2016 Value Formulary - Health Net What is the Health Net Amber (HMO SNP), Health Net Gold Select...

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN

Health Net Amber (HMO SNP), Health Net Gold Select (HMO), Health Net Healthy Heart (HMO), Health Net Jade (HMO SNP), Health Net Jade Cardiovascular (HMO SNP), Health Net Ruby (HMO), Health Net Ruby 1 (HMO), Health Net Ruby 4 (HMO), Health Net Ruby Select (HMO), Health Net Seniority Plus Amber I (HMO SNP), Health Net Seniority Plus Amber II (HMO SNP), Health Net Seniority Plus Amber II Premier (HMO SNP), Health Net Seniority Plus Ruby (HMO), Health Net Seniority Plus Sapphire (HMO SNP), Health Net Seniority Plus Sapphire Premier (HMO SNP), Health Net Violet (PPO), Health Net Violet Option 1 (PPO), Health Net Violet Option 2 (PPO), and Health Net Violet Option 3 (PPO)

HPMS Approved Formulary File Submission ID: 16217, Version Number:

This formulary was updated on For more recent information or other questions, please contact Health Net at:

Arizona Plans: 1-800-977-7522

California HMO Plans: 1-800-275-4737 California HMO SNP Plans: 1-800-431-9007 California PPO Plans: 1-800-960-4638

Oregon/Washington Plans: 1-888-445-8913

or, for TTY users, 711, 8:00 a.m. - 8:00 p.m., seven days a week (automated telephone service is used on some weekends and holidays), or visit www.healthnet.com/medicare.

Material ID# Y0035_2016_0003_A (H0351, H0562, H5439, H5520, H6815, H3561, EG) CMS Accepted 07252015

2016 Value Formulary (List of Covered Drugs)

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12/1/2016.

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Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take.

When this drug list (formulary) refers to “we,” “us”, or “our,” it means Health Net. When it refers to “plan” or “our plan,” it means Health Net Amber (HMO SNP), Health Net Gold Select (HMO), Health Net Healthy Heart (HMO), Health Net Jade (HMO SNP), Health Net Jade Cardiovascular (HMO SNP), Health Net Ruby (HMO), Health Net Ruby 1 (HMO), Health Net Ruby 4 (HMO), Health Net Ruby Select (HMO), Health Net Seniority Plus Amber I (HMO SNP), Health Net Seniority Plus Amber II (HMO SNP), Health Net Seniority Plus Amber II Premier (HMO SNP), Health Net Seniority Plus Ruby (HMO), Health Net Seniority Plus Sapphire (HMO SNP), Health Net Seniority Plus Sapphire Premier (HMO SNP), Health Net Violet (PPO), Health Net Violet Option 1 (PPO), Health Net Violet Option 2 (PPO), and Health Net Violet Option 3 (PPO).

This document includes a list of the drugs (formulary) for our plan which is current as of the date on the front and back cover pages. 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, 2017, and from time to time during the year.

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What is the Health Net Amber (HMO SNP), Health Net Gold Select (HMO), Health Net Healthy Heart (HMO), Health Net Jade (HMO SNP), Health Net Jade Cardiovascular (HMO SNP), Health Net Ruby (HMO), Health Net Ruby 1 (HMO), Health Net Ruby 4 (HMO), Health Net Ruby Select (HMO), Health Net Seniority Plus Amber I (HMO SNP), Health Net Seniority Plus Amber II (HMO SNP), Health Net Seniority Plus Amber II Premier (HMO SNP), Health Net Seniority Plus Ruby (HMO), Health Net Seniority Plus Sapphire (HMO SNP), Health Net Seniority Plus Sapphire Premier (HMO SNP), Health Net Violet (PPO), Health Net Violet Option 1 (PPO), Health Net Violet Option 2 (PPO), and Health Net Violet Option 3 (PPO) Value Formulary?A formulary is a list of covered drugs selected by our plan 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. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change?Generally, if you are taking a drug on our 2016 formulary that was covered at the beginning of the

year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, add prior authorization, quantity limits 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 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. 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 will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of the date on the front and back cover pages. To get updated information about the drugs covered by our plan, please contact us. Our contact information appears on the front and back cover pages.

If we make any other negative changes to a drug you are taking, we will notify you via mail. We will also post the changes on our website.

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How do I use the formulary? There are two ways to find your drug within the formulary:

Medical ConditionThe 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 AGENTS - MISC.”. 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.

Alphabetical ListingIf you are not sure what category to look under, you should look for your drug in the Index that begins on page Index 1. 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. Look in the Index and find your drug. 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.

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.

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: Our plan requires you or your physician to get prior authorization for

certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don’t get approval, we may not cover the drug.

• Quantity Limits: For certain drugs, our plan limits the amount of the drug that we will cover. For example, our plan provides two each per day per prescription for simvastatin 40 mg. This may be in addition to a standard one-month or three-month supply.

• Step Therapy: 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 Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also 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 us 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 Health Net Amber (HMO SNP), Health Net Gold Select (HMO), Health Net Healthy Heart (HMO), Health Net Jade (HMO SNP), Health Net Jade Cardiovascular (HMO SNP), Health Net Ruby (HMO), Health Net Ruby 1 (HMO), Health Net Ruby 4 (HMO), Health Net Ruby Select (HMO),

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Health Net Seniority Plus Amber I (HMO SNP), Health Net Seniority Plus Amber II (HMO SNP), Health Net Seniority Plus Amber II Premier (HMO SNP), Health Net Seniority Plus Ruby (HMO), Health Net Seniority Plus Sapphire (HMO SNP), Health Net Seniority Plus Sapphire Premier (HMO SNP), Health Net Violet (PPO), Health Net Violet Option 1 (PPO), Health Net Violet Option 2 (PPO), and Health Net Violet Option 3 (PPO) Value Formulary?” on page iv 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 Member Services 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 Member Services for a list of similar drugs that are covered by our plan. When you receive the list, show it to your doctor and ask him or her 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 Health Net Amber (HMO SNP), Health Net Gold Select (HMO), Health Net Healthy Heart (HMO), Health Net Jade (HMO SNP), Health Net Jade Cardiovascular (HMO SNP), Health Net Ruby (HMO), Health Net Ruby 1 (HMO), Health Net Ruby 4 (HMO), Health Net Ruby Select (HMO),

Health Net Seniority Plus Amber I (HMO SNP), Health Net Seniority Plus Amber II (HMO SNP), Health Net Seniority Plus Amber II Premier (HMO SNP), Health Net Seniority Plus Ruby (HMO), Health Net Seniority Plus Sapphire (HMO SNP), Health Net Seniority Plus Sapphire Premier (HMO SNP), Health Net Violet (PPO), Health Net Violet Option 1 (PPO), Health Net Violet Option 2 (PPO), and Health Net Violet Option 3 (PPO) Value 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.

• You can ask us to cover a formulary drug at a lower cost-sharing level. 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 drugs included on the plan’s formulary, 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.

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You should contact us to ask us 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 (unless you have a prescription written for fewer days) when you go to

a network pharmacy. 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, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If 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 (unless you have a prescription for fewer days) while you pursue a formulary exception.

Level of care changesIf you experience a change in your level of care, we will cover a transition supply of your drugs. A level of care change occurs when you are discharged from a hospital or moved to or from a long-term care facility.

• If you move home from a long-term care facility or hospital and need a transition supply, we will cover one 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a total of a 30-day supply.

• If you move from home or a hospital to a long-term care facility and need a transition supply, we will cover one 31-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a total of a 31-day supply.

We understand that there are other circumstances when an override may be granted. These situations are managed on a case-by-case basis through communication between the dispensing pharmacy and Health Net.

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For more informationFor more detailed information about your plan’s prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about our plan, please contact us. 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 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 http://www.medicare.gov.

Health Net Amber (HMO SNP), Health Net Gold Select (HMO), Health Net Healthy Heart (HMO), Health Net Jade (HMO SNP), Health Net Jade Cardiovascular (HMO SNP), Health Net Ruby (HMO), Health Net Ruby 1 (HMO), Health Net Ruby 4 (HMO), Health Net Ruby Select (HMO), Health Net Seniority Plus Amber I (HMO SNP), Health Net Seniority Plus Amber II (HMO SNP), Health Net Seniority Plus Amber II Premier (HMO SNP), Health Net Seniority Plus Ruby (HMO), Health Net Seniority Plus Sapphire (HMO SNP), Health Net Seniority Plus Sapphire Premier (HMO SNP), Health Net Violet (PPO), Health Net Violet Option 1 (PPO), Health Net Violet Option 2 (PPO), and Health Net Violet Option 3 (PPO) Value 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 that begins on page Index 1.

The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., LIPITOR) and generic drugs are listed in lower-case italics (e.g., atorvastatin calcium).

The information in the Requirements/Limits column tells you if our plan has any special requirements for coverage of your drug.

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Formulary tier descriptions To find out how much you pay for a drug, the abbreviations below appear in the Drug Tier column on the formulary. The copayment or coinsurance level is shown in the Copayment/Coinsurance column. To find out your copayment or coinsurance for each tier, please check your Evidence of Coverage.

Abbreviation Copayment/Coinsurance Description1 Tier 1 copayment Preferred generic drugs.

2 Tier 2 copayment Generic drugs.

3 Tier 3 copayment Preferred brand drugs and may include some generic drugs. Brand drugs in this tier are not eligible for exceptions for payment at a lower tier.

4 Tier 4 copayment Non-preferred brand drugs and may include some generic drugs.

5 (Specialty Tier)

Tier 5 copayment or coinsurance

High cost drugs. Drugs in this tier are not eligible for exceptions for payment at a lower tier.

6 (Select Care Drugs)

$0 copayment Some brand and generic drugs used to treat specific chronic conditions.

NF Non-formulary - If an exception request is approved for a non-formulary drug; the Tier 4 copayment applies. You may not ask us to provide the drug at a lower cost-sharing level.

Drugs not covered on Health Net’s Medicare Part D formulary. You may request an exception from Health Net to cover these drugs. See the section, “How do I request an exception to the Health Net Medicare Part D Value Formulary?”

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AbbreviationsThe abbreviations below may appear in the Requirement/Limits column on the formulary.

Abbreviation Definition DescriptionAL Age Limit This drug may require prior authorization if your age does not meet

manufacturer, FDA, or clinical recommendations.

B/D Medicare Part B vs. Part D

This drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

GL Gender Limit This drug is only covered for males or females based on manufacturer, FDA, or clinical recommendations.

LA Limited Access This drug may be subject to limited access or restricted access. This means that the drug may only be available at one or a limited number of pharmacies. Limited access may be due to the following reasons:• The FDA has restricted distribution of a drug to certain facilities,

pharmacies or prescribers, or • Certain drugs require special handling, coordination of care, or

patient education that cannot be provided at a retail pharmacyYou should talk to your doctor, or other prescriber, or pharmacist for details about getting limited access drugs.

MO Mail Order This drug is available at Health Net’s mail order pharmacy in addition to other network pharmacies.

PA Prior Authorization This drug requires prior authorization. This means that you or your prescriber must get approval from us before you fill your prescription. If you don’t get approval, we may not cover the drug.

QL Quantity Limit This drug has a limit on the amount that Health Net will cover. For example, we cover two each per day per prescription for simvastatin 40 mg. This may be in addition to a standard one-month or three-month supply limit.

RX/OTC Prescription and Over-The-Counter (OTC)

This drug is available both in a prescription form and in an OTC form. Other than some insulins and insulin supplies, only prescription drugs are covered by Health Net Medicare Part D plans.

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Abbreviation Definition DescriptionSL Safety Limit This drug has a maximum daily dose limit for safety supported by

the FDA. This means that Health Net will not cover more than the maximum daily dose. For example, the FDA maximum daily dose of simvastatin is 80 mg. Therefore, we will only cover two tablets per day for simvastatin 40 mg.

ST Step Therapy This drug requires step therapy. This means that you must first try certain drugs to treat your medical condition before Health Net covers another drug for that condition.

For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

* Additional Gap Coverage

Only for Health Net Gold Select (HMO), Health Net Healthy Heart (HMO) plans in Los Angeles, Orange, Riverside and San Bernardino counties, and Health Net Jade (HMO SNP) in California:We provide additional coverage of this prescription drug in the coverage gap. Please refer to your Evidence of Coverage for more information about this coverage.

Drug Name DrugTier

Requirements/Limits

ADHD/ANTI-NARCOLEPSY/ANTI-OBESITY/ANOREXIANTS - Drugs to TreatADHD, Sleep and Eating DisordersAmphetaminesADDERALL XR CP24(Amphetamine-Dextroamphetamine)

NFMO

amphetamine-dextroamphetamine cp241.25mg-1.25mg-1.25mg-1.25mg, 2.5mg-2.5mg-2.5mg-2.5mg, 3.75mg-3.75mg-3.75mg-3.75mg,5mg-5mg-5mg-5mg,6.25mg-6.25mg-6.25mg-6.25mg, 7.5mg-7.5mg-7.5mg-7.5mg

3

MO

amphetamine-dextroamphetamine tabs1.25mg-1.25mg-1.25mg-1.25mg, 1.875mg-1.875mg-1.875mg-1.875mg, 2.5mg-2.5mg-2.5mg-2.5mg, 3.125mg-3.125mg-3.125mg-3.125mg, 3.75mg-3.75mg-3.75mg-3.75mg, 5mg-5mg-5mg-5mg, 7.5mg-7.5mg-7.5mg-7.5mg

2

MO; *

DESOXYN TABS(Methamphetamine HCl) NF MO

DEXEDRINE CP24(DextroamphetamineSulfate)

NFMO

dextroamphetamine sulfatecp24 10 mg, 15 mg, 5 mg 3 MO

dextroamphetamine sulfatetabs 10 mg, 5 mg 3 MO

methamphetamine hcl tabs 4 MO

VYVANSE CAPS 10 MG 4 SL(7 ea daily);MO

VYVANSE CAPS 20 MG 4 SL(3.5 eadaily); MO



Drug Name DrugTier

Requirements/Limits



VYVANSE CAPS 70 MG 4 SL(1 ea daily);MO

Attention-Deficit/Hyperactivity Disorder (ADHD)clonidine hcl (adhd) tb12 2 MO; *

guanfacine hcl (adhd) tb24 2 AL; MO; *

INTUNIV TB24(Guanfacine HCl (ADHD)) NF AL; MO

KAPVAY TB12 (ClonidineHCl (ADHD)) NF MO

STRATTERA CAPS 10 MG 3 SL(10 ea daily);MO

STRATTERA CAPS 100MG 3 SL(1 ea daily);

MO

STRATTERA CAPS 18 MG 3 SL(5.55 eadaily); MO

STRATTERA CAPS 25 MG 3 SL(4 ea daily);MO




Stimulants - Misc.armodafinil tabs 150 mg,200 mg, 250 mg, 50 mg 2 PA; MO; *

CONCERTA TBCR(Methylphenidate HCl) NF MO

DAYTRANA PTCH 30MG/9HR 4 MO

dexmethylphenidate hclcp24 10 mg, 15 mg, 20 mg 2 MO; *

dexmethylphenidate hcltabs 10 mg, 2.5 mg, 5 mg 1 MO; *

FOCALIN TABS(Dexmethylphenidate HCl) NF MO

FOCALIN XR CP24 10MG, 20 MG(Dexmethylphenidate HCl)

4MO

You can find information on what the symbols and abbreviations in this table mean by going topage viii.

Health Net 2016 Value Formulary Updated 12/1/2016

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Drug Name DrugTier

Requirements/Limits

FOCALIN XR CP24 15 MG(Dexmethylphenidate HCl) NF MO

METADATE CD CPCR(Methylphenidate HCl) NF MO

methylphenidate hcl cp24or 20 mg, 40 mg 3 MO

methylphenidate hcl cp24or 30 mg 2 MO; *

methylphenidate hcl cpcr or10 mg, 20 mg, 30 mg, 40mg, 50 mg, 60 mg

2MO; *

methylphenidate hcl tabs or10 mg, 20 mg, 5 mg 2 MO; *

methylphenidate hcl tb24or 18 mg, 27 mg, 36 mg,54 mg

3

methylphenidate hcl tbcr or10 mg 2 MO; *

methylphenidate hcl tbcr or18 mg, 20 mg, 27 mg, 36mg, 54 mg

3MO

modafinil tabs 100 mg 2 PA; MO; *

modafinil tabs 200 mg 5 PA; MO

NUVIGIL TABS 150 MG,250 MG, 50 MG(Armodafinil)

4PA; MO

NUVIGIL TABS 200 MG 4 PA; MO

PROVIGIL TABS(Modafinil) 5 PA; MO

RITALIN LA CP24 10 MG 4 MO

RITALIN LA CP24 20 MG,30 MG, 40 MG(Methylphenidate HCl)

NFMO

RITALIN TABS(Methylphenidate HCl) NF MO

AMINOGLYCOSIDES - Drugs to Treat BacterialInfectionsAminoglycosidesamikacin sulfate soln ij 1gm/4ml, 500 mg/2ml 1 MO; *

BETHKIS NEBU 5 B/D

Drug Name DrugTier

Requirements/Limits

gentamicin in saline soln0.9%-1mg/ml 2 *

gentamicin sulfate soln ij 40mg/ml 1 MO; *

KITABIS PAK NEBU 5 B/D

neomycin sulfate tabs or 1 MO; *

paromomycin sulfate caps 3 MO

TOBI NEBU (Tobramycin) 5 B/D

TOBI PODHALER CAPS 5

tobramycin nebu in 2 B/D; *

tobramycin sulfate soln ij1.2 gm/30ml, 40 mg/ml, 80mg/2ml

1MO; *

tobramycin sulfate solr ij1.2 gm 1 *

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain, Swelling, Muscle and JointConditionsAnti-TNF-alpha - Monoclonal AntibodiesHUMIRA PEDIATRICCROHNS DISEASESTARTER PACK PSKT

5PA

HUMIRA PEN PNKT 5 PA

HUMIRA PEN-CROHNSDISEASESTARTER PNKT 5 PA

HUMIRA PEN-PSORIASISSTARTER PNKT 5 PA

HUMIRA PSKT 5 PA

SIMPONI ARIA SOLN 5 PA

SIMPONI SOAJ 5 PA

SIMPONI SOSY 5 PA

Antirheumatic - Enzyme InhibitorsXELJANZ TABS 5 PA

XELJANZ XR TB24 5 PA



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Drug Name DrugTier

Requirements/Limits

Antirheumatic AntimetabolitesOTREXUP SOAJ 4 PA

RASUVO SOAJ 4 PA

RHEUMATREX TABS 3 MO

Gold CompoundsRIDAURA CAPS 5 MO

Interleukin-1 BlockersARCALYST SOLR 5 LA

Interleukin-1 Receptor Antagonist (IL-1Ra)KINERET SOSY 5 PA

Interleukin-1beta BlockersILARIS SOLR 5 LA

Interleukin-6 Receptor InhibitorsACTEMRA SOLN 5 PA

ACTEMRA SOSY 5 PA

Nonsteroidal Anti-inflammatory Agents (NSAIDs)ANAPROX DS TABS(Naproxen Sodium) NF MO

ARTHROTEC 50 TBEC(Diclofenac w/ Misoprostol) NF MO

ARTHROTEC 75 TBEC(Diclofenac w/ Misoprostol) NF MO

CATAFLAM TABS(Diclofenac Potassium) NF MO

CELEBREX CAPS(Celecoxib) NF MO

celecoxib caps 2 MO; *

DAYPRO TABS(Oxaprozin) NF MO

diclofenac potassium tabs 2 MO; *

diclofenac sodium tb24 or100 mg 2 MO; *

diclofenac sodium tbec or25 mg, 50 mg, 75 mg 2 MO; *

Drug Name DrugTier

Requirements/Limits

diclofenac w/ misoprostoltbec 3 MO

DUEXIS TABS 5 PA; MO

EC-NAPROSYN TBEC(Naproxen) NF MO

etodolac caps 200 mg, 300mg 2 MO; *

etodolac tabs 400 mg, 500mg 2 MO; *

etodolac tb24 400 mg, 500mg, 600 mg 2 MO; *

FELDENE CAPS(Piroxicam) NF MO

fenoprofen calcium tabs or600 mg 2 MO; *

flurbiprofen tabs or 100 mg,50 mg 1 MO; *

ibuprofen susp or 100mg/5ml 2 RX/OTC; MO; *

ibuprofen tabs or 400 mg 1 SL(8 ea daily);MO; *

ibuprofen tabs or 600 mg 1 SL(5.33 eadaily); MO; *

ibuprofen tabs or 800 mg 1 SL(4 ea daily);MO; *

INDOCIN SUSP OR 25MG/5ML 4 AL; MO

indomethacin caps or 25mg, 50 mg 2 AL; MO; *

indomethacin cpcr or 75mg 2 AL; MO; *

ketoprofen caps or 50 mg,75 mg 2 MO; *

ketoprofen cp24 or 200 mg 3 MO

ketorolac tromethaminesoln ij 15 mg/ml, 30 mg/ml 2 AL; MO; *

ketorolac tromethaminesoln im 30 mg/ml, 60mg/2ml

1AL; MO; *

ketorolac tromethaminetabs or 10 mg 2 AL; MO; *

meclofenamate sodiumcaps or 50 mg 2 MO; *



3

Drug Name DrugTier

Requirements/Limits

mefenamic acid caps or 4 MO

meloxicam tabs or 15 mg,7.5 mg 1 MO; *

MOBIC TABS 15 MG, 7.5MG (Meloxicam) NF MO

nabumetone tabs 2 MO; *

NAPRELAN TB24 375 MG(Naproxen Sodium) 4 MO

NAPRELAN TB24 750 MG 4 MO

NAPROSYN TABS 250MG, 375 MG, 500 MG(Naproxen)

NFMO

naproxen sodium tabs or275 mg, 550 mg 2 MO; *

naproxen sodium tb24 or375 mg 2 MO; *

naproxen tabs or 250 mg,375 mg, 500 mg 1 MO; *

naproxen tbec or 375 mg,500 mg 2 MO; *

oxaprozin tabs 3 MO

piroxicam caps or 10 mg,20 mg 2 MO; *

PONSTEL CAPS(Mefenamic Acid) 4 MO

sulindac tabs or 150 mg,200 mg 2 MO; *

tolmetin sodium caps 400mg 1 MO; *

tolmetin sodium tabs 200mg 1 *

tolmetin sodium tabs 600mg 2 MO; *

VIMOVO TBEC 5 PA; MO

VOLTAREN-XR TB24(Diclofenac Sodium) NF MO

ZIPSOR CAPS 4 MO

Phosphodiesterase 4 (PDE4) InhibitorsOTEZLA TABS 5 PA

Drug Name DrugTier

Requirements/Limits

OTEZLA TBPK 5 PA

Pyrimidine Synthesis InhibitorsARAVA TABS(Leflunomide) NF MO

leflunomide tabs 3 MO

Selective Costimulation ModulatorsORENCIA CLICKJECTSOAJ 5 PA

ORENCIA SOLR 5 PA

ORENCIA SOSY 5 PA

Soluble Tumor Necrosis Factor Receptor AgentsENBREL SOLR 5 PA

ENBREL SOSY 5 PA

ENBREL SURECLICKSOAJ 5 PA

ANALGESICS - NonNarcotic - Drugs to TreatPain, Muscle and Joint ConditionsSalicylatesdiflunisal tabs 1 MO; *

ANALGESICS - OPIOID - Drugs to Treat Pain,Muscle and Joint ConditionsOpioid Agonists

ABSTRAL SUBL 100 MCG 4 PA; QL(6 eadaily)

ABSTRAL SUBL 200 MCG 5 PA; QL(6 eadaily)

ABSTRAL SUBL 300 MCG,400 MCG, 600 MCG, 800MCG

5PA; QL(4 eadaily)

ACTIQ LPOP 1200 MCG,1600 MCG, 400 MCG, 600MCG, 800 MCG (FentanylCitrate)

5

PA; QL(4 eadaily); MO

ACTIQ LPOP 200 MCG(Fentanyl Citrate) 5 PA; QL(6 ea

daily); MO

codeine sulfate tabs 15 mg 2 SL(24 ea daily);MO; *



4

Drug Name DrugTier

Requirements/Limits

CODEINE SULFATE TABS15 MG (Codeine Sulfate) 4 SL(24 ea daily);

MO



DEMEROL TABS OR 100MG, 50 MG (MeperidineHCl)

NFAL; MO

DILAUDID LIQD OR 1MG/ML (HydromorphoneHCl)

NFQL(32 mldaily); MO

DILAUDID TABS OR 2 MG(Hydromorphone HCl) NF QL(29 ea

daily); MODILAUDID TABS OR 4 MG(Hydromorphone HCl) NF QL(14 ea

daily); MODILAUDID TABS OR 8 MG(Hydromorphone HCl) NF QL(7 ea daily);

MODILAUDID-HP SOLN 10MG/ML (HydromorphoneHCl)

NF

DOLOPHINE TABS 10 MG(Methadone HCl) NF QL(19 ea

daily); MODOLOPHINE TABS 5 MG(Methadone HCl) NF QL(38 ea

daily); MODURAGESIC PT72 100MCG/HR (Fentanyl) NF QL(1 ea daily);

MO

DURAGESIC PT72 12MCG/HR (Fentanyl) NF

Limit 43patches permonth;QL(1.44ea daily); MO







EXALGO T24A 12 MG(Hydromorphone HCl) NF QL(4 ea daily);

MOEXALGO T24A 16 MG(Hydromorphone HCl) NF QL(3.67 ea

daily); MO

Drug Name DrugTier

Requirements/Limits

EXALGO T24A 32 MG(Hydromorphone HCl) 4 QL(2 ea daily);

MOEXALGO T24A 8 MG(Hydromorphone HCl) NF QL(7 ea daily);

MOfentanyl citrate lpop bu1200 mcg, 1600 mcg, 400mcg, 600 mcg, 800 mcg

5PA; QL(4 eadaily); MO

fentanyl citrate lpop bu 200mcg 5 PA; QL(6 ea

daily); MO

fentanyl pt72 100 mcg/hr 4 QL(1 ea daily);MO

fentanyl pt72 12 mcg/hr 4








FENTORA TABS 100MCG, 200 MCG 5 PA; QL(6 ea

daily); MOFENTORA TABS 400MCG, 600 MCG, 800 MCG 5 PA; QL(4 ea

daily); MOhydromorphone hcl liqd or1 mg/ml 3 QL(32 ml

daily); MOhydromorphone hcl soln ij10 mg/ml, 50 mg/5ml, 500mg/50ml

3

hydromorphone hcl soln ij 2mg/ml 3 MO

hydromorphone hcl t24a or12 mg 2 QL(4 ea daily);

MO; *hydromorphone hcl t24a or16 mg 2 QL(3.67 ea

daily); MO; *hydromorphone hcl t24a or32 mg 2 QL(2 ea daily);

MO; *hydromorphone hcl t24a or8 mg, 8mg 2 QL(7 ea daily);

MO; *



5

Drug Name DrugTier

Requirements/Limits

hydromorphone hcl tabs or2 mg 3 QL(29 ea

daily); MOhydromorphone hcl tabs or4 mg 3 QL(14 ea

daily); MOhydromorphone hcl tabs or8 mg 3 QL(7 ea daily);

MOHYSINGLA ER T24A 100MG, 120 MG 4 PA; QL(2 ea

daily)HYSINGLA ER T24A 20MG, 30 MG, 40 MG, 60MG, 80 MG


KADIAN CP24 10 MG(Morphine Sulfate) NF QL(6 ea daily);

MOKADIAN CP24 100 MG(Morphine Sulfate) 5 QL(6 ea daily);

MOKADIAN CP24 20 MG, 30MG, 50 MG, 60 MG, 80 MG(Morphine Sulfate)

NFQL(5 ea daily);MO

KADIAN CP24 40 MG 4 PA; QL(5 eadaily); MO

LAZANDA SOLN 100MCG/ACT 5 PA; QL(6 ea

daily); MOLAZANDA SOLN 300MCG/ACT 5 PA; QL(5 ea

daily)LAZANDA SOLN 400MCG/ACT 5 PA; QL(4 ea

daily)meperidine hcl tabs or 100mg, 50 mg 2 AL; MO; *

methadone hcl soln or 10mg/5ml 2 QL(20 ml

daily); MO; *methadone hcl soln or 5mg/5ml 2 QL(40 ml

daily); MO; *methadone hcl tabs or 10mg 2 QL(19 ea

daily); MO; *methadone hcl tabs or 5mg 2 QL(38 ea

daily); MO; *morphine sulfate beadscp24 2 QL(5 ea daily);

MO; *morphine sulfate cp24 or10 mg 2 QL(6 ea daily);

MO; *morphine sulfate cp24 or100 mg 5 QL(6 ea daily);

MOmorphine sulfate cp24 or20 mg, 30 mg, 50 mg, 60mg, 80 mg

4QL(5 ea daily);MO

Drug Name DrugTier

Requirements/Limits

morphine sulfate soln ij 0.5mg/ml 2 *

morphine sulfate soln ij 1mg/ml 2 MO; *

morphine sulfate soln or 10mg/5ml 2 QL(60 ml

daily); MO; *morphine sulfate soln or100 mg/5ml, 20 mg/ml 2 QL(6 ml daily);

MO; *morphine sulfate soln or 20mg/5ml 2 QL(30 ml

daily); MO; *morphine sulfate tabs or 15mg 2 QL(8 ea daily);

MO; *morphine sulfate tabs or 30mg 2 QL(14 ea

daily); MO; *morphine sulfate tbcr or100 mg 3 QL(6 ea daily);

MOmorphine sulfate tbcr or 15mg 3 QL(8 ea daily);

MOmorphine sulfate tbcr or200 mg 3 QL(3 ea daily);

MOmorphine sulfate tbcr or 30mg, 60 mg 3 QL(5 ea daily);

MOMS CONTIN TBCR 100MG (Morphine Sulfate) NF QL(6 ea daily);

MOMS CONTIN TBCR 15 MG(Morphine Sulfate) NF QL(8 ea daily);

MOMS CONTIN TBCR 200MG (Morphine Sulfate) NF QL(3 ea daily);

MOMS CONTIN TBCR 30 MG,60 MG (Morphine Sulfate) NF QL(5 ea daily);

MONUCYNTA ER TB12 100MG 3 QL(4 ea daily);

MONUCYNTA ER TB12 150MG, 200 MG, 250 MG 3 QL(2 ea daily);

MONUCYNTA ER TB12 50MG 3 QL(8 ea daily);

MO

NUCYNTA TABS 100 MG 4 QL(6 ea daily);MO

NUCYNTA TABS 50 MG 4 QL(12 eadaily); MO

NUCYNTA TABS 75 MG 4 QL(8 ea daily);MO

OPANA ER (CRUSHRESISTANT) T12A 40 MG 5 QL(2 ea daily);

MOOPANA TABS OR 10 MG(Oxymorphone HCl) NF QL(4 ea daily);

MO



6

Drug Name DrugTier

Requirements/Limits

OPANA TABS OR 5 MG(Oxymorphone HCl) NF QL(8 ea daily);

MOoxycodone hcl caps or 5mg 2 QL(17 ea

daily); MO; *oxycodone hcl conc or 100mg/5ml 4 QL(4 ml daily);

MOOXYCODONE HCL ERT12A 10 MG, 15 MG, 20MG, 30 MG, 40 MG, 60 MG

3QL(2 ea daily);MO

OXYCODONE HCL ERT12A 80 MG 3 QL(7 ea daily);

MOoxycodone hcl tabs or 10mg 3 QL(16 ea

daily); MOoxycodone hcl tabs or 15mg 3 QL(11 ea

daily); MOoxycodone hcl tabs or 20mg 3 QL(8 ea daily);

MOoxycodone hcl tabs or 30mg 3 QL(15 ea

daily); MO

oxycodone hcl tabs or 5 mg 3 QL(17 eadaily); MO

OXYCONTIN T12A 10 MG,15 MG, 20 MG, 30 MG, 40MG, 60 MG

3QL(2 ea daily);MO

OXYCONTIN T12A 80 MG 3 QL(7 ea daily);MO

oxymorphone hcl tabs 10mg 3 QL(4 ea daily);

MOoxymorphone hcl tabs 5mg 3 QL(8 ea daily);

MOoxymorphone hcl tb12 10mg 4 QL(4 ea daily);

MOoxymorphone hcl tb12 15mg 4 QL(2.67 ea

daily); MOoxymorphone hcl tb12 20mg 4 QL(2 ea daily);

MOoxymorphone hcl tb12 30mg, 40 mg 2 QL(2 ea daily);

MO; *oxymorphone hcl tb12 5mg 1 QL(8 ea daily);

MO; *oxymorphone hcl tb12 7.5mg 4 QL(5 ea daily);

MOROXICODONE TABS 15MG (Oxycodone HCl) NF QL(11 ea

daily); MOROXICODONE TABS 30MG (Oxycodone HCl) NF QL(15 ea

daily); MO

Drug Name DrugTier

Requirements/Limits

ROXICODONE TABS 5MG (Oxycodone HCl) NF QL(17 ea

daily); MOSUBSYS LIQD 100 MCG,200 MCG 5 PA; QL(6 ea

daily); MO

SUBSYS LIQD 1200 MCG 5 PA; QL(4 eadaily)

SUBSYS LIQD 1600 MCG,400 MCG, 600 MCG, 800MCG


tramadol hcl tabs or 50 mg 2 SL(8 ea daily);MO; *

tramadol hcl tb24 or 100mg 3 SL(3 ea daily);

MOtramadol hcl tb24 or 200mg 3 SL(1.5 ea

daily); MOtramadol hcl tb24 or 200mg 2 Biphasic;SL(1.5

ea daily); MO; *tramadol hcl tb24 or 300mg 2 Biphasic;SL(1

ea daily); MO; *tramadol hcl tb24 or 300mg 3 SL(1 ea daily);

MOULTRAM ER TB24 100 MG(Tramadol HCl) NF SL(3 ea daily);

MOULTRAM ER TB24 200 MG(Tramadol HCl) NF SL(1.5 ea

daily); MOULTRAM ER TB24 300 MG(Tramadol HCl) NF SL(1 ea daily);

MOULTRAM TABS (TramadolHCl) NF SL(8 ea daily);

MOZOHYDRO ER C12A 10MG, 15 MG, 20 MG, 30MG, 40 MG, 50 MG


ZOHYDRO ER CP12 10MG, 15 MG, 20 MG, 30MG, 40 MG, 50 MG

4PA; QL(2 eadaily)

Opioid Combinations

acetaminophen w/ codeinesoln 120mg/5ml-12mg/5ml 2

Limit 4980mlspermonth;SL(166ml daily); MO; *

acetaminophen w/ codeinesusp 120mg/5ml-12mg/5ml 2

Limit 4980mlspermonth;SL(166ml daily); MO; *

acetaminophen w/ codeinetabs 300mg-15mg 2 SL(13.3 ea

daily); MO; *



7

Drug Name DrugTier

Requirements/Limits

acetaminophen w/ codeinetabs 300mg-30mg, 300mg-60mg

2SL(13 ea daily);MO; *

butalbital-acetaminophen-caffeine w/ codeine caps300mg-50mg-40mg-30mg

4AL; SL(13 eadaily); MO

butalbital-acetaminophen-caffeine w/ codeine caps325mg-50mg-40mg-30mg

4AL; SL(12 eadaily); MO

butalbital-aspirin-caffeinew/cod caps 2 AL; MO; *

FIORINAL/CODEINE #3CAPS (Butalbital-Aspirin-Caffeine w/Cod)

NFAL; MO

hydrocodone-acetaminophen soln10mg/15ml-325mg/15ml

2

Limit 5535mlspermonth;SL(184.5 ml daily); MO;*

hydrocodone-acetaminophen soln2.5mg/5ml-108mg/5ml,5mg/10ml-217mg/10ml,7.5mg/15ml-325mg/15ml

3

Limit 5535mlspermonth;SL(184.5 ml daily); MO

hydrocodone-acetaminophen tabs 10mg-300mg, 5mg-300mg,7.5mg-300mg

2

SL(13.3 eadaily); MO; *

hydrocodone-acetaminophen tabs 10mg-325mg, 5mg-325mg,7.5mg-325mg

2


hydrocodone-ibuprofentabs 200mg-10mg, 200mg-5mg, 200mg-7.5mg

3MO

oxycodone w/acetaminophen soln5mg/5ml-325mg/5ml

2

Limit 1845mlspermonth;SL(61.5ml daily); *

oxycodone w/acetaminophen tabs 10mg-325mg

3SL(12.3 eadaily); MO

oxycodone w/acetaminophen tabs2.5mg-325mg, 5mg-325mg, 7.5mg-325mg

2


oxycodone-aspirin tabs 1 MO; *

Drug Name DrugTier

Requirements/Limits

PERCODAN TABS(Oxycodone-Aspirin) NF MO

tramadol-acetaminophentabs 2 SL(8 ea daily);

MO; *ULTRACET TABS(Tramadol-Acetaminophen) NF SL(8 ea daily);

MOVICOPROFEN TABS(Hydrocodone-Ibuprofen) NF MO

Opioid Partial AgonistsBUNAVAIL FILM 2.1MG-0.3MG, 4.2MG-0.7MG 4 PA

BUNAVAIL FILM 6.3MG-1MG 4 PA; MO

buprenorphine hcl subl sl 2mg 3 PA; QL(16 ea

daily); MObuprenorphine hcl subl sl 8mg 3 PA; QL(4 ea

daily); MObuprenorphine hcl-naloxone hcl dihydrate subl2mg-0.5mg


buprenorphine hcl-naloxone hcl dihydrate subl8mg-2mg


butorphanol tartrate soln ij2 mg/ml 2 MO; *

butorphanol tartrate soln na10 mg/ml 1

Limit 126mlspermonth;QL(4.2ml daily); MO; *

BUTRANS PTWK 10MCG/HR 3

Limit 8 patchesper 28days;SL(0.29ea daily); MO






Limit 16patches per 28days;SL(0.58ea daily); MO



8

Drug Name DrugTier

Requirements/Limits

BUTRANS PTWK 7.5MCG/HR 3

Limit 10patches per 28days;SL(0.39ea daily); MO

pentazocine w/ naloxonetabs 3 AL; MO

SUBOXONE FILM 4 PA; MO

TALWIN SOLN 4 AL

ZUBSOLV SUBL 1.4MG-0.36MG, 5.7MG-1.4MG,8.6MG-2.1MG

4PA; MO

ZUBSOLV SUBL 11.4MG-2.9MG, 2.9MG-0.71MG 4 PA

ANDROGENS-ANABOLIC - Drugs to RegulateHormonesAnabolic SteroidsANADROL-50 TABS 5 MO

OXANDRIN TABS(Oxandrolone) 5 MO

oxandrolone tabs or 10 mg 5 MO

oxandrolone tabs or 2.5 mg 2 MO; *

AndrogensANDRODERM PT24 3 GL; MO

ANDROGEL GEL 20.25MG/1.25GM, 40.5MG/2.5GM

3GL; MO

ANDROGEL GEL 25MG/2.5GM, 50 MG/5GM(Testosterone)

3GL; MO

ANDROGEL PUMP GEL1.62 % 3 GL; MO

AVEED SOLN 4 LA

AXIRON SOLN 4 GL; MO

danazol caps or 100 mg,200 mg 3 MO

danazol caps or 50 mg 1 MO; *

fluoxymesterone tabs or 2 MO; *

Drug Name DrugTier

Requirements/Limits

FORTESTA GEL 4 GL; MO

methyltestosterone caps or 2 MO; *

methyltestosterone tabs or 2 *

NATESTO GEL 4 GL; MO

TESTIM GEL 4 GL; MO

testosterone cypionate soln 2 MO; *

testosterone enanthatesoln im 1 MO; *

TESTOSTERONE GEL TD1 %, 10 MG/ACT, 25MG/2.5GM, 50 MG/5GM

4GL; MO

testosterone gel td 1 %, 25mg/2.5gm, 50 mg/5gm 2 GL; MO; *

TESTOSTERONE PUMPGEL 4 GL; MO

VOGELXO GEL 4 GL; MO

VOGELXO PUMP GEL 4 GL; MO

ANORECTAL AGENTS - Rectal Drugs to TreatPain, Swelling and ItchingIntrarectal SteroidsCORTENEMA ENEM(Hydrocortisone(Intrarectal))

NFMO

CORTIFOAM FOAM 4 MO

hydrocortisone (intrarectal)enem 3 MO

UCERIS FOAM RE 2MG/ACT 4 MO

Rectal Combinationshydrocortisone acetate w/pramoxine crea 1%-1% 2 MO; *

Rectal Steroidshydrocortisone (rectal) crea 1 MO; *

PROCTOCORT CREA 1 %(Hydrocortisone (Rectal)) NF MO

Vasodilating Agents



9

Drug Name DrugTier

Requirements/Limits

RECTIV OINT 4 MO

ANTHELMINTICS - Drugs to Treat WormInfectionsAnthelminticsALBENZA TABS 4 MO

BILTRICIDE TABS 3 MO

ivermectin tabs or 2 MO; *

STROMECTOL TABS(Ivermectin) 4 MO

ANTI-INFECTIVE AGENTS - MISC. - Drugs toTreat Bacterial InfectionsAnti-infective Agents - Misc.AZACTAM SOLR(Aztreonam) NF MO

aztreonam solr 2 MO; *

CAYSTON SOLR 5 LA

colistimethate sodium solr ij 1 MO; *

COLY-MYCIN M SOLR(Colistimethate Sodium) NF MO

FLAGYL CAPS 375 MG(Metronidazole) NF SL(10.6 ea

daily); MOFLAGYL TABS 250 MG(Metronidazole) NF SL(16 ea daily);

MOFLAGYL TABS 500 MG(Metronidazole) NF SL(8 ea daily);

MOmetronidazole caps or 375mg 2 SL(10.6 ea

daily); MO; *

metronidazole in nacl soln 1 *

metronidazole tabs or 250mg 2 SL(16 ea daily);

MO; *metronidazole tabs or 500mg 2 SL(8 ea daily);

MO; *

NEBUPENT SOLR 3 MO; B/D

ORBACTIV SOLR 5

PENTAM 300 SOLR 4 MO

Drug Name DrugTier

Requirements/Limits

PRIMSOL SOLN 3 MO

TINDAMAX TABS(Tinidazole) NF MO

tinidazole tabs or 250 mg,500 mg 1 MO; *

trimethoprim tabs or 2 MO; *

VANCOCIN HCL CAPS(Vancomycin HCl) 5 PA; MO

vancomycin hcl caps or125 mg, 250 mg 5 PA; MO

VANCOMYCIN HCL INDEXTROSE SOLN 4

vancomycin hcl solr iv 10gm, 1000 mg, 5000 mg,750 mg

2*

vancomycin hcl solr iv 500mg 2 MO; *

XIFAXAN TABS 5 MO

Anti-infective Misc. - CombinationsBACTRIM DS TABS(Sulfamethoxazole-Trimethoprim)

NFMO

BACTRIM TABS(Sulfamethoxazole-Trimethoprim)

NFMO

sulfamethoxazole-trimethoprim soln iv80mg/5ml-400mg/5ml

2MO; *

sulfamethoxazole-trimethoprim susp or40mg/5ml-200mg/5ml

2MO; *

sulfamethoxazole-trimethoprim tabs or160mg-800mg, 80mg-400mg

1

MO; *

Antiprotozoal AgentsALINIA TABS 500 MG 4 MO

atovaquone susp 5 MO

MEPRON SUSP(Atovaquone) 5 MO

Carbapenems



10

Drug Name DrugTier

Requirements/Limits

DORIBAX SOLR 500 MG 4

imipenem-cilastatin solr250mg-250mg 1 MO; *

imipenem-cilastatin solr500mg-500mg 3 MO

INVANZ SOLR IJ 4 MO

meropenem solr 1 gm 5 MO

meropenem solr 500 mg 1 MO; *

MERREM SOLR 1 GM(Meropenem) 5 MO

MERREM SOLR 500 MG(Meropenem) NF MO

PRIMAXIN IV SOLR(Imipenem-Cilastatin) NF MO

Chloramphenicolschloramphenicol sodiumsuccinate solr 2 *

Cyclic LipopeptidesCUBICIN RF SOLR(Daptomycin) 5

CUBICIN SOLR(Daptomycin) 5

daptomycin solr 5

GlycylcyclinesTIGECYCLINE SOLR 5

TYGACIL SOLR 5

KetolidesKETEK TABS 300 MG 4

KETEK TABS 400 MG 4 MO

Leprostaticsdapsone tabs or 100 mg,25 mg 2 MO; *

LincosamidesCLEOCIN CAPS OR 150MG, 300 MG, 75 MG(Clindamycin HCl)

NFMO

Drug Name DrugTier

Requirements/Limits

CLEOCIN IN D5W SOLN(Clindamycin Phosphate inD5W)

4

CLEOCIN PHOSPHATESOLN IJ 600 MG/4ML, 900MG/6ML (ClindamycinPhosphate)

NF

MO

CLEOCIN PHOSPHATESOLN IV 300MG/50ML-5%, 600MG/50ML-5%,900MG/50ML-5%(Clindamycin Phosphate inD5W)

4

clindamycin hcl caps or 150mg, 300 mg, 75 mg 2 MO; *

clindamycin palmitatehydrochloride solr 3 MO

clindamycin phosphate ind5w soln 2 *

clindamycin phosphate solnij 150 mg/ml, 9000 mg/60ml 1 *

clindamycin phosphate solnij 600 mg/4ml, 900 mg/6ml 1 MO; *

clindamycin phosphate solniv 150 mg/ml, 300 mg/2ml,600 mg/4ml

2*

LINCOCIN SOLN(Lincomycin HCl) 4 MO

lincomycin hcl soln ij 2 MO; *

Oxazolidinoneslinezolid soln iv 600mg/300ml 5

LINEZOLID SOLN IV600MG/300ML-0.9% 5

linezolid susr or 100mg/5ml 5 MO

linezolid tabs or 600 mg 5 MO

SIVEXTRO SOLR IV 5

SIVEXTRO TABS OR 5 MO

ZYVOX SOLN IV 200MG/100ML 5

ZYVOX SOLN IV 600MG/300ML (Linezolid) 5



11

Drug Name DrugTier

Requirements/Limits

ZYVOX SUSR OR 100MG/5ML (Linezolid) 5 MO

ZYVOX TABS OR 600 MG(Linezolid) 5 MO

Polymyxinspolymyxin b sulfate solr ij 2 *

StreptograminsSYNERCID SOLR 5

ANTIANGINAL AGENTS - Drugs to Treat ChestPainAntianginals-OtherRANEXA TB12 4 PA; MO

NitratesDILATRATE SR CPCR 4 MO

ISORDIL TITRADOSETABS 40 MG 4 MO

ISORDIL TITRADOSETABS 5 MG (IsosorbideDinitrate)

NFMO

isosorbide dinitrate tabs 10mg, 20 mg, 30 mg, 5 mg 2 MO; *

isosorbide dinitrate tbcr 40mg 1 MO; *

isosorbide mononitratetabs 10 mg 2 MO; *

isosorbide mononitratetabs 20 mg 1 MO; *

isosorbide mononitratetb24 120 mg, 30 mg, 60 mg 2 MO; *

NITRO-DUR PT24 0.1MG/HR, 0.2 MG/HR, 0.4MG/HR, 0.6 MG/HR(Nitroglycerin)

NF

MO

NITRO-DUR PT24 0.3MG/HR, 0.8 MG/HR 4 MO

NITROGLYCERINLINGUAL AERS 4 MO

nitroglycerin pt24 td 0.1mg/hr, 0.2 mg/hr, 0.4mg/hr, 0.6 mg/hr

1MO; *

Drug Name DrugTier

Requirements/Limits

nitroglycerin soln iv 5mg/ml 2 *

nitroglycerin soln tl 0.4mg/spray 2 MO; *

nitroglycerin subl sl 0.3 mg,0.4 mg, 0.6 mg 2 MO; *

NITROLINGUALPUMPSPRAY SOLN(Nitroglycerin)

NFMO

NITROMIST AERS 4 MO

NITROSTAT SUBL(Nitroglycerin) 3 MO

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc.buspirone hcl tabs or 10mg, 15 mg, 30 mg, 5 mg,7.5 mg

2MO; *

hydroxyzine hcl soln im 25mg/ml, 50 mg/ml 2 AL; MO; *

hydroxyzine hcl soln or 10mg/5ml 2 AL; MO; *

hydroxyzine hcl syrp or 10mg/5ml 2 AL; MO; *

hydroxyzine hcl tabs or 10mg, 25 mg, 50 mg 2 AL; MO; *

hydroxyzine pamoate capsor 100 mg, 25 mg, 50 mg 2 AL; MO; *

meprobamate tabs 3 AL; MO

VISTARIL CAPS(Hydroxyzine Pamoate) NF AL; MO

Benzodiazepinesalprazolam tabs or 0.25mg, 0.5 mg, 1 mg, 2 mg 2 MO; *

alprazolam tb24 or 0.5 mg,1 mg, 2 mg, 3 mg 2 MO; *

alprazolam tbdp or 0.25mg, 0.5 mg, 1 mg, 2 mg 2 MO; *

ATIVAN SOLN IJ 2 MG/ML(Lorazepam) NF MO

ATIVAN SOLN IJ 4 MG/ML(Lorazepam) NF

ATIVAN TABS OR 0.5 MG,1 MG, 2 MG (Lorazepam) NF MO



12

Drug Name DrugTier

Requirements/Limits

chlordiazepoxide hcl caps 1 MO; *

clorazepate dipotassiumtabs 1 MO; *

diazepam conc or 5 mg/ml 2 MO; *

diazepam soln ij 5 mg/ml 2 MO; *

diazepam soln or 1 mg/ml 2 MO; *

diazepam tabs or 10 mg, 2mg, 5 mg 2 MO; *

lorazepam conc or 2 mg/ml 2 MO; *

lorazepam soln ij 2 mg/ml,20 mg/10ml 2 MO; *

lorazepam soln ij 4 mg/ml 2 *

lorazepam tabs or 0.5 mg,1 mg, 2 mg 2 MO; *

oxazepam caps 1 MO; *

TRANXENE T TABS(Clorazepate Dipotassium) NF MO

VALIUM TABS (Diazepam) NF MO

XANAX TABS (Alprazolam) NF MO

XANAX XR TB24(Alprazolam) NF MO

ANTIARRHYTHMICS - Drugs to treat abnormalheart rhythmsAntiarrhythmics Type I-Adisopyramide phosphatecaps 2 AL; MO; *

NORPACE CAPS(Disopyramide Phosphate) NF AL; MO

NORPACE CR CP12 100MG 4 AL; MO

procainamide hcl soln ij500 mg/ml 2 *

quinidine gluconate tbcr or324 mg 1 MO; *

quinidine sulfate tabs 1 MO; *

Antiarrhythmics Type I-B

Drug Name DrugTier

Requirements/Limits

lidocaine hcl (cardiac) soln 1 *

mexiletine hcl caps 1 MO; *

XYLOCAINE SOLN IV 20MG/ML (Lidocaine HCl(Cardiac))

NF

Antiarrhythmics Type I-Cflecainide acetate tabs 100mg 2 SL(4 ea daily);

MO; *flecainide acetate tabs 150mg 2 SL(2.66 ea

daily); MO; *flecainide acetate tabs 50mg 2 SL(8 ea daily);

MO; *

propafenone hcl cp12 1 MO; *

propafenone hcl tabs 1 MO; *

RYTHMOL SR CP12(Propafenone HCl) NF MO

RYTHMOL TABS(Propafenone HCl) NF MO

Antiarrhythmics Type IIIamiodarone hcl soln iv 900mg/18ml 2 *

amiodarone hcl tabs or 100mg, 200 mg, 400 mg 2 MO; *

CORDARONE TABS(Amiodarone HCl) NF MO

dofetilide caps 2 *

MULTAQ TABS 3 MO

TIKOSYN CAPS(Dofetilide) 4

ANTIASTHMATIC AND BRONCHODILATORAGENTS - Drugs to Treat Lung ConditionsAnti-Inflammatory Agentscromolyn sodium nebu in 1 MO; B/D; *

Antiasthmatic - Monoclonal AntibodiesCINQAIR SOLN 5 PA

NUCALA SOLR 5 PA; LA



13

Drug Name DrugTier

Requirements/Limits

XOLAIR SOLR 5 PA; LA

Bronchodilators - Anticholinergics

ATROVENT HFA AERS 4

Limit 2 inhalerspermonth;QL(0.86gm daily); MO

INCRUSE ELLIPTA AEPB 3 QL(1 ea daily);MO

ipratropium bromide soln in 1 MO; B/D; *

SPIRIVA HANDIHALERCAPS 3 QL(1 ea daily);

MO

SPIRIVA RESPIMATAERS 1.25 MCG/ACT, 2.5MCG/ACT

3

Limit 1 inhalerper month (60actuations);SL(0.14 gm daily);MO

SPIRIVA RESPIMATAERS 2.5 MCG/ACT 3

Limit 2 inhalersper month(InstitutionalPack) ;SL(0.29gm daily); MO

TUDORZA PRESSAIRAEPB 3

Limit 1 inhalerpermonth;QL(0.04ea daily); MO

Leukotriene ModulatorsACCOLATE TABS(Zafirlukast) NF MO

montelukast sodium chew4 mg, 5 mg 3 QL(1 ea daily);

MOmontelukast sodium tabs10 mg 3 QL(1 ea daily);

MOSINGULAIR CHEW 4 MG,5 MG (MontelukastSodium)

NFQL(1 ea daily);MO

SINGULAIR TABS 10 MG(Montelukast Sodium) NF QL(1 ea daily);

MO

zafirlukast tabs 1 MO; *

ZYFLO CR TB12 5 SL(4 ea daily);MO

Selective Phosphodiesterase 4 (PDE4) Inhibitors

DALIRESP TABS 4 QL(1 ea daily);MO

Drug Name DrugTier

Requirements/Limits

Steroid Inhalants

AEROSPAN AERS 3

Limit 2 inhalersper month (120actuations);SL(0.6 gm daily);MO

AEROSPAN AERS 3

Limit 3 inhalersper month(Institutionalpack);SL(0.6gm daily); MO

ALVESCO AERS 160MCG/ACT 4

Limit 2 inhalerspermonth;SL(0.41gm daily); MO

ALVESCO AERS 80MCG/ACT 4


ARNUITY ELLIPTA AEPB 3 SL(1 ea daily);MO

ASMANEX HFA AERO 100MCG/ACT 3


ASMANEX HFA AERO 200MCG/ACT 3

Limit 1 inhalerpermonth;SL(0.44gm daily); MO

ASMANEX TWISTHALER120 METERED DOSESAEPB

3

Limit 1 inhalerpermonth;SL(0.04ea daily); MO


3

Limit 8 inhalerspermonth;SL(0.29ea daily); MO

ASMANEX TWISTHALER30 METERED DOSESAEPB 110 MCG/INH

3

Limit 1 inhalerpermonth;SL(0.04ea daily); MO

ASMANEX TWISTHALER30 METERED DOSESAEPB 220 MCG/INH

3




14

Drug Name DrugTier

Requirements/Limits


3



3


budesonide (inhalation)susp 0.25 mg/2ml 1 QL(8 ml daily);

MO; B/D; *budesonide (inhalation)susp 0.5 mg/2ml 1 QL(4 ml daily);

MO; B/D; *budesonide (inhalation)susp 1 mg/2ml 2 QL(2 ml daily);

MO; B/D; *FLOVENT DISKUS AEPB100 MCG/BLIST 3 SL(20 ea daily);

MOFLOVENT DISKUS AEPB250 MCG/BLIST 3 SL(8 ea daily);

MOFLOVENT DISKUS AEPB50 MCG/BLIST 3 SL(40 ea daily);

MO

FLOVENT HFA AERO 110MCG/ACT, 220 MCG/ACT 3


FLOVENT HFA AERO 44MCG/ACT 3

Limit 1 inhalerpermonth;QL(0.36gm daily); MO

PULMICORT FLEXHALERAEPB 180 MCG/ACT 4

Limit 2 inhalerspermonth;QL(0.07ea daily); MO

PULMICORT FLEXHALERAEPB 90 MCG/ACT 4

Limit 8 inhalerspermonth;QL(0.27ea daily); MO

PULMICORT SUSP 0.25MG/2ML (Budesonide(Inhalation))

NFQL(8 ml daily);MO; B/D

PULMICORT SUSP 0.5MG/2ML (Budesonide(Inhalation))

NFQL(4 ml daily);MO; B/D

PULMICORT SUSP 1MG/2ML (Budesonide(Inhalation))

4QL(2 ml daily);MO; B/D

Drug Name DrugTier

Requirements/Limits

QVAR AERS 3


Sympathomimetics

ADVAIR DISKUS AEPB 3 QL(2 ea daily);MO

ADVAIR HFA AERO 3 QL(4 gm daily);MO

albuterol sulfate nebu in0.083 %, 0.5 %, 0.63mg/3ml, 1.25 mg/3ml

1MO; B/D; *

albuterol sulfate syrp or 2mg/5ml 1 MO; *

albuterol sulfate tabs or 2mg, 4 mg 3 MO

albuterol sulfate tb12 or 4mg, 8 mg 1 MO; *

ANORO ELLIPTA AEPB 3 QL(2 ea daily);MO

ARCAPTA NEOHALERCAPS 4 QL(1 ea daily);

MOBREO ELLIPTA AEPB25MCG/INH-100MCG/INH,25MCG/INH-200MCG/INH

3Limit 1 inhalerper month;SL(2ea daily); MO

BREO ELLIPTA AEPB25MCG/INH-100MCG/INH,25MCG/INH-200MCG/INH

3

Limit 2 inhalersper month(InstitutionalPack);SL(2 eadaily); MO

BROVANA NEBU 4 MO; B/D

COMBIVENT RESPIMATAERS 4

Limit 1 inhalerpermonth;SL(0.2gm daily); MO

DULERA AERO 3 QL(4 gm daily);MO

FORADIL AEROLIZERCAPS 3 QL(2 ea daily)

ipratropium-albuterol soln 1 MO; B/D; *

levalbuterol hcl nebu in0.31 mg/3ml, 0.63 mg/3ml,1.25 mg/0.5ml, 1.25mg/3ml

1

MO; B/D; *



15

Drug Name DrugTier

Requirements/Limits

LEVALBUTEROLTARTRATE HFA AERO 4 MO

PERFOROMIST NEBU 4 QL(4 ml daily);MO; B/D

PROAIR HFA AERS 3 MO

PROAIR RESPICLICKAEPB 3 MO

PROVENTIL HFA AERS 3 MO

SEREVENT DISKUSAEPB 3 QL(2 ea daily);

MO

STIOLTO RESPIMATAERS 3


STRIVERDI RESPIMATAERS 3

Limit 1 inhalerper month (60actuations);SL(0.14 gm daily);MO

SYMBICORT AERO4.5MCG/ACT-160MCG/ACT

4

Limit 2 inhalersper month(InstitutionalPack);QL(0.4gm daily); MO

SYMBICORT AERO4.5MCG/ACT-160MCG/ACT,4.5MCG/ACT-80MCG/ACT

4


SYMBICORT AERO4.5MCG/ACT-80MCG/ACT 4

Limit 2 inhalersper month(InstitutionalPack);QL(0.46gm daily); MO

terbutaline sulfate tabs or2.5 mg, 5 mg 1 MO; *

VENTOLIN HFA AERS 4 MO

XOPENEXCONCENTRATE NEBU(Levalbuterol HCl)

NFMO; B/D

XOPENEX HFA AERO 4 MO

XOPENEX NEBU(Levalbuterol HCl) NF MO; B/D

Xanthines

Drug Name DrugTier

Requirements/Limits

aminophylline soln 2 *

theophylline tb12 100 mg,200 mg, 300 mg, 450 mg 1 MO; *

theophylline tb24 400 mg,600 mg 1 MO; *

ANTICOAGULANTS - Blood Thinners

Coumarin AnticoagulantsCOUMADIN TABS(Warfarin Sodium) 4 MO

warfarin sodium tabs 1 MO; *

Direct Factor Xa InhibitorsELIQUIS TABS 4 MO

SAVAYSA TABS 4 MO

XARELTO STARTERPACK TBPK 3 MO

XARELTO TABS 3 MO

Heparins And Heparinoid-Like AgentsARIXTRA SOLN 10MG/0.8ML, 5 MG/0.4ML,7.5 MG/0.6ML(Fondaparinux Sodium)

5

MO

ARIXTRA SOLN 2.5MG/0.5ML (FondaparinuxSodium)

NFMO

enoxaparin sodium soln ij300 mg/3ml 4 MO

enoxaparin sodium soln sc100 mg/ml, 60 mg/0.6ml,80 mg/0.8ml

3MO

enoxaparin sodium soln sc120 mg/0.8ml, 150 mg/ml,30 mg/0.3ml, 40 mg/0.4ml

4MO

fondaparinux sodium soln10 mg/0.8ml, 5 mg/0.4ml,7.5 mg/0.6ml

5MO

fondaparinux sodium soln2.5 mg/0.5ml 1 MO; *

FRAGMIN SOLN 10000UNIT/ML, 2500UNIT/0.2ML, 5000UNIT/0.2ML

4

MO



16

Drug Name DrugTier

Requirements/Limits

FRAGMIN SOLN 12500UNIT/0.5ML, 15000UNIT/0.6ML, 18000UNT/0.72ML, 7500UNIT/0.3ML, 95000UNIT/3.8ML

5

MO

FRAGMIN SOLN 25000UNIT/ML 5

heparin sodium (porcine)soln 1000 unit/ml 2 MO; *

heparin sodium (porcine)soln 10000 unit/ml, 20000unit/ml, 5000 unit/0.5ml,5000 unit/ml

1

MO; *

LOVENOX SOLN(Enoxaparin Sodium) NF MO

Thrombin Inhibitorsargatroban soln 250mg/2.5ml 2 MO; *

IPRIVASK SOLR 5

PRADAXA CAPS 3 MO

ANTICONVULSANTS - Drugs to Treat Seizures

AMPA Glutamate Receptor AntagonistsFYCOMPA SUSP 0.5MG/ML 4

FYCOMPA TABS 10 MG,12 MG, 2 MG, 4 MG, 6 MG,8 MG

4MO

Anticonvulsants - Benzodiazepines

clonazepam tabs or 0.5 mg 2 SL(40 ea daily);MO; *

clonazepam tabs or 1 mg 2 SL(20 ea daily);MO; *

clonazepam tabs or 2 mg 2 SL(10 ea daily);MO; *

clonazepam tbdp or 0.125mg, 0.25 mg, 0.5 mg, 1 mg,2 mg

2MO; *

DIASTAT ACUDIAL GEL 4 MO

DIASTAT PEDIATRIC GEL 4 MO

DIAZEPAM GEL RE 10MG, 2.5 MG, 20 MG 4 MO

Drug Name DrugTier

Requirements/Limits

KLONOPIN TABS 0.5 MG(Clonazepam) 4 SL(40 ea daily);

MOKLONOPIN TABS 1 MG(Clonazepam) 4 SL(20 ea daily);

MOKLONOPIN TABS 2 MG(Clonazepam) 4 SL(10 ea daily);

MO

ONFI SUSP 2.5 MG/ML 4 MO

ONFI TABS 10 MG 4 MO

ONFI TABS 20 MG 5 MO

Anticonvulsants - Misc.APTIOM TABS 200 MG 4 MO

APTIOM TABS 400 MG,600 MG, 800 MG 5 MO

BANZEL SUSP 40 MG/ML 4 MO

BANZEL TABS 200 MG 4 MO

BANZEL TABS 400 MG 5 MO

BRIVIACT SOLN IV 50MG/5ML 5 SL(20 ml daily)

BRIVIACT SOLN OR 10MG/ML 5 PA; SL(20 ml

daily)BRIVIACT TABS OR 10MG 5 PA; SL(20 ea

daily)BRIVIACT TABS OR 100MG 5 PA; SL(2 ea

daily); MOBRIVIACT TABS OR 25MG 5 PA; SL(8 ea

daily); MOBRIVIACT TABS OR 50MG 5 PA; SL(4 ea

daily); MOBRIVIACT TABS OR 75MG 5 PA; SL(2.67 ea

daily)carbamazepine chew or100 mg 2 MO; *

carbamazepine cp12 or100 mg, 200 mg, 300 mg 3 MO

carbamazepine susp or100 mg/5ml 2 MO; *

carbamazepine tabs or 200mg 2 MO; *

carbamazepine tb12 or 100mg, 200 mg, 400 mg 2 MO; *



17

Drug Name DrugTier

Requirements/Limits

CARBATROL CP12(Carbamazepine) NF MO

gabapentin caps or 100mg, 300 mg, 400 mg 2 MO; *

gabapentin soln or 250mg/5ml, 300 mg/6ml 2 MO; *

gabapentin tabs or 600 mg,800 mg 2 MO; *

KEPPRA SOLN(Levetiracetam) 4 MO

KEPPRA TABS(Levetiracetam) 4 MO

KEPPRA XR TB24(Levetiracetam) 4 MO

LAMICTAL CHEWABLEDISPERSIBLE CHEW(Lamotrigine)

4MO

LAMICTAL ODT TBDP 100MG, 200 MG, 25 MG, 50MG (Lamotrigine)

4MO

LAMICTAL STARTER/NOTTAKINGCARBAMAZEPINE KIT

4MO

LAMICTALSTARTER/TAKINGCARBAMAZEPINE/NOTTAKING VALPROATE KIT

4

MO

LAMICTALSTARTER/TAKINGVALPROATE KIT

4MO

LAMICTAL TABS(Lamotrigine) 4 MO

LAMICTAL XR KIT 4 MO

LAMICTAL XR TB24 100MG, 250 MG (Lamotrigine) 4 MO

LAMICTAL XR TB24 200MG, 25 MG, 300 MG, 50MG (Lamotrigine)

NFMO

lamotrigine chew 25 mg, 5mg 2 MO; *

lamotrigine tabs 100 mg,150 mg, 200 mg, 25 mg 2 MO; *

lamotrigine tb24 100 mg,250 mg 2 MO; *

lamotrigine tb24 200 mg,25 mg, 300 mg, 50 mg 4 MO

Drug Name DrugTier

Requirements/Limits

lamotrigine tbdp 100 mg,200 mg, 25 mg, 50 mg 2 MO; *

LEVETIRACETAM SOLNIV 1000MG/100ML-750MG/100ML,1500MG/100ML-540MG/100ML,500MG/100ML-820MG/100ML

4

levetiracetam soln iv 500mg/5ml 3 MO

levetiracetam soln or 100mg/ml, 500 mg/5ml 3 MO

levetiracetam tabs or 1000mg, 250 mg, 500 mg, 750mg

3MO

levetiracetam tb24 or 500mg, 750 mg 3 MO

LYRICA CAPS 100 MG 3 SL(6 ea daily);MO



LYRICA CAPS 225 MG 3 SL(2.66 eadaily); MO





LYRICA SOLN 20 MG/ML 3 SL(30 ml daily);MO

MYSOLINE TABS(Primidone) 4 MO

NEURONTIN CAPS(Gabapentin) 4 MO

NEURONTIN SOLN(Gabapentin) 4 MO

NEURONTIN TABS(Gabapentin) 4 MO

oxcarbazepine susp 300mg/5ml, 60 mg/ml 3 MO



18

Drug Name DrugTier

Requirements/Limits

oxcarbazepine tabs 150mg, 300 mg, 600 mg 2 MO; *

POTIGA TABS 200 MG 5 SL(6 ea daily);MO




primidone tabs or 250 mg,50 mg 2 MO; *

SPRITAM TB3D 1000 MG 4 PA; SL(3 eadaily); MO

SPRITAM TB3D 250 MG 4 PA; SL(12 eadaily)



TEGRETOL SUSP(Carbamazepine) 4 MO

TEGRETOL TABS(Carbamazepine) 4 MO

TEGRETOL-XR TB12(Carbamazepine) 4 MO

TOPAMAX SPRINKLECPSP (Topiramate) 4 MO

TOPAMAX TABS(Topiramate) 4 MO

topiramate cpsp or 15 mg,25 mg 2 MO; *

topiramate tabs or 100 mg,200 mg, 25 mg, 50 mg 2 MO; *

TRILEPTAL SUSP 300MG/5ML (Oxcarbazepine) NF MO

TRILEPTAL TABS 150MG, 300 MG, 600 MG(Oxcarbazepine)

4MO

VIMPAT SOLN IV 200MG/20ML 4

VIMPAT SOLN OR 10MG/ML 4 MO

VIMPAT TABS OR 100MG, 50 MG 4 MO

Drug Name DrugTier

Requirements/Limits

VIMPAT TABS OR 150MG, 200 MG 5 MO

ZONEGRAN CAPS(Zonisamide) 4 MO

zonisamide caps 2 MO; *

Carbamatesfelbamate susp 600 mg/5ml 2 MO; *

felbamate tabs 400 mg 2 MO; *

felbamate tabs 600 mg 4 MO

FELBATOL SUSP 600MG/5ML (Felbamate) 4 MO

FELBATOL TABS 400 MG(Felbamate) 4 MO

FELBATOL TABS 600 MG(Felbamate) 5 MO

GABA ModulatorsGABITRIL TABS 12 MG,16 MG 4 MO

GABITRIL TABS 2 MG, 4MG (Tiagabine HCl) NF MO

SABRIL PACK 5 LA

SABRIL TABS 5 LA

tiagabine hcl tabs 4 MO

HydantoinsCEREBYX SOLN 100 MGPE/2ML (FosphenytoinSodium)

4

CEREBYX SOLN 500 MGPE/10ML (FosphenytoinSodium)

4MO

DILANTIN-125 SUSP(Phenytoin) 4 MO

fosphenytoin sodium soln100 mg pe/2ml 2 *

fosphenytoin sodium soln500 mg pe/10ml 2 MO; *

PEGANONE TABS 4 MO



19

Drug Name DrugTier

Requirements/Limits

phenytoin chew or 50 mg 2 MO; *

phenytoin sodium extendedcaps 2 MO; *

phenytoin sodium soln ij 2 *

phenytoin susp or 125mg/5ml 2 MO; *

SuccinimidesCELONTIN CAPS 4 MO

ethosuximide caps or 250mg 1 MO; *

ethosuximide soln or 250mg/5ml 2 MO; *

ZARONTIN CAPS(Ethosuximide) 4 MO

Valproic AcidDEPACON SOLN(Valproate Sodium) 4

DEPAKENE CAPS(Valproic Acid) 4 MO

DEPAKENE SYRP(Valproate Sodium) 4 MO

DEPAKOTE ER TB24(Divalproex Sodium) 4 MO

DEPAKOTE SPRINKLESCSDR (Divalproex Sodium) 4 MO

DEPAKOTE TBEC(Divalproex Sodium) 4 MO

divalproex sodium csdr 125mg 2 MO; *

divalproex sodium tb24 250mg, 500 mg 3 MO

divalproex sodium tbec 125mg, 250 mg, 500 mg 2 MO; *

valproate sodium soln iv100 mg/ml, 500 mg/5ml 2 *

valproate sodium soln or250 mg/5ml 2 MO; *

valproate sodium syrp or250 mg/5ml 2 MO; *

valproic acid caps or 2 MO; *

ANTIDEPRESSANTS - Drugs to Treat Depression

Drug Name DrugTier

Requirements/Limits

Alpha-2 Receptor Antagonists (Tetracyclics)mirtazapine tabs 2 MO; *

mirtazapine tbdp 2 MO; *

REMERON SOLTAB TBDP(Mirtazapine) NF MO

REMERON TABS(Mirtazapine) NF MO

Antidepressants - Misc.

APLENZIN TB24 174 MG 4 ST; SL(3 eadaily); MO

APLENZIN TB24 348 MG 4 ST; SL(1.5 eadaily); MO

APLENZIN TB24 522 MG 4 ST; SL(1 eadaily); MO

bupropion hcl tabs or 100mg 3 SL(4.5 ea

daily); MObupropion hcl tabs or 75mg 3 SL(6 ea daily);

MObupropion hcl tb12 or 100mg 3 SL(4 ea daily);

MObupropion hcl tb12 or 150mg 3 SL(2.66 ea

daily); MObupropion hcl tb12 or 200mg 3 SL(2 ea daily);

MObupropion hcl tb24 or 150mg 3 SL(3 ea daily);

MObupropion hcl tb24 or 300mg 3 SL(1.5 ea

daily); MO

FORFIVO XL TB24 4 ST; MO

maprotiline hcl tabs 25 mg,50 mg 1 MO; *

maprotiline hcl tabs 75 mg 2 MO; *

WELLBUTRIN SR TB12100 MG (Bupropion HCl) NF SL(4 ea daily);

MOWELLBUTRIN SR TB12150 MG (Bupropion HCl) NF SL(2.66 ea

daily); MOWELLBUTRIN SR TB12200 MG (Bupropion HCl) NF SL(2 ea daily);

MOWELLBUTRIN TABS 100MG (Bupropion HCl) NF SL(4.5 ea

daily); MOWELLBUTRIN TABS 75MG (Bupropion HCl) NF SL(6 ea daily);

MO



20

Drug Name DrugTier

Requirements/Limits

WELLBUTRIN XL TB24150 MG (Bupropion HCl) NF SL(3 ea daily);

MOWELLBUTRIN XL TB24300 MG (Bupropion HCl) NF SL(1.5 ea

daily); MOMonoamine Oxidase Inhibitors (MAOIs)EMSAM PT24 5 MO

MARPLAN TABS 4 MO

NARDIL TABS (PhenelzineSulfate) NF MO

PARNATE TABS(Tranylcypromine Sulfate) NF MO

phenelzine sulfate tabs or 4 MO

tranylcypromine sulfatetabs 3 MO

Selective Serotonin Reuptake Inhibitors (SSRIs)CELEXA TABS 10 MG(Citalopram Hydrobromide) NF SL(4 ea daily);

MOCELEXA TABS 20 MG(Citalopram Hydrobromide) NF SL(2 ea daily);

MOCELEXA TABS 40 MG(Citalopram Hydrobromide) NF SL(1 ea daily);

MOcitalopram hydrobromidesoln 10 mg/5ml 4 SL(20 ml daily);

MOcitalopram hydrobromidetabs 10 mg 1 SL(4 ea daily);

MO; *citalopram hydrobromidetabs 20 mg 1 SL(2 ea daily);

MO; *citalopram hydrobromidetabs 40 mg 1 SL(1 ea daily);

MO; *

escitalopram oxalate soln 3 MO

escitalopram oxalate tabs 3 MO

fluoxetine hcl caps or 10mg, 20 mg, 40 mg 2 MO; *

fluoxetine hcl cpdr or 90mg 2 MO; *

fluoxetine hcl soln or 20mg/5ml 2 MO; *

fluoxetine hcl tabs or 10mg, 20 mg 2 MO; *

FLUOXETINE HCL TABSOR 60 MG 4 MO

Drug Name DrugTier

Requirements/Limits

fluvoxamine maleate cp24100 mg, 150 mg 3 MO

fluvoxamine maleate tabs100 mg, 25 mg, 50 mg 2 MO; *

LEXAPRO SOLN(Escitalopram Oxalate) NF MO

LEXAPRO TABS(Escitalopram Oxalate) NF MO

LUVOX CR CP24(Fluvoxamine Maleate) NF MO

paroxetine hcl tabs 10 mg,20 mg, 30 mg, 40 mg 2 MO; *

paroxetine hcl tb24 12.5mg, 25 mg, 37.5 mg 3 MO

PAXIL CR TB24(Paroxetine HCl) NF MO

PAXIL SUSP 10 MG/5ML 4 MO

PAXIL TABS 10 MG, 20MG, 30 MG, 40 MG(Paroxetine HCl)

NFMO

PEXEVA TABS 4 ST; MO

PROZAC CAPS(Fluoxetine HCl) NF MO

PROZAC WEEKLY CPDR(Fluoxetine HCl) NF MO

sertraline hcl conc or 20mg/ml 2 MO; *

sertraline hcl tabs or 100mg, 25 mg, 50 mg 1 MO; *

ZOLOFT CONC (SertralineHCl) NF MO

ZOLOFT TABS (SertralineHCl) NF MO

Serotonin Modulators

BRINTELLIX TABS 10 MG 4 ST; QL(2 eadaily); MO



nefazodone hcl tabs 2 MO; *



21

Drug Name DrugTier

Requirements/Limits

trazodone hcl tabs or 100mg, 150 mg, 300 mg, 50mg

1MO; *

TRINTELLIX TABS 10 MG 4 ST; QL(2 eadaily); MO



VIIBRYD KIT 4 ST

VIIBRYD STARTER PACKKIT 4 ST; MO

VIIBRYD TABS 10 MG, 20MG, 40 MG 4 ST; MO

Serotonin-Norepinephrine Reuptake InhibitorsCYMBALTA CPEP(Duloxetine HCl) NF MO

DESVENLAFAXINE ERTB24 100 MG, 50 MG 4 ST; Fumarate

DESVENLAFAXINE ERTB24 100 MG, 50 MG 4 ST; MO

duloxetine hcl cpep 20 mg,30 mg, 60 mg 3 MO

EFFEXOR XR CP24 150MG (Venlafaxine HCl) NF SL(1.5 ea

daily); MOEFFEXOR XR CP24 37.5MG (Venlafaxine HCl) NF SL(6 ea daily);

MOEFFEXOR XR CP24 75MG (Venlafaxine HCl) NF SL(3 ea daily);

MOFETZIMA CP24 120 MG,40 MG, 80 MG 4 ST; QL(1 ea

daily); MO

FETZIMA CP24 20 MG 4 ST; QL(2 eadaily); MO

FETZIMA TITRATIONPACK C4PK 4 ST; MO

KHEDEZLA TB24 4 ST; MO

PRISTIQ TB24 4 ST; MO

venlafaxine hcl cp24 150mg 3 SL(1.5 ea

daily); MOvenlafaxine hcl cp24 37.5mg 3 SL(6 ea daily);

MO

venlafaxine hcl cp24 75 mg 3 SL(3 ea daily);MO

Drug Name DrugTier

Requirements/Limits

VENLAFAXINE HCL ERTB24 4 ST; SL(1 ea

daily); MOvenlafaxine hcl tabs 100mg 2 SL(3.75 ea

daily); MO; *

venlafaxine hcl tabs 25 mg 2 SL(15 ea daily);MO; *

venlafaxine hcl tabs 37.5mg 2 SL(10 ea daily);

MO; *

venlafaxine hcl tabs 50 mg 2 SL(7.5 eadaily); MO; *

venlafaxine hcl tabs 75 mg 2 SL(5 ea daily);MO; *

venlafaxine hcl tb24 150mg 2 SL(1.5 ea

daily); MO; *venlafaxine hcl tb24 37.5mg 2 SL(6 ea daily);

MO; *

venlafaxine hcl tb24 75 mg 2 SL(3 ea daily);MO; *

Tricyclic Agentsamitriptyline hcl tabs 2 AL; MO; *

amoxapine tabs 100 mg,25 mg, 50 mg 1 MO; *

amoxapine tabs 150 mg 2 MO; *

ANAFRANIL CAPS(Clomipramine HCl) NF AL; MO

clomipramine hcl caps or25 mg, 50 mg 3 AL; MO

clomipramine hcl caps or75 mg 2 AL; MO; *

desipramine hcl tabs or 10mg, 100 mg, 150 mg, 25mg, 50 mg, 75 mg

4MO

doxepin hcl caps or 10 mg,100 mg, 150 mg, 25 mg, 50mg, 75 mg

2AL; MO; *

doxepin hcl conc or 10mg/ml 2 AL; MO; *

ELAVIL TABS(Amitriptyline HCl) 4 AL; MO

imipramine hcl tabs or 10mg, 25 mg, 50 mg 2 AL; MO; *

imipramine pamoate caps 4 AL; MO



22

Drug Name DrugTier

Requirements/Limits

NORPRAMIN TABS(Desipramine HCl) NF MO

nortriptyline hcl caps or 10mg, 25 mg, 50 mg, 75 mg 1 MO; *

nortriptyline hcl soln or 10mg/5ml 2 MO; *

PAMELOR CAPS(Nortriptyline HCl) NF MO

protriptyline hcl tabs 1 MO; *

SURMONTIL CAPS(Trimipramine Maleate) 4 AL; MO

TOFRANIL-PM CAPS(Imipramine Pamoate) NF AL; MO

trimipramine maleate capsor 100 mg 2 AL; MO; *

trimipramine maleate capsor 25 mg, 50 mg 4 AL; MO

ANTIDIABETICS - Drugs to Regulate Blood Sugar

Alpha-Glucosidase Inhibitors

acarbose tabs 6 QL(3 ea daily);MO; *

GLYSET TABS (Miglitol) 3 QL(3 ea daily);MO

miglitol tabs 2 QL(3 ea daily);MO; *

PRECOSE TABS(Acarbose) NF QL(3 ea daily);

MOAntidiabetic - Amylin Analogs

SYMLINPEN 120 SOPN 4Limit 12mls permonth;QL(0.4ml daily); MO

SYMLINPEN 60 SOPN 4Limit 12mls permonth;QL(0.4ml daily); MO

Antidiabetic CombinationsACTOPLUS MET TABS(Pioglitazone HCl-Metformin HCl)

NFSL(3 ea daily);MO

ACTOPLUS MET XR TB2415MG-1000MG 3 SL(2.55 ea

daily); MOACTOPLUS MET XR TB2430MG-1000MG 3 SL(1.5 ea

daily); MO

Drug Name DrugTier

Requirements/Limits

ALOGLIPTIN/METFORMINHCL TABS 4 PA; SL(2 ea

daily); MOALOGLIPTIN/PIOGLITAZONE TABS 12.5MG-15MG 4 PA; SL(2 ea

daily); MOALOGLIPTIN/PIOGLITAZONE TABS 12.5MG-30MG 4 PA; SL(1.5 ea

daily); MOALOGLIPTIN/PIOGLITAZONE TABS 12.5MG-45MG,25MG-15MG, 25MG-30MG, 25MG-45MG

4

PA; SL(1 eadaily); MO

DUETACT TABS(Pioglitazone HCl-Glimepiride)

NFSL(1.5 eadaily); MO

glipizide-metformin hcl tabs2.5mg-250mg 6 SL(8 ea daily);

MO; *glipizide-metformin hcl tabs2.5mg-500mg, 5mg-500mg 6 SL(4 ea daily);

MO; *GLUCOVANCE TABS1.25MG-250MG(Glyburide-Metformin)

NFAL; SL(8 eadaily); MO

GLUCOVANCE TABS2.5MG-500MG, 5MG-500MG (Glyburide-Metformin)

NF

AL; SL(4 eadaily); MO

glyburide-metformin tabs1.25mg-250mg 2 AL; SL(8 ea

daily); MO; *glyburide-metformin tabs2.5mg-500mg, 5mg-500mg 2 AL; SL(4 ea

daily); MO; *INVOKAMET TABS150MG-1000MG, 150MG-500MG, 50MG-1000MG

3SL(2 ea daily);MO

INVOKAMET TABS 50MG-500MG 3 SL(4 ea daily);

MO

JANUMET TABS 3 SL(2 ea daily);MO

JANUMET XR TB24100MG-1000MG 3 SL(1 ea daily);

MOJANUMET XR TB2450MG-1000MG, 50MG-500MG

3SL(2 ea daily);MO

JENTADUETO TABS 3 SL(2 ea daily);MO

JENTADUETO XR TB242.5MG-1000MG 3 SL(2 ea daily);

MOJENTADUETO XR TB245MG-1000MG 3 SL(1 ea daily);

MO



23

Drug Name DrugTier

Requirements/Limits

KAZANO TABS 4 PA; SL(2 eadaily); MO

KOMBIGLYZE XR TB242.5MG-1000MG 4 PA; SL(2 ea

daily); MOKOMBIGLYZE XR TB245MG-1000MG, 5MG-500MG

4PA; SL(1 eadaily); MO

OSENI TABS 12.5MG-15MG 4 PA; SL(2 ea

daily); MOOSENI TABS 12.5MG-30MG 4 PA; SL(1.5 ea

daily); MOOSENI TABS 12.5MG-45MG, 25MG-15MG,25MG-30MG, 25MG-45MG

4PA; SL(1 eadaily); MO

pioglitazone hcl-glimepiridetabs 6 SL(1.5 ea

daily); MO; *pioglitazone hcl-metforminhcl tabs 6 SL(3 ea daily);

MO; *PRANDIMET TABS(Repaglinide-MetforminHCl)

3SL(5 ea daily);MO

repaglinide-metformin hcltabs 2 SL(5 ea daily);

MO; *SYNJARDY TABS12.5MG-1000MG, 5MG-1000MG

3SL(2 ea daily);MO

SYNJARDY TABS12.5MG-500MG, 5MG-500MG

3SL(4 ea daily);MO

XIGDUO XR TB24 10MG-1000MG, 10MG-500MG 4 SL(1 ea daily);

MOXIGDUO XR TB24 5MG-1000MG, 5MG-500MG 4 SL(2 ea daily);

MOBiguanides

FORTAMET TB24 1000MG (Metformin HCl) NF

(FORTAMET);SL(2.5 eadaily); MO

FORTAMET TB24 500 MG(Metformin HCl) NF

(FORTAMET);SL(5 ea daily);MO

GLUCOPHAGE TABS1000 MG (Metformin HCl) NF SL(2.55 ea

daily); MOGLUCOPHAGE TABS 500MG (Metformin HCl) NF SL(5.1 ea

daily); MOGLUCOPHAGE TABS 850MG (Metformin HCl) NF SL(3 ea daily);

MO

Drug Name DrugTier

Requirements/Limits

GLUCOPHAGE XR TB24500 MG (Metformin HCl) NF

(GLUCOPHAGE XR);SL(4 eadaily); MO

GLUCOPHAGE XR TB24750 MG (Metformin HCl) NF

(GLUCOPHAGE XR);SL(2.66ea daily); MO

GLUMETZA TB24 1000MG (Metformin HCl) NF

(GLUMETZA);SL(2 ea daily);MO

GLUMETZA TB24 500 MG(Metformin HCl) NF


metformin hcl tabs or 1000mg 6 SL(2.55 ea

daily); MO; *metformin hcl tabs or 500mg 6 SL(5.1 ea

daily); MO; *metformin hcl tabs or 850mg 6 SL(3 ea daily);

MO; *

metformin hcl tb24 or 1000mg 3



(FORTAMET);SL(2.5 eadaily); MO; *




(FORTAMET);SL(5 ea daily);MO; *


(GLUCOPHAGE XR);SL(4 eadaily); MO; *


(GLUCOPHAGE XR);SL(2.66ea daily); MO; *

RIOMET SOLN 3

Limit 765mlspermonth;SL(25.5ml daily); MO

Diabetic OtherGLUCAGEN HYPOKITSOLR 3 MO

glucagon (rdna) kit 1 MO; *

KORLYM TABS 4 SL(4 ea daily);LA



24

Drug Name DrugTier

Requirements/Limits

PROGLYCEM SUSP 4 MO

Dipeptidyl Peptidase-4 (DPP-4) InhibitorsALOGLIPTIN TABS 4 PA; MO

JANUVIA TABS 3 MO

NESINA TABS 4 PA; MO

ONGLYZA TABS 4 PA; MO

TRADJENTA TABS 3 MO

Dopamine Receptor Agonists - Antidiabetic

CYCLOSET TABS 4 QL(6 ea daily);MO

Incretin Mimetic Agents (GLP-1 ReceptorBYDUREON PEN PEN 3 ST; MO

BYDUREON SRER 3 ST; MO

BYETTA SOPN 3 ST; MO

TANZEUM PEN 4 ST; MO

TRULICITY SOPN 4 ST; MO

VICTOZA SOPN 3 ST; MO

Insulin Sensitizing AgentsACTOS TABS 15 MG(Pioglitazone HCl) NF SL(3 ea daily);

MOACTOS TABS 30 MG(Pioglitazone HCl) NF SL(1.5 ea

daily); MOACTOS TABS 45 MG(Pioglitazone HCl) NF SL(1 ea daily);

MO

AVANDIA TABS 2 MG 4 SL(4 ea daily);MO

AVANDIA TABS 4 MG 4 SL(2 ea daily);MO

pioglitazone hcl tabs 15 mg 6 SL(3 ea daily);MO; *

pioglitazone hcl tabs 30 mg 6 SL(1.5 eadaily); MO; *

pioglitazone hcl tabs 45 mg 6 SL(1 ea daily);MO; *

Drug Name DrugTier

Requirements/Limits

Insulin

AFREZZA POWD 4 QL(18 eadaily); MO

APIDRA SOLN 4Limit 45mls permonth;QL(1.5ml daily); MO

APIDRA SOLOSTARSOPN 4

Limit 45mls permonth;QL(1.5ml daily); MO

HUMALOG KWIKPENSOPN 3


HUMALOG MIX 50/50KWIKPEN SUPN 3


HUMALOG MIX 50/50SUSP 3


HUMALOG MIX 75/25KWIKPEN SUPN 3


HUMALOG MIX 75/25SUSP 3


HUMALOG SOCT 3Limit 45mls permonth;QL(1.5ml daily); MO

HUMALOG SOLN 3Limit 45mls permonth;QL(1.5ml daily); MO

HUMULIN 70/30 KWIKPENSUPN 3


HUMULIN 70/30 SUSP 3Limit 45mls permonth;QL(1.5ml daily); MO

HUMULIN N KWIKPENSUPN 3


HUMULIN N SUSP 3Limit 45mls permonth;QL(1.5ml daily); MO

HUMULIN R SOLN 3Limit 45mls permonth;QL(1.5ml daily); MO



25

Drug Name DrugTier

Requirements/Limits

HUMULIN R U-500(CONCENTRATED) SOLN 3


HUMULIN R U-500KWIKPEN SOPN 3


LANTUS SOLN 3Limit 45mls permonth;QL(1.5ml daily); MO

LANTUS SOLOSTARSOPN 3


LEVEMIR FLEXTOUCHSOPN 3


LEVEMIR SOLN 3Limit 45mls permonth;QL(1.5ml daily); MO

NOVOLIN 70/30 RELIONSUSP 4


NOVOLIN 70/30 SUSP 4Limit 45mls permonth;QL(1.5ml daily); MO

NOVOLIN N RELIONSUSP 4


NOVOLIN N SUSP 4Limit 45mls permonth;QL(1.5ml daily); MO

NOVOLIN R RELIONSOLN 4


NOVOLIN R SOLN 4Limit 45mls permonth;QL(1.5ml daily); MO

NOVOLOG FLEXPENSOPN 4


NOVOLOG MIX 70/30PREFILLED FLEXPENSUPN

4Limit 45mls permonth;QL(1.5ml daily); MO

NOVOLOG MIX 70/30SUSP 4


NOVOLOG PENFILLSOCT 4


Drug Name DrugTier

Requirements/Limits

NOVOLOG SOLN 4Limit 45mls permonth;QL(1.5ml daily); MO

TOUJEO SOLOSTARSOPN 3


TRESIBA FLEXTOUCHSOPN 100 UNIT/ML 3 QL(1.5 ml

daily); MOTRESIBA FLEXTOUCHSOPN 200 UNIT/ML 3 QL(0.9 ml

daily); MOMeglitinide Analogues

nateglinide tabs 6 QL(3 ea daily);MO; *

PRANDIN TABS 0.5 MG(Repaglinide) NF SL(32 ea daily);

MOPRANDIN TABS 1 MG(Repaglinide) NF SL(16 ea daily);

MOPRANDIN TABS 2 MG(Repaglinide) NF SL(8 ea daily);

MO

repaglinide tabs 0.5 mg 6 SL(32 ea daily);MO; *

repaglinide tabs 1 mg 6 SL(16 ea daily);MO; *

repaglinide tabs 2 mg 6 SL(8 ea daily);MO; *

STARLIX TABS(Nateglinide) NF QL(3 ea daily);

MOSodium-Glucose Co-Transporter 2 (SGLT2)FARXIGA TABS 4 MO

INVOKANA TABS 3 MO

JARDIANCE TABS 3 MO

SulfonylureasAMARYL TABS 1 MG(Glimepiride) NF SL(8 ea daily);

MOAMARYL TABS 2 MG(Glimepiride) NF SL(4 ea daily);

MOAMARYL TABS 4 MG(Glimepiride) NF SL(2 ea daily);

MOchlorpropamide tabs 100mg 2 AL; SL(7.5 ea

daily); MO; *chlorpropamide tabs 250mg 2 AL; SL(3 ea

daily); MO; *



26

Drug Name DrugTier

Requirements/Limits

DIABETA TABS 1.25 MG(Glyburide) 4 AL; SL(16 ea

daily); MODIABETA TABS 2.5 MG(Glyburide) 4 AL; SL(8 ea

daily); MODIABETA TABS 5 MG(Glyburide) 4 AL; SL(4 ea

daily); MO

glimepiride tabs 1 mg 6 SL(8 ea daily);MO; *



glipizide tabs or 10 mg 6 SL(4 ea daily);MO; *

glipizide tabs or 5 mg 6 SL(8 ea daily);MO; *

glipizide tb24 or 10 mg 6 SL(2 ea daily);MO; *

glipizide tb24 or 2.5 mg 6 SL(8 ea daily);MO; *

glipizide tb24 or 5 mg 6 SL(4 ea daily);MO; *

GLUCOTROL TABS 10MG (Glipizide) NF SL(4 ea daily);

MOGLUCOTROL TABS 5 MG(Glipizide) NF SL(8 ea daily);

MOGLUCOTROL XL TB24 10MG (Glipizide) NF SL(2 ea daily);

MOGLUCOTROL XL TB24 2.5MG (Glipizide) NF SL(8 ea daily);

MOGLUCOTROL XL TB24 5MG (Glipizide) NF SL(4 ea daily);

MOglyburide micronized tabs1.5 mg 2 AL; SL(8 ea

daily); MO; *glyburide micronized tabs 3mg 2 AL; SL(4 ea

daily); MO; *glyburide micronized tabs 6mg 2 AL; SL(2 ea

daily); MO; *

glyburide tabs or 1.25 mg 2 AL; SL(16 eadaily); MO; *

glyburide tabs or 2.5 mg 2 AL; SL(8 eadaily); MO; *

glyburide tabs or 5 mg 2 AL; SL(4 eadaily); MO; *

GLYNASE TABS 1.5 MG(Glyburide Micronized) NF AL; SL(8 ea

daily); MO

Drug Name DrugTier

Requirements/Limits

GLYNASE TABS 3 MG(Glyburide Micronized) NF AL; SL(4 ea

daily); MOGLYNASE TABS 6 MG(Glyburide Micronized) NF AL; SL(2 ea

daily); MOTOLAZAMIDE TABS 250MG 6 SL(4 ea daily);

MO; *

tolazamide tabs 250 mg 6 SL(4 ea daily);MO; *

tolazamide tabs 500 mg 6 SL(2 ea daily);MO; *

tolbutamide tabs 6 SL(6 ea daily);MO; *

ANTIDIARRHEALS - Drugs to Treat Diarrhea

Antidiarrheal - Chloride Channel Antagonists

FULYZAQ TBEC 4 PA; QL(2 eadaily); MO

MYTESI TBEC 4 PA; QL(2 eadaily); MO

Antiperistaltic Agentsdiphenoxylate w/ atropineliqd 2 MO; *

diphenoxylate w/ atropinetabs 2 MO; *

LOMOTIL TABS(Diphenoxylate w/ Atropine) NF MO

loperamide hcl caps or 2mg 2 RX/OTC; MO; *

opium tincture tinc 5 MO

ANTIDOTES AND SPECIFIC ANTAGONISTS

Antidotes - Chelating AgentsCHEMET CAPS 4 MO

EXJADE TBSO 5 LA

FERRIPROX TABS 500MG 4 PA; LA

JADENU TABS 5

Opioid AntagonistsEVZIO SOAJ 4 PA; MO

naloxone hcl sosy ij 2mg/2ml 2 MO; *



27

Drug Name DrugTier

Requirements/Limits

naltrexone hcl tabs or 1 MO; *

NARCAN LIQD 4Limit 4 permonth;QL(0.134 ea daily); MO

REVIA TABS (NaltrexoneHCl) NF MO

ANTIEMETICS - Drugs to Treat Nausea andVomiting5-HT3 Receptor Antagonistsgranisetron hcl tabs or 1mg 3 MO; B/D

ondansetron hcl soln ij 4mg/2ml 3 MO

ondansetron hcl soln ij 40mg/20ml 2 MO; *

ondansetron hcl soln or 4mg/5ml 2 MO; B/D; *

ondansetron hcl tabs or 24mg, 4 mg, 8 mg 2 MO; B/D; *

ondansetron tbdp 2 MO; B/D; *

SANCUSO PTCH 5 MO

ZOFRAN ODT TBDP(Ondansetron) NF MO; B/D

ZOFRAN SOLN IJ 40MG/20ML (OndansetronHCl)

NFMO

ZOFRAN SOLN OR 4MG/5ML (OndansetronHCl)

NFMO; B/D

ZOFRAN TABS OR 4 MG,8 MG (Ondansetron HCl) NF MO; B/D

Antiemetics - Anticholinergicdimenhydrinate soln ij 50mg/ml 2 *

meclizine hcl tabs 12.5 mg,25 mg 2 RX/OTC; MO; *

TIGAN CAPS OR 300 MG(Trimethobenzamide HCl) NF AL; MO

TRANSDERM-SCOP PT72 4 MO

trimethobenzamide hclcaps or 2 AL; MO; *

Antiemetics - Miscellaneous

Drug Name DrugTier

Requirements/Limits

AKYNZEO CAPS 4 MO; B/D

CESAMET CAPS 4 MO; B/D

dronabinol caps 10 mg 5 MO; B/D

dronabinol caps 2.5 mg 2 MO; B/D; *

dronabinol caps 5 mg 4 MO; B/D

MARINOL CAPS 10 MG, 5MG (Dronabinol) 5 MO; B/D

MARINOL CAPS 2.5 MG(Dronabinol) NF MO; B/D

Substance P/Neurokinin 1 (NK1) ReceptorEMEND CAPS OR 125MG, 80 MG 4 MO; B/D

EMEND CAPS OR 40 MG 4 PA; MO

VARUBI TABS 4 B/D

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungal - Glucan Synthesis InhibitorsERAXIS SOLR 100 MG 4

MYCAMINE SOLR 100 MG 5 MO

AntifungalsABELCET SUSP 4

AMBISOME SUSR 4

amphotericin b solr ij 50 mg 1 MO; *

ANCOBON CAPS 500 MG(Flucytosine) NF MO

flucytosine caps 500 mg 2 MO; *

GRIS-PEG TABS(GriseofulvinUltramicrosize)

NFMO

griseofulvin microsize susp125 mg/5ml 2 MO; *

griseofulvin microsize tabs500 mg 3 MO



28

Drug Name DrugTier

Requirements/Limits

griseofulvin ultramicrosizetabs 125 mg 1 MO; *

griseofulvin ultramicrosizetabs 250 mg 3 MO

LAMISIL PACK 125 MG 3 PA; MO

LAMISIL TABS 250 MG(Terbinafine HCl) NF MO

nystatin tabs or 1 MO; *

terbinafine hcl tabs or 2 MO; *

Imidazole-Related AntifungalsCRESEMBA CAPS OR186 MG 5 MO

CRESEMBA SOLR IV 372MG 5

DIFLUCAN SUSR(Fluconazole) NF MO

DIFLUCAN TABS(Fluconazole) NF MO

fluconazole in dextrosesoln 2 *

fluconazole in nacl soln200mg/100ml-0.9%,400mg/200ml-0.9%

1*

fluconazole susr or 10mg/ml 2 MO; *

fluconazole susr or 40mg/ml 3 MO

fluconazole tabs or 100mg, 150 mg, 200 mg, 50mg

2MO; *

itraconazole caps or 4 MO

ketoconazole tabs or 2 MO; *

NOXAFIL SOLN IV 300MG/16.7ML 5

NOXAFIL SUSP OR 40MG/ML 5 MO

NOXAFIL TBEC OR 100MG 5 MO

ONMEL TABS 4 MO

SPORANOX CAPS 100MG (Itraconazole) NF MO

Drug Name DrugTier

Requirements/Limits

SPORANOX PULSEPAKCAPS (Itraconazole) NF MO

SPORANOX SOLN 10MG/ML 5 MO

VFEND IV SOLR(Voriconazole) NF

VFEND SUSR 40 MG/ML(Voriconazole) NF MO

VFEND TABS 200 MG, 50MG (Voriconazole) 5 MO

voriconazole solr iv 200 mg 2 *

voriconazole susr or 40mg/ml 2 MO; *

voriconazole tabs or 200mg, 50 mg 5 MO

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Ethanolaminescarbinoxamine maleatesoln 2 AL; MO; *

carbinoxamine maleatetabs 2 AL; MO; *

clemastine fumarate tabsor 2.68 mg 2 AL; MO; *

diphenhydramine hcl soln ij50 mg/ml 1 AL; MO; *

Antihistamines - Non-Sedatingcetirizine hcl soln 1 mg/ml 1 RX/OTC; MO; *

cetirizine hcl syrp 1 mg/ml 1 RX/OTC; MO; *

CLARINEX TABS 5 MG(Desloratadine) NF MO

desloratadine tabs 3 MO

desloratadine tbdp 3 MO

levocetirizinedihydrochloride soln 2.5mg/5ml

3MO

levocetirizinedihydrochloride tabs 5 mg 2 MO; *

XYZAL SOLN(LevocetirizineDihydrochloride)

NFMO



29

Drug Name DrugTier

Requirements/Limits

XYZAL TABS(LevocetirizineDihydrochloride)

NFMO

Antihistamines - Phenothiazinespromethazine hcl soln ij 25mg/ml, 50 mg/ml 2 AL; MO; *

promethazine hcl soln or6.25 mg/5ml 2 AL; MO; *

promethazine hcl supp re12.5 mg, 25 mg, 50 mg 2 AL; MO; *

promethazine hcl syrp or6.25 mg/5ml 2 AL; MO; *

promethazine hcl tabs or12.5 mg, 25 mg, 50 mg 2 AL; MO; *

Antihistamines - Piperidinescyproheptadine hcl syrp or2 mg/5ml 2 AL; MO; *

cyproheptadine hcl tabs or4 mg 2 AL; MO; *

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterolAntihyperlipidemics - CombinationsVYTORIN TABS 10MG-10MG 3 QL(8 ea daily);

MOVYTORIN TABS 10MG-20MG 3 QL(4 ea daily);

MOVYTORIN TABS 40MG-10MG 3 QL(2 ea daily);

MOVYTORIN TABS 80MG-10MG 3 PA; QL(1 ea

daily); MOAntihyperlipidemics - Misc.KYNAMRO SOSY 5 PA; LA

LOVAZA CAPS (Omega-3-acid Ethyl Esters) NF MO

omega-3-acid ethyl esterscaps 3 MO

VASCEPA CAPS 0.5 GM 4 ST

VASCEPA CAPS 1 GM 4 ST; MO

Bile Acid Sequestrantscholestyramine light pack 1 MO; *

Drug Name DrugTier

Requirements/Limits

cholestyramine light powd 1 MO; *

cholestyramine pack or 4gm 2 MO; *

cholestyramine powd or 4gm/dose 2 Powder

Canister;MO; *COLESTID FLAVOREDGRAN 5 GM (ColestipolHCl)

NFMO

COLESTID GRAN(Colestipol HCl) NF MO

COLESTID PACK(Colestipol HCl) NF MO

COLESTID TABS(Colestipol HCl) NF MO

colestipol hcl gran 5 gm 1 MO; *

colestipol hcl pack 5 gm 2 MO; *

colestipol hcl tabs 1 gm 1 MO; *

WELCHOL PACK 4 MO

WELCHOL TABS 4 MO

Fibric Acid Derivatives

ANTARA CAPS 30 MG 4 SL(4.33 eadaily); MO

ANTARA CAPS 90 MG 4 SL(1.44 eadaily); MO

choline fenofibrate cpdr 3 MO

FENOFIBRATE CAPS 150MG, 50 MG 4 MO

fenofibrate micronized caps130 mg 2 SL(1 ea daily);

MO; *fenofibrate micronized caps134 mg, 200 mg, 67 mg 2 MO; *

fenofibrate micronized caps43 mg 2 SL(3.02 ea

daily); MO; *fenofibrate tabs 120 mg,145 mg, 160 mg, 40 mg, 48mg, 54 mg

2MO; *

FENOGLIDE TABS(Fenofibrate) 4 MO

gemfibrozil tabs or 2 MO; *



30

Drug Name DrugTier

Requirements/Limits

LIPOFEN CAPS 4 MO

LOPID TABS (Gemfibrozil) NF MO

TRICOR TABS(Fenofibrate) NF MO

TRILIPIX CPDR (CholineFenofibrate) NF MO

HMG CoA Reductase InhibitorsALTOPREV TB24 4 MO

atorvastatin calcium tabs 6 MO; *

CRESTOR TABS(Rosuvastatin Calcium) 4 ST; MO

fluvastatin sodium caps 20mg, 40 mg 6 MO; *

fluvastatin sodium tb24 80mg 2 MO; *

LESCOL CAPS(Fluvastatin Sodium) NF MO

LESCOL XL TB24(Fluvastatin Sodium) 4 MO

LIPITOR TABS(Atorvastatin Calcium) NF MO

LIVALO TABS 4 MO

lovastatin tabs 6 MO; *

MEVACOR TABS(Lovastatin) NF MO

PRAVACHOL TABS(Pravastatin Sodium) NF MO

pravastatin sodium tabs 6 MO; *

rosuvastatin calcium tabs 2 ST; MO; *

simvastatin tabs or 10 mg 6 SL(8 ea daily);MO; *





Drug Name DrugTier

Requirements/Limits

ZOCOR TABS 10 MG(Simvastatin) NF SL(8 ea daily);

MOZOCOR TABS 20 MG(Simvastatin) NF SL(4 ea daily);




MOIntestinal Cholesterol Absorption InhibitorsZETIA TABS 3 MO

Microsomal Triglyceride Transfer Protein (MTP)

JUXTAPID CAPS 10 MG 5 PA; SL(6 eadaily); LA



JUXTAPID CAPS 40 MG 5 PA; SL(1.5 eadaily); LA



Nicotinic Acid Derivativesniacin (antihyperlipidemic)tabs 500 mg 2 MO; *

niacin (antihyperlipidemic)tbcr 1000 mg, 500 mg, 750mg

3MO

NIASPAN TBCR (Niacin(Antihyperlipidemic)) NF MO

Proprotein Convertase Subtilisin/Kexin Type 9

PRALUENT SOPN 150MG/ML 5

PA; Limit 2mlsper 28days;SL(0.08ml daily)

PRALUENT SOPN 75MG/ML 5




31

Drug Name DrugTier

Requirements/Limits

PRALUENT SOSY 150MG/ML 5


PRALUENT SOSY 75MG/ML 5


REPATHA PUSHTRONEXSYSTEM SOCT 5 PA

REPATHA SOSY 5 PA

REPATHA SURECLICKSOAJ 5 PA

ANTIHYPERTENSIVES - Drugs to Treat HighBlood PressureACE InhibitorsACCUPRIL TABS(Quinapril HCl) NF MO

ACEON TABS 4 MG(Perindopril Erbumine) NF SL(4 ea daily);

MOACEON TABS 8 MG(Perindopril Erbumine) NF SL(2 ea daily);

MO

ALTACE CAPS (Ramipril) NF MO

benazepril hcl tabs or 10mg, 20 mg, 40 mg, 5 mg 6 MO; *

captopril tabs or 100 mg,12.5 mg, 25 mg, 50 mg 6 MO; *

enalapril maleate tabs or10 mg 6 SL(4 ea daily);

MO; *enalapril maleate tabs or2.5 mg 6 SL(16 ea daily);

MO; *enalapril maleate tabs or20 mg 6 SL(2 ea daily);

MO; *enalapril maleate tabs or 5mg 6 SL(8 ea daily);

MO; *

enalaprilat inj 6 *

fosinopril sodium tabs 6 MO; *

lisinopril tabs or 10 mg, 2.5mg, 20 mg, 30 mg, 40 mg,5 mg

6MO; *

LOTENSIN TABS(Benazepril HCl) NF MO

Drug Name DrugTier

Requirements/Limits

MAVIK TABS (Trandolapril) NF MO

moexipril hcl tabs 6 MO; *

perindopril erbumine tabs 2mg 6 SL(8 ea daily);

MO; *perindopril erbumine tabs 4mg 6 SL(4 ea daily);

MO; *perindopril erbumine tabs 8mg 6 SL(2 ea daily);

MO; *

PRINIVIL TABS (Lisinopril) NF MO

quinapril hcl tabs 6 MO; *

ramipril caps 6 MO; *

trandolapril tabs 6 MO; *

VASOTEC TABS 10 MG(Enalapril Maleate) NF SL(4 ea daily);

MOVASOTEC TABS 2.5 MG(Enalapril Maleate) NF SL(16 ea daily);

MOVASOTEC TABS 20 MG(Enalapril Maleate) NF SL(2 ea daily);

MOVASOTEC TABS 5 MG(Enalapril Maleate) NF SL(8 ea daily);

MO

ZESTRIL TABS (Lisinopril) NF MO

Agents for PheochromocytomaDEMSER CAPS 5 MO

DIBENZYLINE CAPS(Phenoxybenzamine HCl) 4 MO

phenoxybenzamine hclcaps or 2 MO; *

Angiotensin II Receptor AntagonistsATACAND TABS(Candesartan Cilexetil) NF MO

AVAPRO TABS(Irbesartan) NF MO

BENICAR TABS(Olmesartan Medoxomil) 3 MO

candesartan cilexetil tabs 6 MO; *

COZAAR TABS (LosartanPotassium) NF MO



32

Drug Name DrugTier

Requirements/Limits

DIOVAN TABS (Valsartan) NF MO

EDARBI TABS 4 MO

EPROSARTANMESYLATE TABS 6 MO; *

irbesartan tabs 6 MO; *

losartan potassium tabs 6 MO; *

MICARDIS TABS(Telmisartan) NF MO

olmesartan medoxomil tabs 2 MO; *

telmisartan tabs 3 MO

valsartan tabs 6 MO; *

Antiadrenergic AntihypertensivesCARDURA TABS(Doxazosin Mesylate) NF MO

CATAPRES TABS(Clonidine HCl) NF MO

CATAPRES-TTS-1 PTWK(Clonidine HCl) NF MO



clonidine hcl ptwk td 0.1mg/24hr, 0.2 mg/24hr, 0.3mg/24hr

3MO

clonidine hcl tabs or 0.1mg, 0.2 mg, 0.3 mg 1 MO; *

doxazosin mesylate tabs 2 MO; *

guanfacine hcl tabs 2 AL; MO; *

methyldopa tabs 2 AL; MO; *

MINIPRESS CAPS(Prazosin HCl) NF MO

prazosin hcl caps 1 MO; *

RESERPINE TABS OR 0.1MG 4

Drug Name DrugTier

Requirements/Limits

RESERPINE TABS OR0.25 MG 4 AL

TENEX TABS (GuanfacineHCl) NF AL; MO

terazosin hcl caps 1 MO; *

Antihypertensive CombinationsACCURETIC TABS(Quinapril-Hydrochlorothiazide)

NFMO

amlodipine besylate-benazepril hcl caps 6 MO; *

amlodipine besylate-olmesartan medoxomil tabs 2 MO; *

amlodipine besylate-valsartan tabs 2 MO; *

amlodipine-valsartan-hydrochlorothiazide tabs 2 MO; *

ATACAND HCT TABS(Candesartan Cilexetil-Hydrochlorothiazide)

NFMO

atenolol & chlorthalidonetabs 1 MO; *

AVALIDE TABS(Irbesartan-Hydrochlorothiazide)

NFMO

AZOR TABS (AmlodipineBesylate-OlmesartanMedoxomil)

3MO

benazepril &hydrochlorothiazide tabs 6 MO; *

BENICAR HCT TABS(Olmesartan Medoxomil-Hydrochlorothiazide)

3MO

bisoprolol &hydrochlorothiazide tabs 1 MO; *

BYVALSON TABS 4 MO

candesartan cilexetil-hydrochlorothiazide tabs 6 MO; *

CAPTOPRIL/HYDROCHLOROTHIAZIDE TABS 6 MO; *

CORZIDE TABS (Nadolol& Bendroflumethiazide) NF MO



33

Drug Name DrugTier

Requirements/Limits

DIOVAN HCT TABS(Valsartan-Hydrochlorothiazide)

NFMO

EDARBYCLOR TABS 4 MO

enalapril maleate &hydrochlorothiazide tabs 6 MO; *

EXFORGE HCT TABS(Amlodipine-Valsartan-Hydrochlorothiazide)

NFMO

EXFORGE TABS(Amlodipine Besylate-Valsartan)

NFMO

fosinopril sodium &hydrochlorothiazide tabs 6 MO; *

HYZAAR TABS (LosartanPotassium &Hydrochlorothiazide)

NFMO

irbesartan-hydrochlorothiazide tabs 6 MO; *

lisinopril &hydrochlorothiazide tabs 6 MO; *

LOPRESSOR HCT TABS(Metoprolol &Hydrochlorothiazide)

NFMO

losartan potassium &hydrochlorothiazide tabs 6 MO; *

LOTENSIN HCT TABS(Benazepril &Hydrochlorothiazide)

NFMO

LOTREL CAPS(Amlodipine Besylate-Benazepril HCl)

NFMO

methyldopa &hydrochlorothiazide tabs 2 AL; MO; *

metoprolol &hydrochlorothiazide tabs100mg-25mg, 50mg-25mg

1MO; *

metoprolol &hydrochlorothiazide tabs100mg-50mg

2MO; *

MICARDIS HCT TABS(Telmisartan-Hydrochlorothiazide)

NFMO

moexipril-hydrochlorothiazide tabs 6 MO; *

Drug Name DrugTier

Requirements/Limits

nadolol &bendroflumethiazide tabs40mg-5mg

1MO; *

nadolol &bendroflumethiazide tabs80mg-5mg

2MO; *

olmesartan medoxomil-amlodipine-hydrochlorothiazide tabs

2MO; *

olmesartan medoxomil-hydrochlorothiazide tabs 2 MO; *

quinapril-hydrochlorothiazide tabs 6 MO; *

TEKTURNA HCT TABS 3 MO

telmisartan-amlodipine tabs 2 MO; *

telmisartan-hydrochlorothiazide tabs 2 MO; *

TENORETIC 100 TABS(Atenolol & Chlorthalidone) NF MO

TENORETIC 50 TABS(Atenolol & Chlorthalidone) NF MO

TRIBENZOR TABS(Olmesartan Medoxomil-Amlodipine-Hydrochlorothiazide)

3

MO

TWYNSTA TABS(Telmisartan-Amlodipine) NF MO

valsartan-hydrochlorothiazide tabs 6 MO; *

VASERETIC TABS(Enalapril Maleate &Hydrochlorothiazide)

NFMO

ZESTORETIC TABS(Lisinopril &Hydrochlorothiazide)

NFMO

ZIAC TABS (Bisoprolol &Hydrochlorothiazide) NF MO

Direct Renin InhibitorsTEKTURNA TABS 3 MO

Selective Aldosterone Receptor Antagonistseplerenone tabs 25 mg 1 MO; *

eplerenone tabs 50 mg 2 MO; *



34

Drug Name DrugTier

Requirements/Limits

INSPRA TABS(Eplerenone) NF MO

Vasodilatorshydralazine hcl tabs or 10mg, 100 mg, 25 mg, 50 mg 2 MO; *

minoxidil tabs or 10 mg, 2.5mg 1 MO; *

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections)Antimalarial Combinationsatovaquone-proguanil hcltabs 250mg-100mg 3 MO

atovaquone-proguanil hcltabs 62.5mg-25mg 2 MO; *

COARTEM TABS 3 MO

MALARONE TABS250MG-100MG(Atovaquone-ProguanilHCl)

NF

MO

MALARONE TABS62.5MG-25MG(Atovaquone-ProguanilHCl)

4

MO

AntimalarialsARALEN TABS(Chloroquine Phosphate) NF MO

chloroquine phosphatetabs or 250 mg, 500 mg 1 MO; *

DARAPRIM TABS 4

hydroxychloroquine sulfatetabs or 2 MO; *

mefloquine hcl tabs 1 MO; *

PLAQUENIL TABS(HydroxychloroquineSulfate)

NFMO

PRIMAQUINEPHOSPHATE TABS 4 MO

primaquine phosphate tabs 2 MO; *

QUALAQUIN CAPS(Quinine Sulfate) NF PA; MO

quinine sulfate caps or 3 PA; MO

Drug Name DrugTier

Requirements/Limits

ANTIMYASTHENIC/CHOLINERGIC AGENTS

Antimyasthenic/Cholinergic Agentsguanidine hcl tabs 2 *

MESTINON TABS 60 MG(Pyridostigmine Bromide) NF MO

MESTINON TIMESPANTBCR (PyridostigmineBromide)

4MO

pyridostigmine bromidetabs or 60 mg 2 MO; *

pyridostigmine bromide tbcror 180 mg 2 MO; *

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections)Anti TB CombinationsRIFAMATE CAPS 4 MO

RIFATER TABS 4 MO

Antimycobacterial Agentsaminosalicylic acid pack or 2 MO; *

CAPASTAT SULFATESOLR 4

ethambutol hcl tabs or 100mg, 400 mg 1 MO; *

isoniazid tabs or 100 mg,300 mg 1 MO; *

MYAMBUTOL TABS(Ethambutol HCl) NF MO

MYCOBUTIN CAPS(Rifabutin) NF MO

PRIFTIN TABS 4 MO

pyrazinamide tabs or 1 MO; *

rifabutin caps 2 MO; *

RIFADIN CAPS (Rifampin) NF MO

RIFADIN SOLR (Rifampin) NF MO

rifampin caps or 150 mg,300 mg 2 MO; *



35

Drug Name DrugTier

Requirements/Limits

rifampin solr iv 600 mg 2 MO; *

SIRTURO TABS 5

TRECATOR TABS 4 MO

ANTINEOPLASTICS AND ADJUNCTIVETHERAPIES - Drugs to Treat CancerAlkylating AgentsALKERAN SOLR IV 50 MG(Melphalan HCl) NF

ALKERAN TABS OR 2 MG 4 MO; B/D

BENDEKA SOLN 5

BICNU SOLR 4

BUSULFEX SOLN 4

carboplatin soln 1 *

cisplatin soln 100mg/100ml, 50 mg/50ml 4

CISPLATIN SOLN 200MG/200ML 4

CYCLOPHOSPHAMIDECAPS OR 25 MG, 50 MG 3 MO; B/D

cyclophosphamide solr ij 1gm, 500 mg 1 *

ELOXATIN SOLN 100MG/20ML (Oxaliplatin) NF

ELOXATIN SOLN 50MG/10ML (Oxaliplatin) 5

EVOMELA SOLR 5

GLEOSTINE CAPS 3

HEXALEN CAPS 5 MO

IFEX SOLR 1 GM(Ifosfamide) 4

IFEX SOLR 3 GM 4

ifosfamide soln 1 gm/20ml,3 gm/60ml 2 *

ifosfamide solr 1 gm 2 *

Drug Name DrugTier

Requirements/Limits

IFOSFAMIDE SOLR 3 GM 4

LEUKERAN TABS 4 MO

melphalan hcl solr 2 *

MUSTARGEN SOLR 4

oxaliplatin soln 100mg/20ml 2 *

oxaliplatin soln 50 mg/10ml 5

oxaliplatin solr 100 mg, 50mg 5

TEMODAR SOLR IV 100MG 5

THIOTEPA SOLR IJ 5

TREANDA SOLN 5

TREANDA SOLR 5

YONDELIS SOLR 5 LA

ZANOSAR SOLR 4 MO

AntimetabolitesALIMTA SOLR 100 MG 5

ALIMTA SOLR 500 MG 5 MO

ARRANON SOLN 5

azacitidine susr 5

cladribine soln 2 *

CLOLAR SOLN 4

cytarabine soln 100 mg/ml 1 *

cytarabine soln 20 mg/ml 1 PreservativeFree; *

cytarabine soln 20 mg/ml 2 *

DACOGEN SOLR(Decitabine) NF

decitabine solr 2 *



36

Drug Name DrugTier

Requirements/Limits

fludarabine phosphate soln 2 *

fludarabine phosphate solr 2 *

fluorouracil soln iv 1gm/20ml, 2.5 gm/50ml, 500mg/10ml

4

FOLOTYN SOLN 5

gemcitabine hcl soln 1gm/26.3ml, 2 gm/52.6ml,200 mg/5.26ml

5

gemcitabine hcl solr 1 gm 1 *

gemcitabine hcl solr 2 gm 2 *

gemcitabine hcl solr 200mg 5

GEMZAR SOLR 1 GM(Gemcitabine HCl) NF

GEMZAR SOLR 200 MG(Gemcitabine HCl) 5

mercaptopurine tabs or 2 MO; *

methotrexate sodium soln ij1 gm/40ml, 100 mg/4ml,200 mg/8ml, 250 mg/10ml,50 mg/2ml

1

PreservativeFree; *

methotrexate sodium soln ij250 mg/10ml, 50 mg/2ml 2 *

methotrexate sodium solr ij1 gm 2 *

methotrexate sodium tabsor 10 mg, 15 mg 1 MO; *

methotrexate sodium tabsor 2.5 mg, 5 mg, 7.5 mg 2 MO; *

PURINETHOL TABS(Mercaptopurine) NF MO

PURIXAN SUSP 5 PA

TABLOID TABS 3 MO

VIDAZA SUSR(Azacitidine) 5

Antineoplastic - Angiogenesis InhibitorsAVASTIN SOLN 5

Drug Name DrugTier

Requirements/Limits

CYRAMZA SOLN 5 LA

ZALTRAP SOLN 5

Antineoplastic - AntibodiesARZERRA CONC 5

BLINCYTO SOLR 5

CAMPATH SOLN 5

DARZALEX SOLN 5 LA

EMPLICITI SOLR 5

ERBITUX SOLN 5

GAZYVA SOLN 5 LA

HERCEPTIN SOLR 5

KADCYLA SOLR 5

KEYTRUDA SOLN 5

KEYTRUDA SOLR 5

LARTRUVO SOLN 5

OPDIVO SOLN 5

PERJETA SOLN 5

PORTRAZZA SOLN 5

RITUXAN SOLN 5

TECENTRIQ SOLN 5

VECTIBIX SOLN 5

YERVOY SOLN 5

Antineoplastic - BCL-2 InhibitorsVENCLEXTA STARTINGPACK TBPK 4 PA; LA

VENCLEXTA TABS 4 PA; LA



37

Drug Name DrugTier

Requirements/Limits

Antineoplastic - Hedgehog Pathway InhibitorsERIVEDGE CAPS 5 LA

ODOMZO CAPS 5 LA

Antineoplastic - Hormonal and Related Agentsanastrozole tabs or 2 MO; *

ARIMIDEX TABS(Anastrozole) NF MO

AROMASIN TABS(Exemestane) NF MO

bicalutamide tabs 2 MO; *

CASODEX TABS(Bicalutamide) NF MO

DEPO-PROVERA SUSP 4 MO

ELIGARD KIT 4

EMCYT CAPS 4 MO

exemestane tabs 3 MO

FARESTON TABS 5 MO

FASLODEX SOLN 5

FEMARA TABS (Letrozole) NF MO

FIRMAGON SOLR 120 MG 5

FIRMAGON SOLR 80 MG 4

flutamide caps 3 MO

HYDROXYPROGESTERONE CAPROATE SOLN IM 5

letrozole tabs 2 MO; *

leuprolide acetate kit ij 1 *

LUPRON DEPOT KIT 5

LYSODREN TABS 3 MO

MEGACE ORAL SUSP(Megestrol Acetate) NF AL; MO

Drug Name DrugTier

Requirements/Limits

megestrol acetate susp or40 mg/ml, 400 mg/10ml 2 AL; MO; *

megestrol acetate tabs or20 mg, 40 mg 2 AL; MO; *

NILANDRON TABS(Nilutamide) 5 MO

nilutamide tabs 2 MO; *

SOLTAMOX SOLN 4 MO

tamoxifen citrate tabs or 10mg, 20 mg 2 MO; *

TRELSTAR MIXJECTSUSR 5

TRELSTAR SUSR 5

VANTAS KIT 5

XTANDI CAPS 5 PA; LA

ZOLADEX IMPL 4

ZYTIGA TABS 5

Antineoplastic - ImmunomodulatorsPOMALYST CAPS 5 LA

Antineoplastic Antibioticsbleomycin sulfate solr 2 *

COSMEGEN SOLR 4

daunorubicin hcl inj 2 *

DOXIL INJ (DoxorubicinHCl Liposomal) NF

doxorubicin hcl liposomalinj 2 *

doxorubicin hcl soln 2mg/ml 1 MO; *

doxorubicin hcl solr 10 mg,50 mg 1 *

ELLENCE SOLN(Epirubicin HCl) 4

epirubicin hcl soln 200mg/100ml 4



38

Drug Name DrugTier

Requirements/Limits

epirubicin hcl soln 50mg/25ml 2 *

IDAMYCIN PFS SOLN(Idarubicin HCl) 4

idarubicin hcl soln 2 *

mitomycin solr iv 20 mg, 40mg, 5 mg 2 MO; *

mitoxantrone hcl conc 2 *

VALSTAR SOLN 5

Antineoplastic CombinationsLONSURF TABS 5 PA

Antineoplastic Enzyme InhibitorsAFINITOR DISPERZ TBSO 5

AFINITOR TABS 5

ALECENSA CAPS 5 PA; LA

BELEODAQ SOLR 5

BOSULIF TABS 5 PA

CABOMETYX TABS 5 PA

CAPRELSA TABS 5 LA

COMETRIQ KIT 5 LA

COTELLIC TABS 5 LA

FARYDAK CAPS 5 PA; LA

GILOTRIF TABS 5 LA

GLEEVEC TABS 100 MG,400 MG (ImatinibMesylate)

5

GLEEVEC TABS 400 MG 5

IBRANCE CAPS 5 LA

ICLUSIG TABS 5 LA

Drug Name DrugTier

Requirements/Limits

imatinib mesylate tabs 5

IMBRUVICA CAPS 5 PA; LA

INLYTA TABS 5 PA; LA

IRESSA TABS 5 LA; MO

ISTODAX (OVERFILL)SOLR 5

ISTODAX SOLR 5

JAKAFI TABS 5 LA

LENVIMA 10 MG DAILYDOSE CPPK 5 PA






LYNPARZA CAPS 5 PA; LA

MEKINIST TABS 5

NEXAVAR TABS 5 LA

NINLARO CAPS 5 PA

SPRYCEL TABS 5

STIVARGA TABS 5 PA; LA

SUTENT CAPS 5

TAFINLAR CAPS 5

TAGRISSO TABS 5 LA

TARCEVA TABS 5

TASIGNA CAPS 5



39

Drug Name DrugTier

Requirements/Limits

TORISEL SOLN 5

TYKERB TABS 5

VELCADE SOLR 5

VOTRIENT TABS 5

XALKORI CAPS 5

ZELBORAF TABS 5 LA

ZOLINZA CAPS 5

ZYDELIG TABS 5 PA; LA

ZYKADIA CAPS 5 PA; LA

Antineoplastic EnzymesERWINAZE SOLR 5

ONCASPAR SOLN 5

Antineoplastics Misc.ACTIMMUNE SOLN 5 LA

bexarotene caps 5

dacarbazine solr 2 *

HYDREA CAPS(Hydroxyurea) NF MO

hydroxyurea caps or 2 MO; *

INTRON A SOLN 10MU/ML 5

INTRON A SOLN 6000000UNIT/ML 4

INTRON A SOLR 10 MU,18 MU, 50 MU 5

INTRON A W/DILUENTSOLR 5

MATULANE CAPS 5 LA

NIPENT SOLR 4

PROLEUKIN SOLR 5

Drug Name DrugTier

Requirements/Limits

SYLATRON KIT 5

SYNRIBO SOLR 5

TARGRETIN CAPS OR 75MG (Bexarotene) 5

THERACYS SUSR 5

TICE BCG SUSR 5

tretinoin (chemotherapy)caps 5 MO

TRISENOX SOLN 4

UVADEX SOLN 4

Chemotherapy AdjunctsELITEK SOLR 5

KEPIVANCE SOLR 5

Chemotherapy Rescue/Antidote Agentsamifostine crystalline solr 2 MO; *

dexrazoxane solr 250 mg,500 mg 2 *

FUSILEV SOLR(Levoleucovorin Calcium) 4

leucovorin calcium solr ij100 mg, 350 mg 2 MO; *

leucovorin calcium solr ij200 mg, 50 mg, 500 mg 2 *

leucovorin calcium tabs or10 mg, 15 mg, 25 mg, 5 mg 2 MO; *

levoleucovorin calcium soln175 mg/17.5ml 5

levoleucovorin calcium solr50 mg 2 *

LEVOLEUCOVORIN SOLN 5

mesna soln 2 MO; *

MESNEX SOLN IV 100MG/ML (Mesna) 4 MO

MESNEX TABS OR 400MG 5 MO



40

Drug Name DrugTier

Requirements/Limits

ZINECARD SOLR(Dexrazoxane) 4

Mitotic InhibitorsABRAXANE SUSR 5 MO

DOCEFREZ SOLR 5

DOCETAXEL CONC 140MG/7ML, 20 MG/0.5ML, 20MG/ML, 80 MG/4ML

5

docetaxel conc 20 mg/ml,80 mg/4ml 5

DOCETAXEL SOLN 160MG/16ML, 20 MG/2ML,200 MG/20ML, 80 MG/8ML

5

ETOPOPHOS SOLR 4

etoposide soln iv 1gm/50ml, 100 mg/5ml, 500mg/25ml

2*

HALAVEN SOLN 5

IXEMPRA KIT SOLR 5

JEVTANA SOLN 5

MARQIBO SUSP 5

NAVELBINE SOLN(Vinorelbine Tartrate) NF MO

paclitaxel conc 100mg/16.7ml, 150 mg/25ml 2 *

paclitaxel conc 30 mg/5ml,300 mg/50ml 2 MO; *

TAXOTERE CONC(Docetaxel) 5

vinblastine sulfate soln 2 MO; *

vincristine sulfate soln 1 MO; *

vinorelbine tartrate soln 2 MO; *

Topoisomerase I InhibitorsCAMPTOSAR SOLN 100MG/5ML, 40 MG/2ML(Irinotecan HCl)

4

Drug Name DrugTier

Requirements/Limits

CAMPTOSAR SOLN 300MG/15ML 4

HYCAMTIN SOLR IV 4 MG(Topotecan HCl) 4 MO

irinotecan hcl soln 2 *

topotecan hcl solr 4 mg 2 MO; *

ANTIPARKINSON AGENTS - Drugs to TreatParkinson's DiseaseAntiparkinson Adjuvantscarbidopa tabs or 2 MO; *

LODOSYN TABS(Carbidopa) NF MO

Antiparkinson Anticholinergicsbenztropine mesylate solnij 1 mg/ml 2 MO; *

benztropine mesylate tabsor 0.5 mg, 1 mg, 2 mg 2 AL; MO; *

COGENTIN SOLN(Benztropine Mesylate) 4 MO

trihexyphenidyl hcl elix 2 AL; MO; *

trihexyphenidyl hcl tabs 2 AL; MO; *

Antiparkinson COMT InhibitorsCOMTAN TABS(Entacapone) NF SL(8 ea daily);

MO

entacapone tabs 4 SL(8 ea daily);MO

TASMAR TABS(Tolcapone) 4 MO

tolcapone tabs 2 MO; *

Antiparkinson Dopaminergicsamantadine hcl caps or 100mg 2 MO; *

amantadine hcl syrp or 50mg/5ml 2 MO; *

amantadine hcl tabs or 100mg 2 MO; *

APOKYN SOLN 5 LA



41

Drug Name DrugTier

Requirements/Limits

bromocriptine mesylatecaps or 5 mg 1 MO; *

bromocriptine mesylatetabs or 2.5 mg 1 MO; *

carbidopa-levodopa tabs 2 MO; *

carbidopa-levodopa tbcr 2 MO; *

carbidopa-levodopa tbdp 2 MO; *

carbidopa-levodopa-entacapone tabs 2 MO; *

DUOPA SUSP 4 B/D

MIRAPEX ER TB24(PramipexoleDihydrochloride)

4MO

MIRAPEX TABS(PramipexoleDihydrochloride)

NFMO

NEUPRO PT24 4 MO

PARLODEL CAPS(Bromocriptine Mesylate) NF MO

PARLODEL TABS(Bromocriptine Mesylate) NF MO

pramipexoledihydrochloride tabs 2 MO; *

pramipexoledihydrochloride tb24 2 MO; *

REQUIP TABS (RopiniroleHydrochloride) NF MO

REQUIP XL TB24(Ropinirole Hydrochloride) NF MO

ropinirole hydrochloridetabs 0.25 mg, 0.5 mg, 1mg, 2 mg, 3 mg, 4 mg, 5mg

2

MO; *

ropinirole hydrochloridetb24 12 mg, 2 mg, 4 mg, 6mg, 8 mg

3MO

RYTARY CPCR 4 MO

SINEMET CR TBCR(Carbidopa-Levodopa) NF MO

SINEMET TABS(Carbidopa-Levodopa) NF MO

Drug Name DrugTier

Requirements/Limits

STALEVO 100 TABS(Carbidopa-Levodopa-Entacapone)

NFMO


NFMO


NFMO


NFMO


NFMO


NFMO

Antiparkinson Monoamine Oxidase InhibitorsAZILECT TABS 3 MO

ELDEPRYL CAPS(Selegiline HCl) NF MO

selegiline hcl caps or 2 MO; *

selegiline hcl tabs or 2 MO; *

ZELAPAR TBDP 4 MO

ANTIPSYCHOTICS/ANTIMANIC AGENTS -Drugs to Treat Mood DisordersAntimanic Agentslithium carbonate caps or150 mg, 300 mg, 600 mg 2 MO; *

lithium carbonate tabs or300 mg 2 MO; *

lithium carbonate tbcr or300 mg, 450 mg 2 MO; *

lithium soln 1 MO; *

LITHOBID TBCR (LithiumCarbonate) NF MO

Antipsychotics - Misc.EQUETRO CP12 4 MO



42

Drug Name DrugTier

Requirements/Limits

GEODON CAPS OR 20MG, 40 MG, 60 MG, 80 MG(Ziprasidone HCl)

NFMO

GEODON SOLR IM 20 MG 4 MO

LATUDA TABS 120 MG 5 PA; SL(1.33 eadaily); MO

LATUDA TABS 20 MG 5 PA; SL(8 eadaily); MO


LATUDA TABS 60 MG 5 PA; SL(2.67 eadaily); MO


NUPLAZID TABS 5 PA; LA

VRAYLAR CAPS 1.5 MG 4 PA; SL(4 eadaily); MO

VRAYLAR CAPS 3 MG 4 PA; SL(2 eadaily); MO

VRAYLAR CAPS 4.5 MG 4 PA; SL(1.4 eadaily); MO

VRAYLAR CAPS 6 MG 4 PA; SL(1 eadaily); MO

VRAYLAR CPPK 4 PA; MO

ziprasidone hcl caps 4 MO

BenzisoxazolesFANAPT TABS 1 MG, 10MG, 2 MG, 4 MG 4 MO

FANAPT TABS 12 MG, 6MG, 8 MG 5 MO

FANAPT TITRATIONPACK TABS 4

INVEGA SUSTENNASUSP 117 MG/0.75ML,156 MG/ML, 234MG/1.5ML

5

MO

INVEGA SUSTENNASUSP 39 MG/0.25ML, 78MG/0.5ML

4MO

INVEGA TB24 1.5 MG(Paliperidone) 5 SL(8 ea daily);

MOINVEGA TB24 3 MG(Paliperidone) 5 SL(4 ea daily);

MO

Drug Name DrugTier

Requirements/Limits

INVEGA TB24 6 MG(Paliperidone) 5 SL(2 ea daily);

MOINVEGA TB24 9 MG(Paliperidone) 5 SL(1.33 ea

daily); MO

INVEGA TRINZA SUSP 5

paliperidone tb24 1.5 mg 2 SL(8 ea daily);MO; *

paliperidone tb24 3 mg 2 SL(4 ea daily);MO; *

paliperidone tb24 6 mg 2 SL(2 ea daily);MO; *

paliperidone tb24 9 mg 5 SL(1.33 eadaily); MO

RISPERDAL CONSTASUSR 12.5 MG 4

Limit 8 vials per28days;SL(0.29ea daily); MO

RISPERDAL CONSTASUSR 25 MG 4


RISPERDAL CONSTASUSR 37.5 MG 5

Limit 4 vials per42 days;SL(0.1ea daily); MO

RISPERDAL CONSTASUSR 50 MG 5


RISPERDAL M-TAB TBDP(Risperidone) NF MO

RISPERDAL SOLN(Risperidone) NF MO

RISPERDAL TABS(Risperidone) NF MO

risperidone soln 1 mg/ml 3 MO

risperidone tabs 0.25 mg,0.5 mg, 1 mg, 2 mg, 3 mg,4 mg

2MO; *

risperidone tbdp 0.25 mg, 3mg, 4 mg 2 MO; *

risperidone tbdp 0.5 mg, 1mg, 2 mg 3 MO

Butyrophenones



43

Drug Name DrugTier

Requirements/Limits

HALDOL DECANOATE100 SOLN (HaloperidolDecanoate)

NFMO

HALDOL DECANOATE 50SOLN (HaloperidolDecanoate)

NFMO

HALDOL SOLN(Haloperidol Lactate) NF MO

haloperidol decanoate soln 2 MO; *

haloperidol lactate conc 1 MO; *

haloperidol lactate soln 1 MO; *

haloperidol tabs 2 MO; *

DibenzapinesCLOZAPINE ODT TBDP12.5 MG, 150 MG 4

CLOZAPINE ODT TBDP200 MG 5

clozapine tabs 100 mg, 25mg 3

clozapine tabs 200 mg, 50mg 2 *

clozapine tbdp 100 mg, 25mg 2 *

CLOZARIL TABS(Clozapine) NF

FAZACLO TBDP 100 MG,25 MG (Clozapine) 4

FAZACLO TBDP 12.5 MG,150 MG 4

FAZACLO TBDP 200 MG 5

loxapine succinate caps 2 MO; *

olanzapine solr im 10 mg 3 MO

olanzapine tabs or 10 mg,15 mg, 2.5 mg, 20 mg, 5mg, 7.5 mg

3MO

olanzapine tbdp or 10 mg,15 mg, 20 mg, 5 mg 4 MO

QUETIAPINE FUMARATEER TB24 4 PA; MO

Drug Name DrugTier

Requirements/Limits

quetiapine fumarate tabs100 mg, 200 mg, 25 mg,300 mg, 400 mg, 50 mg

3MO

quetiapine fumarate tb24400 mg 2 PA; MO; *

SAPHRIS SUBL 10 MG 4 SL(2 ea daily);MO

SAPHRIS SUBL 2.5 MG 4 SL(8 ea daily);MO

SAPHRIS SUBL 5 MG 4 SL(4 ea daily);MO

SEROQUEL TABS(Quetiapine Fumarate) NF MO

SEROQUEL XR TB24 150MG, 200 MG, 300 MG, 50MG

4PA; MO

SEROQUEL XR TB24 400MG (Quetiapine Fumarate) 5 PA; MO

VERSACLOZ SUSP 5 PA; SL(18 mldaily)

ZYPREXA RELPREVVSUSR 210 MG 4

ZYPREXA SOLR(Olanzapine) NF MO

ZYPREXA TABS(Olanzapine) NF MO

ZYPREXA ZYDIS TBDP(Olanzapine) NF MO

Dihydroindolonesmolindone hcl tabs 4 MO

Phenothiazineschlorpromazine hcl soln ij25 mg/ml 2 MO; *

chlorpromazine hcl soln ij50 mg/2ml 2 *

chlorpromazine hcl tabs or10 mg, 100 mg, 200 mg, 25mg, 50 mg

3MO

fluphenazine decanoatesoln ij 2 MO; *

fluphenazine hcl conc or 5mg/ml 2 MO; *

fluphenazine hcl soln ij 2.5mg/ml 2 MO; *



44

Drug Name DrugTier

Requirements/Limits

fluphenazine hcl tabs or 1mg, 10 mg, 2.5 mg, 5 mg 2 MO; *

perphenazine tabs or 16mg, 2 mg, 4 mg, 8 mg 2 MO; *

prochlorperazine edisylatesoln ij 2 MO; *

prochlorperazine maleatetabs or 10 mg, 5 mg 2 MO; *

prochlorperazine supp 2 MO; *

thioridazine hcl tabs or 10mg, 100 mg, 25 mg, 50 mg 2 AL; MO; *

trifluoperazine hcl tabs 1 MO; *

Quinolinone DerivativesABILIFY DISCMELT TBDP10 MG 5 SL(3 ea daily);

MOABILIFY DISCMELT TBDP15 MG 5 SL(2 ea daily);

MO

ABILIFY MAINTENA SUSR 5 MO

ABILIFY SOLN IM 9.75MG/1.3ML 4 SL(4 ml daily);

MOABILIFY SOLN OR 1MG/ML 5 SL(30 ml daily);

MOABILIFY TABS OR 10 MG(Aripiprazole) 5 SL(3 ea daily);



MOABILIFY TABS OR 20 MG(Aripiprazole) 5 SL(1.5 ea

daily); MOABILIFY TABS OR 30 MG(Aripiprazole) 5 SL(1 ea daily);


MO

aripiprazole soln 1 mg/ml 2 SL(30 ml daily);MO; *

aripiprazole tabs 10 mg 2 SL(3 ea daily);MO; *



Drug Name DrugTier

Requirements/Limits

aripiprazole tabs 20 mg 5 SL(1.5 eadaily); MO

aripiprazole tabs 30 mg 5 SL(1 ea daily);MO


aripiprazole tbdp 10 mg 5 SL(3 ea daily);MO

aripiprazole tbdp 15 mg 5 SL(2 ea daily);MO

ARISTADA PRSY 5

REXULTI TABS 0.25 MG 5 PA; SL(16 eadaily); MO

REXULTI TABS 0.5 MG 5 PA; SL(8 eadaily); MO

REXULTI TABS 1 MG 5 PA; SL(4 eadaily); MO


REXULTI TABS 3 MG 5 PA; SL(1.33 eadaily); MO


Thioxanthenesthiothixene caps 2 MO; *

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretroviralsabacavir sulfate tabs 4 MO

abacavir sulfate-lamivudinetabs 5 MO

abacavir sulfate-lamivudine-zidovudine tabs 5 MO

APTIVUS CAPS 250 MG 5 MO

APTIVUS SOLN 100MG/ML 3

ATRIPLA TABS 5 MO

COMBIVIR TABS(Lamivudine-Zidovudine) 5 MO

COMPLERA TABS 5 MO



45

Drug Name DrugTier

Requirements/Limits

CRIXIVAN CAPS 4 MO

DESCOVY TABS 5 MO

didanosine cpdr 1 MO; *

EDURANT TABS 5 MO

EMTRIVA CAPS 4 MO

EMTRIVA SOLN 4 MO

EPIVIR SOLN 10 MG/ML(Lamivudine) 3 MO

EPIVIR TABS 150 MG, 300MG (Lamivudine) NF MO

EPZICOM TABS (AbacavirSulfate-Lamivudine) 5 MO

EVOTAZ TABS 5 MO

FUZEON SOLR 5

GENVOYA TABS 5 MO

INTELENCE TABS 100MG, 200 MG 5 MO

INTELENCE TABS 25 MG 4

INVIRASE CAPS 5 MO

INVIRASE TABS 5 MO

ISENTRESS CHEW 100MG 3 SL(6 ea daily);

MO

ISENTRESS CHEW 25 MG 3 SL(24 ea daily);MO

ISENTRESS PACK 100MG 4 SL(2 ea daily)

ISENTRESS TABS 400MG 5 MO

KALETRA SOLN400MG/5ML-100MG/5ML 5 MO

KALETRA TABS 100MG-25MG 4 MO

KALETRA TABS 200MG-50MG 5 MO

lamivudine soln 10 mg/ml 2 MO; *

Drug Name DrugTier

Requirements/Limits

lamivudine tabs 150 mg,300 mg 3 MO

lamivudine-zidovudine tabs 2 MO; *

LEXIVA SUSP 50 MG/ML 3 MO

LEXIVA TABS 700 MG 5 MO

NEVIRAPINE SUSP 50MG/5ML 4 MO

nevirapine tabs 200 mg 3 MO

nevirapine tb24 100 mg,400 mg 2 MO; *

NORVIR CAPS 4 MO

NORVIR SOLN 4 MO

NORVIR TABS 4 MO

ODEFSEY TABS 5 MO

PREZCOBIX TABS 5 MO

PREZISTA SUSP 100MG/ML 5 MO

PREZISTA TABS 150 MG,75 MG 4 MO

PREZISTA TABS 600 MG,800 MG 5 MO

RESCRIPTOR TABS 100MG 3 MO

RESCRIPTOR TABS 200MG 4 MO

RETROVIR CAPS(Zidovudine) NF MO

RETROVIR IV INFUSIONSOLN 4

RETROVIR SYRP(Zidovudine) NF MO

REYATAZ CAPS 5 MO

REYATAZ PACK 5 MO

SELZENTRY TABS 5 MO

stavudine caps 15 mg 2 MO; *



46

Drug Name DrugTier

Requirements/Limits

stavudine caps 20 mg, 30mg, 40 mg 1 MO; *

stavudine solr 1 mg/ml 2 MO; *

STRIBILD TABS 5 MO

SUSTIVA CAPS 200 MG,50 MG 4 MO

SUSTIVA TABS 600 MG 5 MO

TIVICAY TABS 10 MG 4 MO

TIVICAY TABS 25 MG, 50MG 5 MO

TRIUMEQ TABS 5 MO

TRIZIVIR TABS (AbacavirSulfate-Lamivudine-Zidovudine)

5MO

TRUVADA TABS 5 MO

TYBOST TABS 4 MO

VIDEX EC CPDR(Didanosine) 4 MO

VIDEXPEDIATRIC SOLR 4 MO

VIRACEPT TABS 5 MO

VIRAMUNE SUSP 50MG/5ML 4 MO

VIRAMUNE TABS 200 MG(Nevirapine) NF MO

VIRAMUNE XR TB24 100MG (Nevirapine) 4 MO

VIRAMUNE XR TB24 400MG (Nevirapine) 5 MO

VIREAD POWD 5 MO

VIREAD TABS 5 MO

VITEKTA TABS 5

ZERIT CAPS (Stavudine) NF MO

ZERIT SOLR (Stavudine) NF MO

Drug Name DrugTier

Requirements/Limits

ZIAGEN SOLN 20 MG/ML 3 MO

ZIAGEN TABS 300 MG(Abacavir Sulfate) NF MO

zidovudine caps 100 mg 1 MO; *

zidovudine syrp 50 mg/5ml 2 MO; *

zidovudine tabs 300 mg 1 MO; *

CMV Agentscidofovir soln 5

CYTOVENE SOLR(Ganciclovir Sodium) NF MO

ganciclovir sodium solr 2 MO; *

VALCYTE SOLR(Valganciclovir HCl) 5 MO

VALCYTE TABS(Valganciclovir HCl) 5 MO

valganciclovir hcl solr 5 MO

valganciclovir hcl tabs 5 MO

VISTIDE SOLN (Cidofovir) 5

Hepatitis Agentsadefovir dipivoxil tabs 5 MO

BARACLUDE SOLN 0.05MG/ML 4 MO

BARACLUDE TABS 0.5MG, 1 MG (Entecavir) 5 MO

COPEGUS TABS(Ribavirin (Hepatitis C)) NF

DAKLINZA TABS 5 PA

entecavir tabs 5 MO

EPIVIR HBV SOLN 5MG/ML 3 MO

EPIVIR HBV TABS 100MG (Lamivudine (HBV)) NF MO

HARVONI TABS 5 PA



47

Drug Name DrugTier

Requirements/Limits

HEPSERA TABS (AdefovirDipivoxil) 5 MO

lamivudine (hbv) tabs 2 MO; *

OLYSIO CAPS 5 PA

PEG-INTRON KIT 5

PEG-INTRON REDIPENKIT 5

PEG-INTRON REDIPENPAK 4 KIT 5

PEGASYS PROCLICKSOLN 5

PEGASYS SOLN 5

PEGINTRON KIT 5

REBETOL CAPS 200 MG(Ribavirin (Hepatitis C)) NF

REBETOL SOLN 40MG/ML 3

ribavirin (hepatitis c) caps200 mg 4

ribavirin (hepatitis c) misc 2 *

ribavirin (hepatitis c) tabs200 mg 4

ribavirin (hepatitis c) tabs400 mg, 600 mg 2 *

SOVALDI TABS 5 PA

TECHNIVIE TABS 5 PA

TYZEKA TABS 5 MO

VICTRELIS CAPS 5 PA

VIEKIRA PAK TBPK 5 PA

ZEPATIER TABS 5 PA

Herpes Agentsacyclovir caps or 200 mg 2 MO; *

acyclovir sodium soln 50mg/ml 2 *

Drug Name DrugTier

Requirements/Limits

acyclovir sodium solr 500mg 2 MO; *

acyclovir susp or 200mg/5ml 2 MO; *

acyclovir tabs or 400 mg,800 mg 2 MO; *

famciclovir tabs 125 mg 2 MO; *

famciclovir tabs 250 mg,500 mg 3 MO

FAMVIR TABS(Famciclovir) NF MO

valacyclovir hcl tabs or 1gm, 1000 mg, 500 mg 3 MO

VALTREX TABS(Valacyclovir HCl) NF MO

ZOVIRAX CAPS OR 200MG (Acyclovir) NF MO

ZOVIRAX SUSP OR 200MG/5ML (Acyclovir) NF MO

ZOVIRAX TABS OR 400MG, 800 MG (Acyclovir) NF MO

Influenza AgentsFLUMADINE TABS(RimantadineHydrochloride)

NFMO

RELENZA DISKHALERAEPB 4 MO

rimantadine hydrochloridetabs 1 MO; *

TAMIFLU CAPS 4 MO

TAMIFLU SUSR 4 MO

Respiratory Syncytial Virus (RSV) AgentsVIRAZOLE SOLR 4

ASSORTED CLASSES - Miscellaneous Drugs

Chelating AgentsDEPEN TITRATABS TABS 3 MO

SYPRINE CAPS 5 MO

Enzymes



48

Drug Name DrugTier

Requirements/Limits

XIAFLEX SOLR 5

ImmunomodulatorsREVLIMID CAPS 5 LA

THALOMID CAPS 5

Immunosuppressive AgentsASTAGRAF XL CP24 4 MO; B/D

ATGAM INJ 4 B/D

AZATHIOPRINE SOLR IJ100 MG 4 B/D

azathioprine tabs or 100mg, 50 mg, 75 mg 2 MO; B/D; *

CELLCEPT CAPS 250 MG(Mycophenolate Mofetil) NF MO; B/D

CELLCEPTINTRAVENOUS SOLR 4 B/D

CELLCEPT SUSR 200MG/ML (MycophenolateMofetil)

5MO; B/D

CELLCEPT TABS 500 MG(Mycophenolate Mofetil) NF MO; B/D

cyclosporine caps or 100mg, 25 mg 3 MO; B/D

cyclosporine modified (formicroemulsion) caps 100mg, 25 mg

3MO; B/D

cyclosporine modified (formicroemulsion) caps 50 mg 2 MO; B/D; *

cyclosporine soln iv 50mg/ml 2 B/D; *

ENVARSUS XR TB24 4 MO; B/D

IMURAN TABS(Azathioprine) 4 MO; B/D

mycophenolate mofetilcaps 250 mg 3 MO; B/D

mycophenolate mofetil susr200 mg/ml 5 MO; B/D

mycophenolate mofetil tabs500 mg 3 MO; B/D

mycophenolate sodiumtbec 180 mg 2 MO; B/D; *

Drug Name DrugTier

Requirements/Limits

mycophenolate sodiumtbec 360 mg 5 MO; B/D

MYFORTIC TBEC 180 MG(Mycophenolate Sodium) 4 MO; B/D

MYFORTIC TBEC 360 MG(Mycophenolate Sodium) 5 MO; B/D

NEORAL CAPS 100 MG,25 MG (CyclosporineModified (ForMicroemulsion))

NF

MO; B/D

NULOJIX SOLR 5 B/D

PROGRAF CAPS OR 0.5MG, 1 MG, 5 MG(Tacrolimus)

NFMO; B/D

PROGRAF SOLN IV 5MG/ML 4 B/D

RAPAMUNE SOLN 1MG/ML 3 MO; B/D

RAPAMUNE TABS 0.5 MG(Sirolimus) 3 MO; B/D

RAPAMUNE TABS 1 MG,2 MG (Sirolimus) 5 MO; B/D

SANDIMMUNE CAPS OR100 MG, 25 MG(Cyclosporine)

NFMO; B/D

SANDIMMUNE SOLN IV50 MG/ML (Cyclosporine) 4 B/D

SANDIMMUNE SOLN OR100 MG/ML 4 MO; B/D

SIMULECT SOLR 5 B/D

sirolimus tabs 0.5 mg, 1 mg 2 MO; B/D; *

sirolimus tabs 2 mg 5 MO; B/D

tacrolimus caps or 0.5 mg,1 mg, 5 mg 3 MO; B/D

THYMOGLOBULIN SOLR 3 B/D

ZORTRESS TABS 0.25MG 3 MO; B/D

ZORTRESS TABS 0.5 MG,0.75 MG 5 MO; B/D

Irrigation Solutionsirrigation solutions,physiological soln 2 *



49

Drug Name DrugTier

Requirements/Limits

water for irrigation, sterilesoln 1 MO; *

Potassium Removing AgentsKAYEXALATE POWD(Sodium PolystyreneSulfonate)

NFMO

sodium polystyrenesulfonate powd or 3 MO

sodium polystyrenesulfonate susp or 15gm/60ml

2MO; *

VELTASSA PACK 16.8 GM 4 ST; SL(1.5 eadaily); LA

VELTASSA PACK 25.2 GM 4 ST; SL(1 eadaily); LA

VELTASSA PACK 8.4 GM 4 ST; SL(3 eadaily); LA

Systemic Lupus Erythematosus AgentsBENLYSTA SOLR 5

BETA BLOCKERS - Drugs to Treat High BloodPressureAlpha-Beta Blockers

carvedilol tabs 12.5 mg 1 SL(8 ea daily);MO; *

carvedilol tabs 25 mg 1 SL(4 ea daily);MO; *



COREG CR CP24 4 MO

COREG TABS 12.5 MG(Carvedilol) NF SL(8 ea daily);

MOCOREG TABS 25 MG(Carvedilol) NF SL(4 ea daily);

MOCOREG TABS 3.125 MG(Carvedilol) NF SL(32 ea daily);

MOCOREG TABS 6.25 MG(Carvedilol) NF SL(16 ea daily);

MOlabetalol hcl tabs or 100mg, 200 mg, 300 mg 2 MO; *

Beta Blockers Cardio-Selective

Drug Name DrugTier

Requirements/Limits

acebutolol hcl caps or 200mg, 400 mg 1 MO; *

atenolol tabs or 100 mg, 25mg, 50 mg 1 MO; *

betaxolol hcl tabs 10 mg 1 MO; *

betaxolol hcl tabs 20 mg 2 MO; *

bisoprolol fumarate tabs 1 MO; *

BYSTOLIC TABS 4 MO

KERLONE TABS(Betaxolol HCl) NF MO

LOPRESSOR TABS OR100 MG, 50 MG(Metoprolol Tartrate)

NFMO

metoprolol succinate tb24 2 MO; *

metoprolol tartrate tabs or100 mg, 25 mg, 50 mg 1 MO; *

SECTRAL CAPS(Acebutolol HCl) NF MO

TENORMIN TABS(Atenolol) NF MO

TOPROL XL TB24(Metoprolol Succinate) NF MO

ZEBETA TABS (BisoprololFumarate) NF MO

Beta Blockers Non-SelectiveBETAPACE AF TABS(Sotalol HCl (AFIB/AFL)) NF MO

BETAPACE TABS (SotalolHCl) NF tabs;MO

CORGARD TABS(Nadolol) NF MO

INDERAL LA CP24(Propranolol HCl) NF MO

INDERAL XL CP24 4 MO

INNOPRAN XL CP24 4 MO

nadolol tabs or 20 mg, 40mg, 80 mg 1 MO; *

pindolol tabs 1 MO; *



50

Drug Name DrugTier

Requirements/Limits

propranolol hcl cp24 or 120mg, 160 mg, 60 mg, 80 mg 2 MO; *

propranolol hcl tabs or 10mg, 20 mg, 40 mg, 60 mg,80 mg

1MO; *

sotalol hcl (afib/afl) tabs 2 MO; *

Sotalol Hcl IV Soln NF

sotalol hcl tabs 2 tabs;MO; *

SOTYLIZE SOLN 4 MO

BIOLOGICALS MISC - Drugs to Treat LowEnzymesAllergenic ExtractsGRASTEK SUBL 4 PA; MO

ORALAIR SUBL 4 PA

RAGWITEK SUBL 4 PA; MO

Biologicals MiscADAGEN SOLN 5 LA

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood PressureCalcium Channel BlockersADALAT CC TB24(Nifedipine) NF MO

amlodipine besylate tabs or10 mg 1 SL(1 ea daily);

MO; *amlodipine besylate tabs or2.5 mg 1 SL(4 ea daily);

MO; *amlodipine besylate tabs or5 mg 1 SL(2 ea daily);

MO; *CALAN SR TBCR(Verapamil HCl) NF MO

CALAN TABS (VerapamilHCl) NF MO

CARDIZEM CD CP24(Diltiazem HCl CoatedBeads)

NFMO

CARDIZEM LA TB24 120MG 4 MO

Drug Name DrugTier

Requirements/Limits

CARDIZEM LA TB24 180MG, 240 MG, 300 MG, 360MG, 420 MG (DiltiazemHCl Coated Beads)

NF

MO

CARDIZEM TABS(Diltiazem HCl) NF MO

diltiazem hcl coated beadscp24 2 MO; *

diltiazem hcl coated beadstb24 2 MO; *

diltiazem hcl cp12 or 120mg, 60 mg, 90 mg 2 MO; *

diltiazem hcl cp24 or 120mg, 180 mg, 240 mg 2 MO; *

diltiazem hcl extendedrelease beads cp24 2 MO; *

diltiazem hcl solr iv 100 mg 2 *

diltiazem hcl tabs or 120mg, 30 mg, 60 mg, 90 mg 2 MO; *

felodipine tb24 2 MO; *

nicardipine hcl caps or 20mg, 30 mg 1 MO; *

nifedipine caps or 10 mg,20 mg 2 AL; MO; *

nifedipine tb24 or 30 mg,60 mg, 90 mg 2 MO; *

nimodipine caps or 30 mg,30mg 2 MO; *

nisoldipine tb24 17 mg, 34mg, 8.5 mg 1 MO; *

NORVASC TABS 10 MG(Amlodipine Besylate) NF SL(1 ea daily);

MONORVASC TABS 2.5 MG(Amlodipine Besylate) NF SL(4 ea daily);

MONORVASC TABS 5 MG(Amlodipine Besylate) NF SL(2 ea daily);

MO

NYMALIZE SOLN 5

PROCARDIA CAPS(Nifedipine) NF AL; MO

PROCARDIA XL TB24(Nifedipine) NF MO

SULAR TB24 (Nisoldipine) NF MO



51

Drug Name DrugTier

Requirements/Limits

TIAZAC CP24 (DiltiazemHCl Extended ReleaseBeads)

NFMO

verapamil hcl cp24 or 100mg, 120 mg, 180 mg, 200mg, 240 mg, 300 mg, 360mg

2

MO; *

verapamil hcl tabs or 120mg, 40 mg, 80 mg 1 MO; *

verapamil hcl tbcr or 120mg, 180 mg, 240 mg 2 MO; *

VERELAN CP24(Verapamil HCl) NF MO

VERELAN PM CP24(Verapamil HCl) NF MO

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart RhythmCardiac GlycosidesDIGOXIN SOLN OR 0.05MG/ML 4 MO

digoxin tabs or 0.125 mg,125 mcg 2 MO; *

digoxin tabs or 0.25 mg,250 mcg 2 AL; MO; *

LANOXIN PEDIATRICSOLN 4

LANOXIN TABS OR 125MCG (Digoxin) 4 MO

LANOXIN TABS OR 187.5MCG 4 AL; MO

LANOXIN TABS OR 250MCG (Digoxin) 4 AL; MO

LANOXIN TABS OR 62.5MCG 4 MO

CARDIOVASCULAR AGENTS - MISC. - Drugs toTreat Heart and Circulation ConditionsCardiovascular Agents Misc. - Combinationsamlodipine besylate-atorvastatin calcium tabs 2 MO; *

BIDIL TABS 4 MO

CADUET TABS(Amlodipine Besylate-Atorvastatin Calcium)

NFMO

Drug Name DrugTier

Requirements/Limits

ENTRESTO TABS 4 PA; MO

Prostaglandin VasodilatorsORENITRAM TBCR 0.125MG 4 PA

ORENITRAM TBCR 0.25MG, 1 MG, 2.5 MG 5 PA

REMODULIN SOLN 5 LA; B/D

TYVASO REFILL SOLN 5 LA; B/D

TYVASO SOLN 5 LA; B/D

TYVASO STARTER SOLN 5 LA; B/D

VENTAVIS SOLN 10MCG/ML 3 LA; B/D

VENTAVIS SOLN 20MCG/ML 5 LA; B/D

Pulmonary Hypertension - Endothelin ReceptorLETAIRIS TABS 5 LA

OPSUMIT TABS 5

TRACLEER TABS 5 LA

Pulmonary Hypertension - PhosphodiesteraseADCIRCA TABS 5 PA

REVATIO SOLN IV 10MG/12.5ML (SildenafilCitrate (PulmonaryHypertension))

5

PA

REVATIO TABS OR 20MG (Sildenafil Citrate(Pulmonary Hypertension))

5PA

sildenafil citrate (pulmonaryhypertension) soln iv 10mg/12.5ml

5PA

sildenafil citrate (pulmonaryhypertension) tabs or 20mg

2PA; *

Pulmonary Hypertension - Prostacyclin ReceptorUPTRAVI TABS 5 PA; LA

UPTRAVI TBPK 5 PA; LA



52

Drug Name DrugTier

Requirements/Limits

Pulmonary Hypertension - Sol Guanylate Cyclase

ADEMPAS TABS 0.5 MG 5 PA; SL(15 eadaily)

ADEMPAS TABS 1 MG 5 PA; SL(7.5 eadaily)


ADEMPAS TABS 2 MG 5 PA; SL(3.75 eadaily)


Sinus Node Inhibitors

CORLANOR TABS 5 MG 4 SL(3 ea daily);MO

CORLANOR TABS 7.5 MG 4 SL(2 ea daily);MO

CEPHALOSPORINS - Drugs to Treat BacterialInfectionsCephalosporins - 1st Generationcefadroxil caps 500 mg 1 MO; *

cefadroxil susr 500 mg/5ml 1 MO; *

cefadroxil tabs 1 gm 1 MO; *

cefazolin sodium solr ij 1gm, 10 gm 1 MO; *

cefazolin sodium solr ij 500mg 2 MO; *

cephalexin caps 250 mg,500 mg 1 MO; *

cephalexin caps 750 mg 2 MO; *

cephalexin susr 125mg/5ml, 250 mg/5ml 2 MO; *

KEFLEX CAPS(Cephalexin) NF MO

Cephalosporins - 2nd Generationcefaclor caps 250 mg, 500mg 1 MO; *

cefoxitin sodium solr ij 10gm 2 *

cefoxitin sodium solr iv 1gm 2 MO; *

Drug Name DrugTier

Requirements/Limits

cefoxitin sodium solr iv 2gm 2 *

cefprozil susr 250 mg/5ml 1 MO; *

cefprozil tabs 250 mg, 500mg 1 MO; *

CEFTIN TABS 250 MG,500 MG (CefuroximeAxetil)

NFMO

cefuroxime axetil tabs 2 MO; *

cefuroxime sodium solr ij1.5 gm 1 *

ZINACEF SOLR IJ 1.5 GM(Cefuroxime Sodium) NF

Cephalosporins - 3rd Generation

CEDAX CAPS 400 MG 4 SL(1 ea daily);MO

cefdinir caps 300 mg 2 MO; *

cefdinir susr 125 mg/5ml 2 MO; *

cefdinir susr 250 mg/5ml 3 MO

cefixime chew 200 mg 2 MO; *

cefpodoxime proxetil susr100 mg/5ml 2 MO; *

cefpodoxime proxetil tabs100 mg, 200 mg 2 MO; *

ceftazidime solr ij 1 gm, 2gm 3 MO

ceftazidime solr ij 6 gm 1 *

CEFTIBUTEN CAPS 400MG 4 SL(1 ea daily);

MOceftriaxone sodium solr ij 1gm 3 SL(4 ea daily)

ceftriaxone sodium solr ij 2gm 3 SL(2 ea daily);

MOceftriaxone sodium solr ij250 mg 1 SL(16 ea daily);

MO; *ceftriaxone sodium solr ij500 mg 3 SL(8 ea daily);

MOceftriaxone sodium solr iv 1gm 1 SL(4 ea daily);

*



53

Drug Name DrugTier

Requirements/Limits

ceftriaxone sodium solr iv10 gm 3 MO

FORTAZ SOLR IJ 1 GM, 2GM (Ceftazidime) NF MO

FORTAZ SOLR IJ 6 GM(Ceftazidime) NF

ROCEPHIN SOLR(Ceftriaxone Sodium) NF SL(4 ea daily)

SUPRAX CAPS 400 MG 4 MO

Cephalosporins - 4th Generationcefepime hcl solr 3 MO

CEFEPIME SOLN 2GM/100ML 4

MAXIPIME SOLR IJ 1 GM,2 GM (Cefepime HCl) NF MO

Cephalosporins - 5th GenerationTEFLARO SOLR 600 MG 4

CONTRACEPTIVES - Drugs to PreventPregnancyCombination Contraceptives - OralBEYAZ TABS(Drospirenone-EthinylEstradiol-LevomefolateCalcium)

4

MO

BREVICON-28 TABS(Norethindrone & EthEstradiol)

NFMO

DESOGEN TABS(Desogestrel & EthinylEstradiol)

NFMO

desogestrel & ethinylestradiol tabs 1 MO; *

desogestrel-ethinylestradiol (biphasic) tabs 1 MO; *

drospirenone-ethinylestradiol tabs 1 MO; *

drospirenone-ethinylestradiol-levomefolatecalcium tabs

2MO; *

ethynodiol diacet & ethestrad tabs 1mg-35mcg 1 MO; *

ethynodiol diacet & ethestrad tabs 1mg-50mcg 2 MO; *

Drug Name DrugTier

Requirements/Limits

FEMCON FE CHEW(Norethindrone & EthinylEstradiol-Fe)

NFMO

GENERESS FE CHEW(Norethindrone & EthinylEstradiol-Fe)

4MO

levonorgestrel & ethestradiol tabs 1 MO; *

levonorgestrel-eth estradiol(triphasic) tabs 1 MO; *

levonorgestrel-ethinylestradiol (91-day) tabs 1 MO; *

LO LOESTRIN FE TABS 4 MO

LOSEASONIQUE TABS(Levonorgestrel-EthinylEstradiol (91-Day))

NFMO

MINASTRIN 24 FE CHEW 4 MO

MODICON TABS(Norethindrone & EthEstradiol)

NFMO

norethin acet & estrad-fetabs 75mg-20mcg-1mg,75mg-30mcg-1.5mg

1MO; *

norethindrone & ethestradiol tabs 0.4mg-35mcg, 1mg-35mcg

1MO; *

norethindrone & ethestradiol tabs 0.5mg-35mcg

2MO; *

norethindrone & ethinylestradiol-fe chew 2 MO; *

norethindrone acet & ethestra tabs 20mcg-1mg,30mcg-1.5mg

1MO; *

norethindrone-eth estradiol(triphasic) tabs 2 MO; *

norgestimate-ethinylestradiol (triphasic) tabs 2 Low Dose;MO;

*norgestimate-ethinylestradiol (triphasic) tabs 1 MO; *

norgestimate-ethinylestradiol tabs 1 MO; *

norgestrel & ethinylestradiol tabs 1 MO; *



54

Drug Name DrugTier

Requirements/Limits

NORINYL 1+35 TABS(Norethindrone & EthEstradiol)

NFMO

ORTHO TRI-CYCLEN LOTABS (Norgestimate-Ethinyl Estradiol(Triphasic))

NF

Low Dose;MO

ORTHO TRI-CYCLENTABS (Norgestimate-Ethinyl Estradiol(Triphasic))

NF

MO

ORTHO-CEPT TABS(Desogestrel & EthinylEstradiol)

NFMO

ORTHO-CYCLEN TABS(Norgestimate-EthinylEstradiol)

NFMO

ORTHO-NOVUM 1/35TABS (Norethindrone &Eth Estradiol)

NFMO

ORTHO-NOVUM 7/7/7TABS (Norethindrone-EthEstradiol (Triphasic))

NFMO

QUARTETTE TABS 4 MO

SAFYRAL TABS 4 MO

SEASONIQUE TABS(Levonorgestrel-EthinylEstradiol (91-Day))

NFMO

YASMIN 28 TABS(Drospirenone-EthinylEstradiol)

NFMO

YAZ TABS (Drospirenone-Ethinyl Estradiol) NF MO

Combination Contraceptives - Transdermalnorelgestromin-ethinylestradiol ptwk 2 MO; *

ORTHO EVRA PTWK(Norelgestromin-EthinylEstradiol)

NFMO

Combination Contraceptives - VaginalNUVARING RING 3 MO

Emergency ContraceptivesELLA TABS 3

Drug Name DrugTier

Requirements/Limits

levonorgestrel (emergencyoc) tabs 0.75 mg 1 *

levonorgestrel (emergencyoc) tabs 1.5 mg 1 RX/OTC; *

Progestin Contraceptives - InjectableDEPO-PROVERACONTRACEPTIVE SUSP(MedroxyprogesteroneAcetate (Contraceptive))

NF

MO

DEPO-PROVERACONTRACEPTIVE SUSY(MedroxyprogesteroneAcetate (Contraceptive))

NF

MO

DEPO-SUBQ PROVERA104 SUSY 4 MO

medroxyprogesteroneacetate (contraceptive)susp

1MO; *

medroxyprogesteroneacetate (contraceptive)susy

1MO; *

Progestin Contraceptives - OralNOR-QD TABS(Norethindrone(Contraceptive))

NFMO

norethindrone(contraceptive) tabs 1 MO; *

ORTHO MICRONORTABS (Norethindrone(Contraceptive))

NFMO

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling ConditionsGlucocorticosteroidsbetamethasone sodphosphate & acetate susp 1 MO; *

budesonide cpep or 5 MO

CELESTONE-SOLUSPANSUSP (BetamethasoneSod Phosphate & Acetate)

4MO

CORTEF TABS(Hydrocortisone) NF MO

cortisone acetate tabs or 1 MO; *

DEPO-MEDROL SUSP 20MG/ML 4 MO



55

Drug Name DrugTier

Requirements/Limits

DEPO-MEDROL SUSP 40MG/ML, 80 MG/ML(MethylprednisoloneAcetate)

NF

MO

dexamethasone conc or 1mg/ml 2 MO; *

dexamethasone elix or 0.5mg/5ml 2 MO; *

dexamethasone sodiumphosphate soln ij 10 mg/ml 1 *

dexamethasone sodiumphosphate soln ij 10 mg/ml 1 Preservative

Free;MO; *dexamethasone sodiumphosphate soln ij 100mg/10ml, 120 mg/30ml, 20mg/5ml, 4 mg/ml

1

MO; *

dexamethasone soln or 0.5mg/5ml 2 MO; *

dexamethasone tabs or 0.5mg, 0.75 mg, 1 mg, 1.5 mg,2 mg, 4 mg, 6 mg

1MO; *

dexamethasone tbpk or 1.5mg 2 MO; *

ENTOCORT EC CPEP(Budesonide) 5 MO

hydrocortisone tabs or 10mg, 20 mg, 5 mg 2 MO; *

KENALOG-10 SUSP 4 MO

KENALOG-40 SUSP 4 MO

MEDROL DOSEPAK TBPK(Methylprednisolone) NF MO

MEDROL TABS 16 MG, 32MG, 4 MG, 8 MG(Methylprednisolone)

NFMO

MEDROL TABS 2 MG 3 MO

methylprednisolone acetatesusp ij 40 mg/ml, 80 mg/ml 1 MO; *

methylprednisolone sodsucc solr 1 MO; *

methylprednisolone tabs or16 mg, 32 mg, 4 mg, 8 mg 2 MO; *

methylprednisolone tbpk or4 mg 2 MO; *

Drug Name DrugTier

Requirements/Limits

MILLIPRED TABS 5 MG 4 MO

ORAPRED ODT TBDP 10MG (Prednisolone SodiumPhosphate)

4MO

ORAPRED ODT TBDP 15MG, 30 MG (PrednisoloneSodium Phosphate)

NFMO

prednisolone sodiumphosphate soln or 15mg/5ml, 5 mg/5ml, 6.7mg/5ml

1

MO; *

prednisolone sodiumphosphate soln or 20mg/5ml

2*

prednisolone sodiumphosphate soln or 25mg/5ml

2MO; *

prednisolone sodiumphosphate tbdp or 10 mg,15 mg, 30 mg

2MO; *

prednisolone soln or 15mg/5ml 1 MO; *

prednisolone syrp or 15mg/5ml 1 MO; *

prednisolone tbpk or 5 mg 2 *

prednisolone tbpk or 5 mg 2 21 tabletpack;MO; *

prednisone conc or 5mg/ml 2 MO; *

prednisone soln or 5mg/5ml 2 MO; *

prednisone tabs or 1 mg,10 mg, 2.5 mg, 20 mg, 5mg, 50 mg

1MO; *

prednisone tbpk or 10 mg,5 mg 2 Dose Pack;MO;

*

RAYOS TBEC 2 MG, 5 MG 4 MO

SOLU-CORTEF SOLR 100MG, 250 MG 4 MO

SOLU-MEDROL SOLR1000 MG, 125 MG, 40 MG(Methylprednisolone SodSucc)

NF

MO



56

Drug Name DrugTier

Requirements/Limits

SOLU-MEDROL SOLR 2GM 4

UCERIS TB24 OR 9 MG 5 MO

Mineralocorticoidsfludrocortisone acetatetabs or 2 MO; *

COUGH/COLD/ALLERGY - Drugs to TreatCough, Cold and Allergy SymptomsCough/Cold/Allergy CombinationsCLARINEX-D 12 HOURTB12 4 MO

promethazine &phenylephrine syrp 2 AL; MO; *

SEMPREX-D CAPS 4 MO

Mucolyticsacetylcysteine soln in 10%, 20 % 1 MO; B/D; *

DERMATOLOGICALS - Drugs to Treat SkinConditionsAcne ProductsABSORICA CAPS 30 MG(Isotretinoin) NF

ACANYA GEL 4 MO

adapalene crea 0.1 % 1 MO; *

adapalene gel 0.1 % 3 MO

adapalene gel 0.3 % 2 MO; *

ATRALIN GEL (Tretinoin) 4 MO

AZELEX CREA 4 MO

BENZACLIN GEL(Clindamycin Phosphate-Benzoyl Peroxide)

NFMO

BENZACLIN WITH PUMPGEL (ClindamycinPhosphate-BenzoylPeroxide)

NF

MO

BENZAMYCIN GEL(Benzoyl Peroxide-Erythromycin)

NFMO

Drug Name DrugTier

Requirements/Limits

benzoyl peroxide-erythromycin gel 1 MO; *

CLEOCIN-T GEL(Clindamycin Phosphate(Topical))

NFMO

CLEOCIN-T LOTN(Clindamycin Phosphate(Topical))

NFMO

CLEOCIN-T SOLN(Clindamycin Phosphate(Topical))

NFMO

CLEOCIN-T SWAB(Clindamycin Phosphate(Topical))

NFMO

clindamycin phosphate(topical) foam 3 MO

clindamycin phosphate(topical) gel 2 MO; *

clindamycin phosphate(topical) lotn 2 MO; *

clindamycin phosphate(topical) soln 2 MO; *

clindamycin phosphate(topical) swab 2 MO; *

clindamycin phosphate-benzoyl peroxide(refrigerate) gel

3MO

clindamycin phosphate-benzoyl peroxide gel 3 MO

clindamycin phosphate-tretinoin gel 2 MO; *

DIFFERIN CREA 0.1 %(Adapalene) NF MO

DIFFERIN GEL 0.1 %, 0.3% (Adapalene) NF MO

DUAC GEL (ClindamycinPhosphate-BenzoylPeroxide (Refrigerate))

NFMO

EPIDUO GEL 4 MO

erythromycin (acne aid) gel 1 MO; *

erythromycin (acne aid)soln 1 MO; *

EVOCLIN FOAM(Clindamycin Phosphate(Topical))

NFMO



57

Drug Name DrugTier

Requirements/Limits

FABIOR FOAM 4

Limit 100gmspermonth;QL(3.34gm daily); MO

isotretinoin caps or 10 mg,30 mg 2 *

isotretinoin caps or 20 mg 1 *

isotretinoin caps or 40 mg 4

KLARON LOTN(Sulfacetamide Sodium(Acne))

NFMO

RETIN-A CREA (Tretinoin) NF MO

RETIN-A GEL (Tretinoin) NF MO

RETIN-A MICRO GEL(Tretinoin Microsphere) NF MO

RETIN-A MICRO PUMPGEL 0.04 %, 0.1 %(Tretinoin Microsphere)

NFMO

RETIN-A MICRO PUMPGEL 0.08 % 4 MO

sulfacetamide sodium(acne) lotn 1 MO; *

sulfacetamide sodium(acne) susp 1 MO; *

tretinoin crea ex 0.025 %,0.05 %, 0.1 % 3 MO

tretinoin crea ex 0.038 % 2 *

tretinoin gel ex 0.01 %,0.025 % 3 MO

tretinoin gel ex 0.05 % 2 MO; *

tretinoin microsphere gel 4 MO

VELTIN GEL 4 MO

ZIANA GEL (ClindamycinPhosphate-Tretinoin) 4 MO

Agents for External Genital and Perianal WartsVEREGEN OINT 4 MO

Anti-inflammatory Agents - Topical

Drug Name DrugTier

Requirements/Limits

diclofenac sodium (topical)gel 2 MO; *

diclofenac sodium (topical)soln 2 MO; *

FLECTOR PTCH 4 PA; MO

PENNSAID SOLN 1.5 %(Diclofenac Sodium(Topical))

NFMO

PENNSAID SOLN 2 % 4 MO

VOLTAREN GEL(Diclofenac Sodium(Topical))

4MO

Antibiotics - TopicalALTABAX OINT 4 MO

BACTROBAN CREA(Mupirocin Calcium(Topical))

NFMO

BACTROBAN OINT(Mupirocin) NF MO

CORTISPORIN CREA 3 MO

CORTISPORIN OINT 3 MO

gentamicin sulfate (topical)crea 1 MO; *

gentamicin sulfate (topical)oint 1 MO; *

mupirocin calcium (topical)crea 2 MO; *

mupirocin oint ex 2 MO; *

Antifungals - Topicalciclopirox gel 0.77 % 3 MO

ciclopirox olamine crea ex 2 MO; *

ciclopirox olamine susp ex 2 MO; *

ciclopirox sham 1 % 3 MO

ciclopirox soln 8 % 2 MO; *

clotrimazole (topical) crea 2 RX/OTC; MO; *



58

Drug Name DrugTier

Requirements/Limits

clotrimazole (topical) soln 2 RX/OTC; MO; *

clotrimazole w/betamethasone crea 2 MO; *

clotrimazole w/betamethasone lotn 3 MO

econazole nitrate crea 2 MO; *

EXELDERM SOLN 4 MO

EXTINA FOAM(Ketoconazole (Topical)) NF MO

JUBLIA SOLN 4 PA; MO

KERYDIN SOLN 4 PA; MO

ketoconazole (topical) crea 2 MO; *

ketoconazole (topical) foam 3 MO

ketoconazole (topical)sham 2 MO; *

LOPROX CREA 0.77 %(Ciclopirox Olamine) NF MO

LOPROX SHAMPOOSHAM (Ciclopirox) NF MO

LOTRISONE CREA(Clotrimazole w/Betamethasone)

NFMO

LUZU CREA 4 MO

naftifine hcl crea 2 MO; *

NAFTIN CREA 1 %, 2 %(Naftifine HCl) 4 MO

NAFTIN GEL 1 %, 2 % 4 MO

NIZORAL SHAM(Ketoconazole (Topical)) NF MO

nystatin (topical) crea 2 MO; *

nystatin (topical) oint 2 MO; *

nystatin (topical) powd 2 MO; *

nystatin-triamcinolone crea 3 MO

Drug Name DrugTier

Requirements/Limits

nystatin-triamcinolone oint 3 MO

oxiconazole nitrate crea 2 MO; *

OXISTAT CREA(Oxiconazole Nitrate) 4 MO

OXISTAT LOTN 4 MO

PENLAC NAIL LACQUERSOLN (Ciclopirox) NF MO

Antineoplastic or Premalignant Lesion Agents -CARAC CREA 5 MO

diclofenac sodium (actinickeratoses) gel 5 MO

EFUDEX CREA(Fluorouracil (Topical)) NF MO

fluorouracil (topical) crea 4 MO

fluorouracil (topical) soln 4 MO

FLUOROURACIL CREAEX 0.5 % 5 MO

PANRETIN GEL 5 MO

PICATO GEL 5 MO

SOLARAZE GEL(Diclofenac Sodium (ActinicKeratoses))

5MO

TARGRETIN GEL EX 1 % 5

VALCHLOR GEL 5 PA

Antipsoriaticsacitretin caps 5 MO

calcipotriene crea 4 MO

calcipotriene oint 4 MO

calcipotriene soln 3 MO

CALCITRIOL OINT EX 3MCG/GM 4 MO

COSENTYXSENSOREADY PEN SOAJ 5 PA; LA



59

Drug Name DrugTier

Requirements/Limits

COSENTYX SOSY 5 PA; LA

DOVONEX CREA(Calcipotriene) NF MO

methoxsalen rapid caps 5 MO

OXSORALEN ULTRACAPS (Methoxsalen Rapid) 5 MO

SORIATANE CAPS(Acitretin) 5 MO

SORILUX FOAM 4 MO

STELARA SOSY SC 45MG/0.5ML, 90 MG/ML 5 PA

TALTZ SOAJ 5 PA

TALTZ SOSY 5 PA

TAZORAC CREA 3 MO

TAZORAC GEL 3 MO

VECTICAL OINT 4 MO

Antiseborrheic Productsselenium sulfide lotn ex 2.5% 2 MO; *

Antivirals - Topicalacyclovir topical oint 4 MO

DENAVIR CREA 5 MO

XERESE CREA 4 MO

ZOVIRAX CREA EX 5 % 5 MO

ZOVIRAX OINT EX 5 %(Acyclovir Topical) NF MO

Burn ProductsSILVADENE CREA (SilverSulfadiazine) NF MO

silver sulfadiazine crea ex 2 MO; *

SULFAMYLON CREA 85MG/GM 4 MO

Corticosteroids - Topical

Drug Name DrugTier

Requirements/Limits

alclometasone dipropionatecrea 1 MO; *

alclometasone dipropionateoint 1 MO; *

amcinonide crea 3 MO

amcinonide lotn 2 MO; *

amcinonide oint 2 MO; *

betamethasonedipropionate (topical) crea 2 MO; *

betamethasonedipropionate (topical) lotn 2 MO; *

betamethasonedipropionate (topical) oint 2 MO; *

betamethasonedipropionate augmentedcrea

2MO; *

betamethasonedipropionate augmentedgel

2MO; *

betamethasonedipropionate augmentedlotn

3MO

betamethasonedipropionate augmentedoint

3MO

betamethasone valeratecrea ex 0.1 % 2 MO; *

betamethasone valeratefoam ex 0.12 % 3 MO

betamethasone valeratelotn ex 0.1 % 2 MO; *

betamethasone valerateoint ex 0.1 % 2 MO; *

calcipotriene-betamethasonedipropionate oint

5MO

CAPEX SHAM 4 MO

clobetasol propionate creaex 3 MO

clobetasol propionateemollient base crea 2 MO; *

clobetasol propionateemulsion foam 4 Foam;MO



60

Drug Name DrugTier

Requirements/Limits

clobetasol propionate foamex 3 MO

clobetasol propionate gelex 3 MO

clobetasol propionate liqdex 2 MO; *

clobetasol propionate lotnex 4 MO

clobetasol propionate ointex 3 MO

clobetasol propionate shamex 3 MO

clobetasol propionate solnex 2 MO; *

CLOBEX LIQD (ClobetasolPropionate) NF MO

CLOBEX LOTN(Clobetasol Propionate) NF MO

CLOBEX SHAM(Clobetasol Propionate) NF MO

CLOCORTOLONEPIVALATE CREA 4 MO

CLOCORTOLONEPIVALATE PUMP CREA 4 MO

CLODERM CREA 4 MO

CLODERM PUMP CREA 4 MO

CORDRAN TAPE 4MCG/SQCM 4 MO

CORDRAN TAPE TAPE 4 MO

CUTIVATE CREA(Fluticasone Propionate) NF MO

CUTIVATE LOTN(Fluticasone Propionate) NF MO

DERMA-SMOOTHE/FSBODY OIL (FluocinoloneAcetonide)

NFMO

DERMA-SMOOTHE/FSSCALP OIL (FluocinoloneAcetonide)

NFMO

DERMATOP CREA(Prednicarbate) NF MO

DESONATE GEL 4 MO

Drug Name DrugTier

Requirements/Limits

desonide crea ex 3 MO

desonide lotn ex 3 MO

desonide oint ex 2 MO; *

DESOWEN CREA(Desonide) NF MO

desoximetasone crea ex0.25 % 3 MO

desoximetasone gel ex0.05 % 3 MO

DESOXIMETASONE OINTEX 0.05 % 4 MO

desoximetasone oint ex0.25 % 3 MO

diflorasone diacetate oint 1 MO; *

DIPROLENE AF CREA(BetamethasoneDipropionate Augmented)

NFMO

DIPROLENE LOTN(BetamethasoneDipropionate Augmented)

NFMO

DIPROLENE OINT(BetamethasoneDipropionate Augmented)

NFMO

ELOCON CREA(Mometasone Furoate) NF MO

ELOCON OINT(Mometasone Furoate) NF MO

ENSTILAR FOAM 5 MO

fluocinolone acetonide creaex 0.01 %, 0.025 % 2 MO; *

fluocinolone acetonide oilex 0.01 % 2 MO; *

fluocinolone acetonide ointex 0.025 % 2 MO; *

fluocinolone acetonide solnex 0.01 % 3 MO

fluocinonide crea ex 0.05 % 1 MO; *

fluocinonide crea ex 0.1 % 5 MO

fluocinonide emulsifiedbase crea 1 MO; *



61

Drug Name DrugTier

Requirements/Limits

fluocinonide gel ex 0.05 % 2 MO; *

fluocinonide oint ex 0.05 % 2 MO; *

fluocinonide soln ex 0.05 % 2 MO; *

flurandrenolide lotn 4 MO

fluticasone propionate creaex 0.05 % 1 MO; *

fluticasone propionate lotnex 0.05 % 4 MO

fluticasone propionate ointex 0.005 % 1 MO; *

halobetasol propionatecrea 3 MO

halobetasol propionate oint 3 MO

HALOG CREA 4 MO

hydrocortisone (topical)crea 1 % 1 RX/OTC; MO; *

hydrocortisone (topical)crea 2.5 % 1 MO; *

hydrocortisone (topical)lotn 2.5 % 2 MO; *

hydrocortisone (topical)oint 1 % 1 RX/OTC; MO; *

hydrocortisone (topical)oint 2.5 % 1 MO; *

hydrocortisone butyratecrea 1 MO; *

hydrocortisone butyratehydrophilic lipo base crea 2 MO; *

hydrocortisone butyrateoint 1 MO; *

hydrocortisone butyratesoln 1 MO; *

hydrocortisone valeratecrea 2 MO; *

hydrocortisone valerateoint 3 MO

KENALOG AERS(Triamcinolone Acetonide(Topical))

3MO

LOCOID CREA(Hydrocortisone Butyrate) NF MO

Drug Name DrugTier

Requirements/Limits

LOCOID LIPOCREAMCREA (HydrocortisoneButyrate Hydrophilic LipoBase)

NF

MO

LOCOID LOTN 4 MO

LOCOID OINT(Hydrocortisone Butyrate) NF MO

LOCOID SOLN(Hydrocortisone Butyrate) NF MO

LUXIQ FOAM(Betamethasone Valerate) NF MO

mometasone furoate creaex 2 MO; *

mometasone furoate ointex 2 MO; *

mometasone furoate solnex 2 MO; *

OLUX FOAM (ClobetasolPropionate) NF MO

OLUX-E FOAM (ClobetasolPropionate Emulsion) NF Foam;MO

pramoxine-hc crea 1%-1% 1 MO; *

prednicarbate crea 1 MO; *

SYNALAR CREA(Fluocinolone Acetonide) NF MO

SYNALAR OINT(Fluocinolone Acetonide) NF MO

SYNALAR SOLN(Fluocinolone Acetonide) NF MO

TACLONEX OINT(Calcipotriene-BetamethasoneDipropionate)

5

MO

TACLONEX SUSP 5 MO

TEMOVATE CREA(Clobetasol Propionate) NF MO

TEMOVATE E CREA(Clobetasol PropionateEmollient Base)

NFMO

TEMOVATE GEL(Clobetasol Propionate) NF MO

TEMOVATE OINT(Clobetasol Propionate) NF MO



62

Drug Name DrugTier

Requirements/Limits

TEMOVATE SOLN(Clobetasol Propionate) NF MO

TOPICORT LIQD 0.25 % 4 MO

TOPICORT OINT 0.05 % 4 MO

triamcinolone acetonide(topical) aers 2 MO; *

triamcinolone acetonide(topical) crea 2 MO; *

triamcinolone acetonide(topical) lotn 2 MO; *

triamcinolone acetonide(topical) oint 2 MO; *

ULTRAVATE CREA(Halobetasol Propionate) NF MO

ULTRAVATE LOTN 5 PA; MO

ULTRAVATE OINT(Halobetasol Propionate) NF MO

VANOS CREA(Fluocinonide) 5 MO

WESTCORT OINT(Hydrocortisone Valerate) NF MO

EmollientsLAC-HYDRIN CREA(Lactic Acid (AmmoniumLactate))

NFRX/OTC; MO

LAC-HYDRIN LOTN(Lactic Acid (AmmoniumLactate))

NFRX/OTC; MO

lactic acid (ammoniumlactate) crea 12 % 2 RX/OTC; MO; *

lactic acid (ammoniumlactate) lotn 12 % 2 RX/OTC; MO; *

Enzymes - TopicalSANTYL OINT 3 MO

Immunomodulating Agents - TopicalALDARA CREA(Imiquimod) NF MO

imiquimod crea ex 4 MO

ZYCLARA CREA 5 MO

Drug Name DrugTier

Requirements/Limits

ZYCLARA PUMP CREA 5 MO

Immunosuppressive Agents - TopicalELIDEL CREA 4 MO

PROTOPIC OINT(Tacrolimus (Topical)) NF MO

tacrolimus (topical) oint 2 MO; *

Keratolytic/Antimitotic AgentsCONDYLOX GEL 4 MO

CONDYLOX SOLN(Podofilox) NF MO

podofilox soln ex 1 MO; *

Local Anesthetics - TopicalEMLA CREA (Lidocaine-Prilocaine) NF MO

lidocaine hcl gel ex 2 % 2 RX/OTC; MO; *

lidocaine hcl soln ex 4 % 2 MO; *

lidocaine oint ex 5 % 2 MO; *

lidocaine ptch ex 5 % 3 PA; MO

lidocaine-prilocaine crea 3 MO

LIDODERM PTCH(Lidocaine) NF PA; MO

XYLOCAINE SOLN EX 4% (Lidocaine HCl) NF MO

Rosacea AgentsDOXYCYCLINE CPDR 4 MO

FINACEA FOAM 4 MO

FINACEA GEL 4 MO

METROCREAM CREA(Metronidazole (Topical)) NF MO

METROGEL GEL(Metronidazole (Topical)) NF MO

METROLOTION LOTN(Metronidazole (Topical)) NF MO



63

Drug Name DrugTier

Requirements/Limits

metronidazole (topical)crea 3 MO

metronidazole (topical) gel 3 MO

metronidazole (topical) lotn 3 MO

MIRVASO GEL 4 PA; MO

NORITATE CREA 4 MO

ORACEA CPDR 4 MO

SOOLANTRA CREA 4 MO

Scabicides & PediculicidesEURAX CREA 4 MO

EURAX LOTN 4 MO

lindane lotn 1 *

malathion lotn 3 MO

permethrin crea ex 5 % 2 MO; *

Wound Care ProductsREGRANEX GEL 5 MO

DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymesDigestive EnzymesCREON CPEP 3 MO

PANCREAZE CPEP10000UNIT-4200UNIT-17500UNIT, 25000UNIT-10500UNIT-43750UNIT,37000UNIT-21000UNIT-61000UNIT, 40000UNIT-16800UNIT-70000UNIT

3

MO

PANCREAZE CPEP6200UNIT-2600UNIT-10850UNIT

3

PANCRELIPASE CPEP 4 MO

PERTZYE CPEP 4 MO

Drug Name DrugTier

Requirements/Limits

VIOKACE TABS 4 MO

ZENPEP CPEP10000UNIT-3000UNIT-16000UNIT, 17000UNIT-5000UNIT-27000UNIT,34000UNIT-10000UNIT-55000UNIT, 51000UNIT-15000UNIT-82000UNIT,68000UNIT-20000UNIT-109000UNIT, 85000UNIT-25000UNIT-136000UNIT

4

MO

ZENPEP CPEP136000UNIT-40000UNIT-218000UNIT

5MO

DIURETICS - Drugs to Treat Heart, CirculationConditions and Blood PressureCarbonic Anhydrase Inhibitorsacetazolamide cp12 or 500mg 1 MO; *

acetazolamide tabs or 125mg 2 MO; *

acetazolamide tabs or 250mg 1 MO; *

DIAMOX CP12(Acetazolamide) NF MO

KEVEYIS TABS 5 PA; SL(4 eadaily)

methazolamide tabs or 25mg, 50 mg 1 MO; *

Diuretic CombinationsALDACTAZIDE TABS25MG-25MG(Spironolactone &Hydrochlorothiazide)

NF

MO

ALDACTAZIDE TABS50MG-50MG 3 MO

amiloride &hydrochlorothiazide tabs 1 MO; *

DYAZIDE CAPS(Triamterene &Hydrochlorothiazide)

NFMO

MAXZIDE TABS(Triamterene &Hydrochlorothiazide)

NFMO



64

Drug Name DrugTier

Requirements/Limits

MAXZIDE-25 TABS(Triamterene &Hydrochlorothiazide)

NFMO

spironolactone &hydrochlorothiazide tabs 1 MO; *

triamterene &hydrochlorothiazide caps37.5mg-25mg

1MO; *

triamterene &hydrochlorothiazide caps50mg-25mg

2MO; *

triamterene &hydrochlorothiazide tabs37.5mg-25mg, 75mg-50mg

1MO; *

Loop Diureticsbumetanide tabs or 0.5 mg,1 mg, 2 mg 2 MO; *

BUMEX TABS(Bumetanide) NF MO

DEMADEX TABS(Torsemide) NF MO

EDECRIN TABS(Ethacrynic Acid) 4 MO

ethacrynic acid tabs 2 MO; *

furosemide soln ij 10 mg/ml 1 MO; *

furosemide soln or 10mg/ml 1 MO; *

furosemide soln or 8 mg/ml 2 MO; *

furosemide tabs or 20 mg,40 mg, 80 mg 1 MO; *

LASIX TABS (Furosemide) NF MO

torsemide tabs or 10 mg,100 mg, 20 mg, 5 mg 1 MO; *

Potassium Sparing DiureticsALDACTONE TABS(Spironolactone) NF MO

amiloride hcl tabs or 1 MO; *

DYRENIUM CAPS 4 MO

spironolactone tabs or 100mg, 25 mg, 50 mg 1 MO; *

Drug Name DrugTier

Requirements/Limits

Thiazides and Thiazide-Like Diureticschlorothiazide tabs 500 mg 1 MO; *

chlorthalidone tabs 25 mg,50 mg 2 MO; *

hydrochlorothiazide caps or12.5 mg 1 MO; *

hydrochlorothiazide tabs or12.5 mg, 25 mg, 50 mg 1 MO; *

indapamide tabs 1 MO; *

methyclothiazide tabs 2 MO; *

metolazone tabs 2 MO; *

MICROZIDE CAPS(Hydrochlorothiazide) NF MO

ZAROXOLYN TABS(Metolazone) NF MO

ENDOCRINE AND METABOLIC AGENTS -MISC. - Drugs to Treat Bone Disease andRegulate HormonesBone Density RegulatorsACTONEL TABS 150 MG(Risedronate Sodium) NF QL(0.04 ea

daily); MOACTONEL TABS 30 MG, 5MG (Risedronate Sodium) 4 QL(1 ea daily);

MOACTONEL TABS 35 MG(Risedronate Sodium) 4 QL(0.15 ea

daily); MOalendronate sodium tabs10 mg, 5 mg 1 MO; *

alendronate sodium tabs35 mg, 70 mg 1 QL(0.15 ea

daily); MO; *ATELVIA TBEC(Risedronate Sodium) 4 QL(0.15 ea

daily); MO

BONIVA SOLN IV 3MG/3ML (IbandronateSodium)

NF

Limit 3mls per3months;QL(0.04 ml daily); MO

BONIVA TABS OR 150 MG(Ibandronate Sodium) NF

Limit 1 tab per28 days (3 per84);QL(0.036ea daily); MO

calcitonin (salmon) soln 2 MO; *



65

Drug Name DrugTier

Requirements/Limits

etidronate disodium tabs200 mg 2 MO; *

FORTEO SOLN 5

Limit 2.4mlsper 28days;QL(0.09ml daily)

FOSAMAX PLUS D TABS 4 QL(0.15 eadaily); MO

FOSAMAX TABS(Alendronate Sodium) NF QL(0.15 ea

daily); MO

ibandronate sodium soln iv3 mg/3ml 2

Limit 3mls per3months;QL(0.04 ml daily); MO;*

ibandronate sodium tabs or150 mg 2

Limit 1 tab per28 days (3 per84);QL(0.036ea daily); MO; *

MIACALCIN SOLN IJ 200UNIT/ML 4 MO

MIACALCIN SOLN NA 200UNIT/ACT (Calcitonin(Salmon))

NFMO

NATPARA CART 5 PA; LA

PROLIA SOLN 3Limit 1 ml per 6months;QL(0.01 ml daily)

RECLAST SOLN(Zoledronic Acid) NF

Limit 100mlsperyear;QL(0.28ml daily)

risedronate sodium tabs150 mg 3 QL(0.04 ea

daily); MOrisedronate sodium tabs 30mg, 5 mg 2 QL(1 ea daily);

MO; *risedronate sodium tabs 35mg 2 QL(0.15 ea

daily); MO; *risedronate sodium tbec 35mg 2 QL(0.15 ea

daily); MO; *

XGEVA SOLN 5

Limit 6.8mlsper 28days;QL(0.243ml daily)

zoledronic acid conc 4mg/5ml 4

Drug Name DrugTier

Requirements/Limits

zoledronic acid soln 5mg/100ml 2

Limit 100mlsperyear;QL(0.28ml daily); *

ZOLEDRONIC ACID SOLR4 MG 5

ZOMETA CONC 4MG/5ML (Zoledronic Acid) 5

CorticotropinH.P. ACTHAR GEL 5 PA; LA

Fertility Regulatorschorionic gonadotropin solrim 4

Growth Hormone Receptor AntagonistsSOMAVERT SOLR 5 LA

Growth Hormone Releasing Hormones (GHRH)EGRIFTA SOLR 5

Growth HormonesGENOTROPIN MINIQUICKSOLR 0.4 MG 5 PA

GENOTROPIN SOLR 5MG 5 PA

HUMATROPE COMBOPACK SOLR 5 PA

HUMATROPE SOLR 5 PA

NORDITROPIN FLEXPROSOLN 10 MG/1.5ML, 5MG/1.5ML

5PA

NUTROPIN AQ NUSPIN20 SOLN 5 PA

NUTROPIN AQ PEN SOLN20 MG/2ML 5 PA

OMNITROPE SOLN 10MG/1.5ML, 5 MG/1.5ML 5 PA

SEROSTIM SOLR 4 MG, 6MG 5 PA

ZOMACTON SOLR 5 MG 5 PA

Hormone Receptor ModulatorsEVISTA TABS (RaloxifeneHCl) NF QL(1 ea daily);

MO



66

Drug Name DrugTier

Requirements/Limits

raloxifene hcl tabs 3 QL(1 ea daily);MO

Insulin-Like Growth Factors (Somatomedins)INCRELEX SOLN 4 LA

LHRH/GnRH Agonist Analog PituitaryLUPRON DEPOT-PED KIT11.25 MG 5 3 Month Kit

LUPRON DEPOT-PED KIT11.25 MG, 7.5 MG 5

LUPRON DEPOT-PED KIT15 MG 4

LUPRON DEPOT-PED KIT30 MG 5

SYNAREL SOLN 5 MO

Metabolic Modifierscalcitriol caps or 0.25 mcg,0.5 mcg 2 MO; *

calcitriol soln or 1 mcg/ml 2 MO; *

CARBAGLU TABS 4 LA

CYSTADANE POWD 4 LA

doxercalciferol caps or 0.5mcg, 1 mcg, 2.5 mcg 2 MO; *

FABRAZYME SOLR 35MG 5 LA

HECTOROL CAPS OR 0.5MCG, 2.5 MCG(Doxercalciferol)

NFMO

HECTOROL CAPS OR 1MCG (Doxercalciferol) 5 MO

KANUMA SOLN 5 LA

KUVAN PACK 5 LA

KUVAN TBSO 5 LA

levocarnitine (metabolicmodifiers) tabs or 330 mg 1 RX/OTC; MO; *

LUMIZYME SOLR 5 LA

MYALEPT SOLR 5 LA

Drug Name DrugTier

Requirements/Limits

MYOZYME SOLR 5 LA

NAGLAZYME SOLN 5 LA

ORFADIN CAPS 10 MG, 2MG, 20 MG, 5 MG 3 LA

paricalcitol caps or 1 mcg 3 MO

paricalcitol caps or 2 mcg,4 mcg 2 MO; *

RAVICTI LIQD 4 LA

ROCALTROL CAPS(Calcitriol) NF MO

ROCALTROL SOLN(Calcitriol) NF MO

SENSIPAR TABS 30 MG 3

SENSIPAR TABS 60 MG,90 MG 5

STRENSIQ SOLN 5 PA; LA

VIMIZIM SOLN 5

ZEMPLAR CAPS OR 1MCG, 2 MCG (Paricalcitol) NF MO

Posterior Pituitary HormonesDDAVP SOLN(Desmopressin AcetateRefrigerated)

NFMO

DDAVP SOLN(Desmopressin AcetateSpray)

NFMO

DDAVP SOLN(Desmopressin Acetate) NF MO

DDAVP TABS(Desmopressin Acetate) NF MO

desmopressin acetaterefrigerated soln 1 MO; *

desmopressin acetate solnij 4 mcg/ml 2 MO; *

desmopressin acetatespray refrigerated soln 3 MO

desmopressin acetatespray soln 3 MO

desmopressin acetate tabsor 0.1 mg, 0.2 mg 2 MO; *



67

Drug Name DrugTier

Requirements/Limits

STIMATE SOLN 4

Prolactin Inhibitorscabergoline tabs 3 MO

Somatostatic Agentsoctreotide acetate soln 100mcg/ml 4

octreotide acetate soln 200mcg/ml, 50 mcg/ml 1 *

SANDOSTATIN LARDEPOT KIT 20 MG, 30 MG 5

SANDOSTATIN SOLN 100MCG/ML (OctreotideAcetate)

5

SANDOSTATIN SOLN 200MCG/ML, 50 MCG/ML(Octreotide Acetate)

NF

SIGNIFOR LAR SUSR 20MG 5

Limit 3 vials per28days;SL(0.11ea daily); LA


Limit 3 vials per56days;SL(0.054ea daily); LA


Limit 1 vial per28days;SL(0.036ea daily); LA

SIGNIFOR SOLN 5 LA

SOMATULINE DEPOTSOLN 5

Vasopressin Receptor AntagonistsSAMSCA TABS 5

ESTROGENS - Hormone Replacement/ModifyingDrugsEstrogen CombinationsACTIVELLA TABS(Estradiol & NorethindroneAcetate)

NFAL; MO

ANGELIQ TABS 0.5MG-1MG 4 AL; MO

Drug Name DrugTier

Requirements/Limits

CLIMARA PRO PTWK 4 AL; MO

COMBIPATCH PTTW 4 AL; MO

DUAVEE TABS 4 AL; MO

estradiol & norethindroneacetate tabs 2 AL; MO; *

estradiol-norgestimate tabs 2 AL; MO; *

FEMHRT LOW DOSETABS (NorethindroneAcetate-Ethinyl Estradiol)

4AL; MO

norethindrone acetate-ethinyl estradiol tabs2.5mcg-0.5mg

2AL; MO; *

PREMPHASE TABS 4 AL; MO

PREMPRO TABS 4 AL; MO

EstrogensCLIMARA PTWK(Estradiol) NF AL; MO

DELESTROGEN OIL 20MG/ML, 40 MG/ML(Estradiol Valerate)

NFMO

DIVIGEL GEL 4 AL; MO

ELESTRIN GEL 4 AL; MO

ENJUVIA TABS 0.3 MG,0.45 MG, 0.9 MG 4 AL

estradiol cypionate oil im 2 MO; *

estradiol pttw td 0.025mg/24hr, 0.0375 mg/24hr,0.05 mg/24hr, 0.075mg/24hr, 0.1 mg/24hr

2

AL; MO; *

estradiol ptwk td 0.025mg/24hr, 0.05 mg/24hr,0.06 mg/24hr, 0.075mg/24hr, 0.1 mg/24hr, 37.5mcg/24hr

2

AL; MO; *

estradiol tabs or 0.5 mg, 1mg, 2 mg 2 AL; MO; *

estradiol valerate oil im 20mg/ml, 40 mg/ml 1 MO; *



68

Drug Name DrugTier

Requirements/Limits

estropipate tabs 0.75 mg,1.5 mg 2 AL; MO; *

EVAMIST SOLN 4 AL; MO

MENOSTAR PTWK 4 AL; MO

PREMARIN TABS OR 0.3MG, 0.45 MG, 0.625 MG,0.9 MG, 1.25 MG

4AL; MO

VIVELLE-DOT PTTW(Estradiol) NF AL; MO

FLUOROQUINOLONES - Drugs to Treat BacterialInfectionsFluoroquinolonesAVELOX ABC PACK TABS(Moxifloxacin HCl) NF MO

AVELOX TABS OR 400MG (Moxifloxacin HCl) NF MO

CIPRO I.V.-IN D5W SOLN(Ciprofloxacin in D5W) NF MO

CIPRO SUSR 5GM/100ML (Ciprofloxacin) 4 MO

CIPRO SUSR 500MG/5ML (Ciprofloxacin) NF MO

CIPRO TABS 250 MG, 500MG (Ciprofloxacin HCl) NF MO

CIPRO XR TB24(Ciprofloxacin-CiprofloxacinHCl)

NFMO

ciprofloxacin hcl tabs or100 mg, 250 mg, 500 mg,750 mg

1MO; *

ciprofloxacin in d5w soln200mg/100ml-5% 2 *

ciprofloxacin in d5w soln400mg/200ml-5% 1 MO; *

ciprofloxacin susr or 250mg/5ml, 500 mg/5ml 2 MO; *

ciprofloxacin-ciprofloxacinhcl tb24 3 MO

LEVAQUIN SOLN IV250MG/50ML-5%,500MG/100ML-5%,750MG/150ML-5%(Levofloxacin in D5W)

NF

Drug Name DrugTier

Requirements/Limits

LEVAQUIN SOLN OR 25MG/ML (Levofloxacin) NF MO

LEVAQUIN TABS OR 250MG, 750 MG (Levofloxacin) NF MO

LEVAQUIN TABS OR 500MG (Levofloxacin) 4 MO

levofloxacin in d5w soln 1 *

levofloxacin soln iv 25mg/ml 2 *

levofloxacin soln or 25mg/ml 3 MO

levofloxacin tabs or 250mg, 500 mg, 750 mg 2 MO; *

moxifloxacin hcl tabs or400 mg 2 MO; *

GASTROINTESTINAL AGENTS - MISC. -Miscellaneous Gastrointestinal DrugsFarnesoid X Receptor (FXR) Agonists

OCALIVA TABS 10 MG 5 PA; SL(1 eadaily)

OCALIVA TABS 5 MG 5 PA; SL(2 eadaily)

Gallstone Solubilizing AgentsACTIGALL CAPS(Ursodiol) NF MO

CHENODAL TABS 5 LA

URSO 250 TABS(Ursodiol) NF MO

URSO FORTE TABS(Ursodiol) NF MO

ursodiol caps or 300 mg 3 MO

ursodiol tabs or 250 mg,500 mg 3 MO

Gastrointestinal Antiallergy Agentscromolyn sodium(mastocytosis) conc 4 MO

GASTROCROM CONC(Cromolyn Sodium(Mastocytosis))

NFMO

Gastrointestinal Chloride Channel ActivatorsAMITIZA CAPS 3 MO



69

Drug Name DrugTier

Requirements/Limits

Gastrointestinal Stimulantsmetoclopramide hcl soln ij5 mg/ml 2 MO; *

metoclopramide hcl soln or10 mg/10ml, 5 mg/5ml 2 MO; *

metoclopramide hcl tabs or10 mg, 5 mg 1 MO; *

REGLAN TABS(Metoclopramide HCl) NF MO

Inflammatory Bowel AgentsAPRISO CP24 3 MO

ASACOL HD TBEC 3 MO

AZULFIDINE EN-TABSTBEC (Sulfasalazine) NF MO

AZULFIDINE TABS(Sulfasalazine) NF MO

balsalazide disodium caps 3 MO

CANASA SUPP 5 MO

CIMZIA KIT 5 PA

CIMZIA STARTER KIT KIT 5 PA

COLAZAL CAPS(Balsalazide Disodium) NF MO

DELZICOL CPDR 3 MO

DIPENTUM CAPS 5 MO

ENTYVIO SOLR 5 PA

LIALDA TBEC 3 MO

MESALAMINE DR TBEC 3 MO

mesalamine enem re 4 MO

mesalamine w/ cleanser kit 4 MO

PENTASA CPCR 250 MG 4 MO

PENTASA CPCR 500 MG 5 MO

REMICADE SOLR 5 PA

Drug Name DrugTier

Requirements/Limits

ROWASA KIT (Mesalaminew/ Cleanser) NF MO

sulfasalazine tabs or 2 MO; *

sulfasalazine tbec or 2 MO; *

Intestinal Acidifierslactulose (encephalopathy)soln 2 MO; *

Irritable Bowel Syndrome (IBS) Agentsalosetron hcl tabs 5 MO

LINZESS CAPS 3 MO

LOTRONEX TABS(Alosetron HCl) 5 MO

VIBERZI TABS 5 PA; MO

Peripheral Opioid Receptor AntagonistsMOVANTIK TABS 4 MO

RELISTOR SOLN SC 12MG/0.6ML 4 MO

RELISTOR SOLN SC 8MG/0.4ML 5 MO

Phosphate Binder AgentsAURYXIA TABS 5 MO

calcium acetate (phosphatebinder) caps 2 MO; *

calcium acetate (phosphatebinder) tabs 2 RX/OTC; MO; *

FOSRENOL CHEW 1000MG, 500 MG, 750 MG 3 MO

PHOSLO CAPS (CalciumAcetate (PhosphateBinder))

NFMO

PHOSLYRA SOLN 4 MO

RENAGEL TABS 800 MG 5 MO

RENVELA PACK 5 MO

RENVELA TABS 5 MO

VELPHORO CHEW 5 MO



70

Drug Name DrugTier

Requirements/Limits

Short Bowel Syndrome (SBS) AgentsGATTEX KIT 5 PA; LA

GENITOURINARY AGENTS - MISCELLANEOUS- Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary SystemAlkalinizerspotassium citrate(alkalinizer) tbcr 1080 mg 2 MO; *

potassium citrate(alkalinizer) tbcr 540 mg 1 MO; *

UROCIT-K 10 TBCR(Potassium Citrate(Alkalinizer))

NFMO

UROCIT-K 5 TBCR(Potassium Citrate(Alkalinizer))

NFMO

Cystinosis AgentsCYSTAGON CAPS 4

PROCYSBI CPDR 4 LA

Genitourinary Irrigantsacetic acid soln 1 MO; *

neomycin/polymyxin b gusoln 1 MO; *

sodium chloride (guirrigant) soln 2 MO; *

Interstitial Cystitis AgentsELMIRON CAPS 4 MO

Prostatic Hypertrophy Agentsalfuzosin hcl tb24 2 MO; *

AVODART CAPS(Dutasteride) 3 GL; MO

CARDURA XL TB24 4 MO

dutasteride caps 2 GL; MO; *

dutasteride-tamsulosin hclcaps 2 GL; MO; *

finasteride tabs or 2 GL; MO; *

Drug Name DrugTier

Requirements/Limits

FLOMAX CAPS(Tamsulosin HCl) NF MO

JALYN CAPS (Dutasteride-Tamsulosin HCl) 3 GL; MO

PROSCAR TABS(Finasteride) NF GL; MO

RAPAFLO CAPS 4 MO

tamsulosin hcl caps 2 MO; *

UROXATRAL TB24(Alfuzosin HCl) NF MO

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinationscolchicine w/ probenecidtabs 1 MO; *

Gout Agents

allopurinol tabs or 100 mg 1 SL(8 ea daily);MO; *

allopurinol tabs or 300 mg 1 SL(2.66 eadaily); MO; *

COLCHICINE CAPS OR 4 MO

COLCHICINE TABS OR 3 MO

COLCRYS TABS 3 MO

MITIGARE CAPS 4 MO

ULORIC TABS 3 MO

ZYLOPRIM TABS 100 MG(Allopurinol) NF SL(8 ea daily);

MOZYLOPRIM TABS 300 MG(Allopurinol) NF SL(2.66 ea

daily); MOUricosuricsprobenecid tabs 2 MO; *

HEMATOLOGICAL AGENTS - MISC. - Drugs toTreat Blood DisordersBradykinin B2 Receptor AntagonistsFIRAZYR SOLN 5

Complement Inhibitors



71

Drug Name DrugTier

Requirements/Limits

BERINERT KIT 5 LA

CINRYZE SOLR 5 LA

RUCONEST SOLR 5

Hematorheologic Agentspentoxifylline tbcr or 2 MO; *

Plasma Kallikrein InhibitorsKALBITOR SOLN 5

Platelet Aggregation InhibitorsAGGRENOX CP12 3 MO

AGRYLIN CAPS(Anagrelide HCl) NF MO

anagrelide hcl caps 1 MO; *

ASPIRIN/DIPYRIDAMOLECP12 3 MO

BRILINTA TABS 3 MO

cilostazol tabs 2 MO; *

clopidogrel bisulfate tabs300 mg 2 *

clopidogrel bisulfate tabs75 mg 2 MO; *

dipyridamole tabs or 25mg, 50 mg, 75 mg 2 AL; MO; *

EFFIENT TABS 3 MO

PERSANTINE TABS(Dipyridamole) NF AL; MO

PLAVIX TABS 300 MG(Clopidogrel Bisulfate) NF

PLAVIX TABS 75 MG(Clopidogrel Bisulfate) NF MO

PLETAL TABS (Cilostazol) NF MO

ticlopidine hcl tabs 2 AL; *

ZONTIVITY TABS 3 MO

HEMATOPOIETIC AGENTS - Drugs to TreatBlood Disorders

Drug Name DrugTier

Requirements/Limits

Agents for Gaucher DiseaseCERDELGA CAPS 5 PA

CEREZYME SOLR 5 LA

ELELYSO SOLR 5

VPRIV SOLR 5

ZAVESCA CAPS 5 LA

Agents for Sickle Cell AnemiaDROXIA CAPS 4 MO

Hematopoietic Growth FactorsARANESP ALBUMINFREE SOLN 10MCG/0.4ML, 25 MCG/ML,40 MCG/ML, 60 MCG/ML

4

PA

ARANESP ALBUMINFREE SOLN 100 MCG/ML,150 MCG/0.75ML, 200MCG/ML, 300 MCG/ML

5

PA

ARANESP ALBUMINFREE SOSY 100MCG/0.5ML, 150MCG/0.3ML, 200MCG/0.4ML, 300MCG/0.6ML, 500 MCG/ML

5

PA

ARANESP ALBUMINFREE SOSY 25MCG/0.42ML, 40MCG/0.4ML, 60MCG/0.3ML

4

PA

EPOGEN SOLN 4 PA; B/D

GRANIX SOSY 5 PA

LEUKINE SOLR 5 PA

MIRCERA SOSY 100MCG/0.3ML, 50MCG/0.3ML, 75MCG/0.3ML

4

PA; B/D

MIRCERA SOSY 200MCG/0.3ML 5 PA; B/D

NEULASTA ONPRO KITPSKT 5 PA



72

Drug Name DrugTier

Requirements/Limits

NEULASTA SOSY 5 PA

NEUMEGA SOLR 3 PA

NEUPOGEN SOLN 5 PA

NEUPOGEN SOSY 5 PA

PROCRIT SOLN 10000UNIT/ML, 2000 UNIT/ML,3000 UNIT/ML, 4000UNIT/ML

3

PA; B/D

PROCRIT SOLN 20000UNIT/ML, 40000 UNIT/ML 5 PA; B/D

PROMACTA TABS 12.5MG 5 SL(12 ea daily);

LA

PROMACTA TABS 25 MG 5 SL(6 ea daily);LA



ZARXIO SOSY 5 PA

Stem Cell MobilizersMOZOBIL SOLN 5

HEMOSTATICS - Drugs to Stop Bleeding/TreatBlood DisordersHemostatics - SystemicAMICAR SOLN 0.25GM/ML 5 MO

AMICAR TABS 1000 MG 5

AMICAR TABS 500 MG 5 MO

AMINOCAPROIC ACIDTABS OR 1000 MG 5

aminocaproic acid tabs or500 mg 2 MO; *

CYKLOKAPRON SOLN(Tranexamic Acid) NF

LYSTEDA TABS(Tranexamic Acid) NF MO

tranexamic acid soln iv1000 mg/10ml 1 *

Drug Name DrugTier

Requirements/Limits

tranexamic acid tabs or 650mg 3 MO

HYPNOTICS/SEDATIVES/SLEEP DISORDERAGENTSBarbiturate HypnoticsBUTISOL SODIUM TABS30 MG 4 AL; MO

pentobarbital sodium soln ij 2 AL; *

phenobarbital elix or 20mg/5ml 2 AL; MO; *

phenobarbital soln or 20mg/5ml 2 AL; MO; *

phenobarbital tabs or 100mg, 15 mg, 16.2 mg, 30mg, 32.4 mg, 60 mg, 64.8mg, 97.2 mg

2

AL; MO; *

Hypnotics - Tricyclic AgentsSILENOR TABS 4 MO

Non-Barbiturate HypnoticsAMBIEN CR TBCR 12.5MG (Zolpidem Tartrate) NF AL; SL(1 ea

daily); MOAMBIEN CR TBCR 6.25MG (Zolpidem Tartrate) NF AL; SL(2 ea

daily); MOAMBIEN TABS 10 MG(Zolpidem Tartrate) NF AL; SL(1 ea

daily); MOAMBIEN TABS 5 MG(Zolpidem Tartrate) NF AL; SL(2 ea

daily); MO

EDLUAR SUBL 4 AL; MO

eszopiclone tabs 3 AL; MO

flurazepam hcl caps 1 MO; *

HALCION TABS(Triazolam) NF MO

INTERMEZZO SUBL(Zolpidem Tartrate) 4 AL; MO

LUNESTA TABS(Eszopiclone) NF AL; MO

RESTORIL CAPS(Temazepam) NF MO

SONATA CAPS (Zaleplon) NF AL; MO



73

Drug Name DrugTier

Requirements/Limits

temazepam caps 2 MO; *

triazolam tabs 0.125 mg,0.25 mg 2 MO; *

zaleplon caps 2 AL; MO; *

zolpidem tartrate subl sl1.75 mg, 3.5 mg 2 AL; MO; *

zolpidem tartrate tabs or 10mg 2 AL; SL(1 ea

daily); MO; *zolpidem tartrate tabs or 5mg 2 AL; SL(2 ea

daily); MO; *zolpidem tartrate tbcr or12.5 mg 4 AL; SL(1 ea

daily); MOzolpidem tartrate tbcr or6.25 mg 4 AL; SL(2 ea

daily); MO

ZOLPIMIST SOLN 4 AL; MO

Orexin Receptor Antagonists

BELSOMRA TABS 10 MG 4 PA; SL(2 eadaily); MO

BELSOMRA TABS 15 MG 4 PA; SL(1.33 eadaily); MO



Selective Melatonin Receptor AgonistsHETLIOZ CAPS 5 PA

ROZEREM TABS 4 MO

LAXATIVES - Bowel Treatment Drugs

Laxative Combinationsbisacodyl-peg 3350-potchloride-sod bicarb-sodchloride kit

2MO; *

COLYTE-FLAVOR PACKSSOLR 227.1GM-21.5GM-5.53GM-2.82GM-6.36GM

4

Drug Name DrugTier

Requirements/Limits

COLYTE-FLAVOR PACKSSOLR 240GM-22.72GM-5.84GM-2.98GM-6.72GM(PEG 3350-KCl-SodBicarb-Sod Chloride-SodSulfate)

NF

MO

GOLYTELY SOLR227.1GM-21.5GM-5.53GM-2.82GM-6.36GM

4MO

GOLYTELY SOLR 236GM-22.74GM-5.86GM-2.97GM-6.74GM (PEG 3350-KCl-Sod Bicarb-Sod Chloride-Sod Sulfate)

NF

MO

MOVIPREP SOLR 4 MO

NULYTELY/FLAVORPACKS SOLR (PEG 3350-Potassium Chloride-SodBicarbonate-Sod Chloride)

NF

MO

peg 3350-kcl-sod bicarb-sod chloride-sod sulfatesolr

2MO; *

peg 3350-potassiumchloride-sod bicarbonate-sod chloride solr

2MO; *

PREPOPIK PACK 4 MO

SUPREP BOWEL PREPSOLN 4 MO

Laxatives - Miscellaneouslactulose soln 2 MO; *

polyethylene glycol 3350pack or 2 RX/OTC; MO; *

polyethylene glycol 3350powd or 2 RX/OTC; MO; *

Saline LaxativesOSMOPREP TABS 4 MO

LOCAL ANESTHETICS-Parenteral - Drugs forNumbingLocal Anesthetics - Amideslidocaine hcl (local anesth.)soln 1 %, 2 % 1 *



74

Drug Name DrugTier

Requirements/Limits

XYLOCAINE SOLN IJ 1 %,2 % (Lidocaine HCl (LocalAnesth.))

NF

XYLOCAINE-MPF SOLN 1% (Lidocaine HCl (LocalAnesth.))

NF

MACROLIDES - Drugs to Treat BacterialInfectionsAzithromycinazithromycin solr iv 500 mg 2 MO; *

azithromycin susr or 100mg/5ml, 200 mg/5ml 2 MO; *

azithromycin tabs or 250mg, 500 mg, 600 mg 2 MO; *

ZITHROMAX SOLR IV 500MG (Azithromycin) NF MO

ZITHROMAX SUSR OR100 MG/5ML, 200 MG/5ML(Azithromycin)

NFMO

ZITHROMAX TABS OR250 MG, 500 MG, 600 MG(Azithromycin)

NFMO

ZITHROMAX TRI-PAKTABS (Azithromycin) NF MO

ZITHROMAX Z-PAK TABS(Azithromycin) NF MO

ClarithromycinBIAXIN SUSR(Clarithromycin) NF MO

BIAXIN TABS(Clarithromycin) NF MO

clarithromycin susr or 250mg/5ml 3 MO

clarithromycin tabs or 250mg, 500 mg 2 MO; *

clarithromycin tb24 or 500mg 2 MO; *

ErythromycinsE.E.S. GRANULES SUSR(ErythromycinEthylsuccinate)

4SL(100 mldaily); MO

ERYPED 200 SUSR(ErythromycinEthylsuccinate)

4SL(100 mldaily); MO

Drug Name DrugTier

Requirements/Limits

ERYPED 400 SUSR 4 SL(50 ml daily);MO

erythromycin base cpep250 mg 2 SL(16 ea daily);

MO; *erythromycin base tabs 250mg 2 SL(16 ea daily);

MO; *erythromycin base tabs 500mg 2 SL(8 ea daily);

MO; *erythromycinethylsuccinate susr or 200mg/5ml

2SL(100 mldaily); MO; *

erythromycinethylsuccinate tabs or 400mg

2SL(10 ea daily);MO; *

erythromycin lactobionatesolr 2 SL(8 ea daily);

*

PCE TBEC 333 MG 4 SL(12 ea daily);MO

FidaxomicinDIFICID TABS 5 MO

MEDICAL DEVICES

Bandages-Dressings-Tapegauze pads 2" x 2" 1 RX/OTC; MO; *

Misc. DevicesALCOHOL PADS 3 RX/OTC; MO

Parenteral Therapy SuppliesINSULIN SYRINGES ANDPEN NEEDLES 3 MO

MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadachesMigraine CombinationsMIGERGOT SUPP 4 MO

TREXIMET TABS 10MG-60MG 4

TREXIMET TABS 85MG-500MG 4 MO

Migraine Products - NSAIDsCAMBIA PACK 4 MO



75

Drug Name DrugTier

Requirements/Limits

Migraine ProductsD.H.E. 45 SOLN(DihydroergotamineMesylate)

NFMO

dihydroergotaminemesylate soln ij 1 mg/ml 1 MO; *

DIHYDROERGOTAMINEMESYLATE SOLN NA 4MG/ML

5MO

ERGOMAR SUBL 4

MIGRANAL SOLN 5 MO

Serotonin Agonists

almotriptan malate tabs 2 QL(0.4 eadaily); MO; *

AMERGE TABS(Naratriptan HCl) NF QL(0.3 ea

daily); MOAXERT TABS (AlmotriptanMalate) 4 QL(0.4 ea

daily); MOFROVA TABS (FrovatriptanSuccinate) 4 QL(0.6 ea

daily); MO

frovatriptan succinate tabs 2 QL(0.6 eadaily); MO; *

IMITREX SOLN SC 6MG/0.5ML (SumatriptanSuccinate)

NFLimit 8mls permonth;QL(0.27ml daily); MO

IMITREX STATDOSEREFILL SOCT 4 MG/0.5ML(Sumatriptan Succinate)

NF

Solutioncartridge; Limit4mls permonth;QL(0.14ml daily); MO

IMITREX STATDOSEREFILL SOCT 6 MG/0.5ML(Sumatriptan Succinate)

NF

Solutioncartridge; Limit8mls permonth;QL(0.27ml daily); MO

IMITREX STATDOSESYSTEM SOAJ 4MG/0.5ML (SumatriptanSuccinate)

NF

Auto-injector;Limit 4mls permonth;QL(0.14ml daily); MO

IMITREX STATDOSESYSTEM SOAJ 6MG/0.5ML (SumatriptanSuccinate)

NF


Drug Name DrugTier

Requirements/Limits

IMITREX TABS OR 100MG (SumatriptanSuccinate)

NFQL(0.3 eadaily); MO

IMITREX TABS OR 25 MG(Sumatriptan Succinate) NF QL(0.9 ea

daily); MOIMITREX TABS OR 50 MG(Sumatriptan Succinate) NF QL(0.6 ea

daily); MOMAXALT TABS 10 MG(Rizatriptan Benzoate) NF QL(0.4 ea

daily); MOMAXALT TABS 5 MG(Rizatriptan Benzoate) NF QL(0.8 ea

daily); MOMAXALT-MLT TBDP 10MG (Rizatriptan Benzoate) NF QL(0.4 ea

daily); MOMAXALT-MLT TBDP 5 MG(Rizatriptan Benzoate) NF QL(0.8 ea

daily); MO

naratriptan hcl tabs 1 QL(0.3 eadaily); MO; *

RELPAX TABS 4 QL(0.2 eadaily); MO

rizatriptan benzoate tabs10 mg 2 QL(0.4 ea

daily); MO; *rizatriptan benzoate tabs 5mg 2 QL(0.8 ea

daily); MO; *rizatriptan benzoate tbdp10 mg 3 QL(0.4 ea

daily); MOrizatriptan benzoate tbdp 5mg 3 QL(0.8 ea

daily); MO

sumatriptan succinate soajsc 4 mg/0.5ml 3


sumatriptan succinate soajsc 6 mg/0.5ml 3


sumatriptan succinate soctsc 4 mg/0.5ml 2

Solutioncartridge; Limit4mls permonth;QL(0.14ml daily); MO; *

sumatriptan succinate soctsc 6 mg/0.5ml 2

Solutioncartridge; Limit8mls permonth;QL(0.27ml daily); MO; *



76

Drug Name DrugTier

Requirements/Limits

sumatriptan succinate solnsc 6 mg/0.5ml 4


sumatriptan succinate sosysc 6 mg/0.5ml 2 Prefilled

syringe; *sumatriptan succinate tabsor 100 mg 2 QL(0.3 ea

daily); MO; *sumatriptan succinate tabsor 25 mg 2 QL(0.9 ea

daily); MO; *sumatriptan succinate tabsor 50 mg 2 QL(0.6 ea

daily); MO; *

SUMAVEL DOSEPROSOTJ 4


zolmitriptan tabs 2.5 mg 2 SL(4 ea daily);MO; *

zolmitriptan tabs 5 mg 2 SL(2 ea daily);MO; *

zolmitriptan tbdp 2.5 mg 2 SL(4 ea daily);MO; *

zolmitriptan tbdp 5 mg 2 SL(2 ea daily);MO; *

ZOMIG NASAL SPRAYSOLN 4 SL(2 ea daily);

MO

ZOMIG SOLN NA 2.5 MG 4 SL(4 ea daily);MO

ZOMIG TABS OR 2.5 MG(Zolmitriptan) NF SL(4 ea daily);

MOZOMIG TABS OR 5 MG(Zolmitriptan) NF SL(2 ea daily);

MOZOMIG ZMT TBDP 2.5 MG(Zolmitriptan) NF SL(4 ea daily);

MOZOMIG ZMT TBDP 5 MG(Zolmitriptan) NF SL(2 ea daily);

MO

MINERALS & ELECTROLYTES

Bicarbonatessodium bicarbonate soln iv8.4 % 1 MO; *

Chlorideammonium chloride soln iv 2 MO; *

Electrolyte Mixturesdextrose in lactated ringerssoln 1 *

Drug Name DrugTier

Requirements/Limits

dextrose w/ sodiumchloride soln 0.45%-2.5% 2 *

dextrose w/ sodiumchloride soln 0.45%-5% 1 *

dextrose w/ sodiumchloride soln 0.9%-5% 1 MO; *

lactated ringer's soln 1 *

parenteral electrolytes conc 2 B/D; *

parenteral electrolytes soln 2 B/D; *

potassium chloride indextrose & sodium chloridesoln 0.45%-20meq/l-5%

1*

Fluoridesodium fluoride tabs or 1mg 1 *

Magnesiummagnesium sulfate soln ij50 % 1 MO; *

PotassiumK-TAB TBCR 10 MEQ(Potassium Chloride) NF MO

MICRO-K CPCR(Potassium Chloride) NF MO

potassium chloride cpcr or10 meq, 8 meq 2 MO; *

POTASSIUM CHLORIDEER TBCR 2 MO; *

potassium chloridemicroencapsulated crystalscr tbcr

2MO; *

potassium chloride soln iv 2meq/ml 1 MO; *

potassium chloride soln or10 %, 20 % 2 MO; *

potassium chloride tbcr or10 meq, 8 meq 2 MO; *

Sodiumsodium chloride soln iv0.45 % 2 *

sodium chloride soln iv 0.9% 2 MO; *



77

Drug Name DrugTier

Requirements/Limits

MOUTH/THROAT/DENTAL AGENTS

Anesthetics Topical Orallidocaine hcl (mouth-throat)soln 2 MO; *

Anti-infectives - Throatclotrimazole lozg mt 2 MO; *

clotrimazole troc mt 2 MO; *

nystatin (mouth-throat)susp 2 MO; *

Antiseptics - Mouth/Throatchlorhexidine gluconate(mouth-throat) soln 1 MO; *

PERIDEX SOLN(Chlorhexidine Gluconate(Mouth-Throat))

NFMO

Steroids - Mouth/Throattriamcinolone acetonide(mouth) pste 2 MO; *

Throat Products - Misc.cevimeline hcl caps 3 MO

EVOXAC CAPS(Cevimeline HCl) NF MO

pilocarpine hcl (oral) tabs 2 MO; *

SALAGEN TABS(Pilocarpine HCl (Oral)) NF MO

MULTIVITAMINS

Prenatal VitaminsTRINATAL RX 1 TABS 2 MO; *

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat SpasmsCentral Muscle Relaxants

baclofen tabs or 10 mg 2 SL(8 ea daily);MO; *

baclofen tabs or 20 mg 2 SL(4 ea daily);MO; *

carisoprodol tabs or 250mg, 350 mg 2 AL; MO; *

Drug Name DrugTier

Requirements/Limits

chlorzoxazone tabs 2 AL; MO; *

cyclobenzaprine hcl tabs or10 mg, 5 mg, 7.5 mg 2 AL; MO; *

metaxalone tabs 3 AL; MO

methocarbamol tabs or 500mg, 750 mg 2 AL; MO; *

orphenadrine citrate soln ij30 mg/ml 2 AL; MO; *

orphenadrine citrate tb12 or100 mg 2 AL; MO; *

PARAFON FORTE DSCTABS (Chlorzoxazone) NF AL; MO

ROBAXIN TABS OR 500MG (Methocarbamol) NF AL; MO

ROBAXIN-750 TABS(Methocarbamol) NF AL; MO

SKELAXIN TABS(Metaxalone) NF AL; MO

SOMA TABS(Carisoprodol) NF AL; MO

tizanidine hcl caps or 2 mg 3 SL(18 ea daily);MO



tizanidine hcl tabs or 2 mg 2 SL(18 ea daily);MO; *

tizanidine hcl tabs or 4 mg 2 SL(9 ea daily);MO; *

ZANAFLEX CAPS 2 MG(Tizanidine HCl) NF SL(18 ea daily);

MOZANAFLEX CAPS 4 MG(Tizanidine HCl) NF SL(9 ea daily);

MOZANAFLEX CAPS 6 MG(Tizanidine HCl) NF SL(6 ea daily);

MOZANAFLEX TABS 4 MG(Tizanidine HCl) NF SL(9 ea daily);

MODirect Muscle RelaxantsDANTRIUM CAPS(Dantrolene Sodium) NF MO

dantrolene sodium caps or100 mg, 50 mg 1 MO; *



78

Drug Name DrugTier

Requirements/Limits

dantrolene sodium caps or25 mg 3 MO

Muscle Relaxant Combinationscarisoprodol w/ aspirin &codeine tabs 2 AL; MO; *

carisoprodol w/ aspirin tabs 3 AL; MO

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or SinusNasal Agent CombinationsDYMISTA SUSP 4 MO

Nasal Anti-infectivesBACTROBAN NASALOINT 4 MO

Nasal AntiallergyASTEPRO SOLN(Azelastine HCl) NF MO

azelastine hcl soln 2 MO; *

olopatadine hcl (nasal) soln 2 MO; *

PATANASE SOLN(Olopatadine HCl (Nasal)) NF MO

Nasal AnticholinergicsATROVENT SOLN(Ipratropium Bromide(Nasal))

NFMO

ipratropium bromide (nasal)soln 2 MO; *

Nasal SteroidsBECONASE AQ SUSP 4 MO

budesonide (nasal) susp 2 RX/OTC; MO; *

flunisolide (nasal) soln 2 MO; *

fluticasone propionate(nasal) susp 2 RX/OTC; MO; *

mometasone furoate(nasal) susp 2 MO; *

NASONEX SUSP(Mometasone Furoate(Nasal))

3MO

Drug Name DrugTier

Requirements/Limits

OMNARIS SUSP 4 MO

QNASL AERS 4 MO

QNASL CHILDRENSAERS 4 MO

RHINOCORT AQUA SUSP(Budesonide (Nasal)) NF RX/OTC; MO

triamcinolone acetonide(nasal) aero 2 RX/OTC; MO; *

VERAMYST SUSP 4 MO

ZETONNA AERS 4 MO

Sympathomimetic Decongestantstetrahydrozoline hcl soln na 2 *

NEUROMUSCULAR AGENTS - Drugs toRelax/Paralyze MusclesALS AgentsRILUTEK TABS (Riluzole) 5 MO

riluzole tabs 2 MO; *

Neuromuscular Blocking Agent - NeurotoxinsBOTOX SOLR 4 PA

XEOMIN SOLR 4 PA

NUTRIENTS

Carbohydratesdextrose soln iv 10 % 2 B/D; *

dextrose soln iv 5 % 1 MO; B/D; *

Lipidsfat emulsion emul 20gm/100ml 3 B/D

Proteinsamino acid infusion 15% 4 B/D

AMINOSYN II 15% (Useamino acid infusion) 4 B/D



79

Drug Name DrugTier

Requirements/Limits

CLINIMIX2.75%/DEXTROSE 5%SOLN

4B/D

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Beta-blockers - OphthalmicBETAGAN SOLN(Levobunolol HCl) NF MO

betaxolol hcl (ophth) soln 1 MO; *

BETIMOL SOLN 4 MO

BETOPTIC-S SUSP 3 MO

carteolol hcl (ophth) soln 1 MO; *

COMBIGAN SOLN 4 MO

COSOPT PF SOLN 4 MO

COSOPT SOLN(Dorzolamide HCl-TimololMaleate)

NFMO

dorzolamide hcl-timololmaleate soln 2 MO; *

ISTALOL SOLN 3 MO

levobunolol hcl soln 2 MO; *

metipranolol soln 1 *

timolol maleate (ophth)solg 0.25 %, 0.5 % 2 Gel Forming

Soln;MO; *timolol maleate (ophth)soln 0.25 %, 0.5 % 1 MO; *

TIMOPTIC SOLN (TimololMaleate (Ophth)) NF MO

TIMOPTIC-XE SOLG(Timolol Maleate (Ophth)) NF Gel Forming

Soln;MOCycloplegic Mydriaticscyclopentolate hcl soln op0.5 % 2 MO; *

cyclopentolate hcl soln op1 %, 2 % 1 MO; *

MioticsISOPTO CARPINE SOLN(Pilocarpine HCl) 4 MO

Drug Name DrugTier

Requirements/Limits

PHOSPHOLINE IODIDESOLR 4

pilocarpine hcl soln op 1 %,2 %, 4 % 2 MO; *

Ophthalmic - Angiogenesis InhibitorsEYLEA SOLN 5 LA

Ophthalmic Adrenergic AgentsALPHAGAN P SOLN 0.1 % 3 MO

ALPHAGAN P SOLN 0.15% (Brimonidine Tartrate) NF MO

apraclonidine hcl soln 1 MO; *

brimonidine tartrate soln 2 MO; *

IOPIDINE SOLN 0.5 %(Apraclonidine HCl) NF MO

IOPIDINE SOLN 1 % 4 MO

SIMBRINZA SUSP 4 MO

Ophthalmic Anti-infectivesAZASITE SOLN 4 MO

bacitracin-polymyxin b(ophth) oint 1 MO; *

BESIVANCE SUSP 4 MO

BLEPH-10 SOLN(Sulfacetamide Sodium(Ophth))

NFMO

CILOXAN OINT 4 MO

CILOXAN SOLN(Ciprofloxacin HCl (Ophth)) NF MO

ciprofloxacin hcl (ophth)soln 2 MO; *

erythromycin (ophth) oint 2 MO; *

gatifloxacin (ophth) soln 2 MO; *

gentamicin sulfate (ophth)oint 2 MO; *

gentamicin sulfate (ophth)soln 2 MO; *



80

Drug Name DrugTier

Requirements/Limits

levofloxacin (ophth) soln 1 MO; *

MOXEZA SOLN 3 MO

NATACYN SUSP 3 MO

neomycin-bacitracin zn-polymyxin oint 1 MO; *

neomycin-polymyxin-gramicidin soln 1 MO; *

OCUFLOX SOLN(Ofloxacin (Ophth)) NF MO

ofloxacin (ophth) soln 2 MO; *

polymyxin b-trimethoprimsoln 2 MO; *

POLYTRIM SOLN(Polymyxin B-Trimethoprim)

NFMO

sulfacetamide sodium(ophth) soln 2 MO; *

tobramycin (ophth) soln 2 MO; *

TOBREX OINT 4 MO

TOBREX SOLN(Tobramycin (Ophth)) NF MO

trifluridine soln op 3 MO

VIGAMOX SOLN 3 MO

VIROPTIC SOLN(Trifluridine) NF MO

ZIRGAN GEL 4 MO

ZYMAXID SOLN(Gatifloxacin (Ophth)) NF MO

Ophthalmic Decongestantsnaphazoline hcl soln op 1 MO; *

Ophthalmic ImmunomodulatorsRESTASIS EMUL 3 MO

RESTASIS MULTIDOSEEMUL 3 MO

Ophthalmic Local Anesthetics

Drug Name DrugTier

Requirements/Limits

proparacaine hcl soln op 1 MO; *

Ophthalmic SteroidsALREX SUSP 4 MO

bacitracin-poly-neomycin-hc oint 1 MO; *

BLEPHAMIDE SUSP 4 MO

dexamethasone sodiumphosphate (ophth) soln 1 MO; *

DUREZOL EMUL 3 MO

FLAREX SUSP 3 MO

fluorometholone (ophth)susp 2 MO; *

FML FORTE SUSP 3 MO

FML LIQUIFILM SUSP(Fluorometholone (Ophth)) NF MO

FML OINT 3 MO

LOTEMAX GEL 4 MO

LOTEMAX OINT 4 MO

LOTEMAX SUSP 4 MO

MAXIDEX SUSP 4 MO

MAXITROL OINT(Neomycin-Polymy-Dexameth)

NFMO

MAXITROL SUSP(Neomycin-Polymy-Dexameth)

NFMO

neomycin-polymy-dexameth oint 2 MO; *

neomycin-polymy-dexameth susp 2 MO; *

neomycin-polymyxin-hc(ophth) susp 2 MO; *

OMNIPRED SUSP(Prednisolone Acetate(Ophth))

NFMO



81

Drug Name DrugTier

Requirements/Limits

PRED FORTE SUSP(Prednisolone Acetate(Ophth))

NFMO

PRED MILD SUSP 3 MO

prednisolone acetate(ophth) susp 2 MO; *

prednisolone sodiumphosphate (ophth) soln 2 MO; *

sulfacetamide sod-prednisolone oint 10%-0.2%

2MO; *

sulfacetamide sod-prednisolone soln 10%-0.23%

1MO; *

TOBRADEX OINT 4 MO

TOBRADEX ST SUSP 4 MO

TOBRADEX SUSP(Tobramycin-Dexamethasone)

NFMO

tobramycin-dexamethasone susp 2 MO; *

VEXOL SUSP 4

ZYLET SUSP 3 MO

Ophthalmics - Misc.ACULAR LS SOLN(Ketorolac Tromethamine(Ophth))

NFMO

ACULAR SOLN (KetorolacTromethamine (Ophth)) NF MO

ACUVAIL SOLN 4 MO

ALOCRIL SOLN 4 MO

ALOMIDE SOLN 4 MO

azelastine hcl (ophth) soln 2 MO; *

AZOPT SUSP 3 MO

BEPREVE SOLN 4 MO

bromfenac sodium (ophth)soln 1 MO; *

Drug Name DrugTier

Requirements/Limits

bromfenac sodium (ophth)soln 2 Once daily

dosing;MO; *cromolyn sodium (ophth)soln 2 MO; *

CYSTARAN SOLN 4

Limit 60mls per28days;QL(2.15ml daily); LA

diclofenac sodium (ophth)soln 3 MO

dorzolamide hcl soln 2 MO; *

ELESTAT SOLN(Epinastine HCl (Ophth)) NF MO

epinastine hcl (ophth) soln 1 MO; *

flurbiprofen sodium soln 1 MO; *

ILEVRO SUSP 3 MO

ketorolac tromethamine(ophth) soln 2 MO; *

LASTACAFT SOLN 4 MO

NEVANAC SUSP 3 MO

OCUFEN SOLN(Flurbiprofen Sodium) NF MO

olopatadine hcl soln 2 MO; *

OPTIVAR SOLN(Azelastine HCl (Ophth)) NF MO

PATADAY SOLN 3 MO

PATANOL SOLN(Olopatadine HCl) 4 MO

PROLENSA SOLN 4 MO

TRUSOPT SOLN(Dorzolamide HCl) NF MO

Prostaglandins - OphthalmicBIMATOPROST SOLN 3 MO

latanoprost soln 2 MO; *

LUMIGAN SOLN 3 MO



82

Drug Name DrugTier

Requirements/Limits

TRAVATAN Z SOLN 3 MO

XALATAN SOLN(Latanoprost) NF MO

ZIOPTAN SOLN 4 MO

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneousacetic acid (otic) soln 1 MO; *

acetic acid-aluminumacetate soln 1 MO; *

Otic Anti-infectivesFLOXIN OTIC SOLN(Ofloxacin (Otic)) NF MO

ofloxacin (otic) soln 2 MO; *

Otic CombinationsCIPRO HC SUSP 4 MO

CIPRODEX SUSP 3 MO

COLY-MYCIN S SUSP 4 MO

CORTISPORIN-TC SUSP 4 MO

neomycin-polymyxin-hc(otic) soln 2 MO; *

neomycin-polymyxin-hc(otic) susp 2 MO; *

Otic SteroidsDERMOTIC OIL(Fluocinolone Acetonide(Otic))

NFMO

fluocinolone acetonide(otic) oil 2 MO; *

hydrocortisone w/aceticacid soln 3 MO

OXYTOCICS - Drugs to Prevent/Control UterineBleedingOxytocicsmethylergonovine maleatetabs or 0.2 mg 3 MO

Drug Name DrugTier

Requirements/Limits

PASSIVE IMMUNIZING AGENTS - AntibodyDrugs to Treat Low Immune SystemImmune SerumsBIVIGAM SOLN 5 B/D

CUVITRU SOLN 1GM/5ML 4 B/D

CUVITRU SOLN 2GM/10ML, 4 GM/20ML, 8GM/40ML

5B/D

FLEBOGAMMA DIF SOLN10 % 5 B/D

GAMASTAN S/D INJ 4 B/D

GAMMAGARD LIQUIDSOLN 5 B/D

GAMMAKED SOLN 5 B/D

GAMUNEX-C SOLN 5 B/D

HIZENTRA SOLN 1GM/5ML 4 B/D

HIZENTRA SOLN 10GM/50ML, 2 GM/10ML, 4GM/20ML

5B/D

OCTAGAM SOLN 10GM/100ML, 2 GM/20ML,20 GM/200ML, 5 GM/50ML

5B/D

PRIVIGEN SOLN 5 B/D

VARIZIG SOLN 125UNIT/1.2ML 5

Monoclonal AntibodiesSYNAGIS SOLN 5

Passive Immunizing Agents - CombinationsHYQVIA KIT 5 B/D

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillinsamoxicillin caps 250 mg,500 mg 1 MO; *

amoxicillin susr 125mg/5ml, 200 mg/5ml, 250mg/5ml, 400 mg/5ml

2MO; *



83

Drug Name DrugTier

Requirements/Limits

amoxicillin tabs 500 mg,875 mg 2 MO; *

ampicillin caps 250 mg,500 mg 2 MO; *

ampicillin sodium solr ij 1gm 2 MO; *

ampicillin sodium solr ij 2gm 1 MO; *

ampicillin sodium solr iv 10gm 2 *

Natural PenicillinsBICILLIN L-A SUSP1200000 UNIT/2ML,2400000 UNIT/4ML

4MO

penicillin g potassium solr20 mu, 20000000 unit 1 MO; *

penicillin g potassium solr5000000 unit 4 MO

penicillin v potassium solr250 mg/5ml 2 MO; *

penicillin v potassium tabs250 mg, 500 mg 2 MO; *

Penicillin Combinationsamoxicillin & potclavulanate chew 200mg-28.5mg, 400mg-57mg

2MO; *

amoxicillin & potclavulanate susr200mg/5ml-28.5mg/5ml,250mg/5ml-62.5mg/5ml,400mg/5ml-57mg/5ml,600mg/5ml-42.9mg/5ml

2

MO; *

amoxicillin & potclavulanate tabs 250mg-125mg, 500mg-125mg,875mg-125mg

2

MO; *

amoxicillin & potclavulanate tb12 1000mg-62.5mg

2*

ampicillin & sulbactamsodium solr ij 1gm-2gm 1 MO; *

ampicillin & sulbactamsodium solr iv 5gm-10gm 2 *

AUGMENTIN ES-600SUSR (Amoxicillin & PotClavulanate)

NFMO

Drug Name DrugTier

Requirements/Limits

AUGMENTIN SUSR250MG/5ML-62.5MG/5ML(Amoxicillin & PotClavulanate)

NF

MO

AUGMENTIN TABS500MG-125MG, 875MG-125MG (Amoxicillin & PotClavulanate)

NF

MO

AUGMENTIN XR TB12(Amoxicillin & PotClavulanate)

NF

piperacillin sodium-tazobactam sodium solr0.25gm-2gm, 0.375gm-3gm, 4.5gm-36gm

3

piperacillin sodium-tazobactam sodium solr0.5gm-4gm

1*

UNASYN SOLR 1GM-2GM(Ampicillin & SulbactamSodium)

NFMO

ZOSYN SOLN0.375GM/50ML-3GM/50ML-5%

4

ZOSYN SOLR 0.25GM-2GM, 0.375GM-3GM,0.5GM-4GM, 4.5GM-36GM(Piperacillin Sodium-Tazobactam Sodium)

NF

Penicillinase-Resistant Penicillinsdicloxacillin sodium caps 2 MO; *

nafcillin sodium solr ij 10gm 5

nafcillin sodium solr ij 2 gm 5 MO

PROGESTINS - Hormone Replacement/ModifyingDrugsProgestinsmedroxyprogesteroneacetate tabs or 10 mg, 2.5mg, 5 mg

1MO; *

MEGACE ES SUSP(Megestrol Acetate(Appetite))

5AL; MO

megestrol acetate(appetite) susp 5 AL; MO



84

Drug Name DrugTier

Requirements/Limits

norethindrone acetate tabsor 1 MO; *

progesterone micronizedcaps or 100 mg, 200 mg 2 MO; *

PROMETRIUM CAPS(Progesterone Micronized) NF MO

PROVERA TABS(MedroxyprogesteroneAcetate)

NFMO

PSYCHOTHERAPEUTIC AND NEUROLOGICALAGENTS - MISC. - Drugs to Treat Mental andEmotional ConditionsAgents for Chemical Dependencyacamprosate calcium tbec 3 MO

CAMPRAL TBEC(Acamprosate Calcium) NF MO

disulfiram tabs or 250 mg,500 mg 3 MO

Anti-Cataplectic AgentsXYREM SOLN 5 LA

Antidementia AgentsARICEPT ODT TBDP(Donepezil Hydrochloride) NF MO

ARICEPT TABS (DonepezilHydrochloride) NF MO

donepezil hydrochloridetabs 2 MO; *

donepezil hydrochloridetbdp 2 MO; *

EXELON CAPS OR 1.5MG, 3 MG, 4.5 MG, 6 MG(Rivastigmine Tartrate)

NFMO

EXELON PT24 TD 13.3MG/24HR, 4.6 MG/24HR,9.5 MG/24HR(Rivastigmine)

3

MO

galantamine hydrobromidecp24 16 mg, 24 mg, 8 mg 3 MO

galantamine hydrobromidesoln 4 mg/ml 2 MO; *

galantamine hydrobromidetabs 12 mg, 4 mg, 8 mg 3 MO

Drug Name DrugTier

Requirements/Limits

memantine hcl soln 2mg/ml 2 AL; MO; *

memantine hcl tabs 10 mg,5 mg 2 MO; *

NAMENDA SOLN 10MG/5ML (Memantine HCl) 4 AL; MO

NAMENDA TABS 10 MG, 5MG (Memantine HCl) 4 MO

NAMENDA TITRATIONPAK TABS (MemantineHCl)

4MO

NAMENDA XR CP24 14MG 4 AL; SL(2 ea

daily); MONAMENDA XR CP24 21MG 4 AL; SL(1.33 ea

daily); MONAMENDA XR CP24 28MG 4 AL; SL(1 ea

daily); MO

NAMENDA XR CP24 7 MG 4 AL; SL(4 eadaily); MO

NAMENDA XR TITRATIONPACK CP24 4 AL; MO

RAZADYNE ER CP24(GalantamineHydrobromide)

NFMO

RAZADYNE SOLN(GalantamineHydrobromide)

NFMO

RAZADYNE TABS(GalantamineHydrobromide)

NFMO

rivastigmine pt24 2 MO; *

rivastigmine tartrate caps 3 MO

Combination Psychotherapeuticschlordiazepoxide-amitriptyline tabs 2 AL; MO; *

olanzapine-fluoxetine hclcaps 4 MO

perphenazine-amitriptylinetabs 2 AL; MO; *

SYMBYAX CAPS(Olanzapine-FluoxetineHCl)

NFMO

Fibromyalgia Agents



85

Drug Name DrugTier

Requirements/Limits

SAVELLA TABS 4 PA; MO

SAVELLA TITRATIONPACK MISC 4 PA; MO

Movement Disorder Drug Therapytetrabenazine tabs 5

XENAZINE TABS(Tetrabenazine) 5 LA

Multiple Sclerosis AgentsAMPYRA TB12 5

AUBAGIO TABS 5 PA

AVONEX KIT 5 PA

AVONEX PEN AJKT 5 PA

AVONEX PSKT 5 PA

BETASERON KIT 5 PA

COPAXONE SOSY 20MG/ML (GlatiramerAcetate)

5PA

COPAXONE SOSY 40MG/ML 5 PA

EXTAVIA KIT 5 PA

GILENYA CAPS 5 PA

glatiramer acetate sosy 5 PA

LEMTRADA SOLN 5 PA; LA

PLEGRIDY SOPN 5 PA

PLEGRIDY SOSY 5 PA

PLEGRIDY STARTERPACK SOPN 5 PA

PLEGRIDY STARTERPACK SOSY 5 PA

REBIF REBIDOSE SOAJ 5 PA

REBIF REBIDOSETITRATIONPACK SOAJ 5 PA

Drug Name DrugTier

Requirements/Limits

REBIF SOSY 5 PA

REBIF TITRATION PACKSOSY 5 PA

TECFIDERA CPDR 5 PA

TECFIDERA STARTERPACK MISC 5 PA

TYSABRI CONC 5 PA

Postherpetic Neuralgia (PHN) AgentsGRALISE STARTER MISC 4 MO

GRALISE TABS 4 MO

Premenstrual Dysphoric Disorder (PMDD) Agentsfluoxetine hcl (pmdd) cap10 mg, 20 mg NF

Pseudobulbar Affect (PBA) AgentsNUEDEXTA CAPS 3 MO

Psychotherapeutic and Neurological Agents -ergoloid mesylates tabs or 2 AL; MO; *

ORAP TABS (Pimozide) 4 MO

pimozide tabs 2 MO; *

Restless Leg Syndrome (RLS) AgentsHORIZANT TBCR 4 MO

Smoking Deterrentsbupropion hcl (smokingdeterrent) tb12 1 SL(2 ea daily);

MO; *CHANTIX CONTINUINGMONTHPAK TABS 4 PA; MO

CHANTIX STARTINGMONTH PAK TABS 4 PA; MO

CHANTIX TABS 4 PA; MO

NICOTROL INHALERINHA 4 SL(17 ea daily);

MO

NICOTROL NS SOLN 4 MO

ZYBAN TB12 (BupropionHCl (Smoking Deterrent)) NF SL(2 ea daily);

MO



86

Drug Name DrugTier

Requirements/Limits

Vasomotor Symptom AgentsBRISDELLE CAPS 4 MO

RESPIRATORY AGENTS - MISC. - Drugs toTreat Lung ConditionsAlpha-Proteinase Inhibitor (Human)ARALAST NP SOLR 1000MG 5 LA

GLASSIA SOLN 4 LA

PROLASTIN-C SOLR 5 LA

ZEMAIRA SOLR 5 LA

Cystic Fibrosis AgentsKALYDECO PACK 5 PA

KALYDECO TABS 5 PA

ORKAMBI TABS 5 PA; LA

PULMOZYME SOLN 5 B/D

Pulmonary Fibrosis AgentsESBRIET CAPS 5 PA; LA

OFEV CAPS 5 PA; LA

SULFONAMIDES - Drugs to Treat BacterialInfectionsSulfonamidessulfadiazine tabs or 2 MO; *

TETRACYCLINES - Drugs to Treat BacterialInfectionsTetracyclinesADOXA PAK 1/100 TABS(Doxycycline(Monohydrate))

NFMO

ADOXA PAK 1/150 TABS(Doxycycline(Monohydrate))

NFMO

ADOXA PAK 2/100 TABS(Doxycycline(Monohydrate))

NFMO

Drug Name DrugTier

Requirements/Limits

ADOXA TABS 100 MG, 50MG, 75 MG (Doxycycline(Monohydrate))

NFMO

demeclocycline hcl tabs 1 MO; *

doxycycline (monohydrate)caps 100 mg, 50 mg, 75mg

2MO; *

doxycycline (monohydrate)susr 25 mg/5ml 2 MO; *

doxycycline (monohydrate)tabs 100 mg, 150 mg, 50mg, 75 mg

2MO; *

doxycycline hyclate caps or100 mg, 50 mg 2 MO; *

doxycycline hyclate solr iv100 mg 2 MO; *

doxycycline hyclate tabs or100 mg, 20 mg 2 MO; *

doxycycline hyclate tbec or100 mg, 150 mg 3 MO

doxycycline hyclate tbec or200 mg 2 MO; *

MINOCIN CAPS OR 100MG, 50 MG, 75 MG(Minocycline HCl)

NFMO

minocycline hcl caps or 100mg, 50 mg, 75 mg 2 MO; *

minocycline hcl tabs or 100mg, 50 mg 3 MO

MONODOX CAPS(Doxycycline(Monohydrate))

NFMO

tetracycline hcl caps or 250mg, 500 mg 1 MO; *

VIBRAMYCIN CAPS 100MG (Doxycycline Hyclate) NF MO

VIBRAMYCIN SUSR 25MG/5ML (Doxycycline(Monohydrate))

4MO

VIBRAMYCIN SYRP 50MG/5ML 4 MO

THYROID AGENTS - Drugs to Regulate ThyroidHormonesAntithyroid Agents



87

Drug Name DrugTier

Requirements/Limits

methimazole tabs or 10mg, 5 mg 2 MO; *

propylthiouracil tabs or 2 MO; *

Thyroid HormonesCYTOMEL TABS(Liothyronine Sodium) NF MO

levothyroxine sodium tabsor 100 mcg, 112 mcg, 125mcg, 137 mcg, 150 mcg,175 mcg, 200 mcg, 25mcg, 300 mcg, 50 mcg, 75mcg, 88 mcg

2

MO; *

liothyronine sodium tabs or25 mcg, 5 mcg, 50 mcg 2 MO; *

SYNTHROID TABS(Levothyroxine Sodium) 4 MO

TOXOIDS

Toxoid CombinationsADACEL SUSP 4

BOOSTRIX SUSP 4

DAPTACEL SUSP 4

DIPHTHERIA/TETANUSTOXOIDS ADSORBEDPEDIATRIC SUSP

4

INFANRIX SUSP 4

TENIVAC INJ 4 B/D

TETANUS/DIPHTHERIATOXOIDS-ADSORBEDADULT SUSP

4B/D

TETANUS/DIPHTHERIATOXOIDS-ADSORBEDSUSP

4B/D

ULCER DRUGS - Drugs to Treat Bowel, Intestineand Stomach ConditionsAntispasmodicsBENTYL CAPS OR 10 MG(Dicyclomine HCl) NF MO

BENTYL TABS OR 20 MG(Dicyclomine HCl) NF MO

Drug Name DrugTier

Requirements/Limits

CANTIL TABS 4

dicyclomine hcl caps or 10mg 2 MO; *

dicyclomine hcl tabs or 20mg 2 MO; *

glycopyrrolate soln ij 0.2mg/ml 2 MO; *

glycopyrrolate tabs or 1 mg 1 SL(8 ea daily);MO; *

glycopyrrolate tabs or 2 mg 1 SL(4 ea daily);MO; *

methscopolamine bromidetabs or 2.5 mg, 5 mg 1 MO; *

PAMINE FORTE TABS(MethscopolamineBromide)

NFMO

PAMINE TABS(MethscopolamineBromide)

NFMO

propantheline bromide tabsor 2 MO; *

ROBINUL FORTE TABS(Glycopyrrolate) NF SL(4 ea daily);

MOROBINUL SOLN IJ 0.2MG/ML (Glycopyrrolate) NF MO

ROBINUL TABS OR 1 MG(Glycopyrrolate) NF SL(8 ea daily);

MOH-2 Antagonistscimetidine tabs or 200 mg 1 RX/OTC; MO; *

cimetidine tabs or 300 mg,400 mg, 800 mg 1 MO; *

famotidine soln iv 20mg/2ml, 200 mg/20ml, 40mg/4ml

1*

famotidine susr or 40mg/5ml 3 MO

famotidine tabs or 20 mg 1 RX/OTC; MO; *

famotidine tabs or 40 mg 1 MO; *

nizatidine caps 150 mg,300 mg 1 MO; *

PEPCID SUSR(Famotidine) NF MO



88

Drug Name DrugTier

Requirements/Limits

ranitidine hcl caps or 150mg, 300 mg 2 MO; *

ranitidine hcl syrp or 15mg/ml, 150 mg/10ml, 75mg/5ml

3MO

ranitidine hcl tabs or 150mg 1 RX/OTC; MO; *

ranitidine hcl tabs or 300mg 1 MO; *

ZANTAC TABS OR 150MG (Ranitidine HCl) NF RX/OTC; MO

ZANTAC TABS OR 300MG (Ranitidine HCl) NF MO

Misc. Anti-UlcerCARAFATE SUSP 1GM/10ML 4 MO

CARAFATE TABS 1 GM(Sucralfate) NF MO

sucralfate tabs or 2 MO; *

Proton Pump InhibitorsDEXILANT CPDR 3 ST; MO

esomeprazole magnesiumcpdr 20 mg 2 ST; RX/OTC;

MO; *esomeprazole magnesiumcpdr 40 mg 2 ST; MO; *

esomeprazole sodium solr40 mg 2 *

ESOMEPRAZOLESTRONTIUM CPDR 49.3MG

4ST

lansoprazole cpdr or 15 mg 4 RX/OTC; MO

lansoprazole cpdr or 30 mg 4 MO

NEXIUM CPDR 20 MG(EsomeprazoleMagnesium)

4ST; RX/OTC;MO

NEXIUM CPDR 40 MG(EsomeprazoleMagnesium)

4ST; MO

NEXIUM I.V. SOLR(Esomeprazole Sodium) NF

NEXIUM PACK 10 MG, 2.5MG, 20 MG, 40 MG, 5 MG 4 ST; MO

Drug Name DrugTier

Requirements/Limits

omeprazole cpdr or 10 mg,20 mg, 40 mg 2 MO; *

pantoprazole sodium solr iv40 mg 2 *

pantoprazole sodium tbecor 20 mg, 40 mg 1 MO; *

PREVACID CPDR 15 MG(Lansoprazole) NF RX/OTC; MO

PREVACID CPDR 30 MG(Lansoprazole) NF MO

PRILOSEC CPDR 10 MG,20 MG, 40 MG(Omeprazole)

NFMO

PROTONIX PACK OR 40MG 4 QL(1 ea daily);

MOPROTONIX SOLR IV 40MG (Pantoprazole Sodium) NF

PROTONIX TBEC OR 20MG, 40 MG (PantoprazoleSodium)

NFMO

Ulcer Drugs - ProstaglandinsCYTOTEC TABS(Misoprostol) NF MO

misoprostol tabs or 100mcg, 200 mcg 2 MO; *

Ulcer Therapy Combinationsamoxicillin-clarithromycinw/ lansoprazole misc 4 MO

omeprazole-sodiumbicarbonate caps 20mg-1100mg

2RX/OTC; MO; *

omeprazole-sodiumbicarbonate caps 40mg-1100mg

4MO

omeprazole-sodiumbicarbonate pack 20mg-1680mg

2ST; MO; *

omeprazole-sodiumbicarbonate pack 40mg-1680mg

2MO; *

PREVPAC MISC(Amoxicillin-Clarithromycinw/ Lansoprazole)

NFMO

PYLERA CAPS 4 MO



89

Drug Name DrugTier

Requirements/Limits

ZEGERID CAPS 20MG-1100MG (Omeprazole-Sodium Bicarbonate)

NFRX/OTC; MO

ZEGERID CAPS 40MG-1100MG (Omeprazole-Sodium Bicarbonate)

NFMO

ZEGERID PACK 20MG-1680MG (Omeprazole-Sodium Bicarbonate)

4ST; MO

ZEGERID PACK 40MG-1680MG (Omeprazole-Sodium Bicarbonate)

4MO

URINARY ANTI-INFECTIVES - Drugs to TreatBladder/Kidney InfectionsUrinary Anti-infectivesFURADANTIN SUSP(Nitrofurantoin) NF AL; MO

HIPREX TABS(Methenamine Hippurate) NF MO

MACROBID CAPS(Nitrofurantoin MonohydMacro)

NFMO

MACRODANTIN CAPS100 MG, 50 MG(NitrofurantoinMacrocrystal)

NF

AL; MO

MACRODANTIN CAPS 25MG (NitrofurantoinMacrocrystal)

4AL; MO

methenamine hippuratetabs 2 MO; *

MONUROL PACK 4 MO

nitrofurantoin macrocrystalcaps or 100 mg, 25 mg, 50mg

2AL; MO; *

nitrofurantoin monohydmacro caps 2 MO; *

nitrofurantoin susp or 4 AL; MO

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder SpasmsUrinary Antispasmodic - Antimuscarinicsdarifenacin hydrobromidetb24 2 MO; *

Drug Name DrugTier

Requirements/Limits

DETROL LA CP24(Tolterodine Tartrate) NF MO

DETROL TABS(Tolterodine Tartrate) NF MO

DITROPAN XL TB24(Oxybutynin Chloride) NF MO

ENABLEX TB24(Darifenacin Hydrobromide) 4 MO

GELNIQUE GEL 10 % 4 MO

GELNIQUE GEL 3 % 4

oxybutynin chloride syrp 5mg/5ml 2 MO; *

oxybutynin chloride tabs 5mg 3 MO

oxybutynin chloride tb24 10mg, 15 mg, 5 mg 3 MO

OXYTROL PTTW 4 RX/OTC; MO

tolterodine tartrate cp24 3 MO

tolterodine tartrate tabs 3 MO

TOVIAZ TB24 3 MO

trospium chloride cp24 60mg 3 MO

trospium chloride tabs 20mg 2 MO; *

VESICARE TABS 3 MO

Urinary Antispasmodics - Beta-3 AdrenergicMYRBETRIQ TB24 4 MO

Urinary Antispasmodics - Cholinergic Agonistsbethanechol chloride tabs10 mg, 25 mg, 5 mg, 50 mg 2 MO; *

Urinary Antispasmodics - Direct Muscle Relaxantsflavoxate hcl tabs 1 MO; *

VACCINES

Bacterial VaccinesACTHIB SOLR 4



90

Drug Name DrugTier

Requirements/Limits

MENACTRA INJ 4

MENOMUNE-A/C/Y/W-135INJ 4

MENVEO SOLR 4

PEDVAX HIB SUSP 4

TYPHIM VI SOLN 4

Mixed Vaccine CombinationsCOMVAX SUSP 4

Viral VaccinesCERVARIX SUSP 4

ENGERIX-B SUSP IJ 10MCG/0.5ML, 20 MCG/ML 4 B/D

GARDASIL 9 SUSP 3

GARDASIL 9 SUSY 3

GARDASIL SUSP 4

HAVRIX SUSP 4

IMOVAX RABIES(H.D.C.V.) INJ 4 B/D

IPOL INACTIVATED IPVINJ 4

IXIARO SUSP 4

M-M-R II INJ 4

PROQUAD INJ 4

RABAVERT SUSR 4 B/D

RECOMBIVAX HB SUSP 4 B/D

ROTARIX SUSR 4

ROTATEQ SOLN 3

TWINRIX SUSP 4

VAQTA SUSP 4

Drug Name DrugTier

Requirements/Limits

VARIVAX INJ 4

YF-VAX INJ 4

ZOSTAVAX SOLR 4

VAGINAL PRODUCTS - Drugs to Treat VaginalInfections and Low HormonesVaginal Anti-infectivesbutoconazole nitrate (onedose) crea 2 MO; *

CLEOCIN CREA VA 2 %(Clindamycin PhosphateVaginal)

NFMO

CLEOCIN SUPP VA 100MG 4 MO

clindamycin phosphatevaginal crea 1 MO; *

METROGEL-VAGINALGEL (MetronidazoleVaginal)

NFMO

metronidazole vaginal gel 2 MO; *

miconazole nitrate vaginalsupp 200 mg 2 MO; *

TERAZOL 3 CREA(Terconazole Vaginal) NF MO

TERAZOL 7 CREA(Terconazole Vaginal) NF MO

terconazole vaginal crea 2 MO; *

terconazole vaginal supp 2 MO; *

Vaginal Estrogensestradiol vaginal tabs 2 MO; *

ESTRING RING 4 MO

FEMRING RING 4 MO

PREMARIN CREA VA0.625 MG/GM 3 MO

VAGIFEM TABS (EstradiolVaginal) 4 MO

Vaginal Progestins



91

Drug Name DrugTier

Requirements/Limits

CRINONE GEL 4 MO

ENDOMETRIN INST 4 MO

VASOPRESSORS - Drugs to Treat Heart andCirculation ConditionsAnaphylaxis Therapy AgentsADRENACLICK SOAJ 3 MO

AUVI-Q SOAJ 3 MO

EPINEPHRINE SOAJ IJ0.15 MG/0.15ML, 0.3MG/0.3ML

3MO

EPIPEN 2-PAK SOAJ 3 MO

EPIPEN-JR 2-PAK SOAJ 3 MO

Neurogenic Orthostatic Hypotension (NOH) -NORTHERA CAPS 100MG 5 PA; SL(18 ea

daily)NORTHERA CAPS 200MG 5 PA; SL(9 ea

daily)NORTHERA CAPS 300MG 5 PA; SL(6 ea

daily)Vasopressorsdobutamine hcl soln 1 *

dopamine hcl soln 80mg/ml 2 *

midodrine hcl tabs 3 MO



92

Indexabacavir sulfate 45abacavir sulfate-lamivudine 45abacavir sulfate-lamivudine-zidovudine 45ABELCET 28ABILIFY 1 MG/ML 45ABILIFY 10 MG 45ABILIFY 15 MG 45ABILIFY 2 MG 45ABILIFY 20 MG 45ABILIFY 30 MG 45ABILIFY 5 MG 45ABILIFY 9.75 MG/1.3ML 45ABILIFY DISCMELT 10 MG 45ABILIFY DISCMELT 15 MG 45ABILIFY MAINTENA 45ABRAXANE 41ABSORICA 30 MG 57ABSTRAL 100 MCG 4ABSTRAL 200 MCG 4ABSTRAL 300 MCG, 400 MCG,600 MCG, 800 MCG 4acamprosate calcium 85ACANYA 57acarbose 23ACCOLATE 14ACCUPRIL 32ACCURETIC 33acebutolol hcl 200 mg, 400mg 50ACEON 4 MG 32ACEON 8 MG 32acetaminophen w/ codeine120mg/5ml-12mg/5ml 7acetaminophen w/ codeine300mg-15mg 7acetaminophen w/ codeine300mg-30mg, 300mg-60mg 8acetazolamide 125 mg 64acetazolamide 250 mg 64acetazolamide 500 mg 64acetic acid 71acetic acid (otic) 83acetic acid-aluminumacetate 83acetylcysteine 10 %, 20 % 57acitretin 59ACTEMRA 3ACTHIB 90

ACTIGALL 69ACTIMMUNE 40ACTIQ 1200 MCG, 1600 MCG,400 MCG, 600 MCG, 800MCG 4ACTIQ 200 MCG 4ACTIVELLA 68ACTONEL 150 MG 65ACTONEL 30 MG, 5 MG 65ACTONEL 35 MG 65ACTOPLUS MET 23ACTOPLUS MET XR 15MG-1000MG 23ACTOPLUS MET XR 30MG-1000MG 23ACTOS 15 MG 25ACTOS 30 MG 25ACTOS 45 MG 25ACULAR 82ACULAR LS 82ACUVAIL 82acyclovir 200 mg 48acyclovir 200 mg/5ml 48acyclovir 400 mg, 800 mg 48acyclovir sodium 50 mg/ml 48acyclovir sodium 500 mg 48acyclovir topical 60ADACEL 88ADAGEN 51ADALAT CC 51adapalene 0.1 % 57adapalene 0.3 % 57ADCIRCA 52ADDERALL XR 1adefovir dipivoxil 47ADEMPAS 0.5 MG 53ADEMPAS 1 MG 53ADEMPAS 1.5 MG 53ADEMPAS 2 MG 53ADEMPAS 2.5 MG 53ADOXA 100 MG, 50 MG, 75MG 87ADOXA PAK 1/100 87ADOXA PAK 1/150 87ADOXA PAK 2/100 87ADRENACLICK 92ADVAIR DISKUS 15ADVAIR HFA 15

AEROSPAN 14AFINITOR 39AFINITOR DISPERZ 39AFREZZA 25AGGRENOX 72AGRYLIN 72AKYNZEO 28ALBENZA 10albuterol sulfate 0.083 %, 0.5 %,0.63 mg/3ml, 1.25 mg/3ml 15albuterol sulfate 2 mg, 4 mg 15albuterol sulfate 2 mg/5ml 15albuterol sulfate 4 mg, 8 mg 15alclometasone dipropionate 60ALCOHOL PADS 75ALDACTAZIDE 25MG-25MG 64ALDACTAZIDE 50MG-50MG 64ALDACTONE 65ALDARA 63ALECENSA 39alendronate sodium 10 mg, 5mg 65alendronate sodium 35 mg, 70mg 65alfuzosin hcl 71ALIMTA 100 MG 36ALIMTA 500 MG 36ALINIA 500 MG 10ALKERAN 2 MG 36ALKERAN 50 MG 36allopurinol 100 mg 71allopurinol 300 mg 71almotriptan malate 76ALOCRIL 82ALOGLIPTIN 25ALOGLIPTIN/METFORMINHCL 23ALOGLIPTIN/PIOGLITAZONE12.5MG-15MG 23ALOGLIPTIN/PIOGLITAZONE12.5MG-30MG 23ALOGLIPTIN/PIOGLITAZONE12.5MG-45MG, 25MG-15MG,25MG-30MG, 25MG-45MG 23ALOMIDE 82alosetron hcl 70ALPHAGAN P 0.1 % 80ALPHAGAN P 0.15 % 80

Index 1

alprazolam 0.25 mg, 0.5 mg, 1mg, 2 mg 12alprazolam 0.5 mg, 1 mg, 2 mg, 3mg 12ALREX 81ALTABAX 58ALTACE 32ALTOPREV 31ALVESCO 160 MCG/ACT 14ALVESCO 80 MCG/ACT 14amantadine hcl 100 mg 41amantadine hcl 50 mg/5ml 41AMARYL 1 MG 26AMARYL 2 MG 26AMARYL 4 MG 26AMBIEN 10 MG 73AMBIEN 5 MG 73AMBIEN CR 12.5 MG 73AMBIEN CR 6.25 MG 73AMBISOME 28amcinonide 60AMERGE 76AMICAR 0.25 GM/ML 73AMICAR 1000 MG 73AMICAR 500 MG 73amifostine crystalline 40amikacin sulfate 1 gm/4ml, 500mg/2ml 2amiloride &hydrochlorothiazide 64amiloride hcl 65amino acid infusion 15% 79AMINOCAPROIC ACID 1000MG 73aminocaproic acid 500 mg 73aminophylline 16aminosalicylic acid 35AMINOSYN II 15% (Use aminoacid infusion) 79amiodarone hcl 100 mg, 200 mg,400 mg 13amiodarone hcl 900mg/18ml 13AMITIZA 69amitriptyline hcl 22amlodipine besylate 10 mg 51amlodipine besylate 2.5 mg 51amlodipine besylate 5 mg 51amlodipine besylate-atorvastatincalcium 52

amlodipine besylate-benazeprilhcl 33amlodipine besylate-olmesartanmedoxomil 33amlodipine besylate-valsartan 33amlodipine-valsartan-hydrochlorothiazide 33ammonium chloride 77amoxapine 100 mg, 25 mg, 50mg 22amoxapine 150 mg 22amoxicillin & pot clavulanate1000mg-62.5mg 84amoxicillin & pot clavulanate200mg-28.5mg, 400mg-57mg 84amoxicillin & pot clavulanate200mg/5ml-28.5mg/5ml,250mg/5ml-62.5mg/5ml,400mg/5ml-57mg/5ml,600mg/5ml-42.9mg/5ml 84amoxicillin & pot clavulanate250mg-125mg, 500mg-125mg,875mg-125mg 84amoxicillin 125 mg/5ml, 200mg/5ml, 250 mg/5ml, 400mg/5ml 83amoxicillin 250 mg, 500mg 83amoxicillin 500 mg, 875mg 84amoxicillin-clarithromycin w/lansoprazole 89amphetamine-dextroamphetamine 1.25mg-1.25mg-1.25mg-1.25mg,1.875mg-1.875mg-1.875mg-1.875mg, 2.5mg-2.5mg-2.5mg-2.5mg, 3.125mg-3.125mg-3.125mg-3.125mg, 3.75mg-3.75mg-3.75mg-3.75mg, 5mg-5mg-5mg-5mg, 7.5mg-7.5mg-7.5mg-7.5mg 1amphetamine-dextroamphetamine 1.25mg-1.25mg-1.25mg-1.25mg,2.5mg-2.5mg-2.5mg-2.5mg,3.75mg-3.75mg-3.75mg-3.75mg, 5mg-5mg-5mg-5mg,6.25mg-6.25mg-6.25mg-6.25mg, 7.5mg-7.5mg-7.5mg-7.5mg 1amphotericin b 50 mg 28ampicillin & sulbactam sodium1gm-2gm 84ampicillin & sulbactam sodium5gm-10gm 84

ampicillin 250 mg, 500 mg 84ampicillin sodium 1 gm 84ampicillin sodium 10 gm 84ampicillin sodium 2 gm 84AMPYRA 86ANADROL-50 9ANAFRANIL 22anagrelide hcl 72ANAPROX DS 3anastrozole 38ANCOBON 500 MG 28ANDRODERM 9ANDROGEL 20.25 MG/1.25GM,40.5 MG/2.5GM 9ANDROGEL 25 MG/2.5GM, 50MG/5GM 9ANDROGEL PUMP 1.62 % 9ANGELIQ 0.5MG-1MG 68ANORO ELLIPTA 15ANTARA 30 MG 30ANTARA 90 MG 30APIDRA 25APIDRA SOLOSTAR 25APLENZIN 174 MG 20APLENZIN 348 MG 20APLENZIN 522 MG 20APOKYN 41apraclonidine hcl 80APRISO 70APTIOM 200 MG 17APTIOM 400 MG, 600 MG, 800MG 17APTIVUS 100 MG/ML 45APTIVUS 250 MG 45ARALAST NP 1000 MG 87ARALEN 35ARANESP ALBUMIN FREE 10MCG/0.4ML, 25 MCG/ML, 40MCG/ML, 60 MCG/ML 72ARANESP ALBUMIN FREE 100MCG/0.5ML, 150 MCG/0.3ML,200 MCG/0.4ML, 300MCG/0.6ML, 500 MCG/ML 72ARANESP ALBUMIN FREE 100MCG/ML, 150 MCG/0.75ML, 200MCG/ML, 300 MCG/ML 72ARANESP ALBUMIN FREE 25MCG/0.42ML, 40 MCG/0.4ML, 60MCG/0.3ML 72ARAVA 4

Index 2

ARCALYST 3ARCAPTA NEOHALER 15argatroban 250 mg/2.5ml 17ARICEPT 85ARICEPT ODT 85ARIMIDEX 38aripiprazole 1 mg/ml 45aripiprazole 10 mg 45aripiprazole 15 mg 45aripiprazole 2 mg 45aripiprazole 20 mg 45aripiprazole 30 mg 45aripiprazole 5 mg 45ARISTADA 45ARIXTRA 10 MG/0.8ML, 5MG/0.4ML, 7.5 MG/0.6ML 16ARIXTRA 2.5 MG/0.5ML 16armodafinil 150 mg, 200 mg, 250mg, 50 mg 1ARNUITY ELLIPTA 14AROMASIN 38ARRANON 36ARTHROTEC 50 3ARTHROTEC 75 3ARZERRA 37ASACOL HD 70ASMANEX HFA 100MCG/ACT 14ASMANEX HFA 200MCG/ACT 14ASMANEX TWISTHALER 120METERED DOSES 14ASMANEX TWISTHALER 14METERED DOSES 14ASMANEX TWISTHALER 30METERED DOSES 110MCG/INH 14ASMANEX TWISTHALER 30METERED DOSES 220MCG/INH 14ASMANEX TWISTHALER 60METERED DOSES 15ASMANEX TWISTHALER 7METERED DOSES 15ASPIRIN/DIPYRIDAMOLE 72ASTAGRAF XL 49ASTEPRO 79ATACAND 32ATACAND HCT 33ATELVIA 65atenolol & chlorthalidone 33

atenolol 100 mg, 25 mg, 50mg 50ATGAM 49ATIVAN 0.5 MG, 1 MG, 2MG 12ATIVAN 2 MG/ML 12ATIVAN 4 MG/ML 12atorvastatin calcium 31atovaquone 10atovaquone-proguanil hcl250mg-100mg 35atovaquone-proguanil hcl62.5mg-25mg 35ATRALIN 57ATRIPLA 45ATROVENT 79ATROVENT HFA 14AUBAGIO 86AUGMENTIN 250MG/5ML-62.5MG/5ML 84AUGMENTIN 500MG-125MG,875MG-125MG 84AUGMENTIN ES-600 84AUGMENTIN XR 84AURYXIA 70AUVI-Q 92AVALIDE 33AVANDIA 2 MG 25AVANDIA 4 MG 25AVAPRO 32AVASTIN 37AVEED 9AVELOX 400 MG 69AVELOX ABC PACK 69AVODART 71AVONEX 86AVONEX PEN 86AXERT 76AXIRON 9azacitidine 36AZACTAM 10AZASITE 80AZATHIOPRINE 100 MG 49azathioprine 100 mg, 50 mg, 75mg 49azelastine hcl 79azelastine hcl (ophth) 82AZELEX 57AZILECT 42

azithromycin 100 mg/5ml, 200mg/5ml 75azithromycin 250 mg, 500 mg,600 mg 75azithromycin 500 mg 75AZOPT 82AZOR 33aztreonam 10AZULFIDINE 70AZULFIDINE EN-TABS 70bacitracin-poly-neomycin-hc 81bacitracin-polymyxin b(ophth) 80baclofen 10 mg 78baclofen 20 mg 78BACTRIM 10BACTRIM DS 10BACTROBAN 58BACTROBAN NASAL 79balsalazide disodium 70BANZEL 200 MG 17BANZEL 40 MG/ML 17BANZEL 400 MG 17BARACLUDE 0.05 MG/ML 47BARACLUDE 0.5 MG, 1 MG 47BECONASE AQ 79BELEODAQ 39BELSOMRA 10 MG 74BELSOMRA 15 MG 74BELSOMRA 20 MG 74BELSOMRA 5 MG 74benazepril &hydrochlorothiazide 33benazepril hcl 10 mg, 20 mg, 40mg, 5 mg 32BENDEKA 36BENICAR 32BENICAR HCT 33BENLYSTA 50BENTYL 10 MG 88BENTYL 20 MG 88BENZACLIN 57BENZACLIN WITH PUMP 57BENZAMYCIN 57benzoyl peroxide-erythromycin 57benztropine mesylate 0.5 mg, 1mg, 2 mg 41benztropine mesylate 1mg/ml 41

Index 3

BEPREVE 82BERINERT 72BESIVANCE 80BETAGAN 80betamethasone dipropionate(topical) 60betamethasone dipropionateaugmented 60betamethasone sod phosphate &acetate 55betamethasone valerate 0.1% 60betamethasone valerate 0.12% 60BETAPACE 50BETAPACE AF 50BETASERON 86betaxolol hcl (ophth) 80betaxolol hcl 10 mg 50betaxolol hcl 20 mg 50bethanechol chloride 10 mg, 25mg, 5 mg, 50 mg 90BETHKIS 2BETIMOL 80BETOPTIC-S 80bexarotene 40BEYAZ 54BIAXIN 75bicalutamide 38BICILLIN L-A 1200000UNIT/2ML, 2400000UNIT/4ML 84BICNU 36BIDIL 52BILTRICIDE 10BIMATOPROST 82bisacodyl-peg 3350-pot chloride-sod bicarb-sod chloride 74bisoprolol &hydrochlorothiazide 33bisoprolol fumarate 50BIVIGAM 83bleomycin sulfate 38BLEPH-10 80BLEPHAMIDE 81BLINCYTO 37BONIVA 150 MG 65BONIVA 3 MG/3ML 65BOOSTRIX 88BOSULIF 39

BOTOX 79BREO ELLIPTA 25MCG/INH-100MCG/INH, 25MCG/INH-200MCG/INH 15BREVICON-28 54BRILINTA 72brimonidine tartrate 80BRINTELLIX 10 MG 21BRINTELLIX 20 MG 21BRINTELLIX 5 MG 21BRISDELLE 87BRIVIACT 10 MG 17BRIVIACT 10 MG/ML 17BRIVIACT 100 MG 17BRIVIACT 25 MG 17BRIVIACT 50 MG 17BRIVIACT 50 MG/5ML 17BRIVIACT 75 MG 17bromfenac sodium (ophth) 82bromocriptine mesylate 2.5mg 42bromocriptine mesylate 5mg 42BROVANA 15budesonide 55budesonide (inhalation) 0.25mg/2ml 15budesonide (inhalation) 0.5mg/2ml 15budesonide (inhalation) 1mg/2ml 15budesonide (nasal) 79bumetanide 0.5 mg, 1 mg, 2mg 65BUMEX 65BUNAVAIL 2.1MG-0.3MG,4.2MG-0.7MG 8BUNAVAIL 6.3MG-1MG 8buprenorphine hcl 2 mg 8buprenorphine hcl 8 mg 8buprenorphine hcl-naloxone hcldihydrate 2mg-0.5mg 8buprenorphine hcl-naloxone hcldihydrate 8mg-2mg 8bupropion hcl (smokingdeterrent) 86bupropion hcl 100 mg 20bupropion hcl 150 mg 20bupropion hcl 200 mg 20bupropion hcl 300 mg 20bupropion hcl 75 mg 20

buspirone hcl 10 mg, 15 mg, 30mg, 5 mg, 7.5 mg 12BUSULFEX 36butalbital-acetaminophen-caffeine w/ codeine 300mg-50mg-40mg-30mg 8butalbital-acetaminophen-caffeine w/ codeine 325mg-50mg-40mg-30mg 8butalbital-aspirin-caffeinew/cod 8BUTISOL SODIUM 30 MG 73butoconazole nitrate (onedose) 91butorphanol tartrate 10 mg/ml 8butorphanol tartrate 2 mg/ml 8BUTRANS 10 MCG/HR 8BUTRANS 15 MCG/HR 8BUTRANS 20 MCG/HR 8BUTRANS 5 MCG/HR 8BUTRANS 7.5 MCG/HR 9BYDUREON 25BYDUREON PEN 25BYETTA 25BYSTOLIC 50BYVALSON 33cabergoline 68CABOMETYX 39CADUET 52CALAN 51CALAN SR 51calcipotriene 59calcipotriene-betamethasonedipropionate 60calcitonin (salmon) 65calcitriol 0.25 mcg, 0.5 mcg 67calcitriol 1 mcg/ml 67CALCITRIOL 3 MCG/GM 59calcium acetate (phosphatebinder) 70CAMBIA 75CAMPATH 37CAMPRAL 85CAMPTOSAR 100 MG/5ML, 40MG/2ML 41CAMPTOSAR 300MG/15ML 41CANASA 70candesartan cilexetil 32candesartan cilexetil-hydrochlorothiazide 33

Index 4

CANTIL 88CAPASTAT SULFATE 35CAPEX 60CAPRELSA 39captopril 100 mg, 12.5 mg, 25mg, 50 mg 32CAPTOPRIL/HYDROCHLOROTHIAZIDE 33CARAC 59CARAFATE 1 GM 89CARAFATE 1 GM/10ML 89CARBAGLU 67carbamazepine 100 mg 17carbamazepine 100 mg, 200 mg,300 mg 17carbamazepine 100 mg, 200 mg,400 mg 17carbamazepine 100 mg/5ml 17carbamazepine 200 mg 17CARBATROL 18carbidopa 41carbidopa-levodopa 42carbidopa-levodopa-entacapone

42carbinoxamine maleate 29carboplatin 36CARDIZEM 51CARDIZEM CD 51CARDIZEM LA 120 MG 51CARDIZEM LA 180 MG, 240 MG,300 MG, 360 MG, 420 MG 51CARDURA 33CARDURA XL 71carisoprodol 250 mg, 350mg 78carisoprodol w/ aspirin 79carisoprodol w/ aspirin &codeine 79carteolol hcl (ophth) 80carvedilol 12.5 mg 50carvedilol 25 mg 50carvedilol 3.125 mg 50carvedilol 6.25 mg 50CASODEX 38CATAFLAM 3CATAPRES 33CATAPRES-TTS-1 33CATAPRES-TTS-2 33CATAPRES-TTS-3 33CAYSTON 10

CEDAX 400 MG 53cefaclor 250 mg, 500 mg 53cefadroxil 1 gm 53cefadroxil 500 mg 53cefadroxil 500 mg/5ml 53cefazolin sodium 1 gm, 10gm 53cefazolin sodium 500 mg 53cefdinir 125 mg/5ml 53cefdinir 250 mg/5ml 53cefdinir 300 mg 53CEFEPIME 2 GM/100ML 54cefepime hcl 54cefixime 200 mg 53cefoxitin sodium 1 gm 53cefoxitin sodium 10 gm 53cefoxitin sodium 2 gm 53cefpodoxime proxetil 100 mg,200 mg 53cefpodoxime proxetil 100mg/5ml 53cefprozil 250 mg, 500 mg 53cefprozil 250 mg/5ml 53ceftazidime 1 gm, 2 gm 53ceftazidime 6 gm 53CEFTIBUTEN 400 MG 53CEFTIN 250 MG, 500 MG 53ceftriaxone sodium 1 gm 53ceftriaxone sodium 10 gm 54ceftriaxone sodium 2 gm 53ceftriaxone sodium 250 mg53ceftriaxone sodium 500 mg53cefuroxime axetil 53cefuroxime sodium 1.5 gm 53CELEBREX 3celecoxib 3CELESTONE-SOLUSPAN 55CELEXA 10 MG 21CELEXA 20 MG 21CELEXA 40 MG 21CELLCEPT 200 MG/ML 49CELLCEPT 250 MG 49CELLCEPT 500 MG 49CELLCEPTINTRAVENOUS 49CELONTIN 20cephalexin 125 mg/5ml, 250mg/5ml 53

cephalexin 250 mg, 500 mg 53cephalexin 750 mg 53CERDELGA 72CEREBYX 100 MG PE/2ML 19CEREBYX 500 MGPE/10ML 19CEREZYME 72CERVARIX 91CESAMET 28cetirizine hcl 1 mg/ml 29cevimeline hcl 78CHANTIX 86CHANTIX CONTINUINGMONTHPAK 86CHANTIX STARTING MONTHPAK 86CHEMET 27CHENODAL 69chloramphenicol sodiumsuccinate 11chlordiazepoxide hcl 13chlordiazepoxide-amitriptyline

85chlorhexidine gluconate (mouth-throat) 78chloroquine phosphate 250 mg,500 mg 35chlorothiazide 500 mg 65chlorpromazine hcl 10 mg, 100mg, 200 mg, 25 mg, 50 mg 44chlorpromazine hcl 25 mg/ml44chlorpromazine hcl 50mg/2ml 44chlorpropamide 100 mg 26chlorpropamide 250 mg 26chlorthalidone 25 mg, 50 mg 65chlorzoxazone 78cholestyramine 4 gm 30cholestyramine 4 gm/dose 30cholestyramine light 30choline fenofibrate 30chorionic gonadotropin 66ciclopirox 0.77 % 58ciclopirox 1 % 58ciclopirox 8 % 58ciclopirox olamine 58cidofovir 47cilostazol 72CILOXAN 80cimetidine 200 mg 88

Index 5

cimetidine 300 mg, 400 mg, 800mg 88CIMZIA 70CIMZIA STARTER KIT 70CINQAIR 13CINRYZE 72CIPRO 250 MG, 500 MG 69CIPRO 5 GM/100ML 69CIPRO 500 MG/5ML 69CIPRO HC 83CIPRO I.V.-IN D5W 69CIPRO XR 69CIPRODEX 83ciprofloxacin 250 mg/5ml, 500mg/5ml 69ciprofloxacin hcl (ophth) 80ciprofloxacin hcl 100 mg, 250 mg,500 mg, 750 mg 69ciprofloxacin in d5w200mg/100ml-5% 69ciprofloxacin in d5w400mg/200ml-5% 69ciprofloxacin-ciprofloxacinhcl 69cisplatin 100 mg/100ml, 50mg/50ml 36CISPLATIN 200 MG/200ML 36citalopram hydrobromide 10mg 21citalopram hydrobromide 10mg/5ml 21citalopram hydrobromide 20mg 21citalopram hydrobromide 40mg 21cladribine 36CLARINEX 5 MG 29CLARINEX-D 12 HOUR 57clarithromycin 250 mg, 500mg 75clarithromycin 250 mg/5ml 75clarithromycin 500 mg 75clemastine fumarate 2.68 mg29CLEOCIN 100 MG 91CLEOCIN 150 MG, 300 MG, 75MG 11CLEOCIN 2 % 91CLEOCIN IN D5W 11CLEOCIN PHOSPHATE300MG/50ML-5%, 600MG/50ML-5%, 900MG/50ML-5% 11CLEOCIN PHOSPHATE 600MG/4ML, 900 MG/6ML 11

CLEOCIN-T 57CLIMARA 68CLIMARA PRO 68clindamycin hcl 150 mg, 300mg, 75 mg 11clindamycin palmitatehydrochloride 11clindamycin phosphate(topical) 57clindamycin phosphate 150mg/ml, 300 mg/2ml, 600mg/4ml 11clindamycin phosphate 150mg/ml, 9000 mg/60ml 11clindamycin phosphate 600mg/4ml, 900 mg/6ml 11clindamycin phosphate ind5w 11clindamycin phosphatevaginal 91clindamycin phosphate-benzoylperoxide 57clindamycin phosphate-benzoylperoxide (refrigerate) 57clindamycin phosphate-tretinoin 57CLINIMIX 2.75%/DEXTROSE5% 80clobetasol propionate 60clobetasol propionate emollientbase 60clobetasol propionateemulsion 60CLOBEX 61CLOCORTOLONEPIVALATE 61CLOCORTOLONE PIVALATEPUMP 61CLODERM 61CLODERM PUMP 61CLOLAR 36clomipramine hcl 25 mg, 50mg 22clomipramine hcl 75 mg 22clonazepam 0.125 mg, 0.25mg, 0.5 mg, 1 mg, 2 mg 17clonazepam 0.5 mg 17clonazepam 1 mg 17clonazepam 2 mg 17clonidine hcl (adhd) 1clonidine hcl 0.1 mg, 0.2 mg,0.3 mg 33clonidine hcl 0.1 mg/24hr, 0.2mg/24hr, 0.3 mg/24hr 33clopidogrel bisulfate 300mg 72

clopidogrel bisulfate 75 mg 72clorazepate dipotassium 13clotrimazole 78clotrimazole (topical) 58clotrimazole w/betamethasone 59clozapine 100 mg, 25 mg 44clozapine 200 mg, 50 mg 44CLOZAPINE ODT 12.5 MG, 150MG 44CLOZAPINE ODT 200 MG 44CLOZARIL 44COARTEM 35codeine sulfate 15 mg 4CODEINE SULFATE 15 MG 5codeine sulfate 30 mg 5codeine sulfate 60 mg 5COGENTIN 41COLAZAL 70COLCHICINE 71colchicine w/ probenecid 71COLCRYS 71COLESTID 30COLESTID FLAVORED 5GM 30colestipol hcl 1 gm 30colestipol hcl 5 gm 30colistimethate sodium 10COLY-MYCIN M 10COLY-MYCIN S 83COLYTE-FLAVOR PACKS227.1GM-21.5GM-5.53GM-2.82GM-6.36GM 74COLYTE-FLAVOR PACKS240GM-22.72GM-5.84GM-2.98GM-6.72GM 74COMBIGAN 80COMBIPATCH 68COMBIVENT RESPIMAT 15COMBIVIR 45COMETRIQ 39COMPLERA 45COMTAN 41COMVAX 91CONCERTA 1CONDYLOX 63COPAXONE 20 MG/ML 86COPAXONE 40 MG/ML 86COPEGUS 47

Index 6

CORDARONE 13CORDRAN 4 MCG/SQCM 61CORDRAN TAPE 61COREG 12.5 MG 50COREG 25 MG 50COREG 3.125 MG 50COREG 6.25 MG 50COREG CR 50CORGARD 50CORLANOR 5 MG 53CORLANOR 7.5 MG 53CORTEF 55CORTENEMA 9CORTIFOAM 9cortisone acetate 55CORTISPORIN 58CORTISPORIN-TC 83CORZIDE 33COSENTYX 60COSENTYX SENSOREADYPEN 59COSMEGEN 38COSOPT 80COSOPT PF 80COTELLIC 39COUMADIN 16COZAAR 32CREON 64CRESEMBA 186 MG 29CRESEMBA 372 MG 29CRESTOR 31CRINONE 92CRIXIVAN 46cromolyn sodium 13cromolyn sodium(mastocytosis) 69cromolyn sodium (ophth) 82CUBICIN 11CUBICIN RF 11CUTIVATE 61CUVITRU 1 GM/5ML 83CUVITRU 2 GM/10ML, 4GM/20ML, 8 GM/40ML 83cyclobenzaprine hcl 10 mg, 5 mg,7.5 mg 78cyclopentolate hcl 0.5 % 80cyclopentolate hcl 1 %, 2 % 80

cyclophosphamide 1 gm, 500mg 36CYCLOPHOSPHAMIDE 25MG, 50 MG 36CYCLOSET 25cyclosporine 100 mg, 25mg 49cyclosporine 50 mg/ml 49cyclosporine modified (formicroemulsion) 100 mg, 25mg 49cyclosporine modified (formicroemulsion) 50 mg 49CYKLOKAPRON 73CYMBALTA 22cyproheptadine hcl 2mg/5ml 30cyproheptadine hcl 4 mg 30CYRAMZA 37CYSTADANE 67CYSTAGON 71CYSTARAN 82cytarabine 100 mg/ml 36cytarabine 20 mg/ml 36CYTOMEL 88CYTOTEC 89CYTOVENE 47D.H.E. 45 76dacarbazine 40DACOGEN 36DAKLINZA 47DALIRESP 14danazol 100 mg, 200 mg 9danazol 50 mg 9DANTRIUM 78dantrolene sodium 100 mg, 50mg 78dantrolene sodium 25 mg 79dapsone 100 mg, 25 mg 11DAPTACEL 88daptomycin 11DARAPRIM 35darifenacin hydrobromide 90DARZALEX 37daunorubicin hcl 38DAYPRO 3DAYTRANA 30 MG/9HR 1DDAVP 67decitabine 36

DELESTROGEN 20 MG/ML, 40MG/ML 68DELZICOL 70DEMADEX 65demeclocycline hcl 87DEMEROL 100 MG, 50 MG 5DEMSER 32DENAVIR 60DEPACON 20DEPAKENE 20DEPAKOTE 20DEPAKOTE ER 20DEPAKOTE SPRINKLES 20DEPEN TITRATABS 48DEPO-MEDROL 20 MG/ML 55DEPO-MEDROL 40 MG/ML, 80MG/ML 56DEPO-PROVERA 38DEPO-PROVERACONTRACEPTIVE 55DEPO-SUBQ PROVERA104 55DERMA-SMOOTHE/FSBODY 61DERMA-SMOOTHE/FSSCALP 61DERMATOP 61DERMOTIC 83DESCOVY 46desipramine hcl 10 mg, 100 mg,150 mg, 25 mg, 50 mg, 75mg 22desloratadine 29desmopressin acetate 0.1 mg,0.2 mg 67desmopressin acetate 4mcg/ml 67desmopressin acetaterefrigerated 67desmopressin acetate spray 67desmopressin acetate sprayrefrigerated 67DESOGEN 54desogestrel & ethinylestradiol 54desogestrel-ethinyl estradiol(biphasic) 54DESONATE 61desonide 61DESOWEN 61desoximetasone 0.05 % 61DESOXIMETASONE 0.05 %61

Index 7

desoximetasone 0.25 % 61DESOXYN 1DESVENLAFAXINE ER 100 MG,50 MG 22DETROL 90DETROL LA 90dexamethasone 0.5 mg, 0.75 mg,1 mg, 1.5 mg, 2 mg, 4 mg, 6mg 56dexamethasone 0.5 mg/5ml 56dexamethasone 1 mg/ml 56dexamethasone 1.5 mg 56dexamethasone sodiumphosphate (ophth) 81dexamethasone sodiumphosphate 10 mg/ml 56dexamethasone sodiumphosphate 100 mg/10ml, 120mg/30ml, 20 mg/5ml, 4mg/ml 56DEXEDRINE 1DEXILANT 89dexmethylphenidate hcl 10 mg,15 mg, 20 mg 1dexmethylphenidate hcl 10 mg,2.5 mg, 5 mg 1dexrazoxane 250 mg, 500mg 40dextroamphetamine sulfate 10mg, 15 mg, 5 mg 1dextroamphetamine sulfate 10mg, 5 mg 1dextrose 10 % 79dextrose 5 % 79dextrose in lactated ringers 77dextrose w/ sodium chloride0.45%-2.5% 77dextrose w/ sodium chloride0.45%-5% 77dextrose w/ sodium chloride0.9%-5% 77DIABETA 1.25 MG 27DIABETA 2.5 MG 27DIABETA 5 MG 27DIAMOX 64DIASTAT ACUDIAL 17DIASTAT PEDIATRIC 17diazepam 1 mg/ml 13diazepam 10 mg, 2 mg, 5mg 13DIAZEPAM 10 MG, 2.5 MG, 20MG 17diazepam 5 mg/ml 13

DIBENZYLINE 32diclofenac potassium 3diclofenac sodium (actinickeratoses) 59diclofenac sodium (ophth) 82diclofenac sodium (topical) 58diclofenac sodium 100 mg 3diclofenac sodium 25 mg, 50mg, 75 mg 3diclofenac w/ misoprostol 3dicloxacillin sodium 84dicyclomine hcl 10 mg 88dicyclomine hcl 20 mg 88didanosine 46DIFFERIN 0.1 % 57DIFFERIN 0.1 %, 0.3 % 57DIFICID 75diflorasone diacetate 61DIFLUCAN 29diflunisal 4DIGOXIN 0.05 MG/ML 52digoxin 0.125 mg, 125 mcg52digoxin 0.25 mg, 250 mcg 52dihydroergotamine mesylate 1mg/ml 76DIHYDROERGOTAMINEMESYLATE 4 MG/ML 76DILANTIN-125 19DILATRATE SR 12DILAUDID 1 MG/ML 5DILAUDID 2 MG 5DILAUDID 4 MG 5DILAUDID 8 MG 5DILAUDID-HP 10 MG/ML 5diltiazem hcl 100 mg 51diltiazem hcl 120 mg, 180 mg,240 mg 51diltiazem hcl 120 mg, 30 mg, 60mg, 90 mg 51diltiazem hcl 120 mg, 60 mg, 90mg 51diltiazem hcl coated beads 51diltiazem hcl extended releasebeads 51dimenhydrinate 50 mg/ml 28DIOVAN 33DIOVAN HCT 34DIPENTUM 70diphenhydramine hcl 50mg/ml 29

diphenoxylate w/ atropine 27DIPHTHERIA/TETANUSTOXOIDS ADSORBEDPEDIATRIC 88DIPROLENE 61DIPROLENE AF 61dipyridamole 25 mg, 50 mg, 75mg 72disopyramide phosphate 13disulfiram 250 mg, 500 mg 85DITROPAN XL 90divalproex sodium 125 mg 20divalproex sodium 125 mg, 250mg, 500 mg 20divalproex sodium 250 mg, 500mg 20DIVIGEL 68dobutamine hcl 92DOCEFREZ 41DOCETAXEL 140 MG/7ML, 20MG/0.5ML, 20 MG/ML, 80MG/4ML 41DOCETAXEL 160 MG/16ML, 20MG/2ML, 200 MG/20ML, 80MG/8ML 41docetaxel 20 mg/ml, 80mg/4ml 41dofetilide 13DOLOPHINE 10 MG 5DOLOPHINE 5 MG 5donepezil hydrochloride 85dopamine hcl 80 mg/ml 92DORIBAX 500 MG 11dorzolamide hcl 82dorzolamide hcl-timololmaleate 80DOVONEX 60doxazosin mesylate 33doxepin hcl 10 mg, 100 mg, 150mg, 25 mg, 50 mg, 75 mg 22doxepin hcl 10 mg/ml 22doxercalciferol 0.5 mcg, 1 mcg,2.5 mcg 67DOXIL 38doxorubicin hcl 10 mg, 50mg 38doxorubicin hcl 2 mg/ml 38doxorubicin hcl liposomal 38DOXYCYCLINE 63doxycycline (monohydrate) 100mg, 150 mg, 50 mg, 75 mg 87

Index 8

doxycycline (monohydrate) 100mg, 50 mg, 75 mg 87doxycycline (monohydrate) 25mg/5ml 87doxycycline hyclate 100 mg 87doxycycline hyclate 100 mg, 150mg 87doxycycline hyclate 100 mg, 20mg 87doxycycline hyclate 100 mg, 50mg 87doxycycline hyclate 200 mg 87dronabinol 10 mg 28dronabinol 2.5 mg 28dronabinol 5 mg 28drospirenone-ethinylestradiol 54drospirenone-ethinyl estradiol-levomefolate calcium 54DROXIA 72DUAC 57DUAVEE 68DUETACT 23DUEXIS 3DULERA 15duloxetine hcl 20 mg, 30 mg, 60mg 22DUOPA 42DURAGESIC 100 MCG/HR 5DURAGESIC 12 MCG/HR 5DURAGESIC 25 MCG/HR 5DURAGESIC 50 MCG/HR 5DURAGESIC 75 MCG/HR 5DUREZOL 81dutasteride 71dutasteride-tamsulosin hcl 71DYAZIDE 64DYMISTA 79DYRENIUM 65E.E.S. GRANULES 75EC-NAPROSYN 3econazole nitrate 59EDARBI 33EDARBYCLOR 34EDECRIN 65EDLUAR 73EDURANT 46EFFEXOR XR 150 MG 22EFFEXOR XR 37.5 MG 22EFFEXOR XR 75 MG 22

EFFIENT 72EFUDEX 59EGRIFTA 66ELAVIL 22ELDEPRYL 42ELELYSO 72ELESTAT 82ELESTRIN 68ELIDEL 63ELIGARD 38ELIQUIS 16ELITEK 40ELLA 55ELLENCE 38ELMIRON 71ELOCON 61ELOXATIN 100 MG/20ML 36ELOXATIN 50 MG/10ML 36EMCYT 38EMEND 125 MG, 80 MG 28EMEND 40 MG 28EMLA 63EMPLICITI 37EMSAM 21EMTRIVA 46ENABLEX 90enalapril maleate &hydrochlorothiazide 34enalapril maleate 10 mg 32enalapril maleate 2.5 mg 32enalapril maleate 20 mg 32enalapril maleate 5 mg 32enalaprilat 32ENBREL 4ENBREL SURECLICK 4ENDOMETRIN 92ENGERIX-B 10 MCG/0.5ML,20 MCG/ML 91ENJUVIA 0.3 MG, 0.45 MG, 0.9MG 68enoxaparin sodium 100 mg/ml,60 mg/0.6ml, 80 mg/0.8ml 16enoxaparin sodium 120mg/0.8ml, 150 mg/ml, 30mg/0.3ml, 40 mg/0.4ml 16enoxaparin sodium 300mg/3ml 16ENSTILAR 61entacapone 41

entecavir 47ENTOCORT EC 56ENTRESTO 52ENTYVIO 70ENVARSUS XR 49EPIDUO 57epinastine hcl (ophth) 82EPINEPHRINE 0.15 MG/0.15ML,0.3 MG/0.3ML 92EPIPEN 2-PAK 92EPIPEN-JR 2-PAK 92epirubicin hcl 200 mg/100ml 38epirubicin hcl 50 mg/25ml 39EPIVIR 10 MG/ML 46EPIVIR 150 MG, 300 MG 46EPIVIR HBV 100 MG 47EPIVIR HBV 5 MG/ML 47eplerenone 25 mg 34eplerenone 50 mg 34EPOGEN 72EPROSARTAN MESYLATE 33EPZICOM 46EQUETRO 42ERAXIS 100 MG 28ERBITUX 37ergoloid mesylates 86ERGOMAR 76ERIVEDGE 38ERWINAZE 40ERYPED 200 75ERYPED 400 75erythromycin (acne aid) 57erythromycin (ophth) 80erythromycin base 250 mg 75erythromycin base 500 mg 75erythromycin ethylsuccinate 200mg/5ml 75erythromycin ethylsuccinate 400mg 75erythromycin lactobionate 75ESBRIET 87escitalopram oxalate 21esomeprazole magnesium 20mg 89esomeprazole magnesium 40mg 89esomeprazole sodium 40 mg89ESOMEPRAZOLE STRONTIUM49.3 MG 89

Index 9

estradiol & norethindroneacetate 68estradiol 0.025 mg/24hr, 0.0375mg/24hr, 0.05 mg/24hr, 0.075mg/24hr, 0.1 mg/24hr 68estradiol 0.025 mg/24hr, 0.05mg/24hr, 0.06 mg/24hr, 0.075mg/24hr, 0.1 mg/24hr, 37.5mcg/24hr 68estradiol 0.5 mg, 1 mg, 2 mg 68estradiol cypionate 68estradiol vaginal 91estradiol valerate 20 mg/ml, 40mg/ml 68estradiol-norgestimate 68ESTRING 91estropipate 0.75 mg, 1.5 mg 69eszopiclone 73ethacrynic acid 65ethambutol hcl 100 mg, 400mg 35ethosuximide 250 mg 20ethosuximide 250 mg/5ml 20ethynodiol diacet & eth estrad1mg-35mcg 54ethynodiol diacet & eth estrad1mg-50mcg 54etidronate disodium 200 mg 66etodolac 200 mg, 300 mg 3etodolac 400 mg, 500 mg 3etodolac 400 mg, 500 mg, 600mg 3ETOPOPHOS 41etoposide 1 gm/50ml, 100mg/5ml, 500 mg/25ml 41EURAX 64EVAMIST 69EVISTA 66EVOCLIN 57EVOMELA 36EVOTAZ 46EVOXAC 78EVZIO 27EXALGO 12 MG 5EXALGO 16 MG 5EXALGO 32 MG 5EXALGO 8 MG 5EXELDERM 59EXELON 1.5 MG, 3 MG, 4.5 MG,6 MG 85EXELON 13.3 MG/24HR, 4.6MG/24HR, 9.5 MG/24HR 85

exemestane 38EXFORGE 34EXFORGE HCT 34EXJADE 27EXTAVIA 86EXTINA 59EYLEA 80FABIOR 58FABRAZYME 35 MG 67famciclovir 125 mg 48famciclovir 250 mg, 500mg 48famotidine 20 mg 88famotidine 20 mg/2ml, 200mg/20ml, 40 mg/4ml 88famotidine 40 mg 88famotidine 40 mg/5ml 88FAMVIR 48FANAPT 1 MG, 10 MG, 2 MG,4 MG 43FANAPT 12 MG, 6 MG, 8MG 43FANAPT TITRATIONPACK 43FARESTON 38FARXIGA 26FARYDAK 39FASLODEX 38fat emulsion 20 gm/100ml 79FAZACLO 100 MG, 25 MG44FAZACLO 12.5 MG, 150MG 44FAZACLO 200 MG 44felbamate 400 mg 19felbamate 600 mg 19felbamate 600 mg/5ml 19FELBATOL 400 MG 19FELBATOL 600 MG 19FELBATOL 600 MG/5ML 19FELDENE 3felodipine 51FEMARA 38FEMCON FE 54FEMHRT LOW DOSE 68FEMRING 91fenofibrate 120 mg, 145 mg,160 mg, 40 mg, 48 mg, 54mg 30FENOFIBRATE 150 MG, 50MG 30

fenofibrate micronized 130mg 30fenofibrate micronized 134 mg,200 mg, 67 mg 30fenofibrate micronized 43mg 30FENOGLIDE 30fenoprofen calcium 600 mg 3fentanyl 100 mcg/hr 5fentanyl 12 mcg/hr 5fentanyl 25 mcg/hr 5fentanyl 50 mcg/hr 5fentanyl 75 mcg/hr 5fentanyl citrate 1200 mcg, 1600mcg, 400 mcg, 600 mcg, 800mcg 5fentanyl citrate 200 mcg 5FENTORA 100 MCG, 200MCG 5FENTORA 400 MCG, 600 MCG,800 MCG 5FERRIPROX 500 MG 27FETZIMA 120 MG, 40 MG, 80MG 22FETZIMA 20 MG 22FETZIMA TITRATION PACK22FINACEA 63finasteride 71FIORINAL/CODEINE #3 8FIRAZYR 71FIRMAGON 120 MG 38FIRMAGON 80 MG 38FLAGYL 250 MG 10FLAGYL 375 MG 10FLAGYL 500 MG 10FLAREX 81flavoxate hcl 90FLEBOGAMMA DIF 10 % 83flecainide acetate 100 mg 13flecainide acetate 150 mg 13flecainide acetate 50 mg 13FLECTOR 58FLOMAX 71FLOVENT DISKUS 100MCG/BLIST 15FLOVENT DISKUS 250MCG/BLIST 15FLOVENT DISKUS 50MCG/BLIST 15FLOVENT HFA 110 MCG/ACT,220 MCG/ACT 15

Index 10

FLOVENT HFA 44MCG/ACT 15FLOXIN OTIC 83fluconazole 10 mg/ml 29fluconazole 100 mg, 150 mg, 200mg, 50 mg 29fluconazole 40 mg/ml 29fluconazole in dextrose 29fluconazole in nacl 200mg/100ml-0.9%, 400mg/200ml-0.9% 29flucytosine 500 mg 28fludarabine phosphate 37fludrocortisone acetate 57FLUMADINE 48flunisolide (nasal) 79fluocinolone acetonide (otic) 83fluocinolone acetonide 0.01% 61fluocinolone acetonide 0.01 %,0.025 % 61fluocinolone acetonide 0.025% 61fluocinonide 0.05 % 61fluocinonide 0.1 % 61fluocinonide emulsified base 61fluorometholone (ophth) 81fluorouracil (topical) 59FLUOROURACIL 0.5 % 59fluorouracil 1 gm/20ml, 2.5gm/50ml, 500 mg/10ml 37fluoxetine hcl (PMDD) cap 10 mg,20 mg 86fluoxetine hcl 10 mg, 20 mg 21fluoxetine hcl 10 mg, 20 mg, 40mg 21fluoxetine hcl 20 mg/5ml 21FLUOXETINE HCL 60 MG 21fluoxetine hcl 90 mg 21fluoxymesterone 9fluphenazine decanoate 44fluphenazine hcl 1 mg, 10 mg, 2.5mg, 5 mg 45fluphenazine hcl 2.5 mg/ml 44fluphenazine hcl 5 mg/ml 44flurandrenolide 62flurazepam hcl 73flurbiprofen 100 mg, 50 mg 3flurbiprofen sodium 82flutamide 38fluticasone propionate(nasal) 79

fluticasone propionate 0.005% 62fluticasone propionate 0.05% 62fluvastatin sodium 20 mg, 40mg 31fluvastatin sodium 80 mg 31fluvoxamine maleate 100 mg,150 mg 21fluvoxamine maleate 100 mg,25 mg, 50 mg 21FML 81FML FORTE 81FML LIQUIFILM 81FOCALIN 1FOCALIN XR 10 MG, 20MG 1FOCALIN XR 15 MG 2FOLOTYN 37fondaparinux sodium 10mg/0.8ml, 5 mg/0.4ml, 7.5mg/0.6ml 16fondaparinux sodium 2.5mg/0.5ml 16FORADIL AEROLIZER 15FORFIVO XL 20FORTAMET 1000 MG 24FORTAMET 500 MG 24FORTAZ 1 GM, 2 GM 54FORTAZ 6 GM 54FORTEO 66FORTESTA 9FOSAMAX 66FOSAMAX PLUS D 66fosinopril sodium 32fosinopril sodium &hydrochlorothiazide 34fosphenytoin sodium 100 mgpe/2ml 19fosphenytoin sodium 500 mgpe/10ml 19FOSRENOL 1000 MG, 500MG, 750 MG 70FRAGMIN 10000 UNIT/ML,2500 UNIT/0.2ML, 5000UNIT/0.2ML 16FRAGMIN 12500 UNIT/0.5ML,15000 UNIT/0.6ML, 18000UNT/0.72ML, 7500UNIT/0.3ML, 95000UNIT/3.8ML 17FRAGMIN 25000 UNIT/ML17FROVA 76

frovatriptan succinate 76FULYZAQ 27FURADANTIN 90furosemide 10 mg/ml 65furosemide 20 mg, 40 mg, 80mg 65furosemide 8 mg/ml 65FUSILEV 40FUZEON 46FYCOMPA 0.5 MG/ML 17FYCOMPA 10 MG, 12 MG, 2MG, 4 MG, 6 MG, 8 MG 17gabapentin 100 mg, 300 mg, 400mg 18gabapentin 250 mg/5ml, 300mg/6ml 18gabapentin 600 mg, 800 mg 18GABITRIL 12 MG, 16 MG 19GABITRIL 2 MG, 4 MG 19galantamine hydrobromide 12mg, 4 mg, 8 mg 85galantamine hydrobromide 16mg, 24 mg, 8 mg 85galantamine hydrobromide 4mg/ml 85GAMASTAN S/D 83GAMMAGARD LIQUID 83GAMMAKED 83GAMUNEX-C 83ganciclovir sodium 47GARDASIL 91GARDASIL 9 91GASTROCROM 69gatifloxacin (ophth) 80GATTEX 71gauze pads 2" X 2" 75GAZYVA 37GELNIQUE 10 % 90GELNIQUE 3 % 90gemcitabine hcl 1 gm 37gemcitabine hcl 1 gm/26.3ml, 2gm/52.6ml, 200 mg/5.26ml 37gemcitabine hcl 2 gm 37gemcitabine hcl 200 mg 37gemfibrozil 30GEMZAR 1 GM 37GEMZAR 200 MG 37GENERESS FE 54GENOTROPIN 5 MG 66

Index 11

GENOTROPIN MINIQUICK 0.4MG 66gentamicin in saline 0.9%-1mg/ml 2gentamicin sulfate (ophth) 80gentamicin sulfate (topical) 58gentamicin sulfate 40 mg/ml 2GENVOYA 46GEODON 20 MG 43GEODON 20 MG, 40 MG, 60MG, 80 MG 43GILENYA 86GILOTRIF 39GLASSIA 87glatiramer acetate 86GLEEVEC 100 MG, 400 MG 39GLEEVEC 400 MG 39GLEOSTINE 36glimepiride 1 mg 27glimepiride 2 mg 27glimepiride 4 mg 27glipizide 10 mg 27glipizide 2.5 mg 27glipizide 5 mg 27glipizide-metformin hcl 2.5mg-250mg 23glipizide-metformin hcl 2.5mg-500mg, 5mg-500mg 23GLUCAGEN HYPOKIT 24glucagon (rdna) 24GLUCOPHAGE 1000 MG 24GLUCOPHAGE 500 MG 24GLUCOPHAGE 850 MG 24GLUCOPHAGE XR 500 MG 24GLUCOPHAGE XR 750 MG 24GLUCOTROL 10 MG 27GLUCOTROL 5 MG 27GLUCOTROL XL 10 MG 27GLUCOTROL XL 2.5 MG 27GLUCOTROL XL 5 MG 27GLUCOVANCE 1.25MG-250MG 23GLUCOVANCE 2.5MG-500MG,5MG-500MG 23GLUMETZA 1000 MG 24GLUMETZA 500 MG 24glyburide 1.25 mg 27glyburide 2.5 mg 27glyburide 5 mg 27

glyburide micronized 1.5mg 27glyburide micronized 3 mg 27glyburide micronized 6 mg 27glyburide-metformin 1.25mg-250mg 23glyburide-metformin 2.5mg-500mg, 5mg-500mg 23glycopyrrolate 0.2 mg/ml 88glycopyrrolate 1 mg 88glycopyrrolate 2 mg 88GLYNASE 1.5 MG 27GLYNASE 3 MG 27GLYNASE 6 MG 27GLYSET 23GOLYTELY 227.1GM-21.5GM-5.53GM-2.82GM-6.36GM 74GOLYTELY 236GM-22.74GM-5.86GM-2.97GM-6.74GM 74GRALISE 86GRALISE STARTER 86granisetron hcl 1 mg 28GRANIX 72GRASTEK 51GRIS-PEG 28griseofulvin microsize 125mg/5ml 28griseofulvin microsize 500mg 28griseofulvin ultramicrosize 125mg 29griseofulvin ultramicrosize 250mg 29guanfacine hcl 33guanfacine hcl (adhd) 1guanidine hcl 35H.P. ACTHAR 66HALAVEN 41HALCION 73HALDOL 44HALDOL DECANOATE100 44HALDOL DECANOATE 50 44halobetasol propionate 62HALOG 62haloperidol 44haloperidol decanoate 44haloperidol lactate 44HARVONI 47HAVRIX 91

HECTOROL 0.5 MCG, 2.5MCG 67HECTOROL 1 MCG 67heparin sodium (porcine) 1000unit/ml 17heparin sodium (porcine) 10000unit/ml, 20000 unit/ml, 5000unit/0.5ml, 5000 unit/ml 17HEPSERA 48HERCEPTIN 37HETLIOZ 74HEXALEN 36HIPREX 90HIZENTRA 1 GM/5ML 83HIZENTRA 10 GM/50ML, 2GM/10ML, 4 GM/20ML 83HORIZANT 86HUMALOG 25HUMALOG KWIKPEN 25HUMALOG MIX 50/50 25HUMALOG MIX 50/50KWIKPEN 25HUMALOG MIX 75/25 25HUMALOG MIX 75/25KWIKPEN 25HUMATROPE 66HUMATROPE COMBOPACK 66HUMIRA 2HUMIRA PEDIATRIC CROHNSDISEASE STARTER PACK 2HUMIRA PEN 2HUMIRA PEN-CROHNSDISEASESTARTER 2HUMIRA PEN-PSORIASISSTARTER 2HUMULIN 70/30 25HUMULIN 70/30 KWIKPEN 25HUMULIN N 25HUMULIN N KWIKPEN 25HUMULIN R 25HUMULIN R U-500(CONCENTRATED) 26HUMULIN R U-500KWIKPEN 26HYCAMTIN 4 MG 41hydralazine hcl 10 mg, 100 mg,25 mg, 50 mg 35HYDREA 40hydrochlorothiazide 12.5 mg 65hydrochlorothiazide 12.5 mg, 25mg, 50 mg 65

Index 12

hydrocodone-acetaminophen10mg-300mg, 5mg-300mg,7.5mg-300mg 8hydrocodone-acetaminophen10mg-325mg, 5mg-325mg,7.5mg-325mg 8hydrocodone-acetaminophen10mg/15ml-325mg/15ml 8hydrocodone-acetaminophen2.5mg/5ml-108mg/5ml,5mg/10ml-217mg/10ml,7.5mg/15ml-325mg/15ml 8hydrocodone-ibuprofen 200mg-10mg, 200mg-5mg, 200mg-7.5mg 8hydrocortisone (intrarectal) 9hydrocortisone (rectal) 9hydrocortisone (topical) 1 % 62hydrocortisone (topical) 2.5% 62hydrocortisone 10 mg, 20 mg, 5mg 56hydrocortisone acetate w/pramoxine 1%-1% 9hydrocortisone butyrate 62hydrocortisone butyratehydrophilic lipo base 62hydrocortisone valerate 62hydrocortisone w/acetic acid 83hydromorphone hcl 1 mg/ml 5hydromorphone hcl 10 mg/ml, 50mg/5ml, 500 mg/50ml 5hydromorphone hcl 12 mg 5hydromorphone hcl 16 mg 5hydromorphone hcl 2 mg 6hydromorphone hcl 2 mg/ml 5hydromorphone hcl 32 mg 5hydromorphone hcl 4 mg 6hydromorphone hcl 8 mg 6hydromorphone hcl 8 mg,8mg 5hydroxychloroquine sulfate 35HYDROXYPROGESTERONECAPROATE 38hydroxyurea 40hydroxyzine hcl 10 mg, 25 mg, 50mg 12hydroxyzine hcl 10 mg/5ml 12hydroxyzine hcl 25 mg/ml, 50mg/ml 12hydroxyzine pamoate 100 mg, 25mg, 50 mg 12HYQVIA 83

HYSINGLA ER 100 MG, 120MG 6HYSINGLA ER 20 MG, 30 MG,40 MG, 60 MG, 80 MG 6HYZAAR 34ibandronate sodium 150mg 66ibandronate sodium 3mg/3ml 66IBRANCE 39ibuprofen 100 mg/5ml 3ibuprofen 400 mg 3ibuprofen 600 mg 3ibuprofen 800 mg 3ICLUSIG 39IDAMYCIN PFS 39idarubicin hcl 39IFEX 1 GM 36IFEX 3 GM 36ifosfamide 1 gm 36ifosfamide 1 gm/20ml, 3gm/60ml 36IFOSFAMIDE 3 GM 36ILARIS 3ILEVRO 82imatinib mesylate 39IMBRUVICA 39imipenem-cilastatin 250mg-250mg 11imipenem-cilastatin 500mg-500mg 11imipramine hcl 10 mg, 25 mg,50 mg 22imipramine pamoate 22imiquimod 63IMITREX 100 MG 76IMITREX 25 MG 76IMITREX 50 MG 76IMITREX 6 MG/0.5ML 76IMITREX STATDOSE REFILL4 MG/0.5ML 76IMITREX STATDOSE REFILL6 MG/0.5ML 76IMITREX STATDOSE SYSTEM4 MG/0.5ML 76IMITREX STATDOSE SYSTEM6 MG/0.5ML 76IMOVAX RABIES(H.D.C.V.) 91IMURAN 49INCRELEX 67INCRUSE ELLIPTA 14

indapamide 65INDERAL LA 50INDERAL XL 50INDOCIN 25 MG/5ML 3indomethacin 25 mg, 50 mg 3indomethacin 75 mg 3INFANRIX 88INLYTA 39INNOPRAN XL 50INSPRA 35INSULIN SYRINGES AND PENNEEDLES 75INTELENCE 100 MG, 200MG 46INTELENCE 25 MG 46INTERMEZZO 73INTRON A 10 MU, 18 MU, 50MU 40INTRON A 10 MU/ML 40INTRON A 6000000UNIT/ML 40INTRON A W/DILUENT 40INTUNIV 1INVANZ 11INVEGA 1.5 MG 43INVEGA 3 MG 43INVEGA 6 MG 43INVEGA 9 MG 43INVEGA SUSTENNA 117MG/0.75ML, 156 MG/ML, 234MG/1.5ML 43INVEGA SUSTENNA 39MG/0.25ML, 78 MG/0.5ML 43INVEGA TRINZA 43INVIRASE 46INVOKAMET 150MG-1000MG,150MG-500MG, 50MG-1000MG 23INVOKAMET 50MG-500MG 23INVOKANA 26IOPIDINE 0.5 % 80IOPIDINE 1 % 80IPOL INACTIVATED IPV 91ipratropium bromide 14ipratropium bromide (nasal) 79ipratropium-albuterol 15IPRIVASK 17irbesartan 33irbesartan-hydrochlorothiazide

34

Index 13

IRESSA 39irinotecan hcl 41irrigation solutions,physiological 49ISENTRESS 100 MG 46ISENTRESS 25 MG 46ISENTRESS 400 MG 46isoniazid 100 mg, 300 mg 35ISOPTO CARPINE 80ISORDIL TITRADOSE 40MG 12ISORDIL TITRADOSE 5 MG 12isosorbide dinitrate 10 mg, 20mg, 30 mg, 5 mg 12isosorbide dinitrate 40 mg 12isosorbide mononitrate 10mg 12isosorbide mononitrate 120 mg,30 mg, 60 mg 12isosorbide mononitrate 20mg 12isotretinoin 10 mg, 30 mg 58isotretinoin 20 mg 58isotretinoin 40 mg 58ISTALOL 80ISTODAX 39ISTODAX (OVERFILL) 39itraconazole 29ivermectin 10IXEMPRA KIT 41IXIARO 91JADENU 27JAKAFI 39JALYN 71JANUMET 23JANUMET XR 100MG-1000MG 23JANUMET XR 50MG-1000MG,50MG-500MG 23JANUVIA 25JARDIANCE 26JENTADUETO 23JENTADUETO XR 2.5MG-1000MG 23JENTADUETO XR 5MG-1000MG 23JEVTANA 41JUBLIA 59JUXTAPID 10 MG 31JUXTAPID 20 MG 31

JUXTAPID 30 MG 31JUXTAPID 40 MG 31JUXTAPID 5 MG 31JUXTAPID 60 MG 31K-TAB 10 MEQ 77KADCYLA 37KADIAN 10 MG 6KADIAN 100 MG 6KADIAN 20 MG, 30 MG, 50MG, 60 MG, 80 MG 6KADIAN 40 MG 6KALBITOR 72KALETRA 100MG-25MG 46KALETRA 200MG-50MG 46KALETRA 400MG/5ML-100MG/5ML 46KALYDECO 87KANUMA 67KAPVAY 1KAYEXALATE 50KAZANO 24KEFLEX 53KENALOG 62KENALOG-10 56KENALOG-40 56KEPIVANCE 40KEPPRA 18KEPPRA XR 18KERLONE 50KERYDIN 59KETEK 300 MG 11KETEK 400 MG 11ketoconazole 29ketoconazole (topical) 59ketoprofen 200 mg 3ketoprofen 50 mg, 75 mg 3ketorolac tromethamine(ophth) 82ketorolac tromethamine 10mg 3ketorolac tromethamine 15mg/ml, 30 mg/ml 3ketorolac tromethamine 30mg/ml, 60 mg/2ml 3KEVEYIS 64KEYTRUDA 37KHEDEZLA 22KINERET 3KITABIS PAK 2

KLARON 58KLONOPIN 0.5 MG 17KLONOPIN 1 MG 17KLONOPIN 2 MG 17KOMBIGLYZE XR 2.5MG-1000MG 24KOMBIGLYZE XR 5MG-1000MG, 5MG-500MG 24KORLYM 24KUVAN 67KYNAMRO 30labetalol hcl 100 mg, 200 mg, 300mg 50LAC-HYDRIN 63lactated ringer's 77lactic acid (ammonium lactate) 12% 63lactulose 74lactulose (encephalopathy) 70LAMICTAL 18LAMICTAL CHEWABLEDISPERSIBLE 18LAMICTAL ODT 100 MG, 200MG, 25 MG, 50 MG 18LAMICTAL STARTER/NOTTAKING CARBAMAZEPINE 18LAMICTAL STARTER/TAKINGCARBAMAZEPINE/NOT TAKINGVALPROATE 18LAMICTAL STARTER/TAKINGVALPROATE 18LAMICTAL XR 18LAMICTAL XR 100 MG, 250MG 18LAMICTAL XR 200 MG, 25 MG,300 MG, 50 MG 18LAMISIL 125 MG 29LAMISIL 250 MG 29lamivudine (hbv) 48lamivudine 10 mg/ml 46lamivudine 150 mg, 300 mg 46lamivudine-zidovudine 46lamotrigine 100 mg, 150 mg, 200mg, 25 mg 18lamotrigine 100 mg, 200 mg, 25mg, 50 mg 18lamotrigine 100 mg, 250 mg 18lamotrigine 200 mg, 25 mg, 300mg, 50 mg 18lamotrigine 25 mg, 5 mg 18LANOXIN 125 MCG 52LANOXIN 187.5 MCG 52

Index 14

LANOXIN 250 MCG 52LANOXIN 62.5 MCG 52LANOXIN PEDIATRIC 52lansoprazole 15 mg 89lansoprazole 30 mg 89LANTUS 26LANTUS SOLOSTAR 26LARTRUVO 37LASIX 65LASTACAFT 82latanoprost 82LATUDA 120 MG 43LATUDA 20 MG 43LATUDA 40 MG 43LATUDA 60 MG 43LATUDA 80 MG 43LAZANDA 100 MCG/ACT 6LAZANDA 300 MCG/ACT 6LAZANDA 400 MCG/ACT 6leflunomide 4LEMTRADA 86LENVIMA 10 MG DAILYDOSE 39LENVIMA 14 MG DAILYDOSE 39LENVIMA 18 MG DAILYDOSE 39LENVIMA 20 MG DAILYDOSE 39LENVIMA 24 MG DAILYDOSE 39LENVIMA 8 MG DAILYDOSE 39LESCOL 31LESCOL XL 31LETAIRIS 52letrozole 38leucovorin calcium 10 mg, 15 mg,25 mg, 5 mg 40leucovorin calcium 100 mg, 350mg 40leucovorin calcium 200 mg, 50mg, 500 mg 40LEUKERAN 36LEUKINE 72leuprolide acetate 38levalbuterol hcl 0.31 mg/3ml, 0.63mg/3ml, 1.25 mg/0.5ml, 1.25mg/3ml 15LEVALBUTEROL TARTRATEHFA 16

LEVAQUIN 25 MG/ML 69LEVAQUIN 250 MG, 750MG 69LEVAQUIN 250MG/50ML-5%,500MG/100ML-5%,750MG/150ML-5% 69LEVAQUIN 500 MG 69LEVEMIR 26LEVEMIR FLEXTOUCH 26levetiracetam 100 mg/ml, 500mg/5ml 18levetiracetam 1000 mg, 250mg, 500 mg, 750 mg 18LEVETIRACETAM1000MG/100ML-750MG/100ML,1500MG/100ML-540MG/100ML, 500MG/100ML-820MG/100ML 18levetiracetam 500 mg, 750mg 18levetiracetam 500 mg/5ml 18levobunolol hcl 80levocarnitine (metabolicmodifiers) 330 mg 67levocetirizine dihydrochloride2.5 mg/5ml 29levocetirizine dihydrochloride 5mg 29levofloxacin (ophth) 81levofloxacin 25 mg/ml 69levofloxacin 250 mg, 500 mg,750 mg 69levofloxacin in d5w 69LEVOLEUCOVORIN 40levoleucovorin calcium 175mg/17.5ml 40levoleucovorin calcium 50mg 40levonorgestrel & ethestradiol 54levonorgestrel (emergency oc)0.75 mg 55levonorgestrel (emergency oc)1.5 mg 55levonorgestrel-eth estradiol(triphasic) 54levonorgestrel-ethinyl estradiol(91-day) 54levothyroxine sodium 100 mcg,112 mcg, 125 mcg, 137 mcg,150 mcg, 175 mcg, 200 mcg,25 mcg, 300 mcg, 50 mcg, 75mcg, 88 mcg 88LEXAPRO 21LEXIVA 50 MG/ML 46

LEXIVA 700 MG 46LIALDA 70lidocaine 5 % 63lidocaine hcl (cardiac) 13lidocaine hcl (local anesth.) 1 %,2 % 74lidocaine hcl (mouth-throat) 78lidocaine hcl 2 % 63lidocaine hcl 4 % 63lidocaine-prilocaine 63LIDODERM 63LINCOCIN 11lincomycin hcl 11lindane 64linezolid 100 mg/5ml 11linezolid 600 mg 11linezolid 600 mg/300ml 11LINEZOLID 600MG/300ML-0.9% 11LINZESS 70liothyronine sodium 25 mcg, 5mcg, 50 mcg 88LIPITOR 31LIPOFEN 31lisinopril &hydrochlorothiazide 34lisinopril 10 mg, 2.5 mg, 20 mg,30 mg, 40 mg, 5 mg 32lithium 42lithium carbonate 150 mg, 300mg, 600 mg 42lithium carbonate 300 mg 42lithium carbonate 300 mg, 450mg 42LITHOBID 42LIVALO 31LO LOESTRIN FE 54LOCOID 62LOCOID LIPOCREAM 62LODOSYN 41LOMOTIL 27LONSURF 39loperamide hcl 2 mg 27LOPID 31LOPRESSOR 100 MG, 50MG 50LOPRESSOR HCT 34LOPROX 0.77 % 59LOPROX SHAMPOO 59

Index 15

lorazepam 0.5 mg, 1 mg, 2mg 13lorazepam 2 mg/ml 13lorazepam 2 mg/ml, 20mg/10ml 13lorazepam 4 mg/ml 13losartan potassium 33losartan potassium &hydrochlorothiazide 34LOSEASONIQUE 54LOTEMAX 81LOTENSIN 32LOTENSIN HCT 34LOTREL 34LOTRISONE 59LOTRONEX 70lovastatin 31LOVAZA 30LOVENOX 17loxapine succinate 44LUMIGAN 82LUMIZYME 67LUNESTA 73LUPRON DEPOT 38LUPRON DEPOT-PED 11.25MG 67LUPRON DEPOT-PED 11.25MG, 7.5 MG 67LUPRON DEPOT-PED 15MG 67LUPRON DEPOT-PED 30MG 67LUVOX CR 21LUXIQ 62LUZU 59LYNPARZA 39LYRICA 100 MG 18LYRICA 150 MG 18LYRICA 20 MG/ML 18LYRICA 200 MG 18LYRICA 225 MG 18LYRICA 25 MG 18LYRICA 300 MG 18LYRICA 50 MG 18LYRICA 75 MG 18LYSODREN 38LYSTEDA 73M-M-R II 91MACROBID 90

MACRODANTIN 100 MG, 50MG 90MACRODANTIN 25 MG 90magnesium sulfate 50 % 77MALARONE 250MG-100MG 35MALARONE 62.5MG-25MG 35malathion 64maprotiline hcl 25 mg, 50mg 20maprotiline hcl 75 mg 20MARINOL 10 MG, 5 MG 28MARINOL 2.5 MG 28MARPLAN 21MARQIBO 41MATULANE 40MAVIK 32MAXALT 10 MG 76MAXALT 5 MG 76MAXALT-MLT 10 MG 76MAXALT-MLT 5 MG 76MAXIDEX 81MAXIPIME 1 GM, 2 GM 54MAXITROL 81MAXZIDE 64MAXZIDE-25 65meclizine hcl 12.5 mg, 25mg 28meclofenamate sodium 50mg 3MEDROL 16 MG, 32 MG, 4MG, 8 MG 56MEDROL 2 MG 56MEDROL DOSEPAK 56medroxyprogesterone acetate(contraceptive) 55medroxyprogesterone acetate10 mg, 2.5 mg, 5 mg 84mefenamic acid 4mefloquine hcl 35MEGACE ES 84MEGACE ORAL 38megestrol acetate(appetite) 84megestrol acetate 20 mg, 40mg 38megestrol acetate 40 mg/ml,400 mg/10ml 38MEKINIST 39meloxicam 15 mg, 7.5 mg 4

melphalan hcl 36memantine hcl 10 mg, 5 mg 85memantine hcl 2 mg/ml 85MENACTRA 91MENOMUNE-A/C/Y/W-135 91MENOSTAR 69MENVEO 91meperidine hcl 100 mg, 50 mg6meprobamate 12MEPRON 10mercaptopurine 37meropenem 1 gm 11meropenem 500 mg 11MERREM 1 GM 11MERREM 500 MG 11mesalamine 70MESALAMINE DR 70mesalamine w/ cleanser 70mesna 40MESNEX 100 MG/ML 40MESNEX 400 MG 40MESTINON 60 MG 35MESTINON TIMESPAN 35METADATE CD 2metaxalone 78metformin hcl 1000 mg 24metformin hcl 500 mg 24metformin hcl 750 mg 24metformin hcl 850 mg 24methadone hcl 10 mg 6methadone hcl 10 mg/5ml 6methadone hcl 5 mg 6methadone hcl 5 mg/5ml 6methamphetamine hcl 1methazolamide 25 mg, 50mg 64methenamine hippurate 90methimazole 10 mg, 5 mg 88methocarbamol 500 mg, 750mg 78methotrexate sodium 1 gm 37methotrexate sodium 1 gm/40ml,100 mg/4ml, 200 mg/8ml, 250mg/10ml, 50 mg/2ml 37methotrexate sodium 10 mg, 15mg 37methotrexate sodium 2.5 mg, 5mg, 7.5 mg 37

Index 16

methotrexate sodium 250mg/10ml, 50 mg/2ml 37methoxsalen rapid 60methscopolamine bromide 2.5mg, 5 mg 88methyclothiazide 65methyldopa 33methyldopa &hydrochlorothiazide 34methylergonovine maleate 0.2mg 83methylphenidate hcl 10 mg 2methylphenidate hcl 10 mg, 20mg, 30 mg, 40 mg, 50 mg, 60mg 2methylphenidate hcl 10 mg, 20mg, 5 mg 2methylphenidate hcl 18 mg, 20mg, 27 mg, 36 mg, 54 mg 2methylphenidate hcl 18 mg, 27mg, 36 mg, 54 mg 2methylphenidate hcl 20 mg, 40mg 2methylphenidate hcl 30 mg 2methylprednisolone 16 mg, 32mg, 4 mg, 8 mg 56methylprednisolone 4 mg 56methylprednisolone acetate 40mg/ml, 80 mg/ml 56methylprednisolone sodsucc 56methyltestosterone 9metipranolol 80metoclopramide hcl 10 mg, 5mg 70metoclopramide hcl 10 mg/10ml,5 mg/5ml 70metoclopramide hcl 5 mg/ml 70metolazone 65metoprolol & hydrochlorothiazide100mg-25mg, 50mg-25mg 34metoprolol & hydrochlorothiazide100mg-50mg 34metoprolol succinate 50metoprolol tartrate 100 mg, 25mg, 50 mg 50METROCREAM 63METROGEL 63METROGEL-VAGINAL 91METROLOTION 63metronidazole (topical) 64metronidazole 250 mg 10metronidazole 375 mg 10metronidazole 500 mg 10

metronidazole in nacl 10metronidazole vaginal 91MEVACOR 31mexiletine hcl 13MIACALCIN 200UNIT/ACT 66MIACALCIN 200 UNIT/ML 66MICARDIS 33MICARDIS HCT 34miconazole nitrate vaginal 200mg 91MICRO-K 77MICROZIDE 65midodrine hcl 92MIGERGOT 75miglitol 23MIGRANAL 76MILLIPRED 5 MG 56MINASTRIN 24 FE 54MINIPRESS 33MINOCIN 100 MG, 50 MG, 75MG 87minocycline hcl 100 mg, 50mg 87minocycline hcl 100 mg, 50 mg,75 mg 87minoxidil 10 mg, 2.5 mg 35MIRAPEX 42MIRAPEX ER 42MIRCERA 100 MCG/0.3ML, 50MCG/0.3ML, 75MCG/0.3ML 72MIRCERA 200MCG/0.3ML 72mirtazapine 20MIRVASO 64misoprostol 100 mcg, 200mcg 89MITIGARE 71mitomycin 20 mg, 40 mg, 5mg 39mitoxantrone hcl 39MOBIC 15 MG, 7.5 MG 4modafinil 100 mg 2modafinil 200 mg 2MODICON 54moexipril hcl 32moexipril-hydrochlorothiazide

34molindone hcl 44mometasone furoate 62

mometasone furoate (nasal) 79MONODOX 87montelukast sodium 10 mg 14montelukast sodium 4 mg, 5mg 14MONUROL 90morphine sulfate 0.5 mg/ml 6morphine sulfate 1 mg/ml 6morphine sulfate 10 mg 6morphine sulfate 10 mg/5ml 6morphine sulfate 100 mg 6morphine sulfate 100 mg/5ml, 20mg/ml 6morphine sulfate 15 mg 6morphine sulfate 20 mg, 30 mg,50 mg, 60 mg, 80 mg 6morphine sulfate 20 mg/5ml 6morphine sulfate 200 mg 6morphine sulfate 30 mg 6morphine sulfate 30 mg, 60mg 6morphine sulfate beads 6MOVANTIK 70MOVIPREP 74MOXEZA 81moxifloxacin hcl 400 mg 69MOZOBIL 73MS CONTIN 100 MG 6MS CONTIN 15 MG 6MS CONTIN 200 MG 6MS CONTIN 30 MG, 60 MG 6MULTAQ 13mupirocin 58mupirocin calcium (topical) 58MUSTARGEN 36MYALEPT 67MYAMBUTOL 35MYCAMINE 100 MG 28MYCOBUTIN 35mycophenolate mofetil 200mg/ml 49mycophenolate mofetil 250mg 49mycophenolate mofetil 500mg 49mycophenolate sodium 180mg 49mycophenolate sodium 360mg 49MYFORTIC 180 MG 49

Index 17

MYFORTIC 360 MG 49MYOZYME 67MYRBETRIQ 90MYSOLINE 18MYTESI 27nabumetone 4nadolol & bendroflumethiazide40mg-5mg 34nadolol & bendroflumethiazide80mg-5mg 34nadolol 20 mg, 40 mg, 80mg 50nafcillin sodium 10 gm 84nafcillin sodium 2 gm 84naftifine hcl 59NAFTIN 1 %, 2 % 59NAGLAZYME 67naloxone hcl 2 mg/2ml 27naltrexone hcl 28NAMENDA 10 MG, 5 MG 85NAMENDA 10 MG/5ML 85NAMENDA TITRATION PAK85NAMENDA XR 14 MG 85NAMENDA XR 21 MG 85NAMENDA XR 28 MG 85NAMENDA XR 7 MG 85NAMENDA XR TITRATIONPACK 85naphazoline hcl 81NAPRELAN 375 MG 4NAPRELAN 750 MG 4NAPROSYN 250 MG, 375 MG,500 MG 4naproxen 250 mg, 375 mg, 500mg 4naproxen 375 mg, 500 mg 4naproxen sodium 275 mg, 550mg 4naproxen sodium 375 mg 4naratriptan hcl 76NARCAN 28NARDIL 21NASONEX 79NATACYN 81nateglinide 26NATESTO 9NATPARA 66NAVELBINE 41NEBUPENT 10

nefazodone hcl 21neomycin sulfate 2neomycin-bacitracin zn-polymyxin 81neomycin-polymy-dexameth 81neomycin-polymyxin-gramicidin

81neomycin-polymyxin-hc(ophth) 81neomycin-polymyxin-hc(otic) 83neomycin/polymyxin b gu 71NEORAL 100 MG, 25 MG 49NESINA 25NEULASTA 73NEULASTA ONPRO KIT 72NEUMEGA 73NEUPOGEN 73NEUPRO 42NEURONTIN 18NEVANAC 82nevirapine 100 mg, 400mg 46nevirapine 200 mg 46NEVIRAPINE 50 MG/5ML 46NEXAVAR 39NEXIUM 10 MG, 2.5 MG, 20MG, 40 MG, 5 MG 89NEXIUM 20 MG 89NEXIUM 40 MG 89NEXIUM I.V. 89niacin (antihyperlipidemic) 1000mg, 500 mg, 750 mg 31niacin (antihyperlipidemic) 500mg 31NIASPAN 31nicardipine hcl 20 mg, 30mg 51NICOTROL INHALER 86NICOTROL NS 86nifedipine 10 mg, 20 mg 51nifedipine 30 mg, 60 mg, 90mg 51NILANDRON 38nilutamide 38nimodipine 30 mg, 30mg 51NINLARO 39NIPENT 40nisoldipine 17 mg, 34 mg, 8.5mg 51

NITRO-DUR 0.1 MG/HR, 0.2MG/HR, 0.4 MG/HR, 0.6MG/HR 12NITRO-DUR 0.3 MG/HR, 0.8MG/HR 12nitrofurantoin 90nitrofurantoin macrocrystal 100mg, 25 mg, 50 mg 90nitrofurantoin monohydmacro 90nitroglycerin 0.1 mg/hr, 0.2 mg/hr,0.4 mg/hr, 0.6 mg/hr 12nitroglycerin 0.3 mg, 0.4 mg, 0.6mg 12nitroglycerin 0.4 mg/spray 12nitroglycerin 5 mg/ml 12NITROGLYCERIN LINGUAL12NITROLINGUALPUMPSPRAY 12NITROMIST 12NITROSTAT 12nizatidine 150 mg, 300 mg 88NIZORAL 59NOR-QD 55NORDITROPIN FLEXPRO 10MG/1.5ML, 5 MG/1.5ML 66norelgestromin-ethinylestradiol 55norethin acet & estrad-fe 75mg-20mcg-1mg, 75mg-30mcg-1.5mg 54norethindrone & eth estradiol0.4mg-35mcg, 1mg-35mcg 54norethindrone & eth estradiol0.5mg-35mcg 54norethindrone & ethinyl estradiol-fe 54norethindrone(contraceptive) 55norethindrone acet & eth estra20mcg-1mg, 30mcg-1.5mg 54norethindrone acetate 85norethindrone acetate-ethinylestradiol 2.5mcg-0.5mg 68norethindrone-eth estradiol(triphasic) 54norgestimate-ethinylestradiol 54norgestimate-ethinyl estradiol(triphasic) 54norgestrel & ethinyl estradiol 54NORINYL 1+35 55NORITATE 64NORPACE 13NORPACE CR 100 MG 13

Index 18

NORPRAMIN 23NORTHERA 100 MG 92NORTHERA 200 MG 92NORTHERA 300 MG 92nortriptyline hcl 10 mg, 25 mg, 50mg, 75 mg 23nortriptyline hcl 10 mg/5ml 23NORVASC 10 MG 51NORVASC 2.5 MG 51NORVASC 5 MG 51NORVIR 46NOVOLIN 70/30 26NOVOLIN 70/30 RELION 26NOVOLIN N 26NOVOLIN N RELION 26NOVOLIN R 26NOVOLIN R RELION 26NOVOLOG 26NOVOLOG FLEXPEN 26NOVOLOG MIX 70/30 26NOVOLOG MIX 70/30PREFILLED FLEXPEN 26NOVOLOG PENFILL 26NOXAFIL 100 MG 29NOXAFIL 300 MG/16.7ML 29NOXAFIL 40 MG/ML 29NUCALA 13NUCYNTA 100 MG 6NUCYNTA 50 MG 6NUCYNTA 75 MG 6NUCYNTA ER 100 MG 6NUCYNTA ER 150 MG, 200 MG,250 MG 6NUCYNTA ER 50 MG 6NUEDEXTA 86NULOJIX 49NULYTELY/FLAVORPACKS 74NUPLAZID 43NUTROPIN AQ NUSPIN 20 66NUTROPIN AQ PEN 20MG/2ML 66NUVARING 55NUVIGIL 150 MG, 250 MG, 50MG 2NUVIGIL 200 MG 2NYMALIZE 51nystatin 29nystatin (mouth-throat) 78

nystatin (topical) 59nystatin-triamcinolone 59OCALIVA 10 MG 69OCALIVA 5 MG 69OCTAGAM 10 GM/100ML, 2GM/20ML, 20 GM/200ML, 5GM/50ML 83octreotide acetate 100mcg/ml 68octreotide acetate 200 mcg/ml,50 mcg/ml 68OCUFEN 82OCUFLOX 81ODEFSEY 46ODOMZO 38OFEV 87ofloxacin (ophth) 81ofloxacin (otic) 83olanzapine 10 mg 44olanzapine 10 mg, 15 mg, 2.5mg, 20 mg, 5 mg, 7.5 mg 44olanzapine 10 mg, 15 mg, 20mg, 5 mg 44olanzapine-fluoxetine hcl 85olmesartan medoxomil 33olmesartan medoxomil-amlodipine-hydrochlorothiazide

34olmesartan medoxomil-hydrochlorothiazide 34olopatadine hcl 82olopatadine hcl (nasal) 79OLUX 62OLUX-E 62OLYSIO 48omega-3-acid ethyl esters 30omeprazole 10 mg, 20 mg, 40mg 89omeprazole-sodiumbicarbonate 20mg-1100mg89omeprazole-sodiumbicarbonate 20mg-1680mg89omeprazole-sodiumbicarbonate 40mg-1100mg89omeprazole-sodiumbicarbonate 40mg-1680mg89OMNARIS 79OMNIPRED 81OMNITROPE 10 MG/1.5ML, 5MG/1.5ML 66ONCASPAR 40ondansetron 28

ondansetron hcl 24 mg, 4 mg, 8mg 28ondansetron hcl 4 mg/2ml 28ondansetron hcl 4 mg/5ml 28ondansetron hcl 40 mg/20ml 28ONFI 10 MG 17ONFI 2.5 MG/ML 17ONFI 20 MG 17ONGLYZA 25ONMEL 29OPANA 10 MG 6OPANA 5 MG 7OPANA ER (CRUSHRESISTANT) 40 MG 6OPDIVO 37opium tincture 27OPSUMIT 52OPTIVAR 82ORACEA 64ORALAIR 51ORAP 86ORAPRED ODT 10 MG 56ORAPRED ODT 15 MG, 30MG 56ORBACTIV 10ORENCIA 4ORENCIA CLICKJECT 4ORENITRAM 0.125 MG 52ORENITRAM 0.25 MG, 1 MG,2.5 MG 52ORFADIN 10 MG, 2 MG, 20 MG,5 MG 67ORKAMBI 87orphenadrine citrate 100 mg 78orphenadrine citrate 30mg/ml 78ORTHO EVRA 55ORTHO MICRONOR 55ORTHO TRI-CYCLEN 55ORTHO TRI-CYCLEN LO 55ORTHO-CEPT 55ORTHO-CYCLEN 55ORTHO-NOVUM 1/35 55ORTHO-NOVUM 7/7/7 55OSENI 12.5MG-15MG 24OSENI 12.5MG-30MG 24OSENI 12.5MG-45MG, 25MG-15MG, 25MG-30MG, 25MG-45MG 24

Index 19

OSMOPREP 74OTEZLA 4OTREXUP 3oxaliplatin 100 mg, 50 mg 36oxaliplatin 100 mg/20ml 36oxaliplatin 50 mg/10ml 36OXANDRIN 9oxandrolone 10 mg 9oxandrolone 2.5 mg 9oxaprozin 4oxazepam 13oxcarbazepine 150 mg, 300 mg,600 mg 19oxcarbazepine 300 mg/5ml, 60mg/ml 18oxiconazole nitrate 59OXISTAT 59OXSORALEN ULTRA 60oxybutynin chloride 10 mg, 15mg, 5 mg 90oxybutynin chloride 5 mg 90oxybutynin chloride 5mg/5ml 90oxycodone hcl 10 mg 7oxycodone hcl 100 mg/5ml 7oxycodone hcl 15 mg 7oxycodone hcl 20 mg 7oxycodone hcl 30 mg 7oxycodone hcl 5 mg 7OXYCODONE HCL ER 10 MG,15 MG, 20 MG, 30 MG, 40 MG,60 MG 7OXYCODONE HCL ER 80MG 7oxycodone w/ acetaminophen10mg-325mg 8oxycodone w/ acetaminophen2.5mg-325mg, 5mg-325mg,7.5mg-325mg 8oxycodone w/ acetaminophen5mg/5ml-325mg/5ml 8oxycodone-aspirin 8OXYCONTIN 10 MG, 15 MG, 20MG, 30 MG, 40 MG, 60 MG 7OXYCONTIN 80 MG 7oxymorphone hcl 10 mg 7oxymorphone hcl 15 mg 7oxymorphone hcl 20 mg 7oxymorphone hcl 30 mg, 40mg 7oxymorphone hcl 5 mg 7

oxymorphone hcl 7.5 mg 7OXYTROL 90paclitaxel 100 mg/16.7ml, 150mg/25ml 41paclitaxel 30 mg/5ml, 300mg/50ml 41paliperidone 1.5 mg 43paliperidone 3 mg 43paliperidone 6 mg 43paliperidone 9 mg 43PAMELOR 23PAMINE 88PAMINE FORTE 88PANCREAZE 10000UNIT-4200UNIT-17500UNIT,25000UNIT-10500UNIT-43750UNIT, 37000UNIT-21000UNIT-61000UNIT,40000UNIT-16800UNIT-70000UNIT 64PANCREAZE 6200UNIT-2600UNIT-10850UNIT 64PANCRELIPASE 64PANRETIN 59pantoprazole sodium 20 mg, 40mg 89pantoprazole sodium 40mg 89PARAFON FORTE DSC 78parenteral electrolytes 77paricalcitol 1 mcg 67paricalcitol 2 mcg, 4 mcg 67PARLODEL 42PARNATE 21paromomycin sulfate 2paroxetine hcl 10 mg, 20 mg,30 mg, 40 mg 21paroxetine hcl 12.5 mg, 25 mg,37.5 mg 21PATADAY 82PATANASE 79PATANOL 82PAXIL 10 MG, 20 MG, 30 MG,40 MG 21PAXIL 10 MG/5ML 21PAXIL CR 21PCE 333 MG 75PEDVAX HIB 91peg 3350-kcl-sod bicarb-sodchloride-sod sulfate 74

peg 3350-potassium chloride-sodbicarbonate-sod chloride 74PEG-INTRON 48PEG-INTRON REDIPEN 48PEG-INTRON REDIPEN PAK4 48PEGANONE 19PEGASYS 48PEGASYS PROCLICK 48PEGINTRON 48penicillin g potassium 20 mu,20000000 unit 84penicillin g potassium 5000000unit 84penicillin v potassium 250 mg,500 mg 84penicillin v potassium 250mg/5ml 84PENLAC NAIL LACQUER 59PENNSAID 1.5 % 58PENNSAID 2 % 58PENTAM 300 10PENTASA 250 MG 70PENTASA 500 MG 70pentazocine w/ naloxone 9pentobarbital sodium 73pentoxifylline 72PEPCID 88PERCODAN 8PERFOROMIST 16PERIDEX 78perindopril erbumine 2 mg 32perindopril erbumine 4 mg 32perindopril erbumine 8 mg 32PERJETA 37permethrin 5 % 64perphenazine 16 mg, 2 mg, 4 mg,8 mg 45perphenazine-amitriptyline 85PERSANTINE 72PERTZYE 64PEXEVA 21phenelzine sulfate 21phenobarbital 100 mg, 15 mg,16.2 mg, 30 mg, 32.4 mg, 60 mg,64.8 mg, 97.2 mg 73phenobarbital 20 mg/5ml 73phenoxybenzamine hcl 32phenytoin 125 mg/5ml 20phenytoin 50 mg 20

Index 20

phenytoin sodium 20phenytoin sodium extended 20PHOSLO 70PHOSLYRA 70PHOSPHOLINE IODIDE 80PICATO 59pilocarpine hcl (oral) 78pilocarpine hcl 1 %, 2 %, 4% 80pimozide 86pindolol 50pioglitazone hcl 15 mg 25pioglitazone hcl 30 mg 25pioglitazone hcl 45 mg 25pioglitazone hcl-glimepiride 24pioglitazone hcl-metforminhcl 24piperacillin sodium-tazobactamsodium 0.25gm-2gm, 0.375gm-3gm, 4.5gm-36gm 84piperacillin sodium-tazobactamsodium 0.5gm-4gm 84piroxicam 10 mg, 20 mg 4PLAQUENIL 35PLAVIX 300 MG 72PLAVIX 75 MG 72PLEGRIDY 86PLEGRIDY STARTERPACK 86PLETAL 72podofilox 63polyethylene glycol 3350 74polymyxin b sulfate 12polymyxin b-trimethoprim 81POLYTRIM 81POMALYST 38PONSTEL 4PORTRAZZA 37potassium chloride 10 %, 20% 77potassium chloride 10 meq, 8meq 77potassium chloride 2 meq/ml 77POTASSIUM CHLORIDEER 77potassium chloride in dextrose &sodium chloride 0.45%-20meq/l-5% 77potassium chloridemicroencapsulated crystalscr 77

potassium citrate (alkalinizer)1080 mg 71potassium citrate (alkalinizer)540 mg 71POTIGA 200 MG 19POTIGA 300 MG 19POTIGA 400 MG 19POTIGA 50 MG 19PRADAXA 17PRALUENT 150 MG/ML 31PRALUENT 75 MG/ML 31pramipexoledihydrochloride 42pramoxine-hc 1%-1% 62PRANDIMET 24PRANDIN 0.5 MG 26PRANDIN 1 MG 26PRANDIN 2 MG 26PRAVACHOL 31pravastatin sodium 31prazosin hcl 33PRECOSE 23PRED FORTE 82PRED MILD 82prednicarbate 62prednisolone 15 mg/5ml 56prednisolone 5 mg 56prednisolone acetate(ophth) 82prednisolone sodiumphosphate (ophth) 82prednisolone sodiumphosphate 10 mg, 15 mg, 30mg 56prednisolone sodiumphosphate 15 mg/5ml, 5mg/5ml, 6.7 mg/5ml 56prednisolone sodiumphosphate 20 mg/5ml 56prednisolone sodiumphosphate 25 mg/5ml 56prednisone 1 mg, 10 mg, 2.5mg, 20 mg, 5 mg, 50 mg 56prednisone 10 mg, 5 mg 56prednisone 5 mg/5ml 56prednisone 5 mg/ml 56PREMARIN 0.3 MG, 0.45 MG,0.625 MG, 0.9 MG, 1.25MG 69PREMARIN 0.625 MG/GM 91PREMPHASE 68PREMPRO 68

PREPOPIK 74PREVACID 15 MG 89PREVACID 30 MG 89PREVPAC 89PREZCOBIX 46PREZISTA 100 MG/ML 46PREZISTA 150 MG, 75 MG 46PREZISTA 600 MG, 800 MG46PRIFTIN 35PRILOSEC 10 MG, 20 MG, 40MG 89PRIMAQUINE PHOSPHATE35primaquine phosphate 35PRIMAXIN IV 11primidone 250 mg, 50 mg 19PRIMSOL 10PRINIVIL 32PRISTIQ 22PRIVIGEN 83PROAIR HFA 16PROAIR RESPICLICK 16probenecid 71procainamide hcl 500 mg/ml 13PROCARDIA 51PROCARDIA XL 51prochlorperazine 45prochlorperazine edisylate 45prochlorperazine maleate 10 mg,5 mg 45PROCRIT 10000 UNIT/ML, 2000UNIT/ML, 3000 UNIT/ML, 4000UNIT/ML 73PROCRIT 20000 UNIT/ML,40000 UNIT/ML 73PROCTOCORT 1 % 9PROCYSBI 71progesterone micronized 100 mg,200 mg 85PROGLYCEM 25PROGRAF 0.5 MG, 1 MG, 5MG 49PROGRAF 5 MG/ML 49PROLASTIN-C 87PROLENSA 82PROLEUKIN 40PROLIA 66PROMACTA 12.5 MG 73PROMACTA 25 MG 73PROMACTA 50 MG 73

Index 21

PROMACTA 75 MG 73promethazine &phenylephrine 57promethazine hcl 12.5 mg, 25mg, 50 mg 30promethazine hcl 25 mg/ml, 50mg/ml 30promethazine hcl 6.25mg/5ml 30PROMETRIUM 85propafenone hcl 13propantheline bromide 88proparacaine hcl 81propranolol hcl 10 mg, 20 mg, 40mg, 60 mg, 80 mg 51propranolol hcl 120 mg, 160 mg,60 mg, 80 mg 51propylthiouracil 88PROQUAD 91PROSCAR 71PROTONIX 20 MG, 40 MG 89PROTONIX 40 MG 89PROTOPIC 63protriptyline hcl 23PROVENTIL HFA 16PROVERA 85PROVIGIL 2PROZAC 21PROZAC WEEKLY 21PULMICORT 0.25 MG/2ML 15PULMICORT 0.5 MG/2ML 15PULMICORT 1 MG/2ML 15PULMICORT FLEXHALER 180MCG/ACT 15PULMICORT FLEXHALER 90MCG/ACT 15PULMOZYME 87PURINETHOL 37PURIXAN 37PYLERA 89pyrazinamide 35pyridostigmine bromide 180mg 35pyridostigmine bromide 60mg 35QNASL 79QNASL CHILDRENS 79QUALAQUIN 35QUARTETTE 55

quetiapine fumarate 100 mg,200 mg, 25 mg, 300 mg, 400mg, 50 mg 44quetiapine fumarate 400mg 44QUETIAPINE FUMARATEER 44quinapril hcl 32quinapril-hydrochlorothiazide

34quinidine gluconate 324mg 13quinidine sulfate 13quinine sulfate 35QVAR 15RABAVERT 91RAGWITEK 51raloxifene hcl 67ramipril 32RANEXA 12ranitidine hcl 15 mg/ml, 150mg/10ml, 75 mg/5ml 89ranitidine hcl 150 mg 89ranitidine hcl 150 mg, 300mg 89ranitidine hcl 300 mg 89RAPAFLO 71RAPAMUNE 0.5 MG 49RAPAMUNE 1 MG, 2 MG 49RAPAMUNE 1 MG/ML 49RASUVO 3RAVICTI 67RAYOS 2 MG, 5 MG 56RAZADYNE 85RAZADYNE ER 85REBETOL 200 MG 48REBETOL 40 MG/ML 48REBIF 86REBIF REBIDOSE 86REBIF REBIDOSETITRATIONPACK 86REBIF TITRATION PACK 86RECLAST 66RECOMBIVAX HB 91RECTIV 10REGLAN 70REGRANEX 64RELENZA DISKHALER 48RELISTOR 12 MG/0.6ML 70RELISTOR 8 MG/0.4ML 70

RELPAX 76REMERON 20REMERON SOLTAB 20REMICADE 70REMODULIN 52RENAGEL 800 MG 70RENVELA 70repaglinide 0.5 mg 26repaglinide 1 mg 26repaglinide 2 mg 26repaglinide-metformin hcl 24REPATHA 32REPATHA PUSHTRONEXSYSTEM 32REPATHA SURECLICK 32REQUIP 42REQUIP XL 42RESCRIPTOR 100 MG 46RESCRIPTOR 200 MG 46RESERPINE 0.1 MG 33RESERPINE 0.25 MG 33RESTASIS 81RESTASIS MULTIDOSE 81RESTORIL 73RETIN-A 58RETIN-A MICRO 58RETIN-A MICRO PUMP 0.04 %,0.1 % 58RETIN-A MICRO PUMP 0.08% 58RETROVIR 46RETROVIR IV INFUSION 46REVATIO 10 MG/12.5ML 52REVATIO 20 MG 52REVIA 28REVLIMID 49REXULTI 0.25 MG 45REXULTI 0.5 MG 45REXULTI 1 MG 45REXULTI 2 MG 45REXULTI 3 MG 45REXULTI 4 MG 45REYATAZ 46RHEUMATREX 3RHINOCORT AQUA 79ribavirin (hepatitis c) 48ribavirin (hepatitis c) 200 mg 48

Index 22

ribavirin (hepatitis c) 400 mg, 600mg 48RIDAURA 3rifabutin 35RIFADIN 35RIFAMATE 35rifampin 150 mg, 300 mg 35rifampin 600 mg 36RIFATER 35RILUTEK 79riluzole 79rimantadine hydrochloride 48RIOMET 24risedronate sodium 150 mg 66risedronate sodium 30 mg, 5mg 66risedronate sodium 35 mg 66RISPERDAL 43RISPERDAL CONSTA 12.5MG 43RISPERDAL CONSTA 25MG 43RISPERDAL CONSTA 37.5MG 43RISPERDAL CONSTA 50MG 43RISPERDAL M-TAB 43risperidone 0.25 mg, 0.5 mg, 1mg, 2 mg, 3 mg, 4 mg 43risperidone 0.25 mg, 3 mg, 4mg 43risperidone 0.5 mg, 1 mg, 2mg 43risperidone 1 mg/ml 43RITALIN 2RITALIN LA 10 MG 2RITALIN LA 20 MG, 30 MG, 40MG 2RITUXAN 37rivastigmine 85rivastigmine tartrate 85rizatriptan benzoate 10 mg 76rizatriptan benzoate 5 mg 76ROBAXIN 500 MG 78ROBAXIN-750 78ROBINUL 0.2 MG/ML 88ROBINUL 1 MG 88ROBINUL FORTE 88ROCALTROL 67ROCEPHIN 54

ropinirole hydrochloride 0.25mg, 0.5 mg, 1 mg, 2 mg, 3 mg,4 mg, 5 mg 42ropinirole hydrochloride 12 mg,2 mg, 4 mg, 6 mg, 8 mg 42rosuvastatin calcium 31ROTARIX 91ROTATEQ 91ROWASA 70ROXICODONE 15 MG 7ROXICODONE 30 MG 7ROXICODONE 5 MG 7ROZEREM 74RUCONEST 72RYTARY 42RYTHMOL 13RYTHMOL SR 13SABRIL 19SAFYRAL 55SALAGEN 78SAMSCA 68SANCUSO 28SANDIMMUNE 100 MG, 25MG 49SANDIMMUNE 100MG/ML 49SANDIMMUNE 50 MG/ML 49SANDOSTATIN 100MCG/ML 68SANDOSTATIN 200 MCG/ML,50 MCG/ML 68SANDOSTATIN LAR DEPOT20 MG, 30 MG 68SANTYL 63SAPHRIS 10 MG 44SAPHRIS 2.5 MG 44SAPHRIS 5 MG 44SAVAYSA 16SAVELLA 86SAVELLA TITRATIONPACK 86SEASONIQUE 55SECTRAL 50selegiline hcl 42selenium sulfide 2.5 % 60SELZENTRY 46SEMPREX-D 57SENSIPAR 30 MG 67SENSIPAR 60 MG, 90 MG 67SEREVENT DISKUS 16

SEROQUEL 44SEROQUEL XR 150 MG, 200MG, 300 MG, 50 MG 44SEROQUEL XR 400 MG 44SEROSTIM 4 MG, 6 MG 66sertraline hcl 100 mg, 25 mg, 50mg 21sertraline hcl 20 mg/ml 21SIGNIFOR 68SIGNIFOR LAR 20 MG 68SIGNIFOR LAR 40 MG 68SIGNIFOR LAR 60 MG 68sildenafil citrate (pulmonaryhypertension) 10 mg/12.5ml 52sildenafil citrate (pulmonaryhypertension) 20 mg 52SILENOR 73SILVADENE 60silver sulfadiazine 60SIMBRINZA 80SIMPONI 2SIMPONI ARIA 2SIMULECT 49simvastatin 10 mg 31simvastatin 20 mg 31simvastatin 40 mg 31simvastatin 5 mg 31simvastatin 80 mg 31SINEMET 42SINEMET CR 42SINGULAIR 10 MG 14SINGULAIR 4 MG, 5 MG 14sirolimus 0.5 mg, 1 mg 49sirolimus 2 mg 49SIRTURO 36SIVEXTRO 11SKELAXIN 78sodium bicarbonate 8.4 % 77sodium chloride (gu irrigant) 71sodium chloride 0.45 % 77sodium chloride 0.9 % 77sodium fluoride 1 mg 77sodium polystyrenesulfonate 50sodium polystyrene sulfonate 15gm/60ml 50SOLARAZE 59SOLTAMOX 38

Index 23

SOLU-CORTEF 100 MG, 250MG 56SOLU-MEDROL 1000 MG, 125MG, 40 MG 56SOLU-MEDROL 2 GM 57SOMA 78SOMATULINE DEPOT 68SOMAVERT 66SONATA 73SOOLANTRA 64SORIATANE 60SORILUX 60sotalol hcl 51sotalol hcl (afib/afl) 51Sotalol Hcl IV Soln 51SOTYLIZE 51SOVALDI 48SPIRIVA HANDIHALER 14SPIRIVA RESPIMAT 1.25MCG/ACT, 2.5 MCG/ACT 14SPIRIVA RESPIMAT 2.5MCG/ACT 14spironolactone &hydrochlorothiazide 65spironolactone 100 mg, 25 mg,50 mg 65SPORANOX 10 MG/ML 29SPORANOX 100 MG 29SPORANOX PULSEPAK 29SPRITAM 1000 MG 19SPRITAM 250 MG 19SPRITAM 500 MG 19SPRITAM 750 MG 19SPRYCEL 39STALEVO 100 42STALEVO 125 42STALEVO 150 42STALEVO 200 42STALEVO 50 42STALEVO 75 42STARLIX 26stavudine 1 mg/ml 47stavudine 15 mg 46stavudine 20 mg, 30 mg, 40mg 47STELARA 45 MG/0.5ML, 90MG/ML 60STIMATE 68STIOLTO RESPIMAT 16STIVARGA 39

STRATTERA 10 MG 1STRATTERA 100 MG 1STRATTERA 18 MG 1STRATTERA 25 MG 1STRATTERA 40 MG 1STRATTERA 60 MG 1STRATTERA 80 MG 1STRENSIQ 67STRIBILD 47STRIVERDI RESPIMAT 16STROMECTOL 10SUBOXONE 9SUBSYS 100 MCG, 200MCG 7SUBSYS 1200 MCG 7SUBSYS 1600 MCG, 400MCG, 600 MCG, 800 MCG 7sucralfate 89SULAR 51sulfacetamide sod-prednisolone10%-0.2% 82sulfacetamide sod-prednisolone10%-0.23% 82sulfacetamide sodium(acne) 58sulfacetamide sodium(ophth) 81sulfadiazine 87sulfamethoxazole-trimethoprim160mg-800mg, 80mg-400mg 10sulfamethoxazole-trimethoprim40mg/5ml-200mg/5ml 10sulfamethoxazole-trimethoprim80mg/5ml-400mg/5ml 10SULFAMYLON 85 MG/GM60sulfasalazine 70sulindac 150 mg, 200 mg 4sumatriptan succinate 100mg 77sumatriptan succinate 25mg 77sumatriptan succinate 4mg/0.5ml 76sumatriptan succinate 50mg 77sumatriptan succinate 6mg/0.5ml 76SUMAVEL DOSEPRO 77SUPRAX 400 MG 54SUPREP BOWEL PREP 74SURMONTIL 23

SUSTIVA 200 MG, 50 MG 47SUSTIVA 600 MG 47SUTENT 39SYLATRON 40SYMBICORT 4.5MCG/ACT-160MCG/ACT 16SYMBICORT 4.5MCG/ACT-160MCG/ACT, 4.5MCG/ACT-80MCG/ACT 16SYMBICORT 4.5MCG/ACT-80MCG/ACT 16SYMBYAX 85SYMLINPEN 120 23SYMLINPEN 60 23SYNAGIS 83SYNALAR 62SYNAREL 67SYNERCID 12SYNJARDY 12.5MG-1000MG,5MG-1000MG 24SYNJARDY 12.5MG-500MG,5MG-500MG 24SYNRIBO 40SYNTHROID 88SYPRINE 48TABLOID 37TACLONEX 62tacrolimus (topical) 63tacrolimus 0.5 mg, 1 mg, 5mg 49TAFINLAR 39TAGRISSO 39TALTZ 60TALWIN 9TAMIFLU 48tamoxifen citrate 10 mg, 20mg 38tamsulosin hcl 71TANZEUM 25TARCEVA 39TARGRETIN 1 % 59TARGRETIN 75 MG 40TASIGNA 39TASMAR 41TAXOTERE 41TAZORAC 60TECENTRIQ 37TECFIDERA 86TECFIDERA STARTERPACK 86

Index 24

TECHNIVIE 48TEFLARO 600 MG 54TEGRETOL 19TEGRETOL-XR 19TEKTURNA 34TEKTURNA HCT 34telmisartan 33telmisartan-amlodipine 34telmisartan-hydrochlorothiazide

34temazepam 74TEMODAR 100 MG 36TEMOVATE 62TEMOVATE E 62TENEX 33TENIVAC 88TENORETIC 100 34TENORETIC 50 34TENORMIN 50TERAZOL 3 91TERAZOL 7 91terazosin hcl 33terbinafine hcl 29terbutaline sulfate 2.5 mg, 5mg 16terconazole vaginal 91TESTIM 9TESTOSTERONE 1 %, 10MG/ACT, 25 MG/2.5GM, 50MG/5GM 9testosterone 1 %, 25 mg/2.5gm,50 mg/5gm 9testosterone cypionate 9testosterone enanthate 9TESTOSTERONE PUMP 9TETANUS/DIPHTHERIATOXOIDS-ADSORBED 88TETANUS/DIPHTHERIATOXOIDS-ADSORBEDADULT 88tetrabenazine 86tetracycline hcl 250 mg, 500mg 87tetrahydrozoline hcl 79THALOMID 49theophylline 100 mg, 200 mg,300 mg, 450 mg 16theophylline 400 mg, 600 mg16THERACYS 40

thioridazine hcl 10 mg, 100 mg,25 mg, 50 mg 45THIOTEPA 36thiothixene 45THYMOGLOBULIN 49tiagabine hcl 19TIAZAC 52TICE BCG 40ticlopidine hcl 72TIGAN 300 MG 28TIGECYCLINE 11TIKOSYN 13timolol maleate (ophth) 0.25 %,0.5 % 80TIMOPTIC 80TIMOPTIC-XE 80TINDAMAX 10tinidazole 250 mg, 500 mg 10TIVICAY 10 MG 47TIVICAY 25 MG, 50 MG 47tizanidine hcl 2 mg 78tizanidine hcl 4 mg 78tizanidine hcl 6 mg 78TOBI 2TOBI PODHALER 2TOBRADEX 82TOBRADEX ST 82tobramycin 2tobramycin (ophth) 81tobramycin sulfate 1.2 gm 2tobramycin sulfate 1.2 gm/30ml,40 mg/ml, 80 mg/2ml 2tobramycin-dexamethasone 82TOBREX 81TOFRANIL-PM 23TOLAZAMIDE 250 MG 27tolazamide 250 mg 27tolazamide 500 mg 27tolbutamide 27tolcapone 41tolmetin sodium 200 mg 4tolmetin sodium 400 mg 4tolmetin sodium 600 mg 4tolterodine tartrate 90TOPAMAX 19TOPAMAX SPRINKLE 19TOPICORT 0.05 % 63

TOPICORT 0.25 % 63topiramate 100 mg, 200 mg, 25mg, 50 mg 19topiramate 15 mg, 25 mg 19topotecan hcl 4 mg 41TOPROL XL 50TORISEL 40torsemide 10 mg, 100 mg, 20 mg,5 mg 65TOUJEO SOLOSTAR 26TOVIAZ 90TRACLEER 52TRADJENTA 25tramadol hcl 100 mg 7tramadol hcl 200 mg 7tramadol hcl 300 mg 7tramadol hcl 50 mg 7tramadol-acetaminophen 8trandolapril 32tranexamic acid 1000mg/10ml 73tranexamic acid 650 mg 73TRANSDERM-SCOP 28TRANXENE T 13tranylcypromine sulfate 21TRAVATAN Z 83trazodone hcl 100 mg, 150 mg,300 mg, 50 mg 22TREANDA 36TRECATOR 36TRELSTAR 38TRELSTAR MIXJECT 38TRESIBA FLEXTOUCH 100UNIT/ML 26TRESIBA FLEXTOUCH 200UNIT/ML 26tretinoin (chemotherapy) 40tretinoin 0.01 %, 0.025 % 58tretinoin 0.025 %, 0.05 %, 0.1% 58tretinoin 0.038 % 58tretinoin 0.05 % 58tretinoin microsphere 58TREXIMET 10MG-60MG 75TREXIMET 85MG-500MG 75triamcinolone acetonide(mouth) 78triamcinolone acetonide(nasal) 79

Index 25

triamcinolone acetonide(topical) 63triamterene & hydrochlorothiazide37.5mg-25mg 65triamterene & hydrochlorothiazide37.5mg-25mg, 75mg-50mg 65triamterene & hydrochlorothiazide50mg-25mg 65triazolam 0.125 mg, 0.25 mg 74TRIBENZOR 34TRICOR 31trifluoperazine hcl 45trifluridine 81trihexyphenidyl hcl 41TRILEPTAL 150 MG, 300 MG,600 MG 19TRILEPTAL 300 MG/5ML 19TRILIPIX 31trimethobenzamide hcl 28trimethoprim 10trimipramine maleate 100mg 23trimipramine maleate 25 mg, 50mg 23TRINATAL RX 1 78TRINTELLIX 10 MG 22TRINTELLIX 20 MG 22TRINTELLIX 5 MG 22TRISENOX 40TRIUMEQ 47TRIZIVIR 47trospium chloride 20 mg 90trospium chloride 60 mg 90TRULICITY 25TRUSOPT 82TRUVADA 47TUDORZA PRESSAIR 14TWINRIX 91TWYNSTA 34TYBOST 47TYGACIL 11TYKERB 40TYPHIM VI 91TYSABRI 86TYVASO 52TYVASO REFILL 52TYVASO STARTER 52TYZEKA 48UCERIS 2 MG/ACT 9

UCERIS 9 MG 57ULORIC 71ULTRACET 8ULTRAM 7ULTRAM ER 100 MG 7ULTRAM ER 200 MG 7ULTRAM ER 300 MG 7ULTRAVATE 63UNASYN 1GM-2GM 84UPTRAVI 52UROCIT-K 10 71UROCIT-K 5 71UROXATRAL 71URSO 250 69URSO FORTE 69ursodiol 250 mg, 500 mg 69ursodiol 300 mg 69UVADEX 40VAGIFEM 91valacyclovir hcl 1 gm, 1000 mg,500 mg 48VALCHLOR 59VALCYTE 47valganciclovir hcl 47VALIUM 13valproate sodium 100 mg/ml,500 mg/5ml 20valproate sodium 250mg/5ml 20valproic acid 20valsartan 33valsartan-hydrochlorothiazide

34VALSTAR 39VALTREX 48VANCOCIN HCL 10vancomycin hcl 10 gm, 1000mg, 5000 mg, 750 mg 10vancomycin hcl 125 mg, 250mg 10vancomycin hcl 500 mg 10VANCOMYCIN HCL INDEXTROSE 10VANOS 63VANTAS 38VAQTA 91VARIVAX 91VARIZIG 125 UNIT/1.2ML 83VARUBI 28

VASCEPA 0.5 GM 30VASCEPA 1 GM 30VASERETIC 34VASOTEC 10 MG 32VASOTEC 2.5 MG 32VASOTEC 20 MG 32VASOTEC 5 MG 32VECTIBIX 37VECTICAL 60VELCADE 40VELPHORO 70VELTASSA 16.8 GM 50VELTASSA 25.2 GM 50VELTASSA 8.4 GM 50VELTIN 58VENCLEXTA 37VENCLEXTA STARTINGPACK 37venlafaxine hcl 100 mg 22venlafaxine hcl 150 mg 22venlafaxine hcl 25 mg 22venlafaxine hcl 37.5 mg 22venlafaxine hcl 50 mg 22venlafaxine hcl 75 mg 22VENLAFAXINE HCL ER 22VENTAVIS 10 MCG/ML 52VENTAVIS 20 MCG/ML 52VENTOLIN HFA 16VERAMYST 79verapamil hcl 100 mg, 120 mg,180 mg, 200 mg, 240 mg, 300mg, 360 mg 52verapamil hcl 120 mg, 180 mg,240 mg 52verapamil hcl 120 mg, 40 mg, 80mg 52VEREGEN 58VERELAN 52VERELAN PM 52VERSACLOZ 44VESICARE 90VEXOL 82VFEND 200 MG, 50 MG 29VFEND 40 MG/ML 29VFEND IV 29VIBERZI 70VIBRAMYCIN 100 MG 87VIBRAMYCIN 25 MG/5ML 87

Index 26

VIBRAMYCIN 50 MG/5ML 87VICOPROFEN 8VICTOZA 25VICTRELIS 48VIDAZA 37VIDEX EC 47VIDEXPEDIATRIC 47VIEKIRA PAK 48VIGAMOX 81VIIBRYD 22VIIBRYD 10 MG, 20 MG, 40MG 22VIIBRYD STARTER PACK 22VIMIZIM 67VIMOVO 4VIMPAT 10 MG/ML 19VIMPAT 100 MG, 50 MG 19VIMPAT 150 MG, 200 MG 19VIMPAT 200 MG/20ML 19vinblastine sulfate 41vincristine sulfate 41vinorelbine tartrate 41VIOKACE 64VIRACEPT 47VIRAMUNE 200 MG 47VIRAMUNE 50 MG/5ML 47VIRAMUNE XR 100 MG 47VIRAMUNE XR 400 MG 47VIRAZOLE 48VIREAD 47VIROPTIC 81VISTARIL 12VISTIDE 47VITEKTA 47VIVELLE-DOT 69VOGELXO 9VOGELXO PUMP 9VOLTAREN 58VOLTAREN-XR 4voriconazole 200 mg 29voriconazole 200 mg, 50 mg 29voriconazole 40 mg/ml 29VOTRIENT 40VPRIV 72VRAYLAR 43VRAYLAR 1.5 MG 43

VRAYLAR 3 MG 43VRAYLAR 4.5 MG 43VRAYLAR 6 MG 43VYTORIN 10MG-10MG 30VYTORIN 10MG-20MG 30VYTORIN 40MG-10MG 30VYTORIN 80MG-10MG 30VYVANSE 10 MG 1VYVANSE 20 MG 1VYVANSE 30 MG 1VYVANSE 40 MG 1VYVANSE 50 MG 1VYVANSE 60 MG 1VYVANSE 70 MG 1warfarin sodium 16water for irrigation, sterile 50WELCHOL 30WELLBUTRIN 100 MG 20WELLBUTRIN 75 MG 20WELLBUTRIN SR 100 MG20WELLBUTRIN SR 150 MG20WELLBUTRIN SR 200 MG20WELLBUTRIN XL 150 MG 21WELLBUTRIN XL 300 MG 21WESTCORT 63XALATAN 83XALKORI 40XANAX 13XANAX XR 13XARELTO 16XARELTO STARTERPACK 16XELJANZ 2XELJANZ XR 2XENAZINE 86XEOMIN 79XERESE 60XGEVA 66XIAFLEX 49XIFAXAN 10XIGDUO XR 10MG-1000MG,10MG-500MG 24XIGDUO XR 5MG-1000MG,5MG-500MG 24XOLAIR 14XOPENEX 16XOPENEXCONCENTRATE 16

XOPENEX HFA 16XTANDI 38XYLOCAINE 1 %, 2 % 75XYLOCAINE 20 MG/ML 13XYLOCAINE 4 % 63XYLOCAINE-MPF 1 % 75XYREM 85XYZAL 29YASMIN 28 55YAZ 55YERVOY 37YF-VAX 91YONDELIS 36zafirlukast 14zaleplon 74ZALTRAP 37ZANAFLEX 2 MG 78ZANAFLEX 4 MG 78ZANAFLEX 6 MG 78ZANOSAR 36ZANTAC 150 MG 89ZANTAC 300 MG 89ZARONTIN 20ZAROXOLYN 65ZARXIO 73ZAVESCA 72ZEBETA 50ZEGERID 20MG-1100MG 90ZEGERID 20MG-1680MG 90ZEGERID 40MG-1100MG 90ZEGERID 40MG-1680MG 90ZELAPAR 42ZELBORAF 40ZEMAIRA 87ZEMPLAR 1 MCG, 2 MCG 67ZENPEP 10000UNIT-3000UNIT-16000UNIT, 17000UNIT-5000UNIT-27000UNIT,34000UNIT-10000UNIT-55000UNIT, 51000UNIT-15000UNIT-82000UNIT,68000UNIT-20000UNIT-109000UNIT, 85000UNIT-25000UNIT-136000UNIT 64ZENPEP 136000UNIT-40000UNIT-218000UNIT 64ZEPATIER 48ZERIT 47

Index 27

ZESTORETIC 34ZESTRIL 32ZETIA 31ZETONNA 79ZIAC 34ZIAGEN 20 MG/ML 47ZIAGEN 300 MG 47ZIANA 58zidovudine 100 mg 47zidovudine 300 mg 47zidovudine 50 mg/5ml 47ZINACEF 1.5 GM 53ZINECARD 41ZIOPTAN 83ziprasidone hcl 43ZIPSOR 4ZIRGAN 81ZITHROMAX 100 MG/5ML, 200MG/5ML 75ZITHROMAX 250 MG, 500 MG,600 MG 75ZITHROMAX 500 MG 75ZITHROMAX TRI-PAK 75ZITHROMAX Z-PAK 75ZOCOR 10 MG 31ZOCOR 20 MG 31ZOCOR 40 MG 31ZOCOR 5 MG 31ZOCOR 80 MG 31ZOFRAN 4 MG, 8 MG 28ZOFRAN 4 MG/5ML 28ZOFRAN 40 MG/20ML 28ZOFRAN ODT 28ZOHYDRO ER 10 MG, 15 MG,20 MG, 30 MG, 40 MG, 50MG 7ZOLADEX 38ZOLEDRONIC ACID 4 MG 66zoledronic acid 4 mg/5ml 66zoledronic acid 5 mg/100ml 66ZOLINZA 40zolmitriptan 2.5 mg 77zolmitriptan 5 mg 77ZOLOFT 21zolpidem tartrate 1.75 mg, 3.5mg 74zolpidem tartrate 10 mg 74zolpidem tartrate 12.5 mg 74

zolpidem tartrate 5 mg 74zolpidem tartrate 6.25 mg 74ZOLPIMIST 74ZOMACTON 5 MG 66ZOMETA 4 MG/5ML 66ZOMIG 2.5 MG 77ZOMIG 5 MG 77ZOMIG NASAL SPRAY 77ZOMIG ZMT 2.5 MG 77ZOMIG ZMT 5 MG 77ZONEGRAN 19zonisamide 19ZONTIVITY 72ZORTRESS 0.25 MG 49ZORTRESS 0.5 MG, 0.75MG 49ZOSTAVAX 91ZOSYN 0.25GM-2GM,0.375GM-3GM, 0.5GM-4GM,4.5GM-36GM 84ZOSYN 0.375GM/50ML-3GM/50ML-5% 84ZOVIRAX 200 MG 48ZOVIRAX 200 MG/5ML 48ZOVIRAX 400 MG, 800MG 48ZOVIRAX 5 % 60ZUBSOLV 1.4MG-0.36MG,5.7MG-1.4MG, 8.6MG-2.1MG 9ZUBSOLV 11.4MG-2.9MG,2.9MG-0.71MG 9ZYBAN 86ZYCLARA 63ZYCLARA PUMP 63ZYDELIG 40ZYFLO CR 14ZYKADIA 40ZYLET 82ZYLOPRIM 100 MG 71ZYLOPRIM 300 MG 71ZYMAXID 81ZYPREXA 44ZYPREXA RELPREVV 210MG 44ZYPREXA ZYDIS 44ZYTIGA 38ZYVOX 100 MG/5ML 12ZYVOX 200 MG/100ML 11ZYVOX 600 MG 12

ZYVOX 600 MG/300ML 11

Index 28

This formulary was updated on For more recent information or other questions, please contact Health Net at:

Arizona Plans: 1-800-977-7522

California HMO Plans: 1-800-275-4737 California HMO SNP Plans: 1-800-431-9007 California PPO Plans: 1-800-960-4638

Oregon/Washington Plans: 1-888-445-8913

or, for TTY users, 711, 8:00 a.m. - 8:00 p.m., seven days a week (automated telephone service is used on some weekends and holidays), or visit www.healthnet.com/medicare.

The Formulary may change at any time. You will receive notice when necessary.

This information is available for free in other languages. Please call Member Services at the phone number listed above.

Esta información está disponible en forma gratuita en otros idiomas. Por favor llame a nuestro número de servicio al cliente al número de teléfono que aparece arriba.

Health Net has a contract with Medicare to offer HMO, PPO and HMO SNP plans. Health Net has a contract with Medicare and the state Medicaid program to offer HMO SNP coordinated care plans. Enrollment in a Health Net Medicare Advantage plan depends on contract renewal.

12/1/2016.

DIR008915EO00 (12/16)

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