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MassHealth Drug List A - Z


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This is a listing of all of the drugs covered by MassHealth. Please select a letter to see drugs listed by that letter, or enter the name of the drug you wish to search for.



MassHealth Drug List table
Drug - Brand Name (Generic Name) PA Status Class Drug Notes
Azulfidine EN-TabsdrugId:4864 (sulfasalazine delayed-release)drugId:4864 GI ANTI-INFLAMMATORY #
AzulfidinedrugId:1910 (sulfasalazine)drugId:1910 GI ANTI-INFLAMMATORY #
aztreonam injectiondrugId:120 ANTIBIOTICS #
aztreonam ANTIBIOTICS BP
Azstarys (serdexmethylphenidate / dexmethylphenidate); See Table 31drugId:7977; See Table 71drugId:7978 PA CEREBRAL STIMULANTS
AzordrugId:46 (amlodipine / olmesartan)drugId:46 CARDIOVASCULAR #
Azopt (brinzolamide)drugId:375 OPHTHALMIC PREPARATIONS BP
azithromycin ophthalmic solutiondrugId:119 PA OPHTHALMIC PREPARATIONS BP
azithromycin; See Table 35drugId:117; See Table 66drugId:2622 ANTIBIOTICS #
azilsartan / chlorthalidonedrugId:2480 CARDIOVASCULAR
azilsartandrugId:2240 CARDIOVASCULAR
Azilect (rasagiline)drugId:1640 PA > 1 unit/day ANTIPARKINSON
azelastine ophthalmic solutiondrugId:114 ANTIHISTAMINES
azelastine 137 mcg nasal spraydrugId:115 NASAL PREPARATIONS
azelastine 0.15% nasal spraydrugId:116 PA NASAL PREPARATIONS
azelastine / fluticasone propionatedrugId:2580 NASAL PREPARATIONS BP
azelaic acid geldrugId:113 PA DERMATOLOGICAL BP
azelaic acid foamdrugId:5106 PA DERMATOLOGICAL
Azedra (iobenguane I 131)drugId:6980 CHEMOTHERAPY ^
azathioprine injectiondrugId:5501 IMMUNOMODULATOR
azathioprine 75 mg, 100 mg tabletdrugId:2857 PA IMMUNOMODULATOR
azathioprine 50 mg tabletdrugId:111 IMMUNOMODULATOR #
Azasite (azithromycin ophthalmic solution)drugId:119 PA OPHTHALMIC PREPARATIONS BP
AzactamdrugId:120 (aztreonam injection)drugId:120 ANTIBIOTICS #
azacitidine vialdrugId:110 CHEMOTHERAPY #
azacitidine tabletdrugId:7565 PA CHEMOTHERAPY
Ayvakit (avapritinib)drugId:7360 PA CHEMOTHERAPY
Aygestin (norethindrone 5 mg) HORMONE REPLACEMENT THERAPY
axitinibdrugId:2484 PA CHEMOTHERAPY PD
axicabtagene ciloleuceldrugId:6414 PA CHEMOTHERAPY CO ^
Avycaz (ceftazidime / avibactam)drugId:4902 PA ANTIBIOTICS
Avsola (infliximab-axxq)drugId:7386 PA IMMUNOMODULATOR
Avonex (interferon beta-1a-Avonex)drugId:825 MULTIPLE SCLEROSIS AGENTS
Avodart (dutasteride)drugId:586 PA BENIGN PROSTATIC HYPERPLASIA AGENTS
AvitadrugId:1747 (tretinoin-Avita)drugId:1747 PA ≥ 22 years DERMATOLOGICAL #
avelumabdrugId:6100 PA CHEMOTHERAPY
Avelox (moxifloxacin tablet)drugId:1398 PA ANTIBIOTICS
Avelox (moxifloxacin injection)drugId:2748 ANTIBIOTICS
Aveed (testosterone undecanoate injection)drugId:2954 PA HORMONE REPLACEMENT THERAPY ^
AVC (sulfanilamide)drugId:1909 ANTIBIOTICS
avatrombopagdrugId:6990 PA HEMATOLOGIC
Avastin (bevacizumab)drugId:360 PA CHEMOTHERAPY
AvaprodrugId:968 (irbesartan)drugId:968 CARDIOVASCULAR #
avapritinibdrugId:7360 PA CHEMOTHERAPY
Avandia (rosiglitazone)drugId:1456 DIABETIC AGENTS
AvalidedrugId:969 (irbesartan / hydrochlorothiazide)drugId:969 CARDIOVASCULAR #
Austedo (deutetrabenazine)drugId:6121 PA NEUROLOGIC AGENT
Auryxia (ferric citrate) ELECTROLYTES AND NUTRIENTS
auranofin IMMUNOMODULATOR
Augmentin XR (amoxicillin / clavulanate extended-release)drugId:55 PA ANTIBIOTICS
AugmentindrugId:6420 (amoxicillin / clavulanate chewable tablet, 200/28.5, 250/62.5, 400/57, 600/42.9 mg/5 mL suspension, tablet)drugId:6420 ANTIBIOTICS #
Augmentin (amoxicillin / clavulanate 125/31.25 mg/5 mL suspension)drugId:54 PA ANTIBIOTICS
Aubagio (teriflunomide)drugId:2657 PA MULTIPLE SCLEROSIS AGENTS
Atrovent HFA (ipratropium inhalation aerosol)drugId:833 BRONCHODILATORS
Atrovent (ipratropium nasal spray) NASAL PREPARATIONS #
atropine ophthalmic OPHTHALMIC PREPARATIONS #
atropine injection ANTISPASMODICS,ANTICHOLINERGIC
AtripladrugId:591 (efavirenz / emtricitabine / tenofovir)drugId:591 ANTIVIRALS #
Atralin (tretinoin 0.05% gel)drugId:2432 PA DERMATOLOGICAL
atovaquone / proguanil ANTIMALARIALS #
atovaquonedrugId:106 ANTIPARASITICS #
atorvastatin 80 mgdrugId:2933 PA > 1 unit/day LIPID LOWERING AGENTS #
atorvastatin 10 mg, 20 mg, 40 mgdrugId:105 PA > 1.5 units/day LIPID LOWERING AGENTS #
atomoxetine; See Table 31drugId:104; See Table 71drugId:3080 PA < 6 years NONSTIMULANT ADHD AGENTS BP
Ativan (lorazepam solution, tablet); See Table 69drugId:1100; See Table 71drugId:4400 PA < 6 years BENZODIAZEPINES #
AtivandrugId:7662 (lorazepam injection)drugId:7662 BENZODIAZEPINES #
Atgam (antithymocyte globulin, equine)drugId:1112 BIOLOGICAL
atezolizumabdrugId:5593 PA CHEMOTHERAPY
atenolol / chlorthalidonedrugId:103 CARDIOVASCULAR #
atenololdrugId:102 CARDIOVASCULAR #
Atelvia (risedronate delayed-release)drugId:2101 PA ELECTROLYTES AND NUTRIENTS
atazanavir / cobicistatdrugId:4768 ANTIVIRALS
atazanavirdrugId:101 ANTIVIRALS #
Atacand HCT (candesartan / hydrochlorothiazide)drugId:434 PA CARDIOVASCULAR
Atacand (candesartan)drugId:433 PA CARDIOVASCULAR
Astramorph-PF (morphine, injection-Astramorph-PF)drugId:1391 PA > 120 mg/day OPIOID ANALGESICS
Astepro (azelastine 0.15% nasal spray)drugId:116 PA NASAL PREPARATIONS
Astagraf XL (tacrolimus extended-release capsule)drugId:2838 IMMUNOMODULATOR
aspirin with buffersdrugId:99 ANALGESICS *
aspirindrugId:98 ANALGESICS *
aspirin / extended-release dipyridamoledrugId:100 ANTIPLATELET AGENT
Asparlas (calaspargase pegol-mknl)drugId:7328 PA CHEMOTHERAPY ^
asparaginase erwinia chrysanthemi-rywndrugId:7981 PA CHEMOTHERAPY ^
asparaginase erwinia chrysanthemidrugId:2420 PA CHEMOTHERAPY ^
Asmanex Twisthaler (mometasone 220 mcg inhalation powder)drugId:1379 PA < 12 years BRONCHODILATORS
Asmanex Twisthaler (mometasone 110 mcg inhalation powder)drugId:2663 PA ≥ 12 years BRONCHODILATORS
Asmanex HFA (mometasone inhalation aerosol)drugId:5102 BRONCHODILATORS
asfotase alfadrugId:5300 PA ENZYMES
asenapine transdermal; See Table 24drugId:7354; See Table 71drugId:7355 PA ANTIPSYCHOTIC
asenapine sublingual tablet; See Table 24drugId:97; See Table 71drugId:4260 PA ANTIPSYCHOTIC
ascorbic acid powderdrugId:7339 PA ELECTROLYTES AND NUTRIENTS
ascorbic aciddrugId:96 ELECTROLYTES AND NUTRIENTS *
Asclera (polidocanol)drugId:2934 PA CARDIOVASCULAR ^
Asceniv (immune globulin IV, human-slra)drugId:7327 PA BIOLOGICAL
Asacol HD (mesalamine high dose delayed-release)drugId:1152 GI ANTI-INFLAMMATORY BP
Arzerra (ofatumumab vial)drugId:1270 PA CHEMOTHERAPY
artificial tearsdrugId:678 OPHTHALMIC PREPARATIONS *
ArthrotecdrugId:514 (diclofenac / misoprostol)drugId:514 PA < 60 years NONSTEROIDAL ANTI-INFLAMMATORY #
artemether / lumefantrinedrugId:95 PA > 24 units/365 days ANTIMALARIALS
arsenic trioxidedrugId:2697 CHEMOTHERAPY #
Arranon (nelarabine)drugId:1182 PA CHEMOTHERAPY
AromasindrugId:450 (exemestane)drugId:450 CHEMOTHERAPY #
Arnuity (fluticasone furoate inhalation powder)drugId:4760 PA BRONCHODILATORS
Armonair Digihaler (fluticasone propionate inhalation powder-Armonair Digihaler)drugId:7486 PA BRONCHODILATORS
armodafinil; See Table 50drugId:94; See Table 71drugId:7449 PA < 6 years and PA > 1 unit/day NARCOLEPSY AGENTS #
ArixtradrugId:904 (fondaparinux)drugId:904 ANTICOAGULANTS #
Aristospan (triamcinolone injection)drugId:1750 GLUCOCORTICOIDS
Aristada Initio (aripiprazole lauroxil 675 mg); See Table 24drugId:6861; See Table 71drugId:6860 PA < 6 years and PA > 1 injection/month ANTIPSYCHOTIC PD
Aristada (aripiprazole lauroxil 441 mg, 662 mg, 882 mg); See Table 24drugId:5240; See Table 71drugId:5241 PA < 6 years and PA > 1 injection/month ANTIPSYCHOTIC PD
Aristada (aripiprazole lauroxil 1,064 mg); See Table 24drugId:6300; See Table 71drugId:6301 PA < 6 years and PA > 1 injection/2 months ANTIPSYCHOTIC PD
aripiprazole tablet with sensor; See Table 24drugId:7230; See Table 71drugId:7231 PA ANTIPSYCHOTIC
aripiprazole tablet; See Table 24drugId:90; See Table 71drugId:4180 PA < 6 years and PA > 2 units/day ANTIPSYCHOTIC #
aripiprazole solution; See Table 24drugId:91; See Table 71drugId:4240 PA < 6 years or ≥ 18 years and PA > 25 mL/day ANTIPSYCHOTIC
aripiprazole orally disintegrating tablet; See Table 24drugId:92; See Table 71drugId:4220 PA ANTIPSYCHOTIC
aripiprazole lauroxil 675 mg; See Table 24drugId:6861; See Table 71drugId:6860 PA < 6 years and PA > 1 injection/month ANTIPSYCHOTIC PD
aripiprazole lauroxil 441 mg, 662 mg, 882 mg; See Table 24drugId:5240; See Table 71drugId:5241 PA < 6 years and PA > 1 injection/month ANTIPSYCHOTIC PD
aripiprazole lauroxil 1,064 mg; See Table 24drugId:6300; See Table 71drugId:6301 PA < 6 years and PA > 1 injection/2 months ANTIPSYCHOTIC PD
aripiprazole extended-release injection; See Table 24drugId:2717; See Table 71drugId:4200 PA ANTIPSYCHOTIC
ArimidexdrugId:69 (anastrozole)drugId:69 CHEMOTHERAPY #
Arikayce (amikacin liposome inhalation)drugId:7040 PA ANTIBIOTICS
Aricept (donepezil 5 mg, 23 mg tablet); See Table 56drugId:559; See Table 71drugId:7401 PA < 6 years and PA > 1 unit/day ALZHEIMER'S THERAPY #
Aricept (donepezil 10 mg tablet); See Table 56drugId:2422; See Table 71drugId:7399 PA < 6 years and PA > 2 units/day ALZHEIMER'S THERAPY #
arformoteroldrugId:88 PA BRONCHODILATORS BP
ArediadrugId:1474 (pamidronate)drugId:1474 ELECTROLYTES AND NUTRIENTS #
Arcalyst (rilonacept)drugId:1434 PA BIOLOGICAL
Arazlo (tazarotene lotion)drugId:7365 PA DERMATOLOGICAL
Arava (leflunomide) IMMUNOMODULATOR #
Aranesp (darbepoetin alfa)drugId:327 PA HEMATINIC AGENT
Aralast NP (alpha-1-proteinase inhibitor, human-Aralast NP) ENZYMES
Aralast (alpha-1-proteinase inhibitor, human-Aralast) ENZYMES
Aquadeks (multivitamins / minerals / folic acid / coenzyme Q10-Aquadeks)drugId:2385 PA HEMATINIC AGENT
Aquadeks (multivitamins / minerals / coenzyme Q10-Aquadeks)drugId:2380 PA HEMATINIC AGENT
Aptivus (tipranavir)drugId:1709 ANTIVIRALS
Aptiom (eslicarbazepine); See Table 20drugId:2953; See Table 71drugId:3380 PA ANTICONVULSANTS
Aptensio XR (methylphenidate extended-release-Aptensio XR); See Table 31drugId:5100; See Table 71drugId:5101 PA CEREBRAL STIMULANTS
Apriso (mesalamine extended-release)drugId:1150 GI ANTI-INFLAMMATORY BP
aprepitant trifold packdrugId:87 PA > 2 packs/28 days ANTIEMETICS BP
aprepitant injectable emulsiondrugId:6604 PA ANTIEMETICS
aprepitant 80 mgdrugId:85 PA > 4 capsules/28 days ANTIEMETICS #
aprepitant 40 mgdrugId:86 PA > 2 capsules/28 days ANTIEMETICS #
aprepitant 125 mg powder for oral suspensiondrugId:5726 PA > 6 units/28 days ANTIEMETICS
aprepitant 125 mg capsuledrugId:7498 PA > 2 capsules/28 days ANTIEMETICS
apremilastdrugId:2941 PA IMMUNOMODULATOR
apraclonidinedrugId:84 OPHTHALMIC PREPARATIONS #
apomorphine injectiondrugId:83 ANTIPARKINSON
apomorphine filmdrugId:7490 PA ANTIPARKINSON
Apokyn (apomorphine injection)drugId:83 ANTIPARKINSON
Aplenzin (bupropion hydrobromide extended-release); See Table 17drugId:395; See Table 71drugId:3640 PA < 6 years and PA > 1 unit/day ANTIDEPRESSANTS
apixabandrugId:2721 ANTICOAGULANTS
Apidra (insulin glulisine)drugId:810 DIABETIC AGENTS
Apexicon-E (diflorasone cream / emollient)drugId:520 PA GLUCOCORTICOIDS
apalutamidedrugId:6682 PA CHEMOTHERAPY
Apadaz (benzhydrocodone / acetaminophen)drugId:7234 PA OPIOID ANALGESICS
Anusol-HCdrugId:740 (hydrocortisone hemorrhoidal cream)drugId:740 GLUCOCORTICOIDS #
antithymocyte globulin, rabbitdrugId:1111 BIOLOGICAL
antithymocyte globulin, equinedrugId:1112 BIOLOGICAL
anti-inhibitor coagulant complex-Feiba VH ANTI-HEMOPHILIA AGENTS
anti-inhibitor coagulant complex-Feiba NF ANTI-HEMOPHILIA AGENTS
antihemophilic factor / von willebrand factor complex, human ANTI-HEMOPHILIA AGENTS
antihemophilic factor, recombinant-Xyntha ANTI-HEMOPHILIA AGENTS PD
antihemophilic factor, recombinant-Recombinate ANTI-HEMOPHILIA AGENTS
antihemophilic factor, recombinant pegylated-aucl-Jivi ANTI-HEMOPHILIA AGENTS
antihemophilic factor, recombinant pegylated-Adynovate ANTI-HEMOPHILIA AGENTS
antihemophilic factor, recombinant-Nuwiq ANTI-HEMOPHILIA AGENTS
antihemophilic factor, recombinant-Novoeight ANTI-HEMOPHILIA AGENTS
antihemophilic factor, recombinant-Kovaltry ANTI-HEMOPHILIA AGENTS
antihemophilic factor, recombinant-Kogenate ANTI-HEMOPHILIA AGENTS
antihemophilic factor, recombinant-Hemofil-M ANTI-HEMOPHILIA AGENTS
antihemophilic factor, recombinant-Helixate ANTI-HEMOPHILIA AGENTS
antihemophilic factor, recombinant-Advate ANTI-HEMOPHILIA AGENTS
antihemophilic factor, recombinant, single chain-Afstyla ANTI-HEMOPHILIA AGENTS
antihemophilic factor, recombinant, porcine sequence-Obizur ANTI-HEMOPHILIA AGENTS
antihemophilic factor, human-Monoclate-P ANTI-HEMOPHILIA AGENTS
antihemophilic factor, human-Koate-DVI ANTI-HEMOPHILIA AGENTS
antihemophilic factor, human-Humate-P ANTI-HEMOPHILIA AGENTS
Antara (fenofibrate 30 mg, 90 mg capsule)drugId:468 LIPID LOWERING AGENTS BP
AntabusedrugId:549 (disulfiram)drugId:549 ALCOHOL AND DRUG CESSATION AGENT #
Anoro (umeclidinium / vilanterol)drugId:2952 PA BRONCHODILATORS
Annovera (segesterone / ethinyl estradiol) CONTRACEPTIVES
anidulafungin ANTIBIOTICS
Angeliq (estradiol / drospirenone) HORMONE REPLACEMENT THERAPY
Androxy (fluoxymesterone) ANABOLIC STEROID
Androgel (testosterone 1% gel packet)drugId:2248 PA HORMONE REPLACEMENT THERAPY BP
Androgel (testosterone 1.62% gel packet, pump)drugId:2280 PA HORMONE REPLACEMENT THERAPY BP
Androderm (testosterone patch)drugId:1682 PA HORMONE REPLACEMENT THERAPY
AncobondrugId:861 (flucytosine)drugId:861 ANTIBIOTICS #
anastrozoledrugId:69 CHEMOTHERAPY #
Anascorp (centruroides immune F(ab’)2, equine) ANTIDOTES ^
anakinradrugId:66 PA IMMUNOMODULATOR
anagrelidedrugId:65 ANTIPLATELET AGENT #
Anafranil (clomipramine); See Table 17drugId:272; See Table 71drugId:4002 PA ANTIDEPRESSANTS
Anadrol-50 (oxymetholone) ANABOLIC STEROID
Amzeeq (minocycline 4% foam)drugId:7344 PA ANTIBIOTICS
Amrix (cyclobenzaprine extended-release)drugId:304 PA MUSCLE RELAXANT
Ampyra (dalfampridine)drugId:320 PA MULTIPLE SCLEROSIS AGENTS
ampicillin / sulbactamdrugId:64 ANTIBIOTICS #
ampicillin; See Table 35drugId:63; See Table 66drugId:2623 ANTIBIOTICS
amphotericin B liposome ANTIBIOTICS
amphotericin B lipid complex ANTIBIOTICS
amphotericin B ANTIBIOTICS
amphetamine sulfate; See Table 31drugId:4901; See Table 71drugId:4920 PA CEREBRAL STIMULANTS
amphetamine sulfate orally disintegrating tablet; See Table 31drugId:7235; See Table 71drugId:7236 PA CEREBRAL STIMULANTS
amphetamine salts; See Table 31drugId:60; See Table 71drugId:3100 PA < 3 years and PA > 3 units/day CEREBRAL STIMULANTS #
amphetamine salts extended-release-Mydayis; See Table 31drugId:6285; See Table 71drugId:6286 PA CEREBRAL STIMULANTS
amphetamine salts extended-release-Adderall XR; See Table 31drugId:59; See Table 71drugId:3000 PA < 3 years and PA > 2 units/day CEREBRAL STIMULANTS BP PD
amphetamine extended-release orally disintegrating tablet; See Table 31drugId:5360; See Table 71drugId:5361 PA CEREBRAL STIMULANTS
amphetamine extended-release 2.5 mg/mL oral suspension; See Table 31drugId:5383; See Table 71drugId:5384 PA CEREBRAL STIMULANTS
amphetamine extended-release 1.25 mg/mL oral suspension; See Table 31drugId:6600; See Table 71drugId:6601 PA CEREBRAL STIMULANTS
amoxicillin / clavulanate extended-releasedrugId:55 PA ANTIBIOTICS
amoxicillin / clavulanate chewable tablet, 200/28.5, 250/62.5, 400/57, 600/42.9 mg/5 mL suspension, tabletdrugId:6420 ANTIBIOTICS #
amoxicillin / clavulanate 125/31.25 mg/5 mL suspensiondrugId:54 PA ANTIBIOTICS
amoxicillindrugId:57 ANTIBIOTICS
amoxapine; See Table 17drugId:56; See Table 71drugId:4001 PA < 6 years ANTIDEPRESSANTS
Amondys 45 (casimersen)drugId:7878 PA BIOLOGICAL
Ammonul (sodium phenylacetate / sodium benzoate) ELECTROLYTES AND NUTRIENTS #
ammonium lactate DERMATOLOGICAL
amlodipine suspensiondrugId:7260 PA CARDIOVASCULAR
amlodipine / valsartan / hydrochlorothiazidedrugId:50 CARDIOVASCULAR #
amlodipine / valsartandrugId:48 CARDIOVASCULAR #
amlodipine / telmisartandrugId:1661 PA CARDIOVASCULAR
amlodipine / olmesartan / hydrochlorothiazidedrugId:1969 PA CARDIOVASCULAR
amlodipine / olmesartandrugId:46 CARDIOVASCULAR #
amlodipine / benazeprildrugId:44 CARDIOVASCULAR #
amlodipine / atorvastatin; See Table 13drugId:42; See Table 18drugId:43 PA CARDIOVASCULAR/STATIN
amlodipinedrugId:41 CARDIOVASCULAR #
amivantamab-vmjwdrugId:7982 PA CHEMOTHERAPY
amitriptyline tablet; See Table 17drugId:39; See Table 71drugId:4000 PA < 6 years ANTIDEPRESSANTS
amitriptyline powder; See Table 17drugId:6368; See Table 71drugId:6369 PA ANTIDEPRESSANTS
amitriptyline / perphenazine; See Table 24drugId:6320; See Table 71drugId:1512 PA < 6 years ANTIPSYCHOTIC
amitriptyline / chlordiazepoxide; See Table 69drugId:7366; See Table 71drugId:40 PA < 6 years ANTIDEPRESSANTS
Amitiza (lubiprostone)drugId:1110 PA CONSTIPATION AGENTS BP
amiodaronedrugId:37 CARDIOVASCULAR
aminosalicylic aciddrugId:2500 TB PREPARATIONS
aminophylline BRONCHODILATORS
aminolevulinic acid CHEMOTHERAPY ^
aminocaproic acid HEMATINIC AGENT BP
amino acid and electrolyte IV infusion ELECTROLYTES AND NUTRIENTS
amiloride / hydrochlorothiazidedrugId:34 CARDIOVASCULAR
amiloridedrugId:33 CARDIOVASCULAR
amikacin liposome inhalationdrugId:7040 PA ANTIBIOTICS
amikacindrugId:32 ANTIBIOTICS
amifostinedrugId:2670 ANTIDOTES #
amifampridinedrugId:7041 PA POTASSIUM CHANNEL BLOCKER
Amicar (aminocaproic acid) HEMATINIC AGENT BP
Amerge (naratriptan)drugId:1175 PA TRIPTAN
Ameluz (aminolevulinic acid) CHEMOTHERAPY ^
amcinonide cream, lotiondrugId:31 PA GLUCOCORTICOIDS
ambrisentandrugId:30 PA CARDIOVASCULAR
Ambisome (amphotericin B liposome) ANTIBIOTICS
Ambien CR (zolpidem extended-release tablet); See Table 15drugId:1934; See Table 71drugId:4345 PA < 6 years and PA > 1 unit/day SEDATIVES #
Ambien (zolpidem 5 mg tablet); See Table 15drugId:1933; See Table 71drugId:4344 PA < 6 years and PA > 1.5 units/day SEDATIVES #
Ambien (zolpidem 10 mg tablet); See Table 15drugId:1932; See Table 71drugId:4342 PA < 6 years and PA > 1 unit/day SEDATIVES #
AmaryldrugId:931 (glimepiride)drugId:931 DIABETIC AGENTS #
amantadine immediate-release capsule, solution, tabletdrugId:29 ANTIPARKINSON
amantadine extended-release tabletdrugId:7006 PA ANTIPARKINSON
amantadine extended-release capsuledrugId:6402 PA ANTIPARKINSON
Alvesco (ciclesonide inhaler)drugId:230 PA BRONCHODILATORS
Alunbrig (brigatinib)drugId:6180 PA CHEMOTHERAPY
aluminum hydroxidedrugId:28 ANTACIDS *
aluminum carbonate GASTROINTESTINAL AGENT *
Altreno (tretinoin 0.05% lotion)drugId:6900 PA DERMATOLOGICAL
Altoprev (lovastatin extended-release)drugId:1107 PA LIPID LOWERING AGENTS
AltacedrugId:2588 (ramipril)drugId:2588 CARDIOVASCULAR #
Alrex (loteprednol 0.2%)drugId:1105 OPHTHALMIC PREPARATIONS
Alprolix (factor IX recombinant, Fc fusion protein) ANTI-HEMOPHILIA AGENTS
alprazolam powder; See Table 69drugId:27; See Table 71drugId:4360 PA BENZODIAZEPINES
alprazolam; See Table 69drugId:25; See Table 71drugId:4358 PA < 6 years BENZODIAZEPINES #
alprazolam orally disintegrating tablet; See Table 69drugId:24; See Table 71drugId:4357 PA BENZODIAZEPINES
alprazolam extended-release; See Table 69drugId:26; See Table 71drugId:4359 PA < 6 years and PA > 2 units/day BENZODIAZEPINES #
Alphanine SD (factor IX, human) ANTI-HEMOPHILIA AGENTS
Alphanate (antihemophilic factor / von willebrand factor complex, human) ANTI-HEMOPHILIA AGENTS
Alphagan P (brimonidine 0.1%, 0.15% eye drops)drugId:2505 OPHTHALMIC PREPARATIONS BP
alpha-1-proteinase inhibitor, human-Zemaira ENZYMES
alpha-1-proteinase inhibitor, human-Prolastin ENZYMES
alpha-1-proteinase inhibitor, human-Glassia ENZYMES
alpha-1-proteinase inhibitor, human-Aralast NP ENZYMES
alpha-1-proteinase inhibitor, human-Aralast ENZYMES
alpelisibdrugId:7225 PA CHEMOTHERAPY
AloxidrugId:1473 (palonosetron 0.25 mg/5 mL injection)drugId:1473 PA > 2 units/28 days ANTIEMETICS #
alosetrondrugId:19 PA GASTROINTESTINAL AGENT
Alora (estradiol-Alora) HORMONE REPLACEMENT THERAPY
AloprimdrugId:7545 (allopurinol sodium)drugId:7545 CHEMOTHERAPY #
Alomide (lodoxamide)drugId:1095 OPHTHALMIC PREPARATIONS
alogliptindrugId:2784 PA DIABETIC AGENTS BP
alogliptin / pioglitazonedrugId:2783 PA DIABETIC AGENTS BP
alogliptin / metformindrugId:2782 PA DIABETIC AGENTS BP
Alocril (nedocromil)drugId:1180 OPHTHALMIC PREPARATIONS
almotriptandrugId:18 PA TRIPTAN
allopurinol sodiumdrugId:7545 CHEMOTHERAPY #
allopurinoldrugId:17 GOUT AGENTS #
Alkindi (hydrocortisone sprinkle capsule)drugId:7639 PA GLUCOCORTICOIDS
AlkerandrugId:5504 (melphalan tablet)drugId:5504 CHEMOTHERAPY #
AlkerandrugId:1138 (melphalan hydrochloride injection)drugId:1138 CHEMOTHERAPY #
aliskirendrugId:13 PA CARDIOVASCULAR BP
aliskiren / hydrochlorothiazidedrugId:14 CARDIOVASCULAR
alirocumabdrugId:5119 PA LIPID LOWERING AGENTS
Aliqopa (copanlisib)drugId:6500 PA CHEMOTHERAPY
Alimta (pemetrexed)drugId:1492 CHEMOTHERAPY
Align (bifidobacterium infantis)drugId:6200 PA ≥ 19 years GASTROINTESTINAL AGENT
alglucosidase alfadrugId:11 PA ENZYMES
alfuzosin extended-releasedrugId:10 URINARY ANTISPASMODICS #
alendronate tabletdrugId:7 ELECTROLYTES AND NUTRIENTS #
alendronate solutiondrugId:2796 ELECTROLYTES AND NUTRIENTS
alendronate / cholecalciferoldrugId:9 PA ELECTROLYTES AND NUTRIENTS
alemtuzumab 30 mgdrugId:6110 CHEMOTHERAPY
alemtuzumab 12 mgdrugId:4782 PA MULTIPLE SCLEROSIS AGENTS ^
alectinibdrugId:5221 PA CHEMOTHERAPY
Alecensa (alectinib)drugId:5221 PA CHEMOTHERAPY
Aldurazyme (laronidase)drugId:1026 PA ENZYMES
AldaradrugId:783 (imiquimod 5% cream)drugId:783 DERMATOLOGICAL #
AldactonedrugId:1892 (spironolactone tablet)drugId:1892 ALDOSTERONE ANTAGONISTS #
AldactazidedrugId:1893 (spironolactone / hydrochlorothiazide)drugId:1893 CARDIOVASCULAR #
alclometasone cream, ointmentdrugId:4 GLUCOCORTICOIDS
alcaftadinedrugId:2173 ANTIHISTAMINES
albuterol syrup, tabletdrugId:2193 BRONCHODILATORS
albuterol inhaler-VentolindrugId:3 PA BRONCHODILATORS
albuterol inhaler-ProventildrugId:2 PA BRONCHODILATORS
albuterol inhaler-Proair HFAdrugId:1 BRONCHODILATORS BP
albuterol inhalation solutiondrugId:168 BRONCHODILATORS #
albuterol inhalation powder-Proair RespiclickdrugId:5109 PA BRONCHODILATORS
albuterol inhalation powder-Proair DigihalerdrugId:7352 PA BRONCHODILATORS
albuterol / ipratropium inhalation spraydrugId:2557 BRONCHODILATORS
albuterol / ipratropium inhalation solutiondrugId:835 BRONCHODILATORS
albumin, human solutions PLASMA PROTEINS
AlbenzadrugId:166 (albendazole)drugId:166 ANTIPARASITICS #
albendazoledrugId:166 ANTIPARASITICS #
Akynzeo (netupitant / palonosetron capsule)drugId:4761 PA > 2 capsules/28 days ANTIEMETICS
Akynzeo (fosnetupitant / palonosetron injection)drugId:6620 PA > 2 vials/28 days ANTIEMETICS
Akten (lidocaine ophthalmic gel) OPHTHALMIC PREPARATIONS
Aklief (trifarotene)drugId:7369 PA DERMATOLOGICAL
Ajovy (fremanezumab-vfrm for migraine prophylaxis)drugId:7000 PA BIOLOGICAL PD
Airduo Respiclick (fluticasone / salmeterol inhalation powder-Airduo Respiclick)drugId:6120 PA BRONCHODILATORS
Airduo Digihaler (fluticasone / salmeterol inhalation powder-Airduo Digihaler)drugId:7485 PA BRONCHODILATORS
Aimovig (erenumab-aooe)drugId:6661 PA BIOLOGICAL
A-HydrocortdrugId:730 (hydrocortisone injection)drugId:730 GLUCOCORTICOIDS #
AgrylindrugId:65 (anagrelide)drugId:65 ANTIPLATELET AGENT #
agalsidase betadrugId:162 PA ENZYMES
Afstyla (antihemophilic factor, recombinant, single chain-Afstyla) ANTI-HEMOPHILIA AGENTS
Afrezza (insulin human inhalation powder)drugId:4900 PA DIABETIC AGENTS
Afluria (influenza virus vaccine-Afluria)drugId:2046 BIOLOGICAL 1
aflibercept OPHTHALMIC PREPARATIONS ^
Afinitor Disperz (everolimus tablets for oral suspension); See Table 20drugId:6880; See Table 57drugId:2795 PA CHEMOTHERAPY BP
Afinitor (everolimus 2.5 mg, 5 mg, 7.5 mg, 10 mg); See Table 20drugId:448; See Table 57drugId:1954 PA CHEMOTHERAPY BP
afatinibdrugId:2843 PA CHEMOTHERAPY
Adzenys XR-ODT (amphetamine extended-release orally disintegrating tablet); See Table 31drugId:5360; See Table 71drugId:5361 PA CEREBRAL STIMULANTS
Adzenys ER (amphetamine extended-release 1.25 mg/mL oral suspension); See Table 31drugId:6600; See Table 71drugId:6601 PA CEREBRAL STIMULANTS
Adynovate (antihemophilic factor, recombinant pegylated-Adynovate) ANTI-HEMOPHILIA AGENTS
Advate (antihemophilic factor, recombinant-Advate) ANTI-HEMOPHILIA AGENTS
Advair (fluticasone / salmeterol inhalation powder-Advair)drugId:896 BRONCHODILATORS BP
Advair (fluticasone / salmeterol inhalation aerosol)drugId:897 BRONCHODILATORS
AdrucildrugId:875 (fluorouracil injection)drugId:875 CHEMOTHERAPY #
AdriamycindrugId:571 (doxorubicin)drugId:571 CHEMOTHERAPY #
Adrenalin (epinephrine injection)drugId:606 ADRENERGICS
ado-trastuzumabdrugId:2781 PA CHEMOTHERAPY
Admelog (insulin lispro-Admelog)drugId:6660 PA DIABETIC AGENTS
Adlyxin (lixisenatide)drugId:5760 PA DIABETIC AGENTS
Adhansia XR (methylphenidate extended-release-Adhansia XR); See Table 31drugId:7232; See Table 71drugId:7233 PA CEREBRAL STIMULANTS
adenovirus live vaccine delayed-release oral tabletsdrugId:2837 BIOLOGICAL
Adempas (riociguat)drugId:2883 PA CARDIOVASCULAR
adefovirdrugId:161 PA > 1 unit/day ANTIVIRALS #
Adderall XR (amphetamine salts extended-release-Adderall XR); See Table 31drugId:59; See Table 71drugId:3000 PA < 3 years and PA > 2 units/day CEREBRAL STIMULANTS BP PD
Adderall (amphetamine salts); See Table 31drugId:60; See Table 71drugId:3100 PA < 3 years and PA > 3 units/day CEREBRAL STIMULANTS #
Adcirca (tadalafil-Adcirca)drugId:1920 PA CARDIOVASCULAR
Adcetris (brentuximab)drugId:2374 PA CHEMOTHERAPY
adapalene cream, 0.3% gel pump, lotiondrugId:159 PA DERMATOLOGICAL BP
adapalene 0.1%, 0.3% gel tubedrugId:7678 PA DERMATOLOGICAL
adapalene / benzoyl peroxidedrugId:160 PA DERMATOLOGICAL
adalimumabdrugId:158 PA IMMUNOMODULATOR PD
AdalatdrugId:1213 (nifedipine tablet)drugId:1213 CARDIOVASCULAR #
Adakveo (crizanlizumab-tmca)drugId:7326 PA HEMATOLOGIC
Adacel (tetanus toxoids / diphtheria / acellular pertussis vaccine)drugId:539 BIOLOGICAL 1
Aczone (dapsone gel)drugId:325 PA DERMATOLOGICAL
acyclovir suspensiondrugId:7997 ANTIVIRALS BP
acyclovir ointmentdrugId:156 ANTIVIRALS #
acyclovir injectiondrugId:2744 ANTIVIRALS
acyclovir creamdrugId:157 ANTIVIRALS BP
acyclovir capsule, tabletdrugId:155 ANTIVIRALS
acyclovir buccal tabletdrugId:2945 PA ANTIVIRALS
acyclovir / hydrocortisonedrugId:1973 DERMATOLOGICAL
Acuvail (ketorolac 0.45% ophthalmic solution)drugId:999 OPHTHALMIC PREPARATIONS
Acular LSdrugId:2271 (ketorolac 0.4% ophthalmic solution)drugId:2271 OPHTHALMIC PREPARATIONS #
AculardrugId:2270 (ketorolac 0.5% ophthalmic solution)drugId:2270 OPHTHALMIC PREPARATIONS #
ActosdrugId:1534 (pioglitazone)drugId:1534 DIABETIC AGENTS #
Actoplus MetdrugId:1536 (pioglitazone / metformin)drugId:1536 DIABETIC AGENTS #
Actonel (risedronate)drugId:1439 PA ELECTROLYTES AND NUTRIENTS
Activella (estradiol / norethindrone-Activella) HORMONE REPLACEMENT THERAPY #
Actiq (fentanyl transmucosal system)drugId:844 PA OPIOID ANALGESICS
Actimmune (interferon gamma-1b)drugId:829 CHEMOTHERAPY
ActigalldrugId:1774 (ursodiol 300 mg capsule)drugId:1774 BILE THERAPY #
Acthib (haemophilus B conjugate vaccine-Acthib)drugId:693 BIOLOGICAL 1
Acthar (corticotropin)drugId:294 PA HORMONE AGENTS
Actemra (tocilizumab COVID EUA – June 24, 2021) COVID - 19 related Treatments and Vaccines COVID H
Actemra (tocilizumab)drugId:1719 PA IMMUNOMODULATOR
acrivastine / pseudoephedrinedrugId:1608 PA DECONGESTANT
aclidinium / formoteroldrugId:7330 PA BRONCHODILATORS
aclidiniumdrugId:2649 BRONCHODILATORS
acitretindrugId:153 DERMATOLOGICAL #
Aciphex Sprinkle (rabeprazole delayed-release capsule)drugId:2882 PA PROTON PUMP INHIBITORS
AciphexdrugId:1624 (rabeprazole delayed-release tablet)drugId:1624 PA > 1 unit/day PROTON PUMP INHIBITORS #
acetylcysteine injection ANTIDOTES ^
acetylcysteine MUCOLYTICS
acetylcholine chloridedrugId:1982 OPHTHALMIC PREPARATIONS
acetohydroxamic acid ANTIBIOTICS
acetic acid / hydrocortisonedrugId:149 OTIC PREPARATIONS
acetic aciddrugId:148 OTIC PREPARATIONS
acetazolamidedrugId:147 CARDIOVASCULAR
acetaminophendrugId:145 PA > 4 g/day ANALGESICS *
acetaminophen / codeinedrugId:146 PA < 12 years and PA > 4 g/day acetaminophen and PA > 360 mg/day codeine OPIOID ANALGESICS #
Acetadote (acetylcysteine injection) ANTIDOTES ^
acebutololdrugId:144 CARDIOVASCULAR
AccureticdrugId:1621 (quinapril / hydrochlorothiazide)drugId:1621 CARDIOVASCULAR #
AccuprildrugId:1620 (quinapril)drugId:1620 CARDIOVASCULAR #
AccunebdrugId:168 (albuterol inhalation solution)drugId:168 BRONCHODILATORS #
Accrufer (ferric maltol)drugId:7918 PA HEMATINIC AGENT
Accolate (zafirlukast)drugId:1816 PA BRONCHODILATORS
acarbosedrugId:143 DIABETIC AGENTS #
Acanya (clindamycin / benzoyl peroxide-Acanya)drugId:262 PA DERMATOLOGICAL
acamprosatedrugId:142 ALCOHOL AND DRUG CESSATION AGENT
acalabrutinibdrugId:6483 PA CHEMOTHERAPY
Abstral (fentanyl sublingual tablet)drugId:2157 PA OPIOID ANALGESICS
Absorica LD (isotretinoin micronized)drugId:7368 PA DERMATOLOGICAL
Absorica (isotretinoin-Absorica)drugId:2881 PA DERMATOLOGICAL BP
Abraxane (paclitaxel injectable suspension)drugId:1468 CHEMOTHERAPY
abobotulinumtoxinAdrugId:141 PA BIOLOGICAL
abiraterone 250 mg, 500 mgdrugId:2297 PA CHEMOTHERAPY BP
abiraterone 125 mgdrugId:6824 PA CHEMOTHERAPY
Abilify Mycite (aripiprazole tablet with sensor); See Table 24drugId:7230; See Table 71drugId:7231 PA ANTIPSYCHOTIC
Abilify Maintena (aripiprazole extended-release injection); See Table 24drugId:2717; See Table 71drugId:4200 PA ANTIPSYCHOTIC
Abilify (aripiprazole tablet); See Table 24drugId:90; See Table 71drugId:4180 PA < 6 years and PA > 2 units/day ANTIPSYCHOTIC #
abemaciclibdrugId:6410 PA CHEMOTHERAPY
Abelcet (amphotericin B lipid complex) ANTIBIOTICS
Abecma (idecabtagene vicleucel)drugId:7877 PA CHEMOTHERAPY CO ^
abataceptdrugId:140 PA IMMUNOMODULATOR
abaloparatidedrugId:6362 PA HORMONE AGENTS
abacavir / lamivudine / zidovudinedrugId:139 ANTIVIRALS #
abacavir / lamivudinedrugId:138 ANTIVIRALS #
abacavir / dolutegravir / lamivudinedrugId:4642 ANTIVIRALS PD
abacavirdrugId:137 ANTIVIRALS #

Note: Any drug that does not appear on the List requires prior authorization.


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Last updated 11/19/21

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