2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
1
Drug Name Drug Tier
Requirements/Limits
ANALGESICS
GOUT allopurinol tab (generic of
ZYLOPRIM) 1
ALOPRIM 3 colchicine w/ probenecid 1
COLCRYS QL (120 tabs / 30 days)
2 QL
probenecid 1
ULORIC 2 ST
MISCELLANEOUS diclofenac w/ misoprostol (generic of ARTHROTEC 50)
1
diclofenac w/ misoprostol
(generic of ARTHROTEC 75) 1
DUEXIS 3 NM
VIMOVO 3 NM
NSAIDS celecoxib (generic of
CELEBREX) CAPS 1
diclofenac potassium 1 diclofenac sodium TB24;
TBEC 1
diflunisal 1 etodolac 1
etodolac er 1
FENOPROFEN CALCIUM CAPS
1
fenoprofen calcium TABS 1
flurbiprofen TABS 1 ibuprofen SUSP 1
ibuprofen TABS 400mg,
600mg, 800mg 1
ketoprofen CAPS; CP24 1
mefenamic acid (generic of
PONSTEL) CAPS 1
MELOXICAM SUSP 1 meloxicam tabs (generic of
MOBIC) 1
nabumetone TABS 1
NAPRELAN 375mg, 750mg 3 NM
naproxen SUSP 1
naproxen (generic of
NAPROSYN) TABS 250mg, 500mg
1
naproxen TABS 375mg 1
Drug Name Drug Tier
Requirements/Limits
naproxen (generic of
EC-NAPROSYN) TBEC 1
naproxen sodium TABS
275mg 1
naproxen sodium (generic of
ANAPROX DS) TABS 550mg
1
naproxen sodium (generic of NAPRELAN) TB24 375mg
3 NM
NAPROXEN SODIUM TB24 500mg
3 NM
oxaprozin (generic of DAYPRO)
1
piroxicam (generic of
FELDENE) CAPS 1
sulindac TABS 1 tolmetin sodium 1
VIVLODEX 3
ZIPSOR 3
ZORVOLEX 3
OPIOID ANALGESICS acetaminophen w/ codeine
SOLN QL (5000 mL / 30 days)
1 QL
acetaminophen w/ codeine TABS
QL (400 tabs / 30 days)
1 QL
acetaminophen w/ codeine
(generic of TYLENOL/CODEINE #3) TABS
QL (400 tabs / 30 days)
1 QL
acetaminophen w/ codeine (generic of TYLENOL/CODEINE #4) TABS
QL (400 tabs / 30 days)
1 QL
acetaminophen-caff-dihydrocod
QL (360 caps / 30 days)
1 QL
ASPIRIN-CAFFEINE-DIHYDROCODEINE CAP 356.4-30-16 MG
QL (360 caps / 30 days)
1 QL
butorphanol nasal spray
QL (10 mL / 30 days) 1 QL
butorphanol tartrate SOLN 1
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
2
Drug Name Drug Tier
Requirements/Limits
BUTRANS 5mcg/hr QL (16 patches / 28 days)
2 QL
BUTRANS 7.5mcg/hr, 10mcg/hr
QL (8 patches / 28 days)
2 QL
BUTRANS 15mcg/hr, 20mcg/hr
QL (4 patches / 28 days)
2 QL
capital and codeine
QL (5000 mL / 30 days) 3 QL
CONZIP 100mg QL (90 caps / 30 days)
3 QL
CONZIP 200mg QL (60 caps / 30 days)
3 QL
CONZIP 300mg QL (30 caps / 30 days)
3 QL
nalbuphine hcl (generic of
NUBAIN) SOLN 10mg/ml 1
nalbuphine hcl SOLN 20mg/ml
1
TRAMADOL HCL CP24 100mg
QL (90 caps / 30 days)
1 QL
TRAMADOL HCL CP24 200mg
QL (60 caps / 30 days)
1 QL
TRAMADOL HCL CP24 300mg
QL (30 caps / 30 days)
1 QL
tramadol hcl er (generic of
ULTRAM ER) TB24 100mg QL (90 tabs / 30 days)
1 QL
tramadol hcl er (generic of
ULTRAM ER) TB24 200mg QL (30 tabs / 30 days)
1 QL
TRAMADOL HCL ER TB24 300mg
QL (30 tabs / 30 days)
1 QL
tramadol hcl er (biphasic) 100mg
QL (90 tabs / 30 days)
1 QL
tramadol hcl er (biphasic) 200mg
QL (30 tabs / 30 days)
1 QL
tramadol hcl er (biphasic) 300mg
QL (30 tabs / 30 days)
1 QL
Drug Name Drug Tier
Requirements/Limits
tramadol hcl tab 50 mg
(generic of ULTRAM) QL (240 tabs / 30 days)
1 QL
tramadol-acetaminophen (generic of ULTRACET)
QL (240 tabs / 30 days)
1 QL
trezix QL (360 caps / 30 days)
3 QL
OPIOID ANALGESICS, CII ABSTRAL
QL (120 tabs / 30 days) 3 QL NM PA
CODEINE SULFATE 15mg QL (720 tabs / 30 days)
1 QL
CODEINE SULFATE 30mg QL (360 tabs / 30 days)
1 QL
CODEINE SULFATE 60mg QL (180 tabs / 30 days)
1 QL
DILAUDID-HP INJ 250MG 3 B/D
DURAMORPH 1 B/D
EMBEDA QL (60 caps / 30 days)
3 QL
endocet (generic of
PERCOCET) QL (360 tabs / 30 days)
1 QL
fentanyl citrate (generic of
ACTIQ) LPOP QL (120 lozenges / 30 days)
3 QL NM PA
fentanyl patch 12 mcg/hr
(generic of DURAGESIC) QL (10 patches / 30 days)
1 QL
fentanyl patch 25 mcg/hr
(generic of DURAGESIC) QL (10 patches / 30 days)
1 QL
fentanyl patch 50 mcg/hr
(generic of DURAGESIC) QL (10 patches / 30 days)
1 QL
fentanyl patch 75 mcg/hr
(generic of DURAGESIC) QL (10 patches / 30 days)
1 QL
fentanyl patch 100 mcg/hr
(generic of DURAGESIC) QL (10 patches / 30 days)
1 QL
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
3
Drug Name Drug Tier
Requirements/Limits
FENTORA QL (120 tabs / 30 days)
3 QL NM PA
hydrocodone-acetaminophen 2.5-325mg
QL (360 tabs / 30 days)
1 QL
hydrocodone-acetaminophen 5-300mg (generic of XODOL)
QL (400 tabs / 30 days)
1 QL
hydrocodone-acetaminophen 5-325mg (generic of NORCO)
QL (360 tabs / 30 days)
1 QL
hydrocodone-acetaminophen 7.5-300mg (generic of
XODOL) QL (400 tabs / 30 days)
1 QL
hydrocodone-acetaminophen 7.5-325 mg/15ml (generic of
HYCET) QL (5400 mL / 30 days)
1 QL
hydrocodone-acetaminophen 7.5-325mg (generic of
NORCO) QL (360 tabs / 30 days)
1 QL
hydrocodone-acetaminophen 10-300mg (generic of
XODOL) QL (400 tabs / 30 days)
1 QL
hydrocodone-acetaminophen tab 10-325mg (generic of
NORCO) QL (360 tabs / 30 days)
1 QL
hydrocodone-ibuprofen tab 2.5-200mg
QL (150 tabs / 30 days)
1 QL
hydrocodone-ibuprofen tab 5-200mg (generic of
REPREXAIN) QL (150 tabs / 30 days)
1 QL
hydrocodone-ibuprofen tab 7.5-200 mg (generic of
VICOPROFEN) QL (150 tabs / 30 days)
1 QL
hydrocodone-ibuprofen tab 10-200mg
QL (150 tabs / 30 days)
1 QL
hydromorphone hcl (generic of DILAUDID) LIQD
1
Drug Name Drug Tier
Requirements/Limits
HYDROMORPHONE HCL SOLN 1mg/ml, 2mg/ml, 4mg/ml
1 B/D
hydromorphone hcl (generic of DILAUDID-HP) SOLN 500mg/50ml
1 B/D
hydromorphone hcl (generic of DILAUDID) TABS
QL (270 tabs / 30 days)
1 QL
hydromorphone tab 8mg er
(generic of EXALGO) QL (60 tabs / 30 days)
1 QL
hydromorphone tab 12mg er
(generic of EXALGO) QL (60 tabs / 30 days)
1 QL
hydromorphone tab 16mg er
(generic of EXALGO) QL (60 tabs / 30 days)
3 QL NM
HYDROMORPHONE TABS 32MG
QL (60 tabs / 30 days)
3 QL NM
HYSINGLA ER 20mg, 30mg, 40mg, 60mg
QL (60 tabs / 30 days)
3 QL
HYSINGLA ER 80mg, 100mg, 120mg
QL (30 tabs / 30 days)
3 QL NM
ibudone tab 5-200mg (generic
of REPREXAIN) QL (150 tabs / 30 days)
1 QL
ibudone tab 10-200mg QL (150 tabs / 30 days)
1 QL
INFUMORPH 200 3 B/D
INFUMORPH 500 3 B/D
KADIAN 40mg, 200mg QL (60 caps / 30 days)
3 QL NM
LAZANDA QL (30 bottles / 30 days)
3 QL NM PA
levorphanol tartrate TABS
QL (180 tabs / 30 days) 1 QL
lorcet hd tab 10-325mg
(generic of NORCO) QL (360 tabs / 30 days)
1 QL
lorcet plus tab 7.5-325 (generic of NORCO)
QL (360 tabs / 30 days)
1 QL
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
4
Drug Name Drug Tier
Requirements/Limits
lorcet tab 5-325mg (generic of
NORCO) QL (360 tabs / 30 days)
1 QL
lortab tab 5-325mg (generic of NORCO)
QL (360 tabs / 30 days)
1 QL
lortab tab 7.5-325 (generic of NORCO)
QL (360 tabs / 30 days)
1 QL
lortab tab 10-325mg (generic
of NORCO) QL (360 tabs / 30 days)
1 QL
methadone hcl (generic of
METHADOSE) CONC QL (120 mL / 30 days)
1 QL
methadone hcl SOLN
QL (600 mL / 30 days) 1 QL
methadone hcl (generic of
DOLOPHINE) TABS QL (240 tabs / 30 days)
1 QL
METHADONE INJ 10MG/ML 3
MORPHINE SUL 20MG/ML ORAL SOL
1
MORPHINE SUL INJ 1MG/ML
1 B/D
MORPHINE SUL INJ 4MG/ML
3 B/D
MORPHINE SUL INJ 10MG/ML
1 B/D
MORPHINE SUL INJ 15MG/ML
1 B/D
morphine sulfate (generic of KADIAN) CP24 10mg, 20mg, 30mg, 50mg, 60mg
QL (60 caps / 30 days)
1 QL
morphine sulfate (generic of
KADIAN) CP24 80mg, 100mg
QL (60 caps / 30 days)
3 QL NM
MORPHINE SULFATE SOLN 2mg/ml, 8mg/ml
3 B/D
MORPHINE SULFATE SOLN 10mg/5ml, 20mg/5ml
1
morphine sulfate SOLN
.5mg/ml, 1mg/ml, 4mg/ml, 8mg/ml
1 B/D
Drug Name Drug Tier
Requirements/Limits
MORPHINE SULFATE TABS
QL (180 tabs / 30 days)
1 QL
morphine sulfate beads QL (60 caps / 30 days)
1 QL
morphine sulfate ext-rel tab
(generic of MS CONTIN) 15mg, 30mg, 60mg, 100mg
QL (90 tabs / 30 days)
1 QL
morphine sulfate ext-rel tab
(generic of MS CONTIN) 200mg
QL (60 tabs / 30 days)
1 QL
NUCYNTA 50mg QL (360 tabs / 30 days)
2 QL
NUCYNTA 75mg QL (240 tabs / 30 days)
2 QL
NUCYNTA 100mg QL (180 tabs / 30 days)
2 QL
NUCYNTA ER 50mg, 100mg
QL (120 tabs / 30 days)
2 QL
NUCYNTA ER 150mg, 200mg, 250mg
QL (60 tabs / 30 days)
2 QL
OPANA ER (CRUSH RESISTANT
QL (120 tabs / 30 days)
2 QL
oxycodone hcl CAPS
QL (180 caps / 30 days) 1 QL
oxycodone hcl CONC 1
OXYCODONE HCL SOLN 1
oxycodone hcl (generic of
ROXICODONE) TABS 5mg, 15mg, 30mg
QL (180 tabs / 30 days)
1 QL
oxycodone hcl TABS 10mg,
20mg QL (180 tabs / 30 days)
1 QL
oxycodone w/ acetaminophen 2.5-325mg (generic of
PERCOCET) QL (360 tabs / 30 days)
1 QL
oxycodone w/ acetaminophen 5-325mg (generic of
PERCOCET) QL (360 tabs / 30 days)
1 QL
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
5
Drug Name Drug Tier
Requirements/Limits
oxycodone w/ acetaminophen 7.5-325mg (generic of
PERCOCET) QL (360 tabs / 30 days)
1 QL
oxycodone w/ acetaminophen 10-325mg (generic of
PERCOCET) QL (360 tabs / 30 days)
1 QL
oxycodone-aspirin (generic of
PERCODAN) QL (360 tabs / 30 days)
1 QL
oxycodone-ibuprofen
QL (28 tabs / 30 days) 1 QL
OXYCONTIN QL (120 tabs / 30 days)
2 QL
oxymorphone hcl (generic of
OPANA) TABS QL (180 tabs / 30 days)
1 QL
reprexain tab 10-200mg QL (150 tabs / 30 days)
1 QL
roxicet soln
QL (1800 mL / 30 days) 2 QL
roxicet tab 5-325mg (generic of PERCOCET)
QL (360 tabs / 30 days)
1 QL
SUBSYS QL (120 sprays / 30 days)
3 QL NM PA
vicodin (generic of XODOL)
QL (400 tabs / 30 days) 1 QL
vicodin es (generic of XODOL)
QL (400 tabs / 30 days)
1 QL
vicodin hp (generic of
XODOL) QL (400 tabs / 30 days)
1 QL
XARTEMIS XR QL (120 tabs / 30 days)
3 QL
xylon tab 10-200mg QL (150 tabs / 30 days)
1 QL
zamicet
QL (5400 mL / 30 days) 1 QL
ZOHYDRO ER (ABUSE DETERRENT) 10mg, 15mg, 20mg
QL (120 caps / 30 days)
3 QL
Drug Name Drug Tier
Requirements/Limits
ZOHYDRO ER (ABUSE DETERRENT) 30mg, 40mg, 50mg
QL (60 caps / 30 days)
3 QL
ANESTHETICS
LOCAL ANESTHETICS lidocaine hcl (local anesth.)
(generic of XYLOCAINE-MPF) 1%
1 B/D
lidocaine hcl (local anesth.) (generic of XYLOCAINE-MPF) 4%
1
lidocaine hcl (local anesth.)
(generic of XYLOCAINE) .5%
1 B/D
lidocaine inj 0.5% (generic of
XYLOCAINE-MPF) 1 B/D
lidocaine inj 1% (generic of XYLOCAINE)
1 B/D
lidocaine inj 1.5% (generic of
XYLOCAINE-MPF) 1 B/D
lidocaine inj 2% (generic of XYLOCAINE) 2%
1 B/D
lidocaine inj 2% (generic of
XYLOCAINE-MPF) 2% 1 B/D
ANTI-INFECTIVES ANTI-BACTERIALS - MISCELLANEOUS amikacin sulfate SOLN 1
BETHKIS 3 B/D NM
gentamicin in saline 0.8 mg/ml 1
gentamicin in saline 0.9mg/ml 3
gentamicin in saline 1 mg/ml 1 gentamicin in saline 1.2 mg/ml 1
gentamicin in saline 1.4mg/ml 3 gentamicin in saline 1.6 mg/ml 1
gentamicin in saline 2 mg/ml 1
gentamicin sulfate SOLN 1 neomycin sulfate TABS 1
paromomycin sulfate CAPS 1 streptomycin sulfate SOLR 1
sulfadiazine TABS 3
TOBI PODHALER 3 NM LA PA
tobramycin (generic of TOBI) NEBU
3 B/D NM
tobramycin sulfate SOLN;
SOLR 1
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
6
Drug Name Drug Tier
Requirements/Limits
ANTI-INFECTIVES - MISCELLANEOUS ALBENZA 2
ALINIA 2
atovaquone (generic of
MEPRON) SUSP 3 NM
AZACTAM/DEX INJ 1GM 3
AZACTAM/DEX INJ 2GM 3 NM
aztreonam (generic of
AZACTAM) 1
BILTRICIDE 2
CAYSTON 2 NM LA PA
clindamycin hcl (generic of
CLEOCIN) CAPS 1
clindamycin palmitate hydrochloride (generic of
CLEOCIN PEDIATRIC GRANULE)
1
clindamycin phosphate
SOLN 150mg/ml 1
clindamycin phosphate
(generic of CLEOCIN PHOSPHATE) SOLN 150mg/ml, 300mg/2ml, 600mg/4ml, 900mg/6ml, 9000mg/60ml
1
clindamycin phosphate in d5w
(generic of CLEOCIN IN D5W)
1
colistimethate sodium (generic of COLY-MYCIN M) SOLR
1
CUBICIN 3 NM
DALVANCE 3 NM
dapsone TABS 1
DARAPRIM 3
DORIBAX 3 imipenem-cilastatin (generic
of PRIMAXIN IV) 1
INVANZ 3 ivermectin (generic of
STROMECTOL) TABS 1
linezolid (generic of ZYVOX)
SOLN 2mg/ml 3 NM
LINEZOLID SOLN 2mg/ml 3 NM
LINEZOLID SUSR 3 NM
LINEZOLID TABS 3 NM
Drug Name Drug Tier
Requirements/Limits
MACRODANTIN 25mg PA applies if 65 years and older after a 90 day supply in a calendar year
3 PA
meropenem (generic of
MERREM) 1
MEROPENEM/SODIUM CHLORIDE
1
methenamine hippurate
(generic of HIPREX) 1
METRO IV 3 metronidazole (generic of
FLAGYL) CAPS; TABS 1
metronidazole inj 1
NEBUPENT 3 B/D
nitrofurantoin (generic of
FURADANTIN) SUSP PA applies if 65 years and older after a 90 day supply in a calendar year
1 PA
nitrofurantoin macrocrystal
(generic of MACRODANTIN) PA applies if 65 years and older after a 90 day supply in a calendar year
3 PA
nitrofurantoin monohyd macro (generic of MACROBID)
PA applies if 65 years and older after a 90 day supply in a calendar year
3 PA
PENTAM 300 3
polymyxin b sulfate SOLR 1
PRIMSOL SOL 50MG/5ML 3
SIVEXTRO 3 NM
sulfamethoxazole-trimethop
SUSP 1
sulfamethoxazole-trimethop (generic of BACTRIM) TABS
1
sulfamethoxazole-trimethop
(generic of BACTRIM DS) TABS
1
sulfamethoxazole-trimethoprim inj
1
SYNERCID 3 NM
trimethoprim TABS 1
TYGACIL 3 NM
vancomycin hcl (generic of
VANCOCIN HCL) CAPS 3 NM
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
7
Drug Name Drug Tier
Requirements/Limits
vancomycin hcl inj 5gm 1
vancomycin hcl inj 10gm 1
vancomycin hcl inj 500mg 1 vancomycin hcl inj 750mg 3
vancomycin hcl inj 1000mg 1
XIFAXAN TAB 200MG 3 NM
ZYVOX SUSR; TABS 3 NM
ANTIFUNGALS ABELCET 3 B/D NM
AMBISOME 3 B/D NM
amphotericin b SOLR 1 B/D
CANCIDAS 3 NM
CRESEMBA 3 NM
ERAXIS 3 NM
fluconazole (generic of DIFLUCAN) SUSR; TABS
1
fluconazole in dextrose 1
fluconazole in nacl 1 flucytosine (generic of
ANCOBON) CAPS 3 NM
griseofulvin microsize 1
griseofulvin ultramicrosize (generic of GRIS-PEG)
1
itraconazole (generic of
SPORANOX) CAPS 1 PA
ketoconazole TABS 1 PA
LAMISIL PACK 3
MYCAMINE 3 NM
NOXAFIL 3 NM
nystatin TABS 1
ONMEL 3 NM PA
SPORANOX SOL 10MG/ML 3 NM
terbinafine hcl (generic of
LAMISIL) TABS QL (90 tabs / 365 days)
1 QL
voriconazole (generic of
VFEND) SUSR; TABS 3 NM
voriconazole inj 200mg (generic of VFEND IV)
1
ANTIMALARIALS atovaquone-proguanil hcl tab 62.5-25 mg (generic of MALARONE)
1
atovaquone-proguanil hcl tab 250-100 mg (generic of
MALARONE)
1
Drug Name Drug Tier
Requirements/Limits
chloroquine phosphate
TABS 250mg 1
chloroquine phosphate
(generic of ARALEN) TABS 500mg
1
COARTEM 2
mefloquine hcl 1
PRIMAQUINE PHOSPHATE 3
quinine sulfate (generic of
QUALAQUIN) CAPS 1 PA
ANTIRETROVIRAL AGENTS abacavir sulfate (generic of
ZIAGEN) 1
APTIVUS 3 NM
CRIXIVAN 3
didanosine (generic of VIDEX
EC) 1
EDURANT 3 NM
EMTRIVA 2
FUZEON 2 NM
INTELENCE 25mg 2
INTELENCE 100mg, 200mg 3 NM
INVIRASE 3 NM
ISENTRESS CHEW 25mg 2
ISENTRESS CHEW 100mg 3 NM
ISENTRESS PACK 2
ISENTRESS TABS 3 NM
lamivudine (generic of
EPIVIR) 1
LEXIVA SUSP 3
LEXIVA TABS 3 NM
NEVIRAPINE SUSP 1
nevirapine (generic of VIRAMUNE) TABS
1
nevirapine (generic of
VIRAMUNE XR) TB24 1
NORVIR 2
PREZISTA SUSP 3 NM
PREZISTA TABS 75mg, 150mg
2
PREZISTA TABS 600mg, 800mg
3 NM
RESCRIPTOR 2
RETROVIR IV INFUSION 3
REYATAZ 3 NM
SELZENTRY 3 NM
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
8
Drug Name Drug Tier
Requirements/Limits
stavudine (generic of ZERIT) 1
SUSTIVA CAPS 2
SUSTIVA TABS 3 NM
TIVICAY 3 NM
TYBOST 2
VIDEX PEDIATRIC 3
VIRACEPT 3 NM
VIRAMUNE XR 100mg 2
VIREAD 3 NM
VITEKTA 3 NM
ZIAGEN SOLN 2 zidovudine (generic of
RETROVIR) CAPS; SYRP 1
zidovudine TABS 1
ANTIRETROVIRAL COMBINATION AGENTS abacavir sulfate-lamivudine-zidovudine
(generic of TRIZIVIR)
3 NM
ATRIPLA 3 NM
COMPLERA 3 NM
EPZICOM 3 NM
EVOTAZ 3 NM
GENVOYA 3 NM
KALETRA SOL 3 NM
KALETRA TAB 100-25MG 2
KALETRA TAB 200-50MG 3 NM
lamivudine-zidovudine
(generic of COMBIVIR) 3 NM
PREZCOBIX 3 NM
STRIBILD 3 NM
TRIUMEQ 3 NM
TRUVADA QL (30 tabs / 30 days)
3 QL NM
ANTITUBERCULAR AGENTS CAPASTAT SULFATE 3
cycloserine CAPS 3 NM
ethambutol hcl (generic of MYAMBUTOL) TABS
1
isoniazid SOLN; SYRP 1
isoniazid tabs 1 paser d/r 3
PRIFTIN 3
pyrazinamide TABS 1 rifabutin (generic of
MYCOBUTIN) 1
Drug Name Drug Tier
Requirements/Limits
rifamate 3
rifampin (generic of RIFADIN)
CAPS; SOLR 1
RIFATER 3
SIRTURO 3 NM LA PA
TRECATOR 3
ANTIVIRALS acyclovir (generic of
ZOVIRAX) CAPS; SUSP; TABS
1
acyclovir sodium SOLN 1 B/D
acyclovir sodium SOLR
500mg 1 B/D
adefovir dipivoxil (generic of HEPSERA)
3 NM
BARACLUDE SOLN 2
cidofovir (generic of VISTIDE) 3 NM
DAKLINZA 3 NM PA
entecavir (generic of BARACLUDE)
3 NM
EPIVIR HBV SOLN 2
famciclovir (generic of FAMVIR) TABS
1
ganciclovir inj 500mg (generic
of CYTOVENE) 1 B/D
HARVONI 3 NM PA
lamivudine (hbv) (generic of EPIVIR HBV)
1
moderiba pak MISC 3 NM
moderiba pak TABS 400mg 3 NM
MODERIBA PAK TABS 600mg
3 NM
moderiba tab 200mg (generic
of COPEGUS) 1 NM
PEG-INTRON 3 NM PA
PEG-INTRON REDIPEN 3 NM PA
PEGASYS 3 NM PA
PEGASYS PROCLICK 3 NM PA
PEGINTRON 80mcg/0.5ml, 120mcg/0.5ml, 150mcg/0.5ml
3 NM PA
REBETOL SOLN 3 NM
RELENZA DISKHALER 2 ribapak mis 600/day 3 NM
ribasphere (generic of
REBETOL) CAPS 1 NM
ribasphere (generic of
COPEGUS) TABS 200mg 1 NM
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
9
Drug Name Drug Tier
Requirements/Limits
ribasphere TABS 400mg 1 NM
ribasphere TABS 600mg 3 NM
ribasphere ribapak 800 3 NM
ribasphere ribapak 1000 3 NM
ribasphere ribapak 1200 3 NM
ribavirin 200mg (generic of
REBETOL) CAPS 1 NM
ribavirin 200mg (generic of
COPEGUS) TABS 1 NM
rimantadine hydrochloride
(generic of FLUMADINE) 1
SOVALDI 3 NM PA
TAMIFLU 2
TYZEKA 3 NM
valacyclovir hcl (generic of
VALTREX) TABS 1
VALCYTE SOLR 3 NM
valganciclovir hcl (generic of VALCYTE)
3 NM
CEPHALOSPORINS AVYCAZ 3 NM
cefaclor 1 cefaclor er tab 500mg 3
cefadroxil 1
cefazolin in dextrose 1gm/50ml-5%
3
CEFAZOLIN IN DEXTROSE 2GM/100ML-4%
3
cefazolin inj 1 cefazolin sodium 1gm, 20gm 1
cefdinir 1
CEFEPIME 1GM SOLN 3
CEFEPIME 2GM SOLN 3
CEFEPIME HCL AND DEXTROSE
3
cefepime inj 1gm (generic of
MAXIPIME) 1
cefepime inj 2gm (generic of MAXIPIME)
1
cefixime (generic of SUPRAX) 1
cefotaxime sodium (generic of
CLAFORAN) 1gm, 2gm, 500mg
1
cefotetan disodium 3
cefoxitin sodium 1
Drug Name Drug Tier
Requirements/Limits
CEFOXITIN SODIUM IN DEXTROSE
3
cefpodoxime proxetil 1 cefprozil 1
ceftazidime (generic of
FORTAZ) 1
CEFTAZIDIME/DEXTROSE 3
CEFTIBUTEN 1
CEFTIN SUSR 3 ceftriaxone sodium SOLR
1gm, 2gm, 10gm, 250mg 1
ceftriaxone sodium (generic of
ROCEPHIN) SOLR 1gm, 500mg
1
cefuroxime axetil SUSR 1
cefuroxime axetil (generic of
CEFTIN) TABS 1
cefuroxime sodium (generic of
ZINACEF) 1.5gm, 7.5gm, 750mg
1
cefuroxime sodium 7.5gm 3 cephalexin (generic of
KEFLEX) CAPS 1
cephalexin SUSR; TABS 1 claforan 1gm, 2gm 3
CLAFORAN/D5W 3
FORTAZ SOLN 3
FORTAZ SOLR 500mg 3
MAXIPIME 3
SUPRAX CAPS 2
suprax CHEW 2
SUPRAX SUSR 500mg/5ml 2 tazicef (generic of FORTAZ)
SOLR 1
tazicef vial (generic of
FORTAZ) 1
TEFLARO 3
ZERBAXA 3 NM
ZINACEF SOLR 750mg 3
ERYTHROMYCINS/MACROLIDES AZITHROMYCIN PACK 1
azithromycin (generic of ZITHROMAX) SOLR 500mg
1
azithromycin (generic of
ZITHROMAX) SUSR 1
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
10
Drug Name Drug Tier
Requirements/Limits
azithromycin (generic of
ZITHROMAX) TABS 1
clarithromycin SUSR
125mg/5ml 1
clarithromycin (generic of
BIAXIN) SUSR 250mg/5ml 1
clarithromycin (generic of
BIAXIN) TABS 1
clarithromycin (generic of
BIAXIN XL) TB24 1
DIFICID 3 NM
e.e.s. 400 tab 400mg 1
E.E.S. GRANULES 3
ery-tab 1
ERYPED 200 3
ERYPED 400 3
erythrocin lactobionate
500mg 3
erythrocin stearate 1
erythromycin base 1
erythromycin cap 250mg ec 1 erythromycin ethylsuccinate 1
PCE 3
ZMAX 3
FLUOROQUINOLONES AVELOX SOLN 3 ciprofloxacin SOLN
200mg/20ml 1
ciprofloxacin (generic of
CIPRO) SUSR 1
ciprofloxacin er (generic of
CIPRO XR) 1
ciprofloxacin hcl TABS
100mg, 750mg 1
ciprofloxacin hcl (generic of CIPRO) TABS 250mg, 500mg
1
ciprofloxacin in d5w (generic of CIPRO I.V.-IN D5W)
1
ciprofloxacn inj 400mg/40ml 1
levofloxacin SOLN 1
levofloxacin (generic of LEVAQUIN) TABS
1
levofloxacin in d5w 1
MOXIFLOXACIN HCL SOLN 3
Drug Name Drug Tier
Requirements/Limits
moxifloxacin hcl (generic of
AVELOX) TABS 1
PENICILLINS amoxicillin 1
amoxicillin & pot clavulanate
CHEW 1
amoxicillin & pot clavulanate SUSR
1
amoxicillin & pot clavulanate
(generic of AUGMENTIN) SUSR
1
amoxicillin & pot clavulanate
(generic of AUGMENTIN ES-600) SUSR
1
amoxicillin & pot clavulanate TABS
1
amoxicillin & pot clavulanate
(generic of AUGMENTIN) TABS
1
amoxicillin & pot clavulanate
(generic of AUGMENTIN XR) TB12
1
ampicillin & sulbactam sodium 1 ampicillin & sulbactam sodium
(generic of UNASYN) 1
ampicillin & sulbactam sodium (generic of UNASYN BULK PACK)
1
ampicillin cap 250mg 1
ampicillin cap 500 mg 1 ampicillin inj 1
ampicillin sodium 1 ampicillin susp 1
AUGMENTIN SUSR 3
BACTOCILL INJ DEX 1GM 3
BACTOCILL INJ DEX 2GM 3 NM
BICILLIN C-R 3
BICILLIN L-A 3 dicloxacillin sodium 1
nafcillin sodium 1gm 1
nafcillin sodium 2gm, 10gm 3 NM
NALLPEN ISO-OSMOTIC IN DE
3
NALLPEN/DEXTROSE 3
oxacillin sodium 1gm, 2gm 1 oxacillin sodium 10gm 3 NM
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
11
Drug Name Drug Tier
Requirements/Limits
PENICILLIN G POT IN DEXTROSE
3
PENICILLIN G POTASSIUM IN
3
penicillin g procaine 3
penicillin g sodium 1
penicillin v potassium 1 penicilln gk inj 5mu 1
penicilln gk inj 20mu 1 pfizerpen g inj 5mu 1
pfizerpen-g inj 20mu 1
piperacillin sodium-tazobactam sodium
(generic of ZOSYN)
1
ZOSYN SOLN 3
TETRACYCLINES demeclocycline hcl 1
doxy 1 doxycycline (monohydrate)
CAPS 50mg 1
doxycycline (monohydrate)
(generic of MONODOX) CAPS 75mg, 100mg
1
doxycycline (monohydrate)
(generic of ADOXA) CAPS 150mg
1
doxycycline (monohydrate)
(generic of VIBRAMYCIN) SUSR
1
doxycycline (monohydrate) (generic of ADOXA) TABS 50mg, 75mg, 100mg
1
doxycycline (monohydrate)
(generic of ADOXA PAK 1/150) TABS 150mg
1
doxycycline hyclate CAPS
50mg 1
doxycycline hyclate (generic of VIBRAMYCIN) CAPS 100mg
1
doxycycline hyclate SOLR 1
doxycycline hyclate TABS 1 doxycycline hyclate TBEC 1
minocycline hcl (generic of MINOCIN) CAPS
1
minocycline hcl TABS; TB24 1
Drug Name Drug Tier
Requirements/Limits
SOLODYN 3 NM
TETRACYCLINE HCL CAPS
1
VIBRAMYCIN SYRP 2
ANTINEOPLASTIC AGENTS
ALKYLATING AGENTS BICNU 3 B/D
BUSULFEX 3 B/D NM
CYCLOPHOSPHAMIDE CAPS
2 B/D
cyclophosphamide SOLR 1gm, 500mg
3 B/D NM
cyclophosphamide SOLR
2gm 1 B/D
dacarbazine 1 B/D
EMCYT 2
GLEOSTINE 3
HEXALEN 3 NM
IFEX INJ 3GM 3 B/D
ifosfamide inj 1gm (generic of
IFEX) 1 B/D
ifosfamide inj 1gm/20ml
(generic of IFOSFAMIDE) 1 B/D
IFOSFAMIDE INJ 3GM 3 B/D
ifosfamide inj 3gm/60ml
(generic of IFOSFAMIDE) 1 B/D
LEUKERAN 2 melphalan hcl (generic of
ALKERAN) 3 B/D NM
MUSTARGEN 3 B/D
thiotepa SOLR 3 B/D NM
TREANDA 3 B/D NM
ZANOSAR 3 B/D
ANTHRACYCLINES daunorubicin hcl 1 B/D
doxorubicin hcl 50mg 1 B/D
doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml
(generic of DOXIL)
3 B/D NM
doxorubicin inj 50mg 1 B/D
epirubicin inj 50mg/25ml (generic of ELLENCE)
1 B/D
epirubicin inj 200mg (generic
of ELLENCE) 1 B/D
idarubicin hcl (generic of IDAMYCIN PFS)
3 B/D NM
ANTIBIOTICS
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
12
Drug Name Drug Tier
Requirements/Limits
bleomycin sulfate 1 B/D
COSMEGEN 3 B/D NM
mitomycin SOLR 1 B/D
VALSTAR 3 NM PA
ANTIMETABOLITES adrucil 1 B/D
ALIMTA 3 B/D NM
ARRANON 3 B/D NM
azacitidine (generic of VIDAZA)
3 B/D NM
cladribine 3 B/D NM
CLOLAR 3 B/D NM
cytarabine inj 1 B/D
decitabine (generic of DACOGEN)
3 B/D NM
fludarabine phosphate
SOLN 1 B/D
fludarabine phosphate (generic of FLUDARA) SOLR
1 B/D
fluorouracil SOLN 1 B/D
FOLOTYN 3 NM PA
GEMCITABINE 3 B/D NM
gemcitabine hcl (generic of GEMZAR) 1gm, 200mg
3 B/D NM
gemcitabine hcl 2gm 3 B/D NM
mercaptopurine TABS 1
METHOTREXATE SODIUM 25mg/ml
1 B/D
methotrexate sodium
50mg/2ml, 100mg/4ml, 200mg/8ml, 250mg/10ml
1 B/D
methotrexate sodium inj 1 B/D
NIPENT 3 B/D NM
PURIXAN 3 NM
TABLOID 2
ANTIMITOTIC, TAXOIDS ABRAXANE 3 B/D NM
DOCETAXEL CONC 20mg/ml, 80mg/4ml
3 B/D NM
docetaxel CONC 140mg/7ml 3 B/D NM
DOCETAXEL SOLN 20mg/2ml
1 B/D
DOCETAXEL SOLN 160mg/16ml, 200mg/20ml
3 B/D NM
DOCETAXEL SOLN 80MG/8ML
3 B/D NM
Drug Name Drug Tier
Requirements/Limits
JEVTANA 3 NM PA
paclitaxel 1 B/D
ANTIMITOTIC, VINCA ALKALOIDS vinblastine sulfate 1 B/D
vincasar 1 B/D
vincristine sulfate 1 B/D
vinorelbine tartrate (generic of
NAVELBINE) 1 B/D
BIOLOGIC RESPONSE MODIFIERS ARZERRA 3 B/D NM
AVASTIN 3 B/D NM LA
BELEODAQ 3 NM PA
CYRAMZA 3 NM PA
ERBITUX 3 B/D NM
ERIVEDGE 3 NM LA PA
FARYDAK 3 NM LA PA
GAZYVA 3 NM PA
HERCEPTIN 3 B/D NM
IBRANCE 3 NM LA PA
ISTODAX 3 B/D NM
KADCYLA 3 B/D NM
KEYTRUDA 3 NM PA
LYNPARZA 3 NM LA PA
NINLARO 3 NM PA
OPDIVO 3 NM PA
PERJETA 3 NM PA
PROLEUKIN 3 B/D NM
RITUXAN 2 NM LA PA
TORISEL 3 B/D NM
VECTIBIX 3 B/D NM
VELCADE 3 B/D NM
YERVOY 3 NM PA
ZALTRAP 3 NM PA
ZOLINZA 3 NM PA
HORMONAL ANTINEOPLASTIC AGENTS anastrozole (generic of ARIMIDEX) TABS
1
bicalutamide (generic of
CASODEX) 1
DEPO-PROVERA INJ 400/ML 3 B/D
ELIGARD INJ 7.5MG 3 B/D NM
ELIGARD INJ 22.5MG 3 B/D NM
ELIGARD INJ 30MG 3 B/D NM
ELIGARD INJ 45MG 3 B/D NM
exemestane (generic of AROMASIN)
1
FARESTON 3 NM
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
13
Drug Name Drug Tier
Requirements/Limits
FASLODEX 3 B/D NM
FIRMAGON 3 B/D NM
flutamide 1
letrozole (generic of FEMARA) TABS
1
leuprolide acetate KIT 1 NM PA
LUPRON DEP INJ 11.25MG 3 NM PA
LUPRON DEP-PED INJ 7.5MG
3 NM PA
LUPRON DEP-PED INJ 11.25MG
3 NM PA
LUPRON DEP-PED INJ 15MG
3 NM PA
LUPRON DEP-PED INJ 30MG (3-MONTH)
3 NM PA
LUPRON DEPOT 3 NM PA
LUPRON DEPOT INJ 22.5MG (3-MONTH)
3 NM PA
LUPRON DEPOT INJ 30MG (3-MONTH)
3 NM PA
LYSODREN 2
MEGACE ES 3 NM PA
megestrol ac sus 40mg/ml
(generic of MEGACE ORAL) PA if 65 years and older
3 PA
megestrol ac tab 20mg
PA if 65 years and older 3 PA
megestrol ac tab 40mg
PA if 65 years and older 3 PA
MEGESTROL SUS 625MG/5ML
3 NM PA
NILANDRON 3 NM
SOLTAMOX 3
tamoxifen citrate TABS 1
TRELSTAR MIXJECT 3 NM PA
VANTAS 3 NM PA
XTANDI 3 NM LA PA
ZOLADEX 3 NM PA
ZYTIGA 3 NM LA PA
KINASE INHIBITORS AFINITOR 3 NM PA
AFINITOR DISPERZ 3 NM PA
ALECENSA 3 NM LA PA
BOSULIF 3 NM PA
CAPRELSA 3 NM LA PA
COMETRIQ 3 NM LA PA
COTELLIC 3 NM LA PA
Drug Name Drug Tier
Requirements/Limits
GILOTRIF TAB 20MG 3 NM LA PA
GILOTRIF TAB 30MG 3 NM LA PA
GILOTRIF TAB 40MG 3 NM LA PA
GLEEVEC 2 NM PA
ICLUSIG 3 NM LA PA
imatinib mesylate (generic of
GLEEVEC) 2 NM PA
IMBRUVICA CAP 140MG 3 NM LA PA
INLYTA 3 NM LA PA
IRESSA 3 NM LA PA
JAKAFI 3 NM LA PA
LENVIMA 10MG DAILY DOSE
3 NM LA PA
LENVIMA 14MG DAILY DOSE
3 NM LA PA
LENVIMA 20MG DAILY DOSE
3 NM LA PA
LENVIMA 24MG DAILY DOSE
3 NM LA PA
MEKINIST 3 NM LA PA
NEXAVAR 3 NM LA PA
SPRYCEL 3 NM PA
STIVARGA 3 NM LA PA
SUTENT 3 NM PA
TAFINLAR 3 NM LA PA
TAGRISSO 3 NM LA PA
TARCEVA 3 NM LA PA
TASIGNA 3 NM PA
TYKERB 3 NM LA PA
VOTRIENT 3 NM LA PA
XALKORI 3 NM LA PA
ZELBORAF 3 NM LA PA
ZYDELIG 3 NM LA PA
ZYKADIA 3 NM LA PA
MISCELLANEOUS bexarotene (generic of
TARGRETIN) 3 NM PA
DROXIA 3
ERWINAZE 3 NM PA
HALAVEN 3 B/D NM
hydroxyurea (generic of
HYDREA) CAPS 1
IXEMPRA KIT 3 B/D NM
LONSURF 3 NM PA
MATULANE 3 NM LA
mitoxantrone hcl 1 B/D NM
ODOMZO 3 NM LA PA
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
14
Drug Name Drug Tier
Requirements/Limits
ONCASPAR 3 NM PA
POMALYST 3 NM LA PA
SYLATRON KIT 200MCG 3 NM PA
SYLATRON KIT 300MCG 3 NM PA
SYLATRON KIT 600MCG 3 NM PA
SYLVANT 3 NM PA
SYNRIBO 3 NM PA
TARGRETIN CAPS 3 NM PA
tretinoin CAPS 2 NM
TRISENOX 3 B/D NM
UVADEX 3 B/D
PLATINUM-BASED AGENTS carboplatin 1 B/D
cisplatin 1 B/D
ELOXATIN 3 B/D NM
oxaliplatin 3 B/D NM
PROTECTIVE AGENTS amifostine crystalline (generic
of ETHYOL) 3 B/D NM
dexrazoxane (generic of
ZINECARD) 250mg 3 B/D NM
ELITEK 3 B/D NM
FUSILEV 3 B/D NM
KEPIVANCE 3 B/D NM
leucovorin calcium TABS 1 leucovorin calcium inj 50mg 1 B/D
leucovorin calcium inj 100mg 1 B/D
leucovorin calcium inj 200mg 1 B/D
leucovorin calcium inj 350mg 1 B/D
leucovorin calcium inj 500mg 3 B/D
levoleucovorin calcium 3 B/D NM
mesna (generic of MESNEX) 1 B/D
MESNEX TABS 3 NM
TOPOISOMERASE INHIBITORS CAMPTOSAR 300mg/15ml 3 B/D
ETOPOPHOS 3 B/D
etoposide SOLN
500mg/25ml 1 B/D
irinotecan inj 40mg/2ml (generic of CAMPTOSAR)
1 B/D
irinotecan inj 100/5ml (generic
of CAMPTOSAR) 1 B/D
irinotecan inj 500mg/25ml 1 B/D
toposar 1gm/50ml 1 B/D
topotecan hcl (generic of
HYCAMTIN) SOLR 3 B/D NM
CARDIOVASCULAR
Drug Name Drug Tier
Requirements/Limits
ACE INHIBITOR COMBINATIONS amlodipine besylate-benazepril hcl
1
amlodipine besylate-benazepril hcl
(generic of LOTREL)
1
benazepril & hydrochlorothiazide
1
benazepril & hydrochlorothiazide (generic of LOTENSIN HCT)
1
captopril & hydrochlorothiazide
1
enalapril maleate & hydrochlorothiazide
1
enalapril maleate & hydrochlorothiazide (generic
of VASERETIC)
1
fosinopril sodium & hydrochlorothiazide
1
lisinopril & hydrochlorothiazide (generic
of ZESTORETIC)
1
moexipril-hydrochlorothiazide 1
quinapril-hydrochlorothiazide
(generic of ACCURETIC) 1
trandolapril-verapamil hcl (generic of TARKA)
1
ACE INHIBITORS benazepril hcl TABS 5mg 1 benazepril hcl (generic of
LOTENSIN) TABS 10mg, 20mg, 40mg
1
captopril TABS 1 enalapril maleate (generic of
VASOTEC) TABS 1
fosinopril sodium 1 lisinopril (generic of ZESTRIL)
TABS 2.5mg, 30mg, 40mg 1
lisinopril (generic of PRINIVIL)
TABS 5mg, 10mg, 20mg 1
moexipril hcl 1
perindopril erbumine 2mg 1
perindopril erbumine (generic of ACEON) 4mg, 8mg
1
quinapril hcl (generic of
ACCUPRIL) 1
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
15
Drug Name Drug Tier
Requirements/Limits
ramipril (generic of ALTACE) 1
trandolapril (generic of
MAVIK) 1
ALDOSTERONE RECEPTOR ANTAGONISTS eplerenone (generic of INSPRA)
1
spironolactone (generic of
ALDACTONE) TABS 1
ALPHA BLOCKERS doxazosin mesylate (generic
of CARDURA) 1
prazosin hcl (generic of MINIPRESS)
1
terazosin hcl 1
ANGIOTENSIN II RECEPTOR ANTAGONIST COMBINATIONS amlodipine besylate-valsartan tab 5-160 mg (generic of EXFORGE)
1
amlodipine besylate-valsartan tab 5-320 mg (generic of
EXFORGE)
1
amlodipine besylate-valsartan tab 10-160 mg (generic of
EXFORGE)
1
amlodipine besylate-valsartan tab 10-320 mg (generic of
EXFORGE)
1
amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg (generic of EXFORGE HCT)
1
amlodipine-valsartan-hydrochlorothiazide 5-160-25mg
(generic of EXFORGE HCT)
1
amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg
(generic of EXFORGE HCT)
1
amlodipine-valsartan-hydrochlorothiazide 10-160-25mg
(generic of EXFORGE HCT)
1
amlodipine-valsartan-hydrochlorothiazide 10-320-25mg (generic of EXFORGE HCT)
1
AZOR 2
BENICAR HCT 2
Drug Name Drug Tier
Requirements/Limits
candesartan cilexetil-hydrochlorothiazide
(generic of ATACAND HCT)
1
EDARBYCLOR 3
ENTRESTO 3 PA
irbesartan-hydrochlorothiazide
(generic of AVALIDE) 1
losartan-hydrochlorothiazide (generic of HYZAAR)
1
telmisartan-amlodipine
(generic of TWYNSTA) 1
telmisartan-hydrochlorothiazide (generic of MICARDIS HCT)
1
TEVETEN HCT 3
TRIBENZOR 2 valsartan-hydrochlorothiazide
(generic of DIOVAN HCT) 1
ANGIOTENSIN II RECEPTOR ANTAGONISTS BENICAR 2
candesartan cilexetil (generic of ATACAND)
1
EDARBI 3
eprosartan mesylate 1 irbesartan (generic of
AVAPRO) 1
losartan potassium (generic of
COZAAR) 1
telmisartan (generic of
MICARDIS) 1
valsartan (generic of
DIOVAN) 1
ANTIARRHYTHMICS amiodarone hcl SOLN 1
amiodarone hcl TABS 100mg, 400mg
1
amiodarone hcl (generic of
CORDARONE) TABS 200mg
1
amiodarone inj 50mg/ml 1 disopyramide phosphate
(generic of NORPACE) PA if 65 years and older
3 PA
flecainide acetate 1
mexiletine hcl 1
MULTAQ 3
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
16
Drug Name Drug Tier
Requirements/Limits
NORPACE CR PA if 65 years and older
3 PA
pacerone 100mg, 400mg 1 pacerone (generic of
CORDARONE) 200mg 1
propafenone hcl (generic of
RYTHMOL SR) CP12 1
propafenone hcl (generic of RYTHMOL) TABS 225mg
1
propafenone hcl TABS
300mg 1
propafenone hcl 12hr (generic of RYTHMOL SR) CP12
1
propafenone hcl 12hr (generic
of RYTHMOL) TABS 1
quinidine gluconate TBCR 1 quinidine sulfate TABS 1
sorine (generic of
BETAPACE) 80mg, 120mg, 160mg
1
sorine 240mg 1
sotalol hcl (generic of BETAPACE) 80mg, 120mg, 160mg
1
sotalol hcl 240mg 1
sotalol hcl (afib/afl) (generic of BETAPACE AF)
1
TIKOSYN 2 NM
ANTILIPEMICS, HMG-CoA REDUCTASE INHIBITORS ALTOPREV 3
atorvastatin calcium (generic of LIPITOR) TABS
1
CRESTOR 2
fluvastatin sodium cap 20 mg
(generic of LESCOL) 1
fluvastatin sodium cap 40 mg 1
fluvastatin sodium tab sr 24 hr 80 mg (generic of LESCOL XL)
1
LESCOL XL 3
LIVALO 3 lovastatin 10mg, 20mg 1
lovastatin (generic of
MEVACOR) 40mg 1
pravastatin sodium 10mg 1
Drug Name Drug Tier
Requirements/Limits
pravastatin sodium (generic of
PRAVACHOL) 20mg, 40mg, 80mg
1
simvastatin (generic of ZOCOR) TABS 5mg, 10mg, 20mg, 40mg
1
simvastatin (generic of ZOCOR) TABS 80mg
QL (30 tabs / 30 days)
1 QL
ANTILIPEMICS, MISCELLANEOUS ADVICOR 3
ANTARA 3
cholestyramine (generic of
QUESTRAN) 1
cholestyramine light 1
choline fenofibrate (generic of
TRILIPIX) 1
colestipol hcl (generic of COLESTID)
1
FENOFIBRATE CAPS 1
FENOFIBRATE TABS 40mg, 120mg
1
fenofibrate (generic of
TRICOR) TABS 48mg, 145mg
1
fenofibrate (generic of
LOFIBRA) TABS 54mg, 160mg
1
fenofibrate micronized 43mg, 130mg
1
fenofibrate micronized
(generic of LOFIBRA) 67mg, 134mg, 200mg
1
FENOFIBRIC ACID 1
FENOGLIDE 3
gemfibrozil (generic of LOPID) TABS
1
JUXTAPID 3 NM LA PA
KYNAMRO 3 NM PA
niacin er (antihyperlipidemic)
(generic of NIASPAN) 1
niacor 1
omega-3-acid ethyl esters
(generic of LOVAZA) 1
prevalite (generic of QUESTRAN LIGHT)
1
SIMCOR 2
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
17
Drug Name Drug Tier
Requirements/Limits
TRIGLIDE 3
VASCEPA 3
VYTORIN 2
WELCHOL 2
ZETIA TAB 10MG 2
BETA-BLOCKER/DIURETIC COMBINATIONS atenolol & chlorthalidone
(generic of TENORETIC 50) 1
atenolol & chlorthalidone
(generic of TENORETIC 100) 1
bisoprolol & hydrochlorothiazide (generic
of ZIAC)
1
DUTOPROL 3 metoprolol & hctz tab 50-25mg (generic of
LOPRESSOR HCT)
1
metoprolol & hctz tab 100-25mg (generic of
LOPRESSOR HCT)
1
metoprolol & hctz tab 100-50mg
1
nadolol & bendroflumethiazide
(generic of CORZIDE) 1
propranolol & hydrochlorothiazide
1
BETA-BLOCKERS acebutolol hcl (generic of
SECTRAL) CAPS 1
atenolol (generic of TENORMIN) TABS
1
betaxolol hcl (generic of
KERLONE) 1
bisoprolol fumarate (generic of ZEBETA)
1
BYSTOLIC 2
carvedilol (generic of
COREG) 1
COREG CR 2
labetalol hcl SOLN; TABS 1
metoprolol succinate (generic of TOPROL XL)
1
metoprolol tartrate SOLN 1
metoprolol tartrate TABS 25mg
1
Drug Name Drug Tier
Requirements/Limits
metoprolol tartrate (generic of
LOPRESSOR) TABS 50mg, 100mg
1
nadolol (generic of CORGARD) TABS
1
pindolol 1
propranolol hcl er (generic of INDERAL LA)
1
propranolol inj 1mg/ml 1
propranolol sol 1 propranolol tab 1
SOTYLIZE 3 NM
timolol maleate TABS 1
CALCIUM CHANNEL BLOCKER/ANTILIPEMIC COMBINATIONS amlodipine besylate/atorv (generic of CADUET)
1
CALCIUM CHANNEL BLOCKERS afeditab cr (generic of ADALAT CC)
1
amlodipine besylate (generic
of NORVASC) TABS 1
CARDIZEM LA 120mg 3 cartia xt (generic of
CARDIZEM CD) 1
dilt-xr cap 1
diltiazem cap 120mg/24hr 1 diltiazem cap 240mg/24hr 1
diltiazem cap er/12hr 1 diltiazem hcl (generic of
CARDIZEM) TABS 30mg, 60mg, 120mg
1
diltiazem hcl TABS 90mg 1 diltiazem hcl coated beads
(generic of CARDIZEM CD) 1
diltiazem hcl er (generic of
TIAZAC) 1
diltiazem hcl extended release beads (generic of TIAZAC)
1
diltiazem inj 25mg/5ml 1
diltiazem inj 50/10ml 1 diltiazem inj 100mg 3
diltiazem inj 125/25ml 1 felodipine 1
isradipine 1
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
18
Drug Name Drug Tier
Requirements/Limits
matzim la (generic of
CARDIZEM LA) 1
nicardipine hcl CAPS 1 nifedical (generic of
PROCARDIA XL) 1
nifedipine (generic of ADALAT
CC) TB24 1
nifedipine er (generic of PROCARDIA XL)
1
nimodipine CAPS 3 NM
nisoldipine (generic of
SULAR) 8.5mg, 17mg, 34mg 1
nisoldipine 20mg, 25.5mg,
30mg, 40mg 1
NYMALIZE 3 NM
taztia xt (generic of TIAZAC) 1 verapamil hcl (generic of
VERELAN PM) CP24 100mg, 200mg, 300mg
1
verapamil hcl (generic of VERELAN) CP24 120mg, 180mg, 240mg
1
VERAPAMIL HCL CP24 360mg
1
verapamil hcl SOLN 1
verapamil hcl TABS 40mg 1
verapamil hcl (generic of CALAN) TABS 80mg, 120mg
1
verapamil hcl (generic of
CALAN SR) TBCR 1
DIGITALIS GLYCOSIDES digitek (generic of LANOXIN)
.25mg PA if 65 years and older
1 PA
digitek (generic of LANOXIN)
.125mg QL (30 tabs / 30 days)
1 QL
digox (generic of LANOXIN)
125mcg QL (30 tabs / 30 days)
1 QL
digox (generic of LANOXIN) 250mcg
PA if 65 years and older
1 PA
digoxin (generic of LANOXIN)
TABS 125mcg QL (30 tabs / 30 days)
1 QL
Drug Name Drug Tier
Requirements/Limits
digoxin (generic of LANOXIN)
TABS 250mcg PA if 65 years and older
1 PA
digoxin inj (generic of LANOXIN)
1
DIGOXIN SOL 50MCG/ML PA if 65 years and older
1 PA
LANOXIN TABS 62.5mcg QL (60 tabs / 30 days)
2 QL
LANOXIN TABS 187.5mcg PA if 65 years and older
2 PA
LANOXIN PEDIATRIC 3
DIRECT RENIN INHIBITORS/COMBINATIONS TEKTURNA 2
TEKTURNA HCT 2
DIURETICS acetazolamide (generic of
DIAMOX) CP12 1
acetazolamide TABS 1 acetazolamide sodium 1
ALDACTAZIDE TAB 50/50 3
amiloride & hydrochlorothiazide
1
amiloride hcl TABS 1
bumetanide SOLN 1 bumetanide (generic of
BUMEX) TABS 1
chlorothiazide tabs 1
chlorthalidone 25mg, 50mg 1
DIURIL SUS 250/5ML 3
DYRENIUM 3
EDECRIN 3
furosemide SOLN 1
furosemide (generic of LASIX) TABS
1
furosemide inj 10mg/ml 1
FUROSEMIDE INJ 10mg/ml 1 furosemide oral soln 8 mg/ml 1
hydrochlorothiazide (generic
of MICROZIDE) CAPS 1
hydrochlorothiazide TABS 1 indapamide 1
methazolamide (generic of
NEPTAZANE) TABS 1
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
19
Drug Name Drug Tier
Requirements/Limits
methyclothiazide 1
metolazone 1
spironolactone & hydrochlorothiazide (generic
of ALDACTAZIDE)
1
torsemide inj 50mg/5ml 3 torsemide tabs (generic of
DEMADEX) 5mg, 10mg, 20mg
1
torsemide tabs 100mg 1 triamt/hctz cap 37.5-25
(generic of DYAZIDE) 1
triamt/hctz cap 50-25mg 1 triamt/hctz tab 37.5-25
(generic of MAXZIDE-25) 1
triamt/hctz tab 75-50mg
(generic of MAXZIDE) 1
MISCELLANEOUS BIDIL 2
clonidine hcl (generic of CATAPRES-TTS-1) PTWK .1mg/24hr
1
clonidine hcl (generic of
CATAPRES-TTS-2) PTWK .2mg/24hr
1
clonidine hcl (generic of
CATAPRES-TTS-3) PTWK .3mg/24hr
1
clonidine hcl (generic of
CATAPRES) TABS 1
clorpres 1
CORLANOR 3
DEMSER 3 NM
DIBENZYLINE 3 NM
hydralazine hcl SOLN; TABS 1 midodrine hcl 1
minoxidil TABS 1
phenoxybenzamine hcl (generic of DIBENZYLINE) CAPS
3 NM
RANEXA 2
NITRATES DILATRATE SR 3
ISORDIL TITRADOSE 40mg 2 isosorbide dinitrate (generic of
ISORDIL TITRADOSE) 5mg 1
Drug Name Drug Tier
Requirements/Limits
isosorbide dinitrate 10mg,
20mg, 30mg 1
isosorbide dinitrate er 1 isosorbide mononitrate 1
isosorbide mononitrate er 1
minitran (generic of NITRO-DUR)
1
nitro-bid 3
NITRO-DUR .3mg/hr, .8mg/hr
2
nitroglycerin (generic of
NITROLINGUAL PUMPSPRAY) .4mg/spray
1
NITROGLYCERIN LINGUAL 1 nitroglycerin patches 1
NITROSTAT 2
PULMONARY ARTERIAL HYPERTENSION ADCIRCA 3 NM PA
ADEMPAS 3 NM LA PA
epoprostenol sodium (generic
of FLOLAN) 3 B/D NM LA
FLOLAN 3 B/D NM LA
LETAIRIS 3 NM LA PA
OPSUMIT 3 NM LA PA
ORENITRAM TAB 0.25MG 3 NM LA PA
ORENITRAM TAB 0.125MG 3 NM LA PA
ORENITRAM TAB 1MG 3 NM LA PA
ORENITRAM TAB 2.5MG 3 NM LA PA
REMODULIN 3 B/D NM LA
REVATIO SUSR 3 NM PA
sildenafil citrate (pulmonary hypertension) (generic of
REVATIO) SOLN
3 NM PA
sildenafil citrate (pulmonary hypertension) (generic of
REVATIO) TABS
1 NM PA
TRACLEER 3 NM LA PA
TYVASO 3 B/D NM
VELETRI 3 B/D NM LA
VENTAVIS 3 B/D NM
CENTRAL NERVOUS SYSTEM
ANTIANXIETY alprazolam CONC
QL (300 mL / 30 days) 3 QL
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
20
Drug Name Drug Tier
Requirements/Limits
alprazolam (generic of
XANAX) TABS 1mg QL (120 tabs / 30 days)
1 QL
alprazolam (generic of XANAX) TABS 2mg
QL (150 tabs / 30 days)
1 QL
alprazolam (generic of XANAX) TABS .5mg
QL (240 tabs / 30 days)
1 QL
alprazolam (generic of
XANAX) TABS .25mg QL (480 tabs / 30 days)
1 QL
buspirone hcl TABS 1
fluvoxamine maleate 25mg,
50mg QL (45 tabs / 30 days)
1 QL
fluvoxamine maleate 100mg 1
fluvoxamine maleate er 100mg
QL (90 caps / 30 days)
1 QL
fluvoxamine maleate er
150mg QL (60 caps / 30 days)
1 QL
lorazepam CONC
QL (150 mL / 30 days) 1 QL
lorazepam (generic of ATIVAN) SOLN
1
lorazepam (generic of
ATIVAN) TABS QL (150 tabs / 30 days)
1 QL
ANTICONVULSANTS APTIOM 200mg 3
APTIOM 400mg, 600mg, 800mg
3 NM
BANZEL SUS 40MG/ML 3 NM PA
BANZEL TAB 200MG 3 PA
BANZEL TAB 400MG 3 NM PA
carbamazepine CHEW 1 carbamazepine (generic of
CARBATROL) CP12 1
carbamazepine (generic of
TEGRETOL) SUSP; TABS 1
carbamazepine (generic of
TEGRETOL-XR) TB12 1
CELONTIN 3
clonazepam (generic of KLONOPIN) TABS 1mg
QL (120 tabs / 30 days)
1 QL
Drug Name Drug Tier
Requirements/Limits
clonazepam (generic of
KLONOPIN) TABS 2mg QL (300 tabs / 30 days)
1 QL
clonazepam (generic of KLONOPIN) TABS .5mg
QL (240 tabs / 30 days)
1 QL
clonazepam TBDP 1mg QL (120 tabs / 30 days)
1 QL
clonazepam TBDP 2mg
QL (300 tabs / 30 days) 1 QL
clonazepam TBDP .5mg
QL (240 tabs / 30 days) 1 QL
clonazepam TBDP .25mg
QL (480 tabs / 30 days) 1 QL
clonazepam TBDP .125mg
QL (960 tabs / 30 days) 1 QL
clorazepate dipotassium
(generic of TRANXENE T) 3.75mg, 7.5mg
QL (120 tabs / 30 days)
1 QL PA
clorazepate dipotassium
(generic of TRANXENE T) 15mg
QL (180 tabs / 30 days)
1 QL PA
diazepam CONC
QL (240 mL / 30 days) 1 QL PA
diazepam SOLN 1mg/ml
QL (1200 mL / 30 days) 1 QL PA
diazepam SOLN 5mg/ml 1
diazepam (generic of
VALIUM) TABS QL (120 tabs / 30 days)
1 QL PA
DIAZEPAM GEL (ANTICONVULSANT)
1
dilantin 3
DILANTIN-125 3
divalproex sodium (generic of
DEPAKOTE SPRINKLES) CPSP
1
divalproex sodium (generic of
DEPAKOTE ER) TB24 1
divalproex sodium (generic of DEPAKOTE) TBEC
1
epitol (generic of TEGRETOL) 1
ethosuximide (generic of
ZARONTIN) CAPS; SOLN 1
felbamate (generic of
FELBATOL) SUSP 3 NM
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
21
Drug Name Drug Tier
Requirements/Limits
felbamate (generic of
FELBATOL) TABS 1
FYCOMPA 3 PA
gabapentin (generic of NEURONTIN) CAPS 100mg
QL (1080 caps / 30 days)
1 QL
gabapentin (generic of NEURONTIN) CAPS 300mg
QL (360 caps / 30 days)
1 QL
gabapentin (generic of
NEURONTIN) CAPS 400mg QL (270 caps / 30 days)
1 QL
gabapentin (generic of
NEURONTIN) SOLN QL (2160 mL / 30 days)
1 QL
gabapentin (generic of
NEURONTIN) TABS 600mg QL (180 tabs / 30 days)
1 QL
gabapentin (generic of NEURONTIN) TABS 800mg
QL (120 tabs / 30 days)
1 QL
GABITRIL 12mg, 16mg 2
LAMICTAL ODT KIT 3
LAMICTAL STARTER 3
LAMICTAL XR KIT 2 lamotrigine (generic of
LAMICTAL CHEWABLE DISPERS) CHEW
1
lamotrigine KIT 1
lamotrigine (generic of
LAMICTAL) TABS 1
lamotrigine (generic of LAMICTAL XR) TB24
1
lamotrigine (generic of
LAMICTAL ODT) TBDP 1
levetiracetam (generic of KEPPRA) SOLN; TABS
1
levetiracetam (generic of
KEPPRA XR) TB24 1
LEVETIRACETAM IV 3 levetiracetam oral soln 100 mg/ml (generic of KEPPRA)
1
LYRICA CAPS 25mg, 50mg, 75mg, 100mg, 150mg
QL (120 caps / 30 days)
2 QL
LYRICA CAPS 200mg QL (90 caps / 30 days)
2 QL
Drug Name Drug Tier
Requirements/Limits
LYRICA CAPS 225mg, 300mg
QL (60 caps / 30 days)
2 QL
LYRICA SOLN QL (946 mL / 30 days)
2 QL
ONFI SUSP 3 NM PA
ONFI TABS 10mg 3 PA
ONFI TABS 20mg 3 NM PA
oxcarbazepine (generic of TRILEPTAL)
1
OXTELLAR XR 3
PEGANONE 3 phenobarbital ELIX; TABS
PA if 65 years and older 3 PA
PHENOBARBITAL SODIUM SOLN 65mg/ml
PA if 65 years and older
3 PA
phenobarbital sodium SOLN
130mg/ml PA if 65 years and older
3 PA
phenytek 3
phenytoin (generic of
DILANTIN INFATABS) CHEW
1
phenytoin (generic of
DILANTIN-125) SUSP 1
phenytoin inj 50mg/ml 1 phenytoin sodium extended
(generic of DILANTIN) 100mg
1
phenytoin sodium extended (generic of PHENYTEK) 200mg, 300mg
1
POTIGA 50mg 3
POTIGA 200mg QL (180 tabs / 30 days)
3 QL NM
POTIGA 300mg, 400mg QL (90 tabs / 30 days)
3 QL NM
primidone (generic of
MYSOLINE) TABS 1
SABRIL PACK QL (180 packets / 30 days)
3 QL NM LA PA
SABRIL TABS QL (180 tabs / 30 days)
3 QL NM LA PA
TEGRETOL 3
TEGRETOL-XR 3
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
22
Drug Name Drug Tier
Requirements/Limits
tiagabine hcl (generic of
GABITRIL) 1
topiramate (generic of
TOPAMAX SPRINKLE) CPSP
1
TOPIRAMATE CS24 1
topiramate (generic of TOPAMAX) TABS
1
TROKENDI XR 25mg, 50mg, 100mg
3
TROKENDI XR 200mg 3 NM
valproate sodium (generic of DEPACON) SOLN
1
valproate sodium (generic of
DEPAKENE) SYRP 1
valproic acid (generic of DEPAKENE)
1
VIMPAT SOLN 2
VIMPAT TABS 50mg 2
VIMPAT TABS 100mg, 150mg, 200mg
3 NM
zonisamide (generic of
ZONEGRAN) CAPS 25mg, 100mg
1
zonisamide CAPS 50mg 1
ANTIDEMENTIA donepezil odt 5mg 1
donepezil odt 10mg 1
donepezil tab hcl 23mg (generic of ARICEPT)
1
donepezil tabs 5mg (generic
of ARICEPT) 1
donepezil tabs 10mg (generic of ARICEPT)
1
EXELON PATCHES 2
galantamine hydrobromide
SOLN 1
galantamine hydrobromide
(generic of RAZADYNE) TABS
1
galantamine hydrobromide er (generic of RAZADYNE ER)
1
memantine hcl (generic of
NAMENDA) PA if < 30 yrs
1 PA
NAMENDA SOL 10MG/5ML PA if < 30 yrs
2 PA
Drug Name Drug Tier
Requirements/Limits
NAMENDA TAB PA if < 30 yrs
2 PA
NAMENDA XR PA if < 30 yrs
2 PA
NAMENDA XR TITRATION PACK
PA if < 30 yrs
2 PA
NAMZARIC 3 rivastigmine tartrate (generic
of EXELON) 1
rivastigmine td patch 24hr 4.6 mg/24hr (generic of EXELON)
1
rivastigmine td patch 24hr 9.5 mg/24hr (generic of EXELON)
1
rivastigmine td patch 24hr 13.3 mg/24hr (generic of EXELON)
1
ANTIDEPRESSANTS amitriptyline hcl TABS
PA if 65 years and older 3 PA
amoxapine 1
APLENZIN 3 NM
BRINTELLIX 2 bupropion hcl TABS 75mg 1
bupropion hcl (generic of
WELLBUTRIN) TABS 100mg
1
bupropion hcl (generic of
WELLBUTRIN SR) TB12 1
bupropion hcl (generic of WELLBUTRIN XL) TB24
1
citalopram hydrobromide
SOLN 1
citalopram hydrobromide (generic of CELEXA) TABS
1
clomipramine hcl (generic of
ANAFRANIL) CAPS PA if 65 years and older
3 PA
desipramine hcl (generic of
NORPRAMIN) TABS 1
doxepin hcl CAPS; CONC
PA if 65 years and older 3 PA
duloxetine hcl (generic of CYMBALTA) CPEP 20mg, 30mg, 60mg
1
EMSAM 3 NM PA
escitalopram oxalate (generic of LEXAPRO)
1
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
23
Drug Name Drug Tier
Requirements/Limits
FETZIMA 3
FETZIMA TITRATION PACK 3
fluoxetine cap 10mg (generic of PROZAC)
1
fluoxetine cap 20mg (generic
of PROZAC) 1
fluoxetine cap 40mg (generic of PROZAC)
1
fluoxetine hcl (generic of
PROZAC WEEKLY) CPDR 1
fluoxetine hcl SOLN 1 fluoxetine hcl TABS 10mg,
20mg 1
FLUOXETINE HCL TABS 60mg
2
FORFIVO XL QL (30 tabs / 30 days)
3 QL
imipramine hcl (generic of
TOFRANIL) TABS PA if 65 years and older
3 PA
imipramine pamoate
PA if 65 years and older 3 PA
maprotiline hcl 1
MARPLAN 3
mirtazapine TABS 7.5mg 1
mirtazapine (generic of REMERON) TABS 15mg, 30mg, 45mg
1
mirtazapine (generic of REMERON SOLTAB) TBDP
1
nefazodone hcl 1
nortriptyline hcl (generic of
PAMELOR) CAPS 1
nortriptyline hcl SOLN 1
paroxetine er tab (generic of
PAXIL CR) 1
paroxetine hcl tabs (generic of PAXIL)
1
PAXIL SUSP 3
PEXEVA 3 phenelzine sulfate (generic of
NARDIL) TABS 1
PRISTIQ 2
protriptyline hcl 1 sertraline hcl (generic of
ZOLOFT) CONC; TABS 1
Drug Name Drug Tier
Requirements/Limits
SURMONTIL PA if 65 years and older
3 PA
tranylcypromine sulfate
(generic of PARNATE) 1
trazodone hcl TABS 1
trimipramine maleate CAPS
25mg, 50mg PA if 65 years and older
3 PA
trimipramine maleate (generic
of SURMONTIL) CAPS 100mg
PA if 65 years and older
3 PA
venlafaxine cap er (generic of
EFFEXOR XR) 1
venlafaxine hcl 1 venlafaxine tab 1
VENLAFAXINE TAB 225MG ER
1
venlafaxine tab er (generic of
VENLAFAXINE HCL ER) 1
VIIBRYD 2
VIIBRYD STARTER PACK 2
ANTIPARKINSONIAN AGENTS amantadine hcl CAPS;
SYRP; TABS 1
APOKYN 3 NM LA PA
AZILECT 2
BENZTROPINE MESYLATE SOLN
1
benztropine mesylate TABS
PA if 65 years and older 3 PA
bromocriptine mesylate
(generic of PARLODEL) CAPS
1
bromocriptine mesylate
TABS 1
carbidopa (generic of LODOSYN) TABS
3 NM
carbidopa-levodopa (generic
of SINEMET) TABS 1
carbidopa-levodopa (generic of SINEMET CR) TBCR
1
carbidopa-levodopa TBDP 1
CARBIDOPA/LEVODOPA/ENTACAPONE
1
CARBIDOPA/LEVODOPA/ENTACAPONE
1
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
24
Drug Name Drug Tier
Requirements/Limits
CARBIDOPA/LEVODOPA/ENTACAPONE
1
CARBIDOPA/LEVODOPA/ENTACAPONE
1
CARBIDOPA/LEVODOPA/ENTACAPONE
1
CARBIDOPA/LEVODOPA/ENTACAPONE
1
DUOPA 3 B/D NM
ENTACAPONE 1
MIRAPEX .75mg 3
MIRAPEX ER .375mg, 2.25mg, 3mg, 3.75mg, 4.5mg
2
NEUPRO 2
pramipexole dihydrochloride (generic of MIRAPEX) TABS
1
pramipexole dihydrochloride
(generic of MIRAPEX ER) TB24
1
ropinirole hydrochloride
(generic of REQUIP) TABS 1
ropinirole hydrochloride
(generic of REQUIP XL) TB24
1
RYTARY 3
selegiline hcl (generic of ELDEPRYL) CAPS
1
selegiline hcl TABS 1
ZELAPAR 3 NM
ANTIPSYCHOTICS ABILIFY DISCMELT TAB 10MG
QL (60 tabs / 30 days)
3 QL NM
ABILIFY MAINTENA QL (1 injection / 28 days)
3 QL NM
aripiprazole odt
QL (60 tabs / 30 days) 3 QL NM
aripiprazole oral solution 1 mg/ml
QL (900ml / 30 days)
3 QL NM
aripiprazole tabs (generic of ABILIFY)
QL (30 tabs / 30 days)
3 QL NM
ARISTADA QL (1 syringe / 28 days)
3 QL NM
chlorpromazine hcl TABS 1
Drug Name Drug Tier
Requirements/Limits
chlorpromazine inj 3
clozapine (generic of
CLOZARIL) TABS 25mg 1
clozapine TABS 50mg 1
clozapine (generic of
CLOZARIL) TABS 100mg QL (270 tabs / 30 days)
1 QL
clozapine TABS 200mg
QL (135 tabs / 30 days) 1 QL
CLOZAPINE TBDP 150mg QL (180 tabs / 30 days)
3 QL NM PA
CLOZAPINE TBDP 200mg QL (135 tabs / 30 days)
3 QL NM PA
CLOZAPINE ODT 12.5mg 1 PA
CLOZAPINE ODT 25mg 1 PA
CLOZAPINE ODT 100mg QL (270 tabs / 30 days)
1 QL PA
FANAPT QL (60 tabs / 30 days)
3 QL ST
FANAPT TITRATION PACK 3 ST
FAZACLO 150mg QL (180 tabs / 30 days)
3 QL NM PA
FAZACLO 200mg QL (135 tabs / 30 days)
3 QL NM PA
fluphenazine decanoate SOLN
1
fluphenazine hcl 1
GEODON INJ QL (6 mL / 3 days)
3 QL
haloperidol TABS 1
haloperidol decanoate
(generic of HALDOL DECANOATE 50) SOLN 50mg/ml
1
haloperidol decanoate (generic of HALDOL DECANOATE 100) SOLN 100mg/ml
1
haloperidol lactate 1 haloperidol lactate inj 5 mg/ml
(generic of HALDOL) 1
INVEGA 1.5mg, 3mg, 9mg QL (30 tabs / 30 days)
3 QL
INVEGA 6mg QL (60 tabs / 30 days)
3 QL
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
25
Drug Name Drug Tier
Requirements/Limits
INVEGA SUST INJ 39 MG/0.25 ML
QL (1 injection / 28 days)
3 QL
INVEGA SUST INJ 78 MG/0.5 ML
QL (1 injection / 28 days)
3 QL NM
INVEGA SUST INJ 117 MG/0.75 ML
QL (1 injection / 28 days)
3 QL NM
INVEGA SUST INJ 156MG/ML
QL (1 injection / 28 days)
3 QL NM
INVEGA SUST INJ 234 MG/1.5 ML
QL (1 injection / 28 days)
3 QL NM
INVEGA TRINZA QL (1 syringe / 90 days)
3 QL NM
LATUDA 20mg QL (240 tabs / 30 days)
2 QL
LATUDA 40mg, 120mg QL (30 tabs / 30 days)
2 QL
LATUDA 60mg, 80mg QL (60 tabs / 30 days)
2 QL
loxapine succinate 1
molindone hcl 1 olanzapine (generic of
ZYPREXA) SOLR QL (3 vials / 1 day)
1 QL
olanzapine (generic of ZYPREXA) TABS 2.5mg, 5mg, 7.5mg
QL (30 tabs / 30 days)
1 QL
olanzapine (generic of ZYPREXA) TABS 10mg, 15mg, 20mg
QL (60 tabs / 30 days)
1 QL
olanzapine odt (generic of
ZYPREXA ZYDIS) 5mg QL (30 tabs / 30 days)
1 QL
olanzapine odt (generic of ZYPREXA ZYDIS) 10mg, 15mg, 20mg
QL (60 tabs / 30 days)
1 QL
Drug Name Drug Tier
Requirements/Limits
ORAP 3
paliperidone (generic of
INVEGA) 1.5mg, 3mg, 9mg QL (30 tabs / 30 days)
1 QL
paliperidone (generic of
INVEGA) 6mg QL (60 tabs / 30 days)
1 QL
perphenazine TABS 1
pimozide (generic of ORAP) 1
quetiapine fumarate (generic of SEROQUEL)
QL (90 tabs / 30 days)
1 QL
REXULTI 1mg QL (90 tabs / 30 days)
3 QL NM ST
REXULTI 2mg QL (60 tabs / 30 days)
3 QL NM ST
REXULTI 3mg, 4mg QL (30 tabs / 30 days)
3 QL NM ST
REXULTI .5mg QL (180 tabs / 30 days)
3 QL NM ST
REXULTI .25mg QL (360 tabs / 30 days)
3 QL NM ST
RISPERDAL INJ 12.5MG QL (2 injections / 28 days)
2 QL
RISPERDAL INJ 25MG QL (2 injections / 28 days)
2 QL
RISPERDAL INJ 37.5MG QL (2 injections / 28 days)
3 QL NM
RISPERDAL INJ 50MG QL (2 injections / 28 days)
3 QL NM
risperidone (generic of
RISPERDAL) SOLN QL (240 mL / 30 days)
1 QL
risperidone (generic of RISPERDAL) TABS 1mg, 2mg, 3mg
QL (60 tabs / 30 days)
1 QL
risperidone (generic of RISPERDAL) TABS 4mg
QL (120 tabs / 30 days)
1 QL
risperidone (generic of
RISPERDAL) TABS .25mg, .5mg
QL (90 tabs / 30 days)
1 QL
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
26
Drug Name Drug Tier
Requirements/Limits
risperidone odt (generic of
RISPERDAL M-TAB) 1mg, 2mg, 3mg
QL (60 tabs / 30 days)
1 QL
risperidone odt (generic of
RISPERDAL M-TAB) 4mg QL (120 tabs / 30 days)
1 QL
risperidone odt (generic of
RISPERDAL M-TAB) .5mg QL (90 tabs / 30 days)
1 QL
risperidone odt .25mg QL (90 tabs / 30 days)
1 QL
SAPHRIS 2.5mg QL (240 tabs / 30 days)
3 QL
SAPHRIS 5mg QL (120 tabs / 30 days)
3 QL
SAPHRIS 10mg QL (60 tabs / 30 days)
3 QL
SEROQUEL XR 50mg QL (120 tabs / 30 days)
2 QL
SEROQUEL XR 150mg, 200mg
QL (30 tabs / 30 days)
2 QL
SEROQUEL XR 300mg, 400mg
QL (60 tabs / 30 days)
2 QL
thioridazine hcl TABS
PA if 65 years and older 3 PA
thiothixene 1
trifluoperazine hcl 1
VERSACLOZ QL (600 mL / 30 days)
3 QL NM PA
ziprasidone hcl (generic of
GEODON) 20mg, 40mg QL (60 caps / 30 days)
1 QL
ziprasidone hcl (generic of
GEODON) 60mg, 80mg QL (90 caps / 30 days)
1 QL
ZYPREXA RELPREVV 300mg
QL (2 vials / 28 days)
3 QL NM PA
ZYPREXA RELPREVV 405mg
QL (1 vial / 28 days)
3 QL NM PA
ZYPREXA RELPREVV INJ 210MG
QL (2 vials / 28 days)
3 QL NM PA
Drug Name Drug Tier
Requirements/Limits
ATTENTION DEFICIT HYPERACTIVITY DISORDER amphetamine cap 10mg er
(generic of ADDERALL XR) QL (90 caps / 30 days)
1 QL
amphetamine cap 15mg er (generic of ADDERALL XR)
QL (30 caps / 30 days)
1 QL
amphetamine cap 20mg er (generic of ADDERALL XR)
QL (30 caps / 30 days)
1 QL
amphetamine cap 25mg er
(generic of ADDERALL XR) QL (30 caps / 30 days)
1 QL
amphetamine cap 30mg er
(generic of ADDERALL XR) QL (30 caps / 30 days)
1 QL
amphetamine-dextroamphetamine cap sr 24hr 5 mg
(generic of ADDERALL XR) QL (90 caps / 30 days)
1 QL
amphetamine-dextroamphetamine tab 5 mg (generic of
ADDERALL) QL (360 tabs / 30 days)
1 QL
amphetamine-dextroamphetamine tab 7.5 mg (generic of
ADDERALL) QL (240 tabs / 30 days)
1 QL
amphetamine-dextroamphetamine tab 10 mg (generic of
ADDERALL) QL (180 tabs / 30 days)
1 QL
amphetamine-dextroamphetamine tab 12.5 mg (generic of
ADDERALL) QL (144 tabs / 30 days)
1 QL
amphetamine-dextroamphetamine tab 15 mg (generic of
ADDERALL) QL (120 tabs / 30 days)
1 QL
amphetamine-dextroamphetamine tab 20 mg (generic of
ADDERALL) QL (90 tabs / 30 days)
1 QL
amphetamine-dextroamphetamine tab 30 mg (generic of ADDERALL)
QL (60 tabs / 30 days)
1 QL
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
27
Drug Name Drug Tier
Requirements/Limits
APTENSIO XR 10mg, 15mg, 20mg, 30mg
QL (60 caps / 30 days)
3 QL
APTENSIO XR 40mg, 50mg, 60mg
QL (30 caps / 30 days)
3 QL
DAYTRANA QL (30 patches / 30 days)
2 QL
guanfacine er (adhd) (generic
of INTUNIV) PA if 65 years and older
3 PA
metadate er tab 20mg
QL (90 tabs / 30 days) 1 QL
methylphenidate hcl (generic of METHYLIN) CHEW
QL (180 tabs / 30 days)
1 QL
methylphenidate hcl (generic
of RITALIN LA) CP24 20mg QL (60 caps / 30 days)
1 QL
METHYLPHENIDATE HCL CP24 30mg
QL (60 caps / 30 days)
1 QL
methylphenidate hcl (generic
of RITALIN LA) CP24 40mg QL (30 caps / 30 days)
1 QL
methylphenidate hcl (generic of METADATE CD) CPCR 10mg, 20mg, 30mg
QL (60 caps / 30 days)
1 QL
methylphenidate hcl (generic of METADATE CD) CPCR 40mg, 50mg, 60mg
QL (30 caps / 30 days)
1 QL
methylphenidate hcl (generic of METHYLIN) SOLN 5mg/5ml
QL (1800 mL / 30 days)
1 QL
methylphenidate hcl (generic of METHYLIN) SOLN 10mg/5ml
QL (900 mL / 30 days)
1 QL
methylphenidate hcl (generic
of RITALIN) TABS 5mg, 10mg
QL (180 tabs / 30 days)
1 QL
methylphenidate hcl (generic
of RITALIN) TABS 20mg QL (90 tabs / 30 days)
1 QL
Drug Name Drug Tier
Requirements/Limits
methylphenidate hcl TB24
QL (60 tabs / 30 days) 1 QL
methylphenidate hcl TBCR
QL (90 tabs / 30 days) 1 QL
methylphenidate hcl er TB24
27mg, 36mg QL (60 tabs / 30 days)
1 QL
methylphenidate hcl er TB24 54mg
QL (30 tabs / 30 days)
1 QL
QUILLIVANT XR QL (360 mL / 30 days)
2 QL
RITALIN LA 10mg QL (180 tabs / 30 days)
3 QL
RITALIN LA 60mg QL (30 caps / 30 days)
3 QL
STRATTERA 10mg, 18mg, 25mg
QL (120 caps / 30 days)
2 QL
STRATTERA 40mg QL (60 caps / 30 days)
2 QL
STRATTERA 60mg, 80mg, 100mg
QL (30 caps / 30 days)
2 QL
VYVANSE 10mg, 20mg, 30mg
QL (60 caps / 30 days)
2 QL
VYVANSE 40mg, 50mg, 60mg, 70mg
QL (30 caps / 30 days)
2 QL
HYPNOTICS HETLIOZ 3 NM LA PA
ROZEREM QL (30 tabs / 30 days)
3 QL
SILENOR 3mg QL (60 tabs / 30 days)
2 QL
SILENOR 6mg QL (30 tabs / 30 days)
2 QL
temazepam (generic of
RESTORIL) 7.5mg QL (30 caps / 30 days)
PA applies if 65 years and older after a 90 day supply in a calendar year
1 QL PA
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
28
Drug Name Drug Tier
Requirements/Limits
temazepam (generic of
RESTORIL) 15mg QL (60 caps / 30 days)
PA applies if 65 years and older after a 90 day supply in a calendar year
1 QL PA
zolpidem tartrate (generic of AMBIEN) TABS
QL (30 tabs / 30 days) PA applies if 65 years and older after a 90 day supply in a calendar year
3 QL PA
MIGRAINE almotriptan malate (generic of AXERT)
QL (12 tabs / 30 days)
1 QL
ALSUMA QL (12 injections / 30 days)
3 QL
AXERT QL (12 tabs / 30 days)
3 QL
cafergot tab 1-100mg 3 dihydroergotamine mesylate
(generic of D.H.E. 45) 1mg/ml
1
DIHYDROERGOTAMINE MESYLATE 4mg/ml
QL (8 mL / 30 days)
3 QL NM
ergomar 3
FROVA TAB 2.5MG QL (18 tabs / 30 days)
3 QL
migergot 3 NM
naratriptan hcl (generic of AMERGE)
QL (9 tabs / 30 days)
1 QL
RELPAX QL (12 tabs / 30 days)
2 QL
rizatriptan benzoate (generic
of MAXALT) TABS QL (18 tabs / 30 days)
1 QL
rizatriptan benzoate (generic of MAXALT-MLT) TBDP
QL (18 tabs / 30 days)
1 QL
SUMATRIPTAN INJ 4MG/0.5ML
QL (12 injections / 30 days)
1 QL
Drug Name Drug Tier
Requirements/Limits
sumatriptan inj 6mg/0.5ml
(generic of IMITREX STATDOSE SYSTEM) SOAJ
QL (12 injections / 30 days)
1 QL
SUMATRIPTAN INJ 6MG/0.5ML SOCT
QL (12 injections / 30 days)
1 QL
sumatriptan inj 6mg/0.5ml (generic of IMITREX) SOLN
QL (12 injections / 30 days)
1 QL
sumatriptan inj 6mg/0.5ml SOSY
QL (12 injections / 30 days)
1 QL
SUMATRIPTAN SUCCINATE SOLN 5mg/act
QL (24 inhalers / 30 days)
1 QL
SUMATRIPTAN SUCCINATE SOLN 20mg/act
QL (12 inhalers / 30 days)
1 QL
sumatriptan succinate
(generic of IMITREX) TABS QL (9 tabs / 30 days)
1 QL
SUMAVEL DOSEPRO QL (12 injections / 30 days)
3 QL NM
TREXIMET QL (9 tabs / 30 days)
3 QL NM
zolmitriptan (generic of
ZOMIG) TABS QL (12 tabs / 30 days)
1 QL
zolmitriptan odt (generic of ZOMIG ZMT)
QL (12 tabs / 30 days)
1 QL
ZOMIG NASAL SPRAY QL (12 inhalers / 30 days)
2 QL
MISCELLANEOUS BRISDELLE 2
EQUETRO 3
GRALISE 300mg QL (180 tabs / 30 days)
2 QL
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
29
Drug Name Drug Tier
Requirements/Limits
GRALISE 600mg QL (90 tabs / 30 days)
2 QL
GRALISE STARTER 2
HORIZANT 3
lithium carbonate CAPS 1
lithium carbonate TABS 1 lithium carbonate (generic of
LITHOBID) TBCR 300mg 1
lithium carbonate TBCR
450mg 1
LITHIUM SOLN 8MEQ/5ML 3
MESTINON SYRUP 2
MESTINON TIMESPAN 2
NUEDEXTA 2
pyridostigmine bromide
(generic of MESTINON) TABS
1
pyridostigmine bromide
(generic of MESTINON TIMESPAN) TBCR
1
riluzole (generic of RILUTEK) 1
SAVELLA 12.5mg QL (480 tabs / 30 days)
2 QL
SAVELLA 25mg QL (240 tabs / 30 days)
2 QL
SAVELLA 50mg QL (120 tabs / 30 days)
2 QL
SAVELLA 100mg QL (60 tabs / 30 days)
2 QL
SAVELLA TITRATION PACK 2
tetrabenazine (generic of XENAZINE) 12.5mg
QL (240 tabs / 30 days)
3 QL NM PA
tetrabenazine (generic of
XENAZINE) 25mg QL (120 tabs / 30 days)
3 QL NM PA
XENAZINE 12.5mg QL (240 tabs / 30 days)
3 QL NM LA PA
XENAZINE 25mg QL (120 tabs / 30 days)
3 QL NM LA PA
MULTIPLE SCLEROSIS AGENTS AMPYRA 3 NM LA PA
AUBAGIO QL (30 tabs / 30 days)
3 QL NM LA PA
AVONEX QL (4 injections / 28 days)
3 QL NM PA
Drug Name Drug Tier
Requirements/Limits
AVONEX PEN QL (4 injections / 28 days)
3 QL NM PA
BETASERON QL (14 syringes / 28 days)
3 QL NM PA
COPAXONE INJ 40MG/ML QL (12 syringes / 28 days)
3 QL NM PA
EXTAVIA QL (15 syringes / 30 days)
3 QL NM PA
GILENYA CAP 0.5MG QL (28 caps / 28 days)
3 QL NM PA
glatopa (generic of COPAXONE)
QL (30 syringes / 30 days)
3 QL NM PA
LEMTRADA 3 NM LA PA
PLEGRIDY SOPN QL (2 pens / 28 days)
3 QL NM PA
PLEGRIDY SOSY QL (2 syringes / 28 days)
3 QL NM PA
PLEGRIDY STARTER PACK SOPN
QL (2 pens / 28 days)
3 QL NM PA
PLEGRIDY STARTER PACK SOSY
QL (2 syringes / 28 days)
3 QL NM PA
REBIF QL (6 mL / 28 days)
3 QL NM PA
REBIF REBIDOSE QL (6 mL / 28 days)
3 QL NM PA
REBIF REBIDOSE TITRATION
QL (6 mL / 28 days)
3 QL NM PA
REBIF TITRATION PACK QL (6 mL / 30 days)
3 QL NM PA
TECFIDERA CAP 120MG QL (14 caps / 7 days)
3 QL NM LA PA
TECFIDERA CAP 240MG QL (60 caps / 30 days)
3 QL NM LA PA
TECFIDERA MIS STARTER 3 NM LA PA
TYSABRI 3 NM LA PA
MUSCULOSKELETAL THERAPY AGENTS baclofen TABS 1
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
30
Drug Name Drug Tier
Requirements/Limits
BOTOX INJ 100UNIT 3 NM PA
BOTOX INJ 200UNIT 3 NM PA
cyclobenzaprine hcl TABS
5mg, 10mg PA if 65 years and older
3 PA
dantrolene sodium (generic of
DANTRIUM) CAPS 25mg, 50mg
1
dantrolene sodium CAPS
100mg 1
DYSPORT 3 NM PA
tizanidine (generic of ZANAFLEX) CAPS
1
tizanidine TABS 2mg 1
tizanidine (generic of
ZANAFLEX) TABS 4mg 1
XEOMIN INJ 50 UNIT 3 NM PA
XEOMIN INJ 100 UNIT 3 NM PA
NARCOLEPSY/CATAPLEXY modafinil (generic of PROVIGIL) 100mg
QL (30 tabs / 30 days)
1 QL PA
modafinil (generic of
PROVIGIL) 200mg QL (60 tabs / 30 days)
3 QL NM PA
NUVIGIL 50mg QL (150 tabs / 30 days)
2 QL PA
NUVIGIL 150mg QL (60 tabs / 30 days)
2 QL PA
NUVIGIL 200mg, 250mg QL (30 tabs / 30 days)
2 QL PA
XYREM QL (540 mL / 30 days)
3 QL NM LA PA
PSYCHOTHERAPEUTIC-MISC acamprosate calcium 1
BUNAVAIL MIS 2.1-0.3MG QL (120 buccal films / 30 days)
3 QL PA
BUNAVAIL MIS 4.2-0.7MG QL (120 buccal films / 30 days)
3 QL PA
BUNAVAIL MIS 6.3-1MG QL (60 buccal films / 30 days)
3 QL PA
buprenorphine hcl SUBL 1 PA
buprenorphine hcl-naloxone hcl sl
QL (120 tabs / 30 days)
1 QL PA
Drug Name Drug Tier
Requirements/Limits
buproban (generic of ZYBAN) 1
bupropion hcl (smoking deterrent) (generic of ZYBAN)
1
CHANTIX 2 PA
CHANTIX CONTINUING MONTH
2 PA
CHANTIX STARTER PACK 2 PA
disulfiram (generic of ANTABUSE) TABS
1
naloxone hcl SOLN 1
naltrexone hcl (generic of REVIA) TABS
1
NICOTROL INHALER 3
NICOTROL NS 3
SARAFEM 3
SUBOXONE MIS 2-0.5MG QL (120 SL films / 30 days)
2 QL PA
SUBOXONE MIS 4-1MG QL (120 SL films / 30 days)
2 QL PA
SUBOXONE MIS 8-2MG QL (120 SL films / 30 days)
2 QL PA
SUBOXONE MIS 12-3MG QL (60 SL films / 30 days)
2 QL PA
VIVITROL 3 NM PA
ZUBSOLV SUB 1.4-0.36MG QL (120 tabs / 30 days)
3 QL PA
ZUBSOLV SUB 2.9-0.71MG QL (120 tabs / 30 days)
3 QL PA
ZUBSOLV SUB 5.7-1.4MG QL (120 tabs / 30 days)
3 QL PA
ZUBSOLV SUB 8.6-2.1MG QL (60 tabs / 30 days)
3 QL PA
ZUBSOLV SUB 11.4-2.9MG QL (60 tabs / 30 days)
3 QL PA
ENDOCRINE AND METABOLIC ANDROGENS ANDRODERM
QL (30 patches / 30 days)
2 QL PA
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
31
Drug Name Drug Tier
Requirements/Limits
ANDROGEL 20.25mg/1.25gm, 40.5mg/2.5gm
QL (150 grams / 30 days)
3 QL PA
ANDROGEL 25mg/2.5gm QL (300 grams / 30 days)
3 QL PA
ANDROGEL 1% QL (300 grams / 30 days)
3 QL PA
ANDROGEL 1.62% QL (150 grams / 30 days)
3 QL PA
ANDROGEL PUMP QL (300 grams / 30 days)
3 QL PA
AVEED 3 NM PA
AXIRON QL (440 mL / 30 days)
2 QL PA
depo-testosterone 100mg/ml 3 PA
FORTESTA QL (120 grams / 30 days)
3 QL PA
oxandrolone (generic of
OXANDRIN) TABS 2.5mg 1 PA
oxandrolone (generic of
OXANDRIN) TABS 10mg 3 NM PA
STRIANT QL (60 buccal systems / 30 days)
3 QL PA
TESTIM QL (300 grams / 30 days)
3 QL PA
testosterone cypionate
SOLN 100mg/ml 1 PA
testosterone cypionate
(generic of DEPO-TESTOSTERONE) SOLN 200mg/ml
1 PA
testosterone enanthate
SOLN 1 PA
VOGELXO QL (300 grams / 30 days)
3 QL PA
VOGELXO PUMP QL (300 grams / 30 days)
3 QL PA
Drug Name Drug Tier
Requirements/Limits
ANTIDIABETICS, INJECTABLE ALCOHOL SWABS 2
APIDRA 3
APIDRA SOLOSTAR 3
BYDUREON PEN QL (4 pens / 28 days)
3 QL
BYDUREON SUSR QL (4 vials / 28 days)
3 QL
BYETTA QL (1 pen / 30 days)
3 QL
GAUZE PADS 2X2 2
HUMALOG 3
HUMALOG KWIKPEN 3
HUMALOG MIX 50/50 3
HUMALOG MIX 50/50 KWIKPEN
3
HUMALOG MIX 75/25 3
HUMALOG MIX 75/25 KWIKPEN
3
HUMULIN 70/30 3
HUMULIN 70/30 KWIKPEN 3
HUMULIN N 3
HUMULIN N KWIKPEN 3
HUMULIN R 3
HUMULIN R U-500 (CONCENTRATE)
3 B/D NM
INSULIN PEN NEEDLES 2
INSULIN SAFETY NEEDLES 2
INSULIN SYRINGES 2
LANTUS 2
LANTUS SOLOSTAR 2
LEVEMIR 2
LEVEMIR FLEXTOUCH 2
NOVOLIN 70/30 2
NOVOLIN 70/30 RELION 3
NOVOLIN N 2
NOVOLIN N RELION 3
NOVOLIN R 2
NOVOLIN R RELION 3
NOVOLOG 2
NOVOLOG FLEXPEN 2
NOVOLOG MIX 70/30 2
NOVOLOG MIX 70/30 PREFILL
2
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
32
Drug Name Drug Tier
Requirements/Limits
NOVOLOG PENFILL 2
SYMLINPEN 60 2 PA
SYMLINPEN 120 3 NM PA
TANZEUM QL (4 pens / 28 days)
3 QL
TOUJEO SOLOSTAR 2
TRESIBA FLEXTOUCH 2
TRULICITY QL (4 pens / 28 days)
2 QL
VICTOZA QL (3 pens / 30 days)
2 QL
ANTIDIABETICS, ORAL acarbose (generic of
PRECOSE) 1
ACTOPLUS MET XR 15-1000MG
QL (60 tabs / 30 days)
3 QL
ACTOPLUS MET XR 30-1000MG
QL (30 tabs / 30 days)
3 QL
FARXIGA 5mg QL (60 tabs / 30 days)
2 QL
FARXIGA 10mg QL (30 tabs / 30 days)
2 QL
glimepiride (generic of
AMARYL) 1mg QL (240 tabs / 30 days)
1 QL
glimepiride (generic of
AMARYL) 2mg QL (120 tabs / 30 days)
1 QL
glimepiride (generic of AMARYL) 4mg
QL (60 tabs / 30 days)
1 QL
glipizide (generic of
GLUCOTROL) TABS 5mg QL (240 tabs / 30 days)
1 QL
glipizide (generic of
GLUCOTROL) TABS 10mg QL (120 tabs / 30 days)
1 QL
glipizide er (generic of
GLUCOTROL XL) 2.5mg QL (240 tabs / 30 days)
1 QL
glipizide er (generic of GLUCOTROL XL) 5mg
QL (120 tabs / 30 days)
1 QL
glipizide er (generic of GLUCOTROL XL) 10mg
QL (60 tabs / 30 days)
1 QL
Drug Name Drug Tier
Requirements/Limits
GLIPIZIDE XL TB24 2.5MG QL (240 tabs / 30 days)
1 QL
GLIPIZIDE XL TB24 5MG QL (120 tabs / 30 days)
1 QL
glipizide-metformin 2.5-250 mg
QL (240 tabs / 30 days)
1 QL
glipizide-metformin 2.5-500 mg
QL (120 tabs / 30 days)
1 QL
glipizide-metformin 5-500mg
QL (120 tabs / 30 days) 1 QL
GLUMETZA 500mg QL (120 tabs / 30 days)
3 QL
GLUMETZA 1000mg QL (60 tabs / 30 days)
3 QL
GLYSET 3
GLYXAMBI QL (30 tabs / 30 days)
3 QL
INVOKAMET TAB 50-500MG QL (120 tabs / 30 days)
3 QL
INVOKAMET TAB 50-1000 QL (60 tabs / 30 days)
3 QL
INVOKAMET TAB 150-500 QL (60 tabs / 30 days)
3 QL
INVOKAMET TAB 150-1000 QL (60 tabs / 30 days)
3 QL
INVOKANA TAB 100MG QL (90 tabs / 30 days)
3 QL
INVOKANA TAB 300MG QL (30 tabs / 30 days)
3 QL
JANUMET QL (60 tabs / 30 days)
2 QL
JANUMET XR TAB 50-500MG
QL (60 tabs / 30 days)
2 QL
JANUMET XR TAB 50-1000 QL (60 tabs / 30 days)
2 QL
JANUMET XR TAB 100-1000 QL (30 tabs / 30 days)
2 QL
JANUVIA QL (30 tabs / 30 days)
2 QL
JARDIANCE 10mg QL (60 tabs / 30 days)
2 QL
JARDIANCE 25mg QL (30 tabs / 30 days)
2 QL
JENTADUETO QL (60 tabs / 30 days)
2 QL
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
33
Drug Name Drug Tier
Requirements/Limits
KAZANO QL (60 tabs / 30 days)
3 QL
KOMBIGLYZE XR 2.5-1000MG
QL (60 tabs / 30 days)
3 QL
KOMBIGLYZE XR 5-500MG QL (30 tabs / 30 days)
3 QL
KOMBIGLYZE XR 5-1000MG QL (30 tabs / 30 days)
3 QL
metformin er (generic of
GLUCOPHAGE XR) 500mg QL (120 tabs / 30 days)
1 QL
metformin er (generic of
GLUCOPHAGE XR) 750mg QL (60 tabs / 30 days)
1 QL
metformin hcl (generic of GLUCOPHAGE) TABS 500mg
QL (150 tabs / 30 days)
1 QL
metformin hcl (generic of GLUCOPHAGE) TABS 850mg
QL (90 tabs / 30 days)
1 QL
metformin hcl (generic of
GLUCOPHAGE) TABS 1000mg
QL (75 tabs / 30 days)
1 QL
metformin hcl (generic of
GLUMETZA) TB24 500mg QL (120 tabs / 30 days)
1 QL
metformin hcl (generic of GLUMETZA) TB24 1000mg
QL (60 tabs / 30 days)
1 QL
metformin hcl osmotic 500mg
(generic of FORTAMET) QL (150 tabs / 30 days)
1 QL
metformin hcl osmotic 1000mg (generic of
FORTAMET) QL (75 tabs / 30 days)
1 QL
nateglinide (generic of
STARLIX) QL (90 tabs / 30 days)
1 QL
NESINA 6.25mg QL (120 tabs / 30 days)
3 QL
NESINA 12.5mg QL (60 tabs / 30 days)
3 QL
NESINA 25mg QL (30 tabs / 30 days)
3 QL
Drug Name Drug Tier
Requirements/Limits
ONGLYZA QL (30 tabs / 30 days)
3 QL
OSENI TAB 12.5-15MG QL (60 tabs / 30 days)
3 QL
OSENI TAB 12.5-30MG QL (30 tabs / 30 days)
3 QL
OSENI TAB 12.5-45MG QL (30 tabs / 30 days)
3 QL
OSENI TAB 25-15MG QL (30 tabs / 30 days)
3 QL
OSENI TAB 25-30MG QL (30 tabs / 30 days)
3 QL
OSENI TAB 25-45MG QL (30 tabs / 30 days)
3 QL
pioglitazone hcl (generic of
ACTOS) QL (30 tabs / 30 days)
1 QL
pioglitazone hcl-glimepiride
(generic of DUETACT) QL (30 tabs / 30 days)
1 QL
pioglitazone hcl-metformin hcl
(generic of ACTOPLUS MET) QL (90 tabs / 30 days)
1 QL
PRANDIMET QL (150 tabs / 30 days)
3 QL
repaglinide (generic of
PRANDIN) 2mg QL (240 tabs / 30 days)
1 QL
repaglinide (generic of
PRANDIN) .5mg, 1mg QL (120 tabs / 30 days)
1 QL
repaglinide-metformin hcl QL (150 tabs / 30 days)
1 QL
RIOMET QL (946 mL / 30 days)
3 QL
SYNJARDY TAB 5-500MG QL (120 tabs / 30 days)
3 QL
SYNJARDY TAB 5-1000MG QL (60 tabs / 30 days)
3 QL
SYNJARDY TAB 12.5-500 QL (60 tabs / 30 days)
3 QL
SYNJARDY TAB 12.5-1000 QL (60 tabs / 30 days)
3 QL
TRADJENTA QL (30 tabs / 30 days)
2 QL
XIGDUO XR TAB 5-500MG QL (60 tabs / 30 days)
2 QL
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
34
Drug Name Drug Tier
Requirements/Limits
XIGDUO XR TAB 5-1000MG QL (60 tabs / 30 days)
2 QL
XIGDUO XR TAB 10-500MG QL (30 tabs / 30 days)
2 QL
XIGDUO XR TAB 10-1000MG QL (30 tabs / 30 days)
2 QL
BISPHOSPHONATES alendronate sodium SOLN
QL (300 mL / 28 days) 1 QL
alendronate sodium TABS
5mg, 10mg, 35mg, 40mg 1
alendronate sodium (generic of FOSAMAX) TABS 70mg
1
BINOSTO 3
FOSAMAX PLUS D 3 ibandronate sodium (generic
of BONIVA) QL (1 injection / 90 days)
1 B/D QL
ibandronate tab 150mg
(generic of BONIVA) 1 B/D
pamidronate disodium SOLN
6mg/ml 3 B/D
pamidronate disodium SOLN
30mg/10ml, 90mg/10ml 1 B/D
RISEDRONATE SODIUM TABS 5mg, 30mg
1
risedronate sodium (generic
of ACTONEL) TABS 35mg, 150mg
1
risedronate sodium (generic of ATELVIA) TBEC
1
zoledronic inj 4mg/5ml
(generic of ZOMETA) 1 B/D NM
zoledronic inj 5/100ml (generic of RECLAST)
1 B/D NM
ZOMETA SOLN 3 B/D NM
CALCIUM RECEPTOR AGONISTS SENSIPAR 2 NM
CHELATING AGENTS CHEMET 3
DEPEN TITRATABS 3 NM
EXJADE 3 NM LA PA
FERRIPROX 3 NM LA PA
JADENU 3 NM PA
kionex (generic of
KAYEXALATE) 1
Drug Name Drug Tier
Requirements/Limits
sodium polystyrene sulfonate
(generic of KAYEXALATE) POWD
1
sodium polystyrene sulfonate SUSP
1
sps susp 15gm/60ml 1
SYPRINE 3 NM
CONTRACEPTIVES altavera 1
amethia 91 day (generic of SEASONIQUE)
1
amethyst 28 day 1
apri 28 day (generic of
DESOGEN) 1
aranelle 28 (generic of
TRI-NORINYL 28) 1
ashlyna 91 day (generic of
SEASONIQUE) 1
aubra 28 day 1
aviane 28 1
balziva 28 day (generic of OVCON-35)
1
bekyree 28 day (generic of
MIRCETTE) 1
BEYAZ 2 blisovi 21 fe 1.5/30 28 day pack (generic of LOESTRIN
FE 1.5/30)
1
blisovi 21 fe 1/20 28 day pack (generic of LOESTRIN FE 1/20)
1
blisovi 24 fe 1/20 28 day 1
briellyn 28 day (generic of OVCON-35)
1
camila 28 day (generic of
NOR-QD) 1
CAMRESE LO TAB 1 cryselle 28 1
cyclafem 1/35 28 day (generic
of NORINYL 1+35) 1
cyclafem 7/7/7 28 day
(generic of ORTHO-NOVUM 7/7/7)
1
cyred tab (generic of DESOGEN)
1
deblitane 28 day (generic of
NOR-QD) 1
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
35
Drug Name Drug Tier
Requirements/Limits
delyla 28 day 1
DEPO-SUBQ PROVERA 104 2
desogestrel-ethinyl estradiol (biphasic) (generic of
MIRCETTE)
1
drospirenone-ethinyl estradiol (generic of YASMIN 28)
1
drospirenone-ethinyl estradiol
(generic of YAZ) 1
ELLA 3 emoquette (generic of
DESOGEN) 1
enpresse 28 day 1
errin 28 day (generic of ORTHO MICRONOR)
1
estarylla tab 0.25-35 (generic
of ORTHO-CYCLEN) 1
falmina 28 day 1
GIANVI TAB 3-0.02MG 1
gildagia (generic of
OVCON-35) 1
gildess 1.5/30 21 day (generic
of LOESTRIN 1.5/30-21) 1
gildess 24 fe 28 day 1
heather (generic of NOR-QD) 1 introvale 91 day 1
JOLESSA TAB 0.15-0.03 MG 1
JOLIVETTE 1
juleber 28 day (generic of
DESOGEN) 1
junel 1.5/30 21 day (generic of LOESTRIN 1.5/30-21)
1
junel 1/20 21 day (generic of
LOESTRIN 1/20-21) 1
junel fe 1.5/30 28 day (generic of LOESTRIN FE 1.5/30)
1
junel fe 1/20 28 day (generic
of LOESTRIN FE 1/20) 1
junel fe 24 1/20 28 day 1 kaitlib fe 28 day (generic of
GENERESS FE) 1
kariva 28 day (generic of
MIRCETTE) 1
kelnor 1/35 28 day 1
kimidess 28 day (generic of
MIRCETTE) 1
Drug Name Drug Tier
Requirements/Limits
larin 1.5/30 (generic of
LOESTRIN 1.5/30-21) 1
larin 1/20 (generic of
LOESTRIN 1/20-21) 1
larin fe 1.5/30 (generic of
LOESTRIN FE 1.5/30) 1
larin fe 1/20 (generic of
LOESTRIN FE 1/20) 1
LAYOLIS FE CHW 1
LEENA TAB 1
lessina 28 day 1 levonest 28 day 1
levonor/ethi tab 1
levonorgestrel & eth estradiol 1 levonorgestrel (emergency oc) (generic of PLAN B
ONE-STEP) 1.5mg
1
levonorgestrel (emergency oc) .75mg
1
levonorgestrel-ethinyl estradiol (91-day)
1
levonorgestrel-ethinyl estradiol (91-day) (generic of
SEASONIQUE)
1
levonorgestrel-ethinyl estradiol (continuous)
1
levora 0.15/30 28 day 1
LO LOESTRIN FE 2 lomedia 24 fe 1
loryna 28 day (generic of
YAZ) 1
low-ogestrel 1 lutera 28 day 1
lyza (generic of ORTHO
MICRONOR) 1
marlissa 28 day 1
medroxyprogesterone acetate (contraceptive) (generic of DEPO-PROVERA CONTRACEPTIV)
1
MICROGESTIN 1.5/30 1
MICROGESTIN 1/20 1
MICROGESTIN FE 1.5/30 1
MICROGESTIN FE 1/20 1
MINASTRIN 24 FE 2
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
36
Drug Name Drug Tier
Requirements/Limits
mono-linyah tab 0.25-35
(generic of ORTHO-CYCLEN) 1
MONONESSA 1 myzilra 1
necon 0.5/35 28 day (generic
of BREVICON-28) 1
necon 1/35 28 day (generic of NORINYL 1+35)
1
NECON 7/7/7 1
necon 10/11 28 day 3
NECON TAB 1/50-28 1
next choice tab 1.5mg
(generic of PLAN B ONE-STEP)
1
nikki 28 day (generic of YAZ) 1
NORA-BE TAB 1 norethin acet & estrad-fe 1
norethindrone & ethinyl estradiol-fe (generic of GENERESS FE)
1
norethindrone (contraceptive)
(generic of NOR-QD) 1
norgest/ethi tab 0.25/35
(generic of ORTHO-CYCLEN) 1
norgestimate-ethinyl estradiol (triphasic) (generic of ORTHO
TRI-CYCLEN)
1
norlyroc 28 day (generic of NOR-QD)
1
nortrel 0.5/35 28 day (generic
of BREVICON-28) 1
nortrel 1/35 21 day (generic of NORINYL 1+35)
1
nortrel 1/35 28 day (generic of
NORINYL 1+35) 1
nortrel 7/7/7 28 day (generic of ORTHO-NOVUM 7/7/7)
1
NUVARING 2
OCELLA TAB 3-0.03MG 1
ogestrel 28 day 1 orsythia 28 day 1
ORTHO TRI-CYCLEN LO 2 philith (generic of OVCON-35) 1
pimtrea pack (generic of
MIRCETTE) 1
pirmella 1/35 28 day (generic of NORINYL 1+35)
1
Drug Name Drug Tier
Requirements/Limits
portia 28 day 1
previfem 28 day (generic of
ORTHO-CYCLEN) 1
QUARTETTE 3
quasense 91 day 1
reclipsen 28 day (generic of DESOGEN)
1
setlakin tab 1
sharobel 28 day (generic of
ORTHO MICRONOR) 1
sprintec 28 day (generic of
ORTHO-CYCLEN) 1
sronyx 28 day 1
syeda (generic of YASMIN 28)
1
tarina fe 1/20 28 day (generic
of LOESTRIN FE 1/20) 1
tri-legest 28 day (generic of ESTROSTEP FE)
1
tri-previfem 28 day (generic of
ORTHO TRI-CYCLEN) 1
tri-sprintec 28 day (generic of ORTHO TRI-CYCLEN)
1
TRINESSA 1
trivora 28 day 1 velivet 28 day (generic of
CYCLESSA) 1
vestura (generic of YAZ) 1
vienva 28 day 1 viorele (generic of
MIRCETTE) 1
vyfemla 28 day (generic of OVCON-35)
1
wymzya fe (generic of
FEMCON FE) 1
xulane dis 150-35 1 zarah (generic of YASMIN 28) 1
zenchent fe 28 day (generic of
FEMCON FE) 1
zenchent tab (generic of OVCON-35)
1
zovia 1/35e 28 day 1
zovia 1/50e 28 day 1
ENDOMETRIOSIS danazol CAPS 1
LUPANETA PACK 3 NM PA
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
37
Drug Name Drug Tier
Requirements/Limits
SYNAREL 3 NM
ENZYME REPLACEMENTS ADAGEN 3 NM LA PA
ALDURAZYME 3 NM LA PA
CARBAGLU 3 NM LA PA
CERDELGA 3 NM PA
CEREZYME 3 NM LA PA
CYSTADANE 3 NM LA
CYSTAGON 3 NM LA PA
ELAPRASE 3 NM LA PA
ELELYSO 3 NM PA
FABRAZYME 3 NM LA PA
KUVAN 3 NM LA PA
levocarnitine (metabolic modifiers) (generic of CARNITOR)
1 B/D
LUMIZYME 3 NM LA PA
MYOZYME 3 NM LA PA
NAGLAZYME 3 NM LA PA
ORFADIN 3 NM LA PA
PROCYSBI 3 NM LA PA
RAVICTI 3 NM PA
sodium phenylbutyrate
(generic of BUPHENYL) 3 NM
VIMIZIM 3 NM PA
VPRIV 3 NM PA
ZAVESCA 3 NM LA PA
ESTROGENS ALORA
PA if 65 years and older 3 PA
DELESTROGEN 10mg/ml 3
depo-estradiol 3 estrace CREA 2
estradiol (generic of
VIVELLE-DOT) PTTW PA if 65 years and older
3 PA
estradiol (generic of
CLIMARA) PTWK PA if 65 years and older
3 PA
estradiol (generic of ESTRACE) TABS
PA if 65 years and older
3 PA
estradiol valerate (generic of
DELESTROGEN) OIL 1
ESTRING 3
FEMRING 3
Drug Name Drug Tier
Requirements/Limits
jinteli
PA if 65 years and older 3 PA
MENOSTAR PA if 65 years and older
3 PA
MINIVELLE PA if 65 years and older
3 PA
norethindrone acetate-ethinyl estradiol
PA if 65 years and older
3 PA
PREMARIN CREAM 2
PREMARIN INJ 3
VAGIFEM 2
GLUCOCORTICOIDS a-hydrocort 1 cortisone acetate TABS 1
DEPO-MEDROL INJ 20MG/ML
3 B/D
dexamethasone CONC 3
dexamethasone ELIX;
SOLN; TABS 1
dexamethasone sodium phosphate
1
dexpak 6 day 2
dexpak 10 day 2 dexpak taperpak 13 day 2
FLO-PRED SUS 3 B/D
fludrocortisone acetate TABS
1
hydrocortisone (generic of
CORTEF) TABS 1
MEDROL TAB 2MG 3 B/D
methylpr ace inj 40mg/ml (generic of DEPO-MEDROL)
1 B/D
methylpr ace inj 80mg/ml
(generic of DEPO-MEDROL) 1 B/D
methylpr ss inj 1gm (generic of SOLU-MEDROL)
1 B/D
methylpr ss inj 40mg (generic
of SOLU-MEDROL) 1 B/D
methylpr ss inj 125mg (generic of SOLU-MEDROL)
1 B/D
methylpred pak 4mg (generic
of MEDROL DOSEPAK) 1 B/D
methylpred tab 4mg (generic
of MEDROL) 1 B/D
methylpred tab 8mg (generic
of MEDROL) 1 B/D
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
38
Drug Name Drug Tier
Requirements/Limits
methylpred tab 16mg (generic
of MEDROL) 1 B/D
methylpred tab 32mg (generic
of MEDROL) 1 B/D
millipred 3 B/D
millipred dp 3 B/D
pred sod pho sol 5mg/5ml
(generic of PEDIAPRED) 1 B/D
prednisolone sodium phosphate (generic of
ORAPRED ODT)
1 B/D
prednisolone sol 15mg/5ml 1 B/D
prednisolone sol 25mg/5ml 1 B/D
prednisolone syrup 15 mg/5ml 1 B/D
prednisone con 5mg/ml 3 B/D
prednisone pak 5mg 1 B/D
prednisone pak 10mg 1 B/D
prednisone sol 5mg/5ml 1 B/D
prednisone tab 1mg 1 B/D
prednisone tab 2.5mg 1 B/D
prednisone tab 5mg 1 B/D
prednisone tab 10mg 1 B/D
prednisone tab 20mg 1 B/D
prednisone tab 50mg 1 B/D
RAYOS TAB 1MG 3 B/D NM
RAYOS TAB 2MG 3 B/D NM
RAYOS TAB 5MG 3 B/D NM
SOLU-CORTEF 100MG 3
SOLU-CORTEF 250MG 3
SOLU-CORTEF 500MG 3
SOLU-CORTEF 1000MG 3
SOLU-MEDROL INJ 2GM 3 B/D
veripred 3 B/D
GLUCOSE ELEVATING AGENTS GLUCAGEN HYPOKIT 2
GLUCAGON EMERGENCY KIT
2
KORLYM 3 NM LA PA
PROGLYCEM SUS 50MG/ML 3
HUMAN GROWTH HORMONES GENOTROPIN 3 NM LA PA
GENOTROPIN MINIQUICK 3 NM LA PA
HUMATROPE 3 NM LA PA
HUMATROPE COMBO PACK 3 NM LA PA
NORDITROPIN FLEXPRO 3 NM PA
Drug Name Drug Tier
Requirements/Limits
NUTROPIN AQ INJ 20MG/2ML
3 NM LA PA
NUTROPIN AQ NUSPIN 5 3 NM LA PA
NUTROPIN AQ PEN 3 NM LA PA
OMNITROPE 5.8MG 3 NM LA PA
OMNITROPE 5MG 3 NM LA PA
OMNITROPE 10MG 3 NM LA PA
SAIZEN 3 NM LA PA
SAIZEN CLICK.EASY 3 NM LA PA
SEROSTIM 3 NM LA PA
ZOMACTON 3 NM PA
ZORBTIVE 3 NM PA
MISCELLANEOUS AFREZZA 3 cabergoline 1
calcitonin (salmon) nasal spray (generic of MIACALCIN)
1
CHORIONIC GONADOTROPIN SOLR
1 NM PA
EGRIFTA 1mg 3 NM LA PA
FORTICAL SPR 200/ACT 3
H.P. ACTHAR QL (1.5 ml / 1 day)
3 QL NM LA PA
INCRELEX 3 NM LA PA
methylergonovine maleate (generic of METHERGINE) TABS
1
MIACALCIN INJ 200U/ML 3 B/D NM
MYALEPT 3 NM LA PA
NOVAREL INJ 10000UNT 1 NM PA
octreotide acetate (generic of
SANDOSTATIN) 50mcg/ml, 100mcg/ml
1 NM PA
octreotide acetate (generic of SANDOSTATIN) 200mcg/ml, 500mcg/ml, 1000mcg/ml
3 NM PA
PREGNYL W/DILUENT BENZYL
1 NM PA
PROLIA QL (1 syringe / 180 days)
3 QL NM
raloxifene hcl (generic of
EVISTA) 1
SAMSCA 3 NM PA
SANDOSTATIN LAR DEPOT 3 NM PA
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
39
Drug Name Drug Tier
Requirements/Limits
SIGNIFOR 3 NM LA PA
SIGNIFOR LAR 3 NM LA PA
SOMATULINE DEPOT 3 NM PA
SOMAVERT 3 NM LA PA
XGEVA 3 NM PA
PARATHYROID HORMONES FORTEO 3 NM PA
NATPARA 3 NM PA
PHOSPHATE BINDER AGENTS AURYXIA 3 NM
calcium acetate (phosphate binder) (generic of PHOSLO)
CAPS
1
calcium acetate (phosphate binder) (generic of ELIPHOS)
TABS
1
FOSRENOL 3 NM
PHOSLYRA 2
RENAGEL 400mg 3
RENAGEL 800mg 3 NM
RENVELA PAK 2
RENVELA TAB 800MG 2
VELPHORO 3 NM
PROGESTINS CRINONE 2
medroxyprogesterone acetate
(generic of PROVERA) 1
norethindrone acetate
(generic of AYGESTIN) TABS
1
progesterone micronized (generic of PROMETRIUM) CAPS
1
THYROID AGENTS levothyroxine sodium (generic
of SYNTHROID) TABS 1
LEVOXYL 1
liothyronine sodium (generic of TRIOSTAT) SOLN
1
liothyronine sodium (generic
of CYTOMEL) TABS 1
methimazole (generic of TAPAZOLE) TABS
1
propylthiouracil TABS 1
SYNTHROID 2
TIROSINT 3
Drug Name Drug Tier
Requirements/Limits
UNITHROID 1
VASOPRESSINS DESMOPRESSIN ACETATE SOLN
1
desmopressin acetate
(generic of DDAVP) TABS 1
desmopressin acetate inj (generic of DDAVP)
1
desmopressin acetate spray
(generic of DDAVP) 1
desmopressin acetate spray refrigerated
1
STIMATE 3 NM
GASTROINTESTINAL
ANTIEMETICS AKYNZEO 3 B/D
ALOXI 3 NM
CESAMET QL (60 caps / 30 days)
3 B/D QL NM
compro supp 1
dronabinol (generic of
MARINOL) 2.5mg, 5mg QL (60 caps / 30 days)
1 B/D QL
dronabinol (generic of
MARINOL) 10mg QL (60 caps / 30 days)
3 B/D QL NM
EMEND CAP 40MG 3 B/D
EMEND CAP 80MG 3 B/D
EMEND CAP 125MG 3 B/D
EMEND PAK 80 & 125 3 B/D
granisetron hcl SOLN 1 granisetron hcl TABS 1 B/D
meclizine hcl TABS 1
metoclopramide hcl SOLN 1 metoclopramide hcl (generic
of REGLAN) TABS 1
metoclopramide hcl (generic
of METOZOLV ODT) TBDP 1
metoclopramide hcl inj 5 mg/ml
1
metoclopramide odt 1
ondansetron hcl (generic of ZOFRAN) TABS 4mg, 8mg
1 B/D
ondansetron hcl TABS 24mg 1 B/D
ondansetron hcl inj 4mg/2ml 1
ondansetron hcl inj (generic of ZOFRAN) 40mg/20ml
1
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
40
Drug Name Drug Tier
Requirements/Limits
ondansetron hcl oral soln
(generic of ZOFRAN) 1 B/D
ondansetron odt (generic of
ZOFRAN ODT) 1 B/D
phenadoz
PA if 65 years and older 3 PA
phenergan SUPP
PA if 65 years and older 3 PA
prochlorperazine inj 5 mg/ml 1
prochlorperazine maleate
(generic of COMPAZINE) TABS
1
prochlorperazine supp 1
promethazine hcl (generic of
PHENERGAN) SOLN PA if 65 years and older
3 PA
promethazine hcl SUPP;
SYRP; TABS PA if 65 years and older
3 PA
promethegan
PA if 65 years and older 3 PA
SANCUSO QL (4 patches / 30 days)
3 QL NM
TRANSDERM-SCOP QL (10 patches / 30 days)
PA if 65 years and older
3 QL PA
ZUPLENZ 3 B/D NM
ANTISPASMODICS ATROPINE SULFATE SOLN .05mg/ml, .1mg/ml
1
BENTYL SOLN 3
CANTIL 3
CUVPOSA 3 dicyclomine hcl (generic of
BENTYL) CAPS; TABS 1
dicyclomine hcl SOLN 1 glycate 3
glycopyrrolate (generic of
ROBINUL) SOLN 1
glycopyrrolate (generic of ROBINUL) TABS 1mg
1
glycopyrrolate (generic of
ROBINUL FORTE) TABS 2mg
1
Drug Name Drug Tier
Requirements/Limits
methscopolamine bromide
(generic of PAMINE) TABS 2.5mg
1
methscopolamine bromide (generic of PAMINE FORTE) TABS 5mg
1
H2-RECEPTOR ANTAGONISTS cimetidine TABS 1
cimetidine sol 300/5ml 1
famotidine (generic of PEPCID) SUSR
1
famotidine (generic of
PEPCID) TABS 20mg, 40mg 1
famotidine inj 1 nizatidine CAPS 150mg 1
nizatidine (generic of AXID)
CAPS 300mg 1
nizatidine SOLN 1
ranitidine hcl CAPS 1
ranitidine hcl (generic of ZANTAC) SOLN
1
ranitidine hcl SYRP 1
ranitidine hcl (generic of
ZANTAC) TABS 150mg, 300mg
1
INFLAMMATORY BOWEL DISEASE APRISO 2
ASACOL HD 3
balsalazide disodium (generic
of COLAZAL) 1
budesonide (generic of
ENTOCORT EC) CP24 3 NM
CANASA 3 NM
colocort (generic of
CORTENEMA) 1
DELZICOL 3
DIPENTUM 3 NM
ENTYVIO 3 NM PA
GIAZO 3 NM
HYDROCORTISONE (INTRARECTAL)
1
LIALDA 2
mesalamine enema ENEM 1 mesalamine enema (generic
of ROWASA) KIT 1
PENTASA 2
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
41
Drug Name Drug Tier
Requirements/Limits
SF-ROWASA 3 NM
sulfasalazine dr (generic of
AZULFIDINE EN-TABS) 1
sulfasalazine ir (generic of AZULFIDINE)
1
UCERIS AER 2MG/ACT 3
UCERIS TAB 9MG 3 NM
LAXATIVES COLYTE-FLAVOR PACKS 227.1 GM
3
constulose 1 enulose 1
gaviltye-g (generic of
GOLYTELY) 1
gavilyte-c (generic of COLYTE-FLAVOR PACKS)
1
gavilyte-h 1
gavilyte-n (generic of NULYTELY/FLAVOR PACKS)
1
generlac 1
GOLYTELY 3 kristalose 3
lactulose 1
lactulose (encephalopathy) 1
MOVIPREP 2
NULYTELY/FLAVOR PACKS 3
OSMOPREP 3
PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE
1
PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE
1
peg 3350-potassium chloride-sod bicarbonate-sod chloride (generic of
NULYTELY/FLAVOR PACKS)
1
polyethylene glycol 3350 PACK; POWD
1
PREPOPIK 3
RELISTOR 3 NM PA
SUCLEAR 2
SUPREP BOWEL PREP 2
trilyte (generic of
NULYTELY/FLAVOR PACKS) 1
MISCELLANEOUS
Drug Name Drug Tier
Requirements/Limits
alosetron hcl (generic of
LOTRONEX) 3 NM PA
AMITIZA 2 amoxicillin-clarithromycin w/ lansoprazole (generic of
PREVPAC)
1
CARAFATE SUSP 2 cromolyn sodium (mastocytosis) (generic of
GASTROCROM)
3 NM
diphenoxylate w/ atropine LIQD
1
diphenoxylate w/ atropine
(generic of LOMOTIL) TABS 1
GATTEX 3 NM LA PA
LINZESS 2
loperamide hcl CAPS 1
misoprostol (generic of CYTOTEC) TABS
1
MOVANTIK 2
OMECLAMOX-PAK 3
PYLERA 3 NM
SUCRAID 3 NM LA
sucralfate (generic of
CARAFATE) TABS 1
ursodiol (generic of ACTIGALL) CAPS
1
ursodiol (generic of URSO
250) TABS 250mg 1
ursodiol (generic of URSO FORTE) TABS 500mg
1
VIBERZI 3 NM PA
XIFAXAN TAB 550MG 3 NM PA
PANCREATIC ENZYMES CREON 2
PANCREAZE 3
PERTZYE 3
ULTRESA 2
VIOKACE 10 2
VIOKACE 20 3 NM
ZENPEP 2
PROTON PUMP INHIBITORS ACIPHEX SPR CAP 5MG 3
ACIPHEX SPR CAP 10MG QL (60 caps / 30 days)
3 QL
DEXILANT 2
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
42
Drug Name Drug Tier
Requirements/Limits
esomeprazole magnesium
(generic of NEXIUM) 1
esomeprazole sodium inj
20mg 1
esomeprazole sodium inj
(generic of NEXIUM I.V.) 40mg
1
lansoprazole (generic of PREVACID) CPDR
QL (30 caps / 30 days)
1 QL
NEXIUM CAP 20MG 2
NEXIUM CAP 40MG 2
NEXIUM GRA 2.5MG DR 2
NEXIUM GRA 5MG DR 2
NEXIUM GRA 10MG DR 2
NEXIUM GRA 20MG DR 2
NEXIUM GRA 40MG DR 2 omeprazole (generic of
PRILOSEC) CPDR 10mg, 40mg
QL (30 caps / 30 days)
1 QL
omeprazole (generic of
PRILOSEC) CPDR 20mg 1
OMEPRAZOLE-SODIUM BICARBONATE
QL (30 caps / 30 days)
1 QL
pantoprazole sodium (generic
of PROTONIX) QL (30 tabs / 30 days)
1 QL
PREVACID SOLUTAB QL (30 tabs / 30 days)
3 QL
PRILOSEC PACK 3
PROTONIX PACK QL (30 packets / 30 days)
3 QL
rabeprazole sodium (generic
of ACIPHEX) QL (30 tabs / 30 days)
1 QL
ZEGERID PACK QL (30 packets / 30 days)
3 QL
GENITOURINARY BENIGN PROSTATIC HYPERPLASIA alfuzosin hcl (generic of
UROXATRAL) 1
AVODART 2
CARDURA XL 3
Drug Name Drug Tier
Requirements/Limits
dutasteride (generic of
AVODART) 1
dutasteride-tamsulosin hcl
(generic of JALYN) 1
finasteride (generic of
PROSCAR) TABS 5mg 1
JALYN 3
RAPAFLO 2 tamsulosin hcl (generic of
FLOMAX) 1
MISCELLANEOUS bethanechol chloride (generic
of URECHOLINE) TABS 1
ELMIRON 3 potassium citrate (alkalinizer)
(generic of UROCIT-K 15) 15meq
1
POTASSIUM CITRATE (ALKALINIZER) 540mg
1
POTASSIUM CITRATE (ALKALINIZER) 1080mg
1
URINARY ANTISPASMODICS ENABLEX 3
GELNIQUE 2
MYRBETRIQ 2 oxybutynin chloride SYRP;
TABS 1
oxybutynin chloride (generic of DITROPAN XL) TB24
1
OXYTROL 3
tolterodine tartrate er (generic
of DETROL LA) 1
tolterodine tartrate tab 1 mg
(generic of DETROL) 1
tolterodine tartrate tab 2 mg
(generic of DETROL) 1
TOVIAZ 3
trospium chloride 1
trospium chloride er 1
VESICARE 2
VAGINAL ANTI-INFECTIVES AVC 3
CLEOCIN VAG SUPP 100MG 3
clindamycin cre 2% vag
(generic of CLEOCIN) 1
CLINDESSE 3
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
43
Drug Name Drug Tier
Requirements/Limits
metronidazole vaginal
(generic of METROGEL-VAGINAL)
1
miconazole 3 sup 200mg 1
NUVESSA 3
terconazole vaginal (generic of TERAZOL 7) CREA .4%
1
terconazole vaginal (generic
of TERAZOL 3) CREA .8% 1
terconazole vaginal SUPP 1
VANDAZOLE 1
zazole (generic of TERAZOL
7) .4% 1
ZAZOLE .8% 1
HEMATOLOGIC
ANTICOAGULANTS COUMADIN 3
ELIQUIS TAB 2.5MG 2
ELIQUIS TAB 5MG 2 enoxaparin sodium (generic of
LOVENOX) 30mg/0.3ml, 40mg/0.4ml, 60mg/0.6ml, 80mg/0.8ml, 300mg/3ml
1
enoxaparin sodium (generic of
LOVENOX) 100mg/ml, 120mg/0.8ml, 150mg/ml
3 NM
fondaparinux sodium (generic
of ARIXTRA) 2.5mg/0.5ml 1
fondaparinux sodium (generic
of ARIXTRA) 5mg/0.4ml, 7.5mg/0.6ml, 10mg/0.8ml
3 NM
FRAGMIN 2500unit/0.2ml, 5000unit/0.2ml
2
FRAGMIN 7500unit/0.3ml, 10000unit/ml, 12500unit/0.5ml, 15000unit/0.6ml, 18000unt/0.72ml, 95000unit/3.8ml
3 NM
HEP SOD/NACL INJ 25000 1
HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML
1
heparin sod inj 1000u/ml 1 B/D
HEPARIN SOD INJ 2000U/ML
3 B/D
Drug Name Drug Tier
Requirements/Limits
HEPARIN SOD INJ 2500U/ML
3 B/D
heparin sod inj 5000u/0.5ml 1 B/D
heparin sod inj 5000u/ml 1 B/D
heparin sod inj 10000u/ml 1 B/D
heparin sod inj 20000u/ml 1 B/D
HEPARIN SODIUM/D5W 1
HEPARIN SODIUM/NACL 0.45%
3
jantoven (generic of
COUMADIN) 1
PRADAXA 2
SAVAYSA 3
warfarin sodium (generic of
COUMADIN) 1
XARELTO 2
XARELTO STARTER PACK 2
HEMATOPOIETIC GROWTH FACTORS ARANESP ALBUMIN FREE 2 NM PA
EPOGEN 3 NM PA
GRANIX 3 NM PA
LEUKINE 3 NM PA
MIRCERA 3 NM PA
MOZOBIL 3 NM PA
NEULASTA 3 NM PA
NEULASTA ONPRO KIT 3 NM PA
NEUMEGA 3 NM PA
NEUPOGEN 3 NM PA
NPLATE 3 NM PA
PROCRIT 2 NM PA
MISCELLANEOUS anagrelide hcl 1mg 1
anagrelide hcl (generic of AGRYLIN) .5mg
1
BERINERT 3 NM PA
cilostazol 1
CINRYZE 3 NM LA PA
FIRAZYR 2 NM PA
KALBITOR 3 NM PA
pentoxifylline TBCR 1
PROMACTA 12.5mg QL (360 tabs / 30 days)
3 QL NM LA PA
PROMACTA 25mg QL (180 tabs / 30 days)
3 QL NM LA PA
PROMACTA 50mg QL (90 tabs / 30 days)
3 QL NM LA PA
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
44
Drug Name Drug Tier
Requirements/Limits
PROMACTA 75mg QL (60 tabs / 30 days)
3 QL NM LA PA
RUCONEST 3 NM PA
SOLIRIS 3 NM PA
tranexamic acid (generic of
CYKLOKAPRON) SOLN 1
tranexamic acid (generic of
LYSTEDA) TABS 1
PLATELET AGGREGATION INHIBITORS AGGRENOX 2
ASPIRIN-DIPYRIDAMOLE 1
BRILINTA 2
clopidogrel bisulfate (generic
of PLAVIX) 1
EFFIENT 2
ZONTIVITY 3
IMMUNOLOGIC AGENTS DISEASE-MODIFYING ANTI-RHEUMATIC DRUGS (DMARDS) ACTEMRA 3 NM PA
CIMZIA 3 NM PA
ENBREL 3 NM PA
ENBREL SURECLICK 3 NM PA
HUMIRA 3 NM PA
HUMIRA PEDIATRIC CROHNS
3 NM PA
HUMIRA PEN 3 NM PA
HUMIRA PEN-CROHNS STARTER KIT
3 NM PA
HUMIRA PEN-PSORIASIS STARTER KIT
3 NM PA
hydroxychloroquine sulfate
(generic of PLAQUENIL) 1
KINERET 3 NM PA
leflunomide (generic of
ARAVA) TABS 1
methotrexate sodium tabs 1
ORENCIA 3 NM PA
OTEZLA 3 NM PA
OTREXUP 3 NM PA
RASUVO 3 NM PA
REMICADE 3 NM PA
RHEUMATREX 2
SIMPONI 3 NM PA
SIMPONI ARIA 3 NM PA
trexall 2 B/D
Drug Name Drug Tier
Requirements/Limits
XELJANZ 3 NM PA
IMMUNOGLOBULINS BIVIGAM 3 NM PA
CARIMUNE NANOFILTERED 3 NM PA
FLEBOGAMMA 3 NM PA
FLEBOGAMMA DIF 3 NM PA
GAMASTAN S/D 2 B/D NM
GAMMAGARD LIQUID 3 NM PA
GAMMAGARD S/D 3 NM PA
GAMMAGARD S/D IGA LESS TH
3 NM PA
GAMMAKED 3 NM PA
GAMMAPLEX 2.5gm/50ml, 5gm/100ml, 10gm/200ml
3 NM PA
GAMUNEX-C 3 NM PA
HIZENTRA 3 NM PA
HYQVIA 3 NM PA
OCTAGAM 1gm/20ml, 2gm/20ml, 2.5gm/50ml, 5gm/100ml, 10gm/200ml, 25gm/500ml
3 NM PA
PRIVIGEN 3 NM PA
IMMUNOMODULATORS ACTIMMUNE 3 NM LA PA
ARCALYST 3 NM PA
GRASTEK 2 PA
ILARIS 3 NM PA
INTRON-A INJ 10MU 3 B/D NM
INTRON-A INJ 18MU 3 B/D NM
INTRON-A INJ 25MU 3 B/D NM
INTRON-A INJ 50MU 3 B/D NM
RAGWITEK 2 PA
REVLIMID 3 NM LA PA
THALOMID 2 NM PA
IMMUNOSUPPRESSANTS ASTAGRAF XL 5mg 3 B/D NM
ASTAGRAF XL .5mg, 1mg 3 B/D
ATGAM 3 B/D NM
azasan 2 B/D
azathioprine (generic of
IMURAN) TABS 1 B/D
BENLYSTA 3 NM PA
CELLCEPT INTRAVENOUS 3 B/D
cyclosporine (generic of SANDIMMUNE) CAPS; SOLN
1 B/D
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
45
Drug Name Drug Tier
Requirements/Limits
cyclosporine modified (for microemulsion) (generic of
NEORAL) CAPS 25mg, 100mg
1 B/D
cyclosporine modified (for microemulsion) CAPS 50mg
1 B/D
cyclosporine modified (for microemulsion) (generic of
NEORAL) SOLN
1 B/D
gengraf (generic of NEORAL) 1 B/D
mycophenolate mofetil
(generic of CELLCEPT) CAPS; TABS
1 B/D
mycophenolate mofetil
(generic of CELLCEPT) SUSR
3 B/D NM
mycophenolate sodium
(generic of MYFORTIC) 180mg
1 B/D
mycophenolate sodium (generic of MYFORTIC) 360mg
3 B/D NM
NEORAL 2 B/D
NULOJIX 3 B/D NM
PROGRAF CAPS 5mg 3 B/D NM
PROGRAF CAPS .5mg, 1mg
2 B/D
PROGRAF SOLN 3 B/D
RAPAMUNE SOLN 3 B/D NM
SANDIMMUNE SOLN 2 B/D
SIMULECT 10mg 3 B/D
SIMULECT 20mg 3 B/D NM
SIROLIMUS TABS 2mg 3 B/D NM
sirolimus (generic of RAPAMUNE) TABS .5mg, 1mg
1 B/D
tacrolimus (generic of
PROGRAF) CAPS 5mg 3 B/D NM
tacrolimus (generic of PROGRAF) CAPS .5mg, 1mg
1 B/D
THYMOGLOBULIN 3 B/D NM
ZORTRESS TAB 0.5MG 3 B/D NM
ZORTRESS TAB 0.25MG 3 B/D
ZORTRESS TAB 0.75MG 3 B/D NM
VACCINES ACTHIB 3
ADACEL 3
Drug Name Drug Tier
Requirements/Limits
BCG VACCINE 3
BEXSERO 3
BOOSTRIX 3
CERVARIX 3
COMVAX 3
DAPTACEL 3
DIPHTHERIA/TETANUS TOXOID
3 B/D
ENGERIX-B SUSP 3 B/D
GARDASIL 3
GARDASIL 9 3
HAVRIX 3
HIBERIX 3
IMOVAX RABIES (H.D.C.V.) 3
INFANRIX 3
IPOL INACTIVATED IPV 2
IXIARO 3
KINRIX 3
M-M-R II 3
MENACTRA 3
MENOMUNE-A/C/Y/W-135 3
MENVEO 3
PEDVAX HIB 3
PROQUAD 3
QUADRACEL 3
RABAVERT 3
RECOMBIVAX HB 3 B/D
ROTARIX 2
ROTATEQ 3
SYNAGIS 3 NM
TENIVAC 3 B/D
TETANUS/DIPHTHERIA TOXOID
3 B/D
TRUMENBA 3
TWINRIX INJ 3
TYPHIM VI 3
VAQTA 3
VARIVAX 3
YF-VAX 3
ZOSTAVAX 3
NUTRITIONAL/SUPPLEMENTS ELECTROLYTES ammonium chloride SOLN 3
KLOR-CON 8 1
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
46
Drug Name Drug Tier
Requirements/Limits
KLOR-CON 10 1
klor-con m10 1
klor-con m15 3 klor-con m20 1
klor-con pow 20meq 1 klor-con spr cap 8meq
(generic of MICRO-K) 1
klor-con spr cap 10meq
(generic of MICRO-K) 1
MAGNESIUM SULFATE SOLN 2gm/50ml, 4gm/100ml, 4gm/50ml, 20gm/500ml, 40gm/1000ml
3
magnesium sulfate SOLN
50% 1
MAGNESIUM SULFATE IN D5W
3
MAGNESIUM SULFATE INJ 50%
1
POTASSIUM CHLORIDE SOLN 10%, 20%
1
potassium chloride TBCR 8meq
1
POTASSIUM CHLORIDE TBCR 20meq
1
potassium chloride caps er (generic of MICRO-K)
1
potassium chloride microencapsulated crystals cr
1
POTASSIUM CHLORIDE TAB CR 10 MEQ
1
SODIUM CHLORIDE SOLN 2.5meq/ml
1
SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN
1
TPN ELECTROLYTES 1 B/D
IV NUTRITION AMINOSYN 3 B/D
AMINOSYN 7%/ELECTROLYTES
3 B/D
AMINOSYN II 3 B/D
AMINOSYN II 8.5%/ELECTROL
1 B/D
AMINOSYN INJ 8.5/LYTE 1 B/D
AMINOSYN M 3 B/D
AMINOSYN-HBC 3 B/D
Drug Name Drug Tier
Requirements/Limits
AMINOSYN-PF 7% 3 B/D
AMINOSYN-PF INJ 10% 3 B/D
AMINOSYN-RF 3 B/D
CLINIMIX 2.75%/DEXTROSE 5%
3 B/D
CLINIMIX 4.25%/DEXTROSE 5%
3 B/D
CLINIMIX 4.25%/DEXTROSE 10%
3 B/D
CLINIMIX 4.25%/DEXTROSE 20%
3 B/D
CLINIMIX 4.25%/DEXTROSE 25%
3 B/D
CLINIMIX 5%/DEXTROSE 15%
3 B/D
CLINIMIX 5%/DEXTROSE 20%
3 B/D
CLINIMIX 5%/DEXTROSE 25%
3 B/D
CLINIMIX E 2.75%/DEXTROSE 5%
3 B/D
CLINIMIX E 2.75%/DEXTROSE 10%
3 B/D
CLINIMIX E 4.25%/D10 3 B/D
CLINIMIX E 4.25%/DEXTROSE 5%
3 B/D
CLINIMIX E 4.25%/DEXTROSE 25%
3 B/D
CLINIMIX E 5%/DEXTROSE 15%
3 B/D
CLINIMIX E 5%/DEXTROSE 20%
3 B/D
CLINIMIX E 5%/DEXTROSE 25%
3 B/D
clinisol 15 1 B/D
FREAMINE HBC 6.9% 3 B/D
FREAMINE III 3 B/D
HEPATAMINE 1 B/D
INTRALIPID INJ 20% 1 B/D
INTRALIPID INJ 30% 3 B/D
LIPOSYN III 3 B/D
NEPHRAMINE 3 B/D
NUTRILIPID INJ 20% 1 B/D
plenamine 1 B/D
premasol 6% 1 B/D
premasol 10% 3 B/D
PROCALAMINE 3 B/D
PROSOL 3 B/D
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
47
Drug Name Drug Tier
Requirements/Limits
TRAVASOL 3 B/D
TROPHAMINE INJ 10% 3 B/D
IV REPLACEMENT SOLUTIONS DEXTROSE SOLN 1
DEXTROSE 2.5%/NACL 0.45%
1
DEXTROSE 5% 1
DEXTROSE 5% /ELECTROLYTE
3
DEXTROSE 5%/LACTATED RING
1
DEXTROSE 5%/NACL 0.2% 1
DEXTROSE 5%/NACL 0.3% 3
DEXTROSE 5%/NACL 0.9% 1
DEXTROSE 5%/NACL 0.33% 1
DEXTROSE 5%/NACL 0.45% 1
DEXTROSE 5%/NACL 0.225%
1
DEXTROSE 5%/POTASSIUM CHL
1
DEXTROSE 10% FLEX CONTAIN
1
DEXTROSE 10% W/ SODIUM CHLORIDE 0.2%
3
DEXTROSE 10%/NACL 0.45%
1
ELECTROLYTE-R IN DEXTROSE
3
IONOSOL-B/DEXTROSE 5% 3
IONOSOL-MB/DEXTROSE 5%
3
ISOLYTE P 3
ISOLYTE S 3
KCL0.15%/D5W/NACL0.2% 1
KCL0.15%/D5W/NACL0.225%
3
KCL 0.3%/D5W/LR IV LAC RI 3
KCL 0.3%/D5W/NACL 0.9% 3
KCL 0.3%/D5W/NACL 0.45% 1
KCL 0.15%/D5W/LR 3
KCL 0.15%/D5W/NACL 0.9% 1
KCL 0.075%/D5W/NACL 0.45%
1
KCL IN NACL INJ .15-0.45 1
KCL/D5W/NACL INJ 0.22%/0.45%
1
Drug Name Drug Tier
Requirements/Limits
KCL/D5W/NACL INJ .15/.33% 1
KCL/D5W/NACL INJ .15/.45% 1
KCL/NACL INJ 0.15%-0.9% 1
LACTATED RINGERS VIAFLEX
1
NORMOSOL-M IN D5W 1
NORMOSOL-R 3
PLASMA-LYTE A 3
PLASMA-LYTE-56/D5W 3
PLASMA-LYTE-148 3
pot chloride inj 2meq/ml 1
POTASSIUM CHLORIDE SOLN .4meq/ml, 10meq/100ml, 10meq/50ml, 20meq/100ml, 40meq/100ml
1
POTASSIUM CHLORIDE 0.3%/D
1
potassium chloride in nacl 1
POTASSIUM CHLORIDE IN NACL
1
RINGER'S 1
SODIUM CHLORIDE SOLN .9%, 3%, 5%
1
SODIUM CHLORIDE 0.45% VIA
1
VITAMINS calcitriol (generic of
ROCALTROL) CAPS 1 B/D
calcitriol SOLN 1mcg/ml 1 B/D
calcitriol (generic of ROCALTROL) SOLN 1mcg/ml
1 B/D
doxercalciferol (generic of
HECTOROL) CAPS 1mcg, 2.5mcg
3 B/D NM
doxercalciferol (generic of
HECTOROL) CAPS .5mcg 1 B/D
doxercalciferol (generic of HECTOROL) SOLN
1 B/D
HECTOROL SOLN 2mcg/ml 3 B/D
paricalcitol (generic of
ZEMPLAR) CAPS 1mcg, 2mcg
1 B/D
paricalcitol CAPS 4mcg 1 B/D
PARICALCITOL SOLN 1 B/D
PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC)
1
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
48
Drug Name Drug Tier
Requirements/Limits
ZEMPLAR SOLN 2mcg/ml 3 B/D
OPHTHALMIC
ANTI-INFECTIVE/ANTI-INFLAMMATORY bacitracin-poly-neomycin-hc 1
blephamide OINT 3
BLEPHAMIDE SUSP 3
neomycin-polymy-dexameth
(generic of MAXITROL) 1
neomycin-polymyxin-hc (ophth)
1
PRED-G 3
PRED-G S.O.P. 3 sulfacetamide sod-prednisolone
1
TOBRADEX OINT 2
TOBRADEX ST 2 tobramycin-dexamethasone
(generic of TOBRADEX) 1
ZYLET 2
ANTI-INFECTIVES AZASITE 3
bacitracin (ophthalmic) 1 bacitracin-polymyxin b (ophth) 1
BESIVANCE 2
CILOXAN OIN 0.3% OP 3
ciprofloxacin hcl (ophth)
(generic of CILOXAN) 1
erythromycin (ophth) 1 gatifloxacin (ophth) (generic of
ZYMAXID) 1
gentak 1 gentamicin sulfate (ophth)
OINT 1
gentamicin sulfate (ophth)
(generic of GARAMYCIN) SOLN
1
ilotycin 1
levofloxacin (ophth) 1
MOXEZA 2
NATACYN 3
neomycin-bacitracin zn-polymyxin
1
neomycin-polymyxin-gramicidin (generic of NEOSPORIN)
1
ofloxacin (ophth) (generic of OCUFLOX)
1
Drug Name Drug Tier
Requirements/Limits
polymyxin b-trimethoprim
(generic of POLYTRIM) 1
sulfacet sod oin 10% op 1 sulfacetamide sodium (ophth)
(generic of BLEPH-10) 1
tobramycin (ophth) (generic of
TOBREX) 1
TOBREX OINT 0.3% 3 trifluridine (generic of
VIROPTIC) SOLN 1
VIGAMOX 2
ZIRGAN 3
ANTI-INFLAMMATORIES ACUVAIL 3
ALREX 2
bromfenac sodium (ophth) 1
BROMFENAC SODIUM (OPHTH)(ONCE-DAILY)
1
dexamethasone sodium phosphate (ophth)
1
diclofenac sodium (ophth) 1
DUREZOL 2
FLAREX 3
FLUOROMETHOLONE (OPHTH)
1
flurbiprofen sodium (generic
of OCUFEN) 1
FML 3
FML FORTE 3
ILEVRO 3 ketorolac tromethamine (ophth) (generic of ACULAR
LS) .4%
1
ketorolac tromethamine (ophth) (generic of ACULAR)
.5%
1
LOTEMAX 2
MAXIDEX 3
PRED MILD 3
PREDNISOLONE ACETATE (OPHTH)
1
prednisolone sodium phosphate (ophth)
3
VEXOL 3
ANTIALLERGICS ALOCRIL 3
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
49
Drug Name Drug Tier
Requirements/Limits
ALOMIDE 3
azelastine drop 0.05% 1
BEPREVE 3 cromolyn sodium (ophth) 1
EMADINE 3 epinastine hcl (ophth) (generic
of ELESTAT) 1
LASTACAFT 3
olopatadine hcl (generic of PATANOL)
1
PATADAY 2
PATANOL 2
PAZEO 3
ANTIGLAUCOMA ALPHAGAN P 2
ALPHAGAN P 0.1% 2
AZOPT 2 betaxolol hcl (ophth) 1
BETIMOL 2
BETOPTIC-S 2 brimonidine sol 0.2% 1
BRIMONIDINE SOL 0.15% 1
carteolol hcl (ophth) 1
COMBIGAN 2
COSOPT PF 2 dorzolamide hcl (generic of
TRUSOPT) 1
dorzolamide hcl-timolol maleate (generic of COSOPT)
1
ISTALOL 3
latanoprost (generic of
XALATAN) SOLN 1
levobunolol hcl (generic of BETAGAN) .5%
1
LUMIGAN 3
metipranolol 1
PHOSPHOLINE IODIDE 3
PILOCARPINE HCL SOLN 1
SIMBRINZA SUS 1-0.2% 2 timolol maleate (ophth)
(generic of TIMOPTIC) 1
TIMOLOL MALEATE GEL 1
TIMOPTIC OCUDOSE 3
TRAVATAN Z 2
Drug Name Drug Tier
Requirements/Limits
ZIOPTAN 2
MISCELLANEOUS CYSTARAN 3 NM LA PA
EYLEA 3 NM PA
LACRISERT 3
LUCENTIS 3 NM PA
naphazoline 0.1% 1
PROLENSA 2
proparacaine hcl (generic of
ALCAINE) SOLN 1
RESTASIS 2
RESPIRATORY
ANTICHOLINERGIC/BETA AGONIST COMBINATIONS ANORO ELLIPT AER 62.5-25
QL (60 inhalations / 30 days)
2 QL
COMBIVENT RESPIMAT QL (2 inhalers / 30 days)
2 QL
ipratropium-albuterol 1 B/D
STIOLTO RESPIMAT QL (1 inhaler / 30 days)
3 QL
ANTICHOLINERGICS ATROVENT HFA
QL (2 inhalers / 30 days) 3 QL
INCRUSE ELLIPTA QL (1 inhaler / 30 days)
3 QL
ipratropium bromide (nasal)
(generic of ATROVENT) 1
ipratropium sol inhal 1 B/D
SPIRIVA HANDIHALER QL (30 caps / 30 days)
2 QL
SPIRIVA RESPIMAT QL (1 inhaler / 30 days)
2 QL
TUDORZA PRESSAIR QL (1 inhaler / 30 days)
3 QL
TUDORZA PRESSAIR (INSTITUTIONAL PACK)
QL (2 inhalers / 30 days)
3 QL
ANTIHISTAMINE COMBINATIONS CLARINEX-D TAB 2.5-120 3
DYMISTA SPR 137-50 QL (1 bottle / 30 days)
3 QL
SEMPREX-D 3
ANTIHISTAMINES ASTEPRO 3
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
50
Drug Name Drug Tier
Requirements/Limits
azelastine spr 0.1% 1
azelastine spr 0.15% (generic
of ASTEPRO) 1
cetirizine syrup 1
CLARINEX SYRP 3
desloratadine (generic of CLARINEX) TABS
1
desloratadine (generic of
CLARINEX REDITABS) TBDP
1
diphenhydram inj 50mg/ml 1
hydroxyzine hcl SOLN
PA if 65 years and older 3 PA
levocetirizine soln 2.5mg/5ml (generic of XYZAL)
1
levocetirizine tab 5 mg
(generic of XYZAL) 1
olopatadine hcl (nasal) (generic of PATANASE)
1
BETA AGONISTS albuterol sulfate NEBU 1 B/D
albuterol sulfate SYRP; TABS
1
albuterol sulfate er (generic of
VOSPIRE ER) 1
ARCAPTA NEOHALER QL (30 caps / 30 days)
2 QL
BROVANA 3 B/D
FORADIL AEROLIZER QL (60 caps / 30 days)
2 QL
levalbuterol conc 1.25mg/0.5ml (generic of
XOPENEX CONCENTRATE)
1 B/D
LEVALBUTEROL HCL NEBU 1.25mg/3ml
1 B/D
levalbuterol hcl (generic of
XOPENEX) NEBU .31mg/3ml, .63mg/3ml
1 B/D
PERFOROMIST 2 B/D
PROAIR HFA QL (2 inhalers / 30 days)
2 QL
PROAIR RESPICLICK QL (2 inhalers / 30 days)
3 QL
PROVENTIL HFA QL (2 inhalers / 30 days)
3 QL
SEREVENT DISKUS QL (60 inhalations / 30 days)
2 QL
Drug Name Drug Tier
Requirements/Limits
STRIVERDI RESPIMAT QL (1 inhaler / 30 days)
3 QL
terbutaline sulfate SOLN 3 NM
terbutaline sulfate TABS 1
VENTOLIN HFA QL (2 inhalers / 30 days)
3 QL
XOPENEX HFA QL (2 inhalers / 30 days)
3 QL
LEUKOTRIENE RECEPTOR ANTAGONISTS montelukast sodium (generic
of SINGULAIR) CHEW; PACK; TABS
1
zafirlukast (generic of ACCOLATE)
1
ZYFLO CR 3 NM
MAST CELL STABILIZERS cromolyn sodium NEBU 1 B/D
MISCELLANEOUS acetylcysteine SOLN 10%,
20% 1 B/D
ARALAST NP 500mg, 1000mg
3 NM LA PA
AUVI-Q 2
DALIRESP 2
EPINEPHRINE SOAJ 1
EPIPEN 2-PAK 2
EPIPEN-JR 2-PAK 2
ESBRIET 3 NM PA
GLASSIA 3 NM LA PA
KALYDECO 3 NM PA
OFEV 3 NM PA
ORKAMBI 3 NM PA
PROLASTIN-C 3 NM LA PA
PULMOZYME 3 B/D NM
tyzine .05% 3
XOLAIR 3 NM LA PA
ZEMAIRA 3 NM LA PA
NASAL STEROIDS BECONASE AQ
QL (2 inhalers / 30 days) 3 QL
budesonide (nasal) (generic of RHINOCORT AQUA)
QL (2 bottles / 30 days)
1 QL
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
51
Drug Name Drug Tier
Requirements/Limits
flunisolide (nasal)
QL (2 bottles / 30 days) 1 QL
fluticasone propionate (nasal)
(generic of FLONASE) QL (1 bottle / 30 days)
1 QL
NASONEX QL (2 inhalers / 30 days)
2 QL
OMNARIS QL (1 inhaler / 30 days)
3 QL
QNASL QL (1 inhaler / 30 days)
3 QL
QNASL CHILDRENS QL (1 inhaler / 30 days)
3 QL
TRIAMCINOLONE ACETONIDE (NASAL)
QL (1 bottle / 30 days)
1 QL
VERAMYST QL (1 bottle / 30 days)
3 QL
ZETONNA QL (1 inhaler / 30 days)
3 QL
STEROID INHALANTS AEROSPAN
QL (2 inhalers / 30 days) 3 QL
ALVESCO QL (2 inhalers / 30 days)
3 QL
ARNUITY ELLIPTA QL (30 inhalations / 30 days)
3 QL
ASMANEX QL (2 inhalers / 30 days)
2 QL
ASMANEX HFA 100mcg/act QL (2 inhalers / 30 days)
2 QL
ASMANEX HFA 200mcg/act QL (1 inhaler / 30 days)
2 QL
budesonide (inhalation)
(generic of PULMICORT) 1 B/D
FLOVENT DISKUS 50mcg/blist, 100mcg/blist
QL (120 inhalations / 30 days)
2 QL
FLOVENT DISKUS 250mcg/blist
QL (240 inhalations / 30 days)
2 QL
FLOVENT HFA QL (2 inhalers / 30 days)
2 QL
PULMICORT FLEXHALER QL (2 inhalers / 30 days)
2 QL
Drug Name Drug Tier
Requirements/Limits
PULMICORT INH SUSP 1MG/2ML
3 B/D NM
QVAR 40mcg/act QL (1 inhaler / 30 days)
2 QL
QVAR 80mcg/act QL (2 inhalers / 30 days)
2 QL
STEROID/BETA-AGONIST COMBINATIONS ADVAIR DISKUS
QL (60 inhalations / 30 days)
2 QL
ADVAIR HFA QL (1 inhaler / 30 days)
2 QL
BREO ELLIPTA QL (60 blisters / 30 days)
3 QL
DULERA QL (1 inhaler / 30 days)
2 QL
SYMBICORT QL (1 inhaler / 30 days)
3 QL
XANTHINES aminophylline inj 1 elixophyllin 3
theo-24 3
theophylline 1
TOPICAL
DERMATOLOGY, ACNE ABSORICA 3 NM
ACANYA 2
ACZONE 3 adapalene (generic of
DIFFERIN) CREA; GEL 1
amnesteem 1
ATRALIN 2
AVITA CREA 1
AVITA GEL 1
AZELEX 3
benzoyl peroxide-erythromycin (generic of BENZAMYCIN)
1
claravis 1
CLINDAGEL 3 clindamax (generic of
CLEOCIN-T) 1
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
52
Drug Name Drug Tier
Requirements/Limits
clindamycin phosphate (topical) (generic of
EVOCLIN) FOAM
1
clindamycin phosphate (topical) (generic of
CLEOCIN-T) GEL; LOTN; SOLN; SWAB
1
clindamycin phosphate-benzoyl peroxide
(generic of BENZACLIN WITH PUMP)
1
clindamycin phosphate-benzoyl peroxide (refrigerate) (generic of
DUAC)
1
DIFFERIN LOTN 2
EPIDUO 2
EPIDUO FORTE 3 ery pad 2% 1
erythromycin (acne aid)
(generic of ERYGEL) GEL 1
erythromycin (acne aid)
SOLN 1
FABIOR 3
myorisan 1 neuac gel 1.2-5% (generic of
DUAC) 1
ONEXTON 3
RETIN-A MICRO PUMP .08%
2
sulfacetamide sodium (acne)
(generic of KLARON) 1
tretin-x CREA 3
tretinoin (generic of RETIN-A)
CREA 1
TRETINOIN GEL .01% 1
tretinoin (generic of ATRALIN)
GEL .05% 1
tretinoin (generic of RETIN-A) GEL .025%
1
TRETINOIN MICROSPHERE 1
VELTIN 3 zenatane 1
ZIANA 3
DERMATOLOGY, ANTIBIOTICS ALTABAX 3
Drug Name Drug Tier
Requirements/Limits
BACTROBAN NASAL 3
CENTANY 3
CORTISPORIN 3 gentamicin sulfate (topical) 1
mupirocin (generic of BACTROBAN) OINT
1
mupirocin calcium (topical)
(generic of BACTROBAN) 1
SILVER SULFADIAZINE CREA
1
SSD 1
SULFAMYLON CREA 3
SULFAMYLON PACK 3 NM
DERMATOLOGY, ANTIFUNGALS ciclopirox GEL 1
ciclopirox cre 0.77% 1 ciclopirox shampoo 1%
(generic of LOPROX SHAMPOO)
1
ciclopirox sus 0.77% 1 clotrimazole (topical) 1
econazole nitrate CREA 1
ERTACZO 3
EXELDERM 3
ketoconazole (topical) CREA 1 ketoconazole (topical)
(generic of EXTINA) FOAM 1
ketodan aer 2% (generic of EXTINA)
1
LUZU 2
MENTAX 3
NAFTIFINE HCL 1% 1 naftifine hcl (generic of
NAFTIN) 2% 1
NAFTIN 2 nyamyc 1
nystatin (topical) 1
nystatin pow 100000 1 nystop 1
OXISTAT 3
DERMATOLOGY, ANTIPRURITIC CORTIFOAM 2
procto-pak 1 proctosol hc 2.5 % (generic of
ANUSOL-HC) 1
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
53
Drug Name Drug Tier
Requirements/Limits
proctozone hc (generic of
ANUSOL-HC) 1
PRUDOXIN CRE 5% 1
DERMATOLOGY, ANTIPSORIATICS acitretin (generic of
SORIATANE) 3 NM PA
calcipotriene (generic of DOVONEX) CREA
1
calcipotriene OINT; SOLN 1
calcitrene oin 0.005% 1
CALCITRIOL OINT 1
COSENTYX 3 NM PA
COSENTYX SENSOREADY PEN
3 NM PA
methoxsalen rapid (generic of
OXSORALEN ULTRA) 3 NM
8-MOP 3
SORILUX 2
STELARA 3 NM PA
TAZORAC 2 PA
DERMATOLOGY, ANTISEBORRHEICS ketoconazole shampoo
(generic of NIZORAL) 1
selenium sulfide LOTN 1
DERMATOLOGY, CORTICOSTEROIDS ala-cort 1
alclometasone dipropionate (generic of ACLOVATE) CREA
1
alclometasone dipropionate
OINT 1
amcinonide CREA; LOTN 1 amcinonide OINT 3
apexicon e cream 3 betamethasone dipropionate (topical)
1
betamethasone dipropionate augmented (generic of DIPROLENE AF) CREA
1
betamethasone dipropionate augmented GEL
1
betamethasone dipropionate augmented (generic of
DIPROLENE) LOTN; OINT
1
betamethasone valerate
CREA; LOTN; OINT 1
Drug Name Drug Tier
Requirements/Limits
betamethasone valerate
(generic of LUXIQ) FOAM 1
calcipotriene/betamethasone
(generic of TACLONEX) 3 NM
CAPEX 2
clobetasol e cream 0.05%
(generic of TEMOVATE E) 1
clobetasol propionate (generic of TEMOVATE) CREA; GEL; OINT; SOLN
1
clobetasol propionate (generic of OLUX) FOAM
1
clobetasol propionate (generic
of CLOBEX) LIQD; LOTN; SHAM
1
clobetasol propionate emulsion (generic of OLUX-E)
1
CLOCORTOLONE PIVALATE 1
clodan sha 0.05% (generic of CLOBEX)
1
CORDRAN TAPE 3
cormax (generic of
TEMOVATE) 1
DESONATE 3
DESONIDE CREA 1
desonide (generic of DESOWEN) LOTN; OINT
1
desoximetasone (generic of
TOPICORT) CREA 1
desoximetasone (generic of TOPICORT) GEL
1
DESOXIMETASONE OINT .05%
1
desoximetasone (generic of TOPICORT) OINT .25%
1
diflorasone diacetate 1
fluocinolone acetonide
CREA .01% 1
fluocinolone acetonide
(generic of SYNALAR) CREA .025%
1
fluocinolone acetonide (generic of DERMA-SMOOTHE/FS BODY) OIL .01%
1
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
54
Drug Name Drug Tier
Requirements/Limits
fluocinolone acetonide
(generic of DERMA-SMOOTHE/FS SCALP) OIL .01%
1
fluocinolone acetonide
(generic of SYNALAR) OINT 1
fluocinolone acetonide (generic of SYNALAR) SOLN
1
fluocinonide (generic of
VANOS) CREA .1% 3 NM
fluocinonide CREA .05% 1 fluocinonide GEL 1
fluocinonide OINT 1 fluocinonide SOLN 1
fluocinonide emulsified base 1
fluticasone propionate (generic of CUTIVATE) CREA; LOTN
1
fluticasone propionate OINT 1 halobetasol propionate
(generic of ULTRAVATE) 1
HALOG 3
hydrocortisone (topical) 1 hydrocortisone butyrate
(generic of LOCOID) 1
hydrocortisone butyrate hydrophilic lipo base (generic
of LOCOID LIPOCREAM)
1
hydrocortisone valerate
CREA 1
hydrocortisone valerate (generic of WESTCORT) OINT
1
LOCOID LOTN 2 lokara (generic of
DESOWEN) 1
mometasone furoate (generic
of ELOCON) CREA; OINT; SOLN
1
PANDEL 3
PREDNICARBATE CREA 1 prednicarbate (generic of
DERMATOP) OINT 1
psorcon 3
TACLONEX SUSP 3 NM
texacort 2
Drug Name Drug Tier
Requirements/Limits
TOPICORT SPRAY 0.25% 3
triamcinolone acetonide (topical) (generic of KENALOG) AERS
1
triamcinolone acetonide (topical) CREA; LOTN; OINT
1
trianex 3 triderm 1
DERMATOLOGY, LOCAL ANESTHETICS lidocaine OINT 1 lidocaine (generic of
LIDODERM) PTCH 1 PA
lidocaine hcl GEL 1 lidocaine hcl (generic of
XYLOCAINE) SOLN 4% 1
lidocaine-prilocaine (generic
of EMLA) 1 B/D
SYNERA 3
DERMATOLOGY, MISCELLANEOUS SKIN AND MUCOUS MEMBRANE acyclovir topical (generic of
ZOVIRAX) 1
ammonium lactate (generic of LAC-HYDRIN) CREA; LOTN
1
CONDYLOX GEL 2
DENAVIR 3 NM
diclofenac sodium (actinic keratoses) (generic of
SOLARAZE)
3 NM PA
diclofenac sodium (topical) 1
DOXYCYCLINE (ROSACEA) 1
ELIDEL 2 PA
FINACEA AER 15% 2
FINACEA GEL 15% 2 fluorouracil (topical) (generic
of EFUDEX) CREA 5% 1
FLUOROURACIL (TOPICAL) CREA .5%
3 NM
fluorouracil (topical) SOLN 1
imiquimod (generic of
ALDARA) CREA 1
metronidazole (topical)
(generic of METROCREAM) CREA
1
2016 632 3T Platinum Comm eff 04/01/2016
PA - Prior Authorization QL - Quantity Limits ST - Step Therapy NM - Not available at mail-order B/D - Covered under Medicare B or D LA - Limited Access
55
Drug Name Drug Tier
Requirements/Limits
metronidazole (topical)
(generic of METROGEL) GEL 1%
1
metronidazole (topical) GEL .75%
1
metronidazole (topical)
(generic of METROLOTION) LOTN
1
NORITATE 3 NM
ORACEA 2
PANRETIN 3 NM
PENNSAID 3
PICATO 3 NM
podofilox (generic of
CONDYLOX) SOLN 1
RECTIV 3 rosadan cre 0.75% (generic of
METROCREAM) 1
SOOLANTRA 2 tacrolimus (topical) (generic of
PROTOPIC) 1 PA
TARGRETIN GEL 3 NM PA
TOLAK 3
VALCHLOR 3 NM LA PA
VOLTAREN GEL 1% 2
XERESE 3 NM
ZOVIRAX CREA 3 NM
ZYCLARA 3 NM
DERMATOLOGY, SCABICIDES AND PEDICULIDES EURAX 3
malathion (generic of OVIDE) 1
permethrin (generic of ELIMITE)
1
SKLICE 3
DERMATOLOGY, WOUND CARE AGENTS acetic acid .25% 1
neomycin/polymyxin b gu
(generic of NEOSPORIN GU IRRIGANT)
1
REGRANEX 3 NM PA
SANTYL 3
SODIUM CHLORIDE 0.9% 1
STERILE WATER IRRIGATION
1
MOUTH/THROAT/DENTAL AGENTS
Drug Name Drug Tier
Requirements/Limits
cevimeline hcl (generic of
EVOXAC) 1
chlorhexidine gluconate (mouth-throat) (generic of PERIDEX)
1
clotrimazole TROC 1
lidocaine hcl (mouth-throat) 1 nystatin (mouth-throat) 1
ORAVIG 3 NM
paroex sol 0.12% (generic of PERIDEX)
1
periogard soln 0.12% (generic
of PERIDEX) 1
PILOCARPINE HCL (ORAL) 5mg
1
pilocarpine hcl (oral) (generic
of SALAGEN) 7.5mg 1
triamcinolone acetonide (mouth)
1
OTIC acetasol hc 1
acetic acid (otic) 1 acetic acid sol/hc 1
acetic acid-aluminum acetate 1
CIPRO HC 3
CIPRODEX 2
COLY-MYCIN S 3
CORTISPORIN-TC 3
fluocinolone acetonide (otic)
(generic of DERMOTIC) 1
neomycin-polymyxin-hc (otic) (generic of CORTISPORIN) SOLN
1
neomycin-polymyxin-hc (otic) SUSP
1
ofloxacin (otic) 1
2016 632 3T Platinum Comm eff 04/01/2016
56
Index 8 8-MOP...............................53 A abacavir sulfate ...................7 abacavir sulfate-lamivudine-zidovudine ..........................................8 ABELCET............................7 ABILIFY
see aripiprazole tabs .....24 ABILIFY DISCMELT TAB 10MG ................................24 ABILIFY MAINTENA .........24 ABRAXANE ......................12 ABSORICA .......................51 ABSTRAL............................2 acamprosate calcium ........30 ACANYA ...........................51 acarbose ...........................32 ACCOLATE
see zafirlukast ...............50 ACCUPRIL
see quinapril hcl ............14 ACCURETIC
see quinapril-hydrochlorothiazide ..................................14
acebutolol hcl ....................17 ACEON
see perindopril erbumine ......................................14
acetaminophen w/ codeine .1 acetaminophen-caff-dihydrocod ........................................1 acetasol hc ........................55 acetazolamide ...................18 acetazolamide sodium ......18 acetic acid .........................55 acetic acid (otic) ................55 acetic acid sol/hc ...............55 acetic acid-aluminum acetate ..........................................55 acetylcysteine ...................50 ACIPHEX
see rabeprazole sodium 42 ACIPHEX SPR CAP 10MG ..........................................41
ACIPHEX SPR CAP 5MG . 41 acitretin ............................. 53 ACLOVATE
see alclometasone dipropionate .................. 53
ACTEMRA ........................ 44 ACTHIB ............................. 45 ACTIGALL
see ursodiol ................... 41 ACTIMMUNE .................... 44 ACTIQ
see fentanyl citrate .......... 2 ACTONEL
see risedronate sodium . 34 ACTOPLUS MET
see pioglitazone hcl-metformin hcl ........... 33
ACTOPLUS MET XR 15-1000MG ....................... 32 ACTOPLUS MET XR 30-1000MG ....................... 32 ACTOS
see pioglitazone hcl ....... 33 ACULAR
see ketorolac tromethamine (ophth) .... 48
ACULAR LS see ketorolac tromethamine (ophth) .... 48
ACUVAIL .......................... 48 acyclovir .............................. 8 acyclovir sodium ................. 8 acyclovir topical ................ 54 ACZONE ........................... 51 ADACEL ........................... 45 ADAGEN ........................... 37 ADALAT CC
see afeditab cr ............... 17 see nifedipine ................ 18
adapalene ......................... 51 ADCIRCA .......................... 19 ADDERALL
see amphetamine-dextroamphetamine tab 10 mg......... 26 see amphetamine-dextroamph
etamine tab 12.5 mg ..... 26 see amphetamine-dextroamphetamine tab 15 mg ........ 26 see amphetamine-dextroamphetamine tab 20 mg ........ 26 see amphetamine-dextroamphetamine tab 30 mg ........ 26 see amphetamine-dextroamphetamine tab 5 mg .......... 26 see amphetamine-dextroamphetamine tab 7.5 mg ....... 26
ADDERALL XR see amphetamine cap 10mg er ......................... 26 see amphetamine cap 15mg er ......................... 26 see amphetamine cap 20mg er ......................... 26 see amphetamine cap 25mg er ......................... 26 see amphetamine cap 30mg er ......................... 26 see amphetamine-dextroamphetamine cap sr 24hr 5 mg ...................................... 26
adefovir dipivoxil ................. 8 ADEMPAS ........................ 19 ADOXA
see doxycycline (monohydrate) ............... 11
ADOXA PAK 1/150 see doxycycline (monohydrate) ............... 11
adrucil ............................... 12 ADVAIR DISKUS .............. 51 ADVAIR HFA .................... 51 ADVICOR ......................... 16 AEROSPAN ...................... 51 afeditab cr ......................... 17 AFINITOR ......................... 13 AFINITOR DISPERZ ........ 13
2016 632 3T Platinum Comm eff 04/01/2016
57
AFREZZA..........................38 AGGRENOX .....................44 AGRYLIN
see anagrelide hcl .........43 a-hydrocort ........................37 AKYNZEO .........................39 ala-cort ..............................53 ALBENZA............................6 albuterol sulfate .................50 albuterol sulfate er ............50 ALCAINE
see proparacaine hcl .....49 alclometasone dipropionate ..........................................53 ALCOHOL SWABS ...........31 ALDACTAZIDE
see spironolactone & hydrochlorothiazide .......19
ALDACTAZIDE TAB 50/50 ..........................................18 ALDACTONE
see spironolactone ........15 ALDARA
see imiquimod ...............54 ALDURAZYME .................37 ALECENSA .......................13 alendronate sodium ..........34 alfuzosin hcl ......................42 ALIMTA .............................12 ALINIA.................................6 ALKERAN
see melphalan hcl .........11 allopurinol tab ......................1 almotriptan malate ............28 ALOCRIL...........................48 ALOMIDE ..........................49 ALOPRIM ............................1 ALORA ..............................37 alosetron hcl ......................41 ALOXI ...............................39 ALPHAGAN P ...................49 ALPHAGAN P 0.1% ..........49 alprazolam .................. 19, 20 ALREX ..............................48 ALSUMA ...........................28 ALTABAX ..........................52 ALTACE
see ramipril ....................15
altavera ............................. 34 ALTOPREV ....................... 16 ALVESCO ......................... 51 amantadine hcl ................. 23 AMARYL
see glimepiride .............. 32 AMBIEN
see zolpidem tartrate ..... 28 AMBISOME ........................ 7 amcinonide ....................... 53 AMERGE
see naratriptan hcl ......... 28 amethia 91 day ................. 34 amethyst 28 day ............... 34 amifostine crystalline......... 14 amikacin sulfate .................. 5 amiloride & hydrochlorothiazide ........... 18 amiloride hcl ...................... 18 aminophylline inj ............... 51 AMINOSYN ....................... 46 AMINOSYN 7%/ELECTROLYTES ....... 46 AMINOSYN II .................... 46 AMINOSYN II 8.5%/ELECTROL .............. 46 AMINOSYN INJ 8.5/LYTE 46 AMINOSYN M ................... 46 AMINOSYN-HBC .............. 46 AMINOSYN-PF 7% ........... 46 AMINOSYN-PF INJ 10% .. 46 AMINOSYN-RF ................. 46 amiodarone hcl ................. 15 amiodarone inj 50mg/ml.... 15 AMITIZA ............................ 41 amitriptyline hcl ................. 22 amlodipine besylate .......... 17 amlodipine besylate/atorv . 17 amlodipine besylate-benazepril hcl ..... 14 amlodipine besylate-valsartan tab 10-160 mg ......................... 15 amlodipine besylate-valsartan tab 10-320 mg ......................... 15 amlodipine besylate-valsartan tab 5-160
mg ..................................... 15 amlodipine besylate-valsartan tab 5-320 mg ..................................... 15 amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg.......................................... 15 amlodipine-valsartan-hydrochlorothiazide 10-160-25mg.......................................... 15 amlodipine-valsartan-hydrochlorothiazide 10-320-25mg.......................................... 15 amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg.......................................... 15 amlodipine-valsartan-hydrochlorothiazide 5-160-25mg . 15 ammonium chloride .......... 45 ammonium lactate ............ 54 amnesteem ....................... 51 amoxapine ........................ 22 amoxicillin ......................... 10 amoxicillin & pot clavulanate.......................................... 10 amoxicillin-clarithromycin w/ lansoprazole ..................... 41 amphetamine cap 10mg er.......................................... 26 amphetamine cap 15mg er.......................................... 26 amphetamine cap 20mg er.......................................... 26 amphetamine cap 25mg er.......................................... 26 amphetamine cap 30mg er.......................................... 26 amphetamine-dextroamphetamine cap sr 24hr 5 mg .... 26 amphetamine-dextroamphetamine tab 10 mg ............... 26 amphetamine-dextroamphetamine tab 12.5 mg ............ 26 amphetamine-dextroamphetamine tab 15 mg ............... 26 amphetamine-dextroamphetamine tab 20 mg ............... 26 amphetamine-dextroamphet
2016 632 3T Platinum Comm eff 04/01/2016
58
amine tab 30 mg ...............26 amphetamine-dextroamphetamine tab 5 mg .................26 amphetamine-dextroamphetamine tab 7.5 mg ..............26 amphotericin b ....................7 ampicillin & sulbactam sodium ..............................10 ampicillin cap 250mg ........10 ampicillin cap 500 mg .......10 ampicillin inj .......................10 ampicillin sodium ...............10 ampicillin susp ...................10 AMPYRA ...........................29 ANAFRANIL
see clomipramine hcl .....22 anagrelide hcl ....................43 ANAPROX DS
see naproxen sodium ......1 anastrozole .......................12 ANCOBON
see flucytosine .................7 ANDRODERM ..................30 ANDROGEL ......................31 ANDROGEL 1% ................31 ANDROGEL 1.62% ...........31 ANDROGEL PUMP ..........31 ANORO ELLIPT AER 62.5-25 ..............................49 ANTABUSE
see disulfiram ................30 ANTARA ...........................16 ANUSOL-HC
see proctosol hc 2.5 % ..52 see proctozone hc .........53
apexicon e cream ..............53 APIDRA.............................31 APIDRA SOLOSTAR ........31 APLENZIN ........................22 APOKYN ...........................23 apri 28 day ........................34 APRISO ............................40 APTENSIO XR ..................27 APTIOM ............................20 APTIVUS.............................7 ARALAST NP ....................50 ARALEN
see chloroquine
phosphate ....................... 7 aranelle 28 ........................ 34 ARANESP ALBUMIN FREE .......................................... 43 ARAVA
see leflunomide ............. 44 ARCALYST ....................... 44 ARCAPTA NEOHALER .... 50 ARICEPT
see donepezil tab hcl 23mg ............................. 22 see donepezil tabs 10mg ...................................... 22 see donepezil tabs 5mg 22
ARIMIDEX see anastrozole ............. 12
aripiprazole odt ................. 24 aripiprazole oral solution 1 mg/ml ................................ 24 aripiprazole tabs ............... 24 ARISTADA ........................ 24 ARIXTRA
see fondaparinux sodium ...................................... 43
ARNUITY ELLIPTA ........... 51 AROMASIN
see exemestane ............ 12 ARRANON ........................ 12 ARTHROTEC 50
see diclofenac w/ misoprostol ...................... 1
ARTHROTEC 75 see diclofenac w/ misoprostol ...................... 1
ARZERRA ......................... 12 ASACOL HD ..................... 40 ashlyna 91 day .................. 34 ASMANEX ........................ 51 ASMANEX HFA ................ 51 ASPIRIN-CAFFEINE-DIHYDROCODEINE CAP 356.4-30-16 MG .................. 1 ASPIRIN-DIPYRIDAMOLE .......................................... 44 ASTAGRAF XL ................. 44 ASTEPRO ......................... 49
see azelastine spr 0.15% ...................................... 50
ATACAND see candesartan cilexetil ...................................... 15
ATACAND HCT see candesartan cilexetil-hydrochlorothiazide .................................... 15
ATELVIA see risedronate sodium . 34
atenolol ............................. 17 atenolol & chlorthalidone .. 17 ATGAM ............................. 44 ATIVAN
see lorazepam............... 20 atorvastatin calcium .......... 16 atovaquone ......................... 6 atovaquone-proguanil hcl tab 250-100 mg ........................ 7 atovaquone-proguanil hcl tab 62.5-25 mg ......................... 7 ATRALIN .......................... 51
see tretinoin................... 52 ATRIPLA ............................. 8 ATROPINE SULFATE ...... 40 ATROVENT
see ipratropium bromide (nasal) ........................... 49
ATROVENT HFA .............. 49 AUBAGIO ......................... 29 aubra 28 day ..................... 34 AUGMENTIN .................... 10
see amoxicillin & pot clavulanate .................... 10
AUGMENTIN ES-600 see amoxicillin & pot clavulanate .................... 10
AUGMENTIN XR see amoxicillin & pot clavulanate .................... 10
AURYXIA .......................... 39 AUVI-Q ............................. 50 AVALIDE
see irbesartan-hydrochlorothiazide ............................... 15
AVAPRO see irbesartan ............... 15
AVASTIN .......................... 12
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AVC ..................................42 AVEED ..............................31 AVELOX............................10
see moxifloxacin hcl ......10 aviane 28 ..........................34 AVITA................................51 AVODART.........................42
see dutasteride ..............42 AVONEX ...........................29 AVONEX PEN ...................29 AVYCAZ..............................9 AXERT ..............................28
see almotriptan malate ..28 AXID
see nizatidine ................40 AXIRON ............................31 AYGESTIN
see norethindrone acetate ......................................39
azacitidine .........................12 AZACTAM
see aztreonam .................6 AZACTAM/DEX INJ 1GM ...6 AZACTAM/DEX INJ 2GM ...6 azasan ..............................44 AZASITE ...........................48 azathioprine ......................44 azelastine drop 0.05% ......49 azelastine spr 0.1% ...........50 azelastine spr 0.15% .........50 AZELEX ............................51 AZILECT ...........................23 azithromycin .................. 9, 10 AZITHROMYCIN .................9 AZOPT ..............................49 AZOR ................................15 aztreonam ...........................6 AZULFIDINE
see sulfasalazine ir ........41 AZULFIDINE EN-TABS
see sulfasalazine dr .......41 B bacitracin (ophthalmic) ......48 bacitracin-polymyxin b (ophth)...............................48 bacitracin-poly-neomycin-hc ..........................................48 baclofen ............................29
BACTOCILL INJ DEX 1GM .......................................... 10 BACTOCILL INJ DEX 2GM .......................................... 10 BACTRIM
see sulfamethoxazole-trimethop ...................................... 6
BACTRIM DS see sulfamethoxazole-trimethop ...................................... 6
BACTROBAN see mupirocin ................ 52 see mupirocin calcium (topical) ......................... 52
BACTROBAN NASAL ....... 52 balsalazide disodium......... 40 balziva 28 day ................... 34 BANZEL SUS 40MG/ML ... 20 BANZEL TAB 200MG ....... 20 BANZEL TAB 400MG ....... 20 BARACLUDE ...................... 8
see entecavir ................... 8 BCG VACCINE ................. 45 BECONASE AQ ................ 50 bekyree 28 day ................. 34 BELEODAQ ...................... 12 benazepril & hydrochlorothiazide ........... 14 benazepril hcl .................... 14 BENICAR .......................... 15 BENICAR HCT ................. 15 BENLYSTA ....................... 44 BENTYL ............................ 40
see dicyclomine hcl ....... 40 BENZACLIN WITH PUMP
see clindamycin phosphate-benzoyl peroxide ........................ 52
BENZAMYCIN see benzoyl peroxide-erythromycin ... 51
benzoyl peroxide-erythromycin ...... 51 benztropine mesylate ........ 23 BENZTROPINE MESYLATE .......................................... 23
BEPREVE ......................... 49 BERINERT ....................... 43 BESIVANCE ..................... 48 BETAGAN
see levobunolol hcl ........ 49 betamethasone dipropionate (topical) ............................. 53 betamethasone dipropionate augmented ........................ 53 betamethasone valerate ... 53 BETAPACE
see sorine ..................... 16 see sotalol hcl ............... 16
BETAPACE AF see sotalol hcl (afib/afl) . 16
BETASERON.................... 29 betaxolol hcl ...................... 17 betaxolol hcl (ophth) ......... 49 bethanechol chloride ......... 42 BETHKIS ............................ 5 BETIMOL .......................... 49 BETOPTIC-S .................... 49 bexarotene ........................ 13 BEXSERO ........................ 45 BEYAZ .............................. 34 BIAXIN
see clarithromycin ......... 10 BIAXIN XL
see clarithromycin ......... 10 bicalutamide ..................... 12 BICILLIN C-R .................... 10 BICILLIN L-A .................... 10 BICNU .............................. 11 BIDIL ................................. 19 BILTRICIDE ........................ 6 BINOSTO ......................... 34 bisoprolol & hydrochlorothiazide........... 17 bisoprolol fumarate ........... 17 BIVIGAM ........................... 44 bleomycin sulfate .............. 12 BLEPH-10
see sulfacetamide sodium (ophth) ........................... 48
blephamide ....................... 48 BLEPHAMIDE................... 48 blisovi 21 fe 1.5/30 28 day pack .................................. 34
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blisovi 21 fe 1/20 28 day pack ..................................34 blisovi 24 fe 1/20 28 day ...34 BONIVA
see ibandronate sodium 34 see ibandronate tab 150mg ...........................34
BOOSTRIX .......................45 BOSULIF...........................13 BOTOX INJ 100UNIT ........30 BOTOX INJ 200UNIT ........30 BREO ELLIPTA ................51 BREVICON-28
see necon 0.5/35 28 day ......................................36 see nortrel 0.5/35 28 day ......................................36
briellyn 28 day ...................34 BRILINTA ..........................44 BRIMONIDINE SOL 0.15% ..........................................49 brimonidine sol 0.2% .........49 BRINTELLIX .....................22 BRISDELLE ......................28 bromfenac sodium (ophth) 48 BROMFENAC SODIUM (OPHTH)(ONCE-DAILY) ...48 bromocriptine mesylate .....23 BROVANA ........................50 budesonide .......................40 budesonide (inhalation) .....51 budesonide (nasal) ...........50 bumetanide .......................18 BUMEX
see bumetanide .............18 BUNAVAIL MIS 2.1-0.3MG ..........................................30 BUNAVAIL MIS 4.2-0.7MG ..........................................30 BUNAVAIL MIS 6.3-1MG ..30 BUPHENYL
see sodium phenylbutyrate ......................................37
buprenorphine hcl .............30 buprenorphine hcl-naloxone hcl sl ..................................30 buproban ...........................30 bupropion hcl ....................22
bupropion hcl (smoking deterrent) .......................... 30 buspirone hcl .................... 20 BUSULFEX ....................... 11 butorphanol nasal spray...... 1 butorphanol tartrate............. 1 BUTRANS ........................... 2 BYDUREON ..................... 31 BYETTA ............................ 31 BYSTOLIC ........................ 17 C cabergoline ....................... 38 CADUET
see amlodipine besylate/atorv ................ 17
cafergot tab 1-100mg ........ 28 CALAN
see verapamil hcl .......... 18 CALAN SR
see verapamil hcl .......... 18 calcipotriene ...................... 53 calcipotriene/betamethasone .......................................... 53 calcitonin (salmon) nasal spray ................................. 38 calcitrene oin 0.005%........ 53 calcitriol ............................. 47 CALCITRIOL ..................... 53 calcium acetate (phosphate binder)............................... 39 camila 28 day .................... 34 CAMPTOSAR ................... 14
see irinotecan inj 100/5ml ...................................... 14 see irinotecan inj 40mg/2ml ...................... 14
CAMRESE LO TAB .......... 34 CANASA ........................... 40 CANCIDAS ......................... 7 candesartan cilexetil ......... 15 candesartan cilexetil-hydrochlorothiazide .......................................... 15 CANTIL ............................. 40 CAPASTAT SULFATE ........ 8 CAPEX .............................. 53 capital
and codeine ..................... 2
CAPRELSA ...................... 13 captopril ............................ 14 captopril & hydrochlorothiazide........... 14 CARAFATE ...................... 41
see sucralfate ................ 41 CARBAGLU ...................... 37 carbamazepine ................. 20 CARBATROL
see carbamazepine ....... 20 carbidopa .......................... 23 CARBIDOPA/LEVODOPA/ENTACAPONE ............. 23, 24 carbidopa-levodopa .......... 23 carboplatin ........................ 14 CARDIZEM
see diltiazem hcl............ 17 CARDIZEM CD
see cartia xt ................... 17 see diltiazem hcl coated beads ............................ 17
CARDIZEM LA.................. 17 see matzim la ................ 18
CARDURA see doxazosin mesylate 15
CARDURA XL................... 42 CARIMUNE NANOFILTERED .............. 44 CARNITOR
see levocarnitine (metabolic modifiers) ..... 37
carteolol hcl (ophth) .......... 49 cartia xt ............................. 17 carvedilol .......................... 17 CASODEX
see bicalutamide ........... 12 CATAPRES
see clonidine hcl............ 19 CATAPRES-TTS-1
see clonidine hcl............ 19 CATAPRES-TTS-2
see clonidine hcl............ 19 CATAPRES-TTS-3
see clonidine hcl............ 19 CAYSTON .......................... 6 cefaclor ............................... 9 cefaclor er tab 500mg ......... 9 cefadroxil ............................ 9
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cefazolin in dextrose 1gm/50ml-5% ......................9 CEFAZOLIN IN DEXTROSE 2GM/100ML-4% ..................9 cefazolin inj .........................9 cefazolin sodium .................9 cefdinir ................................9 CEFEPIME 1GM SOLN ......9 CEFEPIME 2GM SOLN ......9 CEFEPIME HCL AND DEXTROSE ........................9 cefepime inj 1gm .................9 cefepime inj 2gm .................9 cefixime ...............................9 cefotaxime sodium ..............9 cefotetan disodium ..............9 cefoxitin sodium ..................9 CEFOXITIN SODIUM IN DEXTROSE ........................9 cefpodoxime proxetil ...........9 cefprozil...............................9 ceftazidime ..........................9 CEFTAZIDIME/DEXTROSE ............................................9 CEFTIBUTEN .....................9 CEFTIN ...............................9
see cefuroxime axetil .......9 ceftriaxone sodium ..............9 cefuroxime axetil .................9 cefuroxime sodium ..............9 CELEBREX
see celecoxib ...................1 celecoxib .............................1 CELEXA
see citalopram hydrobromide ................22
CELLCEPT see mycophenolate mofetil ......................................45
CELLCEPT INTRAVENOUS ..........................................44 CELONTIN ........................20 CENTANY .........................52 cephalexin ...........................9 CERDELGA ......................37 CEREZYME ......................37 CERVARIX........................45 CESAMET.........................39
cetirizine syrup .................. 50 cevimeline hcl ................... 55 CHANTIX .......................... 30 CHANTIX CONTINUING MONTH ............................. 30 CHANTIX STARTER PACK .......................................... 30 CHEMET ........................... 34 chlorhexidine gluconate (mouth-throat) ................... 55 chloroquine phosphate........ 7 chlorothiazide tabs ............ 18 chlorpromazine hcl ............ 24 chlorpromazine inj ............. 24 chlorthalidone ................... 18 cholestyramine .................. 16 cholestyramine light .......... 16 choline fenofibrate ............ 16 CHORIONIC GONADOTROPIN ............ 38 ciclopirox ........................... 52 ciclopirox cre 0.77% .......... 52 ciclopirox shampoo 1% ..... 52 ciclopirox sus 0.77% ......... 52 cidofovir .............................. 8 cilostazol ........................... 43 CILOXAN
see ciprofloxacin hcl (ophth) ........................... 48
CILOXAN OIN 0.3% OP ... 48 cimetidine .......................... 40 cimetidine sol 300/5ml ...... 40 CIMZIA .............................. 44 CINRYZE .......................... 43 CIPRO
see ciprofloxacin............ 10 see ciprofloxacin hcl ...... 10
CIPRO HC ........................ 55 CIPRO I.V.-IN D5W
see ciprofloxacin in d5w 10 CIPRO XR
see ciprofloxacin er ....... 10 CIPRODEX ....................... 55 ciprofloxacin ...................... 10 ciprofloxacin er .................. 10 ciprofloxacin hcl ................ 10 ciprofloxacin hcl (ophth) .... 48 ciprofloxacin in d5w........... 10
ciprofloxacn inj 400mg/40ml.......................................... 10 cisplatin ............................. 14 citalopram hydrobromide .. 22 cladribine .......................... 12 claforan ............................... 9 CLAFORAN
see cefotaxime sodium ... 9 CLAFORAN/D5W ............... 9 claravis ............................. 51 CLARINEX ........................ 50
see desloratadine .......... 50 CLARINEX REDITABS
see desloratadine .......... 50 CLARINEX-D TAB 2.5-120.......................................... 49 clarithromycin.................... 10 CLEOCIN
see clindamycin cre 2% vag ................................ 42 see clindamycin hcl ......... 6
CLEOCIN IN D5W see clindamycin phosphate in d5w ............ 6
CLEOCIN PEDIATRIC GRANULE
see clindamycin palmitate hydrochloride................... 6
CLEOCIN PHOSPHATE see clindamycin phosphate ....................... 6
CLEOCIN VAG SUPP 100MG .............................. 42 CLEOCIN-T
see clindamax ............... 51 see clindamycin phosphate (topical) ........ 52
CLIMARA see estradiol .................. 37
CLINDAGEL ..................... 51 clindamax ......................... 51 clindamycin cre 2% vag .... 42 clindamycin hcl ................... 6 clindamycin palmitate hydrochloride ...................... 6 clindamycin phosphate ....... 6 clindamycin phosphate (topical) ............................. 52
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clindamycin phosphate in d5w .....................................6 clindamycin phosphate-benzoyl peroxide ..........................................52 clindamycin phosphate-benzoyl peroxide (refrigerate) .......................52 CLINDESSE ......................42 CLINIMIX 2.75%/DEXTROSE 5% .....46 CLINIMIX 4.25%/DEXTROSE 10% ...46 CLINIMIX 4.25%/DEXTROSE 20% ...46 CLINIMIX 4.25%/DEXTROSE 25% ...46 CLINIMIX 4.25%/DEXTROSE 5% .....46 CLINIMIX 5%/DEXTROSE 15% ...................................46 CLINIMIX 5%/DEXTROSE 20% ...................................46 CLINIMIX 5%/DEXTROSE 25% ...................................46 CLINIMIX E 2.75%/DEXTROSE 10% ...46 CLINIMIX E 2.75%/DEXTROSE 5% .....46 CLINIMIX E 4.25%/D10 ....46 CLINIMIX E 4.25%/DEXTROSE 25% ...46 CLINIMIX E 4.25%/DEXTROSE 5% .....46 CLINIMIX E 5%/DEXTROSE 15% ...................................46 CLINIMIX E 5%/DEXTROSE 20% ...................................46 CLINIMIX E 5%/DEXTROSE 25% ...................................46 clinisol 15 ..........................46 clobetasol e cream 0.05% .53 clobetasol propionate ........53 clobetasol propionate emulsion............................53 CLOBEX
see clobetasol propionate ......................................53
see clodan sha 0.05% ... 53 CLOCORTOLONE PIVALATE ......................... 53 clodan sha 0.05% ............. 53 CLOLAR ........................... 12 clomipramine hcl ............... 22 clonazepam ...................... 20 clonidine hcl ...................... 19 clopidogrel bisulfate .......... 44 clorazepate dipotassium ... 20 clorpres ............................. 19 clotrimazole ....................... 55 clotrimazole (topical) ......... 52 clozapine ........................... 24 CLOZAPINE ..................... 24 CLOZAPINE ODT ............. 24 CLOZARIL
see clozapine ................ 24 COARTEM .......................... 7 codeine
and capital ....................... 2 CODEINE SULFATE .......... 2 COLAZAL
see balsalazide disodium ...................................... 40
colchicine w/ probenecid ..... 1 COLCRYS .......................... 1 COLESTID
see colestipol hcl ........... 16 colestipol hcl ..................... 16 colistimethate sodium ......... 6 colocort ............................. 40 COLY-MYCIN M
see colistimethate sodium ........................................ 6
COLY-MYCIN S ................ 55 COLYTE-FLAVOR PACKS
see gavilyte-c ................ 41 COLYTE-FLAVOR PACKS 227.1 GM .......................... 41 COMBIGAN ...................... 49 COMBIVENT RESPIMAT . 49 COMBIVIR
see lamivudine-zidovudine ........................................ 8
COMETRIQ ...................... 13 COMPAZINE
see prochlorperazine
maleate ......................... 40 COMPLERA ....................... 8 compro supp ..................... 39 COMVAX .......................... 45 CONDYLOX ..................... 54
see podofilox ................. 55 constulose ........................ 41 CONZIP .............................. 2 COPAXONE
see glatopa ................... 29 COPAXONE INJ 40MG/ML.......................................... 29 COPEGUS
see moderiba tab 200mg 8 see ribasphere ................ 8 see ribavirin 200mg ......... 9
CORDARONE see amiodarone hcl ....... 15 see pacerone ................ 16
CORDRAN ....................... 53 COREG
see carvedilol ................ 17 COREG CR ...................... 17 CORGARD
see nadolol .................... 17 CORLANOR ..................... 19 cormax .............................. 53 CORTEF
see hydrocortisone ........ 37 CORTENEMA
see colocort ................... 40 CORTIFOAM .................... 52 cortisone acetate .............. 37 CORTISPORIN ................. 52
see neomycin-polymyxin-hc (otic) .............................. 55
CORTISPORIN-TC ........... 55 CORZIDE
see nadolol & bendroflumethiazide ...... 17
COSENTYX ...................... 53 COSENTYX SENSOREADY PEN .................................. 53 COSMEGEN ..................... 12 COSOPT
see dorzolamide hcl-timolol maleate ........ 49
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COSOPT PF .....................49 COTELLIC ........................13 COUMADIN ......................43
see jantoven ..................43 see warfarin sodium ......43
COZAAR see losartan potassium..15
CREON .............................41 CRESEMBA ........................7 CRESTOR ........................16 CRINONE .........................39 CRIXIVAN ...........................7 cromolyn sodium ...............50 cromolyn sodium (mastocytosis) ...................41 cromolyn sodium (ophth)...49 cryselle 28 .........................34 CUBICIN .............................6 CUTIVATE
see fluticasone propionate ......................................54
CUVPOSA ........................40 cyclafem 1/35 28 day ........34 cyclafem 7/7/7 28 day .......34 CYCLESSA
see velivet 28 day ..........36 cyclobenzaprine hcl ..........30 cyclophosphamide ............11 CYCLOPHOSPHAMIDE ...11 cycloserine ..........................8 cyclosporine ......................44 cyclosporine modified (for microemulsion) ..................45 CYKLOKAPRON
see tranexamic acid ......44 CYMBALTA
see duloxetine hcl ..........22 CYRAMZA ........................12 cyred tab ...........................34 CYSTADANE ....................37 CYSTAGON ......................37 CYSTARAN ......................49 cytarabine inj .....................12 CYTOMEL
see liothyronine sodium .39 CYTOTEC
see misoprostol .............41 CYTOVENE
see ganciclovir inj 500mg 8 D D.H.E. 45
see dihydroergotamine mesylate ........................ 28
dacarbazine ...................... 11 DACOGEN
see decitabine ............... 12 DAKLINZA .......................... 8 DALIRESP ........................ 50 DALVANCE ........................ 6 danazol ............................. 36 DANTRIUM
see dantrolene sodium .. 30 dantrolene sodium ............ 30 dapsone .............................. 6 DAPTACEL ....................... 45 DARAPRIM ......................... 6 daunorubicin hcl ................ 11 DAYPRO
see oxaprozin .................. 1 DAYTRANA ...................... 27 DDAVP
see desmopressin acetate ...................................... 39 see desmopressin acetate inj................................... 39 see desmopressin acetate spray ............................. 39
deblitane 28 day ............... 34 decitabine ......................... 12 DELESTROGEN ............... 37
see estradiol valerate .... 37 delyla 28 day ..................... 35 DELZICOL ........................ 40 DEMADEX
see torsemide tabs ........ 19 demeclocycline hcl ............ 11 DEMSER .......................... 19 DENAVIR .......................... 54 DEPACON
see valproate sodium .... 22 DEPAKENE
see valproate sodium .... 22 see valproic acid............ 22
DEPAKOTE see divalproex sodium ... 20
DEPAKOTE ER
see divalproex sodium .. 20 DEPAKOTE SPRINKLES
see divalproex sodium .. 20 DEPEN TITRATABS ......... 34 depo-estradiol ................... 37 DEPO-MEDROL
see methylpr ace inj 40mg/ml ........................ 37 see methylpr ace inj 80mg/ml ........................ 37
DEPO-MEDROL INJ 20MG/ML .......................... 37 DEPO-PROVERA CONTRACEPTIV
see medroxyprogesterone acetate (contraceptive) .. 35
DEPO-PROVERA INJ 400/ML .............................. 12 DEPO-SUBQ PROVERA 104 .................................... 35 depo-testosterone ............. 31 DEPO-TESTOSTERONE
see testosterone cypionate ...................................... 31
DERMA-SMOOTHE/FS BODY
see fluocinolone acetonide ...................................... 53
DERMA-SMOOTHE/FS SCALP
see fluocinolone acetonide ...................................... 54
DERMATOP see prednicarbate ......... 54
DERMOTIC see fluocinolone acetonide (otic) .............................. 55
desipramine hcl................. 22 desloratadine .................... 50 desmopressin acetate ....... 39 DESMOPRESSIN ACETATE.......................................... 39 desmopressin acetate inj .. 39 desmopressin acetate spray.......................................... 39 desmopressin acetate spray refrigerated ....................... 39 DESOGEN
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see apri 28 day ..............34 see cyred tab .................34 see emoquette ...............35 see juleber 28 day .........35 see reclipsen 28 day .....36
desogestrel-ethinyl estradiol (biphasic) ..........................35 DESONATE ......................53 desonide ...........................53 DESONIDE .......................53 DESOWEN
see desonide .................53 see lokara ......................54
desoximetasone ................53 DESOXIMETASONE ........53 DETROL
see tolterodine tartrate tab 1 mg ..............................42 see tolterodine tartrate tab 2 mg ..............................42
DETROL LA see tolterodine tartrate er ......................................42
dexamethasone ................37 dexamethasone sodium phosphate .........................37 dexamethasone sodium phosphate (ophth) .............48 DEXILANT ........................41 dexpak 10 day ...................37 dexpak 6 day .....................37 dexpak taperpak 13 day ....37 dexrazoxane .....................14 DEXTROSE ......................47 DEXTROSE 10% FLEX CONTAIN ..........................47 DEXTROSE 10% W/ SODIUM CHLORIDE 0.2% ..........................................47 DEXTROSE 10%/NACL 0.45% ................................47 DEXTROSE 2.5%/NACL 0.45% ................................47 DEXTROSE 5% ................47 DEXTROSE 5% /ELECTROLYTE ...............47 DEXTROSE 5%/LACTATED RING .................................47
DEXTROSE 5%/NACL 0.2% .......................................... 47 DEXTROSE 5%/NACL 0.225%.............................. 47 DEXTROSE 5%/NACL 0.3% .......................................... 47 DEXTROSE 5%/NACL 0.33%................................ 47 DEXTROSE 5%/NACL 0.45%................................ 47 DEXTROSE 5%/NACL 0.9% .......................................... 47 DEXTROSE 5%/POTASSIUM CHL ...... 47 DIAMOX
see acetazolamide ........ 18 diazepam .......................... 20 DIAZEPAM GEL (ANTICONVULSANT) ....... 20 DIBENZYLINE .................. 19
see phenoxybenzamine hcl.................................. 19
diclofenac potassium .......... 1 diclofenac sodium ............... 1 diclofenac sodium (actinic keratoses) ......................... 54 diclofenac sodium (ophth) . 48 diclofenac sodium (topical)54 diclofenac w/ misoprostol .... 1 dicloxacillin sodium ........... 10 dicyclomine hcl ................. 40 didanosine .......................... 7 DIFFERIN ......................... 52
see adapalene ............... 51 DIFICID ............................. 10 diflorasone diacetate ......... 53 DIFLUCAN
see fluconazole ............... 7 diflunisal .............................. 1 digitek ............................... 18 digox ................................. 18 digoxin .............................. 18 digoxin inj .......................... 18 DIGOXIN SOL 50MCG/ML .......................................... 18 dihydroergotamine mesylate .......................................... 28 DIHYDROERGOTAMINE
MESYLATE ...................... 28 dilantin .............................. 20 DILANTIN
see phenytoin sodium extended ....................... 21
DILANTIN INFATABS see phenytoin ................ 21
DILANTIN-125 .................. 20 see phenytoin ................ 21
DILATRATE SR ................ 19 DILAUDID
see hydromorphone hcl ... 3 DILAUDID-HP
see hydromorphone hcl ... 3 DILAUDID-HP INJ 250MG .. 2 diltiazem cap 120mg/24hr . 17 diltiazem cap 240mg/24hr . 17 diltiazem cap er/12hr ........ 17 diltiazem hcl ...................... 17 diltiazem hcl coated beads 17 diltiazem hcl er .................. 17 diltiazem hcl extended release beads ................... 17 diltiazem inj 100mg ........... 17 diltiazem inj 125/25ml ....... 17 diltiazem inj 25mg/5ml ...... 17 diltiazem inj 50/10ml ......... 17 dilt-xr cap .......................... 17 DIOVAN
see valsartan ................. 15 DIOVAN HCT
see valsartan-hydrochlorothiazide .................................. 15
DIPENTUM ....................... 40 diphenhydram inj 50mg/ml 50 diphenoxylate w/ atropine . 41 DIPHTHERIA/TETANUS TOXOID ............................ 45 DIPROLENE
see betamethasone dipropionate augmented 53
DIPROLENE AF see betamethasone dipropionate augmented 53
disopyramide phosphate ... 15 disulfiram .......................... 30 DITROPAN XL
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see oxybutynin chloride .42 DIURIL SUS 250/5ML .......18 divalproex sodium .............20 docetaxel...........................12 DOCETAXEL ....................12 DOCETAXEL SOLN 80MG/8ML ........................12 DOLOPHINE
see methadone hcl ..........4 donepezil odt 10mg ...........22 donepezil odt 5mg .............22 donepezil tab hcl 23mg .....22 donepezil tabs 10mg .........22 donepezil tabs 5mg ...........22 DORIBAX ............................6 dorzolamide hcl .................49 dorzolamide hcl-timolol maleate .............................49 DOVONEX
see calcipotriene ...........53 doxazosin mesylate ..........15 doxepin hcl ........................22 doxercalciferol ...................47 DOXIL
see doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml ...........11
doxorubicin hcl ..................11 doxorubicin hcl liposomal inj (for iv infusion) 2 mg/ml .....11 doxorubicin inj 50mg .........11 doxy ..................................11 doxycycline (monohydrate) ..........................................11 DOXYCYCLINE (ROSACEA) ......................54 doxycycline hyclate ...........11 dronabinol .........................39 drospirenone-ethinyl estradiol ............................35 DROXIA ............................13 DUAC
see clindamycin phosphate-benzoyl peroxide (refrigerate) .....52 see neuac gel 1.2-5% ....52
DUETACT see pioglitazone
hcl-glimepiride ............... 33 DUEXIS .............................. 1 DULERA ........................... 51 duloxetine hcl .................... 22 DUOPA ............................. 24 DURAGESIC
see fentanyl patch 100 mcg/hr ............................. 2 see fentanyl patch 12 mcg/hr ............................. 2 see fentanyl patch 25 mcg/hr ............................. 2 see fentanyl patch 50 mcg/hr ............................. 2 see fentanyl patch 75 mcg/hr ............................. 2
DURAMORPH .................... 2 DUREZOL ......................... 48 dutasteride ........................ 42 dutasteride-tamsulosin hcl 42 DUTOPROL ...................... 17 DYAZIDE
see triamt/hctz cap 37.5-25 .......................... 19
DYMISTA SPR 137-50 ..... 49 DYRENIUM ....................... 18 DYSPORT ........................ 30 E e.e.s. 400 tab 400mg ........ 10 E.E.S. GRANULES ........... 10 EC-NAPROSYN
see naproxen .................. 1 econazole nitrate .............. 52 EDARBI ............................ 15 EDARBYCLOR ................. 15 EDECRIN .......................... 18 EDURANT .......................... 7 EFFEXOR XR
see venlafaxine cap er .. 23 EFFIENT ........................... 44 EFUDEX
see fluorouracil (topical) 54 EGRIFTA .......................... 38 ELAPRASE ....................... 37 ELDEPRYL
see selegiline hcl ........... 24 ELECTROLYTE-R IN DEXTROSE ...................... 47
ELELYSO ......................... 37 ELESTAT
see epinastine hcl (ophth) ...................................... 49
ELIDEL ............................. 54 ELIGARD INJ 22.5MG ...... 12 ELIGARD INJ 30MG ......... 12 ELIGARD INJ 45MG ......... 12 ELIGARD INJ 7.5MG ........ 12 ELIMITE
see permethrin .............. 55 ELIPHOS
see calcium acetate (phosphate binder) ........ 39
ELIQUIS TAB 2.5MG ........ 43 ELIQUIS TAB 5MG ........... 43 ELITEK ............................. 14 elixophyllin ........................ 51 ELLA ................................. 35 ELLENCE
see epirubicin inj 200mg 11 see epirubicin inj 50mg/25ml .................... 11
ELMIRON ......................... 42 ELOCON
see mometasone furoate ...................................... 54
ELOXATIN ........................ 14 EMADINE ......................... 49 EMBEDA ............................ 2 EMCYT ............................. 11 EMEND CAP 125MG ........ 39 EMEND CAP 40MG .......... 39 EMEND CAP 80MG .......... 39 EMEND PAK 80 & 125 ..... 39 EMLA
see lidocaine-prilocaine . 54 emoquette ......................... 35 EMSAM ............................ 22 EMTRIVA ............................ 7 ENABLEX ......................... 42 enalapril maleate .............. 14 enalapril maleate & hydrochlorothiazide........... 14 ENBREL ........................... 44 ENBREL SURECLICK ...... 44 endocet ............................... 2 ENGERIX-B ...................... 45
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enoxaparin sodium ............43 enpresse 28 day ...............35 ENTACAPONE .................24 entecavir .............................8 ENTOCORT EC
see budesonide .............40 ENTRESTO ......................15 ENTYVIO ..........................40 enulose .............................41 EPIDUO ............................52 EPIDUO FORTE ...............52 epinastine hcl (ophth) ........49 EPINEPHRINE ..................50 EPIPEN 2-PAK .................50 EPIPEN-JR 2-PAK ............50 epirubicin inj 200mg ..........11 epirubicin inj 50mg/25ml ...11 epitol .................................20 EPIVIR
see lamivudine ................7 EPIVIR HBV ........................8
see lamivudine (hbv) .......8 eplerenone ........................15 EPOGEN...........................43 epoprostenol sodium .........19 eprosartan mesylate .........15 EPZICOM............................8 EQUETRO ........................28 ERAXIS ...............................7 ERBITUX ..........................12 ergomar.............................28 ERIVEDGE .......................12 errin 28 day .......................35 ERTACZO .........................52 ERWINAZE .......................13 ery pad 2% ........................52 ERYGEL
see erythromycin (acne aid) ................................52
ERYPED 200 ....................10 ERYPED 400 ....................10 ery-tab ...............................10 erythrocin lactobionate ......10 erythrocin stearate ............10 erythromycin (acne aid).....52 erythromycin (ophth) .........48 erythromycin base .............10 erythromycin cap 250mg ec
.......................................... 10 erythromycin ethylsuccinate .......................................... 10 ESBRIET .......................... 50 escitalopram oxalate ......... 22 esomeprazole magnesium 42 esomeprazole sodium inj .. 42 estarylla tab 0.25-35 ......... 35 estrace .............................. 37 ESTRACE
see estradiol .................. 37 estradiol ............................ 37 estradiol valerate .............. 37 ESTRING .......................... 37 ESTROSTEP FE
see tri-legest 28 day ...... 36 ethambutol hcl .................... 8 ethosuximide ..................... 20 ETHYOL
see amifostine crystalline ...................................... 14
etodolac .............................. 1 etodolac er .......................... 1 ETOPOPHOS ................... 14 etoposide .......................... 14 EURAX ............................. 55 EVISTA
see raloxifene hcl .......... 38 EVOCLIN
see clindamycin phosphate (topical) ........ 52
EVOTAZ ............................. 8 EVOXAC
see cevimeline hcl ......... 55 EXALGO
see hydromorphone tab 12mg er ........................... 3 see hydromorphone tab 16mg er ........................... 3 see hydromorphone tab 8mg er ............................. 3
EXELDERM ...................... 52 EXELON
see rivastigmine tartrate 22 see rivastigmine td patch 24hr 13.3 mg/24hr ......... 22 see rivastigmine td patch 24hr 4.6 mg/24hr ........... 22
see rivastigmine td patch 24hr 9.5 mg/24hr ........... 22
EXELON PATCHES ......... 22 exemestane ...................... 12 EXFORGE
see amlodipine besylate-valsartan tab 10-160 mg ..................... 15 see amlodipine besylate-valsartan tab 10-320 mg ..................... 15 see amlodipine besylate-valsartan tab 5-160 mg ....................... 15 see amlodipine besylate-valsartan tab 5-320 mg ....................... 15
EXFORGE HCT see amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg .............. 15 see amlodipine-valsartan-hydrochlorothiazide 10-160-25mg ................. 15 see amlodipine-valsartan-hydrochlorothiazide 10-320-25mg ................. 15 see amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg ................ 15 see amlodipine-valsartan-hydrochlorothiazide 5-160-25mg ................... 15
EXJADE ............................ 34 EXTAVIA .......................... 29 EXTINA
see ketoconazole (topical) ...................................... 52 see ketodan aer 2% ...... 52
EYLEA .............................. 49 F FABIOR ............................ 52 FABRAZYME .................... 37
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falmina 28 day ...................35 famciclovir ...........................8 famotidine .........................40 famotidine inj .....................40 FAMVIR
see famciclovir .................8 FANAPT ............................24 FANAPT TITRATION PACK ..........................................24 FARESTON ......................12 FARXIGA ..........................32 FARYDAK .........................12 FASLODEX .......................13 FAZACLO .........................24 felbamate .................... 20, 21 FELBATOL
see felbamate .......... 20, 21 FELDENE
see piroxicam ..................1 felodipine...........................17 FEMARA
see letrozole ..................13 FEMCON FE
see wymzya fe ...............36 see zenchent fe 28 day .36
FEMRING .........................37 fenofibrate .........................16 FENOFIBRATE .................16 fenofibrate micronized .......16 FENOFIBRIC ACID ...........16 FENOGLIDE .....................16 fenoprofen calcium ..............1 FENOPROFEN CALCIUM ..1 fentanyl citrate .....................2 fentanyl patch 100 mcg/hr ...2 fentanyl patch 12 mcg/hr .....2 fentanyl patch 25 mcg/hr .....2 fentanyl patch 50 mcg/hr .....2 fentanyl patch 75 mcg/hr .....2 FENTORA ...........................3 FERRIPROX .....................34 FETZIMA...........................23 FETZIMA TITRATION PACK ..........................................23 FINACEA AER 15% ..........54 FINACEA GEL 15% ..........54 finasteride .........................42 FIRAZYR...........................43
FIRMAGON ...................... 13 FLAGYL
see metronidazole ........... 6 FLAREX ............................ 48 FLEBOGAMMA ................ 44 FLEBOGAMMA DIF .......... 44 flecainide acetate .............. 15 FLOLAN ............................ 19
see epoprostenol sodium ...................................... 19
FLOMAX see tamsulosin hcl ......... 42
FLONASE see fluticasone propionate (nasal) ........................... 51
FLO-PRED SUS ............... 37 FLOVENT DISKUS ........... 51 FLOVENT HFA ................. 51 fluconazole .......................... 7 fluconazole in dextrose ....... 7 fluconazole in nacl .............. 7 flucytosine ........................... 7 FLUDARA
see fludarabine phosphate ...................................... 12
fludarabine phosphate ...... 12 fludrocortisone acetate...... 37 FLUMADINE
see rimantadine hydrochloride ................... 9
flunisolide (nasal) .............. 51 fluocinolone acetonide 53, 54 fluocinolone acetonide (otic) .......................................... 55 fluocinonide ....................... 54 fluocinonide emulsified base .......................................... 54 FLUOROMETHOLONE (OPHTH) ........................... 48 fluorouracil ........................ 12 fluorouracil (topical)........... 54 FLUOROURACIL (TOPICAL) ........................ 54 fluoxetine cap 10mg .......... 23 fluoxetine cap 20mg .......... 23 fluoxetine cap 40mg .......... 23 fluoxetine hcl ..................... 23 FLUOXETINE HCL ........... 23
fluphenazine decanoate .... 24 fluphenazine hcl ................ 24 flurbiprofen .......................... 1 flurbiprofen sodium ........... 48 flutamide ........................... 13 fluticasone propionate ....... 54 fluticasone propionate (nasal) ............................... 51 fluvastatin sodium cap 20 mg.......................................... 16 fluvastatin sodium cap 40 mg.......................................... 16 fluvastatin sodium tab sr 24 hr 80 mg ........................... 16 fluvoxamine maleate ......... 20 fluvoxamine maleate er ..... 20 FML .................................. 48 FML FORTE ..................... 48 FOLOTYN ......................... 12 fondaparinux sodium ........ 43 FORADIL AEROLIZER ..... 50 FORFIVO XL .................... 23 FORTAMET
see metformin hcl osmotic 1000mg ......................... 33 see metformin hcl osmotic 500mg ........................... 33
FORTAZ ............................. 9 see ceftazidime ............... 9 see tazicef ....................... 9 see tazicef vial................. 9
FORTEO ........................... 39 FORTESTA ...................... 31 FORTICAL SPR 200/ACT 38 FOSAMAX
see alendronate sodium 34 FOSAMAX PLUS D .......... 34 fosinopril sodium ............... 14 fosinopril sodium & hydrochlorothiazide........... 14 FOSRENOL ...................... 39 FRAGMIN ......................... 43 FREAMINE HBC 6.9% ..... 46 FREAMINE III ................... 46 FROVA TAB 2.5MG .......... 28 FURADANTIN
see nitrofurantoin ............ 6 furosemide ........................ 18
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furosemide inj ....................18 FUROSEMIDE INJ ............18 furosemide oral soln 8 mg/ml ..........................................18 FUSILEV ...........................14 FUZEON .............................7 FYCOMPA ........................21 G gabapentin ........................21 GABITRIL..........................21
see tiagabine hcl ...........22 galantamine hydrobromide22 galantamine hydrobromide er .......................................22 GAMASTAN S/D ...............44 GAMMAGARD LIQUID .....44 GAMMAGARD S/D ...........44 GAMMAGARD S/D IGA LESS TH ...........................44 GAMMAKED .....................44 GAMMAPLEX ...................44 GAMUNEX-C ....................44 ganciclovir inj 500mg ..........8 GARAMYCIN
see gentamicin sulfate (ophth) ...........................48
GARDASIL ........................45 GARDASIL 9 .....................45 GASTROCROM
see cromolyn sodium (mastocytosis) ...............41
gatifloxacin (ophth) ............48 GATTEX............................41 GAUZE PADS 2X2 ...........31 gaviltye-g...........................41 gavilyte-c ...........................41 gavilyte-h...........................41 gavilyte-n...........................41 GAZYVA ...........................12 GELNIQUE .......................42 GEMCITABINE .................12 gemcitabine hcl .................12 gemfibrozil.........................16 GEMZAR
see gemcitabine hcl .......12 GENERESS FE
see kaitlib fe 28 day .......35 see norethindrone &
ethinyl estradiol-fe ......... 36 generlac ............................ 41 gengraf.............................. 45 GENOTROPIN .................. 38 GENOTROPIN MINIQUICK .......................................... 38 gentak ............................... 48 gentamicin in saline 0.8 mg/ml .................................. 5 gentamicin in saline 0.9mg/ml ............................. 5 gentamicin in saline 1 mg/ml ............................................ 5 gentamicin in saline 1.2 mg/ml .................................. 5 gentamicin in saline 1.4mg/ml ............................. 5 gentamicin in saline 1.6 mg/ml .................................. 5 gentamicin in saline 2 mg/ml ............................................ 5 gentamicin sulfate ............... 5 gentamicin sulfate (ophth) . 48 gentamicin sulfate (topical) .......................................... 52 GENVOYA .......................... 8 GEODON
see ziprasidone hcl........ 26 GEODON INJ ................... 24 GIANVI TAB 3-0.02MG ..... 35 GIAZO............................... 40 gildagia ............................. 35 gildess 1.5/30 21 day ........ 35 gildess 24 fe 28 day .......... 35 GILENYA CAP 0.5MG ...... 29 GILOTRIF TAB 20MG....... 13 GILOTRIF TAB 30MG....... 13 GILOTRIF TAB 40MG....... 13 GLASSIA .......................... 50 glatopa .............................. 29 GLEEVEC ......................... 13
see imatinib mesylate .... 13 GLEOSTINE ..................... 11 glimepiride ........................ 32 glipizide ............................. 32 glipizide er ......................... 32 GLIPIZIDE XL TB24 2.5MG .......................................... 32
GLIPIZIDE XL TB24 5MG . 32 glipizide-metformin 2.5-250 mg ..................................... 32 glipizide-metformin 2.5-500 mg ..................................... 32 glipizide-metformin 5-500mg.......................................... 32 GLUCAGEN HYPOKIT ..... 38 GLUCAGON EMERGENCY KIT .................................... 38 GLUCOPHAGE
see metformin hcl .......... 33 GLUCOPHAGE XR
see metformin er ........... 33 GLUCOTROL
see glipizide .................. 32 GLUCOTROL XL
see glipizide er .............. 32 GLUMETZA ...................... 32
see metformin hcl .......... 33 glycate .............................. 40 glycopyrrolate ................... 40 GLYSET ........................... 32 GLYXAMBI ....................... 32 GOLYTELY ....................... 41
see gaviltye-g ................ 41 GRALISE .................... 28, 29 GRALISE STARTER ........ 29 granisetron hcl .................. 39 GRANIX ............................ 43 GRASTEK ........................ 44 griseofulvin microsize ......... 7 griseofulvin ultramicrosize .. 7 GRIS-PEG
see griseofulvin ultramicrosize .................. 7
guanfacine er (adhd) ......... 27 H H.P. ACTHAR ................... 38 HALAVEN ......................... 13 HALDOL
see haloperidol lactate inj 5 mg/ml ......................... 24
HALDOL DECANOATE 100 see haloperidol decanoate ...................................... 24
HALDOL DECANOATE 50 see haloperidol decanoate
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......................................24 halobetasol propionate ......54 HALOG .............................54 haloperidol ........................24 haloperidol decanoate .......24 haloperidol lactate .............24 haloperidol lactate inj 5 mg/ml ................................24 HARVONI............................8 HAVRIX.............................45 heather ..............................35 HECTOROL ......................47
see doxercalciferol ........47 HEP SOD/NACL INJ 25000 ..........................................43 HEPARIN (PORCINE) IN SODIUM CHLORIDE 100U/ML ...........................43 heparin sod inj 10000u/ml .43 heparin sod inj 1000u/ml ...43 heparin sod inj 20000u/ml .43 HEPARIN SOD INJ 2000U/ML .........................43 HEPARIN SOD INJ 2500U/ML .........................43 heparin sod inj 5000u/0.5ml ..........................................43 heparin sod inj 5000u/ml ...43 HEPARIN SODIUM/D5W ..43 HEPARIN SODIUM/NACL 0.45% ................................43 HEPATAMINE ...................46 HEPSERA
see adefovir dipivoxil .......8 HERCEPTIN .....................12 HETLIOZ ...........................27 HEXALEN .........................11 HIBERIX............................45 HIPREX
see methenamine hippurate .........................6
HIZENTRA ........................44 HORIZANT........................29 HUMALOG ........................31 HUMALOG KWIKPEN ......31 HUMALOG MIX 50/50 ......31 HUMALOG MIX 50/50 KWIKPEN .........................31
HUMALOG MIX 75/25 ...... 31 HUMALOG MIX 75/25 KWIKPEN ......................... 31 HUMATROPE ................... 38 HUMATROPE COMBO PACK ................................ 38 HUMIRA ............................ 44 HUMIRA PEDIATRIC CROHNS .......................... 44 HUMIRA PEN ................... 44 HUMIRA PEN-CROHNS STARTER KIT .................. 44 HUMIRA PEN-PSORIASIS STARTER KIT .................. 44 HUMULIN 70/30 ............... 31 HUMULIN 70/30 KWIKPEN .......................................... 31 HUMULIN N ...................... 31 HUMULIN N KWIKPEN .... 31 HUMULIN R ...................... 31 HUMULIN R U-500 (CONCENTRATE) ............ 31 HYCAMTIN
see topotecan hcl .......... 14 HYCET
see hydrocodone-acetaminophen 7.5-325 mg/15ml ........ 3
hydralazine hcl .................. 19 HYDREA
see hydroxyurea ............ 13 hydrochlorothiazide ........... 18 hydrocodone-acetaminophen 10-300mg ............................ 3 hydrocodone-acetaminophen 2.5-325mg ........................... 3 hydrocodone-acetaminophen 5-300mg .............................. 3 hydrocodone-acetaminophen 5-325mg .............................. 3 hydrocodone-acetaminophen 7.5-300mg ........................... 3 hydrocodone-acetaminophen 7.5-325 mg/15ml ................. 3 hydrocodone-acetaminophen 7.5-325mg ........................... 3 hydrocodone-acetaminophen tab 10-325mg ...................... 3
hydrocodone-ibuprofen tab 10-200mg ........................... 3 hydrocodone-ibuprofen tab 2.5-200mg .......................... 3 hydrocodone-ibuprofen tab 5-200mg ............................. 3 hydrocodone-ibuprofen tab 7.5-200 mg ......................... 3 hydrocortisone .................. 37 HYDROCORTISONE (INTRARECTAL) .............. 40 hydrocortisone (topical) .... 54 hydrocortisone butyrate .... 54 hydrocortisone butyrate hydrophilic lipo base ......... 54 hydrocortisone valerate .... 54 hydromorphone hcl ............. 3 HYDROMORPHONE HCL . 3 hydromorphone tab 12mg er............................................ 3 hydromorphone tab 16mg er............................................ 3 hydromorphone tab 8mg er 3 HYDROMORPHONE TABS 32MG .................................. 3 hydroxychloroquine sulfate.......................................... 44 hydroxyurea ...................... 13 hydroxyzine hcl ................. 50 HYQVIA ............................ 44 HYSINGLA ER.................... 3 HYZAAR
see losartan-hydrochlorothiazide .................................. 15
I ibandronate sodium .......... 34 ibandronate tab 150mg ..... 34 IBRANCE .......................... 12 ibudone tab 10-200mg ........ 3 ibudone tab 5-200mg .......... 3 ibuprofen ............................. 1 ICLUSIG ........................... 13 IDAMYCIN PFS
see idarubicin hcl .......... 11 idarubicin hcl ..................... 11 IFEX
see ifosfamide inj 1gm .. 11
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IFEX INJ 3GM ...................11 IFOSFAMIDE
see ifosfamide inj 1gm/20ml .......................11 see ifosfamide inj 3gm/60ml .......................11
ifosfamide inj 1gm .............11 ifosfamide inj 1gm/20ml ....11 IFOSFAMIDE INJ 3GM .....11 ifosfamide inj 3gm/60ml ....11 ILARIS...............................44 ILEVRO .............................48 ilotycin ...............................48 imatinib mesylate ..............13 IMBRUVICA CAP 140MG .13 imipenem-cilastatin .............6 imipramine hcl ...................23 imipramine pamoate .........23 imiquimod..........................54 IMITREX
see sumatriptan inj 6mg/0.5ml ......................28 see sumatriptan succinate ......................................28
IMITREX STATDOSE SYSTEM
see sumatriptan inj 6mg/0.5ml ......................28
IMOVAX RABIES (H.D.C.V.) ..........................................45 IMURAN
see azathioprine ............44 INCRELEX ........................38 INCRUSE ELLIPTA ..........49 indapamide .......................18 INDERAL LA
see propranolol hcl er ....17 INFANRIX .........................45 INFUMORPH 200 ...............3 INFUMORPH 500 ...............3 INLYTA .............................13 INSPRA
see eplerenone ..............15 INSULIN PEN NEEDLES ..31 INSULIN SAFETY NEEDLES .........................31 INSULIN SYRINGES ........31 INTELENCE ........................7
INTRALIPID INJ 20%........ 46 INTRALIPID INJ 30%........ 46 INTRON-A INJ 10MU........ 44 INTRON-A INJ 18MU........ 44 INTRON-A INJ 25MU........ 44 INTRON-A INJ 50MU........ 44 introvale 91 day ................ 35 INTUNIV
see guanfacine er (adhd) ...................................... 27
INVANZ ............................... 6 INVEGA ............................ 24
see paliperidone ............ 25 INVEGA SUST INJ 117 MG/0.75 ML ...................... 25 INVEGA SUST INJ 156MG/ML ........................ 25 INVEGA SUST INJ 234 MG/1.5 ML ........................ 25 INVEGA SUST INJ 39 MG/0.25 ML ...................... 25 INVEGA SUST INJ 78 MG/0.5 ML ........................ 25 INVEGA TRINZA .............. 25 INVIRASE ........................... 7 INVOKAMET TAB 150-1000 .......................................... 32 INVOKAMET TAB 150-500 .......................................... 32 INVOKAMET TAB 50-1000 .......................................... 32 INVOKAMET TAB 50-500MG ......................... 32 INVOKANA TAB 100MG ... 32 INVOKANA TAB 300MG ... 32 IONOSOL-B/DEXTROSE 5%..................................... 47 IONOSOL-MB/DEXTROSE 5%..................................... 47 IPOL INACTIVATED IPV .. 45 ipratropium bromide (nasal) .......................................... 49 ipratropium sol inhal .......... 49 ipratropium-albuterol ......... 49 irbesartan .......................... 15 irbesartan-hydrochlorothiazide ........................................ 15 IRESSA ............................. 13
irinotecan inj 100/5ml ........ 14 irinotecan inj 40mg/2ml ..... 14 irinotecan inj 500mg/25ml . 14 ISENTRESS ....................... 7 ISOLYTE P ....................... 47 ISOLYTE S ....................... 47 isoniazid .............................. 8 isoniazid tabs ...................... 8 ISORDIL TITRADOSE ...... 19
see isosorbide dinitrate . 19 isosorbide dinitrate............ 19 isosorbide dinitrate er ....... 19 isosorbide mononitrate ..... 19 isosorbide mononitrate er . 19 isradipine .......................... 17 ISTALOL ........................... 49 ISTODAX .......................... 12 itraconazole ........................ 7 ivermectin ........................... 6 IXEMPRA KIT ................... 13 IXIARO ............................. 45 J JADENU ........................... 34 JAKAFI ............................. 13 JALYN .............................. 42
see dutasteride-tamsulosin hcl ................................. 42
jantoven ............................ 43 JANUMET ......................... 32 JANUMET XR TAB 100-1000 .......................... 32 JANUMET XR TAB 50-1000.......................................... 32 JANUMET XR TAB 50-500MG ......................... 32 JANUVIA .......................... 32 JARDIANCE ..................... 32 JENTADUETO .................. 32 JEVTANA ......................... 12 jinteli ................................. 37 JOLESSA TAB 0.15-0.03 MG .................................... 35 JOLIVETTE ...................... 35 juleber 28 day ................... 35 junel 1.5/30 21 day ........... 35 junel 1/20 21 day .............. 35 junel fe 1.5/30 28 day ....... 35 junel fe 1/20 28 day .......... 35
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junel fe 24 1/20 28 day ......35 JUXTAPID.........................16 K KADCYLA .........................12 KADIAN...............................3
see morphine sulfate .......4 kaitlib fe 28 day .................35 KALBITOR ........................43 KALETRA SOL ...................8 KALETRA TAB 100-25MG ..8 KALETRA TAB 200-50MG ..8 KALYDECO ......................50 kariva 28 day .....................35 KAYEXALATE
see kionex .....................34 see sodium polystyrene sulfonate ........................34
KAZANO ...........................33 KCL 0.075%/D5W/NACL 0.45% ................................47 KCL 0.15%/D5W/LR .........47 KCL 0.15%/D5W/NACL 0.9% ..................................47 KCL 0.3%/D5W/LR IV LAC RI ......................................47 KCL 0.3%/D5W/NACL 0.45% ................................47 KCL 0.3%/D5W/NACL 0.9% ..........................................47 KCL IN NACL INJ .15-0.45 ..........................................47 KCL/D5W/NACL INJ .15/.33% ............................47 KCL/D5W/NACL INJ .15/.45% ............................47 KCL/D5W/NACL INJ 0.22%/0.45% .....................47 KCL/NACL INJ 0.15%-0.9% ..........................................47 KCL0.15%/D5W/NACL0.2% ..........................................47 KCL0.15%/D5W/NACL0.225% .......................................47 KEFLEX
see cephalexin ................9 kelnor 1/35 28 day ............35 KENALOG
see triamcinolone
acetonide (topical) ......... 54 KEPIVANCE ..................... 14 KEPPRA
see levetiracetam .......... 21 see levetiracetam oral soln 100 mg/ml ..................... 21
KEPPRA XR see levetiracetam .......... 21
KERLONE see betaxolol hcl............ 17
ketoconazole ....................... 7 ketoconazole (topical) ....... 52 ketoconazole shampoo ..... 53 ketodan aer 2% ................. 52 ketoprofen ........................... 1 ketorolac tromethamine (ophth) .............................. 48 KEYTRUDA ...................... 12 kimidess 28 day ................ 35 KINERET .......................... 44 KINRIX .............................. 45 kionex ............................... 34 KLARON
see sulfacetamide sodium (acne) ............................ 52
KLONOPIN see clonazepam ............ 20
KLOR-CON 10 .................. 46 KLOR-CON 8 .................... 45 klor-con m10 ..................... 46 klor-con m15 ..................... 46 klor-con m20 ..................... 46 klor-con pow 20meq.......... 46 klor-con spr cap 10meq .... 46 klor-con spr cap 8meq ...... 46 KOMBIGLYZE XR 2.5-1000MG ...................... 33 KOMBIGLYZE XR 5-1000MG ......................... 33 KOMBIGLYZE XR 5-500MG .......................................... 33 KORLYM ........................... 38 kristalose ........................... 41 KUVAN ............................. 37 KYNAMRO ........................ 16 L labetalol hcl ....................... 17 LAC-HYDRIN
see ammonium lactate .. 54 LACRISERT ..................... 49 LACTATED RINGERS VIAFLEX ........................... 47 lactulose ........................... 41 lactulose (encephalopathy).......................................... 41 LAMICTAL
see lamotrigine .............. 21 LAMICTAL CHEWABLE DISPERS
see lamotrigine .............. 21 LAMICTAL ODT................ 21
see lamotrigine .............. 21 LAMICTAL STARTER ...... 21 LAMICTAL XR .................. 21
see lamotrigine .............. 21 LAMISIL .............................. 7
see terbinafine hcl ........... 7 lamivudine .......................... 7 lamivudine (hbv) ................. 8 lamivudine-zidovudine ........ 8 lamotrigine ........................ 21 LANOXIN .......................... 18
see digitek ..................... 18 see digox ....................... 18 see digoxin .................... 18 see digoxin inj ............... 18
LANOXIN PEDIATRIC ...... 18 lansoprazole ..................... 42 LANTUS ........................... 31 LANTUS SOLOSTAR ....... 31 larin 1.5/30 ........................ 35 larin 1/20 ........................... 35 larin fe 1.5/30 .................... 35 larin fe 1/20 ....................... 35 LASIX
see furosemide.............. 18 LASTACAFT ..................... 49 latanoprost ........................ 49 LATUDA ........................... 25 LAYOLIS FE CHW ............ 35 LAZANDA ........................... 3 LEENA TAB ...................... 35 leflunomide ....................... 44 LEMTRADA ...................... 29 LENVIMA 10MG DAILY DOSE ............................... 13
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LENVIMA 14MG DAILY DOSE ................................13 LENVIMA 20MG DAILY DOSE ................................13 LENVIMA 24MG DAILY DOSE ................................13 LESCOL
see fluvastatin sodium cap 20 mg ............................16
LESCOL XL ......................16 see fluvastatin sodium tab sr 24 hr 80 mg ...............16
lessina 28 day ...................35 LETAIRIS ..........................19 letrozole ............................13 leucovorin calcium ............14 leucovorin calcium inj 100mg ..........................................14 leucovorin calcium inj 200mg ..........................................14 leucovorin calcium inj 350mg ..........................................14 leucovorin calcium inj 500mg ..........................................14 leucovorin calcium inj 50mg ..........................................14 LEUKERAN .......................11 LEUKINE...........................43 leuprolide acetate ..............13 levalbuterol conc 1.25mg/0.5ml ....................50 levalbuterol hcl ..................50 LEVALBUTEROL HCL ......50 LEVAQUIN
see levofloxacin .............10 LEVEMIR ..........................31 LEVEMIR FLEXTOUCH....31 levetiracetam .....................21 LEVETIRACETAM IV ........21 levetiracetam oral soln 100 mg/ml ................................21 levobunolol hcl ..................49 levocarnitine (metabolic modifiers) ..........................37 levocetirizine soln 2.5mg/5ml ..........................................50 levocetirizine tab 5 mg ......50 levofloxacin .......................10
levofloxacin (ophth) ........... 48 levofloxacin in d5w ............ 10 levoleucovorin calcium ...... 14 levonest 28 day ................. 35 levonor/ethi tab ................. 35 levonorgestrel & eth estradiol .......................................... 35 levonorgestrel (emergency oc) ..................................... 35 levonorgestrel-ethinyl estradiol (91-day) .............. 35 levonorgestrel-ethinyl estradiol (continuous)........ 35 levora 0.15/30 28 day ....... 35 levorphanol tartrate ............. 3 levothyroxine sodium ........ 39 LEVOXYL ......................... 39 LEXAPRO
see escitalopram oxalate ...................................... 22
LEXIVA ............................... 7 LIALDA ............................. 40 lidocaine ............................ 54 lidocaine hcl ...................... 54 lidocaine hcl (local anesth.) . 5 lidocaine hcl (mouth-throat) .......................................... 55 lidocaine inj 0.5% ................ 5 lidocaine inj 1% ................... 5 lidocaine inj 1.5% ................ 5 lidocaine inj 2% ................... 5 lidocaine-prilocaine ........... 54 LIDODERM
see lidocaine ................. 54 linezolid ............................... 6 LINEZOLID ......................... 6 LINZESS ........................... 41 liothyronine sodium ........... 39 LIPITOR
see atorvastatin calcium 16 LIPOSYN III ...................... 46 lisinopril ............................. 14 lisinopril & hydrochlorothiazide ........... 14 lithium carbonate .............. 29 LITHIUM SOLN 8MEQ/5ML .......................................... 29 LITHOBID
see lithium carbonate .... 29 LIVALO ............................. 16 LO LOESTRIN FE ............ 35 LOCOID ............................ 54
see hydrocortisone butyrate ......................... 54
LOCOID LIPOCREAM see hydrocortisone butyrate hydrophilic lipo base .............................. 54
LODOSYN see carbidopa................ 23
LOESTRIN 1.5/30-21 see gildess 1.5/30 21 day ...................................... 35 see junel 1.5/30 21 day . 35 see larin 1.5/30.............. 35
LOESTRIN 1/20-21 see junel 1/20 21 day .... 35 see larin 1/20................. 35
LOESTRIN FE 1.5/30 see blisovi 21 fe 1.5/30 28 day pack ........................ 34 see junel fe 1.5/30 28 day ...................................... 35 see larin fe 1.5/30 .......... 35
LOESTRIN FE 1/20 see blisovi 21 fe 1/20 28 day pack ........................ 34 see junel fe 1/20 28 day 35 see larin fe 1/20............. 35 see tarina fe 1/20 28 day ...................................... 36
LOFIBRA see fenofibrate .............. 16 see fenofibrate micronized ...................................... 16
lokara ................................ 54 lomedia 24 fe .................... 35 LOMOTIL
see diphenoxylate w/ atropine ......................... 41
LONSURF ........................ 13 loperamide hcl .................. 41 LOPID
see gemfibrozil .............. 16 LOPRESSOR
see metoprolol tartrate .. 17
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LOPRESSOR HCT see metoprolol & hctz tab 100-25mg ......................17 see metoprolol & hctz tab 50-25mg ........................17
LOPROX SHAMPOO see ciclopirox shampoo 1% .................................52
lorazepam .........................20 lorcet hd tab 10-325mg .......3 lorcet plus tab 7.5-325 ........3 lorcet tab 5-325mg ..............4 lortab tab 10-325mg ............4 lortab tab 5-325mg ..............4 lortab tab 7.5-325 ................4 loryna 28 day ....................35 losartan potassium ............15 losartan-hydrochlorothiazide ..........................................15 LOTEMAX .........................48 LOTENSIN
see benazepril hcl .........14 LOTENSIN HCT
see benazepril & hydrochlorothiazide .......14
LOTREL see amlodipine besylate-benazepril hcl ..14
LOTRONEX see alosetron hcl ...........41
lovastatin ...........................16 LOVAZA
see omega-3-acid ethyl esters.............................16
LOVENOX see enoxaparin sodium .43
low-ogestrel.......................35 loxapine succinate ............25 LUCENTIS ........................49 LUMIGAN..........................49 LUMIZYME .......................37 LUPANETA PACK ............36 LUPRON DEP INJ 11.25MG ..........................................13 LUPRON DEPOT ..............13 LUPRON DEPOT INJ 22.5MG (3-MONTH) .........13 LUPRON DEPOT INJ 30MG
(3-MONTH) ....................... 13 LUPRON DEP-PED INJ 11.25MG ........................... 13 LUPRON DEP-PED INJ 15MG ................................ 13 LUPRON DEP-PED INJ 30MG (3-MONTH) ............ 13 LUPRON DEP-PED INJ 7.5MG ............................... 13 lutera 28 day ..................... 35 LUXIQ
see betamethasone valerate ......................... 53
LUZU ................................ 52 LYNPARZA ....................... 12 LYRICA ............................. 21 LYSODREN ...................... 13 LYSTEDA
see tranexamic acid ...... 44 lyza ................................... 35 M MACROBID
see nitrofurantoin monohyd macro............... 6
MACRODANTIN ................. 6 see nitrofurantoin macrocrystal .................... 6
magnesium sulfate ............ 46 MAGNESIUM SULFATE ... 46 MAGNESIUM SULFATE IN D5W .................................. 46 MAGNESIUM SULFATE INJ 50%................................... 46 MALARONE
see atovaquone-proguanil hcl tab 250-100 mg.......... 7 see atovaquone-proguanil hcl tab 62.5-25 mg........... 7
malathion .......................... 55 maprotiline hcl ................... 23 MARINOL
see dronabinol ............... 39 marlissa 28 day ................. 35 MARPLAN ........................ 23 MATULANE ...................... 13 matzim la .......................... 18 MAVIK
see trandolapril .............. 15
MAXALT see rizatriptan benzoate 28
MAXALT-MLT see rizatriptan benzoate 28
MAXIDEX ......................... 48 MAXIPIME .......................... 9
see cefepime inj 1gm ...... 9 see cefepime inj 2gm ...... 9
MAXITROL see neomycin-polymy-dexameth .................................... 48
MAXZIDE see triamt/hctz tab 75-50mg ........................ 19
MAXZIDE-25 see triamt/hctz tab 37.5-25 ...................................... 19
meclizine hcl ..................... 39 MEDROL
see methylpred tab 16mg ...................................... 38 see methylpred tab 32mg ...................................... 38 see methylpred tab 4mg 37 see methylpred tab 8mg 37
MEDROL DOSEPAK see methylpred pak 4mg ...................................... 37
MEDROL TAB 2MG .......... 37 medroxyprogesterone acetate .............................. 39 medroxyprogesterone acetate (contraceptive) ..... 35 mefenamic acid................... 1 mefloquine hcl..................... 7 MEGACE ES .................... 13 MEGACE ORAL
see megestrol ac sus 40mg/ml ........................ 13
megestrol ac sus 40mg/ml 13 megestrol ac tab 20mg ..... 13 megestrol ac tab 40mg ..... 13 MEGESTROL SUS 625MG/5ML ...................... 13 MEKINIST ......................... 13 MELOXICAM ...................... 1 meloxicam tabs ................... 1
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melphalan hcl ....................11 memantine hcl ...................22 MENACTRA ......................45 MENOMUNE-A/C/Y/W-135 ..........................................45 MENOSTAR ......................37 MENTAX ...........................52 MENVEO ..........................45 MEPRON
see atovaquone ...............6 mercaptopurine .................12 meropenem .........................6 MEROPENEM/SODIUM CHLORIDE .........................6 MERREM
see meropenem ..............6 mesalamine enema ...........40 mesna ...............................14 MESNEX ...........................14
see mesna .....................14 MESTINON
see pyridostigmine bromide .........................29
MESTINON SYRUP ..........29 MESTINON TIMESPAN ....29
see pyridostigmine bromide .........................29
METADATE CD see methylphenidate hcl 27
metadate er tab 20mg .......27 metformin er ......................33 metformin hcl ....................33 metformin hcl osmotic 1000mg .............................33 metformin hcl osmotic 500mg ...............................33 methadone hcl ....................4 METHADONE INJ 10MG/ML ............................................4 METHADOSE
see methadone hcl ..........4 methazolamide ..................18 methenamine hippurate ......6 METHERGINE
see methylergonovine maleate..........................38
methimazole ......................39 methotrexate sodium ........12
METHOTREXATE SODIUM .......................................... 12 methotrexate sodium inj .... 12 methotrexate sodium tabs . 44 methoxsalen rapid ............ 53 methscopolamine bromide 40 methyclothiazide ............... 19 methylergonovine maleate 38 METHYLIN
see methylphenidate hcl 27 methylphenidate hcl .......... 27 METHYLPHENIDATE HCL .......................................... 27 methylphenidate hcl er ...... 27 methylpr ace inj 40mg/ml .. 37 methylpr ace inj 80mg/ml .. 37 methylpr ss inj 125mg ....... 37 methylpr ss inj 1gm ........... 37 methylpr ss inj 40mg ......... 37 methylpred pak 4mg ......... 37 methylpred tab 16mg ........ 38 methylpred tab 32mg ........ 38 methylpred tab 4mg .......... 37 methylpred tab 8mg .......... 37 metipranolol ...................... 49 metoclopramide hcl ........... 39 metoclopramide hcl inj 5 mg/ml ................................ 39 metoclopramide odt .......... 39 metolazone ....................... 19 metoprolol & hctz tab 100-25mg .......................... 17 metoprolol & hctz tab 100-50mg .......................... 17 metoprolol & hctz tab 50-25mg ............................ 17 metoprolol succinate ......... 17 metoprolol tartrate ............. 17 METOZOLV ODT
see metoclopramide hcl 39 METRO IV .......................... 6 METROCREAM
see metronidazole (topical) ......................... 54 see rosadan cre 0.75% . 55
METROGEL see metronidazole (topical) ......................... 55
METROGEL-VAGINAL see metronidazole vaginal ...................................... 43
METROLOTION see metronidazole (topical) ......................... 55
metronidazole ..................... 6 metronidazole (topical) 54, 55 metronidazole inj................. 6 metronidazole vaginal ....... 43 MEVACOR
see lovastatin ................ 16 mexiletine hcl .................... 15 MIACALCIN
see calcitonin (salmon) nasal spray .................... 38
MIACALCIN INJ 200U/ML 38 MICARDIS
see telmisartan .............. 15 MICARDIS HCT
see telmisartan-hydrochlorothiazide ............................. 15
miconazole 3 sup 200mg .. 43 MICROGESTIN 1.5/30 ..... 35 MICROGESTIN 1/20 ........ 35 MICROGESTIN FE 1.5/30 35 MICROGESTIN FE 1/20 ... 35 MICRO-K
see klor-con spr cap 10meq ........................... 46 see klor-con spr cap 8meq ...................................... 46 see potassium chloride caps er .......................... 46
MICROZIDE see hydrochlorothiazide 18
midodrine hcl .................... 19 migergot ............................ 28 millipred ............................ 38 millipred dp ....................... 38 MINASTRIN 24 FE ........... 35 MINIPRESS
see prazosin hcl ............ 15 minitran ............................. 19 MINIVELLE ....................... 37 MINOCIN
see minocycline hcl ....... 11
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minocycline hcl ..................11 minoxidil ............................19 MIRAPEX ..........................24
see pramipexole dihydrochloride ..............24
MIRAPEX ER ....................24 see pramipexole dihydrochloride ..............24
MIRCERA .........................43 MIRCETTE
see bekyree 28 day .......34 see desogestrel-ethinyl estradiol (biphasic) ........35 see kariva 28 day ..........35 see kimidess 28 day ......35 see pimtrea pack ...........36 see viorele .....................36
mirtazapine .......................23 misoprostol........................41 mitomycin ..........................12 mitoxantrone hcl ................13 M-M-R II ............................45 MOBIC
see meloxicam tabs .........1 modafinil............................30 moderiba pak ......................8 MODERIBA PAK .................8 moderiba tab 200mg ...........8 moexipril hcl ......................14 moexipril-hydrochlorothiazide ........................................14 molindone hcl ....................25 mometasone furoate .........54 MONODOX
see doxycycline (monohydrate) ...............11
mono-linyah tab 0.25-35 ...36 MONONESSA ...................36 montelukast sodium ..........50 MORPHINE SUL 20MG/ML ORAL SOL ..........................4 MORPHINE SUL INJ 10MG/ML ............................4 MORPHINE SUL INJ 15MG/ML ............................4 MORPHINE SUL INJ 1MG/ML ..............................4 MORPHINE SUL INJ
4MG/ML .............................. 4 morphine sulfate ................. 4 MORPHINE SULFATE ....... 4 morphine sulfate beads....... 4 morphine sulfate ext-rel tab 4 MOVANTIK ....................... 41 MOVIPREP ....................... 41 MOXEZA ........................... 48 moxifloxacin hcl ................ 10 MOXIFLOXACIN HCL....... 10 MOZOBIL .......................... 43 MS CONTIN
see morphine sulfate ext-rel tab ........................ 4
MULTAQ ........................... 15 mupirocin .......................... 52 mupirocin calcium (topical)52 MUSTARGEN ................... 11 MYALEPT ......................... 38 MYAMBUTOL
see ethambutol hcl .......... 8 MYCAMINE ........................ 7 MYCOBUTIN
see rifabutin ..................... 8 mycophenolate mofetil ...... 45 mycophenolate sodium ..... 45 MYFORTIC
see mycophenolate sodium ........................... 45
myorisan ........................... 52 MYOZYME ........................ 37 MYRBETRIQ .................... 42 MYSOLINE
see primidone ................ 21 myzilra .............................. 36 N nabumetone ........................ 1 nadolol .............................. 17 nadolol & bendroflumethiazide.......... 17 nafcillin sodium ................. 10 naftifine hcl ........................ 52 NAFTIFINE HCL ............... 52 NAFTIN ............................. 52
see naftifine hcl ............. 52 NAGLAZYME .................... 37 nalbuphine hcl ..................... 2 NALLPEN ISO-OSMOTIC IN
DE ..................................... 10 NALLPEN/DEXTROSE ..... 10 naloxone hcl ..................... 30 naltrexone hcl ................... 30 NAMENDA
see memantine hcl ........ 22 NAMENDA SOL 10MG/5ML.......................................... 22 NAMENDA TAB ................ 22 NAMENDA XR .................. 22 NAMENDA XR TITRATION PACK ................................ 22 NAMZARIC ....................... 22 naphazoline 0.1% ............. 49 NAPRELAN ........................ 1
see naproxen sodium ...... 1 NAPROSYN
see naproxen .................. 1 naproxen ............................. 1 naproxen sodium ................ 1 NAPROXEN SODIUM ........ 1 naratriptan hcl ................... 28 NARDIL
see phenelzine sulfate .. 23 NASONEX ........................ 51 NATACYN ........................ 48 nateglinide ........................ 33 NATPARA ......................... 39 NAVELBINE
see vinorelbine tartrate .. 12 NEBUPENT ........................ 6 necon 0.5/35 28 day ......... 36 necon 1/35 28 day ............ 36 necon 10/11 28 day .......... 36 NECON 7/7/7 .................... 36 NECON TAB 1/50-28 ........ 36 nefazodone hcl ................. 23 neomycin sulfate ................. 5 neomycin/polymyxin b gu . 55 neomycin-bacitracin zn-polymyxin ..................... 48 neomycin-polymy-dexameth.......................................... 48 neomycin-polymyxin-gramicidin ..................................... 48 neomycin-polymyxin-hc (ophth) .............................. 48 neomycin-polymyxin-hc (otic)
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..........................................55 NEORAL ...........................45
see cyclosporine modified (for microemulsion) ........45 see gengraf ...................45
NEOSPORIN see neomycin-polymyxin-gramicidin ...............................48
NEOSPORIN GU IRRIGANT see neomycin/polymyxin b gu ..................................55
NEPHRAMINE ..................46 NEPTAZANE
see methazolamide .......18 NESINA.............................33 neuac gel 1.2-5% ..............52 NEULASTA .......................43 NEULASTA ONPRO KIT ..43 NEUMEGA ........................43 NEUPOGEN .....................43 NEUPRO...........................24 NEURONTIN
see gabapentin ..............21 nevirapine ...........................7 NEVIRAPINE ......................7 NEXAVAR .........................13 NEXIUM
see esomeprazole magnesium ....................42
NEXIUM CAP 20MG .........42 NEXIUM CAP 40MG .........42 NEXIUM GRA 10MG DR ..42 NEXIUM GRA 2.5MG DR .42 NEXIUM GRA 20MG DR ..42 NEXIUM GRA 40MG DR ..42 NEXIUM GRA 5MG DR ....42 NEXIUM I.V.
see esomeprazole sodium inj ...................................42
next choice tab 1.5mg .......36 niacin er (antihyperlipidemic) ..........................................16 niacor ................................16 NIASPAN
see niacin er (antihyperlipidemic) .......16
nicardipine hcl ...................18
NICOTROL INHALER ....... 30 NICOTROL NS ................. 30 nifedical ............................. 18 nifedipine .......................... 18 nifedipine er ...................... 18 nikki 28 day ....................... 36 NILANDRON ..................... 13 nimodipine ........................ 18 NINLARO .......................... 12 NIPENT ............................. 12 nisoldipine ......................... 18 nitro-bid ............................. 19 NITRO-DUR ...................... 19
see minitran ................... 19 nitrofurantoin ....................... 6 nitrofurantoin macrocrystal .. 6 nitrofurantoin monohyd macro .................................. 6 nitroglycerin ...................... 19 NITROGLYCERIN LINGUAL .......................................... 19 nitroglycerin patches ......... 19 NITROLINGUAL PUMPSPRAY
see nitroglycerin ............ 19 NITROSTAT ..................... 19 nizatidine ........................... 40 NIZORAL
see ketoconazole shampoo ....................... 53
NORA-BE TAB ................. 36 NORCO
see hydrocodone-acetaminophen 5-325mg ..................... 3 see hydrocodone-acetaminophen 7.5-325mg .................. 3 see hydrocodone-acetaminophen tab 10-325mg ............. 3 see lorcet hd tab 10-325mg ........................ 3 see lorcet plus tab 7.5-325 ........................................ 3 see lorcet tab 5-325mg .... 4 see lortab tab 10-325mg . 4 see lortab tab 5-325mg ... 4
see lortab tab 7.5-325 ..... 4 NORDITROPIN FLEXPRO.......................................... 38 norethin acet & estrad-fe .. 36 norethindrone & ethinyl estradiol-fe ........................ 36 norethindrone (contraceptive) .................. 36 norethindrone acetate ....... 39 norethindrone acetate-ethinyl estradiol ............................ 37 norgest/ethi tab 0.25/35 .... 36 norgestimate-ethinyl estradiol (triphasic) ........... 36 NORINYL 1+35
see cyclafem 1/35 28 day ...................................... 34 see necon 1/35 28 day .. 36 see nortrel 1/35 21 day . 36 see nortrel 1/35 28 day . 36 see pirmella 1/35 28 day ...................................... 36
NORITATE ....................... 55 norlyroc 28 day ................. 36 NORMOSOL-M IN D5W ... 47 NORMOSOL-R ................. 47 NORPACE
see disopyramide phosphate ..................... 15
NORPACE CR .................. 16 NORPRAMIN
see desipramine hcl ...... 22 NOR-QD
see camila 28 day ......... 34 see deblitane 28 day ..... 34 see heather ................... 35 see norethindrone (contraceptive) .............. 36 see norlyroc 28 day ....... 36
nortrel 0.5/35 28 day ......... 36 nortrel 1/35 21 day ............ 36 nortrel 1/35 28 day ............ 36 nortrel 7/7/7 28 day ........... 36 nortriptyline hcl.................. 23 NORVASC
see amlodipine besylate 17 NORVIR .............................. 7 NOVAREL INJ 10000UNT 38
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NOVOLIN 70/30 ................31 NOVOLIN 70/30 RELION..31 NOVOLIN N ......................31 NOVOLIN N RELION ........31 NOVOLIN R ......................31 NOVOLIN R RELION ........31 NOVOLOG ........................31 NOVOLOG FLEXPEN ......31 NOVOLOG MIX 70/30 ......31 NOVOLOG MIX 70/30 PREFILL ...........................31 NOVOLOG PENFILL ........32 NOXAFIL.............................7 NPLATE ............................43 NUBAIN
see nalbuphine hcl ..........2 NUCYNTA...........................4 NUCYNTA ER .....................4 NUEDEXTA ......................29 NULOJIX ...........................45 NULYTELY/FLAVOR PACKS ..............................41
see gavilyte-n ................41 see peg 3350-potassium chloride-sod bicarbonate-sod chloride ......................................41 see trilyte .......................41
NUTRILIPID INJ 20% .......46 NUTROPIN AQ INJ 20MG/2ML ........................38 NUTROPIN AQ NUSPIN 538 NUTROPIN AQ PEN .........38 NUVARING .......................36 NUVESSA .........................43 NUVIGIL............................30 nyamyc..............................52 NYMALIZE ........................18 nystatin................................7 nystatin (mouth-throat) ......55 nystatin (topical) ................52 nystatin pow 100000 .........52 nystop ...............................52 O OCELLA TAB 3-0.03MG ...36 OCTAGAM ........................44 octreotide acetate .............38 OCUFEN
see flurbiprofen sodium . 48 OCUFLOX
see ofloxacin (ophth) ..... 48 ODOMZO .......................... 13 OFEV ................................ 50 ofloxacin (ophth) ............... 48 ofloxacin (otic) ................... 55 ogestrel 28 day ................. 36 olanzapine ........................ 25 olanzapine odt .................. 25 olopatadine hcl .................. 49 olopatadine hcl (nasal) ...... 50 OLUX
see clobetasol propionate ...................................... 53
OLUX-E see clobetasol propionate emulsion ........................ 53
OMECLAMOX-PAK .......... 41 omega-3-acid ethyl esters . 16 omeprazole ....................... 42 OMEPRAZOLE-SODIUM BICARBONATE ................ 42 OMNARIS ......................... 51 OMNITROPE 10MG ......... 38 OMNITROPE 5.8MG ........ 38 OMNITROPE 5MG ........... 38 ONCASPAR ...................... 14 ondansetron hcl ................ 39 ondansetron hcl inj ............ 39 ondansetron hcl oral soln .. 40 ondansetron odt ................ 40 ONEXTON ........................ 52 ONFI ................................. 21 ONGLYZA ......................... 33 ONMEL ............................... 7 OPANA
see oxymorphone hcl ...... 5 OPANA ER (CRUSH RESISTANT ........................ 4 OPDIVO ............................ 12 OPSUMIT ......................... 19 ORACEA ........................... 55 ORAP................................ 25
see pimozide ................. 25 ORAPRED ODT
see prednisolone sodium phosphate ..................... 38
ORAVIG ............................ 55 ORENCIA ......................... 44 ORENITRAM TAB 0.125MG.......................................... 19 ORENITRAM TAB 0.25MG.......................................... 19 ORENITRAM TAB 1MG ... 19 ORENITRAM TAB 2.5MG 19 ORFADIN ......................... 37 ORKAMBI ......................... 50 orsythia 28 day ................. 36 ORTHO MICRONOR
see errin 28 day ............ 35 see lyza ......................... 35 see sharobel 28 day ...... 36
ORTHO TRI-CYCLEN see norgestimate-ethinyl estradiol (triphasic) ........ 36 see tri-previfem 28 day .. 36 see tri-sprintec 28 day ... 36
ORTHO TRI-CYCLEN LO 36 ORTHO-CYCLEN
see estarylla tab 0.25-35 ...................................... 35 see mono-linyah tab 0.25-35 .......................... 36 see norgest/ethi tab 0.25/35 .......................... 36 see previfem 28 day ...... 36 see sprintec 28 day ....... 36
ORTHO-NOVUM 7/7/7 see cyclafem 7/7/7 28 day ...................................... 34 see nortrel 7/7/7 28 day 36
OSENI TAB 12.5-15MG .... 33 OSENI TAB 12.5-30MG .... 33 OSENI TAB 12.5-45MG .... 33 OSENI TAB 25-15MG ....... 33 OSENI TAB 25-30MG ....... 33 OSENI TAB 25-45MG ....... 33 OSMOPREP ..................... 41 OTEZLA ............................ 44 OTREXUP ........................ 44 OVCON-35
see balziva 28 day ........ 34 see briellyn 28 day ........ 34 see gildagia ................... 35 see philith ...................... 36
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see vyfemla 28 day .......36 see zenchent tab ...........36
OVIDE see malathion ................55
oxacillin sodium .................10 oxaliplatin ..........................14 OXANDRIN
see oxandrolone ............31 oxandrolone ......................31 oxaprozin ............................1 oxcarbazepine ...................21 OXISTAT...........................52 OXSORALEN ULTRA
see methoxsalen rapid ..53 OXTELLAR XR .................21 oxybutynin chloride ...........42 oxycodone hcl .....................4 OXYCODONE HCL ............4 oxycodone w/ acetaminophen 10-325mg ..5 oxycodone w/ acetaminophen 2.5-325mg .4 oxycodone w/ acetaminophen 5-325mg ....4 oxycodone w/ acetaminophen 7.5-325mg .5 oxycodone-aspirin ...............5 oxycodone-ibuprofen ..........5 OXYCONTIN .......................5 oxymorphone hcl .................5 OXYTROL .........................42 P pacerone ...........................16 paclitaxel ...........................12 paliperidone ......................25 PAMELOR
see nortriptyline hcl .......23 pamidronate disodium .......34 PAMINE
see methscopolamine bromide .........................40
PAMINE FORTE see methscopolamine bromide .........................40
PANCREAZE ....................41 PANDEL............................54 PANRETIN ........................55 pantoprazole sodium .........42
paricalcitol ......................... 47 PARICALCITOL ................ 47 PARLODEL
see bromocriptine mesylate ........................ 23
PARNATE see tranylcypromine sulfate ............................ 23
paroex sol 0.12% .............. 55 paromomycin sulfate ........... 5 paroxetine er tab ............... 23 paroxetine hcl tabs ............ 23 paser d/r .............................. 8 PATADAY ......................... 49 PATANASE
see olopatadine hcl (nasal) ...................................... 50
PATANOL ......................... 49 see olopatadine hcl ....... 49
PAXIL................................ 23 see paroxetine hcl tabs . 23
PAXIL CR see paroxetine er tab..... 23
PAZEO .............................. 49 PCE .................................. 10 PEDIAPRED
see pred sod pho sol 5mg/5ml ........................ 38
PEDVAX HIB .................... 45 PEG 3350-KCL-SOD BICARB-SOD CHLORIDE-SOD SULFATE .......................................... 41 peg 3350-potassium chloride-sod bicarbonate-sod chloride ............................. 41 PEGANONE ..................... 21 PEGASYS ........................... 8 PEGASYS PROCLICK ....... 8 PEGINTRON ...................... 8 PEG-INTRON ..................... 8 PEG-INTRON REDIPEN .... 8 PENICILLIN G POT IN DEXTROSE ...................... 11 PENICILLIN G POTASSIUM IN ...................................... 11 penicillin g procaine .......... 11 penicillin g sodium............. 11
penicillin v potassium ........ 11 penicilln gk inj 20mu ......... 11 penicilln gk inj 5mu ........... 11 PENNSAID ....................... 55 PENTAM 300 ...................... 6 PENTASA ......................... 40 pentoxifylline ..................... 43 PEPCID
see famotidine ............... 40 PERCOCET
see endocet..................... 2 see oxycodone w/ acetaminophen 10-325mg ........................................ 5 see oxycodone w/ acetaminophen 2.5-325mg ........................................ 4 see oxycodone w/ acetaminophen 5-325mg 4 see oxycodone w/ acetaminophen 7.5-325mg ........................................ 5 see roxicet tab 5-325mg .. 5
PERCODAN see oxycodone-aspirin .... 5
PERFOROMIST ............... 50 PERIDEX
see chlorhexidine gluconate (mouth-throat) ...................................... 55 see paroex sol 0.12% .... 55 see periogard soln 0.12% ...................................... 55
perindopril erbumine ......... 14 periogard soln 0.12% ........ 55 PERJETA ......................... 12 permethrin ........................ 55 perphenazine .................... 25 PERTZYE ......................... 41 PEXEVA ........................... 23 pfizerpen g inj 5mu ........... 11 pfizerpen-g inj 20mu ......... 11 phenadoz .......................... 40 phenelzine sulfate ............. 23 phenergan ........................ 40 PHENERGAN
see promethazine hcl .... 40 phenobarbital .................... 21
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phenobarbital sodium ........21 PHENOBARBITAL SODIUM ..........................................21 phenoxybenzamine hcl .....19 phenytek ...........................21 PHENYTEK
see phenytoin sodium extended........................21
phenytoin ..........................21 phenytoin inj 50mg/ml .......21 phenytoin sodium extended ..........................................21 philith ................................36 PHOSLO
see calcium acetate (phosphate binder) ........39
PHOSLYRA ......................39 PHOSPHOLINE IODIDE ...49 PICATO.............................55 PILOCARPINE HCL ..........49 pilocarpine hcl (oral) ..........55 PILOCARPINE HCL (ORAL) ..........................................55 pimozide............................25 pimtrea pack .....................36 pindolol..............................17 pioglitazone hcl .................33 pioglitazone hcl-glimepiride ..........................................33 pioglitazone hcl-metformin hcl .....................................33 piperacillin sodium-tazobactam sodium ..........................................11 pirmella 1/35 28 day ..........36 piroxicam.............................1 PLAN B ONE-STEP
see levonorgestrel (emergency oc) .............35 see next choice tab 1.5mg ......................................36
PLAQUENIL see hydroxychloroquine sulfate ............................44
PLASMA-LYTE A ..............47 PLASMA-LYTE-148 ..........47 PLASMA-LYTE-56/D5W ...47 PLAVIX
see clopidogrel bisulfate 44 PLEGRIDY ........................ 29 PLEGRIDY STARTER PACK ................................ 29 plenamine ......................... 46 podofilox ........................... 55 polyethylene glycol 3350... 41 polymyxin b sulfate ............. 6 polymyxin b-trimethoprim .. 48 POLYTRIM
see polymyxin b-trimethoprim ............... 48
POMALYST ...................... 14 PONSTEL
see mefenamic acid ........ 1 portia 28 day ..................... 36 pot chloride inj 2meq/ml .... 47 potassium chloride ............ 46 POTASSIUM CHLORIDE 46, 47 POTASSIUM CHLORIDE 0.3%/D .............................. 47 potassium chloride caps er .......................................... 46 potassium chloride in nacl . 47 POTASSIUM CHLORIDE IN NACL ................................ 47 potassium chloride microencapsulated crystals cr ....................................... 46 POTASSIUM CHLORIDE TAB CR 10 MEQ .............. 46 potassium citrate (alkalinizer) .......................................... 42 POTASSIUM CITRATE (ALKALINIZER) ................ 42 POTIGA ............................ 21 PRADAXA ......................... 43 pramipexole dihydrochloride .......................................... 24 PRANDIMET ..................... 33 PRANDIN
see repaglinide .............. 33 PRAVACHOL
see pravastatin sodium . 16 pravastatin sodium ............ 16 prazosin hcl ....................... 15 PRECOSE
see acarbose................. 32 PRED MILD ...................... 48 pred sod pho sol 5mg/5ml 38 PRED-G ............................ 48 PRED-G S.O.P. ................ 48 prednicarbate .................... 54 PREDNICARBATE ........... 54 PREDNISOLONE ACETATE (OPHTH) ........................... 48 prednisolone sodium phosphate ......................... 38 prednisolone sodium phosphate (ophth)............. 48 prednisolone sol 15mg/5ml.......................................... 38 prednisolone sol 25mg/5ml.......................................... 38 prednisolone syrup 15 mg/5ml .............................. 38 prednisone con 5mg/ml .... 38 prednisone pak 10mg ....... 38 prednisone pak 5mg ......... 38 prednisone sol 5mg/5ml .... 38 prednisone tab 10mg ........ 38 prednisone tab 1mg .......... 38 prednisone tab 2.5mg ....... 38 prednisone tab 20mg ........ 38 prednisone tab 50mg ........ 38 prednisone tab 5mg .......... 38 PREGNYL W/DILUENT BENZYL ............................ 38 PREMARIN CREAM ......... 37 PREMARIN INJ ................ 37 premasol 10% ................... 46 premasol 6% ..................... 46 PRENATAL VITAMIN/FOLIC ACID > 0.8 MG (GENERIC).......................................... 47 PREPOPIK ....................... 41 PREVACID
see lansoprazole ........... 42 PREVACID SOLUTAB ...... 42 prevalite ............................ 16 previfem 28 day ................ 36 PREVPAC
see amoxicillin-clarithromycin w/ lansoprazole ............. 41
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PREZCOBIX .......................8 PREZISTA ..........................7 PRIFTIN ..............................8 PRILOSEC ........................42
see omeprazole .............42 PRIMAQUINE PHOSPHATE ............................................7 PRIMAXIN IV
see imipenem-cilastatin ...6 primidone ..........................21 PRIMSOL SOL 50MG/5ML .6 PRINIVIL
see lisinopril ...................14 PRISTIQ............................23 PRIVIGEN .........................44 PROAIR HFA ....................50 PROAIR RESPICLICK ......50 probenecid ..........................1 PROCALAMINE ................46 PROCARDIA XL
see nifedical ..................18 see nifedipine er ............18
prochlorperazine inj 5 mg/ml ..........................................40 prochlorperazine maleate..40 prochlorperazine supp ......40 PROCRIT ..........................43 procto-pak .........................52 proctosol hc 2.5 % ............52 proctozone hc ...................53 PROCYSBI .......................37 progesterone micronized...39 PROGLYCEM SUS 50MG/ML ..........................38 PROGRAF ........................45
see tacrolimus ...............45 PROLASTIN-C ..................50 PROLENSA ......................49 PROLEUKIN .....................12 PROLIA .............................38 PROMACTA ................ 43, 44 promethazine hcl ...............40 promethegan .....................40 PROMETRIUM
see progesterone micronized .....................39
propafenone hcl ................16 propafenone hcl 12hr ........16
proparacaine hcl ............... 49 propranolol & hydrochlorothiazide ........... 17 propranolol hcl er .............. 17 propranolol inj 1mg/ml....... 17 propranolol sol .................. 17 propranolol tab .................. 17 propylthiouracil .................. 39 PROQUAD ........................ 45 PROSCAR
see finasteride ............... 42 PROSOL ........................... 46 PROTONIX ....................... 42
see pantoprazole sodium ...................................... 42
PROTOPIC see tacrolimus (topical) . 55
protriptyline hcl .................. 23 PROVENTIL HFA ............. 50 PROVERA
see medroxyprogesterone acetate .......................... 39
PROVIGIL see modafinil ................. 30
PROZAC see fluoxetine cap 10mg23 see fluoxetine cap 20mg23 see fluoxetine cap 40mg23
PROZAC WEEKLY see fluoxetine hcl........... 23
PRUDOXIN CRE 5% ........ 53 psorcon ............................. 54 PULMICORT
see budesonide (inhalation) .................... 51
PULMICORT FLEXHALER .......................................... 51 PULMICORT INH SUSP 1MG/2ML .......................... 51 PULMOZYME ................... 50 PURIXAN .......................... 12 PYLERA ............................ 41 pyrazinamide ...................... 8 pyridostigmine bromide ..... 29 Q QNASL .............................. 51 QNASL CHILDRENS ........ 51 QUADRACEL ................... 45
QUALAQUIN see quinine sulfate .......... 7
QUARTETTE .................... 36 quasense 91 day .............. 36 QUESTRAN
see cholestyramine ....... 16 QUESTRAN LIGHT
see prevalite .................. 16 quetiapine fumarate .......... 25 QUILLIVANT XR ............... 27 quinapril hcl ...................... 14 quinapril-hydrochlorothiazide.......................................... 14 quinidine gluconate ........... 16 quinidine sulfate ................ 16 quinine sulfate..................... 7 QVAR ............................... 51 R RABAVERT ...................... 45 rabeprazole sodium .......... 42 RAGWITEK ...................... 44 raloxifene hcl .................... 38 ramipril .............................. 15 RANEXA ........................... 19 ranitidine hcl ..................... 40 RAPAFLO ......................... 42 RAPAMUNE ..................... 45
see sirolimus ................. 45 RASUVO .......................... 44 RAVICTI ........................... 37 RAYOS TAB 1MG ............ 38 RAYOS TAB 2MG ............ 38 RAYOS TAB 5MG ............ 38 RAZADYNE
see galantamine hydrobromide ................ 22
RAZADYNE ER see galantamine hydrobromide er ............ 22
REBETOL ........................... 8 see ribasphere ................ 8 see ribavirin 200mg ......... 9
REBIF ............................... 29 REBIF REBIDOSE ............ 29 REBIF REBIDOSE TITRATION ....................... 29 REBIF TITRATION PACK 29 RECLAST
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see zoledronic inj 5/100ml ......................................34
reclipsen 28 day ................36 RECOMBIVAX HB ............45 RECTIV .............................55 REGLAN
see metoclopramide hcl.39 REGRANEX ......................55 RELENZA DISKHALER ......8 RELISTOR ........................41 RELPAX ............................28 REMERON
see mirtazapine .............23 REMERON SOLTAB
see mirtazapine .............23 REMICADE .......................44 REMODULIN ....................19 RENAGEL .........................39 RENVELA PAK .................39 RENVELA TAB 800MG.....39 repaglinide ........................33 repaglinide-metformin hcl ..33 REPREXAIN
see hydrocodone-ibuprofen tab 5-200mg ..........................3 see ibudone tab 5-200mg 3
reprexain tab 10-200mg ......5 REQUIP
see ropinirole hydrochloride .................24
REQUIP XL see ropinirole hydrochloride .................24
RESCRIPTOR ....................7 RESTASIS ........................49 RESTORIL
see temazepam ....... 27, 28 RETIN-A
see tretinoin ...................52 RETIN-A MICRO PUMP ...52 RETROVIR
see zidovudine ................8 RETROVIR IV INFUSION ...7 REVATIO ..........................19
see sildenafil citrate (pulmonary hypertension) ......................................19
REVIA see naltrexone hcl ......... 30
REVLIMID ......................... 44 REXULTI ........................... 25 REYATAZ ........................... 7 RHEUMATREX ................. 44 RHINOCORT AQUA
see budesonide (nasal) . 50 ribapak mis 600/day ............ 8 ribasphere ....................... 8, 9 ribasphere ribapak 1000 ..... 9 ribasphere ribapak 1200 ..... 9 ribasphere ribapak 800 ....... 9 ribavirin 200mg ................... 9 rifabutin ............................... 8 RIFADIN
see rifampin ..................... 8 rifamate ............................... 8 rifampin ............................... 8 RIFATER ............................ 8 RILUTEK
see riluzole .................... 29 riluzole .............................. 29 rimantadine hydrochloride ... 9 RINGER'S ......................... 47 RIOMET ............................ 33 risedronate sodium ........... 34 RISEDRONATE SODIUM . 34 RISPERDAL
see risperidone .............. 25 RISPERDAL INJ 12.5MG . 25 RISPERDAL INJ 25MG .... 25 RISPERDAL INJ 37.5MG . 25 RISPERDAL INJ 50MG .... 25 RISPERDAL M-TAB
see risperidone odt ........ 26 risperidone ........................ 25 risperidone odt .................. 26 RITALIN
see methylphenidate hcl 27 RITALIN LA ....................... 27
see methylphenidate hcl 27 RITUXAN .......................... 12 rivastigmine tartrate .......... 22 rivastigmine td patch 24hr 13.3 mg/24hr ..................... 22 rivastigmine td patch 24hr 4.6 mg/24hr ....................... 22
rivastigmine td patch 24hr 9.5 mg/24hr ...................... 22 rizatriptan benzoate .......... 28 ROBINUL
see glycopyrrolate ......... 40 ROBINUL FORTE
see glycopyrrolate ......... 40 ROCALTROL
see calcitriol .................. 47 ROCEPHIN
see ceftriaxone sodium ... 9 ropinirole hydrochloride .... 24 rosadan cre 0.75%............ 55 ROTARIX .......................... 45 ROTATEQ ........................ 45 ROWASA
see mesalamine enema 40 roxicet soln ......................... 5 roxicet tab 5-325mg ............ 5 ROXICODONE
see oxycodone hcl .......... 4 ROZEREM ........................ 27 RUCONEST ..................... 44 RYTARY ........................... 24 RYTHMOL
see propafenone hcl ...... 16 see propafenone hcl 12hr ...................................... 16
RYTHMOL SR see propafenone hcl ...... 16 see propafenone hcl 12hr ...................................... 16
S SABRIL ............................. 21 SAIZEN ............................. 38 SAIZEN CLICK.EASY ....... 38 SALAGEN
see pilocarpine hcl (oral) ...................................... 55
SAMSCA .......................... 38 SANCUSO ........................ 40 SANDIMMUNE
see cyclosporine ........... 44 SANDIMMUNE SOLN ...... 45 SANDOSTATIN
see octreotide acetate ... 38 SANDOSTATIN LAR DEPOT ............................. 38
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SANTYL ............................55 SAPHRIS ..........................26 SARAFEM.........................30 SAVAYSA .........................43 SAVELLA ..........................29 SAVELLA TITRATION PACK ................................29 SEASONIQUE
see amethia 91 day .......34 see ashlyna 91 day .......34 see levonorgestrel-ethinyl estradiol (91-day) ..........35
SECTRAL see acebutolol hcl ..........17
selegiline hcl .....................24 selenium sulfide ................53 SELZENTRY .......................7 SEMPREX-D .....................49 SENSIPAR ........................34 SEREVENT DISKUS ........50 SEROQUEL
see quetiapine fumarate 25 SEROQUEL XR ................26 SEROSTIM .......................38 sertraline hcl ......................23 setlakin tab ........................36 SF-ROWASA ....................41 sharobel 28 day ................36 SIGNIFOR.........................39 SIGNIFOR LAR .................39 sildenafil citrate (pulmonary hypertension) ....................19 SILENOR ..........................27 SILVER SULFADIAZINE...52 SIMBRINZA SUS 1-0.2% ..49 SIMCOR............................16 SIMPONI ...........................44 SIMPONI ARIA .................44 SIMULECT ........................45 simvastatin ........................16 SINEMET
see carbidopa-levodopa 23 SINEMET CR
see carbidopa-levodopa 23 SINGULAIR
see montelukast sodium 50 sirolimus ............................45 SIROLIMUS ......................45
SIRTURO ............................ 8 SIVEXTRO .......................... 6 SKLICE ............................. 55 SODIUM CHLORIDE .. 46, 47 SODIUM CHLORIDE 0.45% VIA .................................... 47 SODIUM CHLORIDE 0.9% .......................................... 55 SODIUM FLUORIDE CHEW; TAB; 1.1 (0.5 F) MG/ML SOLN ................................ 46 sodium phenylbutyrate ...... 37 sodium polystyrene sulfonate .......................................... 34 SOLARAZE
see diclofenac sodium (actinic keratoses) ......... 54
SOLIRIS ............................ 44 SOLODYN ........................ 11 SOLTAMOX ...................... 13 SOLU-CORTEF 1000MG . 38 SOLU-CORTEF 100MG ... 38 SOLU-CORTEF 250MG ... 38 SOLU-CORTEF 500MG ... 38 SOLU-MEDROL
see methylpr ss inj 125mg ...................................... 37 see methylpr ss inj 1gm . 37 see methylpr ss inj 40mg ...................................... 37
SOLU-MEDROL INJ 2GM 38 SOMATULINE DEPOT ..... 39 SOMAVERT ...................... 39 SOOLANTRA .................... 55 SORIATANE
see acitretin ................... 53 SORILUX .......................... 53 sorine ................................ 16 sotalol hcl .......................... 16 sotalol hcl (afib/afl) ............ 16 SOTYLIZE ........................ 17 SOVALDI ............................ 9 SPIRIVA HANDIHALER .... 49 SPIRIVA RESPIMAT ........ 49 spironolactone .................. 15 spironolactone & hydrochlorothiazide ........... 19 SPORANOX
see itraconazole .............. 7 SPORANOX SOL 10MG/ML............................................ 7 sprintec 28 day ................. 36 SPRYCEL ......................... 13 sps susp 15gm/60ml ......... 34 sronyx 28 day ................... 36 SSD .................................. 52 STARLIX
see nateglinide .............. 33 stavudine ............................ 8 STELARA ......................... 53 STERILE WATER IRRIGATION ..................... 55 STIMATE .......................... 39 STIOLTO RESPIMAT ....... 49 STIVARGA ....................... 13 STRATTERA .................... 27 streptomycin sulfate ............ 5 STRIANT .......................... 31 STRIBILD ........................... 8 STRIVERDI RESPIMAT ... 50 STROMECTOL
see ivermectin ................. 6 SUBOXONE MIS 12-3MG 30 SUBOXONE MIS 2-0.5MG.......................................... 30 SUBOXONE MIS 4-1MG .. 30 SUBOXONE MIS 8-2MG .. 30 SUBSYS ............................. 5 SUCLEAR ......................... 41 SUCRAID ......................... 41 sucralfate .......................... 41 SULAR
see nisoldipine .............. 18 sulfacet sod oin 10% op .... 48 sulfacetamide sodium (acne).......................................... 52 sulfacetamide sodium (ophth) .............................. 48 sulfacetamide sod-prednisolone .............. 48 sulfadiazine ......................... 5 sulfamethoxazole-trimethop 6 sulfamethoxazole-trimethoprim inj .................................... 6 SULFAMYLON ................. 52 sulfasalazine dr ................. 41
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sulfasalazine ir ..................41 sulindac ...............................1 SUMATRIPTAN INJ 4MG/0.5ML .......................28 sumatriptan inj 6mg/0.5ml .28 SUMATRIPTAN INJ 6MG/0.5ML .......................28 sumatriptan succinate .......28 SUMATRIPTAN SUCCINATE .....................28 SUMAVEL DOSEPRO ......28 suprax .................................9 SUPRAX .............................9
see cefixime ....................9 SUPREP BOWEL PREP...41 SURMONTIL .....................23
see trimipramine maleate ......................................23
SUSTIVA.............................8 SUTENT............................13 syeda ................................36 SYLATRON KIT 200MCG .14 SYLATRON KIT 300MCG .14 SYLATRON KIT 600MCG .14 SYLVANT..........................14 SYMBICORT .....................51 SYMLINPEN 120 ..............32 SYMLINPEN 60 ................32 SYNAGIS ..........................45 SYNALAR
see fluocinolone acetonide ................................ 53, 54
SYNAREL .........................37 SYNERA ...........................54 SYNERCID .........................6 SYNJARDY TAB 12.5-1000 ..........................................33 SYNJARDY TAB 12.5-500 33 SYNJARDY TAB 5-1000MG ..........................................33 SYNJARDY TAB 5-500MG ..........................................33 SYNRIBO ..........................14 SYNTHROID .....................39
see levothyroxine sodium ......................................39
SYPRINE ..........................34
T TABLOID .......................... 12 TACLONEX ...................... 54
see calcipotriene/betamethasone .................................. 53
tacrolimus ......................... 45 tacrolimus (topical) ............ 55 TAFINLAR ........................ 13 TAGRISSO ....................... 13 TAMIFLU ............................ 9 tamoxifen citrate ............... 13 tamsulosin hcl ................... 42 TANZEUM ........................ 32 TAPAZOLE
see methimazole ........... 39 TARCEVA ......................... 13 TARGRETIN ............... 14, 55
see bexarotene ............. 13 tarina fe 1/20 28 day ......... 36 TARKA
see trandolapril-verapamil hcl.................................. 14
TASIGNA .......................... 13 tazicef ................................. 9 tazicef vial ........................... 9 TAZORAC ......................... 53 taztia xt ............................. 18 TECFIDERA CAP 120MG 29 TECFIDERA CAP 240MG 29 TECFIDERA MIS STARTER .......................................... 29 TEFLARO ........................... 9 TEGRETOL ...................... 21
see carbamazepine ....... 20 see epitol ....................... 20
TEGRETOL-XR ................ 21 see carbamazepine ....... 20
TEKTURNA ...................... 18 TEKTURNA HCT .............. 18 telmisartan ........................ 15 telmisartan-amlodipine ...... 15 telmisartan-hydrochlorothiazide ...................................... 15 temazepam ................. 27, 28 TEMOVATE
see clobetasol propionate ...................................... 53
see cormax.................... 53 TEMOVATE E
see clobetasol e cream 0.05% ............................ 53
TENIVAC .......................... 45 TENORETIC 100
see atenolol & chlorthalidone ................ 17
TENORETIC 50 see atenolol & chlorthalidone ................ 17
TENORMIN see atenolol ................... 17
TERAZOL 3 see terconazole vaginal 43
TERAZOL 7 see terconazole vaginal 43 see zazole ..................... 43
terazosin hcl ..................... 15 terbinafine hcl ..................... 7 terbutaline sulfate ............. 50 terconazole vaginal ........... 43 TESTIM ............................ 31 testosterone cypionate ...... 31 testosterone enanthate ..... 31 TETANUS/DIPHTHERIA TOXOID ............................ 45 tetrabenazine .................... 29 TETRACYCLINE HCL ...... 11 TEVETEN HCT ................. 15 texacort ............................. 54 THALOMID ....................... 44 theo-24 ............................. 51 theophylline ...................... 51 thioridazine hcl .................. 26 thiotepa ............................. 11 thiothixene ........................ 26 THYMOGLOBULIN ........... 45 tiagabine hcl ..................... 22 TIAZAC
see diltiazem hcl er ....... 17 see diltiazem hcl extended release beads................ 17 see taztia xt ................... 18
TIKOSYN .......................... 16 timolol maleate.................. 17 timolol maleate (ophth) ..... 49 TIMOLOL MALEATE GEL 49
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TIMOPTIC see timolol maleate (ophth) ...........................49
TIMOPTIC OCUDOSE ......49 TIROSINT .........................39 TIVICAY ..............................8 tizanidine ...........................30 TOBI
see tobramycin ................5 TOBI PODHALER ...............5 TOBRADEX ......................48
see tobramycin-dexamethasone ....................................48
TOBRADEX ST .................48 tobramycin ..........................5 tobramycin (ophth) ............48 tobramycin sulfate ...............5 tobramycin-dexamethasone ..........................................48 TOBREX
see tobramycin (ophth) ..48 TOBREX OINT 0.3% ........48 TOFRANIL
see imipramine hcl ........23 TOLAK ..............................55 tolmetin sodium ...................1 tolterodine tartrate er .........42 tolterodine tartrate tab 1 mg ..........................................42 tolterodine tartrate tab 2 mg ..........................................42 TOPAMAX
see topiramate ...............22 TOPAMAX SPRINKLE
see topiramate ...............22 TOPICORT
see desoximetasone .....53 TOPICORT SPRAY 0.25% ..........................................54 topiramate .........................22 TOPIRAMATE ...................22 toposar ..............................14 topotecan hcl .....................14 TOPROL XL
see metoprolol succinate ......................................17
TORISEL...........................12
torsemide inj 50mg/5ml ..... 19 torsemide tabs .................. 19 TOUJEO SOLOSTAR ....... 32 TOVIAZ ............................. 42 TPN ELECTROLYTES ..... 46 TRACLEER ....................... 19 TRADJENTA ..................... 33 TRAMADOL HCL ................ 2 tramadol hcl er .................... 2 TRAMADOL HCL ER .......... 2 tramadol hcl er (biphasic) 100mg ................................. 2 tramadol hcl er (biphasic) 200mg ................................. 2 tramadol hcl er (biphasic) 300mg ................................. 2 tramadol hcl tab 50 mg ....... 2 tramadol-acetaminophen .... 2 trandolapril ........................ 15 trandolapril-verapamil hcl .. 14 tranexamic acid ................. 44 TRANSDERM-SCOP ........ 40 TRANXENE T
see clorazepate dipotassium ................... 20
tranylcypromine sulfate ..... 23 TRAVASOL ....................... 47 TRAVATAN Z ................... 49 trazodone hcl .................... 23 TREANDA ......................... 11 TRECATOR ........................ 8 TRELSTAR MIXJECT ....... 13 TRESIBA FLEXTOUCH .... 32 tretinoin ....................... 14, 52 TRETINOIN ...................... 52 TRETINOIN MICROSPHERE ............... 52 tretin-x ............................... 52 trexall ................................ 44 TREXIMET ........................ 28 trezix ................................... 2 triamcinolone acetonide (mouth) ............................. 55 TRIAMCINOLONE ACETONIDE (NASAL) ...... 51 triamcinolone acetonide (topical) ............................. 54 triamt/hctz cap 37.5-25 ..... 19
triamt/hctz cap 50-25mg ... 19 triamt/hctz tab 37.5-25 ...... 19 triamt/hctz tab 75-50mg .... 19 trianex ............................... 54 TRIBENZOR ..................... 15 TRICOR
see fenofibrate .............. 16 triderm .............................. 54 trifluoperazine hcl.............. 26 trifluridine .......................... 48 TRIGLIDE ......................... 17 tri-legest 28 day ................ 36 TRILEPTAL
see oxcarbazepine ........ 21 TRILIPIX
see choline fenofibrate .. 16 trilyte ................................. 41 trimethoprim ........................ 6 trimipramine maleate ........ 23 TRINESSA ........................ 36 TRI-NORINYL 28
see aranelle 28.............. 34 TRIOSTAT
see liothyronine sodium 39 tri-previfem 28 day ............ 36 TRISENOX ....................... 14 tri-sprintec 28 day ............. 36 TRIUMEQ ........................... 8 trivora 28 day .................... 36 TRIZIVIR
see abacavir sulfate-lamivudine-zidovudine ................................... 8
TROKENDI XR ................. 22 TROPHAMINE INJ 10% ... 47 trospium chloride .............. 42 trospium chloride er .......... 42 TRULICITY ....................... 32 TRUMENBA ..................... 45 TRUSOPT
see dorzolamide hcl ...... 49 TRUVADA .......................... 8 TUDORZA PRESSAIR ..... 49 TUDORZA PRESSAIR (INSTITUTIONAL PACK) .. 49 TWINRIX INJ .................... 45 TWYNSTA
see telmisartan-amlodipine
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......................................15 TYBOST..............................8 TYGACIL.............................6 TYKERB............................13 TYLENOL/CODEINE #3
see acetaminophen w/ codeine ............................1
TYLENOL/CODEINE #4 see acetaminophen w/ codeine ............................1
TYPHIM VI ........................45 TYSABRI...........................29 TYVASO ...........................19 TYZEKA ..............................9 tyzine ................................50 U UCERIS AER 2MG/ACT ...41 UCERIS TAB 9MG ............41 ULORIC ..............................1 ULTRACET
see tramadol-acetaminophen .2
ULTRAM see tramadol hcl tab 50 mg ...................................2
ULTRAM ER see tramadol hcl er ..........2
ULTRAVATE see halobetasol propionate .....................54
ULTRESA .........................41 UNASYN
see ampicillin & sulbactam sodium ...........................10
UNASYN BULK PACK see ampicillin & sulbactam sodium ...........................10
UNITHROID ......................39 URECHOLINE
see bethanechol chloride ......................................42
UROCIT-K 15 see potassium citrate (alkalinizer) ....................42
UROXATRAL see alfuzosin hcl ............42
URSO 250 see ursodiol ...................41
URSO FORTE see ursodiol ................... 41
ursodiol ............................. 41 UVADEX ........................... 14 V VAGIFEM .......................... 37 valacyclovir hcl .................... 9 VALCHLOR ...................... 55 VALCYTE ........................... 9
see valganciclovir hcl ...... 9 valganciclovir hcl ................. 9 VALIUM
see diazepam ................ 20 valproate sodium .............. 22 valproic acid ...................... 22 valsartan ........................... 15 valsartan-hydrochlorothiazide ........................................ 15 VALSTAR ......................... 12 VALTREX
see valacyclovir hcl ......... 9 VANCOCIN HCL
see vancomycin hcl ......... 6 vancomycin hcl ................... 6 vancomycin hcl inj 1000mg . 7 vancomycin hcl inj 10gm ..... 7 vancomycin hcl inj 500mg ... 7 vancomycin hcl inj 5gm ....... 7 vancomycin hcl inj 750mg ... 7 VANDAZOLE .................... 43 VANOS
see fluocinonide ............ 54 VANTAS ........................... 13 VAQTA .............................. 45 VARIVAX .......................... 45 VASCEPA ......................... 17 VASERETIC
see enalapril maleate & hydrochlorothiazide ....... 14
VASOTEC see enalapril maleate .... 14
VECTIBIX ......................... 12 VELCADE ......................... 12 VELETRI ........................... 19 velivet 28 day .................... 36 VELPHORO ...................... 39 VELTIN ............................. 52 venlafaxine cap er ............. 23
venlafaxine hcl .................. 23 VENLAFAXINE HCL ER
see venlafaxine tab er ... 23 venlafaxine tab.................. 23 VENLAFAXINE TAB 225MG ER ..................................... 23 venlafaxine tab er ............. 23 VENTAVIS ........................ 19 VENTOLIN HFA................ 50 VERAMYST ...................... 51 verapamil hcl .................... 18 VERAPAMIL HCL ............. 18 VERELAN
see verapamil hcl .......... 18 VERELAN PM
see verapamil hcl .......... 18 veripred ............................. 38 VERSACLOZ .................... 26 VESICARE ....................... 42 vestura .............................. 36 VEXOL .............................. 48 VFEND
see voriconazole ............. 7 VFEND IV
see voriconazole inj 200mg ............................. 7
VIBERZI ............................ 41 VIBRAMYCIN ................... 11
see doxycycline (monohydrate) ............... 11 see doxycycline hyclate 11
vicodin ................................ 5 vicodin es ............................ 5 vicodin hp ........................... 5 VICOPROFEN
see hydrocodone-ibuprofen tab 7.5-200 mg ...................... 3
VICTOZA .......................... 32 VIDAZA
see azacitidine .............. 12 VIDEX EC
see didanosine ................ 7 VIDEX PEDIATRIC ............. 8 vienva 28 day.................... 36 VIGAMOX ......................... 48 VIIBRYD ........................... 23 VIIBRYD STARTER PACK
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..........................................23 VIMIZIM ............................37 VIMOVO..............................1 VIMPAT.............................22 vinblastine sulfate .............12 vincasar.............................12 vincristine sulfate ..............12 vinorelbine tartrate ............12 VIOKACE 10 .....................41 VIOKACE 20 .....................41 viorele ...............................36 VIRACEPT ..........................8 VIRAMUNE
see nevirapine .................7 VIRAMUNE XR ...................8
see nevirapine .................7 VIREAD...............................8 VIROPTIC
see trifluridine ................48 VISTIDE
see cidofovir ....................8 VITEKTA .............................8 VIVELLE-DOT
see estradiol ..................37 VIVITROL..........................30 VIVLODEX ..........................1 VOGELXO ........................31 VOGELXO PUMP .............31 VOLTAREN GEL 1% ........55 voriconazole ........................7 voriconazole inj 200mg .......7 VOSPIRE ER
see albuterol sulfate er ..50 VOTRIENT ........................13 VPRIV ...............................37 vyfemla 28 day ..................36 VYTORIN ..........................17 VYVANSE .........................27 W warfarin sodium .................43 WELCHOL ........................17 WELLBUTRIN
see bupropion hcl ..........22 WELLBUTRIN SR
see bupropion hcl ..........22 WELLBUTRIN XL
see bupropion hcl ..........22 WESTCORT
see hydrocortisone valerate ......................... 54
wymzya fe ......................... 36 X XALATAN
see latanoprost .............. 49 XALKORI .......................... 13 XANAX
see alprazolam .............. 20 XARELTO ......................... 43 XARELTO STARTER PACK .......................................... 43 XARTEMIS XR ................... 5 XELJANZ .......................... 44 XENAZINE ........................ 29
see tetrabenazine .......... 29 XEOMIN INJ 100 UNIT ..... 30 XEOMIN INJ 50 UNIT ....... 30 XERESE ........................... 55 XGEVA ............................. 39 XIFAXAN TAB 200MG ........ 7 XIFAXAN TAB 550MG ...... 41 XIGDUO XR TAB 10-1000MG ....................... 34 XIGDUO XR TAB 10-500MG .......................................... 34 XIGDUO XR TAB 5-1000MG .......................................... 34 XIGDUO XR TAB 5-500MG .......................................... 33 XODOL
see hydrocodone-acetaminophen 10-300mg ................... 3 see hydrocodone-acetaminophen 5-300mg ..................... 3 see hydrocodone-acetaminophen 7.5-300mg .................. 3 see vicodin ...................... 5 see vicodin es ................. 5 see vicodin hp ................. 5
XOLAIR ............................. 50 XOPENEX
see levalbuterol hcl........ 50 XOPENEX CONCENTRATE
see levalbuterol conc
1.25mg/0.5ml ................ 50 XOPENEX HFA ................ 50 XTANDI ............................ 13 xulane dis 150-35 ............. 36 XYLOCAINE
see lidocaine hcl............ 54 see lidocaine hcl (local anesth.) ........................... 5 see lidocaine inj 1% ........ 5 see lidocaine inj 2% ........ 5
XYLOCAINE-MPF see lidocaine hcl (local anesth.) ........................... 5 see lidocaine inj 0.5% ..... 5 see lidocaine inj 1.5% ..... 5 see lidocaine inj 2% ........ 5
xylon tab 10-200mg ............ 5 XYREM ............................. 30 XYZAL
see levocetirizine soln 2.5mg/5ml ..................... 50 see levocetirizine tab 5 mg ...................................... 50
Y YASMIN 28
see drospirenone-ethinyl estradiol ........................ 35 see syeda ...................... 36 see zarah ...................... 36
YAZ see drospirenone-ethinyl estradiol ........................ 35 see loryna 28 day .......... 35 see nikki 28 day ............ 36 see vestura.................... 36
YERVOY ........................... 12 YF-VAX ............................. 45 Z zafirlukast ......................... 50 ZALTRAP ......................... 12 zamicet ............................... 5 ZANAFLEX
see tizanidine ................ 30 ZANOSAR ........................ 11 ZANTAC
see ranitidine hcl ........... 40 zarah ................................. 36 ZARONTIN
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see ethosuximide ..........20 ZAVESCA .........................37 zazole ...............................43 ZAZOLE ............................43 ZEBETA
see bisoprolol fumarate .17 ZEGERID ..........................42 ZELAPAR..........................24 ZELBORAF .......................13 ZEMAIRA ..........................50 ZEMPLAR .........................48
see paricalcitol ...............47 zenatane ...........................52 zenchent fe 28 day ............36 zenchent tab .....................36 ZENPEP............................41 ZERBAXA ...........................9 ZERIT
see stavudine ..................8 ZESTORETIC
see lisinopril & hydrochlorothiazide .......14
ZESTRIL see lisinopril ...................14
ZETIA TAB 10MG .............17 ZETONNA .........................51 ZIAC
see bisoprolol & hydrochlorothiazide .......17
ZIAGEN...............................8 see abacavir sulfate ........7
ZIANA ...............................52 zidovudine ...........................8 ZINACEF.............................9
see cefuroxime sodium....9 ZINECARD
see dexrazoxane ...........14 ZIOPTAN ..........................49 ziprasidone hcl ..................26 ZIPSOR...............................1 ZIRGAN ............................48 ZITHROMAX
see azithromycin ....... 9, 10 ZMAX ................................ 10 ZOCOR
see simvastatin ............. 16 ZOFRAN
see ondansetron hcl ...... 39 see ondansetron hcl inj . 39 see ondansetron hcl oral soln................................ 40
ZOFRAN ODT see ondansetron odt...... 40
ZOHYDRO ER (ABUSE DETERRENT) ..................... 5 ZOLADEX ......................... 13 zoledronic inj 4mg/5ml ...... 34 zoledronic inj 5/100ml ....... 34 ZOLINZA ........................... 12 zolmitriptan ....................... 28 zolmitriptan odt ................. 28 ZOLOFT
see sertraline hcl ........... 23 zolpidem tartrate ............... 28 ZOMACTON ..................... 38 ZOMETA ........................... 34
see zoledronic inj 4mg/5ml ...................................... 34
ZOMIG see zolmitriptan ............. 28
ZOMIG NASAL SPRAY .... 28 ZOMIG ZMT
see zolmitriptan odt ....... 28 ZONEGRAN
see zonisamide ............. 22 zonisamide ........................ 22 ZONTIVITY ....................... 44 ZORBTIVE ........................ 38 ZORTRESS TAB 0.25MG . 45 ZORTRESS TAB 0.5MG ... 45 ZORTRESS TAB 0.75MG . 45 ZORVOLEX ........................ 1 ZOSTAVAX ....................... 45 ZOSYN ............................. 11
see piperacillin sodium-tazobactam sodium .......................... 11
zovia 1/35e 28 day............ 36 zovia 1/50e 28 day............ 36 ZOVIRAX .......................... 55
see acyclovir ................... 8 see acyclovir topical ...... 54
ZUBSOLV SUB 1.4-0.36MG.......................................... 30 ZUBSOLV SUB 11.4-2.9MG.......................................... 30 ZUBSOLV SUB 2.9-0.71MG.......................................... 30 ZUBSOLV SUB 5.7-1.4MG.......................................... 30 ZUBSOLV SUB 8.6-2.1MG.......................................... 30 ZUPLENZ ......................... 40 ZYBAN
see buproban ................ 30 see bupropion hcl (smoking deterrent) ....... 30
ZYCLARA ......................... 55 ZYDELIG .......................... 13 ZYFLO CR ........................ 50 ZYKADIA .......................... 13 ZYLET .............................. 48 ZYLOPRIM
see allopurinol tab ........... 1 ZYMAXID
see gatifloxacin (ophth) . 48 ZYPREXA
see olanzapine .............. 25 ZYPREXA RELPREVV ..... 26 ZYPREXA RELPREVV INJ 210MG .............................. 26 ZYPREXA ZYDIS
see olanzapine odt ........ 25 ZYTIGA ............................. 13 ZYVOX ............................... 7
see linezolid .................... 6
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