Formulary 2015 - Premera Blue Cross Medicare Advantage...

Formulary

2015

List of Covered Drugs

premera.com

Version 6

Premera Blue Cross Medicare Advantage (HMO)Premera Blue Cross Medicare Advantage Plus (HMO)Premera Blue Cross Medicare Advantage (HMO-POS)Premera Blue Cross Medicare Advantage Plus (HMO-POS)

Customer Service:

PLEASE READ: This document contains information about the drugs we cover in this plan.

Premera Blue Cross Medicare AdvantagePO Box 4196, Portland, OR 97208-4196Call toll free 888-850-8526 (TTY: 711). Representatives are available between 8 a.m. and 8 p.m., seven days a week.

H7245_2015PBCRX11_Errata 031902 (10-2014)

Correction

Please note:

On pages 50 and 87, the following drug was included in the printed formulary document in error:

omeprazole magnesium

This drug is not covered for Medicare members by the Centers for Medicare and Medicaid Services (CMS).

Your Premera Blue Cross Medicare Advantage plan does cover omeprazole (10mg, 40mg, 20mg).

Please insert this document in your current Premera Blue Cross Medicare Advantage formulary booklet for future reference.

If you have any questions regarding this notice, please contact the Premera Blue Cross Medicare Advantage Customer Service Team at 1-888-850-8526 (TTY 711), between 8 a.m. and 8 p.m., seven days a week.

The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance may change on January 1 of each year.

Premera Blue Cross is an HMO and HMO-POS plan with a Medicare contract. Enrollment in Premera Blue Cross depends on contract renewal.

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Premera Blue Cross Medicare Advantage (HMO),

Premera Blue Cross Medicare Advantage Plus (HMO),

Premera Blue Cross Medicare Advantage (HMO-POS) and

Premera Blue Cross Medicare Advantage Plus (HMO-POS)

2015 Formulary

(List of Covered Drugs)

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

Formulary ID: 00015063, Version: 6 This formulary was updated on 08/01/2014. For more recent information or other questions, please contact Premera Blue Cross Medicare Advantage Plans Customer Service at 1-888-850-8526 or, for TTY users, 711, seven days a week between 8 a.m. and 8 p.m., or visit www.premera.com.

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

When this drug list (formulary) refers to “we,” “us,” or “our,” it means Premera Blue Cross Medicare Advantage Plans. When it refers to “plan” or “our plan,” it means Premera Blue Cross Medicare Advantage Plans.

This document includes a list of the drugs (formulary) for our plan, which is current as of 01/2015. 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, provider network and/or copayments/coinsurance may change on January 1, 2016, and from time to time during the year.

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What is the Premera Blue Cross Medicare Advantage (HMO), Premera Blue Cross Medicare Advantage Plus (HMO), Premera Blue Cross Medicare Advantage (HMO-POS) and Premera Blue Cross Medicare Advantage Plus (HMO-POS) Formulary?

A formulary is a list of covered drugs selected by Premera Blue Cross Medicare Advantage Plans 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. Premera Blue Cross Medicare Advantage Plans will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Premera Blue Cross Medicare Advantage Plans network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Can the Formulary (drug list) change?

Generally, if you are taking a drug on our 2015 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2015 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. The enclosed formulary is current as of 01/01/2015. To get updated information about the drugs covered by Premera Blue Cross Medicare Advantage Plans, please contact us. Our contact information appears on the front and back cover pages. If we make any mid-year non-maintenance changes to the Premera Blue Cross Medicare Advantage Plans formulary, we will mail you a copy of the formulary changes via errata sheets to ensure that you have a complete and updated formulary.

How do I use the Formulary?

There are two ways to find your drug within the formulary:

Medical Condition

The formulary begins on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs

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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 94. Then look under the category name for your drug.

Alphabetical Listing

If you are not sure what category to look under, you should look for your drug in the Index that begins on page 76. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.

What are generic drugs?

Premera Blue Cross Medicare Advantage Plans 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: Premera Blue Cross Medicare Advantage Plans requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Premera Blue Cross Medicare Advantage Plans before you fill your prescriptions. If you don’t get approval, Premera Blue Cross Medicare Advantage Plans may not cover the drug.

• Quantity Limits: For certain drugs, Premera Blue Cross Medicare Advantage Plans limits the amount of the drug that Premera Blue Cross Medicare Advantage Plans will cover. For example, Premera Blue Cross Medicare Advantage Plans provides 30 tablets per prescription for Zolpidem. This may be in addition to a standard one-month or three-month supply.

• Step Therapy: In some cases, Premera Blue Cross Medicare Advantage Plans 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, Premera Blue Cross Medicare Advantage Plans may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Premera Blue Cross Medicare Advantage Plans will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 1. You can also get more information about the restrictions applied to specific covered drugs by visiting our website. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact

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information, along with the date we last updated the formulary, appears on the front and back cover pages.

You can ask Premera Blue Cross Medicare Advantage Plans 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 Premera Blue Cross Medicare Advantage Plans’ formulary?” on page iv for information about how to request an exception.

What if my drug is not on the Formulary?

If your drug is not included in this formulary (list of covered drugs), you should first contact Customer Service and ask if your drug is covered.

If you learn that Premera Blue Cross Medicare Advantage Plans does not cover your drug, you have two options:

• You can ask Customer Service for a list of similar drugs that are covered by Premera Blue Cross Medicare Advantage Plans. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by Premera Blue Cross Medicare Advantage Plans.

• You can ask Premera Blue Cross Medicare Advantage Plans 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 Premera Blue Cross Medicare Advantage (HMO), Premera Blue Cross Medicare Advantage Plus (HMO), Premera Blue Cross Medicare Advantage (HMO-POS) and Premera Blue Cross Medicare Advantage Plus (HMO-POS)’s Formulary?

You can ask Premera Blue Cross Medicare Advantage Plans to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

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

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

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

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

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

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 90-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 90-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 34-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.

Level of care change: Day Supply For members transitioning from a SNF to LTC: 34 day supply SNF to Home (Retail): 30 day supply LTC LTC: -‐ 34 day supply Hospital to Home (Retail): 30 day supply

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For more information

For more detailed information about your Premera Blue Cross Medicare Advantage Plans prescription drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions about Premera Blue Cross Medicare Advantage Plans, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages.

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

Premera Blue Cross Medicare Advantage Plans’ Formulary

The formulary that begins on page 1 provides coverage information about some of the drugs covered by Premera Blue Cross Medicare Advantage Plans. If you have trouble finding your drug in the list, turn to the Index that begins on page 76.

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

The second column of the chart lists the Drug Tier. The Drug Tier name lets you know the amount you will pay at the pharmacy.

The information in the Requirements/Limits column tells you if Premera Blue Cross Medicare Advantage Plans has any special requirements for coverage of your drug.

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Initial Coverage Level for a 30-Day Supply at a Pharmacy with Preferred Cost-Sharing*

Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Tier 6

Plans Preferred Generic

Non-Preferred Generic

Preferred Brand

Non- Preferred

Brand

Injectable Drugs

Specialty Drugs

Premera Blue Cross $4.00 $9.00 $45.00 $95.00 33% 33% Medicare Advantage

(HMO) copayment copayment copayment copayment coinsurance coinsurance


Plus (HMO) copayment copayment copayment copayment coinsurance coinsurance


(HMO-POS) copayment copayment copayment copayment coinsurance coinsurance


Plus (HMO-POS) copayment copayment copayment copayment coinsurance coinsurance

*Table shows initial coverage level for a 30-day supply. Coverage level shown does not reflect deductibles, gap coverage, catastrophic benefit coverage, or mail order pharmacy cost shares. Please refer to your 2015 Summary of Benefits or Evidence of Coverage for details.

Initial Coverage Level for a 30-Day Supply at a Pharmacy with Standard Cost-Sharing*

Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Tier 6

Plans Preferred Generic

Non- Preferred Generic

Preferred Brand

Non- Preferred

Brand

Injectable Drugs

Specialty Drugs


(HMO) copayment copayment copayment copayment coinsurance coinsurance


Plus (HMO) copayment copayment copayment copayment coinsurance coinsurance


(HMO-POS) copayment copayment copayment copayment coinsurance coinsurance


Plus (HMO-POS) copayment copayment copayment copayment coinsurance coinsurance

*Table shows initial coverage level for a 30-day supply. Coverage level shown does not reflect deductibles, gap coverage, catastrophic benefit coverage, or mail order pharmacy cost shares. Please refer to your 2015 Summary of Benefits or Evidence of Coverage for details.

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The following abbreviations may be found within the body of this document

COVERAGE NOTES ABBREVIATIONS

ABBREVIATION DESCRIPTION EXPLANATION

Utilization Management Restrictions

PA Prior Authorization Restriction

You (or your physician) are required to get prior authorization from Premera Blue Cross Medicare Advantage Plans before you fill your prescription for this drug. Without prior approval, Premera Blue Cross Medicare Advantage Plans may not cover this drug.

QL Quantity Limit Restriction

Premera Blue Cross Medicare Advantage Plans limits the amount of this drug that is covered per prescription, or within a specific time frame.

ST Step Therapy Restriction

Before Premera Blue Cross Medicare Advantage Plans will provide coverage for this drug, you must first try another drug to treat your medical condition. This drug may only be covered if the other drug does not work for you.

Other Special Requirements for Coverage

LA Limited Access Drug

This prescription is limited to certain pharmacies. For more information consult your Provider and Pharmacy Directory or call Customer Service at 1-888-850-8526, daily between 8 a.m. and 8 p.m., seven days a week. TTY/TDD users should call 711.

Medicare Advantage Plans 2015 Formulary (List of Covered Drugs)

Drug Name Drug Tier Requirements/Limits

Analgesics - Drugs to treat pain

Analgesicsalagesic lq 2-generic PA FOR 65 YEARS AND OLDER

butalbital/acetaminophen 2-generic PA FOR 65 YEARS AND OLDER

butalbital/acetaminophen/caffeine(tablet, capsule)

2-generic PA FOR 65 YEARS AND OLDER

butalbital/aspirin/caffeine 50-325-40capsule


capacet 2-generic PA FOR 65 YEARS AND OLDER

fioricet 50-325-40 mg tablet 2-generic PA FOR 65 YEARS AND OLDER

tencon 50-325 mg tablet 2-generic PA FOR 65 YEARS AND OLDER

Opioid Analgesics, Long-actingDURAMORPH 5-INJECTABLE

fentanyl (50mcg/hr, 25mcg/hr, 100mcg/hr, 75mcg/hr, 12 mcg/hr)

2-generic QL (15 PER 30 DAYS)

fentanyl citrate (400 mcg, 600 mcg, 200mcg, 800 mcg, 1600 mcg, 1200 mcg)

2-generic PA, QL (120 PER 30 DAYS)

levorphanol tartrate 2 mg tablet 2-generic

methadone hcl (5 ml, 10 ml) 2-generic

methadone hcl 10 mg tablet 2-generic QL (120 PER 30 DAYS)

methadone hcl 10 mg/ml vial 5-INJECTABLE

methadone hcl 5 mg tablet 2-generic QL (8 PER DAY)

morphine sulfate (10 mg/5 ml solution,200 mg tablet er)

2-generic

morphine sulfate (100 mg tablet er, 100mg cap er pel, 80 mg cap er pel)

2-generic QL (1 PER DAY)

morphine sulfate (30 mg cap er pel, 30mg tablet er)


morphine sulfate (60 mg cap er pel, 60mg tablet er, 50 mg cap er pel)


morphine sulfate 15 mg tablet er 2-generic QL (8 PER DAY)

morphine sulfate 20 mg cap er pel 2-generic QL (6 PER DAY)

OXYCONTIN (10 MG, 15 MG, 20 MG) 4-BRAND PA, QL (3 PER DAY)

You can find information on what the symbols and abbreviationson this table mean by going to page viii of the Introduction.

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OXYCONTIN (30 MG, 40 MG) 4-BRAND PA, QL (2 PER DAY)

OXYCONTIN (60 MG, 80 MG) 4-BRAND PA, QL (1 PER DAY)

tramadol hcl (300 mg tab er 24h, 200 2-genericmg tbmp 24hr, 100 mg tbmp 24hr, 200mg tab er 24h, 100 mg tab er 24h, 300mg tbmp 24hr)

Opioid Analgesics, Short-actingacetaminophen with codeine phosphate 2-generic(300mg/12.5 solution, 360-36/15solution, 240-24/10 solution, 300mg-30mg tablet, 120-12mg/5 solution,300mg-60mg tablet, 300mg-15mgtablet)

ascomp with codeine 2-generic PA FOR 65 YEARS AND OLDER

butalbit/acetamin/caff/codeine 50-325- 2-generic PA FOR 65 YEARS AND OLDER30 capsule

BUTORPHANOL TARTRATE (2 MG/ML, 1 5-INJECTABLEMG/ML)

butorphanol tartrate 10 mg/ml spray 2-generic

codeine 2-generic PA FOR 65 YEARS AND OLDERphosphate/butalbital/aspirin/caffeine

endocet (5-325, 7.5-325 mg, 2.5-325 2-genericmg)

endocet 10-325 mg tablet 2-generic QL (8 PER DAY)

endodan 2-generic

hydrocodone bitartrate/acetaminophen 2-generic(10mg-325mg tablet, 7.5-325/15solution, 7.5-325mg tablet, 5mg-325mgtablet, 5-217mg/10 solution, 2.5-108/5solution)

hydrocodone/ibuprofen 7.5-200 mg 2-generictablet

hydromorphone hcl (1 mg/ml liquid, 2 2-genericmg tablet)

hydromorphone hcl 4 mg tablet 2-generic QL (8 PER DAY)

hydromorphone hcl 8 mg tablet 2-generic QL (4 PER DAY)

HYDROMORPHONE HCL/PF (10 MG/ML 5-INJECTABLEAMPUL, 10 MG/ML VIAL)


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LAZANDA 4-BRAND PA, QL (150 PER 30 DAYS)

lorcet plus 7.5-325 mg tablet 2-generic

lortab (10-325 mg, 5-325 mg, 7.5-325mg)

2-generic

MORPHINE SULFATE (2 MG/MLCARTRIDGE, 4 MG/ML SYRINGE, 4MG/ML CARTRIDGE, 2 MG/MLSYRINGE)

5-INJECTABLE

morphine sulfate 100 mg/5ml solution 2-generic QL (6 ML PER DAY)

morphine sulfate 15 mg tablet 2-generic QL (8 PER DAY)

morphine sulfate 20 mg/5 ml solution 2-generic

morphine sulfate 30 mg tablet 2-generic QL (4 PER DAY)

oxycodone hcl (5 mg/5 ml solution, 5mg capsule, 5 mg tablet)

2-generic

oxycodone hcl 10 mg tablet 2-generic QL (8 PER DAY)




oxycodone hcl/acetaminophen (2.5-325mg, 5mg-325mg, 7.5-325mg)

2-generic

oxycodone hcl/acetaminophen 10mg-325mg tablet


oxycodone hcl/aspirin 2-generic

oxymorphone hcl 10 mg tablet 2-generic PA, QL (4 PER DAY)

oxymorphone hcl 5 mg tablet 2-generic PA, QL (8 PER DAY)

ROXICET 5-325 ORAL SOLUTION 3-PREF. BRAND

roxicet 5-325 tablet 2-generic

tramadol hcl 50 mg tablet 2-generic QL (240 PER 30 DAYS)

tramadol hcl/acetaminophen 2-generic QL (240 PER 30 DAYS)

Analgesics - Drugs to treat pain & inflammation

Nonsteroidal Anti-inflammatory DrugsCELEBREX (200 MG, 50 MG, 100 MG) 4-BRAND QL (60 PER 30 DAYS)


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CELEBREX 400 MG CAPSULE 4-BRAND

diclofenac potassium 2-generic

diclofenac sodium (50 mg tablet dr, 100mg tab er 24h, 3 % gel (gram), 25 mgtablet dr, 75 mg tablet dr)

2-generic

diflunisal 2-generic

etodolac (200 mg capsule, 400 mg taber 24h, 400 mg tablet, 300 mg capsule,500 mg tablet, 500 mg tab er 24h, 600mg tab er 24h)

2-generic

fenoprofen calcium 2-generic

flurbiprofen (50 mg, 100 mg) 2-generic

ibuprofen (400 mg tablet, 600 mgtablet, 800 mg tablet, 100 mg/5ml oralsusp)

2-generic

ketoprofen (75 mg capsule, 50 mgcapsule, 200 mg cap24h pel)

2-generic

meclofenamate sodium (50 mg, 100mg)

2-generic

meloxicam (15 mg tablet, 7.5 mg tablet,7.5 mg/5ml oral susp)

2-generic

nabumetone 2-generic

naproxen (125 mg/5ml oral susp, 500mg tablet dr, 250 mg tablet, 375 mgtablet, 500 mg tablet, 375 mg tablet dr)

2-generic

naproxen sodium (550 mg, 275 mg) 2-generic

piroxicam (20 mg, 10 mg) 2-generic

sulindac (200 mg, 150 mg) 2-generic

tolmetin sodium 2-generic

VOLTAREN 4-BRAND

Anesthetics

Local Anestheticslidocaine 5 % oint. (g) 2-generic PA TO CONFIRM PART D COVERAGE

lidocaine 5%(700mg) adh. patch 2-generic PA, QL (90 PER 30 DAYS)


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lidocaine hcl (40 mg/ml solution, 2 %solution, 2 % jel (ml))

2-generic

lidocaine hcl 5 mg/ml vial 5-INJECTABLE

lidocaine hcl/pf 5 mg/ml vial 5-INJECTABLE

lidocaine/prilocaine (2.5 cream (g), 2.5kit)

2-generic PA TO CONFIRM PART D COVERAGE

Anti-Addiction/Substance Abuse Treatment Agents

Alcohol Deterrents/Anti-cravingacamprosate calcium 2-generic PA

disulfiram (500 mg, 250 mg) 2-generic

Opioid Dependence TreatmentsBUPRENORPHINE HCL (0.3 MG/MLVIAL, 0.3 MG/ML SYRINGE)

5-INJECTABLE

buprenorphine hcl (2 mg, 8 mg) 2-generic QL (90 PER 30 DAYS)

buprenorphine hcl/naloxone hcl 2-generic PA, QL (90 PER 30 DAYS)

depade 2-generic

naltrexone hcl 50 mg tablet 2-generic

revia 2-generic

Opioid Reversal Agentsnaloxone hcl 1 mg/ml syringe 5-INJECTABLE

Smoking Cessation AgentsCHANTIX 3-PREF. BRAND

NICOTROL 4-BRAND

NICOTROL NS 4-BRAND

Antibacterials - Drugs to treat bacterial infections

Aminoglycosidesgaramycin 0.3% eye drops 2-generic

gentak (0.3 % ointment, 3 mg/ml drops) 2-generic

gentamicin sulfate (0.3 oint. (g), 0.1 2-generic


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oint. (g), 0.3 drops, 0.1 cream (g))

gentamicin sulfate 40 mg/ml vial 5-INJECTABLE

gentamicin sulfate/pf 5-INJECTABLE

neomycin sulfate 500 mg tablet 2-generic

paromomycin sulfate 250 mg capsule 2-generic

streptomycin sulfate 1 g vial 5-INJECTABLE

TOBRADEX EYE OINTMENT 4-BRAND

tobramycin 0.3 % drops 2-generic

tobramycin in 0.225 % sodium chloride 2-generic PA TO CONFIRM PART D COVERAGE

TOBRAMYCIN SULFATE (10 MG/ML, 40MG/ML, 1.2 G)

5-INJECTABLE

Antibacterials, Otheracetic acid 2 % solution 2-generic

BACIIM 5-INJECTABLE

bacitracin 500 unit/g oint. (g) 2-generic

bacitracin 50000 unit vial 5-INJECTABLE

chloramphenicol sod succ 5-INJECTABLE

clinda-derm 2-generic

clindacin etz 1% pledget 2-generic

clindacin p 2-generic

clindamycin hcl (150 mg, 75 mg, 300mg)

2-generic

clindamycin palmitate hcl 2-generic

clindamycin phosphate (1 foam, 1lotion, 2 cream/appl, 1 med. swab, 1 gel(gram), 1 solution)

2-generic

CLINDAMYCIN PHOSPHATE (300MG/2ML PORT, 900MG/6ML PORT, 600MG/4ML PORT, 150 MG/ML)

5-INJECTABLE

clindamycin phosphate/dextrose 5 % inwater

5-INJECTABLE

colistin (colistimethate na) 150 mg vial 5-INJECTABLE

CUBICIN 6-Specialty


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methenamine hippurate 2-generic

metronidazole (250 mg tablet, 0.75 %gel (gram), 0.75 % cream (g), 0.75 % gelw/appl, 0.75 % lotion, 500 mg tablet,375 mg capsule)

2-generic

metronidazole in sodium chloride 5-INJECTABLE

MONUROL 4-BRAND

mupirocin 2 % oint. (g) 2-generic

nitrofurantoin (25 mg/5 ml oral susp, 50mg capsule)

2-generic

nitrofurantoin macrocrystal 50 mgcapsule

2-generic

nitrofurantoinmonohydrate/macrocrystals

2-generic

rosadan (gel, cream) 2-generic

SYNERCID 6-Specialty

tinidazole (250 mg, 500 mg) 2-generic

trimethoprim 100 mg tablet 2-generic

TYGACIL 5-INJECTABLE

VANCOMYCIN HCL (10 G, 500 MG, 1 G,750 MG, 5 G, 1 G PORT, 500 MG PORT)

5-INJECTABLE PA TO CONFIRM PART D COVERAGE

vancomycin hcl (250 mg, 125 mg) 2-generic

vitazol 2-generic

XIFAXAN 200 MG TABLET 3-PREF. BRAND PA, QL (90 PER 30 DAYS)

XIFAXAN 550 MG TABLET 3-PREF. BRAND PA, QL (60 PER 30 DAYS)

ZYVOX (200 MG/100 ML IV SOLN, 600MG/300 ML IV SOLN, 600 MG TABLET,100 MG/5 ML SUSPENSION)

6-Specialty PA

Beta-lactam, CephalosporinsCEDAX 400 MG CAPSULE 4-BRAND

cefaclor (500 mg, 250 mg) 2-generic

cefadroxil (500 mg capsule, 500 mg/5mlsusp recon, 250 mg/5ml susp recon, 1 gtablet)

2-generic


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CEFAZOLIN SODIUM (300GBULKBAGINJ, 1 G VIAL, 20 G VIAL, 10 GVIAL, 500 MG VIAL, 100G BULKBAGINJ)

5-INJECTABLE

cefdinir (125 mg/5ml susp recon, 300mg capsule, 250 mg/5ml susp recon)

2-generic

cefepime hcl 5-INJECTABLE

cefotaxime sodium 5-INJECTABLE

cefotetan disodium 5-INJECTABLE

cefoxitin sodium 5-INJECTABLE

cefpodoxime proxetil (100 mg tablet,100 mg/5ml susp recon, 50 mg/5 mlsusp recon, 200 mg tablet)

2-generic

cefprozil (250 mg tablet, 250 mg/5mlsusp recon, 125 mg/5ml susp recon, 500mg tablet)

2-generic

CEFTAZIDIME PENTAHYDRATE (6G, 1 G,2 G)

5-INJECTABLE

CEFTIN 250 MG/5 ML ORAL SUSP 4-BRAND

CEFTRIAXONE SODIUM (1 G VIAL, 2 GVIAL PORT, 1 G VIAL PORT, 1 G PGGYBKBTL, 2 G PGGYBK BTL, 10 G VIAL, 500MG VIAL, 250 MG VIAL, 2 G VIAL)

5-INJECTABLE

CEFTRIAXONE SODIUM/DEXTROSE, ISO-OSMOTIC (2 ML, 1 ML)

5-INJECTABLE

cefuroxime axetil 2-generic

CEFUROXIME SODIUM (7.5G, 750 MG,1.5 G)

5-INJECTABLE

cephalexin (250 mg tablet, 250 mgcapsule, 500 mg tablet, 250 mg/5mlsusp recon, 125 mg/5ml susp recon, 500mg capsule)

2-generic

TAZICEF (6, 1, 2) 5-INJECTABLE

Beta-lactam, Otheraztreonam 5-INJECTABLE

DORIBAX 500 MG VIAL 5-INJECTABLE

imipenem/cilastatin sodium 5-INJECTABLE

INVANZ 1 GM VIAL 5-INJECTABLE


8



meropenem 5-INJECTABLE

Beta-lactam, Penicillinsamoxicillin (250 mg capsule, 500 mgtablet, 400 mg/5ml susp recon, 500 mgcapsule, 125 mg tab chew, 250 mg tabchew, 125 mg/5ml susp recon, 875 mgtablet, 250 mg/5ml susp recon, 200mg/5ml susp recon)

2-generic

amoxicillin/potassium clavulanate (600-42.9/5 susp recon, 400-57mg tab chew,200-28.5mg tab chew, 875-125 mgtablet, 400-57mg/5 susp recon, 250-62.5/5 susp recon, 250-125 mg tablet,200-28.5/5 susp recon, 1000-62.5 tab er12h, 500-125 mg tablet)

2-generic

AMPICILLIN SODIUM (500 MG, 10 G, 1G, 2 G, 1 G PORT, 250 MG, 125 MG)

5-INJECTABLE

AMPICILLIN SODIUM/SULBACTAMSODIUM (15, 1.5 PORT, 3, 1.5)

5-INJECTABLE

ampicillin trihydrate (250 mg capsule,500 mg capsule, 250 mg/5ml susprecon, 125 mg/5ml susp recon)

2-generic

BICILLIN C-R 5-INJECTABLE

BICILLIN L-A 5-INJECTABLE

dicloxacillin sodium 2-generic

NAFCILLIN SODIUM (2, 1, 10) 5-INJECTABLE

OXACILLIN SODIUM (10, 2 PORT, 1, 2) 5-INJECTABLE

oxacillin sodium/dextrose, iso-osmotic 5-INJECTABLE

penicillin g potassium 5-INJECTABLE

penicillin g procaine 1.2mm/2 mlsyringe

5-INJECTABLE

penicillin g sodium 5-INJECTABLE

penicillin v potassium (500 mg tablet,250 mg tablet, 250 mg/5ml soln recon,125 mg/5ml soln recon)

2-generic

PFIZERPEN 5-INJECTABLE

PIPERACILLIN SODIUM/TAZOBACTAMSODIUM (4.5G PORT, 3.375 G, 3.375 G

5-INJECTABLE


9



PORT, 4.5G, 40.5G, 2.25 G)

TIMENTIN (3.1 GM/100 ML ISO, 31 GMBULK VIAL, 3.1 GM ADD-VANT VL, 3.1GM VIAL)

5-INJECTABLE

MacrolidesAZASITE 4-BRAND

azithromycin (200 mg/5ml susp recon,100 mg/5ml susp recon, 500 mg tablet,600 mg tablet, 250 mg tablet)

2-generic

AZITHROMYCIN (500 MG PORT, 500MG)

5-INJECTABLE

clarithromycin (250 mg/5ml susp recon,500 mg tab er 24h, 500 mg tablet, 250mg tablet, 125 mg/5ml susp recon)

2-generic

E.E.S. 200 3-PREF. BRAND

e.e.s. 400 2-generic

ery 2-generic

ERY-TAB 3-PREF. BRAND

erygel 2-generic

ERYPED 200 3-PREF. BRAND

ERYTHROCIN LACTOBIONATE (500 MGVIAL, 500 MG ADDVNT VL)

5-INJECTABLE

ERYTHROCIN STEARATE 3-PREF. BRAND

erythromycin base (500 mg tablet, 250mg tablet, 5 mg/g oint. (g), 5mg/g oint.(g))

2-generic

erythromycin base/ethyl alcohol (2med. swab, 2 solution, 2 gel (gram))

2-generic

erythromycin ethylsuccinate 400 mgtablet

2-generic

QuinolonesAVELOX IV 5-INJECTABLE

ciprofloxacin hcl (100 mg tablet, 0.3 %drops, 500 mg tablet, 750 mg tablet,250 mg tablet)

2-generic

ciprofloxacin lactate 5-INJECTABLE


10


ciprofloxacin lactate/dextrose 5 % inwater

5-INJECTABLE

ciprofloxacin/ciprofloxacin hcl 2-generic

gatifloxacin 2-generic

levofloxacin (250mg/10ml solution, 0.5% drops, 500 mg tablet, 500mg/20mlsolution, 750 mg tablet, 250 mg tablet)

2-generic

levofloxacin 25 mg/ml vial 5-INJECTABLE

levofloxacin/dextrose 5 % in water 5-INJECTABLE

moxifloxacin hcl 2-generic

ofloxacin (0.3 % drops, 400 mg tablet,300 mg tablet, 200 mg tablet)

2-generic

VIGAMOX 3-PREF. BRAND

Sulfonamidessilver sulfadiazine 1 % cream (g) 2-generic

sulfacetamide sodium (10 drops, 10suspension, 10 oint. (g))

2-generic

sulfadiazine 500 mg tablet 2-generic

sulfamethoxazole/trimethoprim (800-160/20 oral susp, 200-40mg/5 oralsusp, 400mg-80mg tablet, 800-160 mgtablet)

2-generic

sulfamethoxazole/trimethoprim 80-16mg/ml vial

5-INJECTABLE

sulfamide 2-generic

Tetracyclinesavidoxy 2-generic

demeclocycline hcl (150 mg, 300 mg) 2-generic

DOXY 100 5-INJECTABLE

doxycycline hyclate (100 mg capsule,100 mg tablet, 20 mg tablet, 50 mgcapsule)

2-generic

doxycycline hyclate 100 mg vial 5-INJECTABLE

doxycycline monohydrate (150 mgtablet, 100 mg tablet, 75 mg tablet, 100

2-generic



11



mg capsule, 50 mg tablet)

dynacin (50 mg, 100 mg) 2-generic

minocycline hcl (100 mg capsule, 75 mg 2-genericcapsule, 100 mg tablet, 50 mg tablet,75 mg tablet, 50 mg capsule)

morgidox 100 mg capsule 2-generic

Anticonvulsants - Drugs to treat or prevent seizures

Anticonvulsants, Otherlevetiracetam (1000 mg tablet, 500 2-genericmg/5ml solution, 500 mg tab er 24h,100 mg/ml solution, 500 mg tablet, 750mg tablet, 750 mg tab er 24h, 250 mgtablet)

levetiracetam 500 mg/5ml vial 5-INJECTABLE

POTIGA 4-BRAND PA FOR NEW STARTS ONLY

Calcium Channel Modifying AgentsCELONTIN 4-BRAND

ethosuximide (250 mg/5ml solution, 2-generic250 mg capsule)

LYRICA (50 MG CAPSULE, 100 MG 4-BRAND PA FOR NEW STARTS ONLYCAPSULE, 300 MG CAPSULE, 225 MGCAPSULE, 150 MG CAPSULE, 200 MGCAPSULE, 20 MG/ML ORAL SOLUTION,75 MG CAPSULE, 25 MG CAPSULE)

zonisamide 2-generic

Gamma-aminobutyric Acid (GABA) Augmenting Agentsclonazepam (0.125 mg tab rapdis, 0.5 2-generic PA FOR NEW STARTS ONLY AND FORmg tablet, 1 mg tab rapdis, 0.25 mg tab 65 YEARS AND OLDERrapdis, 1 mg tablet, 0.5 mg tab rapdis, 2mg tab rapdis, 2 mg tablet)

clorazepate dipotassium 2-generic PA FOR NEW STARTS ONLY AND FOR65 YEARS AND OLDER

DIAZEPAM (12.5-15-20, 2.5 MG, 5-7.5- 3-PREF. BRAND10MG)

diazepam (2 mg tablet, 10 mg tablet, 5 2-generic PA FOR NEW STARTS ONLY AND FORmg/5 ml solution, 5 mg/ml oral conc, 5 65 YEARS AND OLDER


12



mg tablet)

divalproex sodium (125 mg, 500 mg,250 mg)

1-preferredgeneric

divalproex sodium (250 mg tab er 24h,125 mg cap sprink, 500 mg tab er 24h)

2-generic

gabapentin (250 mg/5ml, 300 mg/6ml) 2-generic

gabapentin (800 mg tablet, 100 mgcapsule, 300 mg capsule, 600 mg tablet,400 mg capsule)

1-preferredgeneric

GABITRIL (12 MG, 16 MG) 4-BRAND

ONFI (20 MG, 10 MG) 4-BRAND PA FOR NEW STARTS ONLY AND FOR65 YEARS AND OLDER, QL (60 PER 30DAYS)

ONFI 2.5 MG/ML SUSPENSION 4-BRAND PA FOR NEW STARTS ONLY AND FOR65 YEARS AND OLDER

phenobarbital (60 mg tablet, 15 mgtablet, 100 mg tablet, 64.8 mg tablet,30 mg tablet, 97.2mg tablet, 16.2 mgtablet, 32.4 mg tablet, 20 mg/5 mlelixir)

2-generic PA FOR NEW STARTS ONLY AND FOR65 YEARS AND OLDER

primidone (250 mg, 50 mg) 2-generic

SABRIL 6-Specialty LA

tiagabine hcl 2-generic

valproic acid (as sodium salt) (valproatesodium) (250 mg/5ml, 500mg/10ml)

1-preferredgeneric

valproic acid (as sodium salt) 500mg/5ml vial

5-INJECTABLE

valproic acid 250 mg capsule 1-preferredgeneric

Glutamate Reducing Agentsfelbamate (400 mg tablet, 600 mgtablet, 600 mg/5ml oral susp)

2-generic

FYCOMPA 4-BRAND PA FOR NEW STARTS ONLY

LAMICTAL (BLUE) 4-BRAND

LAMICTAL (GREEN) 4-BRAND

LAMICTAL (ORANGE) 4-BRAND


13



LAMICTAL XR (BLUE) 4-BRAND

LAMICTAL XR (GREEN) 4-BRAND

LAMICTAL XR (ORANGE) 4-BRAND

lamotrigine (200 mg, 150 mg, 25 mg,100 mg)

1-preferredgeneric

lamotrigine (5 mg, 25 mg) 2-generic

topiragen 1-preferredgeneric

topiramate (200 mg, 50 mg, 25 mg, 100mg)

1-preferredgeneric

topiramate (25 mg, 15 mg) 2-generic

Sodium Channel AgentsAPTIOM 4-BRAND PA FOR NEW STARTS ONLY

BANZEL (400 MG TABLET, 40 MG/MLSUSPENSION, 200 MG TABLET)

4-BRAND PA FOR NEW STARTS ONLY

carbamazepine (200 mg tablet, 100 mgtab chew)

1-preferredgeneric

carbamazepine (400 mg tab er 12h, 300mg cpmp 12hr, 200 mg tab er 12h, 200mg cpmp 12hr, 100 mg cpmp 12hr, 100mg/5ml oral susp)

2-generic

DILANTIN 30 MG CAPSULE 3-PREF. BRAND

epitol 1-preferredgeneric

oxcarbazepine (150 mg tablet, 300 mgtablet, 600 mg tablet, 300 mg/5ml oralsusp)

1-preferredgeneric

PEGANONE 4-BRAND

phenytoin (50 mg tab chew, 125mg/5ml oral susp, 100 mg/4ml oralsusp)

1-preferredgeneric

PHENYTOIN SODIUM (50 MG/ML VIAL,50 MG/ML AMPUL)

5-INJECTABLE

phenytoin sodium extended 1-preferredgeneric

VIMPAT (10 MG/ML SOLUTION, 150MG TABLET, 100 MG TABLET, 200 MG

4-BRAND PA FOR NEW STARTS ONLY


14



TABLET, 50 MG TABLET)

VIMPAT 200 MG/20 ML VIAL 5-INJECTABLE PA TO CONFIRM PART D COVERAGE

Antidementia Agents - Drugs to treat dementia

Cholinesterase Inhibitorsdonepezil hcl (10 mg tablet, 5 mg tab 2-genericrapdis, 10 mg tab rapdis, 5 mg tablet)

QL (30 PER 30 DAYS)

donepezil hcl 23 mg tablet 2-generic PA

EXELON (13.3, 4.6, 9.5) 4-BRAND QL (30 PER 30 DAYS)

galantamine hbr (12 mg tablet, 24 mg 2-genericcap24h pel, 4 mg tablet, 8 mg cap24hpel, 8 mg tablet, 16 mg cap24h pel, 4mg/ml solution)

rivastigmine tartrate 2-generic QL (60 PER 30 DAYS)

N-methyl-D-aspartate (NMDA) Receptor AntagonistNAMENDA 10 MG/5 ML SOLUTION 3-PREF. BRAND PA, QL (360 ML PER 30 DAYS)

NAMENDA XR 4-BRAND PA, QL (30 PER 30 DAYS)

Antidepressants - Drugs to treat depression

Antidepressants, OtherABILIFY (2 MG TABLET, 10 MG TABLET,30 MG TABLET, 20 MG TABLET, 15 MGTABLET, 5 MG TABLET, 1 MG/MLSOLUTION)

3-PREF. BRAND

ABILIFY 9.7 MG/1.3 ML VIAL 5-INJECTABLE

ABILIFY DISCMELT 3-PREF. BRAND

ABILIFY MAINTENA 6-Specialty

budeprion sr 2-generic

budeprion xl 2-generic

buproban 2-generic

bupropion hcl (150 mg tab er 24h, 75mg tablet, 200 mg tablet er, 150 mgtablet er, 100 mg tablet er, 300 mg taber 24h, 100 mg tablet)

2-generic


15


Drug Name Drug Tier

maprotiline hcl 2-generic

mirtazapine (15 mg, 45 mg, 7.5 mg, 30 1-preferred

Requirements/Limits

mg) generic

mirtazapine (45 mg, 15 mg, 30 mg) 2-generic

olanzapine/fluoxetine hcl 2-generic

trazodone hcl (100 mg, 50 mg, 300 mg, 1-preferred150 mg) generic

Monoamine Oxidase InhibitorsEMSAM 4-BRAND

MARPLAN 4-BRAND

phenelzine sulfate 15 mg tablet 2-generic

tranylcypromine sulfate 2-generic

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors

PA FOR NEW STARTS ONLY

/Serotonin and NorepinephrineReuptake Inhibitor

BRINTELLIX 4-BRAND PA FOR NEW STARTS ONLY

citalopram hydrobromide (40 mg, 10 1-preferredmg, 20 mg) generic

citalopram hydrobromide 10 mg/5 ml 2-genericsolution

desvenlafaxine 4-BRAND PA FOR NEW STARTS ONLY, QL (30 PER30 DAYS)

duloxetine hcl (30 mg, 20 mg) 2-generic PA FOR NEW STARTS ONLY, QL (60 PER30 DAYS)

duloxetine hcl 60 mg capsule dr 2-generic PA FOR NEW STARTS ONLY, QL (30 PER30 DAYS)

escitalopram oxalate (20 mg tablet, 10 1-preferredmg tablet, 5 mg/5 ml solution, 5 mg generictablet)

FETZIMA 4-BRAND PA FOR NEW STARTS ONLY

fluoxetine hcl (20 mg tablet, 40 mg 1-preferredcapsule, 20 mg/5 ml solution, 60 mg generictablet, 10 mg tablet, 20 mg capsule, 10mg capsule)

fluoxetine hcl 90 mg capsule dr 2-generic

fluvoxamine maleate (25 mg, 100 mg, 2-generic


16



50 mg)

KHEDEZLA 4-BRAND PA FOR NEW STARTS ONLY, QL (30 PER30 DAYS)

nefazodone hcl 2-generic

paroxetine hcl (10 mg, 20 mg, 40 mg, 1-preferred30 mg) generic

PAXIL 10 MG/5 ML SUSPENSION 4-BRAND

PRISTIQ ER 4-BRAND PA FOR NEW STARTS ONLY, QL (30 PER30 DAYS)

sertraline hcl (50 mg, 25 mg, 100 mg) 1-preferredgeneric

sertraline hcl 20 mg/ml oral conc 2-generic

venlafaxine hcl (75 mg tab er 24, 75 mg 2-genericcap er 24h, 37.5 mg cap er 24h, 50 mgtablet, 75 mg tablet, 25 mg tablet, 37.5mg tab er 24, 150 mg cap er 24h, 37.5mg tablet, 100 mg tablet, 150 mg tab er24)

venlafaxine hcl 225 mg tab er 24 4-BRAND QL (30 PER 30 DAYS)

VIIBRYD 4-BRAND PA FOR NEW STARTS ONLY

Tricyclicsamitriptyline hcl (50 mg, 75 mg, 100 2-generic PA FOR NEW STARTS ONLY AND FORmg, 25 mg, 10 mg, 150 mg) 65 YEARS AND OLDER

amoxapine 2-generic

clomipramine hcl (50 mg, 75 mg, 25 2-generic PA FOR NEW STARTS ONLYmg)

desipramine hcl (10 mg, 75 mg, 100 mg, 2-generic25 mg, 50 mg, 150 mg)

doxepin hcl (150 mg, 75 mg, 50 mg, 25 2-generic PA FOR NEW STARTS ONLYmg, 100 mg, 10 mg)

doxepin hcl 10 mg/ml oral conc 2-generic

imipramine hcl (25 mg, 10 mg, 50 mg) 2-generic PA FOR NEW STARTS ONLY

imipramine pamoate 2-generic PA FOR NEW STARTS ONLY

nortriptyline hcl (50 mg, 25 mg, 10 mg, 1-preferred75 mg) generic

nortriptyline hcl 10 mg/5 ml solution 2-generic


17



protriptyline hcl 2-generic

SURMONTIL 4-BRAND

Antidotes

Chemotherapy Antidote AgentMESNEX 400 MG TABLET 3-PREF. BRAND

Antiemetics - Drugs to treat or prevent nausea

Antiemetics, Otherchlorpromazine hcl (100 mg, 200 mg, 25mg, 10 mg, 50 mg)

2-generic

chlorpromazine hcl 25 mg/ml ampul 5-INJECTABLE

compro 2-generic

diphenhydramine hcl 50 mg/ml vial 5-INJECTABLE

meclizine hcl (25 mg, 12.5 mg) 2-generic

metoclopramide hcl (10 mg tablet, 5 mgtablet, 10 mg/10ml solution, 5 mg/5 mlsolution)

1-preferredgeneric

metoclopramide hcl 5 mg/ml vial 5-INJECTABLE

perphenazine 2-generic

PROCHLORPERAZINE EDISYLATE (10MG/2 ML, 5 MG/ML)

5-INJECTABLE

prochlorperazine maleate (5 mg tablet,10 mg tablet, 25 mg supp.rect)

2-generic

Emetogenic Therapy Adjunctsdronabinol 2-generic PA

EMEND 125 MG CAPSULE 3-PREF. BRAND PA TO CONFIRM PART D COVERAGE,QL (2 PER 30 DAYS)

EMEND 80 MG CAPSULE 3-PREF. BRAND PA TO CONFIRM PART D COVERAGE,QL (4 PER 30 DAYS)

EMEND TRIFOLD PACK 3-PREF. BRAND PA TO CONFIRM PART D COVERAGE

ondansetron 1-preferredgeneric

PA TO CONFIRM PART D COVERAGE


18



ondansetron hcl (4 mg/5 ml solution, 24mg tablet)


ondansetron hcl (8 mg, 4 mg) 1-preferredgeneric


ondansetron hcl 2 mg/ml vial 5-INJECTABLE

ONDANSETRON HCL/PF (4 ML AMPUL,4 ML VIAL)

5-INJECTABLE

Antifungals - Drugs to treat fungal infections

AntifungalsABELCET 6-Specialty

AMBISOME 6-Specialty

amphotericin b 50 mg vial 5-INJECTABLE

CANCIDAS 6-Specialty

ciclodan (8% solution, 0.77% cream) 2-generic

ciclopirox (1 shampoo, 0.77 gel (gram),8 solution)

2-generic

ciclopirox olamine (0.77 cream (g), 0.77suspension)

2-generic

clotrimazole (10 mg troche, 1 % cream(g), 1 % solution)

2-generic

econazole nitrate 1 % cream (g) 2-generic

fluconazole (150 mg tablet, 10 mg/mlsusp recon, 50 mg tablet, 40 mg/mlsusp recon, 200 mg tablet, 100 mgtablet)

2-generic

fluconazole in dextrose, iso-osmotic 5-INJECTABLE

FLUCYTOSINE (500 MG, 250 MG) 6-Specialty

griseofulvin ultramicrosize 2-generic

griseofulvin, microsize (500 mg tablet,125 mg/5ml oral susp)

2-generic

itraconazole 100 mg capsule 2-generic

ketoconazole (2 cream (g), 2 shampoo) 2-generic

miconazole nitrate 200 mg supp.vag 2-generic


19



NATACYN 4-BRAND

NOXAFIL (40 MG/ML SUSPENSION, DR100 MG TABLET)

4-BRAND PA

nyamyc 2-generic

nystatin (100000/ml oral susp, 500mmunit powder(ea), 150mm unitpowder(ea), 100000/g powder,100000/g cream (g), 100000/g oint. (g),50mm unit powder(ea), 500k unittablet)

2-generic

nystatin/triamcinolone acetonide 2-generic

nystop 2-generic

pedi-dri 2-generic

terbinafine hcl 250 mg tablet 2-generic

terconazole (0.4 % cream/appl, 80 mgsupp.vag, 0.8 % cream/appl)

2-generic

voriconazole (200 mg tablet, 200mg/5ml susp recon, 50 mg tablet)

2-generic

voriconazole 200 mg vial 5-INJECTABLE

Antigout Agents - Drugs to treat or prevent gout

Antigout Agentsallopurinol (300 mg, 100 mg) 1-preferred

generic

colchicine/probenecid 2-generic

COLCRYS 3-PREF. BRAND QL (60 PER 30 DAYS)

probenecid 2-generic

ULORIC 4-BRAND PA

Antimigraine Agents - Drugs to treat or prevent migraines

Ergot AlkaloidsDIHYDROERGOTAMINE MESYLATE (1MG/ML AMPUL, 1 MG/ML VIAL)

5-INJECTABLE

migergot 2-generic


20



MIGRANAL 4-BRAND QL (21 ML PER 30 DAYS)

Serotonin (5-HT) 1b/1d Receptor Agonistsnaratriptan hcl 2-generic QL (9 PER 30 DAYS)

rizatriptan benzoate (10 mg tablet, 10 2-generic QL (12 PER 30 DAYS)mg tab rapdis)

rizatriptan benzoate (5 mg tablet, 5 mg 2-generic QL (9 PER 30 DAYS)tab rapdis)

sumatriptan succinate (50 mg, 100 mg, 2-generic QL (9 PER 30 DAYS)25 mg)

SUMATRIPTAN SUCCINATE (6 PEN 5-INJECTABLE QL (4 ML PER 30 DAYS)INJCTR, 6 SYRINGE, 6 CARTRIDGE, 6VIAL)

zolmitriptan (5 mg tab rapdis, 2.5 mg 2-generic ST, QL (9 PER 30 DAYS)tab rapdis, 5 mg tablet, 2.5 mg tablet)

Antimyasthenic Agents – Drugs to treat Myasthenia Gravis

Parasympathomimeticsguanidine hcl 2-generic

MESTINON (180 MG TIMESPAN, 60 3-PREF. BRANDMG/5 ML SYRUP)

pyridostigmine bromide 60 mg tablet 2-generic

Antimycobacterials - Drugs to treat tuberculosis

Antimycobacterials, Otherdapsone (100 mg, 25 mg) 2-generic

rifabutin 2-generic

AntitubercularsCAPASTAT SULFATE 5-INJECTABLE

ethambutol hcl 2-generic

isoniazid (50 mg/5 ml solution, 300 mg 2-generictablet, 100 mg tablet)

isoniazid 100 mg/ml vial 5-INJECTABLE

PASER 4-BRAND


21



PRIFTIN 4-BRAND

pyrazinamide 2-generic

rifampin (150 mg, 300 mg) 2-generic

rifampin 600 mg vial 5-INJECTABLE

RIFATER 4-BRAND

SIRTURO 6-Specialty LA

TRECATOR 4-BRAND

Antineoplastics - Drugs to treat cancer

Alkylating AgentsCEENU 4-BRAND

CYCLOPHOSPHAMIDE CAPSULES (25MG, 50 MG)

3-PREF. BRAND PA TO CONFIRM PART D COVERAGE

cyclophosphamide tablets (25 mg, 50mg)


HEXALEN 6-Specialty

LEUKERAN 3-PREF. BRAND

lomustine 4-BRAND

MATULANE 6-Specialty

Antiandrogensbicalutamide 2-generic

flutamide 2-generic

NILANDRON 3-PREF. BRAND

XTANDI 6-Specialty PA FOR NEW STARTS ONLY, LA

ZYTIGA 6-Specialty PA FOR NEW STARTS ONLY

Antiangiogenic AgentsPOMALYST 6-Specialty PA FOR NEW STARTS ONLY

REVLIMID 6-Specialty PA FOR NEW STARTS ONLY, LA

THALOMID 6-Specialty

Antiestrogens/ModifiersEMCYT 4-BRAND


22



FARESTON 4-BRAND

SOLTAMOX 4-BRAND

tamoxifen citrate (10 mg, 20 mg) 1-preferredgeneric

AntimetabolitesADRUCIL 5-INJECTABLE

DROXIA 4-BRAND

FLUOROURACIL (2.5 G/50ML, 1 G/20ML, 5 G/100 ML, 500MG/10ML)

5-INJECTABLE

hydroxyurea 500 mg capsule 2-generic

mercaptopurine 50 mg tablet 2-generic

tabloid 2-generic

Antineoplastics, OtherALIMTA 6-Specialty

amifostine crystalline 5-INJECTABLE

azacitidine 6-Specialty PA FOR NEW STARTS ONLY

bleomycin sulfate 5-INJECTABLE

ELITEK 6-Specialty

FASLODEX 6-Specialty PA FOR NEW STARTS ONLY

IXEMPRA 6-Specialty PA FOR NEW STARTS ONLY

leucovorin calcium (10 mg, 5 mg, 25mg, 15 mg)

2-generic

LEUCOVORIN CALCIUM (100 MG,500MG/50ML, 500 MG, 50 MG, 200MG, 10 MG/ML, 350 MG)

5-INJECTABLE

mitoxantrone hcl 5-INJECTABLE

PROLEUKIN 6-Specialty

TRISENOX 5-INJECTABLE

VELCADE 6-Specialty PA FOR NEW STARTS ONLY

ZOLINZA 6-Specialty PA FOR NEW STARTS ONLY

Antineoplastics, otherSYNRIBO 6-Specialty PA FOR NEW STARTS ONLY


23



Aromatase Inhibitors, 3rd Generationanastrozole 1 mg tablet 2-generic

exemestane 2-generic

letrozole 2.5 mg tablet 2-generic

Enzyme Inhibitorsetoposide 20 mg/ml vial 5-INJECTABLE

TOPOSAR 5-INJECTABLE

TOPOTECAN HCL (4 MG/4 ML, 4 MG) 5-INJECTABLE

Molecular Target InhibitorsAFINITOR 6-Specialty PA FOR NEW STARTS ONLY

AFINITOR DISPERZ 6-Specialty PA FOR NEW STARTS ONLY

BOSULIF 6-Specialty PA FOR NEW STARTS ONLY

CAPRELSA 6-Specialty PA FOR NEW STARTS ONLY

COMETRIQ 6-Specialty PA FOR NEW STARTS ONLY

ERIVEDGE 6-Specialty PA FOR NEW STARTS ONLY, LA

GILOTRIF 6-Specialty PA FOR NEW STARTS ONLY, LA

GLEEVEC 6-Specialty PA FOR NEW STARTS ONLY

IMBRUVICA 6-Specialty PA FOR NEW STARTS ONLY, LA

INLYTA 6-Specialty PA FOR NEW STARTS ONLY, LA

JAKAFI 6-Specialty PA FOR NEW STARTS ONLY, LA

MEKINIST 6-Specialty PA FOR NEW STARTS ONLY

NEXAVAR 6-Specialty PA FOR NEW STARTS ONLY

SPRYCEL 6-Specialty PA FOR NEW STARTS ONLY

STIVARGA 6-Specialty PA FOR NEW STARTS ONLY

SUTENT (50 MG, 12.5 MG, 25 MG) 6-Specialty PA FOR NEW STARTS ONLY

TAFINLAR 6-Specialty PA FOR NEW STARTS ONLY

TARCEVA 6-Specialty PA FOR NEW STARTS ONLY

TASIGNA 6-Specialty PA FOR NEW STARTS ONLY

TYKERB 6-Specialty PA FOR NEW STARTS ONLY

vandetanib 6-Specialty PA FOR NEW STARTS ONLY


24



VOTRIENT 6-Specialty PA FOR NEW STARTS ONLY

XALKORI 6-Specialty PA FOR NEW STARTS ONLY, LA

ZELBORAF 6-Specialty PA FOR NEW STARTS ONLY

ZYKADIA 6-Specialty PA FOR NEW STARTS ONLY, LA

Monoclonal AntibodiesAVASTIN 6-Specialty PA FOR NEW STARTS ONLY

RITUXAN 6-Specialty PA FOR NEW STARTS ONLY

RetinoidsPANRETIN 6-Specialty

TARGRETIN (75 MG SOFTGEL, 1% GEL,75 MG CAPSULE)

6-Specialty PA FOR NEW STARTS ONLY

tretinoin 10 mg capsule 6-Specialty PA FOR NEW STARTS ONLY

Antiparasitics - Drugs to treat parasites

AnthelminticsALBENZA 4-BRAND

STROMECTOL 3-PREF. BRAND

AntiprotozoalsALINIA 100 MG/5 ML SUSPENSION 4-BRAND

ALINIA 500 MG TABLET 3-PREF. BRAND

atovaquone 6-Specialty

chloroquine phosphate (500 mg, 250mg)

2-generic

DARAPRIM 4-BRAND

hydroxychloroquine sulfate 200 mgtablet

2-generic

mefloquine hcl 2-generic

NEBUPENT 4-BRAND PA TO CONFIRM PART D COVERAGE

PENTAM 300 5-INJECTABLE

primaquine phosphate 2-generic

Pediculicides/Scabicides


25



elimite 2-generic

lindane 2-generic

permethrin 5 % cream (g) 2-generic

ULESFIA 4-BRAND

Antiparkinson Agents - Drugs to treat Parkinsonism

Anticholinergicsbenztropine mesylate (1 mg, 2 mg, 0.5 2-genericmg)

PA

trihexyphenidyl hcl (2 mg/5 ml elixir, 2 2-genericmg tablet, 5 mg tablet)

PA

Antiparkinson Agents, Otheramantadine hcl (100 mg tablet, 50 2-genericmg/5 ml syrup, 100 mg capsule)

carbidopa/levodopa/entacapone 2-generic

entacapone 2-generic

STALEVO 75 4-BRAND

Dopamine AgonistsAPOKYN 6-Specialty PA, LA

bromocriptine mesylate (2.5 mg tablet, 2-generic5 mg capsule)

pramipexole di-hcl 2-generic

ropinirole hcl (3 mg, 1 mg, 5 mg, 0.5 2-genericmg, 4 mg, 0.25 mg, 2 mg)

Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitorscarbidopa 25 mg tablet 2-generic

carbidopa/levodopa 2-generic

Monoamine Oxidase B (MAO-B) InhibitorsAZILECT 3-PREF. BRAND

selegiline hcl (5 mg tablet, 5 mg 2-genericcapsule)


26



Antipsychotics - Drugs used in psychotherapy

1st Generation/Typicalfluphenazine decanoate 25 mg/ml vial 5-INJECTABLE

fluphenazine hcl (2.5 mg/5ml elixir, 10mg tablet, 5 mg tablet, 2.5 mg tablet, 5mg/ml oral conc, 1 mg tablet)

2-generic

fluphenazine hcl 2.5 mg/ml vial 5-INJECTABLE

HALDOL DECANOATE 100 5-INJECTABLE

HALDOL DECANOATE 50 5-INJECTABLE

haloperidol (20 mg, 0.5 mg, 2 mg, 10mg, 1 mg, 5 mg)

2-generic

HALOPERIDOL DECANOATE (50 MG/MLVIAL, 100 MG/ML AMPUL, 50 MG/MLAMPUL, 100 MG/ML VIAL)

5-INJECTABLE

HALOPERIDOL LACTATE (5 MG/ML VIAL,5 MG/ML AMPUL)

5-INJECTABLE

haloperidol lactate 2 mg/ml oral conc 2-generic

loxapine succinate (10 mg, 5 mg, 50mg, 25 mg)

2-generic

ORAP 4-BRAND

perphenazine/amitriptyline hcl 2-generic PA FOR NEW STARTS ONLY AND FOR65 YEARS AND OLDER

thioridazine hcl (50 mg, 10 mg, 25 mg,100 mg)

2-generic PA FOR NEW STARTS ONLY

thiothixene 2-generic

trifluoperazine hcl 2-generic

2nd Generation/AtypicalFANAPT 4-BRAND PA FOR NEW STARTS ONLY

GEODON 20 MG/ML VIAL 5-INJECTABLE QL (6 PER 30 DAYS)

INVEGA 4-BRAND PA FOR NEW STARTS ONLY

INVEGA SUSTENNA 117 MG PREF SY 6-Specialty PA FOR NEW STARTS ONLY, QL (0.75ML PER 30 DAYS)

INVEGA SUSTENNA 156 MG PREF SY 6-Specialty PA FOR NEW STARTS ONLY, QL (1 MLPER 30 DAYS)


27



INVEGA SUSTENNA 234 MG PREF SY 6-Specialty PA FOR NEW STARTS ONLY, QL (1.5 MLPER 30 DAYS)

INVEGA SUSTENNA 39 MG PREF SYR 5-INJECTABLE PA FOR NEW STARTS ONLY, QL (0.25ML PER 30 DAYS)

INVEGA SUSTENNA 78 MG PREF SYR 5-INJECTABLE PA FOR NEW STARTS ONLY, QL (0.5 MLPER 30 DAYS)

LATUDA 4-BRAND PA FOR NEW STARTS ONLY, QL (30 PER30 DAYS)

olanzapine (20 mg tablet, 15 mg tabrapdis, 10 mg tab rapdis, 10 mg tablet,5 mg tablet, 2.5 mg tablet, 5 mg tabrapdis, 7.5 mg tablet, 20 mg tab rapdis,15 mg tablet)

2-generic

olanzapine 10 mg vial 5-INJECTABLE

quetiapine fumarate 2-generic

RISPERDAL CONSTA 5-INJECTABLE QL (4 PER 30 DAYS)

risperidone (2 mg tablet, 1 mg tabrapdis, 4 mg tab rapdis, 4 mg tablet, 1mg/ml solution, 0.25 mg tablet, 2 mgtab rapdis, 0.25 mg tab rapdis, 3 mg tabrapdis, 3 mg tablet, 1 mg tablet, 0.5 mgtab rapdis, 0.5 mg tablet)

2-generic

SAPHRIS 4-BRAND PA FOR NEW STARTS ONLY

ziprasidone hcl 2-generic

Treatment-Resistantclozapine (50 mg, 200 mg, 25 mg, 100mg)

2-generic

FAZACLO 4-BRAND

VERSACLOZ 4-BRAND

Antispasticity Agents - Drugs to treat muscle spasms

Antispasticity Agentsbaclofen (20 mg, 10 mg) 2-generic

dantrolene sodium (100 mg, 50 mg, 25mg)

2-generic

tizanidine hcl (4 mg, 2 mg) 2-generic


28



Antivirals - Drugs to treat viral infections

Anti-HIV Agents, Integrase Inhibitors (INSTI)ATRIPLA 6-Specialty

ISENTRESS (100 MG POWDER PACKET, 3-PREF. BRAND25 MG TABLET CHEW)

ISENTRESS (400 MG, 100 MG CHEW) 6-Specialty

STRIBILD 6-Specialty

TIVICAY 4-BRAND

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors (NNRTI)COMPLERA 6-Specialty

EDURANT 6-Specialty

INTELENCE (200 MG, 100 MG) 6-Specialty

INTELENCE 25 MG TABLET 3-PREF. BRAND

nevirapine (50 mg/5 ml oral susp, 200 2-genericmg tablet, 400 mg tab er 24h)

RESCRIPTOR 3-PREF. BRAND

SUSTIVA 3-PREF. BRAND

VIRAMUNE XR 3-PREF. BRAND

Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTI)abacavir sulfate 2-generic

abacavir sulfate/lamivudine/zidovudine 2-generic

didanosine 2-generic

EMTRIVA (10 MG/ML SOLUTION, 200 3-PREF. BRANDMG CAPSULE)

EPIVIR 10 MG/ML ORAL SOLN 3-PREF. BRAND

EPZICOM 6-Specialty

lamivudine (300 mg, 150 mg) 2-generic

lamivudine/zidovudine 2-generic

RETROVIR 10 MG/ML VIAL 5-INJECTABLE

stavudine (30 mg capsule, 40 mg 2-genericcapsule, 15 mg capsule, 20 mg capsule,


29



1 mg/ml soln recon)

TRUVADA 6-Specialty

VIDEX 3-PREF. BRAND

VIREAD (POWDER, 300 MG TABLET, 200MG TABLET, 150 MG TABLET, 250 MGTABLET)

6-Specialty

ZIAGEN 20 MG/ML SOLUTION 3-PREF. BRAND

zidovudine (10 mg/ml syrup, 300 mgtablet, 100 mg capsule)

2-generic

Anti-HIV Agents, OtherFUZEON 6-Specialty

SELZENTRY 6-Specialty

Anti-HIV Agents, Protease InhibitorsAPTIVUS (100 MG/ML SOLUTION, 250MG CAPSULE)

6-Specialty

CRIXIVAN 3-PREF. BRAND

INVIRASE 6-Specialty

KALETRA (400-100/5 ML ORAL SOLU,200-50 MG TABLET)

6-Specialty

KALETRA 100-25 MG TABLET 3-PREF. BRAND

LEXIVA 50 MG/ML SUSPENSION 3-PREF. BRAND

LEXIVA 700 MG TABLET 6-Specialty

NORVIR (80 MG/ML SOLUTION, 100 MGTABLET, 100 MG SOFTGEL CAP)

3-PREF. BRAND

PREZISTA (150 MG, 75 MG) 3-PREF. BRAND

PREZISTA (600 MG TABLET, 100 MG/MLSUSPENSION, 800 MG TABLET)

6-Specialty

REYATAZ (200 MG, 300 MG, 150 MG) 6-Specialty

VIRACEPT 3-PREF. BRAND

Anti-cytomegalovirus (CMV) Agentsfoscarnet sodium 24 mg/ml infus. btl 5-INJECTABLE

ganciclovir sodium 5-INJECTABLE


30



VALCYTE (450 MG TABLET, 50 MG/ML 6-SpecialtySOLUTION)

ZIRGAN 3-PREF. BRAND

Anti-hepatitis B (HBV) Agentsadefovir dipivoxil 6-Specialty

BARACLUDE (0.5 MG, 1 MG) 6-Specialty PA

BARACLUDE 0.05 MG/ML SOLUTION 4-BRAND PA

EPIVIR HBV 25 MG/5 ML SOLN 3-PREF. BRAND

lamivudine 100 mg tablet 2-generic

TYZEKA 6-Specialty PA

Anti-hepatitis B (HBV) Agents/Anti-hepatitis C (HCV) AgentsINTRON A (6 UNIT/ML VL, 10 UNIT/ML, 6-Specialty PA10 UNITS VIL)

PEGASYS (180 MCG/ML VIAL, 180 6-Specialty PAMCG/0.5 ML SYRINGE)

PEGASYS PROCLICK 6-Specialty PA

PEGINTRON 6-Specialty PA

PEGINTRON REDIPEN 6-Specialty PA

SYLATRON 6-Specialty PA FOR NEW STARTS ONLY

SYLATRON 4-PACK 6-Specialty PA FOR NEW STARTS ONLY

Anti-hepatitis C (HCV) AgentsINCIVEK 6-Specialty PA

moderiba (600-600 mg dosepack, 400- 2-generic PA400 mg dosepack, 200 mg tablet)

OLYSIO 6-Specialty PA

REBETOL 40 MG/ML SOLUTION 6-Specialty PA

RIBAPAK (600-600 MG, 400-600 MG, 6-Specialty PA400-400 MG, 600-400 MG)

ribasphere (200 mg tablet, 200 mg 2-generic PAcapsule)

RIBASPHERE 400 MG TABLET 4-BRAND PA

RIBASPHERE 600 MG TABLET 6-Specialty PA


31



RIBATAB 6-Specialty PA

ribavirin (200 mg capsule, 200 mgtablet)

2-generic PA

ribavirin 400 mg tablet 4-BRAND PA

ribavirin 600 mg tablet 6-Specialty PA

SOVALDI 6-Specialty PA

VICTRELIS 6-Specialty PA

Anti-influenza AgentsRELENZA 3-PREF. BRAND

rimantadine hcl 2-generic

TAMIFLU (6 MG/ML SUSPENSION, 45MG GELCAP, 30 MG GELCAP, 75 MGCAPSULE)

3-PREF. BRAND

Antiherpetic Agentsacyclovir (200 mg capsule, 400 mgtablet, 800 mg tablet, 200 mg/5ml oralsusp)

2-generic

ACYCLOVIR SODIUM (500 MG, 50MG/ML, 1000 MG)

5-INJECTABLE

famciclovir 2-generic

trifluridine 1 % drops 2-generic

valacyclovir hcl (500 mg, 1000 mg) 2-generic

Antivirals, OtherSYNAGIS 6-Specialty

Anxiolytics - Drugs to treat anxiety

Anxiolytics, Otherbuspirone hcl (5 mg, 30 mg, 7.5 mg, 10mg, 15 mg)

1-preferredgeneric

Benzodiazepineslorazepam (0.5 mg tablet, 1 mg tablet,2 mg/ml oral conc, 2 mg tablet)

2-generic PA FOR NEW STARTS ONLY AND FOR65 YEARS AND OLDER

lorazepam intensol 2-generic PA FOR NEW STARTS ONLY AND FOR


32



65 YEARS AND OLDER

oxazepam 2-generic PA FOR NEW STARTS ONLY AND FOR65 YEARS AND OLDER

Bipolar Agents - Drugs to treat bipolar disorders

Mood Stabilizerslithium carbonate (300 mg tablet er,300 mg tablet, 300 mg capsule, 600 mgcapsule, 150 mg capsule, 450 mg tableter)

1-preferredgeneric

lithium citrate 2-generic

Blood Glucose Regulators - Drugs to treat diabetes

Antidiabetic Agentsacarbose 2-generic

BYDUREON 5-INJECTABLE PA

BYDUREON PEN 5-INJECTABLE PA

BYETTA 5-INJECTABLE PA

CYCLOSET 4-BRAND PA, QL (180 PER 30 DAYS)

FARXIGA 4-BRAND PA

glimepiride 1-preferredgeneric

glipizide (10 mg er 24, 5 mg er 24, 2.5mg er 24)

2-generic

glipizide (5 mg, 10 mg) 1-preferredgeneric

glipizide/metformin hcl 2-generic

INVOKANA 4-BRAND PA

JANUMET 4-BRAND PA

JANUMET XR 4-BRAND PA

JANUVIA 4-BRAND PA

JENTADUETO 4-BRAND PA

KAZANO 4-BRAND PA


33



KOMBIGLYZE XR 4-BRAND PA

metformin hcl (850 mg tablet, 750 mgtab er 24h, 1000 mg tablet, 500 mg taber 24, 500 mg tablet, 500 mg tab er24h)

1-preferredgeneric

nateglinide 2-generic

NESINA 4-BRAND PA

ONGLYZA 4-BRAND PA

OSENI 4-BRAND PA

pioglitazone hcl 2-generic

pioglitazone hcl/glimepiride 2-generic

pioglitazone hcl/metformin hcl 2-generic

RIOMET 4-BRAND

SYMLINPEN 120 5-INJECTABLE PA, QL (10.8 ML PER 30 DAYS)

SYMLINPEN 60 5-INJECTABLE PA, QL (6 ML PER 30 DAYS)

tolbutamide 2-generic

TRADJENTA 4-BRAND PA

VICTOZA 2-PAK 5-INJECTABLE PA

VICTOZA 3-PAK 5-INJECTABLE PA

WELCHOL 4-BRAND PA

Glycemic AgentsGLUCAGEN 3-PREF. BRAND

GLUCAGON EMERGENCY KIT 3-PREF. BRAND QL (2 PER 30 DAYS)

PROGLYCEM 4-BRAND

InsulinsHUMALOG 3-PREF. BRAND

HUMALOG MIX 50-50 3-PREF. BRAND

HUMALOG MIX 75-25 3-PREF. BRAND

HUMULIN 70-30 3-PREF. BRAND

HUMULIN N 3-PREF. BRAND

HUMULIN R 100 UNITS/ML VIAL 3-PREF. BRAND


34



LANTUS 3-PREF. BRAND

LANTUS SOLOSTAR 3-PREF. BRAND

LEVEMIR 3-PREF. BRAND

LEVEMIR FLEXPEN 3-PREF. BRAND

LEVEMIR FLEXTOUCH 3-PREF. BRAND

Blood Products/Modifiers/Volume Expanders

AnticoagulantsELIQUIS 3-PREF. BRAND

ENOXAPARIN SODIUM (150 MG/ML,100 MG/ML)

6-Specialty QL (60 ML PER 30 DAYS)

enoxaparin sodium 120mg/.8ml syringe 6-Specialty QL (48 ML PER 30 DAYS)

enoxaparin sodium 30mg/0.3ml syringe 5-INJECTABLE QL (18 ML PER 30 DAYS)




fondaparinux sodium 10mg/0.8mlsyringe


fondaparinux sodium 2.5 mg/0.5syringe

5-INJECTABLE QL (15 ML PER 30 DAYS)

fondaparinux sodium 5mg/0.4mlsyringe


fondaparinux sodium 7.5mg/0.6 syringe 6-Specialty QL (18 ML PER 30 DAYS)

FRAGMIN (5,000, 2,500) 5-INJECTABLE QL (6 ML PER 30 DAYS)

FRAGMIN 10,000 UNITS SYRINGE 6-Specialty QL (30 ML PER 30 DAYS)



FRAGMIN 18,000 UNITS SYRINGE 6-Specialty QL (21.6 ML PER 30 DAYS)

FRAGMIN 25,000 UNITS/ML VIAL 6-Specialty QL (30.4 ML PER 30 DAYS)


HEPARIN SODIUM,PORCINE (20000/MLVIAL, 100/ML (1) SYRINGE, 100/MLVIAL, 5000/ML VIAL, 5000/ML(1)

5-INJECTABLE


35



CARTRIDGE, 500/5 ML SYRINGE,10000/ML VIAL)

heparin sodium,porcine 1000/ml vial 5-INJECTABLE PA TO CONFIRM PART D COVERAGE

heparin sodium,porcine/dextrose 5 % in 5-INJECTABLEwater

HEPARIN SODIUM,PORCINE/PF (500/5 5-INJECTABLEML SYRINGE, 100/ML (1) VIAL, 1000/10ML SYRINGE)

heparin sodium,porcine/pf 1000/ml vial 5-INJECTABLE PA TO CONFIRM PART D COVERAGE

jantoven 1-preferredgeneric

MONOJECT PREFILL ADVANCED (500 5-INJECTABLEUNIT/5 ML, 1,000 UNIT/10)

PRADAXA 3-PREF. BRAND

warfarin sodium (5 mg, 2.5 mg, 7.5 mg, 1-preferred1 mg, 2 mg, 10 mg, 6 mg, 3 mg, 4 mg) generic

XARELTO 3-PREF. BRAND

Blood Formation Modifiersanagrelide hcl 2-generic

ARANESP (40 MCG/ML VIAL, 40 5-INJECTABLE PAMCG/0.4 ML SYRINGE, 100 MCG/0.5 MLSYRINGE, 60 MCG/0.3 ML SYRINGE, 25MCG/0.42 ML SYRING, 25 MCG/MLVIAL, 60 MCG/ML VIAL)

ARANESP (500 MCG/1 ML SYRINGE, 150 6-Specialty PAMCG/0.3 ML SYRINGE, 300 MCG/0.6 MLSYRINGE, 100 MCG/ML VIAL, 300MCG/ML VIAL, 200 MCG/0.4 MLSYRINGE, 150 MCG/0.75 ML VIAL, 200MCG/ML VIAL)

EPOGEN (2,000 UNITS/ML, 10,000 5-INJECTABLE PAUNITS/ML, 3,000 UNITS/ML, 20,000UNITS/2 ML, 20,000 UNITS/ML, 4,000UNITS/ML)

EPOGEN 40,000 UNITS/ML VIAL 6-Specialty PA

GRANIX 6-Specialty

LEUKINE 250 MCG VIAL 6-Specialty PA

NEULASTA 6-Specialty QL (1.2 ML PER 28 DAYS)


36



NEUMEGA 6-Specialty PA

NEUPOGEN 6-Specialty

PROCRIT (10,000, 2,000, 3,000, 4,000) 5-INJECTABLE PA

PROCRIT (20,000, 40,000) 6-Specialty PA

PROMACTA 6-Specialty PA

CoagulantsTRANEXAMIC ACID (1000 VIAL, 1000AMPUL)

5-INJECTABLE

tranexamic acid 650 mg tablet 2-generic

Platelet Modifying AgentsAGGRENOX 3-PREF. BRAND

BRILINTA 4-BRAND

cilostazol 2-generic

clopidogrel bisulfate 75 mg tablet 1-preferredgeneric

EFFIENT 3-PREF. BRAND

Cardiovascular Agents - Drugs to treat blood pressure, cholesterol and the heart

Alpha-adrenergic Agonistsclonidine 2-generic

clonidine hcl (0.3 mg, 0.2 mg, 0.1 mg) 1-preferredgeneric

midodrine hcl 2-generic

Alpha-adrenergic Blocking Agentsdoxazosin mesylate 2-generic

prazosin hcl 2-generic

terazosin hcl 1-preferredgeneric

Angiotensin II Receptor Antagonistscandesartan cilexetil 2-generic

DIOVAN (40 MG, 160 MG, 80 MG) 4-BRAND ST


37



DIOVAN 320 MG TABLET 4-BRAND

eprosartan mesylate 2-generic

irbesartan 2-generic

irbesartan/hydrochlorothiazide 2-generic

losartan potassium 1-preferredgeneric

losartan potassium/hydrochlorothiazide 1-preferredgeneric

valsartan (80 mg, 40 mg, 160 mg) 2-generic ST

valsartan 320 mg tablet 2-generic

valsartan/hydrochlorothiazide 2-generic

Angiotensin-converting Enzyme (ACE) Inhibitorsbenazepril hcl (20 mg, 5 mg, 40 mg, 10 1-preferredmg) generic

benazepril hcl/hydrochlorothiazide 1-preferredgeneric

captopril (50 mg, 25 mg, 100 mg, 12.5 1-preferredmg) generic

captopril/hydrochlorothiazide 2-generic

enalapril maleate (5 mg, 20 mg, 2.5 mg, 1-preferred10 mg) generic

enalapril maleate/hydrochlorothiazide 1-preferredgeneric

EPANED 4-BRAND

fosinopril sodium 1-preferredgeneric

fosinopril sodium/hydrochlorothiazide 2-generic

lisinopril (10 mg, 30 mg, 40 mg, 2.5 mg, 1-preferred5 mg, 20 mg) generic

lisinopril/hydrochlorothiazide 1-preferredgeneric

moexipril hcl 2-generic

moexipril hcl/hydrochlorothiazide 2-generic

perindopril erbumine 2-generic


38



quinapril hcl 1-preferredgeneric

quinapril hcl/hydrochlorothiazide 2-generic

ramipril 1-preferredgeneric

trandolapril 2-generic

Antiarrhythmicsamiodarone hcl (200 mg, 400 mg) 2-generic

disopyramide phosphate 2-generic

flecainide acetate 2-generic

mexiletine hcl (150 mg, 200 mg, 250 2-genericmg)

MULTAQ 3-PREF. BRAND

NORPACE CR 3-PREF. BRAND

pacerone 200 mg tablet 2-generic

PROCAINAMIDE HCL (500 MG/ML, 100 5-INJECTABLEMG/ML)

propafenone hcl 2-generic

quinidine gluconate 324 mg tablet er 2-generic

quinidine gluconate 80 mg/ml vial 5-INJECTABLE

quinidine sulfate (300 mg er, 300 mg, 2-generic200 mg)

sorine 2-generic

sotalol hcl (240 mg, 160 mg, 120 mg, 80 2-genericmg)

TIKOSYN 3-PREF. BRAND

Beta-adrenergic Blocking Agentsacebutolol hcl (400 mg, 200 mg) 2-generic

atenolol (25 mg, 50 mg, 100 mg) 1-preferredgeneric

atenolol/chlorthalidone 1-preferredgeneric

betaxolol hcl (20 mg, 10 mg) 2-generic


39


bisoprolol fumarate 2-generic

bisoprolol 2-genericfumarate/hydrochlorothiazide

carvedilol 1-preferredgeneric

COREG CR 4-BRAND

labetalol hcl (100 mg, 200 mg, 300 mg) 2-generic

labetalol hcl 5 mg/ml vial 5-INJECTABLE

LEVATOL 4-BRAND

metoprolol succinate 2-generic

METOPROLOL TARTRATE (5 ML 5-INJECTABLESYRINGE, 5 ML AMPUL, 5 ML VIAL)

metoprolol tartrate (50 mg, 25 mg, 100 1-preferredmg) generic

metoprolol 2-generictartrate/hydrochlorothiazide

nadolol (20 mg, 80 mg, 40 mg) 2-generic

pindolol 2-generic

propranolol hcl (60 mg, 80 mg, 120 mg, 2-generic160 mg)

propranolol hcl (80 mg tablet, 60 mg 1-preferredtablet, 10 mg tablet, 20 mg/5 ml genericsolution, 40 mg tablet, 20 mg tablet,40mg/5ml solution)

propranolol hcl 1 mg/ml vial 5-INJECTABLE

propranolol hcl/hydrochlorothiazide 2-generic

timolol maleate (10 mg, 20 mg, 5 mg) 2-generic

Calcium Channel Blocking Agentsafeditab cr 2-generic

amlodipine besylate (5 mg, 2.5 mg, 10 1-preferredmg) generic

amlodipine besylate/benazepril hcl 2-generic

cartia xt 2-generic

dilt-cd 2-generic



40



dilt-xr 2-generic

diltia xt 2-generic

diltiazem hcl (120 mg cap er 12h, 300 2-genericmg capsule er, 180 mg cap er 24h, 180mg capsule er, 180 mg tab er 24h,420mg tab er 24h, 420mg capsule er,120 mg cap er 24h, 60 mg cap er 12h,300 mg tab er 24h, 240 mg tab er 24h,360 mg cap er 24h, 240 mg cap er deg,300 mg cap er 24h, 240 mg cap er 24h,90 mg cap er 12h, 360 mg capsule er,120 mg cap er deg, 120 mg capsule er,240 mg capsule er, 360 mg tab er 24h,180 mg cap er deg)

DILTIAZEM HCL (5 MG/ML, 100 MG 5-INJECTABLEPORT)

diltiazem hcl (60 mg, 90 mg, 30 mg, 120 1-preferredmg) generic

diltzac er 2-generic

felodipine 2-generic

isradipine 2-generic

matzim la 2-generic

nicardipine hcl (20 mg, 30 mg) 2-generic

nifediac cc 2-generic

nifedical xl 2-generic

nifedipine (60 mg tablet er, 30 mg tab 2-genericer 24, 60 mg tab er 24, 30 mg tablet er,90 mg tab er 24, 90 mg tablet er)

nimodipine 30 mg capsule 2-generic

nisoldipine 2-generic

taztia xt 2-generic

verapamil hcl (300 mg cap24h pct, 120 2-genericmg tablet er, 240 mg cap24h pel, 200mg cap24h pct, 240 mg tablet er, 180mg tablet er, 180 mg cap24h pel, 120mg cap24h pel, 360 mg cap24h pel, 100mg cap24h pct)

verapamil hcl (40 mg, 80 mg, 120 mg) 1-preferredgeneric


41



Cardiovascular Agents, OtherDEMSER 6-Specialty

digox 2-generic

digoxin (125 mcg tablet, 50 mcg/ml 2-genericsolution, 250 mcg tablet)

DIGOXIN (250 MCG/ML AMPUL, 250 5-INJECTABLEMCG/ML SYRINGE)

pentoxifylline 400 mg tablet er 2-generic

RANEXA 3-PREF. BRAND

Diuretics, Carbonic Anhydrase Inhibitorsacetazolamide (125 mg tablet, 500 mg 2-genericcapsule er, 250 mg tablet)

acetazolamide sodium 5-INJECTABLE

methazolamide (50 mg, 25 mg) 2-generic

Diuretics, Loopbumetanide (1 mg, 0.5 mg, 2 mg) 2-generic

EDECRIN 4-BRAND

furosemide (80 mg tablet, 20 mg tablet, 1-preferred40 mg tablet, 10 mg/ml solution, generic40mg/5ml solution)

furosemide 10 mg/ml vial 5-INJECTABLE

torsemide (5 mg, 10 mg, 20 mg, 100 2-genericmg)

Diuretics, Potassium-sparingamiloride hcl 5 mg tablet 2-generic

amiloride hcl/hydrochlorothiazide 2-generic

DYRENIUM 3-PREF. BRAND

eplerenone 2-generic

spironolactone (50 mg, 100 mg, 25 mg) 1-preferredgeneric

spironolactone/hydrochlorothiazide 1-preferredgeneric

triamterene/hydrochlorothiazide 1-preferred


42



generic

Diuretics, Thiazidechlorothiazide 2-generic

chlorthalidone 1-preferredgeneric

hydrochlorothiazide (12.5 mg capsule, 1-preferred50 mg tablet, 12.5 mg tablet, 25 mg generictablet)

indapamide 2-generic

metolazone 2-generic

Dyslipidemics, Fibric Acid Derivativesfenofibrate (54 mg, 160 mg) 2-generic

fenofibrate nanocrystallized 2-generic

fenofibrate,micronized (67 mg, 134mg, 2-generic200 mg)

fenofibric acid (choline) 2-generic

gemfibrozil 600 mg tablet 2-generic

lofibra 2-generic

Dyslipidemics, HMG CoA Reductase Inhibitorsatorvastatin calcium 1-preferred

generic

fluvastatin sodium 2-generic

lovastatin 2-generic

pravastatin sodium 1-preferredgeneric

simvastatin (20 mg, 5 mg, 10 mg) 1-preferredgeneric

simvastatin 40 mg tablet 1-preferred QL (1 PER DAY)generic

simvastatin 80 mg tablet 2-generic PA

Dyslipidemics, Othercholestyramine (with sugar) 4 g powd 2-genericpack


43



cholestyramine/aspartame (4 powd 2-genericpack, 4 powder)

colestipol hcl (5 packet, 1 tablet, 5 2-genericranules)

JUXTAPID 6-Specialty PA, LA

KYNAMRO 6-Specialty PA, LA

prevalite (packet, powder) 2-generic

VASCEPA 4-BRAND PA

Vasodilators, Direct-acting Arterialhydralazine hcl (50 mg, 10 mg, 25 mg, 2-generic100 mg)

minoxidil (10 mg, 2.5 mg) 2-generic

Vasodilators, Direct-acting Arterial/Venousisochron 2-generic

isosorbide dinitrate (5 mg, 10 mg, 20 1-preferredmg, 30 mg) generic

isosorbide dinitrate 40 mg tablet er 2-generic

isosorbide mononitrate 1-preferredgeneric

minitran 2-generic

NITRO-DUR (0.8, 0.3) 3-PREF. BRAND

nitroglycerin (0.2mg/hr patch td24, 2-generic0.6mg/hr patch td24, 400mcg/sprspray, 0.4mg/hr patch td24, 0.1mg/hrpatch td24)

NITROSTAT 3-PREF. BRAND

Central Nervous System Agents - Drugs that affect the brain

Attention Deficit Hyperactivity Disorder Agents, Amphetaminesdextroamphetamine sulf- 2-generic PA FOR 65 YEARS AND OLDER, QL (30saccharate/amphetamine sulf- PER 30 DAYS)aspartate (10 mg er, 30 mg er, 15 mger, 5 mg er, 25 mg er)

dextroamphetamine sulf- 2-generic PA FOR 65 YEARS AND OLDERsaccharate/amphetamine sulf-


44



aspartate (30 mg, 20 mg, 7.5 mg, 10mg, 12.5 mg, 5 mg, 15 mg)

dextroamphetamine sulfate (15 mg 2-generic PA FOR 65 YEARS AND OLDERcapsule er, 5 mg tablet, 5 mg capsuleer, 10 mg tablet, 10 mg capsule er)

dextroamphetamine/amphetamine 20 2-generic PA FOR 65 YEARS AND OLDER, QL (60mg cap er 24h PER 30 DAYS)

VYVANSE 4-BRAND PA FOR 65 YEARS AND OLDER, QL (30PER 30 DAYS)

zenzedi (5 mg, 10 mg) 2-generic PA FOR 65 YEARS AND OLDER

Attention Deficit Hyperactivity Disorder Agents, Non-amphetaminesclonidine hcl 0.1 mg tab er 12h 2-generic PA

DAYTRANA 4-BRAND PA, QL (30 PER 30 DAYS)

dexmethylphenidate hcl (5 mg, 10 mg, 2-generic PA FOR 65 YEARS AND OLDER2.5 mg)

metadate er 2-generic PA FOR 65 YEARS AND OLDER

methylphenidate hcl (10 mg, 5 mg, 20 2-generic PA FOR 65 YEARS AND OLDERmg er, 20 mg)

methylphenidate hcl (30 mg cpbp 50- 2-generic PA FOR 65 YEARS AND OLDER, QL (6050, 36 mg tab er 24, 30 mg cpbp 30-70) PER 30 DAYS)

methylphenidate hcl (54 mg tab er 24, 2-generic PA FOR 65 YEARS AND OLDER, QL (3027 mg tab er 24, 20 mg cpbp 30-70, 18 PER 30 DAYS)mg tab er 24, 50 mg cpbp 30-70, 40 mgcpbp 30-70, 60 mg cpbp 30-70, 10 mgcpbp 30-70, 40 mg cpbp 50-50, 20 mgcpbp 50-50)

STRATTERA 4-BRAND PA, QL (30 PER 30 DAYS)

Central Nervous System, OtherNUEDEXTA 3-PREF. BRAND PA

riluzole 2-generic

XENAZINE 6-Specialty PA, LA

Fibromyalgia AgentsSAVELLA (50 MG, 100 MG, 25 MG, 12.5 3-PREF. BRAND PA, QL (60 PER 30 DAYS)MG)

SAVELLA TITRATION PACK 3-PREF. BRAND PA, QL (55 PER 28 DAYS)


45



Multiple Sclerosis AgentsAMPYRA 6-Specialty PA, LA, QL (60 PER 30 DAYS)

AUBAGIO 6-Specialty PA, QL (30 PER 30 DAYS)

AVONEX 6-Specialty

AVONEX ADMINISTRATION PACK 6-Specialty

AVONEX PEN 6-Specialty

BETASERON 6-Specialty PA, QL (15 PER 30 DAYS)

COPAXONE 20 MG INJECTION KIT 6-Specialty QL (30 PER 30 DAYS)

COPAXONE 40 MG/ML SYRINGE 6-Specialty QL (12 ML PER 28 DAYS)

EXTAVIA 6-Specialty PA, QL (15 PER 30 DAYS)

GILENYA 6-Specialty PA, QL (30 PER 30 DAYS)

REBIF 6-Specialty QL (6 ML PER 30 DAYS)

REBIF REBIDOSE 6-Specialty QL (6 ML PER 30 DAYS)

TECFIDERA 6-Specialty QL (60 PER 30 DAYS)

TYSABRI 6-Specialty PA

Dental and Oral Agents

Dental and Oral Agentschlorhexidine gluconate 0.12 %mouthwash

2-generic

oralone 2-generic

paroex 2-generic

periogard 2-generic

pilocarpine hcl (7.5 mg, 5 mg) 2-generic

triamcinolone acetonide 0.1 % paste (g) 2-generic

Dermatological Agents - Drugs to treat skin conditions

Dermatological Agentsacitretin 2-generic

adapalene (0.1 gel (gram), 0.1 cream(g))

2-generic


46



ammonium lactate (12 lotion, 12 cream(g))

2-generic

amnesteem 2-generic

calcipotriene (0.005 cream (g), 0.005oint. (g), 0.005 solution)

2-generic

calcitrene 2-generic

CARAC 3-PREF. BRAND

claravis 2-generic

clotrimazole/betamethasonedipropionate (1 -0.05 lotion, 1 -0.05cream (g))

2-generic

ELIDEL 4-BRAND PA

erythromycin base/benzoyl peroxide 2-generic

fluorouracil (5 solution, 2 solution, 5cream (g))

2-generic

imiquimod 5 % cream pack 2-generic

laclotion 2-generic

methoxsalen, rapid 6-Specialty

myorisan 2-generic

OXSORALEN-ULTRA 6-Specialty

PICATO 4-BRAND PA

podofilox 0.5 % solution 2-generic

PROTOPIC 4-BRAND PA

refissa 2-generic

REGRANEX 4-BRAND PA

SANTYL 3-PREF. BRAND QL (30 GM PER 30 DAYS)

selenium sulfide 2.5 % suspension 2-generic

TAZORAC 3-PREF. BRAND

tretinoin (0.05 cream (g), 0.1 cream (g),0.025 gel (gram), 0.025 cream (g), 0.01gel (gram))

2-generic

tretinoin/emollient base 2-generic


47



Enzyme Replacement/Modifiers

Enzyme Replacement/ModifiersADAGEN 6-Specialty LA

ALDURAZYME 6-Specialty

CARBAGLU 6-Specialty

CEREZYME 6-Specialty

CREON 3-PREF. BRAND

CYSTADANE 4-BRAND

CYSTAGON 4-BRAND LA

CYSTARAN 6-Specialty PA, LA, QL (60 ML PER 30 DAYS)

ELAPRASE 6-Specialty

ELELYSO 6-Specialty

FABRAZYME 6-Specialty

KUVAN 100 MG TABLET 6-Specialty PA, LA

LUMIZYME 6-Specialty PA

MYOZYME 6-Specialty PA

NAGLAZYME 6-Specialty PA, LA

ORFADIN 6-Specialty LA

RAVICTI 6-Specialty LA

sodium phenylbutyrate 0.94 g/g powder 6-Specialty

SUCRAID 6-Specialty LA

ZAVESCA 6-Specialty LA

ZENPEP 3-PREF. BRAND

Gastrointestinal Agents - Drugs to treat acid, digestion and bowel conditions

Antispasmodics, Gastrointestinalglycopyrrolate (1 mg, 2 mg) 2-generic

glycopyrrolate 0.2 mg/ml vial 5-INJECTABLE

methscopolamine bromide (2.5 mg, 5mg)

2-generic


48



Gastrointestinal Agents, OtherFULYZAQ 4-BRAND PA

GATTEX 6-Specialty PA, LA

lansoprazole/amoxicillin 2-generictrihydrate/clarithromycin

loperamide hcl 2 mg capsule 2-generic

PYLERA 4-BRAND

RELISTOR (12 ML KIT, 12 ML VIAL) 4-BRAND PA, QL (18 ML PER 30 DAYS)

ursodiol (250 mg tablet, 300 mg 2-genericcapsule, 500 mg tablet)

Histamine2 (H2) Receptor Antagonistscimetidine (300 mg, 800 mg, 200 mg, 2-generic400 mg)

cimetidine hcl 2-generic

famotidine (20 mg, 40 mg) 1-preferredgeneric

famotidine 40mg/5ml oral susp 2-generic

famotidine in sodium chloride, iso- 5-INJECTABLEosmotic/pf

nizatidine (150mg/10ml solution, 300 2-genericmg capsule, 150 mg capsule)

ranitidine hcl (150 mg capsule, 300 mg 1-preferredtablet, 300 mg capsule, 150 mg tablet) generic

RANITIDINE HCL (25 MG/ML, 50 MG/2 5-INJECTABLEML)

ranitidine hcl 15 mg/ml syrup 2-generic

Irritable Bowel Syndrome AgentsAMITIZA 4-BRAND

LOTRONEX 3-PREF. BRAND

Laxativesconstulose 2-generic

enulose 2-generic

gavilyte-c 2-generic


49



gavilyte-g 2-generic

gavilyte-n 2-generic

generlac 2-generic

lactulose 2-generic

MOVIPREP 4-BRAND

peg 3350/na sulf,bicarb,cl/kcl 240-22.72g soln recon

2-generic

polyethylene glycol 3350 (3350 17gpowd pack, 3350 powder, 335017g/dose powder)

2-generic

sodium chloride/sodiumbicarbonate/potassium chloride/peg

2-generic

SUPREP 4-BRAND

trilyte with flavor packets 2-generic

ProtectantsCARAFATE 1 GM/10 ML SUSP 3-PREF. BRAND

misoprostol (200 mcg, 100 mcg) 2-generic

sucralfate 1 g tablet 2-generic

Proton Pump Inhibitorslansoprazole (15 mg, 30 mg) 2-generic QL (60 PER 30 DAYS)

omeprazole (10 mg, 40 mg, 20 mg) 1-preferredgeneric

QL (60 PER 30 DAYS)

omeprazole magnesium 1-preferredgeneric

QL (60 PER 30 DAYS)

pantoprazole sodium (20 mg, 40 mg) 2-generic QL (60 PER 30 DAYS)

pantoprazole sodium 40 mg vial 5-INJECTABLE

PROTONIX 40 MG SUSPENSION 3-PREF. BRAND

rabeprazole sodium 2-generic

Genitourinary Agents - Drugs to treat genitourinary conditions

Antispasmodics, Urinaryflavoxate hcl 2-generic


50



MYRBETRIQ 4-BRAND PA

oxybutynin chloride (10 mg tab er 24, 5mg tablet, 5 mg tab er 24, 15 mg tab er24)

2-generic

OXYTROL 3-PREF. BRAND

tolterodine tartrate (1 mg, 2 mg) 2-generic

tolterodine tartrate (4 mg er, 2 mg er) 2-generic QL (30 PER 30 DAYS)

trospium chloride 20 mg tablet 2-generic

Benign Prostatic Hypertrophy Agentsalfuzosin hcl 2-generic

finasteride 5 mg tablet 2-generic

tamsulosin hcl 2-generic

Genitourinary Agents, Otherbethanechol chloride (5 mg, 25 mg, 10mg, 50 mg)

2-generic

DEPEN 4-BRAND

ELMIRON 3-PREF. BRAND

methylergonovine maleate 0.2 mgtablet

2-generic

Phosphate Binderscalcium acetate 2-generic

eliphos 2-generic

RENVELA (0.8, 2.4) 4-BRAND PA

RENVELA 800 MG TABLET 3-PREF. BRAND PA

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)alclometasone dipropionate 2-generic

amcinonide (0.1 cream (g), 0.1 lotion, 2-generic0.1 oint. (g))

betamethasone dipropionate (0.05 2-genericlotion, 0.05 cream (g), 0.05 oint. (g))


51



betamethasone dipropionate/propylene 2-genericglycol (0.05 cream (g), 0.05 oint. (g),0.05 lotion)

betamethasone valerate (0.1 cream (g), 2-generic0.1 lotion, 0.1 oint. (g))

budesonide 3 mg capdr & er 2-generic

clobetasol propionate (0.05 solution, 2-generic0.05 lotion, 0.05 shampoo, 0.05 foam,0.05 oint. (g), 0.05 gel (gram))

clobetasol propionate/emoll 0.05 % 2-genericcream (g)

clodan 0.05% shampoo 2-generic

colocort 2-generic

cormax 2-generic

cortisone acetate 25 mg tablet 2-generic

desonide (0.05 lotion, 0.05 cream (g), 2-generic0.05 oint. (g))

desoximetasone 2-generic

dexamethasone (6 mg tablet, 0.5 mg 2-generictablet, 2 mg tablet, 0.75 mg tablet, 4mg tablet, 1.5 mg tablet, 0.5 mg/5mlelixir, 1 mg tablet, 0.5 mg/5ml solution)

DEXAMETHASONE SOD PHOSPHATE (10 5-INJECTABLEMG/ML, 4 MG/ML)

dexamethasone sodium phosphate/pf 5-INJECTABLE

diflorasone diacetate 2-generic

fludrocortisone acetate 0.1 mg tablet 2-generic

fluocinolone acetonide (0.025 oint. (g), 2-generic0.01 cream (g), 0.025 cream (g), 0.01oil, 0.01 solution)

fluocinolone acetonide oil 2-generic

fluocinonide (0.05 gel (gram), 0.05 2-genericsolution, 0.05 oint. (g))

fluocinonide/emollient base 2-generic

fluticasone propionate (0.005 oint. (g), 2-generic0.05 lotion, 0.05 cream (g))


52



halobetasol propionate 2-generic

hydrocortisone (5 mg tablet, 2.5 %lotion, 10 mg tablet, 2.5 % cream (g), 1% oint. (g), 1 % cream (g), 20 mg tablet,100mg/60ml enema, 2.5 % oint. (g))

2-generic

hydrocortisone butyrate (0.1 oint. (g),0.1 solution)

2-generic

hydrocortisone valerate 2-generic

methylprednisolone 2-generic

methylprednisolone acetate 5-INJECTABLE

METHYLPREDNISOLONE SODIUMSUCCINATE (40 MG, 1000 MG, 125 MG)

5-INJECTABLE

millipred 5 mg tablet 2-generic

mometasone furoate (0.1 cream (g), 0.1oint. (g), 0.1 solution)

2-generic

prednisolone 15 mg/5 ml solution 2-generic

prednisolone sod phosphate (5 ml, 15ml, 25 ml)

2-generic

prednisone (2.5 mg tablet, 5 mg tablet,1 mg tablet, 50 mg tablet, 5 mg/5 mlsolution, 20 mg tablet, 10 mg tablet, 10mg tab ds pk, 5 mg tab ds pk)

2-generic

prednisone intensol 2-generic

proctocream-hc 2-generic

proctosol-hc 2-generic

proctozone-hc 2-generic

triamcinolone acetonide (0.5 % oint. (g),0.1 % lotion, 55 mcg spray, 0.025 %cream (g), 0.5 % cream (g), 0.1 % oint.(g), 0.1 % cream (g), 0.025 % oint. (g),0.025 % lotion)

2-generic

triderm 2-generic

UCERIS 4-BRAND PA

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)


53



desmopressin (non-refrigerated) 2-generic PA

desmopressin acetate (0.1 mg tablet,0.2 mg tablet, 10/spray spray/pump)

2-generic PA

DESMOPRESSIN ACETATE (AMPUL,VIAL)

5-INJECTABLE PA

EGRIFTA 6-Specialty PA

GENOTROPIN (MINIQUICK 2 MG, 5 MGCARTRIDGE, MINIQUICK 1.6 MG,MINIQUICK 1.2 MG, MINIQUICK 0.4MG, MINIQUICK 1.8 MG, MINIQUICK0.6 MG, MINIQUICK 1 MG, MINIQUICK1.4 MG, MINIQUICK 0.8 MG, 12 MGCARTRIDGE)

6-Specialty PA

GENOTROPIN MINIQUICK 0.2 MG 4-BRAND PA

HUMATROPE 6-Specialty PA

INCRELEX 6-Specialty PA, LA

NORDITROPIN 5 MG/1.5 ML CRTG 5-INJECTABLE PA

NORDITROPIN FLEXPRO 6-Specialty PA

NORDITROPIN NORDIFLEX 6-Specialty PA

NUTROPIN 5 MG VIAL 6-Specialty PA

NUTROPIN AQ (CARTRIDGE, 20MG/2ML CART)

6-Specialty PA

NUTROPIN AQ NUSPIN 6-Specialty PA

OMNITROPE (5 ML, 10 ML) 5-INJECTABLE PA

OMNITROPE 5.8 MG VIAL 6-Specialty PA

SAIZEN 6-Specialty PA

SEROSTIM 6-Specialty PA

STIMATE 3-PREF. BRAND

TEV-TROPIN 6-Specialty PA

ZORBTIVE 6-Specialty PA

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

Anabolic Steroidsoxandrolone (2.5 mg, 10 mg) 2-generic


54



AndrogensANDROGEL 3-PREF. BRAND

ANDROXY 4-BRAND

danazol (200 mg, 50 mg, 100 mg) 2-generic

TESTIM 3-PREF. BRAND

TESTOSTERONE CYPIONATE (100MG/ML, 200 MG/ML)

5-INJECTABLE

testosterone enanthate 200 mg/ml vial 5-INJECTABLE

VOGELXO 3-PREF. BRAND

EstrogensALORA 4-BRAND PA FOR 65 YEARS AND OLDER

altavera 2-generic

alyacen 2-generic

amethyst 2-generic

apri 2-generic

aranelle 2-generic

aubra 2-generic

aviane 2-generic

azurette 2-generic

balziva 2-generic

briellyn 2-generic

caziant 2-generic

chateal 2-generic

cryselle 2-generic

cyclafem 2-generic

dasetta 2-generic

delyla 2-generic

desogestrel-ethinyl estradiol 2-generic

desogestrel-ethinyl estradiol/ethinylestradiol

2-generic

elinest 2-generic


55



emoquette 2-generic

enpresse 2-generic

enskyce 2-generic

estarylla 2-generic

ESTRACE 0.01% CREAM 3-PREF. BRAND

estradiol (0.5 mg tablet, .0375mg/24 2-generic PA FOR 65 YEARS AND OLDERpatch tdwk, 0.06mg/24h patch tdwk,0.1mg/24hr patch tdwk, .075mg/24hpatch tdwk, 1 mg tablet, 2 mg tablet,.025mg/24h patch tdwk, 0.05mg/24hpatch tdwk)

ESTRADIOL VALERATE (40 MG/ML, 20 5-INJECTABLEMG/ML)

estradiol/norethindrone acetate 2-generic PA FOR 65 YEARS AND OLDER

ESTRING 3-PREF. BRAND

estropipate (0.75 mg, 3 mg, 1.5 mg) 2-generic PA FOR 65 YEARS AND OLDER

ethinyl estradiol/drospirenone 2-generic

falmina 2-generic

gianvi 2-generic

gildagia 2-generic

gildess 2-generic

gildess fe 2-generic

jinteli 2-generic PA FOR 65 YEARS AND OLDER

jolessa 2-generic

junel 2-generic

junel fe 2-generic

kariva 2-generic

kelnor 1-35 2-generic

kurvelo 2-generic

larin 2-generic

larin fe 2-generic

leena 2-generic

lessina 2-generic


56



levonest 2-generic

levonorgestrel-ethinyl estradiol (0.1-0.02, 0.15-0.03)

2-generic

levora-28 2-generic

lomedia 24 fe 2-generic

loryna 2-generic

low-ogestrel 2-generic

lutera 2-generic

marlissa 2-generic

MENEST 4-BRAND PA FOR 65 YEARS AND OLDER

microgestin 2-generic

microgestin fe 2-generic

mimvey lo 2-generic PA FOR 65 YEARS AND OLDER

MINIVELLE 4-BRAND PA FOR 65 YEARS AND OLDER

mircette 2-generic

mono-linyah 2-generic

mononessa 2-generic

myzilra 2-generic

necon (1-35-28, 7-7-7-28, 10-11-28, 0.5-35-28)

2-generic

nikki 2-generic

norethindrone acetate-ethinyl estradiol 2-generic

norethindrone acetate-ethinylestradiol/ferrous fumarate

2-generic

norgestimate-ethinyl estradiol 2-generic

norinyl 1+35 2-generic

nortrel 2-generic

ocella 2-generic

ogestrel 2-generic

orsythia 2-generic

philith 2-generic

pimtrea 2-generic


57



pirmella 2-generic

portia 2-generic

PREMARIN (1.25 MG, 0.3 MG, 0.625MG, 0.45 MG, 0.9 MG)

4-BRAND PA FOR 65 YEARS AND OLDER, QL (30PER 30 DAYS)

PREMARIN 25 MG VIAL 5-INJECTABLE

PREMARIN VAGINAL CREAM-APPL 3-PREF. BRAND

PREMPHASE 4-BRAND PA FOR 65 YEARS AND OLDER

PREMPRO 4-BRAND PA FOR 65 YEARS AND OLDER

previfem 2-generic

reclipsen 2-generic

sprintec 2-generic

sronyx 2-generic

syeda 2-generic

tri-estarylla 2-generic

tri-linyah 2-generic

tri-previfem 2-generic

tri-sprintec 2-generic

trinessa 2-generic

trivora-28 2-generic

VAGIFEM 3-PREF. BRAND

velivet 2-generic

vestura 2-generic

viorele 2-generic

VIVELLE-DOT 4-BRAND PA FOR 65 YEARS AND OLDER

vyfemla 2-generic

wera 2-generic

xulane 2-generic

zarah 2-generic

zenchent 2-generic

zovia 1-35e 2-generic

zovia 1-50e 2-generic


58



Progesterone Agonists/AntagonistsELLA 4-BRAND

Progestinscamila 2-generic

DEPO-SUBQ PROVERA 104 5-INJECTABLE

errin 2-generic

heather 2-generic

jencycla 2-generic

jolivette 2-generic

lyza 2-generic

MEDROXYPROGESTERONE ACETATE 5-INJECTABLE(150 MG/ML VIAL, 150 MG/MLSYRINGE)

medroxyprogesterone acetate (2.5 mg, 2-generic5 mg, 10 mg)

megestrol acetate (20 mg tablet, 2-generic400mg/10ml oral susp, 40 mg tablet)

nora-be 2-generic

norethindrone 0.35 mg tablet 2-generic

norethindrone acetate 5 mg tablet 2-generic

norlyroc 2-generic

progesterone,micronized (100 mg, 200 2-genericmg)

Selective Estrogen Receptor Modifying Agentsraloxifene hcl 2-generic

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)levothroid (88 mcg, 175 mcg, 25 mcg, 1-preferred50 mcg, 200 mcg, 137 mcg, 125 mcg, generic100 mcg, 150 mcg, 112 mcg, 75 mcg)

LEVOTHROID 300 MCG TABLET 4-BRAND


59



levothyroxine sodium (75 mcg, 300mcg, 25 mcg, 112 mcg, 137 mcg, 125mcg, 100 mcg, 200 mcg, 50 mcg,175mcg, 88 mcg, 150 mcg)

1-preferredgeneric

levothyroxine sodium 100 mcg vial 5-INJECTABLE

levoxyl 1-preferredgeneric

liothyronine sodium (25 mcg, 5 mcg, 50mcg)

2-generic

liothyronine sodium 10 mcg/ml vial 5-INJECTABLE

SYNTHROID 4-BRAND

unithroid 1-preferredgeneric

Hormonal Agents, Suppressant (Adrenal)

Hormonal Agents, Suppressant (Adrenal)KORLYM 6-Specialty PA

LYSODREN 3-PREF. BRAND

Hormonal Agents, Suppressant (Parathyroid)

Hormonal Agents, Suppressant (Parathyroid)SENSIPAR 30 MG TABLET 3-PREF. BRAND QL (60 PER 30 DAYS)

SENSIPAR 60 MG TABLET 6-Specialty QL (60 PER 30 DAYS)

SENSIPAR 90 MG TABLET 6-Specialty QL (120 PER 30 DAYS)

Hormonal Agents, Suppressant (Pituitary)

Hormonal Agents, Suppressant (Pituitary)cabergoline 2-generic

ELIGARD 5-INJECTABLE

leuprolide acetate 1 mg/0.2ml kit 5-INJECTABLE

LUPRON DEPOT 6-Specialty

LUPRON DEPOT-PED 6-Specialty

OCTREOTIDE ACETATE (500 MCG/ML 5-INJECTABLE PA


60



AMPUL, 50 MCG/ML VIAL,1000MCG/ML VIAL, 50 MCG/MLAMPUL, 100 MCG/ML AMPUL, 100MCG/ML VIAL, 200 MCG/ML VIAL, 500MCG/ML VIAL)

SIGNIFOR 6-Specialty PA, LA

SOMATULINE DEPOT 6-Specialty PA

SOMAVERT 6-Specialty PA, LA

Hormonal Agents, Suppressant (Thyroid)

Antithyroid Agentsmethimazole (5 mg, 10 mg) 2-generic

propylthiouracil 50 mg tablet 2-generic

Immunological Agents - Drugs to stimulate, suppress or regulate the immune system

Angioedema (HAE) AgentsCINRYZE 6-Specialty PA, LA

FIRAZYR 6-Specialty PA, QL (9 ML PER 30 DAYS)

Immune SuppressantsASTAGRAF XL 4-BRAND PA TO CONFIRM PART D COVERAGE

azathioprine 50 mg tablet 2-generic PA TO CONFIRM PART D COVERAGE

CELLCEPT 200 MG/ML ORAL SUSP 6-Specialty PA TO CONFIRM PART D COVERAGE

cyclosporine (100 mg, 25 mg) 2-generic PA TO CONFIRM PART D COVERAGE

CYCLOSPORINE (250 VIAL, 250 AMPUL) 5-INJECTABLE PA TO CONFIRM PART D COVERAGE

cyclosporine, modified (50 mg capsule,100 mg/ml solution, 100 mg capsule, 25mg capsule)


ENBREL (50 MG/ML SYRINGE, 25 MGKIT, 50 MG/ML SURECLICK SYR, 25MG/0.5 ML SYRINGE)

6-Specialty

gengraf (25 mg capsule, 100 mg/mlsolution, 100 mg capsule)


hecoria 2-generic PA TO CONFIRM PART D COVERAGE

HUMIRA 6-Specialty


61



methotrexate sodium 2.5 mg tablet 1-preferredgeneric

methotrexate sodium 25 mg/ml vial 5-INJECTABLE

METHOTREXATE SODIUM/PF (1 G, 25MG/ML)

5-INJECTABLE

mycophenolate mofetil 2-generic PA TO CONFIRM PART D COVERAGE

mycophenolate sodium 2-generic PA TO CONFIRM PART D COVERAGE

NULOJIX 6-Specialty PA FOR NEW STARTS ONLY

PROGRAF 5 MG/ML AMPULE 5-INJECTABLE PA TO CONFIRM PART D COVERAGE

RAPAMUNE (1 MG TABLET, 1 MG/MLORAL SOLN, 2 MG TABLET)

4-BRAND PA TO CONFIRM PART D COVERAGE

REMICADE 6-Specialty PA

sirolimus 0.5 mg tablet 2-generic PA TO CONFIRM PART D COVERAGE

tacrolimus (1 mg, 5 mg, 0.5 mg) 2-generic PA TO CONFIRM PART D COVERAGE

ZORTRESS (0.75 MG, 0.5 MG) 6-Specialty PA TO CONFIRM PART D COVERAGE,QL (60 PER 30 DAYS)

ZORTRESS 0.25 MG TABLET 4-BRAND PA TO CONFIRM PART D COVERAGE,QL (60 PER 30 DAYS)

Immunizing Agents, PassiveBIVIGAM 6-Specialty PA

CARIMUNE NF NANOFILTERED 6-Specialty PA

FLEBOGAMMA DIF 6-Specialty PA

GAMMAGARD LIQUID 6-Specialty PA

GAMMAGARD S-D 6-Specialty PA

GAMMAKED 5-INJECTABLE PA

GAMMAPLEX 6-Specialty PA

GAMUNEX 5-INJECTABLE PA

GAMUNEX-C 5-INJECTABLE PA

PRIVIGEN 6-Specialty PA

THYMOGLOBULIN 6-Specialty

ImmunomodulatorsACTIMMUNE 6-Specialty PA FOR NEW STARTS ONLY, LA


62



ARCALYST 6-Specialty PA, LA

ILARIS 6-Specialty PA, LA

leflunomide 2-generic

VaccinesACTHIB 5-INJECTABLE

ADACEL TDAP VIAL 5-INJECTABLE

bcg live 5-INJECTABLE

bcg vaccine, live/pf 5-INJECTABLE

BOOSTRIX TDAP 5-INJECTABLE

CERVARIX 5-INJECTABLE PA

COMVAX 5-INJECTABLE

DAPTACEL DTAP 5-INJECTABLE

DIPHTHERIA-TETANUS TOXOIDS-PED 5-INJECTABLE

ENGERIX-B ADULT 5-INJECTABLE PA TO CONFIRM PART D COVERAGE

ENGERIX-B PEDIATRIC-ADOLESCENT 5-INJECTABLE PA TO CONFIRM PART D COVERAGE

GARDASIL VIAL 5-INJECTABLE PA

HAVRIX (1,440 UNITS/ML VIAL, 720UNITS/0.5 ML VIAL, 720 UNIT/0.5 MLSYRINGE)

5-INJECTABLE

IMOVAX RABIES VACCINE 5-INJECTABLE

INFANRIX DTAP VIAL 5-INJECTABLE

IPOL 5-INJECTABLE

IXIARO 5-INJECTABLE

M-M-R II VACCINE 5-INJECTABLE

MENACTRA 5-INJECTABLE

MENOMUNE-A-C-Y-W-135 5-INJECTABLE

MENVEO A-C-Y-W-135-DIP 5-INJECTABLE

PEDVAXHIB 5-INJECTABLE

PENTACEL ACTHIB COMPONENT 5-INJECTABLE

PROQUAD 5-INJECTABLE

RABAVERT 5-INJECTABLE


63



RECOMBIVAX HB (10 MCG/ML VIAL, 5MCG/0.5 ML VL, 40 MCG/ML VIAL)

5-INJECTABLE PA TO CONFIRM PART D COVERAGE

ROTARIX 5-INJECTABLE

ROTATEQ 3-PREF. BRAND

tetanus and diphtheria toxoids, adult 5-INJECTABLE

tetanus toxoid, adsorbed/pf 5-INJECTABLE

tetanus,diphtheria toxoid ped/pf 5-INJECTABLE

TWINRIX VACCINE VIAL 5-INJECTABLE

TYPHIM VI 25 MCG/0.5 ML VIAL 5-INJECTABLE

VAQTA (25 UNITS/0.5 ML, 50UNITS/ML)

5-INJECTABLE

VARIVAX VACCINE 5-INJECTABLE

YF-VAX 5-INJECTABLE

ZOSTAVAX 5-INJECTABLE

Inflammatory Bowel Disease Agents - Drugs to treat inflammatory bowel disorders

AminosalicylatesAPRISO 3-PREF. BRAND

ASACOL HD 4-BRAND

balsalazide disodium 2-generic

CANASA 3-PREF. BRAND

DELZICOL 4-BRAND

LIALDA 4-BRAND

mesalamine with cleansing wipes 2-generic

PENTASA 3-PREF. BRAND

Sulfonamidessulfasalazine (500 mg, 500 mg dr) 2-generic

sulfazine 2-generic

sulfazine ec 2-generic

Metabolic Bone Disease Agents - Drugs to treat metabolic bone disorders


64



Metabolic Bone Disease AgentsACTONEL (5 MG, 30 MG, 35 MG) 3-PREF. BRAND PA

alendronate sodium (10 mg, 40 mg, 35mg, 70 mg, 5 mg)

1-preferredgeneric

alendronate sodium 70 mg/75mlsolution

2-generic

ATELVIA 4-BRAND PA

BINOSTO 4-BRAND PA

BONIVA 3 MG/3 ML SYRINGE 5-INJECTABLE PA

calcitonin,salmon,synthetic 2-generic

calcitriol (1 mcg/ml solution, 0.5 mcgcapsule, 0.25 mcg capsule)


calcitriol 1 mcg/ml ampul 5-INJECTABLE PA TO CONFIRM PART D COVERAGE

doxercalciferol (1 mcg, 2.5 mcg, 0.5mcg)

2-generic PA TO CONFIRM PART D COVERAGE,ST

DOXERCALCIFEROL (AMPUL, VIAL) 5-INJECTABLE PA TO CONFIRM PART D COVERAGE,ST

etidronate disodium 2-generic

FORTEO 6-Specialty PA

ibandronate sodium 150 mg tablet 2-generic

PAMIDRONATE DISODIUM (30 MG, 90MG, 60 MG/10ML, 90 MG/10ML,30MG/10ML)

5-INJECTABLE

paricalcitol 2-generic PA TO CONFIRM PART D COVERAGE,ST

PROLIA 5-INJECTABLE PA

risedronate sodium 2-generic PA

XGEVA 6-Specialty PA FOR NEW STARTS ONLY

ZEMPLAR (2 MCG/ML, 5 MCG/ML, 10MCG/2 ML)

5-INJECTABLE PA TO CONFIRM PART D COVERAGE,ST

ZOLEDRONIC ACID (4 MG/5 ML, 4 MG) 6-Specialty PA TO CONFIRM PART D COVERAGE

ZOMETA 4 MG/100 ML INJECTION 6-Specialty PA TO CONFIRM PART D COVERAGE

Miscellaneous


65



Miscellaneousalcohol antiseptic pads 2-generic

gauze bandage 2" x 2" bandage 2-generic

needles, insulin disposable 2-generic

needles, insulin disposable, safety 2-generic

pen needle, diabetic disposable, safety 2-generic

pen needle, diabetic, remover &disposal unit

2-generic

syring w-ndl,disp,insul,0.3ml/container,empty

2-generic

syring w-ndl,disp,insul,0.5ml/container,empty

2-generic

syringe with needle, insulin, safety, 0.3ml

2-generic

syringe with needle, insulin, safety, 0.5ml

2-generic

syringe with needle, insulin, safety, 1 ml 2-generic

syringe with needle, insulin,1 ml andsharps container

2-generic

syringe with needle,disposable,insulin 1ml

2-generic

syringe with needle,insulindisposable,0.3 ml

2-generic

syringe with needle,insulindisposable,0.5 ml

2-generic

Ophthalmic Agents - Drugs to treat eye conditions

Ophthalmic Agents, Otherak-poly-bac 2-generic

bacitracin/polymyxin b sulfate 2-generic

BLEPHAMIDE 3-PREF. BRAND

BLEPHAMIDE S.O.P. 3-PREF. BRAND

LACRISERT 4-BRAND

naphazoline hcl 0.1 % drops 2-generic


66



neo-polycin 2-generic

neo-polycin hc 2-generic

neomycin sulfate/bacitracinzinc/polymyxin b/hydrocortisone

2-generic

neomycin sulfate/bacitracin/polymyxinb

2-generic

neomycin sulfate/polymyxin bsulfate/gramicidin d

2-generic

neomycin/polymyxin b sulf/hc 3.5-10k-10 drops susp

2-generic

neomycin/polymyxin bsulfate/dexamethasone (0.1 % dropssusp, 3.5-10k-.1 oint. (g))

2-generic

neosporin eye drops 2-generic

polycin 2-generic

polymyxin b sulfate/trimethoprim 2-generic

RESTASIS 3-PREF. BRAND QL (60 PER 30 DAYS)

sulfacetamide sodium/prednisolonesodium phosphate

2-generic

tobramycin/dexamethasone 2-generic

ZYLET 3-PREF. BRAND

Ophthalmic Anti-allergy Agentsazelastine hcl 0.05 % drops 2-generic

cromolyn sodium 4 % drops 2-generic

epinastine hcl 2-generic

Ophthalmic Anti-inflammatoriesALREX 3-PREF. BRAND

bromfenac sodium 2-generic

dexamethasone sod phosphate 0.1 %drops

2-generic

dexasol 2-generic

diclofenac sodium 0.1 % drops 2-generic

FLAREX 3-PREF. BRAND


67



flurbiprofen sodium 2-generic

FML FORTE 3-PREF. BRAND

FML S.O.P. 3-PREF. BRAND

ketorolac tromethamine (0.5, 0.4) 2-generic

LOTEMAX (EYE DROPS, OPHTHALMIC 3-PREF. BRANDGEL, EYE OINTMENT)

prednisolone acetate 1 % drops susp 2-generic

prednisolone sod phosphate 1 % drops 2-generic

VEXOL 4-BRAND

Ophthalmic Antiglaucoma AgentsALPHAGAN P 0.1% DROPS 3-PREF. BRAND

AZOPT 4-BRAND

betaxolol hcl 0.5 % drops 2-generic

BETIMOL 0.5% EYE DROPS 3-PREF. BRAND

brimonidine tartrate 0.15 % drops 2-generic

brimonidine tartrate 0.2 % drops 1-preferredgeneric

carteolol hcl 2-generic

dorzolamide hcl 2-generic

dorzolamide hcl/timolol maleate 2-generic

ISOPTO CARPINE 4-BRAND

ISTALOL 3-PREF. BRAND

levobunolol hcl 0.5 % drops 1-preferredgeneric

metipranolol 2-generic

pilocarpine hcl (4, 2, 1) 2-generic

timolol maleate (0.25, 0.5) 1-preferredgeneric

timolol maleate (0.5, 0.25) 2-generic

Ophthalmic Prostaglandin and Prostamide Analogslatanoprost 2-generic

LUMIGAN 0.01% EYE DROPS 3-PREF. BRAND ST, QL (2.5 ML PER 30 DAYS)


68



Otic Agents - Drugs to treat ear conditions

Otic Agentsacetasol hc 2-generic

acetic acid/hydrocortisone 2-generic

CIPRO HC 3-PREF. BRAND

CIPRODEX 3-PREF. BRAND

neomycin sulfate/polymyxin bsulfate/hydrocortisone (solution, dropssusp)

2-generic

vosol hc 2-generic

Respiratory Tract/Pulmonary Agents - Drugs to treat allergies or breathing conditions

Anti-inflammatories, Inhaled CorticosteroidsASMANEX (TWISTHALER 220 MCG #60, 3-PREF. BRANDTWISTHALER 110 MCG #30, TWISTHALR220 MCG #120, TWISTHALER 220 MCG#30)

budesonide (0.5 mg/2ml, 0.25mg/2ml) 2-generic PA TO CONFIRM PART D COVERAGE

budesonide 32mcg spray/pump 2-generic

FLOVENT DISKUS 3-PREF. BRAND

FLOVENT HFA 3-PREF. BRAND

flunisolide 25 mcg spray 2-generic

fluticasone propionate 50 mcg spray 2-genericsusp

NASONEX 4-BRAND

QVAR 3-PREF. BRAND

Antihistaminesazelastine hcl 137 mcg spray/pump 2-generic

clemastine fumarate (2.68 mg tablet, 2-generic0.67mg/5ml syrup)

cyproheptadine hcl (4 mg/10 ml syrup, 2-generic4 mg tablet, 2 mg/5 ml syrup)


69



levocetirizine dihydrochloride (5 mgtablet, 2.5 mg/5ml solution)

2-generic

Antileukotrienesmontelukast sodium (4 mg gran pack,10 mg tablet, 4 mg tab chew, 5 mg tabchew)

2-generic

zafirlukast 2-generic

Bronchodilators, AnticholinergicATROVENT HFA 3-PREF. BRAND

COMBIVENT RESPIMAT 3-PREF. BRAND QL (4 GM PER 30 DAYS)

ipratropium bromide (21 mcg, 42mcg) 2-generic

ipratropium bromide 0.2 mg/mlsolution


ipratropium bromide/albuterol sulfate 2-generic PA TO CONFIRM PART D COVERAGE

SPIRIVA 3-PREF. BRAND

Bronchodilators, SympathomimeticADRENACLICK 4-BRAND QL (2 PER 90 DAYS)

albuterol sulfate (1.25mg/3ml vial-neb,2.5 mg/3ml vial-neb, 2.5 mg/0.5 vial-neb, 0.63mg/3ml vial-neb, 5 mg/mlsolution)


albuterol sulfate (2 mg/5 ml syrup, 8mg tab er 12h, 4 mg tab er 12h, 2 mgtablet, 4 mg tablet)

2-generic

AUVI-Q 4-BRAND QL (2 PER 90 DAYS)

EPIPEN 2-PAK 3-PREF. BRAND QL (2 PER 90 DAYS)

EPIPEN JR 2-PAK 3-PREF. BRAND QL (2 PER 90 DAYS)

metaproterenol sulfate (10 mg tablet,20 mg tablet, 10 mg/5 ml syrup)

2-generic

proair hfa 2-generic QL (36 GM PER 30 DAYS)

PROVENTIL HFA 4-BRAND QL (36 GM PER 30 DAYS)

SEREVENT DISKUS 3-PREF. BRAND

terbutaline sulfate (5 mg, 2.5 mg) 2-generic

ventolin hfa 2-generic QL (36 GM PER 30 DAYS)


70



XOPENEX HFA 4-BRAND

Cystic Fibrosis AgentsCAYSTON 6-Specialty LA

KALYDECO 6-Specialty PA, QL (60 PER 30 DAYS)

TOBI PODHALER 6-Specialty

Mast Cell Stabilizerscromolyn sodium 20 mg/2 ml ampul- 2-genericneb


cromolyn sodium 20 mg/ml solution 2-generic

Phosphodiesterase Inhibitors, Airways Diseaseaminophylline (500mg/20ml vial, 2-generic250mg/10ml vial, 250mg/10ml ampul,500mg/20ml ampul)

DALIRESP 4-BRAND PA

theochron 2-generic

theophylline anhydrous (300 mg tab er 2-generic12h, 600 mg tablet er, 400 mg tablet er,100 mg tab er 12h, 450 mg tab er 12h,200 mg tab er 12h)

Pulmonary AntihypertensivesADCIRCA 6-Specialty PA, QL (60 PER 30 DAYS)

ADEMPAS 6-Specialty PA

LETAIRIS 6-Specialty PA

OPSUMIT 6-Specialty PA, LA

REVATIO 10 MG/12.5 ML VIAL 6-Specialty PA

sildenafil citrate 20 mg tablet 2-generic PA, QL (90 PER 30 DAYS)

TRACLEER 6-Specialty PA, LA

VENTAVIS 6-Specialty PA, LA

Respiratory Tract Agents, Otheracetylcysteine (100 mg/ml, 200 mg/ml) 2-generic PA TO CONFIRM PART D COVERAGE

ADVAIR DISKUS 3-PREF. BRAND

ADVAIR HFA 3-PREF. BRAND


71



AEROSPAN 4-BRAND

ANORO ELLIPTA 3-PREF. BRAND

ARALAST NP 6-Specialty PA

BREO ELLIPTA 3-PREF. BRAND

GLASSIA 5-INJECTABLE PA

PROLASTIN 6-Specialty PA

PROLASTIN C 6-Specialty PA, LA

PULMOZYME 6-Specialty PA TO CONFIRM PART D COVERAGE

SYMBICORT 3-PREF. BRAND

XOLAIR 6-Specialty PA

ZEMAIRA 6-Specialty PA, LA

Skeletal Muscle Relaxants - Drugs to treat muscle spasms

Skeletal Muscle Relaxantscyclobenzaprine hcl (10 mg, 5 mg, 7.5mg)


methocarbamol (750 mg, 500 mg) 2-generic PA FOR 65 YEARS AND OLDER

Sleep Disorder Agents - Drugs to treat sleep disorders

GABA Receptor Modulatorstemazepam (15 mg, 30 mg) 2-generic PA FOR NEW STARTS ONLY AND FOR

65 YEARS AND OLDER

zaleplon 2-generic PA FOR 65 YEARS AND OLDER, QL (30PER 30 DAYS)

zolpidem tartrate (10 mg, 5 mg) 2-generic PA FOR 65 YEARS AND OLDER, QL (30PER 30 DAYS)

Sleep Disorders, Othermodafinil 2-generic PA, QL (30 PER 30 DAYS)

NUVIGIL (150 MG, 250 MG) 4-BRAND PA, QL (30 PER 30 DAYS)

NUVIGIL 50 MG TABLET 4-BRAND PA, QL (60 PER 30 DAYS)

XYREM 6-Specialty PA, LA, QL (540 ML PER 30 DAYS)


72



Therapeutic Nutrients/Minerals/Electrolytes

Electrolyte/Mineral ModifiersEXJADE 6-Specialty LA

kayexalate 2-generic

kionex (15 gm/60 ml suspension,powder)

2-generic

marlexate 2-generic

SAMSCA 6-Specialty PA

sodium polystyrene sulfonate (powder,30g/120ml enema, 15g/60ml oral susp,50g/200ml enema)

2-generic

SYPRINE 4-BRAND

Electrolyte/Mineral Replacement0.9 % SODIUM CHLORIDE (0.9 0.9 IVSOLN, 0.9 PGGYBK PRT, 0.9 0.9 VIAL,0.9 PGY VL PRT)

5-INJECTABLE

fluor-a-day (1 mg tablet, 0.25 mg tab,0.5 mg tab)

2-generic

fluoritab (1 mg, 0.5 mg) 2-generic

k-tab er 2-generic

klor-con 10 2-generic

klor-con m10 2-generic



ludent fluoride 2-generic

potassium chloride (10 tablet er, 10 taber prt, 8 capsule er, 20 tablet er, 20 taber prt, 10 capsule er)

2-generic

POTASSIUM CHLORIDE (2 MEQ/MLVIAL, 20MEQ/50ML PIGGYBACK,40MEQ/0.1L PIGGYBACK, 20MEQ/0.1LPIGGYBACK, 2 MEQ/ML IV SOLN,10MEQ/0.1L PIGGYBACK, 10MEQ/50MLPIGGYBACK)

5-INJECTABLE

potassium citrate (10 er, 5 er) 2-generic


73



sodium chloride irrigating solution 2-generic

sodium fluoride (0.5(1.1)mg tab chew, 2-generic1mg(2.2mg) tab chew, 1mg(2.2mg)tablet, 0.25(0.55) tab chew)

Therapeutic Nutrients/Minerals/ElectrolytesAMINOSYN II 15% IV SOLUTION 5-INJECTABLE PA TO CONFIRM PART D COVERAGE

b-nexa 2-generic

dextrose 10 % in water 5-INJECTABLE

dextrose 2.5 % and 0.45 % sodium 5-INJECTABLEchloride

dextrose 5 % and 0.2 % sodium chloride 5-INJECTABLE


dextrose 5 % and 0.45 % sodium 5-INJECTABLEchloride


dextrose 5 % in lactated ringers 2-generic

dextrose 5 % in water 5-INJECTABLE

focalgin-b 2-generic

folbecal 2-generic

folinatal plus b 2-generic

INTRALIPID 5-INJECTABLE PA TO CONFIRM PART D COVERAGE

levocarnitine (with sugar) 2-generic PA TO CONFIRM PART D COVERAGE

levocarnitine 200 mg/ml vial 5-INJECTABLE PA TO CONFIRM PART D COVERAGE

levocarnitine 330 mg tablet 2-generic PA TO CONFIRM PART D COVERAGE

LIPOSYN II 5-INJECTABLE PA TO CONFIRM PART D COVERAGE

LIPOSYN III (20%, 30%) 5-INJECTABLE PA TO CONFIRM PART D COVERAGE

potassium chloride in dextrose 5 % and 5-INJECTABLE0.9 % sodium chloride

POTASSIUM CHLORIDE IN DEXTROSE 5 5-INJECTABLE%-0.45 % SODIUM CHLORIDE (10, 20,30)

potassium chloride in lr-d5 20 meq/l iv 5-INJECTABLEsoln


74



potassium chloride/d5-0.2%nacl 20 5-INJECTABLEmeq/l iv soln

prenaissance next 2-generic

prenaissance next-b 2-generic

prenatal plus iron tablet 2-generic

prenatal plus tablet 2-generic

prenatal vitamins tablet 2-generic

ringers solution,lactated iv soln 5-INJECTABLE

TPN ELECTROLYTES 5-INJECTABLE

trimesis rx 2-generic

vol-plus tablet 2-generic

vp-ggr-b6 2-generic

zingiber 2-generic


75

Alphabetical Listing

00.9 % sodium chloride 73

Aabacavir sulfate 29

abacavir sulfate/lamivudine/zidovudine 29

ABELCET 19

ABILIFY 15

ABILIFY DISCMELT 15

ABILIFY MAINTENA 15

acamprosate calcium 5

acarbose 33

acebutolol hcl 39

acetaminophen with codeine phosphate 2

acetasol hc 68

acetazolamide 42

acetazolamide sodium 42

acetic acid 6

acetic acid/hydrocortisone 69

acetylcysteine 71

acitretin 46

ACTHIB 63

ACTIMMUNE 62

ACTONEL 64

acyclovir 32

acyclovir sodium 32

ADACEL TDAP 63

ADAGEN 47

adapalene 46

ADCIRCA 71

adefovir dipivoxil 31

ADEMPAS 71

ADRENACLICK 70

ADRUCIL 23

ADVAIR DISKUS 71

ADVAIR HFA 71

AEROSPAN 71

afeditab cr 40

AFINITOR 24

AFINITOR DISPERZ 24

AGGRENOX 37

ak-poly-bac 66

alagesic lq 1

ALBENZA 25

albuterol sulfate 70

alclometasone dipropionate 51

alcohol antiseptic pads 65

ALDURAZYME 48

alendronate sodium 65

alfuzosin hcl 51

ALIMTA 23

ALINIA 25

allopurinol 20

ALORA 55

ALPHAGAN P 68

ALREX 67

altavera 55

alyacen 55

amantadine hcl 26

AMBISOME 19

amcinonide 51

amethyst 55

amifostine crystalline 23

amiloride hcl 42

amiloride hcl/hydrochlorothiazide 42

aminophylline 71

AMINOSYN II 74

amiodarone hcl 39

AMITIZA 49

amitriptyline hcl 17

amlodipine besylate 40

amlodipine besylate/benazepril hcl 40

ammonium lactate 46

amnesteem 47

amoxapine 17

amoxicillin 9

amoxicillin/potassium clavulanate 9

amphotericin b 19

ampicillin sodium 9

ampicillin sodium/sulbactam sodium 9

ampicillin trihydrate 9


76

AMPYRA 45

anagrelide hcl 36

anastrozole 23

ANDROGEL 54

ANDROXY 55

ANORO ELLIPTA 72

APOKYN 26

apri 55

APRISO 64

APTIOM 14

APTIVUS 30

ARALAST NP 72

aranelle 55

ARANESP 36

ARCALYST 62

ASACOL HD 64

ascomp with codeine 2

ASMANEX 69

ASTAGRAF XL 61

ATELVIA 65

atenolol 39

atenolol/chlorthalidone 39

atorvastatin calcium 43

atovaquone 25

ATRIPLA 28

ATROVENT HFA 70

AUBAGIO 46

aubra 55

AUVI-Q 70

AVASTIN 25

AVELOX IV 10

aviane 55

avidoxy 11

AVONEX 46

AVONEX ADMINISTRATION PACK 46

AVONEX PEN 46

azacitidine 23

AZASITE 10

azathioprine 61

azelastine hcl 69

AZILECT 26

azithromycin 10

AZOPT 68

aztreonam 8

azurette 55

Bb-nexa 74

BACIIM 6

bacitracin 6

bacitracin/polymyxin b sulfate 66

baclofen 28

balsalazide disodium 64

balziva 55

BANZEL 14

BARACLUDE 31

bcg live 63

bcg vaccine, live/pf 63

benazepril hcl 38

benazepril hcl/hydrochlorothiazide 38

benztropine mesylate 26

betamethasone dipropionate 51

betamethasone dipropionate/propylene glycol 51

betamethasone valerate 52

BETASERON 46

betaxolol hcl 68

bethanechol chloride 51

BETIMOL 68

bicalutamide 22

BICILLIN C-R 9

BICILLIN L-A 9

BINOSTO 65

bisoprolol fumarate 39

bisoprolol fumarate/hydrochlorothiazide 40

BIVIGAM 62

bleomycin sulfate 23

BLEPHAMIDE 66

BLEPHAMIDE S.O.P. 66

BONIVA 65

BOOSTRIX TDAP 63

BOSULIF 24

BREO ELLIPTA 72


77

briellyn 55

BRILINTA 37

brimonidine tartrate 68

BRINTELLIX 16

bromfenac sodium 67

bromocriptine mesylate 26

budeprion sr 15

budeprion xl 15

budesonide 69

bumetanide 42

buprenorphine hcl 5

buprenorphine hcl/naloxone hcl 5

buproban 15

bupropion hcl 15

buspirone hcl 32

butalbital/acetaminophen 1

butalbital/acetaminophen/caffeine 1

butalbital/acetaminophen/caffeine/codeine phosphate 2

butalbital/aspirin/caffeine 1

butorphanol tartrate 2

BYDUREON 33

BYDUREON PEN 33

BYETTA 33

Ccabergoline 60

calcipotriene 47

calcitonin,salmon,synthetic 65

calcitrene 47

calcitriol 65

calcium acetate 51

camila 59

CANASA 64

CANCIDAS 19

candesartan cilexetil 37

capacet 1

CAPASTAT SULFATE 21

CAPRELSA 24

captopril 38

captopril/hydrochlorothiazide 38

CARAC 47

CARAFATE 50

CARBAGLU 48

carbamazepine 14

carbidopa 26

carbidopa/levodopa 26

carbidopa/levodopa/entacapone 26

CARIMUNE NF NANOFILTERED 62

carteolol hcl 68

cartia xt 40

carvedilol 40

CAYSTON 71

caziant 55

CEDAX 7

CEENU 22

cefaclor 7

cefadroxil 7

cefazolin sodium 7

cefdinir 8

cefepime hcl 8

cefotaxime sodium 8

cefotetan disodium 8

cefoxitin sodium 8

cefpodoxime proxetil 8

cefprozil 8

ceftazidime pentahydrate 8

CEFTIN 8

ceftriaxone sodium 8

ceftriaxone sodium/dextrose, iso-osmotic 8

cefuroxime axetil 8

cefuroxime sodium 8

CELEBREX 3

CELLCEPT 61

CELONTIN 12

cephalexin 8

CEREZYME 48

CERVARIX 63

CHANTIX 5

chateal 55

chloramphenicol sod succ 6

chlorhexidine gluconate 46

chloroquine phosphate 25


78

chlorothiazide 43

chlorpromazine hcl 18

chlorthalidone 43

cholestyramine (with sugar) 43

cholestyramine/aspartame 43

ciclodan 19

ciclopirox 19

ciclopirox olamine 19

cilostazol 37

cimetidine 49

cimetidine hcl 49

CINRYZE 61

CIPRO HC 69

CIPRODEX 69

ciprofloxacin hcl 10

ciprofloxacin lactate 10

ciprofloxacin lactate/dextrose 5 % in water 10

ciprofloxacin/ciprofloxacin hcl 11

citalopram hydrobromide 16

claravis 47

clarithromycin 10

clemastine fumarate 69

clinda-derm 6

clindacin etz 6

clindacin p 6

clindamycin hcl 6

clindamycin palmitate hcl 6

clindamycin phosphate 6

clindamycin phosphate/dextrose 5 % in water 6

clobetasol propionate 52

clobetasol propionate/emollient base 52

clodan 52

clomipramine hcl 17

clonazepam 12

clonidine 37

clonidine hcl 45

clopidogrel bisulfate 37

clorazepate dipotassium 12

clotrimazole 19

clotrimazole/betamethasone dipropionate 47

clozapine 28

codeine phosphate/butalbital/aspirin/caffeine 2

colchicine/probenecid 20

COLCRYS 20

colestipol hcl 44

colistin (as colistimethate sodium) 6

colocort 52

COMBIVENT RESPIMAT 70

COMETRIQ 24

COMPLERA 29

compro 18

COMVAX 63

constulose 49

COPAXONE 46

COREG CR 40

cormax 52

cortisone acetate 52

CREON 48

CRIXIVAN 30

cromolyn sodium 71

cryselle 55

CUBICIN 6

cyclafem 55

cyclobenzaprine hcl 72

CYCLOPHOSPHAMIDE CAPSULES (25 MG, 50

MG) 22

cyclophosphamide tablets (25 mg, 50 mg) 22

CYCLOSET 33

cyclosporine 61

cyclosporine, modified 61

cyproheptadine hcl 69

CYSTADANE 48

CYSTAGON 48

CYSTARAN 48

DDALIRESP 71

danazol 55

dantrolene sodium 28

dapsone 21

DAPTACEL DTAP 63

DARAPRIM 25


79

dasetta 55

DAYTRANA 45

delyla 55

DELZICOL 64

demeclocycline hcl 11

DEMSER 41

depade 5

DEPEN 51

DEPO-SUBQ PROVERA 104 59

desipramine hcl 17

desmopressin (non-refrigerated) 53

desmopressin acetate 54

desogestrel-ethinyl estradiol 55

desogestrel-ethinyl estradiol/ethinyl estradiol 55

desonide 52

desoximetasone 52

desvenlafaxine 16

dexamethasone 52

dexamethasone sod phosphate 67

dexamethasone sodium phosphate/pf 52

dexasol 67

dexmethylphenidate hcl 45

dextroamphetamine sulf-saccharate/amphetamine sulf-

aspartate 45

dextroamphetamine sulfate 45

dextrose 10 % in water 74

dextrose 2.5 % and 0.45 % sodium chloride 74

dextrose 5 % and 0.2 % sodium chloride 74




dextrose 5 % in lactated ringers 74

dextrose 5 % in water 74

diazepam 12

diclofenac potassium 4

diclofenac sodium 67

dicloxacillin sodium 9

didanosine 29

diflorasone diacetate 52

diflunisal 4

digox 42

digoxin 42

dihydroergotamine mesylate 20

DILANTIN 14

dilt-cd 40

dilt-xr 40

diltia xt 41

diltiazem hcl 41

diltzac er 41

DIOVAN 37

diphenhydramine hcl 18

disopyramide phosphate 39

disulfiram 5

divalproex sodium 13

donepezil hcl 15

DORIBAX 8

dorzolamide hcl 68

dorzolamide hcl/timolol maleate 68

doxazosin mesylate 37

doxepin hcl 17

doxercalciferol 65

DOXY 100 11

doxycycline hyclate 11

doxycycline monohydrate 11

dronabinol 18

DROXIA 23

duloxetine hcl 16

DURAMORPH 1

dynacin 12

DYRENIUM 42

EE.E.S. 200 10

e.e.s. 400 10

econazole nitrate 19

EDECRIN 42

EDURANT 29

EFFIENT 37

EGRIFTA 54

ELAPRASE 48

ELELYSO 48

ELIDEL 47


80

ELIGARD 60

elimite 25

elinest 55

eliphos 51

ELIQUIS 35

ELITEK 23

ELLA 58

ELMIRON 51

EMCYT 22

EMEND 18

emoquette 55

EMSAM 16

EMTRIVA 29

enalapril maleate 38

enalapril maleate/hydrochlorothiazide 38

ENBREL 61

endocet 2

endodan 2

ENGERIX-B ADULT 63

ENGERIX-B PEDIATRIC-ADOLESCENT 63

enoxaparin sodium 35

enpresse 56

enskyce 56

entacapone 26

enulose 49

EPANED 38

epinastine hcl 67

EPIPEN 2-PAK 70

EPIPEN JR 2-PAK 70

epitol 14

EPIVIR 29

EPIVIR HBV 31

eplerenone 42

EPOGEN 36

eprosartan mesylate 38

EPZICOM 29

ERIVEDGE 24

errin 59

ery 10

ERY-TAB 10

erygel 10

ERYPED 200 10

ERYTHROCIN LACTOBIONATE 10

ERYTHROCIN STEARATE 10

erythromycin base 10

erythromycin base/benzoyl peroxide 47

erythromycin base/ethyl alcohol 10

erythromycin ethylsuccinate 10

escitalopram oxalate 16

estarylla 56

ESTRACE 56

estradiol 56

estradiol valerate 56

estradiol/norethindrone acetate 56

ESTRING 56

estropipate 56

ethambutol hcl 21

ethinyl estradiol/drospirenone 56

ethosuximide 12

etidronate disodium 65

etodolac 4

etoposide 24

EXELON 15

exemestane 24

EXJADE 72

EXTAVIA 46

FFABRAZYME 48

falmina 56

famciclovir 32

famotidine 49

famotidine in sodium chloride, iso-osmotic/pf 49

FANAPT 27

FARESTON 22

FARXIGA 33

FASLODEX 23

FAZACLO 28

felbamate 13

felodipine 41

fenofibrate 43

fenofibrate nanocrystallized 43


81

fenofibrate,micronized 43

fenofibric acid (choline) 43

fenoprofen calcium 4

fentanyl 1

fentanyl citrate 1

FETZIMA 16

finasteride 51

fioricet 1

FIRAZYR 61

FLAREX 67

flavoxate hcl 50

FLEBOGAMMA DIF 62

flecainide acetate 39

FLOVENT DISKUS 69

FLOVENT HFA 69

fluconazole 19

fluconazole in dextrose, iso-osmotic 19

flucytosine 19

fludrocortisone acetate 52

flunisolide 69

fluocinolone acetonide 52

fluocinolone acetonide oil 52

fluocinonide 52

fluocinonide/emollient base 52

fluor-a-day 73

fluoritab 73

fluorouracil 47

fluoxetine hcl 16

fluphenazine decanoate 26

fluphenazine hcl 27

flurbiprofen 4

flurbiprofen sodium 67

flutamide 22

fluticasone propionate 69

fluvastatin sodium 43

fluvoxamine maleate 16

FML FORTE 68

FML S.O.P. 68

focalgin-b 74

folbecal 74

folinatal plus b 74

fondaparinux sodium 35

FORTEO 65

foscarnet sodium 30

fosinopril sodium 38

fosinopril sodium/hydrochlorothiazide 38

FRAGMIN 35

FULYZAQ 48

furosemide 42

FUZEON 30

FYCOMPA 13

Ggabapentin 13

GABITRIL 13

galantamine hbr 15

GAMMAGARD LIQUID 62

GAMMAGARD S-D 62

GAMMAKED 62

GAMMAPLEX 62

GAMUNEX 62

GAMUNEX-C 62

ganciclovir sodium 30

garamycin 5

GARDASIL 63

gatifloxacin 11

GATTEX 49

gauze bandage 66

gavilyte-c 49

gavilyte-g 49

gavilyte-n 50

gemfibrozil 43

generlac 50

gengraf 61

GENOTROPIN 54

gentak 5

gentamicin sulfate 6

gentamicin sulfate/pf 6

GEODON 27

gianvi 56

gildagia 56

gildess 56


82

gildess fe 56

GILENYA 46

GILOTRIF 24

GLASSIA 72

GLEEVEC 24

glimepiride 33

glipizide 33

glipizide/metformin hcl 33

GLUCAGEN 34

GLUCAGON EMERGENCY KIT 34

glycopyrrolate 48

GRANIX 36

griseofulvin ultramicrosize 19

griseofulvin, microsize 19

guanidine hcl 21

HHALDOL DECANOATE 100 27

HALDOL DECANOATE 50 27

halobetasol propionate 52

haloperidol 27

haloperidol decanoate 27

haloperidol lactate 27

HAVRIX 63

heather 59

hecoria 61

heparin sodium,porcine 36

heparin sodium,porcine/dextrose 5 % in water 36

heparin sodium,porcine/pf 36

HEXALEN 22

HUMALOG 34

HUMALOG MIX 50-50 34

HUMALOG MIX 75-25 34

HUMATROPE 54

HUMIRA 61

HUMULIN 70-30 34

HUMULIN N 34

HUMULIN R 34

hydralazine hcl 44

hydrochlorothiazide 43

hydrocodone bitartrate/acetaminophen 2

hydrocodone/ibuprofen 2

hydrocortisone 53

hydrocortisone butyrate 53

hydrocortisone valerate 53

hydromorphone hcl 2

hydromorphone hcl/pf 2

hydroxychloroquine sulfate 25

hydroxyurea 23

Iibandronate sodium 65

ibuprofen 4

ILARIS 63

IMBRUVICA 24

imipenem/cilastatin sodium 8

imipramine hcl 17

imipramine pamoate 17

imiquimod 47

IMOVAX RABIES VACCINE 63

INCIVEK 31

INCRELEX 54

indapamide 43

INFANRIX DTAP 63

INLYTA 24

INTELENCE 29

INTRALIPID 74

INTRON A 31

INVANZ 8

INVEGA 27

INVEGA SUSTENNA 28

INVIRASE 30

INVOKANA 33

IPOL 63

ipratropium bromide 70

ipratropium bromide/albuterol sulfate 70

irbesartan 38

irbesartan/hydrochlorothiazide 38

ISENTRESS 29

isochron 44

isoniazid 21

ISOPTO CARPINE 68


83

isosorbide dinitrate 44

isosorbide mononitrate 44

isradipine 41

ISTALOL 68

itraconazole 19

IXEMPRA 23

IXIARO 63

JJAKAFI 24

jantoven 36

JANUMET 33

JANUMET XR 33

JANUVIA 33

jencycla 59

JENTADUETO 33

jinteli 56

jolessa 56

jolivette 59

junel 56

junel fe 56

JUXTAPID 44

Kk-tab er 73

KALETRA 30

KALYDECO 71

kariva 56

kayexalate 73

KAZANO 33

kelnor 1-35 56

ketoconazole 19

ketoprofen 4

ketorolac tromethamine 68

KHEDEZLA 17

kionex 73

klor-con 10 73

klor-con m10 73

klor-con m15 73

klor-con m20 73

KOMBIGLYZE XR 33

KORLYM 60

kurvelo 56

KUVAN 48

KYNAMRO 44

Llabetalol hcl 40

laclotion 47

LACRISERT 66

lactulose 50

LAMICTAL (BLUE) 13

LAMICTAL (GREEN) 13

LAMICTAL (ORANGE) 13

LAMICTAL XR (BLUE) 13

LAMICTAL XR (GREEN) 14

LAMICTAL XR (ORANGE) 14

lamivudine 31

lamivudine/zidovudine 29

lamotrigine 14

lansoprazole 50

lansoprazole/amoxicillin trihydrate/clarithromycin 49

LANTUS 34

LANTUS SOLOSTAR 35

larin 56

larin fe 56

latanoprost 68

LATUDA 28

LAZANDA 2

leena 56

leflunomide 63

lessina 56

LETAIRIS 71

letrozole 24

leucovorin calcium 23

LEUKERAN 22

LEUKINE 36

leuprolide acetate 60

LEVATOL 40

LEVEMIR 35

LEVEMIR FLEXPEN 35

LEVEMIR FLEXTOUCH 35


84

levetiracetam 12

levobunolol hcl 68

levocarnitine 74

levocarnitine (with sugar) 74

levocetirizine dihydrochloride 69

levofloxacin 11

levofloxacin/dextrose 5 % in water 11

levonest 56

levonorgestrel-ethinyl estradiol 57

levora-28 57

levorphanol tartrate 1

levothroid 59

LEVOTHROID 59

levothyroxine sodium 60

levoxyl 60

LEXIVA 30

LIALDA 64

lidocaine 4

lidocaine hcl 5

lidocaine hcl/pf 5

lidocaine/prilocaine 5

lindane 26

liothyronine sodium 60

LIPOSYN II 74

LIPOSYN III 74

lisinopril 38

lisinopril/hydrochlorothiazide 38

lithium carbonate 33

lithium citrate 33

lofibra 43

lomedia 24 fe 57

lomustine 22

loperamide hcl 49

lorazepam 32

lorazepam intensol 32

lorcet plus 3

lortab 3

loryna 57

losartan potassium 38

losartan potassium/hydrochlorothiazide 38

LOTEMAX 68

LOTRONEX 49

lovastatin 43

low-ogestrel 57

loxapine succinate 27

ludent fluoride 73

LUMIGAN 68

LUMIZYME 48

LUPRON DEPOT 60

LUPRON DEPOT-PED 60

lutera 57

LYRICA 12

LYSODREN 60

lyza 59

MM-M-R II VACCINE 63

maprotiline hcl 15

marlexate 73

marlissa 57

MARPLAN 16

MATULANE 22

matzim la 41

meclizine hcl 18

meclofenamate sodium 4

medroxyprogesterone acetate 59

mefloquine hcl 25

megestrol acetate 59

MEKINIST 24

meloxicam 4

MENACTRA 63

MENEST 57

MENOMUNE-A-C-Y-W-135 63

MENVEO A-C-Y-W-135-DIP 63

mercaptopurine 23

meropenem 8

mesalamine with cleansing wipes 64

MESNEX 18

MESTINON 21

metadate er 45

metaproterenol sulfate 70

metformin hcl 34


85

methadone hcl 1

methazolamide 42

methenamine hippurate 6

methimazole 61

methocarbamol 72

methotrexate sodium 62

methotrexate sodium/pf 62

methoxsalen, rapid 47

methscopolamine bromide 48

methylergonovine maleate 51

methylphenidate hcl 45

methylprednisolone 53

methylprednisolone acetate 53

methylprednisolone sodium succinate 53

metipranolol 68

metoclopramide hcl 18

metolazone 43

metoprolol succinate 40

metoprolol tartrate 40

metoprolol tartrate/hydrochlorothiazide 40

metronidazole 7

metronidazole in sodium chloride 7

mexiletine hcl 39

miconazole nitrate 19

microgestin 57

microgestin fe 57

midodrine hcl 37

migergot 20

MIGRANAL 20

millipred 53

mimvey lo 57

minitran 44

MINIVELLE 57

minocycline hcl 12

minoxidil 44

mircette 57

mirtazapine 16

misoprostol 50

mitoxantrone hcl 23

modafinil 72

moderiba 31

moexipril hcl 38

moexipril hcl/hydrochlorothiazide 38

mometasone furoate 53

mono-linyah 57

MONOJECT PREFILL ADVANCED 36

mononessa 57

montelukast sodium 70

MONUROL 7

morgidox 12

morphine sulfate 3

MOVIPREP 50

moxifloxacin hcl 11

MULTAQ 39

mupirocin 7

mycophenolate mofetil 62

mycophenolate sodium 62

myorisan 47

MYOZYME 48

MYRBETRIQ 50

myzilra 57

Nnabumetone 4

nadolol 40

nafcillin sodium 9

NAGLAZYME 48

naloxone hcl 5

naltrexone hcl 5

NAMENDA 15

NAMENDA XR 15

naphazoline hcl 66

naproxen 4

naproxen sodium 4

naratriptan hcl 21

NASONEX 69

NATACYN 19

nateglinide 34

NEBUPENT 25

necon 57

needles, insulin disposable 66

needles, insulin disposable, safety 66


86

nefazodone hcl 17

neo-polycin 66

neo-polycin hc 67

neomycin sulfate 6

neomycin sulfate/bacitracin zinc/polymyxin

b/hydrocortisone 67

neomycin sulfate/bacitracin/polymyxin b 67

neomycin sulfate/polymyxin b sulfate/gramicidin d 67

neomycin sulfate/polymyxin b sulfate/hydrocortisone 69

neomycin/polymyxin b sulfate/dexamethasone 67

neosporin 67

NESINA 34

NEULASTA 36

NEUMEGA 36

NEUPOGEN 37

nevirapine 29

NEXAVAR 24

nicardipine hcl 41

NICOTROL 5

NICOTROL NS 5

nifediac cc 41

nifedical xl 41

nifedipine 41

nikki 57

NILANDRON 22

nimodipine 41

nisoldipine 41

NITRO-DUR 44

nitrofurantoin 7

nitrofurantoin macrocrystal 7

nitrofurantoin monohydrate/macrocrystals 7

nitroglycerin 44

NITROSTAT 44

nizatidine 49

nora-be 59

NORDITROPIN 54

NORDITROPIN FLEXPRO 54

NORDITROPIN NORDIFLEX 54

norethindrone 59

norethindrone acetate 59

norethindrone acetate-ethinyl estradiol 57

norethindrone acetate-ethinyl estradiol/ferrous

fumarate 57

norgestimate-ethinyl estradiol 57

norinyl 1+35 57

norlyroc 59

NORPACE CR 39

nortrel 57

nortriptyline hcl 17

NORVIR 30

NOXAFIL 20

NUEDEXTA 45

NULOJIX 62

NUTROPIN 54

NUTROPIN AQ 54

NUTROPIN AQ NUSPIN 54

NUVIGIL 72

nyamyc 20

nystatin 20

nystatin/triamcinolone acetonide 20

nystop 20

Oocella 57

octreotide acetate 60

ofloxacin 11

ogestrel 57

olanzapine 28

olanzapine/fluoxetine hcl 16

OLYSIO 31

omeprazole 50

omeprazole magnesium 50

OMNITROPE 54

ondansetron 18

ondansetron hcl 19

ondansetron hcl/pf 19

ONFI 13

ONGLYZA 34

OPSUMIT 71

oralone 46

ORAP 27

ORFADIN 48


87

orsythia 57

OSENI 34

oxacillin sodium 9

oxacillin sodium/dextrose, iso-osmotic 9

oxandrolone 54

oxazepam 33

oxcarbazepine 14

OXSORALEN-ULTRA 47

oxybutynin chloride 51

oxycodone hcl 3

oxycodone hcl/acetaminophen 3

oxycodone hcl/aspirin 3

OXYCONTIN 2

oxymorphone hcl 3

OXYTROL 51

Ppacerone 39

pamidronate disodium 65

PANRETIN 25

pantoprazole sodium 50

paricalcitol 65

paroex 46

paromomycin sulfate 6

paroxetine hcl 17

PASER 21

PAXIL 17

pedi-dri 20

PEDVAXHIB 63

peg 3350/sod sulf/sod bicarbonate/sod

chloride/potassium chl 50

PEGANONE 14

PEGASYS 31

PEGASYS PROCLICK 31

PEGINTRON 31

PEGINTRON REDIPEN 31

pen needle, diabetic disposable, safety 66

pen needle, diabetic, remover & disposal unit 66

penicillin g potassium 9

penicillin g procaine 9

penicillin g sodium 9

penicillin v potassium 9

PENTACEL ACTHIB COMPONENT 63

PENTAM 300 25

PENTASA 64

pentoxifylline 42

perindopril erbumine 38

periogard 46

permethrin 26

perphenazine 18

perphenazine/amitriptyline hcl 27

PFIZERPEN 9

phenelzine sulfate 16

phenobarbital 13

phenytoin 14

phenytoin sodium 14

phenytoin sodium extended 14

philith 57

PICATO 47

pilocarpine hcl 68

pimtrea 57

pindolol 40

pioglitazone hcl 34

pioglitazone hcl/glimepiride 34

pioglitazone hcl/metformin hcl 34

piperacillin sodium/tazobactam sodium 9

pirmella 57

piroxicam 4

podofilox 47

polycin 67

polyethylene glycol 3350 50

polymyxin b sulfate/trimethoprim 67

POMALYST 22

portia 58

potassium chloride 73

potassium chloride in dextrose 5 % and 0.9 % sodium

chloride 74

potassium chloride in dextrose 5 %-0.2 % sodium

chloride 74

potassium chloride in dextrose 5 %-0.45 % sodium

chloride 74


88

potassium chloride in lactated ringers and 5 %

dextrose 74

potassium citrate 73

POTIGA 12

PRADAXA 36

pramipexole di-hcl 26

pravastatin sodium 43

prazosin hcl 37

prednisolone 53

prednisolone acetate 68

prednisolone sod phosphate 68

prednisone 53

prednisone intensol 53

PREMARIN 58

PREMPHASE 58

PREMPRO 58

prenaissance next 75

prenaissance next-b 75

prenatal plus iron tablet 75

prenatal plus tablet 75

prenatal vitamins tablet 75

prevalite 44

previfem 58

PREZISTA 30

PRIFTIN 21

primaquine phosphate 25

primidone 13

PRISTIQ ER 17

PRIVIGEN 62

proair hfa 70

probenecid 20

procainamide hcl 39

prochlorperazine edisylate 18

prochlorperazine maleate 18

PROCRIT 37

proctocream-hc 53

proctosol-hc 53

proctozone-hc 53

progesterone,micronized 59

PROGLYCEM 34

PROGRAF 62

PROLASTIN 72

PROLASTIN C 72

PROLEUKIN 23

PROLIA 65

PROMACTA 37

propafenone hcl 39

propranolol hcl 40

propranolol hcl/hydrochlorothiazide 40

propylthiouracil 61

PROQUAD 63

PROTONIX 50

PROTOPIC 47

protriptyline hcl 17

PROVENTIL HFA 70

PULMOZYME 72

PYLERA 49

pyrazinamide 22

pyridostigmine bromide 21

Qquetiapine fumarate 28

quinapril hcl 38

quinapril hcl/hydrochlorothiazide 39

quinidine gluconate 39

quinidine sulfate 39

QVAR 69

RRABAVERT 63

rabeprazole sodium 50

raloxifene hcl 59

ramipril 39

RANEXA 42

ranitidine hcl 49

RAPAMUNE 62

RAVICTI 48

REBETOL 31

REBIF 46

REBIF REBIDOSE 46

reclipsen 58

RECOMBIVAX HB 63


89

refissa 47

REGRANEX 47

RELENZA 32

RELISTOR 49

REMICADE 62

RENVELA 51

RESCRIPTOR 29

RESTASIS 67

RETROVIR 29

REVATIO 71

revia 5

REVLIMID 22

REYATAZ 30

RIBAPAK 31

ribasphere 31

RIBASPHERE 31

RIBATAB 31

ribavirin 32

rifabutin 21

rifampin 22

RIFATER 22

riluzole 45

rimantadine hcl 32

ringers solution,lactated 75

RIOMET 34

risedronate sodium 65

RISPERDAL CONSTA 28

risperidone 28

RITUXAN 25

rivastigmine tartrate 15

rizatriptan benzoate 21

ropinirole hcl 26

rosadan 7

ROTARIX 64

ROTATEQ 64

ROXICET 3

roxicet 3

SSABRIL 13

SAIZEN 54

SAMSCA 73

SANTYL 47

SAPHRIS 28

SAVELLA 45

selegiline hcl 26

selenium sulfide 47

SELZENTRY 30

SENSIPAR 60

SEREVENT DISKUS 70

SEROSTIM 54

sertraline hcl 17

SIGNIFOR 61

sildenafil citrate 71

silver sulfadiazine 11

simvastatin 43

sirolimus 62

SIRTURO 22

sodium chloride irrigating solution 73

sodium chloride/sodium bicarbonate/potassium

chloride/peg 50

sodium fluoride 74

sodium phenylbutyrate 48

sodium polystyrene sulfonate 73

SOLTAMOX 23

SOMATULINE DEPOT 61

SOMAVERT 61

sorine 39

sotalol hcl 39

SOVALDI 32

SPIRIVA 70

spironolactone 42

spironolactone/hydrochlorothiazide 42

sprintec 58

SPRYCEL 24

sronyx 58

STALEVO 75 26

stavudine 29

STIMATE 54

STIVARGA 24

STRATTERA 45

streptomycin sulfate 6


90

STRIBILD 29

STROMECTOL 25

SUCRAID 48

sucralfate 50

sulfacetamide sodium 11

sulfacetamide sodium/prednisolone sodium

phosphate 67

sulfadiazine 11

sulfamethoxazole/trimethoprim 11

sulfamide 11

sulfasalazine 64

sulfazine 64

sulfazine ec 64

sulindac 4

sumatriptan succinate 21

SUPREP 50

SURMONTIL 18

SUSTIVA 29

SUTENT 24

syeda 58

SYLATRON 31

SYLATRON 4-PACK 31

SYMBICORT 72

SYMLINPEN 120 34

SYMLINPEN 60 34

SYNAGIS 32

SYNERCID 7

SYNRIBO 23

SYNTHROID 60

SYPRINE 73

syring w-ndl,disp,insul,0.3ml/container,empty 66

syring w-ndl,disp,insul,0.5ml/container,empty 66

syringe with needle, insulin, safety, 0.3 ml 66

syringe with needle, insulin, safety, 0.5 ml 66

syringe with needle, insulin, safety, 1 ml 66

syringe with needle, insulin,1 ml and sharps

container 66

syringe with needle,disposable,insulin 1 ml 66

syringe with needle,insulin disposable,0.3 ml 66

syringe with needle,insulin disposable,0.5 ml 66

Ttabloid 23

tacrolimus 62

TAFINLAR 24

TAMIFLU 32

tamoxifen citrate 23

tamsulosin hcl 51

TARCEVA 24

TARGRETIN 25

TASIGNA 24

TAZICEF 8

TAZORAC 47

taztia xt 41

TECFIDERA 46

temazepam 72

tencon 1

terazosin hcl 37

terbinafine hcl 20

terbutaline sulfate 70

terconazole 20

TESTIM 55

testosterone cypionate 55

testosterone enanthate 55

tetanus and diphtheria toxoids, adult 64

tetanus toxoid, adsorbed/pf 64

tetanus,diphtheria toxoid ped/pf 64

TEV-TROPIN 54

THALOMID 22

theochron 71

theophylline anhydrous 71

thioridazine hcl 27

thiothixene 27

THYMOGLOBULIN 62

tiagabine hcl 13

TIKOSYN 39

TIMENTIN 10

timolol maleate 68

tinidazole 7

TIVICAY 29

tizanidine hcl 28


91

TOBI PODHALER 71

TOBRADEX 6

tobramycin 6

tobramycin in 0.225 % sodium chloride 6

tobramycin sulfate 6

tobramycin/dexamethasone 67

tolbutamide 34

tolmetin sodium 4

tolterodine tartrate 51

topiragen 14

topiramate 14

TOPOSAR 24

topotecan hcl 24

torsemide 42

TPN ELECTROLYTES 75

TRACLEER 71

TRADJENTA 34

tramadol hcl 3

tramadol hcl/acetaminophen 3

trandolapril 39

tranexamic acid 37

tranylcypromine sulfate 16

trazodone hcl 16

TRECATOR 22

tretinoin 47

tretinoin/emollient base 47

tri-estarylla 58

tri-linyah 58

tri-previfem 58

tri-sprintec 58

triamcinolone acetonide 53

triamterene/hydrochlorothiazide 42

triderm 53

trifluoperazine hcl 27

trifluridine 32

trihexyphenidyl hcl 26

trilyte with flavor packets 50

trimesis rx 75

trimethoprim 7

trinessa 58

TRISENOX 23

trivora-28 58

trospium chloride 51

TRUVADA 30

TWINRIX 64

TYGACIL 7

TYKERB 24

TYPHIM VI 64

TYSABRI 46

TYZEKA 31

UUCERIS 53

ULESFIA 26

ULORIC 20

unithroid 60

ursodiol 49

VVAGIFEM 58

valacyclovir hcl 32

VALCYTE 30

valproic acid 13

valproic acid (as sodium salt) (valproate sodium) 13

valsartan 38

valsartan/hydrochlorothiazide 38

vancomycin hcl 7

vandetanib 24

VAQTA 64

VARIVAX VACCINE 64

VASCEPA 44

VELCADE 23

velivet 58

venlafaxine hcl 17

VENTAVIS 71

ventolin hfa 70

verapamil hcl 41

VERSACLOZ 28

vestura 58

VEXOL 68

VICTOZA 2-PAK 34

VICTOZA 3-PAK 34


92

VICTRELIS 32

VIDEX 30

VIGAMOX 11

VIIBRYD 17

VIMPAT 15

viorele 58

VIRACEPT 30

VIRAMUNE XR 29

VIREAD 30

vitazol 7

VIVELLE-DOT 58

VOGELXO 55

vol-plus tablet 75

VOLTAREN 4

voriconazole 20

vosol hc 69

VOTRIENT 24

vp-ggr-b6 75

vyfemla 58

VYVANSE 45

Wwarfarin sodium 36

WELCHOL 34

wera 58

XXALKORI 25

XARELTO 36

XENAZINE 45

XGEVA 65

XIFAXAN 7

XOLAIR 72

XOPENEX HFA 70

XTANDI 22

xulane 58

XYREM 72

YYF-VAX 64

Zzafirlukast 70

zaleplon 72

zarah 58

ZAVESCA 48

ZELBORAF 25

ZEMAIRA 72

ZEMPLAR 65

zenchent 58

ZENPEP 48

zenzedi 45

ZIAGEN 30

zidovudine 30

zingiber 75

ziprasidone hcl 28

ZIRGAN 31

zoledronic acid 65

ZOLINZA 23

zolmitriptan 21

zolpidem tartrate 72

ZOMETA 65

zonisamide 12

ZORBTIVE 54

ZORTRESS 62

ZOSTAVAX 64

zovia 1-35e 58

zovia 1-50e 58

ZYKADIA 25

ZYLET 67

ZYTIGA 22

ZYVOX 7


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Category ListingAnalgesics - Drugs to treat pain 1

Analgesics - Drugs to treat pain & inflammation 3

Anesthetics 4

Anti-Addiction/Substance Abuse Treatment Agents 5

Antibacterials - Drugs to treat bacterial infections 5

Anticonvulsants - Drugs to treat or prevent seizures 12

Antidementia Agents - Drugs to treat dementia 15

Antidepressants - Drugs to treat depression 15

Antidotes 18

Antiemetics - Drugs to treat or prevent nausea 18

Antifungals - Drugs to treat fungal infections 19

Antigout Agents - Drugs to treat or prevent gout 20

Antimigraine Agents - Drugs to treat or prevent migraines 20

Antimyasthenic Agents – Drugs to treat Myasthenia Gravis 21

Antimycobacterials - Drugs to treat tuberculosis 21

Antineoplastics - Drugs to treat cancer 22

Antiparasitics - Drugs to treat parasites 25

Antiparkinson Agents - Drugs to treat Parkinsonism 26

Antipsychotics - Drugs used in psychotherapy 26

Antispasticity Agents - Drugs to treat muscle spasms 28

Antivirals - Drugs to treat viral infections 28

Anxiolytics - Drugs to treat anxiety 32

Bipolar Agents - Drugs to treat bipolar disorders 33

Blood Glucose Regulators - Drugs to treat diabetes 33

Blood Products/Modifiers/Volume Expanders 35

Cardiovascular Agents - Drugs to treat blood pressure, cholesterol and the heart 37

Central Nervous System Agents - Drugs that affect the brain 44

Dental and Oral Agents 46

Dermatological Agents - Drugs to treat skin conditions 46

Enzyme Replacement/Modifiers 47

Gastrointestinal Agents - Drugs to treat acid, digestion and bowel conditions 48

Genitourinary Agents - Drugs to treat genitourinary conditions 50

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) 51

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) 53

Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) 54

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) 59

Hormonal Agents, Suppressant (Adrenal) 60

Hormonal Agents, Suppressant (Parathyroid) 60

Hormonal Agents, Suppressant (Pituitary) 60

Hormonal Agents, Suppressant (Thyroid) 61

Immunological Agents - Drugs to stimulate, suppress or regulate the immune system 61

Inflammatory Bowel Disease Agents - Drugs to treat inflammatory bowel disorders 64


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Metabolic Bone Disease Agents - Drugs to treat metabolic bone disorders 64Miscellaneous 65Ophthalmic Agents - Drugs to treat eye conditions 66Otic Agents - Drugs to treat ear conditions 68Respiratory Tract/Pulmonary Agents - Drugs to treat allergies or breathing conditions 69Skeletal Muscle Relaxants - Drugs to treat muscle spasms 72Sleep Disorder Agents - Drugs to treat sleep disorders 72Therapeutic Nutrients/Minerals/Electrolytes 72


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Premera Blue Cross is an HMO and HMO-POS plan with a Medicare contract. Enrollment in Premera Blue Cross depends on contract renewal.

Customer Service:

Premera Blue Cross Medicare AdvantagePO Box 4196Portland, OR 97208-4196

Call toll free 888-850-8526 (TTY: 711)Representatives are available between8 a.m. and 8 p.m., seven days a week.

premera.com

027877 (10-2014)H7245_2015Rx_Accepted

Version 6

Formulary 2015 - Premera Blue Cross Medicare Advantage...

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Transcript of Formulary 2015 - Premera Blue Cross Medicare Advantage...