Comprehensive Drug List (Formulary) Cigna-HealthSpring

Plans coveredCigna-HealthSpring Preferred (HMO)Cigna-HealthSpring Preferred Plus (HMO)Cigna-HealthSpring Achieve Plus (HMO SNP)

Please read: This document contains information about all of the drugs we cover in this plan.

2016 Cigna COMPREHENSIVE DRUG LIST (Formulary)

This drug list was updated on November 1, 2016. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-627-7534 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m., hours apply Monday – Friday, February 15 – September 30, or visit www.CignaHealthSpring.com. Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal.HPMS Approved Formulary File Submission ID 16158, Version Number 18 Y0036_16_32224c_Final_3j Approved 08102015

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What is the Cigna Comprehensive Drug List?A drug list is a list of covered drugs selected by Cigna in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Cigna will generally cover the drugs listed in our drug list as long as the drug is medically necessary, the prescription is filled at a Cigna network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Drug List (formulary) change?Generally, if you are taking a drug on our 2016 drug list that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2016 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of drug list changes, such as removing a drug from our drug list, will not affect customers who are currently taking the drug. It will remain available at the same cost-sharing for those customers 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 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 drug list, 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 customers of the change at least 60 days before the change becomes effective, or at the time the customer requests a refill

of the drug, at which time the customer will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our drug list to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our drug list and provide notice to customers who take the drug. The enclosed drug list is current as of November 2016. To get updated information about the drugs covered by Cigna, please contact us. Our contact information appears on the front and back cover pages. If there are significant changes made to the printed drug list within the covered year, you may be notified by mail identifying the changes. Drug lists located on our website are reviewed and updated on a monthly basis.

How do I use the Drug List? There are two ways to find your drug within the drug list:Medical ConditionThe drug list begins on page 7. The drugs in this drug list 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 7. Then look under the category name for your drug. Covered Drug IndexIf you are not sure what category to look under, you should look for your drug in the Covered Drugs Index section that begins on page 50. The Covered Drugs Index provides a list of all of the drugs included in this document. Both brand name drugs and generic drugs are in the Drug List.

Note to existing customers: This drug list 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 Cigna. When it refers to “plan” or “our plan,” it means Cigna-HealthSpring Preferred (HMO), Cigna-HealthSpring Preferred Plus (HMO) and Cigna-HealthSpring Achieve Plus (HMO SNP).

This document includes a list of the drugs (formulary) for our plans, which is current as of November 2016. For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2017, and from time to time during the year.

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What are generic drugs?Cigna covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

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

• Prior Authorization: Cigna requires you or your doctor to get prior authorization for certain drugs. This means that you will need to get approval from Cigna before you fill your prescriptions. If you don’t get approval, Cigna may not cover the drug.

• Quantity Limits: For certain drugs, Cigna limits the amount of the drug that Cigna will cover. For example, Cigna allows for 1 tablet per day for CRESTOR. This applies to standard one-month supply (for total quantity of 30 per 30 days) or three-month supply (for total quantity of 90 per 90 days).

• Step Therapy: In some cases, Cigna 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, Cigna may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Cigna will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the drug list that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.You can ask Cigna 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 Cigna drug list?” on this page for information about how to request an exception.

Options for Maintenance MedicationsTaking the medications prescribed by your doctor (or other prescriber) is important to your health. We are committed to helping you achieve control of chronic conditions by making it easy for you to receive your maintenance medications. As part of our commitment to coordinating your healthcare needs, we have set a goal of

helping you take your medications at least 80% of the time. There are several ways we can work together to accomplish this goal:• Talk with your doctor about whether a 90 day supply of your

ongoing, stable medications may be appropriate. Taking these medications every day as prescribed is important for your overall health, and getting 90 day prescriptions of these medications can ensure that you don’t miss a dose.

• You can receive a 90-day supply at most retail pharmacies or through one of our mail-order pharmacies.

• Talk to your pharmacist if you are experiencing any new challenges with your maintenance medications.

How can I use my prescription drug coverage to save money on my medications?There may be opportunities for you to save money on your medications using your Cigna coverage.• Ask your doctor (or other prescriber) if there are any lower-

cost generic alternatives available for any of your current medications.

• Explore whether the ‘CMS extra help’ program may offer additional financial support for your medications.

• If your medication is not covered on the Cigna drug list, talk with your doctor about alternative medications which are covered in the drug list.

What if my drug is not in the Drug List?If your drug is not included in this drug list, you should first contact Customer Service and ask if your drug is covered. If you learn that Cigna does not cover your drug, you have two options:• You can ask Customer Service for a list of similar drugs that

are covered by Cigna. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Cigna.

• You can ask Cigna 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 Cigna Drug List?You can ask Cigna 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 in our drug

list. If approved, this drug will be covered at a pre-determined

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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 waive coverage restrictions or limits on your drug. For example, for certain drugs, Cigna 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.

• You can ask us to provide a tiering exception for a higher cost sharing drug to be covered at a lower cost-sharing tier. If your drug is contained in the Non-Preferred Brand tier or the Generic tier, you can ask us to cover it at the cost-sharing amount that applies to drugs in the respective Preferred Brand or Preferred Generic tier instead. This would lower the amount you must pay for your drug. If your drug is contained in our Brand tier you can ask to cover it at the cost-sharing amount that applies to drugs in the respective Generic tier if all generic alternatives in the lower cost tier used to treat the same condition/disease are determined to be not as effective as the Brand. Please note, if we grant your request to cover a drug that is not in our drug list, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for drugs that are in the Specialty tier.

Generally, Cigna will only approve your request for an exception if the alternative drugs included on the plan’s drug list, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a drug list, tiering or utilization restriction exception. When you request a drug list, tiering or utilization restriction exception you should submit a statement from your prescriber or doctor supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?As a new or continuing customer in our plan you may be taking drugs that are not in our drug list. Or, you may be taking a drug that is on our drug list 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 drug list exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a customer of our plan.For each of your drugs that is not on our drug list 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 customer 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 91- to 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a customer of our plan. If you need a drug that is not in our drug list or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a drug list exception. In order to accommodate unexpected transitions of our customers that do not leave time for advanced planning, such as level-of-care changes due to discharge from a hospital to a nursing facility or to a home, Cigna will allow a one-time 31-day supply (unless the prescription is written for fewer days).

Cigna’s Drug ListThe comprehensive drug list provides coverage information about all of the drugs covered by Cigna. If you have trouble finding your drug in the list, turn to the Covered Drug Index that begins on page 50. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., CRESTOR) and generic drugs are listed in lower-case italics (e.g., simvastatin).The information in the Requirements/Limits column tells you if Cigna has any special requirements for coverage of your drug. We provide quantity limits on certain drugs which are indicated with a QL in the Covered Drugs by Category list on page 7 along with the amount dispensed per the days supplied. (For example: CRESTOR 30/30; this means the drug CRESTOR is limited to 30 tablets per 30 days. For 90-day supplies, this quantity limit would be expanded to 90 tablets per 90 days).

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For more information

For more detailed information about your Cigna prescription drug coverage, please review your Evidence of Coverage and other plan materials.If you have questions about Cigna, please contact us. Our contact information, along with the date we last updated the drug list, appears on the front and back cover pages.If you have general questions about Medicare prescription drug coverage, please call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Or, visit http://www.medicare.gov.

Key:B/D – This prescription drug has a Part B versus D administrative prior authorization requirement. This drug may be covered under Medicare Part B or D depending on circumstances.

HI (Home Infusion) – This prescription drug may be covered under our medical benefit. For more information, contact Customer Service.

PA – This drug requires prior authorization

QL – This drug has quantity limits

ST – This drug has step therapy requirements

Generally all medications in the drug list are available through mail order, except when special circumstances or situations prohibit mailing a particular medication to your home.

Drug Tier and Cost-Share TableThe following table represents the plan name, plan service area, the drug tier number as it appears in the drug list, and the cost-share amount for that tier number. Tier 1 is for Preferred Generic drugs. Tier 2 is for Generic drugs. Tier number 3 is for Preferred Brand drugs. Tier number 4 is for Non-Preferred Brand drugs. Tier 5 is for Specialty tier drugs. You may also refer to your Evidence of Coverage document for additional details.

Note for customers receiving Extra Help: Your LIS copay level will be based on how the Food and Drug Administration (FDA) classifies certain drugs. Due to this, a generic drug may receive a preferred brand copay, or a preferred brand drug may receive a generic drug copay. Please see your LIS Rider for additional information on these copay levels. Or call Customer Service for further clarification regarding a specific drug.

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To locate your drug cost, please refer to the table(s) below to find your service area and the Medicare Advantage plan in which you are currently enrolled or would like to enroll.

Service Area: Arizona

H0354-001Cigna-HealthSpring Preferred (HMO)H0354-027Cigna-HealthSpring Achieve Plus (HMO SNP)Maricopa county and select zip codes in Pinal county (85117, 85118, 85119, 85120, 85140, 85143, 85178), Arizona

Standard Retail Cost-Sharing

Standard Mail Order Cost-Sharing

30/60/90 Days 30/90 Days

Tier 1: Preferred Generic Drugs $0/$0/$0 $0/$0

Tier 2: Generic Drugs $15/$30/$45 $15/$45

Tier 3: Preferred Brand Drugs $45/$90/$135 $45/$135

Tier 4: Non-Preferred Brand Drugs $100/$200/$300 $100/$300

Tier 5: Specialty Tier 33% 33%


H0354-023Cigna-HealthSpring Preferred Plus (HMO)Maricopa county and select zip codes in Pinal county (85117, 85118, 85119, 85120, 85140, 85143, 85178), Arizona

H0354-024Cigna-HealthSpring Preferred (HMO)Pima County, Arizona



30/60/90 Days 30/90 Days






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H0354-026Cigna-HealthSpring Preferred Plus (HMO)Pima County, Arizona



30/60/90 Days 30/90 Days






My MedicationsIn this section, you can write down all of the medications you are currently taking. You can then find your drug in the following drug list pages. Look and see what tier your drug is on. Once you find out what tier your drug is on, you can look at the charts before this page and locate your cost-share for that drug. If you need help locating your drugs and cost-share, please call Customer Service at 1-800-627-7534, 7 days a week, 8 a.m. – 8 p.m., hours apply Monday – Friday, February 15 – September 30. TTY users can call 711.

My Medications Page Number in the Drug List

Cost-Share through Cigna

Generic Available?

Generic Cost-Share

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Covered Drugs By Category

CAPITALIZED = BRAND NAME DRUG Lower case italic = Generic drugQL = Quantity Limits listed as (qty/days) ST = Step Therapy rules applyPA = Prior Authorization may be required B/D = Drugs covered under Medicare Part B or Part DHI = Home Infusion You can find more information on the symbols by going to page 4.

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Analgesics

Analgesicsbutalbital/acetaminophen 2 PA QL(180/30)butalbital/acetaminophen/caffeine caps

2 PA QL(180/30)

butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg

2 PA QL(180/30)

butalbital/aspirin/caffeine 2 PA QL(180/30)esgic caps 2 PA QL(180/30)margesic 2 PA QL(180/30)marten-tab 2 PA QL(180/30)PRIALT 5 B/D PAtencon tabs 325mg; 50mg 2 PA QL(180/30)zebutal caps 325mg; 50mg; 40mg

2 PA QL(180/30)

Nonsteroidal Anti-inflammatory DrugsCAMBIA 4celecoxib 2 QL(60/30)choline magnesium trisalicylate liqd

2

diclofenac potassium 2diclofenac sodium dr 2diclofenac sodium er 2diclofenac sodium/misoprostol 2diflunisal 2etodolac 2etodolac er 2fenoprofen calcium caps 400mg

2

fenoprofen calcium tabs 2flurbiprofen 2ibuprofen lysine 2ibuprofen susp 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ibuprofen tabs 400mg, 600mg, 800mg

2

ketoprofen 2ketoprofen er 2ketorolac tromethamine inj 15mg/ml, 30mg/ml

2 PA QL(20/30)

ketorolac tromethamine tabs 2 PA QL(20/30)meclofenamate sodium 2meloxicam 2nabumetone 2naproxen 2naproxen dr 2naproxen sodium tabs 275mg, 550mg

2

NEOPROFEN 3oxaprozin 2piroxicam 2salsalate 2sulindac 2tolmetin sodium 2Opioid Analgesics, Long-actingBUTRANS 3 QL(4/28)DURAMORPH 4fentanyl 2 QL(15/30)INFUMORPH 200 4INFUMORPH 500 4levorphanol tartrate 2 QL(180/30)methadone hcl conc 2 QL(500/30)methadone hcl inj 2methadone hcl intensol 2 QL(500/30)methadone hcl oral soln 10mg/5ml

2 QL(2000/30)

methadone hcl oral soln 5mg/5ml

2 QL(4000/30)

methadone hcl tabs 2 QL(360/30)

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fentanyl citrate oral transmucosal lpop 200mcg

2 PA QL(120/30)

fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 400mcg, 600mcg, 800mcg

5 PA QL(120/30)

hydrocodone bitartrate/acetaminophen oral soln 325mg/15ml; 7.5mg/15ml

2 QL(5400/30)

hydrocodone bitartrate/acetaminophen tabs 325mg; 2.5mg

2 QL(360/30)

hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg, 300mg; 5mg, 300mg; 7.5mg

2 QL(390/30)

hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg

2 QL(360/30)

hydrocodone/ibuprofen tabs 5mg; 200mg, 7.5mg; 200mg

2 QL(150/30)

hydrocodone/ibuprofen tabs 10mg; 200mg

2 QL(180/30)

hydromorphone hcl dosette 2hydromorphone hcl inj 1mg/ml, 2mg/ml, 4mg/ml, 500mg/50ml

2

hydromorphone hcl liqd 2 QL(1200/30)hydromorphone hcl supp 2hydromorphone hcl tabs 2 QL(240/30)ibudone tabs 5mg; 200mg 2 QL(150/30)LAZANDA 5 PA QL(44/28)lorcet 2 QL(360/30)lorcet hd 2 QL(360/30)lorcet plus tabs 325mg; 7.5mg 2 QL(360/30)lortab tabs 2 QL(360/30)morphine sulfate add-vantage 2morphine sulfate inj 10mg/ml, 150mg/30ml, 15mg/ml, 1mg/ml, 25mg/ml, 2mg/ml, 4mg/ml, 50mg/ml, 5mg/ml, 8mg/ml

2

morphine sulfate oral soln 100mg/5ml

2 QL(540/30)


2 QL(2700/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

methadone hcl tbso 2 QL(90/30)methadose conc 2 QL(500/30)methadose sugar-free 2 QL(500/30)methadose tbso 2 QL(90/30)morphine sulfate er cp24 2 QL(60/30)morphine sulfate er tbcr 2 QL(90/30)morphine sulfate inj 0.5mg/ml, 10mg/0.7ml, 1mg/ml

2

morphine sulfate supp 2OPANA ER (CRUSH RESISTANT) T12A 40MG

5 QL(120/30)

OPANA ER (CRUSH RESISTANT) T12A 10MG, 15MG, 20MG, 30MG, 5MG, 7.5MG

3 QL(60/30)

oxymorphone hydrochloride er 2 QL(60/30)tramadol hcl er tb24 2 QL(30/30)Opioid Analgesics, Short-actingacetaminophen/codeine #2 2 QL(360/30)acetaminophen/codeine #3 2 QL(360/30)acetaminophen/codeine #4 2 QL(240/30)acetaminophen/codeine oral soln

2 QL(5000/30)

acetaminophen/codeine phosphate tabs 300mg; 60mg

2 QL(240/30)

acetaminophen/codeine tabs 300mg; 60mg

2 QL(240/30)

acetaminophen/codeine tabs 300mg; 15mg

2 QL(360/30)

ascomp/codeine 2 PA QL(180/30)aspirin-caffeine-dihydrocodeine 2 QL(330/30)butalbital/aspirin/caffeine/codeine

2 PA QL(180/30)

butorphanol tartrate inj 2butorphanol tartrate nasal soln 2 QL(6/30)CAPITAL/CODEINE 3 QL(5000/30)codeine sulfate tabs 60mg 2 QL(180/30)codeine sulfate tabs 30mg 2 QL(360/30)codeine sulfate tabs 15mg 2 QL(720/30)endocet 2 QL(360/30)fentanyl citrate inj 100mcg/2ml 2 B/D PA

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

lidocaine hcl viscous 2lidocaine oint 2lidocaine ptch 2 PA QL(90/30)lidocaine viscous 2lidocaine/prilocaine crea 2premium lidocaine 2SYNERA 4 B/D PA

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-cravingacamprosate calcium dr 2disulfiram 2VIVITROL 5 PAOpioid Dependence Treatmentsbuprenorphine hcl inj 2buprenorphine hcl subl 2 QL(90/30)buprenorphine hcl/naloxone hcl 2naltrexone hcl 2SUBOXONE 3Opioid Reversal Agentsnaloxone hcl inj 0.4mg/ml, 2mg/2ml

2

NARCAN 3 QL(4/30)Smoking Cessation Agentsbupropion hcl sr tb12 150mg 2 QL(60/30)CHANTIX 3 QL(336/365)CHANTIX CONTINUING MONTH PAK

3 QL(336/365)

CHANTIX STARTING MONTH PAK

3 QL(106/365)

NICOTROL INHALER 3NICOTROL NS 3

Antibacterials

Aminoglycosidesamikacin sulfate 2 HI

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS


2 QL(5400/30)

morphine sulfate tabs 2 QL(360/30)nalbuphine hcl 2OPIUM 3OPIUM TINCTURE 3oxycodone hcl caps 2 QL(240/30)oxycodone hcl conc 2 QL(360/30)oxycodone hcl oral soln 2 QL(1200/30)oxycodone hcl tabs 2 QL(240/30)oxycodone/acetaminophen oral soln

2 QL(1800/30)

oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg, 325mg; 5mg, 325mg; 7.5mg

2 QL(360/30)

oxycodone/aspirin 2 QL(360/30)oxycodone/ibuprofen 2 QL(150/30)oxymorphone hydrochloride 2 QL(180/30)reprexain tabs 10mg; 200mg 2 QL(180/30)roxicet 2 QL(360/30)SYNALGOS-DC 3 QL(330/30)TALWIN 4tramadol hcl 2 QL(240/30)tramadol hydrochloride/acetaminophen

2 QL(240/30)

xylon 2 QL(180/30)

Anesthetics

Local Anestheticsglydo 2lidocaine hcl external soln 2lidocaine hcl gel 2lidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4%

2

lidocaine hcl jelly 2lidocaine hcl mouth/throat soln 2

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

clindamycin phosphate inj 300mg/2ml, 600mg/4ml, 900mg/6ml

2 HI

clindamycin phosphate lotn 2clindamycin phosphate pharmacy bulk package

2 HI

clindamycin phosphate swab 2CLINDESSE 4colistimethate sodium 2CORTISPORIN CREA 3CORTISPORIN OINT 3CUBICIN 5 HIdaptomycin 5 HIFEM PH 4FLAGYL ER 4lansoprazole/amoxicillin/clarithromycin

2 QL(224/30)

LINCOCIN 3lincomycin hcl 2linezolid inj 600mg/300ml 2linezolid susr 5 QL(1680/28)linezolid tabs 5 QL(56/28)methenamine hippurate 2methenamine mandelate 2METRO IV 3 HImetronidazole caps 2metronidazole crea 2metronidazole gel 2metronidazole in nacl 0.79% 2 HImetronidazole inj 2 HImetronidazole lotn 2metronidazole tabs 2metronidazole vaginal 2MONUROL 4mupirocin 2neomycin/bacitracin/polymyxin 2neomycin/polymyxin/bacitracin/hydrocortisone

2

neomycin/polymyxin/gramicidin 2neomycin/polymyxin/hydrocortisone

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

gentak 2gentamicin sulfate 2gentamicin sulfate pediatric 2gentamicin sulfate/0.9% sodium chloride inj 0.9mg/ml; 0.9%, 1.2mg/ml; 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ml; 0.9%, 1mg/ml; 0.9%, 2mg/ml; 0.9%

2

isotonic gentamicin inj 0.8mg/ml; 0.9%

2

neomycin sulfate 2neomycin/polymyxin b sulfates 2paromomycin sulfate 2streptomycin sulfate 2tobramycin sulfate 2TOBREX OINT 3ZYLET 4Antibacterials, OtherALCOHOL PREP PADS 3ALTABAX 4baciim 2bacitracin inj 2bacitracin ophthalmic oint 2bacitracin/polymyxin b 2chloramphenicol sodium succinate

2

CLEOCIN SUPP 4clindacin etz pledgets 2clindacin-p 2clindamax 2clindamycin hcl 2clindamycin palmitate hcl 2clindamycin phosphate add-vantage

2 HI

clindamycin phosphate crea 2clindamycin phosphate external soln

2

clindamycin phosphate foam 2clindamycin phosphate gel 2clindamycin phosphate in d5w 2 HI

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DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Beta-lactam, CephalosporinsCEDAX CAPS 4cefaclor 2cefaclor er 2cefadroxil 2cefazolin 2 HIcefazolin sodium 2 HIcefazolin sodium/dextrose 2 HIcefdinir 2cefditoren pivoxil 2cefepime 2 HIcefepime/dextrose 2 HIcefixime 2cefotaxime sodium inj 1gm, 2gm, 500mg

2

cefotetan/dextrose 2cefoxitin sodium 2 HIcefpodoxime proxetil 2cefprozil 2ceftazidime 2 HIceftazidime/dextrose 2 HIceftibuten 2CEFTIN SUSR 4ceftriaxone in iso-osmotic dextrose

2

ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg

2

ceftriaxone/dextrose 2cefuroxime axetil 2cefuroxime sodium inj 1.5gm, 7.5gm, 750mg, 75gm

2

cephalexin 2FORTAZ INJ 500MG 4MAXIPIME 4 HISPECTRACEF TABS 400MG 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

nitrofurantoin 2nitrofurantoin macrocrystals caps 100mg, 50mg

2 QL(90/365)

nitrofurantoin monohydrate 2 QL(90/365)nitrofurantoin monohydrate/macrocrystals

2 QL(90/365)

polymyxin b sulfate 2polymyxin b sulfate/trimethoprim sulfate

2

PRIMSOL 4RELAGARD 4rosadan 2SILVER NITRATE EXTERNAL SOLN

3

silver sulfadiazine 2ssd 2SULFAMYLON 4SYNERCID 5trimethoprim 2trimethoprim sulfate/polymyxin b sulfate

2

TYGACIL 5 HIvancomycin 2 HIvancomycin hcl caps 125mg 5 QL(40/10)vancomycin hcl caps 250mg 5 QL(80/10)vancomycin hcl in dextrose 2 HIvancomycin hcl inj 0.9%; 1gm/200ml, 1000mg, 10gm, 500mg, 750mg

2 HI

vancomycin hcl inj 5000mg 2 B/D PAvandazole 2VIBATIV INJ 250MG 4 HIXIFAXAN TABS 200MG 5 PA QL(9/30)XIFAXAN TABS 550MG 5 PA QL(60/30)ZYVOX SUSR 5 QL(1680/28)

12


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

penicillin g potassium in iso-osmotic dextrose

2 HI

penicillin g potassium inj 20000000unit, 5000000unit

2 HI

penicillin g procaine 2penicillin g sodium 2penicillin v potassium 2pfizerpen-g 2 HIpiperacillin sodium/ tazobactam sodium

2 HI

piperacillin sodium/tazobactam sodium

2 HI

piperacillin/tazobactam 2 HIUNASYN 3 HIUNASYN BULK PACK 3 HIZOSYN 3 HIMacrolidesAZASITE 3azithromycin inj 2 HIazithromycin pack 2azithromycin susr 2azithromycin tabs 2clarithromycin 2clarithromycin er 2DIFICID 5 PA QL(20/30)e.e.s. 400 2E.E.S. GRANULES 3ery 2ERY-TAB 3ERYPED 200 3ERYPED 400 3ERYTHROCIN LACTOBIONATE

3

erythrocin stearate 2erythromycin 2erythromycin base 2erythromycin ethylsuccinate tabs

2

ilotycin 2KETEK 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SUPRAX CAPS 4SUPRAX CHEW 4SUPRAX SUSR 500MG/5ML 4tazicef 2TEFLARO 4 HIBeta-lactam, OtherAZACTAM IN ISO-OSMOTIC DEXTROSE INJ 1GM; 0

4 HI

AZACTAM IN ISO-OSMOTIC DEXTROSE INJ 2GM; 0

5 HI

AZACTAM INJ 1GM 4 HIAZACTAM INJ 2GM 5 HIaztreonam 2 HIcefotetan 2DORIBAX 4 HIimipenem/cilastatin 2 HIINVANZ 4 HImeropenem 2 HImeropenem/sodium chloride 2 HIMERREM 4 HIPRIMAXIN IV 4 HIPRIMAXIN IV ADD-VANTAGE 4 HIBeta-lactam, Penicillinsamoxicillin 2amoxicillin/clavulanate potassium

2

ampicillin 2ampicillin sodium inj 125mg, 250mg, 500mg

2

ampicillin sodium inj 10gm, 1gm, 2gm

2 HI

ampicillin-sulbactam 2 HIbactocill in dextrose 2 HIBICILLIN C-R 4BICILLIN L-A 4dicloxacillin sodium 2NAFCILLIN 3 HInafcillin sodium 2 HIoxacillin sodium 2 HI

13



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

sulfamethoxazole/trimethoprim 2sulfamethoxazole/trimethoprim ds

2

sulfatrim pediatric 2Tetracyclinesdemeclocycline hcl 2doxy 100 2doxycycline caps 150mg, 75mg 2doxycycline hyclate 2doxycycline hyclate dr tbec 100mg, 150mg, 75mg

2

doxycycline monohydrate 2minocycline hcl 2mondoxyne nl 2tetracycline hcl 2

Anticonvulsants

Anticonvulsants, OtherAPTIOM TABS 200MG, 400MG, 800MG

4 QL(30/30)

APTIOM TABS 600MG 4 QL(60/30)BRIVIACT INJ 5 QL(600/30)BRIVIACT ORAL SOLN 5 QL(1200/30)BRIVIACT TABS 10MG, 25MG, 50MG, 75MG

5 QL(60/30)

BRIVIACT TABS 100MG 5 QL(120/30)FYCOMPA 4levetiracetam 2levetiracetam er 2POTIGA TABS 50MG 4 QL(90/30)POTIGA TABS 200MG, 300MG, 400MG

5 QL(90/30)

roweepra 2SPRITAM 4Calcium Channel Modifying AgentsCELONTIN 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PCE 3ZMAX 4 QL(60/30)QuinolonesAVELOX INJ 3BESIVANCE 4CILOXAN OINT 3CIPRO HC 3CIPRODEX 3ciprofloxacin er 2ciprofloxacin hcl 2ciprofloxacin i.v.-in d5w 2 HIciprofloxacin inj 400mg/40ml 2 HIciprofloxacin susr 2gatifloxacin 2levofloxacin in d5w 2 HIlevofloxacin inj 2 HIlevofloxacin ophthalmic soln 2levofloxacin oral soln 2levofloxacin tabs 2 QL(30/30)MOXEZA 3moxifloxacin hcl inj 2moxifloxacin hcl tabs 2 QL(30/30)ofloxacin 2VIGAMOX 3SulfonamidesBLEPHAMIDE 4BLEPHAMIDE S.O.P. 4sodium sulfacetamide ophthalmic soln

2

sulfacetamide sodium oint 2sulfacetamide sodium susp 2sulfacetamide sodium/prednisolone sodium phosphate

2

sulfadiazine 2

14


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

carbamazepine 2carbamazepine er 2DILANTIN 4DILANTIN INFATABS 4DILANTIN-125 4epitol 2EQUETRO 4fosphenytoin sodium inj 100mg pe/2ml

2

oxcarbazepine 2OXTELLAR XR 4PEGANONE 4PHENYTEK 4phenytoin 2phenytoin sodium 2phenytoin sodium extended 2TEGRETOL-XR TB12 100MG 4VIMPAT INJ 3VIMPAT ORAL SOLN 3 QL(1200/30)VIMPAT TABS 3 QL(60/30)

Antidementia Agents

Antidementia Agents, Otherergoloid mesylates 2 PACholinesterase Inhibitorsdonepezil hcl tabs 23mg, 5mg 2 QL(30/30)donepezil hcl tabs 10mg 2 QL(60/30)donepezil hcl tbdp 5mg 2 QL(30/30)donepezil hcl tbdp 10mg 2 QL(60/30)EXELON PT24 3 QL(30/30)galantamine hydrobromide cp24

2 QL(30/30)

galantamine hydrobromide oral soln

2 QL(200/30)

galantamine hydrobromide tabs 2 QL(60/30)rivastigmine tartrate 2 QL(60/30)rivastigmine transdermal system

2 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ethosuximide 2LYRICA CAPS 225MG, 300MG 3 QL(60/30)LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG

3 QL(90/30)

LYRICA ORAL SOLN 3 QL(900/30)zonisamide 2Gamma-aminobutyric Acid (GABA) Augmenting Agentsclonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg

2 QL(150/30)

clonazepam odt tbdp 2mg 2 QL(300/30)clonazepam tabs 0.5mg, 1mg 2 QL(150/30)clonazepam tabs 2mg 2 QL(300/30)diazepam gel 2divalproex sodium 2divalproex sodium dr 2divalproex sodium er 2gabapentin 2ONFI SUSP 4 QL(480/30)ONFI TABS 10MG 4 QL(60/30)ONFI TABS 20MG 4 QL(120/30)phenobarbital 2primidone 2SABRIL PACK 5 QL(200/30)SABRIL TABS 5 QL(180/30)tiagabine hydrochloride 2valproate sodium 2valproic acid 2Glutamate Reducing Agentsfelbamate susp 5felbamate tabs 2lamotrigine 2lamotrigine er 2lamotrigine odt 2topiramate 2Sodium Channel AgentsBANZEL SUSP 5BANZEL TABS 400MG 5BANZEL TABS 200MG 4

15



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin and Norepinephrine Reuptake Inhibitorcitalopram hydrobromide oral soln

2 QL(600/30)

citalopram hydrobromide tabs 40mg

2 QL(30/30)

citalopram hydrobromide tabs 10mg, 20mg

2 QL(60/30)

duloxetine hcl cpep 20mg, 60mg

2 QL(60/30)

duloxetine hcl cpep 30mg 2 QL(90/30)escitalopram oxalate oral soln 2 QL(600/30)escitalopram oxalate tabs 2 QL(60/30)FETZIMA 4 QL(30/30)FETZIMA TITRATION PACK 4 QL(28/28)fluoxetine 2fluoxetine hcl 2fluvoxamine maleate 2olanzapine/fluoxetine 2 QL(30/30)paroxetine hcl tabs 10mg 2 QL(30/30)paroxetine hcl tabs 20mg, 30mg, 40mg

2 QL(60/30)

PAXIL SUSP 4 QL(900/30)PRISTIQ 3 QL(30/30)sertraline hcl conc 2 QL(300/30)sertraline hcl tabs 25mg 2 QL(30/30)sertraline hcl tabs 100mg 2 QL(60/30)sertraline hcl tabs 50mg 2 QL(90/30)venlafaxine hcl 2venlafaxine hcl er cp24 150mg, 37.5mg

2 QL(30/30)

venlafaxine hcl er cp24 75mg 2 QL(90/30)VENLAFAXINE HCL ER TB24 150MG, 225MG, 37.5MG

4 QL(30/30)

VENLAFAXINE HCL ER TB24 75MG

4 QL(90/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

N-methyl-D-aspartate (NMDA) Receptor Antagonistmemantine hcl tabs 10mg 2 QL(60/30)memantine hcl tabs 5mg 2 QL(90/30)memantine hcl titration pak 2 QL(49/28)memantine hydrochloride 2 QL(300/30)NAMENDA ORAL SOLN 3 QL(300/30)NAMENDA TABS 10MG 3 QL(60/30)NAMENDA TABS 5MG 3 QL(90/30)NAMENDA TITRATION PAK 3 QL(49/28)NAMENDA XR 3 QL(30/30)NAMENDA XR TITRATION PACK

3 QL(28/28)

Antidepressants

Antidepressants, OtherAPLENZIN 4 QL(30/30)bupropion hcl 2bupropion hcl er tb12 100mg 2 QL(60/30)bupropion hcl er tb12 150mg 2 QL(90/30)bupropion hcl sr tb12 100mg, 200mg

2 QL(60/30)

bupropion hcl sr tb12 150mg 2 QL(90/30)bupropion hcl xl tb24 300mg 2 QL(30/30)bupropion hcl xl tb24 150mg 2 QL(90/30)maprotiline hcl 2mirtazapine 2mirtazapine odt 2nefazodone hcl 2trazodone hcl 2TRINTELLIX 4 QL(30/30)Monoamine Oxidase InhibitorsEMSAM 5MARPLAN 4phenelzine sulfate 2tranylcypromine sulfate 2

16


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

granisetron hcl inj 2 HIgranisetron hcl tabs 2 B/D PA QL(60/30)ondansetron hcl inj 40mg/20ml, 4mg/2ml

2 B/D PA

ondansetron hcl oral soln 2 B/D PA QL(900/30)ondansetron hcl tabs 24mg 2 B/D PAondansetron hcl tabs 4mg, 8mg 2 B/D PA QL(90/30)ondansetron odt 2 B/D PA QL(90/30)SANCUSO 5 PA QL(4/30)

Antifungals

AntifungalsABELCET 5 B/D PAAMBISOME 5 B/D PAamphotericin b 2 B/D PABENSAL HP 3CANCIDAS 5 HIciclodan 2ciclopirox 2ciclopirox nail lacquer 2ciclopirox olamine 2ciclopirox treatment 2clotrimazole external crea 2clotrimazole external soln 2clotrimazole troc 2clotrimazole/betamethasone dipropionate

2

econazole nitrate 2ERAXIS 5ERTACZO 4fluconazole 2fluconazole in dextrose 2 HIfluconazole in nacl inj 100mg/50ml; 0.9%, 200mg/100ml; 0.9%

2 HI

flucytosine 5griseofulvin microsize 2griseofulvin ultramicrosize 2GYNAZOLE-1 4itraconazole 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

VIIBRYD 3 QL(30/30)VIIBRYD STARTER PACK 3 QL(30/30)Tricyclicsamitriptyline hcl 2 PAamoxapine 2clomipramine hcl 2 PAdesipramine hcl 2doxepin hcl 2 PAimipramine hcl 2 PAimipramine pamoate 2 PAnortriptyline hcl 2perphenazine/amitriptyline 2 PAprotriptyline hcl 2SURMONTIL 4 PAtrimipramine maleate 2 PA

Antiemetics

Antiemeticsgranisetron hcl inj 2 HIAntiemetics, Otherdimenhydrinate inj 2droperidol 2meclizine hcl tabs 2phenadoz 2 PAphenergan supp 2 PApromethazine hcl 2 PApromethazine hcl plain 2 PApromethegan 2 PATRANSDERM-SCOP 4Emetogenic Therapy AdjunctsALOXI 4 B/D PAANZEMET 4 B/D PA QL(5/30)CESAMET 5 B/D PAdronabinol 2 B/D PAEMEND CAPS 40MG 3 B/D PA QL(2/30)EMEND CAPS 125MG 3 B/D PA QL(4/30)EMEND CAPS 80MG 3 B/D PA QL(8/30)EMEND CAPS 3 B/D PA QL(12/30)EMEND SUSR 3 B/D PA QL(6/28)

17



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

COLCRYS 3probenecid 2probenecid/colchicine 2ULORIC 3 QL(30/30) ST

Antimigraine Agents

Ergot AlkaloidsCAFERGOT 4dihydroergotamine mesylate inj 2dihydroergotamine mesylate nasal soln

2 QL(8/30)

ERGOMAR 4migergot 2MIGRANAL 5 QL(8/30)Serotonin (5-HT) 1b/1d Receptor Agonistsalmotriptan malate tabs 12.5mg 2 QL(12/30) STalmotriptan malate tabs 6.25mg 2 QL(18/30) STAXERT TABS 12.5MG 4 QL(12/30) STAXERT TABS 6.25MG 4 QL(18/30) STFROVA 4 QL(18/30) STfrovatriptan succinate 2 QL(18/30) STnaratriptan hcl 2 QL(9/30) STRELPAX TABS 40MG 4 QL(6/30) STRELPAX TABS 20MG 4 QL(12/30) STrizatriptan benzoate 2 QL(12/30)rizatriptan benzoate odt 2 QL(12/30)sumatriptan 2 QL(12/30)sumatriptan succinate inj 2 QL(8/30)sumatriptan succinate refill 2 QL(8/30)sumatriptan succinate tabs 2 QL(9/30)zolmitriptan odt tbdp 5mg 2 QL(6/30)zolmitriptan odt tbdp 2.5mg 2 QL(12/30)zolmitriptan tabs 5mg 2 QL(6/30)zolmitriptan tabs 2.5mg 2 QL(12/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ketoconazole crea 2ketoconazole sham 2ketoconazole tabs 2miconazole 3 2MYCAMINE 5 HInaftifine hcl 2naftifine hydrochloride 2NAFTIN 3NATACYN 4NOXAFIL SUSP 5NOXAFIL TBEC 5nyamyc 2nystatin crea 2nystatin oint 2nystatin powd 100000unit/gm 2nystatin susp 2nystatin tabs 2nystatin/triamcinolone 2nystop 2oxiconazole nitrate 2OXISTAT 4SPORANOX ORAL SOLN 5terbinafine hcl tabs 2terconazole 2voriconazole inj 2voriconazole susr 5voriconazole tabs 5zazole crea 2

Antigout Agents

Antigout Agentsallopurinol 2ALOPRIM 4colchicine 2

18


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MUSTARGEN 3 B/D PAthiotepa 2 B/D PATREANDA 5 B/D PAVALCHLOR 5YONDELIS 5 B/D PAZANOSAR 4 B/D PAAntiandrogensbicalutamide 2flutamide 2NILANDRON 5nilutamide 5XTANDI 5ZYTIGA 5Antiangiogenic AgentsPOMALYST 5REVLIMID 5 QL(28/28)THALOMID 5Antiestrogens/ModifiersEMCYT 3FARESTON 5FASLODEX 5 B/D PASOLTAMOX 4tamoxifen citrate 2Antimetabolitesadrucil 2 B/D PAALIMTA 5 B/D PAARRANON 5 B/D PAcladribine 5 B/D PACLOLAR 5 B/D PAcytarabine aqueous 2 B/D PAcytarabine inj 100mg/ml 2 B/D PADROXIA 3ELITEK 5 B/D PAfloxuridine 2fluorouracil inj 2 B/D PAFOLOTYN 5 B/D PAgemcitabine 2 B/D PAgemcitabine hcl 2 B/D PAhydroxyurea 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antimyasthenic Agents

ParasympathomimeticsGUANIDINE HCL 3MESTINON SYRP 3MESTINON TIMESPAN 3pyridostigmine bromide 2pyridostigmine bromide er 2

Antimycobacterials

Antimycobacterials, Otherdapsone 2rifabutin 2AntitubercularsCAPASTAT SULFATE 3cycloserine 2ethambutol hcl 2isoniazid 2PASER 4pyrazinamide 2RIFAMATE 4rifampin 2RIFATER 4SIRTURO 5TRECATOR 3

Antineoplastics

Alkylating AgentsBENDEKA 5 B/D PABICNU 3 B/D PABUSULFEX 3 B/D PAcyclophosphamide 2 B/D PAdacarbazine 2 B/D PAEVOMELA 5 B/D PAGLEOSTINE 3HEXALEN 5ifosfamide 2 B/D PALEUKERAN 3MATULANE 5melphalan hydrochloride 2 B/D PA

19



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

JEVTANA 5 B/D PAleucovorin calcium 2levoleucovorin calcium 5levoleucovorin inj 250mg/25ml 5LYNPARZA 5 QL(480/30)MARQIBO 5 B/D PAmesna 2 B/D PAMESNEX TABS 5mitomycin 2 B/D PAmitoxantrone hcl 2 B/D PANINLARO 5 QL(3/28)ODOMZO 5 QL(30/30)ONCASPAR 5 B/D PAoxaliplatin inj 100mg, 100mg/20ml, 50mg/10ml

5 B/D PA

paclitaxel 2 B/D PAPHOTOFRIN 5PORTRAZZA 5 B/D PAPROLEUKIN 5 B/D PASYLATRON 5 PASYNRIBO 5 B/D PAteniposide 2 B/D PATHERACYS 4TICE BCG 3TRISENOX 4 B/D PAVELCADE 5 B/D PAVENCLEXTA STARTING PACK 5 QL(84/365)VENCLEXTA TABS 50MG 4 QL(30/30)VENCLEXTA TABS 10MG 4 QL(60/30)VENCLEXTA TABS 100MG 5 QL(120/30)vinblastine sulfate 2 B/D PAvincasar pfs 2 B/D PAvincristine sulfate 2 B/D PAvinorelbine tartrate 2 B/D PAZOLINZA 5

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LONSURF TABS 8.19MG; 20MG

5 QL(80/28)

LONSURF TABS 6.14MG; 15MG

5 QL(100/28)

mercaptopurine 2NIPENT 5 B/D PAPURIXAN 4TABLOID 4Antineoplastics, OtherABRAXANE 5 B/D PAamifostine 5 B/D PAazacitidine 5 B/D PABELEODAQ 5 B/D PAbleomycin sulfate 2 B/D PAcarboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml

2 B/D PA

cisplatin 2 B/D PACOSMEGEN 5 B/D PAdaunorubicin hcl 2 B/D PAdecitabine 5 B/D PAdexrazoxane 2 B/D PADOCEFREZ INJ 20MG 5 B/D PAdocetaxel 5 B/D PAdoxorubicin hcl 2 B/D PAdoxorubicin hcl liposome 5 B/D PAepirubicin hcl inj 200mg/100ml, 50mg/25ml

2 B/D PA

ERWINAZE 5 B/D PAfludarabine phosphate 2 B/D PAHALAVEN 5IBRANCE 5 QL(21/28)idarubicin hcl 5 B/D PAirinotecan 2 B/D PAISTODAX 5 B/D PAIXEMPRA KIT 5 B/D PA

20


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

LENVIMA 24 MG DAILY DOSE 5LENVIMA 8 MG DAILY DOSE 5MEKINIST 5NEXAVAR 5SPRYCEL 5STIVARGA 5SUTENT 5TAFINLAR 5TAGRISSO 5 QL(30/30)TARCEVA 5TASIGNA 5TYKERB 5VOTRIENT 5XALKORI 5ZELBORAF 5ZYKADIA 5 QL(150/30)Monoclonal AntibodiesAVASTIN 5 B/D PACYRAMZA 5 B/D PADARZALEX 5 B/D PAEMPLICITI 5 B/D PAERBITUX 5 B/D PAGAZYVA 5 B/D PAHERCEPTIN 5 B/D PAKADCYLA 5 B/D PAKEYTRUDA 5 B/D PAOPDIVO 5 B/D PAPERJETA 5 B/D PARITUXAN INJ 500MG/50ML 5 PATECENTRIQ 5 PA QL(20/21)UNITUXIN 5 B/D PAVECTIBIX 5 B/D PAYERVOY 5 B/D PAZALTRAP 5 B/D PARetinoidsbexarotene 5PANRETIN 5TARGRETIN 5tretinoin caps 5

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Aromatase Inhibitors, 3rd Generationanastrozole 2 QL(30/30)exemestane 2letrozole 2Enzyme InhibitorsETOPOPHOS 4 B/D PAetoposide inj 2 B/D PAtoposar 2 B/D PAtopotecan hcl 5 B/D PAZYDELIG 5 QL(60/30)Molecular Target InhibitorsAFINITOR DISPERZ TBSO 2MG, 3MG

5 QL(60/30)

AFINITOR DISPERZ TBSO 5MG

5 QL(120/30)

AFINITOR TABS 2.5MG, 5MG, 7.5MG

5 QL(30/30)

AFINITOR TABS 10MG 5 QL(60/30)ALECENSA 5 QL(240/30)BOSULIF 5CABOMETYX TABS 20MG, 60MG

5 PA QL(30/30)

CABOMETYX TABS 40MG 5 PA QL(60/30)CAPRELSA 5COMETRIQ 5COTELLIC 5 QL(63/28)ERIVEDGE 5FARYDAK 5 QL(9/28)GILOTRIF 5GLEEVEC 5ICLUSIG 5imatinib mesylate 5IMBRUVICA 5INLYTA 5IRESSA 5JAKAFI 5LENVIMA 10 MG DAILY DOSE 5LENVIMA 14 MG DAILY DOSE 5LENVIMA 18 MG DAILY DOSE 5LENVIMA 20 MG DAILY DOSE 5

21



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Dopamine AgonistsAPOKYN 5bromocriptine mesylate 2NEUPRO 4 QL(30/30)pramipexole dihydrochloride 2pramipexole dihydrochloride er 2ropinirole er 2ropinirole hcl 2Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitorscarbidopa 2carbidopa/levodopa 2carbidopa/levodopa er 2carbidopa/levodopa odt 2carbidopa/levodopa/entacapone

2

Monoamine Oxidase B (MAO-B) InhibitorsAZILECT 3selegiline hcl 2ZELAPAR 4

Antipsychotics

1st Generation/Typicalchlorpromazine hcl inj 50mg/2ml

2

chlorpromazine hcl tabs 2compro 2fluphenazine decanoate 2fluphenazine hcl 2haloperidol 2haloperidol decanoate 2haloperidol lactate 2loxapine succinate 2ORAP 4perphenazine 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antiparasitics

AnthelminticsALBENZA 4ivermectin 2AntiprotozoalsALINIA 4atovaquone 5atovaquone/proguanil hcl 2chloroquine phosphate 2COARTEM 4 QL(24/30)DARAPRIM 4hydroxychloroquine sulfate 2mefloquine hcl 2NEBUPENT 4 B/D PAPENTAM 300 4PRIMAQUINE PHOSPHATE 4quinine sulfate 2 PAtinidazole 2Pediculicides/ScabicidesEURAX 4lindane 2malathion 2permethrin 2SKLICE 4

Antiparkinson Agents

Anticholinergicsbenztropine mesylate inj 2benztropine mesylate tabs 2 PAtrihexyphenidyl hcl 2 PAAntiparkinson Agents, Otherentacapone 2tolcapone 5

22


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

olanzapine tabs 2.5mg 2 QL(60/30)paliperidone er tb24 1.5mg, 3mg

2 QL(30/30)

paliperidone er tb24 6mg 2 QL(60/30)paliperidone er tb24 9mg 5 QL(30/30)quetiapine fumarate 2 QL(90/30)REXULTI 5 QL(30/30)RISPERDAL CONSTA INJ 37.5MG, 50MG

5

RISPERDAL CONSTA INJ 12.5MG, 25MG

4

risperidone m-tab tbdp 0.5mg, 2mg

2 QL(90/30)

risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg

2 QL(90/30)

risperidone odt tbdp 4mg 2 QL(120/30)risperidone oral soln 2 QL(360/30)risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg

2 QL(90/30)

risperidone tabs 4mg 2 QL(120/30)SAPHRIS 3 QL(60/30)SEROQUEL XR TB24 150MG, 200MG

3 QL(30/30)

SEROQUEL XR TB24 300MG, 400MG, 50MG

3 QL(60/30)

VRAYLAR CAPS 5 QL(30/30)VRAYLAR CPPK 4 QL(14/365)ziprasidone hcl 2 QL(60/30)ZYPREXA RELPREVV INJ 405MG

5 QL(1/28)

ZYPREXA RELPREVV INJ 300MG

5 QL(2/28)

ZYPREXA RELPREVV INJ 210MG

5 QL(2.8/28)

Antipsychoticsmolindone hydrochloride 2Treatment-Resistantclozapine 2clozapine odt 2FAZACLO TBDP 100MG, 12.5MG, 25MG

4

VERSACLOZ 5

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

pimozide 2prochlorperazine 2prochlorperazine edisylate 2prochlorperazine maleate 2thioridazine hcl 2 PAthiothixene 2trifluoperazine hcl 22nd Generation/AtypicalABILIFY MAINTENA INJ 300MG

5 QL(1.5/30)

ABILIFY MAINTENA INJ 400MG

5 QL(2/30)

aripiprazole odt 5 QL(60/30)aripiprazole oral soln 2 QL(900/30)aripiprazole tabs 2 QL(30/30)ARISTADA INJ 441MG/1.6ML 5 QL(1.6/30)ARISTADA INJ 662MG/2.4ML 5 QL(2.4/30)ARISTADA INJ 882MG/3.2ML 5 QL(3.2/30)FANAPT TABS 10MG, 12MG, 6MG, 8MG

5 QL(60/30)

FANAPT TABS 1MG, 2MG, 4MG

4 QL(60/30)

FANAPT TITRATION PACK 4 QL(16/30)GEODON INJ 4INVEGA SUSTENNA INJ 39MG/0.25ML, 78MG/0.5ML

4

INVEGA SUSTENNA INJ 117MG/0.75ML, 156MG/ML, 234MG/1.5ML

5

INVEGA TB24 9MG 5 QL(30/30)INVEGA TB24 1.5MG, 3MG 4 QL(30/30)INVEGA TB24 6MG 4 QL(60/30)INVEGA TRINZA 5LATUDA TABS 120MG, 20MG, 40MG, 60MG

3 QL(30/30)

LATUDA TABS 80MG 3 QL(60/30)NUPLAZID 5 PA QL(60/30)olanzapine inj 2olanzapine odt 2 QL(30/30)olanzapine tabs 10mg, 15mg, 20mg, 5mg, 7.5mg

2 QL(30/30)

23



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PEGINTRON 5 PAREBETOL ORAL SOLN 5ribasphere caps 2ribasphere ribapak 5ribasphere tabs 200mg, 400mg 2ribasphere tabs 600mg 5ribavirin 2SOVALDI 5 PA QL(28/28)Anti-HIV Agents, Integrase Inhibitors (INSTI)GENVOYA 5ISENTRESS CHEW 3ISENTRESS PACK 3ISENTRESS TABS 5TIVICAY TABS 50MG 5TIVICAY TABS 10MG, 25MG 4VITEKTA 5Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)COMPLERA 5EDURANT 5INTELENCE TABS 100MG, 200MG

5

INTELENCE TABS 25MG 4nevirapine 2nevirapine er 2ODEFSEY 5RESCRIPTOR 4STRIBILD 5SUSTIVA CAPS 200MG 5SUSTIVA CAPS 50MG 3SUSTIVA TABS 5VIRAMUNE XR TB24 100MG 4Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)abacavir 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Antispasticity Agents

Antispasticity Agentsbaclofen tabs 2dantrolene sodium 2tizanidine hcl 2XEOMIN 4 PA

Antivirals

Anti-cytomegalovirus (CMV) Agentscidofovir 5ganciclovir inj 2 B/D PAVALCYTE ORAL SOLN 5valganciclovir 5valganciclovir hydrochlorde 5ZIRGAN 4Anti-hepatitis B (HBV) Agentsadefovir dipivoxil 5BARACLUDE ORAL SOLN 5entecavir 2EPIVIR HBV ORAL SOLN 4INTRON A 5INTRON A W/DILUENT 5lamivudine 2TYZEKA 5Anti-hepatitis C (HCV) AgentsHARVONI 5 PA QL(28/28)moderiba 1200 dose pack 5moderiba 800 dose pack 5moderiba misc 5moderiba tabs 2OLYSIO 5 PA QL(28/28)PEG-INTRON REDIPEN 5 PAPEG-INTRON REDIPEN PAK 4 5 PA

24


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PREZISTA TABS 150MG, 75MG

4

REYATAZ 5VIRACEPT 5Anti-influenza Agentsamantadine hcl 2RELENZA DISKHALER 4 QL(120/365)rimantadine hcl 2TAMIFLU CAPS 75MG 3 QL(56/365)TAMIFLU CAPS 45MG 3 QL(60/365)TAMIFLU CAPS 30MG 3 QL(120/365)TAMIFLU SUSR 3Antiherpetic Agentsacyclovir 2acyclovir sodium inj 500mg, 50mg/ml

2 B/D PA

DENAVIR 3famciclovir 2trifluridine 2valacyclovir hcl 2ZOVIRAX CREA 4

Anxiolytics

Anxiolytics, Otherbuspirone hcl 2Benzodiazepinesalprazolam er tb24 1mg, 2mg, 3mg

2 QL(90/30)

alprazolam intensol 2 QL(300/30)alprazolam odt tbdp 0.25mg, 0.5mg

2 QL(90/30)

alprazolam odt tbdp 1mg 2 QL(120/30)alprazolam odt tbdp 2mg 2 QL(150/30)alprazolam tabs 0.25mg, 0.5mg 2 QL(90/30)alprazolam tabs 1mg 2 QL(120/30)alprazolam tabs 2mg 2 QL(150/30)alprazolam xr 2 QL(90/30)clorazepate dipotassium tabs 3.75mg, 7.5mg

2 QL(90/30)

clorazepate dipotassium tabs 15mg

2 QL(120/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

abacavir sulfate/lamivudine/zidovudine

5

DESCOVY 5 QL(30/30)didanosine 2EMTRIVA 4EPZICOM 5lamivudine 2lamivudine/zidovudine 2RETROVIR IV INFUSION 4stavudine 2TRUVADA 5VIDEX PEDIATRIC 3VIREAD 5ZIAGEN ORAL SOLN 4zidovudine 2Anti-HIV Agents, OtherATRIPLA 5FUZEON 5SELZENTRY 5TRIUMEQ 5TYBOST 3Anti-HIV Agents, Protease InhibitorsAPTIVUS 5CRIXIVAN 3EVOTAZ 5INVIRASE CAPS 4INVIRASE TABS 5KALETRA ORAL SOLN 5KALETRA TABS 200MG; 50MG

5

KALETRA TABS 100MG; 25MG

4

LEXIVA SUSP 4LEXIVA TABS 5NORVIR 4PREZCOBIX 5PREZISTA SUSP 5PREZISTA TABS 600MG, 800MG

5

25



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

JANUMET XR TB24 1000MG; 100MG

3 QL(30/30)

JANUMET XR TB24 1000MG; 50MG, 500MG; 50MG

3 QL(60/30)

JANUVIA 3 QL(30/30)JENTADUETO 3 QL(60/30)JENTADUETO XR TB24 5MG; 1000MG

3 QL(30/30)

JENTADUETO XR TB24 2.5MG; 1000MG

3 QL(60/30)

metformin hcl 1metformin hcl er 1miglitol 2nateglinide 1pioglitazone hcl 1 QL(30/30)pioglitazone hcl-glimepiride 2 QL(30/30)pioglitazone hcl/metformin hcl 2 QL(90/30)repaglinide 2RIOMET 3SYMLINPEN 120 4 QL(11/30)SYMLINPEN 60 4 QL(6/30)TRADJENTA 3 QL(30/30)TRULICITY 3 QL(2/28)VICTOZA 3 QL(9/30)Glycemic AgentsGLUCAGEN HYPOKIT 3GLUCAGON EMERGENCY KIT

3

PROGLYCEM 4InsulinsHUMALOG 3HUMALOG KWIKPEN 3HUMALOG MIX 50/50 3HUMALOG MIX 50/50 KWIKPEN

3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

diazepam conc 2 QL(240/30)diazepam inj 2diazepam intensol 2 QL(240/30)diazepam oral soln 2 QL(1200/30)diazepam tabs 2 QL(120/30)lorazepam conc 2 QL(150/30)lorazepam inj 20mg/10ml, 2mg/ml, 4mg/ml

2

lorazepam intensol 2 QL(150/30)lorazepam tabs 2 QL(120/30)oxazepam 2 QL(120/30)

Bipolar Agents

Mood Stabilizerslithium 2lithium carbonate 2lithium carbonate er 2

Blood Glucose Regulators

Antidiabetic Agentsacarbose 2AVANDIA 4 QL(60/30)BYDUREON 3 QL(4/28)BYDUREON PEN 3 QL(4/28)BYETTA 3 QL(2.4/30)glimepiride 1glipizide 1glipizide er 1glipizide xl 1glipizide/metformin hcl 1GLYSET 4INVOKAMET 3 QL(60/30)INVOKAMET XR 3 QL(60/30)INVOKANA 3 QL(30/30)JANUMET 3 QL(60/30)

26


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

enoxaparin sodium inj 60mg/0.6ml

2 QL(18/30)


2 QL(24/30)

enoxaparin sodium inj 100mg/ml

2 QL(30/30)

enoxaparin sodium inj 300mg/3ml

2 QL(90/30)


5 QL(24/30)

enoxaparin sodium inj 150mg/ml

5 QL(30/30)

fondaparinux sodium inj 5mg/0.4ml

5 QL(12/30)

fondaparinux sodium inj 7.5mg/0.6ml

5 QL(18/30)

fondaparinux sodium inj 10mg/0.8ml

5 QL(24/30)

fondaparinux sodium inj 2.5mg/0.5ml

2 QL(15/30)

FRAGMIN INJ 7500UNIT/0.3ML

5 QL(9/30) ST


5 QL(15/30) ST


5 QL(18/30) ST

FRAGMIN INJ 18000UNT/0.72ML

5 QL(21.6/30) ST


5 QL(22.8/30) ST

FRAGMIN INJ 10000UNIT/ML 5 QL(30/30) STFRAGMIN INJ 2500UNIT/0.2ML, 5000UNIT/0.2ML

4 QL(6/30) ST

heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 2000unit/ml, 2500unit/ml, 5000unit/0.5ml, 5000unit/ml

2

heparin sodium/d5w 2heparin sodium/nacl 0.45% 2heparin sodium/nacl 0.9% 2heparin sodium/sodium chloride 0.9%

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

HUMALOG MIX 75/25 3HUMALOG MIX 75/25 KWIKPEN

3

HUMULIN 70/30 3HUMULIN 70/30 KWIKPEN 3HUMULIN N 3HUMULIN N KWIKPEN 3HUMULIN R 3HUMULIN R U-500 (CONCENTRATED)

3

HUMULIN R U-500 KWIKPEN 3LANTUS 3LANTUS SOLOSTAR 3LEVEMIR 3LEVEMIR FLEXTOUCH 3NOVOLIN 70/30 4 STNOVOLIN 70/30 RELION 4 STNOVOLIN N 4 STNOVOLIN N RELION 4 STNOVOLIN R 4 STNOVOLIN R INNOLET 4 STNOVOLIN R RELION 4 STNOVOLOG 4 STNOVOLOG FLEXPEN 4 STNOVOLOG MIX 70/30 4 STNOVOLOG MIX 70/30 PREFILLED FLEXPEN

4 ST

NOVOLOG PENFILL 4 STTOUJEO SOLOSTAR 3TRESIBA FLEXTOUCH 3

Blood Products/Modifiers/Volume Expanders

AnticoagulantsCOUMADIN 4ELIQUIS TABS 2.5MG 3 QL(60/30)ELIQUIS TABS 5MG 3 QL(74/30)enoxaparin sodium inj 30mg/0.3ml

2 QL(9/30)


2 QL(12/30)

27



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tranexamic acid tabs 2 QL(180/30)Platelet Modifying AgentsAGGRENOX 3 QL(60/30)aspirin/dipyridamole 2 QL(60/30)BRILINTA 3 QL(60/30)cilostazol 2clopidogrel tabs 75mg 2clopidogrel tabs 300mg 2 QL(1/30)EFFIENT TABS 10MG 4 QL(36/30)EFFIENT TABS 5MG 4 QL(42/30)

Cardiovascular Agents

Alpha-adrenergic Agonistsclonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr

2 QL(4/28)

clonidine hcl ptwk 0.3mg/24hr 2 QL(8/28)clonidine hcl tabs 2clorpres 2midodrine hcl 2Alpha-adrenergic Blocking AgentsDIBENZYLINE 3phenoxybenzamine hydrochloride

2

prazosin hcl 2Angiotensin II Receptor AntagonistsBENICAR 3 QL(30/30)BENICAR HCT 3 QL(30/30)candesartan cilexetil 1 QL(30/30)candesartan cilexetil/hydrochlorothiazide

1 QL(30/30)

ENTRESTO 3 PA QL(60/30)eprosartan mesylate 2 QL(30/30)irbesartan 1 QL(30/30)irbesartan/hydrochlorothiazide 1 QL(30/30)losartan potassium tabs 100mg 1 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

heparin sodium/sodium chloride 0.9% premix

2

jantoven 2PRADAXA 3 QL(60/30)warfarin sodium 2XARELTO STARTER PACK 3 QL(102/365)XARELTO TABS 10MG, 20MG 3 QL(30/30)XARELTO TABS 15MG 3 QL(60/30)Blood Formation Modifiersanagrelide hydrochloride 2ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 25MCG/0.42ML, 25MCG/ML, 40MCG/0.4ML, 40MCG/ML, 60MCG/0.3ML, 60MCG/ML

3 PA

ARANESP ALBUMIN FREE INJ 100MCG/0.5ML, 100MCG/ML, 150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML, 300MCG/0.6ML, 300MCG/ML, 500MCG/ML

5 PA

EPOGEN 4 PAGRANIX 5LEUKINE INJ 250MCG 5NEULASTA 5NEUPOGEN 5PROCRIT INJ 20000UNIT/ML, 40000UNIT/ML

5 PA

PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML

3 PA

PROMACTA TABS 12.5MG, 25MG, 50MG

5

ZARXIO 5Coagulantsaminocaproic acid 2tranexamic acid inj 2

28


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

trandolapril/verapamil hcl er tbcr 4mg; 240mg

2 QL(60/30)

trandolapril/verapamil hcl tbcr 1mg; 240mg, 2mg; 180mg, 2mg; 240mg

2 QL(30/30)

trandolapril/verapamil hcl tbcr 4mg; 240mg

2 QL(60/30)

Antiarrhythmicsamiodarone hcl inj 50mg/ml, 900mg/18ml

2

amiodarone hcl tabs 2dofetilide 4flecainide acetate 2lidocaine hcl inj 10mg/ml, 20mg/ml

2

mexiletine hcl 2MULTAQ 3 QL(60/30)pacerone 2procainamide hcl 2propafenone hcl 2propafenone hcl er 2quinidine gluconate 2quinidine gluconate cr 2quinidine gluconate er 2quinidine sulfate 2sorine 2sotalol hcl 2sotalol hcl (af) 2TIKOSYN 4Beta-adrenergic Blocking Agentsacebutolol hcl 2atenolol 2atenolol/chlorthalidone 2betaxolol hcl 2bisoprolol fumarate 2bisoprolol fumarate/hydrochlorothiazide

2

BYSTOLIC TABS 20MG 3 QL(60/30)BYSTOLIC TABS 2.5MG, 5MG 3 QL(90/30)BYSTOLIC TABS 10MG 3 QL(120/30)BYVALSON 3 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

losartan potassium tabs 50mg 1 QL(60/30)losartan potassium tabs 25mg 1 QL(90/30)losartan potassium/hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg

1 QL(30/30)

losartan potassium/hydrochlorothiazide tabs 12.5mg; 50mg

1 QL(60/30)

telmisartan 1 QL(30/30)telmisartan/amlodipine 2 QL(30/30)telmisartan/hydrochlorothiazide 1 QL(30/30)valsartan tabs 320mg 1 QL(30/30)valsartan tabs 160mg, 40mg, 80mg

1 QL(60/30)

valsartan/hydrochlorothiazide 1 QL(30/30)Angiotensin-converting Enzyme (ACE) Inhibitorsbenazepril hcl 1benazepril hcl/hydrochlorothiazide

1

captopril 1captopril/hydrochlorothiazide 1enalapril maleate 1enalapril maleate/hydrochlorothiazide

1

enalaprilat 2fosinopril sodium 1fosinopril sodium/hydrochlorothiazide

1

lisinopril 1lisinopril/hydrochlorothiazide 1moexipril hcl 1moexipril/hydrochlorothiazide 1perindopril erbumine 1quinapril hcl 1quinapril/hydrochlorothiazide 1ramipril 1trandolapril 1trandolapril/verapamil hcl er tbcr 1mg; 240mg, 2mg; 180mg, 2mg; 240mg

2 QL(30/30)

29



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

diltiazem hcl cd 2diltiazem hcl er 2diltiazem hcl inj 100mg, 125mg/25ml, 25mg/5ml, 50mg/10ml

2

diltiazem hcl tabs 2felodipine er 2 QL(60/30)isradipine 2matzim la 2nicardipine hcl 2nifedical xl 2nifedipine er 2nimodipine 2nisoldipine er 2 QL(30/30)nisoldipine tb24 30mg 2nisoldipine tb24 17mg, 20mg, 34mg, 40mg, 8.5mg

2 QL(30/30)

NYMALIZE 5taztia xt 2verapamil hcl 2verapamil hcl er 2verapamil hcl sr cp24 2Cardiovascular Agents, OtherDEMSER 3digitek tabs 0.125mg 2 QL(30/30)digitek tabs 0.25mg 2 PAdigox tabs 125mcg 2 QL(30/30)digox tabs 250mcg 2 PAdigoxin inj 2 PAdigoxin oral soln 2 PAdigoxin tabs 125mcg 2 QL(30/30)digoxin tabs 250mcg 2 PALANOXIN PEDIATRIC 3 PALANOXIN TABS 62.5MCG 4 QL(30/30)LANOXIN TABS 187.5MCG 4 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

carvedilol 2COREG CR 3 QL(30/30)DUTOPROL 4esmolol hcl 2INNOPRAN XL 4labetalol hcl 2metoprolol succinate er tb24 200mg

2 QL(60/30)

metoprolol succinate er tb24 100mg, 25mg, 50mg

2 QL(90/30)

metoprolol tartrate 2metoprolol/hydrochlorothiazide 2nadolol 2nadolol/bendroflumethiazide 2pindolol 2propranolol hcl 2propranolol hcl er 2propranolol/hydrochlorothiazide 2timolol maleate 2Calcium Channel Blocking Agentsafeditab cr 2amlodipine besylate tabs 10mg, 5mg

2 QL(60/30)

amlodipine besylate tabs 2.5mg 2 QL(90/30)amlodipine besylate/atorvastatin calcium

2 QL(30/30)

amlodipine besylate/benazepril hydrochloride

2 QL(30/30)

amlodipine besylate/valsartan 2 QL(30/30)amlodipine/valsartan/hctz 2 QL(30/30)CARDENE IV 4cartia xt 2dilt-xr 2diltiazem cd cp24 180mg, 240mg, 300mg

2

30


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

fenofibrate tabs 145mg, 160mg 2 QL(30/30)fenofibrate tabs 48mg, 54mg 2 QL(60/30)fenofibric acid dr cpdr 135mg 2 QL(30/30)fenofibric acid dr cpdr 45mg 2 QL(60/30)gemfibrozil 2TRIGLIDE 4 QL(30/30)Dyslipidemics, HMG CoA Reductase Inhibitorsatorvastatin calcium 1 QL(30/30)CRESTOR 3 QL(30/30)fluvastatin caps 20mg 1 QL(30/30)fluvastatin caps 40mg 1 QL(60/30)fluvastatin sodium er 2 QL(30/30)LESCOL XL 4 QL(30/30)lovastatin tabs 40mg 1 QL(60/30)lovastatin tabs 10mg, 20mg 1 QL(90/30)pravastatin sodium tabs 80mg 1 QL(30/30)pravastatin sodium tabs 40mg 1 QL(60/30)pravastatin sodium tabs 10mg, 20mg

1 QL(90/30)

rosuvastatin calcium 2 QL(30/30)simvastatin tabs 20mg, 40mg, 80mg

1 QL(30/30)

simvastatin tabs 10mg, 5mg 1 QL(90/30)Dyslipidemics, Othercholestyramine 2cholestyramine light 2colestipol hcl 2JUXTAPID 5KYNAMRO 5niacin er tbcr 500mg 2 QL(30/30)niacin er tbcr 1000mg, 750mg 2 QL(60/30)niacor 2omega-3-acid ethyl esters 2 QL(120/30)prevalite 2REPATHA 5 PA QL(3/30)REPATHA PUSHTRONEX SYSTEM

5 PA QL(3.5/30)

REPATHA SURECLICK 5 PA QL(3/30)VASCEPA CAPS 1GM 4 QL(120/30)VYTORIN 4 QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NORTHERA 5 PA QL(180/30)pentoxifylline er 2RANEXA 3TEKTURNA 4 QL(30/30)TEKTURNA HCT 4 QL(30/30)Diuretics, Carbonic Anhydrase Inhibitorsacetazolamide 2acetazolamide sodium 2Diuretics, Loopbumetanide 2EDECRIN 3ethacrynate sodium 2ethacrynic acid 3furosemide 2SODIUM EDECRIN 3torsemide 2Diuretics, Potassium-sparingamiloride hcl 2amiloride/hydrochlorothiazide 2DYRENIUM 4eplerenone 2spironolactone 2spironolactone/hydrochlorothiazide

2

triamterene/hydrochlorothiazide 2Diuretics, Thiazidechlorothiazide 2chlorothiazide sodium 2chlorthalidone tabs 25mg, 50mg

2

DIURIL 3hydrochlorothiazide 2indapamide 2methyclothiazide 2metolazone 2Dyslipidemics, Fibric Acid Derivativesfenofibrate caps 130mg, 150mg, 43mg

2 QL(30/30)

fenofibrate caps 50mg 2 QL(60/30)fenofibrate micronized 2 QL(30/30)

31



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

dexmethylphenidate hcl 2metadate er 2 QL(90/30)METHYLIN CHEW 4methylphenidate hcl 2methylphenidate hcl cd 2methylphenidate hcl er cp24 20mg, 40mg

2

methylphenidate hcl er tb24 2 QL(30/30)methylphenidate hcl er tbcr 20mg

2 QL(90/30)

methylphenidate hcl er tbcr 10mg

2 QL(180/30)

methylphenidate hydrochloride 2STRATTERA CAPS 100MG, 60MG, 80MG

3 QL(30/30)

STRATTERA CAPS 10MG, 18MG, 25MG, 40MG

3 QL(60/30)

Central Nervous System, OtherHETLIOZ 5 PA QL(30/30)HORIZANT 4NUEDEXTA 3 QL(60/30)riluzole 2tetrabenazine 5XENAZINE 5Fibromyalgia AgentsSAVELLA 3 QL(60/30)SAVELLA TITRATION PACK 3 QL(55/30)Multiple Sclerosis AgentsAMPYRA 5 PA QL(60/30)AUBAGIO 5 PA QL(30/30)AVONEX 5AVONEX PEN 5COPAXONE INJ 40MG/ML 5EXTAVIA 5 PAGILENYA 5 PA QL(30/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

WELCHOL 3ZETIA 3 QL(30/30)Vasodilators, Direct-acting Arterialhydralazine hcl 2minoxidil 2Vasodilators, Direct-acting Arterial/VenousBIDIL 4isosorbide dinitrate er 2isosorbide dinitrate tabs 2isosorbide mononitrate 2isosorbide mononitrate er 2minitran 2NITRO-BID 4NITRO-DUR PT24 0.3MG/HR, 0.8MG/HR

4

nitroglycerin 2nitroglycerin lingual translingual soln

2

nitroglycerin transdermal 2NITROSTAT 3RECTIV 4

Central Nervous System Agents

Attention Deficit Hyperactivity Disorder Agents, Amphetaminesamphetamine/dextroamphetamine cp24

2 QL(60/30)

amphetamine/dextroamphetamine tabs

2

dextroamphetamine sulfate 2dextroamphetamine sulfate er 2methamphetamine hcl 2 PAAttention Deficit Hyperactivity Disorder Agents, Non-amphetaminesclonidine hcl er 2 QL(120/30)DAYTRANA 4 QL(30/30)

32


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CONDYLOX GEL 4CURITY GAUZE PADS 2”X2” 3diclofenac sodium gel 3% 2DIFFERIN LOTN 4doxepin hydrochloride 2doxycycline cpdr 2DRITHO-CREME HP 3ELIDEL 4erythromycin/benzoyl peroxide 2FINACEA 3fluorouracil crea 2fluorouracil external soln 2GORDONS UREA OINT 40% 4imiquimod 2latrix 2LEVULAN KERASTICK 3methoxsalen 5myorisan 2neuac 2ORACEA 4OXSORALEN 4podocon 25 in benzoin tincture 2podofilox 2PRUDOXIN 3rea lo 39 2rea lo 40 crea 2REGRANEX 5 PAremeven 2SANTYL 3selenium sulfide 2TAZORAC 4tretinoin crea 2 PAtretinoin gel 0.01%, 0.025% 2 PAtretinoin microsphere 2 PAtretinoin microsphere pump 2 PAumecta 2umecta mousse 2urea 40% nail film 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

glatopa 5REBIF 5REBIF REBIDOSE 5REBIF REBIDOSE TITRATION PACK

5

REBIF TITRATION PACK 5TYSABRI 5 PA

Dental and Oral Agents

Dental and Oral AgentsARESTIN 4cevimeline hcl 2chlorhexidine gluconate mouth/throat soln

2

fluoridex daily defense sensitivity relief pste

2

KEPIVANCE 5oralone 2paroex 2periogard 2pilocarpine hcl 2pilocarpine hydrochloride 2triamcinolone acetonide pste 2triamcinolone in orabase 2

Dermatological Agents

Dermatological Agents8-MOP 3acitretin 5adapalene 2ammonium lactate 2AZELEX 3BENZAMYCINPAK 4bpo 2calcipotriene 2calcitrene 2CARAC 4claravis 2clindamycin phosphate/tretinoin 4clindamycin/benzoyl peroxide 2

33



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

XIAFLEX 5 PAZAVESCA 5ZENPEP 3

Gastrointestinal Agents

Antispasmodics, Gastrointestinalanaspaz 2atropine sulfate inj 0.05mg/ml, 0.1mg/ml, 0.4mg/ml, 0.8mg/ml, 1mg/ml

2

belladonna & opium 2belladonna alkaloids & opium 2CUVPOSA 4dicyclomine hcl caps 2dicyclomine hcl oral soln 2dicyclomine hcl tabs 2ed-spaz 2glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml

2

glycopyrrolate tabs 2hyoscyamine sulfate elix 2hyoscyamine sulfate odt 2hyoscyamine sulfate subl 2hyoscyamine sulfate tabs 2hyoscyamine sulfate tbdp 2hyosyne 2methscopolamine bromide 2nulev 2oscimin 2propantheline bromide 2symax-sl 2Gastrointestinal Agents, OtherCHENODAL 5cromolyn sodium conc 5diphenoxylate/atropine 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

urea crea 39%, 40%, 45%, 47%, 50%

2

urea gel 2urea nail gel 2urea susp 2UVADEX 3 B/D PAVELTIN 4VOLTAREN GEL 3XERAC AC 3zenatane 2ZIANA 4ZONALON 3ZYCLARA 3ZYCLARA PUMP 3

Enzyme Replacement/Modifiers

Enzyme Replacement/ModifiersADAGEN 5ALDURAZYME 5BUPHENYL TABS 5CEREZYME 5 B/D PACREON 3CYSTADANE 5CYSTAGON 3ELAPRASE 5ELELYSO 5FABRAZYME 5 B/D PAKUVAN 5LUMIZYME 5NAGLAZYME 5ORFADIN 5RAVICTI 5sodium phenylbutyrate 5SUCRAID 5VPRIV 5 B/D PA

34


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

trilyte 2ProtectantsCARAFATE SUSP 4misoprostol 2sucralfate 2Proton Pump InhibitorsDEXILANT 4 QL(60/30)esomeprazole magnesium 2 QL(60/30)esomeprazole sodium 2lansoprazole 2 QL(60/30)omeprazole cpdr 2 QL(60/30)omeprazole/sodium bicarbonate caps

2 QL(60/30)

omeprazole/sodium bicarbonate pack

4 QL(60/30)

pantoprazole sodium inj 2pantoprazole sodium tbec 2 QL(60/30)rabeprazole sodium 2 QL(60/30)ZEGERID PACK 4 QL(60/30)

Genitourinary Agents

Antispasmodics, Urinaryazuphen mb 2flavoxate hcl 2GELNIQUE 3 QL(30/30)HYOLEV MB 4MYRBETRIQ 4 QL(30/30)oxybutynin chloride 2oxybutynin chloride er tb24 5mg

2 QL(30/30)

oxybutynin chloride er tb24 10mg, 15mg

2 QL(60/30)

phosphasal 2tolterodine tartrate 2 QL(60/30)tolterodine tartrate er 2 QL(30/30)trospium chloride 2 QL(60/30)trospium chloride er 2 QL(30/30)ur n-c 2uramit mb 2URELLE 4

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

GATTEX 5 PAloperamide hcl caps 2metoclopramide hcl 2MOTOFEN 3OSMOPREP 4PAREGORIC 3RELISTOR INJ 3ursodiol 2Histamine2 (H2) Receptor Antagonistscimetidine 2cimetidine hcl 2famotidine inj 2famotidine premixed 2famotidine susr 2famotidine tabs 20mg, 40mg 2nizatidine caps 2ranitidine hcl 2Irritable Bowel Syndrome Agentsalosetron hydrochloride 5 PAAMITIZA 3 QL(60/30)LINZESS 4 QL(30/30)Laxativesconstulose 2enulose 2gavilyte-c 2gavilyte-g 2gavilyte-n/flavor pack 2generlac 2GOLYTELY 3KRISTALOSE 4lactulose 2MOVIPREP 3NULYTELY/FLAVOR PACKS 3peg 3350/electrolytes 2peg-3350/electrolytes 2peg-3350/nacl/na bicarbonate/kcl

2

polyethylene glycol 3350 2SUPREP BOWEL PREP 3

35



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)a-hydrocort 2ala cort 2ALA SCALP 3alclometasone dipropionate 2amcinonide 2augmented betamethasone dipropionate

2

betamethasone dipropionate 2betamethasone sodium phosphate/betamethasone acetate

2

betamethasone valerate 2clobetasol propionate 2clobetasol propionate e 2clobetasol propionate emollient foam

2

clocortolone pivalate 2clocortolone pivalate pump 2clodan 2CORDRAN TAPE 3cormax scalp application 2CORTIFOAM 4cortisone acetate 2DEPO-MEDROL INJ 20MG/ML 4DESONATE 4desonide 2desoximetasone 2dexamethasone 2dexamethasone intensol 2dexamethasone sodium phosphate

2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

uribel 2urin d/s 2uro-mp 2ustell 2utira-c 2VESICARE 3 QL(30/30)Benign Prostatic Hypertrophy Agentsalfuzosin hcl er 2 QL(30/30)AVODART 3 QL(30/30)CIALIS TABS 2.5MG, 5MG 3 PA QL(30/30)doxazosin 2doxazosin mesylate tabs 1mg, 2mg, 8mg

2

dutasteride 2 QL(30/30)dutasteride/tamsulosin hydrochloride

2 QL(30/30)

finasteride tabs 5mg 2JALYN 3 QL(30/30)tamsulosin hcl 2terazosin hcl 2Genitourinary Agents, Otheracetic acid 0.25% 2bethanechol chloride 2ELMIRON 4LITHOSTAT 4phenazopyridine hcl 2Phosphate BindersAURYXIA 4calcium acetate caps 2calcium acetate tabs 667mg 2FOSRENOL 5 STPHOSLYRA 4RENVELA 3VELPHORO 4 ST

36


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

procto-med hc 2procto-pak 2proctosol hc 2proctozone-hc 2SOLU-CORTEF 3SOLU-MEDROL INJ 500MG 3SOLU-MEDROL INJ 2GM 3 HITEXACORT 3triamcinolone acetonide aers 2triamcinolone acetonide crea 2triamcinolone acetonide lotn 2triamcinolone acetonide oint 2trianex 2triderm 2VERDESO 4

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)desmopressin acetate 2EGRIFTA INJ 1MG 5 PA QL(60/30)H.P. ACTHAR 5 PASAIZEN 5 PASAIZEN CLICK.EASY 5 PASEROSTIM 5 PAZORBTIVE 5 PA

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers)

Anabolic SteroidsANADROL-50 5 PAoxandrolone 2 PAAndrogensANDRODERM 3ANDROGEL 3ANDROGEL PUMP GEL 1.62% 3ANDROXY 4danazol 2methitest 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

diflorasone diacetate 2fludrocortisone acetate 2fluocinolone acetonide 2fluocinolone acetonide body 2fluocinolone acetonide ear drops

2

fluocinolone acetonide scalp 2fluocinonide 2fluocinonide-e 2flurandrenolide crea 2fluticasone propionate 2halobetasol propionate 2hydrocortisone butyrate 2hydrocortisone external crea 2hydrocortisone lotn 2.5% 2hydrocortisone oint 1%, 2.5% 2hydrocortisone tabs 2hydrocortisone valerate 2KENALOG 4lokara 2MEDROL TABS 2MG 4methylprednisolone 2methylprednisolone acetate 2methylprednisolone dose pack 2methylprednisolone sodiumsuccinate inj 125mg, 40mg

2

methylprednisolone sodiumsuccinate inj 1000mg

2 HI

mometasone furoate crea 2mometasone furoate external soln

2

mometasone furoate oint 2PANDEL 3prednicarbate 2prednisolone oral soln 2prednisolone sodium phosphate

2

prednisone 2prednisone intensol 2

37



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

delyla 2DEPO-ESTRADIOL 3desogestrel/ethinyl estradiol 2DIVIGEL GEL 0.25MG/0.25GM, 0.5MG/0.5GM

4

drospirenone/ethinyl estradiol 2emoquette 2enpresse-28 2enskyce 2estarylla 2ESTRACE CREA 4estradiol pttw 2 PAestradiol ptwk 2 PAestradiol tabs 2 PAestradiol/norethindrone acetate 2 PAESTRING 4ESTROGEL 4estropipate 2 PAfalmina 2FEMRING 4 QL(1/90)fyavolv 2 PAgianvi 2gildagia 2gildess 1.5/30 2gildess 24 fe 2introvale 2jevantique lo 2 PAjinteli 2 PAjolessa 2juleber 2junel 1.5/30 2junel 1/20 2junel fe 1.5/30 2junel fe 1/20 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

STRIANT 4TESTIM 3testosterone cypionate 2testosterone enanthate 2testosterone gel 25mg/2.5gm 2testosterone pump 2EstrogensALORA 4 PAaltavera 2amethia 2amethyst 2ANGELIQ 4 PAapri 2aranelle 2ashlyna 2aubra 2aviane 2azurette 2balziva 2bekyree 2blisovi fe 1.5/30 2blisovi fe 1/20 2briellyn 2camrese 2camrese lo 2caziant 2chateal 2CLIMARA PRO 4 PA QL(4/28)COMBIPATCH 4 PAcryselle-28 2cyclafem 1/35 2cyclafem 7/7/7 2cyred 2daysee 2

38


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

necon 7/7/7 2nikki 2norethindrone & ethinyl estradiol ferrous fumarate

2

norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg

2

norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg, 5mcg; 1mg

2 PA

norethindrone acetate/ethinyl estradiol/ferrous fumarate

2

norgestimate/ethinyl estradiol 2nortrel 0.5/35 (28) 2nortrel 1/35 2nortrel 7/7/7 2NUVARING 4ocella 2ogestrel 2orsythia 2ORTHO TRI-CYCLEN LO 4pimtrea 2pirmella 1/35 2portia-28 2PREFEST 4 PAPREMARIN CREA 3PREMARIN INJ 4PREMARIN TABS 4 PA QL(30/30)PREMPHASE 4 PAPREMPRO 4 PAprevifem 2quasense 2reclipsen 2setlakin 2sprintec 28 2sronyx 2tarina fe 1/20 2tri-estarylla 2tri-legest fe 2tri-linyah 2tri-lo-estarylla 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

junel fe 24 2kaitlib fe 2kariva 2kelnor 1/35 2kimidess 2kurvelo 2larin 1.5/30 2larin 1/20 2larin fe 1.5/30 2larin fe 1/20 2larissia 2layolis fe 2lessina 2levonest 2levonorgestrel and ethinyl estradiol

2

levonorgestrel/ethinyl estradiol 2levora 0.15/30-28 2lomedia 24 fe 2lopreeza 2 PAloryna 2low-ogestrel 2lutera 2marlissa 2MENEST 4 PAMENOSTAR 4 PAmicrogestin 1.5/30 2microgestin 1/20 2microgestin fe 2microgestin fe 1.5/30 2mimvey 2 PAmimvey lo 2 PAmono-linyah 2mononessa 2myzilra 2necon 0.5/35-28 2necon 1/35 2necon 1/50-28 2necon 10/11-28 2

39



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

MEGACE ES 3 PAmegestrol acetate 2 PAnora-be 2norethindrone 2norethindrone acetate 2norlyroc 2progesterone 2sharobel 2Selective Estrogen Receptor Modifying Agentsraloxifene hydrochloride 2

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothyroxine sodium inj 5levothyroxine sodium tabs 2LEVOXYL 3liothyronine sodium 2SYNTHROID 4THYROLAR-1 4THYROLAR-1/2 4THYROLAR-1/4 4THYROLAR-2 4THYROLAR-3 4

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)LYSODREN 3

Hormonal Agents, Suppressant (Parathyroid)

Hormonal Agents, Suppressant (Parathyroid)SENSIPAR TABS 30MG 3 QL(60/30)SENSIPAR TABS 60MG 5 QL(60/30)SENSIPAR TABS 90MG 5 QL(120/30)

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

tri-lo-marzia 2tri-lo-sprintec 2tri-previfem 2tri-sprintec 2trinessa 2trinessa lo 2trivora-28 2VAGIFEM 4velivet 2vestura 2vienva 2viorele 2vyfemla 2wymzya fe 2xulane 2zenchent 2zenchent fe 2zovia 1/35e 2zovia 1/50e 2Progestinscamila 2deblitane 2DEPO-PROVERA 3DEPO-SUBQ PROVERA 104 3errin 2heather 2hydroxyprogesterone caproate 5 PAjencycla 2jolivette 2lyza 2MAKENA 5 PAmedroxyprogesterone acetate 2

40


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

FIRAZYR 5 PAKALBITOR 5 PAImmune SuppressantsASTAGRAF XL 4 PAazathioprine 2 PABENLYSTA 5 PACELLCEPT CAPS 4 PACELLCEPT INTRAVENOUS 4 PACELLCEPT SUSR 5 PACELLCEPT TABS 5 PAcyclosporine 2 PAcyclosporine modified 2 PAENBREL 5 PAENBREL SURECLICK 5 PAENVARSUS XR 4 PAgengraf 2 PAHUMIRA 5 PAHUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK

5 PA

HUMIRA PEN 5 PAHUMIRA PEN-CROHNS DISEASESTARTER

5 PA

HUMIRA PEN-PSORIASIS STARTER

5 PA

KINERET 5 PAmethotrexate 2methotrexate sodium inj 1gm, 1gm/40ml, 250mg/10ml

2

mycophenolate mofetil 2 PAmycophenolic acid dr 2 PAMYFORTIC 3 PANEORAL 4 PANULOJIX 5 PAORENCIA INJ 250MG 5 PAPROGRAF CAPS 5MG 5 PAPROGRAF CAPS 0.5MG, 1MG 4 PAPROGRAF INJ 4 PARAPAMUNE ORAL SOLN 5 PARAPAMUNE TABS 1MG, 2MG 5 PARAPAMUNE TABS 0.5MG 4 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)cabergoline 2ELIGARD INJ 30MG 4 PA QL(1/120)ELIGARD INJ 45MG 4 PA QL(1/180)ELIGARD INJ 7.5MG 4 PA QL(1/30)ELIGARD INJ 22.5MG 4 PA QL(1/90)FIRMAGON INJ 80MG 4 B/D PAFIRMAGON INJ 120MG 5 B/D PAleuprolide acetate 2 PALUPRON DEPOT 5 PALUPRON DEPOT-PED 5 PAoctreotide acetate inj 1000mcg/ml, 500mcg/ml

5

octreotide acetate inj 100mcg/ml, 200mcg/ml, 50mcg/ml

2

SANDOSTATIN LAR DEPOT 5SIGNIFOR 5SOMATULINE DEPOT 5SOMAVERT 5SYNAREL 5 PATRELSTAR INJ 3.75MG 5 PA QL(2/28)TRELSTAR INJ 11.25MG 5 PA QL(2/84)TRELSTAR MIXJECT INJ 22.5MG

5 PA QL(2/168)

TRELSTAR MIXJECT INJ 3.75MG

5 PA QL(2/28)

TRELSTAR MIXJECT INJ 11.25MG

5 PA QL(2/84)

ZOLADEX 4 PA

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agentsmethimazole 2propylthiouracil 2

Immunological Agents

Angioedema (HAE) AgentsBERINERT 5 PACINRYZE 5 PA

41



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SIMULECT 5 B/D PASYNAGIS 5 PAVaccinesACTHIB 3ADACEL 3BCG VACCINE 3BEXSERO 3BOOSTRIX 3CERVARIX 3DAPTACEL 3DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC

3

ENGERIX-B 3 B/D PAGARDASIL 3GARDASIL 9 3HAVRIX 3HIBERIX 3IMOVAX RABIES (H.D.C.V.) 3INFANRIX 3IPOL INACTIVATED IPV 3IXIARO 3KINRIX 3M-M-R II 3MENACTRA 3MENHIBRIX 3MENOMUNE-A/C/Y/W-135 3MENVEO 3PEDIARIX 3PEDVAX HIB 3PENTACEL 3PROQUAD 3QUADRACEL 3RABAVERT 3RECOMBIVAX HB 3 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

REMICADE 5 PARHEUMATREX 4SANDIMMUNE 3 PAsirolimus 2 PAtacrolimus caps 2 PATORISEL 5 B/D PATREXALL 4ZORTRESS TABS 0.25MG 4 B/D PAZORTRESS TABS 0.5MG, 0.75MG

5 B/D PA

Immunizing Agents, PassiveATGAM 5 PABIVIGAM 5 B/D PACARIMUNE NANOFILTERED 5 B/D PAFLEBOGAMMA DIF 5 B/D PAGAMASTAN S/D 3 B/D PAGAMMAGARD LIQUID INJ 2.5GM/25ML, 30GM/300ML

5 B/D PA

GAMMAGARD S/D IGA LESS THAN 1MCG/ML

5 B/D PA

GAMMAKED INJ 1GM/10ML 5 B/D PAGAMMAPLEX 5 B/D PAGAMUNEX-C 5 B/D PAHIZENTRA 5 B/D PAOCTAGAM INJ 10GM/100ML, 1GM/20ML, 20GM/200ML, 2GM/20ML, 5GM/50ML

5 B/D PA

PRIVIGEN 5 B/D PATHYMOGLOBULIN 5 B/D PAImmunomodulatorsACTIMMUNE 5ARCALYST 5 PAILARIS 5 PAleflunomide 2RIDAURA 5

42


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

FORTEO 5FORTICAL 3FOSAMAX PLUS D 4 QL(4/28) STibandronate sodium 2MIACALCIN INJ 4pamidronate disodium 2 B/D PAparicalcitol 2PROLIA 4risedronate sodium tabs 150mg 2XGEVA 5 PAzoledronic acid 2 B/D PA

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic AgentsBD SAFETYGLIDE 27G X 5/8” 3BOTOX 4 PADYSPORT 4 PAFERRIPROX 5fomepizole 5KORLYM 5 PA QL(120/30)LACTATED RINGERS IRRIGATION

3

levocarnitine 2methylergonovine maleate 2NATPARA 5 PANOVOFINE 30GX8MM 3NOVOFINE 31 3NOVOFINE 32GX6MM 3NOVOFINE AUTOCOVER 30GX8MM

3

NOVOTWIST 32GX5MM 3PHYSIOLYTE 3 B/D PAPHYSIOSOL IRRIGATION 3 B/D PARINGERS IRRIGATION 3sodium chloride 0.9% 2sterile water irrigation 2V-GO 20 4V-GO 30 4V-GO 40 4XEOMIN 4 PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ROTARIX 3ROTATEQ 3TENIVAC 3TETANUS/DIPHTHERIA TOXOIDS-ADSORBED

3

TRUMENBA 3TWINRIX 3TYPHIM VI 3VAQTA 3VARIVAX 3VARIZIG INJ 125UNIT/1.2ML 4YF-VAX 3ZOSTAVAX 3

Inflammatory Bowel Disease Agents

AminosalicylatesAPRISO 3ASACOL HD 4 STbalsalazide disodium 2CANASA 3DIPENTUM 3LIALDA 3mesalamine 2PENTASA 3Glucocorticoidsbudesonide cpep 2colocort 2hydrocortisone enem 2Sulfonamidessulfasalazine 2

Metabolic Bone Disease Agents

Metabolic Bone Disease Agentsalendronate sodium 2calcitonin-salmon 2calcitriol caps 2calcitriol inj 2calcitriol oral soln 2doxercalciferol 2etidronate disodium 2

43



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

epinastine hcl 2olopatadine hcl ophthalmic soln 2PATADAY 3PAZEO 3Ophthalmic Anti-inflammatoriesbromfenac 2dexamethasone sodium phosphate

2

diclofenac sodium ophthalmic soln

2

DUREZOL 3FLAREX 4fluorometholone 2flurbiprofen sodium 2FML 4FML FORTE 4ketorolac tromethamine ophthalmic soln

2

LOTEMAX 4MAXIDEX 4neomycin/polymyxin/dexamethasone

2

NEVANAC 3PRED MILD 4PRED-G 3PRED-G S.O.P. 3prednisolone acetate 2prednisolone sodium phosphate

2

TOBRADEX OINT 4tobramycin/dexamethasone 2VEXOL 4Ophthalmic Antiglaucoma Agentsacetazolamide er 2ALPHAGAN P OPHTHALMIC SOLN 0.1%

3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

Ophthalmic Agents

Ophthalmic Prostaglandin and Prostamide Analogsbimatoprost 2 QL(5/30)COMBIGAN 3latanoprost 2LUMIGAN 3 QL(5/30)TRAVATAN Z 3 QL(5/30)travoprost 2 QL(5/30)ZIOPTAN 4 QL(30/30)Ophthalmic Agents, Otheratropine sulfate oint 2atropine sulfate ophthalmic soln 2CYCLOGYL OPHTHALMIC SOLN 0.5%

3

CYCLOMYDRIL 3cyclopentolate hcl 2cyclopentolate hydrochloride 2CYSTARAN 5homatropaire 2LACRISERT 4phenylephrine hcl ophthalmic soln 10%, 2.5%

2

polycin 2PROCYSBI 5proparacaine hcl 2RESTASIS 3tropicamide 2Ophthalmic Anti-allergy AgentsALOCRIL 4ALOMIDE 4azelastine hcl 2cromolyn sodium ophthalmic soln

2

EMADINE 4

44


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ADVAIR HFA 3ALVESCO 4ASMANEX HFA 3ASMANEX TWISTHALER 120 METERED DOSES

3

ASMANEX TWISTHALER 14 METERED DOSES

3


3


3


3

budesonide susp 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml

2 B/D PA

FLOVENT DISKUS 3FLOVENT HFA 3flunisolide 2fluticasone propionate 2PULMICORT FLEXHALER 4 STPULMICORT SUSP 1MG/2ML 4 B/D PAQVAR 3SYMBICORT 3Antihistaminesazelastine hcl 2CLARINEX-D 12 HOUR 4 QL(60/30)desloratadine 2 QL(30/30)desloratadine odt 2 QL(30/30)diphenhydramine hcl inj 2DYMISTA 3levocetirizine dihydrochloride oral soln

2 QL(300/30)

levocetirizine dihydrochloride tabs

2 QL(30/30)

promethazine hcl 2 PASEMPREX-D 4Antileukotrienesmontelukast sodium 2zafirlukast 2Bronchodilators, AnticholinergicCOMBIVENT RESPIMAT 3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

apraclonidine 2AZOPT 3betaxolol hcl 2BETIMOL 4BETOPTIC-S 3brimonidine tartrate 2carteolol hcl 2dorzolamide hcl 2dorzolamide hcl/timolol maleate 2IOPIDINE OPHTHALMIC SOLN 1%

4

isopto carpine 2ISTALOL 4levobunolol hcl 2methazolamide 2metipranolol 2PHOSPHOLINE IODIDE 4pilocarpine hcl 2SIMBRINZA 4timolol maleate 2timolol maleate ophthalmic gel forming

2

Otic Agents

Otic Agentsacetasol hc 2acetic acid 2acetic acid/aluminum acetate 2antipyrine/benzocaine otic soln 54mg/ml; 14mg/ml

2

aurodex 2COLY-MYCIN S 4fluocinolone acetonide 2hydrocortisone/acetic acid 2neomycin/polymyxin/hc 2neomycin/polymyxin/hydrocortisone

2

Respiratory Tract/Pulmonary Agents

Anti-inflammatories, Inhaled CorticosteroidsADVAIR DISKUS 3

45



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CAYSTON 5KALYDECO 5 PA QL(60/30)PULMOZYME 5 B/D PATOBI PODHALER 5tobramycin 5 B/D PAMast Cell Stabilizerscromolyn sodium nebu 2 B/D PAPhosphodiesterase Inhibitors, Airways Diseaseaminophylline 2DALIRESP 3ELIXOPHYLLIN 4THEO-24 3theochron 2theophylline 2theophylline cr 2theophylline er 2theophylline/d5w inj 5%; 0.8mg/ml

2

Pulmonary AntihypertensivesADCIRCA 5 PA QL(60/30)ADEMPAS 5 QL(90/30)LETAIRIS 5OPSUMIT 5 PA QL(30/30)REMODULIN 5 B/D PAsildenafil tabs 2 PATRACLEER 5TYVASO 5 B/D PAVENTAVIS 5 PARespiratory Tract Agents, Otheracetylcysteine inhalation soln 2 B/D PAARALAST NP INJ 500MG 5 B/D PAESBRIET 5 PAGLASSIA 5 B/D PAPROLASTIN-C 5 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ipratropium bromide inhalation soln

2 B/D PA

ipratropium bromide nasal soln 2ipratropium bromide/albuterol sulfate

2 B/D PA

SPIRIVA HANDIHALER 3SPIRIVA RESPIMAT 3TUDORZA PRESSAIR 3Bronchodilators, SympathomimeticADRENALIN INJ 3albuterol 2albuterol sulfate er 2albuterol sulfate nebu 2 B/D PAalbuterol sulfate syrp 2albuterol sulfate tabs 2ARCAPTA NEOHALER 4BROVANA 4 B/D PAepinephrine 2 QL(2/30)epinephrine hcl 2EPIPEN 2-PAK 3 QL(2/30)EPIPEN-JR 2-PAK 3 QL(2/30)ISUPREL 3levalbuterol 2 B/D PAlevalbuterol hcl 2 B/D PAmetaproterenol sulfate 2PERFOROMIST 4 B/D PAPROAIR HFA 3PROAIR RESPICLICK 3PROVENTIL HFA 4SEREVENT DISKUS 3STRIVERDI RESPIMAT 3terbutaline sulfate 2XOPENEX HFA 4Cystic Fibrosis AgentsBETHKIS 5 B/D PA

46


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

SODIUM LACTATE INJ 5MEQ/ML

3 B/D PA

sodium polystyrene sulfonate powd

2

sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml

2

SYPRINE 5Electrolyte/Mineral ReplacementAMINOSYN 3 B/D PAAMINOSYN 7%/ELECTROLYTES

3 B/D PA

AMINOSYN 8.5%/ELECTROLYTES

3 B/D PA

AMINOSYN II 3 B/D PAAMINOSYN II 8.5%/ELECTROLYTES

3 B/D PA

AMINOSYN M 3 B/D PAAMINOSYN-HBC 3 B/D PAAMINOSYN-PF 3 B/D PAAMINOSYN-PF 7% 3 B/D PAAMINOSYN-RF 3 B/D PAammonium chloride 2calcium chloride 2calcium gluconate inj 2CARBAGLU 5citric acid/sodium citrate 2CLINIMIX 2.75%/DEXTROSE 5%

3 B/D PA

CLINIMIX 4.25%/DEXTROSE 10%

3 B/D PA


3 B/D PA


3 B/D PA


3 B/D PA

CLINIMIX 5%/DEXTROSE 15% 3 B/D PACLINIMIX 5%/DEXTROSE 20% 3 B/D PACLINIMIX 5%/DEXTROSE 25% 3 B/D PACLINIMIX E 2.75%/DEXTROSE 10%

3 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

promethazine vc plain 2 PASTIOLTO RESPIMAT 3TYZINE PEDIATRIC NASAL DROPS

4

VIRAZOLE 5 B/D PAXOLAIR 5 PAZEMAIRA 5 B/D PA

Skeletal Muscle Relaxants

Skeletal Muscle Relaxantscyclobenzaprine hcl tabs 10mg, 5mg

2 PA

orphenadrine citrate er 2 PA

Sleep Disorder Agents

GABA Receptor Modulatorstemazepam 2 QL(90/365)zaleplon 2 QL(90/365)zolpidem tartrate tabs 2 QL(90/365)Sleep Disorders, Otherarmodafinil 4 PA QL(30/30)modafinil tabs 100mg 2 PA QL(30/30)modafinil tabs 200mg 2 PA QL(60/30)NUVIGIL 4 PA QL(30/30)ROZEREM 4 QL(30/30)SILENOR 4 QL(30/30)XYREM 5

Therapeutic Nutrients/Minerals/Electrolytes

Electrolyte/Mineral ModifiersCHEMET 4CUPRIMINE 5DEPEN TITRATABS 3EXJADE 5JADENU 5kionex 2SAMSCA TABS 30MG 5 QL(60/30)SAMSCA TABS 15MG 5 QL(90/30)sodium bicarbonate inj 2 B/D PAsodium bicarbonate partial fill 2 B/D PA

47



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

DEXTROSE 5%/NACL 0.225% 3 B/D PADEXTROSE 5%/NACL 0.3% 3 B/D PADEXTROSE 5%/NACL 0.33% 3 B/D PADEXTROSE 5%/NACL 0.45% 3 B/D PADEXTROSE 5%/NACL 0.9% 3 B/D PADEXTROSE 5%/POTASSIUM CHLORIDE 0.15%

3 B/D PA

dextrose 50% 2 B/D PAdextrose 70% 2 B/D PAeffer-k tbef 25meq 2effervescent pot chloride 2fluor-a-day 2fluoride chew 0.25mg, 1.1mg, 2.2mg

2

fluoridex daily defense 2fluoritab chew 0.5mg, 1mg 2fluoritab oral soln 2flura-drops oral soln 0.25mg/drop

2

FREAMINE HBC 6.9% 3 B/D PAFREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML

3 B/D PA

HEPATAMINE 3 B/D PAhyperlyte-cr 2 B/D PAIONOSOL-B/DEXTROSE 5% 3 B/D PAIONOSOL-MB/DEXTROSE 5% 3 B/D PAISOLYTE-P/DEXTROSE 5% 3 B/D PA

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

CLINIMIX E 2.75%/DEXTROSE 5%

3 B/D PA


3 B/D PA


3 B/D PA


3 B/D PA

CLINIMIX E 5%/DEXTROSE 15%

3 B/D PA


3 B/D PA


3 B/D PA

CLINISOL SF 15% 3 B/D PAclinpro 5000 2cytra k crystals 2cytra-2 2cytra-3 2cytra-k 2denta 5000 plus 2dentagel 2DEXTROSE 10%/NACL 0.45% 3 B/D PADEXTROSE 5% /ELECTROLYTE #48 VIAFLEX

3 B/D PA

dextrose 10% 2 B/D PADEXTROSE 10%/NACL 0.2% 3 B/D PADEXTROSE 2.5%/NACL 0.45% 3 B/D PAdextrose 20% 2 B/D PAdextrose 25% 2 B/D PAdextrose 30% 2 B/D PAdextrose 40% 2 B/D PAdextrose 5% 2 B/D PADEXTROSE 5%/LACTATED RINGERS

3 B/D PA

DEXTROSE 5%/NACL 0.2% 3 B/D PA

48


DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

NUTRILYTE INJ 2.03MEQ/ML; 0.25MEQ/ML; 1.68MEQ/ML; 0.25MEQ/ML; 0.4MEQ/ML; 2.03MEQ/ML; 1.25MEQ

4 B/D PA

phospha 250 neutral 2PLASMA-LYTE A 3 B/D PAPLASMA-LYTE-148 3 B/D PAPLASMA-LYTE-56/D5W 3 B/D PAPLENAMINE 3 B/D PAPOTASSIUM CHLORIDE 0.15% /NACL 0.45% VIAFLEX

3 B/D PA

POTASSIUM CHLORIDE 0.15% D5W/NACL 0.33%

3 B/D PA


3 B/D PA

POTASSIUM CHLORIDE 0.15% D5W/NACL 0.45% VIAFLEX

3 B/D PA

POTASSIUM CHLORIDE 0.15% NACL 0.9%

3 B/D PA

POTASSIUM CHLORIDE 0.15% W/NACL 0.9% VIAFLEX

3 B/D PA

POTASSIUM CHLORIDE 0.15%/NACL 0.9%

3 B/D PA


3 B/D PA

POTASSIUM CHLORIDE 0.3%/ NACL 0.9%

3 B/D PA

POTASSIUM CHLORIDE 0.3%/D5W

3 B/D PA

potassium chloride cr 2potassium chloride er 2potassium chloride inj 0.4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 2meq/ml, 40meq/100ml

2 B/D PA

potassium chloride oral soln 2potassium chloride pack 2potassium chloride sr 2potassium citrate er 2potassium citrate-citric acid crystals

2

potassium citrate/citric acid 2

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

ISOLYTE-S 3 B/D PAISOLYTE-S PH 7.4 3 B/D PAk-effervescent 2K-PHOS 3K-PHOS NO 2 3k-sol 2K-TAB TBCR 10MEQ, 20MEQ 3k-vescent tbef 2KCL 0.075%/D5W/NACL 0.45% 3 B/D PAKCL 0.15%/D5W/ NACL 0.3% 3 B/D PAKCL 0.15%/D5W/LR 3 B/D PAKCL 0.15%/D5W/NACL 0.2% 3 B/D PAKCL 0.15%/D5W/NACL 0.225% 3 B/D PAKCL 0.15%/D5W/NACL 0.45% 3 B/D PAKCL 0.15%/D5W/NACL 0.9% 3 B/D PAKCL 0.3%/D5W/LR IV LAC RING

3 B/D PA

KCL 0.3%/D5W/NACL 0.45% 3 B/D PAKCL 0.3%/D5W/NACL 0.9% 3 B/D PAklor-con 2KLOR-CON 10 3KLOR-CON 8 3klor-con m10 2klor-con m15 2klor-con m20 2klor-con sprinkle 2klor-con/25 2LACTATED RINGERS VIAFLEX

3

ludent 2magnesium sulfate in d5w inj 5%; 10mg/ml

2

magnesium sulfate inj 2 B/D PAMOZOBIL 5NEPHRAMINE 3 B/D PANORMOSOL -R 3NORMOSOL-M IN D5W 3 B/D PANORMOSOL-R 3 B/D PANORMOSOL-R IN D5W 3 B/D PA

49



DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

multi-vitamin/fluoride oral soln 35mg/ml; 400unit/ml; 2mcg/ml; 5unit/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 1500unit/ml, 35mg/ml; 400unit/ml; 2mcg/ml; 5unit/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 0.5mg/ml; 1500unit/ml

2

multivitamin with fluoride 2multivitamin/fluoride chew 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 0.25mg; 1.05mg; 15unit; 2500unit

2

mvc-fluoride 2tl-fluorivite 2tri-vit/fluoride 2tri-vit/fluoride/iron 2tri-vitamin/fluoride 2triple-vitamin/fluoride 2vitamins a/c/d/fluoride 2VP-PNV-DHA 3

Needles And Syringes

Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic Agentsbd eclipse syringe/1ml/30gx1/2” 3bd insulin syringe safetyglide/1ml/29g x 1/2”

3

bd insulin syringe ultrafine/0.3ml/31g x 5/16”

3

bd insulin syringe ultrafine/0.5ml/30g x 1/2”

3

bd insulin syringe ultrafine/1ml/31g x 5/16”

3

bd pen needle/ultrafine/29g x 12.7mm

3

DRUG NAME DRUG TIER

REQUIREMENTS/LIMITS

PREMASOL 3 B/D PAPROCALAMINE 3 B/D PAPROSOL 4 B/D PARINGERS INJECTION 3sf 2sf 5000 plus 2sodium chloride 0.45% 2sodium chloride bacteriostatic 2sodium chloride bacteriostatic/benzyl alcohol

2

sodium chloride inj 2sodium fluoride chew 0.5mg, 1mg

2

sodium fluoride oral soln 2sodium fluoride tabs 2TPN ELECTROLYTES 3 B/D PATRAVASOL 4 B/D PATROPHAMINE 3 B/D PAvirt-phos 250 neutral 2virtrate-2 2virtrate-k 2Therapeutic Nutrients/Minerals/ElectrolytesINTRALIPID 3 B/D PAKABIVEN 4 B/D PANUTRILIPID 3 B/D PAPERIKABIVEN 4 B/D PAVitaminsmult-vitamin/fluoride 2multi vitamin/fluoride 2multi-vit/fluoride 2multi-vit/iron/fluoride oral soln 35mg/ml; 400unit/ml; 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml

2

DRUG PAGE DRUG PAGE DRUG PAGE

Covered Drugs Index

50

88-MOP . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Aabacavir . . . . . . . . . . . . . . . . . . . . . . . . . . 23abacavir sulfate/ lamivudine/zidovudine . . . . . . . . . . . . . 24ABELCET . . . . . . . . . . . . . . . . . . . . . . . . . 16ABILIFY MAINTENA INJ 300MG . . . 22ABILIFY MAINTENA INJ 400MG . . . 22ABRAXANE . . . . . . . . . . . . . . . . . . . . . . . 19acamprosate calcium dr . . . . . . . . . . . . . 9acarbose . . . . . . . . . . . . . . . . . . . . . . . . . . 25acebutolol hcl . . . . . . . . . . . . . . . . . . . . . 28acetaminophen/codeine #2 . . . . . . . . . . 8acetaminophen/codeine #3 . . . . . . . . . . 8acetaminophen/codeine #4 . . . . . . . . . . 8acetaminophen/codeine oral soln . . . 8acetaminophen/codeine phosphate tabs 300mg; 60mg . . . . . . . 8acetaminophen/codeine tabs 300mg; 15mg . . . . . . . . . . . . . . . . . . 8acetaminophen/codeine tabs 300mg; 60mg . . . . . . . . . . . . . . . . . . 8acetasol hc . . . . . . . . . . . . . . . . . . . . . . . . 44acetazolamide . . . . . . . . . . . . . . . . . . . . . 30acetazolamide er . . . . . . . . . . . . . . . . . . 43acetazolamide sodium . . . . . . . . . . . . . 30acetic acid . . . . . . . . . . . . . . . . . . . . . . . . 44acetic acid 0.25% . . . . . . . . . . . . . . . . . . 35acetic acid/aluminum acetate . . . . . . . 44acetylcysteine inhalation soln . . . . . . 45acitretin . . . . . . . . . . . . . . . . . . . . . . . . . . . 32ACTHIB . . . . . . . . . . . . . . . . . . . . . . . . . . . 41ACTIMMUNE . . . . . . . . . . . . . . . . . . . . . 41acyclovir . . . . . . . . . . . . . . . . . . . . . . . . . . 24acyclovir sodium inj 500mg, 50mg/ml . . . . . . . . . . . . . . . . . . 24ADACEL . . . . . . . . . . . . . . . . . . . . . . . . . . 41ADAGEN . . . . . . . . . . . . . . . . . . . . . . . . . 33

adapalene . . . . . . . . . . . . . . . . . . . . . . . . 32ADCIRCA . . . . . . . . . . . . . . . . . . . . . . . . . 45adefovir dipivoxil . . . . . . . . . . . . . . . . . . . 23ADEMPAS . . . . . . . . . . . . . . . . . . . . . . . . 45ADRENALIN INJ . . . . . . . . . . . . . . . . . . 45adrucil . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18ADVAIR DISKUS . . . . . . . . . . . . . . . . . . 44ADVAIR HFA . . . . . . . . . . . . . . . . . . . . . . 44afeditab cr . . . . . . . . . . . . . . . . . . . . . . . . 29AFINITOR DISPERZ TBSO 2MG, 3MG . . . . . . . . . . . . . . . . . 20AFINITOR DISPERZ TBSO 5MG . . . 20AFINITOR TABS 2.5MG, 5MG, 7.5MG . . . . . . . . . . . . . . 20AFINITOR TABS 10MG . . . . . . . . . . . . 20AGGRENOX . . . . . . . . . . . . . . . . . . . . . . 27a-hydrocort . . . . . . . . . . . . . . . . . . . . . . . . 35ala cort . . . . . . . . . . . . . . . . . . . . . . . . . . . 35ALA SCALP . . . . . . . . . . . . . . . . . . . . . . . 35ALBENZA . . . . . . . . . . . . . . . . . . . . . . . . . 21albuterol . . . . . . . . . . . . . . . . . . . . . . . . . . 45albuterol sulfate er . . . . . . . . . . . . . . . . . 45albuterol sulfate nebu . . . . . . . . . . . . . 45albuterol sulfate syrp . . . . . . . . . . . . . . 45albuterol sulfate tabs . . . . . . . . . . . . . . 45alclometasone dipropionate . . . . . . . . 35ALCOHOL PREP PADS . . . . . . . . . . . . 10ALDURAZYME . . . . . . . . . . . . . . . . . . . . 33ALECENSA . . . . . . . . . . . . . . . . . . . . . . . 20alendronate sodium . . . . . . . . . . . . . . . . 42alfuzosin hcl er . . . . . . . . . . . . . . . . . . . . 35ALIMTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 18ALINIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21allopurinol . . . . . . . . . . . . . . . . . . . . . . . . . 17almotriptan malate tabs 6.25mg . . . . 17almotriptan malate tabs 12.5mg . . . . 17ALOCRIL . . . . . . . . . . . . . . . . . . . . . . . . . 43ALOMIDE . . . . . . . . . . . . . . . . . . . . . . . . . 43ALOPRIM . . . . . . . . . . . . . . . . . . . . . . . . . 17ALORA . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

alosetron hydrochloride . . . . . . . . . . . . 34ALOXI . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16ALPHAGAN P OPHTHALMIC SOLN 0.1% . . . . . . . . 43alprazolam er tb24 1mg, 2mg, 3mg . . . . . . . . . . . . . . . . . . . . 24alprazolam intensol . . . . . . . . . . . . . . . . 24alprazolam odt tbdp 0.25mg, 0.5mg . . . . . . . . . . . . . . . . . . . . 24alprazolam odt tbdp 1mg . . . . . . . . . . . 24alprazolam odt tbdp 2mg . . . . . . . . . . . 24alprazolam tabs 0.25mg, 0.5mg . . . . 24alprazolam tabs 1mg . . . . . . . . . . . . . . 24alprazolam tabs 2mg . . . . . . . . . . . . . . 24alprazolam xr . . . . . . . . . . . . . . . . . . . . . . 24ALTABAX . . . . . . . . . . . . . . . . . . . . . . . . . 10altavera . . . . . . . . . . . . . . . . . . . . . . . . . . . 37ALVESCO . . . . . . . . . . . . . . . . . . . . . . . . 44amantadine hcl . . . . . . . . . . . . . . . . . . . . 24AMBISOME . . . . . . . . . . . . . . . . . . . . . . . 16amcinonide . . . . . . . . . . . . . . . . . . . . . . . 35amethia . . . . . . . . . . . . . . . . . . . . . . . . . . . 37amethyst . . . . . . . . . . . . . . . . . . . . . . . . . . 37amifostine . . . . . . . . . . . . . . . . . . . . . . . . . 19amikacin sulfate . . . . . . . . . . . . . . . . . . . . 9amiloride hcl . . . . . . . . . . . . . . . . . . . . . . 30amiloride/hydrochlorothiazide . . . . . . 30aminocaproic acid . . . . . . . . . . . . . . . . . 27aminophylline . . . . . . . . . . . . . . . . . . . . . 45AMINOSYN . . . . . . . . . . . . . . . . . . . . . . . 46AMINOSYN 7%/ELECTROLYTES . . 46AMINOSYN 8.5%/ ELECTROLYTES . . . . . . . . . . . . . . . . . . 46AMINOSYN-HBC . . . . . . . . . . . . . . . . . . 46AMINOSYN II . . . . . . . . . . . . . . . . . . . . . 46AMINOSYN II 8.5%/ ELECTROLYTES . . . . . . . . . . . . . . . . . . 46AMINOSYN M . . . . . . . . . . . . . . . . . . . . . 46AMINOSYN-PF . . . . . . . . . . . . . . . . . . . . 46AMINOSYN-PF 7% . . . . . . . . . . . . . . . . 46AMINOSYN-RF . . . . . . . . . . . . . . . . . . . 46


Covered Drugs Index

51

ASMANEX TWISTHALER 30 METERED DOSES . . . . . . . . . . . . . 44ASMANEX TWISTHALER 60 METERED DOSES . . . . . . . . . . . . . 44ASMANEX TWISTHALER 120 METERED DOSES . . . . . . . . . . . . 44aspirin-caffeine-dihydrocodeine . . . . . . 8aspirin/dipyridamole . . . . . . . . . . . . . . . 27ASTAGRAF XL . . . . . . . . . . . . . . . . . . . . 40atenolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 28atenolol/chlorthalidone . . . . . . . . . . . . . 28ATGAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 41atorvastatin calcium . . . . . . . . . . . . . . . 30atovaquone . . . . . . . . . . . . . . . . . . . . . . . 21atovaquone/proguanil hcl . . . . . . . . . . 21ATRIPLA . . . . . . . . . . . . . . . . . . . . . . . . . . 24atropine sulfate inj 0.05mg/ml, 0.1mg/ml, 0.4mg/ml, 0.8mg/ml, 1mg/ml . . . . . . . 33atropine sulfate oint . . . . . . . . . . . . . . . 43atropine sulfate ophthalmic soln . . . . 43AUBAGIO . . . . . . . . . . . . . . . . . . . . . . . . . 31aubra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37augmented betamethasone dipropionate . . . . . . . . . . . . . . . . . . . . . . . 35aurodex . . . . . . . . . . . . . . . . . . . . . . . . . . . 44AURYXIA . . . . . . . . . . . . . . . . . . . . . . . . . 35AVANDIA . . . . . . . . . . . . . . . . . . . . . . . . . 25AVASTIN . . . . . . . . . . . . . . . . . . . . . . . . . . 20AVELOX INJ . . . . . . . . . . . . . . . . . . . . . . 13aviane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37AVODART . . . . . . . . . . . . . . . . . . . . . . . . 35AVONEX . . . . . . . . . . . . . . . . . . . . . . . . . . 31AVONEX PEN . . . . . . . . . . . . . . . . . . . . . 31AXERT TABS 6.25MG . . . . . . . . . . . . . 17AXERT TABS 12.5MG . . . . . . . . . . . . . 17azacitidine . . . . . . . . . . . . . . . . . . . . . . . . 19AZACTAM IN ISO-OSMOTIC DEXTROSE INJ 1GM; 0 . . . . . . . . . . . 12AZACTAM IN ISO-OSMOTIC DEXTROSE INJ 2GM; 0 . . . . . . . . . . . 12

ANZEMET . . . . . . . . . . . . . . . . . . . . . . . . 16APLENZIN . . . . . . . . . . . . . . . . . . . . . . . . 15APOKYN . . . . . . . . . . . . . . . . . . . . . . . . . . 21apraclonidine . . . . . . . . . . . . . . . . . . . . . . 44apri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37APRISO . . . . . . . . . . . . . . . . . . . . . . . . . . 42APTIOM TABS 200MG, 400MG, 800MG . . . . . . . . . . . 13APTIOM TABS 600MG . . . . . . . . . . . . . 13APTIVUS . . . . . . . . . . . . . . . . . . . . . . . . . 24ARALAST NP INJ 500MG . . . . . . . . . . 45aranelle . . . . . . . . . . . . . . . . . . . . . . . . . . . 37ARANESP ALBUMIN FREE INJ 10MCG/0.4ML, 25MCG/0.42ML, 25MCG/ML, 40MCG/0.4ML, 40MCG/ML, 60MCG/0.3ML, 60MCG/ML . . . . . . . . . . . . . . . . . . . . . . . 27ARANESP ALBUMIN FREE INJ 100MCG/0.5ML, 100MCG/ML, 150MCG/0.3ML, 200MCG/0.4ML, 200MCG/ML, 300MCG/0.6ML, 300MCG/ML, 500MCG/ML . . . . . . . . . 27ARCALYST . . . . . . . . . . . . . . . . . . . . . . . 41ARCAPTA NEOHALER . . . . . . . . . . . . 45ARESTIN . . . . . . . . . . . . . . . . . . . . . . . . . 32aripiprazole odt . . . . . . . . . . . . . . . . . . . . 22aripiprazole oral soln . . . . . . . . . . . . . . 22aripiprazole tabs . . . . . . . . . . . . . . . . . . 22ARISTADA INJ 441MG/1.6ML . . . . . . 22ARISTADA INJ 662MG/2.4ML . . . . . . 22ARISTADA INJ 882MG/3.2ML . . . . . . 22armodafinil . . . . . . . . . . . . . . . . . . . . . . . . 46ARRANON . . . . . . . . . . . . . . . . . . . . . . . . 18ASACOL HD . . . . . . . . . . . . . . . . . . . . . . 42ascomp/codeine . . . . . . . . . . . . . . . . . . . . 8ashlyna . . . . . . . . . . . . . . . . . . . . . . . . . . . 37ASMANEX HFA . . . . . . . . . . . . . . . . . . . 44ASMANEX TWISTHALER 7 METERED DOSES . . . . . . . . . . . . . . 44ASMANEX TWISTHALER 14 METERED DOSES . . . . . . . . . . . . . 44

amiodarone hcl inj 50mg/ml, 900mg/18ml . . . . . . . . . . . . . 28amiodarone hcl tabs . . . . . . . . . . . . . . 28AMITIZA . . . . . . . . . . . . . . . . . . . . . . . . . . 34amitriptyline hcl . . . . . . . . . . . . . . . . . . . . 16amlodipine besylate/ atorvastatin calcium . . . . . . . . . . . . . . . 29amlodipine besylate/ benazepril hydrochloride . . . . . . . . . . . 29amlodipine besylate tabs 2.5mg . . . . 29amlodipine besylate tabs 10mg, 5mg . . . . . . . . . . . . . . . . . . . . . . . . 29amlodipine besylate/valsartan . . . . . . 29amlodipine/valsartan/hctz . . . . . . . . . . 29ammonium chloride . . . . . . . . . . . . . . . . 46ammonium lactate . . . . . . . . . . . . . . . . . 32amoxapine . . . . . . . . . . . . . . . . . . . . . . . . 16amoxicillin . . . . . . . . . . . . . . . . . . . . . . . . . 12amoxicillin/clavulanate potassium . . . 12amphetamine/ dextroamphetamine cp24 . . . . . . . . . . 31amphetamine/ dextroamphetamine tabs . . . . . . . . . . 31amphotericin b . . . . . . . . . . . . . . . . . . . . 16ampicillin . . . . . . . . . . . . . . . . . . . . . . . . . . 12ampicillin sodium inj 10gm, 1gm, 2gm . . . . . . . . . . . . . . . . . . 12ampicillin sodium inj 125mg, 250mg, 500mg . . . . . . . . . . . . 12ampicillin-sulbactam . . . . . . . . . . . . . . . 12AMPYRA . . . . . . . . . . . . . . . . . . . . . . . . . 31ANADROL-50 . . . . . . . . . . . . . . . . . . . . . 36anagrelide hydrochloride . . . . . . . . . . . 27anaspaz . . . . . . . . . . . . . . . . . . . . . . . . . . 33anastrozole . . . . . . . . . . . . . . . . . . . . . . . 20ANDRODERM . . . . . . . . . . . . . . . . . . . . 36ANDROGEL . . . . . . . . . . . . . . . . . . . . . . 36ANDROGEL PUMP GEL 1.62% . . . . 36ANDROXY . . . . . . . . . . . . . . . . . . . . . . . . 36ANGELIQ . . . . . . . . . . . . . . . . . . . . . . . . . 37antipyrine/benzocaine otic soln 54mg/ml; 14mg/ml . . . . . . . . . . . . . . . . . 44


Covered Drugs Index

52

briellyn . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37BRILINTA . . . . . . . . . . . . . . . . . . . . . . . . . 27brimonidine tartrate . . . . . . . . . . . . . . . . 44BRIVIACT INJ . . . . . . . . . . . . . . . . . . . . 13BRIVIACT ORAL SOLN . . . . . . . . . . . 13BRIVIACT TABS 10MG, 25MG, 50MG, 75MG . . . . . . . 13BRIVIACT TABS 100MG . . . . . . . . . . . 13bromfenac . . . . . . . . . . . . . . . . . . . . . . . . 43bromocriptine mesylate . . . . . . . . . . . . 21BROVANA . . . . . . . . . . . . . . . . . . . . . . . . 45budesonide cpep . . . . . . . . . . . . . . . . . 42budesonide susp 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml . . . . . . . . . . . . . . . 44bumetanide . . . . . . . . . . . . . . . . . . . . . . . 30BUPHENYL TABS . . . . . . . . . . . . . . . . 33buprenorphine hcl inj . . . . . . . . . . . . . . . 9buprenorphine hcl/naloxone hcl . . . . . . 9buprenorphine hcl subl . . . . . . . . . . . . . 9bupropion hcl . . . . . . . . . . . . . . . . . . . . . . 15bupropion hcl er tb12 100mg . . . . . . . 15bupropion hcl er tb12 150mg . . . . . . . 15bupropion hcl sr tb12 100mg, 200mg . . . . . . . . . . . . . . . . . . . . 15bupropion hcl sr tb12 150mg . . . . . . . . 9bupropion hcl sr tb12 150mg . . . . . . . 15bupropion hcl xl tb24 150mg . . . . . . . 15bupropion hcl xl tb24 300mg . . . . . . . 15buspirone hcl . . . . . . . . . . . . . . . . . . . . . . 24BUSULFEX . . . . . . . . . . . . . . . . . . . . . . . 18butalbital/acetaminophen . . . . . . . . . . . . 7butalbital/acetaminophen/ caffeine caps . . . . . . . . . . . . . . . . . . . . . . 7butalbital/acetaminophen/ caffeine tabs 325mg; 50mg; 40mg . . . 7butalbital/aspirin/caffeine . . . . . . . . . . . . 7butalbital/aspirin/caffeine/codeine . . . . 8butorphanol tartrate inj . . . . . . . . . . . . . 8butorphanol tartrate nasal soln . . . . . . 8BUTRANS . . . . . . . . . . . . . . . . . . . . . . . . . 7BYDUREON . . . . . . . . . . . . . . . . . . . . . . 25

BENICAR . . . . . . . . . . . . . . . . . . . . . . . . . 27BENICAR HCT . . . . . . . . . . . . . . . . . . . . 27BENLYSTA . . . . . . . . . . . . . . . . . . . . . . . . 40BENSAL HP . . . . . . . . . . . . . . . . . . . . . . 16BENZAMYCINPAK . . . . . . . . . . . . . . . . 32benztropine mesylate inj . . . . . . . . . . . 21benztropine mesylate tabs . . . . . . . . . 21BERINERT . . . . . . . . . . . . . . . . . . . . . . . . 40BESIVANCE . . . . . . . . . . . . . . . . . . . . . . 13betamethasone dipropionate . . . . . . . 35betamethasone sodium phosphate/betamethasone acetate . . . . . . . . . . . . 35betamethasone valerate . . . . . . . . . . . 35betaxolol hcl . . . . . . . . . . . . . . . . . . . . . . . 28betaxolol hcl . . . . . . . . . . . . . . . . . . . . . . . 44bethanechol chloride . . . . . . . . . . . . . . . 35BETHKIS . . . . . . . . . . . . . . . . . . . . . . . . . 45BETIMOL . . . . . . . . . . . . . . . . . . . . . . . . . 44BETOPTIC-S . . . . . . . . . . . . . . . . . . . . . . 44bexarotene . . . . . . . . . . . . . . . . . . . . . . . . 20BEXSERO . . . . . . . . . . . . . . . . . . . . . . . . 41bicalutamide . . . . . . . . . . . . . . . . . . . . . . 18BICILLIN C-R . . . . . . . . . . . . . . . . . . . . . 12BICILLIN L-A . . . . . . . . . . . . . . . . . . . . . . 12BICNU . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18BIDIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31bimatoprost . . . . . . . . . . . . . . . . . . . . . . . 43bisoprolol fumarate . . . . . . . . . . . . . . . . 28bisoprolol fumarate/ hydrochlorothiazide . . . . . . . . . . . . . . . . 28BIVIGAM . . . . . . . . . . . . . . . . . . . . . . . . . . 41bleomycin sulfate . . . . . . . . . . . . . . . . . . 19BLEPHAMIDE . . . . . . . . . . . . . . . . . . . . . 13BLEPHAMIDE S.O.P. . . . . . . . . . . . . . . 13blisovi fe 1.5/30 . . . . . . . . . . . . . . . . . . . . 37blisovi fe 1/20 . . . . . . . . . . . . . . . . . . . . . 37BOOSTRIX . . . . . . . . . . . . . . . . . . . . . . . 41BOSULIF . . . . . . . . . . . . . . . . . . . . . . . . . 20BOTOX . . . . . . . . . . . . . . . . . . . . . . . . . . . 42bpo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

AZACTAM INJ 1GM . . . . . . . . . . . . . . . 12AZACTAM INJ 2GM . . . . . . . . . . . . . . . 12AZASITE . . . . . . . . . . . . . . . . . . . . . . . . . . 12azathioprine . . . . . . . . . . . . . . . . . . . . . . . 40azelastine hcl . . . . . . . . . . . . . . . . . . . . . 43azelastine hcl . . . . . . . . . . . . . . . . . . . . . 44AZELEX . . . . . . . . . . . . . . . . . . . . . . . . . . 32AZILECT . . . . . . . . . . . . . . . . . . . . . . . . . . 21azithromycin inj . . . . . . . . . . . . . . . . . . . 12azithromycin pack . . . . . . . . . . . . . . . . . 12azithromycin susr . . . . . . . . . . . . . . . . . 12azithromycin tabs . . . . . . . . . . . . . . . . . 12AZOPT . . . . . . . . . . . . . . . . . . . . . . . . . . . 44aztreonam . . . . . . . . . . . . . . . . . . . . . . . . 12azuphen mb . . . . . . . . . . . . . . . . . . . . . . . 34azurette . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Bbaciim . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10bacitracin inj . . . . . . . . . . . . . . . . . . . . . . 10bacitracin ophthalmic oint . . . . . . . . . . 10bacitracin/polymyxin b . . . . . . . . . . . . . 10baclofen tabs . . . . . . . . . . . . . . . . . . . . . 23bactocill in dextrose . . . . . . . . . . . . . . . . 12balsalazide disodium . . . . . . . . . . . . . . 42balziva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37BANZEL SUSP . . . . . . . . . . . . . . . . . . . 14BANZEL TABS 200MG . . . . . . . . . . . . 14BANZEL TABS 400MG . . . . . . . . . . . . 14BARACLUDE ORAL SOLN . . . . . . . . 23BCG VACCINE . . . . . . . . . . . . . . . . . . . . 41BD SAFETYGLIDE 27G X 5/8” . . . . . 42bekyree . . . . . . . . . . . . . . . . . . . . . . . . . . . 37BELEODAQ . . . . . . . . . . . . . . . . . . . . . . . 19belladonna alkaloids & opium . . . . . . 33belladonna & opium . . . . . . . . . . . . . . . 33benazepril hcl . . . . . . . . . . . . . . . . . . . . . 28benazepril hcl/hydrochlorothiazide . . . 28BENDEKA . . . . . . . . . . . . . . . . . . . . . . . . 18


Covered Drugs Index

53

ceftriaxone in iso-osmotic dextrose . . 11ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg . . . . . . . . . 11cefuroxime axetil . . . . . . . . . . . . . . . . . . 11cefuroxime sodium inj 1.5gm, 7.5gm, 750mg, 75gm . . . . . . . 11celecoxib . . . . . . . . . . . . . . . . . . . . . . . . . . . 7CELLCEPT CAPS . . . . . . . . . . . . . . . . 40CELLCEPT INTRAVENOUS . . . . . . . 40CELLCEPT SUSR . . . . . . . . . . . . . . . . 40CELLCEPT TABS . . . . . . . . . . . . . . . . . 40CELONTIN . . . . . . . . . . . . . . . . . . . . . . . . 13cephalexin . . . . . . . . . . . . . . . . . . . . . . . . 11CEREZYME . . . . . . . . . . . . . . . . . . . . . . . 33CERVARIX . . . . . . . . . . . . . . . . . . . . . . . . 41CESAMET . . . . . . . . . . . . . . . . . . . . . . . . 16cevimeline hcl . . . . . . . . . . . . . . . . . . . . . 32CHANTIX . . . . . . . . . . . . . . . . . . . . . . . . . . 9CHANTIX CONTINUING MONTH PAK . . . . . . . . . . . . . . . . . . . . . . . 9CHANTIX STARTING MONTH PAK . . . . . . . . . . . . . . . . . . . . . . . 9chateal . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37CHEMET . . . . . . . . . . . . . . . . . . . . . . . . . 46CHENODAL . . . . . . . . . . . . . . . . . . . . . . . 33chloramphenicol sodium succinate . . 10chlorhexidine gluconate mouth/throat soln . . . . . . . . . . . . . . . . . 32chloroquine phosphate . . . . . . . . . . . . . 21chlorothiazide . . . . . . . . . . . . . . . . . . . . . 30chlorothiazide sodium . . . . . . . . . . . . . . 30chlorpromazine hcl inj 50mg/2ml . . . . 21chlorpromazine hcl tabs . . . . . . . . . . . 21chlorthalidone tabs 25mg, 50mg . . . . 30cholestyramine . . . . . . . . . . . . . . . . . . . . 30cholestyramine light . . . . . . . . . . . . . . . 30choline magnesium trisalicylate liqd . . . 7CIALIS TABS 2.5MG, 5MG . . . . . . . . . 35ciclodan . . . . . . . . . . . . . . . . . . . . . . . . . . . 16ciclopirox . . . . . . . . . . . . . . . . . . . . . . . . . . 16ciclopirox nail lacquer . . . . . . . . . . . . . . 16

carbamazepine . . . . . . . . . . . . . . . . . . . . 14carbamazepine er . . . . . . . . . . . . . . . . . 14carbidopa . . . . . . . . . . . . . . . . . . . . . . . . . 21carbidopa/levodopa . . . . . . . . . . . . . . . . 21carbidopa/levodopa/entacapone . . . . 21carbidopa/levodopa er . . . . . . . . . . . . . 21carbidopa/levodopa odt . . . . . . . . . . . . 21carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml . . . . . . . . . . . . 19CARDENE IV . . . . . . . . . . . . . . . . . . . . . 29CARIMUNE NANOFILTERED . . . . . . 41carteolol hcl . . . . . . . . . . . . . . . . . . . . . . . 44cartia xt . . . . . . . . . . . . . . . . . . . . . . . . . . . 29carvedilol . . . . . . . . . . . . . . . . . . . . . . . . . 29CAYSTON . . . . . . . . . . . . . . . . . . . . . . . . 45caziant . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37CEDAX CAPS . . . . . . . . . . . . . . . . . . . . 11cefaclor . . . . . . . . . . . . . . . . . . . . . . . . . . . 11cefaclor er . . . . . . . . . . . . . . . . . . . . . . . . 11cefadroxil . . . . . . . . . . . . . . . . . . . . . . . . . 11cefazolin . . . . . . . . . . . . . . . . . . . . . . . . . . 11cefazolin sodium . . . . . . . . . . . . . . . . . . 11cefazolin sodium/dextrose . . . . . . . . . . 11cefdinir . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11cefditoren pivoxil . . . . . . . . . . . . . . . . . . 11cefepime . . . . . . . . . . . . . . . . . . . . . . . . . . 11cefepime/dextrose . . . . . . . . . . . . . . . . . 11cefixime . . . . . . . . . . . . . . . . . . . . . . . . . . . 11cefotaxime sodium inj 1gm, 2gm, 500mg . . . . . . . . . . . . . . . . . 11cefotetan . . . . . . . . . . . . . . . . . . . . . . . . . . 12cefotetan/dextrose . . . . . . . . . . . . . . . . . 11cefoxitin sodium . . . . . . . . . . . . . . . . . . . 11cefpodoxime proxetil . . . . . . . . . . . . . . . 11cefprozil . . . . . . . . . . . . . . . . . . . . . . . . . . 11ceftazidime . . . . . . . . . . . . . . . . . . . . . . . . 11ceftazidime/dextrose . . . . . . . . . . . . . . . 11ceftibuten . . . . . . . . . . . . . . . . . . . . . . . . . 11CEFTIN SUSR . . . . . . . . . . . . . . . . . . . . 11ceftriaxone/dextrose . . . . . . . . . . . . . . . 11

BYDUREON PEN . . . . . . . . . . . . . . . . . 25BYETTA . . . . . . . . . . . . . . . . . . . . . . . . . . 25BYSTOLIC TABS 2.5MG, 5MG . . . . . 28BYSTOLIC TABS 10MG . . . . . . . . . . . 28BYSTOLIC TABS 20MG . . . . . . . . . . . 28BYVALSON . . . . . . . . . . . . . . . . . . . . . . . 28

Ccabergoline . . . . . . . . . . . . . . . . . . . . . . . 40CABOMETYX TABS 20MG, 60MG . . . 20CABOMETYX TABS 40MG . . . . . . . . 20CAFERGOT . . . . . . . . . . . . . . . . . . . . . . . 17calcipotriene . . . . . . . . . . . . . . . . . . . . . . 32calcitonin-salmon . . . . . . . . . . . . . . . . . . 42calcitrene . . . . . . . . . . . . . . . . . . . . . . . . . 32calcitriol caps . . . . . . . . . . . . . . . . . . . . . 42calcitriol inj . . . . . . . . . . . . . . . . . . . . . . . 42calcitriol oral soln . . . . . . . . . . . . . . . . . 42calcium acetate caps . . . . . . . . . . . . . . 35calcium acetate tabs 667mg . . . . . . . . 35calcium chloride . . . . . . . . . . . . . . . . . . . 46calcium gluconate inj . . . . . . . . . . . . . . 46CAMBIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 7camila . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39camrese . . . . . . . . . . . . . . . . . . . . . . . . . . 37camrese lo . . . . . . . . . . . . . . . . . . . . . . . . 37CANASA . . . . . . . . . . . . . . . . . . . . . . . . . . 42CANCIDAS . . . . . . . . . . . . . . . . . . . . . . . 16candesartan cilexetil . . . . . . . . . . . . . . . 27candesartan cilexetil/ hydrochlorothiazide . . . . . . . . . . . . . . . . 27CAPASTAT SULFATE . . . . . . . . . . . . . . 18CAPITAL/CODEINE . . . . . . . . . . . . . . . . 8CAPRELSA . . . . . . . . . . . . . . . . . . . . . . . 20captopril . . . . . . . . . . . . . . . . . . . . . . . . . . 28captopril/hydrochlorothiazide . . . . . . . 28CARAC . . . . . . . . . . . . . . . . . . . . . . . . . . . 32CARAFATE SUSP . . . . . . . . . . . . . . . . 34CARBAGLU . . . . . . . . . . . . . . . . . . . . . . . 46


Covered Drugs Index

54

CLOLAR . . . . . . . . . . . . . . . . . . . . . . . . . . 18clomipramine hcl . . . . . . . . . . . . . . . . . . 16clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg . . . . . . . . . . . . . . . 14clonazepam odt tbdp 2mg . . . . . . . . . . 14clonazepam tabs 0.5mg, 1mg . . . . . . 14clonazepam tabs 2mg . . . . . . . . . . . . . 14clonidine hcl er . . . . . . . . . . . . . . . . . . . . 31clonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr . . . . . . . . . . . . 27clonidine hcl ptwk 0.3mg/24hr . . . . . . 27clonidine hcl tabs . . . . . . . . . . . . . . . . . 27clopidogrel tabs 75mg . . . . . . . . . . . . . 27clopidogrel tabs 300mg . . . . . . . . . . . . 27clorazepate dipotassium tabs 3.75mg, 7.5mg . . . . . . . . . . . . . . . 24clorazepate dipotassium tabs 15mg . . . . . . . . . . . . . . . . . . . . . . . . 24clorpres . . . . . . . . . . . . . . . . . . . . . . . . . . . 27clotrimazole/betamethasone dipropionate . . . . . . . . . . . . . . . . . . . . . . . 16clotrimazole external crea . . . . . . . . . 16clotrimazole external soln . . . . . . . . . . 16clotrimazole troc . . . . . . . . . . . . . . . . . . 16clozapine . . . . . . . . . . . . . . . . . . . . . . . . . 22clozapine odt . . . . . . . . . . . . . . . . . . . . . . 22COARTEM . . . . . . . . . . . . . . . . . . . . . . . . 21codeine sulfate tabs 15mg . . . . . . . . . . 8codeine sulfate tabs 30mg . . . . . . . . . . 8codeine sulfate tabs 60mg . . . . . . . . . . 8colchicine . . . . . . . . . . . . . . . . . . . . . . . . . 17COLCRYS . . . . . . . . . . . . . . . . . . . . . . . . 17colestipol hcl . . . . . . . . . . . . . . . . . . . . . . 30colistimethate sodium . . . . . . . . . . . . . . 10colocort . . . . . . . . . . . . . . . . . . . . . . . . . . . 42COLY-MYCIN S . . . . . . . . . . . . . . . . . . . 44COMBIGAN . . . . . . . . . . . . . . . . . . . . . . . 43COMBIPATCH . . . . . . . . . . . . . . . . . . . . 37COMBIVENT RESPIMAT . . . . . . . . . . 44COMETRIQ . . . . . . . . . . . . . . . . . . . . . . . 20COMPLERA . . . . . . . . . . . . . . . . . . . . . . 23

clindamycin phosphate foam . . . . . . . 10clindamycin phosphate gel . . . . . . . . 10clindamycin phosphate in d5w . . . . . . 10clindamycin phosphate inj 300mg/2ml, 600mg/4ml, 900mg/6ml . . . . . . . . . . . . . . . . . . . . . . . . 10clindamycin phosphate lotn . . . . . . . . 10clindamycin phosphate pharmacy bulk package . . . . . . . . . . . . 10clindamycin phosphate swab . . . . . . 10clindamycin phosphate/tretinoin . . . . 32CLINDESSE . . . . . . . . . . . . . . . . . . . . . . 10CLINIMIX 2.75%/DEXTROSE 5% . . . 46CLINIMIX 4.25%/DEXTROSE 5% . . . 46CLINIMIX 4.25%/DEXTROSE 10% . . 46CLINIMIX 4.25%/DEXTROSE 20% . . 46CLINIMIX 4.25%/DEXTROSE 25% . . 46CLINIMIX 5%/DEXTROSE 15% . . . . 46CLINIMIX 5%/DEXTROSE 20% . . . . 46CLINIMIX 5%/DEXTROSE 25% . . . . 46CLINIMIX E 2.75%/ DEXTROSE 5% . . . . . . . . . . . . . . . . . . . 47CLINIMIX E 2.75%/ DEXTROSE 10% . . . . . . . . . . . . . . . . . . 46CLINIMIX E 4.25%/ DEXTROSE 5% . . . . . . . . . . . . . . . . . . . 47CLINIMIX E 4.25%/ DEXTROSE 10% . . . . . . . . . . . . . . . . . . 47CLINIMIX E 4.25%/ DEXTROSE 25% . . . . . . . . . . . . . . . . . . 47CLINIMIX E 5%/DEXTROSE 15% . . . 47CLINIMIX E 5%/DEXTROSE 20% . . . 47CLINIMIX E 5%/DEXTROSE 25% . . . 47CLINISOL SF 15% . . . . . . . . . . . . . . . . 47clinpro 5000 . . . . . . . . . . . . . . . . . . . . . . . 47clobetasol propionate . . . . . . . . . . . . . . 35clobetasol propionate e . . . . . . . . . . . . 35clobetasol propionate emollient foam . . . . . . . . . . . . . . . . . . . . 35clocortolone pivalate . . . . . . . . . . . . . . . 35clocortolone pivalate pump . . . . . . . . . 35clodan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

ciclopirox olamine . . . . . . . . . . . . . . . . . 16ciclopirox treatment . . . . . . . . . . . . . . . . 16cidofovir . . . . . . . . . . . . . . . . . . . . . . . . . . 23cilostazol . . . . . . . . . . . . . . . . . . . . . . . . . . 27CILOXAN OINT . . . . . . . . . . . . . . . . . . . 13cimetidine . . . . . . . . . . . . . . . . . . . . . . . . . 34cimetidine hcl . . . . . . . . . . . . . . . . . . . . . 34CINRYZE . . . . . . . . . . . . . . . . . . . . . . . . . 40CIPRODEX . . . . . . . . . . . . . . . . . . . . . . . 13ciprofloxacin er . . . . . . . . . . . . . . . . . . . . 13ciprofloxacin hcl . . . . . . . . . . . . . . . . . . . 13ciprofloxacin inj 400mg/40ml . . . . . . . 13ciprofloxacin i.v.-in d5w . . . . . . . . . . . . 13ciprofloxacin susr . . . . . . . . . . . . . . . . . 13CIPRO HC . . . . . . . . . . . . . . . . . . . . . . . . 13cisplatin . . . . . . . . . . . . . . . . . . . . . . . . . . . 19citalopram hydrobromide oral soln . . . 15citalopram hydrobromide tabs 10mg, 20mg . . . . . . . . . . . . . . . . . . 15citalopram hydrobromide tabs 40mg . . . . . . . . . . . . . . . . . . . . . . . . 15citric acid/sodium citrate . . . . . . . . . . . 46cladribine . . . . . . . . . . . . . . . . . . . . . . . . . 18claravis . . . . . . . . . . . . . . . . . . . . . . . . . . . 32CLARINEX-D 12 HOUR. . . . . . . . . . . . 44clarithromycin . . . . . . . . . . . . . . . . . . . . . 12clarithromycin er . . . . . . . . . . . . . . . . . . . 12CLEOCIN SUPP . . . . . . . . . . . . . . . . . . 10CLIMARA PRO . . . . . . . . . . . . . . . . . . . . 37clindacin etz pledgets . . . . . . . . . . . . . . 10clindacin-p . . . . . . . . . . . . . . . . . . . . . . . . 10clindamax . . . . . . . . . . . . . . . . . . . . . . . . . 10clindamycin/benzoyl peroxide . . . . . . 32clindamycin hcl . . . . . . . . . . . . . . . . . . . . 10clindamycin palmitate hcl . . . . . . . . . . . 10clindamycin phosphate add-vantage . . . . . . . . . . . . . . . . . . . . . . . 10clindamycin phosphate crea . . . . . . . 10clindamycin phosphate external soln . . . . . . . . . . . . . . . . . . . . . . 10


Covered Drugs Index

55

desloratadine odt . . . . . . . . . . . . . . . . . . 44desmopressin acetate . . . . . . . . . . . . . 36desogestrel/ethinyl estradiol . . . . . . . . 37DESONATE . . . . . . . . . . . . . . . . . . . . . . . 35desonide . . . . . . . . . . . . . . . . . . . . . . . . . . 35desoximetasone . . . . . . . . . . . . . . . . . . . 35dexamethasone . . . . . . . . . . . . . . . . . . . 35dexamethasone intensol . . . . . . . . . . . 35dexamethasone sodium phosphate . . 35dexamethasone sodium phosphate . . 43DEXILANT . . . . . . . . . . . . . . . . . . . . . . . . 34dexmethylphenidate hcl . . . . . . . . . . . . 31dexrazoxane . . . . . . . . . . . . . . . . . . . . . . 19dextroamphetamine sulfate . . . . . . . . 31dextroamphetamine sulfate er . . . . . . 31DEXTROSE 2.5%/NACL 0.45% . . . . 47dextrose 5% . . . . . . . . . . . . . . . . . . . . . . . 47DEXTROSE5% / ELECTROLYTE #48 VIAFLEX . . . . . 47DEXTROSE 5%/ LACTATED RINGERS . . . . . . . . . . . . . 47DEXTROSE 5%/NACL 0.2% . . . . . . . 47DEXTROSE 5%/NACL 0.3% . . . . . . . 47DEXTROSE 5%/NACL 0.9% . . . . . . . 47DEXTROSE 5%/NACL 0.33% . . . . . . 47DEXTROSE 5%/NACL 0.45% . . . . . . 47DEXTROSE 5%/NACL 0.225% . . . . . 47DEXTROSE 5%/ POTASSIUM CHLORIDE 0.15%. . . . 47dextrose 10% . . . . . . . . . . . . . . . . . . . . . 47DEXTROSE 10%/NACL 0.2% . . . . . . 47DEXTROSE10%/NACL 0.45% . . . . . 47dextrose 20% . . . . . . . . . . . . . . . . . . . . . 47dextrose 25% . . . . . . . . . . . . . . . . . . . . . 47dextrose 30% . . . . . . . . . . . . . . . . . . . . . 47dextrose 40% . . . . . . . . . . . . . . . . . . . . . 47dextrose 50% . . . . . . . . . . . . . . . . . . . . . 47dextrose 70% . . . . . . . . . . . . . . . . . . . . . 47diazepam conc . . . . . . . . . . . . . . . . . . . 25diazepam gel . . . . . . . . . . . . . . . . . . . . . 14

CYSTADANE . . . . . . . . . . . . . . . . . . . . . 33CYSTAGON . . . . . . . . . . . . . . . . . . . . . . . 33CYSTARAN . . . . . . . . . . . . . . . . . . . . . . . 43cytarabine aqueous . . . . . . . . . . . . . . . . 18cytarabine inj 100mg/ml . . . . . . . . . . . . 18cytra-2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47cytra-3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47cytra-k . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47cytra k crystals . . . . . . . . . . . . . . . . . . . . 47

Ddacarbazine . . . . . . . . . . . . . . . . . . . . . . . 18DALIRESP . . . . . . . . . . . . . . . . . . . . . . . . 45danazol . . . . . . . . . . . . . . . . . . . . . . . . . . . 36dantrolene sodium . . . . . . . . . . . . . . . . . 23dapsone . . . . . . . . . . . . . . . . . . . . . . . . . . 18DAPTACEL . . . . . . . . . . . . . . . . . . . . . . . 41daptomycin . . . . . . . . . . . . . . . . . . . . . . . 10DARAPRIM . . . . . . . . . . . . . . . . . . . . . . . 21DARZALEX . . . . . . . . . . . . . . . . . . . . . . . 20daunorubicin hcl . . . . . . . . . . . . . . . . . . . 19daysee . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37DAYTRANA . . . . . . . . . . . . . . . . . . . . . . . 31deblitane . . . . . . . . . . . . . . . . . . . . . . . . . . 39decitabine . . . . . . . . . . . . . . . . . . . . . . . . . 19delyla . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37demeclocycline hcl . . . . . . . . . . . . . . . . 13DEMSER . . . . . . . . . . . . . . . . . . . . . . . . . 29DENAVIR . . . . . . . . . . . . . . . . . . . . . . . . . 24denta 5000 plus . . . . . . . . . . . . . . . . . . . 47dentagel . . . . . . . . . . . . . . . . . . . . . . . . . . 47DEPEN TITRATABS . . . . . . . . . . . . . . . 46DEPO-ESTRADIOL . . . . . . . . . . . . . . . 37DEPO-MEDROL INJ 20MG/ML . . . . . 35DEPO-PROVERA . . . . . . . . . . . . . . . . . 39DEPO-SUBQ PROVERA 104 . . . . . . 39DESCOVY . . . . . . . . . . . . . . . . . . . . . . . . 24desipramine hcl . . . . . . . . . . . . . . . . . . . 16desloratadine . . . . . . . . . . . . . . . . . . . . . . 44

compro . . . . . . . . . . . . . . . . . . . . . . . . . . . 21CONDYLOX GEL . . . . . . . . . . . . . . . . . 32constulose . . . . . . . . . . . . . . . . . . . . . . . . 34COPAXONE INJ 40MG/ML . . . . . . . . . 31CORDRAN TAPE . . . . . . . . . . . . . . . . . . 35COREG CR . . . . . . . . . . . . . . . . . . . . . . . 29cormax scalp application . . . . . . . . . . . 35CORTIFOAM . . . . . . . . . . . . . . . . . . . . . . 35cortisone acetate . . . . . . . . . . . . . . . . . . 35CORTISPORIN CREA . . . . . . . . . . . . . 10CORTISPORIN OINT . . . . . . . . . . . . . 10COSMEGEN . . . . . . . . . . . . . . . . . . . . . . 19COTELLIC . . . . . . . . . . . . . . . . . . . . . . . . 20COUMADIN . . . . . . . . . . . . . . . . . . . . . . . 26CREON . . . . . . . . . . . . . . . . . . . . . . . . . . . 33CRESTOR . . . . . . . . . . . . . . . . . . . . . . . . 30CRIXIVAN . . . . . . . . . . . . . . . . . . . . . . . . 24cromolyn sodium conc . . . . . . . . . . . . 33cromolyn sodium nebu . . . . . . . . . . . . 45cromolyn sodium ophthalmic soln . . . 43cryselle-28 . . . . . . . . . . . . . . . . . . . . . . . . 37CUBICIN . . . . . . . . . . . . . . . . . . . . . . . . . . 10CUPRIMINE . . . . . . . . . . . . . . . . . . . . . . 46CURITY GAUZE PADS 2”X2” . . . . . . 32CUVPOSA . . . . . . . . . . . . . . . . . . . . . . . . 33cyclafem 1/35 . . . . . . . . . . . . . . . . . . . . . 37cyclafem 7/7/7 . . . . . . . . . . . . . . . . . . . . . 37cyclobenzaprine hcl tabs 10mg, 5mg . . . . . . . . . . . . . . . . . . . 46CYCLOGYL OPHTHALMIC SOLN 0.5% . . . . . . . . 43CYCLOMYDRIL . . . . . . . . . . . . . . . . . . . 43cyclopentolate hcl . . . . . . . . . . . . . . . . . 43cyclopentolate hydrochloride . . . . . . . 43cyclophosphamide . . . . . . . . . . . . . . . . . 18cycloserine . . . . . . . . . . . . . . . . . . . . . . . . 18cyclosporine . . . . . . . . . . . . . . . . . . . . . . . 40cyclosporine modified . . . . . . . . . . . . . . 40CYRAMZA . . . . . . . . . . . . . . . . . . . . . . . . 20cyred . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37


Covered Drugs Index

56

doxycycline hyclate dr tbec 100mg, 150mg, 75mg . . . . . . . . . . . . . . 13doxycycline monohydrate . . . . . . . . . . 13DRITHO-CREME HP . . . . . . . . . . . . . . 32dronabinol . . . . . . . . . . . . . . . . . . . . . . . . 16droperidol . . . . . . . . . . . . . . . . . . . . . . . . . 16drospirenone/ethinyl estradiol . . . . . . 37DROXIA . . . . . . . . . . . . . . . . . . . . . . . . . . 18duloxetine hcl cpep 20mg, 60mg . . . 15duloxetine hcl cpep 30mg . . . . . . . . . . 15DURAMORPH . . . . . . . . . . . . . . . . . . . . . 7DUREZOL . . . . . . . . . . . . . . . . . . . . . . . . 43dutasteride . . . . . . . . . . . . . . . . . . . . . . . . 35dutasteride/tamsulosin hydrochloride . . . . . . . . . . . . . . . . . . . . . . 35DUTOPROL . . . . . . . . . . . . . . . . . . . . . . . 29DYMISTA . . . . . . . . . . . . . . . . . . . . . . . . . 44DYRENIUM . . . . . . . . . . . . . . . . . . . . . . . 30DYSPORT . . . . . . . . . . . . . . . . . . . . . . . . 42

Eeconazole nitrate . . . . . . . . . . . . . . . . . . 16EDECRIN . . . . . . . . . . . . . . . . . . . . . . . . . 30ed-spaz . . . . . . . . . . . . . . . . . . . . . . . . . . . 33EDURANT . . . . . . . . . . . . . . . . . . . . . . . . 23e.e.s. 400 . . . . . . . . . . . . . . . . . . . . . . . . . 12E.E.S. GRANULES . . . . . . . . . . . . . . . . 12effer-k tbef 25meq . . . . . . . . . . . . . . . . . 47effervescent pot chloride . . . . . . . . . . . 47EFFIENT TABS 5MG . . . . . . . . . . . . . . 27EFFIENT TABS 10MG . . . . . . . . . . . . . 27EGRIFTA INJ 1MG . . . . . . . . . . . . . . . . 36ELAPRASE . . . . . . . . . . . . . . . . . . . . . . . 33ELELYSO . . . . . . . . . . . . . . . . . . . . . . . . . 33ELIDEL . . . . . . . . . . . . . . . . . . . . . . . . . . . 32ELIGARD INJ 7.5MG . . . . . . . . . . . . . . 40ELIGARD INJ 22.5MG . . . . . . . . . . . . . 40ELIGARD INJ 30MG . . . . . . . . . . . . . . . 40ELIGARD INJ 45MG . . . . . . . . . . . . . . . 40ELIQUIS TABS 2.5MG . . . . . . . . . . . . . 26

diltiazem hcl inj 100mg, 125mg/25ml, 25mg/5ml, 50mg/10ml . . . . . . . . . . . . . 29diltiazem hcl tabs . . . . . . . . . . . . . . . . . 29dilt-xr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29dimenhydrinate inj . . . . . . . . . . . . . . . . 16DIPENTUM . . . . . . . . . . . . . . . . . . . . . . . 42diphenhydramine hcl inj . . . . . . . . . . . 44diphenoxylate/atropine . . . . . . . . . . . . . 33DIPHTHERIA/TETANUS TOXOIDS ADSORBED PEDIATRIC . . . . . . . . . . 41disulfiram . . . . . . . . . . . . . . . . . . . . . . . . . . 9DIURIL . . . . . . . . . . . . . . . . . . . . . . . . . . . 30divalproex sodium . . . . . . . . . . . . . . . . . 14divalproex sodium dr . . . . . . . . . . . . . . . 14divalproex sodium er . . . . . . . . . . . . . . . 14DIVIGEL GEL 0.25MG/0.25GM, 0.5MG/0.5GM . . . . 37DOCEFREZ INJ 20MG . . . . . . . . . . . . 19docetaxel . . . . . . . . . . . . . . . . . . . . . . . . . 19dofetilide . . . . . . . . . . . . . . . . . . . . . . . . . . 28donepezil hcl tabs 10mg . . . . . . . . . . . 14donepezil hcl tabs 23mg, 5mg . . . . . . 14donepezil hcl tbdp 5mg . . . . . . . . . . . . 14donepezil hcl tbdp 10mg . . . . . . . . . . . 14DORIBAX . . . . . . . . . . . . . . . . . . . . . . . . . 12dorzolamide hcl . . . . . . . . . . . . . . . . . . . 44dorzolamide hcl/timolol maleate . . . . 44doxazosin . . . . . . . . . . . . . . . . . . . . . . . . . 35doxazosin mesylate tabs 1mg, 2mg, 8mg . . . . . . . . . . . . . . . . . . . . 35doxepin hcl . . . . . . . . . . . . . . . . . . . . . . . . 16doxepin hydrochloride . . . . . . . . . . . . . 32doxercalciferol . . . . . . . . . . . . . . . . . . . . . 42doxorubicin hcl . . . . . . . . . . . . . . . . . . . . 19doxorubicin hcl liposome . . . . . . . . . . . 19doxy 100 . . . . . . . . . . . . . . . . . . . . . . . . . . 13doxycycline caps 150mg, 75mg . . . . 13doxycycline cpdr . . . . . . . . . . . . . . . . . . 32doxycycline hyclate . . . . . . . . . . . . . . . . 13

diazepam inj . . . . . . . . . . . . . . . . . . . . . . 25diazepam intensol . . . . . . . . . . . . . . . . . 25diazepam oral soln . . . . . . . . . . . . . . . . 25diazepam tabs . . . . . . . . . . . . . . . . . . . . 25DIBENZYLINE . . . . . . . . . . . . . . . . . . . . 27diclofenac potassium . . . . . . . . . . . . . . . 7diclofenac sodium dr . . . . . . . . . . . . . . . . 7diclofenac sodium er . . . . . . . . . . . . . . . . 7diclofenac sodium gel 3% . . . . . . . . . . 32diclofenac sodium/misoprostol . . . . . . . 7diclofenac sodium ophthalmic soln . . . 43dicloxacillin sodium . . . . . . . . . . . . . . . . 12dicyclomine hcl caps . . . . . . . . . . . . . . 33dicyclomine hcl oral soln . . . . . . . . . . . 33dicyclomine hcl tabs . . . . . . . . . . . . . . . 33didanosine . . . . . . . . . . . . . . . . . . . . . . . . 24DIFFERIN LOTN . . . . . . . . . . . . . . . . . . 32DIFICID . . . . . . . . . . . . . . . . . . . . . . . . . . . 12diflorasone diacetate . . . . . . . . . . . . . . . 36diflunisal . . . . . . . . . . . . . . . . . . . . . . . . . . . 7digitek tabs 0.25mg . . . . . . . . . . . . . . . . 29digitek tabs 0.125mg . . . . . . . . . . . . . . . 29digoxin inj . . . . . . . . . . . . . . . . . . . . . . . . 29digoxin oral soln . . . . . . . . . . . . . . . . . . 29digoxin tabs 125mcg . . . . . . . . . . . . . . . 29digoxin tabs 250mcg . . . . . . . . . . . . . . . 29digox tabs 125mcg . . . . . . . . . . . . . . . . 29digox tabs 250mcg . . . . . . . . . . . . . . . . 29dihydroergotamine mesylate inj . . . . . 17dihydroergotamine mesylate nasal soln . . . . . . . . . . . . . . . . . . . . . . . . 17DILANTIN . . . . . . . . . . . . . . . . . . . . . . . . . 14DILANTIN-125 . . . . . . . . . . . . . . . . . . . . 14DILANTIN INFATABS . . . . . . . . . . . . . . 14diltiazem cd cp24 180mg, 240mg, 300mg . . . . . . . . . . . . 29diltiazem hcl cd . . . . . . . . . . . . . . . . . . . . 29diltiazem hcl er . . . . . . . . . . . . . . . . . . . . 29


Covered Drugs Index

57

estradiol/norethindrone acetate . . . . . 37estradiol pttw . . . . . . . . . . . . . . . . . . . . . 37estradiol ptwk . . . . . . . . . . . . . . . . . . . . . 37estradiol tabs . . . . . . . . . . . . . . . . . . . . . 37ESTRING . . . . . . . . . . . . . . . . . . . . . . . . . 37ESTROGEL . . . . . . . . . . . . . . . . . . . . . . . 37estropipate . . . . . . . . . . . . . . . . . . . . . . . . 37ethacrynate sodium . . . . . . . . . . . . . . . . 30ethacrynic acid . . . . . . . . . . . . . . . . . . . . 30ethambutol hcl . . . . . . . . . . . . . . . . . . . . 18ethosuximide . . . . . . . . . . . . . . . . . . . . . . 14etidronate disodium . . . . . . . . . . . . . . . . 42etodolac . . . . . . . . . . . . . . . . . . . . . . . . . . . 7etodolac er . . . . . . . . . . . . . . . . . . . . . . . . . 7ETOPOPHOS . . . . . . . . . . . . . . . . . . . . . 20etoposide inj . . . . . . . . . . . . . . . . . . . . . . 20EURAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 21EVOMELA . . . . . . . . . . . . . . . . . . . . . . . . 18EVOTAZ . . . . . . . . . . . . . . . . . . . . . . . . . . 24EXELON PT24 . . . . . . . . . . . . . . . . . . . 14exemestane . . . . . . . . . . . . . . . . . . . . . . . 20EXJADE . . . . . . . . . . . . . . . . . . . . . . . . . . 46EXTAVIA . . . . . . . . . . . . . . . . . . . . . . . . . . 31

FFABRAZYME . . . . . . . . . . . . . . . . . . . . . 33falmina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37famciclovir . . . . . . . . . . . . . . . . . . . . . . . . 24famotidine inj . . . . . . . . . . . . . . . . . . . . . 34famotidine premixed . . . . . . . . . . . . . . . 34famotidine susr . . . . . . . . . . . . . . . . . . . 34famotidine tabs 20mg, 40mg . . . . . . . 34FANAPT TABS 1MG, 2MG, 4MG . . . 22FANAPT TABS 10MG, 12MG, 6MG, 8MG . . . . . . . . . . 22FANAPT TITRATION PACK . . . . . . . . 22FARESTON . . . . . . . . . . . . . . . . . . . . . . . 18FARYDAK . . . . . . . . . . . . . . . . . . . . . . . . 20FASLODEX . . . . . . . . . . . . . . . . . . . . . . . 18

epinephrine . . . . . . . . . . . . . . . . . . . . . . . 45epinephrine hcl . . . . . . . . . . . . . . . . . . . . 45EPIPEN 2-PAK . . . . . . . . . . . . . . . . . . . . 45EPIPEN-JR 2-PAK . . . . . . . . . . . . . . . . . 45epirubicin hcl inj 200mg/100ml, 50mg/25ml . . . . . . . . . . 19epitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14EPIVIR HBV ORAL SOLN . . . . . . . . . 23eplerenone . . . . . . . . . . . . . . . . . . . . . . . . 30EPOGEN . . . . . . . . . . . . . . . . . . . . . . . . . 27eprosartan mesylate . . . . . . . . . . . . . . . 27EPZICOM . . . . . . . . . . . . . . . . . . . . . . . . . 24EQUETRO . . . . . . . . . . . . . . . . . . . . . . . . 14ERAXIS . . . . . . . . . . . . . . . . . . . . . . . . . . . 16ERBITUX . . . . . . . . . . . . . . . . . . . . . . . . . 20ergoloid mesylates . . . . . . . . . . . . . . . . . 14ERGOMAR . . . . . . . . . . . . . . . . . . . . . . . 17ERIVEDGE . . . . . . . . . . . . . . . . . . . . . . . 20errin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39ERTACZO . . . . . . . . . . . . . . . . . . . . . . . . 16ERWINAZE . . . . . . . . . . . . . . . . . . . . . . . 19ery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12ERYPED 200 . . . . . . . . . . . . . . . . . . . . . 12ERYPED 400 . . . . . . . . . . . . . . . . . . . . . 12ERY-TAB . . . . . . . . . . . . . . . . . . . . . . . . . . 12ERYTHROCIN LACTOBIONATE . . . 12erythrocin stearate . . . . . . . . . . . . . . . . . 12erythromycin . . . . . . . . . . . . . . . . . . . . . . 12erythromycin base . . . . . . . . . . . . . . . . . 12erythromycin/benzoyl peroxide . . . . . 32erythromycin ethylsuccinate tabs . . . 12ESBRIET . . . . . . . . . . . . . . . . . . . . . . . . . 45escitalopram oxalate oral soln . . . . . 15escitalopram oxalate tabs . . . . . . . . . 15esgic caps . . . . . . . . . . . . . . . . . . . . . . . . . 7esmolol hcl . . . . . . . . . . . . . . . . . . . . . . . . 29esomeprazole magnesium . . . . . . . . . 34esomeprazole sodium . . . . . . . . . . . . . 34estarylla . . . . . . . . . . . . . . . . . . . . . . . . . . 37ESTRACE CREA . . . . . . . . . . . . . . . . . 37

ELIQUIS TABS 5MG . . . . . . . . . . . . . . . 26ELITEK . . . . . . . . . . . . . . . . . . . . . . . . . . . 18ELIXOPHYLLIN . . . . . . . . . . . . . . . . . . . 45ELMIRON . . . . . . . . . . . . . . . . . . . . . . . . . 35EMADINE . . . . . . . . . . . . . . . . . . . . . . . . . 43EMCYT . . . . . . . . . . . . . . . . . . . . . . . . . . . 18EMEND CAPS . . . . . . . . . . . . . . . . . . . . 16EMEND CAPS 40MG . . . . . . . . . . . . . . 16EMEND CAPS 80MG . . . . . . . . . . . . . . 16EMEND CAPS 125MG . . . . . . . . . . . . . 16EMEND SUSR . . . . . . . . . . . . . . . . . . . . 16emoquette . . . . . . . . . . . . . . . . . . . . . . . . 37EMPLICITI . . . . . . . . . . . . . . . . . . . . . . . . 20EMSAM . . . . . . . . . . . . . . . . . . . . . . . . . . . 15EMTRIVA . . . . . . . . . . . . . . . . . . . . . . . . . 24enalaprilat . . . . . . . . . . . . . . . . . . . . . . . . . 28enalapril maleate . . . . . . . . . . . . . . . . . . 28enalapril maleate/ hydrochlorothiazide . . . . . . . . . . . . . . . . 28ENBREL . . . . . . . . . . . . . . . . . . . . . . . . . . 40ENBREL SURECLICK . . . . . . . . . . . . . 40endocet . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8ENGERIX-B . . . . . . . . . . . . . . . . . . . . . . . 41enoxaparin sodium inj 30mg/0.3ml . . 26enoxaparin sodium inj 40mg/0.4ml . . 26enoxaparin sodium inj 60mg/0.6ml . . 26enoxaparin sodium inj 80mg/0.8ml . . 26enoxaparin sodium inj 100mg/ml . . . 26enoxaparin sodium inj 120mg/0.8ml . . . . . . . . . . . . . . . . . . . . . . 26enoxaparin sodium inj 150mg/ml . . . 26enoxaparin sodium inj 300mg/3ml . . . 26enpresse-28 . . . . . . . . . . . . . . . . . . . . . . . 37enskyce . . . . . . . . . . . . . . . . . . . . . . . . . . . 37entacapone . . . . . . . . . . . . . . . . . . . . . . . 21entecavir . . . . . . . . . . . . . . . . . . . . . . . . . . 23ENTRESTO . . . . . . . . . . . . . . . . . . . . . . . 27enulose . . . . . . . . . . . . . . . . . . . . . . . . . . . 34ENVARSUS XR . . . . . . . . . . . . . . . . . . . 40epinastine hcl . . . . . . . . . . . . . . . . . . . . . 43


Covered Drugs Index

58

fluvoxamine maleate . . . . . . . . . . . . . . . 15FML . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43FML FORTE . . . . . . . . . . . . . . . . . . . . . . 43FOLOTYN . . . . . . . . . . . . . . . . . . . . . . . . 18fomepizole . . . . . . . . . . . . . . . . . . . . . . . . 42fondaparinux sodium inj 2.5mg/0.5ml . . . . . . . . . . . . . . . . . . . . . . . 26fondaparinux sodium inj 5mg/0.4ml . . . . . . . . . . . . . . . . . . . . . . . . 26fondaparinux sodium inj 7.5mg/0.6ml . . . . . . . . . . . . . . . . . . . . . . . 26fondaparinux sodium inj 10mg/0.8ml . . . . . . . . . . . . . . . . . . . . . . . 26FORTAZ INJ 500MG . . . . . . . . . . . . . . . 11FORTEO . . . . . . . . . . . . . . . . . . . . . . . . . . 42FORTICAL . . . . . . . . . . . . . . . . . . . . . . . . 42FOSAMAX PLUS D . . . . . . . . . . . . . . . . 42fosinopril sodium . . . . . . . . . . . . . . . . . . 28fosinopril sodium/ hydrochlorothiazide . . . . . . . . . . . . . . . . 28fosphenytoin sodium inj 100mg pe/2ml . . . . . . . . . . . . . . . . . . . . . 14FOSRENOL . . . . . . . . . . . . . . . . . . . . . . . 35FRAGMIN INJ 2500UNIT/0.2ML, 5000UNIT/0.2ML . . . . . . . . . . . . . . . . . . 26FRAGMIN INJ 7500UNIT/0.3ML . . . . 26FRAGMIN INJ 10000UNIT/ML. . . . . . 26FRAGMIN INJ 12500UNIT/0.5ML. . . 26FRAGMIN INJ 15000UNIT/0.6ML. . . 26FRAGMIN INJ 18000UNT/0.72ML . . 26FRAGMIN INJ 95000UNIT/3.8ML. . . 26FREAMINE HBC 6.9% . . . . . . . . . . . . . 47FREAMINE III INJ 89MEQ/L; 710MG/100ML; 950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML; 280MG/100ML; 690MG/100ML; 910MG/100ML; 730MG/100ML; 530MG/100ML; 560MG/100ML; 10MMOLE/L; 120MG/100ML; 1120MG/100ML; 590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML; 660MG/100ML . . . . . 47

fluconazole in dextrose . . . . . . . . . . . . 16fluconazole in nacl inj 100mg/50ml; 0.9%, 200mg/100ml; 0.9% . . . . . . . . . 16flucytosine . . . . . . . . . . . . . . . . . . . . . . . . 16fludarabine phosphate . . . . . . . . . . . . . 19fludrocortisone acetate . . . . . . . . . . . . . 36flunisolide . . . . . . . . . . . . . . . . . . . . . . . . . 44fluocinolone acetonide . . . . . . . . . . . . . 36fluocinolone acetonide . . . . . . . . . . . . . 44fluocinolone acetonide body . . . . . . . . 36fluocinolone acetonide ear drops . . . 36fluocinolone acetonide scalp . . . . . . . 36fluocinonide . . . . . . . . . . . . . . . . . . . . . . . 36fluocinonide-e . . . . . . . . . . . . . . . . . . . . . 36fluor-a-day . . . . . . . . . . . . . . . . . . . . . . . . 47fluoride chew 0.25mg, 1.1mg, 2.2mg . . . . . . . . . . . . . 47fluoridex daily defense . . . . . . . . . . . . . 47fluoridex daily defense sensitivity relief pste . . . . . . . . . . . . . . . 32fluoritab chew 0.5mg, 1mg . . . . . . . . . 47fluoritab oral soln . . . . . . . . . . . . . . . . . 47fluorometholone . . . . . . . . . . . . . . . . . . . 43fluorouracil crea . . . . . . . . . . . . . . . . . . . 32fluorouracil external soln . . . . . . . . . . . 32fluorouracil inj . . . . . . . . . . . . . . . . . . . . . 18fluoxetine . . . . . . . . . . . . . . . . . . . . . . . . . 15fluoxetine hcl . . . . . . . . . . . . . . . . . . . . . . 15fluphenazine decanoate . . . . . . . . . . . . 21fluphenazine hcl . . . . . . . . . . . . . . . . . . . 21flura-drops oral soln 0.25mg/drop . . . 47flurandrenolide crea . . . . . . . . . . . . . . . 36flurbiprofen . . . . . . . . . . . . . . . . . . . . . . . . . 7flurbiprofen sodium . . . . . . . . . . . . . . . . 43flutamide . . . . . . . . . . . . . . . . . . . . . . . . . . 18fluticasone propionate . . . . . . . . . . . . . 36fluticasone propionate . . . . . . . . . . . . . 44fluvastatin caps 20mg . . . . . . . . . . . . . . 30fluvastatin caps 40mg . . . . . . . . . . . . . . 30fluvastatin sodium er . . . . . . . . . . . . . . . 30

FAZACLO TBDP 100MG, 12.5MG, 25MG . . . . . . . . . . . 22felbamate susp . . . . . . . . . . . . . . . . . . . 14felbamate tabs . . . . . . . . . . . . . . . . . . . . 14felodipine er . . . . . . . . . . . . . . . . . . . . . . . 29FEM PH . . . . . . . . . . . . . . . . . . . . . . . . . . 10FEMRING . . . . . . . . . . . . . . . . . . . . . . . . . 37fenofibrate caps 50mg . . . . . . . . . . . . . 30fenofibrate caps 130mg, 150mg, 43mg . . . . . . . . . . . . . . 30fenofibrate micronized . . . . . . . . . . . . . 30fenofibrate tabs 48mg, 54mg . . . . . . . 30fenofibrate tabs 145mg, 160mg . . . . . 30fenofibric acid dr cpdr 45mg . . . . . . . . 30fenofibric acid dr cpdr 135mg . . . . . . . 30fenoprofen calcium caps 400mg . . . . . 7fenoprofen calcium tabs . . . . . . . . . . . . 7fentanyl . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7fentanyl citrate inj 100mcg/2ml . . . . . . 8fentanyl citrate oral transmucosal lpop 200mcg . . . . . . . . . . 8fentanyl citrate oral transmucosal lpop 1200mcg, 1600mcg, 400mcg, 600mcg, 800mcg . . . . . . . . . . . . . . . . . . . 8FERRIPROX . . . . . . . . . . . . . . . . . . . . . . 42FETZIMA . . . . . . . . . . . . . . . . . . . . . . . . . 15FETZIMA TITRATION PACK . . . . . . . 15FINACEA . . . . . . . . . . . . . . . . . . . . . . . . . 32finasteride tabs 5mg . . . . . . . . . . . . . . . 35FIRAZYR . . . . . . . . . . . . . . . . . . . . . . . . . 40FIRMAGON INJ 80MG . . . . . . . . . . . . . 40FIRMAGON INJ 120MG . . . . . . . . . . . 40FLAGYL ER . . . . . . . . . . . . . . . . . . . . . . . 10FLAREX . . . . . . . . . . . . . . . . . . . . . . . . . . 43flavoxate hcl . . . . . . . . . . . . . . . . . . . . . . . 34FLEBOGAMMA DIF . . . . . . . . . . . . . . . 41flecainide acetate . . . . . . . . . . . . . . . . . . 28FLOVENT DISKUS . . . . . . . . . . . . . . . . 44FLOVENT HFA . . . . . . . . . . . . . . . . . . . . 44floxuridine . . . . . . . . . . . . . . . . . . . . . . . . . 18fluconazole . . . . . . . . . . . . . . . . . . . . . . . . 16


Covered Drugs Index

59

HHALAVEN . . . . . . . . . . . . . . . . . . . . . . . . . 19halobetasol propionate . . . . . . . . . . . . . 36haloperidol . . . . . . . . . . . . . . . . . . . . . . . . 21haloperidol decanoate . . . . . . . . . . . . . 21haloperidol lactate . . . . . . . . . . . . . . . . . 21HARVONI . . . . . . . . . . . . . . . . . . . . . . . . . 23HAVRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 41heather . . . . . . . . . . . . . . . . . . . . . . . . . . . 39heparin sodium/d5w . . . . . . . . . . . . . . . 26heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml, 2000unit/ml, 2500unit/ml, 5000unit/0.5ml, 5000unit/ml . . . . . . . . 26heparin sodium/nacl 0.9% . . . . . . . . . . 26heparin sodium/nacl 0.45% . . . . . . . . 26heparin sodium/ sodium chloride 0.9% . . . . . . . . . . . . . . 26heparin sodium/ sodium chloride 0.9% premix . . . . . . . 27HEPATAMINE . . . . . . . . . . . . . . . . . . . . . 47HERCEPTIN . . . . . . . . . . . . . . . . . . . . . . 20HETLIOZ . . . . . . . . . . . . . . . . . . . . . . . . . 31HEXALEN . . . . . . . . . . . . . . . . . . . . . . . . 18HIBERIX . . . . . . . . . . . . . . . . . . . . . . . . . . 41HIZENTRA . . . . . . . . . . . . . . . . . . . . . . . . 41homatropaire . . . . . . . . . . . . . . . . . . . . . . 43HORIZANT . . . . . . . . . . . . . . . . . . . . . . . 31H.P. ACTHAR . . . . . . . . . . . . . . . . . . . . . 36HUMALOG . . . . . . . . . . . . . . . . . . . . . . . . 25HUMALOG KWIKPEN . . . . . . . . . . . . . 25HUMALOG MIX 50/50 . . . . . . . . . . . . . 25HUMALOG MIX 50/50 KWIKPEN . . . 25HUMALOG MIX 75/25 . . . . . . . . . . . . . 26HUMALOG MIX 75/25 KWIKPEN . . . 26HUMIRA . . . . . . . . . . . . . . . . . . . . . . . . . . 40HUMIRA PEDIATRIC CROHNS DISEASE STARTER PACK . . . . . . . . 40HUMIRA PEN . . . . . . . . . . . . . . . . . . . . . 40

gentamicin sulfate/0.9% sodium chloride inj 0.9mg/ml; 0.9%, 1.2mg/ml; 0.9%, 1.4mg/ml; 0.9%, 1.6mg/ml; 0.9%, 1mg/ml; 0.9%, 2mg/ml; 0.9% . . . . . . . . . . . . . . . . . . . . . 10gentamicin sulfate pediatric . . . . . . . . 10GENVOYA . . . . . . . . . . . . . . . . . . . . . . . . 23GEODON INJ . . . . . . . . . . . . . . . . . . . . 22gianvi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37gildagia . . . . . . . . . . . . . . . . . . . . . . . . . . . 37gildess 1.5/30 . . . . . . . . . . . . . . . . . . . . . 37gildess 24 fe . . . . . . . . . . . . . . . . . . . . . . 37GILENYA . . . . . . . . . . . . . . . . . . . . . . . . . 31GILOTRIF . . . . . . . . . . . . . . . . . . . . . . . . . 20GLASSIA . . . . . . . . . . . . . . . . . . . . . . . . . 45glatopa . . . . . . . . . . . . . . . . . . . . . . . . . . . 32GLEEVEC . . . . . . . . . . . . . . . . . . . . . . . . 20GLEOSTINE . . . . . . . . . . . . . . . . . . . . . . 18glimepiride . . . . . . . . . . . . . . . . . . . . . . . . 25glipizide . . . . . . . . . . . . . . . . . . . . . . . . . . . 25glipizide er . . . . . . . . . . . . . . . . . . . . . . . . 25glipizide/metformin hcl . . . . . . . . . . . . . 25glipizide xl . . . . . . . . . . . . . . . . . . . . . . . . . 25GLUCAGEN HYPOKIT . . . . . . . . . . . . 25GLUCAGON EMERGENCY KIT . . . . 25glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml . . . . 33glycopyrrolate tabs . . . . . . . . . . . . . . . . 33glydo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9GLYSET . . . . . . . . . . . . . . . . . . . . . . . . . . 25GOLYTELY . . . . . . . . . . . . . . . . . . . . . . . 34GORDONS UREA OINT 40% . . . . . . 32granisetron hcl inj . . . . . . . . . . . . . . . . . 16granisetron hcl inj . . . . . . . . . . . . . . . . . 16granisetron hcl tabs . . . . . . . . . . . . . . . 16GRANIX . . . . . . . . . . . . . . . . . . . . . . . . . . 27griseofulvin microsize . . . . . . . . . . . . . . 16griseofulvin ultramicrosize . . . . . . . . . . 16GUANIDINE HCL . . . . . . . . . . . . . . . . . . 18GYNAZOLE-1 . . . . . . . . . . . . . . . . . . . . . 16

FROVA . . . . . . . . . . . . . . . . . . . . . . . . . . . 17frovatriptan succinate . . . . . . . . . . . . . . 17furosemide . . . . . . . . . . . . . . . . . . . . . . . . 30FUZEON . . . . . . . . . . . . . . . . . . . . . . . . . . 24fyavolv . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37FYCOMPA . . . . . . . . . . . . . . . . . . . . . . . . 13

Ggabapentin . . . . . . . . . . . . . . . . . . . . . . . . 14galantamine hydrobromide cp24 . . . 14galantamine hydrobromide oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 14galantamine hydrobromide tabs . . . . 14GAMASTAN S/D . . . . . . . . . . . . . . . . . . 41GAMMAGARD LIQUID INJ 2.5GM/25ML, 30GM/300ML . . . . . . . . 41GAMMAGARD S/D IGA LESS THAN 1MCG/ML . . . . . . . . . . . . 41GAMMAKED INJ 1GM/10ML . . . . . . . 41GAMMAPLEX . . . . . . . . . . . . . . . . . . . . . 41GAMUNEX-C . . . . . . . . . . . . . . . . . . . . . 41ganciclovir inj . . . . . . . . . . . . . . . . . . . . . 23GARDASIL . . . . . . . . . . . . . . . . . . . . . . . . 41GARDASIL 9 . . . . . . . . . . . . . . . . . . . . . . 41gatifloxacin . . . . . . . . . . . . . . . . . . . . . . . . 13GATTEX . . . . . . . . . . . . . . . . . . . . . . . . . . 34gavilyte-c . . . . . . . . . . . . . . . . . . . . . . . . . 34gavilyte-g . . . . . . . . . . . . . . . . . . . . . . . . . 34gavilyte-n/flavor pack . . . . . . . . . . . . . . 34GAZYVA . . . . . . . . . . . . . . . . . . . . . . . . . . 20GELNIQUE . . . . . . . . . . . . . . . . . . . . . . . 34gemcitabine . . . . . . . . . . . . . . . . . . . . . . . 18gemcitabine hcl . . . . . . . . . . . . . . . . . . . . 18gemfibrozil . . . . . . . . . . . . . . . . . . . . . . . . 30generlac . . . . . . . . . . . . . . . . . . . . . . . . . . 34gengraf . . . . . . . . . . . . . . . . . . . . . . . . . . . 40gentak . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10gentamicin sulfate . . . . . . . . . . . . . . . . . 10


Covered Drugs Index

60

INTELENCE TABS 25MG . . . . . . . . . . 23INTELENCE TABS 100MG, 200MG . . . . . . . . . . . . . . . . . . . 23INTRALIPID . . . . . . . . . . . . . . . . . . . . . . . 49INTRON A . . . . . . . . . . . . . . . . . . . . . . . . 23INTRON A W/DILUENT . . . . . . . . . . . . 23introvale . . . . . . . . . . . . . . . . . . . . . . . . . . 37INVANZ . . . . . . . . . . . . . . . . . . . . . . . . . . . 12INVEGA SUSTENNA INJ 39MG/0.25ML, 78MG/0.5ML . . . . . . . 22INVEGA SUSTENNA INJ 117MG/0.75ML, 156MG/ML, 234MG/1.5ML . . . . . . . . . . . . . . . . . . . . . 22INVEGA TB24 1.5MG, 3MG . . . . . . . . 22INVEGA TB24 6MG . . . . . . . . . . . . . . . 22INVEGA TB24 9MG . . . . . . . . . . . . . . . 22INVEGA TRINZA . . . . . . . . . . . . . . . . . . 22INVIRASE CAPS . . . . . . . . . . . . . . . . . 24INVIRASE TABS . . . . . . . . . . . . . . . . . . 24INVOKAMET . . . . . . . . . . . . . . . . . . . . . . 25INVOKAMET XR . . . . . . . . . . . . . . . . . . 25INVOKANA . . . . . . . . . . . . . . . . . . . . . . . 25IONOSOL-B/DEXTROSE 5% . . . . . . 47IONOSOL-MB/DEXTROSE 5% . . . . . 47IOPIDINE OPHTHALMIC SOLN 1% . . . . . . . . . . 44IPOL INACTIVATED IPV . . . . . . . . . . . 41ipratropium bromide/ albuterol sulfate . . . . . . . . . . . . . . . . . . . 45ipratropium bromide inhalation soln . . . . . . . . . . . . . . . . . . . . 45ipratropium bromide nasal soln . . . . . 45irbesartan . . . . . . . . . . . . . . . . . . . . . . . . . 27irbesartan/hydrochlorothiazide . . . . . . 27IRESSA . . . . . . . . . . . . . . . . . . . . . . . . . . . 20irinotecan . . . . . . . . . . . . . . . . . . . . . . . . . 19ISENTRESS CHEW . . . . . . . . . . . . . . . 23ISENTRESS PACK . . . . . . . . . . . . . . . 23ISENTRESS TABS . . . . . . . . . . . . . . . . 23ISOLYTE-P/DEXTROSE 5% . . . . . . . 47ISOLYTE-S . . . . . . . . . . . . . . . . . . . . . . . 48

hydromorphone hcl tabs . . . . . . . . . . . . 8hydroxychloroquine sulfate . . . . . . . . . 21hydroxyprogesterone caproate . . . . . 39hydroxyurea . . . . . . . . . . . . . . . . . . . . . . . 18HYOLEV MB . . . . . . . . . . . . . . . . . . . . . . 34hyoscyamine sulfate elix . . . . . . . . . . . 33hyoscyamine sulfate odt . . . . . . . . . . . 33hyoscyamine sulfate subl . . . . . . . . . . 33hyoscyamine sulfate tabs . . . . . . . . . . 33hyoscyamine sulfate tbdp . . . . . . . . . . 33hyosyne . . . . . . . . . . . . . . . . . . . . . . . . . . 33hyperlyte-cr . . . . . . . . . . . . . . . . . . . . . . . 47

Iibandronate sodium . . . . . . . . . . . . . . . . 42IBRANCE . . . . . . . . . . . . . . . . . . . . . . . . . 19ibudone tabs 5mg; 200mg . . . . . . . . . . . 8ibuprofen lysine . . . . . . . . . . . . . . . . . . . . 7ibuprofen susp . . . . . . . . . . . . . . . . . . . . . 7ibuprofen tabs 400mg, 600mg, 800mg . . . . . . . . . . . . . 7ICLUSIG . . . . . . . . . . . . . . . . . . . . . . . . . . 20idarubicin hcl . . . . . . . . . . . . . . . . . . . . . . 19ifosfamide . . . . . . . . . . . . . . . . . . . . . . . . . 18ILARIS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41ilotycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12imatinib mesylate . . . . . . . . . . . . . . . . . . 20IMBRUVICA . . . . . . . . . . . . . . . . . . . . . . . 20imipenem/cilastatin . . . . . . . . . . . . . . . . 12imipramine hcl . . . . . . . . . . . . . . . . . . . . . 16imipramine pamoate . . . . . . . . . . . . . . . 16imiquimod . . . . . . . . . . . . . . . . . . . . . . . . . 32IMOVAX RABIES (H.D.C.V.) . . . . . . . 41indapamide . . . . . . . . . . . . . . . . . . . . . . . 30INFANRIX . . . . . . . . . . . . . . . . . . . . . . . . . 41INFUMORPH 200 . . . . . . . . . . . . . . . . . . 7INFUMORPH 500 . . . . . . . . . . . . . . . . . . 7INLYTA . . . . . . . . . . . . . . . . . . . . . . . . . . . 20INNOPRAN XL . . . . . . . . . . . . . . . . . . . . 29

HUMIRA PEN-CROHNS DISEASESTARTER . . . . . . . . . . . . . . . 40HUMIRA PEN-PSORIASIS STARTER . . . . . . . . . . . . . . . . . . . . . . . . . 40HUMULIN 70/30 . . . . . . . . . . . . . . . . . . . 26HUMULIN 70/30 KWIKPEN . . . . . . . . 26HUMULIN N . . . . . . . . . . . . . . . . . . . . . . . 26HUMULIN N KWIKPEN . . . . . . . . . . . . 26HUMULIN R . . . . . . . . . . . . . . . . . . . . . . . 26HUMULIN R U-500 (CONCENTRATED) . . . . . . . . . . . . . . . 26HUMULIN R U-500 KWIKPEN. . . . . . 26hydralazine hcl . . . . . . . . . . . . . . . . . . . . 31hydrochlorothiazide . . . . . . . . . . . . . . . . 30hydrocodone/acetaminophen tabs 325mg; 10mg, 325mg; 5mg, 325mg; 7.5mg . . . . . . . . . . . . . . . . 8hydrocodone bitartrate/ acetaminophen oral soln 325mg/15ml; 7.5mg/15ml . . . . . . . . . . . 8hydrocodone bitartrate/ acetaminophen tabs 300mg; 10mg, 300mg; 5mg, 300mg; 7.5mg . . . . . . . . . 8hydrocodone bitartrate/ acetaminophen tabs 325mg; 2.5mg. . . 8hydrocodone/ibuprofen tabs 5mg; 200mg, 7.5mg; 200mg . . . . . . . . . 8hydrocodone/ibuprofen tabs 10mg; 200mg . . . . . . . . . . . . . . . . . . . . . . 8hydrocortisone/acetic acid . . . . . . . . . . 44hydrocortisone butyrate . . . . . . . . . . . . 36hydrocortisone enem . . . . . . . . . . . . . . 42hydrocortisone external crea . . . . . . . 36hydrocortisone lotn 2.5% . . . . . . . . . . . 36hydrocortisone oint 1%, 2.5% . . . . . . 36hydrocortisone tabs . . . . . . . . . . . . . . . 36hydrocortisone valerate . . . . . . . . . . . . 36hydromorphone hcl dosette . . . . . . . . . 8hydromorphone hcl inj 1mg/ml, 2mg/ml, 4mg/ml, 500mg/50ml . . . . . . . 8hydromorphone hcl liqd . . . . . . . . . . . . 8hydromorphone hcl supp . . . . . . . . . . . 8


Covered Drugs Index

61

ketorolac tromethamine inj 15mg/ml, 30mg/ml . . . . . . . . . . . . . . . . . . 7ketorolac tromethamine ophthalmic soln . . . . . . . . . . . . . . . . . . . 43ketorolac tromethamine tabs . . . . . . . . 7KEYTRUDA . . . . . . . . . . . . . . . . . . . . . . . 20kimidess . . . . . . . . . . . . . . . . . . . . . . . . . . 38KINERET . . . . . . . . . . . . . . . . . . . . . . . . . 40KINRIX . . . . . . . . . . . . . . . . . . . . . . . . . . . 41kionex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46klor-con . . . . . . . . . . . . . . . . . . . . . . . . . . . 48KLOR-CON 8 . . . . . . . . . . . . . . . . . . . . . 48KLOR-CON 10 . . . . . . . . . . . . . . . . . . . . 48klor-con/25 . . . . . . . . . . . . . . . . . . . . . . . . 48klor-con m10 . . . . . . . . . . . . . . . . . . . . . . 48klor-con m15 . . . . . . . . . . . . . . . . . . . . . . 48klor-con m20 . . . . . . . . . . . . . . . . . . . . . . 48klor-con sprinkle . . . . . . . . . . . . . . . . . . . 48KORLYM . . . . . . . . . . . . . . . . . . . . . . . . . . 42K-PHOS . . . . . . . . . . . . . . . . . . . . . . . . . . 48K-PHOS NO 2 . . . . . . . . . . . . . . . . . . . . . 48KRISTALOSE . . . . . . . . . . . . . . . . . . . . . 34k-sol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48K-TAB TBCR 10MEQ, 20MEQ . . . . . 48kurvelo . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38KUVAN . . . . . . . . . . . . . . . . . . . . . . . . . . . 33k-vescent tbef . . . . . . . . . . . . . . . . . . . . 48KYNAMRO . . . . . . . . . . . . . . . . . . . . . . . . 30

Llabetalol hcl . . . . . . . . . . . . . . . . . . . . . . . 29LACRISERT . . . . . . . . . . . . . . . . . . . . . . 43LACTATED RINGERS IRRIGATION . . . . . . . . . . . . . . . . . . . . . . 42LACTATED RINGERS VIAFLEX . . . . 48lactulose . . . . . . . . . . . . . . . . . . . . . . . . . . 34lamivudine . . . . . . . . . . . . . . . . . . . . . . . . 23lamivudine . . . . . . . . . . . . . . . . . . . . . . . . 24lamivudine/zidovudine . . . . . . . . . . . . . 24lamotrigine . . . . . . . . . . . . . . . . . . . . . . . . 14

juleber . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37junel 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . 37junel 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . 37junel fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 37junel fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 37junel fe 24 . . . . . . . . . . . . . . . . . . . . . . . . . 38JUXTAPID . . . . . . . . . . . . . . . . . . . . . . . . 30

KKABIVEN . . . . . . . . . . . . . . . . . . . . . . . . . 49KADCYLA . . . . . . . . . . . . . . . . . . . . . . . . 20kaitlib fe . . . . . . . . . . . . . . . . . . . . . . . . . . . 38KALBITOR . . . . . . . . . . . . . . . . . . . . . . . . 40KALETRA ORAL SOLN . . . . . . . . . . . 24KALETRA TABS 100MG; 25MG . . . . 24KALETRA TABS 200MG; 50MG . . . . 24KALYDECO . . . . . . . . . . . . . . . . . . . . . . . 45kariva . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38KCL 0.3%/D5W/LR IV LAC RING . . . 48KCL 0.3%/D5W/NACL 0.9% . . . . . . . . 48KCL 0.3%/D5W/NACL 0.45% . . . . . . 48KCL 0.15%/D5W/LR . . . . . . . . . . . . . . . 48KCL 0.15%/D5W/NACL 0.2% . . . . . . 48KCL 0.15%/D5W/ NACL 0.3% . . . . . . 48KCL 0.15%/D5W/NACL 0.9% . . . . . . 48KCL 0.15%/D5W/NACL 0.45% . . . . . 48KCL 0.15%/D5W/NACL 0.225% . . . . 48KCL 0.075%/D5W/NACL 0.45% . . . . 48k-effervescent . . . . . . . . . . . . . . . . . . . . . 48kelnor 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 38KENALOG . . . . . . . . . . . . . . . . . . . . . . . . 36KEPIVANCE . . . . . . . . . . . . . . . . . . . . . . 32KETEK . . . . . . . . . . . . . . . . . . . . . . . . . . . 12ketoconazole crea . . . . . . . . . . . . . . . . 17ketoconazole sham . . . . . . . . . . . . . . . 17ketoconazole tabs . . . . . . . . . . . . . . . . . 17ketoprofen . . . . . . . . . . . . . . . . . . . . . . . . . 7ketoprofen er . . . . . . . . . . . . . . . . . . . . . . . 7

ISOLYTE-S PH 7.4 . . . . . . . . . . . . . . . . 48isoniazid . . . . . . . . . . . . . . . . . . . . . . . . . . 18isopto carpine . . . . . . . . . . . . . . . . . . . . . 44isosorbide dinitrate er . . . . . . . . . . . . . . 31isosorbide dinitrate tabs . . . . . . . . . . . 31isosorbide mononitrate . . . . . . . . . . . . . 31isosorbide mononitrate er . . . . . . . . . . 31isotonic gentamicin inj 0.8mg/ml; 0.9% . . . . . . . . . . . . . . . . . . . . 10isradipine . . . . . . . . . . . . . . . . . . . . . . . . . 29ISTALOL . . . . . . . . . . . . . . . . . . . . . . . . . . 44ISTODAX . . . . . . . . . . . . . . . . . . . . . . . . . 19ISUPREL . . . . . . . . . . . . . . . . . . . . . . . . . 45itraconazole . . . . . . . . . . . . . . . . . . . . . . . 16ivermectin . . . . . . . . . . . . . . . . . . . . . . . . . 21IXEMPRA KIT . . . . . . . . . . . . . . . . . . . . . 19IXIARO . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

JJADENU . . . . . . . . . . . . . . . . . . . . . . . . . . 46JAKAFI . . . . . . . . . . . . . . . . . . . . . . . . . . . 20JALYN . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35jantoven . . . . . . . . . . . . . . . . . . . . . . . . . . 27JANUMET . . . . . . . . . . . . . . . . . . . . . . . . 25JANUMET XR TB24 1000MG; 50MG, 500MG; 50MG . . . . 25JANUMET XR TB24 1000MG; 100MG . . . . . . . . . . . . . . . . . . 25JANUVIA . . . . . . . . . . . . . . . . . . . . . . . . . 25jencycla . . . . . . . . . . . . . . . . . . . . . . . . . . . 39JENTADUETO . . . . . . . . . . . . . . . . . . . . 25JENTADUETO XR TB24 2.5MG; 1000MG . . . . . . . . . . . . . . . . . . . 25JENTADUETO XR TB24 5MG; 1000MG . . . . . . . . . . . . . . . . . . . . 25jevantique lo . . . . . . . . . . . . . . . . . . . . . . 37JEVTANA . . . . . . . . . . . . . . . . . . . . . . . . . 19jinteli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37jolessa . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37jolivette . . . . . . . . . . . . . . . . . . . . . . . . . . . 39


Covered Drugs Index

62

LINCOCIN . . . . . . . . . . . . . . . . . . . . . . . . 10lincomycin hcl . . . . . . . . . . . . . . . . . . . . . 10lindane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21linezolid inj 600mg/300ml . . . . . . . . . . 10linezolid susr . . . . . . . . . . . . . . . . . . . . . 10linezolid tabs . . . . . . . . . . . . . . . . . . . . . 10LINZESS . . . . . . . . . . . . . . . . . . . . . . . . . . 34liothyronine sodium . . . . . . . . . . . . . . . . 39lisinopril . . . . . . . . . . . . . . . . . . . . . . . . . . . 28lisinopril/hydrochlorothiazide . . . . . . . 28lithium . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25lithium carbonate . . . . . . . . . . . . . . . . . . 25lithium carbonate er . . . . . . . . . . . . . . . . 25LITHOSTAT . . . . . . . . . . . . . . . . . . . . . . . 35lokara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36lomedia 24 fe . . . . . . . . . . . . . . . . . . . . . . 38LONSURF TABS 6.14MG; 15MG . . . 19LONSURF TABS 8.19MG; 20MG . . . 19loperamide hcl caps . . . . . . . . . . . . . . . 34lopreeza . . . . . . . . . . . . . . . . . . . . . . . . . . 38lorazepam conc . . . . . . . . . . . . . . . . . . . 25lorazepam inj 20mg/10ml, 2mg/ml, 4mg/ml . . . . . . . 25lorazepam intensol . . . . . . . . . . . . . . . . 25lorazepam tabs . . . . . . . . . . . . . . . . . . . 25lorcet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8lorcet hd . . . . . . . . . . . . . . . . . . . . . . . . . . . 8lorcet plus tabs 325mg; 7.5mg . . . . . . . 8lortab tabs . . . . . . . . . . . . . . . . . . . . . . . . . 8loryna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38losartan potassium/ hydrochlorothiazide tabs 12.5mg; 50mg . . . . . . . . . . . . . . . . . . . . . 28losartan potassium/ hydrochlorothiazide tabs 12.5mg; 100mg, 25mg; 100mg . . . . . 28losartan potassium tabs 25mg . . . . . . 28losartan potassium tabs 50mg . . . . . . 28losartan potassium tabs 100mg . . . . . 27LOTEMAX . . . . . . . . . . . . . . . . . . . . . . . . 43lovastatin tabs 10mg, 20mg . . . . . . . . 30

LEVEMIR FLEXTOUCH . . . . . . . . . . . 26levetiracetam . . . . . . . . . . . . . . . . . . . . . . 13levetiracetam er . . . . . . . . . . . . . . . . . . . 13levobunolol hcl . . . . . . . . . . . . . . . . . . . . 44levocarnitine . . . . . . . . . . . . . . . . . . . . . . 42levocetirizine dihydrochloride oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . 44levocetirizine dihydrochloride tabs . . . 44levofloxacin in d5w . . . . . . . . . . . . . . . . 13levofloxacin inj . . . . . . . . . . . . . . . . . . . . 13levofloxacin ophthalmic soln . . . . . . . 13levofloxacin oral soln . . . . . . . . . . . . . . 13levofloxacin tabs . . . . . . . . . . . . . . . . . . 13levoleucovorin calcium . . . . . . . . . . . . . 19levoleucovorin inj 250mg/25ml . . . . . 19levonest . . . . . . . . . . . . . . . . . . . . . . . . . . 38levonorgestrel and ethinyl estradiol . . . . . . . . . . . . . . . . . . . . 38levonorgestrel/ethinyl estradiol . . . . . 38levora 0.15/30-28 . . . . . . . . . . . . . . . . . . 38levorphanol tartrate . . . . . . . . . . . . . . . . . 7levothyroxine sodium inj . . . . . . . . . . . 39levothyroxine sodium tabs . . . . . . . . . 39LEVOXYL . . . . . . . . . . . . . . . . . . . . . . . . . 39LEVULAN KERASTICK . . . . . . . . . . . . 32LEXIVA SUSP . . . . . . . . . . . . . . . . . . . . 24LEXIVA TABS . . . . . . . . . . . . . . . . . . . . . 24LIALDA . . . . . . . . . . . . . . . . . . . . . . . . . . . 42lidocaine hcl external soln . . . . . . . . . . 9lidocaine hcl gel . . . . . . . . . . . . . . . . . . . . 9lidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4% . . . . . . . . . . . . 9lidocaine hcl inj 10mg/ml, 20mg/ml . . 28lidocaine hcl jelly . . . . . . . . . . . . . . . . . . . 9lidocaine hcl mouth/throat soln . . . . . . 9lidocaine hcl viscous . . . . . . . . . . . . . . . . 9lidocaine oint . . . . . . . . . . . . . . . . . . . . . . 9lidocaine/prilocaine crea . . . . . . . . . . . . 9lidocaine ptch . . . . . . . . . . . . . . . . . . . . . . 9lidocaine viscous . . . . . . . . . . . . . . . . . . . 9

lamotrigine er . . . . . . . . . . . . . . . . . . . . . 14lamotrigine odt . . . . . . . . . . . . . . . . . . . . 14LANOXIN PEDIATRIC . . . . . . . . . . . . . 29LANOXIN TABS 62.5MCG . . . . . . . . . 29LANOXIN TABS 187.5MCG . . . . . . . . 29lansoprazole . . . . . . . . . . . . . . . . . . . . . . 34lansoprazole/amoxicillin/ clarithromycin . . . . . . . . . . . . . . . . . . . . . 10LANTUS . . . . . . . . . . . . . . . . . . . . . . . . . . 26LANTUS SOLOSTAR . . . . . . . . . . . . . . 26larin 1.5/30 . . . . . . . . . . . . . . . . . . . . . . . . 38larin 1/20 . . . . . . . . . . . . . . . . . . . . . . . . . . 38larin fe 1.5/30 . . . . . . . . . . . . . . . . . . . . . 38larin fe 1/20 . . . . . . . . . . . . . . . . . . . . . . . 38larissia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38latanoprost . . . . . . . . . . . . . . . . . . . . . . . . 43latrix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32LATUDA TABS 80MG . . . . . . . . . . . . . . 22LATUDA TABS 120MG, 20MG, 40MG, 60MG . . . . . . 22layolis fe . . . . . . . . . . . . . . . . . . . . . . . . . . 38LAZANDA . . . . . . . . . . . . . . . . . . . . . . . . . . 8leflunomide . . . . . . . . . . . . . . . . . . . . . . . 41LENVIMA 8 MG DAILY DOSE . . . . . . 20LENVIMA 10 MG DAILY DOSE . . . . . 20LENVIMA 14 MG DAILY DOSE . . . . . 20LENVIMA 18 MG DAILY DOSE . . . . . 20LENVIMA 20 MG DAILY DOSE . . . . . 20LENVIMA 24 MG DAILY DOSE . . . . . 20LESCOL XL . . . . . . . . . . . . . . . . . . . . . . . 30lessina . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38LETAIRIS . . . . . . . . . . . . . . . . . . . . . . . . . 45letrozole . . . . . . . . . . . . . . . . . . . . . . . . . . 20leucovorin calcium . . . . . . . . . . . . . . . . . 19LEUKERAN . . . . . . . . . . . . . . . . . . . . . . . 18LEUKINE INJ 250MCG . . . . . . . . . . . . 27leuprolide acetate . . . . . . . . . . . . . . . . . 40levalbuterol . . . . . . . . . . . . . . . . . . . . . . . 45levalbuterol hcl . . . . . . . . . . . . . . . . . . . . 45LEVEMIR . . . . . . . . . . . . . . . . . . . . . . . . . 26


Covered Drugs Index

63

methimazole . . . . . . . . . . . . . . . . . . . . . . 40methitest . . . . . . . . . . . . . . . . . . . . . . . . . . 36methotrexate . . . . . . . . . . . . . . . . . . . . . . 40methotrexate sodium inj 1gm, 1gm/40ml, 250mg/10ml . . . . . . . 40methoxsalen . . . . . . . . . . . . . . . . . . . . . . 32methscopolamine bromide . . . . . . . . . 33methyclothiazide . . . . . . . . . . . . . . . . . . 30methylergonovine maleate . . . . . . . . . 42METHYLIN CHEW . . . . . . . . . . . . . . . . 31methylphenidate hcl . . . . . . . . . . . . . . . 31methylphenidate hcl cd . . . . . . . . . . . . 31methylphenidate hcl er cp24 20mg, 40mg . . . . . . . . . . . . . . . . . . . . . . . 31methylphenidate hcl er tb24 . . . . . . . 31methylphenidate hcl er tbcr 10mg . . . 31methylphenidate hcl er tbcr 20mg . . . 31methylphenidate hydrochloride . . . . . 31methylprednisolone . . . . . . . . . . . . . . . . 36methylprednisolone acetate . . . . . . . . 36methylprednisolone dose pack . . . . . 36methylprednisolone sodiumsuccinate inj 125mg, 40mg . . 36methylprednisolone sodiumsuccinate inj 1000mg . . . . . . . 36metipranolol . . . . . . . . . . . . . . . . . . . . . . . 44metoclopramide hcl . . . . . . . . . . . . . . . . 34metolazone . . . . . . . . . . . . . . . . . . . . . . . 30metoprolol/hydrochlorothiazide . . . . . 29metoprolol succinate er tb24 100mg, 25mg, 50mg . . . . . . . . . . 29metoprolol succinate er tb24 200mg . . . . . . . . . . . . . . . . . . . . . . . 29metoprolol tartrate . . . . . . . . . . . . . . . . . 29METRO IV . . . . . . . . . . . . . . . . . . . . . . . . 10metronidazole caps . . . . . . . . . . . . . . . 10metronidazole crea . . . . . . . . . . . . . . . . 10metronidazole gel . . . . . . . . . . . . . . . . . 10metronidazole inj . . . . . . . . . . . . . . . . . . 10metronidazole in nacl 0.79% . . . . . . . 10metronidazole lotn . . . . . . . . . . . . . . . . 10

MEKINIST . . . . . . . . . . . . . . . . . . . . . . . . 20meloxicam . . . . . . . . . . . . . . . . . . . . . . . . . 7melphalan hydrochloride . . . . . . . . . . . 18memantine hcl tabs 5mg . . . . . . . . . . . 15memantine hcl tabs 10mg . . . . . . . . . . 15memantine hcl titration pak . . . . . . . . . 15memantine hydrochloride . . . . . . . . . . 15MENACTRA . . . . . . . . . . . . . . . . . . . . . . 41MENEST . . . . . . . . . . . . . . . . . . . . . . . . . . 38MENHIBRIX . . . . . . . . . . . . . . . . . . . . . . . 41MENOMUNE-A/C/Y/W-135 . . . . . . . . 41MENOSTAR . . . . . . . . . . . . . . . . . . . . . . 38MENVEO . . . . . . . . . . . . . . . . . . . . . . . . . 41mercaptopurine . . . . . . . . . . . . . . . . . . . . 19meropenem . . . . . . . . . . . . . . . . . . . . . . . 12meropenem/sodium chloride . . . . . . . 12MERREM . . . . . . . . . . . . . . . . . . . . . . . . . 12mesalamine . . . . . . . . . . . . . . . . . . . . . . . 42mesna . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19MESNEX TABS . . . . . . . . . . . . . . . . . . . 19MESTINON SYRP . . . . . . . . . . . . . . . . 18MESTINON TIMESPAN . . . . . . . . . . . . 18metadate er . . . . . . . . . . . . . . . . . . . . . . . 31metaproterenol sulfate . . . . . . . . . . . . . 45metformin hcl . . . . . . . . . . . . . . . . . . . . . . 25metformin hcl er . . . . . . . . . . . . . . . . . . . 25methadone hcl conc . . . . . . . . . . . . . . . . 7methadone hcl inj . . . . . . . . . . . . . . . . . . 7methadone hcl intensol . . . . . . . . . . . . . 7methadone hcl oral soln 5mg/5ml . . . . 7methadone hcl oral soln 10mg/5ml . . . 7methadone hcl tabs . . . . . . . . . . . . . . . . 7methadone hcl tbso . . . . . . . . . . . . . . . . 8methadose conc . . . . . . . . . . . . . . . . . . . 8methadose sugar-free . . . . . . . . . . . . . . 8methadose tbso . . . . . . . . . . . . . . . . . . . . 8methamphetamine hcl . . . . . . . . . . . . . 31methazolamide . . . . . . . . . . . . . . . . . . . . 44methenamine hippurate . . . . . . . . . . . . 10methenamine mandelate . . . . . . . . . . . 10

lovastatin tabs 40mg . . . . . . . . . . . . . . . 30low-ogestrel . . . . . . . . . . . . . . . . . . . . . . . 38loxapine succinate . . . . . . . . . . . . . . . . . 21ludent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48LUMIGAN . . . . . . . . . . . . . . . . . . . . . . . . . 43LUMIZYME . . . . . . . . . . . . . . . . . . . . . . . 33LUPRON DEPOT . . . . . . . . . . . . . . . . . 40LUPRON DEPOT-PED . . . . . . . . . . . . 40lutera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38LYNPARZA . . . . . . . . . . . . . . . . . . . . . . . 19LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG, 75MG . . . . . . 14LYRICA CAPS 225MG, 300MG . . . . . 14LYRICA ORAL SOLN . . . . . . . . . . . . . . 14LYSODREN . . . . . . . . . . . . . . . . . . . . . . . 39lyza . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Mmagnesium sulfate in d5w inj 5%; 10mg/ml . . . . . . . . . . . . . . . . . . . . . . 48magnesium sulfate inj . . . . . . . . . . . . . 48MAKENA . . . . . . . . . . . . . . . . . . . . . . . . . 39malathion . . . . . . . . . . . . . . . . . . . . . . . . . 21maprotiline hcl . . . . . . . . . . . . . . . . . . . . . 15margesic . . . . . . . . . . . . . . . . . . . . . . . . . . . 7marlissa . . . . . . . . . . . . . . . . . . . . . . . . . . 38MARPLAN . . . . . . . . . . . . . . . . . . . . . . . . 15MARQIBO . . . . . . . . . . . . . . . . . . . . . . . . 19marten-tab . . . . . . . . . . . . . . . . . . . . . . . . . 7MATULANE . . . . . . . . . . . . . . . . . . . . . . . 18matzim la . . . . . . . . . . . . . . . . . . . . . . . . . 29MAXIDEX . . . . . . . . . . . . . . . . . . . . . . . . . 43MAXIPIME . . . . . . . . . . . . . . . . . . . . . . . . 11meclizine hcl tabs . . . . . . . . . . . . . . . . . 16meclofenamate sodium . . . . . . . . . . . . . 7MEDROL TABS 2MG . . . . . . . . . . . . . . 36medroxyprogesterone acetate . . . . . . 39mefloquine hcl . . . . . . . . . . . . . . . . . . . . . 21MEGACE ES . . . . . . . . . . . . . . . . . . . . . . 39megestrol acetate . . . . . . . . . . . . . . . . . 39


Covered Drugs Index

64

multi-vit/iron/fluoride oral soln 35mg/ml; 400unit/ml; 10mg/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 5unit/ml; 1500unit/ml . . . . . . . . . . . . . . . 49mult-vitamin/fluoride . . . . . . . . . . . . . . . 49mupirocin . . . . . . . . . . . . . . . . . . . . . . . . . 10MUSTARGEN . . . . . . . . . . . . . . . . . . . . . 18mvc-fluoride . . . . . . . . . . . . . . . . . . . . . . . 49MYCAMINE . . . . . . . . . . . . . . . . . . . . . . . 17mycophenolate mofetil . . . . . . . . . . . . . 40mycophenolic acid dr . . . . . . . . . . . . . . 40MYFORTIC . . . . . . . . . . . . . . . . . . . . . . . 40myorisan . . . . . . . . . . . . . . . . . . . . . . . . . . 32MYRBETRIQ . . . . . . . . . . . . . . . . . . . . . . 34myzilra . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Nnabumetone . . . . . . . . . . . . . . . . . . . . . . . . 7nadolol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29nadolol/bendroflumethiazide . . . . . . . . 29NAFCILLIN . . . . . . . . . . . . . . . . . . . . . . . 12nafcillin sodium . . . . . . . . . . . . . . . . . . . . 12naftifine hcl . . . . . . . . . . . . . . . . . . . . . . . . 17naftifine hydrochloride . . . . . . . . . . . . . 17NAFTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . 17NAGLAZYME . . . . . . . . . . . . . . . . . . . . . 33nalbuphine hcl . . . . . . . . . . . . . . . . . . . . . . 9naloxone hcl inj 0.4mg/ml, 2mg/2ml . . . 9naltrexone hcl . . . . . . . . . . . . . . . . . . . . . . 9NAMENDA ORAL SOLN . . . . . . . . . . 15NAMENDA TABS 5MG . . . . . . . . . . . . . 15NAMENDA TABS 10MG . . . . . . . . . . . 15NAMENDA TITRATION PAK . . . . . . . 15NAMENDA XR . . . . . . . . . . . . . . . . . . . . 15NAMENDA XR TITRATION PACK . . 15naproxen . . . . . . . . . . . . . . . . . . . . . . . . . . . 7naproxen dr . . . . . . . . . . . . . . . . . . . . . . . . 7naproxen sodium tabs 275mg, 550mg . . . . . . . . . . . . . . . . . . . . . 7

mononessa . . . . . . . . . . . . . . . . . . . . . . . 38montelukast sodium . . . . . . . . . . . . . . . 44MONUROL . . . . . . . . . . . . . . . . . . . . . . . 10morphine sulfate add-vantage . . . . . . . 8morphine sulfate er cp24 . . . . . . . . . . . 8morphine sulfate er tbcr . . . . . . . . . . . . 8morphine sulfate inj 0.5mg/ml, 10mg/0.7ml, 1mg/ml . . . . . . . . . . . . . . . . 8morphine sulfate inj 10mg/ml, 150mg/30ml, 15mg/ml, 1mg/ml, 25mg/ml, 2mg/ml, 4mg/ml, 50mg/ml, 5mg/ml, 8mg/ml . . . . . . . . . . . 8morphine sulfate oral soln 10mg/5ml . . . . . . . . . . . . . . . . . 9morphine sulfate oral soln 20mg/5ml . . . . . . . . . . . . . . . . . 8morphine sulfate oral soln 100mg/5ml . . . . . . . . . . . . . . . . 8morphine sulfate supp . . . . . . . . . . . . . . 8morphine sulfate tabs . . . . . . . . . . . . . . 9MOTOFEN . . . . . . . . . . . . . . . . . . . . . . . . 34MOVIPREP . . . . . . . . . . . . . . . . . . . . . . . 34MOXEZA . . . . . . . . . . . . . . . . . . . . . . . . . 13moxifloxacin hcl inj . . . . . . . . . . . . . . . . 13moxifloxacin hcl tabs . . . . . . . . . . . . . . 13MOZOBIL . . . . . . . . . . . . . . . . . . . . . . . . . 48MULTAQ . . . . . . . . . . . . . . . . . . . . . . . . . . 28multi vitamin/fluoride . . . . . . . . . . . . . . . 49multivitamin/fluoride chew 60mg; 400unit; 4.5mcg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 0; 0.25mg; 1.05mg; 15unit; 2500unit . . . . . . . . . . . 49multi-vitamin/fluoride oral soln 35mg/ml; 400unit/ml; 2mcg/ml; 5unit/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.25mg/ml; 0.5mg/ml; 1500unit/ml, 35mg/ml; 400unit/ml; 2mcg/ml; 5unit/ml; 8mg/ml; 0.4mg/ml; 0.6mg/ml; 0.5mg/ml; 0.5mg/ml; 1500unit/ml . . . . . . . . . . . . . 49multivitamin with fluoride . . . . . . . . . . . 49multi-vit/fluoride . . . . . . . . . . . . . . . . . . . 49

metronidazole tabs . . . . . . . . . . . . . . . . 10metronidazole vaginal . . . . . . . . . . . . . . 10mexiletine hcl . . . . . . . . . . . . . . . . . . . . . 28MIACALCIN INJ . . . . . . . . . . . . . . . . . . 42miconazole 3 . . . . . . . . . . . . . . . . . . . . . . 17microgestin 1.5/30 . . . . . . . . . . . . . . . . . 38microgestin 1/20 . . . . . . . . . . . . . . . . . . . 38microgestin fe . . . . . . . . . . . . . . . . . . . . . 38microgestin fe 1.5/30 . . . . . . . . . . . . . . 38midodrine hcl . . . . . . . . . . . . . . . . . . . . . . 27migergot . . . . . . . . . . . . . . . . . . . . . . . . . . 17miglitol . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25MIGRANAL . . . . . . . . . . . . . . . . . . . . . . . 17mimvey . . . . . . . . . . . . . . . . . . . . . . . . . . . 38mimvey lo . . . . . . . . . . . . . . . . . . . . . . . . . 38minitran . . . . . . . . . . . . . . . . . . . . . . . . . . . 31minocycline hcl . . . . . . . . . . . . . . . . . . . . 13minoxidil . . . . . . . . . . . . . . . . . . . . . . . . . . 31mirtazapine . . . . . . . . . . . . . . . . . . . . . . . 15mirtazapine odt . . . . . . . . . . . . . . . . . . . . 15misoprostol . . . . . . . . . . . . . . . . . . . . . . . 34mitomycin . . . . . . . . . . . . . . . . . . . . . . . . . 19mitoxantrone hcl . . . . . . . . . . . . . . . . . . . 19M-M-R II . . . . . . . . . . . . . . . . . . . . . . . . . . 41modafinil tabs 100mg . . . . . . . . . . . . . . 46modafinil tabs 200mg . . . . . . . . . . . . . . 46moderiba 800 dose pack . . . . . . . . . . . 23moderiba 1200 dose pack . . . . . . . . . . 23moderiba misc . . . . . . . . . . . . . . . . . . . . 23moderiba tabs . . . . . . . . . . . . . . . . . . . . 23moexipril hcl . . . . . . . . . . . . . . . . . . . . . . . 28moexipril/hydrochlorothiazide . . . . . . . 28molindone hydrochloride . . . . . . . . . . . 22mometasone furoate crea . . . . . . . . . 36mometasone furoate external soln . . . 36mometasone furoate oint . . . . . . . . . . 36mondoxyne nl . . . . . . . . . . . . . . . . . . . . . 13mono-linyah . . . . . . . . . . . . . . . . . . . . . . . 38


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norgestimate/ethinyl estradiol . . . . . . 38norlyroc . . . . . . . . . . . . . . . . . . . . . . . . . . . 39NORMOSOL-M IN D5W . . . . . . . . . . . 48NORMOSOL -R . . . . . . . . . . . . . . . . . . . 48NORMOSOL-R . . . . . . . . . . . . . . . . . . . . 48NORMOSOL-R IN D5W. . . . . . . . . . . . 48NORTHERA . . . . . . . . . . . . . . . . . . . . . . 30nortrel 0.5/35 (28) . . . . . . . . . . . . . . . . . 38nortrel 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 38nortrel 7/7/7 . . . . . . . . . . . . . . . . . . . . . . . 38nortriptyline hcl . . . . . . . . . . . . . . . . . . . . 16NORVIR . . . . . . . . . . . . . . . . . . . . . . . . . . 24NOVOFINE 30GX8MM . . . . . . . . . . . . 42NOVOFINE 31 . . . . . . . . . . . . . . . . . . . . 42NOVOFINE 32GX6MM . . . . . . . . . . . . 42NOVOFINE AUTOCOVER 30GX8MM . . . . . . . . . . . . . . . . . . . . . . . . 42NOVOLIN 70/30 . . . . . . . . . . . . . . . . . . . 26NOVOLIN 70/30 RELION . . . . . . . . . . 26NOVOLIN N . . . . . . . . . . . . . . . . . . . . . . . 26NOVOLIN N RELION . . . . . . . . . . . . . . 26NOVOLIN R . . . . . . . . . . . . . . . . . . . . . . . 26NOVOLIN R INNOLET . . . . . . . . . . . . . 26NOVOLIN R RELION . . . . . . . . . . . . . . 26NOVOLOG . . . . . . . . . . . . . . . . . . . . . . . . 26NOVOLOG FLEXPEN . . . . . . . . . . . . . 26NOVOLOG MIX 70/30 . . . . . . . . . . . . . 26NOVOLOG MIX 70/30 PREFILLED FLEXPEN . . . . . . . . . . . . 26NOVOLOG PENFILL . . . . . . . . . . . . . . 26NOVOTWIST 32GX5MM . . . . . . . . . . . 42NOXAFIL SUSP . . . . . . . . . . . . . . . . . . 17NOXAFIL TBEC . . . . . . . . . . . . . . . . . . 17NUEDEXTA . . . . . . . . . . . . . . . . . . . . . . . 31nulev . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33NULOJIX . . . . . . . . . . . . . . . . . . . . . . . . . 40NULYTELY/FLAVOR PACKS . . . . . . . 34NUPLAZID . . . . . . . . . . . . . . . . . . . . . . . . 22NUTRILIPID . . . . . . . . . . . . . . . . . . . . . . . 49

NICOTROL INHALER. . . . . . . . . . . . . . . 9NICOTROL NS . . . . . . . . . . . . . . . . . . . . . 9nifedical xl . . . . . . . . . . . . . . . . . . . . . . . . 29nifedipine er . . . . . . . . . . . . . . . . . . . . . . . 29nikki . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38NILANDRON . . . . . . . . . . . . . . . . . . . . . . 18nilutamide . . . . . . . . . . . . . . . . . . . . . . . . . 18nimodipine . . . . . . . . . . . . . . . . . . . . . . . . 29NINLARO . . . . . . . . . . . . . . . . . . . . . . . . . 19NIPENT . . . . . . . . . . . . . . . . . . . . . . . . . . . 19nisoldipine er . . . . . . . . . . . . . . . . . . . . . . 29nisoldipine tb24 17mg, 20mg, 34mg, 40mg, 8.5mg . . . . . . . . . 29nisoldipine tb24 30mg . . . . . . . . . . . . . . 29NITRO-BID . . . . . . . . . . . . . . . . . . . . . . . 31NITRO-DUR PT24 0.3MG/HR, 0.8MG/HR . . . . . . . . . . . . . 31nitrofurantoin . . . . . . . . . . . . . . . . . . . . . . 11nitrofurantoin macrocrystals caps 100mg, 50mg . . . . . . . . . . . . . . . . 11nitrofurantoin monohydrate . . . . . . . . . 11nitrofurantoin monohydrate/macrocrystals . . . . . . . . . . . . . . . . . . . . . 11nitroglycerin . . . . . . . . . . . . . . . . . . . . . . . 31nitroglycerin lingual translingual soln . . . . . . . . . . . . . . . . . . 31nitroglycerin transdermal . . . . . . . . . . . 31NITROSTAT . . . . . . . . . . . . . . . . . . . . . . . 31nizatidine caps . . . . . . . . . . . . . . . . . . . . 34nora-be . . . . . . . . . . . . . . . . . . . . . . . . . . . 39norethindrone . . . . . . . . . . . . . . . . . . . . . 39norethindrone acetate . . . . . . . . . . . . . . 39norethindrone acetate/ethinyl estradiol/ferrous fumarate . . . . . . . . . . 38norethindrone acetate/ethinyl estradiol tabs 2.5mcg; 0.5mg, 5mcg; 1mg . . . . . . . . . . . . . . . . . . . . . . . . 38norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg . . . . . . . . . 38norethindrone & ethinyl estradiol ferrous fumarate . . . . . . . . . . 38

naratriptan hcl . . . . . . . . . . . . . . . . . . . . . 17NARCAN . . . . . . . . . . . . . . . . . . . . . . . . . . 9NATACYN . . . . . . . . . . . . . . . . . . . . . . . . . 17nateglinide . . . . . . . . . . . . . . . . . . . . . . . . 25NATPARA . . . . . . . . . . . . . . . . . . . . . . . . . 42NEBUPENT . . . . . . . . . . . . . . . . . . . . . . . 21necon 0.5/35-28 . . . . . . . . . . . . . . . . . . . 38necon 1/35 . . . . . . . . . . . . . . . . . . . . . . . . 38necon 1/50-28 . . . . . . . . . . . . . . . . . . . . . 38necon 7/7/7 . . . . . . . . . . . . . . . . . . . . . . . 38necon 10/11-28 . . . . . . . . . . . . . . . . . . . . 38nefazodone hcl . . . . . . . . . . . . . . . . . . . . 15neomycin/bacitracin/polymyxin . . . . . 10neomycin/polymyxin/ bacitracin/hydrocortisone . . . . . . . . . . . 10neomycin/polymyxin b sulfates . . . . . 10neomycin/polymyxin/ dexamethasone . . . . . . . . . . . . . . . . . . . 43neomycin/polymyxin/gramicidin . . . . . 10neomycin/polymyxin/hc . . . . . . . . . . . . 44neomycin/polymyxin/ hydrocortisone . . . . . . . . . . . . . . . . . . . . 10neomycin/polymyxin/ hydrocortisone . . . . . . . . . . . . . . . . . . . . 44neomycin sulfate . . . . . . . . . . . . . . . . . . 10NEOPROFEN . . . . . . . . . . . . . . . . . . . . . . 7NEORAL . . . . . . . . . . . . . . . . . . . . . . . . . . 40NEPHRAMINE . . . . . . . . . . . . . . . . . . . . 48neuac . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32NEULASTA . . . . . . . . . . . . . . . . . . . . . . . 27NEUPOGEN . . . . . . . . . . . . . . . . . . . . . . 27NEUPRO . . . . . . . . . . . . . . . . . . . . . . . . . 21NEVANAC . . . . . . . . . . . . . . . . . . . . . . . . 43nevirapine . . . . . . . . . . . . . . . . . . . . . . . . . 23nevirapine er . . . . . . . . . . . . . . . . . . . . . . 23NEXAVAR . . . . . . . . . . . . . . . . . . . . . . . . . 20niacin er tbcr 500mg . . . . . . . . . . . . . . . 30niacin er tbcr 1000mg, 750mg . . . . . . 30niacor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30nicardipine hcl . . . . . . . . . . . . . . . . . . . . . 29


Covered Drugs Index

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oscimin . . . . . . . . . . . . . . . . . . . . . . . . . . . 33OSMOPREP . . . . . . . . . . . . . . . . . . . . . . 34oxacillin sodium . . . . . . . . . . . . . . . . . . . 12oxaliplatin inj 100mg, 100mg/20ml, 50mg/10ml . . . . . . . . . . . 19oxandrolone . . . . . . . . . . . . . . . . . . . . . . . 36oxaprozin . . . . . . . . . . . . . . . . . . . . . . . . . . 7oxazepam . . . . . . . . . . . . . . . . . . . . . . . . . 25oxcarbazepine . . . . . . . . . . . . . . . . . . . . 14oxiconazole nitrate . . . . . . . . . . . . . . . . . 17OXISTAT . . . . . . . . . . . . . . . . . . . . . . . . . . 17OXSORALEN . . . . . . . . . . . . . . . . . . . . . 32OXTELLAR XR . . . . . . . . . . . . . . . . . . . . 14oxybutynin chloride . . . . . . . . . . . . . . . . 34oxybutynin chloride er tb24 5mg . . . . 34oxybutynin chloride er tb24 10mg, 15mg . . . . . . . . . . . . . . . . . . 34oxycodone/acetaminophen oral soln . . . . . . . . . . . . . . . . . . . . . . . . . . . 9oxycodone/acetaminophen tabs 325mg; 10mg, 325mg; 2.5mg, 325mg; 5mg, 325mg; 7.5mg . . . . . . . . . 9oxycodone/aspirin . . . . . . . . . . . . . . . . . . 9oxycodone hcl caps . . . . . . . . . . . . . . . . 9oxycodone hcl conc . . . . . . . . . . . . . . . . 9oxycodone hcl oral soln . . . . . . . . . . . . 9oxycodone hcl tabs . . . . . . . . . . . . . . . . 9oxycodone/ibuprofen . . . . . . . . . . . . . . . 9oxymorphone hydrochloride . . . . . . . . . 9oxymorphone hydrochloride er . . . . . . 8

Ppacerone . . . . . . . . . . . . . . . . . . . . . . . . . . 28paclitaxel . . . . . . . . . . . . . . . . . . . . . . . . . . 19paliperidone er tb24 1.5mg, 3mg . . . 22paliperidone er tb24 6mg . . . . . . . . . . . 22paliperidone er tb24 9mg . . . . . . . . . . . 22pamidronate disodium . . . . . . . . . . . . . 42PANDEL . . . . . . . . . . . . . . . . . . . . . . . . . . 36PANRETIN . . . . . . . . . . . . . . . . . . . . . . . . 20

olanzapine/fluoxetine . . . . . . . . . . . . . . 15olanzapine inj . . . . . . . . . . . . . . . . . . . . . 22olanzapine odt . . . . . . . . . . . . . . . . . . . . 22olanzapine tabs 2.5mg . . . . . . . . . . . . . 22olanzapine tabs 10mg, 15mg, 20mg, 5mg, 7.5mg . . . 22olopatadine hcl ophthalmic soln . . . . 43OLYSIO . . . . . . . . . . . . . . . . . . . . . . . . . . . 23omega-3-acid ethyl esters . . . . . . . . . . 30omeprazole cpdr . . . . . . . . . . . . . . . . . . 34omeprazole/sodium bicarbonate caps . . . . . . . . . . . . . . . . . 34omeprazole/sodium bicarbonate pack . . . . . . . . . . . . . . . . . 34ONCASPAR . . . . . . . . . . . . . . . . . . . . . . . 19ondansetron hcl inj 40mg/20ml, 4mg/2ml . . . . . . . . . . . . . . 16ondansetron hcl oral soln . . . . . . . . . . 16ondansetron hcl tabs 4mg, 8mg . . . . 16ondansetron hcl tabs 24mg . . . . . . . . 16ondansetron odt . . . . . . . . . . . . . . . . . . . 16ONFI SUSP . . . . . . . . . . . . . . . . . . . . . . 14ONFI TABS 10MG . . . . . . . . . . . . . . . . . 14ONFI TABS 20MG . . . . . . . . . . . . . . . . . 14OPANA ER (CRUSH RESISTANT) T12A 10MG, 15MG, 20MG, 30MG, 5MG, 7.5MG . . . . . . . . . . . . . . . . 8OPANA ER (CRUSH RESISTANT) T12A 40MG . . . . . . . . . . . . . . . . . . . . . . . . 8OPDIVO . . . . . . . . . . . . . . . . . . . . . . . . . . 20OPIUM . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9OPIUM TINCTURE . . . . . . . . . . . . . . . . . 9OPSUMIT . . . . . . . . . . . . . . . . . . . . . . . . . 45ORACEA . . . . . . . . . . . . . . . . . . . . . . . . . 32oralone . . . . . . . . . . . . . . . . . . . . . . . . . . . 32ORAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21ORENCIA INJ 250MG . . . . . . . . . . . . . 40ORFADIN . . . . . . . . . . . . . . . . . . . . . . . . . 33orphenadrine citrate er . . . . . . . . . . . . . 46orsythia . . . . . . . . . . . . . . . . . . . . . . . . . . . 38ORTHO TRI-CYCLEN LO . . . . . . . . . . 38

NUTRILYTE INJ 2.03MEQ/ML; 0.25MEQ/ML; 1.68MEQ/ML; 0.25MEQ/ML; 0.4MEQ/ML; 2.03MEQ/ML; 1.25MEQ . . . . . . . . . . . 48NUVARING . . . . . . . . . . . . . . . . . . . . . . . 38NUVIGIL . . . . . . . . . . . . . . . . . . . . . . . . . . 46nyamyc . . . . . . . . . . . . . . . . . . . . . . . . . . . 17NYMALIZE . . . . . . . . . . . . . . . . . . . . . . . . 29nystatin crea . . . . . . . . . . . . . . . . . . . . . . 17nystatin oint . . . . . . . . . . . . . . . . . . . . . . 17nystatin powd 100000unit/gm . . . . . . 17nystatin susp . . . . . . . . . . . . . . . . . . . . . 17nystatin tabs . . . . . . . . . . . . . . . . . . . . . . 17nystatin/triamcinolone . . . . . . . . . . . . . . 17nystop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Needles and Syringesbd eclipse syringe/1ml/30gx1/2” . . . . 49bd insulin syringe safetyglide/ 1ml/29g x 1/2” . . . . . . . . . . . . . . . . . . . . . 49bd insulin syringe ultrafine/ 0.3ml/31g x 5/16” . . . . . . . . . . . . . . . . . . 49bd insulin syringe ultrafine/ 0.5ml/30g x 1/2” . . . . . . . . . . . . . . . . . . . 49bd insulin syringe ultrafine/ 1ml/31g x 5/16” . . . . . . . . . . . . . . . . . . . . 49bd pen needle/ultrafine/ 29g x 12.7mm . . . . . . . . . . . . . . . . . . . . . 49

Oocella . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38OCTAGAM INJ 10GM/100ML, 1GM/20ML, 20GM/200ML, 2GM/20ML, 5GM/50ML . . . . . . . . . . . . 41octreotide acetate inj 100mcg/ml, 200mcg/ml, 50mcg/ml . . . . . . . . . . . . . 40octreotide acetate inj 1000mcg/ml, 500mcg/ml . . . . . . . . . . . 40ODEFSEY . . . . . . . . . . . . . . . . . . . . . . . . 23ODOMZO . . . . . . . . . . . . . . . . . . . . . . . . . 19ofloxacin . . . . . . . . . . . . . . . . . . . . . . . . . . 13ogestrel . . . . . . . . . . . . . . . . . . . . . . . . . . . 38


Covered Drugs Index

67

PLASMA-LYTE A . . . . . . . . . . . . . . . . . . 48PLENAMINE . . . . . . . . . . . . . . . . . . . . . . 48podocon 25 in benzoin tincture . . . . . 32podofilox . . . . . . . . . . . . . . . . . . . . . . . . . . 32polycin . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43polyethylene glycol 3350 . . . . . . . . . . . 34polymyxin b sulfate . . . . . . . . . . . . . . . . 11polymyxin b sulfate/ trimethoprim sulfate . . . . . . . . . . . . . . . . 11POMALYST . . . . . . . . . . . . . . . . . . . . . . . 18portia-28 . . . . . . . . . . . . . . . . . . . . . . . . . . 38PORTRAZZA . . . . . . . . . . . . . . . . . . . . . 19POTASSIUM CHLORIDE 0.3%/ D5W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48POTASSIUM CHLORIDE 0.3%/ NACL 0.9% . . . . . . . . . . . . . . . . . . . . . . . 48POTASSIUM CHLORIDE 0.15% D5W/NACL 0.33% . . . . . . . . . . . . . . . . . 48POTASSIUM CHLORIDE 0.15% D5W/NACL 0.45% . . . . . . . . . . . . . . . . . 48POTASSIUM CHLORIDE 0.15% D5W/NACL 0.45%VIAFLEX . . . . . . . . 48POTASSIUM CHLORIDE 0.15% NACL 0.9% . . . . . . . . . . . . . . . . . . . . . . . 48POTASSIUM CHLORIDE 0.15%/ NACL 0.9% . . . . . . . . . . . . . . . . . . . . . . . 48POTASSIUM CHLORIDE 0.15% / NACL 0.45% VIAFLEX . . . . . . . . . . . . . 48POTASSIUM CHLORIDE 0.15% W/NACL 0.9% VIAFLEX . . . . . . . . . . . 48POTASSIUM CHLORIDE 0.22% D5W/NACL 0.45% . . . . . . . . . . . . . . . . . 48potassium chloride cr . . . . . . . . . . . . . . 48potassium chloride er . . . . . . . . . . . . . . 48potassium chloride inj 0.4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 2meq/ml, 40meq/100ml . . . . . . . . . . . . 48potassium chloride oral soln . . . . . . . 48potassium chloride pack . . . . . . . . . . . 48potassium chloride sr . . . . . . . . . . . . . . 48potassium citrate/citric acid . . . . . . . . . 48

perphenazine . . . . . . . . . . . . . . . . . . . . . 21perphenazine/amitriptyline . . . . . . . . . 16pfizerpen-g . . . . . . . . . . . . . . . . . . . . . . . . 12phenadoz . . . . . . . . . . . . . . . . . . . . . . . . . 16phenazopyridine hcl . . . . . . . . . . . . . . . 35phenelzine sulfate . . . . . . . . . . . . . . . . . 15phenergan supp . . . . . . . . . . . . . . . . . . 16phenobarbital . . . . . . . . . . . . . . . . . . . . . 14phenoxybenzamine hydrochloride . . . 27phenylephrine hcl ophthalmic soln 10%, 2.5% . . . . . . . . 43PHENYTEK . . . . . . . . . . . . . . . . . . . . . . . 14phenytoin . . . . . . . . . . . . . . . . . . . . . . . . . 14phenytoin sodium . . . . . . . . . . . . . . . . . . 14phenytoin sodium extended . . . . . . . . 14PHOSLYRA . . . . . . . . . . . . . . . . . . . . . . . 35phospha 250 neutral . . . . . . . . . . . . . . . 48phosphasal . . . . . . . . . . . . . . . . . . . . . . . 34PHOSPHOLINE IODIDE . . . . . . . . . . . 44PHOTOFRIN . . . . . . . . . . . . . . . . . . . . . . 19PHYSIOLYTE . . . . . . . . . . . . . . . . . . . . . 42PHYSIOSOL IRRIGATION . . . . . . . . . 42pilocarpine hcl . . . . . . . . . . . . . . . . . . . . . 32pilocarpine hcl . . . . . . . . . . . . . . . . . . . . . 44pilocarpine hydrochloride . . . . . . . . . . . 32pimozide . . . . . . . . . . . . . . . . . . . . . . . . . . 22pimtrea . . . . . . . . . . . . . . . . . . . . . . . . . . . 38pindolol . . . . . . . . . . . . . . . . . . . . . . . . . . . 29pioglitazone hcl . . . . . . . . . . . . . . . . . . . . 25pioglitazone hcl-glimepiride . . . . . . . . 25pioglitazone hcl/metformin hcl . . . . . . 25piperacillin sodium/ tazobactam sodium . . . . . . . . . . . . . . . . 12piperacillin sodium/ tazobactam sodium . . . . . . . . . . . . . . . . 12piperacillin/tazobactam . . . . . . . . . . . . . 12pirmella 1/35 . . . . . . . . . . . . . . . . . . . . . . 38piroxicam . . . . . . . . . . . . . . . . . . . . . . . . . . 7PLASMA-LYTE-56/D5W . . . . . . . . . . . 48PLASMA-LYTE-148 . . . . . . . . . . . . . . . 48

pantoprazole sodium inj . . . . . . . . . . . 34pantoprazole sodium tbec . . . . . . . . . 34PAREGORIC . . . . . . . . . . . . . . . . . . . . . . 34paricalcitol . . . . . . . . . . . . . . . . . . . . . . . . 42paroex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32paromomycin sulfate . . . . . . . . . . . . . . . 10paroxetine hcl tabs 10mg . . . . . . . . . . 15paroxetine hcl tabs 20mg, 30mg, 40mg . . . . . . . . . . . . . . . . 15PASER . . . . . . . . . . . . . . . . . . . . . . . . . . . 18PATADAY . . . . . . . . . . . . . . . . . . . . . . . . . 43PAXIL SUSP . . . . . . . . . . . . . . . . . . . . . . 15PAZEO . . . . . . . . . . . . . . . . . . . . . . . . . . . 43PCE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13PEDIARIX . . . . . . . . . . . . . . . . . . . . . . . . 41PEDVAX HIB . . . . . . . . . . . . . . . . . . . . . . 41peg 3350/electrolytes . . . . . . . . . . . . . . 34peg-3350/electrolytes . . . . . . . . . . . . . . 34peg-3350/nacl/na bicarbonate/kcl . . . 34PEGANONE . . . . . . . . . . . . . . . . . . . . . . 14PEGINTRON . . . . . . . . . . . . . . . . . . . . . . 23PEG-INTRON REDIPEN . . . . . . . . . . . 23PEG-INTRON REDIPEN PAK 4 . . . . 23penicillin g potassium in iso-osmotic dextrose . . . . . . . . . . . . . . . 12penicillin g potassium inj 20000000unit, 5000000unit . . . . . . . . 12penicillin g procaine . . . . . . . . . . . . . . . . 12penicillin g sodium . . . . . . . . . . . . . . . . . 12penicillin v potassium . . . . . . . . . . . . . . 12PENTACEL . . . . . . . . . . . . . . . . . . . . . . . 41PENTAM 300 . . . . . . . . . . . . . . . . . . . . . 21PENTASA . . . . . . . . . . . . . . . . . . . . . . . . . 42pentoxifylline er . . . . . . . . . . . . . . . . . . . . 30PERFOROMIST . . . . . . . . . . . . . . . . . . . 45PERIKABIVEN . . . . . . . . . . . . . . . . . . . . 49perindopril erbumine . . . . . . . . . . . . . . . 28periogard . . . . . . . . . . . . . . . . . . . . . . . . . 32PERJETA . . . . . . . . . . . . . . . . . . . . . . . . . 20permethrin . . . . . . . . . . . . . . . . . . . . . . . . 21


Covered Drugs Index

68

propafenone hcl . . . . . . . . . . . . . . . . . . . 28propafenone hcl er . . . . . . . . . . . . . . . . . 28propantheline bromide . . . . . . . . . . . . . 33proparacaine hcl . . . . . . . . . . . . . . . . . . . 43propranolol hcl . . . . . . . . . . . . . . . . . . . . 29propranolol hcl er . . . . . . . . . . . . . . . . . . 29propranolol/hydrochlorothiazide . . . . 29propylthiouracil . . . . . . . . . . . . . . . . . . . . 40PROQUAD . . . . . . . . . . . . . . . . . . . . . . . . 41PROSOL . . . . . . . . . . . . . . . . . . . . . . . . . . 49protriptyline hcl . . . . . . . . . . . . . . . . . . . . 16PROVENTIL HFA . . . . . . . . . . . . . . . . . . 45PRUDOXIN . . . . . . . . . . . . . . . . . . . . . . . 32PULMICORT FLEXHALER . . . . . . . . . 44PULMICORT SUSP 1MG/2ML . . . . . 44PULMOZYME . . . . . . . . . . . . . . . . . . . . . 45PURIXAN . . . . . . . . . . . . . . . . . . . . . . . . . 19pyrazinamide . . . . . . . . . . . . . . . . . . . . . . 18pyridostigmine bromide . . . . . . . . . . . . 18pyridostigmine bromide er . . . . . . . . . . 18

QQUADRACEL . . . . . . . . . . . . . . . . . . . . . 41quasense . . . . . . . . . . . . . . . . . . . . . . . . . 38quetiapine fumarate . . . . . . . . . . . . . . . 22quinapril hcl . . . . . . . . . . . . . . . . . . . . . . . 28quinapril/hydrochlorothiazide . . . . . . . 28quinidine gluconate . . . . . . . . . . . . . . . . 28quinidine gluconate cr . . . . . . . . . . . . . . 28quinidine gluconate er . . . . . . . . . . . . . 28quinidine sulfate . . . . . . . . . . . . . . . . . . . 28quinine sulfate . . . . . . . . . . . . . . . . . . . . . 21QVAR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

RRABAVERT . . . . . . . . . . . . . . . . . . . . . . . 41rabeprazole sodium . . . . . . . . . . . . . . . . 34raloxifene hydrochloride . . . . . . . . . . . . 39ramipril . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

PRIMAXIN IV . . . . . . . . . . . . . . . . . . . . . 12PRIMAXIN IV ADD-VANTAGE . . . . . . 12primidone . . . . . . . . . . . . . . . . . . . . . . . . . 14PRIMSOL . . . . . . . . . . . . . . . . . . . . . . . . . 11PRISTIQ . . . . . . . . . . . . . . . . . . . . . . . . . . 15PRIVIGEN . . . . . . . . . . . . . . . . . . . . . . . . 41PROAIR HFA . . . . . . . . . . . . . . . . . . . . . 45PROAIR RESPICLICK . . . . . . . . . . . . . 45probenecid . . . . . . . . . . . . . . . . . . . . . . . . 17probenecid/colchicine . . . . . . . . . . . . . . 17procainamide hcl . . . . . . . . . . . . . . . . . . 28PROCALAMINE . . . . . . . . . . . . . . . . . . . 49prochlorperazine . . . . . . . . . . . . . . . . . . 22prochlorperazine edisylate . . . . . . . . . 22prochlorperazine maleate . . . . . . . . . . 22PROCRIT INJ 10000UNIT/ML, 2000UNIT/ML, 3000UNIT/ML, 4000UNIT/ML . . . . . . 27PROCRIT INJ 20000UNIT/ML, 40000UNIT/ML . . . . 27procto-med hc . . . . . . . . . . . . . . . . . . . . . 36procto-pak . . . . . . . . . . . . . . . . . . . . . . . . 36proctosol hc . . . . . . . . . . . . . . . . . . . . . . . 36proctozone-hc . . . . . . . . . . . . . . . . . . . . . 36PROCYSBI . . . . . . . . . . . . . . . . . . . . . . . 43progesterone . . . . . . . . . . . . . . . . . . . . . . 39PROGLYCEM . . . . . . . . . . . . . . . . . . . . . 25PROGRAF CAPS 0.5MG, 1MG . . . . 40PROGRAF CAPS 5MG . . . . . . . . . . . . 40PROGRAF INJ . . . . . . . . . . . . . . . . . . . 40PROLASTIN-C . . . . . . . . . . . . . . . . . . . . 45PROLEUKIN . . . . . . . . . . . . . . . . . . . . . . 19PROLIA . . . . . . . . . . . . . . . . . . . . . . . . . . . 42PROMACTA TABS 12.5MG, 25MG, 50MG . . . . . . . . . . . . . 27promethazine hcl . . . . . . . . . . . . . . . . . . 16promethazine hcl . . . . . . . . . . . . . . . . . . 44promethazine hcl plain . . . . . . . . . . . . . 16promethazine vc plain . . . . . . . . . . . . . . 46promethegan . . . . . . . . . . . . . . . . . . . . . . 16

potassium citrate- citric acid crystals . . . . . . . . . . . . . . . . . . 48potassium citrate er . . . . . . . . . . . . . . . . 48POTIGA TABS 50MG . . . . . . . . . . . . . . 13POTIGA TABS 200MG, 300MG, 400MG . . . . . . . . . . . 13PRADAXA . . . . . . . . . . . . . . . . . . . . . . . . 27pramipexole dihydrochloride . . . . . . . . 21pramipexole dihydrochloride er . . . . . 21pravastatin sodium tabs 10mg, 20mg . . . . . . . . . . . . . . . . . . . . . . . 30pravastatin sodium tabs 40mg . . . . . . 30pravastatin sodium tabs 80mg . . . . . . 30prazosin hcl . . . . . . . . . . . . . . . . . . . . . . . 27PRED-G . . . . . . . . . . . . . . . . . . . . . . . . . . 43PRED-G S.O.P. . . . . . . . . . . . . . . . . . . . 43PRED MILD . . . . . . . . . . . . . . . . . . . . . . . 43prednicarbate . . . . . . . . . . . . . . . . . . . . . 36prednisolone acetate . . . . . . . . . . . . . . 43prednisolone oral soln . . . . . . . . . . . . . 36prednisolone sodium phosphate . . . . 36prednisolone sodium phosphate . . . . 43prednisone . . . . . . . . . . . . . . . . . . . . . . . . 36prednisone intensol . . . . . . . . . . . . . . . . 36PREFEST . . . . . . . . . . . . . . . . . . . . . . . . . 38PREMARIN CREA . . . . . . . . . . . . . . . . 38PREMARIN INJ . . . . . . . . . . . . . . . . . . . 38PREMARIN TABS . . . . . . . . . . . . . . . . 38PREMASOL . . . . . . . . . . . . . . . . . . . . . . . 49premium lidocaine . . . . . . . . . . . . . . . . . . 9PREMPHASE . . . . . . . . . . . . . . . . . . . . . 38PREMPRO . . . . . . . . . . . . . . . . . . . . . . . . 38prevalite . . . . . . . . . . . . . . . . . . . . . . . . . . 30previfem . . . . . . . . . . . . . . . . . . . . . . . . . . 38PREZCOBIX . . . . . . . . . . . . . . . . . . . . . . 24PREZISTA SUSP . . . . . . . . . . . . . . . . . 24PREZISTA TABS 150MG, 75MG . . . 24PREZISTA TABS 600MG, 800MG . . . 24PRIALT . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7PRIMAQUINE PHOSPHATE . . . . . . . 21


Covered Drugs Index

69

roxicet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9ROZEREM . . . . . . . . . . . . . . . . . . . . . . . . 46

SSABRIL PACK . . . . . . . . . . . . . . . . . . . . 14SABRIL TABS . . . . . . . . . . . . . . . . . . . . 14SAIZEN . . . . . . . . . . . . . . . . . . . . . . . . . . . 36SAIZEN CLICK.EASY . . . . . . . . . . . . . 36salsalate . . . . . . . . . . . . . . . . . . . . . . . . . . . 7SAMSCA TABS 15MG . . . . . . . . . . . . . 46SAMSCA TABS 30MG . . . . . . . . . . . . . 46SANCUSO . . . . . . . . . . . . . . . . . . . . . . . . 16SANDIMMUNE . . . . . . . . . . . . . . . . . . . . 41SANDOSTATIN LAR DEPOT . . . . . . . 40SANTYL . . . . . . . . . . . . . . . . . . . . . . . . . . 32SAPHRIS . . . . . . . . . . . . . . . . . . . . . . . . . 22SAVELLA . . . . . . . . . . . . . . . . . . . . . . . . . 31SAVELLA TITRATION PACK . . . . . . . 31selegiline hcl . . . . . . . . . . . . . . . . . . . . . . 21selenium sulfide . . . . . . . . . . . . . . . . . . . 32SELZENTRY . . . . . . . . . . . . . . . . . . . . . . 24SEMPREX-D . . . . . . . . . . . . . . . . . . . . . . 44SENSIPAR TABS 30MG . . . . . . . . . . . 39SENSIPAR TABS 60MG . . . . . . . . . . . 39SENSIPAR TABS 90MG . . . . . . . . . . . 39SEREVENT DISKUS . . . . . . . . . . . . . . 45SEROQUEL XR TB24 150MG, 200MG . . . . . . . . . . . . . . . . . . . 22SEROQUEL XR TB24 300MG, 400MG, 50MG . . . . . . . . . . . . 22SEROSTIM . . . . . . . . . . . . . . . . . . . . . . . 36sertraline hcl conc . . . . . . . . . . . . . . . . . 15sertraline hcl tabs 25mg . . . . . . . . . . . . 15sertraline hcl tabs 50mg . . . . . . . . . . . . 15sertraline hcl tabs 100mg . . . . . . . . . . 15setlakin . . . . . . . . . . . . . . . . . . . . . . . . . . . 38sf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49sf 5000 plus . . . . . . . . . . . . . . . . . . . . . . . 49sharobel . . . . . . . . . . . . . . . . . . . . . . . . . . 39SIGNIFOR . . . . . . . . . . . . . . . . . . . . . . . . 40

ribasphere caps . . . . . . . . . . . . . . . . . . . 23ribasphere ribapak . . . . . . . . . . . . . . . . . 23ribasphere tabs 200mg, 400mg . . . . . 23ribasphere tabs 600mg . . . . . . . . . . . . 23ribavirin . . . . . . . . . . . . . . . . . . . . . . . . . . . 23RIDAURA . . . . . . . . . . . . . . . . . . . . . . . . . 41rifabutin . . . . . . . . . . . . . . . . . . . . . . . . . . . 18RIFAMATE . . . . . . . . . . . . . . . . . . . . . . . . 18rifampin . . . . . . . . . . . . . . . . . . . . . . . . . . . 18RIFATER . . . . . . . . . . . . . . . . . . . . . . . . . . 18riluzole . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31rimantadine hcl . . . . . . . . . . . . . . . . . . . . 24RINGERS INJECTION . . . . . . . . . . . . . 49RINGERS IRRIGATION . . . . . . . . . . . . 42RIOMET . . . . . . . . . . . . . . . . . . . . . . . . . . 25risedronate sodium tabs 150mg . . . . 42RISPERDAL CONSTA INJ 12.5MG, 25MG . . . . . . . . . . . . . . . . . . . . 22RISPERDAL CONSTA INJ 37.5MG, 50MG . . . . . . . . . . . . . . . . . . . . 22risperidone m-tab tbdp 0.5mg, 2mg . . . . . . . . . . . . . . . . . . . . . . . 22risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 22risperidone odt tbdp 4mg . . . . . . . . . . . 22risperidone oral soln . . . . . . . . . . . . . . 22risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg . . . . 22risperidone tabs 4mg . . . . . . . . . . . . . . 22RITUXAN INJ 500MG/50ML . . . . . . . . 20rivastigmine tartrate . . . . . . . . . . . . . . . . 14rivastigmine transdermal system . . . . 14rizatriptan benzoate . . . . . . . . . . . . . . . . 17rizatriptan benzoate odt . . . . . . . . . . . . 17ropinirole er . . . . . . . . . . . . . . . . . . . . . . . 21ropinirole hcl . . . . . . . . . . . . . . . . . . . . . . 21rosadan . . . . . . . . . . . . . . . . . . . . . . . . . . . 11rosuvastatin calcium . . . . . . . . . . . . . . . 30ROTARIX . . . . . . . . . . . . . . . . . . . . . . . . . 42ROTATEQ . . . . . . . . . . . . . . . . . . . . . . . . 42roweepra . . . . . . . . . . . . . . . . . . . . . . . . . . 13

RANEXA . . . . . . . . . . . . . . . . . . . . . . . . . . 30ranitidine hcl . . . . . . . . . . . . . . . . . . . . . . 34RAPAMUNE ORAL SOLN . . . . . . . . . 40RAPAMUNE TABS 0.5MG . . . . . . . . . 40RAPAMUNE TABS 1MG, 2MG . . . . . 40RAVICTI . . . . . . . . . . . . . . . . . . . . . . . . . . 33rea lo 39 . . . . . . . . . . . . . . . . . . . . . . . . . . 32rea lo 40 crea . . . . . . . . . . . . . . . . . . . . . 32REBETOL ORAL SOLN . . . . . . . . . . . 23REBIF . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32REBIF REBIDOSE . . . . . . . . . . . . . . . . 32REBIF REBIDOSE TITRATION PACK . . . . . . . . . . . . . . . . . 32REBIF TITRATION PACK . . . . . . . . . . 32reclipsen . . . . . . . . . . . . . . . . . . . . . . . . . . 38RECOMBIVAX HB . . . . . . . . . . . . . . . . . 41RECTIV . . . . . . . . . . . . . . . . . . . . . . . . . . . 31REGRANEX . . . . . . . . . . . . . . . . . . . . . . 32RELAGARD . . . . . . . . . . . . . . . . . . . . . . . 11RELENZA DISKHALER . . . . . . . . . . . . 24RELISTOR INJ . . . . . . . . . . . . . . . . . . . 34RELPAX TABS 20MG . . . . . . . . . . . . . . 17RELPAX TABS 40MG . . . . . . . . . . . . . . 17remeven . . . . . . . . . . . . . . . . . . . . . . . . . . 32REMICADE . . . . . . . . . . . . . . . . . . . . . . . 41REMODULIN . . . . . . . . . . . . . . . . . . . . . . 45RENVELA . . . . . . . . . . . . . . . . . . . . . . . . 35repaglinide . . . . . . . . . . . . . . . . . . . . . . . . 25REPATHA . . . . . . . . . . . . . . . . . . . . . . . . . 30REPATHA PUSHTRONEX SYSTEM . . . . . . . . . . 30REPATHA SURECLICK . . . . . . . . . . . . 30reprexain tabs 10mg; 200mg . . . . . . . . 9RESCRIPTOR . . . . . . . . . . . . . . . . . . . . 23RESTASIS . . . . . . . . . . . . . . . . . . . . . . . . 43RETROVIR IV INFUSION . . . . . . . . . . 24REVLIMID . . . . . . . . . . . . . . . . . . . . . . . . 18REXULTI . . . . . . . . . . . . . . . . . . . . . . . . . . 22REYATAZ . . . . . . . . . . . . . . . . . . . . . . . . . 24RHEUMATREX . . . . . . . . . . . . . . . . . . . . 41


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sumatriptan . . . . . . . . . . . . . . . . . . . . . . . 17sumatriptan succinate inj . . . . . . . . . . 17sumatriptan succinate refill . . . . . . . . . 17sumatriptan succinate tabs . . . . . . . . 17SUPRAX CAPS . . . . . . . . . . . . . . . . . . . 12SUPRAX CHEW . . . . . . . . . . . . . . . . . . 12SUPRAX SUSR 500MG/5ML . . . . . . . 12SUPREP BOWEL PREP . . . . . . . . . . . 34SURMONTIL . . . . . . . . . . . . . . . . . . . . . . 16SUSTIVA CAPS 50MG . . . . . . . . . . . . . 23SUSTIVA CAPS 200MG . . . . . . . . . . . 23SUSTIVA TABS . . . . . . . . . . . . . . . . . . . 23SUTENT . . . . . . . . . . . . . . . . . . . . . . . . . . 20SYLATRON . . . . . . . . . . . . . . . . . . . . . . . 19symax-sl . . . . . . . . . . . . . . . . . . . . . . . . . . 33SYMBICORT . . . . . . . . . . . . . . . . . . . . . . 44SYMLINPEN 60 . . . . . . . . . . . . . . . . . . . 25SYMLINPEN 120 . . . . . . . . . . . . . . . . . . 25SYNAGIS . . . . . . . . . . . . . . . . . . . . . . . . . 41SYNALGOS-DC . . . . . . . . . . . . . . . . . . . . 9SYNAREL . . . . . . . . . . . . . . . . . . . . . . . . 40SYNERA . . . . . . . . . . . . . . . . . . . . . . . . . . . 9SYNERCID . . . . . . . . . . . . . . . . . . . . . . . 11SYNRIBO . . . . . . . . . . . . . . . . . . . . . . . . . 19SYNTHROID . . . . . . . . . . . . . . . . . . . . . . 39SYPRINE . . . . . . . . . . . . . . . . . . . . . . . . . 46

TTABLOID . . . . . . . . . . . . . . . . . . . . . . . . . 19tacrolimus caps . . . . . . . . . . . . . . . . . . . 41TAFINLAR . . . . . . . . . . . . . . . . . . . . . . . . 20TAGRISSO . . . . . . . . . . . . . . . . . . . . . . . . 20TALWIN . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9TAMIFLU CAPS 30MG . . . . . . . . . . . . 24TAMIFLU CAPS 45MG . . . . . . . . . . . . 24TAMIFLU CAPS 75MG . . . . . . . . . . . . 24TAMIFLU SUSR . . . . . . . . . . . . . . . . . . 24tamoxifen citrate . . . . . . . . . . . . . . . . . . . 18tamsulosin hcl . . . . . . . . . . . . . . . . . . . . . 35

sotalol hcl (af) . . . . . . . . . . . . . . . . . . . . . 28SOVALDI . . . . . . . . . . . . . . . . . . . . . . . . . 23SPECTRACEF TABS 400MG . . . . . . 11SPIRIVA HANDIHALER . . . . . . . . . . . . 45SPIRIVA RESPIMAT . . . . . . . . . . . . . . . 45spironolactone . . . . . . . . . . . . . . . . . . . . 30spironolactone/ hydrochlorothiazide . . . . . . . . . . . . . . . . 30SPORANOX ORAL SOLN . . . . . . . . . 17sprintec 28 . . . . . . . . . . . . . . . . . . . . . . . . 38SPRITAM . . . . . . . . . . . . . . . . . . . . . . . . . 13SPRYCEL . . . . . . . . . . . . . . . . . . . . . . . . 20sronyx . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38ssd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11stavudine . . . . . . . . . . . . . . . . . . . . . . . . . 24sterile water irrigation . . . . . . . . . . . . . . 42STIOLTO RESPIMAT . . . . . . . . . . . . . . 46STIVARGA . . . . . . . . . . . . . . . . . . . . . . . . 20STRATTERA CAPS 10MG, 18MG, 25MG, 40MG . . . . . . . 31STRATTERA CAPS 100MG, 60MG, 80MG . . . . . . . . . . . . . 31streptomycin sulfate . . . . . . . . . . . . . . . 10STRIANT . . . . . . . . . . . . . . . . . . . . . . . . . 37STRIBILD . . . . . . . . . . . . . . . . . . . . . . . . . 23STRIVERDI RESPIMAT . . . . . . . . . . . . 45SUBOXONE . . . . . . . . . . . . . . . . . . . . . . . 9SUCRAID . . . . . . . . . . . . . . . . . . . . . . . . . 33sucralfate . . . . . . . . . . . . . . . . . . . . . . . . . 34sulfacetamide sodium oint . . . . . . . . . 13sulfacetamide sodium/ prednisolone sodium phosphate . . . . 13sulfacetamide sodium susp . . . . . . . . 13sulfadiazine . . . . . . . . . . . . . . . . . . . . . . . 13sulfamethoxazole/trimethoprim . . . . . 13sulfamethoxazole/trimethoprim ds . . . 13SULFAMYLON . . . . . . . . . . . . . . . . . . . . 11sulfasalazine . . . . . . . . . . . . . . . . . . . . . . 42sulfatrim pediatric . . . . . . . . . . . . . . . . . . 13sulindac . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

sildenafil tabs . . . . . . . . . . . . . . . . . . . . . 45SILENOR . . . . . . . . . . . . . . . . . . . . . . . . . 46SILVER NITRATE EXTERNAL SOLN . . . . . . . . . . . . . . . . 11silver sulfadiazine . . . . . . . . . . . . . . . . . 11SIMBRINZA . . . . . . . . . . . . . . . . . . . . . . . 44SIMULECT . . . . . . . . . . . . . . . . . . . . . . . . 41simvastatin tabs 10mg, 5mg . . . . . . . . 30simvastatin tabs 20mg, 40mg, 80mg . . . . . . . . . . . . . . . . 30sirolimus . . . . . . . . . . . . . . . . . . . . . . . . . . 41SIRTURO . . . . . . . . . . . . . . . . . . . . . . . . . 18SKLICE . . . . . . . . . . . . . . . . . . . . . . . . . . . 21sodium bicarbonate inj . . . . . . . . . . . . 46sodium bicarbonate partial fill . . . . . . . 46sodium chloride 0.9% . . . . . . . . . . . . . . 42sodium chloride 0.45% . . . . . . . . . . . . . 49sodium chloride bacteriostatic . . . . . . 49sodium chloride bacteriostatic/ benzyl alcohol . . . . . . . . . . . . . . . . . . . . . 49sodium chloride inj . . . . . . . . . . . . . . . . 49SODIUM EDECRIN . . . . . . . . . . . . . . . . 30sodium fluoride chew 0.5mg, 1mg . . 49sodium fluoride oral soln . . . . . . . . . . . 49sodium fluoride tabs . . . . . . . . . . . . . . . 49SODIUM LACTATE INJ 5MEQ/ML . . 46sodium phenylbutyrate . . . . . . . . . . . . . 33sodium polystyrene sulfonate powd . . . . . . . . . . . . . . . . . . . 46sodium polystyrene sulfonate susp 15gm/60ml, 30gm/120ml . . . . . . 46sodium sulfacetamide ophthalmic soln . . . . . . . . . . . . . . . . . . . 13SOLTAMOX . . . . . . . . . . . . . . . . . . . . . . . 18SOLU-CORTEF . . . . . . . . . . . . . . . . . . . 36SOLU-MEDROL INJ 2GM . . . . . . . . . . 36SOLU-MEDROL INJ 500MG . . . . . . . 36SOMATULINE DEPOT . . . . . . . . . . . . . 40SOMAVERT . . . . . . . . . . . . . . . . . . . . . . . 40sorine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28sotalol hcl . . . . . . . . . . . . . . . . . . . . . . . . . 28


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TRADJENTA . . . . . . . . . . . . . . . . . . . . . . 25tramadol hcl . . . . . . . . . . . . . . . . . . . . . . . . 9tramadol hcl er tb24 . . . . . . . . . . . . . . . . 8tramadol hydrochloride/ acetaminophen . . . . . . . . . . . . . . . . . . . . . 9trandolapril . . . . . . . . . . . . . . . . . . . . . . . . 28trandolapril/verapamil hcl er tbcr 1mg; 240mg, 2mg; 180mg, 2mg; 240mg . . . . . . . . . . . . . . . 28trandolapril/verapamil hcl er tbcr 4mg; 240mg . . . . . . . . . . . . . . . . . . 28trandolapril/verapamil hcl tbcr 1mg; 240mg, 2mg; 180mg, 2mg; 240mg . . . . . . . . . . . . . . . 28trandolapril/verapamil hcl tbcr 4mg; 240mg . . . . . . . . . . . . . . . . . . 28tranexamic acid inj . . . . . . . . . . . . . . . . 27tranexamic acid tabs . . . . . . . . . . . . . . 27TRANSDERM-SCOP . . . . . . . . . . . . . . 16tranylcypromine sulfate . . . . . . . . . . . . 15TRAVASOL . . . . . . . . . . . . . . . . . . . . . . . 49TRAVATAN Z . . . . . . . . . . . . . . . . . . . . . . 43travoprost . . . . . . . . . . . . . . . . . . . . . . . . . 43trazodone hcl . . . . . . . . . . . . . . . . . . . . . . 15TREANDA . . . . . . . . . . . . . . . . . . . . . . . . 18TRECATOR . . . . . . . . . . . . . . . . . . . . . . . 18TRELSTAR INJ 3.75MG . . . . . . . . . . . 40TRELSTAR INJ 11.25MG . . . . . . . . . . 40TRELSTAR MIXJECT INJ 3.75MG . . 40TRELSTAR MIXJECT INJ 11.25MG . . 40TRELSTAR MIXJECT INJ 22.5MG . . 40TRESIBA FLEXTOUCH . . . . . . . . . . . . 26tretinoin caps . . . . . . . . . . . . . . . . . . . . . 20tretinoin crea . . . . . . . . . . . . . . . . . . . . . 32tretinoin gel 0.01%, 0.025% . . . . . . . . 32tretinoin microsphere . . . . . . . . . . . . . . 32tretinoin microsphere pump . . . . . . . . 32TREXALL . . . . . . . . . . . . . . . . . . . . . . . . . 41triamcinolone acetonide aers . . . . . . 36triamcinolone acetonide crea . . . . . . 36triamcinolone acetonide lotn . . . . . . . 36

THERACYS . . . . . . . . . . . . . . . . . . . . . . . 19thioridazine hcl . . . . . . . . . . . . . . . . . . . . 22thiotepa . . . . . . . . . . . . . . . . . . . . . . . . . . . 18thiothixene . . . . . . . . . . . . . . . . . . . . . . . . 22THYMOGLOBULIN . . . . . . . . . . . . . . . . 41THYROLAR-1 . . . . . . . . . . . . . . . . . . . . . 39THYROLAR-1/2 . . . . . . . . . . . . . . . . . . . 39THYROLAR-1/4 . . . . . . . . . . . . . . . . . . . 39THYROLAR-2 . . . . . . . . . . . . . . . . . . . . . 39THYROLAR-3 . . . . . . . . . . . . . . . . . . . . . 39tiagabine hydrochloride . . . . . . . . . . . . 14TICE BCG . . . . . . . . . . . . . . . . . . . . . . . . 19TIKOSYN . . . . . . . . . . . . . . . . . . . . . . . . . 28timolol maleate . . . . . . . . . . . . . . . . . . . . 29timolol maleate . . . . . . . . . . . . . . . . . . . . 44timolol maleate ophthalmic gel forming . . . . . . . . . . . . . 44tinidazole . . . . . . . . . . . . . . . . . . . . . . . . . 21TIVICAY TABS 10MG, 25MG . . . . . . . 23TIVICAY TABS 50MG . . . . . . . . . . . . . . 23tizanidine hcl . . . . . . . . . . . . . . . . . . . . . . 23tl-fluorivite . . . . . . . . . . . . . . . . . . . . . . . . . 49TOBI PODHALER . . . . . . . . . . . . . . . . . 45TOBRADEX OINT . . . . . . . . . . . . . . . . 43tobramycin . . . . . . . . . . . . . . . . . . . . . . . . 45tobramycin/dexamethasone . . . . . . . . 43tobramycin sulfate . . . . . . . . . . . . . . . . . 10TOBREX OINT . . . . . . . . . . . . . . . . . . . 10tolcapone . . . . . . . . . . . . . . . . . . . . . . . . . 21tolmetin sodium . . . . . . . . . . . . . . . . . . . . 7tolterodine tartrate . . . . . . . . . . . . . . . . . 34tolterodine tartrate er . . . . . . . . . . . . . . 34topiramate . . . . . . . . . . . . . . . . . . . . . . . . 14toposar . . . . . . . . . . . . . . . . . . . . . . . . . . . 20topotecan hcl . . . . . . . . . . . . . . . . . . . . . . 20TORISEL . . . . . . . . . . . . . . . . . . . . . . . . . 41torsemide . . . . . . . . . . . . . . . . . . . . . . . . . 30TOUJEO SOLOSTAR . . . . . . . . . . . . . . 26TPN ELECTROLYTES . . . . . . . . . . . . . 49TRACLEER . . . . . . . . . . . . . . . . . . . . . . . 45

TARCEVA . . . . . . . . . . . . . . . . . . . . . . . . . 20TARGRETIN . . . . . . . . . . . . . . . . . . . . . . 20tarina fe 1/20 . . . . . . . . . . . . . . . . . . . . . . 38TASIGNA . . . . . . . . . . . . . . . . . . . . . . . . . 20tazicef . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12TAZORAC . . . . . . . . . . . . . . . . . . . . . . . . 32taztia xt . . . . . . . . . . . . . . . . . . . . . . . . . . . 29TECENTRIQ . . . . . . . . . . . . . . . . . . . . . . 20TEFLARO . . . . . . . . . . . . . . . . . . . . . . . . . 12TEGRETOL-XR TB12 100MG . . . . . . 14TEKTURNA . . . . . . . . . . . . . . . . . . . . . . . 30TEKTURNA HCT . . . . . . . . . . . . . . . . . . 30telmisartan . . . . . . . . . . . . . . . . . . . . . . . . 28telmisartan/amlodipine . . . . . . . . . . . . . 28telmisartan/hydrochlorothiazide . . . . . 28temazepam . . . . . . . . . . . . . . . . . . . . . . . 46tencon tabs 325mg; 50mg . . . . . . . . . . . 7teniposide . . . . . . . . . . . . . . . . . . . . . . . . . 19TENIVAC . . . . . . . . . . . . . . . . . . . . . . . . . 42terazosin hcl . . . . . . . . . . . . . . . . . . . . . . 35terbinafine hcl tabs . . . . . . . . . . . . . . . . 17terbutaline sulfate . . . . . . . . . . . . . . . . . 45terconazole . . . . . . . . . . . . . . . . . . . . . . . 17TESTIM . . . . . . . . . . . . . . . . . . . . . . . . . . . 37testosterone cypionate . . . . . . . . . . . . . 37testosterone enanthate . . . . . . . . . . . . 37testosterone gel 25mg/2.5gm . . . . . . . 37testosterone pump . . . . . . . . . . . . . . . . . 37TETANUS/DIPHTHERIA TOXOIDS-ADSORBED . . . . . . . . . . . . 42tetrabenazine . . . . . . . . . . . . . . . . . . . . . 31tetracycline hcl . . . . . . . . . . . . . . . . . . . . 13TEXACORT . . . . . . . . . . . . . . . . . . . . . . . 36THALOMID . . . . . . . . . . . . . . . . . . . . . . . 18THEO-24 . . . . . . . . . . . . . . . . . . . . . . . . . 45theochron . . . . . . . . . . . . . . . . . . . . . . . . . 45theophylline . . . . . . . . . . . . . . . . . . . . . . . 45theophylline cr . . . . . . . . . . . . . . . . . . . . . 45theophylline/d5w inj 5%; 0.8mg/ml . . . 45theophylline er . . . . . . . . . . . . . . . . . . . . 45


Covered Drugs Index

72

VALCHLOR . . . . . . . . . . . . . . . . . . . . . . . 18VALCYTE ORAL SOLN . . . . . . . . . . . 23valganciclovir . . . . . . . . . . . . . . . . . . . . . . 23valganciclovir hydrochlorde . . . . . . . . 23valproate sodium . . . . . . . . . . . . . . . . . . 14valproic acid . . . . . . . . . . . . . . . . . . . . . . . 14valsartan/hydrochlorothiazide . . . . . . 28valsartan tabs 160mg, 40mg, 80mg . . . . . . . . . . . . . . . 28valsartan tabs 320mg . . . . . . . . . . . . . . 28vancomycin . . . . . . . . . . . . . . . . . . . . . . . 11vancomycin hcl caps 125mg . . . . . . . 11vancomycin hcl caps 250mg . . . . . . . 11vancomycin hcl in dextrose . . . . . . . . . 11vancomycin hcl inj 0.9%; 1gm/200ml, 1000mg, 10gm, 500mg, 750mg . . . . . . . . . . . . . . 11vancomycin hcl inj 5000mg . . . . . . . . . 11vandazole . . . . . . . . . . . . . . . . . . . . . . . . . 11VAQTA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42VARIVAX . . . . . . . . . . . . . . . . . . . . . . . . . 42VARIZIG INJ 125UNIT/1.2ML . . . . . . 42VASCEPA CAPS 1GM . . . . . . . . . . . . . 30VECTIBIX . . . . . . . . . . . . . . . . . . . . . . . . . 20VELCADE . . . . . . . . . . . . . . . . . . . . . . . . 19velivet . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39VELPHORO . . . . . . . . . . . . . . . . . . . . . . . 35VELTIN . . . . . . . . . . . . . . . . . . . . . . . . . . . 33VENCLEXTA STARTING PACK . . . . 19VENCLEXTA TABS 10MG . . . . . . . . . 19VENCLEXTA TABS 50MG . . . . . . . . . 19VENCLEXTA TABS 100MG . . . . . . . . 19venlafaxine hcl . . . . . . . . . . . . . . . . . . . . 15venlafaxine hcl er cp24 75mg . . . . . . 15venlafaxine hcl er cp24 150mg, 37.5mg . . . . . . . . . . . . . . . . . . . . 15VENLAFAXINE HCL ER TB24 75MG . . . . . . . . . . . . . . . . . . . . . . . 15VENLAFAXINE HCL ER TB24 150MG, 225MG, 37.5MG . . . . . 15VENTAVIS . . . . . . . . . . . . . . . . . . . . . . . . 45

TUDORZA PRESSAIR . . . . . . . . . . . . . 45TWINRIX . . . . . . . . . . . . . . . . . . . . . . . . . 42TYBOST . . . . . . . . . . . . . . . . . . . . . . . . . . 24TYGACIL . . . . . . . . . . . . . . . . . . . . . . . . . 11TYKERB . . . . . . . . . . . . . . . . . . . . . . . . . . 20TYPHIM VI . . . . . . . . . . . . . . . . . . . . . . . . 42TYSABRI . . . . . . . . . . . . . . . . . . . . . . . . . 32TYVASO . . . . . . . . . . . . . . . . . . . . . . . . . . 45TYZEKA . . . . . . . . . . . . . . . . . . . . . . . . . . 23TYZINE PEDIATRIC NASAL DROPS . . . . . . . . . . . . . . . . . . . 46

UULORIC . . . . . . . . . . . . . . . . . . . . . . . . . . 17umecta . . . . . . . . . . . . . . . . . . . . . . . . . . . 32umecta mousse . . . . . . . . . . . . . . . . . . . 32UNASYN . . . . . . . . . . . . . . . . . . . . . . . . . . 12UNASYN BULK PACK . . . . . . . . . . . . . 12UNITUXIN . . . . . . . . . . . . . . . . . . . . . . . . 20uramit mb . . . . . . . . . . . . . . . . . . . . . . . . . 34urea 40% nail film . . . . . . . . . . . . . . . . . 32urea crea 39%, 40%, 45%, 47%, 50% . . . . . . . . 33urea gel . . . . . . . . . . . . . . . . . . . . . . . . . . 33urea nail gel . . . . . . . . . . . . . . . . . . . . . . 33urea susp . . . . . . . . . . . . . . . . . . . . . . . . 33URELLE . . . . . . . . . . . . . . . . . . . . . . . . . . 34uribel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35urin d/s . . . . . . . . . . . . . . . . . . . . . . . . . . . 35ur n-c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34uro-mp . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35ursodiol . . . . . . . . . . . . . . . . . . . . . . . . . . . 34ustell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35utira-c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35UVADEX . . . . . . . . . . . . . . . . . . . . . . . . . . 33

VVAGIFEM . . . . . . . . . . . . . . . . . . . . . . . . . 39valacyclovir hcl . . . . . . . . . . . . . . . . . . . . 24

triamcinolone acetonide oint . . . . . . . 36triamcinolone acetonide pste . . . . . . 32triamcinolone in orabase . . . . . . . . . . . 32triamterene/hydrochlorothiazide . . . . 30trianex . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36triderm . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36tri-estarylla . . . . . . . . . . . . . . . . . . . . . . . . 38trifluoperazine hcl . . . . . . . . . . . . . . . . . . 22trifluridine . . . . . . . . . . . . . . . . . . . . . . . . . 24TRIGLIDE . . . . . . . . . . . . . . . . . . . . . . . . . 30trihexyphenidyl hcl . . . . . . . . . . . . . . . . . 21tri-legest fe . . . . . . . . . . . . . . . . . . . . . . . . 38tri-linyah . . . . . . . . . . . . . . . . . . . . . . . . . . 38tri-lo-estarylla . . . . . . . . . . . . . . . . . . . . . . 38tri-lo-marzia . . . . . . . . . . . . . . . . . . . . . . . 39tri-lo-sprintec . . . . . . . . . . . . . . . . . . . . . . 39trilyte . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34trimethoprim . . . . . . . . . . . . . . . . . . . . . . . 11trimethoprim sulfate/ polymyxin b sulfate . . . . . . . . . . . . . . . . 11trimipramine maleate . . . . . . . . . . . . . . 16trinessa . . . . . . . . . . . . . . . . . . . . . . . . . . . 39trinessa lo . . . . . . . . . . . . . . . . . . . . . . . . . 39TRINTELLIX . . . . . . . . . . . . . . . . . . . . . . 15triple-vitamin/fluoride . . . . . . . . . . . . . . . 49tri-previfem . . . . . . . . . . . . . . . . . . . . . . . . 39TRISENOX . . . . . . . . . . . . . . . . . . . . . . . 19tri-sprintec . . . . . . . . . . . . . . . . . . . . . . . . 39TRIUMEQ . . . . . . . . . . . . . . . . . . . . . . . . . 24tri-vitamin/fluoride . . . . . . . . . . . . . . . . . 49tri-vit/fluoride . . . . . . . . . . . . . . . . . . . . . . 49tri-vit/fluoride/iron . . . . . . . . . . . . . . . . . . 49trivora-28 . . . . . . . . . . . . . . . . . . . . . . . . . 39TROPHAMINE . . . . . . . . . . . . . . . . . . . . 49tropicamide . . . . . . . . . . . . . . . . . . . . . . . 43trospium chloride . . . . . . . . . . . . . . . . . . 34trospium chloride er . . . . . . . . . . . . . . . . 34TRULICITY . . . . . . . . . . . . . . . . . . . . . . . 25TRUMENBA . . . . . . . . . . . . . . . . . . . . . . 42TRUVADA . . . . . . . . . . . . . . . . . . . . . . . . 24


Covered Drugs Index

73

Zzafirlukast . . . . . . . . . . . . . . . . . . . . . . . . . 44zaleplon . . . . . . . . . . . . . . . . . . . . . . . . . . 46ZALTRAP . . . . . . . . . . . . . . . . . . . . . . . . . 20ZANOSAR . . . . . . . . . . . . . . . . . . . . . . . . 18ZARXIO . . . . . . . . . . . . . . . . . . . . . . . . . . 27ZAVESCA . . . . . . . . . . . . . . . . . . . . . . . . . 33zazole crea . . . . . . . . . . . . . . . . . . . . . . . 17zebutal caps 325mg; 50mg; 40mg . . . 7ZEGERID PACK . . . . . . . . . . . . . . . . . . 34ZELAPAR . . . . . . . . . . . . . . . . . . . . . . . . . 21ZELBORAF . . . . . . . . . . . . . . . . . . . . . . . 20ZEMAIRA . . . . . . . . . . . . . . . . . . . . . . . . . 46zenatane . . . . . . . . . . . . . . . . . . . . . . . . . . 33zenchent . . . . . . . . . . . . . . . . . . . . . . . . . . 39zenchent fe . . . . . . . . . . . . . . . . . . . . . . . 39ZENPEP . . . . . . . . . . . . . . . . . . . . . . . . . . 33ZETIA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31ZIAGEN ORAL SOLN . . . . . . . . . . . . . 24ZIANA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33zidovudine . . . . . . . . . . . . . . . . . . . . . . . . 24ZIOPTAN . . . . . . . . . . . . . . . . . . . . . . . . . 43ziprasidone hcl . . . . . . . . . . . . . . . . . . . . 22ZIRGAN . . . . . . . . . . . . . . . . . . . . . . . . . . 23ZMAX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13ZOLADEX . . . . . . . . . . . . . . . . . . . . . . . . 40zoledronic acid . . . . . . . . . . . . . . . . . . . . 42ZOLINZA . . . . . . . . . . . . . . . . . . . . . . . . . 19zolmitriptan odt tbdp 2.5mg . . . . . . . . 17zolmitriptan odt tbdp 5mg . . . . . . . . . . 17zolmitriptan tabs 2.5mg . . . . . . . . . . . . 17zolmitriptan tabs 5mg . . . . . . . . . . . . . . 17zolpidem tartrate tabs . . . . . . . . . . . . . 46ZONALON . . . . . . . . . . . . . . . . . . . . . . . . 33zonisamide . . . . . . . . . . . . . . . . . . . . . . . . 14ZORBTIVE . . . . . . . . . . . . . . . . . . . . . . . . 36ZORTRESS TABS 0.5MG, 0.75MG . . . . . . . . . . . . . . . . . . . 41ZORTRESS TABS 0.25MG . . . . . . . . 41

VOTRIENT . . . . . . . . . . . . . . . . . . . . . . . . 20VP-PNV-DHA . . . . . . . . . . . . . . . . . . . . . 49VPRIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33VRAYLAR CAPS . . . . . . . . . . . . . . . . . . 22VRAYLAR CPPK . . . . . . . . . . . . . . . . . . 22vyfemla . . . . . . . . . . . . . . . . . . . . . . . . . . . 39VYTORIN . . . . . . . . . . . . . . . . . . . . . . . . . 30

Wwarfarin sodium . . . . . . . . . . . . . . . . . . . 27WELCHOL . . . . . . . . . . . . . . . . . . . . . . . . 31wymzya fe . . . . . . . . . . . . . . . . . . . . . . . . 39

XXALKORI . . . . . . . . . . . . . . . . . . . . . . . . . 20XARELTO STARTER PACK . . . . . . . . 27XARELTO TABS 10MG, 20MG . . . . . 27XARELTO TABS 15MG . . . . . . . . . . . . 27XENAZINE . . . . . . . . . . . . . . . . . . . . . . . . 31XEOMIN . . . . . . . . . . . . . . . . . . . . . . . . . . 23XEOMIN . . . . . . . . . . . . . . . . . . . . . . . . . . 42XERAC AC . . . . . . . . . . . . . . . . . . . . . . . . 33XGEVA . . . . . . . . . . . . . . . . . . . . . . . . . . . 42XIAFLEX . . . . . . . . . . . . . . . . . . . . . . . . . . 33XIFAXAN TABS 200MG . . . . . . . . . . . . 11XIFAXAN TABS 550MG . . . . . . . . . . . . 11XOLAIR . . . . . . . . . . . . . . . . . . . . . . . . . . . 46XOPENEX HFA . . . . . . . . . . . . . . . . . . . 45XTANDI . . . . . . . . . . . . . . . . . . . . . . . . . . . 18xulane . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39xylon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9XYREM . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

YYERVOY . . . . . . . . . . . . . . . . . . . . . . . . . . 20YF-VAX . . . . . . . . . . . . . . . . . . . . . . . . . . . 42YONDELIS . . . . . . . . . . . . . . . . . . . . . . . . 18

verapamil hcl . . . . . . . . . . . . . . . . . . . . . . 29verapamil hcl er . . . . . . . . . . . . . . . . . . . 29verapamil hcl sr cp24 . . . . . . . . . . . . . . 29VERDESO . . . . . . . . . . . . . . . . . . . . . . . . 36VERSACLOZ . . . . . . . . . . . . . . . . . . . . . 22VESICARE . . . . . . . . . . . . . . . . . . . . . . . . 35vestura . . . . . . . . . . . . . . . . . . . . . . . . . . . 39VEXOL . . . . . . . . . . . . . . . . . . . . . . . . . . . 43V-GO 20 . . . . . . . . . . . . . . . . . . . . . . . . . . 42V-GO 30 . . . . . . . . . . . . . . . . . . . . . . . . . . 42V-GO 40 . . . . . . . . . . . . . . . . . . . . . . . . . . 42VIBATIV INJ 250MG . . . . . . . . . . . . . . . 11VICTOZA . . . . . . . . . . . . . . . . . . . . . . . . . 25VIDEX PEDIATRIC . . . . . . . . . . . . . . . . 24vienva . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39VIGAMOX . . . . . . . . . . . . . . . . . . . . . . . . 13VIIBRYD . . . . . . . . . . . . . . . . . . . . . . . . . . 16VIIBRYD STARTER PACK . . . . . . . . . 16VIMPAT INJ . . . . . . . . . . . . . . . . . . . . . . 14VIMPAT ORAL SOLN . . . . . . . . . . . . . 14VIMPAT TABS . . . . . . . . . . . . . . . . . . . . 14vinblastine sulfate . . . . . . . . . . . . . . . . . 19vincasar pfs . . . . . . . . . . . . . . . . . . . . . . . 19vincristine sulfate . . . . . . . . . . . . . . . . . . 19vinorelbine tartrate . . . . . . . . . . . . . . . . . 19viorele . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39VIRACEPT . . . . . . . . . . . . . . . . . . . . . . . . 24VIRAMUNE XR TB24 100MG . . . . . . 23VIRAZOLE . . . . . . . . . . . . . . . . . . . . . . . . 46VIREAD . . . . . . . . . . . . . . . . . . . . . . . . . . 24virt-phos 250 neutral . . . . . . . . . . . . . . . 49virtrate-2 . . . . . . . . . . . . . . . . . . . . . . . . . . 49virtrate-k . . . . . . . . . . . . . . . . . . . . . . . . . . 49vitamins a/c/d/fluoride . . . . . . . . . . . . . . 49VITEKTA . . . . . . . . . . . . . . . . . . . . . . . . . . 23VIVITROL . . . . . . . . . . . . . . . . . . . . . . . . . . 9VOLTAREN GEL . . . . . . . . . . . . . . . . . . 33voriconazole inj . . . . . . . . . . . . . . . . . . . 17voriconazole susr . . . . . . . . . . . . . . . . . 17voriconazole tabs . . . . . . . . . . . . . . . . . 17


Covered Drugs Index

74

ZOSTAVAX . . . . . . . . . . . . . . . . . . . . . . . 42ZOSYN . . . . . . . . . . . . . . . . . . . . . . . . . . . 12zovia 1/35e . . . . . . . . . . . . . . . . . . . . . . . 39zovia 1/50e . . . . . . . . . . . . . . . . . . . . . . . 39ZOVIRAX CREA . . . . . . . . . . . . . . . . . . 24ZYCLARA . . . . . . . . . . . . . . . . . . . . . . . . . 33ZYCLARA PUMP . . . . . . . . . . . . . . . . . . 33ZYDELIG . . . . . . . . . . . . . . . . . . . . . . . . . 20ZYKADIA . . . . . . . . . . . . . . . . . . . . . . . . . 20ZYLET . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10ZYPREXA RELPREVV INJ 210MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 22ZYPREXA RELPREVV INJ 300MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 22ZYPREXA RELPREVV INJ 405MG . . . . . . . . . . . . . . . . . . . . . . . . . . . 22ZYTIGA . . . . . . . . . . . . . . . . . . . . . . . . . . . 18ZYVOX SUSR . . . . . . . . . . . . . . . . . . . . 11

1-800-627-7534 (TTY 711) 7 days a week, 8 a.m. – 8 p.m., hours apply Monday – Friday, February 15 – September 30

CignaHealthSpring.com

This drug list was updated on November 1, 2016. For more recent information or other questions, please contact Cigna Customer Service, at 1-800-627-7534 or, for TTY users, 711, 7 days a week, 8 a.m. – 8 p.m., hours apply Monday – Friday, February 15 – September 30, or visit www.CignaHealthSpring.com. This information is available for free in other languages. Please call our customer service number at 1-800-627-7534 (TTY 711), 7 days a week, 8 a.m. – 8 p.m., hours apply Monday – Friday, February 15 – September 30. Esta información está disponible de forma gratuita en otros idiomas. Por favor, llame a nuestro servicio al cliente al 1-800-627-7534 (TTY 711), los 7 días de la semana, de 8 a.m. a 8 p.m. Del 15 de febrero al 30 de septiembre, llame de lunes a viernes. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St. Louis, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Tennessee, Inc., HealthSpring of Alabama, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2016 Cigna

Comprehensive Drug List (Formulary) Cigna-HealthSpring

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