Aetna Medicare Rx offered by SilverScript Employer PDP
for Aetna Open Access (Basic - JN)
2024 Formulary
(List of Covered Drugs)
PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION
ABOUT THE DRUGS WE COVER IN THIS PLAN
This formulary was updated on 10/27/2023. For more recent information or other questions, please
contact Customer Care at 1-833-271-9775, 24 hours a day, 7 days a week. TTY users should call
711, or visit Caremark.com.
Formulary ID Number: 24194
When this drug list (formulary) refers to “we,” “us,” or “our,” it means SilverScript
®
Insurance
Company. When it refers to “plan” or “our plan,” it means Aetna Medicare Rx offered by
SilverScript.
This document includes a list of the drugs (formulary) for our plan, which is current as of January 1,
2024. For an updated formulary, please contact us. Our contact information, along with the date we
last updated the formulary, appears on the front and back cover pages.
You must generally use network pharmacies to use your prescription drug benefit. Benefits,
formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2025, and
from time to time during the year.
Y0001_GRP_5807_2024_C_9368_1176_816
10/27/2023
P.O. Box 30006, Pittsburgh, PA 15222-0330
l
What is the Aetna Medicare Rx offered by SilverScript Formulary?
A formulary is a list of covered drugs selected by Aetna Medicare Rx offered by SilverScript in
consultation with a team of health care providers, which represents the prescription therapies
believed to be a necessary part of a quality treatment program. Aetna Medicare Rx offered by
SilverScript will generally cover the drugs listed in our formulary as long as the drug is medically
necessary, the prescription is filled at an Aetna Medicare Rx offered by SilverScript network
pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions,
please review your Evidence of Coverage.
Please note: Aetna Medicare Rx offered by SilverScript may provide additional coverage for
prescription drugs not included in your Medicare Part D benefit. For more information about your
share of the cost or which prescription drugs may or may not be covered, please call Customer
Care, or refer to your Evidence of Coverage.
Some of the additional coverage provided by FEHBP covers certain prescription drugs not covered
under Medicare Part D. Payments made for these prescription drugs will not count toward your
initial coverage limit or total out-of-pocket costs. These prescription drugs are not subject to the
appeals and exceptions process.
Please contact Customer Care for any questions regarding your supplemental benefits.
Can the Formulary (drug list) change?
Most changes in drug coverage happen on January 1, but Aetna Medicare Rx offered by
SilverScript may add or remove drugs on the Drug List during the year, move them to different
cost-sharing tiers, or add new restrictions. We must follow Medicare rules in making these
changes.
Changes that can affect you this year: In the below cases, you will be affected by coverage
changes during the year:
· New generic drugs. When adding a new generic drug, we may move the brand drug to a
different cost-sharing tier or add new restrictions. If you are currently taking that
brand-name drug, we may not tell you in advance before we make that change, but we
will later provide you with information about the specific change(s) we have made.
o If we make such a change, you or your prescriber can ask us to make an exception
and continue to cover the brand-name drug for you. The notice we provide you will
also include information on how to request an exception, and you can find
information in the section below titled “How do I request an exception to the Aetna
Medicare Rx offered by SilverScript Formulary?”
· Drugs removed from the market. If the Food and Drug Administration deems a drug on
our formulary to be unsafe or the drug’s manufacturer removes the drug from the
market, we may immediately remove the drug from our formulary and provide notice to
members who take the drug.
· Other changes. We may make changes based on new clinical guidelines. If we remove
drugs from our formulary, add quantity limits, prior authorization, and/or step therapy
restrictions on a drug; or move a drug to a higher cost-sharing tier, we must notify
affected members of the change at least 30 days before the change becomes effective
10/27/2023 II
or at the time the member requests a refill of the drug, at which time the member will
receive a 30-day supply of the drug.
o If we make these other changes, you or your prescriber can ask us to make an
exception and continue to cover the brand-name drug for you. The notice we
provide you will also include information on how to request an exception, and you
can find information in the section below titled “How do I request an exception to the
Aetna Medicare Rx offered by SilverScript Formulary?”
Changes that will not affect you if you are currently taking the drug. Generally, if you are taking
a drug on our 2024 formulary that was covered at the beginning of the year, we will not discontinue
or reduce coverage of the drug during the 2024 coverage year except as described above. This
means these drugs will remain available at the same cost-sharing and with no new restrictions for
those members taking them for the remainder of the coverage year. You will not get direct notice
this year about changes that do not affect you. However, on January 1 of the next year, such
changes would affect you, and it is important to check the Drug List for the new benefit year for any
changes to drugs.
This formulary is current as of January 1, 2024. To get updated information about the drugs
covered by our plan, please contact us at the number on your member ID card. Our contact
information also appears on the front and back cover pages.
How do I use the Formulary?
There are two ways to find your drug within the formulary:
Alphabetical Listing
If you are not sure what category to look under, you should look for your drug in the Index at
the back of this document. The Index provides an alphabetical list of all of the drugs
included in this document. Both brand-name drugs and generic drugs are listed in the
Index. Next to your drug, you will see the page number where you can find coverage
information. Turn to the page listed in the Index and find the name of your drug in the first
column of the list.
Medical Condition
The formulary begins on page 1. The drugs in this formulary are grouped into categories
depending on the type of medical conditions that they are used to treat. For example, drugs
used to treat a heart condition are listed under the category “Cardiovascular.” If you know
what your drug is used for, look for the category name in the list that begins on page 1. Then
look under the category name for your drug.
What are generic drugs?
Our plan covers both brand-name drugs and generic drugs. A generic drug is approved by the FDA
as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less
than brand-name drugs.
10/27/2023 III
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. These requirements
and limits may include:
· Prior Authorization (PA): Some drugs require you or your physician to get prior
authorization. You must get an approval from us before you can get your prescription
filled. If you don’t get approval, we may not cover the drug.
· Quantity Limits (QL): For certain drugs, there is a quantity limit in the amount of the drug
that we will cover. For example, our plan provides up to 30 tablets per 30-day
prescription for atorvastatin. This may be in addition to a standard one-month or
three-month supply.
· Step Therapy (ST): In some cases, our 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
DrugB unless you try Drug A first. If Drug A does not work for you, Aetna Medicare Rx
offered by SilverScript will then cover DrugB.
You can find out if your drug has any additional requirements or limits by looking in the formulary
that begins on page 1. You may ask us to send you a copy. Our contact information, along with the
date we last updated the formulary, appears on the front and back cover pages.
You can ask Aetna Medicare Rx offered by SilverScript to make an exception to these restrictions
or limits or for a list of other, similar drugs that may treat your health condition. See the section,
“How do I request an exception to the Aetna Medicare Rx offered by SilverScript Formulary?” for
information about how to request an exception.
What if my drug is not on the Formulary?
If your drug is not included in this formulary (list of covered drugs), you should first contact
Customer Care and ask if your drug is covered.
If you learn that our plan does not cover your drug, you have two options:
§ You can ask Customer Care for a list of similar drugs that are covered by our plan. When you
receive the list, show it to your doctor and ask them to prescribe a similar drug that is
covered by our plan.
§ You can ask us to make an exception and cover your drug. See below for information about
how to request an exception.
How do I request an exception to the Aetna Medicare Rx offered by SilverScript Formulary?
You can ask us to make an exception to our coverage rules. There are several types of exceptions
that you can ask us to make:
§ You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be
covered at a pre-determined cost-sharing level and you would not be able to ask us to
provide the drug at a lower cost-sharing level.
10/27/2023 IV
§ You can ask us to cover a formulary drug at a lower cost-sharing level unless the drug is on
the Specialty tier. If approved, this would lower the amount you must pay for your drug.
§ You can ask us to waive coverage restrictions or limits on your drug. For example, for
certain drugs our plan limits the amount of the drug that we will cover. If your drug has a
quantity limit, you can ask us to waive the limit and cover a greater amount.
Generally, we will only approve your request for an exception if the alternative drug is included on
the plan’s formulary or if the lower cost-sharing drug or additional utilization restrictions would not
be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact us to ask for an initial coverage decision for a formulary, tiering, or utilization
restriction exception. When you request a formulary, tiering, or utilization restriction exception,
you should submit a statement from your prescriber or physician supporting your request.
Generally, we must make our decision within 72 hours of getting your prescriber’s supporting
statement. You can request an expedited (fast) exception if you or your doctor believe that your
health could be seriously harmed by waiting up to 72 hours for a decision. If your request to
expedite is granted, we must give you a decision no later than 24 hours after we get a supporting
statement from your doctor or other prescriber.
What do I do before I can talk to my doctor about changing my drugs or requesting an
exception?
As a new or continuing member in our plan, you may be taking drugs that are not on our formulary.
Or you may be taking a drug that is on our formulary but your ability to get it is limited. For example,
you may need a prior authorization from us before you can fill your prescription. You should talk to
your doctor to decide if you should switch to an appropriate drug that we cover or request a
formulary exception so that we will cover the drug you take. While you talk to your doctor to
determine the right course of action for you, we may cover your drug in certain cases during the
first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we
will cover a temporary 30-day supply. If your prescription is written for fewer than 30 days, we’ll
allow refills to provide up to a maximum 30-day supply of medication. After your first 30-day
supply, we will not pay for these drugs, even if you have been a member of the plan less than 90
days.
If you are a resident of a long-term care facility and you need a drug that is not on our formulary or
if your ability to get your drugs is limited, but you are past the first 90 days of membership in our
plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception.
If you experience a change in your level of care, such as a move from a home to a long-term care
setting, and need a drug that is not on our formulary (or if your ability to get your drugs is limited),
we may cover a one-time temporary supply from a network pharmacy for up to 31 days, unless you
have a prescription for fewer days. You should use the plan’s exception process if you wish to have
continued coverage of the drug after the temporary supply is finished.
10/27/2023 V
Initial Coverage Stage Copayment/Coinsurance Levels
The plan has five Cost-Sharing Tiers
Every drug on the plan’s drug list is in one of five cost-sharing tiers. In general, the higher the
cost-sharing tier number, the higher your cost for the drug.
· Cost-Sharing Tier 1: Preferred Generic
· Cost-Sharing Tier 2: Generic
· Cost-Sharing Tier 3: Preferred Brand
· Cost-Sharing Tier 4: Non-Preferred Brand
· Cost-Sharing Tier 5: Specialty
To find out which cost-sharing tier your drug is in, look it up in the plan’s drug list that begins on
page1.
Your share of the cost when you get a one-month supply of a covered Part D prescription drug
before your Individual maximum out-of-pocket is met:
Preferred
Network Retail
Pharmacy
(Up to a 30-day
supply)
Standard
Network Retail
Pharmacy or
Mail-Order
(Up to a 30-day
supply)
Preferred
Mail-Order
Pharmacy
(Up to a 30-day
supply)
Long-Term Care
(LTC) Pharmacy
(Up to a 31-day
supply)
Tier 1:
Preferred Generic
$0 $0 $0 $0
Tier 2:
Generic
$4.00 $5.00 $4.00 $5.00
Tier 3:
Preferred Brand
$40.00 $40.00 $40.00 $40.00
Tier 4:
Non-Preferred
Brand
$100.00 $100.00 $100.00 $100.00
Tier 5:
Specialty
25% of total cost
Maximum
$150.00
25% of total cost
Maximum
$150.00
25% of total cost
Maximum
$150.00
25% of total cost
Maximum
$150.00
You won’t pay more than $35 for a one-month supply of each covered insulin product regardless of
the cost-sharing tier.
Please note: Your plan includes a $0 copay supplemental benefit which covers some Part D and
some non-Part D drugs at a $0 copay. To view medications that have a $0 copay, visit
AetnaFeds.com/Pharmacy.
10/27/2023 VI
Your share of the costs will vary by tier and coverage phase. You will pay a copay amount or
coinsurance percentage for each tier. Look in Chapter 4 of the 2024 Evidence of Coverage for your
cost shares.
For more information
For more detailed information about your Aetna Medicare Rx offered by SilverScript prescription
drug coverage, please review your Evidence of Coverage and other plan materials.
If you have questions about our plan, please contact us at the number on the back of your member
ID card. Our contact information, along with the date we last updated the formulary, appears on the
front and back cover pages.
If you have general questions about Medicare Part D prescription drug coverage, please call
Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should
call 1-877-486-2048. Or visit www.medicare.gov.
Aetna Medicare Rx offered by SilverScript’s Formulary
The formulary that begins on page 1 provides coverage information about the drugs covered by our
plan. If you have trouble finding your drug in the list, turn to the Index at the back of this book.
The first column of the chart lists the drug name. Brand-name drugs are capitalized (e.g.,
SYNTHROID) and generic drugs are listed in lower-case italics (e.g., levothyroxine).
The information in the Requirements/Limits column tells you if Aetna Medicare Rx offered by
SilverScript has any special requirements for coverage of your drug.
PA Prior Authorization
QL Drug has Quantity Limits
ST Step Therapy required
MO Available at our mail-order pharmacies
ACS Available at CVS Specialty Pharmacy
HRM High Risk Medication
LA
Limited Access. This prescription may be available only at certain
pharmacies.
B/D
This drug may be covered under Medicare Part B or D depending
upon the circumstances. Information may need to be submitted
describing the use and setting of the drug to make the
determination.
10/27/2023 VII
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 1
Drug Name
Drug
Tier
Requirements/Limits
ANALGESICS
GOUT
allopurinol sodium injection
2
ALLOPURINOL TABLET 200MG
4
MO
allopurinol tablet 100mg, 300mg
1
MO
ALOPRIM
4
COLCHICINE CAPSULE
3
QL (60 EA per 30 days) MO
colchicine tablet 0.6mg
2
QL (120 EA per 30 days) MO
COLCRYS
4
QL (120 EA per 30 days) MO
febuxostat
2
ST MO
KRYSTEXXA
5
QL (2 ML per 28 days) PA LA; ACS
MITIGARE
3
QL (60 EA per 30 days) MO
probenecid
2
MO
probenecid/colchicine
2
MO
ULORIC
4
ST MO
ZYLOPRIM
4
MO
MISCELLANEOUS
acetaminophen injection solution 10mg/ml
2
ALLZITAL
4
QL (180 EA per 30 days) PA MO
bupap tablet 50mg; 300mg
2
QL (180 EA per 30 days) PA
butalbital/acetaminophen/caffeine
2
QL (180 EA per 30 days) PA MO
butalbital/acetaminophen capsule
2
QL (180 EA per 30 days) PA MO
butalbital/acetaminophen tablet 325mg; 50mg
2
QL (180 EA per 30 days) PA MO
butalbital/acetaminophen tablet 300mg; 50mg
5
QL (180 EA per 30 days) PA MO
butalbital/aspirin/caffeine
2
QL (180 EA per 30 days) PA MO
clonidine hcl injection 100mcg/ml, 500mcg/ml
2
DURACLON
4
ESGIC TABLET
4
QL (180 EA per 30 days) PA MO
esgic capsule
2
QL (180 EA per 30 days) PA
FIORICET CAPSULE 50MG; 300MG; 40MG
4
QL (180 EA per 30 days) PA MO
PRIALT INJECTION 500MCG/20ML, 500MCG/5ML
4
B/D MO
PRIALT INJECTION 100MCG/ML
5
B/D MO
tencon tablet 50mg; 325mg
2
QL (180 EA per 30 days) PA
zebutal
2
QL (180 EA per 30 days) PA
NSAIDS
ARTHROTEC 50
4
QL (120 EA per 30 days) MO
ARTHROTEC 75
4
QL (90 EA per 30 days) MO
CALDOLOR
4
CELEBREX CAPSULE 400MG
4
QL (30 EA per 30 days) ST MO
CELEBREX CAPSULE 100MG, 200MG, 50MG
4
QL (60 EA per 30 days) ST MO
celecoxib capsule 400mg
2
QL (30 EA per 30 days) MO
celecoxib capsule 100mg, 200mg, 50mg
2
QL (60 EA per 30 days) MO
DAYPRO
4
QL (90 EA per 30 days) MO
diclofenac potassium capsule 25mg
2
QL (120 EA per 30 days) PA MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 2
Drug Name
Drug
Tier
Requirements/Limits
diclofenac potassium tablet 50mg
2
QL (120 EA per 30 days) MO
diclofenac potassium tablet 25mg
5
QL (120 EA per 30 days) PA MO
diclofenac sodium dr
2
MO
diclofenac sodium er
2
QL (60 EA per 30 days) MO
diclofenac sodium/misoprostol tablet delayed release 50mg;
200mcg
2
QL (120 EA per 30 days) MO
diclofenac sodium/misoprostol tablet delayed release 75mg;
200mcg
2
QL (90 EA per 30 days) MO
diflunisal
2
QL (90 EA per 30 days) MO
DUEXIS
5
QL (90 EA per 30 days) PA MO
ec-naproxen tablet delayed release 375mg
2
QL (120 EA per 30 days)
ec-naproxen tablet delayed release 500mg
2
QL (90 EA per 30 days) MO
etodolac er tablet extended release 24 hour 600mg
2
QL (30 EA per 30 days) MO
etodolac er tablet extended release 24 hour 400mg, 500mg
2
QL (60 EA per 30 days) MO
etodolac capsule 300mg
2
QL (120 EA per 30 days) MO
etodolac capsule 200mg
2
QL (90 EA per 30 days) MO
etodolac tablet 500mg
2
QL (60 EA per 30 days) MO
etodolac tablet 400mg
2
QL (90 EA per 30 days) MO
FELDENE CAPSULE 20MG
4
QL (30 EA per 30 days) MO
FELDENE CAPSULE 10MG
4
QL (60 EA per 30 days) MO
FENOPROFEN CALCIUM CAPSULE 400MG
4
QL (240 EA per 30 days) MO
fenoprofen calcium tablet
2
QL (150 EA per 30 days) MO
flurbiprofen tablet 100mg
2
QL (90 EA per 30 days) MO
ibu tablet 400mg, 600mg, 800mg
2
MO
ibuprofen tablet 400mg, 600mg, 800mg
2
MO
ibuprofen/famotidine
2
QL (90 EA per 30 days) PA MO
INDOCIN SUSPENSION
5
PA MO
indocin suppository
5
PA MO; HRM
indomethacin er
2
PA MO
indomethacin capsule
2
PA MO
indomethacin suppository
5
PA; HRM
ketoprofen er
2
QL (30 EA per 30 days) MO
ketoprofen capsule 25mg
5
QL (120 EA per 30 days)
ketoprofen capsule 50mg
5
QL (180 EA per 30 days)
ketorolac tromethamine injection 15mg/ml, 30mg/ml
2
QL (20 ML per 30 days) MO
ketorolac tromethamine nasal solution 15.75mg/spray
5
QL (5 EA per 30 days) PA LA; ACS
ketorolac tromethamine tablet 10mg
2
QL (20 EA per 30 days) PA MO
LODINE
4
QL (90 EA per 30 days) ST MO
lofena
5
QL (120 EA per 30 days) PA
meclofenamate sodium
2
QL (120 EA per 30 days) MO
mefenamic acid
2
MO
meloxicam capsule 10mg
2
MO
meloxicam capsule 5mg
5
MO
meloxicam tablet
1
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 3
Drug Name
Drug
Tier
Requirements/Limits
nabumetone
2
MO
NALFON TABLET
4
QL (150 EA per 30 days) ST
NALFON CAPSULE
4
QL (240 EA per 30 days) ST MO
NAPRELAN TABLET EXTENDED RELEASE 24 HOUR
375MG
4
QL (120 EA per 30 days) ST MO
NAPRELAN TABLET EXTENDED RELEASE 24 HOUR
500MG
4
QL (90 EA per 30 days) ST MO
NAPRELAN TABLET EXTENDED RELEASE 24 HOUR
750MG
5
QL (60 EA per 30 days) ST MO
NAPROXEN SODIUM CR
4
QL (120 EA per 30 days) MO
NAPROXEN SODIUM ER TABLET EXTENDED
RELEASE 24 HOUR 375MG
4
QL (120 EA per 30 days) MO
naproxen sodium er tablet extended release 24 hour 500mg
5
QL (90 EA per 30 days) MO
NAPROXEN SODIUM TABLET EXTENDED RELEASE
24 HOUR 500MG, 750MG
4
QL (60 EA per 30 days) MO
naproxen sodium tablet 275mg, 550mg
2
MO
naproxen/esomeprazole magnesium
5
QL (60 EA per 30 days) PA MO
naproxen tablet 250mg, 375mg, 500mg
1
MO
naproxen suspension
2
MO
naproxen tablet delayed release 375mg
2
QL (120 EA per 30 days) MO
naproxen tablet delayed release 500mg
2
QL (90 EA per 30 days) MO
oxaprozin
2
QL (90 EA per 30 days) MO
piroxicam capsule 20mg
2
QL (30 EA per 30 days) MO
piroxicam capsule 10mg
2
QL (60 EA per 30 days) MO
RELAFEN DS TABLET 1000MG
5
QL (60 EA per 30 days) ST MO
salsalate tablet 750mg
2
QL (120 EA per 30 days) MO
salsalate tablet 500mg
2
QL (180 EA per 30 days) MO
SPRIX
5
QL (5 EA per 30 days) PA LA; ACS
sulindac
2
QL (60 EA per 30 days) MO
tolmetin sodium capsule
2
tolmetin sodium tablet
2
MO
VIMOVO
5
QL (60 EA per 30 days) PA MO
ZIPSOR
5
QL (120 EA per 30 days) PA MO
ZORVOLEX
4
QL (90 EA per 30 days) MO
OPIOID ANALGESICS, LONG-ACTING
BELBUCA
3
QL (60 EA per 30 days) PA MO
buprenorphine transdermal patch
2
QL (4 EA per 28 days) PA MO
BUTRANS
4
QL (4 EA per 28 days) PA MO
CONZIP
4
QL (30 EA per 30 days) MO; HRM
fentanyl transdermal patch
2
QL (10 EA per 30 days) PA MO
hydrocodone bitartrate er tablet er 24 hour abuse-deterrent
2
QL (30 EA per 30 days) PA MO
hydrocodone bitartrate er capsule extended release 12 hour
2
QL (60 EA per 30 days) PA MO
hydromorphone hcl er tablet extended release 24 hour 12mg,
16mg, 8mg
2
QL (30 EA per 30 days) PA MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 4
Drug Name
Drug
Tier
Requirements/Limits
hydromorphone hydrochloride er tablet extended release 24
hour 32mg
4
QL (30 EA per 30 days) PA MO
HYSINGLA ER
3
QL (30 EA per 30 days) PA MO
levorphanol tartrate
5
QL (180 EA per 30 days) MO
methadone hcl oral concentrate 10mg/ml
2
QL (90 ML per 30 days) PA MO
METHADONE HCL INJECTION
2
PA
methadone hcl oral solution
2
QL (450 ML per 30 days) PA MO
methadone hcl tablet 10mg, 5mg
2
QL (90 EA per 30 days) PA MO
METHADOSE ORAL CONCENTRATE
4
QL (90 ML per 30 days) PA MO
METHADOSE SUGAR-FREE ORAL CONCENTRATE
4
QL (90 ML per 30 days) PA MO
morphine sulfate er capsule extended release 24 hour (generic
Avinza) 120mg, 30mg, 45mg, 60mg, 75mg, 90mg
2
QL (30 EA per 30 days) MO
morphine sulfate er capsule extended release 24 hour (generic
Kadian) 100mg, 10mg, 20mg, 30mg, 50mg, 60mg, 80mg
2
QL (60 EA per 30 days) MO
morphine sulfate er tablet extended release 30mg, 60mg
2
QL (60 EA per 30 days) MO
morphine sulfate er tablet extended release 100mg, 200mg
2
QL (60 EA per 30 days) PA MO
morphine sulfate er tablet extended release 15mg
2
QL (90 EA per 30 days) MO
MORPHINE SULFATE/SODIUM CHLORIDE
4
B/D
MS CONTIN TABLET EXTENDED RELEASE 30MG,
60MG
4
QL (60 EA per 30 days) MO
MS CONTIN TABLET EXTENDED RELEASE 100MG,
200MG
4
QL (60 EA per 30 days) PA MO
MS CONTIN TABLET EXTENDED RELEASE 15MG
4
QL (90 EA per 30 days) MO
NUCYNTA ER
3
QL (60 EA per 30 days) MO
OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-
DETERRENT 10MG, 20MG, 40MG
2
QL (60 EA per 30 days) PA
OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-
DETERRENT 80MG
2
QL (60 EA per 30 days) PA MO
OXYCODONE HCL ER TABLET ER 12 HOUR ABUSE-
DETERRENT 15MG, 30MG, 60MG
4
QL (60 EA per 30 days) PA
OXYCONTIN
4
QL (60 EA per 30 days) PA MO
oxymorphone hydrochloride er
2
QL (60 EA per 30 days) PA MO
oxymorphone hydrochlorideer
5
QL (60 EA per 30 days) PA MO
TRAMADOL HCL ER CAPSULE EXTENDED RELEASE
24 HOUR
4
QL (30 EA per 30 days) MO; HRM
tramadol hcl er tablet extended release 24 hour
2
QL (30 EA per 30 days) MO; HRM
XTAMPZA ER CAPSULE ER 12 HOUR ABUSE-
DETERRENT 36MG
3
QL (240 EA per 30 days) PA MO
XTAMPZA ER CAPSULE ER 12 HOUR ABUSE-
DETERRENT 13.5MG, 18MG, 27MG, 9MG
3
QL (60 EA per 30 days) PA MO
OPIOID ANALGESICS, SHORT-ACTING
acetaminophen/caffeine/dihydrocodeine
2
QL (300 EA per 30 days) MO
acetaminophen/codeine tablet
2
QL (180 EA per 30 days) MO
acetaminophen/codeine solution
2
QL (2700 ML per 30 days) MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 5
Drug Name
Drug
Tier
Requirements/Limits
APADAZ
4
QL (168 EA per 30 days)
ascomp/codeine
2
QL (180 EA per 30 days) PA MO;
HRM
BENZHYDROCODONE/ACETAMINOPHEN
4
QL (168 EA per 30 days)
BUPRENEX
4
MO
buprenorphine hcl injection 0.3mg/ml
2
MO
butalbital/acetaminophen/caffeine/codeine
2
QL (180 EA per 30 days) PA MO
butalbital/aspirin/caffeine/codeine
2
QL (180 EA per 30 days) PA MO;
HRM
butorphanol tartrate nasal solution
2
QL (5 ML per 30 days) MO
butorphanol tartrate injection 1mg/ml
2
butorphanol tartrate injection 2mg/ml
2
MO
CODEINE SULFATE TABLET 30MG
2
QL (180 EA per 30 days) MO
CODEINE SULFATE TABLET 15MG, 60MG
4
QL (180 EA per 30 days) MO
DEMEROL
4
PA; HRM
DILAUDID INJECTION
4
B/D
DILAUDID TABLET
4
QL (180 EA per 30 days) MO
DILAUDID LIQUID
4
QL (600 ML per 30 days) MO
DURAMORPH
4
B/D
endocet tablet 10mg; 325mg, 2.5mg; 325mg, 5mg; 325mg,
7.5mg; 325mg
2
QL (180 EA per 30 days)
fentanyl citrate oral transmucosal lozenge on a handle
200mcg
2
QL (120 EA per 30 days) PA MO
fentanyl citrate oral transmucosal lozenge on a handle
1200mcg, 1600mcg, 400mcg, 600mcg, 800mcg
4
QL (120 EA per 30 days) PA MO
FENTANYL CITRATE TABLET
2
QL (120 EA per 30 days) PA MO
FENTANYL CITRATE INJECTION 1000MCG/20ML,
100MCG/2ML, 2500MCG/50ML, 250MCG/5ML,
500MCG/10ML, 50MCG/ML
4
B/D
fentanyl citrate injection 100mcg/2ml, 50mcg/ml
2
fentanyl citrate cartridge 100mcg/2ml
2
B/D
FENTORA
5
QL (120 EA per 30 days) PA MO
FIORICET/CODEINE
5
QL (180 EA per 30 days) PA MO
hydrocodone bitartrate/acetaminophen tablet
2
QL (180 EA per 30 days) MO
hydrocodone bitartrate/acetaminophen solution
2
QL (2700 ML per 30 days) MO
hydrocodone/ibuprofen
2
QL (150 EA per 30 days) MO
hydromorphone hcl tablet
2
QL (180 EA per 30 days) MO
hydromorphone hcl oral liquid
2
QL (600 ML per 30 days) MO
HYDROMORPHONE HCL INJECTION 4MG/ML
4
B/D
HYDROMORPHONE HCL INJECTION 1MG/ML
4
B/D MO
hydromorphone hcl pf injection 10mg/ml
2
B/D
HYDROMORPHONE HYDROCHLORIDE PF INJECTION
1MG/ML, 2MG/ML
4
B/D
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 6
Drug Name
Drug
Tier
Requirements/Limits
HYDROMORPHONE HYDROCHLORIDE PF INJECTION
4MG/ML
4
B/D MO
hydromorphone hydrochloride pf injection 50mg/5ml
2
B/D
hydromorphone hydrochloride injection 2mg/ml
2
B/D MO
INFUMORPH 200
4
B/D
INFUMORPH 500
4
B/D
LORTAB
2
MO
meperidine hcl oral solution
2
QL (3600 ML per 30 days) PA MO;
HRM
meperidine hcl tablet
5
QL (120 EA per 30 days) PA MO;
HRM
meperidine hcl injection 25mg/ml
2
PA MO; HRM
meperidine hcl injection 100mg/ml, 50mg/ml
2
PA; HRM
mitigo
2
B/D
morphine sulfate tablet 15mg, 30mg
2
QL (180 EA per 30 days) MO
MORPHINE SULFATE INJECTION 10MG/ML, 2MG/ML,
4MG/ML, 5MG/ML, 8MG/ML
4
B/D
morphine sulfate injection 0.5mg/ml, 10mg/ml, 4mg/ml,
50mg/ml, 8mg/ml
2
B/D
morphine sulfate injection 1mg/ml
2
B/D MO
morphine sulfate oral solution 20mg/ml
2
QL (180 ML per 30 days) MO
morphine sulfate oral solution 10mg/5ml, 20mg/5ml
2
QL (900 ML per 30 days) MO
morphine sulfate suppository 5mg
2
QL (60 EA per 30 days)
morphine sulfate suppository 10mg, 20mg
2
QL (60 EA per 30 days) MO
morphine sulfate suppository 30mg
5
QL (60 EA per 30 days)
nalbuphine hcl
2
MO
nalocet
5
QL (180 EA per 30 days)
NUCYNTA
3
QL (180 EA per 30 days) MO
OXAYDO TABLET 5MG
4
QL (180 EA per 30 days) MO
OXAYDO TABLET 7.5MG
5
QL (180 EA per 30 days) MO
OXYCODONE AND ACETAMINOPHEN
5
QL (180 EA per 30 days) PA MO
OXYCODONE HYDROCHLORIDE/ACETAMINOPHEN
SOLUTION 325MG/5ML; 5MG/5ML
4
QL (1800 ML per 30 days) MO
oxycodone hydrochloride/acetaminophen solution 300mg/5ml;
10mg/5ml
5
QL (900 ML per 30 days) PA
oxycodone hydrochloride capsule
2
QL (180 EA per 30 days) MO
oxycodone hydrochloride oral concentrate
2
QL (180 ML per 30 days) MO
oxycodone hydrochloride oral solution
2
QL (900 ML per 30 days) MO
oxycodone hydrochloride tablet 30mg
2
QL (120 EA per 30 days) MO
oxycodone hydrochloride tablet 10mg, 15mg, 20mg, 5mg
2
QL (180 EA per 30 days) MO
oxycodone/acetaminophen tablet 325mg; 10mg, 325mg;
2.5mg, 325mg; 5mg, 325mg; 7.5mg
2
QL (180 EA per 30 days) MO
oxycodone/acetaminophen tablet 300mg; 2.5mg
5
QL (180 EA per 30 days)
oxycodone/acetaminophen tablet 300mg; 10mg
5
QL (180 EA per 30 days) PA
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 7
Drug Name
Drug
Tier
Requirements/Limits
oxycodone/acetaminophen tablet 300mg; 5mg
5
QL (180 EA per 30 days) PA MO
oxymorphone hydrochloride tablet 10mg, 5mg
2
QL (180 EA per 30 days) MO
pentazocine/naloxone hcl
2
QL (360 EA per 30 days) PA MO
PERCOCET TABLET 325MG; 2.5MG
4
QL (180 EA per 30 days) MO
PERCOCET TABLET 325MG; 10MG, 325MG; 5MG,
325MG; 7.5MG
5
QL (180 EA per 30 days) MO
PROLATE SOLUTION
5
QL (900 ML per 30 days) PA
PROLATE TABLET 300MG; 10MG
5
QL (180 EA per 30 days) PA
PROLATE TABLET 300MG; 5MG, 300MG; 7.5MG
5
QL (180 EA per 30 days) PA MO
ROXICODONE TABLET 30MG
4
QL (120 EA per 30 days) MO
ROXICODONE TABLET 15MG
4
QL (180 EA per 30 days) MO
ROXYBOND TABLET ABUSE-DETERRENT 15MG
5
QL (180 EA per 30 days)
ROXYBOND TABLET ABUSE-DETERRENT 30MG, 5MG
5
QL (180 EA per 30 days) MO
SEGLENTIS
4
QL (120 EA per 30 days) PA MO;
HRM
SUBSYS LIQUID 100MCG, 200MCG, 400MCG, 600MCG,
800MCG
5
QL (120 EA per 30 days) PA MO
SUBSYS LIQUID 1200MCG
5
QL (240 EA per 30 days) PA
SUBSYS LIQUID 1600MCG
5
QL (240 EA per 30 days) PA MO
tramadol hcl tablet 50mg
2
QL (240 EA per 30 days) MO; HRM
tramadol hydrochloride/acetaminophen
2
QL (240 EA per 30 days) MO; HRM
tramadol hydrochloride tablet 100mg
2
QL (120 EA per 30 days) MO; HRM
tramadol hydrochloride solution
2
QL (1800 ML per 30 days) PA MO;
HRM
trezix
2
QL (300 EA per 30 days)
ANESTHETICS
LOCAL ANESTHETICS
bupivacaine fisiopharma injection 2.5mg/ml
2
bupivacaine fisiopharma injection 5mg/ml
2
MO
bupivacaine hcl injection 0.25%
2
bupivacaine hcl injection 0.5%
2
MO
bupivacaine hydrochloride injection 0.25%, 0.75%
2
bupivacaine hydrochloride injection 0.5%
2
MO
bupivacaine/epinephrine injection 0.25%; 1:200000, 0.5%;
1:200000 pf
2
bupivacaine/epinephrine injection 0.5%; 1:200000
2
MO
EXPAREL
4
lidocaine hcl injection 0.5%, 1%, 1.5%, 2%, 4%
2
lidocaine/epinephrine
2
MARCAINE/EPINEPHRINE INJECTION 0.25%; 1:200000
4
MARCAINE/EPINEPHRINE INJECTION 0.5%; 1:200000
4
MO
MARCAINE INJECTION 0.25%, 0.75%
4
MARCAINE INJECTION 0.5%
4
MO
NAROPIN
4
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 8
Drug Name
Drug
Tier
Requirements/Limits
ropivacaine hydrochloride
2
sensorcaine-mpf
2
SENSORCAINE-MPF/EPINEPHRINE INJECTION 0.5%;
1:200000, 0.75%; 1:200000
4
sensorcaine-mpf/epinephrine injection 0.25%; 1:200000
2
sensorcaine/epinephrine
2
SENSORCAINE INJECTION 0.25%
4
SENSORCAINE INJECTION 0.5%
4
MO
XYLOCAINE
4
XYLOCAINE-MPF
4
XYLOCAINE-MPF/EPINEPHRINE
4
XYLOCAINE/EPINEPHRINE
4
ANTI-INFECTIVES
ANTI-INFECTIVES - MISCELLANEOUS
AEMCOLO
4
MO
albendazole
4
MO
amikacin sulfate
2
MO
ARIKAYCE
5
PA LA MO
atovaquone
2
PA MO
AZACTAM
4
aztreonam
2
MO
bacitracin injection 50000unit
2
BACTRIM
4
MO
BACTRIM DS
4
MO
BENZNIDAZOLE
4
PA
BETHKIS
5
QL (224 ML per 56 days) PA LA;
ACS
BILTRICIDE
4
MO
CAYSTON
5
PA LA; ACS
chloramphenical sodium succinate iv solution injection
2
CLEOCIN PEDIATRIC GRANULES
4
MO
CLEOCIN PHOSPHATE INJECTION 300MG/2ML,
9GM/60ML
4
CLEOCIN PHOSPHATE INJECTION 600MG/4ML,
900MG/6ML
4
MO
CLEOCIN CAPSULE 150MG, 300MG, 75MG
4
MO
clindamycin hcl capsule 300mg
2
MO
clindamycin hydrochloride capsule 150mg, 75mg
2
MO
clindamycin palmitate hcl solution 75mg/5ml
2
MO
clindamycin phosphate/dextrose
2
clindamycin phosphate injection 300mg/2ml, 9000mg/60ml,
900mg/6ml
2
clindamycin phosphate injection 600mg/4ml
2
MO
CLINDAMYCIN/SODIUM CHLORIDE
4
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 9
Drug Name
Drug
Tier
Requirements/Limits
colistimethate sodium
2
PA MO
COLY-MYCIN M
4
PA MO
CUBICIN RF
5
DALVANCE
5
dapsone tablet 100mg, 25mg
2
MO
DAPTOMYCIN INJECTION 350MG
5
daptomycin injection 500mg
5
DARAPRIM
5
QL (90 EA per 30 days) PA MO
EMVERM
4
QL (12 EA per 365 days) MO
ertapenem
2
MO
FIRVANQ SOLUTION RECONSTITUTED 25MG/ML
4
QL (1800 ML per 180 days)
FIRVANQ SOLUTION RECONSTITUTED 50MG/ML
4
QL (1800 ML per 180 days) MO
FLAGYL
4
MO
fosfomycin tromethamine
2
MO
gentamicin sulfate pediatric injection 10mg/ml
2
MO
gentamicin sulfate/0.9% sodium chloride injection 1.2mg/ml;
0.9%, 1mg/ml; 0.9%, 2mg/ml; 0.9%
2
gentamicin sulfate/0.9% sodium chloride injection 1.6mg/ml;
0.9%
2
MO
gentamicin sulfate injection 40mg/ml
2
MO
HIPREX
4
MO
HUMATIN
5
MO
imipenem/cilastatin
2
MO
IMPAVIDO
4
QL (84 EA per 28 days) PA MO
INVANZ
4
MO
isotonic gentamicin
2
ivermectin tablet 3mg
2
QL (12 EA per 90 days) PA MO
KIMYRSA
5
KITABIS PAK
5
QL (280 ML per 56 days) PA LA;
ACS
LAMPIT
4
PA
LINCOCIN
4
MO
lincomycin hcl
2
linezolid oral suspension reconstituted 100mg/5ml
2
QL (1800 ML per 30 days) PA MO
linezolid tablet
2
QL (56 EA per 28 days) PA MO
LINEZOLID INJECTION 600MG/300ML; 0.9%
2
PA
linezolid injection 600mg/300ml
2
PA
MACROBID
4
MO
MACRODANTIN
4
MO
me/naphos/mb/hyo 1
2
MO; HRM
MEPRON
5
PA MO
meropenem
2
MO
MEROPENEM/SODIUM CHLORIDE
4
methenamine hippurate
2
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 10
Drug Name
Drug
Tier
Requirements/Limits
methenamine mandelate
2
MO
metronidazole capsule 375mg
2
MO
metronidazole injection 500mg/100ml
2
metronidazole tablet 250mg, 500mg
2
MO
MONUROL
4
MO
NEBUPENT
4
B/D MO
neomycin sulfate
2
MO
nitazoxanide
2
QL (6 EA per 30 days) MO
nitrofurantin oral suspension 25mg/5ml
4
MO
nitrofurantoin monohydrate macrocrystals capsule 100mg
2
MO
nitrofurantoin monohydrate/macrocrystals
2
MO
ORBACTIV
5
MO
paromomycin sulfate
2
PENTAM 300
4
MO
pentamidine isethionate inhalation solution reconstituted
2
B/D MO
pentamidine isethionate injection
2
MO
polymyxin b sulfate
2
praziquantel
2
MO
PRIMAXIN IV
4
MO
pyrimethamine
2
QL (90 EA per 30 days) PA MO
RECARBRIO
5
PA
SIVEXTRO INJECTION
4
SIVEXTRO TABLET
4
MO
SOLOSEC
4
MO
streptomycin sulfate
5
MO
STROMECTOL
4
QL (12 EA per 90 days) PA MO
sulfadiazine
2
MO
sulfamethoxazole/trimethoprim ds
1
MO
sulfamethoxazole/trimethoprim tablet
1
MO
sulfamethoxazole/trimethoprim injection, suspension
2
MO
tinidazole
2
MO
TOBI
5
QL (280 ML per 56 days) PA LA;
ACS
TOBI PODHALER
5
QL (224 EA per 56 days) PA LA;
ACS
tobramycin sulfate injection 10mg/ml, 40mg/ml
2
tobramycin sulfate injection 1.2gm/30ml, 80mg/2ml
2
MO
tobramycin sulfate injection 1.2gm
5
tobramycin nebulization solution 300mg/4ml
5
QL (224 ML per 56 days) PA; ACS
tobramycin nebulization solution 300mg/5ml
5
QL (280 ML per 56 days) PA; ACS
trimethoprim
1
MO
UROGESIC-BLUE
4
MO; HRM
VABOMERE
5
PA
VANCOCIN CAPSULE 125MG
5
QL (120 EA per 30 days) MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 11
Drug Name
Drug
Tier
Requirements/Limits
VANCOCIN CAPSULE 250MG
5
QL (240 EA per 30 days) MO
VANCOMYCIN
4
VANCOMYCIN HCL INJECTION 0.9%; 1GM/200ML
4
vancomycin hcl injection 100gm, 10gm
2
VANCOMYCIN HYDROCHLORIDE/DEXTROSE
4
vancomycin hydrochloride capsule 125mg
2
QL (120 EA per 30 days) MO
vancomycin hydrochloride capsule 250mg
2
QL (240 EA per 30 days) MO
VANCOMYCIN HYDROCHLORIDE INJECTION
1000MG/200ML, 1250MG/250ML, 1500MG/300ML,
1750MG/350ML, 500MG/100ML, 750MG/150ML
4
vancomycin hydrochloride injection 1.25gm, 1.5gm, 1gm,
5gm, 750mg
2
vancomycin hydrochloride injection 500mg
2
MO
vancomycin hydrochloride oral solution reconstituted
25mg/ml
2
QL (1800 ML per 180 days)
vancomycin hydrochloride oral solution reconstituted
250mg/5ml
2
QL (1800 ML per 180 days) MO
VIBATIV
5
PA
XENLETA
4
PA MO; ACS
XIFAXAN TABLET 200MG
4
QL (9 EA per 30 days) PA MO
ZEMDRI
5
PA
ZYVOX INJECTION
4
PA
ZYVOX ORAL SUSPENSION RECONSTITUTED
4
QL (1800 ML per 30 days) PA MO
ZYVOX TABLET
5
QL (56 EA per 28 days) PA MO
ANTIFUNGALS
ABELCET
4
B/D
AMBISOME
5
B/D MO
amphotericin b
2
B/D MO
amphotericin b liposome
5
B/D MO
ANCOBON CAPSULE 250MG
5
PA
ANCOBON CAPSULE 500MG
5
PA MO
CANCIDAS INJECTION 50MG
5
CANCIDAS INJECTION 70MG
5
MO
caspofungin acetate
2
CRESEMBA INJECTION
5
QL (34 EA per 30 days)
CRESEMBA CAPSULE
5
QL (70 EA per 30 days) MO
DIFLUCAN ORAL SUSPENSION RECONSTITUTED
4
MO
DIFLUCAN TABLET 100MG, 150MG
4
MO
DIFLUCAN TABLET 200MG
5
MO
ERAXIS INJECTION 100MG
4
PA
ERAXIS INJECTION 50MG
5
PA
fluconazole in sodium chloride injection 200mg; 100ml,
400mg; 100ml
2
fluconazole tablet, oral suspension
2
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 12
Drug Name
Drug
Tier
Requirements/Limits
fluconazole/sodium chloride injection 100mg/50ml
2
flucytosine capsule 250mg
2
PA MO
flucytosine capsule 500mg
5
PA MO
griseofulvin microsize
2
MO
griseofulvin ultramicrosize
2
MO
itraconazole capsule
2
PA MO
itraconazole solution
4
PA MO
ketoconazole tablet 200mg
2
PA MO
micafungin
5
MYCAMINE INJECTION 100MG
5
mycamine injection 50mg
5
MO
NOXAFIL INJECTION
5
NOXAFIL PACKET
5
QL (32 EA per 30 days) PA
NOXAFIL SUSPENSION
5
QL (630 ML per 30 days) PA MO
NOXAFIL TABLET DELAYED RELEASE
5
QL (93 EA per 30 days) PA MO
nystatin tablet 500000unit
2
MO
posaconazole dr tablet delayed release 100mg
5
QL (93 EA per 30 days) PA MO
posaconazole injection
5
posaconazole suspension
5
QL (630 ML per 30 days) MO
REZZAYO
5
PA
SPORANOX SOLUTION
4
PA MO
SPORANOX CAPSULE
5
PA MO
terbinafine hcl
2
QL (90 EA per 365 days) MO
TOLSURA
5
PA MO
VFEND IV
5
PA
VFEND SUSPENSION RECONSTITUTED
5
PA MO
VFEND TABLET 200MG
4
QL (120 EA per 30 days) MO
VFEND TABLET 50MG
5
QL (480 EA per 30 days) MO
VIVJOA
4
QL (18 EA per 84 days) PA
voriconazole injection
2
PA
voriconazole suspension reconstituted
2
PA MO
voriconazole tablet 200mg
2
QL (120 EA per 30 days) MO
voriconazole tablet 50mg
2
QL (480 EA per 30 days) MO
ANTIMALARIALS
atovaquone/proguanil hcl
2
MO
chloroquine phosphate
2
MO
COARTEM
4
MO
KRINTAFEL
4
PA
MALARONE
4
MO
mefloquine hcl
2
MO
primaquine phosphate
2
QUALAQUIN
4
PA MO
quinine sulfate
2
PA MO
ANTIRETROVIRAL AGENTS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 13
Drug Name
Drug
Tier
Requirements/Limits
abacavir
2
MO
APRETUDE
5
QL (21 ML per 365 days) LA MO
APTIVUS
5
MO
atazanavir sulfate
2
MO
darunavir tablet 800mg
5
QL (30 EA per 30 days) MO
darunavir tablet 600mg
5
QL (60 EA per 30 days) MO
EDURANT
3
MO
efavirenz
2
MO
emtricitabine
2
MO
EMTRIVA SOLUTION
3
MO
EMTRIVA CAPSULE
4
MO
EPIVIR
4
MO
etravirine
2
MO
fosamprenavir calcium
2
MO
FUZEON
5
LA MO
INTELENCE TABLET 25MG
3
INTELENCE TABLET 100MG, 200MG
5
MO
ISENTRESS
3
MO
ISENTRESS HD
3
MO
lamivudine solution 10mg/ml
2
MO
lamivudine tablet 150mg, 300mg
2
MO
LEXIVA SUSPENSION
4
MO
LEXIVA TABLET
5
MO
maraviroc
2
MO
nevirapine
2
MO
nevirapine er tablet extended release 24 hour 100mg
2
nevirapine er tablet extended release 24 hour 400mg
2
MO
NORVIR PACKET
3
MO
NORVIR SOLUTION, TABLET
4
MO
PIFELTRO
5
MO
PREZISTA SUSPENSION
3
QL (400 ML per 30 days) MO
PREZISTA TABLET 150MG
3
QL (240 EA per 30 days) MO
PREZISTA TABLET 800MG
3
QL (30 EA per 30 days) MO
PREZISTA TABLET 75MG
3
QL (480 EA per 30 days) MO
PREZISTA TABLET 600MG
3
QL (60 EA per 30 days) MO
RETROVIR CAPSULE, ORAL SYRUP
4
MO
RETROVIR IV INFUSION
4
REYATAZ PACKET
4
MO
REYATAZ CAPSULE
5
MO
ritonavir
2
MO
RUKOBIA
4
MO
SELZENTRY SOLUTION
4
MO
SELZENTRY TABLET 25MG
3
SELZENTRY TABLET 75MG
4
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 14
Drug Name
Drug
Tier
Requirements/Limits
SELZENTRY TABLET 150MG, 300MG
5
MO
stavudine
2
MO
SUNLENCA INJECTION
5
QL (3 ML per 180 days) LA MO
SUNLENCA TABLET THERAPY PACK (5 TAB PACK)
300MG
5
QL (10 EA per 365 days) LA MO
SUNLENCA TABLET THERAPY PACK (4 TAB PACK)
300MG
5
QL (8 EA per 365 days) LA MO
SUSTIVA CAPSULE 50MG
4
MO
SUSTIVA CAPSULE 200MG
5
MO
tenofovir disoproxil fumarate
2
MO
TIVICAY
3
MO
TIVICAY PD
3
MO
TROGARZO
5
LA MO
TYBOST
4
MO
VIRACEPT
5
MO
VIREAD POWDER
4
MO
VIREAD TABLET 150MG, 200MG, 250MG
4
MO
VIREAD TABLET 300MG
5
MO
ZIAGEN
4
MO
zidovudine
2
MO
ANTIRETROVIRAL COMBINATION AGENTS
abacavir sulfate/lamivudine
2
MO
BIKTARVY
3
MO
CABENUVA INJECTION 400MG/2ML; 600MG/2ML
5
QL (4 ML per 30 days) MO
CABENUVA INJECTION 600MG/3ML; 900MG/3ML
5
QL (6 ML per 30 days) MO
CIMDUO
3
MO
COMBIVIR
5
MO
COMPLERA
5
MO
DELSTRIGO
5
MO
DESCOVY
3
MO
DOVATO
3
MO
efavirenz/emtricitabine/tenofovir disoproxil fumarate
2
MO
efavirenz/lamivudine/tenofovir disoproxil fumarate
2
MO
emtricitabine/tenofovir disoproxil fumarate
2
QL (30 EA per 30 days) MO
emtricitabine/tenofovir disoproxil tablet 167mg; 250mg
2
QL (30 EA per 30 days) MO
EPZICOM
5
MO
EVOTAZ
3
MO
GENVOYA
3
MO
JULUCA
4
MO
KALETRA SOLUTION
5
MO
KALETRA TABLET 100MG; 25MG
4
MO
KALETRA TABLET 200MG; 50MG
5
MO
lamivudine/zidovudine
2
MO
lopinavir/ritonavir capsule, oral solution
2
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 15
Drug Name
Drug
Tier
Requirements/Limits
ODEFSEY
3
MO
PREZCOBIX
3
MO
STRIBILD
5
MO
SYMFI
5
MO
SYMFI LO
5
MO
SYMTUZA
3
MO
TRIUMEQ
4
MO
TRIUMEQ PD
4
MO
TRIZIVIR
4
MO
TRUVADA
5
QL (30 EA per 30 days) MO
ANTITUBERCULAR AGENTS
cycloserine
4
MO
ethambutol hydrochloride
2
MO
isoniazid tablet
1
MO
isoniazid injection
2
isoniazid syrup
2
MO
MYAMBUTOL
4
MO
MYCOBUTIN
4
MO
PRETOMANID
4
QL (30 EA per 30 days) PA
PRIFTIN
4
MO
pyrazinamide
2
MO
rifabutin
2
MO
RIFADIN INJECTION 600MG
4
rifampin injection
2
rifampin capsule
2
MO
SIRTURO
5
PA LA; ACS
TRECATOR
4
MO
ANTIVIRALS
acyclovir sodium
2
B/D
acyclovir capsule 200mg
2
MO
acyclovir suspension 200mg/5ml
2
MO
acyclovir tablet 400mg, 800mg
2
MO
adefovir dipivoxil
2
QL (30 EA per 30 days) MO
BARACLUDE SOLUTION
4
QL (630 ML per 30 days) MO
BARACLUDE TABLET
5
QL (30 EA per 30 days) MO
cidofovir
2
entecavir
2
QL (30 EA per 30 days) MO
EPCLUSA
5
PA; ACS
EPIVIR HBV
4
MO
famciclovir tablet 500mg
2
QL (21 EA per 30 days) MO
famciclovir tablet 125mg, 250mg
2
QL (60 EA per 30 days) MO
foscarnet sodium
5
PA
ganciclovir injection 500mg/10ml, 500mg
2
B/D
HARVONI
5
PA; ACS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 16
Drug Name
Drug
Tier
Requirements/Limits
lamivudine tablet 100mg
2
MO
LEDIPASVIR/SOFOSBUVIR
5
PA; ACS
LIVTENCITY
5
QL (120 EA per 30 days) PA LA
MO
MAVYRET
5
PA; ACS
oseltamivir phosphate capsule 30mg
2
QL (168 EA per 365 days) MO
oseltamivir phosphate capsule 45mg, 75mg
2
QL (84 EA per 365 days) MO
oseltamivir phosphate oral suspension reconstituted
2
QL (1080 ML per 365 days) MO
PEGASYS
5
PA; ACS
PREVYMIS TABLET
4
QL (28 EA per 28 days) PA MO
PREVYMIS INJECTION
5
RAPIVAB
5
RELENZA DISKHALER
3
QL (120 EA per 365 days) MO
ribavirin capsule 200mg, tablet 100mg
2
ACS
rimantadine hydrochloride
2
MO
SITAVIG
5
QL (2 EA per 30 days) MO
SOFOSBUVIR/VELPATASVIR
5
PA; ACS
SOVALDI TABLET
5
QL (28 EA per 28 days) PA; ACS
SOVALDI PACKET 150MG
5
QL (28 EA per 28 days) PA; ACS
SOVALDI PACKET 200MG
5
QL (56 EA per 28 days) PA; ACS
TAMIFLU ORAL SUSPENSION RECONSTITUTED
4
QL (1080 ML per 365 days) MO
TAMIFLU CAPSULE 30MG
4
QL (168 EA per 365 days) MO
TAMIFLU CAPSULE 45MG, 75MG
4
QL (84 EA per 365 days) MO
valacyclovir hcl tablet 1gm
2
MO
valacyclovir hydrochloride tablet 500mg
2
MO
VALCYTE
5
MO
valganciclovir hydrochloride oral solution
2
MO
valganciclovir tablet 450mg
2
MO
VALTREX TABLET 500MG
4
MO
VALTREX TABLET 1GM
5
MO
VEKLURY
5
QL (4 EA per 30 days) PA
VEMLIDY
5
MO
VIEKIRA PAK
5
QL (112 EA per 28 days) PA; ACS
VOSEVI
5
PA; ACS
XOFLUZA
4
QL (1 EA per 180 days) MO
ZEPATIER
5
PA; ACS
ZOVIRAX SUSPENSION 200MG/5ML
4
MO
CEPHALOSPORINS
AVYCAZ
5
PA
CEFACLOR ER
4
MO
cefaclor capsule
2
MO
cefaclor suspension reconstituted 250mg/5ml
2
cefaclor suspension reconstituted 125mg/5ml, 375mg/5ml
2
MO
cefadroxil
2
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 17
Drug Name
Drug
Tier
Requirements/Limits
CEFAZOLIN SODIUM/DEXTROSE
4
CEFAZOLIN SODIUM INJECTION 1GM/50ML; 4%
3
CEFAZOLIN SODIUM INJECTION 100GM, 300GM
4
cefazolin sodium injection 1gm
2
cefazolin sodium injection 10gm, 1gm, 500mg
2
MO
CEFAZOLIN INJECTION 2GM/100ML; 4%
3
CEFAZOLIN INJECTION 2GM, 3GM
4
cefazolin injection 2gm
2
cefdinir capsule, oral suspension
2
MO
CEFEPIME HYDROCHLORIDE INJECTION 100GM
4
CEFEPIME HYDROCHLORIDE INJECTION 2GM
4
MO
CEFEPIME/DEXTROSE
4
CEFEPIME INJECTION 1GM/50ML, 2GM/100ML
4
cefepime injection 1gm, 2gm
2
MO
cefixime capsule, oral suspension
2
MO
cefotetan
2
CEFOXITIN SODIUM INJECTION 1GM; 4%, 2GM; 2.2%
4
cefoxitin sodium injection 10gm, 1gm, 2gm
2
cefpodoxime proxetil
2
MO
cefprozil
2
MO
CEFTAZIDIME/DEXTROSE
4
ceftazidime injection 6gm
2
ceftazidime injection 1gm, 2gm
2
MO
ceftriaxone in iso-osmotic dextrose
2
CEFTRIAXONE SODIUM INJECTION 100GM
4
ceftriaxone sodium injection 1gm
2
ceftriaxone sodium injection 10gm, 1gm, 250mg, 2gm, 500mg
2
MO
CEFTRIAXONE/DEXTROSE
4
cefuroxime axetil
2
MO
cefuroxime sodium injection 1.5gm
2
cefuroxime sodium injection 750mg
2
MO
cephalexin oral suspension reconstituted, tablet, capsule
2
MO
FETROJA
5
SUPRAX CAPSULE
4
MO
SUPRAX SUSPENSION RECONSTITUTED 500MG/5ML
3
SUPRAX SUSPENSION RECONSTITUTED 200MG/5ML
4
MO
SUPRAX TABLET CHEWABLE 100MG
3
SUPRAX TABLET CHEWABLE 200MG
3
MO
tazicef injection
2
TEFLARO
5
ZERBAXA
5
ERYTHROMYCINS/MACROLIDES
AZITHROMYCIN PACKET
2
MO
azithromycin injection, suspension reconstituted, tablet
2
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 18
Drug Name
Drug
Tier
Requirements/Limits
clarithromycin er tablet extended release 24 hour 500mg
2
MO
clarithromycin immediate release tablet, oral susp
2
MO
DIFICID SUSPENSION RECONSTITUTED
3
DIFICID TABLET
3
MO
e.e.s. 400 tablet 400mg
2
MO
E.E.S. ORAL SUSPENSION
4
MO
ery-tab
2
ERYPED 200
5
MO
ERYPED 400
5
MO
ERYTHROCIN LACTOBIONATE INJECTION
5
erythrocin stearate
2
MO
erythromycin base
2
MO
erythromycin dr
2
MO
erythromycin ethylsuccinate
2
MO
erythromycin lactobionate
5
erythromycin stearate
2
MO
erythromycin capsule delayed release particles 250mg
2
MO
ZITHROMAX
4
MO
ZITHROMAX TRI-PAK
4
MO
ZITHROMAX Z-PAK
4
MO
FLUOROQUINOLONES
BAXDELA TABLET
4
PA MO
BAXDELA INJECTION
5
PA
CIPRO TABLET, ORAL SUSPENSION
4
MO
ciprofloxacin hcl tablet 100mg, 750mg
1
MO
ciprofloxacin hydrochloride tablet 250mg, 500mg
1
MO
ciprofloxacin i.v.-in d5w injection 200mg/100ml; 5%
2
ciprofloxacin i.v.-in d5w injection 400mg/200ml; 5%
2
MO
ciprofloxacin suspension reconstituted 500mg/5ml,
5gm/100ml
2
levofloxacin in d5w
2
levofloxacin injection 25mg/ml
2
levofloxacin oral solution 25mg/ml
2
MO
levofloxacin tablet 250mg, 500mg, 750mg
2
MO
moxifloxacin hydrochloride/sodium hydrochloride
2
moxifloxacin hydrochloride injection 400mg/250ml
2
moxifloxacin hydrochloride tablet 400mg
2
MO
ofloxacin tablet 300mg, 400mg
2
MO
PENICILLINS
amoxicillin
1
MO
amoxicillin/clavulanate potassium
2
MO
amoxicillin/clavulanate potassium er
2
MO
ampicillin
1
MO
ampicillin sodium injection 10gm, 125mg, 1gm, 250mg, 2gm
2
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 19
Drug Name
Drug
Tier
Requirements/Limits
ampicillin sodium injection 1gm, 2gm, 500mg
2
MO
ampicillin-sulfactam injection
2
ampicillin/sulbactam
2
AUGMENTIN TABLET 500MG, ORAL SUSPENSION
125MG/5ML
4
MO
AUGMENTIN ES-600 ORAL SUSPENSION
4
BICILLIN C-R INJECTION 900000UNIT/2ML;
300000UNIT/2ML
4
BICILLIN C-R INJECTION 300000UNIT/ML;
300000UNIT/ML
4
MO
BICILLIN L-A
4
MO
dicloxacillin sodium capsule 250mg, 500mg
2
MO
nafcillin sodium injection 1gm
2
nafcillin sodium injection 2gm
2
MO
nafcillin sodium injection 10gm, 2gm
5
NAFCILLIN INJECTION 5%; 1GM/50ML
4
NAFCILLIN INJECTION 5%; 2GM/100ML
5
OXACILLIN SODIUM INJECTION 1.5GM/50ML;
1GM/50ML, 300MG/50ML; 2GM/50ML
4
oxacillin sodium injection 10gm, 1gm, 2gm
2
penicillin g potassium
2
MO
PENICILLIN G POTASSIUM IN ISO-OSMOTIC
DEXTROSE
4
PENICILLIN G PROCAINE
4
MO
penicillin g sodium
2
penicillin v potassium
1
MO
pfizerpen injection 20000000unit
2
pfizerpen injection 5000000unit
2
MO
piperacillin sodium/tazobactam sodium
2
UNASYN BULK PACK
4
UNASYN INJECTION 1GM; 0.5GM
4
UNASYN INJECTION 2GM; 1GM
4
MO
ZOSYN
4
TETRACYCLINES
demeclocycline hcl
2
MO
DORYX MPC TABLET DELAYED RELEASE 120MG
4
ST MO
DORYX MPC TABLET DELAYED RELEASE 60MG
5
ST
DORYX TABLET DELAYED RELEASE 50MG
4
ST MO
DORYX TABLET DELAYED RELEASE 80MG
5
ST
doxy 100 injection
2
MO
doxycycline hyclate capsule, injection, tablet
2
MO
doxycycline hyclate dr tablet delayed release 100mg, 150mg,
200mg, 50mg, 75mg
2
MO
doxycycline monohydrate capsule, tablet
2
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 20
Drug Name
Drug
Tier
Requirements/Limits
doxycycline suspension reconstituted 25mg/5ml
2
MO
MINOCIN
5
minocycline hcl capsule
2
MO
minocycline hcl tablet
2
ST MO
minocycline hydrochloride
2
MO
minocycline hydrochloride er
2
ST MO
MINOLIRA
4
ST MO
mondoxyne nl
2
NUZYRA
5
LA MO; ACS
SEYSARA
5
QL (30 EA per 30 days) PA MO
SOLODYN TABLET EXTENDED RELEASE 24 HOUR
105MG, 80MG
4
ST MO
SOLODYN TABLET EXTENDED RELEASE 24 HOUR
115MG, 55MG, 65MG
5
ST MO
targadox
2
tetracycline hydrochloride capsule
2
MO
tigecycline
5
TYGACIL
4
VIBRAMYCIN CAPSULE, ORAL SUSPENSION
4
ST MO
XERAVA INJECTION 50MG
4
XERAVA INJECTION 100MG
5
XIMINO
4
ST MO
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS
ALKERAN TABLET
4
B/D MO
ALKERAN INJECTION
5
BENDAMUSTINE HYDROCHLORIDE INJECTION
100MG/4ML
5
ACS
bendamustine hydrochloride injection 100mg, 25mg
5
ACS
BENDEKA
5
LA; ACS
BICNU
5
busulfan
5
BUSULFEX
5
carboplatin
2
carmustine
5
cisplatin
2
CYCLOPHOSPHAMIDE MONOHYDRATE
4
CYCLOPHOSPHAMIDE TABLET
3
PA
cyclophosphamide capsule
2
PA MO
CYCLOPHOSPHAMIDE INJECTION 1GM/5ML,
500MG/2.5ML, 500MG/ML
5
cyclophosphamide injection 1gm, 2gm, 500mg
2
EVOMELA
5
ACS
GLEOSTINE CAPSULE 10MG, 40MG
4
ACS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 21
Drug Name
Drug
Tier
Requirements/Limits
GLEOSTINE CAPSULE 100MG
5
ACS
IFEX
4
IFOSFAMIDE INJECTION 3GM
4
ifosfamide injection 1gm/20ml, 1gm, 3gm/60ml
2
LEUKERAN
4
MO
melphalan hydrochloride injection
5
melphalan tablet 2mg
2
B/D MO
oxaliplatin injection 100mg/20ml, 200mg/40ml, 50mg/10ml
2
oxaliplatin injection 100mg, 50mg
5
paraplatin
2
TEMODAR
5
ACS
TEPADINA
5
ACS
thiotepa
5
TREANDA
5
LA; ACS
YONDELIS
5
PA; ACS
ZANOSAR
4
ZEPZELCA
5
PA LA; ACS
ANTIBIOTICS
adriamycin
2
B/D
bleomycin sulfate
2
B/D
COSMEGEN
5
dactinomycin
5
DAUNORUBICIN HYDROCHLORIDE INJECTION
50MG/10ML
4
daunorubicin hydrochloride injection 20mg/4ml
2
DOXIL
5
doxorubicin hcl injection 2mg/ml
2
B/D
doxorubicin hydrochloride injection 200mg/100ml
2
B/D
doxorubicin hydrochloride liposomal 20mg/10ml; 50mg/25ml
5
ELLENCE
5
IDAMYCIN PFS
5
idarubicin hcl
2
mitomycin injection 5mg
2
mitomycin injection 20mg, 40mg
5
mutamycin injection 20mg, 5mg
2
mutamycin injection 40mg
5
valrubicin
5
ACS
VALSTAR
5
LA; ACS
ANTIMETABOLITES
ALIMTA
5
ARRANON
5
azacitidine
5
ACS
cladribine
5
B/D
clofarabine
5
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 22
Drug Name
Drug
Tier
Requirements/Limits
CLOLAR
5
cytarabine injection 100mg/ml
2
B/D
cytarabine aqueous injection 20mg/ml
2
B/D
decitabine
5
ACS
fludarabine phosphate
2
fluorouracil injection 1gm/20ml, 2.5gm/50ml, 500mg/10ml,
5gm/100ml
2
B/D
FOLOTYN
5
ACS
gemcitabine hcl
2
GEMCITABINE HYDROCHLORIDE INJECTION
1GM/10ML, 2GM/20ML
4
gemcitabine hydrochloride injection 1gm/26.3ml, 200mg/2ml,
200mg/5.26ml, 2gm/52.6ml
2
INFUGEM
5
INQOVI
5
QL (5 EA per 28 days) PA LA; ACS
LONSURF
5
PA LA; ACS
mercaptopurine
2
MO
methotrexate sodium injection pf 50mg/2ml
2
MO
methotrexate sodium injection 1gm/40ml, 1gm
2
methotrexate sodium injection 250mg/10ml, 50mg/2ml
2
MO
nelarabine
5
ONUREG
5
QL (14 EA per 28 days) PA LA;
ACS
PEMETREXED INJECTION 100MG/4ML, 100MG,
1GM/40ML, 500MG/20ML, 500MG
5
pemetrexed injection 1000mg, 100mg, 500mg, 750mg
5
PURIXAN
5
LA; ACS
TABLOID
4
MO
VIDAZA
5
LA; ACS
HORMONAL ANTINEOPLASTIC AGENTS
abiraterone acetate
5
PA; ACS
anastrozole
2
MO
ARIMIDEX
5
MO
AROMASIN
5
MO
bicalutamide
2
MO
CASODEX
5
MO
ELIGARD
4
PA; ACS
EMCYT
4
MO
ERLEADA
5
PA LA; ACS
EULEXIN
5
exemestane
2
MO
FARESTON
5
PA MO
FASLODEX
5
FEMARA
4
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 23
Drug Name
Drug
Tier
Requirements/Limits
FIRMAGON INJECTION 80MG
4
PA; ACS
FIRMAGON INJECTION 120MG/VIAL
5
PA; ACS
fulvestrant
5
hydroxyprogesterone caproate injection 1.25gm/5ml
5
letrozole
2
MO
LEUPROLIDE ACETATE INJECTION 22.5MG
5
PA; ACS
leuprolide acetate injection 1mg/0.2ml
2
PA; ACS
LUPRON DEPOT (1-MONTH)
5
PA; ACS
LUPRON DEPOT (3-MONTH)
5
PA; ACS
LUPRON DEPOT (4-MONTH)
5
PA; ACS
LUPRON DEPOT (6-MONTH)
5
PA; ACS
LYSODREN
5
LA MO
megestrol acetate tablet 20mg, 40mg
2
MO
NILANDRON
5
MO
nilutamide
5
MO
NUBEQA
5
PA LA; ACS
ORGOVYX
5
PA LA MO
ORSERDU TABLET 345MG
5
QL (30 EA per 30 days) PA LA MO
ORSERDU TABLET 86MG
5
QL (90 EA per 30 days) PA LA MO
SOLTAMOX
5
MO
tamoxifen citrate
2
MO
toremifene citrate
5
PA MO
TRELSTAR MIXJECT INJECTION 11.25MG, 22.5MG,
3.75MG
5
PA; ACS
XTANDI
5
PA LA; ACS
YONSA
5
PA LA; ACS
ZOLADEX
4
ACS
ZYTIGA
5
PA LA; ACS
IMMUNOMODULATORS
lenalidomide capsule 20mg, 25mg
5
QL (21 EA per 28 days) PA LA;
ACS
lenalidomide capsule 10mg, 15mg, 2.5mg, 5mg
5
QL (28 EA per 28 days) PA LA;
ACS
POMALYST
5
QL (21 EA per 28 days) PA LA;
ACS
REVLIMID CAPSULE 20MG, 25MG
5
QL (21 EA per 28 days) PA LA;
ACS
REVLIMID CAPSULE 10MG, 15MG, 2.5MG, 5MG
5
QL (28 EA per 28 days) PA LA;
ACS
THALOMID CAPSULE 100MG, 50MG
5
QL (28 EA per 28 days) PA LA;
ACS
THALOMID CAPSULE 150MG, 200MG
5
QL (56 EA per 28 days) PA LA;
ACS
MISCELLANEOUS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 24
Drug Name
Drug
Tier
Requirements/Limits
arsenic trioxide
5
ASPARLAS
5
PA LA; ACS
BESREMI
5
QL (2 ML per 28 days) PA LA
bexarotene capsule 75mg
5
PA; ACS
CAMPTOSAR
4
dacarbazine
2
HYCAMTIN
5
HYDREA
4
MO
hydroxyurea
2
MO
IMLYGIC
5
PA
irinotecan
2
irinotecan hydrochloride injection 300mg/15ml, 40mg/2ml
2
irinotecan hydrochloride injection 100mg/5ml
5
KISQALI FEMARA 200 DOSE
5
PA; ACS
KISQALI FEMARA 400 DOSE
5
PA; ACS
KISQALI FEMARA 600 DOSE
5
PA; ACS
MATULANE
5
LA MO
mitoxantrone hcl
2
ACS
NIPENT
5
ONCASPAR
5
PA LA
ONIVYDE
5
PA LA; ACS
RYLAZE
5
PA LA; ACS
SYNRIBO
5
PA; ACS
TARGRETIN CAPSULE 75MG
5
PA; ACS
TICE BCG
4
TOPOTECAN HCL INJECTION 4MG/4ML
5
topotecan hcl injection 4mg
5
tretinoin capsule 10mg
5
MO
TRISENOX
5
VYXEOS
5
PA; ACS
WELIREG
5
QL (90 EA per 30 days) PA LA MO
MITOTIC INHIBITORS
ABRAXANE
5
LA; ACS
DOCETAXEL INJECTION 160MG/16ML, 160MG/8ML,
20MG/2ML, 80MG/8ML
5
docetaxel injection 20mg/ml, 80mg/4ml
2
ETOPOPHOS
5
etoposide
2
HALAVEN
5
PA; ACS
IXEMPRA KIT
5
PA; ACS
JEVTANA
5
PA LA; ACS
paclitaxel
2
paclitaxel protein-bound particles
5
ACS
toposar
2
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 25
Drug Name
Drug
Tier
Requirements/Limits
vinblastine sulfate
2
B/D
vincasar pfs
2
B/D
vincristine sulfate
2
B/D
vinorelbine tartrate
2
MOLECULAR TARGET AGENTS
AFINITOR
5
QL (30 EA per 30 days) PA; ACS
AFINITOR DISPERZ TABLET SOLUBLE 2MG
5
QL (150 EA per 30 days) PA; ACS
AFINITOR DISPERZ TABLET SOLUBLE 5MG
5
QL (60 EA per 30 days) PA; ACS
AFINITOR DISPERZ TABLET SOLUBLE 3MG
5
QL (90 EA per 30 days) PA; ACS
ALECENSA
5
QL (240 EA per 30 days) PA LA;
ACS
ALIQOPA
5
QL (3 EA per 28 days) PA LA
ALUNBRIG TABLET THERAPY PACK
5
PA LA MO
ALUNBRIG TABLET 30MG
5
QL (120 EA per 30 days) PA LA
MO
ALUNBRIG TABLET 180MG, 90MG
5
QL (30 EA per 30 days) PA LA MO
ALYMSYS
5
PA; ACS
ARZERRA
5
PA LA; ACS
AVASTIN
5
PA LA; ACS
AYVAKIT
5
QL (30 EA per 30 days) PA LA MO
BALVERSA TABLET 5MG
5
QL (28 EA per 28 days) PA LA;
ACS
BALVERSA TABLET 4MG
5
QL (56 EA per 28 days) PA LA;
ACS
BALVERSA TABLET 3MG
5
QL (84 EA per 28 days) PA LA;
ACS
BAVENCIO
5
PA LA; ACS
BELEODAQ
5
PA LA; ACS
BESPONSA
5
PA LA; ACS
BLENREP
5
PA LA
BLINCYTO
5
PA; ACS
BORTEZOMIB INJECTION 1MG, 2.5MG, 3.5MG
5
PA; ACS
bortezomib injection 3.5mg
5
PA; ACS
BOSULIF TABLET 100MG
5
QL (180 EA per 30 days) PA; ACS
BOSULIF TABLET 400MG, 500MG
5
QL (30 EA per 30 days) PA; ACS
BRAFTOVI CAPSULE 75MG
5
QL (180 EA per 30 days) PA LA;
ACS
BRUKINSA
5
QL (120 EA per 30 days) PA LA
MO
CABOMETYX
5
QL (30 EA per 30 days) PA LA;
ACS
CALQUENCE
5
QL (60 EA per 30 days) PA LA MO
CAPRELSA TABLET 300MG
5
QL (30 EA per 30 days) PA LA MO
CAPRELSA TABLET 100MG
5
QL (60 EA per 30 days) PA LA MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 26
Drug Name
Drug
Tier
Requirements/Limits
COLUMVI
5
PA LA; ACS
COMETRIQ KIT 140MG/DAY
5
QL (112 EA per 28 days) PA LA;
ACS
COMETRIQ KIT 100MG/DAY
5
QL (56 EA per 28 days) PA LA;
ACS
COMETRIQ KIT 20MG
5
QL (84 EA per 28 days) PA LA;
ACS
COPIKTRA
5
QL (56 EA per 28 days) PA LA;
ACS
COTELLIC
5
QL (63 EA per 28 days) PA LA;
ACS
CYRAMZA
5
PA LA; ACS
DARZALEX
5
PA LA; ACS
DARZALEX FASPRO
5
PA LA; ACS
DAURISMO TABLET 100MG
5
QL (30 EA per 30 days) PA LA;
ACS
DAURISMO TABLET 25MG
5
QL (60 EA per 30 days) PA LA;
ACS
EMPLICITI
5
PA LA; ACS
ENHERTU
5
PA LA; ACS
EPKINLY
5
PA LA
ERBITUX
5
PA; ACS
ERIVEDGE
5
PA LA; ACS
erlotinib hydrochloride tablet 100mg, 150mg
5
QL (30 EA per 30 days) PA; ACS
erlotinib hydrochloride tablet 25mg
5
QL (90 EA per 30 days) PA; ACS
everolimus tablet soluble 2mg
5
QL (150 EA per 30 days) PA; ACS
everolimus tablet soluble 5mg
5
QL (60 EA per 30 days) PA; ACS
everolimus tablet soluble 3mg
5
QL (90 EA per 30 days) PA; ACS
everolimus tablet 10mg, 2.5mg, 5mg, 7.5mg
5
QL (30 EA per 30 days) PA; ACS
EXKIVITY
5
QL (120 EA per 30 days) PA LA
MO
FOTIVDA
5
QL (21 EA per 28 days) PA LA MO
FYARRO
5
PA LA
GAVRETO
5
QL (120 EA per 30 days) PA LA;
ACS
GAZYVA
5
PA LA; ACS
gefitinib
5
QL (30 EA per 30 days) PA; ACS
GILOTRIF
5
QL (30 EA per 30 days) PA LA MO
GLEEVEC TABLET 400MG
5
QL (60 EA per 30 days) PA; ACS
GLEEVEC TABLET 100MG
5
QL (90 EA per 30 days) PA; ACS
HERCEPTIN
5
PA LA; ACS
HERCEPTIN HYLECTA
5
PA LA; ACS
HERZUMA
5
PA; ACS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 27
Drug Name
Drug
Tier
Requirements/Limits
IBRANCE
5
QL (21 EA per 28 days) PA LA;
ACS
ICLUSIG TABLET 10MG, 30MG
5
PA LA MO
ICLUSIG TABLET 15MG, 45MG
5
QL (30 EA per 30 days) PA LA MO
IDHIFA
5
QL (30 EA per 30 days) PA LA;
ACS
imatinib mesylate tablet 400mg
5
QL (60 EA per 30 days) PA; ACS
imatinib mesylate tablet 100mg
5
QL (90 EA per 30 days) PA; ACS
IMBRUVICA SUSPENSION
5
QL (216 ML per 27 days) PA LA
MO
IMBRUVICA TABLET
5
QL (30 EA per 30 days) PA LA MO
IMBRUVICA CAPSULE 70MG
5
QL (30 EA per 30 days) PA LA MO
IMBRUVICA CAPSULE 140MG
5
QL (90 EA per 30 days) PA LA MO
IMFINZI
5
PA LA; ACS
IMJUDO
5
PA LA; ACS
INLYTA TABLET 5MG
5
QL (120 EA per 30 days) PA LA;
ACS
INLYTA TABLET 1MG
5
QL (180 EA per 30 days) PA LA;
ACS
INREBIC
5
QL (120 EA per 30 days) PA LA;
ACS
IRESSA
5
QL (30 EA per 30 days) PA LA;
ACS
ISTODAX
5
ACS
JAKAFI
5
QL (60 EA per 30 days) PA LA;
ACS
JAYPIRCA TABLET 50MG
5
QL (30 EA per 30 days) PA LA;
ACS
JAYPIRCA TABLET 100MG
5
QL (60 EA per 30 days) PA LA;
ACS
JEMPERLI
5
PA LA; ACS
KADCYLA
5
LA; ACS
KANJINTI
5
PA LA; ACS
KEYTRUDA INJECTION 100MG/4ML
5
PA LA; ACS
KIMMTRAK
5
PA LA
KISQALI TABLET THERAPY PACK 200MG, 400MG,
600MG
5
PA; ACS
KOSELUGO
5
PA LA MO
KRAZATI
5
QL (180 EA per 30 days) PA LA
MO
KYPROLIS
5
PA LA; ACS
lapatinib ditosylate
5
QL (180 EA per 30 days) PA LA;
ACS
LENVIMA 10 MG DAILY DOSE
5
PA LA; ACS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 28
Drug Name
Drug
Tier
Requirements/Limits
LENVIMA 12MG DAILY DOSE
5
PA LA; ACS
LENVIMA 14 MG DAILY DOSE
5
PA LA; ACS
LENVIMA 18 MG DAILY DOSE
5
PA LA; ACS
LENVIMA 20 MG DAILY DOSE
5
PA LA; ACS
LENVIMA 24 MG DAILY DOSE
5
PA LA; ACS
LENVIMA 4 MG DAILY DOSE
5
PA LA; ACS
LENVIMA 8 MG DAILY DOSE
5
PA LA; ACS
LIBTAYO
5
PA LA
LORBRENA TABLET 100MG
5
QL (30 EA per 30 days) PA LA;
ACS
LORBRENA TABLET 25MG
5
QL (90 EA per 30 days) PA LA;
ACS
LUMAKRAS TABLET 120MG
5
QL (240 EA per 30 days) PA LA;
ACS
LUMAKRAS TABLET 320MG
5
QL (90 EA per 30 days) PA LA;
ACS
LUNSUMIO
5
PA LA; ACS
LYNPARZA
5
QL (120 EA per 30 days) PA LA;
ACS
LYTGOBI TABLET THERAPY PACK 16MG
5
QL (112 EA per 28 days) PA LA
MO
LYTGOBI TABLET THERAPY PACK 20MG
5
QL (140 EA per 28 days) PA LA
MO
LYTGOBI TABLET THERAPY PACK 12MG
5
QL (84 EA per 28 days) PA LA MO
MARGENZA
5
PA LA; ACS
MEKINIST SOLUTION RECONSTITUTED
5
QL (1260 ML per 30 days) PA LA;
ACS
MEKINIST TABLET 2MG
5
QL (30 EA per 30 days) PA LA;
ACS
MEKINIST TABLET 0.5MG
5
QL (90 EA per 30 days) PA LA;
ACS
MEKTOVI
5
QL (180 EA per 30 days) PA LA;
ACS
MONJUVI
5
PA LA
MVASI
5
PA LA; ACS
MYLOTARG
5
PA LA; ACS
NERLYNX
5
QL (180 EA per 30 days) PA LA;
ACS
NEXAVAR
5
QL (120 EA per 30 days) PA LA;
ACS
NINLARO
5
PA; ACS
ODOMZO
5
PA LA; ACS
OGIVRI
5
PA LA; ACS
ONTRUZANT
5
PA LA; ACS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 29
Drug Name
Drug
Tier
Requirements/Limits
OPDIVO
5
PA LA; ACS
OPDUALAG
5
PA LA; ACS
PADCEV
5
PA LA; ACS
PEMAZYRE
5
QL (14 EA per 21 days) PA LA MO
PERJETA
5
PA LA; ACS
PHESGO
5
PA LA; ACS
PIQRAY 200MG DAILY DOSE
5
QL (28 EA per 28 days) PA; ACS
PIQRAY 250MG DAILY DOSE
5
QL (56 EA per 28 days) PA; ACS
PIQRAY 300MG DAILY DOSE
5
QL (56 EA per 28 days) PA; ACS
POLIVY
5
PA LA; ACS
PORTRAZZA
5
PA LA; ACS
POTELIGEO
5
PA LA; ACS
QINLOCK
5
QL (90 EA per 30 days) PA LA MO
RETEVMO CAPSULE 80MG
5
QL (120 EA per 30 days) PA LA;
ACS
RETEVMO CAPSULE 40MG
5
QL (180 EA per 30 days) PA LA;
ACS
REZLIDHIA
5
QL (60 EA per 30 days) PA LA MO
RIABNI
5
PA LA; ACS
RITUXAN
5
PA LA; ACS
RITUXAN HYCELA
5
PA LA; ACS
romidepsin
5
ACS
ROZLYTREK CAPSULE 100MG
5
QL (150 EA per 30 days) PA LA;
ACS
ROZLYTREK CAPSULE 200MG
5
QL (90 EA per 30 days) PA LA;
ACS
RUBRACA
5
PA LA; ACS
RUXIENCE
5
PA; ACS
RYBREVANT
5
PA LA; ACS
RYDAPT
5
QL (224 EA per 28 days) PA; ACS
SARCLISA
5
PA LA; ACS
SCEMBLIX TABLET 40MG
5
QL (300 EA per 30 days) PA; ACS
SCEMBLIX TABLET 20MG
5
QL (60 EA per 30 days) PA; ACS
sorafenib tosylate
5
QL (120 EA per 30 days) PA; ACS
SPRYCEL TABLET 100MG, 140MG, 50MG, 70MG, 80MG
5
QL (30 EA per 30 days) PA; ACS
SPRYCEL TABLET 20MG
5
QL (90 EA per 30 days) PA; ACS
STIVARGA
5
QL (84 EA per 28 days) PA LA;
ACS
sunitinib malate
5
QL (30 EA per 30 days) PA; ACS
SUTENT
5
QL (30 EA per 30 days) PA LA;
ACS
TABRECTA
5
QL (112 EA per 28 days) PA; ACS
TAFINLAR CAPSULE
5
QL (120 EA per 30 days) PA LA;
ACS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 30
Drug Name
Drug
Tier
Requirements/Limits
TAFINLAR TABLET SOLUBLE
5
QL (900 EA per 30 days) PA LA;
ACS
TAGRISSO
5
QL (30 EA per 30 days) PA LA;
ACS
TALZENNA CAPSULE 0.1MG, 0.35MG, 0.5MG, 0.75MG,
1MG
5
QL (30 EA per 30 days) PA LA;
ACS
TALZENNA CAPSULE 0.25MG
5
QL (90 EA per 30 days) PA LA;
ACS
TARCEVA TABLET 100MG, 150MG
5
QL (30 EA per 30 days) PA LA;
ACS
TARCEVA TABLET 25MG
5
QL (90 EA per 30 days) PA LA;
ACS
TASIGNA CAPSULE 150MG, 200MG
5
QL (112 EA per 28 days) PA; ACS
TASIGNA CAPSULE 50MG
5
QL (120 EA per 30 days) PA; ACS
TAZVERIK
5
QL (240 EA per 30 days) PA LA
MO
TECENTRIQ
5
PA LA; ACS
TECVAYLI
5
PA LA
temsirolimus
5
ACS
TEPMETKO
5
QL (60 EA per 30 days) PA LA MO
TIBSOVO
5
PA LA MO
TIVDAK
5
PA LA; ACS
TORISEL
5
ACS
TRAZIMERA
5
PA; ACS
TRODELVY
5
PA LA
TRUSELTIQ CAPSULE THERAPY PACK 100MG
5
QL (21 EA per 28 days) PA LA;
ACS
TRUSELTIQ CAPSULE THERAPY PACK 0, 25MG
5
QL (42 EA per 28 days) PA LA;
ACS
TRUSELTIQ CAPSULE THERAPY PACK 25MG
5
QL (63 EA per 28 days) PA LA;
ACS
TRUXIMA
5
PA; ACS
TUKYSA TABLET 150MG
5
QL (120 EA per 30 days) PA LA
MO
TUKYSA TABLET 50MG
5
QL (240 EA per 30 days) PA LA
MO
TURALIO
5
QL (120 EA per 30 days) PA LA
MO
TYKERB
5
QL (180 EA per 30 days) PA LA;
ACS
VANFLYTA
5
QL (56 EA per 28 days) PA LA
VECTIBIX
5
PA LA; ACS
VEGZELMA
5
PA; ACS
VELCADE
5
PA; ACS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 31
Drug Name
Drug
Tier
Requirements/Limits
VENCLEXTA STARTING PACK
5
QL (42 EA per 28 days) PA LA MO
VENCLEXTA TABLET 10MG
4
QL (120 EA per 30 days) PA LA
MO
VENCLEXTA TABLET 50MG
5
QL (120 EA per 30 days) PA LA
MO
VENCLEXTA TABLET 100MG
5
QL (180 EA per 30 days) PA LA
MO
VERZENIO
5
PA LA; ACS
VITRAKVI SOLUTION
5
QL (300 ML per 30 days) PA LA;
ACS
VITRAKVI CAPSULE 25MG
5
QL (180 EA per 30 days) PA LA;
ACS
VITRAKVI CAPSULE 100MG
5
QL (60 EA per 30 days) PA LA;
ACS
VIZIMPRO
5
QL (30 EA per 30 days) PA LA;
ACS
VONJO
5
QL (120 EA per 30 days) PA LA
MO
VOTRIENT
5
QL (120 EA per 30 days) PA LA;
ACS
XALKORI
5
QL (120 EA per 30 days) PA LA;
ACS
XOSPATA
5
PA LA; ACS
XPOVIO 60 MG TWICE WEEKLY
5
QL (24 EA per 28 days) PA LA MO
XPOVIO 80 MG TWICE WEEKLY
5
QL (32 EA per 28 days) PA LA MO
XPOVIO TABLET THERAPY PACK 40MG, 60MG
5
QL (4 EA per 28 days) PA LA MO
XPOVIO TABLET THERAPY PACK 40MG, 50MG
5
QL (8 EA per 28 days) PA LA MO
YERVOY
5
PA LA; ACS
ZALTRAP
5
PA LA; ACS
ZEJULA CAPSULE
5
PA LA; ACS
ZEJULA TABLET
5
QL (30 EA per 30 days) PA LA;
ACS
ZELBORAF
5
QL (240 EA per 30 days) PA LA;
ACS
ZIRABEV
5
PA LA; ACS
ZOLINZA
5
PA; ACS
ZYDELIG
5
QL (60 EA per 30 days) PA LA;
ACS
ZYKADIA
5
QL (84 EA per 28 days) PA LA;
ACS
ZYNLONTA
5
PA LA
ZYNYZ
5
PA LA; ACS
PROTECTIVE AGENTS
dexrazoxane injection 500mg
2
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 32
Drug Name
Drug
Tier
Requirements/Limits
dexrazoxane injection 250mg
5
ELITEK
5
KEPIVANCE
5
KHAPZORY
5
B/D LA; ACS
leucovorin calcium injection
2
leucovorin calcium tablet
2
MO
levoleucovorin calcium injection 50mg
5
ACS
levoleucovorin calcium injection 250mg/25ml
2
ACS
levoleucovorin calcium injection 175mg/17.5ml
5
ACS
mesna
2
MESNEX INJECTION
4
MESNEX TABLET
5
MO
CARDIOVASCULAR
ACE INHIBITOR COMBINATIONS
ACCURETIC
4
MO
amlodipine besylate/benazepril hydrochloride
1
QL (30 EA per 30 days) MO
benazepril hcl/hydrochlorothiazide
1
MO
captopril/hydrochlorothiazide
1
MO
enalapril maleate/hydrochlorothiazide
1
MO
fosinopril sodium/hydrochlorothiazide
1
MO
lisinopril/hydrochlorothiazide
1
MO
LOTENSIN HCT
4
MO
LOTREL
4
QL (30 EA per 30 days) MO
quinapril/hydrochlorothiazide
1
MO
trandolapril/verapamil hcl er
1
MO
VASERETIC
4
MO
ZESTORETIC
4
MO
ACE INHIBITORS
ACCUPRIL
4
MO
ALTACE
4
MO
benazepril hcl tablet 10mg, 40mg, 5mg
1
MO
benazepril hydrochloride tablet 20mg
1
MO
captopril
1
MO
enalapril maleate tablet
1
MO
enalapril maleate oral solution
2
MO
enalaprilat i.v. injection
2
EPANED
5
MO
fosinopril sodium
1
MO
lisinopril
1
MO
LOTENSIN
4
MO
moexipril hcl
1
MO
perindopril erbumine
1
MO
QBRELIS
4
MO
quinapril hcl tablet 20mg, 40mg
1
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 33
Drug Name
Drug
Tier
Requirements/Limits
quinapril hydrochloride tablet 10mg, 5mg
1
MO
ramipril
1
MO
trandolapril
1
MO
VASOTEC TABLET 10MG, 2.5MG, 5MG
4
MO
VASOTEC TABLET 20MG
5
MO
ZESTRIL
4
MO
ALDOSTERONE RECEPTOR ANTAGONISTS
ALDACTONE
4
MO
CAROSPIR
4
MO
eplerenone
2
MO
INSPRA
4
MO
KERENDIA
3
QL (30 EA per 30 days) MO
spironolactone
1
MO
ALPHA BLOCKERS
CARDURA TABLET 2MG, 4MG, 8MG
4
MO
CARDURA TABLET 1MG
5
MO
doxazosin mesylate
2
MO
MINIPRESS
4
MO
prazosin hydrochloride
2
MO
terazosin hcl capsule 10mg, 1mg, 5mg
1
MO
terazosin hydrochloride capsule 2mg
1
MO
ANGIOTENSIN II RECEPTOR ANTAGONIST
COMBINATIONS
amlodipine besylate/valsartan
1
QL (30 EA per 30 days) MO
amlodipine/olmesartan medoxomil
1
QL (30 EA per 30 days) MO
amlodipine/valsartan/hydrochlorothiazide
1
QL (30 EA per 30 days) MO
ATACAND HCT TABLET 32MG; 12.5MG, 32MG; 25MG
4
QL (30 EA per 30 days) ST MO
ATACAND HCT TABLET 16MG; 12.5MG
4
QL (60 EA per 30 days) ST MO
AVALIDE TABLET 12.5MG; 300MG
4
QL (30 EA per 30 days) ST MO
AVALIDE TABLET 12.5MG; 150MG
4
QL (60 EA per 30 days) ST MO
AZOR
4
QL (30 EA per 30 days) ST MO
BENICAR HCT
4
QL (30 EA per 30 days) ST MO
candesartan cilexetil/hydrochlorothiazide tablet 32mg;
12.5mg, 32mg; 25mg
1
QL (30 EA per 30 days) MO
candesartan cilexetil/hydrochlorothiazide tablet 16mg;
12.5mg
1
QL (60 EA per 30 days) MO
DIOVAN HCT
4
QL (30 EA per 30 days) ST MO
EDARBYCLOR
4
QL (30 EA per 30 days) MO
ENTRESTO
3
MO
EXFORGE
4
QL (30 EA per 30 days) ST MO
EXFORGE HCT
4
QL (30 EA per 30 days) ST MO
HYZAAR
4
QL (30 EA per 30 days) ST MO
irbesartan/hydrochlorothiazide tablet 12.5mg; 300mg
1
QL (30 EA per 30 days) MO
irbesartan/hydrochlorothiazide tablet 12.5mg; 150mg
1
QL (60 EA per 30 days) MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 34
Drug Name
Drug
Tier
Requirements/Limits
losartan potassium/hydrochlorothiazide
1
QL (30 EA per 30 days) MO
MICARDIS HCT TABLET 12.5MG; 40MG, 25MG; 80MG
4
QL (30 EA per 30 days) ST MO
MICARDIS HCT TABLET 12.5MG; 80MG
4
QL (60 EA per 30 days) ST MO
olmesartan medoxomil/amlodipine/hydrochlorothiazide
1
QL (30 EA per 30 days) MO
olmesartan medoxomil/hydrochlorothiazide
1
QL (30 EA per 30 days) MO
telmisartan/amlodipine
1
QL (30 EA per 30 days) MO
telmisartan/hydrochlorothiazide tablet 12.5mg; 40mg, 25mg;
80mg
1
QL (30 EA per 30 days) MO
telmisartan/hydrochlorothiazide tablet 12.5mg; 80mg
1
QL (60 EA per 30 days) MO
TRIBENZOR
4
QL (30 EA per 30 days) ST MO
valsartan/hydrochlorothiazide
1
QL (30 EA per 30 days) MO
ANGIOTENSIN II RECEPTOR ANTAGONISTS
ATACAND TABLET 32MG
4
QL (30 EA per 30 days) ST MO
ATACAND TABLET 16MG, 4MG, 8MG
4
QL (60 EA per 30 days) ST MO
AVAPRO
4
QL (30 EA per 30 days) ST MO
BENICAR TABLET 20MG, 40MG
4
QL (30 EA per 30 days) ST MO
BENICAR TABLET 5MG
4
QL (60 EA per 30 days) ST MO
candesartan cilexetil tablet 32mg
1
QL (30 EA per 30 days) MO
candesartan cilexetil tablet 16mg, 4mg, 8mg
1
QL (60 EA per 30 days) MO
COZAAR TABLET 100MG
4
QL (30 EA per 30 days) ST MO
COZAAR TABLET 25MG, 50MG
4
QL (60 EA per 30 days) ST MO
DIOVAN TABLET 320MG
4
QL (30 EA per 30 days) ST MO
DIOVAN TABLET 160MG, 40MG, 80MG
4
QL (60 EA per 30 days) ST MO
EDARBI
4
QL (30 EA per 30 days) MO
irbesartan
1
QL (30 EA per 30 days) MO
losartan potassium tablet 100mg
1
QL (30 EA per 30 days) MO
losartan potassium tablet 25mg, 50mg
1
QL (60 EA per 30 days) MO
MICARDIS
4
QL (30 EA per 30 days) ST MO
olmesartan medoxomil tablet 20mg, 40mg
1
QL (30 EA per 30 days) MO
olmesartan medoxomil tablet 5mg
1
QL (60 EA per 30 days) MO
telmisartan
1
QL (30 EA per 30 days) MO
VALSARTAN SOLUTION
5
QL (2400 ML per 30 days) PA MO
valsartan tablet 320mg
1
QL (30 EA per 30 days) MO
valsartan tablet 160mg, 40mg, 80mg
1
QL (60 EA per 30 days) MO
ANTIARRHYTHMICS
amiodarone hcl injection 50mg/ml
2
amiodarone hydrochloride injection 150mg/3ml, 450mg/9ml,
900mg/18ml
2
amiodarone hydrochloride tablet
2
MO
BETAPACE
5
MO
BETAPACE AF
4
MO
disopyramide phosphate
2
PA MO
dofetilide
2
ACS
flecainide acetate
2
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 35
Drug Name
Drug
Tier
Requirements/Limits
LIDOCAINE HCL IN D5W
4
LIDOCAINE HCL INJECTION 100MG/5ML
4
lidocaine hcl injection 100mg/5ml, 50mg/5ml
2
mexiletine hcl
2
MO
MULTAQ
3
MO
NEXTERONE
4
NORPACE CR
4
MO
NORPACE CAPSULE 100MG
4
PA MO
NORPACE CAPSULE 150MG
5
PA MO
pacerone
2
procainamide hcl
2
propafenone hcl tablet
2
MO
propafenone hydrochloride er capsule extended release 12
hour
2
MO
quinidine gluconate cr
2
MO
quinidine gluconate er
2
MO
quinidine sulfate
2
MO
RYTHMOL SR CAPSULE EXTENDED RELEASE 12
HOUR 225MG
4
MO
RYTHMOL SR CAPSULE EXTENDED RELEASE 12
HOUR 325MG, 425MG
5
MO
sorine tablet 160mg, 240mg, 80mg
2
sorine tablet 120mg
2
MO
sotalol hcl
2
MO
sotalol hydrochloride (af)
2
MO
SOTYLIZE
4
MO
TIKOSYN
4
ST; ACS
ANTILIPEMICS, FIBRATES
ANTARA
4
MO
FENOFIBRATE MICRONIZED CAPSULE 30MG, 90MG
4
MO
fenofibrate micronized capsule 134mg, 200mg, 67mg
2
MO
fenofibrate tablet 145mg, 160mg, 48mg, 54mg
2
MO
fenofibric acid dr capsule delayed release 135mg, 45mg
2
MO
FENOGLIDE
4
MO
gemfibrozil
2
MO
LIPOFEN
4
MO
LOPID
4
MO
TRICOR
4
MO
TRILIPIX
4
MO
ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS
ALTOPREV
5
QL (30 EA per 30 days) ST MO
ATORVALIQ
4
QL (600 ML per 30 days) ST
atorvastatin calcium
1
QL (30 EA per 30 days) MO
CRESTOR
4
QL (30 EA per 30 days) ST MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 36
Drug Name
Drug
Tier
Requirements/Limits
EZALLOR SPRINKLE
4
QL (30 EA per 30 days) ST MO
FLOLIPID
4
QL (300 ML per 30 days) ST MO
fluvastatin capsule 20mg, 40mg
1
QL (60 EA per 30 days) MO
fluvastatin sodium er tablet extended release 24 hour 80mg
1
QL (30 EA per 30 days) MO
LESCOL XL
4
QL (30 EA per 30 days) ST MO
LIPITOR
4
QL (30 EA per 30 days) ST MO
LIVALO
4
QL (30 EA per 30 days) ST MO
lovastatin
1
MO
pravastatin sodium
1
QL (30 EA per 30 days) MO
rosuvastatin calcium
1
QL (30 EA per 30 days) MO
simvastatin
1
QL (30 EA per 30 days) MO
ZOCOR
4
QL (30 EA per 30 days) ST MO
ZYPITAMAG TABLET 2MG, 4MG
4
QL (30 EA per 30 days) ST MO
ANTILIPEMICS, MISCELLANEOUS
cholestyramine
2
MO
cholestyramine light
2
MO
colesevelam hydrochloride
2
MO
COLESTID
4
MO
COLESTID FLAVORED
4
MO
colestipol hcl
2
MO
EVKEEZA
5
PA LA MO
ezetimibe
2
MO
EZETIMIBE/ROSUVASTATIN
4
QL (30 EA per 30 days) ST MO
ezetimibe/simvastatin
1
QL (30 EA per 30 days) MO
icosapent ethyl
2
MO
JUXTAPID CAPSULE 10MG, 20MG, 30MG, 5MG
5
PA LA MO
LEQVIO
4
PA LA MO; ACS
LOVAZA
4
QL (120 EA per 30 days) MO
NEXLETOL
3
QL (30 EA per 30 days) PA MO
NEXLIZET
3
QL (30 EA per 30 days) PA MO
niacin er tablet extended release 1000mg, 750mg
2
MO
niacin er tablet extended release 500mg
2
QL (60 EA per 30 days) MO
niacin immediate release tablet 500mg
2
MO
niacor
2
MO
omega-3-acid ethyl esters
2
QL (120 EA per 30 days) MO
PRALUENT
3
PA
prevalite
2
QUESTRAN
4
MO
QUESTRAN LIGHT
4
MO
REPATHA
3
PA
REPATHA PUSHTRONEX SYSTEM
3
PA
REPATHA SURECLICK
3
PA
ROSZET
4
QL (30 EA per 30 days) ST MO
VASCEPA
3
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 37
Drug Name
Drug
Tier
Requirements/Limits
VYTORIN
4
QL (30 EA per 30 days) ST MO
WELCHOL
4
MO
ZETIA
4
MO
BETA-BLOCKER/DIURETIC COMBINATIONS
atenolol/chlorthalidone
1
MO
bisoprolol fumarate/hydrochlorothiazide
2
MO
metoprolol/hydrochlorothiazide
2
MO
TENORETIC 100
4
MO
TENORETIC 50
4
MO
ZIAC TABLET 10MG; 6.25MG, 5MG; 6.25MG
4
MO
ZIAC TABLET 2.5MG; 6.25MG
5
MO
BETA-BLOCKERS
acebutolol hydrochloride
2
MO
atenolol
1
MO
betaxolol hcl tablet 10mg, 20mg
2
MO
bisoprolol fumarate
2
MO
BYSTOLIC TABLET 10MG, 2.5MG, 5MG
4
QL (30 EA per 30 days) MO
BYSTOLIC TABLET 20MG
4
QL (60 EA per 30 days) MO
carvedilol phosphate er capsule extended release 24 hour
2
QL (30 EA per 30 days) MO
carvedilol tablet
1
MO
COREC CR CAPSULE EXTENDED RELEASE 24 HOUR
4
QL (30 EA per 30 days) MO
COREG TABLET
4
MO
CORGARD
4
MO
HEMANGEOL
4
MO; ACS
INDERAL LA
5
MO
INDERAL XL
5
MO
INNOPRAN XL
5
MO
KAPSPARGO SPRINKLE
4
MO
LABETALOL HYDROCHLORIDE/DEXTROSE
4
LABETALOL HYDROCHLORIDE/SODIUM CHLORIDE
4
labetalol hydrochloride tablet
2
MO
LABETALOL HYDROCHLORIDE INJECTION
10MG/2ML
4
labetalol hydrochloride injection 5mg/ml
2
MO
LOPRESSOR
4
MO
metoprolol succinate er
2
MO
metoprolol tartrate tablet
1
MO
metoprolol tartrate injection
2
nadolol
2
MO
nebivolol hydrochloride tablet 10mg, 2.5mg, 5mg
2
QL (30 EA per 30 days) MO
nebivolol hydrochloride tablet 20mg
2
QL (60 EA per 30 days) MO
pindolol
2
MO
propranolol hcl er capsule extended release 24 hour 120mg,
160mg
2
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 38
Drug Name
Drug
Tier
Requirements/Limits
propranolol hcl er capsule extended release 24 hour 60mg,
80mg
2
MO
propranolol hcl tablet 10mg, 20mg, 80mg, 60mg
2
MO
propranolol hcl injection
2
propranolol hcl oral solution 20mg/5ml, 40mg/5ml, tablet
40mg
2
MO
TENORMIN
4
MO
timolol maleate tablet 10mg, 20mg, 5mg
1
MO
TOPROL XL
4
MO
CALCIUM CHANNEL BLOCKERS
amlodipine besylate
1
MO
CALAN SR
4
MO
CARDENE IV
4
CARDIZEM CD CAPSULE EXTENDED RELEASE 24
HOUR 180MG, 300MG
4
MO
CARDIZEM CD CAPSULE EXTENDED RELEASE 24
HOUR 120MG, 240MG, 360MG
5
MO
CARDIZEM LA TABLET EXTENDED RELEASE 24
HOUR
4
MO
CARDIZEM TABLET 120MG, 30MG
4
MO
CARDIZEM TABLET 60MG
5
MO
cartia xt
2
CONJUPRI
4
dilt-xr
2
MO
diltiazem hcl cd
2
MO
diltiazem hcl immediate release tablet
2
MO
DILTIAZEM HCL INJECTION 100MG
4
diltiazem hcl injection 125mg/25ml, 50mg/10ml
2
diltiazem hydrochloride er
2
MO
diltiazem hydrochloride injection
2
diltiazem hydrochloride tablet
2
MO
felodipine er
2
MO
isradipine
2
MO
KATERZIA ORAL SUSPENSION 1MG/ML
4
MO
LEVAMLODIPINE
4
matzim la
2
nicardipine hcl capsule 20mg, 30mg
2
MO
NICARDIPINE HYDROCHLORIDE/SODIUM CHLORIDE
INJ 40MG/200ML; 0.9%
4
NICARDIPINE HYDROCHLORIDE INJECTION
20MG/200ML; 0.9%
4
nicardipine hydrochloride injection 2.5mg/ml
2
nifedipine capsule 10mg, 20mg
2
PA MO
nifedipine er tablet extended release 24 hour
2
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 39
Drug Name
Drug
Tier
Requirements/Limits
nimodipine
2
MO
nisoldipine er
2
MO
NORLIQVA
5
MO
NORVASC
4
MO
NYMALIZE
4
PROCARDIA XL
4
MO
SULAR
5
MO
taztia xt
2
tiadylt er capsule extended release 24 hour 120mg, 180mg,
240mg, 300mg, 360mg
2
tiadylt er capsule extended release 24 hour 420mg
2
MO
TIAZAC
4
MO
verapamil hcl er capsule extended release 24 hour
2
MO
VERAPAMIL HCL SR CAPSULE EXTENDED RELEASE
24 HOUR 360MG
2
MO
verapamil hcl sr capsule extended release 24 hour 120mg,
180mg, 240mg
2
MO
verapamil hcl sr tablet extended release
2
MO
verapamil hcl tablet 40mg, 80mg
1
MO
verapamil hydrochloride er tablet extended release
2
MO
verapamil hydrochloride tablet 120mg
1
MO
verapamil hydrochloride injection
2
MO
VERELAN
4
MO
VERELAN PM
4
MO
DIURETICS
acetazolamide tablet
2
MO
acetazolamide er capsule extended release
2
MO
acetazolamide sodium injection
2
ALDACTAZIDE
4
MO
amiloride hcl
2
MO
amiloride/hydrochlorothiazide
2
MO
bumetanide
2
MO
BUMEX TABLET 0.5MG
4
chlorothiazide sodium injection 500mg
2
chlorthalidone
2
MO
dichlorphenamide
5
QL (120 EA per 30 days) PA LA;
ACS
DIURIL
4
MO
DYRENIUM
4
MO
EDECRIN TABLET 25MG
5
MO
ethacrynate sodium injection
5
ethacrynic acid tabs
4
MO
FUROSCIX
5
furosemide oral solution, tablet
1
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 40
Drug Name
Drug
Tier
Requirements/Limits
furosemide injection
2
MO
hydrochlorothiazide
1
MO
indapamide
2
MO
KEVEYIS
5
QL (120 EA per 30 days) PA LA
MO
LASIX
4
MO
MANNITOL INJECTION 20%
4
mannitol injection 25%
2
MO
methazolamide
2
MO
metolazone
2
MO
OSMITROL VIAFLEX
4
SOAANZ
4
MO
SODIUM EDECRIN
4
spironolactone/hydrochlorothiazide
2
MO
THALITONE
4
QL (390 EA per 30 days) MO
torsemide
2
MO
triamterene
2
MO
triamterene/hydrochlorothiazide
1
MO
MISCELLANEOUS
ADRENALIN INJECTION 30MG/30ML
4
ADRENALIN INJECTION 1MG/ML
4
MO
aliskiren
1
MO
amlodipine besylate/atorvastatin calcium
1
MO
ASPRUZYO SPRINKLE
4
QL (60 EA per 30 days) PA MO
BIDIL
4
MO
CADUET
4
MO
CAMZYOS
5
QL (30 EA per 30 days) PA LA;
ACS
clonidine hcl patch weekly 0.1mg/24hr, 0.2mg/24hr,
0.3mg/24hr
2
QL (8 EA per 28 days) MO
clonidine hydrochloride tablet
2
MO
CORLANOR TABLET
3
MO
CORLANOR SOLUTION
4
DEMSER
5
PA MO
DIBENZYLINE
4
MO
digox
2
QL (30 EA per 30 days)
digoxin injection, oral solution
2
MO
digoxin tablet 125mcg, 250mcg
2
QL (30 EA per 30 days) MO
digoxin tablet 62.5mcg
2
QL (90 EA per 30 days) MO
dobutamine hcl injection 250mg/20ml
2
B/D
DOBUTAMINE HCL/D5W INJECTION 1MG/ML; 5%
4
B/D
DOBUTAMINE HYDROCHLORIDE/DEXTROSE
INJECTION 2MG/ML; 5%, 4MG/ML; 5%
4
B/D
DOPAMINE HYDROCHLORIDE INJECTION 40MG/ML
4
B/D
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 41
Drug Name
Drug
Tier
Requirements/Limits
DOPAMINE HYDROCHLORIDE/DEXTROSE INJECTION
0.8MG/ML; 5%, 1.6MG/ML; 5%
4
B/D
DOPAMINE/D5W INJECTION 3.2MG/ML; 5%
4
B/D
droxidopa capsule 100mg
2
QL (90 EA per 30 days) PA; ACS
droxidopa capsule 200mg, 300mg
5
QL (180 EA per 30 days) PA; ACS
epinephrine injection 1mg/ml, 30mg/30ml
2
guanfacine hydrochloride tablet 1mg, 2mg
2
PA MO
hydralazine hcl tablet 10mg
2
MO
hydralazine hydrochloride tablet 100mg, 25mg, 50mg
2
MO
INPEFA
4
QL (30 EA per 30 days) PA
isosorbide dinitrate/hydralazine hydrochloride
2
MO
LANOXIN PEDIATRIC
4
LANOXIN INJECTION
4
MO
LANOXIN TABLET 125MCG, 250MCG
4
QL (30 EA per 30 days) MO
LANOXIN TABLET 62.5MCG
4
QL (90 EA per 30 days) MO
metyrosine
4
PA MO
midodrine hcl
2
MO
milrinone lactate in dextrose
2
B/D
milrinone lactate injection 10mg/10ml, 50mg/50ml
2
B/D
milrinone lactate injection 20mg/20ml
5
B/D
minoxidil tablet 10mg, 2.5mg
2
MO
NORTHERA CAPSULE 200MG, 300MG
5
QL (180 EA per 30 days) PA LA;
ACS
NORTHERA CAPSULE 100MG
5
QL (90 EA per 30 days) PA LA;
ACS
phenoxybenzamine hydrochloride
2
MO
RANEXA
4
MO
ranolazine er
2
MO
TEKTURNA
4
MO
TEKTURNA HCT
3
MO
VECAMYL
4
QL (300 EA per 30 days) PA
VERQUVO
3
MO
VYNDAMAX
5
QL (30 EA per 30 days) PA LA;
ACS
VYNDAQEL
5
QL (120 EA per 30 days) PA LA;
ACS
NITRATES
GONITRO
4
MO
ISORDIL TITRADOSE TABLET 5MG
4
MO
ISORDIL TITRADOSE TABLET 40MG
5
MO
isosorbide dinitrate tablet 10mg, 20mg, 30mg, 5mg
2
MO
isosorbide dinitrate tablet 40mg
5
MO
isosorbide mononitrate
1
MO
isosorbide mononitrate er
2
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 42
Drug Name
Drug
Tier
Requirements/Limits
NITRO-BID
3
MO
NITRO-DUR
4
MO
NITROGLYCERIN IN DEXTROSE 5%
4
nitroglycerin lingual spray
2
MO
nitroglycerin transdermal
2
MO
NITROGLYCERIN INJECTION
4
nitroglycerin tablet sublingual
2
MO
NITROLINGUAL PUMPSPRAY
4
MO
NITROSTAT
4
MO
PULMONARY ARTERIAL HYPERTENSION
ADCIRCA
5
PA; ACS
ADEMPAS
5
QL (90 EA per 30 days) PA LA;
ACS
alyq
5
PA; ACS
ambrisentan
5
QL (30 EA per 30 days) PA LA;
ACS
bosentan tablet 62.5mg
5
QL (120 EA per 30 days) PA LA;
ACS
bosentan tablet 125mg
5
QL (60 EA per 30 days) PA LA;
ACS
epoprostenol sodium
2
B/D LA; ACS
FLOLAN INJECTION 0.5MG
4
B/D LA; ACS
FLOLAN INJECTION 1.5MG
5
B/D LA; ACS
LETAIRIS
5
QL (30 EA per 30 days) PA LA;
ACS
LIQREV
5
QL (244 ML per 30 days) PA; ACS
OPSUMIT
5
QL (30 EA per 30 days) PA LA;
ACS
ORENITRAM TITRATION KIT MONTH 1
5
PA LA; ACS
ORENITRAM TITRATION KIT MONTH 2
5
PA LA; ACS
ORENITRAM TITRATION KIT MONTH 3
5
PA LA; ACS
ORENITRAM TABLET EXTENDED RELEASE 0.125MG
4
PA LA; ACS
ORENITRAM TABLET EXTENDED RELEASE 0.25MG,
1MG, 2.5MG, 5MG
5
PA LA; ACS
REMODULIN
5
PA LA; ACS
REVATIO INJECTION
5
QL (1125 ML per 30 days) PA; ACS
REVATIO TABLET
5
QL (360 EA per 30 days) PA; ACS
REVATIO ORAL SUSPENSION RECONSTITUTED
5
QL (784 ML per 30 days) PA; ACS
sildenafil injection
5
QL (1125 ML per 30 days) PA; ACS
sildenafil citrate tablet
2
QL (360 EA per 30 days) PA; ACS
sildenafil citrate oral suspension reconstituted
5
QL (784 ML per 30 days) PA; ACS
tadalafil
5
PA; ACS
TADLIQ
5
QL (300 ML per 30 days) PA LA;
ACS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 43
Drug Name
Drug
Tier
Requirements/Limits
TRACLEER TABLET SOLUBLE
5
QL (120 EA per 30 days) PA LA;
ACS
TRACLEER TABLET 62.5MG
5
QL (120 EA per 30 days) PA LA;
ACS
TRACLEER TABLET 125MG
5
QL (60 EA per 30 days) PA LA;
ACS
treprostinil
5
PA LA; ACS
TYVASO
5
PA LA; ACS
TYVASO DPI MAINTENANCE KIT POWDER 16MCG,
32MCG, 48MCG, 64MCG
5
QL (112 EA per 28 days) PA LA;
ACS
TYVASO DPI MAINTENANCE KIT POWD 32MCG;
48MCG
5
QL (224 EA per 28 days) PA LA;
ACS
TYVASO DPI TITRATION KIT POWD 16MCG; 32MCG
5
QL (196 EA per 28 days) PA LA;
ACS
TYVASO DPI TITRATION KIT POWD 16MCG; 32MCG;
48MCG
5
QL (252 EA per 28 days) PA LA;
ACS
TYVASO REFILL
5
PA; ACS
TYVASO STARTER
5
PA; ACS
UPTRAVI TITRATION PACK
5
PA LA; ACS
UPTRAVI INJECTION
5
QL (60 EA per 30 days) PA LA MO
UPTRAVI TABLET 800MCG
5
QL (120 EA per 30 days) PA LA;
ACS
UPTRAVI TABLET 600MCG
5
QL (150 EA per 30 days) PA LA;
ACS
UPTRAVI TABLET 400MCG
5
QL (240 EA per 30 days) PA LA;
ACS
UPTRAVI TABLET 200MCG
5
QL (480 EA per 30 days) PA LA;
ACS
UPTRAVI TABLET 1200MCG, 1400MCG, 1600MCG
5
QL (60 EA per 30 days) PA LA;
ACS
UPTRAVI TABLET 1000MCG
5
QL (90 EA per 30 days) PA LA;
ACS
VELETRI
5
B/D LA; ACS
VENTAVIS
5
PA LA; ACS
CENTRAL NERVOUS SYSTEM
ANTIANXIETY
alprazolam er tablet extended release 24 hour 1mg
2
QL (30 EA per 30 days) MO; HRM
alprazolam er tablet extended release 24 hour 3mg
2
QL (60 EA per 30 days) MO; HRM
alprazolam er tablet extended release 24 hour 0.5mg
2
QL (600 EA per 30 days) MO; HRM
alprazolam er tablet extended release 24 hour 2mg
2
QL (90 EA per 30 days) MO; HRM
ALPRAZOLAM INTENSOL
4
QL (300 ML per 30 days) MO;
HRM
alprazolam odt tablet disintegrating 0.25mg
2
QL (120 EA per 30 days) MO; HRM
alprazolam odt tablet disintegrating 0.5mg, 1mg, 2mg
2
QL (150 EA per 30 days) MO; HRM
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 44
Drug Name
Drug
Tier
Requirements/Limits
ALPRAZOLAM XR TABLET EXTENDED RELEASE 24
HOUR 1MG
2
QL (30 EA per 30 days) MO; HRM
ALPRAZOLAM XR TABLET EXTENDED RELEASE 24
HOUR 3MG
2
QL (60 EA per 30 days) MO; HRM
ALPRAZOLAM XR TABLET EXTENDED RELEASE 24
HOUR 2MG
2
QL (90 EA per 30 days) MO; HRM
alprazolam tablet 0.25mg, 0.5mg
2
QL (120 EA per 30 days) MO; HRM
alprazolam tablet 1mg, 2mg
2
QL (150 EA per 30 days) MO; HRM
ATIVAN INJECTION 2MG/ML
4
QL (150 ML per 30 days) MO;
HRM
ATIVAN INJECTION 4MG/ML
4
QL (150 ML per 30 days); HRM
ATIVAN TABLET 0.5MG
5
QL (120 EA per 30 days) MO; HRM
ATIVAN TABLET 1MG, 2MG
5
QL (150 EA per 30 days) MO; HRM
buspirone hcl tablet 15mg, 30mg
2
MO
buspirone hydrochloride tablet 5mg, 7.5mg, 10mg
2
MO
chlordiazepoxide hcl capsule 5mg, 10mg
2
QL (120 EA per 30 days) PA MO;
HRM
chlordiazepoxide hydrochloride capsule 25mg
2
QL (120 EA per 30 days) PA MO;
HRM
droperidol
2
fluvoxamine maleate er capsule extended release 24 hour
2
QL (60 EA per 30 days) MO; HRM
fluvoxamine maleate tablet 100mg, 25mg, 50mg
2
MO; HRM
lorazepam intensol
2
QL (150 ML per 30 days) MO;
HRM
lorazepam injection
2
QL (150 ML per 30 days) MO;
HRM
lorazepam tablet 0.5mg
2
QL (120 EA per 30 days) MO; HRM
lorazepam tablet 1mg, 2mg
2
QL (150 EA per 30 days) MO; HRM
LOREEV XR CAPSULE ER 24 HOUR SPRINKLE 1MG,
2MG
5
QL (150 EA per 30 days) PA MO;
HRM
LOREEV XR CAPSULE ER 24 HOUR SPRINKLE 1.5MG
5
QL (150 EA per 30 days) PA; HRM
LOREEV XR CAPSULE ER 24 HOUR SPRINKLE 3MG
5
QL (90 EA per 30 days) PA MO;
HRM
meprobamate
2
PA MO
oxazepam
2
QL (120 EA per 30 days) PA MO;
HRM
XANAX XR TABLET EXTENDED RELEASE 24 HOUR
1MG
4
QL (30 EA per 30 days) ST MO;
HRM
XANAX XR TABLET EXTENDED RELEASE 24 HOUR
3MG
4
QL (60 EA per 30 days) ST MO;
HRM
XANAX XR TABLET EXTENDED RELEASE 24 HOUR
0.5MG
4
QL (600 EA per 30 days) ST MO;
HRM
XANAX XR TABLET EXTENDED RELEASE 24 HOUR
2MG
4
QL (90 EA per 30 days) ST MO;
HRM
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 45
Drug Name
Drug
Tier
Requirements/Limits
XANAX TABLET 0.25MG, 0.5MG
4
QL (120 EA per 30 days) ST MO;
HRM
XANAX TABLET 1MG
4
QL (150 EA per 30 days) ST MO;
HRM
XANAX TABLET 2MG
5
QL (150 EA per 30 days) ST MO;
HRM
ANTIDEMENTIA
ADLARITY
4
QL (4 EA per 28 days) PA MO
ARICEPT
4
QL (30 EA per 30 days) MO
donepezil hcl tablet disintegrating 10mg, 5mg
2
QL (30 EA per 30 days) MO
donepezil hydrochloride tablet 10mg, 23mg, 5mg
2
QL (30 EA per 30 days) MO
ergoloid mesylates
4
PA MO
EXELON PATCH 24 HOUR
4
QL (30 EA per 30 days) MO
galantamine hydrobromide er capsule extended release 24
hour
2
QL (30 EA per 30 days) MO
galantamine hydrobromide solution
2
QL (200 ML per 30 days) MO
galantamine hydrobromide tablet
2
QL (60 EA per 30 days) MO
memantine hcl titration pak
2
QL (98 EA per 365 days) PA MO
memantine hydrochloride er capsule extended release 24 hour
2
PA MO
memantine hydrochloride solution
2
QL (360 ML per 30 days) PA MO
memantine hydrochloride tablet
2
QL (60 EA per 30 days) PA MO
NAMENDA
4
QL (60 EA per 30 days) PA MO
NAMENDA TITRATION PAK
4
QL (98 EA per 365 days) PA MO
NAMENDA XR
4
PA MO
NAMZARIC
3
MO
RAZADYNE ER
4
QL (30 EA per 30 days) MO
rivastigmine tartrate capsule
2
QL (60 EA per 30 days) MO
rivastigmine transdermal system
2
QL (30 EA per 30 days) MO
ANTIDEPRESSANTS
amitriptyline hcl tablet 100mg, 150mg, 75mg, 25mg
2
PA MO; HRM
amitriptyline hydrochloride tablet 10mg, 50mg
2
PA MO; HRM
amoxapine
2
MO; HRM
ANAFRANIL
5
PA MO; HRM
APLENZIN TABLET EXTENDED RELEASE 24 HOUR
348MG, 522MG
4
QL (30 EA per 30 days) ST MO
APLENZIN TABLET EXTENDED RELEASE 24 HOUR
174MG
4
QL (60 EA per 30 days) ST MO
AUVELITY
4
QL (60 EA per 30 days) PA MO
bupropion hcl tablet 100mg
2
QL (120 EA per 30 days) MO
bupropion hydrochloride er (sr) tablet extended release 12
hour 100mg, 150mg, 200mg
2
QL (60 EA per 30 days) MO
BUPROPION HYDROCHLORIDE ER (XL) TABLET
EXTENDED RELEASE 24 HOUR 450MG
4
QL (30 EA per 30 days) MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 46
Drug Name
Drug
Tier
Requirements/Limits
bupropion hydrochloride er (xl) tablet extended release 24
hour 150mg, 300mg
2
QL (30 EA per 30 days) MO
bupropion hydrochloride tablet 75mg
2
QL (180 EA per 30 days) MO
CELEXA TABLET 10MG
4
QL (120 EA per 30 days) ST MO;
HRM
CELEXA TABLET 40MG
4
QL (30 EA per 30 days) ST MO;
HRM
CELEXA TABLET 20MG
4
QL (60 EA per 30 days) ST MO;
HRM
chlordiazepoxide/amitriptyline
2
PA MO; HRM
CITALOPRAM HYDROBROMIDE CAPSULE
4
QL (30 EA per 30 days) PA MO;
HRM
citalopram hydrobromide solution
2
QL (600 ML per 30 days) MO;
HRM
citalopram hydrobromide tablet 10mg
1
QL (120 EA per 30 days) MO; HRM
citalopram hydrobromide tablet 40mg
1
QL (30 EA per 30 days) MO; HRM
citalopram hydrobromide tablet 20mg
1
QL (60 EA per 30 days) MO; HRM
clomipramine hydrochloride capsule
2
PA MO; HRM
CYMBALTA
4
QL (60 EA per 30 days) MO; HRM
desipramine hydrochloride tablet
2
PA MO; HRM
DESVENLAFAXINE ER TABLET (GENERIC
KHEDEZLA) EXTENDED RELEASE 24 HOUR 100MG,
50MG
3
QL (30 EA per 30 days); HRM
desvenlafaxine er tablet (generic Pristiq) extended release 24
hour 100mg, 25mg, 50mg
2
QL (30 EA per 30 days) PA MO;
HRM
doxepin hcl capsule 75mg, oral concentrate 10mg/ml
2
PA MO; HRM
doxepin hydrochloride capsule 100mg, 10mg, 150mg, 25mg,
50mg
2
PA MO; HRM
DRIZALMA SPRINKLE CAPSULE DELAYED RELEASE
SPRINKLE 20MG, 30MG, 60MG
4
QL (60 EA per 30 days) PA MO;
HRM
DRIZALMA SPRINKLE CAPSULE DELAYED RELEASE
SPRINKLE 40MG
4
QL (90 EA per 30 days) PA MO;
HRM
duloxetine hcl capsule 40mg
2
QL (60 EA per 30 days) MO; HRM
duloxetine hydrochloride capsule 20mg, 30mg, 60mg
2
QL (60 EA per 30 days) MO; HRM
EFFEXOR XR CAPSULE EXTENDED RELEASE 24
HOUR 37.5MG, 75MG
4
QL (30 EA per 30 days) ST MO;
HRM
EFFEXOR XR CAPSULE EXTENDED RELEASE 24
HOUR 150MG
4
QL (60 EA per 30 days) ST MO;
HRM
EMSAM
4
QL (30 EA per 30 days) PA MO
escitalopram oxalate solution
2
QL (600 ML per 30 days) MO;
HRM
escitalopram oxalate tablet 20mg
2
QL (30 EA per 30 days) MO; HRM
escitalopram oxalate tablet 10mg, 5mg
2
QL (45 EA per 30 days) MO; HRM
FETZIMA TITRATION PACK
4
PA MO; HRM
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 47
Drug Name
Drug
Tier
Requirements/Limits
FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR
120MG, 80MG
4
QL (30 EA per 30 days) PA MO;
HRM
FETZIMA CAPSULE EXTENDED RELEASE 24 HOUR
20MG, 40MG
4
QL (60 EA per 30 days) PA MO;
HRM
fluoxetine dr capsule delayed release 90mg
2
QL (4 EA per 28 days) MO; HRM
fluoxetine hcl capsule 20mg
1
QL (120 EA per 30 days) MO; HRM
fluoxetine hydrochloride capsule 10mg
1
QL (30 EA per 30 days) MO; HRM
fluoxetine hydrochloride capsule 40mg
1
QL (60 EA per 30 days) MO; HRM
fluoxetine hydrochloride solution
2
MO; HRM
fluoxetine hydrochloride (generic Prozac) tablet 10mg, 20mg,
60mg
2
MO; HRM
fluoxetine hydrochloride (generic Sarafem) tablet 20mg
2
QL (120 EA per 30 days) MO; HRM
fluoxetine hydrochloride (generic Sarafem) tablet 10mg
2
QL (30 EA per 30 days) MO; HRM
FORFIVO XL
4
QL (30 EA per 30 days) ST MO
imipramine hcl tablet 25mg, 50mg
2
PA MO; HRM
imipramine hydrochloride tablet 10mg
2
PA MO; HRM
imipramine pamoate
2
PA MO; HRM
LEXAPRO TABLET 20MG
4
QL (30 EA per 30 days) MO; HRM
LEXAPRO TABLET 10MG, 5MG
4
QL (45 EA per 30 days) MO; HRM
MARPLAN
4
QL (180 EA per 30 days) MO
mirtazapine odt
2
QL (30 EA per 30 days) MO
mirtazapine tablet
2
QL (30 EA per 30 days) MO
NARDIL
4
MO
nefazodone hydrochloride
2
MO
NORPRAMIN
4
PA MO; HRM
nortriptyline hcl caps 25mg, 75mg, oral solution 10mg/5ml
2
MO; HRM
nortriptyline hydrochloride capsule 10mg, 50mg
2
MO; HRM
olanzapine/fluoxetine
2
QL (30 EA per 30 days) MO; HRM
PAMELOR
5
MO; HRM
PARNATE
5
MO
paroxetine hcl er tablet extended release 24 hour 37.5mg
2
QL (60 EA per 30 days) MO; HRM
paroxetine hcl er tablet extended release 24 hour 12.5mg,
25mg
2
QL (90 EA per 30 days) MO; HRM
paroxetine hcl tablet 40mg
2
QL (30 EA per 30 days) MO; HRM
paroxetine hcl tablet 30mg
2
QL (60 EA per 30 days) MO; HRM
paroxetine hcl tablet 10mg, 20mg
2
QL (30 EA per 30 days) MO; HRM
paroxetine hydrochloride suspension
2
QL (900 ML per 30 days) MO;
HRM
PAXIL CR TABLET EXTENDED RELEASE 24 HOUR
37.5MG
4
QL (60 EA per 30 days) ST MO;
HRM
PAXIL CR TABLET EXTENDED RELEASE 24 HOUR
12.5MG, 25MG
4
QL (90 EA per 30 days) ST MO;
HRM
PAXIL SUSPENSION
4
QL (900 ML per 30 days) MO;
HRM
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 48
Drug Name
Drug
Tier
Requirements/Limits
PAXIL TABLET 10MG, 20MG, 40MG
4
QL (30 EA per 30 days) ST MO;
HRM
PAXIL TABLET 30MG
4
QL (60 EA per 30 days) ST MO;
HRM
perphenazine/amitriptyline
2
PA MO; HRM
PEXEVA TABLET 10MG
4
QL (30 EA per 30 days) ST MO;
HRM
PEXEVA TABLET 20MG, 30MG
4
QL (60 EA per 30 days) ST MO;
HRM
phenelzine sulfate
2
MO
PRISTIQ
4
QL (30 EA per 30 days) ST MO;
HRM
protriptyline hcl
2
PA MO; HRM
PROZAC CAPSULE 10MG
4
QL (30 EA per 30 days) ST MO;
HRM
PROZAC CAPSULE 20MG
5
QL (120 EA per 30 days) ST MO;
HRM
PROZAC CAPSULE 40MG
5
QL (60 EA per 30 days) ST MO;
HRM
REMERON
4
QL (30 EA per 30 days) MO
REMERON SOLTAB
4
QL (30 EA per 30 days) MO
sertraline hcl concentrate
2
QL (300 ML per 30 days) MO;
HRM
sertraline hcl tablet 25mg
1
QL (30 EA per 30 days) MO; HRM
sertraline hcl tablet 50mg
1
QL (60 EA per 30 days) MO; HRM
SERTRALINE HYDROCHLORIDE CAPSULE
4
QL (30 EA per 30 days) ST MO;
HRM
sertraline hydrochloride tablet 100mg
1
QL (60 EA per 30 days) MO; HRM
SPRAVATO 56MG DOSE
5
SPRAVATO 84MG DOSE
5
SYMBYAX
4
QL (30 EA per 30 days) MO; HRM
tranylcypromine sulfate
2
MO
trazodone hydrochloride tablet
1
MO
trimipramine maleate capsule 50mg
2
QL (120 EA per 30 days) PA MO;
HRM
trimipramine maleate capsule 25mg
2
QL (240 EA per 30 days) PA MO;
HRM
trimipramine maleate capsule 100mg
2
QL (60 EA per 30 days) PA MO;
HRM
TRINTELLIX
3
QL (30 EA per 30 days) MO
VENLAFAXINE BESYLATE ER TABLET EXTENDED
RELEASE 24 HOUR 112.5MG
4
QL (60 EA per 30 days) MO; HRM
venlafaxine hcl er capsule extended release 24 hour 37.5mg
2
QL (30 EA per 30 days) MO; HRM
venlafaxine hcl er capsule extended release 24 hour 150mg
2
QL (60 EA per 30 days) MO; HRM
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 49
Drug Name
Drug
Tier
Requirements/Limits
venlafaxine hydrochloride tablet 100mg, 25mg, 37.5mg,
50mg, 75mg
2
MO; HRM
venlafaxine hydrochloride er capsule extended release 24
hour 75mg
2
QL (30 EA per 30 days) MO; HRM
venlafaxine hydrochloride er tablet extended release 24 hour
225mg, 37.5mg, 75mg
2
QL (30 EA per 30 days) MO; HRM
venlafaxine hydrochloride er tablet extended release 24 hour
150mg
2
QL (60 EA per 30 days) MO; HRM
VIIBRYD
4
QL (30 EA per 30 days) MO
VIIBRYD STARTER PACK
4
MO
vilazodone hydrochloride
2
QL (30 EA per 30 days) MO
WELLBUTRIN SR
4
QL (60 EA per 30 days) ST MO
WELLBUTRIN XL
5
QL (30 EA per 30 days) ST MO
ZOLOFT CONCENTRATE
4
QL (300 ML per 30 days) MO;
HRM
ZOLOFT TABLET 25MG
4
QL (30 EA per 30 days) ST MO;
HRM
ZOLOFT TABLET 100MG, 50MG
4
QL (60 EA per 30 days) ST MO;
HRM
ZULRESSO
5
B/D LA; ACS
ANTIPARKINSONIAN AGENTS
amantadine hcl solution, tablet
2
MO
amantadine hcl capsule
2
QL (120 EA per 30 days) MO
APOKYN
5
QL (60 ML per 30 days) PA LA;
ACS
apomorphine hydrochloride
5
QL (60 ML per 30 days) PA; ACS
AZILECT
5
MO
benztropine mesylate injection
2
MO
benztropine mesylate tablet
2
PA MO; HRM
bromocriptine mesylate capsule, tablet
2
MO
carbidopa tablet
2
MO
carbidopa/levodopa
2
MO
carbidopa/levodopa er
2
MO
carbidopa/levodopa odt
2
MO
CARBIDOPA/LEVODOPA/ENTACAPONE
4
MO
COMTAN
5
MO
DHIVY
4
MO
DUOPA
5
B/D LA; ACS
entacapone
2
MO
GOCOVRI CAPSULE EXTENDED RELEASE 24 HOUR
68.5MG
5
QL (30 EA per 30 days) LA MO;
ACS
GOCOVRI CAPSULE EXTENDED RELEASE 24 HOUR
137MG
5
QL (60 EA per 30 days) LA MO;
ACS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 50
Drug Name
Drug
Tier
Requirements/Limits
INBRIJA
5
QL (300 EA per 30 days) PA LA
MO
LODOSYN
5
MO
MIRAPEX ER TABLET EXTENDED RELEASE 24 HOUR
0.75MG, 2.25MG, 3.75MG, 3MG, 4.5MG
4
QL (30 EA per 30 days) ST MO
MIRAPEX ER TABLET EXTENDED RELEASE 24 HOUR
0.375MG, 1.5MG
5
QL (30 EA per 30 days) ST MO
NEUPRO
3
MO
NOURIANZ
5
QL (30 EA per 30 days) PA LA MO;
ACS
ONGENTYS CAPSULE 50MG
4
QL (30 EA per 30 days) PA MO
ONGENTYS CAPSULE 25MG
5
QL (30 EA per 30 days) PA MO
OSMOLEX ER
4
QL (30 EA per 30 days) ST LA MO;
ACS
PARLODEL
4
MO
pramipexole dihydrochloride er
2
QL (30 EA per 30 days) MO
pramipexole dihydrochloride immediate release tablet
2
MO
rasagiline mesylate
2
MO
ropinirole er tablet extended release 24 hour 6mg
2
QL (120 EA per 30 days) MO
ropinirole er tablet extended release 24 hour 4mg
2
QL (150 EA per 30 days) MO
ropinirole er tablet extended release 24 hour 2mg
2
QL (30 EA per 30 days) MO
ropinirole er tablet extended release 24 hour 12mg
2
QL (60 EA per 30 days) MO
ropinirole er tablet extended release 24 hour 8mg
2
QL (90 EA per 30 days) MO
ropinirole hcl immediate release tablet 0.25mg, 3mg
2
MO
ropinirole hcl immediate release tablet 0.5mg, 1mg, 2mg,
4mg, 5mg
2
MO
RYTARY
4
ST MO
selegiline hcl capsule, tablet
2
MO
SINEMET
4
MO
STALEVO 100
5
ST MO
STALEVO 125
5
ST MO
STALEVO 150
5
ST MO
STALEVO 200
5
ST MO
STALEVO 50
5
ST MO
STALEVO 75
5
ST MO
TASMAR
5
MO
tolcapone
4
MO
trihexyphenidyl hcl oral solution
2
PA MO; HRM
trihexyphenidyl hydrochloride tablet
2
PA MO; HRM
XADAGO
5
QL (30 EA per 30 days) ST MO
ZELAPAR
5
QL (60 EA per 30 days) MO
ANTIPSYCHOTICS
ABILIFY
5
QL (30 EA per 30 days) MO; HRM
ABILIFY ASIMTUFII INJECTION 720MG/2.4ML
5
QL (2.4 ML per 56 days) PA
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 51
Drug Name
Drug
Tier
Requirements/Limits
ABILIFY ASIMTUFII INJECTION 960MG/3.2ML
5
QL (3.2 ML per 56 days) PA MO
ABILIFY MAINTENA
3
QL (1 EA per 28 days) MO; HRM
ABILIFY MYCITE MAINTENANCE KIT
5
QL (30 EA per 30 days) PA; HRM
ABILIFY MYCITE STARTER KIT
5
QL (30 EA per 30 days) PA; HRM
aripiprazole odt
2
QL (60 EA per 30 days) MO; HRM
aripiprazole tablet
2
QL (30 EA per 30 days) MO; HRM
aripiprazole solution
2
QL (900 ML per 30 days) MO;
HRM
ARISTADA INITIO
4
HRM
ARISTADA INJECTION 441MG/1.6ML
4
QL (1.6 ML per 28 days); HRM
ARISTADA INJECTION 662MG/2.4ML
4
QL (2.4 ML per 28 days); HRM
ARISTADA INJECTION 882MG/3.2ML
4
QL (3.2 ML per 28 days); HRM
ARISTADA INJECTION 1064MG/3.9ML
4
QL (3.9 ML per 56 days); HRM
asenapine maleate sl
2
QL (60 EA per 30 days) MO; HRM
CAPLYTA
5
QL (30 EA per 30 days) MO; HRM
chlorpromazine hcl tablet
2
MO; HRM
chlorpromazine hcl injection 50mg/2ml
2
HRM
chlorpromazine hcl injection 25mg/ml
2
MO; HRM
chlorpromazine hydrochloride concentrate
2
HRM
chlorpromazine hydrochloride tablet
2
MO; HRM
CLOZAPINE ODT TABLET DISINTEGRATING 200MG
2
QL (120 EA per 30 days) PA; HRM
CLOZAPINE ODT TABLET DISINTEGRATING 150MG
2
QL (180 EA per 30 days) PA; HRM
clozapine odt tablet disintegrating 12.5mg, 25mg
2
PA; HRM
clozapine odt tablet disintegrating 100mg
2
QL (270 EA per 30 days) PA; HRM
clozapine tablet 25mg, 50mg
2
HRM
clozapine tablet 200mg
2
QL (120 EA per 30 days); HRM
clozapine tablet 100mg
2
QL (270 EA per 30 days); HRM
CLOZARIL TABLET 25MG, 50MG
4
HRM
CLOZARIL TABLET 200MG
5
QL (120 EA per 30 days); HRM
CLOZARIL TABLET 100MG
5
QL (270 EA per 30 days); HRM
FANAPT
5
QL (60 EA per 30 days) PA MO;
HRM
FANAPT TITRATION PACK
4
PA MO; HRM
fluphenazine decanoate injection
2
MO; HRM
fluphenazine hcl oral concentrate, tablet, injection
2
MO; HRM
fluphenazine hydrochloride oral elixir
2
MO; HRM
GEODON INJECTION
4
QL (6 EA per 3 days) MO; HRM
GEODON CAPSULE
5
QL (60 EA per 30 days) MO; HRM
HALDOL DECANOATE 100
4
MO; HRM
HALDOL DECANOATE 50
4
MO; HRM
haloperidol tablet, oral concentrate
2
MO; HRM
haloperidol decanoate
2
MO; HRM
haloperidol lactate injection
2
MO; HRM
INVEGA HAFYERA INJECTION 1092MG/3.5ML
5
QL (3.5 ML per 180 days); HRM
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 52
Drug Name
Drug
Tier
Requirements/Limits
INVEGA HAFYERA INJECTION 1560MG/5ML
5
QL (5 ML per 180 days); HRM
INVEGA SUSTENNA INJECTION 39MG/0.25ML
4
QL (0.25 ML per 28 days) MO;
HRM
INVEGA SUSTENNA INJECTION 78MG/0.5ML
4
QL (0.5 ML per 28 days) MO; HRM
INVEGA SUSTENNA INJECTION 117MG/0.75ML
4
QL (0.75 ML per 28 days) MO;
HRM
INVEGA SUSTENNA INJECTION 156MG/ML
4
QL (1 ML per 28 days) MO; HRM
INVEGA SUSTENNA INJECTION 234MG/1.5ML
4
QL (1.5 ML per 28 days) MO; HRM
INVEGA TRINZA INJECTION 273MG/0.88ML
5
QL (0.88 ML per 90 days); HRM
INVEGA TRINZA INJECTION 410MG/1.32ML
5
QL (1.32 ML per 90 days); HRM
INVEGA TRINZA INJECTION 546MG/1.75ML
5
QL (1.75 ML per 90 days); HRM
INVEGA TRINZA INJECTION 819MG/2.63ML
5
QL (2.63 ML per 90 days); HRM
INVEGA TABLET EXTENDED RELEASE 24 HOUR
1.5MG, 3MG, 9MG
4
QL (30 EA per 30 days) MO; HRM
INVEGA TABLET EXTENDED RELEASE 24 HOUR 6MG
4
QL (60 EA per 30 days) MO; HRM
LATUDA TABLET 120MG, 20MG, 40MG, 60MG
5
QL (30 EA per 30 days) MO; HRM
LATUDA TABLET 80MG
5
QL (60 EA per 30 days) MO; HRM
loxapine
2
MO; HRM
lurasidone hydrochloride tablet 120mg, 20mg, 40mg, 60mg
2
QL (30 EA per 30 days) MO; HRM
lurasidone hydrochloride tablet 80mg
2
QL (60 EA per 30 days) MO; HRM
LYBALVI
5
QL (30 EA per 30 days) PA MO;
HRM
molindone hydrochloride
2
HRM
NUPLAZID
5
QL (30 EA per 30 days) PA LA;
ACS HRM
olanzapine odt
2
QL (30 EA per 30 days) MO; HRM
olanzapine injection
2
QL (3 EA per 1 days) MO; HRM
olanzapine tablet 10mg, 15mg, 20mg, 7.5mg
2
QL (30 EA per 30 days) MO; HRM
olanzapine tablet 2.5mg, 5mg
2
QL (60 EA per 30 days) MO; HRM
paliperidone er tablet extended release 24 hour 1.5mg, 3mg,
9mg
2
QL (30 EA per 30 days) MO; HRM
paliperidone er tablet extended release 24 hour 6mg
2
QL (60 EA per 30 days) MO; HRM
perphenazine
2
MO; HRM
PERSERIS
3
QL (1 EA per 30 days); HRM
pimozide
2
MO
quetiapine fumarate er tablet extended release 24 hour
150mg, 200mg
2
QL (30 EA per 30 days) PA MO;
HRM
quetiapine fumarate er tablet extended release 24 hour
300mg, 400mg, 50mg
2
QL (60 EA per 30 days) PA MO;
HRM
quetiapine fumarate tablet 200mg
2
QL (120 EA per 30 days) MO; HRM
quetiapine fumarate tablet 25mg
2
QL (180 EA per 30 days) MO; HRM
quetiapine fumarate tablet 300mg, 400mg
2
QL (60 EA per 30 days) MO; HRM
quetiapine fumarate tablet 100mg, 150mg, 50mg
2
QL (90 EA per 30 days) MO; HRM
REXULTI TABLET 3MG, 4MG
4
QL (30 EA per 30 days) MO; HRM
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 53
Drug Name
Drug
Tier
Requirements/Limits
REXULTI TABLET 0.25MG, 0.5MG, 1MG, 2MG
4
QL (60 EA per 30 days) MO; HRM
RISPERDAL CONSTA
4
QL (2 EA per 28 days) MO; HRM
RISPERDAL SOLUTION
4
QL (480 ML per 30 days) MO;
HRM
RISPERDAL TABLET 1MG
4
QL (60 EA per 30 days) MO; HRM
RISPERDAL TABLET 0.5MG
4
QL (90 EA per 30 days) MO; HRM
RISPERDAL TABLET 4MG
5
QL (120 EA per 30 days) MO; HRM
RISPERDAL TABLET 2MG
5
QL (60 EA per 30 days) MO; HRM
RISPERDAL TABLET 3MG
5
QL (90 EA per 30 days) MO; HRM
risperidone odt tablet disintegrating 4mg
2
QL (120 EA per 30 days) MO; HRM
risperidone odt tablet disintegrating 1mg, 2mg, 3mg
2
QL (60 EA per 30 days) MO; HRM
risperidone odt tablet disintegrating 0.25mg, 0.5mg
2
QL (90 EA per 30 days) MO; HRM
risperidone solution
2
QL (480 ML per 30 days) MO;
HRM
risperidone tablet 4mg
2
QL (120 EA per 30 days) MO; HRM
risperidone tablet 1mg, 2mg
2
QL (60 EA per 30 days) MO; HRM
risperidone tablet 0.25mg, 0.5mg, 3mg
2
QL (90 EA per 30 days) MO; HRM
SAPHRIS
5
QL (60 EA per 30 days) MO; HRM
SECUADO
5
QL (30 EA per 30 days) MO; HRM
SEROQUEL XR TABLET EXTENDED RELEASE 24
HOUR 150MG, 200MG
4
QL (30 EA per 30 days) PA MO;
HRM
SEROQUEL XR TABLET EXTENDED RELEASE 24
HOUR 50MG
4
QL (60 EA per 30 days) PA MO;
HRM
SEROQUEL XR TABLET EXTENDED RELEASE 24
HOUR 300MG, 400MG
5
QL (60 EA per 30 days) PA MO;
HRM
SEROQUEL TABLET 200MG
4
QL (120 EA per 30 days) MO; HRM
SEROQUEL TABLET 25MG
4
QL (180 EA per 30 days) MO; HRM
SEROQUEL TABLET 300MG
4
QL (60 EA per 30 days) MO; HRM
SEROQUEL TABLET 100MG, 50MG
4
QL (90 EA per 30 days) MO; HRM
SEROQUEL TABLET 400MG
5
QL (60 EA per 30 days) MO; HRM
thioridazine hcl tablet
2
PA MO; HRM
thiothixene
2
MO; HRM
trifluoperazine hcl tablet 2mg, 5mg, 10mg
2
MO; HRM
trifluoperazine hydrochloride tablet 1mg
2
MO; HRM
UZEDY INJECTION 50MG/0.14ML
5
QL (0.14 ML per 30 days) PA
UZEDY INJECTION 75MG/0.21ML
5
QL (0.21 ML per 30 days) PA
UZEDY INJECTION 100MG/0.28ML
5
QL (0.28 ML per 30 days) PA
UZEDY INJECTION 125MG/0.35ML
5
QL (0.35 ML per 30 days) PA
UZEDY INJECTION 150MG/0.42ML
5
QL (0.42 ML per 60 days) PA
UZEDY INJECTION 200MG/0.56ML
5
QL (0.56 ML per 60 days) PA
UZEDY INJECTION 250MG/0.7ML
5
QL (0.7 ML per 60 days) PA
VERSACLOZ
4
QL (600 ML per 30 days) PA; HRM
VRAYLAR CAPSULE THERAPY PACK
3
MO; HRM
VRAYLAR CAPSULE 3MG, 4.5MG, 6MG
3
QL (30 EA per 30 days) MO; HRM
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 54
Drug Name
Drug
Tier
Requirements/Limits
VRAYLAR CAPSULE 1.5MG
3
QL (60 EA per 30 days) MO; HRM
ziprasidone hcl capsule
2
QL (60 EA per 30 days) MO; HRM
ziprasidone mesylate injection
2
QL (6 EA per 3 days) MO; HRM
ZYPREXA RELPREVV INJECTION 405MG
4
QL (1 EA per 28 days) PA MO;
ACS HRM
ZYPREXA RELPREVV INJECTION 210MG, 300MG
4
QL (2 EA per 28 days) PA MO;
ACS HRM
ZYPREXA ZYDIS TABLET DISINTEGRATING 5MG
5
QL (30 EA per 30 days) MO
ZYPREXA ZYDIS TABLET DISINTEGRATING 10MG,
15MG, 20MG
5
QL (30 EA per 30 days) MO; HRM
ZYPREXA INJECTION
4
QL (3 EA per 1 days) MO; HRM
ZYPREXA TABLET 7.5MG
4
QL (30 EA per 30 days) MO; HRM
ZYPREXA TABLET 2.5MG, 5MG
4
QL (60 EA per 30 days) MO; HRM
ZYPREXA TABLET 10MG, 15MG, 20MG
5
QL (30 EA per 30 days) MO; HRM
ANTISEIZURE AGENTS
APTIOM TABLET 200MG, 400MG
5
QL (30 EA per 30 days) MO
APTIOM TABLET 600MG, 800MG
5
QL (60 EA per 30 days) MO
BANZEL SUSPENSION
5
QL (2760 ML per 30 days) PA MO
BANZEL TABLET 400MG
4
QL (240 EA per 30 days) PA MO
BANZEL TABLET 200MG
4
QL (480 EA per 30 days) PA MO
BRIVIACT TABLET
4
QL (60 EA per 30 days) PA MO
BRIVIACT INJECTION
4
QL (600 ML per 30 days) PA
BRIVIACT ORAL SOLUTION
4
QL (600 ML per 30 days) PA MO
carbamazepine
2
MO; HRM
carbamazepine er
2
MO; HRM
CARBATROL
4
MO; HRM
CELONTIN
4
MO
CEREBYX INJECTION 500MG PE/10ML
4
MO
CEREBYX INJECTION 100MG PE/2ML
5
clobazam suspension
2
QL (480 ML per 30 days) PA MO;
HRM
clobazam tablet
2
QL (60 EA per 30 days) PA MO;
HRM
clonazepam odt tablet disintegrating 2mg
2
QL (300 EA per 30 days) MO
clonazepam odt tablet disintegrating 0.125mg, 0.25mg, 0.5mg,
1mg
2
QL (90 EA per 30 days) MO
clonazepam tablet 2mg
2
QL (300 EA per 30 days) MO
clonazepam tablet 0.5mg, 1mg
2
QL (90 EA per 30 days) MO
clorazepate dipotassium tablet 15mg
2
QL (180 EA per 30 days) PA MO;
HRM
clorazepate dipotassium tablet 3.75mg, 7.5mg
2
QL (90 EA per 30 days) PA MO;
HRM
DEPAKOTE
4
MO
DEPAKOTE ER
4
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 55
Drug Name
Drug
Tier
Requirements/Limits
DEPAKOTE SPRINKLES
4
MO
DIACOMIT CAPSULE 500MG
5
QL (180 EA per 30 days) PA LA
MO
DIACOMIT CAPSULE 250MG
5
QL (360 EA per 30 days) PA LA
MO
DIACOMIT PACKET 500MG
5
QL (180 EA per 30 days) PA LA
MO
DIACOMIT PACKET 250MG
5
QL (360 EA per 30 days) PA LA
MO
DIASTAT ACUDIAL
4
MO; HRM
DIASTAT PEDIATRIC
4
MO; HRM
diazepam intensol
2
QL (240 ML per 30 days) PA MO;
HRM
DIAZEPAM RECTAL GEL
2
MO; HRM
diazepam tablet
2
QL (120 EA per 30 days) PA MO;
HRM
diazepam oral solution
2
QL (1200 ML per 30 days) PA MO;
HRM
diazepam concentrate, injection
2
QL (240 ML per 30 days) PA MO;
HRM
DILANTIN
4
MO
DILANTIN INFATABS
4
MO
DILANTIN-125
4
MO
divalproex sodium dr tablet delayed release
2
MO
divalproex sodium er tablet extended release 24 hour
2
MO
divalproex sodium sprinkle capsule
2
MO
EPIDIOLEX
5
QL (600 ML per 30 days) PA LA;
ACS
epitol
2
HRM
EPRONTIA
4
QL (480 ML per 30 days) PA MO
ethosuximide
2
MO
felbamate
2
MO
FELBATOL
5
MO
FINTEPLA
5
QL (360 ML per 30 days) PA LA
MO
fosphenytoin sodium injection 100mg pe/2ml
2
fosphenytoin sodium injection 500mg pe/10ml
2
MO
FYCOMPA SUSPENSION
3
QL (720 ML per 30 days) PA MO
FYCOMPA TABLET 10MG, 12MG, 4MG, 6MG, 8MG
3
QL (30 EA per 30 days) PA MO
FYCOMPA TABLET 2MG
3
QL (60 EA per 30 days) PA MO
gabapentin capsule 100mg
2
QL (180 EA per 30 days) MO
gabapentin capsule 400mg
2
QL (270 EA per 30 days) MO
gabapentin capsule 300mg
2
QL (360 EA per 30 days) MO
gabapentin solution
2
QL (2160 ML per 30 days) MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 56
Drug Name
Drug
Tier
Requirements/Limits
gabapentin tablet 600mg
2
QL (180 EA per 30 days) MO
gabapentin tablet 800mg
2
QL (90 EA per 30 days) MO
GABITRIL
5
MO
KEPPRA XR
5
MO
KEPPRA INJECTION
4
KEPPRA ORAL SOLUTION
5
MO
KEPPRA TABLET 250MG
4
MO
KEPPRA TABLET 1000MG, 500MG, 750MG
5
MO
KLONOPIN TABLET 2MG
4
QL (300 EA per 30 days) MO
KLONOPIN TABLET 0.5MG, 1MG
4
QL (90 EA per 30 days) MO
lacosamide injection
2
lacosamide oral solution
2
QL (1200 ML per 30 days) MO
lacosamide tablet 50mg
2
QL (120 EA per 30 days) MO
lacosamide tablet 100mg, 150mg, 200mg
2
QL (60 EA per 30 days) MO
LAMICTAL CHEWABLE DISPERSIBLE
5
MO
LAMICTAL ODT KIT
4
MO
LAMICTAL ODT TABLET DISINTEGRATING
5
MO
LAMICTAL STARTER/NOT TAKING CARBAMAZEPINE
4
MO
LAMICTAL STARTER/TAKING CARBAMAZEPINE/NOT
TAKING VALPROATE
5
MO
LAMICTAL STARTER/TAKING VALPROATE
4
MO
LAMICTAL TABLET
5
MO
LAMICTAL XR KIT
4
MO
LAMICTAL XR TABLET EXTENDED RELEASE 24
HOUR
5
MO
lamotrigine er
2
MO
lamotrigine immediate release tablet, chewable tablet
2
MO
lamotrigine odt tablet disintegrating 100mg, 200mg, 25mg,
50mg
2
MO
lamotrigine starter kit/blue
2
MO
lamotrigine starter kit/green
2
MO
lamotrigine starter kit/orange
2
MO
lamotrigine odt titration kit (blue and green)
2
lamotrigine odt titration kit (orange)
2
MO
levetiracetam er
2
MO
levetiracetam/sodium chloride injection
2
levetiracetam oral solution, tablet
2
MO
LYRICA SOLUTION
5
QL (900 ML per 30 days) PA MO
LYRICA CAPSULE 100MG, 150MG, 25MG, 50MG, 75MG
4
QL (120 EA per 30 days) PA MO
LYRICA CAPSULE 225MG, 300MG
4
QL (60 EA per 30 days) PA MO
LYRICA CAPSULE 200MG
4
QL (90 EA per 30 days) PA MO
methsuximide
2
MO
MYSOLINE
5
MO
NAYZILAM
3
QL (10 EA per 30 days) PA MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 57
Drug Name
Drug
Tier
Requirements/Limits
NEURONTIN SOLUTION
5
QL (2160 ML per 30 days) MO
NEURONTIN CAPSULE 100MG
4
QL (180 EA per 30 days) MO
NEURONTIN CAPSULE 400MG
5
QL (270 EA per 30 days) MO
NEURONTIN CAPSULE 300MG
5
QL (360 EA per 30 days) MO
NEURONTIN TABLET 600MG
5
QL (180 EA per 30 days) MO
NEURONTIN TABLET 800MG
5
QL (90 EA per 30 days) MO
ONFI SUSPENSION
5
QL (480 ML per 30 days) PA MO;
HRM
ONFI TABLET
5
QL (60 EA per 30 days) PA MO;
HRM
oxcarbazepine
2
MO; HRM
OXTELLAR XR
3
MO; HRM
phenobarbital sodium injection
2
PA; HRM
phenobarbital tablet
2
QL (120 EA per 30 days) PA MO;
HRM
phenobarbital elixir
2
QL (1500 ML per 30 days) PA MO;
HRM
PHENYTEK
4
MO
phenytoin oral suspension, tablet chewable
2
MO
phenytoin sodium extended release capsule
2
MO
phenytoin sodium injection
2
pregabalin capsule 100mg, 150mg, 25mg, 50mg, 75mg
2
QL (120 EA per 30 days) PA MO
pregabalin capsule 225mg, 300mg
2
QL (60 EA per 30 days) PA MO
pregabalin capsule 200mg
2
QL (90 EA per 30 days) PA MO
pregabalin solution
2
QL (900 ML per 30 days) PA MO
primidone
2
MO
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 25MG,
50MG
4
MO
QUDEXY XR CAPSULE ER 24 HOUR SPRINKLE 100MG,
150MG, 200MG
5
MO
roweepra
2
rufinamide suspension
2
QL (2760 ML per 30 days) PA MO
rufinamide tablet 400mg
2
QL (240 EA per 30 days) PA MO
rufinamide tablet 200mg
2
QL (480 EA per 30 days) PA MO
SABRIL
5
QL (180 EA per 30 days) PA LA;
ACS
SPRITAM
4
PA MO
subvenite
2
subvenite starter kit/blue
2
subvenite starter kit/green
2
subvenite starter kit/orange
2
SYMPAZAN
5
QL (60 EA per 30 days) PA MO;
HRM
TEGRETOL
4
MO; HRM
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 58
Drug Name
Drug
Tier
Requirements/Limits
TEGRETOL-XR
4
MO; HRM
tiagabine hydrochloride
2
MO
TOPAMAX SPRINKLE CAPSULE SPRINKLE 15MG
4
MO
TOPAMAX SPRINKLE CAPSULE SPRINKLE 25MG
5
MO
TOPAMAX TABLET 25MG
4
QL (90 EA per 30 days) MO
TOPAMAX TABLET 100MG
5
QL (120 EA per 30 days) MO
TOPAMAX TABLET 200MG
5
QL (60 EA per 30 days) MO
TOPAMAX TABLET 50MG
5
QL (90 EA per 30 days) MO
topiramate er
2
MO
topiramate immediate release capsule sprinkle
2
MO
topiramate tablet 100mg
2
QL (120 EA per 30 days) MO
topiramate tablet 200mg
2
QL (60 EA per 30 days) MO
topiramate tablet 25mg, 50mg
2
QL (90 EA per 30 days) MO
TRILEPTAL SUSPENSION
5
MO; HRM
TRILEPTAL TABLET 150MG
4
MO; HRM
TRILEPTAL TABLET 300MG, 600MG
5
MO; HRM
TROKENDI XR CAPSULE EXTENDED RELEASE 24
HOUR 200MG
3
MO
TROKENDI XR CAPSULE EXTENDED RELEASE 24
HOUR 25MG, 50MG
4
MO
TROKENDI XR CAPSULE EXTENDED RELEASE 24
HOUR 100MG
5
MO
VALIUM
4
QL (120 EA per 30 days) PA MO;
HRM
valproate sodium injection
2
valproic acid capsule, oral solution
2
MO
VALTOCO 10 MG DOSE
3
QL (10 EA per 30 days) PA MO
VALTOCO 15 MG DOSE
3
QL (10 EA per 30 days) PA MO
VALTOCO 20 MG DOSE
3
QL (10 EA per 30 days) PA MO
VALTOCO 5 MG DOSE
3
QL (10 EA per 30 days) PA MO
vigabatrin
5
QL (180 EA per 30 days) PA LA;
ACS
vigadrone packet
2
QL (180 EA per 30 days) PA LA
vigadrone tablet
5
QL (180 EA per 30 days) PA LA
VIMPAT INJECTION
5
VIMPAT ORAL SOLUTION
5
QL (1200 ML per 30 days) MO
VIMPAT TABLET 50MG
5
QL (120 EA per 30 days) MO
VIMPAT TABLET 100MG, 150MG, 200MG
5
QL (60 EA per 30 days) MO
XCOPRI TITRATION PACK 12.5MG; 25MG, 50MG;
100MG, 150MG; 200MG
3
QL (28 EA per 28 days) MO
XCOPRI MAINTENANCE PACK 100MG; 150MG, 150MG;
200MG
3
QL (56 EA per 28 days) MO
XCOPRI TABLET 100MG, 50MG
3
QL (30 EA per 30 days) MO
XCOPRI TABLET 150MG, 200MG
3
QL (60 EA per 30 days) MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 59
Drug Name
Drug
Tier
Requirements/Limits
ZARONTIN
4
MO
ZONEGRAN
5
MO
ZONISADE
5
QL (900 ML per 30 days) PA MO
zonisamide capsule 100mg, 25mg
2
MO
zonisamide capsule 50mg
2
MO; HRM
ZTALMY
5
QL (1100 ML per 30 days) PA LA
MO
ATTENTION DEFICIT HYPERACTIVITY DISORDER
ADDERALL XR
4
QL (30 EA per 30 days) MO
ADDERALL TABLET 5MG, 7.5MG, 10MG, 12.5MG,
15MG, 30MG
4
QL (60 EA per 30 days) MO
ADDERALL TABLET 20MG
4
QL (90 EA per 30 days) MO
ADZENYS XR-ODT
4
QL (30 EA per 30 days) MO
amphetamine sulfate tablet
2
QL (180 EA per 30 days) MO
amphetamine/dextroamphetamine capsule extended release 24
hour
2
QL (30 EA per 30 days) MO
amphetamine/dextroamphetamine tablet 5mg, 7.5mg, 10mg,
12.5mg, 15mg, 30mg
2
QL (60 EA per 30 days) MO
amphetamine/dextroamphetamine tablet 20mg
2
QL (90 EA per 30 days) MO
APTENSIO XR
4
QL (30 EA per 30 days) MO
atomoxetine hydrochloride capsule 10mg, 25mg
2
QL (120 EA per 30 days) MO
atomoxetine capsule 18mg
2
QL (120 EA per 30 days) MO
atomoxetine capsule 100mg, 60mg, 80mg
2
QL (30 EA per 30 days) MO
atomoxetine capsule 40mg
2
QL (60 EA per 30 days) MO
AZSTARYS
4
QL (30 EA per 30 days) MO
clonidine hydrochloride er tablet extended release 0.1mg
2
MO
CONCERTA
4
QL (30 EA per 30 days) MO
COTEMPLA XR-ODT
4
QL (30 EA per 30 days) MO
DAYTRANA
4
QL (30 EA per 30 days) MO
DEXEDRINE
4
QL (120 EA per 30 days) MO
dexmethylphenidate hcl er capsule extended release 24 hour
20mg, 35mg
2
QL (30 EA per 30 days) MO
dexmethylphenidate hcl tablet 5mg, 10mg
2
QL (60 EA per 30 days) MO
dexmethylphenidate hydrochloride er capsule extended
release 24 hour 10mg, 15mg, 25mg, 30mg, 40mg, 5mg
2
QL (30 EA per 30 days) MO
dexmethylphenidate hydrochloride tablet 2.5mg
2
QL (60 EA per 30 days) MO
dextroamphetamine sulfate er
2
QL (120 EA per 30 days) MO
dextroamphetamine sulfate solution
2
QL (1800 ML per 30 days) MO
dextroamphetamine sulfate tablet 15mg
2
QL (120 EA per 30 days) MO
dextroamphetamine sulfate tablet 10mg, 5mg
2
QL (180 EA per 30 days) MO
dextroamphetamine sulfate tablet 30mg
2
QL (60 EA per 30 days) MO
dextroamphetamine sulfate tablet 20mg
2
QL (90 EA per 30 days) MO
DYANAVEL XR SUSPENSION EXTENDED RELEASE
4
QL (240 ML per 30 days) MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 60
Drug Name
Drug
Tier
Requirements/Limits
DYANAVEL XR TABLET CHEWABLE EXTENDED
RELEASE 10MG, 15MG, 20MG
4
QL (30 EA per 30 days) MO
DYANAVEL XR TABLET CHEWABLE EXTENDED
RELEASE 5MG
4
QL (60 EA per 30 days) MO
EVEKEO
4
QL (180 EA per 30 days) MO
EVEKEO ODT
4
QL (60 EA per 30 days) MO
FOCALIN
4
QL (60 EA per 30 days) MO
FOCALIN XR
4
QL (30 EA per 30 days) MO
guanfacine er tablet extended release 24 hour 2mg
2
QL (30 EA per 30 days) PA MO
guanfacine hydrochloride tablet extended release 24 hour
1mg, 4mg
2
QL (30 EA per 30 days) PA MO
guanfacine hydrochloride tablet extended release 24 hour
3mg
2
QL (60 EA per 30 days) PA MO
INTUNIV TABLET EXTENDED RELEASE 24 HOUR
1MG, 2MG, 4MG
4
QL (30 EA per 30 days) PA MO
INTUNIV TABLET EXTENDED RELEASE 24 HOUR 3MG
4
QL (60 EA per 30 days) PA MO
JORNAY PM
4
QL (30 EA per 30 days) MO
KAPVAY
4
MO
lisdexamfetamine dimesylate
2
QL (30 EA per 30 days)
methamphetamine hcl
2
QL (150 EA per 30 days) MO
METHYLIN SOLUTION 5MG/5ML
4
QL (1800 ML per 30 days) MO
METHYLIN SOLUTION 10MG/5ML
4
QL (900 ML per 30 days) MO
methylphenidate transdermal patch
2
QL (30 EA per 30 days) MO
methylphenidate hydrochloride cd capsule extended release
20mg, 30mg, 50mg, 60mg
2
QL (30 EA per 30 days) MO
methylphenidate hydrochloride er capsule extended release 24
hour (generic Ritalin LA) 10mg, 20mg, 40mg, 60mg
2
QL (30 EA per 30 days) MO
methylphenidate hydrochloride er capsule extended release 24
hour (generic Aptensio XR) 10mg, 15mg, 20mg, 30mg, 40mg,
50mg, 60mg
2
QL (30 EA per 30 days) MO
methylphenidate hydrochloride er capsule extended release 24
hour (generic Ritalin LA) 30mg
2
QL (60 EA per 30 days) MO
methylphenidate hydrochloride cd capsule extended release
10mg, 40mg
2
QL (30 EA per 30 days) MO
methylphenidate hydrochloride er tablet extended release 24
hour 18mg, 36mg
2
QL (30 EA per 30 days)
methylphenidate hydrochloride er tablet extended release 24
hour 27mg, 54mg
2
QL (30 EA per 30 days) MO
METHYLPHENIDATE HYDROCHLORIDE ER TABLET
EXTENDED RELEASE 45MG, 63MG, 72MG
4
QL (30 EA per 30 days) MO
methylphenidate hydrochloride er tablet extended release
(generic Concerta) 18mg, 27mg, 36mg, 54mg
2
QL (30 EA per 30 days) MO
methylphenidate hydrochloride er tablet extended release
10mg, 20mg
2
QL (90 EA per 30 days) MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 61
Drug Name
Drug
Tier
Requirements/Limits
methylphenidate hydrochloride tablet chewable
2
QL (180 EA per 30 days) MO
methylphenidate hydrochloride tablet
2
QL (90 EA per 30 days) MO
methylphenidate hydrochloride solution 5mg/5ml
2
QL (1800 ML per 30 days) MO
methylphenidate hydrochloride solution 10mg/5ml
2
QL (900 ML per 30 days) MO
MYDAYIS
3
QL (30 EA per 30 days) MO
procentra oral solution
2
QL (1800 ML per 30 days)
QELBREE CAPSULE EXTENDED RELEASE 24 HOUR
100MG
4
QL (30 EA per 30 days) PA MO
QELBREE CAPSULE EXTENDED RELEASE 24 HOUR
150MG
4
QL (60 EA per 30 days) PA MO
QELBREE CAPSULE EXTENDED RELEASE 24 HOUR
200MG
4
QL (90 EA per 30 days) PA MO
QUILLICHEW ER TABLET CHEWABLE EXTENDED
RELEASE 40MG
4
QL (30 EA per 30 days) MO
QUILLICHEW ER TABLET CHEWABLE EXTENDED
RELEASE 30MG
4
QL (60 EA per 30 days) MO
QUILLICHEW ER TABLET CHEWABLE EXTENDED
RELEASE 20MG
4
QL (90 EA per 30 days) MO
QUILLIVANT XR
4
QL (360 ML per 30 days) MO
RELEXXII
4
QL (30 EA per 30 days) MO
RITALIN
4
QL (90 EA per 30 days) MO
RITALIN LA CAPSULE EXTENDED RELEASE 24 HOUR
10MG, 20MG, 40MG
4
QL (30 EA per 30 days) MO
RITALIN LA CAPSULE EXTENDED RELEASE 24 HOUR
30MG
4
QL (60 EA per 30 days) MO
STRATTERA CAPSULE 10MG, 18MG, 25MG
4
QL (120 EA per 30 days) MO
STRATTERA CAPSULE 100MG, 60MG, 80MG
4
QL (30 EA per 30 days) MO
STRATTERA CAPSULE 40MG
4
QL (60 EA per 30 days) MO
VYVANSE
3
QL (30 EA per 30 days) MO
XELSTRYM
4
QL (30 EA per 30 days) MO
zenzedi tablet 15mg
2
QL (120 EA per 30 days)
zenzedi tablet 10mg, 5mg
2
QL (180 EA per 30 days)
zenzedi tablet 2.5mg
2
QL (180 EA per 30 days) MO
zenzedi tablet 7.5mg
2
QL (240 EA per 30 days) MO
zenzedi tablet 30mg
2
QL (60 EA per 30 days)
zenzedi tablet 20mg
2
QL (90 EA per 30 days)
HYPNOTICS
AMBIEN
4
QL (30 EA per 30 days) PA MO;
HRM
AMBIEN CR
4
QL (30 EA per 30 days) PA MO;
HRM
BELSOMRA
4
QL (30 EA per 30 days) MO
DAYVIGO
3
QL (30 EA per 30 days) MO
doxepin hydrochloride tablet 3mg, 6mg
2
QL (30 EA per 30 days) MO; HRM
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 62
Drug Name
Drug
Tier
Requirements/Limits
EDLUAR TABLET SUBLINGUAL 10MG
4
QL (30 EA per 30 days) PA MO;
HRM
EDLUAR TABLET SUBLINGUAL 5MG
4
QL (60 EA per 30 days) PA MO;
HRM
estazolam
2
QL (30 EA per 30 days) PA MO;
HRM
eszopiclone
2
QL (30 EA per 30 days) PA MO;
HRM
flurazepam hcl
2
QL (30 EA per 30 days) MO
HALCION
4
QL (60 EA per 30 days) PA MO;
HRM
HETLIOZ CAPSULE
5
QL (30 EA per 30 days) PA LA MO
HETLIOZ LQ ORAL SUSPENSION
5
QL (158 ML per 30 days) PA LA
MO
LUNESTA
4
QL (30 EA per 30 days) PA MO;
HRM
midazolam hcl injection pf 5mg/5ml, 2mg/2ml, 10mg/2ml,
5mg/1ml
2
HRM
midazolam hcl syrup
2
QL (300 ML per 30 days); HRM
midazolam hydrochloride injection 5mg/1ml, 10mg/2ml,
10mg/10ml, 25mg/5ml, 2mg/2ml, 50mg/10ml
2
HRM
pentobarbital sodium injection
2
QUVIVIQ
4
QL (30 EA per 30 days) PA MO
ramelteon
2
QL (30 EA per 30 days) MO
RESTORIL CAPSULE 22.5MG
4
QL (30 EA per 30 days) PA MO;
HRM
RESTORIL CAPSULE 15MG, 30MG, 7.5MG
5
QL (30 EA per 30 days) PA MO;
HRM
ROZEREM
4
QL (30 EA per 30 days) MO
SILENOR
4
QL (30 EA per 30 days) MO; HRM
tasimelteon
5
QL (30 EA per 30 days) PA; ACS
temazepam
2
QL (30 EA per 30 days) PA MO;
HRM
triazolam
2
QL (60 EA per 30 days) PA MO;
HRM
zaleplon capsule 5mg
2
QL (30 EA per 30 days) PA MO;
HRM
zaleplon capsule 10mg
2
QL (60 EA per 30 days) PA MO;
HRM
zolpidem tartrate er
2
QL (30 EA per 30 days) PA MO;
HRM
ZOLPIDEM TARTRATE CAPSULE
4
QL (30 EA per 30 days) PA MO
zolpidem tartrate tablet sublingual, tablet
2
QL (30 EA per 30 days) PA MO;
HRM
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 63
Drug Name
Drug
Tier
Requirements/Limits
ZOLPIMIST
4
QL (9 ML per 30 days) PA MO;
HRM
MIGRAINE
AIMOVIG
3
QL (1 ML per 30 days) PA MO;
ACS
AJOVY AUTO-INJECTOR 225MG/1.5ML
3
QL (1.5 ML per 28 days) PA MO;
ACS
AJOVY PREFILLED SYRINGE 225MG/1.5ML
3
QL (4.5 ML per 90 days) PA MO;
ACS
almotriptan maleate tablet 6.25mg, 12.5mg
2
QL (8 EA per 30 days) MO
CAMBIA
5
QL (9 EA per 30 days) PA MO
diclofenac potassium packet 50mg
5
QL (9 EA per 30 days) PA MO
dihydroergotamine mesylate injection
4
PA MO
dihydroergotamine mesylate nasal solution
5
QL (8 ML per 30 days) PA MO
eletriptan hydrobromide
2
QL (12 EA per 30 days) MO
ELYXYB
4
QL (28.8 ML per 21 days) PA MO
EMGALITY INJECTION 120MG/ML
3
QL (2 ML per 30 days) PA MO;
ACS
EMGALITY INJECTION 100MG/ML
3
QL (3 ML per 30 days) PA MO;
ACS
ERGOMAR
4
ergotamine tartrate/caffeine
2
QL (40 EA per 28 days) PA MO
FROVA
4
QL (12 EA per 30 days) ST MO
frovatriptan succinate
2
QL (12 EA per 30 days) MO
IMITREX STATDOSE REFILL
4
QL (4 ML per 30 days) ST MO
IMITREX STATDOSE SYSTEM
4
QL (4 ML per 30 days) ST MO
IMITREX NASAL SOLUTION
4
QL (12 EA per 30 days) ST MO
IMITREX TABLET 100MG
4
QL (12 EA per 30 days) ST MO
IMITREX TABLET 25MG, 50MG
4
QL (9 EA per 30 days) ST MO
MAXALT
4
QL (12 EA per 30 days) ST MO
MAXALT-MLT
4
QL (12 EA per 30 days) ST MO
migergot
5
QL (20 EA per 28 days) PA MO
MIGRANAL
5
QL (8 ML per 30 days) PA MO
naratriptan hcl
2
QL (9 EA per 30 days) MO
NURTEC
3
QL (16 EA per 30 days) PA MO
ONZETRA XSAIL
4
QL (16 EA per 30 days) ST MO
QULIPTA
5
QL (30 EA per 30 days) PA MO
RELPAX
4
QL (12 EA per 30 days) MO
REYVOW
4
QL (8 EA per 30 days) PA MO
rizatriptan benzoate odt
2
QL (12 EA per 30 days) MO
rizatriptan benzoate tablet
2
QL (12 EA per 30 days) MO
sumatriptan nasal spray
2
QL (12 EA per 30 days) MO
sumatriptan succinate refill injection
2
QL (4 ML per 30 days) MO
sumatriptan succinate injection
2
QL (4 ML per 30 days) MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 64
Drug Name
Drug
Tier
Requirements/Limits
sumatriptan succinate tablet 100mg
2
QL (12 EA per 30 days) MO
sumatriptan succinate tablet 25mg, 50mg
2
QL (9 EA per 30 days) MO
sumatriptan/naproxen sodium
2
QL (9 EA per 30 days) MO
TOSYMRA
4
QL (12 EA per 30 days) ST MO
TREXIMET
5
QL (9 EA per 30 days) ST MO
TRUDHESA
5
QL (12 ML per 28 days) PA
UBRELVY
3
QL (16 EA per 30 days) PA MO
VYEPTI
5
QL (1 ML per 90 days) PA LA MO;
ACS
ZAVZPRET
5
QL (6 EA per 21 days) PA
ZEMBRACE SYMTOUCH
4
QL (8 ML per 30 days) ST MO
zolmitriptan odt
2
QL (6 EA per 30 days) MO
zolmitriptan nasal spray
2
QL (12 EA per 30 days) MO
zolmitriptan tablet
2
QL (6 EA per 30 days) MO
ZOMIG SOLUTION
3
QL (12 EA per 30 days) ST MO
ZOMIG TABLET
4
QL (6 EA per 30 days) ST MO
MISCELLANEOUS
AMONDYS 45
5
PA MO
AMVUTTRA
5
QL (0.5 ML per 90 days) PA LA;
ACS
AUSTEDO XR PATIENT TITRATION KIT
5
QL (84 EA per 365 days) PA; ACS
AUSTEDO XR TABLET EXTENDED RELEASE 24 HOUR
12MG
5
QL (120 EA per 30 days) PA; ACS
AUSTEDO XR TABLET EXTENDED RELEASE 24 HOUR
24MG
5
QL (60 EA per 30 days) PA; ACS
AUSTEDO XR TABLET EXTENDED RELEASE 24 HOUR
6MG
5
QL (90 EA per 30 days) PA; ACS
AUSTEDO TABLET 12MG, 9MG
5
QL (120 EA per 30 days) PA LA;
ACS
AUSTEDO TABLET 6MG
5
QL (60 EA per 30 days) PA LA;
ACS
DAYBUE
5
QL (3600 ML per 30 days) PA LA
MO
ENSPRYNG
5
PA LA; ACS
EQUETRO
4
MO; HRM
EVRYSDI
5
QL (80 ML per 12 days) PA LA MO
EXONDYS 51
5
PA MO
EXSERVAN
5
QL (60 EA per 30 days) LA MO;
ACS
FIRDAPSE
5
PA LA MO
flumazenil
2
GRALISE TABLET 300MG, 600MG
3
QL (60 EA per 30 days) MO
GRALISE TABLET 750MG, 900MG
4
QL (60 EA per 30 days) MO
GRALISE TABLET 450MG
4
QL (90 EA per 30 days)
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 65
Drug Name
Drug
Tier
Requirements/Limits
HORIZANT
4
QL (60 EA per 30 days) MO
INGREZZA CAPSULE THERAPY PACK
5
QL (28 EA per 28 days) PA LA;
ACS
INGREZZA CAPSULE
5
QL (30 EA per 30 days) PA LA;
ACS
lithium carbonate capsule, tablet
1
MO
lithium carbonate er
2
MO
LITHOBID
5
MO
LYRICA CR TABLET EXTENDED RELEASE 24 HOUR
330MG
4
QL (60 EA per 30 days) PA MO
LYRICA CR TABLET EXTENDED RELEASE 24 HOUR
165MG, 82.5MG
4
QL (90 EA per 30 days) PA MO
MESTINON
5
MO
MESTINON TIMESPAN
5
MO
NUEDEXTA
4
QL (60 EA per 30 days) PA MO
paroxetine capsule 7.5mg
2
PA MO; HRM
pregabalin er tablet extended release 24 hour 330mg
2
QL (60 EA per 30 days) PA MO
pregabalin er tablet extended release 24 hour 165mg, 82.5mg
2
QL (90 EA per 30 days) PA MO
pyridostigmine bromide tablet, oral solution
2
MO
pyridostigmine bromide er
2
MO
RADICAVA INJECTION
5
QL (2800 ML per 28 days) PA LA;
ACS
RADICAVA ORS ORAL SUSPENSION
5
QL (50 ML per 28 days) PA LA;
ACS
RADICAVA ORS ORAL SUSPENSION STARTER KIT
5
QL (140 ML per 365 days) PA LA;
ACS
REGONOL
5
RELYVRIO
5
QL (56 EA per 28 days) PA LA;
ACS
RILUTEK
5
MO
riluzole
2
MO
SAVELLA
4
QL (60 EA per 30 days) PA MO
SAVELLA TITRATION PACK
4
QL (110 EA per 365 days) PA MO
SKYCLARYS
5
QL (90 EA per 30 days) PA LA MO
TEGSEDI
5
QL (6 ML per 28 days) PA LA MO
tetrabenazine tablet 25mg
5
QL (120 EA per 30 days) PA LA;
ACS
tetrabenazine tablet 12.5mg
5
QL (90 EA per 30 days) PA LA;
ACS
TIGLUTIK
5
QL (600 ML per 30 days) LA MO;
ACS
UPLIZNA
5
PA LA; ACS
VILTEPSO
5
PA MO
VYONDYS 53
5
PA MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 66
Drug Name
Drug
Tier
Requirements/Limits
XENAZINE TABLET 25MG
5
QL (120 EA per 30 days) PA LA;
ACS
XENAZINE TABLET 12.5MG
5
QL (90 EA per 30 days) PA LA;
ACS
MULTIPLE SCLEROSIS AGENTS
AMPYRA
5
PA LA; ACS
AUBAGIO
5
QL (30 EA per 30 days) PA LA;
ACS
AVONEX
5
QL (1 EA per 28 days) PA; ACS
AVONEX PEN
5
QL (1 EA per 28 days) PA; ACS
BAFIERTAM
5
QL (120 EA per 30 days) PA LA;
ACS
BETASERON
5
QL (14 EA per 28 days) PA; ACS
BRIUMVI
5
QL (42 ML per 365 days) PA LA;
ACS
COPAXONE INJECTION 40MG/ML
5
QL (12 ML per 28 days) PA; ACS
COPAXONE INJECTION 20MG/ML
5
QL (30 ML per 30 days) PA; ACS
dalfampridine er
2
PA; ACS
dimethyl fumarate starterpack
5
QL (120 EA per 365 days) PA LA;
ACS
dimethyl fumarate capsule delayed release 120mg
5
QL (14 EA per 7 days) PA LA; ACS
dimethyl fumarate capsule delayed release 240mg
5
QL (60 EA per 30 days) PA LA;
ACS
EXTAVIA
5
QL (15 EA per 30 days) PA; ACS
fingolimod
5
QL (30 EA per 30 days) PA; ACS
GILENYA CAPSULE 0.25MG
5
QL (28 EA per 28 days) PA; ACS
GILENYA CAPSULE 0.5MG
5
QL (30 EA per 30 days) PA; ACS
glatiramer acetate injection 40mg/ml
5
QL (12 ML per 28 days) PA; ACS
glatiramer acetate injection 20mg/ml
5
QL (30 ML per 30 days) PA; ACS
glatopa injection 40mg/ml
5
QL (12 ML per 28 days) PA; ACS
glatopa injection 20mg/ml
5
QL (30 ML per 30 days) PA; ACS
KESIMPTA
5
QL (6.4 ML per 365 days) PA LA;
ACS
LEMTRADA
5
QL (6 ML per 365 days) PA LA;
ACS
MAVENCLAD TABLET THERAPY PACK (4 TAB PACK)
10MG
5
QL (16 EA per 999 days) PA LA;
ACS
MAVENCLAD TABLET THERAPY PACK (5 TAB PACK)
10MG
5
QL (20 EA per 999 days) PA LA;
ACS
MAVENCLAD TABLET THERAPY PACK (6 TAB PACK)
10MG
5
QL (24 EA per 999 days) PA LA;
ACS
MAVENCLAD TABLET THERAPY PACK (7 TAB PACK)
10MG
5
QL (28 EA per 999 days) PA LA;
ACS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 67
Drug Name
Drug
Tier
Requirements/Limits
MAVENCLAD TABLET THERAPY PACK (8 TAB PACK)
10MG
5
QL (32 EA per 999 days) PA LA;
ACS
MAVENCLAD TABLET THERAPY PACK (9 TAB PACK)
10MG
5
QL (36 EA per 999 days) PA LA;
ACS
MAVENCLAD TABLET THERAPY PACK (10 TAB
PACK) 10MG
5
QL (40 EA per 999 days) PA LA;
ACS
MAYZENT STARTER PACK TABLET THERAPY PACK
0.25MG (FOR 1MG MAINTENANCE DOSAGE)
4
QL (14 EA per 365 days) PA LA;
ACS
MAYZENT STARTER PACK TABLET THERAPY PACK
0.25MG (FOR 2MG MAINTENANCE DOSAGE)
5
QL (24 EA per 365 days) PA LA;
ACS
MAYZENT TABLET 0.25MG
5
QL (112 EA per 28 days) PA LA;
ACS
MAYZENT TABLET 1MG, 2MG
5
QL (30 EA per 30 days) PA LA;
ACS
OCREVUS
5
QL (20 ML per 180 days) PA LA;
ACS
PLEGRIDY
5
QL (1 ML per 28 days) PA LA; ACS
PLEGRIDY STARTER PACK
5
QL (2 ML per 365 days) PA LA;
ACS
PONVORY
5
QL (30 EA per 30 days) PA LA;
ACS
PONVORY 14-DAY STARTER PACK
5
QL (28 EA per 365 days) PA LA;
ACS
REBIF
5
QL (6 ML per 28 days) PA; ACS
REBIF REBIDOSE
5
QL (6 ML per 28 days) PA; ACS
REBIF REBIDOSE TITRATION PACK
5
QL (8.4 ML per 365 days) PA; ACS
REBIF TITRATION PACK
5
QL (8.4 ML per 365 days) PA; ACS
TASCENSO ODT
5
QL (30 EA per 30 days) PA LA MO
TECFIDERA STARTER PACK
5
QL (120 EA per 365 days) PA LA;
ACS
TECFIDERA CAPSULE DELAYED RELEASE 120MG
5
QL (14 EA per 7 days) PA LA; ACS
TECFIDERA CAPSULE DELAYED RELEASE 240MG
5
QL (60 EA per 30 days) PA LA;
ACS
teriflunomide
2
QL (30 EA per 30 days) PA; ACS
TYSABRI
5
PA LA; ACS
VUMERITY
5
QL (120 EA per 30 days) PA LA;
ACS
ZEPOSIA
5
QL (30 EA per 30 days) PA LA;
ACS
ZEPOSIA 7-DAY STARTER PACK
5
QL (14 EA per 365 days) PA LA;
ACS
ZEPOSIA 28-CAPSULE STARTER KIT
5
QL (56 EA per 365 days) PA LA;
ACS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 68
Drug Name
Drug
Tier
Requirements/Limits
ZEPOSIA 37-CAPSULE STARTER KIT
5
QL (74 EA per 365 days) PA LA;
ACS
MUSCULOSKELETAL THERAPY AGENTS
AMRIX
5
QL (30 EA per 30 days) PA MO;
HRM
BACLOFEN ORAL SUSPENSION
5
QL (480 ML per 30 days) PA MO
baclofen tablet
2
MO
BACLOFEN INJECTION 50MCG/ML
4
B/D
baclofen injection 20000mcg/20ml, 40mg/20ml, 500mcg/ml
2
B/D
BOTOX INJECTION 200UNIT
4
QL (2 EA per 84 days) PA
BOTOX INJECTION 100UNIT
4
QL (4 EA per 84 days) PA
carisoprodol tablet
2
QL (84 EA per 30 days) PA MO
CHLORZOXAZONE TABLET 250MG
5
QL (120 EA per 30 days) PA
chlorzoxazone tablet 375mg, 750mg
2
QL (120 EA per 30 days) PA MO
chlorzoxazone tablet 500mg
2
QL (180 EA per 30 days) PA MO
cyclobenzaprine hydrochloride tablet
2
QL (90 EA per 30 days) PA MO;
HRM
cyclobenzaprine hydrochloride er
5
QL (30 EA per 30 days) PA MO;
HRM
DANTRIUM CAPSULE 25MG
4
MO
dantrolene sodium capsule 25mg, 50mg, 100mg
2
MO
DYSPORT
4
PA MO; ACS
fexmid
2
QL (90 EA per 30 days) PA; HRM
FLEQSUVY
5
QL (480 ML per 30 days) PA MO
GABLOFEN INJECTION 10000MCG/20ML,
20000MCG/20ML, 50MCG/ML
4
B/D
GABLOFEN INJECTION 40000MCG/20ML
5
B/D
LORZONE TABLET 375MG
4
QL (120 EA per 30 days) PA
lorzone tablet 750mg
2
QL (120 EA per 30 days) PA
LYVISPAH PACKET 10MG
4
QL (120 EA per 30 days) PA MO
LYVISPAH PACKET 5MG
4
QL (360 EA per 30 days) PA MO
LYVISPAH PACKET 20MG
5
QL (120 EA per 30 days) PA
metaxalone
2
QL (120 EA per 30 days) PA MO
methocarbamol injection
2
PA
methocarbamol tablet 750mg
2
QL (240 EA per 30 days) PA MO
methocarbamol tablet 500mg
2
QL (360 EA per 30 days) PA MO
methocarbamol tablet 1000mg
5
QL (120 EA per 30 days) PA
MYOBLOC
4
PA MO; ACS
norgesic
5
QL (120 EA per 30 days) PA; HRM
NORGESIC FORTE
5
QL (120 EA per 30 days) PA; HRM
orphenadrine citrate er
2
QL (60 EA per 30 days) PA MO;
HRM
orphenadrine citrate injection
2
PA MO; HRM
orphenadrine/aspirin/caffeine
5
QL (120 EA per 30 days) PA; HRM
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 69
Drug Name
Drug
Tier
Requirements/Limits
orphengesic forte
2
QL (120 EA per 30 days) PA; HRM
ROBAXIN
4
PA MO
SOMA TABLET 250MG
4
QL (84 EA per 30 days) PA MO
SOMA TABLET 350MG
5
QL (84 EA per 30 days) PA MO
tizanidine hcl capsule 4mg, tablet 2mg
2
MO
tizanidine hydrochloride capsule 2mg, 6mg, tablet 4mg
2
MO
XEOMIN
4
PA LA MO; ACS
ZANAFLEX TABLET
4
MO
ZANAFLEX CAPSULE 2MG, 4MG
4
MO
ZANAFLEX CAPSULE 6MG
5
MO
NARCOLEPSY/CATAPLEXY
armodafinil tablet 150mg, 200mg, 250mg
2
QL (30 EA per 30 days) PA MO
armodafinil tablet 50mg
2
QL (60 EA per 30 days) PA MO
LUMRYZ
5
QL (30 EA per 30 days) PA LA
modafinil tablet 100mg
2
QL (30 EA per 30 days) PA MO
modafinil tablet 200mg
2
QL (60 EA per 30 days) PA MO
NUVIGIL TABLET 50MG
4
QL (60 EA per 30 days) PA MO
NUVIGIL TABLET 150MG, 200MG, 250MG
5
QL (30 EA per 30 days) PA MO
PROVIGIL TABLET 100MG
5
QL (30 EA per 30 days) PA MO
PROVIGIL TABLET 200MG
5
QL (60 EA per 30 days) PA MO
SODIUM OXYBATE
5
QL (540 ML per 30 days) PA LA
MO
SUNOSI
3
QL (30 EA per 30 days) PA MO
WAKIX
5
QL (60 EA per 30 days) PA LA;
ACS
XYREM
5
QL (540 ML per 30 days) PA LA
MO
XYWAV
5
QL (540 ML per 30 days) PA LA
MO
PSYCHOTHERAPEUTIC-MISC
acamprosate calcium dr
2
MO
buprenorphine hcl/naloxone hcl sublingual tablet
2
QL (90 EA per 30 days) MO
buprenorphine hcl tablet sublingual 2mg, 8mg
2
QL (90 EA per 30 days) PA MO
buprenorphine hydrochloride/naloxone hydrochloride film
12mg; 3mg
2
QL (60 EA per 30 days) MO
buprenorphine hydrochloride/naloxone hydrochloride film
2mg; 0.5mg, 4mg; 1mg, 8mg; 2mg
2
QL (90 EA per 30 days) MO
bupropion hydrochloride er (sr) tablet (smoking deterrent)
extended release 12 hour 150mg
2
QL (60 EA per 30 days) MO
disulfiram tablet
2
MO
KLOXXADO
4
MO
LUCEMYRA
5
QL (224 EA per 14 days) PA MO
naloxone hcl injection 2mg/2ml
2
naloxone hcl injection 4mg/10ml
2
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 70
Drug Name
Drug
Tier
Requirements/Limits
naloxone hydrochloride nasal spray
2
MO
naloxone hydrochloride cartridge injection 0.4mg/ml
2
naloxone hydrochloride vial injection 0.4mg/ml
2
MO
naltrexone hcl tablet
2
MO
NARCAN
4
MO
NICOTROL INHALER
4
MO
NICOTROL NASAL SPRAY
4
QL (360 ML per 365 days) MO
SUBLOCADE
5
QL (1.5 ML per 30 days) PA LA
MO; ACS
SUBOXONE FILM 12MG; 3MG
4
QL (60 EA per 30 days) MO
SUBOXONE FILM 2MG; 0.5MG, 4MG; 1MG, 8MG; 2MG
4
QL (90 EA per 30 days) MO
VARENICLINE STARTING MONTH BOX
4
PA MO
VARENICLINE TARTRATE
4
PA MO
VIVITROL
5
MO; ACS
ZIMHI
4
ZUBSOLV TABLET SUBLINGUAL 11.4MG; 2.9MG
4
QL (30 EA per 30 days) MO
ZUBSOLV TABLET SUBLINGUAL 1.4MG; 0.36MG,
2.9MG; 0.71MG, 5.7MG; 1.4MG, 8.6MG; 2.1MG
4
QL (60 EA per 30 days) MO
ZUBSOLV TABLET SUBLINGUAL 0.7MG; 0.18MG
4
QL (90 EA per 30 days) MO
ENDOCRINE AND METABOLIC
ANDROGENS
ANDRODERM
3
QL (30 EA per 30 days) PA MO
ANDROGEL PUMP
5
QL (150 GM per 30 days) PA MO
AVEED
4
LA; ACS
DEPO-TESTOSTERONE
4
PA
FORTESTA
4
QL (120 GM per 30 days) PA MO
JATENZO CAPSULE 158MG, 198MG
4
QL (120 EA per 30 days) PA MO
JATENZO CAPSULE 237MG
5
QL (60 EA per 30 days) PA MO
METHITEST
4
PA
methyltestosterone capsule
2
PA MO
NATESTO
3
QL (21.96 GM per 30 days) PA MO
oxandrolone tablet 2.5mg
2
QL (120 EA per 30 days) PA MO
oxandrolone tablet 10mg
2
QL (60 EA per 30 days) PA MO
TESTIM
4
QL (300 GM per 30 days) PA MO
TESTOPEL
4
PA MO; ACS
testosterone cypionate injection
2
MO
testosterone enanthate injection
2
PA MO
testosterone pump gel 1.62%
2
QL (150 GM per 30 days) MO
testosterone pump gel 1%
2
QL (300 GM per 30 days) MO
testosterone pump gel 2% (10mg/act)
2
QL (120 GM per 30 days) MO
testosterone gel 1.62% (20.25mg/1.25gm, 40.5mg/2.5gm)
2
QL (150 GM per 30 days) MO
testosterone gel 1% (25mg/2.5gm, 50mg/5gm)
2
QL (300 GM per 30 days) MO
testosterone topical solution
2
QL (180 ML per 30 days) MO
TLANDO
4
QL (120 EA per 30 days) PA MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 71
Drug Name
Drug
Tier
Requirements/Limits
VOGELXO
4
QL (300 GM per 30 days) PA MO
VOGELXO PUMP
4
QL (300 GM per 30 days) PA MO
XYOSTED
4
PA MO
ANTIDIABETICS, INSULINS
ADMELOG
3
MO
ADMELOG SOLOSTAR
3
MO
AFREZZA
4
MO
BD ALCOHOL SWABS
3
MO
APIDRA
4
ST MO
APIDRA SOLOSTAR
4
ST MO
B-D INSULIN SYRINGE ULTRAFINE II/0.3ML/31G X
5/16"
3
MO
BASAGLAR KWIKPEN
3
MO
BASAGLAR TEMPO PEN
4
MO
BD INSULIN SYRINGE SAFETYGLIDE/1ML/29G X 1/2"
3
MO
BD INSULIN SYRINGE ULTRA-FINE/0.5ML/30G X 1/2"
3
MO
BD INSULIN SYRINGE ULTRA-FINE/1ML/31G X 5/16"
3
MO
BD/NOVO PEN NEEDLE ULTRA-FINE
3
MO
BD VEO INSULIN SYRINGE ULTRA-FINE/0.3ML/31G X
15/64"
3
MO
CEQUR SIMPLICITY 2U
4
MO
CEQUR SIMPLICITY INSERTER
4
MO
CURITY GAUZE PADS 2"X2" 12 PLY
3
MO
FIASP
3
MO
FIASP FLEXTOUCH
3
MO
FIASP PENFILL
3
MO
HUMALOG
4
ST MO
HUMALOG JUNIOR KWIKPEN
4
ST MO
HUMALOG KWIKPEN INJECTION 100UNIT/ML
4
ST MO
HUMALOG KWIKPEN INJECTION 200UNIT/ML
5
ST MO
HUMALOG MIX 50/50
5
ST MO
HUMALOG MIX 50/50 KWIKPEN
4
ST MO
HUMALOG MIX 75/25
4
ST MO
HUMALOG MIX 75/25 KWIKPEN
4
ST MO
HUMALOG TEMPO PEN
4
ST
HUMULIN 70/30
4
ST MO
HUMULIN 70/30 KWIKPEN
4
ST MO
HUMULIN N
4
ST MO
HUMULIN N KWIKPEN
4
ST MO
HUMULIN R
4
ST MO
HUMULIN R U-500 (CONCENTRATED)
3
B/D MO
HUMULIN R U-500 KWIKPEN
3
MO
INSULIN ASPART
4
ST MO
INSULIN ASPART FLEXPEN
4
ST MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 72
Drug Name
Drug
Tier
Requirements/Limits
INSULIN ASPART PENFILL
4
ST MO
INSULIN ASPART PROTAMINE/INSULIN ASPART
4
ST MO
INSULIN ASPART PROTAMINE/INSULIN ASPART
FLEXPEN
4
ST MO
INSULIN DEGLUDEC
4
ST MO
INSULIN DEGLUDEC FLEXTOUCH
4
ST MO
INSULIN GLARGINE SOLOSTAR
4
ST
INSULIN GLARGINE INJECTION 100UNIT/ML
4
ST
INSULIN LISPRO
4
ST MO
INSULIN LISPRO JUNIOR KWIKPEN
4
ST MO
INSULIN LISPRO KWIKPEN
4
ST MO
INSULIN LISPRO PROTAMINE/INSULIN LISPRO
KWIKPEN
4
ST MO
LANTUS
3
MO
LANTUS SOLOSTAR
3
MO
LEVEMIR
3
ST MO
LEVEMIR FLEXPEN
3
ST MO
LEVEMIR FLEXTOUCH
4
ST MO
LYUMJEV
4
ST MO
LYUMJEV KWIKPEN
4
ST MO
LYUMJEV TEMPO PEN
4
ST MO
MYXREDLIN
4
ST
NOVOLIN 70/30
3
MO
NOVOLIN 70/30 FLEXPEN
3
MO
NOVOLIN 70/30 FLEXPEN RELION
4
ST MO
NOVOLIN 70/30 RELION
4
ST MO
NOVOLIN N
3
MO
NOVOLIN N FLEXPEN
3
MO
NOVOLIN N FLEXPEN RELION
4
ST MO
NOVOLIN N RELION
4
ST MO
NOVOLIN R
3
MO
NOVOLIN R FLEXPEN
3
MO
NOVOLIN R FLEXPEN RELION
4
ST MO
NOVOLIN R RELION
4
ST MO
NOVOLOG
3
MO
NOVOLOG FLEXPEN
3
MO
NOVOLOG FLEXPEN RELION
4
ST MO
NOVOLOG MIX 70/30
3
MO
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
3
MO
NOVOLOG MIX 70/30 PREFILLED FLEXPEN RELION
4
ST MO
NOVOLOG MIX 70/30 RELION
4
ST MO
NOVOLOG PENFILL
3
MO
NOVOLOG RELION
4
ST MO
OMNIPOD 5 G6 INTRO KIT (GEN 5)
4
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 73
Drug Name
Drug
Tier
Requirements/Limits
OMNIPOD 5 G6 PODS (GEN 5)
4
MO
OMNIPOD CLASSIC PODS (GEN 3)
4
MO
OMNIPOD DASH INTRO KIT (GEN 4)
4
MO
OMNIPOD DASH PODS (GEN 4)
4
MO
OMNIPOD GO 10 UNITS/DAY
4
OMNIPOD GO 15 UNITS/DAY
4
OMNIPOD GO 20 UNITS/DAY
4
MO
OMNIPOD GO 25 UNITS/DAY
4
OMNIPOD GO 30 UNITS/DAY
4
MO
OMNIPOD GO 35 UNITS/DAY
4
OMNIPOD GO 40 UNITS/DAY
4
MO
OMNIPOD POD PALS
4
REZVOGLAR KWIKPEN
4
ST MO
SEMGLEE
4
ST MO
SOLIQUA 100/33
3
QL (15 ML per 25 days) MO
TOUJEO MAX SOLOSTAR
3
MO
TOUJEO SOLOSTAR
3
MO
TRESIBA
3
MO
TRESIBA FLEXTOUCH
3
MO
V-GO 20
4
QL (30 EA per 30 days) MO
V-GO 30
4
QL (30 EA per 30 days) MO
V-GO 40
4
QL (30 EA per 30 days) MO
XULTOPHY 100/3.6
3
QL (15 ML per 30 days) MO
ANTIDIABETICS
acarbose tablet
1
QL (90 EA per 30 days) MO
ACTOPLUS MET
4
QL (90 EA per 30 days) MO
ACTOS
4
QL (30 EA per 30 days) MO
ALOGLIPTIN
4
QL (30 EA per 30 days) ST MO
ALOGLIPTIN/METFORMIN HCL TABLET 12.5MG;
500MG
4
QL (60 EA per 30 days) ST MO
ALOGLIPTIN/METFORMIN HYDROCHLORIDE TABLET
12.5MG; 1000MG
4
QL (60 EA per 30 days) ST MO
ALOGLIPTIN/PIOGLITAZONE TABLET 12.5MG; 15MG
4
QL (30 EA per 30 days) ST
ALOGLIPTIN/PIOGLITAZONE TABLET 12.5MG; 30MG,
12.5MG; 45MG, 25MG; 15MG, 25MG; 30MG, 25MG;
45MG
4
QL (30 EA per 30 days) ST MO
BYDUREON BCISE
3
QL (3.4 ML per 28 days) PA MO
BYETTA INJECTION 5MCG/0.02ML
4
QL (1.2 ML per 30 days) PA MO
BYETTA INJECTION 10MCG/0.04ML
4
QL (2.4 ML per 30 days) PA MO
CYCLOSET
4
QL (180 EA per 30 days) PA MO
DUETACT
4
QL (30 EA per 30 days) MO
FARXIGA
3
QL (30 EA per 30 days) MO
glimepiride tablet 4mg
1
QL (60 EA per 30 days) MO
glimepiride tablet 1mg, 2mg
1
QL (90 EA per 30 days) MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 74
Drug Name
Drug
Tier
Requirements/Limits
glipizide er tablet extended release 24 hour 10mg
1
QL (60 EA per 30 days) MO
glipizide er tablet extended release 24 hour 2.5mg, 5mg
1
QL (90 EA per 30 days) MO
glipizide xl tablet extended release 24 hour 10mg
1
QL (60 EA per 30 days) MO
glipizide xl tablet extended release 24 hour 2.5mg, 5mg
1
QL (90 EA per 30 days) MO
glipizide/metformin hydrochloride tablet 2.5mg; 500mg, 5mg;
500mg
1
QL (120 EA per 30 days) MO
glipizide/metformin hydrochloride tablet 2.5mg; 250mg
1
QL (240 EA per 30 days) MO
glipizide tablet 10mg
1
QL (120 EA per 30 days) MO
glipizide tablet 5mg
1
QL (240 EA per 30 days) MO
GLUCOTROL XL TABLET EXTENDED RELEASE 24
HOUR 10MG
4
QL (60 EA per 30 days) MO
GLUCOTROL XL TABLET EXTENDED RELEASE 24
HOUR 2.5MG, 5MG
4
QL (90 EA per 30 days) MO
GLUMETZA TABLET EXTENDED RELEASE 24 HOUR
500MG
5
QL (120 EA per 30 days) PA MO
GLUMETZA TABLET EXTENDED RELEASE 24 HOUR
1000MG
5
QL (60 EA per 30 days) PA MO
glyburide tablet
2
PA MO
glyburide micronized tablet
2
PA MO
glyburide/metformin hydrochloride
2
PA MO
GLYNASE
4
PA MO
GLYXAMBI
3
QL (30 EA per 30 days) MO
INVOKAMET XR TABLET EXTENDED RELEASE 24
HOUR 50MG; 500MG
4
QL (120 EA per 30 days) ST MO
INVOKAMET XR TABLET EXTENDED RELEASE 24
HOUR 150MG; 1000MG, 150MG; 500MG, 50MG; 1000MG
4
QL (60 EA per 30 days) ST MO
INVOKAMET TABLET 50MG; 500MG
4
QL (120 EA per 30 days) ST MO
INVOKAMET TABLET 150MG; 1000MG, 150MG; 500MG,
50MG; 1000MG
4
QL (60 EA per 30 days) ST MO
INVOKANA TABLET 300MG
4
QL (30 EA per 30 days) ST MO
INVOKANA TABLET 100MG
4
QL (60 EA per 30 days) ST MO
JANUMET
3
QL (60 EA per 30 days) MO
JANUMET XR TABLET EXTENDED RELEASE 24 HOUR
1000MG; 100MG
3
QL (30 EA per 30 days) MO
JANUMET XR TABLET EXTENDED RELEASE 24 HOUR
1000MG; 50MG, 500MG; 50MG
3
QL (60 EA per 30 days) MO
JANUVIA
3
QL (30 EA per 30 days) MO
JARDIANCE
3
QL (30 EA per 30 days) MO
JENTADUETO
3
QL (60 EA per 30 days) MO
JENTADUETO XR TABLET EXTENDED RELEASE 24
HOUR 5MG; 1000MG
3
QL (30 EA per 30 days) MO
JENTADUETO XR TABLET EXTENDED RELEASE 24
HOUR 2.5MG; 1000MG
3
QL (60 EA per 30 days) MO
KAZANO
4
QL (60 EA per 30 days) ST MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 75
Drug Name
Drug
Tier
Requirements/Limits
KOMBIGLYZE XR TABLET EXTENDED RELEASE 24
HOUR 1000MG; 5MG, 500MG; 5MG
4
QL (30 EA per 30 days) ST MO
KOMBIGLYZE XR TABLET EXTENDED RELEASE 24
HOUR 1000MG; 2.5MG
4
QL (60 EA per 30 days) ST MO
metformin hydrochloride er (generic Glucophage XR) tablet
extended release 24 hour 500mg
1
QL (120 EA per 30 days) MO
metformin hydrochloride er tablet extended release 24 hour
(generic Glucophage XR) 750mg
1
QL (60 EA per 30 days) MO
metformin hydrochloride er (generic Fortamet and Glumetza)
tablet extended release 24 hour 500mg
2
QL (120 EA per 30 days) PA MO
metformin hydrochloride er tablet extended release 24 hour
1000mg
5
QL (60 EA per 30 days) PA MO
metformin hydrochloride solution
2
MO
METFORMIN HYDROCHLORIDE TABLET 625MG
5
QL (120 EA per 30 days) PA MO
metformin hydrochloride tablet 500mg
1
QL (150 EA per 30 days) MO
metformin hydrochloride tablet 1000mg
1
QL (75 EA per 30 days) MO
metformin hydrochloride tablet 850mg
1
QL (90 EA per 30 days) MO
miglitol
2
QL (90 EA per 30 days) MO
MOUNJARO INJECTION 10MG/0.5ML, 12.5MG/0.5ML,
15MG/0.5ML, 5MG/0.5ML, 7.5MG/0.5ML
3
QL (2 ML per 28 days) PA MO
MOUNJARO INJECTION 2.5MG/0.5ML
3
QL (4 ML per 365 days) PA MO
nateglinide
1
QL (90 EA per 30 days) MO
NESINA
4
QL (30 EA per 30 days) ST MO
ONGLYZA
4
QL (30 EA per 30 days) ST MO
OSENI
4
QL (30 EA per 30 days) ST MO
OZEMPIC INJECTION 2MG/1.5ML
3
QL (1.5 ML per 28 days) PA
OZEMPIC INJECTION 2MG/3ML, 4MG/3ML, 5.5MG/ML;
14MG/ML; 8MG/3ML
3
QL (3 ML per 28 days) PA MO
pioglitazone hcl tablet 45mg
1
QL (30 EA per 30 days) MO
pioglitazone hcl-glimepiride
1
QL (30 EA per 30 days) MO
pioglitazone hcl/metformin hcl
1
QL (90 EA per 30 days) MO
pioglitazone hydrochloride tablet 15mg, 30mg
1
QL (30 EA per 30 days) MO
QTERN
4
QL (30 EA per 30 days) MO
repaglinide tablet 0.5mg, 1mg
1
QL (120 EA per 30 days) MO
repaglinide tablet 2mg
1
QL (240 EA per 30 days) MO
RIOMET
4
MO
RYBELSUS
3
QL (30 EA per 30 days) PA MO
saxagliptin hydrochloride
2
QL (30 EA per 30 days) ST
saxagliptin hydrochloride/metformin hydrochloride er tablet
extended release 24 hour 1000mg; 5mg, 500mg; 5mg
2
QL (30 EA per 30 days) ST
saxagliptin hydrochloride/metformin hydrochloride er tablet
extended release 24 hour 1000mg; 2.5mg
2
QL (60 EA per 30 days) ST
SEGLUROMET TABLET 2.5MG; 500MG
4
QL (120 EA per 30 days) ST MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 76
Drug Name
Drug
Tier
Requirements/Limits
SEGLUROMET TABLET 2.5MG; 1000MG, 7.5MG;
1000MG, 7.5MG; 500MG
4
QL (60 EA per 30 days) ST MO
STEGLATRO
4
QL (30 EA per 30 days) ST MO
STEGLUJAN
4
QL (30 EA per 30 days) MO
SYMLINPEN 120
3
QL (10.8 ML per 30 days) PA MO
SYMLINPEN 60
3
QL (6 ML per 30 days) PA MO
SYNJARDY XR TABLET EXTENDED RELEASE 24
HOUR 25MG; 1000MG
3
QL (30 EA per 30 days) MO
SYNJARDY XR TABLET EXTENDED RELEASE 24
HOUR 10MG; 1000MG, 12.5MG; 1000MG, 5MG; 1000MG
3
QL (60 EA per 30 days) MO
SYNJARDY TABLET 5MG; 500MG
3
QL (120 EA per 30 days) MO
SYNJARDY TABLET 12.5MG; 1000MG, 12.5MG; 500MG,
5MG; 1000MG
3
QL (60 EA per 30 days) MO
TRADJENTA
3
QL (30 EA per 30 days) MO
TRIJARDY XR TABLET EXTENDED RELEASE 24 HOUR
10MG; 5MG; 1000MG, 25MG; 5MG; 1000MG
3
QL (30 EA per 30 days) MO
TRIJARDY XR TABLET EXTENDED RELEASE 24 HOUR
12.5MG; 2.5MG; 1000MG, 5MG; 2.5MG; 1000MG
3
QL (60 EA per 30 days) MO
TRULICITY
3
QL (2 ML per 28 days) PA MO
TZIELD
5
PA LA MO
VICTOZA
3
QL (9 ML per 30 days) PA MO
XIGDUO XR TABLET EXTENDED RELEASE 24 HOUR
10MG; 1000MG, 10MG; 500MG
3
QL (30 EA per 30 days) MO
XIGDUO XR TABLET EXTENDED RELEASE 24 HOUR
2.5MG; 1000MG, 5MG; 1000MG, 5MG; 500MG
3
QL (60 EA per 30 days) MO
CALCIUM REGULATORS
ACTONEL TABLET 150MG
4
QL (1 EA per 28 days) ST MO
ACTONEL TABLET 35MG
4
QL (4 EA per 28 days) ST MO
alendronate sodium solution
1
MO
alendronate sodium tablet 10mg
1
QL (120 EA per 30 days) MO
alendronate sodium tablet 35mg, 70mg
1
QL (4 EA per 28 days) MO
ATELVIA
4
QL (4 EA per 28 days) ST MO
BINOSTO
4
QL (4 EA per 28 days) ST MO
calcitonin salmon injection
5
PA MO
calcitonin-salmon nasal spray
2
MO
EVENITY
5
QL (2.34 ML per 28 days) PA; ACS
FORTEO
5
PA; ACS
FOSAMAX
4
QL (4 EA per 28 days) ST MO
FOSAMAX PLUS D
4
QL (4 EA per 28 days) ST MO
ibandronate sodium tablet
2
QL (1 EA per 30 days) MO
ibandronate sodium injection
2
QL (3 ML per 90 days) MO
MIACALCIN
5
PA MO
NATPARA
5
PA LA; ACS
PAMIDRONATE DISODIUM INJECTION 6MG/ML
4
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 77
Drug Name
Drug
Tier
Requirements/Limits
pamidronate disodium injection 30mg/10ml, 90mg/10ml
2
PROLIA
4
QL (1 ML per 180 days); ACS
RECLAST
4
ACS
risedronate sodium dr tablet 35mg
2
QL (4 EA per 28 days) MO
risedronate sodium tablet 150mg
2
QL (1 EA per 28 days) MO
risedronate sodium tablet 30mg, 5mg
2
QL (30 EA per 30 days) MO
risedronate sodium tablet 35mg
2
QL (4 EA per 28 days) MO
TERIPARATIDE
5
PA; ACS
TYMLOS
5
PA; ACS
XGEVA
5
PA; ACS
ZOLEDRONIC ACID INJECTION 4MG/100ML
4
ACS
zoledronic acid injection 4mg/5ml, 5mg/100ml
2
ACS
CHELATING AGENTS
CHEMET
4
MO
CUPRIMINE
5
ACS
CUVRIOR
5
PA LA MO
deferasirox packet
5
PA; ACS
deferasirox tablet soluble 125mg
2
PA; ACS
deferasirox tablet soluble 250mg, 500mg
5
PA; ACS
deferasirox tablet 180mg, 90mg
2
PA; ACS
deferasirox tablet 360mg
5
PA; ACS
deferiprone
5
PA LA; ACS
deferoxamine mesylate
2
B/D; ACS
DEPEN TITRATABS
4
ACS
DESFERAL
5
B/D; ACS
EXJADE
5
PA LA; ACS
FERRIPROX
5
PA LA MO
FERRIPROX TWICE-A-DAY
5
PA LA MO
JADENU
5
PA LA; ACS
JADENU SPRINKLE PACKET 90MG
4
PA LA; ACS
JADENU SPRINKLE PACKET 180MG, 360MG
5
PA LA; ACS
LOKELMA PACKET 10GM
3
QL (34 EA per 30 days) MO
LOKELMA PACKET 5GM
3
QL (96 EA per 30 days) MO
penicillamine tablet
2
ACS
penicillamine capsule
5
ACS
sodium polystyrene sulfonate oral powder
2
MO
sps oral suspension 15gm/60ml
2
MO
SYPRINE
5
PA; ACS
trientine hydrochloride
5
PA; ACS
VELTASSA PACKET 16.8GM, 25.2GM
3
QL (30 EA per 30 days) MO
VELTASSA PACKET 8.4GM
3
QL (90 EA per 30 days) MO
CONTRACEPTIVES
afirmelle
2
altavera
2
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 78
Drug Name
Drug
Tier
Requirements/Limits
alyacen 1/35
2
MO
alyacen 7/7/7
2
amethia
2
amethyst
2
ANNOVERA
4
QL (1 EA per 365 days) MO
apri
2
aranelle
2
MO
ashlyna
2
aubra eq
2
aurovela 1.5/30
2
aurovela 1/20
2
aurovela 24 fe
2
aurovela fe 1.5/30
2
aurovela fe 1/20
2
aviane
2
ayuna
2
azurette
2
BALCOLTRA
4
MO
balziva
2
BEYAZ
4
MO
blisovi 24 fe
2
MO
blisovi fe 1.5/30
2
MO
blisovi fe 1/20
2
briellyn
2
camila
2
MO
CAMRESE
3
CAMRESE LO
3
charlotte 24 fe
2
chateal eq
2
cryselle-28
2
MO
cyred
2
cyred eq
2
dasetta 1/35
2
dasetta 7/7/7
2
daysee
2
deblitane
2
delyla
2
DEPO-PROVERA CONTRACEPTIVE
4
MO
DEPO-SUBQ PROVERA 104
4
MO
desogestrel/ethinyl estradiol
2
MO
dolishale
2
drospirenone/ethinyl estradiol
2
MO
drospirenone/ethinyl estradiol/levomefolate calcium
2
MO
elinest
2
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 79
Drug Name
Drug
Tier
Requirements/Limits
ELLA
3
MO
eluryng
2
enpresse-28
2
enskyce
2
MO
errin
2
MO
estarylla
2
MO
ethynodiol diacetate/ethinyl estradiol
2
MO
ETONOGESTREL/ETHINYL ESTRADIOL
4
MO
falmina
2
fayosim
2
femynor
2
finzala
2
gemmily
2
MO
GENERESS FE
4
MO
hailey 1.5/30
2
MO
hailey 24 fe
2
hailey fe 1.5/30
2
hailey fe 1/20
2
haloette
2
heather
2
iclevia
2
incassia
2
introvale
2
isibloom
2
jaimiess
2
jasmiel
2
jencycla
2
JOLESSA
3
joyeaux
2
juleber
2
junel 1.5/30
2
junel 1/20
2
junel fe 1.5/30
2
MO
junel fe 1/20
2
MO
junel fe 24
2
kaitlib fe
2
MO
kalliga
2
kariva
2
kelnor 1/35
2
MO
kelnor 1/50
2
MO
kurvelo
2
KYLEENA
4
MO; ACS
larin 1.5/30
2
larin 1/20
2
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 80
Drug Name
Drug
Tier
Requirements/Limits
larin 24 fe
2
larin fe 1.5/30
2
larin fe 1/20
2
LAYOLIS FE
4
LEENA
3
lessina
2
levonest
2
levonorgestrel/ethinyl estradiol
2
MO
levora 0.15/30-28
2
LILETTA
4
MO; ACS
LO LOESTRIN FE
4
MO
lo-zumandimine
2
MO
loestrin 1.5/30-21
2
loestrin 1/20-21
2
loestrin fe 1.5/30
2
loestrin fe 1/20
2
lojaimiess
2
MO
loryna
2
LOSEASONIQUE
4
MO
low-ogestrel
2
lutera
2
MO
lyleq
2
lyza
2
marlissa
2
MO
medroxyprogesterone acetate injection 150mg/ml
2
MO
merzee
2
MO
mibelas 24 fe
2
MICROGESTIN 1.5/30
3
MICROGESTIN 1/20
3
microgestin 24 fe
2
MICROGESTIN FE 1.5/30
3
MICROGESTIN FE 1/20
3
mili
2
MINASTRIN 24 FE
4
MO
MIRCETTE
4
MO
MIRENA
4
MO; ACS
mono-linyah
2
NATAZIA
4
MO
necon 0.5/35-28
2
NEXPLANON
4
MO; ACS
NEXTSTELLIS
4
MO
nikki
2
NORA-BE
3
norethindrone tablet 0.35mg
2
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 81
Drug Name
Drug
Tier
Requirements/Limits
norethindrone & ethinyl estradiol ferrous fumarate
2
MO
norethindrone acetate/ethinyl estradiol/ferrous fumarate
2
MO
norethindrone acetate/ethinyl estradiol tablet 20mcg; 1mg,
30mcg; 1.5mg
2
MO
norgestimate/ethinyl estradiol
2
MO
norlyda
2
norlyroc
2
nortrel 0.5/35 (28)
2
MO
nortrel 1/35 28-day regimen
2
nortrel 1/35 21-day regimen
2
MO
nortrel 7/7/7
2
NUVARING
4
MO
nylia 1/35
2
nylia 7/7/7
2
MO
nymyo
2
OCELLA
3
orsythia
2
PHEXXI
4
MO
philith
2
pimtrea
2
pirmella 1/35
2
MO
pirmella 7/7/7
2
MO
portia-28
2
QUARTETTE
4
MO
reclipsen
2
RIVELSA
3
SAFYRAL
4
MO
SEASONIQUE
4
MO
setlakin
2
sharobel
2
simliya
2
simpesse
2
MO
SKYLA
4
MO; ACS
SLYND
3
MO
sprintec 28
2
sronyx
2
MO
syeda
2
tarina 24 fe
2
tarina fe 1/20 eq
2
TAYTULLA
4
MO
TILIA FE
3
tri femynor
2
tri-estarylla
2
MO
tri-legest fe
2
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 82
Drug Name
Drug
Tier
Requirements/Limits
tri-linyah
2
tri-lo-estarylla
2
tri-lo-marzia
2
tri-lo-mili
2
tri-lo-sprintec
2
MO
tri-mili
2
tri-nymyo
2
tri-sprintec
2
tri-vylibra
2
tri-vylibra lo
2
trivora-28
2
MO
TYBLUME
4
MO
tydemy
2
velivet
2
MO
vestura
2
vienva
2
viorele
2
MO
volnea
2
MO
vyfemla
2
MO
vylibra
2
wera
2
wymzya fe
2
xulane
2
MO
YASMIN 28
4
MO
YAZ
4
MO
zafemy
2
zovia 1/35
2
zumandimine
2
ENDOMETRIOSIS
danazol capsule
2
MO
ORILISSA TABLET 150MG
3
QL (28 EA per 28 days) PA MO
ORILISSA TABLET 200MG
3
QL (56 EA per 28 days) PA MO
SYNAREL
4
MO
ESTROGENS
ACTIVELLA
4
MO
amabelz
2
MO
ANGELIQ
4
MO
BIJUVA
3
QL (30 EA per 30 days) MO
CLIMARA
4
QL (4 EA per 28 days) MO
CLIMARA PRO
3
QL (4 EA per 28 days) MO
COMBIPATCH
4
QL (8 EA per 28 days) MO
DELESTROGEN
4
MO
DEPO-ESTRADIOL
4
MO
DIVIGEL
4
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 83
Drug Name
Drug
Tier
Requirements/Limits
dotti
2
QL (8 EA per 28 days)
DUAVEE
4
MO
ELESTRIN
4
MO
ESTRACE
4
MO
estradiol valerate injection
2
MO
estradiol/norethindrone acetate tablet 1mg/0.5mg,
0.5mg/0.1mg
2
MO
estradiol vaginal cream, transdermal gel, oral tablet, vaginal
tablet
2
MO
estradiol patch weekly
2
QL (4 EA per 28 days) MO
estradiol patch twice weekly
2
QL (8 EA per 28 days) MO
ESTRING
4
QL (1 EA per 90 days) MO
ESTROGEL
4
MO
EVAMIST
3
QL (16.2 ML per 30 days) MO
FEMRING
4
QL (1 EA per 90 days) MO
fyavolv
2
MO
IMVEXXY MAINTENANCE PACK
3
PA MO
IMVEXXY STARTER PACK
3
PA MO
jinteli
2
lyllana
2
QL (8 EA per 28 days)
MENEST
4
MO
MENOSTAR
4
QL (4 EA per 28 days) MO
mimvey
2
MINIVELLE
4
QL (8 EA per 28 days) MO
norethindrone acetate/ethinyl estradiol tablet 2.5mcg; 0.5mg,
5mcg; 1mg
2
MO
PREFEST
4
MO
PREMARIN
4
MO
PREMPHASE
4
MO
PREMPRO
4
MO
VAGIFEM
3
MO
VIVELLE-DOT
4
QL (8 EA per 28 days) MO
yuvafem
2
GLUCOCORTICOIDS
ALKINDI SPRINKLE
5
PA LA MO; ACS
betamethasone sodium phosphate/betamethasone acetate
injection
2
MO
CELESTONE-SOLUSPAN
4
MO
CORTEF
4
MO
CORTISONE ACETATE TABLET
4
DEPO-MEDROL
4
B/D MO
DEXABLISS
4
dexamethasone 10-day dose pack
2
dexamethasone 13-day dose pack
2
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 84
Drug Name
Drug
Tier
Requirements/Limits
dexamethasone 6-day dose pack
2
MO
DEXAMETHASONE INTENSOL
4
MO
dexamethasone sodium phosphate injection vial 10mg/ml
2
dexamethasone sodium phosphate injection vial 100mg/10ml,
10mg/ml pf, 120mg/30ml, 20mg/5ml, 4mg/ml
2
MO
dexamethasone tablet, oral solution, oral elixir
2
MO
DXEVO 11-DAY
4
EMFLAZA SUSPENSION
5
PA MO
EMFLAZA TABLET 18MG, 30MG, 6MG
5
PA
EMFLAZA TABLET 36MG
5
PA MO
fludrocortisone acetate tablet
2
MO
HEMADY
4
HEXATRIONE
4
hidex 6-day
2
hydrocortisone tablet 10mg, 20mg, 5mg
2
MO
KENALOG-10
4
MO
KENALOG-40
4
MO
KENALOG-80
4
MO
MEDROL
4
B/D MO
MEDROL DOSEPAK
4
MO
methylprednisolone acetate injection
2
B/D MO
methylprednisolone dose pack
2
MO
methylprednisolone sodium succinate injection 500mg
2
B/D
methylprednisolone sodium succinate injection 1000mg
2
B/D MO
methylprednisolone sodiumsuccinate
2
B/D MO
methylprednisolone tablet
2
B/D MO
millipred
5
B/D
ORAPRED ODT
4
B/D MO
PEDIAPRED
4
B/D MO
prednisolone sodium phosphate odt
2
B/D MO
prednisolone sodium phosphate oral solution 10mg/5ml,
15mg/5ml, 20mg/5ml, 25mg/5ml, 5mg/5ml
2
B/D MO
prednisolone solution
2
B/D MO
prednisolone tablet
5
B/D MO
PREDNISONE INTENSOL
4
B/D MO
prednisone solution, tablet
1
B/D MO
prednisone tablet therapy pack
1
MO
RAYOS
5
B/D MO
SOLU-CORTEF
4
MO
SOLU-MEDROL INJECTION 2GM
4
B/D
SOLU-MEDROL INJECTION PRESERVATIVE FREE
1000MG, 125MG, 40MG, 500MG
4
B/D MO
taperdex 12-day
2
taperdex 6-day
2
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 85
Drug Name
Drug
Tier
Requirements/Limits
taperdex 7-day
2
triamcinolone acetonide injection 40mg/ml
2
MO
ZILRETTA
4
LA MO; ACS
GLUCOSE ELEVATING AGENTS
BAQSIMI ONE PACK
3
MO
BAQSIMI TWO PACK
3
MO
diazoxide oral suspension
2
MO
GLUCAGEN HYPOKIT
3
MO
GLUCAGON EMERGENCY KIT FOR LOW BLOOD
SUGAR
4
GVOKE HYPOPEN 1-PACK
3
MO
GVOKE HYPOPEN 2-PACK
3
MO
GVOKE KIT
3
MO
GVOKE PFS
3
MO
PROGLYCEM
5
MO
ZEGALOGUE
4
MO
MISCELLANEOUS
ACETADOTE
4
acetylcysteine injection 200mg/ml
2
ACTHAR
5
QL (1.5 ML per 1 days) PA LA;
ACS
ALDURAZYME
5
PA LA; ACS
betaine anhydrous
5
LA MO
BUPHENYL
5
PA LA; ACS
cabergoline
2
MO
CARBAGLU
5
PA LA MO
carglumic acid
5
PA LA MO
CARNITOR
4
MO
CARNITOR SF
4
MO
CERDELGA
5
PA LA; ACS
CEREZYME
5
PA LA; ACS
CHORIONIC GONADOTROPIN INJECTION
4
PA; ACS
cinacalcet hydrochloride tablet 30mg
2
QL (60 EA per 30 days); ACS
cinacalcet hydrochloride tablet 90mg
5
QL (120 EA per 30 days); ACS
cinacalcet hydrochloride tablet 60mg
5
QL (60 EA per 30 days); ACS
CORTROPHIN
5
QL (1.5 ML per 1 days) PA LA;
ACS
CRYSVITA
5
PA LA; ACS
CYSTADANE
5
LA MO
CYSTAGON
4
PA LA; ACS
DDAVP
5
MO
desmopressin acetate nasal solution, tablet
2
MO
desmopressin acetate pf injection 4mcg/ml
2
MO
desmopressin acetate injection 4mcg/ml
5
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 86
Drug Name
Drug
Tier
Requirements/Limits
DOJOLVI
5
PA LA; ACS
EGRIFTA SV
5
QL (30 EA per 30 days) PA LA;
ACS
ELAPRASE
5
PA LA; ACS
ELELYSO
5
PA LA; ACS
ELFABRIO
5
PA LA
EVISTA
4
MO
FABRAZYME
5
PA LA; ACS
FENSOLVI
5
PA LA; ACS
fomepizole
5
GALAFOLD
5
QL (14 EA per 28 days) PA LA
GENOTROPIN
5
PA; ACS
GENOTROPIN MINIQUICK INJECTION 0.2MG
3
PA; ACS
GENOTROPIN MINIQUICK INJECTION 0.4MG, 0.6MG,
0.8MG, 1.2MG, 1.4MG, 1.6MG, 1.8MG, 1MG, 2MG
5
PA; ACS
HUMATROPE
5
PA; ACS
INCRELEX
5
PA LA; ACS
ISTURISA TABLET 10MG
5
QL (180 EA per 30 days) PA LA
MO
ISTURISA TABLET 1MG
5
QL (240 EA per 30 days) PA LA
MO
ISTURISA TABLET 5MG
5
QL (60 EA per 30 days) PA LA MO
javygtor
5
PA LA
JYNARQUE TABLET
5
PA LA MO
JYNARQUE TABLET THERAPY PACK 45MG; 15MG,
60MG; 30MG, 90MG; 30MG
5
PA LA
JYNARQUE TABLET THERAPY PACK 30MG; 15MG,
15MG; 15MG
5
PA LA MO
KANUMA
5
PA LA; ACS
KORLYM
5
PA LA MO
KUVAN
5
PA LA; ACS
LAMZEDE
5
PA LA MO
LANREOTIDE ACETATE
5
PA; ACS
LEVOCARNITINE TABLET
2
MO
levocarnitine injection
2
levocarnitine oral solution
2
MO
LUMIZYME
5
PA LA; ACS
LUPRON DEPOT-PED (6-MONTH) INJECTION 45MG
5
PA; ACS
LUPRON DEPOT-PED (1-MONTH) INJECTION 11.25MG,
15MG, 7.5MG
5
PA; ACS
LUPRON DEPOT-PED (3-MONTH) INJECTION 11.25MG,
30MG
5
PA; ACS
MEPSEVII
5
PA MO
methergine
2
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 87
Drug Name
Drug
Tier
Requirements/Limits
methylergonovine maleate tablet
2
MO
miglustat
5
QL (90 EA per 30 days) PA LA;
ACS
MYALEPT
5
QL (30 EA per 30 days) PA LA MO
MYCAPSSA
5
QL (112 EA per 28 days) PA LA
MO
MYFEMBREE
4
QL (28 EA per 28 days) PA MO
NAGLAZYME
5
PA LA; ACS
NEXVIAZYME
5
PA LA; ACS
NGENLA
5
PA LA; ACS
nitisinone
5
PA; ACS
NITYR
5
PA LA MO
NOCDURNA
4
QL (30 EA per 30 days) PA MO
NORDITROPIN FLEXPRO
5
PA; ACS
NOVAREL
4
PA; ACS
NULIBRY
5
PA MO
NUTROPIN AQ NUSPIN 10
5
PA LA; ACS
NUTROPIN AQ NUSPIN 20
5
PA LA; ACS
NUTROPIN AQ NUSPIN 5
5
PA LA; ACS
octreotide acetate injection 100mcg/ml, 200mcg/ml,
500mcg/ml, 50mcg/ml
2
PA; ACS
octreotide acetate injection 1000mcg/ml
5
PA; ACS
OLPRUVA
5
PA LA; ACS
OMNITROPE
5
PA LA; ACS
ORFADIN
5
PA LA MO
ORIAHNN
3
QL (56 EA per 28 days) PA MO
OSPHENA
4
QL (30 EA per 30 days) PA MO
PALYNZIQ
5
PA LA; ACS
PHEBURANE
5
PA LA MO
PREGNYL INJECTION
4
PA; ACS
PROCYSBI PACKET
5
PA LA MO
PROCYSBI CAPSULE DELAYED RELEASE 25MG
5
QL (120 EA per 30 days) PA LA
MO
PROCYSBI CAPSULE DELAYED RELEASE 75MG
5
QL (810 EA per 30 days) PA LA
MO
raloxifene hydrochloride
2
MO
RAVICTI
5
PA LA; ACS
RECORLEV
5
QL (240 EA per 30 days) PA LA
MO
REVCOVI
5
PA LA MO
SAIZEN
5
PA LA; ACS
SAIZENPREP RECONSTITUTIONKIT
5
PA LA; ACS
SAMSCA TABLET 15MG
5
QL (30 EA per 30 days) PA LA;
ACS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 88
Drug Name
Drug
Tier
Requirements/Limits
SAMSCA TABLET 30MG
5
QL (60 EA per 30 days) PA LA;
ACS
SANDOSTATIN
5
PA; ACS
SANDOSTATIN LAR DEPOT
5
PA; ACS
sapropterin dihydrochloride
5
PA; ACS
SENSIPAR TABLET 30MG
4
QL (60 EA per 30 days); ACS
SENSIPAR TABLET 90MG
5
QL (120 EA per 30 days); ACS
SENSIPAR TABLET 60MG
5
QL (60 EA per 30 days); ACS
SEROSTIM
5
PA LA; ACS
SIGNIFOR INJECTION
5
PA LA MO
SIGNIFOR LAR INJECTION
5
QL (1 EA per 28 days) PA LA MO
SKYTROFA
5
PA LA; ACS
sodium phenylbutyrate tablet, oral powder
5
PA; ACS
SOGROYA
5
PA LA; ACS
SOMATULINE DEPOT
5
PA LA; ACS
SOMAVERT
5
PA LA; ACS
STRENSIQ
5
PA LA MO
TEPEZZA
5
PA LA; ACS
tolvaptan tablet 15mg
5
QL (30 EA per 30 days) PA LA;
ACS
tolvaptan tablet 30mg
5
QL (60 EA per 30 days) PA LA;
ACS
TRIPTODUR
5
PA MO
vasopressin
2
VASOSTRICT
4
VEOZAH
4
QL (30 EA per 30 days) PA MO
VIJOICE TABLET THERAPY PACK 125MG, 50MG
5
QL (28 EA per 28 days) PA LA;
ACS
VIJOICE TABLET THERAPY PACK 250MG
5
QL (56 EA per 28 days) PA LA;
ACS
VIMIZIM
5
PA LA; ACS
VISTOGARD
5
QL (20 EA per 166 days) MO
VOXZOGO
5
QL (30 EA per 30 days) PA LA;
ACS
VPRIV
5
PA LA; ACS
XENPOZYME INJECTION 20MG
5
PA LA; ACS
XIAFLEX
5
PA; ACS
XURIDEN
5
QL (120 EA per 30 days) PA MO
ZAVESCA
5
QL (90 EA per 30 days) PA LA MO
ZOKINVY
5
QL (120 EA per 30 days) PA; ACS
ZOMACTON
4
PA; ACS
ZORBTIVE
5
PA; ACS
PHOSPHATE BINDER AGENTS
AURYXIA
4
QL (360 EA per 30 days) PA MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 89
Drug Name
Drug
Tier
Requirements/Limits
calcium acetate capsule, tablet 667mg
2
QL (360 EA per 30 days) MO
FOSRENOL
5
MO
lanthanum carbonate
5
MO
PHOSLYRA
3
MO
RENAGEL
5
ST MO
RENVELA TABLET
5
QL (540 EA per 30 days) ST MO
RENVELA PACKET 2.4GM
5
QL (180 EA per 30 days) ST MO
RENVELA PACKET 0.8GM
5
QL (540 EA per 30 days) ST MO
sevelamer carbonate tablet 800mg
2
QL (540 EA per 30 days) MO
sevelamer carbonate packet 2.4gm
2
QL (180 EA per 30 days) MO
sevelamer carbonate packet 0.8gm
2
QL (540 EA per 30 days) MO
sevelamer hydrochloride tablet 400mg, 800mg
2
MO
VELPHORO
3
QL (180 EA per 30 days) MO
PROGESTINS
AYGESTIN
4
MO
CRINONE
4
PA MO
hydroxyprogesterone caproate injection 250mg/ml
5
ACS
MAKENA
5
ACS
medroxyprogesterone acetate tablet 10mg, 2.5mg, 5mg
2
MO
megestrol acetate suspension 40mg/ml, 625mg/5ml
2
MO
norethindrone acetate tablet 5mg
2
MO
progesterone capsule, injection
2
MO
PROMETRIUM
4
MO
PROVERA
4
MO
THYROID AGENTS
ADTHYZA
4
MO
ARMOUR THYROID
4
MO
CYTOMEL
4
MO
ERMEZA
4
MO
euthyrox
1
MO
levo-t
1
LEVOTHYROXINE SODIUM CAPSULE
4
MO
levothyroxine sodium tablet
1
MO
LEVOTHYROXINE SODIUM INJECTION SOLUTION
100MCG/ML, 200MCG/5ML, 500MCG/5ML
4
LEVOTHYROXINE SODIUM INJECTION SOLUTION
100MCG/5ML
5
levothyroxine sodium injection powder 100mcg, 200mcg,
500mcg
5
MO
levoxyl
1
MO
liothyronine sodium tablet
2
MO
liothyronine sodium injection
5
methimazole tablet
1
MO
np thyroid 120
2
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 90
Drug Name
Drug
Tier
Requirements/Limits
np thyroid 15
2
MO
np thyroid 30
2
MO
np thyroid 60
2
MO
np thyroid 90
2
MO
propylthiouracil tablet
2
MO
SYNTHROID
4
MO
THYQUIDITY
4
MO
TIROSINT-SOL SOLUTION 37.5MCG/ML, 44MCG/ML
4
TIROSINT-SOL SOLUTION 100MCG/ML, 112MCG/ML,
125MCG/ML, 137MCG/ML, 13MCG/ML, 150MCG/ML,
175MCG/ML, 200MCG/ML, 25MCG/ML, 50MCG/ML,
62.5MCG/ML, 75MCG/ML, 88MCG/ML
4
MO
TIROSINT CAPSULE 44MCG, 62.5MCG
4
TIROSINT CAPSULE 100MCG, 112MCG, 125MCG,
137MCG, 13MCG, 150MCG, 175MCG, 200MCG, 25MCG,
37.5MCG, 50MCG, 75MCG, 88MCG
4
MO
TRIOSTAT
5
unithroid
1
VITAMIN D ANALOGS
calcitriol capsule 0.25mcg, 0.5mcg
2
MO
calcitriol oral solution 1mcg/ml
2
MO
doxercalciferol injection
2
doxercalciferol capsule
2
MO
HECTOROL
4
paricalcitol
2
MO
RAYALDEE
4
MO
ROCALTROL
4
MO
ZEMPLAR CAPSULE
4
MO
ZEMPLAR INJECTION 2MCG/ML
4
MO
ZEMPLAR INJECTION 5MCG/ML
5
MO
GASTROINTESTINAL
ANTIEMETICS
AKYNZEO CAPSULE
4
QL (4 EA per 30 days) B/D
AKYNZEO INJECTION POWDER 235MG; 0.25MG
4
LA MO; ACS
AKYNZEO INJECTION SOLUTION 235MG/20ML;
0.25MG/20ML
5
LA MO; ACS
ANTIVERT
4
HRM
ANZEMET
4
B/D
APONVIE
4
aprepitant
2
B/D MO
BONJESTA
4
QL (60 EA per 30 days) MO; HRM
CINVANTI
4
PA
compro
2
MO; HRM
DICLEGIS
4
QL (120 EA per 30 days) MO; HRM
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 91
Drug Name
Drug
Tier
Requirements/Limits
DIMENHYDRINATE INJECTION
4
doxylamine succinate/pyridoxine hydrochloride
2
QL (120 EA per 30 days) MO; HRM
dronabinol
2
QL (60 EA per 30 days) PA MO
EMEND TRIPACK
4
B/D MO
EMEND CAPSULE
4
B/D MO
EMEND INJECTION
4
MO
EMEND ORAL SUSPENSION RECONSTITUTED
5
B/D
fosaprepitant dimeglumine
2
MO
GIMOTI
5
QL (9.8 ML per 28 days) PA
granisetron hcl injection
2
MO
granisetron hydrochloride tablet
2
QL (60 EA per 30 days) B/D MO
MARINOL
4
QL (60 EA per 30 days) PA MO
meclizine hcl tablet 12.5mg, 25mg
2
MO; HRM
meclizine hydrochloride
2
metoclopramide hcl tablet 5mg
1
MO
metoclopramide hcl oral solution
2
MO
metoclopramide hydrochloride tablet
1
MO
metoclopramide hydrochloride injection
2
MO
metoclopramide odt
2
MO
ondansetron hcl tablet 24mg
2
B/D
ondansetron hcl oral solution
2
QL (900 ML per 30 days) B/D MO
ondansetron hydrochloride tablet 4mg, 8mg
2
B/D MO
ondansetron hydrochloride injection
2
MO
ondansetron odt
2
B/D MO
PALONOSETRON HYDROCHLORIDE INJECTION
0.25MG/2ML
4
palonosetron hydrochloride injection 0.25mg/5ml
2
PHENERGAN
4
PA MO; HRM
prochlorperazine edisylate injection
2
MO; HRM
prochlorperazine maleate tablet
2
MO; HRM
prochlorperazine rectal suppository
2
MO; HRM
promethazine hcl tablet 12.5mg, injection, suppository
2
PA MO; HRM
promethazine hcl plain oral syrup 6.25mg/5ml
2
PA MO; HRM
promethazine hydrochloride tablet 25mg, 50mg
2
PA MO; HRM
promethegan suppository 12.5mg, 50mg
2
PA MO; HRM
promethegan suppository 25mg
2
PA; HRM
REGLAN
4
MO
SANCUSO
3
QL (4 EA per 28 days) MO
scopolamine patch
2
QL (10 EA per 30 days) PA MO;
HRM
SUSTOL
4
SYNDROS
5
PA MO
TIGAN
5
PA MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 92
Drug Name
Drug
Tier
Requirements/Limits
TRANSDERM-SCOP
4
QL (10 EA per 30 days) PA MO;
HRM
trimethobenzamide hydrochloride capsule
2
PA MO
VARUBI
5
QL (4 EA per 30 days) B/D MO;
ACS
ANTISPASMODICS
ANASPAZ
4
PA MO; HRM
ATROPINE SULFATE INJECTION 0.25MG/5ML,
8MG/20ML
4
PA
ATROPINE SULFATE INJECTION 1MG/10ML
4
PA MO
atropine sulfate injection 0.4mg/ml, 0.5mg/5ml, 1mg/ml,
8mg/20ml intramuscular, intravenous, or subcutaneous
2
PA
atropine sulfate injection pf 0.4mg/ml
2
PA MO
BELLADONNA/OPIUM
4
PA MO
BENTYL
4
PA MO; HRM
CHLORDIAZEPOXIDE HCL/CLIDINIUM BROMIDE
CAPSULE 5MG; 2.5MG
5
QL (240 EA per 30 days) PA MO;
HRM
CUVPOSA
4
QL (1350 ML per 30 days) MO
DARTISLA ODT
4
QL (120 EA per 30 days) MO
dicyclomine hcl oral solution
2
PA MO; HRM
dicyclomine hydrochloride capsule, tablet, injection
2
PA MO; HRM
GLYCATE
4
MO
glycopyrrolate oral solution
2
MO
glycopyrrolate injection 0.2mg/ml pf, 0.4mg/2ml, 0.6mg/3ml
2
glycopyrrolate injection 0.2mg/ml, 1mg/5ml, 4mg/20ml
2
MO
GLYCOPYRROLATE TABLET 1.5MG
4
MO
glycopyrrolate tablet 1mg, 2mg
2
MO
hyoscyamine sulfate odt
2
PA MO; HRM
hyoscyamine sulfate oral elixir, tablet sublingual, immediate
release tablet
2
PA MO; HRM
hyoscyamine sulfate solution
5
PA MO; HRM
LEVSIN
4
PA MO; HRM
LEVSIN/SL
4
PA MO; HRM
LIBRAX
5
QL (240 EA per 30 days) PA MO;
HRM
methscopolamine bromide tablet
2
PA MO
nulev
2
PA MO; HRM
oscimin tablet sublingual
2
PA MO; HRM
oscimin tablet
2
PA; HRM
ROBINUL
4
MO
ROBINUL FORTE
4
MO
H2-RECEPTOR ANTAGONISTS
cimetidine hcl
2
MO
cimetidine hydrochloride
2
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 93
Drug Name
Drug
Tier
Requirements/Limits
cimetidine tablet
2
MO
famotidine premixed injection 20mg/50ml
2
famotidine injection
2
famotidine oral suspension reconstituted, tablet
2
MO
nizatidine
2
MO
PEPCID TABLET 20MG
4
MO
PEPCID TABLET 40MG
5
MO
INFLAMMATORY BOWEL DISEASE
APRISO
4
QL (120 EA per 30 days) MO
ASACOL HD
5
MO
AZULFIDINE
4
MO
AZULFIDINE EN-TABS
4
MO
balsalazide disodium
2
MO
budesonide er tablet extended release 24 hour 9mg
2
MO
budesonide capsule delayed release particles 3mg
2
MO
budesonide foam 2mg
2
QL (66.8 GM per 28 days) MO
CANASA
5
MO
COLAZAL
5
MO
CORTENEMA
4
MO
DELZICOL
4
MO
DIPENTUM
4
MO
hydrocortisone enema 100mg/60ml
2
MO
LIALDA
5
MO
mesalamine kit, suppository, enema
2
MO
mesalamine dr capsule delayed release 400mg, tablet delayed
release 1.2gm, 800mg
2
MO
mesalamine er capsule extended release 24 hour 0.375gm
2
QL (120 EA per 30 days) MO
mesalamine er capsule extended release 24 hour 500mg
2
QL (240 EA per 30 days) MO
ORTIKOS
5
MO
PENTASA CAPSULE EXTENDED RELEASE 250MG
3
QL (480 EA per 30 days) MO
PENTASA CAPSULE EXTENDED RELEASE 500MG
5
QL (240 EA per 30 days) MO
ROWASA
5
MO
SFROWASA
5
QL (1680 ML per 28 days) MO
sulfasalazine tablet, delayed release tablet
2
MO
UCERIS FOAM
4
QL (66.8 GM per 28 days) MO
UCERIS TABLET EXTENDED RELEASE 24 HOUR
5
MO
LAXATIVES
CLENPIQ SOLUTION 12GM/160ML; 3.5GM/160ML;
10MG/160ML
4
CLENPIQ SOLUTION 12GM/175ML; 3.5GM/175ML;
10MG/175ML
4
MO
constulose
2
enulose
2
MO
gavilyte-c
1
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 94
Drug Name
Drug
Tier
Requirements/Limits
gavilyte-g
1
MO
generlac
2
GOLYTELY
3
MO
KRISTALOSE
4
PA MO
LACTULOSE PACKET
5
PA MO
lactulose oral solution (constipation)
2
MO
MOVIPREP
4
MO
OSMOPREP
4
MO
peg-3350/electrolytes
2
MO
peg-3350/electrolytes/ascorbate
2
peg-3350/nacl/na bicarbonate/kcl
1
MO
PLENVU
4
MO
SODIUM SULFATE/POTASSIUM
SULFATE/MAGNESIUM SULFATE
4
MO
SUFLAVE
4
SUPREP BOWEL PREP KIT
4
MO
SUTAB
4
MO
MISCELLANEOUS
alosetron hydrochloride
2
QL (60 EA per 30 days) PA MO
AMITIZA
4
QL (60 EA per 30 days) PA MO
bismuth subcitrate pot/metronidazole/tetracycline
hydrochloride
2
MO
BYLVAY (PELLETS) CAPSULE SPRINKLE 200MCG
5
QL (1080 EA per 30 days) PA LA
MO
BYLVAY (PELLETS) CAPSULE SPRINKLE 600MCG
5
QL (360 EA per 30 days) PA LA
MO
BYLVAY CAPSULE 1200MCG
5
QL (180 EA per 30 days) PA LA
MO
BYLVAY CAPSULE 400MCG
5
QL (540 EA per 30 days) PA LA
MO
CARAFATE
4
MO
CHENODAL
5
PA MO
CHOLBAM
5
PA LA MO
cromolyn sodium oral concentrate 100mg/5ml
2
MO
CYTOTEC
4
MO
diphenoxylate hydrochloride/atropine sulfate tablet
2
MO; HRM
diphenoxylate/atropine oral solution
2
MO; HRM
GASTROCROM
5
MO
GATTEX
5
PA LA; ACS
HELIDAC THERAPY
5
QL (448 EA per 365 days)
IBSRELA
5
PA MO
lansoprazole/amoxicillin/clarithromycin
2
QL (224 EA per 365 days) MO
LINZESS
3
QL (30 EA per 30 days) MO
LIVMARLI
5
QL (90 ML per 30 days) PA LA MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 95
Drug Name
Drug
Tier
Requirements/Limits
LOMOTIL
4
MO; HRM
loperamide hcl capsule
2
MO
LOTRONEX
4
QL (60 EA per 30 days) PA MO
LUBIPROSTONE
2
QL (60 EA per 30 days) PA MO
misoprostol tablet
2
MO
MOTEGRITY
4
QL (30 EA per 30 days) PA MO
MOTOFEN
4
QL (240 EA per 30 days) ST MO;
HRM
MOVANTIK TABLET 25MG
3
QL (30 EA per 30 days) MO
MOVANTIK TABLET 12.5MG
3
QL (60 EA per 30 days) MO
MYTESI
5
PA MO; ACS
OCALIVA
5
QL (30 EA per 30 days) PA LA;
ACS
OMECLAMOX-PAK
4
QL (160 EA per 365 days) MO
opium tincture
2
MO
PYLERA
5
MO
REBYOTA
5
PA LA MO
RELISTOR INJECTION
5
PA MO
RELISTOR TABLET
5
QL (90 EA per 30 days) PA MO
RELTONE
5
PA
SUCRAID
5
LA MO
SUCRALFATE SUSPENSION
4
MO
sucralfate tablet
2
MO
SYMPROIC
3
MO
TALICIA
4
QL (336 EA per 365 days) MO
TRULANCE
4
QL (30 EA per 30 days) MO
URSO 250
4
MO
URSO FORTE
4
MO
URSODIOL CAPSULE 200MG, 400MG
4
PA
ursodiol capsule 300mg
2
MO
ursodiol tablet
2
MO
VIBERZI
3
QL (60 EA per 30 days) PA MO
VOQUEZNA DUAL PAK
4
QL (224 EA per 365 days)
VOQUEZNA TRIPLE PAK
4
QL (224 EA per 365 days)
VOWST
5
PA LA MO
XERMELO
5
QL (84 EA per 28 days) PA LA MO
XIFAXAN TABLET 550MG
3
PA MO
PANCREATIC ENZYMES
CREON
3
MO
PANCREAZE CAPSULE DELAYED RELEASE
PARTICLES 2600UNIT, 4200UNIT, 10500UNIT
4
MO
PANCREAZE CAPSULE DELAYED RELEASE
PARTICLES 21000UNIT, 16800UNIT
5
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 96
Drug Name
Drug
Tier
Requirements/Limits
PERTZYE CAPSULE DELAYED RELEASE PARTICLES
4000UNIT, 8000UNIT
4
MO
PERTZYE CAPSULE DELAYED RELEASE PARTICLES
16000UNIT, 24000UNIT
5
MO
VIOKACE
3
MO
ZENPEP
3
MO
PROTON PUMP INHIBITORS
ACIPHEX
4
QL (30 EA per 30 days) MO
DEXILANT
4
QL (30 EA per 30 days) MO
dexlansoprazole
2
QL (30 EA per 30 days) MO
esomeprazole magnesium capsule delayed release
2
QL (30 EA per 30 days) MO
esomeprazole sodium injection
2
KONVOMEP
4
QL (600 ML per 30 days) PA
lansoprazole capsule delayed release 15mg
2
QL (30 EA per 30 days) MO
lansoprazole capsule delayed release 30mg
2
QL (42 EA per 30 days) MO
lansoprazole tablet delayed release disintegrating 15mg
2
QL (30 EA per 30 days) MO
lansoprazole tablet delayed release disintegrating 30mg
2
QL (42 EA per 30 days) MO
NEXIUM CAPSULE, PACKET
4
QL (30 EA per 30 days) MO
NEXIUM I.V. INJECTION
4
PA
omeprazole dr capsule delayed release 20mg, 40mg
2
QL (60 EA per 30 days) MO
omeprazole dr capsule delayed release 10mg
2
QL (30 EA per 30 days) MO
omeprazole/sodium bicarbonate
5
QL (30 EA per 30 days) MO
pantoprazole sodium injection
2
pantoprazole sodium packet
2
QL (30 EA per 30 days) MO
pantoprazole sodium tablet delayed release 20mg
1
QL (30 EA per 30 days) MO
pantoprazole sodium tablet delayed release 40mg
1
QL (60 EA per 30 days) MO
PREVACID CAPSULE DELAYED RELEASE 30MG
4
QL (42 EA per 30 days) MO
PREVACID SOLUTAB TABLET DELAYED RELEASE
DISINTEGRATING 15MG
4
QL (30 EA per 30 days) MO
PREVACID SOLUTAB TABLET DELAYED RELEASE
DISINTEGRATING 30MG
4
QL (42 EA per 30 days) MO
PRILOSEC PACKET 10MG
4
QL (120 EA per 30 days) MO
PRILOSEC PACKET 2.5MG
4
QL (90 EA per 30 days) MO
PROTONIX INJECTION
4
PROTONIX PACKET
4
QL (30 EA per 30 days) MO
PROTONIX TABLET DELAYED RELEASE 20MG
4
QL (30 EA per 30 days) MO
PROTONIX TABLET DELAYED RELEASE 40MG
4
QL (60 EA per 30 days) MO
rabeprazole sodium delayed release tablet 20mg
2
QL (30 EA per 30 days) MO
ZEGERID
5
QL (30 EA per 30 days) PA MO
GENITOURINARY
BENIGN PROSTATIC HYPERPLASIA
alfuzosin hcl er
2
QL (30 EA per 30 days) MO
AVODART
4
QL (30 EA per 30 days) MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 97
Drug Name
Drug
Tier
Requirements/Limits
CARDURA XL TABLET EXTENDED RELEASE 24 HOUR
8MG
4
QL (30 EA per 30 days) MO
CARDURA XL TABLET EXTENDED RELEASE 24 HOUR
4MG
4
QL (60 EA per 30 days) MO
dutasteride
2
QL (30 EA per 30 days) MO
dutasteride/tamsulosin hydrochloride
2
QL (30 EA per 30 days) MO
ENTADFI
4
QL (30 EA per 30 days) PA
finasteride tablet 5mg
1
QL (30 EA per 30 days) MO
FLOMAX
4
QL (60 EA per 30 days) MO
PROSCAR
4
QL (30 EA per 30 days) MO
RAPAFLO
4
QL (30 EA per 30 days) MO
silodosin
2
QL (30 EA per 30 days) MO
tamsulosin hydrochloride
2
QL (60 EA per 30 days) MO
UROXATRAL
4
QL (30 EA per 30 days) MO
MISCELLANEOUS
acetic acid 0.25% irrigation soln
2
MO
bethanechol chloride tablet
2
MO
ELMIRON
4
QL (90 EA per 30 days) MO
FILSPARI
5
QL (30 EA per 30 days) PA LA;
ACS
flavoxate hcl
2
MO; HRM
INTRAROSA
4
QL (28 EA per 28 days) PA MO
LITHOSTAT
5
MO
neomycin sulfate/polymyxin b sulfate solution for irrigation
2
MO
ORACIT
4
MO
OXLUMO
5
PA LA MO
potassium citrate er
2
MO
potassium citrate/citric acid
2
MO
potassium citrate/sodium citrate/citric acid
2
MO
RENACIDIN
4
MO
RIMSO-50
5
MO
sodium citrate/citric acid
2
MO
SORBITOL IRRIGATION SOLUTION
4
TARPEYO
5
QL (120 EA per 30 days) PA LA
MO
THIOLA
5
LA MO
THIOLA EC
5
LA MO
tiopronin
5
ACS
tricitrates
2
MO
UROCIT-K 10
4
MO
UROCIT-K 15
4
MO
UROCIT-K 5
4
MO
URINARY ANTISPASMODICS
darifenacin hydrobromide er
2
QL (30 EA per 30 days) MO; HRM
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 98
Drug Name
Drug
Tier
Requirements/Limits
DETROL
4
QL (60 EA per 30 days) MO; HRM
DETROL LA
4
QL (30 EA per 30 days) MO; HRM
DITROPAN XL TABLET EXTENDED RELEASE 24
HOUR 5MG
4
QL (30 EA per 30 days) MO; HRM
DITROPAN XL TABLET EXTENDED RELEASE 24
HOUR 10MG
4
QL (60 EA per 30 days) MO; HRM
fesoterodine fumarate er
2
QL (30 EA per 30 days) MO; HRM
GELNIQUE
4
QL (30 GM per 30 days) MO; HRM
GEMTESA
4
QL (30 EA per 30 days) MO
MYRBETRIQ TABLET EXTENDED RELEASE 24 HOUR
3
QL (30 EA per 30 days) MO
MYRBETRIQ SUSPENSION RECONSTITUTED ER
3
QL (300 ML per 28 days) MO
oxybutynin chloride er tablet extended release 24 hour 5mg
2
QL (30 EA per 30 days) MO; HRM
oxybutynin chloride er tablet extended release 24 hour 10mg,
15mg
2
QL (60 EA per 30 days) MO; HRM
oxybutynin chloride solution
2
QL (600 ML per 30 days) MO;
HRM
OXYBUTYNIN CHLORIDE TABLET 2.5MG
4
QL (90 EA per 30 days) MO
oxybutynin chloride tablet 5mg
2
QL (120 EA per 30 days) MO; HRM
OXYTROL
4
QL (8 EA per 28 days) MO; HRM
solifenacin succinate
2
QL (30 EA per 30 days) MO; HRM
tolterodine tartrate
2
QL (60 EA per 30 days) MO; HRM
tolterodine tartrate er
2
QL (30 EA per 30 days) MO; HRM
TOVIAZ
4
QL (30 EA per 30 days) MO; HRM
trospium chloride
2
QL (60 EA per 30 days) MO; HRM
trospium chloride er
2
QL (30 EA per 30 days) MO; HRM
VESICARE
4
QL (30 EA per 30 days) MO; HRM
VESICARE LS
4
QL (300 ML per 30 days); HRM
VAGINAL ANTI-INFECTIVES
CLEOCIN CREAM 2%
4
MO
CLEOCIN SUPPOSITORY 100MG
4
MO
clindamycin phosphate vaginal cream 2%
2
MO
CLINDESSE
4
QL (5 GM per 30 days) MO
GYNAZOLE-1
4
MO
metronidazole vaginal gel 0.75%
2
MO
miconazole 3 vaginal suppository
2
MO
NUVESSA
4
MO
terconazole
2
MO
VANDAZOLE
4
MO
XACIATO
4
HEMATOLOGIC
ANTICOAGULANTS
argatroban
2
ARIXTRA INJECTION 2.5MG/0.5ML
4
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 99
Drug Name
Drug
Tier
Requirements/Limits
ARIXTRA INJECTION 10MG/0.8ML, 5MG/0.4ML,
7.5MG/0.6ML
5
MO
dabigatran etexilate
2
QL (60 EA per 30 days) MO
ELIQUIS STARTER PACK
3
QL (74 EA per 30 days) MO
ELIQUIS TABLET 2.5MG
3
QL (60 EA per 30 days) MO
ELIQUIS TABLET 5MG
3
QL (74 EA per 30 days) MO
enoxaparin sodium
2
MO
fondaparinux sodium injection 2.5mg/0.5ml
2
MO
fondaparinux sodium injection 10mg/0.8ml, 5mg/0.4ml,
7.5mg/0.6ml
4
MO
FRAGMIN INJECTION 10000UNIT/4ML
4
FRAGMIN INJECTION 2500UNIT/0.2ML,
95000UNIT/3.8ML
4
MO
FRAGMIN INJECTION 10000UNIT/ML,
12500UNIT/0.5ML, 15000UNIT/0.6ML, 18000UNT/0.72ML,
5000UNIT/0.2ML, 7500UNIT/0.3ML
5
MO
HEPARIN SODIUM/D5W INJ 20000UNIT/500ML,
25000UNIT/500ML
4
HEPARIN SODIUM/DEXTROSE 25000UNIT/250ML
(100UNIT/ML)
4
HEPARIN SODIUM/SODIUM CHLORIDE 0.45%
3
HEPARIN SODIUM INJECTION 5000UNIT/0.5ML,
5000UNIT/ML
2
heparin sodium injection 10000unit/ml, 1000unit/ml,
20000unit/ml, 5000unit/0.5ml, 5000unit/ml
2
MO
jantoven
1
MO
LOVENOX INJECTION 120MG/0.8ML, 300MG/3ML,
30MG/0.3ML
4
MO
LOVENOX INJECTION 100MG/ML, 150MG/ML,
40MG/0.4ML, 60MG/0.6ML, 80MG/0.8ML
5
MO
PRADAXA CAPSULE 110MG
4
QL (120 EA per 30 days) MO
PRADAXA CAPSULE 150MG, 75MG
4
QL (60 EA per 30 days) MO
PRADAXA PACKET 110MG, 30MG, 40MG, 50MG
4
QL (120 EA per 30 days)
PRADAXA PACKET 150MG, 20MG
4
QL (60 EA per 30 days)
SAVAYSA
4
QL (30 EA per 30 days) ST MO
warfarin sodium
1
MO
XARELTO STARTER PACK
3
QL (51 EA per 30 days) MO
XARELTO SUSPENSION RECONSTITUTED
3
QL (620 ML per 30 days) MO
XARELTO TABLET 10MG, 15MG, 20MG
3
QL (30 EA per 30 days) MO
XARELTO TABLET 2.5MG
3
QL (60 EA per 30 days) MO
HEMATOPOIETIC GROWTH FACTORS
ARANESP ALBUMIN FREE INJECTION 60MCG/0.3ML
4
QL (1.2 ML per 28 days) PA; ACS
ARANESP ALBUMIN FREE INJECTION 10MCG/0.4ML,
40MCG/0.4ML
4
QL (1.6 ML per 28 days) PA; ACS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 100
Drug Name
Drug
Tier
Requirements/Limits
ARANESP ALBUMIN FREE INJECTION 25MCG/0.42ML
4
QL (1.68 ML per 28 days) PA; ACS
ARANESP ALBUMIN FREE INJECTION 25MCG/ML,
40MCG/ML, 60MCG/ML
4
QL (4 ML per 28 days) PA; ACS
ARANESP ALBUMIN FREE INJECTION 500MCG/ML
5
QL (1 ML per 21 days) PA; ACS
ARANESP ALBUMIN FREE INJECTION 150MCG/0.3ML
5
QL (1.2 ML per 28 days) PA; ACS
ARANESP ALBUMIN FREE INJECTION 200MCG/0.4ML
5
QL (1.6 ML per 28 days) PA; ACS
ARANESP ALBUMIN FREE INJECTION 100MCG/0.5ML
5
QL (2 ML per 28 days) PA; ACS
ARANESP ALBUMIN FREE INJECTION 300MCG/0.6ML
5
QL (2.4 ML per 28 days) PA; ACS
ARANESP ALBUMIN FREE INJECTION 100MCG/ML,
200MCG/ML
5
QL (4 ML per 28 days) PA; ACS
EPOGEN
4
QL (12 ML per 28 days) PA; ACS
FULPHILA
5
PA; ACS
FYLNETRA
5
PA LA; ACS
GRANIX INJECTION 480MCG/1.6ML
4
PA; ACS
GRANIX INJECTION 300MCG/0.5ML, 300MCG/ML,
480MCG/0.8ML
5
PA; ACS
LEUKINE
5
PA; ACS
MOZOBIL
5
PA LA; ACS
NEULASTA
5
PA; ACS
NEULASTA ONPRO KIT
5
PA; ACS
NEUPOGEN
5
PA; ACS
NIVESTYM
5
PA; ACS
NPLATE
5
PA; ACS
NYVEPRIA
5
PA; ACS
plerixafor
5
PA; ACS
PROCRIT INJECTION 10000UNIT/ML, 2000UNIT/ML,
3000UNIT/ML, 4000UNIT/ML
3
PA; ACS
PROCRIT INJECTION 20000UNIT/ML, 40000UNIT/ML
5
PA; ACS
RELEUKO
5
PA LA; ACS
RETACRIT INJECTION 10000UNIT/ML, 20000UNIT/2ML,
2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML
4
PA; ACS
RETACRIT INJECTION 20000UNIT/ML, 40000UNIT/ML
5
PA; ACS
ROLVEDON
5
PA LA; ACS
UDENYCA
5
PA; ACS
ZARXIO
5
PA; ACS
ZIEXTENZO
5
PA; ACS
MISCELLANEOUS
ADAKVEO
5
PA; ACS
AGRYLIN
4
MO
AMICAR
5
MO
aminocaproic acid injection
2
aminocaproic acid oral solution, tablet
2
MO
anagrelide hydrochloride
2
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 101
Drug Name
Drug
Tier
Requirements/Limits
BERINERT
5
QL (24 EA per 30 days) PA LA;
ACS
CABLIVI
5
PA LA MO
cilostazol
1
MO
CINRYZE
5
QL (20 EA per 30 days) PA LA;
ACS
CYKLOKAPRON
4
DOPTELET
5
QL (60 EA per 30 days) PA LA;
ACS
DROXIA
3
MO
EMPAVELI
5
QL (200 ML per 30 days) PA LA
MO
ENDARI
5
PA LA; ACS
ENJAYMO
5
PA LA; ACS
FIRAZYR
5
QL (27 ML per 30 days) PA; ACS
GIVLAARI
5
PA LA MO
HAEGARDA INJECTION 3000UNIT
5
QL (20 EA per 30 days) PA LA;
ACS
HAEGARDA INJECTION 2000UNIT
5
QL (30 EA per 30 days) PA LA;
ACS
icatibant acetate
5
QL (27 ML per 30 days) PA; ACS
KALBITOR
5
QL (12 ML per 30 days) PA LA;
ACS
MULPLETA
5
QL (14 EA per 365 days) PA; ACS
ORLADEYO
5
QL (28 EA per 28 days) PA LA MO
OXBRYTA TABLET SOLUBLE
5
QL (150 EA per 30 days) PA LA;
ACS
OXBRYTA TABLET
5
QL (90 EA per 30 days) PA LA;
ACS
pentoxifylline er
2
MO
PROMACTA PACKET 25MG
5
QL (180 EA per 30 days) PA LA;
ACS
PROMACTA PACKET 12.5MG
5
QL (360 EA per 30 days) PA LA;
ACS
PROMACTA TABLET 12.5MG, 25MG
5
QL (30 EA per 30 days) PA LA;
ACS
PROMACTA TABLET 50MG, 75MG
5
QL (60 EA per 30 days) PA LA;
ACS
PYRUKYND
5
QL (56 EA per 28 days) PA LA MO
PYRUKYND TAPER PACK TABLET THERAPY PACK 0
5
QL (14 EA per 14 days) PA LA MO
PYRUKYND TAPER PACK TABLET THERAPY PACK
5MG
5
QL (7 EA per 7 days) PA LA MO
REBLOZYL
5
PA LA; ACS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 102
Drug Name
Drug
Tier
Requirements/Limits
RUCONEST
5
QL (12 EA per 30 days) PA LA;
ACS
sajazir
5
QL (27 ML per 30 days) PA LA
SIKLOS
3
PA MO
SOLIRIS
5
PA LA; ACS
TAKHZYRO INJECTION 150MG/ML
5
QL (2 ML per 28 days) PA LA; ACS
TAKHZYRO INJECTION 300MG/2ML
5
QL (4 ML per 28 days) PA LA; ACS
TAVALISSE
5
QL (60 EA per 30 days) PA LA
TAVNEOS
5
QL (180 EA per 30 days) PA LA
MO
tranexamic acid injection
2
tranexamic acid tablet
2
MO
ULTOMIRIS
5
PA LA; ACS
PLATELET AGGREGATION INHIBITORS
aspirin/dipyridamole er
2
QL (60 EA per 30 days) MO
BRILINTA
3
MO
clopidogrel tablet 300mg
1
QL (2 EA per 365 days) MO
clopidogrel tablet 75mg
1
QL (30 EA per 30 days) MO
dipyridamole tablet
2
PA MO
EFFIENT
4
MO
PLAVIX
4
QL (30 EA per 30 days) ST MO
prasugrel
2
MO
ZONTIVITY
4
MO
IMMUNOLOGIC AGENTS
AUTOIMMUNE AGENTS
ACTEMRA ACTPEN
5
QL (3.6 ML per 28 days) PA LA;
ACS
ACTEMRA INJECTION 162MG/0.9ML
5
QL (3.6 ML per 28 days) PA; ACS
ACTEMRA INJECTION 200MG/10ML, 400MG/20ML,
80MG/4ML
5
QL (40 ML per 28 days) PA LA;
ACS
ADBRY
5
QL (56 ML per 365 days) PA LA;
ACS
AMJEVITA INJECTION 20MG/0.4ML
5
QL (10.4 ML per 365 days) PA;
ACS
AMJEVITA INJECTION 40MG/0.8ML
5
QL (44.8 ML per 365 days) PA;
ACS
AMJEVITA INJECTION 10MG/0.2ML
5
QL (5.2 ML per 365 days) PA; ACS
AVSOLA
5
PA LA; ACS
CIBINQO
5
QL (30 EA per 30 days) PA; ACS
CIMZIA
5
QL (2 EA per 28 days) PA; ACS
CIMZIA STARTER KIT
5
QL (6 EA per 365 days) PA; ACS
COSENTYX SENSOREADY PEN
5
QL (32 ML per 365 days) PA LA;
ACS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 103
Drug Name
Drug
Tier
Requirements/Limits
COSENTYX UNOREADY
5
QL (32 ML per 365 days) PA LA;
ACS
COSENTYX INJECTION 150MG/ML
5
QL (32 ML per 365 days) PA LA;
ACS
COSENTYX INJECTION 75MG/0.5ML
5
QL (8 ML per 365 days) PA LA;
ACS
DUPIXENT INJECTION 100MG/0.67ML
5
QL (1.34 ML per 28 days) PA; ACS
DUPIXENT INJECTION 200MG/1.14ML
5
QL (4.56 ML per 28 days) PA; ACS
DUPIXENT INJECTION 300MG/2ML
5
QL (8 ML per 28 days) PA; ACS
ENBREL
5
QL (8 ML per 28 days) PA; ACS
ENBREL MINI
5
QL (8 ML per 28 days) PA; ACS
ENBREL SURECLICK
5
QL (8 ML per 28 days) PA; ACS
ENTYVIO
5
QL (8 EA per 365 days) PA LA;
ACS
HUMIRA PEDIATRIC CROHNS DISEASE STARTER
PACK
5
PA; ACS
HUMIRA PEN-CD/UC/HS STARTER
5
PA; ACS
HUMIRA PEN-PEDIATRIC UC STARTER PACK
5
PA; ACS
HUMIRA PEN-PS/UV STARTER
5
PA; ACS
HUMIRA PEN INJECTION 80MG/0.8ML
5
PA; ACS
HUMIRA PEN INJECTION 40MG/0.4ML, 40MG/0.8ML
5
QL (6 EA per 28 days) PA; ACS
HUMIRA INJECTION 10MG/0.1ML, 20MG/0.2ML
5
QL (2 EA per 28 days) PA; ACS
HUMIRA INJECTION 40MG/0.4ML, 40MG/0.8ML
5
QL (6 EA per 28 days) PA; ACS
ILUMYA
5
PA LA; ACS
INFLECTRA
5
PA LA; ACS
INFLIXIMAB
5
PA LA; ACS
KEVZARA
5
QL (2.28 ML per 28 days) PA; ACS
KINERET
5
QL (18.76 ML per 28 days) PA MO
LITFULO
5
QL (28 EA per 28 days) PA LA
OLUMIANT
5
QL (30 EA per 30 days) PA LA;
ACS
ORENCIA CLICKJECT
5
QL (4 ML per 28 days) PA; ACS
ORENCIA INJECTION 250MG
5
PA; ACS
ORENCIA INJECTION 50MG/0.4ML
5
QL (1.6 ML per 28 days) PA; ACS
ORENCIA INJECTION 87.5MG/0.7ML
5
QL (2.8 ML per 28 days) PA; ACS
ORENCIA INJECTION 125MG/ML
5
QL (4 ML per 28 days) PA; ACS
OTEZLA TABLET THERAPY PACK
5
QL (110 EA per 365 days) PA; ACS
OTEZLA TABLET
5
QL (60 EA per 30 days) PA; ACS
REMICADE
5
PA LA; ACS
RENFLEXIS
5
PA LA; ACS
RINVOQ
5
QL (30 EA per 30 days) PA; ACS
SILIQ
5
QL (4.5 ML per 28 days) PA; ACS
SIMPONI ARIA
5
PA; ACS
SIMPONI INJECTION 50MG/0.5ML
5
QL (0.5 ML per 28 days) PA; ACS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 104
Drug Name
Drug
Tier
Requirements/Limits
SIMPONI INJECTION 100MG/ML
5
QL (3 ML per 28 days) PA; ACS
SKYRIZI PEN
5
QL (6 ML per 365 days) PA; ACS
SKYRIZI INJECTION 180MG/1.2ML
5
QL (1.2 ML per 56 days) PA; ACS
SKYRIZI INJECTION 360MG/2.4ML
5
QL (2.4 ML per 56 days) PA; ACS
SKYRIZI INJECTION 150MG/ML
5
QL (6 ML per 365 days) PA; ACS
SKYRIZI INJECTION 600MG/10ML
5
QL (60 ML per 365 days) PA; ACS
SOTYKTU
5
QL (30 EA per 30 days) PA LA;
ACS
SPEVIGO
5
PA LA MO
STELARA INJECTION 45MG/0.5ML VIAL
5
QL (0.5 ML per 28 days) PA LA;
ACS
STELARA INJECTION 45MG/0.5ML PREFILLED
SYRINGE
5
QL (0.5 ML per 28 days) PA; ACS
STELARA INJECTION 90MG/ML
5
QL (1 ML per 28 days) PA; ACS
STELARA INJECTION 130MG/26ML
5
QL (208 ML per 365 days) PA LA;
ACS
TALTZ
5
QL (3 ML per 28 days) PA LA; ACS
TREMFYA
5
QL (1 ML per 28 days) PA; ACS
XELJANZ XR
5
QL (30 EA per 30 days) PA; ACS
XELJANZ SOLUTION
5
QL (480 ML per 24 days) PA; ACS
XELJANZ TABLET
5
QL (60 EA per 30 days) PA; ACS
DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS
(DMARDS)
ARAVA
5
QL (30 EA per 30 days) MO
HYDROXYCHLOROQUINE SULFATE TABLET 100MG,
300MG, 400MG
4
MO
hydroxychloroquine sulfate tablet 200mg
2
MO
leflunomide
1
QL (30 EA per 30 days) MO
methotrexate sodium tablet 2.5mg
1
MO
OTREXUP
4
QL (1.6 ML per 28 days); ACS
PLAQUENIL
4
MO
RASUVO INJECTION 7.5MG/0.15ML
4
QL (0.6 ML per 28 days); ACS
RASUVO INJECTION 10MG/0.2ML
4
QL (0.8 ML per 28 days); ACS
RASUVO INJECTION 12.5MG/0.25ML
4
QL (1 ML per 28 days); ACS
RASUVO INJECTION 15MG/0.3ML
4
QL (1.2 ML per 28 days); ACS
RASUVO INJECTION 17.5MG/0.35ML
4
QL (1.4 ML per 28 days); ACS
RASUVO INJECTION 20MG/0.4ML
4
QL (1.6 ML per 28 days); ACS
RASUVO INJECTION 22.5MG/0.45ML
4
QL (1.8 ML per 28 days); ACS
RASUVO INJECTION 25MG/0.5ML
4
QL (2 ML per 28 days); ACS
RASUVO INJECTION 30MG/0.6ML
4
QL (2.4 ML per 28 days); ACS
REDITREX INJECTION 7.5MG/0.3ML
4
QL (1.2 ML per 28 days); ACS
REDITREX INJECTION 10MG/0.4ML
4
QL (1.6 ML per 28 days); ACS
REDITREX INJECTION 12.5MG/0.5ML
4
QL (2 ML per 28 days); ACS
REDITREX INJECTION 15MG/0.6ML
4
QL (2.4 ML per 28 days); ACS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 105
Drug Name
Drug
Tier
Requirements/Limits
REDITREX INJECTION 17.5MG/0.7ML
4
QL (2.8 ML per 28 days); ACS
REDITREX INJECTION 20MG/0.8ML
4
QL (3.2 ML per 28 days); ACS
REDITREX INJECTION 22.5MG/0.9ML
4
QL (3.6 ML per 28 days); ACS
REDITREX INJECTION 25MG/ML
4
QL (4 ML per 28 days); ACS
RIDAURA
4
MO
TREXALL
4
MO
XATMEP
4
MO
IMMUNOGLOBULINS
ASCENIV
5
PA; ACS
BIVIGAM
5
PA LA; ACS
CUTAQUIG
5
PA LA; ACS
CUVITRU
5
PA LA; ACS
CYTOGAM
5
ACS
FLEBOGAMMA DIF
5
PA; ACS
GAMASTAN
3
B/D LA; ACS
GAMMAGARD LIQUID
5
PA; ACS
GAMMAGARD S/D INJ LESS THAN 1MCG/ML 5GM
5
PA; ACS
GAMMAKED
5
PA; ACS
GAMMAPLEX
5
PA LA; ACS
GAMUNEX-C
5
PA; ACS
HEPAGAM B
4
ACS
HIZENTRA
5
PA LA; ACS
HYPERHEP B
4
ACS
HYPERRAB INJECTION 300UNIT/ML
4
HYPERRAB INJECTION 1500UNIT/5ML, 900UNIT/3ML
5
HYPERRHO S/D
4
ACS
HYPERRHO S/D MINI-DOSE
4
ACS
HYPERTET
4
HYQVIA
5
PA LA; ACS
IMOGAM RABIES-HT
4
KEDRAB INJECTION 300UNIT/2ML
4
KEDRAB INJECTION 1500UNIT/10ML
5
MICRHOGAM ULTRA-FILTERED PLUS
4
ACS
NABI-HB
4
ACS
OCTAGAM
5
PA; ACS
PANZYGA
5
PA; ACS
PRIVIGEN
5
PA; ACS
RHOGAM ULTRA-FILTERED PLUS
4
ACS
RHOPHYLAC
4
ACS
VARIZIG
5
ACS
WINRHO SDF
4
ACS
XEMBIFY
5
PA LA; ACS
IMMUNOMODULATORS
ACTIMMUNE
5
PA LA; ACS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 106
Drug Name
Drug
Tier
Requirements/Limits
ARCALYST
5
PA LA; ACS
BEYFORTUS
4
GRASTEK
3
QL (30 EA per 30 days) PA MO
ILARIS
5
QL (2 ML per 28 days) PA LA; ACS
JOENJA
5
QL (60 EA per 30 days) PA LA MO
ODACTRA
4
QL (30 EA per 30 days) PA MO
ORALAIR
4
QL (30 EA per 30 days) PA LA MO;
ACS
PALFORZIA INITIAL DOSE ESCALATION
4
QL (26 EA per 365 days) PA LA
MO; ACS
PALFORZIA LEVEL 1
4
QL (90 EA per 365 days) PA LA
MO; ACS
PALFORZIA LEVEL 10
4
QL (120 EA per 365 days) PA LA
MO; ACS
PALFORZIA LEVEL 11 (MAINTENANCE)
4
QL (30 EA per 30 days) PA LA MO;
ACS
PALFORZIA LEVEL 11 (TITRATION)
4
QL (30 EA per 365 days) PA LA
MO; ACS
PALFORZIA LEVEL 2
4
QL (180 EA per 365 days) PA LA
MO; ACS
PALFORZIA LEVEL 3
4
QL (90 EA per 365 days) PA LA
MO; ACS
PALFORZIA LEVEL 4
4
QL (30 EA per 365 days) PA LA
MO; ACS
PALFORZIA LEVEL 5
4
QL (60 EA per 365 days) PA LA
MO; ACS
PALFORZIA LEVEL 6
4
QL (120 EA per 365 days) PA LA
MO; ACS
PALFORZIA LEVEL 7
4
QL (60 EA per 365 days) PA LA
MO; ACS
PALFORZIA LEVEL 8
4
QL (120 EA per 365 days) PA LA
MO; ACS
PALFORZIA LEVEL 9
4
QL (60 EA per 365 days) PA LA
MO; ACS
RAGWITEK
3
QL (30 EA per 30 days) PA MO
RYSTIGGO
5
QL (24 ML per 28 days) PA LA
SYNAGIS
5
ACS
VYVGART
5
QL (240 ML per 28 days) PA LA;
ACS
VYVGART HYTRULO
5
QL (22.4 ML per 28 days) PA LA
ZINPLAVA
5
PA
IMMUNOSUPPRESSANTS
ASTAGRAF XL
4
B/D MO
ATGAM
5
B/D
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 107
Drug Name
Drug
Tier
Requirements/Limits
azasan
2
B/D
AZATHIOPRINE INJECTION
4
B/D
azathioprine tablet
2
B/D MO
BENLYSTA
5
PA LA; ACS
CELLCEPT
5
B/D MO
CELLCEPT IV SOLUTION
4
B/D
cyclosporine modified capsule, oral solution
2
B/D MO
cyclosporine capsule 100mg, 25mg
2
B/D MO
cyclosporine injection 50mg/ml
2
B/D MO
ENVARSUS XR
4
B/D MO
everolimus tablet 0.25mg, 0.5mg, 0.75mg, 1mg
2
B/D MO
gengraf capsule
2
B/D
gengraf solution
2
B/D MO
IMURAN
4
B/D MO
LUPKYNIS
5
QL (180 EA per 30 days) PA LA
MO
mycophenolate mofetil
2
B/D MO
mycophenolic acid dr
2
B/D MO
MYFORTIC TABLET DELAYED RELEASE 180MG
4
B/D MO
MYFORTIC TABLET DELAYED RELEASE 360MG
5
B/D MO
NEORAL
4
B/D MO
NULOJIX
5
B/D
PROGRAF INJECTION
4
B/D
PROGRAF GRANULES
4
B/D MO
PROGRAF CAPSULE 0.5MG, 1MG
4
B/D MO
PROGRAF CAPSULE 5MG
5
B/D MO
RAPAMUNE SOLUTION
5
B/D MO
RAPAMUNE TABLET 0.5MG
4
B/D MO
RAPAMUNE TABLET 1MG, 2MG
5
B/D MO
REZUROCK
5
QL (30 EA per 30 days) PA LA MO
SANDIMMUNE INJECTION
4
B/D
SANDIMMUNE ORAL SOLUTION
4
B/D MO
SANDIMMUNE CAPSULE 25MG
4
B/D MO
SANDIMMUNE CAPSULE 100MG
5
B/D MO
SAPHNELO
5
QL (2 ML per 28 days) PA LA; ACS
SIMULECT
5
B/D
sirolimus
2
B/D MO
tacrolimus capsule 0.5mg, 1mg, 5mg
2
B/D MO
THYMOGLOBULIN
5
B/D
ZORTRESS
5
B/D MO
VACCINES
ABRYSVO
3
ACTHIB
1
ADACEL
1
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 108
Drug Name
Drug
Tier
Requirements/Limits
AREXVY
3
BCG VACCINE
1
BEXSERO
1
BOOSTRIX
1
DAPTACEL
1
DENGVAXIA
1
DIPHTHERIA/TETANUS TOXOIDS ADSORBED
PEDIATRIC
1
ENGERIX-B
1
B/D
GARDASIL 9
1
HAVRIX
1
HEPLISAV-B
1
B/D
HIBERIX
1
IMOVAX RABIES (H.D.C.V.)
1
B/D
INFANRIX
1
IPOL INACTIVATED IPV
1
IXIARO
1
JYNNEOS
1
B/D
KINRIX
1
M-M-R II
1
MENACTRA
1
MENQUADFI
1
MENVEO
1
PEDIARIX
1
PEDVAX HIB
1
PENTACEL
1
PREHEVBRIO
1
B/D
PRIORIX
1
PROQUAD
1
QUADRACEL
1
RABAVERT
1
B/D
RECOMBIVAX HB
1
B/D
ROTARIX
1
ROTATEQ
1
SHINGRIX
1
QL (2 EA per 999 days)
TDVAX
1
TENIVAC
1
TICOVAC
1
TRUMENBA
1
TWINRIX
1
TYPHIM VI
1
VAQTA
1
VARIVAX
1
YF-VAX
1
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 109
Drug Name
Drug
Tier
Requirements/Limits
NUTRITIONAL/SUPPLEMENTS
ELECTROLYTES/MINERALS, INJECTABLE
CALCIUM GLUCONATE INJECTION SOLUTION 10%
4
DEXTROSE 10%/NACL 0.45%
4
DEXTROSE 5% /ELECTROLYTE #48 VIAFLEX
3
DEXTROSE 10%/NACL 0.2%
4
DEXTROSE 2.5%/NACL 0.45%
4
DEXTROSE 5%/LACTATED RINGERS
4
DEXTROSE 5%/NACL 0.2%
4
dextrose 5%/nacl 0.3%
2
DEXTROSE 5%/NACL 0.33%
4
DEXTROSE 5%/NACL 0.45%
4
DEXTROSE 5%/NACL 0.9%
4
MO
DEXTROSE 5%/NACL 0.225%
4
hyperlyte-cr
2
B/D
ISOLYTE-P/DEXTROSE 5%
4
ISOLYTE-S
4
B/D
ISOLYTE-S PH 7.4
4
B/D
KCL 0.075%/D5W/NACL 0.45%
4
KCL 0.15%/D5W/NACL 0.2%
4
KCL 0.15%/D5W/NACL 0.45%
4
KCL 0.15%/D5W/NACL 0.9%
4
KCL 0.3%/D5W/NACL 0.45%
4
KCL 0.3%/D5W/NACL 0.9%
4
lactated ringers
2
magnesium sulfate in d5w injection 1gm/100ml
2
MAGNESIUM SULFATE INJECTION 20GM/500ML,
40GM/1000ML, 4GM/50ML
4
magnesium sulfate injection 2gm/50ml, 4gm/100ml, 50%
2
multiple electrolytes injection type 1
2
PLASMA-LYTE A
4
PLASMA-LYTE-148
4
POTASSIUM ACETATE SOLUTION 100MEQ; 50ML
4
POTASSIUM CHLORIDE/DEXTROSE
4
POTASSIUM CHLORIDE/DEXTROSE/LACTATED
RINGERS
4
POTASSIUM CHLORIDE/DEXTROSE/SODIUM
CHLORIDE
4
POTASSIUM CHLORIDE/SODIUM CHLORIDE
INJECTION 40MEQ/L; 0.9%
4
potassium chloride/sodium chloride injection 20meq/l; 0.45%,
20meq/l; 0.9%
2
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 110
Drug Name
Drug
Tier
Requirements/Limits
POTASSIUM CHLORIDE INJECTION 0.4MEQ/ML,
10MEQ/100ML, 10MEQ/50ML, 20MEQ/100ML,
40MEQ/100ML
4
potassium chloride injection 2meq/ml
2
MO
potassium phosphate solution 3mmol/ml
2
RINGERS INJECTION
3
SODIUM ACETATE INJECTION 2MEQ/ML
4
sodium acetate injection 4meq/ml
2
SODIUM BICARBONATE INJECTION 7.5%
4
sodium bicarbonate injection 4.2%
2
sodium bicarbonate injection 8.4%
2
MO
sodium chloride 0.45%
2
SODIUM CHLORIDE INJECTION 2.5MEQ/ML, 5%
4
MO
sodium chloride injection 0.9%, 3%, 4meq/ml
2
MO
sodium phosphate i.v. solution 45mmol/15ml, 15mmol/5ml
2
sodium phosphates i.v. solution 150mmol/50ml
2
TPN ELECTROLYTES
4
B/D
ELECTROLYTES/MINERALS/VITAMINS, ORAL
adc/fluoride drops
2
MO
C-NATE DHA
3
MO
CITRANATAL 90 DHA
3
MO
CITRANATAL B-CALM
3
MO
CITRANATAL BLOOM
3
MO
CITRANATAL HARMONY
3
MO
CITRANATAL MEDLEY
3
MO
COMPLETENATE
3
MO
CONCEPT DHA
3
MO
CONCEPT OB
3
MO
DUET DHA 400
3
MO
DUET DHA BALANCED
3
MO
EFFER-K TABLET EFFERVESCENT 0.84GM; 1GM,
1.68GM; 2GM
4
MO
effer-k tablet effervescent 25meq
2
MO
ELITE-OB
2
MO
ENBRACE HR
3
MO
FLORIVA DROPS, CHEWABLE TABLET
4
MO
fluoride chewable tablet
2
MO
fluoritab drops
2
FOLIVANE-OB
3
MO
K-TAB
4
MO
klor-con 10
2
klor-con 8
2
klor-con effervescent tablet
2
MO
klor-con m10
2
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 111
Drug Name
Drug
Tier
Requirements/Limits
klor-con m15
2
MO
klor-con m20
2
MO
klor-con powder packet 20meq
2
M-NATAL PLUS
3
MO
multi-vitamin/fluoride drops
2
MO
multi-vitamin/fluoride/iron drops
2
MO
multivitamin/fluoride chewable tablet 1mg, 0.5mg, 0.25mg
2
MO
NATACHEW
3
MO
NEONATAL 19
3
NEONATAL COMPLETE
3
MO
NEONATAL FE
3
NEONATAL PLUS
3
MO
NESTABS
3
MO
NESTABS ONE
3
MO
NIVA-PLUS
3
MO
OB COMPLETE
3
MO
OB COMPLETE ONE
3
MO
OB COMPLETE PETITE
3
MO
OB COMPLETE PREMIER
3
MO
OB COMPLETE/DHA
3
MO
PNV PRENATAL PLUS MULTIVITAMIN
3
MO
pnv-dha
2
MO
PNV-DHA+DOCUSATE
3
MO
PNV-OMEGA
3
MO
pnv-select
2
MO
POLY-VI-FLOR CHEWABLE TABLET, SUSPENSION
4
MO
POLY-VI-FLOR/IRON CHEWABLE TABLET,
SUSPENSION
4
MO
potassium chloride er capsule extended release
2
MO
potassium chloride er tablet extended release 15meq
2
potassium chloride er tablet extended release 10meq, 20meq,
8meq
2
MO
potassium chloride packet 20meq
2
MO
potassium chloride oral solution 10%, 20%
2
MO
PRENAISSANCE
3
MO
PRENAISSANCE PLUS
3
MO
PRENATAL
3
MO
PRENATAL PLUS
3
MO
PRENATE
3
MO
PRENATE AM
3
MO
PRENATE DHA
3
MO
PRENATE ELITE
3
MO
PRENATE ENHANCE
3
MO
PRENATE ESSENTIAL
3
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 112
Drug Name
Drug
Tier
Requirements/Limits
PRENATE MINI
3
MO
PRENATE PIXIE
3
MO
PRENATE RESTORE
3
MO
PRENATVITE COMPLETE
3
PRENATVITE PLUS
3
PRIMACARE
3
MO
PROVIDA OB
3
MO
QUFLORA FE PEDIATRIC LIQUID
4
QUFLORA FE TABLET CHEWABLE
4
QUFLORA PEDIATRIC TABLET CHEWABLE
4
MO
QUFLORA PEDIATRIC SOLUTION 0.5MG/ML
4
QUFLORA PEDIATRIC SOLUTION 0.25 MG/ML
4
MO
SE-NATAL 19
3
MO
SELECT-OB CHEWABLE TABLET 29MG; 1MG
3
SELECT-OB CHEWABLE TABLET 29MG; 0.6MG; 0.4MG
3
MO
sodium fluoride oral solution 0.5mg/ml
2
MO
sodium fluoride tablet chewable 0.25mg, 0.5mg, 1mg
2
MO
TARON-C DHA
3
MO
THRIVITE RX
3
MO
TRI-VI-FLOR
4
MO
tri-vite/fluoride
2
MO
TRICARE PRENATAL TABLET
3
MO
TRINATAL RX 1
3
MO
TRISTART DHA
3
MO
TRISTART FREE
3
TRISTART ONE
3
VIRT-NATE DHA
3
MO
VIRT-PN DHA
3
MO
VITAFOL GUMMIES
3
MO
VITAFOL STRIPS
3
VITAFOL ULTRA
3
MO
VITAFOL-NANO
3
MO
VITAFOL-OB
3
MO
VITAFOL-ONE
3
MO
WESCAP-C DHA
3
MO
WESCAP-PN DHA
3
MO
WESNATE DHA
3
MO
WESTAB PLUS
3
MO
WESTGEL DHA
3
MO
IV NUTRITION
CLINIMIX 4.25%/DEXTROSE 10%
4
B/D
CLINIMIX 4.25%/DEXTROSE 5%
4
B/D
CLINIMIX 5%/DEXTROSE 15%
4
B/D
CLINIMIX 5%/DEXTROSE 20%
4
B/D
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 113
Drug Name
Drug
Tier
Requirements/Limits
CLINIMIX 6/5
4
B/D
CLINIMIX 8/10
4
B/D
CLINIMIX 8/14
4
B/D
CLINIMIX E 2.75%/DEXTROSE 5%
4
B/D
CLINIMIX E 4.25%/DEXTROSE 10%
4
B/D
CLINIMIX E 4.25%/DEXTROSE 5%
4
B/D
CLINIMIX E 5%/DEXTROSE 15%
4
B/D
CLINIMIX E 5%/DEXTROSE 20%
4
B/D
CLINIMIX E 8/10
4
B/D
CLINIMIX E 8/14
4
B/D
clinisol sf 15%
2
B/D MO
CLINOLIPID
3
B/D
dextrose 10%
2
DEXTROSE 25%
4
B/D
dextrose 5%
2
MO
DEXTROSE 50%
3
B/D
DEXTROSE 70%
3
B/D
HEPATAMINE
4
B/D
INTRALIPID INJECTION 20GM/100ML
3
B/D
INTRALIPID INJECTION 30GM/100ML
4
B/D
KABIVEN
4
B/D
NUTRILIPID
3
B/D
OMEGAVEN
5
B/D
PERIKABIVEN
4
B/D
plenamine
2
B/D
POTASSIUM PHOSPHATES
4
PREMASOL
5
B/D
PROSOL
4
B/D
SMOFLIPID
4
B/D
TRAVASOL
4
B/D
TROPHAMINE
4
B/D
OPHTHALMIC
ANTI-INFECTIVE/ANTI-INFLAMMATORY
MAXITROL
4
MO
neo-polycin hc ophthalmic ointment
2
neomycin/polymyxin/bacitracin/hydrocortisone
2
MO
neomycin/polymyxin/dexamethasone ophthalmic suspension,
ophthalmic ointment
2
MO
neomycin/polymyxin/hydrocortisone ophthalmic suspension
1%; 3.5mg/ml; 10000unit/ml
2
MO
sulfacetamide sodium/prednisolone sodium phosphate
2
MO
TOBRADEX ST
3
MO
TOBRADEX OINTMENT
3
MO
TOBRADEX SUSPENSION
4
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 114
Drug Name
Drug
Tier
Requirements/Limits
tobramycin/dexamethasone
2
MO
ZYLET
3
MO
ANTI-INFECTIVES
ak-poly-bac
2
AZASITE
4
MO
bacitracin/polymyxin b ophthalmic ointment
2
MO
bacitracin ointment 500unit/gm
2
MO
BESIVANCE
3
MO
BETADINE OPHTHALMIC PREP
4
MO
CILOXAN OINTMENT
3
QL (42 GM per 30 days) MO
ciprofloxacin hydrochloride ophthalmic solution 0.3%
2
QL (30 ML per 30 days) MO
erythromycin ointment 5mg/gm
2
QL (42 GM per 30 days) MO
gatifloxacin ophthalmic solution
2
QL (20 ML per 30 days) MO
gentak
2
gentamicin sulfate ophthalmic solution 0.3%
2
QL (30 ML per 30 days) MO
levofloxacin ophthalmic solution 1.5%
2
QL (20 ML per 30 days)
levofloxacin ophthalmic solution 0.5%
2
QL (30 ML per 30 days) MO
moxifloxacin hydrochloride ophthalmic solution 0.5%
2
QL (12 ML per 30 days) MO
NATACYN
4
MO
neo-polycin ophthalmic ointment
2
neomycin/bacitracin/polymyxin ophthalmic ointment
2
MO
neomycin/polymyxin/gramicidin
2
MO
OCUFLOX
4
QL (60 ML per 30 days) MO
ofloxacin ophthalmic solution 0.3%
2
QL (60 ML per 30 days) MO
polycin
2
polymyxin b sulfate/trimethoprim sulfate
1
MO
POLYTRIM
4
MO
sulfacetamide sodium ointment 10%
2
MO
sulfacetamide sodium ophthalmic solution 10%
2
QL (90 ML per 30 days) MO
tobramycin solution 0.3%
2
QL (30 ML per 30 days) MO
TOBREX
4
MO
trifluridine
2
MO
trimethoprim sulfate/polymyxin b sulfate
2
MO
VIGAMOX
4
QL (12 ML per 30 days) MO
XDEMVY
5
QL (10 ML per 42 days) PA LA;
ACS
ZIRGAN
4
MO
ZYMAXID
4
QL (20 ML per 30 days) MO
ANTI-INFLAMMATORIES
ACULAR
4
MO
ACULAR LS
4
MO
ACUVAIL
4
MO
ALREX
3
MO
bromfenac ophthalmic solution
2
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 115
Drug Name
Drug
Tier
Requirements/Limits
BROMSITE
4
MO
dexamethasone sodium phosphate ophthalmic solution 0.1%
2
MO
DEXYCU
5
LA
diclofenac sodium ophthalmic solution 0.1%
2
QL (10 ML per 30 days) MO
difluprednate
2
MO
DUREZOL
4
MO
EYSUVIS
4
MO
FLAREX
4
MO
FLUOROMETHOLONE
2
MO
flurbiprofen sodium ophthalmic solution 0.03%
2
MO
FML FORTE
4
MO
FML LIQUIFILM
4
MO
ILEVRO
4
MO
INVELTYS
4
MO
ketorolac tromethamine ophthalmic solution 0.4%, 0.5%
2
MO
LOTEMAX SM
3
MO
LOTEMAX OINTMENT
3
MO
LOTEMAX GEL, SUSPENSION
4
MO
loteprednol etabonate
2
MO
MAXIDEX
4
MO
NEVANAC
4
MO
OZURDEX
5
ACS
PRED FORTE
4
MO
PRED MILD
4
MO
prednisolone acetate ophthalmic suspension 1%
2
MO
PREDNISOLONE SODIUM PHOSPHATE OPHTHALMIC
SOLUTION 1%
3
MO
PROLENSA
3
MO
TRIESENCE
4
MO
XIPERE
5
PA LA MO
YUTIQ
5
LA MO
ANTIALLERGICS
ALOCRIL
4
MO
ALOMIDE
4
MO
azelastine hcl ophthalmic solution 0.05%
2
MO
bepotastine besilate
2
MO
BEPREVE
4
MO
cromolyn sodium ophthalmic solution 4%
2
MO
epinastine hcl
2
MO
olopatadine hcl ophthalmic solution 0.1%
2
MO
olopatadine hydrochloride ophthalmic solution 0.2%
2
MO
ZERVIATE
4
MO
ANTIGLAUCOMA
ALPHAGAN P SOLUTION 0.1%
3
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 116
Drug Name
Drug
Tier
Requirements/Limits
ALPHAGAN P SOLUTION 0.15%
4
MO
apraclonidine
2
MO
AZOPT
4
MO
betaxolol hcl solution 0.5%
2
MO
BETIMOL
4
MO
BETOPTIC-S
3
MO
bimatoprost
2
MO
brimonidine tartrate/timolol maleate
2
MO
BRIMONIDINE TARTRATE SOLUTION 0.15%
3
MO
brimonidine tartrate solution 0.2%
2
MO
brinzolamide
2
MO
carteolol hcl
2
MO
COMBIGAN
3
MO
COSOPT
4
MO
COSOPT PF
4
MO
dorzolamide hcl/timolol maleate
2
MO
dorzolamide hydrochloride
1
MO
dorzolamide hydrochloride/timolol maleate soln 2%-0.5%
preservative free
2
MO
DURYSTA
5
PA MO; ACS
IOPIDINE
4
MO
ISTALOL
4
MO
latanoprost ophthalmic solution
2
MO
levobunolol hcl
2
MO
LUMIGAN
3
MO
PHOSPHOLINE IODIDE
4
pilocarpine hcl ophthalmic solution
2
MO
RHOPRESSA
3
MO
ROCKLATAN
3
MO
SIMBRINZA
3
MO
tafluprost
2
ST MO
TIMOLOL MALEATE OPHTHALMIC GEL FORMING
SOLUTION
2
MO
timolol maleate (generic Timoptic) solution 0.25%, 0.5%
1
MO
timolol maleate (generic Istalol and Timoptic Ocudose)
solution 0.25%, 0.5%
2
MO
TIMOPTIC
4
MO
TIMOPTIC OCUDOSE
4
MO
TIMOPTIC-XE
4
MO
TRAVATAN Z
4
MO
travoprost
2
MO
TRUSOPT
4
MO
VUITY
4
PA MO
VYZULTA
4
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 117
Drug Name
Drug
Tier
Requirements/Limits
XALATAN
4
MO
XELPROS
4
ST
ZIOPTAN
4
ST MO
MISCELLANEOUS
ALCAINE
4
MO
atropine sulfate ointment 1%
2
MO
ATROPINE SULFATE OPHTHALMIC SOLUTION 1%
2
MO
BEOVU
5
PA LA; ACS
BYOOVIZ
5
PA LA; ACS
CEQUA
4
QL (60 EA per 30 days) PA MO
CIMERLI
5
PA LA; ACS
CYCLOGYL
4
MO
cyclopentolate hydrochloride
2
MO
cyclosporine emulsion 0.05%
2
QL (60 EA per 30 days) MO
CYSTADROPS
5
PA LA MO
CYSTARAN
5
PA LA MO
EYLEA
5
PA LA; ACS
ISOPTO ATROPINE
3
MO
LACRISERT
4
MO
LUCENTIS SOLUTION PREFILLED SYRINGE
0.3MG/0.05ML
5
PA LA; ACS
LUCENTIS SOLUTION PREFILLED SYRINGE
0.5MG/0.05ML
5
PA; ACS
MIEBO
5
QL (12 ML per 30 days) PA
nan
2
MO
OXERVATE
5
QL (28 ML per 28 days) PA LA MO
PHENYLEPHRINE HCL OPHTHALMIC SOLUTION 10%,
2.5%
2
MO
proparacaine hcl
2
MO
RESTASIS
3
QL (60 EA per 30 days) MO
RESTASIS MULTIDOSE
3
QL (5.5 ML per 30 days) MO
SUSVIMO
5
PA LA; ACS
SYFOVRE
4
PA LA MO
TETRACAINE HYDROCHLORIDE OPHTHALMIC
SOLUTION 0.5%
4
MO
TYRVAYA
4
QL (8.4 ML per 30 days) MO
VABYSMO
5
PA LA; ACS
VERKAZIA
5
QL (120 EA per 30 days) PA MO
XIIDRA
3
QL (60 EA per 30 days) MO
OTIC
OTIC AGENTS
acetic acid otic solution 0.25%
2
MO
CETRAXAL
4
MO
CIPRO HC
4
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 118
Drug Name
Drug
Tier
Requirements/Limits
CIPRODEX
4
MO
ciprofloxacin/dexamethasone
2
MO
CIPROFLOXACIN/FLUOCINOLONE ACETONIDE PF
4
MO
CIPROFLOXACIN SOLUTION 0.2%
3
MO
CORTISPORIN-TC
4
MO
DERMOTIC
4
MO
flac otic oil
2
fluocinolone acetonide otic oil 0.01%
2
MO
hydrocortisone/acetic acid otic solution
2
MO
neomycin/polymyxin/hc otic solution 1%
2
MO
neomycin/polymyxin/hydrocortisone otic suspension 1%;
3.5mg/ml; 10000unit/ml
2
MO
ofloxacin otic solution 0.3%
2
MO
OTOVEL
4
MO
RESPIRATORY
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS
ANORO ELLIPTA
3
QL (60 EA per 30 days) MO
BEVESPI AEROSPHERE
3
QL (10.7 GM per 30 days) MO
BREZTRI AEROSPHERE
3
QL (10.7 GM per 30 days) MO
COMBIVENT RESPIMAT
4
QL (8 GM per 30 days) MO
DUAKLIR PRESSAIR
4
QL (1 EA per 30 days) ST MO
ipratropium bromide/albuterol sulfate nebulized solution
2
B/D MO
STIOLTO RESPIMAT
3
QL (4 GM per 30 days) MO
TRELEGY ELLIPTA
3
QL (60 EA per 30 days) MO
ANTICHOLINERGICS
ATROVENT HFA
4
QL (25.8 GM per 30 days) MO
INCRUSE ELLIPTA
3
QL (30 EA per 30 days) MO
ipratropium bromide inhalation solution 0.02%
2
B/D MO
ipratropium bromide nasal solution 0.03%
2
QL (30 ML per 28 days) MO
ipratropium bromide nasal solution 0.06%
2
QL (45 ML per 30 days) MO
SPIRIVA HANDIHALER
3
QL (30 EA per 30 days) MO
SPIRIVA RESPIMAT
3
QL (4 GM per 30 days) MO
YUPELRI
3
QL (90 ML per 30 days) PA MO
ANTIHISTAMINE COMBINATIONS
azelastine hydrochloride/fluticasone propionate
2
QL (23 GM per 30 days) MO
CLARINEX-D 12 HOUR
4
MO
DYMISTA
4
QL (23 GM per 30 days) MO
promethazine vc
2
PA MO; HRM
RYALTRIS
4
MO
ANTIHISTAMINES
azelastine hcl nasal solution 0.1%
2
QL (30 ML per 25 days) MO
azelastine hcl nasal solution 0.15%
2
QL (30 ML per 25 days) MO
carbinoxamine maleate solution
2
PA MO
CARBINOXAMINE MALEATE TABLET 6MG
5
PA MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 119
Drug Name
Drug
Tier
Requirements/Limits
carbinoxamine maleate tablet 4mg
2
PA MO
cetirizine hydrochloride oral solution 1mg/ml
2
QL (300 ML per 30 days) MO
CLARINEX
4
QL (30 EA per 30 days) MO
CLEMASTINE FUMARATE SYRUP
5
QL (1800 ML per 30 days) PA
clemastine fumarate tablet
2
PA MO
cyproheptadine hcl syrup
2
PA MO; HRM
cyproheptadine hydrochloride tablet
2
PA MO; HRM
desloratadine
2
QL (30 EA per 30 days) MO
desloratadine odt
2
QL (30 EA per 30 days) MO
diphenhydramine hcl injection
2
MO; HRM
diphenhydramine hcl elixir
2
PA; HRM
hydroxyzine hcl tablet
2
PA MO; HRM
hydroxyzine hydrochloride injection, syrup 10mg/5ml
2
PA MO; HRM
hydroxyzine pamoate capsule
2
PA MO; HRM
levocetirizine dihydrochloride tablet
1
QL (30 EA per 30 days) MO
levocetirizine dihydrochloride solution
2
MO
olopatadine hcl nasal solution 0.6%
2
QL (30.5 GM per 30 days) MO
QUZYTTIR
5
PA MO
ryclora
2
PA MO; HRM
RYVENT
4
PA MO
VISTARIL
4
PA MO; HRM
BETA AGONISTS
albuterol sulfate hfa (generic Proventil HFA) aers 108mcg/act
2
QL (13.4 GM per 30 days) MO
albuterol sulfate hfa (generic ProAir HFA) aers 108mcg/act
2
QL (17 GM per 30 days) MO
albuterol sulfate hfa (generic Ventolin HFA) aers 108mcg/act
2
QL (36 GM per 30 days) MO
albuterol sulfate nebulization solution
2
B/D MO
albuterol sulfate syrup, tablet
2
MO
ARFORMOTEROL TARTRATE
4
QL (120 ML per 30 days) PA MO
BROVANA
5
QL (120 ML per 30 days) PA MO
formoterol fumarate
2
QL (120 ML per 30 days) PA MO
levalbuterol hcl nebulization solution 0.31mg/3ml,
0.63mg/3ml, 0.125mg/3ml
2
B/D MO
levalbuterol nebulization solution 1.25mg/0.5ml
2
B/D MO
LEVALBUTEROL TARTRATE HFA
3
QL (30 GM per 30 days) MO
PERFOROMIST
5
QL (120 ML per 30 days) PA MO
PROAIR DIGIHALER
4
QL (2 EA per 30 days) PA MO
PROAIR RESPICLICK
4
QL (2 EA per 30 days) MO
PROVENTIL HFA
4
QL (13.4 GM per 30 days) MO
SEREVENT DISKUS
3
QL (60 EA per 30 days) MO
STRIVERDI RESPIMAT
3
QL (4 GM per 30 days) MO
terbutaline sulfate injection, tablet
2
MO
VENTOLIN HFA
3
QL (36 GM per 30 days) MO
XOPENEX HFA
4
QL (30 GM per 30 days) MO
LEUKOTRIENE MODULATORS
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 120
Drug Name
Drug
Tier
Requirements/Limits
ACCOLATE
4
QL (60 EA per 30 days) MO
montelukast sodium tablet chewable, tablet, packet
2
QL (30 EA per 30 days) MO
SINGULAIR
4
QL (30 EA per 30 days) ST MO
zafirlukast
2
QL (60 EA per 30 days) MO
zileuton er
5
QL (120 EA per 30 days) MO
ZYFLO
5
QL (120 EA per 30 days) MO
MISCELLANEOUS
acetylcysteine inhalation solution 10%, 20%
2
B/D MO
aminophylline
2
ARALAST NP
5
PA LA; ACS
AUVI-Q INJECTION 0.1MG/0.1ML
4
QL (2 EA per 30 days) MO
AUVI-Q INJECTION 0.3MG/0.3ML
4
QL (2 EA per 30 days) ST MO
AUVI-Q INJECTION 0.15MG/0.15ML
5
QL (2 EA per 30 days) ST MO
BRONCHITOL
5
QL (560 EA per 28 days) PA LA;
ACS
BRONCHITOL TOLERANCE TEST
5
QL (560 EA per 28 days) PA LA;
ACS
CINQAIR
5
PA LA; ACS
COCAINE HYDROCHLORIDE
4
PA
cromolyn sodium nebulization solution 20mg/2ml
2
B/D MO
DALIRESP
4
MO
elixophyllin
2
epinephrine injection 0.15mg/0.15ml, 0.15mg/0.3ml,
0.3mg/0.3ml
2
QL (2 EA per 30 days) MO
EPIPEN 2-PAK
4
QL (2 EA per 30 days) MO
EPIPEN-JR 2-PAK
4
QL (2 EA per 30 days) MO
ESBRIET CAPSULE
5
QL (270 EA per 30 days) PA LA;
ACS
ESBRIET TABLET 267MG
5
QL (270 EA per 30 days) PA LA;
ACS
ESBRIET TABLET 801MG
5
QL (90 EA per 30 days) PA LA;
ACS
FASENRA
5
QL (1 ML per 28 days) PA LA; ACS
FASENRA PEN
5
QL (1 ML per 28 days) PA LA; ACS
GLASSIA
5
PA LA; ACS
GOPRELTO
4
PA
KALYDECO PACKET
5
QL (56 EA per 28 days) PA LA MO
KALYDECO TABLET
5
QL (60 EA per 30 days) PA LA MO
NUCALA INJECTION 40MG/0.4ML
5
QL (0.4 ML per 28 days) PA LA;
ACS
NUCALA INJECTION 100MG
5
QL (3 EA per 28 days) PA LA; ACS
NUCALA INJECTION 100MG/ML
5
QL (3 ML per 28 days) PA LA; ACS
NUMBRINO
4
PA
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 121
Drug Name
Drug
Tier
Requirements/Limits
OFEV
5
QL (60 EA per 30 days) PA LA;
ACS
ORKAMBI TABLET
5
QL (112 EA per 28 days) PA LA
MO
ORKAMBI PACKET
5
QL (56 EA per 28 days) PA LA MO
pirfenidone capsule
5
QL (270 EA per 30 days) PA; ACS
pirfenidone tablet 267mg
5
QL (270 EA per 30 days) PA; ACS
pirfenidone tablet 534mg, 801mg
5
QL (90 EA per 30 days) PA; ACS
PROLASTIN-C
5
PA LA MO
PULMOZYME
5
PA; ACS
roflumilast
2
MO
SYMDEKO
5
QL (56 EA per 28 days) PA LA
SYMJEPI
3
QL (2 EA per 30 days) MO
TEZSPIRE
5
QL (1.91 ML per 28 days) PA LA;
ACS
THEO-24
4
MO
theophylline oral solution, oral elixir
2
MO
theophylline er tablet extended release 24 hour
2
MO
theophylline er tablet extended release 12 hour 100mg, 200mg
2
theophylline er tablet extended release 12 hour 300mg, 450mg
2
MO
TRIKAFTA THERAPY PACK
5
QL (56 EA per 28 days) PA LA
TRIKAFTA TABLET THERAPY PACK
5
QL (84 EA per 28 days) PA LA MO
XOLAIR
5
PA LA; ACS
ZEMAIRA
5
PA LA; ACS
NASAL STEROIDS
BECONASE AQ
4
QL (50 GM per 30 days) MO
flunisolide nasal spray 0.025%
2
QL (75 ML per 30 days) MO
fluticasone propionate suspension 50mcg/act
2
QL (16 GM per 30 days) MO
mometasone furoate suspension 50mcg/act
2
QL (34 GM per 30 days) MO
OMNARIS
4
QL (12.5 GM per 30 days) MO
QNASL
4
QL (10.6 GM per 30 days) MO
QNASL CHILDRENS
4
QL (6.8 GM per 30 days) MO
XHANCE
4
QL (32 ML per 30 days) PA MO
ZETONNA
4
QL (6.1 GM per 30 days) MO
STEROID INHALANTS
ALVESCO
4
QL (12.2 GM per 30 days) ST MO
ARMONAIR DIGIHALER
4
QL (1 EA per 30 days) ST MO
ARNUITY ELLIPTA
3
QL (30 EA per 30 days) MO
ASMANEX HFA
4
QL (13 GM per 30 days) ST MO
ASMANEX TWISTHALER 120 METERED DOSES
4
QL (1 EA per 30 days) ST MO
ASMANEX TWISTHALER 14 METERED DOSES
4
QL (2 EA per 28 days) ST MO
ASMANEX TWISTHALER 30 METERED DOSES
4
QL (1 EA per 30 days) ST MO
ASMANEX TWISTHALER 60 METERED DOSES
4
QL (1 EA per 30 days) ST MO
budesonide suspension 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml
2
B/D MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 122
Drug Name
Drug
Tier
Requirements/Limits
FLOVENT DISKUS AEROSOL POWDER BREATH
ACTIVATED 100MCG/BLIST, 50MCG/BLIST
3
QL (120 EA per 30 days) MO
FLOVENT DISKUS AEROSOL POWDER BREATH
ACTIVATED 250MCG/BLIST
3
QL (240 EA per 30 days) MO
FLOVENT HFA AEROSOL 44MCG/ACT
3
QL (21.2 GM per 30 days) MO
FLOVENT HFA AEROSOL 110MCG/ACT, 220MCG/ACT
3
QL (24 GM per 30 days) MO
FLUTICASONE PROPIONATE HFA AEROSOL
44MCG/ACT
4
QL (21.2 GM per 30 days) PA MO
FLUTICASONE PROPIONATE HFA AEROSOL
110MCG/ACT, 220MCG/ACT
4
QL (24 GM per 30 days) PA MO
PULMICORT FLEXHALER
3
QL (2 EA per 30 days) ST MO
PULMICORT SUSPENSION 0.25MG/2ML, 0.5MG/2ML
4
B/D MO
PULMICORT SUSPENSION 1MG/2ML
5
B/D MO
QVAR REDIHALER
3
QL (21.2 GM per 30 days) ST MO
STEROID/BETA-AGONIST COMBINATIONS
ADVAIR DISKUS
3
QL (60 EA per 30 days) ST MO
ADVAIR HFA
3
QL (12 GM per 30 days) MO
AIRDUO DIGIHALER 113/14
4
QL (1 EA per 30 days) ST MO
AIRDUO DIGIHALER 232/14
4
QL (1 EA per 30 days) ST MO
AIRDUO DIGIHALER 55/14
4
QL (1 EA per 30 days) ST MO
AIRDUO RESPICLICK 113/14
4
QL (1 EA per 30 days) ST MO
AIRDUO RESPICLICK 232/14
4
QL (1 EA per 30 days) ST MO
AIRDUO RESPICLICK 55/14
4
QL (1 EA per 30 days) ST MO
BREO ELLIPTA
3
QL (60 EA per 30 days) MO
breyna
2
QL (10.3 GM per 30 days)
budesonide/formoterol fumarate dihydrate
2
QL (10.2 GM per 30 days) MO
DULERA
3
QL (13 GM per 30 days) MO
FLUTICASONE FUROATE/VILANTEROL ELLIPTA
4
QL (60 EA per 30 days) PA MO
FLUTICASONE PROPIONATE/SALMETEROL
INHALATION POWDER
4
QL (1 EA per 30 days) ST MO
fluticasone propionate/salmeterol diskus
2
QL (60 EA per 30 days) MO
fluticasone propionate/salmeterol hfa
2
QL (12 GM per 30 days) MO
SYMBICORT
3
QL (10.2 GM per 30 days) ST MO
wixela inhub
2
QL (60 EA per 30 days) MO
TOPICAL
DERMATOLOGY, ACNE
ABSORICA
5
PA
ABSORICA LD
5
ACANYA
4
MO
accutane
2
PA
ACZONE
4
QL (90 GM per 30 days) MO
adapalene pump
2
QL (45 GM per 30 days) PA MO
ADAPALENE/BENZOYL PEROXIDE PAD
5
QL (28 EA per 28 days) PA
adapalene/benzoyl peroxide gel 0.1%; 2.5%
2
QL (45 GM per 30 days) PA MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 123
Drug Name
Drug
Tier
Requirements/Limits
adapalene/benzoyl peroxide gel 0.3%; 2.5%
2
QL (70 GM per 30 days) PA MO
ADAPALENE SOLUTION
4
QL (120 ML per 30 days) PA
adapalene cream, gel
2
QL (45 GM per 30 days) PA MO
adapalene pad
5
QL (28 EA per 28 days) PA
AKLIEF
4
QL (45 GM per 30 days) PA MO
ALTRENO
4
QL (45 GM per 30 days) PA MO
amnesteem
2
PA
AMZEEQ
4
QL (30 GM per 30 days) MO
ARAZLO
4
MO
ATRALIN
4
QL (45 GM per 30 days) PA MO
AVITA CREAM
2
QL (45 GM per 30 days) PA
AVITA GEL
2
QL (45 GM per 30 days) PA MO
AZELEX
4
QL (50 GM per 30 days) MO
BENZAMYCIN
4
MO
claravis
2
PA
CLEOCIN-T LOTION 1%
4
QL (60 ML per 30 days) MO
clindacin foam
2
QL (100 GM per 30 days)
clindacin etz pledgets
2
clindacin-p
2
MO
CLINDAGEL
5
QL (75 ML per 30 days) MO
clindamycin phosphate/benzoyl peroxide gel 1.2;2.5%,
1.2%;5%
2
MO
clindamycin phosphate/tretinoin gel 1.2%; 0.025%
2
QL (60 GM per 30 days) PA MO
clindamycin phosphate foam 1%
2
QL (100 GM per 30 days) MO
clindamycin phosphate gel 1%
2
QL (75 GM per 30 days) MO
clindamycin phosphate lotion 1%
2
QL (60 ML per 30 days) MO
clindamycin phosphate external solution 1%
2
QL (60 ML per 30 days) MO
clindamycin phosphate swab 1%
2
MO
clindamycin/benzoyl peroxide gel 5%; 1%
2
MO
dapsone gel 5%, 7.5%
2
QL (90 GM per 30 days) MO
DIFFERIN LOTION
4
QL (118 ML per 30 days) PA MO
DIFFERIN CREAM, GEL
4
QL (45 GM per 30 days) PA MO
EPIDUO
4
QL (45 GM per 30 days) PA MO
EPIDUO FORTE
4
QL (70 GM per 30 days) PA MO
EPSOLAY
4
QL (30 GM per 30 days) PA MO
ery pad 2%
2
MO
ERYGEL
4
QL (60 GM per 30 days) MO
erythromycin/benzoyl peroxide gel 5%; 3%
2
MO
erythromycin gel 2%
2
QL (60 GM per 30 days) MO
erythromycin solution 2%
2
QL (60 ML per 30 days) MO
EVOCLIN
4
QL (100 GM per 30 days) MO
FABIOR
4
QL (100 GM per 30 days) MO
isotretinoin
2
PA
KLARON
4
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 124
Drug Name
Drug
Tier
Requirements/Limits
neuac
2
ONEXTON
3
MO
RETIN-A CREAM, GEL
4
QL (45 GM per 30 days) PA MO
RETIN-A MICRO
4
QL (50 GM per 30 days) PA MO
RETIN-A MICRO PUMP GEL 0.04%, 0.08%
4
QL (50 GM per 30 days) PA MO
RETIN-A MICRO PUMP GEL 0.1%
5
QL (50 GM per 30 days) PA MO
SODIUM SULFACETAMIDE/SULFUR CLEANSER IN
UREA SUSPENSION 10%; 5%; 10%
4
QL (355 ML per 30 days) MO
sodium sulfacetamide/sulfur suspension 8%; 4%
2
QL (473 ML per 30 days) MO
sulfacetamide sodium lotion 10%
2
MO
sulfacleanse 8/4
2
QL (473 ML per 30 days) MO
TAZAROTENE FOAM 0.1%
4
QL (100 GM per 30 days) MO
TRETINOIN MICROSPHERE GEL 0.04%, 0.1%
4
QL (50 GM per 30 days) PA MO
TRETINOIN MICROSPHERE PUMP GEL 0.04%, 0.1%
2
QL (50 GM per 30 days) PA MO
tretinoin cream 0.025%, 0.05%, 0.1%
2
QL (45 GM per 30 days) PA MO
tretinoin gel 0.01%, 0.025%, 0.05%
2
QL (45 GM per 30 days) PA MO
TWYNEO
4
QL (30 GM per 30 days) PA MO
VELTIN
4
QL (60 GM per 30 days) PA MO
WINLEVI
4
QL (60 GM per 30 days) PA MO
zenatane
2
PA
ZIANA
4
QL (60 GM per 30 days) PA MO
DERMATOLOGY, ANTIBIOTICS
ALTABAX
4
QL (30 GM per 30 days) MO
gentamicin sulfate cream 0.1%
2
QL (30 GM per 30 days) MO
gentamicin sulfate ointment 0.1%
2
QL (30 GM per 30 days) MO
mafenide acetate packet
2
MO
mupirocin ointment, cream
2
QL (30 GM per 30 days) MO
NEO-SYNALAR
4
QL (60 GM per 30 days) MO
SILVADENE
4
MO
silver sulfadiazine cream
2
MO
SSD
2
SULFAMYLON CREAM 85MG/GM
4
MO
DERMATOLOGY, ANTIFUNGALS
ciclodan topical solution 8%
2
QL (6.6 ML per 30 days)
ciclopirox nail lacquer
2
QL (6.6 ML per 30 days) MO
ciclopirox olamine cream 0.77%
2
QL (90 GM per 30 days) MO
ciclopirox gel
2
QL (100 GM per 30 days) MO
ciclopirox shampoo
2
QL (120 ML per 30 days) MO
ciclopirox olamine suspension
2
QL (60 ML per 30 days) MO
clotrimazole/betamethasone dipropionate lotion
2
QL (30 ML per 30 days) MO
clotrimazole/betamethasone dipropionate cream
2
QL (45 GM per 30 days) MO
clotrimazole cream 1%
2
QL (45 GM per 30 days) MO
clotrimazole solution 1%
2
QL (30 ML per 30 days) MO
econazole nitrate cream
2
QL (85 GM per 30 days) MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 125
Drug Name
Drug
Tier
Requirements/Limits
ERTACZO
5
QL (60 GM per 30 days) MO
EXELDERM SOLUTION
4
QL (30 ML per 30 days) MO
EXELDERM CREAM
4
QL (60 GM per 30 days) MO
EXTINA
5
QL (100 GM per 30 days) MO
JUBLIA
5
QL (8 ML per 30 days) PA MO
KERYDIN
4
QL (10 ML per 30 days) PA MO
ketoconazole cream 2%
2
QL (60 GM per 30 days) MO
ketoconazole foam 2%
2
QL (100 GM per 30 days) MO
ketodan foam 2%
2
QL (100 GM per 30 days)
LOPROX SUSPENSION
4
QL (60 ML per 30 days) MO
LOPROX SHAMPOO
4
QL (120 ML per 30 days) MO
LULICONAZOLE
4
QL (60 GM per 30 days) ST MO
LUZU
4
QL (60 GM per 30 days) ST MO
MENTAX
4
QL (30 GM per 30 days) MO
MICONAZOLE NITRATE/ZINC OXIDE/WHITE
PETROLATUM
4
QL (50 GM per 30 days) PA MO
naftifine hcl cream 1%
2
QL (90 GM per 30 days) MO
naftifine hydrochloride cream, gel 2%
2
QL (60 GM per 30 days) MO
NAFTIN GEL 2%
4
QL (60 GM per 30 days) MO
NAFTIN GEL 1%
4
QL (90 GM per 30 days) MO
nyamyc powder
2
QL (60 GM per 30 days) MO
nystatin/triamcinolone cream, ointment
2
QL (60 GM per 30 days) MO
nystatin cream 100000unit/gm
2
QL (30 GM per 30 days) MO
nystatin ointment 100000unit/gm
2
QL (30 GM per 30 days) MO
nystatin powder 100000unit/gm
2
QL (60 GM per 30 days) MO
nystop powder
2
QL (60 GM per 30 days)
oxiconazole nitrate
4
QL (90 GM per 30 days) MO
OXISTAT LOTION
4
QL (60 ML per 30 days) MO
OXISTAT CREAM
4
QL (90 GM per 30 days) MO
tavaborole
2
QL (10 ML per 30 days) PA MO
VUSION
4
QL (50 GM per 30 days) PA MO
DERMATOLOGY, ANTIPSORIATICS
acitretin
2
PA MO
CALCIPOTRIENE FOAM
4
QL (120 GM per 30 days) PA
calcipotriene cream, ointment
2
QL (120 GM per 30 days) PA MO
calcipotriene solution
2
QL (60 ML per 30 days) PA MO
calcitrene
2
QL (120 GM per 30 days) PA MO
CALCITRIOL OINTMENT 3MCG/GM
4
QL (800 GM per 28 days) PA MO
methoxsalen capsule
2
MO
SORILUX
5
QL (120 GM per 30 days) PA MO
tazarotene cream 0.1%
2
QL (60 GM per 30 days) PA MO
tazarotene gel 0.05%, 0.1%
2
QL (100 GM per 30 days) PA MO
TAZORAC GEL
4
QL (100 GM per 30 days) PA MO
TAZORAC CREAM
4
QL (60 GM per 30 days) PA MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 126
Drug Name
Drug
Tier
Requirements/Limits
VECTICAL
5
QL (800 GM per 28 days) PA MO
VTAMA
5
QL (60 GM per 30 days) PA MO
ZORYVE
4
QL (60 GM per 30 days) PA MO
DERMATOLOGY, ANTISEBORRHEICS
ketoconazole shampoo 2%
2
MO
selenium sulfide lotion
2
MO
selenium sulfide shampoo
2
QL (180 ML per 30 days) MO
DERMATOLOGY, CORTICOSTEROIDS
ala-cort cream 1%
1
ala-cort cream 2.5%
1
QL (30 GM per 30 days)
ALA-SCALP
4
MO
alclometasone dipropionate
2
MO
AMCINONIDE OINTMENT
4
QL (60 GM per 30 days) MO
amcinonide lotion
2
QL (60 ML per 30 days) MO
APEXICON E
5
QL (60 GM per 30 days) MO
betamethasone dipropionate cream, ointment, lotion
2
MO
betamethasone dipropionate augmented cream, gel, ointment
2
MO
betamethasone dipropionate augmented lotion
2
QL (120 ML per 30 days) MO
betamethasone valerate cream, lotion, ointment
2
MO
betamethasone valerate foam
2
QL (120 GM per 30 days) MO
BRYHALI
3
QL (100 GM per 30 days) MO
CALCIPOTRIENE/BETAMETHASONE DIPROPIONATE
SUSPENSION
5
QL (120 GM per 30 days) PA MO
calcipotriene/betamethasone dipropionate ointment
2
QL (400 GM per 28 days) PA MO
CAPEX
4
QL (120 ML per 30 days) MO
clobetasol propionate e cream 0.05%
2
QL (60 GM per 30 days) MO
clobetasol propionate emollient foam 0.05%
2
QL (100 GM per 30 days) MO
clobetasol propionate foam
2
QL (100 GM per 30 days) MO
clobetasol propionate lotion, shampoo
2
QL (118 ML per 30 days) MO
clobetasol propionate spray liquid
2
QL (125 ML per 30 days) MO
clobetasol propionate solution
2
QL (50 ML per 30 days) MO
clobetasol propionate cream, gel, ointment
2
QL (60 GM per 30 days) MO
CLOBEX LOTION, SHAMPOO
4
QL (118 ML per 30 days) MO
CLOBEX LIQUID
5
QL (125 ML per 30 days) MO
CLOCORTOLONE PIVALATE
4
QL (90 GM per 30 days) MO
clodan shampoo 0.05%
2
QL (118 ML per 30 days)
CLODERM
4
QL (90 GM per 30 days) MO
CORDRAN CREAM
4
QL (120 GM per 30 days) MO
CORDRAN TAPE
5
MO
CORDRAN LOTION
5
QL (120 ML per 30 days) MO
DERMA-SMOOTHE/FS BODY
4
QL (118.28 ML per 30 days) MO
DERMA-SMOOTHE/FS SCALP
4
QL (118.28 ML per 30 days) MO
desonide lotion
2
QL (118 ML per 30 days) MO
desonide cream, gel, ointment
2
QL (60 GM per 30 days) MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 127
Drug Name
Drug
Tier
Requirements/Limits
DESOWEN
4
QL (60 GM per 30 days) MO
desoximetasone cream, ointment
2
QL (100 GM per 30 days) MO
desoximetasone liquid
2
QL (100 ML per 30 days) MO
desoximetasone gel
2
QL (60 GM per 30 days) MO
desrx
2
QL (60 GM per 30 days)
diflorasone diacetate
2
QL (60 GM per 30 days) MO
DIPROLENE OINTMENT
4
MO
DUOBRII
3
QL (200 GM per 28 days) PA MO
ENSTILAR
3
QL (120 GM per 30 days) PA MO
EPIFOAM
4
QL (10 GM per 30 days) MO
fluocinolone acetonide body
2
QL (118.28 ML per 30 days) MO
fluocinolone acetonide scalp
2
QL (118.28 ML per 30 days) MO
fluocinolone acetonide cream 0.025%
2
QL (120 GM per 30 days) MO
fluocinolone acetonide cream 0.01%
2
QL (60 GM per 30 days) MO
fluocinolone acetonide ointment 0.025%
2
QL (120 GM per 30 days) MO
fluocinolone acetonide solution 0.01%
2
QL (90 ML per 30 days) MO
fluocinonide emulsified base cream 0.05%
2
QL (120 GM per 30 days) MO
fluocinonide cream 0.05%
2
QL (120 GM per 30 days) MO
fluocinonide cream 0.1%
5
QL (120 GM per 30 days) MO
fluocinonide gel, ointment
2
QL (60 GM per 30 days) MO
fluocinonide solution
2
QL (60 ML per 30 days) MO
flurandrenolide cream
2
QL (120 GM per 30 days) MO
flurandrenolide lotion
2
QL (120 ML per 30 days) MO
fluticasone propionate cream 0.05%
2
MO
fluticasone propionate lotion 0.05%
2
QL (120 ML per 30 days) MO
fluticasone propionate ointment 0.005%
2
MO
halcinonide
5
QL (60 GM per 30 days) MO
HALOBETASOL PROPIONATE FOAM
5
QL (100 GM per 30 days) MO
halobetasol propionate cream, ointment
2
QL (50 GM per 30 days) MO
HALOG CREAM, OINTMENT
4
QL (60 GM per 30 days) MO
HALOG SOLUTION
5
QL (120 ML per 30 days) PA MO
hydrocortisone butyrate (lipophilic)
2
QL (60 GM per 30 days) MO
hydrocortisone butyrate lotion
2
QL (118 ML per 30 days) MO
hydrocortisone butyrate cream, ointment
2
QL (45 GM per 30 days) MO
hydrocortisone butyrate solution
2
QL (60 ML per 30 days) MO
hydrocortisone valerate cream, ointment
2
QL (60 GM per 30 days) MO
hydrocortisone cream 1%
1
MO
hydrocortisone cream 2.5%
1
QL (30 GM per 30 days) MO
hydrocortisone lotion 2.5%
2
MO
hydrocortisone ointment 2.5%
1
QL (30 GM per 30 days) MO
hydrocortisone ointment 1%
2
QL (30 GM per 30 days) MO
IMPEKLO
4
QL (68 GM per 30 days) MO
KENALOG
4
MO
LEXETTE
5
QL (100 GM per 30 days) MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 128
Drug Name
Drug
Tier
Requirements/Limits
LOCOID LOTION
4
QL (118 ML per 30 days) MO
LOCOID LIPOCREAM
4
QL (60 GM per 30 days) MO
mometasone furoate cream 0.1%
2
MO
mometasone furoate ointment 0.1%
2
MO
mometasone furoate solution 0.1%
2
MO
OLUX
4
QL (100 GM per 30 days) MO
OLUX-E
5
QL (100 GM per 30 days) MO
PANDEL
4
QL (80 GM per 30 days) MO
prednicarbate ointment
2
QL (60 GM per 30 days) MO
proctosol hc cream 2.5%
2
SERNIVO
5
QL (120 ML per 30 days) MO
SYNALAR CREAM, OINTMENT
4
QL (120 GM per 30 days) MO
SYNALAR SOLUTION
4
QL (90 ML per 30 days) MO
TACLONEX SUSPENSION
5
QL (120 GM per 30 days) PA MO
TACLONEX OINTMENT
5
QL (400 GM per 28 days) PA MO
TEXACORT
4
MO
TOPICORT CREAM, OINTMENT
4
QL (100 GM per 30 days) MO
TOPICORT LIQUID
4
QL (100 ML per 30 days) MO
TOPICORT GEL
4
QL (60 GM per 30 days) MO
tovet
2
QL (100 GM per 30 days)
triamcinolone acetonide aerosol spray 0.147mg/gm
2
MO
triamcinolone acetonide cream 0.025%, 0.5%
2
MO
triamcinolone acetonide cream 0.1%
2
QL (454 GM per 30 days) MO
triamcinolone acetonide lotion 0.025%, 0.1%
2
MO
triamcinolone acetonide ointment 0.025%, 0.1%, 0.5%
2
MO
triamcinolone acetonide ointment 0.05%
2
QL (430 GM per 30 days) MO
trianex
2
QL (430 GM per 30 days)
triderm cream 0.5%
2
triderm cream 0.1%
2
QL (454 GM per 30 days)
tritocin
2
QL (430 GM per 30 days)
ULTRAVATE
5
QL (60 ML per 30 days) MO
VANOS
5
QL (120 GM per 30 days) MO
VERDESO
5
QL (100 GM per 30 days) MO
DERMATOLOGY, LOCAL ANESTHETICS
DERMACINRX LIDOGEL
5
QL (100 GM per 30 days) PA
glydo
2
QL (60 ML per 30 days) PA MO
lidocaine hcl jelly
2
MO
lidocaine hcl prefilled syringe 2%
2
QL (60 ML per 30 days) PA MO
lidocaine hcl external solution 4%
2
QL (50 ML per 30 days) PA MO
lidocaine/prilocaine
2
QL (30 GM per 30 days) MO
lidocaine ointment
2
QL (35.44 GM per 30 days) PA MO
lidocaine patch
2
QL (90 EA per 30 days) PA MO
LIDODERM
4
QL (90 EA per 30 days) PA MO
LIDOREX
5
QL (100 GM per 30 days) PA
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 129
Drug Name
Drug
Tier
Requirements/Limits
PLIAGLIS
4
QL (30 GM per 30 days) PA
QUTENZA KIT 8% (1-PATCH)
5
QL (1 EA per 90 days) PA LA MO
QUTENZA KIT 8% (2-PATCH)
5
QL (2 EA per 90 days) PA LA MO
QUTENZA KIT 8% (4-PATCH)
5
QL (4 EA per 90 days) PA LA MO
SYNERA
4
QL (10 EA per 30 days) PA MO
ZTLIDO
4
QL (90 EA per 30 days) PA MO
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS
MEMBRANE
ACYCLOVIR CREAM 5%
4
QL (5 GM per 30 days) MO
acyclovir ointment 5%
2
QL (30 GM per 30 days) MO
ammonium lactate cream, lotion
2
MO
ANUSOL-HC
4
MO
azelaic acid gel
2
QL (50 GM per 30 days) MO
BENSAL HP
5
QL (30 GM per 30 days) MO
bexarotene gel 1%
5
QL (60 GM per 30 days) PA; ACS
brimonidine tartrate gel 0.33%
2
MO
CARAC
5
QL (30 GM per 30 days) PA MO
CONDYLOX
4
QL (7 GM per 28 days) MO
CORTIFOAM
3
QL (15 GM per 30 days) MO
DENAVIR
4
QL (5 GM per 30 days) MO
DICLOFENAC EPOLAMINE
2
QL (60 EA per 30 days) PA MO
diclofenac sodium gel 3%
2
QL (100 GM per 30 days) PA MO
diclofenac sodium gel 1%
2
QL (1000 GM per 30 days) MO
diclofenac sodium external solution 1.5%
2
QL (300 ML per 28 days) PA MO
diclofenac sodium external solution 2%
5
QL (224 GM per 28 days) PA MO
DOXEPIN HYDROCHLORIDE CREAM 5%
4
QL (45 GM per 30 days) PA MO
DOXYCYCLINE CAPSULE DELAYED RELEASE 40MG
4
QL (30 EA per 30 days) PA MO
EFUDEX
4
QL (40 GM per 30 days) PA MO
ELIDEL
4
QL (100 GM per 30 days) ST MO
EUCRISA
3
QL (60 GM per 30 days) ST MO
FINACEA FOAM
3
QL (50 GM per 30 days) MO
FINACEA GEL
4
QL (50 GM per 30 days) MO
FLECTOR
4
QL (60 EA per 30 days) PA MO
FLUOROURACIL CREAM 0.5%
5
QL (30 GM per 30 days) PA MO
fluorouracil cream 5%
2
QL (40 GM per 30 days) PA MO
fluorouracil external solution 2%, 5%
2
QL (10 ML per 30 days) MO
hydrocortisone acetate/pramoxine
2
QL (30 GM per 30 days) MO
hydrocortisone perianal cream 1%
2
MO
HYFTOR
5
QL (20 GM per 25 days) PA LA
MO; ACS
IMIQUIMOD PUMP
4
QL (15 GM per 28 days) MO
imiquimod cream 5%
2
QL (24 EA per 30 days) MO
imiquimod cream 3.75%
2
QL (28 EA per 28 days) MO
ivermectin cream 1%
2
QL (45 GM per 30 days) MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 130
Drug Name
Drug
Tier
Requirements/Limits
KLISYRI
5
QL (5 EA per 30 days) PA MO
LEVULAN KERASTICK
4
QL (6 EA per 30 days)
LICART
5
PA MO
METROCREAM
4
MO
METROGEL
4
MO
METROLOTION
4
MO
metronidazole cream 0.75%
2
MO
metronidazole gel 0.75%, 1%
2
MO
metronidazole lotion 0.75%
2
MO
MIRVASO
4
MO
NORITATE
5
QL (60 GM per 30 days) MO
OPZELURA
5
QL (60 GM per 28 days) PA MO
ORACEA
3
QL (30 EA per 30 days) PA MO
PANRETIN
4
QL (60 GM per 30 days) PA
penciclovir
2
QL (5 GM per 30 days) MO
PENNSAID
5
QL (224 GM per 28 days) PA MO
pimecrolimus
2
QL (100 GM per 30 days) ST MO
PODOCON-25
4
QL (15 ML per 30 days)
podofilox
2
MO
procto-med hc
2
PROCTOCORT
4
MO
PROCTOFOAM HC
3
QL (10 GM per 30 days) MO
proctozone-hc
2
PRUDOXIN
4
QL (45 GM per 30 days) PA MO
QBREXZA
4
QL (30 EA per 30 days) PA MO
RECTIV
4
QL (30 GM per 30 days) MO
RHOFADE
4
QL (30 GM per 30 days) PA MO
salicylic acid wart remover 27.5%
2
QL (10 ML per 30 days) MO
SALICYLIC ACID OINTMENT
4
QL (30 GM per 30 days) MO
salicylic acid solution 26%
2
QL (10 ML per 30 days) MO
salicylic acid shampoo
2
QL (177 ML per 30 days) MO
SILVER NITRATE
4
QL (960 ML per 30 days) MO
SOOLANTRA
4
QL (45 GM per 30 days) MO
tacrolimus ointment 0.03%, 0.1%
2
QL (60 GM per 30 days) MO
TARGRETIN GEL 1%
5
QL (60 GM per 30 days) PA; ACS
TOLAK
4
QL (40 GM per 30 days) PA
VALCHLOR
5
QL (60 GM per 30 days) PA LA MO
VEREGEN
5
QL (30 GM per 28 days) MO
VIRASAL
4
QL (10 ML per 30 days) MO
XERESE
5
QL (5 GM per 30 days) MO
ZILXI
4
QL (30 GM per 30 days) PA MO
ZONALON
4
QL (45 GM per 30 days) PA MO
ZOVIRAX CREAM 5%
5
QL (5 GM per 30 days) MO
ZOVIRAX OINTMENT 5%
4
QL (30 GM per 30 days) MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 131
Drug Name
Drug
Tier
Requirements/Limits
ZYCLARA
5
QL (28 EA per 28 days) MO
ZYCLARA PUMP CREAM 3.75%
5
QL (15 GM per 28 days) MO
ZYCLARA PUMP CREAM 2.5%
5
QL (7.5 GM per 28 days) MO
DERMATOLOGY, SCABICIDES AND PEDICULIDES
crotan
2
QL (237 GM per 30 days)
lindane
2
MO
malathion
2
MO
NATROBA
4
QL (120 ML per 30 days) MO
OVIDE
4
MO
permethrin cream 5%
2
MO
SPINOSAD
2
QL (120 ML per 30 days) MO
DERMATOLOGY, WOUND CARE AGENTS
LACTATED RINGERS IRRIGATION
2
PHYSIOLYTE
2
REGRANEX
4
QL (30 GM per 30 days) PA MO
RINGERS IRRIGATION
2
SANTYL
4
MO
sodium chloride 0.9% irrigation soln
2
MO
sterile water for irrigation
2
MO
TIS-U-SOL
2
VYJUVEK
5
QL (10 ML per 28 days) PA LA
MOUTH/THROAT/DENTAL AGENTS
ARESTIN
5
PA MO; ACS
cevimeline hydrochloride
2
MO
chlorhexidine gluconate oral rinse 0.12%
1
MO
clinpro 5000
2
MO
clotrimazole troche 10mg
2
MO
denta 5000 plus cream 1.1% (2-pack)
2
QL (51 GM per 30 days)
denta 5000 plus cream 1.1%
2
QL (51 GM per 30 days) MO
dentagel
2
MO
EVOXAC
4
MO
fluoridex daily defense
2
fluoridex sensitivity relief/sls free
2
fluorimax 5000
2
fluorimax 5000 sensitive
2
just right 5000
2
lidocaine hcl mouth/throat solution 4%
2
lidocaine hydrochloride viscous solution 2%
2
MO
nystatin suspension 100000unit/ml
2
MO
oralone dental paste
2
periogard
1
pilocarpine hydrochloride tablet
2
MO
PREVIDENT 5000 BOOSTER PLUS
4
MO
PREVIDENT 5000 DRY MOUTH
4
MO
2024 FEHB v9 effective 01/01/2024
Information on the symbols, abbreviations, and what they mean can be found on the page prior to the start
of the drug list.
01/01/2024 Page 132
Drug Name
Drug
Tier
Requirements/Limits
PREVIDENT 5000 ENAMEL PROTECT
4
MO
PREVIDENT 5000 ORTHO DEFENSE
4
MO
PREVIDENT 5000 PLUS
4
QL (51 GM per 30 days) MO
PREVIDENT FLUORIDE
4
MO
PREVIDENT RINSE
4
MO
SALAGEN
4
MO
sf 5000 plus
2
QL (51 GM per 30 days) MO
sf gel 1.1%
2
MO
sodium fluoride 5000 plus
2
QL (51 GM per 30 days)
sodium fluoride 5000 ppm dry mouth gel
2
MO
sodium fluoride 5000 ppm sensitive
2
MO
sodium fluoride 5000 ppm paste
2
MO
sodium fluoride 5000 ppm cream
2
QL (51 GM per 30 days)
sodium fluoride gel 1.1%
2
MO
sodium fluoride mouth/throat solution 0.2%
2
MO
triamcinolone acetonide dental paste
2
MO
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 133
Index
abacavir ........................................................ 13, 14
abacavir sulfate/lamivudine ............................... 14
ABELCET .......................................................... 11
ABILIFY ...................................................... 50, 51
ABILIFY ASIMTUFII ................................. 50, 51
ABILIFY MAINTENA ...................................... 51
ABILIFY MYCITE MAINTENANCE KIT ...... 51
ABILIFY MYCITE STARTER KIT ................. 51
abiraterone acetate ............................................ 22
ABRAXANE ...................................................... 24
ABRYSVO ....................................................... 107
ABSORICA ...................................................... 122
ABSORICA LD ............................................... 122
acamprosate calcium dr ..................................... 69
ACANYA ......................................................... 122
acarbose ............................................................. 73
ACCOLATE ..................................................... 120
ACCUPRIL ........................................................ 32
ACCURETIC ..................................................... 32
accutane ........................................................... 122
acebutolol hydrochloride ................................... 37
ACETADOTE .................................................... 85
acetaminophen ..................................................... 1
acetaminophen/caffeine/dihydrocodeine .............. 4
acetaminophen/codeine ........................................ 4
acetazolamide ..................................................... 39
acetazolamide er ................................................ 39
acetazolamide sodium ........................................ 39
acetic acid .......................................................... 97
acetic acid otic ................................................. 117
acetylcysteine ............................................. 85, 120
ACIPHEX........................................................... 96
acitretin ............................................................ 125
ACTEMRA ...................................................... 102
ACTEMRA ACTPEN ...................................... 102
ACTHAR ........................................................... 85
ACTHIB ........................................................... 107
ACTIMMUNE ................................................. 105
ACTIVELLA ..................................................... 82
ACTONEL ......................................................... 76
ACTOPLUS MET .............................................. 73
ACTOS ............................................................... 73
ACULAR ......................................................... 114
ACULAR LS .................................................... 114
ACUVAIL ........................................................ 114
acyclovir ..................................................... 15, 129
ACYCLOVIR .................................................. 129
acyclovir sodium ................................................ 15
ACZONE ......................................................... 122
ADACEL ......................................................... 107
ADAKVEO ..................................................... 100
adapalene................................................. 122, 123
ADAPALENE ................................................. 123
adapalene/benzoyl peroxide .................... 122, 123
ADAPALENE/BENZOYL PEROXIDE ......... 122
ADBRY ........................................................... 102
adc/fluoride ...................................................... 110
ADCIRCA ......................................................... 42
ADDERALL ...................................................... 59
ADDERALL XR ............................................... 59
adefovir dipivoxil ............................................... 15
ADEMPAS ........................................................ 42
ADLARITY ....................................................... 45
ADMELOG ....................................................... 71
ADMELOG SOLOSTAR.................................. 71
ADRENALIN .................................................... 40
adriamycin ......................................................... 21
ADTHYZA ........................................................ 89
ADVAIR DISKUS .......................................... 122
ADVAIR HFA ................................................. 122
ADZENYS XR-ODT ........................................ 59
AEMCOLO ......................................................... 8
AFINITOR......................................................... 25
AFINITOR DISPERZ ....................................... 25
afirmelle ............................................................. 77
AFREZZA ......................................................... 71
AGRYLIN ....................................................... 100
AIMOVIG ......................................................... 63
AIRDUO DIGIHALER ................................... 122
AIRDUO RESPICLICK .................................. 122
AJOVY .............................................................. 63
AKLIEF ........................................................... 123
ak-poly-bac ...................................................... 114
AKYNZEO ........................................................ 90
ala-cort ............................................................ 126
ALA-SCALP ................................................... 126
albendazole .......................................................... 8
albuterol sulfate ............................................... 119
albuterol sulfate hfa ......................................... 119
ALCAINE ........................................................ 117
alclometasone dipropionate ............................ 126
ALDACTAZIDE ............................................... 39
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 134
ALDACTONE ................................................... 33
ALDURAZYME ................................................ 85
ALECENSA ....................................................... 25
alendronate sodium ............................................ 76
alfuzosin hcl........................................................ 96
ALIMTA ............................................................ 21
ALIQOPA .......................................................... 25
aliskiren .............................................................. 40
ALKERAN ......................................................... 20
ALKINDI SPRINKLE ....................................... 83
allopurinol ............................................................ 1
ALLOPURINOL .................................................. 1
allopurinol sodium ............................................... 1
ALLZITAL ........................................................... 1
almotriptan maleate ........................................... 63
ALOCRIL......................................................... 115
ALOGLIPTIN .................................................... 73
ALOGLIPTIN/METFORMIN HCL .................. 73
ALOGLIPTIN/METFORMIN
HYDROCHLORIDE ...................................... 73
ALOGLIPTIN/PIOGLITAZONE ...................... 73
ALOMIDE ....................................................... 115
ALOPRIM ............................................................ 1
alosetron hydrochloride ..................................... 94
ALPHAGAN P ......................................... 115, 116
alprazolam .......................................................... 44
alprazolam er ..................................................... 43
ALPRAZOLAM INTENSOL ............................ 43
alprazolam odt.................................................... 43
ALPRAZOLAM XR .......................................... 44
ALREX............................................................. 114
ALTABAX ....................................................... 124
ALTACE ............................................................ 32
altavera ............................................................... 77
ALTOPREV ....................................................... 35
ALTRENO ....................................................... 123
ALUNBRIG ....................................................... 25
ALVESCO ....................................................... 121
alyacen 1/35 ....................................................... 78
alyacen 7/7/7 ...................................................... 78
ALYMSYS ......................................................... 25
alyq ..................................................................... 42
amabelz............................................................... 82
amantadine ......................................................... 49
AMBIEN ............................................................ 61
AMBIEN CR ...................................................... 61
AMBISOME ...................................................... 11
ambrisentan ........................................................ 42
amcinonide ....................................................... 126
AMCINONIDE ............................................... 126
amethia .............................................................. 78
amethyst ............................................................. 78
AMICAR ......................................................... 100
amikacin sulfate ................................................... 8
amiloride hcl ...................................................... 39
amiloride/hydrochlorothiazide .......................... 39
aminocaproic acid ........................................... 100
aminophylline .................................................. 120
amiodarone hcl .................................................. 34
amiodarone hydrochloride ................................ 34
AMITIZA .......................................................... 94
amitriptyline hcl ................................................. 45
amitriptyline hydrochloride ............................... 45
AMJEVITA ..................................................... 102
amlodipine besylate ......................... 32, 33, 38, 40
amlodipine besylate/atorvastatin calcium ......... 40
amlodipine besylate/benazepril hydrochloride . 32
amlodipine besylate/valsartan ........................... 33
amlodipine/olmesartan medoxomil.................... 33
amlodipine/valsartan/hydrochlorothiazide ....... 33
ammonium lactate............................................ 129
amnesteem ....................................................... 123
AMONDYS 45 .................................................. 64
amoxapine .......................................................... 45
amoxicillin ......................................................... 18
amoxicillin/clavulanate potassium .................... 18
amoxicillin/clavulanate potassium er ................ 18
amphetamine sulfate .......................................... 59
amphetamine/dextroamphetamine ..................... 59
amphetamine/dextroamphetamine er ................ 59
amphotericin b ................................................... 11
amphotericin b liposome ................................... 11
ampicillin ..................................................... 18, 19
ampicillin sodium ........................................ 18, 19
ampicillin/sulbactam ......................................... 19
ampicillin-sulfactam .......................................... 19
AMPYRA .......................................................... 66
AMRIX .............................................................. 68
AMVUTTRA..................................................... 64
AMZEEQ......................................................... 123
ANAFRANIL .................................................... 45
anagrelide hydrochloride ................................ 100
ANASPAZ ......................................................... 92
anastrozole......................................................... 22
ANCOBON ....................................................... 11
ANDRODERM ................................................. 70
ANDROGEL PUMP ......................................... 70
ANGELIQ ......................................................... 82
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 135
ANNOVERA ..................................................... 78
ANORO ELLIPTA .......................................... 118
ANTARA ........................................................... 35
ANTIVERT ........................................................ 90
ANUSOL-HC ................................................... 129
ANZEMET ......................................................... 90
APADAZ .............................................................. 5
APEXICON E .................................................. 126
APIDRA ............................................................. 71
APIDRA SOLOSTAR ....................................... 71
APLENZIN ........................................................ 45
APOKYN ........................................................... 49
apomorphine hydrochloride ............................... 49
APONVIE .......................................................... 90
apraclonidine ................................................... 116
aprepitant ........................................................... 90
APRETUDE ....................................................... 13
apri ..................................................................... 78
APRISO .............................................................. 93
APTENSIO XR .................................................. 59
APTIOM............................................................. 54
APTIVUS ........................................................... 13
ARALAST NP ................................................. 120
aranelle ............................................................... 78
ARANESP ALBUMIN FREE ................... 99, 100
ARAVA ............................................................ 104
ARAZLO .......................................................... 123
ARCALYST ..................................................... 106
ARESTIN ......................................................... 131
AREXVY ......................................................... 108
ARFORMOTEROL TARTRATE ................... 119
argatroban .......................................................... 98
ARICEPT ........................................................... 45
ARIKAYCE ......................................................... 8
ARIMIDEX ........................................................ 22
aripiprazole ........................................................ 51
aripiprazole odt .................................................. 51
ARISTADA ........................................................ 51
ARISTADA INITIO .......................................... 51
ARIXTRA .................................................... 98, 99
armodafinil ......................................................... 69
ARMONAIR DIGIHALER ............................. 121
ARMOUR THYROID ....................................... 89
ARNUITY ELLIPTA ....................................... 121
AROMASIN ....................................................... 22
ARRANON ........................................................ 21
arsenic trioxide ................................................... 24
ARTHROTEC 50 ................................................. 1
ARTHROTEC 75 ................................................. 1
ARZERRA......................................................... 25
ASACOL HD .................................................... 93
ASCENIV ........................................................ 105
ascomp/codeine ................................................... 5
asenapine maleate sl .......................................... 51
ashlyna ............................................................... 78
ASMANEX HFA ............................................ 121
ASMANEX TWISTHALER ........................... 121
ASPARLAS ....................................................... 24
aspirin/dipyridamole er ................................... 102
ASPRUZYO SPRINKLE .................................. 40
ASTAGRAF XL .............................................. 106
ATACAND ........................................................ 34
ATACAND HCT ............................................... 33
atazanavir sulfate .............................................. 13
ATELVIA .......................................................... 76
atenolol .............................................................. 37
atenolol/chlorthalidone ..................................... 37
ATGAM........................................................... 106
ATIVAN ............................................................ 44
atomoxetine ........................................................ 59
ATORVALIQ .................................................... 35
atorvastatin calcium .......................................... 35
atovaquone..................................................... 8, 12
atovaquone/proguanil hcl .................................. 12
ATRALIN ........................................................ 123
atropine sulfate .......................................... 92, 117
ATROPINE SULFATE ............................. 92, 117
ATROVENT HFA ........................................... 118
AUBAGIO ......................................................... 66
aubra eq ............................................................. 78
AUGMENTIN ................................................... 19
AUGMENTIN ES-600 ...................................... 19
aurovela 1.5/30 .................................................. 78
aurovela 1/20 ..................................................... 78
aurovela 24 fe .................................................... 78
aurovela fe 1.5/30 .............................................. 78
aurovela fe 1/20 ................................................. 78
AURYXIA ......................................................... 88
AUSTEDO......................................................... 64
AUSTEDO XR .................................................. 64
AUVELITY ....................................................... 45
AUVI-Q ........................................................... 120
AVALIDE ......................................................... 33
AVAPRO ........................................................... 34
AVASTIN .......................................................... 25
AVEED .............................................................. 70
aviane................................................................. 78
AVITA ............................................................. 123
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 136
AVODART ........................................................ 96
AVONEX ........................................................... 66
AVSOLA .......................................................... 102
AVYCAZ ........................................................... 16
AYGESTIN ........................................................ 89
ayuna .................................................................. 78
AYVAKIT .......................................................... 25
azacitidine .......................................................... 21
AZACTAM .......................................................... 8
azasan ............................................................... 107
AZASITE ......................................................... 114
azathioprine ...................................................... 107
AZATHIOPRINE............................................. 107
azelaic acid ....................................................... 129
azelastine hcl ............................................ 115, 118
azelastine hydrochloride/fluticasone propionate
....................................................................... 118
AZELEX .......................................................... 123
AZILECT ........................................................... 49
azithromycin ....................................................... 17
AZITHROMYCIN ............................................. 17
AZOPT ............................................................. 116
AZOR ................................................................. 33
AZSTARYS ....................................................... 59
aztreonam ............................................................. 8
AZULFIDINE .................................................... 93
AZULFIDINE EN-TABS .................................. 93
azurette ............................................................... 78
bacitracin ..................................................... 8, 114
bacitracin/polymyxin b ..................................... 114
baclofen .............................................................. 68
BACLOFEN ....................................................... 68
BACTRIM ............................................................ 8
BACTRIM DS...................................................... 8
BAFIERTAM ..................................................... 66
BALCOLTRA .................................................... 78
balsalazide disodium .......................................... 93
BALVERSA ....................................................... 25
balziva ................................................................ 78
BANZEL ............................................................ 54
BAQSIMI ONE PACK ...................................... 85
BAQSIMI TWO PACK ..................................... 85
BARACLUDE ................................................... 15
BASAGLAR KWIKPEN ................................... 71
BASAGLAR TEMPO PEN ............................... 71
BAVENCIO ....................................................... 25
BAXDELA ......................................................... 18
BCG VACCINE ............................................... 108
BD ALCOHOL SWABS ................................... 71
BD INSULIN SYRINGE .................................. 71
B-D INSULIN SYRINGE ULTRAFINE .......... 71
BD/NOVO PEN NEEDLE ................................ 71
BECONASE AQ ............................................. 121
BELBUCA........................................................... 3
BELEODAQ ...................................................... 25
BELLADONNA/OPIUM .................................. 92
BELSOMRA ..................................................... 61
benazepril hcl .................................................... 32
benazepril hcl/hydrochlorothiazide ................... 32
benazepril hydrochloride ................................... 32
bendamustine hydrochloride ............................. 20
BENDAMUSTINE HYDROCHLORIDE ........ 20
BENDEKA ........................................................ 20
BENICAR .......................................................... 34
BENICAR HCT ................................................. 33
BENLYSTA .................................................... 107
BENSAL HP.................................................... 129
BENTYL ........................................................... 92
BENZAMYCIN............................................... 123
BENZHYDROCODONE/ACETAMINOPHEN 5
BENZNIDAZOLE............................................... 8
benztropine mesylate ......................................... 49
BEOVU ........................................................... 117
bepotastine besilate ......................................... 115
BEPREVE ....................................................... 115
BERINERT ...................................................... 101
BESIVANCE ................................................... 114
BESPONSA ....................................................... 25
BESREMI .......................................................... 24
BETADINE OPHTHALMIC PREP ............... 114
betaine anhydrous.............................................. 85
betamethasone dipropionate............................ 126
betamethasone dipropionate augmented ......... 126
betamethasone sodium phosphate/betamethasone
acetate ............................................................ 83
betamethasone valerate ................................... 126
BETAPACE....................................................... 34
BETAPACE AF ................................................ 34
BETASERON .................................................... 66
betaxolol hcl .............................................. 37, 116
bethanechol chloride ......................................... 97
BETHKIS ............................................................ 8
BETIMOL ....................................................... 116
BETOPTIC-S................................................... 116
BEVESPI AEROSPHERE .............................. 118
bexarotene ................................................. 24, 129
BEXSERO ....................................................... 108
BEYAZ .............................................................. 78
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 137
BEYFORTUS................................................... 106
bicalutamide ....................................................... 22
BICILLIN C-R ................................................... 19
BICILLIN L-A ................................................... 19
BICNU ............................................................... 20
BIDIL ................................................................. 40
BIJUVA .............................................................. 82
BIKTARVY ....................................................... 14
BILTRICIDE ........................................................ 8
bimatoprost....................................................... 116
BINOSTO........................................................... 76
bismuth subcitrate pot/metronidazole/tetracycline
hydrochloride .................................................. 94
bisoprolol fumarate ............................................ 37
bisoprolol fumarate/hydrochlorothiazide .......... 37
BIVIGAM ........................................................ 105
BLENREP .......................................................... 25
bleomycin sulfate ................................................ 21
BLINCYTO ........................................................ 25
blisovi 24 fe ........................................................ 78
blisovi fe 1.5/30 .................................................. 78
blisovi fe 1/20 ..................................................... 78
BONJESTA ........................................................ 90
BOOSTRIX ...................................................... 108
bortezomib .......................................................... 25
BORTEZOMIB .................................................. 25
bosentan ............................................................. 42
BOSULIF ........................................................... 25
BOTOX .............................................................. 68
BRAFTOVI ........................................................ 25
BREO ELLIPTA .............................................. 122
breyna ............................................................... 122
BREZTRI AEROSPHERE .............................. 118
briellyn ............................................................... 78
BRILINTA ....................................................... 102
brimonidine tartrate ................................. 116, 129
BRIMONIDINE TARTRATE ......................... 116
brimonidine tartrate/timolol maleate ............... 116
brinzolamide ..................................................... 116
BRIUMVI........................................................... 66
BRIVIACT ......................................................... 54
bromfenac ......................................................... 114
bromocriptine mesylate ...................................... 49
BROMSITE ...................................................... 115
BRONCHITOL ................................................ 120
BRONCHITOL TOLERANCE TEST ............. 120
BROVANA ...................................................... 119
BRUKINSA ....................................................... 25
BRYHALI ........................................................ 126
budesonide ................................................. 93, 121
budesonide dr .................................................... 93
budesonide er ..................................................... 93
budesonide/formoterol fumarate dihydrate ..... 122
bumetanide......................................................... 39
BUMEX ............................................................. 39
bupap ................................................................... 1
BUPHENYL ...................................................... 85
bupivacaine fisiopharma ..................................... 7
bupivacaine hcl .................................................... 7
bupivacaine hydrochloride .................................. 7
bupivacaine/epinephrine ..................................... 7
BUPRENEX ........................................................ 5
buprenorphine ..................................................... 3
buprenorphine hcl.......................................... 5, 69
buprenorphine hcl/naloxone hcl ........................ 69
buprenorphine hydrochloride/naloxone
hydrochloride ................................................. 69
bupropion hcl ..................................................... 45
bupropion hydrochloride ................................... 46
bupropion hydrochloride er ................... 45, 46, 69
BUPROPION HYDROCHLORIDE ER (XL) .. 45
buspirone hcl ..................................................... 44
buspirone hydrochloride.................................... 44
busulfan ............................................................. 20
BUSULFEX....................................................... 20
butalbital/acetaminophen .................................... 1
butalbital/acetaminophen/caffeine .................. 1, 5
butalbital/acetaminophen/caffeine/codeine ......... 5
butalbital/aspirin/caffeine ............................... 1, 5
butalbital/aspirin/caffeine/codeine ...................... 5
butorphanol tartrate ............................................ 5
BUTRANS........................................................... 3
BYDUREON BCISE ......................................... 73
BYETTA ........................................................... 73
BYLVAY........................................................... 94
BYOOVIZ ....................................................... 117
BYSTOLIC ........................................................ 37
CABENUVA ..................................................... 14
cabergoline ........................................................ 85
CABLIVI ......................................................... 101
CABOMETYX .................................................. 25
CADUET ........................................................... 40
CALAN SR........................................................ 38
calcipotriene .................................................... 125
CALCIPOTRIENE .......................................... 125
calcipotriene/betamethasone dipropionate ..... 126
CALCIPOTRIENE/BETAMETHASONE
DIPROPIONATE ......................................... 126
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 138
calcitonin salmon ............................................... 76
calcitonin-salmon ............................................... 76
calcitrene .......................................................... 125
calcitriol ............................................................. 90
CALCITRIOL .................................................. 125
calcium acetate ................................................... 89
CALCIUM GLUCONATE .............................. 109
CALDOLOR ........................................................ 1
CALQUENCE .................................................... 25
CAMBIA ............................................................ 63
camila ................................................................. 78
CAMPTOSAR ................................................... 24
CAMRESE ......................................................... 78
CAMRESE LO ................................................... 78
CAMZYOS ........................................................ 40
CANASA ........................................................... 93
CANCIDAS ....................................................... 11
candesartan cilexetil .......................................... 34
candesartan cilexetil/hydrochlorothiazide ......... 33
CAPEX ............................................................. 126
CAPLYTA ......................................................... 51
CAPRELSA ....................................................... 25
captopril ............................................................. 32
captopril/hydrochlorothiazide ............................ 32
CARAC ............................................................ 129
CARAFATE ....................................................... 94
CARBAGLU ...................................................... 85
carbamazepine ................................................... 54
carbamazepine er ............................................... 54
CARBATROL .................................................... 54
carbidopa ........................................................... 49
carbidopa/levodopa ............................................ 49
carbidopa/levodopa er ....................................... 49
carbidopa/levodopa odt ...................................... 49
CARBIDOPA/LEVODOPA/ENTACAPONE .. 49
carbinoxamine maleate ............................ 118, 119
CARBINOXAMINE MALEATE .................... 118
carboplatin ......................................................... 20
CARDENE IV .................................................... 38
CARDIZEM ....................................................... 38
CARDIZEM CD ................................................ 38
CARDIZEM LA ................................................. 38
CARDURA ........................................................ 33
CARDURA XL .................................................. 97
carglumic acid .................................................... 85
carisoprodol ....................................................... 68
carmustine .......................................................... 20
CARNITOR ....................................................... 85
CARNITOR SF .................................................. 85
CAROSPIR ........................................................ 33
carteolol hcl ..................................................... 116
cartia xt .............................................................. 38
carvedilol ........................................................... 37
carvedilol phosphate er ..................................... 37
CASODEX ........................................................ 22
caspofungin acetate ........................................... 11
CAYSTON .......................................................... 8
cefaclor .............................................................. 16
CEFACLOR ER ................................................ 16
cefadroxil ........................................................... 16
cefazolin ............................................................. 17
CEFAZOLIN ..................................................... 17
cefazolin sodium ................................................ 17
CEFAZOLIN SODIUM .................................... 17
CEFAZOLIN SODIUM/DEXTROSE .............. 17
cefdinir ............................................................... 17
cefepime ............................................................. 17
CEFEPIME ........................................................ 17
CEFEPIME HYDROCHLORIDE .................... 17
CEFEPIME/DEXTROSE .................................. 17
cefixime .............................................................. 17
cefotetan............................................................. 17
cefoxitin sodium ................................................. 17
CEFOXITIN SODIUM ..................................... 17
cefpodoxime proxetil.......................................... 17
cefprozil ............................................................. 17
ceftazidime ......................................................... 17
CEFTAZIDIME/DEXTROSE........................... 17
ceftriaxone in iso-osmotic dextrose ................... 17
ceftriaxone sodium ............................................. 17
CEFTRIAXONE SODIUM ............................... 17
CEFTRIAXONE/DEXTROSE ......................... 17
cefuroxime axetil ................................................ 17
cefuroxime sodium ............................................. 17
CELEBREX......................................................... 1
celecoxib .............................................................. 1
CELESTONE-SOLUSPAN .............................. 83
CELLCEPT ..................................................... 107
CELLCEPT IV ................................................ 107
CELONTIN ....................................................... 54
CELXA .............................................................. 46
cephalexin .......................................................... 17
CEQUA ........................................................... 117
CEQUR SIMPLICITY 2U ................................ 71
CEQUR SIMPLICITY INSERTER .................. 71
CERDELGA ...................................................... 85
CEREBYX......................................................... 54
CEREZYME ...................................................... 85
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 139
cetirizine hydrochloride ................................... 119
CETRAXAL ..................................................... 117
cevimeline hydrochloride ................................. 131
charlotte 24 fe ..................................................... 78
chateal eq ........................................................... 78
CHEMET ........................................................... 77
CHENODAL ...................................................... 94
chloramphenical sodium succinate ...................... 8
chlordiazepoxide hcl .......................................... 44
CHLORDIAZEPOXIDE HCL/CLIDINIUM
BROMIDE ...................................................... 92
chlordiazepoxide hydrochloride ......................... 44
chlordiazepoxide/amitriptyline ........................... 46
chlorhexidine gluconate ................................... 131
chloroquine phosphate ....................................... 12
chlorothiazide sodium ........................................ 39
chlorpromazine hcl ............................................. 51
chlorpromazine hydrochloride ........................... 51
chlorthalidone .................................................... 39
chlorzoxazone ..................................................... 68
CHOLBAM ........................................................ 94
cholestyramine ................................................... 36
cholestyramine light ........................................... 36
CHORIONIC GONADOTROPIN ..................... 85
CIBINQO ......................................................... 102
ciclodan ............................................................ 124
ciclopirox .......................................................... 124
ciclopirox nail lacquer ..................................... 124
ciclopirox olamine ............................................ 124
cidofovir ............................................................. 15
cilostazol........................................................... 101
CILOXAN ........................................................ 114
CIMDUO ............................................................ 14
CIMERLI ......................................................... 117
cimetidine ........................................................... 93
cimetidine hcl ..................................................... 92
cimetidine hydrochloride .................................... 92
CIMZIA ............................................................ 102
CIMZIA STARTER KIT ................................. 102
cinacalcet hydrochloride .................................... 85
CINQAIR ......................................................... 120
CINRYZE......................................................... 101
CINVANTI ......................................................... 90
CIPRO ................................................................ 18
CIPRO HC........................................................ 117
CIPRODEX ...................................................... 118
ciprofloxacin ....................................................... 18
CIPROFLOXACIN .......................................... 118
ciprofloxacin hcl ................................................. 18
ciprofloxacin hydrochloride ...................... 18, 114
ciprofloxacin i.v.-in d5w .................................... 18
ciprofloxacin/dexamethasone .......................... 118
CIPROFLOXACIN/FLUOCINOLONE
ACETONIDE PF ......................................... 118
cisplatin ............................................................. 20
citalopram hydrobromide .................................. 46
CITALOPRAM HYDROBROMIDE................ 46
CITRANATAL 90 DHA ................................. 110
CITRANATAL B-CALM ............................... 110
CITRANATAL BLOOM ................................ 110
CITRANATAL HARMONY .......................... 110
CITRANATAL MEDLEY .............................. 110
cladribine ........................................................... 21
claravis ............................................................ 123
CLARINEX ............................................. 118, 119
CLARINEX-D ................................................. 118
clarithromycin ................................................... 18
clarithromycin er ............................................... 18
clemastine fumarate ......................................... 119
CLEMASTINE FUMARATE ......................... 119
CLENPIQ .......................................................... 93
CLEOCIN ...................................................... 8, 98
CLEOCIN PEDIATRIC ...................................... 8
CLEOCIN PHOSPHATE .................................... 8
CLEOCIN-T .................................................... 123
CLIMARA ......................................................... 82
CLIMARA PRO ................................................ 82
clindacin .......................................................... 123
clindacin etz pledgets ....................................... 123
clindacin-p ....................................................... 123
CLINDAGEL .................................................. 123
clindamycin hcl .................................................... 8
clindamycin hydrochloride .................................. 8
clindamycin palmitate hcl .................................... 8
clindamycin phosphate .......................... 8, 98, 123
clindamycin phosphate/benzoyl peroxide ........ 123
clindamycin phosphate/dextrose.......................... 8
clindamycin phosphate/tretinoin ..................... 123
clindamycin/benzoyl peroxide ......................... 123
CLINDAMYCIN/SODIUM CHLORIDE ........... 8
CLINDESSE ...................................................... 98
CLINIMIX 4.25%/DEXTROSE 10% ............. 112
CLINIMIX 4.25%/DEXTROSE 5% ............... 112
CLINIMIX 5%/DEXTROSE 15% .................. 112
CLINIMIX 5%/DEXTROSE 20% .................. 112
CLINIMIX 6/5 ................................................. 113
CLINIMIX 8/10 ............................................... 113
CLINIMIX 8/14 ............................................... 113
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 140
CLINIMIX E 2.75%/DEXTROSE 5% ............ 113
CLINIMIX E 4.25%/DEXTROSE 10% .......... 113
CLINIMIX E 4.25%/DEXTROSE 5% ............ 113
CLINIMIX E 5%/DEXTROSE 15% ............... 113
CLINIMIX E 5%/DEXTROSE 20% ............... 113
CLINIMIX E 8/10 ............................................ 113
CLINIMIX E 8/14 ............................................ 113
clinisol sf 15% .................................................. 113
CLINOLIPID ................................................... 113
clinpro 5000 ..................................................... 131
clobazam............................................................. 54
clobetasol propionate ....................................... 126
clobetasol propionate e .................................... 126
clobetasol propionate emollient ....................... 126
CLOBEX .......................................................... 126
CLOCORTOLONE PIVALATE ..................... 126
clodan ............................................................... 126
CLODERM ...................................................... 126
clofarabine ......................................................... 21
CLOLAR ............................................................ 22
clomipramine hydrochloride .............................. 46
clonazepam ......................................................... 54
clonazepam odt ................................................... 54
clonidine hcl ................................................... 1, 40
clonidine hydrochloride ..................................... 40
clonidine hydrochloride er ................................. 59
clopidogrel ....................................................... 102
clorazepate dipotassium ..................................... 54
clotrimazole ...................................................... 124
clotrimazole troche ........................................... 131
clotrimazole/betamethasone dipropionate ....... 124
clozapine ............................................................. 51
clozapine odt ...................................................... 51
CLOZAPINE ODT ............................................ 51
CLOZARIL ........................................................ 51
C-NATE DHA.................................................. 110
COARTEM ........................................................ 12
COCAINE HYDROCHLORIDE ..................... 120
CODEINE SULFATE .......................................... 5
COLAZAL ......................................................... 93
colchicine ............................................................. 1
COLCHICINE ...................................................... 1
COLCRYS ........................................................... 1
colesevelam hydrochloride ................................. 36
COLESTID......................................................... 36
COLESTID FLAVORED .................................. 36
colestipol hcl ...................................................... 36
colistimethate sodium ........................................... 9
COLUMVI ......................................................... 26
COLY-MYCIN M ............................................... 9
COMBIGAN ................................................... 116
COMBIPATCH ................................................. 82
COMBIVENT RESPIMAT ............................. 118
COMBIVIR ....................................................... 14
COMETRIQ ...................................................... 26
COMPLERA ..................................................... 14
COMPLETENATE ......................................... 110
compro ............................................................... 90
COMTAN .......................................................... 49
CONCEPT DHA ............................................. 110
CONCEPT OB ................................................ 110
CONCERTA ...................................................... 59
CONDYLOX ................................................... 129
CONJUPRI ........................................................ 38
constulose .......................................................... 93
CONZIP ............................................................... 3
COPAXONE ..................................................... 66
COPIKTRA ....................................................... 26
CORDRAN ...................................................... 126
COREC CR ....................................................... 37
COREG .............................................................. 37
CORGARD ........................................................ 37
CORLANOR ..................................................... 40
CORTEF ............................................................ 83
CORTENEMA .................................................. 93
CORTIFOAM .................................................. 129
CORTISONE ACETATE.................................. 83
CORTISPORIN-TC ........................................ 118
CORTROPHIN .................................................. 85
COSENTYX .................................................... 103
COSENTYX SENSOREADY PEN ................ 102
COSENTYX UNOREADY ............................ 103
COSMEGEN ..................................................... 21
COSOPT .......................................................... 116
COSOPT PF .................................................... 116
COTELLIC ........................................................ 26
COTEMPLA XR-ODT...................................... 59
COZAAR ........................................................... 34
CREON .............................................................. 95
CRESEMBA ...................................................... 11
CRESTOR ......................................................... 35
CRINONE ......................................................... 89
cromolyn sodium................................ 94, 115, 120
crotan ............................................................... 131
cryselle-28 ......................................................... 78
CRYSVITA ....................................................... 85
CUBICIN RF ....................................................... 9
CUPRIMINE ..................................................... 77
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 141
CUTAQUIG ..................................................... 105
CUVITRU ........................................................ 105
CUVPOSA ......................................................... 92
CUVRIOR .......................................................... 77
cyclobenzaprine hydrochloride .......................... 68
cyclobenzaprine hydrochloride er ...................... 68
CYCLOGYL .................................................... 117
cyclopentolate hydrochloride ........................... 117
cyclophosphamide .............................................. 20
CYCLOPHOSPHAMIDE .................................. 20
CYCLOPHOSPHAMIDE MONOHYDRATE .. 20
cycloserine .......................................................... 15
CYCLOSET ....................................................... 73
cyclosporine ............................................. 107, 117
cyclosporine modified ...................................... 107
CYKLOKAPRON ............................................ 101
CYMBALTA ..................................................... 46
cyproheptadine hcl ........................................... 119
cyproheptadine hydrochloride ......................... 119
CYRAMZA ........................................................ 26
cyred ................................................................... 78
cyred eq .............................................................. 78
CYSTADANE .................................................... 85
CYSTADROPS ................................................ 117
CYSTAGON ...................................................... 85
CYSTARAN .................................................... 117
cytarabine ........................................................... 22
CYTOGAM ...................................................... 105
CYTOMEL......................................................... 89
CYTOTEC ......................................................... 94
dabigatran etexilate ............................................ 99
dacarbazine ........................................................ 24
dactinomycin ...................................................... 21
dalfampridine er ................................................. 66
DALIRESP ....................................................... 120
DALVANCE ........................................................ 9
danazol ............................................................... 82
DANTRIUM ...................................................... 68
dantrolene ........................................................... 68
dapsone......................................................... 9, 123
DAPTACEL ..................................................... 108
daptomycin ........................................................... 9
DAPTOMYCIN ................................................... 9
DARAPRIM ......................................................... 9
darifenacin hydrobromide er ............................. 97
DARTISLA ODT ............................................... 92
darunavir ............................................................ 13
DARZALEX ...................................................... 26
DARZALEX FASPRO ...................................... 26
dasetta 1/35........................................................ 78
dasetta 7/7/7 ...................................................... 78
daunorubicin hydrochloride .............................. 21
DAUNORUBICIN HYDROCHLORIDE ......... 21
DAURISMO ...................................................... 26
DAYBUE........................................................... 64
DAYPRO ............................................................. 1
daysee ................................................................ 78
DAYTRANA ..................................................... 59
DAYVIGO......................................................... 61
DDAVP ............................................................. 85
deblitane ............................................................ 78
decitabine........................................................... 22
deferasirox ......................................................... 77
deferiprone......................................................... 77
deferoxamine mesylate ...................................... 77
DELESTROGEN............................................... 82
DELSTRIGO ..................................................... 14
delyla ................................................................. 78
DELZICOL ........................................................ 93
demeclocycline hcl ............................................. 19
DEMEROL .......................................................... 5
DEMSER ........................................................... 40
DENAVIR ....................................................... 129
DENGVAXIA ................................................. 108
denta 5000 plus ................................................ 131
dentagel ........................................................... 131
DEPAKOTE ................................................ 54, 55
DEPAKOTE ER ................................................ 54
DEPAKOTE SPRINKLES ................................ 55
DEPEN TITRATABS ....................................... 77
DEPO-ESTRADIOL ......................................... 82
DEPO-MEDROL............................................... 83
DEPO-PROVERA CONTRACEPTIVE ........... 78
DEPO-SUBQ PROVERA ................................. 78
DEPO-TESTOSTERONE ................................. 70
DERMACINRX LIDOGEL ............................ 128
DERMA-SMOOTHE/FS BODY .................... 126
DERMA-SMOOTHE/FS SCALP ................... 126
DERMOTIC .................................................... 118
DESCOVY ........................................................ 14
DESFERAL ....................................................... 77
desipramine hydrochloride ................................ 46
desloratadine ................................................... 119
desloratadine odt ............................................. 119
desmopressin acetate ......................................... 85
desogestrel/ethinyl estradiol .............................. 78
desonide ........................................................... 126
DESOWEN ...................................................... 127
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 142
desoximetasone................................................. 127
desrx ................................................................. 127
desvenlafaxine er ................................................ 46
DESVENLAFAXINE ER .................................. 46
DETROL ............................................................ 98
DETROL LA ...................................................... 98
DEXABLISS ...................................................... 83
dexamethasone ................................................... 84
dexamethasone 10-day dose pack ...................... 83
dexamethasone 13-day dose pack ...................... 83
dexamethasone 6-day dose pack ........................ 84
DEXAMETHASONE INTENSOL.................... 84
dexamethasone sodium phosphate ............. 84, 115
DEXEDRINE ..................................................... 59
DEXILANT ........................................................ 96
dexlansoprazole .................................................. 96
dexmethylphenidate hcl ...................................... 59
dexmethylphenidate hcl er .................................. 59
dexmethylphenidate hydrochloride .................... 59
dexmethylphenidate hydrochloride er ................ 59
dexrazoxane .................................................. 31, 32
dextroamphetamine sulfate ................................ 59
dextroamphetamine sulfate er ............................ 59
DEXTROSE 10%/NACL 0.45% .................... 109
DEXTROSE 5% /ELECTROLYTE #48
VIAFLEX ..................................................... 109
dextrose 10% ............................................ 109, 113
DEXTROSE 10%/NACL 0.2% ....................... 109
DEXTROSE 2.5%/NACL 0.45% .................... 109
DEXTROSE 25% ............................................. 113
dextrose 5% .............................................. 109, 113
DEXTROSE 5%/LACTATED RINGERS ...... 109
DEXTROSE 5%/NACL 0.2% ......................... 109
DEXTROSE 5%/NACL 0.225% ..................... 109
dextrose 5%/nacl 0.3% ..................................... 109
DEXTROSE 5%/NACL 0.33% ....................... 109
DEXTROSE 5%/NACL 0.45% ....................... 109
DEXTROSE 5%/NACL 0.9% ......................... 109
DEXTROSE 50% ............................................. 113
DEXTROSE 70% ............................................. 113
DEXYCU ......................................................... 115
DHIVY ............................................................... 49
DIACOMIT ........................................................ 55
DIASTAT ACUDIAL ........................................ 55
DIASTAT PEDIATRIC ..................................... 55
diazepam............................................................. 55
DIAZEPAM RECTAL GEL .............................. 55
diazoxide ............................................................. 85
DIBENZYLINE ................................................. 40
dichlorphenamide .............................................. 39
DICLEGIS ......................................................... 90
DICLOFENAC EPOLAMINE ........................ 129
diclofenac potassium ................................. 1, 2, 63
diclofenac sodium .................................... 115, 129
diclofenac sodium dr ........................................... 2
diclofenac sodium er ............................................ 2
diclofenac sodium/misoprostol ............................ 2
dicloxacillin sodium ........................................... 19
dicyclomine hcl .................................................. 92
dicyclomine hydrochloride ................................ 92
DIFFERIN ....................................................... 123
DIFICID............................................................. 18
diflorasone diacetate ....................................... 127
DIFLUCAN ....................................................... 11
diflunisal .............................................................. 2
difluprednate .................................................... 115
digox .................................................................. 40
digoxin ............................................................... 40
dihydroergotamine mesylate.............................. 63
DILANTIN ........................................................ 55
DILANTIN INFATABS.................................... 55
DILANTIN-125 ................................................. 55
DILAUDID .......................................................... 5
diltiazem hcl ....................................................... 38
DILTIAZEM HCL ............................................ 38
diltiazem hcl cd .................................................. 38
diltiazem hydrochloride ..................................... 38
diltiazem hydrochloride er................................. 38
dilt-xr ................................................................. 38
DIMENHYDRINATE ....................................... 91
dimethyl fumarate .............................................. 66
dimethyl fumarate starterpack ........................... 66
DIOVAN ........................................................... 34
DIOVAN HCT .................................................. 33
DIPENTUM....................................................... 93
diphenhydramine hcl ....................................... 119
diphenoxylate hydrochloride/atropine sulfate ... 94
diphenoxylate/atropine ...................................... 94
DIPHTHERIA/TETANUS TOXOIDS
ADSORBED PEDIATRIC .......................... 108
DIPROLENE ................................................... 127
dipyridamole .................................................... 102
disopyramide phosphate .................................... 34
disulfiram ........................................................... 69
DITROPAN XL ................................................. 98
DIURIL .............................................................. 39
divalproex sodium.............................................. 55
divalproex sodium dr ......................................... 55
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 143
divalproex sodium er .......................................... 55
DIVIGEL ............................................................ 82
dobutamine hcl ................................................... 40
DOBUTAMINE HCL/D5W .............................. 40
DOBUTAMINE
HYDROCHLORIDE/DEXTROSE ................ 40
docetaxel ............................................................. 24
DOCETAXEL .................................................... 24
dofetilide ............................................................. 34
DOJOLVI ........................................................... 86
dolishale ............................................................. 78
donepezil hcl ....................................................... 45
donepezil hydrochloride ..................................... 45
DOPAMINE HYDROCHLORIDE ................... 40
DOPAMINE HYDROCHLORIDE/DEXTROSE
......................................................................... 41
DOPAMINE/D5W ............................................. 41
DOPTELET ...................................................... 101
DORYX .............................................................. 19
DORYX MPC .................................................... 19
dorzolamide hcl/timolol maleate ...................... 116
dorzolamide hydrochloride .............................. 116
dorzolamide hydrochloride/timolol maleate .... 116
dotti..................................................................... 83
DOVATO ........................................................... 14
doxazosin mesylate ............................................. 33
doxepin hcl ......................................................... 46
doxepin hydrochloride .................................. 46, 61
DOXEPIN HYDROCHLORIDE ..................... 129
doxercalciferol ................................................... 90
DOXIL ............................................................... 21
doxorubicin hcl ................................................... 21
doxorubicin hydrochloride ................................. 21
doxy 100 ............................................................. 19
doxycycline ......................................................... 20
DOXYCYCLINE ............................................. 129
doxycycline hyclate ............................................ 19
doxycycline hyclate dr ........................................ 19
doxycycline monohydrate ................................... 19
doxylamine succinate/pyridoxine hydrochloride 91
DRIZALMA ....................................................... 46
dronabinol .......................................................... 91
droperidol ........................................................... 44
drospirenone/ethinyl estradiol ........................... 78
drospirenone/ethinyl estradiol/levomefolate
calcium ............................................................ 78
DROXIA .......................................................... 101
droxidopa ........................................................... 41
DUAKLIR PRESSAIR .................................... 118
DUAVEE ........................................................... 83
DUET DHA 400 .............................................. 110
DUET DHA BALANCED .............................. 110
DUETACT......................................................... 73
DUEXIS............................................................... 2
DULERA ......................................................... 122
duloxetine hcl ..................................................... 46
duloxetine hydrochloride ................................... 46
DUOBRII......................................................... 127
DUOPA ............................................................. 49
DUPIXENT ..................................................... 103
DURACLON ....................................................... 1
DURAMORPH .................................................... 5
DUREZOL....................................................... 115
DURYSTA ...................................................... 116
dutasteride ......................................................... 97
dutasteride/tamsulosin hydrochloride ............... 97
DXEVO 11-DAY .............................................. 84
DYANAVEL XR ........................................ 59, 60
DYMISTA ....................................................... 118
DYRENIUM ...................................................... 39
DYSPORT ......................................................... 68
E.E.S. ................................................................. 18
e.e.s. 400 ............................................................ 18
ec-naproxen ......................................................... 2
econazole nitrate.............................................. 124
EDARBI ............................................................ 34
EDARBYCLOR ................................................ 33
EDECRIN .......................................................... 39
EDLUAR ........................................................... 62
EDURANT ........................................................ 13
efavirenz....................................................... 13, 14
efavirenz/emtricitabine/tenofovir disoproxil
fumarate ......................................................... 14
efavirenz/lamivudine/tenofovir disoproxil
fumarate ......................................................... 14
effer-k ............................................................... 110
EFFER-K ......................................................... 110
EFFEXOR XR ................................................... 46
EFFIENT ......................................................... 102
EFUDEX ......................................................... 129
EGRIFTA SV .................................................... 86
ELAPRASE ....................................................... 86
ELELYSO ......................................................... 86
ELESTRIN ........................................................ 83
eletriptan hydrobromide .................................... 63
ELFABRIO ........................................................ 86
ELIDEL ........................................................... 129
ELIGARD .......................................................... 22
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 144
elinest ................................................................. 78
ELIQUIS ............................................................ 99
ELIQUIS STARTER PACK .............................. 99
ELITEK .............................................................. 32
ELITE-OB ........................................................ 110
ELIXOPHYLLIN ............................................... 120
ELLA .................................................................. 79
ELLENCE .......................................................... 21
ELMIRON .......................................................... 97
eluryng ................................................................ 79
ELYXYB ............................................................ 63
EMCYT .............................................................. 22
EMEND .............................................................. 91
EMEND TRIPACK............................................ 91
EMFLAZA ......................................................... 84
EMGALITY ....................................................... 63
EMPAVELI ...................................................... 101
EMPLICITI ........................................................ 26
EMSAM ............................................................. 46
emtricitabine................................................. 13, 14
emtricitabine/tenofovir disoproxil ...................... 14
emtricitabine/tenofovir disoproxil fumarate ...... 14
EMTRIVA .......................................................... 13
EMVERM ............................................................ 9
enalapril maleate................................................ 32
enalapril maleate/hydrochlorothiazide .............. 32
enalaprilat i.v. .................................................... 32
ENBRACE HR ................................................. 110
ENBREL .......................................................... 103
ENBREL MINI ................................................ 103
ENBREL SURECLICK ................................... 103
ENDARI ........................................................... 101
endocet ................................................................. 5
ENGERIX-B .................................................... 108
ENHERTU ......................................................... 26
ENJAYMO ....................................................... 101
enoxaparin sodium ............................................. 99
enpresse-28 ......................................................... 79
enskyce ............................................................... 79
ENSPRYNG ....................................................... 64
ENSTILAR....................................................... 127
entacapone ......................................................... 49
ENTADFI ........................................................... 97
entecavir ............................................................. 15
ENTRESTO ....................................................... 33
ENTYVIO ........................................................ 103
enulose ................................................................ 93
ENVARSUS XR .............................................. 107
EPANED ............................................................ 32
EPCLUSA ......................................................... 15
EPIDIOLEX ...................................................... 55
EPIDUO........................................................... 123
EPIDUO FORTE ............................................. 123
EPIFOAM ........................................................ 127
epinastine hcl ................................................... 115
epinephrine ................................................ 41, 120
EPIPEN ............................................................ 120
EPIPEN-JR ...................................................... 120
epitol .................................................................. 55
EPIVIR ........................................................ 13, 15
EPIVIR HBV ..................................................... 15
EPKINLY .......................................................... 26
eplerenone ......................................................... 33
EPOGEN ......................................................... 100
epoprostenol sodium .......................................... 42
EPRONTIA ....................................................... 55
EPSOLAY ....................................................... 123
EPZICOM .......................................................... 14
EQUETRO......................................................... 64
ERAXIS ............................................................. 11
ERBITUX .......................................................... 26
ergoloid mesylates ............................................. 45
ERGOMAR ....................................................... 63
ergotamine tartrate/caffeine .............................. 63
ERIVEDGE ....................................................... 26
ERLEADA......................................................... 22
erlotinib hydrochloride ...................................... 26
ERMEZA ........................................................... 89
errin ................................................................... 79
ERTACZO ....................................................... 125
ertapenem ............................................................ 9
ery .................................................................... 123
ERYGEL ......................................................... 123
ERYPED 200 ..................................................... 18
ERYPED 400 ..................................................... 18
ery-tab ................................................................ 18
ERYTHROCIN LACTOBIONATE.................. 18
erythrocin stearate ............................................. 18
erythromycin ...................................... 18, 114, 123
erythromycin base.............................................. 18
erythromycin dr ................................................. 18
erythromycin ethylsuccinate .............................. 18
erythromycin lactobionate ................................. 18
erythromycin stearate ........................................ 18
erythromycin/benzoyl peroxide ........................ 123
ESBRIET ......................................................... 120
escitalopram oxalate.......................................... 46
esgic ..................................................................... 1
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 145
ESGIC .................................................................. 1
esomeprazole magnesium ................................... 96
esomeprazole sodium ......................................... 96
estarylla .............................................................. 79
estazolam ............................................................ 62
ESTRACE .......................................................... 83
estradiol .............................................................. 83
estradiol/norethindrone acetate ......................... 83
ESTRING ........................................................... 83
ESTROGEL ....................................................... 83
eszopiclone ......................................................... 62
ethacrynate sodium ............................................ 39
ethacrynic acid ................................................... 39
ethambutol hydrochloride .................................. 15
ethosuximide ....................................................... 55
ethynodiol diacetate/ethinyl estradiol ................ 79
etodolac ................................................................ 2
etodolac er ............................................................ 2
ETONOGESTREL/ETHINYL ESTRADIOL ... 79
ETOPOPHOS ..................................................... 24
etoposide ............................................................. 24
etravirine ............................................................ 13
EUCRISA ......................................................... 129
EULEXIN ........................................................... 22
euthyrox .............................................................. 89
EVAMIST .......................................................... 83
EVEKEO ............................................................ 60
EVEKEO ODT ................................................... 60
EVENITY ........................................................... 76
everolimus .................................................. 26, 107
EVISTA .............................................................. 86
EVKEEZA ......................................................... 36
EVOCLIN ........................................................ 123
EVOMELA ........................................................ 20
EVOTAZ ............................................................ 14
EVOXAC ......................................................... 131
EVRYSDI........................................................... 64
EXELDERM .................................................... 125
EXELON ............................................................ 45
exemestane ......................................................... 22
EXFORGE ......................................................... 33
EXFORGE HCT ................................................ 33
EXJADE ............................................................. 77
EXKIVITY ......................................................... 26
EXONDYS 51 .................................................... 64
EXPAREL ............................................................ 7
EXSERVAN ....................................................... 64
EXTAVIA .......................................................... 66
EXTINA ........................................................... 125
EYLEA ............................................................ 117
EYSUVIS ........................................................ 115
EZALLOR SPRINKLE ..................................... 36
ezetimibe ............................................................ 36
EZETIMIBE/ROSUVASTATIN ...................... 36
ezetimibe/simvastatin ......................................... 36
FABIOR........................................................... 123
FABRAZYME................................................... 86
falmina ............................................................... 79
famciclovir ......................................................... 15
famotidine .......................................................... 93
famotidine premixed .......................................... 93
FANAPT ............................................................ 51
FANAPT TITRATION PACK .......................... 51
FARESTON....................................................... 22
FARXIGA ......................................................... 73
FASENRA ....................................................... 120
FASENRA PEN .............................................. 120
FASLODEX ...................................................... 22
fayosim ............................................................... 79
febuxostat ............................................................. 1
felbamate ........................................................... 55
FELBATOL ....................................................... 55
FELDENE ........................................................... 2
felodipine er ....................................................... 38
FEMARA........................................................... 22
FEMRING ......................................................... 83
femynor .............................................................. 79
fenofibrate .......................................................... 35
FENOFIBRATE ................................................ 35
fenofibric acid dr ............................................... 35
FENOGLIDE ..................................................... 35
fenoprofen calcium .............................................. 2
FENOPROFEN CALCIUM ................................ 2
FENSOLVI ........................................................ 86
fentanyl ................................................................ 3
fentanyl citrate ..................................................... 5
FENTANYL CITRATE ...................................... 5
FENTORA ........................................................... 5
FERRIPROX ..................................................... 77
FERRIPROX TWICE-A-DAY ......................... 77
fesoterodine fumarate er .................................... 98
FETROJA .......................................................... 17
FETZIMA .......................................................... 47
FETZIMA TITRATION PACK ........................ 46
fexmid................................................................. 68
FIASP ................................................................ 71
FIASP FLEXTOUCH........................................ 71
FIASP PENFILL ............................................... 71
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 146
FILSPARI........................................................... 97
FINACEA......................................................... 129
finasteride ........................................................... 97
fingolimod........................................................... 66
FINTEPLA ......................................................... 55
finzala ................................................................. 79
FIORICET ............................................................ 1
FIORICET/CODEINE ......................................... 5
FIRAZYR ......................................................... 101
FIRDAPSE ......................................................... 64
FIRMAGON ....................................................... 23
FIRVANQ ............................................................ 9
flac .................................................................... 118
FLAGYL .............................................................. 9
FLAREX .......................................................... 115
flavoxate hcl ....................................................... 97
FLEBOGAMMA DIF ...................................... 105
flecainide acetate ................................................ 34
FLECTOR ........................................................ 129
FLEQSUVY ....................................................... 68
FLOLAN ............................................................ 42
FLOLIPID .......................................................... 36
FLOMAX ........................................................... 97
FLORIVA......................................................... 110
FLOVENT DISKUS ........................................ 122
FLOVENT HFA ............................................... 122
fluconazole ......................................................... 11
fluconazole in sodium chloride .......................... 11
fluconazole/sodium chloride .............................. 12
flucytosine ........................................................... 12
fludarabine phosphate ........................................ 22
fludrocortisone acetate ....................................... 84
flumazenil ........................................................... 64
flunisolide ......................................................... 121
fluocinolone acetonide ............................. 118, 127
fluocinolone acetonide body ............................. 127
fluocinolone acetonide scalp ............................ 127
fluocinonide ...................................................... 127
fluocinonide emulsified .................................... 127
fluoride ............................................................. 110
fluoridex ........................................................... 131
fluoridex sensitivity relief/sls free .................... 131
fluorimax 5000 ................................................. 131
fluorimax 5000 sensitive................................... 131
fluoritab ............................................................ 110
FLUOROMETHOLONE ................................. 115
fluorouracil................................................. 22, 129
FLUOROURACIL ........................................... 129
fluoxetine dr ........................................................ 47
fluoxetine hcl...................................................... 47
fluoxetine hydrochloride .................................... 47
fluphenazine decanoate ..................................... 51
fluphenazine hcl ................................................. 51
fluphenazine hydrochloride ............................... 51
flurandrenolide ................................................ 127
flurazepam hcl ................................................... 62
flurbiprofen .......................................................... 2
flurbiprofen sodium ......................................... 115
FLUTICASONE FUROATE/VILANTEROL
ELLIPTA ...................................................... 122
fluticasone propionate ............................. 121, 127
FLUTICASONE PROPIONATE HFA ........... 122
fluticasone propionate/salmeterol ................... 122
FLUTICASONE
PROPIONATE/SALMETEROL ................. 122
fluticasone propionate/salmeterol hfa ............. 122
fluvastatin .......................................................... 36
fluvastatin sodium er ......................................... 36
fluvoxamine maleate .......................................... 44
fluvoxamine maleate er ...................................... 44
FML FORTE ................................................... 115
FML LIQUIFILM............................................ 115
FOCALIN .......................................................... 60
FOCALIN XR ................................................... 60
FOLIVANE-OB .............................................. 110
FOLOTYN......................................................... 22
fomepizole .......................................................... 86
fondaparinux sodium ......................................... 99
FORFIVO XL .................................................... 47
formoterol fumarate ......................................... 119
FORTEO ............................................................ 76
FORTESTA ....................................................... 70
FOSAMAX ........................................................ 76
FOSAMAX PLUS D ......................................... 76
fosamprenavir calcium ...................................... 13
fosaprepitant dimeglumine ................................ 91
foscarnet sodium ................................................ 15
fosfomycin tromethamine ..................................... 9
fosinopril sodium ............................................... 32
fosinopril sodium/hydrochlorothiazide ............. 32
fosphenytoin sodium .......................................... 55
FOSRENOL....................................................... 89
FOTIVDA .......................................................... 26
FRAGMIN ......................................................... 99
FROVA .............................................................. 63
frovatriptan succinate ........................................ 63
FULPHILA ...................................................... 100
fulvestrant .......................................................... 23
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 147
FUROSCIX ........................................................ 39
furosemide .................................................... 39, 40
FUZEON ............................................................ 13
FYARRO ............................................................ 26
fyavolv ................................................................ 83
FYCOMPA......................................................... 55
FYLNETRA ..................................................... 100
gabapentin .................................................... 55, 56
GABITRIL ......................................................... 56
GABLOFEN ....................................................... 68
GALAFOLD ...................................................... 86
galantamine hydrobromide ................................ 45
galantamine hydrobromide er ............................ 45
GAMASTAN ................................................... 105
GAMMAGARD LIQUID ................................ 105
GAMMAGARD S/D ........................................ 105
GAMMAKED .................................................. 105
GAMMAPLEX ................................................ 105
GAMUNEX-C ................................................. 105
ganciclovir .......................................................... 15
GARDASIL 9 ................................................... 108
GASTROCROM ................................................ 94
gatifloxacin ....................................................... 114
GATTEX ............................................................ 94
GAUZE PADS ................................................... 71
gavilyte-c ............................................................ 93
gavilyte-g ............................................................ 94
GAVRETO ......................................................... 26
GAZYVA ........................................................... 26
gefitinib............................................................... 26
GELNIQUE ........................................................ 98
gemcitabine hcl .................................................. 22
gemcitabine hydrochloride ................................. 22
GEMCITABINE HYDROCHLORIDE ............. 22
gemfibrozil .......................................................... 35
gemmily .............................................................. 79
GEMTESA ......................................................... 98
GENERESS FE .................................................. 79
generlac .............................................................. 94
gengraf ............................................................. 107
GENOTROPIN .................................................. 86
GENOTROPIN MINIQUICK ............................ 86
gentak ............................................................... 114
gentamicin sulfate ................................ 9, 114, 124
gentamicin sulfate pediatric ................................. 9
gentamicin sulfate/sodium chloride ..................... 9
GENVOYA ........................................................ 14
GEODON ........................................................... 51
GILENYA .......................................................... 66
GILOTRIF ......................................................... 26
GIMOTI ............................................................. 91
GIVLAARI ...................................................... 101
GLASSIA ........................................................ 120
glatiramer acetate.............................................. 66
glatopa ............................................................... 66
GLEEVEC ......................................................... 26
GLEOSTINE ............................................... 20, 21
glimepiride ......................................................... 73
glipizide ............................................................. 74
glipizide er ......................................................... 74
glipizide xl.......................................................... 74
glipizide/metformin hydrochloride .................... 74
GLUCAGEN HYPOKIT ................................... 85
GLUCAGON EMERGENCY KIT FOR LOW
BLOOD SUGAR............................................ 85
GLUCOTROL XL ............................................. 74
GLUMETZA ..................................................... 74
glyburide ............................................................ 74
glyburide micronized ......................................... 74
glyburide/metformin hydrochloride ................... 74
GLYCATE......................................................... 92
glycopyrrolate .................................................... 92
GLYCOPYRROLATE ...................................... 92
glydo ................................................................ 128
GLYNASE......................................................... 74
GLYXAMBI ...................................................... 74
GOCOVRI ......................................................... 49
GOLYTELY ...................................................... 94
GONITRO ......................................................... 41
GOPRELTO .................................................... 120
GRALISE .......................................................... 64
granisetron hcl ................................................... 91
granisetron hydrochloride ................................. 91
GRANIX .......................................................... 100
GRASTEK ....................................................... 106
griseofulvin microsize ........................................ 12
griseofulvin ultramicrosize ................................ 12
guanfacine er ..................................................... 60
guanfacine hydrochloride .................................. 41
guanfacine hydrochloride er ............................. 60
GVOKE HYPOPEN .......................................... 85
GVOKE KIT...................................................... 85
GVOKE PFS...................................................... 85
GYNAZOLE-1 .................................................. 98
HAEGARDA ................................................... 101
hailey 1.5/30 ...................................................... 79
hailey 24 fe......................................................... 79
hailey fe 1.5/30 .................................................. 79
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 148
hailey fe 1/20 ...................................................... 79
HALAVEN ......................................................... 24
halcinonide ....................................................... 127
HALCION .......................................................... 62
HALDOL DECANOATE 100 ........................... 51
HALDOL DECANOATE 50 ............................. 51
halobetasol propionate ..................................... 127
HALOBETASOL PROPIONATE ................... 127
haloette ............................................................... 79
HALOG ............................................................ 127
haloperidol ......................................................... 51
haloperidol decanoate ........................................ 51
haloperidol lactate ............................................. 51
HARVONI ......................................................... 15
HAVRIX .......................................................... 108
heather ................................................................ 79
HECTOROL ....................................................... 90
HELIDAC THERAPY ....................................... 94
HEMADY .......................................................... 84
HEMANGEOL................................................... 37
HEPAGAM B .................................................. 105
heparin sodium ................................................... 99
HEPARIN SODIUM .......................................... 99
HEPARIN SODIUM/D5W ................................ 99
HEPARIN SODIUM/DEXTROSE .................... 99
HEPARIN SODIUM/SODIUM CHLORIDE .... 99
HEPATAMINE ................................................ 113
HEPLISAV-B................................................... 108
HERCEPTIN ...................................................... 26
HERCEPTIN HYLECTA .................................. 26
HERZUMA ........................................................ 26
HETLIOZ ........................................................... 62
HETLIOZ LQ ..................................................... 62
HEXATRIONE .................................................. 84
HIBERIX .......................................................... 108
hidex 6-day ......................................................... 84
HIPREX ............................................................... 9
HIZENTRA ...................................................... 105
HORIZANT ....................................................... 65
HUMALOG ....................................................... 71
HUMALOG JUNIOR KWIKPEN ..................... 71
HUMALOG KWIKPEN .................................... 71
HUMALOG MIX 50/50 ..................................... 71
HUMALOG MIX 75/25 ..................................... 71
HUMALOG TEMPO PEN ................................ 71
HUMATIN ........................................................... 9
HUMATROPE ................................................... 86
HUMIRA .......................................................... 103
HUMIRA PEDIATRIC CROHNS DISEASE
STARTER PACK ........................................ 103
HUMIRA PEN ................................................ 103
HUMIRA PEN-PEDIATRIC UC STARTER
PACK ........................................................... 103
HUMULIN 70/30 .............................................. 71
HUMULIN 70/30 KWIKPEN ........................... 71
HUMULIN N .................................................... 71
HUMULIN N KWIKPEN ................................. 71
HUMULIN R ..................................................... 71
HUMULIN R U-500 (CONCENTRATED) ...... 71
HUMULIN R U-500 KWIKPEN ...................... 71
HYCAMTIN ...................................................... 24
hydralazine hcl .................................................. 41
hydralazine hydrochloride ................................. 41
HYDREA........................................................... 24
hydrochlorothiazide ........................................... 40
hydrocodone bitartrate er .................................... 3
hydrocodone bitartrate/acetaminophen .............. 5
hydrocodone/ibuprofen ........................................ 5
hydrocortisone ..................................... 84, 93, 127
hydrocortisone acetate/pramoxine .................. 129
hydrocortisone butyrate ................................... 127
hydrocortisone butyrate (lipophilic) ................ 127
hydrocortisone perianal .................................. 129
hydrocortisone valerate ................................... 127
hydrocortisone/acetic acid .............................. 118
hydromorphone hcl .............................................. 5
HYDROMORPHONE HCL................................ 5
hydromorphone hcl er ......................................... 3
hydromorphone hydrochloride ............................ 6
HYDROMORPHONE HYDROCHLORIDE . 5, 6
hydromorphone hydrochloride er ........................ 4
hydroxychloroquine sulfate ............................. 104
HYDROXYCHLOROQUINE SULFATE ...... 104
hydroxyprogesterone caproate .................... 23, 89
hydroxyurea ....................................................... 24
hydroxyzine hcl ................................................ 119
hydroxyzine hydrochloride .............................. 119
hydroxyzine pamoate ....................................... 119
HYFTOR ......................................................... 129
hyoscyamine sulfate ........................................... 92
HYPERHEP B ................................................. 105
hyperlyte-cr ...................................................... 109
HYPERRAB .................................................... 105
HYPERRHO S/D ............................................ 105
HYPERRHO S/D MINI-DOSE....................... 105
HYPERTET ..................................................... 105
HYQVIA ......................................................... 105
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 149
HYSINGLA ER ................................................... 4
HYZAAR ........................................................... 33
ibandronate sodium ............................................ 76
IBRANCE .......................................................... 27
IBSRELA ........................................................... 94
ibu ......................................................................... 2
ibuprofen .............................................................. 2
ibuprofen/famotidine ............................................ 2
icatibant acetate ............................................... 101
iclevia ................................................................. 79
ICLUSIG ............................................................ 27
icosapent ethyl .................................................... 36
IDAMYCIN PFS ................................................ 21
idarubicin hcl ..................................................... 21
IDHIFA .............................................................. 27
IFEX ................................................................... 21
ifosfamide ........................................................... 21
IFOSFAMIDE .................................................... 21
ILARIS ............................................................. 106
ILEVRO ........................................................... 115
ILUMYA .......................................................... 103
imatinib mesylate ................................................ 27
IMBRUVICA ..................................................... 27
IMFINZI ............................................................. 27
imipenem/cilastatin .............................................. 9
imipramine hcl .................................................... 47
imipramine hydrochloride .................................. 47
imipramine pamoate ........................................... 47
imiquimod ......................................................... 129
IMIQUIMOD PUMP ....................................... 129
IMITREX ........................................................... 63
IMITREX STATDOSE REFILL ....................... 63
IMITREX STATDOSE SYSTEM ..................... 63
IMJUDO ............................................................. 27
IMLYGIC ........................................................... 24
IMOGAM RABIES-HT ................................... 105
IMOVAX RABIES (H.D.C.V.) ....................... 108
IMPAVIDO .......................................................... 9
IMPEKLO ........................................................ 127
IMURAN .......................................................... 107
IMVEXXY MAINTENANCE PACK ............... 83
IMVEXXY STARTER PACK ........................... 83
INBRIJA............................................................. 50
incassia ............................................................... 79
INCRELEX ........................................................ 86
INCRUSE ELLIPTA........................................ 118
indapamide ......................................................... 40
INDERAL LA .................................................... 37
INDERAL XL .................................................... 37
indocin ................................................................. 2
INDOCIN ............................................................ 2
indomethacin ....................................................... 2
indomethacin er ................................................... 2
INFANRIX ...................................................... 108
INFLECTRA ................................................... 103
INFLIXIMAB .................................................. 103
INFUGEM ......................................................... 22
INFUMORPH 200 ............................................... 6
INFUMORPH 500 ............................................... 6
INGREZZA ....................................................... 65
INLYTA ............................................................ 27
INNOPRAN XL ................................................ 37
INPEFA ............................................................. 41
INQOVI ............................................................. 22
INREBIC ........................................................... 27
INSPRA ............................................................. 33
INSULIN ASPART ..................................... 71, 72
INSULIN ASPART FLEXPEN ........................ 71
INSULIN ASPART PENFILL .......................... 72
INSULIN ASPART PROTAMINE/INSULIN
ASPART ........................................................ 72
INSULIN ASPART PROTAMINE/INSULIN
ASPART FLEXPEN ...................................... 72
INSULIN DEGLUDEC ..................................... 72
INSULIN DEGLUDEC FLEXTOUCH ............ 72
INSULIN GLARGINE ...................................... 72
INSULIN GLARGINE SOLOSTAR ................ 72
INSULIN LISPRO ............................................ 72
INSULIN LISPRO JUNIOR KWIKPEN .......... 72
INSULIN LISPRO KWIKPEN ......................... 72
INSULIN LISPRO PROTAMINE/INSULIN
LISPRO KWIKPEN ....................................... 72
INTELENCE ..................................................... 13
INTRALIPID ................................................... 113
INTRAROSA .................................................... 97
introvale ............................................................. 79
INTUNIV........................................................... 60
INVANZ .............................................................. 9
INVEGA ............................................................ 52
INVEGA HAFYERA .................................. 51, 52
INVEGA SUSTENNA ...................................... 52
INVEGA TRINZA ............................................ 52
INVELTYS ...................................................... 115
INVOKAMET ................................................... 74
INVOKAMET XR ............................................ 74
INVOKANA ...................................................... 74
IOPIDINE ........................................................ 116
IPOL INACTIVATED IPV ............................. 108
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 150
ipratropium bromide ........................................ 118
ipratropium bromide/albuterol sulfaten ........... 118
irbesartan ..................................................... 33, 34
irbesartan/hydrochlorothiazide .......................... 33
IRESSA .............................................................. 27
irinotecan ........................................................... 24
irinotecan hydrochloride .................................... 24
ISENTRESS ....................................................... 13
ISENTRESS HD ................................................ 13
isibloom .............................................................. 79
ISOLYTE-P/DEXTROSE 5% ......................... 109
ISOLYTE-S ...................................................... 109
ISOLYTE-S PH 7.4.......................................... 109
isoniazid ............................................................. 15
ISOPTO ATROPINE ....................................... 117
ISORDIL TITRADOSE ..................................... 41
isosorbide dinitrate ............................................ 41
isosorbide dinitrate/hydralazine hydrochloride . 41
isosorbide mononitrate ....................................... 41
isosorbide mononitrate er .................................. 41
isotonic gentamicin .............................................. 9
isotretinoin ....................................................... 123
isradipine ............................................................ 38
ISTALOL ......................................................... 116
ISTODAX .......................................................... 27
ISTURISA .......................................................... 86
itraconazole ........................................................ 12
ivermectin ..................................................... 9, 129
IXEMPRA KIT .................................................. 24
IXIARO ............................................................ 108
JADENU ............................................................ 77
jaimiess ............................................................... 79
JAKAFI .............................................................. 27
jantoven .............................................................. 99
JANUMET ......................................................... 74
JANUMET XR ................................................... 74
JANUVIA........................................................... 74
JARDIANCE ...................................................... 74
jasmiel ................................................................ 79
JATENZO .......................................................... 70
javygtor ............................................................... 86
JAYPIRCA ......................................................... 27
JEMPERLI ......................................................... 27
jencycla ............................................................... 79
JENTADUETO .................................................. 74
JENTADUETO XR ............................................ 74
JEVTANA .......................................................... 24
jinteli................................................................... 83
JOENJA ............................................................ 106
JOLESSA........................................................... 79
JORNAY PM ..................................................... 60
joyeaux ............................................................... 79
JUBLIA ........................................................... 125
juleber ................................................................ 79
JULUCA ............................................................ 14
junel 1.5/30 ........................................................ 79
junel 1/20 ........................................................... 79
junel fe 1.5/30 .................................................... 79
junel fe 1/20 ....................................................... 79
junel fe 24 .......................................................... 79
just right 5000 .................................................. 131
JUXTAPID ........................................................ 36
JYNARQUE ...................................................... 86
JYNNEOS ....................................................... 108
KABIVEN ....................................................... 113
KADCYLA ........................................................ 27
kaitlib fe ............................................................. 79
KALBITOR ..................................................... 101
KALETRA......................................................... 14
kalliga ................................................................ 79
KALYDECO ................................................... 120
KANJINTI ......................................................... 27
KANUMA ......................................................... 86
KAPSPARGO SPRINKLE ............................... 37
KAPVAY........................................................... 60
kariva ................................................................. 79
KATERZIA ....................................................... 38
KAZANO .......................................................... 74
KCL 0.075%/D5W/NACL 0.45% ................... 109
KCL 0.15%/D5W/NACL 0.2% ....................... 109
KCL 0.15%/D5W/NACL 0.45% ..................... 109
KCL 0.15%/D5W/NACL 0.9% ....................... 109
KCL 0.3%/D5W/NACL 0.45% ....................... 109
KCL 0.3%/D5W/NACL 0.9% ......................... 109
KEDRAB ......................................................... 105
kelnor 1/35 ......................................................... 79
kelnor 1/50 ......................................................... 79
KENALOG ................................................ 84, 127
KENALOG-10................................................... 84
KENALOG-40................................................... 84
KENALOG-80................................................... 84
KEPIVANCE..................................................... 32
KEPPRA ............................................................ 56
KEPPRA XR ..................................................... 56
KERENDIA ....................................................... 33
KERYDIN ....................................................... 125
KESIMPTA ....................................................... 66
ketoconazole ...................................... 12, 125, 126
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 151
ketodan ............................................................. 125
ketoprofen ............................................................. 2
ketoprofen er ........................................................ 2
ketorolac tromethamine................................ 2, 115
KEVEYIS ........................................................... 40
KEVZARA ....................................................... 103
KEYTRUDA ...................................................... 27
KHAPZORY ...................................................... 32
KIMMTRAK ...................................................... 27
KIMYRSA ........................................................... 9
KINERET ......................................................... 103
KINRIX ............................................................ 108
KISQALI ............................................................ 27
KISQALI FEMARA 200 DOSE ........................ 24
KISQALI FEMARA 400 DOSE ........................ 24
KISQALI FEMARA 600 DOSE ........................ 24
KITABIS PAK ..................................................... 9
KLARON ......................................................... 123
KLISYRI .......................................................... 130
KLONOPIN ....................................................... 56
klor-con .................................................... 110, 111
klor-con 10 ....................................................... 110
klor-con 8 ......................................................... 110
klor-con m10 .................................................... 110
klor-con m15 .................................................... 111
klor-con m20 .................................................... 111
KLOXXADO ..................................................... 69
KOMBIGLYZE XR ........................................... 75
KONVOMEP ..................................................... 96
KORLYM........................................................... 86
KOSELUGO ...................................................... 27
KRAZATI .......................................................... 27
KRINTAFEL ...................................................... 12
KRISTALOSE ................................................... 94
KRYSTEXXA ...................................................... 1
K-TAB .............................................................. 110
kurvelo ................................................................ 79
KUVAN ............................................................. 86
KYLEENA ......................................................... 79
KYPROLIS ........................................................ 27
labetalol hydrochloride ...................................... 37
LABETALOL HYDROCHLORIDE ................. 37
LABETALOL
HYDROCHLORIDE/DEXTROSE ................ 37
LABETALOL HYDROCHLORIDE/SODIUM
CHLORIDE .................................................... 37
lacosamide .......................................................... 56
LACRISERT .................................................... 117
lactated ringers ........................................ 109, 131
LACTATED RINGERS IRRIGATION .......... 131
lactulose ............................................................. 94
LACTULOSE .................................................... 94
LAMICTAL....................................................... 56
LAMICTAL ODT ............................................. 56
LAMICTAL STARTER/NOT TAKING
CARBAMAZEPINE ...................................... 56
LAMICTAL STARTER/TAKING
CARBAMAZEPINE/NOT TAKING
VALPROATE ................................................ 56
LAMICTAL STARTER/TAKING VALPROATE
........................................................................ 56
LAMICTAL XR ................................................ 56
lamivudine ................................................... 13, 16
lamivudine/zidovudine ....................................... 14
lamotrigine......................................................... 56
lamotrigine er .................................................... 56
lamotrigine odt .................................................. 56
lamotrigine odt titration .................................... 56
lamotrigine odt titration kit ............................... 56
lamotrigine starter kit/blue ................................ 56
lamotrigine starter kit/green .............................. 56
lamotrigine starter kit/orange ........................... 56
LAMPIT .............................................................. 9
LAMZEDE ........................................................ 86
LANOXIN ......................................................... 41
LANOXIN PEDIATRIC ................................... 41
LANREOTIDE ACETATE ............................... 86
lansoprazole ...................................................... 96
lansoprazole/amoxicillin/clarithromycin........... 94
lanthanum carbonate ......................................... 89
LANTUS ........................................................... 72
LANTUS SOLOSTAR ...................................... 72
lapatinib ditosylate ............................................ 27
larin 1.5/30 ........................................................ 79
larin 1/20 ........................................................... 79
larin 24 fe........................................................... 80
larin fe 1.5/30 .................................................... 80
larin fe 1/20 ....................................................... 80
LASIX ............................................................... 40
latanoprost ....................................................... 116
LATUDA ........................................................... 52
LAYOLIS FE .................................................... 80
LEDIPASVIR/SOFOSBUVIR .......................... 16
LEENA .............................................................. 80
leflunomide ...................................................... 104
LEMTRADA ..................................................... 66
lenalidomide ...................................................... 23
LENVIMA ......................................................... 28
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 152
LENVIMA 10 MG DAILY DOSE .................... 27
LENVIMA 14 MG DAILY DOSE .................... 28
LENVIMA 18 MG DAILY DOSE .................... 28
LENVIMA 20 MG DAILY DOSE .................... 28
LENVIMA 24 MG DAILY DOSE .................... 28
LENVIMA 8 MG DAILY DOSE ...................... 28
LEQVIO ............................................................. 36
LESCOL XL ...................................................... 36
lessina ................................................................. 80
LETAIRIS .......................................................... 42
letrozole .............................................................. 23
leucovorin calcium ............................................. 32
LEUKERAN ...................................................... 21
LEUKINE ......................................................... 100
leuprolide acetate ............................................... 23
LEUPROLIDE ACETATE ................................ 23
levalbuterol ....................................................... 119
levalbuterol hcl ................................................. 119
LEVALBUTEROL TARTRATE HFA ........... 119
LEVAMLODIPINE ........................................... 38
LEVEMIR .......................................................... 72
LEVEMIR FLEXPEN........................................ 72
LEVEMIR FLEXTOUCH ................................. 72
levetiracetam ...................................................... 56
levetiracetam er .................................................. 56
levetiracetam/sodium chloride ........................... 56
levobunolol hcl ................................................. 116
levocarnitine ....................................................... 86
LEVOCARNITINE ............................................ 86
levocetirizine dihydrochloride .......................... 119
levofloxacin ................................................ 18, 114
levofloxacin in d5w ............................................. 18
levoleucovorin calcium ...................................... 32
levonest ............................................................... 80
levonorgestrel/ethinyl estradiol .......................... 80
levora .................................................................. 80
levorphanol tartrate ............................................. 4
levo-t ................................................................... 89
levothyroxine sodium.......................................... 89
LEVOTHYROXINE SODIUM ......................... 89
levoxyl ................................................................. 89
LEVSIN .............................................................. 92
LEVSIN/SL ........................................................ 92
LEVULAN KERASTICK ................................ 130
LEXAPRO ......................................................... 47
LEXETTE ........................................................ 127
LEXIVA ............................................................. 13
LIALDA ............................................................. 93
LIBRAX ............................................................. 92
LIBTAYO .......................................................... 28
LICART ........................................................... 130
lidocaine .......................................................... 128
lidocaine hcl .................................. 7, 35, 128, 131
LIDOCAINE HCL ............................................ 35
LIDOCAINE HCL IN D5W .............................. 35
lidocaine hydrochloride viscous ...................... 131
lidocaine/epinephrine .......................................... 7
lidocaine/prilocaine ......................................... 128
LIDODERM .................................................... 128
LIDOREX ........................................................ 128
LILETTA ........................................................... 80
LINCOCIN .......................................................... 9
lincomycin hcl ...................................................... 9
lindane ............................................................. 131
linezolid ............................................................... 9
LINEZOLID ........................................................ 9
LINZESS ........................................................... 94
liothyronine sodium ........................................... 89
LIPITOR ............................................................ 36
LIPOFEN ........................................................... 35
LIQREV............................................................. 42
lisdexamfetamine dimesylate ............................. 60
lisinopril............................................................. 32
lisinopril/hydrochlorothiazide ........................... 32
LITFULO......................................................... 103
lithium carbonate ............................................... 65
lithium carbonate er .......................................... 65
LITHOBID ........................................................ 65
LITHOSTAT ..................................................... 97
LIVALO ............................................................ 36
LIVMARLI ........................................................ 94
LIVTENCITY ................................................... 16
LO LOESTRIN FE ............................................ 80
LOCOID .......................................................... 128
LOCOID LIPOCREAM .................................. 128
LODINE .............................................................. 2
LODOSYN ........................................................ 50
loestrin 1.5/30-21 .............................................. 80
loestrin 1/20-21 ................................................. 80
loestrin fe 1.5/30 ................................................ 80
loestrin fe 1/20 ................................................... 80
lofena ................................................................... 2
lojaimiess ........................................................... 80
LOKELMA ........................................................ 77
LOMOTIL ......................................................... 95
LONSURF ......................................................... 22
loperamide hcl ................................................... 95
LOPID ............................................................... 35
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 153
lopinavir/ritonavir .............................................. 14
LOPRESSOR ..................................................... 37
LOPROX .......................................................... 125
lorazepam ........................................................... 44
lorazepam intensol ............................................. 44
LORBRENA ...................................................... 28
LOREEV XR ...................................................... 44
LORTAB .............................................................. 6
loryna ................................................................. 80
lorzone ................................................................ 68
LORZONE ......................................................... 68
losartan potassium ............................................. 34
losartan potassium/hydrochlorothiazide ............ 34
LOSEASONIQUE ............................................. 80
LOTEMAX ...................................................... 115
LOTEMAX SM................................................ 115
LOTENSIN ........................................................ 32
LOTENSIN HCT ............................................... 32
loteprednol etabonate ....................................... 115
LOTREL ............................................................. 32
LOTRONEX ...................................................... 95
lovastatin ............................................................ 36
LOVAZA ........................................................... 36
LOVENOX ......................................................... 99
low-ogestrel ........................................................ 80
loxapine .............................................................. 52
lo-zumandimine .................................................. 80
LUBIPROSTONE .............................................. 95
LUCEMYRA ..................................................... 69
LUCENTIS....................................................... 117
LULICONAZOLE ........................................... 125
LUMAKRAS ..................................................... 28
LUMIGAN ....................................................... 116
LUMIZYME ...................................................... 86
LUMRYZ ........................................................... 69
LUNESTA .......................................................... 62
LUNSUMIO ....................................................... 28
LUPKYNIS ...................................................... 107
LUPRON DEPOT (1-MONTH) ........................ 23
LUPRON DEPOT (3-MONTH) ........................ 23
LUPRON DEPOT (4-MONTH) ........................ 23
LUPRON DEPOT (6-MONTH) ........................ 23
LUPRON DEPOT-PED ..................................... 86
lurasidone hydrochloride ................................... 52
lutera .................................................................. 80
LUZU ............................................................... 125
LYBALVI .......................................................... 52
lyleq .................................................................... 80
lyllana ................................................................. 83
LYNPARZA ...................................................... 28
LYRICA ............................................................ 56
LYRICA CR ...................................................... 65
LYSODREN ...................................................... 23
LYTGOBI .......................................................... 28
LYUMJEV......................................................... 72
LYUMJEV KWIKPEN ..................................... 72
LYUMJEV TEMPO PEN ................................. 72
LYVISPAH ....................................................... 68
lyza ..................................................................... 80
MACROBID ........................................................ 9
MACRODANTIN ............................................... 9
mafenide acetate .............................................. 124
magnesium sulfate ........................................... 109
MAGNESIUM SULFATE .............................. 109
magnesium sulfate in d5w................................ 109
MAKENA .......................................................... 89
MALARONE..................................................... 12
malathion ......................................................... 131
mannitol ............................................................. 40
MANNITOL ...................................................... 40
maraviroc........................................................... 13
MARCAINE ........................................................ 7
MARCAINE/EPINEPHRINE ............................. 7
MARGENZA..................................................... 28
MARINOL......................................................... 91
marlissa ............................................................. 80
MARPLAN ........................................................ 47
MATULANE ..................................................... 24
matzim la............................................................ 38
MAVENCLAD ............................................ 66, 67
MAVYRET ....................................................... 16
MAXALT .......................................................... 63
MAXALT-MLT ................................................ 63
MAXIDEX ...................................................... 115
MAXITROL .................................................... 113
MAYZENT ........................................................ 67
me/naphos/mb/hyo 1 ............................................ 9
meclizine hcl ...................................................... 91
meclizine hydrochloride .................................... 91
meclofenamate sodium ........................................ 2
MEDROL .......................................................... 84
MEDROL DOSEPAK ....................................... 84
medroxyprogesterone acetate ...................... 80, 89
mefenamic acid .................................................... 2
mefloquine hcl.................................................... 12
megestrol acetate ......................................... 23, 89
MEKINIST ........................................................ 28
MEKTOVI ......................................................... 28
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 154
meloxicam ............................................................. 2
melphalan ........................................................... 21
melphalan hydrochloride ................................... 21
memantine hcl .................................................... 45
memantine hydrochloride ................................... 45
memantine hydrochloride er .............................. 45
MENACTRA ................................................... 108
MENEST ............................................................ 83
MENOSTAR ...................................................... 83
MENQUADFI .................................................. 108
MENTAX ......................................................... 125
MENVEO ......................................................... 108
meperidine hcl ...................................................... 6
meprobamate ...................................................... 44
MEPRON ............................................................. 9
MEPSEVII ......................................................... 86
mercaptopurine .................................................. 22
meropenem ........................................................... 9
MEROPENEM/SODIUM CHLORIDE ............... 9
merzee ................................................................. 80
mesalamine ......................................................... 93
mesalamine dr .................................................... 93
mesalamine er .................................................... 93
mesna .................................................................. 32
MESNEX ........................................................... 32
MESTINON ....................................................... 65
MESTINON TIMESPAN .................................. 65
metaxalone ......................................................... 68
metformin hydrochloride .................................... 75
METFORMIN HYDROCHLORIDE ................ 75
metformin hydrochloride er ............................... 75
methadone hcl ...................................................... 4
METHADONE HCL............................................ 4
METHADOSE ..................................................... 4
METHADOSE SUGAR-FREE............................ 4
methamphetamine hcl ......................................... 60
methazolamide .................................................... 40
methenamine hippurate ........................................ 9
methenamine mandelate ..................................... 10
methergine .......................................................... 86
methimazole ........................................................ 89
METHITEST ...................................................... 70
methocarbamol ................................................... 68
methotrexate sodium .................................. 22, 104
methoxsalen ...................................................... 125
methscopolamine bromide.................................. 92
methsuximide ...................................................... 56
methylergonovine maleate .................................. 87
METHYLIN ....................................................... 60
methylphenidate hydrochloride ......................... 61
methylphenidate hydrochloride cd .................... 60
methylphenidate hydrochloride er ..................... 60
METHYLPHENIDATE HYDROCHLORIDE ER
........................................................................ 60
methylphenidate transdermal ............................ 60
methylprednisolone ............................................ 84
methylprednisolone acetate ............................... 84
methylprednisolone sodium succinate ............... 84
methylprednisolone sodiumsuccinate ................ 84
methyltestosterone ............................................. 70
metoclopramide hcl ........................................... 91
metoclopramide hydrochloride.......................... 91
metoclopramide odt ........................................... 91
metolazone ......................................................... 40
metoprolol succinate er ..................................... 37
metoprolol tartrate ............................................ 37
metoprolol/hydrochlorothiazide ........................ 37
METROCREAM ............................................. 130
METROGEL ................................................... 130
METROLOTION ............................................ 130
metronidazole ...................................... 10, 98, 130
metyrosine .......................................................... 41
mexiletine hcl ..................................................... 35
MIACALCIN..................................................... 76
mibelas 24 fe ...................................................... 80
micafungin ......................................................... 12
MICARDIS ........................................................ 34
MICARDIS HCT ............................................... 34
miconazole 3 ...................................................... 98
MICONAZOLE NITRATE/ZINC
OXIDE/WHITE PETROLATUM................ 125
MICRHOGAM ULTRA-FILTERED PLUS ... 105
MICROGESTIN 1.5/30 ..................................... 80
MICROGESTIN 1/20 ........................................ 80
microgestin 24 fe ............................................... 80
MICROGESTIN FE 1.5/30 ............................... 80
MICROGESTIN FE 1/20 .................................. 80
midazolam hcl .................................................... 62
midazolam hydrochloride .................................. 62
midodrine hcl ..................................................... 41
MIEBO ............................................................ 117
migergot ............................................................. 63
miglitol ............................................................... 75
miglustat ............................................................ 87
MIGRANAL ...................................................... 63
mili ..................................................................... 80
MILLIPRED....................................................... 84
milrinone lactate ................................................ 41
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 155
milrinone lactate in dextrose .............................. 41
mimvey ................................................................ 83
MINASTRIN 24 FE ........................................... 80
MINIPRESS ....................................................... 33
MINIVELLE ...................................................... 83
MINOCIN .......................................................... 20
minocycline hcl ................................................... 20
minocycline hydrochloride ................................. 20
minocycline hydrochloride er ............................. 20
MINOLIRA ........................................................ 20
minoxidil ............................................................. 41
MIRAPEX ER .................................................... 50
MIRCETTE ........................................................ 80
MIRENA ............................................................ 80
mirtazapine ......................................................... 47
mirtazapine odt ................................................... 47
MIRVASO ....................................................... 130
misoprostol ......................................................... 95
MITIGARE .......................................................... 1
mitigo .................................................................... 6
mitomycin ........................................................... 21
mitoxantrone hcl ................................................. 24
M-M-R II .......................................................... 108
M-NATAL PLUS ............................................. 111
modafinil............................................................. 69
moexipril hcl ....................................................... 32
molindone hydrochloride ................................... 52
mometasone furoate ................................. 121, 128
mondoxyne nl...................................................... 20
MONJUVI .......................................................... 28
mono-linyah ........................................................ 80
montelukast sodium .......................................... 120
MONUROL ........................................................ 10
morphine sulfate ................................................... 6
MORPHINE SULFATE ...................................... 6
morphine sulfate er ............................................... 4
MORPHINE SULFATE/SODIUM CHLORIDE 4
MOTEGRITY .................................................... 95
MOTOFEN......................................................... 95
MOUNJARO ...................................................... 75
MOVANTIK ...................................................... 95
MOVIPREP ........................................................ 94
moxifloxacin hydrochloride ........................ 18, 114
moxifloxacin hydrochloride/sodium hydrochloride
......................................................................... 18
MOZOBIL ........................................................ 100
MS CONTIN ........................................................ 4
MULPLETA ..................................................... 101
MULTAQ ........................................................... 35
multiple electrolytes injection type 1 ............... 109
multivitamin/fluoride ....................................... 111
multi-vitamin/fluoride ...................................... 111
multi-vitamin/fluoride/iron .............................. 111
mupirocin ......................................................... 124
MVASI .............................................................. 28
MYALEPT ........................................................ 87
MYAMBUTOL ................................................. 15
mycamine ........................................................... 12
MYCAMINE ..................................................... 12
MYCAPSSA ...................................................... 87
MYCOBUTIN ................................................... 15
mycophenolate mofetil ..................................... 107
mycophenolic acid dr....................................... 107
MYDAYIS......................................................... 61
MYFEMBREE .................................................. 87
MYFORTIC..................................................... 107
MYLOTARG..................................................... 28
MYOBLOC ....................................................... 68
MYRBETRIQ .................................................... 98
MYSOLINE....................................................... 56
mytamycin .......................................................... 21
MYTESI ............................................................ 95
MYXREDLIN ................................................... 72
NABI-HB......................................................... 105
nabumetone .......................................................... 3
nadolol ............................................................... 37
NAFCILLIN ...................................................... 19
nafcillin sodium ................................................. 19
naftifine hcl ...................................................... 125
naftifine hydrochloride .................................... 125
NAFTIN........................................................... 125
NAGLAZYME .................................................. 87
nalbuphine hcl ..................................................... 6
NALFON ............................................................. 3
nalocet ................................................................. 6
naloxone hcl ....................................................... 69
naloxone hydrochloride ..................................... 70
naltrexone hcl .................................................... 70
NAMENDA ....................................................... 45
NAMENDA TITRATION PAK ....................... 45
NAMENDA XR ................................................ 45
NAMZARIC ...................................................... 45
nan ................................................................... 117
NAPRELAN ........................................................ 3
naproxen .............................................................. 3
naproxen sodium.................................................. 3
NAPROXEN SODIUM ....................................... 3
NAPROXEN SODIUM CR ................................ 3
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 156
naproxen sodium er .............................................. 3
NAPROXEN SODIUM ER ................................. 3
naproxen/esomeprazole magnesium .................... 3
naratriptan hcl .................................................... 63
NARCAN ........................................................... 70
NARDIL ............................................................. 47
NAROPIN ............................................................ 7
NATACHEW ................................................... 111
NATACYN ...................................................... 114
NATAZIA .......................................................... 80
nateglinide .......................................................... 75
NATESTO .......................................................... 70
NATPARA ......................................................... 76
NATROBA....................................................... 131
NAYZILAM....................................................... 56
nebivolol hydrochloride ..................................... 37
NEBUPENT ....................................................... 10
necon 0.5/35-28 .................................................. 80
nefazodone hydrochloride .................................. 47
nelarabine ........................................................... 22
neomycin sulfate ........................................... 10, 97
neomycin sulfate/polymyxin b sulfate solution for
irrigation ......................................................... 97
neomycin/bacitracin/polymyxin ....................... 114
neomycin/polymyxin/bacitracin/hydrocortisone
....................................................................... 113
neomycin/polymyxin/dexamethasone ............... 113
neomycin/polymyxin/gramicidin ...................... 114
neomycin/polymyxin/hc .................................... 118
neomycin/polymyxin/hydrocortisone ........ 113, 118
NEONATAL 19 ............................................... 111
NEONATAL COMPLETE .............................. 111
NEONATAL FE .............................................. 111
NEONATAL PLUS ......................................... 111
neo-polycin ....................................................... 114
neo-polycin hc .................................................. 113
NEORAL .......................................................... 107
NEO-SYNALAR ............................................. 124
NERLYNX ......................................................... 28
NESINA ............................................................. 75
NESTABS ........................................................ 111
NESTABS ONE ............................................... 111
neuac ................................................................ 124
NEULASTA ..................................................... 100
NEULASTA ONPRO KIT ............................... 100
NEUPOGEN .................................................... 100
NEUPRO ............................................................ 50
NEURONTIN ..................................................... 57
NEVANAC ...................................................... 115
nevirapine .......................................................... 13
nevirapine er ...................................................... 13
NEXAVAR ........................................................ 28
NEXIUM ........................................................... 96
NEXIUM I.V. .................................................... 96
NEXLETOL ...................................................... 36
NEXLIZET ........................................................ 36
NEXPLANON ................................................... 80
NEXTERONE ................................................... 35
NEXTSTELLIS ................................................. 80
NEXVIAZYME................................................. 87
NGENLA ........................................................... 87
niacin ................................................................. 36
niacin er ............................................................. 36
niacor ................................................................. 36
nicardipine hcl ................................................... 38
nicardipine hydrochloride ................................. 38
NICARDIPINE HYDROCHLORIDE/SODIUM
CHLORIDE .................................................... 38
NICOTROL ....................................................... 70
NICOTROL INHALER .................................... 70
nifedipine ........................................................... 38
nifedipine er ....................................................... 38
nikki ................................................................... 80
NILANDRON ................................................... 23
nilutamide .......................................................... 23
nimodipine ......................................................... 39
NINLARO ......................................................... 28
NIPENT ............................................................. 24
nisoldipine er ..................................................... 39
nitazoxanide ....................................................... 10
nitisinone ........................................................... 87
NITRO-BID ....................................................... 42
NITRO-DUR ..................................................... 42
nitrofurantin....................................................... 10
nitrofurantoin monohydrate macrocrystals ....... 10
nitrofurantoin monohydrate/macrocrystals ....... 10
NITROGLYCERIN ........................................... 42
NITROGLYCERIN IN DEXTROSE 5% ......... 42
nitroglycerin lingual spray ................................ 42
nitroglycerin sublingual .................................... 42
nitroglycerin transdermal .................................. 42
NITROLINGUAL PUMPSPRAY .................... 42
NITROSTAT ..................................................... 42
NITYR ............................................................... 87
NIVA-PLUS .................................................... 111
NIVESTYM..................................................... 100
nizatidine ........................................................... 93
NOCDURNA..................................................... 87
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 157
NORA-BE .......................................................... 80
NORDITROPIN FLEXPRO .............................. 87
norethindrone ..................................................... 80
norethindrone & ethinyl estradiol ferrous
fumarate .......................................................... 81
norethindrone acetate ........................................ 89
norethindrone acetate/ethinyl estradiol ....... 81, 83
norethindrone acetate/ethinyl estradiol/ferrous
fumarate .......................................................... 81
norgesic .............................................................. 68
NORGESIC FORTE .......................................... 68
norgestimate/ethinyl estradiol ............................ 81
NORITATE ...................................................... 130
NORLIQVA ....................................................... 39
norlyda ............................................................... 81
norlyroc .............................................................. 81
NORPACE ......................................................... 35
NORPACE CR ................................................... 35
NORPRAMIN .................................................... 47
NORTHERA ...................................................... 41
nortrel 0.5/35 (28) .............................................. 81
nortrel 1/35 ......................................................... 81
nortrel 7/7/7........................................................ 81
nortriptyline hcl .................................................. 47
nortriptyline hydrochloride ................................ 47
NORVASC ......................................................... 39
NORVIR............................................................. 13
NOURIANZ ....................................................... 50
NOVAREL ......................................................... 87
NOVOLIN 70/30................................................ 72
NOVOLIN 70/30 FLEXPEN ............................. 72
NOVOLIN N ...................................................... 72
NOVOLIN N FLEXPEN ................................... 72
NOVOLIN R ...................................................... 72
NOVOLIN R FLEXPEN ................................... 72
NOVOLOG ........................................................ 72
NOVOLOG FLEXPEN...................................... 72
NOVOLOG FLEXPEN RELION ...................... 72
NOVOLOG MIX 70/30 ..................................... 72
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
......................................................................... 72
NOVOLOG MIX 70/30 PREFILLED FLEXPEN
RELION .......................................................... 72
NOVOLOG MIX 70/30 RELION ...................... 72
NOVOLOG PENFILL ....................................... 72
NOVOLOG RELION ........................................ 72
NOXAFIL .......................................................... 12
np thyroid ..................................................... 89, 90
NPLATE........................................................... 100
NUBEQA........................................................... 23
NUCALA......................................................... 120
NUCYNTA ...................................................... 4, 6
NUCYNTA ER ................................................... 4
NUEDEXTA ..................................................... 65
nulev................................................................... 92
NULIBRY ......................................................... 87
NULOJIX ........................................................ 107
NUMBRINO ................................................... 120
NUPLAZID ....................................................... 52
NURTEC ........................................................... 63
NUTRILIPID ................................................... 113
NUTROPIN AQ NUSPIN ................................. 87
NUVARING ...................................................... 81
NUVESSA ......................................................... 98
NUVIGIL........................................................... 69
NUZYRA........................................................... 20
nyamyc ............................................................. 125
nylia 1/35 ........................................................... 81
nylia 7/7/7 .......................................................... 81
NYMALIZE ...................................................... 39
nymyo ................................................................. 81
nystatin............................................... 12, 125, 131
nystatin/triamcinolone ..................................... 125
nystop ............................................................... 125
NYVEPRIA ..................................................... 100
OB COMPLETE.............................................. 111
OB COMPLETE ONE .................................... 111
OB COMPLETE PETITE ............................... 111
OB COMPLETE PREMIER ........................... 111
OB COMPLETE/DHA .................................... 111
OCALIVA ......................................................... 95
OCELLA ........................................................... 81
OCREVUS......................................................... 67
OCTAGAM ..................................................... 105
octreotide acetate .............................................. 87
OCUFLOX ...................................................... 114
ODACTRA ...................................................... 106
ODEFSEY ......................................................... 15
ODOMZO .......................................................... 28
OFEV ............................................................... 121
ofloxacin ............................................ 18, 114, 118
OGIVRI ............................................................. 28
olanzapine .......................................................... 52
olanzapine odt ................................................... 52
olanzapine/fluoxetine ......................................... 47
olmesartan medoxomil ....................................... 34
olmesartan
medoxomil/amlodipine/hydrochlorothiazide .. 34
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 158
olmesartan medoxomil/hydrochlorothiazide ...... 34
olopatadine hcl ......................................... 115, 119
olopatadine hydrochloride ............................... 115
OLPRUVA ......................................................... 87
OLUMIANT ..................................................... 103
OLUX ............................................................... 128
OLUX-E ........................................................... 128
OMECLAMOX-PAK ........................................ 95
omega-3-acid ethyl esters ................................... 36
OMEGAVEN ................................................... 113
omeprazole dr ..................................................... 96
omeprazole/sodium bicarbonate ........................ 96
OMNARIS ....................................................... 121
OMNIPOD ......................................................... 73
OMNIPOD 5 ................................................ 72, 73
OMNIPOD CLASSIC ........................................ 73
OMNIPOD DASH ............................................. 73
OMNITROPE ..................................................... 87
ONCASPAR....................................................... 24
ondansetron hcl .................................................. 91
ondansetron hydrochloride ................................ 91
ondansetron odt .................................................. 91
ONEXTON ....................................................... 124
ONFI................................................................... 57
ONGENTYS ...................................................... 50
ONGLYZA ......................................................... 75
ONIVYDE .......................................................... 24
ONTRUZANT ................................................... 28
ONUREG ........................................................... 22
ONZETRA XSAIL ............................................ 63
OPDIVO ............................................................. 29
OPDUALAG ...................................................... 29
opium tincture .................................................... 95
OPSUMIT .......................................................... 42
OPZELURA ..................................................... 130
ORACEA ......................................................... 130
ORACIT ............................................................. 97
ORALAIR ........................................................ 106
oralone dental paste ......................................... 131
ORAPRED ODT ................................................ 84
ORBACTIV ....................................................... 10
ORENCIA ........................................................ 103
ORENCIA CLICKJECT .................................. 103
ORENITRAM .................................................... 42
ORENITRAM TITRATION .............................. 42
ORFADIN .......................................................... 87
ORGOVYX ........................................................ 23
ORIAHNN ......................................................... 87
ORILISSA .......................................................... 82
ORKAMBI ...................................................... 121
ORLADEYO ................................................... 101
orphenadrine citrate .......................................... 68
orphenadrine citrate er ...................................... 68
orphenadrine/aspirin/caffeine ........................... 68
orphengesic forte ............................................... 69
ORSERDU......................................................... 23
orsythia .............................................................. 81
ORTIKOS .......................................................... 93
oscimin ............................................................... 92
oscimin sublingual ............................................. 92
oseltamivir phosphate ........................................ 16
OSENI ............................................................... 75
OSMITROL VIAFLEX ..................................... 40
OSMOLEX ER .................................................. 50
OSMOPREP ...................................................... 94
OSPHENA ......................................................... 87
OTEZLA .......................................................... 103
OTOVEL ......................................................... 118
OTREXUP ....................................................... 104
OVIDE ............................................................. 131
oxacillin sodium ................................................. 19
OXACILLIN SODIUM ..................................... 19
oxaliplatin .......................................................... 21
oxandrolone ....................................................... 70
oxaprozin ............................................................. 3
OXAYDO ............................................................ 6
oxazepam ........................................................... 44
OXBRYTA ...................................................... 101
oxcarbazepine .................................................... 57
OXERVATE .................................................... 117
oxiconazole nitrate .......................................... 125
OXISTAT ........................................................ 125
OXLUMO .......................................................... 97
OXTELLAR XR................................................ 57
oxybutynin chloride ........................................... 98
OXYBUTYNIN CHLORIDE ........................... 98
oxybutynin chloride er ....................................... 98
OXYCODONE AND ACETAMINOPHEN ....... 6
OXYCODONE HCL ER ..................................... 4
oxycodone hydrochloride .................................... 6
oxycodone hydrochloride/acetaminophen ........... 6
OXYCODONE
HYDROCHLORIDE/ACETAMINOPHEN .... 6
oxycodone/acetaminophen............................... 6, 7
OXYCONTIN ..................................................... 4
oxymorphone hydrochloride ................................ 7
oxymorphone hydrochloride er ........................... 4
OXYTROL ........................................................ 98
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 159
OZEMPIC .......................................................... 75
OZURDEX ....................................................... 115
pacerone ............................................................. 35
paclitaxel ............................................................ 24
paclitaxel protein-bound particles ..................... 24
PADCEV ............................................................ 29
PALFORZIA INITIAL DOSE ESCALATION
....................................................................... 106
PALFORZIA LEVEL 1 ................................... 106
PALFORZIA LEVEL 10 ................................. 106
PALFORZIA LEVEL 11 (MAINTENANCE) 106
PALFORZIA LEVEL 11 (TITRATION) ........ 106
PALFORZIA LEVEL 2 ................................... 106
PALFORZIA LEVEL 3 ................................... 106
PALFORZIA LEVEL 4 ................................... 106
PALFORZIA LEVEL 5 ................................... 106
PALFORZIA LEVEL 6 ................................... 106
PALFORZIA LEVEL 7 ................................... 106
PALFORZIA LEVEL 8 ................................... 106
PALFORZIA LEVEL 9 ................................... 106
paliperidone er ................................................... 52
palonosetron hydrochloride ............................... 91
PALONOSETRON HYDROCHLORIDE ......... 91
PALYNZIQ ........................................................ 87
PAMELOR ......................................................... 47
pamidronate disodium ........................................ 77
PAMIDRONATE DISODIUM .......................... 76
PANCREAZE .................................................... 95
PANDEL .......................................................... 128
PANRETIN ...................................................... 130
pantoprazole sodium .......................................... 96
PANZYGA ....................................................... 105
paraplatin ........................................................... 21
paricalcitol ......................................................... 90
PARLODEL ....................................................... 50
PARNATE ......................................................... 47
paromomycin sulfate .......................................... 10
paroxetine ........................................................... 65
paroxetine hcl ..................................................... 47
paroxetine hcl er ................................................. 47
paroxetine hydrochloride ................................... 47
PAXIL .......................................................... 47, 48
PAXIL CR .......................................................... 47
PEDIAPRED ...................................................... 84
PEDIARIX ....................................................... 108
PEDVAX HIB .................................................. 108
peg-3350/electrolytes ......................................... 94
peg-3350/electrolytes/ascorbate ........................ 94
peg-3350/nacl/na bicarbonate/kcl ...................... 94
PEGASYS ......................................................... 16
PEMAZYRE ...................................................... 29
PEMETREXED ................................................. 22
pemtrexed........................................................... 22
penciclovir ....................................................... 130
penicillamine ..................................................... 77
penicillin g potassium ........................................ 19
PENICILLIN G POTASSIUM IN ISO-
OSMOTIC DEXTROSE ................................ 19
PENICILLIN G PROCAINE ............................ 19
penicillin g sodium............................................. 19
penicillin v potassium ........................................ 19
PENNSAID ..................................................... 130
PENTACEL ..................................................... 108
PENTAM 300 .................................................... 10
pentamidine isethionate ..................................... 10
PENTASA ......................................................... 93
pentazocine/naloxone hcl .................................... 7
pentobarbital sodium ......................................... 62
pentoxifylline er ............................................... 101
PEPCID ............................................................. 93
PERCOCET ......................................................... 7
PERFOROMIST .............................................. 119
PERIKABIVEN............................................... 113
perindopril erbumine ......................................... 32
periogard ......................................................... 131
PERJETA........................................................... 29
permethrin ....................................................... 131
perphenazine ................................................ 48, 52
perphenazine/amitriptyline ................................ 48
PERSERIS ......................................................... 52
PERTZYE .......................................................... 96
PEXEVA ........................................................... 48
pfizerpen ............................................................ 19
PHEBURANE ................................................... 87
phenelzine sulfate .............................................. 48
PHENERGAN ................................................... 91
phenobarbital .................................................... 57
phenobarbital sodium ........................................ 57
phenoxybenzamine hydrochloride ..................... 41
PHENYLEPHRINE HCL................................ 117
PHENYTEK ...................................................... 57
phenytoin ........................................................... 57
phenytoin sodium ............................................... 57
phenytoin sodium er........................................... 57
PHESGO ............................................................ 29
PHEXXI............................................................. 81
philith ................................................................. 81
PHOSLYRA ...................................................... 89
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 160
PHOSPHOLINE IODIDE ................................ 116
PHYSIOLYTE ................................................. 131
PIFELTRO ......................................................... 13
pilocarpine hcl .................................................. 116
pilocarpine hydrochloride ................................ 131
pimecrolimus .................................................... 130
pimozide ............................................................. 52
pimtrea ............................................................... 81
pindolol............................................................... 37
pioglitazone hcl .................................................. 75
pioglitazone hcl/metformin hcl ........................... 75
pioglitazone hcl-glimepiride .............................. 75
pioglitazone hydrochloride ................................ 75
piperacillin sodium/tazobactam sodium ............. 19
PIQRAY ............................................................. 29
pirfenidone ....................................................... 121
pirmella 1/35 ...................................................... 81
pirmella 7/7/7 ..................................................... 81
piroxicam .............................................................. 3
PLAQUENIL ................................................... 104
PLASMA-LYTE A .......................................... 109
PLASMA-LYTE-148 ....................................... 109
PLAVIX ........................................................... 102
PLEGRIDY ........................................................ 67
PLEGRIDY STARTER PACK .......................... 67
plenamine ......................................................... 113
PLENVU ............................................................ 94
plerixafor .......................................................... 100
PLIAGLIS ........................................................ 129
PNV PRENATAL PLUS MULTIVITAMIN .. 111
pnv-dha ............................................................. 111
PNV-DHA+DOCUSATE ................................ 111
PNV-OMEGA .................................................. 111
pnv-select .......................................................... 111
PODOCON-25 ................................................. 130
podofilox ........................................................... 130
POLIVY ............................................................. 29
polycin .............................................................. 114
polymyxin b sulfate ..................................... 10, 114
polymyxin b sulfate/trimethoprim sulfate ......... 114
POLYTRIM ..................................................... 114
POLY-VI-FLOR .............................................. 111
POLY-VI-FLOR/IRON ................................... 111
POMALYST ...................................................... 23
PONVORY......................................................... 67
PONVORY 14-DAY STARTER PACK ........... 67
portia-28 ............................................................. 81
PORTRAZZA .................................................... 29
posaconazole ...................................................... 12
posaconazole dr ................................................. 12
POTASSIUM ACETATE ............................... 109
potassium chloride ................................... 110, 111
POTASSIUM CHLORIDE ............................. 110
potassium chloride er ...................................... 111
POTASSIUM CHLORIDE/DEXTROSE ....... 109
POTASSIUM
CHLORIDE/DEXTROSE/LACTATED
RINGERS ..................................................... 109
POTASSIUM
CHLORIDE/DEXTROSE/SODIUM
CHLORIDE .................................................. 109
potassium chloride/sodium chloride ................ 109
POTASSIUM CHLORIDE/SODIUM
CHLORIDE .................................................. 109
potassium citrate er ........................................... 97
potassium citrate/citric acid .............................. 97
potassium citrate/sodium citrate/citric acid ...... 97
potassium phosphate........................................ 110
POTASSIUM PHOSPHATES ........................ 113
POTELIGEO ..................................................... 29
PRADAXA ........................................................ 99
PRALUENT ...................................................... 36
pramipexole dihydrochloride ............................ 50
pramipexole dihydrochloride er ........................ 50
prasugrel .......................................................... 102
pravastatin sodium ............................................ 36
praziquantel ....................................................... 10
prazosin hydrochloride ...................................... 33
PRED FORTE ................................................. 115
PRED MILD .................................................... 115
prednicarbate................................................... 128
prednisolone ...................................................... 84
prednisolone acetate ........................................ 115
prednisolone sodium phosphate ........................ 84
PREDNISOLONE SODIUM PHOSPHATE .. 115
prednisolone sodium phosphate odt .................. 84
prednisone ......................................................... 84
PREDNISONE INTENSOL .............................. 84
PREFEST .......................................................... 83
pregabalin .......................................................... 57
pregabalin er ..................................................... 65
PREGNYL ......................................................... 87
PREHEVBRIO ................................................ 108
PREMARIN....................................................... 83
PREMASOL .................................................... 113
PREMPHASE .................................................... 83
PREMPRO ........................................................ 83
PRENAISSANCE ........................................... 111
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 161
PRENAISSANCE PLUS ................................. 111
PRENATAL ..................................................... 111
PRENATAL PLUS .......................................... 111
PRENATE ................................................ 111, 112
PRENATE AM ................................................ 111
PRENATE DHA .............................................. 111
PRENATE ELITE ............................................ 111
PRENATE ENHANCE .................................... 111
PRENATE ESSENTIAL .................................. 111
PRENATE MINI .............................................. 112
PRENATE PIXIE ............................................. 112
PRENATE RESTORE ..................................... 112
PRENATVITE COMPLETE ........................... 112
PRENATVITE PLUS ...................................... 112
PRETOMANID .................................................. 15
PREVACID ........................................................ 96
PREVACID SOLUTAB .................................... 96
prevalite .............................................................. 36
PREVIDENT 5000 BOOSTER PLUS ............. 131
PREVIDENT 5000 DRY MOUTH.................. 131
PREVIDENT 5000 ENAMEL PROTECT ...... 132
PREVIDENT 5000 ORTHO DEFENSE ......... 132
PREVIDENT 5000 PLUS ................................ 132
PREVIDENT FLUORIDE ............................... 132
PREVIDENT RINSE ....................................... 132
PREVYMIS ........................................................ 16
PREZCOBIX ...................................................... 15
PREZISTA ......................................................... 13
PRIALT ................................................................ 1
PRIFTIN ............................................................. 15
PRILOSEC ......................................................... 96
PRIMACARE................................................... 112
primaquine phosphate ........................................ 12
PRIMAXIN IV ................................................... 10
primidone ........................................................... 57
PRIORIX .......................................................... 108
PRISTIQ ............................................................. 48
PRIVIGEN ....................................................... 105
PROAIR DIGIHALER .................................... 119
PROAIR RESPICLICK ................................... 119
probenecid ............................................................ 1
probenecid/colchicine .......................................... 1
procainamide hcl ................................................ 35
PROCARDIA XL .............................................. 39
procentra ............................................................ 61
prochlorperazine ................................................ 91
prochlorperazine edisylate ................................. 91
prochlorperazine maleate .................................. 91
PROCRIT ......................................................... 100
PROCTOCORT ............................................... 130
PROCTOFOAM HC ....................................... 130
procto-med hc .................................................. 130
proctosol hc ..................................................... 128
proctozone-hc .................................................. 130
PROCYSBI ........................................................ 87
progesterone ...................................................... 89
PROGLYCEM................................................... 85
PROGRAF ....................................................... 107
PROLASTIN-C ............................................... 121
PROLATE ........................................................... 7
PROLENSA..................................................... 115
PROLIA ............................................................. 77
PROMACTA ................................................... 101
promethazine hcl................................................ 91
promethazine hydrochloride .............................. 91
promethazine vc ............................................... 118
promethegan ...................................................... 91
PROMETRIUM................................................. 89
propafenone hcl ................................................. 35
propafenone hydrochloride er ........................... 35
proparacaine hcl.............................................. 117
propranolol hcl .................................................. 38
propranolol hcl er ........................................ 37, 38
propylthiouracil ................................................. 90
PROQUAD ...................................................... 108
PROSCAR ......................................................... 97
PROSOL .......................................................... 113
PROTONIX ....................................................... 96
protriptyline hcl ................................................. 48
PROVENTIL HFA .......................................... 119
PROVERA......................................................... 89
PROVIDA OB ................................................. 112
PROVIGIL......................................................... 69
PROZAC ........................................................... 48
PRUDOXIN..................................................... 130
PULMICORT .................................................. 122
PULMICORT FLEXHALER .......................... 122
PULMOZYME ................................................ 121
PURIXAN ......................................................... 22
PYLERA ............................................................ 95
pyrazinamide ..................................................... 15
pyridostigmine bromide ..................................... 65
pyridostigmine bromide er................................. 65
pyrimethamine ................................................... 10
PYRUKYND ................................................... 101
QBRELIS........................................................... 32
QBREXZA ...................................................... 130
QELBREE ......................................................... 61
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 162
QINLOCK .......................................................... 29
QNASL............................................................. 121
QNASL CHILDRENS ..................................... 121
QTERN............................................................... 75
QUADRACEL ................................................. 108
QUALAQUIN .................................................... 12
QUARTETTE .................................................... 81
QUDEXY XR .................................................... 57
QUESTRAN ....................................................... 36
QUESTRAN LIGHT .......................................... 36
quetiapine fumarate............................................ 52
quetiapine fumarate er ....................................... 52
QUFLORA FE ................................................. 112
QUFLORA FE PEDIATRIC ........................... 112
QUILLICHEW ER ............................................. 61
QUILLIVANT XR ............................................. 61
quinapril hcl ....................................................... 32
quinapril hydrochloride ..................................... 33
quinapril/hydrochlorothiazide ........................... 32
quinidine gluconate cr ........................................ 35
quinidine gluconate er ........................................ 35
quinidine sulfate ................................................. 35
quinine sulfate .................................................... 12
QULIPTA ........................................................... 63
QUTENZA KIT ............................................... 129
QUVIVIQ ........................................................... 62
QUZYTTIR ...................................................... 119
QVAR REDIHALER ....................................... 122
RABAVERT .................................................... 108
rabeprazole sodium dr ....................................... 96
RADICAVA ....................................................... 65
RADICAVA ORS .............................................. 65
RAGWITEK ..................................................... 106
raloxifene hydrochloride .................................... 87
ramelteon ............................................................ 62
ramipril............................................................... 33
RANEXA ........................................................... 41
ranolazine er ...................................................... 41
RAPAFLO .......................................................... 97
RAPAMUNE ................................................... 107
RAPIVAB .......................................................... 16
rasagiline mesylate ............................................. 50
RASUVO ......................................................... 104
RAVICTI ............................................................ 87
RAYALDEE ...................................................... 90
RAYOS .............................................................. 84
RAZADYNE ER ................................................ 45
REBIF................................................................. 67
REBIF REBIDOSE ............................................ 67
REBLOZYL .................................................... 101
REBYOTA ........................................................ 95
RECARBRIO .................................................... 10
RECLAST ......................................................... 77
reclipsen............................................................. 81
RECOMBIVAX HB ........................................ 108
RECORLEV ...................................................... 87
RECTIV ........................................................... 130
REDITREX ............................................. 104, 105
REGLAN ........................................................... 91
REGONOL ........................................................ 65
REGRANEX ................................................... 131
RELAFEN DS ..................................................... 3
RELENZA DISKHALER ................................. 16
RELEUKO....................................................... 100
RELEXXII ......................................................... 61
RELISTOR ........................................................ 95
RELPAX ............................................................ 63
RELTONE ......................................................... 95
RELYVRIO ....................................................... 65
REMERON ........................................................ 48
REMERON SOLTAB ....................................... 48
REMICADE .................................................... 103
REMODULIN ................................................... 42
RENACIDIN ..................................................... 97
RENAGEL......................................................... 89
RENFLEXIS .................................................... 103
RENVELA......................................................... 89
repaglinide ......................................................... 75
REPATHA ......................................................... 36
REPATHA PUSHTRONEX SYSTEM............. 36
REPATHA SURECLICK.................................. 36
RESTASIS ....................................................... 117
RESTASIS MULTIDOSE ............................... 117
RESTORIL ........................................................ 62
RETACRIT ...................................................... 100
RETEVMO ........................................................ 29
RETIN-A ......................................................... 124
RETIN-A MICRO ........................................... 124
RETROVIR ....................................................... 13
RETROVIR IV .................................................. 13
REVATIO .......................................................... 42
REVCOVI ......................................................... 87
REVLIMID ........................................................ 23
REXULTI .................................................... 52, 53
REYATAZ......................................................... 13
REYVOW .......................................................... 63
REZLIDHIA ...................................................... 29
REZUROCK .................................................... 107
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 163
REZVOGLAR KWIKPEN ................................ 73
REZZAYO ......................................................... 12
RHOFADE ....................................................... 130
RHOGAM ULTRA-FILTERED PLUS ........... 105
RHOPHYLAC ................................................. 105
RHOPRESSA ................................................... 116
RIABNI .............................................................. 29
ribavirin .............................................................. 16
RIDAURA ........................................................ 105
rifabutin .............................................................. 15
RIFADIN ............................................................ 15
rifampin .............................................................. 15
RILUTEK ........................................................... 65
riluzole ................................................................ 65
rimantadine hydrochloride ................................. 16
RIMSO-50 .......................................................... 97
RINGERS INJECTION ................................... 110
RINGERS IRRIGATION ................................ 131
RINVOQ .......................................................... 103
RIOMET............................................................. 75
risedronate sodium ............................................. 77
risedronate sodium dr ........................................ 77
RISPERDAL ...................................................... 53
RISPERDAL CONSTA ..................................... 53
risperidone ......................................................... 53
risperidone odt ................................................... 53
RITALIN ............................................................ 61
RITALIN LA ...................................................... 61
ritonavir .............................................................. 13
RITUXAN .......................................................... 29
RITUXAN HYCELA ......................................... 29
rivastigmine tartrate ........................................... 45
rivastigmine transdermal system ........................ 45
RIVELSA ........................................................... 81
rizatriptan benzoate............................................ 63
rizatriptan benzoate odt ..................................... 63
ROBAXIN .......................................................... 69
ROBINUL .......................................................... 92
ROBINUL FORTE ............................................ 92
ROCALTROL .................................................... 90
ROCKLATAN ................................................. 116
roflumilast ........................................................ 121
ROLVEDON .................................................... 100
romidepsin .......................................................... 29
ropinirole er ....................................................... 50
ropinirole hcl ...................................................... 50
ropivacaine hydrochloride ................................... 8
rosuvastatin calcium .......................................... 36
ROSZET ............................................................. 36
ROTARIX ....................................................... 108
ROTATEQ....................................................... 108
ROWASA .......................................................... 93
roweepra ............................................................ 57
ROXICODONE ................................................... 7
ROXYBOND....................................................... 7
ROZEREM ........................................................ 62
ROZLYTREK ................................................... 29
RUBRACA ........................................................ 29
RUCONEST .................................................... 102
rufinamide .......................................................... 57
RUKOBIA ......................................................... 13
RUXIENCE ....................................................... 29
RYALTRIS ...................................................... 118
RYBELSUS ....................................................... 75
RYBREVANT ................................................... 29
ryclora ............................................................. 119
RYDAPT ........................................................... 29
RYLAZE ........................................................... 24
RYSTIGGO ..................................................... 106
RYTARY ........................................................... 50
RYTHMOL SR ................................................. 35
RYVENT ......................................................... 119
SABRIL ............................................................. 57
SAFYRAL ......................................................... 81
SAIZEN ............................................................. 87
SAIZENPREP RECONSTITUTIONKIT ......... 87
sajazir .............................................................. 102
SALAGEN....................................................... 132
salicylic acid .................................................... 130
SALICYLIC ACID.......................................... 130
salsalate ............................................................... 3
salsalate 750mg ................................................... 3
SAMSCA ..................................................... 87, 88
SANCUSO ........................................................ 91
SANDIMMUNE .............................................. 107
SANDOSTATIN ............................................... 88
SANDOSTATIN LAR ...................................... 88
SANTYL ......................................................... 131
SAPHNELO .................................................... 107
SAPHRIS ........................................................... 53
sapropterin dihydrochloride .............................. 88
SARCLISA ........................................................ 29
SAVAYSA ........................................................ 99
SAVELLA ......................................................... 65
SAVELLA TITRATION PACK ....................... 65
saxagliptin hydrochloride .................................. 75
saxagliptin hydrochloride/metformin
hydrochloride er ............................................. 75
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 164
SCEMBLIX ........................................................ 29
scopolamine ........................................................ 91
SEASONIQUE ................................................... 81
SECUADO ......................................................... 53
SEGLENTIS ......................................................... 7
SEGLUROMET ........................................... 75, 76
SELECT-OB .................................................... 112
selegiline hcl ....................................................... 50
selenium sulfide ................................................ 126
SELZENTRY ............................................... 13, 14
SEMGLEE ......................................................... 73
SE-NATAL 19 ................................................. 112
SENSIPAR ......................................................... 88
SENSORCAINE .................................................. 8
sensorcaine/epinephrine ....................................... 8
sensorcaine-mpf ................................................... 8
sensorcaine-mpf/epinephrine ............................... 8
SENSORCAINE-MPF/EPINEPHRINE .............. 8
SEREVENT DISKUS ...................................... 119
SERNIVO......................................................... 128
SEROQUEL ....................................................... 53
SEROQUEL XR ................................................ 53
SEROSTIM ........................................................ 88
sertraline hcl ...................................................... 48
sertraline hydrochloride ..................................... 48
SERTRALINE HYDROCHLORIDE ................ 48
setlakin ............................................................... 81
sevelamer carbonate .......................................... 89
sevelamer hydrochloride .................................... 89
SEYSARA .......................................................... 20
sf 132
sf 5000 plus....................................................... 132
SFROWASA ...................................................... 93
sharobel .............................................................. 81
SHINGRIX ....................................................... 108
SIGNIFOR ......................................................... 88
SIGNIFOR LAR ................................................ 88
SIKLOS ............................................................ 102
sildenafil ............................................................. 42
sildenafil citrate .................................................. 42
SILENOR ........................................................... 62
SILIQ ................................................................ 103
silodosin ............................................................. 97
SILVADENE ................................................... 124
SILVER NITRATE .......................................... 130
silver sulfadiazine ............................................. 124
SIMBRINZA .................................................... 116
simliya ................................................................ 81
simpesse .............................................................. 81
SIMPONI ................................................. 103, 104
SIMPONI ARIA .............................................. 103
SIMULECT ..................................................... 107
simvastatin ......................................................... 36
SINEMET .......................................................... 50
SINGULAIR .................................................... 120
sirolimus .......................................................... 107
SIRTURO .......................................................... 15
SITAVIG ........................................................... 16
SIVEXTRO ....................................................... 10
SKYCLARYS ................................................... 65
SKYLA .............................................................. 81
SKYRIZI ......................................................... 104
SKYRIZI PEN ................................................. 104
SKYTROFA ...................................................... 88
SLYND .............................................................. 81
SMOFLIPID .................................................... 113
SOAANZ ........................................................... 40
sodium acetate ................................................. 110
SODIUM ACETATE ...................................... 110
sodium bicarbonate ......................................... 110
SODIUM BICARBONATE ............................ 110
sodium chloride ............................................... 110
SODIUM CHLORIDE .................................... 110
sodium chloride 0.45% .................................... 110
sodium chloride 0.9% ...................................... 131
sodium citrate/citric acid ................................... 97
SODIUM EDECRIN ......................................... 40
sodium fluoride ........................................ 112, 132
sodium fluoride 5000 ....................................... 132
sodium fluoride 5000 plus ............................... 132
sodium fluoride 5000 ppm ............................... 132
sodium fluoride 5000 ppm paste ...................... 132
sodium fluoride 5000 ppm sensitive ................ 132
sodium fluoride mouth/throat .......................... 132
SODIUM OXYBATE ....................................... 69
sodium phenylbutyrate ....................................... 88
sodium phosphate ............................................ 110
sodium polystyrene sulfonate ............................. 77
sodium sulfacetamide/sulfur ............................ 124
SODIUM SULFACETAMIDE/SULFUR
CLEANSER IN UREA ................................ 124
SODIUM SULFATE/POTASSIUM
SULFATE/MAGNESIUM SULFATE .......... 94
SOFOSBUVIR/VELPATASVIR ...................... 16
SOGROYA ........................................................ 88
solifenacin succinate .......................................... 98
SOLIQUA 100/33 ............................................. 73
SOLIRIS .......................................................... 102
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 165
SOLODYN ......................................................... 20
SOLOSEC .......................................................... 10
SOLTAMOX ...................................................... 23
SOLU-CORTEF ................................................. 84
SOLU-MEDROL ............................................... 84
SOMA ................................................................ 69
SOMATULINE DEPOT .................................... 88
SOMAVERT ...................................................... 88
SOOLANTRA .................................................. 130
sorafenib tosylate ............................................... 29
SORBITOL IRRIGATION SOLUTION ........... 97
SORILUX......................................................... 125
sorine .................................................................. 35
sotalol hcl ........................................................... 35
sotalol hydrochloride (af) ................................... 35
SOTYKTU ....................................................... 104
SOTYLIZE ......................................................... 35
SOVALDI .......................................................... 16
SPEVIGO ......................................................... 104
SPINOSAD ...................................................... 131
SPIRIVA HANDIHALER ............................... 118
SPIRIVA RESPIMAT...................................... 118
spironolactone .............................................. 33, 40
spironolactone/hydrochlorothiazide .................. 40
SPORANOX ...................................................... 12
SPRAVATO ....................................................... 48
sprintec 28 .......................................................... 81
SPRITAM........................................................... 57
SPRIX................................................................... 3
SPRYCEL .......................................................... 29
sps ....................................................................... 77
sronyx ................................................................. 81
SSD................................................................... 124
STALEVO 100 ................................................... 50
STALEVO 125 ................................................... 50
STALEVO 150 ................................................... 50
STALEVO 200 ................................................... 50
STALEVO 50 ..................................................... 50
STALEVO 75 ..................................................... 50
stavudine ............................................................. 14
STEGLATRO ..................................................... 76
STEGLUJAN ..................................................... 76
STELARA ........................................................ 104
sterile water for irrigation ................................ 131
STIOLTO RESPIMAT .................................... 118
STIVARGA ........................................................ 29
STRATTERA ..................................................... 61
STRENSIQ ......................................................... 88
streptomycin sulfate ............................................ 10
STRIBILD ......................................................... 15
STRIVERDI RESPIMAT................................ 119
STROMECTOL ................................................ 10
SUBLOCADE ................................................... 70
SUBOXONE ..................................................... 70
SUBSYS .............................................................. 7
subvenite ............................................................ 57
subvenite starter kit ........................................... 57
SUCRAID .......................................................... 95
sucralfate ........................................................... 95
SUCRALFATE ................................................. 95
SUFLAVE ......................................................... 94
SULAR .............................................................. 39
sulfacetamide sodium .............................. 114, 124
sulfacetamide sodium/prednisolone sodium
phosphate ..................................................... 113
sulfacleanse ..................................................... 124
sulfadiazine ........................................................ 10
sulfamethoxazole/trimethoprim ......................... 10
sulfamethoxazole/trimethoprim ds ..................... 10
SULFAMYLON .............................................. 124
sulfasalazine ...................................................... 93
sulindac ................................................................ 3
sumatriptan ........................................................ 63
sumatriptan succinate .................................. 63, 64
sumatriptan/naproxen sodium ........................... 64
sunitinib malate ................................................. 29
SUNLENCA ...................................................... 14
SUNOSI ............................................................. 69
SUPRAX ........................................................... 17
SUPREP BOWEL PREP ................................... 94
SUSTIVA .......................................................... 14
SUSTOL ............................................................ 91
SUSVIMO ....................................................... 117
SUTAB .............................................................. 94
SUTENT ............................................................ 29
syeda .................................................................. 81
SYFOVRE ....................................................... 117
SYMBICORT .................................................. 122
SYMBYAX ....................................................... 48
SYMDEKO ..................................................... 121
SYMFI ............................................................... 15
SYMFI LO ......................................................... 15
SYMJEPI ......................................................... 121
SYMLINPEN 120 ............................................. 76
SYMLINPEN 60 ............................................... 76
SYMPAZAN ..................................................... 57
SYMPROIC ....................................................... 95
SYMTUZA ........................................................ 15
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 166
SYNAGIS......................................................... 106
SYNALAR ....................................................... 128
SYNAREL ......................................................... 82
SYNDROS ......................................................... 91
SYNERA .......................................................... 129
SYNJARDY ....................................................... 76
SYNJARDY XR ................................................ 76
SYNRIBO .......................................................... 24
SYNTHROID ..................................................... 90
SYPRINE ........................................................... 77
TABLOID .......................................................... 22
TABRECTA ....................................................... 29
TACLONEX .................................................... 128
tacrolimus ................................................. 107, 130
tadalafil .............................................................. 42
TADLIQ ............................................................. 42
TAFINLAR .................................................. 29, 30
tafluprost .......................................................... 116
TAGRISSO ........................................................ 30
TAKHZYRO .................................................... 102
TALICIA ............................................................ 95
TALTZ ............................................................. 104
TALZENNA ....................................................... 30
TAMIFLU .......................................................... 16
tamoxifen citrate ................................................. 23
tamsulosin hydrochloride ................................... 97
taperdex 12-day .................................................. 84
taperdex 6-day .................................................... 84
taperdex 7-day .................................................... 85
TARCEVA ......................................................... 30
targadox ............................................................. 20
TARGRETIN ............................................. 24, 130
tarina 24 fe ......................................................... 81
tarina fe 1/20 eq ................................................. 81
TARON-C DHA .............................................. 112
TARPEYO ......................................................... 97
TASCENSO ODT .............................................. 67
TASIGNA .......................................................... 30
tasimelteon ......................................................... 62
TASMAR ........................................................... 50
tavaborole ......................................................... 125
TAVALISSE .................................................... 102
TAVNEOS ....................................................... 102
TAYTULLA ....................................................... 81
tazarotene ......................................................... 125
TAZAROTENE ............................................... 124
tazicef ................................................................. 17
TAZORAC ....................................................... 125
taztia xt ............................................................... 39
TAZVERIK ....................................................... 30
TDVAX ........................................................... 108
TECENTRIQ ..................................................... 30
TECFIDERA ..................................................... 67
TECFIDERA STARTER PACK ....................... 67
TECVAYLI ....................................................... 30
TEFLARO ......................................................... 17
TEGRETOL................................................. 57, 58
TEGRETOL-XR ................................................ 58
TEGSEDI........................................................... 65
TEKTURNA ...................................................... 41
TEKTURNA HCT ............................................. 41
telmisartan ......................................................... 34
telmisartan/amlodipine ...................................... 34
telmisartan/hydrochlorothiazide ....................... 34
temazepam ......................................................... 62
TEMODAR ....................................................... 21
temsirolimus ...................................................... 30
tencon................................................................... 1
TENIVAC ........................................................ 108
tenofovir disoproxil fumarate ............................ 14
TENORETIC 100 .............................................. 37
TENORETIC 50 ................................................ 37
TENORMIN ...................................................... 38
TEPADINA ....................................................... 21
TEPEZZA .......................................................... 88
TEPMETKO ...................................................... 30
terazosin hcl ....................................................... 33
terazosin hydrochloride ..................................... 33
terbinafine hcl .................................................... 12
terbutaline sulfate ............................................ 119
terconazole......................................................... 98
teriflunomide ...................................................... 67
TERIPARATIDE............................................... 77
TESTIM ............................................................. 70
TESTOPEL ........................................................ 70
testosterone ........................................................ 70
testosterone cypionate ....................................... 70
testosterone enanthate ....................................... 70
testosterone pump .............................................. 70
tetrabenazine ..................................................... 65
TETRACAINE HYDROCHLORIDE ............. 117
tetracycline hydrochloride ................................. 20
TEXACORT .................................................... 128
TEZSPIRE ....................................................... 121
THALITONE..................................................... 40
THALOMID ...................................................... 23
THEO-24 ......................................................... 121
theophylline ..................................................... 121
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 167
theophylline er .................................................. 121
THIOLA ............................................................. 97
THIOLA EC ....................................................... 97
thioridazine hcl ................................................... 53
thiotepa ............................................................... 21
thiothixene .......................................................... 53
THRIVITE RX ................................................. 112
THYMOGLOBULIN ....................................... 107
THYQUIDITY ................................................... 90
tiadylt er ............................................................. 39
tiagabine hydrochloride ..................................... 58
TIAZAC ............................................................. 39
TIBSOVO........................................................... 30
TICE BCG .......................................................... 24
TICOVAC ........................................................ 108
TIGAN ............................................................... 91
tigecycline ........................................................... 20
TIGLUTIK ......................................................... 65
TIKOSYN .......................................................... 35
TILIA FE ............................................................ 81
timolol maleate ........................................... 38, 116
TIMOLOL MALEATE .................................... 116
TIMOPTIC ....................................................... 116
TIMOPTIC OCUDOSE ................................... 116
TIMOPTIC-XE ................................................ 116
tinidazole ............................................................ 10
tiopronin ............................................................. 97
TIROSINT .......................................................... 90
TIROSINT-SOL ................................................. 90
TIS-U-SOL ....................................................... 131
TIVDAK ............................................................. 30
TIVICAY ........................................................... 14
TIVICAY PD ..................................................... 14
tizanidine hcl ...................................................... 69
tizanidine hydrochloride .................................... 69
TLANDO ........................................................... 70
TOBI................................................................... 10
TOBI PODHALER ............................................ 10
TOBRADEX .................................................... 113
TOBRADEX ST .............................................. 113
tobramycin .................................................. 10, 114
tobramycin sulfate .............................................. 10
tobramycin/dexamethasone .............................. 114
TOBREX .......................................................... 114
TOLAK ............................................................ 130
tolcapone ............................................................ 50
tolmetin sodium .................................................... 3
TOLSURA ......................................................... 12
tolterodine tartrate ............................................. 98
tolterodine tartrate er ........................................ 98
tolvaptan ............................................................ 88
TOPAMAX ....................................................... 58
TOPICORT ...................................................... 128
topiramate .......................................................... 58
toposar ............................................................... 24
topotecan hcl...................................................... 24
TOPOTECAN HCL .......................................... 24
TOPROL XL ..................................................... 38
toremifene citrate ............................................... 23
TORISEL ........................................................... 30
torsemide ........................................................... 40
TOSYMRA ........................................................ 64
TOUJEO MAX SOLOSTAR ............................ 73
TOUJEO SOLOSTAR ...................................... 73
tovet ................................................................. 128
TOVIAZ ............................................................ 98
TPN ELECTROLYTES .................................. 110
TRACLEER....................................................... 43
TRADJENTA .................................................... 76
tramadol hcl ......................................................... 7
tramadol hcl er .................................................... 4
TRAMADOL HCL ER ....................................... 4
tramadol hydrochloride ....................................... 7
tramadol hydrochloride/acetaminophen ............. 7
trandolapril .................................................. 32, 33
trandolapril/verapamil hcl er ............................ 32
tranexamic acid ............................................... 102
TRANSDERM-SCOP ....................................... 92
tranylcypromine sulfate ..................................... 48
TRAVASOL .................................................... 113
TRAVATAN Z ................................................ 116
travoprost......................................................... 116
TRAZIMERA .................................................... 30
trazodone hydrochloride.................................... 48
TREANDA ........................................................ 21
TRECATOR ...................................................... 15
TRELEGY ELLIPTA ...................................... 118
TRELSTAR MIXJECT ..................................... 23
TREMFYA ...................................................... 104
treprostinil ......................................................... 43
TRESIBA........................................................... 73
TRESIBA FLEXTOUCH .................................. 73
tretinoin ..................................................... 24, 124
TRETINOIN MICROSPHERE ....................... 124
TREXALL ....................................................... 105
TREXIMET ....................................................... 64
trezix .................................................................... 7
tri femynor ......................................................... 81
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 168
triamcinolone acetonide ............................. 85, 128
triamcinolone acetonide dental paste .............. 132
triamterene ......................................................... 40
triamterene/hydrochlorothiazide ........................ 40
trianex ............................................................... 128
triazolam............................................................. 62
TRIBENZOR ..................................................... 34
TRICARE PRENATAL ................................... 112
tricitrates ............................................................ 97
TRICOR ............................................................. 35
triderm .............................................................. 128
trientine hydrochloride ....................................... 77
TRIESENCE .................................................... 115
tri-estarylla ......................................................... 81
trifluoperazine hcl .............................................. 53
trifluoperazine hydrochloride ............................ 53
trifluridine ........................................................ 114
trihexyphenidyl hcl ............................................. 50
trihexyphenidyl hydrochloride ........................... 50
TRIJARDY XR .................................................. 76
TRIKAFTA ...................................................... 121
tri-legest fe .......................................................... 81
TRILEPTAL ....................................................... 58
tri-linyah ............................................................. 82
TRILIPIX ........................................................... 35
tri-lo-estarylla .................................................... 82
tri-lo-marzia ....................................................... 82
tri-lo-mili ............................................................ 82
tri-lo-sprintec ..................................................... 82
trimethobenzamide hydrochloride ...................... 92
trimethoprim ............................................... 10, 114
trimethoprim sulfate/polymyxin b sulfate ......... 114
tri-mili................................................................. 82
trimipramine maleate ......................................... 48
TRINATAL RX 1 ............................................ 112
TRINTELLIX ..................................................... 48
tri-nymyo ............................................................ 82
TRIOSTAT......................................................... 90
TRIPTODUR ..................................................... 88
TRISENOX ........................................................ 24
tri-sprintec .......................................................... 82
TRISTART DHA ............................................. 112
TRISTART FREE ............................................ 112
TRISTART ONE.............................................. 112
tritocin .............................................................. 128
TRIUMEQ .......................................................... 15
TRIUMEQ PD.................................................... 15
TRI-VI-FLOR .................................................. 112
tri-vite/fluoride ................................................. 112
trivora-28 ........................................................... 82
tri-vylibra ........................................................... 82
tri-vylibra lo ....................................................... 82
TRIZIVIR .......................................................... 15
TRODELVY ...................................................... 30
TROGARZO ..................................................... 14
TROKENDI XR ................................................ 58
TROPHAMINE ............................................... 113
trospium chloride ............................................... 98
trospium chloride er .......................................... 98
TRUDHESA ...................................................... 64
TRULANCE ...................................................... 95
TRULICITY ...................................................... 76
TRUMENBA ................................................... 108
TRUSELTIQ ..................................................... 30
TRUSOPT ....................................................... 116
TRUVADA ........................................................ 15
TRUXIMA......................................................... 30
TUKYSA ........................................................... 30
TURALIO .......................................................... 30
TWINRIX ........................................................ 108
TWYNEO ........................................................ 124
TYBLUME ........................................................ 82
TYBOST ............................................................ 14
tydemy ................................................................ 82
TYGACIL .......................................................... 20
TYKERB ........................................................... 30
TYMLOS ........................................................... 77
TYPHIM VI ..................................................... 108
TYRVAYA ...................................................... 117
TYSABRI .......................................................... 67
TYVASO ........................................................... 43
TYVASO DPI MAINTENANCE ..................... 43
TYVASO DPI MAINTENANCE KIT.............. 43
TYVASO DPI TITRATION KIT...................... 43
TYVASO REFILL ............................................ 43
TYVASO STARTER ........................................ 43
TZIELD ............................................................. 76
UBRELVY ........................................................ 64
UCERIS ............................................................. 93
UCERIS FOAM ................................................ 93
UDENYCA ...................................................... 100
ULORIC .............................................................. 1
ULTOMIRIS ................................................... 102
ULTRAVATE ................................................. 128
UNASYN........................................................... 19
UNASYN BULK PACK ................................... 19
unithroid ............................................................ 90
UPLIZNA .......................................................... 65
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 169
UPTRAVI........................................................... 43
UPTRAVI TITRATION PACK......................... 43
UROCIT-K ......................................................... 97
UROGESIC-BLUE ............................................ 10
UROXATRAL ................................................... 97
URSO 250 .......................................................... 95
URSO FORTE.................................................... 95
ursodiol............................................................... 95
URSODIOL ........................................................ 95
UZEDY .............................................................. 53
VABOMERE ..................................................... 10
VABYSMO ...................................................... 117
VAGIFEM .......................................................... 83
valacyclovir hcl .................................................. 16
valacyclovir hydrochloride ................................ 16
VALCHLOR .................................................... 130
VALCYTE ......................................................... 16
valganciclovir ..................................................... 16
valganciclovir hydrochloride ............................. 16
VALIUM ............................................................ 58
valproate sodium ................................................ 58
valproic acid ....................................................... 58
valrubicin ........................................................... 21
valsartan ............................................................. 34
VALSARTAN .................................................... 34
valsartan/hydrochlorothiazide ........................... 34
VALSTAR ......................................................... 21
VALTOCO ......................................................... 58
VALTREX ......................................................... 16
VANCOCIN ................................................. 10, 11
VANCOMYCIN ................................................ 11
vancomycin hcl ................................................... 11
VANCOMYCIN HCL ....................................... 11
vancomycin hydrochloride ................................. 11
VANCOMYCIN HYDROCHLORIDE ............. 11
VANCOMYCIN
HYDROCHLORIDE/DEXTROSE ................ 11
VANDAZOLE ................................................... 98
VANFLYTA ...................................................... 30
VANOS ............................................................ 128
VAQTA ............................................................ 108
VARENICLINE STARTING MONTH BOX ... 70
VARENICLINE TARTRATE ........................... 70
VARIVAX ....................................................... 108
VARIZIG ......................................................... 105
VARUBI............................................................. 92
VASCEPA .......................................................... 36
VASERETIC ...................................................... 32
vasopressin ......................................................... 88
VASOSTRICT .................................................. 88
VASOTEC ......................................................... 33
VECAMYL ....................................................... 41
VECTIBIX......................................................... 30
VECTICAL ..................................................... 126
VEGZELMA ..................................................... 30
VEKLURY ........................................................ 16
VELCADE......................................................... 30
VELETRI........................................................... 43
velivet ................................................................. 82
VELPHORO ...................................................... 89
VELTASSA ....................................................... 77
VELTIN ........................................................... 124
VEMLIDY ......................................................... 16
VENCLEXTA ................................................... 31
VENCLEXTA STARTING PACK ................... 31
VENLAFAXINE BESYLATE ER ................... 48
venlafaxine hcl er............................................... 48
venlafaxine hydrochloride ................................. 49
venlafaxine hydrochloride er ............................. 49
VENTAVIS ....................................................... 43
VENTOLIN HFA ............................................ 119
VEOZAH ........................................................... 88
verapamil hcl ..................................................... 39
verapamil hcl er ................................................. 39
verapamil hcl sr ................................................. 39
VERAPAMIL HCL SR ..................................... 39
verapamil hydrochloride ................................... 39
verapamil hydrochloride er ............................... 39
VERDESO ....................................................... 128
VEREGEN....................................................... 130
VERELAN......................................................... 39
VERELAN PM .................................................. 39
VERKAZIA ..................................................... 117
VERQUVO ........................................................ 41
VERSACLOZ .................................................... 53
VERZENIO ....................................................... 31
VESICARE ........................................................ 98
VESICARE LS .................................................. 98
vestura ............................................................... 82
VFEND .............................................................. 12
VFEND IV ......................................................... 12
V-GO 20 ............................................................ 73
V-GO 30 ............................................................ 73
V-GO 40 ............................................................ 73
VIBATIV ........................................................... 11
VIBERZI ........................................................... 95
VIBRAMYCIN ................................................. 20
VICTOZA .......................................................... 76
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 170
VIDAZA ............................................................. 22
VIEKIRA PAK .................................................. 16
vienva ................................................................. 82
vigabatrin ........................................................... 58
vigadrone ............................................................ 58
VIGAMOX....................................................... 114
VIIBRYD ........................................................... 49
VIIBRYD STARTER PACK ............................. 49
VIJOICE ............................................................. 88
vilazodone hydrochloride ................................... 49
VILTEPSO ......................................................... 65
VIMIZIM ........................................................... 88
VIMOVO ............................................................. 3
VIMPAT............................................................. 58
vinblastine sulfate ............................................... 25
vincasar pfs ........................................................ 25
vincristine sulfate ............................................... 25
vinorelbine tartrate ............................................ 25
VIOKACE .......................................................... 96
viorele ................................................................. 82
VIRACEPT ........................................................ 14
VIRASAL......................................................... 130
VIREAD ............................................................. 14
VIRT-NATE DHA ........................................... 112
VIRT-PN DHA ................................................ 112
VISTARIL ........................................................ 119
VISTOGARD ..................................................... 88
VITAFOL GUMMIES ..................................... 112
VITAFOL STRIPS ........................................... 112
VITAFOL ULTRA .......................................... 112
VITAFOL-NANO ............................................ 112
VITAFOL-OB .................................................. 112
VITAFOL-ONE ............................................... 112
VITRAKVI ......................................................... 31
VIVELLE-DOT ................................................. 83
VIVITROL ......................................................... 70
VIVJOA ............................................................. 12
VIZIMPRO......................................................... 31
VOGELXO ......................................................... 71
VOGELXO PUMP ............................................. 71
volnea ................................................................. 82
VONJO ............................................................... 31
VOQUEZNA DUAL PAK ................................. 95
VOQUEZNA TRIPLE PAK .............................. 95
voriconazole ....................................................... 12
VOSEVI ............................................................. 16
VOTRIENT ........................................................ 31
VOWST .............................................................. 95
VOXZOGO ........................................................ 88
VPRIV ............................................................... 88
VRAYLAR .................................................. 53, 54
VTAMA........................................................... 126
VUITY ............................................................. 116
VUMERITY ...................................................... 67
VUSION .......................................................... 125
VYEPTI ............................................................. 64
vyfemla ............................................................... 82
VYJUVEK ....................................................... 131
vylibra ................................................................ 82
VYNDAMAX ................................................... 41
VYNDAQEL ..................................................... 41
VYONDYS 53 ................................................... 65
VYTORIN ......................................................... 37
VYVANSE ........................................................ 61
VYVGART ...................................................... 106
VYVGART HYTRULO.................................. 106
VYXEOS ........................................................... 24
VYZULTA ...................................................... 116
WAKIX ............................................................. 69
warfarin sodium ................................................. 99
WELCHOL ........................................................ 37
WELIREG ......................................................... 24
WELLBUTRIN SR ........................................... 49
WELLBUTRIN XL ........................................... 49
wera ................................................................... 82
WESCAP-C DHA ........................................... 112
WESCAP-PN DHA ......................................... 112
WESNATE DHA ............................................ 112
WESTAB PLUS .............................................. 112
WESTGEL DHA ............................................. 112
WINLEVI ........................................................ 124
WINRHO SDF ................................................ 105
wixela ............................................................... 122
wymzya fe ........................................................... 82
XACIATO ......................................................... 98
XADAGO .......................................................... 50
XALATAN ...................................................... 117
XALKORI ......................................................... 31
XANAX ............................................................. 45
XANAX SR ....................................................... 44
XARELTO......................................................... 99
XARELTO STARTER PACK .......................... 99
XATMEP ......................................................... 105
XCOPRI............................................................. 58
XDEMVY ........................................................ 114
XELJANZ ........................................................ 104
XELJANZ XR ................................................. 104
XELPROS ....................................................... 117
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 171
XELSTRYM ...................................................... 61
XEMBIFY ........................................................ 105
XENAZINE ........................................................ 66
XENLETA ......................................................... 11
XENPOZYME ................................................... 88
XEOMIN ............................................................ 69
XERAVA ........................................................... 20
XERESE ........................................................... 130
XERMELO......................................................... 95
XGEVA .............................................................. 77
XHANCE ......................................................... 121
XIAFLEX ........................................................... 88
XIFAXAN .................................................... 11, 95
XIGDUO XR ...................................................... 76
XIIDRA ............................................................ 117
XIMINO ............................................................. 20
XIPERE ............................................................ 115
XOFLUZA ......................................................... 16
XOLAIR ........................................................... 121
XOPENEX HFA .............................................. 119
XOSPATA ......................................................... 31
XPOVIO ............................................................. 31
XTAMPZA ER .................................................... 4
XTANDI ............................................................. 23
xulane ................................................................. 82
XULTOPHY ...................................................... 73
XURIDEN .......................................................... 88
XYLOCAINE....................................................... 8
XYLOCAINE/EPINEPHRINE ............................ 8
XYLOCAINE-MPF ............................................. 8
XYLOCAINE-MPF/EPINEPHRINE .................. 8
XYOSTED ......................................................... 71
XYREM ............................................................. 69
XYWAV ............................................................. 69
YASMIN 28 ....................................................... 82
YAZ .................................................................... 82
YERVOY ........................................................... 31
YF-VAX ........................................................... 108
YONDELIS ........................................................ 21
YONSA .............................................................. 23
YUPELRI ......................................................... 118
YUTIQ ............................................................. 115
yuvafem ............................................................... 83
zafemy ................................................................. 82
zafirlukast ......................................................... 120
zaleplon .............................................................. 62
ZALTRAP .......................................................... 31
ZANAFLEX ....................................................... 69
ZANOSAR ......................................................... 21
ZARONTIN ....................................................... 59
ZARXIO .......................................................... 100
ZAVESCA ......................................................... 88
ZAVZPRET ....................................................... 64
zebutal .................................................................. 1
ZEGALOGUE ................................................... 85
ZEGERID .......................................................... 96
ZEJULA............................................................. 31
ZELAPAR ......................................................... 50
ZELBORAF....................................................... 31
ZEMAIRA ....................................................... 121
ZEMBRACE SYMTOUCH .............................. 64
ZEMDRI ............................................................ 11
ZEMPLAR......................................................... 90
zenatane ........................................................... 124
ZENPEP............................................................. 96
zenzedi ............................................................... 61
ZEPATIER ........................................................ 16
ZEPOSIA ..................................................... 67, 68
ZEPOSIA 7-DAY STARTER PACK ............... 67
ZEPZELCA ....................................................... 21
ZERBAXA ........................................................ 17
ZERVIATE ...................................................... 115
ZESTORETIC ................................................... 32
ZESTRIL ........................................................... 33
ZETIA ................................................................ 37
ZETONNA ...................................................... 121
ZIAC .................................................................. 37
ZIAGEN ............................................................ 14
ZIANA ............................................................. 124
zidovudine .......................................................... 14
ZIEXTENZO ................................................... 100
zileuton er ........................................................ 120
ZILRETTA ........................................................ 85
ZILXI ............................................................... 130
ZIMHI ................................................................ 70
ZINPLAVA ..................................................... 106
ZIOPTAN ........................................................ 117
ziprasidone hcl ................................................... 54
ziprasidone mesylate.......................................... 54
ZIPSOR ............................................................... 3
ZIRABEV .......................................................... 31
ZIRGAN .......................................................... 114
ZITHROMAX ................................................... 18
ZITHROMAX TRI-PAK .................................. 18
ZITHROMAX Z-PAK ...................................... 18
ZOCOR .............................................................. 36
ZOKINVY ......................................................... 88
ZOLADEX ........................................................ 23
2024 FEHB v9 effective 01/01/2024
01/01/2024 Page 172
zoledronic acid ................................................... 77
ZOLEDRONIC ACID ........................................ 77
ZOLINZA ........................................................... 31
zolmitriptan ........................................................ 64
zolmitriptan odt .................................................. 64
ZOLOFT............................................................. 49
zolpidem tartrate ................................................ 62
ZOLPIDEM TARTRATE .................................. 62
zolpidem tartrate er ............................................ 62
ZOLPIMIST ....................................................... 63
ZOMACTON ..................................................... 88
ZOMIG ............................................................... 64
ZONALON ....................................................... 130
ZONEGRAN ...................................................... 59
ZONISADE ........................................................ 59
zonisamide .......................................................... 59
ZONTIVITY .................................................... 102
ZORBTIVE ........................................................ 88
ZORTRESS ...................................................... 107
ZORVOLEX ........................................................ 3
ZORYVE .......................................................... 126
ZOSYN............................................................... 19
zovia 1/35 ........................................................... 82
ZOVIRAX ................................................. 16, 130
ZTALMY........................................................... 59
ZTLIDO ........................................................... 129
ZUBSOLV ......................................................... 70
ZULRESSO ....................................................... 49
zumandimine ...................................................... 82
ZYCLARA ...................................................... 131
ZYDELIG .......................................................... 31
ZYFLO ............................................................ 120
ZYKADIA ......................................................... 31
ZYLET............................................................. 114
ZYLOPRIM ......................................................... 1
ZYMAXID ...................................................... 114
ZYNLONTA ..................................................... 31
ZYNYZ .............................................................. 31
ZYPITAMAG .................................................... 36
ZYPREXA ......................................................... 54
ZYPREXA RELPREVV ................................... 54
ZYPREXA ZYDIS ............................................ 54
ZYTIGA ............................................................ 23
ZYVOX ............................................................. 11
This formulary was updated on 10/27/2023. For more recent information or other questions, please
contact Customer Care at 1-833-271-9775, 24 hours a day, 7 days a week. TTY users should call 711, or
visit Caremark.com.
The formulary and/or pharmacy network may change at any time. You will receive notice when
necessary.
Aetna Medicare Rx offered by SilverScript is a group standalone Medicare Prescription Drug Plan
(PDP). This Plan is offered by SilverScript Insurance Company, which has a Medicare contract.
SilverScript Insurance Company and Aetna are affiliated companies. Enrollment in the Plan depends on
Medicare contract renewal.
P.O. Box 30006, Pittsburgh, PA 15222-0330
10/27/2023
