycline hyclate oral capsule Tier 1

doxycycline hyclate oral tablet 100 mg Tier 1

doxycycline monohydrate oral capsule 100 mg,

50 mg, 75 mg

Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

doxycycline monohydrate oral capsule 150 mg Tier 1 ST

doxycycline monohydrate oral suspension for

reconstitution

Tier 1

doxycycline monohydrate oral tablet 100 mg, 50

Tier 1

minocycline oral capsule Tier 1

minocycline oral tablet Tier 1

tetracycline Tier 1

URINARY ANTI-INFECTIVES

nitrofurantoin macrocrystal Tier 1

nitrofurantoin monohyd/m-cryst Tier 1

nitrofurantoin oral suspension 25 mg/5 ml Tier 1

trimethoprim Tier 1

URETRON D-S Tier 1

URO-SP Tier 1

ANTINEOPLASTIC AGENTS

abiraterone oral tablet 250 mg Tier 4 PA; QL (120 EA per 30 days)

anastrozole Tier 1

bexarotene oral Tier 4 PA

bexarotene topical Tier 4 PA; QL (60 GM per 30 days)

bicalutamide Tier 1

capecitabine Tier 4 PA

CAPRELSA ORAL TABLET 100 MG Tier 4 PA; QL (60 EA per 30 days)

CAPRELSA ORAL TABLET 300 MG Tier 4 PA; QL (30 EA per 30 days)

COMETRIQ ORAL CAPSULE 100 MG/DAY(80

MG X1-20 MG X1)

Tier 4 PA

cyclophosphamide oral capsule Tier 1 PA

ERIVEDGE Tier 4 PA; QL (30 EA per 30 days)

erlotinib oral tablet 100 mg, 150 mg Tier 4 PA; QL (30 EA per 30 days)

erlotinib oral tablet 25 mg Tier 4 PA; QL (60 EA per 30 days)

etoposide oral Tier 1

exemestane Tier 1

fluorouracil topical cream 5 % Tier 1 QL (3 GM per 1 day)

fluorouracil topical solution Tier 1 QL (10 ML per 30 days)

GILOTRIF Tier 4 PA; QL (30 EA per 30 days)

hydroxyurea Tier 1

IBRANCE Tier 4 PA; QL (21 EA per 30 days)

imatinib oral tablet 100 mg Tier 4 PA; QL (180 EA per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

imatinib oral tablet 400 mg Tier 4 PA; QL (60 EA per 30 days)

IMBRUVICA ORAL CAPSULE Tier 4 PA; QL (28 EA per 28 days)

IMBRUVICA ORAL TABLET Tier 4 PA; QL (28 EA per 28 days)

INLYTA ORAL TABLET 1 MG Tier 4 PA; QL (180 EA per 30 days)

INLYTA ORAL TABLET 5 MG Tier 4 PA; QL (120 EA per 30 days)

JAKAFI Tier 4 PA; QL (60 EA per 30 days)

lapatinib Tier 4 PA; QL (180 EA per 30 days)

lenalidomide Tier 4 PA; QL (30 EA per 30 days)

LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG

X 1), 14 MG/DAY(10 MG X 1-4 MG X 1), 18

MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10

MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8

MG/DAY (4 MG X 2)

Tier 4 PA

letrozole Tier 1

LEUKERAN Tier 2 PA

LYSODREN Tier 4

MATULANE Tier 4

megestrol oral suspension 400 mg/10 ml (10 ml),

400 mg/10 ml (40 mg/ml), 625 mg/5 ml (125

mg/ml)

Tier 1

megestrol oral tablet Tier 1

MEKINIST ORAL TABLET 0.5 MG Tier 4 PA; QL (90 EA per 30 days)

MEKINIST ORAL TABLET 2 MG Tier 4 PA; QL (30 EA per 30 days)

mercaptopurine Tier 1

methotrexate sodium oral Tier 1

MYLERAN Tier 2 PA

nilutamide Tier 1 PA

OGSIVEO Tier 4 QL (3 EA per 1 day)

pazopanib Tier 4 PA; QL (120 EA per 30 days)

PEGASYS SUBCUTANEOUS SOLUTION Tier 4 PA; QL (4 ML per 28 days)

PEGASYS SUBCUTANEOUS SYRINGE Tier 4 PA; QL (2 ML per 28 days)

POMALYST Tier 4 PA

REVLIMID Tier 4 PA; QL (30 EA per 30 days)

sorafenib Tier 4 PA; QL (120 EA per 30 days)

sunitinib malate oral capsule 12.5 mg Tier 4 PA; QL (90 EA per 30 days)

sunitinib malate oral capsule 25 mg, 37.5 mg, 50

Tier 4 PA; QL (30 EA per 30 days)

TAFINLAR ORAL CAPSULE Tier 4 PA; QL (120 EA per 30 days)

tamoxifen Tier 1

temozolomide Tier 4 PA

toremifene Tier 1 PA

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

tretinoin (antineoplastic) Tier 1

TREXALL Tier 2

valrubicin Tier 4 PA

VERZENIO Tier 4 PA; QL (60 EA per 30 days)

VOTRIENT Tier 4 PA; QL (120 EA per 30 days)

ZELBORAF Tier 4 PA; QL (240 EA per 30 days)

ZOLINZA Tier 4 PA

ANTITOXINS,IMMUNE

GLOB,TOXOIDS,VACCINES

ANTITOXINS AND IMMUNE GLOBULINS

RHOGAM ULTRA-FILTERED PLUS Tier 2

TOXOIDS

ADACEL(TDAP ADOLESN/ADULT)(PF) Tier 2

BOOSTRIX TDAP Tier 2

DAPTACEL (DTAP PEDIATRIC) (PF) Tier 2

INFANRIX (DTAP) (PF) Tier 2

PEDIARIX (PF) Tier 2

TDVAX Tier 2

TENIVAC (PF) Tier 2

VAXELIS (PF) Tier 2

VACCINES

ABRYSVO (PF) Tier 2

ACTHIB (PF) Tier 2

AREXVY (PF) Tier 2

AREXVY ADJUVANT COMPONENT (PF) Tier 2

AREXVY ANTIGEN COMPONENT Tier 2

bcg vaccine, live (pf) Tier 2

BEXSERO Tier 2

BIOTHRAX Tier 2

DENGVAXIA (PF) Tier 2

ENGERIX-B (PF) Tier 2

ENGERIX-B PEDIATRIC (PF) Tier 2

GARDASIL 9 (PF) Tier 2

HAVRIX (PF) Tier 2

HEPLISAV-B (PF) Tier 2

HIBERIX (PF) Tier 2

IMOVAX RABIES VACCINE (PF) Tier 2

IPOL Tier 2

IXCHIQ (PF) Tier 2

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

IXIARO (PF) Tier 2

JYNNEOS (PF) Tier 2

KINRIX (PF) Tier 2

MENQUADFI (PF) Tier 2

MENVEO A-C-Y-W-135-DIP (PF) Tier 2

M-M-R II (PF) Tier 2

MODERNA COVID 23-24(6M-11Y)PF Tier 2

QL (3 TREATMENT COURSE per

365 days)

NOVAVAX COVID 2023-24(PF)(EUA) Tier 2

QL (3 TREATMENT COURSE per

365 days)

PEDIARIX (PF) Tier 2

PEDVAX HIB (PF) Tier 2

PENBRAYA (PF) Tier 2

PENTACEL (PF) Tier 2

PENTACEL ACTHIB COMPONENT (PF) Tier 2

PNEUMOVAX-23 Tier 2

PREHEVBRIO (PF) Tier 2

PREVNAR 20 (PF) Tier 2

PRIORIX (PF) Tier 2

PROQUAD (PF) Tier 2

QUADRACEL (PF) Tier 2

RABAVERT (PF) Tier 2

RECOMBIVAX HB (PF) Tier 2

ROTARIX Tier 2

ROTATEQ VACCINE Tier 2

SHINGRIX (PF) Tier 2

SPIKEVAX 2023-2024(12Y UP)(PF) Tier 2

QL (3 TREATMENT COURSE per

365 days)

STAMARIL (PF) Tier 2

TRUMENBA Tier 2

TWINRIX (PF) Tier 2

TYPHIM VI Tier 2

VAQTA (PF) Tier 2

VARIVAX (PF) Tier 2

VAXCHORA VACCINE Tier 2

VAXELIS (PF) Tier 2

VAXNEUVANCE (PF) Tier 2

VIVOTIF Tier 2

YF-VAX (PF) Tier 2

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

AUTONOMIC DRUGS

ALPHA- AND BETA-ADRENERGIC AGONISTS

brompheniramine-pseudoeph-dm Tier 1

epinephrine injection auto-injector 0.15 mg/0.15

Tier 2 QL (2 EA per 30 days)

epinephrine injection auto-injector 0.15 mg/0.3

ml, 0.3 mg/0.3 ml

Tier 1 QL (2 EA per 30 days)

GUAIFENESIN DAC Tier 1

RYDEX Tier 1

ALPHA-ADRENERGIC AGONISTS

clonidine Tier 1 QL (4 EA per 30 days)

clonidine hcl oral tablet 0.1 mg, 0.2 mg Tier 1 QL (10 EA per 1 day)

clonidine hcl oral tablet 0.3 mg Tier 1 QL (8 EA per 1 day)

clonidine hcl oral tablet extended release 12 hr Tier 1 QL (4 EA per 1 day)

methyldopa Tier 1

midodrine Tier 1

PROMETHAZINE VC Tier 1

ANTIMUSCARINICS/ANTISPASMODICS

ATROVENT HFA Tier 2 QL (26 GM per 30 days)

chlordiazepoxide-clidinium Tier 1

COMBIVENT RESPIMAT Tier 2 QL (8 GM per 30 days)

dicyclomine oral Tier 1

diphenoxylate-atropine oral tablet Tier 1

ED-SPAZ Tier 1

glycopyrrolate oral solution Tier 1 PA

glycopyrrolate oral tablet 1 mg, 2 mg Tier 1

HYDROMET Tier 1 QL (4 ML per 1 day)

hyoscyamine sulfate oral Tier 1

hyoscyamine sulfate sublingual Tier 1

HYOSYNE Tier 1

ipratropium bromide inhalation Tier 1 QL (10 ML per 1 day)

ipratropium-albuterol Tier 1 QL (540 ML per 30 days)

methscopolamine Tier 1

OSCIMIN Tier 1

OSCIMIN SL Tier 1

SPIRIVA RESPIMAT Tier 2 QL (4 GM per 30 days)

STIOLTO RESPIMAT Tier 2 QL (4 GM per 30 days)

SYMAX-SR Tier 1

tiotropium bromide Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

ANTIPARKINSONIAN AGENTS

amantadine hcl Tier 1

benztropine oral Tier 1

trihexyphenidyl Tier 1

CENTRALLY ACTING SKELETAL MUSCLE

RELAXNT

carisoprodol oral tablet 350 mg Tier 1

carisoprodol-aspirin-codeine Tier 1

chlorzoxazone oral tablet 500 mg Tier 1

cyclobenzaprine oral tablet 10 mg, 5 mg Tier 1

CYCLOTENS STARTER Tier 2

metaxalone oral tablet 800 mg Tier 1

methocarbamol oral tablet 500 mg, 750 mg Tier 1

tizanidine oral tablet Tier 1

DIRECT-ACTING SKELETAL MUSCLE

RELAXANTS

dantrolene oral Tier 1

GABA-DERIVATIVE SKELETAL MUSCLE

RELAXANT

baclofen oral suspension Tier 1

baclofen oral tablet 10 mg, 20 mg, 5 mg Tier 1

INDIRECT-ACTING SKELETAL MUSCLE

RELAXANT

orphenadrine citrate oral Tier 1

NON-SEL. BETA-ADRENERGIC BLOCKING

AGENTS

carvedilol Tier 1

labetalol oral Tier 1

propranolol oral Tier 1

propranolol-hydrochlorothiazid Tier 1

SOTALOL AF Tier 1

sotalol oral Tier 1

timolol maleate oral Tier 1

NON-SEL.ALPHA-1-ADRENERGIC BLOCKING

AGTS

doxazosin oral tablet 1 mg, 2 mg, 4 mg Tier 1 QL (30 EA per 30 days)

doxazosin oral tablet 8 mg Tier 1 QL (60 EA per 30 days)

prazosin Tier 1

terazosin oral capsule 1 mg, 2 mg, 5 mg Tier 1 QL (30 EA per 30 days)

terazosin oral capsule 10 mg Tier 1 QL (60 EA per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

NON-SEL.ALPHA-ADRENERGIC BLOCKING

AGENTS

dihydroergotamine nasal Tier 1 ST; QL (8 ML per 30 days)

ergoloid Tier 1 PA

ergotamine-caffeine Tier 1

phenoxybenzamine Tier 1

PARASYMPATHOMIMETIC (CHOLINERGIC

AGENTS)

bethanechol chloride Tier 1

cevimeline Tier 1 ST

donepezil oral tablet 10 mg, 5 mg Tier 1

galantamine Tier 1

pilocarpine hcl oral Tier 1

pyridostigmine bromide oral syrup Tier 1

pyridostigmine bromide oral tablet 60 mg Tier 1

pyridostigmine bromide oral tablet extended

release

Tier 1

rivastigmine tartrate Tier 1

SELECTIVE ALPHA-1-ADRENERGIC

BLOCK.AGENT

alfuzosin Tier 1

carvedilol Tier 1

dutasteride-tamsulosin Tier 1 ST

labetalol oral Tier 1

silodosin Tier 1

tamsulosin Tier 1

SELECTIVE BETA-2-ADRENERGIC

AGONISTS

albuterol sulfate inhalation hfa aerosol inhaler Tier 1 QL (17 GM per 30 days)

albuterol sulfate inhalation solution for

nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg

/3 ml (0.083 %)

Tier 1 QL (375 ML per 30 days)

albuterol sulfate inhalation solution for

nebulization 2.5 mg/0.5 ml

Tier 1 QL (2 EA per 1 day)

albuterol sulfate inhalation solution for

nebulization 5 mg/ml

Tier 1 QL (2 ML per 1 day)

albuterol sulfate oral Tier 1

BREYNA Tier 1

budesonide-formoterol Tier 2 ST; QL (11 GM per 30 days)

COMBIVENT RESPIMAT Tier 2 QL (8 GM per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

DULERA INHALATION HFA AEROSOL

INHALER 100-5 MCG/ACTUATION

Tier 2 ST; QL (1 GM per 30 days)

DULERA INHALATION HFA AEROSOL

INHALER 200-5 MCG/ACTUATION, 50-5

MCG/ACTUATION

Tier 2 ST; QL (13 GM per 30 days)

fluticasone furoate-vilanterol Tier 2 ST; QL (60 EA per 30 days)

fluticasone propion-salmeterol inhalation aerosol

powdr breath activated

Tier 2 ST; QL (1 EA per 30 days)

fluticasone propion-salmeterol inhalation blister

with device

Tier 1 QL (1 EA per 30 days)

formoterol fumarate Tier 1 QL (120 ML per 30 days)

ipratropium-albuterol Tier 1 QL (540 ML per 30 days)

levalbuterol tartrate Tier 2 QL (30 GM per 30 days)

SEREVENT DISKUS Tier 2 QL (60 EA per 30 days)

STIOLTO RESPIMAT Tier 2 QL (4 GM per 30 days)

STRIVERDI RESPIMAT Tier 2 QL (4 GM per 30 days)

terbutaline oral Tier 1

SELECTIVE BETA-ADRENERGIC BLOCKING

AGENT

acebutolol Tier 1

atenolol Tier 1

atenolol-chlorthalidone Tier 1

bisoprolol fumarate Tier 1

bisoprolol-hydrochlorothiazide Tier 1

metoprolol succinate Tier 1

metoprolol ta-hydrochlorothiaz Tier 1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50

Tier 1

SMOKING CESSATION AGENTS

CHANTIX Tier 2

CHANTIX CONTINUING MONTH BOX Tier 2

CHANTIX STARTING MONTH BOX Tier 2

NICODERM CQ Tier 2 QL (180 EA per 365 days)

NICORETTE Tier 2 QL (180 EA per 365 days)

nicotine Tier 1 QL (180 EA per 365 days)

nicotine (polacrilex) buccal gum Tier 1

nicotine (polacrilex) buccal lozenge Tier 1 QL (180 EA per 365 days)

nicotine (polacrilex) buccal mini lozenge Tier 1 QL (180 EA per 365 days)

NICOTROL NS Tier 2 QL (180 ML per 365 days)

QUIT 2 Tier 1 QL (180 EA per 365 days)

QUIT 4 Tier 1 QL (180 EA per 365 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

STOP SMOKING AID Tier 1 QL (180 EA per 365 days)

varenicline Tier 1

VIVITROL Tier 4 QL (1 EA per 30 days)

BLOOD FORMATION, COAGULATION,

THROMBOSIS

ANTICOAGULANTS, MISCELLANEOUS

ACD SOLUTION A Tier 2

ACD-A Tier 2

anticoag citrate phos dextrose Tier 2

COUMARIN DERIVATIVES

JANTOVEN Tier 1

warfarin Tier 1

DIRECT FACTOR XA INHIBITORS

ELIQUIS Tier 2

ELIQUIS DVT-PE TREAT 30D START Tier 2

XARELTO DVT-PE TREAT 30D START Tier 2 QL (51 EA per 30 days)

XARELTO ORAL SUSPENSION FOR

RECONSTITUTION

Tier 2 PA

XARELTO ORAL TABLET Tier 2

HEMATOPOIETIC AGENTS

PROMACTA ORAL TABLET 12.5 MG Tier 4 PA; QL (90 EA per 30 days)

PROMACTA ORAL TABLET 25 MG Tier 4 PA; QL (30 EA per 30 days)

PROMACTA ORAL TABLET 50 MG, 75 MG Tier 4 PA; QL (60 EA per 30 days)

ZARXIO Tier 4 PA

HEMORRHEOLOGIC AGENTS

pentoxifylline Tier 1

HEMOSTATICS

desmopressin injection Tier 4

desmopressin oral Tier 1

MONSEL'S Tier 2

NOCDURNA (MEN) Tier 3 PA; QL (30 EA per 30 days)

NOCDURNA (WOMEN) Tier 3 PA; QL (30 EA per 30 days)

tranexamic acid oral Tier 1

HEPARINS

enoxaparin Tier 4

heparin (porcine) injection solution 5,000 unit/ml Tier 1

INDIRECT FACTOR XA INHIBITORS

fondaparinux Tier 4

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

IRON PREPARATIONS

CLASSIC PRENATAL Tier 1

MULTI-VIT WITH FLUORIDE-IRON Tier 1

ONE DAILY PRENATAL Tier 1

pnv cmb#95-ferrous fumarate-fa Tier 1

PRENATAL COMPLETE Tier 1

PRENATAL MULTI-DHA (ALGAL OIL) Tier 1

PRENATAL MULTIVITAMINS Tier 1

PRENATAL ONE DAILY Tier 1

PRENATAL ORAL TABLET 28 MG IRON- 800

MCG

Tier 1

PRENATAL TABLET Tier 1

prenatal vit no.179-iron-folic Tier 1

PRENATAL VITAMIN ORAL TABLET 27 MG

IRON- 0.8 MG

Tier 1

PRENATAL VITAMIN WITH MINERALS Tier 1

prenatal vit-iron fum-folic ac Tier 1

STRESS FORMULA WITH IRON Tier 1

STRESS FORMULA WITH IRON(SULF) Tier 1

WESCAP-C DHA Tier 1

WESNATAL DHA COMPLETE Tier 1

PLATELET-AGGREGATION INHIBITORS

ADULT ASPIRIN REGIMEN Tier 1

ASPIRIN CHILDRENS Tier 1

aspirin oral tablet Tier 0

aspirin oral tablet,chewable Tier 1

aspirin oral tablet,delayed release (dr/ec) 325 mg Tier 0

aspirin oral tablet,delayed release (dr/ec) 81 mg Tier 1

aspirin,buffd-calcium carb-mag Tier 0

aspirin-dipyridamole Tier 1 ST

BAYER ASPIRIN Tier 0

BAYER LOW DOSE ASPIRIN Tier 1

BRILINTA Tier 2 ST

BUFFERIN Tier 0

butalbital-aspirin-caffeine oral capsule Tier 1 QL (48 EA per 30 days)

CHILDREN'S ASPIRIN Tier 1

cilostazol Tier 1

clopidogrel oral tablet 75 mg Tier 1

dipyridamole oral Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

ECOTRIN Tier 0

ECOTRIN LOW STRENGTH Tier 1

prasugrel Tier 1

ST JOSEPH ASPIRIN Tier 1

ST. JOSEPH ASPIRIN Tier 1

TRI-BUFFERED ASPIRIN Tier 0

PLATELET-REDUCING AGENTS

anagrelide Tier 1

THROMBOLYTIC AGENTS

ADULT ASPIRIN REGIMEN Tier 1

ASPIRIN CHILDRENS Tier 1

aspirin oral tablet Tier 0

aspirin oral tablet,chewable Tier 1

aspirin oral tablet,delayed release (dr/ec) 325 mg Tier 0

aspirin oral tablet,delayed release (dr/ec) 81 mg Tier 1

aspirin,buffd-calcium carb-mag Tier 0

BAYER ASPIRIN Tier 0

BAYER LOW DOSE ASPIRIN Tier 1

BUFFERIN Tier 0

butalbital-aspirin-caffeine oral capsule Tier 1 QL (48 EA per 30 days)

CHILDREN'S ASPIRIN Tier 1

ECOTRIN Tier 0

ECOTRIN LOW STRENGTH Tier 1

ST JOSEPH ASPIRIN Tier 1

ST. JOSEPH ASPIRIN Tier 1

TRI-BUFFERED ASPIRIN Tier 0

CARDIOVASCULAR DRUGS

ALPHA-ADRENERGIC BLOCKING AGENTS

acebutolol Tier 1

atenolol Tier 1

carvedilol Tier 1

doxazosin oral tablet 1 mg, 2 mg, 4 mg Tier 1 QL (30 EA per 30 days)

doxazosin oral tablet 8 mg Tier 1 QL (60 EA per 30 days)

labetalol oral Tier 1

prazosin Tier 1

terazosin oral capsule 1 mg, 2 mg, 5 mg Tier 1 QL (30 EA per 30 days)

terazosin oral capsule 10 mg Tier 1 QL (60 EA per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

ALPHA-ADRENERGIC BLOCKING

AGT.(HYPOTEN)

doxazosin oral tablet 1 mg, 2 mg, 4 mg Tier 1 QL (30 EA per 30 days)

doxazosin oral tablet 8 mg Tier 1 QL (60 EA per 30 days)

prazosin Tier 1

terazosin oral capsule 1 mg, 2 mg, 5 mg Tier 1 QL (30 EA per 30 days)

terazosin oral capsule 10 mg Tier 1 QL (60 EA per 30 days)

ANGIOTENSIN II RECEP

ANTAGONIST/NEPROLYS

ENTRESTO Tier 2 PA; QL (60 EA per 30 days)

ANGIOTENSIN II RECEPTOR

ANTAGON.(HYPOTN)

amlodipine-olmesartan Tier 1

amlodipine-valsartan Tier 1

candesartan Tier 1

candesartan-hydrochlorothiazid Tier 1

irbesartan Tier 1

irbesartan-hydrochlorothiazide Tier 1

losartan Tier 1

losartan-hydrochlorothiazide Tier 1

olmesartan Tier 1

olmesartan-amlodipin-hcthiazid Tier 1

olmesartan-hydrochlorothiazide Tier 1

telmisartan Tier 1

telmisartan-amlodipine Tier 1

telmisartan-hydrochlorothiazid Tier 1

valsartan oral tablet Tier 1

valsartan-hydrochlorothiazide Tier 1

ANGIOTENSIN II RECEPTOR ANTAGONISTS

amlodipine-olmesartan Tier 1

amlodipine-valsartan Tier 1

candesartan Tier 1

candesartan-hydrochlorothiazid Tier 1

irbesartan Tier 1

irbesartan-hydrochlorothiazide Tier 1

losartan Tier 1

losartan-hydrochlorothiazide Tier 1

olmesartan Tier 1

olmesartan-amlodipin-hcthiazid Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

olmesartan-hydrochlorothiazide Tier 1

telmisartan Tier 1

telmisartan-amlodipine Tier 1

telmisartan-hydrochlorothiazid Tier 1

valsartan oral tablet Tier 1

valsartan-hydrochlorothiazide Tier 1

ANGIOTENSIN-CONVERT.ENZYME

INHIB(HYPOTN)

amlodipine-benazepril Tier 1

benazepril Tier 1

benazepril-hydrochlorothiazide Tier 1

captopril Tier 1

captopril-hydrochlorothiazide Tier 1

enalapril maleate oral solution Tier 1 ST

enalapril maleate oral tablet Tier 1

enalapril-hydrochlorothiazide Tier 1

fosinopril Tier 1

fosinopril-hydrochlorothiazide Tier 1

lisinopril Tier 1

lisinopril-hydrochlorothiazide Tier 1

quinapril Tier 1

quinapril-hydrochlorothiazide Tier 1

ramipril Tier 1

trandolapril Tier 1

ANGIOTENSIN-CONVERTING ENZYME

INHIBITORS

amlodipine-benazepril Tier 1

benazepril Tier 1

benazepril-hydrochlorothiazide Tier 1

captopril Tier 1

captopril-hydrochlorothiazide Tier 1

enalapril maleate oral solution Tier 1 ST

enalapril maleate oral tablet Tier 1

enalapril-hydrochlorothiazide Tier 1

fosinopril Tier 1

fosinopril-hydrochlorothiazide Tier 1

lisinopril Tier 1

lisinopril-hydrochlorothiazide Tier 1

quinapril Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

quinapril-hydrochlorothiazide Tier 1

ramipril Tier 1

trandolapril Tier 1

ANTILIPEMIC AGENTS, MISCELLANEOUS

niacin oral tablet 500 mg Tier 1

niacin oral tablet extended release 24 hr Tier 1

BETA-ADRENERGIC BLOCKING AGENTS

atenolol-chlorthalidone Tier 1

bisoprolol fumarate Tier 1

bisoprolol-hydrochlorothiazide Tier 1

labetalol oral Tier 1

metoprolol succinate Tier 1

metoprolol ta-hydrochlorothiaz Tier 1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50

Tier 1

nadolol Tier 1

propranolol oral Tier 1

propranolol-hydrochlorothiazid Tier 1

SOTALOL AF Tier 1

sotalol oral Tier 1

timolol maleate oral Tier 1

BETA-ADRENERGIC BLOCKING

AGT.(HYPOTEN)

atenolol-chlorthalidone Tier 1

bisoprolol-hydrochlorothiazide Tier 1

labetalol oral Tier 1

metoprolol succinate Tier 1

metoprolol ta-hydrochlorothiaz Tier 1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50

Tier 1

nadolol Tier 1

propranolol oral Tier 1

propranolol-hydrochlorothiazid Tier 1

SOTALOL AF Tier 1

sotalol oral Tier 1

timolol maleate oral Tier 1

BILE ACID SEQUESTRANTS

cholestyramine (with sugar) Tier 1

CHOLESTYRAMINE LIGHT Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

cholestyramine-aspartame Tier 1

colesevelam oral powder in packet Tier 1 PA; QL (30 EA per 30 days)

colesevelam oral tablet Tier 1 PA; QL (180 EA per 30 days)

colestipol oral tablet Tier 1

CALCIUM-CHANNEL BLOCKING AGENTS

amlodipine Tier 1

amlodipine-benazepril Tier 1

amlodipine-olmesartan Tier 1

amlodipine-valsartan Tier 1

CARTIA XT Tier 1

diltiazem hcl oral Tier 1

DILT-XR Tier 1

felodipine Tier 1

MATZIM LA Tier 1

nifedipine Tier 1

olmesartan-amlodipin-hcthiazid Tier 1

telmisartan-amlodipine Tier 1

verapamil oral capsule,ext rel. pellets 24 hr Tier 1

verapamil oral tablet 120 mg, 80 mg Tier 1

verapamil oral tablet 40 mg Tier 1 QL (12 EA per 1 day)

verapamil oral tablet extended release Tier 1

CARBONIC ANHYDRASE INHIBITORS (24:36)

acetazolamide Tier 1

CARDIAC DRUGS, MISCELLANEOUS

ranolazine Tier 1

CARDIOTONIC AGENTS

DIGITEK Tier 1

digoxin oral solution Tier 1

digoxin oral tablet 125 mcg (0.125 mg), 250 mcg

(0.25 mg)

Tier 1

CARDIOVASCULAR DRUGS, NSAID ANTI-

INFL

colchicine oral tablet Tier 1 QL (2 EA per 1 day)

CENTRAL ALPHA-AGONISTS

clonidine Tier 1 QL (4 EA per 30 days)

clonidine hcl oral tablet 0.1 mg, 0.2 mg Tier 1 QL (10 EA per 1 day)

clonidine hcl oral tablet 0.3 mg Tier 1 QL (8 EA per 1 day)

clonidine hcl oral tablet extended release 12 hr Tier 1 QL (4 EA per 1 day)

guanfacine oral tablet Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

guanfacine oral tablet extended release 24 hr Tier 1 QL (1 EA per 1 day)

methyldopa Tier 1

CHOLESTEROL ABSORPTION INHIBITORS

ezetimibe Tier 1

ezetimibe-simvastatin Tier 1 ST; QL (30 EA per 30 days)

CLASS IA ANTIARRHYTHMICS

disopyramide phosphate Tier 1

NORPACE CR Tier 2

quinidine sulfate Tier 1

CLASS IB ANTIARRHYTHMICS

DILANTIN Tier 2

phenytoin Tier 1

phenytoin sodium extended Tier 1

CLASS IC ANTIARRHYTHMICS

flecainide Tier 1

propafenone Tier 1

CLASS II ANTIARRHYTHMICS

acebutolol Tier 1

atenolol Tier 1

atenolol-chlorthalidone Tier 1

bisoprolol fumarate Tier 1

bisoprolol-hydrochlorothiazide Tier 1

carvedilol Tier 1

labetalol oral Tier 1

metoprolol succinate Tier 1

metoprolol ta-hydrochlorothiaz Tier 1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50

Tier 1

nadolol Tier 1

propranolol oral Tier 1

propranolol-hydrochlorothiazid Tier 1

SOTALOL AF Tier 1

sotalol oral Tier 1

timolol maleate oral Tier 1

CLASS III ANTIARRHYTHMICS

amiodarone oral tablet 200 mg, 400 mg Tier 1

dofetilide Tier 1

PACERONE ORAL TABLET 200 MG, 400 MG Tier 1

SOTALOL AF Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

sotalol oral Tier 1

CLASS IV ANTIARRHYTHMICS

CARTIA XT Tier 1

diltiazem hcl oral Tier 1

DILT-XR Tier 1

MATZIM LA Tier 1

verapamil oral capsule,ext rel. pellets 24 hr Tier 1

verapamil oral tablet 120 mg, 80 mg Tier 1

verapamil oral tablet 40 mg Tier 1 QL (12 EA per 1 day)

verapamil oral tablet extended release Tier 1

DIHYDROPYRIDINES

amlodipine Tier 1

amlodipine-benazepril Tier 1

amlodipine-olmesartan Tier 1

amlodipine-valsartan Tier 1

felodipine Tier 1

nifedipine Tier 1

olmesartan-amlodipin-hcthiazid Tier 1

telmisartan-amlodipine Tier 1

DIHYDROPYRIDINES (ANTIHYPERTENSIVE)

amlodipine Tier 1

amlodipine-benazepril Tier 1

amlodipine-olmesartan Tier 1

amlodipine-valsartan Tier 1

felodipine Tier 1

nifedipine Tier 1

olmesartan-amlodipin-hcthiazid Tier 1

telmisartan-amlodipine Tier 1

DIRECT VASODILATORS

hydralazine oral Tier 1

minoxidil oral Tier 1

DIURETICS, MISCELLANEOUS (24:36)

ELIXOPHYLLIN Tier 2

THEO-24 Tier 2

theophylline Tier 1

FIBRIC ACID DERIVATIVES

fenofibrate micronized oral capsule 134 mg, 200

mg, 67 mg

Tier 1

fenofibrate micronized oral capsule 90 mg Tier 2 ST

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

fenofibrate nanocrystallized Tier 1

fenofibrate oral tablet 160 mg, 54 mg Tier 1

gemfibrozil Tier 1

HMG-COA REDUCTASE INHIBITORS

atorvastatin Tier 1 QL (30 EA per 30 days)

ezetimibe-simvastatin Tier 1 ST; QL (30 EA per 30 days)

fluvastatin oral capsule 20 mg Tier 1 QL (30 EA per 30 days)

fluvastatin oral capsule 40 mg Tier 1 QL (60 EA per 30 days)

fluvastatin oral tablet extended release 24 hr Tier 1 QL (30 EA per 30 days)

lovastatin oral tablet 10 mg Tier 1 QL (30 EA per 30 days)

lovastatin oral tablet 20 mg, 40 mg Tier 1 QL (60 EA per 30 days)

pravastatin Tier 1 QL (30 EA per 30 days)

rosuvastatin Tier 1 QL (30 EA per 30 days)

simvastatin Tier 1 QL (30 EA per 30 days)

HYPOTENSIVE AGENTS, MISCELLANEOUS

amlodipine Tier 1

amlodipine-benazepril Tier 1

amlodipine-olmesartan Tier 1

amlodipine-valsartan Tier 1

doxazosin oral tablet 1 mg, 2 mg, 4 mg Tier 1 QL (30 EA per 30 days)

doxazosin oral tablet 8 mg Tier 1 QL (60 EA per 30 days)

felodipine Tier 1

nifedipine Tier 1

phenoxybenzamine Tier 1

propranolol oral Tier 1

SOTALOL AF Tier 1

sotalol oral Tier 1

terazosin oral capsule 1 mg, 2 mg, 5 mg Tier 1 QL (30 EA per 30 days)

terazosin oral capsule 10 mg Tier 1 QL (60 EA per 30 days)

timolol maleate oral Tier 1

LOOP DIURETICS (24:36)

bumetanide oral Tier 1

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8

mg/ml)

Tier 1

furosemide oral tablet Tier 1

torsemide Tier 1

MINERALOCORTICOID (ALDOSTERONE)

ANTAGNTS

eplerenone Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

spironolacton-hydrochlorothiaz Tier 1

MINERALOCORTICOID(ALDOSTER.)ANTAG(H

YPOT)

eplerenone Tier 1

spironolactone oral tablet Tier 1

spironolacton-hydrochlorothiaz Tier 1

NITRATES AND NITRITES

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30

mg, 5 mg

Tier 1

isosorbide mononitrate Tier 1

NITRO-DUR Tier 2

nitroglycerin sublingual Tier 1

nitroglycerin transdermal Tier 1

nitroglycerin translingual Tier 1

NITRO-TIME Tier 1

OMEGA-3-MEDIATED ANTILIPEMICS

omega-3 acid ethyl esters Tier 1

PCSK9 INHIBITORS

REPATHA PUSHTRONEX Tier 2 PA; QL (1 ML per 28 days)

PHOSPHODIESTERASE TYPE 5 INHIBITORS

ADCIRCA Tier 4 PA; QL (2 EA per 1 day)

sildenafil (pulm.hypertension) oral tablet Tier 4 PA; QL (90 EA per 30 days)

tadalafil oral tablet 5 mg Tier 1 PA; QL (8 EA per 30 days)

POTASSIUM-SPARING DIURETIC

spironolactone oral tablet Tier 1

POTASSIUM-SPARING DIURETICS

(HYPOTEN)

amiloride Tier 1

amiloride-hydrochlorothiazide Tier 1

eplerenone Tier 1

spironolacton-hydrochlorothiaz Tier 1

triamterene-hydrochlorothiazid oral capsule Tier 1

triamterene-hydrochlorothiazid oral tablet 37.5-25

Tier 1 QL (1 EA per 1 day)

triamterene-hydrochlorothiazid oral tablet 75-50

Tier 1

SCLEROSING AGENTS

carvedilol Tier 1

labetalol oral Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

STEROIDAL MINERALOCORTICOID

RECEPTOR ANT

spironolactone oral tablet Tier 1

THIAZIDE DIURETICS (24:36)

amiloride-hydrochlorothiazide Tier 1

benazepril-hydrochlorothiazide Tier 1

bisoprolol-hydrochlorothiazide Tier 1

candesartan-hydrochlorothiazid Tier 1

captopril-hydrochlorothiazide Tier 1

enalapril-hydrochlorothiazide Tier 1

fosinopril-hydrochlorothiazide Tier 1

hydrochlorothiazide Tier 1

irbesartan-hydrochlorothiazide Tier 1

lisinopril-hydrochlorothiazide Tier 1

losartan-hydrochlorothiazide Tier 1

metoprolol ta-hydrochlorothiaz Tier 1

olmesartan-amlodipin-hcthiazid Tier 1

olmesartan-hydrochlorothiazide Tier 1

propranolol-hydrochlorothiazid Tier 1

quinapril-hydrochlorothiazide Tier 1

spironolacton-hydrochlorothiaz Tier 1

telmisartan-hydrochlorothiazid Tier 1

triamterene-hydrochlorothiazid oral capsule Tier 1

triamterene-hydrochlorothiazid oral tablet 37.5-25

Tier 1 QL (1 EA per 1 day)

triamterene-hydrochlorothiazid oral tablet 75-50

Tier 1

valsartan-hydrochlorothiazide Tier 1

THIAZIDE-LIKE DIURETICS (24:36)

atenolol-chlorthalidone Tier 1

chlorthalidone Tier 1

indapamide Tier 1

metolazone Tier 1

VASODILATING AGENTS, MISCELLANEOUS

ADEMPAS Tier 4 PA; QL (3 EA per 1 day)

ambrisentan Tier 4 PA; QL (30 EA per 30 days)

amlodipine Tier 1

amlodipine-benazepril Tier 1

amlodipine-olmesartan Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

amlodipine-valsartan Tier 1

bosentan Tier 4 PA; QL (2 EA per 1 day)

felodipine Tier 1

nifedipine Tier 1

ORENITRAM Tier 4 PA

telmisartan-amlodipine Tier 1

CENTRAL NERVOUS SYSTEM AGENTS

ADAMANTANES (CNS)

amantadine hcl Tier 1

AMPHETAMINES

amphetamine sulfate Tier 1

dextroamphetamine sulfate oral capsule,

extended release

Tier 1 QL (2 EA per 1 day)

dextroamphetamine sulfate oral solution Tier 1

dextroamphetamine sulfate oral tablet 10 mg Tier 1 QL (4 EA per 1 day)

dextroamphetamine sulfate oral tablet 15 mg, 20

mg, 30 mg, 7.5 mg

Tier 1

dextroamphetamine sulfate oral tablet 2.5 mg, 5

Tier 1 QL (1 EA per 1 day)

dextroamphetamine-amphetamine oral

capsule,extended release 24hr 10 mg, 15 mg, 5

Tier 1 QL (1 EA per 1 day)

dextroamphetamine-amphetamine oral

capsule,extended release 24hr 20 mg, 25 mg, 30

Tier 1 QL (2 EA per 1 day)

dextroamphetamine-amphetamine oral tablet Tier 1 QL (3 EA per 1 day)

methamphetamine Tier 1

ZENZEDI ORAL TABLET 2.5 MG Tier 2 QL (1 EA per 1 day)

ANALGESICS AND ANTIPYRETICS, MISC.

acetaminophen-codeine oral solution Tier 1 PA; QL (125 ML per 1 day)

acetaminophen-codeine oral tablet Tier 1 PA; QL (10 EA per 1 day)

butalbital-acetaminop-caf-cod oral capsule 50-

325-40-30 mg

Tier 1 PA

butalbital-acetaminophen-caff oral capsule 50-

325-40 mg

Tier 1 QL (48 EA per 30 days)

butalbital-acetaminophen-caff oral tablet Tier 1 QL (48 EA per 30 days)

ENDOCET Tier 1 PA; QL (10 EA per 1 day)

gabapentin oral capsule 100 mg, 400 mg Tier 1 QL (6 EA per 1 day)

gabapentin oral capsule 300 mg Tier 1 QL (12 EA per 1 day)

gabapentin oral solution Tier 1 QL (72 ML per 1 day)

gabapentin oral tablet 600 mg Tier 1 QL (6 EA per 1 day)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

gabapentin oral tablet 800 mg Tier 1 QL (4 EA per 1 day)

hydrocodone-acetaminophen oral tablet 10-325

mg, 5-325 mg, 7.5-325 mg

Tier 1 PA; QL (10 EA per 1 day)

oxycodone-acetaminophen oral solution Tier 1 PA

oxycodone-acetaminophen oral tablet 10-325

mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

Tier 1 PA; QL (10 EA per 1 day)

oxycodone-acetaminophen oral tablet 2.5-300

Tier 1

oxycodone-acetaminophen oral tablet 7.5-300

Tier 1 PA

tramadol-acetaminophen Tier 1 PA; QL (240 EA per 30 days)

ANTICHOLINERGIC AGENTS (CNS)

benztropine oral Tier 1

trihexyphenidyl Tier 1

ANTICONVULSANTS, MISCELLANEOUS

carbamazepine Tier 1

EPITOL Tier 1

felbamate Tier 1

FYCOMPA Tier 2 ST

lamotrigine oral tablet Tier 1

lamotrigine oral tablet extended release 24hr Tier 1

lamotrigine oral tablet, chewable dispersible Tier 1

levetiracetam oral Tier 1

ROWEEPRA Tier 1

ROWEEPRA XR Tier 1

topiramate oral capsule, sprinkle Tier 1

topiramate oral tablet Tier 1

valproic acid Tier 1

valproic acid (as sodium salt) Tier 1

ANTIDEPRESSANTS, MISCELLANEOUS

bupropion hcl (smoking deter) Tier 1

bupropion hcl oral tablet Tier 1

bupropion hcl oral tablet extended release 24 hr

150 mg, 300 mg

Tier 1 QL (30 EA per 30 days)

bupropion hcl oral tablet sustained-release 12 hr Tier 1 QL (60 EA per 30 days)

mirtazapine Tier 1

ANTIMANIC AGENTS

ABILIFY MAINTENA Tier 2

aripiprazole oral tablet Tier 1 QL (30 EA per 30 days)

ARISTADA INITIO Tier 2 QL (3 ML per 180 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

ARISTADA INTRAMUSCULAR

SUSPENSION,EXTENDED REL SYRING 1,064

MG/3.9 ML

Tier 2 QL (4 ML per 60 days)

ARISTADA INTRAMUSCULAR

SUSPENSION,EXTENDED REL SYRING 441

MG/1.6 ML

Tier 2 QL (2 ML per 30 days)

ARISTADA INTRAMUSCULAR

SUSPENSION,EXTENDED REL SYRING 662

MG/2.4 ML

Tier 2 QL (3 ML per 30 days)

ARISTADA INTRAMUSCULAR

SUSPENSION,EXTENDED REL SYRING 882

MG/3.2 ML

Tier 2 QL (3.2 ML per 30 days)

carbamazepine Tier 1

divalproex Tier 1

EPITOL Tier 1

lamotrigine oral tablet Tier 1

lamotrigine oral tablet, chewable dispersible Tier 1

lithium carbonate Tier 1

lithium citrate Tier 1

olanzapine oral tablet Tier 1 QL (30 EA per 30 days)

quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50

Tier 1 QL (90 EA per 30 days)

quetiapine oral tablet 300 mg, 400 mg Tier 1 QL (60 EA per 30 days)

quetiapine oral tablet extended release 24 hr 150

mg, 200 mg

Tier 1 QL (30 EA per 30 days)

quetiapine oral tablet extended release 24 hr 300

mg, 400 mg, 50 mg

Tier 1 QL (60 EA per 30 days)

RISPERDAL CONSTA Tier 2

risperidone microspheres Tier 1

risperidone oral solution Tier 1

risperidone oral tablet Tier 1 QL (60 EA per 30 days)

SECUADO Tier 2 PA; QL (30 EA per 30 days)

valproic acid Tier 1

valproic acid (as sodium salt) Tier 1

ziprasidone hcl Tier 1 QL (60 EA per 30 days)

ANTIMIGRAINE AGENTS, MISCELLANEOUS

ADULT ASPIRIN REGIMEN Tier 1

ASPIRIN CHILDRENS Tier 1

aspirin oral tablet Tier 0

aspirin oral tablet,chewable Tier 1

aspirin oral tablet,delayed release (dr/ec) 325 mg Tier 0

aspirin oral tablet,delayed release (dr/ec) 81 mg Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

aspirin,buffd-calcium carb-mag Tier 0

BAYER ASPIRIN Tier 0

BAYER LOW DOSE ASPIRIN Tier 1

BUFFERIN Tier 0

butalbital-acetaminop-caf-cod oral capsule 50-

325-40-30 mg

Tier 1 PA

butalbital-acetaminophen-caff oral capsule 50-

325-40 mg

Tier 1 QL (48 EA per 30 days)

butalbital-acetaminophen-caff oral tablet Tier 1 QL (48 EA per 30 days)

butalbital-aspirin-caffeine oral capsule Tier 1 QL (48 EA per 30 days)

CHILDREN'S ASPIRIN Tier 1

diclofenac potassium oral tablet Tier 1

diclofenac sodium oral Tier 1

dihydroergotamine nasal Tier 1 ST; QL (8 ML per 30 days)

divalproex Tier 1

ECOTRIN Tier 0

ECOTRIN LOW STRENGTH Tier 1

ergotamine-caffeine Tier 1

propranolol oral Tier 1

ST JOSEPH ASPIRIN Tier 1

ST. JOSEPH ASPIRIN Tier 1

timolol maleate oral Tier 1

tramadol-acetaminophen Tier 1 PA; QL (240 EA per 30 days)

TRI-BUFFERED ASPIRIN Tier 0

valproic acid Tier 1

valproic acid (as sodium salt) Tier 1

ANXIOLYTICS,SEDATIVES,AND

HYPNOTICS,MISC

hydroxyzine hcl oral solution 10 mg/5 ml Tier 1

hydroxyzine hcl oral tablet Tier 1

hydroxyzine pamoate Tier 1

promethazine oral Tier 1

promethazine rectal Tier 1

PROMETHEGAN Tier 1

ATYPICAL ANTIPSYCHOTICS

ABILIFY MAINTENA Tier 2

aripiprazole oral tablet Tier 1 QL (30 EA per 30 days)

ARISTADA INITIO Tier 2 QL (3 ML per 180 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

ARISTADA INTRAMUSCULAR

SUSPENSION,EXTENDED REL SYRING 1,064

MG/3.9 ML

Tier 2 QL (4 ML per 60 days)

ARISTADA INTRAMUSCULAR

SUSPENSION,EXTENDED REL SYRING 441

MG/1.6 ML

Tier 2 QL (2 ML per 30 days)

ARISTADA INTRAMUSCULAR

SUSPENSION,EXTENDED REL SYRING 662

MG/2.4 ML

Tier 2 QL (3 ML per 30 days)

ARISTADA INTRAMUSCULAR

SUSPENSION,EXTENDED REL SYRING 882

MG/3.2 ML

Tier 2 QL (3.2 ML per 30 days)

clozapine oral tablet Tier 1

FANAPT ORAL TABLET Tier 3 PA; ST; QL (60 EA per 30 days)

FANAPT ORAL TABLETS,DOSE PACK Tier 3 QL (8 EA per 30 days)

INVEGA SUSTENNA Tier 2

INVEGA TRINZA INTRAMUSCULAR SYRINGE

273 MG/0.88 ML

Tier 2 QL (1 ML per 90 days)

INVEGA TRINZA INTRAMUSCULAR SYRINGE

410 MG/1.32 ML, 546 MG/1.75 ML

Tier 2 QL (2 ML per 90 days)

INVEGA TRINZA INTRAMUSCULAR SYRINGE

819 MG/2.63 ML

Tier 2 QL (3 ML per 90 days)

lurasidone Tier 1 QL (1 EA per 1 day)

olanzapine oral tablet Tier 1 QL (30 EA per 30 days)

olanzapine-fluoxetine oral capsule 12-25 mg, 12-

50 mg, 6-25 mg, 6-50 mg

Tier 1 ST

paliperidone oral tablet extended release 24hr

1.5 mg, 3 mg, 9 mg

Tier 1 QL (30 EA per 30 days)

paliperidone oral tablet extended release 24hr 6

Tier 1 QL (60 EA per 30 days)

quetiapine oral tablet 100 mg, 200 mg, 25 mg, 50

Tier 1 QL (90 EA per 30 days)

quetiapine oral tablet 300 mg, 400 mg Tier 1 QL (60 EA per 30 days)

quetiapine oral tablet extended release 24 hr 150

mg, 200 mg

Tier 1 QL (30 EA per 30 days)

quetiapine oral tablet extended release 24 hr 300

mg, 400 mg, 50 mg

Tier 1 QL (60 EA per 30 days)

RISPERDAL CONSTA Tier 2

risperidone microspheres Tier 1

risperidone oral solution Tier 1

risperidone oral tablet Tier 1 QL (60 EA per 30 days)

SECUADO Tier 2 PA; QL (30 EA per 30 days)

ziprasidone hcl Tier 1 QL (60 EA per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

BARBITURATES (ANTICONVULSANTS)

phenobarbital Tier 1

primidone oral tablet 250 mg, 50 mg Tier 1

BARBITURATES (ANXIOLYTIC,

SEDATIVE/HYP)

butalbital-acetaminop-caf-cod oral capsule 50-

325-40-30 mg

Tier 1 PA

butalbital-acetaminophen-caff oral capsule 50-

325-40 mg

Tier 1 QL (48 EA per 30 days)

butalbital-acetaminophen-caff oral tablet Tier 1 QL (48 EA per 30 days)

butalbital-aspirin-caffeine oral capsule Tier 1 QL (48 EA per 30 days)

phenobarbital Tier 1

BENZODIAZEPINES (ANTICONVULSANTS)

clobazam Tier 1 PA

clonazepam oral tablet Tier 1 QL (4 EA per 1 day)

clorazepate dipotassium Tier 1 QL (4 EA per 1 day)

diazepam oral tablet Tier 1 QL (4 EA per 1 day)

diazepam rectal Tier 1

lorazepam oral tablet Tier 1 QL (3 EA per 1 day)

NAYZILAM Tier 2 PA; QL (2 EA per 30 days)

VALTOCO Tier 2 PA; QL (2 EA per 30 days)

BENZODIAZEPINES

(ANXIOLYTIC,SEDATIV/HYP)

alprazolam oral tablet Tier 1 QL (4 EA per 1 day)

amitriptyline-chlordiazepoxide Tier 1

chlordiazepoxide hcl Tier 1 QL (4 EA per 1 day)

chlordiazepoxide-clidinium Tier 1

clobazam Tier 1 PA

clonazepam oral tablet Tier 1 QL (4 EA per 1 day)

clorazepate dipotassium Tier 1 QL (4 EA per 1 day)

diazepam oral tablet Tier 1 QL (4 EA per 1 day)

diazepam rectal Tier 1

estazolam Tier 1 QL (15 EA per 30 days)

flurazepam Tier 1 QL (15 EA per 30 Days)

lorazepam oral tablet Tier 1 QL (3 EA per 1 day)

midazolam (pf) injection solution Tier 1

midazolam (pf) injection syringe 2 mg/2 ml (1

mg/ml)

Tier 1

midazolam injection Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

midazolam intravenous syringe 150 mg/30 ml (5

mg/ml)

Tier 2

NAYZILAM Tier 2 PA; QL (2 EA per 30 days)

oxazepam Tier 1 QL (4 EA per 1 day)

quazepam Tier 1 QL (15 EA per 30 days)

temazepam oral capsule 15 mg, 30 mg Tier 1 QL (15 EA per 30 days)

triazolam Tier 1 QL (15 EA per 30 days)

VALTOCO Tier 2 PA; QL (2 EA per 30 days)

BUTYROPHENONES

haloperidol Tier 1

haloperidol lactate oral Tier 1

CALCITONIN GENE-RELATED PEPTIDE

ANTAG.

AIMOVIG AUTOINJECTOR Tier 2 PA; QL (1 ML per 28 days)

EMGALITY PEN Tier 2 PA; QL (1 ML per 28 days)

EMGALITY SYRINGE Tier 2 PA; QL (1 ML per 28 days)

CATECHOL-O-

METHYLTRANSFERASE(COMT)INHIB.

carbidopa-levodopa-entacapone Tier 1

entacapone Tier 1

tolcapone Tier 1 PA

CENTRAL NERVOUS SYSTEM AGENTS,

MISC.

carbidopa Tier 1 PA

memantine oral solution Tier 1

memantine oral tablet Tier 1

memantine oral tablets,dose pack Tier 2

CYCLOOXYGENASE-2 (COX-2) INHIBITORS

celecoxib Tier 1 ST

DIBENZOXAPINES

loxapine succinate Tier 1

DIPHENYLBUTYLPERIDINES

pimozide Tier 1

DOPAMINE PRECURSORS

carbidopa-levodopa oral tablet Tier 1

carbidopa-levodopa oral tablet extended release Tier 1

carbidopa-levodopa-entacapone Tier 1

ERGOT-DERIV. DOPAMINE RECEPTOR

AGONISTS

bromocriptine Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

cabergoline Tier 1 QL (8 EA per 30 days)

FIBROMYALGIA AGENTS

duloxetine oral capsule,delayed release(dr/ec) 20

mg, 60 mg

Tier 1 QL (60 EA per 30 days)

duloxetine oral capsule,delayed release(dr/ec) 30

mg, 40 mg

Tier 1 QL (30 EA per 30 days)

pregabalin oral capsule 100 mg, 150 mg, 200

mg, 25 mg, 50 mg, 75 mg

Tier 1 PA; QL (3 EA per 1 day)

pregabalin oral capsule 225 mg, 300 mg Tier 1 PA; QL (2 EA per 1 day)

pregabalin oral solution Tier 1 PA; QL (30 ML per 1 day)

SAVELLA ORAL TABLET Tier 2 ST; QL (60 EA per 30 days)

GABA-MEDIATED ANTICONVULSANTS

divalproex Tier 1

gabapentin oral capsule 100 mg, 400 mg Tier 1 QL (6 EA per 1 day)

gabapentin oral capsule 300 mg Tier 1 QL (12 EA per 1 day)

gabapentin oral solution 250 mg/5 ml Tier 1 QL (72 ML per 1 day)

gabapentin oral solution 250 mg/5 ml (5 ml), 300

mg/6 ml (6 ml)

Tier 1

gabapentin oral tablet 600 mg Tier 1 QL (6 EA per 1 day)

gabapentin oral tablet 800 mg Tier 1 QL (4 EA per 1 day)

pregabalin oral capsule 100 mg, 150 mg, 200

mg, 25 mg, 50 mg, 75 mg

Tier 1 PA; QL (3 EA per 1 day)

pregabalin oral capsule 225 mg, 300 mg Tier 1 PA; QL (2 EA per 1 day)

pregabalin oral solution Tier 1 PA; QL (30 ML per 1 day)

tiagabine Tier 1

HYDANTOINS

DILANTIN Tier 2

phenytoin Tier 1

phenytoin sodium extended Tier 1

INHALATION ANESTHETICS

desflurane Tier 1

FORANE Tier 1

isoflurane Tier 1

sevoflurane Tier 1

TERRELL Tier 1

ION CHANNEL INHIBITION AGENTS

APTIOM Tier 3

lacosamide oral tablet Tier 1 ST

oxcarbazepine Tier 1

OXTELLAR XR Tier 2 ST

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

rufinamide oral suspension Tier 1 PA

rufinamide oral tablet Tier 1 ST

zonisamide Tier 1

MELATONIN RECEPTOR AGONISTS

ramelteon Tier 1 PA; QL (15 EA per 30 days)

MONOAMINE OXIDASE B INHIBITORS

EMSAM Tier 2

rasagiline Tier 1

selegiline hcl Tier 1

MONOAMINE OXIDASE INHIBITORS

EMSAM Tier 2

phenelzine Tier 1

rasagiline Tier 1

selegiline hcl Tier 1

tranylcypromine Tier 1

NON-BENZODIAZEPINE ANXIOLYTICS

buspirone Tier 1

meprobamate Tier 1

NON-BENZODIAZEPINE HYPNOTICS

eszopiclone Tier 1 PA; QL (15 EA per 30 days)

zaleplon Tier 1 QL (15 EA per 30 days)

zolpidem oral tablet Tier 1 QL (15 EA per 30 days)

NONERGOT-DERIV.DOPAMINE RECEPTOR

AGONIST

NEUPRO TRANSDERMAL PATCH 24 HOUR 2

MG/24 HOUR

Tier 2 ST

pramipexole oral tablet Tier 1

ropinirole oral tablet Tier 1

ropinirole oral tablet extended release 24 hr 2

mg, 4 mg, 8 mg

Tier 1 ST

NONSTEROIDAL ANTI-INFLAMM. AGENTS,

MISC

diclofenac sodium topical gel 1 % Tier 1 QL (500 GM per 30 days)

diclofenac-misoprostol Tier 1

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-

200 mg

Tier 1 PA

hydrocodone-ibuprofen oral tablet 7.5-200 mg Tier 1 PA; QL (5 EA per 1 day)

ibuprofen-famotidine Tier 1 PA

naproxen-esomeprazole Tier 1 ST

sumatriptan-naproxen Tier 1 ST; QL (18 EA per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

tolmetin Tier 1 ST

OPIOID AGONISTS

acetaminophen-codeine oral solution Tier 1 PA; QL (125 ML per 1 day)

acetaminophen-codeine oral tablet Tier 1 PA; QL (10 EA per 1 day)

butalbital-acetaminop-caf-cod oral capsule 50-

325-40-30 mg

Tier 1 PA

carisoprodol-aspirin-codeine Tier 1

codeine sulfate Tier 1 PA

ENDOCET Tier 1 PA; QL (10 EA per 1 day)

fentanyl transdermal patch 72 hour 100 mcg/hr,

12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr

Tier 1 PA; QL (15 EA per 30 days)

G TUSSIN AC Tier 1

GUAIFENESIN AC Tier 1

GUAIFENESIN DAC Tier 1

hydrocodone bitartrate oral capsule, oral only, er

12hr

Tier 1 PA; QL (90 EA per 30 days)

hydrocodone-acetaminophen oral tablet 10-325

mg, 5-325 mg, 7.5-325 mg

Tier 1 PA; QL (10 EA per 1 day)

hydrocodone-chlorpheniramine Tier 1

hydrocodone-ibuprofen oral tablet 10-200 mg, 5-

200 mg

Tier 1 PA

hydrocodone-ibuprofen oral tablet 7.5-200 mg Tier 1 PA; QL (5 EA per 1 day)

HYDROMET Tier 1 QL (4 ML per 1 day)

hydromorphone oral liquid Tier 1 PA; QL (6 ML per 1 day)

hydromorphone oral tablet Tier 1 PA; QL (6 EA per 1 day)

hydromorphone oral tablet extended release 24

Tier 1 QL (60 EA per 30 days)

levorphanol tartrate Tier 1 PA

MAXI-TUSS AC Tier 1

METHADONE INTENSOL Tier 1 PA

methadone oral concentrate Tier 1 PA

methadone oral solution 10 mg/5 ml Tier 1 PA; QL (8.67 ML per 1 day)

methadone oral solution 5 mg/5 ml Tier 1 PA; QL (20 ML per 1 day)

methadone oral tablet 10 mg Tier 1 PA; QL (2 EA per 1 day)

methadone oral tablet 5 mg Tier 1 PA; QL (4 EA per 1 day)

morphine concentrate oral solution Tier 1 PA; QL (6 ML per 1 day)

morphine oral capsule,extend.release pellets 10

mg, 100 mg, 20 mg, 50 mg, 80 mg

Tier 1 PA; QL (90 EA per 30 days)

morphine oral solution Tier 1 PA; QL (30 ML per 1 day)

morphine oral tablet Tier 1 PA; QL (6 EA per 1 day)

morphine oral tablet extended release Tier 1 PA; QL (120 EA per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

morphine rectal Tier 1 PA; QL (6 EA per 1 day)

oxycodone oral capsule Tier 1 PA; QL (6 EA per 1 day)

oxycodone oral concentrate Tier 1 PA; QL (6 ML per 1 day)

oxycodone oral solution Tier 1 PA; QL (30 ML per 1 day)

oxycodone oral tablet Tier 1 PA; QL (6 EA per 1 day)

oxycodone oral tablet,oral only,ext.rel.12 hr Tier 2 PA; QL (90 EA per 30 days)

oxycodone-acetaminophen oral solution Tier 1 PA

oxycodone-acetaminophen oral tablet 10-325

mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg

Tier 1 PA; QL (10 EA per 1 day)

oxycodone-acetaminophen oral tablet 2.5-300

Tier 1

oxycodone-acetaminophen oral tablet 7.5-300

Tier 1 PA

oxymorphone oral tablet Tier 1 PA

oxymorphone oral tablet extended release 12 hr Tier 1 PA; QL (90 EA per 30 days)

promethazine-codeine Tier 1

RYDEX Tier 1

tramadol oral tablet 50 mg Tier 1 PA; QL (240 EA per 30 days)

tramadol oral tablet extended release 24 hr Tier 1 PA; QL (30 EA per 30 days)

tramadol oral tablet, er multiphase 24 hr Tier 1 PA; QL (30 EA per 30 days)

tramadol-acetaminophen Tier 1 PA; QL (240 EA per 30 days)

VIRTUSSIN AC Tier 1

OPIOID ANTAGONIST

nalmefene Tier 2 QL (2 Units per 1 Month)

naloxone injection solution Tier 1 QL (2 ML per 30 days)

naloxone injection syringe 1 mg/ml Tier 1

naloxone nasal Tier 1

naltrexone Tier 1

NARCAN Tier 2

OPVEE Tier 2 QL (2 EA per 30 Days)

VIVITROL Tier 4 QL (1 EA per 30 days)

OPIOID PARTIAL AGONISTS

buprenorphine Tier 1 ST

buprenorphine-naloxone sublingual tablet Tier 1

OREXIN RECEPTOR ANTAGONISTS

BELSOMRA Tier 3 PA; QL (1 EA per 1 day)

PHENOTHIAZINES

chlorpromazine oral Tier 1

fluphenazine decanoate Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

fluphenazine hcl Tier 1

perphenazine Tier 1

perphenazine-amitriptyline Tier 1

prochlorperazine maleate Tier 1

thioridazine Tier 1

trifluoperazine Tier 1

RESPIRATORY AND CNS STIMULANTS

atomoxetine oral capsule 10 mg, 18 mg, 25 mg,

40 mg

Tier 1 QL (2 EA per 1 day)

atomoxetine oral capsule 100 mg, 60 mg, 80 mg Tier 1 QL (1 EA per 1 day)

butalbital-acetaminop-caf-cod oral capsule 50-

325-40-30 mg

Tier 1 PA

butalbital-acetaminophen-caff oral capsule 50-

325-40 mg

Tier 1 QL (48 EA per 30 days)

butalbital-acetaminophen-caff oral tablet Tier 1 QL (48 EA per 30 days)

butalbital-aspirin-caffeine oral capsule Tier 1 QL (48 EA per 30 days)

dexmethylphenidate oral capsule,er biphasic 50-

Tier 1 QL (1 EA per 1 day)

dexmethylphenidate oral tablet 10 mg Tier 1 QL (4 EA per 1 day)

dexmethylphenidate oral tablet 2.5 mg, 5 mg Tier 1 QL (2 EA per 1 day)

METADATE ER Tier 1 QL (3 EA per 1 day)

methylphenidate hcl oral capsule, er biphasic 30-

Tier 1 QL (1 EA per 1 day)

methylphenidate hcl oral capsule,er biphasic 50-

50 10 mg, 60 mg

Tier 1

methylphenidate hcl oral capsule,er biphasic 50-

50 20 mg, 40 mg

Tier 1 QL (1 EA per 1 day)

methylphenidate hcl oral capsule,er biphasic 50-

50 30 mg

Tier 1 QL (2 EA per 1 day)

methylphenidate hcl oral solution 10 mg/5 ml Tier 1 QL (30 ML per 1 day)

methylphenidate hcl oral solution 5 mg/5 ml Tier 1 QL (60 ML per 1 day)

methylphenidate hcl oral tablet Tier 1 QL (3 EA per 1 day)

methylphenidate hcl oral tablet extended release Tier 1 QL (3 EA per 1 day)

methylphenidate hcl oral tablet extended release

24hr 18 mg, 27 mg

Tier 1 QL (1 EA per 1 day)

methylphenidate hcl oral tablet extended release

24hr 36 mg, 54 mg

Tier 1 QL (2 EA per 1 day)

methylphenidate hcl oral tablet extended release

24hr 72 mg

Tier 2 ST; QL (1 EA per 1 day)

methylphenidate hcl oral tablet,chewable Tier 1 QL (3 EA per 1 day)

RELEXXII ORAL TABLET EXTENDED

RELEASE 24HR 45 MG, 63 MG, 72 MG

Tier 2 ST; QL (1 EA per 1 day)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

REVERSIBLE COX-1/COX-2 INHIBITORS

diclofenac potassium oral tablet Tier 1

diclofenac sodium oral Tier 1

diflunisal Tier 1

EC-NAPROXEN Tier 1

etodolac Tier 1

fenoprofen oral tablet Tier 1 ST

flurbiprofen Tier 1

IBU Tier 1

ibuprofen oral suspension Tier 1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg Tier 1

indomethacin oral capsule Tier 1

ketoprofen oral capsule 25 mg Tier 1 ST

ketoprofen oral capsule 50 mg, 75 mg Tier 1

ketorolac oral Tier 1 QL (20 EA per 1 FILL)

KIPROFEN Tier 1 ST

mefenamic acid Tier 1

meloxicam oral tablet 15 mg Tier 1

meloxicam oral tablet 7.5 mg Tier 1 QL (30 EA per 30 days)

nabumetone Tier 1

naproxen oral tablet Tier 1

naproxen oral tablet,delayed release (dr/ec) Tier 1

naproxen sodium oral tablet 275 mg, 550 mg Tier 1

oxaprozin oral tablet Tier 1

piroxicam Tier 1

sulindac Tier 1

SALICYLATES

ADULT ASPIRIN REGIMEN Tier 1

ASPIRIN CHILDRENS Tier 1

aspirin oral tablet Tier 0

aspirin oral tablet,chewable Tier 1

aspirin oral tablet,delayed release (dr/ec) 325 mg Tier 0

aspirin oral tablet,delayed release (dr/ec) 81 mg Tier 1

aspirin,buffd-calcium carb-mag Tier 0

aspirin-dipyridamole Tier 1 ST

BAYER ASPIRIN Tier 0

BAYER LOW DOSE ASPIRIN Tier 1

BUFFERIN Tier 0

butalbital-aspirin-caffeine oral capsule Tier 1 QL (48 EA per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

carisoprodol-aspirin-codeine Tier 1

CHILDREN'S ASPIRIN Tier 1

ECOTRIN Tier 0

ECOTRIN LOW STRENGTH Tier 1

ST JOSEPH ASPIRIN Tier 1

ST. JOSEPH ASPIRIN Tier 1

TRI-BUFFERED ASPIRIN Tier 0

SEL.SEROTONIN,NOREPI REUPTAKE

INHIBITOR

desvenlafaxine Tier 2 ST; QL (30 EA per 30 days)

desvenlafaxine succinate Tier 1 QL (30 EA per 30 days)

duloxetine oral capsule,delayed release(dr/ec) 20

mg, 60 mg

Tier 1 QL (60 EA per 30 days)

duloxetine oral capsule,delayed release(dr/ec) 30

mg, 40 mg

Tier 1 QL (30 EA per 30 days)

SAVELLA ORAL TABLET Tier 2 ST; QL (60 EA per 30 days)

venlafaxine oral capsule,extended release 24hr

150 mg, 37.5 mg

Tier 1 QL (30 EA per 30 days)

venlafaxine oral capsule,extended release 24hr

75 mg

Tier 1 QL (90 EA per 30 days)

venlafaxine oral tablet Tier 1 QL (90 EA per 30 days)

SELECTIVE SEROTONIN AGONISTS

almotriptan malate oral tablet 12.5 mg Tier 1 QL (24 EA per 30 days)

almotriptan malate oral tablet 6.25 mg Tier 1 QL (18 EA per 30 days)

eletriptan Tier 1 QL (18 EA per 30 days)

frovatriptan Tier 1 QL (27 EA per 30 days)

naratriptan Tier 1 QL (18 EA per 30 days)

rizatriptan Tier 1 QL (36 EA per 30 days)

sumatriptan nasal spray,non-aerosol 20

mg/actuation

Tier 1 QL (18 EA per 30 days)

sumatriptan nasal spray,non-aerosol 5

mg/actuation

Tier 1 QL (36 EA per 30 days)

sumatriptan succinate oral Tier 1 QL (18 EA per 30 days)

sumatriptan succinate subcutaneous cartridge 6

mg/0.5 ml

Tier 1 QL (8 ML per 30 days)

sumatriptan succinate subcutaneous pen injector

6 mg/0.5 ml

Tier 1 QL (8 ML per 30 days)

sumatriptan succinate subcutaneous syringe Tier 1 QL (8 ML per 30 days)

sumatriptan-naproxen Tier 1 ST; QL (18 EA per 30 days)

zolmitriptan oral Tier 1 QL (18 EA per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

SELECTIVE-SEROTONIN REUPTAKE

INHIBITORS

citalopram oral solution Tier 1

citalopram oral tablet Tier 1 QL (30 EA per 30 days)

escitalopram oxalate oral solution Tier 1

escitalopram oxalate oral tablet Tier 1 QL (30 EA per 30 days)

fluoxetine oral capsule 10 mg Tier 1 QL (30 EA per 30 days)

fluoxetine oral capsule 20 mg Tier 1

fluoxetine oral capsule 40 mg Tier 1 QL (60 EA per 30 days)

fluoxetine oral solution Tier 1

fluoxetine oral tablet 10 mg Tier 1 ST; QL (30 EA per 30 days)

fluoxetine oral tablet 20 mg, 60 mg Tier 1 ST

fluvoxamine oral capsule,extended release 24hr Tier 1 ST; QL (60 EA per 30 days)

fluvoxamine oral tablet 100 mg Tier 1 QL (90 EA per 30 days)

fluvoxamine oral tablet 25 mg Tier 1 QL (30 EA per 30 days)

fluvoxamine oral tablet 50 mg Tier 1 QL (60 EA per 30 days)

olanzapine-fluoxetine oral capsule 12-25 mg, 12-

50 mg, 6-25 mg, 6-50 mg

Tier 1 ST

paroxetine hcl oral tablet 10 mg, 40 mg Tier 1 QL (30 EA per 30 days)

paroxetine hcl oral tablet 20 mg, 30 mg Tier 1 QL (60 EA per 30 days)

paroxetine hcl oral tablet extended release 24 hr Tier 1 ST; QL (60 EA per 30 days)

sertraline oral concentrate Tier 1

sertraline oral tablet 100 mg, 50 mg Tier 1 QL (60 EA per 30 days)

sertraline oral tablet 25 mg Tier 1 QL (45 EA per 30 days)

SEROTONIN MODULATORS

nefazodone Tier 1 QL (2 EA per 1 day)

trazodone Tier 1

TRINTELLIX Tier 3 ST; QL (30 EA per 30 days)

vilazodone Tier 1 PA; QL (30 EA per 30 days)

SUCCINIMIDES

ethosuximide Tier 1

methsuximide Tier 1

THIOXANTHENES

thiothixene Tier 1

TRICYCLICS, OTHER NOREPI-RU

INHIBITORS

amitriptyline Tier 1

amitriptyline-chlordiazepoxide Tier 1

amoxapine Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

clomipramine Tier 1

desipramine Tier 1

doxepin oral capsule Tier 1

doxepin oral concentrate Tier 1

doxepin oral tablet Tier 1 ST; QL (15 EA per 30 days)

imipramine hcl Tier 1

imipramine pamoate Tier 1

nortriptyline Tier 1

perphenazine-amitriptyline Tier 1

protriptyline Tier 1

trimipramine Tier 1

VESICULAR MONOAMINE TRANSPORT2

INHIBITOR

AUSTEDO ORAL TABLET 12 MG, 9 MG Tier 4 PA; QL (120 EA per 30 days)

AUSTEDO ORAL TABLET 6 MG Tier 4 PA; QL (60 EA per 30 days)

AUSTEDO XR ORAL TABLET EXTENDED

RELEASE 24 HR 12 MG, 24 MG, 30 MG, 36 MG,

42 MG, 48 MG, 6 MG

Tier 4 PA; QL (2 EA per 1 day)

AUSTEDO XR TITRATION KT(WK1-4) ORAL

TABLET, EXT REL 24HR DOSE PACK 6 MG

(14)-12 MG (14)-24 MG (14)

Tier 4 PA

tetrabenazine oral tablet 12.5 mg Tier 4 PA; QL (120 EA per 30 days)

tetrabenazine oral tablet 25 mg Tier 4 PA; QL (60 EA per 30 days)

WAKEFULNESS-PROMOTING AGENTS

armodafinil Tier 1 PA; QL (30 EA per 30 days)

modafinil oral tablet 100 mg Tier 1 PA; QL (30 EA per 30 days)

modafinil oral tablet 200 mg Tier 1 PA; QL (60 EA per 30 days)

WAKIX ORAL TABLET 17.8 MG Tier 4 PA; QL (60 EA per 30 days)

WAKIX ORAL TABLET 4.45 MG Tier 4 PA; QL (30 EA per 30 days)

DENTAL AGENTS

DENTA 5000 PLUS Tier 1

fluoride (sodium) dental cream Tier 1

fluoride (sodium) dental gel Tier 1

fluoride (sodium) dental paste Tier 1

fluoride (sodium) oral Tier 1

LUDENT FLUORIDE Tier 1

SF Tier 1

SF 5000 PLUS Tier 1

SODIUM FLUORIDE 5000 DRY MOUTH Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

SODIUM FLUORIDE 5000 PLUS Tier 1

DEVICES

2-IN-1 LANCET DEVICE Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ACCU-CHEK FASTCLIX LANCET DRUM Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ACCU-CHEK FASTCLIX LANCING DEV Tier 2

ACCU-CHEK MULTICLIX LANCET Tier 2

ACCU-CHEK SAFE-T-PRO Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ACCU-CHEK SAFE-T-PRO PLUS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ACCU-CHEK SOFT DEV LANCETS Tier 2

ACCU-CHEK SOFTCLIX LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ACTI-LANCE LANCETS Tier 1 QL (204 EA per 30 days)

ADJUSTABLE LANCING DEVICE Tier 2

ADVANCED LANCING DEVICE Tier 2

ADVANCED TRAVEL LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ADVIN COVID-19 AG HOME TEST Tier 2

ADVOCATE LANCET 21 GAUGE, 23 GAUGE,

28 GAUGE

Tier 2 QL (204 EA per 30 days)

ADVOCATE LANCET 26 GAUGE, 30 GAUGE Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ADVOCATE LANCING DEVICE Tier 2

AEROCHAMBER PLUS FLOW-VU,L MSK Tier 2

AEROCHAMBER PLUS FLOW-VU,M MSK Tier 2

AEROCHAMBER PLUS FLOW-VU,S MSK Tier 2

AEROCHAMBER PLUS Z STAT LG MSK Tier 2

AEROCHAMBER PLUS Z STAT MD MSK Tier 2

AEROCHAMBER PLUS Z STAT SM MSK Tier 2

ALTERNATE SITE LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ALTERNATE SITE LANCING DEVICE Tier 2

AQUA LANCE LANCING DEVICE Tier 2

AQUASTAT 0.9% SODIUM CHLORIDE Tier 1

AQUASTAT SFR 0.9% SODIUM CHLOR Tier 1

ASSURE LANCE Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

ASSURE LANCE PLUS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

AUTO-LANCET MINI Tier 2

AUTOLET IMPRESSION LANC DEV Tier 2

AUTOLET LANCING DEVICE Tier 2

BD ALLERGY SYRINGE Tier 2 QL (400 EA per 30 days)

BD AUTOSHIELD DUO PEN NEEDLE Tier 2

BD BLUNT PLASTIC CANNULA Tier 2 QL (400 EA per 30 days)

BD BULK SYRINGE SLIP TIP Tier 2 QL (400 EA per 30 days)

BD ECCENTRIC TIP SYRINGE Tier 2 QL (400 EA per 30 days)

BD ECLIPSE LUER-LOK NEEDLE Tier 2

BD ECLIPSE LUER-LOK SYRINGE 1 ML 27 X

1/2", 3 ML 23 X 1", 3 ML 25 X 5/8"

Tier 2 QL (400 EA per 30 days)

BD ECLIPSE LUER-LOK SYRINGE 1 ML 30

GAUGE X 1/2"

Tier 2

QL (400 EA per 30 days); $0 on

Diabetic Plans

BD ECLIPSE NEEDLE 21 GAUGE X 1", 25

GAUGE X 1"

Tier 2

BD FILTER NEEDLE 5-MICRON NOKO Tier 2

BD FILTER NEEDLE-5 MICRON Tier 2

BD INSULIN SYRINGE (HALF UNIT) Tier 2 QL (400 EA per 30 days)

BD INSULIN SYRINGE MICRO-FINE Tier 2

QL (400 EA per 30 days); $0 on

Diabetic Plans

BD INSULIN SYRINGE SYRINGE 0.3 ML 29

GAUGE X 1/2"

Tier 2 QL (400 EA per 30 days)

BD INSULIN SYRINGE SYRINGE 0.5 ML 29

GAUGE X 1/2", 1 ML 27 GAUGE X 1/2", 1 ML 28

GAUGE X 1/2", 1 ML 29 GAUGE X 1/2"

Tier 2

QL (400 EA per 30 days); $0 on

Diabetic Plans

BD INSULIN SYRINGE U-500 Tier 2 QL (400 EA per 30 days)

BD INSULIN SYRINGE ULTRA-FINE SYRINGE

0.3 ML 30 GAUGE X 1/2", 0.3 ML 31 GAUGE X

5/16"

Tier 2 QL (400 EA per 30 days)

BD INSULIN SYRINGE ULTRA-FINE SYRINGE

0.5 ML 30 GAUGE X 1/2", 0.5 ML 31 GAUGE X

5/16", 1 ML 30 GAUGE X 1/2", 1 ML 31 GAUGE

X 5/16

Tier 2

QL (400 EA per 30 days); $0 on

Diabetic Plans

BD INTEGRA SYRINGE Tier 2 QL (400 EA per 30 days)

BD INTERLINK BLUNT PLASTIC CAN Tier 2 QL (400 EA per 30 days)

BD INTERLINK SYRINGE Tier 2 QL (400 EA per 30 days)

BD INTRADERMAL BEVEL NEEDLES Tier 2

BD LO-DOSE MICRO-FINE IV Tier 2

QL (400 EA per 30 days); $0 on

Diabetic Plans

BD LUER-LOK BULK SYRINGE Tier 2 QL (400 EA per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

BD LUER-LOK SYRINGE Tier 2 QL (400 EA per 30 days)

BD LUER-LOK TIP CONTROL SYRING Tier 2 QL (400 EA per 30 days)

BD MICROTAINER LANCET 1.5 X 2 MM Tier 2

BD MICROTAINER LANCET 21 GAUGE Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

BD NOKOR ADMIX NEEDLE Tier 2

BD POSIFLUSH NORMAL SALINE 0.9 Tier 1

BD PRECISIONGLIDE Tier 2

BD PRECISIONGLIDE NON-STERILE Tier 2

BD QUINCKE SPINAL NEEDLE Tier 2

BD REGULAR BEVEL NEEDLES Tier 2

BD SAFETYGLIDE ALLERGIST TRAY

SYRINGE 1 ML 26 GAUGE X 3/8"

Tier 2 QL (400 EA per 30 days)

BD SAFETYGLIDE INSULIN SYRINGE

SYRINGE 0.3 ML 29 GAUGE X 1/2", 0.3 ML 31

GAUGE X 15/64", 0.3 ML 31 GAUGE X 5/16",

0.5 ML 30 GAUGE X 5/16", 0.5 ML 31 GAUGE X

15/64", 1 ML 29 GAUGE X 1/2", 1 ML 31 GAUGE

X 15/64"

Tier 2 QL (400 EA per 30 days)

BD SAFETYGLIDE NEEDLE Tier 2

BD SAFETYGLIDE SHIELDING REG Tier 2 QL (400 EA per 30 days)

BD SAFETYGLIDE SYRINGE SYRINGE 1 ML

27 GAUGE X 5/8"

Tier 2

QL (400 EA per 30 days); $0 on

Diabetic Plans

BD SAFETYGLIDE SYRINGE SYRINGE 3 ML

23 X 1", 3 ML 25 X 5/8"

Tier 2 QL (400 EA per 30 days)

BD SAFETYGLIDE TB REG BEVEL Tier 2 QL (400 EA per 30 days)

BD SAFETYGLIDE TUBERCULIN Tier 2 QL (400 EA per 30 days)

BD SHORT BEVEL NEEDLES Tier 2

BD SHORT BEVEL THIN WALL Tier 2

BD SLIP TIP SYRINGE Tier 2 QL (400 EA per 30 days)

B-D SLIP TIP SYRINGE Tier 2 QL (400 EA per 30 days)

BD SPECIALTY USE NEEDLES NEEDLE 16

GAUGE X 1 1/2", 16 GAUGE X 1", 21 GAUGE X

2", 23 GAUGE X 1 1/4", 25 GAUGE X 7/8", 27

GAUGE X 1 1/4", 30 GAUGE X 1"

Tier 2

BD SYRINGE Tier 2 QL (400 EA per 30 days)

BD SYRINGE CATH TIP NONSTERILE Tier 2 QL (400 EA per 30 days)

BD SYRINGE CATHETER TIP Tier 2 QL (400 EA per 30 days)

BD SYRINGE LUER-LOK NONSTERILE Tier 2 QL (400 EA per 30 days)

BD SYRINGE LUER-LOK STERILE Tier 2 QL (400 EA per 30 days)

BD SYRINGE SLIP TIP NONSTERILE Tier 2 QL (400 EA per 30 days)

BD SYRINGE TIP CAP Tier 2 QL (400 EA per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

BD SYRINGE-DUAL CANNULA Tier 2 QL (400 EA per 30 days)

BD TUBERCULIN SLIP-TIP Tier 2 QL (400 EA per 30 days)

BD TUBERCULIN SYRINGE Tier 2 QL (400 EA per 30 days)

BD ULTRA-FINE MICRO PEN NEEDLE Tier 2 $0 on Diabetic Plans

BD ULTRA-FINE MINI PEN NEEDLE Tier 2 $0 on Diabetic Plans

BD ULTRA-FINE ORIG PEN NEEDLE Tier 2

QL (400 EA per 30 days); $0 on

Diabetic Plans

BD ULTRA-FINE SHORT PEN NEEDLE Tier 2 $0 on Diabetic Plans

BD VEO INSULIN SYR (HALF UNIT) Tier 2 QL (400 EA per 30 days)

BD VEO INSULIN SYRINGE UF SYRINGE 0.3

ML 31 GAUGE X 15/64"

Tier 2 QL (400 EA per 30 days)

BD VEO INSULIN SYRINGE UF SYRINGE 1 ML

31 GAUGE X 15/64", 1/2 ML 31 GAUGE X

15/64"

Tier 2

QL (400 EA per 30 days); $0 on

Diabetic Plans

BD VERITOR AT-HOME COVID19 TST Tier 2 QL (8 EA per 30 days)

BINAXNOW COVD AG CARD HOME TST Tier 2 QL (8 EA per 30 days)

BINAXNOW COVID-19 AG SELF TEST Tier 2 QL (8 EA per 30 days)

BIOLON Tier 1

blunt needle, disposable Tier 2

BLUNT SPINAL NEEDLE Tier 2

BREATHERITE SPACER-MASK, NEO. Tier 2

BREATHERITE SPACER-MASK,ADULT Tier 2

BREATHERITE SPACER-MASK,CHILD Tier 2

BREATHERITE SPACER-MASK,INFANT Tier 2

BREATHERITE SPACER-MASK,S.CHLD Tier 2

BULLSEYE MINI SAFETY LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

BUTTERFLY TOUCH LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

CAREONE LANCING DEVICE Tier 2

CAREONE ULTRA THIN LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

CAREPOINT LUER LOCK SYR-NEEDLE Tier 2 QL (400 EA per 30 days)

CAREPOINT SAFETY LL SYR-NEEDLE Tier 2 QL (400 EA per 30 days)

CARESENS LANCETS Tier 2

CARESTART COVID-19 AG HOME TST Tier 2 QL (8 EA per 30 days)

CARETOUCH LANCING DEVICE Tier 2

CARETOUCH LUER LOCK SYR-NEEDLE Tier 2 QL (400 EA per 30 days)

CARETOUCH SAFETY LANCETS Tier 2 QL (204 EA per 30 days)

CARETOUCH TWIST LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

CELLTRION DIATRUST COV-19 HOME Tier 2 QL (8 EA per 30 days)

CHEMO TRANSFER PIN Tier 2

CHOSEN LANCET Tier 2 QL (204 EA per 30 days)

CHOSEN LANCING DEVICE Tier 2

CHOSEN SAFETY LANCET Tier 2 QL (204 EA per 30 days)

CLEVER CHEK LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

CLEVER CHOICE CHAMBER-LRG MASK Tier 2

CLEVER CHOICE CHAMBER-MED MASK Tier 2

CLEVER CHOICE CHAMBER-SM MASK Tier 2

CLINITEST COVID-19 HOME TEST Tier 2 QL (8 EA per 30 days)

COAGUCHEK LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

COLOR LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

COMFORT EZ LANCETS 23 GAUGE Tier 2 QL (204 EA per 30 days)

COMFORT EZ LANCETS 28 GAUGE Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

COMFORT TOUCH PLUS SAFETY LANC Tier 2 QL (204 EA per 30 days)

COMFORT TOUCH ULT THIN LANCETS Tier 2 QL (204 EA per 30 days)

COMFORTSEAL LARGE MASK Tier 2

COMFORTSEAL MEDIUM MASK Tier 2

COMFORTSEAL SMALL MASK Tier 2

COMPACT SPACE CHAMBER-LRG MASK Tier 2

COMPACT SPACE CHAMBER-MED MASK Tier 2

COMPACT SPACE CHAMBER-SM MASK Tier 2

CORDX COVID-19 AG HOME TEST Tier 2

COVID-19 AT-HOME TEST Tier 2 QL (8 EA per 30 days)

CYCLOTENS STARTER Tier 2

DAVOL IRRIGATION SYRINGE Tier 2 QL (400 EA per 30 days)

DAVOL PISTON IRRIGATION Tier 2 QL (400 EA per 30 days)

DEXCOM G6 RECEIVER Tier 2 PA; $0 on Diabetic Plans

DEXCOM G6 SENSOR Tier 2

PA; QL (3 EA per 30 days); $0 on

Diabetic Plans

DEXCOM G6 TRANSMITTER Tier 2

PA; QL (1 EA per 90 days); $0 on

Diabetic Plans

DEXCOM G7 RECEIVER Tier 2 PA; $0 on Diabetic Plans

DEXCOM G7 SENSOR Tier 2

PA; QL (3 EA per 30 days); $0 on

Diabetic Plans

DROPLET GENTEEL LANCING DEVICE Tier 2

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

DROPLET LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

DROPLET LANCING DEVICE Tier 2

EASIVENT MASK LARGE Tier 2

EASIVENT MASK MEDIUM Tier 2

EASIVENT MASK SMALL Tier 2

EASY COMFORT LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

EASY MINI EJECT LANCING DEVICE Tier 2

EASY TOUCH FLIPLOCK SYRINGE SYRINGE

1 ML 25 GAUGE X 1", 1 ML 26 GAUGE X 3/8", 1

ML 27 GAUGE X 1/2"

Tier 2 QL (400 EA per 30 days)

EASY TOUCH FLURINGE Tier 2 QL (400 EA per 30 days)

EASY TOUCH FLURINGE FLIPLOCK Tier 2 QL (400 EA per 30 days)

EASY TOUCH FLURINGE SHEATHLOCK Tier 2 QL (400 EA per 30 days)

EASY TOUCH LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

EASY TOUCH LANCING DEVICE Tier 2

EASY TOUCH SAFETY LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

EASY TOUCH SYRINGE Tier 2 QL (400 EA per 30 days)

EASY TOUCH TUBERCULIN FLIPLOCK Tier 2 QL (400 EA per 30 days)

EASY TOUCH TUBERCULIN SHEATHLK Tier 2 QL (400 EA per 30 days)

EASY TOUCH TWIST LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

EASY TWIST AND CAP LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ECLIPSE SYRINGE Tier 2 QL (400 EA per 30 days)

ELLUME COVID-19 HOME TEST Tier 2 QL (8 EA per 30 days)

EMBRACE LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

EMBRACE LANCING DEVICE Tier 2

EMBRACE PEN NEEDLE NEEDLE 30 GAUGE

X 3/16", 30 GAUGE X 5/16", 31 GAUGE X 1/4",

31 GAUGE X 5/16"

Tier 2 $0 on Diabetic Plans

EMBRACE SAFETY LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

EXCEL SYRINGE Tier 2 QL (400 EA per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

EXEL HYPODERMIC NEEDLES NEEDLE 18

GAUGE X 1 1/2", 19 GAUGE X 1", 20 GAUGE X

1 1/2", 20 GAUGE X 1", 20 X 3/4 ", 21 GAUGE X

1 1/2", 21 GAUGE X 1", 22 GAUGE X 1 1/2", 22

GAUGE X 1", 22 GAUGE X 3/4", 23 GAUGE X

3/4", 25 GAUGE X 1 1/2", 25 GAUGE X 1", 25

GAUGE X 3/4", 25 GAUGE X 5/8", 26 GAUGE X

1 1/2", 26 GAUGE X 1/2", 26 GAUGE X 3/8", 26

GAUGE X 5/8", 27 GAUGE X 1/2", 30 GAUGE X

1/2"

Tier 2

EXEL SYRINGE SYRINGE 10 ML, 3 ML 27

GAUGE X 1 1/4", 30 ML, 50 ML

Tier 2 QL (400 EA per 30 days)

E-Z JECT LANCETS Tier 1

QL (204 EA per 30 days); $0 on

Diabetic Plans

E-Z JECT THIN LANCETS Tier 1

QL (204 EA per 30 days); $0 on

Diabetic Plans

EZ SMART LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

FASTEP COVID-19 AG HOME TEST Tier 2 QL (8 EA per 30 days)

FEMCAP Tier 2 QL (1 EA per 365 days)

filter needles needle 18 gauge x 1 1/2" Tier 2

FINGERSTIX LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

FLEXICHAMBER-LG CHILD MASK Tier 2

FLEXICHAMBER-SM ADULT MASK Tier 2

FLEXICHAMBER-SM CHILD MASK Tier 2

FLOW-EZE VENTED NEEDLE Tier 2

FLOWFLEX COVID-19 AG HOME TEST Tier 2 QL (8 EA per 30 days)

FORA LANCING DEVICE Tier 2

FORACARE LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

FREESTYLE CONTROL Tier 2 QL (4 EA per 365 days)

FREESTYLE LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

FREESTYLE LIBRE 14 DAY READER Tier 2

PA; QL (1 EA per 1 Lifetime); $0

on Diabetic Plans

FREESTYLE LIBRE 14 DAY SENSOR Tier 2

PA; QL (2 EA per 28 days); $0 on

Diabetic Plans

FREESTYLE LIBRE 2 READER Tier 2

PA; QL (1 EA per 1 Lifetime); $0

on Diabetic Plans

FREESTYLE LIBRE 2 SENSOR Tier 2

PA; QL (2 EA per 28 days); $0 on

Diabetic Plans

FREESTYLE LIBRE 3 READER Tier 2 PA; QL (2 EA per 28 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

FREESTYLE LIBRE 3 SENSOR Tier 2

PA; QL (2 EA per 28 days); $0 on

Diabetic Plans

FREESTYLE UNISTIK 2 Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

GENABIO COVID-19 RAPID AT-HOME Tier 2 QL (8 EA per 30 days)

GLUCOCOM LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

GLUCOSE KETONE CONTROL SOLN Tier 2 QL (4 EA per 365 days)

GOJJI LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

GOJJI LANCING DEVICE Tier 2

GOTOKNOW COVID-19 AG HOME TEST Tier 2

HEALON PRO Tier 1

HEALTHY ACCENTS AUTOLET Tier 2

HEALTHY ACCENTS UNILET LANCET Tier 2 QL (204 EA per 30 days)

huber safety needles (disp.) Tier 1

HURRICAINE LUER-LOCK DIS CAP Tier 2

HYPODERMIC NEEDLES Tier 2

HYPOLANCE AST LANCING Tier 2

IHEALTH COVID-19 AG HOME TEST Tier 2 QL (8 EA per 30 days)

INCONTROL LANCING DEVICE Tier 2

INCONTROL SUPER THIN LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

INCONTROL ULTRA THIN LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

INDICAID COVID-19 AG HOME TEST Tier 2 QL (8 EA per 30 days)

INJECT EASE LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

INJECT-EASE Tier 2 QL (400 EA per 30 days)

INSULIN SYRINGE MICROFINE Tier 2

QL (400 EA per 30 days); $0 on

Diabetic Plans

INSULIN SYRINGE SYRINGE 0.5 ML 29

GAUGE X 1/2"

Tier 2 QL (400 EA per 30 days)

insulin syringe-needle u-100 syringe 1 ml 28

gauge x 1/2"

Tier 2 QL (400 EA per 30 days)

INTEGRA SYRINGE Tier 2 QL (400 EA per 30 days)

INTELISWAB COVID-19 HOME TEST Tier 2 QL (8 EA per 30 days)

INTERLINK SYRINGE CANNULA Tier 2 QL (400 EA per 30 days)

INVACARE LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

lancets , 21 gauge, 26 gauge, 28 gauge, 30

gauge

Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

lancets 33 gauge Tier 2 QL (204 EA per 30 days)

LANCETS, SUPER THIN Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

LANCETS,THIN Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

LANCETS,ULTRA THIN Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

lancing device Tier 2

lancing device with lancets kit Tier 2

LANCING SYSTEM Tier 2

LANZO LANCING DEVICE Tier 2

LIFESHIELD BLUNT CANNULA NEEDLE Tier 2

LIFESHIELD BLUNT CANNULA SYRINGE Tier 2 QL (400 EA per 30 days)

LITE TOUCH-MEDIUM MASK Tier 2

LITETOUCH-LARGE MASK Tier 2

LITETOUCH-SMALL MASK Tier 2

LUER LOCK SYRINGE SYRINGE 30 ML Tier 2 QL (400 EA per 30 days)

LUER-LOK TIP Tier 2 QL (400 EA per 30 days)

MAGELLAN SAFETY SYRINGE Tier 2 QL (400 EA per 30 days)

MAGELLAN SYRINGE SYRINGE 1 ML 27

GAUGE X 1/2"

Tier 2 QL (400 EA per 30 days)

MAGELLAN TUBERCULIN SAFETY SYR Tier 2 QL (400 EA per 30 days)

MEDISENSE MID CONTROL Tier 2 QL (4 EA per 365 days)

MEDISENSE THIN LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

MEDLANCE PLUS LANCETS Tier 1

QL (204 EA per 30 days); $0 on

Diabetic Plans

MEDLANCE PLUS SPECIAL BLADE Tier 2

MICRO THIN LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

MICROLET 2 LANCING DEVICE Tier 2

MICROLET LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

MICROLET NEXT LANCING DEVICE Tier 2

MINI LANCING DEVICE Tier 2

MINI TRANSFER PIN Tier 2

MINIMED QUICK-SERTER (MMT-395) Tier 2

MOBILE LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

MONOJECT 0.9% SODIUM CHLORIDE Tier 1

MONOJECT 140CC PISTON SYRINGE Tier 2 QL (400 EA per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

MONOJECT 35CC SYRINGE CATH TIP Tier 2 QL (400 EA per 30 days)

MONOJECT 3CC SYR 25GX1" Tier 2 QL (400 EA per 30 days)

MONOJECT ALLERGY TRAY Tier 2 QL (400 EA per 30 days)

MONOJECT ALLERGY TRAY DETACH Tier 2 QL (400 EA per 30 days)

MONOJECT BLOOD COLLECTION Tier 2

MONOJECT BLUNT CANNULAS Tier 2

MONOJECT CONTROL SYRINGE LUER Tier 2 QL (400 EA per 30 days)

MONOJECT DISPOSABLE SYRINGE Tier 2 QL (400 EA per 30 days)

MONOJECT ECCENTRIC NON-STERILE Tier 2 QL (400 EA per 30 days)

MONOJECT FILTER ASPIRATOR Tier 2

MONOJECT FILTER NEEDLE Tier 2

MONOJECT HYPODERMIC NEEDLES Tier 2

MONOJECT HYPODERMIC POLYPROPYL Tier 2

MONOJECT LUER-LOCK TIP Tier 2 QL (400 EA per 30 days)

MONOJECT MAGELLAN SYRINGE Tier 2 QL (400 EA per 30 days)

MONOJECT MEDICATION TRANSF NDL Tier 2

MONOJECT PHARMACY TRAY LUER Tier 2 QL (400 EA per 30 days)

MONOJECT PHARMACY TRAY REG TIP Tier 2 QL (400 EA per 30 days)

MONOJECT PREFILL ADVANCED NS Tier 1

MONOJECT REG TIP NON-STERILE Tier 2 QL (400 EA per 30 days)

MONOJECT REGULAR LUER Tier 2 QL (400 EA per 30 days)

MONOJECT SAFETY LUER LOCK TIP Tier 2 QL (400 EA per 30 days)

MONOJECT SAFETY SYRINGES Tier 2 QL (400 EA per 30 days)

MONOJECT SYRINGE ECCENTRI LUER Tier 2 QL (400 EA per 30 days)

MONOJECT SYRINGE LUER LOK Tier 2 QL (400 EA per 30 days)

MONOJECT SYRINGE REGULAR LUER Tier 2 QL (400 EA per 30 days)

MONOJECT SYRINGE SYRINGE 12 ML 18

GAUGE X 1", 12 ML 20 X 1 1/2", 12 ML 21

GAUGE X 1 1/2", 12 ML 21 GAUGE X 1", 3 ML,

3 ML 20 GAUGE X 1 1/2", 3 ML 20 GAUGE X 1",

3 ML 20 X 3/4", 3 ML 21 GAUGE X 1 1/2", 3 ML

21 GAUGE X 1", 3 ML 22 GAUGE X 1", 3 ML 22

X 1 1/2", 3 ML 23 X 1", 3 ML 25 GAUGE X 1", 3

ML 25 X 1 1/4", 3 ML 25 X 5/8", 3 ML 27 GAUGE

X 1 1/4", 6 ML, 6 ML 20 X 1 1/2", 6 ML 21 X 1

1/2", 6 ML 21 X 1", 6 ML 22 X 1 1/2"

Tier 2 QL (400 EA per 30 days)

MONOJECT SYRINGE TOOMEY TYPE Tier 2 QL (400 EA per 30 days)

MONOJECT TB Tier 2 QL (400 EA per 30 days)

MONOJECT TB LUER LOK Tier 2 QL (400 EA per 30 days)

MONOJECT TB REGULAR LUER TIP Tier 2 QL (400 EA per 30 days)

MONOJECT TB SAFETY SYRINGE Tier 2 QL (400 EA per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

MONOJECT TIP CAPS/FLEX/LUER Tier 2 QL (400 EA per 30 days)

MONOJECT TUBERCULIN SYRINGE Tier 2 QL (400 EA per 30 days)

MONOLET LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

MONOLET THIN LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

MOUTHPIECE Tier 2

MULTI-DRAW NEEDLE Tier 2

MULTI-LANCET DEVICE 2 Tier 2

MYGLUCOHEALTH LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

NEBUSAL INHALATION SOLUTION FOR

NEBULIZATION 3 %

Tier 1

needle (disp) 16 g Tier 2

needle (disp) 18 g Tier 2

needle (disp) 19 g Tier 2

needle (disp) 23 gauge Tier 2

needles, huber disposable Tier 2

NOKOR NEEDLE Tier 2

NORMAL SALINE FLUSH Tier 1

NOVA SAFETY LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

NOVA SUREFLEX LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

NOVAMAX PLUS KETONE Tier 2

NOVOFINE 32 Tier 2 $0 on Diabetic Plans

NOVOFINE PLUS Tier 2 $0 on Diabetic Plans

OMNIPOD 5 G6 INTRO KIT (GEN 5) Tier 2 PA; QL (1 EA per 1 LIFETIME)

OMNIPOD 5 G6 PODS (GEN 5) Tier 2 PA; QL (10 EA per 21 days)

OMNIPOD DASH INTRO KIT (GEN 4) Tier 2 PA

OMNIPOD DASH PDM KIT (GEN 4) Tier 2 PA

OMNIPOD DASH PODS (GEN 4) Tier 2 PA; QL (10 EA per 21 days)

ON CALL LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ON CALL LANCING DEVICE Tier 2

ON CALL PLUS LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ON CALL PLUS LANCING DEVICE Tier 2

ONE WAY VALVED MOUTHPIECE Tier 2

ONETOUCH DELICA PLUS LANC DEV Tier 2

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

ONETOUCH DELICA PLUS LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ONETOUCH DELICA SAFETY LANCET Tier 2 QL (204 EA per 30 days)

ONETOUCH ULTRASOFT 2 LANCET Tier 2 QL (204 EA per 30 days)

ONETOUCH VERIO FLEX METER Tier 2

QL (1 EA per 1 LIFETIME); $0 on

Diabetic Plans

ONETOUCH VERIO HIGH CONTROL Tier 2

QL (4 EA per 365 days); $0 on

Diabetic Plans

ONETOUCH VERIO MID CONTROL Tier 2

QL (4 EA per 365 days); $0 on

Diabetic Plans

ON-GO COVID-19 AG AT HOME TEST Tier 2 QL (8 EA per 30 days)

ON-THE-GO LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

OPTICHAMBER ADULT MASK-LARGE Tier 2

OPTICHAMBER DIAMOND LG MASK Tier 2

OPTICHAMBER DIAMOND-MED MSK Tier 2

OPTICHAMBER DIAMOND-SML MASK Tier 2

PANDA MASK Tier 2

PEDIATRIC MEDIUM MASK Tier 2

PEDIATRIC PANDA MASK Tier 2

PEDIATRIC SMALL MASK Tier 2

PILOT COVID-19 AT-HOME TEST Tier 2 QL (8 EA per 30 days)

PIP LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

POLY HUB NEEDLE Tier 2

PRECISION XTRA B-KETONE Tier 2

PRESSURE ACTIVATED LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

PRO COMFORT LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

PRO COMFORT SAFETY LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

PRO COMFORT SPACER-ADULT MASK Tier 2

PROCARE SPACER WITH ADULT MASK Tier 2

PROCARE SPACER WITH CHILD MASK Tier 2

PRODIGY COUNT-A-DOSE Tier 2 QL (400 EA per 30 days)

PRODIGY LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

PRODIGY LANCING DEVICE Tier 2

PRODIGY TWIST TOP LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

PULMOSAL Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

PURE COMFORT LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

PURE COMFORT SAFETY LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

PUSH BUTTON SAFETY LANCETS 28 GAUGE Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

QUICKVUE AT-HOME COVID-19 TEST Tier 2 QL (8 EA per 30 days)

RAPID SARS-COV-2 AG HOME TEST Tier 2

RELIAMED LANCET 28 GAUGE Tier 2 QL (204 EA per 30 days)

RELIAMED LANCET 30 GAUGE Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

RELIAMED MINI LANCING DEVICE Tier 2

RELIAMED SAFETY SEAL LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

RIGHTEST GD500 LANCING DEVICE Tier 2

RIGHTEST GL300 LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

SAFESNAP SYRINGE SYRINGE 10 ML, 10 ML

20 GAUGE X 1 1/2", 10 ML 20 GAUGE X 1", 10

ML 21 GAUGE X 1 1/2", 10 ML 21 GAUGE X 1",

10 ML 22 GAUGE X 1", 3 ML, 3 ML 20 GAUGE X

1 1/2", 3 ML 20 GAUGE X 1", 3 ML 21 GAUGE X

1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22 GAUGE X

1 1/2", 3 ML 22 GAUGE X 1", 3 ML 23 GAUGE X

1 1/2", 3 ML 23 GAUGE X 1", 3 ML 25 GAUGE X

1", 3 ML 25 GAUGE X 5/8", 5 ML, 5 ML 20

GAUGE X 1 1/2", 5 ML 21 GAUGE X 1 1/2", 5

ML 21 GAUGE X 1", 5 ML 22 GAUGE X 1 1/2", 5

ML 22 GAUGE X 1"

Tier 2 QL (400 EA per 30 days)

SAFETY LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

safety needles Tier 2

SAFETY SEAL LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

SAFETY-LET LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

SIDESTREAM PEDIATRIC FACE MASK Tier 2

SILICONE MASK - INFANT Tier 2

SILICONE MASK - PEDIATRIC Tier 2

SIL-SERTER Tier 2

SINGLE-LET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

SMART SENSE LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

SMARTDIABETES VANTAGE Tier 2

SMARTEST LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

sodium chloride inhalation solution for

nebulization 0.9 %, 3 %, 7 %

Tier 1

sodium chloride inhalation solution for

nebulization 10 %

Tier 1 QL (4 ML per 1 day)

SOFT TOUCH LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

SOLUS V2 LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

SOLUS V2 LANCING DEVICE Tier 2

SPACE CHAMBER WITH LARGE MASK Tier 2

SPACE CHAMBER WITH MEDIUM MASK Tier 2

SPACE CHAMBER WITH SMALL MASK Tier 2

SPEEDYSWAB COVID-19 HOME TEST Tier 2 QL (8 EA per 30 days)

STERILANCE TL Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

SUPER THIN LANCETS 28 GAUGE Tier 2 QL (204 EA per 30 days)

SUPER THIN LANCETS 30 GAUGE Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

SURE COMFORT LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

SURE COMFORT LANCING PEN Tier 2

SUREFLEX DEVICE WITH LANCETS Tier 2

SUREFLEX LANCING DEVICE Tier 2

SURE-LANCE Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

SURE-LANCE ULTRA THIN Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

SURE-PEN LANCING DEVICE Tier 2

SURE-TOUCH LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

SURGIFOAM TOPICAL SPONGE 12-7 MM Tier 1

SURGUARD2 SAFETY NEEDLE Tier 2

SURGUARD2 SAFETY SYRINGE Tier 2 QL (400 EA per 30 days)

syringe (disposable) Tier 2 QL (400 EA per 30 days)

SYRINGE 3CC/20GX1" Tier 2 QL (400 EA per 30 days)

SYRINGE 3CC/21GX1" Tier 2 QL (400 EA per 30 days)

SYRINGE 3CC/21GX1-1/2" Tier 2 QL (400 EA per 30 days)

SYRINGE 3CC/22GX1" Tier 2 QL (400 EA per 30 days)

SYRINGE 3CC/22GX3/4" Tier 2 QL (400 EA per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

SYRINGE 3CC/25GX1" Tier 2 QL (400 EA per 30 days)

SYRINGE LUER TIP CAP Tier 2 QL (400 EA per 30 days)

SYRINGE TIP CONNECTOR Tier 2 QL (400 EA per 30 days)

syringe with needle syringe 1 ml 25 gauge x 1", 3

ml 20 gauge x 1 1/2", 3 ml 22 x 1 1/2"

Tier 2 QL (400 EA per 30 days)

SYRINGE WITHOUT NEEDLE Tier 2 QL (400 EA per 30 days)

TECHLITE INSULIN SYRINGE Tier 2

QL (400 EA per 30 days); $0 on

Diabetic Plans

TECHLITE INSULN SYR(HALF UNIT) Tier 2 QL (400 EA per 30 days)

TECHLITE LANCETS 26 GAUGE Tier 2 QL (204 EA per 30 days)

TECHLITE LANCETS 28 GAUGE, 30 GAUGE Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

TECHLITE PEN NEEDLE NEEDLE 29 GAUGE X

1/2"

Tier 2

QL (400 EA per 30 days); $0 on

Diabetic Plans

TECHLITE PEN NEEDLE NEEDLE 31 GAUGE X

3/16", 31 GAUGE X 5/16", 32 GAUGE X 1/4"

Tier 2 $0 on Diabetic Plans

TECHLITE PEN NEEDLE NEEDLE 32 GAUGE X

5/32"

Tier 2

QL (200 EA per 30 days); $0 on

Diabetic Plans

TELCARE LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

TERUMO ALLERGY SYRINGE Tier 2 QL (400 EA per 30 days)

TERUMO HYPODERMIC NEEDLE/SYRIN Tier 2 QL (400 EA per 30 days)

TERUMO SYRINGE Tier 2 QL (400 EA per 30 days)

THIN LANCETS Tier 2 QL (204 EA per 30 days)

TOOMEY SYRINGE Tier 2 QL (400 EA per 30 days)

TOPCARE UNIVERSAL1 LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

TRANSFER PIN Tier 2

TRUE COMFORT LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

TRUEDRAW LANCING DEVICE Tier 2

TRUEPLUS LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

TUBERCULIN SYRINGE Tier 2 QL (400 EA per 30 days)

tuberculin-allergy syringes Tier 2 QL (400 EA per 30 days)

TWIST LANCETS 30 GAUGE Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

TWIST LANCETS 32 GAUGE Tier 2 QL (204 EA per 30 days)

ULTICARE LOW DEAD SPACE SYRING

SYRINGE 3 ML 22 X 1 1/2"

Tier 2 QL (400 EA per 30 days)

ULTICARE SYRINGE 1 ML 25 GAUGE X 5/8" Tier 2 QL (400 EA per 30 days)

ULTICARE TB SAFETY SYRINGE Tier 2 QL (400 EA per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

ULTI-LANCE Tier 2

ULTILET BASIC LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ULTILET CLASSIC LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ULTILET LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ULTILET SAFETY LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ULTRA THIN II LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ULTRA THIN LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ULTRA THIN PLUS LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ULTRA TLC LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ULTRA-CARE LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ULTRALANCE LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

ULTRA-THIN II LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

UNILET COMFORTOUCH LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

UNILET GP LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

UNILET LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

UNILET LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

UNILET SUPER THIN LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

UNISTIK 2 DEVICE Tier 2

UNISTIK 2 EXTRA LANCET Tier 2

UNISTIK 2 NORMAL LANCET Tier 2 QL (204 EA per 30 days)

UNISTIK 3 COMFORT LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

UNISTIK 3 EXTRA LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

UNISTIK 3 GENTLE Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

UNISTIK 3 NORMAL LANCET Tier 2 QL (204 EA per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

UNISTIK COMFORT LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

UNISTIK CZT LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

UNISTIK EXTRA LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

UNISTIK NORMAL LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

UNISTIK PRO LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

UNISTIK SAFETY Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

UNISTIK TOUCH LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

UNIVERSAL 1 LANCETS Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

VANISHPOINT SYRINGE SYRINGE 1 ML 25

GAUGE X 1", 3 ML 20 GAUGE X 1", 3 ML 21

GAUGE X 1 1/2", 3 ML 21 GAUGE X 1", 3 ML 22

GAUGE X 1", 3 ML 22 X 1 1/2", 3 ML 23 GAUGE

X 1 1/2", 3 ML 23 X 1", 3 ML 25 GAUGE X 1", 3

ML 25 X 5/8", 5 ML 21 GAUGE X 1", 5 ML 22

GAUGE X 1 1/2"

Tier 2 QL (400 EA per 30 days)

VANISHPOINT TUBERCULIN SYRINGE Tier 2 QL (400 EA per 30 days)

VERIFINE SAFETY LANCET MINI Tier 2 QL (204 EA per 30 days)

VERIFINE UNIVERSAL LANCET Tier 2 QL (204 EA per 30 days)

VIVAGUARD LANCET Tier 2

QL (204 EA per 30 days); $0 on

Diabetic Plans

VIVAGUARD LANCING DEVICE Tier 2

VIVAGUARD SAFETY LANCET Tier 2 QL (204 EA per 30 days)

VORTEX ADULT MASK Tier 2

VORTEX VHC FROG MASK-CHILD Tier 2

VORTEX VHC LADYBUG MASK-TODDLR Tier 2

YALE DISPOSABLE NEEDLES Tier 2

DIAGNOSTIC AGENTS

CARDIAC FUNCTION

aspirin-dipyridamole Tier 1 ST

dipyridamole oral Tier 1

DIABETES MELLITUS

ONETOUCH VERIO TEST STRIPS Tier 2

QL (50 EA per 30 days); $0 on

Diabetic Plans

DIAGNOSTIC AGENTS

glucagon hcl injection recon soln 1 mg/ml Tier 2

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

KETONES

KETONE CARE Tier 2 $0 on Diabetic Plans

KETONE URINE TEST Tier 2 $0 on Diabetic Plans

KETOSTIX Tier 2 $0 on Diabetic Plans

TRUEPLUS KETONE Tier 2

OCULAR DISORDERS

BIOGLO Tier 1

GLOSTRIPS OPHTHALMIC (EYE) STRIP 1 MG Tier 1

PHEOCHROMOCYTOMA

metyrosine Tier 1 PA

ROENTGENOGRAPHY AND OTHER IMAGING

AGENTS

MD-GASTROVIEW Tier 1

SUGAR

DIASTIX Tier 2

URINE AND FECES CONTENTS

CHEK-STIX CONTROL Tier 2

CHEMSTRIP 10 MD Tier 2

CHEMSTRIP 10/SG Tier 2

CHEMSTRIP 2 GP Tier 2

CHEMSTRIP 50B Tier 2

CHEMSTRIP 7 Tier 2

CHEMSTRIP 9 Tier 2

COMBISTIX REAGENT Tier 2

HEMA-COMBISTIX Tier 2

KETO-DIASTIX Tier 2

LABSTIX REAGENT Tier 2

MULTISTIX Tier 2

MULTISTIX 10 SG Tier 2

MULTISTIX 5 Tier 2

MULTISTIX 7 Tier 2

MULTISTIX 8 SG Tier 2

MULTISTIX 9 Tier 2

MULTISTIX 9 SG Tier 2

URISTIX 4 Tier 2

URISTIX REAGENT Tier 2

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

ELECTROLYTIC, CALORIC, AND WATER

BALANCE

ALKALINIZING AGENTS

potassium citrate oral tablet extended release Tier 1

sodium citrate-citric acid oral solution 490-640

mg/5 ml

Tier 1

AMMONIA DETOXICANTS

ENULOSE Tier 1

GENERLAC Tier 1

lactulose oral solution Tier 1

CALORIC AGENTS

ACD SOLUTION A Tier 2

ACD-A SOLUTION 2.45-2.2 GRAM- 730 MG/100

Tier 2

DEX4 GLUCOSE BITS Tier 1

DEX4 GLUCOSE ORAL TABLET,CHEWABLE Tier 1

DEX4 GLUCOSE POUCH PACK Tier 1

DEX4 GLUCOSE QUICK DISSOLVE Tier 1

dextrose oral gel Tier 1

ENFAMIL GLUCOSE Tier 2

GLUCO BURST Tier 1

GLUCOSE BITS Tier 1

GLUCOSE GEL Tier 1

glucose oral tablet,chewable 4 gram Tier 1

GLUTOL GEL Tier 2

GLUTOSE-15 Tier 2

GLUTOSE-45 Tier 2

GLUTOSE-5 Tier 1

RELION GLUCOSE Tier 1

CARBONIC ANHYDRASE INHIBITORS

acetazolamide Tier 1

DIURETICS, MISCELLANEOUS

ELIXOPHYLLIN Tier 2

THEO-24 Tier 2

theophylline Tier 1

IRRIGATING SOLUTIONS

AQUASTAT 0.9% SODIUM CHLORIDE Tier 1

AQUASTAT SFR 0.9% SODIUM CHLOR Tier 1

BD POSIFLUSH NORMAL SALINE 0.9 Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

DELFLEX WITH 2.5 % DEXTROSE Tier 1

DELFLEX-LC/1.5% DEXTROSE Tier 1

DELFLEX-LC/2.5% DEXTROSE Tier 1

DELFLEX-LC/4.25% DEXTROSE Tier 1

EXTRANEAL 7.5 % Tier 2

GLYCINE UROLOGIC Tier 1

glycine urologic solution Tier 1

MONOJECT 0.9% SODIUM CHLORIDE Tier 1

MONOJECT PREFILL ADVANCED NS Tier 1

NEBUSAL INHALATION SOLUTION FOR

NEBULIZATION 3 %

Tier 1

NORMAL SALINE FLUSH Tier 1

PULMOSAL Tier 1

sodium chloride inhalation solution for

nebulization 0.9 %, 3 %, 7 %

Tier 1

sodium chloride inhalation solution for

nebulization 10 %

Tier 1 QL (4 ML per 1 day)

LOOP DIURETICS (40:28)

bumetanide oral Tier 1

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8

mg/ml)

Tier 1

furosemide oral tablet Tier 1

torsemide Tier 1

PHOSPHATE-REMOVING AGENTS

AURYXIA Tier 2

calcium acetate(phosphat bind) Tier 1 QL (360 EA per 30 days)

lanthanum Tier 1 PA; QL (90 EA per 30 days)

sevelamer carbonate oral tablet Tier 1 PA; QL (270 EA per 30 days)

sevelamer hcl oral tablet 400 mg Tier 1 PA; QL (90 EA per 30 days)

VELPHORO Tier 3 PA; QL (120 EA per 30 days)

POTASSIUM-REMOVING AGENTS

KIONEX (WITH SORBITOL) Tier 1

sodium polystyrene sulfonate Tier 1

SPS (WITH SORBITOL) Tier 1

POTASSIUM-SPARING DIURETICS

amiloride Tier 1

amiloride-hydrochlorothiazide Tier 1

spironolactone oral tablet Tier 1

spironolacton-hydrochlorothiaz Tier 1

triamterene-hydrochlorothiazid oral capsule Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

triamterene-hydrochlorothiazid oral tablet 37.5-25

Tier 1 QL (1 EA per 1 day)

triamterene-hydrochlorothiazid oral tablet 75-50

Tier 1

REPLACEMENT PREPARATIONS

cardioplegic soln Tier 1

EFFER-K ORAL TABLET, EFFERVESCENT 25

MEQ

Tier 1

KLOR-CON 10 Tier 1

KLOR-CON 8 Tier 1

KLOR-CON M10 Tier 1

KLOR-CON M15 Tier 1

KLOR-CON M20 Tier 1

KLOR-CON/EF Tier 1

ONE DAILY PRENATAL Tier 1

potassium chloride oral capsule, extended

release

Tier 1

potassium chloride oral liquid Tier 1

potassium chloride oral tablet extended release Tier 1

potassium chloride oral tablet,er particles/crystals

10 meq, 20 meq

Tier 1

PRENATAL COMPLETE Tier 1

PRENATAL ONE DAILY Tier 1

PRENATAL TABLET Tier 1

PRENATAL VITAMIN ORAL TABLET 27 MG

IRON- 0.8 MG

Tier 1

PRENATAL VITAMIN WITH MINERALS Tier 1

prenatal vit-iron fum-folic ac Tier 1

WESNATAL DHA COMPLETE Tier 1

THIAZIDE DIURETICS

amiloride-hydrochlorothiazide Tier 1

benazepril-hydrochlorothiazide Tier 1

bisoprolol-hydrochlorothiazide Tier 1

candesartan-hydrochlorothiazid Tier 1

captopril-hydrochlorothiazide Tier 1

enalapril-hydrochlorothiazide Tier 1

fosinopril-hydrochlorothiazide Tier 1

hydrochlorothiazide Tier 1

irbesartan-hydrochlorothiazide Tier 1

lisinopril-hydrochlorothiazide Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

losartan-hydrochlorothiazide Tier 1

metoprolol ta-hydrochlorothiaz Tier 1

olmesartan-amlodipin-hcthiazid Tier 1

olmesartan-hydrochlorothiazide Tier 1

propranolol-hydrochlorothiazid Tier 1

quinapril-hydrochlorothiazide Tier 1

spironolacton-hydrochlorothiaz Tier 1

telmisartan-hydrochlorothiazid Tier 1

triamterene-hydrochlorothiazid oral capsule Tier 1

triamterene-hydrochlorothiazid oral tablet 37.5-25

Tier 1 QL (1 EA per 1 day)

triamterene-hydrochlorothiazid oral tablet 75-50

Tier 1

valsartan-hydrochlorothiazide Tier 1

THIAZIDE-LIKE DIURETICS

atenolol-chlorthalidone Tier 1

chlorthalidone Tier 1

indapamide Tier 1

metolazone Tier 1

URICOSURIC AGENTS

probenecid Tier 1

probenecid-colchicine Tier 1 ST

VASOPRESSIN ANTAGONISTS

JYNARQUE ORAL TABLET Tier 4 PA; QL (2 EA per 1 day)

tolvaptan oral tablet 15 mg Tier 4 PA; QL (30 EA per 30 days)

tolvaptan oral tablet 30 mg Tier 4 PA; QL (60 EA per 30 days)

ENZYMES

ENZYME COFACTORS/CHAPERONES

sapropterin Tier 4 PA

ENZYMES

PULMOZYME Tier 4 PA; QL (2.5 ML per 1 day)

SANTYL Tier 2 QL (180 GM per 30 days)

EYE, EAR, NOSE AND THROAT (EENT)

PREPS.

ALPHA-ADRENERGIC AGONISTS (EENT)

apraclonidine Tier 1 PA

brimonidine ophthalmic (eye) Tier 1

brimonidine topical Tier 1 PA

brimonidine-timolol Tier 1 PA

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

IOPIDINE Tier 2 PA

ANTIALLERGIC AGENTS

ALOMIDE Tier 2 PA; ST

azelastine nasal spray,non-aerosol 137 mcg (0.1

Tier 1 QL (60 ML per 30 days)

azelastine nasal spray,non-aerosol 205.5 mcg

(0.15 %)

Tier 1

azelastine ophthalmic (eye) Tier 1

azelastine-fluticasone Tier 1 ST; QL (23 GM per 30 days)

bepotastine besilate Tier 1 PA

cromolyn ophthalmic (eye) Tier 1

epinastine Tier 1

LASTACAFT ONCE DAILY RELIEF Tier 2 PA

olopatadine nasal Tier 1 QL (31 GM per 30 days)

olopatadine ophthalmic (eye) Tier 1

ZERVIATE Tier 2 PA; ST

ANTIBACTERIALS (52:04)

AZASITE Tier 2

bacitracin ophthalmic (eye) Tier 1

bacitracin-polymyxin b Tier 1

CIPRO HC Tier 3

ciprofloxacin Tier 1

ciprofloxacin hcl Tier 1

ciprofloxacin-dexamethasone Tier 1 ST

ciprofloxacin-fluocinolone Tier 2

doxycycline hyclate oral capsule Tier 1

doxycycline hyclate oral tablet 100 mg, 20 mg Tier 1

doxycycline monohydrate oral capsule 100 mg,

50 mg, 75 mg

Tier 1

doxycycline monohydrate oral capsule 150 mg Tier 1 ST

doxycycline monohydrate oral suspension for

reconstitution

Tier 1

doxycycline monohydrate oral tablet 100 mg, 50

Tier 1

ERYTHROCIN (AS STEARATE) Tier 1

erythromycin Tier 1

erythromycin ethylsuccinate Tier 1

gatifloxacin Tier 1

gentamicin ophthalmic (eye) Tier 1

levofloxacin ophthalmic (eye) Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

levofloxacin oral Tier 1

moxifloxacin Tier 1

neomycin Tier 1

neomycin-bacitracin-poly-hc Tier 1

neomycin-bacitracin-polymyxin Tier 1

neomycin-polymyxin b-dexameth Tier 1

neomycin-polymyxin-gramicidin Tier 1

neomycin-polymyxin-hc Tier 1

NEO-POLYCIN Tier 1

NEO-POLYCIN HC Tier 1

ofloxacin ophthalmic (eye) Tier 1 QL (10 ML per 30 days)

ofloxacin oral Tier 1 QL (2 EA per 1 day)

ofloxacin otic (ear) Tier 1

POLYCIN Tier 1

polymyxin b sulf-trimethoprim Tier 1

sulfacetamide sodium ophthalmic (eye) drops Tier 1

sulfacetamide-prednisolone Tier 1

tetracycline Tier 1

tobramycin ophthalmic (eye) Tier 1

tobramycin-dexamethasone Tier 1

ANTIFUNGALS (EENT)

NATACYN Tier 2 QL (15 ML per 30 days)

ANTI-INFECTIVES, MISCELLANEOUS (52:04)

acetic acid otic (ear) Tier 1

hydrocortisone-acetic acid Tier 1 QL (10 ML per 30 days)

ANTI-INFLAMMATORY AGENTS (EENT)

cyclosporine ophthalmic (eye) Tier 1 QL (60 EA per 30 days)

ANTIVIRALS (EENT)

trifluridine Tier 1

ASTRINGENTS (52:04)

chlorhexidine gluconate mucous membrane Tier 1

PAROEX ORAL RINSE Tier 1

PERIOGARD Tier 1

BETA-ADRENERGIC BLOCKING AGENTS

(EENT)

betaxolol ophthalmic (eye) Tier 1

brimonidine-timolol Tier 1 PA

carteolol Tier 1

dorzolamide-timolol Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

dorzolamide-timolol (pf) Tier 1

levobunolol Tier 1

timolol maleate (pf) ophthalmic (eye) dropperette

0.25 %

Tier 1

timolol maleate ophthalmic (eye) drops Tier 1

timolol maleate ophthalmic (eye) gel forming

solution

Tier 1

TIMOPTIC OCUDOSE (PF) OPHTHALMIC

(EYE) DROPPERETTE 0.25 %

Tier 2

CARBONIC ANHYDRASE INHIBITORS (EENT)

acetazolamide Tier 1

brinzolamide Tier 1 PA

dorzolamide Tier 1

dorzolamide-timolol Tier 1

dorzolamide-timolol (pf) Tier 1

methazolamide Tier 1

CORTICOSTEROIDS (EENT)

ALVESCO INHALATION HFA AEROSOL

INHALER 160 MCG/ACTUATION

Tier 3 QL (13 GM per 30 days)

ALVESCO INHALATION HFA AEROSOL

INHALER 80 MCG/ACTUATION

Tier 3 QL (7 GM per 30 days)

azelastine-fluticasone Tier 1 ST; QL (23 GM per 30 days)

CIPRO HC Tier 3

ciprofloxacin-dexamethasone Tier 1 ST

ciprofloxacin-fluocinolone Tier 2

dexamethasone sodium phosphate ophthalmic

(eye)

Tier 1

flunisolide Tier 1 ST; QL (50 ML per 30 days)

fluocinolone acetonide oil Tier 1

fluorometholone Tier 1

fluticasone propionate nasal Tier 1 QL (16 GM per 30 days)

hydrocortisone-acetic acid Tier 1 QL (10 ML per 30 days)

loteprednol etabonate ophthalmic (eye)

drops,suspension

Tier 1

mometasone nasal Tier 1 ST; QL (17 GM per 30 days)

neomycin-bacitracin-poly-hc Tier 1

neomycin-polymyxin b-dexameth Tier 1

neomycin-polymyxin-hc ophthalmic (eye) Tier 1

NEO-POLYCIN HC Tier 1

prednisolone acetate Tier 1

prednisolone sodium phosphate ophthalmic (eye) Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

QNASL Tier 3 ST; QL (1 GM per 30 days)

tobramycin-dexamethasone Tier 1

EENT DRUGS, MISCELLANEOUS

BALANCED SALT Tier 1

BSS Tier 1

ipratropium bromide nasal Tier 1 QL (30 ML per 30 days)

OCUCOAT Tier 1

EENT NONSTEROIDAL ANTI-INFLAM.

AGENTS

bromfenac Tier 1

diclofenac sodium ophthalmic (eye) Tier 1

flurbiprofen sodium Tier 1

ketorolac ophthalmic (eye) drops 0.4 % Tier 1 QL (5 ML per 30 days)

ketorolac ophthalmic (eye) drops 0.5 % Tier 1

ketorolac oral Tier 1 QL (20 EA per 1 FILL)

LOCAL ANESTHETICS (EENT)

lidocaine hcl mucous membrane solution 2 % Tier 1 QL (100 ML per 30 days)

lidocaine hcl mucous membrane solution 4 % (40

mg/ml)

Tier 1

LIDOCAINE VISCOUS Tier 1 QL (100 ML per 30 days)

proparacaine Tier 1

MIOTICS

PHOSPHOLINE IODIDE Tier 4 PA

pilocarpine hcl ophthalmic (eye) Tier 1

MOUTHWASHES AND GARGLES

hydrogen peroxide Tier 1

MYDRIATICS

atropine ophthalmic (eye) drops 1 % Tier 1

atropine ophthalmic (eye) ointment Tier 1

cyclopentolate Tier 1

cyclopen-tropic-phenyleph-watr Tier 1

HOMATROPAIRE Tier 1

tropicamide Tier 1

PROSTAGLANDIN ANALOGS

bimatoprost ophthalmic (eye) Tier 1 ST

latanoprost Tier 1

tafluprost (pf) Tier 1 ST

travoprost Tier 1 ST

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

VASOCONSTRICTORS

cyclopen-tropic-phenyleph-watr Tier 1

GASTROINTESTINAL DRUGS

5-HT3 RECEPTOR ANTAGONISTS

AKYNZEO (NETUPITANT) Tier 3 QL (1 EA per 30 days)

granisetron hcl oral Tier 1 QL (6 EA per 30 days)

ondansetron hcl oral solution Tier 1 QL (100 ML per 30 days)

ondansetron hcl oral tablet Tier 1 QL (9 EA per 30 days)

ondansetron oral tablet,disintegrating 4 mg, 8 mg Tier 1 QL (9 EA per 30 days)

ANTIDIARRHEA AGENTS

ANTI-DIARRHEAL (LOPERAMIDE) ORAL

CAPSULE

Tier 1 QL (2 EA per 1 day)

diphenoxylate-atropine oral tablet Tier 1

loperamide oral capsule Tier 1 QL (2 EA per 1 day)

MOTOFEN Tier 3 PA; QL (8 EA per 1 Day)

ANTIEMETICS, MISCELLANEOUS

doxylamine-pyridoxine (vit b6) Tier 1 PA; QL (120 EA per 30 days)

scopolamine base Tier 1

ANTIHISTAMINES (GI DRUGS)

doxylamine-pyridoxine (vit b6) Tier 1 PA; QL (120 EA per 30 days)

meclizine oral tablet 12.5 mg, 25 mg Tier 1

prochlorperazine maleate Tier 1

trimethobenzamide Tier 1

ANTI-INFLAMMATORY AGENTS (GI DRUGS)

alosetron Tier 1 PA

balsalazide Tier 1

DIPENTUM Tier 2 PA

mesalamine oral capsule (with del rel tablets) Tier 1

mesalamine oral capsule,extended release 24hr Tier 1

mesalamine oral tablet,delayed release (dr/ec) Tier 1

mesalamine rectal enema Tier 1

mesalamine with cleansing wipe Tier 1

sulfasalazine Tier 1

ANTIULCER AGENTS AND ACID

SUPPRESSANTS

amoxicillin Tier 1

amoxicillin-pot clavulanate Tier 1

metronidazole oral Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

CATHARTICS AND LAXATIVES

bisacodyl oral Tier 1

CITRATE OF MAGNESIA Tier 1

CITROMA Tier 1

CLEARLAX ORAL POWDER Tier 1

CLENPIQ Tier 2

DULCOLAX (MAGNESIUM HYDROXIDE) ORAL

SUSPENSION

Tier 1

GAVILAX ORAL POWDER Tier 1

GAVILYTE-C Tier 1

GAVILYTE-G Tier 1

GAVILYTE-N Tier 1

GENTLE LAXATIVE (BISACODYL) ORAL Tier 1

GENTLELAX Tier 1

LAXATIVE (BISACODYL) ORAL

TABLET,DELAYED RELEASE (DR/EC)

Tier 1

LAXATIVE PEG 3350 Tier 1

magnesium citrate oral solution Tier 1

magnesium hydroxide Tier 1

MILK OF MAGNESIA Tier 1

MILK OF MAGNESIA CONCENTRATED Tier 1

NATURA-LAX Tier 1

ONELAX MAGNESIUM CITRATE Tier 1

ORAL SALINE LAXATIVE Tier 1

peg 3350-electrolytes Tier 1

peg3350-sod sul-nacl-kcl-asb-c Tier 1

peg-electrolyte soln Tier 1

PHOSPHATE LAXATIVE Tier 1

polyethylene glycol 3350 oral powder Tier 1

POWDERLAX ORAL POWDER Tier 1

PURELAX ORAL POWDER Tier 1

SMOOTHLAX ORAL POWDER Tier 1

sodium,potassium,mag sulfates Tier 1

WOMEN'S GENTLE LAXATIVE(BISAC) Tier 1

CHLORIDE CHANNEL ACTIVATORS

lubiprostone Tier 1 QL (60 EA per 30 days)

CHOLELITHOLYTIC AGENTS

ursodiol Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

DIGESTANTS

CREON Tier 2

VIOKACE Tier 2

GI DRUGS, MISCELLANEOUS

dronabinol Tier 1 PA

GUANYLATE CYCLASE C (GCC) RECEPT

AGONIST

LINZESS Tier 3 QL (30 EA per 30 days)

TRULANCE Tier 2 PA; QL (30 EA per 30 days)

HISTAMINE H2-ANTAGONISTS

cimetidine Tier 1

cimetidine hcl Tier 1

famotidine oral suspension for reconstitution Tier 1

famotidine oral tablet 20 mg, 40 mg Tier 1

ibuprofen-famotidine Tier 1 PA

nizatidine Tier 1

NEUROKININ-1 RECEPTOR ANTAGONISTS

AKYNZEO (NETUPITANT) Tier 3 QL (1 EA per 30 days)

aprepitant oral capsule 125 mg, 40 mg Tier 1 PA; QL (1 EA per 30 days)

aprepitant oral capsule 80 mg Tier 1 PA; QL (2 EA per 30 days)

OPIOID ANTAGONISTS

MOVANTIK Tier 2 PA; QL (30 EA per 30 days)

POTASSIUM-COMPETITIVE ACID BLOCKERS

amoxicillin Tier 1

amoxicillin-pot clavulanate Tier 1

PROKINETIC AGENTS

metoclopramide hcl oral Tier 1

PROSTAGLANDINS

diclofenac-misoprostol Tier 1

misoprostol Tier 1 QL (4 EA per 1 day)

PROTECTANTS

sucralfate oral suspension Tier 1

sucralfate oral tablet Tier 1 QL (4 EA per 1 day)

PROTON-PUMP INHIBITORS

ACID REDUCER (OMEPRAZOLE) Tier 1

amoxicil-clarithromy-lansopraz Tier 1 QL (112 EA per 30 days)

dexlansoprazole oral capsule,biphase delayed

releas 30 mg

Tier 1 QL (60 EA per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

dexlansoprazole oral capsule,biphase delayed

releas 60 mg

Tier 1 ST; QL (60 EA per 30 days)

esomeprazole magnesium oral capsule,delayed

release(dr/ec) 20 mg

Tier 1 QL (30 EA per 30 days)

esomeprazole magnesium oral capsule,delayed

release(dr/ec) 40 mg

Tier 1

esomeprazole magnesium oral granules dr for

susp in packet 10 mg, 20 mg

Tier 1 ST; QL (30 EA per 30 days)

esomeprazole magnesium oral granules dr for

susp in packet 40 mg

Tier 1 ST

lansoprazole oral capsule,delayed release(dr/ec)

15 mg

Tier 1 QL (2 EA per 1 day)

lansoprazole oral capsule,delayed release(dr/ec)

30 mg

Tier 1

naproxen-esomeprazole Tier 1 ST

omeprazole magnesium oral capsule,delayed

release(dr/ec)

Tier 1

omeprazole oral capsule,delayed release(dr/ec)

10 mg

Tier 1 QL (30 EA per 30 days)

omeprazole oral capsule,delayed release(dr/ec)

20 mg, 40 mg

Tier 1 QL (2 EA per 1 day)

omeprazole-sodium bicarbonate oral packet 20-

1,680 mg

Tier 1 PA; QL (30 EA per 30 days)

omeprazole-sodium bicarbonate oral packet 40-

1,680 mg

Tier 1 PA

pantoprazole oral tablet,delayed release (dr/ec)

20 mg

Tier 1 QL (30 EA per 30 days)

pantoprazole oral tablet,delayed release (dr/ec)

40 mg

Tier 1 QL (6 EA per 1 day)

rabeprazole oral tablet,delayed release (dr/ec) Tier 1 ST; QL (60 EA per 30 days)

HEAVY METAL ANTAGONISTS

deferasirox oral tablet Tier 4 PA

deferasirox oral tablet, dispersible Tier 4 PA

D-PENAMINE Tier 2 PA

penicillamine Tier 1 PA

HORMONES AND SYNTHETIC

SUBSTITUTES

ADRENALS

AGAMREE Tier 4

ALVESCO INHALATION HFA AEROSOL

INHALER 160 MCG/ACTUATION

Tier 3 QL (13 GM per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

ALVESCO INHALATION HFA AEROSOL

INHALER 80 MCG/ACTUATION

Tier 3 QL (7 GM per 30 days)

ARNUITY ELLIPTA INHALATION BLISTER

WITH DEVICE 100 MCG/ACTUATION, 200

MCG/ACTUATION

Tier 2 QL (1 EA per 30 days)

ARNUITY ELLIPTA INHALATION BLISTER

WITH DEVICE 50 MCG/ACTUATION

Tier 2 QL (30 EA per 30 days)

ASMANEX HFA Tier 2 QL (13 GM per 30 days)

azelastine-fluticasone Tier 1 ST; QL (23 GM per 30 days)

BREYNA Tier 1

budesonide inhalation suspension for

nebulization 0.25 mg/2 ml, 0.5 mg/2 ml

Tier 1 QL (120 ML per 30 days)

budesonide inhalation suspension for

nebulization 1 mg/2 ml

Tier 1 QL (60 ML per 30 days)

budesonide oral capsule,delayed,extend.release Tier 1

budesonide-formoterol Tier 2 ST; QL (11 GM per 30 days)

cortisone Tier 1

deflazacort oral suspension Tier 4 PA; QL (117 ML per 30 days)

deflazacort oral tablet 18 mg Tier 4 PA; QL (30 EA per 30 days)

deflazacort oral tablet 30 mg, 36 mg Tier 4 PA; QL (90 EA per 30 days)

deflazacort oral tablet 6 mg Tier 4 PA; QL (60 EA per 30 days)

DEXAMETHASONE INTENSOL Tier 1

dexamethasone oral elixir Tier 1

dexamethasone oral solution Tier 1

dexamethasone oral tablet Tier 1

DULERA INHALATION HFA AEROSOL

INHALER 100-5 MCG/ACTUATION

Tier 2 ST; QL (1 GM per 30 days)

DULERA INHALATION HFA AEROSOL

INHALER 200-5 MCG/ACTUATION, 50-5

MCG/ACTUATION

Tier 2 ST; QL (13 GM per 30 days)

EMFLAZA ORAL SUSPENSION Tier 4 PA; QL (117 ML per 30 days)

EMFLAZA ORAL TABLET 18 MG Tier 4 PA; QL (30 EA per 30 days)

EMFLAZA ORAL TABLET 30 MG, 36 MG Tier 4 PA; QL (90 EA per 30 days)

EMFLAZA ORAL TABLET 6 MG Tier 4 PA; QL (60 EA per 30 days)

fludrocortisone Tier 1

flunisolide Tier 1 ST; QL (50 ML per 30 days)

fluticasone furoate-vilanterol Tier 2 ST; QL (60 EA per 30 days)

fluticasone propionate inhalation hfa aerosol

inhaler 110 mcg/actuation

Tier 1 QL (12 GM per 30 days)

fluticasone propionate inhalation hfa aerosol

inhaler 220 mcg/actuation

Tier 1 QL (24 GM per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

fluticasone propionate inhalation hfa aerosol

inhaler 44 mcg/actuation

Tier 1 QL (11 GM per 30 days)

fluticasone propionate nasal Tier 1 QL (16 GM per 30 days)

fluticasone propion-salmeterol inhalation aerosol

powdr breath activated

Tier 2 ST; QL (1 EA per 30 days)

fluticasone propion-salmeterol inhalation blister

with device

Tier 1 QL (1 EA per 30 days)

hydrocortisone oral Tier 1

ISTURISA ORAL TABLET 1 MG Tier 4 PA; QL (240 EA per 30 days)

ISTURISA ORAL TABLET 5 MG Tier 4 PA; QL (60 EA per 30 days)

methylprednisolone Tier 1

mometasone nasal Tier 1 ST; QL (17 GM per 30 days)

prednisolone oral solution Tier 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)

Tier 1

prednisolone sodium phosphate oral

tablet,disintegrating

Tier 1

prednisone Tier 1

PREDNISONE INTENSOL Tier 1

QNASL Tier 3 ST; QL (1 GM per 30 days)

QVAR REDIHALER INHALATION HFA

AEROSOL BREATH ACTIVATED 40

MCG/ACTUATION

Tier 2 QL (11 GM per 30 days)

QVAR REDIHALER INHALATION HFA

AEROSOL BREATH ACTIVATED 80

MCG/ACTUATION

Tier 2 QL (22 GM per 30 days)

ALPHA-GLUCOSIDASE INHIBITORS

acarbose Tier 1

miglitol Tier 1

AMYLINOMIMETICS

SYMLINPEN 120 Tier 2 ST; QL (19 ML per 30 days)

SYMLINPEN 60 Tier 2 ST; QL (11 ML per 30 days)

ANDROGENS

COVARYX Tier 1

COVARYX H.S. Tier 1

danazol Tier 1

EEMT Tier 1

EEMT HS Tier 1

estrogens-methyltestosterone Tier 1

methyltestosterone Tier 1 PA

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

testosterone cypionate Tier 1 PA

testosterone enanthate Tier 1 PA

testosterone transdermal gel Tier 1 PA; QL (60 GM per 30 days)

testosterone transdermal gel in metered-dose

pump 20.25 mg/1.25 gram (1.62 %)

Tier 1 PA; QL (150 GM per 30 days)

testosterone transdermal gel in packet 1 % (25

mg/2.5gram)

Tier 1 PA; QL (75 GM per 30 days)

testosterone transdermal gel in packet 1.62 %

(20.25 mg/1.25 gram)

Tier 1 PA; QL (30 GM per 30 days)

ANTIDIABETIC AGENTS, MISCELLANEOUS

colesevelam oral powder in packet Tier 1 PA; QL (30 EA per 30 days)

colesevelam oral tablet Tier 1 PA; QL (180 EA per 30 days)

ANTIESTROGENS

anastrozole Tier 1

exemestane Tier 1

letrozole Tier 1

ANTIGONADTROPINS

ORILISSA ORAL TABLET 150 MG Tier 2 PA; ST; QL (30 EA per 30 days)

ORILISSA ORAL TABLET 200 MG Tier 2 PA; ST; QL (60 EA per 30 days)

ANTIPARATHYROID AGENTS

calcitonin (salmon) nasal Tier 1

cinacalcet Tier 1 PA

ANTITHYROID AGENTS

methimazole Tier 1

potassium iodide oral solution Tier 1

propylthiouracil Tier 1

SSKI Tier 2

BIGUANIDES

alogliptin-metformin Tier 2

ST; QL (60 EA per 30 days); $0 on

Diabetic Plans

glipizide-metformin Tier 1 $0 on Diabetic Plans

glyburide-metformin oral tablet 1.25-250 mg Tier 1

QL (260 EA per 30 days); $0 on

Diabetic Plans

glyburide-metformin oral tablet 2.5-500 mg, 5-500

Tier 1

QL (5 EA per 1 day); $0 on

Diabetic Plans

metformin oral solution Tier 1 ST

metformin oral tablet 1,000 mg, 500 mg, 850 mg Tier 1 $0 on Diabetic Plans

metformin oral tablet extended release 24 hr 500

Tier 1 QL (120 EA per 30 days)

metformin oral tablet extended release 24 hr 750

Tier 1 QL (60 EA per 30 days)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

pioglitazone-metformin Tier 1

QL (90 EA per 30 days); $0 on

Diabetic Plans

SEGLUROMET Tier 2

ST; QL (60 EA per 30 days); $0 on

Diabetic Plans

SYNJARDY Tier 2

ST; QL (60 EA per 30 days); $0 on

Diabetic Plans

SYNJARDY XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG,

5-1,000 MG

Tier 2

ST; QL (60 EA per 30 days); $0 on

Diabetic Plans

SYNJARDY XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 25-1,000 MG

Tier 2

ST; QL (30 EA per 30 days); $0 on

Diabetic Plans

CONTRACEPTIVES

AFIRMELLE Tier 1

AFTER PILL Tier 1 QL (1 EA per 30 days)

AFTERA Tier 2 QL (1 EA per 30 days)

ALTAVERA (28) Tier 1

ALYACEN 1/35 (28) Tier 1

ALYACEN 7/7/7 (28) Tier 1

AMETHIA Tier 1 QL (1 EA per 1 day)

AMETHYST (28) Tier 1 QL (1 EA per 1 day)

APRI Tier 1

ARANELLE (28) Tier 1

ASHLYNA Tier 1 QL (1 EA per 1 day)

AUBRA Tier 1

AUBRA EQ Tier 1

AUROVELA 1.5/30 (21) Tier 1

AUROVELA 1/20 (21) Tier 1

AUROVELA 24 FE Tier 1

AUROVELA FE 1.5/30 (28) Tier 1

AUROVELA FE 1-20 (28) Tier 1

AVIANE Tier 1

AYUNA Tier 1

AZURETTE (28) Tier 1

BALZIVA (28) Tier 1

BLISOVI 24 FE Tier 1

BLISOVI FE 1.5/30 (28) Tier 1

BLISOVI FE 1/20 (28) Tier 1

BRIELLYN Tier 1

CAMILA Tier 1

CAMRESE Tier 1 QL (1 EA per 1 day)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

CAMRESE LO Tier 1 QL (1 EA per 1 day)

CAZIANT (28) Tier 1

CHARLOTTE 24 FE Tier 1

CHATEAL (28) Tier 1

CHATEAL EQ (28) Tier 1

CRYSELLE (28) Tier 1

CURAE Tier 1 QL (1 EA per 30 days)

CYRED Tier 1

CYRED EQ Tier 1

DASETTA 1/35 (28) Tier 1

DASETTA 7/7/7 (28) Tier 1

DAYSEE Tier 1 QL (1 EA per 1 day)

DEBLITANE Tier 1

desog-e.estradiol/e.estradiol Tier 1

DOLISHALE Tier 1 QL (1 EA per 1 day)

drospirenone-e.estradiol-lm.fa oral tablet 3-0.02-

0.451 mg (24) (4)

Tier 1

drospirenone-ethinyl estradiol Tier 1

ECONTRA EZ Tier 1 QL (1 EA per 30 days)

ECONTRA ONE-STEP Tier 1 QL (1 EA per 30 days)

ELINEST Tier 1

ELLA Tier 2 QL (1 EA per 30 days)

ELURYNG Tier 1

EMZAHH Tier 1

ENILLORING Tier 1

ENPRESSE Tier 1

ENSKYCE Tier 1

ERRIN Tier 1

ESTARYLLA Tier 1

ethynodiol diac-eth estradiol Tier 1

etonogestrel-ethinyl estradiol Tier 1

FALMINA (28) Tier 1

FINZALA Tier 1

GEMMILY Tier 1

HAILEY Tier 1

HAILEY 24 FE Tier 1

HAILEY FE 1.5/30 (28) Tier 1

HAILEY FE 1/20 (28) Tier 1

HALOETTE Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

HEATHER Tier 1

HER STYLE Tier 1 QL (1 EA per 30 days)

ICLEVIA Tier 1 QL (1 EA per 1 day)

INCASSIA Tier 1

ISIBLOOM Tier 1

JAIMIESS Tier 1 QL (1 EA per 1 day)

JASMIEL (28) Tier 1

JENCYCLA Tier 1

JOLESSA Tier 1 QL (1 EA per 1 day)

JULEBER Tier 1

JUNEL 1.5/30 (21) Tier 1

JUNEL 1/20 (21) Tier 1

JUNEL FE 1.5/30 (28) Tier 1

JUNEL FE 1/20 (28) Tier 1

JUNEL FE 24 Tier 1

KAITLIB FE Tier 1

KALLIGA Tier 1

KARIVA (28) Tier 1

KELNOR 1/35 (28) Tier 1

KELNOR 1-50 (28) Tier 1

KURVELO (28) Tier 1

l norgest/e.estradiol-e.estrad oral tablets,dose

pack,3 month 0.1 mg-20 mcg (84)/10 mcg (7),

0.15 mg-30 mcg (84)/10 mcg (7)

Tier 1 QL (1 EA per 1 day)

l norgest/e.estradiol-e.estrad oral tablets,dose

pack,3 month 0.15 mg-20 mcg/ 0.15 mg-25 mcg

Tier 1

LARIN 1.5/30 (21) Tier 1

LARIN 1/20 (21) Tier 1

LARIN 24 FE Tier 1

LARIN FE 1.5/30 (28) Tier 1

LARIN FE 1/20 (28) Tier 1

LAYOLIS FE Tier 1

LEENA 28 Tier 1

LESSINA Tier 1

LEVONEST (28) Tier 1

levonorgestrel Tier 1 QL (1 EA per 30 days)

levonorgestrel-ethinyl estrad oral tablet 0.1-20

mg-mcg, 0.15-0.03 mg

Tier 1

levonorgestrel-ethinyl estrad oral tablet 90-20

mcg (28)

Tier 1 QL (1 EA per 1 day)

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

levonorgestrel-ethinyl estrad oral tablets,dose

pack,3 month

Tier 1 QL (1 EA per 1 day)

levonorg-eth estrad triphasic Tier 1

LEVORA-28 Tier 1

LO LOESTRIN FE Tier 2 ST

LOJAIMIESS Tier 1 QL (1 EA per 1 day)

LORYNA (28) Tier 1

LOW-OGESTREL (28) Tier 1

LO-ZUMANDIMINE (28) Tier 1

LUTERA (28) Tier 1

LYLEQ Tier 1

LYZA Tier 1

MARLISSA (28) Tier 1

MERZEE Tier 1

MIBELAS 24 FE Tier 1

MICROGESTIN 1.5/30 (21) Tier 1

MICROGESTIN 1/20 (21) Tier 1

MICROGESTIN 24 FE Tier 2

MICROGESTIN FE 1.5/30 (28) Tier 1

MICROGESTIN FE 1/20 (28) Tier 1

MILI Tier 1

MONO-LINYAH Tier 1

MY CHOICE Tier 1 QL (1 EA per 30 days)

MY WAY Tier 1 QL (1 EA per 30 days)

NECON 0.5/35 (28) Tier 1

NEW DAY Tier 1 QL (1 EA per 30 days)

NIKKI (28) Tier 1

NORA-BE Tier 1

norelgestromin-ethin.estradiol Tier 1

noreth-ethinyl estradiol-iron Tier 1

norethindrone (contraceptive) Tier 1

norethindrone ac-eth estradiol oral tablet 1-20

mg-mcg, 1.5-30 mg-mcg

Tier 1

norethindrone-e.estradiol-iron Tier 1

norgestimate-ethinyl estradiol Tier 1

NORTREL 0.5/35 (28) Tier 1

NORTREL 1/35 (21) Tier 1

NORTREL 1/35 (28) Tier 1

NORTREL 7/7/7 (28) Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

NYLIA 1/35 (28) Tier 1

NYLIA 7/7/7 (28) Tier 1

NYMYO Tier 1

OCELLA Tier 1

OPCICON ONE-STEP Tier 1 QL (1 EA per 30 days)

OPTION-2 Tier 1 QL (1 EA per 30 days)

PHILITH Tier 1

PIMTREA (28) Tier 1

PLAN B ONE-STEP Tier 2 QL (1 EA per 30 days)

PORTIA 28 Tier 1

RECLIPSEN (28) Tier 1

RIVELSA Tier 1

SETLAKIN Tier 1 QL (1 EA per 1 day)

SHAROBEL Tier 1

SIMLIYA (28) Tier 1

SIMPESSE Tier 1 QL (1 EA per 1 day)

SPRINTEC (28) Tier 1

SRONYX Tier 1

SYEDA Tier 1

TAKE ACTION Tier 2 QL (1 EA per 30 days)

TARINA 24 FE Tier 1

TARINA FE 1/20 (28) Tier 1

TARINA FE 1-20 EQ (28) Tier 1

TILIA FE Tier 1

TRI-ESTARYLLA Tier 1

TRI-LEGEST FE Tier 1

TRI-LINYAH Tier 1

TRI-LO-ESTARYLLA Tier 1

TRI-LO-MARZIA Tier 1

TRI-LO-MILI Tier 1

TRI-LO-SPRINTEC Tier 1

TRI-MILI Tier 1

TRI-NYMYO Tier 1

TRI-SPRINTEC (28) Tier 1

TRIVORA (28) Tier 1

TRI-VYLIBRA Tier 1

TRI-VYLIBRA LO Tier 1

TULANA Tier 1

TURQOZ (28) Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

TYDEMY Tier 1

VELIVET TRIPHASIC REGIMEN (28) Tier 1

VESTURA (28) Tier 1

VIENVA Tier 1

VIORELE (28) Tier 1

VOLNEA (28) Tier 1

VYFEMLA (28) Tier 1

VYLIBRA Tier 1

WERA (28) Tier 1

WYMZYA FE Tier 1

XULANE Tier 1

ZAFEMY Tier 1

ZARAH Tier 1

ZOVIA 1-35 (28) Tier 1

ZUMANDIMINE (28) Tier 1

DIPEPTIDYL PEPTIDASE-4(DPP-4)

INHIBITORS

alogliptin Tier 1

ST; QL (30 EA per 30 days); $0 on

Diabetic Plans

alogliptin-metformin Tier 2

ST; QL (60 EA per 30 days); $0 on

Diabetic Plans

alogliptin-pioglitazone Tier 2

ST; QL (30 EA per 30 days); $0 on

Diabetic Plans

ESTROGEN AGONIST-ANTAGONISTS

CLOMID Tier 1

clomiphene citrate Tier 1

DUAVEE Tier 3 PA; QL (1 EA per 1 Day)

OSPHENA Tier 3 PA; QL (1 EA per 1 Day)

raloxifene Tier 1

tamoxifen Tier 1

toremifene Tier 1 PA

ESTROGENS

COMBIPATCH Tier 2

COVARYX Tier 1

COVARYX H.S. Tier 1

DOTTI TRANSDERMAL PATCH SEMIWEEKLY

0.025 MG/24 HR, 0.05 MG/24 HR, 0.075 MG/24

HR, 0.1 MG/24 HR

Tier 1 QL (8 EA per 30 days)

DUAVEE Tier 3 PA; QL (1 EA per 1 Day)

EEMT Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

EEMT HS Tier 1

estradiol oral Tier 1

estradiol transdermal patch semiweekly Tier 1 QL (8 EA per 30 days)

estradiol transdermal patch weekly Tier 1 QL (4 EA per 30 days)

estradiol vaginal tablet Tier 1

estradiol-norethindrone acet Tier 1

estrogens-methyltestosterone Tier 1

FYAVOLV Tier 1

MIMVEY Tier 1

norethindrone ac-eth estradiol oral tablet 0.5-2.5

mg-mcg, 1-5 mg-mcg

Tier 1

GLYCOGENOLYTIC AGENTS

BAQSIMI Tier 2 PA; ST; QL (2 EA per 30 days)

GLUCAGON (HCL) EMERGENCY KIT Tier 2 QL (2 EA per 30 days)

GLUCAGON EMERGENCY KIT (HUMAN) Tier 1 QL (2 EA per 30 days)

glucagon hcl injection recon soln 1 mg/ml Tier 2

GONADOTROPINS

SYNAREL Tier 2 PA

INCRETIN MIMETICS

MOUNJARO Tier 2 PA; QL (2 ML per 28 days)

OZEMPIC Tier 2 PA; QL (3 ML per 28 days)

RYBELSUS Tier 2 PA; QL (30 EA per 30 days)

SOLIQUA 100/33 Tier 2 ST; QL (15 ML per 30 days)

TRULICITY Tier 2 PA; QL (2 ML per 28 days)

XULTOPHY 100/3.6 Tier 2 PA; ST; QL (15 ML per 30 days)

INSULINS

BASAGLAR KWIKPEN U-100 INSULIN Tier 2

QL (45 ML per 30 days); $0 on

Diabetic Plans

HUMULIN 70/30 U-100 INSULIN Tier 2 QL (40 ML per 30 days)

HUMULIN 70/30 U-100 KWIKPEN Tier 2 QL (45 ML per 30 days)

HUMULIN N NPH INSULIN KWIKPEN Tier 2 QL (45 ML per 30 days)

HUMULIN N NPH U-100 INSULIN Tier 2 QL (40 ML per 30 days)

HUMULIN R REGULAR U-100 INSULN Tier 2 QL (40 ML per 30 days)

HUMULIN R U-500 (CONC) INSULIN Tier 2

HUMULIN R U-500 (CONC) KWIKPEN Tier 2

insulin asp prt-insulin aspart subcutaneous

insulin pen

Tier 2

QL (45 ML per 30 days); $0 on

Diabetic Plans

insulin asp prt-insulin aspart subcutaneous

solution

Tier 2

QL (40 ML per 30 days); $0 on

Diabetic Plans

insulin aspart u-100 subcutaneous insulin pen Tier 2 $0 on Diabetic Plans

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

insulin aspart u-100 subcutaneous solution Tier 2 $0 on Diabetic Plans

insulin lispro protamin-lispro Tier 2

QL (1 ML per 1 day); $0 on

Diabetic Plans

insulin lispro subcutaneous insulin pen Tier 2

QL (45 ML per 30 days); $0 on

Diabetic Plans

insulin lispro subcutaneous insulin pen, half-unit Tier 2

QL (1 ML per 1 day); $0 on

Diabetic Plans

insulin lispro subcutaneous solution Tier 2

QL (45 ML per 30 days); $0 on

Diabetic Plans

NOVOLIN 70/30 U-100 INSULIN Tier 2 QL (40 ML per 30 days)

NOVOLIN 70-30 FLEXPEN U-100 Tier 2 QL (45 ML per 30 days)

NOVOLIN N FLEXPEN Tier 2 QL (45 ML per 30 days)

NOVOLIN N NPH U-100 INSULIN Tier 2 QL (40 ML per 30 days)

NOVOLIN R REGULAR U100 INSULIN Tier 2 QL (40 ML per 30 days)

REZVOGLAR KWIKPEN Tier 2

QL (1.5 ML per 1 Day); $0 on

Diabetic Plans

SOLIQUA 100/33 Tier 2 ST; QL (15 ML per 30 days)

TRESIBA FLEXTOUCH U-100 Tier 2

QL (45 ML per 30 days); $0 on

Diabetic Plans

TRESIBA FLEXTOUCH U-200 Tier 2

QL (27 ML per 30 days); $0 on

Diabetic Plans

TRESIBA U-100 INSULIN Tier 2

QL (40 ML per 30 days); $0 on

Diabetic Plans

XULTOPHY 100/3.6 Tier 2 PA; ST; QL (15 ML per 30 days)

INTERMEDIATE-ACTING INSULINS

HUMULIN 70/30 U-100 INSULIN Tier 2 QL (40 ML per 30 days)

HUMULIN 70/30 U-100 KWIKPEN Tier 2 QL (45 ML per 30 days)

HUMULIN N NPH INSULIN KWIKPEN Tier 2 QL (45 ML per 30 days)

HUMULIN N NPH U-100 INSULIN Tier 2 QL (40 ML per 30 days)

insulin asp prt-insulin aspart subcutaneous

insulin pen

Tier 2

QL (45 ML per 30 days); $0 on

Diabetic Plans

insulin asp prt-insulin aspart subcutaneous

solution

Tier 2

QL (40 ML per 30 days); $0 on

Diabetic Plans

insulin lispro protamin-lispro Tier 2

QL (1 ML per 1 day); $0 on

Diabetic Plans

NOVOLIN 70/30 U-100 INSULIN Tier 2 QL (40 ML per 30 days)

NOVOLIN 70-30 FLEXPEN U-100 Tier 2 QL (45 ML per 30 days)

NOVOLIN N FLEXPEN Tier 2 QL (45 ML per 30 days)

NOVOLIN N NPH U-100 INSULIN Tier 2 QL (40 ML per 30 days)

LONG-ACTING INSULINS

BASAGLAR KWIKPEN U-100 INSULIN Tier 2

QL (45 ML per 30 days); $0 on

Diabetic Plans

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

REZVOGLAR KWIKPEN Tier 2

QL (1.5 ML per 1 Day); $0 on

Diabetic Plans

SOLIQUA 100/33 Tier 2 ST; QL (15 ML per 30 days)

TRESIBA FLEXTOUCH U-100 Tier 2

QL (45 ML per 30 days); $0 on

Diabetic Plans

TRESIBA FLEXTOUCH U-200 Tier 2

QL (27 ML per 30 days); $0 on

Diabetic Plans

TRESIBA U-100 INSULIN Tier 2

QL (40 ML per 30 days); $0 on

Diabetic Plans

XULTOPHY 100/3.6 Tier 2 PA; ST; QL (15 ML per 30 days)

MEGLITINIDES

nateglinide Tier 1

repaglinide Tier 1

PARATHYROID AGENTS

teriparatide subcutaneous pen injector 20

mcg/dose (600mcg/2.4ml)

Tier 4 PA; QL (1 ML per 28 days)

teriparatide subcutaneous pen injector 20

mcg/dose (620mcg/2.48ml)

Tier 4 PA; QL (2.48 ML per 28 days)

PITUITARY

desmopressin injection Tier 4

desmopressin nasal spray with pump Tier 1

desmopressin oral Tier 1

NOCDURNA (MEN) Tier 3 PA; QL (30 EA per 30 days)

NOCDURNA (WOMEN) Tier 3 PA; QL (30 EA per 30 days)

OMNITROPE Tier 4 PA

SKYTROFA Tier 4 PA

PROGESTINS

COMBIPATCH Tier 2

CRINONE VAGINAL GEL 4 % Tier 2

CRINONE VAGINAL GEL 8 % Tier 4

DEPO-SUBQ PROVERA 104 Tier 2 QL (1 ML per 90 days)

estradiol-norethindrone acet Tier 1

FYAVOLV Tier 1

medroxyprogesterone intramuscular Tier 1 QL (1 ML per 90 days)

medroxyprogesterone oral Tier 1

megestrol oral suspension 400 mg/10 ml (10 ml),

400 mg/10 ml (40 mg/ml), 625 mg/5 ml (125

mg/ml)

Tier 1

megestrol oral tablet Tier 1

MIMVEY Tier 1

norethindrone acetate Tier 1

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

norethindrone ac-eth estradiol oral tablet 0.5-2.5

mg-mcg, 1-5 mg-mcg

Tier 1

progesterone micronized Tier 1

RAPID-ACTING INSULINS

insulin asp prt-insulin aspart subcutaneous

insulin pen

Tier 2

QL (45 ML per 30 days); $0 on

Diabetic Plans

insulin asp prt-insulin aspart subcutaneous

solution

Tier 2

QL (40 ML per 30 days); $0 on

Diabetic Plans

insulin aspart u-100 subcutaneous insulin pen Tier 2 $0 on Diabetic Plans

insulin aspart u-100 subcutaneous solution Tier 2 $0 on Diabetic Plans

insulin lispro protamin-lispro Tier 2

QL (1 ML per 1 day); $0 on

Diabetic Plans

insulin lispro subcutaneous insulin pen Tier 2

QL (45 ML per 30 days); $0 on

Diabetic Plans

insulin lispro subcutaneous insulin pen, half-unit Tier 2

QL (1 ML per 1 day); $0 on

Diabetic Plans

insulin lispro subcutaneous solution Tier 2

QL (45 ML per 30 days); $0 on

Diabetic Plans

SHORT-ACTING INSULINS

HUMULIN 70/30 U-100 INSULIN Tier 2 QL (40 ML per 30 days)

HUMULIN 70/30 U-100 KWIKPEN Tier 2 QL (45 ML per 30 days)

HUMULIN R REGULAR U-100 INSULN Tier 2 QL (40 ML per 30 days)

HUMULIN R U-500 (CONC) INSULIN Tier 2

HUMULIN R U-500 (CONC) KWIKPEN Tier 2

NOVOLIN 70/30 U-100 INSULIN Tier 2 QL (40 ML per 30 days)

NOVOLIN 70-30 FLEXPEN U-100 Tier 2 QL (45 ML per 30 days)

NOVOLIN R REGULAR U100 INSULIN Tier 2 QL (40 ML per 30 days)

SODIUM-GLUC COTRANSPORT 2 (SGLT2)

INHIB

FARXIGA Tier 2

PA; ST; QL (30 Tablets per 30

days); $0 on Diabetic Plans

JARDIANCE Tier 2

PA; ST; QL (30 Tablets per 30

days); $0 on Diabetic Plans

SEGLUROMET Tier 2

ST; QL (60 EA per 30 days); $0 on

Diabetic Plans

STEGLATRO Tier 2

PA; ST; QL (30 EA per 30 days);

$0 on Diabetic Plans

SYNJARDY Tier 2

ST; QL (60 EA per 30 days); $0 on

Diabetic Plans

SYNJARDY XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 10-1,000 MG, 12.5-1,000 MG,

5-1,000 MG

Tier 2

ST; QL (60 EA per 30 days); $0 on

Diabetic Plans

Ohio Marketplace 2024 Drug Formulary

Drug Name Tier Restrictions/Limits

SYNJARDY XR ORAL TABLET, IR - ER,

BIPHASIC 24HR 25-1,000 MG

Tier 2

ST; QL (30 EA per 30 days); $0 on

Diabetic Plans

SOMATOTROPIN AGONISTS

INCRELEX Tier 4 PA

SULFONYLUREAS

glimepiride Tier 1 $0 on Diabetic Plans

glipizide Tier 1 $0 on Diabetic Plans

glipizide-metformin Tier 1 $0 on Diabetic Plans

glyburide micronized oral tablet 1.5 mg Tier 1

QL (8 EA per 1 day); $0 on

Diabetic Plans

glyburide micronized oral tablet 3 mg Tier 1

QL (4 EA per 1 day); $0 on

Diabetic Plans

glyburide micronized oral tablet 6 mg Tier 1

QL (2 EA per 1 day); $0 on

Diabetic Plans

glyburide oral tablet 1.25 mg Tier 1

QL (16 EA per 1 day); $0 on

Diabetic Plans

glyburide oral tablet 2.5 mg Tier 1

QL (8 EA per 1 day); $0 on

Diabetic Plans

glyburide oral tablet 5 mg Tier 1

QL (4 EA per 1 day); $0 on

Diabetic Plans

glyburide-metformin oral tablet 1.25-250 mg Tier 1

QL (260 EA per 30 days); $0 on

Diabetic Plans

glyburide-metformin oral tablet 2.5-500 mg, 5-500

Tier 1

QL (5 EA per 1 day); $0 on

Diabetic Plans

pioglitazone-glimepiride Tier 1 ST; QL (30 EA per 30 days)

THIAZOLIDINEDIONES

alogliptin-pioglitazone Tier 2

ST; QL (30 EA per 30 days); $0 on

Diabetic Plans

pioglitazone Tier 1

QL (30 EA per 30 days); $0 on

Diabetic Plans

pioglitazone-glimepiride Tier 1 ST; QL (30 EA per 30 days)

pioglitazone-metformin Tier 1

QL (90 EA per 30 days); $0 on

Diabetic Plans

THYROID AGENTS

ADTHYZA ORAL TABLET 120 MG, 15 MG, 30

MG, 60 MG, 90 MG

Tier 1

EUTHYROX Tier 1

levothyroxine oral tablet Tier 1

LEVOXYL Tier 1

liothyronine oral Tier 1

NIVA THYROID Tier 1

NP THYROID Tier 1

Ohio Marketplace 2024 Drug Formulary

100

Drug Name Tier Restrictions/Limits

SYNTHROID Tier 3

thyroid (pork) Tier 1

UNITHROID Tier 1

IMMUNOMODULATORY AGENTS (90:00)

AMINO ACID POLYMERS

glatiramer subcutaneous syringe 20 mg/ml Tier 4 PA; QL (1 ML per 28 days)

glatiramer subcutaneous syringe 40 mg/ml Tier 4 PA; QL (12 ML per 28 days)

GLATOPA SUBCUTANEOUS SYRINGE 20

MG/ML

Tier 4 PA; QL (1 ML per 28 days)

GLATOPA SUBCUTANEOUS SYRINGE 40

MG/ML

Tier 4 PA; QL (12 ML per 28 days)

ANTIMETABOLITES

teriflunomide Tier 4 PA; QL (30 EA per 30 days)

ANTIMETABOLITES, IMMUNOSUPP

THERAPY MISC

azathioprine Tier 1

mycophenolate mofetil Tier 1

mycophenolate sodium Tier 1

CALCINEURIN INHIBITORS, MISC (90:28)

cyclosporine modified Tier 1

cyclosporine ophthalmic (eye) Tier 1 QL (60 EA per 30 days)

cyclosporine oral Tier 1

GENGRAF Tier 1

tacrolimus oral Tier 1

DISEASE-MODIFYING ANTIRHEUMATIC

DRUGS

methotrexate sodium oral Tier 1

sulfasalazine Tier 1

TREMFYA Tier 4 PA; QL (100 ML per 60 days)

TREXALL Tier 2

FUMARATES

dimethyl fumarate oral capsule,delayed

release(dr/ec) 120 mg, 240 mg

Tier 1 PA; QL (60 EA per 30 days)

VUMERITY Tier 4 PA; QL (120 EA per 30 days)

IMMUNOMODULATORY AGENTS (90:00)

cyclophosphamide oral capsule Tier 1 PA

mercaptopurine Tier 1

INTERFERONS

AVONEX INTRAMUSCULAR PEN INJECTOR

KIT

Tier 4 PA; QL (1 EA per 28 days)

Ohio Marketplace 2024 Drug Formulary

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Drug Name Tier Restrictions/Limits

AVONEX INTRAMUSCULAR SYRINGE KIT Tier 4 PA; QL (1 EA per 28 days)

REBIF (WITH ALBUMIN) Tier 4 PA; QL (6 ML per 28 days)

REBIF REBIDOSE SUBCUTANEOUS PEN

INJECTOR 22 MCG/0.5 ML, 44 MCG/0.5 ML

Tier 4 PA; QL (6 ML per 28 days)

REBIF REBIDOSE SUBCUTANEOUS PEN

INJECTOR 8.8MCG/0.2ML-22 MCG/0.5ML (6)

Tier 4 PA; QL (5 ML per 28 days)

INTERLEUKIN-MEDIATED AGENTS, MISC

ACTEMRA ACTPEN Tier 4

PA; QL (4 SYRINGES per 28

days)

ACTEMRA SUBCUTANEOUS Tier 4

PA; QL (4 SYRINGES per 28

days)

COSENTYX (2 SYRINGES) Tier 4 PA; QL (2 ML per 28 days)

COSENTYX PEN Tier 4 PA; QL (1 ML per 28 days)

COSENTYX PEN (2 PENS) Tier 4 PA; QL (2 ML per 28 days)

COSENTYX SUBCUTANEOUS SYRINGE 150

MG/ML

Tier 4 PA; QL (1 ML per 28 days)

COSENTYX SUBCUTANEOUS SYRINGE 75

MG/0.5 ML

Tier 4 PA

COSENTYX UNOREADY PEN Tier 2 PA

STELARA INTRAVENOUS Tier 4 PA

STELARA SUBCUTANEOUS SOLUTION Tier 4 PA; QL (45 MG per 84 days)

STELARA SUBCUTANEOUS SYRINGE 45

MG/0.5 ML

Tier 4 PA; QL (45 MG per 84 days)

STELARA SUBCUTANEOUS SYRINGE 90

MG/ML

Tier 4 PA; QL (90 MG per 60 days)

JANUS KINASE INHIBITORS,

MISCELLANEOUS

RINVOQ Tier 4 PA; QL (1 EA per 1 day)

MONOCARBOXYLIC ACID AMIDE AGENTS

leflunomide Tier 1 QL (30 EA per 30 days)

MTOR INHIBITORS, MISCELLANEOUS

HYFTOR Tier 4 PA; QL (20 GM per 18 days)

sirolimus oral tablet Tier 1

PHOSPHODIESTERASE-4 INHIBITORS, MISC

OTEZLA Tier 4 PA

SPHINGOSINE 1-PHOSPHATE (S1P) AGENTS

fingolimod Tier 4 PA; QL (30 EA per 30 days)

ZEPOSIA Tier 4 PA

ZEPOSIA STARTER KIT (28-DAY) Tier 4 PA; QL (1 PACK per 292 days)

ZEPOSIA STARTER PACK (7-DAY) Tier 4 PA; QL (1 PACK per 292 days)

Ohio Marketplace 2024 Drug Formulary

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Drug Name Tier Restrictions/Limits

TUMOR NECROSIS FACTOR INHIBITORS,

MISC

adalimumab-adaz Tier 4 PA

adalimumab-fkjp Tier 4 PA

CIMZIA Tier 4

PA; QL (2 SYRINGES per 28

days)

CIMZIA POWDER FOR RECONST Tier 4

PA; QL (1 SYRINGES per 28

days)

CIMZIA STARTER KIT Tier 4

PA; QL (6 SYRINGES per 365

days)

ENBREL MINI Tier 4 PA; QL (4 ML per 28 days)

ENBREL SUBCUTANEOUS SYRINGE 25

MG/0.5 ML (0.5)

Tier 4 PA; QL (8 ML per 28 days)

ENBREL SUBCUTANEOUS SYRINGE 50

MG/ML (1 ML)

Tier 4 PA; QL (4 ML per 28 days)

ENBREL SURECLICK Tier 4 PA; QL (4 ML per 28 days)

HADLIMA Tier 4 PA

HADLIMA PUSHTOUCH Tier 4 PA

HADLIMA(CF) Tier 4 PA

HADLIMA(CF) PUSHTOUCH Tier 4 PA

HUMIRA Tier 4 PA; QL (2 EA per 21 days)

HUMIRA PEN Tier 4 PA

HUMIRA(CF) Tier 4 PA; QL (2 EA per 28 days)

HUMIRA(CF) PEDI CROHNS STARTER

SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML

Tier 4 PA; QL (3 EA per 365 days)

HUMIRA(CF) PEDI CROHNS STARTER

SUBCUTANEOUS SYRINGE KIT 80 MG/0.8 ML-

40 MG/0.4 ML

Tier 4

PA; QL (2 SYRINGES per 365

days)

HUMIRA(CF) PEN CROHNS-UC-HS Tier 4 PA; QL (3 PENS per 365 days)

HUMIRA(CF) PEN PEDIATRIC UC Tier 4 PA; QL (2 EA per 28 days)

HUMIRA(CF) PEN PSOR-UV-ADOL HS Tier 4 PA; QL (3 EA per 365 days)

HUMIRA(CF) PEN SUBCUTANEOUS PEN

INJECTOR KIT 40 MG/0.4 ML

Tier 4 PA; QL (2 EA per 28 days)

HUMIRA(CF) PEN SUBCUTANEOUS PEN

INJECTOR KIT 80 MG/0.8 ML

Tier 4 PA; QL (2 PENS per 28 days)

MISCELLANEOUS THERAPEUTIC

AGENTS

5-ALPHA-REDUCTASE INHIBITORS

dutasteride Tier 1 ST

dutasteride-tamsulosin Tier 1 ST

finasteride oral tablet 5 mg Tier 1

Ohio Marketplace 2024 Drug Formulary

103

Drug Name Tier Restrictions/Limits

ANTIDOTES (92:12)

KIONEX (WITH SORBITOL) Tier 1

naloxone injection solution Tier 1 QL (2 ML per 30 days)

naloxone injection syringe 1 mg/ml Tier 1

naloxone nasal Tier 1

NARCAN Tier 2

sevelamer carbonate oral tablet Tier 1 PA; QL (270 EA per 30 days)

sevelamer hcl oral tablet 400 mg Tier 1 PA; QL (90 EA per 30 days)

sodium polystyrene sulfonate Tier 1

SPS (WITH SORBITOL) Tier 1

ANTIGOUT AGENTS

allopurinol oral tablet 100 mg, 300 mg Tier 1

colchicine oral tablet Tier 1 QL (2 EA per 1 day)

febuxostat Tier 1 ST

indomethacin oral capsule Tier 1

probenecid Tier 1

probenecid-colchicine Tier 1 ST

BONE ANABOLIC AGENTS

teriparatide subcutaneous pen injector 20

mcg/dose (600mcg/2.4ml)

Tier 4 PA; QL (1 ML per 28 days)

teriparatide subcutaneous pen injector 20

mcg/dose (620mcg/2.48ml)

Tier 4 PA; QL (2.48 ML per 28 days)

BONE RESORPTION INHIBITORS

alendronate oral tablet 10 mg, 5 mg Tier 1 QL (30 EA per 30 days)

alendronate oral tablet 35 mg, 70 mg Tier 1 QL (4 EA per 30 days)

calcitonin (salmon) nasal Tier 1

ibandronate oral Tier 1 QL (1 EA per 28 days)

raloxifene Tier 1

risedronate oral tablet 150 mg Tier 1 QL (1 EA per 28 days)

risedronate oral tablet 30 mg, 5 mg Tier 1 QL (30 EA per 30 days)

risedronate oral tablet 35 mg Tier 1 QL (4 EA per 30 days)

risedronate oral tablet,delayed release (dr/ec) Tier 1 QL (4 EA per 30 days)

CARIOSTATIC AGENTS

MULTI-VIT WITH FLUORIDE-IRON Tier 1

MULTI-VITAMIN WITH FLUORIDE Tier 1

MVC-FLUORIDE Tier 1

TRI-VITAMIN WITH FLUORIDE Tier 1

TRI-VITE WITH FLUORIDE Tier 1

VITAMINS A,C,D AND FLUORIDE Tier 1

Ohio Marketplace 2024 Drug Formulary

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Drug Name Tier Restrictions/Limits

DISEASE-MODIFYING ANTIRHEUMATIC

AGENTS

hydroxychloroquine Tier 1

IMMUNOMODULATORY AGENTS

hydroxychloroquine Tier 1

leflunomide Tier 1 QL (30 EA per 30 days)

lenalidomide Tier 4 PA; QL (30 EA per 30 days)

OTEZLA Tier 4 PA; QL (60 EA per 30 days)

PEGASYS SUBCUTANEOUS SOLUTION Tier 4 PA; QL (4 ML per 28 days)

PEGASYS SUBCUTANEOUS SYRINGE Tier 4 PA; QL (2 ML per 28 days)

POMALYST Tier 4 PA

REVLIMID Tier 4 PA; QL (30 EA per 30 days)

THALOMID Tier 4 PA; QL (30 EA per 30 days)

IMMUNOSUPPRESSIVE AGENTS

everolimus (immunosuppressive) oral tablet 0.25

mg, 0.5 mg, 0.75 mg

Tier 1

OTHER MISCELLANEOUS THERAPEUTIC

AGENTS

acetylcysteine Tier 1

CRYOSERV Tier 1

CYSTAGON Tier 4 PA

dalfampridine Tier 4 PA; QL (60 EA per 30 days)

EVOTAZ Tier 2 QL (1 EA per 1 day)

PREZCOBIX Tier 2 QL (1 EA per 1 day)

SYMTUZA Tier 2 QL (1 EA per 1 day)

PROTECTIVE AGENTS

adapalene topical lotion Tier 2 ST

NONHORMONAL CONTRACEPTIVES

AIMSCO LATEX CONDOM Tier 2 QL (24 EA per 30 days)

CAYA CONTOURED Tier 2 QL (1 EA per 365 days)

FANTASY CONDOM Tier 2 QL (24 EA per 30 days)

FC2 FEMALE CONDOM Tier 2 QL (24 EA per 30 days)

FEMCAP Tier 2 QL (1 EA per 365 days)

KIMONO MICROTHIN AQUA LUBE CON Tier 2 QL (24 EA per 30 days)

KIMONO MICROTHIN CONDOMS Tier 2 QL (24 EA per 30 days)

KIMONO MICROTHIN LARGE CONDOMS Tier 2 QL (24 EA per 30 days)

KIMONO TEXTURED CONDOMS Tier 2 QL (24 EA per 30 days)

TRUSTEX LATEX CONDOM Tier 2 QL (24 EA per 30 days)

Ohio Marketplace 2024 Drug Formulary

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Drug Name Tier Restrictions/Limits

TRUSTEX LUBRICATED CONDOMS Tier 2 QL (24 EA per 30 days)

TRUSTEX NON-LUB CONDOMS Tier 2 QL (24 EA per 30 days)

TRUSTEX-RIA LUB/SPERMICIDE Tier 2 QL (24 EA per 30 days)

TRUSTEX-RIA LUBRICATED CONDOMS Tier 2 QL (24 EA per 30 days)

TRUSTEX-RIA NON-LUB CONDOMS Tier 2 QL (24 EA per 30 days)

VAGINAL CONTRACEPTIVE FILM Tier 2

VCF CONTRACEPTIVE FILM Tier 2

VCF CONTRACEPTIVE GEL Tier 2

WIDE-SEAL DIAPHRAGM 60 Tier 2 QL (2 EA per 365 days)

WIDE-SEAL DIAPHRAGM 65 Tier 2 QL (2 EA per 365 days)

WIDE-SEAL DIAPHRAGM 70 Tier 2 QL (2 EA per 365 days)

WIDE-SEAL DIAPHRAGM 75 Tier 2 QL (2 EA per 365 days)

WIDE-SEAL DIAPHRAGM 80 Tier 2 QL (2 EA per 365 days)

WIDE-SEAL DIAPHRAGM 85 Tier 2 QL (2 EA per 365 days)

WIDE-SEAL DIAPHRAGM 90 Tier 2 QL (2 EA per 365 days)

WIDE-SEAL DIAPHRAGM 95 Tier 2 QL (2 EA per 365 days)

OXYTOCICS

methylergonovine oral Tier 1 QL (240 EA per 30 days)

PHARMACEUTICAL AIDS

diluent for treprostinil (gly) Tier 4

hydroxypropyl cellulose Tier 2

hypromellose Tier 2

RESPIRATORY TRACT AGENTS

ALPHA AND BETA ADRENERGIC

AGONIST(RESPR)

brompheniramine-pseudoeph-dm Tier 1

epinephrine injection auto-injector 0.15 mg/0.15

Tier 2 QL (2 EA per 30 days)

epinephrine injection auto-injector 0.15 mg/0.3

ml, 0.3 mg/0.3 ml

Tier 1 QL (2 EA per 30 days)

GUAIFENESIN DAC Tier 1

ANTICHOLINERGIC AGENTS

(RESPIR.TRACT)

ATROVENT HFA Tier 2 QL (26 GM per 30 days)

COMBIVENT RESPIMAT Tier 2 QL (8 GM per 30 days)

ipratropium bromide inhalation Tier 1 QL (10 ML per 1 day)

ipratropium-albuterol Tier 1 QL (540 ML per 30 days)

SPIRIVA RESPIMAT Tier 2 QL (4 GM per 30 days)

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Drug Name Tier Restrictions/Limits

STIOLTO RESPIMAT Tier 2 QL (4 GM per 30 days)

tiotropium bromide Tier 1

TRELEGY ELLIPTA Tier 2 QL (60 EA per 30 days)

ANTIFIBROTIC AGENTS

OFEV Tier 4 PA; QL (60 EA per 30 days)

ANTITUSSIVES

benzonatate oral capsule 100 mg, 200 mg Tier 1 QL (4 EA per 1 day)

benzonatate oral capsule 150 mg Tier 1

brompheniramine-pseudoeph-dm Tier 1

codeine sulfate Tier 1 PA

G TUSSIN AC Tier 1

GUAIFENESIN AC Tier 1

GUAIFENESIN DAC Tier 1

hydrocodone-chlorpheniramine Tier 1

HYDROMET Tier 1 QL (4 ML per 1 day)

MAXI-TUSS AC Tier 1

promethazine-codeine Tier 1

promethazine-dm Tier 1

RYDEX Tier 1

VIRTUSSIN AC Tier 1

CORTICOSTEROIDS (RESPIRATORY TRACT)

azelastine-fluticasone Tier 1 ST; QL (23 GM per 30 days)

flunisolide Tier 1 ST; QL (50 ML per 30 days)

fluticasone propionate nasal Tier 1 QL (16 GM per 30 days)

QNASL Tier 3 ST; QL (1 GM per 30 days)

CYSTIC FIBROSIS (CFTR) CORRECTORS

ORKAMBI ORAL GRANULES IN PACKET Tier 4 PA; QL (56 EA per 28 days)

ORKAMBI ORAL TABLET Tier 4 PA; QL (112 EA per 28 days)

TRIKAFTA ORAL TABLETS, SEQUENTIAL 100-

50-75 MG(D) /150 MG (N)

Tier 4 PA; QL (84 EA per 30 days)

TRIKAFTA ORAL TABLETS, SEQUENTIAL 50-

25-37.5 MG (D)/75 MG (N)

Tier 4 PA; QL (3 EA per 1 day)

CYSTIC FIBROSIS (CFTR) POTENTIATORS

KALYDECO ORAL GRANULES IN PACKET

13.4 MG

Tier 4 PA; QL (2 EA per 1 day)

KALYDECO ORAL GRANULES IN PACKET 25

MG, 50 MG, 75 MG

Tier 4 PA; QL (56 EA per 30 days)

KALYDECO ORAL GRANULES IN PACKET 5.8

Tier 4 PA

KALYDECO ORAL TABLET Tier 4 PA; QL (60 EA per 30 days)

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Drug Name Tier Restrictions/Limits

ORKAMBI ORAL GRANULES IN PACKET Tier 4 PA; QL (56 EA per 28 days)

ORKAMBI ORAL TABLET Tier 4 PA; QL (112 EA per 28 days)

TRIKAFTA ORAL TABLETS, SEQUENTIAL 100-

50-75 MG(D) /150 MG (N)

Tier 4 PA; QL (84 EA per 30 days)

TRIKAFTA ORAL TABLETS, SEQUENTIAL 50-

25-37.5 MG (D)/75 MG (N)

Tier 4 PA; QL (3 EA per 1 day)

EXPECTORANTS

G TUSSIN AC Tier 1

GUAIFENESIN AC Tier 1

GUAIFENESIN DAC Tier 1

MAXI-TUSS AC Tier 1

potassium iodide oral solution Tier 1

SSKI Tier 2

VIRTUSSIN AC Tier 1

FIRST GENERATION ANTIHIST.(RESPIR

TRACT)

brompheniramine-pseudoeph-dm Tier 1

carbinoxamine maleate oral liquid Tier 1

carbinoxamine maleate oral tablet 4 mg Tier 1

carbinoxamine maleate oral tablet 6 mg Tier 1 ST

clemastine oral tablet Tier 1

cyproheptadine Tier 1

dexchlorpheniramine maleate Tier 1

diphenhydramine hcl oral capsule 50 mg Tier 1

diphenhydramine hcl oral elixir Tier 1

doxylamine-pyridoxine (vit b6) Tier 1 PA; QL (120 EA per 30 days)

hydrocodone-chlorpheniramine Tier 1

promethazine oral Tier 1

PROMETHAZINE VC Tier 1

promethazine-codeine Tier 1

promethazine-dm Tier 1

RYDEX Tier 1

LEUKOTRIENE MODIFIERS

montelukast Tier 1

zafirlukast Tier 1 ST

zileuton Tier 1 ST

MAST-CELL STABILIZERS

cromolyn inhalation Tier 1 QL (8 ML per 1 day)

cromolyn ophthalmic (eye) Tier 1

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Drug Name Tier Restrictions/Limits

cromolyn oral Tier 1 PA

MUCOLYTIC AGENTS

acetylcysteine Tier 1

PULMOZYME Tier 4 PA; QL (2.5 ML per 1 day)

ORALLY INHALED PREPARATIONS

(STEROIDS)

ALVESCO INHALATION HFA AEROSOL

INHALER 160 MCG/ACTUATION

Tier 3 QL (13 GM per 30 days)

ALVESCO INHALATION HFA AEROSOL

INHALER 80 MCG/ACTUATION

Tier 3 QL (7 GM per 30 days)

ARNUITY ELLIPTA INHALATION BLISTER

WITH DEVICE 100 MCG/ACTUATION, 200

MCG/ACTUATION

Tier 2 QL (1 EA per 30 days)

ARNUITY ELLIPTA INHALATION BLISTER

WITH DEVICE 50 MCG/ACTUATION

Tier 2 QL (30 EA per 30 days)

ASMANEX HFA Tier 2 QL (13 GM per 30 days)

budesonide inhalation suspension for

nebulization 0.25 mg/2 ml, 0.5 mg/2 ml

Tier 1 QL (120 ML per 30 days)

budesonide inhalation suspension for

nebulization 1 mg/2 ml

Tier 1 QL (60 ML per 30 days)

fluticasone propionate inhalation hfa aerosol

inhaler 110 mcg/actuation

Tier 1 QL (12 GM per 30 days)

fluticasone propionate inhalation hfa aerosol

inhaler 220 mcg/actuation

Tier 1 QL (24 GM per 30 days)

fluticasone propionate inhalation hfa aerosol

inhaler 44 mcg/actuation

Tier 1 QL (11 GM per 30 days)

QVAR REDIHALER INHALATION HFA

AEROSOL BREATH ACTIVATED 40

MCG/ACTUATION

Tier 2 QL (11 GM per 30 days)

QVAR REDIHALER INHALATION HFA

AEROSOL BREATH ACTIVATED 80

MCG/ACTUATION

Tier 2 QL (22 GM per 30 days)

PHOSPHODIESTERASE TYPE 4 INHIBITORS

roflumilast oral tablet 250 mcg Tier 1 PA; QL (30 EA per 30 days)

roflumilast oral tablet 500 mcg Tier 1 PA; QL (1 EA per 1 Day)

PHOSPHODIESTERASE-5 INHIBITORS

(RESPIR)

sildenafil (pulm.hypertension) oral tablet Tier 4 PA; QL (90 EA per 30 days)

tadalafil oral tablet 5 mg Tier 1 PA; QL (8 EA per 30 days)

PROSTACYCLIN & PROSTACYCLIN

DERIVATIVES

VENTAVIS Tier 4 PA; QL (270 ML per 30 days)

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Drug Name Tier Restrictions/Limits

SECOND GENERATION ANTIHIST(RESPIR

TRACT)

azelastine-fluticasone Tier 1 ST; QL (23 GM per 30 days)

cetirizine oral solution 1 mg/ml Tier 1

desloratadine oral tablet Tier 1 ST; QL (30 EA per 30 days)

levocetirizine oral solution Tier 1

levocetirizine oral tablet Tier 1 QL (30 EA per 30 days)

SELECT.BETA-2-ADRENERGIC

AGONIST(RESPIR)

albuterol sulfate inhalation hfa aerosol inhaler Tier 1 QL (17 GM per 30 days)

albuterol sulfate inhalation solution for

nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg

/3 ml (0.083 %)

Tier 1 QL (375 ML per 30 days)

albuterol sulfate inhalation solution for

nebulization 2.5 mg/0.5 ml

Tier 1 QL (2 EA per 1 day)

albuterol sulfate inhalation solution for

nebulization 5 mg/ml

Tier 1 QL (2 ML per 1 day)

albuterol sulfate oral Tier 1

COMBIVENT RESPIMAT Tier 2 QL (8 GM per 30 days)

formoterol fumarate Tier 1 QL (120 ML per 30 days)

ipratropium-albuterol Tier 1 QL (540 ML per 30 days)

levalbuterol tartrate Tier 2 QL (30 GM per 30 days)

SEREVENT DISKUS Tier 2 QL (60 EA per 30 days)

STIOLTO RESPIMAT Tier 2 QL (4 GM per 30 days)

STRIVERDI RESPIMAT Tier 2 QL (4 GM per 30 days)

terbutaline oral Tier 1

TRELEGY ELLIPTA Tier 2 QL (60 EA per 30 days)

VASODILATING AGENTS (RESPIRATORY

TRACT)

ADCIRCA Tier 4 PA; QL (2 EA per 1 day)

ADEMPAS Tier 4 PA; QL (3 EA per 1 day)

ambrisentan Tier 4 PA; QL (30 EA per 30 days)

bosentan Tier 4 PA; QL (2 EA per 1 day)

ORENITRAM Tier 4 PA

sildenafil (pulm.hypertension) oral tablet Tier 4 PA; QL (90 EA per 30 days)

tadalafil oral tablet 5 mg Tier 1 PA; QL (8 EA per 30 days)

XANTHINE DERIVATIVES

ELIXOPHYLLIN Tier 2

THEO-24 Tier 2

theophylline Tier 1

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Drug Name Tier Restrictions/Limits

SKIN AND MUCOUS MEMBRANE AGENTS

ADRENERGIC AGONISTS

brimonidine topical Tier 1 PA

ALLYLAMINES (SKIN AND MUCOUS

MEMBRANE)

naftifine topical cream Tier 1 PA; QL (60 GM per 30 days)

naftifine topical gel Tier 1 PA; QL (60 GM per 28 days)

terbinafine hcl oral Tier 1 QL (1 EA per 1 day)

ANTIBACTERIALS (84:04)

ALTABAX Tier 3 PA; ST; QL (30 GM per 30 days)

CABTREO Tier 3

CLEOCIN VAGINAL SUPPOSITORY Tier 2

CLINDACIN ETZ TOPICAL SWAB Tier 1

clindamycin hcl Tier 1

clindamycin palmitate hcl Tier 1

CLINDAMYCIN PEDIATRIC Tier 1

clindamycin phosphate topical gel Tier 1 QL (120 GM per 30 days)

clindamycin phosphate topical gel, once daily Tier 1 QL (150 ML per 30 days)

clindamycin phosphate topical lotion Tier 1 QL (120 ML per 30 days)

clindamycin phosphate topical solution Tier 1 QL (120 ML per 30 days)

clindamycin phosphate vaginal Tier 1

clindamycin-benzoyl peroxide topical gel Tier 1

clindamycin-benzoyl peroxide topical gel with

pump 1-5 %, 1.2 %(1 % base) -3.75 %

Tier 1

clindamycin-tretinoin Tier 1

dapsone topical Tier 1

doxycycline hyclate oral capsule Tier 1

doxycycline hyclate oral tablet 100 mg Tier 1

doxycycline monohydrate oral capsule 100 mg,

50 mg, 75 mg

Tier 1

doxycycline monohydrate oral capsule 150 mg Tier 1 ST

doxycycline monohydrate oral suspension for

reconstitution

Tier 1

doxycycline monohydrate oral tablet 100 mg, 50

Tier 1

ERY PADS Tier 1

ERYTHROCIN (AS STEARATE) Tier 1

erythromycin ethylsuccinate Tier 1

erythromycin oral Tier 1

erythromycin with ethanol Tier 1

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Drug Name Tier Restrictions/Limits

erythromycin-benzoyl peroxide Tier 1

gentamicin topical Tier 1 QL (60 GM per 30 days)

levofloxacin ophthalmic (eye) Tier 1

levofloxacin oral Tier 1

mafenide acetate Tier 1 PA

metronidazole oral Tier 1

moxifloxacin Tier 1

mupirocin Tier 1 QL (44 GM per 30 days)

neomycin Tier 1

polymyxin b sulf-trimethoprim Tier 1

tetracycline Tier 1

XEPI Tier 2 ST; QL (30 GM per 30 days)

ANTIPROLIFERANTS

bexarotene oral Tier 4 PA

bexarotene topical Tier 4 PA; QL (60 GM per 30 days)

fluorouracil topical cream 5 % Tier 1 QL (3 GM per 1 day)

fluorouracil topical solution Tier 1 QL (10 ML per 30 days)

imiquimod topical cream in packet 5 % Tier 1 PA

ANTIPRURITICS AND LOCAL ANESTHETICS

DERMACINRX PRIZOPAK Tier 1

doxepin topical Tier 1 ST; QL (45 GM per 30 days)

lidocaine hcl laryngotracheal Tier 1

lidocaine hcl topical cream 3 % Tier 1 QL (30 GM per 30 days)

lidocaine topical adhesive patch,medicated 4 % Tier 2 PA

lidocaine topical adhesive patch,medicated 5 % Tier 1 PA; QL (1 EA per 1 day)

lidocaine-prilocaine topical cream Tier 1 QL (30 GM per 30 days)

lidocaine-prilocaine topical kit Tier 1

LIDOPIN TOPICAL CREAM 3 % Tier 1 QL (30 GM per 30 days)

phenazopyridine oral tablet 100 mg, 200 mg Tier 1

ANTIVIRALS (SKIN AND MUCOUS

MEMBRANE)

acyclovir oral capsule Tier 1

acyclovir oral suspension 200 mg/5 ml Tier 1

acyclovir oral tablet Tier 1

acyclovir topical ointment Tier 1 ST; QL (30 GM per 30 days)

penciclovir Tier 1 ST; QL (5 GM per 30 days)

ASTRINGENTS (84:12)

glycopyrrolate oral solution Tier 1 PA

glycopyrrolate oral tablet 1 mg, 2 mg Tier 1

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Drug Name Tier Restrictions/Limits

AZOLES (SKIN AND MUCOUS MEMBRANE)

clotrimazole mucous membrane Tier 1

clotrimazole topical cream Tier 1 QL (45 GM per 30 days)

clotrimazole-betamethasone topical cream Tier 1 QL (45 GM per 30 days)

econazole Tier 1 QL (85 GM per 30 days)

ERTACZO Tier 2 QL (60 GM per 30 days)

GYNAZOLE-1 Tier 3 ST

ketoconazole oral Tier 1

ketoconazole topical cream Tier 1 QL (60 GM per 21 days)

ketoconazole topical shampoo Tier 1 QL (120 ML per 21 days)

luliconazole Tier 2 PA; QL (60 GM per 30 days)

oxiconazole Tier 1 PA; QL (60 GM per 30 days)

sulconazole Tier 2 PA; QL (60 GM per 30 days)

terconazole Tier 1

BASIC LOTIONS AND LINIMENTS

ammonium lactate topical lotion Tier 1

BASIC OILS AND OTHER SOLVENTS

MURI-LUBE Tier 2

BASIC OINTMENTS AND PROTECTANTS

ammonium lactate topical cream Tier 1

calcipotriene scalp Tier 1 QL (120 ML per 30 days)

calcipotriene topical cream Tier 1 QL (120 GM per 30 days)

calcipotriene topical ointment Tier 1 QL (120 GM per 30 days)

calcipotriene-betamethasone Tier 1 QL (60 GM per 30 days)

nitroglycerin rectal Tier 1 PA

RECTIV Tier 2 PA

SANTYL Tier 2 QL (180 GM per 30 days)

zinc oxide topical ointment 20 % Tier 1

zinc oxide topical paste Tier 2

BENZYLAMINES (SKIN AND MUCOUS

MEMBRANE)

MENTAX Tier 2 ST; QL (30 GM per 30 days)

CELL STIMULANTS AND PROLIFERANTS

AVITA TOPICAL CREAM Tier 1 QL (45 GM per 30 days)

AVITA TOPICAL GEL Tier 2 QL (45 GM per 30 days)

clindamycin-tretinoin Tier 1

finasteride oral tablet 5 mg Tier 1

tretinoin Tier 1 QL (45 GM per 30 days)

tretinoin (emollient) Tier 1

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Drug Name Tier Restrictions/Limits

CORTICOSTEROIDS (SKIN, MUCOUS

MEMBRANE)

ALA-CORT Tier 1 QL (28.35 GM per 30 days)

alclometasone Tier 1 QL (2 GM per 1 day)

amcinonide Tier 1 ST

BESER Tier 1 ST; QL (4 ML per 1 day)

betamethasone dipropionate topical cream Tier 1 QL (45 GM per 30 days)

betamethasone dipropionate topical lotion Tier 1 QL (2 ML per 1 day)

betamethasone dipropionate topical ointment Tier 1 ST; QL (45 GM per 30 days)

betamethasone valerate topical cream Tier 1 QL (45 GM per 30 days)

betamethasone valerate topical lotion Tier 1 QL (2 ML per 1 day)

betamethasone valerate topical ointment Tier 1 QL (45 GM per 30 days)

betamethasone, augmented topical cream Tier 1 QL (50 GM per 30 days)

betamethasone, augmented topical lotion Tier 1 QL (2 ML per 1 day)

betamethasone, augmented topical ointment Tier 1 QL (45 GM per 30 days)

clobetasol scalp Tier 1 ST; QL (100 ML per 30 days)

clobetasol topical cream Tier 1 ST; QL (120 GM per 30 days)

clobetasol topical gel Tier 1 ST; QL (120 GM per 30 days)

clobetasol topical ointment Tier 1 QL (120 GM per 30 days)

clobetasol topical shampoo Tier 1 ST; QL (236 ML per 30 days)

clobetasol-emollient topical cream Tier 1 QL (120 GM per 30 days)

CLODAN Tier 1 ST; QL (236 ML per 30 days)

clotrimazole-betamethasone topical cream Tier 1 QL (45 GM per 30 days)

CORTIFOAM Tier 2

desonide topical cream Tier 1 QL (2 GM per 1 day)

desonide topical ointment Tier 1 QL (2 GM per 1 day)

desoximetasone topical cream 0.05 % Tier 1 ST

desoximetasone topical cream 0.25 % Tier 1 ST; QL (2 GM per 1 day)

desoximetasone topical gel Tier 1 ST

desoximetasone topical ointment Tier 1 ST

desoximetasone topical spray,non-aerosol Tier 1 ST

diflorasone Tier 1 ST; QL (120 GM per 30 days)

fluocinolone and shower cap Tier 1 QL (1 ML per 30 days)

fluocinolone topical cream 0.01 % Tier 1 QL (120 GM per 30 days)

fluocinolone topical cream 0.025 % Tier 1 QL (2 GM per 1 day)

fluocinolone topical oil Tier 1 QL (120 ML per 30 days)

fluocinolone topical ointment Tier 1 QL (2 GM per 1 day)

fluocinolone topical solution Tier 1 QL (120 ML per 30 days)

fluocinonide topical cream 0.05 % Tier 1 ST; QL (120 GM per 30 days)

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Drug Name Tier Restrictions/Limits

fluocinonide topical gel Tier 1 PA; ST; QL (120 GM per 30 days)

fluocinonide topical ointment Tier 1 ST; QL (120 GM per 30 days)

fluocinonide topical solution Tier 1 QL (120 ML per 30 days)

FLUOCINONIDE-E Tier 1 QL (120 GM per 30 days)

fluocinonide-emollient Tier 1 QL (120 GM per 30 days)

flurandrenolide topical cream Tier 1 ST; QL (120 GM per 30 days)

flurandrenolide topical lotion Tier 1 ST; QL (120 ML per 30 days)

fluticasone propionate topical cream Tier 1 QL (2 GM per 1 day)

fluticasone propionate topical lotion Tier 1 ST; QL (4 ML per 1 day)

fluticasone propionate topical ointment Tier 1 QL (2 GM per 1 day)

halcinonide topical cream Tier 1 ST

halobetasol propionate topical cream Tier 1 ST

halobetasol propionate topical foam Tier 1 ST

hydrocortisone acetate rectal suppository 25 mg Tier 1

hydrocortisone butyrate topical cream Tier 1 QL (120 GM per 30 days)

hydrocortisone butyrate topical ointment Tier 1 ST; QL (45 GM per 30 days)

hydrocortisone butyrate topical solution Tier 1 ST; QL (120 ML per 30 days)

hydrocortisone rectal Tier 1

hydrocortisone topical cream 1 % Tier 1 QL (28.35 GM per 30 days)

hydrocortisone topical cream 2.5 % Tier 1 QL (1 GM per 1 day)

hydrocortisone topical cream with perineal

applicator

Tier 1

hydrocortisone topical lotion 2 % Tier 1

hydrocortisone topical lotion 2.5 % Tier 1 QL (118 ML per 30 days)

hydrocortisone topical ointment 1 % Tier 1

hydrocortisone topical ointment 2.5 % Tier 1 QL (28.35 GM per 30 days)

hydrocortisone valerate topical cream Tier 1 QL (2 GM per 1 day)

KOURZEQ Tier 1

mometasone nasal Tier 1 ST; QL (17 GM per 30 days)

mometasone topical cream Tier 1 QL (45 GM per 30 days)

mometasone topical ointment Tier 1 QL (45 GM per 30 days)

mometasone topical solution Tier 1 QL (2 ML per 1 day)

ORALONE Tier 1

prednicarbate topical cream Tier 1 QL (2 GM per 1 day)

prednicarbate topical ointment Tier 1

PROCTO-MED HC Tier 1

PROCTOSOL HC Tier 1

PROCTOZONE-HC Tier 1

triamcinolone acetonide dental Tier 1

Ohio Marketplace 2024 Drug Formulary

115

Drug Name Tier Restrictions/Limits

triamcinolone acetonide topical cream Tier 1 QL (454 GM per 30 days)

triamcinolone acetonide topical lotion Tier 1 QL (2 ML per 1 day)

triamcinolone acetonide topical ointment 0.025

%, 0.1 %, 0.5 %

Tier 1 QL (454 GM per 30 days)

triamcinolone acetonide topical ointment 0.05 % Tier 1 ST

TRIDERM TOPICAL CREAM 0.5 % Tier 1 ST; QL (454 GM per 30 days)

HYDROXYPYRIDONES (SKIN, MUCOUS

MEMBRANE)

CICLODAN KIT TOPICAL COMBO PACK Tier 2

CICLODAN KIT TOPICAL SOLUTION Tier 2 ST

CICLODAN TOPICAL CREAM Tier 1 QL (90 GM per 30 days)

CICLODAN TOPICAL SOLUTION Tier 1 QL (6.6 ML per 30 days)

ciclopirox topical cream Tier 1 QL (90 GM per 30 days)

ciclopirox topical gel Tier 1 QL (45 GM per 30 days)

ciclopirox topical shampoo Tier 1 QL (120 ML per 30 days)

ciclopirox topical solution Tier 1 QL (6.6 ML per 30 days)

ciclopirox topical suspension Tier 1 QL (60 ML per 30 days)

ciclopirox-ure-camph-menth-euc Tier 1

IMMUNOMODULATORY AGENTS (84:06)

HYFTOR Tier 4 PA; QL (20 GM per 18 days)

pimecrolimus Tier 1 PA; QL (100 GM per 30 days)

sirolimus oral tablet Tier 1

SKYRIZI SUBCUTANEOUS PEN INJECTOR Tier 4 PA; QL (1 ML per 84 days)

SKYRIZI SUBCUTANEOUS SYRINGE Tier 4 PA; QL (1 ML per 84 days)

SKYRIZI SUBCUTANEOUS WEARABLE

INJECTOR 180 MG/1.2 ML (150 MG/ML)

Tier 4 PA

SKYRIZI SUBCUTANEOUS WEARABLE

INJECTOR 360 MG/2.4 ML (150 MG/ML)

Tier 4 PA; QL (1 ML per 84 days)

tacrolimus topical Tier 1 QL (100 GM per 30 Days)

TREMFYA Tier 4 PA; QL (100 ML per 60 days)

JANUS KINASE INHIBITORS (84:06)

JAKAFI Tier 4 PA; QL (60 EA per 30 days)

roflumilast oral tablet 250 mcg Tier 1 PA; QL (30 EA per 30 days)

roflumilast oral tablet 500 mcg Tier 1 PA

KERATOLYTIC AGENTS

acitretin Tier 1

adapalene topical lotion Tier 2 ST

AVAR Tier 1 QL (341 GM per 30 days)

AVAR-E Tier 2 ST

AVAR-E GREEN Tier 2 ST

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Drug Name Tier Restrictions/Limits

AVAR-E LS Tier 2 ST; QL (57 GM per 30 days)

BPO TOPICAL GEL Tier 1

CICLODAN KIT TOPICAL SOLUTION Tier 2 ST

ciclopirox-ure-camph-menth-euc Tier 1

clindamycin-benzoyl peroxide topical gel Tier 1

clindamycin-benzoyl peroxide topical gel with

pump 1-5 %, 1.2 %(1 % base) -3.75 %

Tier 1

isotretinoin oral capsule 10 mg, 20 mg, 30 mg, 40

Tier 1

podofilox topical solution Tier 1 QL (1 ML per 30 days)

salicylic acid topical cream Tier 1 QL (454 GM per 30 days)

salicylic acid topical cream,extended release Tier 1 QL (454 GM per 30 days)

salicylic acid topical lotion Tier 1 QL (473 ML per 30 days)

salicylic acid topical lotion,extended release Tier 1 QL (473 GM per 30 days)

salicylic acid topical shampoo Tier 1 QL (177 ML per 30 days)

salicylic acid-ceramides no.1 Tier 1

SALIMEZ Tier 1 QL (454 GM per 30 days)

SALYCIM Tier 1 QL (454 GM per 30 days)

SSS 10-5 TOPICAL CREAM Tier 1

sulfacetamide sodium-sulfur topical cleanser 10-5

% (w/w)

Tier 1 QL (341 GM per 30 days)

sulfacetamide sodium-sulfur topical cleanser 9-4

Tier 1

sulfacetamide sodium-sulfur topical cream 10-2

Tier 1 QL (57 GM per 30 days)

sulfacetamide sodium-sulfur topical cream 10-5

% (w/w)

Tier 1

sulfacetamide sodium-sulfur topical lotion 10-5 %

(w/v), 10-5 % (w/w)

Tier 1

sulfacetamide sodium-sulfur topical pads,

medicated 10-4 %

Tier 1

sulfacetamide sodium-sulfur topical suspension

10-5 %, 8-4 %

Tier 1

sulfacetamide sod-sulfur-urea Tier 1

SULFACLEANSE 8-4 Tier 1 ST

LOCAL ANTI-INFECTIVES, MISCELLANEOUS

ALCOHOL PADS Tier 1 $0 on Diabetic Plans

ALCOHOL PREP PADS Tier 1 $0 on Diabetic Plans

alcohol swabs Tier 1 $0 on Diabetic Plans

ALCOHOL WIPES Tier 1 $0 on Diabetic Plans

AVAR Tier 1 QL (341 GM per 30 days)

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Drug Name Tier Restrictions/Limits

AVAR-E Tier 2 ST

AVAR-E GREEN Tier 2 ST

AVAR-E LS Tier 2 ST; QL (57 GM per 30 days)

BD ALCOHOL SWABS Tier 2 $0 on Diabetic Plans

CARETOUCH ALCOHOL PREP PAD Tier 2 $0 on Diabetic Plans

CURITY ALCOHOL SWABS Tier 2 $0 on Diabetic Plans

DROPSAFE ALCOHOL PREP PADS Tier 2 $0 on Diabetic Plans

DY-O-DERM Tier 1

EASY COMFORT ALCOHOL PAD Tier 2 $0 on Diabetic Plans

EASY TOUCH ALCOHOL PREP PADS Tier 2 $0 on Diabetic Plans

guaiacol Tier 2

INCONTROL ALCOHOL PADS Tier 2 $0 on Diabetic Plans

INSTACLEAN Tier 2

isopropyl alcohol solution 70 % Tier 2

isopropyl alcohol solution 99 % Tier 1

IV PREP WIPES Tier 2

PRO COMFORT ALCOHOL PADS Tier 2 $0 on Diabetic Plans

PURE COMFORT ALCOHOL PADS Tier 2 $0 on Diabetic Plans

selenium sulfide topical lotion Tier 1 PA

silver sulfadiazine Tier 1

SSD Tier 1

SSS 10-5 TOPICAL CREAM Tier 1

sulfacetamide sodium (acne) Tier 1 QL (118 ML per 30 days)

sulfacetamide sodium-sulfur topical cleanser 10-5

% (w/w)

Tier 1 QL (341 GM per 30 days)

sulfacetamide sodium-sulfur topical cleanser 9-4

Tier 1

sulfacetamide sodium-sulfur topical cream 10-2

Tier 1 QL (57 GM per 30 days)

sulfacetamide sodium-sulfur topical cream 10-5

% (w/w)

Tier 1

sulfacetamide sodium-sulfur topical lotion 10-5 %

(w/v), 10-5 % (w/w)

Tier 1

sulfacetamide sodium-sulfur topical pads,

medicated 10-4 %

Tier 1

sulfacetamide sodium-sulfur topical suspension

10-5 %, 8-4 %

Tier 1

sulfacetamide sod-sulfur-urea Tier 1

SULFACLEANSE 8-4 Tier 1 ST

SURE COMFORT ALCOHOL PREP PADS Tier 2

SURE-PREP ALCOHOL PREP PADS Tier 2 $0 on Diabetic Plans

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Drug Name Tier Restrictions/Limits

TRUE COMFORT ALCOHOL PADS Tier 2 $0 on Diabetic Plans

TRUE COMFORT PRO ALCOHOL PADS Tier 2 $0 on Diabetic Plans

ULESFIA Tier 2 QL (227 GM per 30 days)

ULTILET ALCOHOL SWAB Tier 2 $0 on Diabetic Plans

WEBCOL Tier 2 $0 on Diabetic Plans

NONSTEROIDAL ANTI-

INFLAMMAT.AGENTS(SKIN)

diclofenac potassium oral tablet Tier 1

diclofenac sodium oral Tier 1

diclofenac sodium topical gel 1 % Tier 1 QL (500 GM per 30 days)

POLYENES (SKIN AND MUCOUS

MEMBRANE)

KLAYESTA Tier 1 QL (180 GM per 1 FILL)

NYAMYC Tier 1 QL (180 GM per 30 days)

nystatin topical cream Tier 1 QL (30 GM per 30 days)

nystatin topical ointment Tier 1 QL (30 GM per 30 days)

nystatin topical powder Tier 1 QL (180 GM per 30 days)

nystatin-triamcinolone Tier 1 QL (60 GM per 30 days)

NYSTOP Tier 1 QL (180 GM per 30 days)

SCABICIDES AND PEDICULICIDES

ivermectin topical lotion Tier 1

malathion Tier 1 QL (59 ML per 30 days)

permethrin Tier 1 QL (2 GM per 1 day)

spinosad Tier 1 PA; QL (4 ML per 1 day)

ULESFIA Tier 2 QL (227 GM per 30 days)

SKIN AND MUCOUS MEMBRANE AGENTS,

MISC.

adapalene-benzoyl peroxide topical gel with

pump 0.1-2.5 %

Tier 1

calcitriol topical Tier 1 PA

CICLODAN KIT TOPICAL COMBO PACK Tier 2

dapsone topical Tier 1

DUPIXENT PEN SUBCUTANEOUS PEN

INJECTOR 200 MG/1.14 ML

Tier 4 PA; QL (400 MG per 28 days)

DUPIXENT PEN SUBCUTANEOUS PEN

INJECTOR 300 MG/2 ML

Tier 4 PA; QL (600 MG per 28 days)

DUPIXENT SYRINGE SUBCUTANEOUS

SYRINGE 200 MG/1.14 ML

Tier 4 PA

DUPIXENT SYRINGE SUBCUTANEOUS

SYRINGE 300 MG/2 ML

Tier 4 PA; QL (600 MG per 28 days)

metronidazole oral Tier 1

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Drug Name Tier Restrictions/Limits

OTEZLA Tier 4 PA; QL (60 EA per 30 days)

TRI-CHLOR Tier 1

trichloroacetic acid topical recon soln 20 %, 30

%, 35 %, 40 %, 50 %, 80 %, 85 %, 90 %

Tier 2

SMOOTH MUSCLE RELAXANTS

ANTIMUSCARINICS

darifenacin Tier 1 PA

flavoxate Tier 1

oxybutynin chloride oral syrup Tier 1

oxybutynin chloride oral tablet 5 mg Tier 1

oxybutynin chloride oral tablet extended release

24hr

Tier 1

solifenacin Tier 1

tolterodine oral capsule,extended release 24hr Tier 1 ST

tolterodine oral tablet Tier 1

trospium Tier 1

RESPIRATORY SMOOTH MUSCLE

RELAXANTS

ELIXOPHYLLIN Tier 2

THEO-24 Tier 2

theophylline Tier 1

SELECTIVE BETA-3-ADRENERGIC

AGONISTS

MYRBETRIQ ORAL TABLET EXTENDED

RELEASE 24 HR

Tier 2 PA

VITAMINS

MULTIVITAMIN PREPARATIONS

CLASSIC PRENATAL Tier 1

MULTI-VIT WITH FLUORIDE-IRON Tier 1

MULTI-VITAMIN WITH FLUORIDE Tier 1

MVC-FLUORIDE Tier 1

ONE DAILY PRENATAL Tier 1

pnv cmb#95-ferrous fumarate-fa Tier 1

PRENATAL COMPLETE Tier 1

PRENATAL MULTI-DHA (ALGAL OIL) Tier 1

PRENATAL MULTIVITAMINS Tier 1

PRENATAL ONE DAILY Tier 1

PRENATAL ORAL TABLET 28 MG IRON- 800

MCG

Tier 1

PRENATAL TABLET Tier 1

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Drug Name Tier Restrictions/Limits

prenatal vit no.179-iron-folic Tier 1

PRENATAL VITAMIN ORAL TABLET 27 MG

IRON- 0.8 MG

Tier 1

PRENATAL VITAMIN WITH MINERALS Tier 1

prenatal vit-iron fum-folic ac Tier 1

TRI-VITAMIN WITH FLUORIDE Tier 1

TRI-VITE WITH FLUORIDE Tier 1

VITAMINS A,C,D AND FLUORIDE Tier 1

WESCAP-C DHA Tier 1

WESNATAL DHA COMPLETE Tier 1

VITAMIN A

TRI-VITAMIN WITH FLUORIDE Tier 1

TRI-VITE WITH FLUORIDE Tier 1

VITAMINS A,C,D AND FLUORIDE Tier 1

VITAMIN B COMPLEX

B COMPLEX 1 (WITH FOLIC ACID) Tier 1

b complex-vitamin c-folic acid oral tablet Tier 1

BALANCE B-100 (FOLIC ACID) Tier 1

BALANCE B-50 (WITH FOLIC ACID) Tier 1

BALANCED B-100 ORAL TABLET Tier 1

B-COMPLEX WITH VITAMIN C ORAL TABLET

400-500 MCG-MG

Tier 1

CLASSIC PRENATAL Tier 1

cyanocobalamin (vitamin b-12) injection Tier 1

DIALYVITE 800 ORAL TABLET Tier 1

doxylamine-pyridoxine (vit b6) Tier 1 PA; QL (120 EA per 30 days)

folic acid oral tablet Tier 1

FOLTABS 800 Tier 1

FULL SPECTRUM B-VITAMIN C Tier 1

KOBEE Tier 1

ONE DAILY PRENATAL Tier 1

pnv cmb#95-ferrous fumarate-fa Tier 1

PRENATAL COMPLETE Tier 1

PRENATAL MULTI-DHA (ALGAL OIL) Tier 1

PRENATAL MULTIVITAMINS Tier 1

PRENATAL ONE DAILY Tier 1

PRENATAL ORAL TABLET 28 MG IRON- 800

MCG

Tier 1

PRENATAL TABLET Tier 1

Ohio Marketplace 2024 Drug Formulary

121

Drug Name Tier Restrictions/Limits

prenatal vit no.179-iron-folic Tier 1

PRENATAL VITAMIN ORAL TABLET 27 MG

IRON- 0.8 MG

Tier 1

PRENATAL VITAMIN WITH MINERALS Tier 1

prenatal vit-iron fum-folic ac Tier 1

RENA-VITE Tier 1

STRESS FORMULA WITH IRON Tier 1

STRESS FORMULA WITH IRON(SULF) Tier 1

SUPER B MAXI COMPLEX Tier 1

SUPER B-50 COMPLEX Tier 1

SUPER QUINTS Tier 1

vitamin b complex-folic acid oral tablet Tier 1

WESCAP-C DHA Tier 1

WESNATAL DHA COMPLETE Tier 1

VITAMIN C

b complex-vitamin c-folic acid oral tablet Tier 1

DIALYVITE 800 ORAL TABLET Tier 1

FULL SPECTRUM B-VITAMIN C Tier 1

RENA-VITE Tier 1

STRESS FORMULA WITH IRON Tier 1

STRESS FORMULA WITH IRON(SULF) Tier 1

TRI-VITAMIN WITH FLUORIDE Tier 1

TRI-VITE WITH FLUORIDE Tier 1

VITAMINS A,C,D AND FLUORIDE Tier 1

VITAMIN D

calcitriol intravenous Tier 1

calcitriol oral Tier 1

doxercalciferol oral capsule 0.5 mcg, 1 mcg Tier 1 ST

ergocalciferol (vitamin d2) oral capsule 1,250

mcg (50,000 unit)

Tier 1

RELION GLUCOSE Tier 1

TRI-VITAMIN WITH FLUORIDE Tier 1

TRI-VITE WITH FLUORIDE Tier 1

VITAMIN D2 Tier 1

VITAMINS A,C,D AND FLUORIDE Tier 1

VITAMIN E

STRESS FORMULA WITH IRON Tier 1

STRESS FORMULA WITH IRON(SULF) Tier 1

Ohio Marketplace 2024 Drug Formulary

122

Drug Name Tier Restrictions/Limits

VITAMIN K ACTIVITY

phytonadione (vitamin k1) injection solution 1

mg/0.5 ml

Tier 2

phytonadione (vitamin k1) injection solution 10

mg/ml

Tier 1

phytonadione (vitamin k1) oral tablet 5 mg Tier 1 QL (10 EA per 1 FILL)

Ohio Marketplace 2024 Drug Formulary

123

Medical Benefit

Drug Name Tier Restrictions/Limits

buprenorphine hcl Tier 1

XOLAIR SUBCUTANEOUS AUTO-INJECTOR Tier 2 PA

XOLAIR SUBCUTANEOUS RECON SOLN Tier 2 PA; QL (6 EA per 28 days)

XOLAIR SUBCUTANEOUS SYRINGE 150

MG/ML

Tier 2

PA; QL (4 SYRINGES per 28

days)

XOLAIR SUBCUTANEOUS SYRINGE 300 MG/2

Tier 2 PA

XOLAIR SUBCUTANEOUS SYRINGE 75

MG/0.5 ML

Tier 2

PA; QL (2 SYRINGES per 28

days)

Ohio Marketplace 2024 Drug Formulary

124

Index

2-IN-1 LANCET DEVICE............57

abacavir......................................17

abacavir-lamivudine................... 17

ABILIFY MAINTENA............ 42, 44

abiraterone................................. 21

ABRYSVO (PF)..........................23

acamprosate.............................. 11

acarbose.................................... 88

ACCU-CHEK FASTCLIX

LANCET DRUM......................... 57

ACCU-CHEK FASTCLIX

LANCING DEV...........................57

ACCU-CHEK MULTICLIX

LANCET..................................... 57

ACCU-CHEK SAFE-T-PRO....... 57

ACCU-CHEK SAFE-T-PRO

PLUS..........................................57

ACCU-CHEK SOFT DEV

LANCETS...................................57

ACCU-CHEK SOFTCLIX

LANCETS...................................57

ACD SOLUTION A...............29, 75

ACD-A.................................. 29, 75

acebutolol.......................28, 31, 36

acetaminophen-codeine.......41, 50

acetazolamide................ 35, 75, 81

acetic acid.................................. 80

acetylcysteine...................105, 109

ACID REDUCER

(OMEPRAZOLE)........................85

acitretin.....................................116

ACTEMRA................................102

ACTEMRA ACTPEN................ 102

ACTHIB (PF).............................. 23

ACTI-LANCE LANCETS............ 57

acyclovir............................. 19, 112

ADACEL(TDAP

ADOLESN/ADULT)(PF)............. 23

adalimumab-adaz.....................103

adalimumab-fkjp.......................103

adapalene........................ 105, 116

adapalene-benzoyl peroxide.... 119

ADCIRCA........................... 39, 110

adefovir...................................... 19

ADEMPAS..........................40, 110

ADJUSTABLE LANCING

DEVICE......................................57

ADTHYZA.................................100

ADULT ASPIRIN REGIMEN

..................................30, 31, 43, 53

ADVANCED LANCING

DEVICE......................................57

ADVANCED TRAVEL

LANCETS...................................57

ADVIN COVID-19 AG HOME

TEST.......................................... 57

ADVOCATE LANCET................ 57

ADVOCATE LANCING

DEVICE......................................57

AEROCHAMBER PLUS

FLOW-VU,L MSK.......................57

AEROCHAMBER PLUS

FLOW-VU,M MSK......................57

AEROCHAMBER PLUS

FLOW-VU,S MSK.......................57

AEROCHAMBER PLUS Z

STAT LG MSK............................57

AEROCHAMBER PLUS Z

STAT MD MSK...........................57

AEROCHAMBER PLUS Z

STAT SM MSK...........................57

AFIRMELLE............................... 90

AFTER PILL............................... 90

AFTERA..................................... 90

AGAMREE................................. 86

AIMOVIG AUTOINJECTOR.......47

AIMSCO LATEX CONDOM..... 105

AKYNZEO (NETUPITANT).. 83, 85

ALA-CORT............................... 114

albendazole................................13

albuterol sulfate..................27, 110

alclometasone.......................... 114

ALCOHOL PADS..................... 117

ALCOHOL PREP PADS...........117

alcohol swabs...........................117

ALCOHOL WIPES....................117

alendronate.............................. 104

alfuzosin..................................... 27

allopurinol.................................104

almotriptan malate......................54

alogliptin..................................... 95

alogliptin-metformin..............89, 95

alogliptin-pioglitazone.........95, 100

ALOMIDE................................... 79

alosetron.................................... 83

alprazolam..................................46

ALTABAX................................. 111

ALTAVERA (28)......................... 90

ALTERNATE SITE LANCET......57

ALTERNATE SITE LANCING

DEVICE......................................57

ALVESCO.............. 81, 86, 87, 109

ALYACEN 1/35 (28)................... 90

ALYACEN 7/7/7 (28).................. 90

amantadine hcl...............13, 26, 41

ambrisentan....................... 40, 110

amcinonide...............................114

AMETHIA................................... 90

AMETHYST (28)........................ 90

amiloride...............................39, 76

amiloride-hydrochlorothiazide

..................................39, 40, 76, 77

amiodarone................................ 36

amitriptyline................................ 55

amitriptyline-chlordiazepoxide

..............................................46, 55

amlodipine................35, 37, 38, 40

amlodipine-benazepril

............................33, 35, 37, 38, 40

amlodipine-olmesartan

............................32, 35, 37, 38, 40

amlodipine-valsartan

............................32, 35, 37, 38, 41

ammonium lactate....................113

amoxapine..................................55

amoxicil-clarithromy-lansopraz

........................................13, 19, 85

amoxicillin.......................13, 83, 85

amoxicillin-pot clavulanate

........................................13, 83, 85

amphetamine sulfate..................41

ampicillin.....................................13

anagrelide.................................. 31

anastrozole...........................21, 89

anticoag citrate phos dextrose... 29

ANTI-DIARRHEAL

(LOPERAMIDE)......................... 83

apraclonidine..............................78

aprepitant................................... 85

APRI...........................................90

APTIOM..................................... 48

APTIVUS....................................17

AQUA LANCE LANCING

DEVICE......................................57

AQUASTAT 0.9% SODIUM

CHLORIDE...........................57, 75

AQUASTAT SFR 0.9%

SODIUM CHLOR................. 57, 75

ARANELLE (28)......................... 90

AREXVY (PF).............................23

AREXVY ADJUVANT

COMPONENT (PF)....................23

AREXVY ANTIGEN

COMPONENT............................23

aripiprazole...........................42, 44

ARISTADA........................... 43, 45

ARISTADA INITIO................42, 44

armodafinil..................................56

ARNUITY ELLIPTA............ 87, 109

ASHLYNA.................................. 90

ASMANEX HFA..................87, 109

aspirin.......................30, 31, 43, 53

125

ASPIRIN CHILDRENS

..................................30, 31, 43, 53

aspirin,buffd-calcium carb-mag

..................................30, 31, 44, 53

aspirin-dipyridamole....... 30, 53, 73

ASSURE LANCE........................57

ASSURE LANCE PLUS............. 58

atazanavir...................................17

atenolol...........................28, 31, 36

atenolol-chlorthalidone

............................28, 34, 36, 40, 78

atomoxetine................................52

atorvastatin.................................38

atovaquone................................ 14

atovaquone-proguanil................ 13

atropine...................................... 82

ATROVENT HFA................25, 106

AUBRA.......................................90

AUBRA EQ.................................90

AUROVELA 1.5/30 (21)............. 90

AUROVELA 1/20 (21)................ 90

AUROVELA 24 FE..................... 90

AUROVELA FE 1.5/30 (28)........90

AUROVELA FE 1-20 (28)...........90

AURYXIA................................... 76

AUSTEDO..................................56

AUSTEDO XR............................56

AUSTEDO XR TITRATION

KT(WK1-4)................................. 56

AUTO-LANCET MINI................. 58

AUTOLET IMPRESSION LANC

DEV............................................58

AUTOLET LANCING DEVICE... 58

AVAR............................... 116, 117

AVAR-E............................116, 118

AVAR-E GREEN.............. 116, 118

AVAR-E LS...................... 117, 118

AVIANE...................................... 90

AVITA.......................................113

AVONEX.......................... 101, 102

AYUNA.......................................90

AZASITE.................................... 79

azathioprine..............................101

azelastine................................... 79

azelastine-fluticasone

........................79, 81, 87, 107, 110

azithromycin............................... 19

AZURETTE (28).........................90

B COMPLEX 1 (WITH FOLIC

ACID)....................................... 121

b complex-vitamin c-folic acid

..........................................121, 122

bacitracin....................................79

bacitracin-polymyxin b................79

baclofen......................................26

BALANCE B-100 (FOLIC ACID)

..................................................121

BALANCE B-50 (WITH FOLIC

ACID)....................................... 121

BALANCED B-100................... 121

BALANCED SALT......................82

balsalazide................................. 83

BALZIVA (28)............................. 90

BAQSIMI.............................. 11, 96

BARACLUDE............................. 19

BASAGLAR KWIKPEN U-100

INSULIN............................... 96, 97

BAYER ASPIRIN......30, 31, 44, 53

BAYER LOW DOSE ASPIRIN

..................................30, 31, 44, 53

bcg vaccine, live (pf)...................23

B-COMPLEX WITH VITAMIN C

..................................................121

BD ALCOHOL SWABS............ 118

BD ALLERGY SYRINGE............58

BD AUTOSHIELD DUO PEN

NEEDLE.....................................58

BD BLUNT PLASTIC

CANNULA.................................. 58

BD BULK SYRINGE SLIP TIP... 58

BD ECCENTRIC TIP SYRINGE.58

BD ECLIPSE.............................. 58

BD ECLIPSE LUER-LOK........... 58

BD FILTER NEEDLE 5-

MICRON NOKO......................... 58

BD FILTER NEEDLE-5

MICRON.....................................58

BD INSULIN SYRINGE..............58

BD INSULIN SYRINGE (HALF

UNIT)..........................................58

BD INSULIN SYRINGE

MICRO-FINE..............................58

BD INSULIN SYRINGE U-500... 58

BD INSULIN SYRINGE

ULTRA-FINE.............................. 58

BD INTEGRA SYRINGE............ 58

BD INTERLINK BLUNT

PLASTIC CAN............................58

BD INTERLINK SYRINGE......... 58

BD INTRADERMAL BEVEL

NEEDLES.................................. 58

BD LO-DOSE MICRO-FINE IV.. 58

BD LUER-LOK BULK

SYRINGE................................... 58

BD LUER-LOK SYRINGE.......... 59

BD LUER-LOK TIP CONTROL

SYRING..................................... 59

BD MICROTAINER LANCET.....59

BD NOKOR ADMIX NEEDLE.... 59

BD POSIFLUSH NORMAL

SALINE 0.9.......................... 59, 75

BD PRECISIONGLIDE...............59

BD PRECISIONGLIDE NON-

STERILE.................................... 59

BD QUINCKE SPINAL

NEEDLE.....................................59

BD REGULAR BEVEL

NEEDLES.................................. 59

BD SAFETYGLIDE

ALLERGIST TRAY.....................59

BD SAFETYGLIDE INSULIN

SYRINGE................................... 59

BD SAFETYGLIDE NEEDLE..... 59

BD SAFETYGLIDE

SHIELDING REG....................... 59

BD SAFETYGLIDE SYRINGE... 59

BD SAFETYGLIDE TB REG

BEVEL........................................59

BD SAFETYGLIDE

TUBERCULIN............................ 59

BD SHORT BEVEL NEEDLES.. 59

BD SHORT BEVEL THIN

WALL......................................... 59

BD SLIP TIP SYRINGE..............59

B-D SLIP TIP SYRINGE.............59

BD SPECIALTY USE

NEEDLES.................................. 59

BD SYRINGE............................. 59

BD SYRINGE CATH TIP

NONSTERILE............................ 59

BD SYRINGE CATHETER TIP.. 59

BD SYRINGE LUER-LOK

NONSTERILE............................ 59

BD SYRINGE LUER-LOK

STERILE.................................... 59

BD SYRINGE SLIP TIP

NONSTERILE............................ 59

BD SYRINGE TIP CAP.............. 59

BD SYRINGE-DUAL

CANNULA.................................. 60

BD TUBERCULIN SLIP-TIP.......60

BD TUBERCULIN SYRINGE..... 60

BD ULTRA-FINE MICRO PEN

NEEDLE.....................................60

BD ULTRA-FINE MINI PEN

NEEDLE.....................................60

BD ULTRA-FINE ORIG PEN

NEEDLE.....................................60

BD ULTRA-FINE SHORT PEN

NEEDLE.....................................60

BD VEO INSULIN SYR (HALF

UNIT)..........................................60

BD VEO INSULIN SYRINGE

UF.............................................. 60

126

BD VERITOR AT-HOME

COVID19 TST............................ 60

BELSOMRA............................... 51

benazepril...................................33

benazepril-hydrochlorothiazide

........................................33, 40, 77

benznidazole.............................. 19

benzonatate............................. 107

benztropine.......................... 26, 42

bepotastine besilate................... 79

BESER..................................... 114

betamethasone dipropionate....114

betamethasone valerate...........114

betamethasone, augmented.... 114

betaxolol.....................................80

bethanechol chloride.................. 27

bexarotene......................... 21, 112

BEXSERO..................................23

bicalutamide............................... 21

BIKTARVY........................... 16, 17

bimatoprost................................ 82

BINAXNOW COVD AG CARD

HOME TST.................................60

BINAXNOW COVID-19 AG

SELF TEST................................ 60

BIOGLO..................................... 74

BIOLON......................................60

BIOTHRAX.................................23

bisacodyl.................................... 84

bisoprolol fumarate.........28, 34, 36

bisoprolol-hydrochlorothiazide

............................28, 34, 36, 40, 77

BLISOVI 24 FE...........................90

BLISOVI FE 1.5/30 (28)............. 90

BLISOVI FE 1/20 (28)................ 90

blunt needle, disposable............ 60

BLUNT SPINAL NEEDLE.......... 60

BOOSTRIX TDAP...................... 23

bosentan............................ 41, 110

BPO..........................................117

BREATHERITE SPACER-

MASK, NEO............................... 60

BREATHERITE SPACER-

MASK,ADULT............................ 60

BREATHERITE SPACER-

MASK,CHILD............................. 60

BREATHERITE SPACER-

MASK,INFANT........................... 60

BREATHERITE SPACER-

MASK,S.CHLD...........................60

BREYNA.............................. 27, 87

BRIELLYN..................................90

BRILINTA................................... 30

brimonidine.........................78, 111

brimonidine-timolol............... 78, 80

brinzolamide...............................81

bromfenac.................................. 82

bromocriptine..............................47

brompheniramine-pseudoeph-

dm...................... 25, 106, 107, 108

BSS............................................ 82

budesonide.........................87, 109

budesonide-formoterol......... 27, 87

BUFFERIN............... 30, 31, 44, 53

BULLSEYE MINI SAFETY

LANCETS...................................60

bumetanide.......................... 38, 76

buprenorphine............................ 51

buprenorphine hcl.................... 124

buprenorphine-naloxone............ 51

bupropion hcl..............................42

bupropion hcl (smoking deter)....42

buspirone................................... 49

butalbital-acetaminop-caf-cod

............................41, 44, 46, 50, 52

butalbital-acetaminophen-caff

..................................41, 44, 46, 52

butalbital-aspirin-caffeine

......................30, 31, 44, 46, 52, 53

BUTTERFLY TOUCH LANCET. 60

cabergoline.................................48

CABTREO................................111

calcipotriene............................. 113

calcipotriene-betamethasone... 113

calcitonin (salmon)............. 89, 104

calcitriol............................ 119, 122

calcium acetate(phosphat bind). 76

CAMILA......................................90

CAMRESE..................................90

CAMRESE LO............................91

candesartan............................... 32

candesartan-hydrochlorothiazid

........................................32, 40, 77

capecitabine............................... 21

CAPRELSA................................ 21

captopril......................................33

captopril-hydrochlorothiazide

........................................33, 40, 77

carbamazepine.....................42, 43

carbidopa................................... 47

carbidopa-levodopa....................47

carbidopa-levodopa-

entacapone................................ 47

carbinoxamine maleate 11, 12, 108

cardioplegic soln.........................77

CAREONE LANCING DEVICE.. 60

CAREONE ULTRA THIN

LANCET..................................... 60

CAREPOINT LUER LOCK

SYR-NEEDLE............................ 60

CAREPOINT SAFETY LL SYR-

NEEDLE.....................................60

CARESENS LANCETS..............60

CARESTART COVID-19 AG

HOME TST.................................60

CARETOUCH ALCOHOL

PREP PAD............................... 118

CARETOUCH LANCING

DEVICE......................................60

CARETOUCH LUER LOCK

SYR-NEEDLE............................ 60

CARETOUCH SAFETY

LANCETS...................................60

CARETOUCH TWIST LANCET. 60

carisoprodol................................26

carisoprodol-aspirin-codeine

........................................26, 50, 54

carteolol......................................80

CARTIA XT...........................35, 37

carvedilol............ 26, 27, 31, 36, 39

CAYA CONTOURED............... 105

CAYSTON..................................18

CAZIANT (28).............................91

cefadroxil....................................12

cefdinir........................................13

cefprozil......................................12

cefuroxime axetil........................ 12

celecoxib.................................... 47

CELLTRION DIATRUST COV-

19 HOME................................... 61

cephalexin.................................. 12

cetirizine............................. 12, 110

cevimeline.................................. 27

CHANTIX....................................28

CHANTIX CONTINUING

MONTH BOX..............................28

CHANTIX STARTING MONTH

BOX............................................28

CHARLOTTE 24 FE...................91

CHATEAL (28)........................... 91

CHATEAL EQ (28)..................... 91

CHEK-STIX CONTROL..............74

CHEMO TRANSFER PIN...........61

CHEMSTRIP 10 MD...................74

CHEMSTRIP 10/SG...................74

CHEMSTRIP 2 GP.....................74

CHEMSTRIP 50B.......................74

CHEMSTRIP 7........................... 74

CHEMSTRIP 9........................... 74

CHILDREN'S ASPIRIN

..................................30, 31, 44, 54

chlordiazepoxide hcl...................46

chlordiazepoxide-clidinium... 25, 46

chlorhexidine gluconate..............80

chloroquine phosphate...............13

127

chlorpromazine...........................51

chlorthalidone.......................40, 78

chlorzoxazone............................ 26

cholestyramine (with sugar)....... 34

CHOLESTYRAMINE LIGHT...... 34

cholestyramine-aspartame.........35

CHOSEN LANCET.....................61

CHOSEN LANCING DEVICE.....61

CHOSEN SAFETY LANCET......61

CICLODAN...............................116

CICLODAN KIT........ 116, 117, 119

ciclopirox.................................. 116

ciclopirox-ure-camph-menth-

euc................................... 116, 117

cilostazol.................................... 30

cimetidine................................... 85

cimetidine hcl..............................85

CIMZIA..................................... 103

CIMZIA POWDER FOR

RECONST................................103

CIMZIA STARTER KIT.............103

cinacalcet................................... 89

CIPRO HC................14, 20, 79, 81

ciprofloxacin................... 14, 20, 79

ciprofloxacin hcl..............14, 20, 79

ciprofloxacin-dexamethasone

........................................20, 79, 81

ciprofloxacin-fluocinolone

........................................20, 79, 81

citalopram...................................55

CITRATE OF MAGNESIA..........84

CITROMA...................................84

clarithromycin....................... 14, 19

CLASSIC PRENATAL 30, 120, 121

CLEARLAX................................ 84

clemastine.................... 11, 12, 108

CLENPIQ................................... 84

CLEOCIN........................... 18, 111

CLEVER CHEK LANCETS........ 61

CLEVER CHOICE CHAMBER-

LRG MASK.................................61

CLEVER CHOICE CHAMBER-

MED MASK................................ 61

CLEVER CHOICE CHAMBER-

SM MASK...................................61

CLINDACIN ETZ................ 18, 111

clindamycin hcl...................18, 111

clindamycin palmitate hcl... 18, 111

CLINDAMYCIN PEDIATRIC

............................................18, 111

clindamycin phosphate.......18, 111

clindamycin-benzoyl peroxide

....................................18, 111, 117

clindamycin-tretinoin...18, 111, 113

CLINITEST COVID-19 HOME

TEST.......................................... 61

clobazam....................................46

clobetasol................................. 114

clobetasol-emollient..................114

CLODAN.................................. 114

CLOMID..................................... 95

clomiphene citrate...................... 95

clomipramine..............................56

clonazepam................................46

clonidine............................... 25, 35

clonidine hcl......................... 25, 35

clopidogrel..................................30

clorazepate dipotassium.............46

clotrimazole.............................. 113

clotrimazole-betamethasone

..........................................113, 114

clozapine.................................... 45

COAGUCHEK LANCETS...........61

COARTEM................................. 13

codeine sulfate................... 50, 107

colchicine........................... 35, 104

colesevelam......................... 35, 89

colestipol.................................... 35

COLOR LANCETS.....................61

COMBIPATCH..................... 95, 98

COMBISTIX REAGENT............. 74

COMBIVENT RESPIMAT

..............................25, 27, 106, 110

COMETRIQ................................21

COMFORT EZ LANCETS..........61

COMFORT TOUCH PLUS

SAFETY LANC...........................61

COMFORT TOUCH ULT THIN

LANCETS...................................61

COMFORTSEAL LARGE

MASK......................................... 61

COMFORTSEAL MEDIUM

MASK......................................... 61

COMFORTSEAL SMALL

MASK......................................... 61

COMPACT SPACE

CHAMBER-LRG MASK..............61

COMPACT SPACE

CHAMBER-MED MASK.............61

COMPACT SPACE

CHAMBER-SM MASK................61

COMPLERA................... 16, 17, 19

CORDX COVID-19 AG HOME

TEST.......................................... 61

CORTIFOAM............................114

cortisone.....................................87

COSENTYX..............................102

COSENTYX (2 SYRINGES).....102

COSENTYX PEN..................... 102

COSENTYX PEN (2 PENS).....102

COSENTYX UNOREADY PEN 102

COVARYX............................88, 95

COVARYX H.S.....................88, 95

COVID-19 AT-HOME TEST.......61

CREON...................................... 85

CRESEMBA............................... 15

CRINONE...................................98

cromolyn.....................79, 108, 109

CRYOSERV............................. 105

CRYSELLE (28)......................... 91

CURAE.......................................91

CURITY ALCOHOL SWABS....118

cyanocobalamin (vitamin b-12) 121

cyclobenzaprine......................... 26

cyclopentolate............................ 82

cyclopen-tropic-phenyleph-watr

..............................................82, 83

cyclophosphamide..............21, 101

cycloserine................................. 14

cyclosporine....................... 80, 101

cyclosporine modified...............101

CYCLOTENS STARTER......26, 61

cyproheptadine.............11, 12, 108

CYRED.......................................91

CYRED EQ.................................91

CYSTAGON............................. 105

dalfampridine............................105

danazol.......................................88

dantrolene.................................. 26

dapsone............... 13, 14, 111, 119

DAPTACEL (DTAP

PEDIATRIC) (PF).......................23

darifenacin................................120

darunavir.................................... 17

DASETTA 1/35 (28)................... 91

DASETTA 7/7/7 (28).................. 91

DAVOL IRRIGATION

SYRINGE................................... 61

DAVOL PISTON IRRIGATION...61

DAYSEE.....................................91

DEBLITANE............................... 91

deferasirox................................. 86

deflazacort..................................87

DELFLEX WITH 2.5 %

DEXTROSE................................76

DELFLEX-LC/1.5%

DEXTROSE................................76

DELFLEX-LC/2.5%

DEXTROSE................................76

DELFLEX-LC/4.25%

DEXTROSE................................76

DELSTRIGO.........................16, 17

demeclocycline...........................20

DENGVAXIA (PF)...................... 23

128

DENTA 5000 PLUS....................56

DEPO-SUBQ PROVERA 104.... 98

DERMACINRX PRIZOPAK......112

DESCOVY............................17, 19

desflurane.................................. 48

desipramine................................56

desloratadine......................12, 110

desmopressin.......................29, 98

desog-e.estradiol/e.estradiol...... 91

desonide...................................114

desoximetasone....................... 114

desvenlafaxine........................... 54

desvenlafaxine succinate........... 54

DEX4 GLUCOSE....................... 75

DEX4 GLUCOSE BITS.............. 75

DEX4 GLUCOSE POUCH

PACK......................................... 75

DEX4 GLUCOSE QUICK

DISSOLVE................................. 75

dexamethasone..........................87

DEXAMETHASONE

INTENSOL................................. 87

dexamethasone sodium

phosphate.................................. 81

dexchlorpheniramine maleate

............................................12, 108

DEXCOM G6 RECEIVER.......... 61

DEXCOM G6 SENSOR..............61

DEXCOM G6 TRANSMITTER... 61

DEXCOM G7 RECEIVER.......... 61

DEXCOM G7 SENSOR..............61

dexlansoprazole................... 85, 86

dexmethylphenidate................... 52

dextroamphetamine sulfate........41

dextroamphetamine-

amphetamine............................. 41

dextrose..................................... 75

DIALYVITE 800................121, 122

DIASTIX..................................... 74

diazepam....................................46

diclofenac potassium....44, 53, 119

diclofenac sodium

..........................44, 49, 53, 82, 119

diclofenac-misoprostol..........49, 85

dicloxacillin................................. 20

dicyclomine.................................25

DIFICID................................ 19, 20

diflorasone................................114

diflunisal..................................... 53

DIGITEK.....................................35

digoxin........................................35

dihydroergotamine................27, 44

DILANTIN.............................36, 48

diltiazem hcl..........................35, 37

DILT-XR............................... 35, 37

diluent for treprostinil (gly)........106

dimethyl fumarate.....................101

DIPENTUM.................................83

diphenhydramine hcl.... 11, 12, 108

diphenoxylate-atropine.........25, 83

dipyridamole.........................30, 73

disopyramide phosphate............ 36

disulfiram....................................11

divalproex.......................43, 44, 48

dofetilide.....................................36

DOLISHALE............................... 91

donepezil....................................27

dorzolamide................................81

dorzolamide-timolol.............. 80, 81

dorzolamide-timolol (pf)..............81

DOTTI........................................ 95

DOVATO.............................. 16, 17

doxazosin................. 26, 31, 32, 38

doxepin...............................56, 112

doxercalciferol.......................... 122

doxycycline hyclate 14, 20, 79, 111

doxycycline monohydrate

..........................14, 20, 21, 79, 111

doxylamine-pyridoxine (vit b6)

....................................83, 108, 121

D-PENAMINE.......................11, 86

dronabinol.................................. 85

DROPLET GENTEEL

LANCING DEVICE.....................61

DROPLET LANCETS.................62

DROPLET LANCING DEVICE...62

DROPSAFE ALCOHOL PREP

PADS....................................... 118

drospirenone-e.estradiol-lm.fa....91

drospirenone-ethinyl estradiol.... 91

DUAVEE.................................... 95

DULCOLAX (MAGNESIUM

HYDROXIDE).............................84

DULERA...............................28, 87

duloxetine.............................48, 54

DUPIXENT PEN.......................119

DUPIXENT SYRINGE..............119

dutasteride............................... 103

dutasteride-tamsulosin....... 27, 103

DY-O-DERM.............................118

EASIVENT MASK LARGE......... 62

EASIVENT MASK MEDIUM.......62

EASIVENT MASK SMALL..........62

EASY COMFORT ALCOHOL

PAD..........................................118

EASY COMFORT LANCETS.....62

EASY MINI EJECT LANCING

DEVICE......................................62

EASY TOUCH............................62

EASY TOUCH ALCOHOL

PREP PADS.............................118

EASY TOUCH FLIPLOCK

SYRINGE................................... 62

EASY TOUCH FLURINGE.........62

EASY TOUCH FLURINGE

FLIPLOCK..................................62

EASY TOUCH FLURINGE

SHEATHLOCK...........................62

EASY TOUCH LANCETS.......... 62

EASY TOUCH LANCING

DEVICE......................................62

EASY TOUCH SAFETY

LANCETS...................................62

EASY TOUCH TUBERCULIN

FLIPLOCK..................................62

EASY TOUCH TUBERCULIN

SHEATHLK................................ 62

EASY TOUCH TWIST

LANCETS...................................62

EASY TWIST AND CAP

LANCETS...................................62

ECLIPSE SYRINGE...................62

EC-NAPROXEN.........................53

econazole.................................113

ECONTRA EZ............................ 91

ECONTRA ONE-STEP.............. 91

ECOTRIN....................... 31, 44, 54

ECOTRIN LOW STRENGTH

........................................31, 44, 54

ED-SPAZ..............................11, 25

EEMT................................... 88, 95

EEMT HS............................. 88, 96

efavirenz.....................................16

efavirenz-lamivu-tenofov disop

..............................................16, 17

EFFER-K....................................77

eletriptan.................................... 54

ELINEST.................................... 91

ELIQUIS..................................... 29

ELIQUIS DVT-PE TREAT 30D

START....................................... 29

ELIXOPHYLLIN....37, 75, 110, 120

ELLA.......................................... 91

ELLUME COVID-19 HOME

TEST.......................................... 62

ELMIRON...................................11

ELURYNG..................................91

EMBRACE LANCETS................62

EMBRACE LANCING DEVICE.. 62

EMBRACE PEN NEEDLE..........62

EMBRACE SAFETY LANCET... 62

EMFLAZA...................................87

EMGALITY PEN.........................47

EMGALITY SYRINGE................47

129

EMSAM...................................... 49

emtricitabine...............................17

emtricitabine-tenofovir (tdf)...17, 19

EMTRIVA................................... 17

EMVERM....................................13

EMZAHH.................................... 91

enalapril maleate........................33

enalapril-hydrochlorothiazide

........................................33, 40, 77

ENBREL...................................103

ENBREL MINI.......................... 103

ENBREL SURECLICK............. 103

ENDOCET............................41, 50

ENFAMIL GLUCOSE................. 75

ENGERIX-B (PF)........................23

ENGERIX-B PEDIATRIC (PF)... 23

ENILLORING..............................91

enoxaparin................................. 29

ENPRESSE................................91

ENSKYCE.................................. 91

entacapone................................ 47

entecavir.....................................19

ENTRESTO................................32

ENULOSE.................................. 75

epinastine...................................79

epinephrine........................ 25, 106

EPITOL................................ 42, 43

eplerenone........................... 38, 39

ergocalciferol (vitamin d2)........ 122

ergoloid...................................... 27

ergotamine-caffeine..............27, 44

ERIVEDGE.................................21

erlotinib.......................................21

ERRIN........................................ 91

ERTACZO................................ 113

ERY PADS............................... 111

ERYTHROCIN (AS

STEARATE)................. 15, 79, 111

erythromycin.................15, 79, 111

erythromycin ethylsuccinate

......................................15, 79, 111

erythromycin with ethanol.........111

erythromycin-benzoyl peroxide 112

escitalopram oxalate.................. 55

esomeprazole magnesium......... 86

ESTARYLLA.............................. 91

estazolam...................................46

estradiol......................................96

estradiol-norethindrone acet.96, 98

estrogens-methyltestosterone

..............................................88, 96

eszopiclone................................ 49

ethambutol................................. 14

ethosuximide.............................. 55

ethynodiol diac-eth estradiol.......91

etodolac......................................53

etonogestrel-ethinyl estradiol..... 91

etoposide....................................21

etravirine.................................... 16

EUTHYROX............................. 100

everolimus

(immunosuppressive)...............105

EVOTAZ.............................18, 105

EXCEL SYRINGE...................... 62

EXEL HYPODERMIC

NEEDLES.................................. 63

EXEL SYRINGE.........................63

exemestane..........................21, 89

EXTRANEAL 7.5 %....................76

E-Z JECT LANCETS..................63

E-Z JECT THIN LANCETS.........63

EZ SMART LANCETS................63

ezetimibe....................................36

ezetimibe-simvastatin...........36, 38

FALMINA (28)............................ 91

famciclovir.................................. 19

famotidine...................................85

FANAPT..................................... 45

FANTASY CONDOM............... 105

FARXIGA................................... 99

FASTEP COVID-19 AG HOME

TEST.......................................... 63

FC2 FEMALE CONDOM..........105

febuxostat.................................104

felbamate................................... 42

felodipine..................35, 37, 38, 41

FEMCAP............................ 63, 105

fenofibrate.................................. 38

fenofibrate micronized................37

fenofibrate nanocrystallized........38

fenoprofen.................................. 53

fentanyl.......................................50

filter needles...............................63

finasteride.........................103, 113

FINGERSTIX LANCETS............ 63

fingolimod.................................102

FINZALA.................................... 91

FIRVANQ................................... 15

flavoxate...................................120

flecainide.................................... 36

FLEXICHAMBER-LG CHILD

MASK......................................... 63

FLEXICHAMBER-SM ADULT

MASK......................................... 63

FLEXICHAMBER-SM CHILD

MASK......................................... 63

FLOW-EZE VENTED NEEDLE..63

FLOWFLEX COVID-19 AG

HOME TEST.............................. 63

fluconazole................................. 15

flucytosine.................................. 20

fludrocortisone............................87

flunisolide..................... 81, 87, 107

fluocinolone.............................. 114

fluocinolone acetonide oil...........81

fluocinolone and shower cap....114

fluocinonide...................... 114, 115

FLUOCINONIDE-E...................115

fluocinonide-emollient...............115

fluoride (sodium).........................56

fluorometholone......................... 81

fluorouracil..........................21, 112

fluoxetine....................................55

fluphenazine decanoate............. 51

fluphenazine hcl......................... 52

flurandrenolide......................... 115

flurazepam................................. 46

flurbiprofen................................. 53

flurbiprofen sodium.....................82

fluticasone furoate-vilanterol 28, 87

fluticasone propionate

................81, 87, 88, 107, 109, 115

fluticasone propion-salmeterol

..............................................28, 88

fluvastatin................................... 38

fluvoxamine................................ 55

folic acid................................... 121

FOLTABS 800..........................121

fondaparinux.............................. 29

FORA LANCING DEVICE..........63

FORACARE LANCETS..............63

FORANE.................................... 48

formoterol fumarate............28, 110

fosamprenavir.............................18

fosinopril.....................................33

fosinopril-hydrochlorothiazide

........................................33, 40, 77

FREESTYLE CONTROL............63

FREESTYLE LANCETS.............63

FREESTYLE LIBRE 14 DAY

READER.................................... 63

FREESTYLE LIBRE 14 DAY

SENSOR.................................... 63

FREESTYLE LIBRE 2

READER.................................... 63

FREESTYLE LIBRE 2

SENSOR.................................... 63

FREESTYLE LIBRE 3

READER.................................... 63

FREESTYLE LIBRE 3

SENSOR.................................... 64

FREESTYLE UNISTIK 2............ 64

frovatriptan................................. 54

FULL SPECTRUM B-VITAMIN

C.......................................121, 122

130

furosemide........................... 38, 76

FYAVOLV.............................96, 98

FYCOMPA..................................42

G TUSSIN AC............ 50, 107, 108

gabapentin..................... 41, 42, 48

galantamine................................27

GARDASIL 9 (PF)...................... 23

gatifloxacin................................. 79

GAVILAX....................................84

GAVILYTE-C..............................84

GAVILYTE-G..............................84

GAVILYTE-N..............................84

gemfibrozil..................................38

GEMMILY...................................91

GENABIO COVID-19 RAPID

AT-HOME...................................64

GENERLAC................................75

GENGRAF................................101

gentamicin..........................79, 112

GENTLE LAXATIVE

(BISACODYL)............................ 84

GENTLELAX.............................. 84

GENVOYA........................... 16, 17

GILOTRIF...................................21

glatiramer................................. 101

GLATOPA................................ 101

glimepiride................................100

glipizide.................................... 100

glipizide-metformin............. 89, 100

GLOSTRIPS...............................74

GLUCAGON (HCL)

EMERGENCY KIT................11, 96

GLUCAGON EMERGENCY

KIT (HUMAN)....................... 11, 96

glucagon hcl......................... 73, 96

GLUCO BURST......................... 75

GLUCOCOM LANCETS.............64

glucose.......................................75

GLUCOSE BITS.........................75

GLUCOSE GEL..........................75

GLUCOSE KETONE

CONTROL SOLN.......................64

GLUTOL GEL.............................75

GLUTOSE-15.............................75

GLUTOSE-45.............................75

GLUTOSE-5...............................75

glyburide...................................100

glyburide micronized................ 100

glyburide-metformin............89, 100

GLYCINE UROLOGIC............... 76

glycine urologic solution............. 76

glycopyrrolate.....................25, 112

GOJJI LANCETS........................64

GOJJI LANCING DEVICE..........64

GOTOKNOW COVID-19 AG

HOME TEST.............................. 64

granisetron hcl............................83

griseofulvin microsize.................13

griseofulvin ultramicrosize..........13

guaiacol....................................118

GUAIFENESIN AC.....50, 107, 108

GUAIFENESIN DAC

......................25, 50, 106, 107, 108

guanfacine............................35, 36

GYNAZOLE-1...........................113

HADLIMA................................. 103

HADLIMA PUSHTOUCH..........103

HADLIMA(CF).......................... 103

HADLIMA(CF) PUSHTOUCH.. 103

HAILEY...................................... 91

HAILEY 24 FE............................91

HAILEY FE 1.5/30 (28)...............91

HAILEY FE 1/20 (28)..................91

halcinonide............................... 115

halobetasol propionate.............115

HALOETTE................................ 91

haloperidol..................................47

haloperidol lactate...................... 47

HAVRIX (PF)..............................23

HEALON PRO............................64

HEALTHY ACCENTS

AUTOLET...................................64

HEALTHY ACCENTS UNILET

LANCET..................................... 64

HEATHER.................................. 92

HEMA-COMBISTIX....................74

heparin (porcine)........................ 29

HEPLISAV-B (PF)...................... 23

HER STYLE............................... 92

HIBERIX (PF).............................23

HOMATROPAIRE...................... 82

huber safety needles (disp.).......64

HUMIRA................................... 103

HUMIRA PEN...........................103

HUMIRA(CF)............................103

HUMIRA(CF) PEDI CROHNS

STARTER.................................103

HUMIRA(CF) PEN....................103

HUMIRA(CF) PEN CROHNS-

UC-HS......................................103

HUMIRA(CF) PEN PEDIATRIC

UC............................................ 103

HUMIRA(CF) PEN PSOR-UV-

ADOL HS................................. 103

HUMULIN 70/30 U-100

INSULIN......................... 96, 97, 99

HUMULIN 70/30 U-100

KWIKPEN.......................96, 97, 99

HUMULIN N NPH INSULIN

KWIKPEN.............................96, 97

HUMULIN N NPH U-100

INSULIN............................... 96, 97

HUMULIN R REGULAR U-100

INSULN................................ 96, 99

HUMULIN R U-500 (CONC)

INSULIN............................... 96, 99

HUMULIN R U-500 (CONC)

KWIKPEN.............................96, 99

HURRICAINE LUER-LOCK DIS

CAP............................................64

hydralazine.................................37

hydrochlorothiazide.............. 40, 77

hydrocodone bitartrate............... 50

hydrocodone-acetaminophen

..............................................42, 50

hydrocodone-chlorpheniramine

..............................12, 50, 107, 108

hydrocodone-ibuprofen........ 49, 50

hydrocortisone....................88, 115

hydrocortisone acetate.............115

hydrocortisone butyrate............115

hydrocortisone valerate............115

hydrocortisone-acetic acid....80, 81

hydrogen peroxide..................... 82

HYDROMET.................25, 50, 107

hydromorphone.......................... 50

hydroxychloroquine............ 14, 105

hydroxypropyl cellulose............106

hydroxyurea............................... 21

hydroxyzine hcl.....................12, 44

hydroxyzine pamoate........... 12, 44

HYFTOR...........................102, 116

hyoscyamine sulfate.............11, 25

HYOSYNE............................11, 25

HYPODERMIC NEEDLES......... 64

HYPOLANCE AST LANCING.... 64

hypromellose............................106

ibandronate.............................. 104

IBRANCE................................... 21

IBU............................................. 53

ibuprofen.................................... 53

ibuprofen-famotidine.............49, 85

ICLEVIA..................................... 92

IHEALTH COVID-19 AG HOME

TEST.......................................... 64

imatinib.................................21, 22

IMBRUVICA............................... 22

imipramine hcl............................ 56

imipramine pamoate...................56

imiquimod.................................112

IMOVAX RABIES VACCINE

(PF)............................................ 23

INCASSIA.................................. 92

131

INCONTROL ALCOHOL PADS

..................................................118

INCONTROL LANCING

DEVICE......................................64

INCONTROL SUPER THIN

LANCETS...................................64

INCONTROL ULTRA THIN

LANCETS...................................64

INCRELEX............................... 100

indapamide...........................40, 78

INDICAID COVID-19 AG

HOME TEST.............................. 64

indomethacin......................53, 104

INFANRIX (DTAP) (PF)..............23

INJECT EASE LANCETS...........64

INJECT-EASE............................64

INLYTA.......................................22

INSTACLEAN...........................118

insulin asp prt-insulin aspart

........................................96, 97, 99

insulin aspart u-100........96, 97, 99

insulin lispro..........................97, 99

insulin lispro protamin-lispro.97, 99

INSULIN SYRINGE....................64

INSULIN SYRINGE

MICROFINE............................... 64

insulin syringe-needle u-100...... 64

INTEGRA SYRINGE.................. 64

INTELISWAB COVID-19

HOME TEST.............................. 64

INTERLINK SYRINGE

CANNULA.................................. 64

INVACARE LANCETS............... 64

INVEGA SUSTENNA................. 45

INVEGA TRINZA........................45

IOPIDINE................................... 79

IPOL........................................... 23

ipratropium bromide..... 25, 82, 106

ipratropium-albuterol

..............................25, 28, 106, 110

irbesartan................................... 32

irbesartan-hydrochlorothiazide

........................................32, 40, 77

ISENTRESS...............................16

ISIBLOOM..................................92

isoflurane....................................48

isoniazid..................................... 14

isopropyl alcohol.......................118

isosorbide dinitrate..................... 39

isosorbide mononitrate...............39

isotretinoin................................117

ISTURISA...................................88

IV PREP WIPES.......................118

ivermectin...........................13, 119

IXCHIQ (PF)...............................23

IXIARO (PF)............................... 24

JAIMIESS...................................92

JAKAFI............................... 22, 116

JANTOVEN................................ 29

JARDIANCE...............................99

JASMIEL (28).............................92

JENCYCLA.................................92

JOLESSA................................... 92

JULEBER................................... 92

JULUCA..................................... 16

JUNEL 1.5/30 (21)......................92

JUNEL 1/20 (21).........................92

JUNEL FE 1.5/30 (28)................92

JUNEL FE 1/20 (28)...................92

JUNEL FE 24............................. 92

JYNARQUE................................78

JYNNEOS (PF).......................... 24

KAITLIB FE................................ 92

KALLIGA.................................... 92

KALYDECO..............................107

KARIVA (28)...............................92

KELNOR 1/35 (28)..................... 92

KELNOR 1-50 (28).....................92

ketoconazole...................... 15, 113

KETO-DIASTIX.......................... 74

KETONE CARE..........................74

KETONE URINE TEST.............. 74

ketoprofen.................................. 53

ketorolac...............................53, 82

KETOSTIX................................. 74

KIMONO MICROTHIN AQUA

LUBE CON...............................105

KIMONO MICROTHIN

CONDOMS...............................105

KIMONO MICROTHIN LARGE

CONDOMS...............................105

KIMONO TEXTURED

CONDOMS...............................105

KINRIX (PF)............................... 24

KIONEX (WITH SORBITOL)

............................................76, 104

KIPROFEN.................................53

KLAYESTA...............................119

KLOR-CON 10........................... 77

KLOR-CON 8............................. 77

KLOR-CON M10........................ 77

KLOR-CON M15........................ 77

KLOR-CON M20........................ 77

KLOR-CON/EF...........................77

KOBEE.....................................121

KOURZEQ................................115

KURVELO (28)...........................92

l norgest/e.estradiol-e.estrad......92

labetalol........26, 27, 31, 34, 36, 39

LABSTIX REAGENT.................. 74

lacosamide................................. 48

lactulose..................................... 75

LAGEVRIO (EUA)...................... 19

lamivudine.................................. 17

lamivudine-zidovudine................17

lamotrigine............................42, 43

lancets..................................64, 65

LANCETS, SUPER THIN...........65

LANCETS,THIN......................... 65

LANCETS,ULTRA THIN.............65

lancing device............................ 65

lancing device with lancets.........65

LANCING SYSTEM....................65

lansoprazole...............................86

lanthanum.................................. 76

LANZO LANCING DEVICE........65

lapatinib......................................22

LARIN 1.5/30 (21)...................... 92

LARIN 1/20 (21)......................... 92

LARIN 24 FE.............................. 92

LARIN FE 1.5/30 (28).................92

LARIN FE 1/20 (28)....................92

LASTACAFT ONCE DAILY

RELIEF.......................................79

latanoprost................................. 82

LAXATIVE (BISACODYL).......... 84

LAXATIVE PEG 3350................ 84

LAYOLIS FE...............................92

LEENA 28.................................. 92

leflunomide.......................102, 105

lenalidomide....................... 22, 105

LENVIMA................................... 22

LESSINA.................................... 92

letrozole................................22, 89

leucovorin calcium......................11

LEUKERAN................................22

levalbuterol tartrate.............28, 110

levetiracetam..............................42

levobunolol................................. 81

levocetirizine.......................12, 110

levofloxacin...... 14, 20, 79, 80, 112

LEVONEST (28).........................92

levonorgestrel.............................92

levonorgestrel-ethinyl estrad 92, 93

levonorg-eth estrad triphasic......93

LEVORA-28............................... 93

levorphanol tartrate.................... 50

levothyroxine............................ 100

LEVOXYL.................................100

lidocaine................................... 112

lidocaine hcl....................... 82, 112

LIDOCAINE VISCOUS...............82

lidocaine-prilocaine...................112

LIDOPIN...................................112

132

LIFESHIELD BLUNT

CANNULA.................................. 65

linezolid...................................... 20

LINZESS.................................... 85

liothyronine...............................100

lisinopril...................................... 33

lisinopril-hydrochlorothiazide

........................................33, 40, 77

LITE TOUCH-MEDIUM MASK...65

LITETOUCH-LARGE MASK...... 65

LITETOUCH-SMALL MASK.......65

lithium carbonate........................43

lithium citrate.............................. 43

LO LOESTRIN FE......................93

LOJAIMIESS.............................. 93

loperamide................................. 83

lopinavir-ritonavir........................18

lorazepam.................................. 46

LORYNA (28)............................. 93

losartan...................................... 32

losartan-hydrochlorothiazide

........................................32, 40, 78

loteprednol etabonate................ 81

lovastatin.................................... 38

LOW-OGESTREL (28)...............93

loxapine succinate......................47

LO-ZUMANDIMINE (28).............93

lubiprostone................................84

LUDENT FLUORIDE..................56

LUER LOCK SYRINGE..............65

LUER-LOK TIP...........................65

luliconazole.............................. 113

lurasidone...................................45

LUTERA (28)..............................93

LYLEQ........................................93

LYSODREN................................22

LYZA.......................................... 93

mafenide acetate......................112

MAGELLAN SAFETY

SYRINGE................................... 65

MAGELLAN SYRINGE...............65

MAGELLAN TUBERCULIN

SAFETY SYR.............................65

magnesium citrate......................84

magnesium hydroxide................ 84

malathion..................................119

maraviroc....................................16

MARLISSA (28)..........................93

MATULANE................................22

MATZIM LA.......................... 35, 37

MAVYRET..................................16

MAXI-TUSS AC..........50, 107, 108

MD-GASTROVIEW.................... 74

meclizine.............................. 12, 83

MEDISENSE MID CONTROL....65

MEDISENSE THIN LANCETS... 65

MEDLANCE PLUS LANCETS... 65

MEDLANCE PLUS SPECIAL

BLADE....................................... 65

medroxyprogesterone................ 98

mefenamic acid.......................... 53

mefloquine..................................14

megestrol............................. 22, 98

MEKINIST.................................. 22

meloxicam.................................. 53

memantine................................. 47

MENQUADFI (PF)......................24

MENTAX.................................. 113

MENVEO A-C-Y-W-135-DIP

(PF)............................................ 24

meprobamate............................. 49

mercaptopurine.................. 22, 101

MERZEE.................................... 93

mesalamine................................83

mesalamine with cleansing

wipe............................................83

METADATE ER..........................52

metaxalone.................................26

metformin................................... 89

methadone................................. 50

METHADONE INTENSOL......... 50

methamphetamine......................41

methazolamide...........................81

methimazole...............................89

methocarbamol...........................26

methotrexate sodium..........22, 101

methscopolamine....................... 25

methsuximide............................. 55

methyldopa...........................25, 36

methylergonovine.....................106

methylphenidate hcl................... 52

methylprednisolone.................... 88

methyltestosterone.....................88

metoclopramide hcl.................... 85

metolazone...........................40, 78

metoprolol succinate...... 28, 34, 36

metoprolol ta-hydrochlorothiaz

............................28, 34, 36, 40, 78

metoprolol tartrate.......... 28, 34, 36

metronidazole.13, 19, 83, 112, 119

metyrosine..................................74

MIBELAS 24 FE......................... 93

MICRO THIN LANCETS............ 65

MICROGESTIN 1.5/30 (21)........93

MICROGESTIN 1/20 (21)...........93

MICROGESTIN 24 FE............... 93

MICROGESTIN FE 1.5/30 (28)..93

MICROGESTIN FE 1/20 (28).....93

MICROLET 2 LANCING

DEVICE......................................65

MICROLET LANCET..................65

MICROLET NEXT LANCING

DEVICE......................................65

midazolam............................46, 47

midazolam (pf)............................46

midodrine................................... 25

miglitol........................................ 88

MILI............................................ 93

MILK OF MAGNESIA.................84

MILK OF MAGNESIA

CONCENTRATED..................... 84

MIMVEY............................... 96, 98

MINI LANCING DEVICE............ 65

MINI TRANSFER PIN................ 65

MINIMED QUICK-SERTER

(MMT-395)..................................65

minocycline.................................21

minoxidil..................................... 37

mirtazapine.................................42

misoprostol.................................85

M-M-R II (PF)............................. 24

MOBILE LANCETS.................... 65

modafinil.....................................56

MODERNA COVID 23-24(6M-

11Y)PF....................................... 24

mometasone................ 81, 88, 115

MONOJECT 0.9% SODIUM

CHLORIDE...........................65, 76

MONOJECT 140CC PISTON

SYRINGE................................... 65

MONOJECT 35CC SYRINGE

CATH TIP...................................66

MONOJECT 3CC SYR 25GX1". 66

MONOJECT ALLERGY TRAY...66

MONOJECT ALLERGY TRAY

DETACH.....................................66

MONOJECT BLOOD

COLLECTION............................ 66

MONOJECT BLUNT

CANNULAS................................66

MONOJECT CONTROL

SYRINGE LUER.........................66

MONOJECT DISPOSABLE

SYRINGE................................... 66

MONOJECT ECCENTRIC

NON-STERILE........................... 66

MONOJECT FILTER

ASPIRATOR...............................66

MONOJECT FILTER NEEDLE.. 66

MONOJECT HYPODERMIC

NEEDLES.................................. 66

MONOJECT HYPODERMIC

POLYPROPYL........................... 66

MONOJECT LUER-LOCK TIP...66

133

MONOJECT MAGELLAN

SYRINGE................................... 66

MONOJECT MEDICATION

TRANSF NDL.............................66

MONOJECT PHARMACY

TRAY LUER............................... 66

MONOJECT PHARMACY

TRAY REG TIP.......................... 66

MONOJECT PREFILL

ADVANCED NS................... 66, 76

MONOJECT REG TIP NON-

STERILE.................................... 66

MONOJECT REGULAR LUER.. 66

MONOJECT SAFETY LUER

LOCK TIP...................................66

MONOJECT SAFETY

SYRINGES.................................66

MONOJECT SYRINGE..............66

MONOJECT SYRINGE

ECCENTRI LUER...................... 66

MONOJECT SYRINGE LUER

LOK............................................ 66

MONOJECT SYRINGE

REGULAR LUER....................... 66

MONOJECT SYRINGE

TOOMEY TYPE......................... 66

MONOJECT TB..........................66

MONOJECT TB LUER LOK.......66

MONOJECT TB REGULAR

LUER TIP................................... 66

MONOJECT TB SAFETY

SYRINGE................................... 66

MONOJECT TIP

CAPS/FLEX/LUER.....................67

MONOJECT TUBERCULIN

SYRINGE................................... 67

MONOLET LANCETS................67

MONOLET THIN LANCETS.......67

MONO-LINYAH..........................93

MONSEL'S.................................29

montelukast..............................108

morphine.............................. 50, 51

morphine concentrate.................50

MOTOFEN................................. 83

MOUNJARO...............................96

MOUTHPIECE........................... 67

MOVANTIK.................................85

moxifloxacin........................80, 112

MULTI-DRAW NEEDLE.............67

MULTI-LANCET DEVICE 2........67

MULTISTIX.................................74

MULTISTIX 10 SG..................... 74

MULTISTIX 5..............................74

MULTISTIX 7..............................74

MULTISTIX 8 SG....................... 74

MULTISTIX 9..............................74

MULTISTIX 9 SG....................... 74

MULTI-VIT WITH FLUORIDE-

IRON.......................... 30, 104, 120

MULTI-VITAMIN WITH

FLUORIDE....................... 104, 120

mupirocin..................................112

MURI-LUBE..............................113

MVC-FLUORIDE..............104, 120

MY CHOICE...............................93

MY WAY.....................................93

mycophenolate mofetil............. 101

mycophenolate sodium............ 101

MYGLUCOHEALTH LANCETS. 67

MYLERAN..................................22

MYRBETRIQ............................120

nabumetone............................... 53

nadolol..................................34, 36

naftifine.....................................111

nalmefene.................................. 51

naloxone.............................51, 104

naltrexone.................................. 51

naproxen.................................... 53

naproxen sodium........................53

naproxen-esomeprazole.......49, 86

naratriptan.................................. 54

NARCAN............................ 51, 104

NATACYN.................................. 80

nateglinide..................................98

NATURA-LAX.............................84

NAYZILAM........................... 46, 47

NEBUSAL............................ 67, 76

NECON 0.5/35 (28)....................93

needle (disp) 16 g...................... 67

needle (disp) 18 g...................... 67

needle (disp) 19 g...................... 67

needle (disp) 23 gauge.............. 67

needles, huber disposable......... 67

nefazodone................................ 55

neomycin......................13, 80, 112

neomycin-bacitracin-poly-hc.80, 81

neomycin-bacitracin-polymyxin.. 80

neomycin-polymyxin b-

dexameth............................. 80, 81

neomycin-polymyxin-gramicidin. 80

neomycin-polymyxin-hc........80, 81

NEO-POLYCIN...........................80

NEO-POLYCIN HC.............. 80, 81

NEUPRO....................................49

nevirapine...................................16

NEW DAY...................................93

niacin..........................................34

NICODERM CQ......................... 28

NICORETTE...............................28

nicotine.......................................28

nicotine (polacrilex).................... 28

NICOTROL NS...........................28

nifedipine..................35, 37, 38, 41

NIKKI (28).................................. 93

nilutamide...................................22

nitazoxanide............................... 14

NITRO-DUR............................... 39

nitrofurantoin.............................. 21

nitrofurantoin macrocrystal.........21

nitrofurantoin monohyd/m-cryst..21

nitroglycerin........................39, 113

NITRO-TIME.............................. 39

NIVA THYROID........................100

nizatidine.................................... 85

NOCDURNA (MEN)............. 29, 98

NOCDURNA (WOMEN).......29, 98

NOKOR NEEDLE.......................67

NORA-BE...................................93

norelgestromin-ethin.estradiol....93

noreth-ethinyl estradiol-iron........93

norethindrone (contraceptive).... 93

norethindrone acetate................ 98

norethindrone ac-eth estradiol

........................................93, 96, 99

norethindrone-e.estradiol-iron.... 93

norgestimate-ethinyl estradiol.... 93

NORMAL SALINE FLUSH... 67, 76

NORPACE CR........................... 36

NORTREL 0.5/35 (28)................93

NORTREL 1/35 (21)...................93

NORTREL 1/35 (28)...................93

NORTREL 7/7/7 (28)..................93

nortriptyline.................................56

NORVIR..................................... 18

NOVA SAFETY LANCETS.........67

NOVA SUREFLEX LANCETS....67

NOVAMAX PLUS KETONE....... 67

NOVAVAX COVID 2023-

24(PF)(EUA)...............................24

NOVOFINE 32............................67

NOVOFINE PLUS...................... 67

NOVOLIN 70/30 U-100

INSULIN............................... 97, 99

NOVOLIN 70-30 FLEXPEN U-

100....................................... 97, 99

NOVOLIN N FLEXPEN.............. 97

NOVOLIN N NPH U-100

INSULIN..................................... 97

NOVOLIN R REGULAR U100

INSULIN............................... 97, 99

NP THYROID........................... 100

NYAMYC..................................119

NYLIA 1/35 (28)......................... 94

NYLIA 7/7/7 (28)........................ 94

NYMYO...................................... 94

134

nystatin...............................20, 119

nystatin-triamcinolone.............. 119

NYSTOP.................................. 119

OCELLA..................................... 94

OCUCOAT................................. 82

ODEFSEY...................... 16, 17, 19

OFEV....................................... 107

ofloxacin............................... 20, 80

OGSIVEO...................................22

olanzapine............................43, 45

olanzapine-fluoxetine........... 45, 55

olmesartan................................. 32

olmesartan-amlodipin-hcthiazid

............................32, 35, 37, 40, 78

olmesartan-hydrochlorothiazide

..................................32, 33, 40, 78

olopatadine.................................79

omega-3 acid ethyl esters.......... 39

omeprazole................................ 86

omeprazole magnesium.............86

omeprazole-sodium

bicarbonate................................ 86

OMNIPOD 5 G6 INTRO KIT

(GEN 5)...................................... 67

OMNIPOD 5 G6 PODS (GEN

5)................................................ 67

OMNIPOD DASH INTRO KIT

(GEN 4)...................................... 67

OMNIPOD DASH PDM KIT

(GEN 4)...................................... 67

OMNIPOD DASH PODS (GEN

4)................................................ 67

OMNITROPE..............................98

ON CALL LANCET.....................67

ON CALL LANCING DEVICE.....67

ON CALL PLUS LANCET.......... 67

ON CALL PLUS LANCING

DEVICE......................................67

ondansetron............................... 83

ondansetron hcl..........................83

ONE DAILY PRENATAL

..............................30, 77, 120, 121

ONE WAY VALVED

MOUTHPIECE........................... 67

ONELAX MAGNESIUM

CITRATE....................................84

ONETOUCH DELICA PLUS

LANC DEV................................. 67

ONETOUCH DELICA PLUS

LANCET..................................... 68

ONETOUCH DELICA SAFETY

LANCET..................................... 68

ONETOUCH ULTRASOFT 2

LANCET..................................... 68

ONETOUCH VERIO FLEX

METER.......................................68

ONETOUCH VERIO HIGH

CONTROL..................................68

ONETOUCH VERIO MID

CONTROL..................................68

ONETOUCH VERIO TEST

STRIPS...................................... 73

ON-GO COVID-19 AG AT

HOME TEST.............................. 68

ON-THE-GO LANCETS............. 68

OPCICON ONE-STEP............... 94

OPTICHAMBER ADULT

MASK-LARGE............................68

OPTICHAMBER DIAMOND LG

MASK......................................... 68

OPTICHAMBER DIAMOND-

MED MSK...................................68

OPTICHAMBER DIAMOND-

SML MASK.................................68

OPTION-2.................................. 94

OPVEE.......................................51

ORAL SALINE LAXATIVE..........84

ORALONE................................115

ORENITRAM......................41, 110

ORILISSA...................................89

ORKAMBI.........................107, 108

orphenadrine citrate................... 26

OSCIMIN..............................11, 25

OSCIMIN SL.........................11, 25

oseltamivir............................ 18, 19

OSPHENA..................................95

OTEZLA................... 102, 105, 120

oxaprozin....................................53

oxazepam...................................47

oxcarbazepine............................48

oxiconazole.............................. 113

OXTELLAR XR...........................48

oxybutynin chloride...................120

oxycodone..................................51

oxycodone-acetaminophen.. 42, 51

oxymorphone............................. 51

OZEMPIC...................................96

PACERONE............................... 36

paliperidone................................45

PANDA MASK............................68

pantoprazole.............................. 86

PAROEX ORAL RINSE..............80

paroxetine hcl.............................55

PASER....................................... 15

PAXLOVID................................. 15

pazopanib...................................22

PEDIARIX (PF).....................23, 24

PEDIATRIC MEDIUM MASK..... 68

PEDIATRIC PANDA MASK........68

PEDIATRIC SMALL MASK........ 68

PEDVAX HIB (PF)......................24

peg 3350-electrolytes.................84

peg3350-sod sul-nacl-kcl-asb-c. 84

PEGASYS.................... 18, 22, 105

peg-electrolyte soln.................... 84

PENBRAYA (PF)........................24

penciclovir................................ 112

penicillamine.........................11, 86

penicillin v potassium................. 18

PENTACEL (PF)........................ 24

PENTACEL ACTHIB

COMPONENT (PF)....................24

pentamidine................................14

pentoxifylline.............................. 29

PERIOGARD..............................80

permethrin................................ 119

perphenazine............................. 52

perphenazine-amitriptyline... 52, 56

phenazopyridine.......................112

phenelzine..................................49

phenobarbital............................. 46

phenoxybenzamine.............. 27, 38

phenytoin..............................36, 48

phenytoin sodium extended. 36, 48

PHILITH..................................... 94

PHOSPHATE LAXATIVE...........84

PHOSPHOLINE IODIDE............82

phytonadione (vitamin k1).. 11, 123

PIFELTRO..................................17

pilocarpine hcl...................... 27, 82

PILOT COVID-19 AT-HOME

TEST.......................................... 68

pimecrolimus............................ 116

pimozide.....................................47

PIMTREA (28)............................94

pioglitazone.............................. 100

pioglitazone-glimepiride............100

pioglitazone-metformin.......90, 100

PIP LANCET.............................. 68

piroxicam....................................53

PLAN B ONE-STEP................... 94

PNEUMOVAX-23....................... 24

pnv cmb#95-ferrous fumarate-

fa................................ 30, 120, 121

podofilox...................................117

POLY HUB NEEDLE..................68

POLYCIN................................... 80

polyethylene glycol 3350............84

polymyxin b sulf-trimethoprim

......................................20, 80, 112

POMALYST........................22, 105

PORTIA 28.................................94

potassium chloride..................... 77

potassium citrate........................ 75

135

potassium iodide.... 11, 13, 89, 108

POWDERLAX............................ 84

pramipexole................................49

prasugrel.................................... 31

pravastatin..................................38

praziquantel................................13

prazosin..........................26, 31, 32

PRECISION XTRA B-KETONE..68

prednicarbate........................... 115

prednisolone...............................88

prednisolone acetate..................81

prednisolone sodium phosphate

..............................................81, 88

prednisone................................. 88

PREDNISONE INTENSOL.........88

pregabalin.................................. 48

PREHEVBRIO (PF)....................24

PRENATAL................ 30, 120, 121

PRENATAL COMPLETE

..............................30, 77, 120, 121

PRENATAL MULTI-DHA

(ALGAL OIL).............. 30, 120, 121

PRENATAL MULTIVITAMINS

....................................30, 120, 121

PRENATAL ONE DAILY

..............................30, 77, 120, 121

PRENATAL TABLET

..............................30, 77, 120, 121

prenatal vit no.179-iron-folic

....................................30, 121, 122

PRENATAL VITAMIN

..............................30, 77, 121, 122

PRENATAL VITAMIN WITH

MINERALS...........30, 77, 121, 122

prenatal vit-iron fum-folic ac

..............................30, 77, 121, 122

PRESSURE ACTIVATED

LANCETS...................................68

pretomanid................................. 15

PREVNAR 20 (PF).....................24

PREZCOBIX.......................18, 105

PREZISTA..................................18

PRIFTIN............................... 15, 20

primaquine................................. 14

primidone................................... 46

PRIORIX (PF).............................24

PRO COMFORT ALCOHOL

PADS....................................... 118

PRO COMFORT LANCET......... 68

PRO COMFORT SAFETY

LANCET..................................... 68

PRO COMFORT SPACER-

ADULT MASK............................ 68

probenecid......................... 78, 104

probenecid-colchicine.........78, 104

PROCARE SPACER WITH

ADULT MASK............................ 68

PROCARE SPACER WITH

CHILD MASK............................. 68

prochlorperazine maleate.....52, 83

PROCTO-MED HC...................115

PROCTOSOL HC.....................115

PROCTOZONE-HC..................115

PRODIGY COUNT-A-DOSE......68

PRODIGY LANCETS................. 68

PRODIGY LANCING DEVICE... 68

PRODIGY TWIST TOP

LANCET..................................... 68

progesterone micronized............99

PROMACTA...............................29

promethazine............... 12, 44, 108

PROMETHAZINE VC...12, 25, 108

promethazine-codeine 51, 107, 108

promethazine-dm....... 12, 107, 108

PROMETHEGAN................. 12, 44

propafenone............................... 36

proparacaine.............................. 82

propranolol......... 26, 34, 36, 38, 44

propranolol-hydrochlorothiazid

............................26, 34, 36, 40, 78

propylthiouracil........................... 89

PROQUAD (PF)......................... 24

protriptyline.................................56

PULMOSAL..........................68, 76

PULMOZYME.....................78, 109

PURE COMFORT ALCOHOL

PADS....................................... 118

PURE COMFORT LANCETS.....69

PURE COMFORT SAFETY

LANCETS...................................69

PURELAX.................................. 84

PUSH BUTTON SAFETY

LANCETS...................................69

pyrazinamide..............................15

pyridostigmine bromide.............. 27

pyrimethamine............................14

QNASL......................... 82, 88, 107

QUADRACEL (PF).....................24

quazepam.................................. 47

quetiapine.............................43, 45

QUICKVUE AT-HOME COVID-

19 TEST..................................... 69

quinapril......................................33

quinapril-hydrochlorothiazide

..................................33, 34, 40, 78

quinidine sulfate................... 14, 36

quinine sulfate............................ 14

QUIT 2........................................28

QUIT 4........................................28

QVAR REDIHALER............88, 109

RABAVERT (PF)........................24

rabeprazole................................ 86

raloxifene............................95, 104

ramelteon................................... 49

ramipril..................................33, 34

ranolazine...................................35

RAPID SARS-COV-2 AG

HOME TEST.............................. 69

rasagiline....................................49

REBIF (WITH ALBUMIN)......... 102

REBIF REBIDOSE................... 102

RECLIPSEN (28)........................94

RECOMBIVAX HB (PF)............. 24

RECTIV.................................... 113

RELEXXII................................... 52

RELIAMED LANCET..................69

RELIAMED MINI LANCING

DEVICE......................................69

RELIAMED SAFETY SEAL

LANCETS...................................69

RELION GLUCOSE........... 75, 122

RENA-VITE.............................. 122

repaglinide..................................98

REPATHA PUSHTRONEX........ 39

REVLIMID.......................... 22, 105

REZVOGLAR KWIKPEN......97, 98

RHOGAM ULTRA-FILTERED

PLUS..........................................23

ribavirin.......................................19

rifabutin................................ 15, 20

rifampin................................ 15, 20

RIGHTEST GD500 LANCING

DEVICE......................................69

RIGHTEST GL300 LANCETS....69

rimantadine................................ 13

RINVOQ................................... 102

risedronate............................... 104

RISPERDAL CONSTA.........43, 45

risperidone........................... 43, 45

risperidone microspheres.....43, 45

ritonavir...................................... 18

rivastigmine tartrate....................27

RIVELSA.................................... 94

rizatriptan................................... 54

roflumilast.........................109, 116

ropinirole.................................... 49

ROSADAN..................................19

rosuvastatin................................38

ROTARIX................................... 24

ROTATEQ VACCINE.................24

ROWEEPRA.............................. 42

ROWEEPRA XR........................ 42

rufinamide.................................. 49

RYBELSUS................................ 96

RYDEX...........12, 25, 51, 107, 108

136

SAFESNAP SYRINGE...............69

SAFETY LANCETS....................69

safety needles............................ 69

SAFETY SEAL LANCETS..........69

SAFETY-LET LANCETS............69

salicylic acid............................. 117

salicylic acid-ceramides no.1....117

SALIMEZ..................................117

SALYCIM................................. 117

SANTYL............................. 78, 113

sapropterin................................. 78

SAVELLA............................. 48, 54

scopolamine base...................... 83

SECUADO............................43, 45

SEGLUROMET.................... 90, 99

selegiline hcl...............................49

selenium sulfide........................118

SELZENTRY.............................. 16

SEREVENT DISKUS..........28, 110

sertraline.................................... 55

SETLAKIN..................................94

sevelamer carbonate..........76, 104

sevelamer hcl..................... 76, 104

sevoflurane.................................48

SF...............................................56

SF 5000 PLUS........................... 56

SHAROBEL................................94

SHINGRIX (PF)..........................24

SIDESTREAM PEDIATRIC

FACE MASK...............................69

sildenafil (pulm.hypertension)

....................................39, 109, 110

SILICONE MASK - INFANT....... 69

SILICONE MASK - PEDIATRIC.69

silodosin..................................... 27

SIL-SERTER.............................. 69

silver sulfadiazine.....................118

SIMLIYA (28)..............................94

SIMPESSE.................................94

simvastatin................................. 38

SINGLE-LET.............................. 69

sirolimus........................... 102, 116

SKYRIZI................................... 116

SKYTROFA................................98

SMART SENSE LANCETS........69

SMARTDIABETES VANTAGE...70

SMARTEST LANCET.................70

SMOOTHLAX.............................84

sodium chloride.................... 70, 76

sodium citrate-citric acid.............75

SODIUM FLUORIDE 5000

DRY MOUTH..............................56

SODIUM FLUORIDE 5000

PLUS..........................................57

sodium polystyrene sulfonate

............................................76, 104

sodium,potassium,mag sulfates.84

sofosbuvir-velpatasvir...........15, 16

SOFT TOUCH LANCETS.......... 70

solifenacin................................ 120

SOLIQUA 100/33........... 96, 97, 98

SOLUS V2 LANCETS................ 70

SOLUS V2 LANCING DEVICE.. 70

sorafenib.................................... 22

sotalol.................26, 34, 36, 37, 38

SOTALOL AF........... 26, 34, 36, 38

SPACE CHAMBER WITH

LARGE MASK............................70

SPACE CHAMBER WITH

MEDIUM MASK..........................70

SPACE CHAMBER WITH

SMALL MASK............................ 70

SPEEDYSWAB COVID-19

HOME TEST.............................. 70

SPIKEVAX 2023-2024(12Y

UP)(PF)...................................... 24

spinosad...................................119

SPIRIVA RESPIMAT..........25, 106

spironolactone................39, 40, 76

spironolacton-hydrochlorothiaz

..................................39, 40, 76, 78

SPRINTEC (28)..........................94

SPS (WITH SORBITOL).... 76, 104

SRONYX.................................... 94

SSD..........................................118

SSKI....................... 11, 13, 89, 108

SSS 10-5..........................117, 118

ST JOSEPH ASPIRIN....31, 44, 54

ST. JOSEPH ASPIRIN...31, 44, 54

STAMARIL (PF)......................... 24

STEGLATRO..............................99

STELARA.................................102

STERILANCE TL........................70

STIOLTO RESPIMAT

..............................25, 28, 107, 110

STOP SMOKING AID.................29

STRESS FORMULA WITH

IRON.................................. 30, 122

STRESS FORMULA WITH

IRON(SULF).......................30, 122

STRIBILD............................. 16, 17

STRIVERDI RESPIMAT.....28, 110

sucralfate....................................85

sulconazole.............................. 113

sulfacetamide sodium.................80

sulfacetamide sodium (acne)... 118

sulfacetamide sodium-sulfur

..........................................117, 118

sulfacetamide sod-sulfur-urea

..........................................117, 118

sulfacetamide-prednisolone....... 80

SULFACLEANSE 8-4.......117, 118

sulfadiazine................................ 20

sulfamethoxazole-trimethoprim.. 20

sulfasalazine................ 20, 83, 101

SULFATRIM...............................20

sulindac...................................... 53

sumatriptan................................ 54

sumatriptan succinate................ 54

sumatriptan-naproxen.......... 49, 54

sunitinib malate.......................... 22

SUPER B MAXI COMPLEX..... 122

SUPER B-50 COMPLEX..........122

SUPER QUINTS...................... 122

SUPER THIN LANCETS............70

SURE COMFORT ALCOHOL

PREP PADS.............................118

SURE COMFORT LANCETS.....70

SURE COMFORT LANCING

PEN............................................70

SUREFLEX DEVICE WITH

LANCETS...................................70

SUREFLEX LANCING DEVICE.70

SURE-LANCE............................ 70

SURE-LANCE ULTRA THIN......70

SURE-PEN LANCING DEVICE. 70

SURE-PREP ALCOHOL PREP

PADS....................................... 118

SURE-TOUCH LANCET............ 70

SURGIFOAM..............................70

SURGUARD2 SAFETY..............70

SYEDA....................................... 94

SYMAX-SR...........................11, 25

SYMLINPEN 120........................88

SYMLINPEN 60..........................88

SYMTUZA.............. 17, 18, 19, 105

SYNAREL.................................. 96

SYNJARDY.......................... 90, 99

SYNJARDY XR............ 90, 99, 100

SYNTHROID............................ 101

syringe (disposable)................... 70

SYRINGE 3CC/20GX1"............. 70

SYRINGE 3CC/21GX1"............. 70

SYRINGE 3CC/21GX1-1/2"....... 70

SYRINGE 3CC/22GX1"............. 70

SYRINGE 3CC/22GX3/4".......... 70

SYRINGE 3CC/25GX1"............. 71

SYRINGE LUER TIP CAP..........71

SYRINGE TIP CONNECTOR.... 71

syringe with needle.....................71

SYRINGE WITHOUT NEEDLE..71

tacrolimus.........................101, 116

tadalafil.......................39, 109, 110

137

TAFINLAR..................................22

tafluprost (pf).............................. 82

TAKE ACTION........................... 94

tamoxifen..............................22, 95

tamsulosin.................................. 27

TARINA 24 FE............................94

TARINA FE 1/20 (28)................. 94

TARINA FE 1-20 EQ (28)...........94

TDVAX....................................... 23

TECHLITE INSULIN SYRINGE..71

TECHLITE INSULN SYR(HALF

UNIT)..........................................71

TECHLITE LANCETS................ 71

TECHLITE PEN NEEDLE.......... 71

TELCARE LANCETS................. 71

telmisartan............................32, 33

telmisartan-amlodipine

............................32, 33, 35, 37, 41

telmisartan-hydrochlorothiazid

..................................32, 33, 40, 78

temazepam................................ 47

temozolomide.............................22

TENIVAC (PF)............................23

tenofovir disoproxil fumarate...... 17

terazosin...................26, 31, 32, 38

terbinafine hcl.....................13, 111

terbutaline.......................... 28, 110

terconazole...............................113

teriflunomide.............................101

teriparatide......................... 98, 104

TERRELL................................... 48

TERUMO ALLERGY SYRINGE.71

TERUMO HYPODERMIC

NEEDLE/SYRIN.........................71

TERUMO SYRINGE...................71

testosterone............................... 89

testosterone cypionate............... 89

testosterone enanthate.............. 89

tetrabenazine............................. 56

tetracycline............. 14, 21, 80, 112

THALOMID...............................105

THEO-24.............. 37, 75, 110, 120

theophylline.......... 37, 75, 110, 120

THIN LANCETS......................... 71

thioridazine.................................52

thiothixene..................................55

thyroid (pork)............................ 101

tiagabine.....................................48

TILIA FE..................................... 94

timolol maleate

......................26, 34, 36, 38, 44, 81

timolol maleate (pf).....................81

TIMOPTIC OCUDOSE (PF).......81

tinidazole.................................... 14

tiotropium bromide..............25, 107

tizanidine.................................... 26

tobramycin............................13, 80

tobramycin in 0.225 % nacl........ 13

tobramycin sulfate...................... 13

tobramycin with nebulizer...........13

tobramycin-dexamethasone.80, 82

tolcapone....................................47

tolmetin.......................................50

tolterodine................................ 120

tolvaptan.....................................78

TOOMEY SYRINGE...................71

TOPCARE UNIVERSAL1

LANCET..................................... 71

topiramate.................................. 42

toremifene............................ 22, 95

torsemide............................. 38, 76

tramadol..................................... 51

tramadol-acetaminophen42, 44, 51

trandolapril........................... 33, 34

tranexamic acid.......................... 29

TRANSFER PIN.........................71

tranylcypromine..........................49

travoprost................................... 82

trazodone................................... 55

TRELEGY ELLIPTA......... 107, 110

TREMFYA........................ 101, 116

TRESIBA FLEXTOUCH U-100

..............................................97, 98

TRESIBA FLEXTOUCH U-200

..............................................97, 98

TRESIBA U-100 INSULIN....97, 98

tretinoin.................................... 113

tretinoin (antineoplastic)............. 23

tretinoin (emollient)...................113

TREXALL........................... 23, 101

triamcinolone acetonide... 115, 116

triamterene-hydrochlorothiazid

............................39, 40, 76, 77, 78

triazolam.....................................47

TRI-BUFFERED ASPIRIN

........................................31, 44, 54

TRI-CHLOR..............................120

trichloroacetic acid....................120

TRIDERM.................................116

TRI-ESTARYLLA........................94

trifluoperazine.............................52

trifluridine....................................80

trihexyphenidyl..................... 26, 42

TRIKAFTA........................107, 108

TRI-LEGEST FE.........................94

TRI-LINYAH............................... 94

TRI-LO-ESTARYLLA..................94

TRI-LO-MARZIA.........................94

TRI-LO-MILI............................... 94

TRI-LO-SPRINTEC.................... 94

trimethobenzamide.....................83

trimethoprim............................... 21

TRI-MILI..................................... 94

trimipramine................................56

TRINTELLIX...............................55

TRI-NYMYO............................... 94

TRI-SPRINTEC (28)...................94

TRIUMEQ.............................16, 17

TRI-VITAMIN WITH FLUORIDE

..................................104, 121, 122

TRI-VITE WITH FLUORIDE

..................................104, 121, 122

TRIVORA (28)............................94

TRI-VYLIBRA............................. 94

TRI-VYLIBRA LO....................... 94

tropicamide.................................82

trospium................................... 120

TRUE COMFORT ALCOHOL

PADS....................................... 119

TRUE COMFORT LANCET....... 71

TRUE COMFORT PRO

ALCOHOL PADS..................... 119

TRUEDRAW LANCING

DEVICE......................................71

TRUEPLUS KETONE................ 74

TRUEPLUS LANCETS...............71

TRULANCE................................85

TRULICITY.................................96

TRUMENBA............................... 24

TRUSTEX LATEX CONDOM...105

TRUSTEX LUBRICATED

CONDOMS...............................106

TRUSTEX NON-LUB

CONDOMS...............................106

TRUSTEX-RIA

LUB/SPERMICIDE...................106

TRUSTEX-RIA LUBRICATED

CONDOMS...............................106

TRUSTEX-RIA NON-LUB

CONDOMS...............................106

TUBERCULIN SYRINGE........... 71

tuberculin-allergy syringes..........71

TULANA..................................... 94

TURQOZ (28).............................94

TWINRIX (PF)............................ 24

TWIST LANCETS.......................71

TYBOST.....................................14

TYDEMY.................................... 95

TYPHIM VI................................. 24

ULESFIA.................................. 119

ULTICARE..................................71

ULTICARE LOW DEAD

SPACE SYRING........................ 71

ULTICARE TB SAFETY

SYRINGE................................... 71

138

ULTI-LANCE.............................. 72

ULTILET ALCOHOL SWAB..... 119

ULTILET BASIC LANCETS........72

ULTILET CLASSIC LANCETS...72

ULTILET LANCETS................... 72

ULTILET SAFETY LANCETS.... 72

ULTRA THIN II LANCETS..........72

ULTRA THIN LANCETS.............72

ULTRA THIN PLUS LANCETS.. 72

ULTRA TLC LANCETS.............. 72

ULTRA-CARE LANCETS...........72

ULTRALANCE LANCETS..........72

ULTRA-THIN II LANCETS......... 72

UNILET COMFORTOUCH

LANCET..................................... 72

UNILET GP LANCET................. 72

UNILET LANCET....................... 72

UNILET LANCETS.....................72

UNILET SUPER THIN

LANCETS...................................72

UNISTIK 2 DEVICE....................72

UNISTIK 2 EXTRA LANCET......72

UNISTIK 2 NORMAL LANCET...72

UNISTIK 3 COMFORT

LANCET..................................... 72

UNISTIK 3 EXTRA LANCET......72

UNISTIK 3 GENTLE...................72

UNISTIK 3 NORMAL LANCET...72

UNISTIK COMFORT LANCETS 73

UNISTIK CZT LANCET..............73

UNISTIK EXTRA LANCETS.......73

UNISTIK NORMAL LANCETS... 73

UNISTIK PRO LANCET............. 73

UNISTIK SAFETY...................... 73

UNISTIK TOUCH LANCETS......73

UNITHROID............................. 101

UNIVERSAL 1 LANCETS.......... 73

URETRON D-S.......................... 21

URISTIX 4.................................. 74

URISTIX REAGENT...................74

URO-SP..................................... 21

ursodiol.......................................84

VAGINAL CONTRACEPTIVE

FILM......................................... 106

valacyclovir.................................19

valproic acid................... 42, 43, 44

valproic acid (as sodium salt)

........................................42, 43, 44

valrubicin.................................... 23

valsartan...............................32, 33

valsartan-hydrochlorothiazide

..................................32, 33, 40, 78

VALTOCO............................ 46, 47

vancomycin................................ 15

VANDAZOLE..............................19

VANISHPOINT SYRINGE..........73

VANISHPOINT TUBERCULIN

SYRINGE................................... 73

VAQTA (PF)............................... 24

varenicline.................................. 29

VARIVAX (PF)............................24

VAXCHORA VACCINE.............. 24

VAXELIS (PF)...................... 23, 24

VAXNEUVANCE (PF)................ 24

VCF CONTRACEPTIVE FILM. 106

VCF CONTRACEPTIVE GEL.. 106

VELIVET TRIPHASIC

REGIMEN (28)........................... 95

VELPHORO............................... 76

venlafaxine................................. 54

VENTAVIS............................... 109

verapamil..............................35, 37

VERIFINE SAFETY LANCET

MINI............................................73

VERIFINE UNIVERSAL

LANCET..................................... 73

VERZENIO.................................23

VESTURA (28)...........................95

VIENVA...................................... 95

vilazodone.................................. 55

VIOKACE................................... 85

VIORELE (28)............................ 95

VIRACEPT................................. 18

VIREAD......................................17

VIRTUSSIN AC.......... 51, 107, 108

vitamin b complex-folic acid..... 122

VITAMIN D2............................. 122

VITAMINS A,C,D AND

FLUORIDE............... 104, 121, 122

VIVAGUARD LANCET...............73

VIVAGUARD LANCING

DEVICE......................................73

VIVAGUARD SAFETY

LANCET..................................... 73

VIVITROL.............................29, 51

VIVOTIF..................................... 24

VOLNEA (28)............................. 95

voriconazole............................... 15

VORTEX ADULT MASK.............73

VORTEX VHC FROG MASK-

CHILD........................................ 73

VORTEX VHC LADYBUG

MASK-TODDLR......................... 73

VOTRIENT................................. 23

VUMERITY...............................101

VYFEMLA (28)........................... 95

VYLIBRA.................................... 95

WAKIX........................................56

warfarin...................................... 29

WEBCOL..................................119

WERA (28)................................. 95

WESCAP-C DHA....... 30, 121, 122

WESNATAL DHA COMPLETE

..............................30, 77, 121, 122

WIDE-SEAL DIAPHRAGM 60..106

WIDE-SEAL DIAPHRAGM 65..106

WIDE-SEAL DIAPHRAGM 70..106

WIDE-SEAL DIAPHRAGM 75..106

WIDE-SEAL DIAPHRAGM 80..106

WIDE-SEAL DIAPHRAGM 85..106

WIDE-SEAL DIAPHRAGM 90..106

WIDE-SEAL DIAPHRAGM 95..106

WOMEN'S GENTLE

LAXATIVE(BISAC).....................84

WYMZYA FE..............................95

XARELTO.................................. 29

XARELTO DVT-PE TREAT

30D START................................29

XEPI......................................... 112

XIFAXAN....................................20

XOFLUZA...................................15

XOLAIR.................................... 124

XULANE.....................................95

XULTOPHY 100/3.6.......96, 97, 98

YALE DISPOSABLE NEEDLES.73

YF-VAX (PF).............................. 24

ZAFEMY.....................................95

zafirlukast................................. 108

zaleplon......................................49

ZARAH....................................... 95

ZARXIO......................................29

ZELBORAF................................ 23

ZENZEDI....................................41

ZEPATIER..................................16

ZEPOSIA..................................102

ZEPOSIA STARTER KIT (28-

DAY).........................................102

ZEPOSIA STARTER PACK (7-

DAY).........................................102

ZERVIATE..................................79

zileuton.....................................108

zinc oxide................................. 113

ziprasidone hcl..................... 43, 45

ZOLINZA.................................... 23

zolmitriptan.................................54

zolpidem.....................................49

zonisamide................................. 49

ZOVIA 1-35 (28).........................95

ZUMANDIMINE (28)...................95

139

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if you need any of these services.

Mail: CareSource, Attn: Civil Rights Coordinator

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Phone: 1-844-539-1732

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You may also file a civil rights complaint with the U.S.

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Mail: U.S. Dept. of Health and Human Services

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Complaint forms are found at:

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If you believe we have not provided these services to

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Multi-EXC-M-1568660

2022

MARKETPLACE PLAN

Kentucky

Drug Formulary

OH-EXC-M-2362834