EFFECTIVE 01/02/2018 TYPHIM VI 25 MCG/0.5 ML VIAL. - Added to Tier 1. typhoid vaccine vi capsular polysaccharide
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- Emily Rodgers
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1 EFFECTIVE 01/02/2018 TYPHIM VI 25 MCG/0.5 ML VIAL typhoid vaccine vi capsular polysaccharide PAGE 1 LAST UPDATED 09/2018
2 EFFECTIVE 01/05/2018 atazanavir sulfate 150 mg capsule atazanavir sulfate 200 mg capsule atazanavir sulfate 300 mg capsule PAGE 2 LAST UPDATED 09/2018
3 EFFECTIVE 01/08/2018 LATUDA 40 MG TABLET lurasidone hcl LATUDA 80 MG TABLET lurasidone hcl - QL Added: 30 / 30 DAYS - QL Added: 60 / 30 DAYS nafcillin sodium 10 g vial PAGE 3 LAST UPDATED 09/2018
4 EFFECTIVE 01/12/2018 BYETTA 10 MCG DOSE PEN INJ exenatide BYETTA 5 MCG DOSE PEN INJ exenatide OPDIVO 240 MG/24 ML VIAL nivolumab PROLASTIN C 1,000 MG/20 ML VL alpha-1-proteinase inhibitor - QL Added: 2.4 / 30 DAYS - ST Added: GLP1 AGONIST THERAPY - QL Added: 1.2 / 30 DAYS - ST Added: GLP1 AGONIST THERAPY - PA Added: Opdivo - LA Added: Limited Access - PA Added: Alpha-1 Proteinase Inhibitors estradiol 0.01 % cream/appl PAGE 4 LAST UPDATED 09/2018
5 EFFECTIVE 01/15/2018 CIALIS 2.5 MG TABLET tadalafil CIALIS 5 MG TABLET tadalafil linezolid 600 mg tablet - Added to Tier 3 - QL Added: 30 / 30 DAYS - PA Added: Cialis - Added to Tier 3 - QL Added: 30 / 30 DAYS - PA Added: Cialis - QL Added: 60 / 30 DAYS sertraline hcl 100 mg tablet - ST Added: ANTIDEPRESSANT THERAPY sertraline hcl 25 mg tablet - ST Added: ANTIDEPRESSANT THERAPY sertraline hcl 50 mg tablet - ST Added: ANTIDEPRESSANT THERAPY PAGE 5 LAST UPDATED 09/2018
6 EFFECTIVE 01/18/2018 BYETTA 10 MCG DOSE PEN INJ exenatide BYETTA 5 MCG DOSE PEN INJ exenatide - Added to Tier 3 - Added to Tier 3 PAGE 6 LAST UPDATED 09/2018
7 EFFECTIVE 01/19/2018 ALUNBRIG 180 MG TABLET brigatinib ALUNBRIG 90 MG TABLET brigatinib ALUNBRIG 90 MG-180 MG TAB PACK brigatinib - QL Added: 30 / 30 DAYS - PA Added: Alunbrig - PA Added: Alunbrig - QL Added: 60 / 30 DAYS - QL Added: 30 / 30 DAYS - PA Added: Alunbrig bortezomib 3.5 mg vial - PA Added: Velcade CINVANTI 130 MG/18 ML VIAL aprepitant romidepsin 10 mg/2 ml vial - PA Added: Istodax gemcitabine hcl 100 mg/ml vial PAGE 7 LAST UPDATED 09/2018
8 EFFECTIVE 01/23/2018 BYSTOLIC 2.5 MG TABLET nebivolol hcl BYSTOLIC 5 MG TABLET nebivolol hcl GAMMAPLEX 10 GRAM/100 ML VIAL immune globulin,gamma (igg)/glycine/iga 0 to 50 mcg/ml GAMMAPLEX 5 GRAM/50 ML VIAL immune globulin,gamma (igg)/glycine/iga 0 to 50 mcg/ml SAPHRIS 10 MG TAB SUBLINGUAL asenapine maleate SAPHRIS 5 MG TAB SUBLINGUAL asenapine maleate - Added to Tier 3 - QL Added: 30 / 30 DAYS - Added to Tier 3 - QL Added: 90 / 30 DAYS - PA Added: IVIG - PA Added: IVIG - ST Added: ATYPICAL ANTIPSYCHOTICS - QL Added: 60 / 30 DAYS - ST Added: ATYPICAL ANTIPSYCHOTICS - QL Added: 60 / 30 DAYS PAGE 8 LAST UPDATED 09/2018
9 EFFECTIVE 01/26/2018 AZACTAM 1 GM VIAL aztreonam AZACTAM 2 GM VIAL aztreonam cefazolin sodium/dextrose,iso 1 g/50 ml froz.piggy cefazolin sodium/dextrose,iso 1 g/50 ml piggyback cefepime hcl in dextrose 5 % 1 g/50 ml piggyback cefepime hcl in dextrose 5 % 2 g/50 ml piggyback cefepime in iso-osm dextrose 1 g/50 ml froz.piggy cefepime in iso-osm dextrose 2 g/100 ml froz.piggy cefoxitin sodium/dextrose,iso 1 g/50 ml piggyback cefoxitin sodium/dextrose,iso 2 g/50 ml piggyback ceftriaxone in is-osm dextrose 1 g/50 ml froz.piggy ceftriaxone in is-osm dextrose 1 g/50 ml piggyback ceftriaxone in is-osm dextrose 2 g/50 ml froz.piggy ceftriaxone in is-osm dextrose 2 g/50 ml piggyback CLINDACIN ETZ KIT clindamycin phosphate/skin cleanser comb no.19 heparin sod,pork in 0.45% nacl 25000/250 iv soln - Added to Tier 2 PAGE 9 LAST UPDATED 09/2018
10 EFFECTIVE 01/26/2018 heparin sod,pork in 0.45% nacl 25000/500 iv soln heparin sodium,porcine/d5w 20k/500ml iv soln heparin sodium,porcine/d5w 25000/250 iv soln heparin sodium,porcine/d5w 25000/500 iv soln - Added to Tier 2 - Added to Tier 2 - Added to Tier 2 lidocaine hcl/pf 20 mg/ml ampul - Added to Tier 2 lidocaine hcl/pf 20 mg/ml vial - Added to Tier 2 LITETOUCH SYR 0.5 ML 30GX5/16" syringe with needle,insulin,0.5 ml METRO IV 500 MG/100 ML metronidazole in sodium chloride - Added to Tier 2 morphine sulfate 10 mg/ml syringe - Added to Tier 2 morphine sulfate 2 mg/ml syringe morphine sulfate 4 mg/ml syringe - Added to Tier 2 morphine sulfate 8 mg/ml syringe - Added to Tier 2 nafcillin in dextrose,iso-osm 1 g/50 ml froz.piggy NEUAC 1.2-5% KIT clindamycin phosphate/benzoyl peroxide/emollient comb no.94 SPS 30 GM/120 ML ENEMA sodium polystyrene sulfonate/sorbitol solution - Added to Tier 2 timolol maleate 0.5 % drop daily tobramycin/nebulizer 300 mg/5ml ampulneb - QL Added: 280 / 56 DAYS PAGE 10 LAST UPDATED 09/2018
11 EFFECTIVE 01/26/2018 ZOSYN 2.25 GRAM VIAL piperacillin sodium/tazobactam sodium ZOSYN GRAM VIAL piperacillin sodium/tazobactam sodium PAGE 11 LAST UPDATED 09/2018
12 EFFECTIVE 02/01/2018 bortezomib 3.5 mg vial BYDUREON BCISE 2 MG AUTOINJECT exenatide microspheres CALQUENCE 100 MG CAPSULE acalabrutinib heparin sod,pork in 0.45% nacl 12500/250 iv soln heparin sodium,porcine 5000/ml syringe heparin sodium,porcine 5000/ml(1) cartridge heparin sodium,porcine/d5w 12500/250 iv soln heparin sodium,porcine/ns/pf 1000/500ml iv soln heparin sodium,porcine/ns/pf 2k/1000ml iv soln heparin sodium,porcine/pf 1000/ml vial heparin sodium,porcine/pf 5000/0.5ml syringe heparin sodium,porcine/pf 5000/0.5ml vial levocarnitine 200 mg/ml vial TREANDA 25 MG VIAL bendamustine hcl TRISENOX 12 MG/6 ML VIAL arsenic trioxide VIVITROL 380 MG VIAL + DILUENT naltrexone microspheres heparin sodium,porcine/ns/pf 2k/1000ml iv soln - PA Added: Bortezomib - QL Added: 3.4 / 28 DAYS - PA Added: Calquence - QL Added: 60 / 30 DAYS - PA Removed: PAGE 12 LAST UPDATED 09/2018
13 EFFECTIVE 02/02/2018 ELIQUIS 5 MG STARTER PACK apixaban haloperidol decanoate 100 mg/ml vial haloperidol decanoate 50 mg/ml ampul haloperidol decanoate 50 mg/ml vial haloperidol decanoate 100 mg/ml ampul haloperidol decanoate 100 mg/ml vial - Added to Tier 3 - QL Added: 74 / 30 DAYS - PA Removed: - PA Removed: - PA Removed: - PA Removed: - PA Removed: PAGE 13 LAST UPDATED 09/2018
14 EFFECTIVE 02/09/2018 ASSURE ID SYR 0.5 ML 29GX1/2" syringe with needle, insulin, safety, 0.5 ml ASSURE ID SYR 1 ML 29GX1/2" syringe with needle, insulin, safety, 1 ml methylphenidate hcl 72 mg tab er 24 - QL Added: 30 / 30 DAYS efavirenz 600 mg tablet isotretinoin 10 mg capsule isotretinoin 20 mg capsule isotretinoin 30 mg capsule isotretinoin 40 mg capsule methylphenidate hcl 36 mg tab er 24 - QL Added: 60 / 30 DAYS PAGE 14 LAST UPDATED 09/2018
15 EFFECTIVE 02/16/2018 haloperidol lactate 5 mg/ml syringe - Added to Tier 2 norgestimate-ethinyl estradiol tablet norgestimate-ethinyl estradiol 7daysx3 28 tablet PAGE 15 LAST UPDATED 09/2018
16 EFFECTIVE 02/23/2018 trientine hcl 250 mg capsule - ST Added: PENICILLAMINE THERAPY PAGE 16 LAST UPDATED 09/2018
17 EFFECTIVE 02/25/2018 levetiracetam 750 mg tab er 24h - Added to Tier 2 - QL Added: 120 / 30 DAYS levetiracetam 500 mg tab er 24h - Added to Tier 2 - QL Added: 180 / 30 DAYS PAGE 17 LAST UPDATED 09/2018
18 EFFECTIVE 03/01/2018 BIKTARVY MG TABLET bictegravir sodium/emtricitabine/tenofovir alafenamide fumar - QL Added: 30 / 30 DAYS doripenem 500 mg vial estradiol 0.01 % cream/appl - Added to Tier 2 PAGE 18 LAST UPDATED 09/2018
19 EFFECTIVE 03/09/2018 MAKENA 275 MG/1.1 ML AUTOINJCT hydroxyprogesterone caproate/pf - PA Added: MAKENA (s) methylphenidate hcl 10 mg cpbp QL Added: 30 / 30 DAYS PAGE 19 LAST UPDATED 09/2018
20 EFFECTIVE 03/10/2018 ONETOUCH ULTRA BLUE TEST STRP blood sugar diagnostic PAGE 20 LAST UPDATED 09/2018
21 EFFECTIVE 03/16/2018 ethynodiol d-ethinyl estradiol 1 mg-50mcg tablet PAGE 21 LAST UPDATED 09/2018
22 EFFECTIVE 03/17/2018 ibuprofen 400 mg tablet ibuprofen 600 mg tablet ibuprofen 800 mg tablet ibuprofen 400 mg tablet ibuprofen 600 mg tablet ibuprofen 800 mg tablet PAGE 22 LAST UPDATED 09/2018
23 EFFECTIVE 03/23/2018 ritonavir 100 mg tablet tiagabine hcl 12 mg tablet tiagabine hcl 16 mg tablet ibuprofen 400 mg tablet ibuprofen 600 mg tablet ibuprofen 800 mg tablet PAGE 23 LAST UPDATED 09/2018
24 EFFECTIVE 03/31/2018 OMNIPOD 10 PACK insulin pump cartridge OMNIPOD 5 PACK POD insulin pump cartridge OMNIPOD STARTER KIT subcutaneous insulin pump - Added to Tier 3 - Added to Tier 3 - Added to Tier 3 PAGE 24 LAST UPDATED 09/2018
25 EFFECTIVE 04/01/2018 DALIRESP 250 MCG TABLET roflumilast ENDARI 5 GRAM POWDER PACKET glutamine ERLEADA 60 MG TABLET apalutamide HEMLIBRA 105 MG/0.7 ML VIAL emicizumab-kxwh HEMLIBRA 150 MG/ML VIAL emicizumab-kxwh HEMLIBRA 30 MG/ML VIAL emicizumab-kxwh HEMLIBRA 60 MG/0.4 ML VIAL emicizumab-kxwh IMBRUVICA 140 MG TABLET ibrutinib IMBRUVICA 280 MG TABLET ibrutinib IMBRUVICA 420 MG TABLET ibrutinib IMBRUVICA 560 MG TABLET ibrutinib IMBRUVICA 70 MG CAPSULE ibrutinib lidocaine 5 % oint. (g) lidocaine hcl 4 % solution - QL Added: 30 / 30 DAYS - PA Added: Daliresp - QL Added: 180 / 30 DAYS - PA Added: Endari - QL Added: 120 / 30 DAYS - PA Added: ERLEADA - PA Added: HEMLIBRA - PA Added: HEMLIBRA - PA Added: HEMLIBRA - PA Added: HEMLIBRA - PA Added: Imbruvica - QL Added: 30 / 30 DAYS - PA Added: Imbruvica - QL Added: 30 / 30 DAYS - PA Added: Imbruvica - QL Added: 30 / 30 DAYS - PA Added: Imbruvica - QL Added: 30 / 30 DAYS - PA Added: Imbruvica - QL Added: 30 / 30 DAYS PAGE 25 LAST UPDATED 09/2018
26 EFFECTIVE 04/01/2018 lidocaine hcl 40 mg/ml solution lidocaine/prilocaine 2.5 %-2.5% kit LIDORXKIT lidocaine/skin cleanser combination no.37 paricalcitol 2 mcg/ml vial paricalcitol 5 mcg/ml vial PREVYMIS 240 MG TABLET letermovir PREVYMIS 240 MG/12 ML VIAL letermovir PREVYMIS 480 MG TABLET letermovir PREVYMIS 480 MG/24 ML VIAL letermovir VIDEX EC 125 MG CAPSULE didanosine lidocaine/prilocaine 2.5 %-2.5% cream (g) methotrexate sodium 2.5 mg tablet prochlorperazine maleate 10 mg tablet prochlorperazine maleate 5 mg tablet - QL Added: 30 / 30 DAYS - QL Added: 30 / 30 DAYS PAGE 26 LAST UPDATED 09/2018
27 EFFECTIVE 04/06/2018 SYMFI LO MG TABLET efavirenz/lamivudine/tenofovir disoproxil fumarate - QL Added: 30 / 30 DAYS palonosetron hcl 0.25mg/2ml vial palonosetron hcl 0.25mg/5ml vial PAGE 27 LAST UPDATED 09/2018
28 EFFECTIVE 04/12/2018 VIDEX EC 125 MG CAPSULE didanosine PAGE 28 LAST UPDATED 09/2018
29 EFFECTIVE 04/13/2018 EASY GLIDE PEN NEEDLE 4MM 33G pen needle, diabetic TOUJEO MAX SOLOSTAR 300UNIT/ML insulin glargine,human recombinant analog TROGARZO 200 MG/1.33 ML VIAL ibalizumab-uiyk VIDEX EC 125 MG CAPSULE didanosine - Added to Tier 3 PAGE 29 LAST UPDATED 09/2018
30 EFFECTIVE 04/15/2018 TASIGNA 50 MG CAPSULE nilotinib hcl - PA Added: Tasigna - QL Added: 240 / 30 DAYS PAGE 30 LAST UPDATED 09/2018
31 EFFECTIVE 04/20/2018 BAXDELA 300 MG VIAL delafloxacin meglumine BAXDELA 450 MG TABLET delafloxacin meglumine BD SAFETYGLID INS 1 ML 6MMX31G syringe with needle, insulin, safety, 1 ml BD SAFTYGLD INS 0.3 ML 6MMX31G syringe with needle, insulin, safety, 0.3 ml BD SAFTYGLD INS 0.5 ML 6MMX31G syringe with needle, insulin, safety, 0.5 ml EASY TOUCH PEN NEEDLE 30GX5/16 pen needle, diabetic FASENRA 30 MG/ML SYRINGE benralizumab FIASP 100 UNIT/ML FLEXTOUCH insulin aspart (niacinamide) FIASP 100 UNIT/ML VIAL insulin aspart (niacinamide) OZEMPIC MG DOSE PEN semaglutide OZEMPIC 1 MG DOSE PEN semaglutide QTERN 10 MG-5 MG TABLET dapagliflozin propanediol/saxagliptin hcl - PA Added: BAXDELA - PA Added: BAXDELA - PA Added: FASENRA - Added to Tier 3 - Added to Tier 3 - QL Added: 1.5 / 28 DAYS - QL Added: 3 / 28 DAYS - QL Added: 30 / 30 DAYS timolol maleate 0.5 % drop daily TRELEGY ELLIPTA fluticasone furoate/umeclidinium bromide/vilanterol trifenat - QL Added: 60 / 30 DAYS PAGE 31 LAST UPDATED 09/2018
32 EFFECTIVE 04/27/2018 miglustat 100 mg capsule - PA Added: Zavesca - LA Added: Limited Access PAGE 32 LAST UPDATED 09/2018
33 EFFECTIVE 04/30/2018 CIMDUO MG TABLET lamivudine/tenofovir disoproxil fumarate EPIPEN 2-PAK 0.3 MG AUTO-INJCT epinephrine EPIPEN JR 2-PAK 0.15 MG INJCTR epinephrine SYLVANT 400 MG VIAL siltuximab SYMFI MG TABLET efavirenz/lamivudine/tenofovir disoproxil fumarate VIRAMUNE 50 MG/5 ML SUSP nevirapine - QL Added: 30 / 30 DAYS - Added to Tier 3 - QL Added: 2 / 30 DAYS - ST Added: EPINEPHRINE AUTO- INJECTOR THERAPY - Added to Tier 3 - QL Added: 2 / 30 DAYS - ST Added: EPINEPHRINE AUTO- INJECTOR THERAPY - PA Removed: - QL Added: 30 / 30 DAYS palonosetron hcl 0.25mg/2ml vial palonosetron hcl 0.25mg/5ml vial PAGE 33 LAST UPDATED 09/2018
34 EFFECTIVE 05/04/2018 BD INS SYRNG UF 0.3 ML 8MMX31G syringe with needle,insulin,0.3 ml BD INS SYRNG UF 0.5 ML 8MMX31G syringe with needle,insulin,0.5 ml BD INSULIN SYR UF 1 ML 8MMX31G syringe with needle,disposable,insulin 1 ml BD VEO INS 0.3ML 6MMX31G (1/2) syringe with needle,insulin 0.3 ml (half unit mark) BD VEO INS SYRING 1 ML 6MMX31G syringe with needle,disposable,insulin 1 ml BD VEO INS SYRN 0.3 ML 6MMX31G syringe with needle,insulin,0.3 ml BD VEO INS SYRN 0.5 ML 6MMX31G syringe with needle,insulin,0.5 ml TECHLITE INS SYR 1 ML 29GX12MM syringe with needle,disposable,insulin 1 ml TECHLITE INS SYR 1 ML 30GX12MM syringe with needle,disposable,insulin 1 ml TECHLITE INS SYR 1 ML 30GX8MM syringe with needle,disposable,insulin 1 ml TECHLITE INS SYR 1 ML 31GX6MM syringe with needle,disposable,insulin 1 ml TECHLITE INS SYR 1 ML 31GX8MM syringe with needle,disposable,insulin 1 ml dexamethasone 0.5 mg/5ml elixir - Added to Tier 2 ganciclovir sodium 500mg/10ml vial - Added to Tier 2 praziquantel 600 mg tablet - Added to Tier 2 PAGE 34 LAST UPDATED 09/2018
35 EFFECTIVE 05/11/2018 HUMIRA 10 MG/0.1 ML SYRINGE adalimumab HUMIRA 20 MG/0.2 ML SYRINGE adalimumab HUMIRA 40 MG/0.4 ML PEN adalimumab HUMIRA 40 MG/0.4 ML SYRINGE adalimumab HUMIRA PED CROHNS 80 MG/0.8 ML adalimumab HUMIRA PEDIATR CROHN'S 80-40MG adalimumab KYMRIAH INFUSION BAG tisagenlecleucel TECHLITE 0.3 ML 29GX12MM (1/2) syringe with needle,insulin 0.3 ml (half unit mark) TECHLITE 0.3 ML 30GX12MM (1/2) syringe with needle,insulin 0.3 ml (half unit mark) TECHLITE 0.3 ML 30GX8MM (1/2) syringe with needle,insulin 0.3 ml (half unit mark) TECHLITE 0.3 ML 31GX6MM (1/2) syringe with needle,insulin 0.3 ml (half unit mark) TECHLITE 0.3 ML 31GX8MM (1/2) syringe with needle,insulin 0.3 ml (half unit mark) TECHLITE 0.5 ML 29GX12MM (1/2) syringe with needle,insulin 0.5 ml (half unit mark) TECHLITE 0.5 ML 30GX12MM (1/2) syringe with needle,insulin 0.5 ml (half unit mark) - PA Added: Humira - QL Added: 2 / 28 DAYS - PA Added: Humira - QL Added: 2 / 28 DAYS - PA Added: Humira - QL Added: 2 / 28 DAYS - PA Added: Humira - QL Added: 2 / 28 DAYS - PA Added: Humira - QL Added: 3 / 28 DAYS - PA Added: Humira - QL Added: 2 / 28 DAYS PAGE 35 LAST UPDATED 09/2018
36 EFFECTIVE 05/11/2018 TECHLITE 0.5 ML 30GX8MM (1/2) syringe with needle,insulin 0.5 ml (half unit mark) TECHLITE 0.5 ML 31GX6MM (1/2) syringe with needle,insulin 0.5 ml (half unit mark) TECHLITE 0.5 ML 31GX8MM (1/2) syringe with needle,insulin 0.5 ml (half unit mark) PAGE 36 LAST UPDATED 09/2018
37 EFFECTIVE 05/25/2018 BD INS SYRNG 0.3 ML 29GX12.7MM syringe with needle,insulin,0.3 ml BD INS SYRNG 0.5 ML 29GX12.7MM syringe with needle,insulin,0.5 ml BD INSULIN SYR 1 ML 27GX12.7MM syringe with needle,disposable,insulin 1 ml BD INSULIN SYR 1 ML 29GX12.7MM syringe with needle,disposable,insulin 1 ml NORVIR 100 MG POWDER PACKET ritonavir baclofen 5 mg tablet - Added to Tier 2 colesevelam hcl 625 mg tablet - Added to Tier 2 norgestimate-ethinyl estradiol tablet PAGE 37 LAST UPDATED 09/2018
38 EFFECTIVE 06/01/2018 BAXDELA 300 MG VIAL delafloxacin meglumine BAXDELA 450 MG TABLET delafloxacin meglumine BENZNIDAZOLE 100 MG TABLET benznidazole BENZNIDAZOLE 12.5 MG TABLET benznidazole norgestimate-ethinyl estradiol 7daysx3 28 tablet - PA Removed: - PA Removed: - Added to Tier 2 - Added to Tier 2 testosterone 10 mg (2%) gel md pmp - Added to Tier 2 testosterone 12.5/1.25g gel md pmp - Added to Tier 2 testosterone 25mg(1%) gel packet - Added to Tier 2 testosterone 50 mg (1%) gel (gram) - Added to Tier 2 testosterone 50 mg (1%) gel packet - Added to Tier 2 PAGE 38 LAST UPDATED 09/2018
39 EFFECTIVE 06/08/2018 ARNUITY ELLIPTA 50 MCG INH fluticasone furoate FLUOR-A-DAY 0.25 MG TAB CHEW sodium fluoride/xylitol FLUOR-A-DAY 0.5 MG TAB CHEW sodium fluoride/xylitol FLUOR-A-DAY 1 MG TABLET CHEW sodium fluoride/xylitol - Added to Tier 3 - QL Added: 30 / 30 DAYS fluoride (sodium) 0.5(1.1)mg tab chew fluoride (sodium) 1mg(2.2mg) tab chew FLUORITAB 1 MG TABLET CHEW fluoride (sodium) PRO COMFORT 0.5 ML 30GX1/2" syringe with needle,insulin,0.5 ml PRO COMFORT 0.5 ML 30GX5/16" syringe with needle,insulin,0.5 ml PRO COMFORT 0.5 ML 31GX5/16" syringe with needle,insulin,0.5 ml PRO COMFORT 1 ML 30GX1/2" syringe with needle,disposable,insulin 1 ml PRO COMFORT 1 ML 30GX5/16" syringe with needle,disposable,insulin 1 ml PRO COMFORT 1 ML 31GX5/16" syringe with needle,disposable,insulin 1 ml fluoride (sodium) 0.25(0.55) tab chew fluoride (sodium) 0.5(1.1)mg tab chew fluoride (sodium) 1mg(2.2mg) tab chew norethindrone 0.35 mg tablet PAGE 39 LAST UPDATED 09/2018
40 EFFECTIVE 06/15/2018 EPINEPHRINE 0.15 MG AUTO-INJCT epinephrine EPINEPHRINE 0.3 MG AUTO-INJECT epinephrine EPIPEN 2-PAK 0.3 MG AUTO-INJCT epinephrine EPIPEN JR 2-PAK 0.15 MG INJCTR epinephrine KEVZARA 150 MG/1.14 ML PEN INJ sarilumab KEVZARA 200 MG/1.14 ML PEN INJ sarilumab KIONEX 15 GM/60 ML SUSPENSION sodium polystyrene sulfonate/sorbitol solution - Added to Tier 2 Epinephrine Auto-injector Therapy - QL Added: 2.28 / 28 DAYS - PA Added: Kevzara - QL Added: 2.28 / 28 DAYS - PA Added: Kevzara - Added to Tier 2 epinephrine 0.15/0.15 auto injct - Added to Tier 2 epinephrine 0.3mg/0.3 auto injct - Added to Tier 2 lamotrigine 100 mg tablet lamotrigine 150 mg tablet lamotrigine 200 mg tablet lamotrigine 25 mg tablet PAGE 40 LAST UPDATED 09/2018
41 EFFECTIVE 06/29/2018 ASSURE ID PEN NEEDLE 31GX3/16" pen needle, diabetic, safety buprenorphine hcl/naloxone hcl 8 mg-2 mg film - Added to Tier 2 - QL Added: 90 / 30 DAYS daptomycin 350 mg vial PAGE 41 LAST UPDATED 09/2018
42 EFFECTIVE 07/06/2018 ASSURE ID PEN NEEDLE 30GX3/16" pen needle, diabetic, safety ASSURE ID PEN NEEDLE 30GX5/16" pen needle, diabetic, safety ertapenem sodium 1 g vial hydromorphone hcl/pf 4 mg/ml vial - Added to Tier 2 vigabatrin 500 mg powd pack - QL Added: 180 / 30 DAYS - LA Added: Limited Access - PA Added: Sabril PAGE 42 LAST UPDATED 09/2018
43 EFFECTIVE 07/13/2018 ARISTADA INITIO ER 675 MG/2.4 aripiprazole lauroxil, submicronized - Removed From Coverage - QL Removed: ritonavir 100 mg tablet - Added to Tier 2 SYMDEKO 100/150 MG-150 MG TABS tezacaftor/ivacaftor TROGARZO 200 MG/1.33 ML VIAL ibalizumab-uiyk hydromorphone hcl/pf 1 mg/ml vial - QL Added: 56 / 28 DAYS - Removed From Coverage PAGE 43 LAST UPDATED 09/2018
44 EFFECTIVE 07/20/2018 CUPRIMINE 250 MG CAPSULE penicillamine DEPEN 250 MG TITRATAB penicillamine SYPRINE 250 MG CAPSULE trientine hcl trientine hcl 250 mg capsule XELJANZ 10 MG TABLET tofacitinib citrate - PA Added: Xeljanz - QL Added: 60 / 30 DAYS budesonide 9 mg tabdr - er - ST Added: UCERIS ORAL THERAPY hydroxyprogesterone caproat/pf 250 mg/ml vial - PA Added: MAKENA (s) ketoprofen 25 mg capsule - Added to Tier 2 PAGE 44 LAST UPDATED 09/2018
45 EFFECTIVE 07/27/2018 ALPHAGAN P 0.1% DROPS brimonidine tartrate AZOPT 1% EYE DROPS brinzolamide betaxolol hcl 0.5 % drops COMBIGAN 0.2%-0.5% EYE DROPS brimonidine tartrate/timolol maleate COSOPT PF EYE DROPS dorzolamide hcl/timolol maleate/pf KIONEX 15 GM/60 ML SUSPENSION sodium polystyrene sulfonate/sorbitol solution latanoprost % drops LUMIGAN 0.01% EYE DROPS bimatoprost metipranolol 0.3 % drops RHOPRESSA 0.02% OPHTH SOLUTION netarsudil mesylate SIMBRINZA 1%-0.2% EYE DROPS brinzolamide/brimonidine tartrate timolol maleate 0.25 % sol-gel timolol maleate 0.5 % drop daily timolol maleate 0.5 % sol-gel TRAVATAN Z 0.004% EYE DROP travoprost travoprost (benzalkonium) % drops VYZULTA 0.024% OPHTH SOLUTION latanoprostene bunod bimatoprost 0.03 % drops brimonidine tartrate 0.15 % drops - Added to Tier 2 PAGE 45 LAST UPDATED 09/2018
46 EFFECTIVE 07/27/2018 brimonidine tartrate 0.2 % drops carteolol hcl 1 % drops colesevelam hcl 3.75 g powd pack - Added to Tier 2 dorzolamide hcl 2 % drops dorzolamide hcl/timolol maleat /1 drops levobunolol hcl 0.5 % drops norethindrone 0.35 mg tablet timolol maleate 0.25 % drops timolol maleate 0.25 % sol-gel timolol maleate 0.5 % drops timolol maleate 0.5 % sol-gel PAGE 46 LAST UPDATED 09/2018
47 EFFECTIVE 07/28/2018 ILARIS 150 MG/ML VIAL canakinumab/pf - LA Added: Limited Access - PA Added: Ilaris - QL Added: 2 / 28 DAYS PAGE 47 LAST UPDATED 09/2018
48 EFFECTIVE 08/01/2018 YONSA 125 MG TABLET abiraterone acetate, submicronized - PA Added: YONSA PAGE 48 LAST UPDATED 09/2018
49 EFFECTIVE 08/03/2018 ILARIS 150 MG/ML VIAL canakinumab/pf - LA Added: Limited Access - PA Added: Ilaris - QL Added: 2 / 28 DAYS immun glob g(igg)/pro/iga % vial - PA Added: IVIG NUPLAZID 10 MG TABLET pimavanserin tartrate NUPLAZID 34 MG CAPSULE pimavanserin tartrate - PA Added: NUPLAZID - QL Added: 30 / 30 DAYS - PA Added: NUPLAZID - QL Added: 30 / 30 DAYS bendamustine hcl 25 mg/ml vial crotamiton 10 % lotion PAGE 49 LAST UPDATED 09/2018
50 EFFECTIVE 08/06/2018 immun glob g(igg)/pro/iga % vial - PA Added: IVIG PAGE 50 LAST UPDATED 09/2018
51 EFFECTIVE 08/10/2018 GAMASTAN VIAL immune globulin,gamma(igg)/glycine HEPLISAV-B 20 MCG/0.5 ML SYRNG hepatitis b vaccine recombinant/vaccine adjuvant cpg 1018/pf HUMIRA PEN CROHN-UC-HS 80 MG adalimumab HUMIRA PEN PSOR-UVEI 80MG-40MG adalimumab dorzolamide/timolol/pf 2 %-0.5 % droperette - Added to Tier 3 - PA Added: Gamastan S/D - PA Added: Humira - QL Added: 3 / 28 DAYS - PA Added: Humira - QL Added: 3 / 28 DAYS - ST Added: RHOPRESSA PAGE 51 LAST UPDATED 09/2018
52 EFFECTIVE 08/17/2018 DROPSAFE PEN NEEDLE 31GX1/4" pen needle, diabetic, safety DROPSAFE PEN NEEDLE 31GX5/16" pen needle, diabetic, safety immun glob g(igg)/pro/iga % vial - PA Added: IVIG KYPROLIS 10 MG VIAL carfilzomib PLENVU POWDER PACKETS peg 3350/sodium sulfate/sod chloride/kcl/ascorbate sod/vit c levonorgestrel-ethin estradiol mg tablet levonorgestrel-ethin estradiol tablet - PA Added: KYPROLIS - Added to Tier 3 PAGE 52 LAST UPDATED 09/2018
53 EFFECTIVE 08/24/2018 ADRIAMYCIN 50 MG VIAL doxorubicin hcl OMNIPOD DASH 5 PACK POD insulin pump cartridge - Added to Tier 2 - Added to Tier 3 doxorubicin hcl 10 mg vial - Added to Tier 2 hydroxyprogesterone caproate 250 mg/ml vial - PA Added: MAKENA (s) metformin hcl 500 mg/5ml solution - QL Added: 750 / 30 DAYS tadalafil 20 mg tablet - PA Added: Adcirca - QL Added: 60 / 30 DAYS temsirolimus fdn 30mg/3 vial PAGE 53 LAST UPDATED 09/2018
54 EFFECTIVE 08/31/2018 BRAFTOVI 50 MG CAPSULE encorafenib BRAFTOVI 75 MG CAPSULE encorafenib MEKTOVI 15 MG TABLET binimetinib SYMTUZA MG TAB darunavir eth/cobicistat/emtricitabine/tenofovir alafenamide TIBSOVO 250 MG TABLET ivosidenib - PA Added: Braftovi - PA Added: Braftovi - PA Added: Mektovi - QL Added: 30 / 30 DAYS - QL Added: 60 / 30 DAYS - PA Added: Tibsovo imiquimod 3.75 % crm md pmp PAGE 54 LAST UPDATED 09/2018
55 EFFECTIVE 09/14/2018 LENVIMA 12 MG DAILY DOSE lenvatinib mesylate LENVIMA 4 MG CAPSULE lenvatinib mesylate POTELIGEO 20 MG/5 ML VIAL mogamulizumab-kpkc - PA Added: Lenvima - PA Added: Lenvima PAGE 55 LAST UPDATED 09/2018
56 EFFECTIVE 09/15/2018 SAPHRIS 10 MG TAB SUBLINGUAL asenapine maleate SAPHRIS 5 MG TAB SUBLINGUAL asenapine maleate - ST Added: ATYPICAL ANTIPSYCHOTICS - QL Added: 60 / 30 DAYS - ST Added: ATYPICAL ANTIPSYCHOTICS - QL Added: 60 / 30 DAYS PAGE 56 LAST UPDATED 09/2018
57 EFFECTIVE 09/21/2018 SAPHRIS 10 MG TAB SUBLINGUAL asenapine maleate SAPHRIS 5 MG TAB SUBLINGUAL asenapine maleate - ST Added: ATYPICAL ANTIPSYCHOTICS - QL Added: 60 / 30 DAYS - ST Added: ATYPICAL ANTIPSYCHOTICS - QL Added: 60 / 30 DAYS dalfampridine 10 mg tab er 12h - LA Added: Limited Access - PA Added: Ampyra - QL Added: 60 / 30 DAYS PAGE 57 LAST UPDATED 09/2018
58 EFFECTIVE 09/22/2018 TECHLITE PEN NEEDLE 31GX3/16" pen needle, diabetic PAGE 58 LAST UPDATED 09/2018
Gundersen Senior Preferred MEDICARE 2018 PART D Updates
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EFFECTIVE 01/05/2018. atazanavir sulfate 150 mg capsule - Added to Tier 1 TYPHIM VI 25 MCG/0.5 ML VIAL. - Added to Tier 2
EFFECTIVE 01/05/2018 atazanavir sulfate 150 mg capsule TYPHIM VI 25 MCG/0.5 ML VIAL typhoid vaccine vi capsular polysaccharide atazanavir sulfate 200 mg capsule atazanavir sulfate 300 mg capsule PAGE 1
Health Partners Medicare Special 2018 Formulary Changes
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EFFECTIVE 01/04/2019. pimecrolimus 1 % cream (g) - Added to Tier 1 - ST Added: TOPICAL IMMUNOMODULATORS
EFFECTIVE 01/04/2019 pimecrolimus 1 % cream (g) - ST Added: TOPICAL IMMUNOMODULATORS PAGE 1 LAST UPDATED 03/2019 EFFECTIVE 01/05/2019 LORBRENA 100 MG TABLET lorlatinib LORBRENA 25 MG TABLET lorlatinib
JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET BYDUREON BCISE 2 MG/0.
ANTI DIABETICS BYDUREON 2 MG SUBCUTANEOUS JANUVIA 25 MG TABLET EXTENDED RELEASE SUSPENSION JANUVIA 50 MG TABLET BYDUREON 2 MG/0.65 ML JARDIANCE 10 MG TABLET SUBCUTANEOUS PEN INJECTOR JARDIANCE 25 MG TABLET
CAREADVANTAGE (CMC/MMP) 2018 Updates
January, 2018 01/05/2018 atazanavir sulfate atazanavir sulfate 01/05/2018 TYPHIM VI typhoid vaccine vi capsular polysaccharide 01/12/2018 PROLASTIN C alpha-1-proteinase inhibitor 01/12/2018 01/12/2018
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2018 Formulary Update
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January, 2018 01/01/2018 TAMIFLU oseltamivir phosphate CHANGE UM: QUANTITY 720 / 365 days 720 / 365 OVER 01/01/2018 oseltamivir phosphate 01/01/2018 oseltamivir phosphate 01/01/2018 oseltamivir phosphate
2018 Formulary Update
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You ll find the most up-to-date comprehensive version of our formulary on our website, Click on Drug Finder.
3/1/2018 Medicare Part D Formulary Change In an effort to cover the most needed, cost-effective prescriptions, the AlohaCare Advantage Plus (HMO SNP) Formulary is updated monthly. The following are drugs
Health Partners Medicare Prime 2019 Formulary Changes
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EFFECTIVE 01/04/2019. pimecrolimus 1 % cream (g) - Added to Tier 1 - ST Added: TOPICAL IMMUNOMODULATORS
EFFECTIVE 01/04/2019 pimecrolimus 1 % cream (g) - ST Added: TOPICAL IMMUNOMODULATORS PAGE 1 LAST UPDATED 02/2019 EFFECTIVE 01/05/2019 LORBRENA 100 MG TABLET lorlatinib LORBRENA 25 MG TABLET lorlatinib
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Partners Notice of Change March 2017
New Added Products: Effective 3/1/2017 Drug Reason Tier Restrictions abacavir 600 mg-lamivudine 300 QL ADRENACLICK 0.15 MG/0.15 ML INJECTION,AUTO- INJECTOR ADRENACLICK 0.3 MG/0.3 ML INJECTION, AUTO- INJECTOR
During non-business hours, your call will be answered by our automated phone system. A representative will return your call the next business day.
MEICARE AVANTAGE BlueCross BlueShield of Western New York 2018 Formulary Update BlueCross BlueShield of Western New York has updated its formulary (drug list) since its original publication in January
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Drug Name Tier Drug Name Tier
Drug Name Tier Drug Name Tier ABELCET 100 MG/20 ML VIAL 4 ACETYLCYSTEINE 10% VIAL 2 ACETYLCYSTEINE 20% VIAL 2 ACYCLOVIR 1,000 MG/20 ML VIAL 2 ACYCLOVIR 500 MG/10 ML VIAL 2 ADRUCIL 500 MG/10 ML VIAL 2 ALBUTEROL
Quarterly pharmacy formulary change notice
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Step Therapy Requirements
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Health Partners Medicare Special Formulary Updates
March 2018 Effective Date Brand Name Generic Name Type of Change 90 / 30 DAYS tenofovir disoproxil fumarate tenofovir disoproxil fumarate clobetasol propionate tenofovir disoproxil fumarate Previous Value
Quarterly pharmacy formulary change notice
The formulary changes listed in the table below apply to all Anthem HealthKeepers Plus and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) members. These formulary changes,
TennCare Program TN MAC Price Change List As of: 03/30/2017
1 TN List Run : 03/30/17 Old PRAZOSIN HCL 5 MG CAPSULE ORAL 03/29/2017 1.11209 1.12560 ( 1.2) CAPTOPRIL 12.5 MG TABLET ORAL 07/07/2015 1.07191 1.10416 ( 2.9) ISOSORBIDE DINITRATE 5 MG TABLET ORAL 03/29/2017
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Quarterly pharmacy formulary change notice
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Medi-Cal Managed Care L. A. Care Major Risk Medical Insurance Program Provider Bulletin The formulary changes listed in the table below were reviewed and approved at our first-quarter 2018 Pharmacy and
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LIST OF DRUGS THAT MAY BE COVERED UNDER YOUR MEDICAL BENEFIT
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Mercy Care Plan. Acyclovir Ointment. Products Affected. acyclovir ointment 5 % external Details. Criteria. Requires use of oral Acyclovir
Acyclovir Ointment Mercy Care Plan acyclovir ointment 5 % external Requires use of oral Acyclovir 1 Adcirca ADCIRCA TABLET 20 MG ORAL Requires use of Sildenafil 2 Albenza ALBENZA TABLET 200 MG ORAL Requires
Nebraska Medicaid Program NE Weekly MAC Price Change List For Period: 12/14/ /20/2017
1 Medicaid Run : 12/21/17 NE Weekly List Old AMIODARONE HCL 200 MG TABLET ORAL 12/20/2017 0.15321 0.14370 6.6 HYDRALAZINE HCL 10 MG TABLET ORAL 12/20/2017 0.05226 0.05213 0.2 LISINOPRIL 10 MG TABLET ORAL
Acyclovir Ointment. Aetna Better Health Pennsylvania. Products Affected. acyclovir ointment 5 % external Details. Criteria
Medications that require Step Therapy (ST) require trial and failure of preferred formulary agents prior to their authorization. If the prerequisite medications have been filled within the specified time
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Y0133_StepTherapyCriteria _C 10/18/18 Y0133_StepTherapyCriteria _C es 10/18/18
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TEST ANTICONVULSANT THERAPY. Products Affected. Step 2: Network Health Insurance Corporation NetworkCares Step Therapy Criteria Last Updated 11/2018
TEST Network Health Insurance Corporation NetworkCares Step Therapy Last Updated 11/2018 ANTICONVULSANT THERAPY Aptiom Banzel Briviact Celontin Dilantin 30 Mg Capsule Equetro Fycompa 0.5 Mg/ml Oral Susp
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Blue Shield 65 Plus Choice Plan (HMO) Blue Shield of California is an independent member of the Blue Shield Association. Formulary Updates:
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TN Cover Rx Tennessee CoverRx MAC Price Change List As of: 04/26/2018
1 Tennessee CoverRx List Run : 04/26/18 Dosage Form amiodarone HCl 200 MG TABLET ORAL 04/25/2018 0.16102 0.14405 11.8 hydralazine HCl 100 MG TABLET ORAL 04/25/2015 0.11390 0.10854 4.9 hydralazine HCl 25
Added, Removed or Changed. Added, Removed or Changed
One mission: you s March 8, 2018 Blue Cross of Idaho reviews its formularies (covered drug lists) periodically to allow members access to new drugs and to provide safe, cost effective options for your
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October 2017 o DOXYLAMINE SUCCINATE 25mg-QL o DULOXETINE CAP 40MG DR-QL o GUANFACIN ER TABS (all strengths)-ql o TOBRAMYCIN NEBU SOLUTION- PA August 2017 Aetna Better Health of Illinois Medicaid 2017 Formulary
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Provider Bulletin April 2018 This table is used by HealthKeepers, Inc. to indicate formulary changes applicable to all Anthem HealthKeepers Plus members. These changes were reviewed and approved at the
CRITERIA Trial of two generic formulary products from the following: atomoxetine or ADHD stimulant medication.
ADHD STIMULANTS ATOMOXETINE HCL, DEXEDRINE 10 MG TABLET, DEXEDRINE 5 MG TABLET, DEXMETHYLPHENIDATE HCL, DEXMETHYLPHENIDATE HCL ER, DEXTROAMPHETAMINE 10 MG TAB, DEXTROAMPHETAMINE 5 MG TAB, DEXTROAMPHETAMINE
MEDICAID QUANTITY LIMIT DRUG LIST
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Aetna Better Health FIDA Plan
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The following list of recommended PDL changes were reviewed and approved by the MHS P&T Committee on December 14 th, 2016.
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Step Therapy Requirements. Effective: 11/01/2018
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ALLERGIC CONJUNCTIVITIS AGENTS
2018 5 Tier Standard- Keystone First VIP Choice Document: 2018 Step Therapy Formulary ID: 18390 Last Updated: 04/2018 Effective Date: 05-01-2018 ALLERGIC CONJUNCTIVITIS AGENTS epinastine 0.05 % eye drops
WVCH Formulary Additions Effective 01/01/2016 Name Strength Dosage Form Route Formulary Restrictions
WVCH Formulary Additions Effective 01/01/2016 Name Strength Dosage Form Route Formulary Restrictions ANORO ELLIPTA 62.5-25MCG BLST W/DEV INHALATION ARCAPTA NEOHALER 75 MCG CAP W/DEV INHALATION CALCIPOTRIENE
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ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID 18354, Version 15 1 ANTIDEPRESSANTS - SCORE Aplenzin Desvenlafaxine Er TB24 100MG, 50MG Emsam Fetzima Fetzima Titration Pack Trial of two of
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Aetna Better Health Illinois Premier Plan November 2015 Formulary Updates desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg RIVASTIGMINE DIS 13.3/24; QL (30 patches/30 days) RIVASTIGMINE DIS 4.6MG/24;
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ALBUTEROL - SCORE Ventolin Hfa Trial of ProAir Formulary ID 18351, Version 15 1 ANTIDEPRESSANTS - SCORE Desvenlafaxine Er TB24 100MG, 50MG Emsam Fetzima Fetzima Titration Pack Trial of two of the following
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ALLERGIC RHINITIS-NASAL
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Riesbeck's Pharmacy Reward Club Generic Medication List February 2018 $4 30 Day Supply
Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Inj 50MG/ML 1 3 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml
PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select Formulary April 1, 2018 Updates. Formulary Alternatives
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PRESCRIPTION DRUG PROGRAM FORMULARY UPDATES Select April 1, 2018 Updates Drug Name adapalene-benzoyl-peroxide Gel 0.1-2.5% (Brand = Epiduo ) prasugrel hcl (Brand = Effient ) vigabatrin pak 500 mg (Brand
AMANTADINE ER. Products Affected Step 2: OSMOLEX ER 129 MG TABLET, EXTENDED RELEASE OSMOLEX ER 193 MG TABLET, Details
AMANTADINE ER OSMOLEX ER 129 MG, EXTENDED RELEASE OSMOLEX ER 193 MG, EXTENDED RELEASE OSMOLEX ER 258 MG, EXTENDED RELEASE PRIOR CLAIM FOR AMANTADINE HCL IMMEDIATE RELEASE WITHIN THE PAST 120 DAYS. 1 ANTICONVULSANTS
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2017 Medicare Part D Formulary Change We may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, or add prior authorizations, quantity limits and/or step therapy
Riesbeck's Pharmacy Reward Club Generic Medication List October 2017
Allergy, Cold & Flu Antibiotic Treatments Arthritis & Pain Benzonatate 100mg cap 14 42 Diphenhydramine HCl Cap 50 MG 30 90 Diphenhydramine HCl Inj 50MG/ML 1 3 Diphenhydramine HCl Liquid 12.5 MG/5ML 720ml
Step Therapy Requirements. Effective: 05/01/2018
Step Therapy Requirements Effective: 05/01/2018 ANTIDEPRESSANTS TRINTELLIX 10 MG TABLET TRINTELLIX 20 MG TABLET TRINTELLIX 5 MG TABLET VIIBRYD 10 MG (7)-20 MG (23) TABLETS IN A DOSE PACK VIIBRYD 10 MG
FirstCarolinaCare Insurance Company. Step Therapy Requirements
FirstCarolinaCare Insurance Company Step Therapy Requirements Effective: 12/01/2018 ANTICONVULSANTS APTIOM 200 MG APTIOM 400 MG APTIOM 600 MG APTIOM 800 MG BANZEL 200 MG BANZEL 40 MG/ML ORAL SUSPENSION