2021 Prescription Drug List - MHS Indiana

2021 Prescription Drug List Effective January 1 2021

Ambettermhsindianacom

Formulary Introduction FORMULARY

The Ambetter from MHS Formulary or Preferred Drug List is a guide to available brand and generic drugs that are approved by the Food and Drug Administration (FDA) and covered through your prescription drug beneft Generic drugs have the same active ingredients as their brand name counterparts and should be considered the frst line of treatment The FDA requires generics to be safe and work the same as brand name drugs If there is no generic available there may be more than one brand name drug to treat a condition Preferred brand name drugs are listed on Tier 2 to help identify brand drugs that are clinically appropriate safe and cost-efective treatment options if a generic medication on the formulary is not suitable for your condition

Please note the Formulary is not meant to be a complete list of the drugs covered under your prescription beneft Not all dosage forms or strengths of a drug may be covered This list is periodically reviewed and updated and may be subject to change Drugs may be added or removed or additional requirements may be added in order to approve continued usage of a specifc drug

Specifc prescription beneft plan designs may not cover certain products or categories regardless of their appearance in this document Please check your benefts for coverage limitations and your share of cost for your drugs

Drug List Key

Brand name drugs are listed in CAPS and generic drugs are lower case Drugs are covered under diferent copay tiers depending on your beneft

Tier 0 - No copayment for those drugs that are used for prevention and are mandated by the Afordable Care Act Select oral contraceptives vitamin D folic acid for women of child bearing age over-the-counter (OTC) aspirin and smoking cessation products may be covered under this tier Certain age or gender limits apply

Tier 1 - Lowest copayment for those drugs that ofer the greatest value compared to other drugs used to treat similar conditions Select over-the-counter (OTC) generic or brand name drugs may be covered under this tier

Tier 2 - Medium copayment covers brand name drugs that are generally more afordable or may be preferred compared to other drugs to treat the same conditions

Tier 3 - Highest copayment covers higher cost brand name drugs This tier may also cover non-specialty drugs that are not on the Preferred Drug List but approval has been granted for coverage

Tier 4 - Coverage for this tier is for ldquospecialtyrdquo drugs used to treat complex chronic conditions that may require special handling storage or clinical management For members who do not have a Tier 4 plan these drugs may be covered under Tier 3

Prior Authorization for Non-Formulary Drugs

To obtain prior authorization for a non-formulary drug your provider must fill out the Prior Authorization form Envolve Pharmacy Solutions will respond via fax or phone within 24 hours of receipt of all necessary information for urgent requests and within 72 hours for non-urgent requests unless state law requires faster response If the request is disapproved the notice of disapproval will contain a clear explanation of the specific reasons for disapproving the prior authorization request or if the request was incomplete the explanation will identify the missing material information that is necessary to complete the request

Formulary Abbreviations

Abbreviation Term What it means

AL Age Limit Some drugs are only covered for certain ages

QL Quantity Limit Some drugs are only covered for a certain amount

PA Prior Authorization Your doctor must ask for approval from Ambetter before

some drugs will be covered

ST Step Therapy

In some cases you must first try certain drugs before

Ambetter covers another drug for your medical condition

For example if Drug A and Drug B both treat your

medical condition Ambetter may not cover Drug B

unless you try Drug A first

NF Non-formulary

This product is not covered unless you or your provider

request an exception Alternative medications are listed

next to non-covered product

RXOTC Prescription and OTC These drugs are made in both prescription form and

Over-the-counter (OTC) form

Drug Name DrugTier

RequirementsLimits

ADHDANTI-NARCOLEPSYANTI-OBESITYANOREXIANTS - Drugs to TreatADHD Sleep and Eating Disorders

Amphetamines ADDERALL TABS 125 MG-125 MG-125 MG-125 MG 1875 MG-1875 MG-1875 MG-1875 MG 25 MG-25 MG-25 MG-25 MG 3125 MG-3125 MG-3125 MG-3125 MG 375 MG-375 MG-375 MG-375 MG 5 MG-5 MG-5 MG-5 MG (Use amphetamine-dextroamphetamine)

NF

QL(3 ea daily)

ADDERALL TABS 75 MG-75 MG-75 MG-75 MG (Use amphetamine-dextroamphetamine)

NF

QL(2 ea daily)

ADDERALL XR CP24 125 MG-125 MG-125 MG-125 MG 25 MG-25 MG-25 MG-25 MG (Use amphetamine-dextroamphetamine)

NF

QL(1 ea daily)

ADDERALL XR CP24 375 MG-375 MG-375 MG-375 MG (Use amphetamine-dextroamphetamine)

NF

ADDERALL XR CP24 5 MG-5 MG-5 MG-5 MG 625 MG-625 MG-625 MG-625 MG 75 MG-75 MG-75 MG-75 MG (Use amphetamine-dextroamphetamine)

NF

QL(2 ea daily)

ADZENYS ER SUER (Use amphetamine) NF

amphetamine-dextroamphetamine cp24125 mg-125 mg-125 mg-125 mg 25 mg-25 mg-25 mg-25 mg

1

QL(1 ea daily)

amphetamine-dextroamphetamine cp24375 mg-375 mg-375 mg-375 mg

1

Drug Name DrugTier

RequirementsLimits

amphetamine-dextroamphetamine cp24 5mg-5 mg-5 mg-5 mg 625mg-625 mg-625 mg-625mg 75 mg-75 mg-75 mg-75 mg

1

QL(2 ea daily)

amphetamine-dextroamphetamine tabs125 mg-125 mg-125 mg-125 mg 1875 mg-1875mg-1875 mg-1875 mg25 mg-25 mg-25 mg-25mg 3125 mg-3125 mg-3125 mg-3125 mg 375mg-375 mg-375 mg-375mg 5 mg-5 mg-5 mg-5 mg

1

QL(3 ea daily)

amphetamine-dextroamphetamine tabs75 mg-75 mg-75 mg-75 mg

1

QL(2 ea daily)

DESOXYN TABS (Use methamphetamine hcl) NF

QL(5 ea daily)AL(At least 6yrs old)

DEXEDRINE CP24 10 MG 15 MG (Use dextroamphetaminesulfate)

NF

QL(4 ea daily)

DEXEDRINE CP24 5 MG (Use dextroamphetaminesulfate)

NF

dextroamphetamine sulfatecp24 10 mg 15 mg 1 QL(4 ea daily)

dextroamphetamine sulfatecp24 5 mg 1

dextroamphetamine sulfatesoln 5 mg5ml 1

dextroamphetamine sulfatetabs 10 mg 5 mg 1 QL(4 ea daily)

methamphetamine hcl tabs 3 QL(5 ea daily)AL(At least 6yrs old)

VYVANSE CAPS 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG 70 MG

3 ST QL(1 eadaily)

VYVANSE CHEW 10 MG 20 MG 30 MG 40 MG 50 MG 60 MG

2 ST QL(1 eadaily)

Anorexiants Non-Amphetamine

Ambetter Indiana Formulary Updated December 1 2021

1

Drug Name DrugTier

RequirementsLimits

ADIPEX-P CAPS (Use phentermine hcl) NF PA

phendimetrazine tartratetabs 1 PA

phentermine hcl caps 1 PA

Anti-Obesity Agents

BELVIQ TABS 3 PA QL(2 eadaily)

CONTRAVE TB12 3 PA QL(4 eadaily)

Attention-DeficitHyperactivity Disorder (ADHD)

atomoxetine hcl caps 10mg 25 mg 40 mg 18 mg 1


atomoxetine hcl caps 100mg 60 mg 80 mg 1


clonidine hcl (adhd) tb12 1

guanfacine hcl (adhd) tb24 1 QL(1 ea daily)AL(At least 6yrs old)

INTUNIV TB24 (Use guanfacine hcl (adhd)) NF


KAPVAY TB12 (Use clonidine hcl (adhd)) NF

STRATTERA CAPS 10 MG 25 MG 40 MG 18 MG (Use atomoxetine hcl)

NF QL(2 ea daily)AL(At least 6yrs old)

STRATTERA CAPS 100 MG 60 MG 80 MG (Use atomoxetine hcl)


Dopamine and Norepinephrine Reuptake

SUNOSI TABS 3 PA

Stimulants - Misc

armodafinil tabs 1

PA QL(1 eadaily) AL(Atleast 17 yrsold)

CONCERTA TBCR 18 MG 27 MG (Use methylphenidate hcl)


Drug Name DrugTier

RequirementsLimits



DAYTRANA PTCH 3 PA QL(1 eadaily)

dexmethylphenidate hclcp24 35 mg 10 mg 15 mg20 mg 25 mg 30 mg 40mg 5 mg

1

QL(1 ea daily)

dexmethylphenidate hcltabs 25 mg 10 mg 5 mg 1


FOCALIN TABS (Use dexmethylphenidate hcl) NF


FOCALIN XR CP24 (Use dexmethylphenidate hcl) NF QL(1 ea daily)

METHYLIN SOLN (Use methylphenidate hcl) NF

QL(30 mldaily) AL(Atleast 6 yrs old)

methylphenidate hcl chew10 mg 25 mg 5 mg 1

methylphenidate hcl cp2420 mg 40 mg 1 AL(At least 6

yrs old)

methylphenidate hcl cp2430 mg 1


methylphenidate hcl cpcr40 mg 20 mg 60 mg 10mg 30 mg 50 mg

1 QL(1 ea daily)AL(At least 6yrs old)

methylphenidate hcl soln10 mg5ml 5 mg5ml 1


methylphenidate hcl tabs10 mg 20 mg 5 mg 1


methylphenidate hcl tbcr 10mg 20 mg 1







2

Drug Name DrugTier

RequirementsLimits

modafinil tabs 100 mg 1




NUVIGIL TABS (Use armodafinil) NF


PROVIGIL TABS 100 MG (Use modafinil) NF




RITALIN LA CP24 20 MG 40 MG (Use methylphenidate hcl)

NF AL(At least 6yrs old)

RITALIN LA CP24 30 MG (Use methylphenidate hcl) NF


RITALIN TABS (Use methylphenidate hcl) NF


ALLERGENIC EXTRACTSBIOLOGICALS MISC

Allergenic Extracts

GRASTEK SUBL 3 PA

AMEBICIDES

Amebicides

SOLOSEC PACK 3 PA

AMINOGLYCOSIDES - Drugs to Treat BacterialInfections

Aminoglycosides

amikacin sulfate soln 1

ARIKAYCE SUSP 4 PA

Drug Name DrugTier

RequirementsLimits

gentamicin in saline soln09 -08 mgml 09 -12mgml 09 -16 mgml 1mgml-09

1

gentamicin sulfate soln 40mgml 1

HUMATIN CAPS (Use paromomycin sulfate) NF

KITABIS PAK NEBU (Use tobramycin) NF PA

neomycin sulfate tabs 1

paromomycin sulfate caps 1

streptomycin sulfate solr 3

TOBI NEBU (Use tobramycin) NF PA

tobramycin nebu 300mg5ml 4 PA

tobramycin sulfate soln 10mgml 40 mgml 80mg2ml

1

ANALGESICS - ANTI-INFLAMMATORY - Drugsto Treat Pain Swelling Muscle and JointConditions

Anti-TNF-alpha - Monoclonal Antibodies

HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK PSKT

4

PA 1 rtl packlmt amt180 rtl pack lmtday(s)1 mailpack lmtamt180 mail pack lmtday(s)

HUMIRA PEN PNKT 40 MG04ML 40 MG08ML 4 PA QL(0143

ea daily)

HUMIRA PEN PNKT 80 MG08ML 4


HUMIRA PEN-CDUCHSSTARTER PNKT 40 MG08ML

4 PA QL(0143ea daily)


3

Drug Name DrugTier

RequirementsLimits


4


HUMIRA PEN-PEDIATRIC UC STARTER PACK PNKT

4


HUMIRA PEN-PSUVSTARTER PNKT 4


HUMIRA PEN-PSUVSTARTER PNKT 4 PA QL(0143

ea daily)

HUMIRA PSKT 4 PA QL(0143ea daily)

Antirheumatic - Enzyme Inhibitors

RINVOQ TB24 4 PA QL(1 eadaily)

XELJANZ TABS 10 MG 4 PA QL(2 eadaily)

XELJANZ TABS 5 MG 4 PA QL(2 eadaily) SP

XELJANZ XR TB24 4 PA QL(1 eadaily)

Antirheumatic Antimetabolites

METHOTREXATE TABS 4 PA QL(1714ea daily) SP

Gold Compounds

RIDAURA CAPS 3 QL(3 ea daily)

Interleukin-1 Blockers

ARCALYST SOLR 4 PA QL(0286ea daily) SP

Drug Name DrugTier

RequirementsLimits

Interleukin-1beta Blockers

ILARIS SOLN 4 PA QL(0072ml daily)

Nonsteroidal Anti-inflammatory Agents (NSAIDs) ARTHROTEC 50 TBEC (Use diclofenac wmisoprostol)

NF

ARTHROTEC 75 TBEC (Use diclofenac wmisoprostol)

NF

CELEBREX CAPS 100 MG 50 MG 200 MG (Use celecoxib)

NF PA QL(2 eadaily)

CELEBREX CAPS 400 MG (Use celecoxib) NF PA QL(1 ea

daily) celecoxib caps 100 mg 50mg 200 mg 1 PA QL(2 ea

daily)

celecoxib caps 400 mg 1 PA QL(1 eadaily)

CHILDRENS ADVIL SUSP (Use ibuprofen) NF RXOTC

CHILDRENS MOTRIN SUSP (Use ibuprofen) NF RXOTC

DAYPRO TABS (Use oxaprozin) NF

diclofenac potassium tabs50 mg 1

diclofenac sodium tb24 1

diclofenac sodium tbec 1

diclofenac w misoprostoltbec 1

EC-NAPROSYN TBEC 500 MG (Use naproxen) NF

etodolac caps 200 mg 300 mg 1

etodolac tabs 400 mg 500 mg 1

FELDENE CAPS (Use piroxicam) NF

fenoprofen calcium tabs600 mg 1 PA QL(1 ea

daily)

flurbiprofen tabs 1


4

Drug Name DrugTier

RequirementsLimits

ibuprofen susp 100 mg5ml 1 RXOTC

ibuprofen tabs 400 mg 600mg 800 mg 1

indomethacin caps 25 mg50 mg 1

indomethacin cpcr 75 mg 1

ketoprofen caps 50 mg 75 mg 1

ketorolac tromethamine tabs or 10 mg 1 QL(0667 ea

daily) LODINE TABS (Use etodolac) NF

meclofenamate sodium caps 1

mefenamic acid caps 1 ST Must tryibuprofenQL(5 ea daily)

meloxicam tabs 15 mg 75 mg 1 QL(1 ea daily)

MOBIC TABS (Use meloxicam) NF QL(1 ea daily)

nabumetone tabs 1

NALFON TABS 600 MG (Use fenoprofen calcium) NF PA QL(1 ea

daily) NAPROSYN SUSP 125 MG5ML (Use naproxen) NF PA

NAPROSYN TABS 500 MG (Use naproxen) NF

naproxen sodium tabs 550 mg 1

naproxen susp 125 mg5ml 1 PA

naproxen tabs 250 mg 375mg 500 mg 1

naproxen tbec 500 mg 1

oxaprozin tabs 1

piroxicam caps 1

sulindac tabs 1

tolmetin sodium caps 1

Drug Name DrugTier

RequirementsLimits

tolmetin sodium tabs 1

Phosphodiesterase 4 (PDE4) Inhibitors

OTEZLA TABS 4 PA QL(2 eadaily)

OTEZLA TBPK 4

PA 1 rtl packlmt amt180 rtl pack lmtday(s)

Pyrimidine Synthesis Inhibitors ARAVA TABS (Use leflunomide) NF QL(1 ea daily)

leflunomide tabs 1 QL(1 ea daily)

Soluble Tumor Necrosis Factor Receptor Agents

ENBREL MINI SOCT 4 PA QL(015 mldaily)

ENBREL SOLN 25 MG05ML 4 PA QL(0146

ml daily)

ENBREL SOLR 25 MG 4 PA QL(0286ea daily) SP

ENBREL SOSY 25 MG05ML 4 PA QL(0146

ml daily) SP

ENBREL SOSY 50 MGML 4 PA QL(028 mldaily) SP

ENBREL SURECLICK SOAJ 4 PA QL(0143

ml daily) SP

ANALGESICS - NonNarcotic - Drugs to TreatPain Muscle and Joint Conditions

Analgesic Combinations butalbital-acetaminophentabs 50 mg-325 mg 1

butalbital-acetaminophen-caffeine caps 40 mg-50mg-300 mg 40 mg-50 mg-325 mg

1

butalbital-acetaminophen-caffeine tabs 325 mg-40mg-50 mg 40 mg-50 mg-325 mg

1

butalbital-aspirin-caffeine caps 1

BUTALBITALACETAMINOPHEN CAPS (Use butalbital-acetaminophen)

NF


5

Drug Name DrugTier

RequirementsLimits

ESGIC TABS (Use butalbital-acetaminophen-caffeine)

NF

FIORICET CAPS (Use butalbital-acetaminophen-caffeine)

NF

FIORINAL CAPS (Use butalbital-aspirin-caffeine) NF

Salicylates

aspirin chew 0 AL(At least 45yrs old - Up to79 yrs old)

aspirin tabs 0 AL(At least 45yrs old - Up to79 yrs old)

aspirin tbec 0 AL(At least 45yrs old - Up to79 yrs old)

diflunisal tabs 1

salsalate tabs 1

ANALGESICS - OPIOID - Drugs to Treat PainMuscle and Joint Conditions

Opioid Agonists ACTIQ LPOP (Use fentanyl citrate) NF PA QL(4 ea

daily)

CODEINE SULFATE TABS 15 MG 60 MG 1

New starts limited to 7 daysupply

codeine sulfate tabs 30 mg 1 New starts limited to 7 daysupply

CONZIP CP24 (Use tramadol hcl) NF

DEMEROL SOLN 100 MGML 25 MGML 50MGML (Use meperidine hcl)

NF

DILAUDID LIQD OR 1 MGML (Use hydromorphone hcl)

NF New starts limited to 7 daysupply

DILAUDID SOLN IJ 1 MGML 2 MGML (Use hydromorphone hcl)

NF

Drug Name DrugTier

RequirementsLimits

DILAUDID TABS OR 2 MG 4 MG 8 MG (Use hydromorphone hcl)

NF

New starts limited to 7 daysupplyQL(8 eadaily)

DURAGESIC PT72 (Use fentanyl) NF QL(034 ea

daily) fentanyl citrate lpop bu1200 mcg 1600 mcg 200mcg 400 mcg 600 mcg800 mcg

1

PA QL(4 eadaily)

fentanyl pt72 td 12 mcghr100 mcghr 25 mcghr 50mcghr 75 mcghr

1 QL(034 eadaily)

FENTORA TABS (Use fentanyl citrate) NF

hydrocodone bitartratecp12 10 mg 15 mg 30 mg40 mg 50 mg

1 PA QL(2 eadaily)

HYDROCODONE BITARTRATE ER CP12 1 PA QL(2 ea

daily)

hydromorphone hcl liqd or1 mgml 1


hydromorphone hcl soln ij10 mgml 50 mg5ml 500mg50ml

1

hydromorphone hcl tabs or2 mg 4 mg 8 mg 1


hydromorphone hcl tb24 or12 mg 16 mg 8 mg 1 PA QL(2 ea

daily) hydromorphone hcl tb24 or32 mg 1 PA QL(1 ea

daily) HYDROMORPHONE HYDROCHLORIDE SOLN IJ 10 MGML (Use hydromorphone hcl)

NF

KADIAN CP24 100 MG 20 MG 30 MG 50 MG 60 MG 80 MG (Use morphine sulfate)

NF

PA QL(2 eadaily)

levorphanol tartrate tabs 2 mg 1


meperidine hcl soln ij 100mgml 25 mgml 50 mgml 1


6

Drug Name DrugTier

RequirementsLimits

meperidine hcl soln or 50mg5ml 1

New starts limited to 7 daysupplyQL(500ml per fill retail)

meperidine hcl tabs or 50 mg 1


methadone hcl conc or 10 mgml 1 QL(10 ml daily)

methadone hcl soln ij 10mgml 1

METHADONE HCL SOLN IJ 10 MGML (Use methadone hcl)

1

methadone hcl soln or 10 mg5ml 1 QL(50 ml daily)

methadone hcl soln or 5 mg5ml 1 QL(100 ml

daily) methadone hcl tabs or 10 mg 1 QL(10 ea daily)

methadone hcl tabs or 5 mg 1 QL(4 ea daily)

methadone hcl tbso or 40 mg 1 QL(2 ea daily)

METHADOSE CONC (Use methadone hcl) NF QL(10 ml daily)

METHADOSE SUGAR-FREE CONC (Use methadone hcl)

NF QL(10 ml daily)

MORPHABOND ER T12A 100 MG 30 MG 60 MG 3 PA QL(1 ea

daily) MORPHABOND ER T12A 15 MG 3 PA QL(3 ea

daily) morphine sulfate cp24 or100 mg 20 mg 30 mg 50mg 60 mg 80 mg

1 PA QL(2 eadaily)

morphine sulfate soln ij 05mgml 1 mgml 1

MORPHINE SULFATE SOLN IV 10 MGML (Use morphine sulfate)

NF

morphine sulfate soln or 10mg5ml 1

New starts limited to 7 daysupplyQL(100ml daily)

Drug Name DrugTier

RequirementsLimits



morphine sulfate tabs or 15 mg 1

morphine sulfate tabs or 15mg 30 mg 1


morphine sulfate tbcr or100 mg 15 mg 200 mg 30mg 60 mg

1 QL(2 ea daily)

MS CONTIN TBCR (Use morphine sulfate) NF QL(2 ea daily)

NUCYNTA ER TB12 2 PA QL(2 eadaily)

NUCYNTA TABS 2 PA QL(6 eadaily)

OPANA TABS (Use oxymorphone hcl) NF PA QL(12 ea

daily)

OXAYDO TABS 5 MG 2

New starts limited to 7 daysupplyQL(12ea daily)

oxycodone hcl t12a 15 mg30 mg 60 mg 80 mg 10mg 20 mg 40 mg

3 PA QL(2 eadaily)

oxycodone hcl tabs 10 mg15 mg 20 mg 30 mg 5 mg 1


OXYCONTIN T12A 3 PA QL(2 eadaily)

oxymorphone hcl tabs 10mg 5 mg 1 PA QL(12 ea

daily) oxymorphone hcl tb12 10mg 15 mg 20 mg 30 mg5 mg 75 mg

1 PA QL(2 eadaily)

oxymorphone hcl tb12 40 mg 1 PA QL(4 ea

daily)

ROXICODONE TABS (Use oxycodone hcl) NF


SUBSYS LIQD 100 MCG 3 PA QL(3 eadaily)


7

Drug Name DrugTier

RequirementsLimits

SUBSYS LIQD 1200 MCG 1600 MCG 800 MCG 3 PA QL(8 ea

daily) SUBSYS LIQD 200 MCG 400 MCG 600 MCG 3 PA QL(4 ea

daily)

tramadol hcl tabs 50 mg 1


tramadol hcl tb24 100 mg200 mg 300 mg 1 QL(1 ea daily)

ULTRAM TABS (Use tramadol hcl) NF


XTAMPZA ER C12A 2 PA QL(2 eadaily)

ZOHYDRO ER CP12 1 PA QL(2 eadaily)

Opioid Combinations acetaminophen w codeinesoln 12 mg5ml-120mg5ml 120 mg5ml-12mg5ml

1


acetaminophen w codeinetabs 15 mg-300 mg 1




acetaminophen w codeinetabs 300 mg-60 mg 60mg-300 mg

1


acetaminophen-caff-dihydrocod caps 16 mg-30mg-3205 mg

1 New starts limited to 7 daysupply


3 PA New starts limited to 7 daysupply

butalbital-acetaminophen-caffeine w codeine caps30 mg-40 mg-50 mg-300 mg

1


Drug Name DrugTier

RequirementsLimits

butalbital-acetaminophen-caffeine w codeine caps30 mg-40 mg-50 mg-325mg 325 mg-30 mg-40 mg-50 mg

1


butalbital-aspirin-caffeinewcod caps 1


FIORICETCODEINECAPS (Use butalbital-acetaminophen-caffeine wcodeine)

NF


FIORINALCODEINE 3CAPS (Use butalbital-aspirin-caffeine wcod)

NF


hydrocodone-acetaminophen soln 10mg15ml-325 mg15ml


hydrocodone-acetaminophen soln 25mg5ml-108 mg5ml 325mg15ml-75 mg15ml 5mg10ml-217 mg10ml 75mg15ml-325 mg15ml

1


hydrocodone-acetaminophen tabs 10mg-300 mg 5 mg-300 mg75 mg-300 mg

1


hydrocodone-acetaminophen tabs 5 mg-325 mg 10 mg-325 mg325 mg-10 mg 325 mg-75mg 75 mg-325 mg

1


hydrocodone-ibuprofentabs 10 mg-200 mg 5 mg-200 mg

1 PA

hydrocodone-ibuprofentabs 75 mg-200 mg 1


LORTAB ELIX 2



8

Drug Name DrugTier

RequirementsLimits

NORCO TABS (Use hydrocodone-acetaminophen)

NF


oxycodone wacetaminophen tabs 75mg-325 mg 10 mg-325mg 325 mg-10 mg 325mg-5 mg 5 mg-325 mg

1


oxycodone-ibuprofen tabs 1


PERCOCET TABS 75 MG-325 MG 10 MG-325 MG 5 MG-325 MG (Use oxycodone wacetaminophen)

NF


tramadol-acetaminophentabs 1


TYLENOLCODEINE 3TABS (Use acetaminophenw codeine)

NF



NF


ULTRACET TABS (Use tramadol-acetaminophen) NF


Opioid Partial Agonists BUNAVAIL FILM 03 MG-21 MG 21 MG-03 MG 3 PA QL(4 ea

daily) BUNAVAIL FILM 07 MG-42 MG 3 PA QL(2 ea


daily) BUPRENEX SOLN (Use buprenorphine hcl) NF

buprenorphine hcl soln ij03 mgml 1

buprenorphine hcl subl sl 2mg 8 mg 1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

buprenorphine hcl-naloxone hcl dihydrate film05 mg-2 mg 1 mg-4 mg

1 QL(3 ea daily)


1 QL(2 ea daily)

buprenorphine hcl-naloxone hcl dihydrate subl05 mg-2 mg 2 mg-8 mg 8mg-2 mg

1

QL(3 ea daily)

buprenorphine ptwk td 10mcghr 15 mcghr 20mcghr 5 mcghr 75mcghr

1

PA QL(0143ea daily)

butorphanol tartrate soln ij1 mgml 2 mgml 1

butorphanol tartrate soln na10 mgml 1 PA

BUTRANS PTWK 10 MCGHR 15 MCGHR 20MCGHR 5 MCGHR (Use buprenorphine)

NF

PA QL(0143ea daily)

BUTRANS PTWK 75 MCGHR (Use buprenorphine)


nalbuphine hcl soln 1 QL(8 ml daily)

pentazocine w naloxonehcl tabs 1


SUBOXONE FILM 05 MG-2 MG 1 MG-4 MG 2 MG-05 MG (Use buprenorphine hcl-naloxone hcl dihydrate)

NF

QL(3 ea daily)

SUBOXONE FILM 2 MG-8 MG 3 MG-12 MG (Use buprenorphine hcl-naloxone hcl dihydrate)

NF

QL(2 ea daily)

ANDROGENS-ANABOLIC - Drugs to Regulate Hormones

Anabolic Steroids

ANADROL-50 TABS 3

oxandrolone tabs 1

Androgens


9

Drug Name DrugTier

RequirementsLimits

ANDRODERM PT24 2 PA QL(1 eadaily)

ANDROGEL GEL 25 MG25GM 50 MG5GM(Use testosterone)

NF

danazol caps 1

DEPO-TESTOSTERONE SOLN (Use testosterone cypionate)

NF

METHITEST TABS 3

TESTIM GEL (Use testosterone) NF

TESTOSTERONE CYPIONATE SOLN IJ 200 MGML

1

testosterone cypionate solnij 200 mgml 1

testosterone cypionate solnim 100 mgml 200 mgml 1

testosterone enanthate soln 1

VOGELXO GEL (Use testosterone) NF

VOGELXO PUMP GEL (Use testosterone) NF

ANORECTAL AND RELATED PRODUCTS -Rectal Drugs to Treat Pain Swelling and Itching

Intrarectal Steroids CORTENEMA ENEM (Use hydrocortisone (intrarectal)) NF

hydrocortisone (intrarectal) enem 1

UCERIS FOAM RE 2 MGACT 4 PA

Rectal Steroids ANUSOL-HC CREA (Use hydrocortisone (rectal)) NF

hydrocortisone (rectal) crea 1

hydrocortisone acetate(rectal) supp 1

PROCTOCORT CREA (Use hydrocortisone(rectal))

NF

Drug Name DrugTier

RequirementsLimits

PROCTOCORT SUPP (Use hydrocortisoneacetate (rectal))

NF

Vasodilating Agents

RECTIV OINT 3 QL(2 gm daily)

ANTHELMINTICS - Drugs to Treat Worm Infections

Anthelmintics

albendazole tabs 1 PA

ALBENZA TABS (Use albendazole) NF PA

BILTRICIDE TABS (Use praziquantel) NF PA

EMVERM CHEW 2

QL(2 ea daily6ea per fillretail6 ea perfill mail)1 rtlMAX fill60 rtl day(s) supply1mail MAX fill60 mail day(s)supply

ivermectin tabs or 3 mg 1

praziquantel tabs 1 PA

STROMECTOL TABS (Use ivermectin) NF

ANTI-INFECTIVE AGENTS - MISC - Drugs to Treat Bacterial Infections

Anti-infective Agents - Misc bacitracin solr 3

FLAGYL TABS 500 MG (Use metronidazole) NF

IMPAVIDO CAPS 3 PA QL(3 eadaily)

metronidazole tabs or 250 mg 500 mg 1

trimethoprim tabs 1

XIFAXAN TABS 3 PA AL(At least12 yrs old)

Anti-infective Misc - Combinations


10

Drug Name DrugTier

RequirementsLimits

BACTRIM DS TABS (Use sulfamethoxazole-trimethoprim)

NF

BACTRIM TABS (Use sulfamethoxazole-trimethoprim)

NF

sulfamethoxazole-trimethoprim soln 1

sulfamethoxazole-trimethoprim susp 1

sulfamethoxazole-trimethoprim tabs 1

Antiprotozoal Agents ALINIA SUSR 100 MG5ML 2 PA

ALINIA TABS 500 MG (Use nitazoxanide) 2 PA

atovaquone susp 1

MEPRON SUSP (Use atovaquone) NF

nitazoxanide tabs or 1 PA

Carbapenems

ertapenem sodium solr 1

imipenem-cilastatin solr 1

INVANZ SOLR (Use ertapenem sodium) NF

meropenem solr 1

MERREM SOLR (Use meropenem) NF

PRIMAXIN IV SOLR (Use imipenem-cilastatin) NF

Chloramphenicols chloramphenicol sodiumsuccinate solr 4 PA SP

Cyclic Lipopeptides CUBICIN RF SOLR (Use daptomycin) NF

CUBICIN SOLR (Use daptomycin) NF

Drug Name DrugTier

RequirementsLimits

DAPTOMYCIN SOLR 350 MG (Use daptomycin) NF

daptomycin solr 500 mg 1

Glycopeptides

FIRVANQ SOLR 2 QL(300 ml perfill retail)

VANCOCIN CAPS (Use vancomycin hcl) NF

QL(4 eadaily40 ea perfill retail)

VANCOCIN HCL CAPS (Use vancomycin hcl) NF


vancomycin hcl caps or125 mg 250 mg 1


vancomycin hcl solr iv 500mg 1 gm 10 gm 1000 mg 1

VANCOMYCIN HYDROCHLORIDE SOLR OR 250 MG5ML

2 QL(300 ml perfill retail)

Leprostatics

dapsone tabs 1

Lincosamides CLEOCIN CAPS OR 75 MG 150 MG 300 MG (Use clindamycin hcl)

NF

CLEOCIN PEDIATRIC GRANULES SOLR (Use clindamycin palmitatehydrochloride)

NF

CLEOCIN PHOSPHATE SOLN IJ 600 MG4ML 900MG6ML 300 MG2ML 9GM60ML (Use clindamycin phosphate)

NF

clindamycin hcl caps 1

clindamycin palmitatehydrochloride solr 1

clindamycin phosphate solnij 600 mg4ml 900 mg6ml300 mg2ml 9 gm60ml9000 mg60ml

1

LINCOCIN SOLN (Use lincomycin hcl) NF


11

Drug Name DrugTier

RequirementsLimits

lincomycin hcl soln 1

Monobactams

CAYSTON SOLR 4 PA QL(3 mldaily)

Oxazolidinones linezolid susr or 100 mg5ml 1

linezolid tabs or 600 mg 1 PA QL(2 eadaily)

SIVEXTRO TABS OR 3 PA

ZYVOX SUSR OR 100 MG5ML (Use linezolid) NF

ZYVOX TABS OR 600 MG (Use linezolid) NF PA QL(2 ea

daily) Polymyxins

polymyxin b sulfate solr 1

Urinary Anti-infectives fosfomycin tromethaminepack 1

HIPREX TABS (Use methenamine hippurate) NF

MACROBID CAPS (Use nitrofurantoin monohyd macro)

NF

MACRODANTIN CAPS 50 MG 100 MG (Use nitrofurantoin macrocrystal)

NF

methenamine hippuratetabs 1

MONUROL PACK (Use fosfomycin tromethamine) 3

nitrofurantoin macrocrystalcaps 50 mg 100 mg 1

nitrofurantoin monohyd macro caps 1

nitrofurantoin susp 1

ANTIANGINAL AGENTS - Drugs to Treat Chest Pain

Antianginals-Other RANEXA TB12 1000 MG (Use ranolazine) NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

RANEXA TB12 500 MG (Use ranolazine) NF QL(3 ea daily)

ranolazine tb12 1000 mg 1 QL(2 ea daily)


Nitrates ISORDIL TITRADOSE TABS 5 MG (Use isosorbide dinitrate)

NF

isosorbide dinitrate tabs 30 mg 10 mg 20 mg 5 mg 1

isosorbide dinitrate tbcr 40 mg 1

isosorbide mononitrate tabs 1

isosorbide mononitrate tb24 1

NITRO-BID OINT 3

NITRO-DUR PT24 01 MGHR 04 MGHR 02MGHR 06 MGHR (Use nitroglycerin)

NF

nitroglycerin cpcr or 25mg 65 mg 9 mg 1 QL(4 ea daily)

nitroglycerin pt24 td 01mghr 04 mghr 02mghr 06 mghr

1

NITROGLYCERIN SOLN IV 5 MGML 1

nitroglycerin subl sl 03 mg04 mg 06 mg 1

NITROSTAT SUBL (Use nitroglycerin) NF

ANTIANXIETY AGENTS - Drugs to Treat Anxiety

Antianxiety Agents - Misc buspirone hcl tabs 10 mg30 mg 75 mg 15 mg 1

buspirone hcl tabs 5 mg 1 QL(1 ea daily)

hydroxyzine hcl soln im 50mgml 1

hydroxyzine hcl syrp or 10mg5ml 1


12

Drug Name DrugTier

RequirementsLimits

hydroxyzine hcl tabs or 10mg 25 mg 50 mg 1

hydroxyzine pamoate caps 1

meprobamate tabs 1

VISTARIL CAPS (Use hydroxyzine pamoate) NF

Benzodiazepines alprazolam tabs 025 mg05 mg 1 mg 2 mg 1 QL(4 ea daily)

alprazolam tb24 05 mg 1mg 2 mg 3 mg 1

alprazolam tbdp 025 mg05 mg 1 mg 2 mg 1

ATIVAN TABS OR 05 MG 2 MG (Use lorazepam) NF QL(3 ea daily)

ATIVAN TABS OR 1 MG (Use lorazepam) NF QL(4 ea daily)

chlordiazepoxide hcl caps 1

clorazepate dipotassiumtabs 1

diazepam conc or 5 mgml 1

diazepam soln or 5 mg5ml 1

diazepam tabs or 10 mg 2mg 5 mg 1 QL(4 ea daily)

lorazepam conc or 2 mgml 1

lorazepam tabs or 05 mg2 mg 1 QL(3 ea daily)

lorazepam tabs or 1 mg 1 QL(4 ea daily)

oxazepam caps 10 mg 15mg 30 mg 1

TRANXENE T TABS (Use clorazepate dipotassium) NF

VALIUM TABS (Use diazepam) NF QL(4 ea daily)

XANAX TABS (Use alprazolam) NF QL(4 ea daily)

XANAX XR TB24 (Use alprazolam) NF

Drug Name DrugTier

RequirementsLimits

ANTIARRHYTHMICS - Drugs to treat abnormal heart rhythms

Antiarrhythmics Type I-A disopyramide phosphate caps 1

NORPACE CAPS (Use disopyramide phosphate) NF

procainamide hcl soln 500mgml 1

quinidine sulfate tabs 1

Antiarrhythmics Type I-B mexiletine hcl caps 200mg 150 mg 250 mg 1

Antiarrhythmics Type I-C

flecainide acetate tabs 1

propafenone hcl cp12 1

propafenone hcl tabs 1

RYTHMOL SR CP12 (Use propafenone hcl) NF

Antiarrhythmics Type III amiodarone hcl soln iv 150 mg3ml 50 mgml 1

amiodarone hcl tabs or 100 mg 200 mg 400 mg 1

dofetilide caps 1

MULTAQ TABS 3

TIKOSYN CAPS (Use dofetilide) NF

ANTIASTHMATIC AND BRONCHODILATOR AGENTS - Drugs to Treat Lung Conditions

Anti-Inflammatory Agents

cromolyn sodium nebu 1 QL(8 ml daily)

Antiasthmatic - Monoclonal Antibodies

FASENRA PEN SOAJ 4 PA

FASENRA SOSY 4 PA


13

Drug Name DrugTier

RequirementsLimits

NUCALA SOAJ 4 PA

NUCALA SOLR 4 PA

NUCALA SOSY 4 PA

XOLAIR SOLR 150 MG 4 PA SP

XOLAIR SOSY 150 MGML 75 MG05ML 4 PA

Bronchodilators - Anticholinergics

ATROVENT HFA AERS 3 QL(044 gmdaily)

INCRUSE ELLIPTA AEPB 2 QL(1 ea daily)

ipratropium bromide soln 1 QL(15 ml daily)

SPIRIVA HANDIHALER CAPS 2 QL(1 ea daily)

SPIRIVA RESPIMAT AERS 2 QL(014 gm

daily) Leukotriene Modulators ACCOLATE TABS (Use zafirlukast) NF QL(2 ea daily)

montelukast sodium chew 4 mg 5 mg 1 QL(1 ea daily)

montelukast sodium pack 4 mg 1 PA QL(1 ea

daily) montelukast sodium tabs 10 mg 1 QL(1 ea daily)

SINGULAIR CHEW 4 MG 5 MG (Use montelukast sodium)

NF QL(1 ea daily)

SINGULAIR PACK 4 MG (Use montelukast sodium) NF PA QL(1 ea

daily) SINGULAIR TABS 10 MG (Use montelukast sodium) NF QL(1 ea daily)

zafirlukast tabs 1 QL(2 ea daily)

zileuton tb12 1 QL(4 ea daily)

Selective Phosphodiesterase 4 (PDE4) Inhibitors

Drug Name DrugTier

RequirementsLimits

DALIRESP TABS 250 MCG 3

QL(1 eadaily)30 rtlMAX day(s)supply180 rtllmt day(s)30mail MAX day(s)supply180 maillmt day(s)

DALIRESP TABS 500 MCG 3 QL(1 ea daily)

Steroid Inhalants

ARNUITY ELLIPTA AEPB 2

budesonide (inhalation) susp 1 PA QL(4 ml

daily)

FLOVENT DISKUS AEPB 2

FLOVENT HFA AERO 2

PULMICORT FLEXHALER AEPB 2

PULMICORT SUSP (Use budesonide (inhalation)) NF PA QL(4 ml

daily)

QVAR REDIHALER AERB 2

Sympathomimetics ADVAIR DISKUS AEPB (Use fluticasone-salmeterol)

NF

ADVAIR HFA AERO 2

AIRDUO RESPICLICK 11314 AEPB (Use fluticasone-salmeterol)

NF


NF


NF

albuterol sulfate aers in 108 mcgact 1

Limit 2 Inhalers per month1 rtlpack lmt perfill2 rtl MAX fill30 rtl day(s)supply


14

Drug Name DrugTier

RequirementsLimits


Limit 2 inhalers per month1 rtlpack lmt perfill2 rtl MAX fill30 rtl day(s)supply

albuterol sulfate nebu in 05 25 mg05ml 1

albuterol sulfate nebu in 063 mg3ml 125 mg3ml0083

1 QL(15 ml daily)

albuterol sulfate syrp or 2mg5ml 1

albuterol sulfate tabs or 2 mg 4 mg 1

albuterol sulfate tb12 or 4 mg 8 mg 1

ANORO ELLIPTA AEPB 2 QL(2 ea daily)

ARCAPTA NEOHALER CAPS 2

arformoterol tartrate nebu 1 PA QL(4 mldaily)

BEVESPI AEROSPHERE AERO 2 QL(036 gm

daily)

BREO ELLIPTA AEPB 2

BROVANA NEBU (Use arformoterol tartrate) 3 PA QL(4 ml

daily) budesonide-formoterol fumarate dihydrate aero 1

fluticasone-salmeterol aepb50 mcgdose-500mcgdose 100 mcgact-50mcgact 50 mcgact-250mcgact 50 mcgdose-100mcgdose 50 mcgdose-250 mcgdose

1

ipratropium-albuterol soln 1 QL(18 ml daily)

levalbuterol hcl nebu 031 mg3ml 063 mg3ml 125mg3ml

1 PA QL(12 mldaily)

levalbuterol hcl nebu 125 mg05ml 1 PA

Drug Name DrugTier

RequirementsLimits

levalbuterol tartrate aero 3

PA Limit 2 inhalers permonthQL(1 gmdaily)

PROAIR HFA AERS (Use albuterol sulfate) NF

PROVENTIL HFA AERS (Use albuterol sulfate) NF

SEREVENT DISKUS AEPB 2

STRIVERDI RESPIMAT AERS 2

SYMBICORT AERO (Use budesonide-formoterol fumarate dihydrate)

2

terbutaline sulfate soln 1

terbutaline sulfate tabs 1

TRELEGY ELLIPTA AEPB 2 QL(2 ea daily)

UTIBRON NEOHALER CAPS 3 PA QL(2 ea

daily) VENTOLIN HFA AERS (Use albuterol sulfate) NF

XOPENEX CONCENTRATE NEBU (Use levalbuterol hcl)

NF PA

XOPENEX HFA AERO (Use levalbuterol tartrate) 3


XOPENEX NEBU (Use levalbuterol hcl) NF PA QL(12 ml

daily) Xanthines

aminophylline soln 1

ELIXOPHYLLIN ELIX 1

theophylline soln 80mg15ml 1 QL(56 ml daily)

theophylline tb12 300 mg450 mg 1


ANTICOAGULANTS - Blood Thinners


15

Drug Name DrugTier

RequirementsLimits

Coumarin Anticoagulants COUMADIN TABS (Use warfarin sodium) 2

warfarin sodium tabs 1

Direct Factor Xa Inhibitors

BEVYXXA CAPS 3

QL(42 ea per42 daysretail42 ea per42 days mail)

ELIQUIS STARTER PACK TBPK 2 QL(247 ea

daily)

ELIQUIS TABS 2 QL(247 eadaily)

XARELTO STARTER PACK TBPK 2

1 rtl MAX fill365 rtl day(s) supply

XARELTO TABS 10 MG 20 MG 2 QL(1 ea daily)


Heparins And Heparinoid-Like Agents

ARIXTRA SOLN 10 MG08ML (Use fondaparinux sodium)

NF

QL(72 ml per180 daysretail72 ml per180 days mail)SP


NF



NF



NF


enoxaparin sodium soln ij300 mg3ml 4 QL(6 ml daily)

enoxaparin sodium soln sc100 mgml 150 mgml 4 QL(2 ml daily)

Drug Name DrugTier

RequirementsLimits

enoxaparin sodium soln sc120 mg08ml 80 mg08ml 4 QL(16 ml

daily) enoxaparin sodium soln sc30 mg03ml 4 QL(06 ml

daily) SP

enoxaparin sodium soln sc40 mg04ml 4

QL(08 mldaily30 day(s)limit) SP



fondaparinux sodium soln10 mg08ml 4




fondaparinux sodium soln 5mg04ml 4




FRAGMIN SOLN 10000 UNITML 12500UNIT05ML 15000UNIT06ML 18000UNT072ML 2500UNIT02ML 5000UNIT02ML 7500UNIT03ML

4

PA SP

HEPARIN LOCK FLUSH SOLN (Use heparin sodium(porcine) lock flush)

NF

heparin sod (porcine) ind5w soln 5 -40 unitml 1

heparin sodium (porcine)soln 10000 unitml 20000unitml 5000 unitml

1


16

Drug Name DrugTier

RequirementsLimits

HEPARIN SODIUMNACL045 SOLN 045 -12500 UNIT250ML

1

LOVENOX SOLN IJ 300 MG3ML (Use enoxaparin sodium)

NF QL(6 ml daily)

LOVENOX SOLN SC 100 MGML 150 MGML (Use enoxaparin sodium)

NF QL(2 ml daily)

LOVENOX SOLN SC 120 MG08ML 80 MG08ML(Use enoxaparin sodium)

NF QL(16 mldaily)

LOVENOX SOLN SC 30 MG03ML (Use enoxaparin sodium)

NF QL(06 mldaily) SP


NF QL(08 mldaily30 day(s)limit) SP



ANTICONVULSANTS - Drugs to Treat Seizures

AMPA Glutamate Receptor Antagonists FYCOMPA TABS 10 MG 12 MG 2 MG 4 MG 6 MG 8 MG

3 PA

Anticonvulsants - Benzodiazepines

clobazam susp 25 mgml 1 PA QL(16 mldaily)

clobazam tabs 10 mg 20 mg 1 PA QL(2 ea

daily)

clonazepam tabs 1

clonazepam tbdp 1

DIASTAT ACUDIAL GEL (Use diazepam(anticonvulsant))

3

DIASTAT PEDIATRIC GEL (Use diazepam(anticonvulsant))

3

diazepam (anticonvulsant)gel 3

KLONOPIN TABS (Use clonazepam) NF

Drug Name DrugTier

RequirementsLimits

NAYZILAM SOLN 3 PA QL(10 eaper 30 daysretail)

ONFI SUSP 25 MGML(Use clobazam) NF PA QL(16 ml

daily) ONFI TABS 10 MG 20 MG (Use clobazam) NF PA QL(2 ea

daily)

VALTOCO LIQD 4 PA QL(10 eaper 30 daysretail)

VALTOCO LQPK 4 PA QL(10 eaper 30 daysretail)

Anticonvulsants - Misc

APTIOM TABS 3 ST QL(2 eadaily)

BANZEL SUSP 40 MGML(Use rufinamide) 2 PA QL(80 ml

daily) BANZEL TABS 200 MG (Use rufinamide) 2 PA QL(2 ea


daily) BRIVIACT SOLN OR 10 MGML 3 PA

BRIVIACT TABS OR 10 MG 100 MG 25 MG 50 MG 75 MG

3 PA

carbamazepine chew 100 mg 1

carbamazepine cp12 100 mg 1

carbamazepine cp12 200 mg 1 QL(6 ea daily)


carbamazepine susp 100mg5ml 1

carbamazepine tabs 200 mg 1

carbamazepine tb12 100mg 400 mg 1 QL(4 ea daily)

carbamazepine tb12 200 mg 1 QL(6 ea daily)

CARBATROL CP12 100 MG (Use carbamazepine) NF


17

Drug Name DrugTier

RequirementsLimits

CARBATROL CP12 200 MG (Use carbamazepine) NF QL(6 ea daily)


DIACOMIT CAPS 250 MG 4 PA QL(12 eadaily)


DIACOMIT PACK 250 MG 4 PA QL(12 eadaily)


EPIDIOLEX SOLN 3 PA

gabapentin caps 100 mg300 mg 400 mg 1

gabapentin soln 250mg5ml 300 mg6ml 1 QL(60 ml daily)

gabapentin tabs 600 mg800 mg 1

KEPPRA SOLN IV 500 MG5ML (Use levetiracetam)

NF QL(30 ml daily)

KEPPRA SOLN OR 100 MGML (Use levetiracetam) NF QL(30 ml daily)

KEPPRA TABS OR 1000 MG (Use levetiracetam) NF QL(3 ea daily)

KEPPRA TABS OR 250 MG 750 MG 500 MG (Use levetiracetam)

NF QL(4 ea daily)

KEPPRA XR TB24 (Use levetiracetam) NF QL(4 ea daily)

LAMICTAL CHEWABLE DISPERSIBLE CHEW 25 MG (Use lamotrigine)

NF QL(20 ea daily)


NF QL(100 eadaily)

LAMICTAL ODT TBDP 100 MG 200 MG 25 MG 50 MG (Use lamotrigine)

NF QL(1 ea daily)

LAMICTAL TABS (Use lamotrigine) NF

LAMICTAL XR TB24 100 MG 200 MG 25 MG 250 MG 300 MG 50 MG (Use lamotrigine)

NF

Drug Name DrugTier

RequirementsLimits

lamotrigine chew 25 mg 1 QL(20 ea daily)

lamotrigine chew 5 mg 1 QL(100 eadaily)

lamotrigine tabs 100 mg150 mg 200 mg 25 mg 1

lamotrigine tb24 100 mg200 mg 25 mg 250 mg300 mg 50 mg

1

lamotrigine tbdp 100 mg200 mg 25 mg 50 mg 1 QL(1 ea daily)

levetiracetam soln iv 500 mg5ml 1 QL(30 ml daily)

levetiracetam soln or 100 mgml 500 mg5ml 1 QL(30 ml daily)

levetiracetam tabs or 1000 mg 1 QL(3 ea daily)

levetiracetam tabs or 250 mg 750 mg 500 mg 1 QL(4 ea daily)

levetiracetam tb24 or 500 mg 750 mg 1 QL(4 ea daily)

LYRICA CAPS 100 MG 150 MG 200 MG 25 MG 50 MG 75 MG (Use pregabalin)

NF

PA QL(3 eadaily)

LYRICA CAPS 225 MG 300 MG (Use pregabalin) NF PA QL(2 ea

daily) LYRICA SOLN 20 MGML(Use pregabalin) NF PA QL(30 ml

daily) MYSOLINE TABS (Use primidone) NF

NEURONTIN CAPS 100 MG 300 MG 400 MG (Use gabapentin)

NF

NEURONTIN SOLN 250 MG5ML (Use gabapentin) NF QL(60 ml daily)

NEURONTIN TABS 600 MG 800 MG (Use gabapentin)

NF

oxcarbazepine susp 300mg5ml 60 mgml 1 QL(40 ml daily)

oxcarbazepine tabs 150mg 300 mg 1 QL(3 ea daily)

oxcarbazepine tabs 600 mg 1 QL(4 ea daily)


18

Drug Name DrugTier

RequirementsLimits

pregabalin caps 100 mg150 mg 200 mg 25 mg 50mg 75 mg

1 PA QL(3 eadaily)

pregabalin caps 225 mg300 mg 1 PA QL(2 ea

daily)

pregabalin soln 20 mgml 1 PA QL(30 mldaily)

primidone tabs 1

QUDEXY XR CS24 (Use topiramate) NF

rufinamide susp 40 mgml 1 PA QL(80 mldaily)

rufinamide tabs 200 mg 1 PA QL(2 eadaily)


TEGRETOL SUSP (Use carbamazepine) 2

TEGRETOL TABS (Use carbamazepine) 2

TEGRETOL-XR TB12 100 MG 400 MG (Use carbamazepine)

NF QL(4 ea daily)

TEGRETOL-XR TB12 200 MG (Use carbamazepine) NF QL(6 ea daily)

TOPAMAX SPRINKLE CPSP 15 MG (Use topiramate)

NF QL(6 ea daily)


NF QL(8 ea daily)

TOPAMAX TABS 100 MG 200 MG (Use topiramate) NF QL(2 ea daily)


topiramate cpsp 15 mg 1 QL(6 ea daily)


topiramate tabs 100 mg200 mg 1 QL(2 ea daily)

topiramate tabs 25 mg 50 mg 1 QL(4 ea daily)

TRILEPTAL SUSP 300 MG5ML (Use oxcarbazepine)

NF QL(40 ml daily)

Drug Name DrugTier

RequirementsLimits

TRILEPTAL TABS 150 MG 300 MG (Use oxcarbazepine)

NF QL(3 ea daily)

TRILEPTAL TABS 600 MG (Use oxcarbazepine) NF QL(4 ea daily)

VIMPAT SOLN IV 200 MG20ML 3 QL(40 ml daily)

VIMPAT SOLN OR 10 MGML 3 PA QL(40 ml

daily) VIMPAT TABS OR 100 MG 150 MG 200 MG 50 MG

3 PA QL(2 eadaily)

ZONEGRAN CAPS (Use zonisamide) NF QL(6 ea daily)

zonisamide caps 1 QL(6 ea daily)

Carbamates

felbamate susp 600 mg5ml 1 QL(30 ml daily)

felbamate tabs 400 mg 1 QL(9 ea daily)


FELBATOL SUSP 600 MG5ML (Use felbamate) NF QL(30 ml daily)

FELBATOL TABS 400 MG (Use felbamate) NF QL(9 ea daily)


GABA Modulators GABITRIL TABS 2 MG 4 MG (Use tiagabine hcl) NF

SABRIL PACK (Use vigabatrin) NF PA QL(6 ea

daily) SP SABRIL TABS (Use vigabatrin) NF PA QL(6 ea

daily) SP tiagabine hcl tabs 2 mg 4 mg 1

vigabatrin pack 4 PA QL(6 eadaily) SP

vigabatrin tabs 4 PA QL(6 eadaily) SP

Hydantoins CEREBYX SOLN (Use fosphenytoin sodium) NF


19

Drug Name DrugTier

RequirementsLimits

DILANTIN CAPS 100 MG (Use phenytoin sodiumextended)

2

DILANTIN CAPS 30 MG 2

DILANTIN INFATABS CHEW (Use phenytoin) 2

DILANTIN-125 SUSP (Use phenytoin) 2

fosphenytoin sodium soln 1

PEGANONE TABS 3

PHENYTEK CAPS (Use phenytoin sodiumextended)

2

phenytoin chew 1

phenytoin sodium extended caps 1

phenytoin sodium soln 1

phenytoin susp 1

Succinimides

CELONTIN CAPS 3 QL(4 ea daily)

ethosuximide caps 250 mg 1 QL(6 ea daily)

ethosuximide soln 250 mg5ml 1 QL(30 ml daily)

ZARONTIN CAPS 250 MG (Use ethosuximide) 2 QL(6 ea daily)

ZARONTIN SOLN 250 MG5ML (Use ethosuximide)

NF QL(30 ml daily)

Valproic Acid DEPAKOTE ER TB24 (Use divalproex sodium) NF

DEPAKOTE TBEC (Use divalproex sodium) NF

divalproex sodium tb24 250mg 500 mg 1

divalproex sodium tbec 125mg 250 mg 500 mg 1

valproate sodium soln 1

Drug Name DrugTier

RequirementsLimits

valproic acid caps or 1

ANTIDEPRESSANTS - Drugs to Treat Depression

Alpha-2 Receptor Antagonists (Tetracyclics) mirtazapine tabs 1 QL(1 ea daily)

mirtazapine tbdp 1 QL(1 ea daily)

REMERON SOLTAB TBDP (Use mirtazapine) NF QL(1 ea daily)

REMERON TABS (Use mirtazapine) NF QL(1 ea daily)

Antidepressants - Misc bupropion hcl tabs 100 mg75 mg 1 QL(3 ea daily)

bupropion hcl tb12 100 mg150 mg 200 mg 1 QL(2 ea daily)

bupropion hcl tb24 150 mg300 mg 1 QL(1 ea daily)

FORFIVO XL TB24 (Use bupropion hcl) NF

maprotiline hcl tabs 3

WELLBUTRIN SR TB12 (Use bupropion hcl) NF QL(2 ea daily)

WELLBUTRIN XL TB24 (Use bupropion hcl) NF QL(1 ea daily)

Monoamine Oxidase Inhibitors (MAOIs) EMSAM PT24 3 QL(1 ea daily)

MARPLAN TABS 2 QL(6 ea daily)

NARDIL TABS (Use phenelzine sulfate) NF

PARNATE TABS (Use tranylcypromine sulfate) NF

phenelzine sulfate tabs 1

tranylcypromine sulfatetabs 1

N-Methyl-D-aspartic acid (NMDA) Receptor SPRAVATO 56MG DOSE SOPK 4 PA


20

Drug Name DrugTier

RequirementsLimits

SPRAVATO 84MG DOSE SOPK 4 PA

Selective Serotonin Reuptake Inhibitors (SSRIs) CELEXA TABS 10 MG (Use citalopramhydrobromide)

NF QL(15 eadaily)

CELEXA TABS 20 MG (Use citalopramhydrobromide)

NF QL(2 ea daily)


NF QL(1 ea daily)

citalopram hydrobromidesoln 10 mg5ml 1 QL(20 ml daily)

citalopram hydrobromidetabs 10 mg 1 QL(15 ea

daily) citalopram hydrobromidetabs 20 mg 1 QL(2 ea daily)

citalopram hydrobromidetabs 40 mg 1 QL(1 ea daily)

escitalopram oxalate soln 5mg5ml 1 QL(20 ml daily)

escitalopram oxalate tabs10 mg 1 QL(2 ea daily)


escitalopram oxalate tabs 5 mg 1 QL(15 ea

daily)

fluoxetine hcl caps 10 mg 1 QL(1 ea daily)



fluoxetine hcl cpdr 90 mg 1

fluoxetine hcl soln 20 mg5ml 1 QL(20 ml daily)

fluoxetine hcl tabs 10 mg60 mg 1 QL(1 ea daily)

fluoxetine hcl tabs 20 mg 1 QL(3 ea daily)

FLUOXETINE HYDROCHLORIDE TABS (Use fluoxetine hcl)

NF QL(1 ea daily)

fluvoxamine maleate tabs 100 mg 1 QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

fluvoxamine maleate tabs 25 mg 50 mg 1 QL(2 ea daily)

LEXAPRO TABS 10 MG (Use escitalopram oxalate) NF QL(2 ea daily)


LEXAPRO TABS 5 MG (Use escitalopram oxalate) NF QL(15 ea

daily) paroxetine hcl susp 10mg5ml 3 QL(30 ml daily)

paroxetine hcl tabs 10 mg20 mg 40 mg 1 QL(1 ea daily)

paroxetine hcl tabs 30 mg 1 QL(2 ea daily)

paroxetine hcl tb24 125 mg 1 QL(1 ea daily)

paroxetine hcl tb24 375mg 25 mg 1 QL(2 ea daily)

PAXIL CR TB24 125 MG (Use paroxetine hcl) NF QL(1 ea daily)

PAXIL CR TB24 375 MG 25 MG (Use paroxetine hcl) NF QL(2 ea daily)

PAXIL SUSP 10 MG5ML(Use paroxetine hcl) 3 QL(30 ml daily)

PAXIL TABS 10 MG 20 MG 40 MG (Use paroxetine hcl)

NF QL(1 ea daily)

PAXIL TABS 30 MG (Use paroxetine hcl) NF QL(2 ea daily)

PROZAC CAPS 10 MG (Use fluoxetine hcl) NF QL(1 ea daily)



sertraline hcl conc 20 mgml 1 QL(10 ml daily)

sertraline hcl tabs 100 mg 1 QL(2 ea daily)

sertraline hcl tabs 25 mg50 mg 1 QL(15 ea

daily) ZOLOFT CONC 20 MGML(Use sertraline hcl) NF QL(10 ml daily)

ZOLOFT TABS 100 MG (Use sertraline hcl) NF QL(2 ea daily)


21

Drug Name DrugTier

RequirementsLimits

ZOLOFT TABS 25 MG 50 MG (Use sertraline hcl) NF QL(15 ea

daily) Serotonin Modulators

nefazodone hcl tabs 3

trazodone hcl tabs 1

TRINTELLIX TABS 3 PA QL(1 eadaily)

VIIBRYD STARTER PACK KIT 3


VIIBRYD TABS 3 PA QL(1 eadaily)

Serotonin-Norepinephrine Reuptake Inhibitors CYMBALTA CPEP (Use duloxetine hcl) NF QL(2 ea daily)

desvenlafaxine succinate tb24 100 mg 1 QL(4 ea daily)

desvenlafaxine succinate tb24 25 mg 50 mg 1 QL(1 ea daily)

duloxetine hcl cpep or 20mg 60 mg 30 mg 1 QL(2 ea daily)

duloxetine hcl cpep or 40 mg 1

EFFEXOR XR CP24 150 MG (Use venlafaxine hcl) NF QL(2 ea daily)

EFFEXOR XR CP24 75 MG 375 MG (Use venlafaxine hcl)

NF QL(1 ea daily)

FETZIMA CP24 3 PA

FETZIMA TITRATION PACK C4PK 3 PA

KHEDEZLA TB24 (Use desvenlafaxine) NF

PRISTIQ TB24 100 MG (Use desvenlafaxine succinate)

NF QL(4 ea daily)

PRISTIQ TB24 25 MG 50 MG (Use desvenlafaxine succinate)

NF QL(1 ea daily)

venlafaxine hcl cp24 150 mg 1 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

venlafaxine hcl cp24 75mg 375 mg 1 QL(1 ea daily)

venlafaxine hcl tabs 100 mg 25 mg 375 mg 50mg 75 mg

1 QL(3 ea daily)

venlafaxine hcl tb24 150 mg 1 QL(2 ea daily)

venlafaxine hcl tb24 225 mg 1 PA QL(1 ea

daily) venlafaxine hcl tb24 75 mg375 mg 1 QL(1 ea daily)

Tricyclic Agents

amitriptyline hcl tabs 1

amoxapine tabs 3

ANAFRANIL CAPS (Use clomipramine hcl) NF PA

clomipramine hcl caps 1 PA

desipramine hcl tabs 1

doxepin hcl caps 1

doxepin hcl conc 1

imipramine hcl tabs 1

imipramine pamoate caps 1

NORPRAMIN TABS (Use desipramine hcl) NF

nortriptyline hcl caps 1

nortriptyline hcl soln 1

PAMELOR CAPS (Use nortriptyline hcl) NF

protriptyline hcl tabs 1

TOFRANIL TABS (Use imipramine hcl) NF

trimipramine maleate caps 1

ANTIDIABETICS - Drugs to Regulate Blood Sugar Alpha-Glucosidase Inhibitors


22

Drug Name DrugTier

RequirementsLimits

acarbose tabs 1 QL(3 ea daily)

GLYSET TABS (Use miglitol) NF

miglitol tabs 1

PRECOSE TABS (Use acarbose) NF QL(3 ea daily)

Antidiabetic - Amylin Analogs

SYMLINPEN 120 SOPN 2 PA QL(036 mldaily)


Antidiabetic Combinations ACTOPLUS MET TABS (Use pioglitazone hcl-metformin hcl)

NF QL(2 ea daily)

DUETACT TABS (Use pioglitazone hcl-glimepiride)

NF QL(1 ea daily)

glipizide-metformin hcl tabs25 mg-250 mg 25 mg-500 mg 500 mg-25 mg

1 QL(2 ea daily)

glipizide-metformin hcl tabs5 mg-500 mg 1 QL(4 ea daily)

glyburide-metformin tabs125 mg-250 mg 250 mg-125 mg

1 QL(2 ea daily)


1 QL(4 ea daily)

GLYXAMBI TABS 2

JANUMET TABS 2 QL(2 ea daily)

JANUMET XR TB24 100 MG-1000 MG 2 QL(1 ea daily)

JANUMET XR TB24 50 MG-1000 MG 50 MG-500 MG 500 MG-50 MG

2 QL(2 ea daily)

KAZANO TABS (Use alogliptin-metformin hcl) NF

OSENI TABS (Use alogliptin-pioglitazone) NF

pioglitazone hcl-glimepiridetabs 1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

pioglitazone hcl-metforminhcl tabs 1 QL(2 ea daily)

repaglinide-metformin hcltabs 1 QL(2 ea daily)

SEGLUROMET TABS 2 QL(2 ea daily)

SYNJARDY TABS 2 QL(2 ea daily)

SYNJARDY XR TB24 10 MG-1000 MG 125 MG-1000 MG 5 MG-1000 MG

2 QL(2 ea daily)

SYNJARDY XR TB24 25 MG-1000 MG 2 QL(1 ea daily)

TRIJARDY XR TB24 2

XIGDUO XR TB24 10 MG-1000 MG 10 MG-500 MG 5 MG-500 MG

3 PA QL(1 eadaily)

XIGDUO XR TB24 25 MG-1000 MG 3 QL(2 ea daily)

XIGDUO XR TB24 5 MG-1000 MG 3 PA QL(2 ea

daily)

XULTOPHY 10036 SOPN 2 PA QL(05 mldaily)

Biguanides metformin hcl tabs 1000 mg 1 QL(25 ea

daily)

metformin hcl tabs 500 mg 1 QL(5 ea daily)


metformin hcl tb24 500 mg 1 QL(4 ea daily)


Diabetic Other BAQSIMI ONE PACK POWD 3 QL(0069 ea

daily) BAQSIMI TWO PACK POWD 3 QL(0069 ea

daily)

diazoxide susp 1

GLUCAGEN HYPOKIT SOLR 3 QL(0035 ea

daily)

glucagon (rdna) kit 1 QL(0035 eadaily)


23

Drug Name DrugTier

RequirementsLimits

GLUCAGON EMERGENCY KIT KIT (Use glucagon (rdna))

3 QL(0035 eadaily)

GVOKE PFS SOSY 3 QL(002 mldaily)

PROGLYCEM SUSP (Use diazoxide) NF

Dipeptidyl Peptidase-4 (DPP-4) Inhibitors

alogliptin benzoate tabs 1 QL(1 ea daily)

JANUVIA TABS 2 QL(1 ea daily)

NESINA TABS (Use alogliptin benzoate) NF

Dopamine Receptor Agonists - Antidiabetic

CYCLOSET TABS 3 QL(6 ea daily)

Incretin Mimetic Agents (GLP-1 Receptor OZEMPIC SOPN 2 MG15ML 2 PA QL(0054

ml daily) OZEMPIC SOPN 2 MG15ML 4 MG3ML 2 PA QL(0108

ml daily)

TRULICITY SOPN 2 PA QL(0143ml daily)

VICTOZA SOPN 2 PA QL(03 mldaily)

Insulin Sensitizing Agents ACTOS TABS (Use pioglitazone hcl) 3 QL(1 ea daily)

AVANDIA TABS 3 QL(1 ea daily)

pioglitazone hcl tabs 1 QL(1 ea daily)

Insulin AFREZZA POWD 12 UNIT 4 UNIT 8 UNIT 3

APIDRA SOLN 3 PA

APIDRA SOLOSTAR SOPN 3 PA

BASAGLAR KWIKPEN SOPN 2

FIASP FLEXTOUCH SOPN 2

Drug Name DrugTier

RequirementsLimits

FIASP PENFILL SOCT 2

FIASP SOLN 2

HUMULIN R U-500 (CONCENTRATED) SOLN 2

HUMULIN R U-500 KWIKPEN SOPN 2

LEVEMIR FLEXTOUCH SOPN 2

LEVEMIR SOLN 2

NOVOLIN 7030 FLEXPENRELION SUPN 2

NOVOLIN 7030 FLEXPENSUPN 2

NOVOLIN 7030 RELIONSUSP 2

NOVOLIN 7030 SUSP 2

NOVOLIN N RELION SUSP 2

NOVOLIN N SUSP 2

NOVOLIN R RELION SOLN 2

NOVOLIN R SOLN 2

NOVOLOG FLEXPEN SOPN 2

NOVOLOG MIX 7030PREFILLED FLEXPEN SUPN

2

NOVOLOG MIX 7030SUSP 2

NOVOLOG PENFILL SOCT 2

NOVOLOG SOLN 2

TRESIBA FLEXTOUCH SOPN 2

TRESIBA SOLN 2

Meglitinide Analogues

nateglinide tabs 1 QL(3 ea daily)


24

Drug Name DrugTier

RequirementsLimits

repaglinide tabs 05 mg 1 mg 1 QL(4 ea daily)

repaglinide tabs 2 mg 1 QL(8 ea daily)

STARLIX TABS (Use nateglinide) NF QL(3 ea daily)

Sodium-Glucose Co-Transporter 2 (SGLT2)

FARXIGA TABS 3 PA QL(1 eadaily)

JARDIANCE TABS 2 QL(1 ea daily)

STEGLATRO TABS 2 QL(1 ea daily)

Sulfonylureas AMARYL TABS 1 MG 2 MG (Use glimepiride) NF QL(1 ea daily)

AMARYL TABS 4 MG (Use glimepiride) NF QL(2 ea daily)

glimepiride tabs 1 mg 2 mg 1 QL(1 ea daily)

glimepiride tabs 4 mg 1 QL(2 ea daily)

glipizide tabs 10 mg 5 mg 1 QL(4 ea daily)

glipizide tb24 10 mg 25mg 5 mg 1 QL(2 ea daily)

GLUCOTROL TABS (Use glipizide) NF QL(4 ea daily)

GLUCOTROL XL TB24 (Use glipizide) 3 QL(2 ea daily)

glyburide micronized tabs 1 QL(4 ea daily)

glyburide tabs 1 QL(4 ea daily)

GLYNASE TABS (Use glyburide micronized) 3 QL(4 ea daily)

tolbutamide tabs 1 QL(6 ea daily)

ANTIDIARRHEALPROBIOTIC AGENTS - Drugs to Treat Diarrhea

Antiperistaltic Agents diphenoxylate w atropineliqd 1

diphenoxylate w atropinetabs 1

Drug Name DrugTier

RequirementsLimits

IMODIUM A-D CAPS (Use loperamide hcl) NF RXOTC

LOMOTIL TABS (Use diphenoxylate w atropine) NF

loperamide hcl caps 2 mg 1 RXOTC

MOTOFEN TABS 3

ANTIDOTES AND SPECIFIC ANTAGONISTS

Antidotes - Chelating Agents

CHEMET CAPS 3

deferasirox pack 180 mg360 mg 90 mg 4 PA

deferasirox tabs 180 mg360 mg 90 mg 4 PA SP

deferasirox tbso 125 mg250 mg 500 mg 4 PA SP

deferiprone tabs 1

EXJADE TBSO (Use deferasirox) NF PA SP

FERRIPROX TABS 500 MG (Use deferiprone) 3

JADENU SPRINKLE PACK (Use deferasirox) NF PA

JADENU TABS (Use deferasirox) NF PA SP

Antidotes and Specific Antagonists

VISTOGARD PACK 4 PA

Opioid Antagonists naloxone hcl soln 04 mgml 4 mg10ml 1

naltrexone hcl tabs 1

NARCAN LIQD 3

QL(2 ea per fillretail)2 rtl MAXfill30 rtl day(s)supply

ANTIEMETICS - Drugs to Treat Nausea andVomiting

5-HT3 Receptor Antagonists ALOXI SOLN (Use palonosetron hcl) NF


25

Drug Name DrugTier

RequirementsLimits

ANZEMET TABS 3 PA QL(0167ea daily)

granisetron hcl soln iv 1mgml 1

granisetron hcl tabs or 1 mg 1 QL(034 ea

daily) ondansetron hcl soln ij 4mg2ml 1

ondansetron hcl soln or 4 mg5ml 1 QL(334 ml

daily) ondansetron hcl tabs or 24 mg 1 QL(0143 ea

daily)

ondansetron hcl tabs or 4 mg 1

QL(4 eadaily60 ea perfill retail60 ea per fill mail)



ondansetron tbdp 4 mg 1 QL(1 ea daily)

ondansetron tbdp 8 mg 1

palonosetron hcl soln 1

ZOFRAN TABS 4 MG (Use ondansetron hcl) NF




Antiemetics - Anticholinergic

meclizine hcl tabs 1 RXOTC

scopolamine pt72 1 QL(034 eadaily)

TIGAN CAPS OR 300 MG (Use trimethobenzamide hcl)

NF

TRANSDERM SCOP PT72 (Use scopolamine) 2 QL(034 ea

daily) TRANSDERM-SCOP PT72 (Use scopolamine) 2 QL(034 ea

daily)

Drug Name DrugTier

RequirementsLimits

trimethobenzamide hcl caps 1

Antiemetics - Miscellaneous AKYNZEO CAPS OR 05 MG-300 MG 3 PA

DICLEGIS TBEC (Use doxylamine-pyridoxine) NF

PA QL(4 eadaily)3 rtl MAXfill365 rtl day(s) supply3mail MAX fill365 mail day(s) supply

doxylamine-pyridoxine tbec 1


dronabinol caps 1

MARINOL CAPS (Use dronabinol) NF

Substance PNeurokinin 1 (NK1) Receptor aprepitant caps 1 PA

aprepitant caps 125 mg 40 mg 1 PA QL(0067

ea daily)

aprepitant caps 80 mg 1 PA QL(0134ea daily)

aprepitant misc 1 PA

EMEND CAPS OR 40 MG (Use aprepitant) NF PA QL(0067

ea daily) EMEND CAPS OR 80 MG (Use aprepitant) NF PA QL(0134

ea daily) EMEND SOLR IV 150 MG (Use fosaprepitantdimeglumine)

NF

EMEND TRIPACK CAPS (Use aprepitant) NF PA

VARUBI TBPK 3 PA

ANTIFUNGALS - Drugs to Treat Fungal Infections

Antifungal - Glucan Synthesis Inhibitors


26

Drug Name DrugTier

RequirementsLimits

CANCIDAS SOLR (Use caspofungin acetate) NF

caspofungin acetate solr 50mg 70 mg 1

ERAXIS SOLR 3

micafungin sodium solr 100mg 50 mg 1

MYCAMINE SOLR 3

Antifungals

ABELCET SUSP 3

AMBISOME SUSR 3

amphotericin b solr 3

ANCOBON CAPS (Use flucytosine) NF

flucytosine caps 1

griseofulvin microsize susp125 mg5ml 1 AL(At least 2

yrs old) griseofulvin microsize tabs500 mg 1

griseofulvin ultramicrosizetabs 1

nystatin tabs 1

terbinafine hcl tabs 1 QL(1 ea daily)

Imidazole-Related Antifungals CRESEMBA CAPS OR 186 MG 3 PA

DIFLUCAN SUSR (Use fluconazole) NF

DIFLUCAN TABS (Use fluconazole) NF

fluconazole susr 1

fluconazole tabs 1

itraconazole caps 100 mg 1 PA QL(4 eadaily)

itraconazole soln 10 mgml 1 PA QL(20 mldaily)

Drug Name DrugTier

RequirementsLimits

ketoconazole tabs 1

NOXAFIL SUSP OR 40 MGML 3 QL(20 ml daily)

SPORANOX CAPS 100 MG (Use itraconazole) NF PA QL(4 ea

daily) SPORANOX PULSEPAK CAPS (Use itraconazole) NF PA QL(4 ea

daily) SPORANOX SOLN 10 MGML (Use itraconazole) NF PA QL(20 ml

daily)

TOLSURA CAPS 4 PA

VFEND TABS 200 MG 50 MG (Use voriconazole) NF QL(4 ea daily)

voriconazole tabs or 200 mg 50 mg 1 QL(4 ea daily)

ANTIHISTAMINES - Drugs to Treat Allergies

Antihistamines - Alkylamines dexchlorpheniraminemaleate soln 1

Antihistamines - Ethanolamines carbinoxamine maleate soln 4 mg5ml 1

carbinoxamine maleate tabs 4 mg 1

CLEMASTINE FUMARATE SYRP 067 MG5ML 1

clemastine fumarate tabs 268 mg 1

diphenhydramine hcl capsor 50 mg 1

diphenhydramine hcl elix or125 mg5ml 1

diphenhydramine hcl liqd or125 mg5ml 1

diphenhydramine hcl soln ij50 mgml 1

Antihistamines - Non-Sedating ALLEGRA ALLERGY CHILDRENS SUSP 30 MG5ML (Use fexofenadine hcl)

1

QL(30 ml daily)

ALLEGRA ALLERGY CHILDRENS TBDP 30 MG 1 QL(2 ea daily)


27

Drug Name DrugTier

RequirementsLimits

ALLEGRA ALLERGY TABS 180 MG (Use fexofenadine hcl)

1 QL(1 ea daily)


1 QL(2 ea daily)

cetirizine hcl caps 10 mg 1 QL(1 ea daily)

cetirizine hcl chew 5 mg10 mg 1 QL(1 ea daily)

cetirizine hcl soln 1 mgml5 mg5ml 1 QL(10 ml

daily) RXOTC cetirizine hcl syrp 1 mgml5 mg5ml 1 QL(10 ml

daily) RXOTC cetirizine hcl tabs 5 mg 10 mg 1 QL(1 ea daily)

CLARINEX TABS (Use desloratadine) NF QL(1 ea daily)

CLARITIN ALLERGY CHILDRENS SYRP (Use loratadine)

1

CLARITIN CAPS (Use loratadine) 1

CLARITIN CHEW (Use loratadine) 1

CLARITIN CHILDRENS CHEW (Use loratadine) 1

CLARITIN REDITABS TBDP 10 MG (Use loratadine)

1

CLARITIN REDITABS TBDP 5 MG 1

CLARITIN SYRP (Use loratadine) 1

CLARITIN TABS (Use loratadine) 1

desloratadine tabs 5 mg 1 QL(1 ea daily)

desloratadine tbdp 25 mg 1 QL(1 ea daily)

fexofenadine hcl susp 30mg5ml 1 QL(30 ml daily)

fexofenadine hcl tabs 180 mg 1 QL(1 ea daily)


Drug Name DrugTier

RequirementsLimits

levocetirizine dihydrochloride soln 25mg5ml

1 QL(10 mldaily) RXOTC

levocetirizine dihydrochloride tabs 5 mg 1 QL(1 ea daily)

RXOTC

loratadine caps 1

loratadine chew 1

loratadine soln 1

loratadine syrp 1

loratadine tabs 1

loratadine tbdp 1

XYZAL ALLERGY 24HR CHILDRENS SOLN (Use levocetirizine dihydrochloride)

NF

QL(10 mldaily) RXOTC

XYZAL ALLERGY 24HR TABS (Use levocetirizine dihydrochloride)

NF QL(1 ea daily)RXOTC

ZYRTEC ALLERGY CAPS (Use cetirizine hcl) 1 QL(1 ea daily)

ZYRTEC ALLERGY TABS (Use cetirizine hcl) 1 QL(1 ea daily)

ZYRTEC CHILDRENS ALLERGY SOLN (Use cetirizine hcl)


Antihistamines - Phenothiazines PHENERGAN SOLN (Use promethazine hcl) NF

promethazine hcl soln 1

promethazine hcl supp 1

promethazine hcl syrp 1

promethazine hcl tabs 1

Antihistamines - Piperidines

cyproheptadine hcl syrp 1

cyproheptadine hcl tabs 1


28

Drug Name DrugTier

RequirementsLimits

ANTIHYPERLIPIDEMICS - Drugs to Treat HighCholesterol Antihyperlipidemics - Combinations

ezetimibe-simvastatin tabs 1 QL(1 ea daily)

VYTORIN TABS (Use ezetimibe-simvastatin) NF QL(1 ea daily)

Antihyperlipidemics - Misc

icosapent ethyl caps 1 PA QL(4 eadaily)

LOVAZA CAPS (Use omega-3-acid ethyl esters) NF QL(4 ea daily)

omega-3-acid ethyl esters caps 1 QL(4 ea daily)

VASCEPA CAPS 05 GM 3 PA

VASCEPA CAPS 1 GM 3 PA QL(4 eadaily)

Bile Acid Sequestrants cholestyramine light pack 4 gm 1 QL(6 ea daily)

cholestyramine light powd4 gmdose 1 QL(24 gm

daily)

cholestyramine pack 4 gm 1 QL(6 ea daily)

cholestyramine powd 4gmdose 1 QL(252 gm

daily) colesevelam hcl pack 375 gm 1 PA QL(1 ea

daily) colesevelam hcl tabs 625 mg 1 QL(7 ea daily)

COLESTID FLAVORED GRAN 5 GM (Use colestipol hcl)

NF QL(6 gm daily)

COLESTID FLAVORED PACK 5 GM75GM (Use colestipol hcl)

NF QL(6 ea daily)

COLESTID GRAN 5 GM (Use colestipol hcl) NF QL(6 gm daily)

COLESTID PACK 5 GM (Use colestipol hcl) NF QL(6 ea daily)

COLESTID TABS 1 GM (Use colestipol hcl) NF QL(16 ea daily)

colestipol hcl gran 5 gm 1 QL(6 gm daily)

Drug Name DrugTier

RequirementsLimits

colestipol hcl pack 5 gm 1 QL(6 ea daily)

colestipol hcl tabs 1 gm 1 QL(16 ea daily)

QUESTRAN LIGHT POWD (Use cholestyramine light) NF QL(24 gm

daily) QUESTRAN PACK 4 GM (Use cholestyramine) NF QL(6 ea daily)

QUESTRAN POWD 4 GMDOSE (Use cholestyramine)

NF QL(252 gmdaily)

WELCHOL PACK 375 GM (Use colesevelam hcl) NF PA QL(1 ea

daily) WELCHOL TABS 625 MG (Use colesevelam hcl) 3 QL(7 ea daily)

Fibric Acid Derivatives

choline fenofibrate cpdr 1 QL(1 ea daily)

fenofibrate micronized caps134 mg 200 mg 67 mg 1 QL(1 ea daily)

fenofibrate tabs 145 mg 48mg 54 mg 160 mg 1 QL(1 ea daily)

FIBRICOR TABS (Use fenofibric acid) NF

gemfibrozil tabs 1 QL(2 ea daily)

LIPOFEN CAPS (Use fenofibrate) NF

LOPID TABS (Use gemfibrozil) NF QL(2 ea daily)

TRICOR TABS (Use fenofibrate) NF QL(1 ea daily)

TRILIPIX CPDR (Use choline fenofibrate) NF QL(1 ea daily)

HMG CoA Reductase Inhibitors ALTOPREV TB24 20 MG 40 MG 3 ST QL(1 ea

daily)

ALTOPREV TB24 60 MG 3 PA QL(1 eadaily)

atorvastatin calcium tabs 1 QL(1 ea daily)

CRESTOR TABS (Use rosuvastatin calcium) NF QL(1 ea daily)

fluvastatin sodium caps 20 mg 1 QL(1 ea daily)


29

Drug Name DrugTier

RequirementsLimits


LIPITOR TABS (Use atorvastatin calcium) NF QL(1 ea daily)

LIVALO TABS 3 ST QL(1 eadaily)

lovastatin tabs 20 mg 10 mg 1

$0 copay forgeneric onlyage 40 to76QL(1 eadaily) PV

lovastatin tabs 40 mg 1


PRAVACHOL TABS (Use pravastatin sodium) NF QL(1 ea daily)

pravastatin sodium tabs 1 QL(1 ea daily)

rosuvastatin calcium tabs 3 QL(1 ea daily)

simvastatin tabs 5 mg 80mg 10 mg 20 mg 40 mg 1 QL(1 ea daily)

ZOCOR TABS (Use simvastatin) NF QL(1 ea daily)

Intestinal Cholesterol Absorption Inhibitors

ezetimibe tabs 1 QL(1 ea daily)

ZETIA TABS (Use ezetimibe) NF QL(1 ea daily)

Nicotinic Acid Derivatives niacin (antihyperlipidemic)tbcr 1000 mg 500 mg 750 mg

1 QL(2 ea daily)

NIASPAN TBCR (Use niacin (antihyperlipidemic)) NF QL(2 ea daily)

Proprotein Convertase SubtilisinKexin Type 9 REPATHA PUSHTRONEX SYSTEM SOCT 4 PA QL(025 ml

daily)

REPATHA SOSY 4 PA QL(00714ml daily)

REPATHA SURECLICK SOAJ 4 PA QL(00714

ml daily) ANTIHYPERTENSIVES - Drugs to Treat HighBlood Pressure

Drug Name DrugTier

RequirementsLimits

ACE Inhibitors ACCUPRIL TABS (Use quinapril hcl) NF

ALTACE CAPS (Use ramipril) NF

benazepril hcl tabs 1

captopril tabs 1

enalapril maleate tabs 10mg 25 mg 20 mg 5 mg 1

fosinopril sodium tabs 1

lisinopril tabs 1

LOTENSIN TABS (Use benazepril hcl) NF

moexipril hcl tabs 1

perindopril erbumine tabs 1

PRINIVIL TABS (Use lisinopril) NF

quinapril hcl tabs 1

ramipril caps 1

trandolapril tabs 1

VASOTEC TABS (Use enalapril maleate) NF

ZESTRIL TABS (Use lisinopril) NF

Agents for Pheochromocytoma DIBENZYLINE CAPS (Use phenoxybenzamine hcl) NF PA

phenoxybenzamine hcl caps 3 PA

Angiotensin II Receptor Antagonists ATACAND TABS (Use candesartan cilexetil) NF QL(1 ea daily)

AVAPRO TABS (Use irbesartan) NF QL(1 ea daily)

BENICAR TABS (Use olmesartan medoxomil) NF QL(1 ea daily)


30

Drug Name DrugTier

RequirementsLimits

candesartan cilexetil tabs 1 QL(1 ea daily)

COZAAR TABS (Use losartan potassium) NF QL(1 ea daily)

DIOVAN TABS (Use valsartan) NF QL(1 ea daily)

EDARBI TABS 3 ST QL(1 eadaily)

eprosartan mesylate tabs 1 QL(1 ea daily)

irbesartan tabs 1 QL(1 ea daily)

losartan potassium tabs or100 mg 25 mg 50 mg 1 QL(1 ea daily)

MICARDIS TABS (Use telmisartan) NF QL(1 ea daily)

olmesartan medoxomil tabs 1 QL(1 ea daily)

telmisartan tabs 1 QL(1 ea daily)

valsartan tabs 1 QL(1 ea daily)

Antiadrenergic Antihypertensives CARDURA TABS (Use doxazosin mesylate) NF

CATAPRES TABS (Use clonidine hcl) NF QL(8 ea daily)

CATAPRES-TTS-1 PTWK (Use clonidine) NF QL(015 ea

daily) CATAPRES-TTS-2 PTWK (Use clonidine) NF QL(015 ea


daily)

clonidine hcl tabs 1 QL(8 ea daily)

clonidine ptwk 3 QL(015 eadaily)

doxazosin mesylate tabs 1

guanfacine hcl tabs 1

MINIPRESS CAPS (Use prazosin hcl) NF QL(4 ea daily)

prazosin hcl caps 1 QL(4 ea daily)

terazosin hcl caps 1

Drug Name DrugTier

RequirementsLimits

Antihypertensive Combinations ACCURETIC TABS (Use quinapril-hydrochlorothiazide)

NF QL(2 ea daily)

amlodipine besylate-benazepril hcl caps 1

amlodipine besylate-olmesartan medoxomil tabs 1 ST

amlodipine besylate-valsartan tabs 1

amlodipine-valsartan-hydrochlorothiazide tabs 1

ATACAND HCT TABS (Use candesartan cilexetil-hydrochlorothiazide)

NF MO

atenolol amp chlorthalidone tabs 1

AVALIDE TABS (Use irbesartan-hydrochlorothiazide)

NF MO

AZOR TABS (Use amlodipine besylate-olmesartan medoxomil)

NF ST

benazepril amphydrochlorothiazide tabs 1

BENICAR HCT TABS (Use olmesartan medoxomil-hydrochlorothiazide)

NF MO

bisoprolol amphydrochlorothiazide tabs 1 QL(2 ea daily)

candesartan cilexetil-hydrochlorothiazide tabs 1 MO

DIOVAN HCT TABS (Use valsartan-hydrochlorothiazide)

NF

enalapril maleate amphydrochlorothiazide tabs 1

EXFORGE HCT TABS 2

EXFORGE TABS (Use amlodipine besylate-valsartan)

NF

fosinopril sodium amphydrochlorothiazide tabs 1


31

Drug Name DrugTier

RequirementsLimits

HYZAAR TABS 125 MG-50 MG (Use losartan potassium amphydrochlorothiazide)

NF

QL(2 ea daily)

HYZAAR TABS 25 MG-100 MG 125 MG-100 MG (Use losartan potassium amphydrochlorothiazide)

NF

QL(1 ea daily)

irbesartan-hydrochlorothiazide tabs 1 MO

lisinopril amphydrochlorothiazide tabs 1

LOPRESSOR HCT TABS (Use metoprolol amphydrochlorothiazide)

NF

losartan potassium amphydrochlorothiazide tabs125 mg-50 mg 50 mg-125 mg

1

QL(2 ea daily)

losartan potassium amphydrochlorothiazide tabs 25mg-100 mg 100 mg-125mg 125 mg-100 mg

1

QL(1 ea daily)

LOTENSIN HCT TABS (Use benazepril amphydrochlorothiazide)

NF

LOTREL CAPS (Use amlodipine besylate-benazepril hcl)

NF

metoprolol amphydrochlorothiazide tabs 1

MICARDIS HCT TABS (Use telmisartan-hydrochlorothiazide)

NF MO

olmesartan medoxomil-amlodipine-hydrochlorothiazide tabs

1 ST

olmesartan medoxomil-hydrochlorothiazide tabs 1 MO

quinapril-hydrochlorothiazide tabs 1 QL(2 ea daily)

TARKA TBCR (Use trandolapril-verapamil hcl) NF

telmisartan-amlodipine tabs 1

telmisartan-hydrochlorothiazide tabs 1 MO

Drug Name DrugTier

RequirementsLimits

TENORETIC 100 TABS (Use atenolol amp chlorthalidone)

NF


NF

trandolapril-verapamil hcltbcr 1

TRANDOLAPRILVERAPAMIL HCL ER TBCR 2

TRIBENZOR TABS (Use olmesartan medoxomil-amlodipine-hydrochlorothiazide)

NF

ST

TWYNSTA TABS (Use telmisartan-amlodipine) NF

valsartan-hydrochlorothiazide tabs 1

VASERETIC TABS (Use enalapril maleate amphydrochlorothiazide)

NF

ZESTORETIC TABS (Use lisinopril amphydrochlorothiazide)

NF

ZIAC TABS (Use bisoprololamp hydrochlorothiazide) NF QL(2 ea daily)

Antihypertensives - Misc VECAMYL TABS 3 PA

Direct Renin Inhibitors

aliskiren fumarate tabs 1 QL(1 ea daily)

TEKTURNA TABS (Use aliskiren fumarate) NF QL(1 ea daily)

Selective Aldosterone Receptor Antagonists

eplerenone tabs 1

INSPRA TABS (Use eplerenone) NF

Vasodilators

hydralazine hcl soln 1

hydralazine hcl tabs 1

minoxidil tabs 1


32

Drug Name DrugTier

RequirementsLimits

ANTIMALARIALS - Drugs to Treat Malaria(Parasitic Infections) Antimalarial Combinations

atovaquone-proguanil hcltabs 1

Covered for malaria treatment onlyLimit 1 fill every180 daysQL(12 eaper fill retail12ea per fillmail)1 rtl MAXfill180 rtl day(s) supply1mail MAX fill180 mail day(s) supply

COARTEM TABS 2


MALARONE TABS (Use atovaquone-proguanil hcl) NF


Antimalarials chloroquine phosphatetabs 1

Drug Name DrugTier

RequirementsLimits

DARAPRIM TABS 3 PA QL(3 eadaily)

hydroxychloroquine sulfatetabs 200 mg 1

KRINTAFEL TABS 3 QL(2 ea per 30days retail)

mefloquine hcl tabs 1

Covered for malaria treatment onlyLimit 1 fill every180 daysQL(5ea daily)1 rtlMAX fill180 rtl day(s) supply1mail MAX fill180 mail day(s) supply

PLAQUENIL TABS (Use hydroxychloroquine sulfate) NF

primaquine phosphate tabs 3

PRIMAQUINE PHOSPHATE TABS (Use primaquine phosphate)

NF

pyrimethamine tabs 1 PA QL(3 eadaily)

QUALAQUIN CAPS (Use quinine sulfate) NF PA

quinine sulfate caps 1 PA

ANTIMYASTHENICCHOLINERGIC AGENTS

AntimyasthenicCholinergic Agents

FIRDAPSE TABS 4 PA

GUANIDINE HCL TABS 2

MESTINON SOLN (Use pyridostigmine bromide) NF

MESTINON TABS (Use pyridostigmine bromide) NF

MESTINON TIMESPAN TBCR (Use pyridostigminebromide)

NF

NEOSTIGMINE METHYLSULFATE SOSY 3 MG3ML

3 PA


33

Drug Name DrugTier

RequirementsLimits

pyridostigmine bromidesoln 60 mg5ml 1

pyridostigmine bromidetabs 60 mg 1

pyridostigmine bromidetbcr 180 mg 1

RUZURGI TABS 4 PA QL(10 eadaily)

ANTIMYCOBACTERIAL AGENTS - Drugs toTreat Tuberculosis (Bacterial Infections) Anti TB Combinations

RIFAMATE CAPS 3

RIFATER TABS 3 QL(6 ea daily)

Antimycobacterial Agents CAPASTAT SULFATE SOLR 3

cycloserine caps 1 QL(4 ea daily)

ethambutol hcl tabs 1

isoniazid soln 1

isoniazid syrp 1

isoniazid tabs 1

MYAMBUTOL TABS (Use ethambutol hcl) NF

MYCOBUTIN CAPS (Use rifabutin) NF PA

PASER PACK 3 QL(3 ea daily)

PRIFTIN TABS 3

pyrazinamide tabs 1

rifabutin caps 1 PA

RIFADIN CAPS (Use rifampin) NF

RIFADIN SOLR (Use rifampin) NF

rifampin caps 1

Drug Name DrugTier

RequirementsLimits

rifampin solr 1

SIRTURO TABS 100 MG 3 PA

TRECATOR TABS 3 QL(4 ea daily)

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer Alkylating Agents ALKERAN SOLR (Use melphalan hcl) NF

ALKERAN TABS (Use melphalan) NF

BICNU SOLR (Use carmustine) NF PA SP

busulfan soln 4 PA SP

BUSULFEX SOLN (Use busulfan) NF PA SP

carboplatin soln 50 mg5ml 4 PA SP

carmustine solr 4 PA SP

cisplatin soln 100mg100ml 4 PA SP

cyclophosphamide caps or25 mg 50 mg 1 PA

cyclophosphamide solr ij 1gm 2 gm 500 mg 4 PA SP

GLEOSTINE CAPS 10 MG 4 PA SP

GLEOSTINE CAPS 100 MG 40 MG 4 PA

IFEX SOLR 1 GM (Use ifosfamide) NF PA SP

ifosfamide soln 1 gm20ml 4 PA SP

ifosfamide solr 1 gm 4 PA SP

LEUKERAN TABS 4 PA SP

melphalan hcl solr 1

melphalan tabs 1

MYLERAN TABS 4 PA SP


34

Drug Name DrugTier

RequirementsLimits

oxaliplatin soln 100mg20ml 50 mg10ml 4 PA SP

TEMODAR CAPS OR 100 MG 140 MG 180 MG 20 MG 250 MG 5 MG (Use temozolomide)

NF

PA SP

TEMODAR SOLR IV 100 MG 4 PA SP

temozolomide caps 4 PA SP

TEPADINA SOLR 100 MG (Use thiotepa) NF

TEPADINA SOLR 15 MG (Use thiotepa) NF PA SP

thiotepa solr 15 mg 4 PA SP

TREANDA SOLR 4 PA SP

ZANOSAR SOLR 4 PA SP

Antimetabolites

ALIMTA SOLR 500 MG 4 PA SP

ARRANON SOLN (Use nelarabine) 4 PA SP

azacitidine susr 4 PA SP

capecitabine tabs 4 PA SP

clofarabine soln 4 PA SP

CLOLAR SOLN (Use clofarabine) NF PA SP

cytarabine soln 100 mgml20 mgml 4 PA SP

DACOGEN SOLR (Use decitabine) NF PA SP

decitabine solr 4 PA SP

floxuridine solr 4 PA SP

fludarabine phosphate soln 4 PA SP

fludarabine phosphate solr 4 PA SP

fluorouracil soln 500 mg10ml 4 PA SP

Drug Name DrugTier

RequirementsLimits

FOLOTYN SOLN 20 MGML 4 PA SP

gemcitabine hcl solr 2 gm200 mg 4 PA SP

GEMCITABINE HYDROCHLORIDE SOLN 1 GM10ML 2 GM20ML200 MG2ML (Use gemcitabine hcl)

NF

mercaptopurine tabs 1

methotrexate sodium soln ij250 mg10ml 50 mg2ml 1

methotrexate sodium solr ij1 gm 1 SP

methotrexate sodium tabs or 25 mg 1 SP

nelarabine soln 4 PA SP

TABLOID TABS 4 PA SP

TREXALL TABS 4 PA SP

VIDAZA SUSR (Use azacitidine) NF PA SP

XELODA TABS (Use capecitabine) NF PA SP

Antineoplastic - Angiogenesis Inhibitors

INLYTA TABS 4 PA QL(2 eadaily) SP

LENVIMA 10 MG DAILY DOSE CPPK 4 PA QL(1 ea

daily) LENVIMA 12MG DAILY DOSE CPPK 4 PA QL(3 ea

daily) LENVIMA 14 MG DAILY DOSE CPPK 4 PA QL(2 ea






daily)


35

Drug Name DrugTier

RequirementsLimits

MVASI SOLN 4 PA

ZALTRAP SOLN 100 MG4ML 4 PA SP

ZIRABEV SOLN 4 PA

Antineoplastic - Anti-HER2 Agents

HERCEPTIN SOLR 4 PA SP

PERJETA SOLN 4 PA SP

TUKYSA TABS 4 PA

Antineoplastic - Antibodies

ADCETRIS SOLR 4 PA SP

ARZERRA CONC 4 PA SP

RITUXAN SOLN 4 PA SP

RUXIENCE SOLN 4 PA

YERVOY SOLN 4 PA SP

Antineoplastic - EGFR Inhibitors

ERBITUX SOLN 4 PA SP

erlotinib hcl tabs 4 PA QL(1 eadaily) SP

GILOTRIF TABS 4 PA QL(1 eadaily)

TARCEVA TABS (Use erlotinib hcl) NF PA QL(1 ea

daily) SP VECTIBIX SOLN 100 MG5ML 4 PA SP

VIZIMPRO TABS 4 PA

Antineoplastic - Hedgehog Pathway Inhibitors

DAURISMO TABS 4 PA

ERIVEDGE CAPS 4 PA QL(1 eadaily) SP

ODOMZO CAPS 4 PA QL(1 eadaily)

Antineoplastic - Hormonal and Related Agents

Drug Name DrugTier

RequirementsLimits

abiraterone acetate tabs 250 mg 4 PA QL(4 ea

daily) SP abiraterone acetate tabs 500 mg 4 PA QL(2 ea

daily)

anastrozole tabs 1 QL(1 ea daily)

ARIMIDEX TABS (Use anastrozole) NF QL(1 ea daily)

AROMASIN TABS (Use exemestane) NF QL(1 ea daily)

SP

bicalutamide tabs 4 PA QL(1 eadaily) SP

CASODEX TABS (Use bicalutamide) NF PA QL(1 ea

daily) SP

ELIGARD KIT 225 MG 4 PA SP



ELIGARD KIT 75 MG 4 PA QL(00089ea daily) SP

EMCYT CAPS 4 PA SP

exemestane tabs 4 QL(1 ea daily)SP

FARESTON TABS (Use toremifene citrate) NF

FASLODEX SOLN (Use fulvestrant) NF PA QL(0357

ml daily) SP FEMARA TABS (Use letrozole) NF QL(1 ea daily)

FIRMAGON SOLR 4 PA QL(0143ea daily) SP

flutamide caps 4 PA QL(6 eadaily) SP

fulvestrant soln 4 PA QL(0357ml daily) SP

letrozole tabs 1 QL(1 ea daily)

leuprolide acetate kit 4 PA SP

LUPRON DEPOT (1-MONTH) KIT 4 PA QL(00357

ea daily) SP LUPRON DEPOT (3-MONTH) KIT 4 PA SP


36

Drug Name DrugTier

RequirementsLimits


ea daily) SP LUPRON DEPOT (6-MONTH) KIT 4 PA QL(00089

ea daily) SP

LYSODREN TABS 4 PA SP

megestrol acetate susp 1

megestrol acetate tabs 1

NILANDRON TABS (Use nilutamide) NF QL(2 ea daily)

nilutamide tabs 1 QL(2 ea daily)

NUBEQA TABS 4 PA

tamoxifen citrate tabs 0

toremifene citrate tabs 1

TRELSTAR MIXJECT SUSR 4 PA SP

XTANDI CAPS 40 MG 4 PA QL(4 eadaily) SP

YONSA TABS 4 PA

ZOLADEX IMPL 108 MG 4 PA QL(00119ea daily) SP


ZYTIGA TABS 250 MG (Use abiraterone acetate) NF PA QL(4 ea

daily) SP ZYTIGA TABS 500 MG (Use abiraterone acetate) 4 PA QL(2 ea

daily) Antineoplastic - Immunomodulators

POMALYST CAPS 4 PA QL(1 eadaily)

Antineoplastic - PDGFR-alpha Inhibitors AYVAKIT TABS 100 MG 200 MG 300 MG 4 PA SL(1 ea

daily) Antineoplastic - XPO1 Inhibitors XPOVIO 100 MG ONCE WEEKLY TBPK 4 PA

XPOVIO 60 MG ONCE WEEKLY TBPK 4 PA

Drug Name DrugTier

RequirementsLimits


XPOVIO 80 MG TWICE WEEKLY TBPK 4 PA

Antineoplastic Antibiotics bleomycin sulfate solr 15unit 4 PA SP

COSMEGEN SOLR (Use dactinomycin) NF PA SP

dactinomycin solr 4 PA SP

DAUNORUBICIN HYDROCHLORIDE SOLN 20 MG4ML (Use daunorubicin hcl)

NF

DOXIL INJ (Use doxorubicin hcl liposomal) NF PA SP

doxorubicin hcl liposomalinj 4 PA SP

doxorubicin hcl soln 2 mgml 200 mg100ml 4 PA SP

doxorubicin hcl solr 50 mg10 mg 4 PA SP

ELLENCE SOLN 50 MG25ML (Use epirubicin hcl)

NF PA SP

epirubicin hcl soln 50mg25ml 4 PA SP

IDAMYCIN PFS SOLN 10 MG10ML 5 MG5ML (Use idarubicin hcl)

NF PA SP

IDAMYCIN PFS SOLN 20 MG20ML (Use idarubicin hcl)

NF PA

idarubicin hcl soln 10 mg10ml 5 mg5ml 4 PA SP

idarubicin hcl soln 20 mg20ml 4 PA

mitomycin solr iv 20 mg 4 PA SP

mitoxantrone hcl conc 4 PA SP

valrubicin soln 4 PA SP

VALSTAR SOLN (Use valrubicin) NF PA SP


37

Drug Name DrugTier

RequirementsLimits

Antineoplastic Combinations KISQALI FEMARA 200 DOSE TBPK 3 PA

KISQALI FEMARA 400 DOSE TBPK 3 PA


Antineoplastic Enzyme Inhibitors AFINITOR TABS (Use everolimus) NF PA QL(1 ea

daily) SP

ALECENSA CAPS 4 PA QL(4 eadaily)

ALUNBRIG TABS 4 PA QL(1 eadaily)

ALUNBRIG TBPK 4 PA QL(1 eadaily)

BALVERSA TABS 4 PA

BORTEZOMIB SOLR 4 PA SP

BOSULIF TABS 100 MG 500 MG 4 PA QL(1 ea

daily) SP

BOSULIF TABS 400 MG 4 PA

BRAFTOVI CAPS 4 PA SP

BRUKINSA CAPS 4 PA

CAPRELSA TABS 4 PA QL(1 eadaily) SP

COMETRIQ KIT 4 PA QL(2 eadaily) SP



COPIKTRA CAPS 4 PA

everolimus tabs 10 mg 5mg 75 mg 25 mg 4 PA QL(1 ea

daily) SP GLEEVEC TABS (Use imatinib mesylate) NF PA QL(2 ea

daily) SP

IBRANCE CAPS 3 PA

IBRANCE TABS 3 PA

Drug Name DrugTier

RequirementsLimits

ICLUSIG TABS 10 MG 30 MG 45 MG 4 PA QL(1 ea

daily)

ICLUSIG TABS 15 MG 4 PA QL(2 eadaily)

imatinib mesylate tabs 4 PA QL(2 eadaily) SP

IMBRUVICA CAPS 140 MG 4 PA QL(3 ea

daily)

IMBRUVICA CAPS 70 MG 4 PA QL(1 eadaily)

IMBRUVICA TABS 140 MG 280 MG 420 MG 560 MG

4 PA QL(1 eadaily)

INREBIC CAPS 4 PA

ISTODAX (OVERFILL) SOLR 4 PA SP

JAKAFI TABS 10 MG 20 MG 4 PA SP

JAKAFI TABS 15 MG 25 MG 5 MG 4 PA QL(2 ea

daily) SP

KISQALI TBPK 3 PA

KOSELUGO CAPS 4 PA

KYPROLIS SOLR 4 PA

lapatinib ditosylate tabs 4 PA QL(6 eadaily) SP

LORBRENA TABS 4 PA

LYNPARZA TABS 4 PA QL(16 eadaily)

MEKINIST TABS 05 MG 4 PA QL(3 eadaily)


MEKTOVI TABS 4 PA SP

NEXAVAR TABS 4 PA QL(4 eadaily) SP

NINLARO CAPS 4 PA QL(0143ea daily)

PEMAZYRE TABS 4 PA QL(1 eadaily)

PIQRAY 200MG DAILY DOSE TBPK 4 PA


38

Drug Name DrugTier

RequirementsLimits



QINLOCK TABS 4 PA

RETEVMO CAPS 4 PA

ROMIDEPSIN SOLR 10 MG 4 PA SP

ROZLYTREK CAPS 4 PA

RUBRACA TABS 4 PA QL(4 eadaily)

SPRYCEL TABS 4 PA QL(1 eadaily) SP

STIVARGA TABS 4 PA QL(4 eadaily) SP

sunitinib malate caps 125mg 25 mg 50 mg 4 PA QL(1 ea

daily) SP SUTENT CAPS 125 MG 25 MG 50 MG (Use sunitinib malate)

4 PA QL(1 eadaily) SP

TABRECTA TABS 4 PA

TAFINLAR CAPS 4 PA QL(4 eadaily)

TALZENNA CAPS 4 PA

TASIGNA CAPS 150 MG 200 MG 4 PA QL(4 ea

daily) SP

TASIGNA CAPS 50 MG 4 PA QL(4 eadaily)

TAZVERIK TABS 4 PA

temsirolimus soln 4 PA QL(0143ml daily) SP

TIBSOVO TABS 4 PA

TORISEL SOLN (Use temsirolimus) NF PA QL(0143

ml daily) SP

TURALIO CAPS 4 PA AC

TYKERB TABS (Use lapatinib ditosylate) 4 PA QL(6 ea

daily) SP

VELCADE SOLR 4 PA SP

Drug Name DrugTier

RequirementsLimits

VERZENIO TABS 4 PA

VITRAKVI CAPS 4 PA

VITRAKVI SOLN 4 PA

VOTRIENT TABS 4 PA QL(4 eadaily) SP

XALKORI CAPS 4 PA QL(2 eadaily) SP

XOSPATA TABS 4 PA

ZEJULA CAPS 4 PA QL(3 eadaily)

ZELBORAF TABS 4 PA SP

ZOLINZA CAPS 4 PA QL(4 eadaily) SP

ZYDELIG TABS 4 PA QL(2 eadaily)

Antineoplastic Enzymes

ERWINASE SOLR 4 PA SP

ERWINAZE SOLR 4 PA SP

ONCASPAR SOLN 4 PA SP

Antineoplastics Misc ACTIMMUNE SOLN 4 PA SP

arsenic trioxide soln 10 mg10ml 4 PA SP

bexarotene caps 4 PA SP

dacarbazine solr 200 mg 4 PA SP

HYDREA CAPS (Use hydroxyurea) NF

hydroxyurea caps 1

INTRON A SOLR 18 MU 4 PA SP

MATULANE CAPS 4 PA SP

NIPENT SOLR 4 PA SP

PHOTOFRIN SOLR 4 PA SP


39

Drug Name DrugTier

RequirementsLimits

PROLEUKIN SOLR 4 PA SP

SYNRIBO SOLR 4 PA SP

TARGRETIN CAPS OR 75 MG (Use bexarotene) NF PA SP

tretinoin (chemotherapy) caps 1

UVADEX SOLN 4 PA SP

Chemotherapy Adjuncts

KEPIVANCE SOLR 4 PA SP

Chemotherapy RescueAntidoteProtective Agents leucovorin calcium solr ij500 mg 100 mg 200 mg350 mg 50 mg

1

leucovorin calcium tabs or 25 mg 5 mg 10 mg 15 mg 1

VORAXAZE SOLR 4 PA SP

Mitotic Inhibitors

ABRAXANE SUSR 4 PA SP

docetaxel conc 20 mgml 4 PA SP

DOCETAXEL CONC 20 MGML (Use docetaxel) NF PA SP

DOCETAXEL CONC 80 MG4ML (Use docetaxel) NF

DOCETAXEL SOLN 20 MG2ML 4 PA SP

docetaxel soln 20 mg2ml 4 PA SP

DOCETAXEL SOLN 20 MG2ML (Use docetaxel) 4 PA SP

ETOPOPHOS SOLR 4 PA SP

etoposide caps 4 PA SP

etoposide soln 4 PA SP

HALAVEN SOLN 4 PA SP

IXEMPRA KIT SOLR 15 MG 4 PA SP

Drug Name DrugTier

RequirementsLimits

JEVTANA SOLN 4 PA SP

NAVELBINE SOLN 10 MGML (Use vinorelbine tartrate)

NF PA SP

paclitaxel conc 150mg25ml 100 mg167ml 6mgml

4 PA SP

TAXOTERE CONC (Use docetaxel) NF PA SP

TENIPOSIDE SOLN 4 PA SP

vincristine sulfate soln 4 PA SP

vinorelbine tartrate soln 10 mgml 4 PA SP

Topoisomerase I Inhibitors CAMPTOSAR SOLN 100 MG5ML 40 MG2ML (Use irinotecan hcl)

NF PA SP

HYCAMTIN CAPS OR 025 MG 1 MG 4 PA SP

HYCAMTIN SOLR IV 4 MG (Use topotecan hcl) NF PA SP

irinotecan hcl soln 100 mg5ml 40 mg2ml 4 PA SP

topotecan hcl solr 4 mg 4 PA SP

ANTIPARKINSON AND RELATED THERAPY AGENTS - Drugs to Treat Parkinsons Disease

Antiparkinson Adjunctive Therapy

carbidopa tabs 1

LODOSYN TABS (Use carbidopa) NF

Antiparkinson Anticholinergics

benztropine mesylate soln 1

benztropine mesylate tabs 1

COGENTIN SOLN (Use benztropine mesylate) NF

trihexyphenidyl hcl soln 1

trihexyphenidyl hcl tabs 1


40

Drug Name DrugTier

RequirementsLimits

Antiparkinson COMT Inhibitors COMTAN TABS (Use entacapone) NF QL(8 ea daily)

entacapone tabs 1 QL(8 ea daily)

TASMAR TABS (Use tolcapone) 3

tolcapone tabs 3

Antiparkinson Dopaminergics

amantadine hcl caps 1

amantadine hcl tabs 1

APOKYN SOCT 4 PA

bromocriptine mesylate caps 1

bromocriptine mesylatetabs 1

carbidopa-levodopa tabs 1

carbidopa-levodopa tbcr 1

carbidopa-levodopa tbdp 1

carbidopa-levodopa-entacapone tabs 1

CARBIDOPALEVODOPAODT TBDP 1

MIRAPEX TABS 0125 MG (Use pramipexoledihydrochloride)

NF QL(4 ea daily)

MIRAPEX TABS 025 MG 05 MG 075 MG 1 MG 15 MG (Use pramipexoledihydrochloride)

NF

NEUPRO PT24 2

PARLODEL CAPS (Use bromocriptine mesylate) NF

PARLODEL TABS (Use bromocriptine mesylate) NF

pramipexoledihydrochloride tabs 0125 mg

1 QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits

pramipexoledihydrochloride tabs 025mg 05 mg 075 mg 1 mg15 mg

1

REQUIP XL TB24 12 MG 8 MG (Use ropinirolehydrochloride)

NF ST QL(2 eadaily)

REQUIP XL TB24 6 MG (Use ropinirolehydrochloride)

NF ST QL(1 eadaily)

ropinirole hydrochloridetabs 025 mg 3 mg 1 mg2 mg 4 mg 5 mg 05 mg

1

ropinirole hydrochloridetb24 12 mg 8 mg 1 ST QL(2 ea

daily) ropinirole hydrochloridetb24 2 mg 4 mg 6 mg 1 ST QL(1 ea

daily) SINEMET CR TBCR (Use carbidopa-levodopa) NF

SINEMET TABS (Use carbidopa-levodopa) NF

STALEVO 100 TABS (Use carbidopa-levodopa-entacapone)

1


NF


1


NF


1


NF


1


NF


41

Drug Name DrugTier

RequirementsLimits


1


NF


1


NF

Antiparkinson Monoamine Oxidase Inhibitors AZILECT TABS (Use rasagiline mesylate) NF PA QL(1 ea

daily)

rasagiline mesylate tabs 1 PA QL(1 eadaily)

selegiline hcl caps 1

selegiline hcl tabs 1

ANTIPSYCHOTICSANTIMANIC AGENTS -Drugs to Treat Mood Disorders

Antimanic Agents

lithium carbonate caps 1

lithium carbonate tabs 1

lithium carbonate tbcr 1

LITHIUM SOLN 1

LITHOBID TBCR (Use lithium carbonate) NF

Antipsychotics - Misc EQUETRO CP12 100 MG 3 QL(2 ea daily)

EQUETRO CP12 200 MG 3 QL(8 ea daily)


GEODON CAPS OR 20 MG 40 MG 60 MG 80 MG (Use ziprasidone hcl)


LATUDA TABS 120 MG 20 MG 40 MG 60 MG 3 PA QL(1 ea

daily)

Drug Name DrugTier

RequirementsLimits

LATUDA TABS 80 MG 3 PA QL(2 eadaily)

ziprasidone hcl caps 1 QL(2 ea daily)AL(At least 18yrs old)

Benzisoxazoles

FANAPT TABS 2 PA QL(2 eadaily)

FANAPT TITRATION PACK TABS 2 PA

INVEGA TB24 15 MG 3 MG 9 MG (Use paliperidone)

NF QL(1 ea daily)

INVEGA TB24 6 MG (Use paliperidone) NF QL(2 ea daily)

paliperidone tb24 15 mg 3mg 9 mg 1 QL(1 ea daily)

paliperidone tb24 6 mg 1 QL(2 ea daily)

PERSERIS PRSY 2 PA QL(0072ea daily)

RISPERDAL CONSTA SRER 2 PA QL(0072

ea daily) RISPERDAL SOLN 1 MGML (Use risperidone) NF QL(8 ml daily)

RISPERDAL TABS 05 MG 1 MG 2 MG 3 MG (Use risperidone)

NF QL(2 ea daily)

RISPERDAL TABS 4 MG (Use risperidone) NF QL(4 ea daily)

risperidone soln 1 mgml 1 QL(8 ml daily)

risperidone tabs 025 mg05 mg 1 mg 2 mg 3 mg 1 QL(2 ea daily)

risperidone tabs 4 mg 1 QL(4 ea daily)

risperidone tbdp 025 mg 1 PA QL(2 eadaily)

risperidone tbdp 05 mg 1mg 2 mg 3 mg 4 mg 1 QL(2 ea daily)

Butyrophenones HALDOL DECANOATE 100 SOLN (Use haloperidol decanoate)

NF QL(0036 mldaily)


42

Drug Name DrugTier

RequirementsLimits

HALDOL DECANOATE 50 SOLN (Use haloperidoldecanoate)

NF QL(0036 mldaily)

HALDOL SOLN (Use haloperidol lactate) NF

haloperidol decanoate soln 1 QL(0036 mldaily)

haloperidol lactate conc 1

haloperidol lactate soln 1

haloperidol tabs 1

Dibenzapines asenapine maleate subl 10mg 5 mg 1 PA QL(2 ea

daily) asenapine maleate subl 25 mg 1 PA QL(4 ea

daily) clozapine tabs 200 mg 50mg 100 mg 25 mg 1

clozapine tbdp 100 mg 1 QL(9 ea daily)

clozapine tbdp 125 mg150 mg 1 QL(6 ea daily)



CLOZARIL TABS (Use clozapine) NF

FAZACLO TBDP 100 MG (Use clozapine) NF QL(9 ea daily)


FAZACLO TBDP 150 MG (Use clozapine) 1 QL(6 ea daily)



loxapine succinate caps 1

olanzapine solr im 10 mg 1 QL(0215 eadaily)

olanzapine tabs or 10 mg25 mg 5 mg 75 mg 1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

olanzapine tabs or 15 mg20 mg 1 QL(2 ea daily)

olanzapine tbdp or 10 mg15 mg 5 mg 1 QL(2 ea daily)

olanzapine tbdp or 20 mg 1 QL(1 ea daily)

quetiapine fumarate tabs100 mg 200 mg 25 mg300 mg 400 mg 50 mg


quetiapine fumarate tb24150 mg 200 mg 50 mg 1 PA QL(1 ea

daily) quetiapine fumarate tb24300 mg 400 mg 1 PA QL(2 ea

daily) SAPHRIS SUBL 10 MG 5 MG (Use asenapinemaleate)

3 PA QL(2 eadaily)

SAPHRIS SUBL 25 MG (Use asenapine maleate) 3 PA QL(4 ea

daily)

SAPHRIS SUBL 5 MG 3 PA QL(2 eadaily)

SEROQUEL TABS (Use quetiapine fumarate) NF


SEROQUEL XR TB24 150 MG 200 MG 50 MG (Use quetiapine fumarate)

NF PA QL(1 eadaily)

SEROQUEL XR TB24 300 MG 400 MG (Use quetiapine fumarate)

NF PA QL(2 eadaily)

ZYPREXA SOLR IM 10 MG (Use olanzapine) NF QL(0215 ea

daily) ZYPREXA TABS OR 10 MG 25 MG 5 MG 75 MG (Use olanzapine)

NF QL(1 ea daily)

ZYPREXA TABS OR 15 MG 20 MG (Use olanzapine)

NF QL(2 ea daily)

ZYPREXA ZYDIS TBDP 10 MG 15 MG 5 MG (Use olanzapine)

NF QL(2 ea daily)

ZYPREXA ZYDIS TBDP 20 MG (Use olanzapine) NF QL(1 ea daily)

Phenothiazines chlorpromazine hcl soln ij25 mgml 50 mg2ml 3


43

Drug Name DrugTier

RequirementsLimits

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

1

fluphenazine hcl conc or 5mgml 1

fluphenazine hcl elix or 25mg5ml 1

fluphenazine hcl soln ij 25mgml 1

fluphenazine hcl tabs or 1mg 10 mg 25 mg 5 mg 1

perphenazine tabs 1

prochlorperazine maleatetabs 1

prochlorperazine supp 1

thioridazine hcl tabs 1

trifluoperazine hcl tabs 1

Quinolinone Derivatives

ABILIFY TABS (Use aripiprazole) NF


aripiprazole soln 1 mgml 3 QL(30 mldaily) AL(Atleast 6 yrs old)

aripiprazole tabs 10 mg 15mg 2 mg 20 mg 30 mg 5 mg


REXULTI TABS 3 PA

Thioxanthenes

thiothixene caps 1

ANTIVIRALS - Drugs to Treat Viral Infections

Antiretrovirals abacavir sulfate soln 20 mgml 1 QL(32 ml daily)

abacavir sulfate tabs 300 mg 1 QL(2 ea daily)

abacavir sulfate-lamivudine tabs 1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

abacavir sulfate-lamivudine-zidovudine tabs 1 QL(2 ea daily)

APTIVUS CAPS 250 MG 2 QL(4 ea daily)

APTIVUS SOLN 100 MGML 2 QL(10 ml daily)

atazanavir sulfate caps 150mg 300 mg 1 QL(1 ea daily)

atazanavir sulfate caps 200 mg 1 QL(2 ea daily)

ATRIPLA TABS (Use efavirenz-emtricitabine-tenofovir disoproxilfumarate)

3

QL(1 ea daily)

BIKTARVY TABS 2 QL(1 ea daily)

CIMDUO TABS 2 ST QL(1 eadaily)

COMBIVIR TABS (Use lamivudine-zidovudine) NF QL(2 ea daily)

COMPLERA TABS 3 QL(1 ea daily)

CRIXIVAN CAPS 200 MG 2 QL(9 ea daily)


DELSTRIGO TABS 3 QL(1 ea daily)

DESCOVY TABS 2 PA QL(1 eadaily)

didanosine cpdr 200 mg 1 QL(2 ea daily)

didanosine cpdr 250 mg400 mg 1 QL(1 ea daily)

DOVATO TABS 2 QL(1 ea daily)

EDURANT TABS 2 QL(1 ea daily)

efavirenz caps 200 mg 1 QL(2 ea daily)


efavirenz tabs 600 mg 1 QL(1 ea daily)

efavirenz-emtricitabine-tenofovir disoproxilfumarate tabs

1 QL(1 ea daily)


44

Drug Name DrugTier

RequirementsLimits

efavirenz-lamivudine-tenofovir disoproxilfumarate tabs

1 QL(1 ea daily)

emtricitabine caps 1 QL(1 ea daily)

emtricitabine-tenofovir disoproxil fumarate tabs133 mg-200 mg 150 mg-100 mg 167 mg-250 mg

1

QL(1 eadaily30 day(s)limit)

emtricitabine-tenofovir disoproxil fumarate tabs200 mg-300 mg 300 mg-200 mg

0

QL(1 ea daily)

emtricitabine-tenofovir disoproxil fumarate tabs300 mg-200 mg

0 QL(1 eadaily30 day(s)limit)

EMTRIVA CAPS 200 MG (Use emtricitabine) 2 QL(1 ea daily)

EMTRIVA SOLN 10 MGML 2 QL(24 ml daily)

EPIVIR SOLN 10 MGML(Use lamivudine) NF QL(30 ml daily)

EPIVIR TABS 150 MG (Use lamivudine) NF QL(2 ea daily)


EPZICOM TABS (Use abacavir sulfate-lamivudine)

NF QL(1 ea daily)

etravirine tabs 100 mg 1 QL(4 ea daily)


fosamprenavir calcium tabs 1 QL(4 ea daily)

FUZEON SOLR 4 PA SP

GENVOYA TABS 2 QL(1 ea daily)

INTELENCE TABS 100 MG (Use etravirine) 2 QL(4 ea daily)


INTELENCE TABS 25 MG 2 QL(8 ea daily)

INVIRASE TABS 2 QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits

ISENTRESS CHEW 100 MG 25 MG 2 QL(6 ea daily)

ISENTRESS HD TABS 2 QL(2 ea daily)

ISENTRESS TABS 400 MG 2 QL(2 ea daily)

JULUCA TABS 3 QL(1 ea daily)

KALETRA SOLN 400 MG5ML-100 MG5ML(Use lopinavir-ritonavir)

NF QL(125 mldaily)

KALETRA TABS 100 MG-25 MG 200 MG-50 MG 25 MG-100 MG 50 MG-200 MG (Use lopinavir-ritonavir)

2

QL(4 ea daily)

lamivudine soln 10 mgml 1 QL(30 ml daily)

lamivudine tabs 150 mg 1 QL(2 ea daily)


lamivudine-zidovudine tabs 1 QL(2 ea daily)

LEXIVA SUSP 50 MGML 2 QL(56 ml daily)

LEXIVA TABS 700 MG (Use fosamprenavircalcium)

NF QL(4 ea daily)

lopinavir-ritonavir soln 100mg5ml-400 mg5ml 1 QL(125 ml

daily) lopinavir-ritonavir tabs 100mg-25 mg 50 mg-200 mg 1 QL(4 ea daily)

nevirapine tabs 200 mg 1 QL(2 ea daily)

nevirapine tb24 100 mg 1 QL(3 ea daily)


NORVIR PACK 100 MG 2

QL(12 eadaily)30 rtl lmtday(s)30 maillmt day(s)

NORVIR SOLN 80 MGML 2 QL(15 ml daily)

NORVIR TABS 100 MG (Use ritonavir) NF QL(12 ea daily)

ODEFSEY TABS 2 QL(1 ea daily)


45

Drug Name DrugTier

RequirementsLimits

PIFELTRO TABS 2 QL(1 ea daily)

PREZCOBIX TABS 2 QL(1 ea daily)

PREZISTA SUSP 100 MGML 2 QL(12 ml daily)

PREZISTA TABS 150 MG 600 MG 75 MG 2 QL(2 ea daily)

PREZISTA TABS 800 MG 2 QL(1 ea daily)

RESCRIPTOR TABS 2 QL(6 ea daily)

RETROVIR CAPS 100 MG (Use zidovudine) NF QL(6 ea daily)

RETROVIR IV INFUSION SOLN 1

RETROVIR SYRP 50 MG5ML (Use zidovudine) NF QL(60 ml daily)

REYATAZ CAPS 150 MG 300 MG (Use atazanavir sulfate)

NF QL(1 ea daily)

REYATAZ CAPS 200 MG (Use atazanavir sulfate) NF QL(2 ea daily)

ritonavir tabs 1 QL(12 ea daily)

RUKOBIA TB12 4 PA

SELZENTRY SOLN 20 MGML 2 QL(30 ml daily)

SELZENTRY TABS 150 MG 25 MG 75 MG 2 QL(2 ea daily)

SELZENTRY TABS 300 MG 2 QL(4 ea daily)

stavudine caps 15 mg 20mg 30 mg 40 mg 1 QL(2 ea daily)

STAVUDINE CAPS 15 MG 30 MG 2 QL(2 ea daily)


STRIBILD TABS 3 QL(1 ea daily)

SUSTIVA CAPS 200 MG (Use efavirenz) NF QL(2 ea daily)


SUSTIVA TABS 600 MG (Use efavirenz) NF QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

SYMFI LO TABS (Use efavirenz-lamivudine-tenofovir disoproxilfumarate)

2

QL(1 ea daily)

SYMFI TABS (Use efavirenz-lamivudine-tenofovir disoproxilfumarate)

2

QL(1 ea daily)

SYMTUZA TABS 3 ST QL(1 eadaily)

TEMIXYS TABS 2 ST QL(1 eadaily)

tenofovir disoproxilfumarate tabs 1

TIVICAY TABS 3 QL(2 ea daily)

TRIUMEQ TABS 2 QL(1 ea daily)

TRIZIVIR TABS (Use abacavir sulfate-lamivudine-zidovudine)

NF QL(2 ea daily)

TRUVADA TABS (Use emtricitabine-tenofovir disoproxil fumarate)


TYBOST TABS 2 QL(1 ea daily)

VIDEX EC CPDR 125 MG 2 QL(2 ea daily)

VIDEX EC CPDR 200 MG (Use didanosine) NF QL(2 ea daily)


VIDEXPEDIATRIC SOLR 2

VIRACEPT TABS 250 MG 2 QL(10 ea daily)


VIRAMUNE SUSP 50 MG5ML NF QL(40 ml daily)

VIRAMUNE TABS 200 MG (Use nevirapine) NF QL(2 ea daily)

VIRAMUNE XR TB24 (Use nevirapine) NF QL(1 ea daily)

VIREAD POWD 40 MGGM 2

VIREAD TABS 150 MG 200 MG 250 MG 2 QL(1 ea daily)


46

Drug Name DrugTier

RequirementsLimits

VIREAD TABS 300 MG (Use tenofovir disoproxilfumarate)

NF

ZIAGEN SOLN 20 MGML(Use abacavir sulfate) NF QL(32 ml daily)

ZIAGEN TABS 300 MG (Use abacavir sulfate) NF QL(2 ea daily)

zidovudine caps 100 mg 1 QL(6 ea daily)

zidovudine syrp 50 mg5ml 1 QL(60 ml daily)

zidovudine tabs 300 mg 1 QL(2 ea daily)

CMV Agents

cidofovir soln 3

CYTOVENE SOLR (Use ganciclovir sodium) NF

ganciclovir sodium solr 1

VALCYTE TABS 450 MG (Use valganciclovir hcl) NF PA QL(4 ea

daily) valganciclovir hcl tabs 450 mg 1 PA QL(4 ea

daily) Hepatitis Agents

adefovir dipivoxil tabs 4 PA QL(1 eadaily) SP

BARACLUDE SOLN 005 MGML 4 PA QL(20 ml

daily) SP BARACLUDE TABS 05 MG 1 MG (Use entecavir) NF PA QL(1 ea

daily) SP

entecavir tabs 4 PA QL(1 eadaily) SP

EPCLUSA TABS 200 MG-50 MG 400 MG-100 MG 4 PA QL(1 ea

daily) EPIVIR HBV SOLN 5 MGML 4 PA QL(60 ml

daily) SP EPIVIR HBV TABS 100 MG (Use lamivudine (hbv)) NF QL(3 ea daily)

SP HEPSERA TABS (Use adefovir dipivoxil) NF PA QL(1 ea

daily) SP

lamivudine (hbv) tabs 1 QL(3 ea daily)SP

MAVYRET TABS 100 MG-40 MG 4 PA QL(3 ea

daily)

Drug Name DrugTier

RequirementsLimits

PEGASYS SOLN 4 PA QL(00714ml daily) SP

PEGINTRON KIT 4 PA QL(0143ea daily) SP

ribavirin (hepatitis c) caps 1 QL(7 ea daily)

ribavirin (hepatitis c) tabs 1 QL(7 ea daily)

SOFOSBUVIRVELPATASVIR TABS 4 PA QL(1 ea

daily)

VEMLIDY TABS 4 PA QL(1 eadaily) SP

VOSEVI TABS 4 PA QL(1 eadaily)

ZEPATIER TABS 4 PA

Herpes Agents

acyclovir caps 200 mg 1


acyclovir susp 200 mg5ml 1 QL(1334 mldaily)

acyclovir tabs 400 mg 800 mg 1 QL(5 ea daily)

famciclovir tabs 125 mg250 mg 1 QL(3 ea daily)

famciclovir tabs 500 mg 1 QL(4 ea daily)

valacyclovir hcl tabs 1 gm1000 mg 1 QL(4 ea daily)

valacyclovir hcl tabs 500 mg 1 QL(2 ea daily)

VALTREX TABS 1 GM (Use valacyclovir hcl) NF QL(4 ea daily)

VALTREX TABS 500 MG (Use valacyclovir hcl) NF QL(2 ea daily)

ZOVIRAX CAPS OR 200 MG (Use acyclovir) NF


ZOVIRAX SUSP OR 200 MG5ML (Use acyclovir) NF QL(1334 ml

daily) ZOVIRAX TABS OR 400 MG 800 MG (Use acyclovir)

NF QL(5 ea daily)


47

Drug Name DrugTier

RequirementsLimits

Influenza Agents FLUMADINE TABS (Use rimantadine hydrochloride) NF QL(2 ea daily)

oseltamivir phosphate capsor 30 mg 45 mg 75 mg 1

Limit 1 fill every90 daysQL(10 ea perfill retail10 ea per fill mail)1 rtlMAX fill90 rtl day(s) supply1mail MAX fill90 mail day(s)supply

oseltamivir phosphate susror 6 mgml 1

Limit 1 fill every90 daysQL(120ml per fillretail)1 rtl MAXfill90 rtl day(s)supply

RELENZA DISKHALER AEPB 2

1 rtl pack lmtamt30 rtl packlmt day(s)

rimantadine hydrochloridetabs 1 QL(2 ea daily)

TAMIFLU CAPS 30 MG 45 MG 75 MG (Use oseltamivir phosphate)

NF


TAMIFLU SUSR 6 MGML(Use oseltamivir phosphate)

NF


BETA BLOCKERS - Drugs to Treat High BloodPressure

Alpha-Beta Blockers

carvedilol tabs 1

Drug Name DrugTier

RequirementsLimits

COREG TABS (Use carvedilol) NF

labetalol hcl soln iv 5 mgml 1

labetalol hcl tabs or 100 mg 200 mg 300 mg 1

Beta Blockers Cardio-Selective

acebutolol hcl caps 1

atenolol tabs 1

betaxolol hcl tabs 1

bisoprolol fumarate tabs or10 mg 5 mg 1

BYSTOLIC TABS 25 MG 10 MG 5 MG (Use nebivolol hcl)

2 PA QL(1 eadaily)

BYSTOLIC TABS 20 MG (Use nebivolol hcl) 2 PA QL(2 ea

daily) LOPRESSOR TABS (Use metoprolol tartrate) NF

metoprolol succinate tb24 1

metoprolol tartrate soln iv 5mg5ml 1

metoprolol tartrate tabs or100 mg 25 mg 50 mg 1

nebivolol hcl tabs 25 mg10 mg 5 mg 1 PA QL(1 ea

daily)

nebivolol hcl tabs 20 mg 1 PA QL(2 eadaily)

TENORMIN TABS (Use atenolol) NF

TOPROL XL TB24 (Use metoprolol succinate) NF

Beta Blockers Non-Selective BETAPACE AF TABS (Use sotalol hcl (afibafl)) NF

BETAPACE TABS (Use sotalol hcl) NF QL(2 ea daily)

CORGARD TABS (Use nadolol) NF

HEMANGEOL SOLN 4 PA QL(75 mldaily)


48

Drug Name DrugTier

RequirementsLimits

INDERAL LA CP24 (Use propranolol hcl) NF

nadolol tabs 1

pindolol tabs 1

propranolol hcl cp24 or 60mg 80 mg 120 mg 160 mg

1

propranolol hcl soln iv 1mgml 1

propranolol hcl soln or 40mg5ml 20 mg5ml 1

propranolol hcl tabs or 10mg 20 mg 80 mg 40 mg60 mg

1

sotalol hcl (afibafl) tabs 1

sotalol hcl tabs 120 mg160 mg 80 mg 1 QL(2 ea daily)

sotalol hcl tabs 240 mg 1

timolol maleate tabs 1

CALCIUM CHANNEL BLOCKERS - Drugs toTreat High Blood Pressure

Calcium Channel Blockers ADALAT CC TB24 (Use nifedipine) NF

amlodipine besylate tabs 1

CALAN SR TBCR (Use verapamil hcl) NF

CARDIZEM CD CP24 (Use diltiazem hcl coated beads) NF

CARDIZEM LA TB24 180 MG 240 MG 300 MG 360 MG 420 MG (Use diltiazem hcl coated beads)

NF

CARDIZEM TABS (Use diltiazem hcl) NF

diltiazem hcl coated beads cp24 1

diltiazem hcl coated beads tb24 1

diltiazem hcl cp12 or 120mg 60 mg 90 mg 1

Drug Name DrugTier

RequirementsLimits


diltiazem hcl extended release beads cp24 120mg 180 mg 240 mg 300mg 360 mg

1

diltiazem hcl soln iv 50 mg10ml 1

DILTIAZEM HCL SOLR IV 100 MG 1

diltiazem hcl tabs or 120 mg 30 mg 60 mg 90 mg 1

felodipine tb24 1

isradipine caps 1

nicardipine hcl caps 1

nicardipine hcl soln 1

nifedipine caps 1

nifedipine tb24 1

nimodipine caps 1

nisoldipine tb24 17 mg 20mg 30 mg 34 mg 40 mg85 mg

1

NORVASC TABS (Use amlodipine besylate) NF

PROCARDIA CAPS (Use nifedipine) NF

PROCARDIA XL TB24 (Use nifedipine) NF

SULAR TB24 (Use nisoldipine) NF

TIAZAC CP24 120 MG 180 MG 240 MG 300 MG 360 MG (Use diltiazem hcl extended release beads)

NF

verapamil hcl cp24 1

verapamil hcl soln 1

verapamil hcl tabs 1


49

Drug Name DrugTier

RequirementsLimits

verapamil hcl tbcr 1

VERELAN CP24 120 MG 180 MG 240 MG (Use verapamil hcl)

NF

VERELAN CP24 360 MG (Use verapamil hcl) 1

VERELAN PM CP24 100 MG 200 MG (Use verapamil hcl)

NF

VERELAN PM CP24 300 MG (Use verapamil hcl) 1

CARDIOTONICS - Drugs to Treat Heart Failureand Abnormal Heart Rhythm

Cardiac Glycosides

digoxin soln 1

digoxin tabs 1

LANOXIN SOLN IJ 025 MGML (Use digoxin) 2

LANOXIN TABS OR 250 MCG 125 MCG (Use digoxin)

2

LANOXIN TABS OR 625 MCG 2

CARDIOVASCULAR AGENTS - MISC - Drugs toTreat Heart and Circulation Conditions

Cardioplegic Solutions PLEGISOL SOLN (Use cardioplegic soln) NF

Cardiovascular Agents Misc - Combinations amlodipine besylate-atorvastatin calcium tabs 1 QL(1 ea daily)

BIDIL TABS 2

CADUET TABS (Use amlodipine besylate-atorvastatin calcium)

NF QL(1 ea daily)

ENTRESTO TABS 3 PA

Impotence Agents

CIALIS TABS 5 MG (Use tadalafil) NF

PA BPH OnlyQL(1 eadaily)

Drug Name DrugTier

RequirementsLimits

sildenafil citrate tabs 1 PA QL(01334ea daily)

STENDRA TABS 3 QL(0134 eadaily)

tadalafil tabs 5 mg 1 PA BPH OnlyQL(1 eadaily)

VIAGRA TABS (Use sildenafil citrate) NF PA QL(01334

ea daily) Prostaglandin Vasodilators

epoprostenol sodium solr 4 PA

FLOLAN SOLR (Use epoprostenol sodium) NF PA

ORENITRAM TBCR 0125 MG 025 MG 1 MG 25 MG

3 PA

treprostinil soln 4 PA SP

VELETRI SOLR (Use epoprostenol sodium) NF PA

VENTAVIS SOLN 4 PA SP

Pulmonary Hypertension - Endothelin Receptor

ambrisentan tabs 4 PA QL(1 eadaily) SP

bosentan tabs 125 mg 4 PA QL(2 eadaily) SP

bosentan tabs 625 mg 4 PA QL(2 eadaily)

LETAIRIS TABS (Use ambrisentan) NF PA QL(1 ea

daily) SP

OPSUMIT TABS 4 PA QL(1 eadaily)

TRACLEER TABS 125 MG (Use bosentan) NF PA QL(2 ea

daily) SP TRACLEER TABS 625 MG (Use bosentan) NF PA QL(2 ea

daily)

TRACLEER TBSO 32 MG 4 PA QL(2 eadaily) SP

Pulmonary Hypertension - Phosphodiesterase ADCIRCA TABS (Use tadalafil (pulmonaryhypertension))

NF PA QL(2 eadaily) SP


50

Drug Name DrugTier

RequirementsLimits

REVATIO SOLN IV 10 MG125ML (Use sildenafil citrate (pulmonaryhypertension))

NF

PA QL(375 mldaily) SP

REVATIO SUSR OR 10 MGML (Use sildenafil citrate (pulmonaryhypertension))

NF

PA QL(6 mldaily)

REVATIO TABS OR 20 MG (Use sildenafil citrate (pulmonary hypertension))


sildenafil citrate (pulmonaryhypertension) soln iv 10mg125ml

4 PA QL(375 mldaily) SP

sildenafil citrate (pulmonaryhypertension) susr or 10mgml

4 PA QL(6 mldaily)

sildenafil citrate (pulmonaryhypertension) tabs or 20 mg


tadalafil (pulmonaryhypertension) tabs 4 PA QL(2 ea

daily) SP

Pulmonary Hypertension - Sol Guanylate Cyclase ADEMPAS TABS 05 MG 15 MG 2 MG 25 MG 4 PA QL(3 ea

daily) Sinus Node Inhibitors CORLANOR SOLN 5 MG5ML 3 PA QL(15 ml

daily) CORLANOR TABS 5 MG 75 MG 3 PA QL(2 ea

daily) Transthyretin Stabilizers

VYNDAMAX CAPS 4 PA QL(1 eadaily)

VYNDAQEL CAPS 4 PA QL(4 eadaily)

CEPHALOSPORINS - Drugs to Treat BacterialInfections

Cephalosporins - 1st Generation

cefadroxil caps 1

cefadroxil susr 1

cefadroxil tabs 1

cefazolin sodium solr ij 500mg 1 gm 10 gm 1

Drug Name DrugTier

RequirementsLimits

cephalexin caps 1

cephalexin susr 1

cephalexin tabs 1

KEFLEX CAPS (Use cephalexin) NF

Cephalosporins - 2nd Generation

cefaclor caps 1

cefaclor susr 1

CEFOTAN SOLR (Use cefotetan disodium) NF

cefotetan disodium solr 1

cefoxitin sodium solr 1 gm2 gm 1

cefprozil susr 1

cefprozil tabs 1

cefuroxime axetil tabs 1

cefuroxime sodium solr ij750 mg 1

Cephalosporins - 3rd Generation

cefdinir caps 1

cefdinir susr 1

cefditoren pivoxil tabs 200 mg 3


cefixime susr 100 mg5ml200 mg5ml 1 PA

cefotaxime sodium solr 1

cefpodoxime proxetil susr 1

cefpodoxime proxetil tabs 1

ceftazidime solr ij 6 gm 1 gm 1


51

Drug Name DrugTier

RequirementsLimits

ceftriaxone sodium solr ij250 mg 500 mg 1 gm 2 gm

1

FORTAZ SOLR IJ 1 GM (Use ceftazidime) NF

FORTAZ SOLR IV 2 GM (Use ceftazidime) NF

SUPRAX SUSR 100 MG5ML 200 MG5ML(Use cefixime)

NF PA

Cephalosporins - 4th Generation

cefepime hcl solr 1

MAXIPIME SOLR IJ 1 GM 2 GM (Use cefepime hcl) NF


TEFLARO SOLR 3

CHEMICALS

Bulk Chemicals - Cs CLINDAMYCIN PHOSPHATE POWD XX 1

CONTRACEPTIVES - Drugs to PreventPregnancy

Combination Contraceptives - Oral BALCOLTRA TABS 0

BEYAZ TABS (Use drospirenone-ethinylestradiol-levomefolate calcium)

NF

desogestrel amp ethinylestradiol tabs 0

desogestrel-ethinylestradiol (biphasic) tabs 0

desogestrel-ethinylestradiol (triphasic) tabs 0

drospirenone-ethinylestradiol tabs 0

drospirenone-ethinylestradiol-levomefolate calcium tabs

0

ESTROSTEP FE TABS (Use norethindrone acetate-ethinyl estradiol-fe)

NF

Drug Name DrugTier

RequirementsLimits

ethynodiol diacet amp ethestrad tabs 0

FALESSA KIT 0

GENERESS FE CHEW (Use norethindrone amp ethinyl estradiol-fe)

NF

levonorgestrel amp ethestradiol tabs 0

levonorgestrel-eth estradiol(triphasic) tabs 0

levonorgestrel-ethinylestradiol (91-day) tabs 0

levonorgestrel-ethinylestradiol (continuous) tabs 0

LO LOESTRIN FE TABS 0

LOSEASONIQUE TABS (Use levonorgestrel-ethinylestradiol (91-day))

NF

MINASTRIN 24 FE CHEW (Use norethin acet amp estrad-fe)

NF

MIRCETTE TABS (Use desogestrel-ethinylestradiol (biphasic))

NF

NATAZIA TABS 0

norethin acet amp estrad-fe caps 0

norethin acet amp estrad-fe chew 0

norethin acet amp estrad-fe tabs 0

norethindrone amp eth estradiol tabs 0

norethindrone amp ethinylestradiol-fe chew 0

norethindrone acet amp eth estra tabs 0

norethindrone acetate-ethinyl estradiol-fe tabs 0

norethindrone-eth estradiol (triphasic) tabs 0

norgestimate-ethinylestradiol (triphasic) tabs 0


52

Drug Name DrugTier

RequirementsLimits

norgestimate-ethinylestradiol tabs 0

norgestrel amp ethinylestradiol tabs 0

ORTHO TRI-CYCLEN LO TABS (Use norgestimate-ethinyl estradiol (triphasic))

NF

ORTHO-NOVUM 135TABS (Use norethindrone amp eth estradiol)

NF

ORTHO-NOVUM 777TABS (Use norethindrone-eth estradiol (triphasic))

NF

QUARTETTE TABS (Use levonorgestrel-ethinylestradiol (91-day))

NF

SAFYRAL TABS (Use drospirenone-ethinylestradiol-levomefolate calcium)

NF

SEASONIQUE TABS (Use levonorgestrel-ethinylestradiol (91-day))

NF

TAYTULLA CAPS (Use norethin acet amp estrad-fe) 0

TYBLUME CHEW 0

YASMIN 28 TABS (Use drospirenone-ethinylestradiol)

NF

YAZ TABS (Use drospirenone-ethinylestradiol)

NF

Combination Contraceptives - Transdermal norelgestromin-ethinylestradiol ptwk 0

TWIRLA PTWK 0 QL(3 ea per 28days retail)

Combination Contraceptives - Vaginal ANNOVERA RING 0 PA

etonogestrel-ethinylestradiol ring 0

NUVARING RING (Use etonogestrel-ethinylestradiol)

NF

Drug Name DrugTier

RequirementsLimits

Copper Contraceptives - IUD PARAGARD INTRAUTERINE COPPER CONTRACEPTIVE T380A IUD

0

Emergency Contraceptives

ELLA TABS 0

levonorgestrel (emergencyoc) tabs 0

PLAN B ONE-STEP TABS (Use levonorgestrel(emergency oc))

NF

Progestin Contraceptives - IUD

KYLEENA IUD 0

LILETTA IUD 0

MIRENA IUD 0

SKYLA IUD 0

Progestin Contraceptives - Implants

NEXPLANON IMPL 0

Progestin Contraceptives - Injectable DEPO-PROVERA CONTRACEPTIVE SUSP (Use medroxyprogesteroneacetate (contraceptive))

NF

QL(1 ml per 90days retail)

DEPO-PROVERA CONTRACEPTIVE SUSY (Use medroxyprogesteroneacetate (contraceptive))

NF


DEPO-SUBQ PROVERA 104 SUSY 0

medroxyprogesteroneacetate (contraceptive) susp

0 QL(1 ml per 90days retail)

medroxyprogesteroneacetate (contraceptive) susy


Progestin Contraceptives - Oral norethindrone (contraceptive) tabs 0


53

Drug Name DrugTier

RequirementsLimits

ORTHO MICRONOR TABS (Use norethindrone (contraceptive))

NF

SLYND TABS 0 QL(1 ea daily)

CORTICOSTEROIDS - Steroid Hormone Drugs toTreat Systemic Swelling Conditions

Glucocorticosteroids

budesonide cpep 3 mg 1 QL(3 ea daily)

CELESTONE SOLUSPAN SUSP (Use betamethasone sod phosphate amp acetate)

NF

CELESTONE-SOLUSPAN SUSP (Use betamethasone sod phosphate amp acetate)

NF

CORTEF TABS (Use hydrocortisone) NF

cortisone acetate tabs 1

DEPO-MEDROL SUSP 20 MGML 3

DEPO-MEDROL SUSP 80 MGML 40 MGML (Use methylprednisolone acetate)

NF

dexamethasone elix 05 mg5ml 1

DEXAMETHASONE INTENSOL CONC 1

dexamethasone sodium phosphate soln ij 120mg30ml 20 mg5ml 4mgml

1

dexamethasone soln 05 mg5ml 1

dexamethasone tabs 1 mg15 mg 2 mg 4 mg 05mg 075 mg 6 mg

1

EMFLAZA SUSP 4 PA

EMFLAZA TABS 4 PA

ENTOCORT EC CPEP (Use budesonide) NF QL(3 ea daily)

Drug Name DrugTier

RequirementsLimits

hydrocortisone tabs 1

KENALOG-40 SUSP (Use triamcinolone acetonide) NF

MEDROL DOSEPAK TBPK (Use methylprednisolone) NF

MEDROL TABS 16 MG 32 MG 4 MG 8 MG (Use methylprednisolone)

NF

MEDROL TABS 2 MG 3

methylprednisolone acetatesusp 80 mgml 40 mgml 1

methylprednisolone sodsucc solr 1

methylprednisolone tabs 1

methylprednisolone tbpk 1

MILLIPRED DP TBPK 3

MILLIPRED TABS 3

ORAPRED ODT TBDP (Use prednisolone sodiumphosphate)

NF

PEDIAPRED SOLN (Use prednisolone sodiumphosphate)

NF

prednisolone sodiumphosphate soln or 10mg5ml 15 mg5ml 25mg5ml 20 mg5ml 5mg5ml 67 mg5ml

1

prednisolone sodiumphosphate tbdp or 10 mg15 mg 30 mg

3

prednisolone soln 1

prednisone soln 1

prednisone tabs 1

prednisone tbpk 1

SOLU-CORTEF SOLR 100 MG 1000 MG 500 MG 3

2 rtl MAX fill30 rtl day(s)supply


54

Drug Name DrugTier

RequirementsLimits

SOLU-CORTEF SOLR 250 MG 3

SOLU-MEDROL SOLR 2 GM 3

SOLU-MEDROL SOLR 500 MG 1000 MG 125 MG 40 MG (Use methylprednisolone sod succ)

NF

triamcinolone acetonide susp 40 mgml 1

Mineralocorticoids fludrocortisone acetate tabs 1

COUGHCOLDALLERGY - Drugs to TreatCough Cold and Allergy Symptoms

Antitussives

benzonatate caps 100 mg 1 QL(6 ea daily)



TESSALON PERLES CAPS (Use benzonatate) NF QL(6 ea daily)

CoughColdAllergy Combinations ALLEGRA-D 12 HOUR ALLERGY amp CONGESTION TB12 (Use fexofenadine-pseudoephedrine)

NF

QL(2 ea daily)

ALLEGRA-D 24 HOUR ALLERGY amp CONGESTION TB24 (Use fexofenadine-pseudoephedrine)

NF

QL(1 ea daily)

cetirizine-pseudoephedrinetb12 1 QL(2 ea daily)

CLARITIN-D 12 HOUR TB12 (Use loratadine amp pseudoephedrine)

1 QL(2 ea daily)


1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits

fexofenadine-pseudoephedrine tb12 120mg-60 mg 60 mg-120 mg

1 QL(2 ea daily)

fexofenadine-pseudoephedrine tb24 180mg-240 mg

1 QL(1 ea daily)

hydrocodone polistirex-chlorpheniramine polistirex suer

1

loratadine amp pseudoephedrine tb12 120mg-5 mg 5 mg-120 mg

1 QL(2 ea daily)

loratadine amp pseudoephedrine tb24 10mg-10 mg-240 mg-240 mg240 mg-10 mg

1

QL(1 ea daily)

TUZISTRA XR SUER 2 PA

ZYRTEC-D ALLERGYCONGESTIONTB12 (Use cetirizine-pseudoephedrine)

1

QL(2 ea daily)

Misc Respiratory Inhalants HYPER-SAL NEBU (Use sodium chloride (inhalant)) NF

HYPERSAL NEBU 35 1

HYPERSAL NEBU 7 (Use sodium chloride (inhalant))

NF

NEBUSAL NEBU 1

sodium chloride (inhalant)nebu 7 1

Mucolytics

acetylcysteine soln 1

DERMATOLOGICALS - Drugs to Treat SkinConditions

Acne Products ABSORICA CAPS 30 MG 10 MG 20 MG 40 MG (Use isotretinoin)

NF PA AL(At least12 yrs old)

adapalene crea 01 1 PA AL(At least12 yrs old)


55

Drug Name DrugTier

RequirementsLimits

adapalene gel 01 1 PA AL(At least12 yrs old)RXOTC

adapalene gel 03 1 ST AL(At least12 yrs old)

adapalene-benzoylperoxide gel 1 ST AL(At least

12 yrs old)

AZELEX CREA 3 ST AL(At least12 yrs old)

BENZACLIN GEL (Use clindamycin phosphate-benzoyl peroxide)


BENZACLIN WITH PUMP GEL (Use clindamycinphosphate-benzoylperoxide)

NF

PA AL(At least12 yrs old)

BENZAMYCIN GEL (Use benzoyl peroxide-erythromycin)


BENZOYL PEROXIDE CLEANSER LIQD 2 AL(At least 12

yrs old)

benzoyl peroxide foam 53 1

AL(At least 12yrs old)RXOTC

benzoyl peroxide foam 98 1 AL(At least 12

yrs old) benzoyl peroxide gel 5 10 1 AL(At least 12

yrs old) benzoyl peroxide liqd 4 7 10 1 AL(At least 12

yrs old) benzoyl peroxide-erythromycin gel 1 PA AL(At least

12 yrs old) CLEOCIN-T GEL (Use clindamycin phosphate(topical))


CLEOCIN-T LOTN (Use clindamycin phosphate(topical))


CLINDAGEL GEL (Use clindamycin phosphate(topical))


clindamycin phosphate(topical) foam 1 PA AL(At least

12 yrs old) clindamycin phosphate(topical) gel 1 AL(At least 12

yrs old) clindamycin phosphate(topical) lotn 1 AL(At least 12

yrs old)

Drug Name DrugTier

RequirementsLimits

clindamycin phosphate(topical) soln 1

QL(4 ml daily)AL(At least 12yrs old)

clindamycin phosphate(topical) swab 1 AL(At least 12

yrs old) clindamycin phosphate-benzoyl peroxide(refrigerate) gel

1 PA AL(At least12 yrs old)

clindamycin phosphate-benzoyl peroxide gel 1 -5


clindamycin phosphate-tretinoin gel 1 ST AL(At least

12 yrs old) DIFFERIN CREA 01 (Use adapalene) NF PA AL(At least

12 yrs old)

DIFFERIN GEL 01 (Use adapalene) NF

PA AL(At least12 yrs old)RXOTC

DIFFERIN GEL 03 (Use adapalene) NF ST AL(At least

12 yrs old)

DIFFERIN LOTN 01 1 ST AL(At least12 yrs old)

DUAC GEL (Use clindamycin phosphate-benzoyl peroxide(refrigerate))

NF


EPIDUO GEL (Use adapalene-benzoylperoxide)

NF ST AL(At least12 yrs old)

erythromycin (acne aid)pads 1 AL(At least 12

yrs old) erythromycin (acne aid)soln 1 AL(At least 12

yrs old) EVOCLIN FOAM (Use clindamycin phosphate(topical))


isotretinoin caps 30 mg 10mg 20 mg 40 mg 3 PA AL(At least

12 yrs old) KLARON LOTN (Use sulfacetamide sodium (acne))


RETIN-A CREA (Use tretinoin) NF

AL(At least 12yrs old - Up to30 yrs old)

RETIN-A GEL (Use tretinoin) NF



56

Drug Name DrugTier

RequirementsLimits

RETIN-A MICRO GEL 01 (Use tretinoin microsphere)

NF PA AL(At least12 yrs old - Upto 30 yrs old)

RETIN-A MICRO PUMP GEL 01 (Use tretinoin microsphere)


sulfacetamide sodium (acne) lotn 1 AL(At least 12

yrs old)

sulfacetamide sodium wsulfur crea 5 -10 1

PA ST AL(Atleast 12 yrsold)

sulfacetamide sodium wsulfur liqd 45 -9 9 -45

1 ST AL(At least12 yrs old)

sulfacetamide sodium-sulfur in urea vehicle emul 1 AL(At least 12

yrs old) SUMADAN WASH LIQD (Use sulfacetamide sodium w sulfur)


tretinoin crea 005 01 0025 1


tretinoin gel 001 0025 1


tretinoin microsphere gel01 1

PA AL(At least12 yrs old - Upto 30 yrs old)

VELTIN GEL (Use clindamycin phosphate-tretinoin)


ZIANA GEL (Use clindamycin phosphate-tretinoin)


Agents for External Genital and Perianal Warts

VEREGEN OINT 3

Anti-inflammatory Agents - Topical

diclofenac epolamine ptch 1 PA QL(2 eadaily)

diclofenac sodium (topical)gel 1 1 QL(334 gm

daily) RXOTC FLECTOR PTCH (Use diclofenac epolamine) 3 PA QL(2 ea

daily) VOLTAREN GEL (Use diclofenac sodium (topical)) NF QL(334 gm

daily) RXOTC

Drug Name DrugTier

RequirementsLimits

Antibiotics - Topical ALTABAX OINT 2

gentamicin sulfate (topical) crea 1 QL(1 gm daily)

gentamicin sulfate (topical)oint 1

mupirocin oint 1

NEO-SYNALAR CREA 3 PA

Antifungals - Topical butenafine hcl crea 1 RXOTC

ciclopirox gel ex 077 1

ciclopirox olamine crea 1

QL(90 gm perfill retail)1 rtlMAX fill30 rtl day(s) supply

ciclopirox olamine susp 1

ciclopirox sham ex 1 1

ciclopirox soln ex 8 1

clotrimazole (topical) crea 1 RXOTC

clotrimazole (topical) soln 1 RXOTC

clotrimazole wbetamethasone crea 1

clotrimazole wbetamethasone lotn 1

econazole nitrate crea 1 QL(85 gm perfill retail85 gmper fill mail)

ERTACZO CREA 3

EXELDERM CREA (Use sulconazole nitrate) 3

EXELDERM SOLN 3

EXELDERM SOLN (Use sulconazole nitrate) 3

JUBLIA SOLN 3 PA


57

Drug Name DrugTier

RequirementsLimits

KERYDIN SOLN (Use tavaborole) 3 PA

ketoconazole (topical) crea2 1

ketoconazole (topical)sham 2 1

LOPROX CREA (Use ciclopirox olamine) NF


LOPROX SHAMPOO SHAM (Use ciclopirox) NF

LOPROX SUSP (Use ciclopirox olamine) NF

LOTRIMIN AF CREA (Use clotrimazole (topical)) NF RXOTC

LOTRIMIN AF JOCK ITCH CREA (Use clotrimazole (topical))

NF RXOTC

LOTRIMIN ULTRA CREA (Use butenafine hcl) 1 RXOTC

LOTRISONE CREA (Use clotrimazole wbetamethasone)

NF

luliconazole crea 1 PA

LUZU CREA (Use luliconazole) 3 PA

naftifine hcl crea 1 1

QL(3 gmdaily)1 rtl MAXfill180 rtl day(s) supply1mail MAX fill180 mail day(s) supply



Drug Name DrugTier

RequirementsLimits

naftifine hcl gel 1 1


NAFTIFINE HYDROCHLORIDE CREA (Use naftifine hcl)

NF


NAFTIN CREA 2 (Use naftifine hcl) NF


NAFTIN GEL 1 (Use naftifine hcl) NF


NIZORAL SHAM (Use ketoconazole (topical)) NF

nystatin (topical) crea 1

nystatin (topical) oint 1

nystatin (topical) powd 1

nystatin-triamcinolone crea 1

nystatin-triamcinolone oint 1

oxiconazole nitrate crea 1

Limit 1 Fill per180 daysQL(3gm daily)1 rtlMAX fill180 rtl day(s) supply1mail MAX fill180 mail day(s) supply


58

Drug Name DrugTier

RequirementsLimits

OXISTAT CREA (Use oxiconazole nitrate) NF


OXISTAT LOTN 2

Limit 1 Fill per180 daysQL(2ml daily)1 rtlMAX fill180 rtl day(s) supply1mail MAX fill180 mail day(s) supply

PENLAC NAIL LACQUER SOLN (Use ciclopirox) NF

sulconazole nitrate crea 1

sulconazole nitrate soln 1

tavaborole soln 1 PA

VUSION OINT (Use miconazole-zinc oxide-white petrolatum)

NF

Antineoplastic or Premalignant Lesion Agents -CARAC CREA (Use fluorouracil (topical)) NF

diclofenac sodium (actinickeratoses) gel 1 PA

EFUDEX CREA (Use fluorouracil (topical)) NF

fluorouracil (topical) crea 5 1

fluorouracil (topical) soln 2 5 1

PANRETIN GEL 3

PICATO GEL 0015 2

QL(3 ea per fillretail3 ea perfill mail)1 rtlMAX fill60 rtl day(s) supply1mail MAX fill60 mail day(s)supply

Drug Name DrugTier

RequirementsLimits

PICATO GEL 005 2


TARGRETIN GEL EX 1 4 PA SP

Antipruritics - Topical

doxepin hcl (antipruritic) crea 3

PA Limit 1 fill every 180daysQL(45 gmper fill retail45gm per fillmail)1 rtl MAXfill180 rtl day(s) supply1mail MAX fill180 mail day(s) supply

PRUDOXIN CREA (Use doxepin hcl (antipruritic)) 3


ZONALON CREA (Use doxepin hcl (antipruritic)) 3


Antipsoriatics acitretin caps 175 mg 10 mg 1 QL(1 ea daily)

acitretin caps 25 mg 1 QL(2 ea daily)


59

Drug Name DrugTier

RequirementsLimits

calcipotriene crea 1 PA QL(4 gmdaily)

calcipotriene oint 1 PA QL(4 gmdaily)

calcipotriene soln 1 PA

calcitriol (topical) oint 1 QL(334 gmdaily)

COSENTYX SENSOREADY PEN SOAJ 4 PA QL(0072

ml daily) COSENTYX SOSY 150 MGML 4 PA QL(0036


ml daily) DOVONEX CREA (Use calcipotriene) NF PA QL(4 gm

daily)

methoxsalen rapid caps 1 QL(4 ea daily)

OXSORALEN ULTRA CAPS (Use methoxsalen rapid)

NF QL(4 ea daily)

SKYRIZI PEN SOAJ 4 PA QL(0025ml daily)

SKYRIZI PSKT 75 MG083ML 4 PA QL(0025

ea daily) SKYRIZI SOSY 150 MGML 4 PA QL(0025

ml daily) SORIATANE CAPS 10 MG (Use acitretin) NF QL(1 ea daily)

SORIATANE CAPS 25 MG (Use acitretin) NF QL(2 ea daily)

STELARA SOLN SC 45 MG05ML 4 PA QL(0012

ml daily) STELARA SOSY SC 45 MG05ML 4 PA QL(0012

ml daily) STELARA SOSY SC 90 MGML 4 PA QL(0018

ml daily) SP

tazarotene crea 1 PA

TAZORAC CREA 005 2

TAZORAC CREA 01 (Use tazarotene) NF PA

TAZORAC GEL 005 01 2

Drug Name DrugTier

RequirementsLimits

TREMFYA SOPN 4 PA QL(0018ml daily)

TREMFYA SOSY 4 PA QL(0018ml daily)

VECTICAL OINT (Use calcitriol (topical)) 1 QL(334 gm

daily) Antiseborrheic Products

selenium sulfide lotn 1

Antivirals - Topical acyclovir topical crea 1

acyclovir topical oint 1

DENAVIR CREA 3 QL(018 gmdaily)

ZOVIRAX CREA EX 5 (Use acyclovir topical) NF

ZOVIRAX OINT EX 5 (Use acyclovir topical) NF

Burn Products

mafenide acetate pack 3

SILVADENE CREA (Use silver sulfadiazine) NF

silver sulfadiazine crea 1

SULFAMYLON CREA 85 MGGM 3

SULFAMYLON PACK 5 (Use mafenide acetate) NF

Corticosteroids - Topical alclometasone dipropionate crea 1

alclometasone dipropionateoint 1

amcinonide crea 1

QL(60 gm perfill retail60 gmper fill mail)1 rtlMAX fill30 rtl day(s) supply1mail MAX fill30 mail day(s)supply

amcinonide lotn 3


60

Drug Name DrugTier

RequirementsLimits

AMCINONIDE OINT 3

betamethasone dipropionate (topical) crea 1

betamethasone dipropionate (topical) lotn 1

betamethasone dipropionate (topical) oint 1

betamethasone dipropionate augmented crea

1

betamethasone dipropionate augmentedlotn

1

betamethasone dipropionate augmentedoint

1

betamethasone valerate crea 01 1

betamethasone valerate foam 012 1 QL(167 gm

daily) betamethasone valerate lotn 01 1

betamethasone valerate oint 01 1

calcipotriene-betamethasone dipropionate oint

1 ST

calcipotriene-betamethasone dipropionate susp

1 ST

clobetasol propionate crea 1 PA QL(3 gmdaily)

clobetasol propionateemollient base crea 1 PA QL(1 gm

daily)

clobetasol propionate foam 1 PA

clobetasol propionate gel 1 PA

clobetasol propionate oint 1 PA QL(1 gmdaily)

clobetasol propionate soln 1 PA QL(334 mldaily)

clocortolone pivalate crea 3

CLODERM CREA (Use clocortolone pivalate) 3

Drug Name DrugTier

RequirementsLimits

CORDRAN CREA 005 (Use flurandrenolide) NF

CORDRAN LOTN 005 (Use flurandrenolide) NF

CORDRAN TAPE 4 MCGSQCM 3

CUTIVATE LOTN (Use fluticasone propionate) NF QL(6 ml daily)

DERMA-SMOOTHEFSBODY OIL (Use fluocinolone acetonide)

NF

QL(11828 mlper fill retail)1rtl MAX fill30 rtl day(s) supply

DERMA-SMOOTHEFSSCALP OIL (Use fluocinolone acetonide)

NF

desonide crea 1 QL(4 gm daily)

desonide lotn 1 QL(4 ml daily)

desonide oint 1 QL(3 gm daily)

DESOWEN CREA (Use desonide) NF QL(4 gm daily)

desoximetasone crea 025 1

desoximetasone gel 005 1

desoximetasone oint 025 1

diflorasone diacetate crea 1 PA

diflorasone diacetate oint 1 PA

DIPROLENE AF CREA (Use betamethasone dipropionate augmented)

NF

DIPROLENE OINT (Use betamethasone dipropionate augmented)

NF

ELOCON CREA (Use mometasone furoate) NF

fluocinolone acetonide crea 001 0025 1

fluocinolone acetonide oil 001 1



61

Drug Name DrugTier

RequirementsLimits


fluocinolone acetonide oint 0025 1

fluocinolone acetonide soln 001 1

fluocinonide crea 005 1 QL(2 gm daily)

fluocinonide emulsified base crea 1 QL(2 gm daily)

fluocinonide gel 005 1

fluocinonide oint 005 1 QL(2 gm daily)

fluocinonide soln 005 1 QL(2 ml daily)

flurandrenolide crea 2

flurandrenolide lotn 2

fluticasone propionate crea005 1

fluticasone propionate lotn005 1 QL(6 ml daily)

fluticasone propionate oint0005 1

halcinonide crea 1 PA

halobetasol propionate crea 1

halobetasol propionate oint 1

HALOG CREA (Use halcinonide) NF PA

HALOG OINT 3 PA

hydrocortisone (topical)crea 1 1 RXOTC

hydrocortisone (topical)crea 25 1

hydrocortisone (topical)lotn 25 1

hydrocortisone (topical)oint 1 1 RXOTC

hydrocortisone (topical)oint 25 1

Drug Name DrugTier

RequirementsLimits

hydrocortisone butyrate crea 1

hydrocortisone butyrateoint 1

hydrocortisone butyratesoln 1

hydrocortisone valerate crea 1

hydrocortisone valerate oint 1

LOCOID CREA (Use hydrocortisone butyrate) NF

LOCOID SOLN (Use hydrocortisone butyrate) NF

LUXIQ FOAM (Use betamethasone valerate) NF QL(167 gm

daily)

mometasone furoate crea 1

mometasone furoate oint 1

mometasone furoate soln 1

MONISTAT SOOTHING CARE ITCH RELIEF CREA (Use hydrocortisone(topical))

NF

RXOTC

OLUX FOAM (Use clobetasol propionate) NF PA

prednicarbate crea 1

prednicarbate oint 1

PSORCON CREA 2 PA

SYNALAR CREA (Use fluocinolone acetonide) NF

SYNALAR OINT (Use fluocinolone acetonide) NF

SYNALAR SOLN (Use fluocinolone acetonide) NF

TACLONEX OINT 0005 -0064 (Use calcipotriene-betamethasone dipropionate)

NF

ST


62

Drug Name DrugTier

RequirementsLimits

TACLONEX SUSP 0005 -0064 0064 -0005 (Use calcipotriene-betamethasone dipropionate)

3

ST

TEMOVATE CREA (Use clobetasol propionate) NF PA QL(3 gm

daily) TEMOVATE OINT (Use clobetasol propionate) NF PA QL(1 gm

daily) TOPICORT CREA 025 (Use desoximetasone) NF

TOPICORT GEL 005 (Use desoximetasone) NF

TOPICORT OINT 025 (Use desoximetasone) NF

triamcinolone acetonide (topical) crea 0025 05

1

triamcinolone acetonide (topical) crea 01 1 QL(334 gm

daily) triamcinolone acetonide (topical) lotn 0025 01

1

triamcinolone acetonide (topical) oint 0025 01 05

1

triamcinolone acetonide-dimethicone-silicone kit 1 PA

TRIDESILON CREA (Use desonide) NF QL(4 gm daily)

Eczema Agents DUPIXENT SOPN 300 MG2ML 4 PA

DUPIXENT SOSY 200 MG114ML 300 MG2ML 4 PA

EmollientKeratolytic Agents HYDRO 35 FOAM (Use urea in lactic acid vehicle) NF

Emollients LAC-HYDRIN CREA (Use lactic acid (ammoniumlactate))

NF RXOTC

LAC-HYDRIN TWELVE LOTN (Use lactic acid (ammonium lactate))

NF RXOTC

Drug Name DrugTier

RequirementsLimits

lactic acid (ammoniumlactate) crea 1 RXOTC

lactic acid (ammoniumlactate) lotn 1 RXOTC

Enzymes - Topical SANTYL OINT 3 PA

Immunomodulating Agents - Topical

ALDARA CREA (Use imiquimod) NF

QL(12 ea perfill retail12 ea per fill mail)

imiquimod crea 5 1 QL(12 ea perfill retail12 ea per fill mail)

ZYCLARA CREA (Use imiquimod) NF

ZYCLARA PUMP CREA 375 (Use imiquimod) NF

Immunosuppressive Agents - Topical ELIDEL CREA (Use pimecrolimus) NF PA AL(At least

2 yrs old)

pimecrolimus crea 1 PA AL(At least2 yrs old)

PROTOPIC OINT (Use tacrolimus (topical)) NF PA AL(At least

2 yrs old)

tacrolimus (topical) oint 1 PA AL(At least2 yrs old)

KeratolyticAntimitotic Agents

podofilox soln 1

Local Anesthetics - Topical lidocaine hcl gel ex 2 1 QL(4 ml daily)

lidocaine hcl gel ex 2 1 QL(4 ml daily)RXOTC

lidocaine hcl prsy ex 2 1 QL(4 ml daily)

lidocaine hcl soln ex 4 1

lidocaine ptch ex 5 1 PA

lidocaine-prilocaine crea 1 QL(1 gm daily)

LIDODERM PTCH (Use lidocaine) NF PA


63

Drug Name DrugTier

RequirementsLimits

SYNERA PTCH 3

QL(10 ea perfill retail10 ea per fill mail)1 rtlMAX fill30 rtl day(s) supply1mail MAX fill30 mail day(s)supply

Phosphodiesterase 4 (PDE4) Inhibitors - Topical

EUCRISA OINT 3 PA QL(2 gmdaily)

Rosacea Agents

azelaic acid gel 1 PA

FINACEA GEL (Use azelaic acid) NF PA

METROCREAM CREA (Use metronidazole (topical))

NF

METROGEL GEL (Use metronidazole (topical)) NF

METROLOTION LOTN (Use metronidazole (topical))

NF

metronidazole (topical) crea 1

metronidazole (topical) gel 1

metronidazole (topical) lotn 1

MIRVASO GEL 3 PA QL(1 gmdaily)

ORACEA CPDR (Use doxycycline (rosacea)) NF

SOOLANTRA CREA (Use ivermectin (rosacea)) NF

Scabicides amp Pediculicides

crotamiton lotn 1 PA

ELIMITE CREA (Use permethrin) NF

EURAX CREA 3

EURAX LOTN (Use crotamiton) NF PA

ivermectin (pediculicide)lotn 1 PA RXOTC

Drug Name DrugTier

RequirementsLimits

IVERMECTIN LOTN EX 05 3 PA RXOTC

lindane sham 3

malathion lotn 1

NATROBA SUSP (Use spinosad) 1 PA

NIX CREME RINSE LIQD (Use permethrin) NF

OVIDE LOTN (Use malathion) NF

permethrin crea 1

permethrin liqd 1

SKLICE LOTN (Use ivermectin (pediculicide)) 3 PA RXOTC

spinosad susp 1 PA

ULESFIA LOTN 3

Wound Care Products

REGRANEX GEL 3

DIAGNOSTIC PRODUCTS

Diagnostic Drugs GLUCAGEN DIAGNOSTIC SOLR 3 QL(0035 ea

daily) Diagnostic Tests

CHEMSTRIP-K STRP 1

FORA GTEL BLOOD KETONE TEST STRIPS STRP

1

GOJJI BLOOD KETONE TEST STRIPS STRP 1

KETONE STRP 1

KETONE TEST STRIPS STRP 1

KETOSTIX STRP 1

NOVA MAX PLUS KETONE TESTSTRIPS STRP

1


64

Drug Name DrugTier

RequirementsLimits

PRECISION XTRA STRP VI 1

PTS PANELS KETONE TEST STRP 1

RELION KETONE TEST STRIPS STRP 1

RELION TRUE METRIX BLOODGLUCOSE TEST STRIPS STRP

1 QL(334 eadaily) RXOTC

TRUE METRIX BLOOD GLUCOSETEST STRIPS STRP

1

Limit 100 permonthQL(334ea daily)RXOTC

TRUETRACK TEST STRP 1


DIGESTIVE AIDS - Drugs to Treat Low DigestiveEnzymes

Digestive Enzymes

CREON CPEP 2

SUCRAID SOLN 3

ZENPEP CPEP 2

DIURETICS - Drugs to Treat Heart CirculationConditions and Blood Pressure

Carbonic Anhydrase Inhibitors acetazolamide cp12 500 mg 1 QL(2 ea daily)

acetazolamide sodium solr 1

acetazolamide tabs 125 mg 1 QL(8 ea daily)


KEVEYIS TABS 4 PA QL(4 eadaily)

methazolamide tabs 1 QL(6 ea daily)

Diuretic Combinations ALDACTAZIDE TABS 25 MG-25 MG (Use spironolactone amphydrochlorothiazide)

NF

Drug Name DrugTier

RequirementsLimits

amiloride amp hydrochlorothiazide tabs 1

DYAZIDE CAPS (Use triamterene amp hydrochlorothiazide)

NF

MAXZIDE TABS (Use triamterene amp hydrochlorothiazide)

NF

MAXZIDE-25 TABS (Use triamterene amp hydrochlorothiazide)

NF

spironolactone amphydrochlorothiazide tabs 1

triamterene amp hydrochlorothiazide caps 1

triamterene amp hydrochlorothiazide tabs 1

Loop Diuretics bumetanide soln ij 025mgml 1

bumetanide tabs or 05 mg1 mg 2 mg 1 QL(5 ea daily)

BUMEX TABS (Use bumetanide) NF QL(5 ea daily)

EDECRIN TABS (Use ethacrynic acid) NF QL(16 ea daily)

ethacrynic acid tabs 1 QL(16 ea daily)

furosemide soln 1

furosemide tabs 1

LASIX TABS (Use furosemide) NF

torsemide tabs 1

Potassium Sparing Diuretics ALDACTONE TABS (Use spironolactone) NF

amiloride hcl tabs 1

DYRENIUM CAPS (Use triamterene) NF QL(3 ea daily)

spironolactone tabs 1

triamterene caps 1 QL(3 ea daily)


65

Drug Name DrugTier

RequirementsLimits

Thiazides and Thiazide-Like Diuretics

chlorthalidone tabs 1

hydrochlorothiazide caps 1 QL(2 ea daily)

hydrochlorothiazide tabs 1 QL(2 ea daily)

indapamide tabs 125 mg 1 QL(1 ea daily)


metolazone tabs 1 QL(2 ea daily)

ENDOCRINE AND METABOLIC AGENTS -MISC - Drugs to Treat Bone Disease andRegulate Hormones

Bone Density Regulators ACTONEL TABS 150 MG (Use risedronate sodium) NF PA QL(0036

ea daily) ACTONEL TABS 35 MG (Use risedronate sodium) NF PA QL(0143

ea daily) alendronate sodium tabs 35 mg 70 mg 1 QL(0143 ea

daily) alendronate sodium tabs 5 mg 10 mg 1 QL(1 ea daily)

ATELVIA TBEC (Use risedronate sodium) NF PA

BONIVA SOLN IV 3 MG3ML (Use ibandronate sodium)

NF PA SP

BONIVA TABS OR 150 MG (Use ibandronate sodium) NF QL(0036 ea

daily) calcitonin (salmon) soln na200 unitact 1

etidronate disodium tabs 1

FOSAMAX PLUS D TABS 3 PA QL(0143ea daily)

FOSAMAX TABS (Use alendronate sodium) NF QL(0143 ea

daily) ibandronate sodium soln iv 3 mg3ml 4 PA SP

ibandronate sodium tabs or 150 mg 1 QL(0036 ea

daily) pamidronate disodium soln30 mg10ml 90 mg10ml 4 PA SP

Drug Name DrugTier

RequirementsLimits

PAMIDRONATE DISODIUM SOLN 6 MGML

4 PA SP

pamidronate disodium solr30 mg 90 mg 4 PA SP

PROLIA SOSY 4

PA 1 rtl MAX fill180 rtl day(s) supplySP

RECLAST SOLN (Use zoledronic acid) NF PA SP

risedronate sodium tabs 150 mg 1 PA QL(0036

ea daily) risedronate sodium tabs 30 mg 5 mg 1 PA QL(1 ea

daily) risedronate sodium tabs 35 mg 1 PA QL(0143

ea daily) risedronate sodium tbec 35 mg 1 PA

TYMLOS SOPN 4 PA

XGEVA SOLN 4 PA SP

zoledronic acid conc 4 mg5ml 4 PA SP

ZOLEDRONIC ACID SOLN 4 MG100ML 4 PA SP

zoledronic acid soln 4 mg100ml 5 mg100ml 4 PA SP

Corticotropin

ACTHAR GEL 4 PA

Fertility Regulators CHORIONIC GONADOTROPIN SOLR 4 PA SP

NOVAREL SOLR 10000 UNIT 4 PA SP

PREGNYL WDILUENTBENZYLALCOHOLNACLSOLR

4 PA SP

GnRHLHRH Antagonists

CETROTIDE KIT 4 PA

ganirelix acetate sosy 4 PA


66

Drug Name DrugTier

RequirementsLimits

GANIRELIX ACETATE SOSY (Use ganirelix acetate)

NF PA

Growth Hormone Receptor Antagonists SOMAVERT SOLR 10 MG 15 MG 20 MG 4 PA SP

Growth Hormone Releasing Hormones (GHRH) EGRIFTA SOLR 4 PA

EGRIFTA SV SOLR 4 PA

Growth Hormones GENOTROPIN MINIQUICK SOLR 02 MG 4 PA SP

GENOTROPIN SOLR 5 MG 4 PA SP

HUMATROPE COMBO PACK SOLR 4 PA SP

HUMATROPE SOLR 4 PA SP

NORDITROPIN FLEXPRO SOPN 10 MG15ML 15MG15ML 5 MG15ML

4 PA SP

NORDITROPIN FLEXPRO SOPN 30 MG3ML 4 PA

NUTROPIN AQ NUSPIN 10 SOPN 4 PA SP

OMNITROPE SOCT 10 MG15ML 5 MG15ML 4 PA SP

SAIZEN SOLR 4 PA SP

SAIZENPREP RECONSTITUTIONKIT SOLR

4 PA SP

SEROSTIM SOLR 4 PA SP

ZOMACTON SOLR 4 PA SP

ZORBTIVE SOLR 4 PA SP

Hormone Receptor Modulators EVISTA TABS (Use raloxifene hcl) NF QL(1 ea daily)

OSPHENA TABS 3 PA

Drug Name DrugTier

RequirementsLimits

raloxifene hcl tabs 0 QL(1 ea daily)

Insulin-Like Growth Factors (Somatomedins) INCRELEX SOLN 4 PA SP

LHRHGnRH Agonist Analog Pituitary

FENSOLVI KIT 4 PA SP

LUPANETA PACK KIT 4 PA

LUPRON DEPOT-PED (1-MONTH) KIT 4 PA SP

LUPRON DEPOT-PED (3-MONTH) KIT 30 MG 4 PA SP

SYNAREL SOLN 4 PA SP

Metabolic Modifiers

ALDURAZYME SOLN 4 PA SP

BUPHENYL POWD (Use sodium phenylbutyrate) NF PA

BUPHENYL TABS (Use sodium phenylbutyrate) NF PA

calcitriol caps 1

calcitriol soln 1

CARBAGLU TABS 4 PA SP

cinacalcet hcl tabs 4 PA QL(4 eadaily) SP

CYSTADANE POWD 4 PA SP

doxercalciferol caps 1

doxercalciferol soln 1

ELAPRASE SOLN 4 PA SP

FABRAZYME SOLR 35 MG 4 PA SP

GALAFOLD CAPS 4 PA QL(05 eadaily)

HECTOROL SOLN 4 MCG2ML (Use doxercalciferol)

NF


67

Drug Name DrugTier

RequirementsLimits

KUVAN PACK (Use sapropterindihydrochloride)

NF PA

KUVAN TABS (Use sapropterindihydrochloride)

NF PA

LUMIZYME SOLR 4 PA SP

MYALEPT SOLR 4 PA

NAGLAZYME SOLN 4 PA SP

nitisinone caps 4 PA SP

ORFADIN CAPS 10 MG 2 MG 5 MG (Use nitisinone) NF PA SP

PALYNZIQ SOSY 4 PA

paricalcitol caps 1

paricalcitol soln 1

ROCALTROL CAPS (Use calcitriol) NF

ROCALTROL SOLN (Use calcitriol) NF

sapropterin dihydrochloridepack 4 PA

sapropterin dihydrochloridetabs 4 PA

SENSIPAR TABS (Use cinacalcet hcl) NF PA QL(4 ea

daily) SP sodium phenylbutyratepowd 1 PA

sodium phenylbutyrate tabs 1 PA

ZEMPLAR CAPS (Use paricalcitol) NF

ZEMPLAR SOLN (Use paricalcitol) NF

Posterior Pituitary Hormones DDAVP SOLN IJ 4 MCGML (Use desmopressin acetate)

NF PA

DDAVP SOLN NA 001 (Use desmopressin acetate spray)

NF

Drug Name DrugTier

RequirementsLimits

DDAVP TABS OR 01 MG (Use desmopressin acetate)

NF QL(6 ea daily)


NF QL(8 ea daily)

desmopressin acetate solnij 4 mcgml 1 PA

DESMOPRESSIN ACETATE SOLN NA 15 MGML

4 PA SP

desmopressin acetatespray refrigerated soln 1

desmopressin acetatespray soln 1

desmopressin acetate tabsor 01 mg 1 QL(6 ea daily)


STIMATE SOLN 4 PA SP

Prolactin Inhibitors

cabergoline tabs 1

Somatostatic Agents

octreotide acetate soln 4 PA SP

SANDOSTATIN SOLN (Use octreotide acetate) NF PA SP

SIGNIFOR SOLN 4 PA

SOMATULINE DEPOT SOLN 120 MG05ML 4 PA QL(00179

ml daily) SP SOMATULINE DEPOT SOLN 60 MG02ML 4 PA QL(00075


ml daily) SP

Vasopressin Receptor Antagonists JYNARQUE TABS 15 MG 30 MG 4 PA QL(2 ea

daily) SP

JYNARQUE TBPK 4 PA SP

SAMSCA TABS (Use tolvaptan) 4 PA QL(2 ea

daily) SP

tolvaptan tabs 4 PA QL(2 eadaily) SP


68

Drug Name DrugTier

RequirementsLimits

ESTROGENS - Hormone ReplacementModifyingDrugs

Estrogen Combinations

CLIMARA PRO PTWK 3

DUAVEE TABS 3 PA

FEMHRT TABS (Use norethindrone acetate-ethinyl estradiol)

NF

norethindrone acetate-ethinyl estradiol tabs 1

PREMPHASE TABS 2

PREMPRO TABS 2

Estrogens CLIMARA PTWK (Use estradiol) NF

DELESTROGEN OIL 10 MGML 1

DELESTROGEN OIL 20 MGML 40 MGML (Use estradiol valerate)

NF

DEPO-ESTRADIOL OIL 3

DIVIGEL GEL 025 MG025GM 05MG05GM 1 MGGM

3

ELESTRIN GEL 3

ESTRACE TABS (Use estradiol) NF

estradiol pttw td 0025mg24hr 00375 mg24hr005 mg24hr 0075mg24hr 01 mg24hr

1

QL(0286 eadaily)

estradiol ptwk td 0025mg24hr 0075 mg24hr01 mg24hr 005 mg24hr006 mg24hr 375mcg24hr

1

estradiol tabs or 05 mg 1mg 2 mg 1

estradiol valerate oil 1

Drug Name DrugTier

RequirementsLimits

ESTROGEL GEL 3

EVAMIST SOLN 3

MENEST TABS 3

MENOSTAR PTWK 3

MINIVELLE PTTW (Use estradiol) NF QL(0286 ea

daily)

PREMARIN SOLR 2

PREMARIN TABS 2

VIVELLE-DOT PTTW (Use estradiol) NF QL(0286 ea

daily) FLUOROQUINOLONES - Drugs to Treat BacterialInfections

Fluoroquinolones AVELOX SOLN (Use moxifloxacin hcl in sodium chloride)

1

BAXDELA SOLR 3 PA

BAXDELA TABS 3 PA

CIPRO SUSR 5 GM100ML 500 MG5ML 2


CIPRO TABS 250 MG 500 MG (Use ciprofloxacin hcl) NF

ciprofloxacin hcl tabs 1

ciprofloxacin in d5w soln200 mg100ml-5 5 -200 mg100ml

3

ciprofloxacin susr 1 2 rtl MAX fill30 rtl day(s)supply

LEVAQUIN TABS (Use levofloxacin) NF

levofloxacin in d5w soln 5 -500 mg100ml 500mg100ml-5

1

levofloxacin soln 1

levofloxacin tabs 1


69

Drug Name DrugTier

RequirementsLimits

moxifloxacin hcl in sodium chloride soln 1

moxifloxacin hcl tabs 1

ofloxacin tabs 1

GASTROINTESTINAL AGENTS - MISC -Miscellaneous Gastrointestinal Drugs

Bile Acid Synthesis Disorder Agents

CHOLBAM CAPS 4 PA SP

Gallstone Solubilizing Agents ACTIGALL CAPS (Use ursodiol) NF

URSO 250 TABS (Use ursodiol) NF

URSO FORTE TABS (Use ursodiol) NF

ursodiol caps 300 mg 1

ursodiol tabs 250 mg 500 mg 1

Gastrointestinal Chloride Channel Activators AMITIZA CAPS (Use lubiprostone) 2 PA QL(2 ea

daily)

lubiprostone caps 1 PA QL(2 eadaily)

Gastrointestinal Stimulants metoclopramide hcl soln ij5 mgml 1

metoclopramide hcl soln or10 mg10ml 5 mg5ml 1 QL(60 ml daily)

metoclopramide hcl tabs or10 mg 5 mg 1 QL(6 ea daily)

REGLAN TABS (Use metoclopramide hcl) NF QL(6 ea daily)

Inflammatory Bowel Agents APRISO CP24 (Use mesalamine) NF

ASACOL HD TBEC (Use mesalamine) NF QL(6 ea daily)

AVSOLA SOLR 4 PA

AZULFIDINE EN-TABS TBEC (Use sulfasalazine) NF

Drug Name DrugTier

RequirementsLimits

AZULFIDINE TABS (Use sulfasalazine) NF

balsalazide disodium caps 1

CANASA SUPP (Use mesalamine) NF

COLAZAL CAPS (Use balsalazide disodium) NF

DELZICOL CPDR (Use mesalamine) NF

DIPENTUM CAPS 2

INFLECTRA SOLR 4 PA 30 rtl lmt day(s)30 maillmt day(s)

LIALDA TBEC (Use mesalamine) NF

mesalamine cp24 or 0375 gm 1

mesalamine cpdr or 400 mg 1

mesalamine enem re 4 gm 1

mesalamine supp re 1000 mg 1

mesalamine tbec or 12 gm 1

mesalamine tbec or 800 mg 1 QL(6 ea daily)

RENFLEXIS SOLR 4 PA 30 rtl lmt day(s)30 maillmt day(s)

STELARA SOLN IV 130 MG26ML 4 PA

sulfasalazine tabs 1

sulfasalazine tbec 1

Intestinal Acidifiers lactulose (encephalopathy)soln 1

Irritable Bowel Syndrome (IBS) Agents

alosetron hcl tabs 1 QL(2 ea daily)

LINZESS CAPS 2 PA QL(1 eadaily)


70

Drug Name DrugTier

RequirementsLimits

LOTRONEX TABS (Use alosetron hcl) NF QL(2 ea daily)

Peripheral Opioid Receptor Antagonists

alvimopan caps 1

ENTEREG CAPS (Use alvimopan) 3

RELISTOR SOLN SC 12 MG06ML 8 MG04ML 3 PA

Phosphate Binder Agents calcium acetate (phosphatebinder) caps 1

calcium acetate (phosphatebinder) tabs 1 RXOTC

FOSRENOL CHEW 1000 MG 500 MG 750 MG (Use lanthanum carbonate)

NF

lanthanum carbonate chew 1

PHOSLYRA SOLN 2

RENAGEL TABS (Use sevelamer hcl) 3

RENVELA PACK (Use sevelamer carbonate) NF

RENVELA TABS (Use sevelamer carbonate) NF

sevelamer carbonate pack 1

sevelamer carbonate tabs 1

sevelamer hcl tabs 1

VELPHORO CHEW 3 PA

GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat ReproductiveOrgans and Urinary System

Alkalinizers potassium citrate(alkalinizer) tbcr 10 meq1080 mg

1

sodium citrate amp citric acid soln 1 RXOTC

Drug Name DrugTier

RequirementsLimits

UROCIT-K 10 TBCR (Use potassium citrate(alkalinizer))

NF

Cystinosis Agents

CYSTAGON CAPS 3 PA

Genitourinary Irrigants

acetic acid soln 1

glycine (gu irrigant) soln 1

RESECTISOL SOLN 1

sodium chloride (guirrigant) soln 1

SORBITOL SOLN 1

SORBITOL-MANNITOL SOLN 1

SORBITOLMANNITOLIRRIGATION SOLN 1

Interstitial Cystitis Agents

ELMIRON CAPS 2

Prostatic Hypertrophy Agents

alfuzosin hcl tb24 1 QL(1 ea daily)

AVODART CAPS (Use dutasteride) NF QL(1 ea daily)

dutasteride caps 1 QL(1 ea daily)

finasteride tabs 1 5 mg only

FLOMAX CAPS (Use tamsulosin hcl) NF

PROSCAR TABS (Use finasteride) NF 5 mg only

RAPAFLO CAPS (Use silodosin) NF

silodosin caps 8 mg 4 mg 1

tamsulosin hcl caps 1

UROXATRAL TB24 (Use alfuzosin hcl) NF QL(1 ea daily)

Urinary Analgesics


71

Drug Name DrugTier

RequirementsLimits

phenazopyridine hcl tabs 1

PYRIDIUM TABS (Use phenazopyridine hcl) NF

GOUT AGENTS - Drugs to Treat Gout

Gout Agent Combinations colchicine w probenecidtabs 1

Gout Agents

allopurinol tabs 1

colchicine tabs 1 QL(1 ea daily)

COLCRYS TABS (Use colchicine) NF QL(1 ea daily)

febuxostat tabs 1 PA QL(1 eadaily)

KRYSTEXXA SOLN 4 PA

MITIGARE CAPS (Use colchicine) NF

ULORIC TABS (Use febuxostat) NF PA QL(1 ea

daily) ZYLOPRIM TABS (Use allopurinol) NF

Uricosurics

probenecid tabs 1

HEMATOLOGICAL AGENTS - MISC - Drugs toTreat Blood Disorders

Bradykinin B2 Receptor Antagonists FIRAZYR SOLN (Use icatibant acetate) NF PA QL(9 ml

daily)

icatibant acetate soln 4 PA QL(9 mldaily)

Complement Inhibitors

CINRYZE SOLR 4 PA

HAEGARDA SOLR 4 PA

RUCONEST SOLR 4 PA QL(0143ea daily)

SOLIRIS SOLN 4 PA

Drug Name DrugTier

RequirementsLimits

Hematorheologic Agents

pentoxifylline tbcr 1 QL(3 ea daily)

Plasma Kallikrein Inhibitors

TAKHZYRO SOLN 4 PA

Platelet Aggregation Inhibitors AGGRENOX CP12 (Use aspirin-dipyridamole) NF PA QL(2 ea

daily) AGRYLIN CAPS (Use anagrelide hcl) NF

anagrelide hcl caps 1

aspirin-dipyridamole cp12 1 PA QL(2 eadaily)

BRILINTA TABS 2

CABLIVI KIT 4 PA

cilostazol tabs 1

clopidogrel bisulfate tabs300 mg 1

clopidogrel bisulfate tabs75 mg 1 QL(1 ea daily)

dipyridamole tabs 1

EFFIENT TABS (Use prasugrel hcl) NF QL(1 ea daily)

PLAVIX TABS (Use clopidogrel bisulfate) NF QL(1 ea daily)

prasugrel hcl tabs 1 QL(1 ea daily)

ZONTIVITY TABS 3 PA

HEMATOPOIETIC AGENTS - Drugs to TreatBlood Disorders

Agents for Gaucher Disease

CERDELGA CAPS 4 PA QL(2 eadaily)

CEREZYME SOLR 4 PA SP

ELELYSO SOLR 4 PA SP

miglustat caps 4 PA QL(3 eadaily) SP


72

Drug Name DrugTier

RequirementsLimits

VPRIV SOLR 4 PA SP

ZAVESCA CAPS (Use miglustat) NF PA QL(3 ea

daily) SP

Agents for Sickle Cell Disease

DROXIA CAPS 3

OXBRYTA TABS 4 PA

Cobalamins cyanocobalamin soln ij1000 mcgml 1 QL(1 ml daily)

Folic AcidFolates

folic acid tabs or 1 mg 0 RXOTC

folic acid tabs or 400 mcg 0

Hematopoietic Growth Factors ARANESP ALBUMIN FREE SOLN 100 MCGML40 MCGML 60 MCGML

4 PA SP

ARANESP ALBUMIN FREE SOLN 25 MCGML 4 SP

ARANESP ALBUMIN FREE SOSY 150 MCG03ML 200MCG04ML 300MCG06ML 500 MCGML

4

PA SP

DOPTELET TABS 4 PA

EPOGEN SOLN 3 PA SP

FULPHILA SOSY 4 PA

LEUKINE SOLR 4 PA SP

MIRCERA SOSY 4 PA

MULPLETA TABS 4 PA

NEULASTA ONPRO KIT PSKT 4 PA SP

NEULASTA SOSY 4 PA SP

NEUPOGEN SOLN 4 PA SP

Drug Name DrugTier

RequirementsLimits

NEUPOGEN SOSY 4 PA SP

NIVESTYM SOSY 300 MCG05ML 480MCG08ML

4 PA

NPLATE SOLR 250 MCG 500 MCG 4 PA SP

PROCRIT SOLN 10000 UNITML 2000 UNITML20000 UNITML 3000UNITML 4000 UNITML

3

PA SP

PROCRIT SOLN 40000 UNITML 4 PA SP

PROMACTA PACK 125 MG 4 PA QL(1 ea

daily) PROMACTA TABS 125 MG 25 MG 50 MG 75 MG 4 PA SP

RETACRIT SOLN 10000 UNITML 2000 UNITML20000 UNIT2ML 3000UNITML 4000 UNITML40000 UNITML

4

PA

UDENYCA SOSY 4 PA

ZARXIO SOSY 4 PA 30 rtl lmt day(s)30 maillmt day(s)

ZIEXTENZO SOSY 4 PA

Hematopoietic Mixtures ferrous fumarate-folic acid tabs 1 QL(1 ea daily)

Iron FER-IN-SOL SOLN (Use ferrous sulfate) 0 AL(Up to 1 yrs

old ) ferrous sulfate soln or 15 mgml 0 AL(Up to 1 yrs

old ) ferrous sulfate tabs or 325 mg 65 mg 0

ferrous sulfate tbec or 325 mg 0

Stem Cell Mobilizers

MOZOBIL SOLN 4 PA SP

HEMOSTATICS - Drugs to Stop BleedingTreatBlood Disorders


73

Drug Name DrugTier

RequirementsLimits

Hemostatics - Systemic AMICAR TABS 1000 MG 500 MG (Use aminocaproic acid)

NF PA

aminocaproic acid tabs or1000 mg 500 mg 1 PA

CYKLOKAPRON SOLN (Use tranexamic acid) NF

LYSTEDA TABS (Use tranexamic acid) NF

tranexamic acid soln 1

tranexamic acid tabs 1

HYPNOTICSSEDATIVESSLEEP DISORDERAGENTS

Barbiturate Hypnotics phenobarbital elix 20mg5ml 1

phenobarbital soln 20mg5ml 1

phenobarbital tabs 100 mg162 mg 324 mg 648 mg972 mg 15 mg 30 mg

1

Hypnotics - Tricyclic Agents

doxepin hcl (sleep) tabs 1 PA QL(1 eadaily)

SILENOR TABS (Use doxepin hcl (sleep)) NF PA QL(1 ea

daily) Non-Barbiturate Hypnotics

AMBIEN CR TBCR (Use zolpidem tartrate) NF

ST Must tryimmediate release zolpidemQL(1ea daily)

AMBIEN TABS (Use zolpidem tartrate) NF


DORAL TABS (Use quazepam) NF

estazolam tabs 1

eszopiclone tabs 1

ST QL(1 eadaily) AL(Atleast 18 yrsold)

Drug Name DrugTier

RequirementsLimits

flurazepam hcl caps 1 QL(1 ea daily)

HALCION TABS (Use triazolam) NF

LUNESTA TABS (Use eszopiclone) NF


RESTORIL CAPS (Use temazepam) NF QL(1 ea daily)

temazepam caps 1 QL(1 ea daily)

triazolam tabs 1

zaleplon caps 10 mg 1 QL(2 ea daily)AL(At least 18yrs old)


zolpidem tartrate tabs or 10mg 5 mg 1


zolpidem tartrate tbcr or625 mg 125 mg 1


Orexin Receptor Antagonists

BELSOMRA TABS 3 PA

Selective Melatonin Receptor Agonists

HETLIOZ CAPS 3 PA QL(1 eadaily)

ramelteon tabs 1


ROZEREM TABS (Use ramelteon) NF


LAXATIVES - Bowel Treatment Drugs

Bulk Laxatives

calcium polycarbophil tabs 1


74

Drug Name DrugTier

RequirementsLimits

FIBERCON TABS (Use calcium polycarbophil) NF

Laxative Combinations

CLENPIQ SOLN 3 PA

COLYTE-FLAVOR PACKS SOLR (Use peg 3350-kcl-sod bicarb-sod chloride-sod sulfate)

NF

GOLYTELY SOLR (Use peg 3350-kcl-sod bicarb-sod chloride-sod sulfate)

0

MOVIPREP SOLR (Use peg 3350-kcl-nacl-nasulfate-na ascorbate-ascorbic acid)

2

PA

peg 3350-kcl-nacl-nasulfate-na ascorbate-ascorbic acid solr

1 PA

peg 3350-kcl-sod bicarb-sod chloride-sod sulfate solr 297 gm-586 gm-674gm-2274 gm-236 gm

0

PREPOPIK PACK 3 PA

SUPREP BOWEL PREP KIT SOLN 0

Laxatives - Miscellaneous lactulose soln 10 gm15ml20 gm30ml 1

Saline Laxatives

OSMOPREP TABS 3 PA

Stimulant Laxatives

bisacodyl tbec 1

DULCOLAX TBEC (Use bisacodyl) NF

Surfactant Laxatives COLACE CAPS (Use docusate sodium) NF

docusate calcium caps 1

docusate sodium caps 1

Drug Name DrugTier

RequirementsLimits

LOCAL ANESTHETICS-Parenteral - Drugs forNumbing

Local Anesthetics - Amides lidocaine hcl (local anesth)soln 05 1 2 1

MARCAINE SOLN 05 (Use bupivacaine hcl) NF

NAROPIN SOLN 5 MGML2 MGML (Use ropivacaine hcl)

NF

XYLOCAINE SOLN 05 1 (Use lidocaine hcl (local anesth))

NF

XYLOCAINE-MPF SOLN 05 1 2 (Use lidocaine hcl (localanesth))

NF

MACROLIDES - Drugs to Treat BacterialInfections

Azithromycin

azithromycin pack or 1 gm 1

azithromycin solr iv 500 mg 1

azithromycin susr or 100mg5ml 200 mg5ml 1

azithromycin tabs or 250 mg 1

QL(6 ea per fillretail6 ea perfill mail)



azithromycin tabs or 600 mg 1 QL(0286 ea

daily) ZITHROMAX PACK OR 1 GM (Use azithromycin) NF

ZITHROMAX SOLR IV 500 MG (Use azithromycin) NF

ZITHROMAX SUSR OR 100 MG5ML 200 MG5ML(Use azithromycin)

NF

ZITHROMAX TABS OR 250 MG (Use azithromycin) NF



75

Drug Name DrugTier

RequirementsLimits



ZITHROMAX TABS OR 600 MG (Use azithromycin) NF QL(0286 ea

daily)

ZITHROMAX TRI-PAK TABS (Use azithromycin) NF


ZITHROMAX Z-PAK TABS (Use azithromycin) NF


Clarithromycin

clarithromycin susr 1

clarithromycin tabs 1

clarithromycin tb24 1

Erythromycins EES GRANULES SUSR (Use erythromycinethylsuccinate)

NF

ERYPED 200 SUSR (Use erythromycinethylsuccinate)

NF


3

erythromycin base cpep250 mg 3

erythromycin base tabs250 mg 500 mg 3

erythromycin base tbec333 mg 500 mg 250 mg 1

erythromycinethylsuccinate susr 200mg5ml 400 mg5ml

1

erythromycinethylsuccinate tabs 400 mg 3

Fidaxomicin

DIFICID TABS 200 MG 2

MEDICAL DEVICES AND SUPPLIES

Contraceptives

Drug Name DrugTier

RequirementsLimits

AIMSCO LUBRICATED MISC 0 QL(2 ea daily)

CAYA DPRH 0

DUREX EXTRA SENSITIVE DEVI 0 QL(2 ea daily)

FANTASY LUBRICATED MISC 0 QL(2 ea daily)

FANTASY LUBRICATEDSPERMICIDE MISC

0 QL(2 ea daily)

FC FEMALE CONDOM MISC 0 QL(1 ea daily)

FEMCAP DEVI 0

K-Y ME amp YOU EXTRA LUBRICATED DEVI 0 QL(2 ea daily)

K-Y ME amp YOU INTENSE DEVI 0 QL(2 ea daily)

KAMELEON LUBRICATED MISC 0 QL(2 ea daily)

KIMONO COLORS DEVI 0 QL(2 ea daily)

KIMONO LUBRICATED MISC 0 QL(2 ea daily)

KIMONO MICRO THIN PLUS SPERMICIDE LUBRICATED MISC

0 QL(2 ea daily)

KIMONO PLUS SPERMICIDE LUBRICATED MISC

0 QL(2 ea daily)

KIMONO PLUS SPERMICIDELUBRICATED MISC

0 QL(2 ea daily)

KIMONO PS LUBRICATED MISC 0 QL(2 ea daily)

KIMONO PS PLUS SPERMICIDELUBRICATED MISC

0 QL(2 ea daily)

KIMONO SENSATION LUBRICATED MISC 0 QL(2 ea daily)

KIMONO SENSATION PLUS SPERMICIDE LUBRICATED MISC

0 QL(2 ea daily)

KIMONO SPECIAL DEVI 0 QL(2 ea daily)


76

Drug Name DrugTier

RequirementsLimits

MAXX LUBRICATED MISC 0 QL(2 ea daily)

MAXX PLUS SPERMICIDE LUBRICATED MISC 0 QL(2 ea daily)

OMNIFLEX DIAPHRAGM DPRH 0

PREMIUM CONDOMS LUBRICATED MISC 0 QL(2 ea daily)

REALITY LATEX CONDOMSLUBRICATEDMISC

0 QL(2 ea daily)

REALITY LATEXULTRATEXTURED DEVI 0 QL(2 ea daily)

REALITY LATEXULTRATHIN DEVI 0 QL(2 ea daily)

TRUSTEX COLOR CONDOMS + LUBE MISC 0 QL(2 ea daily)

TRUSTEX LUBRICATED EXTRALARGE MISC 0 QL(2 ea daily)

TRUSTEX LUBRICATED EXTRASTRENGTH MISC 0 QL(2 ea daily)

TRUSTEX LUBRICATED MISC 0 QL(2 ea daily)

TRUSTEX LUBRICATEDRIBBEDSTUDDED MISC

0 QL(2 ea daily)

TRUSTEX LUBRICATEDSPERMICIDE EXTRA LARGE MISC

0 QL(2 ea daily)

TRUSTEX LUBRICATEDSPERMICIDE EXTRA STRENGTH MISC

0

QL(2 ea daily)

TRUSTEX LUBRICATEDSPERMICIDE MISC

0 QL(2 ea daily)

TRUSTEX NATURAL CONDOMS +LUBELUBRICATEDMISC

0

QL(2 ea daily)

TRUSTEX WITH NONOXYNOL-9RIBBEDSTUDDEDMISC

0

QL(2 ea daily)

TRUSTEXRIALUBRICATED MISC 0 QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

TRUSTEXRIALUBRICATED SPERMICIDE MISC

0 QL(2 ea daily)

TRUSTEXRIALUBRICATEDSPERMICIDE MISC

0 QL(2 ea daily)

WIDE-SEAL SILICONE DIAPHRAGM KIT 60 DPRH

0


0


0


0


0


0


0


0

Diabetic Supplies 1ST TIER UNILET COMFORTOUCH LANCETS 28G MISC

1 QL(66667 eadaily)

1ST TIER UNILET COMFORTOUCH LANCETS 30G MISC

1 QL(66667 eadaily)

ACCU-CHEK FASTCLIX LANCETS MISC 1 QL(66667 ea

daily) ACCU-CHEK MULTICLIX LANCETS MISC 1 QL(66667 ea

daily) ACCU-CHEK SAFE-T-PRO LANCETS MISC 1 QL(66667 ea

daily) ACCU-CHEK SAFE-T-PRO PLUSLANCETS MISC 1 QL(66667 ea

daily) ACCU-CHEK SOFTCLIX LANCETS MISC 1 QL(66667 ea

daily)


77

Drug Name DrugTier

RequirementsLimits

ACTI-LANCE LANCETS 28G MISC 1 QL(66667 ea

daily) ACTI-LANCE LITE SAFETY LANCETS 28G MISC

1 QL(66667 eadaily)

ACTI-LANCE SPECIAL SAFETY LANCETS 17G MISC

1 QL(66667 eadaily)

ACTI-LANCE SPECIAL SAFETYLANCETS 17G MISC

1 QL(66667 eadaily)

ACTI-LANCE UNIVERSAL SAFETY LANCETS 23G MISC

1 QL(66667 eadaily)

ADJUSTABLE LANCING DEVICE MISC 1

ADVANCED MOBILE LANCET 30G MISC 1 QL(66667 ea

daily) ADVOCATE LANCETS 30G MISC 1 QL(66667 ea

daily) ADVOCATE LANCETS MISC 1 QL(66667 ea

daily) ADVOCATE LANCING DEVICE MISC 1

ADVOCATE RAPID-SAFE LANCING DEVICE MISC 1

ADVOCATE SAFETY LANCETS 26G MISC 1 QL(66667 ea

daily) ADVOCATE SAFETY LANCETS MISC 1 QL(66667 ea

daily) AGAMATRIX ULTRA-THIN LANCETS 33G MISC 1 QL(66667 ea

daily) AIMSCO TWIST LANCETS 32G MISC 1 QL(66667 ea


daily) ALTERNATE SITE LANCING DEVICE MISC 1

AQUA LANCE ADJUSTABLE LANCING DEVICE DEVI

1

ASSURE HAEMOLANCE PLUS HIGH FLOW 18G MISC

1 QL(66667 eadaily)

ASSURE HAEMOLANCE PLUS LOW FLOW 25G MISC

1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

ASSURE HAEMOLANCE PLUS MICRO FLOW 28G MISC

1 QL(66667 eadaily)

ASSURE HAEMOLANCE PLUS NORMAL FLOW 21G MISC

1 QL(66667 eadaily)

ASSURE HAEMOLANCE PLUS PEDIATRIC BLADE MISC

1 QL(66667 eadaily)

ASSURE LANCE LANCETS 21G MISC 1 QL(66667 ea

daily) ASSURE LANCE LANCETS MISC 1 QL(66667 ea

daily) ASSURE LANCE PLUS SAFETYLANCETS 25G MISC

1 QL(66667 eadaily)

ASSURE LANCE PLUS SAFETYLANCETS 30G MISC

1 QL(66667 eadaily)

ASSURE LANCE SAFETY LANCET 28G MISC 1 QL(66667 ea

daily)

ASSURE LANCETS MISC 1 QL(66667 eadaily)

AURORA LANCET SUPER THIN30G MISC 1 QL(66667 ea

daily) AURORA LANCET THIN 23G MISC 1 QL(66667 ea

daily)

AUTO-LANCET MINI MISC 1

AUTO-LANCET MISC 1

AUTOLET IMPRESSION LANCING DEVICE MISC 1

AUTOLET LANCING DEVICE MISC 1

AUTOLET MINI MISC 1

AUTOLET PLUS MISC 1

BD LANCET ULTRAFINE 30G MISC 1 QL(66667 ea

daily) BD LANCET ULTRAFINE 33G MISC 1 QL(66667 ea

daily) BD MICROTAINER LANCETS MISC 1 QL(66667 ea

daily) BULLSEYE MINI SAFETY LANCETS MISC 1 QL(66667 ea

daily)


78

Drug Name DrugTier

RequirementsLimits

BULLSEYE SAFETY LANCETS MISC 1 QL(66667 ea

daily) CARDIOCOM LANCING DEVICE MISC 1

CAREONE ADVANCED LANCINGDEVICE MISC 1

CAREONE LANCET SUPER THIN30G MISC 1 QL(66667 ea

daily) CAREONE LANCET THIN MISC 1 QL(66667 ea

daily) CARESENS LANCETS MISC 1 QL(66667 ea

daily) CARETOUCH LANCING DEVICEWITH EJECTOR MISC

1

CARETOUCH SAFETY LANCETS26G MISC 1 QL(66667 ea

daily) CARETOUCH SAFETY LANCETS28G MISC 1 QL(66667 ea


daily) CARETOUCH TWIST LANCETS 28G MISC 1 QL(66667 ea



daily) CLEANLET LANCETS 28G MISC 1 QL(66667 ea

daily) COAGUCHEK LANCETS MISC 1 QL(66667 ea

daily) COMFORT ASSURED LANCETS MICRO THIN 33G MISC

1 QL(66667 eadaily)

COMFORT ASSURED LANCETS SUPER THIN 28G MISC

1 QL(66667 eadaily)

COMFORT LANCETS MISC 1 QL(66667 ea

daily)

CVS LANCETS 21G MISC 1 QL(66667 eadaily)

CVS LANCETS MICRO THIN 33G MISC 1 QL(66667 ea

daily) CVS LANCETS MICRO-THIN 33G MISC 1 QL(66667 ea

daily)

Drug Name DrugTier

RequirementsLimits

CVS LANCETS ORIGINAL MISC 1 QL(66667 ea

daily) CVS LANCETS THIN 26G MISC 1 QL(66667 ea

daily) CVS LANCETS ULTRA THIN 30G MISC 1 QL(66667 ea

daily) CVS LANCETS ULTRA-THIN 30G MISC 1 QL(66667 ea

daily) CVS LANCING DEVICE MISC 1

CVS ULTRA THIN LANCETS MISC 1 QL(66667 ea

daily) DIATHRIVE LANCETS MISC 1 QL(66667 ea

daily) DIATHRIVE LANCETS ULTRA THIN 30G MISC 1 QL(66667 ea

daily) DIATHRIVE LANCING DEVICE MISC 1

DROPLET GENTEEL LANCING DEVICE MISC 1

DROPLET LANCETS ULTRA THIN 30G MISC 1 QL(66667 ea

daily) DROPLET LANCING DEVICE MISC 1

DROPLET PERSONAL LANCETS30G MISC 1 QL(66667 ea

daily) DRUG MART ADJUSTABLE LANCING DEVICE MISC

1

DRUG MART LANCETS THIN MISC 1 QL(66667 ea

daily) DRUG MART ON-THE-GO LANCETS GENTLE 30G MISC

1 QL(66667 eadaily)

DRUG MART UNILET LANCETSSUPER THIN 30G MISC

1 QL(66667 eadaily)

DRUG MART UNILET LANCETSULTRA THIN 28G MISC

1 QL(66667 eadaily)

DRUG MART UNILET MICRO THIN LANCETS 33G MISC

1 QL(66667 eadaily)

E-Z JECT LANCETS 21G MISC 1 QL(66667 ea

daily)


79

Drug Name DrugTier

RequirementsLimits

E-Z JECT LANCETS COLOR MISC 1 QL(66667 ea

daily)

E-Z JECT LANCETS MISC 1 QL(66667 eadaily)

E-Z JECT LANCETS SUPER THIN 30G MISC 1 QL(66667 ea

daily) E-Z JECT LANCETS THIN 26G MISC 1 QL(66667 ea

daily) E-ZJECT LANCETS MICRO-THIN 33G MISC 1 QL(66667 ea

daily) EASY MINI EJECT LANCING DEVICE MISC 1

EASY MINI LANCING DEVICE MISC 1

EASY TOUCH LANCETS 21GPRESSUREACTIVATED MISC

1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)

EASY TOUCH LANCETS 26GPULL-TOP MISC 1 QL(66667 ea

daily) EASY TOUCH LANCETS 28GPRESSUREACTIVATED MISC

1 QL(66667 eadaily)


daily) EASY TOUCH LANCETS 28GTWIST MISC 1 QL(66667 ea

daily) EASY TOUCH LANCETS 30GBUTTON-ACTIVATEDMISC

1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


daily)

Drug Name DrugTier

RequirementsLimits

EASY TOUCH LANCETS 32GTWIST MISC 1 QL(66667 ea


daily) EASY TOUCH LANCING DEVICEEJECTOR MISC 1

EASY TOUCH SAFETY LANCETS21GPRESSUREACTIVATED MISC

1 QL(66667 eadaily)


1 QL(66667 eadaily)

EASY TOUCH SAFETY LANCETS26GBUTTONACTIVATED MISC

1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)

EASY TWIST amp CAP LANCETS MISC 1 QL(66667 ea

daily) EMBRACE LANCETS ULTRA THIN 30G MISC 1 QL(66667 ea

daily) EMBRACE LANCING DEVICE WITH EJECTOR MISC

1

EQL COLOR LANCETS 21G MISC 1 QL(66667 ea

daily) EQL COLOR LANCETS MICRO THIN 33G MISC 1 QL(66667 ea

daily) EQL SUPER THIN LANCETS 30G MISC 1 QL(66667 ea

daily) EQL THIN LANCETS 26G MISC 1 QL(66667 ea

daily) EZ-LETS LANCETS 21G MISC 1 QL(66667 ea

daily) EZ-LETS LANCETS 26G SUPER-SOFT MISC 1 QL(66667 ea

daily) EZ-LETS LANCETS 28G ULTRA-SOFT MISC 1 QL(66667 ea


daily)


80

Drug Name DrugTier

RequirementsLimits

FIFTY50 SAFETY SEAL LANCETS 30G MISC 1 QL(66667 ea

daily) FIFTY50 SAFETY SEAL LANCETS 32G MISC 1 QL(66667 ea

daily) FIFTY50 UNILET LANCETS 33G MISC 1 QL(66667 ea

daily)

FINE 30 MISC 1 QL(66667 eadaily)

FINGERSTIX LANCETS MISC 1 QL(66667 ea

daily)

FORA LANCETS MISC 1 QL(66667 eadaily)

FORA LANCING DEVICE MISC 1

FORA LANCING DEVICECLEARCAP MISC 1

FREDS PHARMACY AUTOLET LANCING DEVICE MISC

1

FREDS PHARMACY UNILET LANCETS SUPER THIN 30G MISC

1 QL(66667 eadaily)

FREDS PHARMACY UNILET LANCETS ULTRA THIN 28G MISC

1 QL(66667 eadaily)

FREESTYLE LANCETS MISC 1 QL(66667 ea

daily) FREESTYLE UNISTICK II LANCETS MISC 1 QL(66667 ea

daily) GENTEEL BUTTERFLY TOUCH LANCETS MISC 1 QL(66667 ea

daily) GENTEEL LANCING DEVICEGLORIOUSGOLD MISC

1

GENTEEL LANCING DEVICEPRECIOUSPLATINUM MISC

1

GENTEEL LANCING DEVICESTATELY SILVERMISC

1

GENTEEL PLUS LANCING DEVICEBUFF BLACKMISC

1

GENTEEL PLUS LANCING DEVICEBUTTERFLYBLUE MISC

1

Drug Name DrugTier

RequirementsLimits

GENTEEL PLUS LANCING DEVICEPLAYFULPURPLE MISC

1

GENTEEL PLUS LANCING DEVICEPRINCESS PINKMISC

1

GENTEEL PLUS LANCING DEVICEWILLOWY WHITEMISC

1

GENTLE-LET GP LANCETS MISC 1 QL(66667 ea

daily) GENTLE-LET LANCETS GENERAL PURPOSE STYLEFINE POINT MISC

1 QL(66667 eadaily)

GENTLE-LET LANCETS GENERAL PURPOSE STYLEMEDIUM POINTMISC

1

QL(66667 eadaily)

GENTLE-LET LANCETS SAFETY STYLEFINEPOINT MISC

1 QL(66667 eadaily)

GENTLE-LET LANCETS SAFETY STYLEMEDIUMPOINT MISC

1 QL(66667 eadaily)

GLOBAL LANCING DEVICE MISC 1

GLUCOCOM LANCETS 28G MISC 1 QL(66667 ea

daily) GLUCOCOM LANCETS 30G MISC 1 QL(66667 ea


daily)

GNP LANCETS 21G MISC 1 QL(66667 eadaily)

GNP LANCETS MICRO THIN 33G MISC 1 QL(66667 ea

daily) GNP LANCETS SUPER THIN 30G MISC 1 QL(66667 ea

daily) GNP LANCETS THIN 26G MISC 1 QL(66667 ea

daily) GNP LANCETS THIN MISC 1 QL(66667 ea

daily) GNP LANCING SYSTEM DEVICE MISC 1

GOJJI LANCING DEVICECLEAR CAPMISC

1


81

Drug Name DrugTier

RequirementsLimits

GOJJI STERILE LANCETS 30G MISC 1 QL(66667 ea

daily) GOODSENSE COLOR LANCETS MICRO-THIN 33G UNIVERSAL MISC

1 QL(66667 eadaily)

GOODSENSE LANCETS MICRO-THIN 33G MISC 1 QL(66667 ea

daily) GOODSENSE LANCETS MICRO-THIN 33G UNIVERSAL MISC

1 QL(66667 eadaily)

GOODSENSE LANCETS ULTRA-THIN 26G UNIVERSAL MISC

1 QL(66667 eadaily)

GOODSENSE LANCETS ULTRA-THIN 30G MISC 1 QL(66667 ea

daily) GOODSENSE LANCETS ULTRA-THIN 30G UNIVERSAL MISC

1 QL(66667 eadaily)

GOODSENSE LANCING DEVICE MISC 1

H-E-B INCONTROL ADVANCEDLANCING DEVICE MISC

1

H-E-B INCONTROL LANCETS MICRO THIN 33G MISC

1 QL(66667 eadaily)

H-E-B INCONTROL LANCETS SUPER THIN 30G MISC

1 QL(66667 eadaily)

H-E-B INCONTROL LANCETS ULTRA THIN 28G MISC

1 QL(66667 eadaily)

HAEMOLANCE LOW FLOW LANCETS MISC 1 QL(66667 ea

daily)

HAEMOLANCE MISC 1 QL(66667 eadaily)

HAEMOLANCE PLUS HIGH FLOW MISC 1 QL(66667 ea

daily) HAEMOLANCE PLUS LOW FLOW MISC 1 QL(66667 ea

daily) HAEMOLANCE PLUS MAX FLOW MISC 1 QL(66667 ea

daily) HAEMOLANCE PLUS MISC 1 QL(66667 ea

daily) HAEMOLANCE PLUS PEDIATRIC FLOW MISC 1 QL(66667 ea

daily)

Drug Name DrugTier

RequirementsLimits

HEALTH CARE LANCING DEVICE MISC 1

HEALTHY ACCENTS AUTOLET IMPRESSION LANCING DEVICE MISC

1

HEALTHY ACCENTS UNILET LANCETS SUPER THIN 30G MISC

1 QL(66667 eadaily)

HY-VEE LANCETS MISC 1 QL(66667 eadaily)

HY-VEE THIN LANCETS MISC 1 QL(66667 ea

daily) IN TOUCH LANCING DEVICE MISC 1

IN TOUCH STERILE LANCETS30G MISC 1 QL(66667 ea

daily)

KINNEY LANCETS MISC 1 QL(66667 eadaily)

KINNEY THIN LANCETS MISC 1 QL(66667 ea

daily) KROGER AUTOLET LANCING DEVICE MISC 1

KROGER HEALTHPRO TWIST LANCETS26GMISC

1 QL(66667 eadaily)

KROGER LANCETS 21G MISC 1 QL(66667 ea

daily) KROGER LANCETS MICRO THIN33G MISC 1 QL(66667 ea

daily)

KROGER LANCETS MISC 1 QL(66667 eadaily)

KROGER LANCETS SUPER THIN MISC 1 QL(66667 ea

daily) KROGER LANCETS THIN 26G MISC 1 QL(66667 ea

daily) KROGER LANCETS THIN MISC 1 QL(66667 ea

daily) KROGER LANCETS ULTRATHIN30G MISC 1 QL(66667 ea

daily) KROGER LANCING DEVICE MISC 1

LANCET DEVICE ADJUSTABLE MISC 1

LANCET DEVICE WITH EJECTOR MISC 1


82

Drug Name DrugTier

RequirementsLimits

LANCETS 26G TWIST TOP MISC 1 QL(66667 ea

daily)

LANCETS 30G MISC 1 QL(66667 eadaily)


daily) LANCETS 30GTWISTTOP MISC 1 QL(66667 ea

daily) LANCETS 31G TWIST TOP MISC 1 QL(66667 ea

daily) LANCETS 33G EXTRA FINE MISC 1 QL(66667 ea

daily) LANCETS MICRO THIN 33G MISC 1 QL(66667 ea

daily)

LANCETS MISC 1 QL(66667 eadaily)

LANCETS SAFETY SEAL 21G MISC 1 QL(66667 ea

daily) LANCETS SAFETY SEAL 26G MISC 1 QL(66667 ea



daily) LANCETS SUPER THIN 28G MISC 1 QL(66667 ea

daily)

LANCETS THIN MISC 1 QL(66667 eadaily)

LANCETS TWIST TOP MISC 1 QL(66667 ea

daily) LANCETS ULTRA THIN 30G MISC 1 QL(66667 ea

daily) LANCETS ULTRA THIN MISC 1 QL(66667 ea

daily) LANCETSBULLSEYE SAFETY MISC 1 QL(66667 ea

daily) LANCING DEVICE ADJUSTABLE MISC 1

LANCING DEVICE MISC 1

LANZO MISC 1

LEADER ADVANCED LANCING DEVICE MISC 1

LIBERTY MEDICAL LANCETS 30G MISC 1 QL(66667 ea

daily)

Drug Name DrugTier

RequirementsLimits

LIBERTY MINI LANCING DEVICE MISC 1

LIFESCAN UNISTIK 2 DEEP PENETRATION MISC

1 QL(66667 eadaily)

LIFESCAN UNISTIK II LANCETS MISC 1 QL(66667 ea

daily) LITE TOUCH LANCETS MISC 1 QL(66667 ea

daily) LITE TOUCH LANCING PEN MISC 1

LITETOUCH LANCETS MICRO THIN 33G MISC 1 QL(66667 ea

daily) LIVE BETTER ADVANCED LANCING DEVICE MISC 1

LIVE BETTER LANCET SUPERTHIN 30G MISC 1 QL(66667 ea

daily) LIVE BETTER LANCET ULTRATHIN 28G MISC 1 QL(66667 ea

daily) LONGS LANCETS STANDARD MISC 1 QL(66667 ea

daily) LONGS LANCETS THIN MISC 1 QL(66667 ea

daily) LONGS LANCETS ULTRA THIN MISC 1 QL(66667 ea

daily) MEDICHOICE PRE-SET SAFETY LANCET DUAL USE MISC

1 QL(66667 eadaily)

MEDICHOICE PRE-SET SAFETY LANCET LOW FLOW MISC

1 QL(66667 eadaily)

MEDICHOICE PRE-SET SAFETY LANCET MEDIUM FLOW MISC

1 QL(66667 eadaily)

MEDICHOICE PRE-SET SAFETY LANCET MODERATE FLOW MISC

1 QL(66667 eadaily)

MEDICHOICE SAFETY LANCETEXTRA MISC 1 QL(66667 ea

daily) MEDICHOICE SAFETY LANCETNORMAL MISC 1 QL(66667 ea

daily) MEDISENSE THIN LANCETS MISC 1 QL(66667 ea

daily) MEDLANCE PLUS EXTRA LANCETS 21G MISC 1 QL(66667 ea

daily)


83

Drug Name DrugTier

RequirementsLimits

MEDLANCE PLUS LANCETS LITE 25G MISC 1 QL(66667 ea

daily) MEDLANCE PLUS LANCETS MISC 1 QL(66667 ea

daily) MEDLANCE PLUS LITE LANCETS 25G MISC 1 QL(66667 ea

daily) MEDLANCE PLUS SPECIAL LANCETS 08MM MISC

1 QL(66667 eadaily)

MEDLANCE PLUS SUPERLITE 30G MISC 1 QL(66667 ea

daily) MEDLANCE PLUS SUPERLITE 30GCOMFORT MAXMISC

1

QL(66667 eadaily)

MEDLANCE PLUS UNIVERSAL LANCETS 21G MISC

1 QL(66667 eadaily)

MEDLANCE PLUSLITE25G MISC 1 QL(66667 ea

daily)

MEDLANCEEXTRA MISC 1 QL(66667 eadaily)

MEDLANCELITE MISC 1 QL(66667 eadaily)

MEDLANCEUNIVERSALMISC 1 QL(66667 ea

daily) MEIJER COLOR LANCETS UNIVERSAL 33G MISC

1 QL(66667 eadaily)

MEIJER LANCETS MISC 1 QL(66667 eadaily)

MEIJER LANCETS THIN MISC 1 QL(66667 ea

daily) MEIJER LANCETS UNIVERSAL21G MISC 1 QL(66667 ea



daily) MEIJER SUPER THIN LANCETS MISC 1 QL(66667 ea

daily) MICROLET LANCETS MISC 1 QL(66667 ea

daily)

MICROLET NEXT MISC 1

Drug Name DrugTier

RequirementsLimits

MINI LANCING DEVICE MISC 1

MM LANCING DEVICE MISC 1

MM TWIST LANCETS MISC 1 QL(66667 ea

daily) MONOLET LANCETS MISC 1 QL(66667 ea

daily) MONOLET OPD LANCETS MISC 1 QL(66667 ea

daily) MONOLETTOR SAFETY LANCETS MISC 1 QL(66667 ea

daily) MPD SAFETY LANCET 21G18MM MISC 1 QL(66667 ea



daily) MPD SAFETY LANCETS 23G18MM MISC 1 QL(66667 ea

daily) MULTI-LANCET DEVICE MISC 1

MYGLUCOHEALTH MGH SOFTLANCE LANCETS 30G MISC

1 QL(66667 eadaily)

NOVA SAFETY LANCETS 23G MISC 1 QL(66667 ea

daily) NOVA SAFETY LANCETS 28G MISC 1 QL(66667 ea

daily) NOVA SUREFLEX LANCETS MISC 1 QL(66667 ea

daily) NOVA SUREFLEX LANCING DEVICE MISC 1

ON CALL LANCING DEVICE MISC 1

ON CALL PLUS LANCING DEVICE MISC 1

ONETOUCH CLUB LANCETS FINE POINT MISC

1 QL(66667 eadaily)

ONETOUCH DELICA LANCETS EXTRA FINE 33G MISC

1 QL(66667 eadaily)

ONETOUCH DELICA LANCETS FINE 30G MISC 1 QL(66667 ea

daily)


84

Drug Name DrugTier

RequirementsLimits

ONETOUCH DELICA LANCING DEVICE MISC 1

ONETOUCH DELICA PLUS LANCETS EXTRA FINE 33G MISC

1 QL(66667 eadaily)

ONETOUCH DELICA PLUS LANCETS FINE 30G MISC

1 QL(66667 eadaily)

ONETOUCH DELICA PLUS LANCING DEVICE MISC

1

ONETOUCH DELICA SAFETY LANCING DEVICE MISC

1

ONETOUCH FINEPOINT LANCETS MISC 1 QL(66667 ea

daily) ONETOUCH ULTRASOFT LANCETS MISC 1 QL(66667 ea

daily) PC LANCETS SUPER THIN 30G MISC 1 QL(66667 ea

daily) PERFECT LANCETS 30G MISC 1 QL(66667 ea

daily) PERFECT PRESSURE ACTIVATED SAFETY LANCETS 28G MISC

1 QL(66667 eadaily)

PHARMACY COUNTER LANCETS MISC 1 QL(66667 ea

daily)

PIP LANCETS28G MISC 1 QL(66667 eadaily)


PRECISION THINS GP LANCET MISC 1 QL(66667 ea

daily) PREFERRED PLUS LANCETS COLORED 21G MISC

1 QL(66667 eadaily)

PREFERRED PLUS LANCETS SUPER THIN 30G MISC

1 QL(66667 eadaily)

PREFERRED PLUS LANCETS THIN 26G MISC 1 QL(66667 ea

daily) PRESSURE ACTIVATED SAFETYLANCET 21G MISC

1 QL(66667 eadaily)

PRODIGY LANCING DEVICE MISC 1

Drug Name DrugTier

RequirementsLimits

PRODIGY PRESSURE ACTIVATED SAFETY LANCETS MISC

1 QL(66667 eadaily)

PRODIGY SAFETY LANCETS MISC 1 QL(66667 ea

daily) PRODIGY TWIST TOP LANCETS MISC 1 QL(66667 ea

daily) PSS SELECT GP LANCETS MISC 1 QL(66667 ea

daily) PSS SELECT SAFETY LANCETS MISC 1 QL(66667 ea

daily) PUSH BUTTON SAFETY LANCETS 21G MISC 1 QL(66667 ea


daily) PX ADVANCED LANCING DEVICE MISC 1

PX LANCET AUTO INJECTOR MISC 1

PX LANCETS ULTRA THIN 28G MISC 1 QL(66667 ea

daily) PX LANCETS ULTRA THIN MISC 1 QL(66667 ea

daily) QC ADVANCED LANCING DEVICE MISC 1

QC LANCETS SUPER THIN MISC 1 QL(66667 ea

daily) QC LANCETS ULTRA THIN MISC 1 QL(66667 ea

daily) QC UNILET LANCETS 28GULTRA THIN MISC 1 QL(66667 ea

daily) QC UNILET LANCETS 33GMICRO THIN MISC 1 QL(66667 ea

daily) RA E-ZJECT LANCETS 28G MISC 1 QL(66667 ea

daily) RA E-ZJECT LANCETS THIN 26G MISC 1 QL(66667 ea


daily) RA E-ZJECT LANCETS ULTRATHIN 30G MISC 1 QL(66667 ea

daily) READYLANCE SAFETY LANCETS21G22MMMISC

1 QL(66667 eadaily)


85

Drug Name DrugTier

RequirementsLimits

READYLANCE SAFETY LANCETS23G18MMMISC

1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)

REALITY LANCETS MISC 1 QL(66667 eadaily)

REALITY TRIGGER LANCETS MISC 1 QL(66667 ea

daily) RELION 2-IN-1 LANCET DEVICES 30G MISC 1

RELION 2-IN-1 LANCING DEVICE 25G MISC 1


RELION LANCETS MICRO-THIN33G MISC 1 QL(66667 ea

daily) RELION LANCETS THIN 26G MISC 1 QL(66667 ea

daily) RELION LANCETS ULTRA-THIN30G MISC 1 QL(66667 ea

daily) RELION LANCING DEVICE MISC 1

RELION ULTRA THIN LANCETS30G MISC 1 QL(66667 ea

daily) RELION ULTRA THIN LANCETS30G MISC 1 QL(66667 ea

daily) RELION ULTRA THIN PLUS LANCETS 32G MISC

1 QL(66667 eadaily)

RELION ULTRA THIN PLUS LANCETS 33G MISC

1 QL(66667 eadaily)

REXALL LANCETS ULTRA THIN MISC 1 QL(66667 ea

daily) RIGHTEST GD500 LANCING DEVICE MISC 1

RIGHTEST GL300 LANCETS MISC 1 QL(66667 ea

daily)

Drug Name DrugTier

RequirementsLimits

SAFE-T-LANCE LOW FLOW 25G MISC 1 QL(66667 ea

daily) SAFE-T-LANCE NORMAL FLOW21G MISC 1 QL(66667 ea

daily) SAFE-T-LANCE PLUS SAFETYLANCET HIGH FLOW MISC

1 QL(66667 eadaily)

SAFE-T-LANCE PLUS SAFETYLANCET LOW FLOW MISC

1 QL(66667 eadaily)

SAFE-T-LANCE PLUS SAFETYLANCET NORMAL FLOW MISC

1 QL(66667 eadaily)

SAFETY LANCET 21GPRESSUREACTIVATED MISC

1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)

SAFETY LANCETS 21G MISC 1 QL(66667 ea

daily) SAFETY LANCETS 28G MISC 1 QL(66667 ea

daily) SAFETY LET LANCETS MISC 1 QL(66667 ea

daily)

SB LANCETS THIN MISC 1 QL(66667 eadaily)

SB LANCETS ULTRA THIN MISC 1 QL(66667 ea

daily) SELECT-LITE LANCING DEVICE MISC 1

SHOPKO AUTOLET LANCING DEVICE MISC 1

SHOPKO ON-THE-GO COMFORTLANCETS 30G MISC

1 QL(66667 eadaily)

SHOPKO UNILET LANCETS SUPER THIN 30G MISC

1 QL(66667 eadaily)

SHOPKO UNILET LANCETS ULTRA THIN 28G MISC

1 QL(66667 eadaily)

SIDE BUTTON SAFETY LANCET21G MISC 1 QL(66667 ea

daily)


86

Drug Name DrugTier

RequirementsLimits

SIMPLE DIAGNOSTICS LANCING DEVICE MISC 1

SINGLE-LET MISC 1 QL(66667 eadaily)

SM MICRO THIN LANCETS 33G MISC 1 QL(66667 ea

daily) SM TRUEDRAW LANCING DEVICE MISC 1

SMART DIABETES VANTAGE LANCING DEVICE MISC

1

SMART SENSE COLOR LANCETS UNIVERSAL 33G MISC

1 QL(66667 eadaily)

SMART SENSE STANDARD LANCETS UNIVERSAL 21G MISC

1 QL(66667 eadaily)

SMART SENSE SUPER THIN LANCETS UNIVERSAL 30G MISC

1 QL(66667 eadaily)

SMART SENSE THIN LANCETSUNIVERSAL 26G MISC

1 QL(66667 eadaily)

SMARTEST LANCETS 28G MISC 1 QL(66667 ea

daily) SOLUS V2 LANCING DEVICE MISC 1

SOLUS V2 PRESSURE ACTIVATED SAFETY LANCETS 28G MISC

1 QL(66667 eadaily)

SOLUS V2 TWIST LANCETS 30G MISC 1 QL(66667 ea

daily)

STERILANCE TL MISC 1 QL(66667 eadaily)

SUPER THIN LANCETS MISC 1 QL(66667 ea

daily) SURE COMFORT LANCETS 18G MISC 1 QL(66667 ea





daily)

Drug Name DrugTier

RequirementsLimits

SURE COMFORT LANCING PEN MISC 1

SURE-LANCE FLAT LANCETS MISC 1 QL(66667 ea

daily) SURE-LANCE LANCETS 26G MISC 1 QL(66667 ea

daily) SURE-LANCE THIN LANCETS 28G MISC 1 QL(66667 ea

daily) SURE-LANCE ULTRA THIN LANCETS MISC 1 QL(66667 ea

daily)

SURE-PEN MISC 1

SURE-TOUCH LANCETS UNIVERSAL MISC 1 QL(66667 ea

daily) SURELITE LANCETS MISC 1 QL(66667 ea

daily) TECHLITE AST LANCETS MISC 1 QL(66667 ea

daily) TECHLITE LANCETS 30G MISC 1 QL(66667 ea

daily) TECHLITE LANCETS MISC 1 QL(66667 ea

daily) TGT LANCET MICRO THIN 33G MISC 1 QL(66667 ea

daily) TGT LANCET THIN 26G MISC 1 QL(66667 ea

daily) TGT LANCET ULTRA THIN 30G MISC 1 QL(66667 ea

daily) TGT LANCING DEVICE MISC 1

THINLETS GP LANCETS MISC 1 QL(66667 ea

daily) TODAYS HEALTH ADVANCED LANCING DEVICE MISC

1

TODAYS HEALTH SUPER THINLANCETS 30G MISC 1 QL(66667 ea

daily) TODAYS HEALTH ULTRA THINLANCETS 28G MISC 1 QL(66667 ea

daily) TOPCARE LANCETS MICRO-THIN 33G MISC 1 QL(66667 ea

daily) TRAVEL LANCETS 30G MISC 1 QL(66667 ea

daily) TRAVEL LANCETS ADVANCED 28G MISC 1 QL(66667 ea

daily)


87

Drug Name DrugTier

RequirementsLimits

TRUE METRIX CONTROL SOLUTION LEVEL 3 SOLN

1

TRUEDRAW LANCING DEVICE MISC 1

TRUEPLUS LANCETS 26G MISC 1 QL(66667 ea

daily) TRUEPLUS LANCETS 28G MISC 1 QL(66667 ea

daily) TRUEPLUS LANCETS 28G SUPER THIN MISC 1 QL(66667 ea


daily) TRUEPLUS LANCETS 30G ULTRA THIN MISC 1 QL(66667 ea

daily) TRUEPLUS LANCETS 33G MICRO THIN MISC 1 QL(66667 ea


daily) TRUEPLUS SAFETY LANCETS 28G MISC 1 QL(66667 ea

daily) ULTI-LANCE AUTOMATICCLEAR TIP MISC 1

ULTILET CLASSIC LANCETS MISC 1 QL(66667 ea

daily) ULTILET LANCETS 33G MISC 1 QL(66667 ea

daily)

ULTILET LANCETS MISC 1 QL(66667 eadaily)

ULTILET SAFETY LANCETS 21G X 22MM MISC

1 QL(66667 eadaily)

ULTILET SAFETY LANCETS 23G MISC 1 QL(66667 ea

daily) ULTRA THIN LANCETS 31G MISC 1 QL(66667 ea

daily) ULTRA-THIN II AUTO LANCET MISC 1 QL(66667 ea

daily) ULTRA-THIN II LANCETS 28G MISC 1 QL(66667 ea


daily) UNILET COMFORTOUCH LANCET MISC 1 QL(66667 ea

daily)

UNILET EXCELITE II MISC 1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits

UNILET EXCELITE MISC 1 QL(66667 eadaily)

UNILET GP LANCET MISC 1 QL(66667 ea

daily) UNILET GP SUPERLITE LANCET MISC 1 QL(66667 ea

daily) UNILET GP 28 ULTRA THIN MISC 1 QL(66667 ea

daily)

UNILET LANCET MISC 1 QL(66667 eadaily)

UNILET LANCETS MICRO-THIN33G MISC 1 QL(66667 ea

daily) UNILET LANCETS SUPER-THIN30G MISC 1 QL(66667 ea

daily) UNILET LANCETS ULTRA-THIN 28G MISC 1 QL(66667 ea

daily) UNILET SUPERLITE LANCET MISC 1 QL(66667 ea

daily)

UNISTIK 3 GENTLE MISC 1 QL(66667 eadaily)

UNISTIK PRO SAFETY LANCET 21G MISC 1 QL(66667 ea

daily) UNISTIK PRO SAFETY LANCET 25G MISC 1 QL(66667 ea


daily) UNISTIK SAFETY LANCETS 28G MISC 1 QL(66667 ea


daily) UNISTIK TOUCH SAFETY LANCETS 21G MISC 1 QL(66667 ea




daily) UNIVERSAL 1 LANCETS THIN26G MISC 1 QL(66667 ea

daily) UNIVERSAL 1 LANCETS ULTRA THIN 30G MISC 1 QL(66667 ea

daily) UNIVERSAL 1 LANCETS33GMICRO-THIN MISC

1 QL(66667 eadaily)


88

Drug Name DrugTier

RequirementsLimits

VALUE PLUS LANCETS STANDARD 21G MISC 1 QL(66667 ea

daily) VALUE PLUS LANCETS SUPERTHIN 30G MISC 1 QL(66667 ea

daily) VALUE PLUS LANCETS THIN 26G MISC 1 QL(66667 ea

daily) VALUE PLUS LANCING DEVICE MISC 1

VALUMARK LANCET SUPER THIN 30G MISC 1 QL(66667 ea

daily) VALUMARK LANCET ULTRA THIN 28G MISC 1 QL(66667 ea

daily) VIDA MIA AUTOLET LANCINGDEVICE MISC 1

VIDA MIA UNILET LANCETS SUPER THIN 30G MISC

1 QL(66667 eadaily)

VIDA MIA UNILET LANCETS ULTRA THIN 28G MISC

1 QL(66667 eadaily)

VIVAGUARD LANCETS MISC 1 QL(66667 ea

daily) VIVAGUARD LANCING DEVICE MISC 1

WALGREENS ADVANCED TRAVELLANCETS 28G MISC

1 QL(66667 eadaily)

WALGREENS COMFORT ASSUREDLANCETS MICRO THIN33G MISC

1 QL(66667 eadaily)

WALGREENS COMFORT ASSUREDLANCETS SUPER THIN28G MISC

1 QL(66667 eadaily)

WALGREENS LANCETS MISC 1 QL(66667 ea

daily) WALGREENS THIN LANCETS MISC 1 QL(66667 ea

daily) WALGREENS ULTRA THIN LANCETS MISC 1 QL(66667 ea

daily) Parenteral Therapy Supplies ADVOCATE INSULIN SYRINGEU-10003ML29GX12 MISC

1 QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

ADVOCATE INSULIN SYRINGEU-10003ML30GX516MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

ADVOCATE INSULIN SYRINGEU-10005ML29GX12 MISC



1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)

ASSURE ID INSULIN SAFETYSYRINGEU-10005ML29G X 12MISC

1

QL(5 ea daily)RXOTC

ASSURE ID INSULIN SAFETYSYRINGEU-1001ML29G X 12 MISC


B-D INSULIN SYRINGE ULTRAFINE II03ML31GX 516 MISC

1 QL(5 ea daily)


1 QL(5 ea daily)

B-D INSULIN SYRINGE ULTRAFINE II1ML31G X516 MISC

1 QL(5 ea daily)

B-D INSULIN SYRINGE ULTRAFINE03ML30G X12 MISC

1 QL(5 ea daily)


89

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)

BD LO-DOSE INSULIN SYRINGE MICROFINE IV05ML28G X 12 MISC


BD AUTOSHIELD 29G X 316 MISC 1 QL(5 ea daily)


BD AUTOSHIELD DUO 30G X 5MM MISC 1 QL(5 ea daily)

BD INSULIN SYRINGE LUER-LOKU-1001MLMISC


BD INSULIN SYRINGE MICROFINE IVU-10005ML28G X 12MISC

1

QL(5 ea daily)RXOTC

BD INSULIN SYRINGE MICROFINE IVU-1001ML27G X 58 MISC

1 QL(5 ea daily)



BD INSULIN SYRINGE MICROFINEU-1001ML27G X 58 MISC

1 QL(5 ea daily)



BD INSULIN SYRINGE SAFETYGLIDE1ML29G X12 MISC


BD INSULIN SYRINGE SLIP TIPU-1001ML MISC 1 QL(5 ea daily)

RXOTC BD INSULIN SYRINGE ULTRA-FINE03ML30G X127MM MISC

1 QL(5 ea daily)

BD INSULIN SYRINGE ULTRA-FINE03ML31G X8MM MISC

1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)

BD INSULIN SYRINGE ULTRA-FINE12UNIT03ML31G X 8MMMISC

1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE HALF-UNIT03ML31G X 516MISC

1

QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINE03ML30G X12 MISC

1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)

BD INSULIN SYRINGE ULTRAFINEU-10003ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

BD INSULIN SYRINGE ULTRAFINEU-1001ML29G X 12 MISC



1

QL(5 ea daily)


90

Drug Name DrugTier

RequirementsLimits

BD INSULIN SYRINGE03ML29G X127MM MISC








BD INSULIN SYRINGEDETACHABLENEEDLEU-1001ML25GX 1 MISC

1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)

BD INSULIN SYRINGEU-1001ML27G X 12 MISC 1 QL(5 ea daily)

RXOTC BD PEN NEEDLEMICROULTRA-FINE32G X 6MM MISC

1 QL(5 ea daily)

BD PEN NEEDLEMINIULTRA-FINE31G X 5MM MISC


BD PEN NEEDLENANO2ND GEN32G X 532MISC


BD PEN NEEDLENANOULTRA-FINE32G X 4MM MISC


BD PEN NEEDLEORIGINALULTRA-FINE29G X 127MMMISC

1

QL(5 ea daily)

BD PEN NEEDLESHORTULTRA-FINE31G X 8MM MISC


Drug Name DrugTier

RequirementsLimits

BD SAFETY-GLIDE INSULIN SYRINGE05ML29G X12 MISC

1

QL(5 ea daily)RXOTC

BD SAFETY-LOK INSULIN SYRINGEPERMNEEDLEUF1ML29G X12 MISC

1

QL(5 ea daily)RXOTC

BD SAFETYGLIDE INSULIN SYRINGE03ML29G X12 MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)

BD SAFETYGLIDE INSULIN SYSYRINGE05ML30G X516 MISC

1

QL(5 ea daily)RXOTC

BD VEO INSULIN SYRINGE ULTRA-FINE1ML31G X 6MMMISC

1

QL(5 ea daily)

BD VEO INSULIN SYRINGE ULTRA-FINEU-1001ML31G X 1564MISC

1

QL(5 ea daily)

CAREONE INSULIN SYRINGES03ML30G X12 MISC

1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


91

Drug Name DrugTier

RequirementsLimits

CAREONE INSULIN SYRINGES1ML31GX516 MISC

1 QL(5 ea daily)

CARETOUCH INSULIN SYRINGE03ML31GX516 MISC

1 QL(5 ea daily)


1 QL(5 ea daily)

CARETOUCH INSULIN SYRINGE1ML30GX516MISC



1 QL(5 ea daily)



CLEVER CHOICE COMFORT EZINSULIN SYRINGE03ML29G X12 MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)

CLEVER CHOICE COMFORT EZINSULIN SYRINGE1ML28G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

CLEVER CHOICE COMFORT EZINSULIN SYRINGEU-1001ML31GX516 MISC

1

QL(5 ea daily)

COMFORT ASSIST INSULIN SYRINGE 03ML29G X 12 MISC


COMFORT ASSIST INSULIN SYRINGE03ML30G X516 MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


92

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)

COMFORT ASSIST INSULIN SYRINGE1ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

COMFORT EZ INSULIN SYRINGEU-10005ML31G X 516MISC

1

QL(5 ea daily)

COMFORT EZ INSULIN SYRINGEU-1001ML31GX 516 MISC

1 QL(5 ea daily)

DROPLET INSULIN SYRINGE 03ML29G X12 MISC




DROPLET INSULIN SYRINGE 1ML29G X 12MISC


DROPLET INSULIN SYRINGE U-1000331GX 516 MISC

1 QL(5 ea daily)

DROPLET INSULIN SYRINGE U-10003ML30G X 12MISC

1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

DROPLET INSULIN SYRINGE U-1001ML30GX 12 MISC

1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)

DROPLET INSULIN SYRINGEU-10003ML31G X 516MISC

1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)

DROPLET INSULIN SYRINGEU-1001ML30GX 12 MISC

1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)

EASY COMFORT INSULIN SYRINGE05ML30G X516 MISC



1 QL(5 ea daily)


93

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)

EASY COMFORT INSULIN SYRINGEU-10005ML30G X 12MISC

1

QL(5 ea daily)

EASY COMFORT INSULIN SYRINGEU-1001ML30GX 12 MISC

1 QL(5 ea daily)

EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML29GX12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

EASY TOUCH INSULIN SYRINGE03ML30G X516 MISC



1 QL(5 ea daily)







EASY TOUCH INSULIN SYRINGESAFETYU-10005ML29G X 12MISC

1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC

EASY TOUCH INSULIN SYRINGESAFETYU-1001ML29G X 12 MISC



1 QL(5 ea daily)

EASY TOUCH INSULIN SYRINGEU-10003ML30G X 12MISC

1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)

EASY TOUCH INSULIN SYRINGEU-1001ML27GX 12 MISC







1 QL(5 ea daily)


94

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)

EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML29GX12 MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

EASY TOUCH SHEATHLOCK SAFETY SYRINGE 1ML30GX12MISC

1

QL(5 ea daily)

ELITE-THIN INSULIN SYRINGE03ML31G X516 MISC

1 QL(5 ea daily)







ELITE-THIN INSULIN SYRINGEU-10005ML28G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

ELITE-THIN INSULIN SYRINGEU-1001ML28GX 12 MISC





1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

EQL INSULIN SYRINGE03ML29G X12 MISC





1 QL(5 ea daily)






1 QL(5 ea daily)

EQL INSULIN SYRINGE1ML29G X 12MISC





1 QL(5 ea daily)

EXEL COMFORT POINT INSULIN SYRINGE03ML29G X12 MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


95

Drug Name DrugTier

RequirementsLimits

EXEL COMFORT POINT INSULIN SYRINGE1ML28G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE03ML31G X516 MISC

1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)

FREESTYLE PRECISION INSULIN SYRINGEU-10005ML30G X 516MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)

FREESTYLE PRECISION INSULIN SYRINGESU-1001ML30G X 516MISC

1

QL(5 ea daily)RXOTC

GLOBAL EASY GLIDE INSULIN SYRINGE1ML31G X1564 MISC

1

QL(5 ea daily)

GLOBAL EASY GLIDE INSULINSYRINGEU-10003ML31G X 516MISC

1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

GLOBAL INJECT EASE INSULIN SYRINGEU-10003ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

GLOBAL INJECT EASE INSULIN SYRINGEU-1001ML28G X 12 MISC





1 QL(5 ea daily)


96

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

GLOBAL INSULIN SYRINGEU-10003ML30G X 12MISC

1

QL(5 ea daily)

GLOBAL INSULIN SYRINGESU-10003ML30GX516MISC

1

QL(5 ea daily)RXOTC

GLUCOPRO INSULIN SYRINGEU-10003ML30G X 12MISC

1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

GLUCOPRO INSULIN SYRINGEU-1001ML30GX 12 MISC

1 QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)

GNP INSULIN SYRINGE03ML29G X12 MISC





1 QL(5 ea daily)








1 QL(5 ea daily)

GNP INSULIN SYRINGE1ML28G X 12MISC







1 QL(5 ea daily)

GNP INSULIN SYRINGES03ML30GX516 MISC




GNP INSULIN SYRINGES1ML28GX12MISC





97

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)

GNP ULTRA COMFORT INSULIN SYRINGE03ML29G X12 MISC

1

QL(5 ea daily)RXOTC

GNP ULTRA COMFORT INSULIN SYRINGE03ML30G X516 SHORT MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

GNP ULTRA COMFORT INSULIN SYRINGE1ML28G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

HEALTHWISE INSULIN SYRINGEU-10003ML30G X 516MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

HEALTHWISE INSULIN SYRINGEU-1001ML30GX 516 MISC



1 QL(5 ea daily)

HM ULTICARE INSULIN SYRINGE1ML30G X 12MISC

1 QL(5 ea daily)

HM ULTICARE INSULIN SYRINGEU-10003ML31G X 516MISC

1

QL(5 ea daily)

INSULIN SYRINGE03ML29G X 1MISC

1 QL(5 ea daily)

INSULIN SYRINGE03ML29G X12 MISC





1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)






98

Drug Name DrugTier

RequirementsLimits



INSULIN SYRINGENEEDLE03ML30G X 516 MISC



1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)

INSULIN SYRINGEU-10003ML29G X 12MISC




INSULIN SYRINGEU-1001ML29G X 12 MISC 1 QL(5 ea daily)

RXOTC INSULIN SYRINGEU-1001ML30G X 516MISC

1 QL(5 ea daily)




1 QL(5 ea daily)

INSULIN SYRINGES05ML27GX12 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits








1 QL(5 ea daily)


1 QL(5 ea daily)

INSULIN SYRINGES1ML27GX12MISC









1 QL(5 ea daily)


1 QL(5 ea daily)

KINRAY INSULIN SYRINGE PREFERRED PLUS03ML31G X 516MISC

1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)

KINRAY INSULIN SYRINGE05ML29G X12 MISC



99

Drug Name DrugTier

RequirementsLimits

KMART VALU PLUS INSULIN SYRINGE1ML29G MISC




KROGER INSULIN SYRINGE03ML29G X12 MISC





1 QL(5 ea daily)






1 QL(5 ea daily)

KROGER INSULIN SYRINGE1ML29G X 12MISC





1 QL(5 ea daily)

LEADER INSULIN SYRINGE03ML29G X12 MISC





1 QL(5 ea daily)





Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)

LEADER INSULIN SYRINGE1ML28G X 12MISC







1 QL(5 ea daily)

LITETOUCH INSULIN SYRINGE03ML29G X12 MISC





1 QL(5 ea daily)




1 QL(5 ea daily)



LITETOUCH INSULIN SYRINGEU-10003ML30G X 516MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


100

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

LITETOUCH INSULIN SYRINGEU-1001ML28GX 12 MISC







1 QL(5 ea daily)

LONGS INSULIN SYRINGE05ML31G X516 MISC

1 QL(5 ea daily)

MAGELLAN INSULIN SAFETY SYRINGEU-10003ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

MAGELLAN INSULIN SAFETY SYRINGEU-1001ML29G X 12 MISC


Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC

MAXI-COMFORT INSULIN SYRINGEU-10005ML28GX12 MISC




MAXICOMFORT INSULIN SYRINGES 27G X 12MISC

1 QL(5 ea daily)



MEDIC INSULIN SYRINGE03ML30G X516 MISC




MM INSULIN SYRINGEU-10003ML30G X 516MISC



1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)

MONOJECT INSULIN SYRINGE1ML MISC 1 QL(5 ea daily)

RXOTC MONOJECT INSULIN SYRINGE1ML31G X516 MISC

1 QL(5 ea daily)


101

Drug Name DrugTier

RequirementsLimits

MONOJECT INSULIN SYRINGEDETACHNEEDLE1ML25G X 58MISC

1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC

MONOJECT INSULIN SYRINGEPERMNEEDLE1ML28G X 12MISC

1

QL(5 ea daily)RXOTC

MONOJECT INSULIN SYRINGEPERMNEEDLEU-10005ML28GX 12 MISC

1

QL(5 ea daily)RXOTC

MONOJECT INSULIN SYRINGESAFETYPERMNEEDLE03ML29G X 12MISC

1

QL(5 ea daily)RXOTC

MONOJECT INSULIN SYRINGESAFETYPERMNEEDLE03ML29GX12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

MONOJECT INSULIN SYRINGESOFTPACK1ML27G X 12 MISC


MONOJECT INSULIN SYRINGESOFTPACKU-10005ML28G X 12MISC

1

QL(5 ea daily)RXOTC

MONOJECT INSULIN SYRINGEU-10003ML30G X 516MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

MONOJECT INSULIN SYRINGEU-1001ML28GX 12 MISC




MONOJECT INSULIN SYRINGEREGULAR LUER TIPSOFTPACK1ML MISC


MONOJECT ULTRA COMFORT INSULIN SYRINGE03ML29G X12 MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

MONOJECT ULTRA COMFORT INSULIN SYRINGE1ML28G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

MS INSULIN SYRINGE03ML31G X516 MISC

1 QL(5 ea daily)


102

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)

PRECISION SURE-DOSE INSULIN SYRINGE03ML30G X516 MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

PRECISION SURE-DOSE INSULIN SYRINGE1ML28G X 12MISC

1

QL(5 ea daily)RXOTC

PRECISION SURE-DOSE PLUSINSULIN SYRINGE03ML29G X12 MISC

1

QL(5 ea daily)RXOTC

PRECISION SURE-DOSE PLUSINSULIN SYRINGE1ML29G X 12MISC

1

QL(5 ea daily)RXOTC

PREFERRED PLUS INSULIN SYRINGEU-10003ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

PREFERRED PLUS INSULIN SYRINGEU-1001ML28G X 12 MISC





1

QL(5 ea daily)RXOTC

PRO COMFORT INSULIN SYRINGES05ML30G X12 MISC

1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)

PRODIGY INSULIN SYRINGU-10003ML31GX 516 MISC

1 QL(5 ea daily)

PRODIGY INSULIN SYRINGE12ML31G X516 MISC

1 QL(5 ea daily)

PRODIGY INSULIN SYRINGE1ML28G X 12MISC


PX INSULIN SYRINGEU-10005ML30G X 12MISC

1 QL(5 ea daily)


103

Drug Name DrugTier

RequirementsLimits

RA INSULIN SYRINGE05ML29G X12 MISC


RA INSULIN SYRINGE1ML29G X 12MISC


RA INSULIN SYRINGEU-10005ML30G X 516MISC


RA INSULIN SYRINGEU-1001 ML30G X 516MISC


REALITY INSULIN SYRINGEU-10005ML28G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

REALITY INSULIN SYRINGEU-1001ML28GX 12 MISC




RELION INSULIN SYRINGE 1ML31GX1564 MISC

1 QL(5 ea daily)

RELION INSULIN SYRINGEU-10003ML31G X 516MISC

1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

RELION INSULIN SYRINGEU-1001ML31GX 1564 MISC

1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits

SAFESNAP INSULIN SYRINGE03ML30G X516 MISC






SAFESNAP INSULIN SYRINGE1ML28G X 12MISC




SAFETY INSULIN SYRINGES 05ML29GX12 MISC




SAFETY INSULIN SYRINGES 1ML27GX12MISC





1 QL(5 ea daily)

SB INSULIN SYRINGEU-10005ML29G X 12MISC




SB INSULIN SYRINGEU-1001ML29G X 12 MISC 1 QL(5 ea daily)

RXOTC SB INSULIN SYRINGEU-1001ML30G X 516MISC



1 QL(5 ea daily)

SECURESAFE SAFETY INSULIN SYRINGESU-10005ML29GX12 MISC



104

Drug Name DrugTier

RequirementsLimits



SURE COMFORT INSULIN SYRINGEU-10003ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

SURE COMFORT INSULIN SYRINGEU-1001ML28G X 12 MISC


Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

SURE-JECT INSULIN SYRINGEU-10003ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

SURE-JECT INSULIN SYRINGEU-1001ML28GX 12 MISC





105

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)

TECHLITE INSULIN SYRINGEU-10003ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

TECHLITE INSULIN SYRINGEU-1001ML29GX 12 MISC



1 QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)

TOPCARE ULTRA COMFORT INSULIN SYRINGE03ML30G X516 MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

TOPCARE ULTRA COMFORT INSULIN SYRINGEU-10003ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

TOPCARE ULTRA COMFORT INSULIN SYRINGEU-1001ML29GX 12 MISC

1

QL(5 ea daily)RXOTC

TRUE COMFORT INSULIN SYRINGE05ML31G X516 MISC

1 QL(5 ea daily)


106

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)

TRUE COMFORT PRO INSULINSYRINGE05ML30G X 516 MISC



1 QL(5 ea daily)




1 QL(5 ea daily)

TRUE COMFORT PRO INSULINSYRINGEU-10005ML30G X 12MISC

1

QL(5 ea daily)

TRUE COMFORT PRO INSULINSYRINGEU-1001ML30G X 12 MISC

1 QL(5 ea daily)

TRUEPLUS INSULIN SYRINGEU-10003ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)

TRUEPLUS INSULIN SYRINGEU-1001ML28GX 12 MISC







1 QL(5 ea daily)

ULTICARE INSULIN SAFETY SYRINGE05ML29G X12 MISC

1

QL(5 ea daily)RXOTC

ULTICARE INSULIN SAFETY SYRINGE1ML29G X 12MISC

1

QL(5 ea daily)RXOTC

ULTICARE INSULIN SYRINGE03ML29G X12 MISC



1 QL(5 ea daily)








1 QL(5 ea daily)



ULTICARE INSULIN SYRINGE1ML28G X 12MISC



107

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)



ULTICARE INSULIN SYRINGESHORT03ML30G X 516 MISC



1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)

ULTICARE INSULIN SYRINGEU-10003ML30G X 12MISC

1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)

ULTICARE INSULIN SYRINGEU-1001ML30GX 12 MISC

1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)

ULTICARE INSULIN SYRINGEULTRAFINE U-10003ML31G X 516MISC

1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)

ULTIGUARD SAFEPACK INSULIN SYRINGE 03ML30G X 12SHARPSC MISC

1

QL(5 ea daily)

ULTIGUARD SAFEPACK INSULIN SYRINGE 12ML30G X 12SHARPS CMISC

1

QL(5 ea daily)

ULTIGUARD SAFEPACK INSULIN SYRINGE 1ML 30G X 12SHARPS CONMISC

1

QL(5 ea daily)

ULTIGUARD SAFEPACK INSULIN SYRINGE 1ML 31G X 516SHARPS COMISC

1

QL(5 ea daily)

ULTIGUARD SAFEPACK INSULIN SYRINGE03ML30G X12SHARPS C MISC

1

QL(5 ea daily)

ULTIGUARD SAFEPACK INSULIN SYRINGE03ML31G X516SHARPS MISC

1

QL(5 ea daily)


1

QL(5 ea daily)

ULTIGUARD SAFEPACKSYRINGENEEDLE31G X516SHARPS CONTAINMISC

1

QL(5 ea daily)


108

Drug Name DrugTier

RequirementsLimits

ULTILET INSULIN SYRINGE03ML30G X8MM MISC



1 QL(5 ea daily)






1 QL(5 ea daily)

ULTILET INSULIN SYRINGESHORT03ML30G X 127MM MISC

1 QL(5 ea daily)

ULTILET INSULIN SYRINGESHORT03ML30G X 516 MISC



1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)

ULTILET INSULIN SYRINGEU-10005ML30G X 12MISC

1

QL(5 ea daily)

ULTILET INSULIN SYRINGEU-1001ML30GX 12 MISC

1 QL(5 ea daily)

ULTRA COMFORT INSULIN SYRINGEU-10003ML30G X 516MISC

1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

ULTRA FLO INSULIN SYRINGE 03ML29G X12 MISC


ULTRA FLO INSULIN SYRINGE 03ML30GX12MISC

1 QL(5 ea daily)

ULTRA FLO INSULIN SYRINGE 03ML30GX516 MISC



1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)

ULTRA FLO INSULIN SYRINGE 12UNIT03ML30GX12MISC

1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

ULTRA FLO INSULIN SYRINGE 1M29GX12MISC



1 QL(5 ea daily)




1 QL(5 ea daily)


109

Drug Name DrugTier

RequirementsLimits

ULTRA-COMFORT INSULIN SYRINGEU-10003ML29G X 12MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

ULTRA-COMFORT INSULIN SYRINGEU-1001ML28G X 12 MISC





1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

ULTRA-THIN II INSULIN SYRINGE SHORTU-10003ML30GX516MISC

1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

ULTRA-THIN II INSULIN SYRINGE SHORTU-1001ML30GX516 MISC



1 QL(5 ea daily)

ULTRA-THIN II INSULIN SYRINGEU-10005ML29GX12 MISC




ULTRACARE INSULIN SYRINGEU-10003ML30G X 516MISC

1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

ULTRACARE INSULIN SYRINGEU-1001ML30GX 12 MISC

1 QL(5 ea daily)


110

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)

VALUE HEALTH INSULIN SYRINGEU-10005ML29G X 12MISC

1

QL(5 ea daily)RXOTC

VALUE HEALTH INSULIN SYRINGEU-1001ML29GX 12 MISC


VANISHPOINT INSULIN SYRINGE05ML30G X12 MISC

1 QL(5 ea daily)



VANISHPOINT INSULIN SYRINGE1ML29G X 12MISC




VP INSULIN SYRINGEU-10003ML29G X 12MISC


ZEVRX INSULIN SYRINGE05ML30G X12 MISC

1 QL(5 ea daily)



ZEVRX INSULIN SYRINGE1ML30G X 12MISC

1 QL(5 ea daily)



MIGRAINE PRODUCTS - Drugs to Treat MigraineHeadaches

Calcitonin Gene-Related Peptide (CGRP)

AIMOVIG SOAJ 2 PA QL(004 mldaily)

EMGALITY SOAJ 120 MGML 2 PA QL(007 ml

daily)

Drug Name DrugTier

RequirementsLimits

EMGALITY SOSY 100 MGML 3 PA QL(01 ml

daily) EMGALITY SOSY 120 MGML 2 PA QL(007 ml

daily) Migraine Combinations CAFERGOT TABS (Use ergotamine w caffeine) NF

ergotamine w caffeine tabsor 1 mg-100 mg 1

sumatriptan-naproxensodium tabs 3


TREXIMET TABS (Use sumatriptan-naproxensodium)

NF


Migraine Products DHE 45 SOLN (Use dihydroergotaminemesylate)

NF

dihydroergotaminemesylate soln ij 1 mgml 1

dihydroergotaminemesylate soln na 4 mgml 1 PA QL(0267

ml daily) dihydroergotaminemesylate soln na 4 mgml 1 QL(0267 ml

daily)

ERGOMAR SUBL 3 QL(0667 eadaily)

MIGRANAL SOLN (Use dihydroergotaminemesylate)

NF QL(0267 mldaily)

Serotonin Agonists

almotriptan malate tabs125 mg 1




AMERGE TABS (Use naratriptan hcl) NF

QL(03 eadaily) AL(Atleast 18 yrsold)


111

Drug Name DrugTier

RequirementsLimits

eletriptan hydrobromidetabs 1


FROVA TABS (Use frovatriptan succinate) NF


frovatriptan succinate tabs 1


IMITREX SOLN NA 20 MGACT 5 MGACT (Use sumatriptan)

NF


IMITREX SOLN SC 6 MG05ML (Use sumatriptan succinate)

NF

QL(0134 mldaily) AL(Atleast 18 yrsold)

IMITREX STATDOSE REFILL SOCT (Use sumatriptan succinate)

NF


IMITREX STATDOSE SYSTEM SOAJ (Use sumatriptan succinate)

NF


IMITREX TABS OR 100 MG 25 MG 50 MG (Use sumatriptan succinate)

NF


MAXALT TABS (Use rizatriptan benzoate) NF

QL(06 eadaily) AL(Atleast 6 yrs old)

MAXALT-MLT TBDP (Use rizatriptan benzoate) NF


naratriptan hcl tabs 1


RELPAX TABS (Use eletriptan hydrobromide) NF


Drug Name DrugTier

RequirementsLimits

rizatriptan benzoate tabs10 mg 1


rizatriptan benzoate tabs 5 mg 1


rizatriptan benzoate tbdp10 mg 1


rizatriptan benzoate tbdp 5 mg 1


sumatriptan soln 1


sumatriptan succinate soajsc 6 mg05ml 4 mg05ml 1


sumatriptan succinate soctsc 6 mg05ml 4 mg05ml 1


sumatriptan succinate solnsc 6 mg05ml 1


sumatriptan succinate sosysc 6 mg05ml 1


sumatriptan succinate tabsor 100 mg 25 mg 50 mg 1


zolmitriptan soln na 25 mg5 mg 1


zolmitriptan tabs or 25 mg5 mg 1


zolmitriptan tbdp or 25 mg5 mg 1



112

Drug Name DrugTier

RequirementsLimits

ZOMIG SOLN NA 25 MG 5 MG (Use zolmitriptan) 3


ZOMIG TABS OR 25 MG 5 MG (Use zolmitriptan) NF


ZOMIG ZMT TBDP (Use zolmitriptan) NF


MINERALS amp ELECTROLYTES

Bicarbonates SODIUM ACETATE SOLN 2 MEQML (Use sodium acetate)

1

sodium acetate soln 2 meqml 4 meqml 1

Calcium calcium chloride (dihydrate)soln 1

CALCIUM GLUCONATE SOLN 1

calcium gluconate soln 1

Electrolyte Mixtures DEXTROSE 5NACL03 SOLN (Use dextrose w sodium chloride)

NF

dextrose in lactated ringerssoln 1

DEXTROSESODIUMCHLORIDE SOLN (Use dextrose w sodiumchloride)

NF

IONOSOL-MBDEXTROSE5 SOLN 3 MEQL-3MEQL-5 -20 MEQL-22MEQL-23 MEQL-25MEQL 3 MEQL-3MMOLEL-5 -20 MEQL-22 MEQL-23 MEQL-25MEQL

1

ISOLYTE-PDEXTROSE5 SOLN 1

Drug Name DrugTier

RequirementsLimits

ISOLYTE-S SOLN 1

KCL 03D5WNACL09 SOLN 1

lactated ringers soln 109meql-3 meql-4 meql-28meql-130 meql 20mg100ml-30 mg100ml-310 mg100ml-600mg100ml 3 meql-130meql-4 meql-28 meql-109meql 3 meql-4 meql-28meql-109 meql-130 meql

1

NORMOSOL-M IN D5W SOLN 1

NORMOSOL-MD5WSOLN 1

NORMOSOL-R SOLN 1

parenteral electrolytes conc 1

PLASMA-LYTE A SOLN 1

PLASMA-LYTE-148 SOLN 1

potassium chloride indextrose amp sodium chloride soln

1

potassium chloride indextrose soln 1

potassium chloride in naclsoln 015 -09 045 -20 meql

1

POTASSIUM CHLORIDEDEXTROSELACTATED RINGERS SOLN 27 MEQL-5 -24MEQL-28 MEQL-129MEQL-130 MEQL 3MEQL-5 -24 MEQL-28MEQL-130 MEQL-149MEQL

1

POTASSIUM CHLORIDESODIUMCHLORIDE SOLN 09 -40 MEQL 045 -20MEQL (Use potassiumchloride in nacl)

1


113

Drug Name DrugTier

RequirementsLimits

ringers soln 1

Fluoride sodium fluoride chew 025 mg 05 mg 1 mg 22 mg 0 QL(1 ea daily)

Magnesium magnesium sulfate soln ij50 1

Phosphate potassium phosphates soln224 mgml-236 mgml 1

Potassium K-TAB TBCR 10 MEQ (Use potassium chloride) NF

K-TAB TBCR 8 MEQ (Use potassium chloride) 1

potassium acetate soln 1

potassium bicarbonate tbef 1

potassium chloride cpcr or10 meq 8 meq 1

potassium chloridemicroencapsulated crystalser tbcr 15 meq 20 meq 10 meq

1

potassium chloride pack or20 meq 1 PA

POTASSIUM CHLORIDE SOLN IV 10 MEQ100ML10 MEQ50ML

1

POTASSIUM CHLORIDE SOLN IV 10 MEQ100ML10 MEQ50ML (Use potassium chloride)

1

potassium chloride soln iv10 meq50ml 20meq50ml 2 meqml

1


NF

potassium chloride soln or10 1

potassium chloride tbcr or10 meq 8 meq 1

Drug Name DrugTier

RequirementsLimits

Sodium sodium chloride soln ij 25meqml 1

sodium chloride soln iv 3 5 4 meqml 045 09

1

MISCELLANEOUS THERAPEUTIC CLASSES

Chelating Agents CUPRIMINE CAPS (Use penicillamine) NF PA

DEPEN TITRATABS TABS (Use penicillamine) NF QL(8 ea daily)

penicillamine caps 1 PA

penicillamine tabs 1 QL(8 ea daily)

SYPRINE CAPS (Use trientine hcl) NF PA QL(8 ea

daily) SP

trientine hcl caps 4 PA QL(8 eadaily) SP

Immunomodulators REVLIMID CAPS 10 MG 15 MG 25 MG 25 MG 5 MG


REVLIMID CAPS 20 MG 4 PA

THALOMID CAPS 4 PA QL(3 eadaily) SP

Immunosuppressive Agents

ATGAM INJ 4 PA SP

AZATHIOPRINE SOLR IJ 100 MG 1

azathioprine tabs or 100mg 50 mg 75 mg 1

CELLCEPT CAPS 250 MG (Use mycophenolatemofetil)

NF

CELLCEPT TABS 500 MG (Use mycophenolatemofetil)

NF

cyclosporine caps 1

cyclosporine modified (formicroemulsion) caps 1


114

Drug Name DrugTier

RequirementsLimits

cyclosporine modified (formicroemulsion) soln 1

cyclosporine soln 1

everolimus (immunosuppressant) tabs025 mg 05 mg 075 mg


IMURAN TABS (Use azathioprine) NF

mycophenolate mofetilcaps or 250 mg 1

mycophenolate mofetil tabsor 500 mg 1

mycophenolate sodiumtbec 1

MYFORTIC TBEC (Use mycophenolate sodium) NF

NEORAL CAPS (Use cyclosporine modified (formicroemulsion))

NF

NEORAL SOLN (Use cyclosporine modified (formicroemulsion))

NF

NULOJIX SOLR 4 PA SP

PROGRAF CAPS OR 05 MG 1 MG 5 MG (Use tacrolimus)

NF

PROGRAF PACK OR 02 MG 1 MG 2 PA

PROGRAF SOLN IV 5 MGML 2

RAPAMUNE TABS 05 MG 1 MG 2 MG (Use sirolimus)

NF

SANDIMMUNE CAPS OR 100 MG 25 MG (Use cyclosporine)

NF

SANDIMMUNE SOLN IV 50 MGML (Use cyclosporine)

NF

SIMULECT SOLR 3

sirolimus tabs 05 mg 1mg 2 mg 1

tacrolimus caps 1

Drug Name DrugTier

RequirementsLimits

THYMOGLOBULIN SOLR 4 PA SP

ZORTRESS TABS 025 MG 05 MG 075 MG (Use everolimus (immunosuppressant))

NF

PA QL(20 eadaily) SP

Irrigation Solutions irrigation solutionsphysiological soln 1

lactated ringers (irrigation)soln 1

ringers irrigation soln 1

water for irrigation sterilesoln 1

Potassium Removing Agents sodium polystyrenesulfonate powd 1

sodium polystyrenesulfonate susp 1

MOUTHTHROATDENTAL AGENTS

Anesthetics Topical Oral lidocaine hcl (mouth-throat)soln 2 1 QL(4 ml daily)

lidocaine hcl (mouth-throat)soln 4 1

Anti-infectives - Throat clotrimazole troc 1

nystatin (mouth-throat) susp 1

Antiseptics - MouthThroat chlorhexidine gluconate(mouth-throat) soln 1

DEBACTEROL SOLN 2

PERIDEX SOLN (Use chlorhexidine gluconate(mouth-throat))

NF

Dental Products

stannous fluoride conc mt 0 RXOTC

Steroids - MouthThroatDental


115

Drug Name DrugTier

RequirementsLimits

triamcinolone acetonide (mouth) pste 1

Throat Products - Misc cevimeline hcl caps 1

EVOXAC CAPS (Use cevimeline hcl) NF

pilocarpine hcl (oral) tabs 1

SALAGEN TABS (Use pilocarpine hcl (oral)) NF

MULTIVITAMINS

Prenatal Vitamins CLASSIC PRENATAL TABS 2 QL(1 ea daily)

CVS PRENATAL TABS 2 QL(1 ea daily)

EQL PRENATAL FORMULA TABS 2 QL(1 ea daily)

GNP PRENATAL TABS 2 QL(1 ea daily)

GOODSENSE PRENATAL VITAMINS TABS 2 QL(1 ea daily)

HM PRENATAL TABS 2 QL(1 ea daily)

KP PRENATAL MULTIVITAMINS TABS 2 QL(1 ea daily)

M-NATAL PLUS TABS 2 QL(1 ea daily)RXOTC

MULTI PRENATAL TABS 2 QL(1 ea daily)

NEONATAL COMPLETE TABS 02 MG-184 MG-2 MG-2 MG-3 MG-5 MG-92 MG-10 MCG-10 MG-12 MCG-20 MG-25 MG-27 MG-120 MG-200 MG-1000 MCG-1200 MCG

2

QL(1 ea daily)RXOTC

NEONATAL PLUS TABS 2 QL(1 ea daily)RXOTC

NEONATAL VITAMIN TABS 2 QL(1 ea daily)

NIVA-PLUS TABS 2 QL(1 ea daily)RXOTC

O-CAL FA TABS 2 QL(1 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

ONE VITE WOMENS PRENATALVITAMIN PLUS TABS


ONE VITE WOMENS PRENATALVITAMIN TABS 2 QL(1 ea daily)

PRENATAL LOW IRON TABS 2 QL(1 ea daily)

PRENATAL MULTIVITAMIN TABS 2 QL(1 ea daily)

PRENATAL ONE DAILY TABS 2 QL(1 ea daily)

PRENATAL TABS 08 MG- QL(1 ea daily) 15 MG-17 MG-26 MG-4 MCG-11 UNIT-18 MG-25 MG-27 MG-100 MG-263 MG-400 UNIT-4000 UNIT 08 MG-15 MG-17 MG-26 MG-4 MCG-18 MG-27 MG-100 MG-263 MG-400 UNIT-4000 UNIT-25 MG-11 UNIT 08 MG-17 MG-18 MG-26 MG-8 MCG-20 MG-25 MG-28 MG-30 UNIT-120 MG-200 MG-400 UNIT-4000 UNIT 15 MG-17 MG-26 MG-4 MCG-5 MG-10 MCG-18 MG-25 MG-27 MG-100 MG-200 MG-800 MCG-1200 MCG 17 MG-18 MG-26 MG-8 2 MCG-20 MG-25 MG-28 MG-30 UNIT-120 MG-200 MG-400 UNIT-800 MCG-4000 UNIT 17 MG-184 MG-26 MG-4 MCG-11 UNIT-18 MG-25 MG-27 MG-100 MG-160 MG-200 MG-400 UNIT-800 MCG-4000 UNIT 8 MCG-17 MG-18 MG-26 MG-20 MG-25 MG-28 MG-30 UNIT-120 MG-200 MG-400 UNIT-800 MCG-4000 UNIT 8 MCG-20 MG-17 MG-18 MG-26 MG-25 MG-28 MG-30 UNIT-120 MG-200 MG-400 UNIT-800 MCG-4000 UNIT


116

Drug Name DrugTier

RequirementsLimits

PRENATAL TABS 1 MG-184 MG-2 MG-3 MG-10 MCG-10 MG-10 MG-12 MCG-20 MG-25 MG-27 MG-120 MG-200 MG-1200 MCG

2

QL(1 ea daily)RXOTC

PRENATAL VITAMIN amp MINERAL TABS 2 QL(1 ea daily)

PRENATAL VITAMIN TABS 2 QL(1 ea daily)

PRENATAL VITAMINIRON TABS 2 QL(1 ea daily)

PRENATAL VITAMINS PLUS LOW IRON TABS 2 QL(1 ea daily)

RXOTC PRENATAL VITAMINS TABS 2 QL(1 ea daily)

PRENATRIX TABS 2 QL(1 ea daily)RXOTC

PRENATRYL TABS 2 QL(1 ea daily)RXOTC

PREPLUS TABS 2 QL(1 ea daily)RXOTC

PX PRENATAL MULTIVITAMINS TABS 2 QL(1 ea daily)

QC PRENATAL TABS 2 QL(1 ea daily)

RA PRENATAL FORMULAFOLICACIDTABS

2 QL(1 ea daily)

RA PRENATAL TABS 2 QL(1 ea daily)

RIGHT STEP PRENATAL TABS 2 QL(1 ea daily)

SM PRENATAL VITAMINS TABS 2 QL(1 ea daily)

THERANATAL CORE NUTRITION TABS 2 QL(1 ea daily)

RXOTC

TRICARE TABS 2 QL(1 ea daily)RXOTC

VITATHELYGINGERTABS 2 QL(1 ea daily)

RXOTC

VOL-PLUS TABS 2 QL(1 ea daily)RXOTC

WESTAB PLUS TABS 2 QL(1 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits

MUSCULOSKELETAL THERAPY AGENTS -Drugs to Treat Spasms

Central Muscle Relaxants baclofen tabs or 10 mg 20 mg 1

carisoprodol tabs 1

chlorzoxazone tabs 500 mg 1 QL(6 ea daily)

cyclobenzaprine hcl tabs10 mg 5 mg 1 QL(3 ea daily)

metaxalone tabs 800 mg 1 QL(4 ea daily)

methocarbamol tabs or 500 mg 750 mg 1

orphenadrine citrate tb12 or100 mg 1 QL(2 ea daily)

ROBAXIN-750 TABS (Use methocarbamol) NF

SKELAXIN TABS (Use metaxalone) NF QL(4 ea daily)

SOMA TABS (Use carisoprodol) NF

tizanidine hcl caps 1

tizanidine hcl tabs 1

ZANAFLEX CAPS (Use tizanidine hcl) NF

ZANAFLEX TABS (Use tizanidine hcl) NF

Direct Muscle Relaxants DANTRIUM CAPS (Use dantrolene sodium) NF QL(4 ea daily)

dantrolene sodium caps or100 mg 25 mg 50 mg 1 QL(4 ea daily)

NASAL AGENTS - SYSTEMIC AND TOPICAL -Drugs to treat the Nose or Sinus

Nasal Antiallergy

azelastine hcl soln 1

olopatadine hcl (nasal) soln 1

PATANASE SOLN (Use olopatadine hcl (nasal)) NF


117

Drug Name DrugTier

RequirementsLimits

Nasal Anticholinergics ipratropium bromide (nasal)soln 003 1 QL(1 ml daily)

ipratropium bromide (nasal)soln 006 1

Nasal Steroids

budesonide (nasal) susp 1

FLONASE ALLERGY RELIEF CHILDRENS SUSP (Use fluticasone propionate (nasal))

NF

Limit 2 inhalers permonthQL(32ml per 30 daysretail) RXOTC

FLONASE ALLERGY RELIEF SUSP (Use fluticasone propionate(nasal))

NF


flunisolide (nasal) soln 1 1 rtl pack lmtper fill

fluticasone propionate(nasal) susp 1


mometasone furoate (nasal) susp 1 PA QL(114

gm daily) NASACORT ALLERGY 24HR AERO (Use triamcinolone acetonide (nasal))

NF

NASACORT ALLERGY 24HR CHILDRENS AERO (Use triamcinolone acetonide (nasal))

NF

NASONEX SUSP (Use mometasone furoate (nasal))

NF PA QL(114gm daily)

triamcinolone acetonide (nasal) aero 1

NEUROMUSCULAR AGENTS - Drugs toRelaxParalyze Muscles

ALS Agents RILUTEK TABS (Use riluzole) NF

riluzole tabs 3

Drug Name DrugTier

RequirementsLimits

Neuromuscular Blocking Agent - Neurotoxins

BOTOX SOLR 3 PA

DYSPORT SOLR 3 PA

XEOMIN SOLR 3 PA

NUTRIENTS

Proteins CLINIMIX 425DEXTROSE 10SOLN

3

CLINIMIX 425DEXTROSE 25SOLN

3


3

CLINIMIX 5DEXTROSE25 SOLN 3

CLINIMIX E 5DEXTROSE 20SOLN

3

OPHTHALMIC AGENTS - Drugs to Treat the Eye

Artificial Tears and Lubricants

LACRISERT INST 3

Beta-blockers - Ophthalmic

betaxolol hcl (ophth) soln 1

carteolol hcl (ophth) soln 1

COMBIGAN SOLN 2

COSOPT SOLN (Use dorzolamide hcl-timolol maleate)

NF

dorzolamide hcl-timolol maleate soln 05 -2 223 mgml-68 mgml 5mgml-20 mgml 68mgml-223 mgml

1

levobunolol hcl soln 1


118

Drug Name DrugTier

RequirementsLimits

timolol maleate (ophth)solg 025 05 1

timolol maleate (ophth)soln 025 05 1

TIMOPTIC SOLN (Use timolol maleate (ophth)) NF

TIMOPTIC-XE SOLG (Use timolol maleate (ophth)) NF

Cycloplegic Mydriatics MYDRIACYL SOLN (Use tropicamide) NF

tropicamide soln 1

Miotics ISOPTO CARPINE SOLN (Use pilocarpine hcl) NF

PHOSPHOLINE IODIDE SOLR 3

pilocarpine hcl soln 1

Ophthalmic Adrenergic Agents ALPHAGAN P SOLN 015 (Use brimonidine tartrate)

NF

apraclonidine hcl soln 1

brimonidine tartrate soln 1

IOPIDINE SOLN 3

SIMBRINZA SUSP 3 PA

Ophthalmic Anti-infectives

AZASITE SOLN 3

bacitracin (ophthalmic) oint 3

BLEPH-10 SOLN (Use sulfacetamide sodium (ophth))

NF

CILOXAN SOLN (Use ciprofloxacin hcl (ophth)) NF

ciprofloxacin hcl (ophth)soln 1

erythromycin (ophth) oint 1

Drug Name DrugTier

RequirementsLimits

gatifloxacin (ophth) soln 1

gentamicin sulfate (ophth)oint 1

gentamicin sulfate (ophth)soln 1

KLARITY-A SOLN 3

levofloxacin (ophth) soln 1

moxifloxacin hcl (ophth)soln 1

NATACYN SUSP 2

neomycin-bacitracin zn-polymyxin oint 1

OCUFLOX SOLN (Use ofloxacin (ophth)) NF

ofloxacin (ophth) soln 1

polymyxin b-trimethoprimsoln 1

POLYTRIM SOLN (Use polymyxin b-trimethoprim) NF

sulfacetamide sodium (ophth) soln 1

tobramycin (ophth) soln 1

TOBREX SOLN (Use tobramycin (ophth)) NF

trifluridine soln 1

VIGAMOX SOLN (Use moxifloxacin hcl (ophth)) NF

ZIRGAN GEL 2

ZYMAXID SOLN (Use gatifloxacin (ophth)) NF

Ophthalmic Immunomodulators

RESTASIS EMUL 2 PA

RESTASIS MULTIDOSE EMUL 2 PA

Ophthalmic Local Anesthetics ALCAINE SOLN (Use proparacaine hcl) NF


119

Drug Name DrugTier

RequirementsLimits

proparacaine hcl soln 1

Ophthalmic Nerve Growth Factors

OXERVATE SOLN 4 PA

Ophthalmic Steroids

ALREX SUSP 3 PA

dexamethasone sodium phosphate (ophth) soln 1

difluprednate emul 1 PA

DUREZOL EMUL (Use difluprednate) 3 PA

fluorometholone (ophth) susp 1

FML FORTE SUSP 3 PA

FML LIQUIFILM SUSP (Use fluorometholone (ophth))

NF

FML OINT 3 PA

LOTEMAX GEL (Use loteprednol etabonate) 3 PA

LOTEMAX OINT 3 PA

LOTEMAX SUSP (Use loteprednol etabonate) NF PA

loteprednol etabonate gel 1 PA

loteprednol etabonate susp 1 PA

MAXIDEX SUSP 3 PA

MAXITROL OINT (Use neomycin-polymy-dexameth)

NF

MAXITROL SUSP (Use neomycin-polymy-dexameth)

NF

neomycin-polymy-dexameth oint 1

neomycin-polymy-dexameth susp 1

neomycin-polymyxin-hc(ophth) susp 1

Drug Name DrugTier

RequirementsLimits

PRED FORTE SUSP (Use prednisolone acetate(ophth))

NF

PRED MILD SUSP 3 PA

prednisolone acetate(ophth) susp 1

PREDNISOLONE ACETATE P-F SUSP 1

PREDNISOLONE SODIUM PHOSPHATE SOLN OP 1

3

TOBRADEX SUSP (Use tobramycin-dexamethasone)

NF

tobramycin-dexamethasone susp 1

Ophthalmics - Misc ACULAR LS SOLN (Use ketorolac tromethamine (ophth))

NF

ACULAR SOLN (Use ketorolac tromethamine (ophth))

NF

ALOCRIL SOLN 3 PA

ALOMIDE SOLN 3 PA

azelastine hcl (ophth) soln 1

bepotastine besilate soln 3 PA

BEPREVE SOLN (Use bepotastine besilate) 3 PA

bromfenac sodium (ophth)soln 1

cromolyn sodium (ophth)soln 1

CYSTARAN SOLN 2 PA QL(2143ml daily)

diclofenac sodium (ophth)soln 1

dorzolamide hcl soln 1

epinastine hcl (ophth) soln 1


120

Drug Name DrugTier

RequirementsLimits

flurbiprofen sodium soln 1

ILEVRO SUSP 3 PA

ketorolac tromethamine (ophth) soln 1

ketotifen fumarate (ophth)soln 1

LASTACAFT SOLN 3 PA

NEVANAC SUSP 3 PA

olopatadine hcl soln 1 RXOTC

PATADAY SOLN (Use olopatadine hcl) NF RXOTC

PATANOL SOLN (Use olopatadine hcl) NF RXOTC

TRUSOPT SOLN (Use dorzolamide hcl) NF

ZADITOR SOLN (Use ketotifen fumarate (ophth)) NF

ZERVIATE SOLN 3 PA

Prostaglandins - Ophthalmic

bimatoprost soln 3

latanoprost soln 1

LUMIGAN SOLN 3 ST

TRAVATAN Z SOLN (Use travoprost) NF

travoprost soln 1

XALATAN SOLN (Use latanoprost) NF

ZIOPTAN SOLN 2

OTIC AGENTS - Drugs to Treat the Ear

Otic Agents - Miscellaneous

acetic acid (otic) soln 1

Otic Anti-infectives CETRAXAL SOLN (Use ciprofloxacin hcl (otic)) 1

Drug Name DrugTier

RequirementsLimits

ciprofloxacin hcl (otic) soln 1

ofloxacin (otic) soln 1

Otic Combinations

CIPRO HC SUSP 3

CIPRODEX SUSP (Use ciprofloxacin-dexamethasone)

NF PA

ciprofloxacin-dexamethasone susp 1 PA

ciprofloxacin-fluocinoloneacetonide soln 3 PA QL(05 ea

daily)

COLY-MYCIN S SUSP 3

CORTISPORIN-TC SUSP 3

neomycin-polymyxin-hc(otic) soln 1

neomycin-polymyxin-hc(otic) susp 1

OTOVEL SOLN (Use ciprofloxacin-fluocinoloneacetonide)

3 PA QL(05 eadaily)

Otic Steroids DERMOTIC OIL (Use fluocinolone acetonide (otic))

NF

fluocinolone acetonide (otic) oil 1

hydrocortisone waceticacid soln 1

PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low ImmuneSystem

Immune Serums CUVITRU SOLN 1 GM5ML 10 GM50ML 2GM10ML 4 GM20ML

4 PA SP

GAMMAGARD LIQUID SOLN 1 GM10ML 10GM100ML 25 GM25ML20 GM200ML 5 GM50ML

4

PA SP

GAMMAGARD LIQUID SOLN 30 GM300ML 4 PA


121

Drug Name DrugTier

RequirementsLimits

GAMMAGARD SD IGALESS THAN 1MCGMLSOLR

4 PA SP

GAMMAKED SOLN 4 PA SP

GAMUNEX-C SOLN 4 PA SP

HIZENTRA SOLN 1 GM5ML 10 GM50ML 2GM10ML 4 GM20ML

4 PA SP

Passive Immunizing Agents - Combinations

HYQVIA KIT 4 PA

PENICILLINS - Drugs to Treat Bacterial Infections

Aminopenicillins

amoxicillin caps 1

amoxicillin chew 1

amoxicillin susr 1

amoxicillin tabs 1

ampicillin caps 1

ampicillin sodium solr ij 1 gm 1

ampicillin sodium solr iv 10 gm 1

Natural Penicillins PENICILLIN G POTASSIUM IN ISO-OSMOTIC DEXTROSE SOLN 40000 UNITML60000 UNITML

1

penicillin g potassium solr5000000 unit 1

PENICILLIN G PROCAINE SUSP 3

penicillin g sodium solr 3

penicillin v potassium solr 1

penicillin v potassium tabs 1

Penicillin Combinations

Drug Name DrugTier

RequirementsLimits

amoxicillin amp potclavulanate chew 1

amoxicillin amp potclavulanate susr 1

amoxicillin amp potclavulanate tabs 1

amoxicillin amp potclavulanate tb12 1

ampicillin amp sulbactamsodium solr ij 05 gm-1 gm1 gm-05 gm 1 gm-2 gm 2gm-1 gm

1

ampicillin amp sulbactamsodium solr iv 10 gm-5 gm5 gm-10 gm

1

AUGMENTIN ES-600 SUSR (Use amoxicillin amp pot clavulanate)

NF

AUGMENTIN SUSR 625 MG5ML-250 MG5ML(Use amoxicillin amp potclavulanate)

NF

AUGMENTIN TABS 125 MG-500 MG (Use amoxicillin amp potclavulanate)

NF

piperacillin sodium-tazobactam sodium solr 1

UNASYN BULK PACK SOLR (Use ampicillin ampsulbactam sodium)

NF

UNASYN SOLR (Use ampicillin amp sulbactamsodium)

NF

ZOSYN SOLR 45 GM-36 GM 025 GM-2 GM 0375 GM-3 GM 05 GM-4 GM 2 GM-025 GM (Use piperacillin sodium-tazobactam sodium)

NF

Penicillinase-Resistant Penicillins

dicloxacillin sodium caps 1

nafcillin sodium solr ij 1 gm 1

nafcillin sodium solr iv 10 gm 1


122

Drug Name DrugTier

RequirementsLimits

oxacillin sodium solr ij 1 gm 1

oxacillin sodium solr iv 10 gm 1

PROGESTINS - Hormone ReplacementModifyingDrugs

Progestins AYGESTIN TABS (Use norethindrone acetate) NF

medroxyprogesteroneacetate tabs 1

MEGACE ES SUSP (Use megestrol acetate(appetite))

NF PA

megestrol acetate(appetite) susp 1 PA

norethindrone acetate tabs 0

progesterone caps or 100mg 200 mg 1

PROMETRIUM CAPS (Use progesterone) NF

PROVERA TABS (Use medroxyprogesterone acetate)

NF

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC - Drugs to Treat Mental andEmotional Conditions

Agents for Chemical Dependency

acamprosate calcium tbec 1

ANTABUSE TABS (Use disulfiram) NF

disulfiram tabs 1

LUCEMYRA TABS 3 PA QL(224 eaper 14 daysretail)

Anti-Cataplectic Agents

XYREM SOLN 4 PA QL(18 mldaily) SP

Antidementia Agents ARICEPT TABS 10 MG (Use donepezilhydrochloride)

NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits

ARICEPT TABS 5 MG (Use donepezilhydrochloride)

NF QL(1 ea daily)

donepezil hydrochloridetabs 10 mg 1 QL(2 ea daily)


donepezil hydrochloridetbdp 10 mg 1 QL(2 ea daily)


galantamine hydrobromidecp24 16 mg 24 mg 8 mg 1 QL(1 ea daily)

galantamine hydrobromidesoln 4 mgml 1 QL(6 ml daily)

galantamine hydrobromidetabs 12 mg 4 mg 8 mg 1 QL(2 ea daily)

memantine hcl tabs 1

memantine hcl tabs 10 mg 1 QL(2 ea daily)


NAMENDA TABS 10 MG (Use memantine hcl) NF QL(2 ea daily)


NAMENDA TITRATION PAK TABS (Use memantine hcl)

NF

RAZADYNE ER CP24 (Use galantamine hydrobromide) NF QL(1 ea daily)

RAZADYNE TABS (Use galantamine hydrobromide) NF QL(2 ea daily)

rivastigmine tartrate caps 1

Combination Psychotherapeutics perphenazine-amitriptylinetabs 1 QL(4 ea daily)

Fibromyalgia Agents

SAVELLA TABS 2 PA QL(2 eadaily)

SAVELLA TITRATION PACK MISC 2 PA

Movement Disorder Drug Therapy


123

Drug Name DrugTier

RequirementsLimits

AUSTEDO TABS 4 PA QL(4 eadaily)

tetrabenazine tabs 4 PA QL(3 eadaily) SP

XENAZINE TABS (Use tetrabenazine) NF PA QL(3 ea

daily) SP

Multiple Sclerosis Agents AMPYRA TB12 (Use dalfampridine) NF PA QL(2 ea

daily) SP

AUBAGIO TABS 4 PA

AVONEX PEN AJKT 4 PA QL(00714ml daily) SP

AVONEX PSKT 4 PA QL(00714ml daily) SP

BETASERON KIT 4 PA QL(00357ea daily) SP

COPAXONE SOSY 20 MGML (Use glatiramer acetate)



3 PA QL(0429ml daily) SP

dalfampridine tb12 4 PA QL(2 eadaily) SP

dimethyl fumarate cpdr 4 PA

dimethyl fumarate misc 4 PA

EXTAVIA KIT 4 PA QL(00357ea daily) SP

GILENYA CAPS 4 PA

glatiramer acetate sosy 20mgml 3 PA QL(1 ml

daily) SP glatiramer acetate sosy 40mgml 3 PA QL(0429

ml daily) SP

MAVENCLAD TBPK 4 PA

MAYZENT STARTER PACK TBPK 4 PA

MAYZENT TABS 4 PA

OCREVUS SOLN 4 PA

PLEGRIDY SOPN SC 4 PA QL(0036ml daily)

Drug Name DrugTier

RequirementsLimits

PLEGRIDY SOSY IM 4 PA QL(0036ml daily)

PLEGRIDY SOSY SC 4 PA

PLEGRIDY STARTER PACK SOPN 4 PA

PLEGRIDY STARTER PACK SOSY 4 PA QL(0036

ml daily)

REBIF REBIDOSE SOAJ 4 PA QL(0214ml daily) SP

REBIF REBIDOSE TITRATIONPACK SOAJ 4 PA SP

REBIF SOSY 4 PA QL(0214ml daily) SP

REBIF TITRATION PACK SOSY 4 PA SP

TECFIDERA CPDR (Use dimethyl fumarate) NF PA

TECFIDERA STARTER PACK MISC (Use dimethyl fumarate)

NF PA

TYSABRI CONC 4 PA QL(0536ml daily) SP

Postherpetic Neuralgia (PHN)Neuropathic Pain LYRICA CR TB24 165 MG 825 MG (Use pregabalin(once-daily))

3 PA QL(1 eadaily)

LYRICA CR TB24 330 MG (Use pregabalin (once-daily))

3 PA QL(2 eadaily)

pregabalin (once-daily)tb24 165 mg 825 mg 3 PA QL(1 ea

daily) pregabalin (once-daily)tb24 330 mg 3 PA QL(2 ea

daily) Pseudobulbar Affect (PBA) Agents

NUEDEXTA CAPS 3 PA

Psychotherapeutic and Neurological Agents -ergoloid mesylates tabs 3

pimozide tabs 1

Restless Leg Syndrome (RLS) Agents

HORIZANT TBCR 3 PA QL(2 eadaily)


124

Drug Name DrugTier

RequirementsLimits

Smoking Deterrents

APO-VARENICLINE TABS 0 QL(2 ea daily)

bupropion hcl (smokingdeterrent) tb12 0 QL(2 ea daily)

CHANTIX CONTINUING MONTHPAK TABS 0 QL(2 ea daily)

CHANTIX STARTING MONTH PAK TABS 0

CHANTIX TABS 0 QL(2 ea daily)

NICODERM CQ PT24 (Use nicotine) NF QL(1 ea daily)

NICORETTE GUM (Use nicotine polacrilex) NF

NICORETTE LOZG (Use nicotine polacrilex) NF

NICORETTE MINI LOZG (Use nicotine polacrilex) NF

NICORETTE STARTER KIT GUM (Use nicotine polacrilex)

NF

nicotine polacrilex gum 0

nicotine polacrilex lozg 0

nicotine pt24 0 QL(1 ea daily)

NICOTINE TRANSDERMAL SYSTEM KIT

0

NICOTROL INHALER INHA 0

NICOTROL NS SOLN 0

VARENICLINE TARTRATE TABS 0 QL(2 ea daily)

Transthyretin Amyloidosis Agents

TEGSEDI SOSY 4 PA

RESPIRATORY AGENTS - MISC - Drugs toTreat Lung Conditions

Alpha-Proteinase Inhibitor (Human) ARALAST NP SOLR 1000 MG 4 PA SP

Drug Name DrugTier

RequirementsLimits

ARALAST NP SOLR 500 MG 4 PA

PROLASTIN-C SOLN 1000 MG20ML 4 PA

PROLASTIN-C SOLR 1000 MG 4 PA SP

ZEMAIRA SOLR 4 PA SP

Cystic Fibrosis Agents

KALYDECO TABS 150 MG 4 PA QL(2 eadaily) SP

ORKAMBI PACK 100 MG-125 MG 150 MG-188 MG 4 PA QL(2 ea

daily) ORKAMBI TABS 100 MG-125 MG 125 MG-200 MG 4 PA QL(4 ea

daily)

PULMOZYME SOLN 4 PA QL(25 mldaily) SP

TRIKAFTA TBPK 50 MG-100 MG 4 PA QL(3 ea

daily) Pulmonary Fibrosis Agents

OFEV CAPS 4 PA QL(2 eadaily)

SULFONAMIDES - Drugs to Treat BacterialInfections

Sulfonamides

SULFADIAZINE TABS 1

TETRACYCLINES - Drugs to Treat BacterialInfections

Glycylcyclines

tigecycline solr 1

TYGACIL SOLR (Use tigecycline) NF

Tetracyclines

demeclocycline hcl tabs 1

doxycycline (monohydrate)caps 50 mg 100 mg 1 QL(2 ea daily)

doxycycline (monohydrate)caps 75 mg 1

doxycycline (monohydrate)tabs 100 mg 1 QL(2 ea daily)


125

Drug Name DrugTier

RequirementsLimits

doxycycline (monohydrate)tabs 50 mg 1

doxycycline hyclate caps or50 mg 100 mg 1 QL(2 ea daily)

doxycycline hyclate solr iv100 mg 1

doxycycline hyclate tabs or20 mg 100 mg 1 QL(2 ea daily)

MINOCIN CAPS OR 50 MG (Use minocycline hcl) NF QL(3 ea daily)

minocycline hcl caps 100mg 50 mg 75 mg 1 QL(3 ea daily)

minocycline hcl tabs 100mg 50 mg 75 mg 1 QL(3 ea daily)

TARGADOX TABS (Use doxycycline hyclate) NF

tetracycline hcl caps 1 QL(8 ea daily)

VIBRAMYCIN CAPS 100 MG (Use doxycyclinehyclate)

NF QL(2 ea daily)

XIMINO CP24 135 MG 45 MG 90 MG (Use minocycline hcl)

NF

THYROID AGENTS - Drugs to Regulate ThyroidHormones

Antithyroid Agents

methimazole tabs 1

propylthiouracil tabs 1

TAPAZOLE TABS (Use methimazole) NF

Thyroid Hormones ARMOUR THYROID TABS 120 MG 15 MG 30 MG 60 MG 90 MG (Use thyroid)

2

QL(1 ea daily)

ARMOUR THYROID TABS 180 MG 240 MG 300 MG 2 QL(1 ea daily)

CYTOMEL TABS (Use liothyronine sodium) NF

Drug Name DrugTier

RequirementsLimits

levothyroxine sodium tabsor 300 mcg 100 mcg 112mcg 125 mcg 137 mcg150 mcg 175 mcg 200mcg 25 mcg 50 mcg 75mcg 88 mcg

1

liothyronine sodium soln 1

liothyronine sodium tabs 1

NATURE-THROID NT-25 TABS 2

NATURE-THROID TABS 2

SYNTHROID TABS (Use levothyroxine sodium) 2

thyroid tabs 1 QL(1 ea daily)

TRIOSTAT SOLN (Use liothyronine sodium) NF

WESTHROID TABS 2

WP THYROID TABS 2

TOXOIDS

Toxoid Combinations

ADACEL SUSP 0

BOOSTRIX SUSP 0

DAPTACEL SUSP 0

DIPHTHERIATETANUSTOXOIDS ADSORBED PEDIATRIC SUSP

0

INFANRIX SUSP 0

KINRIX SUSP 0

PEDIARIX SUSP 0

PENTACEL SUSR 0

QUADRACEL SUSP 0

TDVAX SUSP 0


126

Drug Name DrugTier

RequirementsLimits

TENIVAC INJ 0

TETANUSDIPHTHERIATOXOIDS-ADSORBED ADULT SUSP

0

ULCER DRUGS - Drugs to Treat Bowel Intestineand Stomach Conditions

Antispasmodics atropine sulfate soln ij 04mgml 1 mgml 1

ATROPINE SULFATE SOSY IJ 025 MG5ML(Use atropine sulfate)

1

chlordiazepoxide hcl-clidinium bromide caps 1

dicyclomine hcl caps or 10 mg 1

dicyclomine hcl soln or 10mg5ml 1

dicyclomine hcl tabs or 20 mg 1

glycopyrrolate soln ij 4mg20ml 1

glycopyrrolate tabs or 1mg 2 mg 1

LIBRAX CAPS (Use chlordiazepoxide hcl-clidinium bromide)

NF

methscopolamine bromidetabs 1

H-2 Antagonists cimetidine hcl soln 300 mg5ml 1 QL(20 ml daily)

cimetidine tabs 200 mg 1 RXOTC

cimetidine tabs 300 mg400 mg 800 mg 1

famotidine in nacl soln 1

famotidine soln iv 20 mg2ml 200 mg20ml 40mg4ml

1

famotidine susr or 40 mg5ml 1 QL(10 ml daily)

famotidine tabs or 20 mg 1 RXOTC

Drug Name DrugTier

RequirementsLimits

famotidine tabs or 40 mg 1

nizatidine caps 150 mg300 mg 1

nizatidine soln 15 mgml 1 QL(20 ml daily)

PEPCID AC MAXIMUM STRENGTH TABS (Use famotidine)

NF RXOTC

PEPCID AC TABS (Use famotidine) NF RXOTC

PEPCID TABS 20 MG (Use famotidine) NF RXOTC

PEPCID TABS 40 MG (Use famotidine) NF

ranitidine hcl caps or 150mg 300 mg 1

ranitidine hcl soln ij 150mg6ml 1

ranitidine hcl syrp or 15mgml 150 mg10ml 75mg5ml

1 QL(20 ml daily)

ranitidine hcl tabs or 150 mg 1 RXOTC

ranitidine hcl tabs or 300 mg 1

TAGAMET HB TABS (Use cimetidine) NF RXOTC

ZANTAC 150 MAXIMUM STRENGTH TABS (Use ranitidine hcl)

NF RXOTC

Misc Anti-Ulcer CARAFATE SUSP 1 GM10ML (Use sucralfate) NF QL(40 ml daily)

CARAFATE TABS 1 GM (Use sucralfate) NF QL(4 ea daily)

sucralfate susp 1 gm10ml 1 QL(40 ml daily)

sucralfate tabs 1 gm 1 QL(4 ea daily)

Proton Pump Inhibitors ACIPHEX TBEC (Use rabeprazole sodium) NF QL(1 ea daily)

DEXILANT CPDR 3 PA QL(1 eadaily)


127

Drug Name DrugTier

RequirementsLimits

esomeprazole magnesiumcpdr 20 mg 1 QL(2 ea daily)

RXOTC esomeprazole magnesiumcpdr 40 mg 3 QL(1 ea daily)

esomeprazole magnesiumtbec 20 mg 1 QL(2 ea daily)

lansoprazole cpdr 15 mg 1 QL(1 ea daily)RXOTC

lansoprazole cpdr 30 mg 1

NEXIUM 24HR TBEC (Use esomeprazole magnesium) 1 QL(2 ea daily)

NEXIUM CPDR 20 MG (Use esomeprazolemagnesium)



NF QL(1 ea daily)

omeprazole cpdr 10 mg 40 mg 1 QL(2 ea daily)

omeprazole cpdr 20 mg 1 QL(2 ea daily)RXOTC

omeprazole magnesiumcpdr 1 QL(4 ea daily)

omeprazole magnesiumtbec 1 QL(4 ea daily)

omeprazole tbec 20 mg 1 QL(2 ea daily)

pantoprazole sodium tbecor 20 mg 1 QL(1 ea daily)

pantoprazole sodium tbecor 40 mg 1

PREVACID 24HR CPDR (Use lansoprazole) NF QL(1 ea daily)

RXOTC PREVACID CPDR 15 MG (Use lansoprazole) NF QL(1 ea daily)

RXOTC PREVACID CPDR 30 MG (Use lansoprazole) NF

PRILOSEC OTC TBEC (Use omeprazolemagnesium)

1 QL(4 ea daily)

PROTONIX TBEC OR 20 MG (Use pantoprazolesodium)

NF QL(1 ea daily)


NF

Drug Name DrugTier

RequirementsLimits

rabeprazole sodium tbec 1 QL(1 ea daily)

Ulcer Drugs - Prostaglandins CYTOTEC TABS (Use misoprostol) NF QL(4 ea daily)

misoprostol tabs 1 QL(4 ea daily)

Ulcer Therapy Combinations omeprazole-sodiumbicarbonate caps 20 mg-1100 mg


ZEGERID CAPS 20 MG-1100 MG (Use omeprazole-sodiumbicarbonate)

NF

RXOTC

URINARY ANTISPASMODICS - Drugs to TreatMiscellaneous Bladder Spasms

Urinary Antispasmodic - Antimuscarinics darifenacin hydrobromidetb24 1 QL(1 ea daily)

DETROL LA CP24 (Use tolterodine tartrate) NF QL(1 ea daily)

DETROL TABS (Use tolterodine tartrate) NF

DITROPAN XL TB24 (Use oxybutynin chloride) NF

ENABLEX TB24 (Use darifenacin hydrobromide) NF QL(1 ea daily)

oxybutynin chloride syrp 1

oxybutynin chloride tabs 1

oxybutynin chloride tb24 1

solifenacin succinate tabs 1 PA QL(1 eadaily)

tolterodine tartrate cp24 2mg 4 mg 1 QL(1 ea daily)

tolterodine tartrate tabs 1 mg 2 mg 1

TOVIAZ TB24 3 PA QL(1 eadaily)

trospium chloride cp24 60 mg 1 QL(1 ea daily)

trospium chloride tabs 20 mg 1


128

Drug Name DrugTier

RequirementsLimits

VESICARE TABS (Use solifenacin succinate) NF PA QL(1 ea

daily) Urinary Antispasmodics - Beta-3 Adrenergic MYRBETRIQ TB24 25 MG 50 MG 3 PA

Urinary Antispasmodics - Cholinergic Agonists bethanechol chloride tabs 10 mg 5 mg 50 mg 1 QL(4 ea daily)

bethanechol chloride tabs 25 mg 1

URECHOLINE TABS 10 MG 5 MG 50 MG (Use bethanechol chloride)

NF QL(4 ea daily)

URECHOLINE TABS 25 MG (Use bethanechol chloride)

NF

Urinary Antispasmodics - Direct Muscle Relaxants

flavoxate hcl tabs 1

VACCINES

Bacterial Vaccines

ACTHIB SOLR 0

BEXSERO SUSY 0

HIBERIX SOLR 0

MENQUADFI SOLN 0

MENVEO SOLR 0

PEDVAX HIB SUSP 0

PNEUMOVAX 23 INJ 0

PNEUMOVAX 231 DOSEINJ 0

PREVNAR 13 SUSP 0

TRUMENBA SUSY 0

Viral Vaccines

Drug Name DrugTier

RequirementsLimits

AFLURIA QUADRIVALENT 2019-2020 SUSP 0

Limit 1 dose per season1 rtlMAX fill180 rtl day(s) supply

AFLURIA QUADRIVALENT 2019-2020 SUSY 0










ENGERIX-B INJ 0

3 rtl MAX fill365 rtl day(s) supply3mail MAX fill365 mail day(s) supply

ENGERIX-B SUSP 0


FLUAD 2019-2020 SUSY 0




FLUAD QUADRIVALENT 2021-2022 PRSY 0



129

Drug Name DrugTier

RequirementsLimits

FLUAD QUADRIVALENT INFLUENZA VACCINE FOR ADULTS PRSY

0 1 rtl MAX fill180 rtl day(s) supply

FLUARIX QUADRIVALENT 2019-2020 SUSY 0






FLUBLOK QUADRIVALENT 2019-2020 SOSY

0



0



0


FLUCELVAX QUADRIVALENT 2019-2020 SUSP

0


FLUCELVAX QUADRIVALENT 2019-2020 SUSY

0



0



0



0


Drug Name DrugTier

RequirementsLimits


0


FLULAVAL QUADRIVALENT 2019-2020 SUSP

0


FLULAVAL QUADRIVALENT 2019-2020 SUSY

0



0



0


FLUMIST QUADRIVALENT SUSP 0


FLUZONE HIGH-DOSE PF 2019-2020 SUSY 0






FLUZONE QUADRIVALENT 2019-2020 SUSP

0


FLUZONE QUADRIVALENT 2019-2020 SUSY

0



0



130

Drug Name DrugTier

RequirementsLimits


0



0



0


GARDASIL 9 SUSP 0 3 rtl MAX fill365 rtl day(s) supply

GARDASIL 9 SUSY 0 3 rtl MAX fill365 rtl day(s) supply

HAVRIX SUSP 0


HEPLISAV-B SOSY 0

IPOL INACTIVATED IPV INJ 0

M-M-R II SOLR 0 1 rtl MAX fill365 rtl day(s) supply

RECOMBIVAX HB SUSP 0

ROTARIX SUSR 0

ROTATEQ SOLN 0

SHINGRIX SUSR 0

2 rtl pack lmtamt999 rtl pack lmtday(s) AL(Atleast 18 yrsold)

TWINRIX SUSY 0

Drug Name DrugTier

RequirementsLimits

VAQTA SUSP 0


VARIVAX INJ 0 2 rtl MAX fill365 rtl day(s) supply

ZOSTAVAX SUSR 0


VAGINAL AND RELATED PRODUCTS

Miscellaneous Vaginal Products

INTRAROSA INST 3 PA

Spermicides

SHUR-SEAL GEL 0

TODAY SPONGE MISC 0

Vaginal Anti-infectives CLEOCIN CREA VA 2 (Use clindamycinphosphate vaginal)

NF

clindamycin phosphatevaginal crea 1

clotrimazole vaginal crea 1

GYNAZOLE-1 CREA 3

GYNE-LOTRIMIN CREA (Use clotrimazole vaginal) NF

metronidazole vaginal gel 1

miconazole nitrate vaginal supp 1

terconazole vaginal crea 1

terconazole vaginal supp 1

Vaginal Contraceptive - pH Modulators


131

Drug Name DrugTier

RequirementsLimits

PHEXXI GEL 0 PV

Vaginal Estrogens ESTRACE CREA (Use estradiol vaginal) NF

estradiol vaginal crea 1

estradiol vaginal tabs 1

FEMRING RING 3

PREMARIN CREA 2

VAGIFEM TABS (Use estradiol vaginal) NF

VASOPRESSORS - Drugs to Treat Heart andCirculation Conditions

Anaphylaxis Therapy Agents ADRENALIN SOLN IJ 30 MG30ML (Use epinephrine (anaphylaxis))

NF

epinephrine (anaphylaxis)soaj 015 mg03ml 1

QL(2 ea per fillretail2 ea perfill mail)2 rtlMAX fill365 rtl day(s) supply2mail MAX fill365 mail day(s) supply


QL(2 ea per fillretail)2 rtl MAXfill365 rtl day(s) supply



EPIPEN 2-PAK SOAJ (Use epinephrine (anaphylaxis)) NF

Drug Name DrugTier

RequirementsLimits

EPIPEN-JR 2-PAK SOAJ (Use epinephrine(anaphylaxis))

2


Vasopressors

midodrine hcl tabs 1

VITAMINS

Oil Soluble Vitamins cholecalciferol caps 125mg 50000 unit 1

cholecalciferol tabs 400 unit 0

DRISDOL CAPS (Use ergocalciferol) 0

ergocalciferol caps or 125mg 50000 unit 0

ergocalciferol soln or 200mcgml 8000 unitml 1

VITAMIN D2 TABS 0 AL(At least 65yrs old)

Water Soluble Vitamins niacin cpcr or 500 mg 250 mg 1

niacin tabs or 250 mg 50mg 100 mg 500 mg 1

niacin tbcr or 750 mg 250mg 500 mg 1

NIACIN TR TBCR 1

niacinamide tabs or 100 mg 500 mg 1

SLO-NIACIN TBCR (Use niacin) 1


132

Index 1ST TIER UNILET COMFORTOUCH LANCETS 28G 77 1ST TIER UNILET COMFORTOUCH LANCETS 30G 77 abacavir sulfate 44 abacavir sulfate-lamivudine 44 abacavir sulfate-lamivudine-zidovudine 44 ABELCET 27 ABILIFY 44 abiraterone acetate 36 ABRAXANE 40 ABSORICA 55 acamprosate calcium 123 acarbose 23 ACCOLATE 14 ACCU-CHEK FASTCLIX LANCETS 77 ACCU-CHEK MULTICLIX LANCETS 77 ACCU-CHEK SAFE-T-PRO LANCETS 77 ACCU-CHEK SAFE-T-PRO PLUSLANCETS 77 ACCU-CHEK SOFTCLIX LANCETS 77 ACCUPRIL 30 ACCURETIC 31 acebutolol hcl 48 acetaminophen w codeine 8 acetaminophen-caff-dihydrocod 8 acetazolamide 65 acetazolamide sodium 65 acetic acid 71 acetic acid (otic) 121 acetylcysteine 55 ACIPHEX 127 acitretin 59 ACTHAR 66 ACTHIB 129 ACTI-LANCE LANCETS 28G 78 ACTI-LANCE LITE SAFETY LANCETS 28G 78 ACTI-LANCE SPECIAL SAFETY LANCETS 17G 78 ACTI-LANCE SPECIAL SAFETYLANCETS 17G 78 ACTI-LANCE UNIVERSAL SAFETY LANCETS 23G 78

ACTIGALL 70 ACTIMMUNE 39 ACTIQ 6 ACTONEL 66 ACTOPLUS MET 23 ACTOS 24 ACULAR 120 ACULAR LS 120 acyclovir 47 acyclovir topical 60 ADACEL 126 ADALAT CC 49 adapalene 5556 adapalene-benzoylperoxide 56 ADCETRIS 36 ADCIRCA 50 ADDERALL 1 ADDERALL XR 1 adefovir dipivoxil 47 ADEMPAS 51 ADIPEX-P 2 ADJUSTABLE LANCING DEVICE 78 ADRENALIN 132 ADVAIR DISKUS 14 ADVAIR HFA 14 ADVANCED MOBILE LANCET 30G 78 ADVOCATE INSULIN SYRINGEU-10003ML29GX12 89 ADVOCATE INSULIN SYRINGEU-10003ML30GX516 89 ADVOCATE INSULIN SYRINGEU-10003ML31GX516 89 ADVOCATE INSULIN SYRINGEU-10005ML29GX12 89 ADVOCATE INSULIN SYRINGEU-10005ML30GX516 89 ADVOCATE INSULIN SYRINGEU-10005ML31GX516 89 ADVOCATE INSULIN SYRINGEU-1001ML29GX12 89 ADVOCATE INSULIN SYRINGEU-1001ML30GX516 89

ADVOCATE INSULIN SYRINGEU-1001ML31GX516

89 ADVOCATE LANCETS 78 ADVOCATE LANCETS 30G 78 ADVOCATE LANCING DEVICE 78 ADVOCATE RAPID-SAFE LANCING DEVICE 78 ADVOCATE SAFETY LANCETS 78 ADVOCATE SAFETY LANCETS 26G 78 ADZENYS ER 1 AFINITOR 38 AFLURIA QUADRIVALENT 2019-2020 129 AFLURIA QUADRIVALENT 2020-2021 129 AFLURIA QUADRIVALENT 2021-2022 129 AFREZZA 24 AGAMATRIX ULTRA-THIN LANCETS 33G 78 AGGRENOX 72 AGRYLIN 72 AIMOVIG 111 AIMSCO LUBRICATED 76 AIMSCO TWIST LANCETS 32G 78 AIMSCO TWIST LANCETS 33G 78 AIRDUO RESPICLICK 11314 14 AIRDUO RESPICLICK 23214 14 AIRDUO RESPICLICK 551414 AKYNZEO 26 albendazole 10 ALBENZA 10 albuterol sulfate 1415 ALCAINE 119 alclometasone dipropionate 60 ALDACTAZIDE 65 ALDACTONE 65 ALDARA 63 ALDURAZYME 67 ALECENSA 38 alendronate sodium 66 alfuzosin hcl 71 ALIMTA 35 ALINIA 11

Index 1

aliskiren fumarate 32 amlodipine besylate-benazepril ARICEPT 123 hcl 31 ALKERAN 34 ARIKAYCE 3 amlodipine besylate-olmesartan

ALLEGRA ALLERGY 28 ARIMIDEX 36 medoxomil 31 ALLEGRA ALLERGY CHILDRENS 27 ALLEGRA-D 12 HOUR ALLERGY amp CONGESTION 55 ALLEGRA-D 24 HOUR ALLERGY amp CONGESTION 55 allopurinol 72 almotriptan malate 111 ALOCRIL 120 alogliptin benzoate 24 ALOMIDE 120 alosetron hcl 70 ALOXI 25

amlodipine besylate-valsartan amlodipine-valsartan-hydrochlorothiazide amoxapine amoxicillin amoxicillin amp potclavulanate amphetamine-dextroamphetamine amphotericin b ampicillin ampicillin amp sulbactamsodium

31

31 22

122

122

1 27

122

122

aripiprazole ARIXTRA armodafinil ARMOUR THYROID ARNUITY ELLIPTA AROMASIN ARRANON arsenic trioxide ARTHROTEC 50 ARTHROTEC 75 ARZERRA ASACOL HD

44 16

2 126

14 36 35 39

4 4

36 70

ALPHAGAN P alprazolam ALREX ALTABAX

119 13

120 57

ampicillin sodium AMPYRA ANADROL-50 ANAFRANIL

122 124

9 22

asenapine maleate 43 aspirin 6 aspirin-dipyridamole 72 ASSURE HAEMOLANCE PLUS

ALTACE 30 ALTERNATE SITE LANCING DEVICE 78 ALTOPREV 29 ALUNBRIG 38 alvimopan 71 amantadine hcl 41

anagrelide hcl anastrozole ANCOBON ANDRODERM ANDROGEL ANNOVERA

72 36 27 10 10 53

HIGH FLOW 18G 78 ASSURE HAEMOLANCE PLUS LOW FLOW 25G 78 ASSURE HAEMOLANCE PLUS MICRO FLOW 28G 78 ASSURE HAEMOLANCE PLUS NORMAL FLOW 21G 78 ASSURE HAEMOLANCE PLUS

AMARYL AMBIEN AMBIEN CR AMBISOME ambrisentan amcinonide AMCINONIDE AMERGE

25 74 74 27 50 60 61

111

ANORO ELLIPTA ANTABUSE ANUSOL-HC ANZEMET APIDRA APIDRA SOLOSTAR APO-VARENICLINE APOKYN

15 123

10 26 24 24

125 41

PEDIATRIC BLADE 78 ASSURE ID INSULIN SAFETYSYRINGEU-10005ML29G X 12 89 ASSURE ID INSULIN SAFETYSYRINGEU-1001ML29G X 12 89 ASSURE LANCE LANCETS 78 ASSURE LANCE LANCETS 21G 78

AMICAR amikacin sulfate amiloride amp hydrochlorothiazide amiloride hcl

74 3

65 65

apraclonidine hcl aprepitant APRISO APTIOM APTIVUS

119 26 70 17 44

ASSURE LANCE PLUS SAFETYLANCETS 25G ASSURE LANCE PLUS SAFETYLANCETS 30G ASSURE LANCE SAFETY LANCET 28G

78

78

78 aminocaproic acid aminophylline amiodarone hcl AMITIZA amitriptyline hcl

74 15 13 70 22

AQUA LANCE ADJUSTABLE LANCING DEVICE 78 ARALAST NP 125 ARANESP ALBUMIN FREE 73 ARAVA 5

ASSURE LANCETS ATACAND ATACAND HCT atazanavir sulfate ATELVIA

78 30 31 44 66

amlodipine besylate 49 ARCALYST 4 atenolol 48 amlodipine besylate-atorvastatin atenolol amp chlorthalidone 31 ARCAPTA NEOHALER 15 calcium 50 ATGAM 114 arformoterol tartrate 15

Index 2

ATIVAN 13 B-D INSULIN SYRINGE BD INSULIN SYRINGE ULTRAFINE II03ML31G X SAFETYGLIDE1ML29G Xatomoxetine hcl 2 516 89 12 90 atorvastatin calcium 29 B-D INSULIN SYRINGE BD INSULIN SYRINGE SLIP

atovaquone 11 ULTRAFINE II05ML31G X TIPU-1001ML 90 atovaquone-proguanil hcl 33 516 89 BD INSULIN SYRINGE ULTRA-

B-D INSULIN SYRINGE FINE03ML30G X 127MM 90 ATRIPLA 44 ULTRAFINE II1ML31G X BD INSULIN SYRINGE ULTRA-atropine sulfate 127 516 89 FINE03ML31G X 8MM 90 ATROPINE SULFATE 127 B-D INSULIN SYRINGE BD INSULIN SYRINGE ULTRA-

ULTRAFINE03ML30G X FINE05ML30G X 127MM 90 ATROVENT HFA 14 12 89 BD INSULIN SYRINGE ULTRA-AUBAGIO 124 B-D INSULIN SYRINGE FINE05ML31G X 8MM 90 AUGMENTIN 122 ULTRAFINE05ML30G X BD INSULIN SYRINGE ULTRA-AUGMENTIN ES-600 122 12 90 FINE12 UNIT03ML31G X

8MM 90 AURORA LANCET SUPER bacitracin 10 BD INSULIN SYRINGE ULTRA-THIN30G 78 bacitracin (ophthalmic) 119 FINE1ML30G X 127MM 90 AURORA LANCET THIN baclofen 117 BD INSULIN SYRINGE ULTRA-23G 78 BACTRIM 11 FINE1ML31G X 8MM 90 AUSTEDO 124 BD INSULIN SYRINGE BACTRIM DS 11 AUTO-LANCET 78 ULTRAFINE HALF-BALCOLTRA 52 AUTO-LANCET MINI 78 UNIT03ML31G X 516 90

balsalazide disodium 70 BD INSULIN SYRINGE AUTOLET IMPRESSION LANCING DEVICE 78 BALVERSA 38 ULTRAFINE03ML30G XAUTOLET LANCING 12 90 BANZEL 17 BD INSULIN SYRINGE DEVICE 78 BAQSIMI ONE PACK 23 ULTRAFINE03ML31G XAUTOLET MINI 78

BAQSIMI TWO PACK 23 516 90 AUTOLET PLUS 78 BD INSULIN SYRINGE BARACLUDE 47 AVALIDE 31 ULTRAFINE05ML30G XBASAGLAR KWIKPEN 24 AVANDIA 24 12 90 BAXDELA 69 BD INSULIN SYRINGE AVAPRO 30 BD LO-DOSE INSULIN ULTRAFINE05ML31G X

AVELOX 69 SYRINGE MICROFINE 516 90 AVODART 71 IV05ML28G X 12 90 BD INSULIN SYRINGE AVONEX 124 BD AUTOSHIELD 29G X ULTRAFINE1ML30G X

316 90 12 90 AVONEX PEN 124 BD AUTOSHIELD 29G X BD INSULIN SYRINGE AVSOLA 70 516 90 ULTRAFINEU-10003ML29G XAYGESTIN 123 BD AUTOSHIELD DUO 30G X 12 90

5MM 90 BD INSULIN SYRINGE AYVAKIT 37 BD INSULIN SYRINGE LUER- ULTRAFINEU-10005ML29G Xazacitidine 35 LOKU-1001ML 90 12 90 AZASITE 119 BD INSULIN SYRINGE BD INSULIN SYRINGE AZATHIOPRINE 114 MICROFINE IVU- ULTRAFINEU-1001ML29G X

10005ML28G X 12 90 12 90 azathioprine 114 BD INSULIN SYRINGE BD INSULIN SYRINGE azelaic acid 64 MICROFINE IVU- ULTRAFINEU-1001ML31G Xazelastine hcl 117 1001ML27G X 58 90 516 90

BD INSULIN SYRINGE BD INSULIN azelastine hcl (ophth) 120 MICROFINE IVU- SYRINGE03ML29G XAZELEX 56 1001ML28G X 12 90 127MM 91 AZILECT 42 BD INSULIN SYRINGE BD INSULIN azithromycin 75 MICROFINEU-1001ML27G X SYRINGE05ML29G X

58 90 127MM 91 AZOR 31 BD INSULIN SYRINGE BD INSULIN SYRINGE1ML27GAZULFIDINE 70 MICROFINEU-1001ML28G X X 127MM 91 AZULFIDINE EN-TABS 70 12 90

Index 3

BD INSULIN SYRINGE1ML29G BD VEO INSULIN SYRINGE BLEPH-10 119 X 127MM 91 ULTRA-FINEU-1001ML31G BONIVA 66 BD INSULIN X 1564 91 BOOSTRIX 126 SYRINGEDETACHABLE BELSOMRA 74 NEEDLEU-1001ML25G X BORTEZOMIB 38 BELVIQ 2 1 91 benazepril amp bosentan 50 BD INSULIN hydrochlorothiazide 31 BOSULIF 38 SYRINGEDETACHABLE benazepril hcl 30 BOTOX 118 NEEDLEU-1001ML25G X58 91 BENICAR 30 BRAFTOVI 38 BD INSULIN BENICAR HCT 31 BREO ELLIPTA 15 SYRINGEDETACHABLE BENZACLIN 56 BRILINTA 72 NEEDLEU-1001ML26G X12 91 BENZACLIN WITH PUMP 56 brimonidine tartrate 119 BD INSULIN SYRINGEU- BENZAMYCIN 56 BRIVIACT 17 1001ML27G X 12 91 benzonatate 55 bromfenac sodium (ophth) 120 BD LANCET ULTRAFINE 30G 78 benzoyl peroxide 56 bromocriptine mesylate 41

BENZOYL PEROXIDE BD LANCET ULTRAFINE BROVANA 15 CLEANSER 56 33G 78 BRUKINSA 38 BD MICROTAINER benzoyl peroxide-

LANCETS 78 erythromycin 56 budesonide 54 BD PEN benztropine mesylate 40 budesonide (inhalation) 14 NEEDLEMICROULTRA- bepotastine besilate 120 budesonide (nasal) 118 FINE32G X 6MM 91 BEPREVE 120 budesonide-formoterol fumarate BD PEN NEEDLEMINIULTRA- betamethasone dipropionate dihydrate 15 FINE31G X 5MM 91 BULLSEYE MINI SAFETY (topical) 61 BD PEN NEEDLENANO 2ND betamethasone dipropionate LANCETS 78 GEN32G X 532 91 BULLSEYE SAFETY augmented 61 BD PEN LANCETS 79 betamethasone valerate 61 NEEDLENANOULTRA- bumetanide 65 FINE32G X 4MM 91 BETAPACE 48

BUMEX 65 BD PEN BETAPACE AF 48 NEEDLEORIGINALULTRA- BUNAVAIL 9 BETASERON 124 FINE29G X 127MM 91 BUPHENYL 67 BD PEN betaxolol hcl 48

BUPRENEX 9 NEEDLESHORTULTRA- betaxolol hcl (ophth) 118 FINE31G X 8MM 91 buprenorphine 9 bethanechol chloride 129 BD SAFETY-GLIDE INSULIN buprenorphine hcl 9 BEVESPI AEROSPHERE 15 SYRINGE05ML29G X 12 91 buprenorphine hcl-naloxone hclBD SAFETY-LOK INSULIN BEVYXXA 16 dihydrate 9 SYRINGEPERM bexarotene 39 bupropion hcl 20 NEEDLEUF1ML29G X BEXSERO 129 bupropion hcl (smoking12 91 deterrent) 125 BEYAZ 52 BD SAFETYGLIDE INSULIN buspirone hcl 12 SYRINGE03ML29G X 12 91 bicalutamide 36 BD SAFETYGLIDE INSULIN busulfan 34 BICNU 34 SYRINGE03ML31G X BUSULFEX 34 BIDIL 50 516 91 butalbital-acetaminophen 5 BD SAFETYGLIDE INSULIN BIKTARVY 44 butalbital-acetaminophen-SYRINGE1ML31G X BILTRICIDE 10 caffeine 5 1564 91 bimatoprost 121 butalbital-acetaminophen-BD SAFETYGLIDE INSULIN

bisacodyl 75 caffeine w codeine 8 SYSYRINGE05ML30G X516 91 bisoprolol amp butalbital-aspirin-caffeine 5 BD VEO INSULIN SYRINGE hydrochlorothiazide 31 butalbital-aspirin-caffeineULTRA-FINE1ML31G X bisoprolol fumarate 48 wcod 8

BUTALBITALACETAMINOPHEN6MM 91 bleomycin sulfate 37 5

Index 4

butenafine hcl 57 butorphanol tartrate 9 BUTRANS 9 BYSTOLIC 48 cabergoline 68 CABLIVI 72 CADUET 50 CAFERGOT 111 CALAN SR 49 calcipotriene 60 calcipotriene-betamethasonedipropionate 61 calcitonin (salmon) 66 calcitriol 67 calcitriol (topical) 60 calcium acetate (phosphatebinder) 71 calcium chloride (dihydrate)113 CALCIUM GLUCONATE 113 calcium gluconate 113 calcium polycarbophil 74 CAMPTOSAR 40 CANASA 70 CANCIDAS 27 candesartan cilexetil 31 candesartan cilexetil-hydrochlorothiazide 31 CAPASTAT SULFATE 34 capecitabine 35 CAPRELSA 38 captopril 30 CARAC 59 CARAFATE 127 CARBAGLU 67 carbamazepine 17 CARBATROL 1718 carbidopa 40 carbidopa-levodopa 41 carbidopa-levodopa-entacapone

41 CARBIDOPALEVODOPAODT 41 carbinoxamine maleate 27 carboplatin 34 CARDIOCOM LANCING DEVICE 79 CARDIZEM 49 CARDIZEM CD 49 CARDIZEM LA 49

CARDURA 31 CAREONE ADVANCED LANCINGDEVICE 79 CAREONE INSULIN SYRINGES03ML30G X12 91 CAREONE INSULIN SYRINGES03ML31G X516 91 CAREONE INSULIN SYRINGES05ML30G X12 91 CAREONE INSULIN SYRINGES05ML31G X516 91 CAREONE INSULIN SYRINGES1ML30G X12 91 CAREONE INSULIN SYRINGES1ML31GX516

92 CAREONE LANCET SUPER THIN30G 79 CAREONE LANCET THIN 79 CARESENS LANCETS 79 CARETOUCH INSULIN SYRINGE03ML31GX516

92 CARETOUCH INSULIN SYRINGE05ML31GX516




92 CARETOUCH LANCING DEVICEWITH EJECTOR 79 CARETOUCH SAFETY LANCETS26G 79 CARETOUCH SAFETY LANCETS28G 79 CARETOUCH SAFETY LANCETS30G 79 CARETOUCH TWIST LANCETS 28G 79 CARETOUCH TWIST LANCETS 30G 79 CARETOUCH TWIST LANCETS 33G 79 carisoprodol 117 carmustine 34 carteolol hcl (ophth) 118

carvedilol 48 CASODEX 36 caspofungin acetate 27 CATAPRES 31 CATAPRES-TTS-1 31 CATAPRES-TTS-2 31 CATAPRES-TTS-3 31 CAYA 76 CAYSTON 12 cefaclor 51 cefadroxil 51 cefazolin sodium 51 cefdinir 51 cefditoren pivoxil 51 cefepime hcl 52 cefixime 51 CEFOTAN 51 cefotaxime sodium 51 cefotetan disodium 51 cefoxitin sodium 51 cefpodoxime proxetil 51 cefprozil 51 ceftazidime 51 ceftriaxone sodium 52 cefuroxime axetil 51 cefuroxime sodium 51 CELEBREX 4 celecoxib 4 CELESTONE SOLUSPAN 54 CELESTONE-SOLUSPAN 54 CELEXA 21 CELLCEPT 114 CELONTIN 20 cephalexin 51 CERDELGA 72 CEREBYX 19 CEREZYME 72 cetirizine hcl 28 cetirizine-pseudoephedrine 55 CETRAXAL 121 CETROTIDE 66 cevimeline hcl 116 CHANTIX 125 CHANTIX CONTINUING MONTHPAK 125 CHANTIX STARTING MONTH PAK 125

Index 5

CHEMET 25 CLARITIN 28 CLEVER CHOICE COMFORT

CHEMSTRIP-K CHILDRENS ADVIL CHILDRENS MOTRIN chloramphenicol sodiumsuccinate

64 4 4

11

CLARITIN ALLERGY CHILDRENS CLARITIN CHILDRENS CLARITIN REDITABS CLARITIN-D 12 HOUR

28 28 28 55

EZINSULIN SYRINGE10ML30G X 12 92 CLEVER CHOICE COMFORT EZINSULIN SYRINGE1ML28GX 12 92 CLEVER CHOICE COMFORT

chlordiazepoxide hcl 13 chlordiazepoxide hcl-clidiniumbromide 127 chlorhexidine gluconate (mouth-throat) 115 chloroquine phosphate 33 chlorpromazine hcl 4344 chlorthalidone 66

CLARITIN-D 24 HOUR CLASSIC PRENATAL CLEANLET LANCETS 28G CLEMASTINE FUMARATE clemastine fumarate CLENPIQ

55 116

79

27 27 75

EZINSULIN SYRINGE1ML29GX 12 92 CLEVER CHOICE COMFORT EZINSULIN SYRINGE1ML30GX 516 92 CLEVER CHOICE COMFORT EZINSULIN SYRINGEU-1001ML31GX516 92 CLIMARA 69

chlorzoxazone 117 CLEOCIN 11131 CLIMARA PRO 69 CHOLBAM 70 cholecalciferol 132 cholestyramine 29 cholestyramine light 29 choline fenofibrate 29 CHORIONIC GONADOTROPIN 66 CIALIS 50 ciclopirox 57 ciclopirox olamine 57 cidofovir 47 cilostazol 72 CILOXAN 119 CIMDUO 44 cimetidine 127 cimetidine hcl 127 cinacalcet hcl 67 CINRYZE 72 CIPRO 69 CIPRO HC 121 CIPRODEX 121 ciprofloxacin 69 ciprofloxacin hcl 69 ciprofloxacin hcl (ophth) 119 ciprofloxacin hcl (otic) 121 ciprofloxacin in d5w 69 ciprofloxacin-dexamethasone

121

CLEOCIN PEDIATRIC GRANULES 11 CLEOCIN PHOSPHATE 11 CLEOCIN-T 56 CLEVER CHOICE COMFORT EZINSULIN SYRINGE03ML29G X12 92 CLEVER CHOICE COMFORT EZINSULIN SYRINGE03ML30G X12 92 CLEVER CHOICE COMFORT EZINSULIN SYRINGE03ML30G X516 92 CLEVER CHOICE COMFORT EZINSULIN SYRINGE03ML31G X516 92 CLEVER CHOICE COMFORT EZINSULIN SYRINGE05ML28G X12 92 CLEVER CHOICE COMFORT EZINSULIN SYRINGE05ML29G X12 92 CLEVER CHOICE COMFORT EZINSULIN SYRINGE05ML30G X12 92 CLEVER CHOICE COMFORT EZINSULIN

CLINDAGEL 56 clindamycin hcl 11 clindamycin palmitatehydrochloride 11 clindamycin phosphate 11 CLINDAMYCIN PHOSPHATE 52 clindamycin phosphate(topical) 56 clindamycin phosphatevaginal 131 clindamycin phosphate-benzoylperoxide 56 clindamycin phosphate-benzoylperoxide (refrigerate) 56 clindamycin phosphate-tretinoin 56 CLINIMIX 425DEXTROSE10 118 CLINIMIX 425DEXTROSE25 118 CLINIMIX 425DEXTROSE5 118 CLINIMIX 5DEXTROSE25 118 CLINIMIX E 5DEXTROSE20 118 clobazam 17 clobetasol propionate 61 clobetasol propionate emollientbase 61 clocortolone pivalate 61 CLODERM 61

ciprofloxacin-fluocinoloneacetonide cisplatin citalopram hydrobromide CLARINEX clarithromycin

121 34 21 28 76

SYRINGE05ML30G X516 92 CLEVER CHOICE COMFORT EZINSULIN SYRINGE05ML31G X516 92

clofarabine CLOLAR clomipramine hcl clonazepam clonidine

35 35 22 17 31

Index 6

clonidine hcl 31 COMFORT ASSIST INSULIN CVS LANCETS 21G 79 clonidine hcl (adhd) clopidogrel bisulfate clorazepate dipotassium clotrimazole clotrimazole (topical) clotrimazole vaginal clotrimazole wbetamethasone clozapine CLOZARIL COAGUCHEK LANCETS COARTEM

2 72 13

115 57

131

57 43 43 79 33

SYRINGE1ML31G X516 93 COMFORT ASSURED LANCETS MICRO THIN 33G 79 COMFORT ASSURED LANCETS SUPER THIN 28G 79 COMFORT EZ INSULIN SYRINGEU-10005ML31G X516 93 COMFORT EZ INSULIN SYRINGEU-1001ML31G X516 93 COMFORT LANCETS 79

CVS LANCETS MICRO THIN 33G 79 CVS LANCETS MICRO-THIN 33G 79 CVS LANCETS ORIGINAL 79 CVS LANCETS THIN 26G 79 CVS LANCETS ULTRA THIN 30G 79 CVS LANCETS ULTRA-THIN 30G 79 CVS LANCING DEVICE 79 CVS PRENATAL 116 CVS ULTRA THIN LANCETS 79

CODEINE SULFATE codeine sulfate COGENTIN COLACE COLAZAL

6 6

40 75 70

COMPLERA COMTAN CONCERTA CONTRAVE CONZIP

44 41

2 2 6

cyanocobalamin cyclobenzaprine hcl cyclophosphamide cycloserine CYCLOSET

73 117

34 34 24

colchicine 72 colchicine w probenecid 72 COLCRYS 72 colesevelam hcl 29 COLESTID 29 COLESTID FLAVORED 29 colestipol hcl 29 COLY-MYCIN S 121 COLYTE-FLAVOR PACKS 75 COMBIGAN 118 COMBIVIR 44 COMETRIQ 38 COMFORT ASSIST INSULIN

COPAXONE 124 COPIKTRA 38 CORDRAN 61 COREG 48 CORGARD 48 CORLANOR 51 CORTEF 54 CORTENEMA 10 cortisone acetate 54 CORTISPORIN-TC 121 COSENTYX 60 COSENTYX SENSOREADY PEN 60

cyclosporine cyclosporine modified (formicroemulsion) CYKLOKAPRON CYMBALTA cyproheptadine hcl CYSTADANE CYSTAGON CYSTARAN cytarabine CYTOMEL CYTOTEC CYTOVENE

114

114 74 22 28 67 71

120 35

126 128

47 SYRINGE 03ML29G X 12 92 COMFORT ASSIST INSULIN SYRINGE03ML30G X516 92 COMFORT ASSIST INSULIN SYRINGE03ML31G X516 92 COMFORT ASSIST INSULIN SYRINGE05ML29G X 12 92 COMFORT ASSIST INSULIN

COSMEGEN COSOPT COUMADIN COZAAR CREON CRESEMBA CRESTOR CRIXIVAN

37 118

16 31 65 27 29 44

DHE 45 dacarbazine DACOGEN dactinomycin dalfampridine DALIRESP danazol DANTRIUM

111 39 35 37

124 14 10

117 SYRINGE05ML30G X516 92 COMFORT ASSIST INSULIN

cromolyn sodium 13 cromolyn sodium (ophth) 120

dantrolene sodium dapsone

117 11

SYRINGE05ML31G X516 93 COMFORT ASSIST INSULIN SYRINGE1ML29G X 12 93 COMFORT ASSIST INSULIN

crotamiton CUBICIN CUBICIN RF CUPRIMINE

64 11 11

114

DAPTACEL DAPTOMYCIN daptomycin DARAPRIM

126 11 11 33

SYRINGE1ML30G X 516 93 CUTIVATE 61 darifenacin hydrobromide 128 CUVITRU 121

Index 7

DAUNORUBICIN HYDROCHLORIDE 37 DAURISMO 36 DAYPRO 4 DAYTRANA 2 DDAVP 68 DEBACTEROL 115 decitabine 35 deferasirox 25 deferiprone 25 DELESTROGEN 69 DELSTRIGO 44 DELZICOL 70 demeclocycline hcl 125 DEMEROL 6 DENAVIR 60 DEPAKOTE 20 DEPAKOTE ER 20 DEPEN TITRATABS 114 DEPO-ESTRADIOL 69 DEPO-MEDROL 54 DEPO-PROVERA CONTRACEPTIVE 53 DEPO-SUBQ PROVERA 104 53 DEPO-TESTOSTERONE 10 DERMA-SMOOTHEFSBODY 61 DERMA-SMOOTHEFSSCALP 61 DERMOTIC 121 DESCOVY 44 desipramine hcl 22 desloratadine 28 desmopressin acetate 68 DESMOPRESSIN ACETATE 68 desmopressin acetate 68 desmopressin acetate spray 68 desmopressin acetate sprayrefrigerated 68 desogestrel amp ethinylestradiol 52 desogestrel-ethinyl estradiol(biphasic) 52 desogestrel-ethinyl estradiol(triphasic) 52 desonide 61 DESOWEN 61 desoximetasone 61

DESOXYN 1 desvenlafaxine succinate 22 DETROL 128 DETROL LA 128 dexamethasone 54 DEXAMETHASONE INTENSOL 54 dexamethasone sodium phosphate 54 dexamethasone sodium phosphate (ophth) 120 dexchlorpheniraminemaleate 27 DEXEDRINE 1 DEXILANT 127 dexmethylphenidate hcl 2 dextroamphetamine sulfate 1 DEXTROSE 5NACL03 113 dextrose in lactated ringers 113 DEXTROSESODIUMCHLORIDE 113 DIACOMIT 18 DIASTAT ACUDIAL 17 DIASTAT PEDIATRIC 17 DIATHRIVE LANCETS 79 DIATHRIVE LANCETS ULTRA THIN 30G 79 DIATHRIVE LANCING DEVICE 79 diazepam 13 diazepam (anticonvulsant) 17 diazoxide 23 DIBENZYLINE 30 DICLEGIS 26 diclofenac epolamine 57 diclofenac potassium 4 diclofenac sodium 4 diclofenac sodium (actinickeratoses) 59 diclofenac sodium (ophth)120 diclofenac sodium (topical) 57 diclofenac w misoprostol 4 dicloxacillin sodium 122 dicyclomine hcl 127 didanosine 44 DIFFERIN 56 DIFICID 76 diflorasone diacetate 61

DIFLUCAN 27 diflunisal 6 difluprednate 120 digoxin 50 dihydroergotaminemesylate 111 DILANTIN 20 DILANTIN INFATABS 20 DILANTIN-125 20 DILAUDID 6 diltiazem hcl 49 DILTIAZEM HCL 49 diltiazem hcl 49 diltiazem hcl coated beads 49 diltiazem hcl extended release beads 49 dimethyl fumarate 124 DIOVAN 31 DIOVAN HCT 31 DIPENTUM 70 diphenhydramine hcl 27 diphenoxylate w atropine 25 DIPHTHERIATETANUSTOXOIDS ADSORBED PEDIATRIC 126 DIPROLENE 61 DIPROLENE AF 61 dipyridamole 72 disopyramide phosphate 13 disulfiram 123 DITROPAN XL 128 divalproex sodium 20 DIVIGEL 69 docetaxel 40 DOCETAXEL 40 docetaxel 40 docusate calcium 75 docusate sodium 75 dofetilide 13 donepezil hydrochloride 123 DOPTELET 73 DORAL 74 dorzolamide hcl 120 dorzolamide hcl-timolol maleate 118 DOVATO 44 DOVONEX 60 doxazosin mesylate 31

Index 8

doxepin hcl 22 doxepin hcl (antipruritic) 59 doxepin hcl (sleep) 74 doxercalciferol 67 DOXIL 37 doxorubicin hcl 37 doxorubicin hcl liposomal 37 doxycycline(monohydrate) 125126 doxycycline hyclate 126 doxylamine-pyridoxine 26 DRISDOL 132 dronabinol 26 DROPLET GENTEEL LANCING DEVICE 79 DROPLET INSULIN SYRINGE 03ML29G X 12 93 DROPLET INSULIN SYRINGE 05ML29G X 12 93 DROPLET INSULIN SYRINGE 1ML29G X 12 93 DROPLET INSULIN SYRINGE U-1000331G X 516 93 DROPLET INSULIN SYRINGE U-10003ML30G X 12 93 DROPLET INSULIN SYRINGE U-10003ML30G X 516 93 DROPLET INSULIN SYRINGE U-10005ML30G X 12 93 DROPLET INSULIN SYRINGE U-10005ML30G X 516 93 DROPLET INSULIN SYRINGE U-10005ML31G X 516 93 DROPLET INSULIN SYRINGE U-1001ML30G X 12 93 DROPLET INSULIN SYRINGE U-1001ML30G X 516 93 DROPLET INSULIN SYRINGE U-1001ML31G X 1564 93 DROPLET INSULIN SYRINGE U-1001ML31G X 516 93 DROPLET INSULIN SYRINGEU-10003ML31G X516 93 DROPLET INSULIN SYRINGEU-10005ML30G X12 93 DROPLET INSULIN SYRINGEU-10005ML31G X516 93 DROPLET INSULIN SYRINGEU-1001ML30G X12 93 DROPLET INSULIN SYRINGEU-1001ML31G X1564 93

DROPLET INSULIN SYRINGEU-1001ML31G X516 93 DROPLET LANCETS ULTRA THIN 30G 79 DROPLET LANCING DEVICE 79 DROPLET PERSONAL LANCETS30G 79 drospirenone-ethinylestradiol 52 drospirenone-ethinyl estradiol-levomefolate calcium 52 DROXIA 73 DRUG MART ADJUSTABLE LANCING DEVICE 79 DRUG MART LANCETS THIN 79 DRUG MART ON-THE-GO LANCETS GENTLE 30G 79 DRUG MART UNILET LANCETSSUPER THIN 30G 79 DRUG MART UNILET LANCETSULTRA THIN 28G 79 DRUG MART UNILET MICRO THIN LANCETS 33G 79 DUAC 56 DUAVEE 69 DUETACT 23 DULCOLAX 75 duloxetine hcl 22 DUPIXENT 63 DURAGESIC 6 DUREX EXTRA SENSITIVE 76 DUREZOL 120 dutasteride 71 DYAZIDE 65 DYRENIUM 65 DYSPORT 118 E-Z JECT LANCETS 80 E-Z JECT LANCETS 21G 79 E-Z JECT LANCETS COLOR 80 E-Z JECT LANCETS SUPER THIN 30G 80 E-Z JECT LANCETS THIN 26G 80 E-ZJECT LANCETS MICRO-THIN 33G 80 EES GRANULES 76

EASY COMFORT INSULIN SYRINGE05ML30G X516 93 EASY COMFORT INSULIN SYRINGE05ML31G X516 93 EASY COMFORT INSULIN SYRINGE1ML30G X 516 94 EASY COMFORT INSULIN SYRINGE1ML31G X 516 94 EASY COMFORT INSULIN SYRINGEU-10005ML30G X12 94 EASY COMFORT INSULIN SYRINGEU-1001ML30G X12 94 EASY MINI EJECT LANCING DEVICE 80 EASY MINI LANCING DEVICE 80 EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML29GX12 94 EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML30GX12 94 EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML30GX516 94 EASY TOUCH FLIPLOCK SAFETY INSULIN SYRINGE 1ML31GX516 94 EASY TOUCH INSULIN SYRINGE03ML30G X516 94 EASY TOUCH INSULIN SYRINGE03ML31G X516 94 EASY TOUCH INSULIN SYRINGE05ML29G X 12 94 EASY TOUCH INSULIN SYRINGE05ML30G X516 94 EASY TOUCH INSULIN SYRINGE1ML30G X 516 94 EASY TOUCH INSULIN SYRINGESAFETYU-10005ML29G X 12 94 EASY TOUCH INSULIN SYRINGESAFETYU-10005ML30G X 516 94 EASY TOUCH INSULIN SYRINGESAFETYU-1001ML29G X 12 94 EASY TOUCH INSULIN SYRINGESAFETYU-1001ML30G X 12 94

Index 9

EASY TOUCH INSULIN EASY TOUCH LANCETS EFFIENT 72 SYRINGEU-10003ML30G X12 94 EASY TOUCH INSULIN SYRINGEU-10005ML27G X12 94 EASY TOUCH INSULIN SYRINGEU-10005ML28G X12 94 EASY TOUCH INSULIN SYRINGEU-10005ML29G X12 94 EASY TOUCH INSULIN SYRINGEU-10005ML30G X12 94 EASY TOUCH INSULIN SYRINGEU-10005ML31G X516 94 EASY TOUCH INSULIN SYRINGEU-1001ML27G X12 94 EASY TOUCH INSULIN SYRINGEU-1001ML28G X12 94 EASY TOUCH INSULIN SYRINGEU-1001ML29G X12 94 EASY TOUCH INSULIN SYRINGEU-1001ML30G X12 94 EASY TOUCH INSULIN SYRINGEU-1001ML31G X516 95 EASY TOUCH LANCETS 21GPRESSUREACTIVATED 80 EASY TOUCH LANCETS 23GPRESSUREACTIVATED 80 EASY TOUCH LANCETS 26GPRESSUREACTIVATED 80 EASY TOUCH LANCETS 26GPULL-TOP 80 EASY TOUCH LANCETS 28GPRESSUREACTIVATED 80 EASY TOUCH LANCETS 28GPULL-TOP 80 EASY TOUCH LANCETS

30GTWIST 80 EASY TOUCH LANCETS 32GPRESSUREACTIVATED 80 EASY TOUCH LANCETS 32GPULL-TOP 80 EASY TOUCH LANCETS 32GTWIST 80 EASY TOUCH LANCETS 33GTWIST 80 EASY TOUCH LANCING DEVICEEJECTOR 80 EASY TOUCH SAFETY LANCETS21GPRESSUREACTIVATED 80 EASY TOUCH SAFETY LANCETS23GPRESSUREACTIVATED 80 EASY TOUCH SAFETY LANCETS26GBUTTONACTIVATED 80 EASY TOUCH SAFETY LANCETS26GPRESSUREACTIVATED 80 EASY TOUCH SAFETY LANCETS28GBUTTONACTIVATED 80 EASY TOUCH SAFETY LANCETS28GPRESSUREACTIVATED 80 EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML29GX12 95 EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML30GX516 95 EASY TOUCH SHEATHLOCK SAFETY INSULIN SYRINGE 1ML31GX516 95 EASY TOUCH SHEATHLOCK SAFETY SYRINGE 1ML30GX12 95 EASY TWIST amp CAP LANCETS 80 EC-NAPROSYN 4 econazole nitrate 57 EDARBI 31 EDECRIN 65

EFUDEX 59 EGRIFTA 67 EGRIFTA SV 67 ELAPRASE 67 ELELYSO 72 ELESTRIN 69 eletriptan hydrobromide 112 ELIDEL 63 ELIGARD 36 ELIMITE 64 ELIQUIS 16 ELIQUIS STARTER PACK 16 ELITE-THIN INSULIN SYRINGE03ML31G X516 95 ELITE-THIN INSULIN SYRINGE05ML29G X 12 95 ELITE-THIN INSULIN SYRINGE05ML30G X516 95 ELITE-THIN INSULIN SYRINGE1ML30G X 516 95 ELITE-THIN INSULIN SYRINGEU-10005ML28G X12 95 ELITE-THIN INSULIN SYRINGEU-10005ML31G X516 95 ELITE-THIN INSULIN SYRINGEU-1001ML28G X12 95 ELITE-THIN INSULIN SYRINGEU-1001ML29G X12 95 ELITE-THIN INSULIN SYRINGEU-1001ML31G X516 95 ELIXOPHYLLIN 15 ELLA 53 ELLENCE 37 ELMIRON 71 ELOCON 61 EMBRACE LANCETS ULTRA THIN 30G 80

28GTWIST EASY TOUCH LANCETS 30GBUTTON-ACTIVATED EASY TOUCH LANCETS 30GPRESSUREACTIVATED EASY TOUCH LANCETS 30GPULL-TOP

80

80

80

80

EDURANT 44 efavirenz 44 efavirenz-emtricitabine-tenofovir disoproxilfumarate 44 efavirenz-lamivudine-tenofovir disoproxil fumarate 45 EFFEXOR XR 22

EMBRACE LANCING DEVICE WITH EJECTOR 80 EMCYT 36 EMEND 26 EMEND TRIPACK 26 EMFLAZA 54 EMGALITY 111

Index 10

EMSAM 20 EQL INSULIN ethacrynic acid 65 SYRINGE05ML30G Xemtricitabine 45 ethambutol hcl 34 516 95 emtricitabine-tenofovir disoproxil ethosuximide 20 EQL INSULIN fumarate 45 SYRINGE05ML31G X ethynodiol diacet amp eth

EMTRIVA 45 estrad 52 516 95 EMVERM 10 EQL INSULIN etidronate disodium 66 ENABLEX enalapril maleate enalapril maleate amphydrochlorothiazide ENBREL ENBREL MINI ENBREL SURECLICK ENGERIX-B enoxaparin sodium entacapone entecavir ENTEREG

128 30

31 5 5 5

129 16 41 47 71

SYRINGE1ML29G X 12 95 EQL INSULIN SYRINGE1ML30G X516 95 EQL INSULIN SYRINGE1ML31G X516 95 EQL PRENATAL FORMULA 116 EQL SUPER THIN LANCETS 30G 80 EQL THIN LANCETS 26G 80 EQUETRO 42 ERAXIS 27

etodolac 4 etonogestrel-ethinyl estradiol53 ETOPOPHOS 40 etoposide 40 etravirine 45 EUCRISA 64 EURAX 64 EVAMIST 69 everolimus 38 everolimus (immunosuppressant) 115 EVISTA 67

ENTOCORT EC 54 ERBITUX 36 EVOCLIN 56 ENTRESTO 50 EPCLUSA 47 EPIDIOLEX 18 EPIDUO 56 epinastine hcl (ophth) 120 epinephrine (anaphylaxis) 132 EPIPEN 2-PAK 132 EPIPEN-JR 2-PAK 132 epirubicin hcl 37 EPIVIR 45 EPIVIR HBV 47 eplerenone 32 EPOGEN 73 epoprostenol sodium 50 eprosartan mesylate 31 EPZICOM 45 EQL COLOR LANCETS 21G80 EQL COLOR LANCETS MICRO THIN 33G 80 EQL INSULIN SYRINGE03ML29G X 12 95 EQL INSULIN SYRINGE03ML30G X516 95 EQL INSULIN SYRINGE03ML31G X516 95 EQL INSULIN SYRINGE05ML29G X 12 95

ergocalciferol ergoloid mesylates ERGOMAR ergotamine w caffeine ERIVEDGE erlotinib hcl ERTACZO ertapenem sodium ERWINASE ERWINAZE ERYPED 200 ERYPED 400 erythromycin (acne aid) erythromycin (ophth) erythromycin base erythromycinethylsuccinate escitalopram oxalate ESGIC esomeprazolemagnesium estazolam ESTRACE estradiol estradiol vaginal estradiol valerate ESTROGEL ESTROSTEP FE eszopiclone

132 124 111 111

36 36 57 11 39 39 76 76 56

119 76

76 21

6

128 74 69 69

132 69 69 52 74

EVOXAC 116 EXEL COMFORT POINT INSULIN SYRINGE03ML29G X12 95 EXEL COMFORT POINT INSULIN SYRINGE03ML30G X516 95 EXEL COMFORT POINT INSULIN SYRINGE05ML28G X12 95 EXEL COMFORT POINT INSULIN SYRINGE05ML29G X12 95 EXEL COMFORT POINT INSULIN SYRINGE05ML30G X516 95 EXEL COMFORT POINT INSULIN SYRINGE1ML28G X12 96 EXEL COMFORT POINT INSULIN SYRINGE1ML29G X12 96 EXEL COMFORT POINT INSULIN SYRINGE1ML30G X516 96 EXELDERM 57 exemestane 36 EXFORGE 31 EXFORGE HCT 31 EXJADE 25 EXTAVIA 124 EZ-LETS LANCETS 21G 80 EZ-LETS LANCETS 26G SUPER-SOFT 80

Index 11

EZ-LETS LANCETS 28G ULTRA-SOFT 80 EZ-LETS LANCETS 30G 80 ezetimibe 30 ezetimibe-simvastatin 29 FABRAZYME 67 FALESSA 52 famciclovir 47 famotidine 127 famotidine in nacl 127 FANAPT 42 FANAPT TITRATION PACK 42 FANTASY LUBRICATED 76 FANTASY LUBRICATEDSPERMICIDE

76 FARESTON 36 FARXIGA 25 FASENRA 13 FASENRA PEN 13 FASLODEX 36

FIASP 24 FIASP FLEXTOUCH 24 FIASP PENFILL 24 FIBERCON 75 FIBRICOR 29 FIFTY50 SAFETY SEAL LANCETS 30G 81 FIFTY50 SAFETY SEAL LANCETS 32G 81 FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE03ML31G X516 96 FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE05ML31G X516 96 FIFTY50 SUPERIOR COMFORTINSULIN SYRINGE1ML31G X516 96 FIFTY50 UNILET LANCETS 33G 81 FINACEA 64

FLUAD QUADRIVALENT 2021-2022 129 FLUAD QUADRIVALENT INFLUENZA VACCINE FOR ADULTS 130 FLUARIX QUADRIVALENT 2019-2020 130 FLUARIX QUADRIVALENT 2020-2021 130 FLUARIX QUADRIVALENT 2021-2022 130 FLUBLOK QUADRIVALENT 2019-2020 130 FLUBLOK QUADRIVALENT 2020-2021 130 FLUBLOK QUADRIVALENT 2021-2022 130 FLUCELVAX QUADRIVALENT 2019-2020 130 FLUCELVAX QUADRIVALENT 2020-2021 130 FLUCELVAX QUADRIVALENT 2021-2022 130 fluconazole 27 flucytosine 27

FAZACLO 43 finasteride 71 fludarabine phosphate 35 FC FEMALE CONDOM febuxostat felbamate FELBATOL FELDENE felodipine FEMARA FEMCAP FEMHRT FEMRING fenofibrate fenofibrate micronized

76 72 19 19

4 49 36 76 69

132 29 29

FINE 30 FINGERSTIX LANCETS FIORICET FIORICETCODEINE FIORINAL FIORINALCODEINE 3 FIRAZYR FIRDAPSE FIRMAGON FIRVANQ FLAGYL flavoxate hcl

81 81

6 8 6 8

72 33 36 11 10

129

fludrocortisone acetate 55 FLULAVAL QUADRIVALENT 2019-2020 130 FLULAVAL QUADRIVALENT 2020-2021 130 FLULAVAL QUADRIVALENT 2021-2022 130 FLUMADINE 48 FLUMIST QUADRIVALENT130 flunisolide (nasal) 118 fluocinolone acetonide 6162 fluocinolone acetonide (otic) 121 fluocinonide 62

fenoprofen calcium 4 flecainide acetate 13 fluocinonide emulsified base 62 FENSOLVI fentanyl

67 6

FLECTOR FLOLAN

57 50

fluorometholone (ophth) fluorouracil

120 35

fentanyl citrate FENTORA

6 6

FLOMAX FLONASE ALLERGY

71 fluorouracil (topical) fluoxetine hcl

59 21

FER-IN-SOL 73 FERRIPROX 25 ferrous fumarate-folic acid 73 ferrous sulfate 73 FETZIMA 22 FETZIMA TITRATION PACK22 fexofenadine hcl 28 fexofenadine-pseudoephedrine

55

RELIEF 118 FLONASE ALLERGY RELIEF CHILDRENS 118 FLOVENT DISKUS 14 FLOVENT HFA 14 floxuridine 35 FLUAD 2019-2020 129 FLUAD 2020-2021 129

FLUOXETINE HYDROCHLORIDE fluphenazine hcl flurandrenolide flurazepam hcl flurbiprofen flurbiprofen sodium flutamide

21 44 62 74

4 121

36

Index 12

fluticasone propionate 62 fluticasone propionate(nasal) 118 fluticasone-salmeterol 15 fluvastatin sodium 2930 fluvoxamine maleate 21 FLUZONE HIGH-DOSE PF 2019-2020 130 FLUZONE HIGH-DOSE PF 2020-2021 130 FLUZONE HIGH-DOSE PF 2021-2022 130 FLUZONE QUADRIVALENT 2019-2020 130 FLUZONE QUADRIVALENT 2020-2021 130 FLUZONE QUADRIVALENT 2021-2022 131

FREESTYLE LANCETS 81 FREESTYLE PRECISION INSULIN SYRINGEU-10005ML30G X 516 96 FREESTYLE PRECISION INSULIN SYRINGEU-10005ML31G X 516 96 FREESTYLE PRECISION INSULIN SYRINGEU-1001ML31G X 516 96 FREESTYLE PRECISION INSULIN SYRINGESU-1001ML30G X 516 96 FREESTYLE UNISTICK II LANCETS 81 FROVA 112 frovatriptan succinate 112 FULPHILA 73

GENTEEL LANCING DEVICEGLORIOUS GOLD 81 GENTEEL LANCING DEVICEPRECIOUSPLATINUM 81 GENTEEL LANCING DEVICESTATELY SILVER 81 GENTEEL PLUS LANCING DEVICEBUFF BLACK 81 GENTEEL PLUS LANCING DEVICEBUTTERFLY BLUE 81 GENTEEL PLUS LANCING DEVICEPLAYFUL PURPLE 81 GENTEEL PLUS LANCING DEVICEPRINCESS PINK 81 GENTEEL PLUS LANCING DEVICEWILLOWY WHITE 81 GENTLE-LET GP LANCETS 81 GENTLE-LET LANCETS

FML 120 fulvestrant 36 GENERAL PURPOSE FML FORTE FML LIQUIFILM FOCALIN FOCALIN XR folic acid FOLOTYN

120 120

2 2

73 35

furosemide FUZEON FYCOMPA gabapentin GABITRIL GALAFOLD

65 45 17 18 19 67

STYLEFINE POINT GENTLE-LET LANCETS GENERAL PURPOSE STYLEMEDIUM POINT GENTLE-LET LANCETS SAFETY STYLEFINEPOINT GENTLE-LET LANCETS

81

81

81

fondaparinux sodium 16 FORA GTEL BLOOD KETONE TEST STRIPS 64

galantaminehydrobromide GAMMAGARD LIQUID

123 121

SAFETY STYLEMEDIUMPOINT GENVOYA

81 45

FORA LANCETS 81 FORA LANCING DEVICE 81 FORA LANCING DEVICECLEARCAP 81 FORFIVO XL 20 FORTAZ 52 FOSAMAX 66 FOSAMAX PLUS D 66 fosamprenavir calcium 45 fosfomycin tromethamine 12 fosinopril sodium 30 fosinopril sodium amphydrochlorothiazide 31 fosphenytoin sodium 20 FOSRENOL 71 FRAGMIN 16 FREDS PHARMACY AUTOLET LANCING DEVICE 81 FREDS PHARMACY UNILET LANCETS SUPER THIN 30G 81 FREDS PHARMACY UNILET LANCETS ULTRA THIN 28G 81

GAMMAGARD SD IGA LESSTHAN 1MCGML 122 GAMMAKED 122 GAMUNEX-C 122 ganciclovir sodium 47 ganirelix acetate 66 GANIRELIX ACETATE 67 GARDASIL 9 131 gatifloxacin (ophth) 119 gemcitabine hcl 35 GEMCITABINE HYDROCHLORIDE 35 gemfibrozil 29 GENERESS FE 52 GENOTROPIN 67 GENOTROPIN MINIQUICK 67 gentamicin in saline 3 gentamicin sulfate 3 gentamicin sulfate(ophth) 119 gentamicin sulfate (topical) 57 GENTEEL BUTTERFLY TOUCH LANCETS 81

GEODON 42 GILENYA 124 GILOTRIF 36 glatiramer acetate 124 GLEEVEC 38 GLEOSTINE 34 glimepiride 25 glipizide 25 glipizide-metformin hcl 23 GLOBAL EASY GLIDE INSULIN SYRINGE1ML31G X1564 96 GLOBAL EASY GLIDE INSULINSYRINGEU-10003ML31G X 516 96 GLOBAL INJECT EASE INSULIN SYRINGEU-10003ML29G X12 96 GLOBAL INJECT EASE INSULIN SYRINGEU-10003ML30G X12 96 GLOBAL INJECT EASE INSULIN SYRINGEU-10003ML30G X516 96

Index 13

GLOBAL INJECT EASE INSULIN GLUCOPRO INSULIN GNP INSULIN SYRINGEU-10003ML31G X516 96 GLOBAL INJECT EASE INSULIN SYRINGEU-10005ML28G X12 96 GLOBAL INJECT EASE INSULIN SYRINGEU-10005ML29G X12 96 GLOBAL INJECT EASE INSULIN SYRINGEU-10005ML30G X12 96 GLOBAL INJECT EASE INSULIN

SYRINGEU-10005ML30G X12 97 GLUCOPRO INSULIN SYRINGEU-10005ML30G X516 97 GLUCOPRO INSULIN SYRINGEU-10005ML31G X516 97 GLUCOPRO INSULIN SYRINGEU-1001ML30G X12 97 GLUCOPRO INSULIN

SYRINGE1ML31G X 516 97 GNP INSULIN SYRINGES03ML30GX516

97 GNP INSULIN SYRINGES12ML29GX12

97 GNP INSULIN SYRINGES1ML28GX12 97 GNP INSULIN SYRINGES1ML29GX12 97 GNP INSULIN

SYRINGEU-10005ML30G X516 96 GLOBAL INJECT EASE INSULIN SYRINGEU-10005ML31G X516 96 GLOBAL INJECT EASE INSULIN

SYRINGEU-1001ML30G X516 97 GLUCOPRO INSULIN SYRINGEU-1001ML31G X516 97 GLUCOTROL 25

SYRINGES1ML30GX516 98 GNP INSULIN SYRINGES3ML31GX516 98 GNP LANCETS 21G 81 GNP LANCETS MICRO THIN 33G 81

SYRINGEU-1001ML28G X12 96 GLOBAL INJECT EASE INSULIN SYRINGEU-1001ML29G X12 96 GLOBAL INJECT EASE INSULIN SYRINGEU-1001ML30G X12 96 GLOBAL INJECT EASE INSULIN

GLUCOTROL XL glyburide glyburide micronized glyburide-metformin glycine (gu irrigant) glycopyrrolate GLYNASE

25 25 25 23 71

127 25

GNP LANCETS SUPER THIN 30G 81 GNP LANCETS THIN 81 GNP LANCETS THIN 26G 81 GNP LANCING SYSTEM DEVICE 81 GNP PRENATAL 116 GNP ULTRA COMFORT

SYRINGEU-1001ML30G X516 97 GLOBAL INJECT EASE INSULIN SYRINGEU-1001ML31G X516 97 GLOBAL INSULIN SYRINGEU-10003ML30G X 12 97 GLOBAL INSULIN SYRINGESU-10003ML30GX516 97 GLOBAL LANCING DEVICE 81 GLUCAGEN DIAGNOSTIC 64 GLUCAGEN HYPOKIT 23 glucagon (rdna) 23 GLUCAGON EMERGENCY KIT 24 GLUCOCOM LANCETS 28G 81 GLUCOCOM LANCETS 30G 81 GLUCOCOM LANCETS 33G 81 GLUCOPRO INSULIN SYRINGEU-10003ML30G X12 97 GLUCOPRO INSULIN SYRINGEU-10003ML30G X516 97 GLUCOPRO INSULIN SYRINGEU-10003ML31G X516 97

GLYSET 23 GLYXAMBI 23 GNP INSULIN SYRINGE03ML29G X12 97 GNP INSULIN SYRINGE03ML30G X516 97 GNP INSULIN SYRINGE03ML31G X516 97 GNP INSULIN SYRINGE05ML28G X12 97 GNP INSULIN SYRINGE05ML29G X12 97 GNP INSULIN SYRINGE05ML30G X516 97 GNP INSULIN SYRINGE05ML31G X516 97 GNP INSULIN SYRINGE1ML28G X 12 97 GNP INSULIN SYRINGE1ML29G X 12 97 GNP INSULIN SYRINGE1ML30G X516 97

INSULIN SYRINGE03ML29G X12 98 GNP ULTRA COMFORT INSULIN SYRINGE03ML30G X516 SHORT 98 GNP ULTRA COMFORT INSULIN SYRINGE05ML28G X12 98 GNP ULTRA COMFORT INSULIN SYRINGE05ML29G X12 98 GNP ULTRA COMFORT INSULIN SYRINGE1ML28G X12 98 GNP ULTRA COMFORT INSULIN SYRINGE1ML29G X12 98 GOJJI BLOOD KETONE TEST STRIPS 64 GOJJI LANCING DEVICECLEAR CAP 81 GOJJI STERILE LANCETS 30G 82 GOLYTELY 75 GOODSENSE COLOR LANCETS MICRO-THIN 33G UNIVERSAL 82 GOODSENSE LANCETS MICRO-THIN 33G 82

Index 14

GOODSENSE LANCETS MICRO-THIN 33G UNIVERSAL 82 GOODSENSE LANCETS ULTRA-THIN 26G UNIVERSAL 82 GOODSENSE LANCETS ULTRA-THIN 30G 82 GOODSENSE LANCETS ULTRA-THIN 30G UNIVERSAL 82 GOODSENSE LANCING DEVICE 82 GOODSENSE PRENATAL VITAMINS 116 granisetron hcl 26 GRASTEK 3 griseofulvin microsize 27 griseofulvin ultramicrosize 27 guanfacine hcl 31 guanfacine hcl (adhd) 2 GUANIDINE HCL 33 GVOKE PFS 24 GYNAZOLE-1 131 GYNE-LOTRIMIN 131 H-E-B INCONTROL ADVANCEDLANCING DEVICE 82 H-E-B INCONTROL LANCETS MICRO THIN 33G 82 H-E-B INCONTROL LANCETS SUPER THIN 30G 82 H-E-B INCONTROL LANCETS ULTRA THIN 28G 82 HAEGARDA 72 HAEMOLANCE 82 HAEMOLANCE LOW FLOW LANCETS 82 HAEMOLANCE PLUS 82 HAEMOLANCE PLUS HIGH FLOW 82 HAEMOLANCE PLUS LOW FLOW 82 HAEMOLANCE PLUS MAX FLOW 82 HAEMOLANCE PLUS PEDIATRIC FLOW 82 HALAVEN 40 halcinonide 62 HALCION 74 HALDOL 43 HALDOL DECANOATE 100 42 HALDOL DECANOATE 50 43 halobetasol propionate 62

HALOG 62 haloperidol 43 haloperidol decanoate 43 haloperidol lactate 43 HAVRIX 131 HEALTH CARE LANCING DEVICE 82 HEALTHWISE INSULIN SYRINGEU-10003ML30G X516 98 HEALTHWISE INSULIN SYRINGEU-10003ML31G X516 98 HEALTHWISE INSULIN SYRINGEU-10005ML30G X516 98 HEALTHWISE INSULIN SYRINGEU-10005ML31G X516 98 HEALTHWISE INSULIN SYRINGEU-1001ML30G X516 98 HEALTHWISE INSULIN SYRINGEU-1001ML31G X516 98 HEALTHY ACCENTS AUTOLET IMPRESSION LANCING DEVICE 82 HEALTHY ACCENTS UNILET LANCETS SUPER THIN 30G 82 HECTOROL 67 HEMANGEOL 48 HEPARIN LOCK FLUSH 16 heparin sod (porcine) ind5w 16 heparin sodium (porcine) 16 HEPARIN SODIUMNACL045 17 HEPLISAV-B 131 HEPSERA 47 HERCEPTIN 36 HETLIOZ 74 HIBERIX 129 HIPREX 12 HIZENTRA 122 HM PRENATAL 116 HM ULTICARE INSULIN SYRINGE1ML30G X 12 98 HM ULTICARE INSULIN SYRINGEU-10003ML31G X516 98 HORIZANT 124 HUMATIN 3

HUMATROPE 67 HUMATROPE COMBO PACK 67 HUMIRA 4 HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK 3 HUMIRA PEN 3 HUMIRA PEN-CDUCHSSTARTER 34 HUMIRA PEN-PEDIATRIC UC STARTER PACK 4 HUMIRA PEN-PSUVSTARTER 4 HUMULIN R U-500 (CONCENTRATED) 24 HUMULIN R U-500 KWIKPEN 24 HY-VEE LANCETS 82 HY-VEE THIN LANCETS 82 HYCAMTIN 40 hydralazine hcl 32 HYDREA 39 HYDRO 35 63 hydrochlorothiazide 66 hydrocodone bitartrate 6 HYDROCODONE BITARTRATE ER 6 hydrocodone polistirex-chlorpheniramine polistirex 55 hydrocodone-acetaminophen 8 hydrocodone-ibuprofen 8 hydrocortisone 54 hydrocortisone (intrarectal) 10 hydrocortisone (rectal) 10 hydrocortisone (topical) 62 hydrocortisone acetate(rectal) 10 hydrocortisone butyrate 62 hydrocortisone valerate 62 hydrocortisone waceticacid 121 hydromorphone hcl 6 HYDROMORPHONE HYDROCHLORIDE 6 hydroxychloroquine sulfate 33 hydroxyurea 39 hydroxyzine hcl 1213 hydroxyzine pamoate 13 HYPER-SAL 55 HYPERSAL 55 HYQVIA 122

Index 15

HYZAAR 32 INSULIN SYRINGE05ML27G INSULIN X 12 98 SYRINGES05ML31GX516ibandronate sodium 66 INSULIN SYRINGE05ML28G 99 IBRANCE 38 X 12 98 INSULIN

ibuprofen 5 INSULIN SYRINGE05ML30G SYRINGES1ML27GX12 99 X 12 98 INSULIN icatibant acetate 72 INSULIN SYRINGE05ML30G SYRINGES1ML27GX12 99 ICLUSIG 38 X 516 98 INSULIN

icosapent ethyl 29 INSULIN SYRINGE05ML31G SYRINGES1ML28GX12 99 IDAMYCIN PFS 37 X 516 98 INSULIN

INSULIN SYRINGE1ML28G X SYRINGES1ML29GX12 99 idarubicin hcl 37 12 98 INSULIN IFEX 34 INSULIN SYRINGE1ML29G X SYRINGES1ML30GX12 99 ifosfamide 34 12 98 INSULIN ILARIS 4 INSULIN SYRINGE1ML30G X SYRINGES1ML31GX516 99

516 99 INTELENCE 45 ILEVRO 121 INSULIN SYRINGENEEDLE INTRAROSA 131 imatinib mesylate 38 03ML30G X 516 99 IMBRUVICA 38 INSULIN SYRINGENEEDLE INTRON A 39

03ML31G X 516 99 INTUNIV 2 imipenem-cilastatin 11 INSULIN SYRINGENEEDLE INVANZ 11 imipramine hcl 22 05ML29G X 12 99 INVEGA 42 imipramine pamoate 22 INSULIN SYRINGENEEDLE05ML30G X 516 99 INVIRASE 45 imiquimod 63 INSULIN SYRINGENEEDLE IONOSOL-MBDEXTROSEIMITREX 112 05ML31G X 516 99 5 113

IMITREX STATDOSE INSULIN SYRINGENEEDLE IOPIDINE 119 REFILL 112 1ML29G X 12 99 IPOL INACTIVATED IPV 131 IMITREX STATDOSE INSULIN SYRINGENEEDLESYSTEM 112 1ML30G X 516 99 ipratropium bromide 14 IMODIUM A-D 25 INSULIN SYRINGENEEDLE ipratropium bromide (nasal)118 IMPAVIDO 10 1ML31G X 516 99 ipratropium-albuterol 15 INSULIN SYRINGEU-IMURAN 115 irbesartan 31 10003ML29G X 12 99 IN TOUCH LANCING INSULIN SYRINGEU- irbesartan-hydrochlorothiazideDEVICE 82 10005ML29G X 12 99 32 IN TOUCH STERILE INSULIN SYRINGEU- irinotecan hcl 40 LANCETS30G 82 1001ML29G X 12 99 irrigation solutionsINCRELEX 67 INSULIN SYRINGEU- physiological 115 INCRUSE ELLIPTA 14 1001ML30G X 516 99 ISENTRESS 45

INSULIN SYRINGEU-indapamide 66 ISENTRESS HD 45 1001ML31G X 516 99 INDERAL LA 49 ISOLYTE-PDEXTROSEINSULIN 5 113 indomethacin 5 SYRINGES05ML27GX12ISOLYTE-S 113 99 INFANRIX 126

INSULIN isoniazid 34 INFLECTRA 70 SYRINGES05ML28GX12 ISOPTO CARPINE 119 INLYTA 35 99 ISORDIL TITRADOSE 12 INREBIC 38 INSULIN SYRINGES05ML29GX12 isosorbide dinitrate 12 INSPRA 32

INSULIN SYRINGE03ML29G X 99 isosorbide mononitrate 12 INSULIN 1 98 isotretinoin 56 SYRINGES05ML30GX516INSULIN SYRINGE03ML29G X

99 isradipine 49 12 98 INSULIN ISTODAX (OVERFILL) 38 INSULIN SYRINGE03ML30G X516 98 SYRINGES05ML31GX itraconazole 27

516 INSULIN SYRINGE03ML31G X 99 ivermectin 10 516 98 IVERMECTIN 64

Index 16

ivermectin (pediculicide) 64 KIMONO PLUS SPERMICIDE KROGER INSULIN LUBRICATED 76 SYRINGE03ML29G XIXEMPRA KIT 40 KIMONO PLUS 12 100 JADENU 25 SPERMICIDELUBRICATED KROGER INSULIN

JADENU SPRINKLE 25 76 SYRINGE03ML30G XJAKAFI 38 KIMONO PS 516 100

LUBRICATED 76 KROGER INSULIN JANUMET 23 KIMONO PS PLUS SYRINGE03ML31G XJANUMET XR 23 SPERMICIDELUBRICATED 516 100 JANUVIA 24 76 KROGER INSULIN

KIMONO SENSATION SYRINGE05ML29G XJARDIANCE 25 LUBRICATED 76 12 100 JEVTANA 40 KIMONO SENSATION PLUS KROGER INSULIN JUBLIA 57 SPERMICIDE SYRINGE05ML30G XJULUCA 45 LUBRICATED 76 516 100

KIMONO SPECIAL 76 KROGER INSULIN JYNARQUE 68 SYRINGE05ML31G XKINNEY LANCETS 82 K-TAB 114 516 100 KINNEY THIN LANCETS 82 K-Y ME amp YOU EXTRA KROGER INSULIN LUBRICATED 76 KINRAY INSULIN SYRINGE SYRINGE1ML29G X 12 100 K-Y ME amp YOU INTENSE 76 PREFERRED KROGER INSULIN

PLUS03ML31G X 516 99 SYRINGE1ML30G XKADIAN 6 KINRAY INSULIN SYRINGE 516 100 KALETRA 45 PREFERRED KROGER INSULIN KALYDECO 125 PLUS05ML31G X 516 99 SYRINGE1ML31G X

KINRAY INSULIN SYRINGE KAMELEON LUBRICATED 76 516 100 PREFERRED PLUS1ML31G KROGER LANCETS 82 KAPVAY 2 X 516 99 KROGER LANCETS 21G 82 KAZANO 23 KINRAY INSULIN

KCL 03D5WNACL SYRINGE05ML29G X KROGER LANCETS MICRO 09 113 12 99 THIN33G 82

KROGER LANCETS SUPER KEFLEX 51 KINRIX 126 THIN 82 KENALOG-40 54 KISQALI 38 KROGER LANCETS THIN 82 KEPIVANCE 40 KISQALI FEMARA 200 KROGER LANCETS THIN DOSE 38 KEPPRA 18 26G 82 KISQALI FEMARA 400 KROGER LANCETS KEPPRA XR 18 DOSE 38 ULTRATHIN30G 82 KERYDIN 58 KISQALI FEMARA 600 KROGER LANCING DOSE 38 ketoconazole 27 DEVICE 82 KITABIS PAK 3 ketoconazole (topical) 58 KRYSTEXXA 72

KLARITY-A 119 KETONE 64 KUVAN 68 KLARON 56 KETONE TEST STRIPS 64 KYLEENA 53 KLONOPIN 17 ketoprofen 5 KYPROLIS 38 KMART VALU PLUS INSULIN ketorolac tromethamine 5 labetalol hcl 48 SYRINGE1ML29G 100

ketorolac tromethamine KMART VALU PLUS INSULIN LAC-HYDRIN 63 (ophth) 121 SYRINGE1ML30G 100 LAC-HYDRIN TWELVE 63 KETOSTIX 64 KOSELUGO 38 LACRISERT 118 ketotifen fumarate (ophth) 121 KP PRENATAL lactated ringers 113 KEVEYIS 65 MULTIVITAMINS 116

lactated ringers (irrigation) 115 KRINTAFEL 33 KHEDEZLA 22 lactic acid (ammoniumKROGER AUTOLET LANCING KIMONO COLORS 76 lactate) 63 DEVICE 82 KIMONO LUBRICATED 76 lactulose 75 KROGER HEALTHPRO TWIST KIMONO MICRO THIN PLUS LANCETS26G 82 lactulose (encephalopathy) 70 SPERMICIDE LUBRICATED76 LAMICTAL 18

Index 17

LAMICTAL CHEWABLE LEADER ADVANCED leuprolide acetate 36 DISPERSIBLE 18 LANCING DEVICE 83 levalbuterol hcl 15 LAMICTAL ODT 18 LEADER INSULIN

levalbuterol tartrate 15 SYRINGE03ML29G XLAMICTAL XR 18 12 100 LEVAQUIN 69 lamivudine 45 LEADER INSULIN LEVEMIR 24 lamivudine (hbv) 47 SYRINGE03ML30G X LEVEMIR FLEXTOUCH 24 lamivudine-zidovudine 45 516 100

LEADER INSULIN levetiracetam 18 lamotrigine 18 SYRINGE03ML31G X levobunolol hcl 118 LANCET DEVICE 516 100 levocetirizine dihydrochloride28 ADJUSTABLE 82 LEADER INSULIN LANCET DEVICE WITH levofloxacin 69 SYRINGE05ML28G XEJECTOR 82 12 100 levofloxacin (ophth) 119 LANCETS 83 LEADER INSULIN levofloxacin in d5w 69 LANCETS 26G TWIST TOP 83 SYRINGE05ML29G X levonorgestrel amp eth

12 100 LANCETS 30G 83 estradiol 52 LEADER INSULIN levonorgestrel (emergencyLANCETS 30G TWIST TOP 83 SYRINGE05ML30G X oc) 53 LANCETS 30GTWIST TOP 83 516 100 levonorgestrel-eth estradiolLANCETS 31G TWIST TOP 83 LEADER INSULIN (triphasic) 52 LANCETS 33G EXTRA SYRINGE05ML31G X levonorgestrel-ethinyl estradiolFINE 83 516 100 (91-day) 52 LANCETS MICRO THIN LEADER INSULIN levonorgestrel-ethinyl estradiol33G 83 SYRINGE1ML28G X (continuous) 52

12 100 LANCETS SAFETY SEAL levorphanol tartrate 6 LEADER INSULIN 21G 83 levothyroxine sodium LANCETS SAFETY SEAL SYRINGE1ML29G X 126

26G 83 12 100 LEXAPRO 21 LANCETS SAFETY SEAL LEADER INSULIN LEXIVA 45 28G 83 SYRINGE1ML30G X LIALDA 70 LANCETS SAFETY SEAL 516 100 LIBERTY MEDICAL LANCETS 30G 83 LEADER INSULIN 30G 83 LANCETS SUPER THIN SYRINGE1ML31G X LIBERTY MINI LANCING 28G 83 516 100 DEVICE 83 LANCETS THIN 83 leflunomide 5 LIBRAX 127 LENVIMA 10 MG DAILY LANCETS TWIST TOP 83 lidocaine 63 DOSE 35 LANCETS ULTRA THIN 83 LENVIMA 12MG DAILY lidocaine hcl 63 LANCETS ULTRA THIN DOSE 35 lidocaine hcl (local anesth) 75 30G 83 LENVIMA 14 MG DAILY LANCETSBULLSEYE lidocaine hcl (mouth-throat) 115 DOSE 35 SAFETY 83 LENVIMA 18 MG DAILY lidocaine-prilocaine 63 LANCING DEVICE 83 35 63 DOSE LIDODERM LANCING DEVICE LENVIMA 20 MG DAILY LIFESCAN UNISTIK 2 DEEP ADJUSTABLE 83 DOSE 35 PENETRATION 83 LENVIMA 24 MG DAILY LANOXIN 50 LIFESCAN UNISTIK II

DOSE 35 lansoprazole 128 LANCETS 83 LENVIMA 4 MG DAILY LILETTA 53 lanthanum carbonate 71 DOSE 35 LINCOCIN 11 LANZO 83 LENVIMA 8 MG DAILY

lapatinib ditosylate 38 DOSE 35 lincomycin hcl 12 LETAIRIS 50 lindane 64 LASIX 65 letrozole 36 linezolid 12 LASTACAFT 121 leucovorin calcium 40 latanoprost 121 LINZESS 70

LATUDA 42 LEUKERAN 34 liothyronine sodium 126 LEUKINE 73 LIPITOR 30

Index 18

LIPOFEN 29 lithium carbonate 42 LOVAZA 29 lisinopril lisinopril amphydrochlorothiazide LITE TOUCH LANCETS LITE TOUCH LANCING PEN LITETOUCH INSULIN

30

32 83

83

LITHOBID 42 LIVALO 30 LIVE BETTER ADVANCED LANCING DEVICE 83 LIVE BETTER LANCET SUPERTHIN 30G 83 LIVE BETTER LANCET

LOVENOX loxapine succinate lubiprostone LUCEMYRA luliconazole LUMIGAN

17 43 70

123 58

121 SYRINGE03ML29G X12 100 LITETOUCH INSULIN SYRINGE03ML30G X516 100 LITETOUCH INSULIN SYRINGE03ML31G X516 100 LITETOUCH INSULIN SYRINGE05ML30G X516 100 LITETOUCH INSULIN SYRINGE05ML31G X516 100 LITETOUCH INSULIN SYRINGE1ML30G X516 100 LITETOUCH INSULIN SYRINGEU-10003ML30G X516 100 LITETOUCH INSULIN SYRINGEU-10003ML31G X516 100 LITETOUCH INSULIN SYRINGEU-10005ML28G X12 100 LITETOUCH INSULIN SYRINGEU-10005ML29G X12 101 LITETOUCH INSULIN SYRINGEU-10005ML30G X516 101 LITETOUCH INSULIN SYRINGEU-10005ML31G X516 101 LITETOUCH INSULIN SYRINGEU-1001ML28G X12 101 LITETOUCH INSULIN SYRINGEU-1001ML29G X12 101 LITETOUCH INSULIN SYRINGEU-1001ML30G X516 101 LITETOUCH INSULIN SYRINGEU-1001ML31G X516 101 LITETOUCH LANCETS MICRO THIN 33G 83 LITHIUM 42

ULTRATHIN 28G 83 LO LOESTRIN FE 52 LOCOID 62 LODINE 5 LODOSYN 40 LOMOTIL 25 LONGS INSULIN SYRINGE05ML31G X516 101 LONGS LANCETS STANDARD 83 LONGS LANCETS THIN 83 LONGS LANCETS ULTRA THIN 83 loperamide hcl 25 LOPID 29 lopinavir-ritonavir 45 LOPRESSOR 48 LOPRESSOR HCT 32 LOPROX 58 LOPROX SHAMPOO 58 loratadine 28 loratadine amp pseudoephedrine 55 lorazepam 13 LORBRENA 38 LORTAB 8 losartan potassium 31 losartan potassium amphydrochlorothiazide 32 LOSEASONIQUE 52 LOTEMAX 120 LOTENSIN 30 LOTENSIN HCT 32 loteprednol etabonate 120 LOTREL 32 LOTRIMIN AF 58 LOTRIMIN AF JOCK ITCH 58 LOTRIMIN ULTRA 58 LOTRISONE 58 LOTRONEX 71 lovastatin 30

LUMIZYME 68 LUNESTA 74 LUPANETA PACK 67 LUPRON DEPOT (1-MONTH) 36 LUPRON DEPOT (3-MONTH) 36 LUPRON DEPOT (4-MONTH) 37 LUPRON DEPOT (6-MONTH) 37 LUPRON DEPOT-PED (1-MONTH) 67 LUPRON DEPOT-PED (3-MONTH) 67 LUXIQ 62 LUZU 58 LYNPARZA 38 LYRICA 18 LYRICA CR 124 LYSODREN 37 LYSTEDA 74 M-M-R II 131 M-NATAL PLUS 116 MACROBID 12 MACRODANTIN 12 mafenide acetate 60 MAGELLAN INSULIN SAFETY SYRINGEU-10003ML29G X12 101 MAGELLAN INSULIN SAFETY SYRINGEU-10003ML30G X516 101 MAGELLAN INSULIN SAFETY SYRINGEU-10005ML29G X12 101 MAGELLAN INSULIN SAFETY SYRINGEU-10005ML30G X516 101 MAGELLAN INSULIN SAFETY SYRINGEU-1001ML29G X12 101 MAGELLAN INSULIN SAFETY SYRINGEU-1001ML30G X516 101 magnesium sulfate 114

Index 19

MALARONE malathion maprotiline hcl

33 64 20

MEDICHOICE SAFETY LANCETNORMAL MEDISENSE THIN LANCETS

83

83

melphalan hcl memantine hcl MENEST

34 123

69 MARCAINE 75 MEDLANCE PLUS EXTRA MENOSTAR 69 MARINOL MARPLAN

26 20

LANCETS 21G MEDLANCE PLUS LANCETS

83

84

MENQUADFI MENVEO

129 129

MATULANE MAVENCLAD MAVYRET MAXALT

39 124

47 112

MEDLANCE PLUS LANCETS LITE 25G 84 MEDLANCE PLUS LITE LANCETS 25G 84 MEDLANCE PLUS SPECIAL

meperidine hcl meprobamate MEPRON mercaptopurine

67 13 11 35

MAXALT-MLT 112 MAXI-COMFORT INSULIN SYRINGEU-10005ML28GX12 101 MAXI-COMFORT INSULIN SYRINGEU-1001ML28GX12

101 MAXICOMFORT INSULIN SYRINGES 27G X 12 101 MAXIDEX 120 MAXIPIME 52 MAXITROL 120 MAXX LUBRICATED 77 MAXX PLUS SPERMICIDE LUBRICATED 77 MAXZIDE 65 MAXZIDE-25 65 MAYZENT 124 MAYZENT STARTER PACK 124 meclizine hcl 26 meclofenamate sodium 5 MEDIC INSULIN SYRINGE03ML30G X516 101 MEDIC INSULIN SYRINGE05ML30G X516 101 MEDICHOICE PRE-SET SAFETY LANCET DUAL USE 83 MEDICHOICE PRE-SET SAFETY LANCET LOW FLOW 83 MEDICHOICE PRE-SET SAFETY LANCET MEDIUM FLOW 83 MEDICHOICE PRE-SET SAFETY LANCET MODERATE FLOW 83 MEDICHOICE SAFETY

LANCETS 08MM 84 MEDLANCE PLUS SUPERLITE 30G 84 MEDLANCE PLUS SUPERLITE 30GCOMFORTMAX 84 MEDLANCE PLUS UNIVERSAL LANCETS 21G 84 MEDLANCE PLUSLITE25G 84 MEDLANCEEXTRA 84 MEDLANCELITE 84 MEDLANCEUNIVERSAL 84 MEDROL 54 MEDROL DOSEPAK 54 medroxyprogesterone acetate 123 medroxyprogesterone acetate(contraceptive) 53 mefenamic acid 5 mefloquine hcl 33 MEGACE ES 123 megestrol acetate 37 megestrol acetate(appetite) 123 MEIJER COLOR LANCETS UNIVERSAL 33G 84 MEIJER LANCETS 84 MEIJER LANCETS THIN 84 MEIJER LANCETS UNIVERSAL21G 84 MEIJER LANCETS UNIVERSAL30G 84 MEIJER LANCETS UNIVERSAL33G 84 MEIJER SUPER THIN LANCETS 84 MEKINIST 38 MEKTOVI 38

meropenem 11 MERREM 11 mesalamine 70 MESTINON 33 MESTINON TIMESPAN 33 metaxalone 117 metformin hcl 23 methadone hcl 7 METHADONE HCL 7 methadone hcl 7 METHADOSE 7 METHADOSE SUGAR-FREE 7 methamphetamine hcl 1 methazolamide 65 methenamine hippurate 12 methimazole 126 METHITEST 10 methocarbamol 117 METHOTREXATE 4 methotrexate sodium 35 methoxsalen rapid 60 methscopolamine bromide 127 METHYLIN 2 methylphenidate hcl 2 methylprednisolone 54 methylprednisolone acetate 54 methylprednisolone sod succ 54 metoclopramide hcl 70 metolazone 66 metoprolol amphydrochlorothiazide 32 metoprolol succinate 48 metoprolol tartrate 48 METROCREAM 64

LANCETEXTRA 83 meloxicam 5 METROGEL 64 melphalan 34 METROLOTION 64

Index 20

metronidazole 10 moexipril hcl 30 MONOJECT INSULIN SYRINGEREGULAR LUER metronidazole (topical) 64 mometasone furoate 62 TIPSOFTPACK1ML 102 metronidazole vaginal 131 mometasone furoate MONOJECT ULTRA COMFORT (nasal) 118 mexiletine hcl 13 INSULIN SYRINGE03ML29G XMONISTAT SOOTHING CARE

micafungin sodium 27 12 102 ITCH RELIEF 62 MONOJECT ULTRA COMFORT MICARDIS 31 MONOJECT INSULIN INSULIN SYRINGE03ML30G XSYRINGE1ML 101 MICARDIS HCT 32 516 102 MONOJECT INSULIN miconazole nitrate vaginal 131 MONOJECT ULTRA COMFORT SYRINGE1ML31G X INSULIN SYRINGE03ML31G XMICROLET LANCETS 84 516 101 516 102 MICROLET NEXT 84 MONOJECT INSULIN MONOJECT ULTRA COMFORT SYRINGEDETACHmidodrine hcl 132 INSULIN SYRINGE05ML28G XNEEDLE1ML25G X 58 102 12 102 miglitol 23 MONOJECT INSULIN MONOJECT ULTRA COMFORT miglustat 72 SYRINGEDETACH INSULIN SYRINGE05ML29G XMIGRANAL 111 NEEDLE1ML27G X 12 102 12 102 MONOJECT INSULIN MILLIPRED 54 MONOJECT ULTRA COMFORT SYRINGEPERMMILLIPRED DP 54 INSULIN SYRINGE05ML30G XNEEDLE1ML28G X 12 102 516 102 MINASTRIN 24 FE 52 MONOJECT INSULIN MONOJECT ULTRA COMFORT SYRINGEPERM NEEDLEU-MINI LANCING DEVICE 84 INSULIN SYRINGE05ML31G X10005ML28G X 12 102 MINIPRESS 31 516 102 MONOJECT INSULIN MONOJECT ULTRA COMFORT MINIVELLE 69 SYRINGESAFETYPERM INSULIN SYRINGE1ML28G XMINOCIN 126 NEEDLE03ML29G X 12 102 12 102 minocycline hcl 126 MONOJECT ULTRA COMFORT MONOJECT INSULIN minoxidil 32 INSULIN SYRINGE1ML29G XSYRINGESAFETYPERM 12 102 MIRAPEX 41 NEEDLE03ML29GX12 MONOLET LANCETS 84 102 MIRCERA 73

MONOJECT INSULIN MONOLET OPD LANCETS 84 MIRCETTE 52 SYRINGESAFETYPERM MONOLETTOR SAFETY MIRENA 53 NEEDLE05ML29G X LANCETS 84 mirtazapine 20 12 102 montelukast sodium 14

MONOJECT INSULIN MIRVASO 64 MONUROL 12 SYRINGESAFETYPERMmisoprostol 128 MORPHABOND ER 7 NEEDLE1ML29G X 12 102 MITIGARE 72 MONOJECT INSULIN morphine sulfate 7 mitomycin 37 SYRINGESOFTPACK1ML27 MORPHINE SULFATE 7

G X 12 102 mitoxantrone hcl 37 morphine sulfate 7 MONOJECT INSULIN MM INSULIN SYRINGEU- MOTOFEN 25 SYRINGESOFTPACKU-10003ML30G X 516 101 10005ML28G X 12 102 MOVIPREP 75 MM INSULIN SYRINGEU- MONOJECT INSULIN 10003ML31G X 516 101 moxifloxacin hcl 70 SYRINGEU-10003ML30G XMM INSULIN SYRINGEU- moxifloxacin hcl (ophth) 119 516 102 10012ML30G X 516 101 MONOJECT INSULIN moxifloxacin hcl in sodium MM INSULIN SYRINGEU- chloride 70 SYRINGEU-10005ML30G X10012ML31G X 516 101 516 102 MOZOBIL 73 MM INSULIN SYRINGEU- MONOJECT INSULIN MPD SAFETY LANCET 1001ML30G X 516 101 SYRINGEU-1001ML28G X 21G18MM 84 MM INSULIN SYRINGEU- 12 102 MPD SAFETY LANCET 1001ML31G X 516 101 MONOJECT INSULIN 28G18MM 84 MM LANCING DEVICE 84 SYRINGEU-1001ML30G X MPD SAFETY LANCET MM TWIST LANCETS 84 516 102 30G18MM 84

MPD SAFETY LANCETS MOBIC 5 23G18MM 84 modafinil 3

Index 21

MS CONTIN 7 NARDIL 20 NIACIN TR 132 MS INSULIN NAROPIN 75 niacinamide 132 SYRINGE03ML31G X516 102 MS INSULIN SYRINGE05ML31G X516 103 MS INSULIN SYRINGE1ML31GX 516 103 MULPLETA 73 MULTAQ 13 MULTI PRENATAL 116 MULTI-LANCET DEVICE 84 mupirocin 57 MVASI 36 MYALEPT 68 MYAMBUTOL 34 MYCAMINE 27 MYCOBUTIN 34 mycophenolate mofetil 115 mycophenolate sodium 115 MYDRIACYL 119 MYFORTIC 115 MYGLUCOHEALTH MGH SOFTLANCE LANCETS 30G 84 MYLERAN 34 MYRBETRIQ 129 MYSOLINE 18 nabumetone 5 nadolol 49

NASACORT ALLERGY 24HR 118 NASACORT ALLERGY 24HR CHILDRENS 118 NASONEX 118 NATACYN 119 NATAZIA 52 nateglinide 24 NATROBA 64 NATURE-THROID 126 NATURE-THROID NT-25 126 NAVELBINE 40 NAYZILAM 17 nebivolol hcl 48 NEBUSAL 55 nefazodone hcl 22 nelarabine 35 NEO-SYNALAR 57 neomycin sulfate 3 neomycin-bacitracin zn-polymyxin 119 neomycin-polymy-dexameth 120 neomycin-polymyxin-hc(ophth) 120 neomycin-polymyxin-hc(otic) 121 NEONATAL COMPLETE 116 NEONATAL PLUS 116

NIASPAN 30 nicardipine hcl 49 NICODERM CQ 125 NICORETTE 125 NICORETTE MINI 125 NICORETTE STARTER KIT 125 nicotine 125 nicotine polacrilex 125 NICOTINE TRANSDERMAL SYSTEM 125 NICOTROL INHALER 125 NICOTROL NS 125 nifedipine 49 NILANDRON 37 nilutamide 37 nimodipine 49 NINLARO 38 NIPENT 39 nisoldipine 49 nitazoxanide 11 nitisinone 68 NITRO-BID 12 NITRO-DUR 12 nitrofurantoin 12 nitrofurantoin macrocrystal 12 nitrofurantoin monohyd macro 12

nafcillin sodium 122 NEONATAL VITAMIN 116 nitroglycerin 12 naftifine hcl NAFTIFINE HYDROCHLORIDE NAFTIN NAGLAZYME nalbuphine hcl NALFON naloxone hcl naltrexone hcl NAMENDA NAMENDA TITRATION PAK NAPROSYN naproxen naproxen sodium naratriptan hcl NARCAN

58

58 58 68

9 5

25 25

123

123 5 5 5

112 25

NEORAL 115 NEOSTIGMINE METHYLSULFATE 33 NESINA 24 NEULASTA 73 NEULASTA ONPRO KIT 73 NEUPOGEN 73 NEUPRO 41 NEURONTIN 18 NEVANAC 121 nevirapine 45 NEXAVAR 38 NEXIUM 128 NEXIUM 24HR 128 NEXPLANON 53 niacin 132

NITROGLYCERIN 12 nitroglycerin 12 NITROSTAT 12 NIVA-PLUS 116 NIVESTYM 73 NIX CREME RINSE 64 nizatidine 127 NIZORAL 58 NORCO 9 NORDITROPIN FLEXPRO 67 norelgestromin-ethinylestradiol 53 norethin acet amp estrad-fe 52 norethindrone amp eth estradiol52 norethindrone amp ethinyl estradiol-fe 52 norethindrone

niacin (antihyperlipidemic) 30 (contraceptive)

Index 22

53

norethindrone acet amp eth NUCYNTA 7 ONE VITE WOMENS estra 52 norethindrone acetate 123 norethindrone acetate-ethinylestradiol 69 norethindrone acetate-ethinylestradiol-fe 52 norethindrone-eth estradiol (triphasic) 52 norgestimate-ethinylestradiol 53 norgestimate-ethinyl estradiol(triphasic) 52 norgestrel amp ethinyl estradiol 53 NORMOSOL-M IN D5W 113

NUCYNTA ER NUEDEXTA NULOJIX NUTROPIN AQ NUSPIN 10 NUVARING NUVIGIL nystatin nystatin (mouth-throat) nystatin (topical) nystatin-triamcinolone O-CAL FA

7 124 115

67 53

3 27

115 58 58

116

PRENATALVITAMIN PLUS 116 ONETOUCH CLUB LANCETS FINE POINT 84 ONETOUCH DELICA LANCETS EXTRA FINE 33G 84 ONETOUCH DELICA LANCETS FINE 30G 84 ONETOUCH DELICA LANCING DEVICE 85 ONETOUCH DELICA PLUS LANCETS EXTRA FINE 33G 85 ONETOUCH DELICA PLUS LANCETS FINE 30G 85 ONETOUCH DELICA PLUS

NORMOSOL-MD5W NORMOSOL-R NORPACE

113 113

13

OCREVUS octreotide acetate OCUFLOX

124 68

119

LANCING DEVICE 85 ONETOUCH DELICA SAFETY LANCING DEVICE 85 ONETOUCH FINEPOINT

NORPRAMIN 22 nortriptyline hcl 22 NORVASC 49 NORVIR 45 NOVA MAX PLUS KETONE TESTSTRIPS 64 NOVA SAFETY LANCETS

ODEFSEY ODOMZO OFEV ofloxacin ofloxacin (ophth) ofloxacin (otic)

45 36

125 70

119 121

LANCETS ONETOUCH ULTRASOFT LANCETS ONFI OPANA OPSUMIT ORACEA

85

85 17

7 50 64

23G 84 NOVA SAFETY LANCETS 28G 84 NOVA SUREFLEX LANCETS 84 NOVA SUREFLEX LANCING DEVICE 84 NOVAREL 66 NOVOLIN 7030 24 NOVOLIN 7030 FLEXPEN 24 NOVOLIN 7030 FLEXPENRELION 24 NOVOLIN 7030 RELION 24 NOVOLIN N 24 NOVOLIN N RELION 24 NOVOLIN R 24 NOVOLIN R RELION 24 NOVOLOG 24

olanzapine 43 olmesartan medoxomil 31 olmesartan medoxomil-amlodipine-hydrochlorothiazide

32 olmesartan medoxomil-hydrochlorothiazide 32 olopatadine hcl 121 olopatadine hcl (nasal) 117 OLUX 62 omega-3-acid ethyl esters 29 omeprazole 128 omeprazole magnesium 128 omeprazole-sodiumbicarbonate 128 OMNIFLEX DIAPHRAGM 77 OMNITROPE 67 ON CALL LANCING

ORAPRED ODT ORENITRAM ORFADIN ORKAMBI orphenadrine citrate ORTHO MICRONOR ORTHO TRI-CYCLEN LO ORTHO-NOVUM 135 ORTHO-NOVUM 777 oseltamivir phosphate OSENI OSMOPREP OSPHENA OTEZLA OTOVEL OVIDE

54 50 68

125 117

54 53 53 53 48 23 75 67

5 121

64 NOVOLOG FLEXPEN NOVOLOG MIX 7030 NOVOLOG MIX 7030PREFILLED FLEXPEN NOVOLOG PENFILL

24 24

24 24

DEVICE 84 ON CALL PLUS LANCING DEVICE 84 ONCASPAR 39 ondansetron 26

oxacillin sodium oxaliplatin oxandrolone oxaprozin

123 35

9 5

NOXAFIL 27 ondansetron hcl 26 OXAYDO 7

NPLATE NUBEQA NUCALA

73 37 14

ONE VITE WOMENS PRENATALVITAMIN 116

oxazepam OXBRYTA oxcarbazepine

13 73 18

Index 23

OXERVATE 120 PEMAZYRE 38 PIFELTRO 46 oxiconazole nitrate 58 penicillamine 114 pilocarpine hcl 119 OXISTAT 59 penicillin g potassium 122 pilocarpine hcl (oral) 116 OXSORALEN ULTRA 60 PENICILLIN G POTASSIUM IN pimecrolimus 63

ISO-OSMOTIC oxybutynin chloride 128 pimozide 124 DEXTROSE 122 oxycodone hcl 7 pindolol 49 PENICILLIN G oxycodone w acetaminophen 9 PROCAINE 122 pioglitazone hcl 24 oxycodone-ibuprofen 9 penicillin g sodium 122 pioglitazone hcl-glimepiride 23 OXYCONTIN 7 penicillin v potassium 122 pioglitazone hcl-metforminoxymorphone hcl 7 PENLAC NAIL LACQUER 59 hcl 23

PIP LANCETS28G 85 OZEMPIC 24 PENTACEL 126 PIP LANCETS30G 85 paclitaxel 40 pentazocine w naloxone hcl9 piperacillin sodium-tazobactam

paliperidone 42 pentoxifylline 72 sodium 122 palonosetron hcl 26 PEPCID 127 PIQRAY 200MG DAILY PALYNZIQ 68 PEPCID AC 127 DOSE 38

PIQRAY 250MG DAILY PEPCID AC MAXIMUM PAMELOR 22 DOSE 39 STRENGTH 127 pamidronate disodium 66 PIQRAY 300MG DAILY PERCOCET 9 PAMIDRONATE DISODIUM 66 DOSE 39

PERFECT LANCETS 30G 85 piroxicam 5 pamidronate disodium 66 PERFECT PRESSURE PLAN B ONE-STEP 53 PANRETIN 59 ACTIVATED SAFETY PLAQUENIL 33 pantoprazole sodium 128 LANCETS 28G 85

PARAGARD INTRAUTERINE PERIDEX 115 PLASMA-LYTE A 113 COPPER CONTRACEPTIVE perindopril erbumine 30 PLASMA-LYTE-148 113 T380A 53 PERJETA 36 PLAVIX 72 parenteral electrolytes 113 permethrin 64 PLEGISOL 50 paricalcitol 68 perphenazine 44 PLEGRIDY 124 PARLODEL 41 perphenazine-amitriptyline PLEGRIDY STARTER PARNATE 20 123 PACK 124 paromomycin sulfate 3 PERSERIS 42 PNEUMOVAX 23 129 paroxetine hcl 21 PHARMACY COUNTER PNEUMOVAX 231 DOSE 129

LANCETS 85 PASER 34 podofilox 63 phenazopyridine hcl 72 PATADAY 121 polymyxin b sulfate 12 phendimetrazine tartrate 2 PATANASE 117 polymyxin b-trimethoprim 119 phenelzine sulfate 20 PATANOL 121 POLYTRIM 119 PHENERGAN 28 PAXIL 21 POMALYST 37 phenobarbital 74 PAXIL CR 21 potassium acetate 114 phenoxybenzamine hcl 30 PC LANCETS SUPER THIN potassium bicarbonate 114

30G 85 phentermine hcl 2 potassium chloride 114 PEDIAPRED 54 PHENYTEK 20 POTASSIUM CHLORIDE 114 PEDIARIX 126 phenytoin 20 potassium chloride 114 PEDVAX HIB 129 phenytoin sodium 20 POTASSIUM CHLORIDE 114 peg 3350-kcl-nacl-na sulfate-na phenytoin sodium potassium chloride 114 ascorbate-ascorbic acid 75 extended 20 peg 3350-kcl-sod bicarb-sod PHEXXI 132 potassium chloride inchloride-sod sulfate 75 dextrose 113 PHOSLYRA 71 potassium chloride in dextrose ampPEGANONE 20 PHOSPHOLINE IODIDE 119 sodium chloride 113 PEGASYS 47 PHOTOFRIN 39 potassium chloride in nacl 113 PEGINTRON 47 PICATO 59

Index 24

potassium chloride PREDNISOLONE SODIUM PRENATRYL 117 microencapsulated crystals PHOSPHATE 120 PREPLUS 117 er 114 prednisone 54 PREPOPIK 75 POTASSIUM PREFERRED PLUS INSULIN CHLORIDEDEXTROSELACTA SYRINGEU-10003ML29G X PRESSURE ACTIVATED TED RINGERS 113 SAFETYLANCET 21G 85 12 103 POTASSIUM PREVACID 128 PREFERRED PLUS INSULIN CHLORIDESODIUM SYRINGEU-10003ML30G X PREVACID 24HR 128 CHLORIDE 113 516 103 PREVNAR 13 129 potassium citrate PREFERRED PLUS INSULIN (alkalinizer) 71 SYRINGEU-10005ML28G X PREZCOBIX 46 potassium phosphates 114 12 103 PREZISTA 46 pramipexole dihydrochloride 41 PREFERRED PLUS INSULIN PRIFTIN 34

SYRINGEU-10005ML29G Xprasugrel hcl 72 PRILOSEC OTC 128 12 103 PRAVACHOL 30 primaquine phosphate 33 PREFERRED PLUS INSULIN pravastatin sodium 30 SYRINGEU-10005ML30G X PRIMAQUINE PHOSPHATE 33 praziquantel 10 516 103 PRIMAXIN IV 11

PREFERRED PLUS INSULIN prazosin hcl 31 primidone 19 SYRINGEU-1001ML28G XPRECISION SURE-DOSE PRINIVIL 30 12 103 INSULIN SYRINGE03ML30G X PREFERRED PLUS INSULIN PRISTIQ 22 516 103 SYRINGEU-1001ML29G X PRO COMFORT INSULIN PRECISION SURE-DOSE 12 103 SYRINGES05ML30G XINSULIN SYRINGE05ML28G X PREFERRED PLUS INSULIN 12 103 12 103 SYRINGEU-1001ML30G X PRO COMFORT INSULIN PRECISION SURE-DOSE 516 103 SYRINGES05ML30G XINSULIN SYRINGE05ML29G X PREFERRED PLUS LANCETS 516 103 12 103 COLORED 21G 85 PRO COMFORT INSULIN PRECISION SURE-DOSE PREFERRED PLUS LANCETS SYRINGES05ML31G XINSULIN SYRINGE05ML30G X SUPER THIN 30G 85 516 103 38 103 PREFERRED PLUS LANCETS PRO COMFORT INSULIN PRECISION SURE-DOSE THIN 26G 85 SYRINGES1ML30G XINSULIN SYRINGE1ML28G X pregabalin 19 12 103 12 103 PRECISION SURE-DOSE pregabalin (once-daily) 124 PRO COMFORT INSULIN

SYRINGES1ML30G XPLUSINSULIN PREGNYL WDILUENT516 103 SYRINGE03ML29G X BENZYLALCOHOLNACL 66 PRO COMFORT INSULIN 12 103 PREMARIN 69 SYRINGES1ML31G XPRECISION SURE-DOSE PREMIUM CONDOMS 516 103 PLUSINSULIN LUBRICATED 77 PROAIR HFA 15 SYRINGE1ML29G X 12 103 PREMPHASE 69

PRECISION THINS GP probenecid 72 PREMPRO 69 LANCET 85 procainamide hcl 13 PRENATAL 116117 PRECISION XTRA 65 PROCARDIA 49 PRENATAL LOW IRON 116 PRECOSE 23 PROCARDIA XL 49 PRENATAL PRED FORTE 120 MULTIVITAMIN 116 prochlorperazine 44 PRED MILD 120 PRENATAL ONE DAILY 116 prochlorperazine maleate 44 prednicarbate 62 PRENATAL VITAMIN 117 PROCRIT 73 prednisolone 54 PRENATAL VITAMIN amp PROCTOCORT 10 prednisolone acetate MINERAL 117 PRODIGY INSULIN SYRINGU-(ophth) 120 PRENATAL 10003ML31G X 516 103 PREDNISOLONE ACETATE P- VITAMINIRON 117 PRODIGY INSULIN F 120 PRENATAL VITAMINS 117 SYRINGE12ML31G Xprednisolone sodium PRENATAL VITAMINS PLUS 516 103 phosphate 54 LOW IRON 117 PRODIGY INSULIN

PRENATRIX 117 SYRINGE1ML28G X 12 103

Index 25

PRODIGY LANCING PX LANCETS ULTRA THIN rabeprazole sodium 128 DEVICE 85 28G 85 raloxifene hcl 67 PRODIGY PRESSURE PX PRENATAL

ramelteon 74 ACTIVATED SAFETY MULTIVITAMINS 117 LANCETS 85 pyrazinamide 34 ramipril 30 PRODIGY SAFETY PYRIDIUM 72 RANEXA 12 LANCETS 85 pyridostigmine bromide 34 ranitidine hcl 127 PRODIGY TWIST TOP LANCETS 85 pyrimethamine 33 ranolazine 12 progesterone 123 QC ADVANCED LANCING RAPAFLO 71

DEVICE 85 PROGLYCEM 24 RAPAMUNE 115 QC LANCETS SUPER PROGRAF 115 rasagiline mesylate 42 THIN 85 PROLASTIN-C 125 QC LANCETS ULTRA RAZADYNE 123 PROLEUKIN 40 THIN 85 RAZADYNE ER 123 PROLIA 66 QC PRENATAL 117 READYLANCE SAFETY

QC UNILET LANCETS LANCETS21G22MM 85 PROMACTA 73 28GULTRA THIN 85 READYLANCE SAFETY promethazine hcl 28 QC UNILET LANCETS LANCETS23G18MM 86 PROMETRIUM 123 33GMICRO THIN 85 READYLANCE SAFETY propafenone hcl 13 QINLOCK 39 LANCETS26G18MM 86

READYLANCE SAFETY proparacaine hcl 120 QUADRACEL 126 LANCETS28G18MM 86 propranolol hcl 49 QUALAQUIN 33 READYLANCE SAFETY propylthiouracil 126 QUARTETTE 53 LANCETS30G16MM 86

REALITY INSULIN SYRINGEU-PROSCAR 71 QUDEXY XR 19 10005ML28G X 12 104

PROTONIX 128 QUESTRAN 29 REALITY INSULIN SYRINGEU-PROTOPIC 63 QUESTRAN LIGHT 29 10005ML29G X 12 104

quetiapine fumarate REALITY INSULIN SYRINGEU-protriptyline hcl 22 43 1001ML28G X 12 104 PROVENTIL HFA 15 quinapril hcl 30 REALITY INSULIN SYRINGEU-quinapril-hydrochlorothiazidePROVERA 123

32 1001ML29G X 12 104 PROVIGIL 3 REALITY LANCETS 86 quinidine sulfate 13 REALITY LATEX PROZAC 21 quinine sulfate 33 CONDOMSLUBRICATED 77 PRUDOXIN 59 QVAR REDIHALER 14 REALITY LATEXULTRAPSORCON 62 RA E-ZJECT LANCETS TEXTURED 77 PSS SELECT GP LANCETS 85 28G 85 REALITY LATEXULTRAPSS SELECT SAFETY RA E-ZJECT LANCETS THIN THIN 77 LANCETS 85 26G 85 REALITY TRIGGER PTS PANELS KETONE RA E-ZJECT LANCETS THIN LANCETS 86 TEST 65 28G 85 REBIF 124

RA E-ZJECT LANCETS PULMICORT 14 REBIF REBIDOSE 124 ULTRATHIN 30G 85 PULMICORT FLEXHALER 14 REBIF REBIDOSE RA INSULIN TITRATIONPACK 124 PULMOZYME 125 SYRINGE05ML29G X REBIF TITRATION PACK 124 PUSH BUTTON SAFETY 12 104

LANCETS 21G 85 RA INSULIN RECLAST 66 PUSH BUTTON SAFETY SYRINGE1ML29G X RECOMBIVAX HB 131 LANCETS 28G 85 12 104 RECTIV 10 PX ADVANCED LANCING RA INSULIN SYRINGEU-DEVICE 85 10005ML30G X 516 104 REGLAN 70 PX INSULIN SYRINGEU- RA INSULIN SYRINGEU- REGRANEX 64 10005ML30G X 12 103 1001 ML30G X 516 104 RELENZA DISKHALER 48 PX LANCET AUTO RA PRENATAL 117 RELION 2-IN-1 LANCET INJECTOR 85 RA PRENATAL DEVICES 30G 86 PX LANCETS ULTRA THIN 85 FORMULAFOLICACID 117

Index 26

RELION 2-IN-1 LANCING RESTORIL 74 ROTARIX 131 DEVICE 25G RELION 2-IN-1 LANCING DEVICE 30G

86

86

RETACRIT RETEVMO

73 39

ROTATEQ ROXICODONE

131 7

RELION INSULIN SYRINGE RETIN-A 56 ROZEREM 74 1ML31GX1564 104 RELION INSULIN SYRINGEU-10003ML31G X 516 104 RELION INSULIN SYRINGEU-10005ML29G X 12 104 RELION INSULIN SYRINGEU-10005ML31G X 516 104 RELION INSULIN SYRINGEU-1001ML31G X 1564 104 RELION INSULIN SYRINGEU-1001ML31G X 516 104 RELION KETONE TEST STRIPS 65 RELION LANCETS MICRO-THIN33G 86 RELION LANCETS THIN 26G 86 RELION LANCETS ULTRA-THIN30G 86 RELION LANCING DEVICE 86 RELION TRUE METRIX BLOODGLUCOSE TEST STRIPS 65 RELION ULTRA THIN LANCETS30G 86 RELION ULTRA THIN LANCETS30G 86 RELION ULTRA THIN PLUS LANCETS 32G 86 RELION ULTRA THIN PLUS LANCETS 33G 86 RELISTOR 71 RELPAX 112 REMERON 20 REMERON SOLTAB 20 RENAGEL 71 RENFLEXIS 70

RETIN-A MICRO 57 RETIN-A MICRO PUMP 57 RETROVIR 46 RETROVIR IV INFUSION 46 REVATIO 51 REVLIMID 114 REXALL LANCETS ULTRA THIN 86 REXULTI 44 REYATAZ 46 ribavirin (hepatitis c) 47 RIDAURA 4 rifabutin 34 RIFADIN 34 RIFAMATE 34 rifampin 34 RIFATER 34 RIGHT STEP PRENATAL 117 RIGHTEST GD500 LANCING DEVICE 86 RIGHTEST GL300 LANCETS 86 RILUTEK 118 riluzole 118 rimantadine hydrochloride 48 ringers 114 ringers irrigation 115 RINVOQ 4 risedronate sodium 66 RISPERDAL 42 RISPERDAL CONSTA 42

ROZLYTREK 39 RUBRACA 39 RUCONEST 72 rufinamide 19 RUKOBIA 46 RUXIENCE 36 RUZURGI 34 RYTHMOL SR 13 SABRIL 19 SAFE-T-LANCE LOW FLOW 25G 86 SAFE-T-LANCE NORMAL FLOW21G 86 SAFE-T-LANCE PLUS SAFETYLANCET HIGH FLOW 86 SAFE-T-LANCE PLUS SAFETYLANCET LOW FLOW 86 SAFE-T-LANCE PLUS SAFETYLANCET NORMAL FLOW 86 SAFESNAP INSULIN SYRINGE03ML30G X516 104 SAFESNAP INSULIN SYRINGE05ML29G X12 104 SAFESNAP INSULIN SYRINGE05ML30G X516 104 SAFESNAP INSULIN SYRINGE1ML28G X 12 104 SAFESNAP INSULIN SYRINGE1ML29G X 12 104 SAFETY INSULIN SYRINGES

RENVELA repaglinide repaglinide-metformin hcl

71 25 23

risperidone RITALIN RITALIN LA

42 3 3

05ML29GX12 104 SAFETY INSULIN SYRINGES 05ML30GX516 104 SAFETY INSULIN SYRINGES

REPATHA 30 REPATHA PUSHTRONEX SYSTEM 30 REPATHA SURECLICK 30 REQUIP XL 41 RESCRIPTOR 46 RESECTISOL 71 RESTASIS 119 RESTASIS MULTIDOSE 119

ritonavir RITUXAN rivastigmine tartrate rizatriptan benzoate ROBAXIN-750 ROCALTROL ROMIDEPSIN ropinirole hydrochloride rosuvastatin calcium

46 36

123 112 117

68 39 41 30

1ML27GX12 104 SAFETY INSULIN SYRINGES 1ML29GX12 104 SAFETY INSULIN SYRINGES 1ML30GX12 104 SAFETY LANCET 21GPRESSUREACTIVATED 86 SAFETY LANCET 23GPRESSUREACTIVATED 86

Index 27

SAFETY LANCET sertraline hcl 21 SMART SENSE COLOR 28GPRESSUREACTIVATED SAFETY LANCETS 21G SAFETY LANCETS 28G SAFETY LET LANCETS

86 86 86 86

sevelamer carbonate 71 sevelamer hcl 71 SHINGRIX 131 SHOPKO AUTOLET LANCING DEVICE 86

LANCETS UNIVERSAL 33G 87 SMART SENSE STANDARD LANCETS UNIVERSAL 21G 87 SMART SENSE SUPER THIN LANCETS UNIVERSAL 30G 87 SMART SENSE THIN

SAFYRAL 53 SHOPKO ON-THE-GO LANCETSUNIVERSAL 26G 87 SAIZEN 67 SAIZENPREP RECONSTITUTIONKIT 67 SALAGEN 116 salsalate 6 SAMSCA 68 SANDIMMUNE 115 SANDOSTATIN 68 SANTYL 63 SAPHRIS 43 sapropterin dihydrochloride 68 SAVELLA 123 SAVELLA TITRATION PACK 123

COMFORTLANCETS 30G 86 SHOPKO UNILET LANCETS SUPER THIN 30G 86 SHOPKO UNILET LANCETS ULTRA THIN 28G 86 SHUR-SEAL 131 SIDE BUTTON SAFETY LANCET21G 86 SIGNIFOR 68 sildenafil citrate 50 sildenafil citrate (pulmonaryhypertension) 51 SILENOR 74 silodosin 71 SILVADENE 60

SMARTEST LANCETS 28G 87 SODIUM ACETATE 113 sodium acetate 113 sodium chloride 114 sodium chloride (gu irrigant) 71 sodium chloride (inhalant) 55 sodium citrate amp citric acid 71 sodium fluoride 114 sodium phenylbutyrate 68 sodium polystyrenesulfonate 115 SOFOSBUVIRVELPATASVIR

47 solifenacin succinate 128

SB INSULIN SYRINGEU-10005ML29G X 12 104 SB INSULIN SYRINGEU-10005ML30G X 516 104 SB INSULIN SYRINGEU-1001ML29G X 12 104 SB INSULIN SYRINGEU-1001ML30G X 516 104 SB INSULIN SYRINGEU-1001ML31G X 516 104 SB LANCETS THIN 86 SB LANCETS ULTRA THIN 86 scopolamine 26 SEASONIQUE 53 SECURESAFE SAFETY

silver sulfadiazine SIMBRINZA SIMPLE DIAGNOSTICS LANCING DEVICE SIMULECT simvastatin SINEMET SINEMET CR SINGLE-LET SINGULAIR sirolimus SIRTURO SIVEXTRO

60 119

87 115

30 41 41 87 14

115 34 12

SOLIRIS 72 SOLOSEC 3 SOLU-CORTEF 5455 SOLU-MEDROL 55 SOLUS V2 LANCING DEVICE 87 SOLUS V2 PRESSURE ACTIVATED SAFETY LANCETS 28G 87 SOLUS V2 TWIST LANCETS 30G 87 SOMA 117 SOMATULINE DEPOT 68 SOMAVERT 67

INSULIN SYRINGESU-10005ML29GX12 SECURESAFE SAFETY INSULIN SYRINGESU-1001ML29GX12 SEGLUROMET SELECT-LITE LANCING DEVICE selegiline hcl selenium sulfide

104

105 23

86 42 60

SKELAXIN 117 SKLICE 64 SKYLA 53 SKYRIZI 60 SKYRIZI PEN 60 SLO-NIACIN 132 SLYND 54 SM MICRO THIN LANCETS 33G 87

SOOLANTRA SORBITOL SORBITOL-MANNITOL SORBITOLMANNITOLIRRIGATION SORIATANE sotalol hcl sotalol hcl (afibafl) spinosad

64 71 71

71 60 49 49 64

SELZENTRY SENSIPAR SEREVENT DISKUS SEROQUEL SEROQUEL XR SEROSTIM

46 68 15 43 43 67

SM PRENATAL VITAMINS 117 SM TRUEDRAW LANCING DEVICE 87 SMART DIABETES VANTAGE LANCING DEVICE 87

SPIRIVA HANDIHALER SPIRIVA RESPIMAT spironolactone spironolactone amphydrochlorothiazide SPORANOX

14 14 65

65 27

Index 28

SPORANOX PULSEPAK 27 SPRAVATO 56MG DOSE 20 SPRAVATO 84MG DOSE 21 SPRYCEL 39 STALEVO 100 41 STALEVO 125 41 STALEVO 150 41

sumatriptan-naproxensodium 111 sunitinib malate 39 SUNOSI 2 SUPER THIN LANCETS 87 SUPRAX 52 SUPREP BOWEL PREP KIT 75

SURE COMFORT LANCETS 23G 87 SURE COMFORT LANCETS 28G 87 SURE COMFORT LANCETS 30G 87 SURE COMFORT LANCING PEN 87 SURE-JECT INSULIN

STALEVO 200 41 SURE COMFORT INSULIN SYRINGEU-10003ML29G XSYRINGEU-10003ML29G X 12 105 STALEVO 50 42 12 105 SURE-JECT INSULIN

STALEVO 75 42 SURE COMFORT INSULIN SYRINGEU-10003ML30G Xstannous fluoride 115 SYRINGEU-10003ML30G X 516 105 STARLIX 25 12 105 SURE-JECT INSULIN

SURE COMFORT INSULIN SYRINGEU-10003ML31G Xstavudine 46 SYRINGEU-10003ML30G X 516 105 STAVUDINE 46 516 105 SURE-JECT INSULIN STEGLATRO 25 SURE COMFORT INSULIN SYRINGEU-10005ML28G XSTELARA 6070 SYRINGEU-10003ML31G X 12 105

516 105 SURE-JECT INSULIN STENDRA 50 SURE COMFORT INSULIN SYRINGEU-10005ML29G XSTERILANCE TL 87 SYRINGEU-10003ML31G X 12 105 STIMATE 68 516 105 SURE-JECT INSULIN

SURE COMFORT INSULIN SYRINGEU-10005ML30G XSTIVARGA 39 SYRINGEU-10005ML28G X 516 105 STRATTERA 2 12 105 SURE-JECT INSULIN streptomycin sulfate 3 SURE COMFORT INSULIN SYRINGEU-10005ML31G XSTRIBILD 46 SYRINGEU-10005ML29G X 516 105

12 105 SURE-JECT INSULIN STRIVERDI RESPIMAT 15 SURE COMFORT INSULIN SYRINGEU-1001ML28G XSTROMECTOL 10 SYRINGEU-10005ML30G X 12 105 SUBOXONE 9 12 105 SURE-JECT INSULIN

SURE COMFORT INSULIN SYRINGEU-1001ML29G XSUBSYS 78 SYRINGEU-10005ML30G X 12 105 SUCRAID 65 516 105 SURE-JECT INSULIN

sucralfate 127 SURE COMFORT INSULIN SYRINGEU-1001ML30G XSULAR 49 SYRINGEU-10005ML31G X 516 106

516 105 SURE-JECT INSULIN sulconazole nitrate 59 SURE COMFORT INSULIN SYRINGEU-1001ML31G Xsulfacetamide sodium (acne)57 516 106 SYRINGEU-1001ML28G Xsulfacetamide sodium 12 105 SURE-LANCE FLAT (ophth) 119 SURE COMFORT INSULIN LANCETS 87 sulfacetamide sodium w SYRINGEU-1001ML29G X SURE-LANCE LANCETS sulfur 57 12 105 26G 87 sulfacetamide sodium-sulfur in SURE-LANCE THIN LANCETS SURE COMFORT INSULIN urea vehicle 57 SYRINGEU-1001ML30G X 28G 87 SULFADIAZINE 125 12 105 SURE-LANCE ULTRA THIN sulfamethoxazole-trimethoprim SURE COMFORT INSULIN LANCETS 87

11 SYRINGEU-1001ML30G X SURE-PEN 87 SULFAMYLON 60 516 105 SURE-TOUCH LANCETS

SURE COMFORT INSULIN UNIVERSAL 87 sulfasalazine 70 SYRINGEU-1001ML31G X SURELITE LANCETS 87 sulindac 5 516 105 SUSTIVA 46 SUMADAN WASH 57 SURE COMFORT LANCETS SUTENT 39 sumatriptan 112 18G 87

SURE COMFORT LANCETS SYMBICORT 15 sumatriptan succinate 112 21G 87 SYMFI 46

Index 29

SYMFI LO 46 TECHLITE INSULIN TENIVAC 127 SYMLINPEN 120 SYMLINPEN 60

23 23

SYRINGEU-10003ML30G X12 106 TECHLITE INSULIN

tenofovir disoproxil fumarate 46 TENORETIC 100 32

SYMTUZA SYNALAR SYNAREL SYNERA SYNJARDY

46 62 67 64 23

SYRINGEU-10003ML30G X516 106 TECHLITE INSULIN SYRINGEU-10003ML31G X516 106 TECHLITE INSULIN

TENORETIC 50 TENORMIN TEPADINA terazosin hcl terbinafine hcl

32 48 35 31 27

SYNJARDY XR SYNRIBO

23 40


terbutaline sulfate terconazole vaginal

15 131

SYNTHROID SYPRINE TABLOID TABRECTA TACLONEX tacrolimus tacrolimus (topical)

126 114

35 39

6263 115

63

SYRINGEU-10005ML30G X12 106 TECHLITE INSULIN SYRINGEU-10005ML30G X516 106 TECHLITE INSULIN SYRINGEU-10005ML31G X516 106 TECHLITE INSULIN

TESSALON PERLES TESTIM TESTOSTERONE CYPIONATE testosterone cypionate testosterone enanthate TETANUSDIPHTHERIATOXOIDS-ADSORBED

55 10

10 10 10

tadalafil tadalafil (pulmonaryhypertension) TAFINLAR TAGAMET HB TAKHZYRO TALZENNA TAMIFLU tamoxifen citrate tamsulosin hcl TAPAZOLE TARCEVA TARGADOX

50

51 39

127 72 39 48 37 71

126 36

126

SYRINGEU-1001ML29G X12 106 TECHLITE INSULIN SYRINGEU-1001ML30G X12 106 TECHLITE INSULIN SYRINGEU-1001ML30G X516 106 TECHLITE INSULIN SYRINGEU-1001ML31G X1564 106 TECHLITE INSULIN SYRINGEU-1001ML31G X516 106 TECHLITE LANCETS 87

ADULT 127 tetrabenazine 124 tetracycline hcl 126 TGT LANCET MICRO THIN 33G 87 TGT LANCET THIN 26G 87 TGT LANCET ULTRA THIN 30G 87 TGT LANCING DEVICE 87 THALOMID 114 theophylline 15 THERANATAL CORE NUTRITION 117 THINLETS GP LANCETS 87

TARGRETIN TARKA TASIGNA

4059 32 39

TECHLITE LANCETS 30G 87 TEFLARO 52 TEGRETOL 19

thioridazine hcl thiotepa thiothixene

44 35 44

TASMAR 41 TEGRETOL-XR 19 THYMOGLOBULIN 115 tavaborole TAXOTERE TAYTULLA

59 40 53

TEGSEDI TEKTURNA telmisartan

125 32 31

thyroid tiagabine hcl TIAZAC

126 19 49

tazarotene TAZORAC

60 60

telmisartan-amlodipine 32 telmisartan-hydrochlorothiazide

32

TIBSOVO TIGAN

39 26

TAZVERIK TDVAX

39 126

temazepam TEMIXYS

74 46

tigecycline TIKOSYN

125 13

TECFIDERA 124 TEMODAR 35 timolol maleate 49 TECFIDERA STARTER PACK 124 TECHLITE AST LANCETS 87 TECHLITE INSULIN SYRINGEU-10003ML29G X 12 106

TEMOVATE temozolomide temsirolimus TENIPOSIDE

63 35 39 40

timolol maleate (ophth) TIMOPTIC TIMOPTIC-XE TIVICAY

119 119 119

46

Index 30

tizanidine hcl 117 TOPICORT 63 triamterene amp

TOBI 3 TOBRADEX 120 tobramycin 3 tobramycin (ophth) 119 tobramycin sulfate 3 tobramycin-dexamethasone 120 TOBREX 119 TODAY SPONGE 131 TODAYS HEALTH ADVANCED LANCING DEVICE 87 TODAYS HEALTH SUPER THINLANCETS 30G 87 TODAYS HEALTH ULTRA THINLANCETS 28G 87 TOFRANIL 22 tolbutamide 25 tolcapone 41 tolmetin sodium 5 TOLSURA 27 tolterodine tartrate 128 tolvaptan 68 TOPAMAX 19 TOPAMAX SPRINKLE 19 TOPCARE LANCETS MICRO-THIN 33G 87 TOPCARE ULTRA COMFORT INSULIN SYRINGE03ML30G X516 106 TOPCARE ULTRA COMFORT INSULIN SYRINGE03ML31G X516 106 TOPCARE ULTRA COMFORT INSULIN SYRINGE05ML30G X516 106 TOPCARE ULTRA COMFORT INSULIN SYRINGE05ML31G X516 106 TOPCARE ULTRA COMFORT INSULIN SYRINGE1ML30G X516 106 TOPCARE ULTRA COMFORT INSULIN SYRINGE1ML31G X516 106 TOPCARE ULTRA COMFORT INSULIN SYRINGEU-10003ML29G X 12 106 TOPCARE ULTRA COMFORT INSULIN SYRINGEU-10005ML29G X 12 106 TOPCARE ULTRA COMFORT INSULIN SYRINGEU-1001ML29G X 12 106

topiramate 19 topotecan hcl 40 TOPROL XL 48 toremifene citrate 37 TORISEL 39 torsemide 65 TOVIAZ 128 TRACLEER 50 tramadol hcl 8 tramadol-acetaminophen 9 trandolapril 30 trandolapril-verapamil hcl 32 TRANDOLAPRILVERAPAMILHCL ER 32 tranexamic acid 74 TRANSDERM SCOP 26 TRANSDERM-SCOP 26 TRANXENE T 13 tranylcypromine sulfate 20 TRAVATAN Z 121 TRAVEL LANCETS 30G 87 TRAVEL LANCETS ADVANCED 28G 87 travoprost 121 trazodone hcl 22 TREANDA 35 TRECATOR 34 TRELEGY ELLIPTA 15 TRELSTAR MIXJECT 37 TREMFYA 60 treprostinil 50 TRESIBA 24 TRESIBA FLEXTOUCH 24 tretinoin 57 tretinoin (chemotherapy) 40 tretinoin microsphere 57 TREXALL 35 TREXIMET 111 triamcinolone acetonide 55 triamcinolone acetonide (mouth) 116 triamcinolone acetonide (nasal) 118 triamcinolone acetonide (topical) 63 triamcinolone acetonide-dimethicone-silicone 63 triamterene 65

hydrochlorothiazide 65 triazolam 74 TRIBENZOR 32 TRICARE 117 TRICOR 29 TRIDESILON 63 trientine hcl 114 trifluoperazine hcl 44 trifluridine 119 trihexyphenidyl hcl 40 TRIJARDY XR 23 TRIKAFTA 125 TRILEPTAL 19 TRILIPIX 29 trimethobenzamide hcl 26 trimethoprim 10 trimipramine maleate 22 TRINTELLIX 22 TRIOSTAT 126 TRIUMEQ 46 TRIZIVIR 46 tropicamide 119 trospium chloride 128 TRUE COMFORT INSULIN SYRINGE05ML31G X516 106 TRUE COMFORT INSULIN SYRINGE1ML31G X516 107 TRUE COMFORT PRO INSULINSYRINGE05ML30G X516 107 TRUE COMFORT PRO INSULINSYRINGE05ML31G X516 107 TRUE COMFORT PRO INSULINSYRINGE1ML30G X516 107 TRUE COMFORT PRO INSULINSYRINGE1ML31G X516 107 TRUE COMFORT PRO INSULINSYRINGEU-10005ML30G X 12 107 TRUE COMFORT PRO INSULINSYRINGEU-1001ML30G X 12 107 TRUE METRIX BLOOD GLUCOSETEST STRIPS 65 TRUE METRIX CONTROL SOLUTION LEVEL 3 88

Index 31

TRUEDRAW LANCING TRUSTEX LUBRICATED ULTICARE INSULIN DEVICE 88 EXTRASTRENGTH 77 SYRINGE03ML29G XTRUEPLUS INSULIN TRUSTEX 12 107 SYRINGEU-10003ML29G X LUBRICATEDRIBBEDSTUDD ULTICARE INSULIN 12 107 ED 77 SYRINGE03ML30G XTRUEPLUS INSULIN TRUSTEX 12 107 SYRINGEU-10003ML30G X LUBRICATEDSPERMICIDE ULTICARE INSULIN 516 107 77 SYRINGE03ML30G XTRUEPLUS INSULIN TRUSTEX 516 107 SYRINGEU-10003ML31G X LUBRICATEDSPERMICIDE ULTICARE INSULIN 516 107 EXTRA LARGE 77 SYRINGE05ML28G XTRUEPLUS INSULIN TRUSTEX 12 107 SYRINGEU-10005ML28G X LUBRICATEDSPERMICIDE ULTICARE INSULIN 12 107 EXTRA STRENGTH 77 SYRINGE05ML29G XTRUEPLUS INSULIN TRUSTEX NATURAL 12 107 SYRINGEU-10005ML29G X CONDOMS ULTICARE INSULIN 12 107 +LUBELUBRICATED 77 SYRINGE05ML30G XTRUEPLUS INSULIN TRUSTEX WITH 12 107 SYRINGEU-10005ML30G X NONOXYNOL- ULTICARE INSULIN 516 107 9RIBBEDSTUDDED 77 SYRINGE05ML30G XTRUEPLUS INSULIN TRUSTEXRIA 516 107 SYRINGEU-10005ML31G X LUBRICATED 77 ULTICARE INSULIN 516 107 TRUSTEXRIA LUBRICATED SYRINGE1ML28G X 12 107 TRUEPLUS INSULIN SPERMICIDE 77 ULTICARE INSULIN SYRINGEU-1001ML28G X TRUSTEXRIA SYRINGE1ML29G X 12 108 12 107 LUBRICATEDSPERMICIDE ULTICARE INSULIN TRUEPLUS INSULIN 77 SYRINGE1ML30G X 12 108 SYRINGEU-1001ML29G X TRUVADA 46 ULTICARE INSULIN 12 107 SYRINGE1ML30G XTUKYSA 36 TRUEPLUS INSULIN 516 108 TURALIO 39 SYRINGEU-1001ML30G X ULTICARE INSULIN 516 107 TUZISTRA XR 55 SYRINGESHORT03ML30G XTRUEPLUS INSULIN TWINRIX 131 516 108 SYRINGEU-1001ML31G X ULTICARE INSULIN TWIRLA 53 516 107 SYRINGESHORT03ML31G X

TWYNSTA 32 TRUEPLUS LANCETS 26G 88 516 108 TYBLUME 53 ULTICARE INSULIN TRUEPLUS LANCETS 28G 88 SYRINGESHORT05ML30G XTYBOST 46 TRUEPLUS LANCETS 28G 516 108 SUPER THIN 88 TYGACIL 125 ULTICARE INSULIN

TRUEPLUS LANCETS 30G 88 TYKERB 39 SYRINGESHORT05ML31G XTRUEPLUS LANCETS 30G TYLENOLCODEINE 3 9 516 108 ULTRA THIN 88 ULTICARE INSULIN TYLENOLCODEINE 4 9 TRUEPLUS LANCETS 33G 88 SYRINGESHORT1ML30G X

TYMLOS 66 TRUEPLUS LANCETS 33G 516 108 MICRO THIN 88 TYSABRI 124 ULTICARE INSULIN TRUEPLUS SAFETY LANCETS UCERIS 10 SYRINGESHORT1ML31G X28G 88 516 108 UDENYCA 73 ULTICARE INSULIN TRUETRACK TEST 65 ULESFIA 64 SYRINGEU-10003ML30G XTRULICITY 24 ULORIC 72 12 108 TRUMENBA 129 ULTI-LANCE AUTOMATIC ULTICARE INSULIN TRUSOPT 121 CLEAR TIP 88 SYRINGEU-10003ML31G XTRUSTEX COLOR CONDOMS + ULTICARE INSULIN SAFETY 516 108 LUBE 77 SYRINGE05ML29G X ULTICARE INSULIN TRUSTEX LUBRICATED 77 12 107 SYRINGEU-10005ML30G XTRUSTEX LUBRICATED ULTICARE INSULIN SAFETY 12 108 EXTRALARGE 77 SYRINGE1ML29G X

12 107

Index 32

ULTICARE INSULIN SYRINGEU-10005ML31G X516 108 ULTICARE INSULIN SYRINGEU-1001ML30G X12 108 ULTICARE INSULIN SYRINGEU-1001ML31G X516 108 ULTICARE INSULIN SYRINGEULTRAFINE U-10003ML31G X 516 108 ULTICARE INSULIN SYRINGEULTRAFINE U-10005ML31G X 516 108 ULTICARE INSULIN SYRINGEULTRAFINE U-1001ML31G X 516 108 ULTIGUARD SAFEPACK INSULIN SYRINGE 03ML30G X12SHARPS C 108 ULTIGUARD SAFEPACK INSULIN SYRINGE 12ML 30G X12SHARPS C 108 ULTIGUARD SAFEPACK INSULIN SYRINGE 1ML 30G X 12SHARPS CON 108 ULTIGUARD SAFEPACK INSULIN SYRINGE 1ML 31G X 516SHARPS CO 108 ULTIGUARD SAFEPACK INSULIN SYRINGE03ML30G X12SHARPS C 108 ULTIGUARD SAFEPACK INSULIN SYRINGE03ML31G X516SHARPS 108 ULTIGUARD SAFEPACK INSULIN SYRINGE05ML30G X12SHARPS C 108 ULTIGUARD SAFEPACKSYRINGENEEDLE31G X 516SHARPSCONTAIN 108 ULTILET CLASSIC LANCETS 88 ULTILET INSULIN SYRINGE03ML30G X8MM 109 ULTILET INSULIN SYRINGE03ML31G X8MM 109 ULTILET INSULIN SYRINGE05ML30G X8MM 109 ULTILET INSULIN SYRINGE1ML30G X 8MM109 ULTILET INSULIN SYRINGE1ML31G X 8MM109

ULTILET INSULIN SYRINGESHORT03ML30GX 127MM 109 ULTILET INSULIN SYRINGESHORT03ML30GX 516 109 ULTILET INSULIN SYRINGESHORT03ML31GX 516 109 ULTILET INSULIN SYRINGESHORT05ML30GX 516 109 ULTILET INSULIN SYRINGESHORT05ML31GX 516 109 ULTILET INSULIN SYRINGESHORT1ML30G X516 109 ULTILET INSULIN SYRINGESHORT1ML31G X516 109 ULTILET INSULIN SYRINGEU-10005ML30G X12 109 ULTILET INSULIN SYRINGEU-1001ML30G X12 109 ULTILET LANCETS 88 ULTILET LANCETS 33G 88 ULTILET SAFETY LANCETS 21G X 22MM 88 ULTILET SAFETY LANCETS 23G 88 ULTRA COMFORT INSULIN SYRINGEU-10003ML30G X516 ULTRA FLO INSULIN

109

SYRINGE 03ML29G X12 ULTRA FLO INSULIN

109

SYRINGE 03ML30GX12 ULTRA FLO INSULIN

109


109


109


109


109

SYRINGE 05ML30GX516 109

ULTRA FLO INSULIN SYRINGE 05ML31GX516 109 ULTRA FLO INSULIN SYRINGE 12 UNIT03ML30GX12 109 ULTRA FLO INSULIN SYRINGE 12 UNIT03ML30GX516

109 ULTRA FLO INSULIN SYRINGE 12 UNIT03ML31GX516

109 ULTRA FLO INSULIN SYRINGE 1M29GX12 109 ULTRA FLO INSULIN SYRINGE 1ML30GX12 109 ULTRA FLO INSULIN SYRINGE 1ML30GX516 109 ULTRA FLO INSULIN SYRINGE 1ML31GX516 109 ULTRA THIN LANCETS 31G 88 ULTRA-COMFORT INSULIN SYRINGEU-10003ML29G X12 110 ULTRA-COMFORT INSULIN SYRINGEU-10003ML30G X516 110 ULTRA-COMFORT INSULIN SYRINGEU-10003ML31G X516 110 ULTRA-COMFORT INSULIN SYRINGEU-10005ML28G X12 110 ULTRA-COMFORT INSULIN SYRINGEU-10005ML29G X12 110 ULTRA-COMFORT INSULIN SYRINGEU-10005ML30G X516 110 ULTRA-COMFORT INSULIN SYRINGEU-10005ML31G X516 110 ULTRA-COMFORT INSULIN SYRINGEU-1001ML28G X12 110 ULTRA-COMFORT INSULIN SYRINGEU-1001ML29G X12 110 ULTRA-COMFORT INSULIN SYRINGEU-1001ML30G X516 110 ULTRA-COMFORT INSULIN SYRINGEU-1001ML31G X516 110 ULTRA-THIN II AUTO LANCET 88 ULTRA-THIN II INSULIN SYRINGE SHORTU-10003ML30GX516 110

Index 33

ULTRA-THIN II INSULIN SYRINGE SHORTU-10003ML31GX516 110 ULTRA-THIN II INSULIN SYRINGE SHORTU-10005ML30GX516 110 ULTRA-THIN II INSULIN SYRINGE SHORTU-10005ML31GX516 110 ULTRA-THIN II INSULIN SYRINGE SHORTU-1001ML30GX516 110 ULTRA-THIN II INSULIN SYRINGE SHORTU-1001ML31GX516 110 ULTRA-THIN II INSULIN SYRINGEU-10005ML29GX12 110 ULTRA-THIN II INSULIN SYRINGEU-1001ML29GX12

110 ULTRA-THIN II LANCETS 28G 88 ULTRA-THIN II LANCETS 30G 88 ULTRACARE INSULIN SYRINGEU-10003ML30G X516 110 ULTRACARE INSULIN SYRINGEU-10003ML31G X516 110 ULTRACARE INSULIN SYRINGEU-10005ML30G X12 110 ULTRACARE INSULIN SYRINGEU-10005ML30G X516 110 ULTRACARE INSULIN SYRINGEU-10005ML31G X516 110 ULTRACARE INSULIN SYRINGEU-1001ML30G X12 110 ULTRACARE INSULIN SYRINGEU-1001ML30G X516 111 ULTRACARE INSULIN

UNILET GP LANCET 88 UNILET GP SUPERLITE LANCET 88 UNILET GP 28 ULTRA THIN 88 UNILET LANCET 88 UNILET LANCETS MICRO-THIN33G 88 UNILET LANCETS SUPER-THIN30G 88 UNILET LANCETS ULTRA-THIN 28G 88 UNILET SUPERLITE LANCET 88 UNISTIK 3 GENTLE 88 UNISTIK PRO SAFETY LANCET 21G 88 UNISTIK PRO SAFETY LANCET 25G 88 UNISTIK PRO SAFETY LANCET 28G 88 UNISTIK SAFETY LANCETS 28G 88 UNISTIK SAFETY LANCETS 30G 88 UNISTIK TOUCH SAFETY LANCETS 21G 88 UNISTIK TOUCH SAFETY LANCETS 23G 88 UNISTIK TOUCH SAFETY LANCETS 28G 88 UNISTIK TOUCH SAFETY LANCETS 30G 88 UNIVERSAL 1 LANCETS THIN26G 88 UNIVERSAL 1 LANCETS ULTRA THIN 30G 88 UNIVERSAL 1 LANCETS33GMICRO-THIN

88 URECHOLINE 129 UROCIT-K 10 71 UROXATRAL 71 URSO 250 70 URSO FORTE 70

valproic acid 20 valrubicin 37 valsartan 31 valsartan-hydrochlorothiazide

32 VALSTAR 37 VALTOCO 17 VALTREX 47 VALUE HEALTH INSULIN SYRINGEU-10005ML29G X12 111 VALUE HEALTH INSULIN SYRINGEU-1001ML29G X12 111 VALUE PLUS LANCETS STANDARD 21G 89 VALUE PLUS LANCETS SUPERTHIN 30G 89 VALUE PLUS LANCETS THIN 26G 89 VALUE PLUS LANCING DEVICE 89 VALUMARK LANCET SUPER THIN 30G 89 VALUMARK LANCET ULTRA THIN 28G 89 VANCOCIN 11 VANCOCIN HCL 11 vancomycin hcl 11 VANCOMYCIN HYDROCHLORIDE 11 VANISHPOINT INSULIN SYRINGE05ML30G X12 111 VANISHPOINT INSULIN SYRINGE05ML30G X516 111 VANISHPOINT INSULIN SYRINGE1ML29G X 12 111 VANISHPOINT INSULIN SYRINGE1ML30G X516 111 VAQTA 131 VARENICLINE TARTRATE 125

SYRINGEU-1001ML31G X516 111 ULTRACET 9 ULTRAM 8 UNASYN 122 UNASYN BULK PACK 122 UNILET COMFORTOUCH LANCET 88

ursodiol UTIBRON NEOHALER UVADEX VAGIFEM valacyclovir hcl VALCYTE valganciclovir hcl

70 15 40

132 47 47 47

VARIVAX VARUBI VASCEPA VASERETIC VASOTEC VECAMYL VECTIBIX

131 26 29 32 30 32 36

UNILET EXCELITE 88 VALIUM 13 VECTICAL 60

UNILET EXCELITE II 88 valproate sodium 20 VELCADE 39

Index 34

VELETRI 50 VELPHORO 71 VELTIN 57 VEMLIDY 47 venlafaxine hcl 22 VENTAVIS 50 VENTOLIN HFA 15 verapamil hcl 49 VEREGEN 57 VERELAN 50 VERELAN PM 50 VERZENIO 39 VESICARE 129 VFEND 27 VIAGRA 50 VIBRAMYCIN 126 VICTOZA 24 VIDA MIA AUTOLET LANCINGDEVICE 89 VIDA MIA UNILET LANCETS SUPER THIN 30G 89 VIDA MIA UNILET LANCETS ULTRA THIN 28G 89 VIDAZA 35 VIDEX EC 46 VIDEXPEDIATRIC 46 vigabatrin 19 VIGAMOX 119 VIIBRYD 22 VIIBRYD STARTER PACK 22 VIMPAT 19 vincristine sulfate 40 vinorelbine tartrate 40 VIRACEPT 46 VIRAMUNE 46 VIRAMUNE XR 46 VIREAD 4647 VISTARIL 13 VISTOGARD 25 VITAMIN D2 132 VITATHELYGINGER 117 VITRAKVI 39 VIVAGUARD LANCETS 89 VIVAGUARD LANCING DEVICE 89 VIVELLE-DOT 69 VIZIMPRO 36 VOGELXO 10

VOGELXO PUMP 10 VOL-PLUS 117 VOLTAREN 57 VORAXAZE 40 voriconazole 27 VOSEVI 47 VOTRIENT 39 VP INSULIN SYRINGEU-10003ML29G X 12 111 VPRIV 73 VUSION 59 VYNDAMAX 51 VYNDAQEL 51 VYTORIN 29 VYVANSE 1 WALGREENS ADVANCED TRAVELLANCETS 28G 89 WALGREENS COMFORT ASSUREDLANCETS MICRO THIN33G 89 WALGREENS COMFORT ASSUREDLANCETS SUPER THIN28G 89 WALGREENS LANCETS 89 WALGREENS THIN LANCETS 89 WALGREENS ULTRA THIN LANCETS 89 warfarin sodium 16 water for irrigation sterile 115 WELCHOL 29 WELLBUTRIN SR 20 WELLBUTRIN XL 20 WESTAB PLUS 117 WESTHROID 126 WIDE-SEAL SILICONE DIAPHRAGM KIT 60 77 WIDE-SEAL SILICONE DIAPHRAGM KIT 65 77 WIDE-SEAL SILICONE DIAPHRAGM KIT 70 77 WIDE-SEAL SILICONE DIAPHRAGM KIT 75 77 WIDE-SEAL SILICONE DIAPHRAGM KIT 80 77 WIDE-SEAL SILICONE DIAPHRAGM KIT 85 77 WIDE-SEAL SILICONE DIAPHRAGM KIT 90 77 WIDE-SEAL SILICONE DIAPHRAGM KIT 95 77 WP THYROID 126 XALATAN 121

XALKORI 39 XANAX 13 XANAX XR 13 XARELTO 16 XARELTO STARTER PACK 16 XELJANZ 4 XELJANZ XR 4 XELODA 35 XENAZINE 124 XEOMIN 118 XGEVA 66 XIFAXAN 10 XIGDUO XR 23 XIMINO 126 XOLAIR 14 XOPENEX 15 XOPENEX CONCENTRATE 15 XOPENEX HFA 15 XOSPATA 39 XPOVIO 100 MG ONCE WEEKLY 37 XPOVIO 60 MG ONCE WEEKLY 37 XPOVIO 80 MG ONCE WEEKLY 37 XPOVIO 80 MG TWICE WEEKLY 37 XTAMPZA ER 8 XTANDI 37 XULTOPHY 10036 23 XYLOCAINE 75 XYLOCAINE-MPF 75 XYREM 123 XYZAL ALLERGY 24HR 28 XYZAL ALLERGY 24HR CHILDRENS 28 YASMIN 28 53 YAZ 53 YERVOY 36 YONSA 37 ZADITOR 121 zafirlukast 14 zaleplon 74 ZALTRAP 36 ZANAFLEX 117 ZANOSAR 35 ZANTAC 150 MAXIMUM STRENGTH 127 ZARONTIN 20

Index 35

ZARXIO 73 ZAVESCA 73 ZEGERID 128 ZEJULA 39 ZELBORAF 39 ZEMAIRA 125 ZEMPLAR 68 ZENPEP 65 ZEPATIER 47 ZERVIATE 121 ZESTORETIC 32 ZESTRIL 30 ZETIA 30 ZEVRX INSULIN SYRINGE05ML30G X12 111 ZEVRX INSULIN SYRINGE05ML30G X516 111 ZEVRX INSULIN SYRINGE1ML30G X 12 111 ZEVRX INSULIN SYRINGE1ML30G X516 111 ZIAC 32 ZIAGEN 47 ZIANA 57 zidovudine 47 ZIEXTENZO 73 zileuton 14 ZIOPTAN 121 ziprasidone hcl 42 ZIRABEV 36 ZIRGAN 119 ZITHROMAX 7576 ZITHROMAX TRI-PAK 76 ZITHROMAX Z-PAK 76 ZOCOR 30 ZOFRAN 26 ZOHYDRO ER 8 ZOLADEX 37 zoledronic acid 66 ZOLEDRONIC ACID 66 zoledronic acid 66 ZOLINZA 39 zolmitriptan 112 ZOLOFT 2122 zolpidem tartrate 74

ZOMACTON 67 ZOMIG 113 ZOMIG ZMT 113 ZONALON 59 ZONEGRAN 19 zonisamide 19 ZONTIVITY 72 ZORBTIVE 67 ZORTRESS 115 ZOSTAVAX 131 ZOSYN 122 ZOVIRAX 4760 ZYCLARA 63 ZYCLARA PUMP 63 ZYDELIG 39 ZYLOPRIM 72 ZYMAXID 119 ZYPREXA 43 ZYPREXA ZYDIS 43 ZYRTEC ALLERGY 28 ZYRTEC CHILDRENS ALLERGY 28 ZYRTEC-D ALLERGYCONGESTION 55 ZYTIGA 37 ZYVOX 12

Index 36

copy 2020 Celtic Insurance Company All rights reserved AMB19-IN-C-00236

Statement of Non-Discrimination

Ambetter from MHS complies with applicable Federal civil rights laws and does not discriminate on the basis of race color national origin age disability or sex Ambetter from MHS does not exclude people or treat them differently because of race color national origin age disability or sex

Ambetter from MHS

Provides free aids and services to people with disabilities to communicate effectively with us such as

Qualified sign language interpreters

Written information in other formats (large print audio accessible electronic formats other formats)

Provides free language services to people whose primary language is not English such as

Qualified interpreters

Information written in other languages

If you need these services contact Ambetter from MHS at 1-877-687-1182 (TTYTDD 1-800-743-3333)

If you believe that Ambetter from MHS has failed to provide these services or discriminated in another way on the basis of race color national origin age disability or sex you can file a grievance with Ambetter from MHS Grievance amp Appeals Department PO Box 441567 Indianapolis IN 46244 1-877-687-1182 (TTYTDD 1-800-743-3333) Fax 1-866-714-7993 You can file a grievance by mail fax or email If you need help filing a grievance Ambetter from MHS is available to help you You can also file a civil rights complaint with the US Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at httpsocrportalhhsgovocrportallobbyjsf or by mail or phone at US Department of Health and Human Services 200 Independence Avenue SW Room 509F HHH Building Washington DC 20201 1-800-368-1019 800-537-7697 (TDD)

Complaint forms are available at httpwwwhhsgovocrofficefileindexhtml

AMB19-IN-C-00016 copy 2019 Celtic Insurance Company All rights reserved

Si usted o alguien a quien estaacute ayudando tiene preguntas acerca de Ambetter de MHS tiene derecho a obtener ayuda e informacioacuten en su Spanish

idioma sin costo alguno Para hablar con un inteacuterprete llame al 1-877-687-1182 (TTYTDD 1-800-743-3333)

如果您或是您正在協助的對象有關於 Ambetter from MHS方面的問題您有權利免費以您的母語得到幫助和訊息如果要與一位翻譯員講Chinese

話請撥電話 1-877-687-1182 (TTYTDD 1-800-743-3333)

Falls Sie oder jemand dem Sie helfen Fragen zu Ambetter from MHS hat haben Sie das Recht kostenlose Hilfe und Informationen in Ihrer German

Sprache zu erhalten Um mit einem Dolmetscher zu sprechen rufen Sie bitte die Nummer 1-877-687-1182 (TTYTDD 1-800-743-3333) an

Pennsylvania Vann du adda ebbahs du am helfa bisht ennichi questions hott veyyich Ambetter from MHS dann hosht dus recht fa hilf greeya adda may

Dutch aus finna diveyya in dei shprohch uns kosht nix Fa shvetza mitt ebbah diveyya kawl 1-877-687-1182 (TTYTDD 1-800-743-3333)

သငသႚမဟတသငမႀက ၾ ႀ ပငခ ၾ သငဘာသာစကားဖင ညေနသတစဥးဥးတငAmbetter from MHS အေကာငးေမးစရာမားရပၝကအခမအကအည ရယ ငႎႀငBurmese

အခ အလက ႀပၝသညစကားပနတစဥးႎႀငစကားေပာဆရန1-877-687-1182 (TTYTDD 1-800-743-3333) က ဖနးဆကပၝမားက အခမရယပငခၾင ရ က

Ambetter لوحةئلس أهداعست خصشىد لو أ يكد ل ان ك ذاإ from MHS 877-1- بـ لصت ا مجرت م ع م حدثت لل ةفلتك ةي أ نود ن م كتبلغ ةيرورض ال تامعلوموال ةداعس الم على ولصح ال ي ف قح ال كيد لArabic

(TTYTDD 1-800-743-3333) 687-1182

만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Ambetter from MHS 에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 Korean 부담없이 얻을 수 있는 권리가 있습니다 그렇게 통역사와 얘기하기 위해서는 1-877-687-1182

(TTYTDD 1-800-743-3333) 로 전화하십시오

Nếu quyacute vị hay người magrave quyacute vị đang giuacutep đỡ coacute cacircu hỏi về Ambetter from MHS quyacute vị sẽ coacute quyền được giuacutep vagrave coacute thecircm thocircng tin bằng

Vietnamese ngocircn ngữ của migravenh miễn phiacute Để noacutei chuyện với một thocircng dịch viecircn xin gọi 1-877-687-1182

(TTYTDD 1-800-743-3333)

Si vous-mecircme ou une personne que vous aidez avez des questions agrave propos drsquoAmbetter from MHS vous avez le droit de beacuteneacuteficier French

gratuitement drsquoaide et drsquoinformations dans votre langue Pour parler agrave un interpregravete appelez le 1-877-687-1182 (TTYTDD 1-800-743-3333)

Ambetter from MHS について何かご質問がございましたらご連絡くださいご希望の言語によるサポートや情報を無料でご提供いたします通訳が必要な場合は Japanese

1-877-687-1182 (TTYTDD 1-800-743-3333) までお電話ください

Als u of iemand die u helpt vragen heeft over Ambetter from MHS hebt u recht op gratis hulp en informatie in uw taal Bel 1-877 687-1182 Dutch

(TTYTDD (teksttelefoon) 1-800 743-3333) om met een tolk te spreken

Kung ikaw o ang iyong tinutulangan ay may mga katanungan tungkol sa Ambetter from MHS may karapatan ka na makakuha nang tulong at

Tagalog impormasyon sa iyong wika ng walang gastos Upang makausap ang isang tagasalin tumawag sa 1-877-687-1182 (TTYTDD 1-800-743-

3333)

В случае возникновения у вас или у лица которому вы помогаете каких-либо вопросов о программе страхования Ambetter from MHS

Russian вы имеете право получить бесплатную помощь и информацию на своем родном языке Чтобы поговорить с переводчиком позвоните

по телефону 1-877-687-1182 (TTYTDD 1-800-743-3333)

ਜ ਤਹਾਡ ਜਾ ਤ ਰਹ ਮਨ ਕਿਚ Ambetter from MHS ਦ ਬਾਰ ਣ ਦਾ ਪਰਾ ਹਿ ਹ ਹਾਡੀ ਮਦਦ ਲ ਕਿਸ ਕਿਅਿਤੀ ਦ ਿਈ ਸਿਾਲ ਹਨ ਤਾ ਤਹਾਨ ਆਪਣੀ ਭਾਸ਼ਾ ਕਿਚ ਮਫਤ ਮਦਦ ਲPunjabi

ਦਭਾਸ਼ੀਏ ਨਾਲ ਗ ਲ ਿਰਨ ਲਈ 1-877-687-1182 (TTYTDD 1-800-743-3333) ਤ ਿਾਲ ਿਰ

क

क स

आप या जिसकी आप मदद कर रह ह उनक Ambetter from MHS क बार म कोई सवाल हो तो आपको बबना ककसी खरच अपनी भाषा म मदद और Hindi

िानकारी परापत करन का अधिकार ह ककसी दभाषषय बात करन ललए 1-877-687-1182 (TTYTDD 1-800-743-3333) पर कॉल कर


Classes

ADHDANTI-NARCOLEPSYANTI-OBESITYANOREXIANTS - Drugs to Treat ADHD Sleep and Eating Disorders


AMEBICIDES

AMINOGLYCOSIDES - Drugs to Treat Bacterial Infections

ANALGESICS - ANTI-INFLAMMATORY - Drugs to Treat Pain Swelling Muscle and Joint Conditions

ANALGESICS - NonNarcotic - Drugs to Treat Pain Muscle and Joint Conditions

ANALGESICS - OPIOID - Drugs to Treat Pain Muscle and Joint Conditions


ANORECTAL AND RELATED PRODUCTS - Rectal Drugs to Treat Pain Swelling and Itching










ANTIDIABETICS - Drugs to Regulate Blood Sugar



ANTIEMETICS - Drugs to Treat Nausea and Vomiting



ANTIHYPERLIPIDEMICS - Drugs to Treat High Cholesterol

ANTIHYPERTENSIVES - Drugs to Treat High Blood Pressure

ANTIMALARIALS - Drugs to Treat Malaria (Parasitic Infections)


ANTIMYCOBACTERIAL AGENTS - Drugs to Treat Tuberculosis (Bacterial Infections)

ANTINEOPLASTICS AND ADJUNCTIVE THERAPIES - Drugs to Treat Cancer


ANTIPSYCHOTICSANTIMANIC AGENTS - Drugs to Treat Mood Disorders


BETA BLOCKERS - Drugs to Treat High Blood Pressure

CALCIUM CHANNEL BLOCKERS - Drugs to Treat High Blood Pressure

CARDIOTONICS - Drugs to Treat Heart Failure and Abnormal Heart Rhythm

CARDIOVASCULAR AGENTS - MISC - Drugs to Treat Heart and Circulation Conditions

CEPHALOSPORINS - Drugs to Treat Bacterial Infections

CHEMICALS

CONTRACEPTIVES - Drugs to Prevent Pregnancy

CORTICOSTEROIDS - Steroid Hormone Drugs to Treat Systemic Swelling Conditions

COUGHCOLDALLERGY - Drugs to Treat Cough Cold and Allergy Symptoms

DERMATOLOGICALS - Drugs to Treat Skin Conditions

DIAGNOSTIC PRODUCTS

DIGESTIVE AIDS - Drugs to Treat Low Digestive Enzymes

DIURETICS - Drugs to Treat Heart Circulation Conditions and Blood Pressure

ENDOCRINE AND METABOLIC AGENTS - MISC - Drugs to Treat Bone Disease and Regulate Hormones

ESTROGENS - Hormone ReplacementModifying Drugs

FLUOROQUINOLONES - Drugs to Treat Bacterial Infections

GASTROINTESTINAL AGENTS - MISC - Miscellaneous Gastrointestinal Drugs

GENITOURINARY AGENTS - MISCELLANEOUS - Miscellaneous Drugs to Treat Reproductive Organs and Urinary System


HEMATOLOGICAL AGENTS - MISC - Drugs to Treat Blood Disorders

HEMATOPOIETIC AGENTS - Drugs to Treat Blood Disorders

HEMOSTATICS - Drugs to Stop BleedingTreat Blood Disorders

HYPNOTICSSEDATIVESSLEEP DISORDER AGENTS


LOCAL ANESTHETICS-Parenteral - Drugs for Numbing

MACROLIDES - Drugs to Treat Bacterial Infections


MIGRAINE PRODUCTS - Drugs to Treat Migraine Headaches




MULTIVITAMINS

MUSCULOSKELETAL THERAPY AGENTS - Drugs to Treat Spasms

NASAL AGENTS - SYSTEMIC AND TOPICAL - Drugs to treat the Nose or Sinus

NEUROMUSCULAR AGENTS - Drugs to RelaxParalyze Muscles

NUTRIENTS



PASSIVE IMMUNIZING AND TREATMENT AGENTS - Antibody Drugs to Treat Low Immune System


PROGESTINS - Hormone ReplacementModifying Drugs

PSYCHOTHERAPEUTIC AND NEUROLOGICAL AGENTS - MISC - Drugs to Treat Mental and Emotional Conditions

RESPIRATORY AGENTS - MISC - Drugs to Treat Lung Conditions

SULFONAMIDES - Drugs to Treat Bacterial Infections

TETRACYCLINES - Drugs to Treat Bacterial Infections

THYROID AGENTS - Drugs to Regulate Thyroid Hormones

TOXOIDS

ULCER DRUGS - Drugs to Treat Bowel Intestine and Stomach Conditions

URINARY ANTISPASMODICS - Drugs to Treat Miscellaneous Bladder Spasms

VACCINES


VASOPRESSORS - Drugs to Treat Heart and Circulation Conditions

VITAMINS

Formulary Introduction FORMULARY

The Ambetter from MHS Formulary or Preferred Drug List is a guide to available brand and generic drugs that are approved by the Food and Drug Administration (FDA) and covered through your prescription drug beneft Generic drugs have the same active ingredients as their brand name counterparts and should be considered the frst line of treatment The FDA requires generics to be safe and work the same as brand name drugs If there is no generic available there may be more than one brand name drug to treat a condition Preferred brand name drugs are listed on Tier 2 to help identify brand drugs that are clinically appropriate safe and cost-efective treatment options if a generic medication on the formulary is not suitable for your condition

Please note the Formulary is not meant to be a complete list of the drugs covered under your prescription beneft Not all dosage forms or strengths of a drug may be covered This list is periodically reviewed and updated and may be subject to change Drugs may be added or removed or additional requirements may be added in order to approve continued usage of a specifc drug

Specifc prescription beneft plan designs may not cover certain products or categories regardless of their appearance in this document Please check your benefts for coverage limitations and your share of cost for your drugs

Drug List Key

Brand name drugs are listed in CAPS and generic drugs are lower case Drugs are covered under diferent copay tiers depending on your beneft

Tier 0 - No copayment for those drugs that are used for prevention and are mandated by the Afordable Care Act Select oral contraceptives vitamin D folic acid for women of child bearing age over-the-counter (OTC) aspirin and smoking cessation products may be covered under this tier Certain age or gender limits apply

Tier 1 - Lowest copayment for those drugs that ofer the greatest value compared to other drugs used to treat similar conditions Select over-the-counter (OTC) generic or brand name drugs may be covered under this tier

Tier 2 - Medium copayment covers brand name drugs that are generally more afordable or may be preferred compared to other drugs to treat the same conditions

Tier 3 - Highest copayment covers higher cost brand name drugs This tier may also cover non-specialty drugs that are not on the Preferred Drug List but approval has been granted for coverage

Tier 4 - Coverage for this tier is for ldquospecialtyrdquo drugs used to treat complex chronic conditions that may require special handling storage or clinical management For members who do not have a Tier 4 plan these drugs may be covered under Tier 3

Prior Authorization for Non-Formulary Drugs

To obtain prior authorization for a non-formulary drug your provider must fill out the Prior Authorization form Envolve Pharmacy Solutions will respond via fax or phone within 24 hours of receipt of all necessary information for urgent requests and within 72 hours for non-urgent requests unless state law requires faster response If the request is disapproved the notice of disapproval will contain a clear explanation of the specific reasons for disapproving the prior authorization request or if the request was incomplete the explanation will identify the missing material information that is necessary to complete the request







ST Step Therapy






NF Non-formulary






Drug Name DrugTier

RequirementsLimits



NF

QL(3 ea daily)


NF

QL(2 ea daily)


NF

QL(1 ea daily)


NF


NF

QL(2 ea daily)



1

QL(1 ea daily)


1

Drug Name DrugTier

RequirementsLimits


1

QL(2 ea daily)


1

QL(3 ea daily)


1

QL(2 ea daily)




NF

QL(4 ea daily)


NF







3 ST QL(1 eadaily)


2 ST QL(1 eadaily)



1

Drug Name DrugTier

RequirementsLimits




Anti-Obesity Agents


















SUNOSI TABS 3 PA

Stimulants - Misc

armodafinil tabs 1




Drug Name DrugTier

RequirementsLimits





1

QL(1 ea daily)










yrs old)
















2

Drug Name DrugTier

RequirementsLimits


















Allergenic Extracts

GRASTEK SUBL 3 PA

AMEBICIDES

Amebicides

SOLOSEC PACK 3 PA


Aminoglycosides


ARIKAYCE SUSP 4 PA

Drug Name DrugTier

RequirementsLimits


1










1




4



ea daily)






3

Drug Name DrugTier

RequirementsLimits


4



4





ea daily)









Gold Compounds




Drug Name DrugTier

RequirementsLimits




NF


NF


NF PA QL(2 eadaily)



daily)














daily)

flurbiprofen tabs 1


4

Drug Name DrugTier

RequirementsLimits












nabumetone tabs 1








oxaprozin tabs 1

piroxicam caps 1

sulindac tabs 1


Drug Name DrugTier

RequirementsLimits




OTEZLA TBPK 4







ml daily)



ml daily) SP



ml daily) SP




1


1



NF


5

Drug Name DrugTier

RequirementsLimits


NF


NF


Salicylates




diflunisal tabs 1

salsalate tabs 1



daily)






NF




NF

Drug Name DrugTier

RequirementsLimits


NF




1

PA QL(4 eadaily)


1 QL(034 eadaily)



1 PA QL(2 eadaily)


daily)




1






NF


NF

PA QL(2 eadaily)





6

Drug Name DrugTier

RequirementsLimits








1








NF QL(10 ml daily)




1 PA QL(2 eadaily)



NF



Drug Name DrugTier

RequirementsLimits







1 QL(2 ea daily)





daily)

OXAYDO TABS 5 MG 2



3 PA QL(2 eadaily)






1 PA QL(2 eadaily)


daily)





7

Drug Name DrugTier

RequirementsLimits



daily)









1







1







1


Drug Name DrugTier

RequirementsLimits


1





NF



NF





1



1



1



1 PA



LORTAB ELIX 2



8

Drug Name DrugTier

RequirementsLimits


NF



1





NF





NF



NF










Drug Name DrugTier

RequirementsLimits


1 QL(3 ea daily)


1 QL(2 ea daily)


1

QL(3 ea daily)


1

PA QL(0143ea daily)




NF

PA QL(0143ea daily)







NF

QL(3 ea daily)


NF

QL(2 ea daily)


Anabolic Steroids

ANADROL-50 TABS 3

oxandrolone tabs 1

Androgens


9

Drug Name DrugTier

RequirementsLimits



NF

danazol caps 1


NF

METHITEST TABS 3



1














NF

Drug Name DrugTier

RequirementsLimits


NF

Vasodilating Agents



Anthelmintics




EMVERM CHEW 2










trimethoprim tabs 1




10

Drug Name DrugTier

RequirementsLimits


NF


NF






atovaquone susp 1



Carbapenems




meropenem solr 1






Drug Name DrugTier

RequirementsLimits



Glycopeptides











Leprostatics

dapsone tabs 1


NF


NF


NF




1



11

Drug Name DrugTier

RequirementsLimits


Monobactams







daily) Polymyxins





NF


NF








Drug Name DrugTier

RequirementsLimits





NF





NITRO-BID OINT 3


NF



1










12

Drug Name DrugTier

RequirementsLimits



meprobamate tabs 1




















Drug Name DrugTier

RequirementsLimits














dofetilide caps 1

MULTAQ TABS 3







FASENRA SOSY 4 PA


13

Drug Name DrugTier

RequirementsLimits

NUCALA SOAJ 4 PA

NUCALA SOLR 4 PA

NUCALA SOSY 4 PA














NF QL(1 ea daily)






Drug Name DrugTier

RequirementsLimits




Steroid Inhalants



daily)


FLOVENT HFA AERO 2



daily)



NF

ADVAIR HFA AERO 2


NF


NF


NF




14

Drug Name DrugTier

RequirementsLimits





1 QL(15 ml daily)








daily)

BREO ELLIPTA AEPB 2




1



1 PA QL(12 mldaily)


Drug Name DrugTier

RequirementsLimits








2







NF PA




daily) Xanthines


ELIXOPHYLLIN ELIX 1






15

Drug Name DrugTier

RequirementsLimits




BEVYXXA CAPS 3



daily)








NF



NF



NF



NF




Drug Name DrugTier

RequirementsLimits



daily) SP














4

PA SP


NF



1


16

Drug Name DrugTier

RequirementsLimits


1


NF QL(6 ml daily)


NF QL(2 ml daily)


NF QL(16 mldaily)









3 PA




daily)

clonazepam tabs 1

clonazepam tbdp 1


3


3



Drug Name DrugTier

RequirementsLimits




daily)










3 PA











17

Drug Name DrugTier

RequirementsLimits







EPIDIOLEX SOLN 3 PA





NF QL(30 ml daily)




NF QL(4 ea daily)



NF QL(20 ea daily)


NF QL(100 eadaily)


NF QL(1 ea daily)



NF

Drug Name DrugTier

RequirementsLimits





1








NF

PA QL(3 eadaily)





NF



NF





18

Drug Name DrugTier

RequirementsLimits


1 PA QL(3 eadaily)


daily)


primidone tabs 1








NF QL(4 ea daily)



NF QL(6 ea daily)


NF QL(8 ea daily)








NF QL(40 ml daily)

Drug Name DrugTier

RequirementsLimits


NF QL(3 ea daily)





3 PA QL(2 eadaily)



Carbamates















19

Drug Name DrugTier

RequirementsLimits


2





PEGANONE TABS 3


2

phenytoin chew 1



phenytoin susp 1

Succinimides






NF QL(30 ml daily)






Drug Name DrugTier

RequirementsLimits






















20

Drug Name DrugTier

RequirementsLimits



NF QL(15 eadaily)


NF QL(2 ea daily)


NF QL(1 ea daily)









daily)









NF QL(1 ea daily)


Drug Name DrugTier

RequirementsLimits














NF QL(1 ea daily)











21

Drug Name DrugTier

RequirementsLimits
















NF QL(1 ea daily)

FETZIMA CP24 3 PA




NF QL(4 ea daily)


NF QL(1 ea daily)


Drug Name DrugTier

RequirementsLimits



1 QL(3 ea daily)




Tricyclic Agents


amoxapine tabs 3




doxepin hcl caps 1

doxepin hcl conc 1












22

Drug Name DrugTier

RequirementsLimits



miglitol tabs 1






NF QL(2 ea daily)


NF QL(1 ea daily)


1 QL(2 ea daily)



1 QL(2 ea daily)


1 QL(4 ea daily)

GLYXAMBI TABS 2




2 QL(2 ea daily)




Drug Name DrugTier

RequirementsLimits






2 QL(2 ea daily)


TRIJARDY XR TB24 2


3 PA QL(1 eadaily)



daily)



daily)







daily)

diazoxide susp 1


daily)



23

Drug Name DrugTier

RequirementsLimits


3 QL(0035 eadaily)











ml daily)







APIDRA SOLN 3 PA




Drug Name DrugTier

RequirementsLimits


FIASP SOLN 2




LEVEMIR SOLN 2




NOVOLIN 7030 SUSP 2


NOVOLIN N SUSP 2


NOVOLIN R SOLN 2



2



NOVOLOG SOLN 2


TRESIBA SOLN 2




24

Drug Name DrugTier

RequirementsLimits























Drug Name DrugTier

RequirementsLimits




MOTOFEN TABS 3



CHEMET CAPS 3




deferiprone tabs 1






VISTOGARD PACK 4 PA



NARCAN LIQD 3





25

Drug Name DrugTier

RequirementsLimits







daily)
















NF



daily)

Drug Name DrugTier

RequirementsLimits







dronabinol caps 1




ea daily)






NF


VARUBI TBPK 3 PA




26

Drug Name DrugTier

RequirementsLimits



ERAXIS SOLR 3


MYCAMINE SOLR 3

Antifungals

ABELCET SUSP 3

AMBISOME SUSR 3



flucytosine caps 1




nystatin tabs 1





fluconazole susr 1

fluconazole tabs 1



Drug Name DrugTier

RequirementsLimits

ketoconazole tabs 1





daily)

TOLSURA CAPS 4 PA














1

QL(30 ml daily)



27

Drug Name DrugTier

RequirementsLimits


1 QL(1 ea daily)


1 QL(2 ea daily)








1





1









Drug Name DrugTier

RequirementsLimits




RXOTC

loratadine caps 1

loratadine chew 1

loratadine soln 1

loratadine syrp 1

loratadine tabs 1

loratadine tbdp 1


NF

















28

Drug Name DrugTier

RequirementsLimits












daily)






NF QL(6 gm daily)


NF QL(6 ea daily)





Drug Name DrugTier

RequirementsLimits






NF QL(252 gmdaily)














daily)






29

Drug Name DrugTier

RequirementsLimits

















1 QL(2 ea daily)



daily)




Drug Name DrugTier

RequirementsLimits




captopril tabs 1



lisinopril tabs 1






ramipril caps 1

trandolapril tabs 1









30

Drug Name DrugTier

RequirementsLimits

















daily)








Drug Name DrugTier

RequirementsLimits


NF QL(2 ea daily)






NF MO



NF MO


NF ST



NF MO




NF


EXFORGE HCT TABS 2


NF



31

Drug Name DrugTier

RequirementsLimits


NF

QL(2 ea daily)


NF

QL(1 ea daily)




NF


1

QL(2 ea daily)


1

QL(1 ea daily)


NF


NF



NF MO


1 ST






Drug Name DrugTier

RequirementsLimits


NF


NF




NF

ST




NF


NF







eplerenone tabs 1


Vasodilators



minoxidil tabs 1


32

Drug Name DrugTier

RequirementsLimits




COARTEM TABS 2





Drug Name DrugTier

RequirementsLimits









NF






FIRDAPSE TABS 4 PA





NF


3 PA


33

Drug Name DrugTier

RequirementsLimits






RIFAMATE CAPS 3





isoniazid soln 1

isoniazid syrp 1

isoniazid tabs 1




PRIFTIN TABS 3

pyrazinamide tabs 1

rifabutin caps 1 PA



rifampin caps 1

Drug Name DrugTier

RequirementsLimits

rifampin solr 1




















melphalan tabs 1



34

Drug Name DrugTier

RequirementsLimits



NF

PA SP








Antimetabolites














Drug Name DrugTier

RequirementsLimits




NF




















daily)


35

Drug Name DrugTier

RequirementsLimits

MVASI SOLN 4 PA


ZIRABEV SOLN 4 PA




TUKYSA TABS 4 PA





RUXIENCE SOLN 4 PA

YERVOY SOLN 4 PA SP







VIZIMPRO TABS 4 PA


DAURISMO TABS 4 PA




Drug Name DrugTier

RequirementsLimits



daily)




SP



daily) SP





EMCYT CAPS 4 PA SP













36

Drug Name DrugTier

RequirementsLimits



ea daily) SP






NUBEQA TABS 4 PA





YONSA TABS 4 PA










Drug Name DrugTier

RequirementsLimits







NF






NF PA SP



NF PA SP


NF PA








37

Drug Name DrugTier

RequirementsLimits





daily) SP




BALVERSA TABS 4 PA



daily) SP



BRUKINSA CAPS 4 PA





COPIKTRA CAPS 4 PA



daily) SP

IBRANCE CAPS 3 PA

IBRANCE TABS 3 PA

Drug Name DrugTier

RequirementsLimits


daily)




daily)



4 PA QL(1 eadaily)

INREBIC CAPS 4 PA




daily) SP

KISQALI TBPK 3 PA

KOSELUGO CAPS 4 PA

KYPROLIS SOLR 4 PA


LORBRENA TABS 4 PA










38

Drug Name DrugTier

RequirementsLimits



QINLOCK TABS 4 PA

RETEVMO CAPS 4 PA


ROZLYTREK CAPS 4 PA







TABRECTA TABS 4 PA


TALZENNA CAPS 4 PA


daily) SP


TAZVERIK TABS 4 PA


TIBSOVO TABS 4 PA


ml daily) SP



daily) SP


Drug Name DrugTier

RequirementsLimits

VERZENIO TABS 4 PA

VITRAKVI CAPS 4 PA

VITRAKVI SOLN 4 PA



XOSPATA TABS 4 PA














hydroxyurea caps 1



NIPENT SOLR 4 PA SP



39

Drug Name DrugTier

RequirementsLimits





UVADEX SOLN 4 PA SP




1



Mitotic Inhibitors













Drug Name DrugTier

RequirementsLimits



NF PA SP


4 PA SP






NF PA SP







carbidopa tabs 1









40

Drug Name DrugTier

RequirementsLimits




tolcapone tabs 3




APOKYN SOCT 4 PA









NF QL(4 ea daily)


NF

NEUPRO PT24 2




1 QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits


1


NF ST QL(2 eadaily)


NF ST QL(1 eadaily)


1






1


NF


1


NF


1


NF


1


NF


41

Drug Name DrugTier

RequirementsLimits


1


NF


1


NF


daily)





Antimanic Agents




LITHIUM SOLN 1








daily)

Drug Name DrugTier

RequirementsLimits



Benzisoxazoles




NF QL(1 ea daily)








NF QL(2 ea daily)








NF QL(0036 mldaily)


42

Drug Name DrugTier

RequirementsLimits


NF QL(0036 mldaily)





haloperidol tabs 1

















Drug Name DrugTier

RequirementsLimits









3 PA QL(2 eadaily)


daily)





NF PA QL(1 eadaily)


NF PA QL(2 eadaily)



NF QL(1 ea daily)


NF QL(2 ea daily)


NF QL(2 ea daily)




43

Drug Name DrugTier

RequirementsLimits


1





perphenazine tabs 1











REXULTI TABS 3 PA

Thioxanthenes

thiothixene caps 1





Drug Name DrugTier

RequirementsLimits







3

QL(1 ea daily)

















1 QL(1 ea daily)


44

Drug Name DrugTier

RequirementsLimits


1 QL(1 ea daily)



1



0

QL(1 ea daily)









NF QL(1 ea daily)




FUZEON SOLR 4 PA SP






Drug Name DrugTier

RequirementsLimits






NF QL(125 mldaily)


2

QL(4 ea daily)







NF QL(4 ea daily)












45

Drug Name DrugTier

RequirementsLimits











NF QL(1 ea daily)



RUKOBIA TB12 4 PA











Drug Name DrugTier

RequirementsLimits


2

QL(1 ea daily)


2

QL(1 ea daily)







NF QL(2 ea daily)
















46

Drug Name DrugTier

RequirementsLimits


NF






CMV Agents

cidofovir soln 3









daily) SP






daily) SP



daily)

Drug Name DrugTier

RequirementsLimits






daily)



ZEPATIER TABS 4 PA

Herpes Agents















NF QL(5 ea daily)


47

Drug Name DrugTier

RequirementsLimits










NF



NF



Alpha-Beta Blockers

carvedilol tabs 1

Drug Name DrugTier

RequirementsLimits






atenolol tabs 1




2 PA QL(1 eadaily)







daily)









48

Drug Name DrugTier

RequirementsLimits


nadolol tabs 1

pindolol tabs 1


1




1











NF





Drug Name DrugTier

RequirementsLimits



1




felodipine tb24 1

isradipine caps 1



nifedipine caps 1

nifedipine tb24 1

nimodipine caps 1


1






NF





49

Drug Name DrugTier

RequirementsLimits



NF



NF



Cardiac Glycosides

digoxin soln 1

digoxin tabs 1



2





BIDIL TABS 2


NF QL(1 ea daily)

ENTRESTO TABS 3 PA

Impotence Agents



Drug Name DrugTier

RequirementsLimits









3 PA









daily) SP




daily)





50

Drug Name DrugTier

RequirementsLimits


NF



NF

PA QL(6 mldaily)






4 PA QL(6 mldaily)




daily) SP









cefadroxil caps 1

cefadroxil susr 1

cefadroxil tabs 1


Drug Name DrugTier

RequirementsLimits

cephalexin caps 1

cephalexin susr 1

cephalexin tabs 1



cefaclor caps 1

cefaclor susr 1




cefprozil susr 1

cefprozil tabs 1




cefdinir caps 1

cefdinir susr 1









51

Drug Name DrugTier

RequirementsLimits


1




NF PA


cefepime hcl solr 1



TEFLARO SOLR 3

CHEMICALS





NF






0


NF

Drug Name DrugTier

RequirementsLimits


FALESSA KIT 0


NF







NF


NF


NF

NATAZIA TABS 0











52

Drug Name DrugTier

RequirementsLimits




NF


NF


NF


NF


NF


NF


TYBLUME CHEW 0


NF


NF






NF

Drug Name DrugTier

RequirementsLimits


0


ELLA TABS 0



NF


KYLEENA IUD 0

LILETTA IUD 0

MIRENA IUD 0

SKYLA IUD 0


NEXPLANON IMPL 0


NF



NF









53

Drug Name DrugTier

RequirementsLimits


NF






NF


NF





NF




1



1

EMFLAZA SUSP 4 PA

EMFLAZA TABS 4 PA


Drug Name DrugTier

RequirementsLimits





NF

MEDROL TABS 2 MG 3





MILLIPRED DP TBPK 3

MILLIPRED TABS 3


NF


NF


1


3

prednisolone soln 1

prednisone soln 1

prednisone tabs 1

prednisone tbpk 1




54

Drug Name DrugTier

RequirementsLimits




NF




Antitussives






NF

QL(2 ea daily)


NF

QL(1 ea daily)



1 QL(2 ea daily)


1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits


1 QL(2 ea daily)


1 QL(1 ea daily)


1


1 QL(2 ea daily)


1

QL(1 ea daily)



1

QL(2 ea daily)


HYPERSAL NEBU 35 1


NF

NEBUSAL NEBU 1


Mucolytics







55

Drug Name DrugTier

RequirementsLimits




12 yrs old)





NF





yrs old)
















yrs old)

Drug Name DrugTier

RequirementsLimits










12 yrs old)




12 yrs old)



NF
















56

Drug Name DrugTier

RequirementsLimits






yrs old)



















VEREGEN OINT 3






daily) RXOTC

Drug Name DrugTier

RequirementsLimits




mupirocin oint 1














ERTACZO CREA 3


EXELDERM SOLN 3


JUBLIA SOLN 3 PA


57

Drug Name DrugTier

RequirementsLimits










NF RXOTC



NF







Drug Name DrugTier

RequirementsLimits




NF















58

Drug Name DrugTier

RequirementsLimits



OXISTAT LOTN 2







NF






PANRETIN GEL 3

PICATO GEL 0015 2


Drug Name DrugTier

RequirementsLimits

PICATO GEL 005 2













59

Drug Name DrugTier

RequirementsLimits









daily)



NF QL(4 ea daily)









ml daily) SP


TAZORAC CREA 005 2



Drug Name DrugTier

RequirementsLimits











Burn Products








amcinonide crea 1


amcinonide lotn 3


60

Drug Name DrugTier

RequirementsLimits

AMCINONIDE OINT 3





1


1


1






1 ST


1 ST



daily)







Drug Name DrugTier

RequirementsLimits






NF



NF











NF


NF






61

Drug Name DrugTier

RequirementsLimits


















HALOG OINT 3 PA






Drug Name DrugTier

RequirementsLimits









daily)





NF

RXOTC




PSORCON CREA 2 PA





NF

ST


62

Drug Name DrugTier

RequirementsLimits


3

ST







1



1


1







NF RXOTC


NF RXOTC

Drug Name DrugTier

RequirementsLimits











2 yrs old)



2 yrs old)



podofilox soln 1









63

Drug Name DrugTier

RequirementsLimits

SYNERA PTCH 3




Rosacea Agents




NF



NF










EURAX CREA 3



Drug Name DrugTier

RequirementsLimits


lindane sham 3

malathion lotn 1




permethrin crea 1

permethrin liqd 1


spinosad susp 1 PA

ULESFIA LOTN 3

Wound Care Products

REGRANEX GEL 3

DIAGNOSTIC PRODUCTS



CHEMSTRIP-K STRP 1


1


KETONE STRP 1


KETOSTIX STRP 1


1


64

Drug Name DrugTier

RequirementsLimits







1





Digestive Enzymes

CREON CPEP 2

SUCRAID SOLN 3

ZENPEP CPEP 2









NF

Drug Name DrugTier

RequirementsLimits



NF


NF


NF









furosemide soln 1

furosemide tabs 1


torsemide tabs 1







65

Drug Name DrugTier

RequirementsLimits















NF PA SP









Drug Name DrugTier

RequirementsLimits


4 PA SP


PROLIA SOSY 4







TYMLOS SOPN 4 PA

XGEVA SOLN 4 PA SP




Corticotropin

ACTHAR GEL 4 PA




4 PA SP


CETROTIDE KIT 4 PA



66

Drug Name DrugTier

RequirementsLimits


NF PA









4 PA SP




SAIZEN SOLR 4 PA SP


4 PA SP





OSPHENA TABS 3 PA

Drug Name DrugTier

RequirementsLimits









Metabolic Modifiers




calcitriol caps 1

calcitriol soln 1










NF


67

Drug Name DrugTier

RequirementsLimits


NF PA


NF PA


MYALEPT SOLR 4 PA




PALYNZIQ SOSY 4 PA

paricalcitol caps 1

paricalcitol soln 1











NF PA


NF

Drug Name DrugTier

RequirementsLimits


NF QL(6 ea daily)


NF QL(8 ea daily)



4 PA SP







cabergoline tabs 1

Somatostatic Agents



SIGNIFOR SOLN 4 PA




ml daily) SP


daily) SP



daily) SP



68

Drug Name DrugTier

RequirementsLimits



CLIMARA PRO PTWK 3

DUAVEE TABS 3 PA


NF


PREMPHASE TABS 2

PREMPRO TABS 2




NF



3

ELESTRIN GEL 3



1

QL(0286 eadaily)


1



Drug Name DrugTier

RequirementsLimits

ESTROGEL GEL 3

EVAMIST SOLN 3

MENEST TABS 3

MENOSTAR PTWK 3


daily)

PREMARIN SOLR 2

PREMARIN TABS 2




1

BAXDELA SOLR 3 PA

BAXDELA TABS 3 PA






3




1

levofloxacin soln 1

levofloxacin tabs 1


69

Drug Name DrugTier

RequirementsLimits



ofloxacin tabs 1










daily)








AVSOLA SOLR 4 PA


Drug Name DrugTier

RequirementsLimits






DIPENTUM CAPS 2


















70

Drug Name DrugTier

RequirementsLimits



alvimopan caps 1






NF


PHOSLYRA SOLN 2







VELPHORO CHEW 3 PA



1


Drug Name DrugTier

RequirementsLimits


NF

Cystinosis Agents

CYSTAGON CAPS 3 PA


acetic acid soln 1


RESECTISOL SOLN 1


SORBITOL SOLN 1




ELMIRON CAPS 2












Urinary Analgesics


71

Drug Name DrugTier

RequirementsLimits





Gout Agents

allopurinol tabs 1




KRYSTEXXA SOLN 4 PA




Uricosurics

probenecid tabs 1



daily)



CINRYZE SOLR 4 PA

HAEGARDA SOLR 4 PA


SOLIRIS SOLN 4 PA

Drug Name DrugTier

RequirementsLimits




TAKHZYRO SOLN 4 PA





BRILINTA TABS 2

CABLIVI KIT 4 PA

cilostazol tabs 1



dipyridamole tabs 1




ZONTIVITY TABS 3 PA








72

Drug Name DrugTier

RequirementsLimits

VPRIV SOLR 4 PA SP


daily) SP


DROXIA CAPS 3

OXBRYTA TABS 4 PA


Folic AcidFolates




4 PA SP



4

PA SP

DOPTELET TABS 4 PA

EPOGEN SOLN 3 PA SP

FULPHILA SOSY 4 PA


MIRCERA SOSY 4 PA

MULPLETA TABS 4 PA




Drug Name DrugTier

RequirementsLimits



4 PA



3

PA SP





4

PA

UDENYCA SOSY 4 PA


ZIEXTENZO SOSY 4 PA










73

Drug Name DrugTier

RequirementsLimits


NF PA










1










estazolam tabs 1

eszopiclone tabs 1


Drug Name DrugTier

RequirementsLimits







triazolam tabs 1








BELSOMRA TABS 3 PA



ramelteon tabs 1





Bulk Laxatives



74

Drug Name DrugTier

RequirementsLimits



CLENPIQ SOLN 3 PA


NF


0


2

PA


1 PA


0

PREPOPIK PACK 3 PA



Saline Laxatives

OSMOPREP TABS 3 PA

Stimulant Laxatives

bisacodyl tbec 1





Drug Name DrugTier

RequirementsLimits





NF


NF


NF


Azithromycin












NF




75

Drug Name DrugTier

RequirementsLimits




daily)





Clarithromycin





NF


NF


3





1


Fidaxomicin



Contraceptives

Drug Name DrugTier

RequirementsLimits


CAYA DPRH 0




0 QL(2 ea daily)


FEMCAP DEVI 0







0 QL(2 ea daily)


0 QL(2 ea daily)


0 QL(2 ea daily)



0 QL(2 ea daily)



0 QL(2 ea daily)



76

Drug Name DrugTier

RequirementsLimits






0 QL(2 ea daily)








0 QL(2 ea daily)


0 QL(2 ea daily)


0

QL(2 ea daily)


0 QL(2 ea daily)


0

QL(2 ea daily)


0

QL(2 ea daily)


Drug Name DrugTier

RequirementsLimits


0 QL(2 ea daily)


0 QL(2 ea daily)


0


0


0


0


0


0


0


0


1 QL(66667 eadaily)


1 QL(66667 eadaily)






daily)


77

Drug Name DrugTier

RequirementsLimits



1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)














1


1 QL(66667 eadaily)


1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)




daily)


AUTO-LANCET MISC 1



AUTOLET MINI MISC 1

AUTOLET PLUS MISC 1





daily)


78

Drug Name DrugTier

RequirementsLimits








1










1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)




daily)

Drug Name DrugTier

RequirementsLimits















1



1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)


79

Drug Name DrugTier

RequirementsLimits


daily)








1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)



1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


daily)

Drug Name DrugTier

RequirementsLimits





1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1









daily)


80

Drug Name DrugTier

RequirementsLimits




daily)



daily)





1


1 QL(66667 eadaily)


1 QL(66667 eadaily)





1


1


1


1


1

Drug Name DrugTier

RequirementsLimits


1


1


1



1 QL(66667 eadaily)


1

QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)





daily)








1


81

Drug Name DrugTier

RequirementsLimits



1 QL(66667 eadaily)



1 QL(66667 eadaily)


1 QL(66667 eadaily)



1 QL(66667 eadaily)



1


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)







daily)

Drug Name DrugTier

RequirementsLimits



1


1 QL(66667 eadaily)





daily)





1 QL(66667 eadaily)



daily)










82

Drug Name DrugTier

RequirementsLimits


daily)







daily)







daily)








LANZO MISC 1



daily)

Drug Name DrugTier

RequirementsLimits



1 QL(66667 eadaily)












1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)





daily)


83

Drug Name DrugTier

RequirementsLimits





1 QL(66667 eadaily)



1

QL(66667 eadaily)


1 QL(66667 eadaily)


daily)





1 QL(66667 eadaily)








daily)


Drug Name DrugTier

RequirementsLimits













1 QL(66667 eadaily)








1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)


84

Drug Name DrugTier

RequirementsLimits



1 QL(66667 eadaily)


1 QL(66667 eadaily)


1


1






1 QL(66667 eadaily)


daily)





1 QL(66667 eadaily)


1 QL(66667 eadaily)



1 QL(66667 eadaily)


Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)





















1 QL(66667 eadaily)


85

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)













1 QL(66667 eadaily)


1 QL(66667 eadaily)




daily)

Drug Name DrugTier

RequirementsLimits




1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




daily)






1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)


86

Drug Name DrugTier

RequirementsLimits






1


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


daily)








daily)

Drug Name DrugTier

RequirementsLimits






daily)

SURE-PEN MISC 1












1






daily)


87

Drug Name DrugTier

RequirementsLimits


1













daily)



1 QL(66667 eadaily)







daily)


Drug Name DrugTier

RequirementsLimits





daily)






daily)














1 QL(66667 eadaily)


88

Drug Name DrugTier

RequirementsLimits









1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)






Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


89

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)









1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)




1 QL(5 ea daily)







1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1

QL(5 ea daily)


90

Drug Name DrugTier

RequirementsLimits










1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)



1 QL(5 ea daily)








1

QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


91

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


92

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)








1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


93

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)








1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)








1 QL(5 ea daily)


94

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)








1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


95

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)


96

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)






1 QL(5 ea daily)








1 QL(5 ea daily)








1 QL(5 ea daily)










97

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)






1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)






98

Drug Name DrugTier

RequirementsLimits






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)







1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits








1 QL(5 ea daily)


1 QL(5 ea daily)










1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)




99

Drug Name DrugTier

RequirementsLimits










1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)





Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)








1 QL(5 ea daily)






1 QL(5 ea daily)




1 QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


100

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)








1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC



Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC






1 QL(5 ea daily)










1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)



1 QL(5 ea daily)


101

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits








1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)


102

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC






1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


103

Drug Name DrugTier

RequirementsLimits










1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC






1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits




















1 QL(5 ea daily)









1 QL(5 ea daily)




104

Drug Name DrugTier

RequirementsLimits




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






105

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)


106

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)








1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)








1 QL(5 ea daily)






107

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)






1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


108

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)






1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


109

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)






1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)


110

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)










1 QL(5 ea daily)




1 QL(5 ea daily)







daily)

Drug Name DrugTier

RequirementsLimits








NF



NF




daily)



NF QL(0267 mldaily)

Serotonin Agonists








111

Drug Name DrugTier

RequirementsLimits








NF



NF



NF



NF



NF










Drug Name DrugTier

RequirementsLimits









sumatriptan soln 1



















112

Drug Name DrugTier

RequirementsLimits









1






NF



NF


1


Drug Name DrugTier

RequirementsLimits

ISOLYTE-S SOLN 1



1


NORMOSOL-MD5WSOLN 1

NORMOSOL-R SOLN 1





1



1


1


1


113

Drug Name DrugTier

RequirementsLimits

ringers soln 1










1



1


1


1


NF



Drug Name DrugTier

RequirementsLimits



1







daily) SP







ATGAM INJ 4 PA SP




NF


NF

cyclosporine caps 1



114

Drug Name DrugTier

RequirementsLimits


cyclosporine soln 1









NF


NF



NF




NF


NF


NF

SIMULECT SOLR 3


tacrolimus caps 1

Drug Name DrugTier

RequirementsLimits



NF














DEBACTEROL SOLN 2


NF

Dental Products




115

Drug Name DrugTier

RequirementsLimits






MULTIVITAMINS











2

QL(1 ea daily)RXOTC





Drug Name DrugTier

RequirementsLimits









116

Drug Name DrugTier

RequirementsLimits


2

QL(1 ea daily)RXOTC












2 QL(1 ea daily)





RXOTC



RXOTC



Drug Name DrugTier

RequirementsLimits



carisoprodol tabs 1
















Nasal Antiallergy





117

Drug Name DrugTier

RequirementsLimits



Nasal Steroids



NF



NF







NF


NF






riluzole tabs 3

Drug Name DrugTier

RequirementsLimits


BOTOX SOLR 3 PA

DYSPORT SOLR 3 PA

XEOMIN SOLR 3 PA

NUTRIENTS


3


3


3



3



LACRISERT INST 3




COMBIGAN SOLN 2


NF


1



118

Drug Name DrugTier

RequirementsLimits






tropicamide soln 1





NF



IOPIDINE SOLN 3

SIMBRINZA SUSP 3 PA


AZASITE SOLN 3



NF




Drug Name DrugTier

RequirementsLimits




KLARITY-A SOLN 3



NATACYN SUSP 2









trifluridine soln 1


ZIRGAN GEL 2



RESTASIS EMUL 2 PA




119

Drug Name DrugTier

RequirementsLimits



OXERVATE SOLN 4 PA

Ophthalmic Steroids

ALREX SUSP 3 PA





FML FORTE SUSP 3 PA


NF

FML OINT 3 PA


LOTEMAX OINT 3 PA




MAXIDEX SUSP 3 PA


NF


NF




Drug Name DrugTier

RequirementsLimits


NF

PRED MILD SUSP 3 PA




3


NF



NF


NF

ALOCRIL SOLN 3 PA

ALOMIDE SOLN 3 PA











120

Drug Name DrugTier

RequirementsLimits


ILEVRO SUSP 3 PA



LASTACAFT SOLN 3 PA

NEVANAC SUSP 3 PA






ZERVIATE SOLN 3 PA


bimatoprost soln 3

latanoprost soln 1

LUMIGAN SOLN 3 ST


travoprost soln 1


ZIOPTAN SOLN 2





Drug Name DrugTier

RequirementsLimits



Otic Combinations

CIPRO HC SUSP 3


NF PA



daily)

COLY-MYCIN S SUSP 3





3 PA QL(05 eadaily)


NF





4 PA SP


4

PA SP



121

Drug Name DrugTier

RequirementsLimits


4 PA SP




4 PA SP


HYQVIA KIT 4 PA


Aminopenicillins

amoxicillin caps 1

amoxicillin chew 1

amoxicillin susr 1

amoxicillin tabs 1

ampicillin caps 1




1







Drug Name DrugTier

RequirementsLimits






1


1


NF


NF


NF



NF


NF


NF






122

Drug Name DrugTier

RequirementsLimits







NF PA






NF





disulfiram tabs 1





NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits


NF QL(1 ea daily)














NF





Fibromyalgia Agents





123

Drug Name DrugTier

RequirementsLimits




daily) SP


daily) SP

AUBAGIO TABS 4 PA












GILENYA CAPS 4 PA



ml daily) SP

MAVENCLAD TBPK 4 PA


MAYZENT TABS 4 PA

OCREVUS SOLN 4 PA


Drug Name DrugTier

RequirementsLimits





ml daily)







NF PA



3 PA QL(1 eadaily)


3 PA QL(2 eadaily)




NUEDEXTA CAPS 3 PA


pimozide tabs 1




124

Drug Name DrugTier

RequirementsLimits

Smoking Deterrents











NF





0


NICOTROL NS SOLN 0



TEGSEDI SOSY 4 PA



Drug Name DrugTier

RequirementsLimits









daily)






Sulfonamides

SULFADIAZINE TABS 1


Glycylcyclines

tigecycline solr 1


Tetracyclines






125

Drug Name DrugTier

RequirementsLimits











NF QL(2 ea daily)


NF


Antithyroid Agents

methimazole tabs 1




2

QL(1 ea daily)



Drug Name DrugTier

RequirementsLimits


1








WESTHROID TABS 2

WP THYROID TABS 2

TOXOIDS

Toxoid Combinations

ADACEL SUSP 0

BOOSTRIX SUSP 0

DAPTACEL SUSP 0


0

INFANRIX SUSP 0

KINRIX SUSP 0

PEDIARIX SUSP 0

PENTACEL SUSR 0

QUADRACEL SUSP 0

TDVAX SUSP 0


126

Drug Name DrugTier

RequirementsLimits

TENIVAC INJ 0


0




1








NF







1



Drug Name DrugTier

RequirementsLimits





NF RXOTC







1 QL(20 ml daily)





NF RXOTC








127

Drug Name DrugTier

RequirementsLimits










NF QL(1 ea daily)












1 QL(4 ea daily)


NF QL(1 ea daily)


NF

Drug Name DrugTier

RequirementsLimits







NF

RXOTC

















128

Drug Name DrugTier

RequirementsLimits






NF QL(4 ea daily)


NF



VACCINES

Bacterial Vaccines

ACTHIB SOLR 0

BEXSERO SUSY 0

HIBERIX SOLR 0

MENQUADFI SOLN 0

MENVEO SOLR 0

PEDVAX HIB SUSP 0

PNEUMOVAX 23 INJ 0


PREVNAR 13 SUSP 0

TRUMENBA SUSY 0

Viral Vaccines

Drug Name DrugTier

RequirementsLimits













ENGERIX-B INJ 0


ENGERIX-B SUSP 0









129

Drug Name DrugTier

RequirementsLimits










0



0



0



0



0



0



0



0


Drug Name DrugTier

RequirementsLimits


0



0



0



0



0











0



0



0



130

Drug Name DrugTier

RequirementsLimits


0



0



0




HAVRIX SUSP 0


HEPLISAV-B SOSY 0




ROTARIX SUSR 0

ROTATEQ SOLN 0

SHINGRIX SUSR 0


TWINRIX SUSY 0

Drug Name DrugTier

RequirementsLimits

VAQTA SUSP 0



ZOSTAVAX SUSR 0




INTRAROSA INST 3 PA

Spermicides

SHUR-SEAL GEL 0

TODAY SPONGE MISC 0


NF



GYNAZOLE-1 CREA 3








131

Drug Name DrugTier

RequirementsLimits

PHEXXI GEL 0 PV




FEMRING RING 3

PREMARIN CREA 2




NF








Drug Name DrugTier

RequirementsLimits


2


Vasopressors


VITAMINS










NIACIN TR TBCR 1




132





Index 1




31

31 22

122

122

1 27

122

122


44 16

2 126

14 36 35 39

4 4

36 70


119 13

120 57


122 124

9 22




72 36 27 10 10 53



25 74 74 27 50 60 61

111


15 123

10 26 24 24

125 41



74 3

65 65


119 26 70 17 44


78

78


74 15 13 70 22



78 30 31 44 66


Index 2














Index 3








Index 4











Index 5



64 4 4

11


28 28 28 55




55 116

79

27 27 75



121




121 34 21 28 76



35 35 22 17 31

Index 6


2 72 13

115 57

131

57 43 43 79 33




6 6

40 75 70


44 41

2 2 6


73 117

34 34 24




114

114 74 22 28 67 71

120 35

126 128



37 118

16 31 65 27 29 44


111 39 35 37

124 14 10




117 11



64 11 11

114


126 11 11 33


Index 7




Index 8




Index 9





80

80

80

80



Index 10



128 30

31 5 5 5

129 16 41 47 71





132 124 111 111

36 36 57 11 39 39 76 76 56

119 76

76 21

6

128 74 69 69

132 69 69 52 74


Index 11






76 72 19 19

4 49 36 76 69

132 29 29


81 81

6 8 6 8

72 33 36 11 10

129



67 6

FLECTOR FLOLAN

57 50


120 35


6 6



59 21


55



21 44 62 74

4 121

36

Index 12





120 120

2 2

73 35


65 45 17 18 19 67


81

81

81



123 121


81 45




Index 13











25 25 25 23 71

127 25





Index 14




Index 15













Index 16













Index 17










Index 18


30

32 83

83



17 43 70

123 58




Index 19


33 64 20


83

83


34 123


26 20


83

84

MENQUADFI MENVEO

129 129


39 124

47 112



67 13 11 35






Index 20







Index 21





58

58 58 68

9 5

25 25

123

123 5 5 5

112 25




Index 22

53



7 124 115

67 53

3 27

115 58 58

116



113 113

13


124 68

119




45 36

125 70

119 121


85

85 17

7 50 64





54 50 68

125 117

54 53 53 53 48 23 75 67

5 121


24 24

24 24



123 35

9 5



73 37 14



13 73 18

Index 23










Index 24







Index 25












Index 26


86

86

RETACRIT RETEVMO

73 39

ROTATEQ ROXICODONE

131 7





71 25 23


42 3 3




46 36

123 112 117

68 39 41 30


Index 27


86 86 86 86









60 119

87 115

30 41 41 87 14

115 34 12



104

105 23

86 42 60



64 71 71

71 60 49 49 64


46 68 15 43 43 67



14 14 65

65 27

Index 28
















Index 29


23 23




46 62 67 64 23



32 48 35 31 27

SYNJARDY XR SYNRIBO

23 40



15 131


126 114

35 39

6263 115

63



55 10

10 10 10


50

51 39

127 72 39 48 37 71

126 36

126




4059 32 39



44 35 44


59 40 53


125 32 31


126 19 49

tazarotene TAZORAC

60 60


32

TIBSOVO TIGAN

39 26

TAZVERIK TDVAX

39 126

temazepam TEMIXYS

74 46

tigecycline TIKOSYN

125 13



63 35 39 40


119 119 119

46

Index 30





Index 31





12 107

Index 32



109


109


109


109


109


109


109





Index 33









70 15 40

132 47 47 47


131 26 29 32 30 32 36



Index 34




Index 35



Index 36




Ambetter from MHS














話請撥電話 1-877-687-1182 (TTYTDD 1-800-743-3333)








(TTYTDD 1-800-743-3333) 687-1182





(TTYTDD 1-800-743-3333)









3333)






क

क स




Classes



AMEBICIDES




































CHEMICALS





DIAGNOSTIC PRODUCTS





















MULTIVITAMINS




NUTRIENTS











TOXOIDS



VACCINES



VITAMINS







ST Step Therapy






NF Non-formulary






Drug Name DrugTier

RequirementsLimits



NF

QL(3 ea daily)


NF

QL(2 ea daily)


NF

QL(1 ea daily)


NF


NF

QL(2 ea daily)



1

QL(1 ea daily)


1

Drug Name DrugTier

RequirementsLimits


1

QL(2 ea daily)


1

QL(3 ea daily)


1

QL(2 ea daily)




NF

QL(4 ea daily)


NF







3 ST QL(1 eadaily)


2 ST QL(1 eadaily)



1

Drug Name DrugTier

RequirementsLimits




Anti-Obesity Agents


















SUNOSI TABS 3 PA

Stimulants - Misc

armodafinil tabs 1




Drug Name DrugTier

RequirementsLimits





1

QL(1 ea daily)










yrs old)
















2

Drug Name DrugTier

RequirementsLimits


















Allergenic Extracts

GRASTEK SUBL 3 PA

AMEBICIDES

Amebicides

SOLOSEC PACK 3 PA


Aminoglycosides


ARIKAYCE SUSP 4 PA

Drug Name DrugTier

RequirementsLimits


1










1




4



ea daily)






3

Drug Name DrugTier

RequirementsLimits


4



4





ea daily)









Gold Compounds




Drug Name DrugTier

RequirementsLimits




NF


NF


NF PA QL(2 eadaily)



daily)














daily)

flurbiprofen tabs 1


4

Drug Name DrugTier

RequirementsLimits












nabumetone tabs 1








oxaprozin tabs 1

piroxicam caps 1

sulindac tabs 1


Drug Name DrugTier

RequirementsLimits




OTEZLA TBPK 4







ml daily)



ml daily) SP



ml daily) SP




1


1



NF


5

Drug Name DrugTier

RequirementsLimits


NF


NF


Salicylates




diflunisal tabs 1

salsalate tabs 1



daily)






NF




NF

Drug Name DrugTier

RequirementsLimits


NF




1

PA QL(4 eadaily)


1 QL(034 eadaily)



1 PA QL(2 eadaily)


daily)




1






NF


NF

PA QL(2 eadaily)





6

Drug Name DrugTier

RequirementsLimits








1








NF QL(10 ml daily)




1 PA QL(2 eadaily)



NF



Drug Name DrugTier

RequirementsLimits







1 QL(2 ea daily)





daily)

OXAYDO TABS 5 MG 2



3 PA QL(2 eadaily)






1 PA QL(2 eadaily)


daily)





7

Drug Name DrugTier

RequirementsLimits



daily)









1







1







1


Drug Name DrugTier

RequirementsLimits


1





NF



NF





1



1



1



1 PA



LORTAB ELIX 2



8

Drug Name DrugTier

RequirementsLimits


NF



1





NF





NF



NF










Drug Name DrugTier

RequirementsLimits


1 QL(3 ea daily)


1 QL(2 ea daily)


1

QL(3 ea daily)


1

PA QL(0143ea daily)




NF

PA QL(0143ea daily)







NF

QL(3 ea daily)


NF

QL(2 ea daily)


Anabolic Steroids

ANADROL-50 TABS 3

oxandrolone tabs 1

Androgens


9

Drug Name DrugTier

RequirementsLimits



NF

danazol caps 1


NF

METHITEST TABS 3



1














NF

Drug Name DrugTier

RequirementsLimits


NF

Vasodilating Agents



Anthelmintics




EMVERM CHEW 2










trimethoprim tabs 1




10

Drug Name DrugTier

RequirementsLimits


NF


NF






atovaquone susp 1



Carbapenems




meropenem solr 1






Drug Name DrugTier

RequirementsLimits



Glycopeptides











Leprostatics

dapsone tabs 1


NF


NF


NF




1



11

Drug Name DrugTier

RequirementsLimits


Monobactams







daily) Polymyxins





NF


NF








Drug Name DrugTier

RequirementsLimits





NF





NITRO-BID OINT 3


NF



1










12

Drug Name DrugTier

RequirementsLimits



meprobamate tabs 1




















Drug Name DrugTier

RequirementsLimits














dofetilide caps 1

MULTAQ TABS 3







FASENRA SOSY 4 PA


13

Drug Name DrugTier

RequirementsLimits

NUCALA SOAJ 4 PA

NUCALA SOLR 4 PA

NUCALA SOSY 4 PA














NF QL(1 ea daily)






Drug Name DrugTier

RequirementsLimits




Steroid Inhalants



daily)


FLOVENT HFA AERO 2



daily)



NF

ADVAIR HFA AERO 2


NF


NF


NF




14

Drug Name DrugTier

RequirementsLimits





1 QL(15 ml daily)








daily)

BREO ELLIPTA AEPB 2




1



1 PA QL(12 mldaily)


Drug Name DrugTier

RequirementsLimits








2







NF PA




daily) Xanthines


ELIXOPHYLLIN ELIX 1






15

Drug Name DrugTier

RequirementsLimits




BEVYXXA CAPS 3



daily)








NF



NF



NF



NF




Drug Name DrugTier

RequirementsLimits



daily) SP














4

PA SP


NF



1


16

Drug Name DrugTier

RequirementsLimits


1


NF QL(6 ml daily)


NF QL(2 ml daily)


NF QL(16 mldaily)









3 PA




daily)

clonazepam tabs 1

clonazepam tbdp 1


3


3



Drug Name DrugTier

RequirementsLimits




daily)










3 PA











17

Drug Name DrugTier

RequirementsLimits







EPIDIOLEX SOLN 3 PA





NF QL(30 ml daily)




NF QL(4 ea daily)



NF QL(20 ea daily)


NF QL(100 eadaily)


NF QL(1 ea daily)



NF

Drug Name DrugTier

RequirementsLimits





1








NF

PA QL(3 eadaily)





NF



NF





18

Drug Name DrugTier

RequirementsLimits


1 PA QL(3 eadaily)


daily)


primidone tabs 1








NF QL(4 ea daily)



NF QL(6 ea daily)


NF QL(8 ea daily)








NF QL(40 ml daily)

Drug Name DrugTier

RequirementsLimits


NF QL(3 ea daily)





3 PA QL(2 eadaily)



Carbamates















19

Drug Name DrugTier

RequirementsLimits


2





PEGANONE TABS 3


2

phenytoin chew 1



phenytoin susp 1

Succinimides






NF QL(30 ml daily)






Drug Name DrugTier

RequirementsLimits






















20

Drug Name DrugTier

RequirementsLimits



NF QL(15 eadaily)


NF QL(2 ea daily)


NF QL(1 ea daily)









daily)









NF QL(1 ea daily)


Drug Name DrugTier

RequirementsLimits














NF QL(1 ea daily)











21

Drug Name DrugTier

RequirementsLimits
















NF QL(1 ea daily)

FETZIMA CP24 3 PA




NF QL(4 ea daily)


NF QL(1 ea daily)


Drug Name DrugTier

RequirementsLimits



1 QL(3 ea daily)




Tricyclic Agents


amoxapine tabs 3




doxepin hcl caps 1

doxepin hcl conc 1












22

Drug Name DrugTier

RequirementsLimits



miglitol tabs 1






NF QL(2 ea daily)


NF QL(1 ea daily)


1 QL(2 ea daily)



1 QL(2 ea daily)


1 QL(4 ea daily)

GLYXAMBI TABS 2




2 QL(2 ea daily)




Drug Name DrugTier

RequirementsLimits






2 QL(2 ea daily)


TRIJARDY XR TB24 2


3 PA QL(1 eadaily)



daily)



daily)







daily)

diazoxide susp 1


daily)



23

Drug Name DrugTier

RequirementsLimits


3 QL(0035 eadaily)











ml daily)







APIDRA SOLN 3 PA




Drug Name DrugTier

RequirementsLimits


FIASP SOLN 2




LEVEMIR SOLN 2




NOVOLIN 7030 SUSP 2


NOVOLIN N SUSP 2


NOVOLIN R SOLN 2



2



NOVOLOG SOLN 2


TRESIBA SOLN 2




24

Drug Name DrugTier

RequirementsLimits























Drug Name DrugTier

RequirementsLimits




MOTOFEN TABS 3



CHEMET CAPS 3




deferiprone tabs 1






VISTOGARD PACK 4 PA



NARCAN LIQD 3





25

Drug Name DrugTier

RequirementsLimits







daily)
















NF



daily)

Drug Name DrugTier

RequirementsLimits







dronabinol caps 1




ea daily)






NF


VARUBI TBPK 3 PA




26

Drug Name DrugTier

RequirementsLimits



ERAXIS SOLR 3


MYCAMINE SOLR 3

Antifungals

ABELCET SUSP 3

AMBISOME SUSR 3



flucytosine caps 1




nystatin tabs 1





fluconazole susr 1

fluconazole tabs 1



Drug Name DrugTier

RequirementsLimits

ketoconazole tabs 1





daily)

TOLSURA CAPS 4 PA














1

QL(30 ml daily)



27

Drug Name DrugTier

RequirementsLimits


1 QL(1 ea daily)


1 QL(2 ea daily)








1





1









Drug Name DrugTier

RequirementsLimits




RXOTC

loratadine caps 1

loratadine chew 1

loratadine soln 1

loratadine syrp 1

loratadine tabs 1

loratadine tbdp 1


NF

















28

Drug Name DrugTier

RequirementsLimits












daily)






NF QL(6 gm daily)


NF QL(6 ea daily)





Drug Name DrugTier

RequirementsLimits






NF QL(252 gmdaily)














daily)






29

Drug Name DrugTier

RequirementsLimits

















1 QL(2 ea daily)



daily)




Drug Name DrugTier

RequirementsLimits




captopril tabs 1



lisinopril tabs 1






ramipril caps 1

trandolapril tabs 1









30

Drug Name DrugTier

RequirementsLimits

















daily)








Drug Name DrugTier

RequirementsLimits


NF QL(2 ea daily)






NF MO



NF MO


NF ST



NF MO




NF


EXFORGE HCT TABS 2


NF



31

Drug Name DrugTier

RequirementsLimits


NF

QL(2 ea daily)


NF

QL(1 ea daily)




NF


1

QL(2 ea daily)


1

QL(1 ea daily)


NF


NF



NF MO


1 ST






Drug Name DrugTier

RequirementsLimits


NF


NF




NF

ST




NF


NF







eplerenone tabs 1


Vasodilators



minoxidil tabs 1


32

Drug Name DrugTier

RequirementsLimits




COARTEM TABS 2





Drug Name DrugTier

RequirementsLimits









NF






FIRDAPSE TABS 4 PA





NF


3 PA


33

Drug Name DrugTier

RequirementsLimits






RIFAMATE CAPS 3





isoniazid soln 1

isoniazid syrp 1

isoniazid tabs 1




PRIFTIN TABS 3

pyrazinamide tabs 1

rifabutin caps 1 PA



rifampin caps 1

Drug Name DrugTier

RequirementsLimits

rifampin solr 1




















melphalan tabs 1



34

Drug Name DrugTier

RequirementsLimits



NF

PA SP








Antimetabolites














Drug Name DrugTier

RequirementsLimits




NF




















daily)


35

Drug Name DrugTier

RequirementsLimits

MVASI SOLN 4 PA


ZIRABEV SOLN 4 PA




TUKYSA TABS 4 PA





RUXIENCE SOLN 4 PA

YERVOY SOLN 4 PA SP







VIZIMPRO TABS 4 PA


DAURISMO TABS 4 PA




Drug Name DrugTier

RequirementsLimits



daily)




SP



daily) SP





EMCYT CAPS 4 PA SP













36

Drug Name DrugTier

RequirementsLimits



ea daily) SP






NUBEQA TABS 4 PA





YONSA TABS 4 PA










Drug Name DrugTier

RequirementsLimits







NF






NF PA SP



NF PA SP


NF PA








37

Drug Name DrugTier

RequirementsLimits





daily) SP




BALVERSA TABS 4 PA



daily) SP



BRUKINSA CAPS 4 PA





COPIKTRA CAPS 4 PA



daily) SP

IBRANCE CAPS 3 PA

IBRANCE TABS 3 PA

Drug Name DrugTier

RequirementsLimits


daily)




daily)



4 PA QL(1 eadaily)

INREBIC CAPS 4 PA




daily) SP

KISQALI TBPK 3 PA

KOSELUGO CAPS 4 PA

KYPROLIS SOLR 4 PA


LORBRENA TABS 4 PA










38

Drug Name DrugTier

RequirementsLimits



QINLOCK TABS 4 PA

RETEVMO CAPS 4 PA


ROZLYTREK CAPS 4 PA







TABRECTA TABS 4 PA


TALZENNA CAPS 4 PA


daily) SP


TAZVERIK TABS 4 PA


TIBSOVO TABS 4 PA


ml daily) SP



daily) SP


Drug Name DrugTier

RequirementsLimits

VERZENIO TABS 4 PA

VITRAKVI CAPS 4 PA

VITRAKVI SOLN 4 PA



XOSPATA TABS 4 PA














hydroxyurea caps 1



NIPENT SOLR 4 PA SP



39

Drug Name DrugTier

RequirementsLimits





UVADEX SOLN 4 PA SP




1



Mitotic Inhibitors













Drug Name DrugTier

RequirementsLimits



NF PA SP


4 PA SP






NF PA SP







carbidopa tabs 1









40

Drug Name DrugTier

RequirementsLimits




tolcapone tabs 3




APOKYN SOCT 4 PA









NF QL(4 ea daily)


NF

NEUPRO PT24 2




1 QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits


1


NF ST QL(2 eadaily)


NF ST QL(1 eadaily)


1






1


NF


1


NF


1


NF


1


NF


41

Drug Name DrugTier

RequirementsLimits


1


NF


1


NF


daily)





Antimanic Agents




LITHIUM SOLN 1








daily)

Drug Name DrugTier

RequirementsLimits



Benzisoxazoles




NF QL(1 ea daily)








NF QL(2 ea daily)








NF QL(0036 mldaily)


42

Drug Name DrugTier

RequirementsLimits


NF QL(0036 mldaily)





haloperidol tabs 1

















Drug Name DrugTier

RequirementsLimits









3 PA QL(2 eadaily)


daily)





NF PA QL(1 eadaily)


NF PA QL(2 eadaily)



NF QL(1 ea daily)


NF QL(2 ea daily)


NF QL(2 ea daily)




43

Drug Name DrugTier

RequirementsLimits


1





perphenazine tabs 1











REXULTI TABS 3 PA

Thioxanthenes

thiothixene caps 1





Drug Name DrugTier

RequirementsLimits







3

QL(1 ea daily)

















1 QL(1 ea daily)


44

Drug Name DrugTier

RequirementsLimits


1 QL(1 ea daily)



1



0

QL(1 ea daily)









NF QL(1 ea daily)




FUZEON SOLR 4 PA SP






Drug Name DrugTier

RequirementsLimits






NF QL(125 mldaily)


2

QL(4 ea daily)







NF QL(4 ea daily)












45

Drug Name DrugTier

RequirementsLimits











NF QL(1 ea daily)



RUKOBIA TB12 4 PA











Drug Name DrugTier

RequirementsLimits


2

QL(1 ea daily)


2

QL(1 ea daily)







NF QL(2 ea daily)
















46

Drug Name DrugTier

RequirementsLimits


NF






CMV Agents

cidofovir soln 3









daily) SP






daily) SP



daily)

Drug Name DrugTier

RequirementsLimits






daily)



ZEPATIER TABS 4 PA

Herpes Agents















NF QL(5 ea daily)


47

Drug Name DrugTier

RequirementsLimits










NF



NF



Alpha-Beta Blockers

carvedilol tabs 1

Drug Name DrugTier

RequirementsLimits






atenolol tabs 1




2 PA QL(1 eadaily)







daily)









48

Drug Name DrugTier

RequirementsLimits


nadolol tabs 1

pindolol tabs 1


1




1











NF





Drug Name DrugTier

RequirementsLimits



1




felodipine tb24 1

isradipine caps 1



nifedipine caps 1

nifedipine tb24 1

nimodipine caps 1


1






NF





49

Drug Name DrugTier

RequirementsLimits



NF



NF



Cardiac Glycosides

digoxin soln 1

digoxin tabs 1



2





BIDIL TABS 2


NF QL(1 ea daily)

ENTRESTO TABS 3 PA

Impotence Agents



Drug Name DrugTier

RequirementsLimits









3 PA









daily) SP




daily)





50

Drug Name DrugTier

RequirementsLimits


NF



NF

PA QL(6 mldaily)






4 PA QL(6 mldaily)




daily) SP









cefadroxil caps 1

cefadroxil susr 1

cefadroxil tabs 1


Drug Name DrugTier

RequirementsLimits

cephalexin caps 1

cephalexin susr 1

cephalexin tabs 1



cefaclor caps 1

cefaclor susr 1




cefprozil susr 1

cefprozil tabs 1




cefdinir caps 1

cefdinir susr 1









51

Drug Name DrugTier

RequirementsLimits


1




NF PA


cefepime hcl solr 1



TEFLARO SOLR 3

CHEMICALS





NF






0


NF

Drug Name DrugTier

RequirementsLimits


FALESSA KIT 0


NF







NF


NF


NF

NATAZIA TABS 0











52

Drug Name DrugTier

RequirementsLimits




NF


NF


NF


NF


NF


NF


TYBLUME CHEW 0


NF


NF






NF

Drug Name DrugTier

RequirementsLimits


0


ELLA TABS 0



NF


KYLEENA IUD 0

LILETTA IUD 0

MIRENA IUD 0

SKYLA IUD 0


NEXPLANON IMPL 0


NF



NF









53

Drug Name DrugTier

RequirementsLimits


NF






NF


NF





NF




1



1

EMFLAZA SUSP 4 PA

EMFLAZA TABS 4 PA


Drug Name DrugTier

RequirementsLimits





NF

MEDROL TABS 2 MG 3





MILLIPRED DP TBPK 3

MILLIPRED TABS 3


NF


NF


1


3

prednisolone soln 1

prednisone soln 1

prednisone tabs 1

prednisone tbpk 1




54

Drug Name DrugTier

RequirementsLimits




NF




Antitussives






NF

QL(2 ea daily)


NF

QL(1 ea daily)



1 QL(2 ea daily)


1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits


1 QL(2 ea daily)


1 QL(1 ea daily)


1


1 QL(2 ea daily)


1

QL(1 ea daily)



1

QL(2 ea daily)


HYPERSAL NEBU 35 1


NF

NEBUSAL NEBU 1


Mucolytics







55

Drug Name DrugTier

RequirementsLimits




12 yrs old)





NF





yrs old)
















yrs old)

Drug Name DrugTier

RequirementsLimits










12 yrs old)




12 yrs old)



NF
















56

Drug Name DrugTier

RequirementsLimits






yrs old)



















VEREGEN OINT 3






daily) RXOTC

Drug Name DrugTier

RequirementsLimits




mupirocin oint 1














ERTACZO CREA 3


EXELDERM SOLN 3


JUBLIA SOLN 3 PA


57

Drug Name DrugTier

RequirementsLimits










NF RXOTC



NF







Drug Name DrugTier

RequirementsLimits




NF















58

Drug Name DrugTier

RequirementsLimits



OXISTAT LOTN 2







NF






PANRETIN GEL 3

PICATO GEL 0015 2


Drug Name DrugTier

RequirementsLimits

PICATO GEL 005 2













59

Drug Name DrugTier

RequirementsLimits









daily)



NF QL(4 ea daily)









ml daily) SP


TAZORAC CREA 005 2



Drug Name DrugTier

RequirementsLimits











Burn Products








amcinonide crea 1


amcinonide lotn 3


60

Drug Name DrugTier

RequirementsLimits

AMCINONIDE OINT 3





1


1


1






1 ST


1 ST



daily)







Drug Name DrugTier

RequirementsLimits






NF



NF











NF


NF






61

Drug Name DrugTier

RequirementsLimits


















HALOG OINT 3 PA






Drug Name DrugTier

RequirementsLimits









daily)





NF

RXOTC




PSORCON CREA 2 PA





NF

ST


62

Drug Name DrugTier

RequirementsLimits


3

ST







1



1


1







NF RXOTC


NF RXOTC

Drug Name DrugTier

RequirementsLimits











2 yrs old)



2 yrs old)



podofilox soln 1









63

Drug Name DrugTier

RequirementsLimits

SYNERA PTCH 3




Rosacea Agents




NF



NF










EURAX CREA 3



Drug Name DrugTier

RequirementsLimits


lindane sham 3

malathion lotn 1




permethrin crea 1

permethrin liqd 1


spinosad susp 1 PA

ULESFIA LOTN 3

Wound Care Products

REGRANEX GEL 3

DIAGNOSTIC PRODUCTS



CHEMSTRIP-K STRP 1


1


KETONE STRP 1


KETOSTIX STRP 1


1


64

Drug Name DrugTier

RequirementsLimits







1





Digestive Enzymes

CREON CPEP 2

SUCRAID SOLN 3

ZENPEP CPEP 2









NF

Drug Name DrugTier

RequirementsLimits



NF


NF


NF









furosemide soln 1

furosemide tabs 1


torsemide tabs 1







65

Drug Name DrugTier

RequirementsLimits















NF PA SP









Drug Name DrugTier

RequirementsLimits


4 PA SP


PROLIA SOSY 4







TYMLOS SOPN 4 PA

XGEVA SOLN 4 PA SP




Corticotropin

ACTHAR GEL 4 PA




4 PA SP


CETROTIDE KIT 4 PA



66

Drug Name DrugTier

RequirementsLimits


NF PA









4 PA SP




SAIZEN SOLR 4 PA SP


4 PA SP





OSPHENA TABS 3 PA

Drug Name DrugTier

RequirementsLimits









Metabolic Modifiers




calcitriol caps 1

calcitriol soln 1










NF


67

Drug Name DrugTier

RequirementsLimits


NF PA


NF PA


MYALEPT SOLR 4 PA




PALYNZIQ SOSY 4 PA

paricalcitol caps 1

paricalcitol soln 1











NF PA


NF

Drug Name DrugTier

RequirementsLimits


NF QL(6 ea daily)


NF QL(8 ea daily)



4 PA SP







cabergoline tabs 1

Somatostatic Agents



SIGNIFOR SOLN 4 PA




ml daily) SP


daily) SP



daily) SP



68

Drug Name DrugTier

RequirementsLimits



CLIMARA PRO PTWK 3

DUAVEE TABS 3 PA


NF


PREMPHASE TABS 2

PREMPRO TABS 2




NF



3

ELESTRIN GEL 3



1

QL(0286 eadaily)


1



Drug Name DrugTier

RequirementsLimits

ESTROGEL GEL 3

EVAMIST SOLN 3

MENEST TABS 3

MENOSTAR PTWK 3


daily)

PREMARIN SOLR 2

PREMARIN TABS 2




1

BAXDELA SOLR 3 PA

BAXDELA TABS 3 PA






3




1

levofloxacin soln 1

levofloxacin tabs 1


69

Drug Name DrugTier

RequirementsLimits



ofloxacin tabs 1










daily)








AVSOLA SOLR 4 PA


Drug Name DrugTier

RequirementsLimits






DIPENTUM CAPS 2


















70

Drug Name DrugTier

RequirementsLimits



alvimopan caps 1






NF


PHOSLYRA SOLN 2







VELPHORO CHEW 3 PA



1


Drug Name DrugTier

RequirementsLimits


NF

Cystinosis Agents

CYSTAGON CAPS 3 PA


acetic acid soln 1


RESECTISOL SOLN 1


SORBITOL SOLN 1




ELMIRON CAPS 2












Urinary Analgesics


71

Drug Name DrugTier

RequirementsLimits





Gout Agents

allopurinol tabs 1




KRYSTEXXA SOLN 4 PA




Uricosurics

probenecid tabs 1



daily)



CINRYZE SOLR 4 PA

HAEGARDA SOLR 4 PA


SOLIRIS SOLN 4 PA

Drug Name DrugTier

RequirementsLimits




TAKHZYRO SOLN 4 PA





BRILINTA TABS 2

CABLIVI KIT 4 PA

cilostazol tabs 1



dipyridamole tabs 1




ZONTIVITY TABS 3 PA








72

Drug Name DrugTier

RequirementsLimits

VPRIV SOLR 4 PA SP


daily) SP


DROXIA CAPS 3

OXBRYTA TABS 4 PA


Folic AcidFolates




4 PA SP



4

PA SP

DOPTELET TABS 4 PA

EPOGEN SOLN 3 PA SP

FULPHILA SOSY 4 PA


MIRCERA SOSY 4 PA

MULPLETA TABS 4 PA




Drug Name DrugTier

RequirementsLimits



4 PA



3

PA SP





4

PA

UDENYCA SOSY 4 PA


ZIEXTENZO SOSY 4 PA










73

Drug Name DrugTier

RequirementsLimits


NF PA










1










estazolam tabs 1

eszopiclone tabs 1


Drug Name DrugTier

RequirementsLimits







triazolam tabs 1








BELSOMRA TABS 3 PA



ramelteon tabs 1





Bulk Laxatives



74

Drug Name DrugTier

RequirementsLimits



CLENPIQ SOLN 3 PA


NF


0


2

PA


1 PA


0

PREPOPIK PACK 3 PA



Saline Laxatives

OSMOPREP TABS 3 PA

Stimulant Laxatives

bisacodyl tbec 1





Drug Name DrugTier

RequirementsLimits





NF


NF


NF


Azithromycin












NF




75

Drug Name DrugTier

RequirementsLimits




daily)





Clarithromycin





NF


NF


3





1


Fidaxomicin



Contraceptives

Drug Name DrugTier

RequirementsLimits


CAYA DPRH 0




0 QL(2 ea daily)


FEMCAP DEVI 0







0 QL(2 ea daily)


0 QL(2 ea daily)


0 QL(2 ea daily)



0 QL(2 ea daily)



0 QL(2 ea daily)



76

Drug Name DrugTier

RequirementsLimits






0 QL(2 ea daily)








0 QL(2 ea daily)


0 QL(2 ea daily)


0

QL(2 ea daily)


0 QL(2 ea daily)


0

QL(2 ea daily)


0

QL(2 ea daily)


Drug Name DrugTier

RequirementsLimits


0 QL(2 ea daily)


0 QL(2 ea daily)


0


0


0


0


0


0


0


0


1 QL(66667 eadaily)


1 QL(66667 eadaily)






daily)


77

Drug Name DrugTier

RequirementsLimits



1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)














1


1 QL(66667 eadaily)


1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)




daily)


AUTO-LANCET MISC 1



AUTOLET MINI MISC 1

AUTOLET PLUS MISC 1





daily)


78

Drug Name DrugTier

RequirementsLimits








1










1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)




daily)

Drug Name DrugTier

RequirementsLimits















1



1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)


79

Drug Name DrugTier

RequirementsLimits


daily)








1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)



1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


daily)

Drug Name DrugTier

RequirementsLimits





1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1









daily)


80

Drug Name DrugTier

RequirementsLimits




daily)



daily)





1


1 QL(66667 eadaily)


1 QL(66667 eadaily)





1


1


1


1


1

Drug Name DrugTier

RequirementsLimits


1


1


1



1 QL(66667 eadaily)


1

QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)





daily)








1


81

Drug Name DrugTier

RequirementsLimits



1 QL(66667 eadaily)



1 QL(66667 eadaily)


1 QL(66667 eadaily)



1 QL(66667 eadaily)



1


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)







daily)

Drug Name DrugTier

RequirementsLimits



1


1 QL(66667 eadaily)





daily)





1 QL(66667 eadaily)



daily)










82

Drug Name DrugTier

RequirementsLimits


daily)







daily)







daily)








LANZO MISC 1



daily)

Drug Name DrugTier

RequirementsLimits



1 QL(66667 eadaily)












1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)





daily)


83

Drug Name DrugTier

RequirementsLimits





1 QL(66667 eadaily)



1

QL(66667 eadaily)


1 QL(66667 eadaily)


daily)





1 QL(66667 eadaily)








daily)


Drug Name DrugTier

RequirementsLimits













1 QL(66667 eadaily)








1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)


84

Drug Name DrugTier

RequirementsLimits



1 QL(66667 eadaily)


1 QL(66667 eadaily)


1


1






1 QL(66667 eadaily)


daily)





1 QL(66667 eadaily)


1 QL(66667 eadaily)



1 QL(66667 eadaily)


Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)





















1 QL(66667 eadaily)


85

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)













1 QL(66667 eadaily)


1 QL(66667 eadaily)




daily)

Drug Name DrugTier

RequirementsLimits




1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




daily)






1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)


86

Drug Name DrugTier

RequirementsLimits






1


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


daily)








daily)

Drug Name DrugTier

RequirementsLimits






daily)

SURE-PEN MISC 1












1






daily)


87

Drug Name DrugTier

RequirementsLimits


1













daily)



1 QL(66667 eadaily)







daily)


Drug Name DrugTier

RequirementsLimits





daily)






daily)














1 QL(66667 eadaily)


88

Drug Name DrugTier

RequirementsLimits









1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)






Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


89

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)









1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)




1 QL(5 ea daily)







1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1

QL(5 ea daily)


90

Drug Name DrugTier

RequirementsLimits










1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)



1 QL(5 ea daily)








1

QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


91

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


92

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)








1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


93

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)








1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)








1 QL(5 ea daily)


94

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)








1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


95

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)


96

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)






1 QL(5 ea daily)








1 QL(5 ea daily)








1 QL(5 ea daily)










97

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)






1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)






98

Drug Name DrugTier

RequirementsLimits






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)







1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits








1 QL(5 ea daily)


1 QL(5 ea daily)










1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)




99

Drug Name DrugTier

RequirementsLimits










1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)





Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)








1 QL(5 ea daily)






1 QL(5 ea daily)




1 QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


100

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)








1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC



Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC






1 QL(5 ea daily)










1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)



1 QL(5 ea daily)


101

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits








1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)


102

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC






1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


103

Drug Name DrugTier

RequirementsLimits










1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC






1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits




















1 QL(5 ea daily)









1 QL(5 ea daily)




104

Drug Name DrugTier

RequirementsLimits




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






105

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)


106

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)








1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)








1 QL(5 ea daily)






107

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)






1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


108

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)






1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


109

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)






1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)


110

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)










1 QL(5 ea daily)




1 QL(5 ea daily)







daily)

Drug Name DrugTier

RequirementsLimits








NF



NF




daily)



NF QL(0267 mldaily)

Serotonin Agonists








111

Drug Name DrugTier

RequirementsLimits








NF



NF



NF



NF



NF










Drug Name DrugTier

RequirementsLimits









sumatriptan soln 1



















112

Drug Name DrugTier

RequirementsLimits









1






NF



NF


1


Drug Name DrugTier

RequirementsLimits

ISOLYTE-S SOLN 1



1


NORMOSOL-MD5WSOLN 1

NORMOSOL-R SOLN 1





1



1


1


1


113

Drug Name DrugTier

RequirementsLimits

ringers soln 1










1



1


1


1


NF



Drug Name DrugTier

RequirementsLimits



1







daily) SP







ATGAM INJ 4 PA SP




NF


NF

cyclosporine caps 1



114

Drug Name DrugTier

RequirementsLimits


cyclosporine soln 1









NF


NF



NF




NF


NF


NF

SIMULECT SOLR 3


tacrolimus caps 1

Drug Name DrugTier

RequirementsLimits



NF














DEBACTEROL SOLN 2


NF

Dental Products




115

Drug Name DrugTier

RequirementsLimits






MULTIVITAMINS











2

QL(1 ea daily)RXOTC





Drug Name DrugTier

RequirementsLimits









116

Drug Name DrugTier

RequirementsLimits


2

QL(1 ea daily)RXOTC












2 QL(1 ea daily)





RXOTC



RXOTC



Drug Name DrugTier

RequirementsLimits



carisoprodol tabs 1
















Nasal Antiallergy





117

Drug Name DrugTier

RequirementsLimits



Nasal Steroids



NF



NF







NF


NF






riluzole tabs 3

Drug Name DrugTier

RequirementsLimits


BOTOX SOLR 3 PA

DYSPORT SOLR 3 PA

XEOMIN SOLR 3 PA

NUTRIENTS


3


3


3



3



LACRISERT INST 3




COMBIGAN SOLN 2


NF


1



118

Drug Name DrugTier

RequirementsLimits






tropicamide soln 1





NF



IOPIDINE SOLN 3

SIMBRINZA SUSP 3 PA


AZASITE SOLN 3



NF




Drug Name DrugTier

RequirementsLimits




KLARITY-A SOLN 3



NATACYN SUSP 2









trifluridine soln 1


ZIRGAN GEL 2



RESTASIS EMUL 2 PA




119

Drug Name DrugTier

RequirementsLimits



OXERVATE SOLN 4 PA

Ophthalmic Steroids

ALREX SUSP 3 PA





FML FORTE SUSP 3 PA


NF

FML OINT 3 PA


LOTEMAX OINT 3 PA




MAXIDEX SUSP 3 PA


NF


NF




Drug Name DrugTier

RequirementsLimits


NF

PRED MILD SUSP 3 PA




3


NF



NF


NF

ALOCRIL SOLN 3 PA

ALOMIDE SOLN 3 PA











120

Drug Name DrugTier

RequirementsLimits


ILEVRO SUSP 3 PA



LASTACAFT SOLN 3 PA

NEVANAC SUSP 3 PA






ZERVIATE SOLN 3 PA


bimatoprost soln 3

latanoprost soln 1

LUMIGAN SOLN 3 ST


travoprost soln 1


ZIOPTAN SOLN 2





Drug Name DrugTier

RequirementsLimits



Otic Combinations

CIPRO HC SUSP 3


NF PA



daily)

COLY-MYCIN S SUSP 3





3 PA QL(05 eadaily)


NF





4 PA SP


4

PA SP



121

Drug Name DrugTier

RequirementsLimits


4 PA SP




4 PA SP


HYQVIA KIT 4 PA


Aminopenicillins

amoxicillin caps 1

amoxicillin chew 1

amoxicillin susr 1

amoxicillin tabs 1

ampicillin caps 1




1







Drug Name DrugTier

RequirementsLimits






1


1


NF


NF


NF



NF


NF


NF






122

Drug Name DrugTier

RequirementsLimits







NF PA






NF





disulfiram tabs 1





NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits


NF QL(1 ea daily)














NF





Fibromyalgia Agents





123

Drug Name DrugTier

RequirementsLimits




daily) SP


daily) SP

AUBAGIO TABS 4 PA












GILENYA CAPS 4 PA



ml daily) SP

MAVENCLAD TBPK 4 PA


MAYZENT TABS 4 PA

OCREVUS SOLN 4 PA


Drug Name DrugTier

RequirementsLimits





ml daily)







NF PA



3 PA QL(1 eadaily)


3 PA QL(2 eadaily)




NUEDEXTA CAPS 3 PA


pimozide tabs 1




124

Drug Name DrugTier

RequirementsLimits

Smoking Deterrents











NF





0


NICOTROL NS SOLN 0



TEGSEDI SOSY 4 PA



Drug Name DrugTier

RequirementsLimits









daily)






Sulfonamides

SULFADIAZINE TABS 1


Glycylcyclines

tigecycline solr 1


Tetracyclines






125

Drug Name DrugTier

RequirementsLimits











NF QL(2 ea daily)


NF


Antithyroid Agents

methimazole tabs 1




2

QL(1 ea daily)



Drug Name DrugTier

RequirementsLimits


1








WESTHROID TABS 2

WP THYROID TABS 2

TOXOIDS

Toxoid Combinations

ADACEL SUSP 0

BOOSTRIX SUSP 0

DAPTACEL SUSP 0


0

INFANRIX SUSP 0

KINRIX SUSP 0

PEDIARIX SUSP 0

PENTACEL SUSR 0

QUADRACEL SUSP 0

TDVAX SUSP 0


126

Drug Name DrugTier

RequirementsLimits

TENIVAC INJ 0


0




1








NF







1



Drug Name DrugTier

RequirementsLimits





NF RXOTC







1 QL(20 ml daily)





NF RXOTC








127

Drug Name DrugTier

RequirementsLimits










NF QL(1 ea daily)












1 QL(4 ea daily)


NF QL(1 ea daily)


NF

Drug Name DrugTier

RequirementsLimits







NF

RXOTC

















128

Drug Name DrugTier

RequirementsLimits






NF QL(4 ea daily)


NF



VACCINES

Bacterial Vaccines

ACTHIB SOLR 0

BEXSERO SUSY 0

HIBERIX SOLR 0

MENQUADFI SOLN 0

MENVEO SOLR 0

PEDVAX HIB SUSP 0

PNEUMOVAX 23 INJ 0


PREVNAR 13 SUSP 0

TRUMENBA SUSY 0

Viral Vaccines

Drug Name DrugTier

RequirementsLimits













ENGERIX-B INJ 0


ENGERIX-B SUSP 0









129

Drug Name DrugTier

RequirementsLimits










0



0



0



0



0



0



0



0


Drug Name DrugTier

RequirementsLimits


0



0



0



0



0











0



0



0



130

Drug Name DrugTier

RequirementsLimits


0



0



0




HAVRIX SUSP 0


HEPLISAV-B SOSY 0




ROTARIX SUSR 0

ROTATEQ SOLN 0

SHINGRIX SUSR 0


TWINRIX SUSY 0

Drug Name DrugTier

RequirementsLimits

VAQTA SUSP 0



ZOSTAVAX SUSR 0




INTRAROSA INST 3 PA

Spermicides

SHUR-SEAL GEL 0

TODAY SPONGE MISC 0


NF



GYNAZOLE-1 CREA 3








131

Drug Name DrugTier

RequirementsLimits

PHEXXI GEL 0 PV




FEMRING RING 3

PREMARIN CREA 2




NF








Drug Name DrugTier

RequirementsLimits


2


Vasopressors


VITAMINS










NIACIN TR TBCR 1




132





Index 1




31

31 22

122

122

1 27

122

122


44 16

2 126

14 36 35 39

4 4

36 70


119 13

120 57


122 124

9 22




72 36 27 10 10 53



25 74 74 27 50 60 61

111


15 123

10 26 24 24

125 41



74 3

65 65


119 26 70 17 44


78

78


74 15 13 70 22



78 30 31 44 66


Index 2














Index 3








Index 4











Index 5



64 4 4

11


28 28 28 55




55 116

79

27 27 75



121




121 34 21 28 76



35 35 22 17 31

Index 6


2 72 13

115 57

131

57 43 43 79 33




6 6

40 75 70


44 41

2 2 6


73 117

34 34 24




114

114 74 22 28 67 71

120 35

126 128



37 118

16 31 65 27 29 44


111 39 35 37

124 14 10




117 11



64 11 11

114


126 11 11 33


Index 7




Index 8




Index 9





80

80

80

80



Index 10



128 30

31 5 5 5

129 16 41 47 71





132 124 111 111

36 36 57 11 39 39 76 76 56

119 76

76 21

6

128 74 69 69

132 69 69 52 74


Index 11






76 72 19 19

4 49 36 76 69

132 29 29


81 81

6 8 6 8

72 33 36 11 10

129



67 6

FLECTOR FLOLAN

57 50


120 35


6 6



59 21


55



21 44 62 74

4 121

36

Index 12





120 120

2 2

73 35


65 45 17 18 19 67


81

81

81



123 121


81 45




Index 13











25 25 25 23 71

127 25





Index 14




Index 15













Index 16













Index 17










Index 18


30

32 83

83



17 43 70

123 58




Index 19


33 64 20


83

83


34 123


26 20


83

84

MENQUADFI MENVEO

129 129


39 124

47 112



67 13 11 35






Index 20







Index 21





58

58 58 68

9 5

25 25

123

123 5 5 5

112 25




Index 22

53



7 124 115

67 53

3 27

115 58 58

116



113 113

13


124 68

119




45 36

125 70

119 121


85

85 17

7 50 64





54 50 68

125 117

54 53 53 53 48 23 75 67

5 121


24 24

24 24



123 35

9 5



73 37 14



13 73 18

Index 23










Index 24







Index 25












Index 26


86

86

RETACRIT RETEVMO

73 39

ROTATEQ ROXICODONE

131 7





71 25 23


42 3 3




46 36

123 112 117

68 39 41 30


Index 27


86 86 86 86









60 119

87 115

30 41 41 87 14

115 34 12



104

105 23

86 42 60



64 71 71

71 60 49 49 64


46 68 15 43 43 67



14 14 65

65 27

Index 28
















Index 29


23 23




46 62 67 64 23



32 48 35 31 27

SYNJARDY XR SYNRIBO

23 40



15 131


126 114

35 39

6263 115

63



55 10

10 10 10


50

51 39

127 72 39 48 37 71

126 36

126




4059 32 39



44 35 44


59 40 53


125 32 31


126 19 49

tazarotene TAZORAC

60 60


32

TIBSOVO TIGAN

39 26

TAZVERIK TDVAX

39 126

temazepam TEMIXYS

74 46

tigecycline TIKOSYN

125 13



63 35 39 40


119 119 119

46

Index 30





Index 31





12 107

Index 32



109


109


109


109


109


109


109





Index 33









70 15 40

132 47 47 47


131 26 29 32 30 32 36



Index 34




Index 35



Index 36




Ambetter from MHS














話請撥電話 1-877-687-1182 (TTYTDD 1-800-743-3333)








(TTYTDD 1-800-743-3333) 687-1182





(TTYTDD 1-800-743-3333)









3333)






क

क स




Classes



AMEBICIDES




































CHEMICALS





DIAGNOSTIC PRODUCTS





















MULTIVITAMINS




NUTRIENTS











TOXOIDS



VACCINES



VITAMINS

Drug Name DrugTier

RequirementsLimits



NF

QL(3 ea daily)


NF

QL(2 ea daily)


NF

QL(1 ea daily)


NF


NF

QL(2 ea daily)



1

QL(1 ea daily)


1

Drug Name DrugTier

RequirementsLimits


1

QL(2 ea daily)


1

QL(3 ea daily)


1

QL(2 ea daily)




NF

QL(4 ea daily)


NF







3 ST QL(1 eadaily)


2 ST QL(1 eadaily)



1

Drug Name DrugTier

RequirementsLimits




Anti-Obesity Agents


















SUNOSI TABS 3 PA

Stimulants - Misc

armodafinil tabs 1




Drug Name DrugTier

RequirementsLimits





1

QL(1 ea daily)










yrs old)
















2

Drug Name DrugTier

RequirementsLimits


















Allergenic Extracts

GRASTEK SUBL 3 PA

AMEBICIDES

Amebicides

SOLOSEC PACK 3 PA


Aminoglycosides


ARIKAYCE SUSP 4 PA

Drug Name DrugTier

RequirementsLimits


1










1




4



ea daily)






3

Drug Name DrugTier

RequirementsLimits


4



4





ea daily)









Gold Compounds




Drug Name DrugTier

RequirementsLimits




NF


NF


NF PA QL(2 eadaily)



daily)














daily)

flurbiprofen tabs 1


4

Drug Name DrugTier

RequirementsLimits












nabumetone tabs 1








oxaprozin tabs 1

piroxicam caps 1

sulindac tabs 1


Drug Name DrugTier

RequirementsLimits




OTEZLA TBPK 4







ml daily)



ml daily) SP



ml daily) SP




1


1



NF


5

Drug Name DrugTier

RequirementsLimits


NF


NF


Salicylates




diflunisal tabs 1

salsalate tabs 1



daily)






NF




NF

Drug Name DrugTier

RequirementsLimits


NF




1

PA QL(4 eadaily)


1 QL(034 eadaily)



1 PA QL(2 eadaily)


daily)




1






NF


NF

PA QL(2 eadaily)





6

Drug Name DrugTier

RequirementsLimits








1








NF QL(10 ml daily)




1 PA QL(2 eadaily)



NF



Drug Name DrugTier

RequirementsLimits







1 QL(2 ea daily)





daily)

OXAYDO TABS 5 MG 2



3 PA QL(2 eadaily)






1 PA QL(2 eadaily)


daily)





7

Drug Name DrugTier

RequirementsLimits



daily)









1







1







1


Drug Name DrugTier

RequirementsLimits


1





NF



NF





1



1



1



1 PA



LORTAB ELIX 2



8

Drug Name DrugTier

RequirementsLimits


NF



1





NF





NF



NF










Drug Name DrugTier

RequirementsLimits


1 QL(3 ea daily)


1 QL(2 ea daily)


1

QL(3 ea daily)


1

PA QL(0143ea daily)




NF

PA QL(0143ea daily)







NF

QL(3 ea daily)


NF

QL(2 ea daily)


Anabolic Steroids

ANADROL-50 TABS 3

oxandrolone tabs 1

Androgens


9

Drug Name DrugTier

RequirementsLimits



NF

danazol caps 1


NF

METHITEST TABS 3



1














NF

Drug Name DrugTier

RequirementsLimits


NF

Vasodilating Agents



Anthelmintics




EMVERM CHEW 2










trimethoprim tabs 1




10

Drug Name DrugTier

RequirementsLimits


NF


NF






atovaquone susp 1



Carbapenems




meropenem solr 1






Drug Name DrugTier

RequirementsLimits



Glycopeptides











Leprostatics

dapsone tabs 1


NF


NF


NF




1



11

Drug Name DrugTier

RequirementsLimits


Monobactams







daily) Polymyxins





NF


NF








Drug Name DrugTier

RequirementsLimits





NF





NITRO-BID OINT 3


NF



1










12

Drug Name DrugTier

RequirementsLimits



meprobamate tabs 1




















Drug Name DrugTier

RequirementsLimits














dofetilide caps 1

MULTAQ TABS 3







FASENRA SOSY 4 PA


13

Drug Name DrugTier

RequirementsLimits

NUCALA SOAJ 4 PA

NUCALA SOLR 4 PA

NUCALA SOSY 4 PA














NF QL(1 ea daily)






Drug Name DrugTier

RequirementsLimits




Steroid Inhalants



daily)


FLOVENT HFA AERO 2



daily)



NF

ADVAIR HFA AERO 2


NF


NF


NF




14

Drug Name DrugTier

RequirementsLimits





1 QL(15 ml daily)








daily)

BREO ELLIPTA AEPB 2




1



1 PA QL(12 mldaily)


Drug Name DrugTier

RequirementsLimits








2







NF PA




daily) Xanthines


ELIXOPHYLLIN ELIX 1






15

Drug Name DrugTier

RequirementsLimits




BEVYXXA CAPS 3



daily)








NF



NF



NF



NF




Drug Name DrugTier

RequirementsLimits



daily) SP














4

PA SP


NF



1


16

Drug Name DrugTier

RequirementsLimits


1


NF QL(6 ml daily)


NF QL(2 ml daily)


NF QL(16 mldaily)









3 PA




daily)

clonazepam tabs 1

clonazepam tbdp 1


3


3



Drug Name DrugTier

RequirementsLimits




daily)










3 PA











17

Drug Name DrugTier

RequirementsLimits







EPIDIOLEX SOLN 3 PA





NF QL(30 ml daily)




NF QL(4 ea daily)



NF QL(20 ea daily)


NF QL(100 eadaily)


NF QL(1 ea daily)



NF

Drug Name DrugTier

RequirementsLimits





1








NF

PA QL(3 eadaily)





NF



NF





18

Drug Name DrugTier

RequirementsLimits


1 PA QL(3 eadaily)


daily)


primidone tabs 1








NF QL(4 ea daily)



NF QL(6 ea daily)


NF QL(8 ea daily)








NF QL(40 ml daily)

Drug Name DrugTier

RequirementsLimits


NF QL(3 ea daily)





3 PA QL(2 eadaily)



Carbamates















19

Drug Name DrugTier

RequirementsLimits


2





PEGANONE TABS 3


2

phenytoin chew 1



phenytoin susp 1

Succinimides






NF QL(30 ml daily)






Drug Name DrugTier

RequirementsLimits






















20

Drug Name DrugTier

RequirementsLimits



NF QL(15 eadaily)


NF QL(2 ea daily)


NF QL(1 ea daily)









daily)









NF QL(1 ea daily)


Drug Name DrugTier

RequirementsLimits














NF QL(1 ea daily)











21

Drug Name DrugTier

RequirementsLimits
















NF QL(1 ea daily)

FETZIMA CP24 3 PA




NF QL(4 ea daily)


NF QL(1 ea daily)


Drug Name DrugTier

RequirementsLimits



1 QL(3 ea daily)




Tricyclic Agents


amoxapine tabs 3




doxepin hcl caps 1

doxepin hcl conc 1












22

Drug Name DrugTier

RequirementsLimits



miglitol tabs 1






NF QL(2 ea daily)


NF QL(1 ea daily)


1 QL(2 ea daily)



1 QL(2 ea daily)


1 QL(4 ea daily)

GLYXAMBI TABS 2




2 QL(2 ea daily)




Drug Name DrugTier

RequirementsLimits






2 QL(2 ea daily)


TRIJARDY XR TB24 2


3 PA QL(1 eadaily)



daily)



daily)







daily)

diazoxide susp 1


daily)



23

Drug Name DrugTier

RequirementsLimits


3 QL(0035 eadaily)











ml daily)







APIDRA SOLN 3 PA




Drug Name DrugTier

RequirementsLimits


FIASP SOLN 2




LEVEMIR SOLN 2




NOVOLIN 7030 SUSP 2


NOVOLIN N SUSP 2


NOVOLIN R SOLN 2



2



NOVOLOG SOLN 2


TRESIBA SOLN 2




24

Drug Name DrugTier

RequirementsLimits























Drug Name DrugTier

RequirementsLimits




MOTOFEN TABS 3



CHEMET CAPS 3




deferiprone tabs 1






VISTOGARD PACK 4 PA



NARCAN LIQD 3





25

Drug Name DrugTier

RequirementsLimits







daily)
















NF



daily)

Drug Name DrugTier

RequirementsLimits







dronabinol caps 1




ea daily)






NF


VARUBI TBPK 3 PA




26

Drug Name DrugTier

RequirementsLimits



ERAXIS SOLR 3


MYCAMINE SOLR 3

Antifungals

ABELCET SUSP 3

AMBISOME SUSR 3



flucytosine caps 1




nystatin tabs 1





fluconazole susr 1

fluconazole tabs 1



Drug Name DrugTier

RequirementsLimits

ketoconazole tabs 1





daily)

TOLSURA CAPS 4 PA














1

QL(30 ml daily)



27

Drug Name DrugTier

RequirementsLimits


1 QL(1 ea daily)


1 QL(2 ea daily)








1





1









Drug Name DrugTier

RequirementsLimits




RXOTC

loratadine caps 1

loratadine chew 1

loratadine soln 1

loratadine syrp 1

loratadine tabs 1

loratadine tbdp 1


NF

















28

Drug Name DrugTier

RequirementsLimits












daily)






NF QL(6 gm daily)


NF QL(6 ea daily)





Drug Name DrugTier

RequirementsLimits






NF QL(252 gmdaily)














daily)






29

Drug Name DrugTier

RequirementsLimits

















1 QL(2 ea daily)



daily)




Drug Name DrugTier

RequirementsLimits




captopril tabs 1



lisinopril tabs 1






ramipril caps 1

trandolapril tabs 1









30

Drug Name DrugTier

RequirementsLimits

















daily)








Drug Name DrugTier

RequirementsLimits


NF QL(2 ea daily)






NF MO



NF MO


NF ST



NF MO




NF


EXFORGE HCT TABS 2


NF



31

Drug Name DrugTier

RequirementsLimits


NF

QL(2 ea daily)


NF

QL(1 ea daily)




NF


1

QL(2 ea daily)


1

QL(1 ea daily)


NF


NF



NF MO


1 ST






Drug Name DrugTier

RequirementsLimits


NF


NF




NF

ST




NF


NF







eplerenone tabs 1


Vasodilators



minoxidil tabs 1


32

Drug Name DrugTier

RequirementsLimits




COARTEM TABS 2





Drug Name DrugTier

RequirementsLimits









NF






FIRDAPSE TABS 4 PA





NF


3 PA


33

Drug Name DrugTier

RequirementsLimits






RIFAMATE CAPS 3





isoniazid soln 1

isoniazid syrp 1

isoniazid tabs 1




PRIFTIN TABS 3

pyrazinamide tabs 1

rifabutin caps 1 PA



rifampin caps 1

Drug Name DrugTier

RequirementsLimits

rifampin solr 1




















melphalan tabs 1



34

Drug Name DrugTier

RequirementsLimits



NF

PA SP








Antimetabolites














Drug Name DrugTier

RequirementsLimits




NF




















daily)


35

Drug Name DrugTier

RequirementsLimits

MVASI SOLN 4 PA


ZIRABEV SOLN 4 PA




TUKYSA TABS 4 PA





RUXIENCE SOLN 4 PA

YERVOY SOLN 4 PA SP







VIZIMPRO TABS 4 PA


DAURISMO TABS 4 PA




Drug Name DrugTier

RequirementsLimits



daily)




SP



daily) SP





EMCYT CAPS 4 PA SP













36

Drug Name DrugTier

RequirementsLimits



ea daily) SP






NUBEQA TABS 4 PA





YONSA TABS 4 PA










Drug Name DrugTier

RequirementsLimits







NF






NF PA SP



NF PA SP


NF PA








37

Drug Name DrugTier

RequirementsLimits





daily) SP




BALVERSA TABS 4 PA



daily) SP



BRUKINSA CAPS 4 PA





COPIKTRA CAPS 4 PA



daily) SP

IBRANCE CAPS 3 PA

IBRANCE TABS 3 PA

Drug Name DrugTier

RequirementsLimits


daily)




daily)



4 PA QL(1 eadaily)

INREBIC CAPS 4 PA




daily) SP

KISQALI TBPK 3 PA

KOSELUGO CAPS 4 PA

KYPROLIS SOLR 4 PA


LORBRENA TABS 4 PA










38

Drug Name DrugTier

RequirementsLimits



QINLOCK TABS 4 PA

RETEVMO CAPS 4 PA


ROZLYTREK CAPS 4 PA







TABRECTA TABS 4 PA


TALZENNA CAPS 4 PA


daily) SP


TAZVERIK TABS 4 PA


TIBSOVO TABS 4 PA


ml daily) SP



daily) SP


Drug Name DrugTier

RequirementsLimits

VERZENIO TABS 4 PA

VITRAKVI CAPS 4 PA

VITRAKVI SOLN 4 PA



XOSPATA TABS 4 PA














hydroxyurea caps 1



NIPENT SOLR 4 PA SP



39

Drug Name DrugTier

RequirementsLimits





UVADEX SOLN 4 PA SP




1



Mitotic Inhibitors













Drug Name DrugTier

RequirementsLimits



NF PA SP


4 PA SP






NF PA SP







carbidopa tabs 1









40

Drug Name DrugTier

RequirementsLimits




tolcapone tabs 3




APOKYN SOCT 4 PA









NF QL(4 ea daily)


NF

NEUPRO PT24 2




1 QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits


1


NF ST QL(2 eadaily)


NF ST QL(1 eadaily)


1






1


NF


1


NF


1


NF


1


NF


41

Drug Name DrugTier

RequirementsLimits


1


NF


1


NF


daily)





Antimanic Agents




LITHIUM SOLN 1








daily)

Drug Name DrugTier

RequirementsLimits



Benzisoxazoles




NF QL(1 ea daily)








NF QL(2 ea daily)








NF QL(0036 mldaily)


42

Drug Name DrugTier

RequirementsLimits


NF QL(0036 mldaily)





haloperidol tabs 1

















Drug Name DrugTier

RequirementsLimits









3 PA QL(2 eadaily)


daily)





NF PA QL(1 eadaily)


NF PA QL(2 eadaily)



NF QL(1 ea daily)


NF QL(2 ea daily)


NF QL(2 ea daily)




43

Drug Name DrugTier

RequirementsLimits


1





perphenazine tabs 1











REXULTI TABS 3 PA

Thioxanthenes

thiothixene caps 1





Drug Name DrugTier

RequirementsLimits







3

QL(1 ea daily)

















1 QL(1 ea daily)


44

Drug Name DrugTier

RequirementsLimits


1 QL(1 ea daily)



1



0

QL(1 ea daily)









NF QL(1 ea daily)




FUZEON SOLR 4 PA SP






Drug Name DrugTier

RequirementsLimits






NF QL(125 mldaily)


2

QL(4 ea daily)







NF QL(4 ea daily)












45

Drug Name DrugTier

RequirementsLimits











NF QL(1 ea daily)



RUKOBIA TB12 4 PA











Drug Name DrugTier

RequirementsLimits


2

QL(1 ea daily)


2

QL(1 ea daily)







NF QL(2 ea daily)
















46

Drug Name DrugTier

RequirementsLimits


NF






CMV Agents

cidofovir soln 3









daily) SP






daily) SP



daily)

Drug Name DrugTier

RequirementsLimits






daily)



ZEPATIER TABS 4 PA

Herpes Agents















NF QL(5 ea daily)


47

Drug Name DrugTier

RequirementsLimits










NF



NF



Alpha-Beta Blockers

carvedilol tabs 1

Drug Name DrugTier

RequirementsLimits






atenolol tabs 1




2 PA QL(1 eadaily)







daily)









48

Drug Name DrugTier

RequirementsLimits


nadolol tabs 1

pindolol tabs 1


1




1











NF





Drug Name DrugTier

RequirementsLimits



1




felodipine tb24 1

isradipine caps 1



nifedipine caps 1

nifedipine tb24 1

nimodipine caps 1


1






NF





49

Drug Name DrugTier

RequirementsLimits



NF



NF



Cardiac Glycosides

digoxin soln 1

digoxin tabs 1



2





BIDIL TABS 2


NF QL(1 ea daily)

ENTRESTO TABS 3 PA

Impotence Agents



Drug Name DrugTier

RequirementsLimits









3 PA









daily) SP




daily)





50

Drug Name DrugTier

RequirementsLimits


NF



NF

PA QL(6 mldaily)






4 PA QL(6 mldaily)




daily) SP









cefadroxil caps 1

cefadroxil susr 1

cefadroxil tabs 1


Drug Name DrugTier

RequirementsLimits

cephalexin caps 1

cephalexin susr 1

cephalexin tabs 1



cefaclor caps 1

cefaclor susr 1




cefprozil susr 1

cefprozil tabs 1




cefdinir caps 1

cefdinir susr 1









51

Drug Name DrugTier

RequirementsLimits


1




NF PA


cefepime hcl solr 1



TEFLARO SOLR 3

CHEMICALS





NF






0


NF

Drug Name DrugTier

RequirementsLimits


FALESSA KIT 0


NF







NF


NF


NF

NATAZIA TABS 0











52

Drug Name DrugTier

RequirementsLimits




NF


NF


NF


NF


NF


NF


TYBLUME CHEW 0


NF


NF






NF

Drug Name DrugTier

RequirementsLimits


0


ELLA TABS 0



NF


KYLEENA IUD 0

LILETTA IUD 0

MIRENA IUD 0

SKYLA IUD 0


NEXPLANON IMPL 0


NF



NF









53

Drug Name DrugTier

RequirementsLimits


NF






NF


NF





NF




1



1

EMFLAZA SUSP 4 PA

EMFLAZA TABS 4 PA


Drug Name DrugTier

RequirementsLimits





NF

MEDROL TABS 2 MG 3





MILLIPRED DP TBPK 3

MILLIPRED TABS 3


NF


NF


1


3

prednisolone soln 1

prednisone soln 1

prednisone tabs 1

prednisone tbpk 1




54

Drug Name DrugTier

RequirementsLimits




NF




Antitussives






NF

QL(2 ea daily)


NF

QL(1 ea daily)



1 QL(2 ea daily)


1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits


1 QL(2 ea daily)


1 QL(1 ea daily)


1


1 QL(2 ea daily)


1

QL(1 ea daily)



1

QL(2 ea daily)


HYPERSAL NEBU 35 1


NF

NEBUSAL NEBU 1


Mucolytics







55

Drug Name DrugTier

RequirementsLimits




12 yrs old)





NF





yrs old)
















yrs old)

Drug Name DrugTier

RequirementsLimits










12 yrs old)




12 yrs old)



NF
















56

Drug Name DrugTier

RequirementsLimits






yrs old)



















VEREGEN OINT 3






daily) RXOTC

Drug Name DrugTier

RequirementsLimits




mupirocin oint 1














ERTACZO CREA 3


EXELDERM SOLN 3


JUBLIA SOLN 3 PA


57

Drug Name DrugTier

RequirementsLimits










NF RXOTC



NF







Drug Name DrugTier

RequirementsLimits




NF















58

Drug Name DrugTier

RequirementsLimits



OXISTAT LOTN 2







NF






PANRETIN GEL 3

PICATO GEL 0015 2


Drug Name DrugTier

RequirementsLimits

PICATO GEL 005 2













59

Drug Name DrugTier

RequirementsLimits









daily)



NF QL(4 ea daily)









ml daily) SP


TAZORAC CREA 005 2



Drug Name DrugTier

RequirementsLimits











Burn Products








amcinonide crea 1


amcinonide lotn 3


60

Drug Name DrugTier

RequirementsLimits

AMCINONIDE OINT 3





1


1


1






1 ST


1 ST



daily)







Drug Name DrugTier

RequirementsLimits






NF



NF











NF


NF






61

Drug Name DrugTier

RequirementsLimits


















HALOG OINT 3 PA






Drug Name DrugTier

RequirementsLimits









daily)





NF

RXOTC




PSORCON CREA 2 PA





NF

ST


62

Drug Name DrugTier

RequirementsLimits


3

ST







1



1


1







NF RXOTC


NF RXOTC

Drug Name DrugTier

RequirementsLimits











2 yrs old)



2 yrs old)



podofilox soln 1









63

Drug Name DrugTier

RequirementsLimits

SYNERA PTCH 3




Rosacea Agents




NF



NF










EURAX CREA 3



Drug Name DrugTier

RequirementsLimits


lindane sham 3

malathion lotn 1




permethrin crea 1

permethrin liqd 1


spinosad susp 1 PA

ULESFIA LOTN 3

Wound Care Products

REGRANEX GEL 3

DIAGNOSTIC PRODUCTS



CHEMSTRIP-K STRP 1


1


KETONE STRP 1


KETOSTIX STRP 1


1


64

Drug Name DrugTier

RequirementsLimits







1





Digestive Enzymes

CREON CPEP 2

SUCRAID SOLN 3

ZENPEP CPEP 2









NF

Drug Name DrugTier

RequirementsLimits



NF


NF


NF









furosemide soln 1

furosemide tabs 1


torsemide tabs 1







65

Drug Name DrugTier

RequirementsLimits















NF PA SP









Drug Name DrugTier

RequirementsLimits


4 PA SP


PROLIA SOSY 4







TYMLOS SOPN 4 PA

XGEVA SOLN 4 PA SP




Corticotropin

ACTHAR GEL 4 PA




4 PA SP


CETROTIDE KIT 4 PA



66

Drug Name DrugTier

RequirementsLimits


NF PA









4 PA SP




SAIZEN SOLR 4 PA SP


4 PA SP





OSPHENA TABS 3 PA

Drug Name DrugTier

RequirementsLimits









Metabolic Modifiers




calcitriol caps 1

calcitriol soln 1










NF


67

Drug Name DrugTier

RequirementsLimits


NF PA


NF PA


MYALEPT SOLR 4 PA




PALYNZIQ SOSY 4 PA

paricalcitol caps 1

paricalcitol soln 1











NF PA


NF

Drug Name DrugTier

RequirementsLimits


NF QL(6 ea daily)


NF QL(8 ea daily)



4 PA SP







cabergoline tabs 1

Somatostatic Agents



SIGNIFOR SOLN 4 PA




ml daily) SP


daily) SP



daily) SP



68

Drug Name DrugTier

RequirementsLimits



CLIMARA PRO PTWK 3

DUAVEE TABS 3 PA


NF


PREMPHASE TABS 2

PREMPRO TABS 2




NF



3

ELESTRIN GEL 3



1

QL(0286 eadaily)


1



Drug Name DrugTier

RequirementsLimits

ESTROGEL GEL 3

EVAMIST SOLN 3

MENEST TABS 3

MENOSTAR PTWK 3


daily)

PREMARIN SOLR 2

PREMARIN TABS 2




1

BAXDELA SOLR 3 PA

BAXDELA TABS 3 PA






3




1

levofloxacin soln 1

levofloxacin tabs 1


69

Drug Name DrugTier

RequirementsLimits



ofloxacin tabs 1










daily)








AVSOLA SOLR 4 PA


Drug Name DrugTier

RequirementsLimits






DIPENTUM CAPS 2


















70

Drug Name DrugTier

RequirementsLimits



alvimopan caps 1






NF


PHOSLYRA SOLN 2







VELPHORO CHEW 3 PA



1


Drug Name DrugTier

RequirementsLimits


NF

Cystinosis Agents

CYSTAGON CAPS 3 PA


acetic acid soln 1


RESECTISOL SOLN 1


SORBITOL SOLN 1




ELMIRON CAPS 2












Urinary Analgesics


71

Drug Name DrugTier

RequirementsLimits





Gout Agents

allopurinol tabs 1




KRYSTEXXA SOLN 4 PA




Uricosurics

probenecid tabs 1



daily)



CINRYZE SOLR 4 PA

HAEGARDA SOLR 4 PA


SOLIRIS SOLN 4 PA

Drug Name DrugTier

RequirementsLimits




TAKHZYRO SOLN 4 PA





BRILINTA TABS 2

CABLIVI KIT 4 PA

cilostazol tabs 1



dipyridamole tabs 1




ZONTIVITY TABS 3 PA








72

Drug Name DrugTier

RequirementsLimits

VPRIV SOLR 4 PA SP


daily) SP


DROXIA CAPS 3

OXBRYTA TABS 4 PA


Folic AcidFolates




4 PA SP



4

PA SP

DOPTELET TABS 4 PA

EPOGEN SOLN 3 PA SP

FULPHILA SOSY 4 PA


MIRCERA SOSY 4 PA

MULPLETA TABS 4 PA




Drug Name DrugTier

RequirementsLimits



4 PA



3

PA SP





4

PA

UDENYCA SOSY 4 PA


ZIEXTENZO SOSY 4 PA










73

Drug Name DrugTier

RequirementsLimits


NF PA










1










estazolam tabs 1

eszopiclone tabs 1


Drug Name DrugTier

RequirementsLimits







triazolam tabs 1








BELSOMRA TABS 3 PA



ramelteon tabs 1





Bulk Laxatives



74

Drug Name DrugTier

RequirementsLimits



CLENPIQ SOLN 3 PA


NF


0


2

PA


1 PA


0

PREPOPIK PACK 3 PA



Saline Laxatives

OSMOPREP TABS 3 PA

Stimulant Laxatives

bisacodyl tbec 1





Drug Name DrugTier

RequirementsLimits





NF


NF


NF


Azithromycin












NF




75

Drug Name DrugTier

RequirementsLimits




daily)





Clarithromycin





NF


NF


3





1


Fidaxomicin



Contraceptives

Drug Name DrugTier

RequirementsLimits


CAYA DPRH 0




0 QL(2 ea daily)


FEMCAP DEVI 0







0 QL(2 ea daily)


0 QL(2 ea daily)


0 QL(2 ea daily)



0 QL(2 ea daily)



0 QL(2 ea daily)



76

Drug Name DrugTier

RequirementsLimits






0 QL(2 ea daily)








0 QL(2 ea daily)


0 QL(2 ea daily)


0

QL(2 ea daily)


0 QL(2 ea daily)


0

QL(2 ea daily)


0

QL(2 ea daily)


Drug Name DrugTier

RequirementsLimits


0 QL(2 ea daily)


0 QL(2 ea daily)


0


0


0


0


0


0


0


0


1 QL(66667 eadaily)


1 QL(66667 eadaily)






daily)


77

Drug Name DrugTier

RequirementsLimits



1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)














1


1 QL(66667 eadaily)


1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)




daily)


AUTO-LANCET MISC 1



AUTOLET MINI MISC 1

AUTOLET PLUS MISC 1





daily)


78

Drug Name DrugTier

RequirementsLimits








1










1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)




daily)

Drug Name DrugTier

RequirementsLimits















1



1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)


79

Drug Name DrugTier

RequirementsLimits


daily)








1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)



1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


daily)

Drug Name DrugTier

RequirementsLimits





1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1









daily)


80

Drug Name DrugTier

RequirementsLimits




daily)



daily)





1


1 QL(66667 eadaily)


1 QL(66667 eadaily)





1


1


1


1


1

Drug Name DrugTier

RequirementsLimits


1


1


1



1 QL(66667 eadaily)


1

QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)





daily)








1


81

Drug Name DrugTier

RequirementsLimits



1 QL(66667 eadaily)



1 QL(66667 eadaily)


1 QL(66667 eadaily)



1 QL(66667 eadaily)



1


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)







daily)

Drug Name DrugTier

RequirementsLimits



1


1 QL(66667 eadaily)





daily)





1 QL(66667 eadaily)



daily)










82

Drug Name DrugTier

RequirementsLimits


daily)







daily)







daily)








LANZO MISC 1



daily)

Drug Name DrugTier

RequirementsLimits



1 QL(66667 eadaily)












1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)





daily)


83

Drug Name DrugTier

RequirementsLimits





1 QL(66667 eadaily)



1

QL(66667 eadaily)


1 QL(66667 eadaily)


daily)





1 QL(66667 eadaily)








daily)


Drug Name DrugTier

RequirementsLimits













1 QL(66667 eadaily)








1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)


84

Drug Name DrugTier

RequirementsLimits



1 QL(66667 eadaily)


1 QL(66667 eadaily)


1


1






1 QL(66667 eadaily)


daily)





1 QL(66667 eadaily)


1 QL(66667 eadaily)



1 QL(66667 eadaily)


Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)





















1 QL(66667 eadaily)


85

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)













1 QL(66667 eadaily)


1 QL(66667 eadaily)




daily)

Drug Name DrugTier

RequirementsLimits




1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




daily)






1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)


86

Drug Name DrugTier

RequirementsLimits






1


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


daily)








daily)

Drug Name DrugTier

RequirementsLimits






daily)

SURE-PEN MISC 1












1






daily)


87

Drug Name DrugTier

RequirementsLimits


1













daily)



1 QL(66667 eadaily)







daily)


Drug Name DrugTier

RequirementsLimits





daily)






daily)














1 QL(66667 eadaily)


88

Drug Name DrugTier

RequirementsLimits









1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)






Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


89

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)









1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)




1 QL(5 ea daily)







1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1

QL(5 ea daily)


90

Drug Name DrugTier

RequirementsLimits










1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)



1 QL(5 ea daily)








1

QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


91

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


92

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)








1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


93

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)








1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)








1 QL(5 ea daily)


94

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)








1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


95

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)


96

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)






1 QL(5 ea daily)








1 QL(5 ea daily)








1 QL(5 ea daily)










97

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)






1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)






98

Drug Name DrugTier

RequirementsLimits






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)







1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits








1 QL(5 ea daily)


1 QL(5 ea daily)










1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)




99

Drug Name DrugTier

RequirementsLimits










1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)





Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)








1 QL(5 ea daily)






1 QL(5 ea daily)




1 QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


100

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)








1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC



Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC






1 QL(5 ea daily)










1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)



1 QL(5 ea daily)


101

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits








1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)


102

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC






1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


103

Drug Name DrugTier

RequirementsLimits










1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC






1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits




















1 QL(5 ea daily)









1 QL(5 ea daily)




104

Drug Name DrugTier

RequirementsLimits




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






105

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)


106

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)








1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)








1 QL(5 ea daily)






107

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)






1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


108

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)






1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


109

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)






1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)


110

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)










1 QL(5 ea daily)




1 QL(5 ea daily)







daily)

Drug Name DrugTier

RequirementsLimits








NF



NF




daily)



NF QL(0267 mldaily)

Serotonin Agonists








111

Drug Name DrugTier

RequirementsLimits








NF



NF



NF



NF



NF










Drug Name DrugTier

RequirementsLimits









sumatriptan soln 1



















112

Drug Name DrugTier

RequirementsLimits









1






NF



NF


1


Drug Name DrugTier

RequirementsLimits

ISOLYTE-S SOLN 1



1


NORMOSOL-MD5WSOLN 1

NORMOSOL-R SOLN 1





1



1


1


1


113

Drug Name DrugTier

RequirementsLimits

ringers soln 1










1



1


1


1


NF



Drug Name DrugTier

RequirementsLimits



1







daily) SP







ATGAM INJ 4 PA SP




NF


NF

cyclosporine caps 1



114

Drug Name DrugTier

RequirementsLimits


cyclosporine soln 1









NF


NF



NF




NF


NF


NF

SIMULECT SOLR 3


tacrolimus caps 1

Drug Name DrugTier

RequirementsLimits



NF














DEBACTEROL SOLN 2


NF

Dental Products




115

Drug Name DrugTier

RequirementsLimits






MULTIVITAMINS











2

QL(1 ea daily)RXOTC





Drug Name DrugTier

RequirementsLimits









116

Drug Name DrugTier

RequirementsLimits


2

QL(1 ea daily)RXOTC












2 QL(1 ea daily)





RXOTC



RXOTC



Drug Name DrugTier

RequirementsLimits



carisoprodol tabs 1
















Nasal Antiallergy





117

Drug Name DrugTier

RequirementsLimits



Nasal Steroids



NF



NF







NF


NF






riluzole tabs 3

Drug Name DrugTier

RequirementsLimits


BOTOX SOLR 3 PA

DYSPORT SOLR 3 PA

XEOMIN SOLR 3 PA

NUTRIENTS


3


3


3



3



LACRISERT INST 3




COMBIGAN SOLN 2


NF


1



118

Drug Name DrugTier

RequirementsLimits






tropicamide soln 1





NF



IOPIDINE SOLN 3

SIMBRINZA SUSP 3 PA


AZASITE SOLN 3



NF




Drug Name DrugTier

RequirementsLimits




KLARITY-A SOLN 3



NATACYN SUSP 2









trifluridine soln 1


ZIRGAN GEL 2



RESTASIS EMUL 2 PA




119

Drug Name DrugTier

RequirementsLimits



OXERVATE SOLN 4 PA

Ophthalmic Steroids

ALREX SUSP 3 PA





FML FORTE SUSP 3 PA


NF

FML OINT 3 PA


LOTEMAX OINT 3 PA




MAXIDEX SUSP 3 PA


NF


NF




Drug Name DrugTier

RequirementsLimits


NF

PRED MILD SUSP 3 PA




3


NF



NF


NF

ALOCRIL SOLN 3 PA

ALOMIDE SOLN 3 PA











120

Drug Name DrugTier

RequirementsLimits


ILEVRO SUSP 3 PA



LASTACAFT SOLN 3 PA

NEVANAC SUSP 3 PA






ZERVIATE SOLN 3 PA


bimatoprost soln 3

latanoprost soln 1

LUMIGAN SOLN 3 ST


travoprost soln 1


ZIOPTAN SOLN 2





Drug Name DrugTier

RequirementsLimits



Otic Combinations

CIPRO HC SUSP 3


NF PA



daily)

COLY-MYCIN S SUSP 3





3 PA QL(05 eadaily)


NF





4 PA SP


4

PA SP



121

Drug Name DrugTier

RequirementsLimits


4 PA SP




4 PA SP


HYQVIA KIT 4 PA


Aminopenicillins

amoxicillin caps 1

amoxicillin chew 1

amoxicillin susr 1

amoxicillin tabs 1

ampicillin caps 1




1







Drug Name DrugTier

RequirementsLimits






1


1


NF


NF


NF



NF


NF


NF






122

Drug Name DrugTier

RequirementsLimits







NF PA






NF





disulfiram tabs 1





NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits


NF QL(1 ea daily)














NF





Fibromyalgia Agents





123

Drug Name DrugTier

RequirementsLimits




daily) SP


daily) SP

AUBAGIO TABS 4 PA












GILENYA CAPS 4 PA



ml daily) SP

MAVENCLAD TBPK 4 PA


MAYZENT TABS 4 PA

OCREVUS SOLN 4 PA


Drug Name DrugTier

RequirementsLimits





ml daily)







NF PA



3 PA QL(1 eadaily)


3 PA QL(2 eadaily)




NUEDEXTA CAPS 3 PA


pimozide tabs 1




124

Drug Name DrugTier

RequirementsLimits

Smoking Deterrents











NF





0


NICOTROL NS SOLN 0



TEGSEDI SOSY 4 PA



Drug Name DrugTier

RequirementsLimits









daily)






Sulfonamides

SULFADIAZINE TABS 1


Glycylcyclines

tigecycline solr 1


Tetracyclines






125

Drug Name DrugTier

RequirementsLimits











NF QL(2 ea daily)


NF


Antithyroid Agents

methimazole tabs 1




2

QL(1 ea daily)



Drug Name DrugTier

RequirementsLimits


1








WESTHROID TABS 2

WP THYROID TABS 2

TOXOIDS

Toxoid Combinations

ADACEL SUSP 0

BOOSTRIX SUSP 0

DAPTACEL SUSP 0


0

INFANRIX SUSP 0

KINRIX SUSP 0

PEDIARIX SUSP 0

PENTACEL SUSR 0

QUADRACEL SUSP 0

TDVAX SUSP 0


126

Drug Name DrugTier

RequirementsLimits

TENIVAC INJ 0


0




1








NF







1



Drug Name DrugTier

RequirementsLimits





NF RXOTC







1 QL(20 ml daily)





NF RXOTC








127

Drug Name DrugTier

RequirementsLimits










NF QL(1 ea daily)












1 QL(4 ea daily)


NF QL(1 ea daily)


NF

Drug Name DrugTier

RequirementsLimits







NF

RXOTC

















128

Drug Name DrugTier

RequirementsLimits






NF QL(4 ea daily)


NF



VACCINES

Bacterial Vaccines

ACTHIB SOLR 0

BEXSERO SUSY 0

HIBERIX SOLR 0

MENQUADFI SOLN 0

MENVEO SOLR 0

PEDVAX HIB SUSP 0

PNEUMOVAX 23 INJ 0


PREVNAR 13 SUSP 0

TRUMENBA SUSY 0

Viral Vaccines

Drug Name DrugTier

RequirementsLimits













ENGERIX-B INJ 0


ENGERIX-B SUSP 0









129

Drug Name DrugTier

RequirementsLimits










0



0



0



0



0



0



0



0


Drug Name DrugTier

RequirementsLimits


0



0



0



0



0











0



0



0



130

Drug Name DrugTier

RequirementsLimits


0



0



0




HAVRIX SUSP 0


HEPLISAV-B SOSY 0




ROTARIX SUSR 0

ROTATEQ SOLN 0

SHINGRIX SUSR 0


TWINRIX SUSY 0

Drug Name DrugTier

RequirementsLimits

VAQTA SUSP 0



ZOSTAVAX SUSR 0




INTRAROSA INST 3 PA

Spermicides

SHUR-SEAL GEL 0

TODAY SPONGE MISC 0


NF



GYNAZOLE-1 CREA 3








131

Drug Name DrugTier

RequirementsLimits

PHEXXI GEL 0 PV




FEMRING RING 3

PREMARIN CREA 2




NF








Drug Name DrugTier

RequirementsLimits


2


Vasopressors


VITAMINS










NIACIN TR TBCR 1




132





Index 1




31

31 22

122

122

1 27

122

122


44 16

2 126

14 36 35 39

4 4

36 70


119 13

120 57


122 124

9 22




72 36 27 10 10 53



25 74 74 27 50 60 61

111


15 123

10 26 24 24

125 41



74 3

65 65


119 26 70 17 44


78

78


74 15 13 70 22



78 30 31 44 66


Index 2














Index 3








Index 4











Index 5



64 4 4

11


28 28 28 55




55 116

79

27 27 75



121




121 34 21 28 76



35 35 22 17 31

Index 6


2 72 13

115 57

131

57 43 43 79 33




6 6

40 75 70


44 41

2 2 6


73 117

34 34 24




114

114 74 22 28 67 71

120 35

126 128



37 118

16 31 65 27 29 44


111 39 35 37

124 14 10




117 11



64 11 11

114


126 11 11 33


Index 7




Index 8




Index 9





80

80

80

80



Index 10



128 30

31 5 5 5

129 16 41 47 71





132 124 111 111

36 36 57 11 39 39 76 76 56

119 76

76 21

6

128 74 69 69

132 69 69 52 74


Index 11






76 72 19 19

4 49 36 76 69

132 29 29


81 81

6 8 6 8

72 33 36 11 10

129



67 6

FLECTOR FLOLAN

57 50


120 35


6 6



59 21


55



21 44 62 74

4 121

36

Index 12





120 120

2 2

73 35


65 45 17 18 19 67


81

81

81



123 121


81 45




Index 13











25 25 25 23 71

127 25





Index 14




Index 15













Index 16













Index 17










Index 18


30

32 83

83



17 43 70

123 58




Index 19


33 64 20


83

83


34 123


26 20


83

84

MENQUADFI MENVEO

129 129


39 124

47 112



67 13 11 35






Index 20







Index 21





58

58 58 68

9 5

25 25

123

123 5 5 5

112 25




Index 22

53



7 124 115

67 53

3 27

115 58 58

116



113 113

13


124 68

119




45 36

125 70

119 121


85

85 17

7 50 64





54 50 68

125 117

54 53 53 53 48 23 75 67

5 121


24 24

24 24



123 35

9 5



73 37 14



13 73 18

Index 23










Index 24







Index 25












Index 26


86

86

RETACRIT RETEVMO

73 39

ROTATEQ ROXICODONE

131 7





71 25 23


42 3 3




46 36

123 112 117

68 39 41 30


Index 27


86 86 86 86









60 119

87 115

30 41 41 87 14

115 34 12



104

105 23

86 42 60



64 71 71

71 60 49 49 64


46 68 15 43 43 67



14 14 65

65 27

Index 28
















Index 29


23 23




46 62 67 64 23



32 48 35 31 27

SYNJARDY XR SYNRIBO

23 40



15 131


126 114

35 39

6263 115

63



55 10

10 10 10


50

51 39

127 72 39 48 37 71

126 36

126




4059 32 39



44 35 44


59 40 53


125 32 31


126 19 49

tazarotene TAZORAC

60 60


32

TIBSOVO TIGAN

39 26

TAZVERIK TDVAX

39 126

temazepam TEMIXYS

74 46

tigecycline TIKOSYN

125 13



63 35 39 40


119 119 119

46

Index 30





Index 31





12 107

Index 32



109


109


109


109


109


109


109





Index 33









70 15 40

132 47 47 47


131 26 29 32 30 32 36



Index 34




Index 35



Index 36




Ambetter from MHS














話請撥電話 1-877-687-1182 (TTYTDD 1-800-743-3333)








(TTYTDD 1-800-743-3333) 687-1182





(TTYTDD 1-800-743-3333)









3333)






क

क स




Classes



AMEBICIDES




































CHEMICALS





DIAGNOSTIC PRODUCTS





















MULTIVITAMINS




NUTRIENTS











TOXOIDS



VACCINES



VITAMINS

Drug Name DrugTier

RequirementsLimits




Anti-Obesity Agents


















SUNOSI TABS 3 PA

Stimulants - Misc

armodafinil tabs 1




Drug Name DrugTier

RequirementsLimits





1

QL(1 ea daily)










yrs old)
















2

Drug Name DrugTier

RequirementsLimits


















Allergenic Extracts

GRASTEK SUBL 3 PA

AMEBICIDES

Amebicides

SOLOSEC PACK 3 PA


Aminoglycosides


ARIKAYCE SUSP 4 PA

Drug Name DrugTier

RequirementsLimits


1










1




4



ea daily)






3

Drug Name DrugTier

RequirementsLimits


4



4





ea daily)









Gold Compounds




Drug Name DrugTier

RequirementsLimits




NF


NF


NF PA QL(2 eadaily)



daily)














daily)

flurbiprofen tabs 1


4

Drug Name DrugTier

RequirementsLimits












nabumetone tabs 1








oxaprozin tabs 1

piroxicam caps 1

sulindac tabs 1


Drug Name DrugTier

RequirementsLimits




OTEZLA TBPK 4







ml daily)



ml daily) SP



ml daily) SP




1


1



NF


5

Drug Name DrugTier

RequirementsLimits


NF


NF


Salicylates




diflunisal tabs 1

salsalate tabs 1



daily)






NF




NF

Drug Name DrugTier

RequirementsLimits


NF




1

PA QL(4 eadaily)


1 QL(034 eadaily)



1 PA QL(2 eadaily)


daily)




1






NF


NF

PA QL(2 eadaily)





6

Drug Name DrugTier

RequirementsLimits








1








NF QL(10 ml daily)




1 PA QL(2 eadaily)



NF



Drug Name DrugTier

RequirementsLimits







1 QL(2 ea daily)





daily)

OXAYDO TABS 5 MG 2



3 PA QL(2 eadaily)






1 PA QL(2 eadaily)


daily)





7

Drug Name DrugTier

RequirementsLimits



daily)









1







1







1


Drug Name DrugTier

RequirementsLimits


1





NF



NF





1



1



1



1 PA



LORTAB ELIX 2



8

Drug Name DrugTier

RequirementsLimits


NF



1





NF





NF



NF










Drug Name DrugTier

RequirementsLimits


1 QL(3 ea daily)


1 QL(2 ea daily)


1

QL(3 ea daily)


1

PA QL(0143ea daily)




NF

PA QL(0143ea daily)







NF

QL(3 ea daily)


NF

QL(2 ea daily)


Anabolic Steroids

ANADROL-50 TABS 3

oxandrolone tabs 1

Androgens


9

Drug Name DrugTier

RequirementsLimits



NF

danazol caps 1


NF

METHITEST TABS 3



1














NF

Drug Name DrugTier

RequirementsLimits


NF

Vasodilating Agents



Anthelmintics




EMVERM CHEW 2










trimethoprim tabs 1




10

Drug Name DrugTier

RequirementsLimits


NF


NF






atovaquone susp 1



Carbapenems




meropenem solr 1






Drug Name DrugTier

RequirementsLimits



Glycopeptides











Leprostatics

dapsone tabs 1


NF


NF


NF




1



11

Drug Name DrugTier

RequirementsLimits


Monobactams







daily) Polymyxins





NF


NF








Drug Name DrugTier

RequirementsLimits





NF





NITRO-BID OINT 3


NF



1










12

Drug Name DrugTier

RequirementsLimits



meprobamate tabs 1




















Drug Name DrugTier

RequirementsLimits














dofetilide caps 1

MULTAQ TABS 3







FASENRA SOSY 4 PA


13

Drug Name DrugTier

RequirementsLimits

NUCALA SOAJ 4 PA

NUCALA SOLR 4 PA

NUCALA SOSY 4 PA














NF QL(1 ea daily)






Drug Name DrugTier

RequirementsLimits




Steroid Inhalants



daily)


FLOVENT HFA AERO 2



daily)



NF

ADVAIR HFA AERO 2


NF


NF


NF




14

Drug Name DrugTier

RequirementsLimits





1 QL(15 ml daily)








daily)

BREO ELLIPTA AEPB 2




1



1 PA QL(12 mldaily)


Drug Name DrugTier

RequirementsLimits








2







NF PA




daily) Xanthines


ELIXOPHYLLIN ELIX 1






15

Drug Name DrugTier

RequirementsLimits




BEVYXXA CAPS 3



daily)








NF



NF



NF



NF




Drug Name DrugTier

RequirementsLimits



daily) SP














4

PA SP


NF



1


16

Drug Name DrugTier

RequirementsLimits


1


NF QL(6 ml daily)


NF QL(2 ml daily)


NF QL(16 mldaily)









3 PA




daily)

clonazepam tabs 1

clonazepam tbdp 1


3


3



Drug Name DrugTier

RequirementsLimits




daily)










3 PA











17

Drug Name DrugTier

RequirementsLimits







EPIDIOLEX SOLN 3 PA





NF QL(30 ml daily)




NF QL(4 ea daily)



NF QL(20 ea daily)


NF QL(100 eadaily)


NF QL(1 ea daily)



NF

Drug Name DrugTier

RequirementsLimits





1








NF

PA QL(3 eadaily)





NF



NF





18

Drug Name DrugTier

RequirementsLimits


1 PA QL(3 eadaily)


daily)


primidone tabs 1








NF QL(4 ea daily)



NF QL(6 ea daily)


NF QL(8 ea daily)








NF QL(40 ml daily)

Drug Name DrugTier

RequirementsLimits


NF QL(3 ea daily)





3 PA QL(2 eadaily)



Carbamates















19

Drug Name DrugTier

RequirementsLimits


2





PEGANONE TABS 3


2

phenytoin chew 1



phenytoin susp 1

Succinimides






NF QL(30 ml daily)






Drug Name DrugTier

RequirementsLimits






















20

Drug Name DrugTier

RequirementsLimits



NF QL(15 eadaily)


NF QL(2 ea daily)


NF QL(1 ea daily)









daily)









NF QL(1 ea daily)


Drug Name DrugTier

RequirementsLimits














NF QL(1 ea daily)











21

Drug Name DrugTier

RequirementsLimits
















NF QL(1 ea daily)

FETZIMA CP24 3 PA




NF QL(4 ea daily)


NF QL(1 ea daily)


Drug Name DrugTier

RequirementsLimits



1 QL(3 ea daily)




Tricyclic Agents


amoxapine tabs 3




doxepin hcl caps 1

doxepin hcl conc 1












22

Drug Name DrugTier

RequirementsLimits



miglitol tabs 1






NF QL(2 ea daily)


NF QL(1 ea daily)


1 QL(2 ea daily)



1 QL(2 ea daily)


1 QL(4 ea daily)

GLYXAMBI TABS 2




2 QL(2 ea daily)




Drug Name DrugTier

RequirementsLimits






2 QL(2 ea daily)


TRIJARDY XR TB24 2


3 PA QL(1 eadaily)



daily)



daily)







daily)

diazoxide susp 1


daily)



23

Drug Name DrugTier

RequirementsLimits


3 QL(0035 eadaily)











ml daily)







APIDRA SOLN 3 PA




Drug Name DrugTier

RequirementsLimits


FIASP SOLN 2




LEVEMIR SOLN 2




NOVOLIN 7030 SUSP 2


NOVOLIN N SUSP 2


NOVOLIN R SOLN 2



2



NOVOLOG SOLN 2


TRESIBA SOLN 2




24

Drug Name DrugTier

RequirementsLimits























Drug Name DrugTier

RequirementsLimits




MOTOFEN TABS 3



CHEMET CAPS 3




deferiprone tabs 1






VISTOGARD PACK 4 PA



NARCAN LIQD 3





25

Drug Name DrugTier

RequirementsLimits







daily)
















NF



daily)

Drug Name DrugTier

RequirementsLimits







dronabinol caps 1




ea daily)






NF


VARUBI TBPK 3 PA




26

Drug Name DrugTier

RequirementsLimits



ERAXIS SOLR 3


MYCAMINE SOLR 3

Antifungals

ABELCET SUSP 3

AMBISOME SUSR 3



flucytosine caps 1




nystatin tabs 1





fluconazole susr 1

fluconazole tabs 1



Drug Name DrugTier

RequirementsLimits

ketoconazole tabs 1





daily)

TOLSURA CAPS 4 PA














1

QL(30 ml daily)



27

Drug Name DrugTier

RequirementsLimits


1 QL(1 ea daily)


1 QL(2 ea daily)








1





1









Drug Name DrugTier

RequirementsLimits




RXOTC

loratadine caps 1

loratadine chew 1

loratadine soln 1

loratadine syrp 1

loratadine tabs 1

loratadine tbdp 1


NF

















28

Drug Name DrugTier

RequirementsLimits












daily)






NF QL(6 gm daily)


NF QL(6 ea daily)





Drug Name DrugTier

RequirementsLimits






NF QL(252 gmdaily)














daily)






29

Drug Name DrugTier

RequirementsLimits

















1 QL(2 ea daily)



daily)




Drug Name DrugTier

RequirementsLimits




captopril tabs 1



lisinopril tabs 1






ramipril caps 1

trandolapril tabs 1









30

Drug Name DrugTier

RequirementsLimits

















daily)








Drug Name DrugTier

RequirementsLimits


NF QL(2 ea daily)






NF MO



NF MO


NF ST



NF MO




NF


EXFORGE HCT TABS 2


NF



31

Drug Name DrugTier

RequirementsLimits


NF

QL(2 ea daily)


NF

QL(1 ea daily)




NF


1

QL(2 ea daily)


1

QL(1 ea daily)


NF


NF



NF MO


1 ST






Drug Name DrugTier

RequirementsLimits


NF


NF




NF

ST




NF


NF







eplerenone tabs 1


Vasodilators



minoxidil tabs 1


32

Drug Name DrugTier

RequirementsLimits




COARTEM TABS 2





Drug Name DrugTier

RequirementsLimits









NF






FIRDAPSE TABS 4 PA





NF


3 PA


33

Drug Name DrugTier

RequirementsLimits






RIFAMATE CAPS 3





isoniazid soln 1

isoniazid syrp 1

isoniazid tabs 1




PRIFTIN TABS 3

pyrazinamide tabs 1

rifabutin caps 1 PA



rifampin caps 1

Drug Name DrugTier

RequirementsLimits

rifampin solr 1




















melphalan tabs 1



34

Drug Name DrugTier

RequirementsLimits



NF

PA SP








Antimetabolites














Drug Name DrugTier

RequirementsLimits




NF




















daily)


35

Drug Name DrugTier

RequirementsLimits

MVASI SOLN 4 PA


ZIRABEV SOLN 4 PA




TUKYSA TABS 4 PA





RUXIENCE SOLN 4 PA

YERVOY SOLN 4 PA SP







VIZIMPRO TABS 4 PA


DAURISMO TABS 4 PA




Drug Name DrugTier

RequirementsLimits



daily)




SP



daily) SP





EMCYT CAPS 4 PA SP













36

Drug Name DrugTier

RequirementsLimits



ea daily) SP






NUBEQA TABS 4 PA





YONSA TABS 4 PA










Drug Name DrugTier

RequirementsLimits







NF






NF PA SP



NF PA SP


NF PA








37

Drug Name DrugTier

RequirementsLimits





daily) SP




BALVERSA TABS 4 PA



daily) SP



BRUKINSA CAPS 4 PA





COPIKTRA CAPS 4 PA



daily) SP

IBRANCE CAPS 3 PA

IBRANCE TABS 3 PA

Drug Name DrugTier

RequirementsLimits


daily)




daily)



4 PA QL(1 eadaily)

INREBIC CAPS 4 PA




daily) SP

KISQALI TBPK 3 PA

KOSELUGO CAPS 4 PA

KYPROLIS SOLR 4 PA


LORBRENA TABS 4 PA










38

Drug Name DrugTier

RequirementsLimits



QINLOCK TABS 4 PA

RETEVMO CAPS 4 PA


ROZLYTREK CAPS 4 PA







TABRECTA TABS 4 PA


TALZENNA CAPS 4 PA


daily) SP


TAZVERIK TABS 4 PA


TIBSOVO TABS 4 PA


ml daily) SP



daily) SP


Drug Name DrugTier

RequirementsLimits

VERZENIO TABS 4 PA

VITRAKVI CAPS 4 PA

VITRAKVI SOLN 4 PA



XOSPATA TABS 4 PA














hydroxyurea caps 1



NIPENT SOLR 4 PA SP



39

Drug Name DrugTier

RequirementsLimits





UVADEX SOLN 4 PA SP




1



Mitotic Inhibitors













Drug Name DrugTier

RequirementsLimits



NF PA SP


4 PA SP






NF PA SP







carbidopa tabs 1









40

Drug Name DrugTier

RequirementsLimits




tolcapone tabs 3




APOKYN SOCT 4 PA









NF QL(4 ea daily)


NF

NEUPRO PT24 2




1 QL(4 ea daily)

Drug Name DrugTier

RequirementsLimits


1


NF ST QL(2 eadaily)


NF ST QL(1 eadaily)


1






1


NF


1


NF


1


NF


1


NF


41

Drug Name DrugTier

RequirementsLimits


1


NF


1


NF


daily)





Antimanic Agents




LITHIUM SOLN 1








daily)

Drug Name DrugTier

RequirementsLimits



Benzisoxazoles




NF QL(1 ea daily)








NF QL(2 ea daily)








NF QL(0036 mldaily)


42

Drug Name DrugTier

RequirementsLimits


NF QL(0036 mldaily)





haloperidol tabs 1

















Drug Name DrugTier

RequirementsLimits









3 PA QL(2 eadaily)


daily)





NF PA QL(1 eadaily)


NF PA QL(2 eadaily)



NF QL(1 ea daily)


NF QL(2 ea daily)


NF QL(2 ea daily)




43

Drug Name DrugTier

RequirementsLimits


1





perphenazine tabs 1











REXULTI TABS 3 PA

Thioxanthenes

thiothixene caps 1





Drug Name DrugTier

RequirementsLimits







3

QL(1 ea daily)

















1 QL(1 ea daily)


44

Drug Name DrugTier

RequirementsLimits


1 QL(1 ea daily)



1



0

QL(1 ea daily)









NF QL(1 ea daily)




FUZEON SOLR 4 PA SP






Drug Name DrugTier

RequirementsLimits






NF QL(125 mldaily)


2

QL(4 ea daily)







NF QL(4 ea daily)












45

Drug Name DrugTier

RequirementsLimits











NF QL(1 ea daily)



RUKOBIA TB12 4 PA











Drug Name DrugTier

RequirementsLimits


2

QL(1 ea daily)


2

QL(1 ea daily)







NF QL(2 ea daily)
















46

Drug Name DrugTier

RequirementsLimits


NF






CMV Agents

cidofovir soln 3









daily) SP






daily) SP



daily)

Drug Name DrugTier

RequirementsLimits






daily)



ZEPATIER TABS 4 PA

Herpes Agents















NF QL(5 ea daily)


47

Drug Name DrugTier

RequirementsLimits










NF



NF



Alpha-Beta Blockers

carvedilol tabs 1

Drug Name DrugTier

RequirementsLimits






atenolol tabs 1




2 PA QL(1 eadaily)







daily)









48

Drug Name DrugTier

RequirementsLimits


nadolol tabs 1

pindolol tabs 1


1




1











NF





Drug Name DrugTier

RequirementsLimits



1




felodipine tb24 1

isradipine caps 1



nifedipine caps 1

nifedipine tb24 1

nimodipine caps 1


1






NF





49

Drug Name DrugTier

RequirementsLimits



NF



NF



Cardiac Glycosides

digoxin soln 1

digoxin tabs 1



2





BIDIL TABS 2


NF QL(1 ea daily)

ENTRESTO TABS 3 PA

Impotence Agents



Drug Name DrugTier

RequirementsLimits









3 PA









daily) SP




daily)





50

Drug Name DrugTier

RequirementsLimits


NF



NF

PA QL(6 mldaily)






4 PA QL(6 mldaily)




daily) SP









cefadroxil caps 1

cefadroxil susr 1

cefadroxil tabs 1


Drug Name DrugTier

RequirementsLimits

cephalexin caps 1

cephalexin susr 1

cephalexin tabs 1



cefaclor caps 1

cefaclor susr 1




cefprozil susr 1

cefprozil tabs 1




cefdinir caps 1

cefdinir susr 1









51

Drug Name DrugTier

RequirementsLimits


1




NF PA


cefepime hcl solr 1



TEFLARO SOLR 3

CHEMICALS





NF






0


NF

Drug Name DrugTier

RequirementsLimits


FALESSA KIT 0


NF







NF


NF


NF

NATAZIA TABS 0











52

Drug Name DrugTier

RequirementsLimits




NF


NF


NF


NF


NF


NF


TYBLUME CHEW 0


NF


NF






NF

Drug Name DrugTier

RequirementsLimits


0


ELLA TABS 0



NF


KYLEENA IUD 0

LILETTA IUD 0

MIRENA IUD 0

SKYLA IUD 0


NEXPLANON IMPL 0


NF



NF









53

Drug Name DrugTier

RequirementsLimits


NF






NF


NF





NF




1



1

EMFLAZA SUSP 4 PA

EMFLAZA TABS 4 PA


Drug Name DrugTier

RequirementsLimits





NF

MEDROL TABS 2 MG 3





MILLIPRED DP TBPK 3

MILLIPRED TABS 3


NF


NF


1


3

prednisolone soln 1

prednisone soln 1

prednisone tabs 1

prednisone tbpk 1




54

Drug Name DrugTier

RequirementsLimits




NF




Antitussives






NF

QL(2 ea daily)


NF

QL(1 ea daily)



1 QL(2 ea daily)


1 QL(1 ea daily)

Drug Name DrugTier

RequirementsLimits


1 QL(2 ea daily)


1 QL(1 ea daily)


1


1 QL(2 ea daily)


1

QL(1 ea daily)



1

QL(2 ea daily)


HYPERSAL NEBU 35 1


NF

NEBUSAL NEBU 1


Mucolytics







55

Drug Name DrugTier

RequirementsLimits




12 yrs old)





NF





yrs old)
















yrs old)

Drug Name DrugTier

RequirementsLimits










12 yrs old)




12 yrs old)



NF
















56

Drug Name DrugTier

RequirementsLimits






yrs old)



















VEREGEN OINT 3






daily) RXOTC

Drug Name DrugTier

RequirementsLimits




mupirocin oint 1














ERTACZO CREA 3


EXELDERM SOLN 3


JUBLIA SOLN 3 PA


57

Drug Name DrugTier

RequirementsLimits










NF RXOTC



NF







Drug Name DrugTier

RequirementsLimits




NF















58

Drug Name DrugTier

RequirementsLimits



OXISTAT LOTN 2







NF






PANRETIN GEL 3

PICATO GEL 0015 2


Drug Name DrugTier

RequirementsLimits

PICATO GEL 005 2













59

Drug Name DrugTier

RequirementsLimits









daily)



NF QL(4 ea daily)









ml daily) SP


TAZORAC CREA 005 2



Drug Name DrugTier

RequirementsLimits











Burn Products








amcinonide crea 1


amcinonide lotn 3


60

Drug Name DrugTier

RequirementsLimits

AMCINONIDE OINT 3





1


1


1






1 ST


1 ST



daily)







Drug Name DrugTier

RequirementsLimits






NF



NF











NF


NF






61

Drug Name DrugTier

RequirementsLimits


















HALOG OINT 3 PA






Drug Name DrugTier

RequirementsLimits









daily)





NF

RXOTC




PSORCON CREA 2 PA





NF

ST


62

Drug Name DrugTier

RequirementsLimits


3

ST







1



1


1







NF RXOTC


NF RXOTC

Drug Name DrugTier

RequirementsLimits











2 yrs old)



2 yrs old)



podofilox soln 1









63

Drug Name DrugTier

RequirementsLimits

SYNERA PTCH 3




Rosacea Agents




NF



NF










EURAX CREA 3



Drug Name DrugTier

RequirementsLimits


lindane sham 3

malathion lotn 1




permethrin crea 1

permethrin liqd 1


spinosad susp 1 PA

ULESFIA LOTN 3

Wound Care Products

REGRANEX GEL 3

DIAGNOSTIC PRODUCTS



CHEMSTRIP-K STRP 1


1


KETONE STRP 1


KETOSTIX STRP 1


1


64

Drug Name DrugTier

RequirementsLimits







1





Digestive Enzymes

CREON CPEP 2

SUCRAID SOLN 3

ZENPEP CPEP 2









NF

Drug Name DrugTier

RequirementsLimits



NF


NF


NF









furosemide soln 1

furosemide tabs 1


torsemide tabs 1







65

Drug Name DrugTier

RequirementsLimits















NF PA SP









Drug Name DrugTier

RequirementsLimits


4 PA SP


PROLIA SOSY 4







TYMLOS SOPN 4 PA

XGEVA SOLN 4 PA SP




Corticotropin

ACTHAR GEL 4 PA




4 PA SP


CETROTIDE KIT 4 PA



66

Drug Name DrugTier

RequirementsLimits


NF PA









4 PA SP




SAIZEN SOLR 4 PA SP


4 PA SP





OSPHENA TABS 3 PA

Drug Name DrugTier

RequirementsLimits









Metabolic Modifiers




calcitriol caps 1

calcitriol soln 1










NF


67

Drug Name DrugTier

RequirementsLimits


NF PA


NF PA


MYALEPT SOLR 4 PA




PALYNZIQ SOSY 4 PA

paricalcitol caps 1

paricalcitol soln 1











NF PA


NF

Drug Name DrugTier

RequirementsLimits


NF QL(6 ea daily)


NF QL(8 ea daily)



4 PA SP







cabergoline tabs 1

Somatostatic Agents



SIGNIFOR SOLN 4 PA




ml daily) SP


daily) SP



daily) SP



68

Drug Name DrugTier

RequirementsLimits



CLIMARA PRO PTWK 3

DUAVEE TABS 3 PA


NF


PREMPHASE TABS 2

PREMPRO TABS 2




NF



3

ELESTRIN GEL 3



1

QL(0286 eadaily)


1



Drug Name DrugTier

RequirementsLimits

ESTROGEL GEL 3

EVAMIST SOLN 3

MENEST TABS 3

MENOSTAR PTWK 3


daily)

PREMARIN SOLR 2

PREMARIN TABS 2




1

BAXDELA SOLR 3 PA

BAXDELA TABS 3 PA






3




1

levofloxacin soln 1

levofloxacin tabs 1


69

Drug Name DrugTier

RequirementsLimits



ofloxacin tabs 1










daily)








AVSOLA SOLR 4 PA


Drug Name DrugTier

RequirementsLimits






DIPENTUM CAPS 2


















70

Drug Name DrugTier

RequirementsLimits



alvimopan caps 1






NF


PHOSLYRA SOLN 2







VELPHORO CHEW 3 PA



1


Drug Name DrugTier

RequirementsLimits


NF

Cystinosis Agents

CYSTAGON CAPS 3 PA


acetic acid soln 1


RESECTISOL SOLN 1


SORBITOL SOLN 1




ELMIRON CAPS 2












Urinary Analgesics


71

Drug Name DrugTier

RequirementsLimits





Gout Agents

allopurinol tabs 1




KRYSTEXXA SOLN 4 PA




Uricosurics

probenecid tabs 1



daily)



CINRYZE SOLR 4 PA

HAEGARDA SOLR 4 PA


SOLIRIS SOLN 4 PA

Drug Name DrugTier

RequirementsLimits




TAKHZYRO SOLN 4 PA





BRILINTA TABS 2

CABLIVI KIT 4 PA

cilostazol tabs 1



dipyridamole tabs 1




ZONTIVITY TABS 3 PA








72

Drug Name DrugTier

RequirementsLimits

VPRIV SOLR 4 PA SP


daily) SP


DROXIA CAPS 3

OXBRYTA TABS 4 PA


Folic AcidFolates




4 PA SP



4

PA SP

DOPTELET TABS 4 PA

EPOGEN SOLN 3 PA SP

FULPHILA SOSY 4 PA


MIRCERA SOSY 4 PA

MULPLETA TABS 4 PA




Drug Name DrugTier

RequirementsLimits



4 PA



3

PA SP





4

PA

UDENYCA SOSY 4 PA


ZIEXTENZO SOSY 4 PA










73

Drug Name DrugTier

RequirementsLimits


NF PA










1










estazolam tabs 1

eszopiclone tabs 1


Drug Name DrugTier

RequirementsLimits







triazolam tabs 1








BELSOMRA TABS 3 PA



ramelteon tabs 1





Bulk Laxatives



74

Drug Name DrugTier

RequirementsLimits



CLENPIQ SOLN 3 PA


NF


0


2

PA


1 PA


0

PREPOPIK PACK 3 PA



Saline Laxatives

OSMOPREP TABS 3 PA

Stimulant Laxatives

bisacodyl tbec 1





Drug Name DrugTier

RequirementsLimits





NF


NF


NF


Azithromycin












NF




75

Drug Name DrugTier

RequirementsLimits




daily)





Clarithromycin





NF


NF


3





1


Fidaxomicin



Contraceptives

Drug Name DrugTier

RequirementsLimits


CAYA DPRH 0




0 QL(2 ea daily)


FEMCAP DEVI 0







0 QL(2 ea daily)


0 QL(2 ea daily)


0 QL(2 ea daily)



0 QL(2 ea daily)



0 QL(2 ea daily)



76

Drug Name DrugTier

RequirementsLimits






0 QL(2 ea daily)








0 QL(2 ea daily)


0 QL(2 ea daily)


0

QL(2 ea daily)


0 QL(2 ea daily)


0

QL(2 ea daily)


0

QL(2 ea daily)


Drug Name DrugTier

RequirementsLimits


0 QL(2 ea daily)


0 QL(2 ea daily)


0


0


0


0


0


0


0


0


1 QL(66667 eadaily)


1 QL(66667 eadaily)






daily)


77

Drug Name DrugTier

RequirementsLimits



1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)














1


1 QL(66667 eadaily)


1 QL(66667 eadaily)

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)




daily)


AUTO-LANCET MISC 1



AUTOLET MINI MISC 1

AUTOLET PLUS MISC 1





daily)


78

Drug Name DrugTier

RequirementsLimits








1










1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)




daily)

Drug Name DrugTier

RequirementsLimits















1



1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)


79

Drug Name DrugTier

RequirementsLimits


daily)








1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)



1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


daily)

Drug Name DrugTier

RequirementsLimits





1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1









daily)


80

Drug Name DrugTier

RequirementsLimits




daily)



daily)





1


1 QL(66667 eadaily)


1 QL(66667 eadaily)





1


1


1


1


1

Drug Name DrugTier

RequirementsLimits


1


1


1



1 QL(66667 eadaily)


1

QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)





daily)








1


81

Drug Name DrugTier

RequirementsLimits



1 QL(66667 eadaily)



1 QL(66667 eadaily)


1 QL(66667 eadaily)



1 QL(66667 eadaily)



1


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)







daily)

Drug Name DrugTier

RequirementsLimits



1


1 QL(66667 eadaily)





daily)





1 QL(66667 eadaily)



daily)










82

Drug Name DrugTier

RequirementsLimits


daily)







daily)







daily)








LANZO MISC 1



daily)

Drug Name DrugTier

RequirementsLimits



1 QL(66667 eadaily)












1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)





daily)


83

Drug Name DrugTier

RequirementsLimits





1 QL(66667 eadaily)



1

QL(66667 eadaily)


1 QL(66667 eadaily)


daily)





1 QL(66667 eadaily)








daily)


Drug Name DrugTier

RequirementsLimits













1 QL(66667 eadaily)








1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)


84

Drug Name DrugTier

RequirementsLimits



1 QL(66667 eadaily)


1 QL(66667 eadaily)


1


1






1 QL(66667 eadaily)


daily)





1 QL(66667 eadaily)


1 QL(66667 eadaily)



1 QL(66667 eadaily)


Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)





















1 QL(66667 eadaily)


85

Drug Name DrugTier

RequirementsLimits


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)













1 QL(66667 eadaily)


1 QL(66667 eadaily)




daily)

Drug Name DrugTier

RequirementsLimits




1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




daily)






1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


daily)


86

Drug Name DrugTier

RequirementsLimits






1


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


daily)








daily)

Drug Name DrugTier

RequirementsLimits






daily)

SURE-PEN MISC 1












1






daily)


87

Drug Name DrugTier

RequirementsLimits


1













daily)



1 QL(66667 eadaily)







daily)


Drug Name DrugTier

RequirementsLimits





daily)






daily)














1 QL(66667 eadaily)


88

Drug Name DrugTier

RequirementsLimits









1 QL(66667 eadaily)


1 QL(66667 eadaily)




1 QL(66667 eadaily)


1 QL(66667 eadaily)


1 QL(66667 eadaily)






Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


89

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)









1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)




1 QL(5 ea daily)







1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1

QL(5 ea daily)


90

Drug Name DrugTier

RequirementsLimits










1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)



1 QL(5 ea daily)








1

QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


91

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


92

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)








1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


93

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)








1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)








1 QL(5 ea daily)


94

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)








1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


95

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1 QL(5 ea daily)


96

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)






1 QL(5 ea daily)








1 QL(5 ea daily)








1 QL(5 ea daily)










97

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)






1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)






98

Drug Name DrugTier

RequirementsLimits






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)







1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits








1 QL(5 ea daily)


1 QL(5 ea daily)










1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)




99

Drug Name DrugTier

RequirementsLimits










1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)






1 QL(5 ea daily)





Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)








1 QL(5 ea daily)






1 QL(5 ea daily)




1 QL(5 ea daily)




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


100

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)








1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC



Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC






1 QL(5 ea daily)










1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)



1 QL(5 ea daily)


101

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits








1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)


102

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC






1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)


103

Drug Name DrugTier

RequirementsLimits










1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC






1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits




















1 QL(5 ea daily)









1 QL(5 ea daily)




104

Drug Name DrugTier

RequirementsLimits




1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






105

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)



Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1 QL(5 ea daily)


106

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)








1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)








1 QL(5 ea daily)






107

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)






1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)

Drug Name DrugTier

RequirementsLimits


1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)


108

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)






1 QL(5 ea daily)


1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)




1 QL(5 ea daily)


109

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)






1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC

Drug Name DrugTier

RequirementsLimits


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)




1 QL(5 ea daily)






1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1

QL(5 ea daily)


1

QL(5 ea daily)RXOTC


1

QL(5 ea daily)


1 QL(5 ea daily)


110

Drug Name DrugTier

RequirementsLimits




1 QL(5 ea daily)


1

QL(5 ea daily)RXOTC




1 QL(5 ea daily)










1 QL(5 ea daily)




1 QL(5 ea daily)







daily)

Drug Name DrugTier

RequirementsLimits








NF



NF




daily)



NF QL(0267 mldaily)

Serotonin Agonists








111

Drug Name DrugTier

RequirementsLimits








NF



NF



NF



NF



NF










Drug Name DrugTier

RequirementsLimits









sumatriptan soln 1



















112

Drug Name DrugTier

RequirementsLimits









1






NF



NF


1


Drug Name DrugTier

RequirementsLimits

ISOLYTE-S SOLN 1



1


NORMOSOL-MD5WSOLN 1

NORMOSOL-R SOLN 1





1



1


1


1


113

Drug Name DrugTier

RequirementsLimits

ringers soln 1










1



1


1


1


NF



Drug Name DrugTier

RequirementsLimits



1







daily) SP







ATGAM INJ 4 PA SP




NF


NF

cyclosporine caps 1



114

Drug Name DrugTier

RequirementsLimits


cyclosporine soln 1









NF


NF



NF




NF


NF


NF

SIMULECT SOLR 3


tacrolimus caps 1

Drug Name DrugTier

RequirementsLimits



NF














DEBACTEROL SOLN 2


NF

Dental Products




115

Drug Name DrugTier

RequirementsLimits






MULTIVITAMINS











2

QL(1 ea daily)RXOTC





Drug Name DrugTier

RequirementsLimits









116

Drug Name DrugTier

RequirementsLimits


2

QL(1 ea daily)RXOTC












2 QL(1 ea daily)





RXOTC



RXOTC



Drug Name DrugTier

RequirementsLimits



carisoprodol tabs 1
















Nasal Antiallergy





117

Drug Name DrugTier

RequirementsLimits



Nasal Steroids



NF



NF







NF


NF






riluzole tabs 3

Drug Name DrugTier

RequirementsLimits


BOTOX SOLR 3 PA

DYSPORT SOLR 3 PA

XEOMIN SOLR 3 PA

NUTRIENTS


3


3


3



3



LACRISERT INST 3




COMBIGAN SOLN 2


NF


1



118

Drug Name DrugTier

RequirementsLimits






tropicamide soln 1





NF



IOPIDINE SOLN 3

SIMBRINZA SUSP 3 PA


AZASITE SOLN 3



NF




Drug Name DrugTier

RequirementsLimits




KLARITY-A SOLN 3



NATACYN SUSP 2









trifluridine soln 1


ZIRGAN GEL 2



RESTASIS EMUL 2 PA




119

Drug Name DrugTier

RequirementsLimits



OXERVATE SOLN 4 PA

Ophthalmic Steroids

ALREX SUSP 3 PA





FML FORTE SUSP 3 PA


NF

FML OINT 3 PA


LOTEMAX OINT 3 PA




MAXIDEX SUSP 3 PA


NF


NF




Drug Name DrugTier

RequirementsLimits


NF

PRED MILD SUSP 3 PA




3


NF



NF


NF

ALOCRIL SOLN 3 PA

ALOMIDE SOLN 3 PA











120

Drug Name DrugTier

RequirementsLimits


ILEVRO SUSP 3 PA



LASTACAFT SOLN 3 PA

NEVANAC SUSP 3 PA






ZERVIATE SOLN 3 PA


bimatoprost soln 3

latanoprost soln 1

LUMIGAN SOLN 3 ST


travoprost soln 1


ZIOPTAN SOLN 2





Drug Name DrugTier

RequirementsLimits



Otic Combinations

CIPRO HC SUSP 3


NF PA



daily)

COLY-MYCIN S SUSP 3





3 PA QL(05 eadaily)


NF





4 PA SP


4

PA SP



121

Drug Name DrugTier

RequirementsLimits


4 PA SP




4 PA SP


HYQVIA KIT 4 PA


Aminopenicillins

amoxicillin caps 1

amoxicillin chew 1

amoxicillin susr 1

amoxicillin tabs 1

ampicillin caps 1




1







Drug Name DrugTier

RequirementsLimits






1


1


NF


NF


NF



NF


NF


NF






122

Drug Name DrugTier

RequirementsLimits







NF PA






NF





disulfiram tabs 1





NF QL(2 ea daily)

Drug Name DrugTier

RequirementsLimits


NF QL(1 ea daily)














NF





Fibromyalgia Agents





123

Drug Name DrugTier

RequirementsLimits




daily) SP


daily) SP

AUBAGIO TABS 4 PA












GILENYA CAPS 4 PA



ml daily) SP

MAVENCLAD TBPK 4 PA


MAYZENT TABS 4 PA

OCREVUS SOLN 4 PA


Drug Name DrugTier

RequirementsLimits





ml daily)







NF PA



3 PA QL(1 eadaily)


3 PA QL(2 eadaily)




NUEDEXTA CAPS 3 PA


pimozide tabs 1




124

Drug Name DrugTier

RequirementsLimits

Smoking Deterrents











NF





0


NICOTROL NS SOLN 0



TEGSEDI SOSY 4 PA



Drug Name DrugTier

RequirementsLimits









daily)






Sulfonamides

SULFADIAZINE TABS 1


Glycylcyclines

tigecycline solr 1


Tetracyclines






125

Drug Name DrugTier

RequirementsLimits











NF QL(2 ea daily)


NF


Antithyroid Agents

methimazole tabs 1




2

QL(1 ea daily)



Drug Name DrugTier

RequirementsLimits


1








WESTHROID TABS 2

WP THYROID TABS 2

TOXOIDS

Toxoid Combinations

ADACEL SUSP 0

BOOSTRIX SUSP 0

DAPTACEL SUSP 0


0

INFANRIX SUSP 0

KINRIX SUSP 0

PEDIARIX SUSP 0

PENTACEL SUSR 0

QUADRACEL SUSP 0

TDVAX SUSP 0


126

Drug Name DrugTier

RequirementsLimits

TENIVAC INJ 0


0




1








NF







1



Drug Name DrugTier

RequirementsLimits





NF RXOTC







1 QL(20 ml daily)





NF RXOTC








127

Drug Name DrugTier

RequirementsLimits










NF QL(1 ea daily)












1 QL(4 ea daily)


NF QL(1 ea daily)


NF

Drug Name DrugTier

RequirementsLimits







NF

RXOTC

















128

Drug Name DrugTier

RequirementsLimits






NF QL(4 ea daily)


NF



VACCINES

Bacterial Vaccines

ACTHIB SOLR 0

BEXSERO SUSY 0

HIBERIX SOLR 0

MENQUADFI SOLN 0

MENVEO SOLR 0

PEDVAX HIB SUSP 0

PNEUMOVAX 23 INJ 0


PREVNAR 13 SUSP 0

TRUMENBA SUSY 0

Viral Vaccines

Drug Name DrugTier

RequirementsLimits













ENGERIX-B INJ 0


ENGERIX-B SUSP 0









129

Drug Name DrugTier

RequirementsLimits










0



0



0



0



0



0



0



0


Drug Name DrugTier

RequirementsLimits


0



0



0



0



0











0



0



0



130

Drug Name DrugTier

RequirementsLimits


0



0



0




HAVRIX SUSP 0


HEPLISAV-B SOSY 0




ROTARIX SUSR 0

ROTATEQ SOLN 0

SHINGRIX SUSR 0


TWINRIX SUSY 0

Drug Name DrugTier

RequirementsLimits

VAQTA SUSP 0



ZOSTAVAX SUSR 0




INTRAROSA INST 3 PA

Spermicides

SHUR-SEAL GEL 0

TODAY SPONGE MISC 0


NF



GYNAZOLE-1 CREA 3








131

Drug Name DrugTier

RequirementsLimits

PHEXXI GEL 0 PV




FEMRING RING 3

PREMARIN CREA 2




NF








Drug Name DrugTier

RequirementsLimits


2


Vasopressors


VITAMINS










NIACIN TR TBCR 1




132





Index 1




31

31 22

122

122

1 27

122

122


44 16

2 126

14 36 35 39

4 4

36 70


119 13

120 57


122 124

9 22




72 36 27 10 10 53



25 74 74 27 50 60 61

111


15 123

10 26 24 24

125 41



74 3

65 65


119 26 70 17 44


78

78


74 15 13 70 22



78 30 31 44 66


Index 2














Index 3








Index 4











Index 5



64 4 4

11


28 28 28 55




55 116

79

27 27 75



121




121 34 21 28 76



35 35 22 17 31

Index 6


2 72 13

115 57

131

57 43 43 79 33




6 6

40 75 70


44 41

2 2 6


73 117

34 34 24




114

114 74 22 28 67 71

120 35

126 128



37 118

16 31 65 27 29 44


111 39 35 37

124 14 10




117 11



64 11 11

114


126 11 11 33


Index 7




Index 8




Index 9





80

80

80

80



Index 10



128 30

31 5 5 5

129 16 41 47 71





132 124 111 111

36 36 57 11 39 39 76 76 56

119 76

76 21

6

128 74 69 69

132 69 69 52 74


Index 11






76 72 19 19

4 49 36 76 69

132 29 29


81 81

6 8 6 8

72 33 36 11 10

129



67 6

FLECTOR FLOLAN

57 50


120 35


6 6



59 21


55



21 44 62 74

4 121

36

Index 12





120 120

2 2

73 35


65 45 17 18 19 67


81

81

81



123 121


81 45




Index 13











25 25 25 23 71

127 25





Index 14




Index 15













Index 16













Index 17










Index 18


30

32 83

83



17 43 70

123 58




Index 19


33 64 20


83

83


34 123


26 20


83

84

MENQUADFI MENVEO

129 129


39 124

47 112



67 13 11 35






Index 20







Index 21





58

58 58 68

9 5

25 25

123

123 5 5 5

112 25




Index 22

53



7 124 115

67 53

3 27

115 58 58

116



113 113

13


124 68

119




45 36

125 70

119 121


85

85 17

7 50 64





54 50 68

125 117

54 53 53 53 48 23 75 67

5 121


24 24

24 24



123 35

9 5



73 37 14



13 73 18

Index 23










Index 24







Index 25












Index 26


86

86

RETACRIT RETEVMO

73 39

ROTATEQ ROXICODONE

131 7





71 25 23


42 3 3




46 36

123 112 117

68 39 41 30


Index 27


86 86 86 86









60 119

87 115

30 41 41 87 14

115 34 12



104

105 23

86 42 60



64 71 71

71 60 49 49 64


46 68 15 43 43 67



14 14 65

65 27

Index 28
















Index 29


23 23




46 62 67 64 23



32 48 35 31 27

SYNJARDY XR SYNRIBO

23 40



15 131


126 114

35 39

6263 115

63



55 10

10 10 10


50

51 39

127 72 39 48 37 71

126 36

126




4059 32 39



44 35 44


59 40 53


125 32 31


126 19 49

tazarotene TAZORAC

60 60


32

TIBSOVO TIGAN

39 26

TAZVERIK TDVAX

39 126

temazepam TEMIXYS

74 46

tigecycline TIKOSYN

125 13



63 35 39 40


119 119 119

46

Index 30





Index 31





12 107

Index 32



109


109


109


109


109


109


109





Index 33









70 15 40

132 47 47 47


131 26 29 32 30 32 36



Index 34




Index 35



Index 36




Ambetter from MHS














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Classes



AMEBICIDES




































CHEMICALS





DIAGNOSTIC PRODUCTS





















MULTIVITAMINS




NUTRIENTS











TOXOIDS



VACCINES



VITAMINS

2021 Prescription Drug List - MHS Indiana

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Transcript of 2021 Prescription Drug List - MHS Indiana