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H4152_2018formularyNM

2018 Formulary ( List of Covered Drugs)

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

00018136 Version

This formulary was updated on . For more recent information or other ques-tions, please contact the Medicare Concierge Team, at (401) 277-2958 or 1-800-267-0439 (TTY us-ers should call 711), seven days a week from October 1 to February 14, 8:00 a.m. to 8:00 p.m. From February 15 to September 30, you can call Monday through Friday, from 8:00 a.m. to 8:00 p.m. On Saturday and Sunday, call from 8:00 a.m. to noon. You can use our automated answering system outside of these hours, or visit bcbsri.com/Medicare.

This information is available for free in other languages. Please call the Medicare Concierge Team at (401) 277-2958 or 1-800-267-0439 (TTY users should call 711), seven days a week from October 1 to February 14, 8:00 a.m. to 8:00 p.m. From February 15 to September 30, you can call Monday through Friday, from 8:00 a.m. to 8:00 p.m. On Saturday and Sunday, call from 8:00 a.m. to noon. You can use our automated answering system outside of these hours, or visit bcbsri.com/Medicare.

This information is also available in large print English and large print Spanish.

Esta información está disponible gratis en otros idiomas. Si desea obtener información adicional, llame a Equipo de Consejería de Medicare al (401) 277-2958 o 1-800-267-0439 (los usuarios de TTY deben llamar al 711), los siete días de la semana del 1 de octubre al 14 de febrero, de 8:00 a. m. a 8:00 p. m. Del 15 de febrero al 30 de septiembre, puede llamar de lunes a viernes de 8:00 a. m. a 8:00 p. m., y los sábados y domingos, de 8:00 a. m. hasta el mediodía. Fuera de estos horarios, puede utilizar el sistema automatizado de respuesta, o visite bcbsri.com/Medicare. El Servicio al cliente también tiene servicios de intérprete de idiomas gratis disponibles para las personas que no hablan inglés.

BlueCHiP for Medicare Advance (HMO)BlueCHiP for Medicare Standard with Drugs (HMO)BlueCHiP for Medicare Extra (HMO-POS)BlueCHiP for Medicare Plus (HMO)BlueCHiP for Medicare Preferred (HMO-POS)

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April 1, 2018

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

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Blue Cross & Blue Shield of Rhode Island. When it refers to “plan” or “our plan,” it means BlueCHiP for Medicare.

This document includes a list of the drugs (formulary) for our plan which is current as of . For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copay/coinsurance may change on January 1, 2018, and from time to time during the year.

April 1, 2018

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What is the BlueCHiP for Medicare Formulary?A formulary is a list of covered drugs selected by BlueCHiP for Medicare in consultation with a team of healthcare providers, which repre-sents the prescription therapies believed to be a necessary part of a quality treatment program. BlueCHiP for Medicare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a BlueCHiP for Medicare network pharmacy, and other plan rules are followed. For more informa-tion on how to fill your prescriptions, please review your Evidence of Coverage.

Can the formulary (drug list) change?Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce cover-age of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse informa-tion about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not af-fect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, add prior authorization, quantity limits, and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected mem-bers of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of

To get updated information about the drugs covered by BlueCHiP for Medicare, please contact us. Our contact information appears on the front and back cover pages.

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

Medical conditionThe formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, ”Cardiovascular Agents.” If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.

Alphabetical listingIf you are not sure what category to look under, you should look for your drug in the index that begins on page . The index provides an alpha-betical list of all of the drugs included in this docu-ment. Both brand name drugs and generic drugs are listed in the index. Look in the index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the index and find the name of your drug in the first column of the list.

What are generic drugs? BlueCHiP for Medicare covers both brand name drugs and generic drugs. A generic drug is ap-proved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

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April 1, 2018

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Are there any restrictions on my coverage?Some covered drugs may have additional require-ments or limits on coverage. These requirements and limits may include:

• Prior authorization: BlueCHiP for Medicare requires you or your physician to get prior au-thorization for certain drugs. This means that you will need to get approval from BlueCHiP for Medicare before you fill your prescriptions. If you don’t get approval, BlueCHiP for Medicare may not cover the drug.

• Quantity limits: For certain drugs, BlueCHiP for Medicare limits the amount of the drug that we will cover. For example, BlueCHiP for Medicare provides 30 tablets per prescription for alfuzosin hcl. This may be in addition to a standard one-month or three-month supply.

• Step therapy: In some cases, BlueCHiP for Medicare requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, BlueCHiP for Medicare may not cover Drug B unless you try Drug A first. If Drug A does not work for you, BlueCHiP for Medicare will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more infor-mation about the restrictions applied to specific covered drugs by visiting our web site. We have posted our prior authorization and step therapy restrictions online. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask BlueCHiP for Medicare to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, “How do I request an exception to the BlueCHiP for Medicare Formu-lary?” on this page for information about how to request an exception.

What if my drug is not on the formulary?If your drug is not included in this formulary (list of covered drugs), you should first contact the Medicare Concierge Team and ask if your drug is covered.

If you learn that BlueCHiP for Medicare does not cover your drug, you have two options:

• You can ask the Medicare Concierge Team for a list of similar drugs that are covered by BlueCHiP for Medicare. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by BlueCHiP for Medicare.

• You can ask BlueCHiP for Medicare to make an exception and cover your drug. See below for information about how to request an exception.

How do I request an exception to the BlueCHiP for Medicare Formulary?You can ask BlueCHiP for Medicare to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.

• You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved, this would lower the amount you must pay for your drug.

• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, BlueCHiP for Medicare limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, BlueCHiP for Medicare will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restric-tions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

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You should contact us to ask us for an initial cover-age decision for a formulary or utilization restric-tion exception. When you request a formulary or utilization restriction exception you should sub-mit a statement from your prescriber or physi-cian supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can re-quest an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing member in our plan, you may be taking drugs that are not on our formu-lary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to deter-mine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a maximum 98-day transi-tion supply, consistent with dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our for-mulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership

in our plan, we will cover a 31-day emergency sup-ply of that drug (unless you have a prescription for fewer days) while you pursue a formulary excep-tion.

You may have changes that take you from one treatment setting to another. During this level of care change, drugs may be prescribed that are not covered by your plan. If this happens, you and your doctor must use your plan’s exception and appeals processes. However, when you are admit-ted to, or discharged from, an LTC setting, you may not have access to the drugs you were previ-ously given. You may get a refill upon admission or discharge to prevent a gap in care.

For more informationFor more detailed information about your BlueCHiP for Medicare prescription drug cover-age, please review your Evidence of Coverage and other plan materials.

If you have questions about BlueCHiP for Medi-care, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day/7 days a week. TTY users should call 1-877-486-2048. Or visit medicare.gov.

BlueCHiP for Medicare’s FormularyThe formulary that begins on page 1 provides coverage information about the drugs covered by BlueCHiP for Medicare. If you have trouble finding your drug in the list, turn to the index that begins on page .

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

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

All drugs included in this formulary are available via mail order benefit. Contact your plan for de-tails.

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BlueCHiP for Medicare 5-Tier Formulary1 = Preferred generic drugs

2 = Generic drugs

3 = Preferred brand drugs

4 = Non-preferred brand drugs

5 = Specialty drugs

BD = Drugs that may be covered under Medicare Part B or Part D depending on the circumstance. These drugs require prior authorization to determine coverage under Part B or Part D. Information may need to be provided that describes the use or the place where the drug is received to determine cover-age.

PA = Prior authorization, refer to page II for more information.

QL = Quantity limits, refer to page II for more information.

ST = Step therapy, refer to page II for more information.

* = Limited distribution drug. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or contact the Medicare Concierge Team (contact infor-mation is located on the front or back cover).

# = High-risk medication (HRM). Medicine that may be unsafe in patients greater than 65 years of age. Our formulary does include coverage for some of these drugs, but alternatives may be found in lower copay tiers. Please discuss with your doctor if there are alternatives to these medications that would be appropriate for you to use.

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2018 Dosage Form Abbreviations Key

act actuation mcg microgram

ad adsorbed meq milliequivalent

aer, aero aerosol mg milligram

ba, breath act, breath activ breath activated ml milliliter

bau bioequivalent allergy units mu million units

cap capsules nebu nebules

chew tab chewable tablets NF non-formulary

conc concentrate odt orally disintegrating tablets

conj conjugate oin, oint ointment

cr controlled-release op, ophth ophthalmic

crys crystals pak pack

dr delayed-release pow, powd powder

deter deterrent pf preservative-free

ec enteric coated pfu plaque forming units

el, elu enzyme-linked immunosorbent assay pref prefilled

er, extend-release, extended, extended rel, xl, xr extended-release recomb recombinant

ext extract sl sublingual

g, gm gram sol, soln solution

gu genitourinary suppos suppositories

hr hour sus, susp suspension

ig immune globulinsr sustained-release

ir index of reactivity

inh, inhal inhalation syr syringe

inj injection tab, tabs tablets

im intramuscular td transdermal

iv intravenous tl translingual

l liter unt unit

lf flocculation units va vaginal

liqd liquidvac vaccine

la long acting

2018

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.

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Drug Name Drug Tier Requirements/LimitsAnalgesicsABSTRAL - fentanyl citrate sl tab 100 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 200 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 300 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 400 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 600 mcg 5 PA, QL (120 tablets/30 days)ABSTRAL - fentanyl citrate sl tab 800 mcg 5 PA, QL (120 tablets/30 days)acetaminophen w/ codeine soln 120-12 mg/5ml 3 QL (2700 mls/30 days)acetaminophen w/ codeine tab 300-15 mg 3 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-30 mg 3 QL (360 tablets/30 days)acetaminophen w/ codeine tab 300-60 mg 3 QL (180 tablets/30 days)butalbital-acetaminophen tab 50-325 mg# 4 PA, QL (180 tablets/30 days)butalbital-acetaminophen-caffeine cap 50-300-40 mg# 4 PA, QL (180 capsules/30 days)butalbital-acetaminophen-caffeine cap 50-325-40 mg# 4 PA, QL (180 capsules/30 days)butalbital-acetaminophen-caffeine tab 50-325-40 mg# 4 PA, QL (180 tablets/30 days)butalbital-aspirin-caffeine cap 50-325-40 mg# 4 PA, QL (180 capsules/30 days)BUTORPHANOL TARTRATE - butorphanol tartrate inj 1 mg/ml 3butorphanol tartrate inj 2 mg/ml 4butorphanol tartrate nasal soln 10 mg/ml 3 QL (87.5 mls/30 days)celecoxib cap 50 mg 2 QL (60 capsules/30 days)celecoxib cap 100 mg 2 QL (60 capsules/30 days)celecoxib cap 200 mg 2 QL (60 capsules/30 days)celecoxib cap 400 mg 2 QL (30 capsules/30 days)codeine sulfate tab 15 mg 3 QL (180 tablets/30 days)codeine sulfate tab 30 mg 3 QL (180 tablets/30 days)codeine sulfate tab 60 mg 3 QL (180 tablets/30 days)diclofenac potassium tab 50 mg 2 QL (120 tablets/30 days)diclofenac sodium gel 1% 2 STdiclofenac sodium tab delayed release 25 mg 2 QL (240 tablets/30 days)diclofenac sodium tab delayed release 50 mg 2 QL (120 tablets/30 days)diclofenac sodium tab delayed release 75 mg 2 QL (60 tablets/30 days)diclofenac sodium tab er 24hr 100 mg 2 QL (60 tablets/30 days)diclofenac w/ misoprostol tab delayed release 50-0.2 mg 2 QL (120 tablets/30 days)diclofenac w/ misoprostol tab delayed release 75-0.2 mg 2 QL (90 tablets/30 days)etodolac cap 200 mg 2 QL (150 capsules/30 days)etodolac cap 300 mg 2 QL (90 capsules/30 days)etodolac tab er 24hr 400 mg 2 QL (60 tablets/30 days)etodolac tab er 24hr 500 mg 2 QL (60 tablets/30 days)

2018

You can find information on what the symbols and abbreviations on this table mean by going to the beginning ofthis table.2

Drug Name Drug Tier Requirements/Limitsetodolac tab er 24hr 600 mg 2 QL (30 tablets/30 days)etodolac tab 400 mg 2 QL (60 tablets/30 days)etodolac tab 500 mg 2 QL (60 tablets/30 days)fentanyl citrate lozenge on a handle 200 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 400 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 800 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 1200 mcg 5 PA, QL (120 lozenges/30 days)fentanyl citrate lozenge on a handle 1600 mcg 5 PA, QL (120 lozenges/30 days)fentanyl td patch 72hr 12 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 25 mcg/hr 3 PA, QL (15 patches/30 days)fentanyl td patch 72hr 50 mcg/hr 3 PA, QL (15 patches/30 days)fentanyl td patch 72hr 75 mcg/hr 4 PA, QL (15 patches/30 days)fentanyl td patch 72hr 100 mcg/hr 4 PA, QL (15 patches/30 days)flurbiprofen tab 50 mg 2 QL (180 tablets/30 days)flurbiprofen tab 100 mg 2 QL (90 tablets/30 days)hydrocodone-acetaminophen soln 7.5-325 mg/15ml 3 QL (3600 mls/30 days)hydrocodone-acetaminophen tab 10-325 mg 3 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-300 mg 2 QL (360 tablets/30 days)hydrocodone-acetaminophen tab 7.5-300 mg 2 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 5-325 mg 3 QL (360 tablets/30 days)hydrocodone-acetaminophen tab 7.5-325 mg 3 QL (180 tablets/30 days)hydrocodone-acetaminophen tab 10-300 mg 2 QL (180 tablets/30 days)hydrocodone-ibuprofen tab 5-200 mg 2 QL (150 tablets/30 days)hydrocodone-ibuprofen tab 7.5-200 mg 2 QL (150 tablets/30 days)hydrocodone-ibuprofen tab 10-200 mg 2 QL (150 tablets/30 days)hydromorphone hcl liqd 1 mg/ml 3 QL (1440 mls/30 days)hydromorphone hcl preservative free inj 10 mg/ml 3 BDhydromorphone hcl tab 2 mg 3 QL (180 tablets/30 days)hydromorphone hcl tab 4 mg 3 QL (180 tablets/30 days)hydromorphone hcl tab 8 mg 3 QL (180 tablets/30 days)ibuprofen susp 100 mg/5ml 1 QL (4800 mls/30 days)ibuprofen tab 400 mg 1 QL (240 tablets/30 days)ibuprofen tab 600 mg 1 QL (150 tablets/30 days)ibuprofen tab 800 mg 1 QL (120 tablets/30 days)ketoprofen cap 50 mg 2 QL (180 capsules/30 days)ketoprofen cap 75 mg 2 QL (120 capsules/30 days)LAZANDA - fentanyl citrate nasal spray 100 mcg/act 5 PA, QL (30 bottles/30 days)

2018


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Drug Name Drug Tier Requirements/LimitsLAZANDA - fentanyl citrate nasal spray 300 mcg/act 5 PA, QL (30 bottles/30 days)LAZANDA - fentanyl citrate nasal spray 400 mcg/act 5 PA, QL (30 bottles/30 days)LEVORPHANOL TARTRATE - levorphanol tartrate tab 2 mg 4 QL (120 tablets/30 days)meloxicam tab 7.5 mg 1 QL (60 tablets/30 days)meloxicam tab 15 mg 1 QL (30 tablets/30 days)methadone hcl tab 5 mg 3 QL (180 tablets/30 days)methadone hcl tab 10 mg 3 QL (360 tablets/30 days)MORPHINE SULFATE - morphine sulfate tab 15 mg 4 QL (240 tablets/30 days)MORPHINE SULFATE - morphine sulfate tab 30 mg 4 QL (180 tablets/30 days)morphine sulfate inj pf 0.5 mg/ml 3 BDmorphine sulfate inj pf 1 mg/ml 3 BDmorphine sulfate oral soln 10 mg/5ml 2 QL (2700 mls/30 days)morphine sulfate oral soln 20 mg/5ml 2 QL (1350 mls/30 days)morphine sulfate oral soln 100 mg/5ml (20 mg/ml) 2 QL (270 mls/30 days)morphine sulfate tab er 15 mg 2 PA, QL (90 tablets/30 days)morphine sulfate tab er 30 mg 2 PA, QL (90 tablets/30 days)morphine sulfate tab er 60 mg 2 PA, QL (90 tablets/30 days)morphine sulfate tab er 100 mg 2 PA, QL (90 tablets/30 days)morphine sulfate tab er 200 mg 2 PA, QL (90 tablets/30 days)nabumetone tab 500 mg 2 QL (120 tablets/30 days)nabumetone tab 750 mg 2 QL (60 tablets/30 days)naproxen sodium tab 275 mg 1 QL (150 tablets/30 days)naproxen sodium tab 550 mg 1 QL (90 tablets/30 days)naproxen susp 125 mg/5ml 2 QL (1800 mls/30 days)naproxen tab ec 375 mg 2 QL (120 tablets/30 days)naproxen tab ec 500 mg 2 QL (90 tablets/30 days)naproxen tab 250 mg 1 QL (180 tablets/30 days)naproxen tab 375 mg 1 QL (120 tablets/30 days)naproxen tab 500 mg 1 QL (90 tablets/30 days)NUCYNTA ER - tapentadol hcl tab er 12hr 50 mg 3 PA, QL (60 tablets/30 days)NUCYNTA ER - tapentadol hcl tab er 12hr 100 mg 3 PA, QL (60 tablets/30 days)NUCYNTA ER - tapentadol hcl tab er 12hr 150 mg 3 PA, QL (60 tablets/30 days)NUCYNTA ER - tapentadol hcl tab er 12hr 200 mg 3 PA, QL (60 tablets/30 days)NUCYNTA ER - tapentadol hcl tab er 12hr 250 mg 3 PA, QL (60 tablets/30 days)oxaprozin tab 600 mg 2 QL (90 tablets/30 days)oxycodone hcl tab 5 mg 3 QL (360 tablets/30 days)oxycodone hcl tab 10 mg 3 QL (180 tablets/30 days)oxycodone hcl tab 15 mg 3 QL (180 tablets/30 days)

2018


Drug Name Drug Tier Requirements/Limitsoxycodone hcl tab 20 mg 3 QL (180 tablets/30 days)oxycodone hcl tab 30 mg 3 QL (180 tablets/30 days)oxycodone w/ acetaminophen tab 2.5-325 mg 2 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 5-325 mg 3 QL (360 tablets/30 days)oxycodone w/ acetaminophen tab 7.5-325 mg 3 QL (240 tablets/30 days)oxycodone w/ acetaminophen tab 10-325 mg 3 QL (180 tablets/30 days)oxycodone-aspirin tab 4.8355-325 mg 2 QL (360 tablets/30 days)OXYCONTIN - oxycodone hcl tab er 12hr deter 10 mg 3 PA, QL (60 tablets/30 days)OXYCONTIN - oxycodone hcl tab er 12hr deter 15 mg 3 PA, QL (60 tablets/30 days)OXYCONTIN - oxycodone hcl tab er 12hr deter 20 mg 3 PA, QL (60 tablets/30 days)OXYCONTIN - oxycodone hcl tab er 12hr deter 30 mg 3 PA, QL (60 tablets/30 days)OXYCONTIN - oxycodone hcl tab er 12hr deter 40 mg 3 PA, QL (60 tablets/30 days)OXYCONTIN - oxycodone hcl tab er 12hr deter 60 mg 3 PA, QL (120 tablets/30 days)OXYCONTIN - oxycodone hcl tab er 12hr deter 80 mg 3 PA, QL (120 tablets/30 days)piroxicam cap 10 mg 2 QL (60 capsules/30 days)piroxicam cap 20 mg 2 QL (30 capsules/30 days)sulindac tab 150 mg 2 QL (60 tablets/30 days)sulindac tab 200 mg 2 QL (60 tablets/30 days)TENCON - butalbital-acetaminophen tab 50-325 mg# 4 PA, QL (180 tablets/30 days)TOLMETIN SODIUM - tolmetin sodium cap 400 mg 3 QL (120 capsules/30 days)tramadol hcl tab er 24hr 100 mg 2 PA, QL (30 tablets/30 days)tramadol hcl tab er 24hr 200 mg 2 PA, QL (30 tablets/30 days)tramadol hcl tab er 24hr 300 mg 2 PA, QL (30 tablets/30 days)tramadol hcl tab 50 mg 3 QL (240 tablets/30 days)tramadol-acetaminophen tab 37.5-325 mg 2 QL (240 tablets/30 days)ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abuse-

deterrent 10 mg4 PA, QL (60 capsules/30 days)

ZOHYDRO ER - hydrocodone bitartrate cap er 12hr abuse-deterrent 15 mg

4 PA, QL (60 capsules/30 days)









Anestheticslidocaine hcl gel 2% 1 PA, QL (150 mls/30 days)lidocaine hcl local inj 1% 1

2018


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Drug Name Drug Tier Requirements/Limitslidocaine hcl local preservative free inj 1% 1lidocaine hcl soln 4% 2 PAlidocaine hcl viscous soln 2% 1lidocaine oint 5% 2 PA, QL (100 grams/30 days)lidocaine patch 5% 3 PA, QL (90 patches/30 days)lidocaine-prilocaine cream 2.5-2.5% 3 PA, QL (60 grams/30 days)Anti-Addiction/Substance Abuse Treatment Agentsacamprosate calcium tab delayed release 333 mg 2buprenorphine hcl sl tab 2 mg 2 PA, QL (90 tablets/30 days)buprenorphine hcl sl tab 8 mg 2 PA, QL (90 tablets/30 days)buprenorphine hcl-naloxone hcl sl tab 2-0.5 mg 3 PA, QL (120 tablets/30 days)buprenorphine hcl-naloxone hcl sl tab 8-2 mg 4 PA, QL (90 tablets/30 days)bupropion hcl (smoking deterrent) tab er 12hr 150 mg 2CHANTIX - varenicline tartrate tab 0.5 mg 3CHANTIX - varenicline tartrate tab 1 mg 3CHANTIX CONTINUING MONTH PACK - varenicline tartrate tab

1 mg3

CHANTIX STARTING MONTH PACK - varenicline tartrate tab0.5 mg x 11 & tab 1 mg x 42 pack

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disulfiram tab 250 mg 2disulfiram tab 500 mg 2NALOXONE HCL - naloxone hcl soln cartridge 0.4 mg/ml 3NALOXONE HCL - naloxone hcl soln prefilled syringe 2 mg/2ml 3naloxone hcl inj 0.4 mg/ml 2naloxone hcl inj 4 mg/10ml 2naltrexone hcl tab 50 mg 2NARCAN - naloxone hcl nasal spray 4 mg/0.1ml 4NICOTROL INHALER - nicotine inhaler system 10 mg (4 mg

delivered)4

NICOTROL NS - nicotine nasal spray 10 mg/ml (0.5 mg/spray) 4SUBOXONE - buprenorphine hcl-naloxone hcl sl film 2-0.5 mg 4 PA, QL (120 films/30 days)SUBOXONE - buprenorphine hcl-naloxone hcl sl film 4-1 mg 4 PA, QL (30 films/30 days)SUBOXONE - buprenorphine hcl-naloxone hcl sl film 8-2 mg 4 PA, QL (60 films/30 days)SUBOXONE - buprenorphine hcl-naloxone hcl sl film 12-3 mg 4 PA, QL (60 films/30 days)VIVITROL - naltrexone for im extended release susp 380 mg 5Antibacterialsamikacin sulfate inj 500 mg/2ml (250 mg/ml) 2amikacin sulfate inj 1 gm/4ml (250 mg/ml) 2amoxicillin (trihydrate) cap 250 mg 1amoxicillin (trihydrate) cap 500 mg 1

2018


Drug Name Drug Tier Requirements/Limitsamoxicillin (trihydrate) for susp 125 mg/5ml 1amoxicillin (trihydrate) for susp 200 mg/5ml 1amoxicillin (trihydrate) for susp 250 mg/5ml 1amoxicillin (trihydrate) for susp 400 mg/5ml 1amoxicillin (trihydrate) tab 500 mg 1amoxicillin (trihydrate) tab 875 mg 1amoxicillin & k clavulanate for susp 200-28.5 mg/5ml 2amoxicillin & k clavulanate for susp 400-57 mg/5ml 2amoxicillin & k clavulanate for susp 600-42.9 mg/5ml 2amoxicillin & k clavulanate tab 250-125 mg 2amoxicillin & k clavulanate tab 500-125 mg 2amoxicillin & k clavulanate tab 875-125 mg 2AMOXICILLIN/CLAVULANATE POTASSIUM - amoxicillin & k

clavulanate chew tab 200-28.5 mg4

AMOXICILLIN/CLAVULANATE POTASSIUM - amoxicillin & kclavulanate chew tab 400-57 mg

4

ampicillin & sulbactam sodium for inj 3 (2-1) gm 2ampicillin cap 500 mg 1AMPICILLIN SODIUM - ampicillin sodium for iv soln 1 gm 4ampicillin sodium for inj 250 mg 2ampicillin sodium for inj 500 mg 2ampicillin sodium for inj 1 gm 2ampicillin sodium for inj 2 gm 2ampicillin sodium for iv soln 2 gm 2ampicillin sodium for iv soln 10 gm 2AMPICILLIN-SULBACTAM - ampicillin & sulbactam sodium for iv

soln 3 (2-1) gm2

AVELOX - moxifloxacin hcl 400 mg/250ml in sodium chloride 0.8%inj

3

AZACTAM - aztreonam for inj 1 gm 4AZACTAM - aztreonam for inj 2 gm 4AZACTAM IN ISO-OSMOTIC DEXTROSE - aztreonam in dextrose

inj 1 gm/50 ml4

AZACTAM IN ISO-OSMOTIC DEXTROSE - aztreonam in dextroseinj 2 gm/50 ml

4

AZITHROMYCIN - azithromycin powd pack for susp 1 gm 4azithromycin for susp 100 mg/5ml 2azithromycin for susp 200 mg/5ml 2azithromycin iv for soln 500 mg 2azithromycin tab 250 mg 1

2018


7

Drug Name Drug Tier Requirements/Limitsazithromycin tab 500 mg 1azithromycin tab 600 mg 1aztreonam for inj 1 gm 3aztreonam for inj 2 gm 2BICILLIN L-A - penicillin g benzathine intramuscular susp 600000

unit/ml4

BICILLIN L-A - penicillin g benzathine intramuscular susp 1200000unit/2ml

4

BICILLIN L-A - penicillin g benzathine intramuscular susp 2400000unit/4ml

4

cefaclor cap 250 mg 2cefaclor cap 500 mg 2cefadroxil cap 500 mg 1cefadroxil for susp 250 mg/5ml 2cefadroxil for susp 500 mg/5ml 2cefadroxil tab 1 gm 2CEFAZOLIN SODIUM - cefazolin sodium for inj 20 gm 3cefazolin sodium for inj 500 mg 2cefazolin sodium for inj 1 gm 2cefazolin sodium for inj 10 gm 2cefdinir cap 300 mg 2cefdinir for susp 125 mg/5ml 2cefdinir for susp 250 mg/5ml 2cefepime hcl for inj 1 gm 2cefepime hcl for inj 2 gm 2CEFOTAXIME SODIUM - cefotaxime sodium for inj 500 mg 3CEFOTAXIME SODIUM - cefotaxime sodium for inj 2 gm 3CEFOTAXIME SODIUM - cefotaxime sodium for inj 10 gm 3cefotaxime sodium for inj 1 gm 2cefoxitin sodium for inj 10 gm 2cefoxitin sodium for iv soln 1 gm 3cefoxitin sodium for iv soln 2 gm 3cefpodoxime proxetil for susp 50 mg/5ml 2cefpodoxime proxetil for susp 100 mg/5ml 2cefpodoxime proxetil tab 100 mg 2cefpodoxime proxetil tab 200 mg 2cefprozil for susp 125 mg/5ml 2cefprozil for susp 250 mg/5ml 2cefprozil tab 250 mg 2

2018


Drug Name Drug Tier Requirements/Limitscefprozil tab 500 mg 2ceftazidime for inj 1 gm 2ceftazidime for inj 2 gm 2ceftazidime for inj 6 gm 2ceftazidime for iv soln 2 gm 2ceftazidime for iv soln 1 gm 2CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE - ceftriaxone

sodium in dextrose inj 20 mg/ml4

CEFTRIAXONE IN ISO-OSMOTIC DEXTROSE - ceftriaxonesodium in dextrose inj 40 mg/ml

4

ceftriaxone sodium for inj 250 mg 2ceftriaxone sodium for inj 500 mg 2ceftriaxone sodium for inj 1 gm 2ceftriaxone sodium for inj 2 gm 2ceftriaxone sodium for inj 10 gm 3ceftriaxone sodium for iv soln 1 gm 2ceftriaxone sodium for iv soln 2 gm 2CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln 1 gm

and dextrose 3.74%4

CEFTRIAXONE/DEXTROSE - ceftriaxone sodium for iv soln 2 gmand dextrose 2.22%

4

cefuroxime axetil tab 250 mg 2cefuroxime axetil tab 500 mg 2cefuroxime sodium for inj 750 mg 2cefuroxime sodium for inj 1.5 gm 3cefuroxime sodium for inj 7.5 gm 2cefuroxime sodium for iv soln 1.5 gm 3cephalexin cap 250 mg 1cephalexin cap 500 mg 1cephalexin cap 750 mg 1cephalexin for susp 125 mg/5ml 2cephalexin for susp 250 mg/5ml 2CHLORAMPHENICOL SODIUM SUCCINATE - chloramphenicol

sodium succinate for iv inj 1 gm4

CIPROFLOXACIN - ciprofloxacin iv soln 200 mg/20ml (1%) 3CIPROFLOXACIN - ciprofloxacin iv soln 400 mg/40ml (1%) 3ciprofloxacin for oral susp 250 mg/5ml (5%) (5 gm/100ml) 2ciprofloxacin for oral susp 500 mg/5ml (10%) (10 gm/100ml) 2CIPROFLOXACIN HCL - ciprofloxacin hcl tab 100 mg 4ciprofloxacin hcl tab er 24hr 500 mg 2

2018


9

Drug Name Drug Tier Requirements/Limitsciprofloxacin hcl tab er 24hr 1000 mg 2ciprofloxacin hcl tab 250 mg 1ciprofloxacin hcl tab 500 mg 1ciprofloxacin hcl tab 750 mg 1ciprofloxacin 200 mg/100ml in d5w 2ciprofloxacin 400 mg/200ml in d5w 2clarithromycin for susp 125 mg/5ml 2clarithromycin for susp 250 mg/5ml 2clarithromycin tab er 24hr 500 mg 2clarithromycin tab 250 mg 2clarithromycin tab 500 mg 2clindamycin hcl cap 75 mg 1clindamycin hcl cap 150 mg 1clindamycin hcl cap 300 mg 1clindamycin phosphate gel 1% 2clindamycin phosphate in d5w iv soln 300 mg/50ml 2clindamycin phosphate in d5w iv soln 600 mg/50ml 2clindamycin phosphate in d5w iv soln 900 mg/50ml 2clindamycin phosphate inj 300 mg/2ml 1clindamycin phosphate inj 600 mg/4ml 1clindamycin phosphate inj 900 mg/6ml 1clindamycin phosphate inj 9 gm/60ml 1clindamycin phosphate iv soln 300 mg/2ml 1clindamycin phosphate iv soln 600 mg/4ml 1clindamycin phosphate iv soln 900 mg/6ml 1clindamycin phosphate lotion 1% 2clindamycin phosphate soln 1% 2clindamycin phosphate swab 1% 2clindamycin phosphate vaginal cream 2% 2colistimethate sodium for inj 150 mg 5DALVANCE - dalbavancin hcl for iv soln 500 mg 5daptomycin for iv soln 500 mg 5demeclocycline hcl tab 150 mg 2demeclocycline hcl tab 300 mg 2dicloxacillin sodium cap 250 mg 2dicloxacillin sodium cap 500 mg 2DIFICID - fidaxomicin tab 200 mg 5doxycycline hyclate cap 50 mg 2

2018


Drug Name Drug Tier Requirements/Limitsdoxycycline hyclate cap 100 mg 2doxycycline hyclate for inj 100 mg 3doxycycline hyclate tab 20 mg 2doxycycline hyclate tab 100 mg 2doxycycline monohydrate cap 50 mg 2doxycycline monohydrate cap 75 mg 2doxycycline monohydrate cap 100 mg 2doxycycline monohydrate cap 150 mg 2doxycycline monohydrate tab 50 mg 2doxycycline monohydrate tab 75 mg 2doxycycline monohydrate tab 100 mg 2doxycycline monohydrate tab 150 mg 2ERY-TAB - erythromycin tab delayed release 250 mg 4ERY-TAB - erythromycin tab delayed release 333 mg 4ERY-TAB - erythromycin tab delayed release 500 mg 4ERYPED 400 - erythromycin ethylsuccinate for susp 400 mg/5ml 4ERYTHROCIN LACTOBIONATE - erythromycin lactobionate for inj

500 mg4

ERYTHROCIN STEARATE - erythromycin stearate tab 250 mg 4ERYTHROMYCIN BASE - erythromycin tab 250 mg 4ERYTHROMYCIN BASE - erythromycin tab 500 mg 4erythromycin ethylsuccinate for susp 200 mg/5ml 2erythromycin pads 2% 2erythromycin soln 2% 2gentamicin in saline inj 0.8 mg/ml 2gentamicin in saline inj 1 mg/ml 2gentamicin in saline inj 1.2 mg/ml 2gentamicin in saline inj 1.6 mg/ml 2gentamicin sulfate inj 10 mg/ml 2gentamicin sulfate inj 40 mg/ml 2gentamicin sulfate iv soln 10 mg/ml 2imipenem-cilastatin intravenous for soln 250 mg 3imipenem-cilastatin intravenous for soln 500 mg 3IMPAVIDO - miltefosine cap 50 mg 5INVANZ - ertapenem sodium for inj 1 gm 4INVANZ - ertapenem sodium for iv inj 1 gm 4LEVOFLOXACIN - levofloxacin oral soln 25 mg/ml 3levofloxacin in d5w iv soln 250 mg/50ml 2levofloxacin in d5w iv soln 500 mg/100ml 2

2018


11

Drug Name Drug Tier Requirements/Limitslevofloxacin in d5w iv soln 750 mg/150ml 2levofloxacin iv soln 25 mg/ml 3levofloxacin tab 250 mg 1levofloxacin tab 500 mg 1levofloxacin tab 750 mg 1LINEZOLID - linezolid in sodium chloride iv soln

600 mg/300ml-0.9%5

linezolid for susp 100 mg/5ml 5 PAlinezolid iv soln 600 mg/300ml (2 mg/ml) 4linezolid tab 600 mg 3 PAmeropenem iv for soln 500 mg 2meropenem iv for soln 1 gm 2methenamine hippurate tab 1 gm 2METRO IV - metronidazole in nacl 0.74% iv soln 500 mg/100ml 4metronidazole cap 375 mg 2metronidazole in nacl 0.79% iv soln 500 mg/100ml 2metronidazole iv soln 5 mg/ml 2metronidazole tab 250 mg 2metronidazole tab 500 mg 2metronidazole vaginal gel 0.75% 2minocycline hcl cap 50 mg 2minocycline hcl cap 75 mg 2minocycline hcl cap 100 mg 2minocycline hcl tab 50 mg 2minocycline hcl tab 75 mg 2minocycline hcl tab 100 mg 2moxifloxacin hcl tab 400 mg 2moxifloxacin hcl 400 mg/250ml in sodium chloride 0.8% inj 2NAFCILLIN SODIUM - nafcillin sodium for iv soln 1 gm 4NAFCILLIN SODIUM - nafcillin sodium for iv soln 2 gm 4nafcillin sodium for inj 1 gm 3nafcillin sodium for inj 2 gm 2nafcillin sodium for inj 10 gm 5neomycin sulfate tab 500 mg 2neomycin-polymyxin b gu irrigation soln 2nitrofurantoin macrocrystalline cap 50 mg# 4 PAnitrofurantoin macrocrystalline cap 100 mg# 4 PAnitrofurantoin monohydrate macrocrystalline cap 100 mg# 4 PAnitrofurantoin susp 25 mg/5ml# 4 PA

2018


Drug Name Drug Tier Requirements/Limitsofloxacin tab 400 mg 2paromomycin sulfate cap 250 mg 4penicillin g potassium for inj 5000000 unit 2penicillin g potassium for inj 20000000 unit 2PENICILLIN G POTASSIUM IN DEXTROSE - penicillin g

potassium inj 20000 unit/ml in dextrose4

PENICILLIN G POTASSIUM IN DEXTROSE - penicillin gpotassium inj 40000 unit/ml in dextrose

4

PENICILLIN G POTASSIUM IN DEXTROSE - penicillin gpotassium inj 60000 unit/ml in dextrose

4

PENICILLIN G SODIUM - penicillin g sodium for inj 5000000 unit 4penicillin v potassium for soln 125 mg/5ml 2penicillin v potassium for soln 250 mg/5ml 2penicillin v potassium tab 250 mg 1penicillin v potassium tab 500 mg 1piperacillin sod-tazobactam na for inj 3.375 gm (3-0.375 gm) 3piperacillin sod-tazobactam sod for inj 2.25 gm (2-0.25 gm) 2piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5 gm) 3SIVEXTRO - tedizolid phosphate for iv soln 200 mg 5SIVEXTRO - tedizolid phosphate tab 200 mg 5 PASTREPTOMYCIN SULFATE - streptomycin sulfate for inj 1 gm 4sulfacetamide sodium lotion 10% 2SULFADIAZINE - sulfadiazine tab 500 mg 4sulfamethoxazole-trimethoprim iv soln 400-80 mg/5ml 2sulfamethoxazole-trimethoprim susp 200-40 mg/5ml 2sulfamethoxazole-trimethoprim tab 400-80 mg 1sulfamethoxazole-trimethoprim tab 800-160 mg 1SUPRAX - cefixime cap 400 mg 4SUPRAX - cefixime chew tab 100 mg 4SUPRAX - cefixime chew tab 200 mg 4SYNERCID - quinupristin-dalfopristin for inj 500 mg (150-350 mg) 5TEFLARO - ceftaroline fosamil for iv soln 400 mg 5TEFLARO - ceftaroline fosamil for iv soln 600 mg 5tetracycline hcl cap 250 mg 3tetracycline hcl cap 500 mg 3tigecycline for iv soln 50 mg 5TOBRAMYCIN SULFATE - tobramycin sulfate inj 2 gm/50ml

(40 mg/ml)4

tobramycin sulfate for inj 1.2 gm 2

2018


13

Drug Name Drug Tier Requirements/Limitstobramycin sulfate inj 10 mg/ml 2tobramycin sulfate inj 80 mg/2ml (40 mg/ml) 2tobramycin sulfate inj 1.2 gm/30ml (40 mg/ml) 2trimethoprim tab 100 mg 2TYGACIL - tigecycline for iv soln 50 mg 5vancomycin hcl cap 125 mg 4vancomycin hcl cap 250 mg 4vancomycin hcl for inj 100 gm 2vancomycin hcl for inj 500 mg 2vancomycin hcl for inj 750 mg 2vancomycin hcl for inj 1000 mg 2vancomycin hcl for inj 5000 mg 2vancomycin hcl for inj 10 gm 2VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl in dextrose

5% inj 500 mg/100ml4

VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl in dextrose5% inj 750 mg/150ml

4

VANCOMYCIN HCL IN DEXTROSE - vancomycin hcl in dextrose5% inj 1 gm/200ml

4

ZINACEF - cefuroxime in sterile water inj 1.5 gm/50ml 4ZOSYN - piperacillin sod-tazobactam sod in dex iv soln

2-0.25gm/50ml4

ZOSYN - piperacillin sod-tazobactam sod in dex iv soln4-0.5gm/100ml

4

ZOSYN - piperacillin sod-tazobactam sod in dex iv sol3-0.375gm/50ml

4

AnticonvulsantsAPTIOM - eslicarbazepine acetate tab 200 mg 5APTIOM - eslicarbazepine acetate tab 400 mg 5APTIOM - eslicarbazepine acetate tab 600 mg 5APTIOM - eslicarbazepine acetate tab 800 mg 5BANZEL - rufinamide susp 40 mg/ml 5BANZEL - rufinamide tab 200 mg 4BANZEL - rufinamide tab 400 mg 5BRIVIACT - brivaracetam iv soln 50 mg/5ml 4BRIVIACT - brivaracetam oral soln 10 mg/ml 5BRIVIACT - brivaracetam tab 10 mg 5BRIVIACT - brivaracetam tab 25 mg 5BRIVIACT - brivaracetam tab 50 mg 5BRIVIACT - brivaracetam tab 75 mg 5

2018


Drug Name Drug Tier Requirements/LimitsBRIVIACT - brivaracetam tab 100 mg 5carbamazepine cap er 12hr 100 mg 2carbamazepine cap er 12hr 200 mg 2carbamazepine cap er 12hr 300 mg 2carbamazepine chew tab 100 mg 2carbamazepine susp 100 mg/5ml 2carbamazepine tab er 12hr 100 mg 2carbamazepine tab er 12hr 200 mg 2carbamazepine tab er 12hr 400 mg 2carbamazepine tab 200 mg 2CELONTIN - methsuximide cap 300 mg 4DIASTAT ACUDIAL - diazepam rectal gel delivery system 10 mg 4 QL (5 twin pack(s)/30 days)DIASTAT ACUDIAL - diazepam rectal gel delivery system 20 mg 4 QL (5 twin pack(s)/30 days)DIASTAT PEDIATRIC - diazepam rectal gel delivery system 2.5 mg 4 QL (5 twin pack(s)/30 days)DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system

2.5 mg4 QL (5 twin pack(s)/30 days)

DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system10 mg

4 QL (5 twin pack(s)/30 days)

DIAZEPAM RECTAL GEL - diazepam rectal gel delivery system20 mg

4 QL (5 twin pack(s)/30 days)

DILANTIN - phenytoin sodium extended cap 30 mg 4divalproex sodium cap delayed release sprinkle 125 mg 2divalproex sodium tab delayed release 125 mg 2divalproex sodium tab delayed release 250 mg 2divalproex sodium tab delayed release 500 mg 2divalproex sodium tab er 24 hr 250 mg 2divalproex sodium tab er 24 hr 500 mg 2ethosuximide cap 250 mg 2ethosuximide soln 250 mg/5ml 2felbamate susp 600 mg/5ml 5felbamate tab 400 mg 4felbamate tab 600 mg 4fosphenytoin sodium inj 100 mg/2ml 3fosphenytoin sodium inj 500 mg/10ml 3FYCOMPA - perampanel susp 0.5 mg/ml 5FYCOMPA - perampanel tab 2 mg 4FYCOMPA - perampanel tab 4 mg 5FYCOMPA - perampanel tab 6 mg 5FYCOMPA - perampanel tab 8 mg 5

2018


15

Drug Name Drug Tier Requirements/LimitsFYCOMPA - perampanel tab 10 mg 5FYCOMPA - perampanel tab 12 mg 5gabapentin cap 100 mg 1 QL (1080 capsules/30 days)gabapentin cap 300 mg 1 QL (360 capsules/30 days)gabapentin cap 400 mg 1 QL (270 capsules/30 days)gabapentin oral soln 250 mg/5ml 2 QL (2160 mls/30 days)gabapentin tab 600 mg 2 QL (180 tablets/30 days)gabapentin tab 800 mg 2 QL (135 tablets/30 days)GABITRIL - tiagabine hcl tab 12 mg 4GABITRIL - tiagabine hcl tab 16 mg 4lamotrigine tab chewable dispersible 5 mg 2lamotrigine tab chewable dispersible 25 mg 2lamotrigine tab 25 mg 1lamotrigine tab 100 mg 1lamotrigine tab 150 mg 1lamotrigine tab 200 mg 1levetiracetam in sodium chloride iv soln 500 mg/100ml 3levetiracetam in sodium chloride iv soln 1000 mg/100ml 3levetiracetam in sodium chloride iv soln 1500 mg/100ml 3levetiracetam inj 500 mg/5ml (100 mg/ml) 3levetiracetam oral soln 100 mg/ml 2levetiracetam tab 250 mg 2levetiracetam tab 500 mg 2levetiracetam tab 750 mg 2levetiracetam tab 1000 mg 2LYRICA - pregabalin cap 25 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 50 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 75 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 100 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 150 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 200 mg 3 QL (90 capsules/30 days)LYRICA - pregabalin cap 225 mg 3 QL (60 capsules/30 days)LYRICA - pregabalin cap 300 mg 3 QL (60 capsules/30 days)LYRICA - pregabalin soln 20 mg/ml 3 QL (900 mls/30 days)ONFI - clobazam suspension 2.5 mg/ml 5 PA, QL (480 mls/30 days)ONFI - clobazam tab 10 mg 5 PA, QL (60 tablets/30 days)ONFI - clobazam tab 20 mg 5 PA, QL (60 tablets/30 days)oxcarbazepine susp 300 mg/5ml (60 mg/ml) 4

2018


Drug Name Drug Tier Requirements/Limitsoxcarbazepine tab 150 mg 2oxcarbazepine tab 300 mg 2oxcarbazepine tab 600 mg 2PEGANONE - ethotoin tab 250 mg 4PHENOBARBITAL - phenobarbital tab 15 mg# 4 PAPHENOBARBITAL - phenobarbital tab 30 mg# 4 PAPHENOBARBITAL - phenobarbital tab 60 mg# 4 PAPHENOBARBITAL - phenobarbital tab 100 mg# 4 PAphenobarbital elixir 20 mg/5ml# 4 PAPHENOBARBITAL SODIUM - phenobarbital sodium inj 65 mg/ml# 4 PAPHENOBARBITAL SODIUM - phenobarbital sodium inj 130 mg/ml# 4 PAphenobarbital tab 16.2 mg# 4 PAphenobarbital tab 32.4 mg# 4 PAphenobarbital tab 64.8 mg# 4 PAphenobarbital tab 97.2 mg# 4 PAphenytoin chew tab 50 mg 2phenytoin sodium extended cap 100 mg 2phenytoin sodium extended cap 200 mg 2phenytoin sodium extended cap 300 mg 2phenytoin susp 125 mg/5ml 2primidone tab 50 mg 2primidone tab 250 mg 2SABRIL - vigabatrin powd pack 500 mg* 4SABRIL - vigabatrin tab 500 mg* 5SPRITAM - levetiracetam tab disintegrating soluble 250 mg 4SPRITAM - levetiracetam tab disintegrating soluble 500 mg 4SPRITAM - levetiracetam tab disintegrating soluble 750 mg 5SPRITAM - levetiracetam tab disintegrating soluble 1000 mg 4tiagabine hcl tab 2 mg 3tiagabine hcl tab 4 mg 4topiramate sprinkle cap 15 mg 2topiramate sprinkle cap 25 mg 2topiramate tab 25 mg 1topiramate tab 50 mg 1topiramate tab 100 mg 1topiramate tab 200 mg 1valproate sodium inj 100 mg/ml 2valproate sodium oral soln 250 mg/5ml 2

2018


17

Drug Name Drug Tier Requirements/Limitsvalproic acid cap 250 mg 2vigabatrin powd pack 500 mg* 4VIMPAT - lacosamide iv inj 200 mg/20ml (10 mg/ml) 3VIMPAT - lacosamide oral solution 10 mg/ml 3VIMPAT - lacosamide tab 50 mg 3VIMPAT - lacosamide tab 100 mg 3VIMPAT - lacosamide tab 150 mg 3VIMPAT - lacosamide tab 200 mg 3zonisamide cap 25 mg 2zonisamide cap 50 mg 2zonisamide cap 100 mg 2Antidementia Agentsdonepezil hydrochloride orally disintegrating tab 5 mg 2donepezil hydrochloride orally disintegrating tab 10 mg 2donepezil hydrochloride tab 5 mg 1donepezil hydrochloride tab 10 mg 1donepezil hydrochloride tab 23 mg 3ERGOLOID MESYLATES - ergoloid mesylates tab 1 mg# 3 PAGALANTAMINE HYDROBROMIDE - galantamine hydrobromide

oral soln 4 mg/ml4

galantamine hydrobromide cap er 24hr 8 mg 2galantamine hydrobromide cap er 24hr 16 mg 2galantamine hydrobromide cap er 24hr 24 mg 2galantamine hydrobromide tab 4 mg 2galantamine hydrobromide tab 8 mg 2galantamine hydrobromide tab 12 mg 2memantine hcl oral solution 2 mg/ml 2 PAmemantine hcl tab 5 mg 2 PAmemantine hcl tab 10 mg 2 PAmemantine hcl tab 5 mg (28) & 10 mg (21) titration pak 2 PArivastigmine tartrate cap 1.5 mg 2rivastigmine tartrate cap 3 mg 2rivastigmine tartrate cap 4.5 mg 2rivastigmine tartrate cap 6 mg 2rivastigmine td patch 24hr 4.6 mg/24hr 2rivastigmine td patch 24hr 9.5 mg/24hr 2rivastigmine td patch 24hr 13.3 mg/24hr 2Antidepressantsamitriptyline hcl tab 10 mg# 4 PA

2018


Drug Name Drug Tier Requirements/Limitsamitriptyline hcl tab 25 mg# 4 PAamitriptyline hcl tab 50 mg# 4 PAamitriptyline hcl tab 75 mg# 4 PAamitriptyline hcl tab 100 mg# 4 PAamitriptyline hcl tab 150 mg# 4 PAAMOXAPINE - amoxapine tab 25 mg# 4 PAAMOXAPINE - amoxapine tab 50 mg# 4 PAAMOXAPINE - amoxapine tab 100 mg# 4 PAAMOXAPINE - amoxapine tab 150 mg# 4 PAbupropion hcl tab er 12hr 100 mg 3 QL (90 tablets/30 days)bupropion hcl tab er 12hr 150 mg 3 QL (60 tablets/30 days)bupropion hcl tab er 12hr 200 mg 3 QL (60 tablets/30 days)bupropion hcl tab er 24hr 150 mg 3 QL (90 tablets/30 days)bupropion hcl tab er 24hr 300 mg 3 QL (30 tablets/30 days)bupropion hcl tab 75 mg 2 QL (60 tablets/30 days)bupropion hcl tab 100 mg 2 QL (120 tablets/30 days)citalopram hydrobromide oral soln 10 mg/5ml 2 QL (600 mls/30 days)citalopram hydrobromide tab 10 mg 1 QL (45 tablets/30 days)citalopram hydrobromide tab 20 mg 1 QL (45 tablets/30 days)citalopram hydrobromide tab 40 mg 1 QL (30 tablets/30 days)clomipramine hcl cap 25 mg# 4 PAclomipramine hcl cap 50 mg# 4 PAclomipramine hcl cap 75 mg# 4 PAdesipramine hcl tab 10 mg# 3 PAdesipramine hcl tab 25 mg# 3 PAdesipramine hcl tab 50 mg# 3 PAdesipramine hcl tab 75 mg# 3 PAdesipramine hcl tab 100 mg# 3 PAdesipramine hcl tab 150 mg# 3 PAdesvenlafaxine succinate tab er 24hr 25 mg 2 QL (30 tablets/30 days)desvenlafaxine succinate tab er 24hr 50 mg 2 QL (30 tablets/30 days)desvenlafaxine succinate tab er 24hr 100 mg 2 QL (30 tablets/30 days)doxepin hcl cap 10 mg# 4 PAdoxepin hcl cap 25 mg# 4 PAdoxepin hcl cap 50 mg# 4 PAdoxepin hcl cap 75 mg# 4 PAdoxepin hcl cap 100 mg# 4 PAdoxepin hcl cap 150 mg# 4 PA

2018


19

Drug Name Drug Tier Requirements/Limitsdoxepin hcl conc 10 mg/ml# 3 PAduloxetine hcl enteric coated pellets cap 20 mg 3 QL (60 capsules/30 days)duloxetine hcl enteric coated pellets cap 30 mg 3 QL (90 capsules/30 days)duloxetine hcl enteric coated pellets cap 60 mg 3 QL (60 capsules/30 days)EMSAM - selegiline td patch 24hr 6 mg/24hr 5EMSAM - selegiline td patch 24hr 9 mg/24hr 5EMSAM - selegiline td patch 24hr 12 mg/24hr 5escitalopram oxalate soln 5 mg/5ml 2 QL (600 mls/30 days)escitalopram oxalate tab 5 mg 1 QL (45 tablets/30 days)escitalopram oxalate tab 10 mg 1 QL (45 tablets/30 days)escitalopram oxalate tab 20 mg 1 QL (30 tablets/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 20 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 40 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 80 mg 4 QL (30 capsules/30 days)FETZIMA - levomilnacipran hcl cap er 24hr 120 mg 4 QL (30 capsules/30 days)FETZIMA TITRATION PACK - levomilnacipran hcl cap er 24hr 20 &

40 mg therapy pack4 QL (28 capsules/28 days)

FLUOXETINE DR - fluoxetine hcl cap delayed release 90 mg 2 QL (4 capsules/28 days)fluoxetine hcl cap 10 mg 1 QL (90 capsules/30 days)fluoxetine hcl cap 20 mg 1 QL (120 capsules/30 days)fluoxetine hcl cap 40 mg 1 QL (60 capsules/30 days)fluoxetine hcl solution 20 mg/5ml 2 QL (600 mls/30 days)fluoxetine hcl tab 10 mg 2 QL (90 tablets/30 days)fluoxetine hcl tab 20 mg 2 QL (120 tablets/30 days)fluvoxamine maleate tab 25 mg 2 QL (30 tablets/30 days)fluvoxamine maleate tab 50 mg 2 QL (30 tablets/30 days)fluvoxamine maleate tab 100 mg 2 QL (90 tablets/30 days)imipramine hcl tab 10 mg# 4 PAimipramine hcl tab 25 mg# 4 PAimipramine hcl tab 50 mg# 4 PAMAPROTILINE HCL - maprotiline hcl tab 25 mg 4 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 50 mg 4 QL (90 tablets/30 days)MAPROTILINE HCL - maprotiline hcl tab 75 mg 4 QL (90 tablets/30 days)MARPLAN - isocarboxazid tab 10 mg 4mirtazapine orally disintegrating tab 15 mg 2 QL (30 tablets/30 days)mirtazapine orally disintegrating tab 30 mg 2 QL (30 tablets/30 days)mirtazapine orally disintegrating tab 45 mg 2 QL (30 tablets/30 days)mirtazapine tab 7.5 mg 2 QL (30 tablets/30 days)mirtazapine tab 15 mg 2 QL (45 tablets/30 days)

2018


Drug Name Drug Tier Requirements/Limitsmirtazapine tab 30 mg 2 QL (30 tablets/30 days)mirtazapine tab 45 mg 2 QL (30 tablets/30 days)NEFAZODONE HCL - nefazodone hcl tab 100 mg 4NEFAZODONE HCL - nefazodone hcl tab 150 mg 4NEFAZODONE HCL - nefazodone hcl tab 200 mg 4nefazodone hcl tab 50 mg 2nefazodone hcl tab 250 mg 2NORTRIPTYLINE HCL - nortriptyline hcl soln 10 mg/5ml# 4 PAnortriptyline hcl cap 10 mg# 4 PAnortriptyline hcl cap 25 mg# 4 PAnortriptyline hcl cap 50 mg# 4 PAnortriptyline hcl cap 75 mg# 4 PAparoxetine hcl tab 10 mg# 4 PA, QL (45 tablets/30 days)paroxetine hcl tab 20 mg# 4 PA, QL (30 tablets/30 days)paroxetine hcl tab 30 mg# 4 PA, QL (60 tablets/30 days)paroxetine hcl tab 40 mg# 4 PA, QL (45 tablets/30 days)PAXIL - paroxetine hcl oral susp 10 mg/5ml# 4 PA, QL (900 mls/30 days)phenelzine sulfate tab 15 mg 2PRISTIQ - desvenlafaxine succinate tab er 24hr 25 mg 4 QL (30 tablets/30 days)PRISTIQ - desvenlafaxine succinate tab er 24hr 50 mg 4 QL (30 tablets/30 days)PRISTIQ - desvenlafaxine succinate tab er 24hr 100 mg 4 QL (30 tablets/30 days)protriptyline hcl tab 5 mg# 4 PAprotriptyline hcl tab 10 mg# 4 PAsertraline hcl oral conc 20 mg/ml 2 QL (300 mls/30 days)sertraline hcl tab 25 mg 1 QL (45 tablets/30 days)sertraline hcl tab 50 mg 1 QL (45 tablets/30 days)sertraline hcl tab 100 mg 1 QL (60 tablets/30 days)tranylcypromine sulfate tab 10 mg 3trazodone hcl tab 50 mg 1trazodone hcl tab 100 mg 1trazodone hcl tab 150 mg 1trazodone hcl tab 300 mg 1trimipramine maleate cap 25 mg# 4 PAtrimipramine maleate cap 50 mg# 4 PAtrimipramine maleate cap 100 mg# 4 PATRINTELLIX - vortioxetine hbr tab 5 mg 4 QL (30 tablets/30 days)TRINTELLIX - vortioxetine hbr tab 10 mg 4 QL (30 tablets/30 days)TRINTELLIX - vortioxetine hbr tab 20 mg 4 QL (30 tablets/30 days)

2018


21

Drug Name Drug Tier Requirements/Limitsvenlafaxine hcl cap er 24hr 37.5 mg 2 QL (60 capsules/30 days)venlafaxine hcl cap er 24hr 75 mg 2 QL (90 capsules/30 days)venlafaxine hcl cap er 24hr 150 mg 2 QL (30 capsules/30 days)venlafaxine hcl tab er 24hr 37.5 mg 3 QL (60 tablets/30 days)venlafaxine hcl tab er 24hr 75 mg 3 QL (90 tablets/30 days)venlafaxine hcl tab er 24hr 150 mg 3 QL (30 tablets/30 days)venlafaxine hcl tab 25 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 37.5 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 50 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 75 mg 2 QL (90 tablets/30 days)venlafaxine hcl tab 100 mg 2 QL (90 tablets/30 days)VIIBRYD - vilazodone hcl tab 10 mg 4 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 20 mg 4 QL (30 tablets/30 days)VIIBRYD - vilazodone hcl tab 40 mg 4 QL (30 tablets/30 days)VIIBRYD STARTER PACK - vilazodone hcl tab starter kit 10 (7) &

20 (23) mg4 QL (1 kit/30 days)

AntiemeticsALOXI - palonosetron hcl iv soln 0.25 mg/5ml 4aprepitant capsule therapy pack 80 & 125 mg 2 BDaprepitant capsule 40 mg 2 BDaprepitant capsule 80 mg 2 BDaprepitant capsule 125 mg 2 BDCHLORPROMAZINE HCL - chlorpromazine hcl inj 25 mg/ml 4 PACHLORPROMAZINE HCL - chlorpromazine hcl inj 50 mg/2ml 4 PAchlorpromazine hcl tab 10 mg 2 PAchlorpromazine hcl tab 25 mg 3 PAchlorpromazine hcl tab 50 mg 3 PAchlorpromazine hcl tab 100 mg 4 PAchlorpromazine hcl tab 200 mg 4 PAdronabinol cap 2.5 mg 3 BDdronabinol cap 5 mg 4 BDdronabinol cap 10 mg 4 BDEMEND - fosaprepitant dimeglumine for iv infusion 150 mg 4granisetron hcl inj 1 mg/ml 2granisetron hcl inj 4 mg/4ml (1 mg/ml) 2granisetron hcl tab 1 mg 2 BDmeclizine hcl tab 12.5 mg# 4meclizine hcl tab 25 mg# 4ondansetron hcl inj 4 mg/2ml (2 mg/ml) 2

2018


Drug Name Drug Tier Requirements/Limitsondansetron hcl inj 40 mg/20ml (2 mg/ml) 2ondansetron hcl oral soln 4 mg/5ml 2 BDondansetron hcl tab 4 mg 2 BDondansetron hcl tab 8 mg 2 BDondansetron hcl tab 24 mg 2 BDondansetron orally disintegrating tab 4 mg 2 BDondansetron orally disintegrating tab 8 mg 2 BDperphenazine tab 2 mg 2 PAperphenazine tab 4 mg 2 PAperphenazine tab 8 mg 2 PAperphenazine tab 16 mg 2 PAprochlorperazine edisylate inj 5 mg/ml 4prochlorperazine maleate tab 5 mg 1prochlorperazine maleate tab 10 mg 1prochlorperazine suppos 25 mg 2promethazine hcl suppos 12.5 mg# 4 PApromethazine hcl suppos 25 mg# 4 PApromethazine hcl syrup 6.25 mg/5ml# 4 PApromethazine hcl tab 12.5 mg# 4 PApromethazine hcl tab 25 mg# 4 PApromethazine hcl tab 50 mg# 4 PAAntifungalsAMBISOME - amphotericin b liposome iv for susp 50 mg 5 BDAMPHOTERICIN B - amphotericin b for inj 50 mg 4 BDCANCIDAS - caspofungin acetate for iv soln 50 mg 5CANCIDAS - caspofungin acetate for iv soln 70 mg 5caspofungin acetate for iv soln 50 mg 5caspofungin acetate for iv soln 70 mg 5ciclopirox gel 0.77% 2ciclopirox olamine cream 0.77% 2ciclopirox olamine susp 0.77% 2ciclopirox shampoo 1% 2ciclopirox solution 8% 2clotrimazole cream 1% 1clotrimazole troche 10 mg 2CRESEMBA - isavuconazonium sulfate cap 186 mg 5 PACRESEMBA - isavuconazonium sulfate for iv soln 372 mg 5 PAeconazole nitrate cream 1% 2

2018


23

Drug Name Drug Tier Requirements/Limitsfluconazole for susp 10 mg/ml 2fluconazole for susp 40 mg/ml 2fluconazole in dextrose inj 200 mg/100ml 2fluconazole in dextrose inj 400 mg/200ml 2fluconazole in nacl 0.9% inj 200 mg/100ml 2fluconazole in nacl 0.9% inj 400 mg/200ml 2fluconazole tab 50 mg 2fluconazole tab 100 mg 2fluconazole tab 150 mg 2fluconazole tab 200 mg 2flucytosine cap 250 mg 5flucytosine cap 500 mg 5griseofulvin microsize susp 125 mg/5ml 2griseofulvin ultramicrosize tab 125 mg 2griseofulvin ultramicrosize tab 250 mg 2itraconazole cap 100 mg 4ketoconazole cream 2% 2ketoconazole shampoo 2% 2ketoconazole tab 200 mg 2MYCAMINE - micafungin sodium for iv soln 50 mg 5MYCAMINE - micafungin sodium for iv soln 100 mg 5NOXAFIL - posaconazole iv soln 300 mg/16.7ml (18 mg/ml) 4 PANOXAFIL - posaconazole susp 40 mg/ml 5 PANOXAFIL - posaconazole tab delayed release 100 mg 5 PAnystatin cream 100000 unit/gm 2nystatin oint 100000 unit/gm 2nystatin susp 100000 unit/ml 2nystatin tab 500000 unit 2nystatin topical powder 100000 unit/gm 2terbinafine hcl tab 250 mg 1terconazole vaginal cream 0.4% 2terconazole vaginal cream 0.8% 2terconazole vaginal suppos 80 mg 2voriconazole for inj 200 mg 3 PAvoriconazole for susp 40 mg/ml 5 PAvoriconazole tab 50 mg 5 PAvoriconazole tab 200 mg 5 PA

2018


Drug Name Drug Tier Requirements/LimitsAntigout Agentsallopurinol sodium for inj 500 mg 2allopurinol tab 100 mg 1allopurinol tab 300 mg 1colchicine w/ probenecid tab 0.5-500 mg 2COLCRYS - colchicine tab 0.6 mg 3probenecid tab 500 mg 2ULORIC - febuxostat tab 40 mg 3 STULORIC - febuxostat tab 80 mg 3 STAntimigraine AgentsMIGERGOT - ergotamine w/ caffeine suppos 2-100 mg 5MIGRANAL - dihydroergotamine mesylate nasal spray 4 mg/ml 3 QL (8 mls/28 days)naratriptan hcl tab 1 mg 2 QL (18 tablets/30 days)naratriptan hcl tab 2.5 mg 2 QL (18 tablets/30 days)rizatriptan benzoate oral disintegrating tab 5 mg 2 QL (18 tablets/30 days)rizatriptan benzoate oral disintegrating tab 10 mg 2 QL (18 tablets/30 days)rizatriptan benzoate tab 5 mg 2 QL (18 tablets/30 days)rizatriptan benzoate tab 10 mg 2 QL (18 tablets/30 days)sumatriptan nasal spray 5 mg/act 2 QL (12 units (2

packages)/30 days)sumatriptan nasal spray 20 mg/act 2 QL (12 units (2

packages)/30 days)sumatriptan succinate inj 6 mg/0.5ml 4sumatriptan succinate solution auto-injector 4 mg/0.5ml 2sumatriptan succinate solution auto-injector 6 mg/0.5ml 4sumatriptan succinate solution cartridge 4 mg/0.5ml 4sumatriptan succinate solution cartridge 6 mg/0.5ml 4sumatriptan succinate tab 25 mg 2 QL (18 tablets/30 days)sumatriptan succinate tab 50 mg 2 QL (18 tablets/30 days)sumatriptan succinate tab 100 mg 2 QL (18 tablets/30 days)Antimyasthenic AgentsGUANIDINE HCL - guanidine hcl tab 125 mg 4MESTINON - pyridostigmine bromide syrup 60 mg/5ml 5pyridostigmine bromide tab er 180 mg 2pyridostigmine bromide tab 60 mg 2AntimycobacterialsCAPASTAT SULFATE - capreomycin sulfate for inj 1 gm 4CYCLOSERINE - cycloserine cap 250 mg 5dapsone tab 25 mg 2

2018


25

Drug Name Drug Tier Requirements/Limitsdapsone tab 100 mg 2ethambutol hcl tab 100 mg 2ethambutol hcl tab 400 mg 2ISONIAZID - isoniazid inj 100 mg/ml 3isoniazid tab 100 mg 1isoniazid tab 300 mg 1PASER - aminosalicylic acid er granules packet 4 gm 4PRIFTIN - rifapentine tab 150 mg 4pyrazinamide tab 500 mg 2rifabutin cap 150 mg 4rifampin cap 150 mg 2rifampin cap 300 mg 2rifampin for inj 600 mg 5SIRTURO - bedaquiline fumarate tab 100 mg 5TRECATOR - ethionamide tab 250 mg 4AntineoplasticsABRAXANE - paclitaxel protein-bound particles for iv susp 100 mg 5AFINITOR - everolimus tab 2.5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 7.5 mg 5 PA, QL (30 tablets/30 days)AFINITOR - everolimus tab 10 mg 5 PA, QL (30 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 2 mg 5 PA, QL (60 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 3 mg 5 PA, QL (90 tablets/30 days)AFINITOR DISPERZ - everolimus tab for oral susp 5 mg 5 PA, QL (60 tablets/30 days)ALECENSA - alectinib hcl cap 150 mg* 5 PA, QL (240 capsules/30 days)ALIMTA - pemetrexed disodium for iv soln 100 mg 5ALIMTA - pemetrexed disodium for iv soln 500 mg 5ALIQOPA - copanlisib hcl for iv soln 60 mg 5ALUNBRIG - brigatinib tab initiation therapy pack 90 mg & 180 mg 5 PA, QL (30 tablets/30 days)ALUNBRIG - brigatinib tab 30 mg 5 PA, QL (180 tablets/30 days)ALUNBRIG - brigatinib tab 90 mg 5 PA, QL (30 tablets/30 days)ALUNBRIG - brigatinib tab 180 mg 5 PA, QL (30 tablets/30 days)anastrozole tab 1 mg 1ARRANON - nelarabine iv soln 5 mg/ml 5ARZERRA - ofatumumab conc for iv infusion 100 mg/5ml* 5ARZERRA - ofatumumab conc for iv infusion 1000 mg/50ml* 5AVASTIN - bevacizumab iv soln 100 mg/4ml (for infusion)* 5AVASTIN - bevacizumab iv soln 400 mg/16ml (for infusion)* 5

2018


Drug Name Drug Tier Requirements/LimitsBAVENCIO - avelumab soln for iv infusion 200 mg/10ml (20 mg/ml) 5BELEODAQ - belinostat for iv inj 500 mg* 5BENDEKA - bendamustine hcl iv soln 100 mg/4ml (25 mg/ml) 5BESPONSA - inotuzumab ozogamicin for iv soln 0.9 mg 5bexarotene cap 75 mg 5 PAbicalutamide tab 50 mg 2BICNU - carmustine for inj 100 mg 4bleomycin sulfate for inj 15 unit 2 BDbleomycin sulfate for inj 30 unit 3 BDBLINCYTO - blinatumomab for iv infusion 35 mcg* 5 BDBOSULIF - bosutinib tab 100 mg 5 PA, QL (120 tablets/30 days)BOSULIF - bosutinib tab 400 mg 5 PA, QL (30 tablets/30 days)BOSULIF - bosutinib tab 500 mg 5 PA, QL (30 tablets/30 days)busulfan inj 6 mg/ml 5CABOMETYX - cabozantinib s-malate tab 20 mg* 5 PA, QL (30 tablets/30 days)CABOMETYX - cabozantinib s-malate tab 40 mg* 5 PA, QL (30 tablets/30 days)CABOMETYX - cabozantinib s-malate tab 60 mg* 5 PA, QL (30 tablets/30 days)CALQUENCE - acalabrutinib cap 100 mg 5 PA, QL (60 capsules/30 days)CAPRELSA - vandetanib tab 100 mg* 5 PA, QL (60 tablets/30 days)CAPRELSA - vandetanib tab 300 mg* 5 PA, QL (30 tablets/30 days)carboplatin iv soln 50 mg/5ml 2carboplatin iv soln 150 mg/15ml 2carboplatin iv soln 450 mg/45ml 2carboplatin iv soln 600 mg/60ml 2CISPLATIN - cisplatin inj 200 mg/200ml (1 mg/ml) 2cisplatin inj 50 mg/50ml (1 mg/ml) 2cisplatin inj 100 mg/100ml (1 mg/ml) 2cladribine iv soln 10 mg/10ml (1 mg/ml) 5 BDclofarabine iv soln 1 mg/ml 5COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 1 x 20 mg (100

dose) kit*5 PA, QL (56 capsules/28 days)

COMETRIQ - cabozantinib s-mal cap 1 x 80 mg & 3 x 20 mg (140dose) kit*


COMETRIQ - cabozantinib s-malate cap 3 x 20 mg (60 mg dose)kit*


COSMEGEN - dactinomycin for inj 0.5 mg 5COTELLIC - cobimetinib fumarate tab 20 mg* 5 PA, QL (63 tablets/28 days)CYCLOPHOSPHAMIDE - cyclophosphamide cap 25 mg 4 BDCYCLOPHOSPHAMIDE - cyclophosphamide cap 50 mg 4 BD

2018


27

Drug Name Drug Tier Requirements/Limitscyclophosphamide for inj 500 mg 5cyclophosphamide for inj 1 gm 5cyclophosphamide for inj 2 gm 5CYRAMZA - ramucirumab iv soln 100 mg/10ml (for infusion)* 5CYRAMZA - ramucirumab iv soln 500 mg/50ml (for infusion)* 5CYTARABINE - cytarabine inj 20 mg/ml 2 BDcytarabine inj pf 20 mg/ml 2 BDcytarabine inj pf 100 mg/ml 2 BDDACARBAZINE - dacarbazine for inj 100 mg 4dacarbazine for inj 200 mg 2dactinomycin for inj 0.5 mg 5DARZALEX - daratumumab iv soln 100 mg/5ml* 5DARZALEX - daratumumab iv soln 400 mg/20ml* 5daunorubicin hcl inj 5 mg/ml 2decitabine for inj 50 mg 5dexrazoxane for inj 250 mg 5dexrazoxane for inj 500 mg 5DOCETAXEL - docetaxel for inj conc 20 mg/ml 5DOCETAXEL - docetaxel for inj conc 80 mg/4ml (20 mg/ml) 5DOCETAXEL - docetaxel for inj conc 160 mg/8ml (20 mg/ml) 5DOCETAXEL - docetaxel for inj conc 200 mg/10ml (20 mg/ml) 5DOCETAXEL - docetaxel soln for iv infusion 20 mg/2ml 5DOCETAXEL - docetaxel soln for iv infusion 80 mg/8ml 5DOCETAXEL - docetaxel soln for iv infusion 160 mg/16ml 5DOCETAXEL - docetaxel soln for iv infusion 200 mg/20ml 5docetaxel for inj conc 20 mg/ml 5docetaxel for inj conc 80 mg/4ml (20 mg/ml) 5DOXORUBICIN HCL - doxorubicin hcl for inj 10 mg 4 BDDOXORUBICIN HCL - doxorubicin hcl for inj 50 mg 4 BDdoxorubicin hcl inj 2 mg/ml 2 BDdoxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml 5 BDELITEK - rasburicase for iv soln 1.5 mg 5ELITEK - rasburicase for iv soln 7.5 mg 5EMCYT - estramustine phosphate sodium cap 140 mg 4EMPLICITI - elotuzumab for iv soln 300 mg 5EMPLICITI - elotuzumab for iv soln 400 mg 5epirubicin hcl iv soln 50 mg/25ml (2 mg/ml) 2epirubicin hcl iv soln 200 mg/100ml (2 mg/ml) 2

2018


Drug Name Drug Tier Requirements/LimitsERBITUX - cetuximab iv soln 100 mg/50ml (2 mg/ml) 5ERBITUX - cetuximab iv soln 200 mg/100ml (2 mg/ml) 5ERIVEDGE - vismodegib cap 150 mg* 5 PA, QL (30 capsules/30 days)ERWINAZE - asparaginase erwinia chrysanthemi for inj 10000 unit 5ETHYOL - amifostine for inj 500 mg 5ETOPOPHOS - etoposide phosphate iv for inj 100 mg 4etoposide inj 100 mg/5ml (20 mg/ml) 2etoposide inj 500 mg/25ml (20 mg/ml) 2etoposide inj 1 gm/50ml (20 mg/ml) 2EVOMELA - melphalan hcl for inj 50 mg* 5exemestane tab 25 mg 4FARESTON - toremifene citrate tab 60 mg 5FARYDAK - panobinostat lactate cap 10 mg* 5 PA, QL (6 capsules/21 days)FARYDAK - panobinostat lactate cap 15 mg* 5 PA, QL (6 capsules/21 days)FARYDAK - panobinostat lactate cap 20 mg* 5 PA, QL (6 capsules/21 days)FASLODEX - fulvestrant inj 250 mg/5ml 5fludarabine phosphate for inj 50 mg 2fludarabine phosphate inj 25 mg/ml 2fluorouracil inj 500 mg/10ml (50 mg/ml) 1 BDfluorouracil inj 1 gm/20ml (50 mg/ml) 1 BDfluorouracil inj 2.5 gm/50ml (50 mg/ml) 1 BDfluorouracil inj 5 gm/100ml (50 mg/ml) 1 BDflutamide cap 125 mg 2FOLOTYN - pralatrexate iv inj 20 mg/ml 5FOLOTYN - pralatrexate iv inj 40 mg/2ml 5GAZYVA - obinutuzumab soln for iv infusion 1000 mg/40ml (25 mg/

ml)5

gemcitabine hcl for inj 200 mg 3gemcitabine hcl for inj 1 gm 3gemcitabine hcl for inj 2 gm 3gemcitabine hcl inj 200 mg/5.26ml (38 mg/ml) 2gemcitabine hcl inj 1 gm/26.3ml (38 mg/ml) 2gemcitabine hcl inj 2 gm/52.6ml (38 mg/ml) 2GILOTRIF - afatinib dimaleate tab 20 mg 5 PA, QL (30 tablets/30 days)GILOTRIF - afatinib dimaleate tab 30 mg 5 PA, QL (30 tablets/30 days)GILOTRIF - afatinib dimaleate tab 40 mg 5 PA, QL (30 tablets/30 days)GLEOSTINE - lomustine cap 5 mg 4GLEOSTINE - lomustine cap 10 mg 4GLEOSTINE - lomustine cap 40 mg 4

2018


29

Drug Name Drug Tier Requirements/LimitsGLEOSTINE - lomustine cap 100 mg 4HALAVEN - eribulin mesylate inj 1 mg/2ml (0.5 mg/ml) 5HERCEPTIN - trastuzumab for iv soln 150 mg* 5HERCEPTIN - trastuzumab for iv soln 440 mg* 5HEXALEN - altretamine cap 50 mg 5 PAhydroxyurea cap 500 mg 2IBRANCE - palbociclib cap 75 mg* 5 PA, QL (21 capsules/28 days)IBRANCE - palbociclib cap 100 mg* 5 PA, QL (21 capsules/28 days)IBRANCE - palbociclib cap 125 mg* 5 PA, QL (21 capsules/28 days)ICLUSIG - ponatinib hcl tab 15 mg 5 PA, QL (60 tablets/30 days)ICLUSIG - ponatinib hcl tab 45 mg 5 PA, QL (30 tablets/30 days)idarubicin hcl iv inj 5 mg/5ml (1 mg/ml) 5idarubicin hcl iv inj 10 mg/10ml (1 mg/ml) 5idarubicin hcl iv inj 20 mg/20ml (1 mg/ml) 5IDHIFA - enasidenib mesylate tab 50 mg 5 PA, QL (30 tablets/30 days)IDHIFA - enasidenib mesylate tab 100 mg 5 PA, QL (30 tablets/30 days)IFEX - ifosfamide for inj 3 gm 4IFOSFAMIDE - ifosfamide for inj 3 gm 4ifosfamide for inj 1 gm 2ifosfamide iv inj 1 gm/20ml (50 mg/ml) 2ifosfamide iv inj 3 gm/60ml (50 mg/ml) 2imatinib mesylate tab 100 mg 5 PA, QL (90 tablets/30 days)imatinib mesylate tab 400 mg 5 PA, QL (60 tablets/30 days)IMBRUVICA - ibrutinib cap 140 mg 5 PA, QL (120 capsules/30 days)IMFINZI - durvalumab soln for iv infusion 120 mg/2.4ml (50 mg/ml) 5IMFINZI - durvalumab soln for iv infusion 500 mg/10ml (50 mg/ml) 5IMLYGIC - talimogene laherparepvec intralesional inj 1000000 unit/

ml*4

IMLYGIC - talimogene laherparepvec intralesional inj 100000000unit/ml*

5

INLYTA - axitinib tab 1 mg* 5 PA, QL (180 tablets/30 days)INLYTA - axitinib tab 5 mg* 5 PA, QL (120 tablets/30 days)IRESSA - gefitinib tab 250 mg* 5 PA, QL (30 tablets/30 days)IRINOTECAN - irinotecan hcl inj 500 mg/25ml (20 mg/ml) 3irinotecan hcl inj 40 mg/2ml (20 mg/ml) 3irinotecan hcl inj 100 mg/5ml (20 mg/ml) 3ISTODAX - romidepsin for iv inj 10 mg 5ISTODAX (OVERFILL) - romidepsin for iv inj 10 mg 5IXEMPRA KIT - ixabepilone for iv infusion 15 mg 5

2018


Drug Name Drug Tier Requirements/LimitsIXEMPRA KIT - ixabepilone for iv infusion 45 mg 5JAKAFI - ruxolitinib phosphate tab 5 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 10 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 15 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 20 mg* 5 PA, QL (60 tablets/30 days)JAKAFI - ruxolitinib phosphate tab 25 mg* 5 PA, QL (60 tablets/30 days)JEVTANA - cabazitaxel inj 60 mg/1.5ml (for iv infusion) 5KADCYLA - ado-trastuzumab emtansine for iv soln 100 mg 5KADCYLA - ado-trastuzumab emtansine for iv soln 160 mg 5KEYTRUDA - pembrolizumab for iv soln 50 mg* 5KEYTRUDA - pembrolizumab iv soln 100 mg/4ml (25 mg/ml)* 5KISQALI - ribociclib succinate tab 200 mg 5 PA, QL (63 tablets/28 days)KISQALI FEMARA 200 DOSE - ribociclib tab 200 mg & letrozole

tab 2.5 mg therapy pack5 PA, QL (91 tablets/28 days)

KISQALI FEMARA 400 DOSE - ribociclib tab 200 mg & letrozoletab 2.5 mg therapy pack

5 PA, QL (91 tablets/28 days)

KISQALI FEMARA 600 DOSE - ribociclib tab 200 mg & letrozoletab 2.5 mg therapy pack

5 PA, QL (91 tablets/28 days)

KYPROLIS - carfilzomib for inj 30 mg 5KYPROLIS - carfilzomib for inj 60 mg 5LARTRUVO - olaratumab soln for iv infusion 190 mg/19ml (10 mg/

ml)5

LARTRUVO - olaratumab soln for iv infusion 500 mg/50ml (10 mg/ml)

5

LENVIMA 10 MG DAILY DOSE - lenvatinib cap therapy pack10 mg*


LENVIMA 14 MG DAILY DOSE - lenvatinib cap therapy pack 10 &4 mg*


LENVIMA 18 MG DAILY DOSE - lenvatinib cap therapy pack 10 &4 (2) mg*


LENVIMA 20 MG DAILY DOSE - lenvatinib cap therapy pack 10(2) mg*


LENVIMA 24 MG DAILY DOSE - lenvatinib cap therapy pack 10 (2)& 4 mg*


LENVIMA 8 MG DAILY DOSE - lenvatinib cap therapy pack 4(2) mg*


letrozole tab 2.5 mg 1LEUCOVORIN CALCIUM - leucovorin calcium for inj 500 mg 4LEUCOVORIN CALCIUM - leucovorin calcium tab 10 mg 3LEUCOVORIN CALCIUM - leucovorin calcium tab 15 mg 4leucovorin calcium for inj 50 mg 4

2018


31

Drug Name Drug Tier Requirements/Limitsleucovorin calcium for inj 100 mg 4leucovorin calcium for inj 200 mg 4leucovorin calcium for inj 350 mg 3leucovorin calcium tab 5 mg 2leucovorin calcium tab 25 mg 4LEUKERAN - chlorambucil tab 2 mg 3LONSURF - trifluridine-tipiracil tab 15-6.14 mg 5 PA, QL (100 tablets/28 days)LONSURF - trifluridine-tipiracil tab 20-8.19 mg 5 PA, QL (80 tablets/28 days)LYNPARZA - olaparib cap 50 mg* 5 PA, QL (480 capsules/30 days)LYNPARZA - olaparib tab 100 mg* 5 PA, QL (120 tablets/30 days)LYNPARZA - olaparib tab 150 mg* 5 PA, QL (120 tablets/30 days)MARQIBO - vincristine sulfate liposome iv susp 5 mg/31ml

(0.16 mg/ml)5

MATULANE - procarbazine hcl cap 50 mg* 5 PAMEKINIST - trametinib dimethyl sulfoxide tab 0.5 mg* 5 PA, QL (90 tablets/30 days)MEKINIST - trametinib dimethyl sulfoxide tab 2 mg* 5 PA, QL (30 tablets/30 days)melphalan hcl for inj 50 mg 5mercaptopurine tab 50 mg 2mesna inj 100 mg/ml 2MESNEX - mesna tab 400 mg 4mitomycin for iv soln 5 mg 4mitomycin for iv soln 20 mg 2mitomycin for iv soln 40 mg 5mitoxantrone hcl inj conc 20 mg/10ml (2 mg/ml) 2mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/ml) 2mitoxantrone hcl inj conc 30 mg/15ml (2 mg/ml) 2MUSTARGEN - mechlorethamine hcl for inj 10 mg 4MYLOTARG - gemtuzumab ozogamicin for iv soln 4.5 mg 5NERLYNX - neratinib maleate tab 40 mg 5 PA, QL (180 tablets/30 days)NEXAVAR - sorafenib tosylate tab 200 mg* 5 PA, QL (120 tablets/30 days)nilutamide tab 150 mg 5NINLARO - ixazomib citrate cap 2.3 mg 5 PA, QL (3 capsules/28 days)NINLARO - ixazomib citrate cap 3 mg 5 PA, QL (3 capsules/28 days)NINLARO - ixazomib citrate cap 4 mg 5 PA, QL (3 capsules/28 days)NIPENT - pentostatin for inj 10 mg 5ODOMZO - sonidegib phosphate cap 200 mg* 5 PA, QL (30 capsules/30 days)ONCASPAR - pegaspargase inj 750 unit/ml 5ONIVYDE - irinotecan hcl liposome iv inj 43 mg/10ml (4.3 mg/ml) 5OPDIVO - nivolumab iv soln 40 mg/4ml* 5

2018


Drug Name Drug Tier Requirements/LimitsOPDIVO - nivolumab iv soln 100 mg/10ml* 5OPDIVO - nivolumab iv soln 240 mg/24ml* 5oxaliplatin for iv inj 50 mg 5oxaliplatin for iv inj 100 mg 5oxaliplatin iv soln 50 mg/10ml 4oxaliplatin iv soln 100 mg/20ml 4paclitaxel iv conc 30 mg/5ml (6 mg/ml) 3paclitaxel iv conc 100 mg/16.7ml (6 mg/ml) 3paclitaxel iv conc 300 mg/50ml (6 mg/ml) 3PANRETIN - alitretinoin gel 0.1% 5PERJETA - pertuzumab soln for iv infusion 420 mg/14ml (30 mg/

ml)*5

POMALYST - pomalidomide cap 1 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 2 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 3 mg* 5 PA, QL (21 capsules/28 days)POMALYST - pomalidomide cap 4 mg* 5 PA, QL (21 capsules/28 days)PORTRAZZA - necitumumab iv soln 800 mg/50ml (16 mg/ml)* 5PROLEUKIN - aldesleukin for iv soln 22000000 unit 5PURIXAN - mercaptopurine susp 2000 mg/100ml (20 mg/ml)* 5REVLIMID - lenalidomide caps 2.5 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 5 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 10 mg* 5 PA, QL (30 capsules/30 days)REVLIMID - lenalidomide cap 15 mg* 5 PA, QL (21 capsules/28 days)REVLIMID - lenalidomide cap 20 mg* 5 PA, QL (21 capsules/28 days)REVLIMID - lenalidomide cap 25 mg* 5 PA, QL (21 capsules/28 days)RITUXAN - rituximab iv soln 100 mg/10ml* 5 PARITUXAN - rituximab iv soln 500 mg/50ml* 5 PARITUXAN HYCELA - rituximab-hyaluronidase human inj

1400-23400 mg-unit/11.7ml5 PA

RITUXAN HYCELA - rituximab-hyaluronidase human inj1600-26800 mg-unit/13.4ml

5 PA

RUBRACA - rucaparib camsylate tab 200 mg 5 PA, QL (120 tablets/30 days)RUBRACA - rucaparib camsylate tab 250 mg 5 PA, QL (120 tablets/30 days)RUBRACA - rucaparib camsylate tab 300 mg 5 PA, QL (120 tablets/30 days)RYDAPT - midostaurin cap 25 mg 5 PA, QL (240 capsules/30 days)SOLTAMOX - tamoxifen citrate oral soln 10 mg/5ml 4SPRYCEL - dasatinib tab 20 mg 5 PA, QL (90 tablets/30 days)SPRYCEL - dasatinib tab 50 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 70 mg 5 PA, QL (30 tablets/30 days)

2018


33

Drug Name Drug Tier Requirements/LimitsSPRYCEL - dasatinib tab 80 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 100 mg 5 PA, QL (30 tablets/30 days)SPRYCEL - dasatinib tab 140 mg 5 PA, QL (30 tablets/30 days)STIVARGA - regorafenib tab 40 mg* 5 PA, QL (84 tablets/28 days)SUTENT - sunitinib malate cap 12.5 mg 5 PA, QL (90 capsules/30 days)SUTENT - sunitinib malate cap 25 mg 5 PA, QL (30 capsules/30 days)SUTENT - sunitinib malate cap 37.5 mg 5 PA, QL (30 capsules/30 days)SUTENT - sunitinib malate cap 50 mg 5 PA, QL (30 capsules/30 days)SYNRIBO - omacetaxine mepesuccinate for inj 3.5 mg 5TABLOID - thioguanine tab 40 mg 4TAFINLAR - dabrafenib mesylate cap 50 mg* 5 PA, QL (120 capsules/30 days)TAFINLAR - dabrafenib mesylate cap 75 mg* 5 PA, QL (120 capsules/30 days)TAGRISSO - osimertinib mesylate tab 40 mg* 5 PA, QL (30 tablets/30 days)TAGRISSO - osimertinib mesylate tab 80 mg* 5 PA, QL (30 tablets/30 days)tamoxifen citrate tab 10 mg 2tamoxifen citrate tab 20 mg 2TARCEVA - erlotinib hcl tab 25 mg 5 PA, QL (60 tablets/30 days)TARCEVA - erlotinib hcl tab 100 mg 5 PA, QL (30 tablets/30 days)TARCEVA - erlotinib hcl tab 150 mg 5 PA, QL (30 tablets/30 days)TARGRETIN - bexarotene gel 1% 5TASIGNA - nilotinib hcl cap 150 mg 5 PA, QL (120 capsules/30 days)TASIGNA - nilotinib hcl cap 200 mg 5 PA, QL (120 capsules/30 days)TECENTRIQ - atezolizumab iv soln 1200 mg/20ml* 5TEMODAR - temozolomide for iv soln 100 mg 5THALOMID - thalidomide cap 50 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 100 mg 5 PA, QL (30 capsules/30 days)THALOMID - thalidomide cap 150 mg 5 PA, QL (60 capsules/30 days)THALOMID - thalidomide cap 200 mg 5 PA, QL (60 capsules/30 days)thiotepa for inj 15 mg 5TOPOTECAN HCL - topotecan hcl inj 4 mg/4ml (for infusion) 5topotecan hcl for inj 4 mg 5TORISEL - temsirolimus soln for iv infusion 25 mg/ml 5TREANDA - bendamustine hcl for iv soln 25 mg 5TREANDA - bendamustine hcl for iv soln 100 mg 5tretinoin cap 10 mg 5 PATRISENOX - arsenic trioxide inj 10 mg/10ml (1 mg/ml) 4TRISENOX - arsenic trioxide iv soln 12 mg/6ml (2 mg/ml) 5TYKERB - lapatinib ditosylate tab 250 mg* 5 PA, QL (180 tablets/30 days)

2018


Drug Name Drug Tier Requirements/LimitsUNITUXIN - dinutuximab iv soln 17.5 mg/5ml (3.5 mg/ml)* 5VALCHLOR - mechlorethamine hcl gel 0.016%* 5VECTIBIX - panitumumab iv soln 100 mg/5ml 5VECTIBIX - panitumumab iv soln 400 mg/20ml 5VELCADE - bortezomib for inj 3.5 mg 5VENCLEXTA - venetoclax tab 10 mg* 3 PA, QL (60 tablets/30 days)VENCLEXTA - venetoclax tab 50 mg* 4 PA, QL (30 tablets/30 days)VENCLEXTA - venetoclax tab 100 mg* 5 PA, QL (120 tablets/30 days)VENCLEXTA STARTING PACK - venetoclax tab therapy starter

pack 10 & 50 & 100 mg*5 PA, QL (1 pack (42

tablets)/28 days)VERZENIO - abemaciclib tab 50 mg 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 100 mg 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 150 mg 5 PA, QL (60 tablets/30 days)VERZENIO - abemaciclib tab 200 mg 5 PA, QL (60 tablets/30 days)VINBLASTINE SULFATE - vinblastine sulfate inj 1 mg/ml 4 BDvincristine sulfate iv soln 1 mg/ml 2 BDvinorelbine tartrate inj 10 mg/ml 3vinorelbine tartrate inj 50 mg/5ml (10 mg/ml) 3VOTRIENT - pazopanib hcl tab 200 mg* 5 PA, QL (120 tablets/30 days)VYXEOS - daunorubicin-cytarabine liposome for iv inj 44-100 mg 5XALKORI - crizotinib cap 200 mg* 5 PA, QL (60 capsules/30 days)XALKORI - crizotinib cap 250 mg* 5 PA, QL (60 capsules/30 days)XTANDI - enzalutamide cap 40 mg* 5 PA, QL (120 capsules/30 days)YERVOY - ipilimumab soln for iv infusion 50 mg/10ml (5 mg/ml)* 5YERVOY - ipilimumab soln for iv infusion 200 mg/40ml (5 mg/ml)* 5YONDELIS - trabectedin for inj 1 mg 5ZALTRAP - ziv-aflibercept iv soln 100 mg/4ml (for infusion) 5ZALTRAP - ziv-aflibercept iv soln 200 mg/8ml (for infusion) 5ZANOSAR - streptozocin for inj 1 gm 4ZEJULA - niraparib tosylate cap 100 mg 5 PA, QL (90 capsules/30 days)ZELBORAF - vemurafenib tab 240 mg* 5 PA, QL (240 tablets/30 days)ZOLINZA - vorinostat cap 100 mg 5 PA, QL (120 capsules/30 days)ZYDELIG - idelalisib tab 100 mg* 5 PA, QL (60 tablets/30 days)ZYDELIG - idelalisib tab 150 mg* 5 PA, QL (60 tablets/30 days)ZYKADIA - ceritinib cap 150 mg* 5 PA, QL (150 capsules/30 days)ZYTIGA - abiraterone acetate tab 250 mg* 5 PA, QL (120 tablets/30 days)ZYTIGA - abiraterone acetate tab 500 mg* 5 PA, QL (60 tablets/30 days)AntiparasiticsALBENZA - albendazole tab 200 mg 5

2018


35

Drug Name Drug Tier Requirements/LimitsALINIA - nitazoxanide for susp 100 mg/5ml 5ALINIA - nitazoxanide tab 500 mg 5atovaquone susp 750 mg/5ml 5atovaquone-proguanil hcl tab 62.5-25 mg 2atovaquone-proguanil hcl tab 250-100 mg 2BENZNIDAZOLE - benznidazole tab 12.5 mg 4BENZNIDAZOLE - benznidazole tab 100 mg 4BILTRICIDE - praziquantel tab 600 mg 4CHLOROQUINE PHOSPHATE - chloroquine phosphate tab

250 mg3

chloroquine phosphate tab 500 mg 2COARTEM - artemether-lumefantrine tab 20-120 mg 4DARAPRIM - pyrimethamine tab 25 mg 5hydroxychloroquine sulfate tab 200 mg 2ivermectin tab 3 mg 2LINDANE - lindane shampoo 1% 3malathion lotion 0.5% 3mefloquine hcl tab 250 mg 2NEBUPENT - pentamidine isethionate for nebulization soln 300 mg 4 BDPENTAM 300 - pentamidine isethionate for soln 300 mg 4 BDpermethrin cream 5% 2PRIMAQUINE PHOSPHATE - primaquine phosphate tab 26.3 mg 4Antiparkinson Agentsamantadine hcl cap 100 mg 2amantadine hcl syrup 50 mg/5ml 2amantadine hcl tab 100 mg 2APOKYN - apomorphine hcl soln cartridge 30 mg/3ml* 5 PA, QL (60 mls/30 days)benztropine mesylate tab 0.5 mg# 3 PAbenztropine mesylate tab 1 mg# 3 PAbenztropine mesylate tab 2 mg# 3 PAbromocriptine mesylate cap 5 mg 2bromocriptine mesylate tab 2.5 mg 3carbidopa & levodopa orally disintegrating tab 10-100 mg 2carbidopa & levodopa orally disintegrating tab 25-100 mg 2carbidopa & levodopa orally disintegrating tab 25-250 mg 2carbidopa & levodopa tab er 25-100 mg 2carbidopa & levodopa tab er 50-200 mg 2carbidopa & levodopa tab 10-100 mg 2carbidopa & levodopa tab 25-100 mg 2

2018


Drug Name Drug Tier Requirements/Limitscarbidopa & levodopa tab 25-250 mg 2carbidopa tab 25 mg 5CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-

entacapone tabs 12.5-50-200 mg3

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 18.75-75-200 mg

3

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 25-100-200 mg

3


3


3

CARBIDOPA/LEVODOPA/ENTACAPONE - carbidopa-levodopa-entacapone tabs 50-200-200 mg

3

entacapone tab 200 mg 3NEUPRO - rotigotine td patch 24hr 1 mg/24hr 3NEUPRO - rotigotine td patch 24hr 2 mg/24hr 3NEUPRO - rotigotine td patch 24hr 3 mg/24hr 3NEUPRO - rotigotine td patch 24hr 4 mg/24hr 3NEUPRO - rotigotine td patch 24hr 6 mg/24hr 3NEUPRO - rotigotine td patch 24hr 8 mg/24hr 3pramipexole dihydrochloride tab 0.125 mg 1pramipexole dihydrochloride tab 0.25 mg 1pramipexole dihydrochloride tab 0.5 mg 1pramipexole dihydrochloride tab 0.75 mg 1pramipexole dihydrochloride tab 1 mg 1pramipexole dihydrochloride tab 1.5 mg 1rasagiline mesylate tab 0.5 mg 4rasagiline mesylate tab 1 mg 4ropinirole hydrochloride tab 0.25 mg 2ropinirole hydrochloride tab 0.5 mg 2ropinirole hydrochloride tab 1 mg 2ropinirole hydrochloride tab 2 mg 2ropinirole hydrochloride tab 3 mg 2ropinirole hydrochloride tab 4 mg 2ropinirole hydrochloride tab 5 mg 2selegiline hcl cap 5 mg 2selegiline hcl tab 5 mg 2tolcapone tab 100 mg 5

2018


37

Drug Name Drug Tier Requirements/LimitsAntipsychoticsADASUVE - loxapine aerosol powder breath activated 10 mg 4 PAaripiprazole oral solution 1 mg/ml 2 PA, QL (750 mls/30 days)aripiprazole orally disintegrating tab 10 mg 5 PA, QL (60 tablets/30 days)aripiprazole orally disintegrating tab 15 mg 5 PA, QL (60 tablets/30 days)aripiprazole tab 2 mg 4 PA, QL (45 tablets/30 days)aripiprazole tab 5 mg 4 PA, QL (45 tablets/30 days)aripiprazole tab 10 mg 4 PA, QL (30 tablets/30 days)aripiprazole tab 15 mg 4 PA, QL (30 tablets/30 days)aripiprazole tab 20 mg 4 PA, QL (30 tablets/30 days)aripiprazole tab 30 mg 4 PA, QL (30 tablets/30 days)ARISTADA - aripiprazole lauroxil im er susp prefilled syr

441 mg/1.6ml5 PA, QL (1 syringe/28 days)

ARISTADA - aripiprazole lauroxil im er susp prefilled syr662 mg/2.4ml

5 PA, QL (1 syringe/28 days)





clozapine orally disintegrating tab 25 mg 2 PA, QL (270 tablets/30 days)clozapine orally disintegrating tab 100 mg 2 PA, QL (270 tablets/30 days)clozapine tab 25 mg 2 PA, QL (90 tablets/30 days)clozapine tab 50 mg 2 PA, QL (90 tablets/30 days)clozapine tab 100 mg 2 PA, QL (270 tablets/30 days)clozapine tab 200 mg 2 PA, QL (120 tablets/30 days)FANAPT - iloperidone tab 1 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 2 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 4 mg 4 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 6 mg 5 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 8 mg 5 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 10 mg 5 PA, QL (60 tablets/30 days)FANAPT - iloperidone tab 12 mg 5 PA, QL (60 tablets/30 days)FANAPT TITRATION PACK - iloperidone tab 1 mg & 2 mg & 4 mg

& 6 mg titration pak4 PA, QL (7 packs (56

tablets)/28 days)fluphenazine decanoate inj 25 mg/ml 2 PAFLUPHENAZINE HCL - fluphenazine hcl elixir 2.5 mg/5ml 4 PAFLUPHENAZINE HCL - fluphenazine hcl inj 2.5 mg/ml 4 PAFLUPHENAZINE HCL - fluphenazine hcl oral conc 5 mg/ml 4 PAfluphenazine hcl tab 1 mg 2 PAfluphenazine hcl tab 2.5 mg 2 PA

2018


Drug Name Drug Tier Requirements/Limitsfluphenazine hcl tab 5 mg 2 PAfluphenazine hcl tab 10 mg 2 PAGEODON - ziprasidone mesylate for inj 20 mg 4 PA, QL (60 vials/30 days)haloperidol decanoate im soln 50 mg/ml 2 PAhaloperidol decanoate im soln 100 mg/ml 2 PAhaloperidol lactate inj 5 mg/ml 2 PAhaloperidol lactate oral conc 2 mg/ml 2 PAhaloperidol tab 0.5 mg 2 PAhaloperidol tab 1 mg 2 PAhaloperidol tab 2 mg 2 PAhaloperidol tab 5 mg 2 PAhaloperidol tab 10 mg 2 PAhaloperidol tab 20 mg 2 PAINVEGA SUSTENNA - paliperidone palmitate im extend-release

susp 117 mg/0.75ml5 PA, QL (1 kit/28 days)

INVEGA SUSTENNA - paliperidone palmitate im extended-releasesusp 39 mg/0.25ml

4 PA, QL (1 kit/28 days)



INVEGA SUSTENNA - paliperidone palmitate im extended-releasesusp 156 mg/ml




INVEGA TRINZA - paliperidone palmitate im extend-release susp273 mg/0.875ml








LATUDA - lurasidone hcl tab 20 mg 5 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 40 mg 5 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 60 mg 5 PA, QL (30 tablets/30 days)LATUDA - lurasidone hcl tab 80 mg 5 PA, QL (60 tablets/30 days)LATUDA - lurasidone hcl tab 120 mg 5 PA, QL (30 tablets/30 days)loxapine succinate cap 5 mg 2 PAloxapine succinate cap 10 mg 2 PAloxapine succinate cap 25 mg 2 PAloxapine succinate cap 50 mg 2 PANUPLAZID - pimavanserin tartrate tab 17 mg* 5 PA, QL (60 tablets/30 days)

2018


39

Drug Name Drug Tier Requirements/Limitsolanzapine for im inj 10 mg 2 PA, QL (90 vials/30 days)olanzapine orally disintegrating tab 5 mg 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 10 mg 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 15 mg 2 PA, QL (30 tablets/30 days)olanzapine orally disintegrating tab 20 mg 2 PA, QL (30 tablets/30 days)olanzapine tab 2.5 mg 2 PA, QL (45 tablets/30 days)olanzapine tab 5 mg 2 PA, QL (45 tablets/30 days)olanzapine tab 7.5 mg 2 PA, QL (45 tablets/30 days)olanzapine tab 10 mg 2 PA, QL (45 tablets/30 days)olanzapine tab 15 mg 2 PA, QL (30 tablets/30 days)olanzapine tab 20 mg 2 PA, QL (30 tablets/30 days)paliperidone tab er 24hr 1.5 mg 4 PA, QL (30 tablets/30 days)paliperidone tab er 24hr 3 mg 4 PA, QL (30 tablets/30 days)paliperidone tab er 24hr 6 mg 4 PA, QL (60 tablets/30 days)paliperidone tab er 24hr 9 mg 5 PA, QL (30 tablets/30 days)pimozide tab 1 mg 2pimozide tab 2 mg 2quetiapine fumarate tab er 24hr 50 mg 4 PA, QL (60 tablets/30 days)quetiapine fumarate tab er 24hr 150 mg 4 PA, QL (30 tablets/30 days)quetiapine fumarate tab er 24hr 200 mg 4 PA, QL (30 tablets/30 days)quetiapine fumarate tab er 24hr 300 mg 4 PA, QL (60 tablets/30 days)quetiapine fumarate tab er 24hr 400 mg 4 PA, QL (60 tablets/30 days)quetiapine fumarate tab 25 mg 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 50 mg 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 100 mg 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 200 mg 2 PA, QL (120 tablets/30 days)quetiapine fumarate tab 300 mg 2 PA, QL (60 tablets/30 days)quetiapine fumarate tab 400 mg 2 PA, QL (60 tablets/30 days)REXULTI - brexpiprazole tab 0.25 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 0.5 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 1 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 2 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 3 mg 5 PA, QL (30 tablets/30 days)REXULTI - brexpiprazole tab 4 mg 5 PA, QL (30 tablets/30 days)RISPERDAL CONSTA - risperidone microspheres for inj 12.5 mg 4 PA, QL (2 vials/28 days)RISPERDAL CONSTA - risperidone microspheres for inj 25 mg 4 PA, QL (2 vials/28 days)RISPERDAL CONSTA - risperidone microspheres for inj 37.5 mg 4 PA, QL (2 vials/28 days)RISPERDAL CONSTA - risperidone microspheres for inj 50 mg 5 PA, QL (2 vials/28 days)

2018


Drug Name Drug Tier Requirements/Limitsrisperidone orally disintegrating tab 0.25 mg 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 0.5 mg 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 1 mg 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 2 mg 2 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 3 mg 3 PA, QL (60 tablets/30 days)risperidone orally disintegrating tab 4 mg 3 PA, QL (120 tablets/30 days)risperidone soln 1 mg/ml 2 PA, QL (480 mls/30 days)risperidone tab 0.25 mg 1 PA, QL (60 tablets/30 days)risperidone tab 0.5 mg 1 PA, QL (60 tablets/30 days)risperidone tab 1 mg 1 PA, QL (60 tablets/30 days)risperidone tab 2 mg 1 PA, QL (60 tablets/30 days)risperidone tab 3 mg 1 PA, QL (60 tablets/30 days)risperidone tab 4 mg 1 PA, QL (120 tablets/30 days)SAPHRIS - asenapine maleate sl tab 2.5 mg 4 PA, QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 5 mg 4 PA, QL (60 tablets/30 days)SAPHRIS - asenapine maleate sl tab 10 mg 4 PA, QL (60 tablets/30 days)thioridazine hcl tab 10 mg 4 PAthioridazine hcl tab 25 mg 4 PAthioridazine hcl tab 50 mg 4 PAthioridazine hcl tab 100 mg 4 PAthiothixene cap 1 mg 2 PAthiothixene cap 2 mg 2 PAthiothixene cap 5 mg 2 PAthiothixene cap 10 mg 2 PAtrifluoperazine hcl tab 1 mg 2 PAtrifluoperazine hcl tab 2 mg 2 PAtrifluoperazine hcl tab 5 mg 2 PAtrifluoperazine hcl tab 10 mg 2 PAVERSACLOZ - clozapine susp 50 mg/ml 5 PA, QL (540 mls/30 days)VRAYLAR - cariprazine hcl cap 1.5 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 3 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 4.5 mg 5 PA, QL (30 capsules/30 days)VRAYLAR - cariprazine hcl cap 6 mg 5 PA, QL (30 capsules/30 days)ziprasidone hcl cap 20 mg 2 PA, QL (90 capsules/30 days)ziprasidone hcl cap 40 mg 2 PA, QL (90 capsules/30 days)ziprasidone hcl cap 60 mg 2 PA, QL (60 capsules/30 days)ziprasidone hcl cap 80 mg 2 PA, QL (60 capsules/30 days)ZYPREXA RELPREVV - olanzapine pamoate for extended rel im

susp 210 mg5 PA, QL (2 vials/28 days)

2018


41

Drug Name Drug Tier Requirements/LimitsZYPREXA RELPREVV - olanzapine pamoate for extended rel im

susp 300 mg5 PA, QL (2 vials/28 days)

ZYPREXA RELPREVV - olanzapine pamoate for extended rel imsusp 405 mg

5 PA, QL (1 vial/28 days)

Antispasticity Agentsbaclofen tab 10 mg 2baclofen tab 20 mg 2dantrolene sodium cap 25 mg 2dantrolene sodium cap 50 mg 2dantrolene sodium cap 100 mg 2tizanidine hcl cap 2 mg 2tizanidine hcl cap 4 mg 2tizanidine hcl cap 6 mg 2tizanidine hcl tab 2 mg 2tizanidine hcl tab 4 mg 2Antiviralsabacavir sulfate soln 20 mg/ml 4 QL (960 mls/30 days)abacavir sulfate tab 300 mg 4 QL (60 tablets/30 days)abacavir sulfate-lamivudine tab 600-300 mg 5 QL (30 tablets/30 days)abacavir sulfate-lamivudine-zidovudine tab 300-150-300 mg 5 QL (60 tablets/30 days)acyclovir cap 200 mg 1acyclovir oint 5% 2ACYCLOVIR SODIUM - acyclovir sodium for inj 500 mg 3 BDacyclovir sodium iv soln 50 mg/ml 2 BDacyclovir susp 200 mg/5ml 3acyclovir tab 400 mg 2acyclovir tab 800 mg 2adefovir dipivoxil tab 10 mg 5APTIVUS - tipranavir cap 250 mg 5 QL (120 capsules/30 days)APTIVUS - tipranavir oral soln 100 mg/ml 5 QL (380 mls/30 days)atazanavir sulfate cap 150 mg 5 QL (30 capsules/30 days)atazanavir sulfate cap 200 mg 5 QL (60 capsules/30 days)atazanavir sulfate cap 300 mg 5 QL (30 capsules/30 days)ATRIPLA - efavirenz-emtricitabine-tenofovir df tab 600-200-300 mg 5 QL (30 tablets/30 days)BARACLUDE - entecavir oral soln 0.05 mg/ml 4cidofovir iv inj 75 mg/ml 5COMPLERA - emtricitabine-rilpivirine-tenofovir df tab

200-25-300 mg5 QL (30 tablets/30 days)

CRIXIVAN - indinavir sulfate cap 200 mg 3 QL (270 capsules/30 days)CRIXIVAN - indinavir sulfate cap 400 mg 3 QL (180 capsules/30 days)

2018


Drug Name Drug Tier Requirements/LimitsDAKLINZA - daclatasvir dihydrochloride tab 30 mg 5 PADAKLINZA - daclatasvir dihydrochloride tab 60 mg 5 PADAKLINZA - daclatasvir dihydrochloride tab 90 mg 5 PADENAVIR - penciclovir cream 1% 5DESCOVY - emtricitabine-tenofovir alafenamide fumarate tab

200-25 mg5 QL (30 tablets/30 days)

didanosine delayed release capsule 125 mg 2 QL (30 capsules/30 days)didanosine delayed release capsule 200 mg 2 QL (30 capsules/30 days)didanosine delayed release capsule 250 mg 2 QL (30 capsules/30 days)didanosine delayed release capsule 400 mg 3 QL (30 capsules/30 days)EDURANT - rilpivirine hcl tab 25 mg 5 QL (30 tablets/30 days)efavirenz cap 50 mg 2 QL (90 capsules/30 days)efavirenz cap 200 mg 5 QL (60 capsules/30 days)efavirenz tab 600 mg 5 QL (30 tablets/30 days)EMTRIVA - emtricitabine caps 200 mg 4 QL (30 capsules/30 days)EMTRIVA - emtricitabine soln 10 mg/ml 4 QL (850 mls/30 days)entecavir tab 0.5 mg 4entecavir tab 1 mg 4EPCLUSA - sofosbuvir-velpatasvir tab 400-100 mg 5 PAEPIVIR HBV - lamivudine oral soln 5 mg/ml (hbv) 3EVOTAZ - atazanavir sulfate-cobicistat tab 300-150 mg 5 QL (30 tablets/30 days)famciclovir tab 125 mg 2famciclovir tab 250 mg 2famciclovir tab 500 mg 2fosamprenavir calcium tab 700 mg 5 QL (120 tablets/30 days)FUZEON - enfuvirtide for inj 90 mg 5 QL (60 vials/30 days)ganciclovir sodium for inj 500 mg 2 BDGENVOYA - elvitegrav-cobic-emtricitab-tenofov af tab

150-150-200-10 mg5 QL (30 tablets/30 days)

HARVONI - ledipasvir-sofosbuvir tab 90-400 mg 5 PAINTELENCE - etravirine tab 25 mg 4 QL (120 tablets/30 days)INTELENCE - etravirine tab 100 mg 4 QL (60 tablets/30 days)INTELENCE - etravirine tab 200 mg 5 QL (60 tablets/30 days)INTRON A - interferon alfa-2b inj 6000000 unit/ml 5INTRON A - interferon alfa-2b inj 10000000 unit/ml 5INTRON A - interferon alfa-2b for inj 10000000 unit 5INTRON A - interferon alfa-2b for inj 18000000 unit 5INTRON A - interferon alfa-2b for inj 50000000 unit 5INTRON A W/DILUENT - interferon alfa-2b for inj 10000000 unit 5

2018


43

Drug Name Drug Tier Requirements/LimitsINTRON A W/DILUENT - interferon alfa-2b for inj 18000000 unit 5INTRON A W/DILUENT - interferon alfa-2b for inj 50000000 unit 5INVIRASE - saquinavir mesylate cap 200 mg 5 QL (300 capsules/30 days)INVIRASE - saquinavir mesylate tab 500 mg 5 QL (120 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 25 mg 3 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium chew tab 100 mg 3 QL (180 tablets/30 days)ISENTRESS - raltegravir potassium packet for susp 100 mg 4 QL (60 packets/30 days)ISENTRESS - raltegravir potassium tab 400 mg 5 QL (60 tablets/30 days)ISENTRESS HD - raltegravir potassium tab 600 mg 5 QL (60 tablets/30 days)KALETRA - lopinavir-ritonavir tab 100-25 mg 5 QL (300 tablets/30 days)KALETRA - lopinavir-ritonavir tab 200-50 mg 5 QL (120 tablets/30 days)lamivudine oral soln 10 mg/ml 2 QL (960 mls/30 days)lamivudine tab 100 mg (hbv) 4lamivudine tab 150 mg 2 QL (60 tablets/30 days)lamivudine tab 300 mg 2 QL (30 tablets/30 days)lamivudine-zidovudine tab 150-300 mg 4 QL (60 tablets/30 days)LEXIVA - fosamprenavir calcium susp 50 mg/ml 4 QL (1800 mls/30 days)LEXIVA - fosamprenavir calcium tab 700 mg 5 QL (120 tablets/30 days)lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/ml) 5 QL (480 mls/30 days)MAVYRET - glecaprevir-pibrentasvir tab 100-40 mg 5 PANEVIRAPINE - nevirapine susp 50 mg/5ml 4 QL (1200 mls/30 days)nevirapine tab er 24hr 100 mg 3 QL (90 tablets/30 days)nevirapine tab er 24hr 400 mg 4 QL (30 tablets/30 days)nevirapine tab 200 mg 2 QL (60 tablets/30 days)NORVIR - ritonavir cap 100 mg 4 QL (360 capsules/30 days)NORVIR - ritonavir oral soln 80 mg/ml 4 QL (480 mls/30 days)NORVIR - ritonavir tab 100 mg 4 QL (360 tablets/30 days)ODEFSEY - emtricitabine-rilpivirine-tenofovir af tab 200-25-25 mg 5 QL (30 tablets/30 days)OLYSIO - simeprevir sodium cap 150 mg 5 PAoseltamivir phosphate cap 30 mg 2oseltamivir phosphate cap 45 mg 2oseltamivir phosphate cap 75 mg 2oseltamivir phosphate for susp 6 mg/ml 2PEGASYS - peginterferon alfa-2a inj 180 mcg/ml 5 PAPEGASYS - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PAPEGASYS PROCLICK - peginterferon alfa-2a inj 135 mcg/0.5ml 5 PAPEGASYS PROCLICK - peginterferon alfa-2a inj 180 mcg/0.5ml 5 PAPREZCOBIX - darunavir-cobicistat tab 800-150 mg 5 QL (30 tablets/30 days)

2018


Drug Name Drug Tier Requirements/LimitsPREZISTA - darunavir ethanolate susp 100 mg/ml 5 QL (400 mls/30 days)PREZISTA - darunavir ethanolate tab 75 mg 4 QL (300 tablets/30 days)PREZISTA - darunavir ethanolate tab 150 mg 4 QL (180 tablets/30 days)PREZISTA - darunavir ethanolate tab 600 mg 5 QL (60 tablets/30 days)PREZISTA - darunavir ethanolate tab 800 mg 5 QL (30 tablets/30 days)REBETOL - ribavirin soln 40 mg/ml 4RESCRIPTOR - delavirdine mesylate tab 100 mg 4 QL (360 tablets/30 days)RESCRIPTOR - delavirdine mesylate tab 200 mg 4 QL (180 tablets/30 days)RETROVIR IV INFUSION - zidovudine iv soln 10 mg/ml 4REYATAZ - atazanavir sulfate cap 150 mg 5 QL (30 capsules/30 days)REYATAZ - atazanavir sulfate cap 200 mg 5 QL (60 capsules/30 days)REYATAZ - atazanavir sulfate cap 300 mg 5 QL (30 capsules/30 days)REYATAZ - atazanavir sulfate oral powder packet 50 mg 5 QL (240 packets/30 days)RIBASPHERE - ribavirin tab 400 mg 5RIBASPHERE - ribavirin tab 600 mg 5RIBASPHERE RIBAPAK - ribavirin tab 400 mg 5RIBASPHERE RIBAPAK - ribavirin tab 600 mg 5ribavirin cap 200 mg 2ribavirin tab 200 mg 2rimantadine hydrochloride tab 100 mg 2SELZENTRY - maraviroc oral soln 20 mg/ml 5 QL (1840 mls/30 days)SELZENTRY - maraviroc tab 25 mg 4 QL (240 tablets/30 days)SELZENTRY - maraviroc tab 75 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 150 mg 5 QL (60 tablets/30 days)SELZENTRY - maraviroc tab 300 mg 5 QL (120 tablets/30 days)SOVALDI - sofosbuvir tab 400 mg 5 PAstavudine cap 15 mg 2 QL (60 capsules/30 days)stavudine cap 20 mg 2 QL (60 capsules/30 days)stavudine cap 30 mg 2 QL (60 capsules/30 days)stavudine cap 40 mg 2 QL (60 capsules/30 days)STRIBILD - elvitegrav-cobic-emtricitab-tenofovdf tab

150-150-200-300 mg5 QL (30 tablets/30 days)

SUSTIVA - efavirenz cap 50 mg 4 QL (90 capsules/30 days)SUSTIVA - efavirenz cap 200 mg 5 QL (60 capsules/30 days)SUSTIVA - efavirenz tab 600 mg 5 QL (30 tablets/30 days)SYLATRON - peginterferon alfa-2b for inj kit 200 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 300 mcg 5 PASYLATRON - peginterferon alfa-2b for inj kit 600 mcg 5 PATAMIFLU - oseltamivir phosphate for susp 6 mg/ml 4

2018


45

Drug Name Drug Tier Requirements/LimitsTECHNIVIE - ombitasvir-paritaprevir-ritonavir tab 12.5-75-50 mg 5 PAtenofovir disoproxil fumarate tab 300 mg 5 QL (30 tablets/30 days)TIVICAY - dolutegravir sodium tab 10 mg 4 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 25 mg 5 QL (60 tablets/30 days)TIVICAY - dolutegravir sodium tab 50 mg 5 QL (60 tablets/30 days)TRIUMEQ - abacavir-dolutegravir-lamivudine tab 600-50-300 mg 5 QL (30 tablets/30 days)TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab


TRUVADA - emtricitabine-tenofovir disoproxil fumarate tab133-200 mg

5 QL (30 tablets/30 days)





TYBOST - cobicistat tab 150 mg 3 QL (30 tablets/30 days)valacyclovir hcl tab 500 mg 2valacyclovir hcl tab 1 gm 2valganciclovir hcl for soln 50 mg/ml 5valganciclovir hcl tab 450 mg 5VIDEX - didanosine for soln 2 gm 4 QL (1200 mls/30 days)VIDEX - didanosine for soln 4 gm 4 QL (1200 mls/30 days)VIDEX EC - didanosine delayed release capsule 125 mg 4 QL (30 capsules/30 days)VIEKIRA PAK - ombitas-paritapre-riton & dasab tab pak 12.5-75-50

& 250 mg5 PA

VIEKIRA XR - dasab-ombit-paritap-riton tab er 24hr200-8.33-50-33.33 mg

5 PA

VIRACEPT - nelfinavir mesylate tab 250 mg 5 QL (270 tablets/30 days)VIRACEPT - nelfinavir mesylate tab 625 mg 5 QL (120 tablets/30 days)VIRAMUNE - nevirapine susp 50 mg/5ml 4 QL (1200 mls/30 days)VIREAD - tenofovir disoproxil fumarate oral powder 40 mg/gm 5 QL (240 grams/30 days)VIREAD - tenofovir disoproxil fumarate tab 150 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 200 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 250 mg 5 QL (30 tablets/30 days)VIREAD - tenofovir disoproxil fumarate tab 300 mg 5 QL (30 tablets/30 days)VOSEVI - sofosbuvir-velpatasvir-voxilaprevir tab 400-100-100 mg 5 PAZEPATIER - elbasvir-grazoprevir tab 50-100 mg 5 PAZERIT - stavudine for oral soln 1 mg/ml 4 QL (2400 mls/30 days)ZIAGEN - abacavir sulfate soln 20 mg/ml 4 QL (960 mls/30 days)zidovudine cap 100 mg 2 QL (180 capsules/30 days)zidovudine syrup 10 mg/ml 2 QL (1920 mls/30 days)

2018


Drug Name Drug Tier Requirements/Limitszidovudine tab 300 mg 2 QL (60 tablets/30 days)Anxiolyticsalprazolam tab 0.25 mg 3 QL (120 tablets/30 days)alprazolam tab 0.5 mg 3 QL (120 tablets/30 days)alprazolam tab 1 mg 3 QL (120 tablets/30 days)alprazolam tab 2 mg 3 QL (150 tablets/30 days)buspirone hcl tab 5 mg 2buspirone hcl tab 7.5 mg 2buspirone hcl tab 10 mg 2buspirone hcl tab 15 mg 2buspirone hcl tab 30 mg 2clonazepam orally disintegrating tab 0.125 mg 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.25 mg 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 0.5 mg 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 1 mg 2 PA, QL (90 tablets/30 days)clonazepam orally disintegrating tab 2 mg 2 PA, QL (300 tablets/30 days)clonazepam tab 0.5 mg 1 PA, QL (120 tablets/30 days)clonazepam tab 1 mg 1 PA, QL (120 tablets/30 days)clonazepam tab 2 mg 1 PA, QL (300 tablets/30 days)clorazepate dipotassium tab 3.75 mg 2 PA, QL (120 tablets/30 days)clorazepate dipotassium tab 7.5 mg 2 PA, QL (90 tablets/30 days)clorazepate dipotassium tab 15 mg 2 PA, QL (180 tablets/30 days)DIAZEPAM - diazepam oral soln 1 mg/ml 4 PA, QL (1200 mls/30 days)diazepam conc 5 mg/ml 2 PA, QL (240 mls/30 days)diazepam tab 2 mg 1 PA, QL (120 tablets/30 days)diazepam tab 5 mg 1 PA, QL (120 tablets/30 days)diazepam tab 10 mg 1 PA, QL (120 tablets/30 days)hydroxyzine hcl syrup 10 mg/5ml# 4 PAhydroxyzine hcl tab 10 mg# 4 PAhydroxyzine hcl tab 25 mg# 4 PAhydroxyzine hcl tab 50 mg# 4 PAlorazepam tab 0.5 mg 1 PA, QL (120 tablets/30 days)lorazepam tab 1 mg 1 PA, QL (120 tablets/30 days)lorazepam tab 2 mg 1 PA, QL (150 tablets/30 days)Bipolar AgentsLITHIUM - lithium oral solution 8 meq/5ml 4lithium carbonate cap 150 mg 3lithium carbonate cap 300 mg 1lithium carbonate cap 600 mg 3

2018


47

Drug Name Drug Tier Requirements/Limitslithium carbonate tab er 300 mg 2lithium carbonate tab er 450 mg 2lithium carbonate tab 300 mg 2Blood Glucose Regulatorsacarbose tab 25 mg 2 QL (360 tablets/30 days)acarbose tab 50 mg 2 QL (180 tablets/30 days)acarbose tab 100 mg 2 QL (90 tablets/30 days)ALCOHOL SWABS 3BYDUREON - exenatide for inj extended release susp 2 mg 3 QL (4 vials/28 days)BYDUREON BCISE - exenatide extended release susp auto-

injector 2 mg/0.85ml3 QL (4 pens/28 days)

BYDUREON PEN - exenatide extended release for susp pen-injector 2 mg

3 QL (4 pens/28 days)

CYCLOSET - bromocriptine mesylate tab 0.8 mg 4 QL (180 tablets/30 days)GAUZE PADS 2" X 2" 3glimepiride tab 1 mg 1 QL (240 tablets/30 days)glimepiride tab 2 mg 1 QL (120 tablets/30 days)glimepiride tab 4 mg 1 QL (60 tablets/30 days)glipizide tab er 24hr 2.5 mg 2 QL (240 tablets/30 days)glipizide tab er 24hr 5 mg 2 QL (120 tablets/30 days)glipizide tab er 24hr 10 mg 2 QL (60 tablets/30 days)glipizide tab 5 mg 1 QL (240 tablets/30 days)glipizide tab 10 mg 1 QL (120 tablets/30 days)glipizide-metformin hcl tab 2.5-250 mg 2 QL (240 tablets/30 days)glipizide-metformin hcl tab 2.5-500 mg 2 QL (120 tablets/30 days)glipizide-metformin hcl tab 5-500 mg 2 QL (120 tablets/30 days)GLUCAGEN HYPOKIT - glucagon hcl (rdna) for inj 1 mg 3GLUCAGON EMERGENCY KIT - glucagon (rdna) for inj kit 1 mg 3HUMALOG - insulin lispro inj 100 unit/ml 3 QL (60 mls/30 days)HUMALOG - insulin lispro soln cartridge 100 unit/ml 3 QL (20 cartridges/30 days)HUMALOG JUNIOR KWIKPEN - insulin lispro soln pen-injector 100

unit/ml3 QL (20 pens/30 days)

HUMALOG KWIKPEN - insulin lispro soln pen-injector 100 unit/ml 3 QL (20 pens/30 days)HUMALOG KWIKPEN - insulin lispro soln pen-injector 200 unit/ml 3 QL (20 pens/30 days)HUMALOG MIX 50/50 - insulin lispro protamine & lispro inj 100

unit/ml (50-50)3 QL (6 vials/30 days)

HUMALOG MIX 50/50 KWIKPEN - insulin lispro prot & lispro suspen-inj 100 unit/ml (50-50)


HUMALOG MIX 75/25 - insulin lispro prot & lispro inj 100 unit/ml(75-25)

3 QL (6 vials/30 days)

2018


Drug Name Drug Tier Requirements/LimitsHUMALOG MIX 75/25 KWIKPEN - insulin lispro prot & lispro sus

pen-inj 100 unit/ml (75-25)3 QL (20 pens/30 days)

HUMULIN N - insulin nph (human) (isophane) inj 100 unit/ml 3 QL (60 mls/30 days)HUMULIN N KWIKPEN - insulin nph (human) (isophane) susp pen-

injector 100 unit/ml3 QL (20 pens/30 days)

HUMULIN R - insulin regular (human) inj 100 unit/ml 3 QL (60 mls/30 days)HUMULIN R U-500 (CONCENTRATE) - insulin regular (human) inj

500 unit/ml3 BD, QL (3 vials/30 days)

HUMULIN R U-500 KWIKPEN - insulin regular (human) soln pen-injector 500 unit/ml


HUMULIN 70/30 - insulin nph isophane & regular human inj 100unit/ml (70-30)

3 QL (60 mls/30 days)

HUMULIN 70/30 KWIKPEN - insulin nph & regular susp pen-inj 100unit/ml (70-30)


INSULIN INJECTION DEVICE 3INSULIN SYRINGE/NEEDLE 3INVOKAMET - canagliflozin-metformin hcl tab 50-500 mg 3 QL (120 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 50-1000 mg 3 QL (60 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 150-500 mg 3 QL (60 tablets/30 days)INVOKAMET - canagliflozin-metformin hcl tab 150-1000 mg 3 QL (60 tablets/30 days)INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr


INVOKAMET XR - canagliflozin-metformin hcl tab er 24hr50-1000 mg






INVOKANA - canagliflozin tab 100 mg 3 QL (90 tablets/30 days)INVOKANA - canagliflozin tab 300 mg 3 QL (30 tablets/30 days)JANUMET - sitagliptin-metformin hcl tab 50-500 mg 3 QL (60 tablets/30 days)JANUMET - sitagliptin-metformin hcl tab 50-1000 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-500 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 50-1000 mg 3 QL (60 tablets/30 days)JANUMET XR - sitagliptin-metformin hcl tab er 24hr 100-1000 mg 3 QL (30 tablets/30 days)JANUVIA - sitagliptin phosphate tab 25 mg 3 QL (120 tablets/30 days)JANUVIA - sitagliptin phosphate tab 50 mg 3 QL (60 tablets/30 days)JANUVIA - sitagliptin phosphate tab 100 mg 3 QL (30 tablets/30 days)JARDIANCE - empagliflozin tab 10 mg 3 QL (60 tablets/30 days)JARDIANCE - empagliflozin tab 25 mg 3 QL (30 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-500 mg 4 QL (60 tablets/30 days)

2018


49

Drug Name Drug Tier Requirements/LimitsJENTADUETO - linagliptin-metformin hcl tab 2.5-850 mg 4 QL (60 tablets/30 days)JENTADUETO - linagliptin-metformin hcl tab 2.5-1000 mg 4 QL (60 tablets/30 days)JENTADUETO XR - linagliptin-metformin hcl tab er 24hr

2.5-1000 mg4 QL (60 tablets/30 days)

JENTADUETO XR - linagliptin-metformin hcl tab er 24hr 5-1000 mg 4 QL (30 tablets/30 days)KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr

2.5-1000 mg3 QL (60 tablets/30 days)

KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr 5-500 mg 3 QL (30 tablets/30 days)KOMBIGLYZE XR - saxagliptin-metformin hcl tab er 24hr


LANTUS - insulin glargine inj 100 unit/ml 3 QL (6 vials/30 days)LANTUS SOLOSTAR - insulin glargine soln pen-injector 100 unit/ml 3 QL (20 pens/30 days)LEVEMIR - insulin detemir inj 100 unit/ml 3 QL (6 vials/30 days)LEVEMIR FLEXTOUCH - insulin detemir soln pen-injector 100 unit/

ml3 QL (20 pens/30 days)

metformin hcl tab er 24hr 500 mg 2 QL (120 tablets/30 days)metformin hcl tab er 24hr 750 mg 2 QL (60 tablets/30 days)metformin hcl tab 500 mg 1 QL (150 tablets/30 days)metformin hcl tab 850 mg 1 QL (90 tablets/30 days)metformin hcl tab 1000 mg 1 QL (75 tablets/30 days)nateglinide tab 60 mg 2 QL (180 tablets/30 days)nateglinide tab 120 mg 2 QL (90 tablets/30 days)ONGLYZA - saxagliptin hcl tab 2.5 mg 3 QL (60 tablets/30 days)ONGLYZA - saxagliptin hcl tab 5 mg 3 QL (30 tablets/30 days)pioglitazone hcl tab 15 mg 1 QL (90 tablets/30 days)pioglitazone hcl tab 30 mg 1 QL (30 tablets/30 days)pioglitazone hcl tab 45 mg 1 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-2 mg 2 QL (30 tablets/30 days)pioglitazone hcl-glimepiride tab 30-4 mg 2 QL (30 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-500 mg 2 QL (90 tablets/30 days)pioglitazone hcl-metformin hcl tab 15-850 mg 2 QL (90 tablets/30 days)PROGLYCEM - diazoxide susp 50 mg/ml 4repaglinide tab 0.5 mg 2 QL (960 tablets/30 days)repaglinide tab 1 mg 2 QL (480 tablets/30 days)repaglinide tab 2 mg 2 QL (240 tablets/30 days)SYMLINPEN 120 - pramlintide acetate pen-inj 2700 mcg/2.7ml

(1000 mcg/ml)3

SYMLINPEN 60 - pramlintide acetate pen-inj 1500 mcg/1.5ml(1000 mcg/ml)

3

SYNJARDY - empagliflozin-metformin hcl tab 5-500 mg 3 QL (120 tablets/30 days)

2018


Drug Name Drug Tier Requirements/LimitsSYNJARDY - empagliflozin-metformin hcl tab 5-1000 mg 3 QL (60 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 12.5-500 mg 3 QL (60 tablets/30 days)SYNJARDY - empagliflozin-metformin hcl tab 12.5-1000 mg 3 QL (60 tablets/30 days)SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr


SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr10-1000 mg


SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr12.5-1000 mg


SYNJARDY XR - empagliflozin-metformin hcl tab er 24hr25-1000 mg


TOUJEO SOLOSTAR - insulin glargine soln pen-injector 300 unit/ml


TRADJENTA - linagliptin tab 5 mg 4 QL (30 tablets/30 days)TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 100

unit/ml3 QL (20 pens/30 days)

TRESIBA FLEXTOUCH - insulin degludec soln pen-injector 200unit/ml


VICTOZA - liraglutide soln pen-injector 18 mg/3ml (6 mg/ml) 3 QL (1 package/30 days)Blood Products/Modifiers/Volume Expandersanagrelide hcl cap 0.5 mg 2anagrelide hcl cap 1 mg 2ARANESP ALBUMIN FREE - darbepoetin alfa soln inj 25 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 40 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 60 mcg/ml 4 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 100 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 200 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln inj 300 mcg/ml 5 PAARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe

10 mcg/0.4ml4 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe25 mcg/0.42ml

4 PA


4 PA


4 PA


5 PA


5 PA


5 PA

2018


51

Drug Name Drug Tier Requirements/LimitsARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe

300 mcg/0.6ml5 PA

ARANESP ALBUMIN FREE - darbepoetin alfa soln prefilled syringe500 mcg/ml

5 PA

aspirin-dipyridamole cap er 12hr 25-200 mg 2azacitidine for inj 100 mg 5BEVYXXA - betrixaban maleate cap 40 mg 4 QL (43 capsules/42 days)BEVYXXA - betrixaban maleate cap 80 mg 4 QL (43 capsules/42 days)BRILINTA - ticagrelor tab 60 mg 3BRILINTA - ticagrelor tab 90 mg 3cilostazol tab 50 mg 2cilostazol tab 100 mg 2clopidogrel bisulfate tab 75 mg 1COUMADIN - warfarin sodium tab 1 mg 4COUMADIN - warfarin sodium tab 2 mg 4COUMADIN - warfarin sodium tab 2.5 mg 4COUMADIN - warfarin sodium tab 3 mg 4COUMADIN - warfarin sodium tab 4 mg 4COUMADIN - warfarin sodium tab 5 mg 4COUMADIN - warfarin sodium tab 6 mg 4COUMADIN - warfarin sodium tab 7.5 mg 4COUMADIN - warfarin sodium tab 10 mg 4dipyridamole tab 25 mg# 4dipyridamole tab 50 mg# 4dipyridamole tab 75 mg# 4EFFIENT - prasugrel hcl tab 5 mg 3EFFIENT - prasugrel hcl tab 10 mg 3ELIQUIS - apixaban tab 2.5 mg 3 QL (60 tablets/30 days)ELIQUIS - apixaban tab 5 mg 3 QL (120 tablets/30 days)ELIQUIS STARTER PACK - apixaban tab 5 mg 3 QL (120 tablets/30 days)enoxaparin sodium inj 30 mg/0.3ml 2 QL (30 syringes/90 days)enoxaparin sodium inj 40 mg/0.4ml 2 QL (30 syringes/90 days)enoxaparin sodium inj 60 mg/0.6ml 2 QL (30 syringes/90 days)enoxaparin sodium inj 80 mg/0.8ml 2 QL (30 syringes/90 days)enoxaparin sodium inj 100 mg/ml 2 QL (30 syringes/90 days)enoxaparin sodium inj 120 mg/0.8ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 150 mg/ml 4 QL (30 syringes/90 days)enoxaparin sodium inj 300 mg/3ml 4 QL (10 vials/90 days)EPOGEN - epoetin alfa inj 2000 unit/ml 4 PA

2018


Drug Name Drug Tier Requirements/LimitsEPOGEN - epoetin alfa inj 3000 unit/ml 4 PAEPOGEN - epoetin alfa inj 4000 unit/ml 4 PAEPOGEN - epoetin alfa inj 10000 unit/ml 4 PAEPOGEN - epoetin alfa inj 20000 unit/ml 4 PAfondaparinux sodium subcutaneous inj 2.5 mg/0.5ml 4 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 5 mg/0.4ml 5 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 7.5 mg/0.6ml 5 QL (30 syringes/90 days)fondaparinux sodium subcutaneous inj 10 mg/0.8ml 5 QL (30 syringes/90 days)GRANIX - tbo-filgrastim soln prefilled syringe 300 mcg/0.5ml 5GRANIX - tbo-filgrastim soln prefilled syringe 480 mcg/0.8ml 5heparin sodium (porcine) inj 1000 unit/ml 2heparin sodium (porcine) inj 5000 unit/ml 2heparin sodium (porcine) inj 10000 unit/ml 2heparin sodium (porcine) inj 20000 unit/ml 2heparin sodium (porcine) pf inj 5000 unit/0.5ml 2heparin sodium (porcine) 40 unit/ml in d5w 2LEUKINE - sargramostim lyophilized for inj 250 mcg 5MOZOBIL - plerixafor subcutaneous inj 24 mg/1.2ml (20 mg/ml) 5NEULASTA - pegfilgrastim soln prefilled syringe 6 mg/0.6ml 5NEULASTA ONPRO KIT - pegfilgrastim soln prefilled syringe kit

6 mg/0.6ml5

PRADAXA - dabigatran etexilate mesylate cap 75 mg 4 QL (60 capsules/30 days)PRADAXA - dabigatran etexilate mesylate cap 110 mg 4 QL (71 capsules/90 days)PRADAXA - dabigatran etexilate mesylate cap 150 mg 4 QL (60 capsules/30 days)prasugrel hcl tab 5 mg 3prasugrel hcl tab 10 mg 3PROCRIT - epoetin alfa inj 2000 unit/ml 4 PAPROCRIT - epoetin alfa inj 3000 unit/ml 4 PAPROCRIT - epoetin alfa inj 4000 unit/ml 4 PAPROCRIT - epoetin alfa inj 10000 unit/ml 4 PAPROCRIT - epoetin alfa inj 20000 unit/ml 5 PAPROCRIT - epoetin alfa inj 40000 unit/ml 5 PAPROMACTA - eltrombopag olamine tab 12.5 mg* 5 PAPROMACTA - eltrombopag olamine tab 25 mg* 5 PAPROMACTA - eltrombopag olamine tab 50 mg* 5 PAPROMACTA - eltrombopag olamine tab 75 mg* 5 PAtranexamic acid iv soln 1000 mg/10ml (100 mg/ml) 2tranexamic acid tab 650 mg 3warfarin sodium tab 1 mg 1

2018


53

Drug Name Drug Tier Requirements/Limitswarfarin sodium tab 2 mg 1warfarin sodium tab 2.5 mg 1warfarin sodium tab 3 mg 1warfarin sodium tab 4 mg 1warfarin sodium tab 5 mg 1warfarin sodium tab 6 mg 1warfarin sodium tab 7.5 mg 1warfarin sodium tab 10 mg 1XARELTO - rivaroxaban tab 10 mg 3 QL (30 tablets/30 days)XARELTO - rivaroxaban tab 15 mg 3 QL (60 tablets/30 days)XARELTO - rivaroxaban tab 20 mg 3 QL (30 tablets/30 days)XARELTO STARTER PACK - rivaroxaban tab starter therapy pack

15 mg & 20 mg3 QL (51 tablets/30 days)

ZONTIVITY - vorapaxar sulfate tab 2.08 mg 4Cardiovascular Agentsacebutolol hcl cap 200 mg 2acebutolol hcl cap 400 mg 2acetazolamide cap er 12hr 500 mg 2acetazolamide tab 125 mg 2acetazolamide tab 250 mg 2amiloride & hydrochlorothiazide tab 5-50 mg 2amiloride hcl tab 5 mg 2amiodarone hcl tab 200 mg 2amiodarone hcl tab 400 mg 2amlodipine besylate tab 2.5 mg 1amlodipine besylate tab 5 mg 1amlodipine besylate tab 10 mg 1amlodipine besylate-atorvastatin calcium tab 2.5-10 mg 2amlodipine besylate-atorvastatin calcium tab 2.5-20 mg 2amlodipine besylate-atorvastatin calcium tab 2.5-40 mg 2amlodipine besylate-atorvastatin calcium tab 5-10 mg 2amlodipine besylate-atorvastatin calcium tab 5-20 mg 2amlodipine besylate-atorvastatin calcium tab 5-40 mg 2amlodipine besylate-atorvastatin calcium tab 5-80 mg 2amlodipine besylate-atorvastatin calcium tab 10-10 mg 2amlodipine besylate-atorvastatin calcium tab 10-20 mg 2amlodipine besylate-atorvastatin calcium tab 10-40 mg 2amlodipine besylate-atorvastatin calcium tab 10-80 mg 2amlodipine besylate-benazepril hcl cap 2.5-10 mg 2

2018


Drug Name Drug Tier Requirements/Limitsamlodipine besylate-benazepril hcl cap 5-10 mg 2amlodipine besylate-benazepril hcl cap 5-20 mg 2amlodipine besylate-benazepril hcl cap 5-40 mg 2amlodipine besylate-benazepril hcl cap 10-20 mg 2amlodipine besylate-benazepril hcl cap 10-40 mg 2amlodipine besylate-valsartan tab 5-160 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 5-320 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 10-160 mg 2 QL (30 tablets/30 days)amlodipine besylate-valsartan tab 10-320 mg 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 5-160-12.5 mg 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 5-160-25 mg 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-160-12.5 mg 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-160-25 mg 2 QL (30 tablets/30 days)amlodipine-valsartan-hydrochlorothiazide tab 10-320-25 mg 2 QL (30 tablets/30 days)atenolol & chlorthalidone tab 50-25 mg 2atenolol & chlorthalidone tab 100-25 mg 2atenolol tab 25 mg 1atenolol tab 50 mg 1atenolol tab 100 mg 1atorvastatin calcium tab 10 mg 1 QL (45 tablets/30 days)atorvastatin calcium tab 20 mg 1 QL (45 tablets/30 days)atorvastatin calcium tab 40 mg 1 QL (45 tablets/30 days)atorvastatin calcium tab 80 mg 1 QL (30 tablets/30 days)benazepril & hydrochlorothiazide tab 5-6.25 mg 2benazepril & hydrochlorothiazide tab 10-12.5 mg 2benazepril & hydrochlorothiazide tab 20-12.5 mg 2benazepril & hydrochlorothiazide tab 20-25 mg 2benazepril hcl tab 5 mg 1benazepril hcl tab 10 mg 1benazepril hcl tab 20 mg 1benazepril hcl tab 40 mg 1betaxolol hcl tab 10 mg 2betaxolol hcl tab 20 mg 2bisoprolol & hydrochlorothiazide tab 2.5-6.25 mg 1bisoprolol & hydrochlorothiazide tab 5-6.25 mg 1bisoprolol & hydrochlorothiazide tab 10-6.25 mg 1bisoprolol fumarate tab 5 mg 2bisoprolol fumarate tab 10 mg 2

2018


55

Drug Name Drug Tier Requirements/Limitsbumetanide inj 0.25 mg/ml 2bumetanide tab 0.5 mg 2bumetanide tab 1 mg 2bumetanide tab 2 mg 2candesartan cilexetil tab 4 mg 2 QL (60 tablets/30 days)candesartan cilexetil tab 8 mg 2 QL (60 tablets/30 days)candesartan cilexetil tab 16 mg 2 QL (60 tablets/30 days)candesartan cilexetil tab 32 mg 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 16-12.5 mg 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 32-12.5 mg 2 QL (30 tablets/30 days)candesartan cilexetil-hydrochlorothiazide tab 32-25 mg 2 QL (30 tablets/30 days)captopril tab 12.5 mg 2captopril tab 25 mg 2captopril tab 50 mg 2captopril tab 100 mg 2carvedilol tab 3.125 mg 1carvedilol tab 6.25 mg 1carvedilol tab 12.5 mg 1carvedilol tab 25 mg 1CHLOROTHIAZIDE - chlorothiazide tab 250 mg 4chlorothiazide tab 500 mg 2chlorthalidone tab 25 mg 2chlorthalidone tab 50 mg 2cholestyramine light powder packets 4 gm 2cholestyramine light powder 4 gm/dose 2cholestyramine powder packets 4 gm 2cholestyramine powder 4 gm/dose 2choline fenofibrate cap dr 45 mg 2 QL (60 capsules/30 days)choline fenofibrate cap dr 135 mg 2 QL (30 capsules/30 days)clonidine hcl tab 0.1 mg 1clonidine hcl tab 0.2 mg 1clonidine hcl tab 0.3 mg 1clonidine hcl td patch weekly 0.1 mg/24hr 2clonidine hcl td patch weekly 0.2 mg/24hr 2clonidine hcl td patch weekly 0.3 mg/24hr 2colestipol hcl granule packets 5 gm 2colestipol hcl granules 5 gm 2colestipol hcl tab 1 gm 2

2018


Drug Name Drug Tier Requirements/LimitsCORLANOR - ivabradine hcl tab 5 mg 3 PA, QL (60 tablets/30 days)CORLANOR - ivabradine hcl tab 7.5 mg 3 PA, QL (60 tablets/30 days)DEMSER - metyrosine cap 250 mg 5DIGOXIN - digoxin oral soln 0.05 mg/ml# 4 QL (150 mls/30 days)digoxin tab 125 mcg (0.125 mg)# 2 QL (30 tablets/30 days)digoxin tab 250 mcg (0.25 mg)# 4 PA, QL (30 tablets/30 days)diltiazem hcl cap er 12hr 60 mg 3diltiazem hcl cap er 12hr 90 mg 3diltiazem hcl cap er 12hr 120 mg 3diltiazem hcl cap er 24hr 120 mg 3diltiazem hcl cap er 24hr 180 mg 3diltiazem hcl cap er 24hr 240 mg 3diltiazem hcl coated beads cap er 24hr 120 mg 3diltiazem hcl coated beads cap er 24hr 180 mg 3diltiazem hcl coated beads cap er 24hr 240 mg 3diltiazem hcl coated beads cap er 24hr 300 mg 3diltiazem hcl coated beads cap er 24hr 360 mg 2diltiazem hcl coated beads tab er 24hr 180 mg 2diltiazem hcl coated beads tab er 24hr 240 mg 2diltiazem hcl coated beads tab er 24hr 300 mg 2diltiazem hcl coated beads tab er 24hr 360 mg 2diltiazem hcl coated beads tab er 24hr 420 mg 2diltiazem hcl extended release beads cap er 24hr 120 mg 3diltiazem hcl extended release beads cap er 24hr 180 mg 3diltiazem hcl extended release beads cap er 24hr 240 mg 3diltiazem hcl extended release beads cap er 24hr 300 mg 3diltiazem hcl extended release beads cap er 24hr 360 mg 3diltiazem hcl extended release beads cap er 24hr 420 mg 3diltiazem hcl tab 30 mg 2diltiazem hcl tab 60 mg 2diltiazem hcl tab 90 mg 2diltiazem hcl tab 120 mg 2dofetilide cap 125 mcg (0.125 mg) 4dofetilide cap 250 mcg (0.25 mg) 4dofetilide cap 500 mcg (0.5 mg) 4doxazosin mesylate tab 1 mg 2 QL (60 tablets/30 days)doxazosin mesylate tab 2 mg 2 QL (60 tablets/30 days)doxazosin mesylate tab 4 mg 2 QL (60 tablets/30 days)

2018


57

Drug Name Drug Tier Requirements/Limitsdoxazosin mesylate tab 8 mg 2 QL (60 tablets/30 days)enalapril maleate & hydrochlorothiazide tab 5-12.5 mg 1enalapril maleate & hydrochlorothiazide tab 10-25 mg 1enalapril maleate tab 2.5 mg 2enalapril maleate tab 5 mg 2enalapril maleate tab 10 mg 2enalapril maleate tab 20 mg 2ENTRESTO - sacubitril-valsartan tab 24-26 mg 3 PA, QL (60 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 49-51 mg 3 PA, QL (60 tablets/30 days)ENTRESTO - sacubitril-valsartan tab 97-103 mg 3 PA, QL (60 tablets/30 days)eplerenone tab 25 mg 2eplerenone tab 50 mg 2ezetimibe tab 10 mg 3 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-10 mg 3 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-20 mg 3 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-40 mg 3 QL (30 tablets/30 days)ezetimibe-simvastatin tab 10-80 mg 3 QL (30 tablets/30 days)felodipine tab er 24hr 2.5 mg 2felodipine tab er 24hr 5 mg 2felodipine tab er 24hr 10 mg 2fenofibrate micronized cap 67 mg 2 QL (30 capsules/30 days)fenofibrate micronized cap 134 mg 2 QL (30 capsules/30 days)fenofibrate micronized cap 200 mg 2 QL (30 capsules/30 days)fenofibrate tab 48 mg 2 QL (60 tablets/30 days)fenofibrate tab 54 mg 2 QL (60 tablets/30 days)fenofibrate tab 145 mg 2 QL (30 tablets/30 days)fenofibrate tab 160 mg 2 QL (30 tablets/30 days)flecainide acetate tab 50 mg 2flecainide acetate tab 100 mg 2flecainide acetate tab 150 mg 2fosinopril sodium & hydrochlorothiazide tab 10-12.5 mg 2fosinopril sodium & hydrochlorothiazide tab 20-12.5 mg 2fosinopril sodium tab 10 mg 1fosinopril sodium tab 20 mg 1fosinopril sodium tab 40 mg 1furosemide inj 10 mg/ml 2furosemide oral soln 10 mg/ml 2furosemide tab 20 mg 1

2018


Drug Name Drug Tier Requirements/Limitsfurosemide tab 40 mg 1furosemide tab 80 mg 1gemfibrozil tab 600 mg 1 QL (60 tablets/30 days)hydralazine hcl tab 10 mg 2hydralazine hcl tab 25 mg 2hydralazine hcl tab 50 mg 2hydralazine hcl tab 100 mg 2hydrochlorothiazide cap 12.5 mg 1hydrochlorothiazide tab 12.5 mg 1hydrochlorothiazide tab 25 mg 1hydrochlorothiazide tab 50 mg 1indapamide tab 1.25 mg 2indapamide tab 2.5 mg 2irbesartan tab 75 mg 2 QL (30 tablets/30 days)irbesartan tab 150 mg 2 QL (30 tablets/30 days)irbesartan tab 300 mg 2 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 150-12.5 mg 2 QL (30 tablets/30 days)irbesartan-hydrochlorothiazide tab 300-12.5 mg 2 QL (30 tablets/30 days)isosorbide dinitrate tab 5 mg 2isosorbide dinitrate tab 10 mg 2isosorbide dinitrate tab 20 mg 2isosorbide dinitrate tab 30 mg 2isosorbide mononitrate tab er 24hr 30 mg 2isosorbide mononitrate tab er 24hr 60 mg 2isosorbide mononitrate tab er 24hr 120 mg 2isosorbide mononitrate tab 10 mg 2isosorbide mononitrate tab 20 mg 2isradipine cap 2.5 mg 2isradipine cap 5 mg 2JUXTAPID - lomitapide mesylate cap 5 mg* 5 PAJUXTAPID - lomitapide mesylate cap 10 mg* 5 PAJUXTAPID - lomitapide mesylate cap 20 mg* 5 PAJUXTAPID - lomitapide mesylate cap 30 mg* 5 PAJUXTAPID - lomitapide mesylate cap 40 mg* 5 PAJUXTAPID - lomitapide mesylate cap 60 mg* 5 PAKYNAMRO - mipomersen sodium soln prefilled syringe 200 mg/ml* 5 PAlabetalol hcl tab 100 mg 2labetalol hcl tab 200 mg 2

2018


59

Drug Name Drug Tier Requirements/Limitslabetalol hcl tab 300 mg 2LIDOCAINE HCL - lidocaine hcl iv inj 10 mg/ml 4lisinopril & hydrochlorothiazide tab 10-12.5 mg 1lisinopril & hydrochlorothiazide tab 20-12.5 mg 1lisinopril & hydrochlorothiazide tab 20-25 mg 1lisinopril tab 2.5 mg 1lisinopril tab 5 mg 1lisinopril tab 10 mg 1lisinopril tab 20 mg 1lisinopril tab 30 mg 1lisinopril tab 40 mg 1losartan potassium & hydrochlorothiazide tab 50-12.5 mg 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-12.5 mg 1 QL (30 tablets/30 days)losartan potassium & hydrochlorothiazide tab 100-25 mg 1 QL (30 tablets/30 days)losartan potassium tab 25 mg 1 QL (60 tablets/30 days)losartan potassium tab 50 mg 1 QL (60 tablets/30 days)losartan potassium tab 100 mg 1 QL (30 tablets/30 days)lovastatin tab 10 mg 1 QL (60 tablets/30 days)lovastatin tab 20 mg 1 QL (60 tablets/30 days)lovastatin tab 40 mg 1 QL (60 tablets/30 days)methazolamide tab 25 mg 3methazolamide tab 50 mg 4metolazone tab 2.5 mg 2metolazone tab 5 mg 2metolazone tab 10 mg 2metoprolol & hydrochlorothiazide tab 50-25 mg 2metoprolol & hydrochlorothiazide tab 100-25 mg 2metoprolol succinate tab er 24hr 25 mg 2metoprolol succinate tab er 24hr 50 mg 2metoprolol succinate tab er 24hr 100 mg 2metoprolol succinate tab er 24hr 200 mg 2metoprolol tartrate tab 25 mg 1metoprolol tartrate tab 50 mg 1metoprolol tartrate tab 100 mg 1mexiletine hcl cap 150 mg 2mexiletine hcl cap 200 mg 2mexiletine hcl cap 250 mg 2midodrine hcl tab 2.5 mg 2

2018


Drug Name Drug Tier Requirements/Limitsmidodrine hcl tab 5 mg 2midodrine hcl tab 10 mg 2minoxidil tab 2.5 mg 2minoxidil tab 10 mg 2moexipril hcl tab 7.5 mg 2moexipril hcl tab 15 mg 2moexipril-hydrochlorothiazide tab 7.5-12.5 mg 2moexipril-hydrochlorothiazide tab 15-12.5 mg 2moexipril-hydrochlorothiazide tab 15-25 mg 2MULTAQ - dronedarone hcl tab 400 mg 3nadolol tab 20 mg 2nadolol tab 40 mg 2nadolol tab 80 mg 2niacin tab er 500 mg 2 QL (30 tablets/30 days)niacin tab er 750 mg 2 QL (60 tablets/30 days)niacin tab er 1000 mg 2 QL (60 tablets/30 days)nicardipine hcl cap 20 mg 2nicardipine hcl cap 30 mg 2nifedipine tab er 24hr 30 mg 3nifedipine tab er 24hr 60 mg 3nifedipine tab er 24hr 90 mg 2nifedipine tab er 24hr osmotic release 30 mg 3nifedipine tab er 24hr osmotic release 60 mg 3nifedipine tab er 24hr osmotic release 90 mg 3NISOLDIPINE ER - nisoldipine tab er 24hr 25.5 mg 4nisoldipine tab er 24hr 8.5 mg 2nisoldipine tab er 24hr 17 mg 2nisoldipine tab er 24hr 34 mg 2NITRO-BID - nitroglycerin oint 2% 4nitroglycerin sl tab 0.3 mg 2nitroglycerin sl tab 0.4 mg 2nitroglycerin sl tab 0.6 mg 2nitroglycerin td patch 24hr 0.1 mg/hr 2nitroglycerin td patch 24hr 0.2 mg/hr 2nitroglycerin td patch 24hr 0.4 mg/hr 2nitroglycerin td patch 24hr 0.6 mg/hr 2nitroglycerin tl soln 0.4 mg/spray (400 mcg/spray) 2NORTHERA - droxidopa cap 100 mg* 5 PA

2018


61

Drug Name Drug Tier Requirements/LimitsNORTHERA - droxidopa cap 200 mg* 5 PANORTHERA - droxidopa cap 300 mg* 5 PAomega-3-acid ethyl esters cap 1 gm 2pentoxifylline tab er 400 mg 2perindopril erbumine tab 2 mg 2perindopril erbumine tab 4 mg 2perindopril erbumine tab 8 mg 2phenoxybenzamine hcl cap 10 mg 5pindolol tab 5 mg 2pindolol tab 10 mg 2PRALUENT - alirocumab subcutaneous soln pen-injector 75 mg/

ml*5 PA, QL (2 pens/28 days)

PRALUENT - alirocumab subcutaneous soln pen-injector 150 mg/ml*

5 PA, QL (2 pens/28 days)

pravastatin sodium tab 10 mg 2 QL (45 tablets/30 days)pravastatin sodium tab 20 mg 2 QL (45 tablets/30 days)pravastatin sodium tab 40 mg 2 QL (45 tablets/30 days)pravastatin sodium tab 80 mg 2 QL (30 tablets/30 days)prazosin hcl cap 1 mg 2prazosin hcl cap 2 mg 2prazosin hcl cap 5 mg 2propafenone hcl cap er 12hr 225 mg 3propafenone hcl cap er 12hr 325 mg 4propafenone hcl cap er 12hr 425 mg 4propafenone hcl tab 150 mg 2propafenone hcl tab 225 mg 2propafenone hcl tab 300 mg 2propranolol hcl cap er 24hr 60 mg 2propranolol hcl cap er 24hr 80 mg 2propranolol hcl cap er 24hr 120 mg 2propranolol hcl cap er 24hr 160 mg 2propranolol hcl inj 1 mg/ml 2propranolol hcl tab 10 mg 2propranolol hcl tab 20 mg 2propranolol hcl tab 40 mg 2propranolol hcl tab 60 mg 2propranolol hcl tab 80 mg 2quinapril hcl tab 5 mg 1quinapril hcl tab 10 mg 1

2018


Drug Name Drug Tier Requirements/Limitsquinapril hcl tab 20 mg 1quinapril hcl tab 40 mg 1quinapril-hydrochlorothiazide tab 10-12.5 mg 2quinapril-hydrochlorothiazide tab 20-12.5 mg 2quinapril-hydrochlorothiazide tab 20-25 mg 2quinidine gluconate tab er 324 mg 2QUINIDINE SULFATE - quinidine sulfate tab 200 mg 4QUINIDINE SULFATE - quinidine sulfate tab 300 mg 4ramipril cap 1.25 mg 1ramipril cap 2.5 mg 1ramipril cap 5 mg 1ramipril cap 10 mg 1RANEXA - ranolazine tab er 12hr 500 mg 3 QL (60 tablets/30 days)RANEXA - ranolazine tab er 12hr 1000 mg 3 QL (60 tablets/30 days)REPATHA - evolocumab subcutaneous soln prefilled syringe

140 mg/ml5 PA, QL (2 syringes/28 days)

REPATHA PUSHTRONEX SYSTEM - evolocumab subcutaneoussoln cartridge/infusor 420 mg/3.5ml

5 PA, QL (1 system/30 days)

REPATHA SURECLICK - evolocumab subcutaneous soln auto-injector 140 mg/ml

5 PA, QL (2 pens/28 days)

rosuvastatin calcium tab 5 mg 2 QL (45 tablets/30 days)rosuvastatin calcium tab 10 mg 2 QL (45 tablets/30 days)rosuvastatin calcium tab 20 mg 2 QL (45 tablets/30 days)rosuvastatin calcium tab 40 mg 2 QL (30 tablets/30 days)simvastatin tab 5 mg 1 QL (45 tablets/30 days)simvastatin tab 10 mg 1 QL (45 tablets/30 days)simvastatin tab 20 mg 1 QL (60 tablets/30 days)simvastatin tab 40 mg 1 QL (45 tablets/30 days)simvastatin tab 80 mg 1 QL (30 tablets/30 days)sotalol hcl (afib/afl) tab 80 mg 2sotalol hcl (afib/afl) tab 120 mg 2sotalol hcl (afib/afl) tab 160 mg 2sotalol hcl tab 80 mg 2sotalol hcl tab 120 mg 2sotalol hcl tab 160 mg 2sotalol hcl tab 240 mg 2spironolactone & hydrochlorothiazide tab 25-25 mg 2spironolactone tab 25 mg 1spironolactone tab 50 mg 1

2018


63

Drug Name Drug Tier Requirements/Limitsspironolactone tab 100 mg 1TEKTURNA - aliskiren fumarate tab 150 mg 3 QL (30 tablets/30 days)TEKTURNA - aliskiren fumarate tab 300 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 150-12.5 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 150-25 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 300-12.5 mg 3 QL (30 tablets/30 days)TEKTURNA HCT - aliskiren-hydrochlorothiazide tab 300-25 mg 3 QL (30 tablets/30 days)telmisartan tab 20 mg 2 QL (30 tablets/30 days)telmisartan tab 40 mg 2 QL (30 tablets/30 days)telmisartan tab 80 mg 2 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 40-12.5 mg 2 QL (30 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-12.5 mg 2 QL (60 tablets/30 days)telmisartan-hydrochlorothiazide tab 80-25 mg 2 QL (30 tablets/30 days)terazosin hcl cap 1 mg 1 QL (90 capsules/30 days)terazosin hcl cap 2 mg 1 QL (60 capsules/30 days)terazosin hcl cap 5 mg 1 QL (60 capsules/30 days)terazosin hcl cap 10 mg 1 QL (60 capsules/30 days)TIMOLOL MALEATE - timolol maleate tab 5 mg 4TIMOLOL MALEATE - timolol maleate tab 10 mg 4TIMOLOL MALEATE - timolol maleate tab 20 mg 4torsemide tab 5 mg 1torsemide tab 10 mg 1torsemide tab 20 mg 1torsemide tab 100 mg 1trandolapril tab 1 mg 2trandolapril tab 2 mg 2trandolapril tab 4 mg 2triamterene & hydrochlorothiazide cap 37.5-25 mg 1triamterene & hydrochlorothiazide tab 37.5-25 mg 1triamterene & hydrochlorothiazide tab 75-50 mg 1valsartan tab 40 mg 2 QL (60 tablets/30 days)valsartan tab 80 mg 2 QL (60 tablets/30 days)valsartan tab 160 mg 2 QL (60 tablets/30 days)valsartan tab 320 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 80-12.5 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 160-12.5 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 160-25 mg 2 QL (30 tablets/30 days)valsartan-hydrochlorothiazide tab 320-12.5 mg 2 QL (30 tablets/30 days)

2018


Drug Name Drug Tier Requirements/Limitsvalsartan-hydrochlorothiazide tab 320-25 mg 2 QL (30 tablets/30 days)VASCEPA - icosapent ethyl cap 0.5 gm 3VASCEPA - icosapent ethyl cap 1 gm 3verapamil hcl cap er 24hr 100 mg 2verapamil hcl cap er 24hr 120 mg 2verapamil hcl cap er 24hr 180 mg 2verapamil hcl cap er 24hr 200 mg 2verapamil hcl cap er 24hr 240 mg 2verapamil hcl cap er 24hr 300 mg 2verapamil hcl cap er 24hr 360 mg 2verapamil hcl tab er 120 mg 2verapamil hcl tab er 180 mg 2verapamil hcl tab er 240 mg 2verapamil hcl tab 40 mg 1verapamil hcl tab 80 mg 1verapamil hcl tab 120 mg 1WELCHOL - colesevelam hcl packet for susp 3.75 gm 4WELCHOL - colesevelam hcl tab 625 mg 4Central Nervous System Agentsamphetamine-dextroamphetamine cap er 24hr 5 mg 2 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 10 mg 2 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 15 mg 2 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 20 mg 3 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 25 mg 3 QL (30 capsules/30 days)amphetamine-dextroamphetamine cap er 24hr 30 mg 3 QL (30 capsules/30 days)amphetamine-dextroamphetamine tab 5 mg 2 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 7.5 mg 2 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 10 mg 2 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 12.5 mg 2 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 15 mg 2 QL (60 tablets/30 days)amphetamine-dextroamphetamine tab 20 mg 2 QL (90 tablets/30 days)amphetamine-dextroamphetamine tab 30 mg 2 QL (60 tablets/30 days)AMPYRA - dalfampridine tab er 12hr 10 mg* 5 PAatomoxetine hcl cap 10 mg 4 QL (60 capsules/30 days)atomoxetine hcl cap 18 mg 4 QL (60 capsules/30 days)atomoxetine hcl cap 25 mg 4 QL (60 capsules/30 days)atomoxetine hcl cap 40 mg 4 QL (60 capsules/30 days)atomoxetine hcl cap 60 mg 4 QL (30 capsules/30 days)

2018


65

Drug Name Drug Tier Requirements/Limitsatomoxetine hcl cap 80 mg 4 QL (30 capsules/30 days)atomoxetine hcl cap 100 mg 4 QL (30 capsules/30 days)AVONEX - interferon beta-1a for im inj kit 30mcg (33mcg(6.6 mu)/

vial)5 PA, QL (1 kit/28 days)

AVONEX - interferon beta-1a im prefilled syringe kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)AVONEX PEN - interferon beta-1a im auto-injector kit 30 mcg/0.5ml 5 PA, QL (1 kit/28 days)BETASERON - interferon beta-1b for inj kit 0.3 mg 5 PA, QL (15 vials/

syringes/30 days)clonidine hcl tab er 12hr 0.1 mg 3 QL (120 tablets/30 days)COPAXONE - glatiramer acetate soln prefilled syringe 20 mg/ml 5 PA, QL (30 syringes/30 days)COPAXONE - glatiramer acetate soln prefilled syringe 40 mg/ml 5 PA, QL (12 syringes/28 days)dexmethylphenidate hcl tab 2.5 mg 2 QL (60 tablets/30 days)dexmethylphenidate hcl tab 5 mg 2 QL (60 tablets/30 days)dexmethylphenidate hcl tab 10 mg 2 QL (60 tablets/30 days)dextroamphetamine sulfate cap er 24hr 5 mg 2 QL (90 capsules/30 days)dextroamphetamine sulfate cap er 24hr 10 mg 2 QL (120 capsules/30 days)dextroamphetamine sulfate cap er 24hr 15 mg 2 QL (120 capsules/30 days)dextroamphetamine sulfate tab 5 mg 2 QL (90 tablets/30 days)dextroamphetamine sulfate tab 10 mg 2 QL (180 tablets/30 days)glatiramer acetate soln prefilled syringe 20 mg/ml 5 PA, QL (30 syringes/30 days)glatiramer acetate soln prefilled syringe 40 mg/ml 5 PA, QL (12 syringes/28 days)methylphenidate hcl tab er 20 mg 3 QL (90 tablets/30 days)methylphenidate hcl tab 5 mg 2 QL (90 tablets/30 days)methylphenidate hcl tab 10 mg 2 QL (90 tablets/30 days)methylphenidate hcl tab 20 mg 2 QL (90 tablets/30 days)NUEDEXTA - dextromethorphan hbr-quinidine sulfate cap

20-10 mg3

PLEGRIDY - peginterferon beta-1a soln pen-injector 125 mcg/0.5ml 5 PA, QL (2 syringes/28 days)PLEGRIDY - peginterferon beta-1a soln prefilled syringe

125 mcg/0.5ml5 PA, QL (2 syringes/28 days)

PLEGRIDY STARTER PACK - peginterferon beta-1a soln pen-inj63 & 94 mcg/0.5ml pack

5 PA, QL (2 syringes/28 days)

PLEGRIDY STARTER PACK - peginterferon beta-1a soln pref syr63 & 94 mcg/0.5ml pack

5 PA, QL (2 syringes/28 days)

riluzole tab 50 mg 4TECFIDERA - dimethyl fumarate capsule delayed release 120 mg 5 PA, QL (60 capsules/30 days)TECFIDERA - dimethyl fumarate capsule delayed release 240 mg 5 PA, QL (60 capsules/30 days)TECFIDERA STARTER PACK - dimethyl fumarate capsule dr

starter pack 120 mg & 240 mg5 PA, QL (60 capsules/30 days)

tetrabenazine tab 12.5 mg* 5 PA, QL (240 tablets/30 days)

2018


Drug Name Drug Tier Requirements/Limitstetrabenazine tab 25 mg* 5 PA, QL (120 tablets/30 days)TYSABRI - natalizumab for iv inj conc 300 mg/15ml* 5 PADental and Oral Agentschlorhexidine gluconate soln 0.12% 1KEPIVANCE - palifermin for iv inj 6.25 mg 5pilocarpine hcl tab 5 mg 2pilocarpine hcl tab 7.5 mg 2triamcinolone acetonide dental paste 0.1% 2Dermatological Agentsacitretin cap 10 mg 4acitretin cap 17.5 mg 4acitretin cap 25 mg 4alclometasone dipropionate cream 0.05% 2alclometasone dipropionate oint 0.05% 2AZELEX - azelaic acid cream 20% 4benzoyl peroxide-erythromycin gel 5-3% 2betamethasone dipropionate augmented cream 0.05% 2betamethasone dipropionate augmented gel 0.05% 2betamethasone dipropionate augmented lotion 0.05% 2betamethasone dipropionate augmented oint 0.05% 2betamethasone dipropionate cream 0.05% 2betamethasone dipropionate lotion 0.05% 2betamethasone dipropionate oint 0.05% 2betamethasone valerate cream 0.1% 2betamethasone valerate lotion 0.1% 2betamethasone valerate oint 0.1% 2calcipotriene cream 0.005% 4calcipotriene oint 0.005% 4calcipotriene soln 0.005% (50 mcg/ml) 3CARAC - fluorouracil cream 0.5% 5clindamycin phosphate-benzoyl peroxide gel 1-5% 2clobetasol propionate cream 0.05% 2clobetasol propionate emollient base cream 0.05% 2clobetasol propionate gel 0.05% 3clobetasol propionate oint 0.05% 3clobetasol propionate soln 0.05% 2clotrimazole w/ betamethasone cream 1-0.05% 2clotrimazole w/ betamethasone lotion 1-0.05% 2desonide cream 0.05% 2

2018


67

Drug Name Drug Tier Requirements/Limitsdesonide lotion 0.05% 2desonide oint 0.05% 2desoximetasone cream 0.05% 4desoximetasone cream 0.25% 2desoximetasone gel 0.05% 2desoximetasone oint 0.25% 2diclofenac sodium gel 3% 5DIFLORASONE DIACETATE - diflorasone diacetate oint 0.05% 4ELIDEL - pimecrolimus cream 1% 4 PAFINACEA - azelaic acid foam 15% 4FINACEA - azelaic acid gel 15% 4fluocinolone acetonide cream 0.01% 2fluocinonide cream 0.05% 2fluocinonide emulsified base cream 0.05% 2fluocinonide gel 0.05% 2fluocinonide oint 0.05% 2fluocinonide soln 0.05% 2fluorouracil cream 5% 3fluorouracil soln 2% 2fluorouracil soln 5% 2fluticasone propionate cream 0.05% 2fluticasone propionate oint 0.005% 2gentamicin sulfate cream 0.1% 2gentamicin sulfate oint 0.1% 2halobetasol propionate cream 0.05% 2halobetasol propionate oint 0.05% 2hydrocortisone butyrate cream 0.1% 2hydrocortisone butyrate hydrophilic lipo base cream 0.1% 2hydrocortisone butyrate oint 0.1% 2hydrocortisone butyrate soln 0.1% 2hydrocortisone cream 1% 1hydrocortisone cream 2.5% 1hydrocortisone lotion 2.5% 1hydrocortisone oint 1% 1hydrocortisone oint 2.5% 1hydrocortisone valerate cream 0.2% 2hydrocortisone valerate oint 0.2% 2imiquimod cream 5% 2 PA

2018


Drug Name Drug Tier Requirements/Limitsisotretinoin cap 10 mg 3isotretinoin cap 20 mg 4isotretinoin cap 30 mg 4isotretinoin cap 40 mg 4lactic acid (ammonium lactate) cream 12% 2lactic acid (ammonium lactate) lotion 12% 1methoxsalen rapid cap 10 mg 5metronidazole cream 0.75% 2metronidazole gel 0.75% 2metronidazole gel 1% 2metronidazole lotion 0.75% 2mometasone furoate cream 0.1% 2mometasone furoate oint 0.1% 2mometasone furoate solution 0.1% (lotion) 2mupirocin oint 2% 2nystatin-triamcinolone cream 100000-0.1 unit/gm-% 2nystatin-triamcinolone oint 100000-0.1 unit/gm-% 2ORACEA - doxycycline cap delayed release 40 mg 4PICATO - ingenol mebutate gel 0.015% 3 QL (3 tubes/30 days)PICATO - ingenol mebutate gel 0.05% 3 QL (2 tubes/30 days)podofilox soln 0.5% 2prednicarbate cream 0.1% 2prednicarbate oint 0.1% 2REGRANEX - becaplermin gel 0.01% 5 PA, QL (15 grams/30 days)SANTYL - collagenase oint 250 unit/gm 3selenium sulfide lotion 2.5% 1silver sulfadiazine cream 1% 2SOOLANTRA - ivermectin cream 1% 3tacrolimus oint 0.03% 2 PAtacrolimus oint 0.1% 2 PAtazarotene cream 0.1% 4TAZORAC - tazarotene cream 0.05% 4TAZORAC - tazarotene gel 0.05% 4TAZORAC - tazarotene gel 0.1% 4tretinoin cream 0.025% 2tretinoin cream 0.05% 2tretinoin cream 0.1% 2tretinoin gel 0.01% 2

2018


69

Drug Name Drug Tier Requirements/Limitstretinoin gel 0.025% 2triamcinolone acetonide cream 0.025% 2triamcinolone acetonide cream 0.1% 2triamcinolone acetonide cream 0.5% 2triamcinolone acetonide lotion 0.025% 2triamcinolone acetonide lotion 0.1% 2triamcinolone acetonide oint 0.025% 2triamcinolone acetonide oint 0.1% 2triamcinolone acetonide oint 0.5% 2Electrolytes/Minerals/Metals/Vitaminsamino acid infusion 6% 2 BDamino acid infusion 15% 2 BDcalcium acetate cap 667 mg 2calcium acetate tab 667 mg 2CARBAGLU - carglumic acid tab 200 mg 5CHEMET - succimer cap 100 mg 4dextrose inj 5% 1dextrose inj 10% 1dextrose 5% in lactated ringers 2dextrose 2.5% w/ sodium chloride 0.45% 2dextrose 5% w/ sodium chloride 0.2% 2dextrose 5% w/ sodium chloride 0.33% 2dextrose 5% w/ sodium chloride 0.45% 2dextrose 5% w/ sodium chloride 0.9% 2EXJADE - deferasirox tab for oral susp 125 mg* 5EXJADE - deferasirox tab for oral susp 250 mg* 5EXJADE - deferasirox tab for oral susp 500 mg* 5fat emulsion iv soln 20% 3 BDfomepizole inj 1 gm/ml (for iv infusion) 5FOSRENOL - lanthanum carbonate chew tab 500 mg 5FOSRENOL - lanthanum carbonate chew tab 750 mg 5FOSRENOL - lanthanum carbonate chew tab 1000 mg 5FOSRENOL - lanthanum carbonate oral powder pack 750 mg 5FOSRENOL - lanthanum carbonate oral powder pack 1000 mg 5HEPATAMINE - amino acid infusion 8% 3 BDJADENU - deferasirox tab 90 mg 5JADENU - deferasirox tab 180 mg 5JADENU - deferasirox tab 360 mg 5

2018


Drug Name Drug Tier Requirements/LimitsJADENU SPRINKLE - deferasirox granules packet 90 mg 5JADENU SPRINKLE - deferasirox granules packet 180 mg 5JADENU SPRINKLE - deferasirox granules packet 360 mg 5kcl 20 meq/l (0.15%) in nacl 0.45% inj 2kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45% inj 1kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2% inj 1kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.33% inj 1kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.45% inj 1kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45% inj 1kcl 40 meq/l (0.3%) in dextrose 5% & nacl 0.45% inj 1lactated ringer's solution 2lanthanum carbonate chew tab 500 mg 5lanthanum carbonate chew tab 750 mg 5lanthanum carbonate chew tab 1000 mg 5levocarnitine oral soln 1 gm/10ml (10%) 2levocarnitine tab 330 mg 2magnesium sulfate inj 50% 2NORMOSOL-M IN D5W - electrolyte-m in d5w soln 4PHOSLYRA - calcium acetate oral soln 667 mg/5ml 3potassium chloride cap er 8 meq 2potassium chloride cap er 10 meq 2potassium chloride inj 2 meq/ml 2potassium chloride microencapsulated crys er tab 10 meq 2potassium chloride microencapsulated crys er tab 20 meq 2potassium chloride oral soln 10% (20 meq/15ml) 2potassium chloride tab er 8 meq (600 mg) 3potassium chloride tab er 10 meq 2potassium chloride 20 meq/l (0.15%) in dextrose 5% inj 2POTASSIUM CHLORIDE/DEXTROSE - potassium chloride 40

meq/l (0.3%) in dextrose 5% inj3

POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS -potassium chloride 20 meq/l (0.15%) in d5w lactated ringers

4

POTASSIUM CHLORIDE/DEXTROSE/LACTATED RINGERS -potassium chloride 40 meq/l (0.3%) in d5w lactated ringers

4

potassium citrate tab er 5 meq (540 mg) 2potassium citrate tab er 10 meq (1080 mg) 2potassium citrate tab er 15 meq (1620 mg) 2RENVELA - sevelamer carbonate tab 800 mg 5SAMSCA - tolvaptan tab 15 mg 5 PA

2018


71

Drug Name Drug Tier Requirements/LimitsSAMSCA - tolvaptan tab 30 mg 5 PAsevelamer carbonate packet 0.8 gm 5sevelamer carbonate packet 2.4 gm 5sevelamer carbonate tab 800 mg 5sodium chloride inj 0.45% 2sodium chloride irrigation soln 0.9% 2sodium chloride iv soln 0.9% 2sodium polystyrene sulfonate oral susp 15 gm/60ml 2sodium polystyrene sulfonate powder 2sodium polystyrene sulfonate rectal susp 30 gm/120ml 2SYPRINE - trientine hcl cap 250 mg 5 PA, QL (240 capsules/30 days)trientine hcl cap 250 mg 5 PA, QL (240 capsules/30 days)water for irrigation, sterile irrigation soln 2Gastrointestinal Agentsalosetron hcl tab 0.5 mg 4alosetron hcl tab 1 mg 5AMITIZA - lubiprostone cap 8 mcg 3 PAAMITIZA - lubiprostone cap 24 mcg 3 PACHENODAL - chenodiol tab 250 mg* 5cimetidine hcl soln 300 mg/5ml 2cimetidine tab 200 mg 2cimetidine tab 300 mg 2cimetidine tab 400 mg 2cimetidine tab 800 mg 2cromolyn sodium oral conc 100 mg/5ml 2dicyclomine hcl cap 10 mg# 3 PAdicyclomine hcl tab 20 mg# 4 PAesomeprazole magnesium cap delayed release 20 mg 2 QL (30 capsules/30 days)esomeprazole magnesium cap delayed release 40 mg 2 QL (30 capsules/30 days)ESOMEPRAZOLE SODIUM - esomeprazole sodium for

intravenous soln 20 mg4

esomeprazole sodium for intravenous soln 40 mg 3famotidine for susp 40 mg/5ml 2famotidine inj 20 mg/2ml 1famotidine inj 40 mg/4ml 1famotidine inj 200 mg/20ml 1famotidine tab 20 mg 1famotidine tab 40 mg 1GATTEX - teduglutide (rdna) for inj kit 5 mg* 5 PA

2018


Drug Name Drug Tier Requirements/Limitsglycopyrrolate tab 1 mg 2glycopyrrolate tab 2 mg 2lactulose (encephalopathy) solution 10 gm/15ml 2lactulose solution 10 gm/15ml 2lansoprazole cap delayed release 15 mg 2 QL (30 capsules/30 days)lansoprazole cap delayed release 30 mg 2 QL (30 capsules/30 days)LINZESS - linaclotide cap 72 mcg 3 PALINZESS - linaclotide cap 145 mcg 3 PALINZESS - linaclotide cap 290 mcg 3 PAloperamide hcl cap 2 mg 2methscopolamine bromide tab 2.5 mg 2methscopolamine bromide tab 5 mg 2metoclopramide hcl inj 5 mg/ml 2metoclopramide hcl soln 5 mg/5ml (10 mg/10ml) 2metoclopramide hcl tab 5 mg 1metoclopramide hcl tab 10 mg 1misoprostol tab 100 mcg 2misoprostol tab 200 mcg 2MOVIPREP - peg 3350-kcl-nacl-na sulfate-na ascorbate-c for soln

100 gm4

MYALEPT - metreleptin for subcutaneous inj 11.3 mg* 5 PANEXIUM - esomeprazole magnesium for delayed release susp

packet 5 mg4 QL (30 packets/30 days)

NEXIUM - esomeprazole magnesium for delayed release susppacket 10 mg

4 QL (30 packets/30 days)





NEXIUM - esomeprazole magnesium for delayed release susppacket 2.5 mg


nizatidine cap 150 mg 2nizatidine cap 300 mg 2omeprazole cap delayed release 10 mg 1 QL (30 capsules/30 days)omeprazole cap delayed release 20 mg 1 QL (60 capsules/30 days)omeprazole cap delayed release 40 mg 1 QL (60 capsules/30 days)pantoprazole sodium ec tab 20 mg 1 QL (30 tablets/30 days)pantoprazole sodium ec tab 40 mg 1 QL (60 tablets/30 days)pantoprazole sodium for iv soln 40 mg 2peg 3350-kcl-sod bicarb-nacl for soln 420 gm 2

2018


73

Drug Name Drug Tier Requirements/Limitspeg 3350-kcl-na bicarb-nacl-na sulfate for soln 236 gm 2peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240 gm 2polyethylene glycol 3350 oral packet 2polyethylene glycol 3350 oral powder 2PYLERA - bismuth subcit-metronidazole-tetracycline cap

140-125-125 mg3

rabeprazole sodium ec tab 20 mg 2 QL (30 tablets/30 days)ranitidine hcl cap 150 mg 2ranitidine hcl cap 300 mg 2ranitidine hcl syrup 15 mg/ml (75 mg/5ml) 2ranitidine hcl tab 150 mg 2ranitidine hcl tab 300 mg 2RELISTOR - methylnaltrexone bromide inj 8 mg/0.4ml (20 mg/ml) 5 PARELISTOR - methylnaltrexone bromide inj 12 mg/0.6ml (20 mg/ml) 5 PARELISTOR - methylnaltrexone bromide tab 150 mg 5 PAsucralfate tab 1 gm 2SUPREP BOWEL PREP KIT - sod sulfate-pot sulf-mg sulf oral sol

17.5-3.13-1.6 gm/180ml4

ursodiol cap 300 mg 4ursodiol tab 250 mg 2ursodiol tab 500 mg 2XIFAXAN - rifaximin tab 550 mg 5Genetic or Enzyme Disorder: Replacement, Modifiers, TreatmentADAGEN - pegademase bovine inj 250 unit/ml* 5ALDURAZYME - laronidase soln for iv infusion 2.9 mg/5ml (500

unit/5ml)*5

BUPHENYL - sodium phenylbutyrate tab 500 mg 5CEREZYME - imiglucerase for inj 400 unit* 5CREON - pancrelipase (lip-prot-amyl) dr cap 3000-9500-15000 unit 3CREON - pancrelipase (lip-prot-amyl) dr cap 6000-19000-30000

unit3

CREON - pancrelipase (lip-prot-amyl) dr cap 12000-38000-60000unit

3

CREON - pancrelipase (lip-prot-amyl) dr cap 24000-76000-120000unit

3

CREON - pancrelipase (lip-prot-amyl) dr cap36000-114000-180000 unit

3

CYSTADANE - betaine powder for oral solution 5CYSTAGON - cysteamine bitartrate cap 50 mg* 4CYSTAGON - cysteamine bitartrate cap 150 mg* 4ELAPRASE - idursulfase soln for iv infusion 6 mg/3ml (2 mg/ml)* 5

2018


Drug Name Drug Tier Requirements/LimitsELELYSO - taliglucerase alfa for inj 200 unit* 5FABRAZYME - agalsidase beta for iv soln 5 mg* 5FABRAZYME - agalsidase beta for iv soln 35 mg* 5KUVAN - sapropterin dihydrochloride powder packet 100 mg* 5 PAKUVAN - sapropterin dihydrochloride powder packet 500 mg* 5 PAKUVAN - sapropterin dihydrochloride soluble tab 100 mg* 5 PANAGLAZYME - galsulfase soln for iv infusion 1 mg/ml* 5OCALIVA - obeticholic acid tab 5 mg* 5 PA, QL (30 tablets/30 days)OCALIVA - obeticholic acid tab 10 mg* 5 PA, QL (30 tablets/30 days)ORFADIN - nitisinone cap 2 mg* 5ORFADIN - nitisinone cap 5 mg* 5ORFADIN - nitisinone cap 10 mg* 5ORFADIN - nitisinone cap 20 mg* 5ORFADIN - nitisinone susp 4 mg/ml* 5PROLASTIN-C - alpha1-proteinase inhibitor (human) for iv soln

1000 mg*5 PA

PROLASTIN-C - alpha1-proteinase inhibitor (human) inj1000 mg/20ml*

5 PA

sodium phenylbutyrate oral powder 3 gm/teaspoonful 5sodium phenylbutyrate tab 500 mg 5STRENSIQ - asfotase alfa subcutaneous inj 18 mg/0.45ml* 5 PASTRENSIQ - asfotase alfa subcutaneous inj 28 mg/0.7ml* 5 PASTRENSIQ - asfotase alfa subcutaneous inj 40 mg/ml* 5 PASTRENSIQ - asfotase alfa subcutaneous inj 80 mg/0.8ml* 5 PAVIOKACE - pancrelipase (lip-prot-amyl) tab 10440-39150-39150

unit4

VIOKACE - pancrelipase (lip-prot-amyl) tab 20880-78300-78300unit

4

VPRIV - velaglucerase alfa for inj 400 unit 5ZAVESCA - miglustat cap 100 mg* 5 PA, QL (90 capsules/30 days)ZENPEP - pancrelipase (lip-prot-amyl) dr cap 3000-10000-16000

unit3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap 5000-17000-24000unit

3


3


3


3

2018


75

Drug Name Drug Tier Requirements/LimitsZENPEP - pancrelipase (lip-prot-amyl) dr cap 20000-63000-84000

unit3


3


3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap40000-126000-168000 unit

3

ZENPEP - pancrelipase (lip-prot-amyl) dr cap40000-136000-218000 unit

3

Genitourinary Agentsalfuzosin hcl tab er 24hr 10 mg 1 QL (30 tablets/30 days)bethanechol chloride tab 5 mg 2bethanechol chloride tab 10 mg 2bethanechol chloride tab 25 mg 2bethanechol chloride tab 50 mg 2DEPEN TITRATABS - penicillamine tab 250 mg 5dutasteride cap 0.5 mg 2 QL (30 capsules/30 days)dutasteride-tamsulosin hcl cap 0.5-0.4 mg 2 QL (30 capsules/30 days)finasteride tab 5 mg 1 QL (30 tablets/30 days)METHERGINE - methylergonovine maleate tab 0.2 mg 5methylergonovine maleate tab 0.2 mg 5oxybutynin chloride syrup 5 mg/5ml 2 QL (600 mls/30 days)oxybutynin chloride tab er 24hr 5 mg 2 QL (30 tablets/30 days)oxybutynin chloride tab er 24hr 10 mg 2 QL (60 tablets/30 days)oxybutynin chloride tab er 24hr 15 mg 2 QL (60 tablets/30 days)oxybutynin chloride tab 5 mg 2 QL (120 tablets/30 days)RAPAFLO - silodosin cap 4 mg 3 QL (30 capsules/30 days)RAPAFLO - silodosin cap 8 mg 3 QL (30 capsules/30 days)tamsulosin hcl cap 0.4 mg 2 QL (60 capsules/30 days)tolterodine tartrate cap er 24hr 2 mg 2 QL (30 capsules/30 days)tolterodine tartrate cap er 24hr 4 mg 2 QL (30 capsules/30 days)tolterodine tartrate tab 1 mg 2 QL (60 tablets/30 days)tolterodine tartrate tab 2 mg 2 QL (60 tablets/30 days)TOVIAZ - fesoterodine fumarate tab er 24hr 4 mg 3 QL (30 tablets/30 days)TOVIAZ - fesoterodine fumarate tab er 24hr 8 mg 3 QL (30 tablets/30 days)trospium chloride cap er 24hr 60 mg 2 QL (30 capsules/30 days)trospium chloride tab 20 mg 2 QL (60 tablets/30 days)Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)CORTISONE ACETATE - cortisone acetate tab 25 mg 4

2018


Drug Name Drug Tier Requirements/LimitsDEXAMETHASONE - dexamethasone tab 1 mg 4DEXAMETHASONE - dexamethasone tab 2 mg 4dexamethasone elixir 0.5 mg/5ml 2dexamethasone sodium phosphate inj 4 mg/ml 2dexamethasone sodium phosphate inj 20 mg/5ml 2dexamethasone sodium phosphate inj 120 mg/30ml 2dexamethasone tab 0.5 mg 1dexamethasone tab 0.75 mg 1dexamethasone tab 1.5 mg 1dexamethasone tab 4 mg 1dexamethasone tab 6 mg 1fludrocortisone acetate tab 0.1 mg 2H.P. ACTHAR - corticotropin inj gel 80 unit/ml* 5 PAhydrocortisone tab 5 mg 2hydrocortisone tab 10 mg 2hydrocortisone tab 20 mg 2methylprednisolone sod succ for inj 40 mg 2methylprednisolone sod succ for inj 125 mg 2methylprednisolone sod succ for inj 1000 mg 2methylprednisolone tab therapy pack 4 mg (21) 2methylprednisolone tab 4 mg 2methylprednisolone tab 8 mg 2methylprednisolone tab 16 mg 2methylprednisolone tab 32 mg 2prednisolone sod phosph oral soln 6.7 mg/5ml (5 mg/5ml base) 2prednisolone sod phosphate oral soln 15 mg/5ml 2prednisolone syrup 15 mg/5ml 2PREDNISONE - prednisone oral soln 5 mg/5ml 3PREDNISONE - prednisone tab therapy pack 5 mg (21) 2PREDNISONE - prednisone tab therapy pack 5 mg (48) 2PREDNISONE - prednisone tab therapy pack 10 mg (21) 2PREDNISONE - prednisone tab therapy pack 10 mg (48) 2PREDNISONE - prednisone tab 50 mg 4prednisone tab 1 mg 1prednisone tab 2.5 mg 1prednisone tab 5 mg 2prednisone tab 10 mg 2prednisone tab 20 mg 1

2018


77

Drug Name Drug Tier Requirements/LimitsHormonal Agents, Stimulant/Replacement/Modifying (Pituitary)chorionic gonadotropin for im inj 10000 unit(chorionic gonadotropin,

pregnyl)3 PA

desmopressin acetate inj 4 mcg/ml 3desmopressin acetate nasal soln 0.01% (refrigerated) 4desmopressin acetate nasal spray soln 0.01% 2desmopressin acetate nasal spray soln 0.01% (refrigerated) 3desmopressin acetate tab 0.1 mg 2desmopressin acetate tab 0.2 mg 2EGRIFTA - tesamorelin acetate for inj 1 mg* 5 PAEGRIFTA - tesamorelin acetate for inj 2 mg* 5 PAINCRELEX - mecasermin inj 40 mg/4ml (10 mg/ml)* 5OMNITROPE - somatropin for inj 5.8 mg 3 PAOMNITROPE - somatropin inj 5 mg/1.5ml 5 PAOMNITROPE - somatropin inj 10 mg/1.5ml 5 PASTIMATE - desmopressin acetate nasal soln 1.5 mg/ml 5Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)ANADROL-50 - oxymetholone tab 50 mg 5 PAANDRODERM - testosterone td patch 24hr 2 mg/24hr 3 PA, QL (30 patches/30 days)ANDRODERM - testosterone td patch 24hr 4 mg/24hr 3 PA, QL (30 patches/30 days)ANDROGEL - testosterone td gel 20.25 mg/1.25gm (1.62%) 3 PA, QL (30 packets/30 days)ANDROGEL - testosterone td gel 40.5 mg/2.5gm (1.62%) 3 PA, QL (60 packets/30 days)ANDROGEL PUMP - testosterone td gel 20.25 mg/act (1.62%) 3 PA, QL (2 pump bottles/30 days)danazol cap 50 mg 2 PAdanazol cap 100 mg 3 PAdanazol cap 200 mg 4 PADEPO-PROVERA - medroxyprogesterone acetate im susp 400 mg/

ml4

desogest-eth estrad & eth estrad tab 0.15-0.02/0.01 mg(21/5) 2desogest-ethin est tab 0.1-0.025/0.125-0.025/0.15-0.025mg-mg 2desogestrel & ethinyl estradiol tab 0.15 mg-30 mcg 2DIVIGEL - estradiol td gel 0.25 mg/0.25gm (0.1%)# 4 PADIVIGEL - estradiol td gel 0.5 mg/0.5gm (0.1%)# 4 PADIVIGEL - estradiol td gel 1 mg/gm (0.1%)# 4 PAdrospirenone-ethinyl estrad-levomefolate tab 3-0.02-0.451 mg 2drospirenone-ethinyl estradiol tab 3-0.02 mg 2drospirenone-ethinyl estradiol tab 3-0.03 mg 2ELLA - ulipristal acetate tab 30 mg 3ESTRACE - estradiol vaginal cream 0.1 mg/gm 4

2018


Drug Name Drug Tier Requirements/Limitsestradiol & norethindrone acetate tab 0.5-0.1 mg# 4 PAestradiol & norethindrone acetate tab 1-0.5 mg# 4 PAestradiol tab 0.5 mg# 4 PAestradiol tab 1 mg# 4 PAestradiol tab 2 mg# 4 PAestradiol td patch weekly 0.025 mg/24hr# 4 PAestradiol td patch weekly 0.0375 mg/24hr (37.5 mcg/24hr)# 4 PAestradiol td patch weekly 0.05 mg/24hr# 4 PAestradiol td patch weekly 0.06 mg/24hr# 4 PAestradiol td patch weekly 0.075 mg/24hr# 4 PAestradiol td patch weekly 0.1 mg/24hr# 4 PAestradiol vaginal cream 0.1 mg/gm 4estradiol vaginal tab 10 mcg 2ESTROPIPATE - estropipate tab 0.75 mg# 4 PAESTROPIPATE - estropipate tab 1.5 mg# 4 PAESTROPIPATE - estropipate tab 3 mg# 4 PAethynodiol diacetate & ethinyl estradiol tab 1 mg-35 mcg 2ethynodiol diacetate & ethinyl estradiol tab 1 mg-50 mcg 2HYDROXYPROGESTERONE CAPROATE - hydroxyprogesterone

caproate im in oil 1.25 gm/5ml5

levonorg-eth est tab 0.1-0.02mg(84) & eth est tab 0.01mg(7) 2levonorg-eth est tab 0.15-0.03mg(84) & eth est tab 0.01mg(7) 2levonorgestrel & ethinyl estradiol (91-day) tab 0.15-0.03 mg 2levonorgestrel & ethinyl estradiol tab 0.1 mg-20 mcg 2levonorgestrel & ethinyl estradiol tab 0.15 mg-30 mcg 2levonorgestrel-eth estra tab 0.05-30/0.075-40/0.125-30mg-mcg 2levonorgestrel-ethinyl estradiol (continuous) tab 90-20 mcg 2medroxyprogesterone acetate im susp prefilled syr 150 mg/ml 2medroxyprogesterone acetate im susp 150 mg/ml 2medroxyprogesterone acetate tab 2.5 mg 1medroxyprogesterone acetate tab 5 mg 1medroxyprogesterone acetate tab 10 mg 1megestrol acetate susp 40 mg/ml# 4 PAmegestrol acetate tab 20 mg# 4 PAmegestrol acetate tab 40 mg# 4 PAMENEST - esterified estrogens tab 0.3 mg# 4 PAMENEST - esterified estrogens tab 0.625 mg# 4 PAMENEST - esterified estrogens tab 1.25 mg# 4 PAmethyltestosterone cap 10 mg 4 PA

2018


79

Drug Name Drug Tier Requirements/Limitsnorethindrone & ethinyl estradiol tab 0.4 mg-35 mcg 2norethindrone & ethinyl estradiol tab 0.5 mg-35 mcg 2norethindrone & ethinyl estradiol tab 1 mg-35 mcg 2norethindrone & ethinyl estradiol-fe chew tab 0.4 mg-35 mcg 2norethindrone & ethinyl estradiol-fe chew tab 0.8 mg-25 mcg 2norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35 mg-mcg 2norethindrone ace & ethinyl estradiol tab 1 mg-20 mcg 2norethindrone ace & ethinyl estradiol tab 1.5 mg-30 mcg 2norethindrone ace & ethinyl estradiol-fe tab 1 mg-20 mcg 2norethindrone ace & ethinyl estradiol-fe tab 1.5 mg-30 mcg 2norethindrone ace-ethinyl estradiol-fe tab 1 mg-20 mcg (24) 2norethindrone acetate tab 5 mg 2norethindrone tab 0.35 mg 2norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35 mg-mcg 2norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35 mg-mcg 2norgestimate & ethinyl estradiol tab 0.25 mg-35 mcg 2norgestimate-eth estrad tab 0.18-25/0.215-25/0.25-25 mg-mcg 2norgestimate-eth estrad tab 0.18-35/0.215-35/0.25-35 mg-mcg 2norgestrel & ethinyl estradiol tab 0.3 mg-30 mcg 2oxandrolone tab 2.5 mg 3 PAoxandrolone tab 10 mg 5 PAPREMARIN - estrogens, conjugated vaginal cream 0.625 mg/gm 3PREMARIN - estrogens, conjugated tab 0.3 mg# 4 PAPREMARIN - estrogens, conjugated tab 0.45 mg# 4 PAPREMARIN - estrogens, conjugated tab 0.625 mg# 4 PAPREMARIN - estrogens, conjugated tab 0.9 mg# 4 PAPREMARIN - estrogens, conjugated tab 1.25 mg# 4 PAPREMPHASE - conj est 0.625(14)/conj est-medroxypro ac tab

0.625-5mg(14)#4 PA

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.3-1.5 mg#

4 PA


4 PA


4 PA

PREMPRO - conjugated estrogen-medroxyprogest acetate tab0.625-5 mg#

4 PA

raloxifene hcl tab 60 mg 2testosterone cypionate im inj in oil 100 mg/ml 2 PAtestosterone cypionate im inj in oil 200 mg/ml 2 PA

2018


Drug Name Drug Tier Requirements/Limitstestosterone enanthate im inj in oil 200 mg/ml 2 PAtestosterone td gel 25 mg/2.5gm (1%) 2 PA, QL (90 packets/30 days)testosterone td gel 50 mg/5gm (1%) 2 PA, QL (60 packets/30 days)testosterone td gel 12.5 mg/act (1%) 2 PA, QL (4 pump bottles/30 days)testosterone td soln 30 mg/act 4 PA, QL (2 pump bottles/30 days)Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium tab 25 mcg 2levothyroxine sodium tab 50 mcg 2levothyroxine sodium tab 75 mcg 2levothyroxine sodium tab 88 mcg 2levothyroxine sodium tab 100 mcg 2levothyroxine sodium tab 112 mcg 2levothyroxine sodium tab 125 mcg 2levothyroxine sodium tab 137 mcg 2levothyroxine sodium tab 150 mcg 2levothyroxine sodium tab 175 mcg 2levothyroxine sodium tab 200 mcg 2levothyroxine sodium tab 300 mcg 2liothyronine sodium tab 5 mcg 2liothyronine sodium tab 25 mcg 2liothyronine sodium tab 50 mcg 2SYNTHROID - levothyroxine sodium tab 25 mcg 4SYNTHROID - levothyroxine sodium tab 50 mcg 4SYNTHROID - levothyroxine sodium tab 75 mcg 4SYNTHROID - levothyroxine sodium tab 88 mcg 4SYNTHROID - levothyroxine sodium tab 100 mcg 4SYNTHROID - levothyroxine sodium tab 112 mcg 4SYNTHROID - levothyroxine sodium tab 125 mcg 4SYNTHROID - levothyroxine sodium tab 137 mcg 4SYNTHROID - levothyroxine sodium tab 150 mcg 4SYNTHROID - levothyroxine sodium tab 175 mcg 4SYNTHROID - levothyroxine sodium tab 200 mcg 4SYNTHROID - levothyroxine sodium tab 300 mcg 4Hormonal Agents, Suppressant (Adrenal)KORLYM - mifepristone tab 300 mg* 5 PA, QL (120 tablets/30 days)LYSODREN - mitotane tab 500 mg 5Hormonal Agents, Suppressant (Pituitary)cabergoline tab 0.5 mg 2

2018


81

Drug Name Drug Tier Requirements/LimitsELIGARD - leuprolide acetate (3 month) for subcutaneous inj kit

22.5mg4

ELIGARD - leuprolide acetate (4 month) for subcutaneous inj kit30 mg

4

ELIGARD - leuprolide acetate (6 month) for subcutaneous inj kit45 mg

4

ELIGARD - leuprolide acetate for subcutaneous inj kit 7.5 mg 4FIRMAGON - degarelix acetate for inj 80 mg 4FIRMAGON - degarelix acetate for inj 120 mg 5leuprolide acetate inj kit 5 mg/ml 4LUPRON DEPOT (1-MONTH) - leuprolide acetate for inj kit

3.75 mg5

LUPRON DEPOT (1-MONTH) - leuprolide acetate for inj kit 7.5 mg 5LUPRON DEPOT (3-MONTH) - leuprolide acetate (3 month) for inj

kit 11.25 mg5

LUPRON DEPOT (3-MONTH) - leuprolide acetate (3 month) for injkit 22.5 mg

5

LUPRON DEPOT (4-MONTH) - leuprolide acetate (4 month) for injkit 30 mg

5

LUPRON DEPOT (6-MONTH) - leuprolide acetate (6 month) for injkit 45 mg

5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 7.5 mg

5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 11.25 mg

5

LUPRON DEPOT-PED (1-MONTH) - leuprolide acetate for injpediatric kit 15 mg

5

LUPRON DEPOT-PED (3-MONTH) - leuprolide acetate (3 month)for inj pediatric kit 11.25 mg

5

LUPRON DEPOT-PED (3-MONTH) - leuprolide acetate (3 month)for inj pediatric kit 30 mg

5

octreotide acetate inj 50 mcg/ml (0.05 mg/ml) 4 PAoctreotide acetate inj 100 mcg/ml (0.1 mg/ml) 4 PAoctreotide acetate inj 200 mcg/ml (0.2 mg/ml) 4 PAoctreotide acetate inj 500 mcg/ml (0.5 mg/ml) 4 PAoctreotide acetate inj 1000 mcg/ml (1 mg/ml) 5 PASIGNIFOR - pasireotide diaspartate inj 0.3 mg/ml* 5 PASIGNIFOR - pasireotide diaspartate inj 0.6 mg/ml* 5 PASIGNIFOR - pasireotide diaspartate inj 0.9 mg/ml* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 20 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 40 mg* 5 PASIGNIFOR LAR - pasireotide pamoate for im er susp 60 mg* 5 PA

2018


Drug Name Drug Tier Requirements/LimitsSOMATULINE DEPOT - lanreotide acetate extended release inj

60 mg/0.2ml5 PA

SOMATULINE DEPOT - lanreotide acetate extended release inj90 mg/0.3ml

5 PA

SOMATULINE DEPOT - lanreotide acetate extended release inj120 mg/0.5ml

5 PA

SOMAVERT - pegvisomant for inj 10 mg* 5 PASOMAVERT - pegvisomant for inj 15 mg* 5 PASOMAVERT - pegvisomant for inj 20 mg* 5 PASOMAVERT - pegvisomant for inj 25 mg* 5 PASOMAVERT - pegvisomant for inj 30 mg* 5 PASYNAREL - nafarelin acetate nasal soln 2 mg/ml (200 mcg/act) 5TRELSTAR - triptorelin pamoate for im susp 3.75 mg 5TRELSTAR - triptorelin pamoate for im susp 11.25 mg 5TRELSTAR MIXJECT - triptorelin pamoate for im susp 3.75 mg 5TRELSTAR MIXJECT - triptorelin pamoate for im susp 11.25 mg 5TRELSTAR MIXJECT - triptorelin pamoate for im susp 22.5 mg 5Hormonal Agents, Suppressant (Thyroid)methimazole tab 5 mg 1methimazole tab 10 mg 1propylthiouracil tab 50 mg 2Immunological AgentsACTHIB - haemophilus b polysaccharide conjugate vaccine for inj 4ACTIMMUNE - interferon gamma-1b inj 100 mcg/0.5ml (2000000

unit/0.5ml)*5

ADACEL - tet tox-diph-acell pertuss ad inj 5-2-15.5 lf-lf-mcg/0.5ml 4ARCALYST - rilonacept for inj 220 mg* 5 PAATGAM - lymphocyte immune globulin anti-thymocyte g inj 50 mg/

ml(eq)5 BD

AZASAN - azathioprine tab 75 mg 4 BDAZASAN - azathioprine tab 100 mg 4 BDAZATHIOPRINE - azathioprine sodium for inj 100 mg 3 BDazathioprine tab 50 mg 2 BDBCG VACCINE - bcg vaccine inj 4BENLYSTA - belimumab for iv soln 120 mg 5 PABENLYSTA - belimumab for iv soln 400 mg 5 PABENLYSTA - belimumab subcutaneous solution auto-injector

200 mg/ml5 PA

BENLYSTA - belimumab subcutaneous solution prefilled syringe200 mg/ml

5 PA

2018


83

Drug Name Drug Tier Requirements/LimitsBEXSERO - meningococcal vac b (recomb omv adjuv) inj prefilled

syringe4

BOOSTRIX - tet tox-diph-acell pertuss ad inj 5-2.5-18.5 lf-lf-mcg/0.5ml

4

CINRYZE - c1 esterase inhibitor (human) for iv inj 500 unit* 5 PA, QL (20 vials/30 days)COSENTYX - secukinumab subcutaneous soln prefilled syringe

150 mg/ml5 PA

COSENTYX SENSOREADY PEN - secukinumab subcutaneoussoln auto-injector 150 mg/ml

5 PA

cyclosporine cap 25 mg 3 BDcyclosporine cap 100 mg 4 BDcyclosporine iv soln 50 mg/ml 2 BDcyclosporine modified cap 25 mg 2 BDcyclosporine modified cap 50 mg 3 BDcyclosporine modified cap 100 mg 2 BDcyclosporine modified oral soln 100 mg/ml 3 BDDAPTACEL - diph, acellular pert & tet tox inj 15 lf-23 mcg-5 lf/0.5ml 4DIPHTHERIA/TETANUS TOXOIDS ADSORBED - diphtheria-

tetanus tox adsorbed (dt) im inj 25-5 unit/0.5ml4

ENBREL - etanercept for subcutaneous inj 25 mg 5 PAENBREL - etanercept subcutaneous soln prefilled syringe

25 mg/0.5ml5 PA

ENBREL - etanercept subcutaneous soln prefilled syringe 50 mg/ml 5 PAENBREL MINI - etanercept subcutaneous solution cartridge 50 mg/

ml5 PA

ENBREL SURECLICK - etanercept subcutaneous solution auto-injector 50 mg/ml

5 PA

ENGERIX-B - hepatitis b vaccine (recombinant) susp 10 mcg/0.5ml 4 BDENGERIX-B - hepatitis b vaccine (recombinant) susp 20 mcg/ml 4 BDFIRAZYR - icatibant acetate inj 30 mg/3ml* 5 PA, QL (6 syringes/30 days)GAMMAGARD LIQUID - immune globulin (human) iv or

subcutaneous soln 1 gm/10ml5 BD, PA

GAMMAGARD LIQUID - immune globulin (human) iv orsubcutaneous soln 2.5 gm/25ml

5 BD, PA

GAMMAGARD LIQUID - immune globulin (human) iv orsubcutaneous soln 5 gm/50ml

5 BD, PA


5 BD, PA


5 BD, PA


5 BD, PA

2018


Drug Name Drug Tier Requirements/LimitsGAMMAGARD S/D - immune globulin (human) iv for soln 5 gm 5 BD, PAGAMMAGARD S/D - immune globulin (human) iv for soln 10 gm 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 5 gm/100ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 10 gm/200ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 20 gm/400ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 5 gm/50ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 10 gm/100ml 5 BD, PAGAMMAPLEX - immune globulin (human) iv soln 20 gm/200ml 5 BD, PAGAMUNEX-C - immune globulin (human) iv or subcutaneous soln

1 gm/10ml5 BD, PA

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln2.5 gm/25ml

5 BD, PA

GAMUNEX-C - immune globulin (human) iv or subcutaneous soln5 gm/50ml

5 BD, PA


5 BD, PA


5 BD, PA


5 BD, PA

GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vac imsusp

4

GARDASIL 9 - human papillomavirus (hpv) 9-valent recomb vacsusp pref syr

4

HAEGARDA - c1 esterase inhibitor (human) for subcutaneous inj2000 unit

5 PA, QL (24 vials/30 days)

HAEGARDA - c1 esterase inhibitor (human) for subcutaneous inj3000 unit

5 PA, QL (16 vials/30 days)

HAVRIX - hepatitis a vaccine inj susp 720 el unit/0.5ml 4HAVRIX - hepatitis a vaccine inj susp 1440 el unit/ml 4HIBERIX - haemophilus b polysaccharide conjugate vac for inj

10 mcg4

HUMIRA - adalimumab prefilled syringe kit 10 mg/0.2ml 5 PAHUMIRA - adalimumab prefilled syringe kit 20 mg/0.4ml 5 PAHUMIRA - adalimumab prefilled syringe kit 40 mg/0.8ml 5 PAHUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK -

adalimumab prefilled syringe kit 40 mg/0.8ml5 PA

HUMIRA PEN - adalimumab pen-injector kit 40 mg/0.8ml 5 PAHUMIRA PEN-CROHNS DISEASE STARTER - adalimumab pen-

injector kit 40 mg/0.8ml5 PA

HUMIRA PEN-PSORIASIS STARTER - adalimumab pen-injector kit40 mg/0.8ml

5 PA

2018


85

Drug Name Drug Tier Requirements/LimitsILARIS - canakinumab for inj 180 mg* 5 PAILARIS - canakinumab subcutaneous inj 150 mg/ml* 5 PAIMOVAX RABIES (H.D.C.V.) - rabies virus vaccine, hdc inj 3 BDINFANRIX - diph, acellular pert & tet tox inj 25 lf-58 mcg-10 lf/0.5ml 4IPOL INACTIVATED IPV - poliovirus vaccine, ipv injection 4IXIARO - japanese encephalitis vaccine inactivated adsorbed inj 4KINERET - anakinra subcutaneous soln prefilled syringe

100 mg/0.67ml5 PA

KINRIX - diph-tetanus tox ad-acell pert & polio virus, ipv vac inj 4leflunomide tab 10 mg 2leflunomide tab 20 mg 2M-M-R II - measles, mumps & rubella virus vaccines for inj 4MENACTRA - meningococcal (a, c, y, and w-135) conjugate

vaccine inj4

MENVEO - meningococcal (a, c, y, and w-135) oligo conj vac for inj 4METHOTREXATE SODIUM - methotrexate sodium inj

250 mg/10ml (25 mg/ml)2

methotrexate sodium for inj 1 gm 2methotrexate sodium inj pf 50 mg/2ml (25 mg/ml) 2methotrexate sodium inj pf 100 mg/4ml (25 mg/ml) 2methotrexate sodium inj pf 200 mg/8ml (25 mg/ml) 2methotrexate sodium inj pf 250 mg/10ml (25 mg/ml) 2methotrexate sodium inj pf 1000 mg/40ml (25 mg/ml) 2methotrexate sodium inj 50 mg/2ml (25 mg/ml) 2methotrexate sodium tab 2.5 mg 3mycophenolate mofetil cap 250 mg 2 BDmycophenolate mofetil for oral susp 200 mg/ml 5 BDmycophenolate mofetil hcl for iv soln 500 mg 2 BDmycophenolate mofetil tab 500 mg 2 BDmycophenolate sodium tab dr 180 mg 2 BDmycophenolate sodium tab dr 360 mg 2 BDNULOJIX - belatacept for iv infusion 250 mg 5 BDORENCIA - abatacept for iv soln 250 mg 5 PAORENCIA - abatacept subcutaneous soln prefilled syringe

50 mg/0.4ml5 PA

ORENCIA - abatacept subcutaneous soln prefilled syringe87.5 mg/0.7ml

5 PA

ORENCIA - abatacept subcutaneous soln prefilled syringe 125 mg/ml

5 PA

2018


Drug Name Drug Tier Requirements/LimitsORENCIA CLICKJECT - abatacept subcutaneous soln auto-injector

125 mg/ml5 PA

OTEZLA - apremilast tab starter therapy pack 10 mg & 20 mg &30 mg

5 PA

OTEZLA - apremilast tab 30 mg 5 PAPEDIARIX - diph-tetanus tox-acell pert-hepatitis b-polio ipv vac inj 4PEDVAX HIB - haemophilus b polysaccharide conj vac im susp

7.5 mcg/0.5 ml4

PENTACEL - diph-ac per-tet tox ad-poliov-haemoph b poly vac forim susp

4

PROGRAF - tacrolimus inj 5 mg/ml 4 BDPROQUAD - measles-mumps-rubella-varicella virus vaccines for inj 4QUADRACEL - diph-tetanus tox ad-acell pert & polio virus, ipv vac

inj4

RABAVERT - rabies vaccine, pcec for inj 4 BDRAPAMUNE - sirolimus oral soln 1 mg/ml 5 BDRECOMBIVAX HB - hepatitis b vaccine (recombinant) susp

5 mcg/0.5ml4 BD

RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp10 mcg/ml

4 BD

RECOMBIVAX HB - hepatitis b vaccine (recombinant) susp40 mcg/ml

4 BD

REMICADE - infliximab for iv inj 100 mg 5 PARIDAURA - auranofin cap 3 mg 5ROTARIX - rotavirus vaccine, live for oral susp 4ROTATEQ - rotavirus vaccine, live oral pentavalent soln 4SANDIMMUNE - cyclosporine oral soln 100 mg/ml 4 BDSHINGRIX - zoster vaccine recombinant adjuvanted for im inj

50 mcg4 QL (2 vaccines/lifetime)

SIMULECT - basiliximab for iv soln 10 mg 5 BDSIMULECT - basiliximab for iv soln 20 mg 5 BDsirolimus tab 0.5 mg 4 BDsirolimus tab 1 mg 4 BDsirolimus tab 2 mg 5 BDSTAMARIL - yellow fever vaccine for inj suspension 4STELARA - ustekinumab inj 45 mg/0.5ml 5 PASTELARA - ustekinumab iv soln 130 mg/26ml (5 mg/ml) (for iv

infusion)5 PA

STELARA - ustekinumab soln prefilled syringe 45 mg/0.5ml 5 PASTELARA - ustekinumab soln prefilled syringe 90 mg/ml 5 PASYLVANT - siltuximab for iv infusion 100 mg 5

2018


87

Drug Name Drug Tier Requirements/LimitsSYLVANT - siltuximab for iv infusion 400 mg 5SYNAGIS - palivizumab im soln 50 mg/0.5ml* 5SYNAGIS - palivizumab im soln 100 mg/ml* 5tacrolimus cap 0.5 mg 2 BDtacrolimus cap 1 mg 2 BDtacrolimus cap 5 mg 4 BDTENIVAC - tetanus-diphtheria toxoids (td) inj 5-2 lfu 3TETANUS/DIPHTHERIA TOXOIDS ADSORBED - tetanus-

diphtheria toxoids (td) inj 2-2 lf/0.5ml3

THYMOGLOBULIN - anti-thymocyte globulin for iv soln 25 mg(lymphocyte ig)

5 BD

TRUMENBA - meningococcal group b vac (recomb) im suspprefilled syr

4

TWINRIX - hepatitis a (inact)-hep b (recomb) vac inj 720-20 elu-mcg/ml

4

TYPHIM VI - typhoid vi polysaccharide intramuscular vac inj25 mcg/0.5ml

4

VAQTA - hepatitis a vaccine inj susp 25 unit/0.5ml 4VAQTA - hepatitis a vaccine inj susp 50 unit/ml 4VARIVAX - varicella virus vac live for subcutaneous inj 1350

pfu/0.5ml4

XATMEP - methotrexate oral soln 2.5 mg/ml 5 BDXOLAIR - omalizumab for inj 150 mg* 5 PAYF-VAX - yellow fever vaccine subcutaneous inj 4ZORTRESS - everolimus tab 0.25 mg 5 BDZORTRESS - everolimus tab 0.5 mg 5 BDZORTRESS - everolimus tab 0.75 mg 5 BDZOSTAVAX - zoster vaccine live for subcutaneous susp 19400

unit/0.65ml4 QL (1 vaccine/lifetime)

Inflammatory Bowel Disease AgentsAPRISO - mesalamine cap er 24hr 0.375 gm 4ASACOL HD - mesalamine tab delayed release 800 mg 3balsalazide disodium cap 750 mg 2budesonide delayed release particles cap 3 mg 5CANASA - mesalamine suppos 1000 mg 3DELZICOL - mesalamine cap dr 400 mg 3DIPENTUM - olsalazine sodium cap 250 mg 5hydrocortisone enema 100 mg/60ml 2hydrocortisone rectal cream 1% 2hydrocortisone rectal cream 2.5% 2LIALDA - mesalamine tab delayed release 1.2 gm 4

2018


Drug Name Drug Tier Requirements/Limitsmesalamine enema 4 gm 2mesalamine rectal enema 4 gm & cleanser wipe kit 2mesalamine tab delayed release 1.2 gm 4PENTASA - mesalamine cap er 250 mg 4PENTASA - mesalamine cap er 500 mg 4sulfasalazine tab delayed release 500 mg 2sulfasalazine tab 500 mg 2Metabolic Bone Disease Agentsalendronate sodium tab 5 mg 1 QL (30 tablets/30 days)alendronate sodium tab 10 mg 1 QL (120 tablets/30 days)alendronate sodium tab 35 mg 1 QL (4 tablets/28 days)alendronate sodium tab 70 mg 1 QL (4 tablets/28 days)calcitonin (salmon) nasal soln 200 unit/act 2calcitriol cap 0.25 mcg 2calcitriol cap 0.5 mcg 2calcitriol inj 1 mcg/ml 2calcitriol oral soln 1 mcg/ml 3ETIDRONATE DISODIUM - etidronate disodium tab 200 mg 4ETIDRONATE DISODIUM - etidronate disodium tab 400 mg 4FORTEO - teriparatide (recombinant) inj 600 mcg/2.4ml 5 PAibandronate sodium iv soln 3 mg/3ml 2ibandronate sodium tab 150 mg 2 QL (1 tablet/28 days)MIACALCIN - calcitonin (salmon) inj 200 unit/ml 4NATPARA - parathyroid hormone (recombinant) for inj cartridge

25 mcg*5 PA, QL (2 cartridges/28 days)

NATPARA - parathyroid hormone (recombinant) for inj cartridge50 mcg*

5 PA, QL (2 cartridges/28 days)





paricalcitol cap 1 mcg 2paricalcitol cap 2 mcg 4paricalcitol cap 4 mcg 4paricalcitol iv soln 2 mcg/ml 2paricalcitol iv soln 5 mcg/ml 2PROLIA - denosumab inj 60 mg/ml 4 PArisedronate sodium tab delayed release 35 mg 2 QL (4 tablets/28 days)risedronate sodium tab 5 mg 2 QL (30 tablets/30 days)risedronate sodium tab 30 mg 2 QL (30 tablets/30 days)

2018


89

Drug Name Drug Tier Requirements/Limitsrisedronate sodium tab 35 mg 2 QL (4 tablets/28 days)risedronate sodium tab 150 mg 2 QL (1 tablet/28 days)SENSIPAR - cinacalcet hcl tab 30 mg 5 PASENSIPAR - cinacalcet hcl tab 60 mg 5 PASENSIPAR - cinacalcet hcl tab 90 mg 5 PAXGEVA - denosumab inj 120 mg/1.7ml 5zoledronic acid inj conc for iv infusion 4 mg/5ml 3zoledronic acid iv soln 5 mg/100ml 3ZOMETA - zoledronic acid iv soln 4 mg/100ml 5Ophthalmic AgentsALPHAGAN P - brimonidine tartrate ophth soln 0.1% 4azelastine hcl ophth soln 0.05% 2AZOPT - brinzolamide ophth susp 1% 4BACITRACIN - bacitracin ophth oint 500 unit/gm 3bacitracin-polymyxin b ophth oint 2bacitracin-polymyxin-neomycin-hc ophth oint 1% 2BESIVANCE - besifloxacin hcl ophth susp 0.6% 4betaxolol hcl ophth soln 0.5% 2BETOPTIC-S - betaxolol hcl ophth susp 0.25% 4brimonidine tartrate ophth soln 0.15% 2brimonidine tartrate ophth soln 0.2% 1bromfenac sodium ophth soln 0.09% (once-daily) 2carteolol hcl ophth soln 1% 1ciprofloxacin hcl ophth soln 0.3% 1COMBIGAN - brimonidine tartrate-timolol maleate ophth soln

0.2-0.5%3

cromolyn sodium ophth soln 4% 1CYSTARAN - cysteamine hcl ophth soln 0.44% 5DEXAMETHASONE SODIUM PHOSPHATE - dexamethasone

sodium phosphate ophth soln 0.1%4

diclofenac sodium ophth soln 0.1% 2dorzolamide hcl ophth soln 2% 2dorzolamide hcl-timolol maleate ophth soln 22.3-6.8 mg/ml 2DUREZOL - difluprednate ophth emulsion 0.05% 3epinastine hcl ophth soln 0.05% 2erythromycin ophth oint 5 mg/gm 1fluorometholone ophth susp 0.1% 2flurbiprofen sodium ophth soln 0.03% 1gentamicin sulfate ophth oint 0.3% 2

2018


Drug Name Drug Tier Requirements/Limitsgentamicin sulfate ophth soln 0.3% 2ILEVRO - nepafenac ophth susp 0.3% 3ISTALOL - timolol maleate ophth soln 0.5% (once-daily) 4ketorolac tromethamine ophth soln 0.4% 2ketorolac tromethamine ophth soln 0.5% 2LACRISERT - artificial tear ophth insert 4latanoprost ophth soln 0.005% 2levobunolol hcl ophth soln 0.5% 1LOTEMAX - loteprednol etabonate ophth gel 0.5% 3LOTEMAX - loteprednol etabonate ophth oint 0.5% 3LOTEMAX - loteprednol etabonate ophth susp 0.5% 3LUMIGAN - bimatoprost ophth soln 0.01% 3MOXEZA - moxifloxacin hcl ophth soln 0.5% (2 times daily) 4moxifloxacin hcl ophth soln 0.5% 2NATACYN - natamycin ophth susp 5% 4neomycin-bacitrac zn-polymyx 5(3.5)mg-400unt-10000unt op oin 2neomycin-polymy-gramicid op sol 1.75-10000-0.025mg-unt-mg/ml 2neomycin-polymyxin-dexamethasone ophth oint 0.1% 2neomycin-polymyxin-dexamethasone ophth susp 0.1% 2ofloxacin ophth soln 0.3% 2olopatadine hcl ophth soln 0.1% 2olopatadine hcl ophth soln 0.2% 3PAZEO - olopatadine hcl ophth soln 0.7% 3PHOSPHOLINE IODIDE - echothiophate iodide ophth for soln

0.125%4

pilocarpine hcl ophth soln 1% 2pilocarpine hcl ophth soln 2% 2pilocarpine hcl ophth soln 4% 2polymyxin b-trimethoprim ophth soln 10000 unit/ml-0.1% 1prednisolone acetate ophth susp 1% 2PROLENSA - bromfenac sodium ophth soln 0.07% 4RESTASIS - cyclosporine (ophth) emulsion 0.05% 3 PA, QL (60 vials/30 days)RESTASIS MULTIDOSE - cyclosporine (ophth) emulsion 0.05% 3 PA, QL (2 bottles/30 days)SIMBRINZA - brinzolamide-brimonidine tartrate ophth susp 1-0.2% 3sulfacetamide sodium ophth soln 10% 2sulfacetamide sodium-prednisolone ophth soln 10-0.23(0.25)% 2timolol maleate ophth gel forming soln 0.25% 2timolol maleate ophth gel forming soln 0.5% 2timolol maleate ophth soln 0.25% 1

2018


91

Drug Name Drug Tier Requirements/Limitstimolol maleate ophth soln 0.5% 1timolol maleate ophth soln 0.5% (once-daily) 3TOBRADEX - tobramycin-dexamethasone ophth oint 0.3-0.1% 4tobramycin ophth soln 0.3% 2tobramycin-dexamethasone ophth susp 0.3-0.1% 2TRAVATAN Z - travoprost ophth soln 0.004% 3trifluridine ophth soln 1% 2VIGAMOX - moxifloxacin hcl ophth soln 0.5% 3Otic Agentsacetic acid otic soln 2% 2ACETIC ACID/ALUMINUM ACETATE - acetic acid 2% in aluminum

acetate otic soln4

CIPRODEX - ciprofloxacin-dexamethasone otic susp 0.3-0.1% 4fluocinolone acetonide (otic) oil 0.01% 2hydrocortisone w/ acetic acid otic soln 1-2% 2neomycin-polymyxin-hc otic soln 1% 2neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000 unit/ml-1% 2ofloxacin otic soln 0.3% 2Respiratory Tract/Pulmonary Agentsacetylcysteine inhal soln 10% 2 BDacetylcysteine inhal soln 20% 2 BDADCIRCA - tadalafil tab 20 mg 5 PA, QL (60 tablets/30 days)ADEMPAS - riociguat tab 0.5 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 1.5 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2 mg 5 PA, QL (90 tablets/30 days)ADEMPAS - riociguat tab 2.5 mg 5 PA, QL (90 tablets/30 days)ADVAIR DISKUS - fluticasone-salmeterol aer powder ba

100-50 mcg/dose3 QL (1 inhaler/30 days)

ADVAIR DISKUS - fluticasone-salmeterol aer powder ba250-50 mcg/dose

3 QL (1 inhaler/30 days)

ADVAIR DISKUS - fluticasone-salmeterol aer powder ba500-50 mcg/dose


ADVAIR HFA - fluticasone-salmeterol inhal aerosol 45-21 mcg/act 3 QL (1 canister/30 days)ADVAIR HFA - fluticasone-salmeterol inhal aerosol 115-21 mcg/act 3 QL (1 canister/30 days)ADVAIR HFA - fluticasone-salmeterol inhal aerosol 230-21 mcg/act 3 QL (1 canister/30 days)albuterol sulfate soln nebu 0.083% (2.5 mg/3ml) 2 BDalbuterol sulfate soln nebu 0.5% (5 mg/ml) 2 BDalbuterol sulfate soln nebu 0.63 mg/3ml 2 BDalbuterol sulfate soln nebu 1.25 mg/3ml 2 BD

2018


Drug Name Drug Tier Requirements/Limitsalbuterol sulfate syrup 2 mg/5ml 1albuterol sulfate tab er 12hr 4 mg 2albuterol sulfate tab er 12hr 8 mg 2albuterol sulfate tab 2 mg 4albuterol sulfate tab 4 mg 4ANORO ELLIPTA - umeclidinium-vilanterol aero powd ba

62.5-25 mcg/inh3 QL (1 package/30 days)

ARNUITY ELLIPTA - fluticasone furoate aerosol powder breathactiv 100 mcg/act

3 QL (30 blisters/30 days)

ARNUITY ELLIPTA - fluticasone furoate aerosol powder breathactiv 200 mcg/act


ASMANEX HFA - mometasone furoate inhal aerosol suspension100 mcg/act

3 QL (1 canister/30 days)

ASMANEX HFA - mometasone furoate inhal aerosol suspension200 mcg/act


ASMANEX TWISTHALER 120 METERED DOSES - mometasonefuroate inhal powd 220 mcg/inh












ATROVENT HFA - ipratropium bromide hfa inhal aerosol 17 mcg/act

4 QL (2 canisters/30 days)

azelastine hcl nasal spray 0.1% (137 mcg/spray) 2 QL (2 bottles/30 days)azelastine hcl nasal spray 0.15% (205.5 mcg/spray) 2 QL (2 bottles/30 days)BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba

100-25 mcg/inh3 QL (1 package/30 days)

BREO ELLIPTA - fluticasone furoate-vilanterol aero powd ba200-25 mcg/inh

3 QL (1 package/30 days)

budesonide inhalation susp 0.25 mg/2ml 3 BDbudesonide inhalation susp 0.5 mg/2ml 3 BDbudesonide inhalation susp 1 mg/2ml 4 BDcaffeine citrate oral soln 60 mg/3ml 2CLEMASTINE FUMARATE - clemastine fumarate tab 2.68 mg# 4 PACOMBIVENT RESPIMAT - ipratropium-albuterol inhal aerosol soln

20-100 mcg/act4 QL (2 canisters/30 days)

cromolyn sodium soln nebu 20 mg/2ml 3 BD

2018


93

Drug Name Drug Tier Requirements/LimitsDALIRESP - roflumilast tab 500 mcg 4diphenhydramine hcl inj 50 mg/ml 2DULERA - mometasone furoate-formoterol fumarate aerosol

100-5 mcg/act4 QL (1 canister/30 days)

DULERA - mometasone furoate-formoterol fumarate aerosol200-5 mcg/act


EPINEPHRINE - epinephrine solution auto-injector 0.15 mg/0.3ml(1:2000)

3

EPINEPHRINE - epinephrine solution auto-injector 0.3 mg/0.3ml(1:1000) (authorized generic for EpiPen 2-Pak)

3

EPIPEN 2-PAK - epinephrine solution auto-injector 0.3 mg/0.3ml(1:1000)

3

EPIPEN-JR 2-PAK - epinephrine solution auto-injector0.15 mg/0.3ml (1:2000)

3

ESBRIET - pirfenidone cap 267 mg* 5 PA, QL (270 capsules/30 days)ESBRIET - pirfenidone tab 267 mg* 5 PA, QL (270 tablets/30 days)ESBRIET - pirfenidone tab 801 mg* 5 PA, QL (90 tablets/30 days)FLOVENT DISKUS - fluticasone propionate aer pow ba 50 mcg/

blister3 QL (1 inhaler/30 days)

FLOVENT DISKUS - fluticasone propionate aer pow ba 100 mcg/blister


FLOVENT DISKUS - fluticasone propionate aer pow ba 250 mcg/blister

3 QL (4 inhalers/30 days)

FLOVENT HFA - fluticasone propionate hfa inhal aero 44 mcg/act(50/valve)


FLOVENT HFA - fluticasone propionate hfa inhal aer 110 mcg/act(125/valve)


FLOVENT HFA - fluticasone propionate hfa inhal aer 220 mcg/act(250/valve)


fluticasone propionate nasal susp 50 mcg/act 1 QL (1 bottle/30 days)FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-

salmeterol aer powder ba 55-14 mcg/act3 QL (1 inhaler/30 days)

FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-salmeterol aer powder ba 113-14 mcg/act


FLUTICASONE PROPIONATE/SALMETEROL - fluticasone-salmeterol aer powder ba 232-14 mcg/act


INCRUSE ELLIPTA - umeclidinium br aero powd breath act62.5 mcg/inh


ipratropium bromide inhal soln 0.02% 2 BDipratropium bromide nasal soln 0.03% (21 mcg/spray) 2 QL (2 bottles/30 days)ipratropium bromide nasal soln 0.06% (42 mcg/spray) 2 QL (3 bottles/30 days)KALYDECO - ivacaftor packet 50 mg 5 PA, QL (60 packets/30 days)KALYDECO - ivacaftor packet 75 mg 5 PA, QL (60 packets/30 days)

2018


Drug Name Drug Tier Requirements/LimitsKALYDECO - ivacaftor tab 150 mg 5 PA, QL (60 tablets/30 days)LETAIRIS - ambrisentan tab 5 mg* 5 PA, QL (30 tablets/30 days)LETAIRIS - ambrisentan tab 10 mg* 5 PA, QL (30 tablets/30 days)levocetirizine dihydrochloride tab 5 mg 1mometasone furoate nasal susp 50 mcg/act 2 QL (2 bottles/30 days)montelukast sodium chew tab 4 mg 2montelukast sodium chew tab 5 mg 2montelukast sodium oral granules packet 4 mg 2montelukast sodium tab 10 mg 1OFEV - nintedanib esylate cap 100 mg* 5 PA, QL (60 capsules/30 days)OFEV - nintedanib esylate cap 150 mg* 5 PA, QL (60 capsules/30 days)olopatadine hcl nasal soln 0.6% 2 QL (1 bottle/30 days)OPSUMIT - macitentan tab 10 mg* 5 PA, QL (30 tablets/30 days)ORALAIR - grass mixed pollen ext tab sl 300 ir 4 PA, QL (30 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 100-125 mg* 5 PA, QL (120 tablets/30 days)ORKAMBI - lumacaftor-ivacaftor tab 200-125 mg* 5 PA, QL (120 tablets/30 days)PROAIR HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (36 grams/30 days)PROAIR RESPICLICK - albuterol sulfate aer pow ba 108 mcg/act 3 QL (2 canisters/30 days)PULMOZYME - dornase alfa inhal soln 1 mg/ml 5 BDQVAR - beclomethasone diprop inhal aero soln 40 mcg/act (50/

valve)3 QL (1 canister/30 days)

QVAR - beclomethasone diprop inhal aero soln 80 mcg/act (100/valve)


REMODULIN - treprostinil sodium inj 1 mg/ml* 5 BDREMODULIN - treprostinil sodium inj 2.5 mg/ml* 5 BDREMODULIN - treprostinil sodium inj 5 mg/ml* 5 BDREMODULIN - treprostinil sodium inj 10 mg/ml* 5 BDribavirin for inhal soln 6 gm 5SEREVENT DISKUS - salmeterol xinafoate aer pow ba 50 mcg/

dose3 QL (1 inhaler/30 days)

sildenafil citrate tab 20 mg 2 PA, QL (90 tablets/30 days)SPIRIVA HANDIHALER - tiotropium bromide monohydrate inhal

cap 18 mcg3 QL (30 capsules/30 days)

SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhalaerosol 1.25 mcg/act


SPIRIVA RESPIMAT - tiotropium bromide monohydrate inhalaerosol 2.5 mcg/act


STIOLTO RESPIMAT - tiotropium br-olodaterol inhal aero soln2.5-2.5 mcg/act


SYMBICORT - budesonide-formoterol fumarate dihyd aerosol80-4.5 mcg/act


2018


95

Drug Name Drug Tier Requirements/LimitsSYMBICORT - budesonide-formoterol fumarate dihyd aerosol

160-4.5 mcg/act3 QL (1 canister/30 days)

terbutaline sulfate tab 2.5 mg 2terbutaline sulfate tab 5 mg 2theophylline tab er 12hr 100 mg 2theophylline tab er 12hr 200 mg 2theophylline tab er 12hr 300 mg 2theophylline tab er 12hr 450 mg 2theophylline tab er 24hr 400 mg 2theophylline tab er 24hr 600 mg 2tobramycin nebu soln 300 mg/5ml 5 BDTRACLEER - bosentan tab for oral susp 32 mg* 5 PA, QL (120 tablets/30 days)TRACLEER - bosentan tab 62.5 mg* 5 PA, QL (60 tablets/30 days)TRACLEER - bosentan tab 125 mg* 5 PA, QL (60 tablets/30 days)triamcinolone acetonide nasal aerosol suspension 55 mcg/act 2 QL (1 bottle/30 days)UPTRAVI - selexipag tab therapy pack 200 mcg (140) & 800 mcg

(60)*5 PA, QL (1 pack (200

tablets)/28 days)UPTRAVI - selexipag tab 200 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 400 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 600 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 800 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1000 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1200 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1400 mcg* 5 PA, QL (60 tablets/30 days)UPTRAVI - selexipag tab 1600 mcg* 5 PA, QL (60 tablets/30 days)VENTAVIS - iloprost inhalation solution 10 mcg/ml 5 BD, PA, QL (270 mls/30 days)VENTAVIS - iloprost inhalation solution 20 mcg/ml 5 BD, PA, QL (270 mls/30 days)VENTOLIN HFA - albuterol sulfate inhal aero 108 mcg/act 3 QL (36 grams/30 days)XOPENEX HFA - levalbuterol tartrate inhal aerosol 45 mcg/act 4 QL (2 canisters/30 days)zafirlukast tab 10 mg 2zafirlukast tab 20 mg 2Skeletal Muscle Relaxantscyclobenzaprine hcl tab 5 mg# 4 PAcyclobenzaprine hcl tab 7.5 mg# 4 PAcyclobenzaprine hcl tab 10 mg# 4 PAmethocarbamol tab 500 mg# 4 PAmethocarbamol tab 750 mg# 4 PASleep Disorder Agentsarmodafinil tab 50 mg 4 PA, QL (30 tablets/30 days)

2018


Drug Name Drug Tier Requirements/Limitsarmodafinil tab 150 mg 4 PA, QL (30 tablets/30 days)armodafinil tab 200 mg 2 PA, QL (30 tablets/30 days)armodafinil tab 250 mg 4 PA, QL (30 tablets/30 days)HETLIOZ - tasimelteon capsule 20 mg* 5 PA, QL (30 capsules/30 days)modafinil tab 100 mg 4 PA, QL (30 tablets/30 days)modafinil tab 200 mg 4 PA, QL (30 tablets/30 days)SILENOR - doxepin hcl tab 3 mg 3 QL (30 tablets/30 days)SILENOR - doxepin hcl tab 6 mg 3 QL (30 tablets/30 days)temazepam cap 15 mg 3 QL (30 capsules/30 days)temazepam cap 30 mg 3 QL (30 capsules/30 days)XYREM - sodium oxybate oral solution 500 mg/ml* 5 PA, QL (540 mls/30 days)zaleplon cap 5 mg# 4 PAzaleplon cap 10 mg# 4 PAzolpidem tartrate tab 5 mg# 4 PAzolpidem tartrate tab 10 mg# 4 PA

2018

97

INDEX

Aabacavir sulfate-lamivudine tab 600-300

mg................................................................................41abacavir sulfate-lamivudine-zidovudine tab

300-150-300 mg........................................................41abacavir sulfate soln 20 mg/ml.................................. 41abacavir sulfate tab 300 mg.......................................41ABRAXANE...................................................................25ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1ABSTRAL........................................................................ 1acamprosate calcium tab delayed release 333

mg..................................................................................5acarbose tab 100 mg.................................................. 47acarbose tab 25 mg.................................................... 47acarbose tab 50 mg.................................................... 47acebutolol hcl cap 200 mg..........................................53acebutolol hcl cap 400 mg..........................................53acetaminophen w/ codeine soln 120-12

mg/5ml.......................................................................... 1acetaminophen w/ codeine tab 300-15

mg..................................................................................1acetaminophen w/ codeine tab 300-30

mg..................................................................................1acetaminophen w/ codeine tab 300-60

mg..................................................................................1acetazolamide cap er 12hr 500 mg...........................53acetazolamide tab 125 mg......................................... 53acetazolamide tab 250 mg......................................... 53ACETIC ACID/ALUMINUM ACETATE...................... 91acetic acid otic soln 2%.............................................. 91acetylcysteine inhal soln 10%.................................... 91acetylcysteine inhal soln 20%.................................... 91acitretin cap 10 mg......................................................66acitretin cap 17.5 mg...................................................66acitretin cap 25 mg......................................................66ACTHIB..........................................................................82ACTIMMUNE................................................................ 82acyclovir cap 200 mg.................................................. 41acyclovir oint 5%..........................................................41ACYCLOVIR SODIUM................................................ 41acyclovir sodium iv soln 50 mg/ml.............................41acyclovir susp 200 mg/5ml......................................... 41acyclovir tab 400 mg................................................... 41acyclovir tab 800 mg................................................... 41ADACEL........................................................................ 82

ADAGEN........................................................................73ADASUVE..................................................................... 37ADCIRCA...................................................................... 91adefovir dipivoxil tab 10 mg........................................41ADEMPAS..................................................................... 91ADEMPAS..................................................................... 91ADEMPAS..................................................................... 91ADEMPAS..................................................................... 91ADEMPAS..................................................................... 91ADVAIR DISKUS..........................................................91ADVAIR DISKUS..........................................................91ADVAIR DISKUS..........................................................91ADVAIR HFA.................................................................91ADVAIR HFA.................................................................91ADVAIR HFA.................................................................91AFINITOR......................................................................25AFINITOR......................................................................25AFINITOR......................................................................25AFINITOR......................................................................25AFINITOR DISPERZ................................................... 25AFINITOR DISPERZ................................................... 25AFINITOR DISPERZ................................................... 25ALBENZA...................................................................... 34albuterol sulfate soln nebu 0.083% (2.5

mg/3ml).......................................................................91albuterol sulfate soln nebu 0.5% (5 mg/

ml)................................................................................91albuterol sulfate soln nebu 0.63

mg/3ml........................................................................ 91albuterol sulfate soln nebu 1.25

mg/3ml........................................................................ 91albuterol sulfate syrup 2 mg/5ml................................92albuterol sulfate tab 2 mg...........................................92albuterol sulfate tab 4 mg...........................................92albuterol sulfate tab er 12hr 4 mg..............................92albuterol sulfate tab er 12hr 8 mg..............................92alclometasone dipropionate cream

0.05%..........................................................................66alclometasone dipropionate oint

0.05%..........................................................................66ALCOHOL SWABS......................................................47ALDURAZYME............................................................. 73ALECENSA................................................................... 25alendronate sodium tab 10 mg.................................. 88alendronate sodium tab 35 mg.................................. 88alendronate sodium tab 5 mg.................................... 88alendronate sodium tab 70 mg.................................. 88alfuzosin hcl tab er 24hr 10 mg................................. 75ALIMTA.......................................................................... 25ALIMTA.......................................................................... 25ALINIA............................................................................35ALINIA............................................................................35

2018

98

ALIQOPA....................................................................... 25allopurinol sodium for inj 500 mg...............................24allopurinol tab 100 mg.................................................24allopurinol tab 300 mg.................................................24alosetron hcl tab 0.5 mg............................................. 71alosetron hcl tab 1 mg................................................ 71ALOXI.............................................................................21ALPHAGAN P...............................................................89alprazolam tab 0.25 mg.............................................. 46alprazolam tab 0.5 mg................................................ 46alprazolam tab 1 mg....................................................46alprazolam tab 2 mg....................................................46ALUNBRIG....................................................................25ALUNBRIG....................................................................25ALUNBRIG....................................................................25ALUNBRIG....................................................................25amantadine hcl cap 100 mg.......................................35amantadine hcl syrup 50 mg/5ml...............................35amantadine hcl tab 100 mg........................................35AMBISOME...................................................................22amikacin sulfate inj 1 gm/4ml (250 mg/

ml)..................................................................................5amikacin sulfate inj 500 mg/2ml (250 mg/

ml)..................................................................................5amiloride & hydrochlorothiazide tab 5-50

mg................................................................................53amiloride hcl tab 5 mg.................................................53amino acid infusion 15%.............................................69amino acid infusion 6%...............................................69amiodarone hcl tab 200 mg........................................53amiodarone hcl tab 400 mg........................................53AMITIZA.........................................................................71AMITIZA.........................................................................71amitriptyline hcl tab 100 mg....................................... 18amitriptyline hcl tab 10 mg..........................................17amitriptyline hcl tab 150 mg....................................... 18amitriptyline hcl tab 25 mg..........................................18amitriptyline hcl tab 50 mg..........................................18amitriptyline hcl tab 75 mg..........................................18amlodipine besylate-atorvastatin calcium tab 10-10

mg................................................................................53amlodipine besylate-atorvastatin calcium tab 10-20



mg................................................................................53amlodipine besylate-atorvastatin calcium tab 2.5-10

mg................................................................................53amlodipine besylate-atorvastatin calcium tab 2.5-20

mg................................................................................53

amlodipine besylate-atorvastatin calcium tab 2.5-40mg................................................................................53

amlodipine besylate-atorvastatin calcium tab 5-10mg................................................................................53




amlodipine besylate-benazepril hcl cap 10-20mg................................................................................54


amlodipine besylate-benazepril hcl cap 2.5-10mg................................................................................53




amlodipine besylate tab 10 mg..................................53amlodipine besylate tab 2.5 mg.................................53amlodipine besylate tab 5 mg.................................... 53amlodipine besylate-valsartan tab 10-160

mg................................................................................54amlodipine besylate-valsartan tab 10-320



mg................................................................................54amlodipine-valsartan-hydrochlorothiazide tab

10-160-12.5 mg.........................................................54amlodipine-valsartan-hydrochlorothiazide tab

10-160-25 mg............................................................54amlodipine-valsartan-hydrochlorothiazide tab

10-320-25 mg............................................................54amlodipine-valsartan-hydrochlorothiazide tab

5-160-12.5 mg...........................................................54amlodipine-valsartan-hydrochlorothiazide tab

5-160-25 mg.............................................................. 54AMOXAPINE.................................................................18AMOXAPINE.................................................................18AMOXAPINE.................................................................18AMOXAPINE.................................................................18AMOXICILLIN/CLAVULANATE

POTASSIUM................................................................ 6AMOXICILLIN/CLAVULANATE

POTASSIUM................................................................ 6amoxicillin (trihydrate) cap 250 mg..............................5

2018

99

amoxicillin (trihydrate) cap 500 mg..............................5amoxicillin (trihydrate) for susp 125

mg/5ml.......................................................................... 6amoxicillin (trihydrate) for susp 200



mg/5ml.......................................................................... 6amoxicillin (trihydrate) tab 500 mg...............................6amoxicillin (trihydrate) tab 875 mg...............................6amoxicillin & k clavulanate for susp 200-28.5

mg/5ml.......................................................................... 6amoxicillin & k clavulanate for susp 400-57

mg/5ml.......................................................................... 6amoxicillin & k clavulanate for susp 600-42.9

mg/5ml.......................................................................... 6amoxicillin & k clavulanate tab 250-125

mg..................................................................................6amoxicillin & k clavulanate tab 500-125

mg..................................................................................6amoxicillin & k clavulanate tab 875-125

mg..................................................................................6amphetamine-dextroamphetamine cap er 24hr 10

mg................................................................................64amphetamine-dextroamphetamine cap er 24hr 15





mg................................................................................64amphetamine-dextroamphetamine tab 10

mg................................................................................64amphetamine-dextroamphetamine tab 12.5





mg................................................................................64amphetamine-dextroamphetamine tab 7.5

mg................................................................................64AMPHOTERICIN B......................................................22ampicillin & sulbactam sodium for inj 3 (2-1)

gm..................................................................................6

ampicillin cap 500 mg....................................................6AMPICILLIN SODIUM................................................... 6ampicillin sodium for inj 1 gm.......................................6ampicillin sodium for inj 250 mg...................................6ampicillin sodium for inj 2 gm.......................................6ampicillin sodium for inj 500 mg...................................6ampicillin sodium for iv soln 10 gm..............................6ampicillin sodium for iv soln 2 gm................................6AMPICILLIN-SULBACTAM........................................... 6AMPYRA........................................................................64ANADROL-50............................................................... 77anagrelide hcl cap 0.5 mg.......................................... 50anagrelide hcl cap 1 mg............................................. 50anastrozole tab 1 mg...................................................25ANDRODERM.............................................................. 77ANDRODERM.............................................................. 77ANDROGEL.................................................................. 77ANDROGEL.................................................................. 77ANDROGEL PUMP..................................................... 77ANORO ELLIPTA.........................................................92APOKYN........................................................................35aprepitant capsule 125 mg.........................................21aprepitant capsule 40 mg........................................... 21aprepitant capsule 80 mg........................................... 21aprepitant capsule therapy pack 80 & 125

mg................................................................................21APRISO......................................................................... 87APTIOM......................................................................... 13APTIOM......................................................................... 13APTIOM......................................................................... 13APTIOM......................................................................... 13APTIVUS....................................................................... 41APTIVUS....................................................................... 41ARANESP ALBUMIN FREE.......................................50ARANESP ALBUMIN FREE.......................................50ARANESP ALBUMIN FREE.......................................50ARANESP ALBUMIN FREE.......................................50ARANESP ALBUMIN FREE.......................................50ARANESP ALBUMIN FREE.......................................50ARANESP ALBUMIN FREE.......................................50ARANESP ALBUMIN FREE.......................................50ARANESP ALBUMIN FREE.......................................50ARANESP ALBUMIN FREE.......................................50ARANESP ALBUMIN FREE.......................................50ARANESP ALBUMIN FREE.......................................50ARANESP ALBUMIN FREE.......................................50ARANESP ALBUMIN FREE.......................................51ARANESP ALBUMIN FREE.......................................51ARCALYST....................................................................82aripiprazole orally disintegrating tab 10

mg................................................................................37

2018

100

aripiprazole orally disintegrating tab 15mg................................................................................37

aripiprazole oral solution 1 mg/ml..............................37aripiprazole tab 10 mg................................................ 37aripiprazole tab 15 mg................................................ 37aripiprazole tab 20 mg................................................ 37aripiprazole tab 2 mg...................................................37aripiprazole tab 30 mg................................................ 37aripiprazole tab 5 mg...................................................37ARISTADA.....................................................................37ARISTADA.....................................................................37ARISTADA.....................................................................37ARISTADA.....................................................................37armodafinil tab 150 mg............................................... 96armodafinil tab 200 mg............................................... 96armodafinil tab 250 mg............................................... 96armodafinil tab 50 mg................................................. 95ARNUITY ELLIPTA......................................................92ARNUITY ELLIPTA......................................................92ARRANON.................................................................... 25ARZERRA..................................................................... 25ARZERRA..................................................................... 25ASACOL HD.................................................................87ASMANEX HFA............................................................92ASMANEX HFA............................................................92ASMANEX TWISTHALER 120 METERED

DOSES....................................................................... 92ASMANEX TWISTHALER 14 METERED





DOSES....................................................................... 92aspirin-dipyridamole cap er 12hr 25-200

mg................................................................................51atazanavir sulfate cap 150 mg...................................41atazanavir sulfate cap 200 mg...................................41atazanavir sulfate cap 300 mg...................................41atenolol & chlorthalidone tab 100-25

mg................................................................................54atenolol & chlorthalidone tab 50-25 mg.................... 54atenolol tab 100 mg.....................................................54atenolol tab 25 mg.......................................................54atenolol tab 50 mg.......................................................54ATGAM.......................................................................... 82atomoxetine hcl cap 100 mg...................................... 65atomoxetine hcl cap 10 mg........................................ 64atomoxetine hcl cap 18 mg........................................ 64

atomoxetine hcl cap 25 mg........................................ 64atomoxetine hcl cap 40 mg........................................ 64atomoxetine hcl cap 60 mg........................................ 64atomoxetine hcl cap 80 mg........................................ 65atorvastatin calcium tab 10 mg.................................. 54atorvastatin calcium tab 20 mg.................................. 54atorvastatin calcium tab 40 mg.................................. 54atorvastatin calcium tab 80 mg.................................. 54atovaquone-proguanil hcl tab 250-100

mg................................................................................35atovaquone-proguanil hcl tab 62.5-25

mg................................................................................35atovaquone susp 750 mg/5ml....................................35ATRIPLA........................................................................ 41ATROVENT HFA..........................................................92AVASTIN........................................................................25AVASTIN........................................................................25AVELOX...........................................................................6AVONEX........................................................................ 65AVONEX........................................................................ 65AVONEX PEN.............................................................. 65azacitidine for inj 100 mg............................................51AZACTAM........................................................................6AZACTAM........................................................................6AZACTAM IN ISO-OSMOTIC

DEXTROSE................................................................. 6AZACTAM IN ISO-OSMOTIC

DEXTROSE................................................................. 6AZASAN........................................................................ 82AZASAN........................................................................ 82AZATHIOPRINE........................................................... 82azathioprine tab 50 mg............................................... 82azelastine hcl nasal spray 0.1% (137 mcg/

spray)..........................................................................92azelastine hcl nasal spray 0.15% (205.5 mcg/

spray)..........................................................................92azelastine hcl ophth soln 0.05%................................ 89AZELEX......................................................................... 66AZITHROMYCIN............................................................ 6azithromycin for susp 100 mg/5ml...............................6azithromycin for susp 200 mg/5ml...............................6azithromycin iv for soln 500 mg................................... 6azithromycin tab 250 mg...............................................6azithromycin tab 500 mg...............................................7azithromycin tab 600 mg...............................................7AZOPT........................................................................... 89aztreonam for inj 1 gm.................................................. 7aztreonam for inj 2 gm.................................................. 7BBACITRACIN................................................................ 89bacitracin-polymyxin b ophth oint.............................. 89

2018

101

bacitracin-polymyxin-neomycin-hc ophth oint1%............................................................................... 89

baclofen tab 10 mg......................................................41baclofen tab 20 mg......................................................41balsalazide disodium cap 750 mg............................. 87BANZEL.........................................................................13BANZEL.........................................................................13BANZEL.........................................................................13BARACLUDE................................................................ 41BAVENCIO.................................................................... 26BCG VACCINE.............................................................82BELEODAQ.................................................................. 26benazepril & hydrochlorothiazide tab 10-12.5

mg................................................................................54benazepril & hydrochlorothiazide tab 20-12.5

mg................................................................................54benazepril & hydrochlorothiazide tab 20-25

mg................................................................................54benazepril & hydrochlorothiazide tab 5-6.25

mg................................................................................54benazepril hcl tab 10 mg............................................ 54benazepril hcl tab 20 mg............................................ 54benazepril hcl tab 40 mg............................................ 54benazepril hcl tab 5 mg.............................................. 54BENDEKA..................................................................... 26BENLYSTA.................................................................... 82BENLYSTA.................................................................... 82BENLYSTA.................................................................... 82BENLYSTA.................................................................... 82BENZNIDAZOLE..........................................................35BENZNIDAZOLE..........................................................35benzoyl peroxide-erythromycin gel

5-3%............................................................................66benztropine mesylate tab 0.5 mg.............................. 35benztropine mesylate tab 1 mg..................................35benztropine mesylate tab 2 mg..................................35BESIVANCE..................................................................89BESPONSA.................................................................. 26betamethasone dipropionate augmented cream

0.05%..........................................................................66betamethasone dipropionate augmented gel

0.05%..........................................................................66betamethasone dipropionate augmented lotion

0.05%..........................................................................66betamethasone dipropionate augmented oint

0.05%..........................................................................66betamethasone dipropionate cream

0.05%..........................................................................66betamethasone dipropionate lotion

0.05%..........................................................................66betamethasone dipropionate oint

0.05%..........................................................................66

betamethasone valerate cream 0.1%....................... 66betamethasone valerate lotion 0.1%.........................66betamethasone valerate oint 0.1%............................66BETASERON................................................................ 65betaxolol hcl ophth soln 0.5%.................................... 89betaxolol hcl tab 10 mg...............................................54betaxolol hcl tab 20 mg...............................................54bethanechol chloride tab 10 mg.................................75bethanechol chloride tab 25 mg.................................75bethanechol chloride tab 50 mg.................................75bethanechol chloride tab 5 mg...................................75BETOPTIC-S.................................................................89BEVYXXA......................................................................51BEVYXXA......................................................................51bexarotene cap 75 mg................................................ 26BEXSERO..................................................................... 83bicalutamide tab 50 mg...............................................26BICILLIN L-A...................................................................7BICILLIN L-A...................................................................7BICILLIN L-A...................................................................7BICNU............................................................................26BILTRICIDE...................................................................35bisoprolol & hydrochlorothiazide tab 10-6.25

mg................................................................................54bisoprolol & hydrochlorothiazide tab 2.5-6.25

mg................................................................................54bisoprolol & hydrochlorothiazide tab 5-6.25

mg................................................................................54bisoprolol fumarate tab 10 mg................................... 54bisoprolol fumarate tab 5 mg..................................... 54bleomycin sulfate for inj 15 unit................................. 26bleomycin sulfate for inj 30 unit................................. 26BLINCYTO.....................................................................26BOOSTRIX....................................................................83BOSULIF....................................................................... 26BOSULIF....................................................................... 26BOSULIF....................................................................... 26BREO ELLIPTA............................................................ 92BREO ELLIPTA............................................................ 92BRILINTA.......................................................................51BRILINTA.......................................................................51brimonidine tartrate ophth soln 0.15%...................... 89brimonidine tartrate ophth soln 0.2%........................ 89BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................13BRIVIACT......................................................................14bromfenac sodium ophth soln 0.09% (once-

daily)............................................................................89

2018

102

bromocriptine mesylate cap 5 mg..............................35bromocriptine mesylate tab 2.5 mg........................... 35budesonide delayed release particles cap 3

mg................................................................................87budesonide inhalation susp 0.25

mg/2ml........................................................................ 92budesonide inhalation susp 0.5

mg/2ml........................................................................ 92budesonide inhalation susp 1 mg/2ml.......................92bumetanide inj 0.25 mg/ml......................................... 55bumetanide tab 0.5 mg............................................... 55bumetanide tab 1 mg.................................................. 55bumetanide tab 2 mg.................................................. 55BUPHENYL...................................................................73buprenorphine hcl-naloxone hcl sl tab 2-0.5

mg..................................................................................5buprenorphine hcl-naloxone hcl sl tab 8-2

mg..................................................................................5buprenorphine hcl sl tab 2 mg......................................5buprenorphine hcl sl tab 8 mg......................................5bupropion hcl (smoking deterrent) tab er 12hr 150

mg..................................................................................5bupropion hcl tab 100 mg...........................................18bupropion hcl tab 75 mg.............................................18bupropion hcl tab er 12hr 100 mg............................. 18bupropion hcl tab er 12hr 150 mg............................. 18bupropion hcl tab er 12hr 200 mg............................. 18bupropion hcl tab er 24hr 150 mg............................. 18bupropion hcl tab er 24hr 300 mg............................. 18buspirone hcl tab 10 mg............................................. 46buspirone hcl tab 15 mg............................................. 46buspirone hcl tab 30 mg............................................. 46buspirone hcl tab 5 mg............................................... 46buspirone hcl tab 7.5 mg............................................ 46busulfan inj 6 mg/ml.................................................... 26butalbital-acetaminophen-caffeine cap 50-300-40

mg..................................................................................1butalbital-acetaminophen-caffeine cap 50-325-40

mg..................................................................................1butalbital-acetaminophen-caffeine tab 50-325-40

mg..................................................................................1butalbital-acetaminophen tab 50-325

mg..................................................................................1butalbital-aspirin-caffeine cap 50-325-40

mg..................................................................................1BUTORPHANOL TARTRATE.......................................1butorphanol tartrate inj 2 mg/ml................................... 1butorphanol tartrate nasal soln 10 mg/

ml................................................................................... 1BYDUREON..................................................................47BYDUREON BCISE.....................................................47BYDUREON PEN........................................................ 47

Ccabergoline tab 0.5 mg............................................... 80CABOMETYX............................................................... 26CABOMETYX............................................................... 26CABOMETYX............................................................... 26caffeine citrate oral soln 60 mg/3ml...........................92calcipotriene cream 0.005%.......................................66calcipotriene oint 0.005%............................................66calcipotriene soln 0.005% (50 mcg/ml).....................66calcitonin (salmon) nasal soln 200 unit/

act................................................................................88calcitriol cap 0.25 mcg................................................ 88calcitriol cap 0.5 mcg...................................................88calcitriol inj 1 mcg/ml...................................................88calcitriol oral soln 1 mcg/ml........................................88calcium acetate cap 667 mg...................................... 69calcium acetate tab 667 mg....................................... 69CALQUENCE................................................................26CANASA........................................................................87CANCIDAS....................................................................22CANCIDAS....................................................................22candesartan cilexetil-hydrochlorothiazide tab 16-12.5

mg................................................................................55candesartan cilexetil-hydrochlorothiazide tab 32-12.5

mg................................................................................55candesartan cilexetil-hydrochlorothiazide tab 32-25

mg................................................................................55candesartan cilexetil tab 16 mg................................. 55candesartan cilexetil tab 32 mg................................. 55candesartan cilexetil tab 4 mg................................... 55candesartan cilexetil tab 8 mg................................... 55CAPASTAT SULFATE..................................................24CAPRELSA................................................................... 26CAPRELSA................................................................... 26captopril tab 100 mg....................................................55captopril tab 12.5 mg...................................................55captopril tab 25 mg......................................................55captopril tab 50 mg......................................................55CARAC.......................................................................... 66CARBAGLU.................................................................. 69carbamazepine cap er 12hr 100 mg......................... 14carbamazepine cap er 12hr 200 mg......................... 14carbamazepine cap er 12hr 300 mg......................... 14carbamazepine chew tab 100 mg..............................14carbamazepine susp 100 mg/5ml..............................14carbamazepine tab 200 mg........................................14carbamazepine tab er 12hr 100 mg.......................... 14carbamazepine tab er 12hr 200 mg.......................... 14carbamazepine tab er 12hr 400 mg.......................... 14CARBIDOPA/LEVODOPA/

ENTACAPONE..........................................................36

2018

103

CARBIDOPA/LEVODOPA/ENTACAPONE..........................................................36





carbidopa & levodopa orally disintegrating tab10-100 mg..................................................................35



carbidopa & levodopa tab 10-100 mg....................... 35carbidopa & levodopa tab 25-100 mg....................... 35carbidopa & levodopa tab 25-250 mg....................... 36carbidopa & levodopa tab er 25-100

mg................................................................................35carbidopa & levodopa tab er 50-200

mg................................................................................35carbidopa tab 25 mg................................................... 36carboplatin iv soln 150 mg/15ml................................ 26carboplatin iv soln 450 mg/45ml................................ 26carboplatin iv soln 50 mg/5ml.................................... 26carboplatin iv soln 600 mg/60ml................................ 26carteolol hcl ophth soln 1%........................................ 89carvedilol tab 12.5 mg.................................................55carvedilol tab 25 mg....................................................55carvedilol tab 3.125 mg...............................................55carvedilol tab 6.25 mg.................................................55caspofungin acetate for iv soln 50 mg...................... 22caspofungin acetate for iv soln 70 mg...................... 22cefaclor cap 250 mg......................................................7cefaclor cap 500 mg......................................................7cefadroxil cap 500 mg...................................................7cefadroxil for susp 250 mg/5ml....................................7cefadroxil for susp 500 mg/5ml....................................7cefadroxil tab 1 gm........................................................ 7CEFAZOLIN SODIUM................................................... 7cefazolin sodium for inj 10 gm..................................... 7cefazolin sodium for inj 1 gm....................................... 7cefazolin sodium for inj 500 mg................................... 7cefdinir cap 300 mg....................................................... 7cefdinir for susp 125 mg/5ml........................................7cefdinir for susp 250 mg/5ml........................................7cefepime hcl for inj 1 gm.............................................. 7cefepime hcl for inj 2 gm.............................................. 7CEFOTAXIME SODIUM................................................7CEFOTAXIME SODIUM................................................7

CEFOTAXIME SODIUM................................................7cefotaxime sodium for inj 1 gm.................................... 7cefoxitin sodium for inj 10 gm...................................... 7cefoxitin sodium for iv soln 1 gm................................. 7cefoxitin sodium for iv soln 2 gm................................. 7cefpodoxime proxetil for susp 100

mg/5ml.......................................................................... 7cefpodoxime proxetil for susp 50

mg/5ml.......................................................................... 7cefpodoxime proxetil tab 100 mg.................................7cefpodoxime proxetil tab 200 mg.................................7cefprozil for susp 125 mg/5ml...................................... 7cefprozil for susp 250 mg/5ml...................................... 7cefprozil tab 250 mg......................................................7cefprozil tab 500 mg......................................................8ceftazidime for inj 1 gm.................................................8ceftazidime for inj 2 gm.................................................8ceftazidime for inj 6 gm.................................................8ceftazidime for iv soln 1 gm..........................................8ceftazidime for iv soln 2 gm..........................................8CEFTRIAXONE/DEXTROSE....................................... 8CEFTRIAXONE/DEXTROSE....................................... 8CEFTRIAXONE IN ISO-OSMOTIC

DEXTROSE................................................................. 8CEFTRIAXONE IN ISO-OSMOTIC

DEXTROSE................................................................. 8ceftriaxone sodium for inj 10 gm..................................8ceftriaxone sodium for inj 1 gm....................................8ceftriaxone sodium for inj 250 mg................................8ceftriaxone sodium for inj 2 gm....................................8ceftriaxone sodium for inj 500 mg................................8ceftriaxone sodium for iv soln 1 gm.............................8ceftriaxone sodium for iv soln 2 gm.............................8cefuroxime axetil tab 250 mg....................................... 8cefuroxime axetil tab 500 mg....................................... 8cefuroxime sodium for inj 1.5 gm.................................8cefuroxime sodium for inj 7.5 gm.................................8cefuroxime sodium for inj 750 mg................................8cefuroxime sodium for iv soln 1.5 gm..........................8celecoxib cap 100 mg................................................... 1celecoxib cap 200 mg................................................... 1celecoxib cap 400 mg................................................... 1celecoxib cap 50 mg......................................................1CELONTIN.................................................................... 14cephalexin cap 250 mg.................................................8cephalexin cap 500 mg.................................................8cephalexin cap 750 mg.................................................8cephalexin for susp 125 mg/5ml..................................8cephalexin for susp 250 mg/5ml..................................8CEREZYME.................................................................. 73CHANTIX......................................................................... 5CHANTIX......................................................................... 5

2018

104

CHANTIX CONTINUING MONTHPACK.............................................................................5

CHANTIX STARTING MONTH PACK.........................5CHEMET........................................................................69CHENODAL.................................................................. 71CHLORAMPHENICOL SODIUM

SUCCINATE.................................................................8chlorhexidine gluconate soln 0.12%..........................66CHLOROQUINE PHOSPHATE................................. 35chloroquine phosphate tab 500 mg...........................35CHLOROTHIAZIDE..................................................... 55chlorothiazide tab 500 mg.......................................... 55CHLORPROMAZINE HCL..........................................21CHLORPROMAZINE HCL..........................................21chlorpromazine hcl tab 100 mg..................................21chlorpromazine hcl tab 10 mg....................................21chlorpromazine hcl tab 200 mg..................................21chlorpromazine hcl tab 25 mg....................................21chlorpromazine hcl tab 50 mg....................................21chlorthalidone tab 25 mg............................................ 55chlorthalidone tab 50 mg............................................ 55cholestyramine light powder 4 gm/

dose............................................................................ 55cholestyramine light powder packets 4

gm................................................................................55cholestyramine powder 4 gm/dose............................55cholestyramine powder packets 4 gm.......................55choline fenofibrate cap dr 135 mg............................. 55choline fenofibrate cap dr 45 mg............................... 55chorionic gonadotropin for im inj 10000 unit(chorionic

gonadotropin, pregnyl)............................................. 77ciclopirox gel 0.77%.................................................... 22ciclopirox olamine cream 0.77%................................22ciclopirox olamine susp 0.77%...................................22ciclopirox shampoo 1%............................................... 22ciclopirox solution 8%..................................................22cidofovir iv inj 75 mg/ml.............................................. 41cilostazol tab 100 mg.................................................. 51cilostazol tab 50 mg.................................................... 51cimetidine hcl soln 300 mg/5ml..................................71cimetidine tab 200 mg.................................................71cimetidine tab 300 mg.................................................71cimetidine tab 400 mg.................................................71cimetidine tab 800 mg.................................................71CINRYZE.......................................................................83CIPRODEX....................................................................91CIPROFLOXACIN.......................................................... 8CIPROFLOXACIN.......................................................... 8ciprofloxacin 200 mg/100ml in d5w............................. 9ciprofloxacin 400 mg/200ml in d5w............................. 9ciprofloxacin for oral susp 250 mg/5ml (5%) (5

gm/100ml).....................................................................8

ciprofloxacin for oral susp 500 mg/5ml (10%) (10gm/100ml).....................................................................8

CIPROFLOXACIN HCL.................................................8ciprofloxacin hcl ophth soln 0.3%.............................. 89ciprofloxacin hcl tab 250 mg.........................................9ciprofloxacin hcl tab 500 mg.........................................9ciprofloxacin hcl tab 750 mg.........................................9ciprofloxacin hcl tab er 24hr 1000 mg......................... 9ciprofloxacin hcl tab er 24hr 500 mg........................... 8CISPLATIN.................................................................... 26cisplatin inj 100 mg/100ml (1 mg/ml).........................26cisplatin inj 50 mg/50ml (1 mg/ml).............................26citalopram hydrobromide oral soln 10

mg/5ml........................................................................ 18citalopram hydrobromide tab 10 mg..........................18citalopram hydrobromide tab 20 mg..........................18citalopram hydrobromide tab 40 mg..........................18cladribine iv soln 10 mg/10ml (1 mg/

ml)................................................................................26clarithromycin for susp 125 mg/5ml.............................9clarithromycin for susp 250 mg/5ml.............................9clarithromycin tab 250 mg............................................ 9clarithromycin tab 500 mg............................................ 9clarithromycin tab er 24hr 500 mg...............................9CLEMASTINE FUMARATE........................................ 92clindamycin hcl cap 150 mg......................................... 9clindamycin hcl cap 300 mg......................................... 9clindamycin hcl cap 75 mg........................................... 9clindamycin phosphate-benzoyl peroxide gel

1-5%............................................................................66clindamycin phosphate gel 1%.................................... 9clindamycin phosphate in d5w iv soln 300

mg/50ml........................................................................ 9clindamycin phosphate in d5w iv soln 600

mg/50ml........................................................................ 9clindamycin phosphate in d5w iv soln 900

mg/50ml........................................................................ 9clindamycin phosphate inj 300 mg/2ml....................... 9clindamycin phosphate inj 600 mg/4ml....................... 9clindamycin phosphate inj 900 mg/6ml....................... 9clindamycin phosphate inj 9 gm/60ml......................... 9clindamycin phosphate iv soln 300

mg/2ml.......................................................................... 9clindamycin phosphate iv soln 600

mg/4ml.......................................................................... 9clindamycin phosphate iv soln 900

mg/6ml.......................................................................... 9clindamycin phosphate lotion 1%................................ 9clindamycin phosphate soln 1%...................................9clindamycin phosphate swab 1%.................................9clindamycin phosphate vaginal cream

2%..................................................................................9

2018

105

clobetasol propionate cream 0.05%..........................66clobetasol propionate emollient base cream

0.05%..........................................................................66clobetasol propionate gel 0.05%................................66clobetasol propionate oint 0.05%.............................. 66clobetasol propionate soln 0.05%..............................66clofarabine iv soln 1 mg/ml.........................................26clomipramine hcl cap 25 mg...................................... 18clomipramine hcl cap 50 mg...................................... 18clomipramine hcl cap 75 mg...................................... 18clonazepam orally disintegrating tab 0.125

mg................................................................................46clonazepam orally disintegrating tab 0.25

mg................................................................................46clonazepam orally disintegrating tab 0.5

mg................................................................................46clonazepam orally disintegrating tab 1

mg................................................................................46clonazepam orally disintegrating tab 2

mg................................................................................46clonazepam tab 0.5 mg.............................................. 46clonazepam tab 1 mg..................................................46clonazepam tab 2 mg..................................................46clonidine hcl tab 0.1 mg..............................................55clonidine hcl tab 0.2 mg..............................................55clonidine hcl tab 0.3 mg..............................................55clonidine hcl tab er 12hr 0.1 mg................................ 65clonidine hcl td patch weekly 0.1

mg/24hr...................................................................... 55clonidine hcl td patch weekly 0.2

mg/24hr...................................................................... 55clonidine hcl td patch weekly 0.3

mg/24hr...................................................................... 55clopidogrel bisulfate tab 75 mg..................................51clorazepate dipotassium tab 15 mg...........................46clorazepate dipotassium tab 3.75 mg....................... 46clorazepate dipotassium tab 7.5 mg......................... 46clotrimazole cream 1%................................................22clotrimazole troche 10 mg.......................................... 22clotrimazole w/ betamethasone cream

1-0.05%...................................................................... 66clotrimazole w/ betamethasone lotion

1-0.05%...................................................................... 66clozapine orally disintegrating tab 100

mg................................................................................37clozapine orally disintegrating tab 25

mg................................................................................37clozapine tab 100 mg..................................................37clozapine tab 200 mg..................................................37clozapine tab 25 mg....................................................37clozapine tab 50 mg....................................................37COARTEM.....................................................................35

codeine sulfate tab 15 mg............................................ 1codeine sulfate tab 30 mg............................................ 1codeine sulfate tab 60 mg............................................ 1colchicine w/ probenecid tab 0.5-500

mg................................................................................24COLCRYS..................................................................... 24colestipol hcl granule packets 5 gm.......................... 55colestipol hcl granules 5 gm.......................................55colestipol hcl tab 1 gm................................................ 55colistimethate sodium for inj 150 mg...........................9COMBIGAN...................................................................89COMBIVENT RESPIMAT........................................... 92COMETRIQ...................................................................26COMETRIQ...................................................................26COMETRIQ...................................................................26COMPLERA.................................................................. 41COPAXONE.................................................................. 65COPAXONE.................................................................. 65CORLANOR..................................................................56CORLANOR..................................................................56CORTISONE ACETATE..............................................75COSENTYX.................................................................. 83COSENTYX SENSOREADY PEN............................ 83COSMEGEN................................................................. 26COTELLIC.....................................................................26COUMADIN...................................................................51COUMADIN...................................................................51COUMADIN...................................................................51COUMADIN...................................................................51COUMADIN...................................................................51COUMADIN...................................................................51COUMADIN...................................................................51COUMADIN...................................................................51COUMADIN...................................................................51CREON..........................................................................73CREON..........................................................................73CREON..........................................................................73CREON..........................................................................73CREON..........................................................................73CRESEMBA.................................................................. 22CRESEMBA.................................................................. 22CRIXIVAN......................................................................41CRIXIVAN......................................................................41cromolyn sodium ophth soln 4%................................89cromolyn sodium oral conc 100

mg/5ml........................................................................ 71cromolyn sodium soln nebu 20 mg/2ml.................... 92cyclobenzaprine hcl tab 10 mg.................................. 95cyclobenzaprine hcl tab 5 mg.................................... 95cyclobenzaprine hcl tab 7.5 mg................................. 95CYCLOPHOSPHAMIDE............................................. 26CYCLOPHOSPHAMIDE............................................. 26

2018

106

cyclophosphamide for inj 1 gm.................................. 27cyclophosphamide for inj 2 gm.................................. 27cyclophosphamide for inj 500 mg..............................27CYCLOSERINE............................................................24CYCLOSET...................................................................47cyclosporine cap 100 mg............................................83cyclosporine cap 25 mg..............................................83cyclosporine iv soln 50 mg/ml....................................83cyclosporine modified cap 100 mg............................ 83cyclosporine modified cap 25 mg.............................. 83cyclosporine modified cap 50 mg.............................. 83cyclosporine modified oral soln 100 mg/

ml.................................................................................83CYRAMZA.....................................................................27CYRAMZA.....................................................................27CYSTADANE................................................................ 73CYSTAGON.................................................................. 73CYSTAGON.................................................................. 73CYSTARAN...................................................................89CYTARABINE............................................................... 27cytarabine inj pf 100 mg/ml........................................ 27cytarabine inj pf 20 mg/ml.......................................... 27DDACARBAZINE............................................................ 27dacarbazine for inj 200 mg.........................................27dactinomycin for inj 0.5 mg........................................ 27DAKLINZA.....................................................................42DAKLINZA.....................................................................42DAKLINZA.....................................................................42DALIRESP.....................................................................93DALVANCE......................................................................9danazol cap 100 mg....................................................77danazol cap 200 mg....................................................77danazol cap 50 mg......................................................77dantrolene sodium cap 100 mg................................. 41dantrolene sodium cap 25 mg....................................41dantrolene sodium cap 50 mg....................................41dapsone tab 100 mg................................................... 25dapsone tab 25 mg......................................................24DAPTACEL....................................................................83daptomycin for iv soln 500 mg..................................... 9DARAPRIM................................................................... 35DARZALEX................................................................... 27DARZALEX................................................................... 27daunorubicin hcl inj 5 mg/ml.......................................27decitabine for inj 50 mg.............................................. 27DELZICOL.....................................................................87demeclocycline hcl tab 150 mg....................................9demeclocycline hcl tab 300 mg....................................9DEMSER....................................................................... 56DENAVIR.......................................................................42

DEPEN TITRATABS.................................................... 75DEPO-PROVERA........................................................ 77DESCOVY.....................................................................42desipramine hcl tab 100 mg.......................................18desipramine hcl tab 10 mg......................................... 18desipramine hcl tab 150 mg.......................................18desipramine hcl tab 25 mg......................................... 18desipramine hcl tab 50 mg......................................... 18desipramine hcl tab 75 mg......................................... 18desmopressin acetate inj 4 mcg/ml...........................77desmopressin acetate nasal soln 0.01%

(refrigerated).............................................................. 77desmopressin acetate nasal spray soln

0.01%..........................................................................77desmopressin acetate nasal spray soln 0.01%

(refrigerated).............................................................. 77desmopressin acetate tab 0.1 mg............................. 77desmopressin acetate tab 0.2 mg............................. 77desogest-eth estrad & eth estrad tab 0.15-0.02/0.01

mg(21/5)..................................................................... 77desogest-ethin est tab

0.1-0.025/0.125-0.025/0.15-0.025mg-mg................................................................................77

desogestrel & ethinyl estradiol tab 0.15 mg-30mcg..............................................................................77

desonide cream 0.05%............................................... 66desonide lotion 0.05%.................................................67desonide oint 0.05%....................................................67desoximetasone cream 0.05%...................................67desoximetasone cream 0.25%...................................67desoximetasone gel 0.05%........................................ 67desoximetasone oint 0.25%....................................... 67desvenlafaxine succinate tab er 24hr 100

mg................................................................................18desvenlafaxine succinate tab er 24hr 25

mg................................................................................18desvenlafaxine succinate tab er 24hr 50

mg................................................................................18DEXAMETHASONE.................................................... 76DEXAMETHASONE.................................................... 76dexamethasone elixir 0.5 mg/5ml..............................76DEXAMETHASONE SODIUM

PHOSPHATE.............................................................89dexamethasone sodium phosphate inj 120

mg/30ml......................................................................76dexamethasone sodium phosphate inj 20

mg/5ml........................................................................ 76dexamethasone sodium phosphate inj 4 mg/

ml.................................................................................76dexamethasone tab 0.5 mg........................................76dexamethasone tab 0.75 mg......................................76dexamethasone tab 1.5 mg........................................76

2018

107

dexamethasone tab 4 mg...........................................76dexamethasone tab 6 mg...........................................76dexmethylphenidate hcl tab 10 mg............................65dexmethylphenidate hcl tab 2.5 mg...........................65dexmethylphenidate hcl tab 5 mg..............................65dexrazoxane for inj 250 mg........................................27dexrazoxane for inj 500 mg........................................27dextroamphetamine sulfate cap er 24hr 10

mg................................................................................65dextroamphetamine sulfate cap er 24hr 15

mg................................................................................65dextroamphetamine sulfate cap er 24hr 5

mg................................................................................65dextroamphetamine sulfate tab 10 mg......................65dextroamphetamine sulfate tab 5 mg........................65dextrose 2.5% w/ sodium chloride

0.45%..........................................................................69dextrose 5% in lactated ringers................................. 69dextrose 5% w/ sodium chloride 0.2%...................... 69dextrose 5% w/ sodium chloride

0.33%..........................................................................69dextrose 5% w/ sodium chloride

0.45%..........................................................................69dextrose 5% w/ sodium chloride 0.9%...................... 69dextrose inj 10%.......................................................... 69dextrose inj 5%.............................................................69DIASTAT ACUDIAL......................................................14DIASTAT ACUDIAL......................................................14DIASTAT PEDIATRIC..................................................14DIAZEPAM.................................................................... 46diazepam conc 5 mg/ml..............................................46DIAZEPAM RECTAL GEL.......................................... 14DIAZEPAM RECTAL GEL.......................................... 14DIAZEPAM RECTAL GEL.......................................... 14diazepam tab 10 mg....................................................46diazepam tab 2 mg......................................................46diazepam tab 5 mg......................................................46diclofenac potassium tab 50 mg.................................. 1diclofenac sodium gel 1%.............................................1diclofenac sodium gel 3%...........................................67diclofenac sodium ophth soln 0.1%...........................89diclofenac sodium tab delayed release 25

mg..................................................................................1diclofenac sodium tab delayed release 50

mg..................................................................................1diclofenac sodium tab delayed release 75

mg..................................................................................1diclofenac sodium tab er 24hr 100 mg........................1diclofenac w/ misoprostol tab delayed release 50-0.2

mg..................................................................................1diclofenac w/ misoprostol tab delayed release 75-0.2

mg..................................................................................1

dicloxacillin sodium cap 250 mg.................................. 9dicloxacillin sodium cap 500 mg.................................. 9dicyclomine hcl cap 10 mg......................................... 71dicyclomine hcl tab 20 mg..........................................71didanosine delayed release capsule 125

mg................................................................................42didanosine delayed release capsule 200



mg................................................................................42DIFICID............................................................................ 9DIFLORASONE DIACETATE.....................................67DIGOXIN........................................................................56digoxin tab 125 mcg (0.125 mg)................................56digoxin tab 250 mcg (0.25 mg).................................. 56DILANTIN...................................................................... 14diltiazem hcl cap er 12hr 120 mg.............................. 56diltiazem hcl cap er 12hr 60 mg.................................56diltiazem hcl cap er 12hr 90 mg.................................56diltiazem hcl cap er 24hr 120 mg.............................. 56diltiazem hcl cap er 24hr 180 mg.............................. 56diltiazem hcl cap er 24hr 240 mg.............................. 56diltiazem hcl coated beads cap er 24hr 120

mg................................................................................56diltiazem hcl coated beads cap er 24hr 180




mg................................................................................56diltiazem hcl coated beads tab er 24hr 180





mg................................................................................56diltiazem hcl extended release beads cap er 24hr

120 mg....................................................................... 56diltiazem hcl extended release beads cap er 24hr



300 mg....................................................................... 56

2018

108

diltiazem hcl extended release beads cap er 24hr360 mg....................................................................... 56

diltiazem hcl extended release beads cap er 24hr420 mg....................................................................... 56

diltiazem hcl tab 120 mg.............................................56diltiazem hcl tab 30 mg...............................................56diltiazem hcl tab 60 mg...............................................56diltiazem hcl tab 90 mg...............................................56DIPENTUM....................................................................87diphenhydramine hcl inj 50 mg/ml.............................93DIPHTHERIA/TETANUS TOXOIDS

ADSORBED...............................................................83dipyridamole tab 25 mg.............................................. 51dipyridamole tab 50 mg.............................................. 51dipyridamole tab 75 mg.............................................. 51disulfiram tab 250 mg....................................................5disulfiram tab 500 mg....................................................5divalproex sodium cap delayed release sprinkle 125

mg................................................................................14divalproex sodium tab delayed release 125



mg................................................................................14divalproex sodium tab er 24 hr 250 mg.....................14divalproex sodium tab er 24 hr 500 mg.....................14DIVIGEL.........................................................................77DIVIGEL.........................................................................77DIVIGEL.........................................................................77DOCETAXEL.................................................................27DOCETAXEL.................................................................27DOCETAXEL.................................................................27DOCETAXEL.................................................................27DOCETAXEL.................................................................27DOCETAXEL.................................................................27DOCETAXEL.................................................................27DOCETAXEL.................................................................27docetaxel for inj conc 20 mg/ml................................. 27docetaxel for inj conc 80 mg/4ml (20 mg/

ml)................................................................................27dofetilide cap 125 mcg (0.125 mg)............................56dofetilide cap 250 mcg (0.25 mg).............................. 56dofetilide cap 500 mcg (0.5 mg)................................ 56donepezil hydrochloride orally disintegrating tab 10

mg................................................................................17donepezil hydrochloride orally disintegrating tab 5

mg................................................................................17donepezil hydrochloride tab 10 mg........................... 17donepezil hydrochloride tab 23 mg........................... 17donepezil hydrochloride tab 5 mg..............................17dorzolamide hcl ophth soln 2%..................................89

dorzolamide hcl-timolol maleate ophth soln 22.3-6.8mg/ml.......................................................................... 89

doxazosin mesylate tab 1 mg.................................... 56doxazosin mesylate tab 2 mg.................................... 56doxazosin mesylate tab 4 mg.................................... 56doxazosin mesylate tab 8 mg.................................... 57doxepin hcl cap 100 mg..............................................18doxepin hcl cap 10 mg................................................18doxepin hcl cap 150 mg..............................................18doxepin hcl cap 25 mg................................................18doxepin hcl cap 50 mg................................................18doxepin hcl cap 75 mg................................................18doxepin hcl conc 10 mg/ml.........................................19DOXORUBICIN HCL...................................................27DOXORUBICIN HCL...................................................27doxorubicin hcl inj 2 mg/ml.........................................27doxorubicin hcl liposomal inj (for iv infusion) 2 mg/

ml.................................................................................27doxycycline hyclate cap 100 mg................................10doxycycline hyclate cap 50 mg.................................... 9doxycycline hyclate for inj 100 mg.............................10doxycycline hyclate tab 100 mg.................................10doxycycline hyclate tab 20 mg...................................10doxycycline monohydrate cap 100 mg......................10doxycycline monohydrate cap 150 mg......................10doxycycline monohydrate cap 50 mg........................10doxycycline monohydrate cap 75 mg........................10doxycycline monohydrate tab 100 mg...................... 10doxycycline monohydrate tab 150 mg...................... 10doxycycline monohydrate tab 50 mg.........................10doxycycline monohydrate tab 75 mg.........................10dronabinol cap 10 mg................................................. 21dronabinol cap 2.5 mg................................................ 21dronabinol cap 5 mg....................................................21drospirenone-ethinyl estradiol tab 3-0.02

mg................................................................................77drospirenone-ethinyl estradiol tab 3-0.03

mg................................................................................77drospirenone-ethinyl estrad-levomefolate tab

3-0.02-0.451 mg........................................................77DULERA........................................................................ 93DULERA........................................................................ 93duloxetine hcl enteric coated pellets cap 20

mg................................................................................19duloxetine hcl enteric coated pellets cap 30

mg................................................................................19duloxetine hcl enteric coated pellets cap 60

mg................................................................................19DUREZOL..................................................................... 89dutasteride cap 0.5 mg............................................... 75dutasteride-tamsulosin hcl cap 0.5-0.4

mg................................................................................75

2018

109

Eeconazole nitrate cream 1%.......................................22EDURANT..................................................................... 42efavirenz cap 200 mg..................................................42efavirenz cap 50 mg....................................................42efavirenz tab 600 mg...................................................42EFFIENT........................................................................51EFFIENT........................................................................51EGRIFTA....................................................................... 77EGRIFTA....................................................................... 77ELAPRASE................................................................... 73ELELYSO.......................................................................74ELIDEL...........................................................................67ELIGARD.......................................................................81ELIGARD.......................................................................81ELIGARD.......................................................................81ELIGARD.......................................................................81ELIQUIS.........................................................................51ELIQUIS.........................................................................51ELIQUIS STARTER PACK......................................... 51ELITEK...........................................................................27ELITEK...........................................................................27ELLA...............................................................................77EMCYT.......................................................................... 27EMEND..........................................................................21EMPLICITI.....................................................................27EMPLICITI.....................................................................27EMSAM..........................................................................19EMSAM..........................................................................19EMSAM..........................................................................19EMTRIVA.......................................................................42EMTRIVA.......................................................................42enalapril maleate & hydrochlorothiazide tab 10-25

mg................................................................................57enalapril maleate & hydrochlorothiazide tab 5-12.5

mg................................................................................57enalapril maleate tab 10 mg.......................................57enalapril maleate tab 2.5 mg......................................57enalapril maleate tab 20 mg.......................................57enalapril maleate tab 5 mg.........................................57ENBREL........................................................................ 83ENBREL........................................................................ 83ENBREL........................................................................ 83ENBREL MINI...............................................................83ENBREL SURECLICK................................................ 83ENGERIX-B.................................................................. 83ENGERIX-B.................................................................. 83enoxaparin sodium inj 100 mg/ml..............................51enoxaparin sodium inj 120 mg/0.8ml........................ 51enoxaparin sodium inj 150 mg/ml..............................51enoxaparin sodium inj 300 mg/3ml............................51enoxaparin sodium inj 30 mg/0.3ml...........................51

enoxaparin sodium inj 40 mg/0.4ml...........................51enoxaparin sodium inj 60 mg/0.6ml...........................51enoxaparin sodium inj 80 mg/0.8ml...........................51entacapone tab 200 mg..............................................36entecavir tab 0.5 mg....................................................42entecavir tab 1 mg.......................................................42ENTRESTO...................................................................57ENTRESTO...................................................................57ENTRESTO...................................................................57EPCLUSA......................................................................42epinastine hcl ophth soln 0.05%................................89EPINEPHRINE............................................................. 93EPINEPHRINE............................................................. 93EPIPEN 2-PAK............................................................. 93EPIPEN-JR 2-PAK....................................................... 93epirubicin hcl iv soln 200 mg/100ml (2 mg/

ml)................................................................................27epirubicin hcl iv soln 50 mg/25ml (2 mg/

ml)................................................................................27EPIVIR HBV..................................................................42eplerenone tab 25 mg.................................................57eplerenone tab 50 mg.................................................57EPOGEN....................................................................... 51EPOGEN....................................................................... 52EPOGEN....................................................................... 52EPOGEN....................................................................... 52EPOGEN....................................................................... 52ERBITUX....................................................................... 28ERBITUX....................................................................... 28ERGOLOID MESYLATES...........................................17ERIVEDGE....................................................................28ERWINAZE................................................................... 28ERYPED 400................................................................10ERY-TAB....................................................................... 10ERY-TAB....................................................................... 10ERY-TAB....................................................................... 10ERYTHROCIN LACTOBIONATE...............................10ERYTHROCIN STEARATE........................................ 10ERYTHROMYCIN BASE............................................ 10ERYTHROMYCIN BASE............................................ 10erythromycin ethylsuccinate for susp 200

mg/5ml........................................................................ 10erythromycin ophth oint 5 mg/gm.............................. 89erythromycin pads 2%.................................................10erythromycin soln 2%..................................................10ESBRIET....................................................................... 93ESBRIET....................................................................... 93ESBRIET....................................................................... 93escitalopram oxalate soln 5 mg/5ml..........................19escitalopram oxalate tab 10 mg.................................19escitalopram oxalate tab 20 mg.................................19escitalopram oxalate tab 5 mg...................................19

2018

110

esomeprazole magnesium cap delayed release 20mg................................................................................71

esomeprazole magnesium cap delayed release 40mg................................................................................71

ESOMEPRAZOLE SODIUM...................................... 71esomeprazole sodium for intravenous soln 40

mg................................................................................71ESTRACE......................................................................77estradiol & norethindrone acetate tab 0.5-0.1

mg................................................................................78estradiol & norethindrone acetate tab 1-0.5

mg................................................................................78estradiol tab 0.5 mg.....................................................78estradiol tab 1 mg........................................................78estradiol tab 2 mg........................................................78estradiol td patch weekly 0.025

mg/24hr...................................................................... 78estradiol td patch weekly 0.0375 mg/24hr (37.5

mcg/24hr)................................................................... 78estradiol td patch weekly 0.05 mg/24hr.................... 78estradiol td patch weekly 0.06 mg/24hr.................... 78estradiol td patch weekly 0.075

mg/24hr...................................................................... 78estradiol td patch weekly 0.1 mg/24hr...................... 78estradiol vaginal cream 0.1 mg/gm........................... 78estradiol vaginal tab 10 mcg...................................... 78ESTROPIPATE............................................................. 78ESTROPIPATE............................................................. 78ESTROPIPATE............................................................. 78ethambutol hcl tab 100 mg.........................................25ethambutol hcl tab 400 mg.........................................25ethosuximide cap 250 mg...........................................14ethosuximide soln 250 mg/5ml.................................. 14ethynodiol diacetate & ethinyl estradiol tab 1 mg-35

mcg..............................................................................78ethynodiol diacetate & ethinyl estradiol tab 1 mg-50

mcg..............................................................................78ETHYOL........................................................................ 28ETIDRONATE DISODIUM..........................................88ETIDRONATE DISODIUM..........................................88etodolac cap 200 mg.....................................................1etodolac cap 300 mg.....................................................1etodolac tab 400 mg......................................................2etodolac tab 500 mg......................................................2etodolac tab er 24hr 400 mg........................................ 1etodolac tab er 24hr 500 mg........................................ 1etodolac tab er 24hr 600 mg........................................ 2ETOPOPHOS............................................................... 28etoposide inj 100 mg/5ml (20 mg/ml)........................28etoposide inj 1 gm/50ml (20 mg/ml).......................... 28etoposide inj 500 mg/25ml (20 mg/ml)......................28EVOMELA..................................................................... 28

EVOTAZ.........................................................................42exemestane tab 25 mg............................................... 28EXJADE.........................................................................69EXJADE.........................................................................69EXJADE.........................................................................69ezetimibe-simvastatin tab 10-10 mg..........................57ezetimibe-simvastatin tab 10-20 mg..........................57ezetimibe-simvastatin tab 10-40 mg..........................57ezetimibe-simvastatin tab 10-80 mg..........................57ezetimibe tab 10 mg....................................................57FFABRAZYME................................................................ 74FABRAZYME................................................................ 74famciclovir tab 125 mg................................................42famciclovir tab 250 mg................................................42famciclovir tab 500 mg................................................42famotidine for susp 40 mg/5ml...................................71famotidine inj 200 mg/20ml........................................ 71famotidine inj 20 mg/2ml.............................................71famotidine inj 40 mg/4ml.............................................71famotidine tab 20 mg...................................................71famotidine tab 40 mg...................................................71FANAPT.........................................................................37FANAPT.........................................................................37FANAPT.........................................................................37FANAPT.........................................................................37FANAPT.........................................................................37FANAPT.........................................................................37FANAPT.........................................................................37FANAPT TITRATION PACK....................................... 37FARESTON...................................................................28FARYDAK......................................................................28FARYDAK......................................................................28FARYDAK......................................................................28FASLODEX................................................................... 28fat emulsion iv soln 20%.............................................69felbamate susp 600 mg/5ml....................................... 14felbamate tab 400 mg................................................. 14felbamate tab 600 mg................................................. 14felodipine tab er 24hr 10 mg...................................... 57felodipine tab er 24hr 2.5 mg..................................... 57felodipine tab er 24hr 5 mg........................................ 57fenofibrate micronized cap 134 mg........................... 57fenofibrate micronized cap 200 mg........................... 57fenofibrate micronized cap 67 mg............................. 57fenofibrate tab 145 mg................................................57fenofibrate tab 160 mg................................................57fenofibrate tab 48 mg.................................................. 57fenofibrate tab 54 mg.................................................. 57fentanyl citrate lozenge on a handle 1200

mcg................................................................................2

2018

111

fentanyl citrate lozenge on a handle 1600mcg................................................................................2





fentanyl td patch 72hr 100 mcg/hr...............................2fentanyl td patch 72hr 12 mcg/hr................................. 2fentanyl td patch 72hr 25 mcg/hr................................. 2fentanyl td patch 72hr 50 mcg/hr................................. 2fentanyl td patch 72hr 75 mcg/hr................................. 2FETZIMA....................................................................... 19FETZIMA....................................................................... 19FETZIMA....................................................................... 19FETZIMA....................................................................... 19FETZIMA TITRATION PACK......................................19FINACEA....................................................................... 67FINACEA....................................................................... 67finasteride tab 5 mg.....................................................75FIRAZYR....................................................................... 83FIRMAGON...................................................................81FIRMAGON...................................................................81flecainide acetate tab 100 mg....................................57flecainide acetate tab 150 mg....................................57flecainide acetate tab 50 mg...................................... 57FLOVENT DISKUS......................................................93FLOVENT DISKUS......................................................93FLOVENT DISKUS......................................................93FLOVENT HFA.............................................................93FLOVENT HFA.............................................................93FLOVENT HFA.............................................................93fluconazole for susp 10 mg/ml................................... 23fluconazole for susp 40 mg/ml................................... 23fluconazole in dextrose inj 200

mg/100ml....................................................................23fluconazole in dextrose inj 400

mg/200ml....................................................................23fluconazole in nacl 0.9% inj 200

mg/100ml....................................................................23fluconazole in nacl 0.9% inj 400

mg/200ml....................................................................23fluconazole tab 100 mg...............................................23fluconazole tab 150 mg...............................................23fluconazole tab 200 mg...............................................23fluconazole tab 50 mg.................................................23flucytosine cap 250 mg............................................... 23flucytosine cap 500 mg............................................... 23fludarabine phosphate for inj 50 mg..........................28

fludarabine phosphate inj 25 mg/ml.......................... 28fludrocortisone acetate tab 0.1 mg............................ 76fluocinolone acetonide (otic) oil 0.01%..................... 91fluocinolone acetonide cream 0.01%........................ 67fluocinonide cream 0.05%.......................................... 67fluocinonide emulsified base cream

0.05%..........................................................................67fluocinonide gel 0.05%................................................67fluocinonide oint 0.05%...............................................67fluocinonide soln 0.05%..............................................67fluorometholone ophth susp 0.1%.............................89fluorouracil cream 5%................................................. 67fluorouracil inj 1 gm/20ml (50 mg/ml)........................28fluorouracil inj 2.5 gm/50ml (50 mg/ml).....................28fluorouracil inj 500 mg/10ml (50 mg/

ml)................................................................................28fluorouracil inj 5 gm/100ml (50 mg/ml)......................28fluorouracil soln 2%..................................................... 67fluorouracil soln 5%..................................................... 67FLUOXETINE DR........................................................ 19fluoxetine hcl cap 10 mg.............................................19fluoxetine hcl cap 20 mg.............................................19fluoxetine hcl cap 40 mg.............................................19fluoxetine hcl solution 20 mg/5ml.............................. 19fluoxetine hcl tab 10 mg..............................................19fluoxetine hcl tab 20 mg..............................................19fluphenazine decanoate inj 25 mg/ml........................37FLUPHENAZINE HCL.................................................37FLUPHENAZINE HCL.................................................37FLUPHENAZINE HCL.................................................37fluphenazine hcl tab 10 mg........................................ 38fluphenazine hcl tab 1 mg.......................................... 37fluphenazine hcl tab 2.5 mg....................................... 37fluphenazine hcl tab 5 mg.......................................... 38flurbiprofen sodium ophth soln 0.03%.......................89flurbiprofen tab 100 mg.................................................2flurbiprofen tab 50 mg................................................... 2flutamide cap 125 mg..................................................28FLUTICASONE PROPIONATE/

SALMETEROL.......................................................... 93FLUTICASONE PROPIONATE/

SALMETEROL.......................................................... 93FLUTICASONE PROPIONATE/

SALMETEROL.......................................................... 93fluticasone propionate cream 0.05%.........................67fluticasone propionate nasal susp 50 mcg/

act................................................................................93fluticasone propionate oint 0.005%........................... 67fluvoxamine maleate tab 100 mg...............................19fluvoxamine maleate tab 25 mg.................................19fluvoxamine maleate tab 50 mg.................................19FOLOTYN......................................................................28

2018

112

FOLOTYN......................................................................28fomepizole inj 1 gm/ml (for iv infusion)......................69fondaparinux sodium subcutaneous inj 10

mg/0.8ml.....................................................................52fondaparinux sodium subcutaneous inj 2.5

mg/0.5ml.....................................................................52fondaparinux sodium subcutaneous inj 5

mg/0.4ml.....................................................................52fondaparinux sodium subcutaneous inj 7.5

mg/0.6ml.....................................................................52FORTEO........................................................................88fosamprenavir calcium tab 700 mg........................... 42fosinopril sodium & hydrochlorothiazide tab 10-12.5

mg................................................................................57fosinopril sodium & hydrochlorothiazide tab 20-12.5

mg................................................................................57fosinopril sodium tab 10 mg....................................... 57fosinopril sodium tab 20 mg....................................... 57fosinopril sodium tab 40 mg....................................... 57fosphenytoin sodium inj 100 mg/2ml.........................14fosphenytoin sodium inj 500 mg/10ml.......................14FOSRENOL.................................................................. 69FOSRENOL.................................................................. 69FOSRENOL.................................................................. 69FOSRENOL.................................................................. 69FOSRENOL.................................................................. 69furosemide inj 10 mg/ml..............................................57furosemide oral soln 10 mg/ml...................................57furosemide tab 20 mg................................................. 57furosemide tab 40 mg................................................. 58furosemide tab 80 mg................................................. 58FUZEON........................................................................42FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................14FYCOMPA.....................................................................15FYCOMPA.....................................................................15Ggabapentin cap 100 mg.............................................. 15gabapentin cap 300 mg.............................................. 15gabapentin cap 400 mg.............................................. 15gabapentin oral soln 250 mg/5ml.............................. 15gabapentin tab 600 mg............................................... 15gabapentin tab 800 mg............................................... 15GABITRIL...................................................................... 15GABITRIL...................................................................... 15GALANTAMINE HYDROBROMIDE.......................... 17galantamine hydrobromide cap er 24hr 16

mg................................................................................17

galantamine hydrobromide cap er 24hr 24mg................................................................................17

galantamine hydrobromide cap er 24hr 8mg................................................................................17

galantamine hydrobromide tab 12 mg...................... 17galantamine hydrobromide tab 4 mg.........................17galantamine hydrobromide tab 8 mg.........................17GAMMAGARD LIQUID............................................... 83GAMMAGARD LIQUID............................................... 83GAMMAGARD LIQUID............................................... 83GAMMAGARD LIQUID............................................... 83GAMMAGARD LIQUID............................................... 83GAMMAGARD LIQUID............................................... 83GAMMAGARD S/D......................................................84GAMMAGARD S/D......................................................84GAMMAPLEX............................................................... 84GAMMAPLEX............................................................... 84GAMMAPLEX............................................................... 84GAMMAPLEX............................................................... 84GAMMAPLEX............................................................... 84GAMMAPLEX............................................................... 84GAMUNEX-C................................................................ 84GAMUNEX-C................................................................ 84GAMUNEX-C................................................................ 84GAMUNEX-C................................................................ 84GAMUNEX-C................................................................ 84GAMUNEX-C................................................................ 84ganciclovir sodium for inj 500 mg.............................. 42GARDASIL 9.................................................................84GARDASIL 9.................................................................84GATTEX.........................................................................71GAUZE PADS 2" X 2".................................................47GAZYVA.........................................................................28gemcitabine hcl for inj 1 gm....................................... 28gemcitabine hcl for inj 200 mg...................................28gemcitabine hcl for inj 2 gm....................................... 28gemcitabine hcl inj 1 gm/26.3ml (38 mg/

ml)................................................................................28gemcitabine hcl inj 200 mg/5.26ml (38 mg/

ml)................................................................................28gemcitabine hcl inj 2 gm/52.6ml (38 mg/

ml)................................................................................28gemfibrozil tab 600 mg............................................... 58gentamicin in saline inj 0.8 mg/ml............................. 10gentamicin in saline inj 1.2 mg/ml............................. 10gentamicin in saline inj 1.6 mg/ml............................. 10gentamicin in saline inj 1 mg/ml.................................10gentamicin sulfate cream 0.1%..................................67gentamicin sulfate inj 10 mg/ml................................. 10gentamicin sulfate inj 40 mg/ml................................. 10gentamicin sulfate iv soln 10 mg/ml.......................... 10gentamicin sulfate oint 0.1%...................................... 67

2018

113

gentamicin sulfate ophth oint 0.3%........................... 89gentamicin sulfate ophth soln 0.3%...........................90GENVOYA.....................................................................42GEODON.......................................................................38GILOTRIF......................................................................28GILOTRIF......................................................................28GILOTRIF......................................................................28glatiramer acetate soln prefilled syringe 20 mg/

ml.................................................................................65glatiramer acetate soln prefilled syringe 40 mg/

ml.................................................................................65GLEOSTINE..................................................................28GLEOSTINE..................................................................28GLEOSTINE..................................................................28GLEOSTINE..................................................................29glimepiride tab 1 mg....................................................47glimepiride tab 2 mg....................................................47glimepiride tab 4 mg....................................................47glipizide-metformin hcl tab 2.5-250 mg.....................47glipizide-metformin hcl tab 2.5-500 mg.....................47glipizide-metformin hcl tab 5-500 mg........................ 47glipizide tab 10 mg...................................................... 47glipizide tab 5 mg.........................................................47glipizide tab er 24hr 10 mg.........................................47glipizide tab er 24hr 2.5 mg........................................47glipizide tab er 24hr 5 mg...........................................47GLUCAGEN HYPOKIT............................................... 47GLUCAGON EMERGENCY KIT............................... 47glycopyrrolate tab 1 mg.............................................. 72glycopyrrolate tab 2 mg.............................................. 72granisetron hcl inj 1 mg/ml......................................... 21granisetron hcl inj 4 mg/4ml (1 mg/ml)......................21granisetron hcl tab 1 mg.............................................21GRANIX......................................................................... 52GRANIX......................................................................... 52griseofulvin microsize susp 125

mg/5ml........................................................................ 23griseofulvin ultramicrosize tab 125 mg......................23griseofulvin ultramicrosize tab 250 mg......................23GUANIDINE HCL.........................................................24HH.P. ACTHAR............................................................... 76HAEGARDA.................................................................. 84HAEGARDA.................................................................. 84HALAVEN...................................................................... 29halobetasol propionate cream 0.05%........................67halobetasol propionate oint 0.05%............................ 67haloperidol decanoate im soln 100 mg/

ml.................................................................................38haloperidol decanoate im soln 50 mg/

ml.................................................................................38

haloperidol lactate inj 5 mg/ml................................... 38haloperidol lactate oral conc 2 mg/ml........................38haloperidol tab 0.5 mg................................................ 38haloperidol tab 10 mg................................................. 38haloperidol tab 1 mg....................................................38haloperidol tab 20 mg................................................. 38haloperidol tab 2 mg....................................................38haloperidol tab 5 mg....................................................38HARVONI...................................................................... 42HAVRIX..........................................................................84HAVRIX..........................................................................84heparin sodium (porcine) 40 unit/ml in

d5w..............................................................................52heparin sodium (porcine) inj 10000 unit/

ml.................................................................................52heparin sodium (porcine) inj 1000 unit/



ml.................................................................................52heparin sodium (porcine) pf inj 5000

unit/0.5ml....................................................................52HEPATAMINE............................................................... 69HERCEPTIN................................................................. 29HERCEPTIN................................................................. 29HETLIOZ........................................................................96HEXALEN......................................................................29HIBERIX........................................................................ 84HUMALOG.................................................................... 47HUMALOG.................................................................... 47HUMALOG JUNIOR KWIKPEN.................................47HUMALOG KWIKPEN.................................................47HUMALOG KWIKPEN.................................................47HUMALOG MIX 50/50.................................................47HUMALOG MIX 50/50 KWIKPEN............................. 47HUMALOG MIX 75/25.................................................47HUMALOG MIX 75/25 KWIKPEN............................. 48HUMIRA.........................................................................84HUMIRA.........................................................................84HUMIRA.........................................................................84HUMIRA PEDIATRIC CROHNS DISEASE

STARTER PACK.......................................................84HUMIRA PEN............................................................... 84HUMIRA PEN-CROHNS DISEASE

STARTER...................................................................84HUMIRA PEN-PSORIASIS STARTER..................... 84HUMULIN 70/30...........................................................48HUMULIN 70/30 KWIKPEN....................................... 48HUMULIN N..................................................................48HUMULIN N KWIKPEN.............................................. 48HUMULIN R..................................................................48

2018

114

HUMULIN R U-500 (CONCENTRATE).....................48HUMULIN R U-500 KWIKPEN...................................48hydralazine hcl tab 100 mg........................................ 58hydralazine hcl tab 10 mg.......................................... 58hydralazine hcl tab 25 mg.......................................... 58hydralazine hcl tab 50 mg.......................................... 58hydrochlorothiazide cap 12.5 mg...............................58hydrochlorothiazide tab 12.5 mg................................58hydrochlorothiazide tab 25 mg...................................58hydrochlorothiazide tab 50 mg...................................58hydrocodone-acetaminophen soln 7.5-325

mg/15ml........................................................................ 2hydrocodone-acetaminophen tab 10-300

mg..................................................................................2hydrocodone-acetaminophen tab 10-325



mg..................................................................................2hydrocodone-acetaminophen tab 7.5-300

mg..................................................................................2hydrocodone-acetaminophen tab 7.5-325

mg..................................................................................2hydrocodone-ibuprofen tab 10-200 mg.......................2hydrocodone-ibuprofen tab 5-200 mg......................... 2hydrocodone-ibuprofen tab 7.5-200 mg......................2hydrocortisone butyrate cream 0.1%........................ 67hydrocortisone butyrate hydrophilic lipo base cream

0.1%............................................................................67hydrocortisone butyrate oint 0.1%.............................67hydrocortisone butyrate soln 0.1%............................ 67hydrocortisone cream 1%...........................................67hydrocortisone cream 2.5%........................................67hydrocortisone enema 100 mg/60ml.........................87hydrocortisone lotion 2.5%......................................... 67hydrocortisone oint 1%............................................... 67hydrocortisone oint 2.5%............................................ 67hydrocortisone rectal cream 1%................................ 87hydrocortisone rectal cream 2.5%.............................87hydrocortisone tab 10 mg...........................................76hydrocortisone tab 20 mg...........................................76hydrocortisone tab 5 mg............................................. 76hydrocortisone valerate cream 0.2%.........................67hydrocortisone valerate oint 0.2%............................. 67hydrocortisone w/ acetic acid otic soln

1-2%............................................................................91hydromorphone hcl liqd 1 mg/ml..................................2hydromorphone hcl preservative free inj 10 mg/

ml................................................................................... 2hydromorphone hcl tab 2 mg....................................... 2hydromorphone hcl tab 4 mg....................................... 2

hydromorphone hcl tab 8 mg....................................... 2hydroxychloroquine sulfate tab 200 mg.................... 35HYDROXYPROGESTERONE

CAPROATE................................................................78hydroxyurea cap 500 mg............................................ 29hydroxyzine hcl syrup 10 mg/5ml.............................. 46hydroxyzine hcl tab 10 mg..........................................46hydroxyzine hcl tab 25 mg..........................................46hydroxyzine hcl tab 50 mg..........................................46Iibandronate sodium iv soln 3 mg/3ml........................88ibandronate sodium tab 150 mg................................ 88IBRANCE.......................................................................29IBRANCE.......................................................................29IBRANCE.......................................................................29ibuprofen susp 100 mg/5ml.......................................... 2ibuprofen tab 400 mg.................................................... 2ibuprofen tab 600 mg.................................................... 2ibuprofen tab 800 mg.................................................... 2ICLUSIG........................................................................ 29ICLUSIG........................................................................ 29idarubicin hcl iv inj 10 mg/10ml (1 mg/

ml)................................................................................29idarubicin hcl iv inj 20 mg/20ml (1 mg/

ml)................................................................................29idarubicin hcl iv inj 5 mg/5ml (1 mg/ml).....................29IDHIFA............................................................................29IDHIFA............................................................................29IFEX............................................................................... 29IFOSFAMIDE................................................................ 29ifosfamide for inj 1 gm.................................................29ifosfamide iv inj 1 gm/20ml (50 mg/ml)..................... 29ifosfamide iv inj 3 gm/60ml (50 mg/ml)..................... 29ILARIS............................................................................85ILARIS............................................................................85ILEVRO..........................................................................90imatinib mesylate tab 100 mg.................................... 29imatinib mesylate tab 400 mg.................................... 29IMBRUVICA.................................................................. 29IMFINZI..........................................................................29IMFINZI..........................................................................29imipenem-cilastatin intravenous for soln 250

mg................................................................................10imipenem-cilastatin intravenous for soln 500

mg................................................................................10imipramine hcl tab 10 mg........................................... 19imipramine hcl tab 25 mg........................................... 19imipramine hcl tab 50 mg........................................... 19imiquimod cream 5%...................................................67IMLYGIC........................................................................ 29IMLYGIC........................................................................ 29

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IMOVAX RABIES (H.D.C.V.)...................................... 85IMPAVIDO..................................................................... 10INCRELEX.................................................................... 77INCRUSE ELLIPTA..................................................... 93indapamide tab 1.25 mg............................................. 58indapamide tab 2.5 mg............................................... 58INFANRIX......................................................................85INLYTA...........................................................................29INLYTA...........................................................................29INSULIN INJECTION DEVICE...................................48INSULIN SYRINGE/NEEDLE.....................................48INTELENCE.................................................................. 42INTELENCE.................................................................. 42INTELENCE.................................................................. 42INTRON A.....................................................................42INTRON A.....................................................................42INTRON A.....................................................................42INTRON A.....................................................................42INTRON A.....................................................................42INTRON A W/DILUENT..............................................42INTRON A W/DILUENT..............................................43INTRON A W/DILUENT..............................................43INVANZ.......................................................................... 10INVANZ.......................................................................... 10INVEGA SUSTENNA.................................................. 38INVEGA SUSTENNA.................................................. 38INVEGA SUSTENNA.................................................. 38INVEGA SUSTENNA.................................................. 38INVEGA SUSTENNA.................................................. 38INVEGA TRINZA..........................................................38INVEGA TRINZA..........................................................38INVEGA TRINZA..........................................................38INVEGA TRINZA..........................................................38INVIRASE......................................................................43INVIRASE......................................................................43INVOKAMET.................................................................48INVOKAMET.................................................................48INVOKAMET.................................................................48INVOKAMET.................................................................48INVOKAMET XR..........................................................48INVOKAMET XR..........................................................48INVOKAMET XR..........................................................48INVOKAMET XR..........................................................48INVOKANA....................................................................48INVOKANA....................................................................48IPOL INACTIVATED IPV.............................................85ipratropium bromide inhal soln 0.02%.......................93ipratropium bromide nasal soln 0.03% (21 mcg/

spray)..........................................................................93ipratropium bromide nasal soln 0.06% (42 mcg/

spray)..........................................................................93

irbesartan-hydrochlorothiazide tab 150-12.5mg................................................................................58

irbesartan-hydrochlorothiazide tab 300-12.5mg................................................................................58

irbesartan tab 150 mg.................................................58irbesartan tab 300 mg.................................................58irbesartan tab 75 mg................................................... 58IRESSA..........................................................................29IRINOTECAN................................................................29irinotecan hcl inj 100 mg/5ml (20 mg/

ml)................................................................................29irinotecan hcl inj 40 mg/2ml (20 mg/ml).................... 29ISENTRESS..................................................................43ISENTRESS..................................................................43ISENTRESS..................................................................43ISENTRESS..................................................................43ISENTRESS HD...........................................................43ISONIAZID.................................................................... 25isoniazid tab 100 mg................................................... 25isoniazid tab 300 mg................................................... 25isosorbide dinitrate tab 10 mg....................................58isosorbide dinitrate tab 20 mg....................................58isosorbide dinitrate tab 30 mg....................................58isosorbide dinitrate tab 5 mg......................................58isosorbide mononitrate tab 10 mg............................. 58isosorbide mononitrate tab 20 mg............................. 58isosorbide mononitrate tab er 24hr 120

mg................................................................................58isosorbide mononitrate tab er 24hr 30

mg................................................................................58isosorbide mononitrate tab er 24hr 60

mg................................................................................58isotretinoin cap 10 mg.................................................68isotretinoin cap 20 mg.................................................68isotretinoin cap 30 mg.................................................68isotretinoin cap 40 mg.................................................68isradipine cap 2.5 mg..................................................58isradipine cap 5 mg..................................................... 58ISTALOL........................................................................ 90ISTODAX.......................................................................29ISTODAX (OVERFILL)................................................29itraconazole cap 100 mg............................................ 23ivermectin tab 3 mg.....................................................35IXEMPRA KIT...............................................................29IXEMPRA KIT...............................................................30IXIARO...........................................................................85JJADENU........................................................................ 69JADENU........................................................................ 69JADENU........................................................................ 69JADENU SPRINKLE................................................... 70

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JADENU SPRINKLE................................................... 70JADENU SPRINKLE................................................... 70JAKAFI...........................................................................30JAKAFI...........................................................................30JAKAFI...........................................................................30JAKAFI...........................................................................30JAKAFI...........................................................................30JANUMET......................................................................48JANUMET......................................................................48JANUMET XR...............................................................48JANUMET XR...............................................................48JANUMET XR...............................................................48JANUVIA........................................................................48JANUVIA........................................................................48JANUVIA........................................................................48JARDIANCE..................................................................48JARDIANCE..................................................................48JENTADUETO.............................................................. 48JENTADUETO.............................................................. 49JENTADUETO.............................................................. 49JENTADUETO XR....................................................... 49JENTADUETO XR....................................................... 49JEVTANA.......................................................................30JUXTAPID..................................................................... 58JUXTAPID..................................................................... 58JUXTAPID..................................................................... 58JUXTAPID..................................................................... 58JUXTAPID..................................................................... 58JUXTAPID..................................................................... 58KKADCYLA......................................................................30KADCYLA......................................................................30KALETRA...................................................................... 43KALETRA...................................................................... 43KALYDECO...................................................................93KALYDECO...................................................................93KALYDECO...................................................................94kcl 10 meq/l (0.075%) in dextrose 5% & nacl 0.45%

inj................................................................................. 70kcl 20 meq/l (0.15%) in dextrose 5% & nacl 0.2%



inj................................................................................. 70kcl 20 meq/l (0.15%) in nacl 0.45% inj......................70kcl 30 meq/l (0.224%) in dextrose 5% & nacl 0.45%


inj................................................................................. 70KEPIVANCE..................................................................66ketoconazole cream 2%..............................................23

ketoconazole shampoo 2%........................................ 23ketoconazole tab 200 mg........................................... 23ketoprofen cap 50 mg................................................... 2ketoprofen cap 75 mg................................................... 2ketorolac tromethamine ophth soln

0.4%............................................................................90ketorolac tromethamine ophth soln

0.5%............................................................................90KEYTRUDA...................................................................30KEYTRUDA...................................................................30KINERET....................................................................... 85KINRIX........................................................................... 85KISQALI.........................................................................30KISQALI FEMARA 200 DOSE...................................30KISQALI FEMARA 400 DOSE...................................30KISQALI FEMARA 600 DOSE...................................30KOMBIGLYZE XR........................................................49KOMBIGLYZE XR........................................................49KOMBIGLYZE XR........................................................49KORLYM........................................................................80KUVAN...........................................................................74KUVAN...........................................................................74KUVAN...........................................................................74KYNAMRO.................................................................... 58KYPROLIS.................................................................... 30KYPROLIS.................................................................... 30Llabetalol hcl tab 100 mg..............................................58labetalol hcl tab 200 mg..............................................58labetalol hcl tab 300 mg..............................................59LACRISERT.................................................................. 90lactated ringer's solution............................................. 70lactic acid (ammonium lactate) cream

12%............................................................................. 68lactic acid (ammonium lactate) lotion

12%............................................................................. 68lactulose (encephalopathy) solution 10

gm/15ml......................................................................72lactulose solution 10 gm/15ml....................................72lamivudine oral soln 10 mg/ml................................... 43lamivudine tab 100 mg (hbv)......................................43lamivudine tab 150 mg................................................43lamivudine tab 300 mg................................................43lamivudine-zidovudine tab 150-300 mg.................... 43lamotrigine tab 100 mg............................................... 15lamotrigine tab 150 mg............................................... 15lamotrigine tab 200 mg............................................... 15lamotrigine tab 25 mg................................................. 15lamotrigine tab chewable dispersible 25

mg................................................................................15

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117

lamotrigine tab chewable dispersible 5mg................................................................................15

lansoprazole cap delayed release 15mg................................................................................72

lansoprazole cap delayed release 30mg................................................................................72

lanthanum carbonate chew tab 1000mg................................................................................70



LANTUS.........................................................................49LANTUS SOLOSTAR..................................................49LARTRUVO...................................................................30LARTRUVO...................................................................30latanoprost ophth soln 0.005%.................................. 90LATUDA.........................................................................38LATUDA.........................................................................38LATUDA.........................................................................38LATUDA.........................................................................38LATUDA.........................................................................38LAZANDA........................................................................ 2LAZANDA........................................................................ 3LAZANDA........................................................................ 3leflunomide tab 10 mg.................................................85leflunomide tab 20 mg.................................................85LENVIMA 10 MG DAILY DOSE.................................30LENVIMA 14 MG DAILY DOSE.................................30LENVIMA 18 MG DAILY DOSE.................................30LENVIMA 20 MG DAILY DOSE.................................30LENVIMA 24 MG DAILY DOSE.................................30LENVIMA 8 MG DAILY DOSE...................................30LETAIRIS.......................................................................94LETAIRIS.......................................................................94letrozole tab 2.5 mg.....................................................30LEUCOVORIN CALCIUM...........................................30LEUCOVORIN CALCIUM...........................................30LEUCOVORIN CALCIUM...........................................30leucovorin calcium for inj 100 mg.............................. 31leucovorin calcium for inj 200 mg.............................. 31leucovorin calcium for inj 350 mg.............................. 31leucovorin calcium for inj 50 mg................................ 30leucovorin calcium tab 25 mg.................................... 31leucovorin calcium tab 5 mg.......................................31LEUKERAN...................................................................31LEUKINE....................................................................... 52leuprolide acetate inj kit 5 mg/ml............................... 81LEVEMIR.......................................................................49LEVEMIR FLEXTOUCH..............................................49levetiracetam inj 500 mg/5ml (100 mg/

ml)................................................................................15

levetiracetam in sodium chloride iv soln 1000mg/100ml....................................................................15



levetiracetam oral soln 100 mg/ml.............................15levetiracetam tab 1000 mg......................................... 15levetiracetam tab 250 mg........................................... 15levetiracetam tab 500 mg........................................... 15levetiracetam tab 750 mg........................................... 15levobunolol hcl ophth soln 0.5%................................ 90levocarnitine oral soln 1 gm/10ml

(10%).......................................................................... 70levocarnitine tab 330 mg............................................ 70levocetirizine dihydrochloride tab 5 mg.....................94LEVOFLOXACIN..........................................................10levofloxacin in d5w iv soln 250

mg/50ml......................................................................10levofloxacin in d5w iv soln 500

mg/100ml....................................................................10levofloxacin in d5w iv soln 750

mg/150ml....................................................................11levofloxacin iv soln 25 mg/ml..................................... 11levofloxacin tab 250 mg..............................................11levofloxacin tab 500 mg..............................................11levofloxacin tab 750 mg..............................................11levonorgestrel & ethinyl estradiol (91-day) tab

0.15-0.03 mg............................................................. 78levonorgestrel & ethinyl estradiol tab 0.15 mg-30

mcg..............................................................................78levonorgestrel & ethinyl estradiol tab 0.1 mg-20

mcg..............................................................................78levonorgestrel-eth estra tab

0.05-30/0.075-40/0.125-30mg-mcg........................78levonorgestrel-ethinyl estradiol (continuous) tab

90-20 mcg..................................................................78levonorg-eth est tab 0.1-0.02mg(84) & eth est tab

0.01mg(7)...................................................................78levonorg-eth est tab 0.15-0.03mg(84) & eth est tab

0.01mg(7)...................................................................78LEVORPHANOL TARTRATE....................................... 3levothyroxine sodium tab 100 mcg............................80levothyroxine sodium tab 112 mcg............................ 80levothyroxine sodium tab 125 mcg............................80levothyroxine sodium tab 137 mcg............................80levothyroxine sodium tab 150 mcg............................80levothyroxine sodium tab 175 mcg............................80levothyroxine sodium tab 200 mcg............................80levothyroxine sodium tab 25 mcg..............................80levothyroxine sodium tab 300 mcg............................80levothyroxine sodium tab 50 mcg..............................80

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levothyroxine sodium tab 75 mcg..............................80levothyroxine sodium tab 88 mcg..............................80LEXIVA...........................................................................43LEXIVA...........................................................................43LIALDA...........................................................................87LIDOCAINE HCL..........................................................59lidocaine hcl gel 2%.......................................................4lidocaine hcl local inj 1%...............................................4lidocaine hcl local preservative free inj

1%..................................................................................5lidocaine hcl soln 4%.....................................................5lidocaine hcl viscous soln 2%.......................................5lidocaine oint 5%............................................................5lidocaine patch 5%.........................................................5lidocaine-prilocaine cream 2.5-2.5%........................... 5LINDANE....................................................................... 35LINEZOLID....................................................................11linezolid for susp 100 mg/5ml.................................... 11linezolid iv soln 600 mg/300ml (2 mg/

ml)................................................................................11linezolid tab 600 mg.................................................... 11LINZESS........................................................................72LINZESS........................................................................72LINZESS........................................................................72liothyronine sodium tab 25 mcg.................................80liothyronine sodium tab 50 mcg.................................80liothyronine sodium tab 5 mcg................................... 80lisinopril & hydrochlorothiazide tab 10-12.5

mg................................................................................59lisinopril & hydrochlorothiazide tab 20-12.5

mg................................................................................59lisinopril & hydrochlorothiazide tab 20-25

mg................................................................................59lisinopril tab 10 mg...................................................... 59lisinopril tab 2.5 mg..................................................... 59lisinopril tab 20 mg...................................................... 59lisinopril tab 30 mg...................................................... 59lisinopril tab 40 mg...................................................... 59lisinopril tab 5 mg.........................................................59LITHIUM........................................................................ 46lithium carbonate cap 150 mg....................................46lithium carbonate cap 300 mg....................................46lithium carbonate cap 600 mg....................................46lithium carbonate tab 300 mg.....................................47lithium carbonate tab er 300 mg................................47lithium carbonate tab er 450 mg................................47LONSURF..................................................................... 31LONSURF..................................................................... 31loperamide hcl cap 2 mg............................................ 72lopinavir-ritonavir soln 400-100 mg/5ml (80-20 mg/

ml)................................................................................43lorazepam tab 0.5 mg................................................. 46

lorazepam tab 1 mg.................................................... 46lorazepam tab 2 mg.................................................... 46losartan potassium & hydrochlorothiazide tab

100-12.5 mg.............................................................. 59losartan potassium & hydrochlorothiazide tab 100-25

mg................................................................................59losartan potassium & hydrochlorothiazide tab

50-12.5 mg.................................................................59losartan potassium tab 100 mg..................................59losartan potassium tab 25 mg....................................59losartan potassium tab 50 mg....................................59LOTEMAX..................................................................... 90LOTEMAX..................................................................... 90LOTEMAX..................................................................... 90lovastatin tab 10 mg....................................................59lovastatin tab 20 mg....................................................59lovastatin tab 40 mg....................................................59loxapine succinate cap 10 mg....................................38loxapine succinate cap 25 mg....................................38loxapine succinate cap 50 mg....................................38loxapine succinate cap 5 mg......................................38LUMIGAN...................................................................... 90LUPRON DEPOT (1-MONTH)...................................81LUPRON DEPOT (1-MONTH)...................................81LUPRON DEPOT (3-MONTH)...................................81LUPRON DEPOT (3-MONTH)...................................81LUPRON DEPOT (4-MONTH)...................................81LUPRON DEPOT (6-MONTH)...................................81LUPRON DEPOT-PED (1-MONTH)..........................81LUPRON DEPOT-PED (1-MONTH)..........................81LUPRON DEPOT-PED (1-MONTH)..........................81LUPRON DEPOT-PED (3-MONTH)..........................81LUPRON DEPOT-PED (3-MONTH)..........................81LYNPARZA....................................................................31LYNPARZA....................................................................31LYNPARZA....................................................................31LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYRICA.......................................................................... 15LYSODREN...................................................................80Mmagnesium sulfate inj 50%........................................ 70malathion lotion 0.5%..................................................35MAPROTILINE HCL.................................................... 19MAPROTILINE HCL.................................................... 19

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MAPROTILINE HCL.................................................... 19MARPLAN..................................................................... 19MARQIBO......................................................................31MATULANE...................................................................31MAVYRET..................................................................... 43meclizine hcl tab 12.5 mg...........................................21meclizine hcl tab 25 mg..............................................21medroxyprogesterone acetate im susp 150 mg/

ml.................................................................................78medroxyprogesterone acetate im susp prefilled syr

150 mg/ml.................................................................. 78medroxyprogesterone acetate tab 10

mg................................................................................78medroxyprogesterone acetate tab 2.5

mg................................................................................78medroxyprogesterone acetate tab 5

mg................................................................................78mefloquine hcl tab 250 mg......................................... 35megestrol acetate susp 40 mg/ml..............................78megestrol acetate tab 20 mg..................................... 78megestrol acetate tab 40 mg..................................... 78MEKINIST......................................................................31MEKINIST......................................................................31meloxicam tab 15 mg....................................................3meloxicam tab 7.5 mg...................................................3melphalan hcl for inj 50 mg........................................ 31memantine hcl oral solution 2 mg/ml.........................17memantine hcl tab 10 mg...........................................17memantine hcl tab 5 mg............................................. 17memantine hcl tab 5 mg (28) & 10 mg (21) titration

pak...............................................................................17MENACTRA.................................................................. 85MENEST........................................................................78MENEST........................................................................78MENEST........................................................................78MENVEO....................................................................... 85mercaptopurine tab 50 mg......................................... 31meropenem iv for soln 1 gm...................................... 11meropenem iv for soln 500 mg.................................. 11mesalamine enema 4 gm........................................... 88mesalamine rectal enema 4 gm & cleanser wipe

kit................................................................................. 88mesalamine tab delayed release 1.2

gm................................................................................88mesna inj 100 mg/ml...................................................31MESNEX........................................................................31MESTINON................................................................... 24metformin hcl tab 1000 mg.........................................49metformin hcl tab 500 mg...........................................49metformin hcl tab 850 mg...........................................49metformin hcl tab er 24hr 500 mg............................. 49metformin hcl tab er 24hr 750 mg............................. 49

methadone hcl tab 10 mg.............................................3methadone hcl tab 5 mg............................................... 3methazolamide tab 25 mg.......................................... 59methazolamide tab 50 mg.......................................... 59methenamine hippurate tab 1 gm..............................11METHERGINE..............................................................75methimazole tab 10 mg.............................................. 82methimazole tab 5 mg.................................................82methocarbamol tab 500 mg........................................95methocarbamol tab 750 mg........................................95METHOTREXATE SODIUM.......................................85methotrexate sodium for inj 1 gm.............................. 85methotrexate sodium inj 50 mg/2ml (25 mg/

ml)................................................................................85methotrexate sodium inj pf 1000 mg/40ml (25 mg/





ml)................................................................................85methotrexate sodium tab 2.5 mg............................... 85methoxsalen rapid cap 10 mg....................................68methscopolamine bromide tab 2.5 mg......................72methscopolamine bromide tab 5 mg......................... 72methylergonovine maleate tab 0.2 mg......................75methylphenidate hcl tab 10 mg..................................65methylphenidate hcl tab 20 mg..................................65methylphenidate hcl tab 5 mg....................................65methylphenidate hcl tab er 20 mg............................. 65methylprednisolone sod succ for inj 1000

mg................................................................................76methylprednisolone sod succ for inj 125

mg................................................................................76methylprednisolone sod succ for inj 40

mg................................................................................76methylprednisolone tab 16 mg...................................76methylprednisolone tab 32 mg...................................76methylprednisolone tab 4 mg.....................................76methylprednisolone tab 8 mg.....................................76methylprednisolone tab therapy pack 4 mg

(21)..............................................................................76methyltestosterone cap 10 mg...................................78metoclopramide hcl inj 5 mg/ml................................. 72metoclopramide hcl soln 5 mg/5ml (10

mg/10ml).....................................................................72metoclopramide hcl tab 10 mg...................................72metoclopramide hcl tab 5 mg.....................................72metolazone tab 10 mg................................................ 59

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120

metolazone tab 2.5 mg............................................... 59metolazone tab 5 mg...................................................59metoprolol & hydrochlorothiazide tab 100-25

mg................................................................................59metoprolol & hydrochlorothiazide tab 50-25

mg................................................................................59metoprolol succinate tab er 24hr 100




mg................................................................................59metoprolol tartrate tab 100 mg...................................59metoprolol tartrate tab 25 mg.....................................59metoprolol tartrate tab 50 mg.....................................59METRO IV.....................................................................11metronidazole cap 375 mg.........................................11metronidazole cream 0.75%.......................................68metronidazole gel 0.75%............................................ 68metronidazole gel 1%..................................................68metronidazole in nacl 0.79% iv soln 500

mg/100ml....................................................................11metronidazole iv soln 5 mg/ml................................... 11metronidazole lotion 0.75%........................................ 68metronidazole tab 250 mg..........................................11metronidazole tab 500 mg..........................................11metronidazole vaginal gel 0.75%...............................11mexiletine hcl cap 150 mg..........................................59mexiletine hcl cap 200 mg..........................................59mexiletine hcl cap 250 mg..........................................59MIACALCIN...................................................................88midodrine hcl tab 10 mg............................................. 60midodrine hcl tab 2.5 mg............................................ 59midodrine hcl tab 5 mg............................................... 60MIGERGOT...................................................................24MIGRANAL....................................................................24minocycline hcl cap 100 mg.......................................11minocycline hcl cap 50 mg......................................... 11minocycline hcl cap 75 mg......................................... 11minocycline hcl tab 100 mg........................................11minocycline hcl tab 50 mg..........................................11minocycline hcl tab 75 mg..........................................11minoxidil tab 10 mg..................................................... 60minoxidil tab 2.5 mg.................................................... 60mirtazapine orally disintegrating tab 15

mg................................................................................19mirtazapine orally disintegrating tab 30

mg................................................................................19mirtazapine orally disintegrating tab 45

mg................................................................................19

mirtazapine tab 15 mg................................................ 19mirtazapine tab 30 mg................................................ 20mirtazapine tab 45 mg................................................ 20mirtazapine tab 7.5 mg............................................... 19misoprostol tab 100 mcg............................................ 72misoprostol tab 200 mcg............................................ 72mitomycin for iv soln 20 mg....................................... 31mitomycin for iv soln 40 mg....................................... 31mitomycin for iv soln 5 mg..........................................31mitoxantrone hcl inj conc 20 mg/10ml (2 mg/

ml)................................................................................31mitoxantrone hcl inj conc 25 mg/12.5ml (2 mg/

ml)................................................................................31mitoxantrone hcl inj conc 30 mg/15ml (2 mg/

ml)................................................................................31M-M-R II........................................................................ 85modafinil tab 100 mg...................................................96modafinil tab 200 mg...................................................96moexipril hcl tab 15 mg...............................................60moexipril hcl tab 7.5 mg..............................................60moexipril-hydrochlorothiazide tab 15-12.5

mg................................................................................60moexipril-hydrochlorothiazide tab 15-25

mg................................................................................60moexipril-hydrochlorothiazide tab 7.5-12.5

mg................................................................................60mometasone furoate cream 0.1%............................. 68mometasone furoate nasal susp 50 mcg/

act................................................................................94mometasone furoate oint 0.1%..................................68mometasone furoate solution 0.1%

(lotion).........................................................................68montelukast sodium chew tab 4 mg..........................94montelukast sodium chew tab 5 mg..........................94montelukast sodium oral granules packet 4

mg................................................................................94montelukast sodium tab 10 mg..................................94MORPHINE SULFATE.................................................. 3MORPHINE SULFATE.................................................. 3morphine sulfate inj pf 0.5 mg/ml.................................3morphine sulfate inj pf 1 mg/ml....................................3morphine sulfate oral soln 100 mg/5ml (20 mg/

ml)..................................................................................3morphine sulfate oral soln 10 mg/5ml......................... 3morphine sulfate oral soln 20 mg/5ml......................... 3morphine sulfate tab er 100 mg...................................3morphine sulfate tab er 15 mg..................................... 3morphine sulfate tab er 200 mg...................................3morphine sulfate tab er 30 mg..................................... 3morphine sulfate tab er 60 mg..................................... 3MOVIPREP................................................................... 72MOXEZA........................................................................90

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121

moxifloxacin hcl 400 mg/250ml in sodium chloride0.8% inj.......................................................................11

moxifloxacin hcl ophth soln 0.5%.............................. 90moxifloxacin hcl tab 400 mg.......................................11MOZOBIL...................................................................... 52MULTAQ........................................................................ 60mupirocin oint 2%........................................................ 68MUSTARGEN............................................................... 31MYALEPT...................................................................... 72MYCAMINE...................................................................23MYCAMINE...................................................................23mycophenolate mofetil cap 250 mg...........................85mycophenolate mofetil for oral susp 200 mg/

ml.................................................................................85mycophenolate mofetil hcl for iv soln 500

mg................................................................................85mycophenolate mofetil tab 500 mg........................... 85mycophenolate sodium tab dr 180 mg......................85mycophenolate sodium tab dr 360 mg......................85MYLOTARG.................................................................. 31Nnabumetone tab 500 mg...............................................3nabumetone tab 750 mg...............................................3nadolol tab 20 mg........................................................60nadolol tab 40 mg........................................................60nadolol tab 80 mg........................................................60NAFCILLIN SODIUM...................................................11NAFCILLIN SODIUM...................................................11nafcillin sodium for inj 10 gm......................................11nafcillin sodium for inj 1 gm........................................11nafcillin sodium for inj 2 gm........................................11NAGLAZYME................................................................74NALOXONE HCL........................................................... 5NALOXONE HCL........................................................... 5naloxone hcl inj 0.4 mg/ml............................................5naloxone hcl inj 4 mg/10ml...........................................5naltrexone hcl tab 50 mg.............................................. 5naproxen sodium tab 275 mg.......................................3naproxen sodium tab 550 mg.......................................3naproxen susp 125 mg/5ml.......................................... 3naproxen tab 250 mg.................................................... 3naproxen tab 375 mg.................................................... 3naproxen tab 500 mg.................................................... 3naproxen tab ec 375 mg...............................................3naproxen tab ec 500 mg...............................................3naratriptan hcl tab 1 mg..............................................24naratriptan hcl tab 2.5 mg...........................................24NARCAN..........................................................................5NATACYN......................................................................90nateglinide tab 120 mg............................................... 49nateglinide tab 60 mg..................................................49

NATPARA...................................................................... 88NATPARA...................................................................... 88NATPARA...................................................................... 88NATPARA...................................................................... 88NEBUPENT...................................................................35NEFAZODONE HCL....................................................20NEFAZODONE HCL....................................................20NEFAZODONE HCL....................................................20nefazodone hcl tab 250 mg........................................20nefazodone hcl tab 50 mg..........................................20neomycin-bacitrac zn-polymyx

5(3.5)mg-400unt-10000unt op oin..........................90neomycin-polymy-gramicid op sol

1.75-10000-0.025mg-unt-mg/ml............................. 90neomycin-polymyxin b gu irrigation

soln..............................................................................11neomycin-polymyxin-dexamethasone ophth oint

0.1%............................................................................90neomycin-polymyxin-dexamethasone ophth susp

0.1%............................................................................90neomycin-polymyxin-hc otic soln 1%........................ 91neomycin-polymyxin-hc otic susp 3.5 mg/ml-10000

unit/ml-1%.................................................................. 91neomycin sulfate tab 500 mg.....................................11NERLYNX......................................................................31NEULASTA....................................................................52NEULASTA ONPRO KIT............................................ 52NEUPRO....................................................................... 36NEUPRO....................................................................... 36NEUPRO....................................................................... 36NEUPRO....................................................................... 36NEUPRO....................................................................... 36NEUPRO....................................................................... 36NEVIRAPINE................................................................ 43nevirapine tab 200 mg................................................ 43nevirapine tab er 24hr 100 mg...................................43nevirapine tab er 24hr 400 mg...................................43NEXAVAR......................................................................31NEXIUM.........................................................................72NEXIUM.........................................................................72NEXIUM.........................................................................72NEXIUM.........................................................................72NEXIUM.........................................................................72niacin tab er 1000 mg................................................. 60niacin tab er 500 mg................................................... 60niacin tab er 750 mg................................................... 60nicardipine hcl cap 20 mg...........................................60nicardipine hcl cap 30 mg...........................................60NICOTROL INHALER................................................... 5NICOTROL NS............................................................... 5nifedipine tab er 24hr 30 mg...................................... 60nifedipine tab er 24hr 60 mg...................................... 60

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nifedipine tab er 24hr 90 mg...................................... 60nifedipine tab er 24hr osmotic release 30

mg................................................................................60nifedipine tab er 24hr osmotic release 60

mg................................................................................60nifedipine tab er 24hr osmotic release 90

mg................................................................................60nilutamide tab 150 mg.................................................31NINLARO.......................................................................31NINLARO.......................................................................31NINLARO.......................................................................31NIPENT..........................................................................31NISOLDIPINE ER........................................................ 60nisoldipine tab er 24hr 17 mg.................................... 60nisoldipine tab er 24hr 34 mg.................................... 60nisoldipine tab er 24hr 8.5 mg................................... 60NITRO-BID....................................................................60nitrofurantoin macrocrystalline cap 100

mg................................................................................11nitrofurantoin macrocrystalline cap 50

mg................................................................................11nitrofurantoin monohydrate macrocrystalline cap 100

mg................................................................................11nitrofurantoin susp 25 mg/5ml....................................11nitroglycerin sl tab 0.3 mg.......................................... 60nitroglycerin sl tab 0.4 mg.......................................... 60nitroglycerin sl tab 0.6 mg.......................................... 60nitroglycerin td patch 24hr 0.1 mg/hr.........................60nitroglycerin td patch 24hr 0.2 mg/hr.........................60nitroglycerin td patch 24hr 0.4 mg/hr.........................60nitroglycerin td patch 24hr 0.6 mg/hr.........................60nitroglycerin tl soln 0.4 mg/spray (400 mcg/

spray)..........................................................................60nizatidine cap 150 mg.................................................72nizatidine cap 300 mg.................................................72norethindrone & ethinyl estradiol-fe chew tab 0.4

mg-35 mcg.................................................................79norethindrone & ethinyl estradiol-fe chew tab 0.8

mg-25 mcg.................................................................79norethindrone & ethinyl estradiol tab 0.4 mg-35

mcg..............................................................................79norethindrone & ethinyl estradiol tab 0.5 mg-35

mcg..............................................................................79norethindrone & ethinyl estradiol tab 1 mg-35

mcg..............................................................................79norethindrone ace & ethinyl estradiol-fe tab 1.5

mg-30 mcg.................................................................79norethindrone ace & ethinyl estradiol-fe tab 1 mg-20

mcg..............................................................................79norethindrone ace & ethinyl estradiol tab 1.5 mg-30

mcg..............................................................................79

norethindrone ace & ethinyl estradiol tab 1 mg-20mcg..............................................................................79

norethindrone ace-ethinyl estradiol-fe tab 1 mg-20mcg (24).....................................................................79

norethindrone acetate tab 5 mg.................................79norethindrone ac-ethinyl estrad-fe tab 1-20/1-30/1-35

mg-mcg.......................................................................79norethindrone-eth estradiol tab 0.5-35/0.75-35/1-35

mg-mcg.......................................................................79norethindrone-eth estradiol tab 0.5-35/1-35/0.5-35

mg-mcg.......................................................................79norethindrone tab 0.35 mg......................................... 79norgestimate & ethinyl estradiol tab 0.25 mg-35

mcg..............................................................................79norgestimate-eth estrad tab

0.18-25/0.215-25/0.25-25 mg-mcg.........................79norgestimate-eth estrad tab

0.18-35/0.215-35/0.25-35 mg-mcg.........................79norgestrel & ethinyl estradiol tab 0.3 mg-30

mcg..............................................................................79NORMOSOL-M IN D5W............................................. 70NORTHERA.................................................................. 60NORTHERA.................................................................. 61NORTHERA.................................................................. 61NORTRIPTYLINE HCL............................................... 20nortriptyline hcl cap 10 mg......................................... 20nortriptyline hcl cap 25 mg......................................... 20nortriptyline hcl cap 50 mg......................................... 20nortriptyline hcl cap 75 mg......................................... 20NORVIR.........................................................................43NORVIR.........................................................................43NORVIR.........................................................................43NOXAFIL....................................................................... 23NOXAFIL....................................................................... 23NOXAFIL....................................................................... 23NUCYNTA ER.................................................................3NUCYNTA ER.................................................................3NUCYNTA ER.................................................................3NUCYNTA ER.................................................................3NUCYNTA ER.................................................................3NUEDEXTA...................................................................65NULOJIX........................................................................85NUPLAZID.....................................................................38nystatin cream 100000 unit/gm..................................23nystatin oint 100000 unit/gm...................................... 23nystatin susp 100000 unit/ml......................................23nystatin tab 500000 unit..............................................23nystatin topical powder 100000 unit/

gm................................................................................23nystatin-triamcinolone cream 100000-0.1 unit/gm-

%..................................................................................68

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nystatin-triamcinolone oint 100000-0.1 unit/gm-%..................................................................................68

OOCALIVA....................................................................... 74OCALIVA....................................................................... 74octreotide acetate inj 1000 mcg/ml (1 mg/

ml)................................................................................81octreotide acetate inj 100 mcg/ml (0.1 mg/




ml)................................................................................81ODEFSEY..................................................................... 43ODOMZO...................................................................... 31OFEV............................................................................. 94OFEV............................................................................. 94ofloxacin ophth soln 0.3%...........................................90ofloxacin otic soln 0.3%.............................................. 91ofloxacin tab 400 mg...................................................12olanzapine for im inj 10 mg........................................ 39olanzapine orally disintegrating tab 10

mg................................................................................39olanzapine orally disintegrating tab 15



mg................................................................................39olanzapine tab 10 mg..................................................39olanzapine tab 15 mg..................................................39olanzapine tab 2.5 mg.................................................39olanzapine tab 20 mg..................................................39olanzapine tab 5 mg....................................................39olanzapine tab 7.5 mg.................................................39olopatadine hcl nasal soln 0.6%................................ 94olopatadine hcl ophth soln 0.1%................................90olopatadine hcl ophth soln 0.2%................................90OLYSIO..........................................................................43omega-3-acid ethyl esters cap 1 gm.........................61omeprazole cap delayed release 10

mg................................................................................72omeprazole cap delayed release 20

mg................................................................................72omeprazole cap delayed release 40

mg................................................................................72OMNITROPE................................................................ 77OMNITROPE................................................................ 77OMNITROPE................................................................ 77

ONCASPAR.................................................................. 31ondansetron hcl inj 40 mg/20ml (2 mg/

ml)................................................................................22ondansetron hcl inj 4 mg/2ml (2 mg/

ml)................................................................................21ondansetron hcl oral soln 4 mg/5ml.......................... 22ondansetron hcl tab 24 mg.........................................22ondansetron hcl tab 4 mg...........................................22ondansetron hcl tab 8 mg...........................................22ondansetron orally disintegrating tab 4

mg................................................................................22ondansetron orally disintegrating tab 8

mg................................................................................22ONFI...............................................................................15ONFI...............................................................................15ONFI...............................................................................15ONGLYZA......................................................................49ONGLYZA......................................................................49ONIVYDE...................................................................... 31OPDIVO.........................................................................31OPDIVO.........................................................................32OPDIVO.........................................................................32OPSUMIT...................................................................... 94ORACEA........................................................................68ORALAIR.......................................................................94ORENCIA...................................................................... 85ORENCIA...................................................................... 85ORENCIA...................................................................... 85ORENCIA...................................................................... 85ORENCIA CLICKJECT............................................... 86ORFADIN.......................................................................74ORFADIN.......................................................................74ORFADIN.......................................................................74ORFADIN.......................................................................74ORFADIN.......................................................................74ORKAMBI......................................................................94ORKAMBI......................................................................94oseltamivir phosphate cap 30 mg..............................43oseltamivir phosphate cap 45 mg..............................43oseltamivir phosphate cap 75 mg..............................43oseltamivir phosphate for susp 6 mg/

ml.................................................................................43OTEZLA.........................................................................86OTEZLA.........................................................................86oxaliplatin for iv inj 100 mg.........................................32oxaliplatin for iv inj 50 mg...........................................32oxaliplatin iv soln 100 mg/20ml..................................32oxaliplatin iv soln 50 mg/10ml....................................32oxandrolone tab 10 mg............................................... 79oxandrolone tab 2.5 mg..............................................79oxaprozin tab 600 mg....................................................3

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oxcarbazepine susp 300 mg/5ml (60 mg/ml)................................................................................15

oxcarbazepine tab 150 mg.........................................16oxcarbazepine tab 300 mg.........................................16oxcarbazepine tab 600 mg.........................................16oxybutynin chloride syrup 5 mg/5ml..........................75oxybutynin chloride tab 5 mg..................................... 75oxybutynin chloride tab er 24hr 10 mg......................75oxybutynin chloride tab er 24hr 15 mg......................75oxybutynin chloride tab er 24hr 5 mg........................75oxycodone-aspirin tab 4.8355-325 mg........................4oxycodone hcl tab 10 mg..............................................3oxycodone hcl tab 15 mg..............................................3oxycodone hcl tab 20 mg..............................................4oxycodone hcl tab 30 mg..............................................4oxycodone hcl tab 5 mg................................................3oxycodone w/ acetaminophen tab 10-325

mg..................................................................................4oxycodone w/ acetaminophen tab 2.5-325

mg..................................................................................4oxycodone w/ acetaminophen tab 5-325

mg..................................................................................4oxycodone w/ acetaminophen tab 7.5-325

mg..................................................................................4OXYCONTIN...................................................................4OXYCONTIN...................................................................4OXYCONTIN...................................................................4OXYCONTIN...................................................................4OXYCONTIN...................................................................4OXYCONTIN...................................................................4OXYCONTIN...................................................................4Ppaclitaxel iv conc 100 mg/16.7ml (6 mg/

ml)................................................................................32paclitaxel iv conc 300 mg/50ml (6 mg/

ml)................................................................................32paclitaxel iv conc 30 mg/5ml (6 mg/ml).....................32paliperidone tab er 24hr 1.5 mg.................................39paliperidone tab er 24hr 3 mg....................................39paliperidone tab er 24hr 6 mg....................................39paliperidone tab er 24hr 9 mg....................................39PANRETIN.....................................................................32pantoprazole sodium ec tab 20 mg........................... 72pantoprazole sodium ec tab 40 mg........................... 72pantoprazole sodium for iv soln 40 mg..................... 72paricalcitol cap 1 mcg................................................. 88paricalcitol cap 2 mcg................................................. 88paricalcitol cap 4 mcg................................................. 88paricalcitol iv soln 2 mcg/ml....................................... 88paricalcitol iv soln 5 mcg/ml....................................... 88paromomycin sulfate cap 250 mg..............................12

paroxetine hcl tab 10 mg............................................ 20paroxetine hcl tab 20 mg............................................ 20paroxetine hcl tab 30 mg............................................ 20paroxetine hcl tab 40 mg............................................ 20PASER........................................................................... 25PAXIL............................................................................. 20PAZEO........................................................................... 90PEDIARIX......................................................................86PEDVAX HIB................................................................ 86peg 3350-kcl-na bicarb-nacl-na sulfate for soln 236

gm................................................................................73peg 3350-kcl-na bicarb-nacl-na sulfate for soln 240

gm................................................................................73peg 3350-kcl-sod bicarb-nacl for soln 420

gm................................................................................72PEGANONE..................................................................16PEGASYS..................................................................... 43PEGASYS..................................................................... 43PEGASYS PROCLICK................................................43PEGASYS PROCLICK................................................43penicillin g potassium for inj 20000000

unit...............................................................................12penicillin g potassium for inj 5000000

unit...............................................................................12PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 12PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 12PENICILLIN G POTASSIUM IN

DEXTROSE............................................................... 12PENICILLIN G SODIUM............................................. 12penicillin v potassium for soln 125

mg/5ml........................................................................ 12penicillin v potassium for soln 250

mg/5ml........................................................................ 12penicillin v potassium tab 250 mg............................. 12penicillin v potassium tab 500 mg............................. 12PENTACEL....................................................................86PENTAM 300................................................................35PENTASA...................................................................... 88PENTASA...................................................................... 88pentoxifylline tab er 400 mg....................................... 61perindopril erbumine tab 2 mg................................... 61perindopril erbumine tab 4 mg................................... 61perindopril erbumine tab 8 mg................................... 61PERJETA.......................................................................32permethrin cream 5%..................................................35perphenazine tab 16 mg.............................................22perphenazine tab 2 mg............................................... 22perphenazine tab 4 mg............................................... 22perphenazine tab 8 mg............................................... 22phenelzine sulfate tab 15 mg.....................................20

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PHENOBARBITAL....................................................... 16PHENOBARBITAL....................................................... 16PHENOBARBITAL....................................................... 16PHENOBARBITAL....................................................... 16phenobarbital elixir 20 mg/5ml...................................16PHENOBARBITAL SODIUM...................................... 16PHENOBARBITAL SODIUM...................................... 16phenobarbital tab 16.2 mg..........................................16phenobarbital tab 32.4 mg..........................................16phenobarbital tab 64.8 mg..........................................16phenobarbital tab 97.2 mg..........................................16phenoxybenzamine hcl cap 10 mg............................61phenytoin chew tab 50 mg......................................... 16phenytoin sodium extended cap 100

mg................................................................................16phenytoin sodium extended cap 200

mg................................................................................16phenytoin sodium extended cap 300

mg................................................................................16phenytoin susp 125 mg/5ml....................................... 16PHOSLYRA...................................................................70PHOSPHOLINE IODIDE.............................................90PICATO..........................................................................68PICATO..........................................................................68pilocarpine hcl ophth soln 1%.................................... 90pilocarpine hcl ophth soln 2%.................................... 90pilocarpine hcl ophth soln 4%.................................... 90pilocarpine hcl tab 5 mg..............................................66pilocarpine hcl tab 7.5 mg.......................................... 66pimozide tab 1 mg....................................................... 39pimozide tab 2 mg....................................................... 39pindolol tab 10 mg....................................................... 61pindolol tab 5 mg......................................................... 61pioglitazone hcl-glimepiride tab 30-2

mg................................................................................49pioglitazone hcl-glimepiride tab 30-4

mg................................................................................49pioglitazone hcl-metformin hcl tab 15-500

mg................................................................................49pioglitazone hcl-metformin hcl tab 15-850

mg................................................................................49pioglitazone hcl tab 15 mg..........................................49pioglitazone hcl tab 30 mg..........................................49pioglitazone hcl tab 45 mg..........................................49piperacillin sod-tazobactam na for inj 3.375 gm

(3-0.375 gm)..............................................................12piperacillin sod-tazobactam sod for inj 2.25 gm

(2-0.25 gm)................................................................ 12piperacillin sod-tazobactam sod for inj 4.5 gm (4-0.5

gm).............................................................................. 12piroxicam cap 10 mg..................................................... 4piroxicam cap 20 mg..................................................... 4

PLEGRIDY.................................................................... 65PLEGRIDY.................................................................... 65PLEGRIDY STARTER PACK..................................... 65PLEGRIDY STARTER PACK..................................... 65podofilox soln 0.5%..................................................... 68polyethylene glycol 3350 oral packet........................ 73polyethylene glycol 3350 oral powder.......................73polymyxin b-trimethoprim ophth soln 10000 unit/

ml-0.1%...................................................................... 90POMALYST...................................................................32POMALYST...................................................................32POMALYST...................................................................32POMALYST...................................................................32PORTRAZZA................................................................ 32POTASSIUM CHLORIDE/DEXTROSE.....................70POTASSIUM CHLORIDE/DEXTROSE/LACTATED

RINGERS...................................................................70POTASSIUM CHLORIDE/DEXTROSE/LACTATED

RINGERS...................................................................70potassium chloride 20 meq/l (0.15%) in dextrose 5%

inj................................................................................. 70potassium chloride cap er 10 meq............................ 70potassium chloride cap er 8 meq...............................70potassium chloride inj 2 meq/ml................................ 70potassium chloride microencapsulated crys er tab 10

meq............................................................................. 70potassium chloride microencapsulated crys er tab 20

meq............................................................................. 70potassium chloride oral soln 10% (20

meq/15ml).................................................................. 70potassium chloride tab er 10 meq............................. 70potassium chloride tab er 8 meq (600

mg).............................................................................. 70potassium citrate tab er 10 meq (1080



mg).............................................................................. 70PRADAXA..................................................................... 52PRADAXA..................................................................... 52PRADAXA..................................................................... 52PRALUENT................................................................... 61PRALUENT................................................................... 61pramipexole dihydrochloride tab 0.125

mg................................................................................36pramipexole dihydrochloride tab 0.25



mg................................................................................36

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126

pramipexole dihydrochloride tab 1.5mg................................................................................36

pramipexole dihydrochloride tab 1 mg...................... 36prasugrel hcl tab 10 mg..............................................52prasugrel hcl tab 5 mg................................................ 52pravastatin sodium tab 10 mg....................................61pravastatin sodium tab 20 mg....................................61pravastatin sodium tab 40 mg....................................61pravastatin sodium tab 80 mg....................................61prazosin hcl cap 1 mg.................................................61prazosin hcl cap 2 mg.................................................61prazosin hcl cap 5 mg.................................................61prednicarbate cream 0.1%......................................... 68prednicarbate oint 0.1%..............................................68prednisolone acetate ophth susp 1%........................90prednisolone sod phosphate oral soln 15

mg/5ml........................................................................ 76prednisolone sod phosph oral soln 6.7 mg/5ml (5

mg/5ml base).............................................................76prednisolone syrup 15 mg/5ml...................................76PREDNISONE.............................................................. 76PREDNISONE.............................................................. 76PREDNISONE.............................................................. 76PREDNISONE.............................................................. 76PREDNISONE.............................................................. 76PREDNISONE.............................................................. 76prednisone tab 10 mg................................................. 76prednisone tab 1 mg................................................... 76prednisone tab 2.5 mg................................................ 76prednisone tab 20 mg................................................. 76prednisone tab 5 mg................................................... 76PREMARIN................................................................... 79PREMARIN................................................................... 79PREMARIN................................................................... 79PREMARIN................................................................... 79PREMARIN................................................................... 79PREMARIN................................................................... 79PREMPHASE............................................................... 79PREMPRO.................................................................... 79PREMPRO.................................................................... 79PREMPRO.................................................................... 79PREMPRO.................................................................... 79PREZCOBIX................................................................. 43PREZISTA..................................................................... 44PREZISTA..................................................................... 44PREZISTA..................................................................... 44PREZISTA..................................................................... 44PREZISTA..................................................................... 44PRIFTIN.........................................................................25PRIMAQUINE PHOSPHATE......................................35primidone tab 250 mg................................................. 16primidone tab 50 mg................................................... 16

PRISTIQ........................................................................ 20PRISTIQ........................................................................ 20PRISTIQ........................................................................ 20PROAIR HFA................................................................94PROAIR RESPICLICK................................................ 94probenecid tab 500 mg............................................... 24prochlorperazine edisylate inj 5 mg/ml......................22prochlorperazine maleate tab 10 mg.........................22prochlorperazine maleate tab 5 mg...........................22prochlorperazine suppos 25 mg................................ 22PROCRIT...................................................................... 52PROCRIT...................................................................... 52PROCRIT...................................................................... 52PROCRIT...................................................................... 52PROCRIT...................................................................... 52PROCRIT...................................................................... 52PROGLYCEM............................................................... 49PROGRAF.....................................................................86PROLASTIN-C..............................................................74PROLASTIN-C..............................................................74PROLENSA...................................................................90PROLEUKIN................................................................. 32PROLIA..........................................................................88PROMACTA.................................................................. 52PROMACTA.................................................................. 52PROMACTA.................................................................. 52PROMACTA.................................................................. 52promethazine hcl suppos 12.5 mg............................ 22promethazine hcl suppos 25 mg................................22promethazine hcl syrup 6.25 mg/5ml........................ 22promethazine hcl tab 12.5 mg....................................22promethazine hcl tab 25 mg.......................................22promethazine hcl tab 50 mg.......................................22propafenone hcl cap er 12hr 225 mg........................ 61propafenone hcl cap er 12hr 325 mg........................ 61propafenone hcl cap er 12hr 425 mg........................ 61propafenone hcl tab 150 mg...................................... 61propafenone hcl tab 225 mg...................................... 61propafenone hcl tab 300 mg...................................... 61propranolol hcl cap er 24hr 120 mg.......................... 61propranolol hcl cap er 24hr 160 mg.......................... 61propranolol hcl cap er 24hr 60 mg.............................61propranolol hcl cap er 24hr 80 mg.............................61propranolol hcl inj 1 mg/ml......................................... 61propranolol hcl tab 10 mg...........................................61propranolol hcl tab 20 mg...........................................61propranolol hcl tab 40 mg...........................................61propranolol hcl tab 60 mg...........................................61propranolol hcl tab 80 mg...........................................61propylthiouracil tab 50 mg.......................................... 82PROQUAD.................................................................... 86protriptyline hcl tab 10 mg.......................................... 20

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protriptyline hcl tab 5 mg............................................ 20PULMOZYME............................................................... 94PURIXAN.......................................................................32PYLERA.........................................................................73pyrazinamide tab 500 mg........................................... 25pyridostigmine bromide tab 60 mg............................ 24pyridostigmine bromide tab er 180 mg......................24QQUADRACEL................................................................86quetiapine fumarate tab 100 mg................................39quetiapine fumarate tab 200 mg................................39quetiapine fumarate tab 25 mg..................................39quetiapine fumarate tab 300 mg................................39quetiapine fumarate tab 400 mg................................39quetiapine fumarate tab 50 mg..................................39quetiapine fumarate tab er 24hr 150

mg................................................................................39quetiapine fumarate tab er 24hr 200



mg................................................................................39quetiapine fumarate tab er 24hr 50 mg.....................39quinapril hcl tab 10 mg............................................... 61quinapril hcl tab 20 mg............................................... 62quinapril hcl tab 40 mg............................................... 62quinapril hcl tab 5 mg..................................................61quinapril-hydrochlorothiazide tab 10-12.5

mg................................................................................62quinapril-hydrochlorothiazide tab 20-12.5

mg................................................................................62quinapril-hydrochlorothiazide tab 20-25

mg................................................................................62quinidine gluconate tab er 324 mg............................ 62QUINIDINE SULFATE................................................. 62QUINIDINE SULFATE................................................. 62QVAR............................................................................. 94QVAR............................................................................. 94RRABAVERT................................................................... 86rabeprazole sodium ec tab 20 mg............................. 73raloxifene hcl tab 60 mg............................................. 79ramipril cap 1.25 mg....................................................62ramipril cap 10 mg.......................................................62ramipril cap 2.5 mg......................................................62ramipril cap 5 mg.........................................................62RANEXA........................................................................62RANEXA........................................................................62ranitidine hcl cap 150 mg........................................... 73ranitidine hcl cap 300 mg........................................... 73

ranitidine hcl syrup 15 mg/ml (75mg/5ml).......................................................................73

ranitidine hcl tab 150 mg............................................ 73ranitidine hcl tab 300 mg............................................ 73RAPAFLO...................................................................... 75RAPAFLO...................................................................... 75RAPAMUNE.................................................................. 86rasagiline mesylate tab 0.5 mg.................................. 36rasagiline mesylate tab 1 mg..................................... 36REBETOL......................................................................44RECOMBIVAX HB....................................................... 86RECOMBIVAX HB....................................................... 86RECOMBIVAX HB....................................................... 86REGRANEX.................................................................. 68RELISTOR.....................................................................73RELISTOR.....................................................................73RELISTOR.....................................................................73REMICADE................................................................... 86REMODULIN................................................................ 94REMODULIN................................................................ 94REMODULIN................................................................ 94REMODULIN................................................................ 94RENVELA......................................................................70repaglinide tab 0.5 mg................................................ 49repaglinide tab 1 mg....................................................49repaglinide tab 2 mg....................................................49REPATHA...................................................................... 62REPATHA PUSHTRONEX SYSTEM........................62REPATHA SURECLICK.............................................. 62RESCRIPTOR.............................................................. 44RESCRIPTOR.............................................................. 44RESTASIS.....................................................................90RESTASIS MULTIDOSE.............................................90RETROVIR IV INFUSION...........................................44REVLIMID......................................................................32REVLIMID......................................................................32REVLIMID......................................................................32REVLIMID......................................................................32REVLIMID......................................................................32REVLIMID......................................................................32REXULTI........................................................................39REXULTI........................................................................39REXULTI........................................................................39REXULTI........................................................................39REXULTI........................................................................39REXULTI........................................................................39REYATAZ.......................................................................44REYATAZ.......................................................................44REYATAZ.......................................................................44REYATAZ.......................................................................44RIBASPHERE...............................................................44RIBASPHERE...............................................................44

2018

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RIBASPHERE RIBAPAK.............................................44RIBASPHERE RIBAPAK.............................................44ribavirin cap 200 mg....................................................44ribavirin for inhal soln 6 gm........................................ 94ribavirin tab 200 mg.....................................................44RIDAURA...................................................................... 86rifabutin cap 150 mg....................................................25rifampin cap 150 mg....................................................25rifampin cap 300 mg....................................................25rifampin for inj 600 mg................................................ 25riluzole tab 50 mg........................................................ 65rimantadine hydrochloride tab 100 mg......................44risedronate sodium tab 150 mg................................. 89risedronate sodium tab 30 mg................................... 88risedronate sodium tab 35 mg................................... 89risedronate sodium tab 5 mg..................................... 88risedronate sodium tab delayed release 35

mg................................................................................88RISPERDAL CONSTA................................................ 39RISPERDAL CONSTA................................................ 39RISPERDAL CONSTA................................................ 39RISPERDAL CONSTA................................................ 39risperidone orally disintegrating tab 0.25

mg................................................................................40risperidone orally disintegrating tab 0.5

mg................................................................................40risperidone orally disintegrating tab 1




mg................................................................................40risperidone soln 1 mg/ml............................................ 40risperidone tab 0.25 mg..............................................40risperidone tab 0.5 mg................................................ 40risperidone tab 1 mg................................................... 40risperidone tab 2 mg................................................... 40risperidone tab 3 mg................................................... 40risperidone tab 4 mg................................................... 40RITUXAN.......................................................................32RITUXAN.......................................................................32RITUXAN HYCELA......................................................32RITUXAN HYCELA......................................................32rivastigmine tartrate cap 1.5 mg................................ 17rivastigmine tartrate cap 3 mg....................................17rivastigmine tartrate cap 4.5 mg................................ 17rivastigmine tartrate cap 6 mg....................................17rivastigmine td patch 24hr 13.3

mg/24hr...................................................................... 17rivastigmine td patch 24hr 4.6 mg/24hr.....................17

rivastigmine td patch 24hr 9.5 mg/24hr.....................17rizatriptan benzoate oral disintegrating tab 10

mg................................................................................24rizatriptan benzoate oral disintegrating tab 5

mg................................................................................24rizatriptan benzoate tab 10 mg.................................. 24rizatriptan benzoate tab 5 mg.................................... 24ropinirole hydrochloride tab 0.25 mg.........................36ropinirole hydrochloride tab 0.5 mg...........................36ropinirole hydrochloride tab 1 mg.............................. 36ropinirole hydrochloride tab 2 mg.............................. 36ropinirole hydrochloride tab 3 mg.............................. 36ropinirole hydrochloride tab 4 mg.............................. 36ropinirole hydrochloride tab 5 mg.............................. 36rosuvastatin calcium tab 10 mg................................. 62rosuvastatin calcium tab 20 mg................................. 62rosuvastatin calcium tab 40 mg................................. 62rosuvastatin calcium tab 5 mg................................... 62ROTARIX.......................................................................86ROTATEQ......................................................................86RUBRACA.....................................................................32RUBRACA.....................................................................32RUBRACA.....................................................................32RYDAPT........................................................................ 32SSABRIL.......................................................................... 16SABRIL.......................................................................... 16SAMSCA........................................................................70SAMSCA........................................................................71SANDIMMUNE............................................................. 86SANTYL.........................................................................68SAPHRIS.......................................................................40SAPHRIS.......................................................................40SAPHRIS.......................................................................40selegiline hcl cap 5 mg............................................... 36selegiline hcl tab 5 mg................................................ 36selenium sulfide lotion 2.5%.......................................68SELZENTRY.................................................................44SELZENTRY.................................................................44SELZENTRY.................................................................44SELZENTRY.................................................................44SELZENTRY.................................................................44SENSIPAR.....................................................................89SENSIPAR.....................................................................89SENSIPAR.....................................................................89SEREVENT DISKUS...................................................94sertraline hcl oral conc 20 mg/ml...............................20sertraline hcl tab 100 mg............................................ 20sertraline hcl tab 25 mg.............................................. 20sertraline hcl tab 50 mg.............................................. 20sevelamer carbonate packet 0.8 gm......................... 71

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sevelamer carbonate packet 2.4 gm......................... 71sevelamer carbonate tab 800 mg..............................71SHINGRIX..................................................................... 86SIGNIFOR..................................................................... 81SIGNIFOR..................................................................... 81SIGNIFOR..................................................................... 81SIGNIFOR LAR............................................................81SIGNIFOR LAR............................................................81SIGNIFOR LAR............................................................81sildenafil citrate tab 20 mg..........................................94SILENOR.......................................................................96SILENOR.......................................................................96silver sulfadiazine cream 1%......................................68SIMBRINZA...................................................................90SIMULECT.................................................................... 86SIMULECT.................................................................... 86simvastatin tab 10 mg.................................................62simvastatin tab 20 mg.................................................62simvastatin tab 40 mg.................................................62simvastatin tab 5 mg................................................... 62simvastatin tab 80 mg.................................................62sirolimus tab 0.5 mg.................................................... 86sirolimus tab 1 mg....................................................... 86sirolimus tab 2 mg....................................................... 86SIRTURO.......................................................................25SIVEXTRO.................................................................... 12SIVEXTRO.................................................................... 12sodium chloride inj 0.45%...........................................71sodium chloride irrigation soln 0.9%......................... 71sodium chloride iv soln 0.9%..................................... 71sodium phenylbutyrate oral powder 3 gm/

teaspoonful.................................................................74sodium phenylbutyrate tab 500 mg........................... 74sodium polystyrene sulfonate oral susp 15

gm/60ml......................................................................71sodium polystyrene sulfonate powder.......................71sodium polystyrene sulfonate rectal susp 30

gm/120ml....................................................................71SOLTAMOX...................................................................32SOMATULINE DEPOT................................................82SOMATULINE DEPOT................................................82SOMATULINE DEPOT................................................82SOMAVERT.................................................................. 82SOMAVERT.................................................................. 82SOMAVERT.................................................................. 82SOMAVERT.................................................................. 82SOMAVERT.................................................................. 82SOOLANTRA................................................................68sotalol hcl (afib/afl) tab 120 mg..................................62sotalol hcl (afib/afl) tab 160 mg..................................62sotalol hcl (afib/afl) tab 80 mg....................................62sotalol hcl tab 120 mg.................................................62

sotalol hcl tab 160 mg.................................................62sotalol hcl tab 240 mg.................................................62sotalol hcl tab 80 mg...................................................62SOVALDI....................................................................... 44SPIRIVA HANDIHALER.............................................. 94SPIRIVA RESPIMAT....................................................94SPIRIVA RESPIMAT....................................................94spironolactone & hydrochlorothiazide tab 25-25

mg................................................................................62spironolactone tab 100 mg.........................................63spironolactone tab 25 mg........................................... 62spironolactone tab 50 mg........................................... 62SPRITAM.......................................................................16SPRITAM.......................................................................16SPRITAM.......................................................................16SPRITAM.......................................................................16SPRYCEL......................................................................32SPRYCEL......................................................................32SPRYCEL......................................................................32SPRYCEL......................................................................33SPRYCEL......................................................................33SPRYCEL......................................................................33STAMARIL.....................................................................86stavudine cap 15 mg...................................................44stavudine cap 20 mg...................................................44stavudine cap 30 mg...................................................44stavudine cap 40 mg...................................................44STELARA...................................................................... 86STELARA...................................................................... 86STELARA...................................................................... 86STELARA...................................................................... 86STIMATE....................................................................... 77STIOLTO RESPIMAT.................................................. 94STIVARGA.....................................................................33STRENSIQ....................................................................74STRENSIQ....................................................................74STRENSIQ....................................................................74STRENSIQ....................................................................74STREPTOMYCIN SULFATE...................................... 12STRIBILD...................................................................... 44SUBOXONE....................................................................5SUBOXONE....................................................................5SUBOXONE....................................................................5SUBOXONE....................................................................5sucralfate tab 1 gm......................................................73sulfacetamide sodium lotion 10%.............................. 12sulfacetamide sodium ophth soln 10%..................... 90sulfacetamide sodium-prednisolone ophth soln

10-0.23(0.25)%..........................................................90SULFADIAZINE............................................................ 12sulfamethoxazole-trimethoprim iv soln 400-80

mg/5ml........................................................................ 12

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sulfamethoxazole-trimethoprim susp 200-40mg/5ml........................................................................ 12

sulfamethoxazole-trimethoprim tab 400-80mg................................................................................12

sulfamethoxazole-trimethoprim tab 800-160mg................................................................................12

sulfasalazine tab 500 mg............................................88sulfasalazine tab delayed release 500

mg................................................................................88sulindac tab 150 mg...................................................... 4sulindac tab 200 mg...................................................... 4sumatriptan nasal spray 20 mg/act........................... 24sumatriptan nasal spray 5 mg/act..............................24sumatriptan succinate inj 6 mg/0.5ml........................24sumatriptan succinate solution auto-injector 4

mg/0.5ml.....................................................................24sumatriptan succinate solution auto-injector 6

mg/0.5ml.....................................................................24sumatriptan succinate solution cartridge 4

mg/0.5ml.....................................................................24sumatriptan succinate solution cartridge 6

mg/0.5ml.....................................................................24sumatriptan succinate tab 100 mg............................ 24sumatriptan succinate tab 25 mg...............................24sumatriptan succinate tab 50 mg...............................24SUPRAX........................................................................12SUPRAX........................................................................12SUPRAX........................................................................12SUPREP BOWEL PREP KIT.....................................73SUSTIVA........................................................................44SUSTIVA........................................................................44SUSTIVA........................................................................44SUTENT........................................................................ 33SUTENT........................................................................ 33SUTENT........................................................................ 33SUTENT........................................................................ 33SYLATRON................................................................... 44SYLATRON................................................................... 44SYLATRON................................................................... 44SYLVANT.......................................................................86SYLVANT.......................................................................87SYMBICORT.................................................................94SYMBICORT.................................................................95SYMLINPEN 120......................................................... 49SYMLINPEN 60............................................................49SYNAGIS.......................................................................87SYNAGIS.......................................................................87SYNAREL......................................................................82SYNERCID....................................................................12SYNJARDY................................................................... 49SYNJARDY................................................................... 50SYNJARDY................................................................... 50

SYNJARDY................................................................... 50SYNJARDY XR............................................................ 50SYNJARDY XR............................................................ 50SYNJARDY XR............................................................ 50SYNJARDY XR............................................................ 50SYNRIBO...................................................................... 33SYNTHROID.................................................................80SYNTHROID.................................................................80SYNTHROID.................................................................80SYNTHROID.................................................................80SYNTHROID.................................................................80SYNTHROID.................................................................80SYNTHROID.................................................................80SYNTHROID.................................................................80SYNTHROID.................................................................80SYNTHROID.................................................................80SYNTHROID.................................................................80SYNTHROID.................................................................80SYPRINE.......................................................................71TTABLOID........................................................................33tacrolimus cap 0.5 mg.................................................87tacrolimus cap 1 mg....................................................87tacrolimus cap 5 mg....................................................87tacrolimus oint 0.03%..................................................68tacrolimus oint 0.1%.................................................... 68TAFINLAR..................................................................... 33TAFINLAR..................................................................... 33TAGRISSO.................................................................... 33TAGRISSO.................................................................... 33TAMIFLU........................................................................44tamoxifen citrate tab 10 mg........................................33tamoxifen citrate tab 20 mg........................................33tamsulosin hcl cap 0.4 mg..........................................75TARCEVA...................................................................... 33TARCEVA...................................................................... 33TARCEVA...................................................................... 33TARGRETIN..................................................................33TASIGNA....................................................................... 33TASIGNA....................................................................... 33tazarotene cream 0.1%...............................................68TAZORAC......................................................................68TAZORAC......................................................................68TAZORAC......................................................................68TECENTRIQ................................................................. 33TECFIDERA..................................................................65TECFIDERA..................................................................65TECFIDERA STARTER PACK...................................65TECHNIVIE................................................................... 45TEFLARO......................................................................12TEFLARO......................................................................12TEKTURNA...................................................................63

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TEKTURNA...................................................................63TEKTURNA HCT......................................................... 63TEKTURNA HCT......................................................... 63TEKTURNA HCT......................................................... 63TEKTURNA HCT......................................................... 63telmisartan-hydrochlorothiazide tab 40-12.5

mg................................................................................63telmisartan-hydrochlorothiazide tab 80-12.5

mg................................................................................63telmisartan-hydrochlorothiazide tab 80-25

mg................................................................................63telmisartan tab 20 mg................................................. 63telmisartan tab 40 mg................................................. 63telmisartan tab 80 mg................................................. 63temazepam cap 15 mg............................................... 96temazepam cap 30 mg............................................... 96TEMODAR.................................................................... 33TENCON..........................................................................4TENIVAC....................................................................... 87tenofovir disoproxil fumarate tab 300

mg................................................................................45terazosin hcl cap 10 mg..............................................63terazosin hcl cap 1 mg................................................63terazosin hcl cap 2 mg................................................63terazosin hcl cap 5 mg................................................63terbinafine hcl tab 250 mg..........................................23terbutaline sulfate tab 2.5 mg.....................................95terbutaline sulfate tab 5 mg........................................95terconazole vaginal cream 0.4%................................23terconazole vaginal cream 0.8%................................23terconazole vaginal suppos 80 mg............................23testosterone cypionate im inj in oil 100 mg/

ml.................................................................................79testosterone cypionate im inj in oil 200 mg/

ml.................................................................................79testosterone enanthate im inj in oil 200 mg/

ml.................................................................................80testosterone td gel 12.5 mg/act (1%)........................ 80testosterone td gel 25 mg/2.5gm (1%)......................80testosterone td gel 50 mg/5gm (1%).........................80testosterone td soln 30 mg/act...................................80TETANUS/DIPHTHERIA TOXOIDS

ADSORBED...............................................................87tetrabenazine tab 12.5 mg..........................................65tetrabenazine tab 25 mg.............................................66tetracycline hcl cap 250 mg........................................12tetracycline hcl cap 500 mg........................................12THALOMID....................................................................33THALOMID....................................................................33THALOMID....................................................................33THALOMID....................................................................33theophylline tab er 12hr 100 mg................................95

theophylline tab er 12hr 200 mg................................95theophylline tab er 12hr 300 mg................................95theophylline tab er 12hr 450 mg................................95theophylline tab er 24hr 400 mg................................95theophylline tab er 24hr 600 mg................................95thioridazine hcl tab 100 mg........................................ 40thioridazine hcl tab 10 mg.......................................... 40thioridazine hcl tab 25 mg.......................................... 40thioridazine hcl tab 50 mg.......................................... 40thiotepa for inj 15 mg.................................................. 33thiothixene cap 10 mg.................................................40thiothixene cap 1 mg...................................................40thiothixene cap 2 mg...................................................40thiothixene cap 5 mg...................................................40THYMOGLOBULIN......................................................87tiagabine hcl tab 2 mg.................................................16tiagabine hcl tab 4 mg.................................................16tigecycline for iv soln 50 mg.......................................12TIMOLOL MALEATE................................................... 63TIMOLOL MALEATE................................................... 63TIMOLOL MALEATE................................................... 63timolol maleate ophth gel forming soln

0.25%..........................................................................90timolol maleate ophth gel forming soln

0.5%............................................................................90timolol maleate ophth soln 0.25%..............................90timolol maleate ophth soln 0.5%................................91timolol maleate ophth soln 0.5% (once-

daily)............................................................................91TIVICAY......................................................................... 45TIVICAY......................................................................... 45TIVICAY......................................................................... 45tizanidine hcl cap 2 mg............................................... 41tizanidine hcl cap 4 mg............................................... 41tizanidine hcl cap 6 mg............................................... 41tizanidine hcl tab 2 mg................................................41tizanidine hcl tab 4 mg................................................41TOBRADEX...................................................................91tobramycin-dexamethasone ophth susp

0.3-0.1%..................................................................... 91tobramycin nebu soln 300 mg/5ml............................ 95tobramycin ophth soln 0.3%.......................................91TOBRAMYCIN SULFATE........................................... 12tobramycin sulfate for inj 1.2 gm................................12tobramycin sulfate inj 1.2 gm/30ml (40 mg/

ml)................................................................................13tobramycin sulfate inj 10 mg/ml................................. 13tobramycin sulfate inj 80 mg/2ml (40 mg/

ml)................................................................................13tolcapone tab 100 mg................................................. 36TOLMETIN SODIUM..................................................... 4tolterodine tartrate cap er 24hr 2 mg.........................75

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tolterodine tartrate cap er 24hr 4 mg.........................75tolterodine tartrate tab 1 mg.......................................75tolterodine tartrate tab 2 mg.......................................75topiramate sprinkle cap 15 mg...................................16topiramate sprinkle cap 25 mg...................................16topiramate tab 100 mg................................................16topiramate tab 200 mg................................................16topiramate tab 25 mg.................................................. 16topiramate tab 50 mg.................................................. 16TOPOTECAN HCL...................................................... 33topotecan hcl for inj 4 mg........................................... 33TORISEL....................................................................... 33torsemide tab 100 mg................................................. 63torsemide tab 10 mg................................................... 63torsemide tab 20 mg................................................... 63torsemide tab 5 mg......................................................63TOUJEO SOLOSTAR..................................................50TOVIAZ.......................................................................... 75TOVIAZ.......................................................................... 75TRACLEER................................................................... 95TRACLEER................................................................... 95TRACLEER................................................................... 95TRADJENTA................................................................. 50tramadol-acetaminophen tab 37.5-325

mg..................................................................................4tramadol hcl tab 50 mg................................................. 4tramadol hcl tab er 24hr 100 mg..................................4tramadol hcl tab er 24hr 200 mg..................................4tramadol hcl tab er 24hr 300 mg..................................4trandolapril tab 1 mg................................................... 63trandolapril tab 2 mg................................................... 63trandolapril tab 4 mg................................................... 63tranexamic acid iv soln 1000 mg/10ml (100 mg/

ml)................................................................................52tranexamic acid tab 650 mg.......................................52tranylcypromine sulfate tab 10 mg............................ 20TRAVATAN Z................................................................ 91trazodone hcl tab 100 mg...........................................20trazodone hcl tab 150 mg...........................................20trazodone hcl tab 300 mg...........................................20trazodone hcl tab 50 mg.............................................20TREANDA..................................................................... 33TREANDA..................................................................... 33TRECATOR...................................................................25TRELSTAR....................................................................82TRELSTAR....................................................................82TRELSTAR MIXJECT..................................................82TRELSTAR MIXJECT..................................................82TRELSTAR MIXJECT..................................................82TRESIBA FLEXTOUCH.............................................. 50TRESIBA FLEXTOUCH.............................................. 50tretinoin cap 10 mg......................................................33

tretinoin cream 0.025%............................................... 68tretinoin cream 0.05%................................................. 68tretinoin cream 0.1%................................................... 68tretinoin gel 0.01%.......................................................68tretinoin gel 0.025%.....................................................69triamcinolone acetonide cream

0.025%........................................................................69triamcinolone acetonide cream 0.1%........................69triamcinolone acetonide cream 0.5%........................69triamcinolone acetonide dental paste

0.1%............................................................................66triamcinolone acetonide lotion 0.025%..................... 69triamcinolone acetonide lotion 0.1%..........................69triamcinolone acetonide nasal aerosol suspension

55 mcg/act................................................................. 95triamcinolone acetonide oint 0.025%........................ 69triamcinolone acetonide oint 0.1%.............................69triamcinolone acetonide oint 0.5%.............................69triamterene & hydrochlorothiazide cap 37.5-25

mg................................................................................63triamterene & hydrochlorothiazide tab 37.5-25

mg................................................................................63triamterene & hydrochlorothiazide tab 75-50

mg................................................................................63trientine hcl cap 250 mg............................................. 71trifluoperazine hcl tab 10 mg......................................40trifluoperazine hcl tab 1 mg........................................40trifluoperazine hcl tab 2 mg........................................40trifluoperazine hcl tab 5 mg........................................40trifluridine ophth soln 1%............................................ 91trimethoprim tab 100 mg.............................................13trimipramine maleate cap 100 mg............................. 20trimipramine maleate cap 25 mg............................... 20trimipramine maleate cap 50 mg............................... 20TRINTELLIX..................................................................20TRINTELLIX..................................................................20TRINTELLIX..................................................................20TRISENOX....................................................................33TRISENOX....................................................................33TRIUMEQ......................................................................45trospium chloride cap er 24hr 60 mg.........................75trospium chloride tab 20 mg.......................................75TRUMENBA.................................................................. 87TRUVADA......................................................................45TRUVADA......................................................................45TRUVADA......................................................................45TRUVADA......................................................................45TWINRIX........................................................................87TYBOST........................................................................ 45TYGACIL....................................................................... 13TYKERB........................................................................ 33TYPHIM VI.................................................................... 87

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TYSABRI....................................................................... 66UULORIC......................................................................... 24ULORIC......................................................................... 24UNITUXIN......................................................................34UPTRAVI....................................................................... 95UPTRAVI....................................................................... 95UPTRAVI....................................................................... 95UPTRAVI....................................................................... 95UPTRAVI....................................................................... 95UPTRAVI....................................................................... 95UPTRAVI....................................................................... 95UPTRAVI....................................................................... 95UPTRAVI....................................................................... 95ursodiol cap 300 mg....................................................73ursodiol tab 250 mg.....................................................73ursodiol tab 500 mg.....................................................73Vvalacyclovir hcl tab 1 gm............................................ 45valacyclovir hcl tab 500 mg........................................45VALCHLOR................................................................... 34valganciclovir hcl for soln 50 mg/ml.......................... 45valganciclovir hcl tab 450 mg.....................................45valproate sodium inj 100 mg/ml.................................16valproate sodium oral soln 250 mg/5ml.................... 16valproic acid cap 250 mg............................................17valsartan-hydrochlorothiazide tab 160-12.5

mg................................................................................63valsartan-hydrochlorothiazide tab 160-25

mg................................................................................63valsartan-hydrochlorothiazide tab 320-12.5

mg................................................................................63valsartan-hydrochlorothiazide tab 320-25

mg................................................................................64valsartan-hydrochlorothiazide tab 80-12.5

mg................................................................................63valsartan tab 160 mg...................................................63valsartan tab 320 mg...................................................63valsartan tab 40 mg.....................................................63valsartan tab 80 mg.....................................................63vancomycin hcl cap 125 mg.......................................13vancomycin hcl cap 250 mg.......................................13vancomycin hcl for inj 1000 mg................................. 13vancomycin hcl for inj 100 gm................................... 13vancomycin hcl for inj 10 gm......................................13vancomycin hcl for inj 5000 mg................................. 13vancomycin hcl for inj 500 mg................................... 13vancomycin hcl for inj 750 mg................................... 13VANCOMYCIN HCL IN DEXTROSE.........................13VANCOMYCIN HCL IN DEXTROSE.........................13VANCOMYCIN HCL IN DEXTROSE.........................13

VAQTA........................................................................... 87VAQTA........................................................................... 87VARIVAX........................................................................87VASCEPA...................................................................... 64VASCEPA...................................................................... 64VECTIBIX...................................................................... 34VECTIBIX...................................................................... 34VELCADE......................................................................34VENCLEXTA.................................................................34VENCLEXTA.................................................................34VENCLEXTA.................................................................34VENCLEXTA STARTING PACK................................ 34venlafaxine hcl cap er 24hr 150 mg.......................... 21venlafaxine hcl cap er 24hr 37.5 mg......................... 21venlafaxine hcl cap er 24hr 75 mg............................ 21venlafaxine hcl tab 100 mg........................................ 21venlafaxine hcl tab 25 mg...........................................21venlafaxine hcl tab 37.5 mg....................................... 21venlafaxine hcl tab 50 mg...........................................21venlafaxine hcl tab 75 mg...........................................21venlafaxine hcl tab er 24hr 150 mg........................... 21venlafaxine hcl tab er 24hr 37.5 mg..........................21venlafaxine hcl tab er 24hr 75 mg............................. 21VENTAVIS..................................................................... 95VENTAVIS..................................................................... 95VENTOLIN HFA........................................................... 95verapamil hcl cap er 24hr 100 mg.............................64verapamil hcl cap er 24hr 120 mg.............................64verapamil hcl cap er 24hr 180 mg.............................64verapamil hcl cap er 24hr 200 mg.............................64verapamil hcl cap er 24hr 240 mg.............................64verapamil hcl cap er 24hr 300 mg.............................64verapamil hcl cap er 24hr 360 mg.............................64verapamil hcl tab 120 mg........................................... 64verapamil hcl tab 40 mg............................................. 64verapamil hcl tab 80 mg............................................. 64verapamil hcl tab er 120 mg.......................................64verapamil hcl tab er 180 mg.......................................64verapamil hcl tab er 240 mg.......................................64VERSACLOZ................................................................ 40VERZENIO....................................................................34VERZENIO....................................................................34VERZENIO....................................................................34VERZENIO....................................................................34VICTOZA....................................................................... 50VIDEX............................................................................ 45VIDEX............................................................................ 45VIDEX EC..................................................................... 45VIEKIRA PAK................................................................45VIEKIRA XR..................................................................45vigabatrin powd pack 500 mg.................................... 17VIGAMOX......................................................................91

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VIIBRYD.........................................................................21VIIBRYD.........................................................................21VIIBRYD.........................................................................21VIIBRYD STARTER PACK......................................... 21VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VIMPAT.......................................................................... 17VINBLASTINE SULFATE............................................34vincristine sulfate iv soln 1 mg/ml..............................34vinorelbine tartrate inj 10 mg/ml.................................34vinorelbine tartrate inj 50 mg/5ml (10 mg/

ml)................................................................................34VIOKACE.......................................................................74VIOKACE.......................................................................74VIRACEPT.................................................................... 45VIRACEPT.................................................................... 45VIRAMUNE................................................................... 45VIREAD..........................................................................45VIREAD..........................................................................45VIREAD..........................................................................45VIREAD..........................................................................45VIREAD..........................................................................45VIVITROL........................................................................ 5voriconazole for inj 200 mg........................................ 23voriconazole for susp 40 mg/ml.................................23voriconazole tab 200 mg............................................ 23voriconazole tab 50 mg...............................................23VOSEVI..........................................................................45VOTRIENT.................................................................... 34VPRIV............................................................................ 74VRAYLAR...................................................................... 40VRAYLAR...................................................................... 40VRAYLAR...................................................................... 40VRAYLAR...................................................................... 40VYXEOS........................................................................34Wwarfarin sodium tab 10 mg.........................................53warfarin sodium tab 1 mg...........................................52warfarin sodium tab 2.5 mg........................................53warfarin sodium tab 2 mg...........................................53warfarin sodium tab 3 mg...........................................53warfarin sodium tab 4 mg...........................................53warfarin sodium tab 5 mg...........................................53warfarin sodium tab 6 mg...........................................53warfarin sodium tab 7.5 mg........................................53water for irrigation, sterile irrigation

soln..............................................................................71WELCHOL.....................................................................64

WELCHOL.....................................................................64XXALKORI....................................................................... 34XALKORI....................................................................... 34XARELTO...................................................................... 53XARELTO...................................................................... 53XARELTO...................................................................... 53XARELTO STARTER PACK.......................................53XATMEP........................................................................ 87XGEVA...........................................................................89XIFAXAN........................................................................73XOLAIR..........................................................................87XOPENEX HFA............................................................95XTANDI.......................................................................... 34XYREM.......................................................................... 96YYERVOY........................................................................34YERVOY........................................................................34YF-VAX.......................................................................... 87YONDELIS.................................................................... 34Zzafirlukast tab 10 mg...................................................95zafirlukast tab 20 mg...................................................95zaleplon cap 10 mg..................................................... 96zaleplon cap 5 mg....................................................... 96ZALTRAP.......................................................................34ZALTRAP.......................................................................34ZANOSAR..................................................................... 34ZAVESCA...................................................................... 74ZEJULA..........................................................................34ZELBORAF................................................................... 34ZENPEP........................................................................ 74ZENPEP........................................................................ 74ZENPEP........................................................................ 74ZENPEP........................................................................ 74ZENPEP........................................................................ 74ZENPEP........................................................................ 75ZENPEP........................................................................ 75ZENPEP........................................................................ 75ZENPEP........................................................................ 75ZENPEP........................................................................ 75ZEPATIER..................................................................... 45ZERIT.............................................................................45ZIAGEN..........................................................................45zidovudine cap 100 mg...............................................45zidovudine syrup 10 mg/ml.........................................45zidovudine tab 300 mg................................................46ZINACEF....................................................................... 13ziprasidone hcl cap 20 mg..........................................40ziprasidone hcl cap 40 mg..........................................40

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ziprasidone hcl cap 60 mg..........................................40ziprasidone hcl cap 80 mg..........................................40ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4ZOHYDRO ER................................................................4zoledronic acid inj conc for iv infusion 4

mg/5ml........................................................................ 89zoledronic acid iv soln 5 mg/100ml........................... 89ZOLINZA........................................................................34zolpidem tartrate tab 10 mg....................................... 96zolpidem tartrate tab 5 mg..........................................96ZOMETA........................................................................ 89zonisamide cap 100 mg..............................................17zonisamide cap 25 mg................................................17zonisamide cap 50 mg................................................17ZONTIVITY....................................................................53ZORTRESS...................................................................87ZORTRESS...................................................................87ZORTRESS...................................................................87ZOSTAVAX....................................................................87ZOSYN...........................................................................13ZOSYN...........................................................................13ZOSYN...........................................................................13ZYDELIG....................................................................... 34ZYDELIG....................................................................... 34ZYKADIA....................................................................... 34ZYPREXA RELPREVV............................................... 40ZYPREXA RELPREVV............................................... 41ZYPREXA RELPREVV............................................... 41ZYTIGA..........................................................................34ZYTIGA..........................................................................34

Nondiscrimination and Language Assistance

I

English: If you, or someone you’re helping, has questions about Blue Cross & Blue Shield of Rhode Island, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1-800-267-0439.

Spanish: Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Blue Cross & Blue Shield of Rhode Island, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-800-267-0439.

Portuguese: Se você, ou alguém a quem você está ajudando, tem perguntas sobre o Blue Cross & Blue Shield of Rhode Island, você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-800-267-0439.

Chinese: Blue Cross & Blue Shield of Rhode Island .

1-800-267-0439.

French Creole: Si oumenm oswa yon moun w ap ede gen kesyon konsènan Blue Cross & Blue Shield of Rhode Island, se dwa w pou resevwa asistans ak enfòmasyon nan lang ou pale a, san ou pa gen pou peye pou sa. Pou pale avèk yon entèprèt, rele nan 1-800-267-0439.

Cambodian-Mon-Khmer: Blue Cross & Blue Shield of Rhode Island

1-800-267-0439.

French: Si vous, ou quelqu’un que vous êtes en train d’aider, a des questions à propos de Blue Cross & Blue Shield of Rhode Island, vous avez le droit d’obtenir de l’aide et l’information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-800-267-0439.

Italian: Se tu o qualcuno che stai aiutando avete domande su Blue Cross & Blue Shield of Rhode Island, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per parlare con un interprete, puoi chiamare 1-800-267-0439.

Blue Cross & Blue Shield of Rhode Island (BCBSRI) complies with applicable Federal civil rights laws and does not discriminate or treat people differently on the basis of race, color, national origin, age, disability, or sex. BCBSRI provides free aids and services to people with disabilities and to people whose primary language is not English when such services are necessary to communicate effectively with us.If you need these services, contact us at 1-800-267-0439 TTY: 711.If you believe that BCBSRI 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: Director of Grievance and Appeals Department, Blue Cross & Blue Shield of Rhode Island, 500 Exchange Street, Providence RI 02903, or by calling 1-800-267-0439 TTY: 711. You can file a grievance in person, by phone or by mail, fax at (401) 459-5668 or electronically through our member portal at bcbsri.com/Medicare. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

English:

Spanish:

Portuguese:

Chinese:

French Creole:

Cambodian-Mon-Khmer:

French:

Italian:

09/16 BMED-96729 .1370

Laotian: Blue Cross & Blue

Shield of Rhode Island,

. 1-800-267-0439.

Arabic:

Appendix B: Sample Translated Taglines - Languages Are Listed in Alphabetical Order

Language Translated Taglines 1. Albanian General Tagline:

Nëse ju, ose dikush që po ndihmoni, ka pyetje për [insert SBM program name], keni të drejtë të merrni ndihmë dhe informacion falas në gjuhën tuaj. Për të folur me një përkthyes, telefononi numrin [insert number here].

Tagline for Notices: Ky njoftim përmban informacion të rëndësishëm. Ky njoftim përmban informacion të rëndësishëm për aplikimin ose mbulimin tuaj nëpërmjet [insert SBM program name]. Kontrolloni për data të rëndësishme në këtë njoftim. Mund t'ju duhet të ndërmerrni veprim brenda afatave të caktuara për të mbajtur mbulimin tuaj shëndetësor ose për ndihmën me koston. Keni të drejtë ta merrni këtë informacion dhe ndihmë falas në gjuhën tuaj. Telefononi numrin [insert number here].

2. Amharic General Tagline: እርስዎ፣ ወይም እርስዎ የሚያግዙት ግለሰብ፣ ስለ [insert SBM program name] ጥያቄ ካላችሁ፣ ያለ ምንም ክፍያ በቋንቋዎ እርዳታና መረጃ የማግኘት መብት አላችሁ። ከአስተርጓሚ ጋር ለመነጋገር፣ [insert number here] ይደውሉ።

Tagline for Notices: ይህ ማስታወቂያ አስፈላጊ መረጃ ይዟል። ይህ ማስታወቂያ ስለ ማመልከቻዎ ወይም የ[insert SBM program name] ሽፋን አስፈላጊ መረጃ አለው። በዚሀ ማስታወቂያ ውስጥ ቁልፍ ቀኖችን ፈልጉ። የጤናን ሽፋንዎን ለመጠበቅና በአከፋፈል እርዳታ ለማግኘት በተውሰኑ የጊዜ ገደቦች እርምጃ መውሰድ ይገባዎት ይሆናል። ይህን መረጃ እንዲያገኙ እና ያለምንም ክፍያ በቋንቋዎ እርዳታ እንዲያገኙ መብት አለዎት። [insert number here] ይደውሉ።

3. Arabic General Tagline: (، فلديك الحق في الحصول على المساعدة والمعلومات insert SBM program nameإن كان لديك أو لدى شخص تساعده أسئلة بخصوص )

(. insert number hereالضرورية بلغتك من دون اية تكلفة. للتحدث مع مترجم اتصل بـ )

Tagline for Notices: insert SBM programيحوي هذا االشعار معلومات مهمة بخصوص طلبك للحصول على التغطية من خالل ) يحوي هذا االشعار معلومات هامة.

name here ابحث عن التواريخ الهامة في هذا االشعار. قد تحتاج التخاذ اجراء في تواريخ معينة للحفاظ على تغطيتك الصحية او للمساعدة في دفع .) (.insert number hereلمعلومات والمساعدة بلغتك من دون أي تكلفة. اتصل بـ )التكاليف. لك الحق في الحصور على ا

4. Armenian General Tagline: Եթե Դուք կամ Ձեր կողմից օգնություն ստացող անձը հարցեր ունի [insert SBM program name] մասին, Դուք իրավունք ունեք անվճար օգնություն և տեղեկություններ ստանալու Ձեր նախընտրած լեզվով։ Թարգմանչի հետ խոսելու համար զանգահարե՛ք [insert number here]։

Blue Cross & Blue Shield of Rhode Island


































.1-800-267-0439












Russian:

Rhode Island Language Assistance Taglines:

English If you, or someone you’re helping, has questions about Blue Cross & Blue Shield of Rhode Island, you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1‐800‐267‐0439.

1. Spanish Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Blue Cross & Blue Shield of Rhode Island, tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1‐800‐267‐0439.

2. Portuguese Se você, ou alguém a quem você está ajudando, tem perguntas sobre o Blue Cross & Blue Shield of Rhode Island, você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1‐800‐267‐0439.

3. Chinese 如果您，或是您正在協助的對象，有關於[插入SBM項目的名稱 Blue Cross & Blue Shield of Rhode Island 方面的問題，您有權利免費以您的母語得到幫助和訊息。洽詢一位翻譯員，請撥電話在

此插入數字1‐800‐267‐0439。 4. French

Creole Si oumenm oswa yon moun w ap ede gen kesyon konsènan Blue Cross & Blue Shield of Rhode Island, se dwa w pou resevwa asistans ak enfòmasyon nan lang ou pale a, san ou pa gen pou peye pou sa. Pou pale avèk yon entèprèt, rele nan 1‐800‐267‐0439.

5. Cambodian‐Mon‐Khmer

របសិនបេរីអនក ឬនរណាមននក់ែដលអនកកំពុងែដជួយ មននសំណួរអ្◌ពីំ Blue Cross & Blue Shield of Rhode Island េប, អនកមននសិេ◌ធិេ◌េ◌◌ួលជំនួយនិងព័ែ◌◌ម៌នន េបៅកនុងភាសា ររស់អនក េបាយមិនអស់ប្◌ាក់ ។ ែបេ◌ើមបីនិយាយជាមួយអនករកដរប សូម 1‐800‐267‐0439 ។

6. French Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Blue Cross & Blue Shield of Rhode Island, vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1‐800‐267‐0439.

7. Italian Se tu o qualcuno che stai aiutando avete domande su Blue Cross & Blue Shield of Rhode Island, hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per parlare con un interprete, puoi chiamare 1‐800‐267‐0439.

8. Laotian ຖ້າທ່ານ, ຫ ◌ຼ ◌ື ຄົນທ ◌່ ທ່ານກໍາລັງຊ່ວຍເຫ ◌ຼ ◌ື ອ, ມ ຄໍ າຖາມກ່ຽວກັບ Blue Cross & Blue Shield of Rhode Island, ທ່ານມ ສິ ດທ ◌່ ຈະໄດ້ຮັບການຊ່ວຍເຫ ◌ຼ ◌ື ອແລະຂໍ ້ ມູນຂ່າວສານທ ◌່ ເປັນພາສາຂອງທ່ານບໍ່ ມ ຄ່າໃຊ້ຈ່າຍ. ການໂອ້ລົມກັບນາຍພາສາ, ໃຫ້ໂທຫາ 1‐800‐267‐0439.

9. Arabic ��د�� ، Blue Cross & Blue Shield of Rhode Island ��و� أ�� د� �� د� أو ��د�� ن إنو��م��وم�� م��د� �� و� ��

.0439‐267‐800‐1 ب �� م�� مع ��د� .�� دون من �� و��10. Russian Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Blue Cross & Blue

Shield of Rhode Island, то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону 1‐800‐267‐0439.

11. Vietnamese Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Blue Cross & Blue Shield of Rhode Island, quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1‐800‐267‐0439.

12. Kru I bale we, tole mut u ye hola, a gwee mbarga inyu [insert SBM program name], U gwee Kunde I kosna mahola ni biniiguene I hop wong nni nsaa wogui wo. I Nyu ipot ni mut a nla koblene we hop, sebel [insert number here].

13. Ibo Ọ bụrụ gị, ma o bụ onye I na eyere‐aka, nwere ajụjụ gbasara Blue Cross & Blue Shield of Rhode Island, I nwere ohere iwenta nye maka na ọmụma na asụsụ gị na akwu gị ụgwọ. I chọrọ I kwụrụ onye‐ntapịa okwu, kpọ 1‐800‐267‐0439.

14. Yoruba Bí ìwọ, tàbí ẹnikẹni tí o n ranlọwọ, bá ní ibeere nípa Blue Cross & Blue Shield of Rhode Island, o ní ẹtọlati rí iranwọ àti ìfitónilétí gbà ní èdè rẹ láìsanwó. Láti bá ongbufọ kan sọrọ, pè sórí 1‐800‐267‐0439

15. Polish Jeśli Ty lub osoba, której pomagasz ,macie pytania odnośnie (insert SBM program), masz prawo do uzyskania bezpłatnej informacji i pomocy we własnym języku .Aby porozmawiać z tłumaczem, zadzwoń pod numer 1‐800‐267‐0439

16. Korean 만약 귀하 또는 귀하가 돕고 있는 어떤 사람이Blue Cross & Blue Shield of Rhode Island 에 관해서

질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는

권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1‐800‐267‐0439 로 전화하십시오. 17. Tagalog Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Blue Cross & Blue Shield of

Rhode Island, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1‐800‐267‐0439.






此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French



















Vietnamese: Blue Cross & Blue Shield of Rhode Island,

1-800-267-0439.

Kru: I bale we, tole mut u ye hola, a gwee mbarga inyu Blue Cross & Blue Shield of Rhode Island, U gwee Kunde I kosna mahola ni biniiguene I hop wong nni nsaa wogui wo. I Nyu ipot ni mut a nla koblene we hop, sebel 1-800-267-0439.

Ibo:






此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French



















Yoruba: Blue Cross & Blue Shield of Rhode Island,

1-800-267-0439.

Polish: Blue Cross & Blue Shield of Rhode Island, .

1-800-267-0439.

Korean:






此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French
























此插入數字1‐800‐267‐0439。 4. French



















Tagalog: Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Blue Cross & Blue Shield of Rhode Island, may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1-800-267-0439.

This notice is being provided to you in compliance with federal law.

Laotian:

Arabic:

Russian:

Vietnamese:

Kru:

Ibo:

Yoruba:

Polish:

Korean:

Tagalog:

This notice is being provided to you in compliance with federal law.

This formulary was updated on . The formulary may change at any time. You will receive notice when necessary. For more recent information or other questions, please contact the Medicare Concierge Team at (401) 277-2958 or 1-800-267-0439 (TTY users should call 711), seven days a week from October 1 to February 14, 8:00 a.m. to 8:00 p.m. From February 15 to September 30, you can call Monday through Friday, from 8:00 a.m. to 8:00 p.m. On Saturday and Sunday, call from 8:00 a.m. to noon. You can use our automated answering system outside of these hours, or visit bcbsri.com/Medicare.

The formulary may change at any time. You will receive notice when necessary. Blue Cross & Blue Shield of Rhode Island is an HMO plan with a Medicare contract. Enrollment in Blue Cross & Blue Shield of Rhode Island depends on contract renewal.

An independent licensee of the Blue Cross and Blue Shield Association.

500 Exchange Street • Providence, RI 02903-2699 • bcbsri.com/Medicare

April 1, 2018

04/18 BMED-187769

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