Formulary - UnitedHealthcare Medicare Solutions

00013621, 8 Y0066_3398318_000_Final_P04 CMS Approved

Inside• Drug tiers and drug payment stages • Complete list of drugs by category

• Requirements and limits • Index of covered drugs

Please read: This document contains information about the drugs covered by this plan.

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

Formulary

2013

Comprehensive

(Complete list of covered drugs)

AARP® MedicareRx Saver Plus (PDP)

about this complete drug listThis is a complete list of prescription drugs that are covered by the AARP® MedicareRx Saver Plus (PDP) plan, insured through UnitedHealthcare,® for the 2013 plan year. It is called the Comprehensive Formulary (drug list) and includes all of the drugs covered by the plan.

For your drug to be covered by the plan, it must be included in the complete drug list. In most cases, your prescription must also be filled at one of our more than 65,000 network pharmacies. To find out if your drug is covered:

1. See if your drug is included in this complete drug list.2. Visit the plan website at www.AARPMedicareRx.com. You can use online tools to look up your

drugs. The information is updated on a regular basis.3. Call UnitedHealthcare Customer Service at 1-888-867-5575, TTY 711, 8 a.m. to 8 p.m. local time,

7 days a week. UnitedHealthcare Customer Service can look up your drugs and let you know if they are covered.

For more informationPlease take the time to review your Evidence of Coverage and any other 2013 plan materials you have received. These materials give more detailed information about your drug coverage in the plan.

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/TDD users should call 1-877-486-2048. Or visit www.medicare.gov.

Questions?If you have questions, we’re here to help. Call UnitedHealthcare Customer Service at

1-888-867-5575, TTY 711 8 a.m. to 8 p.m. local time, 7 days a week

Or visit www.AARPMedicareRx.com

online toolsVisit www.AARPMedicareRx.com to

• Look up your drugs and see what you could save with lower-cost drugs

• View your cost and benefits summary• Track your payment status and

claims history• Find network pharmacies• Print plan forms and materials

If you are a member of a group sponsored plan (your coverage is provided through a former employer, union group or trust), please call the UnitedHealthcare Customer Service number on the back of your member ID card.

1

2013 Complete drug list

The AARP MedicareRx Saver Plus plan is designed to help you manage your prescription drug costs. An important part of this is giving you choices so you and your doctor can choose the best course of treatment for you.

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

With your doctor’s help, you can use this drug list as a tool to choose the drugs that work best for you and to find lower-cost drugs, if needed.

using the drug listThere are two ways to find your prescription drugs in this complete drug list:

1. Alphabetical list (index): Turn to the “Index of covered drugs” section, which begins on page 46, to see the list of drug names in alphabetical order.

2. Medical condition: Turn to the “Covered drugs by category” section, which begins on page 8, to look for drug names based on your medical conditions. For example, if you want to find drugs used to treat high cholesterol, go to the “Cardiovascular Drugs” category and look under “Cholesterol Control Drugs.”

Is it a generic or brand name drug?The drug list shows brand name drugs in bold type (for example, Crestor) and generic drugs in plain type (for example, Simvastatin).

More information about your drugSome drugs have requirements or limits. Please see the “Requirements and limits” section on page 4 for more information on drugs you may use.

This document is a complete list of covered drugs. If your drug is not included in this drug list, you should contact UnitedHealthcare Customer Service to ask if it’s covered, or go to www.AARPMedicareRx.com to look it up online. If you learn that the plan does not cover your drug, you have two options:

1. You can ask UnitedHealthcare Customer Service for a list of similar drugs that are covered by the plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by the plan.

2. You can ask the plan to make an exception and cover your drug. See the “Coverage decisions” section on page 5 for information about how to request an exception.

Drug tiers and drug payment stagesThe amount you pay for a covered drug will depend on:

• Your drug payment stage. The plan has different stages of drug coverage. When you fill a prescription, the amount you pay depends on the stage you’re in.

• The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier has a different copay or coinsurance amount. The chart below shows the differences between the tiers.

For more information about drug payment stages and copay or coinsurance amounts for each tier, please refer to the plan’s Evidence of Coverage (EOC).

If you qualify for extra helpIf you qualify for extra help for your prescription drugs, your copays and coinsurance may be lower. Members who qualify for extra help will receive the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (LIS Rider). Please read it to find out what your costs are. You can also contact UnitedHealthcare Customer Service.

Drug Tier Copay or Coinsurance Includes Helpful Tips

Tier 1: Preferred genericLowest copay

Lower-cost, commonly used generic drugs.

Use Tier 1 drugs for the lowest out-of-pocket costs.

Tier 2: Non-preferred genericLow copay

Most generic drugs. Use Tier 2 drugs, instead of Tier 3 or 4, to help reduce your out-of-pocket costs.

Tier 3: Preferred brandMedium copay

Many common brand name drugs, called preferred brands, and some higher-cost generic drugs.

Many Tier 3 drugs have lower-cost options in Tier 1 or 2. Ask your doctor if they could work for you.

Tier 4: Non-preferred brandHighest copay

Non-preferred generic and non-preferred brand name drugs.

Many Tier 4 drugs have lower-cost options in Tier 1, 2 or 3. Ask your doctor if you can switch to one of these drugs to help reduce your out-of-pocket costs.

Tier 5: Specialty tierCoinsurance

Unique and/or very high-cost drugs.

You pay a percentage of the total drug cost, called coinsurance.

2

3

Generic drugsThe plan covers both brand name and generic drugs. The Food and Drug Administration (FDA) requires a generic drug to have the same active ingredient as the brand name drug. Using generic drugs, whether preferred or non-preferred, may save you money on your copays or coinsurance and may help you stay out of the coverage gap if you have one.

• To pay less out-of-pocket, talk with your doctor to see if any of the brand name drugs you take have generic versions. While most generics are in Tier 2 of the drug list, some generics can be found in Tier 1.

• While generic drugs usually cost less than brand name drugs, newly available generic drugs can be expensive so they may be in Tier 2, 3 or 4 of the drug list.

VaccinesThe plan covers a number of Part D vaccines. Our coverage may include the cost of both the vaccine medication and the administration of the vaccine shot. Some vaccines, like those for the flu and pneumonia, may be covered by Medicare Part B (doctor and outpatient health care).

For the best coverage, the plan recommends that you get vaccines at a network pharmacy if your state allows it. The administration fee likely will be lower at a network pharmacy than at your doctor’s office. You also won’t have to fill out a form to get paid back (reimbursed). If the administration fee is less than $20, you will pay only your copay or coinsurance amount. If it is more than $20, you will pay the extra amount.

If you get your vaccines at your doctor’s office, you will pay the entire cost of the vaccine and administration fee to your doctor. You will have to submit a form to the plan to get reimbursed. You will pay your copay or coinsurance amount, plus the difference between $20 and the administration fee charged by your doctor.

Please see your Evidence of Coverage for more information about vaccines and their costs.

To make sure a recommended vaccine is covered or to request a reimbursement form, call UnitedHealthcare Customer Service at 1-888-867-5575, TTY 711. Or visit www.AARPMedicareRx.com to download a reimbursement form.

4

requirements and limitsSome of the plan’s drugs have requirements or limits to help ensure safe, effective and affordable use. If your drug has any requirements or limits, there will be a code(s) in the “Requirements & Limits” column of the drug list starting on page 8. The codes and what they mean are shown below. Visit www.AARPMedicareRx.com for more information.

You and your doctor may ask the plan for an exception to the requirement and/or limit for your drug. See the “Coverage decisions” section on the next page or see your Evidence of Coverage to learn more.

If you do not get prior approval from the plan for a drug with a requirement or limit, you may be responsible for paying the full cost of the drug.

B/D Medicare Part B or Part DDepending on how this drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it’s correctly covered by Medicare.

la Limited accessDrugs are considered “limited access” if the FDA says the drug can be given out only by certain facilities or doctors. These drugs may require extra handling, provider coordination or patient education that can’t be done at a network pharmacy.

Pa Prior authorizationThe plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don’t get approval, the plan may not cover the drug.

ST Step therapyThere are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover this drug.

For more information about requirements and limits, call UnitedHealthcare Customer Service at 1-888-867-5575, TTY 711.

5

Coverage decisionsAt times you may need to ask for drug coverage that’s not normally provided by the plan. When you do, the plan will consider your request and respond with a coverage decision (coverage determination).

Examples of coverage decisions you may ask for include:

• Asking the plan to pay you back for the cost of a drug you bought at an out-of-network pharmacy.• Asking for an exception to the plan’s coverage rules.

How to request an exceptionYou can ask the plan to make an exception to the coverage rules. There are several types of exceptions that you can ask the plan to make.

• You can ask the plan to cover your drug even if it is not on the formulary (formulary exception).

• You can ask the plan to waive coverage restrictions or limits on your drug (utilization exception). For example, for certain drugs, the plan limits the amount of the drug that it will cover.

• You can ask the plan to provide a higher level of coverage for your drug (tier exception). If

your drug is in the non-preferred tier, you can ask the plan to cover it at the cost-sharing amount that applies to drugs in the preferred tier instead. This would lower the amount you must pay for your drug. Please note, if we grant your request to cover a drug that is not in the plan’s formulary, you may not ask us to provide a higher level of coverage for the drug. Tier exceptions are not available for drugs in the specialty tier.

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

Asking for a coverage decisionYou (or your authorized representative) and your doctor can ask for an initial coverage decision by calling UnitedHealthcare Customer Service at 1-888-867-5575, TTY 711.

When you are requesting a formulary, tiering or utilization restriction exception, your prescriber or physician should submit a statement supporting your request.

See your Evidence of Coverage for more information.

Receiving a coverage decisionGenerally, the plan will make a coverage decision within 72 hours after receiving your prescribing physician’s statement. You can request an expedited, or fast, decision if you or your doctor believe your health requires it. If the plan agrees to a fast decision, you will receive a decision within 24 hours after the plan receives your prescriber’s or prescribing physician’s supporting statement.

6

Drug list changesThe plan recognizes that drug list stability is very important to you. That is why the plan tries to make as few changes to the drug list as possible during the plan year. From time to time, drug list changes may be necessary for safety or other reasons.

The drug list may change throughout the year when the plan:

• Adds a new drug.• Removes a drug.• Changes the requirements or limits for a drug.• Moves a drug to a lower-cost tier.• Moves a drug to a higher-cost tier.

If the FDA declares a drug to be unsafe or the drug’s manufacturer removes the drug from the market, the plan will immediately remove the drug from the drug list and inform affected members. If a drug moves to a higher-cost tier or undergoes some other change, the plan will inform affected members at least 60 days before the change 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.

Generally, if you are taking a drug on the 2013 drug list that was covered at the beginning of the year, the plan will not remove the drug from the drug list or move a drug to a higher tier during the 2013 coverage year except when a new, less expensive generic equivalent drug becomes available (for example, the brand name drug moves to a higher tier and the less expensive drug is on the lower tier), or when new information about the safety or effectiveness of a drug is released.

Other types of changes, such as removing a drug from the drug list, 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. It is important that you have continued access for the remainder of the coverage year to the list of drugs that were available when you chose the plan, except for cases in which you can save additional money or your safety is a concern.

If there are changes to the drug list such as regular or necessary updates, members may see information in the Explanation of Benefits statement, member newsletters or other member mailings. If there are changes to the drug list outside of regular or necessary updates, members may receive a special mailing. The plan website also has updated information.

7

Transition supply process New or continuing membersAs a new or continuing member in the plan, you may be taking drugs that are not on the formulary. Or you may be taking a drug that is on the formulary but your ability to get it is limited. For example, you may need prior authorization before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that the plan covers, or request a formulary exception so that the plan will cover the drug you take. While you talk to your doctor to determine the right course of action for you, the plan may cover your drug in certain cases during the first 90 days you are a member of the plan.

For each of your drugs that is not on the formulary, or if your ability to get your drugs is limited, the plan will cover a temporary 31-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 31-day supply, the plan will not pay for these drugs, even if you have been a member of the plan less than 90 days.

Long-term care facility residentsIf you’re a resident of a long-term care facility, the plan will allow you to refill your prescription until we have provided you with a 91- and up to a 98-day transition supply of the drug consistent with dispensing increment (unless your prescription is for fewer days). The plan will also cover one or more refills for the first 90 days of your membership. If you need a drug that’s not on the drug list or if you have limited ability to get your drugs but you are past the first 90 days of your plan membership, the plan will cover a 31-day emergency supply of the drug (unless your prescription is for fewer days) while you request a formulary exception.

Other transitionsYou may have an unplanned transition, like a hospital discharge or a change in your level of care, after the first 90 days of your plan membership. If this happens and your doctor prescribes a drug that’s not on the drug list, or if it’s difficult for you to get your drugs, you are required to use the plan’s exception process. You may ask for a one-time emergency supply of up to 31 days to give you time to talk to your doctor about other treatment options or to try to get a formulary exception.

For more informationFor more detailed information about AARP MedicareRx Saver Plus prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions, please call UnitedHealthcare Customer Service at

1-888-867-5575, TTY 7118 a.m. to 8 p.m. local time, 7 days a week


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/TDD users should call 1-877-486-2048. Or visit www.medicare.gov.

Bold type = Brand name drug B/D = Medicare Part B or Part D LA = Limited access drug PA = Prior authorization ST = Step therapy

8

Drug Name Drug Tier

Requirements & Limits

Ketorolac Tromethamine (15mg/ml Injection, 30mg/ml Injection)

3 PA

Mefenamic Acid 3Meloxicam (Tablet) 1Meloxicam (Suspension) 2Naproxen 2Naproxen DR 2Naproxen Sodium (275mg Tablet, 550mg Tablet)

2

Oxycodone/Ibuprofen 3Sulindac 2Opioid Analgesics, Long-Acting — Opioid Pain RelieversAstramorph 3Duramorph 3Exalgo 3Fentanyl (Patch) 3Levorphanol Tartrate 3

Drug Name Drug Tier


Analgesics — Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions

Nonsteroidal Anti-Inflammatory Drugs — Pain/Anti-Inflammatory DrugsDiclofenac Potassium 2Diclofenac Sodium DR 2Diclofenac Sodium ER 2Diflunisal 2Etodolac (200mg Capsule, Tablet)

2

Flurbiprofen 2Ibuprofen (Suspension, 400mg Tablet, 600mg Tablet, 800mg Tablet)

2

Indomethacin (Capsule) 3Ketoprofen 3Ketorolac Tromethamine (Tablet)

3

Covered drugs by categoryThe comprehensive formulary (drug list) below provides coverage information about all of the drugs covered by the plan. It is current as of January 1, 2013.

The first column of the chart lists the drug name. Brand name drugs are listed in bold type (for example, Crestor) and generic drugs are listed in plain type (for example, Simvastatin). The information in the Requirements & Limits column tells you if the plan has any special requirements for coverage of your drug.

If you have trouble finding your drug in the list, turn to the “Index of covered drugs” section that begins on page 46. If your prescription is not in this complete formulary, please visit www.AARPMedicareRx.com or call UnitedHealthcare Customer Service at 1-888-867-5575, TTY 711, for additional help.

9

Drug Name Drug Tier


Methadone HCl (Concentrate, Oral Solution, Tablet)

3

Methadone HCl (Injection) 4

Methadose (Tablet) 3Morphine Sulfate (Oral Solution, Tablet)

3

Morphine Sulfate ER 3Nucynta ER 3Opioid Analgesics, Short-Acting — Opioid Pain RelieversAcetaminophen/Codeine 2Butorphanol Tartrate 3Co-Gesic 3Codeine Sulfate (Tablet) 2Fentanyl Citrate Oral Transmucosal

5 PA

Hydrocodone/Acetaminophen (Oral Solution, 300mg; 10mg Tablet, 300mg; 5mg Tablet, 300mg; 7.5mg Tablet, 325mg; 10mg Tablet, 325mg; 5mg Tablet, 325mg; 7.5mg Tablet, 500mg; 10mg Tablet, 500mg; 2.5mg Tablet, 500mg; 5mg Tablet, 500mg; 7.5mg Tablet, 650mg; 10mg Tablet, 650mg; 7.5mg Tablet, 660mg; 10mg Tablet, 750mg; 10mg Tablet, 750mg; 7.5mg Tablet)

3

Hydrocodone/Ibuprofen 3Hydromorphone HCl (Tablet)

3

Nalbuphine HCl 3Onsolis 5 PA

Drug Name Drug Tier


Oxycodone HCl (Capsule, Concentrate, 15mg Tablet, 30mg Tablet, 5mg Tablet)

3

Oxycodone/Acetaminophen

3

Oxycodone/Aspirin 3Roxicet (500mg; 5mg Tablet)

3

Stagesic 3Tramadol HCl 2Tramadol HCl/Acetaminophen

2

Anesthetics — Drugs for Numbing

Local AnestheticsLidocaine (Ointment) 3 B/DLidocaine HCl (External Solution)

3

Lidocaine HCl (0.5% Injection, 1% Injection)

3 B/D

Lidocaine HCl (Gel) 3Lidocaine Viscous 3Lidocaine/Prilocaine (Cream)

3 B/D

Lidoderm 3

Antibacterials — Drugs to Treat Bacterial Infections

Aminoglycosides — AntibioticsAmikacin Sulfate (500mg/2ml Injection, 50mg/ml Injection)

3

Gentak (Ointment) 2Gentamicin Sulfate (Cream, Injection, 0.1% Ointment, Ophthalmic Solution)

2

Gentamicin Sulfate/NaCl (1.2mg/ml; 0.9% Injection, 1.6mg/ml; 0.9% Injection, 1mg/ml; 0.9% Injection)

2

10


Drug Name Drug Tier


Gentamicin Sulfate/NaCl (0.9mg/ml; 0.9% Injection, 1.4mg/ml; 0.9% Injection)

3

Isotonic Gentamicin (0.8mg/ml; 0.9% Injection)

2

Kanamycin Sulfate 3Neomycin Sulfate 2Neomycin/Polymyxin B Sulfates

3

Paromomycin Sulfate 3Streptomycin Sulfate 4Tobi 5 B/DTobramycin Sulfate (Ophthalmic Solution)

2

Tobramycin Sulfate (10mg/ml Injection, 80mg/2ml Injection)

3

Tobramycin Sulfate/Sodium Chloride

3

Tobrex (Ointment) 3Antibacterials, Other — AntibioticsBaciim 2Bacitracin (Injection, Ophthalmic Ointment)

2

Bacitracin/Polymyxin B 2Chloramphenicol Sodium Succinate 3

Cleocin (75mg Capsule) 4Cleocin Galaxy 4Cleocin in D5W 4Cleocin Phosphate (900mg/6ml Injection) 4

Drug Name Drug Tier


Clindamycin HCl (150mg Capsule, 300mg Capsule)

2

Clindamycin Phosphate (Cream)

2

Clindamycin Phosphate Add-Vantage

3

Colistimethate Sodium 4Cubicin 5 B/DFlagyl ER 4Lincocin 4Methenamine Hippurate 3Metronidazole 3Metronidazole in NaCl 0.79%

3

Metronidazole Vaginal 2Mupirocin 2Neomycin/Bacitracin/Polymyxin

2

Neomycin/Polymyxin/Gramicidin

2

Nitrofurantoin 3Nitrofurantoin Macrocrystalline (50mg Capsule)

3

Nitrofurantoin Monohydrate 3Polymyxin B Sulfate 3Primsol 4Silver Sulfadiazine 2SSD 2Synercid 5Thermazene 2Trimethoprim 2

11

Drug Name Drug Tier


Trimethoprim Sulfate/Polymyxin B Sulfate

2

Tygacil 4Vancocin HCl 5 PAVancomycin HCl (1000mg Injection, 10gm Injection, 500mg Injection)

3 B/D

Vancomycin HCl (Capsule) 5 PAVandazole 2Vibativ (250mg Injection) 4Xifaxan (200mg Tablet) 4Xifaxan (550mg Tablet) 5Zyvox 5 PABeta-Lactam, Cephalosporins — AntibioticsCedax (Capsule) 4Cefaclor 2Cefaclor ER 2Cefadroxil 2Cefazolin Sodium (10gm Injection, 1gm Injection, 1gm; 5% Injection, 500mg Injection)

3

Cefdinir 3Cefepime (1gm Injection, 2gm Injection)

3

Cefotaxime Sodium (10gm Injection, 1gm Injection, 2gm Injection)

3

Cefoxitin Sodium 3Cefoxitin Sodium/Dextrose 4

Cefpodoxime Proxetil 3Cefprozil 3Ceftazidime (1gm Injection, 2gm Injection, 6gm Injection)

3

Ceftazidime/Dextrose 3Ceftriaxone Sodium 3Cefuroxime Axetil (Tablet) 2

Drug Name Drug Tier


Cefuroxime Sodium (1.5gm Injection, 7.5gm Injection, 750mg Injection)

2

Cephalexin 2Claforan (1gm Injection) 4Fortaz (1gm/50ml; 5% Injection, 2gm Injection, 2gm/50ml; 5% Injection, 6gm Injection)

4

Suprax 3Zinacef (750mg Injection) 4

Zinacef in Iso-Osmotic Dextrose 4

Zinacef in Iso-Osmotic Diluent 4

Beta-Lactam, Other — AntibioticsAzactam in Iso-Osmotic Dextrose 4

Aztreonam (1gm Injection) 3Cayston 5 PACefotetan 4Doribax (500mg Injection) 4

Imipenem/Cilastatin 3Invanz 4Meropenem (500mg Injection)

3

Primaxin 4Beta-Lactam, Penicillins — AntibioticsAmoxicillin 2Amoxicillin/Potassium Clavulanate

2

Amoxicillin/Potassium Clavulanate ER

2

Ampicillin 3Ampicillin Sodium (10gm Injection, 125mg Injection, 1gm Injection)

3

12


Drug Name Drug Tier


Ampicillin-Sulbactam (10gm; 5gm Injection, 2gm; 1gm Injection)

3

Bactocill in Dextrose (1gm/50ml Injection) 4

Bactocill in Dextrose (2gm/50ml Injection) 5

Bicillin C-R 4Bicillin L-A 4Dicloxacillin Sodium 2Nafcillin Sodium (10gm Injection, 1gm Injection)

3

Nallpen/Dextrose (1gm/50ml Injection) 4

Oxacillin Sodium (10gm Injection, 1gm Injection)

4

Penicillin G Potassium (5mu Injection)

4

Penicillin G Potassium in Iso-Osmotic Dextrose 3

Penicillin G Procaine 4Penicillin G Sodium 4Penicillin V Potassium 2Pfizerpen-G (20mu Injection) 4

Piperacillin Sodium/Tazobactam Sodium (3gm; 0.375gm Injection, 4gm; 0.5gm Injection)

3

Timentin (0.1gm; 3gm Injection) 4

Drug Name Drug Tier


Zosyn (3gm; 0.375gm Injection, 5%; 2gm/50ml; 0.25gm/50ml Injection, 5%; 3gm/50ml; 0.375gm/50ml Injection)

4

Macrolides — AntibioticsAzithromycin (500mg Injection, Suspension Reconstituted, Tablet)

2

Clarithromycin 3Clarithromycin ER 3Dificid 5 PAE.E.S. 400 2E.E.S. Granules 3Ery 2Ery-Tab 3Eryped 3Erythrocin Lactobionate (500mg Injection) 4

Erythrocin Stearate 4Erythromycin (External Solution, Gel, Ointment)

2

Erythromycin Base 2Erythromycin Ethylsuccinate

2

Ketek 4 PAPCE 4Zmax 4Quinolones — AntibioticsAvelox (Tablet) 3Avelox (Injection) 4Avelox ABC Pack 3

13

Drug Name Drug Tier


Cipro (Suspension Reconstituted) 4

Cipro IV (200mg/100ml; 5% Injection) 4

Ciprofloxacin (400mg/40ml Injection)

2

Ciprofloxacin ER 3Ciprofloxacin HCl 2Factive 4Levofloxacin 3Levofloxacin in D5W (5%; 500mg/100ml Injection)

3

Moxeza 3Noroxin 4Ofloxacin 3Sulfonamides — AntibioticsSodium Sulfacetamide (Ophthalmic Solution)

2

Sulfacetamide Sodium (Ointment)

2

Sulfadiazine 3Sulfamethoxazole/Trimethoprim

2

Sulfamethoxazole/Trimethoprim DS

2

Tetracyclines — AntibioticsDemeclocycline HCl 4Doxycycline (75mg Capsule)

3

Doxycycline Hyclate (Capsule, Injection, Tablet, 100mg Tablet Delayed Release, 75mg Tablet Delayed Release)

3

Doxycycline Hyclate (150mg Tablet Delayed Release)

4

Doxycycline Monohydrate (150mg Tablet, 50mg Tablet, 75mg Tablet)

3

Drug Name Drug Tier


Minocycline HCl (Capsule) 2Minocycline HCl ER 4Tetracycline HCl 2Vibramycin (Syrup) 4

Anticonvulsants — Drugs to Treat Seizures

Anticonvulsants, Other — Seizure Control DrugsLevetiracetam (500mg/5ml Injection, Oral Solution, Tablet)

2

Levetiracetam ER 3Phenobarbital (Elixir, 16.2mg Tablet, 30mg Tablet, 32.4mg Tablet, 64.8mg Tablet, 97.2mg Tablet)

2 PA

Potiga 4Calcium Channel Modifying Agents — Seizure Control DrugsCelontin 4Ethosuximide 3Lyrica 3Zonisamide 2Gamma-Aminobutyric Acid (GABA) Augmenting Agents — Seizure Control DrugsClonazepam 2 PAClonazepam ODT 4Clorazepate Dipotassium 2 PADiazepam (Gel) 4 PADivalproex Sodium 2Divalproex Sodium DR 2Divalproex Sodium ER 2Gabapentin 2Gabitril 4Onfi 4 PAPrimidone 2

14


Drug Name Drug Tier


Sabril 5 PAValproate Sodium (100mg/ml injection)

3

Valproic Acid 2Glutamate Reducing Agents — Seizure Control DrugsFelbamate (Tablet) 4Felbamate (Suspension) 5Felbatol (Tablet) 4Felbatol (Suspension) 5Lamictal ODT (Tablet Dispersible) 4

Lamictal Starter Kit 4Lamotrigine (Tablet) 2Lamotrigine (Tablet Chewable)

3

Topiramate 2Sodium Channel Agents — Seizure Control DrugsBanzel 4Carbamazepine 3Carbamazepine ER (Capsule Extended Release 12 Hour)

3

Dilantin 3Dilantin Infatabs 3Epitol 3Equetro 4Fosphenytoin Sodium (100mg pe/2ml Injection)

3

Oxcarbazepine 3Peganone 4Phenytek 2

Drug Name Drug Tier


Phenytoin 2Phenytoin Sodium 2Phenytoin Sodium Extended

2

Tegretol 3Tegretol-XR 3Trileptal (Suspension) 4Vimpat (Oral Solution, Tablet) 4

Vimpat (Injection) 4 PA

Antidementia Agents — Drugs to Treat Alzheimer’s Disease and Dementia

Cholinesterase Inhibitors — Alzheimer’s Disease and Dementia DrugsDonepezil HCl 2Exelon (Oral Solution) 4Exelon (Patch 24 Hour) 4 STRivastigmine Tartrate 3N-methyl-D-aspartate (NMDA) Receptor Antagonists — Alzheimer’s Disease and Dementia DrugsNamenda 3Namenda Titration Pak 3

Antidepressants — Drugs to Treat Depression

Antidepressants, Other — AntidepressantsBudeprion SR 2Bupropion HCl 2Bupropion HCl SR 2Bupropion XL 2Maprotiline HCl 2

15

Drug Name Drug Tier


Mirtazapine 2Mirtazapine ODT (30mg Tablet Dispersible, 45mg Tablet Dispersible)

2

Nefazodone HCl 2Trazodone HCl 2Monoamine Oxidase Inhibitors — AntidepressantsEmsam 4 STMarplan 4Nardil 3Phenelzine Sulfate 2Selegiline HCl 3Tranylcypromine Sulfate 3Serotonin/Norepinephrine Reuptake Inhibitors — AntidepressantsCitalopram Hydrobromide (Tablet)

1

Citalopram Hydrobromide (Oral Solution)

3

Cymbalta 4 PAEscitalopram Oxalate 2Fluoxetine DR 4Fluoxetine HCl (Capsule, Oral Solution, 10mg Tablet, 20mg Tablet)

2

Fluvoxamine Maleate 2Paroxetine HCl 2Paroxetine HCl ER 4Paxil (Suspension) 4Pristiq 4 PASertraline HCl (Tablet) 1Sertraline HCl (Concentrate)

3

Venlafaxine HCl 3 STVenlafaxine HCl ER (Capsule Extended Release 24 Hour)

2

Viibryd 4 ST

Drug Name Drug Tier


Tricyclics — AntidepressantsAmitriptyline HCl 2Amoxapine 2Clomipramine HCl 2Desipramine HCl 3Doxepin HCl 2Imipramine HCl 2Imipramine Pamoate 3Nortriptyline HCl 2Perphenazine/Amitriptyline 2Protriptyline HCl 3Trimipramine Maleate 3

Antidotes, Deterrents and Toxicologic Agents — Drugs for Overdose or Deterrents

Alcohol Deterrents/Anti-Craving — Antidotes/Deterrents/ProtectantsAntabuse 3Disulfiram 3Naltrexone HCl 3Vivitrol 5Opioid Antagonists — Antidotes/Deterrents/ProtectantsBuprenorphine HCl 3Naloxone HCl (1mg/ml Injection)

3

Suboxone 4Smoking Cessation Agents — DeterrentsBuproban 2Chantix 4Chantix Pak 4Nicotrol Inhaler 4Nicotrol NS 3

16


Drug Name Drug Tier


Antiemetics — Drugs to Treat Nausea and Vomiting

Antiemetics, Other — Nausea and Vomiting DrugsMeclizine HCl 2Emetogenic Therapy Adjuncts — Nausea and Vomiting DrugsAloxi 4Anzemet (50mg Tablet) 4 B/DAnzemet (100mg Tablet) 5 B/DCesamet 5 B/D, PADronabinol (2.5mg Capsule, 5mg Capsule)

3 B/D, PA

Dronabinol (10mg Capsule) 5 B/D, PAEmend (Capsule) 3 B/D, PAGranisetron HCl (0.1mg/ml Injection, 1mg/ml Injection)

3

Granisetron HCl (Tablet) 3 B/DGranisol 3 B/DOndansetron HCl (Tablet) 2 B/DOndansetron HCl (4mg/2ml Injection)

3

Ondansetron HCl (Oral Solution)

3 B/D

Ondansetron ODT 2 B/DSancuso 5

Antifungals — Drugs to Treat Fungal Infections

Antifungals — Fungal Infection DrugsAbelcet 5 B/DAmBisome 5 B/D

Drug Name Drug Tier


Amphotec (50mg Injection) 4 B/D

Amphotericin B 3 B/DAncobon 5Cancidas 5Ciclopirox 3Ciclopirox Nail Lacquer 3Ciclopirox Olamine 3Clotrimazole (External Cream, External Solution, Troche)

2

Clotrimazole/Betamethasone Dipropionate

2

Econazole Nitrate 2Eraxis (100mg Injection) 5Fluconazole 2Fluconazole in Dextrose (56mg/ml; 400mg/200ml Injection)

2

Flucytosine 5Gris-Peg 4Griseofulvin Microsize 3Itraconazole 3 PAKetoconazole (Cream, Shampoo, Tablet)

2

Ketoconazole (Foam) 4Lamisil (Packet) 4Miconazole 3 2Mycamine 5Natacyn 3Noxafil 5Nyamyc 2

17

Drug Name Drug Tier


Nystatin (Cream, Ointment, 100000unit/gm Powder, Suspension, Tablet)

2

Nystatin/Triamcinolone 2Nystop 2Pedi-Dri 2Sporanox (Oral Solution) 4 PATerbinafine HCl (Tablet) 2Terconazole (0.4% Cream, Suppository)

2

Vfend (Suspension Reconstituted) 5

Vfend (Tablet) 5 STVfend IV 4Voriconazole (Tablet) 5Zazole (Cream) 2

Antigout Agents — Drugs to Treat Gout

Antigout Agents — Gout DrugsAllopurinol (Tablet) 2Allopurinol Sodium (Injection)

2

Colcrys 3Probenecid 2Probenecid/Colchicine 2Uloric 3 ST

Antimigraine Agents — Drugs to Treat Migraines

Ergot Alkaloids — Migraine DrugsDihydroergotamine Mesylate

3

Ergotamine Tartrate/Caffeine

3

Migergot 3Serotonin (5-HT) 1b/1d Receptor Agonists — Migraine DrugsMaxalt 3Maxalt-MLT 3

Drug Name Drug Tier


Naratriptan HCl 2Sumatriptan Succinate (Tablet)

2

Sumatriptan Succinate (6mg/0.5ml Injection)

3

Antimyasthenic Agents — Drugs to Treat Myasthenia Gravis

Parasympathomimetics — Myasthenia Gravis DrugsMestinon (Syrup) 4Mestinon Timespan 4Mytelase 4Pyridostigmine Bromide 2Regonol 2

Antimycobacterials — Drugs to Treat Infections

Antimycobacterials, Other — Miscellaneous Anti-InfectivesDapsone 3Mycobutin 4Antituberculars — Tuberculosis DrugsCapastat Sulfate 4Ethambutol HCl 3Isoniazid 3Paser 4Priftin 4Rifampin (Capsule) 3Rifampin (Injection) 4Rifater 4Seromycin 4Trecator 4

Antineoplastics — Drugs to Treat Cancer

Alkylating Agents — Chemotherapy AgentsBiCNU 4Busulfex 5

18


Drug Name Drug Tier


CeeNU 4Cyclophosphamide (Tablet) 3 B/DDacarbazine (200mg Injection)

3

Hexalen 5 PAIfosfamide (1gm Injection) 3Leukeran 3Matulane 5Melphalan HCl 5Mustargen 5Thiotepa 4Treanda (100mg Injection) 5 PA

Zanosar 5Antiangiogenic Agents — Chemotherapy AgentsCaprelsa 5 PARevlimid (10mg Capsule, 15mg Capsule, 25mg Capsule, 5mg Capsule)

5 PA, LA

Thalomid 5 PAAntiestrogens/Modifiers — Chemotherapy AgentsEmcyt 4 PAFareston 4Faslodex 5Tamoxifen Citrate 2Antimetabolites — Chemotherapy AgentsCladribine 5 B/DClolar 5Cytarabine (500mg Injection)

3 B/D

Drug Name Drug Tier


Cytarabine Aqueous (20mg/ml Injection)

2 B/D

Cytarabine Aqueous (100mg/ml Injection)

3 B/D

Droxia 4Elitek (1.5mg Injection) 5Fluorouracil (500mg/10ml Injection)

3 B/D

Folotyn (40mg/2ml Injection) 5 PA

Gemcitabine HCl (1gm Injection)

5

Gemzar (1gm Injection) 5Hydroxyurea 2Mercaptopurine 3Pentostatin 5Tabloid 4 PAAntineoplastics, Other — Chemotherapy AgentsAbraxane 5 PAAdriamycin (2mg/ml Injection)

3 B/D

Alimta (500mg Injection) 5 PAAmifostine 5Arranon 5Bleomycin Sulfate (30unit Injection)

3 B/D

Carboplatin (150mg/15ml Injection)

3

Cerubidine 4Cisplatin (100mg/100ml Injection)

3

Cosmegen 4

19

Drug Name Drug Tier


Dacogen 5Daunorubicin HCl (5mg/ml Injection)

2

Dexrazoxane (500mg Injection)

5 PA

Docefrez 5Docetaxel (80mg/4ml Injection, 80mg/8ml Injection)

5

Doxil 5 B/DDoxorubicin HCl (2mg/ml Injection)

3 B/D

Elspar 4Epirubicin HCl (50mg/25ml Injection)

3

Erivedge 5 PAFludarabine Phosphate (50mg Injection)

5

Fusilev 5Halaven 5 PAIdarubicin HCl (10mg/10ml Injection)

5

Irinotecan (100mg/5ml Injection)

3

Istodax 5 PAIxempra Kit (45mg Injection) 5

Jakafi 5 PAJevtana 5 PALeucovorin Calcium (100mg Injection, 350mg Injection, Tablet)

3

Menest 3Mesna 3Mesnex (Tablet) 4Mitomycin (20mg Injection) 3Mitoxantrone HCl 3 PAOntak 5 PAOxaliplatin (100mg/20ml Injection)

5

Drug Name Drug Tier


Paclitaxel (300mg/50ml Injection)

3

Picato 4Proleukin 5 PASylatron 5 PATaxotere (80mg/4ml Injection) 5

Trisenox 4 PAVelcade 5 PAVidaza 5 PAVinblastine Sulfate (10mg Injection)

3 B/D

Vincasar PFS 3 B/DVincristine Sulfate 3 B/DVinorelbine Tartrate (50mg/5ml Injection)

3

Zolinza 5 PAZytiga 5 PAAromatase Inhibitors, 3rd Generation — Chemotherapy AgentsAnastrozole 2Aromasin 4Exemestane 3Letrozole 2Enzyme Inhibitors — Chemotherapy AgentsEtopophos 5Etoposide (Injection) 3Hycamtin (Injection) 5Toposar 3Topotecan HCl (4mg Injection)

5

Molecular Target Inhibitors — Chemotherapy AgentsAfinitor 5 PAGleevec 5 PAInlyta 5 PANexavar 5 PASprycel 5 PA

20


Drug Name Drug Tier


Sutent 5 PATarceva 5 PATasigna 5 PATykerb 5 PAVotrient 5 PAXalkori 5 PAZelboraf 5 PAMonoclonal Antibodies — Chemotherapy AgentsArzerra 5 PAAvastin (100mg/4ml Injection) 5 PA

Campath 5 PAErbitux (100mg/50ml Injection) 5 PA

Herceptin 5 PARituxan 5 PAVectibix (100mg/5ml Injection) 5 PA

Yervoy (50mg/10ml Injection) 5 PA

Retinoids — Chemotherapy AgentsPanretin 5 PATargretin 5 PATretinoin (Capsule) 5

Antiparasitics — Drugs to Treat Parasitic Infections

Anthelmintics — Worm Infection DrugsAlbenza 3Biltricide 3Stromectol 3

Drug Name Drug Tier


Antiprotozoals — Protozoal Infection DrugsAlinia 4Atovaquone/Proguanil HCl (250mg; 100mg Tablet)

3

Chloroquine Phosphate 3Daraprim 3Hydroxychloroquine Sulfate 2Malarone 4Mefloquine HCl 2Mepron 5Nebupent 4 B/DPentam 300 4Primaquine Phosphate 4Qualaquin 4 PAPediculicides/Scabicides — Scabies and Lice DrugsLindane 3Malathion 3Permethrin (Cream) 2

Antiparkinson Agents — Drugs to Treat Parkinson’s Disease

Anticholinergics — Parkinson’s Disease DrugsBenztropine Mesylate 2Cogentin 4Trihexyphenidyl HCl 2Antiparkinson Agents — Parkinson’s Disease DrugsComtan 3Tasmar 5

21

Drug Name Drug Tier


Dopamine Agonists — Parkinson’s Disease DrugsApokyn 5Bromocriptine Mesylate 3Pramipexole Dihydrochloride

3

Ropinirole HCl 2Dopamine Precursors/L-Amino Acid Decarboxylase Inhibitors — Parkinson’s Disease DrugsCarbidopa/Levodopa 2Carbidopa/Levodopa ER 2Carbidopa/Levodopa ODT 3Stalevo 3

Antipsychotics — Drugs to Treat Mood Disorders

1st Generation/Typical — Mood Disorder DrugsChlorpromazine HCl 2Compro 2Fluphenazine Decanoate 3Fluphenazine HCl 2Haloperidol 2Haloperidol Decanoate 2Haloperidol Lactate 2Loxapine Succinate 2Orap 3Perphenazine 2Prochlorperazine 2Prochlorperazine Edisylate 3Prochlorperazine Maleate 2Thioridazine HCl 3Thiothixene 2Trifluoperazine HCl 2

Drug Name Drug Tier


2nd Generation/Atypical — Mood Disorder DrugsAbilify 4 STAbilify Discmelt 4 STFanapt 4 STFanapt Titration Pack 4 STGeodon (Injection) 4Invega 4 STInvega Sustenna (39mg/0.25ml Injection, 78mg/0.5ml Injection)

4

Invega Sustenna (117mg/0.75ml Injection, 156mg/ml Injection, 234mg/1.5ml Injection)

5

Latuda 4 PAOlanzapine 3Olanzapine ODT 3Quetiapine Fumarate 2Risperdal Consta (12.5mg Injection, 25mg Injection)

4

Risperdal Consta (37.5mg Injection, 50mg Injection)

5

Risperidone (Tablet) 2Risperidone (Oral Solution) 3Risperidone ODT 3Saphris 3Seroquel XR 3Ziprasidone HCl (Capsule) 4Zyprexa (Injection) 4Treatment-Resistant — Mood Disorder DrugsClozapine 3Fazaclo 3

22


Drug Name Drug Tier


Antispasticity Agents — Drugs to Treat Spasms

Antispasticity Agents — Muscle Spasm DrugsBaclofen 2Dantrolene Sodium (Capsule)

3

Gablofen (10000mcg/20ml Injection, 50mcg/ml Injection)

3 B/D, PA

Gablofen (40000mcg/20ml Injection)

5 B/D, PA

Lioresal Intrathecal (0.05mg/ml Injection, 10mg/20ml Injection)

3 B/D, PA

Lioresal Intrathecal (10mg/5ml Injection) 5 B/D, PA

Tizanidine HCl (Tablet) 2

Antivirals — Drugs to Treat Viral Infections

Anti-Cytomegalovirus (CMV) Agents — Miscellaneous Antiviral DrugsCytovene 4 B/DFoscarnet Sodium 3 B/DGanciclovir (Capsule) 4Ganciclovir (Injection) 4 B/DValcyte 5Vistide 5

Drug Name Drug Tier


Anti-HIV Agents, Non-nucleoside Reverse Transcriptase Inhibitors — HIV DrugsAtripla 5Complera 5Edurant 5Intelence (100mg Tablet, 200mg Tablet) 5

Nevirapine (Tablet) 3Rescriptor 4Sustiva 4Viramune (Tablet) 3Viramune (Suspension) 4Viramune XR 3Anti-HIV Agents, Nucleoside and Nucleotide Reverse Transcriptase Inhibitors — HIV DrugsCombivir 5Didanosine 3Emtriva 4Epivir (Oral Solution) 3Epivir (Tablet) 4Epivir HBV 3Epzicom 5Lamivudine 3Lamivudine/Zidovudine 5Retrovir IV Infusion 4Stavudine (Capsule) 3Trizivir 5Truvada 5Videx Pediatric (2gm Oral Solution) 4

Viread 5

23

Drug Name Drug Tier


Zerit (Oral Solution) 4Ziagen 4Zidovudine 3Anti-HIV Agents, Other — HIV DrugsFuzeon 5Isentress 5Selzentry 5Anti-HIV Agents, Protease Inhibitors — HIV DrugsAptivus 5Crixivan 3Invirase (Capsule) 4Invirase (Tablet) 5Kaletra (100mg; 25mg Tablet) 4

Kaletra (Oral Solution, 200mg; 50mg Tablet) 5

Lexiva (Suspension) 4Lexiva (Tablet) 5Norvir 4Prezista (150mg Tablet, 75mg Tablet) 4

Prezista (400mg Tablet, 600mg Tablet) 5

Reyataz (100mg Capsule) 3

Reyataz (150mg Capsule, 200mg Capsule, 300mg Capsule)

5

Viracept 5Anti-Influenza Agents — Flu DrugsAmantadine HCl 2Relenza Diskhaler 4Rimantadine HCl 2Tamiflu 3

Drug Name Drug Tier


Antihepatitis Agents — Hepatitis DrugsBaraclude (Oral Solution) 4

Baraclude (Tablet) 5Hepsera 5Incivek 5 PAInfergen (15mcg/0.5ml Injection) 5 PA

Intron-A (10mu/0.2ml Injection, 3mu/0.2ml Injection, 6000000unit/ml Injection)

4 PA

Intron-A (5mu/0.2ml Injection) 5 PA

Intron-A W/Diluent (10mu Injection) 5 PA

Peg-Intron (50mcg/0.5ml Injection) 5 PA

Peg-Intron Redipen 5 PAPegasys 5 PAPegasys Proclick (135mcg/0.5ml Injection) 5 PA

Rebetol (Oral Solution) 4 PARibapak (Tablet) 5 PARibasphere (Capsule, 200mg Tablet)

3 PA

Ribasphere (400mg Tablet, 600mg Tablet)

5 PA

Ribavirin 3 PATyzeka 5Victrelis 5 PAAntiherpetic Agents — Herpes DrugsAcyclovir 2Acyclovir Sodium (500mg Injection)

2 B/D

Famciclovir 3Trifluridine 3Valacyclovir HCl 3

24


Drug Name Drug Tier


Anxiolytics — Drugs to Treat Anxiety

Anxiolytics, Other — Anxiety DrugsAlprazolam (0.25mg Tablet, 0.5mg Tablet, 1mg Tablet, 2mg Tablet)

2 PA

Buspirone HCl 2Chlordiazepoxide HCl 2 PAChlordiazepoxide/Amitriptyline

2

Diazepam (Oral Solution, Tablet)

2 PA

Diazepam Intensol 2 PALorazepam (Tablet) 2 PALorazepam Intensol 2 PA

Bipolar Agents — Drugs to Treat Mood Disorders

Mood Stabilizers — Mood Disorder DrugsLithium Carbonate 2Lithium Carbonate ER 2Lithium Citrate 2Lithobid 3

Blood Glucose Regulators — Drugs to Regulate Blood Sugar

Antidiabetic Agents — Diabetic DrugsAcarbose 2Actoplus Met (15-500mg Tablet, 15-850mg Tablet) 3

Actos 3Avandamet 4 PAAvandaryl 4 PAAvandia 4 PA

Drug Name Drug Tier


Byetta 3Duetact 3Glimepiride 2Glipizide 1Glipizide ER 2Glipizide/Metformin HCl 2Glyburide 1Glyburide Micronized 1Glyburide/Metformin HCl 2Kombiglyze XR 3Metformin HCl 1Metformin HCl ER (500mg Tablet Extended Release 24 Hour, 750mg Tablet Extended Release 24 Hour)

2

Nateglinide 3Onglyza 3Prandimet 4Prandin 4Riomet 4Symlinpen 120 4 PASymlinpen 60 4 PATolbutamide 2Tradjenta 3Victoza 3Glycemic Agents — Diabetic DrugsClinimix 4.25%/Dextrose 20%

4 B/D

Clinimix 5%/Dextrose 15% 4 B/D


25

Drug Name Drug Tier


Clinimix E 2.75%/Dextrose 10% 4 B/D




Clinimix E 5%/Dextrose 15% 4 B/D


Dextrose 10%/NaCl 0.45% 3

Dextrose 10% Flex Container

3

Dextrose 10%/NaCl 0.2% 3Dextrose 2.5%/Sodium Chloride 0.45%

3

Dextrose 5% 3Dextrose 5%/NaCl 0.2% 3Dextrose 5%/NaCl 0.225% 3

Dextrose 5%/NaCl 0.33% 3Dextrose 5%/NaCl 0.45% 3Dextrose 5%/NaCl 0.9% 3Glucagen Hypokit 4Glucagon Emergency Kit 3

Ionosol-B/Dextrose 5% 4Ionosol-MB/Dextrose 5% 4

KCl 0.075%/D5W/NaCl 0.45%

3

KCl 0.15%/D5W/LR 3KCl 0.15%/D5W/NaCl 0.2%

3

KCl 0.15%/D5W/NaCl 0.225%

3

Drug Name Drug Tier


KCl 0.15%/D5W/NaCl 0.9%

3

KCl 0.3%/D5W/NaCl 0.45%

3

KCl 0.3%/D5W/NaCl 0.9%

3

Normosol-R in D5W 3Potassium Chloride 0.15%/D5W/ NaCl 0.45% Viaflex

3

Potassium Chloride 0.15%/D5W/NaCl 0.33%

3

Potassium Chloride 0.22%/D5W/NaCl 0.45%

3

Proglycem 4Insulins — Diabetic DrugsLevemir (Vial) 3Novolin (Vial) 3Novolog (Vial) 3

Blood Products/Modifiers/Volume Expanders — Drugs to Treat Blood Disorders

Anticoagulants — Blood ThinnersArgatroban (100mg/ml Injection) 5

Argatroban (125mg/125ml; 0.9% Injection)

5

Arixtra (2.5mg/0.5ml Injection) 4

Arixtra (10mg/0.8ml Injection, 5mg/0.4ml Injection, 7.5mg/0.6ml Injection)

5

Coumadin (Tablet) 3Enoxaparin Sodium (30mg/0.3ml Injection, 40mg/0.4ml Injection, 60mg/0.6ml Injection, 80mg/0.8ml Injection)

4

26


Drug Name Drug Tier


Enoxaparin Sodium (100mg/ml Injection, 120mg/0.8ml Injection, 150mg/ml Injection)

5

Fondaparinux Sodium (2.5mg/0.5ml Injection)

4

Fondaparinux Sodium (10mg/0.8ml Injection, 5mg/0.4ml Injection, 7.5mg/0.6ml Injection)

5

Fragmin(25000unit/ml Injection, 2500unit/0.2ml Injection, 5000unit/0.2ml Injection)

4

Fragmin(10000unit/ml Injection, 12500unit/0.5ml Injection, 15000unit/0.6ml Injection, 18000unit/0.72ml Injection, 7500unit/0.3ml Injection)

5

Heparin Sodium (10000unit/ml Injection, 1000unit/ml Injection, 20000unit/ml Injection, 5000unit/ml Injection)

3

Heparin Sodium/D5W (5%; 40unit/ml Injection)

3

Heparin Sodium/NaCl (100unit/ml; 0.45% Injection, 50unit/ml; 0.45% Injection)

3

Drug Name Drug Tier


Heparin Sodium/NaCl 0.9% Premix

3

Jantoven 2Lovenox (300mg/3ml Injection) 4

Pradaxa 3 PAWarfarin Sodium 2Xarelto 3 PABlood Formation Modifiers — Blood Formation DrugsAnagrelide HCl 2Aranesp Albumin Free (100mcg/0.5ml Injection, 100mcg/ml Injection, 25mcg/0.42ml Injection, 25mcg/ml Injection, 40mcg/0.4ml Injection, 40mcg/ml Injection, 60mcg/0.3ml Injection, 60mcg/ml Injection)

4 B/D, PA

Aranesp Albumin Free (150mcg/0.3ml Injection, 200mcg/0.4ml Injection, 200mcg/ml Injection, 300mcg/0.6ml Injection, 300mcg/ml Injection, 500mcg/ml Injection)

5 B/D, PA

Epogen 4 B/D, PALeukine 5 PAMozobil 5 PANeulasta 5 PANeumega 3 PA

27

Drug Name Drug Tier


Neupogen (300mcg/0.5ml Injection, 480mcg/0.8ml Injection, 480mcg/1.6ml Injection)

5 PA

Procrit (10000unit/ml Injection, 2000unit/ml Injection, 3000unit/ml Injection, 4000unit/ml Injection)

4 B/D, PA

Procrit (20000unit/ml Injection, 40000unit/ml Injection)

5 B/D, PA

Promacta 5 PABlood Products/Modifiers/Volume ExpandersCinryze 5 PACoagulants — Blood Clotting DrugsCyklokapron 3Tranexamic Acid 3Platelet Modifying Agents — Platelet Modifying DrugsAggrenox 3Brilinta 4 PACilostazol 2Clopidogrel 2Dipyridamole (Tablet) 2 PAEffient 4 PATiclopidine HCl 3

Cardiovascular Agents — Drugs to Treat Heart and Circulation Conditions

Alpha-Adrenergic Agonists — Blood Pressure DrugsClonidine HCl (Tablet) 2Clonidine HCl (Patch Weekly)

3

Guanfacine HCl 2Methyldopa 2

Drug Name Drug Tier


Methyldopa/Hydrochlorothiazide

2

Methyldopate HCl 2Midodrine HCl 3Alpha-Adrenergic Blocking Agents — Blood Pressure DrugsDibenzyline 4Prazosin HCl 2Reserpine 2Angiotensin II Receptor Antagonists — Blood Pressure DrugsBenicar 3Benicar HCT 3Edarbi 4Edarbyclor 4Losartan Potassium 1Losartan Potassium/Hydrochlorothiazide

1

Micardis 3Micardis HCT 3Angiotensin-Converting Enzyme (ACE) Inhibitors — Blood Pressure DrugsBenazepril HCl 1Benazepril HCl/Hydrochlorothiazide

1

Captopril 2Captopril/Hydrochlorothiazide

2

Enalapril Maleate 2Enalapril Maleate/Hydrochlorothiazide

2

Lisinopril 1Lisinopril/Hydrochlorothiazide

1

Antiarrhythmics — Heart Regulation DrugsAmiodarone HCl (50mg/ml Injection, Tablet)

2

Disopyramide Phosphate 2

28


Drug Name Drug Tier


Flecainide Acetate 2Mexiletine HCl 2Multaq 3Pacerone (200mg Tablet) 2Pacerone (100mg Tablet) 4

Procainamide HCl 3Propafenone HCl 2Propafenone HCl ER 3Quinidine Gluconate 4Quinidine Gluconate ER 2Quinidine Sulfate 2Quinidine Sulfate ER 2Sorine 2Sotalol HCl (Tablet) 2Sotalol HCl (Injection) 3Tikosyn 4Beta-Adrenergic Blocking Agents — Blood Pressure DrugsAtenolol 1Atenolol/Chlorthalidone 1Bisoprolol Fumarate/Hydrochlorothiazide

2

Bystolic 3Carvedilol 1Labetalol HCl 2Metoprolol Succinate ER 3Metoprolol Tartrate (Tablet) 1Metoprolol Tartrate (Injection)

3

Metoprolol/Hydrochlorothiazide

3

Drug Name Drug Tier


Nadolol 3Pindolol 2Propranolol HCl 2Propranolol HCl ER 2Propranolol/Hydrochlorothiazide

2

Timolol Maleate (Tablet) 2Calcium Channel Blocking Agents — Blood Pressure DrugsAmlodipine Besylate 1Cartia XT 2Dilt-CD (120mg Capsule Extended Release 24 Hour, 300mg Capsule Extended Release 24 Hour)

2

Dilt-XR (180mg Capsule Extended Release 24 Hour, 240mg Capsule Extended Release 24 Hour)

2

Diltiazem CD (120mg Capsule Extended Release 24 Hour, 240mg Capsule Extended Release 24 Hour, 300mg Capsule Extended Release 24 Hour)

2

Diltiazem HCl (100mg Injection, 50mg/10ml Injection, Tablet)

2

Nicardipine HCl 2Nimodipine 4

29

Drug Name Drug Tier


Nisoldipine (17mg Tablet Extended Release 24 Hour, 34mg Tablet Extended Release 24 Hour, 8.5mg Tablet Extended Release 24 Hour)

3

Nisoldipine ER 3Verapamil HCl (Tablet) 2Verapamil HCl (Injection) 3Verapamil HCl ER (Tablet Extended Release)

2

Cardiovascular Agents, Other — Miscellaneous Cardiac DrugsDemser 5Digoxin 2Lanoxin (Tablet) 3Pentoxifylline ER 2Ranexa 3 STTekturna 4 STTekturna HCT 4 STDiuretics, Carbonic Anhydrase Inhibitors — Cardiac DrugsAcetazolamide Sodium 3Diuretics, Loop — Cardiac DrugsBumetanide 2Furosemide 2Torsemide (20mg/2ml Injection, Tablet)

2

Diuretics, Potassium-Sparing — Cardiac DrugsAmiloride HCl 2Amiloride/Hydrochlorothiazide

2

Eplerenone 3Spironolactone 2Spironolactone/Hydrochlorothiazide

2

Drug Name Drug Tier


Triamterene/Hydrochlorothiazide

2

Diuretics, Thiazide — Cardiac DrugsChlorothiazide 2Chlorothiazide Sodium 2Chlorthalidone (25mg Tablet, 50mg Tablet)

2

Diuril 4Hydrochlorothiazide 2Indapamide 2Methyclothiazide 2Metolazone 2Dyslipidemics, Fibric Acid Derivatives — Cholesterol Control DrugsAntara 3Fenofibrate 2Fenofibrate Micronized 2Gemfibrozil 2Dyslipidemics, HMG CoA Reductase Inhibitors — Cholesterol Control DrugsAtorvastatin Calcium 2Crestor 3Lovastatin 2Pravastatin Sodium 1Simvastatin 1Dyslipidemics, Other — Miscellaneous Cholesterol Control DrugsCholestyramine Light (Packet)

2

Colestipol HCl (Tablet) 2Colestipol HCl (Granules) 3Lovaza 4Niaspan 3Prevalite (Powder) 2Welchol 3Zetia 3

30


Drug Name Drug Tier


Vasodilators, Direct-Acting Arterial — Chest Pain DrugsHydralazine HCl 2Minoxidil (Tablet) 2Vasodilators, Direct-Acting Arterial/Venous — Chest Pain DrugsIsosorbide Dinitrate 2Isosorbide Dinitrate ER 2Isosorbide Mononitrate (20mg Tablet)

2

Isosorbide Mononitrate ER 2Minitran 2Nitro-Bid 4Nitroglycerin (Injection, Patch)

2

Nitrolingual Pumpspray 4Nitromist 4Nitrostat 3

Central Nervous System Agents — Drugs to Treat Nerve Conditions

Attention Deficit Hyperactivity Disorder Agents, Amphetamines — ADHD DrugsAmphetamine/Dextroamphetamine (Tablet)

3

Dextroamphetamine Sulfate

3

Attention Deficit Hyperactivity Disorder Agents, Non-amphetamines — ADHD DrugsDexmethylphenidate HCl 3Intuniv 4Methylphenidate HCl 2

Drug Name Drug Tier


Methylphenidate HCl ER (20mg Tablet Extended Release)

2

Methylphenidate HCl ER (Capsule Extended Release 24 Hour)

3

Strattera 4 STCentral Nervous System, Other — Miscellaneous Central Nervous System DrugsButalbital/Acetaminophen/Caffeine/Codeine

3

Rilutek 3Xenazine 5 PAMultiple Sclerosis Agents — Multiple Sclerosis DrugsAmpyra 5 PACopaxone 5 PAGilenya 5 PA

Dental and Oral Agents — Drugs to Treat Mouth and Throat Conditions

Dental and Oral AgentsChlorhexidine Gluconate Oral Rinse

2

Kepivance 5Periogard 2Pilocarpine HCl (Tablet) 3Triamcinolone in Orabase 2

Dermatological Agents — Drugs to Treat Skin Conditions

Dermatological Agents — Skin Agents8-MOP 5Adapalene 3

31

Drug Name Drug Tier


Amevive 5 PAAmmonium Lactate 2Amnesteem 3Avita 3 PACalcipotriene 3Carac 4Claravis 3Clindamycin Phosphate (External Solution, Foam, Gel, Lotion, Swab)

3

Clindamycin/Benzoyl Peroxide (5%; 1% Gel)

3

Dovonex 4Elidel 4 STErythromycin/Benzoyl Peroxide

2

Finacea 3Fluorouracil (Cream) 3Imiquimod 4Laclotion 2Oxsoralen 4 PAOxsoralen Ultra 5 PAPodofilox 3Protopic 4 STRegranex 5 PASantyl 4Selenium Sulfide (Lotion) 2Solaraze 4 PASoriatane 5Stelara 5 PASulfacetamide Sodium (Suspension)

3

Tazorac 4 PATretin-X (Kit) 4 PATretinoin (Cream, Gel) 3 PAUvadex 4Vectical 4Zyclara 3

Drug Name Drug Tier


Enzyme Replacements/Modifiers — Drugs to Treat Enzyme Deficiency

Enzyme Replacements/Modifiers — Enzyme Replacement/Modifying DrugsAdagen 5Aldurazyme 5Buphenyl 5Carbaglu 5Cerezyme (200unit Injection) 5 PA

Creon 3Cystadane 5Cystagon 4Elaprase 5Fabrazyme (35mg Injection) 5

Kuvan 5Lumizyme 5Myozyme 5Naglazyme 5Orfadin 5Sucraid 5Vpriv 5 PAZavesca 5Zenpep 3

Gastrointestinal Agents — Drugs to Treat Bowel, Intestine and Stomach Conditions

Antispasmodics, Gastrointestinal — Bowel Treatment DrugsAtropine Sulfate (0.05mg/ml Injection, 0.1mg/ml Injection)

2 PA

Cuvposa 4Dicyclomine HCl (Capsule, Oral Solution, Tablet)

2 PA

Glycopyrrolate 3

32


Drug Name Drug Tier


Methscopolamine Bromide 3Propantheline Bromide 2Gastrointestinal Agents, Other — Miscellaneous Gastrointestinal DrugsCromolyn Sodium (Concentrate)

3

Diphenoxylate/Atropine 2 PAHalflytely Bowel Prep/Flavor Packs 3

Loperamide HCl (Capsule) 2Metoclopramide HCl 2Relistor (12mg/0.6ml Injection) 4 PA

Ursodiol 3Histamine2 (H2) Blocking Agents — Ulcer and Stomach Acid DrugsCimetidine 2Cimetidine HCl 2Famotidine (Injection, 20mg Tablet, 40mg Tablet)

2

Famotidine Premixed 3Nizatidine 2Ranitidine HCl (Capsule, 150mg/6ml Injection, Tablet)

2

Irritable Bowel Syndrome Agents — Bowel Treatment DrugsAmitiza 3 STLotronex 5 PALaxatives — Bowel Treatment DrugsEnulose 2Gavilyte-C 2Gavilyte-G 2

Drug Name Drug Tier


Gavilyte-N/Flavor Pack 2Lactulose 2Nulytely/Flavor Packs 3Polyethylene Glycol 3350 (Powder)

2

Suprep Bowel Prep 4Trilyte 2Protectants — Ulcer and Stomach Acid DrugsCarafate (Suspension) 4Misoprostol (200mcg Tablet)

2

Sucralfate 2Proton Pump Inhibitors — Ulcer and Stomach Acid DrugsDexilant 4Lansoprazole 4Nexium 3Nexium I.V. 4Omeprazole (Capsule Delayed Release)

2

Pantoprazole Sodium 2Vimovo 3

Genitourinary Agents — Drugs to Treat Bladder, Genital and Kidney Conditions

Antispasmodics, Urinary — Bladder Control DrugsFlavoxate HCl 3Oxybutynin Chloride 2Oxybutynin Chloride ER 3Toviaz 3Vesicare 3

33

Drug Name Drug Tier


Benign Prostatic Hypertrophy Agents — Prostate Enlargement DrugsAlfuzosin HCl ER 2Doxazosin Mesylate 2Finasteride (Tablet) 2Rapaflo 3Tamsulosin HCl 2Terazosin HCl 2Genitourinary Agents, Other — Miscellaneous Bladder, Genital and Kidney Conditions DrugsBethanechol Chloride 2Elmiron 4Phosphate Binders — Phosphate-Removing AgentsFosrenol 5Renagel 3 STRenvela 3

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal) — Drugs to Regulate Hormones

Glucocorticoids/Mineralocorticoids — Anti-Inflammatory DrugsA-Hydrocort 3Ala-Cort 3Alclometasone Dipropionate

2

Amcinonide 2Augmented Betamethasone Dipropionate (Lotion)

2

Betamethasone Dipropionate

2

Betamethasone Valerate 2Clobetasol Propionate (External Solution, Gel, Lotion, Ointment, Shampoo)

2

Drug Name Drug Tier


Clobetasol Propionate (Foam)

3

Clobetasol Propionate E 2Cortisone Acetate 2Depo-Medrol (20mg/ml Injection) 4

Desonide 2Desowen (Cream, Lotion) 4

Desoximetasone (Cream, Gel, 0.25% Ointment)

3

Dexamethasone (Elixir, Tablet)

2

Dexamethasone Intensol 2Dexamethasone Sodium Phosphate (4mg/ml Injection)

2

Diflorasone Diacetate 2Fludrocortisone Acetate 2Fluocinolone Acetonide (Cream, External Solution, Ointment)

2

Fluocinonide (External Solution, Gel, Ointment)

2

Fluocinonide-E 2Fluticasone Propionate (Cream, Lotion, Ointment)

2

Halobetasol Propionate 3Hydrocortisone (1% Cream, 2.5% Cream, 2.5% Lotion, 1% Ointment, 2.5% Ointment, Tablet)

3

Hydrocortisone Valerate 3Lokara 2Methylprednisolone (Tablet)

2

Methylprednisolone Acetate (Injection)

3

Methylprednisolone Dose Pack

2

34


Drug Name Drug Tier


Methylprednisolone Sodium Succinate (Injection)

3

Mometasone Furoate 2Prednicarbate 2Prednisolone Sodium Phosphate (Oral Solution)

2

Prednisone 2Prednisone Intensol 2Proctocream HC 3Solu-Cortef (100mg Injection, 250mg Injection)

4

Solu-Medrol (2gm Injection) 4

Triamcinolone Acetonide (Cream, Lotion, Ointment)

2

Triderm 2U-Cort 2

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) — Drugs to Regulate Hormones

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary) — Hormone Replacement/Modifying DrugsChorionic Gonadotropin 3 PADesmopressin Acetate 3Egrifta 5 PAGenotropin 5 PAGenotropin Miniquick (0.2mg Injection) 4 PA

Drug Name Drug Tier


Genotropin Miniquick (0.4mg Injection, 0.6mg Injection, 0.8mg Injection, 1.2mg Injection, 1.4mg Injection, 1.6mg Injection, 1.8mg Injection, 1mg Injection, 2mg Injection)

5 PA

Humatrope 5 PAIncrelex 5 PANorditropin Flexpro 5 PANorditropin Nordiflex Pen 5 PA

Nutropin 5 PANutropin AQ 5 PAOmnitrope (10mg/1.5ml Injection) 4 PA

Omnitrope (5.8mg Injection, 5mg/1.5ml Injection)

5 PA

Pregnyl W/Diluent Benzyl Alcohol/NaCl

3 PA

Saizen 5 PASerostim 5 PAStimate 4Tev-Tropin 4 PAZorbtive 5 PA

35

Drug Name Drug Tier


Hormonal Agents, Stimulant/Replacement/Modifying (Sex Hormones/Modifiers) — Drugs to Regulate Hormones

Anabolic Steroids — Hormone Replacement/Modifying DrugsOxandrolone (2.5mg Tablet)

3 PA

Oxandrolone (10mg Tablet) 5 PAAndrogens — Hormone Replacement/Modifying DrugsAndrogel (50mg/5gm Gel) 3

Androgel Pump (1.62% Gel) 3

Androxy 3Danazol 3Testosterone Cypionate 3Testosterone Enanthate 3Estrogens — Hormone Replacement/Modifying DrugsAmethia 2Amethyst 2Apri 2Aranelle 2Aviane 2Balziva 2Briellyn 2Cryselle 2Cyclafem 1/35 2Cyclafem 7/7/7 2Divigel (1mg/gm Gel) 4Emoquette 2Enjuvia 3Enpresse 2Estradiol 2Estradiol Valerate 3

Drug Name Drug Tier


Estradiol/Norethindrone Acetate (1mg; 0.5mg Tablet)

2

Estropipate 2Gianvi 2Introvale 2Jinteli 2Junel 2Junel Fe 2Kariva 2Kelnor 2Leena 2Lessina 2Levora 2Low-Ogestrel 2Lutera 2Marlissa 2Microgestin 2Microgestin Fe 2Mononessa 2Necon 2Nortrel 2Nuvaring 3Ocella 2Ogestrel 2Orsythia 2Portia 2Premarin (Cream, Tablet) 3Premphase 3Prempro 3Previfem 2Quasense 2Reclipsen 2Sprintec 2Sronyx 2Tri-Legest Fe 2Tri-Previfem 2

36


Drug Name Drug Tier


Tri-Sprintec 2Trinessa 2Trivora 2Velivet 2Vestura 2Zeosa 2Zovia 2Progesterone — Hormone Replacement/Modifying DrugsElla 4Progestins — Hormone Replacement/Modifying DrugsCamila 2Crinone 4Depo-Provera (400mg/ml Injection) 4

Errin 2Jolivette 2Medroxyprogesterone Acetate

2

Megace ES 4Megestrol Acetate 2Next Choice 2Nora-BE 2Norethindrone Acetate 2Selective Estrogen Receptor Modifying Agents — Hormone Replacement/Modifying DrugsEvista 3

Drug Name Drug Tier


Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) — Drugs to Replace Thyroid Hormones

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid) — Thyroid Replacement DrugsLevothroid 3Levothyroxine Sodium (Tablet)

2

Levoxyl 3Liothyronine Sodium 2Synthroid 3Unithroid (100mcg Tablet, 112mcg Tablet, 125mcg Tablet, 150mcg Tablet, 175mcg Tablet, 200mcg Tablet, 25mcg Tablet, 300mcg Tablet, 50mcg Tablet, 75mcg Tablet, 88mcg Tablet)

2

Hormonal Agents, Suppressant (Adrenal) — Drugs to Regulate Hormones

Hormonal Agents, Suppressant (Adrenal) — Hormone SuppressantsLysodren 3

Hormonal Agents, Suppressant (Parathyroid) — Drugs to Regulate Hormones

Hormonal Agents, Suppressant (Parathyroid) — Hormone SuppressantsSensipar (30mg Tablet) 3Sensipar (60mg Tablet, 90mg Tablet) 5

37

Drug Name Drug Tier


Hormonal Agents, Suppressant (Pituitary) — Drugs to Regulate Hormones

Hormonal Agents, Suppressant (Pituitary) — Hormone SuppressantsCabergoline 3Firmagon (80mg Injection) 4 PA

Firmagon (120mg Injection) 5 PA

Leuprolide Acetate 3Lupron Depot (3.75mg Injection) 4

Lupron Depot (22.5mg Injection, 30mg Injection, 45mg Injection, 7.5mg Injection)

5

Lupron Depot-PED (11.25mg Injection – 3 Month)

4

Lupron Depot-PED (11.25mg Injection – 1 Month, 15mg Injection – 1 Month)

5

Octreotide Acetate (100mcg/ml Injection, 50mcg/ml Injection)

4 PA

Octreotide Acetate (1000mcg/ml Injection, 200mcg/ml Injection, 500mcg/ml Injection)

5 PA

Sandostatin LAR Depot 5 PASomatuline Depot 5 PASomavert 5 PASynarel 5 PATrelstar Depot 5Trelstar LA 5Trelstar Mixject 5

Drug Name Drug Tier


Hormonal Agents, Suppressant (Sex Hormones/Modifiers) — Drugs to Regulate Hormones

Antiandrogens — Hormone SuppressantsBicalutamide 2Flutamide 3Nilandron 4

Hormonal Agents, Suppressant (Thyroid) — Drugs to Suppress Thyroid Hormones

Antithyroid Agents — Thyroid Suppressing DrugsMethimazole 2Propylthiouracil 2

Immunological Agents — Drugs that Stimulate or Suppress the Immune System

Immune Suppressants — Immune System DrugsAzasan 4Azathioprine 2Azathioprine Sodium 3Benlysta (120mg Injection) 5 PA

Cellcept (Suspension Reconstituted) 5 B/D, PA

Cellcept Intravenous 4 B/D, PACimzia 5 PACyclosporine 3 B/DCyclosporine Modified (100mg Capsule, 50mg Capsule, Oral Solution)

3 B/D

Enbrel 5 PAGengraf 3 B/DHumira 5 PAHumira Starter Kit 5 PAKineret 5 PA

38


Drug Name Drug Tier


Methotrexate (Tablet) 2Methotrexate Sodium (25mg/ml Injection)

2

Methotrexate Sodium (1gm Injection)

3

Mycophenolate Mofetil 3 B/D, PAMyfortic (180mg Tablet Delayed Release) 4 B/D

Myfortic (360mg Tablet Delayed Release) 5 B/D

Nulojix 5 B/D, PAOrencia 5 PAPrograf (Injection) 4 B/D, PARapamune (0.5mg Tablet) 4 B/D

Rapamune (Oral Solution, 1mg Tablet, 2mg Tablet)

5 B/D

Remicade 5 PASandimmune (Capsule) 4 B/DSimponi 5 PATacrolimus (0.5mg Capsule, 1mg Capsule)

3 B/D, PA

Tacrolimus (5mg Capsule) 5 B/D, PATorisel 5Zortress (0.25mg Tablet) 4 B/D, PAZortress (0.5mg Tablet, 0.75mg Tablet) 5 B/D, PA

Immunizing Agents, Passive — Immune System DrugsAtgam 5 B/DCarimune Nanofiltered (3gm Injection) 5 B/D, PA

Drug Name Drug Tier


Gammagard Liquid 5 B/D, PAGammaplex (10gm/200ml Injection) 5 B/D, PA

Gamunex-C (1gm/10ml Injection) 5 B/D, PA

Hizentra (1gm/5ml Injection) 5 B/D, PA

Privigen (20gm/200ml Injection) 5 B/D, PA

Thymoglobulin 5 B/DImmunomodulators — Immune System DrugsActemra (200mg/10ml Injection) 5 PA

Actimmune 5Arcalyst 5 PAAvonex 5 PAExtavia 5 PAIlaris 5 PALeflunomide 2Simulect (20mg Injection) 5 B/D

Synagis (50mg/0.5ml Injection) 5

Tysabri 5 PA, LAVaccinesActHIB 3Adacel 3Boostrix 3Cervarix 4Comvax 3Daptacel 3Decavac 3

39

Drug Name Drug Tier


Engerix-B 3 B/DGardasil 3Havrix 3Infanrix 3IPOL 3Ixiaro 3M-M-R II 3Menactra 3Menomune-A/C/Y/W-135 3

Menveo 3Pedvax HIB 3ProQuad 3Rabavert 3Recombivax HB (10mcg/ml Injection, 40mcg/ml Injection)

3 B/D

RotaTeq 3Tetanus/Diphtheria Toxoids-Adsorbed Adult

3

Twinrix 3Typhim Vi 3Vaqta (25unit/0.5ml Injection) 3

Varivax 3YF-Vax 3Zostavax 4

Inflammatory Bowel Disease Agents — Drugs to Treat Inflammatory Bowel Disease

Aminosalicylates — Inflammatory Bowel Disease DrugsApriso 3Asacol 4Balsalazide Disodium 3Mesalamine (Kit) 3

Drug Name Drug Tier


Glucocorticoids — Inflammatory Bowel Disease DrugsBudesonide (Capsule Extended Release 24 Hour)

3

Colocort 3Hydrocortisone (Enema) 3Millipred (Tablet) 4Sulfonamides — Inflammatory Bowel Disease DrugsSulfasalazine (Tablet) 2Sulfazine EC 2

Metabolic Bone Disease Agents — Drugs to Treat Bone Conditions

Metabolic Bone Disease Agents — Osteoporosis (Bone Loss) DrugsAlendronate Sodium 2Calcitonin-Salmon 3Calcitriol (Capsule, Injection, Oral Solution)

2 B/D

Etidronate Disodium 3Forteo 4 B/D, PAFortical 3Hectorol 3 B/DMiacalcin (Injection) 4 B/D, PAPamidronate Disodium (30mg/10ml Injection, 90mg/10ml Injection)

3 B/D

Pamidronate Disodium (6mg/ml Injection)

4 B/D

Prolia 4 PAReclast 4 PAXgeva 5 PAZemplar 3 B/DZometa 5

40


Drug Name Drug Tier


Miscellaneous Therapeutic Agents

Miscellaneous Therapeutic AgentsAlcohol Preps (Pad) 2Botox (100unit Injection) 4 PAFerriprox 5 PAFirazyr 5 PAFomepizole 5Gauze Pads 3Insulin Syringes, Needles 3

Intralipid (1.7%; 30% Injection) 4 B/D

Intralipid (2.25%; 20% Injection)

4 B/D

Lactated Ringers Irrigation 3Levocarnitine 3 B/DLiposyn III (1.2%; 2.5%; 10% Injection, 1.2%; 2.5%; 20% Injection)

4 B/D

Methergine 3Methylergonovine Maleate (Tablet)

2

Physiolyte 4Physiosol Irrigation 4Ringers Irrigation 3Sodium Chloride 0.9% (Irrigation Solution)

2

Sterile Water Irrigation 3

Drug Name Drug Tier


Ophthalmic Agents — Drugs to Treat Eye Conditions

Ophthalmic Agents, Other — Miscellaneous Eye DrugsAK-Con 2Proparacaine HCl 2Restasis 3Tropicamide 2Ophthalmic Anti-Allergy Agents — Allergy, Infection and Inflammation DrugsAzelastine HCl (Ophthalmic Solution)

3

Bepreve 4Cromolyn Sodium (Ophthalmic Solution)

2

Epinastine HCl 3Lastacaft 3Ophthalmic Anti-Inflammatories — Allergy, Infection and Inflammation DrugsAlrex 3Blephamide 3Blephamide S.O.P. 3Bromday 4Bromfenac 3Dexamethasone Sodium Phosphate (Ophthalmic Solution)

2

Diclofenac Sodium (Ophthalmic Solution)

2

Durezol 3Flurbiprofen Sodium 2Ketorolac Tromethamine (Ophthalmic Solution)

3

41

Drug Name Drug Tier


Lotemax 3Neomycin/Polymyxin/Bacitracin/Hydrocortisone

2

Neomycin/Polymyxin/Dexamethasone

2

Neomycin/Polymyxin/Hydrocortisone (Ophthalmic Suspension)

2

Nevanac 3Prednisolone Acetate 2Prednisolone Sodium Phosphate (Ophthalmic Solution)

2

Sulfacetamide Sodium/Prednisolone Sodium Phosphate

2

Tobradex (Ointment) 3Tobramycin/Dexamethasone

3

Zylet 3Ophthalmic Antiglaucoma Agents — Glaucoma DrugsAcetazolamide 2Acetazolamide ER 3Alphagan P (0.1% Ophthalmic Solution) 3

Apraclonidine 3Betaxolol HCl (Ophthalmic Solution)

2

Brimonidine Tartrate 2Carteolol HCl 2Combigan 3Dorzolamide HCl 2Dorzolamide HCl/Timolol Maleate

2

Iopidine (1% Ophthalmic Solution) 4

Levobunolol HCl (0.5% Ophthalmic Solution)

2

Drug Name Drug Tier


Methazolamide 2Metipranolol 2Phospholine Iodide 3Pilopine HS 3Timolol Maleate (Gel Forming Solution, Ophthalmic Solution)

2

Ophthalmic Prostaglandin and Prostamide Analogs — Glaucoma DrugsLatanoprost 2Lumigan 3Travatan Z 3

Otic Agents — Drugs to Treat Ear Conditions

Otic Agents — Ear DrugsAcetasol HC 3Acetic Acid 2Dermotic 3Fluocinolone Acetonide (Otic Oil)

2

Hydrocortisone/Acetic Acid

3

Neomycin/Polymyxin/Hydrocortisone (Solution, Suspension)

2

Respiratory Tract Agents — Drugs to Treat Allergies, Cough, Cold and Lung Conditions

Anti-Inflammatories, Inhaled Corticosteroids — Asthma/Lung DrugsAsmanex 4Budesonide (Suspension) 3 B/DDulera 4Flunisolide (0.025% Nasal Solution)

2

Fluticasone Propionate (Nasal Suspension)

2

Nasonex 3

42


Drug Name Drug Tier


Pulmicort 4 B/DPulmicort Flexhaler 3QVAR 3Symbicort 3Triamcinolone Acetonide (Inhaler)

3

Antihistamines — Allergy DrugsAstepro 3Azelastine HCl (Nasal Spray)

3

Carbinoxamine Maleate 2Cetirizine HCl (Syrup) 2Clemastine Fumarate (Syrup, 2.68mg Tablet)

3

Hydroxyzine HCl 2Hydroxyzine Pamoate 2Levocetirizine Dihydrochloride (Tablet)

4

Phenadoz 3Promethazine HCl 3Promethazine VC 3Promethegan (25mg Suppository, 50mg Suppository)

3

Antileukotrienes — Asthma/Lung DrugsSingulair 3Zafirlukast 2Bronchodilators, Anticholinergic — Asthma/Lung DrugsAtrovent HFA 4Combivent 3Ipratropium Bromide (Nasal Solution)

2

Drug Name Drug Tier


Ipratropium Bromide (Inhalation Solution)

2 B/D

Ipratropium Bromide/Albuterol Sulfate

2 B/D

Spiriva Handihaler 3Bronchodilators, Phosphodiesterase Inhibitors (Xanthines) — Asthma/Lung DrugsAminophylline 2Elixophyllin 3Theophylline ER (100mg Tablet Extended Release 12 Hour, 200mg Tablet Extended Release 12 Hour, 300mg Tablet Extended Release 12 Hour, 450mg Tablet Extended Release 12 Hour, Tablet Extended Release 24 Hour)

2

Bronchodilators, Sympathomimetic — Asthma/Lung DrugsAlbuterol Sulfate (Syrup, Tablet)

2

Albuterol Sulfate (Nebulization Solution)

2 B/D

Albuterol Sulfate ER 2Brovana 4 B/DEpinephrine HCl (0.1mg/ml Injection)

3

Epipen 3Foradil Aerolizer 3Levalbuterol 4 B/D, ST

43

Drug Name Drug Tier


Metaproterenol Sulfate 2Perforomist 4 B/DProair HFA 3Serevent Diskus 4 STTerbutaline Sulfate (Tablet) 2Terbutaline Sulfate (Injection)

4

Twinject 4Mast Cell Stabilizers — Asthma/Lung DrugsCromolyn Sodium (Nebulization Solution)

3 B/D

Pulmonary Antihypertensives — Asthma/Lung DrugsAdcirca 5 PALetairis 5Remodulin 5 B/D, PARevatio 5 PATracleer 5 LAVentavis (10mcg/ml Inhalation Solution) 5 B/D, PA

Respiratory Tract Agents, Other — Asthma/Lung DrugsAcetylcysteine 2 B/DAralast NP (400mg Injection) 5 PA

Glassia 5 PAKalydeco 5 PAProlastin-C 5 PAPulmozyme 5 B/DTyzine 3Xolair 5 PAZemaira 5 PA

Drug Name Drug Tier


Sedatives/Hypnotics — Drugs for Sedation and Sleep

GABA Receptor Modulators — Sedation and Sleep DrugsTemazepam (15mg Capsule, 30mg Capsule)

2 PA

Zaleplon 2Zolpidem Tartrate (5mg Tablet, 10mg Tablet)

2

Sleep Disorders, Other — Miscellaneous Sedation and Sleep DrugsProvigil 4 PAXyrem 3 PA, LA

Skeletal Muscle Relaxants — Drugs to Treat Pain, Inflammation, and Muscle and Joint Conditions

Skeletal Muscle Relaxants — Pain/Swelling Management DrugsCarisoprodol (350mg Tablet)

3

Chlorzoxazone 3Cyclobenzaprine HCl (10mg Tablet, 5mg Tablet)

4

Methocarbamol 3Orphenadrine Citrate ER 3Orphenadrine Compound DS

3

Orphenadrine/Aspirin/Caffeine

3

Therapeutic Nutrients/Minerals/Electrolytes — Drugs to Treat Vitamin, Mineral and Body Fluid Deficiencies

Electrolyte/Mineral Modifiers — Vitamin, Mineral and Body Fluid Deficiency DrugsChemet 4Exjade (125mg Tablet Soluble) 4

44


Drug Name Drug Tier


Exjade (250mg Tablet Soluble, 500mg Tablet Soluble)

5

Kionex (Powder) 3Samsca 5 PASodium Lactate 2Sodium Polystyrene Sulfonate (Suspension)

3

Syprine 4Electrolyte/Mineral Replacement — Vitamin, Mineral and Body Fluid Deficiency DrugsAminosyn 8.5%/Electrolytes

3 B/D

Aminosyn II 4 B/DAminosyn II 8.5%/Electrolytes

3 B/D

Aminosyn M 4 B/DAminosyn-HBC 4 B/DAminosyn-PF 4 B/DCalcium Acetate (Capsule) 3Clinimix 2.75%/Dextrose 5% 4 B/D

Clinimix 4.25%/Dextrose 10%

4 B/D

Clinimix 4.25%/Dextrose 25%

4 B/D

Clinimix 4.25%/Dextrose 5% 4 B/D



Clinisol SF 15% 3 B/D

Drug Name Drug Tier


Dextrose 5%/Lactated Ringers

3

Dextrose 5%/Potassium Chloride 0.15%

3

Freamine III (8.5% Injection)

4 B/D

Freamine III 3% 4 B/DHepatamine 3 B/DHepatasol 4 B/DIsolyte-H/Dextrose 5% 4Isolyte-M/Dextrose 5% 3Isolyte-P/Dextrose 5% 4Isolyte-S 4Isolyte-S/Dextrose 5% 4Klor-Con 10 2Klor-Con 8 2Klor-Con M15 3Klor-Con M20 2Lactated Ringers 3Magnesium Sulfate (50% Injection)

3

Nephramine 4 B/DNormosol-M in D5W 3Normosol-R 4Phoslo 3Phoslyra 4 STPlasma-Lyte 4Plasma-Lyte/D5W (16meq/L; 40meq/L; 5%; 3meq/L; 13meq/L; 40meq/L Injection)

4

45

Drug Name Drug Tier


Potassium Chloride (0.4meq/ml Injection, 10meq/100ml Injection, 2meq/ml Injection, 30meq/100ml Injection)

3

Potassium Chloride (10meq/50ml Injection) 3

Potassium Chloride 0.15%/NaCl 0.45% Viaflex

3

Potassium Chloride 0.15%/NaCl 0.9%

3

Potassium Chloride 0.224%/Dextrose 5% Viaflex

3

Potassium Chloride 0.3%/D5W/Viaflex

3

Potassium Chloride 0.3%/NaCl 0.9% 3

Potassium Chloride ER (Capsule Extended Release, 10meq Tablet Extended Release, 20meq Tablet Extended Release)

2

Premasol (10% Injection) 4 B/DPremasol (6% Injection) 4 B/DProcalamine 4 B/DProsol 4 B/DRingers Injection 3Sodium Chloride (0.9% Injection, 2.5meq/ml Injection, 3% Injection, 5% Injection)

2

Sodium Chloride 0.45% Viaflex (Injection)

2

Sodium Fluoride (Tablet) 2TPN Electrolytes 3Travasol 4 B/DTrophamine 4 B/D

Drug Name Drug Tier


Vitamins — Vitamin, Mineral and Body Fluid Deficiency DrugsNiacor 2Prenatal Vitamins 2

46

Index of covered drugs

8-MOP ................................... 30

AAbelcet ................................... 16

Abilify .................................... 21

Abilify Discmelt ..................... 21

Abraxane ................................ 18

Acarbose ................................. 24

Acetaminophen/Codeine .......... 9

Acetasol HC ........................... 41

Acetazolamide ........................ 41

Acetazolamide ER .................. 41

Acetazolamide Sodium ........... 29

Acetic Acid ............................. 41

Acetylcysteine ......................... 43

Actemra .................................. 38

ActHIB .................................. 38

Actimmune............................. 38

Actoplus Met .......................... 24

Actos ...................................... 24

Acyclovir ................................ 23

Acyclovir Sodium ................... 23

Adacel ..................................... 38

Adagen ................................... 31

Adapalene ............................... 30

Adcirca ................................... 43

Adriamycin ............................. 18

Afinitor ................................... 19

Aggrenox ................................ 27

A-Hydrocort ........................... 33

AK-Con ................................. 40

Ala-Cort ................................. 33

Albenza .................................. 20

Albuterol Sulfate .................... 42

Albuterol Sulfate ER .............. 42

Alclometasone Dipropionate ... 33

Alcohol Preps ......................... 40

Aldurazyme ............................ 31

Alendronate Sodium .............. 39

Alfuzosin HCl ER ................. 33

Alimta .................................... 18

Alinia ..................................... 20

Allopurinol ............................. 17

Allopurinol Sodium ................ 17

Aloxi ....................................... 16

Alphagan P ............................. 41

Alprazolam ............................. 24

Alrex ....................................... 40

Amantadine HCl .................... 23

AmBisome .............................. 16

Amcinonide ............................ 33

Amethia.................................. 35

Amethyst ................................ 35

Amevive ................................. 31

Amifostine .............................. 18

Amikacin Sulfate ...................... 9

Amiloride HCl ....................... 29

Amiloride/ Hydrochlorothiazide ............ 29

Aminophylline ........................ 42

Aminosyn 8.5%/Electrolytes ...44

Aminosyn-HBC .....................44

Aminosyn II ...........................44

Aminosyn II 8.5%/ Electrolytes ..........................44

Aminosyn M ..........................44

Aminosyn-PF .........................44

Amiodarone HCl ................... 27

Amitiza................................... 32

Amitriptyline HCl ................. 15

Amlodipine Besylate .............. 28

Ammonium Lactate ............... 31

Amnesteem ............................ 31

Amoxapine ............................. 15

Amoxicillin ............................. 11

Amoxicillin/Potassium Clavulanate .......................... 11

Amoxicillin/Potassium Clavulanate ER ................... 11

Amphetamine/Dextroamphetamine ............ 30

Amphotec ............................... 16

Amphotericin B ...................... 16

Ampicillin .............................. 11

Ampicillin Sodium ................. 11

Ampicillin-Sulbactam ............ 12

Ampyra................................... 30

Anagrelide HCl ...................... 26

Anastrozole ............................ 19

Ancobon ................................. 16

Androgel................................. 35

Androgel Pump ...................... 35

Androxy .................................. 35

Antabuse ................................. 15

Antara .................................... 29

Anzemet ................................. 16

Apokyn ................................... 21

Apraclonidine ......................... 41

Apri ........................................ 35

47

Apriso ..................................... 39

Aptivus ................................... 23

Aralast NP ............................. 43

Aranelle .................................. 35

Aranesp Albumin Free ........... 26

Arcalyst .................................. 38

Argatroban ............................. 25

Arixtra .................................... 25

Aromasin ................................ 19

Arranon .................................. 18

Arzerra ................................... 20

Asacol ..................................... 39

Asmanex ................................. 41

Astepro ................................... 42

Astramorph .............................. 8

Atenolol .................................. 28

Atenolol/Chlorthalidone ........ 28

Atgam..................................... 38

Atorvastatin Calcium ............. 29

Atovaquone/Proguanil HCl ... 20

Atripla .................................... 22

Atropine Sulfate ..................... 31

Atrovent HFA ........................ 42

Augmented Betamethasone Dipropionate ........................ 33

Avandamet ............................. 24

Avandaryl ............................... 24

Avandia .................................. 24

Avastin ................................... 20

Avelox ..................................... 12

Avelox ABC Pack ................... 12

Aviane .................................... 35

Avita ....................................... 31

Avonex .................................... 38

Azactam in Iso-Osmotic Dextrose .............................. 11

Azasan .................................... 37

Azathioprine ........................... 37

Azathioprine Sodium ............. 37

Azelastine HCl ................. 40, 42

Azithromycin ......................... 12

Aztreonam .............................. 11

BBaciim .................................... 10

Bacitracin................................ 10

Bacitracin/Polymyxin B ......... 10

Baclofen .................................. 22

Bactocill in Dextrose .............. 12

Balsalazide Disodium ............. 39

Balziva .................................... 35

Banzel ..................................... 14

Baraclude ................................ 23

Benazepril HCl ...................... 27

Benazepril HCl/Hydrochlorothiazide ............ 27

Benicar ................................... 27

Benicar HCT ......................... 27

Benlysta .................................. 37

Benztropine Mesylate ............. 20

Bepreve ................................... 40

Betamethasone Dipropionate ...33

Betamethasone Valerate .......... 33

Betaxolol HCl ......................... 41

Bethanechol Chloride ............. 33

Bicalutamide ........................... 37

Bicillin C-R ............................ 12

Bicillin L-A ............................ 12

BiCNU ................................... 17

Biltricide ................................. 20

Bisoprolol Fumarate/Hydrochlorothiazide ............ 28

Bleomycin Sulfate ................... 18

Blephamide ............................. 40

Blephamide S.O.P................... 40

Boostrix .................................. 38

Botox ...................................... 40

Briellyn ................................... 35

Brilinta ................................... 27

Brimonidine Tartrate .............. 41

Bromday ................................. 40

Bromfenac .............................. 40

Bromocriptine Mesylate ......... 21

Brovana................................... 42

Budeprion SR ......................... 14

Budesonide ........................39, 41

Bumetanide ............................ 29

Buphenyl ................................. 31

Buprenorphine HCl ................ 15

Buproban ................................ 15

Bupropion HCl ....................... 14

Bupropion HCl SR ................. 14

Bupropion XL ........................ 14

Buspirone HCl ....................... 24

Busulfex .................................. 17

Butalbital/Acetaminophen/Caffeine/Codeine ................ 30

Butorphanol Tartrate ................ 9

Byetta ..................................... 24

Bystolic ................................... 28

CCabergoline ............................ 37

Calcipotriene .......................... 31

Calcitonin-Salmon ................. 39

Calcitriol ................................. 39

48

Calcium Acetate .....................44

Camila .................................... 36

Campath ................................. 20

Cancidas ................................. 16

Capastat Sulfate ...................... 17

Caprelsa .................................. 18

Captopril ................................ 27

Captopril/ Hydrochlorothiazide ............ 27

Carac ...................................... 31

Carafate .................................. 32

Carbaglu ................................. 31

Carbamazepine ....................... 14

Carbamazepine ER ................ 14

Carbidopa/Levodopa .............. 21

Carbidopa/Levodopa ER ....... 21

Carbidopa/Levodopa ODT .... 21

Carbinoxamine Maleate ......... 42

Carboplatin ............................. 18

Carimune Nanofiltered ........... 38

Carisoprodol ........................... 43

Carteolol HCl ......................... 41

Cartia XT ............................... 28

Carvedilol ............................... 28

Cayston ................................... 11

Cedax ..................................... 11

CeeNU ................................... 18

Cefaclor .................................. 11

Cefaclor ER ............................ 11

Cefadroxil ............................... 11

Cefazolin Sodium ................... 11

Cefdinir .................................. 11

Cefepime ................................ 11

Cefotaxime Sodium ................ 11

Cefotetan ................................ 11

Cefoxitin Sodium ................... 11

Cefoxitin Sodium/Dextrose ... 11

Cefpodoxime Proxetil ............. 11

Cefprozil................................. 11

Ceftazidime ............................ 11

Ceftazidime/Dextrose ............ 11

Ceftriaxone Sodium ............... 11

Cefuroxime Axetil .................. 11

Cefuroxime Sodium ............... 11

Cellcept .................................. 37

Cellcept Intravenous ............... 37

Celontin .................................. 13

Cephalexin ............................. 11

Cerezyme ............................... 31

Cerubidine .............................. 18

Cervarix .................................. 38

Cesamet .................................. 16

Cetirizine HCl ....................... 42

Chantix ................................... 15

Chantix Pak ............................ 15

Chemet ................................... 43

Chloramphenicol Sodium Succinate.............................. 10

Chlordiazepoxide/ Amitriptyline ....................... 24

Chlordiazepoxide HCl ........... 24

Chlorhexidine Gluconate Oral Rinse ........................... 30

Chloroquine Phosphate .......... 20

Chlorothiazide ........................ 29

Chlorothiazide Sodium .......... 29

Chlorpromazine HCl ............. 21

Chlorthalidone ....................... 29

Chlorzoxazone ........................ 43

Cholestyramine Light ............ 29

Chorionic Gonadotropin ........ 34

Ciclopirox ............................... 16

Ciclopirox Nail Lacquer ......... 16

Ciclopirox Olamine ................ 16

Cilostazol ................................ 27

Cimetidine .............................. 32

Cimetidine HCl ..................... 32

Cimzia .................................... 37

Cinryze ................................... 27

Cipro ...................................... 13

Ciprofloxacin .......................... 13

Ciprofloxacin ER .................... 13

Ciprofloxacin HCl .................. 13

Cipro IV ................................. 13

Cisplatin ................................. 18

Citalopram Hydrobromide ..... 15

Cladribine ............................... 18

Claforan .................................. 11

Claravis ................................... 31

Clarithromycin ....................... 12

Clarithromycin ER ................. 12

Clemastine Fumarate.............. 42

Cleocin ................................... 10

Cleocin Galaxy ....................... 10

Cleocin in D5W ..................... 10

Cleocin Phosphate .................. 10

Clindamycin/ Benzoyl Peroxide ................. 31

Clindamycin HCl ................... 10

Clindamycin Phosphate .... 10, 31

Clindamycin Phosphate Add-Vantage ........................ 10

Clinimix 2.75%/ Dextrose 5% ........................44

Clinimix 4.25%/ Dextrose 5% ........................44

49

Clinimix 4.25%/ Dextrose 10% ......................44

Clinimix 4.25%/ Dextrose 20% ...................... 24

Clinimix 4.25%/ Dextrose 25% ......................44

Clinimix 5%/Dextrose 15% .... 24

Clinimix 5%/Dextrose 20% ... 24

Clinimix 5%/Dextrose 25%....44

Clinimix E 2.75%/ Dextrose 5% ........................ 25

Clinimix E 2.75%/ Dextrose 10% ...................... 25

Clinimix E 4.25%/ Dextrose 5% ........................ 25

Clinimix E 4.25%/ Dextrose 25% ...................... 25

Clinimix E 5%/ Dextrose 15% ...................... 25

Clinimix E 5%/ Dextrose 20% ......................44

Clinimix E 5%/ Dextrose 25% ...................... 25

Clinisol SF 15% ......................44

Clobetasol Propionate ............. 33

Clobetasol Propionate E ......... 33

Clolar ...................................... 18

Clomipramine HCl ................ 15

Clonazepam ............................ 13

Clonazepam ODT ................. 13

Clonidine HCl........................ 27

Clopidogrel ............................. 27

Clorazepate Dipotassium ........ 13

Clotrimazole ........................... 16

Clotrimazole/Betamethasone Dipropionate ........................ 16

Clozapine................................ 21

Codeine Sulfate ........................ 9

Cogentin ................................. 20

Co-Gesic .................................. 9

Colcrys ................................... 17

Colestipol HCl ....................... 29

Colistimethate Sodium ........... 10

Colocort .................................. 39

Combigan ............................... 41

Combivent .............................. 42

Combivir ................................ 22

Complera ................................ 22

Compro .................................. 21

Comtan................................... 20

Comvax .................................. 38

Copaxone................................ 30

Cortisone Acetate ................... 33

Cosmegen ............................... 18

Coumadin............................... 25

Creon ...................................... 31

Crestor .................................... 29

Crinone................................... 36

Crixivan .................................. 23

Cromolyn Sodium ...... 32, 40, 43

Cryselle ................................... 35

Cubicin ................................... 10

Cuvposa .................................. 31

Cyclafem 1/35 ........................ 35

Cyclafem 7/7/7 ....................... 35

Cyclobenzaprine HCl ............. 43

Cyclophosphamide ................. 18

Cyclosporine ........................... 37

Cyclosporine Modified ........... 37

Cyklokapron ........................... 27

Cymbalta ................................ 15

Cystadane ............................... 31

Cystagon ................................. 31

Cytarabine .............................. 18

Cytarabine Aqueous ............... 18

Cytovene ................................. 22

DDacarbazine ............................ 18

Dacogen ................................. 19

Danazol .................................. 35

Dantrolene Sodium ................ 22

Dapsone .................................. 17

Daptacel.................................. 38

Daraprim ................................ 20

Daunorubicin HCl ................. 19

Decavac .................................. 38

Demeclocycline HCl .............. 13

Demser ................................... 29

Depo-Medrol ......................... 33

Depo-Provera ......................... 36

Dermotic ................................ 41

Desipramine HCl ................... 15

Desmopressin Acetate ............ 34

Desonide ................................ 33

Desowen ................................. 33

Desoximetasone ...................... 33

Dexamethasone ...................... 33

Dexamethasone Intensol ........ 33

Dexamethasone Sodium Phosphate ...................... 33, 40

Dexilant .................................. 32

Dexmethylphenidate HCl ...... 30

Dexrazoxane ........................... 19

Dextroamphetamine Sulfate ... 30

Dextrose 2.5%/ Sodium Chloride 0.45% ...... 25

Dextrose 5% ........................... 25

50

Dextrose 5%/ Lactated Ringers .................44

Dextrose 5%/NaCl 0.2% ........ 25

Dextrose 5%/NaCl 0.9% ........ 25

Dextrose 5%/NaCl 0.33% ...... 25

Dextrose 5%/NaCl 0.45% ...... 25

Dextrose 5%/NaCl 0.225% .... 25

Dextrose 5%/Potassium Chloride 0.15% ....................44

Dextrose 10% Flex Container ..................... 25

Dextrose 10%/NaCl 0.2% ...... 25

Dextrose 10%/NaCl 0.45% ... 25

Diazepam ......................... 13, 24

Diazepam Intensol ................. 24

Dibenzyline ............................ 27

Diclofenac Potassium................ 8

Diclofenac Sodium ................. 40

Diclofenac Sodium DR ............ 8

Diclofenac Sodium ER ............. 8

Dicloxacillin Sodium .............. 12

Dicyclomine HCl ................... 31

Didanosine ............................. 22

Dificid .................................... 12

Diflorasone Diacetate ............. 33

Diflunisal .................................. 8

Digoxin .................................. 29

Dihydroergotamine Mesylate ...17

Dilantin .................................. 14

Dilantin Infatabs .................... 14

Dilt-CD .................................. 28

Diltiazem CD......................... 28

Diltiazem HCl ....................... 28

Dilt-XR .................................. 28

Diphenoxylate/Atropine ......... 32

Dipyridamole .......................... 27

Disopyramide Phosphate ........ 27

Disulfiram .............................. 15

Diuril ...................................... 29

Divalproex Sodium ................. 13

Divalproex Sodium DR .......... 13

Divalproex Sodium ER .......... 13

Divigel .................................... 35

Docefrez ................................. 19

Docetaxel ................................ 19

Donepezil HCl ....................... 14

Doribax .................................. 11

Dorzolamide HCl .................. 41

Dorzolamide HCl/ Timolol Maleate .................. 41

Dovonex ................................. 31

Doxazosin Mesylate ............... 33

Doxepin HCl .......................... 15

Doxil ...................................... 19

Doxorubicin HCl ................... 19

Doxycycline ............................ 13

Doxycycline Hyclate ............... 13

Doxycycline Monohydrate...... 13

Dronabinol ............................. 16

Droxia ..................................... 18

Duetact ................................... 24

Dulera ..................................... 41

Duramorph ............................... 8

Durezol .................................. 40

EEconazole Nitrate ................... 16

Edarbi ..................................... 27

Edarbyclor .............................. 27

Edurant .................................. 22

E.E.S. 400 .............................. 12

E.E.S. Granules ..................... 12

Effient .................................... 27

Egrifta .................................... 34

Elaprase .................................. 31

Elidel ...................................... 31

Elitek ...................................... 18

Elixophyllin ............................ 42

Ella ......................................... 36

Elmiron .................................. 33

Elspar ..................................... 19

Emcyt ..................................... 18

Emend .................................... 16

Emoquette .............................. 35

Emsam ................................... 15

Emtriva ................................... 22

Enalapril Maleate ................... 27

Enalapril Maleate/Hydrochlorothiazide ............ 27

Enbrel ..................................... 37

Engerix-B ............................... 39

Enjuvia ................................... 35

Enoxaparin Sodium .......... 25, 26

Enpresse ................................. 35

Enulose ................................... 32

Epinastine HCl ...................... 40

Epinephrine HCl .................... 42

Epipen .................................... 42

Epirubicin HCl ...................... 19

Epitol ...................................... 14

Epivir ...................................... 22

Epivir HBV ............................ 22

Eplerenone .............................. 29

Epogen ................................... 26

Epzicom ................................. 22

51

Equetro ................................... 14

Eraxis ..................................... 16

Erbitux ................................... 20

Ergotamine Tartrate/ Caffeine ............................... 17

Erivedge ................................. 19

Errin ....................................... 36

Ery .......................................... 12

Eryped .................................... 12

Ery-Tab................................... 12

Erythrocin Lactobionate ........ 12

Erythrocin Stearate ................ 12

Erythromycin ......................... 12

Erythromycin Base ................. 12

Erythromycin/ Benzoyl Peroxide ................. 31

Erythromycin Ethylsuccinate ...12

Escitalopram Oxalate ............. 15

Estradiol ................................. 35

Estradiol/Norethindrone Acetate ................................. 35

Estradiol Valerate ................... 35

Estropipate ............................. 35

Ethambutol HCl .................... 17

Ethosuximide ......................... 13

Etidronate Disodium .............. 39

Etodolac ................................... 8

Etopophos .............................. 19

Etoposide ................................ 19

Evista ...................................... 36

Exalgo ...................................... 8

Exelon .................................... 14

Exemestane............................. 19

Exjade ............................... 43, 44

Extavia.................................... 38

FFabrazyme .............................. 31

Factive .................................... 13

Famciclovir ............................. 23

Famotidine ............................. 32

Famotidine Premixed ............. 32

Fanapt ..................................... 21

Fanapt Titration Pack ............. 21

Fareston .................................. 18

Faslodex .................................. 18

Fazaclo .................................... 21

Felbamate ............................... 14

Felbatol ................................... 14

Fenofibrate .............................. 29

Fenofibrate Micronized .......... 29

Fentanyl .................................... 8

Fentanyl Citrate Oral Transmucosal ......................... 9

Ferriprox ................................. 40

Finacea ................................... 31

Finasteride .............................. 33

Firazyr .................................... 40

Firmagon ................................ 37

Flagyl ER ............................... 10

Flavoxate HCl ........................ 32

Flecainide Acetate .................. 28

Fluconazole............................. 16

Fluconazole in Dextrose ......... 16

Flucytosine ............................. 16

Fludarabine Phosphate ........... 19

Fludrocortisone Acetate ......... 33

Flunisolide .............................. 41

Fluocinolone Acetonide .... 33, 41

Fluocinonide ........................... 33

Fluocinonide-E ....................... 33

Fluorouracil ...................... 18, 31

Fluoxetine DR ........................ 15

Fluoxetine HCl ....................... 15

Fluphenazine Decanoate ........ 21

Fluphenazine HCl .................. 21

Flurbiprofen .............................. 8

Flurbiprofen Sodium .............. 40

Flutamide ............................... 37

Fluticasone Propionate ..... 33, 41

Fluvoxamine Maleate ............. 15

Folotyn ................................... 18

Fomepizole ............................. 40

Fondaparinux Sodium ............ 26

Foradil Aerolizer .................... 42

Fortaz ..................................... 11

Forteo ..................................... 39

Fortical ................................... 39

Foscarnet Sodium ................... 22

Fosphenytoin Sodium ............. 14

Fosrenol .................................. 33

Fragmin .................................. 26

Freamine III ...........................44

Freamine III 3% .....................44

Furosemide ............................. 29

Fusilev .................................... 19

Fuzeon .................................... 23

GGabapentin ............................. 13

Gabitril ................................... 13

Gablofen ................................. 22

Gammagard Liquid ................ 38

Gammaplex ............................ 38

Gamunex-C ............................ 38

52

Ganciclovir ............................. 22

Gardasil .................................. 39

Gauze Pads ............................. 40

Gavilyte-C ............................. 32

Gavilyte-G ............................. 32

Gavilyte-N/Flavor Pack ......... 32

Gemcitabine HCl ................... 18

Gemfibrozil ............................ 29

Gemzar ................................... 18

Gengraf .................................. 37

Genotropin ............................. 34

Genotropin Miniquick ........... 34

Gentak ...................................... 9

Gentamicin Sulfate ................... 9

Gentamicin Sulfate/NaCl ... 9, 10

Geodon ................................... 21

Gianvi ..................................... 35

Gilenya ................................... 30

Glassia .................................... 43

Gleevec ................................... 19

Glimepiride ............................ 24

Glipizide ................................. 24

Glipizide ER .......................... 24

Glipizide/Metformin HCl ..... 24

Glucagen Hypokit .................. 25

Glucagon Emergency Kit ....... 25

Glyburide................................ 24

Glyburide/Metformin HCl .... 24

Glyburide Micronized ............ 24

Glycopyrrolate ........................ 31

Granisetron HCl .................... 16

Granisol .................................. 16

Griseofulvin Microsize ........... 16

Gris-Peg ................................. 16

Guanfacine HCl ..................... 27

HHalaven .................................. 19

Halflytely Bowel Prep/ Flavor Packs ........................ 32

Halobetasol Propionate ........... 33

Haloperidol ............................ 21

Haloperidol Decanoate ........... 21

Haloperidol Lactate ................ 21

Havrix .................................... 39

Hectorol .................................. 39

Heparin Sodium ..................... 26

Heparin Sodium/D5W .......... 26

Heparin Sodium/NaCl........... 26

Heparin Sodium/ NaCl 0.9% Premix ............... 26

Hepatamine ............................44

Hepatasol ................................44

Hepsera .................................. 23

Herceptin ................................ 20

Hexalen .................................. 18

Hizentra ................................. 38

Humatrope ............................. 34

Humira ................................... 37

Humira Starter Kit ................. 37

Hycamtin ................................ 19

Hydralazine HCl .................... 30

Hydrochlorothiazide ............... 29

Hydrocodone/Acetaminophen ...9

Hydrocodone/Ibuprofen ........... 9

Hydrocortisone ................. 33, 39

Hydrocortisone/Acetic Acid ... 41

Hydrocortisone Valerate ......... 33

Hydromorphone HCl ............... 9

Hydroxychloroquine Sulfate ... 20

Hydroxyurea ........................... 18

Hydroxyzine HCl ................... 42

Hydroxyzine Pamoate ............ 42

IIbuprofen .................................. 8

Idarubicin HCl ....................... 19

Ifosfamide ............................... 18

Ilaris ....................................... 38

Imipenem/Cilastatin .............. 11

Imipramine HCl ..................... 15

Imipramine Pamoate .............. 15

Imiquimod .............................. 31

Incivek .................................... 23

Increlex ................................... 34

Indapamide ............................. 29

Indomethacin ........................... 8

Infanrix................................... 39

Infergen .................................. 23

Inlyta ...................................... 19

Insulin Syringes, Needles ...... 40

Intelence ................................. 22

Intralipid................................. 40

Intron-A ................................. 23

Intron-A W/Diluent ............... 23

Introvale ................................. 35

Intuniv .................................... 30

Invanz ..................................... 11

Invega ..................................... 21

Invega Sustenna ...................... 21

Invirase ................................... 23

Ionosol-B/Dextrose 5% .......... 25

Ionosol-MB/Dextrose 5% ...... 25

Iopidine .................................. 41

IPOL ...................................... 39

Ipratropium Bromide .............. 42

53

Ipratropium Bromide/ Albuterol Sulfate .................. 42

Irinotecan ............................... 19

Isentress .................................. 23

Isolyte-H/Dextrose 5% ..........44

Isolyte-M/Dextrose 5% ..........44

Isolyte-P/Dextrose 5% ............44

Isolyte-S .................................44

Isolyte-S/Dextrose 5% ............44

Isoniazid ................................. 17

Isosorbide Dinitrate ................ 30

Isosorbide Dinitrate ER.......... 30

Isosorbide Mononitrate ........... 30

Isosorbide Mononitrate ER .... 30

Isotonic Gentamicin ............... 10

Istodax .................................... 19

Itraconazole ............................ 16

Ixempra Kit ............................ 19

Ixiaro ...................................... 39

JJakafi ....................................... 19

Jantoven .................................. 26

Jevtana .................................... 19

Jinteli ...................................... 35

Jolivette ................................... 36

Junel ........................................ 35

Junel Fe ................................... 35

KKaletra .................................... 23

Kalydeco ................................. 43

Kanamycin Sulfate ................. 10

Kariva ..................................... 35

KCl 0.3%/D5W/NaCl 0.9% ... 25

KCl 0.3%/D5W/NaCl 0.45% ...25

KCl 0.15%/D5W/LR ............. 25

KCl 0.15%/D5W/ NaCl 0.2% ........................... 25

KCl 0.15%/D5W/ NaCl 0.9% ........................... 25

KCl 0.15%/D5W/ NaCl 0.225% ....................... 25

KCl 0.075%/D5W/ NaCl 0.45% ......................... 25

Kelnor ..................................... 35

Kepivance ............................... 30

Ketek ...................................... 12

Ketoconazole .......................... 16

Ketoprofen ................................ 8

Ketorolac Tromethamine .... 8, 40

Kineret .................................... 37

Kionex ....................................44

Klor-Con 8 .............................44

Klor-Con 10 ...........................44

Klor-Con M15 .......................44

Klor-Con M20 .......................44

Kombiglyze XR ...................... 24

Kuvan ..................................... 31

LLabetalol HCl ........................ 28

Laclotion ................................ 31

Lactated Ringers ....................44

Lactated Ringers Irrigation .... 40

Lactulose ................................ 32

Lamictal ODT ....................... 14

Lamictal Starter Kit ............... 14

Lamisil ................................... 16

Lamivudine ............................ 22

Lamivudine/Zidovudine ........ 22

Lamotrigine ............................ 14

Lanoxin .................................. 29

Lansoprazole .......................... 32

Lastacaft ................................. 40

Latanoprost ............................ 41

Latuda .................................... 21

Leena ...................................... 35

Leflunomide ........................... 38

Lessina .................................... 35

Letairis ................................... 43

Letrozole ................................ 19

Leucovorin Calcium ............... 19

Leukeran ................................ 18

Leukine .................................. 26

Leuprolide Acetate ................. 37

Levalbuterol ............................ 42

Levemir .................................. 25

Levetiracetam ......................... 13

Levetiracetam ER ................... 13

Levobunolol HCl .................... 41

Levocarnitine.......................... 40

Levocetirizine Dihydrochloride .................. 42

Levofloxacin ........................... 13

Levofloxacin in D5W ............. 13

Levora ..................................... 35

Levorphanol Tartrate ................ 8

Levothroid .............................. 36

Levothyroxine Sodium ........... 36

Levoxyl ................................... 36

Lexiva ..................................... 23

Lidocaine .................................. 9

Lidocaine HCl .......................... 9

Lidocaine/Prilocaine ................ 9

Lidocaine Viscous ..................... 9

Lidoderm .................................. 9

54

Lincocin ................................. 10

Lindane .................................. 20

Lioresal Intrathecal ................. 22

Liothyronine Sodium ............. 36

Liposyn III ............................. 40

Lisinopril ................................ 27

Lisinopril/ Hydrochlorothiazide ............ 27

Lithium Carbonate ................. 24

Lithium Carbonate ER .......... 24

Lithium Citrate ...................... 24

Lithobid .................................. 24

Lokara .................................... 33

Loperamide HCl .................... 32

Lorazepam.............................. 24

Lorazepam Intensol ................ 24

Losartan Potassium ................ 27

Losartan Potassium/Hydrochlorothiazide ............ 27

Lotemax ................................. 41

Lotronex ................................. 32

Lovastatin ............................... 29

Lovaza .................................... 29

Lovenox .................................. 26

Low-Ogestrel ......................... 35

Loxapine Succinate ................. 21

Lumigan ................................. 41

Lumizyme .............................. 31

Lupron Depot ......................... 37

Lupron Depot-PED ............... 37

Lutera ..................................... 35

Lyrica ..................................... 13

Lysodren ................................. 36

MMagnesium Sulfate .................44

Malarone ................................ 20

Malathion ............................... 20

Maprotiline HCl .................... 14

Marlissa .................................. 35

Marplan .................................. 15

Matulane ................................ 18

Maxalt .................................... 17

Maxalt-MLT .......................... 17

Meclizine HCl........................ 16

Medroxyprogesterone Acetate ................................. 36

Mefenamic Acid ....................... 8

Mefloquine HCl ..................... 20

Megace ES ............................. 36

Megestrol Acetate ................... 36

Meloxicam ................................ 8

Melphalan HCl ...................... 18

Menactra ................................ 39

Menest .................................... 19

Menomune-A/C/Y/W-135 .... 39

Menveo ................................... 39

Mepron ................................... 20

Mercaptopurine ...................... 18

Meropenem ............................ 11

Mesalamine ............................ 39

Mesna ..................................... 19

Mesnex ................................... 19

Mestinon ................................ 17

Mestinon Timespan ............... 17

Metaproterenol Sulfate ........... 43

Metformin HCl ...................... 24

Metformin HCl ER ............... 24

Methadone HCl ....................... 9

Methadose ................................ 9

Methazolamide ....................... 41

Methenamine Hippurate ........ 10

Methergine ............................. 40

Methimazole .......................... 37

Methocarbamol ...................... 43

Methotrexate .......................... 38

Methotrexate Sodium ............. 38

Methscopolamine Bromide .... 32

Methyclothiazide .................... 29

Methyldopa ............................ 27

Methyldopa/Hydrochlorothiazide ............ 27

Methyldopate HCl ................. 27

Methylergonovine Maleate ..... 40

Methylphenidate HCl ............ 30

Methylphenidate HCl ER ...... 30

Methylprednisolone ................ 33

Methylprednisolone Acetate ... 33

Methylprednisolone Dose Pack ............................ 33

Methylprednisolone Sodium Succinate.............................. 34

Metipranolol ........................... 41

Metoclopramide HCl ............. 32

Metolazone ............................. 29

Metoprolol/ Hydrochlorothiazide ............ 28

Metoprolol Succinate ER ....... 28

Metoprolol Tartrate ................ 28

Metronidazole ........................ 10

Metronidazole in NaCl 0.79% ......................... 10

Metronidazole Vaginal ........... 10

Mexiletine HCl ...................... 28

55

Miacalcin ................................ 39

Micardis ................................. 27

Micardis HCT ....................... 27

Miconazole 3 .......................... 16

Microgestin ............................ 35

Microgestin Fe ....................... 35

Midodrine HCl ...................... 27

Migergot ................................. 17

Millipred ................................ 39

Minitran ................................. 30

Minocycline HCl ................... 13

Minocycline HCl ER ............. 13

Minoxidil................................ 30

Mirtazapine ............................ 15

Mirtazapine ODT .................. 15

Misoprostol ............................. 32

Mitomycin .............................. 19

Mitoxantrone HCl .................. 19

M-M-R II .............................. 39

Mometasone Furoate .............. 34

Mononessa .............................. 35

Morphine Sulfate ..................... 9

Morphine Sulfate ER ............... 9

Moxeza ................................... 13

Mozobil .................................. 26

Multaq .................................... 28

Mupirocin ............................... 10

Mustargen .............................. 18

Mycamine ............................... 16

Mycobutin .............................. 17

Mycophenolate Mofetil .......... 38

Myfortic ................................. 38

Myozyme ................................ 31

Mytelase ................................. 17

NNadolol ................................... 28

Nafcillin Sodium .................... 12

Naglazyme .............................. 31

Nalbuphine HCl ....................... 9

Nallpen/Dextrose ................... 12

Naloxone HCl ........................ 15

Naltrexone HCl ...................... 15

Namenda ................................ 14

Namenda Titration Pak .......... 14

Naproxen .................................. 8

Naproxen DR ........................... 8

Naproxen Sodium ..................... 8

Naratriptan HCl ..................... 17

Nardil ..................................... 15

Nasonex .................................. 41

Natacyn .................................. 16

Nateglinide ............................. 24

Nebupent ................................ 20

Necon ..................................... 35

Nefazodone HCl .................... 15

Neomycin/Bacitracin/ Polymyxin ............................ 10

Neomycin/Polymyxin/Bacitracin/Hydrocortisone ...41

Neomycin/Polymyxin B Sulfates ................................ 10

Neomycin/Polymyxin/Dexamethasone ................... 41

Neomycin/Polymyxin/Gramicidin .......................... 10

Neomycin/Polymyxin/Hydrocortisone .................... 41

Neomycin Sulfate ................... 10

Nephramine ............................44

Neulasta .................................. 26

Neumega ................................ 26

Neupogen ............................... 27

Nevanac .................................. 41

Nevirapine .............................. 22

Nexavar .................................. 19

Nexium ................................... 32

Nexium I.V. ............................ 32

Next Choice............................ 36

Niacor ..................................... 45

Niaspan .................................. 29

Nicardipine HCl ..................... 28

Nicotrol Inhaler ...................... 15

Nicotrol NS ............................ 15

Nilandron ............................... 37

Nimodipine ............................ 28

Nisoldipine ............................. 29

Nisoldipine ER ....................... 29

Nitro-Bid ................................ 30

Nitrofurantoin ........................ 10

Nitrofurantoin Macrocrystalline .................. 10

Nitrofurantoin Monohydrate ...10

Nitroglycerin........................... 30

Nitrolingual Pumpspray ......... 30

Nitromist ................................ 30

Nitrostat ................................. 30

Nizatidine ............................... 32

Nora-BE ................................. 36

Norditropin Flexpro ............... 34

Norditropin Nordiflex Pen ..... 34

Norethindrone Acetate ........... 36

Normosol-M in D5W ............44

Normosol-R ............................44

Normosol-R in D5W ............. 25

Noroxin .................................. 13

56

Nortrel .................................... 35

Nortriptyline HCl .................. 15

Norvir ..................................... 23

Novolin ................................... 25

Novolog .................................. 25

Noxafil .................................... 16

Nucynta ER .............................. 9

Nulojix .................................... 38

Nulytely/Flavor Packs ............ 32

Nutropin ................................. 34

Nutropin AQ .......................... 34

Nuvaring................................. 35

Nyamyc ................................... 16

Nystatin .................................. 17

Nystatin/Triamcinolone ......... 17

Nystop .................................... 17

OOcella ..................................... 35

Octreotide Acetate ................. 37

Ofloxacin ................................ 13

Ogestrel .................................. 35

Olanzapine ............................. 21

Olanzapine ODT ................... 21

Omeprazole ............................ 32

Omnitrope .............................. 34

Ondansetron HCl................... 16

Ondansetron ODT ................. 16

Onfi ........................................ 13

Onglyza .................................. 24

Onsolis ..................................... 9

Ontak ..................................... 19

Orap ....................................... 21

Orencia ................................... 38

Orfadin ................................... 31

Orphenadrine/Aspirin/ Caffeine ............................... 43

Orphenadrine Citrate ER ....... 43

Orphenadrine Compound DS .................... 43

Orsythia ................................. 35

Oxacillin Sodium ................... 12

Oxaliplatin.............................. 19

Oxandrolone ........................... 35

Oxcarbazepine ........................ 14

Oxsoralen ............................... 31

Oxsoralen Ultra ...................... 31

Oxybutynin Chloride ............. 32

Oxybutynin Chloride ER ....... 32

Oxycodone/Acetaminophen ..... 9

Oxycodone/Aspirin .................. 9

Oxycodone HCl ....................... 9

Oxycodone/Ibuprofen .............. 8

PPacerone ................................. 28

Paclitaxel ................................ 19

Pamidronate Disodium .......... 39

Panretin .................................. 20

Pantoprazole Sodium .............. 32

Paromomycin Sulfate .............. 10

Paroxetine HCl ....................... 15

Paroxetine HCl ER ................ 15

Paser ....................................... 17

Paxil ....................................... 15

PCE ........................................ 12

Pedi-Dri ................................. 17

Pedvax HIB ............................ 39

Peganone ................................ 14

Pegasys ................................... 23

Pegasys Proclick ..................... 23

Peg-Intron .............................. 23

Peg-Intron Redipen ................ 23

Penicillin G Potassium ........... 12

Penicillin G Potassium in Iso-Osmotic Dextrose ......... 12

Penicillin G Procaine ............. 12

Penicillin G Sodium ............... 12

Penicillin V Potassium ............ 12

Pentam 300 ............................ 20

Pentostatin .............................. 18

Pentoxifylline ER ................... 29

Perforomist ............................. 43

Periogard ................................ 30

Permethrin ............................. 20

Perphenazine .......................... 21

Perphenazine/Amitriptyline ... 15

Pfizerpen-G............................ 12

Phenadoz ................................ 42

Phenelzine Sulfate .................. 15

Phenobarbital ......................... 13

Phenytek ................................. 14

Phenytoin ............................... 14

Phenytoin Sodium .................. 14

Phenytoin Sodium Extended ...14

Phoslo .....................................44

Phoslyra ..................................44

Phospholine Iodide ................. 41

Physiolyte ............................... 40

Physiosol Irrigation ................ 40

Picato ...................................... 19

Pilocarpine HCl ..................... 30

Pilopine HS ............................ 41

Pindolol .................................. 28

Piperacillin Sodium/ Tazobactam Sodium ............ 12

57

Plasma-Lyte ............................44

Plasma-Lyte/D5W .................44

Podofilox................................. 31

Polyethylene Glycol 3350 ........ 32

Polymyxin B Sulfate ............... 10

Portia ...................................... 35

Potassium Chloride ................ 45

Potassium Chloride 0.3%/ D5W/Viaflex ....................... 45

Potassium Chloride 0.3%/ NaCl 0.9% ........................... 45

Potassium Chloride 0.15%/D5W/NaCl 0.33%............... 25

Potassium Chloride 0.15%/D5W/NaCl 0.45% Viaflex ...25

Potassium Chloride 0.15%/ NaCl 0.9% ........................... 45

Potassium Chloride 0.15%/ NaCl 0.45% Viaflex ............. 45

Potassium Chloride 0.22%/D5W/NaCl 0.45% ............... 25

Potassium Chloride 0.224%/Dextrose 5% Viaflex ............ 45

Potassium Chloride ER .......... 45

Potiga ..................................... 13

Pradaxa ................................... 26

Pramipexole Dihydrochloride ...21

Prandimet ............................... 24

Prandin ................................... 24

Pravastatin Sodium................. 29

Prazosin HCl .......................... 27

Prednicarbate .......................... 34

Prednisolone Acetate .............. 41

Prednisolone Sodium Phosphate ...................... 34, 41

Prednisone .............................. 34

Prednisone Intensol ................ 34

Pregnyl W/Diluent Benzyl Alcohol/NaCl ...................... 34

Premarin ................................. 35

Premasol ................................. 45

Premphase .............................. 35

Prempro .................................. 35

Prenatal Vitamins ................... 45

Prevalite .................................. 29

Previfem ................................. 35

Prezista ................................... 23

Priftin ..................................... 17

Primaquine Phosphate ............ 20

Primaxin ................................. 11

Primidone ............................... 13

Primsol ................................... 10

Pristiq ..................................... 15

Privigen .................................. 38

Proair HFA ............................ 43

Probenecid .............................. 17

Probenecid/Colchicine ........... 17

Procainamide HCl.................. 28

Procalamine ............................ 45

Prochlorperazine .................... 21

Prochlorperazine Edisylate ..... 21

Prochlorperazine Maleate ....... 21

Procrit ..................................... 27

Proctocream HC .................... 34

Proglycem ............................... 25

Prograf .................................... 38

Prolastin-C ............................. 43

Proleukin ................................ 19

Prolia ...................................... 39

Promacta ................................. 27

Promethazine HCl ................. 42

Promethazine VC ................... 42

Promethegan .......................... 42

Propafenone HCl ................... 28

Propafenone HCl ER ............. 28

Propantheline Bromide ........... 32

Proparacaine HCl ................... 40

Propranolol HCl ..................... 28

Propranolol HCl ER .............. 28

Propranolol/Hydrochlorothiazide ............ 28

Propylthiouracil ...................... 37

ProQuad ................................. 39

Prosol ...................................... 45

Protopic .................................. 31

Protriptyline HCl ................... 15

Provigil ................................... 43

Pulmicort ................................ 42

Pulmicort Flexhaler ................ 42

Pulmozyme ............................ 43

Pyridostigmine Bromide ........ 17

QQualaquin ............................... 20

Quasense ................................ 35

Quetiapine Fumarate .............. 21

Quinidine Gluconate .............. 28

Quinidine Gluconate ER........ 28

Quinidine Sulfate ................... 28

Quinidine Sulfate ER ............. 28

QVAR .................................... 42

RRabavert ................................. 39

Ranexa .................................... 29

Ranitidine HCl ...................... 32

Rapaflo ................................... 33

Rapamune .............................. 38

58

Rebetol ................................... 23

Reclast .................................... 39

Reclipsen ................................ 35

Recombivax HB ..................... 39

Regonol .................................. 17

Regranex ................................. 31

Relenza Diskhaler .................. 23

Relistor ................................... 32

Remicade ................................ 38

Remodulin .............................. 43

Renagel ................................... 33

Renvela ................................... 33

Rescriptor ............................... 22

Reserpine ................................ 27

Restasis ................................... 40

Retrovir IV Infusion ............... 22

Revatio ................................... 43

Revlimid ................................. 18

Reyataz ................................... 23

Ribapak .................................. 23

Ribasphere .............................. 23

Ribavirin ................................. 23

Rifampin ................................ 17

Rifater..................................... 17

Rilutek .................................... 30

Rimantadine HCl ................... 23

Ringers Injection .................... 45

Ringers Irrigation ................... 40

Riomet .................................... 24

Risperdal Consta .................... 21

Risperidone ............................ 21

Risperidone ODT .................. 21

Rituxan ................................... 20

Rivastigmine Tartrate ............. 14

Ropinirole HCl ....................... 21

RotaTeq .................................. 39

Roxicet ...................................... 9

SSabril ...................................... 14

Saizen ..................................... 34

Samsca ....................................44

Sancuso ................................... 16

Sandimmune .......................... 38

Sandostatin LAR Depot ........ 37

Santyl ..................................... 31

Saphris .................................... 21

Selegiline HCl ........................ 15

Selenium Sulfide ..................... 31

Selzentry ................................. 23

Sensipar .................................. 36

Serevent Diskus ...................... 43

Seromycin ............................... 17

Seroquel XR ........................... 21

Serostim ................................. 34

Sertraline HCl ........................ 15

Silver Sulfadiazine .................. 10

Simponi .................................. 38

Simulect .................................. 38

Simvastatin ............................. 29

Singulair ................................. 42

Sodium Chloride .................... 45

Sodium Chloride 0.9% ........... 40

Sodium Chloride 0.45% Viaflex ................................. 45

Sodium Fluoride ..................... 45

Sodium Lactate ......................44

Sodium Polystyrene Sulfonate ..............................44

Sodium Sulfacetamide ............ 13

Solaraze .................................. 31

Solu-Cortef ............................. 34

Solu-Medrol ........................... 34

Somatuline Depot .................. 37

Somavert ................................. 37

Soriatane ................................. 31

Sorine ..................................... 28

Sotalol HCl ............................ 28

Spiriva Handihaler ................. 42

Spironolactone ........................ 29

Spironolactone/Hydrochlorothiazide ............ 29

Sporanox ................................. 17

Sprintec .................................. 35

Sprycel .................................... 19

Sronyx..................................... 35

SSD ........................................ 10

Stagesic ..................................... 9

Stalevo .................................... 21

Stavudine ................................ 22

Stelara ..................................... 31

Sterile Water Irrigation .......... 40

Stimate ................................... 34

Strattera .................................. 30

Streptomycin Sulfate .............. 10

Stromectol .............................. 20

Suboxone ................................ 15

Sucraid .................................... 31

Sucralfate ................................ 32

Sulfacetamide Sodium ...... 13, 31

Sulfacetamide Sodium/Prednisolone Sodium Phosphate ............................ 41

Sulfadiazine ............................ 13

59

Sulfamethoxazole/ Trimethoprim ...................... 13

Sulfamethoxazole/ Trimethoprim DS ................ 13

Sulfasalazine ........................... 39

Sulfazine EC .......................... 39

Sulindac .................................... 8

Sumatriptan Succinate ............ 17

Suprax ..................................... 11

Suprep Bowel Prep ................. 32

Sustiva .................................... 22

Sutent ..................................... 20

Sylatron .................................. 19

Symbicort ............................... 42

Symlinpen 60 ......................... 24

Symlinpen 120 ....................... 24

Synagis ................................... 38

Synarel .................................... 37

Synercid .................................. 10

Synthroid ................................ 36

Syprine ...................................44

TTabloid .................................... 18

Tacrolimus .............................. 38

Tamiflu ................................... 23

Tamoxifen Citrate .................. 18

Tamsulosin HCl ..................... 33

Tarceva ................................... 20

Targretin ................................. 20

Tasigna ................................... 20

Tasmar .................................... 20

Taxotere .................................. 19

Tazorac ................................... 31

Tegretol .................................. 14

Tegretol-XR ............................ 14

Tekturna ................................. 29

Tekturna HCT ....................... 29

Temazepam ............................ 43

Terazosin HCl ........................ 33

Terbinafine HCl ..................... 17

Terbutaline Sulfate ................. 43

Terconazole ............................. 17

Testosterone Cypionate ........... 35

Testosterone Enanthate .......... 35

Tetanus/Diphtheria Toxoids-Adsorbed Adult ..... 39

Tetracycline HCl .................... 13

Tev-Tropin .............................. 34

Thalomid ................................ 18

Theophylline ER .................... 42

Thermazene ............................ 10

Thioridazine HCl ................... 21

Thiotepa ................................. 18

Thiothixene ............................ 21

Thymoglobulin ....................... 38

Ticlopidine HCl ..................... 27

Tikosyn .................................. 28

Timentin ................................ 12

Timolol Maleate ............... 28, 41

Tizanidine HCl ...................... 22

Tobi ........................................ 10

Tobradex ................................. 41

Tobramycin/Dexamethasone ...41

Tobramycin Sulfate ................. 10

Tobramycin Sulfate/ Sodium Chloride ................. 10

Tobrex ..................................... 10

Tolbutamide............................ 24

Topiramate ............................. 14

Toposar ................................... 19

Topotecan HCl ....................... 19

Torisel ..................................... 38

Torsemide ............................... 29

Toviaz ..................................... 32

TPN Electrolytes.................... 45

Tracleer ................................... 43

Tradjenta................................. 24

Tramadol HCl .......................... 9

Tramadol HCl/ Acetaminophen ..................... 9

Tranexamic Acid .................... 27

Tranylcypromine Sulfate ........ 15

Travasol .................................. 45

Travatan Z .............................. 41

Trazodone HCl ...................... 15

Treanda................................... 18

Trecator .................................. 17

Trelstar Depot ........................ 37

Trelstar LA ............................. 37

Trelstar Mixject ...................... 37

Tretinoin ........................... 20, 31

Tretin-X .................................. 31

Triamcinolone Acetonide ...34, 42

Triamcinolone in Orabase ...... 30

Triamterene/Hydrochlorothiazide ............ 29

Triderm .................................. 34

Trifluoperazine HCl ............... 21

Trifluridine ............................. 23

Trihexyphenidyl HCl ............. 20

Tri-Legest Fe .......................... 35

Trileptal .................................. 14

Trilyte ..................................... 32

Trimethoprim ......................... 10

60

Trimethoprim Sulfate/Polymyxin B Sulfate ............ 11

Trimipramine Maleate ........... 15

Trinessa .................................. 36

Tri-Previfem ........................... 35

Trisenox .................................. 19

Tri-Sprintec ............................ 36

Trivora .................................... 36

Trizivir .................................... 22

Trophamine ............................ 45

Tropicamide ............................ 40

Truvada .................................. 22

Twinject .................................. 43

Twinrix ................................... 39

Tygacil .................................... 11

Tykerb ..................................... 20

Typhim Vi .............................. 39

Tysabri .................................... 38

Tyzeka .................................... 23

Tyzine ..................................... 43

UU-Cort.................................... 34

Uloric ...................................... 17

Unithroid ................................ 36

Ursodiol .................................. 32

Uvadex .................................... 31

VValacyclovir HCl .................... 23

Valcyte .................................... 22

Valproate Sodium ................... 14

Valproic Acid .......................... 14

Vancocin HCl ......................... 11

Vancomycin HCl .................... 11

Vandazole ............................... 11

Vaqta....................................... 39

Varivax .................................... 39

Vectibix ................................... 20

Vectical ................................... 31

Velcade ................................... 19

Velivet ..................................... 36

Venlafaxine HCl ..................... 15

Venlafaxine HCl ER .............. 15

Ventavis .................................. 43

Verapamil HCl ....................... 29

Verapamil HCl ER ................. 29

Vesicare ................................... 32

Vestura .................................... 36

Vfend ...................................... 17

Vfend IV ................................. 17

Vibativ .................................... 11

Vibramycin ............................. 13

Victoza ................................... 24

Victrelis .................................. 23

Vidaza .................................... 19

Videx Pediatric ....................... 22

Viibryd ................................... 15

Vimovo ................................... 32

Vimpat .................................... 14

Vinblastine Sulfate ................. 19

Vincasar PFS .......................... 19

Vincristine Sulfate .................. 19

Vinorelbine Tartrate ............... 19

Viracept .................................. 23

Viramune ................................ 22

Viramune XR ......................... 22

Viread ..................................... 22

Vistide .................................... 22

Vivitrol ................................... 15

Voriconazole ........................... 17

Votrient ................................... 20

Vpriv ....................................... 31

WWarfarin Sodium ................... 26

Welchol .................................. 29

XXalkori.................................... 20

Xarelto .................................... 26

Xenazine ................................. 30

Xgeva ...................................... 39

Xifaxan ................................... 11

Xolair ...................................... 43

Xyrem ..................................... 43

YYervoy ..................................... 20

YF-Vax ................................... 39

ZZafirlukast .............................. 42

Zaleplon ................................. 43

Zanosar ................................... 18

Zavesca ................................... 31

Zazole ..................................... 17

Zelboraf .................................. 20

Zemaira .................................. 43

Zemplar .................................. 39

Zenpep ................................... 31

Zeosa ...................................... 36

Zerit ....................................... 23

Zetia ....................................... 29

Ziagen .................................... 23

Zidovudine ............................. 23

Zinacef ................................... 11

61

Zinacef in Iso-Osmotic Dextrose .............................. 11

Zinacef in Iso-Osmotic Diluent ................................ 11

Ziprasidone HCl ..................... 21

Zmax ...................................... 12

Zolinza ................................... 19

Zolpidem Tartrate .................. 43

Zometa ................................... 39

Zonisamide ............................. 13

Zorbtive .................................. 34

Zortress .................................. 38

Zostavax ................................. 39

Zosyn ..................................... 12

Zovia ...................................... 36

Zyclara .................................... 31

Zylet ....................................... 41

Zyprexa ................................... 21

Zytiga ..................................... 19

Zyvox ...................................... 11

If you are a member of a group sponsored plan (your coverage is provided through a former employer, union group or trust), please call the UnitedHealthcare Customer Service number on the back of your member ID card.

This information is available for free in other languages. Please contact our UnitedHealthcare Customer Service number at 1-888-867-5575, TTY 711, 8 a.m. to 8 p.m. local time, 7 days a week.

Esta información está disponible sin costo en otros idiomas. Comuníquese con el nuestro Servicio al Cliente de UnitedHealthcare al número 1-888-867-5575, TTY 711, de 8 a.m. a 8 p.m. hora local, los 7 días de la semana.

Beneficiaries must use network pharmacies to access their prescription drug benefit. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2014.Plan is insured or covered by UnitedHealthcare Insurance Company or one of its affiliates, a Medicare-approved Part D sponsor. AARP® MedicareRx Plans® carry the AARP name, and UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property. These fees are used for the general purposes of AARP.

FLXAKEN000_PD3403667

This complete formulary (drug list) is effective January 1, 2013. It was updated August 2012. Changes may have been made to this list after it was printed.

Call unitedHealthcare Customer Service for complete, updated information.

1-888-867-5575, TTY 711 8 a.m. to 8 p.m. local time, 7 days a week


Formulary - UnitedHealthcare Medicare Solutions

Documents

Transcript of Formulary - UnitedHealthcare Medicare Solutions