List of Covered Drugs (Formulary) - CignaCarePlan Member Services or read the Cigna-HealthSpring...

If you have questions, please call Cigna-HealthSpring CarePlan at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit www.CarePlanTX.com. I? ?

Cigna-HealthSpring CarePlan | 2016 List of Covered Drugs (Formulary)

This is a list of drugs that members can get in Cigna-HealthSpring CarePlan.

Cigna-HealthSpring CarePlan is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees.

The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you.

Benefits may change on January 1 of each year.

You can always check Cigna-HealthSpring CarePlan’s up-to-date List of Covered Drugs online at www.CarePlanTX.com.

Limitations and restrictions may apply. For more information, call Cigna-HealthSpring CarePlan Member Services or read the Cigna-HealthSpring CarePlan Member Handbook.

You can get this information for free in other formats, such as large print, braille, or audio. Call at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free.

You can get this information for free in other languages. Call 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. Usted puede obtener esta información en otros idiomas, en forma gratuita. Llame al 1-877-653-0327 (TTY: 7-1-1). La llamada es gratuita.

This formulary was updated on 10/26/2016. For more recent information or other questions, please contact Cigna-HealthSpring CarePlan at 1-877-653-0327 or, for TTY users, 7-1-1, 7 days a week, 8 a.m. to 8 p.m. Central Time, or visit www.CarePlanTX.com

HPMS Approved Formulary File Submission ID 16156, Version Number 18

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including HealthSpring Life & Health Insurance Company, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

H8423_16_34813i Approved 12272016 16_F_TXMMP_BL

If you have questions, please call Cigna-HealthSpring CarePlan at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit www.CarePlanTX.com. II?

Frequently Asked Questions (FAQ)

Find answers here to questions you have about this List of Covered Drugs. You can read all of the FAQ to learn more, or look for a question and answer.

1. What prescription drugs are on the List of Covered Drugs?(We call the List of Covered Drugs the “Drug List” for short.)

The drugs on the List of Covered Drugs that starts on page 1 are the drugs covered by Cigna-HealthSpring CarePlan. These drugs are available at pharmacies within our network. A pharmacy is in our network if we have an agreement with them to work with us and provide you services. We refer to these pharmacies as “network pharmacies.”

Cigna-HealthSpring CarePlan will cover all medically necessary drugs on the Drug List if:

your doctor or other prescriber says you need them to get better or stay healthy, and

you fill the prescription at a Cigna-HealthSpring CarePlan network pharmacy.

Cigna-HealthSpring CarePlan may have additional steps to access certain drugs (see question #5 below).

You can also see an up-to-date list of drugs that we cover on our website at www.CarePlanTX.com or call Member Services at 1-877-653-0327 (TTY: 7-1-1).

2. Does the Drug List ever change?

Yes. Cigna-HealthSpring CarePlan may add or remove drugs on the Drug List during the year. Generally, the Drug List will only change if:

a cheaper drug comes along that works as well as a drug on the Drug List now, or

we learn that a drug is not safe.

We may also change our rules about drugs. For example, we could:

Decide to require or not require prior approval for a drug. (Prior approval is permission from Cigna-HealthSpring CarePlan before you can get a drug.)

Add or change the amount of a drug you can get (called “quantity limits”).

If you have questions, please call Cigna-HealthSpring CarePlan at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit www.CarePlanTX.com. III ?

Add or change step therapy restrictions on a drug. (Step therapy means you must try one drug before we will cover another drug.)

(For more information on these drug rules, see pages III IV)

We will tell you when a Medicare Part D drug you are taking is removed from the Drug List. We will also tell you when we change our rules for covering a Medicare Part D drug. Questions 3, 4, and 7 below have more information on what happens when the Drug List changes.

You can always check Cigna-HealthSpring CarePlan’s up to date Drug List online at www.CarePlanTX.com. You can also call Member Services to check the current Drug List at 1-877-653-0327 (TTY: 7-1-1).

3. What happens when a cheaper drug comes along that works as well as a drug on the Drug List now?

If you are taking a Medicare Part D drug that is removed because a cheaper drug that works just as well comes along, we will tell you. We will tell you at least 60 days before we remove it from the Drug List or when you ask for a refill. Then you can get a 60-day supply of the drug before the change to the Drug List is made. We will mail you a letter explaining the change and tell you the next steps to take to switch to a different drug.

4. What happens when we find out a drug is not safe?

If the Food and Drug Administration (FDA) says a drug you are taking is not safe, we will take it off the Drug List right away. We will also send you a letter telling you that. If you have any questions after being notified of the change, you should contact the doctor who prescribed the drug for you.

5. Are there any restrictions or limits on drug coverage? Or are there any required actions to take in order to get certain drugs?

Yes, some drugs have coverage rules or have limits on the amount you can get. In some cases you must do something before you can get the drug. For example:

Prior approval (or prior authorization): For some drugs, you or your doctor or other prescriber must get approval from Cigna-HealthSpring CarePlan before you fill

If you have questions, please call Cigna-HealthSpring CarePlan at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit www.CarePlanTX.com. IV?

your prescription. If you don’t get approval, Cigna-HealthSpring CarePlan may not cover the drug.

Quantity limits: Sometimes Cigna-HealthSpring CarePlan limits the amount of a drug you can get.

Step therapy: Sometimes Cigna-HealthSpring CarePlan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. If your doctor thinks the first drug doesn’t work for you, then we will cover the second.

You can find out if your drug has any additional requirements or limits by looking in the tables on pages 1-95. You can also get more information by visiting our web site at www.CarePlanTX.com. We have posted online documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy.

You can ask for an “exception” from these limits. Please see question 11 for more information on exceptions.

If you are in a nursing home or other long-term care facility and need a drug that is not on the Drug List, or if you cannot easily get the drug you need, we can help. We will cover a 31-day emergency supply of the drug you need (unless you have a prescription for fewer days), whether or not you are a new Cigna-HealthSpring CarePlan member. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception. Please see question 11 for more information about exceptions.

6. How will you know if the drug you want has limitations or if there are requiredactions to take to get the drug?

The List of Covered Drugs on page 1 has a column labeled “Necessary actions, restrictions, or limits on use.”

7. What happens if we change our rules on how we cover some drugs? Forexample, if we add prior authorization (approval), quantity limits, and/or steptherapy restrictions on a drug.

We will tell you if we add prior approval, quantity limits, and/or step therapy restrictions on a drug. We will tell you at least 60 days before the restriction is added or when you next

If you have questions, please call Cigna-HealthSpring CarePlan at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit www.CarePlanTX.com. V?

ask for a refill. Then, you can get a 60-day supply of the drug before the change to the Drug List is made. This gives you time to talk to your doctor or other prescriber about what to do next.

8. How can you find a drug on the Drug List?

There are two ways to find a drug:

You can search alphabetically (if you know how to spell the drug), or

You can search by medical condition.

To search alphabetically, go to the Alphabetical Listing section. You can find it in the section that begins on page 96. If you are not sure what category to look under, you should look for your drug in the Alphabetical Drug List section. This section has a list of all the drugs in this book. Turn to the page listed in the Alphabetical Drug List section and find the name of your drug in the first column of the list.

To search by medical condition, find the section labeled “List of drugs by medical condition” on page 1. The drugs in this section are grouped into categories depending on the type of medical conditions they are used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular Agents That is where you will find drugs that treat heart conditions.

9. What if the drug you want to take is not on the Drug List?

If you don’t see your drug on the Drug List, call Member Services at 1-877-653-0327 (TTY: 7-1-1) and ask about it. If you learn that Cigna-HealthSpring CarePlan will not cover the drug, you can do one of these things:

Ask Member Services for a list of drugs like the one you want to take. Then show the list to your doctor or other prescriber. He or she can prescribe a drug on the Drug List that is like the one you want to take. Or

You can ask the health plan to make an exception to cover your drug. Please see question 11 for more information about exceptions.

If you have questions, please call Cigna-HealthSpring CarePlan at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit www.CarePlanTX.com. VI ?

10. What if you are a new Cigna-HealthSpring CarePlan member and can’t find your drug on the Drug List or have a problem getting your drug?

We can help. We may cover a temporary 30-day supply of your drug during the first 90 days you are a member of Cigna-HealthSpring CarePlan. This will give you time to talk to your doctor or other prescriber. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to request an exception.

We will cover a 30-day supply of your drug if:

you are taking a drug that is not on our Drug List, or

health plan rules do not let you get the amount ordered by your prescriber, or

the drug requires prior approval by Cigna-HealthSpring CarePlan, or

you are taking a drug that is part of a step therapy restriction.

If you live in a nursing home or other long-term care facility, you may refill your prescription for as long as 98 days. You may refill the drug multiple times during your first 98 days in the plan. This gives your prescriber time to change your drugs to ones on the Drug List or ask for an exception.

We will cover a temporary 30-day supply of your drug if an unexpected move happens. For example, if you are released from the hospital to go home or to a nursing home and you are not able to get your medicine.

11. Can you ask for an exception to cover your drug?

Yes. You can ask Cigna-HealthSpring CarePlan to make an exception to cover a drug that is not on the Drug List.

You can also ask us to change the rules on your drug.

For example, Cigna-HealthSpring CarePlan may limit the amount of a drug we will cover. If your drug has a limit, you can ask us to change the limit and cover more.

Other examples: You can ask us to drop step therapy restrictions or prior approval requirements.

If you have questions, please call Cigna-HealthSpring CarePlan at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit www.CarePlanTX.com. VII ?

12. How long does it take to get an exception?

First, we must receive a statement from your prescriber supporting your request for an exception. After we receive the statement, we will give you a decision on your exception request within 72 hours.

If you or your prescriber think your health may be harmed if you have to wait 72 hours for a decision, you can ask for an expedited exception. This is a faster decision. If your prescriber supports your request, we will give you a decision within 24 hours of receiving your prescriber’s supporting statement.

13. How can you ask for an exception?

To ask for an exception, call Member Services. A Member Services representative will work with you and your provider to help you ask for an exception.

14. What are generic drugs?

Generic drugs are made up of the same active ingredients as brand name drugs. They usually cost less than the brand name drug and usually don’t have well-known names. Generic drugs are approved by the Food and Drug Administration (FDA).

Cigna-HealthSpring CarePlan covers both brand name drugs and generic drugs.

15. What are OTC drugs?

OTC stands for “over-the-counter.” Cigna-HealthSpring CarePlan covers some OTC drugs when they are written as prescriptions by your provider.

You can read the Cigna-HealthSpring CarePlan Drug List to see what OTC drugs are covered.

16. Does Cigna-HealthSpring CarePlan cover OTC non-drug products?

Cigna-HealthSpring CarePlan covers some OTC non-drug products when they are written as prescriptions by your provider.

You can read the Cigna-HealthSpring CarePlan Drug List to see what OTC non-drug products are covered.

If you have questions, please call Cigna-HealthSpring CarePlan at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit www.CarePlanTX.com. VIII ?

17. What is your co-pay?

Cigna-HealthSpring CarePlan does not require a copay.

If you have any questions, call Member Services at 1-877-653-0327 (TTY: 7-1-1).

If you have questions, please call Cigna-HealthSpring CarePlan at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit www.CarePlanTX.com. IX?

List of Covered Drugs

The list of covered drugs that begins on the next page gives you information about the drugs covered by Cigna-HealthSpring CarePlan. If you have trouble finding your drug in the list, turn to the Index that begins on page 96.

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

The information in the necessary actions, restrictions, or limits on use column tells you if Cigna-HealthSpring CarePlan has any rules for covering your drug.

Abbreviation Explanation

B/D (Part B/Part D) This drug might be covered under Medicare Part B instead of Medicare Part D. More information might be needed for Cigna-HealthSpring CarePlan (MMP) to decide which plan should cover it.

MO (Mail Order) This drug is a maintenance medication available through mail order.

PA (Prior Authorization) This drug requires prior authorization.

QL (Quantity Limits) This drug has quantity limits.

ST (Step Therapy) This drug has step therapy requirements.

MC (Medicaid Covered) Non-Part D Drugs or OTC items that are covered by Medicaid

Note: The “MC” next to a drug means the drug is not a “Part D drug.” The amount you pay when you fill a prescription for this drug does not count towards your total drug costs (that is, the amount you pay does not help you qualify for catastrophic coverage). In addition, if you are receiving extra help to pay for your prescriptions, you will not get any extra help to pay for these drugs. These drugs also have different rules for appeals. An appeal is a formal way of asking us to review a coverage decision and to change it if you think we made a mistake. For example, we might decide that a drug that you want is not covered or is no longer covered by Medicare or Texas Medicaid. If you or your doctor disagrees with our decision, you can appeal. To ask for instructions on how to appeal, call

If you have questions, please call Cigna-HealthSpring CarePlan at 1-877-653-0327 (TTY: 7-1-1), seven days a week, 8 a.m. to 8 p.m. Central Time. The call is free. For more information, visit www.CarePlanTX.com. X ?

Member Services at 1-877-653-0327 (TTY: 7-1-1). You can also read the Member Handbook to learn how to appeal a decision.

1 Key: QL= Quantity Limits listed as (qty/days); PA= Prior Authorization may be required; ST=Step

Therapy rules apply; B/D= Drugs covered under Medicare Part B or D; MO= Mail order; MC= Non-Part D

drugs or OTC items covered by Medicaid.

List of Drugs by Medical Condition

The drugs in this section are grouped into categories depending on the type of medical conditions they are

used to treat. For example, if you have a heart condition, you should look in the category, Cardiovascular

Agents. That is where you will find drugs that treat heart conditions.

Name of drug

What the drug

will cost you

(tier level)

Necessary actions,

restrictions, or limits on

use

Analgesics (Drugs that Relieve Pain)

Analgesics

acephen $0(Tier 1) MC

acetaminophen tabs 325mg $0(Tier 1) MC

butalbital/acetaminophen/caffeine caps $0(Tier 1) QL (180 per 30 days) PA

butalbital/acetaminophen/caffeine tabs 325mg; 50mg; 40mg $0(Tier 1) QL (180 per 30 days) PA

butalbital/aspirin/caffeine $0(Tier 1) QL (180 per 30 days) PA

childrens mapap rapid tabs $0(Tier 1) MC

ed-apap $0(Tier 1) MC

esgic caps $0(Tier 1) QL (180 per 30 days) PA

gnp arthritis pain relief $0(Tier 1) MC

histaflex $0(Tier 1) MC

junior mapap $0(Tier 1) MC

mapap $0(Tier 1) MC

mapap acetaminophen extrastrength $0(Tier 1) MC

mapap arthritis pain $0(Tier 1) MC

mapap childrens $0(Tier 1) MC

mapap pm $0(Tier 1) MC

margesic $0(Tier 1) QL (180 per 30 days) PA

pain & fever $0(Tier 1) MC

pain & fever childrens $0(Tier 1) MC

pain & fever extra strength $0(Tier 1) MC

pain reliever pm extra strength $0(Tier 1) MC

q-pap $0(Tier 1) MC

q-pap childrens $0(Tier 1) MC

q-pap extra strength $0(Tier 1) MC

q-pap infants $0(Tier 1) MC

qc arthritis pain relief $0(Tier 1) MC

zebutal caps 325mg; 50mg; 40mg $0(Tier 1) QL (180 per 30 days) PA

Nonsteroidal Anti-inflammatory Drugs

all day pain relief $0(Tier 1) MC

all day relief $0(Tier 1) MC

aspirin ec tbec 325mg $0(Tier 1) MC

aspirin chew 81mg $0(Tier 1) MC

aspirin tabs 325mg $0(Tier 1) MC

aspirin tbec 325mg $0(Tier 1) MC

celecoxib caps $0(Tier 1) QL (60 per 30 days)




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

childrens ibuprofen susp 100mg/5ml $0(Tier 1) MC

childs ibuprofen $0(Tier 1) MC

congestion relief $0(Tier 1) MC

diclofenac potassium $0(Tier 1) MO

diclofenac sodium dr $0(Tier 1) MO

diclofenac sodium er $0(Tier 1) MO

diflunisal tabs $0(Tier 1) MO

effervescent pain relief $0(Tier 1) MC

enteric coated aspirin $0(Tier 1) MC

etodolac er $0(Tier 1) MO

etodolac caps $0(Tier 1) MO

etodolac tabs 400mg $0(Tier 1)

etodolac tabs 500mg $0(Tier 1) MO

fenoprofen calcium caps 400mg $0(Tier 1)

fenoprofen calcium tabs $0(Tier 1) MO

flurbiprofen tabs $0(Tier 1) MO

gnp ibuprofen junior strength $0(Tier 1) MC

gnp ibuprofen tabs $0(Tier 1) MC

ibu-200 $0(Tier 1) MC

ibu-drops $0(Tier 1) MC

ibu-drops infants $0(Tier 1) MC

ibuprofen childrens $0(Tier 1) MC

ibuprofen junior strength $0(Tier 1) MC

ibuprofen caps $0(Tier 1) MC

ibuprofen susp 100mg/5ml $0(Tier 1) MC

ibuprofen susp 100mg/5ml $0(Tier 1) MO

ibuprofen tabs 200mg $0(Tier 1) MC

ibuprofen tabs 400mg, 600mg, 800mg $0(Tier 1) MO

infants ibuprofen $0(Tier 1) MC

ketoprofen er $0(Tier 1) MO

ketoprofen caps $0(Tier 1) MO

meclofenamate sodium caps $0(Tier 1) MO

meloxicam tabs $0(Tier 1) MO

migraine formula $0(Tier 1) MC

nabumetone $0(Tier 1) MO

naproxen dr $0(Tier 1) MO

naproxen sodium tabs 275mg, 550mg $0(Tier 1) MO

naproxen susp, tabs $0(Tier 1) MO

oxaprozin $0(Tier 1) MO

piroxicam caps $0(Tier 1) MO

qc ibuprofen caps $0(Tier 1) MC

qc naproxen sodium $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

salsalate $0(Tier 1)

sm ibuprofen tabs $0(Tier 1) MC

sulindac tabs $0(Tier 1) MO

tolmetin sodium $0(Tier 1) MO

Opioid Analgesics, Long-acting

DURAMORPH $0(Tier 2)

fentanyl $0(Tier 1) QL (15 per 30 days)

infumorph 200 $0(Tier 1)

infumorph 500 $0(Tier 1)

levorphanol tartrate tabs $0(Tier 1) QL (180 per 30 days)

methadone hcl intensol $0(Tier 1) QL (500 per 30 days)

METHADONE HCL INJ $0(Tier 2)

methadone hcl tabs $0(Tier 1) QL (360 per 30 days)

methadone hcl conc $0(Tier 1) QL (500 per 30 days)

methadone hcl oral soln 10mg/5ml $0(Tier 1) QL (2000 per 30 days)

methadone hcl oral soln 5mg/5ml $0(Tier 1) QL (4000 per 30 days)

morphine sulfate er tbcr $0(Tier 1) QL (90 per 30 days)

morphine sulfate inj 0.5mg/ml, 1mg/ml $0(Tier 1)

oxymorphone hydrochloride er $0(Tier 1) QL (60 per 30 days)

tramadol hcl er tb24 $0(Tier 1) QL (30 per 30 days)

XARTEMIS XR $0(Tier 2) QL (120 per 30 days)

Opioid Analgesics, Short-acting

acetaminophen/caffeine/dihydrocodeine $0(Tier 1) QL (360 per 30 days)

acetaminophen/codeine #2 $0(Tier 1) QL (360 per 30 days)



acetaminophen/codeine phosphate tabs 300mg; 60mg $0(Tier 1) QL (240 per 30 days)

acetaminophen/codeine soln $0(Tier 1) QL (5000 per 30 days)

acetaminophen/codeine tabs 300mg; 60mg $0(Tier 1) QL (240 per 30 days)

acetaminophen/codeine tabs 300mg; 15mg $0(Tier 1) QL (360 per 30 days)

ascomp/codeine $0(Tier 1) QL (180 per 30 days) PA

butalbital/acetaminophen/caffeine/codeine $0(Tier 1) QL (180 per 30 days) PA

butalbital/aspirin/caffeine/codeine $0(Tier 1) QL (180 per 30 days) PA

butorphanol tartrate inj $0(Tier 1)

butorphanol tartrate nasal soln $0(Tier 1) QL (6 per 30 days)

endocet $0(Tier 1) QL (360 per 30 days)

fentanyl citrate oral transmucosal $0(Tier 1) QL (120 per 30 days) PA

fentanyl citrate inj 100mcg/2ml $0(Tier 1) B/D

hydrocodone bitartrate/acetaminophen soln 325mg/15ml;

7.5mg/15ml

$0(Tier 1) QL (5400 per 30 days)

hydrocodone bitartrate/acetaminophen tabs 325mg; 2.5mg $0(Tier 1) QL (360 per 30 days)




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

hydrocodone bitartrate/acetaminophen tabs 300mg; 10mg,

300mg; 5mg, 300mg; 7.5mg


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

325mg; 7.5mg


hydrocodone/ibuprofen $0(Tier 1) QL (150 per 30 days)

hydromorphone hcl dosette $0(Tier 1)

hydromorphone hcl liqd $0(Tier 1) QL (1200 per 30 days)

hydromorphone hcl tabs $0(Tier 1) QL (240 per 30 days)

hydromorphone hcl inj 1mg/ml, 2mg/ml, 4mg/ml, 500mg/50ml $0(Tier 1)

ibudone tabs 5mg; 200mg $0(Tier 1) QL (150 per 30 days)

LAZANDA $0(Tier 2) QL (44 per 28 days) PA

lorcet $0(Tier 1) QL (360 per 30 days)

lorcet hd $0(Tier 1) QL (360 per 30 days)

lorcet plus tabs 325mg; 7.5mg $0(Tier 1) QL (360 per 30 days)

lortab tabs $0(Tier 1) QL (360 per 30 days)

morphine sulfate add-vantage $0(Tier 1)

morphine sulfate inj 10mg/ml, 150mg/30ml, 15mg/ml, 1mg/ml,

25mg/ml, 2mg/ml, 4mg/ml, 50mg/ml, 5mg/ml, 8mg/ml

$0(Tier 1)

morphine sulfate oral soln 20mg/5ml $0(Tier 1) QL (2700 per 30 days)



MORPHINE SULFATE TABS 15MG, 30MG $0(Tier 2) QL (360 per 30 days)

nalbuphine hcl inj $0(Tier 1)

oxycodone hcl soln $0(Tier 1) QL (1200 per 30 days)

oxycodone hcl caps, tabs $0(Tier 1) QL (240 per 30 days)

oxycodone hcl conc $0(Tier 1) QL (360 per 30 days)

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

325mg; 5mg, 325mg; 7.5mg


oxycodone/aspirin $0(Tier 1) QL (360 per 30 days)

oxycodone/ibuprofen $0(Tier 1) QL (150 per 30 days)

reprexain tabs 10mg; 200mg $0(Tier 1) QL (150 per 30 days)

roxicet tabs $0(Tier 1) QL (360 per 30 days)

TALWIN $0(Tier 2)

tramadol hcl tabs $0(Tier 1) QL (240 per 30 days)

tramadol hydrochloride/acetaminophen $0(Tier 1) QL (240 per 30 days)

trezix caps 320.5mg; 30mg; 16mg $0(Tier 1) QL (360 per 30 days)

vicodin es tabs 300mg; 7.5mg $0(Tier 1) QL (390 per 30 days)

vicodin hp tabs 300mg; 10mg $0(Tier 1) QL (390 per 30 days)

vicodin tabs 300mg; 5mg $0(Tier 1) QL (390 per 30 days)

xylon $0(Tier 1) QL (150 per 30 days)

Anesthetics (Drugs that Decrease Feeling and Awareness)

Local Anesthetics




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

glydo $0(Tier 1)

lidocaine hcl jelly $0(Tier 1)

lidocaine hcl viscous $0(Tier 1)

lidocaine hcl gel 2% $0(Tier 1)

lidocaine hcl inj 0.5%, 1%, 1.5%, 2%, 4% $0(Tier 1)

lidocaine hcl external soln 4% $0(Tier 1)

lidocaine hcl mouth/throat soln 4% $0(Tier 1)

lidocaine viscous $0(Tier 1)

lidocaine/prilocaine crea $0(Tier 1)

lidocaine oint 5% $0(Tier 1)

lidocaine ptch 5% $0(Tier 1) QL (90 per 30 days) PA

premium lidocaine $0(Tier 1)

sore throat & cough lozenges $0(Tier 1) MC

Anti-Addiction/Substance Abuse Treatment Agents (Drugs that Treat Addiction Problems)

Alcohol Deterrents/Anti-craving

acamprosate calcium dr $0(Tier 1) PA

disulfiram tabs 250mg $0(Tier 1)

disulfiram tabs 500mg $0(Tier 1) MO

Opioid Dependence Treatments

buprenorphine hcl/naloxone hcl $0(Tier 1) QL (90 per 30 days) PA

buprenorphine hcl inj $0(Tier 1)

buprenorphine hcl subl $0(Tier 1) QL (90 per 30 days) PA

naltrexone hcl tabs $0(Tier 1) PA

SUBOXONE $0(Tier 2) QL (90 per 30 days) PA

Opioid Reversal Agents

naloxone hcl inj 0.4mg/ml, 2mg/2ml $0(Tier 1)

NARCAN $0(Tier 2) QL (4 per 30 days)

Smoking Cessation Agents

buproban $0(Tier 1) QL (60 per 30 days) MO

bupropion hcl sr tb12 150mg $0(Tier 1) QL (60 per 30 days) MO

CHANTIX CONTINUING MONTH PAK $0(Tier 2) QL (336 per 365 days)

CHANTIX STARTING MONTH PAK $0(Tier 2) QL (106 per 365 days)

CHANTIX TABS 0.5MG, 1MG $0(Tier 2) QL (336 per 365 days)

NICODERM CQ $0(Tier 1) MC

nicorelief $0(Tier 1) MC

NICORETTE $0(Tier 1) MC

NICORETTE MINI $0(Tier 1) MC

NICORETTE STARTER KIT $0(Tier 1) MC

nicotine polacrilex gum, lozg $0(Tier 1) MC

nicotine transdermal system $0(Tier 1) MC

nicotine transdermal system step 1 $0(Tier 1) MC





Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use


NICOTROL INHALER $0(Tier 2) QL (504 per 30 days) PA

NICOTROL NS $0(Tier 2) QL (40 per 30 days)

Antibacterials (Drugs that Treat Infection from Bacteria)

Aminoglycosides

amikacin sulfate inj $0(Tier 1)

gentak $0(Tier 1)

gentamicin sulfate pediatric $0(Tier 1)

gentamicin sulfate/0.9% sodium chloride $0(Tier 1)

gentamicin sulfate crea, inj, external oint, ophthalmic oint,

ophthalmic soln

$0(Tier 1)

isotonic gentamicin inj 0.8mg/ml; 0.9% $0(Tier 1)

neomycin sulfate $0(Tier 1)

neomycin/polymyxin b sulfates $0(Tier 1)

paromomycin sulfate $0(Tier 1)

streptomycin sulfate inj $0(Tier 1)

tobramycin sulfate ophthalmic soln $0(Tier 1)

tobramycin sulfate inj 1.2gm, 10mg/ml, 40mg/ml, 80mg/2ml $0(Tier 1)

TOBREX OINT $0(Tier 2)

ZYLET $0(Tier 2)

Antibacterials, Other

ak-poly-bac $0(Tier 1)

alcohol prep pads $0(Tier 1)

baciim $0(Tier 1)

bacitracin zinc oint $0(Tier 1) MC

bacitracin/neomycin/polymyxin oint $0(Tier 1) MC

bacitracin/polymyxin b $0(Tier 1)

bacitracin inj, ophthalmic oint $0(Tier 1)

bacitracin external oint $0(Tier 1) MC

BACTROBAN NASAL $0(Tier 2)

chloramphenicol sodium succinate $0(Tier 1)

clindacin etz pledgets $0(Tier 1)

clindacin-p $0(Tier 1)

clindamax $0(Tier 1)

clindamycin hcl caps $0(Tier 1)

clindamycin phosphate add-vantage inj 900mg/6ml $0(Tier 1)

clindamycin phosphate in d5w $0(Tier 1)

clindamycin phosphate pharmacy bulk package $0(Tier 1)

clindamycin phosphate crea, gel, lotn, external soln, swab $0(Tier 1)

clindamycin phosphate inj 150mg/ml, 300mg/2ml, 600mg/4ml,

900mg/6ml

$0(Tier 1)

colistimethate sodium $0(Tier 1)




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

CUBICIN $0(Tier 2) B/D

daptomycin $0(Tier 1) B/D

lansoprazole/amoxicillin/clarithromycin $0(Tier 1)

LINCOCIN $0(Tier 2)

lincomycin hcl inj $0(Tier 1)

linezolid susr, tabs $0(Tier 1) PA

linezolid inj 600mg/300ml $0(Tier 1) PA

methenamine hippurate $0(Tier 1)

metronidazole in nacl 0.79% $0(Tier 1)

metronidazole vaginal $0(Tier 1)

metronidazole crea, gel, inj, lotn, tabs $0(Tier 1)

mupirocin calcium $0(Tier 1)

mupirocin crea, oint $0(Tier 1)

neo-polycin $0(Tier 1)

neo-polycin hc $0(Tier 1)

neomycin/bacitracin/polymyxin $0(Tier 1)

neomycin/polymyxin/bacitracin zinc $0(Tier 1)

neomycin/polymyxin/bacitracin/hydrocortisone $0(Tier 1)

neomycin/polymyxin/gramicidin $0(Tier 1)

neomycin/polymyxin/hydrocortisone ophthalmic susp 1%;

3.5mg/ml; 10000unit/ml

$0(Tier 1)

nitrofurantoin macrocrystals caps 100mg, 50mg $0(Tier 1) QL (90 per 365 days)

nitrofurantoin monohydrate $0(Tier 1) QL (90 per 365 days)

nitrofurantoin monohydrate/macrocrystals $0(Tier 1) QL (90 per 365 days)

nitrofurantoin susp $0(Tier 1)

NORITATE $0(Tier 2)

polycin $0(Tier 1)

polymyxin b sulfate/trimethoprim sulfate $0(Tier 1)

polymyxin b sulfate inj $0(Tier 1)

povidone-iodine oint, soln $0(Tier 1) MC

PRIMSOL $0(Tier 2)

rosadan $0(Tier 1)

silver sulfadiazine crea $0(Tier 1)

SSD $0(Tier 2)

SYNERCID $0(Tier 2)

trimethoprim sulfate/polymyxin b sulfate $0(Tier 1)

trimethoprim tabs $0(Tier 1)

triple antibiotic plus oint 500unit/gm; 5mg/gm; 10000unit/gm;

10mg/gm

$0(Tier 1) MC

triple antibiotic oint $0(Tier 1) MC

TYGACIL $0(Tier 2)

vancomycin $0(Tier 1)




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

vancomycin hcl in dextrose $0(Tier 1)

vancomycin hcl caps 125mg $0(Tier 1) QL (40 per 10 days)

vancomycin hcl caps 250mg $0(Tier 1) QL (80 per 10 days)

vancomycin hcl inj $0(Tier 1)

vandazole $0(Tier 1)

XIFAXAN TABS 550MG $0(Tier 2) QL (60 per 30 days) PA

XIFAXAN TABS 200MG $0(Tier 2) QL (9 per 30 days) PA

ZYVOX SUSR $0(Tier 2) PA

Beta-lactam, Cephalosporins

cefaclor $0(Tier 1)

cefaclor er $0(Tier 1)

cefadroxil $0(Tier 1)

CEFAZOLIN $0(Tier 2)

CEFAZOLIN SODIUM/DEXTROSE INJ 2GM; 3% $0(Tier 2)

cefazolin sodium inj 10gm, 1gm, 1gm; 5%, 500mg $0(Tier 1)

cefdinir $0(Tier 1)

cefepime $0(Tier 1)

cefepime/dextrose $0(Tier 1)

cefixime $0(Tier 1)

cefotaxime sodium inj 1gm, 2gm, 500mg $0(Tier 1)

cefoxitin sodium inj 10gm, 1gm, 2gm $0(Tier 1)

cefpodoxime proxetil $0(Tier 1)

cefprozil $0(Tier 1)

ceftazidime $0(Tier 1)

CEFTAZIDIME/DEXTROSE $0(Tier 2)

ceftriaxone in iso-osmotic dextrose $0(Tier 1)

ceftriaxone sodium inj 10gm, 1gm, 250mg, 2gm, 500mg $0(Tier 1)

cefuroxime axetil $0(Tier 1)

cefuroxime sodium inj 1.5gm, 7.5gm, 750mg, 75gm $0(Tier 1)

cephalexin caps 250mg, 500mg $0(Tier 1)

cephalexin susr, tabs $0(Tier 1)

SUPRAX SUSR 500MG/5ML $0(Tier 2)

tazicef inj 1gm, 2gm, 6gm $0(Tier 1)

TEFLARO $0(Tier 2)

Beta-lactam, Other

AZACTAM IN ISO-OSMOTIC DEXTROSE $0(Tier 2)

aztreonam $0(Tier 1)

cefotetan $0(Tier 1)

imipenem/cilastatin $0(Tier 1)

INVANZ $0(Tier 2)

meropenem $0(Tier 1)

meropenem/sodium chloride $0(Tier 1)




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

Beta-lactam, Penicillins

amoxicillin $0(Tier 1)

amoxicillin/clavulanate potassium $0(Tier 1)

amoxicillin/clavulanate potassium er $0(Tier 1)

ampicillin $0(Tier 1)

ampicillin sodium inj $0(Tier 1)

ampicillin-sulbactam $0(Tier 1)

AUGMENTIN SUSR 125MG/5ML; 31.25MG/5ML $0(Tier 2)

BICILLIN L-A $0(Tier 2)

dicloxacillin sodium $0(Tier 1)

nafcillin sodium $0(Tier 1)

oxacillin sodium $0(Tier 1)

penicillin g potassium inj 20000000unit, 5000000unit $0(Tier 1)

penicillin v potassium $0(Tier 1)

PFIZERPEN-G $0(Tier 2)

piperacillin sodium/ tazobactam sodium $0(Tier 1)

piperacillin sodium/tazobactam sodium $0(Tier 1)

piperacillin/tazobactam $0(Tier 1)

TIMENTIN $0(Tier 2)

ZOSYN INJ 5%; 2GM/50ML; 0.25GM/50ML, 5%;

3GM/50ML; 0.375GM/50ML, 5%; 4GM/100ML;

0.5GM/100ML

$0(Tier 2)

Macrolides

AZASITE $0(Tier 2)

azithromycin inj $0(Tier 1)

azithromycin tabs $0(Tier 1) QL (12 per 28 days)

azithromycin pack $0(Tier 1) QL (3 per 30 days)

azithromycin susr 100mg/5ml $0(Tier 1) QL (150 per 30 days)

azithromycin susr 200mg/5ml $0(Tier 1) QL (75 per 30 days)

clarithromycin er $0(Tier 1) QL (60 per 30 days)

clarithromycin susr, tabs $0(Tier 1)

e.e.s. 400 $0(Tier 1)

E.E.S. GRANULES $0(Tier 2)

ery $0(Tier 1)

ERY-TAB $0(Tier 2)

ERYPED 200 $0(Tier 2)

ERYPED 400 $0(Tier 2)

ERYTHROCIN LACTOBIONATE $0(Tier 2)

erythrocin stearate $0(Tier 1)

erythromycin base $0(Tier 1)

erythromycin ethylsuccinate susr, tabs $0(Tier 1)

erythromycin gel, oint, pads, soln $0(Tier 1)




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

ilotycin $0(Tier 1)

KETEK $0(Tier 2) QL (20 per 30 days)

ZMAX $0(Tier 2) QL (60 per 30 days)

Quinolones

AVELOX INJ $0(Tier 2)

BESIVANCE $0(Tier 2)

CILOXAN OINT $0(Tier 2)

CIPRO HC $0(Tier 2)

CIPRODEX $0(Tier 2)

ciprofloxacin er $0(Tier 1)

ciprofloxacin hcl soln, tabs $0(Tier 1)

ciprofloxacin i.v.-in d5w $0(Tier 1)

ciprofloxacin susr $0(Tier 1)

ciprofloxacin inj 400mg/40ml $0(Tier 1)

levofloxacin in d5w $0(Tier 1)

levofloxacin inj, oral soln, tabs $0(Tier 1)

MOXEZA $0(Tier 2)

moxifloxacin hcl $0(Tier 1)

ofloxacin $0(Tier 1)

VIGAMOX $0(Tier 2)

Sulfonamides

BLEPHAMIDE $0(Tier 2)

BLEPHAMIDE S.O.P. $0(Tier 2)

sodium sulfacetamide soln $0(Tier 1)

sulfacetamide sodium/prednisolone sodium phosphate $0(Tier 1)

sulfacetamide sodium soln, susp $0(Tier 1)

sulfadiazine tabs $0(Tier 1)

sulfamethoxazole/trimethoprim $0(Tier 1)

sulfamethoxazole/trimethoprim ds $0(Tier 1)

sulfatrim pediatric $0(Tier 1)

Tetracyclines

demeclocycline hcl $0(Tier 1)

doxy 100 $0(Tier 1)

doxycycline hyclate caps, inj, tabs $0(Tier 1)

doxycycline monohydrate caps, tabs $0(Tier 1)

doxycycline caps 75mg $0(Tier 1)

doxycycline susr $0(Tier 1)

minocycline hcl caps, tabs $0(Tier 1)

mondoxyne nl $0(Tier 1)

morgidox 1x100mg caps $0(Tier 1)

morgidox 1x50mg $0(Tier 1)

morgidox 2x100mg caps $0(Tier 1)




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

tetracycline hcl caps $0(Tier 1)

Anticonvulsants (Drugs that Control Seizures)

Anticonvulsants, Other

APTIOM TABS 200MG, 400MG, 800MG $0(Tier 2) QL (30 per 30 days) MO

APTIOM TABS 600MG $0(Tier 2) QL (60 per 30 days) MO

BRIVIACT ORAL SOLN $0(Tier 2) QL (1200 per 30 days)

BRIVIACT INJ $0(Tier 2) QL (600 per 30 days)

BRIVIACT TABS 100MG $0(Tier 2) QL (120 per 30 days)

BRIVIACT TABS 10MG, 25MG, 50MG, 75MG $0(Tier 2) QL (60 per 30 days)

FYCOMPA $0(Tier 2) MO

levetiracetam er $0(Tier 1)

levetiracetam inj, oral soln $0(Tier 1)

levetiracetam tabs $0(Tier 1) MO

POTIGA $0(Tier 2) QL (90 per 30 days) PA

MO

roweepra $0(Tier 1) MO

SPRITAM TB3D 750MG $0(Tier 2) QL (120 per 30 days)

SPRITAM TB3D 1000MG, 250MG, 500MG $0(Tier 2) QL (60 per 30 days)

Calcium Channel Modifying Agents

CELONTIN $0(Tier 2) MO

ethosuximide $0(Tier 1) MO

LYRICA SOLN $0(Tier 2) QL (900 per 30 days)

LYRICA CAPS 225MG, 300MG $0(Tier 2) QL (60 per 30 days) MO

LYRICA CAPS 100MG, 150MG, 200MG, 25MG, 50MG,

75MG

$0(Tier 2) QL (90 per 30 days) MO

zonisamide $0(Tier 1) MO

Gamma-aminobutyric Acid (GABA) Augmenting Agents

clonazepam odt tbdp 0.125mg, 0.25mg, 0.5mg, 1mg $0(Tier 1) QL (150 per 30 days)

clonazepam odt tbdp 2mg $0(Tier 1) QL (300 per 30 days)

clonazepam tabs 0.5mg, 1mg $0(Tier 1) QL (150 per 30 days)

clonazepam tabs 2mg $0(Tier 1) QL (300 per 30 days)

DIAZEPAM GEL 10MG, 2.5MG, 20MG $0(Tier 2)

divalproex sodium $0(Tier 1) MO

divalproex sodium dr $0(Tier 1) MO

divalproex sodium er $0(Tier 1) MO

gabapentin caps, soln, tabs $0(Tier 1) MO

GABITRIL TABS 12MG $0(Tier 2) QL (120 per 30 days)

GABITRIL TABS 16MG $0(Tier 2) QL (90 per 30 days)

ONFI SUSP $0(Tier 2) QL (480 per 30 days)

ONFI TABS 20MG $0(Tier 2) QL (120 per 30 days)

ONFI TABS 10MG $0(Tier 2) QL (60 per 30 days)

phenobarbital $0(Tier 1) MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

primidone tabs $0(Tier 1) MO

SABRIL TABS $0(Tier 2) QL (180 per 30 days) PA

MO

SABRIL PACK $0(Tier 2) QL (200 per 30 days) PA

MO

tiagabine hydrochloride tabs 4mg $0(Tier 1) MO

tiagabine hydrochloride tabs 2mg $0(Tier 1) QL (240 per 30 days) MO

valproate sodium inj $0(Tier 1)

valproic acid caps, syrp $0(Tier 1) MO

Glutamate Reducing Agents

felbamate $0(Tier 1) MO

lamotrigine er $0(Tier 1) MO

lamotrigine odt $0(Tier 1)

lamotrigine chew, tabs $0(Tier 1) MO

topiramate cpsp, tabs $0(Tier 1) MO

TROKENDI XR CP24 100MG, 25MG, 50MG $0(Tier 2) QL (30 per 30 days)

TROKENDI XR CP24 200MG $0(Tier 2) QL (60 per 30 days)

Sodium Channel Agents

BANZEL $0(Tier 2) PA MO

carbamazepine er cp12 $0(Tier 1)

carbamazepine er tb12 100mg $0(Tier 1)

carbamazepine er tb12 200mg, 400mg $0(Tier 1) MO

carbamazepine chew, susp, tabs $0(Tier 1) MO

DILANTIN CAPS 30MG $0(Tier 2) MO

epitol $0(Tier 1)

fosphenytoin sodium $0(Tier 1)

oxcarbazepine susp $0(Tier 1)

oxcarbazepine tabs $0(Tier 1) MO

PEGANONE $0(Tier 2) MO

phenytoin infatabs $0(Tier 1) MO

phenytoin sodium extended $0(Tier 1) MO

phenytoin sodium inj $0(Tier 1)

phenytoin chew, susp $0(Tier 1) MO

TEGRETOL-XR TB12 100MG $0(Tier 2) MO

VIMPAT INJ $0(Tier 2) QL (1200 per 30 days)

VIMPAT ORAL SOLN $0(Tier 2) QL (1200 per 30 days)

MO

VIMPAT TABS $0(Tier 2) QL (60 per 30 days) MO

Antidementia Agents (Drugs that Help with Memory Loss)

Antidementia Agents, Other

ergoloid mesylates tabs $0(Tier 1) PA

NAMZARIC $0(Tier 2) QL (30 per 30 days)




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

Cholinesterase Inhibitors

donepezil hcl tabs 23mg, 5mg $0(Tier 1) QL (30 per 30 days) MO

donepezil hcl tabs 10mg $0(Tier 1) QL (60 per 30 days) MO

donepezil hcl tbdp 5mg $0(Tier 1) QL (30 per 30 days) MO

donepezil hcl tbdp 10mg $0(Tier 1) QL (60 per 30 days) MO

EXELON PT24 $0(Tier 2) QL (30 per 30 days) MO

galantamine hydrobromide soln $0(Tier 1) QL (200 per 30 days)

galantamine hydrobromide cp24 $0(Tier 1) QL (30 per 30 days) MO

galantamine hydrobromide tabs $0(Tier 1) QL (60 per 30 days) MO

rivastigmine tartrate $0(Tier 1) QL (60 per 30 days) MO

rivastigmine transdermal system $0(Tier 1) QL (30 per 30 days)

N-methyl-D-aspartate (NMDA) Receptor Antagonist

memantine hcl titration pak $0(Tier 1) QL (49 per 28 days)

memantine hcl tabs 10mg $0(Tier 1) QL (60 per 30 days)

memantine hcl tabs 5mg $0(Tier 1) QL (90 per 30 days)

memantine hydrochloride soln $0(Tier 1) QL (300 per 30 days)

NAMENDA TITRATION PAK $0(Tier 2) QL (49 per 28 days) MO

NAMENDA XR $0(Tier 2) QL (30 per 30 days) MO

NAMENDA XR TITRATION PACK $0(Tier 2) QL (28 per 28 days) MO

NAMENDA SOLN $0(Tier 2) QL (300 per 30 days) MO

NAMENDA TABS 10MG $0(Tier 2) QL (60 per 30 days) MO

NAMENDA TABS 5MG $0(Tier 2) QL (90 per 30 days) MO

Antidepressants (Drugs that Help with a Depressed Mood)

Antidepressants, Other

BRINTELLIX $0(Tier 2) QL (30 per 30 days) ST

MO

bupropion hcl er tb12 100mg, 200mg $0(Tier 1) QL (60 per 30 days) MO

bupropion hcl er tb12 150mg $0(Tier 1) QL (90 per 30 days) MO

bupropion hcl sr tb12 100mg, 200mg $0(Tier 1) QL (60 per 30 days) MO

bupropion hcl sr tb12 150mg $0(Tier 1) QL (90 per 30 days) MO

bupropion hcl xl tb24 300mg $0(Tier 1) QL (30 per 30 days) MO

bupropion hcl xl tb24 150mg $0(Tier 1) QL (90 per 30 days) MO

bupropion hcl tabs $0(Tier 1) MO

maprotiline hcl $0(Tier 1) MO

mirtazapine $0(Tier 1) QL (30 per 30 days) MO

mirtazapine odt $0(Tier 1) QL (30 per 30 days) MO

nefazodone hcl $0(Tier 1) QL (60 per 30 days) MO

trazodone hcl tabs $0(Tier 1) MO

TRINTELLIX $0(Tier 2) QL (30 per 30 days) ST

Monoamine Oxidase Inhibitors

EMSAM $0(Tier 2) MO

MARPLAN $0(Tier 2)




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

phenelzine sulfate $0(Tier 1) MO

tranylcypromine sulfate $0(Tier 1) MO

SSRIs/SNRIs (Selective Serotonin Reuptake Inhibitors/Serotonin

and Norepinephrine Reuptake Inhibitor

citalopram hydrobromide soln $0(Tier 1) QL (600 per 30 days) MO

citalopram hydrobromide tabs 40mg $0(Tier 1) QL (30 per 30 days) MO

citalopram hydrobromide tabs 10mg, 20mg $0(Tier 1) QL (60 per 30 days) MO

duloxetine hcl cpep 20mg, 60mg $0(Tier 1) QL (60 per 30 days) MO

duloxetine hcl cpep 30mg $0(Tier 1) QL (90 per 30 days) MO

escitalopram oxalate $0(Tier 1) MO

FETZIMA $0(Tier 2) QL (30 per 30 days) ST

MO

FETZIMA TITRATION PACK $0(Tier 2) QL (28 per 28 days) ST

MO

fluoxetine $0(Tier 1)

fluoxetine dr $0(Tier 1) MO

fluoxetine hcl caps, soln $0(Tier 1) MO

fluoxetine hcl tabs 10mg, 20mg $0(Tier 1)

fluvoxamine maleate $0(Tier 1) MO

fluvoxamine maleate er cp24 150mg $0(Tier 1) QL (60 per 30 days)

fluvoxamine maleate er cp24 100mg $0(Tier 1) QL (90 per 30 days)

olanzapine/fluoxetine $0(Tier 1) QL (30 per 30 days) MO

paroxetine hcl er tb24 12.5mg $0(Tier 1) QL (30 per 30 days) MO

paroxetine hcl er tb24 37.5mg $0(Tier 1) QL (60 per 30 days) MO

paroxetine hcl er tb24 25mg $0(Tier 1) QL (90 per 30 days) MO

paroxetine hcl tabs 10mg $0(Tier 1) QL (30 per 30 days) MO

paroxetine hcl tabs 20mg, 30mg, 40mg $0(Tier 1) QL (60 per 30 days) MO

PAXIL SUSP $0(Tier 2) QL (900 per 30 days) ST

PRISTIQ TB24 25MG $0(Tier 2) QL (30 per 30 days)

PRISTIQ TB24 100MG, 50MG $0(Tier 2) QL (30 per 30 days) MO

sertraline hcl conc $0(Tier 1) QL (300 per 30 days) MO

sertraline hcl tabs 25mg $0(Tier 1) QL (30 per 30 days) MO



venlafaxine hcl $0(Tier 1) MO

venlafaxine hcl er cp24 $0(Tier 1) MO

venlafaxine hcl er tb24 150mg, 37.5mg, 75mg $0(Tier 1) MO

VIIBRYD $0(Tier 2) QL (30 per 30 days) ST

MO

VIIBRYD STARTER PACK $0(Tier 2) QL (30 per 30 days) ST

Tricyclics

amitriptyline hcl tabs $0(Tier 1) PA MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

amoxapine $0(Tier 1) MO

clomipramine hcl caps $0(Tier 1) PA MO

desipramine hcl tabs $0(Tier 1) MO

doxepin hcl caps, conc $0(Tier 1) PA MO

imipramine hcl tabs $0(Tier 1) PA MO

imipramine pamoate $0(Tier 1) PA MO

nortriptyline hcl soln $0(Tier 1)

nortriptyline hcl caps $0(Tier 1) MO

perphenazine/amitriptyline $0(Tier 1) PA MO

protriptyline hcl $0(Tier 1) MO

SURMONTIL $0(Tier 2) PA MO

trimipramine maleate caps $0(Tier 1) PA

Antiemetics (Drugs that Prevent or Treat Nausea and Vomiting)

Antiemetics, Other

dimenhydrinate tabs $0(Tier 1) MC

formula em $0(Tier 1) MC

meclizine hcl tabs 12.5mg, 25mg $0(Tier 1)

meclizine hcl tabs 12.5mg $0(Tier 1) MC

promethazine hcl plain $0(Tier 1) PA

promethazine hcl syrp, tabs $0(Tier 1) PA

TRANSDERM-SCOP $0(Tier 2) QL (12 per 36 days)

travel sickness $0(Tier 1) MC

Antiemetics

granisetron hcl inj 1mg/ml $0(Tier 1) B/D

Emetogenic Therapy Adjuncts

ALOXI $0(Tier 2) B/D

dronabinol $0(Tier 1) QL (90 per 30 days) PA

EMEND SUSR $0(Tier 2) QL (6 per 28 days) B/D

EMEND CAPS 0 $0(Tier 2) QL (12 per 30 days) B/D

EMEND CAPS 40MG $0(Tier 2) QL (2 per 30 days) B/D



granisetron hcl inj 0.1mg/ml, 1mg/ml $0(Tier 1) B/D

granisetron hcl tabs 1mg $0(Tier 1) QL (60 per 30 days) B/D

ondansetron hcl oral soln $0(Tier 1) B/D

ondansetron hcl inj 40mg/20ml, 4mg/2ml $0(Tier 1)

ondansetron hcl tabs 24mg $0(Tier 1) B/D

ondansetron hcl tabs 4mg, 8mg $0(Tier 1) QL (90 per 30 days) B/D

ondansetron odt $0(Tier 1) QL (90 per 30 days) B/D

Antifungals (Drugs that treat Infections with Fungus)

Antifungals

ABELCET $0(Tier 2) PA




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

AMBISOME $0(Tier 2) PA

amphotericin b $0(Tier 1) PA

anti-fungal powder $0(Tier 1) MC

antifungal $0(Tier 1) MC

CANCIDAS $0(Tier 2) PA

ciclodan $0(Tier 1)

ciclopirox nail lacquer $0(Tier 1)

ciclopirox olamine crea $0(Tier 1)

ciclopirox sham, susp $0(Tier 1)

clotrimazole anti-fungal $0(Tier 1) MC

clotrimazole/betamethasone dipropionate $0(Tier 1)

clotrimazole external crea 1% $0(Tier 1)

clotrimazole external crea 1% $0(Tier 1) MC

clotrimazole vaginal crea 1% $0(Tier 1) MC

clotrimazole troc $0(Tier 1)

clotrimazole soln 1% $0(Tier 1)

clotrimazole soln 1% $0(Tier 1) MC

econazole nitrate crea $0(Tier 1)

fluconazole in dextrose $0(Tier 1)

fluconazole in nacl $0(Tier 1)

fluconazole susr $0(Tier 1)

fluconazole tabs 100mg, 200mg, 50mg $0(Tier 1)

fluconazole tabs 150mg $0(Tier 1) QL (8 per 30 days)

flucytosine $0(Tier 1)

FUNGOID TINCTURE SOLN $0(Tier 1) MC

griseofulvin microsize $0(Tier 1)

griseofulvin ultramicrosize $0(Tier 1)

itraconazole caps $0(Tier 1) QL (120 per 30 days) PA

ketoconazole crea, sham, tabs $0(Tier 1)

miconazole 7 supp $0(Tier 1) MC

miconazole nitrate external crea, vaginal crea, supp $0(Tier 1) MC

miconazole crea $0(Tier 1) MC

naftifine hcl $0(Tier 1)

naftifine hydrochloride $0(Tier 1)

NAFTIN GEL $0(Tier 2)

NAFTIN CREA 2% $0(Tier 2)

NATACYN $0(Tier 2)

NOXAFIL SUSP $0(Tier 2) QL (600 per 30 days) PA

NOXAFIL TBEC $0(Tier 2) QL (93 per 30 days) PA

nyamyc $0(Tier 1)

nystatin/triamcinolone $0(Tier 1)

nystatin crea, oint, powd, susp, tabs $0(Tier 1)




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

nystop $0(Tier 1)

qc tolnaftate $0(Tier 1) MC

sm miconazole 7 crea $0(Tier 1) MC

SPORANOX SOLN $0(Tier 2) PA

terbinafine hcl crea $0(Tier 1) MC

terbinafine hcl tabs $0(Tier 1) QL (180 per 365 days)

terconazole $0(Tier 1)

tioconazole-1 $0(Tier 1) MC

tolnaftate crea, powd $0(Tier 1) MC

voriconazole inj, susr, tabs $0(Tier 1) PA

ZEASORB-AF POWD $0(Tier 1) MC

Antigout Agents (Drugs that Treat or Prevent Gout)

Antigout Agents

allopurinol tabs $0(Tier 1) MO

ALOPRIM $0(Tier 2)

colchicine caps, tabs $0(Tier 1)

COLCRYS $0(Tier 2) MO

probenecid/colchicine $0(Tier 1) MO

probenecid tabs $0(Tier 1) MO

ULORIC $0(Tier 2) ST

Antimigraine Agents (Drugs that Treat Migraine Headaches)

Ergot Alkaloids

CAFERGOT $0(Tier 2)

dihydroergotamine mesylate inj $0(Tier 1)

MIGERGOT $0(Tier 2)

Serotonin (5-HT) 1b/1d Receptor Agonists

naratriptan hcl $0(Tier 1) QL (9 per 30 days)

rizatriptan benzoate $0(Tier 1) QL (12 per 30 days)

rizatriptan benzoate odt $0(Tier 1) QL (12 per 30 days)

sumatriptan succinate refill $0(Tier 1) QL (8 per 30 days)

sumatriptan succinate inj $0(Tier 1) QL (8 per 30 days)

sumatriptan succinate tabs $0(Tier 1) QL (9 per 30 days)

sumatriptan soln $0(Tier 1) QL (12 per 30 days)

Antimyasthenic Agents (Drugs used for Problems with Muscle Weakness and Fatigue)

Parasympathomimetics

GUANIDINE HCL $0(Tier 2)

MESTINON TIMESPAN $0(Tier 2)

pyridostigmine bromide er $0(Tier 1)

pyridostigmine bromide tabs $0(Tier 1)

REGONOL $0(Tier 2)

Antimycobacterials (Drugs that Treat Infection with Fungus and Bacteria)

Antimycobacterials, Other




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

dapsone tabs $0(Tier 1) MO

rifabutin $0(Tier 1)

Antituberculars

CAPASTAT SULFATE $0(Tier 2)

cycloserine $0(Tier 1)

ethambutol hcl $0(Tier 1)

isoniazid inj, syrp, tabs $0(Tier 1)

PASER $0(Tier 2)

pyrazinamide tabs $0(Tier 1)

rifampin caps, inj $0(Tier 1)

RIFATER $0(Tier 2)

SIRTURO $0(Tier 2) PA

TRECATOR $0(Tier 2)

Antineoplastics (Drugs that Treat Cancer)

Alkylating Agents

BENDEKA $0(Tier 2) B/D

BICNU $0(Tier 2) B/D

BUSULFEX $0(Tier 2) B/D

cyclophosphamide caps, inj, tabs $0(Tier 1) B/D

dacarbazine $0(Tier 1) B/D

EVOMELA $0(Tier 2) PA

GLEOSTINE $0(Tier 2)

HEXALEN $0(Tier 2)

ifosfamide $0(Tier 1) B/D

LEUKERAN $0(Tier 2)

LOMUSTINE $0(Tier 2)

MATULANE $0(Tier 2)

melphalan hydrochloride $0(Tier 1) B/D

MUSTARGEN $0(Tier 2) B/D

thiotepa $0(Tier 1) PA

TREANDA $0(Tier 2) B/D

VALCHLOR $0(Tier 2) PA

YONDELIS $0(Tier 2) PA

ZANOSAR $0(Tier 2) B/D

Antiandrogens

bicalutamide $0(Tier 1)

flutamide $0(Tier 1)

NILANDRON $0(Tier 2)

nilutamide $0(Tier 1)

XTANDI $0(Tier 2) QL (120 per 30 days) PA

ZYTIGA $0(Tier 2) QL (120 per 30 days) PA

Antiangiogenic Agents




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

POMALYST $0(Tier 2) QL (21 per 28 days) PA

REVLIMID $0(Tier 2) QL (28 per 28 days) PA

THALOMID CAPS 150MG, 200MG, 50MG $0(Tier 2) QL (60 per 30 days) PA

THALOMID CAPS 100MG $0(Tier 2) QL (90 per 30 days) PA

Antiestrogens/Modifiers

EMCYT $0(Tier 2)

FARESTON $0(Tier 2) MO

FASLODEX $0(Tier 2) B/D

SOLTAMOX $0(Tier 2)

tamoxifen citrate tabs $0(Tier 1) MO

Antimetabolites

adrucil $0(Tier 1) B/D

ALIMTA INJ 500MG $0(Tier 2) B/D

ARRANON $0(Tier 2)

cladribine $0(Tier 1) B/D

CLOLAR $0(Tier 2) B/D

cytarabine $0(Tier 1) B/D

cytarabine aqueous $0(Tier 1) B/D

DROXIA $0(Tier 2) MO

ELITEK $0(Tier 2) B/D

fluorouracil inj 1gm/20ml, 2.5gm/50ml, 500mg/10ml,

5gm/100ml

$0(Tier 1) B/D

FOLOTYN $0(Tier 2) B/D

gemcitabine $0(Tier 1) B/D

gemcitabine hcl $0(Tier 1) B/D

hydroxyurea caps $0(Tier 1)

LONSURF TABS 6.14MG; 15MG $0(Tier 2) QL (100 per 28 days) PA

LONSURF TABS 8.19MG; 20MG $0(Tier 2) QL (80 per 28 days) PA

mercaptopurine tabs $0(Tier 1)

NIPENT $0(Tier 2) B/D

PURIXAN $0(Tier 2) PA

TABLOID $0(Tier 2)

Antineoplastics, Other

ABRAXANE $0(Tier 2) B/D

amifostine $0(Tier 1) B/D

azacitidine $0(Tier 1) B/D

BELEODAQ $0(Tier 2) PA

bleomycin sulfate $0(Tier 1) B/D

carboplatin inj 150mg/15ml, 450mg/45ml, 50mg/5ml $0(Tier 1) B/D

carboplatin inj 600mg/60ml $0(Tier 1) B/D MO

cisplatin $0(Tier 1) B/D

COSMEGEN $0(Tier 2) B/D




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

daunorubicin hcl $0(Tier 1) B/D

DECITABINE $0(Tier 2)

dexrazoxane $0(Tier 1) B/D

DOCEFREZ INJ 20MG $0(Tier 2) B/D

docetaxel $0(Tier 1) B/D

doxorubicin hcl $0(Tier 1) B/D

doxorubicin hcl liposome $0(Tier 1) B/D

epirubicin hcl inj 200mg/100ml, 50mg/25ml $0(Tier 1) B/D

ERWINAZE $0(Tier 2) B/D

fludarabine phosphate $0(Tier 1) B/D

FUSILEV $0(Tier 2)

HALAVEN $0(Tier 2) PA

idarubicin hcl inj 10mg/10ml $0(Tier 1) B/D

irinotecan $0(Tier 1) B/D

ISTODAX $0(Tier 2) PA MO

IXEMPRA KIT $0(Tier 2) B/D

JEVTANA $0(Tier 2) B/D

leucovorin calcium tabs $0(Tier 1)

leucovorin calcium inj 100mg, 350mg, 500mg, 50mg $0(Tier 1)

levoleucovorin calcium $0(Tier 1)

levoleucovorin inj 250mg/25ml, 50mg $0(Tier 1)

mesna $0(Tier 1) B/D

MESNEX TABS $0(Tier 2)

mitomycin $0(Tier 1) B/D

mitoxantrone hcl $0(Tier 1) B/D

NINLARO $0(Tier 2) QL (3 per 28 days) PA

ODOMZO $0(Tier 2) QL (30 per 30 days) PA

ONCASPAR $0(Tier 2) B/D

oxaliplatin $0(Tier 1) B/D

paclitaxel $0(Tier 1) B/D

PORTRAZZA $0(Tier 2) QL (100 per 21 days) PA

PROLEUKIN $0(Tier 2) B/D

SYLATRON $0(Tier 2) PA

SYNRIBO $0(Tier 2) PA

TRISENOX $0(Tier 2) B/D

VELCADE $0(Tier 2) B/D

VENCLEXTA STARTING PACK $0(Tier 2) QL (84 per 365 days) PA

VENCLEXTA TABS 100MG $0(Tier 2) QL (120 per 30 days) PA



vinblastine sulfate $0(Tier 1) B/D

vincasar pfs $0(Tier 1) B/D




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

vincristine sulfate $0(Tier 1) B/D

vinorelbine tartrate $0(Tier 1) B/D

ZOLINZA $0(Tier 2) QL (120 per 30 days)

Aromatase Inhibitors, 3rd Generation

anastrozole tabs $0(Tier 1) QL (30 per 30 days) MO

exemestane $0(Tier 1)

letrozole $0(Tier 1) QL (30 per 30 days)

Enzyme Inhibitors

ETOPOPHOS $0(Tier 2) B/D

etoposide inj $0(Tier 1) B/D

toposar $0(Tier 1) B/D

topotecan hcl inj 4mg $0(Tier 1)

ZYDELIG $0(Tier 2) QL (60 per 30 days) PA

Molecular Target Inhibitors

AFINITOR DISPERZ TBSO 5MG $0(Tier 2) QL (120 per 30 days) PA

MO

AFINITOR DISPERZ TBSO 2MG, 3MG $0(Tier 2) QL (60 per 30 days) PA

MO

AFINITOR TABS 2.5MG, 5MG, 7.5MG $0(Tier 2) QL (30 per 30 days) PA

AFINITOR TABS 10MG $0(Tier 2) QL (60 per 30 days) PA

ALECENSA $0(Tier 2) QL (240 per 30 days) PA

BOSULIF $0(Tier 2) PA

CABOMETYX TABS 20MG, 60MG $0(Tier 2) QL (30 per 30 days) PA

CABOMETYX TABS 40MG $0(Tier 2) QL (60 per 30 days) PA

CAPRELSA $0(Tier 2) PA

COMETRIQ $0(Tier 2) PA

COTELLIC $0(Tier 2) QL (63 per 28 days) PA

ERIVEDGE $0(Tier 2) QL (30 per 30 days) PA

FARYDAK $0(Tier 2) QL (9 per 28 days) PA

GILOTRIF $0(Tier 2) QL (30 per 30 days) PA

GLEEVEC $0(Tier 2) QL (60 per 30 days) PA

IBRANCE $0(Tier 2) QL (21 per 28 days) PA

ICLUSIG $0(Tier 2) PA

imatinib mesylate $0(Tier 1) QL (60 per 30 days) PA

IMBRUVICA $0(Tier 2) QL (120 per 30 days) PA

INLYTA TABS 5MG $0(Tier 2) QL (120 per 30 days) PA

INLYTA TABS 1MG $0(Tier 2) QL (240 per 30 days) PA

IRESSA $0(Tier 2) QL (30 per 30 days) PA

JAKAFI $0(Tier 2) QL (60 per 30 days) PA

LENVIMA 10 MG DAILY DOSE $0(Tier 2) PA


LENVIMA 18 MG DAILY DOSE $0(Tier 2) QL (90 per 30 days) PA




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use



LENVIMA 8 MG DAILY DOSE $0(Tier 2) QL (60 per 30 days) PA

LYNPARZA $0(Tier 2) QL (480 per 30 days) PA

MEKINIST $0(Tier 2) PA

NEXAVAR $0(Tier 2) PA

SPRYCEL $0(Tier 2) PA

STIVARGA $0(Tier 2) QL (84 per 21 days) PA

SUTENT $0(Tier 2) PA

TAFINLAR $0(Tier 2) PA

TAGRISSO $0(Tier 2) QL (30 per 30 days) PA

TARCEVA $0(Tier 2) PA

TASIGNA $0(Tier 2) PA

TYKERB $0(Tier 2) PA

VOTRIENT $0(Tier 2) QL (120 per 30 days) PA

XALKORI $0(Tier 2) QL (60 per 30 days) PA

ZELBORAF $0(Tier 2) QL (240 per 30 days) PA

ZYKADIA $0(Tier 2) PA

Monoclonal Antibodies

ARZERRA $0(Tier 2) B/D MO

AVASTIN $0(Tier 2) B/D

CYRAMZA $0(Tier 2) PA

DARZALEX $0(Tier 2) PA

EMPLICITI $0(Tier 2) PA

ERBITUX $0(Tier 2) B/D

GAZYVA $0(Tier 2) PA

HERCEPTIN $0(Tier 2) B/D

KADCYLA $0(Tier 2) PA

KEYTRUDA $0(Tier 2) PA

OPDIVO $0(Tier 2) PA

PERJETA $0(Tier 2) PA

RITUXAN INJ 500MG/50ML $0(Tier 2) PA

TECENTRIQ $0(Tier 2) QL (20 per 21 days) PA

UNITUXIN $0(Tier 2) PA

VECTIBIX INJ 100MG/5ML $0(Tier 2) B/D

YERVOY $0(Tier 2) B/D

ZALTRAP $0(Tier 2) PA

Retinoids

bexarotene $0(Tier 1)

PANRETIN $0(Tier 2)

TARGRETIN $0(Tier 2)

tretinoin caps 10mg $0(Tier 1) MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

Antiparasitics (Drugs that Treat Infections with Parasites)

Anthelmintics

ALBENZA $0(Tier 2)

ivermectin tabs $0(Tier 1)

Antiprotozoals

ALINIA $0(Tier 2)

atovaquone $0(Tier 1)

atovaquone/proguanil hcl $0(Tier 1)

chloroquine phosphate tabs $0(Tier 1) MO

COARTEM $0(Tier 2)

DARAPRIM $0(Tier 2)

hydroxychloroquine sulfate tabs $0(Tier 1) MO

mefloquine hcl $0(Tier 1) MO

NEBUPENT $0(Tier 2) B/D

PENTAM 300 $0(Tier 2)

PRIMAQUINE PHOSPHATE TABS $0(Tier 2)

quinine sulfate $0(Tier 1)

Pediculicides/Scabicides

lindane lotn, sham $0(Tier 1)

malathion $0(Tier 1)

permethrin crea $0(Tier 1)

permethrin lotn $0(Tier 1) MC

Antiparkinson Agents (Drugs used for Parkinson’s Disease)

Anticholinergics

benztropine mesylate inj $0(Tier 1) MO

benztropine mesylate tabs $0(Tier 1) PA MO

trihexyphenidyl hcl $0(Tier 1) PA MO

Antiparkinson Agents, Other

entacapone $0(Tier 1) MO

tolcapone $0(Tier 1) MO

Dopamine Agonists

APOKYN $0(Tier 2) QL (60 per 30 days) PA

MO

bromocriptine mesylate caps, tabs $0(Tier 1) MO

NEUPRO $0(Tier 2) QL (30 per 30 days)

pramipexole dihydrochloride $0(Tier 1) QL (90 per 30 days) MO

pramipexole dihydrochloride er tb24 2.25mg, 3.75mg, 4.5mg $0(Tier 1) QL (30 per 30 days)

pramipexole dihydrochloride er tb24 3mg $0(Tier 1) QL (30 per 30 days) MO

pramipexole dihydrochloride er tb24 0.375mg, 0.75mg, 1.5mg $0(Tier 1) QL (90 per 30 days) MO

ropinirole hcl $0(Tier 1) MO

Dopamine Precursors/L- Amino Acid Decarboxylase Inhibitors

carbidopa/levodopa $0(Tier 1) MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

carbidopa/levodopa er $0(Tier 1) MO

carbidopa/levodopa odt $0(Tier 1) MO

carbidopa/levodopa/entacapone $0(Tier 1) MO

carbidopa tabs $0(Tier 1) MO

Monoamine Oxidase B (MAO-B) Inhibitors

AZILECT $0(Tier 2)

selegiline hcl caps, tabs $0(Tier 1) MO

Antipsychotics (Drugs that Control or Prevent Psychotic Behavior)

1st Generation/Typical

chlorpromazine hcl tabs $0(Tier 1) MO

chlorpromazine hcl inj 50mg/2ml $0(Tier 1)

compro $0(Tier 1)

fluphenazine decanoate inj $0(Tier 1)

fluphenazine hcl inj $0(Tier 1)

fluphenazine hcl conc, elix, tabs $0(Tier 1) MO

haloperidol decanoate $0(Tier 1)

haloperidol lactate $0(Tier 1)

haloperidol conc, tabs $0(Tier 1) MO

loxapine $0(Tier 1) MO

loxapine succinate $0(Tier 1) MO

ORAP $0(Tier 2) MO

perphenazine tabs $0(Tier 1) MO

pimozide $0(Tier 1)

prochlorperazine $0(Tier 1)

prochlorperazine edisylate inj $0(Tier 1)

prochlorperazine maleate tabs $0(Tier 1)

thioridazine hcl tabs $0(Tier 1) PA MO

thiothixene $0(Tier 1) MO

trifluoperazine hcl tabs $0(Tier 1) MO

2nd Generation/Atypical

ABILIFY DISCMELT $0(Tier 2) QL (60 per 30 days) ST

MO

ABILIFY MAINTENA INJ 300MG $0(Tier 2) QL (1.5 per 30 days) MO

ABILIFY MAINTENA INJ 400MG $0(Tier 2) QL (2 per 30 days) MO

aripiprazole odt $0(Tier 1) QL (60 per 30 days) ST

aripiprazole tabs $0(Tier 1) QL (30 per 30 days) ST

MO

aripiprazole soln $0(Tier 1) QL (900 per 30 days) ST

ARISTADA INJ 441MG/1.6ML $0(Tier 2) QL (1.6 per 30 days)






Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

FANAPT $0(Tier 2) QL (60 per 30 days) ST

MO

FANAPT TITRATION PACK $0(Tier 2) QL (16 per 30 days) ST

MO

GEODON INJ $0(Tier 2) QL (60 per 30 days)

INVEGA SUSTENNA INJ 39MG/0.25ML $0(Tier 2) QL (0.25 per 28 days) MO



INVEGA SUSTENNA INJ 156MG/ML $0(Tier 2) QL (1 per 28 days) MO


INVEGA TRINZA INJ 273MG/0.875ML $0(Tier 2) QL (0.88 per 90 days)




INVEGA TB24 1.5MG, 3MG, 9MG $0(Tier 2) QL (30 per 30 days) ST

INVEGA TB24 6MG $0(Tier 2) QL (60 per 30 days) ST

LATUDA TABS 120MG, 20MG, 40MG, 60MG $0(Tier 2) QL (30 per 30 days) ST

MO

LATUDA TABS 80MG $0(Tier 2) QL (60 per 30 days) ST

MO

NUPLAZID $0(Tier 2) QL (60 per 30 days) PA

olanzapine odt $0(Tier 1) QL (30 per 30 days) MO

olanzapine inj $0(Tier 1)

olanzapine tabs $0(Tier 1) QL (30 per 30 days) MO

paliperidone er tb24 1.5mg, 3mg, 9mg $0(Tier 1) QL (30 per 30 days) ST

paliperidone er tb24 6mg $0(Tier 1) QL (60 per 30 days) ST

quetiapine fumarate $0(Tier 1) QL (90 per 30 days) MO

REXULTI $0(Tier 2) QL (30 per 30 days) ST

RISPERDAL CONSTA $0(Tier 2)

risperidone m-tab tbdp 4mg $0(Tier 1) QL (120 per 30 days) MO

risperidone m-tab tbdp 0.5mg, 1mg, 2mg, 3mg $0(Tier 1) QL (90 per 30 days) MO

risperidone odt tbdp 4mg $0(Tier 1) QL (120 per 30 days) MO

risperidone odt tbdp 0.25mg, 0.5mg, 1mg, 2mg, 3mg $0(Tier 1) QL (90 per 30 days) MO

risperidone soln $0(Tier 1) QL (360 per 30 days) MO

risperidone tabs 4mg $0(Tier 1) QL (120 per 30 days) MO

risperidone tabs 0.25mg, 0.5mg, 1mg, 2mg, 3mg $0(Tier 1) QL (90 per 30 days) MO

SAPHRIS $0(Tier 2) QL (60 per 30 days) ST

SEROQUEL XR TB24 150MG, 200MG $0(Tier 2) QL (30 per 30 days) MO

SEROQUEL XR TB24 300MG, 400MG, 50MG $0(Tier 2) QL (60 per 30 days) MO

VRAYLAR CPPK $0(Tier 2) QL (14 per 365 days) ST

VRAYLAR CAPS $0(Tier 2) QL (30 per 30 days) ST

ziprasidone hcl $0(Tier 1) QL (60 per 30 days) MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

ZYPREXA RELPREVV $0(Tier 2)

Antipsychotics

molindone hydrochloride $0(Tier 1)

Treatment-Resistant

clozapine $0(Tier 1)

clozapine odt tbdp 100mg, 150mg, 200mg, 25mg $0(Tier 1)

clozapine odt tbdp 12.5mg $0(Tier 1) MO

FAZACLO TBDP 100MG $0(Tier 2) ST

FAZACLO TBDP 12.5MG, 25MG $0(Tier 2) ST MO

VERSACLOZ $0(Tier 2)

Antispasticity Agents (Drugs used for Muscle Jerks or Twitches)

Antispasticity Agents

baclofen tabs $0(Tier 1) MO

dantrolene sodium caps $0(Tier 1)

tizanidine hcl tabs $0(Tier 1) MO

Antivirals (Drugs that Treat Infection with Viruses)

Anti-cytomegalovirus (CMV) Agents

cidofovir $0(Tier 1)

ganciclovir inj $0(Tier 1) B/D

VALCYTE SOLR $0(Tier 2) MO

valganciclovir $0(Tier 1)

valganciclovir hydrochlorde $0(Tier 1)

ZIRGAN $0(Tier 2) ST

Anti-hepatitis B (HBV) Agents

adefovir dipivoxil $0(Tier 1) QL (30 per 30 days) MO

BARACLUDE SOLN $0(Tier 2) MO

entecavir $0(Tier 1)

EPIVIR HBV SOLN $0(Tier 2) MO

INTRON A $0(Tier 2)

INTRON A W/DILUENT $0(Tier 2)

lamivudine tabs 100mg $0(Tier 1) MO

TYZEKA $0(Tier 2) PA MO

Anti-hepatitis C (HCV) Agents

HARVONI $0(Tier 2) QL (28 per 28 days) PA

MO

moderiba $0(Tier 1) PA

moderiba 1200 dose pack $0(Tier 1) PA

moderiba 800 dose pack $0(Tier 1) PA

OLYSIO $0(Tier 2) QL (28 per 28 days) PA

MO

PEG-INTRON REDIPEN $0(Tier 2) PA

PEG-INTRON REDIPEN PAK 4 $0(Tier 2) PA




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

PEGINTRON $0(Tier 2) PA

REBETOL SOLN $0(Tier 2) PA

RIBASPHERE RIBAPAK TABS 0 $0(Tier 2) PA

ribasphere ribapak tabs 400mg, 600mg $0(Tier 1) PA

ribasphere caps $0(Tier 1) PA

RIBASPHERE TABS 400MG, 600MG $0(Tier 2) PA

ribasphere tabs 200mg $0(Tier 1) PA

RIBATAB $0(Tier 2) PA

ribavirin $0(Tier 1) PA

SOVALDI $0(Tier 2) QL (28 per 28 days) PA

MO

Anti-HIV Agents, Integrase Inhibitors (INSTI)

GENVOYA $0(Tier 2)

ISENTRESS PACK $0(Tier 2)

ISENTRESS TABS $0(Tier 2) QL (60 per 30 days) MO

ISENTRESS CHEW 100MG $0(Tier 2) QL (180 per 30 days)

ISENTRESS CHEW 25MG $0(Tier 2) QL (360 per 30 days)

TIVICAY $0(Tier 2) QL (60 per 30 days)

VITEKTA $0(Tier 2) MO

Anti-HIV Agents, Non-nucleoside Reverse Transcriptase

Inhibitors (NNRTI)

COMPLERA $0(Tier 2) MO

EDURANT $0(Tier 2)

INTELENCE TABS 100MG $0(Tier 2) QL (120 per 30 days) MO

INTELENCE TABS 25MG $0(Tier 2) QL (180 per 30 days) MO

INTELENCE TABS 200MG $0(Tier 2) QL (60 per 30 days)

nevirapine $0(Tier 1) MO

nevirapine er tb24 100mg $0(Tier 1)

nevirapine er tb24 400mg $0(Tier 1) MO

ODEFSEY $0(Tier 2) QL (30 per 30 days)

RESCRIPTOR $0(Tier 2) MO

STRIBILD $0(Tier 2) MO

SUSTIVA $0(Tier 2) MO

VIRAMUNE XR TB24 100MG $0(Tier 2)

Anti-HIV Agents, Nucleoside and Nucleotide Reverse

Transcriptase Inhibitors (NRTI)

abacavir $0(Tier 1) MO

abacavir sulfate/lamivudine/zidovudine $0(Tier 1) MO

abacavir/lamivudine $0(Tier 1)

DESCOVY $0(Tier 2) QL (30 per 30 days)

didanosine $0(Tier 1) MO

EMTRIVA $0(Tier 2) MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

EPZICOM $0(Tier 2) MO

lamivudine/zidovudine $0(Tier 1) MO

lamivudine soln 10mg/ml $0(Tier 1)

lamivudine tabs 150mg, 300mg $0(Tier 1) MO

RETROVIR IV INFUSION $0(Tier 2)

stavudine solr $0(Tier 1)

stavudine caps $0(Tier 1) MO

TRIUMEQ $0(Tier 2) QL (30 per 30 days)

TRUVADA TABS 100MG; 150MG, 133MG; 200MG,

167MG; 250MG

$0(Tier 2)

TRUVADA TABS 200MG; 300MG $0(Tier 2) MO

VIDEX PEDIATRIC $0(Tier 2) MO

VIREAD $0(Tier 2) MO

ZIAGEN SOLN $0(Tier 2) MO

zidovudine $0(Tier 1) MO

Anti-HIV Agents, Other

ATRIPLA $0(Tier 2) MO

FUZEON $0(Tier 2) QL (60 per 30 days) MO

SELZENTRY TABS 300MG $0(Tier 2) QL (120 per 30 days) MO

SELZENTRY TABS 150MG $0(Tier 2) QL (60 per 30 days) MO

TYBOST $0(Tier 2)

Anti-HIV Agents, Protease Inhibitors

APTIVUS $0(Tier 2) MO

CRIXIVAN $0(Tier 2) MO

EVOTAZ $0(Tier 2)

INVIRASE $0(Tier 2) MO

KALETRA $0(Tier 2) MO

LEXIVA $0(Tier 2) MO

NORVIR $0(Tier 2) MO

PREZCOBIX $0(Tier 2)

PREZISTA SUSP $0(Tier 2) QL (400 per 30 days)

PREZISTA TABS 150MG $0(Tier 2) QL (180 per 30 days) MO




REYATAZ PACK $0(Tier 2)

REYATAZ CAPS $0(Tier 2) MO

VIRACEPT $0(Tier 2) MO

Anti-influenza Agents

amantadine hcl syrp $0(Tier 1)

amantadine hcl caps, tabs $0(Tier 1) MO

rimantadine hcl $0(Tier 1)




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

TAMIFLU SUSR $0(Tier 2) QL (700 per 365 days)

TAMIFLU CAPS 30MG $0(Tier 2) QL (120 per 365 days)



Antiherpetic Agents

acyclovir sodium inj 50mg/ml $0(Tier 1)

acyclovir caps, oint, susp, tabs $0(Tier 1)

DENAVIR $0(Tier 2)

famciclovir tabs $0(Tier 1) QL (21 per 7 days)

trifluridine soln $0(Tier 1)

valacyclovir hcl tabs 1000mg $0(Tier 1) QL (30 per 30 days)

valacyclovir hcl tabs 500mg $0(Tier 1) QL (60 per 30 days)

ZOVIRAX CREA $0(Tier 2)

Anxiolytics (Drugs used to Relieve Stress or Anxiety)

Anxiolytics, Other

buspirone hcl tabs $0(Tier 1)

Benzodiazepines

alprazolam odt tbdp 1mg $0(Tier 1) QL (120 per 30 days)

alprazolam odt tbdp 2mg $0(Tier 1) QL (150 per 30 days)

alprazolam odt tbdp 0.25mg, 0.5mg $0(Tier 1) QL (90 per 30 days)

alprazolam tabs 1mg $0(Tier 1) QL (120 per 30 days)

alprazolam tabs 2mg $0(Tier 1) QL (150 per 30 days)

alprazolam tabs 0.25mg, 0.5mg $0(Tier 1) QL (90 per 30 days)

clorazepate dipotassium tabs 15mg $0(Tier 1) QL (120 per 30 days)

clorazepate dipotassium tabs 3.75mg, 7.5mg $0(Tier 1) QL (90 per 30 days)

diazepam inj 5mg/ml $0(Tier 1)

diazepam oral soln 1mg/ml $0(Tier 1) QL (1200 per 30 days)

diazepam tabs 10mg, 2mg, 5mg $0(Tier 1) QL (120 per 30 days)

lorazepam intensol $0(Tier 1) QL (150 per 30 days)

lorazepam tabs $0(Tier 1) QL (120 per 30 days) MO

lorazepam conc $0(Tier 1) QL (150 per 30 days) MO

lorazepam inj 2mg/ml, 4mg/ml $0(Tier 1)

oxazepam $0(Tier 1) QL (120 per 30 days) MO

Bipolar Agents (Drugs that Regulate Severe Mood Changes due to Bipolar Disorder)

Mood Stabilizers

lithium carbonate er $0(Tier 1) MO

lithium carbonate caps, tabs $0(Tier 1) MO

Blood Glucose Regulators (Drugs used to Control Blood Sugar Levels)

Antidiabetic Agents

acarbose $0(Tier 1) QL (90 per 30 days) MO

BYDUREON $0(Tier 2) QL (4 per 28 days) MO

BYDUREON PEN $0(Tier 2) QL (4 per 28 days) MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

BYETTA $0(Tier 2) QL (2.4 per 30 days) MO

CYCLOSET $0(Tier 2)

glimepiride tabs 1mg, 2mg $0(Tier 1) QL (30 per 30 days) MO

glimepiride tabs 4mg $0(Tier 1) QL (60 per 30 days) MO

glipizide er $0(Tier 1) MO

glipizide xl $0(Tier 1)

glipizide/metformin hcl $0(Tier 1) MO

glipizide tabs $0(Tier 1) MO

GLYSET $0(Tier 2) MO

INVOKAMET $0(Tier 2) QL (60 per 30 days) MO

INVOKAMET XR $0(Tier 2) QL (60 per 30 days)

INVOKANA $0(Tier 2) QL (30 per 30 days) MO

JANUMET $0(Tier 2) QL (60 per 30 days) MO

JANUMET XR TB24 1000MG; 100MG $0(Tier 2) QL (30 per 30 days) MO

JANUMET XR TB24 1000MG; 50MG, 500MG; 50MG $0(Tier 2) QL (60 per 30 days) MO

JANUVIA $0(Tier 2) QL (30 per 30 days) MO

JENTADUETO $0(Tier 2) QL (60 per 30 days) MO

JENTADUETO XR TB24 5MG; 1000MG $0(Tier 2) QL (30 per 30 days)

JENTADUETO XR TB24 2.5MG; 1000MG $0(Tier 2) QL (60 per 30 days)

metformin hcl er tb24 500mg, 750mg $0(Tier 1) MO

metformin hcl tabs $0(Tier 1) MO

miglitol $0(Tier 1)

nateglinide $0(Tier 1) QL (90 per 30 days) MO

pioglitazone hcl $0(Tier 1) QL (30 per 30 days) MO

pioglitazone hcl-glimepiride $0(Tier 1) QL (30 per 30 days) MO

pioglitazone hcl/metformin hcl $0(Tier 1) QL (90 per 30 days) MO

repaglinide $0(Tier 1) MO

RIOMET $0(Tier 2) MO

SYMLINPEN 120 $0(Tier 2) QL (11 per 28 days) PA

SYMLINPEN 60 $0(Tier 2) QL (6 per 30 days) PA

TRADJENTA $0(Tier 2) QL (30 per 30 days) MO

TRULICITY $0(Tier 2) QL (2 per 28 days)

VICTOZA $0(Tier 2) QL (9 per 30 days)

Glycemic Agents

GLUCAGEN HYPOKIT $0(Tier 2)

PROGLYCEM $0(Tier 2) MO

Insulins

HUMALOG KWIKPEN INJ 200UNIT/ML $0(Tier 2)

HUMALOG KWIKPEN INJ 100UNIT/ML $0(Tier 2) MO

HUMALOG MIX 50/50 $0(Tier 2) MO

HUMALOG MIX 50/50 KWIKPEN $0(Tier 2) MO

HUMALOG MIX 75/25 $0(Tier 2) MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

HUMALOG MIX 75/25 KWIKPEN $0(Tier 2) MO

HUMALOG INJ 100UNIT/ML $0(Tier 2)

HUMALOG INJ 100UNIT/ML $0(Tier 2) MO

HUMULIN 70/30 $0(Tier 2) MO

HUMULIN 70/30 KWIKPEN $0(Tier 2) MO

HUMULIN N $0(Tier 2) MO

HUMULIN N KWIKPEN $0(Tier 2) MO

HUMULIN R $0(Tier 2) MO

HUMULIN R U-500 (CONCENTRATED) $0(Tier 2) MO

HUMULIN R U-500 KWIKPEN $0(Tier 2) MO

LANTUS $0(Tier 2) MO

LANTUS SOLOSTAR $0(Tier 2) MO

LEVEMIR $0(Tier 2) MO

LEVEMIR FLEXTOUCH $0(Tier 2) MO

TOUJEO SOLOSTAR $0(Tier 2) MO

TRESIBA FLEXTOUCH $0(Tier 2)

Blood Products/Modifiers/Volume Expanders

(Drugs used to Stop Bleeding, Replace Blood, or Break-Up a Clot)

Anticoagulants

ELIQUIS TABS 2.5MG $0(Tier 2) QL (60 per 30 days) MO

ELIQUIS TABS 5MG $0(Tier 2) QL (74 per 30 days) MO

enoxaparin sodium inj 40mg/0.4ml $0(Tier 1) QL (12 per 30 days)


enoxaparin sodium inj 120mg/0.8ml, 80mg/0.8ml $0(Tier 1) QL (24 per 30 days)

enoxaparin sodium inj 100mg/ml, 150mg/ml $0(Tier 1) QL (30 per 30 days)


enoxaparin sodium inj 300mg/3ml $0(Tier 1) QL (90 per 30 days)

fondaparinux sodium inj 5mg/0.4ml $0(Tier 1) QL (12 per 30 days)

fondaparinux sodium inj 2.5mg/0.5ml $0(Tier 1) QL (15 per 30 days)

fondaparinux sodium inj 7.5mg/0.6ml $0(Tier 1) QL (18 per 30 days)

fondaparinux sodium inj 10mg/0.8ml $0(Tier 1) QL (24 per 30 days)

heparin sodium/d5w $0(Tier 1)

heparin sodium/nacl 0.45% inj 50unit/ml; 0.45% $0(Tier 1)

heparin sodium/nacl 0.9% $0(Tier 1)

heparin sodium/sodium chloride 0.9% $0(Tier 1)

heparin sodium/sodium chloride 0.9% premix $0(Tier 1)

heparin sodium inj 10000unit/ml, 1000unit/ml, 20000unit/ml,

2000unit/ml, 2500unit/ml, 5000unit/ml

$0(Tier 1)

jantoven $0(Tier 1) MO

PRADAXA CAPS 110MG $0(Tier 2) QL (60 per 30 days)

PRADAXA CAPS 150MG, 75MG $0(Tier 2) QL (60 per 30 days) MO

warfarin sodium tabs $0(Tier 1) MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

XARELTO STARTER PACK $0(Tier 2) QL (102 per 365 days)

MO

XARELTO TABS 10MG, 20MG $0(Tier 2) QL (30 per 30 days) MO

XARELTO TABS 15MG $0(Tier 2) QL (60 per 30 days) MO

Blood Formation Modifiers

anagrelide hydrochloride $0(Tier 1) MO

ARANESP ALBUMIN FREE $0(Tier 2) PA

LEUKINE INJ 250MCG $0(Tier 2) PA

NEULASTA $0(Tier 2) PA

NEUMEGA $0(Tier 2) PA MO

NEUPOGEN $0(Tier 2) PA

PROCRIT $0(Tier 2) PA

PROMACTA $0(Tier 2) QL (30 per 30 days) PA

ZARXIO $0(Tier 2) PA

Coagulants

tranexamic acid tabs $0(Tier 1)

tranexamic acid inj $0(Tier 1) PA

Platelet Modifying Agents

AGGRENOX $0(Tier 2) QL (60 per 30 days) MO

aspir-low $0(Tier 1) MC

aspirin adult low strength $0(Tier 1) MC

aspirin ec low dose $0(Tier 1) MC

aspirin ec tbec 81mg $0(Tier 1) MC

aspirin low dose $0(Tier 1) MC

aspirin/dipyridamole $0(Tier 1) QL (60 per 30 days)

aspirin chew 81mg $0(Tier 1) MC

aspirin tbec 81mg $0(Tier 1) MC

BRILINTA TABS 60MG $0(Tier 2) QL (60 per 30 days)

BRILINTA TABS 90MG $0(Tier 2) QL (60 per 30 days) MO

childrens aspirin $0(Tier 1) MC

cilostazol $0(Tier 1) MO

clopidogrel tabs 300mg $0(Tier 1) QL (1 per 30 days) MO

clopidogrel tabs 75mg $0(Tier 1) QL (30 per 30 days)

EFFIENT TABS 10MG $0(Tier 2) QL (36 per 30 days) MO

EFFIENT TABS 5MG $0(Tier 2) QL (42 per 30 days) MO

Cardiovascular Agents (Drugs that Affect the Heart and Blood Vessels)

Alpha-adrenergic Agonists

clonidine hcl tabs $0(Tier 1) MO

clonidine hcl ptwk 0.1mg/24hr, 0.2mg/24hr $0(Tier 1) QL (4 per 28 days) MO

clonidine hcl ptwk 0.3mg/24hr $0(Tier 1) QL (8 per 28 days) MO

midodrine hcl $0(Tier 1)

Alpha-adrenergic Blocking Agents




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

DIBENZYLINE $0(Tier 2)

phenoxybenzamine hydrochloride $0(Tier 1)

prazosin hcl $0(Tier 1) MO

Angiotensin II Receptor Antagonists

BENICAR $0(Tier 2) QL (30 per 30 days) MO

BENICAR HCT $0(Tier 2) QL (30 per 30 days) MO

candesartan cilexetil $0(Tier 1) MO

candesartan cilexetil/hydrochlorothiazide $0(Tier 1) MO

ENTRESTO $0(Tier 2) QL (60 per 30 days) PA

irbesartan $0(Tier 1) MO

irbesartan/hydrochlorothiazide $0(Tier 1) MO

losartan potassium/hydrochlorothiazide tabs 12.5mg; 100mg,

25mg; 100mg

$0(Tier 1) QL (30 per 30 days) MO

losartan potassium/hydrochlorothiazide tabs 12.5mg; 50mg $0(Tier 1) QL (60 per 30 days) MO

losartan potassium tabs 100mg $0(Tier 1) QL (30 per 30 days) MO



telmisartan $0(Tier 1) QL (30 per 30 days) MO

telmisartan/amlodipine $0(Tier 1) QL (30 per 30 days) MO

telmisartan/hydrochlorothiazide $0(Tier 1) QL (30 per 30 days) MO

valsartan $0(Tier 1)

valsartan/hydrochlorothiazide $0(Tier 1) MO

Angiotensin-converting Enzyme (ACE) Inhibitors

benazepril hcl/hydrochlorothiazide $0(Tier 1) MO

benazepril hcl tabs $0(Tier 1) MO

captopril/hydrochlorothiazide $0(Tier 1) MO

captopril tabs $0(Tier 1) MO

enalapril maleate/hydrochlorothiazide $0(Tier 1) MO

enalapril maleate tabs $0(Tier 1) MO

fosinopril sodium $0(Tier 1) MO

fosinopril sodium/hydrochlorothiazide $0(Tier 1) MO

lisinopril $0(Tier 1) MO

lisinopril/hydrochlorothiazide $0(Tier 1) MO

moexipril hcl $0(Tier 1) MO

moexipril/hydrochlorothiazide $0(Tier 1) MO

perindopril erbumine $0(Tier 1) MO

quinapril hcl $0(Tier 1) MO

quinapril/hydrochlorothiazide $0(Tier 1) MO

ramipril $0(Tier 1) MO

trandolapril $0(Tier 1) MO

Antiarrhythmics

amiodarone hcl tabs $0(Tier 1) MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

amiodarone hcl inj 50mg/ml, 900mg/18ml $0(Tier 1)

dofetilide $0(Tier 1)

flecainide acetate $0(Tier 1) MO

lidocaine hcl inj 10mg/ml, 20mg/ml $0(Tier 1)

mexiletine hcl $0(Tier 1) MO

MULTAQ $0(Tier 2) QL (60 per 30 days) MO

pacerone $0(Tier 1) MO

propafenone hcl $0(Tier 1) MO

propafenone hcl er $0(Tier 1) MO

quinidine sulfate $0(Tier 1)

sorine $0(Tier 1) MO

sotalol hcl $0(Tier 1) MO

sotalol hcl (af) $0(Tier 1) MO

TIKOSYN $0(Tier 2) MO

Beta-adrenergic Blocking Agents

acebutolol hcl caps $0(Tier 1) MO

atenolol/chlorthalidone $0(Tier 1) MO

atenolol tabs $0(Tier 1) MO

betaxolol hcl tabs 10mg, 20mg $0(Tier 1) MO

bisoprolol fumarate $0(Tier 1) MO

bisoprolol fumarate/hydrochlorothiazide $0(Tier 1) MO

BYSTOLIC TABS 10MG $0(Tier 2) QL (120 per 30 days)

BYSTOLIC TABS 20MG $0(Tier 2) QL (60 per 30 days)

BYSTOLIC TABS 2.5MG, 5MG $0(Tier 2) QL (90 per 30 days)

BYVALSON $0(Tier 2) QL (30 per 30 days)

carvedilol $0(Tier 1) MO

COREG CR $0(Tier 2) MO

labetalol hcl inj, tabs $0(Tier 1) MO

metoprolol succinate er $0(Tier 1) MO

metoprolol tartrate inj $0(Tier 1) MO

metoprolol tartrate tabs 37.5mg, 75mg $0(Tier 1)

metoprolol tartrate tabs 100mg, 25mg, 50mg $0(Tier 1) MO

metoprolol/hydrochlorothiazide $0(Tier 1) MO

nadolol/bendroflumethiazide $0(Tier 1) MO

nadolol tabs $0(Tier 1) MO

pindolol $0(Tier 1) MO

propranolol hcl er $0(Tier 1) MO

propranolol hcl inj, oral soln, tabs $0(Tier 1) MO

propranolol/hydrochlorothiazide $0(Tier 1) MO

timolol maleate tabs 10mg, 20mg, 5mg $0(Tier 1) MO

Calcium Channel Blocking Agents

afeditab cr $0(Tier 1) MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

amlodipine besylate/benazepril hydrochloride $0(Tier 1) MO

amlodipine besylate/valsartan $0(Tier 1) MO

amlodipine besylate tabs $0(Tier 1) MO

amlodipine/valsartan/hctz $0(Tier 1) MO

cartia xt $0(Tier 1) MO

dilt-xr $0(Tier 1) MO

diltiazem cd $0(Tier 1) MO

diltiazem hcl cd $0(Tier 1) MO

diltiazem hcl er $0(Tier 1) MO

diltiazem hcl tabs $0(Tier 1) MO

diltiazem hcl inj 100mg, 125mg/25ml, 25mg/5ml, 50mg/10ml $0(Tier 1) MO

felodipine er $0(Tier 1) MO

isradipine $0(Tier 1) MO

matzim la $0(Tier 1) MO

nicardipine hcl caps, inj $0(Tier 1) MO

nifedical xl $0(Tier 1) MO

nifedipine er $0(Tier 1) MO

nimodipine caps $0(Tier 1) MO

nisoldipine $0(Tier 1) MO

nisoldipine er $0(Tier 1) MO

taztia xt $0(Tier 1) MO

verapamil hcl er $0(Tier 1) MO

verapamil hcl sr cp24 360mg $0(Tier 1) MO

verapamil hcl inj, tabs $0(Tier 1) MO

Cardiovascular Agents, Other

DEMSER $0(Tier 2)

digitek tabs 0.25mg $0(Tier 1) PA

digitek tabs 0.125mg $0(Tier 1) QL (30 per 30 days)

digoxin inj $0(Tier 1) PA

digoxin tabs 250mcg $0(Tier 1) PA MO

digoxin tabs 125mcg $0(Tier 1) QL (30 per 30 days) MO

digox tabs 250mcg $0(Tier 1) PA MO

digox tabs 125mcg $0(Tier 1) QL (30 per 30 days) MO

LANOXIN PEDIATRIC $0(Tier 2) PA

NORTHERA $0(Tier 2) QL (180 per 30 days) PA

pentoxifylline er $0(Tier 1) MO

RANEXA TB12 500MG $0(Tier 2) QL (120 per 30 days) ST

MO

RANEXA TB12 1000MG $0(Tier 2) QL (60 per 30 days) ST

MO

TEKTURNA $0(Tier 2) ST MO

TEKTURNA HCT $0(Tier 2) ST MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

Diuretics, Carbonic Anhydrase Inhibitors

acetazolamide sodium $0(Tier 1)

acetazolamide tabs $0(Tier 1) MO

Diuretics, Loop

bumetanide inj $0(Tier 1)

bumetanide tabs $0(Tier 1) MO

EDECRIN $0(Tier 2) MO

ethacrynate sodium $0(Tier 1)

ethacrynic acid tabs $0(Tier 1)

furosemide inj $0(Tier 1)

furosemide oral soln, tabs $0(Tier 1) MO

SODIUM EDECRIN $0(Tier 2)

torsemide tabs $0(Tier 1) MO

Diuretics, Potassium-sparing

amiloride hcl tabs $0(Tier 1) MO

amiloride/hydrochlorothiazide $0(Tier 1) MO

spironolactone/hydrochlorothiazide $0(Tier 1) MO

spironolactone tabs $0(Tier 1) MO

triamterene/hydrochlorothiazide $0(Tier 1) MO

Diuretics, Thiazide

chlorothiazide $0(Tier 1) MO

chlorothiazide sodium $0(Tier 1)

chlorthalidone tabs 25mg, 50mg $0(Tier 1) MO

hydrochlorothiazide caps, tabs $0(Tier 1) MO

indapamide $0(Tier 1) MO

metolazone $0(Tier 1) MO

Dyslipidemics, Fibric Acid Derivatives

fenofibrate micronized $0(Tier 1) MO

fenofibrate caps $0(Tier 1)

fenofibrate tabs 145mg, 160mg, 48mg, 54mg $0(Tier 1) MO

fenofibric acid dr $0(Tier 1) MO

gemfibrozil tabs $0(Tier 1) MO

LIPOFEN $0(Tier 2)

Dyslipidemics, HMG CoA Reductase Inhibitors

atorvastatin calcium $0(Tier 1) QL (30 per 30 days) MO

CRESTOR $0(Tier 2) QL (30 per 30 days) MO

fluvastatin caps 20mg $0(Tier 1) QL (30 per 30 days) MO

fluvastatin caps 40mg $0(Tier 1) QL (60 per 30 days) MO

lovastatin tabs 40mg $0(Tier 1) QL (60 per 30 days) MO

lovastatin tabs 10mg, 20mg $0(Tier 1) QL (90 per 30 days) MO

pravastatin sodium tabs 80mg $0(Tier 1) QL (30 per 30 days) MO

pravastatin sodium tabs 40mg $0(Tier 1) QL (60 per 30 days) MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

pravastatin sodium tabs 10mg, 20mg $0(Tier 1) QL (90 per 30 days) MO

rosuvastatin calcium $0(Tier 1) QL (30 per 30 days) PA

simvastatin tabs 20mg, 40mg, 80mg $0(Tier 1) QL (30 per 30 days) MO

simvastatin tabs 10mg, 5mg $0(Tier 1) QL (90 per 30 days) MO

Dyslipidemics, Other

cholestyramine light $0(Tier 1) MO

cholestyramine pack, powd $0(Tier 1) MO

colestipol hcl gran, tabs $0(Tier 1) MO

KYNAMRO $0(Tier 2) PA

niacin er tbcr 500mg $0(Tier 1) QL (30 per 30 days) MO

niacin er tbcr 1000mg, 750mg $0(Tier 1) QL (60 per 30 days) MO

niacin tabs 100mg, 250mg, 500mg, 50mg $0(Tier 1) MC

niacin tbcr 500mg $0(Tier 1) MC

niacor $0(Tier 1) MO

omega-3-acid ethyl esters $0(Tier 1) QL (120 per 30 days) MO

prevalite $0(Tier 1) MO

REPATHA $0(Tier 2) QL (3 per 30 days) PA

REPATHA PUSHTRONEX SYSTEM $0(Tier 2) QL (3.5 per 30 days) PA

REPATHA SURECLICK $0(Tier 2) QL (3 per 30 days) PA

VASCEPA CAPS 1GM $0(Tier 2) QL (120 per 30 days) MO

VASCEPA CAPS 0.5GM $0(Tier 2) QL (240 per 30 days)

WELCHOL $0(Tier 2)

ZETIA $0(Tier 2) QL (30 per 30 days) MO

Vasodilators, Direct-acting Arterial/Venous

BIDIL $0(Tier 2) QL (180 per 30 days)

isosorbide dinitrate er $0(Tier 1) MO

isosorbide dinitrate tabs $0(Tier 1) MO

isosorbide mononitrate $0(Tier 1) MO

isosorbide mononitrate er $0(Tier 1) MO

minitran $0(Tier 1) MO

nitroglycerin lingual soln $0(Tier 1)

nitroglycerin transdermal $0(Tier 1) MO

nitroglycerin inj, subl $0(Tier 1)

NITROSTAT $0(Tier 2) MO

Vasodilators, Direct-acting Arterial

hydralazine hcl inj $0(Tier 1)

hydralazine hcl tabs $0(Tier 1) MO

minoxidil tabs $0(Tier 1) MO

Central Nervous System Agents (Drugs that Affect the Nervous System)

Attention Deficit Hyperactivity Disorder Agents, Amphetamines

amphetamine/dextroamphetamine cp24 $0(Tier 1) QL (60 per 30 days) MO

amphetamine/dextroamphetamine tabs $0(Tier 1) QL (90 per 30 days) MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

dextroamphetamine sulfate er cp24 15mg $0(Tier 1) QL (120 per 30 days) MO

dextroamphetamine sulfate er cp24 10mg, 5mg $0(Tier 1) QL (90 per 30 days) MO

dextroamphetamine sulfate soln $0(Tier 1) QL (1800 per 30 days)

dextroamphetamine sulfate tabs 10mg $0(Tier 1) QL (180 per 30 days) MO

dextroamphetamine sulfate tabs 5mg $0(Tier 1) QL (90 per 30 days) MO

Attention Deficit Hyperactivity Disorder Agents,

Non-amphetamines

clonidine hcl er $0(Tier 1)

dexmethylphenidate hcl $0(Tier 1) QL (60 per 30 days) MO

metadate er $0(Tier 1) QL (90 per 30 days)

methylphenidate hcl er tbcr 10mg $0(Tier 1) QL (180 per 30 days) MO

methylphenidate hcl er tbcr 20mg $0(Tier 1) QL (90 per 30 days) MO

methylphenidate hcl sr $0(Tier 1) QL (90 per 30 days) MO

methylphenidate hcl tabs $0(Tier 1) QL (90 per 30 days) MO

STRATTERA $0(Tier 2) MO

Central Nervous System, Other

HETLIOZ $0(Tier 2) QL (30 per 30 days) PA

NUEDEXTA $0(Tier 2)

riluzole $0(Tier 1)

tetrabenazine tabs 25mg $0(Tier 1) QL (120 per 30 days) PA

tetrabenazine tabs 12.5mg $0(Tier 1) QL (90 per 30 days) PA

XENAZINE TABS 25MG $0(Tier 2) QL (120 per 30 days) PA

XENAZINE TABS 12.5MG $0(Tier 2) QL (90 per 30 days) PA

Multiple Sclerosis Agents

AMPYRA $0(Tier 2) QL (60 per 30 days) PA

AVONEX $0(Tier 2) QL (4 per 28 days)

AVONEX PEN $0(Tier 2) QL (4 per 28 days)

COPAXONE INJ 40MG/ML $0(Tier 2)

glatopa $0(Tier 1) QL (30 per 30 days)

REBIF $0(Tier 2) QL (6 per 28 days)

REBIF REBIDOSE $0(Tier 2) QL (6 per 28 days)

REBIF REBIDOSE TITRATION PACK $0(Tier 2) QL (4.2 per 28 days)

REBIF TITRATION PACK $0(Tier 2) QL (4.2 per 28 days)

TYSABRI $0(Tier 2) PA

Dental and Oral Agents (Drugs that Relieve or Prevent Problems of the Mouth)

Dental and Oral Agents

chlorhexidine gluconate soln $0(Tier 1)

oralone $0(Tier 1)

paroex $0(Tier 1)

periogard $0(Tier 1)

pilocarpine hcl tabs 7.5mg $0(Tier 1) MO

pilocarpine hydrochloride $0(Tier 1)




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

triamcinolone acetonide pste 0.1% $0(Tier 1)

triamcinolone in orabase $0(Tier 1)

Dermatological Agents (Drugs used for Skin Problems)

Dermatological Agents

acitretin $0(Tier 1) PA

acne medication 10 $0(Tier 1) MC

acne medication 5 gel $0(Tier 1) MC

ammonium lactate crea, lotn $0(Tier 1)

amnesteem $0(Tier 1)

benzoyl peroxide foam, gel $0(Tier 1) MC

blue gel $0(Tier 1) MC

calcipotriene $0(Tier 1) QL (120 per 30 days)

calcitrene $0(Tier 1) QL (120 per 30 days)

calcitriol oint 3mcg/gm $0(Tier 1)

CARAC $0(Tier 2)

claravis $0(Tier 1)

coats aloe creme $0(Tier 1) MC

coats aloe gelly $0(Tier 1) MC

coats aloe liniment $0(Tier 1) MC

coats aloe moisturizing lotion $0(Tier 1) MC

curity gauze pads 2"x2" $0(Tier 1)

dibucaine $0(Tier 1) MC

diclofenac sodium gel 1% $0(Tier 1) QL (1000 per 30 days) PA

diclofenac sodium transdermal soln 1.5% $0(Tier 1)

doxepin hydrochloride $0(Tier 1)

DR SMITHS DIAPER $0(Tier 1) MC

dr smiths diaper rash spray $0(Tier 1) MC

dr smiths rash + skin aero $0(Tier 1) MC

ELIDEL $0(Tier 2)

erythromycin/benzoyl peroxide $0(Tier 1)

fluorouracil crea 0.5% $0(Tier 1)

fluorouracil crea 5% $0(Tier 1) MO

fluorouracil external soln 2%, 5% $0(Tier 1) MO

hemorrhoidal supp 88.7%; 0.25% $0(Tier 1) MC

imiquimod crea $0(Tier 1)

lidocaine crea 5% $0(Tier 1) MC

major-prep hemorrhoidal $0(Tier 1) MC

medicated body powder powd 0.15% $0(Tier 1) MC

methoxsalen caps $0(Tier 1)

myorisan $0(Tier 1)

PICATO $0(Tier 2) ST

podofilox soln $0(Tier 1)




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

PRUDOXIN $0(Tier 2)

REGRANEX $0(Tier 2) PA

SANTYL $0(Tier 2)

selenium sulfide lotn $0(Tier 1)

tacrolimus oint 0.03%, 0.1% $0(Tier 1)

TAZORAC GEL $0(Tier 2) QL (100 per 30 days)

TAZORAC CREA $0(Tier 2) QL (120 per 30 days)

THERA-GESIC CREA 1%; 15% $0(Tier 1) MC

tretinoin microsphere $0(Tier 1) PA

tretinoin microsphere pump gel 0.1% $0(Tier 1) PA

tretinoin microsphere pump gel 0.04% $0(Tier 1) PA MO

tretinoin crea 0.025%, 0.05%, 0.1% $0(Tier 1) QL (45 per 30 days) PA

MO

tretinoin gel 0.01% $0(Tier 1) QL (45 per 30 days) PA

tretinoin gel 0.025% $0(Tier 1) QL (45 per 30 days) PA

MO

trixaicin $0(Tier 1) MC

trixaicin hp $0(Tier 1) MC

UVADEX $0(Tier 2) B/D

VECTICAL $0(Tier 2)

vitamin a & d oint 15.5%; 53.4% $0(Tier 1) MC

VOLTAREN $0(Tier 2) QL (1000 per 30 days) ST

white petrolatum gel $0(Tier 1) MC

zenatane $0(Tier 1)

zinc oxide oint 20% $0(Tier 1) MC

ZONALON $0(Tier 2)

ZYCLARA $0(Tier 2)

ZYCLARA PUMP CREA 2.5% $0(Tier 2)

Enzyme Replacement/Modifiers (Drugs used to Replace or Change Bodily Enzymes)

Enzyme Replacement/Modifiers

ADAGEN $0(Tier 2) PA MO

ALDURAZYME $0(Tier 2) PA

BUPHENYL TABS $0(Tier 2) MO

CEREZYME $0(Tier 2) B/D

CREON $0(Tier 2) MO

CYSTADANE $0(Tier 2)

CYSTAGON $0(Tier 2)

ELAPRASE $0(Tier 2) PA

FABRAZYME $0(Tier 2) B/D

KUVAN $0(Tier 2) PA

LUMIZYME $0(Tier 2) PA

NAGLAZYME $0(Tier 2) PA




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

ORFADIN SUSP $0(Tier 2)

ORFADIN CAPS 20MG $0(Tier 2)

ORFADIN CAPS 10MG, 2MG, 5MG $0(Tier 2) MO

PANCRELIPASE $0(Tier 2) MO

sodium phenylbutyrate powd $0(Tier 1)

VPRIV $0(Tier 2) PA

ZAVESCA $0(Tier 2)

ZENPEP $0(Tier 2) MO

Gastrointestinal Agents (Drugs that Treat Issues of the Stomach, Bowels, and Gallbladder)

Antispasmodics, Gastrointestinal

anaspaz $0(Tier 1)

atropine sulfate inj 0.05mg/ml, 0.1mg/ml, 0.4mg/ml, 1mg/ml $0(Tier 1)

dicyclomine hcl caps, soln, tabs $0(Tier 1)

ed-spaz $0(Tier 1)

glycopyrrolate tabs $0(Tier 1)

glycopyrrolate inj 0.2mg/ml, 0.4mg/2ml, 1mg/5ml, 4mg/20ml $0(Tier 1)

hyoscyamine sulfate odt $0(Tier 1)

hyoscyamine sulfate elix, subl, tabs, tbdp $0(Tier 1)

hyosyne elix $0(Tier 1)

methscopolamine bromide $0(Tier 1)

nulev $0(Tier 1)

oscimin $0(Tier 1)

propantheline bromide $0(Tier 1)

symax-sl $0(Tier 1)

Gastrointestinal Agents, Other

acid gone susp $0(Tier 1) MC

acid reducer maximum strength $0(Tier 1) MC

ACTIDOSE/SORBITOL LIQD 50GM/240ML; 0 $0(Tier 1) MC

almacone $0(Tier 1) MC

almacone double strength $0(Tier 1) MC

aluminum hydroxide $0(Tier 1) MC

antacid calcium extra st rength $0(Tier 1) MC

antacid calcium regular strength $0(Tier 1) MC

antacid extra strength $0(Tier 1) MC

antacid maximum strength $0(Tier 1) MC

antacid plus anti-gas relief $0(Tier 1) MC

anti-diarrheal tabs $0(Tier 1) MC

anti-nausea $0(Tier 1) MC

anu-med $0(Tier 1) MC

bisacodyl ec tbec 5mg $0(Tier 1) MC

biscolax $0(Tier 1) MC

bismatrol $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

bismatrol maximum strength $0(Tier 1) MC

cal-gest antacid $0(Tier 1) MC

calcium antacid $0(Tier 1) MC

calcium antacid extra strength $0(Tier 1) MC

chewable antacid $0(Tier 1) MC

cromolyn sodium conc 100mg/5ml $0(Tier 1) MO

diocto $0(Tier 1) MC

diphenoxylate/atropine $0(Tier 1)

docqlace caps 100mg $0(Tier 1) MC

docu $0(Tier 1) MC

docusol kids $0(Tier 1) MC

dok caps 100mg, 250mg $0(Tier 1) MC

dok tabs 100mg $0(Tier 1) MC

enemeez mini $0(Tier 1) MC

enemeez plus $0(Tier 1) MC

fiber tabs $0(Tier 1) MC

fiber-lax $0(Tier 1) MC

FLEET PEDIATRIC $0(Tier 1) MC

gas relief $0(Tier 1) MC

gas relief extra strength caps $0(Tier 1) MC

gas relief maximum strength $0(Tier 1) MC

GATTEX $0(Tier 2) PA

gnp antacid anti-gas $0(Tier 1) MC

gnp masanti maximum strength $0(Tier 1) MC

gnp masanti regular strength $0(Tier 1) MC

infants gas relief susp 20mg/0.3ml $0(Tier 1) MC

infants simethicone $0(Tier 1) MC

kao-tin caps 240mg $0(Tier 1) MC

kao-tin susp 262mg/15ml $0(Tier 1) MC

laxative $0(Tier 1) MC

loperamide hcl caps $0(Tier 1)

loperamide hcl liqd, susp $0(Tier 1) MC

magnesium oxide tabs 241.3mg, 400mg, 420mg $0(Tier 1) MC

magnesium caps 500mg $0(Tier 1) MC

magnesium tabs 500mg $0(Tier 1) MC

metoclopramide hcl inj, oral soln $0(Tier 1)

metoclopramide hcl tabs $0(Tier 1) MO

mi-acid gas relief $0(Tier 1) MC

mi-acid maximum strength $0(Tier 1) MC

mi-acid susp $0(Tier 1) MC

milk of magnesia concentrate $0(Tier 1) MC

milk of magnesia susp 400mg/5ml, 7.75% $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

mintox maximum strength $0(Tier 1) MC

mytab gas $0(Tier 1) MC

mytab gas max str $0(Tier 1) MC

natural fiber therapy $0(Tier 1) MC

OSMOPREP $0(Tier 2)

peptic relief chew 262mg $0(Tier 1) MC

phillips tabs $0(Tier 1) MC

pink bismuth chew $0(Tier 1) MC

qc anti-diarrheal $0(Tier 1) MC

reguloid $0(Tier 1) MC

RELISTOR INJ 8MG/0.4ML $0(Tier 2) QL (12 per 30 days) PA

RELISTOR INJ 12MG/0.6ML $0(Tier 2) QL (18 per 30 days) PA

rulox $0(Tier 1) MC

senexon $0(Tier 1) MC

senna lax $0(Tier 1) MC

senna syrp 8.8mg/5ml $0(Tier 1) MC

senna tabs 8.6mg $0(Tier 1) MC

simethicone caps 180mg $0(Tier 1) MC

simethicone susp $0(Tier 1) MC

sm antacid anti-gas $0(Tier 1) MC

sm antacid/antigas $0(Tier 1) MC

sm anti-diarrheal tabs $0(Tier 1) MC

sodium bicarbonate tabs 325mg, 650mg $0(Tier 1) MC

stimulant laxative $0(Tier 1) MC

stool softener extra strength $0(Tier 1) MC

stool softener laxative dc $0(Tier 1) MC

stool softener caps 100mg $0(Tier 1) MC

th antacid regular strength $0(Tier 1) MC

ursodiol caps $0(Tier 1)

ursodiol tabs $0(Tier 1) MO

Histamine2 (H2) Receptor Antagonists

cimetidine hcl $0(Tier 1) MO

cimetidine tabs $0(Tier 1) MO

famotidine premixed $0(Tier 1)

famotidine inj $0(Tier 1)

famotidine tabs 10mg $0(Tier 1) MC

famotidine tabs 20mg, 40mg $0(Tier 1) MO

nizatidine caps 150mg $0(Tier 1)

nizatidine caps 300mg $0(Tier 1) MO

ranitidine 150 maximum strength $0(Tier 1) MC

ranitidine 75 $0(Tier 1) MC

ranitidine hcl caps, syrp $0(Tier 1) MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

ranitidine hcl inj 150mg/6ml $0(Tier 1)

ranitidine hcl tabs 150mg $0(Tier 1)

ranitidine hcl tabs 300mg $0(Tier 1) MO

ranitidine maximum strength $0(Tier 1) MC

Irritable Bowel Syndrome Agents

alosetron hydrochloride $0(Tier 1) QL (60 per 30 days) PA

AMITIZA $0(Tier 2) QL (60 per 30 days) MO

LINZESS $0(Tier 2) QL (30 per 30 days)

Laxatives

bisacodyl ec tbec 5mg $0(Tier 1) MC

constulose $0(Tier 1) MO

cvs laxative dietary supplement $0(Tier 1) MC

doc-q-lax $0(Tier 1) MC

docqlace caps 100mg $0(Tier 1) MC

docusate sodium & senna stimulant laxative/stool softener $0(Tier 1) MC

docusol plus mini-enema $0(Tier 1) MC

dok plus $0(Tier 1) MC

dok caps 100mg, 250mg $0(Tier 1) MC

enema ready-to-use $0(Tier 1) MC

enulose $0(Tier 1) MO

fiber laxative caps $0(Tier 1) MC

gavilyte-c $0(Tier 1)

gavilyte-g $0(Tier 1)

gavilyte-n/flavor pack $0(Tier 1)

generlac $0(Tier 1) MO

gnp enema $0(Tier 1) MC

kao-tin caps 240mg $0(Tier 1) MC

lactulose soln $0(Tier 1) MO

milk of magnesia susp 400mg/5ml $0(Tier 1) MC

MOVIPREP $0(Tier 2)

peg 3350/electrolytes $0(Tier 1)

peg 3350 pack $0(Tier 1) MC

peg-3350/electrolytes $0(Tier 1)

peg-3350/nacl/na bicarbonate/kcl $0(Tier 1)

peg3350 $0(Tier 1) MC

polyethylene glycol 3350 powd $0(Tier 1)

sani-supp adult $0(Tier 1) MC

sani-supp pediatric $0(Tier 1) MC

senna plus $0(Tier 1) MC

senna-lax $0(Tier 1) MC

sennalax-s $0(Tier 1) MC

senna tabs 8.6mg $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

stool softener caps 100mg, 240mg $0(Tier 1) MC

SUPREP BOWEL PREP $0(Tier 2)

trilyte $0(Tier 1)

Protectants

CARAFATE SUSP $0(Tier 2) MO

misoprostol $0(Tier 1) MO

sucralfate tabs $0(Tier 1) MO

Proton Pump Inhibitors

DEXILANT $0(Tier 2) QL (60 per 30 days) ST

esomeprazole magnesium $0(Tier 1) QL (60 per 30 days)

esomeprazole sodium $0(Tier 1)

gnp omeprazole $0(Tier 1) MC

heartburn treatment 24 hour $0(Tier 1) MC

lansoprazole cpdr 15mg $0(Tier 1) MC

lansoprazole cpdr 15mg, 30mg $0(Tier 1) MO

omeprazole magnesium $0(Tier 1) MC

omeprazole tbec $0(Tier 1) MC

omeprazole cpdr $0(Tier 1) MO

pantoprazole sodium tbec $0(Tier 1) MO

Genitourinary Agents (Drugs that Treat Problems of the Urinary Tract)

Antispasmodics, Urinary

flavoxate hcl $0(Tier 1) MO

oxybutynin chloride er tb24 5mg $0(Tier 1) QL (30 per 30 days) MO

oxybutynin chloride er tb24 10mg, 15mg $0(Tier 1) QL (60 per 30 days) MO

oxybutynin chloride syrp $0(Tier 1)

oxybutynin chloride tabs $0(Tier 1) MO

tolterodine tartrate $0(Tier 1)

VESICARE $0(Tier 2) QL (30 per 30 days) MO

Benign Prostatic Hypertrophy Agents

alfuzosin hcl er $0(Tier 1) QL (30 per 30 days)

AVODART $0(Tier 2) MO

doxazosin $0(Tier 1) QL (30 per 30 days) MO

doxazosin mesylate tabs 1mg, 2mg $0(Tier 1) QL (30 per 30 days) MO

doxazosin mesylate tabs 8mg $0(Tier 1) QL (60 per 30 days) MO

dutasteride $0(Tier 1)

dutasteride/tamsulosin hydrochloride $0(Tier 1)

finasteride tabs 5mg $0(Tier 1) QL (30 per 30 days) MO

JALYN $0(Tier 2) MO

tamsulosin hcl $0(Tier 1) MO

terazosin hcl caps 1mg, 5mg $0(Tier 1) QL (30 per 30 days) MO

terazosin hcl caps 10mg, 2mg $0(Tier 1) QL (60 per 30 days) MO

Genitourinary Agents, Other




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

bethanechol chloride $0(Tier 1)

ELMIRON $0(Tier 2)

phenazopyridine hcl tabs 100mg, 200mg $0(Tier 1)

Phosphate Binders

AURYXIA $0(Tier 2) MO

calcium acetate caps $0(Tier 1) MO

calcium acetate tabs 667mg $0(Tier 1) MO

PHOSLYRA $0(Tier 2) MO

RENVELA PACK $0(Tier 2) QL (180 per 30 days) MO

RENVELA TABS $0(Tier 2) QL (540 per 30 days) MO

VELPHORO $0(Tier 2) MO

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

(Drugs that Control or Replace Hormones Associated with the Adrenal Gland)

Hormonal Agents, Stimulant/Replacement/Modifying (Adrenal)

a-hydrocort $0(Tier 1)

ala cort $0(Tier 1)

ALA SCALP $0(Tier 2)

alclometasone dipropionate $0(Tier 1)

amcinonide $0(Tier 1)

augmented betamethasone dipropionate $0(Tier 1)

betamethasone dipropionate crea, lotn, oint $0(Tier 1)

betamethasone valerate crea, foam, lotn, oint $0(Tier 1)

clobetasol propionate e $0(Tier 1)

clobetasol propionate emollient $0(Tier 1)

clobetasol propionate crea, foam, gel, oint, sham, soln $0(Tier 1)

clodan $0(Tier 1)

cormax scalp application $0(Tier 1)

cortisone acetate tabs $0(Tier 1)

DEPO-MEDROL INJ 20MG/ML $0(Tier 2)

desonide lotn, oint $0(Tier 1)

desoximetasone crea, gel $0(Tier 1)

desoximetasone oint 0.25% $0(Tier 1)

dexamethasone intensol $0(Tier 1)

dexamethasone sodium phosphate inj 10mg/ml, 120mg/30ml,

20mg/5ml, 4mg/ml

$0(Tier 1)

dexamethasone elix, soln, tabs $0(Tier 1)

diflorasone diacetate $0(Tier 1)

fludrocortisone acetate tabs $0(Tier 1) MO

fluocinolone acetonide body $0(Tier 1)

fluocinolone acetonide ear drops $0(Tier 1)

fluocinolone acetonide scalp $0(Tier 1)

fluocinolone acetonide crea 0.01%, 0.025% $0(Tier 1)




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

fluocinolone acetonide oint 0.025% $0(Tier 1)

fluocinolone acetonide soln 0.01% $0(Tier 1)

fluocinonide-e $0(Tier 1)

fluocinonide crea, gel, oint, soln $0(Tier 1)

fluticasone propionate crea 0.05% $0(Tier 1)

fluticasone propionate oint 0.005% $0(Tier 1)

halobetasol propionate $0(Tier 1)

hydro skin maximum strength $0(Tier 1) MC

hydrocortisone butyrate (lipid) $0(Tier 1)

hydrocortisone butyrate (lipophilic) $0(Tier 1)

hydrocortisone butyrate crea, oint, soln $0(Tier 1)

hydrocortisone in absorbase $0(Tier 1)

hydrocortisone valerate $0(Tier 1)

hydrocortisone/aloe crea 0; 1% $0(Tier 1) MC

hydrocortisone crea 1%, 2.5% $0(Tier 1)

hydrocortisone crea 0.5%, 1% $0(Tier 1) MC

hydrocortisone lotn 2.5% $0(Tier 1)

hydrocortisone oint 1%, 2.5% $0(Tier 1)

hydrocortisone oint 0.5%, 1% $0(Tier 1) MC

hydrocortisone tabs 10mg, 20mg, 5mg $0(Tier 1)

hydroskin $0(Tier 1) MC

MEDROL TABS 2MG $0(Tier 2)

methylprednisolone acetate inj $0(Tier 1)

methylprednisolone dose pack $0(Tier 1)

methylprednisolone sodiumsuccinate inj 125mg, 40mg $0(Tier 1)

methylprednisolone tabs $0(Tier 1)

mometasone furoate crea, oint, soln $0(Tier 1)

prednicarbate oint $0(Tier 1)

prednisolone sodium phosphate oral soln 15mg/5ml, 5mg/5ml $0(Tier 1)

prednisolone sodium phosphate oral soln 25mg/5ml $0(Tier 1) MO

prednisolone soln $0(Tier 1)

prednisone intensol $0(Tier 1)

prednisone soln, tabs, tbpk $0(Tier 1)

procto-med hc $0(Tier 1)

procto-pak $0(Tier 1)

proctosol hc $0(Tier 1)

proctozone-hc $0(Tier 1)

SOLU-CORTEF $0(Tier 2)

TEXACORT $0(Tier 2)

triamcinolone acetonide crea 0.025%, 0.1%, 0.5% $0(Tier 1)

triamcinolone acetonide lotn 0.025%, 0.1% $0(Tier 1)

triamcinolone acetonide oint 0.025%, 0.1%, 0.5% $0(Tier 1)




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

trianex $0(Tier 1)

triderm $0(Tier 1)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

(Drugs that Control or Replace Hormones Associated with the Pituitary Gland)

Hormonal Agents, Stimulant/Replacement/Modifying (Pituitary)

CHORIONIC GONADOTROPIN $0(Tier 2) PA

desmopressin acetate inj $0(Tier 1)

desmopressin acetate tabs $0(Tier 1) MO

desmopressin acetate nasal soln 0.01% $0(Tier 1)

desmopressin acetate nasal soln 0.01% $0(Tier 1) MO

INCRELEX $0(Tier 2) PA

NOVAREL $0(Tier 2) PA

PREGNYL W/DILUENT BENZYL ALCOHOL/NACL $0(Tier 2) PA

SAIZEN $0(Tier 2) PA MO

SAIZEN CLICK.EASY $0(Tier 2) PA MO

STIMATE $0(Tier 2) MO

Hormonal Agents, Stimulant/Replacement/Modifying (Prostaglandins)

(Drugs that Control Prostaglandins)

Hormonal Agents, Stimulant/Replacement/Modifying

(Prostaglandins)

KORLYM $0(Tier 2) QL (120 per 30 days) PA

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

(Drugs that Control or Replace Sex Hormones)

Anabolic Steroids

ANADROL-50 $0(Tier 2) PA

oxandrolone tabs 2.5mg $0(Tier 1) QL (120 per 30 days) PA

oxandrolone tabs 10mg $0(Tier 1) QL (60 per 30 days) PA

Androgens

ANDROGEL $0(Tier 2) PA MO

ANDROGEL PUMP GEL 1.62% $0(Tier 2) PA MO

ANDROXY $0(Tier 2) PA

danazol caps $0(Tier 1)

TESTIM $0(Tier 2) PA MO

testosterone cypionate inj $0(Tier 1) PA

testosterone enanthate inj $0(Tier 1) PA

testosterone pump $0(Tier 1) PA

testosterone gel 25mg/2.5gm $0(Tier 1) PA

Estrogens

ALORA $0(Tier 2) QL (8 per 28 days) PA

MO

altavera $0(Tier 1) MO

alyacen 1/35 $0(Tier 1) MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

alyacen 7/7/7 $0(Tier 1) MO

amethia $0(Tier 1) MO

amethia lo $0(Tier 1) MO

apri $0(Tier 1) MO

aranelle $0(Tier 1) MO

aubra $0(Tier 1) MO

aviane $0(Tier 1) MO

azurette $0(Tier 1) MO

balziva $0(Tier 1) MO

bekyree $0(Tier 1)

blisovi fe 1.5/30 $0(Tier 1)

blisovi fe 1/20 $0(Tier 1)

briellyn $0(Tier 1) MO

caziant $0(Tier 1) MO

chateal $0(Tier 1) MO

cryselle-28 $0(Tier 1) MO

cyclafem 1/35 $0(Tier 1) MO

cyclafem 7/7/7 $0(Tier 1) MO

cyred $0(Tier 1)

dasetta 1/35 $0(Tier 1) MO

dasetta 7/7/7 $0(Tier 1) MO

DELESTROGEN $0(Tier 2) MO

delyla $0(Tier 1) MO

DEPO-ESTRADIOL $0(Tier 2) MO

desogestrel/ethinyl estradiol $0(Tier 1) MO

elinest $0(Tier 1) MO

emoquette $0(Tier 1) MO

enpresse-28 $0(Tier 1) MO

enskyce $0(Tier 1) MO

estarylla $0(Tier 1) MO

estradiol valerate inj $0(Tier 1) MO

estradiol/norethindrone acetate $0(Tier 1) PA MO

estradiol tabs $0(Tier 1) PA MO

estradiol ptwk $0(Tier 1) QL (4 per 28 days) PA

MO

estradiol pttw $0(Tier 1) QL (8 per 28 days) PA

MO

ESTRING $0(Tier 2) QL (1 per 90 days) MO

falmina $0(Tier 1) MO

FEMRING $0(Tier 2) MO

gildagia $0(Tier 1) MO

gildess 1.5/30 $0(Tier 1) MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

gildess 1/20 $0(Tier 1) MO

gildess fe 1.5/30 $0(Tier 1) MO

gildess fe 1/20 $0(Tier 1) MO

introvale $0(Tier 1) MO

juleber $0(Tier 1)

junel 1.5/30 $0(Tier 1) MO

junel 1/20 $0(Tier 1) MO

junel fe 1.5/30 $0(Tier 1) MO

junel fe 1/20 $0(Tier 1) MO

kariva $0(Tier 1) MO

kelnor 1/35 $0(Tier 1) MO

kimidess $0(Tier 1)

kurvelo $0(Tier 1) MO

larin 1.5/30 $0(Tier 1) MO

larin 1/20 $0(Tier 1) MO

larin fe 1.5/30 $0(Tier 1) MO

larin fe 1/20 $0(Tier 1) MO

larissia $0(Tier 1)

lessina $0(Tier 1) MO

levonest $0(Tier 1) MO

levonorgestrel and ethinyl estradiol tabs 0; 0 $0(Tier 1) MO

levonorgestrel/ethinyl estradiol tabs 0; 0 $0(Tier 1)

levonorgestrel/ethinyl estradiol tabs 0.03mg; 0.15mg, 20mcg;

0.1mg

$0(Tier 1) MO

levora 0.15/30-28 $0(Tier 1) MO

lopreeza $0(Tier 1) PA MO

low-ogestrel $0(Tier 1) MO

lutera $0(Tier 1) MO

marlissa $0(Tier 1) MO

MENEST $0(Tier 2) PA MO

MENOSTAR $0(Tier 2) QL (4 per 28 days) PA

MO

microgestin 1.5/30 $0(Tier 1) MO

microgestin 1/20 $0(Tier 1) MO

microgestin fe $0(Tier 1) MO

microgestin fe 1.5/30 $0(Tier 1) MO

mimvey $0(Tier 1) PA MO

mimvey lo $0(Tier 1) PA MO

MINIVELLE $0(Tier 2) QL (8 per 28 days) PA

MO

mono-linyah $0(Tier 1) MO

myzilra $0(Tier 1) MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

necon 0.5/35-28 $0(Tier 1) MO

necon 1/35 $0(Tier 1) MO

necon 1/50-28 $0(Tier 1)

necon 10/11-28 $0(Tier 1) MO

necon 7/7/7 $0(Tier 1) MO

norethindrone acetate/ethinyl estradiol/ferrous fumarate $0(Tier 1) MO

norethindrone acetate/ethinyl estradiol tabs 20mcg; 1mg $0(Tier 1) MO

norgestimate/ethinyl estradiol $0(Tier 1) MO

nortrel 0.5/35 (28) $0(Tier 1) MO

nortrel 1/35 $0(Tier 1) MO

nortrel 7/7/7 $0(Tier 1) MO

ogestrel $0(Tier 1) MO

orsythia $0(Tier 1) MO

philith $0(Tier 1) MO

pimtrea $0(Tier 1) MO

pirmella 1/35 $0(Tier 1) MO

pirmella 7/7/7 $0(Tier 1) MO

portia-28 $0(Tier 1) MO

PREMARIN CREA, INJ $0(Tier 2) MO

PREMARIN TABS $0(Tier 2) QL (30 per 30 days) PA

MO

previfem $0(Tier 1) MO

quasense $0(Tier 1) MO

reclipsen $0(Tier 1) MO

setlakin $0(Tier 1)

sprintec 28 $0(Tier 1) MO

sronyx $0(Tier 1) MO

tarina fe 1/20 $0(Tier 1) MO

tilia fe $0(Tier 1) MO

tri-estarylla $0(Tier 1) MO

tri-legest fe $0(Tier 1) MO

tri-linyah $0(Tier 1) MO

tri-previfem $0(Tier 1) MO

tri-sprintec $0(Tier 1) MO

trivora-28 $0(Tier 1) MO

VAGIFEM $0(Tier 2)

velivet $0(Tier 1) MO

vienva $0(Tier 1)

viorele $0(Tier 1) MO

vyfemla $0(Tier 1) MO

wera $0(Tier 1) MO

zenchent $0(Tier 1) MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

zovia 1/35e $0(Tier 1) MO

zovia 1/50e $0(Tier 1) MO

Progesterone Agonists/Antagonists

ELLA $0(Tier 2)

Progestins

camila $0(Tier 1) MO

deblitane $0(Tier 1)

DEPO-PROVERA $0(Tier 2)

econtra ez $0(Tier 1) MC

errin $0(Tier 1) MO

fallback solo $0(Tier 1) MC

heather $0(Tier 1)

hydroxyprogesterone caproate inj $0(Tier 1)

jencycla $0(Tier 1)

lyza $0(Tier 1) MO

MAKENA $0(Tier 2)

medroxyprogesterone acetate tabs $0(Tier 1) MO

medroxyprogesterone acetate inj $0(Tier 1) QL (1 per 90 days)

megestrol acetate tabs $0(Tier 1) PA

megestrol acetate susp 40mg/ml $0(Tier 1) PA

my way $0(Tier 1) MC

next choice one dose $0(Tier 1) MC

norethindrone acetate tabs $0(Tier 1) MO

norethindrone tabs $0(Tier 1)

norlyroc $0(Tier 1)

opcicon one-step $0(Tier 1) MC

progesterone caps $0(Tier 1) MO

sharobel $0(Tier 1)

Selective Estrogen Receptor Modifying Agents

raloxifene hydrochloride $0(Tier 1) QL (30 per 30 days) MO

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

(Drugs that Replace Thyroid Hormone)

Hormonal Agents, Stimulant/Replacement/Modifying (Thyroid)

levothyroxine sodium tabs $0(Tier 1) MO

LEVOXYL $0(Tier 2) MO

liothyronine sodium inj $0(Tier 1)

liothyronine sodium tabs $0(Tier 1) MO

SYNTHROID $0(Tier 2) MO

THYROLAR-1 $0(Tier 2) MO

THYROLAR-1/2 $0(Tier 2) MO

THYROLAR-1/4 $0(Tier 2) MO





Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use


UNITHROID $0(Tier 2)

Hormonal Agents, Suppressant (Adrenal)

(Drugs that Decrease Levels of Hormones Associated with the Adrenal Glands)

Hormonal Agents, Suppressant (Adrenal)

LYSODREN $0(Tier 2)

Hormonal Agents, Suppressant (Parathyroid)

(Drugs that Lower Parathyroid Hormone Levels)

Hormonal Agents, Suppressant (Parathyroid)

SENSIPAR TABS 90MG $0(Tier 2) QL (120 per 30 days) MO

SENSIPAR TABS 30MG, 60MG $0(Tier 2) QL (60 per 30 days) MO

Hormonal Agents, Suppressant (Pituitary)

(Drugs that Decrease Thyroid Stimulating Hormone Production)

Hormonal Agents, Suppressant (Pituitary)

cabergoline $0(Tier 1)

ELIGARD INJ 30MG $0(Tier 2) QL (1 per 120 days) PA

ELIGARD INJ 45MG $0(Tier 2) QL (1 per 180 days) PA

ELIGARD INJ 7.5MG $0(Tier 2) QL (1 per 30 days) PA

ELIGARD INJ 22.5MG $0(Tier 2) QL (1 per 90 days) PA

FIRMAGON INJ 80MG $0(Tier 2) QL (4 per 28 days) B/D

FIRMAGON INJ 120MG $0(Tier 2) QL (6 per 365 days) B/D

leuprolide acetate inj $0(Tier 1) QL (5.6 per 28 days) PA

LUPRON DEPOT-PED $0(Tier 2) QL (1 per 30 days) PA

LUPRON DEPOT INJ 30MG $0(Tier 2) QL (1 per 112 days) PA

LUPRON DEPOT INJ 45MG $0(Tier 2) QL (1 per 168 days) PA

LUPRON DEPOT INJ 3.75MG, 7.5MG $0(Tier 2) QL (1 per 30 days) PA

LUPRON DEPOT INJ 22.5MG $0(Tier 2) QL (1 per 84 days) PA

LUPRON DEPOT INJ 11.25MG $0(Tier 2) QL (1 per 90 days) PA

octreotide acetate $0(Tier 1) PA

SANDOSTATIN LAR DEPOT $0(Tier 2) PA

SIGNIFOR $0(Tier 2) PA

SOMATULINE DEPOT $0(Tier 2) PA

SOMAVERT INJ 25MG, 30MG $0(Tier 2) QL (30 per 30 days) PA

SOMAVERT INJ 15MG, 20MG $0(Tier 2) QL (60 per 30 days) PA

SOMAVERT INJ 10MG $0(Tier 2) QL (90 per 30 days) PA

SYNAREL $0(Tier 2) PA MO

TRELSTAR MIXJECT INJ 22.5MG $0(Tier 2) QL (2 per 168 days) PA



TRELSTAR INJ 3.75MG $0(Tier 2) QL (2 per 28 days) PA

TRELSTAR INJ 11.25MG $0(Tier 2) QL (2 per 84 days) PA




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

Hormonal Agents, Suppressant (Thyroid)

(Drugs that Lower Thyroid Hormone Levels)

Antithyroid Agents

methimazole tabs $0(Tier 1) MO

propylthiouracil tabs $0(Tier 1) MO

Immunological Agents

(Drugs used for Prevention of Disease and Infection or can Affect the Immune System)

Angioedema (HAE) Agents

CINRYZE $0(Tier 2) PA

FIRAZYR $0(Tier 2) PA

Immune Suppressants

ASTAGRAF XL $0(Tier 2) PA MO

AZASAN $0(Tier 2) PA MO

azathioprine inj $0(Tier 1) PA

azathioprine tabs $0(Tier 1) PA MO

BENLYSTA $0(Tier 2) PA

CELLCEPT INTRAVENOUS $0(Tier 2) PA

cyclosporine modified $0(Tier 1) PA MO

cyclosporine inj $0(Tier 1) PA

cyclosporine caps $0(Tier 1) PA MO

ENBREL $0(Tier 2) QL (8 per 28 days) PA

MO

ENBREL SURECLICK $0(Tier 2) QL (8 per 28 days) PA

MO

ENVARSUS XR $0(Tier 2) PA

gengraf caps 50mg $0(Tier 1) PA

gengraf caps 100mg, 25mg $0(Tier 1) PA MO

gengraf soln $0(Tier 1) PA MO

hecoria $0(Tier 1) PA

HUMIRA PEDIATRIC CROHNS DISEASE STARTER

PACK

$0(Tier 2) QL (6 per 28 days) PA

MO

HUMIRA PEN $0(Tier 2) QL (6 per 28 days) PA

MO

HUMIRA PEN-CROHNS DISEASESTARTER $0(Tier 2) QL (6 per 28 days) PA

MO

HUMIRA PEN-PSORIASIS STARTER $0(Tier 2) QL (6 per 28 days) PA

MO

HUMIRA INJ 10MG/0.2ML, 20MG/0.4ML $0(Tier 2) QL (2 per 28 days) PA

MO

HUMIRA INJ 40MG/0.8ML $0(Tier 2) QL (6 per 28 days) PA

MO

KINERET $0(Tier 2) QL (20.1 per 30 days) PA




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

methotrexate sodium inj 1gm/40ml, 1gm, 250mg/10ml,

50mg/2ml

$0(Tier 1)

methotrexate tabs $0(Tier 1)

mycophenolate mofetil $0(Tier 1) PA

mycophenolic acid dr $0(Tier 1) PA

NULOJIX $0(Tier 2) PA MO

PROGRAF INJ $0(Tier 2) PA

RAPAMUNE SOLN $0(Tier 2) PA

REMICADE $0(Tier 2) PA

SANDIMMUNE SOLN $0(Tier 2) PA

sirolimus tabs $0(Tier 1) PA MO

tacrolimus caps 0.5mg, 1mg, 5mg $0(Tier 1) PA MO

TORISEL $0(Tier 2) B/D

ZORTRESS $0(Tier 2) B/D

Immunizing Agents, Passive

ATGAM $0(Tier 2) PA

BIVIGAM $0(Tier 2) B/D

FLEBOGAMMA DIF $0(Tier 2) B/D

GAMASTAN S/D $0(Tier 2) B/D

GAMMAGARD LIQUID INJ 2.5GM/25ML, 30GM/300ML $0(Tier 2) B/D

GAMMAKED $0(Tier 2) B/D

GAMMAPLEX INJ 10GM/200ML, 2.5GM/50ML,

5GM/100ML

$0(Tier 2) B/D

GAMUNEX-C $0(Tier 2) B/D

OCTAGAM INJ 10GM/100ML, 10GM/200ML, 1GM/20ML,

2.5GM/50ML, 20GM/200ML, 2GM/20ML, 5GM/100ML,

5GM/50ML

$0(Tier 2) B/D

PRIVIGEN INJ 10GM/100ML, 20GM/200ML, 5GM/50ML $0(Tier 2) B/D

THYMOGLOBULIN $0(Tier 2) B/D

Immunomodulators

ACTIMMUNE $0(Tier 2) PA

ARCALYST $0(Tier 2) PA

ILARIS $0(Tier 2) PA

leflunomide $0(Tier 1) QL (30 per 30 days) MO

RIDAURA $0(Tier 2) MO

SIMULECT $0(Tier 2) B/D

SYNAGIS INJ 50MG/0.5ML $0(Tier 2) PA

Vaccines

ACTHIB $0(Tier 2)

ADACEL $0(Tier 2)

BEXSERO $0(Tier 2)

BOOSTRIX $0(Tier 2)




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

CERVARIX $0(Tier 2)

COMVAX $0(Tier 2)

DAPTACEL $0(Tier 2)

DIPHTHERIA/TETANUS TOXOIDS ADSORBED

PEDIATRIC

$0(Tier 2)

ENGERIX-B $0(Tier 2) B/D

GARDASIL $0(Tier 2)

GARDASIL 9 $0(Tier 2)

HAVRIX $0(Tier 2)

HIBERIX $0(Tier 2)

IMOVAX RABIES (H.D.C.V.) $0(Tier 2)

INFANRIX $0(Tier 2)

IPOL INACTIVATED IPV $0(Tier 2)

IXIARO $0(Tier 2)

KINRIX $0(Tier 2)

M-M-R II $0(Tier 2)

MENACTRA $0(Tier 2)

MENHIBRIX $0(Tier 2)

MENOMUNE-A/C/Y/W-135 $0(Tier 2)

MENVEO $0(Tier 2)

PEDVAX HIB $0(Tier 2)

PROQUAD $0(Tier 2)

QUADRACEL $0(Tier 2)

RABAVERT $0(Tier 2)

RECOMBIVAX HB $0(Tier 2) B/D

ROTARIX $0(Tier 2)

ROTATEQ $0(Tier 2)

TENIVAC $0(Tier 2)

TETANUS/DIPHTHERIA TOXOIDS-ADSORBED $0(Tier 2)

TETANUS/DIPHTHERIA TOXOIDS-ADSORBED ADULT $0(Tier 2)

TRUMENBA $0(Tier 2)

TWINRIX $0(Tier 2)

TYPHIM VI $0(Tier 2)

VAQTA $0(Tier 2)

VARIVAX $0(Tier 2)

VARIZIG $0(Tier 2)

YF-VAX $0(Tier 2)

ZOSTAVAX $0(Tier 2)

Inflammatory Bowel Disease Agents

(Drugs that Treat Inflammation of the Bowels)

Aminosalicylates

APRISO $0(Tier 2) MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

balsalazide disodium $0(Tier 1) MO

DELZICOL $0(Tier 2) MO

mesalamine enem, kit $0(Tier 1) MO

Glucocorticoids

budesonide cpep 3mg $0(Tier 1)

colocort $0(Tier 1)

hydrocortisone enem 100mg/60ml $0(Tier 1)

Sulfonamides

sulfasalazine tabs, tbec $0(Tier 1) MO

Metabolic Bone Disease Agents (Drugs that Treat Weak Bones)

Metabolic Bone Disease Agents

alendronate sodium tabs 10mg, 40mg, 5mg $0(Tier 1) QL (30 per 30 days) MO

alendronate sodium tabs 35mg $0(Tier 1) QL (4 per 28 days)

alendronate sodium tabs 70mg $0(Tier 1) QL (4 per 28 days) MO

calcitonin-salmon $0(Tier 1) QL (3.7 per 30 days) MO

calcitriol caps 0.25mcg, 0.5mcg $0(Tier 1) MO

calcitriol inj 1mcg/ml $0(Tier 1)

calcitriol oral soln 1mcg/ml $0(Tier 1) MO

doxercalciferol inj $0(Tier 1)

doxercalciferol caps $0(Tier 1) MO

etidronate disodium $0(Tier 1)

FORTEO $0(Tier 2) QL (2.4 per 28 days) PA

MO

ibandronate sodium tabs $0(Tier 1) QL (1 per 28 days) MO

MIACALCIN INJ $0(Tier 2)

pamidronate disodium inj 30mg, 90mg $0(Tier 1) B/D

pamidronate disodium inj 30mg/10ml, 6mg/ml, 90mg/10ml $0(Tier 1) B/D MO

paricalcitol caps $0(Tier 1)

PROLIA $0(Tier 2) QL (1 per 180 days) ST

risedronate sodium tabs 150mg $0(Tier 1) QL (1 per 28 days) MO

risedronate sodium tabs 30mg, 5mg $0(Tier 1) QL (30 per 30 days) MO

risedronate sodium tabs 35mg $0(Tier 1) QL (4 per 28 days) MO

XGEVA $0(Tier 2) PA

zoledronic acid $0(Tier 1) B/D

Miscellaneous Therapeutic Agents (Other Drugs)

Miscellaneous Therapeutic Agents

active 1st blood lancets 30g/easy twist cap $0(Tier 1) MC

aerovent plus holding chamber/collapsible $0(Tier 1) MC

assure prism multi test strips $0(Tier 1) MC

bd autoshield duo 30g x 3/16" $0(Tier 1) MC

bd eclipse syringe/1ml/30gx1/2" $0(Tier 1) QL (200 per 30 days)

bd insulin syringe safetyglide/1ml/29g x 1/2" $0(Tier 1) QL (200 per 30 days)




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

bd insulin syringe ultrafine/0.3ml/31g x 5/16" $0(Tier 1) QL (200 per 30 days)

bd insulin syringe ultrafine/0.5ml/30g x 1/2" $0(Tier 1) QL (200 per 30 days)

bd insulin syringe ultrafine/1ml/31g x 5/16" $0(Tier 1) QL (200 per 30 days)

bd pen needle/mini/ultrafine/31g x 3/16" $0(Tier 1) QL (200 per 30 days) MO

bd pen needle/nano/ultra fine/32g x 4mm $0(Tier 1) QL (200 per 30 days) MO

bd pen needle/ultrafine/29g x 12.7mm $0(Tier 1) QL (200 per 30 days)

bd safetyglide 27g x 5/8" $0(Tier 1) QL (200 per 30 days)

clever choice anti-staticvalved holding chamber/adult large $0(Tier 1) MC

clever choice anti-staticvalved holding chamber/medium $0(Tier 1) MC

clever choice anti-staticvalved holding chamber/small $0(Tier 1) MC

compact space chamber/anti-static $0(Tier 1) MC

compact space chamber/anti-static/large mask $0(Tier 1) MC

compact space chamber/anti-static/medium mask $0(Tier 1) MC

compact space chamber/anti-static/small mask $0(Tier 1) MC

cvs lancets ultra-thin 30g $0(Tier 1) MC

easy mini eject lancing device $0(Tier 1) MC

enfamil enfalyte $0(Tier 1) MC

FERRIPROX $0(Tier 2) PA

fifty50 unilet lancets 33g $0(Tier 1) MC

fomepizole $0(Tier 1)

fora d40/g31 blood glucose test strips $0(Tier 1) MC

fora lancets $0(Tier 1) MC

fora lancing device/clearcap $0(Tier 1) MC

fora tn'g/tn'g voice blood glucose test strips $0(Tier 1) MC

freestyle precision neo blood glucose test strips $0(Tier 1) MC

glucose meter test strips advanced $0(Tier 1) MC

gnp easy touch glucose test strips $0(Tier 1) MC

h-e-b incontrol lancets micro thin 33g $0(Tier 1) MC

inspirachamber/large $0(Tier 1) MC

INTRALIPID INJ 30GM/100ML $0(Tier 2) B/D

LACTATED RINGERS IRRIGATION $0(Tier 2)

levocarnitine inj, tabs $0(Tier 1)

levocarnitine oral soln $0(Tier 1) MO

mask vortex/child/frog $0(Tier 1) MC

mask vortex/toddler/lady bug $0(Tier 1) MC

multi-lancet device 2 $0(Tier 1) MC

NATPARA $0(Tier 2) PA

novofine 30gx8mm $0(Tier 1) QL (200 per 30 days) MO

novofine 31 $0(Tier 1) QL (200 per 30 days) MO

novofine 32gx6mm $0(Tier 1) QL (200 per 30 days) MO

novofine autocover 30gx8mm $0(Tier 1) QL (200 per 30 days) MO

novotwist 30gx8mm $0(Tier 1) QL (200 per 30 days) MO




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

novotwist 32gx5mm $0(Tier 1) QL (200 per 30 days)

one-way valved expiratorymouthpiece/disposable $0(Tier 1) MC

one-way valved inspiratory mouthpiece/disposable $0(Tier 1) MC

panda mask large $0(Tier 1) MC

panda mask medium $0(Tier 1) MC

panda mask small $0(Tier 1) MC

pantothenic acid $0(Tier 1) MC

pediatric medium mask $0(Tier 1) MC

pediatric mouthpiece/disposable $0(Tier 1) MC

pediatric panda mask $0(Tier 1) MC

pediatric small mask $0(Tier 1) MC

pharmacist choice no coding blood glucose test strips $0(Tier 1) MC

pharmacist choice ultra thin lancets 33g $0(Tier 1) MC

PHYSIOLYTE $0(Tier 2)

PHYSIOSOL IRRIGATION $0(Tier 2)

premium blood glucose test strips $0(Tier 1) MC

pro comfort lancets 30g $0(Tier 1) MC

prodigy safety lancets $0(Tier 1) MC

qc unilet lancets 33g/micro thin $0(Tier 1) MC

relion prime blood glucose test strips $0(Tier 1) MC

RINGERS IRRIGATION $0(Tier 2)

sidestream pediatric facemask $0(Tier 1) MC

sidestream pediatric facemask/tucker the turtle $0(Tier 1) MC

silicone mask for breatherite chamber/pediatric $0(Tier 1) MC

SODIUM CHLORIDE 0.9% $0(Tier 2)

sterile water irrigation $0(Tier 1)

suspendol-s $0(Tier 1) MC

thyrosafe $0(Tier 1) MC

thyroshield $0(Tier 1) MC

true metrix self monitoring blood glucose strips $0(Tier 1) MC

unilet lancets micro-thin33g $0(Tier 1) MC

zinc/vitamin c $0(Tier 1) MC

Ophthalmic Agents (Drugs that Relieve or Prevent Eye Problems)

Ophthalmic Prostaglandin and Prostamide Analogs

bimatoprost $0(Tier 1) QL (5 per 30 days) MO

COMBIGAN $0(Tier 2) MO

latanoprost $0(Tier 1) QL (5 per 30 days) MO

LUMIGAN $0(Tier 2) QL (5 per 30 days) MO

TRAVATAN Z $0(Tier 2) QL (5 per 30 days) MO

ZIOPTAN $0(Tier 2) QL (30 per 30 days)

Ophthalmic Agents, Other

akwa tears $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

artificial tears oint $0(Tier 1) MC

artificial tears soln 1.4% $0(Tier 1) MC

atropine sulfate ophthalmic soln 1% $0(Tier 1)

eye drops soln 0.05% $0(Tier 1) MC

FRESHKOTE $0(Tier 1) MC

ISOPTO TEARS $0(Tier 1) MC

LACRISERT $0(Tier 2)

liquitears $0(Tier 1) MC

lubricating plus eye drops $0(Tier 1) MC

lubrifresh p.m. $0(Tier 1) MC

MURO 128 SOLN $0(Tier 1) MC

mydral $0(Tier 1)

naphazoline hcl $0(Tier 1)

natural balance tears soln 0.4% $0(Tier 1) MC

natures tears soln 0.4% $0(Tier 1) MC

opti-clear $0(Tier 1) MC

proparacaine hcl $0(Tier 1)

puralube $0(Tier 1) MC

REFRESH CELLUVISC $0(Tier 1) MC

REFRESH LACRI-LUBE $0(Tier 1) MC

REFRESH PLUS $0(Tier 1) MC

RESTASIS $0(Tier 2) QL (64 per 30 days) MO

sodium chloride oint 5% $0(Tier 1) MC

sodium chloride ophthalmic soln 5% $0(Tier 1) MC

tropicamide $0(Tier 1)

Ophthalmic Anti-allergy Agents

ALOCRIL $0(Tier 2)

azelastine hcl ophthalmic soln 0.05% $0(Tier 1)

cromolyn sodium soln 4% $0(Tier 1)

epinastine hcl $0(Tier 1)

olopatadine hcl $0(Tier 1)

PATADAY $0(Tier 2)

PAZEO $0(Tier 2)

Ophthalmic Anti-inflammatories

bromfenac $0(Tier 1)

dexamethasone sodium phosphate ophthalmic soln 0.1% $0(Tier 1)

diclofenac sodium ophthalmic soln 0.1% $0(Tier 1) MO

DUREZOL $0(Tier 2)

fluorometholone $0(Tier 1)

flurbiprofen sodium $0(Tier 1) MO

ILEVRO $0(Tier 2)

ketorolac tromethamine $0(Tier 1)




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

LOTEMAX $0(Tier 2)

neomycin/polymyxin/dexamethasone $0(Tier 1)

PRED MILD $0(Tier 2)

PRED-G $0(Tier 2)

PRED-G S.O.P. $0(Tier 2)

prednisolone acetate $0(Tier 1)

prednisolone sodium phosphate ophthalmic soln 1% $0(Tier 1)

TOBRADEX OINT $0(Tier 2)

tobramycin/dexamethasone $0(Tier 1)

Ophthalmic Antiglaucoma Agents

acetazolamide er $0(Tier 1) MO

apraclonidine $0(Tier 1) MO

AZOPT $0(Tier 2)

betaxolol hcl soln 0.5% $0(Tier 1) MO

brimonidine tartrate soln 0.15% $0(Tier 1)

brimonidine tartrate soln 0.2% $0(Tier 1) MO

carteolol hcl $0(Tier 1) MO

dorzolamide hcl $0(Tier 1) MO

dorzolamide hcl/timolol maleate $0(Tier 1) MO

levobunolol hcl $0(Tier 1) MO

methazolamide tabs $0(Tier 1) MO

metipranolol $0(Tier 1) MO

PHOSPHOLINE IODIDE $0(Tier 2)

pilocarpine hcl soln 1%, 2%, 4% $0(Tier 1)

SIMBRINZA $0(Tier 2)

timolol maleate soln 0.25%, 0.5% $0(Tier 1) MO

Otic Agents (Drugs that Relieve or Prevent Ear Problems)

Otic Agents

acetasol hc $0(Tier 1)

acetic acid $0(Tier 1)

acetic acid/aluminum acetate $0(Tier 1)

COLY-MYCIN S $0(Tier 2)

CORTISPORIN-TC $0(Tier 2)

ear drops earwax removal aid $0(Tier 1) MC

earwax treatment drops $0(Tier 1) MC

fluocinolone acetonide oil 0.01% $0(Tier 1)

hydrocortisone/acetic acid $0(Tier 1)

neomycin/polymyxin/hc $0(Tier 1)

neomycin/polymyxin/hydrocortisone soln 1%; 3.5mg/ml;

10000unit/ml

$0(Tier 1)

neomycin/polymyxin/hydrocortisone otic susp 1%; 3.5mg/ml;

10000unit/ml

$0(Tier 1)




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

Respiratory Tract/Pulmonary Agents (Drugs that are used for Breathing Problems)

Anti-inflammatories, Inhaled Corticosteroids

budesonide inhalation susp 0.25mg/2ml, 0.5mg/2ml, 1mg/2ml $0(Tier 1) QL (120 per 30 days) B/D

budesonide nasal susp 32mcg/act $0(Tier 1) QL (17.2 per 30 days)

DULERA $0(Tier 2) QL (18 per 30 days) MO

FLOVENT DISKUS AEPB 250MCG/BLIST, 50MCG/BLIST $0(Tier 2) QL (120 per 30 days) MO

FLOVENT DISKUS AEPB 100MCG/BLIST $0(Tier 2) QL (180 per 30 days) MO

FLOVENT HFA AERO 44MCG/ACT $0(Tier 2) QL (22 per 30 days) MO

FLOVENT HFA AERO 110MCG/ACT, 220MCG/ACT $0(Tier 2) QL (24 per 30 days) MO

flunisolide $0(Tier 1)

fluticasone propionate susp 50mcg/act $0(Tier 1) MC

fluticasone propionate susp 50mcg/act $0(Tier 1) QL (16 per 30 days)

QVAR $0(Tier 2) QL (18 per 30 days) MO

SYMBICORT AERO 160MCG/ACT; 4.5MCG/ACT $0(Tier 2) QL (12 per 30 days) MO

SYMBICORT AERO 80MCG/ACT; 4.5MCG/ACT $0(Tier 2) QL (14 per 30 days) MO

triamcinolone acetonide aero 55mcg/act $0(Tier 1) QL (16.5 per 30 days) MO

Antihistamines

aceta-gesic $0(Tier 1) MC

acetaminophen/diphenhydramine $0(Tier 1) MC

ALA-HIST IR $0(Tier 1) MC

ALA-HIST PE $0(Tier 1) MC

all day allergy childrens chew $0(Tier 1) MC

all day allergy childrens soln 5mg/5ml $0(Tier 1) MC

all day allergy-d $0(Tier 1) MC

all day allergy tabs $0(Tier 1) MC

aller-chlor $0(Tier 1) MC

allergy relief child $0(Tier 1) MC

allergy relief d-24 $0(Tier 1) MC

allergy relief tabs 10mg $0(Tier 1) MC

allergy tbdp $0(Tier 1) MC

allergy tabs 10mg, 4mg $0(Tier 1) MC

azelastine hcl nasal soln 0.1%, 0.15% $0(Tier 1) QL (60 per 30 days) MO

banophen caps 50mg $0(Tier 1) MC

banophen liqd $0(Tier 1) MC

BROTAPP $0(Tier 1) MC

cetirizine hcl allergy childrens $0(Tier 1) MC

cetirizine hcl childrens allergy syrp 1mg/ml $0(Tier 1) MC

cetirizine hcl/pseudoephedrine hcl er $0(Tier 1) MC

cetirizine hcl chew, tabs $0(Tier 1) MC

childrens allergy $0(Tier 1) MC

childrens loratadine $0(Tier 1) MC

complete allergy medicine caps $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

dallergy tabs $0(Tier 1) MC

dallergy liqd 1mg/ml; 2.5mg/ml $0(Tier 1) MC

desloratadine $0(Tier 1) QL (30 per 30 days) MO

desloratadine odt $0(Tier 1) QL (30 per 30 days)

dimaphen childrens $0(Tier 1) MC

diphenhist liqd $0(Tier 1) MC

diphenhydramine hcl inj $0(Tier 1)

diphenhydramine hcl caps $0(Tier 1) MC

ed a-hist $0(Tier 1) MC

ed a-hist pse $0(Tier 1) MC

ed chlorped $0(Tier 1) MC

ed chlorped d $0(Tier 1) MC

ed chlorped jr $0(Tier 1) MC

ed-chlortan $0(Tier 1) MC

fexofenadine hcl $0(Tier 1) MC

fexofenadine hcl childrens allergy $0(Tier 1) MC

gnp all day allergy $0(Tier 1) MC

gnp allergy tabs 4mg $0(Tier 1) MC

gnp dayhist allergy $0(Tier 1) MC

gnp loratadine $0(Tier 1) MC

histex $0(Tier 1) MC

histex pd $0(Tier 1) MC

J-TAN D PD $0(Tier 1) MC

J-TAN PD $0(Tier 1) MC

levocetirizine dihydrochloride tabs $0(Tier 1) QL (30 per 30 days) MO

levocetirizine dihydrochloride soln $0(Tier 1) QL (300 per 30 days) MO

LODRANE D $0(Tier 1) MC

lohist-d $0(Tier 1) MC

loratadine childrens $0(Tier 1) MC

loratadine hives relief $0(Tier 1) MC

loratadine-d 12hr $0(Tier 1) MC

loratadine-d 24hr $0(Tier 1) MC

loratadine tabs $0(Tier 1) MC

NASOPEN PE $0(Tier 1) MC

night time sleep aid $0(Tier 1) MC

nohist-lq $0(Tier 1) MC

POLY-HIST PD $0(Tier 1) MC

promethazine/codeine syrp 10mg/5ml; 6.25mg/5ml $0(Tier 1) MC

q-dryl $0(Tier 1) MC

qc loratadine allergy relief $0(Tier 1) MC

qc loratadine-d $0(Tier 1) MC

quenalin $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

RESCON TABS $0(Tier 1) MC

restfully sleep $0(Tier 1) MC

ru-hist d $0(Tier 1) MC

rymed $0(Tier 1) MC

rynex pe $0(Tier 1) MC

rynex pse $0(Tier 1) MC

siladryl allergy $0(Tier 1) MC

silphen cough $0(Tier 1) MC

sm allergy 4 hour $0(Tier 1) MC

sm allergy relief liqd $0(Tier 1) MC

sm allergy relief tabs 1.34mg $0(Tier 1) MC

sm lorata-dine d $0(Tier 1) MC

sm loratadine syrp $0(Tier 1) MC

sm sleep aid $0(Tier 1) MC

sudogest sinus & allergy $0(Tier 1) MC

VANAHIST PD $0(Tier 1) MC

virdec $0(Tier 1) MC

Antileukotrienes

montelukast sodium $0(Tier 1) QL (30 per 30 days) MO

zafirlukast $0(Tier 1) MO

Bronchodilators, Anticholinergic

ATROVENT HFA $0(Tier 2) QL (26 per 30 days) MO

COMBIVENT RESPIMAT $0(Tier 2) QL (8 per 30 days) MO

ipratropium bromide/albuterol sulfate $0(Tier 1) QL (540 per 30 days) B/D

MO

ipratropium bromide inhalation soln $0(Tier 1) QL (300 per 30 days) B/D

MO

ipratropium bromide nasal soln 0.06% $0(Tier 1) QL (30 per 30 days) MO

ipratropium bromide nasal soln 0.03% $0(Tier 1) QL (60 per 30 days) MO

SPIRIVA HANDIHALER $0(Tier 2) QL (30 per 30 days) MO

SPIRIVA RESPIMAT $0(Tier 2) QL (4 per 30 days)

Bronchodilators, Sympathomimetic

albuterol sulfate er $0(Tier 1) MO

albuterol sulfate syrp, tabs $0(Tier 1) MO

albuterol sulfate nebu 0.5% $0(Tier 1) QL (360 per 30 days) B/D

MO

albuterol sulfate nebu 0.083%, 0.63mg/3ml, 1.25mg/3ml $0(Tier 1) QL (375 per 30 days) B/D

MO

albuterol tabs $0(Tier 1)

epinephrine hcl $0(Tier 1)

EPIPEN 2-PAK $0(Tier 2) QL (2 per 30 days)

EPIPEN-JR 2-PAK $0(Tier 2) QL (2 per 30 days)




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

FORADIL AEROLIZER $0(Tier 2) QL (60 per 30 days) MO

metaproterenol sulfate syrp, tabs $0(Tier 1) MO

PERFOROMIST $0(Tier 2) QL (120 per 30 days) B/D

PROAIR HFA $0(Tier 2) QL (17 per 30 days) MO

PROAIR RESPICLICK $0(Tier 2) QL (1.3 per 30 days)

S2 $0(Tier 1) MC

SEREVENT DISKUS $0(Tier 2) QL (60 per 30 days)

STRIVERDI RESPIMAT $0(Tier 2) QL (4 per 30 days)

terbutaline sulfate inj $0(Tier 1)

terbutaline sulfate tabs $0(Tier 1) MO

Cystic Fibrosis Agents

CAYSTON $0(Tier 2) PA

KALYDECO $0(Tier 2) QL (60 per 30 days) PA

PULMOZYME $0(Tier 2) B/D

TOBI PODHALER $0(Tier 2) QL (1568 per 365 days)

tobramycin $0(Tier 1) B/D

Mast Cell Stabilizers

cromolyn sodium aers 5.2mg/act $0(Tier 1) MC

cromolyn sodium nebu 20mg/2ml $0(Tier 1) B/D MO

Phosphodiesterase Inhibitors, Airways Disease

aminophylline $0(Tier 1)

DALIRESP $0(Tier 2) QL (30 per 30 days) PA

MO

THEO-24 $0(Tier 2) MO

theochron $0(Tier 1) MO

theophylline cr tb12 100mg, 200mg $0(Tier 1) MO

theophylline er tb24 $0(Tier 1) MO

theophylline er tb12 100mg, 200mg $0(Tier 1)

theophylline er tb12 300mg, 450mg $0(Tier 1) MO

Pulmonary Antihypertensives

ADEMPAS $0(Tier 2) QL (90 per 30 days) PA

LETAIRIS $0(Tier 2) QL (30 per 30 days) PA

OPSUMIT $0(Tier 2) QL (30 per 30 days) PA

REMODULIN $0(Tier 2) B/D

sildenafil tabs $0(Tier 1) QL (90 per 30 days) PA

TRACLEER $0(Tier 2) QL (60 per 30 days) PA

Respiratory Tract Agents, Other

12 hour decongestant $0(Tier 1) MC

acetylcysteine soln $0(Tier 1) B/D

ALAHIST DM LIQD 4MG/5ML; 15MG/5ML; 7.5MG/5ML $0(Tier 1) MC

all-nite cold & flu nighttime relief $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

all-nite multi-symptom cold/flu relief liqd 325mg/15ml;

15mg/15ml; 6.25mg/15ml

$0(Tier 1) MC

ap-hist dm $0(Tier 1) MC

aprodine $0(Tier 1) MC

ARALAST NP INJ 500MG, 800MG $0(Tier 2) B/D

benzonatate $0(Tier 1) MC

bromfed dm $0(Tier 1) MC

bromphen/pseudoephedrine hcl/dextromethorphan hbr $0(Tier 1) MC

BROTAPP DM $0(Tier 1) MC

cheratussin ac syrp $0(Tier 1) MC

cheratussin dac $0(Tier 1) MC

chest congestion relief $0(Tier 1) MC

chest congestion relief pe $0(Tier 1) MC

childrens silfedrine $0(Tier 1) MC

CHLO TUSS EX $0(Tier 1) MC

chlo tuss liqd 12.5mg/5ml; 1mg/5ml; 30mg/5ml $0(Tier 1) MC

codeine/guaifenesin soln $0(Tier 1) MC

cold/cough dm childrens $0(Tier 1) MC

cough dm $0(Tier 1) MC

cough syrup syrp 100mg/5ml $0(Tier 1) MC

day time multi-symptom cold/flu relief caps $0(Tier 1) MC

DECONEX DMX TABS 15MG; 380MG; 10MG $0(Tier 1) MC

DECONEX IR TABS 380MG; 10MG $0(Tier 1) MC

deep sea nasal spray $0(Tier 1) MC

delsym cough + chest congestion dm $0(Tier 1) MC

delsym cough + chest congestion dm childrens $0(Tier 1) MC

delsym cough + cold daytime $0(Tier 1) MC

delsym cough + cold nighttime $0(Tier 1) MC

delsym cough + cold nighttime childrens $0(Tier 1) MC

DELSYM SUER $0(Tier 1) MC

dextromethorphan polistirex $0(Tier 1) MC

dimaphen dm cold & cough $0(Tier 1) MC

dimaphen dm cold/cough childrens $0(Tier 1) MC

DURAFLU TABS 500MG; 20MG; 200MG; 60MG $0(Tier 1) MC

ed a-hist dm $0(Tier 1) MC

ed bron gp $0(Tier 1) MC

endacof-dm $0(Tier 1) MC

ESBRIET $0(Tier 2) PA

extra action cough $0(Tier 1) MC

FLOWTUSS $0(Tier 1) MC

gnp tussin $0(Tier 1) MC

gnp tussin dm $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

guaiatussin ac $0(Tier 1) MC

guaifenesin ac $0(Tier 1) MC

guaifenesin and pseudoephedrine hydrochloride $0(Tier 1) MC

guaifenesin er $0(Tier 1) MC

guaifenesin/codeine $0(Tier 1) MC

histex-dm $0(Tier 1) MC

histex-pe $0(Tier 1) MC

HYCOFENIX $0(Tier 1) MC

hydrocodone bitartrate/chlorpheniramine maleate/pse $0(Tier 1) MC

hydrocodone bitartrate/homatropine methylbromide $0(Tier 1) MC

hydrocodone polistirex/chlorpheniramine polistirex $0(Tier 1) MC

hydrocodone/homatropine $0(Tier 1) MC

hydromet $0(Tier 1) MC

iophen c-nr $0(Tier 1) MC

iophen dm-nr $0(Tier 1) MC

iophen-nr $0(Tier 1) MC

iosat $0(Tier 1) MC

J-MAX SYRP $0(Tier 1) MC

kidkare cough/cold $0(Tier 1) MC

lohist-dm $0(Tier 1) MC

lortuss dm $0(Tier 1) MC

lortuss ex $0(Tier 1) MC

lortuss lq $0(Tier 1) MC

M-END DMX $0(Tier 1) MC

M-END MAX D $0(Tier 1) MC

mapap cold formula multi-symptom $0(Tier 1) MC

mapap sinus maximum strength congestion and pain $0(Tier 1) MC

mucaphed $0(Tier 1) MC

mucinex chest congestion childrens $0(Tier 1) MC

mucinex childrens cold cough & sore throat $0(Tier 1) MC

mucinex childrens multi-symptom cold $0(Tier 1) MC

MUCINEX CHILDRENS MULTI-SYMPTOM COLD &

FEVER

$0(Tier 1) MC

mucinex congestion & cough childrens $0(Tier 1) MC

mucinex cough childrens $0(Tier 1) MC

MUCINEX COUGH FOR KIDS PACK $0(Tier 1) MC

MUCINEX D $0(Tier 1) MC

MUCINEX D MAXIMUM STRENGTH TB12 1200MG;

120MG

$0(Tier 1) MC

mucinex d maximum strength tb12 1200mg; 120mg $0(Tier 1) MC

MUCINEX DM $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

MUCINEX DM MAXIMUM STRENGTH TB12 60MG;

1200MG

$0(Tier 1) MC

mucinex dm maximum strength tb12 60mg; 1200mg $0(Tier 1) MC

mucinex fast-max cold & sinus tabs $0(Tier 1) MC

MUCINEX FAST-MAX COLD FLU& SORE THROAT

LIQD

$0(Tier 1) MC

mucinex fast-max cold flu& sore throat tabs $0(Tier 1) MC

mucinex fast-max day time/night time misc 650mg/20ml;

20mg/20ml; 25mg/20ml; 400mg/20ml; 10mg/20ml

$0(Tier 1) MC

mucinex fast-max day/night maximum strength $0(Tier 1) MC

mucinex fast-max dm max $0(Tier 1) MC

mucinex fast-max night time cold & flu liqd, tabs $0(Tier 1) MC

mucinex fast-max severe cold $0(Tier 1) MC

mucinex fast-max severe congestion & cough $0(Tier 1) MC

MUCINEX FOR KIDS PACK 100MG $0(Tier 1) MC

mucinex maximum strength $0(Tier 1) MC

mucinex multi-symptom cold day/night pack $0(Tier 1) MC

mucinex multi-symptom cold night time childrens $0(Tier 1) MC

mucinex sinus-max day/night misc $0(Tier 1) MC

mucinex sinus-max full force $0(Tier 1) MC

mucinex sinus-max moisture smart $0(Tier 1) MC

mucinex sinus-max pressure & pain tabs $0(Tier 1) MC

mucinex sinus-max severe congestion relief tabs $0(Tier 1) MC

mucinex stuffy nose & cold childrens $0(Tier 1) MC

MUCINEX TB12 600MG $0(Tier 1) MC

mucinex tb12 600mg $0(Tier 1) MC

mucus relief $0(Tier 1) MC

mucus-er $0(Tier 1) MC

mucusrelief sinus $0(Tier 1) MC

nasal decongestant pe $0(Tier 1) MC

nasal decongestant spray $0(Tier 1) MC

nasal decongestant soln, syrp $0(Tier 1) MC

night time multi-symptom cold/flu relief $0(Tier 1) MC

ninjacof $0(Tier 1) MC

ninjacof-a $0(Tier 1) MC

ninjacof-xg $0(Tier 1) MC

nohist-dm $0(Tier 1) MC

nrs nasal relief $0(Tier 1) MC

organ-i nr $0(Tier 1) MC

pain relief sinus pe daytime $0(Tier 1) MC

pediatric cough/cold $0(Tier 1) MC

phenylephrine hcl/pyrilamine maleate $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

phenylhistine dh $0(Tier 1) MC

POLY-HIST DM $0(Tier 1) MC

poly-vent dm $0(Tier 1) MC

poly-vent ir $0(Tier 1) MC

PROLASTIN-C $0(Tier 2) B/D

promethazine vc/codeine $0(Tier 1) MC

promethazine-dm $0(Tier 1) MC

promethazine/codeine syrp 10mg/5ml; 6.25mg/5ml $0(Tier 1) MC

promethazine/dextromethorphan $0(Tier 1) MC

pseudoephedrine hcl tabs 30mg $0(Tier 1) MC

q-tussin $0(Tier 1) MC

q-tussin dm $0(Tier 1) MC

qc cough/sore throat nighttime $0(Tier 1) MC

RESCON DM $0(Tier 1) MC

RESCON-GG $0(Tier 1) MC

RESPAIRE-30 $0(Tier 1) MC

REZIRA $0(Tier 1) MC

robafen $0(Tier 1) MC

robafen cf cough & cold $0(Tier 1) MC

robafen cf multi-symptom cold $0(Tier 1) MC

robafen cough $0(Tier 1) MC

robafen dm $0(Tier 1) MC

robafen dm cough clear $0(Tier 1) MC

rynex dm $0(Tier 1) MC

siltussin dm das $0(Tier 1) MC

siltussin sa $0(Tier 1) MC

siltussin-dm $0(Tier 1) MC

sm nasal decongestant maximum strength $0(Tier 1) MC

sm nasal spray 12 hour $0(Tier 1) MC

sm tussin $0(Tier 1) MC

sm tussin dm $0(Tier 1) MC

sm tussin dm cough/chest congestion $0(Tier 1) MC

stahist ad $0(Tier 1) MC

STIOLTO RESPIMAT $0(Tier 2)

sudogest $0(Tier 1) MC

sudogest 12 hour $0(Tier 1) MC

sudogest pe $0(Tier 1) MC

tussin dm $0(Tier 1) MC

tussin dm clear $0(Tier 1) MC

TUSSIONEX PENNKINETIC EXTENDED RELEASE $0(Tier 1) MC

TYZINE PEDIATRIC NASAL DROPS $0(Tier 2)

VANACOF $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

VANACOF DM $0(Tier 1) MC

VANACOF-8 $0(Tier 1) MC

VIRAZOLE $0(Tier 2) B/D

virdec dm $0(Tier 1) MC

virtussin a/c $0(Tier 1) MC

XOLAIR $0(Tier 2) PA

ZEMAIRA $0(Tier 2) B/D

zinc mouth/throat lozg 10mg $0(Tier 1) MC

ZONATUSS $0(Tier 1) MC

ZUTRIPRO $0(Tier 1) MC

Skeletal Muscle Relaxants (Drugs that Relax Muscle Cramps or Stiff Muscles)

Skeletal Muscle Relaxants

cyclobenzaprine hcl tabs 10mg, 5mg $0(Tier 1) PA

orphenadrine citrate er $0(Tier 1) PA

Sleep Disorder Agents (Drugs that help with Sleep Problems)

GABA Receptor Modulators

temazepam $0(Tier 1) QL (90 per 365 days) MO

zaleplon $0(Tier 1) QL (90 per 365 days)

zolpidem tartrate tabs $0(Tier 1) PA

Sleep Disorders, Other

armodafinil $0(Tier 1) QL (30 per 30 days) PA

modafinil tabs 100mg $0(Tier 1) QL (30 per 30 days) PA

MO

modafinil tabs 200mg $0(Tier 1) QL (60 per 30 days) PA

MO

NUVIGIL $0(Tier 2) QL (30 per 30 days) PA

ROZEREM $0(Tier 2) QL (30 per 30 days)

SILENOR $0(Tier 2) QL (30 per 30 days) MO

XYREM $0(Tier 2) QL (540 per 30 days) PA

Therapeutic Nutrients/Minerals/Electrolytes (Drugs used to Replace Nutrients, Minerals, and Electrolytes)

Electrolyte/Mineral Modifiers

CHEMET $0(Tier 2)

CUPRIMINE $0(Tier 2)

DEPEN TITRATABS $0(Tier 2)

EXJADE $0(Tier 2) MO

JADENU $0(Tier 2) MO

kionex $0(Tier 1)

SAMSCA TABS 30MG $0(Tier 2) QL (60 per 30 days) PA

SAMSCA TABS 15MG $0(Tier 2) QL (90 per 30 days) PA

sodium bicarbonate partial fill $0(Tier 1)

sodium bicarbonate inj 4.2%, 7.5%, 8.4% $0(Tier 1)

SODIUM LACTATE INJ 5MEQ/ML $0(Tier 2) B/D




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

sodium polystyrene sulfonate powd, oral susp $0(Tier 1)

sodium polystyrene sulfonate rectal susp 30gm/120ml $0(Tier 1)

sps $0(Tier 1)

SYPRINE $0(Tier 2)

Electrolyte/Mineral Replacement

AMINOSYN 7%/ELECTROLYTES $0(Tier 2) B/D

AMINOSYN 8.5%/ELECTROLYTES $0(Tier 2) B/D

AMINOSYN II $0(Tier 2) B/D

AMINOSYN II 8.5%/ELECTROLYTES $0(Tier 2) B/D

AMINOSYN M $0(Tier 2) B/D

AMINOSYN-HBC $0(Tier 2) B/D

AMINOSYN-PF $0(Tier 2) B/D

AMINOSYN-PF 7% $0(Tier 2) B/D

AMINOSYN-RF $0(Tier 2) B/D

AMINOSYN INJ 90MEQ/L; 1100MG/100ML;

850MG/100ML; 35MEQ/L; 1100MG/100ML;

260MG/100ML; 620MG/100ML; 810MG/100ML;

624MG/100ML; 340MG/100ML; 380MG/100ML;

5.4MEQ/L; 750MG/100ML; 370MG/100ML;

460MG/100ML; 150MG/100ML; 44MG/100ML;

680MG/100ML

$0(Tier 2) B/D

baby darlings pediatric electrolyte $0(Tier 1) MC

cal-mag-zinc-d $0(Tier 1) MC

calcet petites $0(Tier 1) MC

calci-chew $0(Tier 1) MC

calcitrate $0(Tier 1) MC

calcium & magnesium $0(Tier 1) MC

calcium + d3 $0(Tier 1) MC

calcium 500 +d3 $0(Tier 1) MC

calcium 500/d chew $0(Tier 1) MC

calcium 500/vitamin d3 $0(Tier 1) MC

calcium 600 $0(Tier 1) MC

calcium 600 + d tabs 600mg; 400unit $0(Tier 1) MC

calcium 600 with vitamin d $0(Tier 1) MC

calcium 600+d $0(Tier 1) MC

calcium 600+d3 tabs 600mg; 400unit, 600mg; 800unit $0(Tier 1) MC

calcium 600-d $0(Tier 1) MC

calcium 600/vitamin d $0(Tier 1) MC

calcium 600/vitamin d3 $0(Tier 1) MC

calcium carbonate/d3 $0(Tier 1) MC

calcium carbonate/vitamin d $0(Tier 1) MC

calcium carbonate chew 500mg $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

calcium carbonate susp, tabs $0(Tier 1) MC

calcium citrate + d $0(Tier 1) MC

calcium citrate + d3 maximum $0(Tier 1) MC

calcium citrate malate/vitamin d $0(Tier 1) MC

calcium citrate maximum/vitamin d $0(Tier 1) MC

calcium citrate w/d $0(Tier 1) MC

calcium citrate+d $0(Tier 1) MC

calcium citrate/vitamin d3 tabs $0(Tier 1) MC

calcium citrate/vitamin d tabs 315mg; 200unit, 315mg;

250unit

$0(Tier 1) MC

calcium citrate tabs 200mg $0(Tier 1) MC

calcium gluconate tabs 500mg $0(Tier 1) MC

calcium high potency $0(Tier 1) MC

calcium high potency + vitamin d $0(Tier 1) MC

calcium oyster shell $0(Tier 1) MC

calcium+d3 $0(Tier 1) MC

calcium/d tabs $0(Tier 1) MC

calcium/magnesium/zinc tabs 1000mg; 1mg; 400mg; 15mg,

333.333mg; 133.333mg; 5mg, 333.33mg; 0.33mg; 133.33mg;

5mg, 333mg; 133mg; 5mg

$0(Tier 1) MC

calcium/vitamin d caps 600mg; 400unit $0(Tier 1) MC

calcium/vitamin d tabs 500mg; 200unit, 500mg; 400unit,

600mg; 200unit, 600mg; 400unit

$0(Tier 1) MC

calcium tabs 500mg, 600mg $0(Tier 1) MC

caltrate 600+d plus minerals tabs $0(Tier 1) MC

caltrate 600+d3 soft chews $0(Tier 1) MC

caltrate 600+d tabs 600mg; 800unit $0(Tier 1) MC

calvite p&d $0(Tier 1) MC

CARBAGLU $0(Tier 2)

centamin $0(Tier 1) MC

centratex $0(Tier 1) MC

citracal + d3 maximum $0(Tier 1) MC

citracal maximum $0(Tier 1) MC

CLINIMIX 2.75%/DEXTROSE 5% $0(Tier 2) B/D





CLINIMIX 5%/DEXTROSE 15% $0(Tier 2) B/D



CLINIMIX E 2.75%/DEXTROSE 10% $0(Tier 2) B/D




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use



CLINIMIX E 5%/DEXTROSE 25% $0(Tier 2) B/D

CLINISOL SF 15% $0(Tier 2) B/D

coral calcium caps 100unit; 185mg; 50mg $0(Tier 1) MC

cvs calcium 600 & vitamind3 $0(Tier 1) MC

cvs calcium 600 + d/minerals $0(Tier 1) MC

cvs calcium 600+d $0(Tier 1) MC

cvs calcium carbonate $0(Tier 1) MC

cvs calcium chewables 600plus $0(Tier 1) MC

cvs calcium citrate + d $0(Tier 1) MC

cvs calcium citrate +d $0(Tier 1) MC

cvs calcium citrate+d/magnesium $0(Tier 1) MC

cvs electrolyte solution $0(Tier 1) MC

cvs iron $0(Tier 1) MC

cvs magnesium $0(Tier 1) MC

cvs oyster shell calcium w/ vit d $0(Tier 1) MC

cvs pediatric electrolyte $0(Tier 1) MC

cvs pediatric electrolyte freezer pops $0(Tier 1) MC

cvs selenium $0(Tier 1) MC

cvs slow release iron $0(Tier 1) MC

cvs zinc $0(Tier 1) MC

DEXTROSE 10%/NACL 0.45% $0(Tier 2) B/D

dextrose 5% /electrolyte #48 viaflex $0(Tier 1) B/D

DEXTROSE 10% $0(Tier 2) B/D


DEXTROSE 2.5%/NACL 0.45% $0(Tier 2) B/D






DEXTROSE 5%/LACTATED RINGERS $0(Tier 2)







DEXTROSE 5%/POTASSIUM CHLORIDE 0.15% $0(Tier 2) B/D






Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

duofer $0(Tier 1) MC

enlyte $0(Tier 1) MC

eql pediatric electrolyte $0(Tier 1) MC

ezfe 200 $0(Tier 1) MC

fe c $0(Tier 1) MC

fe c tab $0(Tier 1) MC

feosol bifera $0(Tier 1) MC

feosol tabs 200mg $0(Tier 1) MC

fer-in-sol $0(Tier 1) MC

fer-iron $0(Tier 1) MC

ferate $0(Tier 1) MC

fergon tabs 240mg $0(Tier 1) MC

feriva 21/7 $0(Tier 1) MC

ferivafa $0(Tier 1) MC

ferosul $0(Tier 1) MC

ferralet 90 $0(Tier 1) MC

ferraplus 90 $0(Tier 1) MC

ferretts $0(Tier 1) MC

ferretts ips $0(Tier 1) MC

ferrex 150 $0(Tier 1) MC

ferrex 150 forte $0(Tier 1) MC

ferric x-150 $0(Tier 1) MC

ferrimin 150 $0(Tier 1) MC

ferrocite $0(Tier 1) MC

ferrous drops $0(Tier 1) MC

ferrous fumarate 324 $0(Tier 1) MC

ferrous gluconate tabs 240mg, 324mg, 325mg $0(Tier 1) MC

ferrous sulfate elix, liqd, soln, syrp, tbcr, tbec $0(Tier 1) MC

ferrous sulfate tabs 325mg $0(Tier 1) MC

ferrousul $0(Tier 1) MC

fluoride chew 0.25mg, 1.1mg, 2.2mg $0(Tier 1)

fluoritab chew 0.5mg, 1mg $0(Tier 1)

focalgin dss $0(Tier 1) MC

FREAMINE HBC 6.9% $0(Tier 2) B/D

FREAMINE III INJ 89MEQ/L; 710MG/100ML;

950MG/100ML; 3MEQ/L; 24MG/100ML; 1400MG/100ML;

280MG/100ML; 690MG/100ML; 910MG/100ML;

730MG/100ML; 530MG/100ML; 560MG/100ML;

10MMOLE/L; 120MG/100ML; 1120MG/100ML;

590MG/100ML; 10MEQ/L; 400MG/100ML; 150MG/100ML;

660MG/100ML

$0(Tier 2) B/D

fusion $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

fusion plus $0(Tier 1) MC

gnp calcium $0(Tier 1) MC

gnp calcium 1200 $0(Tier 1) MC

gnp calcium 500 +d3 $0(Tier 1) MC

gnp calcium 500/d $0(Tier 1) MC

gnp calcium 600/d $0(Tier 1) MC

gnp calcium citrate +d3 $0(Tier 1) MC

gnp calcium citrate+d maximum $0(Tier 1) MC

gnp calcium/magnesium/zinc $0(Tier 1) MC

gnp calcuim/vitamin d/minerals $0(Tier 1) MC

gnp iron tbcr $0(Tier 1) MC

gnp iron tabs 200mg $0(Tier 1) MC

gnp magnesium tabs 250mg; 0; 0 $0(Tier 1) MC

gnp niacin tr $0(Tier 1) MC

gnp pediatric electrolyte $0(Tier 1) MC

gnp therapeutic-m $0(Tier 1) MC

gnp vitamin b-12 $0(Tier 1) MC

gnp vitamin b-12 tr $0(Tier 1) MC

gnp vitamin b-6 $0(Tier 1) MC

gnp vitamin c drops $0(Tier 1) MC

gnp vitamin c chew 500mg, 500mg; 0 $0(Tier 1) MC

gnp vitamin c tabs 1000mg, 250mg $0(Tier 1) MC

gnp vitamin e $0(Tier 1) MC

gnp zinc $0(Tier 1) MC

h-e-b oral electrolyte solution $0(Tier 1) MC

hemocyte $0(Tier 1) MC

hemocyte plus $0(Tier 1) MC

hemocyte-f tabs $0(Tier 1) MC

HEPATAMINE $0(Tier 2) B/D

hm pediatric electrolyte $0(Tier 1) MC

i.l.x. b-12 $0(Tier 1) MC

icar pediatric $0(Tier 1) MC

icar-c $0(Tier 1) MC

iferex 150 $0(Tier 1) MC

infed $0(Tier 1) MC

iron tabs 256mg, 27mg, 325mg $0(Tier 1) MC

irospan 24/6 $0(Tier 1) MC

k-sol $0(Tier 1)

KABIVEN $0(Tier 2) B/D

KCL 0.075%/D5W/NACL 0.45% $0(Tier 2) B/D

kcl 0.15%/d5w/ nacl 0.3% $0(Tier 1) B/D

KCL 0.15%/D5W/LR $0(Tier 2) B/D




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use


kcl 0.15%/d5w/nacl 0.225% $0(Tier 1) B/D



KCL 0.3%/D5W/LR IV LAC RING $0(Tier 2) B/D



klor-con $0(Tier 1) MO

klor-con 10 $0(Tier 1)

klor-con 8 $0(Tier 1)

klor-con m10 $0(Tier 1) MO

klor-con m20 $0(Tier 1)

klor-con sprinkle $0(Tier 1)

kp ferrous gluconate $0(Tier 1) MC

kp ferrous sulfate $0(Tier 1) MC

LACTATED RINGERS VIAFLEX $0(Tier 2)

LACTATED RINGERS INJ 3MEQ/L; 109MEQ/L;

28MEQ/L; 4MEQ/L; 130MEQ/L

$0(Tier 2)

liquid calcium/vitamin d $0(Tier 1) MC

ludent $0(Tier 1)

mag-tab sr $0(Tier 1) MC

magnesium 27 $0(Tier 1) MC

magnesium elemental $0(Tier 1) MC

magnesium sulfate in d5w $0(Tier 1) B/D

magnesium sulfate inj $0(Tier 1) B/D

magnesium tabs 250mg, 500mg $0(Tier 1) MC

monocal $0(Tier 1) MC

MOZOBIL $0(Tier 2) QL (9.6 per 30 days)

myferon 150 $0(Tier 1) MC

natalvirt flt $0(Tier 1) MC

NEPHRAMINE $0(Tier 2) B/D

nephron fa $0(Tier 1) MC

NORMOSOL -R $0(Tier 2) B/D

NORMOSOL-M IN D5W $0(Tier 2) B/D

NORMOSOL-R $0(Tier 2) B/D

NORMOSOL-R IN D5W $0(Tier 2) B/D

NOVAFERRUM 125 $0(Tier 1) MC

NOVAFERRUM 50 $0(Tier 1) MC

NOVAFERRUM PEDIATRIC DROPS $0(Tier 1) MC

nu-iron 150 $0(Tier 1) MC

nu-mag $0(Tier 1) MC

NUTRILYTE II $0(Tier 2) B/D




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

NUTRILYTE INJ 2.03MEQ/ML; 0.25MEQ/ML;

1.68MEQ/ML; 0.25MEQ/ML; 0.4MEQ/ML; 2.03MEQ/ML;

1.25MEQ

$0(Tier 2) B/D

oceanic selenium $0(Tier 1) MC

oralyte $0(Tier 1) MC

oralyte freezer pops $0(Tier 1) MC

orazinc $0(Tier 1) MC

os-cal $0(Tier 1) MC

os-cal calcium + d3 $0(Tier 1) MC

os-cal extra d3 $0(Tier 1) MC

os-cal ultra $0(Tier 1) MC

osteo-poretical $0(Tier 1) MC

oysco 500 $0(Tier 1) MC

oysco 500+d tabs $0(Tier 1) MC

oysco d $0(Tier 1) MC

oyst-cal-d 500 $0(Tier 1) MC

oyster calcium $0(Tier 1) MC

oyster shell calcium + d $0(Tier 1) MC

oyster shell calcium + d3 $0(Tier 1) MC

oyster shell calcium + vitamin d $0(Tier 1) MC

oyster shell calcium 250+d $0(Tier 1) MC

oyster shell calcium 500 $0(Tier 1) MC

oyster shell calcium 500 + d tabs 500mg; 125unit $0(Tier 1) MC

oyster shell calcium 500+d $0(Tier 1) MC

oyster shell calcium 500/d $0(Tier 1) MC

oyster shell calcium plusvitamin d $0(Tier 1) MC

oyster shell calcium+d $0(Tier 1) MC

oyster shell calcium/d3 $0(Tier 1) MC

oyster shell calcium/d tabs 250mg; 125unit, 500mg; 200unit $0(Tier 1) MC

oyster shell calcium/vitamin d $0(Tier 1) MC

oyster shell calcium tabs 500mg $0(Tier 1) MC

oystercal-d $0(Tier 1) MC

pedialyte advanced care $0(Tier 1) MC

pedialyte freezer pops $0(Tier 1) MC

pedialyte singles soln 7meq/200ml; 5.3gm/200ml;

4meq/200ml; 9meq/200ml; 1.6mg/200ml, 8.3meq/240ml;

7.1meq/240ml; 4.7gm/240ml; 1.2gm/240ml; 4.7meq/240ml;

10.6meq/240ml

$0(Tier 1) MC

pedialyte soln 2.1meq/59ml; 1.5gm/59ml; 1.2meq/59ml;

2.7meq/59ml; 0.5mg/59ml, 35meq/l; 20gm/l; 5gm/l; 20meq/l;

45meq/l, 35meq/l; 25gm/l; 20meq/l; 45meq/l; 7.8mg/l,

35meq/l; 30meq/l; 25gm/l; 20meq/l; 45meq/l

$0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

pediatric electrolyte $0(Tier 1) MC

pediatric electrolyte freeze pops $0(Tier 1) MC

pediatric electrolyte freezer pops soln 35meq/1000ml;

25gm/1000ml; 20meq/1000ml; 45meq/1000ml

$0(Tier 1) MC

pediatric electrolyte/zinc $0(Tier 1) MC

PERIKABIVEN $0(Tier 2) B/D

phospha 250 neutral $0(Tier 1)

PLENAMINE $0(Tier 2) B/D

poly-iron 150 $0(Tier 1) MC

polysacc iron 150 complex $0(Tier 1) MC

potassium chloride 0.15% /nacl 0.45% viaflex $0(Tier 1) B/D

potassium chloride 0.15% d5w/nacl 0.33% $0(Tier 1) B/D


potassium chloride 0.15% d5w/nacl 0.45% viaflex $0(Tier 1) B/D

potassium chloride 0.15% w/nacl 0.9% viaflex $0(Tier 1) B/D

potassium chloride 0.15%/d5w $0(Tier 1) B/D

potassium chloride 0.15%/nacl 0.9% $0(Tier 1) B/D


potassium chloride 0.224%/d5w/nacl 0.45% $0(Tier 1) B/D

potassium chloride 0.3%/ nacl 0.9% $0(Tier 1) B/D

potassium chloride 0.3%/d5w $0(Tier 1) B/D

potassium chloride 0.3%/nacl 0.9%/viaflex $0(Tier 1) B/D

potassium chloride cr tbcr 10meq $0(Tier 1)

potassium chloride cr tbcr 10meq $0(Tier 1) MO

potassium chloride er cpcr $0(Tier 1) MO

potassium chloride er tbcr 10meq, 20meq, 8meq $0(Tier 1)

potassium chloride er tbcr 10meq, 20meq $0(Tier 1) MO

potassium chloride sr tbcr 8meq $0(Tier 1)

potassium chloride sr tbcr 8meq $0(Tier 1) MO

potassium chloride oral soln $0(Tier 1)

potassium chloride pack $0(Tier 1) MO

POTASSIUM CHLORIDE INJ 10MEQ/100ML,

20MEQ/100ML, 40MEQ/100ML

$0(Tier 2) B/D

potassium chloride inj 2meq/ml $0(Tier 1) B/D

potassium citrate er $0(Tier 1)

PREMASOL $0(Tier 2) B/D

probarimin qt $0(Tier 1) MC

PROCALAMINE $0(Tier 2) B/D

profe $0(Tier 1) MC

proferrin es $0(Tier 1) MC

PROSOL $0(Tier 2) B/D

qc calcium fast dissolution $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

ra calcium 600 $0(Tier 1) MC

ra calcium 600/vit d/minerals $0(Tier 1) MC

ra calcium citrate plus vitamin d-3 $0(Tier 1) MC

ra central-vite cardio $0(Tier 1) MC

ra central-vite performance $0(Tier 1) MC

ra central-vite under 50 mens $0(Tier 1) MC

ra central-vite under 50 womens $0(Tier 1) MC

ra central-vite womens mature $0(Tier 1) MC

ra natural magnesium $0(Tier 1) MC

ra pediatric electrolyte freezer pops $0(Tier 1) MC

ra pediatric electrolyte soln 35meq/l; 20gm/l; 5gm/l; 20meq/l;

45meq/l, 35meq/l; 25gm/l; 20meq/l; 45meq/l; 7.8mg/l,

35meq/l; 30meq/l; 20gm/l; 5gm/l; 20meq/l; 45meq/l, 35meq/l;

30meq/l; 25gm/l; 20meq/l; 45meq/l

$0(Tier 1) MC

ra selenium natural $0(Tier 1) MC

ra selenium tabs 50mcg $0(Tier 1) MC

ra slow release iron $0(Tier 1) MC

ra zinc $0(Tier 1) MC

RINGERS INJECTION $0(Tier 2)

sb pediatric electrolyte $0(Tier 1) MC

se-tan plus $0(Tier 1) MC

selenium tbcr $0(Tier 1) MC

selenium tabs 200mcg, 50mcg $0(Tier 1) MC

slow fe $0(Tier 1) MC

slow release iron tbcr 45mg $0(Tier 1) MC

slow-mag $0(Tier 1) MC

sm balanced b-50 $0(Tier 1) MC

sm calcium 500/vitamin d3 $0(Tier 1) MC

sm calcium 600/vitamin d $0(Tier 1) MC

sm calcium citrate w/vitamin d3 $0(Tier 1) MC

sm calcium soft chews $0(Tier 1) MC

sm calcium/magnesium/zinc tabs 333mg; 133mg; 5mg $0(Tier 1) MC

sm calcium/vitamin d tabs 600mg; 400unit $0(Tier 1) MC

sm complete $0(Tier 1) MC

sm complete advanced formula $0(Tier 1) MC

sm complete senior formula $0(Tier 1) MC

sm iron tabs 325mg $0(Tier 1) MC

sm magnesium $0(Tier 1) MC

sm multiple vitamins essential $0(Tier 1) MC

sm multiple vitamins/iron $0(Tier 1) MC

sm oyster shell calcium/vitamin d3 $0(Tier 1) MC

sm oyster shell calcium/vitamin d tabs 500mg; 400unit $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

sm pediatric electrolyte $0(Tier 1) MC

sm selenium $0(Tier 1) MC

sm slow release iron $0(Tier 1) MC

sm vit c/rose hips $0(Tier 1) MC

sm vitamin b-12 $0(Tier 1) MC

sm vitamin b-6 $0(Tier 1) MC

sm vitamin c $0(Tier 1) MC

sm vitamin e $0(Tier 1) MC

sm vitamin e blended $0(Tier 1) MC

sm zinc $0(Tier 1) MC

SODIUM CHLORIDE 0.45% $0(Tier 2)

SODIUM CHLORIDE INJ 0.9%, 2.5MEQ/ML, 3%, 5% $0(Tier 2)

sodium fluoride chew 0.5mg, 1mg $0(Tier 1)

sodium fluoride tabs 1mg $0(Tier 1)

super calcium 600 + d3 $0(Tier 1) MC

super calcium 600+d 400 $0(Tier 1) MC

super calcium 600+d3 400 $0(Tier 1) MC

super calcium tabs 600mg $0(Tier 1) MC

support $0(Tier 1) MC

TANDEM $0(Tier 1) MC

tandem plus $0(Tier 1) MC

taron forte $0(Tier 1) MC

th calcium $0(Tier 1) MC

th calcium 600 with vitamin d $0(Tier 1) MC

th calcium 600/vitamin d $0(Tier 1) MC

th calcium citrate/vitamin d $0(Tier 1) MC

th iron $0(Tier 1) MC

th oyster shell calcium/vitamin d $0(Tier 1) MC

th zinc $0(Tier 1) MC

therapeutic liquid $0(Tier 1) MC

theratrum complete tabs 60mg; 0; 30mcg; 150mcg; 162mg;

10mg; 72mg; 400unit; 120mcg; 2mg; 6mcg; 18mg; 400mcg;

150mcg; 250mcg; 100mg; 2mg; 20mg; 5mcg; 108mg; 80mg;

2mg; 1.7mg; 2mg; 10mcg; 75mcg; 20mcg; 10mcg; 1.5mg;

30unit; 5000unit; 25mcg; 15mg

$0(Tier 1) MC

totalday multiple $0(Tier 1) MC

TPN ELECTROLYTES $0(Tier 2) B/D

TRAVASOL $0(Tier 2) B/D

TROPHAMINE $0(Tier 2) B/D

virt-phos 250 neutral $0(Tier 1)

wee care $0(Tier 1) MC

zinc 15 $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

zinc chelated tabs 50mg $0(Tier 1) MC

zinc gluconate tabs 100mg, 30mg, 50mg $0(Tier 1) MC

zinc sulfate caps $0(Tier 1) MC

zinc sulfate tabs 220mg $0(Tier 1) MC

zinc-220 $0(Tier 1) MC

zinc oral lozg 100mg; 50mg; 500unit; 15mg $0(Tier 1) MC

zinc tabs 30mg, 50mg $0(Tier 1) MC

Therapeutic Nutrients/Minerals/Electrolytes

INTRALIPID INJ 20GM/100ML $0(Tier 2) B/D

NUTRILIPID $0(Tier 2) B/D

Vitamins

a-10000 $0(Tier 1) MC

abaneu-sl $0(Tier 1) MC

abc plus senior adults 50+ $0(Tier 1) MC

acerola c 500 $0(Tier 1) MC

actical $0(Tier 1) MC

active fe $0(Tier 1) MC

advanced stress formula/zinc $0(Tier 1) MC

alba-lybe nr $0(Tier 1) MC

animal chews chew 60mg; 0; 400unit; 4.5mcg; 300mcg;

10mg; 1.05mg; 1.2mg; 0; 1.05mg; 15unit; 1998unit

$0(Tier 1) MC

animal shapes + iron $0(Tier 1) MC

animal shapes chew 60mg; 0; 4.5mcg; 400unit; 300mcg;

13.5mg; 1.05mg; 1.2mg; 1.05mg; 15unit; 2500unit

$0(Tier 1) MC

antioxidant formula caps 250mg; 5000unit; 1mg; 1.5mg;

15mcg; 200unit; 7.5mg

$0(Tier 1) MC

apatate forte $0(Tier 1) MC

apetex $0(Tier 1) MC

apetigen $0(Tier 1) MC

apetigen-plus $0(Tier 1) MC

aquadeks $0(Tier 1) MC

aqueous vitamin d infants $0(Tier 1) MC

aqueous vitamin e $0(Tier 1) MC

ascorbic acid powd $0(Tier 1) MC

ascorbic acid tabs 250mg, 500mg $0(Tier 1) MC

b complete $0(Tier 1) MC

b complex/c tabs 300mg; 150mg; 10mg; 50mg; 5mg; 10.2mg;

15mg

$0(Tier 1) MC

b complex/folic acid $0(Tier 1) MC

b complex caps 5mg; 1mcg; 60mg; 20mg; 0.5mg; 3mg; 3mg;

60mg

$0(Tier 1) MC

b complex tabs $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

b-12 tr $0(Tier 1) MC

b-12 tbcr $0(Tier 1) MC

b-12 subl 2500mcg $0(Tier 1) MC

b-12 tabs 100mcg, 500mcg, 50mcg $0(Tier 1) MC

b-1 tabs 100mg, 250mg $0(Tier 1) MC

b-2 $0(Tier 1) MC

b-50 complex tbcr 50mcg; 50mg; 50mcg; 400mcg; 50mcg;

50mg; 50mg; 30mg; 50mg; 50mg; 50mg

$0(Tier 1) MC

b-6 tabs 100mg, 50mg $0(Tier 1) MC

b-complex formula 1 $0(Tier 1) MC

b-complex plus vitamin c $0(Tier 1) MC

b-complex w/c tabs $0(Tier 1) MC

b-complex with b-12 $0(Tier 1) MC

b-complex caps 5mg; 1mcg; 400mcg; 60mg; 20mg; 0.5mg;

3mg; 3mg; 60mg, 5mg; 1mcg; 60mg; 20mg; 0.5mg; 3mg;

3mg; 60mg

$0(Tier 1) MC

b-plex plus $0(Tier 1) MC

bacmin $0(Tier 1) MC

balance b-100 $0(Tier 1) MC

balance b-50 $0(Tier 1) MC

balanced b-100 tabs 100mcg; 100mg; 100mcg; 100mcg;

100mg; 100mg; 100mg; 100mg; 100mg; 100mg; 100mg

$0(Tier 1) MC

balanced b-50 complex tabs $0(Tier 1) MC

balanced b-50 tabs 50mcg; 50mg; 50mcg; 100mcg; 50mg;

50mg; 50mg; 50mg; 50mg; 50mg; 50mg

$0(Tier 1) MC

bee zee $0(Tier 1) MC

beta carotene caps 25000unit $0(Tier 1) MC

biocal $0(Tier 1) MC

biosupp $0(Tier 1) MC

biotin 5000 $0(Tier 1) MC

biotin/maximum strength $0(Tier 1) MC

biotin caps 2500mcg, 5000mcg $0(Tier 1) MC

biotin tabs 1000mcg, 300mcg $0(Tier 1) MC

biovol $0(Tier 1) MC

c 1000 $0(Tier 1) MC

c 1000/bioflavonoids/rosehips $0(Tier 1) MC

c 250 tabs $0(Tier 1) MC

c 500 $0(Tier 1) MC

c 500/rose hips tabs 500mg; 37mg $0(Tier 1) MC

c complex $0(Tier 1) MC

c-1000 $0(Tier 1) MC

c-1000 prolonged release $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

c-1000/rose hips tabs 1000mg; 37mg $0(Tier 1) MC

c-250 tabs $0(Tier 1) MC

c-500 $0(Tier 1) MC

c-500 prolonged release $0(Tier 1) MC

c-500/rose hips tabs 500mg; 37mg $0(Tier 1) MC

calcium/c/d $0(Tier 1) MC

centravites $0(Tier 1) MC

centrum adults $0(Tier 1) MC

centrum kids complete $0(Tier 1) MC

centrum silver adult 50+ $0(Tier 1) MC

centrum silver ultra womens $0(Tier 1) MC

centrum silver tabs 60mg; 0; 30mcg; 220mg; 10mg; 72mg;

500unit; 45mcg; 0.5mg; 25mcg; 400mcg; 0; 0; 50mg; 2.3mg;

20mg; 5mcg; 20mg; 30mcg; 80mg; 150mcg; 3mg; 1.7mg;

2mg; 150mcg; 10mcg; 45mcg; 55mcg; 1.5mg; 50unit;

2500unit; 11mg

$0(Tier 1) MC

centrum specialist heart $0(Tier 1) MC

centrum ultra mens $0(Tier 1) MC

centrum chew $0(Tier 1) MC

centrum liqd 0; 60mg/15ml; 300mcg/15ml; 400unit/15ml;

25mcg/15ml; 6mcg/15ml; 0; 150mcg/15ml; 9mg/15ml;

2mg/15ml; 25mcg/15ml; 20mg/15ml; 10mg/15ml; 0;

2mg/15ml; 1.7mg/15ml; 0; 1.1mg/15ml; 1300unit/15ml;

30unit/15ml; 3mg/15ml

$0(Tier 1) MC

cerovite advanced formula $0(Tier 1) MC

cerovite jr $0(Tier 1) MC

certa plus tabs 90mg; 0; 30mcg; 10mg; 200mg; 72mg;

400unit; 35mcg; 0.9mg; 6mcg; 18mg; 500mcg; 250mcg;

300mcg; 100mg; 2.3mg; 20mg; 5mcg; 109mg; 25mcg; 80mg;

150mcg; 2mg; 1.7mg; 2mg; 150mcg; 10mcg; 45mcg; 55mcg;

10mcg; 1.5mg; 30unit; 3500unit; 11mg

$0(Tier 1) MC

certavite senior/antioxidant nutrients $0(Tier 1) MC

certavite/antioxidants $0(Tier 1) MC

chewable vitamin c chew 500mg $0(Tier 1) MC

chewable vite childrens $0(Tier 1) MC

chewable vite with iron/childrens $0(Tier 1) MC

childrens chewable multivitamin $0(Tier 1) MC

childrens chewable vitamin $0(Tier 1) MC

childrens chewable vitamins $0(Tier 1) MC

childrens chewable vitamins/iron chew 400unit; 4.5mcg;

15mg; 0.3mg; 13.5mg; 1.05mg; 1.2mg; 60mg; 1.05mg;

15unit; 2500unit

$0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

citrus calcium +d $0(Tier 1) MC

companion $0(Tier 1) MC

compete $0(Tier 1) MC

complete $0(Tier 1) MC

complex b-100 tbcr 100mcg; 100mg; 100mg; 100mcg;

200mcg; 100mg; 100mg; 100mg; 100mg; 100mg; 100mg

$0(Tier 1) MC

corvita $0(Tier 1) MC

corvite $0(Tier 1) MC

corvite 150 $0(Tier 1) MC

corvite fe tabs 160mg; 5mg; 1000unit; 10mg; 15mg; 1mg;

150mg; 10mg; 25mg

$0(Tier 1) MC

corvite free $0(Tier 1) MC

cranberry urinary comfort $0(Tier 1) MC

cvs b complex plus c $0(Tier 1) MC

cvs b-1 $0(Tier 1) MC

cvs b-12 liqd, tabs $0(Tier 1) MC

cvs b-6 $0(Tier 1) MC

cvs balanced b-100 $0(Tier 1) MC

cvs balanced b-50 $0(Tier 1) MC

cvs beta carotene $0(Tier 1) MC

cvs biotin high potency $0(Tier 1) MC

cvs biotin caps 5000mcg $0(Tier 1) MC

cvs calcium $0(Tier 1) MC

cvs calcium/magnesium/zinc $0(Tier 1) MC

cvs childrens chewable complete $0(Tier 1) MC

cvs childrens chewable multivitamin/iron $0(Tier 1) MC

cvs daily energy $0(Tier 1) MC

cvs daily multiple $0(Tier 1) MC

cvs daily multiple for men $0(Tier 1) MC

cvs daily multiple for men 50+ $0(Tier 1) MC

cvs daily multiple for women $0(Tier 1) MC

cvs daily multiple for women 50+ $0(Tier 1) MC

cvs daily multiple plus iron/calcium/zinc $0(Tier 1) MC

cvs e oil $0(Tier 1) MC

cvs gummy dinos chew 30mg; 75mcg; 5mg; 200unit; 38mg;

5mcg; 200mcg; 20mcg; 40mcg; 1mg; 20unit; 2000unit; 2.5mg

$0(Tier 1) MC

cvs hair skin & nails/an tioxidants $0(Tier 1) MC

cvs spectravite adult 50+ tabs $0(Tier 1) MC

cvs spectravite advanced formula $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

cvs spectravite senior tabs 60mg; 0; 30mcg; 150mcg; 220mg;

10mg; 20mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg; 400mcg;

250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 30mcg; 80mg;

150mcg; 3mg; 1.7mg; 2mg; 10mcg; 45mcg; 55mcg; 1.5mg;

50unit; 2500unit; 11mg

$0(Tier 1) MC

cvs spectravite ultra health mens $0(Tier 1) MC

cvs spectravite ultra mens health $0(Tier 1) MC

cvs spectravite ultra women $0(Tier 1) MC

cvs spectravite ultra womens health $0(Tier 1) MC

cvs spectravite ultra womens health senior $0(Tier 1) MC

cvs super b complex/c $0(Tier 1) MC

cvs vitamin a $0(Tier 1) MC

cvs vitamin b-12 $0(Tier 1) MC

cvs vitamin b-12 tr $0(Tier 1) MC

cvs vitamin b-6 $0(Tier 1) MC

cvs vitamin c/rose hips $0(Tier 1) MC

cvs vitamin c chew $0(Tier 1) MC

cvs vitamin c tabs 1000mg, 500mg $0(Tier 1) MC

cvs vitamin e $0(Tier 1) MC

daily combo multi vitamin $0(Tier 1) MC

daily multiple vitamin/iron tabs 3mcg; 250mg; 30mg; 2mg;

0.5mg; 5mg; 75mg; 5mg

$0(Tier 1) MC

daily multiple vitamins $0(Tier 1) MC

daily multiple vitamin tabs 60mg; 0; 45mg; 10mg; 400unit;

6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 3000unit

$0(Tier 1) MC

daily value multivitamin $0(Tier 1) MC

daily vitamin $0(Tier 1) MC

daily vitamin formula+ir on $0(Tier 1) MC

daily vitamin formula+iron tabs 60mg; 13mg; 10mg; 400unit;

6mcg; 18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 15unit;

5000unit

$0(Tier 1) MC

daily vitamin formula+minerals tabs 50mg; 1mg; 15.8mg;

400unit; 5mcg; 1mcg; 4.5mg; 10mg; 1mg; 20mg; 11.6mg;

150mcg; 1mg; 2.5mg; 5mcg; 2mg; 5000unit; 3.75mg

$0(Tier 1) MC

daily vitamins $0(Tier 1) MC

daily vite $0(Tier 1) MC

daily vite with iron $0(Tier 1) MC

daily-vite/iron/beta-carotene $0(Tier 1) MC

daily-vite tabs 60mg; 0; 45mg; 0; 10mg; 0; 400unit; 6mcg;

400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 3000unit, 60mg;

400unit; 6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 5000unit

$0(Tier 1) MC

dekas essential caps $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

dekas plus caps, liqd $0(Tier 1) MC

dialyvite 800 $0(Tier 1) MC

dialyvite 800/iron $0(Tier 1) MC

dino-life $0(Tier 1) MC

dino-life w extra c $0(Tier 1) MC

dino-life w/iron & zinc $0(Tier 1) MC

DRISDOL CAPS $0(Tier 1) MC

e-400 $0(Tier 1) MC

e-oil $0(Tier 1) MC

e400 mixed $0(Tier 1) MC

ecee plus $0(Tier 1) MC

eql one daily essential tabs 60mg; 0; 6mcg; 400mcg; 20mg;

10mg; 2mg; 1.7mg; 1.5mg; 5000unit; 400unit; 30unit

$0(Tier 1) MC

ergocalciferol soln $0(Tier 1) MC

essentia $0(Tier 1) MC

essential balance $0(Tier 1) MC

flintstones complete chew 0; 40mcg; 10mg; 100mg; 400unit;

38mg; 2mg; 6mcg; 18mg; 400mcg; 20mg; 15mg; 100mg;

150mcg; 2mg; 1.7mg; 60mg; 1.5mg; 3000unit; 30unit; 12mg,

60mg; 0; 40mcg; 100mg; 10mg; 38mg; 2mg; 6mcg; 18mg;

400mcg; 20mg; 15mg; 100mg; 150mcg; 2mg; 1.7mg; 10mg;

1.5mg; 3000unit; 400unit; 30unit; 12mg

$0(Tier 1) MC

flintstones plus extra c $0(Tier 1) MC

flintstones/my first $0(Tier 1) MC

folic acid inj $0(Tier 1) MC

folic acid tabs 1mg $0(Tier 1) MC

folitab 500 $0(Tier 1) MC

foltabs 800 $0(Tier 1) MC

fortavit caps $0(Tier 1) MC

fosfree $0(Tier 1) MC

fruit c 500 $0(Tier 1) MC

fruity c $0(Tier 1) MC

fruity chewables multivitamin $0(Tier 1) MC

full spectrum b/vitamin c $0(Tier 1) MC

gnp animal shapes $0(Tier 1) MC

gnp animal shapes plus extra c $0(Tier 1) MC

gnp animal shapes plus iron $0(Tier 1) MC

gnp b-50 balanced tabs 50mcg; 50mg; 50mcg; 400mcg;

50mg; 50mg; 50mg; 50mg

$0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

gnp century adults 50+ senior tabs 60mg; 0; 30mcg; 220mg;

10mg; 20mg; 72mg; 500unit; 45mcg; 0.5mg; 25mcg; 400mcg;

250mcg; 300mcg; 50mg; 2.3mg; 20mg; 5mcg; 30mcg; 80mg;


1.5mg; 50unit; 2500unit; 11mg

$0(Tier 1) MC

gnp century cardio healthformula tabs 90mg; 0; 30mcg;

40mg; 10mg; 7.5mg; 400unit; 50mcg; 2mg; 12mcg; 9mg;

400mcg; 100mg; 2mg; 20mg; 5mcg; 31mg; 28mcg; 7.5mg;


10mcg; 3mg; 60unit; 5000unit; 15mg

$0(Tier 1) MC

gnp century ultimate mens complete $0(Tier 1) MC

gnp century ultimate womens complete $0(Tier 1) MC

gnp century ultimate womens senior formula $0(Tier 1) MC

gnp century tabs 60mg; 0; 30mcg; 200mg; 10mg; 72mg;

400unit; 35mcg; 0.5mg; 6mcg; 18mg; 400mcg; 50mg; 2.3mg;

20mg; 5mcg; 20mg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg;

2mg; 75mcg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit;

3500unit; 11mg

$0(Tier 1) MC

gnp childrens chewables/extra c $0(Tier 1) MC

gnp childrens chewables/iron $0(Tier 1) MC

gnp essential one daily tabs 60mg; 0; 75mg; 10mg; 400unit;

6mcg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit

$0(Tier 1) MC

gnp hair/skin/nails tabs 60mg; 1250mcg; 0.5mg; 100mg;

100unit; 50mg; 30unit; 1mg; 100mcg; 50mg; 250mcg; 25mg;

50mg; 10mg; 50mg; 0.85mg; 0.75mg; 2500unit; 7.5mg

$0(Tier 1) MC

gnp little ones childrens $0(Tier 1) MC

gnp mega multi for men $0(Tier 1) MC

gnp mega multi for women $0(Tier 1) MC

gnp one daily maximum $0(Tier 1) MC

gnp one daily mens health 50+ $0(Tier 1) MC

gnp one daily plus iron tabs 60mg; 75mg; 10mg; 400unit;

6mcg; 18mg; 400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit;

5000unit

$0(Tier 1) MC

gnp one daily womens health 50+ $0(Tier 1) MC

gnp opti-vitamins tabs 200mg; 1000unit; 2mg; 2mg; 55mcg;

60unit; 40mg

$0(Tier 1) MC

gnp vitamin a caps 8000unit $0(Tier 1) MC

gnp vitamin c tr $0(Tier 1) MC

gnp vitamin c w/rose hips tr $0(Tier 1) MC

gnp vitamin c w/rose hips tabs 500mg $0(Tier 1) MC

gnp vitamin c tabs 500mg $0(Tier 1) MC

gnp zoochews gummies $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

halls defense vitamin c drops $0(Tier 1) MC

hard nails $0(Tier 1) MC

honey bears $0(Tier 1) MC

honey bears w/iron and zinc $0(Tier 1) MC

icaps areds formula $0(Tier 1) MC

icaps mv $0(Tier 1) MC

icaps plus $0(Tier 1) MC

integra $0(Tier 1) MC

integra f $0(Tier 1) MC

integra plus $0(Tier 1) MC

iron 100/c $0(Tier 1) MC

iron supplement childrens $0(Tier 1) MC

iron tabs 27mg $0(Tier 1) MC

kobee $0(Tier 1) MC

kp adults 50+ daily formula $0(Tier 1) MC

kp adults daily formula $0(Tier 1) MC

kp b complex/c $0(Tier 1) MC

kp mens 50+ daily formula $0(Tier 1) MC

kp mens daily formula $0(Tier 1) MC

kp vitamin e $0(Tier 1) MC

kp womens 50+ daily formula $0(Tier 1) MC

kp womens daily formula $0(Tier 1) MC

l-methyl-b6-b12 $0(Tier 1) MC

life pack mens $0(Tier 1) MC

life pack womens $0(Tier 1) MC

lysiplex plus liqd $0(Tier 1) MC

mega multiple w/chelated minerals $0(Tier 1) MC

mega multivitamin for men $0(Tier 1) MC

mega multivitamin for women $0(Tier 1) MC

MEPHYTON $0(Tier 1) MC

meribin $0(Tier 1) MC

mtx support $0(Tier 1) MC

multi complete/iron $0(Tier 1) MC

multi vitamin daily $0(Tier 1) MC

multi-day plus iron $0(Tier 1) MC

multi-day vitamins $0(Tier 1) MC

multi-delyn $0(Tier 1) MC

multi-delyn/iron $0(Tier 1) MC

multi-vitamin daily $0(Tier 1) MC

multi-vitamin hp/minerals $0(Tier 1) MC

multi-vitamin/minerals $0(Tier 1) MC

multi-vitamins $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

multi-vitamin tabs 60mg; 0; 30mcg; 10mg; 400unit; 6mcg;

400mcg; 20mg; 2mg; 1.7mg; 1.5mg; 30unit; 5000unit

$0(Tier 1) MC

multilex $0(Tier 1) MC

multilex-t&m $0(Tier 1) MC

multiple vitamin/minerals/no iron $0(Tier 1) MC

multiple vitamins plain $0(Tier 1) MC

multiple vitamins/iron chew $0(Tier 1) MC

multiple vitamins tabs 50mg; 1mcg; 20mg; 1mg; 1mg; 2.5mg;

2mg; 5000unit; 400unit, 60mg; 20mg; 8mcg; 1.7mg; 1.5mg;

5000unit; 400unit; 30unit

$0(Tier 1) MC

multivitamin & mineral $0(Tier 1) MC

my-vitalife $0(Tier 1) MC

mykidz iron $0(Tier 1) MC

mykidz iron 10 $0(Tier 1) MC

nephro-vite $0(Tier 1) MC

nephrocaps caps 100mg; 150mcg; 5mg; 6mcg; 1mg; 20mg;

10mg; 1.7mg; 1.5mg

$0(Tier 1) MC

nephronex liqd $0(Tier 1) MC

niacin er cpcr 250mg $0(Tier 1) MC

niacin sr cpcr 250mg $0(Tier 1) MC

niacin tr cpcr 250mg $0(Tier 1) MC

niacin tr tbcr 250mg, 500mg $0(Tier 1) MC

niacin cpcr 250mg $0(Tier 1) MC

no iron multiple vitamin/minerals $0(Tier 1) MC

nutricap $0(Tier 1) MC

nutrivit $0(Tier 1) MC

omnicap $0(Tier 1) MC

once daily/iron $0(Tier 1) MC

once daily tabs 50mg; 1mcg; 20mg; 1mg; 1mg; 2.5mg; 2mg;

5000unit; 400unit

$0(Tier 1) MC

oncovite $0(Tier 1) MC

one daily complete $0(Tier 1) MC

one daily maximum $0(Tier 1) MC

one daily mens tabs 90mg; 0; 30mcg; 210mg; 120mcg; 2mg;

3mg; 400mcg; 0.6mg; 120mg; 2mg; 16mg; 5mg; 99mg;

1.7mg; 105mcg; 1.2mg; 3500unit; 18mcg; 400unit; 45unit;

20mcg; 15mg

$0(Tier 1) MC

one daily plus iron $0(Tier 1) MC

one daily plus minerals $0(Tier 1) MC

one daily womens 50+ $0(Tier 1) MC

one daily/iron/calcium $0(Tier 1) MC

one daily/minerals $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

one daily tabs 60mg; 0; 6mcg; 400mcg; 20mg; 10mg; 2mg;

1.7mg; 1.5mg; 5000unit; 400unit; 30unit

$0(Tier 1) MC

one-a-day essential $0(Tier 1) MC

one-a-day mens 50+ advantage $0(Tier 1) MC

one-a-day teen advantage for her $0(Tier 1) MC

one-a-day teen advantage for him $0(Tier 1) MC

one-a-day womens formula $0(Tier 1) MC

one-daily multi vitamins $0(Tier 1) MC

pa b-complex with b-12 $0(Tier 1) MC

pa biotin caps $0(Tier 1) MC

pa oyster shell calcium $0(Tier 1) MC

pa vitamin b-12 tr $0(Tier 1) MC

pa vitamin e $0(Tier 1) MC

peridin-c $0(Tier 1) MC

poly vitamin $0(Tier 1) MC

poly-vita drops $0(Tier 1) MC

poly-vita/iron drops $0(Tier 1) MC

polyvitamin $0(Tier 1) MC

polyvitamin/iron $0(Tier 1) MC

prevent $0(Tier 1) MC

protectiron $0(Tier 1) MC

protexin $0(Tier 1) MC

pure c 500 $0(Tier 1) MC

pureway-c $0(Tier 1) MC

pyridoxine hcl tabs $0(Tier 1) MC

qc calcium/minerals/vitamin d $0(Tier 1) MC

qc childrens chewable vitamins/extra c $0(Tier 1) MC

qc maximum daily multivitamin/multimineral $0(Tier 1) MC

qc multi-vite $0(Tier 1) MC

qc womens daily multivitamin $0(Tier 1) MC

quintabs-m tabs 0; 30mcg; 30mg; 300mg; 30mg; 0.2mg;

30mcg; 50unit; 400unit; 400mcg; 15mg; 2mg; 100mg;

150mcg; 30mg; 30mg; 35mcg; 30mg; 5000unit; 7.5mg

$0(Tier 1) MC

ra b-complex $0(Tier 1) MC

ra b-complex with b-12 $0(Tier 1) MC

ra b-complex/vitamin c tr $0(Tier 1) MC

ra balanced b-100 $0(Tier 1) MC

ra balanced b-50 $0(Tier 1) MC

ra beta carotene $0(Tier 1) MC

ra biotin caps $0(Tier 1) MC

ra calcium 600 plus vitamin d-3 $0(Tier 1) MC

ra calcium soft chews $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

ra calcium/boron $0(Tier 1) MC

ra calcium/magnesium/zinc/copper $0(Tier 1) MC

ra central-vite $0(Tier 1) MC

ra central-vite energy $0(Tier 1) MC

ra central-vite select mature $0(Tier 1) MC

ra central-vite senior $0(Tier 1) MC

ra central-vite/antioxidants tabs 60mg; 0; 30mcg; 162mg;

10mg; 72mg; 120mcg; 2mg; 6mcg; 400unit; 18mg; 400mcg;

250mcg; 300mcg; 100mg; 2mg; 20mg; 5mcg; 109mg; 25mcg;

80mg; 150mcg; 2mg; 1.7mg; 2mg; 150mcg; 10mcg; 75mcg;

20mcg; 10mcg; 1.5mg; 30unit; 3500unit; 15mg

$0(Tier 1) MC

ra coral calcium $0(Tier 1) MC

ra hi cal $0(Tier 1) MC

ra hi-cal plus vitamin d $0(Tier 1) MC

ra high potency iron $0(Tier 1) MC

ra iron $0(Tier 1) MC

ra magnesium $0(Tier 1) MC

ra natural vitamin e $0(Tier 1) MC

ra niacin $0(Tier 1) MC

ra one daily energy formula $0(Tier 1) MC

ra one daily essential $0(Tier 1) MC

ra one daily maximum $0(Tier 1) MC

ra one daily mens 50+ with vitamin d-3 $0(Tier 1) MC

ra one daily multi-vitamin $0(Tier 1) MC

ra one daily multi-vitamin plus iron $0(Tier 1) MC

ra oyster shell calcium/vitamin d $0(Tier 1) MC

ra stress formula advanced $0(Tier 1) MC

ra stress formula energy $0(Tier 1) MC

ra therapeutic m plus beta carotene $0(Tier 1) MC

ra vitamin a $0(Tier 1) MC

ra vitamin b-1 $0(Tier 1) MC

ra vitamin b-12 tr $0(Tier 1) MC

ra vitamin b-12 tabs $0(Tier 1) MC

ra vitamin b-6 $0(Tier 1) MC

ra vitamin b12 $0(Tier 1) MC

ra vitamin c drops $0(Tier 1) MC

ra vitamin c tr $0(Tier 1) MC

ra vitamin c/acerola $0(Tier 1) MC

ra vitamin c/rose hips $0(Tier 1) MC

ra vitamin c/rose hips tr $0(Tier 1) MC

ra vitamin c chew 500mg; 0 $0(Tier 1) MC

ra vitamin c tabs $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

ra vitamin e $0(Tier 1) MC

ra whole source complete formula for men $0(Tier 1) MC

ra whole source dietary $0(Tier 1) MC

ra whole source dietary for men $0(Tier 1) MC

ra whole source dietary mature $0(Tier 1) MC

rabano yodado $0(Tier 1) MC

rena-vite $0(Tier 1) MC

renal vitamin $0(Tier 1) MC

renal-vite $0(Tier 1) MC

risacal-d $0(Tier 1) MC

scooby-doo one a day $0(Tier 1) MC

senior tabs $0(Tier 1) MC

sentry senior $0(Tier 1) MC

sentry tabs 60mg; 0; 30mcg; 75mcg; 200mg; 10mg; 20mg;

72mg; 400unit; 35mcg; 0.5mg; 6mcg; 18mg; 400mcg; 50mg;

2.3mg; 20mg; 5mcg; 25mcg; 80mg; 150mcg; 2mg; 1.7mg;

2mg; 10mcg; 45mcg; 55mcg; 10mcg; 1.5mg; 30unit;

3500unit; 11mg, 90mg; 0; 30mcg; 150mcg; 200mg; 10mg;

109mg; 72mg; 400unit; 35mcg; 0.9mg; 6mcg; 18mg; 500mcg;

250mcg; 300mcg; 100mg; 2.3mg; 20mg; 5mcg; 25mcg;

80mg; 150mcg; 2mg; 1.7mg; 2mg; 10mcg; 45mcg; 55mcg;

10mcg; 1.5mg; 30unit; 3500unit; 11mg

$0(Tier 1) MC

siderol $0(Tier 1) MC

slo-niacin tbcr 250mg, 500mg $0(Tier 1) MC

sm chewable c $0(Tier 1) MC

sm super b complex-vitamin c $0(Tier 1) MC

sm vitamin c/rose hips $0(Tier 1) MC

stress b/zinc $0(Tier 1) MC

stress formula w/iron $0(Tier 1) MC

stress formula/iron tabs 500mg; 45mcg; 12mcg; 27mg;

400mcg; 100mg; 20mg; 5mg; 10mg; 15mg; 30unit

$0(Tier 1) MC

stress formula/zinc tabs 500mg; 45mcg; 3mg; 12mcg;

400mcg; 100mg; 20mg; 5mg; 10mg; 15mg; 30unit; 23.9mg,

600mg; 45mg; 3mg; 12mcg; 400mcg; 100mg; 20mg; 5mg;

10mg; 15mg; 30unit; 23.9mg

$0(Tier 1) MC

stress formula tabs 500mg; 45mcg; 12mcg; 400mcg; 100mg;

20mg; 3mg; 10mg; 10mg; 30unit, 500mg; 45mcg; 12mcg;

400mcg; 100mg; 20mg; 5mg; 10mg; 15mg; 30unit

$0(Tier 1) MC

strovite forte tabs $0(Tier 1) MC

strovite one $0(Tier 1) MC

super b complex maxi $0(Tier 1) MC

super b complex/c $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

super b with c $0(Tier 1) MC

super biotin caps $0(Tier 1) MC

super quints b-50 $0(Tier 1) MC

super thera vite m $0(Tier 1) MC

superplex-t $0(Tier 1) MC

supervite ec $0(Tier 1) MC

suplevit $0(Tier 1) MC

support-500 $0(Tier 1) MC

tab-a-vite $0(Tier 1) MC

tab-a-vite maximum $0(Tier 1) MC

tab-a-vite w/beta carotene $0(Tier 1) MC

tab-a-vite womens $0(Tier 1) MC

tab-a-vite/iron $0(Tier 1) MC

th b 100 complex $0(Tier 1) MC

th b complex/iron/vitamin c/vitamin e $0(Tier 1) MC

th complete multi $0(Tier 1) MC

th complete multi 50+ $0(Tier 1) MC

th daily multiple vitamins $0(Tier 1) MC

th daily multiple vitamins/iron $0(Tier 1) MC

th premium daily multiple $0(Tier 1) MC

th theradex-m $0(Tier 1) MC

th vitamin b 50/b-complex $0(Tier 1) MC

th vitamin b-12 $0(Tier 1) MC

th vitamin b-6 $0(Tier 1) MC

th vitamin b1 $0(Tier 1) MC

th vitamin b12 $0(Tier 1) MC

th vitamin b12 er $0(Tier 1) MC

th vitamin c $0(Tier 1) MC

th vitamin c/rose hips/bioflavonoids $0(Tier 1) MC

th vitamin e/d-alpha $0(Tier 1) MC

th vitamin e caps 200unit, 400unit $0(Tier 1) MC

thera m plus $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

thera-m tabs 120mg; 15mcg; 44mg; 10mg; 7.5mg; 400unit;

15mcg; 2mg; 9mcg; 18mg; 400mcg; 100mg; 5mg; 30mg;

31mg; 7.5mg; 150mcg; 3mg; 3.4mg; 15mcg; 10mcg; 3mg;

30unit; 5500unit; 15mg, 90mg; 0; 30mcg; 150mcg; 40mg;

7.5mg; 26mcg; 2mg; 9mcg; 400mcg; 150mcg; 18mg; 100mg;

3.5mg; 32mcg; 20mg; 5mcg; 10mg; 31mg; 7.5mg; 3mg;

3.4mg; 21mcg; 2mg; 3mg; 10mcg; 10mcg; 5000unit; 400unit;

30unit; 28mcg; 15mg, 90mg; 0; 30mcg; 30mg; 10mg; 50mcg;

2mg; 12mcg; 400unit; 9mg; 400mcg; 100mg; 2mg; 20mg;

5mcg; 23mg; 28mcg; 7.5mg; 7mg; 150mcg; 6mg; 3.4mg;

6mg; 150mcg; 10mcg; 75mcg; 70mcg; 10mcg; 3mg; 60unit;

5000unit; 15mg

$0(Tier 1) MC

thera-tabs $0(Tier 1) MC

thera/beta-carotene $0(Tier 1) MC

thera tabs 90mg; 30mcg; 9mcg; 400mcg; 20mg; 10mg; 3mg;

3.4mg; 3mg; 5000unit; 400unit; 30unit

$0(Tier 1) MC

theratrum complete tabs 60mg; 0; 30mcg; 150mcg; 162mg; 0;

10mg; 0; 400unit; 120mcg; 2mg; 6mcg; 18mg; 400mcg;

250mcg; 300mcg; 100mg; 2mg; 20mg; 5mcg; 109mg; 25mcg;

80mg; 72mg; 150mcg; 2mg; 1.7mg; 2mg; 0; 10mcg; 75mcg;

20mcg; 10mcg; 1.5mg; 30unit; 3500unit; 15mg

$0(Tier 1) MC

therems $0(Tier 1) MC

therems-h $0(Tier 1) MC

therems-m $0(Tier 1) MC

thiamine hcl tabs 100mg $0(Tier 1) MC

total b/c $0(Tier 1) MC

tri-vi-sol $0(Tier 1) MC

tri-vita $0(Tier 1) MC

tri-vitamin $0(Tier 1) MC

unicomplex-m $0(Tier 1) MC

v-c forte $0(Tier 1) MC

vic-forte $0(Tier 1) MC

vita-bee/c $0(Tier 1) MC

vitalee $0(Tier 1) MC

vitalets childrens chew 40mg; 0; 150mcg; 80mg; 5mg; 3mcg;

200unit; 10mg; 200mcg; 20mg; 0.1mg; 10mg; 60mg; 1mg;

0.85mg; 0.75mg; 15unit; 2500unit; 0.8mg

$0(Tier 1) MC

vitalets chew 40mg; 0; 150mcg; 80mg; 3mcg; 200unit; 10mg;

200mcg; 20mg; 0.1mg; 10mg; 5mg; 60mg; 1mg; 0.85mg;

0.75mg; 2500unit; 15unit; 0.8mg

$0(Tier 1) MC

vitamin a caps 10000unit, 8000unit $0(Tier 1) MC

vitamin b 6 $0(Tier 1) MC




Name of drug

What the drug

will cost you

(tier level)

Necessary actions,


use

vitamin b complex-c $0(Tier 1) MC

vitamin b complex tabs 10mg; 10mg; 0.2mg; 2mg; 1.5mg,

2mcg; 15mg; 5mg; 2mg; 2mg; 2mg

$0(Tier 1) MC

vitamin b-1 $0(Tier 1) MC

vitamin b-12 tr tbcr 1000mcg $0(Tier 1) MC

vitamin b-12 subl 2500mcg $0(Tier 1) MC

vitamin b-12 tabs 1000mcg, 100mcg, 250mcg, 500mcg $0(Tier 1) MC

vitamin b-2 $0(Tier 1) MC

vitamin b-6 tabs 100mg, 25mg, 50mg $0(Tier 1) MC

vitamin b-complex $0(Tier 1) MC

vitamin b1 $0(Tier 1) MC

vitamin b12 tabs, tbcr $0(Tier 1) MC

vitamin c sr $0(Tier 1) MC

vitamin c tr/rose hips $0(Tier 1) MC

vitamin c tr cpcr $0(Tier 1) MC

vitamin c tr tbcr 1500mg, 500mg $0(Tier 1) MC

vitamin c/rose hips tabs 1000mg, 1000mg; 0, 500mg, 500mg;

0

$0(Tier 1) MC

vitamin c chew 0; 500mg; 0; 0; 0; 0, 250mg, 500mg $0(Tier 1) MC

vitamin c powd, syrp, tbcr $0(Tier 1) MC

vitamin c tabs 1000mg, 250mg, 500mg $0(Tier 1) MC

vitamin d caps 50000unit $0(Tier 1) MC

vitamin e water dispersible $0(Tier 1) MC

vitamin e water soluble caps 400unit $0(Tier 1) MC

vitamin e-400 $0(Tier 1) MC

vitamin e/d-alpha natural caps 400unit $0(Tier 1) MC

vitamin e/d-alpha caps 1000unit, 400unit $0(Tier 1) MC

vitamin e caps 1000unit, 100unit, 200unit, 400unit $0(Tier 1) MC

vitamin k1 inj 10mg/ml $0(Tier 1) MC

vitamins & minerals $0(Tier 1) MC

vitamins for hair tabs 400mcg; 100mg; 250mg; 2mg; 6mcg;

18mg; 400mcg; 125mg; 150mcg; 5mg; 100mg; 15mg

$0(Tier 1) MC

vitatrum chew $0(Tier 1) MC

vitrum 50+ senior multi $0(Tier 1) MC

VP-PNV-DHA $0(Tier 2)

womens biomultiple $0(Tier 1) MC

womens daily formula $0(Tier 1) MC

womens daily formula/folic acid/calcium/iron $0(Tier 1) MC

womens one daily $0(Tier 1) MC

yelets teenage formula $0(Tier 1) MC

zoo friends $0(Tier 1) MC

zoo friends plus iron $0(Tier 1) MC

96

Index Drug Name Page #

12 hour decongestant 65

a-10000 81

abacavir 27

abacavir sulfate/lamivudine/zidovudine 27

abacavir/lamivudine 27

abaneu-sl 81

abc plus senior adults 50+ 81

ABELCET 15

ABILIFY DISCMELT 24

ABILIFY MAINTENA 24

ABRAXANE 19

acamprosate calcium dr 5

acarbose 29

acebutolol hcl 34

acephen 1

acerola c 500 81

aceta-gesic 62

acetaminophen 1

acetaminophen/caffeine/dihydrocodeine 3

acetaminophen/codeine 3

acetaminophen/codeine #2 3



acetaminophen/codeine phosphate 3

acetaminophen/diphenhydramine 62

acetasol hc 61

acetazolamide 36

acetazolamide er 61

acetazolamide sodium 36

acetic acid 61

acetic acid/aluminum acetate 61

acetylcysteine 65

acid gone 41

acid reducer maximum strength 41

acitretin 39

acne medication 10 39

acne medication 5 39

ACTHIB 55

actical 81

ACTIDOSE/SORBITOL 41

ACTIMMUNE 55

active 1st blood lancets 30g/easy twist cap 57

active fe 81

Drug Name Page #

acyclovir 29

acyclovir sodium 29

ADACEL 55

ADAGEN 40

adefovir dipivoxil 26

ADEMPAS 65

adrucil 19

advanced stress formula/zinc 81

aerovent plus holding chamber/collapsible 57

afeditab cr 34

AFINITOR 21

AFINITOR DISPERZ 21

AGGRENOX 32

a-hydrocort 46

ak-poly-bac 6

akwa tears 59

ala cort 46

ALA SCALP 46

ALAHIST DM 65

ALA-HIST IR 62

ALA-HIST PE 62

alba-lybe nr 81

ALBENZA 23

albuterol 64

albuterol sulfate 64

albuterol sulfate er 64

alclometasone dipropionate 46

alcohol prep pads 6

ALDURAZYME 40

ALECENSA 21

alendronate sodium 57

alfuzosin hcl er 45

ALIMTA 19

ALINIA 23

all day allergy 62

all day allergy childrens 62

all day allergy-d 62

all day pain relief 1

all day relief 1

aller-chlor 62

allergy 62

allergy relief 62

allergy relief child 62

allergy relief d-24 62

all-nite cold & flu nighttime relief 65

all-nite multi-symptom cold/flu relief 66

allopurinol 17

97

Drug Name Page #

almacone 41

almacone double strength 41

ALOCRIL 60

ALOPRIM 17

ALORA 48

alosetron hydrochloride 44

ALOXI 15

alprazolam 29

alprazolam odt 29

altavera 48

aluminum hydroxide 41

alyacen 1/35 48

alyacen 7/7/7 49

amantadine hcl 28

AMBISOME 16

amcinonide 46

amethia 49

amethia lo 49

amifostine 19

amikacin sulfate 6

amiloride hcl 36

amiloride/hydrochlorothiazide 36

aminophylline 65

AMINOSYN 71

AMINOSYN 7%/ELECTROLYTES 71

AMINOSYN 8.5%/ELECTROLYTES 71

AMINOSYN II 71

AMINOSYN II 8.5%/ELECTROLYTES 71

AMINOSYN M 71

AMINOSYN-HBC 71

AMINOSYN-PF 71

AMINOSYN-PF 7% 71

AMINOSYN-RF 71

amiodarone hcl 33

AMITIZA 44

amitriptyline hcl 14

amlodipine besylate 35

amlodipine besylate/benazepril

hydrochloride

35

amlodipine besylate/valsartan 35

amlodipine/valsartan/hctz 35

ammonium lactate 39

amnesteem 39

amoxapine 15

amoxicillin 9

amoxicillin/clavulanate potassium 9

amoxicillin/clavulanate potassium er 9

Drug Name Page #

amphetamine/dextroamphetamine 37

amphotericin b 16

ampicillin 9

ampicillin sodium 9

ampicillin-sulbactam 9

AMPYRA 38

ANADROL-50 48

anagrelide hydrochloride 32

anaspaz 41

anastrozole 21

ANDROGEL 48

ANDROGEL PUMP 48

ANDROXY 48

animal chews 81

animal shapes 81

animal shapes + iron 81

antacid calcium extra st rength 41

antacid calcium regular strength 41

antacid extra strength 41

antacid maximum strength 41

antacid plus anti-gas relief 41

anti-diarrheal 41

antifungal 16

anti-fungal powder 16

anti-nausea 41

antioxidant formula 81

anu-med 41

apatate forte 81

apetex 81

apetigen 81

apetigen-plus 81

ap-hist dm 66

APOKYN 23

apraclonidine 61

apri 49

APRISO 56

aprodine 66

APTIOM 11

APTIVUS 28

aquadeks 81

aqueous vitamin d infants 81

aqueous vitamin e 81

ARALAST NP 66

aranelle 49

ARANESP ALBUMIN FREE 32

ARCALYST 55

aripiprazole 24

98

Drug Name Page #

aripiprazole odt 24

ARISTADA 24

armodafinil 70

ARRANON 19

artificial tears 60

ARZERRA 22

ascomp/codeine 3

ascorbic acid 81

aspirin 1

aspirin 32

aspirin adult low strength 32

aspirin ec 1

aspirin ec 32

aspirin ec low dose 32

aspirin low dose 32

aspirin/dipyridamole 32

aspir-low 32

assure prism multi test strips 57

ASTAGRAF XL 54

atenolol 34

atenolol/chlorthalidone 34

ATGAM 55

atorvastatin calcium 36

atovaquone 23

atovaquone/proguanil hcl 23

ATRIPLA 28

atropine sulfate 41

atropine sulfate 60

ATROVENT HFA 64

aubra 49

augmented betamethasone dipropionate 46

AUGMENTIN 9

AURYXIA 46

AVASTIN 22

AVELOX 10

aviane 49

AVODART 45

AVONEX 38

AVONEX PEN 38

azacitidine 19

AZACTAM IN ISO-OSMOTIC

DEXTROSE

8

AZASAN 54

AZASITE 9

azathioprine 54

azelastine hcl 60

azelastine hcl 62

Drug Name Page #

AZILECT 24

azithromycin 9

AZOPT 61

aztreonam 8

azurette 49

b complete 81

b complex 81

b complex/c 81

b complex/folic acid 81

b-1 82

b-12 82

b-12 tr 82

b-2 82

b-50 complex 82

b-6 82

baby darlings pediatric electrolyte 71

baciim 6

bacitracin 6

bacitracin zinc 6

bacitracin/neomycin/polymyxin 6

bacitracin/polymyxin b 6

baclofen 26

bacmin 82

BACTROBAN NASAL 6

balance b-100 82

balance b-50 82

balanced b-100 82

balanced b-50 82

balanced b-50 complex 82

balsalazide disodium 57

balziva 49

banophen 62

BANZEL 12

BARACLUDE 26

b-complex 82

b-complex formula 1 82

b-complex plus vitamin c 82

b-complex w/c 82

b-complex with b-12 82

bd autoshield duo 30g x 3/16" 57

bd eclipse syringe/1ml/30gx1/2" 57

bd insulin syringe safetyglide/1ml/29g x

1/2"

57

bd insulin syringe ultrafine/0.3ml/31g x

5/16"

58

bd insulin syringe ultrafine/0.5ml/30g x 1/2" 58

bd insulin syringe ultrafine/1ml/31g x 5/16" 58

99

Drug Name Page #

bd pen needle/mini/ultrafine/31g x 3/16" 58

bd pen needle/nano/ultra fine/32g x 4mm 58

bd pen needle/ultrafine/29g x 12.7mm 58

bd safetyglide 27g x 5/8" 58

bee zee 82

bekyree 49

BELEODAQ 19

benazepril hcl 33

benazepril hcl/hydrochlorothiazide 33

BENDEKA 18

BENICAR 33

BENICAR HCT 33

BENLYSTA 54

benzonatate 66

benzoyl peroxide 39

benztropine mesylate 23

BESIVANCE 10

beta carotene 82

betamethasone dipropionate 46

betamethasone valerate 46

betaxolol hcl 34

betaxolol hcl 61

bethanechol chloride 46

bexarotene 22

BEXSERO 55

bicalutamide 18

BICILLIN L-A 9

BICNU 18

BIDIL 37

bimatoprost 59

biocal 82

biosupp 82

biotin 82

biotin 5000 82

biotin/maximum strength 82

biovol 82

bisacodyl ec 41

bisacodyl ec 44

biscolax 41

bismatrol 41

bismatrol maximum strength 42

bisoprolol fumarate 34

bisoprolol fumarate/hydrochlorothiazide 34

BIVIGAM 55

bleomycin sulfate 19

BLEPHAMIDE 10

BLEPHAMIDE S.O.P. 10

Drug Name Page #

blisovi fe 1.5/30 49

blisovi fe 1/20 49

blue gel 39

BOOSTRIX 55

BOSULIF 21

b-plex plus 82

briellyn 49

BRILINTA 32

brimonidine tartrate 61

BRINTELLIX 13

BRIVIACT 11

bromfed dm 66

bromfenac 60

bromocriptine mesylate 23

bromphen/pseudoephedrine

hcl/dextromethorphan hbr

66

BROTAPP 62

BROTAPP DM 66

budesonide 57

budesonide 62

bumetanide 36

BUPHENYL 40

buprenorphine hcl 5

buprenorphine hcl/naloxone hcl 5

buproban 5

bupropion hcl 13

bupropion hcl er 13

bupropion hcl sr 5

bupropion hcl sr 13

bupropion hcl xl 13

buspirone hcl 29

BUSULFEX 18

butalbital/acetaminophen/caffeine 1

butalbital/acetaminophen/caffeine/codeine 3

butalbital/aspirin/caffeine 1

butalbital/aspirin/caffeine/codeine 3

butorphanol tartrate 3

BYDUREON 29

BYDUREON PEN 29

BYETTA 30

BYSTOLIC 34

BYVALSON 34

c 1000 82

c 1000/bioflavonoids/rosehips 82

c 250 82

c 500 82

c 500/rose hips 82

100

Drug Name Page #

c complex 82

c-1000 82

c-1000 prolonged release 82

c-1000/rose hips 83

c-250 83

c-500 83

c-500 prolonged release 83

c-500/rose hips 83

cabergoline 53

CABOMETYX 21

CAFERGOT 17

calcet petites 71

calci-chew 71

calcipotriene 39

calcitonin-salmon 57

calcitrate 71

calcitrene 39

calcitriol 39

calcitriol 57

calcium 72

calcium & magnesium 71

calcium + d3 71

calcium 500 +d3 71

calcium 500/d 71

calcium 500/vitamin d3 71

calcium 600 71

calcium 600 + d 71

calcium 600 with vitamin d 71

calcium 600/vitamin d 71

calcium 600/vitamin d3 71

calcium 600+d 71

calcium 600+d3 71

calcium 600-d 71

calcium acetate 46

calcium antacid 42

calcium antacid extra strength 42

calcium carbonate 71

calcium carbonate/d3 71

calcium carbonate/vitamin d 71

calcium citrate 72

calcium citrate + d 72

calcium citrate + d3 maximum 72

calcium citrate malate/vitamin d 72

calcium citrate maximum/vitamin d 72

calcium citrate w/d 72

calcium citrate/vitamin d 72

calcium citrate/vitamin d3 72

Drug Name Page #

calcium citrate+d 72

calcium gluconate 72

calcium high potency 72

calcium high potency + vitamin d 72

calcium oyster shell 72

calcium/c/d 83

calcium/d 72

calcium/magnesium/zinc 72

calcium/vitamin d 72

calcium+d3 72

cal-gest antacid 42

cal-mag-zinc-d 71

caltrate 600+d 72

caltrate 600+d plus minerals 72

caltrate 600+d3 soft chews 72

calvite p&d 72

camila 52

CANCIDAS 16

candesartan cilexetil 33

candesartan cilexetil/hydrochlorothiazide 33

CAPASTAT SULFATE 18

CAPRELSA 21

captopril 33

captopril/hydrochlorothiazide 33

CARAC 39

CARAFATE 45

CARBAGLU 72

carbamazepine 12

carbamazepine er 12

carbidopa 24

carbidopa/levodopa 23

carbidopa/levodopa er 24

carbidopa/levodopa odt 24

carbidopa/levodopa/entacapone 24

carboplatin 19

carteolol hcl 61

cartia xt 35

carvedilol 34

CAYSTON 65

caziant 49

cefaclor 8

cefaclor er 8

cefadroxil 8

CEFAZOLIN 8

cefazolin sodium 8

CEFAZOLIN SODIUM/DEXTROSE 8

cefdinir 8

101

Drug Name Page #

cefepime 8

cefepime/dextrose 8

cefixime 8

cefotaxime sodium 8

cefotetan 8

cefoxitin sodium 8

cefpodoxime proxetil 8

cefprozil 8

ceftazidime 8

CEFTAZIDIME/DEXTROSE 8

ceftriaxone in iso-osmotic dextrose 8

ceftriaxone sodium 8

cefuroxime axetil 8

cefuroxime sodium 8

celecoxib 1

CELLCEPT INTRAVENOUS 54

CELONTIN 11

centamin 72

centratex 72

centravites 83

centrum 83

centrum adults 83

centrum kids complete 83

centrum silver 83

centrum silver adult 50+ 83

centrum silver ultra womens 83

centrum specialist heart 83

centrum ultra mens 83

cephalexin 8

CEREZYME 40

cerovite advanced formula 83

cerovite jr 83

certa plus 83

certavite senior/antioxidant nutrients 83

certavite/antioxidants 83

CERVARIX 56

cetirizine hcl 62

cetirizine hcl allergy childrens 62

cetirizine hcl childrens allergy 62

cetirizine hcl/pseudoephedrine hcl er 62

CHANTIX 5

CHANTIX CONTINUING MONTH PAK 5

CHANTIX STARTING MONTH PAK 5

chateal 49

CHEMET 70

cheratussin ac 66

cheratussin dac 66

Drug Name Page #

chest congestion relief 66

chest congestion relief pe 66

chewable antacid 42

chewable vitamin c 83

chewable vite childrens 83

chewable vite with iron/childrens 83

childrens allergy 62

childrens aspirin 32

childrens chewable multivitamin 83

childrens chewable vitamin 83

childrens chewable vitamins 83

childrens chewable vitamins/iron 83

childrens ibuprofen 2

childrens loratadine 62

childrens mapap rapid tabs 1

childrens silfedrine 66

childs ibuprofen 2

chlo tuss 66

CHLO TUSS EX 66

chloramphenicol sodium succinate 6

chlorhexidine gluconate 38

chloroquine phosphate 23

chlorothiazide 36

chlorothiazide sodium 36

chlorpromazine hcl 24

chlorthalidone 36

cholestyramine 37

cholestyramine light 37

CHORIONIC GONADOTROPIN 48

ciclodan 16

ciclopirox 16

ciclopirox nail lacquer 16

ciclopirox olamine 16

cidofovir 26

cilostazol 32

CILOXAN 10

cimetidine 43

cimetidine hcl 43

CINRYZE 54

CIPRO HC 10

CIPRODEX 10

ciprofloxacin 10

ciprofloxacin er 10

ciprofloxacin hcl 10

ciprofloxacin i.v.-in d5w 10

cisplatin 19

citalopram hydrobromide 14

102

Drug Name Page #

citracal + d3 maximum 72

citracal maximum 72

citrus calcium +d 84

cladribine 19

claravis 39

clarithromycin 9

clarithromycin er 9

clever choice anti-staticvalved holding

chamber/adult large

58


chamber/medium

58


chamber/small

58

clindacin etz pledgets 6

clindacin-p 6

clindamax 6

clindamycin hcl 6

clindamycin phosphate 6

clindamycin phosphate add-vantage 6

clindamycin phosphate in d5w 6

clindamycin phosphate pharmacy bulk

package

6

CLINIMIX 2.75%/DEXTROSE 5% 72





CLINIMIX 5%/DEXTROSE 15% 72



CLINIMIX E 2.75%/DEXTROSE 10% 72



CLINIMIX E 5%/DEXTROSE 25% 73

CLINISOL SF 15% 73

clobetasol propionate 46

clobetasol propionate e 46

clobetasol propionate emollient 46

clodan 46

CLOLAR 19

clomipramine hcl 15

clonazepam 11

clonazepam odt 11

clonidine hcl 32

clonidine hcl er 38

clopidogrel 32

clorazepate dipotassium 29

Drug Name Page #

clotrimazole 16

clotrimazole anti-fungal 16

clotrimazole/betamethasone dipropionate 16

clozapine 26

clozapine odt 26

COARTEM 23

coats aloe creme 39

coats aloe gelly 39

coats aloe liniment 39

coats aloe moisturizing lotion 39

codeine/guaifenesin 66

colchicine 17

COLCRYS 17

cold/cough dm childrens 66

colestipol hcl 37

colistimethate sodium 6

colocort 57

COLY-MYCIN S 61

COMBIGAN 59

COMBIVENT RESPIMAT 64

COMETRIQ 21

compact space chamber/anti-static 58

compact space chamber/anti-static/large

mask

58

compact space chamber/anti-static/medium

mask

58

compact space chamber/anti-static/small

mask

58

companion 84

compete 84

COMPLERA 27

complete 84

complete allergy medicine 62

complex b-100 84

compro 24

COMVAX 56

congestion relief 2

constulose 44

COPAXONE 38

coral calcium 73

COREG CR 34

cormax scalp application 46

cortisone acetate 46

CORTISPORIN-TC 61

corvita 84

corvite 84

corvite 150 84

103

Drug Name Page #

corvite fe 84

corvite free 84

COSMEGEN 19

COTELLIC 21

cough dm 66

cough syrup 66

cranberry urinary comfort 84

CREON 40

CRESTOR 36

CRIXIVAN 28

cromolyn sodium 42

cromolyn sodium 60

cromolyn sodium 65

cryselle-28 49

CUBICIN 7

CUPRIMINE 70

curity gauze pads 2"x2" 39

cvs b complex plus c 84

cvs b-1 84

cvs b-12 84

cvs b-6 84

cvs balanced b-100 84

cvs balanced b-50 84

cvs beta carotene 84

cvs biotin 84

cvs biotin high potency 84

cvs calcium 84

cvs calcium 600 & vitamind3 73

cvs calcium 600 + d/minerals 73

cvs calcium 600+d 73

cvs calcium carbonate 73

cvs calcium chewables 600plus 73

cvs calcium citrate + d 73

cvs calcium citrate +d 73

cvs calcium citrate+d/magnesium 73

cvs calcium/magnesium/zinc 84

cvs childrens chewable complete 84

cvs childrens chewable multivitamin/iron 84

cvs daily energy 84

cvs daily multiple 84

cvs daily multiple for men 84

cvs daily multiple for men 50+ 84

cvs daily multiple for women 84

cvs daily multiple for women 50+ 84

cvs daily multiple plus iron/calcium/zinc 84

cvs e oil 84

cvs electrolyte solution 73

Drug Name Page #

cvs gummy dinos 84

cvs hair skin & nails/an tioxidants 84

cvs iron 73

cvs lancets ultra-thin 30g 58

cvs laxative dietary supplement 44

cvs magnesium 73

cvs oyster shell calcium w/ vit d 73

cvs pediatric electrolyte 73

cvs pediatric electrolyte freezer pops 73

cvs selenium 73

cvs slow release iron 73

cvs spectravite adult 50+ 84

cvs spectravite advanced formula 84

cvs spectravite senior 85

cvs spectravite ultra health mens 85

cvs spectravite ultra mens health 85

cvs spectravite ultra women 85

cvs spectravite ultra womens health 85

cvs spectravite ultra womens health senior 85

cvs super b complex/c 85

cvs vitamin a 85

cvs vitamin b-12 85

cvs vitamin b-12 tr 85

cvs vitamin b-6 85

cvs vitamin c 85

cvs vitamin c/rose hips 85

cvs vitamin e 85

cvs zinc 73

cyclafem 1/35 49

cyclafem 7/7/7 49

cyclobenzaprine hcl 70

cyclophosphamide 18

cycloserine 18

CYCLOSET 30

cyclosporine 54

cyclosporine modified 54

CYRAMZA 22

cyred 49

CYSTADANE 40

CYSTAGON 40

cytarabine 19

cytarabine aqueous 19

dacarbazine 18

daily combo multi vitamin 85

daily multiple vitamin 85

daily multiple vitamin/iron 85

daily multiple vitamins 85

104

Drug Name Page #

daily value multivitamin 85

daily vitamin 85

daily vitamin formula+ir on 85

daily vitamin formula+iron 85

daily vitamin formula+minerals 85

daily vitamins 85

daily vite 85

daily vite with iron 85

daily-vite 85

daily-vite/iron/beta-carotene 85

DALIRESP 65

dallergy 63

danazol 48

dantrolene sodium 26

dapsone 18

DAPTACEL 56

daptomycin 7

DARAPRIM 23

DARZALEX 22

dasetta 1/35 49

dasetta 7/7/7 49

daunorubicin hcl 20

day time multi-symptom cold/flu relief 66

deblitane 52

DECITABINE 20

DECONEX DMX 66

DECONEX IR 66

deep sea nasal spray 66

dekas essential 85

dekas plus 86

DELESTROGEN 49

DELSYM 66

delsym cough + chest congestion dm 66

delsym cough + chest congestion dm

childrens

66

delsym cough + cold daytime 66

delsym cough + cold nighttime 66

delsym cough + cold nighttime childrens 66

delyla 49

DELZICOL 57

demeclocycline hcl 10

DEMSER 35

DENAVIR 29

DEPEN TITRATABS 70

DEPO-ESTRADIOL 49

DEPO-MEDROL 46

DEPO-PROVERA 52

Drug Name Page #

DESCOVY 27

desipramine hcl 15

desloratadine 63

desloratadine odt 63

desmopressin acetate 48

desogestrel/ethinyl estradiol 49

desonide 46

desoximetasone 46

dexamethasone 46

dexamethasone intensol 46

dexamethasone sodium phosphate 46

dexamethasone sodium phosphate 60

DEXILANT 45

dexmethylphenidate hcl 38

dexrazoxane 20

dextroamphetamine sulfate 38

dextroamphetamine sulfate er 38

dextromethorphan polistirex 66

DEXTROSE 10%/NACL 0.45% 73

dextrose 5% /electrolyte #48 viaflex 73

DEXTROSE 10% 73


DEXTROSE 2.5%/NACL 0.45% 73

DEXTROSE 20% 73

DEXTROSE 25% 73

DEXTROSE 30% 73

DEXTROSE 40% 73

DEXTROSE 5% 73

DEXTROSE 5%/LACTATED RINGERS 73







DEXTROSE 5%/POTASSIUM

CHLORIDE 0.15%

73

DEXTROSE 50% 73

DEXTROSE 70% 73

dialyvite 800 86

dialyvite 800/iron 86

DIAZEPAM 11

diazepam 29

DIBENZYLINE 33

dibucaine 39

diclofenac potassium 2

diclofenac sodium 39

105

Drug Name Page #

diclofenac sodium 60

diclofenac sodium dr 2

diclofenac sodium er 2

dicloxacillin sodium 9

dicyclomine hcl 41

didanosine 27

diflorasone diacetate 46

diflunisal 2

digitek 35

digox 35

digoxin 35

dihydroergotamine mesylate 17

DILANTIN 12

diltiazem cd 35

diltiazem hcl 35

diltiazem hcl cd 35

diltiazem hcl er 35

dilt-xr 35

dimaphen childrens 63

dimaphen dm cold & cough 66

dimaphen dm cold/cough childrens 66

dimenhydrinate 15

dino-life 86

dino-life w extra c 86

dino-life w/iron & zinc 86

diocto 42

diphenhist 63

diphenhydramine hcl 63

diphenoxylate/atropine 42

DIPHTHERIA/TETANUS TOXOIDS

ADSORBED PEDIATRIC

56

disulfiram 5

divalproex sodium 11

divalproex sodium dr 11

divalproex sodium er 11

DOCEFREZ 20

docetaxel 20

docqlace 42

docqlace 44

doc-q-lax 44

docu 42

docusate sodium & senna stimulant

laxative/stool softener

44

docusol kids 42

docusol plus mini-enema 44

dofetilide 34

dok 42

Drug Name Page #

dok 44

dok plus 44

donepezil hcl 13

dorzolamide hcl 61

dorzolamide hcl/timolol maleate 61

doxazosin 45

doxazosin mesylate 45

doxepin hcl 15

doxepin hydrochloride 39

doxercalciferol 57

doxorubicin hcl 20

doxorubicin hcl liposome 20

doxy 100 10

doxycycline 10

doxycycline hyclate 10

doxycycline monohydrate 10

DR SMITHS DIAPER 39

dr smiths diaper rash spray 39

dr smiths rash + skin 39

DRISDOL 86

dronabinol 15

DROXIA 19

DULERA 62

duloxetine hcl 14

duofer 74

DURAFLU 66

DURAMORPH 3

DUREZOL 60

dutasteride 45

dutasteride/tamsulosin hydrochloride 45

e.e.s. 400 9

E.E.S. GRANULES 9

e-400 86

e400 mixed 86

ear drops earwax removal aid 61

earwax treatment drops 61

easy mini eject lancing device 58

ecee plus 86

econazole nitrate 16

econtra ez 52

ed a-hist 63

ed a-hist dm 66

ed a-hist pse 63

ed bron gp 66

ed chlorped 63

ed chlorped d 63

ed chlorped jr 63

106

Drug Name Page #

ed-apap 1

ed-chlortan 63

EDECRIN 36

ed-spaz 41

EDURANT 27

effervescent pain relief 2

EFFIENT 32

ELAPRASE 40

ELIDEL 39

ELIGARD 53

elinest 49

ELIQUIS 31

ELITEK 19

ELLA 52

ELMIRON 46

EMCYT 19

EMEND 15

emoquette 49

EMPLICITI 22

EMSAM 13

EMTRIVA 27

enalapril maleate 33

enalapril maleate/hydrochlorothiazide 33

ENBREL 54

ENBREL SURECLICK 54

endacof-dm 66

endocet 3

enema ready-to-use 44

enemeez mini 42

enemeez plus 42

enfamil enfalyte 58

ENGERIX-B 56

enlyte 74

enoxaparin sodium 31

enpresse-28 49

enskyce 49

entacapone 23

entecavir 26

enteric coated aspirin 2

ENTRESTO 33

enulose 44

ENVARSUS XR 54

e-oil 86

epinastine hcl 60

epinephrine hcl 64

EPIPEN 2-PAK 64

EPIPEN-JR 2-PAK 64

Drug Name Page #

epirubicin hcl 20

epitol 12

EPIVIR HBV 26

EPZICOM 28

eql one daily essential 86

eql pediatric electrolyte 74

ERBITUX 22

ergocalciferol 86

ergoloid mesylates 12

ERIVEDGE 21

errin 52

ERWINAZE 20

ery 9

ERYPED 200 9

ERYPED 400 9

ERY-TAB 9

ERYTHROCIN LACTOBIONATE 9

erythrocin stearate 9

erythromycin 9

erythromycin base 9

erythromycin ethylsuccinate 9

erythromycin/benzoyl peroxide 39

ESBRIET 66

escitalopram oxalate 14

esgic 1

esomeprazole magnesium 45

esomeprazole sodium 45

essentia 86

essential balance 86

estarylla 49

estradiol 49

estradiol valerate 49

estradiol/norethindrone acetate 49

ESTRING 49

ethacrynate sodium 36

ethacrynic acid 36

ethambutol hcl 18

ethosuximide 11

etidronate disodium 57

etodolac 2

etodolac er 2

ETOPOPHOS 21

etoposide 21

EVOMELA 18

EVOTAZ 28

EXELON 13

exemestane 21

107

Drug Name Page #

EXJADE 70

extra action cough 66

eye drops 60

ezfe 200 74

FABRAZYME 40

fallback solo 52

falmina 49

famciclovir 29

famotidine 43

famotidine premixed 43

FANAPT 25

FANAPT TITRATION PACK 25

FARESTON 19

FARYDAK 21

FASLODEX 19

FAZACLO 26

fe c 74

fe c tab 74

felbamate 12

felodipine er 35

FEMRING 49

fenofibrate 36

fenofibrate micronized 36

fenofibric acid dr 36

fenoprofen calcium 2

fentanyl 3

fentanyl citrate 3

fentanyl citrate oral transmucosal 3

feosol 74

feosol bifera 74

ferate 74

fergon 74

fer-in-sol 74

fer-iron 74

feriva 21/7 74

ferivafa 74

ferosul 74

ferralet 90 74

ferraplus 90 74

ferretts 74

ferretts ips 74

ferrex 150 74

ferrex 150 forte 74

ferric x-150 74

ferrimin 150 74

FERRIPROX 58

ferrocite 74

Drug Name Page #

ferrous drops 74

ferrous fumarate 324 74

ferrous gluconate 74

ferrous sulfate 74

ferrousul 74

FETZIMA 14

FETZIMA TITRATION PACK 14

fexofenadine hcl 63

fexofenadine hcl childrens allergy 63

fiber laxative 44

fiber tabs 42

fiber-lax 42

fifty50 unilet lancets 33g 58

finasteride 45

FIRAZYR 54

FIRMAGON 53

flavoxate hcl 45

FLEBOGAMMA DIF 55

flecainide acetate 34

FLEET PEDIATRIC 42

flintstones complete 86

flintstones plus extra c 86

flintstones/my first 86

FLOVENT DISKUS 62

FLOVENT HFA 62

FLOWTUSS 66

fluconazole 16

fluconazole in dextrose 16

fluconazole in nacl 16

flucytosine 16

fludarabine phosphate 20

fludrocortisone acetate 46

flunisolide 62

fluocinolone acetonide 46

fluocinolone acetonide 61

fluocinolone acetonide body 46

fluocinolone acetonide ear drops 46

fluocinolone acetonide scalp 46

fluocinonide 47

fluocinonide-e 47

fluoride 74

fluoritab 74

fluorometholone 60

fluorouracil 19

fluorouracil 39

fluoxetine 14

fluoxetine dr 14

108

Drug Name Page #

fluoxetine hcl 14

fluphenazine decanoate 24

fluphenazine hcl 24

flurbiprofen 2

flurbiprofen sodium 60

flutamide 18

fluticasone propionate 47

fluticasone propionate 62

fluvastatin 36

fluvoxamine maleate 14

fluvoxamine maleate er 14

focalgin dss 74

folic acid 86

folitab 500 86

FOLOTYN 19

foltabs 800 86

fomepizole 58

fondaparinux sodium 31

fora d40/g31 blood glucose test strips 58

fora lancets 58

fora lancing device/clearcap 58

fora tn'g/tn'g voice blood glucose test strips 58

FORADIL AEROLIZER 65

formula em 15

fortavit 86

FORTEO 57

fosfree 86

fosinopril sodium 33

fosinopril sodium/hydrochlorothiazide 33

fosphenytoin sodium 12

FREAMINE HBC 6.9% 74

FREAMINE III 74

freestyle precision neo blood glucose test

strips

58

FRESHKOTE 60

fruit c 500 86

fruity c 86

fruity chewables multivitamin 86

full spectrum b/vitamin c 86

FUNGOID TINCTURE 16

furosemide 36

FUSILEV 20

fusion 74

fusion plus 75

FUZEON 28

FYCOMPA 11

gabapentin 11

Drug Name Page #

GABITRIL 11

galantamine hydrobromide 13

GAMASTAN S/D 55

GAMMAGARD LIQUID 55

GAMMAKED 55

GAMMAPLEX 55

GAMUNEX-C 55

ganciclovir 26

GARDASIL 56

GARDASIL 9 56

gas relief 42

gas relief extra strength 42

gas relief maximum strength 42

GATTEX 42

gavilyte-c 44

gavilyte-g 44

gavilyte-n/flavor pack 44

GAZYVA 22

gemcitabine 19

gemcitabine hcl 19

gemfibrozil 36

generlac 44

gengraf 54

gentak 6

gentamicin sulfate 6

gentamicin sulfate pediatric 6

gentamicin sulfate/0.9% sodium chloride 6

GENVOYA 27

GEODON 25

gildagia 49

gildess 1.5/30 49

gildess 1/20 50

gildess fe 1.5/30 50

gildess fe 1/20 50

GILOTRIF 21

glatopa 38

GLEEVEC 21

GLEOSTINE 18

glimepiride 30

glipizide 30

glipizide er 30

glipizide xl 30

glipizide/metformin hcl 30

GLUCAGEN HYPOKIT 30

glucose meter test strips advanced 58

glycopyrrolate 41

glydo 5

109

Drug Name Page #

GLYSET 30

gnp all day allergy 63

gnp allergy 63

gnp animal shapes 86

gnp animal shapes plus extra c 86

gnp animal shapes plus iron 86

gnp antacid anti-gas 42

gnp arthritis pain relief 1

gnp b-50 balanced 86

gnp calcium 75

gnp calcium 1200 75

gnp calcium 500 +d3 75

gnp calcium 500/d 75

gnp calcium 600/d 75

gnp calcium citrate +d3 75

gnp calcium citrate+d maximum 75

gnp calcium/magnesium/zinc 75

gnp calcuim/vitamin d/minerals 75

gnp century 87

gnp century adults 50+ senior 87

gnp century cardio healthformula 87

gnp century ultimate mens complete 87

gnp century ultimate womens complete 87

gnp century ultimate womens senior formula 87

gnp childrens chewables/extra c 87

gnp childrens chewables/iron 87

gnp dayhist allergy 63

gnp easy touch glucose test strips 58

gnp enema 44

gnp essential one daily 87

gnp hair/skin/nails 87

gnp ibuprofen 2

gnp ibuprofen junior strength 2

gnp iron 75

gnp little ones childrens 87

gnp loratadine 63

gnp magnesium 75

gnp masanti maximum strength 42

gnp masanti regular strength 42

gnp mega multi for men 87

gnp mega multi for women 87

gnp niacin tr 75

gnp omeprazole 45

gnp one daily maximum 87

gnp one daily mens health 50+ 87

gnp one daily plus iron 87

gnp one daily womens health 50+ 87

Drug Name Page #

gnp opti-vitamins 87

gnp pediatric electrolyte 75

gnp therapeutic-m 75

gnp tussin 66

gnp tussin dm 66

gnp vitamin a 87

gnp vitamin b-12 75

gnp vitamin b-12 tr 75

gnp vitamin b-6 75

gnp vitamin c 75

gnp vitamin c 87

gnp vitamin c drops 75

gnp vitamin c tr 87

gnp vitamin c w/rose hips 87

gnp vitamin c w/rose hips tr 87

gnp vitamin e 75

gnp zinc 75

gnp zoochews gummies 87

granisetron hcl 15

granisetron hcl 15

griseofulvin microsize 16

griseofulvin ultramicrosize 16

guaiatussin ac 67

guaifenesin ac 67

guaifenesin and pseudoephedrine

hydrochloride

67

guaifenesin er 67

guaifenesin/codeine 67

GUANIDINE HCL 17

HALAVEN 20

halls defense vitamin c drops 88

halobetasol propionate 47

haloperidol 24

haloperidol decanoate 24

haloperidol lactate 24

hard nails 88

HARVONI 26

HAVRIX 56

heartburn treatment 24 hour 45

heather 52

h-e-b incontrol lancets micro thin 33g 58

h-e-b oral electrolyte solution 75

hecoria 54

hemocyte 75

hemocyte plus 75

hemocyte-f 75

hemorrhoidal 39

110

Drug Name Page #

heparin sodium 31

heparin sodium/d5w 31

heparin sodium/nacl 0.45% 31

heparin sodium/nacl 0.9% 31

heparin sodium/sodium chloride 0.9% 31

heparin sodium/sodium chloride 0.9%

premix

31

HEPATAMINE 75

HERCEPTIN 22

HETLIOZ 38

HEXALEN 18

HIBERIX 56

histaflex 1

histex 63

histex pd 63

histex-dm 67

histex-pe 67

hm pediatric electrolyte 75

honey bears 88

honey bears w/iron and zinc 88

HUMALOG 31

HUMALOG KWIKPEN 30

HUMALOG MIX 50/50 30

HUMALOG MIX 50/50 KWIKPEN 30

HUMALOG MIX 75/25 30

HUMALOG MIX 75/25 KWIKPEN 31

HUMIRA 54

HUMIRA PEDIATRIC CROHNS

DISEASE STARTER PACK

54

HUMIRA PEN 54

HUMIRA PEN-CROHNS

DISEASESTARTER

54

HUMIRA PEN-PSORIASIS STARTER 54

HUMULIN 70/30 31

HUMULIN 70/30 KWIKPEN 31

HUMULIN N 31

HUMULIN N KWIKPEN 31

HUMULIN R 31

HUMULIN R U-500 (CONCENTRATED) 31

HUMULIN R U-500 KWIKPEN 31

HYCOFENIX 67

hydralazine hcl 37

hydro skin maximum strength 47

hydrochlorothiazide 36

hydrocodone bitartrate/acetaminophen 3

hydrocodone bitartrate/chlorpheniramine

maleate/pse

67

Drug Name Page #

hydrocodone bitartrate/homatropine

methylbromide

67

hydrocodone polistirex/chlorpheniramine

polistirex

67

hydrocodone/acetaminophen 4

hydrocodone/homatropine 67

hydrocodone/ibuprofen 4

hydrocortisone 47

hydrocortisone 57

hydrocortisone butyrate 47

hydrocortisone butyrate (lipid) 47

hydrocortisone butyrate (lipophilic) 47

hydrocortisone in absorbase 47

hydrocortisone valerate 47

hydrocortisone/acetic acid 61

hydrocortisone/aloe 47

hydromet 67

hydromorphone hcl 4

hydromorphone hcl dosette 4

hydroskin 47

hydroxychloroquine sulfate 23

hydroxyprogesterone caproate 52

hydroxyurea 19

hyoscyamine sulfate 41

hyoscyamine sulfate odt 41

hyosyne 41

i.l.x. b-12 75

ibandronate sodium 57

IBRANCE 21

ibu-200 2

ibudone 4

ibu-drops 2

ibu-drops infants 2

ibuprofen 2

ibuprofen childrens 2

ibuprofen junior strength 2

icaps areds formula 88

icaps mv 88

icaps plus 88

icar pediatric 75

icar-c 75

ICLUSIG 21

idarubicin hcl 20

iferex 150 75

ifosfamide 18

ILARIS 55

ILEVRO 60

111

Drug Name Page #

ilotycin 10

imatinib mesylate 21

IMBRUVICA 21

imipenem/cilastatin 8

imipramine hcl 15

imipramine pamoate 15

imiquimod 39

IMOVAX RABIES (H.D.C.V.) 56

INCRELEX 48

indapamide 36

INFANRIX 56

infants gas relief 42

infants ibuprofen 2

infants simethicone 42

infed 75

infumorph 200 3

infumorph 500 3

INLYTA 21

inspirachamber/large 58

integra 88

integra f 88

integra plus 88

INTELENCE 27

INTRALIPID 58

INTRALIPID 81

INTRON A 26

INTRON A W/DILUENT 26

introvale 50

INVANZ 8

INVEGA 25

INVEGA SUSTENNA 25

INVEGA TRINZA 25

INVIRASE 28

INVOKAMET 30

INVOKAMET XR 30

INVOKANA 30

iophen c-nr 67

iophen dm-nr 67

iophen-nr 67

iosat 67

IPOL INACTIVATED IPV 56

ipratropium bromide 64

ipratropium bromide/albuterol sulfate 64

irbesartan 33

irbesartan/hydrochlorothiazide 33

IRESSA 21

irinotecan 20

Drug Name Page #

iron 75

iron 88

iron 100/c 88

iron supplement childrens 88

irospan 24/6 75

ISENTRESS 27

isoniazid 18

ISOPTO TEARS 60

isosorbide dinitrate 37

isosorbide dinitrate er 37

isosorbide mononitrate 37

isosorbide mononitrate er 37

isotonic gentamicin 6

isradipine 35

ISTODAX 20

itraconazole 16

ivermectin 23

IXEMPRA KIT 20

IXIARO 56

JADENU 70

JAKAFI 21

JALYN 45

jantoven 31

JANUMET 30

JANUMET XR 30

JANUVIA 30

jencycla 52

JENTADUETO 30

JENTADUETO XR 30

JEVTANA 20

J-MAX 67

J-TAN D PD 63

J-TAN PD 63

juleber 50

junel 1.5/30 50

junel 1/20 50

junel fe 1.5/30 50

junel fe 1/20 50

junior mapap 1

KABIVEN 75

KADCYLA 22

KALETRA 28

KALYDECO 65

kao-tin 42

kao-tin 44

kariva 50

KCL 0.075%/D5W/NACL 0.45% 75

112

Drug Name Page #

kcl 0.15%/d5w/ nacl 0.3% 75

KCL 0.15%/D5W/LR 75

KCL 0.15%/D5W/NACL 0.2% 76

kcl 0.15%/d5w/nacl 0.225% 76

kcl 0.15%/d5w/nacl 0.45% 76

KCL 0.15%/D5W/NACL 0.9% 76

KCL 0.3%/D5W/LR IV LAC RING 76

KCL 0.3%/D5W/NACL 0.45% 76

kcl 0.3%/d5w/nacl 0.9% 76

kelnor 1/35 50

KETEK 10

ketoconazole 16

ketoprofen 2

ketoprofen er 2

ketorolac tromethamine 60

KEYTRUDA 22

kidkare cough/cold 67

kimidess 50

KINERET 54

KINRIX 56

kionex 70

klor-con 76

klor-con 10 76

klor-con 8 76

klor-con m10 76

klor-con m20 76

klor-con sprinkle 76

kobee 88

KORLYM 48

kp adults 50+ daily formula 88

kp adults daily formula 88

kp b complex/c 88

kp ferrous gluconate 76

kp ferrous sulfate 76

kp mens 50+ daily formula 88

kp mens daily formula 88

kp vitamin e 88

kp womens 50+ daily formula 88

kp womens daily formula 88

k-sol 75

kurvelo 50

KUVAN 40

KYNAMRO 37

labetalol hcl 34

LACRISERT 60

LACTATED RINGERS 76

LACTATED RINGERS IRRIGATION 58

Drug Name Page #

LACTATED RINGERS VIAFLEX 76

lactulose 44

lamivudine 26

lamivudine 28

lamivudine/zidovudine 28

lamotrigine 12

lamotrigine er 12

lamotrigine odt 12

LANOXIN PEDIATRIC 35

lansoprazole 45

lansoprazole/amoxicillin/clarithromycin 7

LANTUS 31

LANTUS SOLOSTAR 31

larin 1.5/30 50

larin 1/20 50

larin fe 1.5/30 50

larin fe 1/20 50

larissia 50

latanoprost 59

LATUDA 25

laxative 42

LAZANDA 4

leflunomide 55

LENVIMA 10 MG DAILY DOSE 21






lessina 50

LETAIRIS 65

letrozole 21

leucovorin calcium 20

LEUKERAN 18

LEUKINE 32

leuprolide acetate 53

LEVEMIR 31

LEVEMIR FLEXTOUCH 31

levetiracetam 11

levetiracetam er 11

levobunolol hcl 61

levocarnitine 58

levocetirizine dihydrochloride 63

levofloxacin 10

levofloxacin in d5w 10

levoleucovorin 20

levoleucovorin calcium 20

113

Drug Name Page #

levonest 50

levonorgestrel and ethinyl estradiol 50

levonorgestrel/ethinyl estradiol 50

levora 0.15/30-28 50

levorphanol tartrate 3

levothyroxine sodium 52

LEVOXYL 52

LEXIVA 28

lidocaine 5

lidocaine 39

lidocaine hcl 5

lidocaine hcl 34

lidocaine hcl jelly 5

lidocaine hcl viscous 5

lidocaine viscous 5

lidocaine/prilocaine 5

life pack mens 88

life pack womens 88

LINCOCIN 7

lincomycin hcl 7

lindane 23

linezolid 7

LINZESS 44

liothyronine sodium 52

LIPOFEN 36

liquid calcium/vitamin d 76

liquitears 60

lisinopril 33

lisinopril/hydrochlorothiazide 33

lithium carbonate 29

lithium carbonate er 29

l-methyl-b6-b12 88

LODRANE D 63

lohist-d 63

lohist-dm 67

LOMUSTINE 18

LONSURF 19

loperamide hcl 42

lopreeza 50

loratadine 63

loratadine childrens 63

loratadine hives relief 63

loratadine-d 12hr 63

loratadine-d 24hr 63

lorazepam 29

lorazepam intensol 29

lorcet 4

Drug Name Page #

lorcet hd 4

lorcet plus 4

lortab 4

lortuss dm 67

lortuss ex 67

lortuss lq 67

losartan potassium 33

losartan potassium/hydrochlorothiazide 33

LOTEMAX 61

lovastatin 36

low-ogestrel 50

loxapine 24

loxapine succinate 24

lubricating plus eye drops 60

lubrifresh p.m. 60

ludent 76

LUMIGAN 59

LUMIZYME 40

LUPRON DEPOT 53

LUPRON DEPOT-PED 53

lutera 50

LYNPARZA 22

LYRICA 11

lysiplex plus 88

LYSODREN 53

lyza 52

magnesium 42

magnesium 76

magnesium 27 76

magnesium elemental 76

magnesium oxide 42

magnesium sulfate 76

magnesium sulfate in d5w 76

mag-tab sr 76

major-prep hemorrhoidal 39

MAKENA 52

malathion 23

mapap 1

mapap acetaminophen extrastrength 1

mapap arthritis pain 1

mapap childrens 1

mapap cold formula multi-symptom 67

mapap pm 1

mapap sinus maximum strength congestion

and pain

67

maprotiline hcl 13

margesic 1

114

Drug Name Page #

marlissa 50

MARPLAN 13

mask vortex/child/frog 58

mask vortex/toddler/lady bug 58

MATULANE 18

matzim la 35

meclizine hcl 15

meclofenamate sodium 2

medicated body powder 39

MEDROL 47

medroxyprogesterone acetate 52

mefloquine hcl 23

mega multiple w/chelated minerals 88

mega multivitamin for men 88

mega multivitamin for women 88

megestrol acetate 52

MEKINIST 22

meloxicam 2

melphalan hydrochloride 18

memantine hcl 13

memantine hcl titration pak 13

memantine hydrochloride 13

MENACTRA 56

M-END DMX 67

M-END MAX D 67

MENEST 50

MENHIBRIX 56

MENOMUNE-A/C/Y/W-135 56

MENOSTAR 50

MENVEO 56

MEPHYTON 88

mercaptopurine 19

meribin 88

meropenem 8

meropenem/sodium chloride 8

mesalamine 57

mesna 20

MESNEX 20

MESTINON TIMESPAN 17

metadate er 38

metaproterenol sulfate 65

metformin hcl 30

metformin hcl er 30

METHADONE HCL 3

methadone hcl intensol 3

methazolamide 61

methenamine hippurate 7

Drug Name Page #

methimazole 54

methotrexate 55

methotrexate sodium 55

methoxsalen 39

methscopolamine bromide 41

methylphenidate hcl 38

methylphenidate hcl er 38

methylphenidate hcl sr 38

methylprednisolone 47

methylprednisolone acetate 47

methylprednisolone dose pack 47

methylprednisolone sodiumsuccinate 47

metipranolol 61

metoclopramide hcl 42

metolazone 36

metoprolol succinate er 34

metoprolol tartrate 34

metoprolol/hydrochlorothiazide 34

metronidazole 7

metronidazole in nacl 0.79% 7

metronidazole vaginal 7

mexiletine hcl 34

MIACALCIN 57

mi-acid 42

mi-acid gas relief 42

mi-acid maximum strength 42

miconazole 16

miconazole 7 16

miconazole nitrate 16

microgestin 1.5/30 50

microgestin 1/20 50

microgestin fe 50

microgestin fe 1.5/30 50

midodrine hcl 32

MIGERGOT 17

miglitol 30

migraine formula 2

milk of magnesia 42

milk of magnesia 44

milk of magnesia concentrate 42

mimvey 50

mimvey lo 50

minitran 37

MINIVELLE 50

minocycline hcl 10

minoxidil 37

mintox maximum strength 43

115

Drug Name Page #

mirtazapine 13

mirtazapine odt 13

misoprostol 45

mitomycin 20

mitoxantrone hcl 20

M-M-R II 56

modafinil 70

moderiba 26

moderiba 1200 dose pack 26

moderiba 800 dose pack 26

moexipril hcl 33

moexipril/hydrochlorothiazide 33

molindone hydrochloride 26

mometasone furoate 47

mondoxyne nl 10

monocal 76

mono-linyah 50

montelukast sodium 64

morgidox 1x100mg 10

morgidox 1x50mg 10

morgidox 2x100mg 10

morphine sulfate 3

morphine sulfate 4

morphine sulfate add-vantage 4

morphine sulfate er 3

MOVIPREP 44

MOXEZA 10

moxifloxacin hcl 10

MOZOBIL 76

mtx support 88

mucaphed 67

MUCINEX 68

mucinex chest congestion childrens 67

mucinex childrens cold cough & sore throat 67

mucinex childrens multi-symptom cold 67

MUCINEX CHILDRENS

MULTI-SYMPTOM COLD & FEVER

67

mucinex congestion & cough childrens 67

mucinex cough childrens 67

MUCINEX COUGH FOR KIDS 67

MUCINEX D 67

MUCINEX D MAXIMUM STRENGTH 67

MUCINEX DM 67

MUCINEX DM MAXIMUM STRENGTH 68

mucinex fast-max cold & sinus 68

MUCINEX FAST-MAX COLD FLU&

SORE THROAT

68

Drug Name Page #

mucinex fast-max day time/night time 68

mucinex fast-max day/night maximum

strength

68

mucinex fast-max dm max 68

mucinex fast-max night time cold & flu 68

mucinex fast-max severe cold 68

mucinex fast-max severe congestion &

cough

68

MUCINEX FOR KIDS 68

mucinex maximum strength 68

mucinex multi-symptom cold day/night pack 68

mucinex multi-symptom cold night time

childrens

68

mucinex sinus-max day/night 68

mucinex sinus-max full force 68

mucinex sinus-max moisture smart 68

mucinex sinus-max pressure & pain 68

mucinex sinus-max severe congestion relief 68

mucinex stuffy nose & cold childrens 68

mucus relief 68

mucus-er 68

mucusrelief sinus 68

MULTAQ 34

multi complete/iron 88

multi vitamin daily 88

multi-day plus iron 88

multi-day vitamins 88

multi-delyn 88

multi-delyn/iron 88

multi-lancet device 2 58

multilex 89

multilex-t&m 89

multiple vitamin/minerals/no iron 89

multiple vitamins 89

multiple vitamins plain 89

multiple vitamins/iron 89

multi-vitamin 89

multivitamin & mineral 89

multi-vitamin daily 88

multi-vitamin hp/minerals 88

multi-vitamin/minerals 88

multi-vitamins 88

mupirocin 7

mupirocin calcium 7

MURO 128 60

MUSTARGEN 18

my way 52

116

Drug Name Page #

mycophenolate mofetil 55

mycophenolic acid dr 55

mydral 60

myferon 150 76

mykidz iron 89

mykidz iron 10 89

myorisan 39

mytab gas 43

mytab gas max str 43

my-vitalife 89

myzilra 50

nabumetone 2

nadolol 34

nadolol/bendroflumethiazide 34

nafcillin sodium 9

naftifine hcl 16

naftifine hydrochloride 16

NAFTIN 16

NAGLAZYME 40

nalbuphine hcl 4

naloxone hcl 5

naltrexone hcl 5

NAMENDA 13

NAMENDA TITRATION PAK 13

NAMENDA XR 13

NAMENDA XR TITRATION PACK 13

NAMZARIC 12

naphazoline hcl 60

naproxen 2

naproxen dr 2

naproxen sodium 2

naratriptan hcl 17

NARCAN 5

nasal decongestant 68

nasal decongestant pe 68

nasal decongestant spray 68

NASOPEN PE 63

NATACYN 16

natalvirt flt 76

nateglinide 30

NATPARA 58

natural balance tears 60

natural fiber therapy 43

natures tears 60

NEBUPENT 23

necon 0.5/35-28 51

necon 1/35 51

Drug Name Page #

necon 1/50-28 51

necon 10/11-28 51

necon 7/7/7 51

nefazodone hcl 13

neomycin sulfate 6

neomycin/bacitracin/polymyxin 7

neomycin/polymyxin b sulfates 6

neomycin/polymyxin/bacitracin zinc 7

neomycin/polymyxin/bacitracin/hydrocortis

one

7

neomycin/polymyxin/dexamethasone 61

neomycin/polymyxin/gramicidin 7

neomycin/polymyxin/hc 61

neomycin/polymyxin/hydrocortisone 7

neomycin/polymyxin/hydrocortisone 61

neo-polycin 7

neo-polycin hc 7

NEPHRAMINE 76

nephrocaps 89

nephron fa 76

nephronex 89

nephro-vite 89

NEULASTA 32

NEUMEGA 32

NEUPOGEN 32

NEUPRO 23

nevirapine 27

nevirapine er 27

NEXAVAR 22

next choice one dose 52

niacin 37

niacin 89

niacin er 37

niacin er 89

niacin sr 89

niacin tr 89

niacor 37

nicardipine hcl 35

NICODERM CQ 5

nicorelief 5

NICORETTE 5

NICORETTE MINI 5

NICORETTE STARTER KIT 5

nicotine polacrilex 5

nicotine transdermal system 5

nicotine transdermal system step 1 5


117

Drug Name Page #


NICOTROL INHALER 6

NICOTROL NS 6

nifedical xl 35

nifedipine er 35

night time multi-symptom cold/flu relief 68

night time sleep aid 63

NILANDRON 18

nilutamide 18

nimodipine 35

ninjacof 68

ninjacof-a 68

ninjacof-xg 68

NINLARO 20

NIPENT 19

nisoldipine 35

nisoldipine er 35

nitrofurantoin 7

nitrofurantoin macrocrystals 7

nitrofurantoin monohydrate 7

nitrofurantoin monohydrate/macrocrystals 7

nitroglycerin 37

nitroglycerin lingual 37

nitroglycerin transdermal 37

NITROSTAT 37

nizatidine 43

no iron multiple vitamin/minerals 89

nohist-dm 68

nohist-lq 63

norethindrone 52

norethindrone acetate 52

norethindrone acetate/ethinyl estradiol 51

norethindrone acetate/ethinyl

estradiol/ferrous fumarate

51

norgestimate/ethinyl estradiol 51

NORITATE 7

norlyroc 52

NORMOSOL -R 76

NORMOSOL-M IN D5W 76

NORMOSOL-R 76

NORMOSOL-R IN D5W 76

NORTHERA 35

nortrel 0.5/35 (28) 51

nortrel 1/35 51

nortrel 7/7/7 51

nortriptyline hcl 15

NORVIR 28

Drug Name Page #

NOVAFERRUM 125 76

NOVAFERRUM 50 76

NOVAFERRUM PEDIATRIC DROPS 76

NOVAREL 48

novofine 30gx8mm 58

novofine 31 58

novofine 32gx6mm 58

novofine autocover 30gx8mm 58

novotwist 30gx8mm 58

novotwist 32gx5mm 59

NOXAFIL 16

nrs nasal relief 68

NUEDEXTA 38

nu-iron 150 76

nulev 41

NULOJIX 55

nu-mag 76

NUPLAZID 25

nutricap 89

NUTRILIPID 81

NUTRILYTE 77

NUTRILYTE II 76

nutrivit 89

NUVIGIL 70

nyamyc 16

nystatin 16

nystatin/triamcinolone 16

nystop 17

oceanic selenium 77

OCTAGAM 55

octreotide acetate 53

ODEFSEY 27

ODOMZO 20

ofloxacin 10

ogestrel 51

olanzapine 25

olanzapine odt 25

olanzapine/fluoxetine 14

olopatadine hcl 60

OLYSIO 26

omega-3-acid ethyl esters 37

omeprazole 45

omeprazole magnesium 45

omnicap 89

ONCASPAR 20

once daily 89

once daily/iron 89

118

Drug Name Page #

oncovite 89

ondansetron hcl 15

ondansetron odt 15

one daily 90

one daily complete 89

one daily maximum 89

one daily mens 89

one daily plus iron 89

one daily plus minerals 89

one daily womens 50+ 89

one daily/iron/calcium 89

one daily/minerals 89

one-a-day essential 90

one-a-day mens 50+ advantage 90

one-a-day teen advantage for her 90

one-a-day teen advantage for him 90

one-a-day womens formula 90

one-daily multi vitamins 90

one-way valved

expiratorymouthpiece/disposable

59

one-way valved inspiratory

mouthpiece/disposable

59

ONFI 11

opcicon one-step 52

OPDIVO 22

OPSUMIT 65

opti-clear 60

oralone 38

oralyte 77

oralyte freezer pops 77

ORAP 24

orazinc 77

ORFADIN 41

organ-i nr 68

orphenadrine citrate er 70

orsythia 51

os-cal 77

os-cal calcium + d3 77

os-cal extra d3 77

os-cal ultra 77

oscimin 41

OSMOPREP 43

osteo-poretical 77

oxacillin sodium 9

oxaliplatin 20

oxandrolone 48

oxaprozin 2

Drug Name Page #

oxazepam 29

oxcarbazepine 12

oxybutynin chloride 45

oxybutynin chloride er 45

oxycodone hcl 4

oxycodone/acetaminophen 4

oxycodone/aspirin 4

oxycodone/ibuprofen 4

oxymorphone hydrochloride er 3

oysco 500 77

oysco 500+d 77

oysco d 77

oyst-cal-d 500 77

oyster calcium 77

oyster shell calcium 77

oyster shell calcium + d 77

oyster shell calcium + d3 77

oyster shell calcium + vitamin d 77

oyster shell calcium 250+d 77

oyster shell calcium 500 77

oyster shell calcium 500 + d 77

oyster shell calcium 500/d 77

oyster shell calcium 500+d 77

oyster shell calcium plusvitamin d 77

oyster shell calcium/d 77

oyster shell calcium/d3 77

oyster shell calcium/vitamin d 77

oyster shell calcium+d 77

oystercal-d 77

pa b-complex with b-12 90

pa biotin 90

pa oyster shell calcium 90

pa vitamin b-12 tr 90

pa vitamin e 90

pacerone 34

paclitaxel 20

pain & fever 1

pain & fever childrens 1

pain & fever extra strength 1

pain relief sinus pe daytime 68

pain reliever pm extra strength 1

paliperidone er 25

pamidronate disodium 57

PANCRELIPASE 41

panda mask large 59

panda mask medium 59

panda mask small 59

119

Drug Name Page #

PANRETIN 22

pantoprazole sodium 45

pantothenic acid 59

paricalcitol 57

paroex 38

paromomycin sulfate 6

paroxetine hcl 14

paroxetine hcl er 14

PASER 18

PATADAY 60

PAXIL 14

PAZEO 60

pedialyte 77

pedialyte advanced care 77

pedialyte freezer pops 77

pedialyte singles 77

pediatric cough/cold 68

pediatric electrolyte 78

pediatric electrolyte freeze pops 78

pediatric electrolyte freezer pops 78

pediatric electrolyte/zinc 78

pediatric medium mask 59

pediatric mouthpiece/disposable 59

pediatric panda mask 59

pediatric small mask 59

PEDVAX HIB 56

peg 3350 44

peg 3350/electrolytes 44

peg3350 44

peg-3350/electrolytes 44

peg-3350/nacl/na bicarbonate/kcl 44

PEGANONE 12

PEGINTRON 27

PEG-INTRON REDIPEN 26

PEG-INTRON REDIPEN PAK 4 26

penicillin g potassium 9

penicillin v potassium 9

PENTAM 300 23

pentoxifylline er 35

peptic relief 43

PERFOROMIST 65

peridin-c 90

PERIKABIVEN 78

perindopril erbumine 33

periogard 38

PERJETA 22

permethrin 23

Drug Name Page #

perphenazine 24

perphenazine/amitriptyline 15

PFIZERPEN-G 9

pharmacist choice no coding blood glucose

test strips

59

pharmacist choice ultra thin lancets 33g 59

phenazopyridine hcl 46

phenelzine sulfate 14

phenobarbital 11

phenoxybenzamine hydrochloride 33

phenylephrine hcl/pyrilamine maleate 68

phenylhistine dh 69

phenytoin 12

phenytoin infatabs 12

phenytoin sodium 12

phenytoin sodium extended 12

philith 51

phillips 43

PHOSLYRA 46

phospha 250 neutral 78

PHOSPHOLINE IODIDE 61

PHYSIOLYTE 59

PHYSIOSOL IRRIGATION 59

PICATO 39

pilocarpine hcl 38

pilocarpine hcl 61

pilocarpine hydrochloride 38

pimozide 24

pimtrea 51

pindolol 34

pink bismuth 43

pioglitazone hcl 30

pioglitazone hcl/metformin hcl 30

pioglitazone hcl-glimepiride 30

piperacillin sodium/ tazobactam sodium 9

piperacillin sodium/tazobactam sodium 9

piperacillin/tazobactam 9

pirmella 1/35 51

pirmella 7/7/7 51

piroxicam 2

PLENAMINE 78

podofilox 39

poly vitamin 90

polycin 7

polyethylene glycol 3350 44

POLY-HIST DM 69

POLY-HIST PD 63

120

Drug Name Page #

poly-iron 150 78

polymyxin b sulfate 7

polymyxin b sulfate/trimethoprim sulfate 7

polysacc iron 150 complex 78

poly-vent dm 69

poly-vent ir 69

poly-vita drops 90

poly-vita/iron drops 90

polyvitamin 90

polyvitamin/iron 90

POMALYST 19

portia-28 51

PORTRAZZA 20

potassium chloride 78

potassium chloride 0.15% /nacl 0.45%

viaflex

78

potassium chloride 0.15% d5w/nacl 0.33% 78


potassium chloride 0.15% d5w/nacl 0.45%

viaflex

78

potassium chloride 0.15% w/nacl 0.9%

viaflex

78

potassium chloride 0.15%/d5w 78

potassium chloride 0.15%/nacl 0.9% 78


potassium chloride 0.224%/d5w/nacl 0.45% 78

potassium chloride 0.3%/ nacl 0.9% 78

potassium chloride 0.3%/d5w 78

potassium chloride 0.3%/nacl 0.9%/viaflex 78

potassium chloride cr 78

potassium chloride er 78

potassium chloride sr 78

potassium citrate er 78

POTIGA 11

povidone-iodine 7

PRADAXA 31

pramipexole dihydrochloride 23

pramipexole dihydrochloride er 23

pravastatin sodium 36

prazosin hcl 33

PRED MILD 61

PRED-G 61

PRED-G S.O.P. 61

prednicarbate 47

prednisolone 47

prednisolone acetate 61

prednisolone sodium phosphate 47

Drug Name Page #

prednisolone sodium phosphate 61

prednisone 47

prednisone intensol 47

PREGNYL W/DILUENT BENZYL

ALCOHOL/NACL

48

PREMARIN 51

PREMASOL 78

premium blood glucose test strips 59

premium lidocaine 5

prevalite 37

prevent 90

previfem 51

PREZCOBIX 28

PREZISTA 28

PRIMAQUINE PHOSPHATE 23

primidone 12

PRIMSOL 7

PRISTIQ 14

PRIVIGEN 55

pro comfort lancets 30g 59

PROAIR HFA 65

PROAIR RESPICLICK 65

probarimin qt 78

probenecid 17

probenecid/colchicine 17

PROCALAMINE 78

prochlorperazine 24

prochlorperazine edisylate 24

prochlorperazine maleate 24

PROCRIT 32

procto-med hc 47

procto-pak 47

proctosol hc 47

proctozone-hc 47

prodigy safety lancets 59

profe 78

proferrin es 78

progesterone 52

PROGLYCEM 30

PROGRAF 55

PROLASTIN-C 69

PROLEUKIN 20

PROLIA 57

PROMACTA 32

promethazine hcl 15

promethazine hcl plain 15

promethazine vc/codeine 69

121

Drug Name Page #

promethazine/codeine 63

promethazine/codeine 69

promethazine/dextromethorphan 69

promethazine-dm 69

propafenone hcl 34

propafenone hcl er 34

propantheline bromide 41

proparacaine hcl 60

propranolol hcl 34

propranolol hcl er 34

propranolol/hydrochlorothiazide 34

propylthiouracil 54

PROQUAD 56

PROSOL 78

protectiron 90

protexin 90

protriptyline hcl 15

PRUDOXIN 40

pseudoephedrine hcl 69

PULMOZYME 65

puralube 60

pure c 500 90

pureway-c 90

PURIXAN 19

pyrazinamide 18

pyridostigmine bromide 17

pyridostigmine bromide er 17

pyridoxine hcl 90

qc anti-diarrheal 43

qc arthritis pain relief 1

qc calcium fast dissolution 78

qc calcium/minerals/vitamin d 90

qc childrens chewable vitamins/extra c 90

qc cough/sore throat nighttime 69

qc ibuprofen 2

qc loratadine allergy relief 63

qc loratadine-d 63

qc maximum daily

multivitamin/multimineral

90

qc multi-vite 90

qc naproxen sodium 2

qc tolnaftate 17

qc unilet lancets 33g/micro thin 59

qc womens daily multivitamin 90

q-dryl 63

q-pap 1

q-pap childrens 1

Drug Name Page #

q-pap extra strength 1

q-pap infants 1

q-tussin 69

q-tussin dm 69

QUADRACEL 56

quasense 51

quenalin 63

quetiapine fumarate 25

quinapril hcl 33

quinapril/hydrochlorothiazide 33

quinidine sulfate 34

quinine sulfate 23

quintabs-m 90

QVAR 62

ra balanced b-100 90

ra balanced b-50 90

ra b-complex 90

ra b-complex with b-12 90

ra b-complex/vitamin c tr 90

ra beta carotene 90

ra biotin 90

ra calcium 600 79

ra calcium 600 plus vitamin d-3 90

ra calcium 600/vit d/minerals 79

ra calcium citrate plus vitamin d-3 79

ra calcium soft chews 90

ra calcium/boron 91

ra calcium/magnesium/zinc/copper 91

ra central-vite 91

ra central-vite cardio 79

ra central-vite energy 91

ra central-vite performance 79

ra central-vite select mature 91

ra central-vite senior 91

ra central-vite under 50 mens 79

ra central-vite under 50 womens 79

ra central-vite womens mature 79

ra central-vite/antioxidants 91

ra coral calcium 91

ra hi cal 91

ra hi-cal plus vitamin d 91

ra high potency iron 91

ra iron 91

ra magnesium 91

ra natural magnesium 79

ra natural vitamin e 91

ra niacin 91

122

Drug Name Page #

ra one daily energy formula 91

ra one daily essential 91

ra one daily maximum 91

ra one daily mens 50+ with vitamin d-3 91

ra one daily multi-vitamin 91

ra one daily multi-vitamin plus iron 91

ra oyster shell calcium/vitamin d 91

ra pediatric electrolyte 79

ra pediatric electrolyte freezer pops 79

ra selenium 79

ra selenium natural 79

ra slow release iron 79

ra stress formula advanced 91

ra stress formula energy 91

ra therapeutic m plus beta carotene 91

ra vitamin a 91

ra vitamin b-1 91

ra vitamin b12 91

ra vitamin b-12 91

ra vitamin b-12 tr 91

ra vitamin b-6 91

ra vitamin c 91

ra vitamin c drops 91

ra vitamin c tr 91

ra vitamin c/acerola 91

ra vitamin c/rose hips 91

ra vitamin c/rose hips tr 91

ra vitamin e 92

ra whole source complete formula for men 92

ra whole source dietary 92

ra whole source dietary for men 92

ra whole source dietary mature 92

ra zinc 79

rabano yodado 92

RABAVERT 56

raloxifene hydrochloride 52

ramipril 33

RANEXA 35

ranitidine 150 maximum strength 43

ranitidine 75 43

ranitidine hcl 43

ranitidine maximum strength 44

RAPAMUNE 55

REBETOL 27

REBIF 38

REBIF REBIDOSE 38

REBIF REBIDOSE TITRATION PACK 38

Drug Name Page #

REBIF TITRATION PACK 38

reclipsen 51

RECOMBIVAX HB 56

REFRESH CELLUVISC 60

REFRESH LACRI-LUBE 60

REFRESH PLUS 60

REGONOL 17

REGRANEX 40

reguloid 43

relion prime blood glucose test strips 59

RELISTOR 43

REMICADE 55

REMODULIN 65

renal vitamin 92

renal-vite 92

rena-vite 92

RENVELA 46

repaglinide 30

REPATHA 37

REPATHA PUSHTRONEX SYSTEM 37

REPATHA SURECLICK 37

reprexain 4

RESCON 64

RESCON DM 69

RESCON-GG 69

RESCRIPTOR 27

RESPAIRE-30 69

RESTASIS 60

restfully sleep 64

RETROVIR IV INFUSION 28

REVLIMID 19

REXULTI 25

REYATAZ 28

REZIRA 69

ribasphere 27

RIBASPHERE RIBAPAK 27

RIBATAB 27

ribavirin 27

RIDAURA 55

rifabutin 18

rifampin 18

RIFATER 18

riluzole 38

rimantadine hcl 28

RINGERS INJECTION 79

RINGERS IRRIGATION 59

RIOMET 30

123

Drug Name Page #

risacal-d 92

risedronate sodium 57

RISPERDAL CONSTA 25

risperidone 25

risperidone m-tab 25

risperidone odt 25

RITUXAN 22

rivastigmine tartrate 13

rivastigmine transdermal system 13

rizatriptan benzoate 17

rizatriptan benzoate odt 17

robafen 69

robafen cf cough & cold 69

robafen cf multi-symptom cold 69

robafen cough 69

robafen dm 69

robafen dm cough clear 69

ropinirole hcl 23

rosadan 7

rosuvastatin calcium 37

ROTARIX 56

ROTATEQ 56

roweepra 11

roxicet 4

ROZEREM 70

ru-hist d 64

rulox 43

rymed 64

rynex dm 69

rynex pe 64

rynex pse 64

S2 65

SABRIL 12

SAIZEN 48

SAIZEN CLICK.EASY 48

salsalate 3

SAMSCA 70

SANDIMMUNE 55

SANDOSTATIN LAR DEPOT 53

sani-supp adult 44

sani-supp pediatric 44

SANTYL 40

SAPHRIS 25

sb pediatric electrolyte 79

scooby-doo one a day 92

selegiline hcl 24

selenium 79

Drug Name Page #

selenium sulfide 40

SELZENTRY 28

senexon 43

senior tabs 92

senna 43

senna 44

senna lax 43

senna plus 44

senna-lax 44

sennalax-s 44

SENSIPAR 53

sentry 92

sentry senior 92

SEREVENT DISKUS 65

SEROQUEL XR 25

sertraline hcl 14

se-tan plus 79

setlakin 51

sharobel 52

siderol 92

sidestream pediatric facemask 59

sidestream pediatric facemask/tucker the

turtle

59

SIGNIFOR 53

siladryl allergy 64

sildenafil 65

SILENOR 70

silicone mask for breatherite

chamber/pediatric

59

silphen cough 64

siltussin dm das 69

siltussin sa 69

siltussin-dm 69

silver sulfadiazine 7

SIMBRINZA 61

simethicone 43

SIMULECT 55

simvastatin 37

sirolimus 55

SIRTURO 18

slo-niacin 92

slow fe 79

slow release iron 79

slow-mag 79

sm allergy 4 hour 64

sm allergy relief 64

sm antacid anti-gas 43

124

Drug Name Page #

sm antacid/antigas 43

sm anti-diarrheal 43

sm balanced b-50 79

sm calcium 500/vitamin d3 79

sm calcium 600/vitamin d 79

sm calcium citrate w/vitamin d3 79

sm calcium soft chews 79

sm calcium/magnesium/zinc 79

sm calcium/vitamin d 79

sm chewable c 92

sm complete 79

sm complete advanced formula 79

sm complete senior formula 79

sm ibuprofen 3

sm iron 79

sm loratadine 64

sm lorata-dine d 64

sm magnesium 79

sm miconazole 7 17

sm multiple vitamins essential 79

sm multiple vitamins/iron 79

sm nasal decongestant maximum strength 69

sm nasal spray 12 hour 69

sm oyster shell calcium/vitamin d 79

sm oyster shell calcium/vitamin d3 79

sm pediatric electrolyte 80

sm selenium 80

sm sleep aid 64

sm slow release iron 80

sm super b complex-vitamin c 92

sm tussin 69

sm tussin dm 69

sm tussin dm cough/chest congestion 69

sm vit c/rose hips 80

sm vitamin b-12 80

sm vitamin b-6 80

sm vitamin c 80

sm vitamin c/rose hips 92

sm vitamin e 80

sm vitamin e blended 80

sm zinc 80

sodium bicarbonate 43

sodium bicarbonate 70

sodium bicarbonate partial fill 70

sodium chloride 60

SODIUM CHLORIDE 80

SODIUM CHLORIDE 0.45% 80

Drug Name Page #

SODIUM CHLORIDE 0.9% 59

SODIUM EDECRIN 36

sodium fluoride 80

SODIUM LACTATE 70

sodium phenylbutyrate 41

sodium polystyrene sulfonate 71

sodium sulfacetamide 10

SOLTAMOX 19

SOLU-CORTEF 47

SOMATULINE DEPOT 53

SOMAVERT 53

sore throat & cough lozenges 5

sorine 34

sotalol hcl 34

sotalol hcl (af) 34

SOVALDI 27

SPIRIVA HANDIHALER 64

SPIRIVA RESPIMAT 64

spironolactone 36

spironolactone/hydrochlorothiazide 36

SPORANOX 17

sprintec 28 51

SPRITAM 11

SPRYCEL 22

sps 71

sronyx 51

SSD 7

stahist ad 69

stavudine 28

sterile water irrigation 59

STIMATE 48

stimulant laxative 43

STIOLTO RESPIMAT 69

STIVARGA 22

stool softener 43

stool softener 45

stool softener extra strength 43

stool softener laxative dc 43

STRATTERA 38

streptomycin sulfate 6

stress b/zinc 92

stress formula 92

stress formula w/iron 92

stress formula/iron 92

stress formula/zinc 92

STRIBILD 27

STRIVERDI RESPIMAT 65

125

Drug Name Page #

strovite forte 92

strovite one 92

SUBOXONE 5

sucralfate 45

sudogest 69

sudogest 12 hour 69

sudogest pe 69

sudogest sinus & allergy 64

sulfacetamide sodium 10

sulfacetamide sodium/prednisolone sodium

phosphate

10

sulfadiazine 10

sulfamethoxazole/trimethoprim 10

sulfamethoxazole/trimethoprim ds 10

sulfasalazine 57

sulfatrim pediatric 10

sulindac 3

sumatriptan 17

sumatriptan succinate 17

sumatriptan succinate refill 17

super b complex maxi 92

super b complex/c 92

super b with c 93

super biotin 93

super calcium 80

super calcium 600 + d3 80

super calcium 600+d 400 80

super calcium 600+d3 400 80

super quints b-50 93

super thera vite m 93

superplex-t 93

supervite ec 93

suplevit 93

support 80

support-500 93

SUPRAX 8

SUPREP BOWEL PREP 45

SURMONTIL 15

suspendol-s 59

SUSTIVA 27

SUTENT 22

SYLATRON 20

symax-sl 41

SYMBICORT 62

SYMLINPEN 120 30

SYMLINPEN 60 30

SYNAGIS 55

Drug Name Page #

SYNAREL 53

SYNERCID 7

SYNRIBO 20

SYNTHROID 52

SYPRINE 71

tab-a-vite 93

tab-a-vite maximum 93

tab-a-vite w/beta carotene 93

tab-a-vite womens 93

tab-a-vite/iron 93

TABLOID 19

tacrolimus 40

tacrolimus 55

TAFINLAR 22

TAGRISSO 22

TALWIN 4

TAMIFLU 29

tamoxifen citrate 19

tamsulosin hcl 45

TANDEM 80

tandem plus 80

TARCEVA 22

TARGRETIN 22

tarina fe 1/20 51

taron forte 80

TASIGNA 22

tazicef 8

TAZORAC 40

taztia xt 35

TECENTRIQ 22

TEFLARO 8

TEGRETOL-XR 12

TEKTURNA 35

TEKTURNA HCT 35

telmisartan 33

telmisartan/amlodipine 33

telmisartan/hydrochlorothiazide 33

temazepam 70

TENIVAC 56

terazosin hcl 45

terbinafine hcl 17

terbutaline sulfate 65

terconazole 17

TESTIM 48

testosterone 48

testosterone cypionate 48

testosterone enanthate 48

126

Drug Name Page #

testosterone pump 48

TETANUS/DIPHTHERIA

TOXOIDS-ADSORBED

56

TETANUS/DIPHTHERIA

TOXOIDS-ADSORBED ADULT

56

tetrabenazine 38

tetracycline hcl 11

TEXACORT 47

th antacid regular strength 43

th b 100 complex 93

th b complex/iron/vitamin c/vitamin e 93

th calcium 80

th calcium 600 with vitamin d 80

th calcium 600/vitamin d 80

th calcium citrate/vitamin d 80

th complete multi 93

th complete multi 50+ 93

th daily multiple vitamins 93

th daily multiple vitamins/iron 93

th iron 80

th oyster shell calcium/vitamin d 80

th premium daily multiple 93

th theradex-m 93

th vitamin b 50/b-complex 93

th vitamin b1 93

th vitamin b12 93

th vitamin b-12 93

th vitamin b12 er 93

th vitamin b-6 93

th vitamin c 93

th vitamin c/rose hips/bioflavonoids 93

th vitamin e 93

th vitamin e/d-alpha 93

th zinc 80

THALOMID 19

THEO-24 65

theochron 65

theophylline cr 65

theophylline er 65

thera 94

thera m plus 93

thera/beta-carotene 94

THERA-GESIC 40

thera-m 94

therapeutic liquid 80

thera-tabs 94

theratrum complete 80

Drug Name Page #

theratrum complete 94

therems 94

therems-h 94

therems-m 94

thiamine hcl 94

thioridazine hcl 24

thiotepa 18

thiothixene 24

THYMOGLOBULIN 55

THYROLAR-1 52

THYROLAR-1/2 52

THYROLAR-1/4 52

THYROLAR-2 52

THYROLAR-3 53

thyrosafe 59

thyroshield 59

tiagabine hydrochloride 12

TIKOSYN 34

tilia fe 51

TIMENTIN 9

timolol maleate 34

timolol maleate 61

tioconazole-1 17

TIVICAY 27

tizanidine hcl 26

TOBI PODHALER 65

TOBRADEX 61

tobramycin 65

tobramycin sulfate 6

tobramycin/dexamethasone 61

TOBREX 6

tolcapone 23

tolmetin sodium 3

tolnaftate 17

tolterodine tartrate 45

topiramate 12

toposar 21

topotecan hcl 21

TORISEL 55

torsemide 36

total b/c 94

totalday multiple 80

TOUJEO SOLOSTAR 31

TPN ELECTROLYTES 80

TRACLEER 65

TRADJENTA 30

tramadol hcl 4

127

Drug Name Page #

tramadol hcl er 3

tramadol hydrochloride/acetaminophen 4

trandolapril 33

tranexamic acid 32

TRANSDERM-SCOP 15

tranylcypromine sulfate 14

TRAVASOL 80

TRAVATAN Z 59

travel sickness 15

trazodone hcl 13

TREANDA 18

TRECATOR 18

TRELSTAR 53

TRELSTAR MIXJECT 53

TRESIBA FLEXTOUCH 31

tretinoin 22

tretinoin 40

tretinoin microsphere 40

tretinoin microsphere pump 40

trezix 4

triamcinolone acetonide 39



triamcinolone in orabase 39

triamterene/hydrochlorothiazide 36

trianex 48

triderm 48

tri-estarylla 51

trifluoperazine hcl 24

trifluridine 29

trihexyphenidyl hcl 23

tri-legest fe 51

tri-linyah 51

trilyte 45

trimethoprim 7

trimethoprim sulfate/polymyxin b sulfate 7

trimipramine maleate 15

TRINTELLIX 13

triple antibiotic 7

triple antibiotic plus 7

tri-previfem 51

TRISENOX 20

tri-sprintec 51

TRIUMEQ 28

tri-vi-sol 94

tri-vita 94

tri-vitamin 94

Drug Name Page #

trivora-28 51

trixaicin 40

trixaicin hp 40

TROKENDI XR 12

TROPHAMINE 80

tropicamide 60

true metrix self monitoring blood glucose

strips

59

TRULICITY 30

TRUMENBA 56

TRUVADA 28

tussin dm 69

tussin dm clear 69

TUSSIONEX PENNKINETIC

EXTENDED RELEASE

69

TWINRIX 56

TYBOST 28

TYGACIL 7

TYKERB 22

TYPHIM VI 56

TYSABRI 38

TYZEKA 26

TYZINE PEDIATRIC NASAL DROPS 69

ULORIC 17

unicomplex-m 94

unilet lancets micro-thin33g 59

UNITHROID 53

UNITUXIN 22

ursodiol 43

UVADEX 40

VAGIFEM 51

valacyclovir hcl 29

VALCHLOR 18

VALCYTE 26

valganciclovir 26

valganciclovir hydrochlorde 26

valproate sodium 12

valproic acid 12

valsartan 33

valsartan/hydrochlorothiazide 33

VANACOF 69

VANACOF DM 70

VANACOF-8 70

VANAHIST PD 64

vancomycin 7

vancomycin hcl 8

vancomycin hcl in dextrose 8

128

Drug Name Page #

vandazole 8

VAQTA 56

VARIVAX 56

VARIZIG 56

VASCEPA 37

v-c forte 94

VECTIBIX 22

VECTICAL 40

VELCADE 20

velivet 51

VELPHORO 46

VENCLEXTA 20

VENCLEXTA STARTING PACK 20

venlafaxine hcl 14

venlafaxine hcl er 14

verapamil hcl 35

verapamil hcl er 35

verapamil hcl sr 35

VERSACLOZ 26

VESICARE 45

vic-forte 94

vicodin 4

vicodin es 4

vicodin hp 4

VICTOZA 30

VIDEX PEDIATRIC 28

vienva 51

VIGAMOX 10

VIIBRYD 14

VIIBRYD STARTER PACK 14

VIMPAT 12

vinblastine sulfate 20

vincasar pfs 20

vincristine sulfate 21

vinorelbine tartrate 21

viorele 51

VIRACEPT 28

VIRAMUNE XR 27

VIRAZOLE 70

virdec 64

virdec dm 70

VIREAD 28

virt-phos 250 neutral 80

virtussin a/c 70

vita-bee/c 94

vitalee 94

vitalets 94

Drug Name Page #

vitalets childrens 94

vitamin a 94

vitamin a & d 40

vitamin b 6 94

vitamin b complex 95

vitamin b complex-c 95

vitamin b1 95

vitamin b-1 95

vitamin b12 95

vitamin b-12 95

vitamin b-12 tr 95

vitamin b-2 95

vitamin b-6 95

vitamin b-complex 95

vitamin c 95

vitamin c sr 95

vitamin c tr 95

vitamin c tr/rose hips 95

vitamin c/rose hips 95

vitamin d 95

vitamin e 95

vitamin e water dispersible 95

vitamin e water soluble 95

vitamin e/d-alpha 95

vitamin e/d-alpha natural 95

vitamin e-400 95

vitamin k1 95

vitamins & minerals 95

vitamins for hair 95

vitatrum 95

VITEKTA 27

vitrum 50+ senior multi 95

VOLTAREN 40

voriconazole 17

VOTRIENT 22

VP-PNV-DHA 95

VPRIV 41

VRAYLAR 25

vyfemla 51

warfarin sodium 31

wee care 80

WELCHOL 37

wera 51

white petrolatum 40

womens biomultiple 95

womens daily formula 95

129

Drug Name Page #

womens daily formula/folic

acid/calcium/iron

95

womens one daily 95

XALKORI 22

XARELTO 32

XARELTO STARTER PACK 32

XARTEMIS XR 3

XENAZINE 38

XGEVA 57

XIFAXAN 8

XOLAIR 70

XTANDI 18

xylon 4

XYREM 70

yelets teenage formula 95

YERVOY 22

YF-VAX 56

YONDELIS 18

zafirlukast 64

zaleplon 70

ZALTRAP 22

ZANOSAR 18

ZARXIO 32

ZAVESCA 41

ZEASORB-AF 17

zebutal 1

ZELBORAF 22

ZEMAIRA 70

zenatane 40

zenchent 51

ZENPEP 41

ZETIA 37

ZIAGEN 28

zidovudine 28

zinc 70

zinc 81

zinc 15 80

zinc chelated 81

zinc gluconate 81

zinc oxide 40

zinc sulfate 81

zinc/vitamin c 59

zinc-220 81

ZIOPTAN 59

ziprasidone hcl 25

ZIRGAN 26

ZMAX 10

Drug Name Page #

zoledronic acid 57

ZOLINZA 21

zolpidem tartrate 70

ZONALON 40

ZONATUSS 70

zonisamide 11

zoo friends 95

zoo friends plus iron 95

ZORTRESS 55

ZOSTAVAX 56

ZOSYN 9

zovia 1/35e 52

zovia 1/50e 52

ZOVIRAX 29

ZUTRIPRO 70

ZYCLARA 40

ZYCLARA PUMP 40

ZYDELIG 21

ZYKADIA 22

ZYLET 6

ZYPREXA RELPREVV 26

ZYTIGA 18

ZYVOX 8

List of Covered Drugs (Formulary) - CignaCarePlan Member Services or read the Cigna-HealthSpring...

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