USE THIS DOCUMENT TO LEARN ABOUT THE PRESCRIPTION DRUGS WE COVER IN ALL
QUALIFIED HEALTH PLANS.
Qualified Health Plans (QHP) are Affordable Care Act-compliant plans that cover essential health
benefits and follow established limits on cost-sharing. This includes HAP Personal Alliance and small
group QHPs purchased through the Health Insurance Marketplace or directly from HAP.
For more information
If you have questions about your health plan, please call a Customer Service specialist at one of the
phone numbers listed below or log in at hap.org and send us a message.
Personal Alliance QHPs
HMO Plans: (800) 759-3436
PPO Plans: (800) 944-9399
Hours: April 1 through September 30 – Monday through Friday 8 a.m. to 8 p.m. October 1 through March 31 – Monday through Friday 8 a.m. to 8 p.m.; Saturday 8 a.m. to noon
Small Group QHPs
HMO Plans: (800) 422-4641
Hours: April 1 through September 30 – Monday through Friday 8 a.m. to 7 p.m. October 1 through March 31 – Monday through Friday 8 a.m. to 7 p.m.; Saturday 8 a.m. to noon
PPO Plans: (888) 999-4347
Hours: April 1 through September 30 – Monday through Friday 8 a.m. to 5 p.m. October 1 through March 31 – Monday through Friday 8 a.m. to 5 p.m.; Saturday 8 a.m.
to noon
If you are deaf, hard of hearing or unable to speak, please call 711 for our TTY service.
A drug's formulary status may change prior to being updated in this document. The listing of
a drug does not imply coverage for all benefits. Some dosage forms or strengths of an
existing formulary drug may not be covered. Please contact us for more details.
2016 Drug Formulary for Qualified Health Plans (HAP Personal Alliance
® and
Small Group)
What is the drug formulary?
A formulary is a list of covered prescription drugs. Prescription drugs are self-administered medications
that you can obtain from pharmacies and that you use in the outpatient setting. The list of covered
prescription drugs is selected with a team of health care providers. This represents the prescription
therapies believed to be a necessary part of a quality treatment program. We will cover the drug listed
in our formulary as long as it is medically necessary, the prescription is filled at an in-network pharmacy
and other rules of the health plan are followed.
Formulary list can change over time. We may add new drugs as they are approved by the FDA and
likewise we may remove drugs as new information about safety and effectiveness is available. We may
also change the tier which reflects your cost-share for the drug. We may update our rules for coverage
meaning that we may add or remove the need for prior approval, quantity limits or criteria for coverage
(see page XX for recent formulary changes).
This list only includes “medical drugs” that are required to be obtained from HAP contracted Specialty
Pharmacy. Medical drugs are those that are administered in the doctor’s office or other health care
facility. These are generally supplied by your doctor or other health care provider. Drugs provided for
home infusion therapy are also considered medical. Please refer to your Medical Cost Share Rider for
information about your cost-sharing for Medical drugs.
The Qualified Health Plan Formulary is available at hap.org/formulary.
How do I use the drug formulary?
The formulary has a list of covered generic and brand name drugs and is organized by categories. Each
category depends on the type of medical conditions that the drugs are used to treat. For example, drugs
used to treat a heart condition are listed under the category “Cardiovascular Agents.” If you know what a
drug is used for, look for the category name in the list. Then look under the category name for the drug.
If you are not sure what category to look under, you should look for your drug in the Index that is at the
end of formulary list. The Index provides an alphabetical list of all of the drugs included in this document.
To search for a specific drug within the formulary, select Ctrl-F and enter the name of the drug in the
search box.
What is a generic substitution?
When an FDA approved generic drug is available, your prescription will be filled with the generic form of
the medication. Generic drugs contain the same active ingredients and are equivalent in strength and
dosage to the original brand name product. Generic drugs cost you and your health plan less money
than a brand name drug.
.
What are specialty drugs?
Specialty drugs are biologics or prescription drugs that require close monitoring for safety and efficacy.
For this reason we contract with Pharmacy Advantage, a specialty pharmacy, from whom you can obtain
specialty drugs. Specialty drugs require prior authorization and Pharmacy Advantage can help you and
your doctor submit a request. You or your doctor can contact Pharmacy Advantage at (800) 456-2112.
Are there any restrictions on my coverage?
Some covered drugs may have additional requirements or limits on coverage. The coverage
requirements are listed on the drug formulary. These requirements and limits may include:
Prior Authorization – Some medications on our formulary have criteria you must meet beforewe cover them. This means that you will need to get approval from us before you fill yourprescriptions for these drugs.
Step Therapy – In some cases, we require you to first try certain drugs to treat your medicalcondition before we will cover another drug for that condition. For example, if Drug A and Drug Bboth treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug Adoes not work for you, we will then cover Drug B.
Quantity Limits – Certain drugs have quantity limits. A quantity limit is the maximum quantitythat can be dispensed on each fill of medication or the maximum number of fills allowed fortreatment of certain conditions. Specialty/injectable drugs (except insulin) and select oral drugs(e.g. opioid analgesics) are limited to a maximum 30-day supply per fill. Some specialty drugsrequire a 15-day supply for the first fill.
Benefit limitations
Our drug formulary applies to drugs used in an outpatient setting. It does not include medication
administered in the doctor’s office or while in the hospital. These are known as medical drugs. Note that
some medical drugs are listed on this formulary because they are part of our Specialty Program. Please
refer to “what are specialty drug?” section for information about these medications
The following are general drug coverage exclusions that apply to all members:
• Over-the-counter (OTC) medications and their equivalents are not covered unless specified inthe formulary or on the rider
• Drug products used for cosmetic purposes are not covered• Experimental drugs and/or any drug products used in an experimental manner are not covered• Replacement of lost or stolen medication is not covered
Since the selected drug packages and coverage vary for each Qualified Health Plan, check your
Summary of Benefits and Coverage (SBC) for your cost-sharing and exclusions.
What if my drug is not on the drug formulary?
When your drug is not listed on the formulary it is considered non-formulary. You or your doctor can ask
us to make an exception and cover your drug and one of HAP clinical specialists will evaluate if the
medication will be covered by your plan. However it is best to first discuss with your doctor or pharmacist
if one of the formulary alternatives will work for you.
Exception approvals for standard non-formulary medications will process at the highest non specialty
(Tier three) copayment. Exception approvals for non-formulary specialty drugs will process at the
highest Specialty (Tier four) copayment. Non-formulary specialty drugs when approved for use by the
health plan can be required to be dispensed by Pharmacy Advantage.
How do I request prior authorization or drug formulary exception?
You or your doctor can ask us to make an exception to our requirements or limits. You may also ask us
to cover a drug not included on our formulary or ask us to exempt you from a formulary requirement
through the exception process. Your doctor must submit a request to us indicating why formulary
requirements should not apply. Your doctor may use the forms available at hap.org/mrf to send us
information when requesting either prior authorization or exception to the formulary.
What is included in the drug formulary?
The name of the covered drug is listed in the first column. Brand name drugs are capitalized (e.g., ADVAIR DISKUS) and generic drugs are listed in lower-case (e.g., gabapentin). When a generic drug is listed on the formulary, only the generic is covered.
The second column represents the drug’s cost-sharing level, or Tier. Every drug on the formulary is in
one of four cost-sharing Tiers.
The following table will translate how the four Tiers shown on the formulary are applicable to your health
plan’s prescription drug benefit. Refer to your Summary of Benefits and Coverage for your cost-
sharing information.
Description of Tier Copay
Preventive (HCR) – generic prescription preventive drugs that
are mandated by the Affordable Care Act. These are covered
at zero copay when Health Care Reform rules are met.
Tier 0
Generic – non-brand name drugs that have the lowest copay Tier 1
Preferred Brand – brand name formulary drugs that have
the lowest brand copay
Tier 2
Non-Preferred Brand – brand name formulary drugs that
are not in the Preferred Brand Tier
Tier 3
Specialty Drugs – biologics or drugs that require close
monitoring for safety and efficacy and as designated by us to
be a specialty drug
Tier 4
Medical Drugs - These are drugs that are infused or
administered in doctor’s office or facility and are covered
under the medical benefit of your plan.
Medical Coinsurance
The third column lists the Requirements/Limits that must be met for coverage of your drug. Please
refer to the abbreviations used in this column and their explanation.
The fourth column is the Comment section and may include specific information about strengths or
dosage forms that are covered.
The fifth column is the list of covered lower cost alternatives that you may be able to use.
Abbreviations for Requirements/Limits are as follows:
PA (Prior Authorization) – You or your doctor is required to get prior authorization from us before you fill your prescription for this drug. Without prior approval, we may not cover this drug.
QL (Quantity Limit) – We limit the amount of these drugs that are covered for each prescription. For example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit coverage for your prescription to no more than one pill per day.
ST (Step Therapy) – Before we will provide coverage for this drug, you must first try another drug(s) to treat your medical condition. This drug may only be covered if the other drug(s) does not work for you.
SP (Specialty Pharmacy) –This specialty drug can only be obtained from Pharmacy Advantage by calling them at (800) 456 2112.
TABLE OF CONTENTS
ANTIHISTAMINE DRUGS 1
FIRST GENERATION ANTIHISTAMINES 1
ETHANOLAMINE DERIVATIVES 1
FIRST GEN. ANTIHIST. DERIVATIVES, MISC. 1
PHENOTHIAZINE DERIVATIVES 1
PROPYLAMINE DERIVATIVES 1
SECOND GENERATION ANTIHISTAMINES 1
ANTI-INFECTIVE AGENTS 1
ANTHELMINTICS 1
ANTIBACTERIALS 2
AMINOGLYCOSIDES 2
ANTIBACTERIALS, MISCELLANEOUS 2
CEPHALOSPORINS 2
MACROLIDES 3
MISCELLANEOUS B-LACTAM ANTIBIOTICS 4
PENICILLINS 4
QUINOLONES 5
SULFONAMIDES (SYSTEMIC) 6
TETRACYCLINES 6
ANTIFUNGAL (SYSTEMIC) 7
ALLYLAMINES 7
ANTIFUNGALS, MISCELLANEOUS 7
AZOLES 7
POLYENES 7
PYRIMIDINES 8
ANTIMYCOBACTERIALS 8
ANTIMYCOBACTERIALS, MISCELLANEOUS 8
ANTITUBERCULOSIS AGENTS 8
ANTIPROTOZOALS 8
AMEBICIDES 8
ANTIMALARIALS 8
ANTIPROTOZOALS, MISCELLANEOUS 9
ANTIVIRALS (SYSTEMIC) 9
ADAMANTANES 9
ANTIRETROVIRALS 9
HCV ANTIVIRALS 12
INTERFERONS 12
MONOCLONAL ANTIBODIES 13
NEURAMINIDASE INHIBITORS 13
NUCLEOSIDES AND NUCLEOTIDES 13
URINARY ANTI-INFECTIVES 14
ANTINEOPLASTIC AGENTS 14
AUTONOMIC DRUGS 18
ANTICHOLINERGIC AGENTS 18
ANTIMUSCARINICS/ANTISPASMODICS 18
TABLE OF CONTENTS
AUTONOMIC DRUGS 18
ANTICHOLINERGIC AGENTS 18
ANTIPARKINSONIAN AGENTS 19
AUTONOMIC DRUGS, MISCELLANEOUS 19
PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS) 20
SKELETAL MUSCLE RELAXANTS 21
CENTRALLY ACTING SKELETAL MUSCLE RELAXNT 21
DIRECT-ACTING SKELETAL MUSCLE RELAXANTS 21
GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT 21
SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS 22
SYMPATHOLYTIC ADRENERGIC BLOCKING AGENTS 22
ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH) 22
SYMPATHOMIMETIC (ADRENERGIC) AGENTS 22
ALPHA- AND BETA-ADRENERGIC AGONISTS 22
ALPHA-ADRENERGIC AGONISTS 22
BETA-ADRENERGIC AGONISTS 22
BLOOD FORMATION,COAGULATION & THROMBOSIS 24
ANTIANEMIA DRUGS 24
IRON PREPARATIONS 24
ANTIHEMORRHAGIC AGENTS 25
HEMOSTATICS 25
ANTITHROMBOTIC AGENTS 27
ANTICOAGULANTS 27
PLATELET-AGGREGATION INHIBITORS 29
PLATELET-REDUCING AGENTS 29
HEMATOPOIETIC AGENTS 29
HEMORRHEOLOGIC AGENTS 31
CARDIOVASCULAR DRUGS 31
ALPHA-ADRENERGIC BLOCKING AGENTS 31
ANTILIPEMIC AGENTS 31
ANTILIPEMIC AGENTS, MISCELLANEOUS 31
BILE ACID SEQUESTRANTS 31
CHOLESTEROL ABSORPTION INHIBITORS 32
FIBRIC ACID DERIVATIVES 32
HMG-COA REDUCTASE INHIBITORS 32
BETA-ADRENERGIC BLOCKING AGENTS 33
CALCIUM-CHANNEL BLOCKING AGENTS 36
CALCIUM-CHANNEL BLOCKING AGENTS, MISC. 36
DIHYDROPYRIDINES 38
CARDIAC DRUGS 39
ANTIARRHYTHMIC AGENTS 39
CARDIAC DRUGS, MISCELLANEOUS 40
CARDIOTONIC AGENTS 40
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM 41
HYPOTENSIVE AGENTS 41
TABLE OF CONTENTS
CARDIOVASCULAR DRUGS 31
HYPOTENSIVE AGENTS 41
CENTRAL ALPHA-AGONISTS 41
DIRECT VASODILATORS 41
DIURETICS (HYPOTENSIVE AGENTS) 41
PERIPHERAL ADRENERGIC INHIBITORS 41
RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB 41
ANGIOTENSIN II RECEPTOR ANTAGONISTS 41
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS 43
MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS 44
RENIN INHIBITORS 45
VASODILATING AGENTS 45
NITRATES AND NITRITES 45
PHOSPHODIESTERASE TYPE 5 INHIBITORS 46
VASODILATING AGENTS, MISCELLANEOUS 46
CENTRAL NERVOUS SYSTEM AGENTS 46
ANALGESICS AND ANTIPYRETICS 46
ANALGESICS AND ANTIPYRETICS, MISC. 46
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS 46
OPIATE AGONISTS 49
OPIATE PARTIAL AGONISTS 54
ANOREXIGENICS AGENTS AND RESPIRATORY AND CNS 54
AMPHETAMINES 54
ANOREXIGENIC AGENTS 55
RESPIRATORY AND CNS STIMULANTS 56
WAKEFULNESS-PROMOTING AGENTS 57
ANTICONVULSANTS 57
ANTICONVULSANTS, MISCELLANEOUS 57
BARBITURATES (ANTICONVULSANTS) 62
BENZODIAZEPINES (ANTICONVULSANTS) 62
HYDANTOINS 63
SUCCINIMIDES 63
ANTIMANIC AGENTS 63
ANTIMIGRAINE AGENTS 64
SELECTIVE SEROTONIN AGONISTS 64
ANTIPARKINSONIAN AGENTS (CNS) 64
ADAMANTANES (CNS) 64
ANTICHOLINERGIC AGENTS (CNS) 65
CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB. 65
DOPAMINE PRECURSORS 65
DOPAMINE RECEPTOR AGONISTS 65
MONOAMINE OXIDASE B INHIBITORS 66
ANXIOLYTICS, SEDATIVES AND HYPNOTICS 67
ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC. 67
BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP) 67
TABLE OF CONTENTS
CENTRAL NERVOUS SYSTEM AGENTS 46
ANXIOLYTICS, SEDATIVES AND HYPNOTICS 67
BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP) 68
CENTRAL NERVOUS SYSTEM AGENTS, MISC. 69
FIBROMYALGIA AGENTS 70
OPIATE ANTAGONISTS 70
PSYCHOTHERAPEUTIC AGENTS 70
ANTIDEPRESSANTS 70
ANTIPSYCHOTIC AGENTS 75
CONTRACEPTIVES (E.G. FOAMS, DEVICES) 80
ELECTROLYTIC, CALORIC, AND WATER BALANCE 80
ALKALINIZING AGENTS 80
AMMONIA DETOXICANTS 80
DIURETICS 80
LOOP DIURETICS 80
POTASSIUM-SPARING DIURETICS 81
THIAZIDE DIURETICS 81
THIAZIDE-LIKE DIURETICS 81
VASOPRESSIN ANTAGONISTS 82
ION-REMOVING AGENTS 82
PHOSPHATE-REMOVING AGENTS 82
POTASSIUM-REMOVING AGENTS 82
REPLACEMENT PREPARATIONS 82
URICOSURIC AGENTS 84
EYE, EAR, NOSE AND THROAT (EENT) PREPS. 84
ANTIALLERGIC AGENTS 84
ANTIGLAUCOMA AGENTS 84
ALPHA-ADRENERGIC AGONISTS (EENT) 84
BETA-ADRENERGIC BLOCKING AGENTS (EENT) 85
CARBONIC ANHYDRASE INHIBITORS (EENT) 85
MIOTICS 85
PROSTAGLANDIN ANALOGS 85
ANTI-INFECTIVES (EENT) 86
ANTIBACTERIALS (EENT) 86
ANTIVIRALS (EENT) 87
EENT ANTI-INFECTIVES, MISCELLANEOUS 87
ANTI-INFLAMMATORY AGENTS (EENT) 87
CORTICOSTEROIDS (EENT) 87
EENT NONSTEROIDAL ANTI-INFLAM. AGENTS 88
EENT DRUGS, MISCELLANEOUS 88
LOCAL ANESTHETICS (EENT) 89
MYDRIATICS 89
VASOCONSTRICTORS 89
GASTROINTESTINAL DRUGS 90
ANTIDIARRHEA AGENTS 90
TABLE OF CONTENTS
GASTROINTESTINAL DRUGS 90
ANTIEMETICS 90
5-HT3 RECEPTOR ANTAGONISTS 90
ANTIEMETICS, MISCELLANEOUS 90
ANTIHISTAMINES (GI DRUGS) 91
ANTI-INFLAMMATORY AGENTS (GI DRUGS) 91
ANTIULCER AGENTS AND ACID SUPPRESSANTS 91
HISTAMINE H2-ANTAGONISTS 91
PROSTAGLANDINS 92
PROTECTANTS 92
PROTON-PUMP INHIBITORS 92
CATHARTICS AND LAXATIVES 92
CHOLELITHOLYTIC AGENTS 93
DIGESTANTS 93
GI DRUGS, MISCELLANEOUS 93
PROKINETIC AGENTS 94
GOLD COMPOUNDS 94
HEAVY METAL ANTAGONISTS 94
HORMONES AND SYNTHETIC SUBSTITUTES 94
ADRENALS 94
ANDROGENS 96
ANTIDIABETIC AGENTS 97
ALPHA-GLUCOSIDASE INHIBITORS 97
AMYLINOMIMETICS 97
ANTIDIABETIC AGENTS, MISCELLANEOUS 97
BIGUANIDES 97
DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS 97
INCRETIN MIMETICS 98
INSULINS 98
MEGLITINIDES 99
SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBITORS 99
SULFONYLUREAS 99
THIAZOLIDINEDIONES 100
ANTIHYPOGLYCEMIC AGENTS 101
ANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS 101
GLYCOGENOLYTIC AGENTS 101
CONTRACEPTIVES 101
ESTROGENS AND ANTIESTROGENS 106
ESTROGEN AGONIST-ANTAGONISTS 106
ESTROGENS 106
GONADOTROPINS 108
PARATHYROID 108
PITUITARY 108
PROGESTINS 109
SOMATOSTATIN AGONISTS AND ANTAGONISTS 109
TABLE OF CONTENTS
HORMONES AND SYNTHETIC SUBSTITUTES 94
SOMATOSTATIN AGONISTS AND ANTAGONISTS 109
SOMATOSTATIN AGONISTS 109
SOMATOTROPIN AGONISTS AND ANTAGONISTS 109
SOMATOTROPIN AGONISTS 109
SOMATOTROPIN ANTAGONISTS 109
THYROID AND ANTITHYROID AGENTS 110
ANTITHYROID AGENTS 110
THYROID AGENTS 110
LOCAL ANESTHETICS (PARENTERAL) 113
MISCELLANEOUS THERAPEUTIC AGENTS 113
5-ALPHA-REDUCTASE INHIBITORS 113
ALCOHOL DETERRENTS 114
ANTIDOTES 114
ANTIGOUT AGENTS 114
BIOLOGIC RESPONSE MODIFIERS 114
BONE RESORPTION INHIBITORS 115
CARIOSTATIC AGENTS 115
COMPLEMENT INHIBITORS 115
DISEASE-MODIFYING ANTIRHEUMATIC AGENTS 116
GONADOTROPIN-RELEASING HORMONE ANTAGNTS 117
IMMUNOSUPPRESSIVE AGENTS 117
OTHER MISCELLANEOUS THERAPEUTIC AGENTS 118
RESPIRATORY TRACT AGENTS 118
ANTIFIBROTIC AGENTS 118
ANTI-INFLAMMATORY AGENTS (RESPIRATORY) 118
LEUKOTRIENE MODIFIERS 118
MAST-CELL STABILIZERS 118
ANTITUSSIVES 118
CYSTIC FIBROSIS (CFTR) MODULATORS 119
CYSTIC FIBROSIS (CFTR) POTENTIATORS 119
MUCOLYTIC AGENTS 119
PHOSPHODIESTERASE TYPE 4 INHIBITORS 119
RESPIRATORY TRACT AGENTS, MISCELLANEOUS 119
VASODILATING AGENTS (RESPIRATORY TRACT) 119
SERUMS, TOXOIDS, AND VACCINES 120
SERUMS 120
TOXOIDS 121
VACCINES 121
SKIN AND MUCOUS MEMBRANE AGENTS 122
ANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE) 122
ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE) 122
ANTIFUNGALS (SKIN & MUCOUS MEMBRANE) 123
ANTIVIRALS (SKIN & MUCOUS MEMBRANE) 124
LOCAL ANTI-INFECTIVES, MISCELLANEOUS 125
TABLE OF CONTENTS
SKIN AND MUCOUS MEMBRANE AGENTS 122
ANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE) 122
SCABICIDES AND PEDICULICIDES 126
ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS) 126
ANTIPRURITICS AND LOCAL ANESTHETICS 129
ASTRINGENTS 131
CELL STIMULANTS AND PROLIFERANTS 131
DEPIGMENTING AND PIGMENTING AGENTS 131
PIGMENTING AGENTS 131
EMOLLIENTS, DEMULCENTS, AND PROTECTANTS 131
BASIC LOTIONS AND LINIMENTS 131
KERATOLYTIC AGENTS 131
SKIN AND MUCOUS MEMBRANE AGENTS, MISC. 132
SMOOTH MUSCLE RELAXANTS 133
GENITOURINARY SMOOTH MUSCLE RELAXANTS 133
ANTIMUSCARINICS 133
BETA-3-ADRENERGIC AGONISTS 134
RESPIRATORY SMOOTH MUSCLE RELAXANTS 134
VITAMINS 134
MULTIVITAMIN PREPARATIONS 134
VITAMIN B COMPLEX 135
VITAMIN D 135
Drug Name Tier Requirements/Limits
AlternativesComments
ANTIHISTAMINE DRUGSFIRST GENERATION ANTIHISTAMINES
ETHANOLAMINE DERIVATIVES
T1clemastine syp 0.5/5ml
T1clemastine tab 2.68mg
FIRST GEN. ANTIHIST. DERIVATIVES, MISC.
T1cyproheptad syp 2mg/5ml
T1cyproheptad tab 4mg
PHENOTHIAZINE DERIVATIVES
T1phenadoz sup 25mg (promethazine)
T1phenergan sup 25mg (promethazine)
T1phenergan sup 50mg (promethazine)
T1 QLprometh vc syp 6.25-5/5 (promethazine)
T1 QLprometh vc syp plain (promethazine)
T1 QLprometh/pe syp 6.25-5/5
T1promethazine sol 6.25/5ml
T1promethazine sup 25mg
T1promethazine sup 50mg
T1promethazine syp 6.25/5ml
T1promethazine tab 12.5mg
T1promethazine tab 25mg
T1promethazine tab 50mg
T1promethegan sup 25mg (promethazine)
T1promethegan sup 50mg (promethazine)
PROPYLAMINE DERIVATIVES
T1dexchlorphen syp 2mg/5ml
SECOND GENERATION ANTIHISTAMINES
T1desloratadin tab 5mg
T1levocetirizi sol 2.5/5ml
T1levocetirizi tab 5mg
ANTI-INFECTIVE AGENTSANTHELMINTICS
T3ALBENZA TAB 200MG (albendazole)
1Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIBACTERIALS
AMINOGLYCOSIDES
T1neomycin tab 500mg
T4 PA, QL (2 nebulizers/day)tobramycin neb 300/5ml
ANTIBACTERIALS, MISCELLANEOUS
T1baciim inj 50000unt (bacitracin)
T1bacitracin inj 50000unt
T1clindamycin cap 150mg
T1clindamycin cap 300mg
T1
T1
T1
T1
T1
QL (28 tabs/14 days)
QL (112 caps/14 days)
QL (112 caps/14 days)
T2
T2
T3
T3
T3
PA
PA
QL (840ml/14 days)
clindamycin cap 75mg
clindamycin sol 75mg/5ml
linezolid tab 600mg
vancomycin cap 125mg
vancomycin cap 250mg
VANCOMYCN 25 SOL 25MG/ML (vancomycin)
VANCOMYCN 50 SOL 50MG/ML (vancomycin)
XIFAXAN TAB 200MG (rifaximin)
XIFAXAN TAB 550MG (rifaximin)
ZYVOX SUS 100MG/5M (linezolid)
CEPHALOSPORINS
T2CEDAX CAP 400MG (ceftibuten)
T1cefaclor cap 250mg
T1cefaclor cap 500mg
T1cefaclor er tab 500mg
T1cefadroxil cap 500mg
T1cefadroxil sus 250/5ml
T1cefadroxil sus 500/5ml
T1cefadroxil tab 1gm
T1cefdinir cap 300mg
T1cefdinir sus 125/5ml
T1cefdinir sus 250/5ml
T1cefditoren tab 200mg
T1cefditoren tab 400mg
2Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIBACTERIALS
CEPHALOSPORINS
T1cefixime sus 100/5ml
T1cefixime sus 200/5ml
T1cefpodo prox sus 100/5ml
T1cefpodo prox sus 50mg/5ml
T1cefpodoxime tab 100mg
T1cefpodoxime tab 200mg
T1cefprozil sus 125/5ml
T1cefprozil sus 250/5ml
T1cefprozil tab 250mg
T1cefprozil tab 500mg
T1cefuroxime tab 250mg
T1cefuroxime tab 500mg
T1cephalexin cap 250mg
T1cephalexin cap 500mg
T1cephalexin cap 750mg
T1cephalexin sus 125/5ml
T1cephalexin sus 250/5ml
T3
T3
SUPRAX SUS 500/5ML (cefixime)
SUPRAX TAB 400MG (cefixime)
MACROLIDES
T1 QLazithromycin pow 1gm pak
T1 QL (120 ml/fill)azithromycin sus 100/5ml
T1 QL (120 ml/fill)azithromycin sus 200/5ml
T1 QL (8/5 days)azithromycin tab 250mg
T1 QL (8/5 days)azithromycin tab 500mg
T1 QL (8/5 days)azithromycin tab 600mg
T1clarithromyc sus 125/5ml
T1clarithromyc sus 250/5ml
T1clarithromyc tab 250mg
3Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIBACTERIALS
MACROLIDES
T1clarithromyc tab 500mg
T1clarithromyc tab 500mg er
T3 QL (20/10 days)DIFICID TAB 200MG (fidaxomicin)
T1e.e.s. 400 tab 400mg (erythromycin)
T2E.E.S. GRAN SUS 200/5ML (erythromycin)
T2ERYPED SUS 200/5ML (erythromycin)
T2ERYPED SUS 400/5ML (erythromycin)
T1erythrom eth tab 400mg
T1erythromycin tab 250mg bs
T1erythromycin tab 500mg bs
T3 QL (20 tabs/10 days)KETEK TAB 300MG (telithromycin)
T3 QL (20 tabs/10 days)KETEK TAB 400MG (telithromycin)
T2PCE TAB 333MG EC (erythromycin)
T2PCE TAB 500MG EC (erythromycin)
MISCELLANEOUS B-LACTAM ANTIBIOTICS
T4 PA, QL (1 kit/28 days)CAYSTON INH 75MG (aztreonam)
PENICILLINS
T1amox/k clav chw 200mg
T1amox/k clav chw 400mg
T1amox/k clav sus 200/5ml
T1amox/k clav sus 250/5ml
T1amox/k clav sus 400/5ml
T1amox/k clav sus 600/5ml
T1amox/k clav tab 250mg
T1amox/k clav tab 500mg
T1amox/k clav tab 875mg
T1amoxicillin cap 250mg
T1amoxicillin cap 500mg
T1amoxicillin chw 125mg
T1amoxicillin chw 250mg
T1amoxicillin sus 125/5ml
T1amoxicillin sus 200/5ml
4Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIBACTERIALS
PENICILLINS
T1amoxicillin sus 250/5ml
T1amoxicillin sus 250mg/5m
T1amoxicillin sus 400/5ml
T1amoxicillin tab 500mg
T1amoxicillin tab 875mg
T1amox-pot cla tab er
T1ampicillin cap 250mg
T1ampicillin cap 500mg
T1ampicillin sus 125/5ml
T1ampicillin sus 250/5ml
T1dicloxacill cap 250mg
T1dicloxacill cap 500mg
T1penicilln vk sol 125/5ml
T1penicilln vk sol 250/5ml
T1penicilln vk tab 250mg
T1penicilln vk tab 500mg
QUINOLONES
T1ciprofloxacn sus 250mg/5
T1ciprofloxacn sus 500mg/5
T1 QL (14 tabs/Rx)ciprofloxacn tab 1000mg
T1ciprofloxacn tab 100mg
T1ciprofloxacn tab 250mg
T1ciprofloxacn tab 500mg
T1 QL (14 tabs/Rx)ciprofloxacn tab 500mg er
T1ciprofloxacn tab 750mg
T3 QL (7 tabs/7 days)FACTIVE TAB 320MG (gemifloxacin)
T1levofloxacin inj 25mg/ml
T1levofloxacin sol 25mg/ml
T1levofloxacin tab 250mg
T1levofloxacin tab 500mg
T1levofloxacin tab 750mg
5Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIBACTERIALS
QUINOLONES
T1 QL (14 tabs/Rx)moxifloxacin tab 400mg
T3 QL (56 tabs/28 days)NOROXIN TAB 400MG (norfloxacin)
T1ofloxacin tab 200mg
T1ofloxacin tab 300mg
T1ofloxacin tab 400mg
SULFONAMIDES (SYSTEMIC)
T1smz/tmp ds tab 800-160
T1smz-tmp sus 200-40/5
T1smz-tmp tab 400-80mg
T1smz-tmp ds tab 800-160 (sulfamethoxazole-trimethoprim)
T1sulfadiazine tab 500mg
T1sulfasalazin tab 500mg
T1sulfasalazin tab 500mg dr
T1sulfatrim pd sus 200-40/5 (sulfamethoxazole-trimethoprim)
T1sulfazine tab 500mg (sulfasalazine)
T1sulfazine ec tab 500mg (sulfasalazine)
TETRACYCLINES
T1demeclocycl tab 150mg
T1demeclocycl tab 300mg
T1doxycyc mono cap 100mg
T1doxycycl hyc cap 100mg
T1 QL (90 caps/30 days)doxycycl hyc cap 50mg
T1 QL (90 caps/30 days)doxycycl hyc tab 100mg
T1minocycline cap 100mg
T1minocycline cap 50mg
T1minocycline cap 75mg
T1minocycline tab 100mg
T1minocycline tab 50mg
T1minocycline tab 75mg
T1tetracycline cap 250mg
6Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIBACTERIALS
TETRACYCLINES
T1tetracycline cap 500mg
ANTIFUNGAL (SYSTEMIC)ALLYLAMINES
T1terbinafine tab 250mg
ANTIFUNGALS, MISCELLANEOUS
T1griseofulvin sus 125/5ml
T1griseofulvin tab micr 500
T1griseofulvin tab ultr 125
T1griseofulvin tab ultr 250
AZOLES
T1fluconazole sus 10mg/ml
T1fluconazole sus 40mg/ml
T1fluconazole tab 100mg
T1fluconazole tab 150mg
T1fluconazole tab 200mg
T1fluconazole tab 50mg
T1itraconazole cap 100mg
T1ketoconazole tab 200mg
T3 QL (2 bottles/fill)NOXAFIL SUS 40MG/ML (posaconazole)
T3SPORANOX SOL 10MG/ML (itraconazole)
T1 PAvoriconazole tab 200mg
T1 PAvoriconazole tab 50mg
POLYENES
T1nystatin pow
T1nystatin pow 10bu
T1nystatin pow 150mu
T1nystatin pow 1bu
T1nystatin pow 2bu
T1nystatin pow 500mu
T1nystatin pow 50mu
T1nystatin pow 5bu
T1nystatin sus 100000
7Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIFUNGAL (SYSTEMIC)
POLYENES
T1nystatin tab 500000
PYRIMIDINES
T1flucytosine cap 250mg
T1flucytosine cap 500mg
ANTIMYCOBACTERIALSANTIMYCOBACTERIALS, MISCELLANEOUS
T1dapsone tab 100mg
T1dapsone tab 25mg
ANTITUBERCULOSIS AGENTS
T1cycloserine cap 250mg
T1ethambutol tab 100mg
T1ethambutol tab 400mg
T1isoniazid syp 50mg/5ml
T1isoniazid tab 100mg
T1isoniazid tab 300mg
T1pyrazinamide tab 500mg
T1rifabutin cap 150mg
T2RIFAMATE CAP (isoniazid)
T1rifampin cap 150mg
T1rifampin cap 300mg
T1rifampin inj 600 mg
T4 PASIRTURO TAB 100MG (bedaquiline)
ANTIPROTOZOALSAMEBICIDES
T1paromomycin cap 250mg
ANTIMALARIALS
T1 QLatovaq/progu tab 250-100
T1 QLatovaq/progu tab 62.5-25
T1chloroquine tab 250mg
T1chloroquine tab 500mg
T3 QL (24 tabs/fill)COARTEM TAB 20-120MG (artemether-lumefantrine)
8Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Only covered for treatment
Only covered for treatment
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIPROTOZOALS
ANTIMALARIALS
T3 QL (90 tabs/30 days)DARAPRIM TAB 25MG (pyrimethamine)
T1hydroxychlor tab 200mg
T1 QL (5 tabs/30 days)mefloquine tab 250mg
T2primaquine tab 26.3mg
ANTIPROTOZOALS, MISCELLANEOUS
T3 QL (150ml/3 days)ALINIA SUS 100/5ML (nitazoxanide)
T3 QL (6 tabs/3 days)ALINIA TAB 500MG (nitazoxanide)
T1atovaquone sus 750/5ml
T1metronidazol cap 375mg
T1metronidazol tab 250mg
T1metronidazol tab 500mg
T3 PANEBUPENT INH 300MG (pentamidine)
T1tinidazole tab 250mg
T1tinidazole tab 500mg
ANTIVIRALS (SYSTEMIC)ADAMANTANES
T1rimantadine tab 100mg
ANTIRETROVIRALS
T4abacav/lamiv tab /zidovud
T4 QL (60 tabs/30 days)abacavir tab 300mg
T4APTIVUS CAP 250MG (tipranavir)
T4APTIVUS SOL (tipranavir)
T4 QL (30 tabs/30 days)ATRIPLA TAB (efavirenz-emtricitabine-tenofovir)
T4 QL (30 tabs/30 days)COMPLERA TAB (emtricitabine-rilpivirine-tenofovir)
T4 QL (180 caps/30 days)CRIXIVAN CAP 200MG (indinavir)
T4 QL (180 caps/30 days)CRIXIVAN CAP 400MG (indinavir)
T4CRIXIVAN 100 MG CAPSULE (INDINAVIR)
T4 QL (60 caps/30 day)didanosine cap 125mg
T4 QL (60 caps/30 day)didanosine cap 200mg
T4 QL (60 caps/30 day)didanosine cap 250mg
T4 QL (60 caps/30 day)didanosine cap 400mg
9Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Only covered for treatment
Only covered for treatment
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIVIRALS (SYSTEMIC)
ANTIRETROVIRALS
T4EDURANT TAB 25MG (rilpivirine)
T4EMTRIVA CAP 200MG (emtricitabine)
T4EMTRIVA SOL 10MG/ML (emtricitabine)
T4EPIVIR HBV SOL 5MG/ML (lamivudine)
T4EPZICOM TAB (abacavir)
T4
QL (30 tabs/30 days)
QL (60 caps/30 days)
QL (680ml/23 days)
PA, SP
QL (30 tabs/30 days)
QL (30 tabs/30 days)EPZICOM TAB 600-300 (abacavir)
T4 PAFUZEON INJ 90MG (enfuvirtide)
T4 PAFUZEON CONVENIENCE KIT (ENFUVIRTIDE)
T4 QL (60 tabs/30 days)INTELENCE TAB 100MG (etravirine)
T4 QL (60 tabs/30 days)INTELENCE TAB 200MG (etravirine)
T4 QLINTELENCE TAB 25MG (etravirine)
T4 QL (60 tabs/30 days)ISENTRESS TAB 400MG (raltegravir)
T4 QL (640ml/23 days)KALETRA SOL (lopinavir-ritonavir)
T4 QL (60 tabs/30 days)KALETRA TAB 100-25MG (lopinavir-ritonavir)
T4 QL (60 tabs/30 days)KALETRA TAB 200-50MG (lopinavir-ritonavir)
T4 QL (60 tab/30 day)lamivud/zido tab 150-300
T4lamivudine sol 10mg/ml
T4 PA, SPlamivudine tab 100mg
T4lamivudine tab 150mg
T4lamivudine tab 300mg
T4 QL (1800ml/30 days)LEXIVA SUS 50MG/ML (fosamprenavir)
T4 QL (120 tabs/30 days)LEXIVA TAB 700MG (fosamprenavir)
T4nevirapine sus 50mg/5ml
T4 QL (60 tab/30 day)nevirapine tab 200mg
T4 QL (30 TABS/30 DAYS)nevirapine tab 400mg er
T4 QL (60 caps/30 days)NORVIR CAP 100MG (ritonavir)
T4 QL (240 ml/30 day)NORVIR SOL 80MG/ML (ritonavir)
T4 QL (60 tabs/30 days)NORVIR TAB 100MG (ritonavir)
T4 QL (60 tabs/30 days)PREZISTA TAB 150MG (darunavir)
T4 QL (60 tabs/30 days)PREZISTA TAB 400MG (darunavir)
T4 QL (60 tabs/30 days)PREZISTA TAB 600MG (darunavir)
10Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIVIRALS (SYSTEMIC)
ANTIRETROVIRALS
T4 QL (60 tabs/30 days)PREZISTA TAB 75MG (darunavir)
T4 QL (60 tabs/30 days)PREZISTA TAB 800MG (darunavir)
T4 QL (180 tabs/30 days)RESCRIPTOR TAB 100 MG (delavirdine)
T4 QL (180 tabs/30 days)RESCRIPTOR TAB 200MG (delavirdine)
T4 QL (30 caps/30 days)REYATAZ CAP 100MG (atazanavir)
T4 QL (30 caps/30 days)REYATAZ CAP 150MG (atazanavir)
T4 QL (30 caps/30 days)REYATAZ CAP 200MG (atazanavir)
T4 QL (30 caps/30 days)REYATAZ CAP 300MG (atazanavir)
T4 QL (60 tabs/30 days)SELZENTRY TAB 150MG (maraviroc)
T4 QL (60 tabs/30 days)SELZENTRY TAB 300MG (maraviroc)
T4 QL (60 caps/30 day)stavudine cap 15mg
T4 QL (60 caps/30 day)stavudine cap 20mg
T4 QL (60 caps/30 day)stavudine cap 30mg
T4 QL (60 caps/30 day)stavudine cap 40mg
T4 QL (60 caps/30 day)
T4 QL (30 tabs/30 days)
T4 QL (30 caps/30 days)
T4 QL (30 caps/30 days)
T4 QL (30 tabs/30 days)
T4
T4
T4
T4
T4
T4
T4
T4
QL (60 TABS/30 DAYS)
PA, QL (30 tabs/30 days)
QL (800ml/30 days)
QL (800ml/30 days)
QL (120 tabs/30 days)
QL (120 tabs/30 days)
QL (480 ml /30 day)
QL (30 tabs/30 days)
T4
T4 QL (30 tabs/30 days)
T4 QL (30 tabs/30 days)
stavudine sol 1mg/ml
STRIBILD TAB (elvitegravir-cobicistat-
emtricitabine-tenofovir)
SUSTIVA CAP 200MG (efavirenz)
SUSTIVA CAP 50MG (efavirenz)
SUSTIVA TAB 600MG (efavirenz)
TIVICAY TAB 50MG (dolutegravir)
TRUVADA TAB 200-300 (emtricitabine-tenofovir)
VIDEX SOL 2GM (didanosine)
VIDEX SOL 4GM (didanosine)
VIRACEPT TAB 250MG (nelfinavir)
VIRACEPT TAB 625MG (nelfinavir)
VIRAMUNE SUS 50MG/5ML (nevirapine)
VIRAMUNE XR TAB 100MG (nevirapine) VIREAD
POW 40MG/GM (tenofovir)
VIREAD TAB 150MG (tenofovir)
VIREAD TAB 200MG (tenofovir)
11Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
PA reqyured fior HIV prophylaxis
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIVIRALS (SYSTEMIC)
ANTIRETROVIRALS
T4 QL (30 tabs/30 days)VIREAD TAB 250MG (tenofovir)
T4 QL (30 tabs/30 days)VIREAD TAB 300MG (tenofovir)
T4 QL (480ml/30 days)ZIAGEN SOL 20MG/ML (abacavir)
T4 QL (60 caps/30 day)zidovudine cap 100mg
T4 QL (480ml/30 day)zidovudine syp 50mg/5ml
T4 QL (60 tab/30 day)zidovudine tab 300mg
T4 PA, SP
T4 PA, SP
T4 PA, SP
HCV ANTIVIRALS
HARVONI TAB 90-400MG (ledipasvir-sofosbuvir)
SOVALDI TAB 400MG (sofosbuvir)
ZEPATIER 50MG-100MG TAB (Eelbasvir-grazoprevir)
INTERFERONS
T4 PAINFERGEN INJ 15MCG (interferon)
T4 PAINFERGEN INJ 9MCG (interferon)
T4 PA, SPPEGASYS 180 MCG/0.5 ML CONV.PK (PEGINTERFERON)
T4 PA, SPPEGINTRON KIT 120MCG (peginterferon)
T4 PA, SPPEGINTRON KIT 150MCG (peginterferon)
T4 PA, SPPEGINTRON KIT 50MCG (peginterferon)
T4 PA, SPPEGINTRON KIT 80MCG (peginterferon)
T4 PA, SPPEG-INTRON KIT 120 RP (peginterferon)
T4 PA, SPPEG-INTRON KIT 120MCG (peginterferon)
T4 PA, SPPEG-INTRON KIT 150 RP (peginterferon)
T4 PA, SPPEG-INTRON KIT 150MCG (peginterferon)
T4 PA, SPPEG-INTRON KIT 50MCG (peginterferon)
T4 PA, SPPEG-INTRON KIT 50MCG RP (peginterferon)
T4 PA, SPPEG-INTRON KIT 80MCG (peginterferon)
T4 PA, SPPEG-INTRON KIT 80MCG RP (peginterferon)
12Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIVIRALS (SYSTEMIC)
MONOCLONAL ANTIBODIES
MED PA, SP Medical coinsuranceSYNAGIS INJ 50MG (palivizumab)
NEURAMINIDASE INHIBITORS
T3 QL (20 inhalations/fill; 2 fills/365 days)
RELENZA AER DISKHALE (zanamivir)
T3 QL (20 inhalations/fill; 2 fills/365 days)
RELENZA MIS DISKHALE (zanamivir)
T3 QL (10 caps/fill; 2 fills/365 days)TAMIFLU CAP 30MG (oseltamivir)
T3 QL (10 caps/fill; 2 fills/365 days)TAMIFLU CAP 45MG (oseltamivir)
T3 QL (10 caps/fill; 2 fills/365 days)TAMIFLU CAP 75MG (oseltamivir)
T3 QL (120ml/fill; 2 fills/365 days)TAMIFLU SUS 6MG/ML (oseltamivir)
NUCLEOSIDES AND NUCLEOTIDES
T1acyclovir cap 200mg
T1acyclovir sus 200/5ml
T1acyclovir tab 400mg
T1acyclovir tab 800mg
T4 PA, SPadefov dipiv tab 10mg
T4 PA, SPBARACLUDE SOL .05MG/ML (entecavir)
T4 PA, SPentecavir tab 0.5mg
T4 PA, SPentecavir tab 1mg
T1famciclovir tab 125mg
T1famciclovir tab 250mg
T1famciclovir tab 500mg
T1ganciclovir cap 250 mg
T1 PA, SPmoderiba tab 200mg (ribavirin)
T1 PA, SP ribapak pak 1200/day (ribavirin)
T1 PA, SPribapak pak 800/day (ribavirin)
T1 PA, SPribasphere cap 200mg (ribavirin)
T1 PA, SPribasphere tab 200mg (ribavirin)
T1 PA, SPribasphere tab 400mg (ribavirin)
T1 PA, SPribasphere tab 600mg (ribavirin)
T1 PA, SPribatab pak 1000/day (ribavirin)
T1 PA, SPribatab tab 1200/day (ribavirin)
13Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTI-INFECTIVE AGENTSANTIVIRALS (SYSTEMIC)
T1 PA, SP
T1 PA, SP
T1 PA, SP
T4 PA, SP
T1
T1
T1
QL (30 tabs/30 days)
QL (30 tabs/30 days)
PA
NUCLEOSIDES AND NUCLEOTIDES
ribatab tab 800/day (ribavirin)
ribavirin cap 200mg
ribavirin tab 200mg
TYZEKA TAB 600MG (telbivudine)
valacyclovir tab 1gm
valacyclovir tab 500mg
valganciclov tab 450mg
URINARY ANTI-INFECTIVES
T1 QLhyophen tab (methenamine-hyosc-methylene)
T1methenam hip tab 1gm
T3 PA, QL (3 packs/fill)MONUROL PAK GRANULES (fosfomycin)
T1nitrofur mac cap 100mg
T1nitrofur mac cap 50mg
T1nitrofurantn cap 100mg
T1nitrofurantn sus 25mg/5ml
T1nitrofuranto cap 100mg
T1trimethoprim tab 100mg
ANTINEOPLASTIC AGENTS
T4 PA, SPAFINITOR TAB 10MG (everolimus)
T4 PA, SPAFINITOR TAB 2.5MG (everolimus)
T4 PA, SPAFINITOR TAB 5MG (everolimus)
T4 PA, SPAFINITOR TAB 7.5MG (everolimus)
T4ALKERAN TAB 2MG (melphalan)
T1anastrozole tab 1mg
T4 PA, SPbexarotene cap 75mg
T1bicalutamide tab 50mg
T4 PA, SPBOSULIF TAB 100MG (bosutinib)
T4 PA, SPBOSULIF TAB 500MG (bosutinib)
T4 PA, SPcapecitabine tab 150mg
T4 PA, SPcapecitabine tab 500mg
14Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTINEOPLASTIC AGENTS
T4 PACAPRELSA TAB 100MG (vandetanib)
T4 PACAPRELSA TAB 300MG (vandetanib)
T4 PACOMETRIQ KIT 100MG (cabozantinib)
T4 PACOMETRIQ KIT 140MG (cabozantinib)
T4 PACOMETRIQ KIT 60MG (cabozantinib)
T1cyclophosph cap 25mg
T1cyclophosph tab 25mg
T1cyclophosph tab 50mg
T2DROXIA CAP 200MG (hydroxyurea)
T2DROXIA CAP 300MG (hydroxyurea)
T2DROXIA CAP 400MG (hydroxyurea)
T2EMCYT CAP 140MG (estramustine)
T4 PA, SP
T1
T1
T2
T1
T1
T4 PA, SP
T4 PA, SP
T4 PA, SP
T1 PA, SP
T1 PA, SP
T2
ERIVEDGE CAP 150MG (vismodegib)
etoposide cap 50mg
exemestane tab 25mg
FARESTON TAB 60MG (toremifene)
floxuridine inj 0.5gm
flutamide cap 125mg
GILOTRIF TAB 20MG (afatinib)
GILOTRIF TAB 30MG (afatinib)
GILOTRIF TAB 40MG (afatinib)
imatinib tab 100mg
imatinib tab 400mg
GLEOSTINE CAP 100MG (lomustine)
T2GLEOSTINE CAP 10MG (lomustine)
T2GLEOSTINE CAP 40MG (lomustine)
T2HEXALEN CAP 50MG (altretamine)
T1hydroxyurea cap 500mg
T4 PAIBRANCE CAP 100MG (palbociclib)
T4 PAIBRANCE CAP 125MG (palbociclib)
T4 PAIBRANCE CAP 75MG (palbociclib)
T4 PAICLUSIG TAB 15MG (ponatinib)
T4 PAICLUSIG TAB 45MG (ponatinib)
15Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTINEOPLASTIC AGENTS
T4 PA, SPIMBRUVICA CAP 140MG (ibrutinib)
T4 PA, SPINLYTA TAB 1MG (axitinib)
T4 PA, SPINLYTA TAB 5MG (axitinib)
T4 PAINTRON A INJ 10MU (interferon)
T4INTRON A INJ 18MU (interferon)
T4 PAINTRON A INJ 18MU (interferon)
T4 PAINTRON A INJ 25MU (interferon)
T4INTRON A INJ 50MU (interferon)
T4 PA, SPIRESSA TAB 250MG (gefitinib)
T4 PA, SPJAKAFI TAB 10MG (ruxolitinib)
T4 PA, SPJAKAFI TAB 15MG (ruxolitinib)
T4 PA, SPJAKAFI TAB 20MG (ruxolitinib)
T4 PA, SPJAKAFI TAB 25MG (ruxolitinib)
T4 PA, SP
T1
T2
T2
T2
T1
T1
T1
T1
T1
T4 PA, SP
T4 PA, SP
T1
T1
T4 PA
T4 PA, SP
T4 PA
T4 PA, SP
T4 PA, SP
T4 PA, SP
JAKAFI TAB 5MG (ruxolitinib)
letrozole tab 2.5mg
LEUKERAN TAB 2MG (chlorambucil)
LYSODREN TAB 500MG (mitotane)
MATULANE CAP 50MG (procarbazine)
megestrol ac sus 400mg/10
megestrol ac sus 40mg/ml
megestrol ac sus 800mg/20
megestrol ac tab 20mg
megestrol ac tab 40mg
MEKINIST TAB 0.5MG (trametinib)
MEKINIST TAB 2MG (trametinib)
mercaptopur tab 50mg
methotrexate tab 2.5mg
MYLERAN TAB 2MG (busulfan)
NEXAVAR TAB 200MG (sorafenib)
NILANDRON TAB 150MG (nilutamide)
NINLARO
ODOMZA
POMALYST CAP 3MG (pomalidomide)
16Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTINEOPLASTIC AGENTS
T4 PA, SPPOMALYST CAP 4MG (pomalidomide)
T4 PA, SPREVLIMID CAP 10MG (lenalidomide)
T4 PA, SPREVLIMID CAP 15MG (lenalidomide)
T4 PA, SPREVLIMID CAP 2.5MG (lenalidomide)
T4 PA, SPREVLIMID CAP 20MG (lenalidomide)
T4 PA, SPREVLIMID CAP 25MG (lenalidomide)
T4 PA, SPREVLIMID CAP 5MG (lenalidomide)
MED PA, SP Medical coinsuranceRITUXAN INJ 500MG (rituximab)
T4 PA, SPSPRYCEL TAB 100MG (dasatinib)
T4 PA, SPSPRYCEL TAB 140MG (dasatinib)
T4 PA, SPSPRYCEL TAB 20MG (dasatinib)
T4 PA, SPSPRYCEL TAB 50MG (dasatinib)
T4 PA, SPSPRYCEL TAB 70MG (dasatinib)
T4 PA, SPSPRYCEL TAB 80MG (dasatinib)
T4 PA, SPSTIVARGA TAB 40MG (regorafenib)
T4 PA, SPSUTENT CAP 12.5MG (sunitinib)
T4 PA, SPSUTENT CAP 25MG (sunitinib)
T4 PA, SPSUTENT CAP 37.5MG (sunitinib)
T4 PA, SPSUTENT CAP 50MG (sunitinib)
T4 PA, SPSYLATRON KIT 200MCG (peginterferon)
T4 PA, SPSYLATRON KIT 300MCG (peginterferon)
T4 PA, SPSYLATRON KIT 600MCG (peginterferon)
T4 PA, SPSYLATRON 296 MCG 4-PACK (PEGINTERFERON)
T4 PA, SPSYLATRON 444 MCG 4-PACK (PEGINTERFERON)
T4 PA, SPSYLATRON 888 MCG 4-PACK (PEGINTERFERON)
T2TABLOID TAB 40MG (thioguanine)
T4 PA, SPTAFINLAR CAP 50MG (dabrafenib)
T4 PA, SPTAFINLAR CAP 75MG (dabrafenib)
T0 HCR Rules for Coveragetamoxifen citrate tab 10 mg
T0 HCR Rules for Coveragetamoxifen citrate tab 20 mg
T4 PA, SPTARCEVA TAB 100MG (erlotinib)
T4 PA, SPTARCEVA TAB 150MG (erlotinib)
T4 PA, SPTARCEVA TAB 25MG (erlotinib)
17Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ANTINEOPLASTIC AGENTS
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4 PA, SP
T1
T4 PA
T4 PA
T4 PA
T4 PA
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4 PA, SP
TASIGNA CAP 150MG (nilotinib)
TASIGNA CAP 200MG (nilotinib)
temozolomide cap 100mg
temozolomide cap 140mg
temozolomide cap 180mg
temozolomide cap 20mg
temozolomide cap 250mg
temozolomide cap 5mg
tretinoin cap 10mg
TREXALL TAB 10MG (methotrexate)
TREXALL TAB 15MG (methotrexate)
TREXALL TAB 5MG (methotrexate)
TREXALL TAB 7.5MG (methotrexate)
TYKERB TAB 250MG (lapatinib)
VOTRIENT TAB 200MG (pazopanib)
XALKORI CAP 200MG (crizotinib)
XALKORI CAP 250MG (crizotinib)
XTANDI CAP 40MG (enzalutamide)
ZELBORAF TAB 240MG (vemurafenib)
ZOLINZA CAP 100MG (vorinostat)
ZYDELIG TAB 100MG (idelalisib)
ZYDELIG TAB 150MG (idelalisib)
ZYTIGA TAB 250MG (abiraterone)
AUTONOMIC DRUGSANTICHOLINERGIC AGENTS
ANTIMUSCARINICS/ANTISPASMODICS
T3 PA, QLANORO ELLIPT AER 62.5-25 (umeclidinium-vilanterol)
T1atropine sul inj 0.05mg/1
T1atropine sul inj 0.1mg/ml
T1atropine sul inj 0.4/0.5
T2 QL (2 inhalers/30 days)ATROVENT HFA AER 17MCG (ipratropium)
18Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
AUTONOMIC DRUGSANTICHOLINERGIC AGENTS
ANTIMUSCARINICS/ANTISPASMODICS
T1 QLchlord/clidi cap 5-2.5mg
T1 QLclidi/chlord cap 2.5-5mg
T1dicyclomine cap 10mg
T1dicyclomine sol 10mg/5ml
T1dicyclomine tab 20mg
T1glycopyrrol tab 1mg
T1glycopyrrol tab 2mg
T1 QLhyoscyamine sub 0.125mg
T1 QLhyoscyamine tab 0.125mg
T1ipratropium sol 0.02%inh
T1ipratropium spr 0.03%
T1ipratropium spr 0.06%
T1methscopolam tab 2.5mg
T1methscopolam tab 5mg
T1 QLnulev tab 0.125mg (hyoscyamine)
T1 QLoscimin sub 0.125mg (hyoscyamine)
T1 QLoscimin tab 0.125mg (hyoscyamine)
T2 QL (1 inhaler/30 days)SPIRIVA CAP HANDIHLR (tiotropium)
T2 QLSPIRIVA SPR RESPIMAT (tiotropium)
T2 QLSTIOLTO
T1 QLsymax-sl sub 0.125mg (hyoscyamine)
T2 QL (1 inhaler/30 days)TUDORZA PRES AER 400/ACT (aclidinium)
ANTIPARKINSONIAN AGENTS
T1benztropine tab 1mg
T1benztropine tab 2mg
AUTONOMIC DRUGS, MISCELLANEOUS
T0 QL HCR Rules for CoverageCHANTIX PAK 0.5& 1MG (varenicline)
T0 QL (1 fill/30 days; 6 fills/365 days)
HCR Rules for CoverageCHANTIX PAK 1MG (varenicline)
T0 QL (1 fill/30 days; 6 fills/365 days)
HCR Rules for CoverageCHANTIX TAB 0.5MG (varenicline)
T0 QL (1 fill/30 days; 6 fills/365 days)
HCR Rules for CoverageCHANTIX TAB 1MG (varenicline)
19Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
AUTONOMIC DRUGSAUTONOMIC DRUGS, MISCELLANEOUS
T0 HCR Rules for Coveragenicotine kit
T0 QL (14 Patches/14 days, 12 fills/365 days)
HCR Rules for Coveragenicotine patch 14 mg/24hr
T0 QL HCR Rules for Coveragenicotine patch 14 mg/24hr
T0 QL HCR Rules for Coveragenicotine patch 21 mg/24hr
T0 QL (14 Patches/14 days, 12 fills/365 days)
HCR Rules for Coveragenicotine patch 21 mg/24hr
T0 QL HCR Rules for Coveragenicotine patch 7 mg/24hr
T0 QL (14 Patches/14 days, 12 fills/365 days)
HCR Rules for Coveragenicotine patch 7 mg/24hr
T0 QL (360 units/30 days, 6 fills/365 days)
HCR Rules for Coveragenicotine polacrilex gum 2 mg
T0 QL HCR Rules for Coveragenicotine polacrilex gum 2 mg
T0 QL HCR Rules for Coveragenicotine polacrilex lozg 2 mg
T0 QL (360 units/30 days, 6 fills/365 days)
HCR Rules for Coveragenicotine polacrilex lozg 2 mg
T0 QL (360 units/30 days, 6 fills/365 days)
HCR Rules for Coveragenicotine polacrilex lozg 4 mg
T0 QL HCR Rules for Coveragenicotine polacrilex lozg 4 mg
T0 QL NICOTROL INH (nicotine)
NICOTROL NS SPR 10MG/ML (nicotine) T0
PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)
T1cevimeline cap 30mg
T1donepezil tab 10mg
T1donepezil tab 10mg odt
T1donepezil tab 5mg
T1donepezil tab 5mg odt
T1galantamine cap 16mg er
T1galantamine cap 24mg er
T1galantamine cap 8mg er
T1galantamine sol 4mg/ml
T1galantamine tab 12mg
T1galantamine tab 4mg
T1galantamine tab 8mg
20Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
QL
Drug Name Tier Requirements/Limits
AlternativesComments
AUTONOMIC DRUGSPARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)
T1guanidine tab 125mg
T2MESTINON SYP 60MG/5ML (pyridostigmine)
T1pilocarpine tab 5mg
T1pilocarpine tab 7.5mg
T1pyridostigm tab 60mg
T1pyridostigmi tab 180mg
T1 QL (60 caps/30 days)rivastigmine cap 1.5mg
T1 QL (60 caps/30 days)rivastigmine cap 3mg
T1 QL (60 caps/30 days)rivastigmine cap 4.5mg
T1 QL (60 caps/30 days)rivastigmine cap 6mg
SKELETAL MUSCLE RELAXANTS
T1methocarbam tab 500mg
CENTRALLY ACTING SKELETAL MUSCLE RELAXNT
T1 QL (120 tabs/30 days)carisopr/asa tab 200-325
T1 QL (120 tabs/30 days)carisoprodol tab 250mg
T1 QL (120 tabs/30 days)carisoprodol tab 350mg
T1 QL (120 tabs/30 days)carisoprodol tab asa/cod
T1chlorzoxazon tab 500mg
T1 QL (90 tabs/30 days)cyclobenzapr tab 10mg
T1 QL (90 tabs/30 days)cyclobenzapr tab 5mg
T3LORZONE TAB 750MG (chlorzoxazone)
T1metaxalone tab 400mg
T1metaxalone tab 800mg
T1methocarbam tab 750mg
T1tizanidine tab 2mg
T1tizanidine tab 4mg
DIRECT-ACTING SKELETAL MUSCLE RELAXANTS
T1dantrolene cap 100mg
T1dantrolene cap 25mg
T1dantrolene cap 50mg
GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT
T1baclofen tab 10mg
21Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
AUTONOMIC DRUGSSKELETAL MUSCLE RELAXANTS
GABA-DERIVATIVE SKELETAL MUSCLE RELAXANT
T1baclofen tab 20mg
SKELETAL MUSCLE RELAXANTS, MISCELLANEOUS
T1orphenadrine inj 30mg/ml
T1orphenadrine tab 100mg cr (orphenadrine)
T1orphenadrine tab 100mg er
SYMPATHOLYTIC ADRENERGIC BLOCKING AGENTSALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)
T1alfuzosin tab 10mg
T1ergoloid mes tab 1mg oral
T2 QL (6 units/30 days)MIGRANAL SPR 4MG/ML (dihydroergotamine)
T3 PA, QL (30 caps/30 days) alfuzosin, finasteride, tamsulosin
RAPAFLO CAP 8MG (silodosin)
T1 QL (30 caps/30 days)tamsulosin cap 0.4mg
SYMPATHOMIMETIC (ADRENERGIC) AGENTSALPHA- AND BETA-ADRENERGIC AGONISTS
T1epinephrine inj 0.1mg/ml
T1epinephrine inj 1mg/ml
T2EPIPEN 2-PAK INJ 0.3MG (epinephrine)
T2EPIPEN-JR INJ 2-PAK (epinephrine)
ALPHA-ADRENERGIC AGONISTS
T1midodrine tab 10mg
T1midodrine tab 2.5mg
T1midodrine tab 5mg
BETA-ADRENERGIC AGONISTS
T2 QL (1 inhaler/30 days)ADVAIR DISKU AER 100/50 (fluticasone-salmeterol)
T2 QL (1 inhaler/30 days)ADVAIR DISKU AER 250/50 (fluticasone-salmeterol)
T2 QL (1 inhaler/30 days)ADVAIR DISKU AER 500/50 (fluticasone-salmeterol)
T2 QL (1 inhaler/30 days)ADVAIR HFA AER 115/21 (fluticasone-salmeterol)
T2 QL (1 inhaler/30 days)ADVAIR HFA AER 230/21 (fluticasone-salmeterol)
T2 QL (1 inhaler/30 days)ADVAIR HFA AER 45/21 (fluticasone-salmeterol)
T1albuterol neb 0.083%
22Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
AUTONOMIC DRUGSSYMPATHOMIMETIC (ADRENERGIC) AGENTS
BETA-ADRENERGIC AGONISTS
T1albuterol neb 0.5%
T1albuterol neb 0.63mg/3
T1albuterol neb 1.25mg/3
T1albuterol syp 2mg/5ml
T1albuterol tab 2mg
T1albuterol tab 4mg
T1albuterol tab 4mg er
T3 QL (30 caps/30 days)ARCAPTA CAP 75MCG (indacaterol)
T3 PABROVANA NEB 15MCG (arformoterol)
T2 QLCOMBIVENT AER RESPIMAT (ipratropium-albuterol)
T3FORADIL CAP AEROLIZE (formoterol)
T1levalbuterol neb 0.31mg
T1levalbuterol neb 0.63mg
T1levalbuterol neb 1.25/0.5
T1levalbuterol neb 1.25mg
T3 QL (1 canister/month) PROAIR HFA, VENTOLIN HFA
MAXAIR AUTOH AER 200MCG (pirbuterol)
T1metaproteren syp 10mg/5ml
T1metaproteren tab 10mg
T1metaproteren tab 20mg
T3PERFOROMIST NEB 20MCG (formoterol)
T2PROAIR HFA AER (albuterol)
T2PROAIR RESPI AER (albuterol)
T3
QL
QL (2canister/30days)
QL (2canister/30days)
QL (2canister/30days) PROAIR HFA, VENTOLIN HFA
PROVENTIL AER HFA (albuterol)
T2 QL (1 diskus/30 days)SEREVENT DIS AER 50MCG (salmeterol)
T1terbutaline tab 2.5mg
T1terbutaline tab 5mg
T2VENTOLIN HFA AER (albuterol)
T3
QL (2canister/30days)
PA PROAIR HFA, VENTOLIN HFA
XOPENEX HFA AER (levalbuterol)
23Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
BLOOD FORMATION,COAGULATION & THROMBOSISANTIANEMIA DRUGS
IRON PREPARATIONS
T0 HCR Rules for Coveragecarbonyl iron chew 15 mg
T0 HCR Rules for Coveragecarbonyl iron suspension 15 mg/1.25ml
T1fe c plus tab (iron-vitamin)
T0 HCR Rules for Coverageferrous aspartate tab 112 mg
T0 HCR Rules for Coverageferrous fumarate cap 86 mg
T0 HCR Rules for Coverageferrous fumarate tab 18 mg
T0 HCR Rules for Coverageferrous fumarate tab 29 mg
T0 HCR Rules for Coverageferrous fumarate tab 324 mg
T0 HCR Rules for Coverageferrous fumarate tab 325 mg
T0 HCR Rules for Coverageferrous fumarate tab 90 mg
T0 HCR Rules for Coverageferrous gluconate tab 225 mg
T0 HCR Rules for Coverageferrous gluconate tab 240 mg
T0 HCR Rules for Coverageferrous gluconate tab 27 mg
T0 HCR Rules for Coverageferrous gluconate tab 324 mg
T0 HCR Rules for Coverageferrous gluconate tab 325 mg
T0 HCR Rules for Coverageferrous sulfate elixir 220 mg/5ml
T0 HCR Rules for Coverageferrous sulfate soln 15 mg/ml
T0 HCR Rules for Coverageferrous sulfate syrup 300 mg/5ml
T0 HCR Rules for Coverageferrous sulfate tab 134 mg
T0 HCR Rules for Coverageferrous sulfate tab 140 mg
T0 HCR Rules for Coverageferrous sulfate tab 142 mg
T0 HCR Rules for Coverageferrous sulfate tab 143 mg
T0 HCR Rules for Coverageferrous sulfate tab 160 mg
T0 HCR Rules for Coverageferrous sulfate tab 200 mg
T0 HCR Rules for Coverageferrous sulfate tab 27 mg
T0 HCR Rules for Coverageferrous sulfate tab 28 mg
T0 HCR Rules for Coverageferrous sulfate tab 324 mg
T0 HCR Rules for Coverageferrous sulfate tab 325 mg
T0 HCR Rules for Coverageferrous sulfate tab 45 mg
T0 HCR Rules for Coverageferrous sulfate tab 47.5 mg
T0 HCR Rules for Coverageferrous sulfate tab 50 mg
24Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
BLOOD FORMATION,COAGULATION & THROMBOSISANTIANEMIA DRUGS
IRON PREPARATIONS
T0 HCR Rules for Coverageferrous sulfate tab 65 mg
T0 HCR Rules for Coverageferrous sulfate tab 90 mg
T0 HCR Rules for Coveragepolysaccharide iron complex cap 150 mg
T0 HCR Rules for Coveragepolysaccharide iron complex cap 200 mg
ANTIHEMORRHAGIC AGENTSHEMOSTATICS
MED PA, SP Medical coinsuranceADVATE INJ 1000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceADVATE INJ 1500UNIT (antihemophilic)
MED PA, SP Medical coinsuranceADVATE INJ 2000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceADVATE INJ 250UNIT (antihemophilic)
MED PA, SP Medical coinsuranceADVATE INJ 3000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceADVATE INJ 500UNIT (antihemophilic)
MED PA, SP Medical coinsuranceALPHANATE INJ VWF/HUM (antihemophilic)
MED PA, SP Medical coinsuranceALPHANATE 1,000-400 UNIT VIAL (ANTIHEMOPHILIC)
MED PA, SP Medical coinsuranceALPHANATE 1,500-600 UNIT VIAL (ANTIHEMOPHILIC)
MED PA, SP Medical coinsuranceALPHANATE 500-200 UNIT VIAL (ANTIHEMOPHILIC)
MED PA, SP Medical coinsuranceALPHANINE SD INJ 1000UNIT (coagulation)
MED PA, SP Medical coinsuranceALPHANINE SD INJ 1500UNIT (coagulation)
MED PA, SP Medical coinsuranceBEBULIN INJ 200-1200 (factor)
MED PA, SP Medical coinsuranceBEBULIN VH IMMU 200-1,200 UNIT (FACTOR)
MED PA, SP Medical coinsuranceBENEFIX INJ 1000UNIT (coagulation)
MED PA, SP Medical coinsuranceBENEFIX INJ 2000UNIT (coagulation)
MED PA, SP Medical coinsuranceBENEFIX INJ 250UNIT (coagulation)
MED PA, SP Medical coinsuranceBENEFIX INJ 500UNIT (coagulation)
MED PA, SP Medical coinsuranceCORIFACT KIT (factor)
MED PA, SP Medical coinsuranceELOCTATE INJ 1000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceELOCTATE INJ 1500UNIT (antihemophilic)
MED PA, SP Medical coinsuranceELOCTATE INJ 2000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceELOCTATE INJ 250UNIT (antihemophilic)
MED PA, SP Medical coinsuranceELOCTATE INJ 3000UNIT (antihemophilic)
25Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
BLOOD FORMATION,COAGULATION & THROMBOSISANTIHEMORRHAGIC AGENTS
HEMOSTATICS
MED PA, SP Medical coinsuranceELOCTATE INJ 500UNIT (antihemophilic)
MED PA, SP Medical coinsuranceELOCTATE INJ 750UNIT (antihemophilic)
MED PA, SP Medical coinsuranceFEIBA VH IMMU 1,750-3,250 UNIT (ANTIINHIBITOR)
MED PA, SP Medical coinsuranceHELIXATE FS INJ 1000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceHELIXATE FS INJ 2000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceHELIXATE FS INJ 250UNIT (antihemophilic)
MED PA, SP Medical coinsuranceHELIXATE FS INJ 500UNIT (antihemophilic)
MED PA, SP Medical coinsuranceHEMOFIL M INJ 1700UNIT (antihemophilic)
MED PA, SP Medical coinsuranceHEMOFIL M INJ 220-400 (antihemophilic)
MED PA, SP Medical coinsuranceHEMOFIL M INJ 401-800 (antihemophilic)
MED PA, SP Medical coinsuranceHEMOFIL M SOL 501-2000 (antihemophilic)
MED PA, SP Medical coinsuranceHEMOFIL M SOL 801-1500 (antihemophilic)
MED PA, SP Medical coinsuranceHUMATE-P SOL 2400UNIT (antihemophilic)
MED PA, SP Medical coinsuranceHUMATE-P SOL 250-600 (antihemophilic)
MED PA, SP Medical coinsuranceHUMATE-P SOL 500-1200 (antihemophilic)
MED PA, SP Medical coinsuranceKCENTRA KIT 1000UNIT (prothrombin)
MED PA, SP Medical coinsuranceKCENTRA KIT 500UNIT (prothrombin)
MED PA, SP Medical coinsurancekoate-dvi inj 1000unit (antihemophilic)
MED PA, SP Medical coinsurancekoate-dvi inj 250unit (antihemophilic)
MED PA, SP Medical coinsuranceKOATE-DVI INJ 500UNIT (antihemophilic)
MED PA, SP Medical coinsuranceKOGENATE FS INJ 1000/BS (antihemophilic)
MED PA, SP Medical coinsuranceKOGENATE FS INJ 1000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceKOGENATE FS INJ 2000/BS (antihemophilic)
MED PA, SP Medical coinsuranceKOGENATE FS INJ 2000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceKOGENATE FS INJ 250/BS (antihemophilic)
MED PA, SP Medical coinsuranceKOGENATE FS INJ 250UNIT (antihemophilic)
MED PA, SP Medical coinsuranceKOGENATE FS INJ 3000/BS (antihemophilic)
MED PA, SP Medical coinsuranceKOGENATE FS INJ 3000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceKOGENATE FS INJ 500/BS (antihemophilic)
MED PA, SP Medical coinsuranceKOGENATE FS INJ 500UNIT (antihemophilic)
MED PA, SP Medical coinsuranceMONOCLATE-P INJ 250UNIT (antihemophilic)
26Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
BLOOD FORMATION,COAGULATION & THROMBOSISANTIHEMORRHAGIC AGENTS
HEMOSTATICS
MED PA, SP Medical coinsuranceMONOCLATE-P INJ 500UNIT (antihemophilic)
MED PA, SP Medical coinsuranceMONONINE INJ 500UNIT (coagulation)
MED PA, SP Medical coinsuranceNOVOSEVEN INJ 2400MCG (coagulation)
MED PA, SP Medical coinsuranceNOVOSEVEN 1,200 MCG VIAL (COAGULATION)
MED PA, SP Medical coinsuranceNOVOSEVEN 4,800 MCG VIAL (COAGULATION)
MED PA, SP Medical coinsuranceNOVOSEVEN RT INJ 1MG (coagulation)
MED PA, SP Medical coinsuranceNOVOSEVEN RT INJ 2MG (coagulation)
MED PA, SP Medical coinsuranceNOVOSEVEN RT INJ 5MG (coagulation)
MED PA, SP Medical coinsuranceNOVOSEVEN RT INJ 8MG (coagulation)
MED PA, SP Medical coinsurancePROFILNINE SD 500 UNITS VIAL (FACTOR)
MED PA, SP Medical coinsuranceRECOMBINATE INJ 220-400 (antihemophilic)
MED PA, SP Medical coinsuranceRECOMBINATE INJ 401-800 (antihemophilic)
MED PA, SP Medical coinsuranceRECOMBINATE INJ 801-1240 (antihemophilic)
MED PA, SP Medical coinsuranceRIASTAP SOL 1GM (fibrinogen)
MED PA, SP Medical coinsuranceRIXUBIS INJ 1000UNIT (coagulation)
MED PA, SP Medical coinsuranceRIXUBIS INJ 2000UNIT (coagulation)
MED PA, SP Medical coinsuranceRIXUBIS INJ 250 UNIT (coagulation)
MED PA, SP Medical coinsuranceRIXUBIS INJ 3000UNIT (coagulation)
MED PA, SP Medical coinsuranceRIXUBIS INJ 500UNIT (coagulation)
T1tranex acid tab 650mg
MED PA, SP Medical coinsuranceWILATE INJ (antihemophilic)
MED PA, SP Medical coinsuranceWILATE 1,000-1,000 UNIT KIT (ANTIHEMOPHILIC)
MED PA, SP Medical coinsuranceWILATE 450-450 UNIT KIT (ANTIHEMOPHILIC)
MED PA, SP Medical coinsuranceWILATE 900-900 UNIT KIT (ANTIHEMOPHILIC)
MED PA, SP Medical coinsuranceXYNTHA INJ 1000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceXYNTHA INJ 2000UNIT (antihemophilic)
MED PA, SP Medical coinsuranceXYNTHA INJ 250UNIT (antihemophilic)
MED PA, SP Medical coinsuranceXYNTHA INJ 500UNIT (antihemophilic)
ANTITHROMBOTIC AGENTS
T2
ANTICOAGULANTS
COUMADIN tab 10mg (warfarin)
27Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
BLOOD FORMATION,COAGULATION & THROMBOSISANTITHROMBOTIC AGENTS
ANTICOAGULANTS
T2COUMADIN tab 1mg (warfarin)
T2
T2
COUMADIN tab 2.5mg (warfarin)
COUMADIN tab 2mg (warfarin)
T2
T2
T2
T2
COUMADIN tab 3mg (warfarin)
COUMADIN tab 4mg (warfarin)
COUMADIN tab 5mg (warfarin)
COUMADIN tab 6mg (warfarin)
T2
T2 QL (74 tabs/30 days)
T2 QL (74 tabs/30 days)
T1 QL
T1 QL
T1 QL
T1 QL
T1 QL
COUMADIN tab 7.5mg (warfarin)
ELIQUIS TAB 2.5MG (apixaban)
ELIQUIS TAB 5MG (apixaban)
enoxaparin inj 100mg/ml
enoxaparin inj 120/0.8
enoxaparin inj 150mg/ml
enoxaparin inj 30/0.3ml
enoxaparin inj 300/3ml
T1 QLenoxaparin inj 40/0.4ml
T1 QLenoxaparin inj 60/0.6ml
T1 QLenoxaparin inj 80/0.8ml
T1 QLfondaparinux inj 10/0.8ml
T1 QLfondaparinux inj 2.5/0.5
T1 QLfondaparinux inj 5/0.4ml
T1 QLfondaparinux inj 7.5/0.6
T3 PAFRAGMIN INJ 10000/ML (dalteparin)
T3FRAGMIN INJ 12500UNT (dalteparin)
T3FRAGMIN INJ 15000UNT (dalteparin)
T3FRAGMIN INJ 18000UNT (dalteparin)
T3FRAGMIN INJ 2500/0.2 (dalteparin)
T3FRAGMIN INJ 5000/0.2 (dalteparin)
T3FRAGMIN INJ 7500/0.3 (dalteparin)
T3FRAGMIN INJ 95000UNT (dalteparin)
T2
PA
QL (60 caps/30 days)PRADAXA CAP 150MG (dabigatran)
28Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
PA
PA
PA
PA
PA
PA
Drug Name Tier Requirements/Limits
AlternativesComments
BLOOD FORMATION,COAGULATION & THROMBOSISANTITHROMBOTIC AGENTS
ANTICOAGULANTS
T2PRADAXA CAP 75MG (dabigatran) QL (74 caps/30 days)
T1warfarin tab 10mg
T1warfarin tab 1mg
T1warfarin tab 2.5mg
T1warfarin tab 2mg
T1warfarin tab 3mg
T1warfarin tab 4mg
T1warfarin tab 5mg
T1warfarin tab 6mg
T1warfarin tab 7.5mg
T1warfarin sod tab 10mg
T2 QL (30 tabs/30 days)XARELTO TAB 10MG (rivaroxaban)
T2 QL (30 tabs/30 days)XARELTO TAB 15MG (rivaroxaban)
T2 QL (30 tabs/30 days)XARELTO TAB 20MG (rivaroxaban)
T2 QL (30 tabs/30 days)XARELTO STAR TAB 15/20MG (rivaroxaban)
PLATELET-AGGREGATION INHIBITORS
T2AGGRENOX CAP 25-200MG (aspirin-dipyridamole)
T3 clopidogrelBRILINTA TAB 60MG (ticagrelor)
T3
QL (60 caps/30 days)
PA, QL (60 tabs/30 days)
PA, QL (60 tabs/30 days) clopidogrelBRILINTA TAB 90MG (ticagrelor)
T1cilostazol tab 100mg
T1cilostazol tab 50mg
T1clopidogrel tab 300mg
T1 QL (30 tabs/30 days)clopidogrel tab 75mg
T3 PA, QL (30 tabs/30 days) clopidogrelEFFIENT TAB 10MG (prasugrel)
T3 PA, QL (30 tabs/30 days) clopidogrelEFFIENT TAB 5MG (prasugrel)
T1ticlopidine tab 250mg
PLATELET-REDUCING AGENTS
T1anagrelide cap 0.5mg
T1anagrelide cap 1mg
HEMATOPOIETIC AGENTS
T4ARANESP INJ 100MCG (darbepoetin)
29Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
PRADAXA CAP 110MG (dabigatran
Drug Name Tier Requirements/Limits
AlternativesComments
BLOOD FORMATION,COAGULATION & THROMBOSISHEMATOPOIETIC AGENTS
T4ARANESP INJ 10MCG (darbepoetin)
T4ARANESP INJ 150MCG (darbepoetin)
T4ARANESP INJ 200MCG (darbepoetin)
T4ARANESP INJ 25MCG (darbepoetin)
T4ARANESP INJ 300MCG (darbepoetin)
T4ARANESP INJ 40MCG (darbepoetin)
T4ARANESP INJ 500MCG (darbepoetin)
T4ARANESP INJ 60MCG (darbepoetin)
T4 QL (4 vials/30 days)EPOGEN INJ 10000/ML (epoetin)
T4EPOGEN INJ 2000/ML (epoetin)
T4 QL (4 vials/30 days)EPOGEN INJ 20000/ML (epoetin)
T4EPOGEN INJ 3000/ML (epoetin)
T4EPOGEN INJ 4000/ML (epoetin)
T4LEUKINE INJ 250MCG (sargramostim)
T4LEUKINE INJ 500 MCG (sargramostim)
T4 PANEULASTA INJ 6MG/0.6M (pegfilgrastim)
T4 PANEULASTA KIT 6MG/0.6M (pegfilgrastim)
T4 QLNEUPOGEN INJ 300/0.5 (filgrastim)
T4 QLNEUPOGEN INJ 300MCG (filgrastim)
T4 QLNEUPOGEN INJ 480/0.8 (filgrastim)
T4 QLNEUPOGEN INJ 480MCG (filgrastim)
T4 QL (4 vials/30 days)PROCRIT INJ 10000/ML (epoetin)
T4PROCRIT INJ 2000/ML (epoetin)
T4 QL (4 vials/30 days)PROCRIT INJ 20000/ML (epoetin)
T4PROCRIT INJ 3000/ML (epoetin)
T4PROCRIT INJ 4000/ML (epoetin)
T4PROCRIT INJ 40000/ML (epoetin)
T4 PA, SPPROMACTA TAB 12.5MG (eltrombopag)
T4 PA, SPPROMACTA TAB 25MG (eltrombopag)
T4 PA, SPPROMACTA TAB 50MG (eltrombopag)
T4 PA, SPPROMACTA TAB 75MG (eltrombopag)
30Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
BLOOD FORMATION,COAGULATION & THROMBOSISHEMORRHEOLOGIC AGENTS
T1pentoxifylli tab 400mg cr
T1pentoxifylli tab 400mg er
CARDIOVASCULAR DRUGSALPHA-ADRENERGIC BLOCKING AGENTS
T3 QL (30 tabs/30 days)CARDURA XL TAB 4MG (doxazosin)
T1doxazosin tab 1mg
T1doxazosin tab 2mg
T1doxazosin tab 4mg
T1doxazosin tab 8mg
T1prazosin hcl cap 1mg
T1prazosin hcl cap 2mg
T1prazosin hcl cap 5mg
T1terazosin cap 10mg
T1terazosin cap 1mg
T1terazosin cap 2mg
T1terazosin cap 5mg
ANTILIPEMIC AGENTSANTILIPEMIC AGENTS, MISCELLANEOUS
T1 QLniacin tab 500mg er
T1 QLniacin er tab 1000mg
T1 QLniacin er tab 500mg
T1 QLniacin er tab 750mg
T1 PA, QL (120 caps/30 days)omega-3-acid cap 1gm
BILE ACID SEQUESTRANTS
T1cholestyram pow 4gm
T1cholestyram pow 4gm lite
T1colestipol gra 5gm
T1colestipol tab 1gm (colestipol)
T1prevalite pow 4gm (cholestyramine)
T1prevalite pow 4gm pk (cholestyramine)
T3 PA, QL (30 packets/30 days) cholestyramineWELCHOL PAK 3.75GM (colesevelam)
T3 PA, QL (210 tabs/30 days) cholestyramineWELCHOL TAB 625MG (colesevelam)
31Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CARDIOVASCULAR DRUGSANTILIPEMIC AGENTS
CHOLESTEROL ABSORPTION INHIBITORS
T2 QL (30 tabs/30 days)ZETIA TAB 10MG (ezetimibe)
FIBRIC ACID DERIVATIVES
T1fenofibrate cap 130mg
T1fenofibrate cap 134mg
T1fenofibrate cap 200mg
T1fenofibrate cap 43mg
T1fenofibrate cap 67mg
T1fenofibrate tab 120mg
T1fenofibrate tab 145mg
T1fenofibrate tab 160mg
T1fenofibrate tab 40mg
T1fenofibrate tab 48mg
T1fenofibrate tab 54mg
T1fenofibric tab 105mg
T1fenofibric tab 35mg
T1gemfibrozil tab 600mg
HMG-COA REDUCTASE INHIBITORS
T3 QL (60 tabs/30 days)ADVICOR TAB 1000-20 (niacin-lovastatin)
T3 QL (60 tabs/30 days)ADVICOR TAB 1000-40 (niacin-lovastatin)
T3 QL (60 tabs/30 days)ADVICOR TAB 500-20MG (niacin-lovastatin)
T3 QL (60 tabs/30 days)ADVICOR TAB 750-20MG (niacin-lovastatin)
T1atorvastatin tab 10mg
T1atorvastatin tab 20mg
T1atorvastatin tab 40mg
T1atorvastatin tab 80mg
T3 QL (30 tabs/30 days), (atorvastatin 80MG)
atorvastatin, simvastatin
rosuvastatin tab 20mg
T3 QL (30 tabs/30 days), (atorvastatin 80MG)
atorvastatin, simvastatin
rosuvastatin tab 40mg
T3 QL (30 tabs/30 days), (atorvastatin 80MG)
atorvastatin, simvastatin
rosuvastatin tab 10mg
T3 QL (30 tabs/30 days), (atorvastatin 80MG)
atorvastatin, simvastatin
rosuvastatin tab 5mg
32Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CARDIOVASCULAR DRUGSANTILIPEMIC AGENTS
HMG-COA REDUCTASE INHIBITORS
T1fluvastatin cap 20mg
T1fluvastatin cap 40mg
T1 PA, QL (30 tabs/30 days) atorvastatin, pravastatin, simvastatin
Fluvastatin TAB 80MG
T3 PA, QL (30 tabs/30 days) atorvastatin, pravastatin, simvastatin
LIVALO TAB 1MG (pitavastatin)
T3 PA, QL (30 tabs/30 days) atorvastatin, pravastatin, simvastatin
LIVALO TAB 2MG (pitavastatin)
T3 PA, QL (30 tabs/30 days) atorvastatin, pravastatin, simvastatin
LIVALO TAB 4MG (pitavastatin)
T1lovastatin tab 10mg
T1lovastatin tab 20mg
T1lovastatin tab 40mg
T1pravastatin tab 10mg
T1pravastatin tab 20mg
T1pravastatin tab 40mg
T1pravastatin tab 80mg
T1simvastatin tab 10mg
T1simvastatin tab 20mg
T1simvastatin tab 40mg
T1simvastatin tab 5mg
T1simvastatin tab 80mg
T3 QL (30 tabs/30 days), ST (simvastatin, atorvastatin 80MG)
atorvastatin, simvastatin
VYTORIN TAB 10-10MG (ezetimibe-simvastatin)
T3 QL (30 tabs/30 days), ST (simvastatin, atorvastatin 80MG)
atorvastatin, simvastatin
VYTORIN TAB 10-20MG (ezetimibe-simvastatin)
T3 QL (30 tabs/30 days), ST (simvastatin, atorvastatin 80MG)
atorvastatin, simvastatin
VYTORIN TAB 10-40MG (ezetimibe-simvastatin)
T3 QL (30 tabs/30 days), ST (simvastatin, atorvastatin 80MG)
atorvastatin, simvastatin
VYTORIN TAB 10-80MG (ezetimibe-simvastatin)
BETA-ADRENERGIC BLOCKING AGENTS
T1 atenololacebutolol cap 200mg
33Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CARDIOVASCULAR DRUGSBETA-ADRENERGIC BLOCKING AGENTS
T1 atenololacebutolol cap 400mg
T1 QL (60 tabs/30 days)atenol/chlor tab 100-25mg
T1 QL (60 tabs/30 days)atenol/chlor tab 50-25mg
T1atenolol tab 100mg
T1atenolol tab 25mg
T1atenolol tab 50mg
T1betaxolol tab 10mg
T1betaxolol tab 20mg
T1 QL (60 tabs/30 days)bisoprl/hctz tab 10/6.25
T1 QL (60 tabs/30 days)bisoprl/hctz tab 2.5/6.25
T1 QL (60 tabs/30 days)bisoprl/hctz tab 5-6.25mg
T1bisoprol fum tab 10mg
T1bisoprol fum tab 5mg
T3 PA, QL (30 tabs/30 days)BYSTOLIC TAB 10MG (nebivolol)
T3 PA, QL (30 tabs/30 days)BYSTOLIC TAB 2.5MG (nebivolol)
T3 PA, QL (30 tabs/30 days)BYSTOLIC TAB 20MG (nebivolol)
T3 PA, QL (30 tabs/30 days)BYSTOLIC TAB 5MG (nebivolol)
T1carvedilol tab 12.5mg
T1carvedilol tab 25mg
T1carvedilol tab 3.125mg
T1carvedilol tab 6.25mg
T1labetalol tab 100mg
T1labetalol tab 200mg
T1labetalol tab 300mg
T2 PA, QL (60 tabs/30 days) atenolol, carvedilolLEVATOL TAB 20MG (penbutolol)
T1 QLmetoprl/hctz tab 100-25mg
T1 QLmetoprl/hctz tab 100-50mg
T1 QLmetoprl/hctz tab 50-25mg
T1metoprol tar tab 100mg
T1metoprol tar tab 25mg
T1metoprol tar tab 50mg
T1metoprolol tab 100mg er
34Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CARDIOVASCULAR DRUGSBETA-ADRENERGIC BLOCKING AGENTS
T1metoprolol tab 200mg er
T1metoprolol tab 25mg er
T1metoprolol tab 50mg er
T1nadolol tab 20mg
T1nadolol tab 40mg
T1nadolol tab 80mg
T1 atenololpindolol tab 10mg
T1 atenololpindolol tab 5mg
T1propranolol cap 120mg er
T1propranolol cap 160mg er
T1propranolol cap 60mg er
T1propranolol cap 80mg er
T1propranolol sol 20mg/5ml
T1propranolol sol 40mg/5ml
T1propranolol tab 10mg
T1propranolol tab 20mg
T1propranolol tab 40mg
T1propranolol tab 60mg
T1propranolol tab 80mg
T1sorine tab 120mg (sotalol)
T1sorine tab 160mg (sotalol)
T1sorine tab 240mg (sotalol)
T1sorine tab 80mg (sotalol)
T1sotalol hcl tab 120mg
T1sotalol hcl tab 160mg
T1sotalol hcl tab 240mg
T1sotalol hcl tab 80mg
T1timolol mal tab 10mg
T1timolol mal tab 20mg
T1timolol mal tab 5mg
35Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CARDIOVASCULAR DRUGSCALCIUM-CHANNEL BLOCKING AGENTS
CALCIUM-CHANNEL BLOCKING AGENTS, MISC.
T3CORLANOR
T1cartia xt cap 180/24hr (diltiazem)
T1cartia xt cap 240/24hr (diltiazem)
T1cartia xt cap 300/24hr (diltiazem)
T1dilt-cd cap 120mg (diltiazem)
T1dilt-cd cap 180mg (diltiazem)
T1dilt-cd cap 240mg (diltiazem)
T1dilt-cd cap 300mg (diltiazem)
T1diltiazem cap 120mg cd (diltiazem)
T1diltiazem cap 120mg er
T1 QLdiltiazem cap 120mg er
T1diltiazem cap 180mg cd (diltiazem)
T1 QLdiltiazem cap 180mg er
T1diltiazem cap 180mg er
T1diltiazem cap 180mg/24
T1diltiazem cap 240mg cd
T1 QLdiltiazem cap 240mg er
T1diltiazem cap 240mg er
T1diltiazem cap 240mg/24
T1diltiazem cap 300mg cd
T1diltiazem cap 300mg er
T1diltiazem cap 300mg/24
T1diltiazem cap 360mg cd (diltiazem)
T1diltiazem cap 360mg er
T1diltiazem cap 360mg/24
T1diltiazem cap 420mg/24
T1diltiazem cap 60mg er
T1diltiazem cap 90mg er
T1diltiazem tab 120mg
T1diltiazem tab 30mg
T1diltiazem tab 60mg
36Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CARDIOVASCULAR DRUGSCALCIUM-CHANNEL BLOCKING AGENTS
CALCIUM-CHANNEL BLOCKING AGENTS, MISC.
T1diltiazem tab 90mg
T1 QLdiltiazem er tab 180mg
T1 QLdiltiazem er tab 240mg
T1 QLdiltiazem er tab 300mg
T1 QLdiltiazem er tab 360mg
T1 QLdiltiazem er tab 420mg
T1 QLdilt-xr cap 120mg (diltiazem)
T1 QLdilt-xr cap 180mg (diltiazem)
T1 QLdilt-xr cap 240mg (diltiazem)
T1diltzac cap 180mg/24 (diltiazem)
T1diltzac cap 240mg/24 (diltiazem)
T1diltzac cap 300mg/24 (diltiazem)
T1diltzac cap 360mg/24 (diltiazem)
T1 QLmatzim la tab 180mg/24 (diltiazem)
T1 QLmatzim la tab 240mg/24 (diltiazem)
T1 QLmatzim la tab 300mg/24 (diltiazem)
T1 QLmatzim la tab 360mg/24 (diltiazem)
T1 QLmatzim la tab 420mg/24 (diltiazem)
T1taztia xt cap 180mg/24 (diltiazem)
T1taztia xt cap 240mg/24 (diltiazem)
T1taztia xt cap 300mg/24 (diltiazem)
T1taztia xt cap 360mg/24 (diltiazem)
T1verapamil cap 100mg er
T1verapamil cap 120mg er
T1verapamil cap 120mg sr
T1verapamil cap 180mg er
T1verapamil cap 180mg sr
T1verapamil cap 200mg er
T1verapamil cap 240mg er
T1verapamil cap 240mg sr
T1verapamil cap 300mg er
37Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CARDIOVASCULAR DRUGSCALCIUM-CHANNEL BLOCKING AGENTS
CALCIUM-CHANNEL BLOCKING AGENTS, MISC.
T1verapamil cap 360mg sr
T1verapamil tab 120mg
T1verapamil tab 120mg er
T1verapamil tab 120mg sr
T1verapamil tab 180mg er
T1verapamil tab 180mg sa
T1verapamil tab 180mg sr
T1verapamil tab 240mg cr
T1verapamil tab 240mg er
T1verapamil tab 240mg sa
T1verapamil tab 240mg sr
T1verapamil tab 40mg
T1verapamil tab 80mg
DIHYDROPYRIDINES
T1afeditab tab 30mg cr (nifedipine)
T1afeditab tab 60mg cr (nifedipine)
T1 QL (60 caps/30 days)amlod/benazp cap 10-20mg
T1 QL (60 caps/30 days)amlod/benazp cap 10-40mg
T1 QL (60 caps/30 days)amlod/benazp cap 2.5-10mg
T1 QL (60 caps/30 days)amlod/benazp cap 5-10mg
T1 QL (60 caps/30 days)amlod/benazp cap 5-20mg
T1 QL (60 caps/30 days)amlod/benazp cap 5-40mg
T1 QL (60 caps/30 days)amlod/valsar tab /hctz
T1amlodipine tab 10mg
T1amlodipine tab 2.5mg
T1amlodipine tab 5mg
T1felodipine tab 10mg er
T1felodipine tab 2.5mg er
T1felodipine tab 5mg er
T1isradipine cap 2.5mg
T1isradipine cap 5mg
38Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CARDIOVASCULAR DRUGSCALCIUM-CHANNEL BLOCKING AGENTS
DIHYDROPYRIDINES
T1nicardipine cap 20mg
T1nicardipine cap 30mg
T1nifediac cc tab 30mg er (nifedipine)
T1nifediac cc tab 60mg er (nifedipine)
T1nifedical xl tab 30mg (nifedipine)
T1nifedical xl tab 60mg (nifedipine)
T1nifedipine cap 10mg
T1nifedipine cap 20mg
T1nifedipine tab 30mg er
T1nifedipine tab 60mg er
T1nifedipine tab 90mg er
T1nimodipine cap 30mg
T1nisoldipine tab 17mg er
T1nisoldipine tab 20mg
T1nisoldipine tab 25.5mg
T1nisoldipine tab 30mg
T1nisoldipine tab 34mg er
T1nisoldipine tab 40mg
T1nisoldipine tab 8.5mg er
CARDIAC DRUGSANTIARRHYTHMIC AGENTS
T1amiodarone tab 200mg
T1 QLamiodarone tab 400mg
T1disopyramide cap 100mg
T1disopyramide cap 150mg
T1flecainide tab 100mg
T1flecainide tab 150mg
T1flecainide tab 50mg
T1 QL (90 caps/30 days)mexiletine cap 150mg
T1 QL (90 caps/30 days)mexiletine cap 200mg
T1 QL (90 caps/30 days)mexiletine cap 250mg
39Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CARDIOVASCULAR DRUGSCARDIAC DRUGS
ANTIARRHYTHMIC AGENTS
T2 PA, QL (60 tabs/30 days)MULTAQ TAB 400MG (dronedarone)
T3NORPACE CAP 100MG CR (disopyramide)
T1pacerone tab 200mg (amiodarone)
T1 QLpacerone tab 400mg (amiodarone)
T1propafenone cap 225mg er
T1propafenone cap 325mg er
T1propafenone cap 425mg sr
T1propafenone tab 150mg
T1propafenone tab 225mg
T1propafenone tab 300mg
T1quinidine gl tab 324mg cr
T1quinidine gl tab 324mg er
T1quinidine su tab 300mg
T1quinidine su tab 300mg er
T2 QL (120 caps/30 days)TIKOSYN CAP 125MCG (dofetilide)
T2 QL (120 caps/30 days)TIKOSYN CAP 250MCG (dofetilide)
T2 QL (120 caps/30 days)TIKOSYN CAP 500MCG (dofetilide)
CARDIAC DRUGS, MISCELLANEOUS
T3 QL (60 tabs/30 days)RANEXA TAB 1000MG (ranolazine)
T3 QL (60 tabs/30 days)RANEXA TAB 500MG (ranolazine)
CARDIOTONIC AGENTS
T1digitek tab 0.125mg (digoxin)
T1digitek tab 0.25mg (digoxin)
T1digox tab 0.125mg (digoxin)
T1digox tab 0.25mg (digoxin)
T1digoxin inj 0.25mg/1
T1digoxin sol 50mcg/ml
T1digoxin tab 0.125mg
T1digoxin tab 0.25mg
T1lanoxin tab 0.125mg (digoxin)
T1lanoxin tab 0.25mg (digoxin)
40Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CARDIOVASCULAR DRUGSCARDIAC DRUGS
RENIN-ANGIOTENSIN-ALDOSTERONE SYSTEM INHIBITORS, MISC
T3ENTRESTO TAB 24-26MG (sacubitril-valsartan)
T3ENTRESTO TAB 49-51MG (sacubitril-valsartan)
T3ENTRESTO TAB 97-103MG (sacubitril-valsartan)
HYPOTENSIVE AGENTSCENTRAL ALPHA-AGONISTS
T1clonidine dis 0.1/24hr
T1clonidine dis 0.2/24hr
T1clonidine dis 0.3/24hr
T1clonidine tab 0.1mg
T1clonidine tab 0.2mg
T1clonidine tab 0.3mg
T1guanfacine tab 1mg
T1guanfacine tab 2mg
T1methyldopa tab 250mg
T1methyldopa tab 500mg
DIRECT VASODILATORS
T1hydralazine inj 20mg/ml
T1hydralazine tab 100mg
T1hydralazine tab 10mg
T1hydralazine tab 25mg
T1hydralazine tab 50mg
T1minoxidil tab 10mg
T1minoxidil tab 2.5mg
DIURETICS (HYPOTENSIVE AGENTS)
T1acetazolamid tab 250mg
PERIPHERAL ADRENERGIC INHIBITORS
T1reserpine tab 0.1mg
T1reserpine tab 0.25mg
RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIBANGIOTENSIN II RECEPTOR ANTAGONISTS
T1candesa/hctz tab 16-12.5
T1candesa/hctz tab 32-12.5
41Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
PA
PA
PA
Drug Name Tier Requirements/Limits
AlternativesComments
CARDIOVASCULAR DRUGSRENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB
ANGIOTENSIN II RECEPTOR ANTAGONISTS
T1candesa/hctz tab 32-25mg
T1 PAcandesartan tab 16mg
T1 PAcandesartan tab 32mg
T1 PAcandesartan tab 4mg
T1 PAcandesartan tab 8mg
T3 PAEDARBI TAB 40MG (azilsartan)
T3 PAEDARBI TAB 80MG (azilsartan)
T1eprosart mes tab 600mg
T1irbesar/hctz tab 150-12.5
T1irbesar/hctz tab 300-12.5
T1irbesartan tab 150mg
T1irbesartan tab 300mg
T1irbesartan tab 75mg
T1losartan pot tab 100mg
T1losartan pot tab 25mg
T1losartan pot tab 50mg
T1losartan/hct tab 100-12.5
T1losartan/hct tab 100-25
T1losartan/hct tab 50-12.5
T1 PAtelmisartan tab 20mg
T1 PAtelmisartan tab 40mg
T1 PAtelmisartan tab 80mg
T1valsart/hctz tab 160-12.5
T1valsart/hctz tab 160-25mg
T1valsart/hctz tab 320-12.5
T1valsart/hctz tab 320-25mg
T1valsart/hctz tab 80-12.5
T1 QLvalsartan tab 160mg
T1 QLvalsartan tab 320mg
T1 QLvalsartan tab 40mg
T1 QLvalsartan tab 80mg
42Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CARDIOVASCULAR DRUGSRENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS
T1benazep/hctz tab 10-12.5
T1benazep/hctz tab 20-12.5
T1benazep/hctz tab 20-25mg
T1benazep/hctz tab 5-6.25
T1benazepril tab 10mg
T1benazepril tab 20mg
T1benazepril tab 40mg
T1benazepril tab 5mg
T1captopr/hctz tab 25-15mg
T1captopr/hctz tab 25-25mg
T1captopr/hctz tab 50-15mg
T1captopr/hctz tab 50-25mg
T1captopril tab 100mg
T1captopril tab 12.5mg
T1captopril tab 25mg
T1captopril tab 50mg
T1enalapr/hctz tab 10-25mg
T1enalapr/hctz tab 5-12.5mg
T1enalapril tab 10mg
T1enalapril tab 2.5mg
T1enalapril tab 20mg
T1enalapril tab 5mg
T1fosinop/hctz tab 10/12.5
T1fosinop/hctz tab 20/12.5
T1fosinopril tab 10mg
T1fosinopril tab 20mg
T1fosinopril tab 40mg
T1lisinop/hctz tab 10-12.5
T1lisinop/hctz tab 20-12.5
T1lisinop/hctz tab 20-25mg
T1lisinopril tab 10mg
43Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CARDIOVASCULAR DRUGSRENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB
ANGIOTENSIN-CONVERTING ENZYME INHIBITORS
T1lisinopril tab 2.5mg
T1lisinopril tab 20mg
T1lisinopril tab 30mg
T1lisinopril tab 40mg
T1lisinopril tab 5mg
T1moexipr/hctz tab 15-12.5
T1moexipr/hctz tab 15-25mg
T1moexipr/hctz tab 7.5-12.5
T1moexipril tab 15mg
T1moexipril tab 7.5mg
T1 QL (60 tabs/30 days)perindopril tab 2mg
T1 QL (60 tabs/30 days)perindopril tab 4mg
T1 QL (60 tabs/30 days)perindopril tab 8mg
T1qnapril/hctz tab 10-12.5
T1qnapril/hctz tab 20-12.5
T1qnapril/hctz tab 20-25mg
T1quinapril tab 10mg
T1quinapril tab 20mg
T1quinapril tab 40mg
T1quinapril tab 5mg
T1ramipril cap 1.25mg
T1ramipril cap 10mg
T1ramipril cap 2.5mg
T1ramipril cap 5mg
T1trandolapril tab 1mg
T1trandolapril tab 2mg
T1trandolapril tab 4mg
MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS
T1eplerenone tab 25mg
T1eplerenone tab 50mg
T1spirono/hctz tab 25/25
44Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CARDIOVASCULAR DRUGSRENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIB
MINERALOCORTICOID (ALDOSTERONE) ANTAGNTS
T1spironolact tab 100mg
T1spironolact tab 25mg
T1spironolact tab 50mg
RENIN INHIBITORS
T3 PA, QL (30 tabs/30 days) irbesartan, lisinopril, losartan
TEKTURNA TAB 150MG (aliskiren)
T3 PA, QL (30 tabs/30 days) irbesartan, lisinopril, losartan
TEKTURNA TAB 300MG (aliskiren)
VASODILATING AGENTSNITRATES AND NITRITES
T1isoditrate tab 40mg er (isosorbide)
T3ISORDIL TAB 40MG (isosorbide)
T1isosorb din tab 10mg
T1isosorb din tab 20mg
T1isosorb din tab 30mg
T1isosorb din tab 40mg er
T1isosorb din tab 40mg sa
T1isosorb din tab 5mg
T1isosorb mono tab 10mg
T1isosorb mono tab 120mg er
T1isosorb mono tab 20mg
T1isosorb mono tab 30mg er
T1isosorb mono tab 60mg er
T3NITRO-BID OIN 2% (nitroglycerin)
T3NITRO-DUR DIS 0.3MG/HR (nitroglycerin)
T1nitroglycer aer 400mcg
T1nitroglycer cap 2.5mg er
T1nitroglycer cap 2.5mg sr
T1nitroglycer cap 6.5mg er
T1nitroglycer cap 6.5mg sr
T1nitroglycer cap 9mg er
T3NITRONAL SOL 1MG/ML (nitroglycerin)
45Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CARDIOVASCULAR DRUGSVASODILATING AGENTS
NITRATES AND NITRITES
T3NITROSTAT SUB 0.3MG (nitroglycerin)
T3NITROSTAT SUB 0.4MG (nitroglycerin)
T3NITROSTAT SUB 0.6MG (nitroglycerin)
T1nitro-time cap 2.5mg cr (nitroglycerin)
T1nitro-time cap 6.5mg cr (nitroglycerin)
T1nitro-time cap 9mg cr (nitroglycerin)
PHOSPHODIESTERASE TYPE 5 INHIBITORS
T4 PAADCIRCA TAB 20MG (tadalafil)
T3 PA, QL (30 tabs/30 days) for BPH alfuzosin, finasteride, tamsulosin
CIALIS TAB 5MG (tadalafil)
T1 QLsildenafil tab 20mg
VASODILATING AGENTS, MISCELLANEOUS
T1dipyridamole inj 5mg/ml
T1dipyridamole tab 25mg
T1dipyridamole tab 50mg
T1dipyridamole tab 75mg
CENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICS
ANALGESICS AND ANTIPYRETICS, MISC.
T1 QLbut/apap/caf cap
T1 QL (120 tabs/30 days)but/apap/caf tab
T1zebutal cap (butalbital-acetaminophen-caffeine)
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
T0 QL HCR Rules for Coverageaspirin chew 81 mg
T0 QL HCR Rules for Coverageaspirin chew 81 mg
T0 HCR Rules for Coverageaspirin tab 324 mg
T0 HCR Rules for Coverageaspirin tab 325 mg
T0 HCR Rules for Coverageaspirin tab 325 mg
T0 QL HCR Rules for Coverageaspirin tab 81 mg
T0 QL HCR Rules for Coverageaspirin tab 81 mg
T1 QLBAYER CHILD CHW ASA 81MG (aspirin)
46Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICS
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
T1but/asa/caff cap
T1but/asa/caff tab
T1 QL, STcelecoxib cap 100mg
T1 QL, STcelecoxib cap 200mg
T1 QL, STcelecoxib cap 400mg
T1 QL, STcelecoxib cap 50mg
T1cho mag tris liq 500/5ml
T1cho mag tris tab 1000mg
T1diclo/misopr tab 50-0.2mg
T1diclo/misopr tab 75-0.2mg
T1diclofen pot tab 50mg
T1diclofenac tab 100mg er
T1diclofenac tab 100mg xr
T1diclofenac tab 25mg dr
T1diclofenac tab 50mg dr
T1diclofenac tab 75mg dr
T1diflunisal tab 500mg
T1etodolac cap 200mg
T1etodolac cap 300mg
T1etodolac tab 400mg
T1etodolac tab 500mg
T1etodolac er tab 400mg
T1etodolac er tab 500mg (etodolac)
T1etodolac er tab 600mg
T1fenoprofen tab 600mg
T1flurbiprofen tab 100mg
T1flurbiprofen tab 50mg
T1ibuprofen sus 100/5ml (ibuprofen)
T1ibuprofen tab 400mg
T1ibuprofen tab 600mg
T1ibuprofen tab 800mg
47Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICS
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
T1indomethacin cap 25mg
T1indomethacin cap 50mg
T1indomethacin cap 75mg cr
T1indomethacin cap 75mg er
T1indomethacin cap 75mg sa
T1indomethacin cap 75mg sr
T1ketoprofen cap 200mg er
T1ketoprofen cap 50mg
T1ketoprofen cap 75mg
T1ketorolac tab 10mg
T1meclofen sod cap 100mg
T1meclofen sod cap 50mg
T3MEDI-SELTZER TAB (aspirin)
T1mefenam acid cap 250mg
T1meloxicam sus 7.5/5ml
T1meloxicam tab 15mg
T1meloxicam tab 7.5mg
T1nabumetone tab 500mg
T1nabumetone tab 750mg
T1naproxen sus 125/5ml
T1naproxen tab 250mg
T1naproxen tab 375mg
T1naproxen tab 500mg (naproxen)
T1naproxen dr tab 375mg (naproxen)
T1naproxen dr tab 500mg (naproxen)
T1naproxen ec tab 375mg (naproxen)
T1naproxen ec tab 500mg (naproxen)
T1naproxen sod tab 220mg (naproxen)
T1naproxen sod tab 275mg
T1naproxen sod tab 550mg
T1orph/asa/caf tab
48Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICS
NONSTEROIDAL ANTI-INFLAMMATORY AGENTS
T1oxaprozin tab 600mg
T1piroxicam cap 10mg
T1piroxicam cap 20mg
T1salsalate tab 500mg
T1salsalate tab 750mg
T1sulindac tab 150mg
T1sulindac tab 200mg
T1tolmetin sod cap 400mg
T1tolmetin sod tab 200mg
T1tolmetin sod tab 600mg
OPIATE AGONISTS
T1 QL (240 caps/30 days)apap/caff/di tab hydrocod
T1 QL (4500ml/30 days)apap/codeine sol 120-12/5
T1 QL (300 tabs/30 days)apap/codeine tab 300-15mg
T1 QLapap/codeine tab 300-30mg
T1 QLapap/codeine tab 300-60mg
T1asa/caff/but cap cod 30mg
T1ascomp/cod cap 30mg (acetaminophen)
T1 QL (240 caps/30 days)but/apap/caf cap codeine
T1but/asa/caf/ cap cod 30mg
T1butal cpd/ cap codeine (acetaminophen)
T1codeine sulf tab 15mg
T1codeine sulf tab 30mg
T1codeine sulf tab 60mg
T1 QLcodeine/apap tab 15-300mg
T1 QLcodeine/apap tab 30-300mg
T1 QLcodeine/apap tab 60-300mg
T1duramorph inj 0.5mg/ml (morphine)
T1duramorph inj 1mg/ml (morphine)
T1 QLendocet tab 10-325mg (oxycodone)
T1 QL (300 tabs/30 days)endocet tab 10-650mg (oxycodone)
49Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICS
OPIATE AGONISTS
T1 QLendocet tab 5-325mg (oxycodone)
T1 QLendocet tab 7.5-325 (oxycodone)
T1 QL (300 tabs/30 days)endocet tab 7.5-500m (oxycodone)
T1 QL (10 patches/30 days)fentanyl dis 100mcg/h
T1 QL (10 patches/30 days)fentanyl dis 12mcg/hr
T1 QL (10 patches/30 days)fentanyl dis 25mcg/hr
T1 QLfentanyl dis 37.5mcg
T1 QL (10 patches/30 days)fentanyl dis 50mcg/hr
T1 QLfentanyl dis 62.5mcg
T1 QL (10 patches/30 days)fentanyl dis 75mcg/hr
T1 QLfentanyl dis 87.5mcg
T1 PAfentanyl ot loz 1200mcg
T1 PAfentanyl ot loz 1600mcg
T1 PAfentanyl ot loz 200mcg
T1 PAfentanyl ot loz 400mcg
T1 PAfentanyl ot loz 600mcg
T1 PAfentanyl ot loz 800mcg
T1hydroco/apap sol 5-217/10
T1hydroco/apap sol 7.5-325
T1hydroco/apap tab 10-325mg
T1hydroco/apap tab 5-325mg
T1hydroco/apap tab 7.5-325
T1hydrocod/ibu tab 2.5-200
T1
QL (3600ml/30 days)
QL (3600ml/30 days)
QL
QL
QL
QL
QL hydrocod/ibu tab 7.5-200
T1hydromorphon liq 1mg/ml
T1hydromorphon sup 3mg
T1hydromorphon tab 2mg
T1hydromorphon tab 4mg
T1hydromorphon tab 8mg
T3 PAIBUDONE TAB 10-200MG (hydrocodone-ibuprofen)
T1levorphanol tab 2mg
50Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICS
OPIATE AGONISTS
T1 QL (28 tabs/28 days)lorcet tab 5-325mg (hydrocodone-acetaminophen)
T1 QL (150 tabs/30 days)lorcet hd tab 10-325mg (hydrocodone-acetaminophen)
T1 QL (150 tabs/30 days)lorcet plus tab 7.5-325 (hydrocodone-acetaminophen)
T1 QL (4 patches/28 days)lortab tab 10-325mg (hydrocodone-acetaminophen)
T1 QL (28 tabs/28 days)lortab tab 5-325mg (hydrocodone-acetaminophen)
T1 QL (28 tabs/28 days)lortab tab 7.5-325 (hydrocodone-acetaminophen)
T1meperidine inj 100mg/ml
T1meperidine inj 10mg/ml
T1meperidine inj 25mg/ml
T1meperidine inj 50mg/ml
T1meperidine sol 50mg/5ml
T1meperidine tab 100mg
T1meperidine tab 50mg
T1meperitab tab 100mg (meperidine)
T1meperitab tab 50mg (meperidine)
T1methadone sol 10mg/5ml
T1methadone sol 5mg/5ml
T1methadone tab 10mg
T1methadone tab 5mg
T1 QL (60 caps/30 days)morphine sul cap 100mg er
T1 PA, QL (30 caps/30 days)morphine sul cap 120mg er
T1 QL (60 caps/30 days)morphine sul cap 20mg er
T1 PA, QL (60 caps/30 days)morphine sul cap 30mg er
T1 QL (60 caps/30 days)morphine sul cap 30mg er
T1 PA, QL (60 caps/30 days)morphine sul cap 45mg er
T1 QL (90 caps/30 days)morphine sul cap 50mg er
T1 PA, QL (30 caps/30 days)morphine sul cap 60mg er
T1 QL (90 caps/30 days)morphine sul cap 60mg er
51Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICS
OPIATE AGONISTS
T1 PA, QL (30 caps/30 days)morphine sul cap 75mg er
T1 QL (90 caps/30 days)morphine sul cap 80mg er
T1 PA, QL (30 caps/30 days)morphine sul cap 90mg er
T1morphine sul inj 0.5mg/ml
T1morphine sul inj 10mg/ml
T1morphine sul inj 150/30ml
T1morphine sul inj 15mg/ml
T1morphine sul inj 1mg/ml
T1morphine sul inj 25mg/ml
T1morphine sul inj 2mg/ml
T1morphine sul inj 4mg/ml
T1morphine sul inj 50mg/ml
T1morphine sul inj 8mg/ml
T1morphine sul sol 10/0.5ml
T1morphine sul sol 100/5ml
T1morphine sul sol 10mg/5ml
T1morphine sul sol 20mg/5ml
T1morphine sul sol 20mg/ml
T1morphine sul sup 20mg
T1morphine sul sup 5mg
T1 QLmorphine sul tab 100mg cr
T1 QL (90 tabs/30 days)morphine sul tab 100mg er
T1 QL (120 tabs/30 days)morphine sul tab 15mg
T1 QLmorphine sul tab 15mg cr
T1 QL (90 tabs/30 days)morphine sul tab 15mg er
T1 QL (90 tabs/30 days)morphine sul tab 200mg er
T1 QL (120 tabs/30 days)morphine sul tab 30mg
T1 QLmorphine sul tab 30mg cr
T1 QL (90 tabs/30 days)morphine sul tab 30mg er
T1 QLmorphine sul tab 60mg cr
T1 QL (90 tabs/30 days)morphine sul tab 60mg er
52Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICS
OPIATE AGONISTS
T3 PA, QL (180 tabs/30 days) morphine, oxycodone
NUCYNTA TAB 100MG (tapentadol)
T3 PA, QL (180 tabs/30 days) morphine, oxycodone
NUCYNTA TAB 75MG (tapentadol)
T3 PA, QL (60 tabs/30 days) morphine, oxycodone
NUCYNTA ER TAB 100MG (tapentadol)
T3 PA, QL (60 tabs/30 days) morphine, oxycodone
NUCYNTA ER TAB 200MG (tapentadol)
T1 QL (180 abs/30 days)
T1 QL (180 tabs/30 days)
T1 QL (180 tabs/30 days)
T1 QL (180 tabs/30 days)
T1 QL (180 tabs/30 days)
T1 QL (240 tabs/30 days)
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
oxycod/apap tab 10-325mg
oxycod/apap tab 2.5-325
oxycod/apap tab 5-325mg
oxycod/apap tab 7.5-325
oxycod/apap tab 7.5-500
oxycod/ibu tab 5-400mg
oxycodone cap 5mg
oxycodone sol 5mg/5ml
oxycodone tab 10mg
oxycodone tab 10mg er
oxycodone tab 15mg
oxycodone tab 20mg
oxycodone tab 20mg er
oxycodone tab 30mg
oxycodone tab 40mg er
oxycodone tab 5mg
oxycodone tab 80mg er e)
T1
QL (150 caps/30 days)
QL (500ml/30 days)
QL (120 tabs/30 days
PA, QL
QL (120 tabs/30 days)
QL (120 tabs/30 days)
PA, QL
QL
PA,QL
QL
PA, QL
PA, QL (60 tabs/30 days)oxymorphone tab 10mg er
T1 PA, QL (60 tabs/30 days)oxymorphone tab 15mg er
T1 PA, QL (60 tabs/30 days)oxymorphone tab 20mg er
T1 PA, QL (60 tabs/30 days)oxymorphone tab 30mg er
T1 PA, QL (60 tabs/30 days)oxymorphone tab 40mg er
T1 PA, QL (60 tabs/30 days)oxymorphone tab 5mg er
53Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANALGESICS AND ANTIPYRETICS
OPIATE AGONISTS
T1 PA, QL (60 tabs/30 days)oxymorphone tab 7.5mg er
T1 PA, QL (60 tabs/30 days)oxymorphone tab hcl 10mg
T1 PA, QL (60 tabs/30 days)oxymorphone tab hcl 5mg
T1 QLroxicet tab 5-325mg (oxycodone)
T1 QL (240 tabs/30 days)tramadl/apap tab 37.5-325
T1tramadol hcl tab 100mg er
T1tramadol hcl tab 200mg er
T1tramadol hcl tab 300mg er
T1tramadol hcl tab 50mg
T1 PA, QL
T1 PA, QL
T3
T1
T1
OPIATE PARTIAL AGONISTS
bupren/nalox sub 2-0.5mg
bupren/nalox sub 8-2mg
NARCAN SPRAY
buprenorphin sub 2mg
buprenorphin sub 8mg
T1 QLbutorphanol inj 1mg/ml
T1 QL (2.5ml/14 days)butorphanol sol 10mg/ml
T3 PA, QL (4 patches/28 days)BUTRANS DIS 10MCG/HR (buprenorphine)
T3 PA, QL (4 patches/28 days)BUTRANS DIS 15MCG/HR (buprenorphine)
T3 PA, QL (4 patches/28 days)BUTRANS DIS 20MCG/HR (buprenorphine)
T3 PA, QL (4 patches/28 days)BUTRANS DIS 5MCG/HR (buprenorphine)
T3 PA, QL (4 patches/28 days)BUTRANS DIS 7.5/HR (buprenorphine)
T1penta/apap tab 25-650mg
T1pentaz/nalox tab 50-0.5mg
ANOREXIGENICS AGENTS AND RESPIRATORY AND CNS STIMULANTSAMPHETAMINES
T1 QL (60 caps/30 days)amphetamine cap 10mg er
T1 QL (60 caps/30 days)amphetamine cap 15mg er
T1 QL (60 caps/30 days)amphetamine cap 20mg er
T1 QL (60 caps/30 days)amphetamine cap 25mg er
T1 QL (60 caps/30 days)amphetamine cap 30mg er
T1 QL (60 caps/30 days)amphetamine cap 5mg er
54Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANOREXIGENICS AGENTS AND RESPIRATORY AND CNS STIMULANTS
AMPHETAMINES
T1 QL (60 caps/30 days)amphetamine tab 10mg
T1 QL (60 caps/30 days)amphetamine tab 12.5mg
T1 QL (60 tabs/30 days)amphetamine tab 15mg
T1 QL (60 tabs/30 days)amphetamine tab 20mg
T1 QL (60 tabs/30 days)amphetamine tab 30mg
T1 QL (60 tabs/30 days)amphetamine tab 5mg
T1 QLamphetamine tab 7.5mg
T1benzphetamin tab 50mg
T1 QL (120 tabs/30 days)dexedrine tab 10mg (dextroamphetamine)
T1 QL (180 tabs/30 days)dexedrine tab 5mg (dextroamphetamine)
T1 QL (120 tabs/30 days)dextroamphet cap 10mg er
T1 QL (120 tabs/30 days)dextroamphet cap 15mg er
T1 QL (120 tabs/30 days)dextroamphet cap 5mg er
T1 QL (120 tabs/30 days)dextroamphet tab 10mg
T1 QL (28 tabs/28 days)dextroamphet tab 5mg
T1methamphetam tab 5mg
T3 PA, QL (30 caps/30 days) amphetamine-dextroamphetamine
VYVANSE CAP 10MG (lisdexamfetamine)
T3 PA, QL (30 caps/30 days) amphetamine-dextroamphetamine
VYVANSE CAP 20MG (lisdexamfetamine)
T3 PA, QL (30 caps/30 days) amphetamine-dextroamphetamine
VYVANSE CAP 30MG (lisdexamfetamine)
T3 PA, QL (30 caps/30 days) amphetamine-dextroamphetamine
VYVANSE CAP 40MG (lisdexamfetamine)
T3 PA, QL (30 caps/30 days) amphetamine-dextroamphetamine
VYVANSE CAP 50MG (lisdexamfetamine)
T3 PA, QL (30 caps/30 days) amphetamine-dextroamphetamine
VYVANSE CAP 60MG (lisdexamfetamine)
T3 PA, QL (30 caps/30 days) amphetamine-dextroamphetamine
VYVANSE CAP 70MG (lisdexamfetamine)
ANOREXIGENIC AGENTS
T3 PABELVIQ TAB 10MG (lorcaserin)
T1diethylprop tab 75mg er
T1phentermine tab 37.5mg
55Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANOREXIGENICS AGENTS AND RESPIRATORY AND CNS STIMULANTS
RESPIRATORY AND CNS STIMULANTS
T3 PA, QL (30 patches/30 days) methylphenidateDAYTRANA DIS 10MG/9HR (methylphenidate)
T3 PA, QL (30 patches/30 days) methylphenidateDAYTRANA DIS 15MG/9HR (methylphenidate)
T3 PA, QL (30 patches/30 days) methylphenidateDAYTRANA DIS 20MG/9HR (methylphenidate)
T3 PA, QL (30 patches/30 days) methylphenidateDAYTRANA DIS 30MG/9HR (methylphenidate)
T1 PAdexmethylph cap 15mg er
T1 PAdexmethylph cap 30mg er
T1 PAdexmethylph cap 40mg er
T1 QL (90 tabs/30 days)
T1 QL (90 tabs/30 days)
T1 QL (90 tabs/30 days)
T1 PA, QL
T1 PA, QL
T1 PA, QL
T1 PA, QL
dexmethylph tab 10mg
dexmethylph tab 2.5mg
dexmethylph tab 5mg
dexmethylphe cap 10mg er
dexmethylphe cap 20mg er
dexmethylphe cap 5mg er
dexmethylphenidate cap 30mg er
T1 PA, QL dexmethylphenidate cap 40mg er
T1 QL (60 tabs/30 days)metadate tab 20mg er (methylphenidate)
T1 QL (28 tabs/28 days)methylphenid cap 10mg
T1 QL (28 tabs/28 days)methylphenid cap 20mg
T1 QL (60 tabs/30 days)methylphenid cap 20mg er
T1 QL (28 tabs/28 days)methylphenid cap 30mg
T1 QL (60 tabs/30 days)methylphenid cap 30mg er
T1 QL (60 caps/30 days)methylphenid cap 40mg
T1 QL (60 tabs/30 days)methylphenid cap 40mg er
T1 QL (60 caps/30 days)methylphenid cap 50mg
T1 QL (30 caps/30 days)methylphenid cap 60mg
T1methylphenid sol 10mg/5ml
T1methylphenid sol 5mg/5ml
56Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANOREXIGENICS AGENTS AND RESPIRATORY AND CNS STIMULANTS
RESPIRATORY AND CNS STIMULANTS
T1 QL (28 tabs/28 days)methylphenid tab 10mg
T1 QL (60 tabs/30 days)methylphenid tab 10mg er
T1 QLmethylphenid tab 18mg er
T1 QL (60 tabs/30 days)methylphenid tab 18mg er
T1 QL (28 tabs/28 days)methylphenid tab 20mg
T1 QL (60 tabs/30 days)methylphenid tab 20mg er
T1 QL (60 tabs/30 days)methylphenid tab 20mg sr
T1 QLmethylphenid tab 27mg er
T1 QL (60 tabs/30 days)methylphenid tab 27mg er
T1 QLmethylphenid tab 36mg er
T1 QL (60 tabs/30 days)methylphenid tab 36mg er
T1 QLmethylphenid tab 54mg er
T1 QL (60 tabs/30 days)methylphenid tab 54mg er
T1 QL (28 tabs/28 days)methylphenid tab 5mg
WAKEFULNESS-PROMOTING AGENTS
T1 PA, QL (60 tabs/30 days)modafinil tab 100mg
T1 PA, QL (60 tabs/30 days)modafinil tab 200mg
T3 PA, QL (30 tabs/30 days) modafinilNUVIGIL TAB 150MG (armodafinil)
T3 PA, QL (30 tabs/30 days) modafinilNUVIGIL TAB 200MG (armodafinil)
T3 PA, QL (30 tabs/30 days) modafinilNUVIGIL TAB 250MG (armodafinil)
ANTICONVULSANTSANTICONVULSANTS, MISCELLANEOUS
T3 QL (240 tabs/30 days) carbamazepine, divalproex, lamotrigine, levetiracetam, topiramate, zonisamide
BANZEL TAB 200MG (rufinamide)
T3 QL (240 tabs/30 days) carbamazepine, divalproex, lamotrigine, levetiracetam, topiramate, zonisamide
BANZEL TAB 400MG (rufinamide)
T1carbamazepin cap 100mg er
57Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANTICONVULSANTS
ANTICONVULSANTS, MISCELLANEOUS
T1carbamazepin cap 200mg er
T1carbamazepin cap 300mg er
T1carbamazepin chw 100mg
T1carbamazepin sus 100/5ml
T1carbamazepin tab 200mg
T1carbamazepin tab 200mg er
T1carbamazepin tab 400mg er
T1divalproex cap 125mg
T1divalproex tab 125mg dr
T1divalproex tab 250mg dr
T1divalproex tab 250mg er
T1divalproex tab 500mg dr
T1divalproex tab 500mg er
T1epitol tab 200mg (carbamazepine)
T1felbamate sus 600/5ml
T1felbamate tab 400mg
T1felbamate tab 600mg
T1gabapentin cap 100mg
T1gabapentin cap 300mg
T1gabapentin cap 400mg
T1gabapentin sol 250/5ml
T1gabapentin tab 600mg
T1gabapentin tab 800mg
T3 PAHORIZANT TAB 300MG (gabapentin)
T3 PAHORIZANT TAB 600MG (gabapentin)
T1 PALAMICTAL CHW 25MG (lamotrigine)
T1 PALAMICTAL CHW 5MG (lamotrigine)
T3 PA, QL (1 kit/fill, 1 fill per 365 days)
LAMICTAL KIT START 49 (lamotrigine)
T1 PAlamotrigine chw 25mg
T1 PAlamotrigine chw 5mg
T1lamotrigine tab 100mg
58Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANTICONVULSANTS
ANTICONVULSANTS, MISCELLANEOUS
T1 QL (30 tabs/30 days)lamotrigine tab 100mg er
T1lamotrigine tab 150mg
T1lamotrigine tab 200mg
T1 QL (30 tabs/30 days)lamotrigine tab 200mg er
T1 QL (30 tabs/30 days)lamotrigine tab 250mg er
T1lamotrigine tab 25mg
T1 QL (30 tabs/30 days)lamotrigine tab 25mg er
T1 QL (30 tabs/30 days)lamotrigine tab 300mg er
T1 QL (30 tabs/30 days)lamotrigine tab 50mg er
T1levetiraceta sol 100mg/ml
T1levetiraceta sol 500/5ml
T1levetiraceta tab 1000mg
T1levetiraceta tab 250mg
T1levetiraceta tab 500mg
T1 QLlevetiraceta tab 500mg er
T1levetiraceta tab 750mg
T1 QLlevetiraceta tab 750mg er
T1levetiracetm inj 500/5ml
T3 PA, QL (60 caps/30 days) gabapentinLYRICA CAP 100MG (pregabalin)
T3 PA, QL (60 caps/30 days) gabapentinLYRICA CAP 150MG (pregabalin)
T3 PA, QL (60 caps/30 days) gabapentinLYRICA CAP 200MG (pregabalin)
T3 PA, QL (60 caps/30 days) gabapentinLYRICA CAP 225MG (pregabalin)
T3 PA, QL (60 caps/30 days) gabapentinLYRICA CAP 25MG (pregabalin)
T3 PA, QL (60 caps/30 days) gabapentinLYRICA CAP 300MG (pregabalin)
T3 PA, QL (60 caps/30 days) gabapentinLYRICA CAP 50MG (pregabalin)
T3 PA, QL (60 caps/30 days) gabapentinLYRICA CAP 75MG (pregabalin)
T1oxcarbazepin sus 300mg/5m
T1oxcarbazepin tab 150mg
T1oxcarbazepin tab 300mg
T1oxcarbazepin tab 600mg
59Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANTICONVULSANTS
ANTICONVULSANTS, MISCELLANEOUS
T3 QL (180 tabs/30 days) carbamazepine, divalproex, lamotrigine, levetiracetam, topiramate, zonisamide
POTIGA TAB 200MG (ezogabine)
T3 QL (180 tabs/30 days) carbamazepine, divalproex, lamotrigine, levetiracetam, topiramate, zonisamide
POTIGA TAB 300MG (ezogabine)
T3 QL (180 tabs/30 days) carbamazepine, divalproex, lamotrigine, levetiracetam, topiramate, zonisamide
POTIGA TAB 400MG (ezogabine)
T3 QL (180 tabs/30 days) carbamazepine, divalproex, lamotrigine, levetiracetam, topiramate, zonisamide
POTIGA TAB 50MG (ezogabine)
T3 QL (210 packets/30 days) carbamazepine, divalproex, lamotrigine, levetiracetam, topiramate, zonisamide
SABRIL POW 500MG (vigabatrin)
T3 QL (360 tabs/30 days) carbamazepine, divalproex, lamotrigine, levetiracetam, topiramate, zonisamide
SABRIL TAB 500MG (vigabatrin)
T3 PA divalproex, valproate, valproic
STAVZOR CAP 125MG (valproic)
T3 PA divalproex, valproate, valproic
STAVZOR CAP 250MG (valproic)
T3 PA divalproex, valproate, valproic
STAVZOR CAP 500MG (valproic)
T1tiagabine tab 2mg
60Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANTICONVULSANTS
ANTICONVULSANTS, MISCELLANEOUS
T1tiagabine tab 4mg
T1topiragen tab 100mg (topiramate)
T1topiragen tab 200mg (topiramate)
T1topiragen tab 25mg (topiramate)
T1topiragen tab 50mg (topiramate)
T1topiramate cap 15mg
T1topiramate cap 25mg
T1topiramate tab 100mg
T1topiramate tab 200mg
T1topiramate tab 25mg
T1topiramate tab 50mg
T1valproate inj 100mg/ml
T1valproate inj 500/5ml
T1valproic acd cap 250mg
T1valproic acd sol 250/5ml
T1valproic acd syp 250/5ml
T3 carbamazepine, divalproex, lamotrigine, levetiracetam, topiramate, zonisamide
VIMPAT INJ 200MG/20 (lacosamide)
T3 QL (1200 ml/30 days) carbamazepine, divalproex, lamotrigine, levetiracetam, topiramate, zonisamide
VIMPAT SOL 10MG/ML (lacosamide)
T3 QL (60 tabs/30 days) carbamazepine, divalproex, lamotrigine, levetiracetam, topiramate, zonisamide
VIMPAT TAB 100MG (lacosamide)
61Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANTICONVULSANTS
ANTICONVULSANTS, MISCELLANEOUS
T3 QL (60 tabs/30 days) carbamazepine, divalproex, lamotrigine, levetiracetam, topiramate, zonisamide
VIMPAT TAB 150MG (lacosamide)
T3 QL (60 tabs/30 days) carbamazepine, divalproex, lamotrigine, levetiracetam, topiramate, zonisamide
VIMPAT TAB 200MG (lacosamide)
T3 QL (60 tabs/30 days) carbamazepine, divalproex, lamotrigine, levetiracetam, topiramate, zonisamide
VIMPAT TAB 50MG (lacosamide)
T1zonisamide cap 100mg
T1zonisamide cap 25mg
T1zonisamide cap 50mg
BARBITURATES (ANTICONVULSANTS)
T1primidone tab 250mg
T1primidone tab 50mg
BENZODIAZEPINES (ANTICONVULSANTS)
T1clonazep odt tab 0.125mg
T1clonazep odt tab 0.25mg
T1clonazep odt tab 0.5mg
T1clonazep odt tab 1mg
T1clonazep odt tab 2mg
T1clonazepam tab 0.5mg
T1clonazepam tab 1mg
T1clonazepam tab 2mg
T3 QL (60 tabs/30 days) clonazepam, lamotrigine, topiramate
ONFI TAB 10MG (clobazam)
62Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANTICONVULSANTS
BENZODIAZEPINES (ANTICONVULSANTS)
T3 QL (60 tabs/30 days) clonazepam, lamotrigine, topiramate
ONFI TAB 20MG (clobazam)
T3 QL (60 tabs/30 days) clonazepam, lamotrigine, topiramate
ONFI TAB 5MG (clobazam)
HYDANTOINS
T2DILANTIN CAP 30MG (phenytoin)
T2DILANTIN CHW 50MG (phenytoin)
T2DILANTIN-125 SUS 125/5ML (phenytoin)
T2PEGANONE TAB 250MG (ethotoin)
T2PHENYTEK CAP 200MG (phenytoin)
T2PHENYTEK CAP 300MG (phenytoin)
T1phenytoin chw 50mg (phenytoin)
T1phenytoin inj 50mg/ml
T1phenytoin sus 125/5ml
T1phenytoin ex cap 100mg
T1phenytoin ex cap 200mg
T1phenytoin ex cap 300mg
SUCCINIMIDES
T2 QL (120 caps/30 days)CELONTIN CAP 300MG (methsuximide)
T1 QL (210 caps/30 days)ethosuximide cap 250mg
T1ethosuximide sol 250/5ml
ANTIMANIC AGENTS
T1lithium sol 8meq/5ml
T1lithium carb cap 150mg
T1lithium carb cap 300mg
T1lithium carb cap 600mg
T1lithium carb tab 300mg
T1lithium carb tab 300mg er
T1lithium carb tab 450mg er
63Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANTIMIGRAINE AGENTS
SELECTIVE SEROTONIN AGONISTS
T1 PAalmotrip mal tab 12.5mg
T1 PAalmotrip mal tab 6.25mg
T1 PAalmotriptan tab 12.5mg
T1 PAalmotriptan tab 6.25mg
T3 PA, QL (12 tabs/30 days) naratriptan, rizatriptan, sumatriptan
FROVA TAB 2.5MG (frovatriptan)
T1
T1
T3
QL (12 tabs/30 days)
QL (12 tabs/30 days)
PA, QL (12 tabs/30 days) naratriptan, rizatriptan, sumatriptan
I
naratriptan tab 1mg
naratriptan tab 2.5mg
RELPAX TAB 20MG (eletriptan)
T3 PA, QL (12 tabs/30 days) naratriptan, rizatriptan, sumatriptan
RELPAX TAB 40MG (eletriptan)
T1 QL (12 tabs/30 days)rizatriptan tab 10mg
T1 QL (12 tabs/30 days)rizatriptan tab 10mg odt
T1 QL (12 tabs/30 days)rizatriptan tab 5mg
T1 QL (12 tabs/30 days)rizatriptan tab 5mg odt
T1 QL (12 units/30 days)sumatriptan inj 4mg/0.5
T1 QLsumatriptan inj 4mg/0.5
T1 QL (12 units/30 days)sumatriptan inj 6mg/0.5
T1 QLsumatriptan spr 5mg/act
T1 QL (18 tabs/30 days)sumatriptan tab 100mg
T1 QL (18 tabs/30 days)sumatriptan tab 25mg
T1 QL (18 tabs/30 days)sumatriptan tab 50mg
T1 PA, QL (12 tabs/30 days)zolmitriptan tab 2.5mg
T1 PA, QL (12 tabs/30 days)zolmitriptan tab 5mg
ANTIPARKINSONIAN AGENTS (CNS)ADAMANTANES (CNS)
T1amantadine cap 100mg
T1amantadine syp 50mg/5ml
T1amantadine tab 100mg
64Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANTIPARKINSONIAN AGENTS (CNS)
ANTICHOLINERGIC AGENTS (CNS)
T1benztropine tab 0.5mg
T1trihexyphen elx 0.4mg/ml
T1trihexyphen tab 2mg
T1trihexyphen tab 5mg
CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.
T1entacapone tab 200mg
T1tolcapone tab 100mg
DOPAMINE PRECURSORS
T1carb/levo tab 10-100mg
T1carb/levo tab 25-250mg
T1carb/levo 50 tab /entacap
T1carb/levo 75 tab /entacap
T1carb/levo er tab 25-100mg
T1carb/levo er tab 50-200mg
T1carb/levo sr tab 50-200mg
T1carb/levo100 tab /entacap
T1carb/levo125 tab /entacap
T1carb/levo150 tab /entacap
T1carb/levo200 tab /entacap
T1carbidopa tab 25mg
DOPAMINE RECEPTOR AGONISTS
T1bromocriptin cap 5mg
T1bromocriptin tab 2.5mg
T1cabergoline tab 0.5mg
T3 QL (30 tabs/30 days)MIRAPEX ER TAB 2.25MG (pramipexole)
T3NEUPRO DIS 1MG/24HR (rotigotine)
T3NEUPRO DIS 2MG/24HR (rotigotine)
T3NEUPRO DIS 3MG/24HR (rotigotine)
T3 PA, QL (30 patches/30 days)NEUPRO DIS 4MG/24HR (rotigotine)
T3 PA, QL (30 patches/30 days)NEUPRO DIS 6MG/24HR (rotigotine)
T3 PA, QL (30 patches/30 days)NEUPRO DIS 8MG/24HR (rotigotine)
T1pramipexole tab 0.125mg
65Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANTIPARKINSONIAN AGENTS (CNS)
DOPAMINE RECEPTOR AGONISTS
T1pramipexole tab 0.25mg
T1 QLpramipexole tab 0.375mg
T1pramipexole tab 0.5mg
T1pramipexole tab 0.75mg
T1pramipexole tab 1.5mg
T1pramipexole tab 1mg
T1requip tab 1mg (ropinirole)
T1ropinirole tab 0.25mg
T1ropinirole tab 0.5mg
T1ropinirole tab 12mg er
T1ropinirole tab 1mg
T1ropinirole tab 2mg
T1ropinirole tab 2mg er
T1ropinirole tab 3mg
T1ropinirole tab 4mg
T1ropinirole tab 4mg er
T1ropinirole tab 5mg
T1ropinirole tab 6mg er
T1ropinirole tab 8mg er
MONOAMINE OXIDASE B INHIBITORS
T3 QL (30 tabs/30 days)AZILECT TAB 0.5MG (rasagiline)
T3 QL (30 tabs/30 days)AZILECT TAB 1MG (rasagiline)
T3 PA, QL (30 patches/30 days) amitriptyline, duloxetine, paroxetine, venlafaxine
EMSAM DIS 12MG/24H (selegiline)
T3 PA, QL (30 patches/30 days) amitriptyline, duloxetine, paroxetine, venlafaxine
EMSAM DIS 6MG/24HR (selegiline)
T3 PA, QL (30 patches/30 days) amitriptyline, duloxetine, paroxetine, venlafaxine
EMSAM DIS 9MG/24HR (selegiline)
T1selegiline cap 5mg
66Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANXIOLYTICS, SEDATIVES AND HYPNOTICS
ANXIOLYTICS, SEDATIVES & HYPNOTICS,MISC.
T1buspirone tab 10mg
T1buspirone tab 15mg
T1buspirone tab 30mg
T1buspirone tab 5mg
T1buspirone tab 7.5mg
T1 QL (30 tabs/30 days) zolpidemeszopiclone tab 1mg
T1 QL (30 tabs/30 days) zolpidemeszopiclone tab 2mg
T1 QL (30 tabs/30 days) zolpidemeszopiclone tab 3mg
T1hydroxyz hcl sol 10mg/5ml
T1hydroxyz hcl syp 10mg/5ml
T1hydroxyz hcl tab 10mg
T1hydroxyz hcl tab 25mg
T1hydroxyz hcl tab 50mg
T1hydroxyz pam cap 100mg
T1hydroxyz pam cap 25mg
T1hydroxyz pam cap 50mg
T1meprobamate tab 200mg
T1meprobamate tab 400mg
T3 PA, QL (30 tabs/30 days) zolpidemROZEREM TAB 8MG (ramelteon)
T1zaleplon cap 10mg
T1zaleplon cap 5mg
T1 QL (30 tabs/30 days)zolpidem tab 10mg
T1 QL (30 tabs/30 days)zolpidem tab 5mg
T1zolpidem er tab 12.5mg
T1 QL (30 tabs/30 days)zolpidem er tab 6.25mg
BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)
T1phenobarb elx 20mg/5ml
T1phenobarb sol 20mg/5ml
T1phenobarb tab 100mg
T1phenobarb tab 15mg
T1phenobarb tab 16.2mg
67Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANXIOLYTICS, SEDATIVES AND HYPNOTICS
BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)
T1phenobarb tab 30mg
T1phenobarb tab 32.4mg
T1phenobarb tab 60mg
T1phenobarb tab 64.8mg
T1phenobarb tab 97.2mg
BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)
T1alprazolam tab 0.25 odt
T1alprazolam tab 0.25mg
T1alprazolam tab 0.5mg
T1alprazolam tab 0.5mg er
T1alprazolam tab 0.5mg od
T1alprazolam tab 0.5mg xr (alprazolam)
T1alprazolam tab 1mg
T1alprazolam tab 1mg er
T1alprazolam tab 1mg odt
T1alprazolam tab 1mg xr (alprazolam)
T1alprazolam tab 2mg
T1alprazolam tab 2mg er
T1alprazolam tab 2mg odt
T1alprazolam tab 2mg xr (alprazolam)
T1alprazolam tab 3mg er
T1alprazolam tab 3mg xr (alprazolam)
T1chlordiazep cap 10mg
T1chlordiazep cap 25mg
T1chlordiazep cap 5mg
T1cloraz dipot tab 15mg
T1cloraz dipot tab 3.75mg
T1cloraz dipot tab 7.5mg
T1diazepam gel 10mg
T1diazepam gel 2.5mg
T1diazepam gel 20mg
68Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSANXIOLYTICS, SEDATIVES AND HYPNOTICS
BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)
T1diazepam inj 5mg/ml
T1diazepam sol 1mg/ml
T1diazepam sol 5mg/5ml
T1diazepam tab 10mg
T1diazepam tab 2mg
T1diazepam tab 5mg
T1estazolam tab 1mg
T1estazolam tab 2mg
T1flurazepam cap 15mg
T1flurazepam cap 30mg
T1lorazepam tab 0.5mg
T1lorazepam tab 1mg
T1lorazepam tab 2mg
T1midazolam syp 2mg/ml
T1oxazepam cap 10mg
T1oxazepam cap 15mg
T1oxazepam cap 30mg
T1temazepam cap 15mg
T1temazepam cap 22.5mg
T1temazepam cap 30mg
T1temazepam cap 7.5mg
T1triazolam tab 0.125mg
T1triazolam tab 0.25mg
CENTRAL NERVOUS SYSTEM AGENTS, MISC.
T1acampro cal tab 333mg
T1 PAguanfacine tab 1mg er
T1 PAguanfacine tab 2mg er
T1 PAguanfacine tab 3mg er
T1 PAguanfacine tab 4mg er
T1memantine tab hcl 5mg
T1memantine hc tab 10mg
69Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSCENTRAL NERVOUS SYSTEM AGENTS, MISC.
T1 ST (donepezil)
T1 ST (donepezil)
T1 ST (donepezil)
T3 PA, QL (60 caps/30 days)
T1
T3 PA, QL (30 caps/30 days)
T3 PA, QL (60 caps/30 days)
memantine sol 10mg/5ml
memantine tab 10mg
memantibe tab 5mg
NUEDEXTA CAP 20-10MG (dextromethorphan)
riluzole tab 50mg
STRATTERA CAP 100MG (atomoxetine)
STRATTERA CAP 10MG (atomoxetine)T3 PA, QL (60 caps/30 days)STRATTERA CAP 18MG (atomoxetine)
T3 PA, QL (60 caps/30 days)STRATTERA CAP 25MG (atomoxetine)
T3 PA, QL (60 caps/30 days)STRATTERA CAP 40MG (atomoxetine)
T3 PA, QL (60 caps/30 days)STRATTERA CAP 60MG (atomoxetine)
T3 PA, QL (30 caps/30 days)STRATTERA CAP 80MG (atomoxetine)
T4 PAtetrabenazin tab 12.5mg
T4 PAtetrabenazin tab 25mg
T4 PA, QL (540 ml/30 days)XYREM SOL 500MG/ML (sodium)
FIBROMYALGIA AGENTS
T3 PA, QL (60 tabs/30 days)SAVELLA MIS TITR PAK (milnacipran)
T3 PA, QL (60 tabs/30 days)SAVELLA TAB 100MG (milnacipran)
T3 PA, QL (60 tabs/30 days)SAVELLA TAB 25MG (milnacipran)
T3 PA, QL (60 tabs/30 days)SAVELLA TAB 50MG (milnacipran)
OPIATE ANTAGONISTS
T1naloxone inj 1mg/ml
T1naltrexone tab 50mg
MED PA, SP Medical coinsuranceVIVITROL INJ 380MG (naltrexone)
PSYCHOTHERAPEUTIC AGENTSANTIDEPRESSANTS
T1amitriptylin tab 100mg
T1amitriptylin tab 10mg
T1amitriptylin tab 150mg
T1amitriptylin tab 25mg
T1amitriptylin tab 50mg
T1amitriptylin tab 75mg
70Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSPSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
T1amoxapine tab 100mg
T1amoxapine tab 150mg
T1amoxapine tab 25mg
T1amoxapine tab 50mg
T1budeprion tab 100mg sr (bupropion)
T1budeprion tab 150mg sr (bupropion)
T1bupropion tab 100mg
T1bupropion tab 100mg er
T1bupropion tab 100mg sr
T1bupropion tab 150mg er
T1bupropion tab 150mg sr
T1bupropion tab 200mg er
T1bupropion tab 200mg sr
T1bupropion tab 75mg
T0 QL (30 tabs/30 days) HCR Rules for Coveragebupropion hcl (smoking deterrent) tab 150 mg
T1bupropn hcl tab 150mg xl
T1bupropn hcl tab 300mg xl
T1citalopram sol 10mg/5ml
T1citalopram tab 10mg
T1citalopram tab 20mg
T1citalopram tab 40mg
T1clomipramine cap 25mg
T1clomipramine cap 50mg
T1clomipramine cap 75mg
T1desipramine tab 100mg
T1desipramine tab 10mg
T1desipramine tab 150mg
T1desipramine tab 25mg
T1desipramine tab 50mg
T1desipramine tab 75mg
T1 PAdesvenlafax tab 100mg er
71Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSPSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
T1 PAdesvenlafax tab 50mg er
T1doxepin hcl cap 100mg
T1doxepin hcl cap 10mg
T1doxepin hcl cap 150mg
T1doxepin hcl cap 25mg
T1doxepin hcl cap 50mg
T1doxepin hcl cap 75mg
T1doxepin hcl con 10mg/ml
T1 QL (60 caps/30 days)duloxetine cap 20mg
T1 QL (60 caps/30 days)duloxetine cap 30mg
T1 QL (60 caps/30 days)duloxetine cap 60mg
T1escitalopram sol 5mg/5ml
T1escitalopram tab 10mg
T1escitalopram tab 20mg
T1escitalopram tab 5mg
T1fluoxetine cap 10mg
T1fluoxetine cap 20mg
T1fluoxetine cap 40mg
T1 PAfluoxetine cap 90mg dr
T1fluoxetine sol 20mg/5ml
T1fluoxetine tab 10mg
T1fluoxetine tab 20mg
T1fluvoxamine tab 100mg
T1fluvoxamine tab 25mg
T1fluvoxamine tab 50mg
T1imipram hcl tab 10mg
T1imipram hcl tab 25mg
T1imipram hcl tab 50mg
T1imipram pam cap 100mg
T1imipram pam cap 125mg
T1imipram pam cap 150mg
72Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSPSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
T1imipram pam cap 75mg
T1 PAmaprotiline tab 25mg
T1 PAmaprotiline tab 50mg
T1 PAmaprotiline tab 75mg
T3 QL (180 tabs/30 days) amitriptyline, duloxetine, paroxetine, venlafaxine
MARPLAN TAB 10MG (isocarboxazid)
T1mirtazapine tab 15mg
T1mirtazapine tab 15mg odt
T1mirtazapine tab 30mg
T1mirtazapine tab 30mg odt
T1mirtazapine tab 45mg
T1mirtazapine tab 45mg odt
T1mirtazapine tab 7.5mg
T1nefazodone tab 100mg
T1nefazodone tab 150mg
T1nefazodone tab 200mg
T1nefazodone tab 250mg
T1nefazodone tab 50mg
T1nortriptylin cap 10mg
T1nortriptylin cap 25mg
T1nortriptylin cap 50mg
T1nortriptylin cap 75mg
T1nortriptylin sol 10mg/5ml
T1 QL (30 caps/30 days)olanza/fluox cap 12-25mg
T1 QL (30 caps/30 days)olanza/fluox cap 12-50mg
T1 QL (30 caps/30 days)olanza/fluox cap 6-25mg
T1 QL (30 caps/30 days)olanza/fluox cap 6-50mg
T1 QL (30 tabs/30 days)paroxetine tab 10mg
T1 QL (30 tabs/30 days)paroxetine tab 20mg
T1 QL (30 tabs/30 days)paroxetine tab 30mg
T1 QL (30 tabs/30 days)paroxetine tab 40mg
73Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSPSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
T1phenelzine tab 15mg
T1 venlafaxine
T1 venlafaxine
desvenlafaxine tab 100mg er
desvenlafaxine tab 50mg er
PA, QL (30 tabs/30 days)
PA, QL (30 tabs/30 days)
T1protriptylin tab 10mg
T1protriptylin tab 5mg
T1sertraline con 20mg/ml
T1sertraline tab 100mg
T1sertraline tab 25mg
T1sertraline tab 50mg
T1tranylcyprom tab 10mg
T1trazodone tab 100mg
T1trazodone tab 150mg
T1trazodone tab 300mg
T1trazodone tab 50mg
T1 QL (60 caps/30 days)venlafaxine cap 150mg er
T1 QL (60 caps/30 days)venlafaxine cap 37.5 er
T1 QL (60 caps/30 days)venlafaxine cap 37.5mg
T1 QL (60 caps/30 days)venlafaxine cap 75mg er
T1 QLvenlafaxine tab 100mg
T1 QLvenlafaxine tab 150mg er
T1 QLvenlafaxine tab 225mg er
T1 QLvenlafaxine tab 25mg
T1 QLvenlafaxine tab 37.5 er
T1 QLvenlafaxine tab 37.5mg
T1 QLvenlafaxine tab 50mg
T1 QLvenlafaxine tab 75mg
T1 QLvenlafaxine tab 75mg er
74Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSPSYCHOTHERAPEUTIC AGENTS
ANTIDEPRESSANTS
T3 PA, QL (30 tabs/30 days) amitriptyline, duloxetine, paroxetine, venlafaxine
VIIBRYD TAB 10MG (vilazodone)
T3 PA, QL (30 tabs/30 days) amitriptyline, duloxetine, paroxetine, venlafaxine
VIIBRYD TAB 20MG (vilazodone)
T3 PA, QL (30 tabs/30 days) amitriptyline, duloxetine, paroxetine, venlafaxine
VIIBRYD TAB 40MG (vilazodone)
ANTIPSYCHOTIC AGENTS
T1 PA olanzapine, quetiapine, risperidone
aripiprazole tab 10mg
75Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSPSYCHOTHERAPEUTIC AGENTS
ANTIPSYCHOTIC AGENTS
T1 PA olanzapine, quetiapine, risperidone
aripiprazole tab 15mg
T1 PA olanzapine, quetiapine, risperidone
aripiprazole tab 20mg
T1 PA olanzapine, quetiapine, risperidone
aripiprazole tab 2mg
T1 PA olanzapine, quetiapine, risperidone
aripiprazole tab 30mg
T1 PA olanzapine, quetiapine, risperidone
aripiprazole tab 5mg
T1chlorpromaz inj 25mg/ml
T1chlorpromaz inj 50mg/2ml
T1chlorpromaz tab 100mg
T1chlorpromaz tab 10mg
T1chlorpromaz tab 200mg
T1chlorpromaz tab 25mg
T1chlorpromaz tab 50mg
T1 QL (150 tabs/30 days)clozapine tab 100mg
T1 QL (150 tabs/30 days)clozapine tab 200mg
T1 QL (150 tabs/30 days)clozapine tab 25mg
T1 QL (150 tabs/30 days)clozapine tab 50mg
T1compazine sup 25mg (prochlorperazine)
T1compro sup 25mg (prochlorperazine)
T3FANAPT TAB 10MG (iloperidone)
T3FANAPT TAB 12MG (iloperidone)
T3FANAPT TAB 1MG (iloperidone)
T3FANAPT TAB 2MG (iloperidone)
T3FANAPT TAB 4MG (iloperidone)
T3FANAPT TAB 6MG (iloperidone)
T3FANAPT TAB 8MG (iloperidone)
76Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSPSYCHOTHERAPEUTIC AGENTS
ANTIPSYCHOTIC AGENTS
T1fluphenazine tab 10mg
T1
T1
T1
T1
T1
T1
T1
T1
T1
T1
T3
fluphenazine tab 1mg
fluphenazine tab 2.5mg
fluphenazine tab 5mg
haloperidol con 2mg/ml
haloperidol tab 0.5mg
haloperidol tab 10mg
haloperidol tab 1mg
haloperidol tab 20mg
haloperidol tab 2mg
haloperidol tab 5mg
T3LATUDA TAB 120MG (lurasidone)
T3LATUDA TAB 20MG (lurasidone)
T3
PA, QL (30 tabs/30 days)
PA, QL (30 tabs/30 days)LATUDA TAB 40MG (lurasidone)
T3LATUDA TAB 60MG (lurasidone)
T3 PA, QL (30 tabs/30 days)LATUDA TAB 80MG (lurasidone)
T1loxapine cap 10mg
T1loxapine cap 25mg
T1loxapine cap 50mg
T1loxapine cap 5mg
T1 QL (30 tabs/30 days)olanzapine tab 10mg
T1 QL (30 tabs/30 days)olanzapine tab 10mg odt
T1 QL (30 tabs/30 days)olanzapine tab 15mg
T1 QL (30 tabs/30 days)olanzapine tab 15mg odt
T1 QL (30 tabs/30 days)olanzapine tab 2.5mg
77Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
PA, QL (30tabs/30days)
PA, QL (30tabs/30days)
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSPSYCHOTHERAPEUTIC AGENTS
ANTIPSYCHOTIC AGENTS
T1 QL (30 tabs/30 days)olanzapine tab 20mg
T1 QL (30 tabs/30 days)olanzapine tab 20mg odt
T1 QL (30 tabs/30 days)olanzapine tab 5mg
T1 QL (30 tabs/30 days)olanzapine tab 5mg odt
T1 QL (30 tabs/30 days)olanzapine tab 7.5mg
T2ORAP TAB 1MG (PIMOZIDE)
T2ORAP TAB 2MG (PIMOZIDE)
T4 PApaliperidone tab er 1.5mg
T4paliperidone tab er 3mg
T4paliperidone tab er 6mg
T4paliperidone tab er 9mg
T1perphenazine tab 16mg
T1perphenazine tab 2mg
T1perphenazine tab 4mg
T1perphenazine tab 8mg
T1prochlorper sup 25mg
T1prochlorper tab 10mg
T1prochlorper tab 5mg
T1 QL (60 tabs/30 days)quetiapine tab 100mg
T1 QL (60 tabs/30 days)quetiapine tab 200mg
T1 QL (60 tabs/30 days)quetiapine tab 25mg
T1 QL (60 tabs/30 days)quetiapine tab 300mg
T1 QL (60 tabs/30 days)quetiapine tab 400mg
T1 QL (60 tabs/30 days)quetiapine tab 50mg
T1risperidone sol 1mg/ml
T1risperidone tab 0.25 odt
T1 QL (280 tabs/30 days)risperidone tab 0.25mg
T1 QL (280 tabs/30 days)risperidone tab 0.5mg
T1risperidone tab 0.5mg od (risperidone)
T1 QL (280 tabs/30 days)risperidone tab 1 mg
T1 QL (280 tabs/30 days)risperidone tab 1mg
78Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CENTRAL NERVOUS SYSTEM AGENTSPSYCHOTHERAPEUTIC AGENTS
ANTIPSYCHOTIC AGENTS
T1 QL (280 tabs/30 days)risperidone tab 1mg odt
T1 QL (280 tabs/30 days)risperidone tab 2mg
T1 QL (280 tabs/30 days)risperidone tab 2mg odt
T1 QL (280 tabs/30 days)risperidone tab 3mg
T1 QL (280 tabs/30 days)risperidone tab 3mg odt
T1 QL (280 tabs/30 days)risperidone tab 4mg
T1 QL (280 tabs/30 days)risperidone tab 4mg odt
T3 PA, QL (60 tabs/30 days)SAPHRIS SUB 10MG (asenapine)
T3 PASAPHRIS SUB 2.5MG (asenapine)
T3 PASAPHRIS SUB 5MG (asenapine)
T3 PA, QL (30 tabs/30 days)SEROQUEL XR TAB 150MG (quetiapine)
T3 PA, QL (30 tabs/30 days)SEROQUEL XR TAB 200MG (quetiapine)
T3 PA, QL (30 tabs/30 days)SEROQUEL XR TAB 300MG (quetiapine)
T3 PA, QL (30 tabs/30 days)SEROQUEL XR TAB 400MG (quetiapine)
T3 PA, QL (30 tabs/30 days)SEROQUEL XR TAB 50MG (quetiapine)
T1thioridazine tab 100mg
T1thioridazine tab 10mg
T1thioridazine tab 25mg
T1thioridazine tab 50mg
T1thiothixene cap 10mg
T1thiothixene cap 1mg
T1thiothixene cap 2mg
T1thiothixene cap 5mg
T1trifluoperaz tab 10mg
T1trifluoperaz tab 1mg
T1trifluoperaz tab 2mg
T1trifluoperaz tab 5mg
T1 QL (60 caps/30 days)ziprasidone cap 20mg
T1 QL (120 caps/30 days)ziprasidone cap 40mg
T1 QL (60 caps/30 days)ziprasidone cap 60mg
T1 QL (120 caps/30 days)ziprasidone cap 80mg
79Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
CONTRACEPTIVES (E.G. FOAMS, DEVICES)
T0 HCR Rules for Coverage
T0 HCR Rules for Coverage
T0 HCR Rules for Coverage
encare sup 100mg (nonoxynol-9)
vcf vaginal aer contracp (nonoxynol-9)
vcf vaginal gel contrace (nonoxynol-9)
ELECTROLYTIC, CALORIC, AND WATER BALANCEALKALINIZING AGENTS
T1cytra-k sol (potassium)
T1k citrate sol citr acd
T1pot citrate tab 1080mg
T1pot citrate tab 1620mg
T1pot citrate tab 540mg er
T1virtrate-k sol (potassium)
T1virtrate-k sol 1100-334 (potassium)
AMMONIA DETOXICANTS
T4 PA, SPBUPHENYL TAB 500MG (sodium)
T1constulose sol 10gm/15 (lactulose)
T1enulose sol 10gm/15 (lactulose)
T1generlac sol 10gm/15 (lactulose)
T2KRISTALOSE PAK 10GM (lactulose)
T2KRISTALOSE PAK 20GM (lactulose)
T1lactulose sol 10gm/15
T1lactulose sol 20gm/30
DIURETICSLOOP DIURETICS
T1bumetanide inj 0.25/ml
T1bumetanide tab 0.5mg
T1bumetanide tab 1mg
T1bumetanide tab 2mg
T3 QL (480 tabs/30 days)EDECRIN TAB 25MG (ethacrynic)
T1furosemide inj 100/10ml
T1furosemide inj 10mg/ml
T1furosemide inj 20mg/2ml
T1furosemide inj 40mg/4ml
80Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ELECTROLYTIC, CALORIC, AND WATER BALANCEDIURETICS
LOOP DIURETICS
T1furosemide sol 10mg/ml
T1furosemide sol 40mg/4ml
T1furosemide sol 8mg/ml
T1furosemide tab 20mg
T1furosemide tab 40mg
T1furosemide tab 80mg
T1torsemide tab 100mg
T1torsemide tab 10mg
T1torsemide tab 20mg
T1torsemide tab 5mg
POTASSIUM-SPARING DIURETICS
T1amilor/hctz tab 5-50
T1amiloride tab 5mg
T3 PA, QL (120 caps/30 days)DYRENIUM CAP 100MG (triamterene)
T3 PA, QL (120 caps/30 days)DYRENIUM CAP 50MG (triamterene)
T1triamt/hctz cap 37.5-25
T1triamt/hctz cap 50-25mg
T1triamt/hctz tab 37.5-25
T1triamt/hctz tab 75-50mg
THIAZIDE DIURETICS
T1chlorothiaz tab 250mg
T1chlorothiaz tab 500mg
T1hydrochlorot cap 12.5mg
T1hydrochlorot tab 12.5mg
T1hydrochlorot tab 25mg
T1hydrochlorot tab 50mg
T1methyclothia tab 5mg
THIAZIDE-LIKE DIURETICS
T1chlorthalid tab 100mg
T1chlorthalid tab 25mg
T1chlorthalid tab 50mg
T1indapamide tab 1.25mg
81Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ELECTROLYTIC, CALORIC, AND WATER BALANCEDIURETICS
THIAZIDE-LIKE DIURETICS
T1indapamide tab 2.5mg
T1metolazone tab 10mg
T1metolazone tab 2.5mg
T1metolazone tab 5mg
VASOPRESSIN ANTAGONISTS
T4 PASAMSCA TAB 15MG (tolvaptan)
T4 PASAMSCA TAB 30MG (tolvaptan)
ION-REMOVING AGENTSPHOSPHATE-REMOVING AGENTS
T3 QL (150 tabs/30 days)FOSRENOL CHW 1000MG (lanthanum)
T3 QL (150 tabs/30 days)FOSRENOL CHW 500MG (lanthanum)
T3 QL (150 tabs/30 days)FOSRENOL CHW 750MG (lanthanum)
T3 QL (120 tabs/30 days)RENAGEL TAB 400MG (sevelamer)
T3 QL (120 tabs/30 days)RENAGEL TAB 800MG (sevelamer)
T3
T3
T3
QL (300 packs/30 days)
PA
RENVELA PAK 0.8GM (sevelamer)
RENVELA PAK 2.4GM (sevelamer)
VELTASSA
POTASSIUM-REMOVING AGENTS
T1kionex sus 15gm/60 (sodium)
T1sod poly sul sus 15gm/60
T1sod poly sul sus 30/120ml
T1sod poly sul sus 50/200ml
T1sps sus 15gm/60 (sodium)
REPLACEMENT PREPARATIONS
T1calc acetate cap 667mg
T1chloromag inj 20% (magnesium)
T2EFFER-K TAB 10MEQ (potassium)
T2EFFER-K TAB 20MEQ (potassium)
T1effer-k tab 25meq ef (potassium)
T1k-effervesce tab 25meq ef (potassium)
T1klor-con 10 tab 10meq er (potassium)
82Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ELECTROLYTIC, CALORIC, AND WATER BALANCEREPLACEMENT PREPARATIONS
T1klor-con 8 tab 8meq er (potassium)
T1klor-con m10 tab 10meq er (potassium)
T3KLOR-CON M15 TAB (potassium)
T3KLOR-CON M15 TAB 15MEQ ER (potassium)
T1klor-con m20 tab 20meq er (potassium)
T1klor-con spr cap 10meq (potassium)
T1klor-con spr cap 8meq (potassium)
T1klor-con/ef tab 25meq ef (potassium)
T1klor-con/ef tab 25meq fr (potassium)
T1k-prime tab 25meq ef (potassium)
T1k-sol sol 10% (potassium)
T1k-sol sol 20% (potassium)
T1k-vescent tab 25meq ef (potassium)
T1magnesium cl inj 20%
T3PHOSLYRA SOL (calcium)
T1 QLphospha 250 tab neutral (potassium)
T1pot bicarbon tab 25meq ef
T1pot chloride cap 10meq er
T1pot chloride cap 8meq er
T1pot chloride inj 10meq
T1pot chloride inj 20meq
T1pot chloride inj 2meq/ml
T1pot chloride inj 40meq
T1pot chloride sol 10%
T1pot chloride sol 10% sf
T1pot chloride sol 20%
T1pot chloride sol 20% sf
T1pot chloride tab 10meq cr
T1pot chloride tab 10meq er
T1pot chloride tab 20meq er
T1pot chloride tab 25meq ef (potassium)
T1pot chloride tab 8meq cr
83Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
ELECTROLYTIC, CALORIC, AND WATER BALANCEREPLACEMENT PREPARATIONS
T1pot chloride tab 8meq er
T1pot chloride tab 8meq sa
T1pot chloride tab 8meq sr
T1pot cl micro tab 10meq cr
T1pot cl micro tab 10meq er
T1pot cl micro tab 20meq cr
T1pot cl micro tab 20meq er
T1pot/chloride tab 25meq ef
T1potassium tab 25meq ef
T1 QLvirt-phos tab 250 neut (potassium)
T1zinc sulfate cap 220mg
URICOSURIC AGENTS
T1proben/colch tab 500-0.5
T1probenecid tab 500mg
EYE, EAR, NOSE AND THROAT (EENT) PREPS.ANTIALLERGIC AGENTS
T3 QL (5 ml/fill)ALOCRIL SOL 2% (nedocromil)
T2ALOMIDE SOL 0.1% OP (lodoxamide)
T1azelastine dro 0.05%
T1azelastine spr 0.1%
T1azelastine spr 0.15%
T3 PABEPREVE DRO 1.5% (bepotastine)
T1cromolyn sod sol 4% op
T3 QL (5 ml/fill)EMADINE SOL 0.05% OP (emedastine)
T1epinastine dro 0.05%
T1ketotif fum dro 0.025%op
T3 QL (3 ml/fill)LASTACAFT SOL 0.25% (alcaftadine)
T3 QL (2.5 ml/fill)PATADAY SOL 0.2% (olopatadine)
T1 QL (5 ml/fill)Olopatadine SOL 0.1% OP
ANTIGLAUCOMA AGENTSALPHA-ADRENERGIC AGONISTS (EENT)
T1brimonidine sol 0.15%
84Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
EYE, EAR, NOSE AND THROAT (EENT) PREPS.ANTIGLAUCOMA AGENTS
ALPHA-ADRENERGIC AGONISTS (EENT)
T1brimonidine sol 0.2% op
T3 QL (10 ml/fill)COMBIGAN SOL 0.2/0.5% (brimonidine)
T3 PASIMBRINZA SUS 1-0.2% (brinzolamide-brimonidine)
BETA-ADRENERGIC BLOCKING AGENTS (EENT)
T1betaxolol sol 0.5% op
T3 QL (10 ml/fill) betaxololBETOPTIC-S SUS 0.25% OP (betaxolol)
T1carteolol sol 1% op
T1levobunolol sol 0.25% op
T1levobunolol sol 0.5% op
T1metipranolol sol 0.3% oph
T1timolol gel sol 0.25% op
T1timolol gel sol 0.5% op
T1timolol mal sol 0.25% op
T1timolol mal sol 0.5% op
CARBONIC ANHYDRASE INHIBITORS (EENT)
T1acetazolamid cap 500mg er
T1acetazolamid tab 125mg
T2 QL (10 ml/fill)AZOPT SUS 1% OP (brinzolamide)
T1dorzol/timol sol 22.3-6.8
T1dorzolamide sol 2% op
T1methazolamid tab 25mg
T1methazolamid tab 50mg
MIOTICS
T3PHOSPHOLINE SOL 0.125%OP (echothiophate)
T1pilocarpine sol 1% op
T1pilocarpine sol 2% op
T1pilocarpine sol 4% op
PROSTAGLANDIN ANALOGS
T1latanoprost sol 0.005%
T2 QL (5 ml/fill), ST (latanoprost)LUMIGAN SOL 0.01% (bimatoprost)
T2 QL (5 ml/fill), ST (latanoprost)TRAVATAN Z DRO 0.004% (travoprost)
T1 QL, ST (latanoprost)travoprost dro 0.004%
85Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
EYE, EAR, NOSE AND THROAT (EENT) PREPS.ANTIGLAUCOMA AGENTS
PROSTAGLANDIN ANALOGS
T3 PA, QL (3 pouches/fill)ZIOPTAN DRO 0.0015% (tafluprost)
ANTI-INFECTIVES (EENT)ANTIBACTERIALS (EENT)
T2 QL (2.5 ml/30 days)AZASITE SOL 1% (azithromycin)
T1bacitracin oin op
T3 QL (5 ml/30 days)BESIVANCE SUS 0.6% (besifloxacin)
T2CILOXAN OIN 0.3% OP (ciprofloxacin)
T1ciprofloxacn sol 0.2%
T1ciprofloxacn sol 0.3% op
T1erythromycin oin 5mg/gm
T1erythromycin oin op
T1garamycin oin 0.3% op (gentamicin)
T1 QLgatifloxacin sol 0.5%
T1gentak oin 0.3% op (gentamicin)
T1gentamicin oin 0.3% op
T1gentamicin sol 0.3% op
T1ilotycin oin op (erythromycin)
T1 QL (5 ml/30 days)levofloxacin sol 0.5%
T3 QL (3 ml (1 bottle)/fill)MOXEZA SOL 0.5% (moxifloxacin)
T1ofloxacin dro 0.3% op
T1ofloxacin dro 0.3%otic
T1polymyxin b/ sol trimethp
T1polytrim sol op (polymyxin)
T1romycin oin op (erythromycin)
T1sod sulfacet sol 10% op
T1sulfacet sod sol 10% op
T1tobramycin sol 0.3% op
T3 QL (1 tube/fill)TOBREX OIN 0.3% OP (tobramycin)
T1tobrex sol 0.3% op (tobramycin)
T1trimethoprim sol polymyxn
T2 QL (3 ml (1 bottle)/fill)VIGAMOX DRO 0.5% (moxifloxacin)
86Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
EYE, EAR, NOSE AND THROAT (EENT) PREPS.ANTI-INFECTIVES (EENT)
ANTIVIRALS (EENT)
T1trifluridine sol 1% op
T3 QL (5 gram/ fill)ZIRGAN GEL 0.15% (ganciclovir)
EENT ANTI-INFECTIVES, MISCELLANEOUS
T1chlorhex glu sol 0.12%
T1paroex sol 0.12% (chlorhexidine)
T1periogard sol 0.12% (chlorhexidine)
ANTI-INFLAMMATORY AGENTS (EENT)CORTICOSTEROIDS (EENT)
T1acetasol hc sol otic (hydrocortisone)
T2ALREX SUS 0.2% (loteprednol)
T1antibiot ear sol 1% otic (neomycin-polymyxin-hc)
T3 ST (fluticasone nasal spray, triamcinolone nasal spray)
fluticasone, triamcinolone
BECONASE AQ SUS 0.042% (beclomethasone)
T2 QLBLEPHAMIDE SUS LIQUIFLM (sulfacetamide)
T2 QLBLEPHAMIDE SUS OP (sulfacetamide)
T1budesonide sus 32mcg
T3 QL (1 bottle/fill)CIPRO HC SUS OTIC (ciprofloxacin-hydrocortisone)
T2 QL (7.5ml/ fill)CIPRODEX SUS 0.3-0.1% (ciprofloxacin-dexamethasone)
T2COLY-MYCIN S SUS OTIC (neomycin-colistin-hc-thonzonium)
T2CORTISPORIN SUS -TC OTIC (neomycin-colistin-hc-thonzonium)
T1dexameth pho sol 0.1% op
T2DUREZOL EMU 0.05% (difluprednate)
T2FLAREX SUS 0.1% OP (fluorometholone)
T1flunisolide spr 0.025%
T1fluocin acet oil 0.01%
T1fluocin acet oil ear0.01%
T1fluoromethol sus 0.1% op
T1fluticasone spr 50mcg
T1 hc = hydrocortisonehc/acet acid sol otic
T3LOTEMAX SUS 0.5% (loteprednol)
87Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
EYE, EAR, NOSE AND THROAT (EENT) PREPS.ANTI-INFLAMMATORY AGENTS (EENT)
CORTICOSTEROIDS (EENT)
T2MAXIDEX SUS 0.1% OP (dexamethasone)
T3 ST (fluticasone nasal spray, triamcinolone nasal spray)
fluticasone, triamcinolone
NASONEX SPR 50MCG/AC (mometasone)
T1 QLneo/poly/dex sus 0.1% op
T1neo/poly/hc sol 1% otic
T1neo/poly/hc sus 1% otic
T3PRED MILD SUS 0.12% OP (prednisolone)
T1pred sod pho sol 1% op
T1prednisolone sus 1% op
T1sulf/pred na sol op
T1 QLtobra/dexame sus 0.3-0.1%
T2TOBRADEX OIN 0.3-0.1% (tobramycin-dexamethasone)
T1triamcinolon aer 55mcg/ac
T3 PA fluticasone, triamcinolone
VERAMYST SPR 27.5MCG (fluticasone)
T3 PAVEXOL SUS 1% OP (rimexolone)
T3 ST (fluticasone nasal spray, triamcinolone nasal spray)
fluticasone, triamcinolone
ZETONNA AER 37MCG (ciclesonide)
EENT NONSTEROIDAL ANTI-INFLAM. AGENTS
T3ACUVAIL SOL 0.45% (ketorolac)
T1bromfenac sol 0.09%
T1bromfenac sol 0.09% op
T1diclofenac sol 0.1% op
T1flurbiprofen sol 0.03% op
T2 QL (1.7 ml/fill)ILEVRO DRO 0.3% OP (nepafenac)
T1ketorolac sol 0.4%
T1ketorolac sol 0.5%
T2NEVANAC SUS 0.1% (nepafenac)
EENT DRUGS, MISCELLANEOUS
T1acetic acid sol 2% otic
T1apraclonidin sol 0.5% op
T2IOPIDINE SOL 1% OP (apraclonidine)
88Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
EYE, EAR, NOSE AND THROAT (EENT) PREPS.LOCAL ANESTHETICS (EENT)
T1a/b sol otic (antipyrine-benzocaine)
T1altacaine sol 0.5% op (tetracaine)
T1antipy/benzo sol otic
T1aurodex sol otic (antipyrine-benzocaine)
T1auroguard sol otic (antipyrine-benzocaine)
T1lidocaine sol 2% visc
T1parcaine sol 0.5% op (proparacaine)
T1proparacaine sol 0.5% op
T1tetcaine sol 0.5% op (tetracaine)
T1tetracaine sol 0.5% op
T1tetravisc sol 0.5% op (tetracaine)
T1tetravisc sol forte (tetracaine)
MYDRIATICS
T1atropin-care sol 1% op (atropine)
T1atropine sul oin 1% op
T1atropine sul sol 1% op
T1cyclopentol sol 1% op
T1cyclopentol sol 2% op
T1homatropaire sol 5% op (homatropine)
T1homatropine sol 5% op
T1mydral sol 0.5% op (tropicamide)
T1mydral sol 1% op (tropicamide)
T1tropicamide sol 0.5% op
T1tropicamide sol 1% op
VASOCONSTRICTORS
T1altafrin sol 10% op (phenylephrine)
T1altafrin sol 2.5% op (phenylephrine)
T1naphazoline sol 0.1% op
T1neofrin sol 10% op (phenylephrine)
T1neofrin sol 2.5% op (phenylephrine)
T1phenylephrin sol 10% op
T1phenylephrin sol 2.5% op
89Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
EYE, EAR, NOSE AND THROAT (EENT) PREPS.VASOCONSTRICTORS
T3TYZINE PED DRO 0.05% (tetrahydrozoline)
GASTROINTESTINAL DRUGSANTIDIARRHEA AGENTS
T1diphen/atrop liq 2.5/5
T1diphen/atrop tab 2.5mg
T1diphenatol tab 2.5mg (diphenoxylate)
T1kaopectate tab (bismuth)
T1lofene tab 2.5mg (diphenoxylate)
T1lonox tab 2.5mg (diphenoxylate)
T1 QLloperamide cap 2mg (loperamide)
ANTIEMETICS5-HT3 RECEPTOR ANTAGONISTS
T3 QL (3 tabs/21 days), ST (ondansetron, granisetron)
ondansetronANZEMET TAB 100MG (dolasetron)
T3 QL (3 tabs/21 days), ST (ondansetron, granisetron)
ondansetronANZEMET TAB 50MG (dolasetron)
T1granisetron tab 1mg
T1ondansetron inj 4mg/2ml
T1ondansetron sol 4mg/5ml
T1ondansetron tab 24mg
T1ondansetron tab 4mg
T1ondansetron tab 4mg odt
T1ondansetron tab 8mg
T1ondansetron tab 8mg odt
ANTIEMETICS, MISCELLANEOUS
T3 PACESAMET CAP 1MG (nabilone)
T4 PA, SP, QL (120 tabs/ 30 days)DICLEGIS TAB 10-10MG (doxylamine-pyridoxine)
T1 QLdronabinol cap 10mg
T1 QLdronabinol cap 2.5mg
T1 QLdronabinol cap 5mg
T3 QLEMEND CAP 125MG (aprepitant)
T3 QL (1 capsule/fill)EMEND CAP 40MG (aprepitant)
T3 QL (1 capsule/fill)EMEND CAP 80MG (aprepitant)
90Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
GASTROINTESTINAL DRUGSANTIEMETICS
ANTIEMETICS, MISCELLANEOUS
T3 QL (1 capsule/fill)EMEND PAK 80 & 125 (aprepitant)
T3 QL (3 patches/fill)TRANSDERM-SC DIS 1.5MG (scopolamine)
T3 QL (3 patches/fill)TRANSDERM-SC DIS 1MG (scopolamine)
ANTIHISTAMINES (GI DRUGS)
T1meclizine tab 12.5mg
T1meclizine tab 25mg
T1trimethobenz cap 300mg
ANTI-INFLAMMATORY AGENTS (GI DRUGS)
T1balsalazide cap 750mg
T3 QL (30 supp/30 days)CANASA SUP 1000MG (mesalamine)
T2 QL (180 caps/30 days)DELZICOL CAP 400MG (mesalamine)
T2DIPENTUM CAP 250MG (olsalazine)
T3 QL (180 tabs/30 days)LIALDA TAB 1.2GM (mesalamine)
T1mesalamine ene 4gm
T1 QL (1 kit/fill)
T2 QL (360 caps/30 days)
T3 QL (360 caps/30 days)
mesalamine kit 4gm
ASACOL HD (mesalamine)
PENTASA CAP CR (mesalamine)
ANTIULCER AGENTS AND ACID SUPPRESSANTSHISTAMINE H2-ANTAGONISTS
T1cimetidine tab 200mg (cimetidine)
T1cimetidine tab 300mg
T1cimetidine tab 400mg
T1cimetidine tab 800mg
T1famotidine tab 20mg (famotidine)
T1famotidine tab 40mg
T1nizatidine cap 150mg
T1nizatidine cap 300mg
T1nizatidine sol 15mg/ml
T1ranitidine syp 150/10ml
T1ranitidine syp 15mg/ml
T1ranitidine syp 75mg/5ml
91Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
GASTROINTESTINAL DRUGSANTIULCER AGENTS AND ACID SUPPRESSANTS
HISTAMINE H2-ANTAGONISTS
T1ranitidine tab 150mg
T1ranitidine tab 300mg
PROSTAGLANDINS
T1misoprostol tab 100mcg
T1misoprostol tab 200mcg
PROTECTANTS
T2CARAFATE SUS 1GM/10ML (sucralfate)
T1sucralfate tab 1gm
PROTON-PUMP INHIBITORS
T1 QL (30 tabs/30 days)lansoprazole cap 15mg dr
T1 QL (30 tabs/30 days)lansoprazole cap 30mg dr
T3 QLLANSOPRAZOLE SUS 3MG/ML (lansoprazole)
T1 QL (60 caps/30 days)omeprazole cap 10mg
T1omeprazole cap 20mg
T1 QL (60 caps/30 days)omeprazole cap 40mg
T1pantoprazole tab 20mg
T1pantoprazole tab 40mg
T1 QL (30 tabs/30 days) lansoprazole, omeprazole, pantoprazole
rabeprazole tab 20mg
CATHARTICS AND LAXATIVES
T1gavilyte-c sol (peg)
T1gavilyte-g sol (peg)
T1 QLgavilyte-n sol flav pk (peg)
T3OSMOPREP TAB 1.5GM (sodium)
T1peg 3350 sol electrol
T1peg-3350 sol electrol
T1 QLpeg-3350/kcl sol /sodium
T1pegylax pow (polyethylene)
T1polyeth glyc pow 3350 nf (polyethylene)
T3 PAPREPOPIK PAK (sodium)
T3SUPREP BOWEL SOL PREP (sodium)
92Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
GASTROINTESTINAL DRUGSCATHARTICS AND LAXATIVES
T1 QLtrilyte sol (peg)
CHOLELITHOLYTIC AGENTS
T1ursodiol cap 300mg
T1ursodiol tab 250mg
T1ursodiol tab 500mg
DIGESTANTS
T3CREON CAP 12000UNT (pancrelipase)
T3CREON CAP 24000UNT (pancrelipase)
T3CREON CAP 3000UNIT (pancrelipase)
T3CREON CAP 36000UNT (pancrelipase)
T3CREON CAP 6000UNIT (pancrelipase)
T3PANCREAZE CAP 10500UNT (pancrelipase)
T3PANCREAZE CAP 16800UNT (pancrelipase)
T3PANCREAZE CAP 21000UNT (pancrelipase)
T3PANCREAZE CAP 4200UNIT (pancrelipase)
T1pancrelipase cap 5000unit
T3PERTZYE CAP (pancrelipase)
T3ZENPEP CAP 10000UNT (pancrelipase)
T3ZENPEP CAP 15000UNT (pancrelipase)
T3ZENPEP CAP 20000UNT (pancrelipase)
T3ZENPEP CAP 25000UNT (pancrelipase)
T3ZENPEP CAP 3000UNIT (pancrelipase)
T3ZENPEP CAP 40000UNT (pancrelipase)
T3ZENPEP CAP 5000UNIT (pancrelipase)
GI DRUGS, MISCELLANEOUS
T3
T3
T4
T3
T3
T3
PA, QL (60 caps/30 days)
PA, QL (60 caps/30 days)
PA, SP
PA, QL (30 caps/30 days)
PA, QL (30 caps/30 days)
PA
AMITIZA CAP 24MCG (lubiprostone)
AMITIZA CAP 8MCG (lubiprostone)
GATTEX KIT 5MG (teduglutide)
LINZESS CAP 145MCG (linaclotide)
LINZESS CAP 290MCG (linaclotide)
XENICAL CAP 120MG (orlistat)
93Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
GASTROINTESTINAL DRUGSPROKINETIC AGENTS
T1metoclopram inj 10mg/2ml
T1metoclopram inj 5mg/ml
T1metoclopram sol 10/10ml
T1metoclopram sol 5mg/5ml
T1metoclopram tab 10mg
T1metoclopram tab 5mg
GOLD COMPOUNDS
T2RIDAURA CAP 3MG (auranofin)
HEAVY METAL ANTAGONISTS
T2CHEMET CAP 100MG (succimer)
T3CUPRIMINE CAP 250MG (penicillamine)
T2DEPEN TITRA TAB 250MG (penicillamine)
T4 PA, SPEXJADE TAB 125MG (deferasirox)
T4 PA, SPEXJADE TAB 250MG (deferasirox)
T4 PA, SPEXJADE TAB 500MG (deferasirox)
T3SYPRINE CAP 250MG (trientine)
HORMONES AND SYNTHETIC SUBSTITUTESADRENALS
T3 QL (1 inhaler/30 days) ADVAIR DISKUS, FLOVENT DISKUS, QVAR
ALVESCO AER 160MCG (ciclesonide)
T3 QL (1 inhaler/30 days) ADVAIR DISKUS, FLOVENT DISKUS, QVAR
ALVESCO AER 80MCG (ciclesonide)
T3 QL (1 inhaler/30 days) ADVAIR DISKUS, FLOVENT DISKUS, QVAR
ASMANEX 120 AER 220MCG (mometasone)
T3 QLASMANEX 30 AER 110MCG (mometasone)
T3ASMANEX 30 AER 220MCG (mometasone)
T3 QL (1 inhaler/30 days) ADVAIR DISKUS, FLOVENT DISKUS, QVAR
ASMANEX 60 AER 220MCG (mometasone)
T3 QLASMANEX 7 AER 110MCG (mometasone)
T3ASMANEX HFA AER 100 MCG (mometasone)
94Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESADRENALS
T3ASMANEX HFA AER 200 MCG (mometasone)
T1 QLbaycadron elx 0.5/5ml (dexamethasone)
T1 PAbudesonide cap 3mg/24hr
T1budesonide sus 0.25mg/2
T1budesonide sus 0.5mg/2
T1budesonide sus 1mg/2ml
T1cortisone ac tab 25mg
T1deltasone tab 20mg (prednisone)
T2 QL (30 ml/ fill)DEXAMETHASON CON 1MG/ML (dexamethasone)
T1 QLdexamethason elx 0.5/5ml
T1dexamethason sol 0.5/5ml
T1dexamethason tab 0.5mg
T1dexamethason tab 0.75mg
T1dexamethason tab 1.5mg
T1dexamethason tab 1mg
T1dexamethason tab 2mg
T1dexamethason tab 4mg
T1dexamethason tab 6mg
T3 QL (1 inhaler/30 days) ADVAIR DISKUS, FLOVENT DISKUS, QVAR
DULERA AER 100-5MCG (mometasone)
T3 QL (1 inhaler/30 days) ADVAIR DISKUS, FLOVENT DISKUS, QVAR
DULERA AER 200-5MCG (mometasone)
T2FLOVENT DISK AER 100MCG (fluticasone)
T2FLOVENT DISK AER 250MCG (fluticasone)
T2FLOVENT DISK AER 50MCG (fluticasone)
T2FLOVENT HFA AER 110MCG (fluticasone)
T2FLOVENT HFA AER 220MCG (fluticasone)
T2FLOVENT HFA AER 44MCG (fluticasone)
T1fludrocort tab 0.1mg
T1hydrocort tab 10mg
T1hydrocort tab 20mg
T1hydrocort tab 5mg
95Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESADRENALS
T1methylpred pak 4mg
T1methylpred tab 16mg
T1methylpred tab 32mg
T1methylpred tab 4mg
T1methylpred tab 8mg
T1pred sod pho sol 5mg/5ml
T1prednisolone sol 15mg/5ml
T1 QLprednisolone sol 15mg/5ml
T1prednisolone sol 25mg/5ml
T1 QLprednisolone syp 15mg/5ml
T2PREDNISONE CON 5MG/ML (prednisone)
T1prednisone pak 10mg
T1prednisone pak 5mg
T1prednisone sol 5mg/5ml
T1prednisone tab 10mg
T1prednisone tab 1mg
T1prednisone tab 2.5mg
T1prednisone tab 20mg
T1prednisone tab 50mg
T1prednisone tab 5mg
T2 QL (1 inhaler/30 days)PULMICORT INH 180MCG (budesonide)
T2 QL (1 inhaler/30 days)PULMICORT INH 90MCG (budesonide)
T2QVAR AER 40MCG (beclomethasone)
T2QVAR AER 80MCG (beclomethasone)
T3 QL (1 inhaler/30 days) ADVAIR DISKUS, FLOVENT DISKUS, QVAR
SYMBICORT AER 160-4.5 (budesonide-formoterol)
T3 QL (1 inhaler/30 days) ADVAIR DISKUS, FLOVENT DISKUS, QVAR
SYMBICORT AER 80-4.5 (budesonide-formoterol)
T2 QL (480ml/30 days)VERIPRED 20 SOL 20MG/5ML (prednisolone)
ANDROGENS
)
96Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESANDROGENS
T3 PA
T1 PA
T1 PA
T1 PA
ANDROGEL GEL 1.62% (testosterone)
danazol cap 100mg
danazol cap 200mg
danazol cap 50mg
T3NATESTO GEL 5.5MG (testosterone)
T1oxandrolone tab 10mg
T1oxandrolone tab 2.5mg
T1 PA, QLtestosterone gel 1%(25mg)
T1 PA, QLtestosterone gel 1%(50mg)
T1 PA, QLtestosterone gel pump 1%
ANTIDIABETIC AGENTSALPHA-GLUCOSIDASE INHIBITORS
T1acarbose tab 100mg
T1acarbose tab 25mg
T1acarbose tab 50mg
T3 acarboseGLYSET TAB 100MG (miglitol)
T3 acarboseGLYSET TAB 25MG (miglitol)
T3 acarboseGLYSET TAB 50MG (miglitol)
AMYLINOMIMETICS
T3 PASYMLINPEN 60 INJ 1000MCG (pramlintide)
ANTIDIABETIC AGENTS, MISCELLANEOUS
T3 PA, QL (180 tabs/30 days)CYCLOSET TAB 0.8MG (bromocriptine)
BIGUANIDES
T1metformin tab 1000mg
T1metformin tab 500mg
T1metformin tab 500mg er
T1metformin tab 750mg er
T1metformin tab 850mg
DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS
T2 QL (30 tabs/30 days)JANUVIA TAB 100MG (sitagliptin)
T2 QL (30 tabs/30 days)JANUVIA TAB 25MG (sitagliptin)
97Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Generic for Glutmetza & Fortamet not coveredGeneric for Glutmetza & Fortamet not covered
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESANTIDIABETIC AGENTS
DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS
T2 QL (30 tabs/30 days)JANUVIA TAB 50MG (sitagliptin)
T3 PA, QL (30 tabs/30 days) JANUVIAONGLYZA TAB 2.5MG (saxagliptin)
T3 PA, QL (30 tabs/30 days) JANUVIAONGLYZA TAB 5MG (saxagliptin)
T3 PA, QL (30 tabs/30 days) JANUVIATRADJENTA TAB 5MG (linagliptin)
INCRETIN MIMETICS
T3 PABYDUREON INJ (exenatide)
T3 PABYDUREON INJ (exenatide)
T3 PA, QL (1 cartridge/month)BYETTA INJ 5MCG (exenatide)
T3 PA, QL (2 pens/30 days)VICTOZA INJ 18MG/3ML (liraglutide)
INSULINS
T2 QL (60 ml/30 days)APIDRA INJ SOLOSTAR (insulin)
T2 QL (60 ml/30 days)APIDRA INJ U-100 (insulin)
T3 QL (60ml/30 days) NOVOLOGHUMALOG INJ 100/ML (insulin)
T3 QL (60ml/30 days) NOVOLOG, NOVOLOG MIX 70/30
HUMALOG KWIK INJ 100/ML (insulin)
T3 QL (60ml/30 days) NOVOLOG, NOVOLOG MIX 70/30
HUMALOG MIX INJ 50/50 (insulin)
T3 QL (60ml/30 days) NOVOLOG, NOVOLOG MIX 70/30
HUMALOG MIX INJ 50/50KWP (insulin)
T3 QL (60ml/30 days) NOVOLOG, NOVOLOG MIX 70/30
HUMALOG MIX INJ 75/25KWP (insulin)
T3 QL (60ml/30 days) NOVOLOG, NOVOLOG MIX 70/30
HUMALOG MIX SUS 75/25 (insulin)
T3 QL (60 ml/30 days)HUMULIN INJ 70/30 (insulin)
T3 QL (60 ml/30 days)HUMULIN INJ 70/30KWP (insulin)
T3 QL (60 ml/30 days)HUMULIN N INJ U-100 (insulin)
T3 QL (60 ml/30 days)HUMULIN N INJ U-100KWP (insulin)
T3 QL (60 ml/30 days)HUMULIN N PN INJ U-100 (insulin)
T3 QL (60 ml/30 days)HUMULIN PEN INJ 70/30 (insulin)
98Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESANTIDIABETIC AGENTS
INSULINS
T3 QL (60 ml/30 days) NOVOLOG, NOVOLOG MIX 70/30, quetiapine
HUMULIN R INJ U-100 (insulin)
T3 ST, QL
T1
T1
T3
T2
T2
T2
T2
T2
T2
T2
T2
T2
QL (60 ml/30 days)
QL (60 ml/30 days)
ST, QL(60ml/30days
ST, QL(60ml/30days
QL (60 ml/30 days)
QL (60 ml/30 days)
QL (60 ml/30 days)
QL (60ml/30 days)
QL (60ml/30 days)
QL (60ml/30 days)
QL (60ml/30 days)
QL (60ml/30 days)
QL (9ml/30 days)
HUMULIN R INJ U-500 (insulin)
LANTUS INJ 100/ML (insulin)
LANTUS INJ SOLOSTAR (insulin)
LEVEMIR INJ (insulin)
LEVEMIR INJ FLEXTOUC (insulin)
NOVOLIN INJ 70/30 (insulin)
NOVOLIN N INJ U-100 (insulin)
NOVOLIN R INJ U-100 (insulin)
NOVOLOG INJ 100/ML (insulin)
NOVOLOG INJ FLEXPEN (insulin)
NOVOLOG INJ PENFILL (insulin)
NOVOLOG MIX INJ 70/30 (insulin)
NOVOLOG MIX INJ FLEXPEN (insulin)
TOUJEO SOLO INJ 300IU/ML (insulin)
MEGLITINIDES
T1nateglinide tab 120mg
T1nateglinide tab 60mg
T1 QL (240 tabs/30 days)repaglinide tab 0.5mg
T1 QL (240 tabs/30 days)repaglinide tab 1mg
T1 QL (240 tabs/30 days)repaglinide tab 2mg
SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIBITORS
T3 PAFARXIGA TAB 10MG (dapagliflozin)
T3 PAFARXIGA TAB 5MG (dapagliflozin)
SULFONYLUREAS
T1chlorpropam tab 100mg
T1chlorpropam tab 250mg
T1glimepiride tab 1mg
T1glimepiride tab 2mg
99Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
LANTUS
T3 LANTUS
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESANTIDIABETIC AGENTS
SULFONYLUREAS
T1glimepiride tab 4mg
T1glip/metform tab 2.5-250m
T1glip/metform tab 2.5-500m
T1glip/metform tab 5-500mg
T1glipizide tab 10mg
T1glipizide tab 5mg
T1glipizide er tab 10mg
T1glipizide er tab 2.5mg
T1glipizide er tab 5mg
T1glipizide xl tab 10mg (glipizide)
T1glipizide xl tab 2.5mg (glipizide)
T1glipizide xl tab 5mg (glipizide)
T1glyb/metform tab 1.25-250
T1glyb/metform tab 2.5-500
T1glyb/metform tab 5-500mg
T1glyburid mcr tab 1.5mg
T1glyburid mcr tab 3mg
T1glyburid mcr tab 6mg
T1glyburide tab 1.25mg
T1glyburide tab 2.5mg
T1glyburide tab 5mg
T1tolazamide tab 250mg
T1tolazamide tab 500mg
T1tolbutamide tab 500mg
THIAZOLIDINEDIONES
T2 QL (60 tabs/30 days)AVANDIA TAB 2MG (rosiglitazone)
T2 QL (60 tabs/30 days)AVANDIA TAB 4MG (rosiglitazone)
T2 QL (60 tabs/30 days)AVANDIA TAB 8MG (rosiglitazone)
T1 QL (120 tabs/30 days)pioglita/met tab 15-500mg
T1 QL (120 tabs/30 days)pioglita/met tab 15-850mg
T1pioglitazone tab 15mg
100Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESANTIDIABETIC AGENTS
THIAZOLIDINEDIONES
T1pioglitazone tab 30mg
T1pioglitazone tab 45mg
ANTIHYPOGLYCEMIC AGENTSANTIHYPOGLYCEMIC AGENTS, MISCELLANEOUS
T2PROGLYCEM SUS 50MG/ML (diazoxide)
GLYCOGENOLYTIC AGENTS
T3GLUCAGEN INJ HYPOKIT (glucagon)
T3GLUCAGON KIT 1MG (glucagon)
CONTRACEPTIVES
T0 QL HCR Rules for Coverageaftera tab 1.5mg (levonorgestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coveragealtavera tab (levonorgestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coveragealyacen tab 1/35 (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragealyacen tab 7/7/7 (norethindrone-eth)
T0 QL (28 tabs/28 days) HCR Rules for Coverageamethia tab (levonorgestrel-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coverageamethia lo tab (levonorgestrel-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coverageamethyst tab 90-20mcg (levonorgestrel-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coverageapri tab (desogestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coveragearanelle tab (norethindrone-eth)
T0 QL HCR Rules for Coverageashlyna tab (levonorgestrel-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coverageaubra tab 0.1-0.02 (levonorgestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coverageaviane tab (levonorgestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coverageazurette tab 28 day (desogestrel-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragebalziva tab (norethindrone)
T0 QL (2.5ml/14 days) HCR Rules for Coveragebriellyn tab (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragecamila tab 0.35mg (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragecamrese tab (levonorgestrel-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragecamrese lo tab (levonorgestrel-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragecaziant pak (desogestrel-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragecesia pak (desogestrel-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragechateal tab 0.15/30 (levonorgestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coveragecryselle-28 tab 28 tabs (norgestrel)
101Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESCONTRACEPTIVES
T0 QL (28 tabs/28 days) HCR Rules for Coveragecyclafem tab 1/35 (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragecyclafem tab 7/7/7 (norethindrone-eth)
T0 QL HCR Rules for Coveragecyred tab (desogestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coveragedasetta tab 1/35 (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragedasetta tab 7/7/7 (norethindrone-eth)
T0 QL (28 tabs/28 days) HCR Rules for Coveragedaysee tab (levonorgestrel-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragedeblitane tab 0.35mg (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragedelyla tab 0.1-0.02 (levonorgestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coveragedeso/ethinyl tab estradio
T0 QL (28 tabs/28 days) HCR Rules for Coveragedrospir/ethi tab 3-0.03mg
T0 QL HCR Rules for Coveragedrospirenone tab ethy est
T0 QL HCR Rules for Coverageecontra ez tab 1.5mg (levonorgestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coverageelinest tab (norgestrel)
T0 QL (1 pack /fill, 3 fills/365 days)ELLA TAB 30MG (ulipristal)
T0 QL (28 tabs/28 days) HCR Rules for Coverageemoquette tab (desogestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coverageenpresse-28 tab (levonorgestrel-eth)
T0 QL (28 tabs/28 days) HCR Rules for Coverageenskyce tab (desogestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coverageerrin tab 0.35mg (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coverageestarylla tab 0.25-35 (norgestimate-ethinyl)
T0 QL HCR Rules for Coveragefallback tab 1.5mg (levonorgestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coveragefalmina tab (levonorgestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coveragegianvi tab 3-0.02mg (drospirenone-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragegildagia tab 0.4-35 (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragegildess tab 1.5/30 (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragegildess tab 1/20 (norethindrone)
T0 QL HCR Rules for Coveragegildess 24 tab fe 1/20 (norethin)
T0 QL (28 tabs/28 days) HCR Rules for Coveragegildess fe tab 1.5/30 (norethin)
T0 QL (28 tabs/28 days) HCR Rules for Coveragegildess fe tab 1/20 (norethin)
T0 QL (28 tabs/28 days) HCR Rules for Coverageheather tab 0.35mg (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coverageintrovale tab (levonorgestrel-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragejencycla tab 0.35mg (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragejolessa tab (levonorgestrel-ethinyl)
102Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESCONTRACEPTIVES
T0 QL (28 tabs/28 days) HCR Rules for Coveragejolivette tab 0.35mg (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragejunel 1.5/30 tab (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragejunel 1/20 tab (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragejunel fe tab 1.5/30 (norethin)
T0 QL (28 tabs/28 days) HCR Rules for Coveragejunel fe tab 1/20 (norethin)
T0 QL HCR Rules for Coveragejunel fe 24 tab 1/20 (norethin)
T0 QL (28 tabs/28 days) HCR Rules for Coveragekariva tab 28 day (desogestrel-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragekelnor tab 1/35 (ethynodiol)
T0 QL HCR Rules for Coveragekimidess tab (desogestrel-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragekurvelo tab 0.15/30 (levonorgestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coveragelarin tab 1.5/30 (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragelarin tab 1/20 (norethindrone)
T0 QL HCR Rules for Coveragelarin 24 tab fe 1/20 (norethin)
T0 QL (28 tabs/28 days) HCR Rules for Coveragelarin fe tab 1.5/30 (norethin)
T0 QL (28 tabs/28 days) HCR Rules for Coveragelarin fe tab 1/20 (norethin)
T0 QL HCR Rules for Coveragelayolis fe chw (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coverageleena tab (norethindrone-eth)
T0 QL (28 tabs/28 days) HCR Rules for Coveragelessina tab (levonorgestrel)
T0 QL HCR Rules for Coveragelevo-eth est tab 90-20mcg
T0 QL (28 tabs/28 days) HCR Rules for Coveragelevonest tab (levonorgestrel-eth)
T0 QL (28 tabs/28 days) HCR Rules for Coveragelevonor/ethi tab 0.1-0.02
T0 QL (28 tabs/28 days) HCR Rules for Coveragelevonor/ethi tab estradio
T0 QL (28 tabs/28 days) HCR Rules for Coveragelevonorgestr tab 0.75mg
T0 QL (28 tabs/28 days) HCR Rules for Coveragelevonorgestr tab 1.5mg
T0 QL (28 tabs/28 days) HCR Rules for Coveragelevora-28 tab 0.15/30 (levonorgestrel)
T0 QL HCR Rules for Coveragelomedia 24 tab fe (norethin)
T0 QL (28 tabs/28 days) HCR Rules for Coverageloryna tab 3-0.02mg (drospirenone-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragelow-ogestrel tab (norgestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coveragelutera tab (levonorgestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coveragelyza tab 0.35mg (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragemarlissa tab 0.15/30 (levonorgestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coveragemicrogestin tab 1.5/30 (norethindrone)
103Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESCONTRACEPTIVES
T0 HCR Rules for Coveragemicrogestin tab 1/20 (norethindrone)
T0 HCR Rules for Coveragemicrogestin tab fe 1/20 (norethin)
T0 HCR Rules for Coveragemicrogestin tab fe1.5/30 (norethin)
T0 HCR Rules for Coveragemono-linyah tab 0.25-35 (norgestimate-ethinyl)
T0 HCR Rules for Coveragemononessa tab (norgestimate-ethinyl)
T0 HCR Rules for Coveragemy way tab 1.5mg (levonorgestrel)
T0 HCR Rules for Coveragemyzilra tab (levonorgestrel-eth)
T0 HCR Rules for Coveragenecon tab 0.5/35 (norethindrone)
T0 HCR Rules for Coveragenecon tab 1/35 (norethindrone)
T0 HCR Rules for Coveragenecon tab 1/50-28 (norethindrone)
T0 HCR Rules for Coveragenecon tab 10/11-28 (norethindrone-eth)
T0
QL (28 tabs/28 days)
QL (28 tabs/28 days)
QL (28 tabs/28 days)
QL (28 tabs/28 days)
QL(28tabs/28days)
QL(1tabs/fill,3fillsper365days)
QL (28 tabs/28 days)
QL (28 tabs/28 days)
QL (28 tabs/28 days)
QL (28 tabs/28 days)
QL (28 tabs/28 days)
QL (28 tabs/28 days) HCR Rules for Coveragenecon tab 7/7/7 (norethindrone-eth)
T0 QL (1 tab/fill, 3 fill per 365 days) HCR Rules for Coveragenext choice tab 1.5mg (levonorgestrel)
T0 HCR Rules for Coveragenikki tab 3-0.02mg (drospirenone-ethinyl)
T0 HCR Rules for Coveragenora-be tab 0.35mg (norethindrone)
T0 HCR Rules for Coveragenoreth/ethin chw fe
T0 HCR Rules for Coveragenoreth/ethin tab 1/20
T0 HCR Rules for Coveragenoreth/ethin tab fe 1/20
T0 HCR Rules for Coveragenorethindron tab 0.35mg
T0 HCR Rules for Coveragenorgest/ethi tab 0.25/35
T0 HCR Rules for Coveragenorgest/ethi tab estradio
T0 HCR Rules for Coveragenorlyroc tab 0.35mg (norethindrone)
T0 HCR Rules for Coveragenortrel tab 0.5/35 (norethindrone)
T0 HCR Rules for Coveragenortrel tab 1/35 (norethindrone)
T0 HCR Rules for Coveragenortrel tab 7/7/7 (norethindrone-eth)
T0 HCR Rules for CoverageNUVARING MIS (etonogestrel-ethinyl)
T0 HCR Rules for Coverageocella tab 3-0.03mg (drospirenone-ethinyl)
T0 HCR Rules for Coverageogestrel tab (norgestrel)
T0 HCR Rules for Coverageopcicon tab 1.5mg (levonorgestrel)
T0 HCR Rules for Coverageorsythia tab (levonorgestrel)
T0 HCR Rules for Coveragephilith tab 0.4-35 (norethindrone)
T0
QL (28 tabs/28 days)
QL (28 tabs/28 days)
QL (28 tabs/28 days)
QL (28 tabs/28 days)
QL (28 tabs/28 days)
QL (28 tabs/28 days)
QL (28 tabs/28 days)
QL (28 tabs/28 days)
QL (28 tabs/28 days)
QL (28 tabs/28 days)
QL (28 tabs/28 days)
QL (28 tabs/28 days)
QL (1 per 28 days)
QL (28 tabs/28 days)
QL (28 tabs/28 days)
QL
QL (28 tabs/28 days)
QL (28 tabs/28 days)
QL (28 tabs/28 days) HCR Rules for Coveragepimtrea tab (desogestrel-ethinyl)
104Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESCONTRACEPTIVES
T0 QL (28 tabs/28 days) HCR Rules for Coveragepirmella tab 1/35 (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragepirmella tab 7/7/7 (norethindrone-eth)
T0 QL (28 tabs/28 days) HCR Rules for Coverageportia-28 tab (levonorgestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coverageprevifem tab (norgestimate-ethinyl)
T0 QL (14 patch/14 days, 12 fills/365 days)
HCR Rules for Coveragequasense tab (levonorgestrel-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragereclipsen tab (desogestrel)
T0 QL HCR Rules for Coveragesetlakin tab (levonorgestrel-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragesharobel tab 0.35mg (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragesolia tab (desogestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coveragesprintec 28 tab 28 day (norgestimate-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragesronyx tab (levonorgestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coveragesyeda tab 3-0.03mg (drospirenone-ethinyl)
T0 QL HCR Rules for Coveragetake action tab 1.5mg (levonorgestrel)
T0 QL (28 tabs/28 days) HCR Rules for Coveragetarina fe tab 1/20 (norethin)
T0 QL (28 tabs/28 days) HCR Rules for Coveragetilia fe tab (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragetri-estaryll tab (norgestimate-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragetri-legest tab fe (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragetri-linyah tab (norgestimate-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragetrinessa tab (norgestimate-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragetri-previfem tab (norgestimate-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragetri-sprintec tab (norgestimate-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragetrivora-28 tab (levonorgestrel-eth)
T0 QL (28 tabs/28 days) HCR Rules for Coveragevelivet pak (desogestrel-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragevestura tab 3-0.02mg (drospirenone-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coverageviorele tab (desogestrel-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragevyfemla tab 0.4-35 (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragewera tab 0.5/35 (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragewymzya fe chw 0.4mg-35 (norethindrone)
T0 QL (3 patches/28 days) HCR Rules for Coveragexulane dis 150-35 (norelgestromin-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragezarah tab 3-0.03mg (drospirenone-ethinyl)
T0 QL (28 tabs/28 days) HCR Rules for Coveragezenchent tab (norethindrone)
T0 QL (28 tabs/28 days) HCR Rules for Coveragezenchent fe chw 0.4mg-35 (norethindrone)
105Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESCONTRACEPTIVES
T0 QL (28 tabs/28 days) HCR Rules for Coveragezovia 1/35e tab (ethynodiol)
T0 QL (28 tabs/28 days) HCR Rules for Coveragezovia 1/50e tab (ethynodiol)
ESTROGENS AND ANTIESTROGENSESTROGEN AGONIST-ANTAGONISTS
T1 QLclomiphene tab 50mg
T0 HCR Rules for Coverage
T1 QL
raloxifene hcl tab 60 mg
serophene tab 50mg (clomiphene)
ESTROGENS
T3 QL (30 tabs/30 days)CENESTIN TAB 0.3MG (estrogens,)
T3 QL (30 tabs/30 days)CENESTIN TAB 0.45MG (estrogens,)
T3 QL (30 tabs/30 days)CENESTIN TAB 0.625MG (estrogens,)
T3 QL (30 tabs/30 days)CENESTIN TAB 0.9MG (estrogens,)
T3 QL (30 tabs/30 days)CENESTIN TAB 1.25MG (estrogens,)
T3 QL (4/30 days)CLIMARA PRO DIS WEEKLY (estradiol-levonorgestrel)
T3 QL (8 patches/28 days)COMBIPATCH DIS .05/.14 (estradiol)
T3 QL (8 patches/28 days)COMBIPATCH DIS .05/.25 (estradiol)
T3 QL (1 bottle/30 days)DIVIGEL GEL 0.25MG (estradiol)
T3 QL (1 bottle/30 days)DIVIGEL GEL 0.5MG (estradiol)
T3 QL (1 bottle/30 days)DIVIGEL GEL 1MG/GM (estradiol)
T3 QL (1 bottle/30 days)ELESTRIN GEL 0.06% (estradiol)
T3 QL (30 tabs/30 days)ENJUVIA TAB 0.3MG (estrogens,)
T3 QL (30 tabs/30 days)ENJUVIA TAB 0.45MG (estrogens,)
T3 QL (30 tabs/30 days)ENJUVIA TAB 0.625MG (estrogens,)
T3 QL (30 tabs/30 days)ENJUVIA TAB 0.9MG (estrogens,)
T3 QL (30 tabs/30 days)ENJUVIA TAB 1.25MG (estrogens,)
T1estra/noreth tab 0.5-0.1
T1estra/noreth tab 1-0.5mg
T3 QL (1 tube = 42.5gm/fill)ESTRACE VAG CRE 0.1MG/GM (estradiol)
T1 QLestradiol dis 0.025mg
T1 QLestradiol dis 0.0375mg
T1 QLestradiol dis 0.05mg
106Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESESTROGENS AND ANTIESTROGENS
ESTROGENS
T1 QLestradiol dis 0.06mg
T1 QLestradiol dis 0.075mg
T1 QLestradiol dis 0.1mg
T1estradiol tab 0.5mg
T1estradiol tab 1mg
T1estradiol tab 2mg
T3ESTRASORB EMU (estradiol)
T3 QL (1 ring/90 days)ESTRING MIS 2MG (estradiol)
T3 QL (1 bottle/30 days)ESTROGEL GEL (estradiol)
T1estropipate tab 0.75mg
T1estropipate tab 1.5mg
T1estropipate tab 3mg
T3 QL (1 bottle/30 days)EVAMIST SPR 1.53MG (estradiol)
T3 PA, QL (1 ring/90 days)FEMRING MIS 0.05/24H (estradiol)
T3 PA, QL (1 ring/90 days)FEMRING MIS 0.1MG/24 (estradiol)
T1jinteli tab 1mg-5mcg (norethindrone)
T1lopreeza tab 0.5-0.1 (estradiol)
T1lopreeza tab 1-0.5mg (estradiol)
T2MENEST TAB 0.3MG (esterified)
T2MENEST TAB 0.625MG (esterified)
T2MENEST TAB 1.25MG (esterified)
T2MENEST TAB 2.5MG (esterified)
T3 QL (4 patches/28 days)MENOSTAR DIS 14MCG (estradiol)
T1mimvey tab 1-0.5mg (estradiol)
T1mimvey lo tab 0.5-0.1 (estradiol)
T1noreth/ethin tab 0.5-2.5
T1noreth/ethin tab 1mg-5mcg
T1ortho-est tab 0.625 (estropipate)
T1ortho-est tab 1.25 (estropipate)
T3PREFEST TAB (estradiol-norgestimate)
T2PREMARIN TAB 0.3MG (estrogens,)
107Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESESTROGENS AND ANTIESTROGENS
ESTROGENS
T2PREMARIN TAB 0.45MG (estrogens,)
T2PREMARIN TAB 0.625MG (estrogens,)
T2PREMARIN TAB 0.9MG (estrogens,)
T2PREMARIN TAB 1.25MG (estrogens,)
T2PREMARIN VAG CRE 0.625MG (estrogens,)
T2 QL (30 tabs/30 days)PREMPHASE TAB (conjugated)
T2 QL (30 tabs/30 days)PREMPRO TAB .625-2.5 (conjugated)
T2 QL (30 tabs/30 days)PREMPRO TAB 0.3-1.5 (conjugated)
T2 QL (30 tabs/30 days)PREMPRO TAB 0.45-1.5 (conjugated)
T2 QL (30 tabs/30 days)PREMPRO TAB 0.625-5 (conjugated)
T2VAGIFEM TAB 10MCG (estradiol)
GONADOTROPINS
T4 PA
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4 PA
T3
chor gonadot inj 10000unt
GONAL-F RFF INJ 300 (follitropin)
GONAL-F RFF INJ 300/0.5 (follitropin)
GONAL-F RFF INJ 450 (follitropin)
GONAL-F RFF INJ 450/0.75 (follitropin)
GONAL-F RFF INJ 900 (follitropin)
GONAL-F RFF INJ 900/1.5 (follitropin)
MENOPUR INJ 75UNIT (menotropins)
pregnyl inj 10000unt (chorionic)
SYNAREL SOL 2MG/ML (nafarelin)
PARATHYROID
T4 ST, SP, QL (1 pen/28 days), alendronate, ibandronate, Prolia (medical benefit))
alendronate, ibandronate, PROLIA
FORTEO SOL 600/2.4 (teriparatide)
PITUITARY
T1desmopressin sol 0.01%
T1desmopressin tab 0.1mg
T1desmopressin tab 0.2mg
108Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESPROGESTINS
T2CRINONE GEL 4% VAG (progesterone)
T2CRINONE GEL 8% VAG (progesterone)
T3DEPO-PROVERA INJ 400/ML (medroxyprogesterone)
T3ENDOMETRIN SUP 100MG (progesterone)
T0 QL HCR Rules for Coveragemedroxypr ac inj 150mg/ml
T1medroxypr ac tab 10mg
T1medroxypr ac tab 2.5mg
T1medroxypr ac tab 5mg
T3 QL (175ml/30 days)MEGACE ES SUS (megestrol)
T1megestrol sus 625mg/5m
T1norethin ace tab 5mg
T1progesterone cap 100mg
T1progesterone cap 200mg
T1progesterone inj 50mg/ml
SOMATOSTATIN AGONISTS AND ANTAGONISTSSOMATOSTATIN AGONISTS
T4 PA, SPSIGNIFOR INJ 0.3MG/ML (pasireotide)
T4 PA, SPSIGNIFOR INJ 0.6MG/ML (pasireotide)
T4 PA, SPSIGNIFOR INJ 0.9MG/ML (pasireotide)
T3 PA, QLSOMATULINE INJ 90/0.3ML (lanreotide)
SOMATOTROPIN AGONISTS AND ANTAGONISTSSOMATOTROPIN AGONISTS
T4 PAINCRELEX INJ 40MG/4ML (mecasermin)
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4 PA, SP
NUTROPIN INJ 10MG (somatropin)
NUTROPIN AQ INJ 10MG/2ML (somatropin)
NUTROPIN AQ INJ 20MG/2ML (somatropin)
NUTROPIN AQ INJ NUSPIN 5 (somatropin)
SOMATOTROPIN ANTAGONISTS
T3 PASOMAVERT INJ 10MG (pegvisomant)
T3 PASOMAVERT INJ 15MG (pegvisomant)
T3 PASOMAVERT INJ 20MG (pegvisomant)
109Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
QL
QL
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESSOMATOTROPIN AGONISTS AND ANTAGONISTS
SOMATOTROPIN ANTAGONISTS
T3 PASOMAVERT INJ 25MG (pegvisomant)
T3 PASOMAVERT INJ 30MG (pegvisomant)
THYROID AND ANTITHYROID AGENTSANTITHYROID AGENTS
T1methimazole tab 10mg
T1methimazole tab 5mg
T1propylthiour tab 50mg
THYROID AGENTS
T1 QL (30 tab / 30 days)armour thyro tab 120mg (thyroid)
T2 QL (30 tab / 30 days)ARMOUR THYRO TAB 120MG (thyroid)
T2 QL (30 tab / 30 days)ARMOUR THYRO TAB 15MG (thyroid)
T2 QL (30 tab / 30 days)ARMOUR THYRO TAB 180MG (thyroid)
T1 QL (30 tab / 30 days)armour thyro tab 180mg (thyroid)
T2 QL (30 tab / 30 days)ARMOUR THYRO TAB 240MG (thyroid)
T2 QL (30 tab / 30 days)ARMOUR THYRO TAB 300MG (thyroid)
T2ARMOUR THYRO TAB 30MG (thyroid)
T1armour thyro tab 30mg (thyroid)
T2ARMOUR THYRO TAB 60MG (thyroid)
T1armour thyro tab 60mg (thyroid)
T2ARMOUR THYRO TAB 90MG (thyroid)
T1levothyroxin tab 100mcg
T1levothyroxin tab 112mcg
T1levothyroxin tab 125mcg
T1levothyroxin tab 137mcg
T1levothyroxin tab 150mcg
T1levothyroxin tab 175mcg
T1levothyroxin tab 200mcg
T1levothyroxin tab 25mcg
T1
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QL
QLlevothyroxin tab 300mcg
110Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESTHYROID AND ANTITHYROID AGENTS
THYROID AGENTS
T1 QLlevothyroxin tab 50mcg
T1 QLlevothyroxin tab 75mcg
T1 QLlevothyroxin tab 88mcg
T1 QL
T2 QL (30 tabs/30 days) levothyroxine
T2 QL (30 tabs/30 days) levothyroxine
T2 QL (30 tabs/30 days) levothyroxine
T2 QL (30 tabs/30 days) levothyroxine
T2 QL (30 tabs/30 days) levothyroxine
T2 QL (30 tabs/30 days) levothyroxine
T2 QL (30 tabs/30 days) levothyroxine
T2 QL (30 tabs/30 days) levothyroxine
levothyroxine tab 0.075mg
LEVOXYL (levothyroxine) tab 100mcg
LEVOXYL (levothyroxine) tab 112mcg
LEVOXYL (levothyroxine) tab 125mcg
LEVOXYL (levothyroxine) tab 137mcg
LEVOXYL (levothyroxine) tab 150mcg
LEVOXYL (levothyroxine) tab 175mcg
LEVOXYL (levothyroxine) tab 200mcg
LEVOXYL (levothyroxine) tab 25mcg
T2 QL (30 tabs/30 days) levothyroxine
T2 QL (30 tabs/30 days) levothyroxine
T2 QL (30 tabs/30 days) levothyroxine
LEVOXYL (levothyroxine) tab 50mcg
LEVOXYL(levothyroxine)tab 75mcg
LEVOXYL (levothyroxine) tab 88mcg
(levothyroxine) T1liothyronine tab 25mcg
T1liothyronine tab 50mcg
T1liothyronine tab 5mcg
T1 QLnature-throi tab 130mg (thyroid)
T1 QLnature-throi tab 16.25mg (thyroid)
T1 QLnature-throi tab 195mg (thyroid)
T1 QLnature-throi tab 32.5mg (thyroid)
T1 QLnature-throi tab 65mg (thyroid)
T1 QLnp thyroid tab 30mg (thyroid)
T1 QLnp thyroid tab 60mg (thyroid)
T1 QLnp thyroid tab 90mg (thyroid)
T2 QL (30 tabs/30 days) levothyroxineSYNTHROID TAB 100MCG (levothyroxine)
T2 QL (30 tabs/30 days) levothyroxineSYNTHROID TAB 112MCG (levothyroxine)
T2 QL (30 tabs/30 days) levothyroxineSYNTHROID TAB 125MCG (levothyroxine)
T2 QL (30 tabs/30 days) levothyroxineSYNTHROID TAB 137MCG (levothyroxine)
T2 QL (30 tabs/30 days) levothyroxineSYNTHROID TAB 150MCG (levothyroxine)
111Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESTHYROID AND ANTITHYROID AGENTS
THYROID AGENTS
T2 QL (30 tabs/30 days) levothyroxineSYNTHROID TAB 175MCG (levothyroxine)
T2 QL (30 tabs/30 days) levothyroxineSYNTHROID TAB 200MCG (levothyroxine)
T2 QL (30 tabs/30 days) levothyroxineSYNTHROID TAB 25MCG (levothyroxine)
T2 QL (30 tabs/30 days) levothyroxineSYNTHROID TAB 300MCG (levothyroxine)
T2 QL (30 tabs/30 days) levothyroxineSYNTHROID TAB 50MCG (levothyroxine)
T2 QL (30 tabs/30 days) levothyroxineSYNTHROID TAB 75MCG (levothyroxine)
T2 QL (30 tabs/30 days) levothyroxineSYNTHROID TAB 88MCG (levothyroxine)
T2THYROLAR-1 TAB 60MG (liotrix)
T2THYROLAR-1/2 TAB 30MG (liotrix)
T2THYROLAR-1/4 TAB 15MG (liotrix)
T2THYROLAR-2 TAB 120MG (liotrix)
T2THYROLAR-3 TAB 180MG (liotrix)
T2 QLTIROSINT CAP 100MCG (levothyroxine)
T2 QLTIROSINT CAP 112MCG (levothyroxine)
T2 QLTIROSINT CAP 125MCG (levothyroxine)
T2 QLTIROSINT CAP 137MCG (levothyroxine)
T2 QLTIROSINT CAP 13MCG (levothyroxine)
T2 QLTIROSINT CAP 150MCG (levothyroxine)
T2 QLTIROSINT CAP 25MCG (levothyroxine)
T2 QLTIROSINT CAP 50MCG (levothyroxine)
T2 QLTIROSINT CAP 75MCG (levothyroxine)
T2 QLTIROSINT CAP 88MCG (levothyroxine)
T1 QL
T1 QL
T1 QL
T1 QL
T1 QL
T1 QL
T1 QL
T1 QL
unith direct tab 100mcg (levothyroxine)
unith direct tab 112mcg (levothyroxine)
unith direct tab 125mcg (levothyroxine)
unith direct tab 150mcg (levothyroxine)
unith direct tab 175mcg (levothyroxine)
unith direct tab 200mcg (levothyroxine)
unith direct tab 25mcg (levothyroxine)
unith direct tab 50mcg (levothyroxine)
112Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
HORMONES AND SYNTHETIC SUBSTITUTESTHYROID AND ANTITHYROID AGENTS
THYROID AGENTS
T1 QLunith direct tab 75mcg (levothyroxine)
T1 QLunith direct tab 88mcg (levothyroxine)
T2 QL
T2 QL
T2 QL
T2 QL
T2 QL
T2 QL
T2 QL
UNITHROID tab 100mcg (levothyroxine)
UNITHROID tab 112mcg (levothyroxine)
UNITHROID tab 125mcg (levothyroxine)
UNITHROID tab 137mcg (levothyroxine)
UNITHROID tab 150mcg (levothyroxine)
UNITHROID tab 175mcg (levothyroxine)
UNITHROID tab 200mcg (levothyroxine)
T2 QLunithroid tab 25mcg (levothyroxine)
T2 QLunithroid tab 300mcg (levothyroxine)
T2 QLunithroid tab 50mcg (levothyroxine)
T2 QLunithroid tab 75mcg (levothyroxine)
T2 QLunithroid tab 88mcg (levothyroxine)
T1 QL
T1 QL
westhroid tab 32.5mg (thyroid)
westhroid tab 65mg (thyroid) )
LOCAL ANESTHETICS (PARENTERAL)
T1chloroproc inj 2%
T1chloroproc inj 3%
T1tetracaine inj 1%
MISCELLANEOUS THERAPEUTIC AGENTS
T1colchicine tab 0.6mg
T1leucovor ca tab 15mg
T1leucovor ca tab 25mg
T1leucovor ca tab 5mg
5-ALPHA-REDUCTASE INHIBITORS
T1 QL (30 caps/30 days), ST (finasteride)
Dutasteride 0.5MG
T1finasteride tab 5mg
113Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
MISCELLANEOUS THERAPEUTIC AGENTSALCOHOL DETERRENTS
T1disulfiram tab 250mg
T1disulfiram tab 500mg
ANTIDOTES
T1leucovor ca tab 10mg
ANTIGOUT AGENTS
T1allopurinol tab 100mg
T1allopurinol tab 300mg
T1colchicine cap 0.6mg
BIOLOGIC RESPONSE MODIFIERS
T4 PA, QL (3 vials / 30 days)
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4
T1
PA, SP
PA, SP
T4
T4
T4
PA, SP
PA, SP
PA, SP
T4
T4
T4
T4
T4
PA, SP
PA, SP
PA, SP
PA,SP
PA,SP
ACTIMMUNE INJ 2MU/0.5 (interferon)
AUBAGIO TAB 14MG (teriflunomide)
AUBAGIO TAB 7MG (teriflunomide)
AVONEX KIT 30MCG (interferon)
AVONEX PEN KIT 30MCG (interferon)
AVONEX PREFL KIT 30MCG (interferon)
T4 PA, SP
T4 PA, SP
T4 PA, SP
T4 PA, SP
MED PA, SP, QL (15 ml (1 vial) every 23 days)
Medical coinsurance
glatiramer inj 20MG/ML
EXTAVIA INJ 0.3MG (interferon)
GILENYA CAP 0.5MG (fingolimod)
REBIF INJ 22/0.5 (interferon)
REBIF INJ 44/0.5 (interferon)
REBIF REBIDO INJ 22/0.5 (interferon)
REBIF REBIDO INJ 44/0.5 (interferon)
REBIF REBIDO INJ TITRATN (interferon)
REBIF TITRTN INJ PACK (interferon)
THALOMID CAP 100MG (thalidomide)
THALOMID CAP 150MG (thalidomide)
THALOMID CAP 200MG (thalidomide)
THALOMID CAP 50MG (thalidomide)
TYSABRI INJ 300/15ML (natalizumab)
114Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
MISCELLANEOUS THERAPEUTIC AGENTSBONE RESORPTION INHIBITORS
T1 QL (4 tabs/28 days), ST (alendronate, ibandronate)
alendronaterisedronate tab 35mg
T1alendronate tab 10mg
T1alendronate tab 35mg
T1alendronate tab 40mg
T1alendronate tab 5mg
T1alendronate tab 70mg
T1etidron disd tab 200mg
T1etidron disd tab 400mg
T3 QL (4 tabs/28 days), ST (alendronate, ibandronate)
FOSAMAX + D TAB 70-2800 (alendronate)
T3 QL (4 tabs/28 days), ST (alendronate, ibandronate)
FOSAMAX + D TAB 70-5600 (alendronate)
T1 QL (1 tab/28 days)ibandronate tab 150mg
MED PA, SP Medical coinsurancePROLIA SOL 60MG/ML (denosumab)
T1 QL (1 tab/28 days)risedronate tab 150mg
MED PA, SP Medical coinsuranceXGEVA INJ (denosumab)
CARIOSTATIC AGENTS
T0 HCR Rules for Coveragesodium fluoride chew 0.25 mg
T0 HCR Rules for Coveragesodium fluoride chew 0.5 mg
T0 HCR Rules for Coveragesodium fluoride chew 1 mg
T0 HCR Rules for Coveragesodium fluoride chew 1.1 mg
T0 HCR Rules for Coveragesodium fluoride chew 2.2 mg
T0 HCR Rules for Coveragesodium fluoride lozg 1 mg
T0 HCR Rules for Coveragesodium fluoride soln 0.125 mg/drop
T0 HCR Rules for Coveragesodium fluoride soln 0.25 mg/drop
T0 HCR Rules for Coveragesodium fluoride soln 0.5 mg/ml
T0 HCR Rules for Coveragesodium fluoride tab 0.5 mg
T0 HCR Rules for Coveragesodium fluoride tab 1 mg
COMPLEMENT INHIBITORS
MED PA, SP Medical coinsuranceBERINERT INJ 500UNIT (c1)
MED PA, SP Medical coinsuranceCINRYZE SOL 500 UNIT (c1)
115Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
MISCELLANEOUS THERAPEUTIC AGENTSDISEASE-MODIFYING ANTIRHEUMATIC AGENTS
MED PA, SPACTEMRA INJ 162/0.9 (tocilizumab)
MED PA, SP Medical coinsuranceACTEMRA INJ 200/10ML (tocilizumab)
MED PA, SP Medical coinsuranceACTEMRA INJ 400/20ML (tocilizumab)
MED PA, SP Medical coinsuranceACTEMRA INJ 80MG/4ML (tocilizumab)
T4 PA, SP ENBREL, HUMIRA, CIMZIA KIT (certolizumab)
T4 PA, SP ENBREL, HUMIRA, CIMZIA KIT STARTER (certolizumab)
T4 PA, SP ENBREL, HUMIRA, CIMZIA PREFL KIT 200MG/ML (certolizumab)
T4 PA, SPENBREL INJ 25/0.5ML (etanercept)
T4 PA, SPENBREL INJ 25MG (etanercept)
T4 PA, SPENBREL INJ 50MG/ML (etanercept)
T4 PA, SPENBREL SRCLK INJ 50MG/ML (etanercept)
T4 PA, SPHUMIRA INJ 10MG/0.2 (adalimumab)
T4 PA, SPHUMIRA INJ 40MG/0.8 (adalimumab)
T4 PA, SPHUMIRA KIT 20MG/0.4 (adalimumab)
T4 PA,SPHUMIRA PEDIA INJ CROHNS (adalimumab)
T4 PA,SPHUMIRA PEN INJ 40MG/0.8 (adalimumab)
T4 PA,SPHUMIRA PEN INJ CROHNS (adalimumab)
T4 PA, SPHUMIRA PEN INJ PSORIASI (adalimumab)
T1leflunomide tab 10mg
T1leflunomide tab 20mg
T4ORENCIA INJ 125MG/ML (abatacept)
T4OTEZLA TAB 10/20/30 (apremilast)
T4OTEZLA TAB 30MG (apremilast)
MED Medical coinsuranceREMICADE INJ 100MG (infliximab)
T4SIMPONI INJ 100MG/ML (golimumab)
T4
PA, SP
PA, SP, QL (1 kit/ 365 days)
PA, SP, QL (60 tab / 30 days)
PA, SP
PA, SP
PA, SPSIMPONI INJ 50/0.5ML (golimumab)
T4SIMPONI ARIA SOL 50MG/4ML (golimumab)
T4 PA, SP ENBREL, leflunomide,
XELJANZ TAB 5MG (tofacitinib)
116Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
PA, SP
Drug Name Tier Requirements/Limits
AlternativesComments
MISCELLANEOUS THERAPEUTIC AGENTSGONADOTROPIN-RELEASING HORMONE ANTAGNTS
T4 PA, SPCETROTIDE KIT 0.25MG (cetrorelix)
T4 PA, SP ganirelix ac inj
IMMUNOSUPPRESSIVE AGENTS
T1azathioprine tab 50mg
MED PA, SP Medical coinsuranceBENLYSTA INJ 120MG (belimumab)
MED PA, SP Medical coinsuranceBENLYSTA INJ 400MG (belimumab)
T1cyclosporine cap 100mg
T1cyclosporine cap 100mg md
T1cyclosporine cap 25mg
T1cyclosporine cap 25mg mod
T1cyclosporine cap 50mg mod
T1gengraf cap 100mg (cyclosporine)
T1gengraf cap 25mg (cyclosporine)
T1hecoria cap 0.5mg (tacrolimus)
T1hecoria cap 1mg (tacrolimus)
T1hecoria cap 5mg (tacrolimus)
T1mycophenolat cap 250mg
T1mycophenolat sus 200mg/ml
T1mycophenolat tab 500mg
T1mycophenolic tab 180mg dr
T1mycophenolic tab 360mg dr
T2RAPAMUNE SOL 1MG/ML (sirolimus)
T3SANDIMMUNE SOL 100MG/ML (cyclosporine)
T1sirolimus tab 0.5mg
T1sirolimus tab 1mg
T1sirolimus tab 2mg
T1tacrolimus cap 0.5mg
T1tacrolimus cap 1mg
T1tacrolimus cap 5mg
T3 PAZORTRESS TAB 0.25MG (everolimus)
T3 PAZORTRESS TAB 0.5MG (everolimus)
T3 PAZORTRESS TAB 0.75MG (everolimus)
117Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
MISCELLANEOUS THERAPEUTIC AGENTSOTHER MISCELLANEOUS THERAPEUTIC AGENTS
T4 PA, SPAMPYRA TAB 10MG (dalfampridine)
T3 PAARCALYST INJ 220MG (rilonacept)
T2CYSTAGON CAP 150MG (cysteamine)
T2CYSTAGON CAP 50MG (cysteamine)
T2ELMIRON CAP 100MG (pentosan)
T2ORFADIN CAP 10MG (nitisinone)
T2ORFADIN CAP 2MG (nitisinone)
T2ORFADIN CAP 5MG (nitisinone)
T3 QL (360 tabs/30 days)SENSIPAR TAB 30MG (cinacalcet)
T3 QL (180 tabs/30 days)SENSIPAR TAB 60MG (cinacalcet)
T3 QL (120 tabs/30 days)SENSIPAR TAB 90MG (cinacalcet)
RESPIRATORY TRACT AGENTSANTIFIBROTIC AGENTS
T4 PAESBRIET CAP 267MG (pirfenidone)
T4 PAOFEV CAP 100MG (nintedanib)
T4 PAOFEV CAP 150MG (nintedanib)
ANTI-INFLAMMATORY AGENTS (RESPIRATORY)LEUKOTRIENE MODIFIERS
T1montelukast chw 4mg
T1montelukast chw 5mg
T1montelukast gra 4mg
T1montelukast tab 10mg
T1zafirlukast tab 10mg
T1zafirlukast tab 20mg
T3 QL (120 tabs/30 days) montelukastZYFLO CR TAB 600MG (zileuton)
MAST-CELL STABILIZERS
T1cromolyn sod con 100/5ml
ANTITUSSIVES
T1benzonatate cap 100mg
T1benzonatate cap 150mg
T1 QLbenzonatate cap 200mg
T1chlor/phen dro dm
118Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
RESPIRATORY TRACT AGENTSANTITUSSIVES
T1dm/cpm/pe dro
T1 QLhyd pol/cpm liq 10-8/5ml
T1nohist-dm liq (phenylephrine-chlorphen-dm)
T1prometh/cod syp 6.25-10
T1promethazine syp dm
CYSTIC FIBROSIS (CFTR) MODULATORSCYSTIC FIBROSIS (CFTR) POTENTIATORS
T4 PA, SPKALYDECO TAB 150MG (ivacaftor)
MUCOLYTIC AGENTS
T1pulmosal neb 7% (sodium)
T3 PAPULMOZYME SOL 1MG/ML (dornase)
T1sodium chlor neb 7%
PHOSPHODIESTERASE TYPE 4 INHIBITORS
T3 PA, QL (30 tabs/30 days)DALIRESP TAB 500MCG (roflumilast)
RESPIRATORY TRACT AGENTS, MISCELLANEOUS
MED PA, SP Medical coinsuranceXOLAIR SOL 150MG (omalizumab)
VASODILATING AGENTS (RESPIRATORY TRACT)
T4
T4
T4
T4
T4
T4
T4
T4
T4
T4
PA, QL (90 tabs/30 days)
PA, QL (90 tabs/30 days)
PA, QL (90 tabs/30 days)
PA, QL (90 tabs/30 days)
PA, QL (90 tabs/30 days)
PA, QL (30 tabs/30 days)
PA, QL (30 tabs/30 days)
PA, QL (30 tabs/30 days)
SP, PA
PA, QL (60 tabs/30 days)
T4 PA, QL (28 units / 30 days)
T4 PA, QL (28 units / 30 days)
T4 PA, QL (28 units / 30 days)
T4
T4
PA
PA, QL (270 ampules/ 30 days)
ADEMPAS TAB 0.5MG (riociguat)
ADEMPAS TAB 1.5MG (riociguat)
ADEMPAS TAB 1MG (riociguat)
ADEMPAS TAB 2.5MG (riociguat)
ADEMPAS TAB 2MG (riociguat)
LETAIRIS TAB 10MG (ambrisentan)
LETAIRIS TAB 5MG (ambrisentan)
OPSUMIT TAB 10MG (macitentan)
ORKAMBI TAB
TRACLEER TAB 62.5MG (bosentan)
TYVASO SOL 0.6MG/ML (treprostinil)
TYVASO REFIL SOL 0.6MG/ML (treprostinil)
TYVASO START SOL 0.6MG/ML (treprostinil)
UPTRAVI TAB
VENTAVIS SOL 20MCG/ML (iloprost)
119Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SERUMS, TOXOIDS, AND VACCINESSERUMS
MED PA, SP Medical coinsuranceBIVIGAM INJ 10% (immune)
MED PA, SP Medical coinsurancecarimune nf inj 12gm (immune)
MED PA, SP Medical coinsurancecarimune nf inj 3gm (immune)
MED PA, SP Medical coinsurancecarimune nf inj 6gm (immune)
MED PA, SP Medical coinsuranceFLEBOGAMMA INJ 20/400ML (immune)
MED PA, SP Medical coinsuranceflebogamma 5% vial
MED PA, SP Medical coinsurancegamastan s/d inj (immune)
MED PA, SP Medical coinsurancegammagard inj 1gm/10ml (immune)
MED PA, SP Medical coinsurancegammagard inj 2.5gm/25 (immune)
MED PA, SP Medical coinsurancegammagard inj 20gm/200 (immune)
MED PA, SP Medical coinsurancegammagard inj 5gm/50ml (immune)
MED PA, SP Medical coinsuranceGAMMAGARD S-D 10 G (IGA<1) SOL
MED PA, SP Medical coinsurancegammagard s-d 2.5 gm vl w/st
MED PA, SP Medical coinsuranceGAMMAGARD S-D 5 G (IGA<1) SOLN
MED PA, SP Medical coinsuranceGAMMAKED INJ 10GM/100 (immune)
MED PA, SP Medical coinsuranceGAMMAKED INJ 1GM/10ML (immune)
MED PA, SP Medical coinsuranceGAMMAKED INJ 2.5GM/25 (immune)
MED PA, SP Medical coinsuranceGAMMAKED INJ 20GM/200 (immune)
MED PA, SP Medical coinsuranceGAMMAKED INJ 5GM/50ML (immune)
MED PA, SP Medical coinsuranceGAMMAPLEX INJ 10GM (immune)
MED PA, SP Medical coinsuranceGAMMAPLEX INJ 2.5GM (immune)
MED PA, SP Medical coinsuranceGAMMAPLEX INJ 5GM (immune)
MED PA, SP Medical coinsuranceGAMUNEX 10% VIAL (IMMUNE)
MED PA, SP Medical coinsuranceHIZENTRA INJ 1GM/5ML (immune)
MED PA, SP Medical coinsuranceHIZENTRA INJ 2GM/10ML (immune)
MED PA, SP Medical coinsuranceHIZENTRA INJ 4GM/20ML (immune)
MED PA, SP Medical coinsuranceOCTAGAM INJ 10GM (immune)
MED PA, SP Medical coinsuranceOCTAGAM INJ 1GM (immune)
MED PA, SP Medical coinsuranceOCTAGAM INJ 2.5GM (immune)
MED PA, SP Medical coinsuranceOCTAGAM INJ 25GM (immune)
MED PA, SP Medical coinsuranceOCTAGAM INJ 5GM (immune)
MED PA, SP Medical coinsurancePRIVIGEN INJ 10GRAMS (immune)
120Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SERUMS, TOXOIDS, AND VACCINESSERUMS
MED PA, SP Medical coinsurancePRIVIGEN INJ 20GRAMS (immune)
MED PA, SP Medical coinsurancePRIVIGEN INJ 5 GRAMS (immune)
MED PA, SP Medical coinsuranceVIVAGLOBIN SOL 160MG/ML (immune)
TOXOIDS
VACCINES
T0 HCR Rules for CoverageAFLURIA INJ 2015-16 (influenza)
T0 HCR Rules for CoverageAFLURIA INJ PF 12-13 (influenza)
T0 HCR Rules for CoverageAFLURIA INJ PF 13-14 (influenza)
T0 HCR Rules for CoverageAFLURIA INJ PF 14-15 (influenza)
T0 HCR Rules for CoverageAFLURIA INJ PF 15-16 (influenza)
T0 HCR Rules for Coverage
T0 HCR Rules for Coverage
T0 HCR Rules for Coverage
T0 HCR Rules for Coverage
T0 HCR Rules for Coverage
T0 HCR Rules for Coverage
T0 HCR Rules for Coverage
T0 HCR Rules for Coverage
T0 HCR Rules for Coverage
T0 HCR Rules for Coverage
T0 HCR Rules for Coverage
T0 HCR Rules for Coverage
T0 HCR Rules for Coverage
EZ FLU SHOT INJ 2015-16 (influenza)
FLUARIX PF INJ 2013-14 (influenza)
FLUARIX PF INJ 2014-15 (influenza)
FLUARIX QUAD INJ 2013-14 (influenza)
FLUARIX QUAD INJ 2014-15 (influenza)
FLUARIX QUAD INJ 2015-16 (influenza)
FLUBLOK SOL 2013-14 (influenza)
FLUBLOK SOL 2014-15 (influenza)
FLUBLOK SOL 2015-16 (influenza)
FLUCELVAX INJ 2013-14 (influenza)
FLUCELVAX INJ 2014-15 (influenza)
FLUCELVAX INJ 2015-16 (influenza)
FLULAVAL INJ 2013-14 (influenza)
T0 HCR Rules for CoverageFLULAVAL QUA INJ 2013-14 (influenza)
T0 HCR Rules for CoverageFLULAVAL QUA INJ 2014-15 (influenza)
T0 HCR Rules for CoverageFLULAVAL QUA INJ 2015-16 (influenza)
T0 HCR Rules for CoverageFLUMIST QUAD SUS 2013-14 (influenza)
T0 HCR Rules for CoverageFLUMIST QUAD SUS 2014-15 (influenza)
T0 HCR Rules for CoverageFLUMIST QUAD SUS 2015-16 (influenza)
T0 HCR Rules for CoverageFLUVIRIN INJ 2013-14 (influenza)
121Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SERUMS, TOXOIDS, AND VACCINESVACCINES
T0 HCR Rules for CoverageFLUVIRIN INJ 2015-16 (influenza)
T0 HCR Rules for CoverageFLUVIRIN INJ PF 13-14 (influenza)
T0 HCR Rules for CoverageFLUVIRIN PF INJ 2014-15 (influenza)
T0 HCR Rules for CoverageFLUZONE INJ INTRADRM (influenza)
T0 HCR Rules for CoverageFLUZONE INJ PF 13-14 (influenza)
T0 HCR Rules for CoverageFLUZONE INJ PF 14-15 (influenza)
T0 HCR Rules for CoverageFLUZONE HD INJ PF 13-14 (influenza)
T0 HCR Rules for CoverageFLUZONE HD INJ PF 14-15 (influenza)
T0 HCR Rules for CoverageFLUZONE HD INJ PF 15-16 (influenza)
T0 HCR Rules for CoverageFLUZONE PED/ INJ PF 13-14 (influenza)
T0 HCR Rules for CoverageFLUZONE QUAD INJ 13-14 (influenza)
T0 HCR Rules for CoverageFLUZONE QUAD INJ 14-15 (influenza)
T0 HCR Rules for CoverageFLUZONE QUAD INJ 15-16 (influenza)
T0 HCR Rules for Coverage
T0 HCR Rules for Coverage
T0 HCR Rules for Coverage
T0 HCR Rules for Coverage
FLUZONE QUAD INJ 2015-16 (influenza)
FLUZONE QUAD INJ 9MCG (influenza)
FLUZONE SPLT INJ 2015-16 (influenza)
INFLUENZA FIRUS VACCINE (INFLUENZA)
SKIN AND MUCOUS MEMBRANE AGENTSANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE)
ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)
T3 QL (1 tube/fill) clindamycin, erythromycin
ALTABAX OIN 1% (retapamulin)
T2BACTROBAN OIN NASAL 2% (mupirocin)
T1clindacin mis etz 1% (clindamycin)
T1clindacin-p pad 1% (clindamycin)
T1clindamax gel 1% (clindamycin)
T1clindamax lot 10mg/ml (clindamycin)
T1 QLclindamy/ben gel 1.2-5%
T1clindamy/ben gel 1-5%
T1clindamycin cre 2% vag
122Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE)
ANTIBACTERIALS (SKIN & MUCOUS MEMBRANE)
T1clindamycin gel 1%
T1clindamycin lot 1%
T1clindamycin lot 10mg/ml
T1clindamycin pad 1%
T1clindamycin sol 1%
T1ery pad 2% (erythromycin)
T1erythromycin gel /benzoyl
T1erythromycin gel 2%
T1erythromycin pad 2%
T1erythromycin sol 2%
T1gentamicin cre 0.1%
T1gentamicin oin 0.1%
T1metronidazol cre 0.75%
T1metronidazol gel 0.75%vag
T1metronidazol lot 0.75%
T1 QLmupirocin cre 2%
T1mupirocin oin 2%
T1 QLmupirocin ca cre 2%
T1 QLneuac gel 1.2-5% (clindamycin)
T1rosadan cre 0.75% (metronidazole)
T1sulfacetamid lot 10%
T1sulfacetamid sus 10%
T1vandazole gel 0.75% (metronidazole)
ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)
T1ciclodan cre 0.77% (ciclopirox)
T1ciclodan sol 8% (ciclopirox)
T1ciclopirox cre 0.77%
T1ciclopirox gel 0.77%
T1ciclopirox sha 1%
T1ciclopirox sol 8%
T1ciclopirox sus 0.77%
123Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE)
ANTIFUNGALS (SKIN & MUCOUS MEMBRANE)
T1 QL (60 gram tube/fill)clotrim/beta cre 1-0.05%
T1 QL (60 gram tube/fill)clotrim/beta cre diprop
T1clotrim/beta lot diprop
T1 QLclotrimazole cre 1% (clotrimazole)
T1clotrimazole loz 10mg
T1clotrimazole tro 10mg
T1econazole cre 1%
T3 QL (60 gm/fill) ciclopirox, econazole, ketoconazole, nystatin
ERTACZO CRE 2% (sertaconazole)
T3 QL (30 gram tube/fill)EXELDERM SOL 1% (sulconazole)
T1ketoconazole aer 2%
T1ketoconazole cre 2%
T1ketoconazole sha 2%
T1ketodan aer 2% (ketoconazole)
T3 QL (30 gram tube/fill) ciclopirox, nystatinMENTAX CRE 1% (butenafine)
T1nyamyc pow 100000 (nystatin)
T1nystatin cre 100000
T1nystatin oin 100000
T1nystatin pow 100000
T1nystop pow 100000 (nystatin)
T3 QL (60 gm/fill) ciclopirox, nystatinOXISTAT CRE 1% (oxiconazole)
T3 QL (60 gm/fill) ciclopirox, nystatinOXISTAT LOT 1% (oxiconazole)
T1pedi-dri pow 100000 (nystatin)
T1 QLterconazole cre 0.4%
T1 QLterconazole cre 0.8%
T1terconazole sup 80mg
T1 QLzazole cre 0.4% (terconazole)
T1 QLzazole cre 0.8% (terconazole)
T1zazole sup 80mg (terconazole)
ANTIVIRALS (SKIN & MUCOUS MEMBRANE)
T1 QL (60gm/30 days)acyclovir oin 5%
124Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE)
ANTIVIRALS (SKIN & MUCOUS MEMBRANE)
T3 QL (5gram / fill) acyclovirDENAVIR CRE 1% (penciclovir)
LOCAL ANTI-INFECTIVES, MISCELLANEOUS
T1 QLacne medicat gel 10% (benzoyl)
T1 QLacne medicat gel 5% (benzoyl)
T1 QLacne pimple gel 10% (benzoyl)
T1 QLacne treatmn gel 10% (benzoyl)
T1 QLacne-clear gel 10% (benzoyl)
T1benzepro aer 5.3% (benzoyl)
T1benzepro liq creamy (benzoyl)
T1benzepro sc aer 9.8% (benzoyl)
T1benziq wash liq 5.25% (benzoyl)
T1benzoyl per aer 5.3%
T1benzoyl per aer 9.8%
T1 QLbenzoyl per gel 10% (benzoyl)
T1 QLbenzoyl per gel 5% (benzoyl)
T1benzoyl per liq 10% wash (benzoyl)
T1benzoyl pero aer 9.8%
T1benzoyl pero kit acne pck (benzoyl)
T1bp foam aer 5.3% (benzoyl)
T1bp foam aer 9.8% (benzoyl)
T1bp foaming liq wash 10% (benzoyl)
T1 QLbp gel gel 10% (benzoyl)
T1 QLbp gel gel 5% (benzoyl)
T1bp wash liq 2.5% (benzoyl)
T1bp wash liq 7% (benzoyl)
T1bpo gel 4% (benzoyl)
T1bpo gel 8% (benzoyl)
T1bpo creamy kit 4% wash (benzoyl)
T1bpo creamy kit 8% wash (benzoyl)
T1 QLclearplex v gel 5% (benzoyl)
T1 QLclearplex x gel 10% (benzoyl)
125Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSANTI-INFECTIVES (SKIN & MUCOUS MEMBRANE)
LOCAL ANTI-INFECTIVES, MISCELLANEOUS
T1 QLpersa-gel gel 10% (benzoyl)
T1 QLpersa-gel xs gel 5% (benzoyl)
T1pr benzoyl liq 7% wash (benzoyl)
T1 QLra renewal gel 10% (benzoyl)
T1se bpo wash liq 7% (benzoyl)
T1selenium sul lot 2.5%
T1selenium sul sha 2.25%
T1selenium sul sha 2.5%
T1silver sulfa cre 1%
T1ssd cre 1% (silver)
T1thermazene cre 1% (silver)
SCABICIDES AND PEDICULICIDES
T1acticin cre 5% (permethrin)
T2EURAX CRE 10% (crotamiton)
T2 QL (454 ml/30 days)EURAX LOT 10% (crotamiton)
T1lindane lot 1%
T1lindane sha 1%
T1malathion lot 0.5%
T1permethrin cre 5%
T3SKLICE LOT 0.5% (ivermectin)
T3 QL (227 ml/30 days)ULESFIA LOT 5% (benzyl)
ANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)
T1ala cort cre 1% (hydrocortisone)
T1alclometason cre 0.05%
T1alclometason oin 0.05%
T1 QL (60 gram tube/fill)alphatrex gel 0.05% (betamethasone)
T1amcinonide cre 0.1%
T1amcinonide lot 0.1%
T1amcinonide oin 0.1%
T1 QLanucort-hc sup 25mg (hydrocortisone)
T2 QL (30 gm/fill)APEXICON E CRE 0.05% (diflorasone)
126Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)
T1 QL (60 gram tube/fill)aug betamet cre 0.05%
T1 QL (60 gram tube/fill)aug betamet gel 0.05%
T1 QL (60 gram tube/fill)aug betamet lot 0.05%
T1 QL (60 gram tube/fill)aug betamet oin 0.05%
T1beta diprop gel 0.05%
T1 QL (60 gram tube/fill)betameth dip cre 0.05%
T1 QL (60 gram tube/fill)betameth dip lot 0.05%
T1 QL (60 gram tube/fill)betameth dip oin 0.05%
T1 QL (60 gram tube/fill)betameth val cre 0.1%
T1 PA, QL (60 gram tube/fill)betameth val lot 0.1%
T1 PA, QL (60 gram tube/fill)betameth val oin 0.1%
T3 JANUVIACAPEX SHA 0.01% (fluocinolone)
T1clobetasol aer 0.05%
T1clobetasol cre 0.05%
T1clobetasol gel 0.05%
T1clobetasol lot 0.05%
T1clobetasol oin 0.05%
T1clobetasol sha 0.05%
T1clobetasol sol 0.05%
T1
T1
T3 betamethasone
T3 betamethasone
T1 betamethasone
T1
T3
T2
QL (60gram/30 days)
QL (60gram/30 days)
QL (60gram/30 days)
QL (60gram/30 days)
QL (60gram/30 days)
QL (60gram/30 days)
QL (60gram/30 days)
QL
QL (60gram/30 days)
QL (45gm/fill)
QL
QL (60 grams/fill)
QL (60gram/30 days)
PA
QL (60gm/fill) desonide
T1
T1
T1
T1 QL (30 gram tube /fill)
T1 QL (30 gram tube /fill)
clobetasol e cre 0.05% (clobetasol)
clodan sha 0.05% (clobetasol)
CLODERM CRE 0.1% (clocortolone)
CLODERM CRE 0.1% PMP (clocortolone)
flurandrenolide cre 0.05%
cormax scalp sol 0.05% (clobetasol)
CORTISPORIN CRE 0.5% (neomycin-polymyxin-hc)
DESONATE GEL 0.05% (desonide)
desonide cre 0.05%
desonide lot 0.05%
desonide oin 0.05%
diflorasone cre 0.05%
diflorasone oin 0.05%
127Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)
T1fluocin acet cre 0.01%
T1fluocin acet oil 0.01% sc (fluocinolone)
T1fluocin acet oil body (fluocinolone)
T1fluocin acet oil scalp (fluocinolone)
T1fluocin acet sol 0.01%
T1fluocinonide cre 0.05%
T1 PAfluocinonide cre 0.1%
T1fluocinonide gel 0.05%
T1fluocinonide oin 0.05%
T1fluocinonide sol 0.05%
T1fluticasone cre 0.05%
T1fluticasone lot 0.05%
T1fluticasone oin 0.005%
T1 QLgrx hicort sup 25mg (hydrocortisone)
T1halobetasol cre 0.05%
T1halobetasol oin 0.05%
T3 QL (30 grams/fill) betamethasone, clobetasol
HALOG CRE 0.1% (halcinonide)
T1 hc = hydrocortisonehc butyrate cre 0.1%
T1 hc = hydrocortisonehc butyrate oin 0.1%
T1 hc = hydrocortisonehc butyrate sol 0.1%
T1 QL hc = hydrocortisonehc pramoxine cre 1-2.5%
T1 QL hc = hydrocortisonehc pramoxine cre 2.5-1%
T1 hc = hydrocortisonehc valerate cre 0.2%
T1 hc = hydrocortisonehc valerate oin 0.2%
T1 QLhemorrhoidal sup -hc 25mg (hydrocortisone)
T1hydrocort cre 1% (hydrocortisone)
T1hydrocort cre 2.5%
T1hydrocort lot 2.5%
T1hydrocort oin 1%
T1hydrocort oin 2.5%
T1 QLhydrocort ac sup 25mg
T1hydrocort/ab oin 1%
128Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSANTI-INFLAMMATORY AGENTS (SKIN & MUCOUS)
T1 QLhydrocortiso cre 2.5%
T3KENALOG AER SPRAY (triamcinolone)
T1locoid cre 0.1% (hydrocortisone)
T1lokara lot 0.05% (desonide)
T1mometasone cre 0.1%
T1mometasone oin 0.1%
T1mometasone sol 0.1%
T1nystat/triam cre
T1nystat/triam oin
T1oralone pst 0.1% (triamcinolone)
T1prednicarbat cre 0.1%
T1 QLproctocare cre -hc 2.5% (hydrocortisone)
T1 QLprocto-pak cre 1% (hydrocortisone)
T1 QLproctosol hc cre 2.5% (hydrocortisone)
T1 QLproctozone cre -hc 2.5% (hydrocortisone)
T1proctozone cre -hc 2.5% (hydrocortisone)
T1 QLrectacort-hc sup 25mg (hydrocortisone)
T1scalacort lot 2% (hydrocortisone)
T1triamcin/ora pst 0.1%
T1triamcinolon aer spray
T1triamcinolon cre 0.025%
T1 QLtriamcinolon cre 0.1%
T1triamcinolon cre 0.5%
T1triamcinolon lot 0.025%
T1triamcinolon lot 0.1%
T1triamcinolon oin 0.025%
T1triamcinolon oin 0.1%
T1triamcinolon oin 0.5%
T1triamcinolon pst 0.1%
T1 QLtriderm cre 0.1% (triamcinolone)
ANTIPRURITICS AND LOCAL ANESTHETICS
T1 QLanecream cre 4% (lidocaine)
129Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSANTIPRURITICS AND LOCAL ANESTHETICS
T1 QL
T1 QL
T1 QL
T1 QL
T1 QL
T1 QL
T1
T1 QL
T1
T1 QL
T1
T1
T1 QL
T1 QL
T1
T1
T1 QL
T1
T1 QL
T1 QL
T1
T1
T1 QL
T1 QL
T1 QL
T1 QL
T1 QL
T1 QL
T1
T1 QL
T1 QL
T1 QL
aspercreme cre lidocain (lidocaine)
azo dine tab 95mg (phenazopyridine)
azo dine tab max st (phenazopyridine)
azo pain rel tab 95mg (phenazopyridine)
azo tabs tab 95mg (phenazopyridine)
azo urinary tab 97.5mg (phenazopyridine)
azo urinary tab 97.5mg (phenazopyridine)
azo-standard tab 95mg (phenazopyridine)
glydo gel 2% (lidocaine)
lc-4 lidocne cre 4% (lidocaine)
lido/prilocn cre 2.5-2.5%
lido/prilocn kit 2.5-2.5%
lidocaine cre 3%
lidocaine cre 4%
lidocaine gel 2%
lidocaine gel 2% jelly
lidocaine oin 5%
lidocaine sol 4%
lidocream cre 4% (lidocaine)
lidopin cre 3% (lidocaine)
livixil pak kit 2.5-2.5% (lidocaine-prilocaine)
lp lite pak kit 2.5-2.5% (lidocaine-prilocaine)
phenazo tab 200mg (phenazopyridine)
phenazo tab 95mg (phenazopyridine)
phenazopyrid tab 100mg
phenazopyrid tab 200mg
phenazopyrid tab 95mg
phenazoyrid tab 95mg
lidocaine pad 5% (lidocaine)
qc azo tab 95mg (phenazopyridine)
ra urinary tab 95mg (phenazopyridine)
ra urinary tab pain max (phenazopyridine)
130Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSANTIPRURITICS AND LOCAL ANESTHETICS
T1relador pak kit 2.5-2.5% (lidocaine-prilocaine)
T1relador pak kit plus (lidocaine-prilocaine)
T1 QLsb urinary tab pain max (phenazopyridine)
T1 QLsm urinary tab pain max (phenazopyridine)
T1 QLurinary pain tab 95mg (phenazopyridine)
T1 QLurinary pain tab 97.5mg (phenazopyridine)
T1 QLuti relief tab 97.2mg (phenazopyridine)
ASTRINGENTS
T1hypercare sol 20% (aluminum)
CELL STIMULANTS AND PROLIFERANTS
T1 QL (45 gm/30 days)avita cre 0.025% (tretinoin)
T1 QL (45 gm/30 days)avita gel 0.025% (tretinoin)
T1 QL (45 gm/30 days)tretinoin cre 0.025%
T1 QL (45 gm/30 days)tretinoin cre 0.05%
T1 QL (45 gm/30 days)tretinoin cre 0.1%
T1 QL (45 gm/30 days)tretinoin gel 0.01%
T1 QL (45 gm/30 days)tretinoin gel 0.025%
T1tretinoin gel 0.05%
DEPIGMENTING AND PIGMENTING AGENTSPIGMENTING AGENTS
T2OXSORALEN LOT 1% (methoxsalen)
EMOLLIENTS, DEMULCENTS, AND PROTECTANTSBASIC LOTIONS AND LINIMENTS
T1ammonium lac cre 12%
T1ammonium lac lot 12%
T1laclotion lot 12% (lactic)
T1lactic acid lot 10%
KERATOLYTIC AGENTS
T1 QLavar cleanse emu 10-5% (sulfacetamide)
T1 QLbp 10-1 emu (sulfacetamide)
T1 QLcerisa wash emu 10-1% (sulfacetamide)
T1 QLprascion emu (sulfacetamide)
131Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSKERATOLYTIC AGENTS
T1 QLrosanil emu cleanser (sulfacetamide)
T1 QLsod sul/sulf emu 10-5%
T1urea cre 47%
SKIN AND MUCOUS MEMBRANE AGENTS, MISC.
T3 PA, QL (30gram /30 days) clindamycin, erythromycin
ACZONE GEL 5% (dapsone)
T1 QL (45 gram/ 30 days)adapalene cre 0.1%
T1 QL (45 gram/ 30 days)adapalene gel 0.1%
T1 QLadapalene gel 0.3%
MED PA, SP Medical coinsurance
T1 QL (60gm tube/ 30 days)
T1 QL (60gm/30 days)
T1
T1 QL (60gm/30 days)
T1
T1 PA
AMEVIVE 15 MG VIAL (ALEFACEPT)
calcipotrien cre 0.005%
calcipotrien oin 0.005%
calcipotrien sol 0.005%
calcitrene oin 0.005% (calcipotriene)
calcitriol oin 3mcg/gm
amnesteem cap (isotretinoin)
T1 PA
T1 PA
T1 PA
zenatane cap (isotretinoin)
claravis cap 30mg (isotretinoin)
claravis cap 40mg (isotretinoin)
T3 QL (30gm/30 days)ELIDEL CRE 1% (pimecrolimus)
T3EPIDUO FORTE GEL 0.3-2.5% (adapalene-benzoyl)
T1fluorouracil cre 0.5%
T1fluorouracil cre 5%
T1fluorouracil dro 2%
T1fluorouracil dro 5%
T1fluorouracil sol 2%
T1fluorouracil sol 5%
T1imiquimod cre 5%
T1minocycline tab 135mg er
T1minocycline tab 45mg er
T1minocycline tab 90mg er
T3 PAMIRVASO GEL 0.33% (brimonidine)
132Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
All strengths
QL (30gm/30 days)
All strengths
All strengths
Drug Name Tier Requirements/Limits
AlternativesComments
SKIN AND MUCOUS MEMBRANE AGENTSSKIN AND MUCOUS MEMBRANE AGENTS, MISC.
T3 fluorouracilPICATO GEL 0.015% (ingenol)
T3 fluorouracilPICATO GEL 0.05% (ingenol)
T1podofilox sol 0.5%
T3RECTIV OIN 0.4% (nitroglycerin)
T3 PA, QLREGRANEX GEL 0.01% (becaplermin)
T2SANTYL OIN 250/GM (collagenase)
MED PA, SP Medical coinsuranceSTELARA INJ 45MG/0.5 (ustekinumab)
T1 PAtacrolimus oin 0.03%
T1 PAtacrolimus oin 0.1%
T3 PA calcipotrieneTAZORAC CRE 0.05% (tazarotene)
T3 PA calcipotrieneTAZORAC CRE 0.1% (tazarotene)
T3 PA calcipotrieneTAZORAC GEL 0.05% (tazarotene)
T3 PA calcipotrieneTAZORAC GEL 0.1% (tazarotene)
T3 PA, QL (15gm/fill)VEREGEN OIN 15% (sinecatechins)
T3 QL (400gm/28 days)VOLTAREN GEL 1% (diclofenac)
SMOOTH MUSCLE RELAXANTSGENITOURINARY SMOOTH MUSCLE RELAXANTS
ANTIMUSCARINICS
T3 PAENABLEX TAB 15MG (darifenacin)
T3 PAENABLEX TAB 7.5MG (darifenacin)
T1flavoxate tab 100mg
T1oxybutynin syp 5mg/5ml
T1 QL(30 caps/30 days)oxybutynin tab 10mg er
T1oxybutynin tab 15mg er
T1oxybutynin tab 5mg
T1oxybutynin tab 5mg er
T1tolterodine cap 2mg er
T1
QL(30 caps/30 days)
QL (60 tabs/30 days)
QL(30 caps/30 days)
QL (30 caps/30 days)
QL (30 caps/30 days)tolterodine cap 4mg er
T1tolterodine tab 1mg
T1tolterodine tab 2mg
T3 PATOVIAZ TAB 4MG (fesoterodine)
T3 PATOVIAZ TAB 8MG (fesoterodine)
133Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
SMOOTH MUSCLE RELAXANTSGENITOURINARY SMOOTH MUSCLE RELAXANTS
ANTIMUSCARINICS
T3 QL (( 30 tabs/ 30 days)), STVESICARE TAB 10MG (solifenacin)
T3 QL (( 30 tabs/ 30 days)), STVESICARE TAB 5MG (solifenacin)
BETA-3-ADRENERGIC AGONISTS
T3 QL (30 tabs/30 days), ST (Oxybutynin ER, tolterodine)
oxybutynin, tolterodine
MYRBETRIQ TAB 25MG (mirabegron)
T3 QL (30 tabs/30 days), ST (Oxybutynin ER, tolterodine)
oxybutynin, tolterodine
MYRBETRIQ TAB 50MG (mirabegron)
RESPIRATORY SMOOTH MUSCLE RELAXANTS
T1aminophyllin inj 25mg/ml
T3THEO-24 CAP 100MG CR (theophylline)
T3THEO-24 CAP 200MG CR (theophylline)
T3THEO-24 CAP 300MG CR (theophylline)
T3THEO-24 CAP 400MG ER (theophylline)
T1theochron tab 100mg cr (theophylline)
T1theochron tab 200mg cr (theophylline)
T1theochron tab 300mg cr (theophylline)
T1theophylline elx 80/15ml
T1theophylline tab 100mg cr (theophylline)
T1theophylline tab 100mg er
T1theophylline tab 200mg cr
T1theophylline tab 200mg er
T1theophylline tab 200mg sr
T1theophylline tab 300mg cr
T1theophylline tab 300mg er
T1theophylline tab 300mg sr
T1theophylline tab 400mg er
T1theophylline tab 450mg er (theophylline)
T1theophylline tab 600mg er
VITAMINSMULTIVITAMIN PREPARATIONS
T0 HCR Rules for Coverageprenatal multivit-min w/fe-fa tab
T0 HCR Rules for Coverageprenatal vit w/ ferrous fumarate-folic acid cap
134Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
VITAMINSMULTIVITAMIN PREPARATIONS
T0 HCR Rules for Coverageprenatal vit w/ ferrous fumarate-folic acid tab
T0 HCR Rules for Coverageprenatal vit w/ ferrous gluconate-folic acid tab
VITAMIN B COMPLEX
T1 QL (30 tabs/ 30 days)folic acid tab 1mg
T0 HCR Rules for Coveragefolic acid tab 400 mcg
T0 HCR Rules for Coveragefolic acid tab 800 mcg
VITAMIN D
T1calcitriol cap 0.25mcg
T1calcitriol cap 0.5mcg
T0 HCR Rules for Coveragecholecalciferol cap 1000 unit
T0 HCR Rules for Coveragecholecalciferol cap 10000 unit
T0 HCR Rules for Coveragecholecalciferol cap 2000 unit
T0 HCR Rules for Coveragecholecalciferol cap 400 unit
T0 HCR Rules for Coveragecholecalciferol cap 5000 unit
T0 HCR Rules for Coveragecholecalciferol cap 50000 unit
T0 HCR Rules for Coveragecholecalciferol chew 1000 unit
T0 HCR Rules for Coveragecholecalciferol chew 2000 unit
T0 HCR Rules for Coveragecholecalciferol chew 400 unit
T0 HCR Rules for Coveragecholecalciferol chew 5000 unit
T0 HCR Rules for Coveragecholecalciferol liqd 1000 unit/spray
T0 HCR Rules for Coveragecholecalciferol liqd 1200 unit/15ml
T0 HCR Rules for Coveragecholecalciferol liqd 2000 unt/0.03ml
T0 HCR Rules for Coveragecholecalciferol liqd 400 unit/ml
T0 HCR Rules for Coveragecholecalciferol liqd 400 unt/0.03ml
T0 HCR Rules for Coveragecholecalciferol liqd 5000 unit/ml
T0 HCR Rules for Coveragecholecalciferol tab 1000 unit
T0 HCR Rules for Coveragecholecalciferol tab 3000 unit
T0 HCR Rules for Coveragecholecalciferol tab 400 unit
T0 HCR Rules for Coveragecholecalciferol tab 5000 unit
T1doxercalcif cap 0.5mcg
T1doxercalcif cap 1mcg
T1doxercalcif cap 2.5mcg
135Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Drug Name Tier Requirements/Limits
AlternativesComments
VITAMINSVITAMIN D
T1 QL (30 caps/ 30 days)ergocalcifer cap 50000unt
T1 QL (60 caps/30 days)paricalcitol cap 1 mcg
T1paricalcitol cap 2 mcg
T1paricalcitol cap 4 mcg
T1 QL (28 tabs/28 days)vitamin d cap 50000unt
136Coverage Rules: (PA) Prior authorization (ST) Step-Therapy (QL) Quantity limit (SP) This Specialty drug can only be obtained from Pharmacy Advantage. Call Pharmacy Advantage at (800) 456 2112HCR = Health Care Reform
Index
Drug Name Page # Drug Name Page #
89
9
9
69
97
97
97
33
34
87
85
85
41
88
125
125
125
125
125
116
116
116
116
126
114
115
88
13
124
13
13
13
132
a/b sol otic
abacav/lamiv tab /zidovud
abacavir tab 300mg
acampro cal tab 333mg
acarbose tab 100mg
acarbose tab 25mg
acarbose tab 50mg
acebutolol cap 200mg
acebutolol cap 400mg
acetasol hc sol otic
acetazolamid cap 500mg er
acetazolamid tab 125mg
acetazolamid tab 250mg
acetic acid sol 2% otic
acne medicat gel 10%
acne medicat gel 5%
acne pimple gel 10%
acne treatmn gel 10%
acne-clear gel 10%
ACTEMRA INJ 162/0.9
ACTEMRA INJ 200/10ML
ACTEMRA INJ 400/20ML
ACTEMRA INJ 80MG/4ML
acticin cre 5%
ACTIMMUNE INJ 2MU/0.5
risedronate tab 35 mgACUVAIL SOL 0.45%
acyclovir cap 200mg
acyclovir oin 5%
acyclovir sus 200/5ml
acyclovir tab 400mg
acyclovir tab 800mg
ACZONE GEL 5%
132adapalene cre 0.1%
132adapalene gel 0.1%
132adapalene gel 0.3%
46ADCIRCA TAB 20MG
13adefov dipiv tab 10mg
119ADEMPAS TAB 0.5MG
119ADEMPAS TAB 1.5MG
119ADEMPAS TAB 1MG
119ADEMPAS TAB 2.5MG
119ADEMPAS TAB 2MG
22ADVAIR DISKU AER 100/50
22ADVAIR DISKU AER 250/50
22ADVAIR DISKU AER 500/50
22ADVAIR HFA AER 115/21
22ADVAIR HFA AER 230/21
22ADVAIR HFA AER 45/21
25ADVATE INJ 1000UNIT
25ADVATE INJ 1500UNIT
25ADVATE INJ 2000UNIT
25ADVATE INJ 250UNIT
25ADVATE INJ 3000UNIT
25ADVATE INJ 500UNIT
32ADVICOR TAB 1000-20
32ADVICOR TAB 1000-40
32ADVICOR TAB 500-20MG
32ADVICOR TAB 750-20MG
38afeditab tab 30mg cr
38afeditab tab 60mg cr
14AFINITOR TAB 10MG
14AFINITOR TAB 2.5MG
14AFINITOR TAB 5MG
14AFINITOR TAB 7.5MG
121AFLURIA INJ 2015-16
121AFLURIA INJ PF 12-13
121AFLURIA INJ PF 13-14
121AFLURIA INJ PF 14-15
121AFLURIA INJ PF 15-16
101aftera tab 1.5mg
29AGGRENOX CAP 25-200MG
126ala cort cre 1%
1ALBENZA TAB 200MG
22albuterol neb 0.083%
23albuterol neb 0.5%
23albuterol neb 0.63mg/3
23albuterol neb 1.25mg/3
23albuterol syp 2mg/5ml
23albuterol tab 2mg
Drug Name Page # Drug Name Page #
23albuterol tab 4mg
23albuterol tab 4mg er
126alclometason cre 0.05%
126alclometason oin 0.05%
115alendronate tab 10mg
115alendronate tab 35mg
115alendronate tab 40mg
115alendronate tab 5mg
115alendronate tab 70mg
22alfuzosin tab 10mg
9ALINIA SUS 100/5ML
9ALINIA TAB 500MG
14ALKERAN TAB 2MG
114allopurinol tab 100mg
114allopurinol tab 300mg
64almotrip mal tab 12.5mg
64almotrip mal tab 6.25mg
64almotriptan tab 12.5mg
64almotriptan tab 6.25mg
84ALOCRIL SOL 2%
84ALOMIDE SOL 0.1% OP
25ALPHANATE 1,000-400 UNIT VIAL
25ALPHANATE 1,500-600 UNIT VIAL
25ALPHANATE 500-200 UNIT VIAL
25ALPHANATE INJ VWF/HUM
25ALPHANINE SD INJ 1000UNIT
25ALPHANINE SD INJ 1500UNIT
126alphatrex gel 0.05%
68alprazolam tab 0.25 odt
68alprazolam tab 0.25mg
68alprazolam tab 0.5mg
68alprazolam tab 0.5mg er
68alprazolam tab 0.5mg od
68alprazolam tab 0.5mg xr
68alprazolam tab 1mg
68alprazolam tab 1mg er
68alprazolam tab 1mg odt
68alprazolam tab 1mg xr
68alprazolam tab 2mg
68alprazolam tab 2mg er
68alprazolam tab 2mg odt
68alprazolam tab 2mg xr
68alprazolam tab 3mg er
68alprazolam tab 3mg xr
87ALREX SUS 0.2%
122ALTABAX OIN 1%
89altacaine sol 0.5% op
89altafrin sol 10% op
89altafrin sol 2.5% op
101altavera tab
94ALVESCO AER 160MCG
94ALVESCO AER 80MCG
101alyacen tab 1/35
101alyacen tab 7/7/7
64amantadine cap 100mg
64amantadine syp 50mg/5ml
64amantadine tab 100mg
126amcinonide cre 0.1%
126amcinonide lot 0.1%
126amcinonide oin 0.1%
101amethia lo tab
101amethia tab
101amethyst tab 90-20mcg
132AMEVIVE 15 MG VIAL
81amilor/hctz tab 5-50
81amiloride tab 5mg
134aminophyllin inj 25mg/ml
39amiodarone tab 200mg
39amiodarone tab 400mg
93AMITIZA CAP 24MCG
93AMITIZA CAP 8MCG
70amitriptylin tab 100mg
70amitriptylin tab 10mg
70amitriptylin tab 150mg
70amitriptylin tab 25mg
70amitriptylin tab 50mg
70amitriptylin tab 75mg
38amlod/benazp cap 10-20mg
38amlod/benazp cap 10-40mg
38amlod/benazp cap 2.5-10mg
38amlod/benazp cap 5-10mg
38amlod/benazp cap 5-20mg
38amlod/benazp cap 5-40mg
38amlod/valsar tab /hctz
38amlodipine tab 10mg
38amlodipine tab 2.5mg
38amlodipine tab 5mg
131ammonium lac cre 12%
131ammonium lac lot 12%
4amox/k clav chw 200mg
4amox/k clav chw 400mg
4amox/k clav sus 200/5ml
4amox/k clav sus 250/5ml
4amox/k clav sus 400/5ml
Drug Name Page # Drug Name Page #
4amox/k clav sus 600/5ml
4amox/k clav tab 250mg
4amox/k clav tab 500mg
4amox/k clav tab 875mg
71amoxapine tab 100mg
71amoxapine tab 150mg
71amoxapine tab 25mg
71amoxapine tab 50mg
4amoxicillin cap 250mg
4amoxicillin cap 500mg
4amoxicillin chw 125mg
4amoxicillin chw 250mg
4amoxicillin sus 125/5ml
4amoxicillin sus 200/5ml
5amoxicillin sus 250/5ml
5amoxicillin sus 250mg/5m
5amoxicillin sus 400/5ml
5amoxicillin tab 500mg
5amoxicillin tab 875mg
5amox-pot cla tab er
54amphetamine cap 10mg er
54amphetamine cap 15mg er
54amphetamine cap 20mg er
54amphetamine cap 25mg er
54amphetamine cap 30mg er
54amphetamine cap 5mg er
55amphetamine tab 10mg
55amphetamine tab 12.5mg
55amphetamine tab 15mg
55amphetamine tab 20mg
55amphetamine tab 30mg
55amphetamine tab 5mg
55amphetamine tab 7.5mg
5ampicillin cap 250mg
5ampicillin cap 500mg
5ampicillin sus 125/5ml
5ampicillin sus 250/5ml
118AMPYRA TAB 10MG
29anagrelide cap 0.5mg
29anagrelide cap 1mg
14anastrozole tab 1mg
96ANDROGEL GEL 1%(25MG)
97ANDROGEL GEL 1.62%
97ANDROGEL GEL PUMP 1%
129anecream cre 4%
18ANORO ELLIPT AER 62.5-25
87antibiot ear sol 1% otic
89antipy/benzo sol otic
126anucort-hc sup 25mg
90ANZEMET TAB 100MG
90ANZEMET TAB 50MG
49apap/caff/di tab hydrocod
49apap/codeine sol 120-12/5
49apap/codeine tab 300-15mg
49apap/codeine tab 300-30mg
49apap/codeine tab 300-60mg
126APEXICON E CRE 0.05%
98APIDRA INJ SOLOSTAR
98APIDRA INJ U-100
88apraclonidin sol 0.5% op
101apri tab
9APTIVUS CAP 250MG
9APTIVUS SOL
101aranelle tab
29ARANESP INJ 100MCG
30ARANESP INJ 10MCG
30ARANESP INJ 150MCG
30ARANESP INJ 200MCG
30ARANESP INJ 25MCG
30ARANESP INJ 300MCG
30ARANESP INJ 40MCG
30ARANESP INJ 500MCG
30ARANESP INJ 60MCG
118ARCALYST INJ 220MG
23ARCAPTA CAP 75MCG
75aripiprazole tab 10mg
76aripiprazole tab 15mg
76aripiprazole tab 20mg
76aripiprazole tab 2mg
76aripiprazole tab 30mg
76aripiprazole tab 5mg
110ARMOUR THYRO TAB 120MG
110armour thyro tab 120mg
110ARMOUR THYRO TAB 15MG
110armour thyro tab 180mg
110ARMOUR THYRO TAB 180MG
110ARMOUR THYRO TAB 240MG
110ARMOUR THYRO TAB 300MG
110ARMOUR THYRO TAB 30MG
110armour thyro tab 30mg
110armour thyro tab 60mg
110ARMOUR THYRO TAB 60MG
110ARMOUR THYRO TAB 90MG
49asa/caff/but cap cod 30mg
Drug Name Page # Drug Name Page #
49ascomp/cod cap 30mg
101ashlyna tab
94ASMANEX 120 AER 220MCG
94ASMANEX 30 AER 110MCG
94ASMANEX 30 AER 220MCG
94ASMANEX 60 AER 220MCG
94ASMANEX 7 AER 110MCG
94ASMANEX HFA AER 100 MCG
95ASMANEX HFA AER 200 MCG
130aspercreme cre lidocain
46aspirin chew 81 mg
46aspirin chew 81 mg
46aspirin tab 324 mg
46aspirin tab 325 mg
46aspirin tab 325 mg
46aspirin tab 81 mg
46aspirin tab 81 mg
34atenol/chlor tab 100-25mg
34atenol/chlor tab 50-25mg
34atenolol tab 100mg
34atenolol tab 25mg
34atenolol tab 50mg
32atorvastatin tab 10mg
32atorvastatin tab 20mg
32atorvastatin tab 40mg
32atorvastatin tab 80mg
8atovaq/progu tab 250-100
8atovaq/progu tab 62.5-25
9atovaquone sus 750/5ml
9ATRIPLA TAB
89atropin-care sol 1% op
18atropine sul inj 0.05mg/1
18atropine sul inj 0.1mg/ml
18atropine sul inj 0.4/0.5
89atropine sul oin 1% op
89atropine sul sol 1% op
18ATROVENT HFA AER 17MCG
114AUBAGIO TAB 14MG
114AUBAGIO TAB 7MG
101aubra tab 0.1-0.02
127aug betamet cre 0.05%
127aug betamet gel 0.05%
127aug betamet lot 0.05%
127aug betamet oin 0.05%
89aurodex sol otic
89auroguard sol otic
100AVANDIA TAB 2MG
100AVANDIA TAB 4MG
100AVANDIA TAB 8MG
131avar cleanse emu 10-5%
101aviane tab
131avita cre 0.025%
131avita gel 0.025%
114AVONEX KIT 30MCG
114AVONEX PEN KIT 30MCG
114AVONEX PREFL KIT 30MCG
86AZASITE SOL 1%
117azathioprine tab 50mg
84azelastine dro 0.05%
84azelastine spr 0.1%
84azelastine spr 0.15%
66AZILECT TAB 0.5MG
66AZILECT TAB 1MG
3azithromycin pow 1gm pak
3azithromycin sus 100/5ml
3azithromycin sus 200/5ml
3azithromycin tab 250mg
3azithromycin tab 500mg
3azithromycin tab 600mg
130azo dine tab 95mg
130azo dine tab max st
130azo pain rel tab 95mg
130azo tabs tab 95mg
130azo urinary tab 97.5mg
130azo urinary tab 97.5mg
85AZOPT SUS 1% OP
130azo-standard tab 95mg
101azurette tab 28 day
2baciim inj 50000unt
2bacitracin inj 50000unt
86bacitracin oin op
21baclofen tab 10mg
22baclofen tab 20mg
122BACTROBAN OIN NASAL 2%
91balsalazide cap 750mg
101balziva tab
57BANZEL TAB 200MG
57BANZEL TAB 400MG
13BARACLUDE SOL .05MG/ML
95baycadron elx 0.5/5ml
46BAYER CHILD CHW ASA 81MG
25BEBULIN INJ 200-1200
25BEBULIN VH IMMU 200-1,200 UNIT
87BECONASE AQ SUS 0.042%
Drug Name Page # Drug Name Page #
55BELVIQ TAB 10MG
43benazep/hctz tab 10-12.5
43benazep/hctz tab 20-12.5
43benazep/hctz tab 20-25mg
43benazep/hctz tab 5-6.25
43benazepril tab 10mg
43benazepril tab 20mg
43benazepril tab 40mg
43benazepril tab 5mg
25BENEFIX INJ 1000UNIT
25BENEFIX INJ 2000UNIT
25BENEFIX INJ 250UNIT
25BENEFIX INJ 500UNIT
117BENLYSTA INJ 120MG
117BENLYSTA INJ 400MG
125benzepro aer 5.3%
125benzepro liq creamy
125benzepro sc aer 9.8%
125benziq wash liq 5.25%
118benzonatate cap 100mg
118benzonatate cap 150mg
118benzonatate cap 200mg
125benzoyl per aer 5.3%
125benzoyl per aer 9.8%
125benzoyl per gel 10%
125benzoyl per gel 5%
125benzoyl per liq 10% wash
125benzoyl pero aer 9.8%
125benzoyl pero kit acne pck
55benzphetamin tab 50mg
65benztropine tab 0.5mg
19benztropine tab 1mg
19benztropine tab 2mg
84BEPREVE DRO 1.5%
115BERINERT INJ 500UNIT
86BESIVANCE SUS 0.6%
127beta diprop gel 0.05%
127betameth dip cre 0.05%
127betameth dip lot 0.05%
127betameth dip oin 0.05%
127betameth val cre 0.1%
127betameth val lot 0.1%
127betameth val oin 0.1%
85
34
34
betaxolol sol 0.5% op
betaxolol tab 10mg
betaxolol tab 20mg
85
14
14
34
34
34
34
34
120
87
BETOPTIC-S SUS 0.25% OP
bexarotene cap 75mg
bicalutamide tab 50mg
bisoprl/hctz tab 10/6.25
bisoprl/hctz tab 2.5/6.25
bisoprl/hctz tab 5-6.25mg
bisoprol fum tab 10mg
bisoprol fum tab 5mg
BIVIGAM INJ 10%
BLEPHAMIDE SUS LIQUIFLM
87BLEPHAMIDE SUS OP
14BOSULIF TAB 100MG
14BOSULIF TAB 500MG
131bp 10-1 emu
125bp foam aer 5.3%
125bp foam aer 9.8%
125bp foaming liq wash 10%
125bp gel gel 10%
125bp gel gel 5%
125bp wash liq 2.5%
125bp wash liq 7%
125bpo gel 4%
125bpo gel 8%
125bpo creamy kit 4% wash
125bpo creamy kit 8% wash
101briellyn tab
29BRILINTA TAB 60MG
29BRILINTA TAB 90MG
84brimonidine sol 0.15%
85brimonidine sol 0.2% op
88bromfenac sol 0.09%
88bromfenac sol 0.09% op
65bromocriptin cap 5mg
65bromocriptin tab 2.5mg
23BROVANA NEB 15MCG
71budeprion tab 100mg sr
71budeprion tab 150mg sr
95budesonide cap 3mg/24hr
95budesonide sus 0.25mg/2
95budesonide sus 0.5mg/2
95budesonide sus 1mg/2ml
87budesonide sus 32mcg
80bumetanide inj 0.25/ml
80bumetanide tab 0.5mg
80bumetanide tab 1mg
80bumetanide tab 2mg
Drug Name Page # Drug Name Page #
80BUPHENYL TAB 500MG
54bupren/nalox sub 2-0.5mg
54bupren/nalox sub 8-2mg
54buprenorphin inj 0.3mg/ml
54buprenorphin sub 2mg
54buprenorphin sub 8mg
71bupropion hcl (smoking deterrent) tab 150 mg
71bupropion tab 100mg
71bupropion tab 100mg er
71bupropion tab 100mg sr
71bupropion tab 150mg er
71bupropion tab 150mg sr
71bupropion tab 200mg er
71bupropion tab 200mg sr
71bupropion tab 75mg
71bupropn hcl tab 150mg xl
71bupropn hcl tab 300mg xl
67buspirone tab 10mg
67buspirone tab 15mg
67buspirone tab 30mg
67buspirone tab 5mg
67buspirone tab 7.5mg
46but/apap/caf cap
49but/apap/caf cap codeine
46but/apap/caf tab
49but/asa/caf/ cap cod 30mg
47but/asa/caff cap
47but/asa/caff tab
49butal cpd/ cap codeine
54butorphanol inj 1mg/ml
54butorphanol sol 10mg/ml
54BUTRANS DIS 10MCG/HR
54BUTRANS DIS 15MCG/HR
54BUTRANS DIS 20MCG/HR
54BUTRANS DIS 5MCG/HR
54BUTRANS DIS 7.5/HR
98BYDUREON INJ
98BYDUREON INJ
98BYETTA INJ 5MCG
34BYSTOLIC TAB 10MG
34BYSTOLIC TAB 2.5MG
34BYSTOLIC TAB 20MG
34BYSTOLIC TAB 5MG
65cabergoline tab 0.5mg
82calc acetate cap 667mg
132calcipotrien cre 0.005%
132calcipotrien oin 0.005%
132calcipotrien sol 0.005%
132calcitrene oin 0.005%
135calcitriol cap 0.25mcg
135calcitriol cap 0.5mcg
132calcitriol oin 3mcg/gm
101camila tab 0.35mg
101camrese lo tab
101camrese tab
91CANASA SUP 1000MG
41candesa/hctz tab 16-12.5
41candesa/hctz tab 32-12.5
42candesa/hctz tab 32-25mg
42candesartan tab 16mg
42candesartan tab 32mg
42candesartan tab 4mg
42candesartan tab 8mg
14capecitabine tab 150mg
14capecitabine tab 500mg
127CAPEX SHA 0.01%
15CAPRELSA TAB 100MG
15CAPRELSA TAB 300MG
43captopr/hctz tab 25-15mg
43captopr/hctz tab 25-25mg
43captopr/hctz tab 50-15mg
43captopr/hctz tab 50-25mg
43captopril tab 100mg
43captopril tab 12.5mg
43captopril tab 25mg
43captopril tab 50mg
92CARAFATE SUS 1GM/10ML
65carb/levo 50 tab /entacap
65carb/levo 75 tab /entacap
65carb/levo er tab 25-100mg
65carb/levo er tab 50-200mg
65carb/levo sr tab 50-200mg
65carb/levo tab 10-100mg
65carb/levo tab 25-250mg
65carb/levo100 tab /entacap
65carb/levo125 tab /entacap
65carb/levo150 tab /entacap
65carb/levo200 tab /entacap
57carbamazepin cap 100mg er
58carbamazepin cap 200mg er
58carbamazepin cap 300mg er
58carbamazepin chw 100mg
58carbamazepin sus 100/5ml
Drug Name Page # Drug Name Page #
58carbamazepin tab 200mg
58carbamazepin tab 200mg er
58carbamazepin tab 400mg er
65carbidopa tab 25mg
24carbonyl iron chew 15 mg
24carbonyl iron suspension 15 mg/1.25ml
31CARDURA XL TAB 4MG
120carimune nf inj 12gm
120carimune nf inj 3gm
120carimune nf inj 6gm
21carisopr/asa tab 200-325
21carisoprodol tab 250mg
21carisoprodol tab 350mg
21carisoprodol tab asa/cod
85carteolol sol 1% op
36cartia xt cap 120/24hr
36cartia xt cap 180/24hr
36cartia xt cap 240/24hr
36cartia xt cap 300/24hr
34carvedilol tab 12.5mg
34carvedilol tab 25mg
34carvedilol tab 3.125mg
34carvedilol tab 6.25mg
4CAYSTON INH 75MG
101caziant pak
2CEDAX CAP 400MG
2cefaclor cap 250mg
2cefaclor cap 500mg
2cefaclor er tab 500mg
2cefadroxil cap 500mg
2cefadroxil sus 250/5ml
2cefadroxil sus 500/5ml
2cefadroxil tab 1gm
2cefdinir cap 300mg
2cefdinir sus 125/5ml
2cefdinir sus 250/5ml
2cefditoren tab 200mg
2cefditoren tab 400mg
3cefixime sus 100/5ml
3cefixime sus 200/5ml
3cefpodo prox sus 100/5ml
3cefpodo prox sus 50mg/5ml
3cefpodoxime tab 100mg
3cefpodoxime tab 200mg
3cefprozil sus 125/5ml
3cefprozil sus 250/5ml
3cefprozil tab 250mg
3cefprozil tab 500mg
3cefuroxime tab 250mg
3cefuroxime tab 500mg
47celecoxib cap 100mg
47celecoxib cap 200mg
47celecoxib cap 400mg
47celecoxib cap 50mg
63CELONTIN CAP 300MG
106CENESTIN TAB 0.3MG
106CENESTIN TAB 0.45MG
106CENESTIN TAB 0.625MG
106CENESTIN TAB 0.9MG
106CENESTIN TAB 1.25MG
3cephalexin cap 250mg
3cephalexin cap 500mg
3cephalexin cap 750mg
3cephalexin sus 125/5ml
3cephalexin sus 250/5ml
131cerisa wash emu 10-1%
90CESAMET CAP 1MG
101cesia pak
117CETROTIDE KIT 0.25MG
20cevimeline cap 30mg
19CHANTIX PAK 0.5& 1MG
19CHANTIX PAK 1MG
19CHANTIX TAB 0.5MG
19CHANTIX TAB 1MG
101chateal tab 0.15/30
94CHEMET CAP 100MG
118chlor/phen dro dm
19chlord/clidi cap 5-2.5mg
68chlordiazep cap 10mg
68chlordiazep cap 25mg
68chlordiazep cap 5mg
87chlorhex glu sol 0.12%
82chloromag inj 20%
113chloroproc inj 2%
113chloroproc inj 3%
8chloroquine tab 250mg
8chloroquine tab 500mg
81chlorothiaz tab 250mg
81chlorothiaz tab 500mg
76chlorpromaz inj 25mg/ml
76chlorpromaz inj 50mg/2ml
76chlorpromaz tab 100mg
76chlorpromaz tab 10mg
76chlorpromaz tab 200mg
Drug Name Page # Drug Name Page #
76chlorpromaz tab 25mg
76chlorpromaz tab 50mg
99chlorpropam tab 100mg
99chlorpropam tab 250mg
81chlorthalid tab 100mg
81chlorthalid tab 25mg
81chlorthalid tab 50mg
21chlorzoxazon tab 500mg
47cho mag tris liq 500/5ml
47cho mag tris tab 1000mg
135cholecalciferol cap 1000 unit
135cholecalciferol cap 10000 unit
135cholecalciferol cap 2000 unit
135cholecalciferol cap 400 unit
135cholecalciferol cap 5000 unit
135cholecalciferol cap 50000 unit
135cholecalciferol chew 1000 unit
135cholecalciferol chew 2000 unit
135cholecalciferol chew 400 unit
135cholecalciferol chew 5000 unit
135cholecalciferol liqd 1000 unit/spray
135cholecalciferol liqd 1200 unit/15ml
135cholecalciferol liqd 2000 unt/0.03ml
135cholecalciferol liqd 400 unit/ml
135cholecalciferol liqd 400 unt/0.03ml
135cholecalciferol liqd 5000 unit/ml
135cholecalciferol tab 1000 unit
135cholecalciferol tab 3000 unit
135cholecalciferol tab 400 unit
135cholecalciferol tab 5000 unit
31cholestyram pow 4gm
31cholestyram pow 4gm lite
108chor gonadot inj 10000unt
46CIALIS TAB 5MG
123ciclodan cre 0.77%
123ciclodan sol 8%
123ciclopirox cre 0.77%
123ciclopirox gel 0.77%
123ciclopirox sha 1%
123ciclopirox sol 8%
123ciclopirox sus 0.77%
29cilostazol tab 100mg
29cilostazol tab 50mg
86CILOXAN OIN 0.3% OP
91cimetidine tab 200mg
91cimetidine tab 300mg
91cimetidine tab 400mg
91cimetidine tab 800mg
116CIMZIA KIT
116CIMZIA KIT STARTER
116CIMZIA PREFL KIT 200MG/ML
115CINRYZE SOL 500 UNIT
87CIPRO HC SUS OTIC
87CIPRODEX SUS 0.3-0.1%
86ciprofloxacn sol 0.2%
86ciprofloxacn sol 0.3% op
5ciprofloxacn sus 250mg/5
5ciprofloxacn sus 500mg/5
5ciprofloxacn tab 1000mg
5ciprofloxacn tab 100mg
5ciprofloxacn tab 250mg
5ciprofloxacn tab 500mg
5ciprofloxacn tab 500mg er
5ciprofloxacn tab 750mg
71citalopram sol 10mg/5ml
71citalopram tab 10mg
71citalopram tab 20mg
71citalopram tab 40mg
132claravis cap 10mg
132claravis cap 20mg
132claravis cap 30mg
132claravis cap 40mg
3clarithromyc sus 125/5ml
3clarithromyc sus 250/5ml
3clarithromyc tab 250mg
4clarithromyc tab 500mg
4clarithromyc tab 500mg er
125clearplex v gel 5%
125clearplex x gel 10%
1clemastine syp 0.5/5ml
1clemastine tab 2.68mg
19clidi/chlord cap 2.5-5mg
106CLIMARA PRO DIS WEEKLY
122clindacin mis etz 1%
122clindacin-p pad 1%
122clindamax gel 1%
122clindamax lot 10mg/ml
122clindamy/ben gel 1.2-5%
122clindamy/ben gel 1-5%
2clindamycin cap 150mg
2clindamycin cap 300mg
2clindamycin cap 75mg
122clindamycin cre 2% vag
123clindamycin gel 1%
Drug Name Page # Drug Name Page #
123clindamycin lot 1%
123clindamycin lot 10mg/ml
123clindamycin pad 1%
123clindamycin sol 1%
2clindamycin sol 75mg/5ml
127clobetasol aer 0.05%
127clobetasol cre 0.05%
127clobetasol e cre 0.05%
127clobetasol gel 0.05%
127clobetasol lot 0.05%
127clobetasol oin 0.05%
127clobetasol sha 0.05%
127clobetasol sol 0.05%
127clodan sha 0.05%
127CLODERM CRE 0.1%
127CLODERM CRE 0.1% PMP
106clomiphene tab 50mg
71clomipramine cap 25mg
71clomipramine cap 50mg
71clomipramine cap 75mg
62clonazep odt tab 0.125mg
62clonazep odt tab 0.25mg
62clonazep odt tab 0.5mg
62clonazep odt tab 1mg
62clonazep odt tab 2mg
62clonazepam tab 0.5mg
62clonazepam tab 1mg
62clonazepam tab 2mg
41clonidine dis 0.1/24hr
41clonidine dis 0.2/24hr
41clonidine dis 0.3/24hr
41clonidine tab 0.1mg
41clonidine tab 0.2mg
41clonidine tab 0.3mg
29clopidogrel tab 300mg
29clopidogrel tab 75mg
68cloraz dipot tab 15mg
68cloraz dipot tab 3.75mg
68cloraz dipot tab 7.5mg
124clotrim/beta cre 1-0.05%
124clotrim/beta cre diprop
124clotrim/beta lot diprop
124clotrimazole cre 1%
124clotrimazole loz 10mg
124clotrimazole tro 10mg
76clozapine tab 100mg
76clozapine tab 200mg
76clozapine tab 25mg
76clozapine tab 50mg
8COARTEM TAB 20-120MG
49codeine sulf tab 15mg
49codeine sulf tab 30mg
49codeine sulf tab 60mg
49codeine/apap tab 15-300mg
49codeine/apap tab 30-300mg
49codeine/apap tab 60-300mg
114colchicine cap 0.6mg
113colchicine tab 0.6mg
31colestipol gra 5gm
31colestipol tab 1gm
87COLY-MYCIN S SUS OTIC
85COMBIGAN SOL 0.2/0.5%
106COMBIPATCH DIS .05/.14
106COMBIPATCH DIS .05/.25
23COMBIVENT AER RESPIMAT
15COMETRIQ KIT 100MG
15COMETRIQ KIT 140MG
15COMETRIQ KIT 60MG
76compazine sup 25mg
9COMPLERA TAB
76compro sup 25mg
80constulose sol 10gm/15
114COPAXONE INJ 20MG/ML
127CORDRAN CRE 0.05%
25CORIFACT KIT
127cormax scalp sol 0.05%
95cortisone ac tab 25mg
127CORTISPORIN CRE 0.5%
87CORTISPORIN SUS -TC OTIC
27coumadin tab 10mg
28coumadin tab 1mg
28coumadin tab 2.5mg
28coumadin tab 2mg
28coumadin tab 3mg
28coumadin tab 4mg
28coumadin tab 5mg
28coumadin tab 6mg
28
93
93
93
93
93
32
coumadin tab 7.5mg CREON CAP 12000UNT CREON CAP 24000UNT CREON CAP 3000UNIT CREON CAP 36000UNT CREON CAP 6000UNIT rosuvastatin tab 10mg
Drug Name Page # Drug Name Page #
32
32
32
109
109
9
9
9
118
84
101
94
102
102
21
rosuvastatin tab 20mg rosuvastatin tab 40mg rosuvastatin tab 5mg CRINONE GEL 4% VAG CRINONE GEL 8% VAG CRIXIVAN CAP 200MG CRIXIVAN CAP 400MG CRIXIVAN 100 MG CAPSULE cromolyn sod con 100/5ml cromolyn sod sol 4% op cryselle-28 tab 28 tabs CUPRIMINE CAP 250MG cyclafem tab 1/35 cyclafem
tab 7/7/7 cyclobenzapr tab
10mg
21cyclobenzapr tab 5mg
89cyclopentol sol 1% op
89cyclopentol sol 2% op
15cyclophosph cap 25mg
15cyclophosph tab 25mg
15cyclophosph tab 50mg
8cycloserine cap 250mg
97CYCLOSET TAB 0.8MG
117cyclosporine cap 100mg
117cyclosporine cap 100mg md
117cyclosporine cap 25mg
117cyclosporine cap 25mg mod
117cyclosporine cap 50mg mod
1cyproheptad syp 2mg/5ml
1cyproheptad tab 4mg
102cyred tab
118CYSTAGON CAP 150MG
118CYSTAGON CAP 50MG
80cytra-k sol
119DALIRESP TAB 500MCG
97danazol cap 100mg
97danazol cap 200mg
97danazol cap 50mg
21dantrolene cap 100mg
21dantrolene cap 25mg
21dantrolene cap 50mg
8dapsone tab 100mg
8dapsone tab 25mg
9DARAPRIM TAB 25MG
102dasetta tab 1/35
102dasetta tab 7/7/7
102daysee tab
56DAYTRANA DIS 10MG/9HR
56DAYTRANA DIS 15MG/9HR
56DAYTRANA DIS 20MG/9HR
56DAYTRANA DIS 30MG/9HR
102deblitane tab 0.35mg
95deltasone tab 20mg
102delyla tab 0.1-0.02
91DELZICOL CAP 400MG
6demeclocycl tab 150mg
6demeclocycl tab 300mg
125DENAVIR CRE 1%
94DEPEN TITRA TAB 250MG
109DEPO-PROVERA INJ 400/ML
71desipramine tab 100mg
71desipramine tab 10mg
71desipramine tab 150mg
71desipramine tab 25mg
71desipramine tab 50mg
71desipramine tab 75mg
1desloratadin tab 5mg
108desmopressin sol 0.01%
108desmopressin tab 0.1mg
108desmopressin tab 0.2mg
102deso/ethinyl tab estradio
127DESONATE GEL 0.05%
127desonide cre 0.05%
127desonide lot 0.05%
127desonide oin 0.05%
71desvenlafax tab 100mg er
72desvenlafax tab 50mg er
87dexameth pho sol 0.1% op
95DEXAMETHASON CON 1MG/ML
95dexamethason elx 0.5/5ml
95dexamethason sol 0.5/5ml
95dexamethason tab 0.5mg
95dexamethason tab 0.75mg
95dexamethason tab 1.5mg
95dexamethason tab 1mg
95dexamethason tab 2mg
95dexamethason tab 4mg
95dexamethason tab 6mg
1dexchlorphen syp 2mg/5ml
55dexedrine tab 10mg
55dexedrine tab 5mg
56dexmethylph cap 15mg er
56dexmethylph cap 30mg er
56dexmethylph cap 40mg er
Drug Name Page # Drug Name Page #
56dexmethylph tab 10mg
56dexmethylph tab 2.5mg
56dexmethylph tab 5mg
56dexmethylphe cap 10mg er
56dexmethylphe cap 20mg er
56dexmethylphe cap 5mg er
55dextroamphet cap 10mg er
55dextroamphet cap 15mg er
55dextroamphet cap 5mg er
55dextroamphet tab 10mg
55dextroamphet tab 5mg
68diazepam gel 10mg
68diazepam gel 2.5mg
68diazepam gel 20mg
69diazepam inj 5mg/ml
69diazepam sol 1mg/ml
69diazepam sol 5mg/5ml
69diazepam tab 10mg
69diazepam tab 2mg
69diazepam tab 5mg
90DICLEGIS TAB 10-10MG
47diclo/misopr tab 50-0.2mg
47diclo/misopr tab 75-0.2mg
47diclofen pot tab 50mg
88diclofenac sol 0.1% op
47diclofenac tab 100mg er
47diclofenac tab 100mg xr
47diclofenac tab 25mg dr
47diclofenac tab 50mg dr
47diclofenac tab 75mg dr
5dicloxacill cap 250mg
5dicloxacill cap 500mg
19dicyclomine cap 10mg
19dicyclomine sol 10mg/5ml
19dicyclomine tab 20mg
9didanosine cap 125mg
9didanosine cap 200mg
9didanosine cap 250mg
9didanosine cap 400mg
55diethylprop tab 75mg er
4DIFICID TAB 200MG
127diflorasone cre 0.05%
127diflorasone oin 0.05%
47diflunisal tab 500mg
40digitek tab 0.125mg
40digitek tab 0.25mg
40digox tab 0.125mg
40digox tab 0.25mg
40digoxin inj 0.25mg/1
40digoxin sol 50mcg/ml
40digoxin tab 0.125mg
40digoxin tab 0.25mg
63DILANTIN CAP 30MG
63DILANTIN CHW 50MG
63DILANTIN-125 SUS 125/5ML
36dilt-cd cap 120mg
36dilt-cd cap 180mg
36dilt-cd cap 240mg
36dilt-cd cap 300mg
36diltiazem cap 120mg cd
36diltiazem cap 120mg er
36diltiazem cap 120mg er
36diltiazem cap 180mg cd
36diltiazem cap 180mg er
36diltiazem cap 180mg er
36diltiazem cap 180mg/24
36diltiazem cap 240mg cd
36diltiazem cap 240mg er
36diltiazem cap 240mg er
36diltiazem cap 240mg/24
36diltiazem cap 300mg cd
36diltiazem cap 300mg er
36diltiazem cap 300mg/24
36diltiazem cap 360mg cd
36diltiazem cap 360mg er
36diltiazem cap 360mg/24
36diltiazem cap 420mg/24
36diltiazem cap 60mg er
36diltiazem cap 90mg er
37diltiazem er tab 180mg
37diltiazem er tab 240mg
37diltiazem er tab 300mg
37diltiazem er tab 360mg
37diltiazem er tab 420mg
36diltiazem tab 120mg
36diltiazem tab 30mg
36diltiazem tab 60mg
37diltiazem tab 90mg
37dilt-xr cap 120mg
37dilt-xr cap 180mg
37dilt-xr cap 240mg
37diltzac cap 180mg/24
37diltzac cap 240mg/24
37diltzac cap 300mg/24
Drug Name Page # Drug Name Page #
37diltzac cap 360mg/24
91DIPENTUM CAP 250MG
90diphen/atrop liq 2.5/5
90diphen/atrop tab 2.5mg
90diphenatol tab 2.5mg
46dipyridamole inj 5mg/ml
46dipyridamole tab 25mg
46dipyridamole tab 50mg
46dipyridamole tab 75mg
39disopyramide cap 100mg
39disopyramide cap 150mg
114disulfiram tab 250mg
114disulfiram tab 500mg
58divalproex cap 125mg
58divalproex tab 125mg dr
58divalproex tab 250mg dr
58divalproex tab 250mg er
58divalproex tab 500mg dr
58divalproex tab 500mg er
106DIVIGEL GEL 0.25MG
106DIVIGEL GEL 0.5MG
106DIVIGEL GEL 1MG/GM
119dm/cpm/pe dro
20donepezil tab 10mg
20donepezil tab 10mg odt
20donepezil tab 5mg
20donepezil tab 5mg odt
85dorzol/timol sol 22.3-6.8
85dorzolamide sol 2% op
31doxazosin tab 1mg
31doxazosin tab 2mg
31doxazosin tab 4mg
31doxazosin tab 8mg
72doxepin hcl cap 100mg
72doxepin hcl cap 10mg
72doxepin hcl cap 150mg
72doxepin hcl cap 25mg
72doxepin hcl cap 50mg
72doxepin hcl cap 75mg
72doxepin hcl con 10mg/ml
135doxercalcif cap 0.5mcg
135doxercalcif cap 1mcg
135doxercalcif cap 2.5mcg
6doxycyc mono cap 100mg
6doxycycl hyc cap 100mg
6doxycycl hyc cap 50mg
6doxycycl hyc tab 100mg
90dronabinol cap 10mg
90dronabinol cap 2.5mg
90dronabinol cap 5mg
102drospir/ethi tab 3-0.03mg
102drospirenone tab ethy est
15DROXIA CAP 200MG
15DROXIA CAP 300MG
15DROXIA CAP 400MG
95DULERA AER 100-5MCG
95DULERA AER 200-5MCG
72duloxetine cap 20mg
72duloxetine cap 30mg
72duloxetine cap 60mg
49duramorph inj 0.5mg/ml
49duramorph inj 1mg/ml
87DUREZOL EMU 0.05%
113Dutasteride 0.5MG
81DYRENIUM CAP 100MG
81DYRENIUM CAP 50MG
4e.e.s. 400 tab 400mg
4E.E.S. GRAN SUS 200/5ML
124econazole cre 1%
102econtra ez tab 1.5mg
42EDARBI TAB 40MG
42EDARBI TAB 80MG
80EDECRIN TAB 25MG
10EDURANT TAB 25MG
82EFFER-K TAB 10MEQ
82EFFER-K TAB 20MEQ
82effer-k tab 25meq ef
29EFFIENT TAB 10MG
29EFFIENT TAB 5MG
106ELESTRIN GEL 0.06%
132ELIDEL CRE 1%
102elinest tab
28ELIQUIS TAB 2.5MG
28ELIQUIS TAB 5MG
102ELLA TAB 30MG
118ELMIRON CAP 100MG
25ELOCTATE INJ 1000UNIT
25ELOCTATE INJ 1500UNIT
25ELOCTATE INJ 2000UNIT
25ELOCTATE INJ 250UNIT
25ELOCTATE INJ 3000UNIT
26ELOCTATE INJ 500UNIT
26ELOCTATE INJ 750UNIT
84EMADINE SOL 0.05% OP
Drug Name Page # Drug Name Page #
15EMCYT CAP 140MG
90EMEND CAP 125MG
90EMEND CAP 40MG
90EMEND CAP 80MG
91EMEND PAK 80 & 125
102emoquette tab
66EMSAM DIS 12MG/24H
66EMSAM DIS 6MG/24HR
66EMSAM DIS 9MG/24HR
10EMTRIVA CAP 200MG
10EMTRIVA SOL 10MG/ML
133ENABLEX TAB 15MG
133ENABLEX TAB 7.5MG
43enalapr/hctz tab 10-25mg
43enalapr/hctz tab 5-12.5mg
43enalapril tab 10mg
43enalapril tab 2.5mg
43enalapril tab 20mg
43enalapril tab 5mg
116ENBREL INJ 25/0.5ML
116ENBREL INJ 25MG
116ENBREL INJ 50MG/ML
116ENBREL SRCLK INJ 50MG/ML
80encare sup 100mg
49endocet tab 10-325mg
49endocet tab 10-650mg
50endocet tab 5-325mg
50endocet tab 7.5-325
50endocet tab 7.5-500m
109ENDOMETRIN SUP 100MG
106ENJUVIA TAB 0.3MG
106ENJUVIA TAB 0.45MG
106ENJUVIA TAB 0.625MG
106ENJUVIA TAB 0.9MG
106ENJUVIA TAB 1.25MG
28enoxaparin inj 100mg/ml
28enoxaparin inj 120/0.8
28enoxaparin inj 150mg/ml
28enoxaparin inj 30/0.3ml
28enoxaparin inj 300/3ml
28enoxaparin inj 40/0.4ml
28enoxaparin inj 60/0.6ml
28enoxaparin inj 80/0.8ml
102enpresse-28 tab
102enskyce tab
65entacapone tab 200mg
13entecavir tab 0.5mg
13entecavir tab 1mg
41ENTRESTO TAB 24-26MG
41ENTRESTO TAB 49-51MG
41ENTRESTO TAB 97-103MG
93ENTYVIO INJ 300MG
80enulose sol 10gm/15
132EPIDUO FORTE GEL 0.3-2.5%
84epinastine dro 0.05%
22epinephrine inj 0.1mg/ml
22epinephrine inj 1mg/ml
22EPIPEN 2-PAK INJ 0.3MG
22EPIPEN-JR INJ 2-PAK
58epitol tab 200mg
10EPIVIR HBV SOL 5MG/ML
44eplerenone tab 25mg
44eplerenone tab 50mg
30EPOGEN INJ 10000/ML
30EPOGEN INJ 2000/ML
30EPOGEN INJ 20000/ML
30EPOGEN INJ 3000/ML
30EPOGEN INJ 4000/ML
42eprosart mes tab 600mg
10EPZICOM TAB
10EPZICOM TAB 600-300
136ergocalcifer cap 50000unt
22ergoloid mes tab 1mg oral
15ERIVEDGE CAP 150MG
102errin tab 0.35mg
124ERTACZO CRE 2%
123ery pad 2%
4ERYPED SUS 200/5ML
4ERYPED SUS 400/5ML
4erythrom eth tab 400mg
123erythromycin gel /benzoyl
123erythromycin gel 2%
86erythromycin oin 5mg/gm
86erythromycin oin op
123erythromycin pad 2%
123erythromycin sol 2%
4erythromycin tab 250mg bs
4erythromycin tab 500mg bs
118ESBRIET CAP 267MG
72escitalopram sol 5mg/5ml
72escitalopram tab 10mg
72escitalopram tab 20mg
72escitalopram tab 5mg
102estarylla tab 0.25-35
Drug Name Page # Drug Name Page #
69estazolam tab 1mg
69estazolam tab 2mg
106estra/noreth tab 0.5-0.1
106estra/noreth tab 1-0.5mg
106ESTRACE VAG CRE 0.1MG/GM
106estradiol dis 0.025mg
106estradiol dis 0.0375mg
106estradiol dis 0.05mg
107estradiol dis 0.06mg
107estradiol dis 0.075mg
107estradiol dis 0.1mg
107estradiol tab 0.5mg
107estradiol tab 1mg
107estradiol tab 2mg
107ESTRASORB EMU
107ESTRING MIS 2MG
107ESTROGEL GEL
107estropipate tab 0.75mg
107estropipate tab 1.5mg
107estropipate tab 3mg
67eszopiclone tab 1mg
67eszopiclone tab 2mg
67eszopiclone tab 3mg
8ethambutol tab 100mg
8ethambutol tab 400mg
63ethosuximide cap 250mg
63ethosuximide sol 250/5ml
115etidron disd tab 200mg
115etidron disd tab 400mg
47etodolac cap 200mg
47etodolac cap 300mg
47etodolac tab 400mg
47etodolac tab 500mg
47
47
47
15
126
126
107
124
15
etodolac er tab 400mg
etodolac er tab 500mg
etodolac er tab 600mg
etoposide cap 50mg
EURAX CRE 10%
EURAX LOT 10%
EVAMIST SPR 1.53MG
EVAMIST SPR 1.53MGEXELDERM SOL 1%
exemestane tab 25mg
94EXJADE TAB 125MG
94EXJADE TAB 250MG
94EXJADE TAB 500MG
114EXTAVIA INJ 0.3MG
121EZ FLU SHOT INJ 2015-16
5FACTIVE TAB 320MG
102fallback tab 1.5mg
102falmina tab
13famciclovir tab 125mg
13famciclovir tab 250mg
13famciclovir tab 500mg
91famotidine tab 20mg
91famotidine tab 40mg
76FANAPT TAB 10MG
76FANAPT TAB 12MG
76FANAPT TAB 1MG
76FANAPT TAB 2MG
76FANAPT TAB 4MG
76FANAPT TAB 6MG
76FANAPT TAB 8MG
15FARESTON TAB 60MG
99FARXIGA TAB 10MG
99FARXIGA TAB 5MG
24fe c plus tab
26FEIBA VH IMMU 1,750-3,250 UNIT
58felbamate sus 600/5ml
58felbamate tab 400mg
58felbamate tab 600mg
38felodipine tab 10mg er
38felodipine tab 2.5mg er
38felodipine tab 5mg er
107FEMRING MIS 0.05/24H
107FEMRING MIS 0.1MG/24
32fenofibrate cap 130mg
32fenofibrate cap 134mg
32fenofibrate cap 200mg
32fenofibrate cap 43mg
32fenofibrate cap 67mg
32fenofibrate tab 120mg
32fenofibrate tab 145mg
32fenofibrate tab 160mg
32fenofibrate tab 40mg
32fenofibrate tab 48mg
32fenofibrate tab 54mg
32fenofibric tab 105mg
32fenofibric tab 35mg
47fenoprofen tab 600mg
50fentanyl dis 100mcg/h
50fentanyl dis 12mcg/hr
50fentanyl dis 25mcg/hr
50fentanyl dis 37.5mcg
Drug Name Page # Drug Name Page #
50fentanyl dis 50mcg/hr
50fentanyl dis 62.5mcg
50fentanyl dis 75mcg/hr
50fentanyl dis 87.5mcg
50fentanyl ot loz 1200mcg
50fentanyl ot loz 1600mcg
50fentanyl ot loz 200mcg
50fentanyl ot loz 400mcg
50fentanyl ot loz 600mcg
50fentanyl ot loz 800mcg
24ferrous aspartate tab 112 mg
24ferrous fumarate cap 86 mg
24ferrous fumarate tab 18 mg
24ferrous fumarate tab 29 mg
24ferrous fumarate tab 324 mg
24ferrous fumarate tab 325 mg
24ferrous fumarate tab 90 mg
24ferrous gluconate tab 225 mg
24ferrous gluconate tab 240 mg
24ferrous gluconate tab 27 mg
24ferrous gluconate tab 324 mg
24ferrous gluconate tab 325 mg
24ferrous sulfate elixir 220 mg/5ml
24ferrous sulfate soln 15 mg/ml
24ferrous sulfate syrup 300 mg/5ml
24ferrous sulfate tab 134 mg
24ferrous sulfate tab 140 mg
24ferrous sulfate tab 142 mg
24ferrous sulfate tab 143 mg
24ferrous sulfate tab 160 mg
24ferrous sulfate tab 200 mg
24ferrous sulfate tab 27 mg
24ferrous sulfate tab 28 mg
24ferrous sulfate tab 324 mg
24ferrous sulfate tab 325 mg
24ferrous sulfate tab 45 mg
24ferrous sulfate tab 47.5 mg
24ferrous sulfate tab 50 mg
25ferrous sulfate tab 65 mg
25ferrous sulfate tab 90 mg
113finasteride tab 5mg
87FLAREX SUS 0.1% OP
133flavoxate tab 100mg
120flebogamma 5% vial
120FLEBOGAMMA INJ 20/400ML
39flecainide tab 100mg
39flecainide tab 150mg
39flecainide tab 50mg
95FLOVENT DISK AER 100MCG
95FLOVENT DISK AER 250MCG
95FLOVENT DISK AER 50MCG
95FLOVENT HFA AER 110MCG
95FLOVENT HFA AER 220MCG
95FLOVENT HFA AER 44MCG
15floxuridine inj 0.5gm
121FLUARIX PF INJ 2013-14
121FLUARIX PF INJ 2014-15
121FLUARIX QUAD INJ 2013-14
121FLUARIX QUAD INJ 2014-15
121FLUARIX QUAD INJ 2015-16
121FLUBLOK SOL 2013-14
121FLUBLOK SOL 2014-15
121FLUBLOK SOL 2015-16
121FLUCELVAX INJ 2013-14
121FLUCELVAX INJ 2014-15
121FLUCELVAX INJ 2015-16
7fluconazole sus 10mg/ml
7fluconazole sus 40mg/ml
7fluconazole tab 100mg
7fluconazole tab 150mg
7fluconazole tab 200mg
7fluconazole tab 50mg
8flucytosine cap 250mg
8flucytosine cap 500mg
95fludrocort tab 0.1mg
121FLULAVAL INJ 2013-14
121FLULAVAL QUA INJ 2013-14
121FLULAVAL QUA INJ 2014-15
121FLULAVAL QUA INJ 2015-16
121FLUMIST QUAD SUS 2013-14
121FLUMIST QUAD SUS 2014-15
121FLUMIST QUAD SUS 2015-16
87flunisolide spr 0.025%
128fluocin acet cre 0.01%
87fluocin acet oil 0.01%
128fluocin acet oil 0.01% sc
128fluocin acet oil body
87fluocin acet oil ear0.01%
128fluocin acet oil scalp
128fluocin acet sol 0.01%
128fluocinonide cre 0.05%
128fluocinonide cre 0.1%
128fluocinonide gel 0.05%
128fluocinonide oin 0.05%
Drug Name Page # Drug Name Page #
128fluocinonide sol 0.05%
87fluoromethol sus 0.1% op
132fluorouracil cre 0.5%
132fluorouracil cre 5%
132fluorouracil dro 2%
132fluorouracil dro 5%
132fluorouracil sol 2%
132fluorouracil sol 5%
72fluoxetine cap 10mg
72fluoxetine cap 20mg
72fluoxetine cap 40mg
72fluoxetine cap 90mg dr
72fluoxetine sol 20mg/5ml
72fluoxetine tab 10mg
72fluoxetine tab 20mg
77fluphenazine tab 10mg
77fluphenazine tab 1mg
77fluphenazine tab 2.5mg
77fluphenazine tab 5mg
69flurazepam cap 15mg
69flurazepam cap 30mg
88flurbiprofen sol 0.03% op
47flurbiprofen tab 100mg
47flurbiprofen tab 50mg
15flutamide cap 125mg
128fluticasone cre 0.05%
128fluticasone lot 0.05%
128fluticasone oin 0.005%
87fluticasone spr 50mcg
33Fluvastatin TAB 80MG
33fluvastatin cap 20mg
33fluvastatin cap 40mg
121FLUVIRIN INJ 2013-14
122FLUVIRIN INJ 2015-16
122FLUVIRIN INJ PF 13-14
122FLUVIRIN PF INJ 2014-15
72fluvoxamine tab 100mg
72fluvoxamine tab 25mg
72fluvoxamine tab 50mg
122FLUZONE HD INJ PF 13-14
122FLUZONE HD INJ PF 14-15
122FLUZONE HD INJ PF 15-16
122FLUZONE INJ INTRADRM
122FLUZONE INJ PF 13-14
122FLUZONE INJ PF 14-15
122FLUZONE PED/ INJ PF 13-14
122FLUZONE QUAD INJ 13-14
122
122
122
122
122
FLUZONE QUAD INJ 14-15
FLUZONE QUAD INJ 15-16
FLUZONE QUAD INJ 2015-16
FLUZONE QUAD INJ 9MCG
FLUZONE SPLT INJ 2015-16
135folic acid tab 1mg
135folic acid tab 400 mcg
135folic acid tab 800 mcg
28fondaparinux inj 10/0.8ml
28fondaparinux inj 2.5/0.5
28fondaparinux inj 5/0.4ml
28fondaparinux inj 7.5/0.6
23FORADIL CAP AEROLIZE
108FORTEO SOL 600/2.4
115FOSAMAX + D TAB 70-2800
115FOSAMAX + D TAB 70-5600
43fosinop/hctz tab 10/12.5
43fosinop/hctz tab 20/12.5
43fosinopril tab 10mg
43fosinopril tab 20mg
43fosinopril tab 40mg
82FOSRENOL CHW 1000MG
82FOSRENOL CHW 500MG
82FOSRENOL CHW 750MG
28FRAGMIN INJ 10000/ML
28FRAGMIN INJ 12500UNT
28FRAGMIN INJ 15000UNT
28FRAGMIN INJ 18000UNT
28FRAGMIN INJ 2500/0.2
28FRAGMIN INJ 5000/0.2
28FRAGMIN INJ 7500/0.3
28FRAGMIN INJ 95000UNT
64FROVA TAB 2.5MG
80furosemide inj 100/10ml
80furosemide inj 10mg/ml
80furosemide inj 20mg/2ml
80furosemide inj 40mg/4ml
81furosemide sol 10mg/ml
81furosemide sol 40mg/4ml
81furosemide sol 8mg/ml
81furosemide tab 20mg
81furosemide tab 40mg
81furosemide tab 80mg
Drug Name Page # Drug Name Page #
10FUZEON INJ 90MG
10FUZEON CONVENIENCE KIT
58gabapentin cap 100mg
58gabapentin cap 300mg
58gabapentin cap 400mg
58
58
58
20
20
20
20
20
20
20
120
120
120
120
120
120
120
120
120
120
120
120
120
120
120
120
120
13
117
86
86
93
92
92
92
32
80
117
117
86
123
gabapentin sol 250/5ml
gabapentin tab 600mg
gabapentin tab 800mg
galantamine cap 16mg er
galantamine cap 24mg er
galantamine cap 8mg er
galantamine sol 4mg/ml
galantamine tab 12mg
galantamine tab 4mg
galantamine tab 8mg
gamastan s/d inj
gammagard inj 1gm/10ml
gammagard inj 2.5gm/25
gammagard inj 20gm/200
gammagard inj 5gm/50ml
GAMMAGARD S-D 10 G (IGA<1) SOL
gammagard s-d 2.5 gm vl w/st
GAMMAGARD S-D 5 G (IGA<1) SOLN
GAMMAKED INJ 10GM/100
GAMMAKED INJ 1GM/10ML
GAMMAKED INJ 2.5GM/25
GAMMAKED INJ 20GM/200
GAMMAKED INJ 5GM/50ML
GAMMAPLEX INJ 10GM
GAMMAPLEX INJ 2.5GM
GAMMAPLEX INJ 5GM
GAMUNEX 10% VIAL
ganciclovir cap 250 mg
ganirelix ac inj
garamycin oin 0.3% op
gatifloxacin sol 0.5%
GATTEX KIT 5MG
gavilyte-c sol
gavilyte-g sol
gavilyte-n sol flav pk
gemfibrozil tab 600mg
generlac sol 10gm/15
gengraf cap 100mg
gengraf cap 25mg
gentak oin 0.3% op
gentamicin cre 0.1%
123gentamicin oin 0.1%
86gentamicin oin 0.3% op
86gentamicin sol 0.3% op
102gianvi tab 3-0.02mg
102gildagia tab 0.4-35
102gildess 24 tab fe 1/20
102gildess fe tab 1.5/30
102gildess fe tab 1/20
102gildess tab 1.5/30
102gildess tab 1/20
114GILENYA CAP 0.5MG
15GILOTRIF TAB 20MG
15GILOTRIF TAB 30MG
15GILOTRIF TAB 40MG
114
15
15
15
15
15
99
99
100
100
100
100
100
100
100
100
100
100
100
100
101
101
100
100
100
100
glatiramer inj 20mg/ml imatinab tab 100MG imatinab tab 400MG GLEOSTINE CAP 100MG GLEOSTINE CAP 10MG GLEOSTINE CAP 40MG glimepiride tab 1mg glimepiride tab 2mg glimepiride tab 4mg
glip/metform tab 2.5-250m glip/metform tab 2.5-500m glip/metform tab 5-500mg glipizide er tab 10mg glipizide er tab 2.5mg glipizide er tab 5mg glipizide tab 10mg glipizide
tab 5mg
glipizide xl tab 10mg glipizide xl tab 2.5mg glipizide xl tab 5mg GLUCAGEN INJ HYPOKIT GLUCAGON KIT 1MG glyb/
metform tab 1.25-250 glyb/
metform tab 2.5-500 glyb/
metform tab 5-500mg glyburid mcr tab 1.5mg
100glyburid mcr tab 3mg
100glyburid mcr tab 6mg
100glyburide tab 1.25mg
100glyburide tab 2.5mg
100glyburide tab 5mg
19glycopyrrol tab 1mg
19glycopyrrol tab 2mg
Drug Name Page # Drug Name Page #
130glydo gel 2%
97GLYSET TAB 100MG
97GLYSET TAB 25MG
97GLYSET TAB 50MG
108GONAL-F RFF INJ 300
108GONAL-F RFF INJ 300/0.5
108GONAL-F RFF INJ 450
108GONAL-F RFF INJ 450/0.75
108GONAL-F RFF INJ 900
108GONAL-F RFF INJ 900/1.5
90granisetron tab 1mg
7griseofulvin sus 125/5ml
7griseofulvin tab micr 500
7griseofulvin tab ultr 125
7griseofulvin tab ultr 250
128grx hicort sup 25mg
41guanfacine tab 1mg
69guanfacine tab 1mg er
41guanfacine tab 2mg
69guanfacine tab 2mg er
69guanfacine tab 3mg er
69guanfacine tab 4mg er
21guanidine tab 125mg
128halobetasol cre 0.05%
128halobetasol oin 0.05%
128HALOG CRE 0.1%
77haloperidol con 2mg/ml
77haloperidol tab 0.5mg
77haloperidol tab 10mg
77haloperidol tab 1mg
77haloperidol tab 20mg
77haloperidol tab 2mg
77haloperidol tab 5mg
12HARVONI TAB 90-400MG
128hc butyrate cre 0.1%
128hc butyrate oin 0.1%
128hc butyrate sol 0.1%
128hc pramoxine cre 1-2.5%
128hc pramoxine cre 2.5-1%
128hc valerate cre 0.2%
128hc valerate oin 0.2%
87hc/acet acid sol otic
102heather tab 0.35mg
117hecoria cap 0.5mg
117hecoria cap 1mg
117hecoria cap 5mg
26HELIXATE FS INJ 1000UNIT
26HELIXATE FS INJ 2000UNIT
26HELIXATE FS INJ 250UNIT
26HELIXATE FS INJ 500UNIT
26HEMOFIL M INJ 1700UNIT
26HEMOFIL M INJ 220-400
26HEMOFIL M INJ 401-800
26HEMOFIL M SOL 501-2000
26HEMOFIL M SOL 801-1500
128hemorrhoidal sup -hc 25mg
15HEXALEN CAP 50MG
120HIZENTRA INJ 1GM/5ML
120HIZENTRA INJ 2GM/10ML
120HIZENTRA INJ 4GM/20ML
89homatropaire sol 5% op
89homatropine sol 5% op
58HORIZANT TAB 300MG
58HORIZANT TAB 600MG
98HUMALOG INJ 100/ML
98HUMALOG KWIK INJ 100/ML
98HUMALOG MIX INJ 50/50
98HUMALOG MIX INJ 50/50KWP
98HUMALOG MIX INJ 75/25KWP
98HUMALOG MIX SUS 75/25
26HUMATE-P SOL 2400UNIT
26HUMATE-P SOL 250-600
26HUMATE-P SOL 500-1200
116HUMIRA INJ 10MG/0.2
116HUMIRA INJ 40MG/0.8
116HUMIRA KIT 20MG/0.4
116HUMIRA PEDIA INJ CROHNS
116HUMIRA PEN INJ 40MG/0.8
116HUMIRA PEN INJ CROHNS
116HUMIRA PEN INJ PSORIASI
98HUMULIN INJ 70/30
98HUMULIN INJ 70/30KWP
98HUMULIN N INJ U-100
98HUMULIN N INJ U-100KWP
98HUMULIN N PN INJ U-100
98HUMULIN PEN INJ 70/30
99HUMULIN R INJ U-100
99HUMULIN R INJ U-500
119hyd pol/cpm liq 10-8/5ml
41hydralazine inj 20mg/ml
41hydralazine tab 100mg
41hydralazine tab 10mg
41hydralazine tab 25mg
41hydralazine tab 50mg
Drug Name Page # Drug Name Page #
81hydrochlorot cap 12.5mg
81hydrochlorot tab 12.5mg
81hydrochlorot tab 25mg
81hydrochlorot tab 50mg
50hydroco/apap sol 5-217/10
50hydroco/apap sol 7.5-325
50hydroco/apap tab 10-325mg
50hydroco/apap tab 5-325mg
50hydroco/apap tab 7.5-325
50hydrocod/ibu tab 2.5-200
50hydrocod/ibu tab 7.5-200
128hydrocort ac sup 25mg
128hydrocort cre 1%
128hydrocort cre 2.5%
128hydrocort lot 2.5%
128hydrocort oin 1%
128hydrocort oin 2.5%
95hydrocort tab 10mg
95hydrocort tab 20mg
95hydrocort tab 5mg
128hydrocort/ab oin 1%
129hydrocortiso cre 2.5%
50hydromorphon liq 1mg/ml
50hydromorphon sup 3mg
50hydromorphon tab 2mg
50hydromorphon tab 4mg
50hydromorphon tab 8mg
9hydroxychlor tab 200mg
15hydroxyurea cap 500mg
67hydroxyz hcl sol 10mg/5ml
67hydroxyz hcl syp 10mg/5ml
67hydroxyz hcl tab 10mg
67hydroxyz hcl tab 25mg
67hydroxyz hcl tab 50mg
67hydroxyz pam cap 100mg
67hydroxyz pam cap 25mg
67hydroxyz pam cap 50mg
14hyophen tab
19hyoscyamine sub 0.125mg
19hyoscyamine tab 0.125mg
131hypercare sol 20%
115ibandronate tab 150mg
15IBRANCE CAP 100MG
15IBRANCE CAP 125MG
15IBRANCE CAP 75MG
50IBUDONE TAB 10-200MG
47ibuprofen sus 100/5ml
47ibuprofen tab 400mg
47ibuprofen tab 600mg
47ibuprofen tab 800mg
15ICLUSIG TAB 15MG
15ICLUSIG TAB 45MG
88ILEVRO DRO 0.3% OP
86ilotycin oin op
16IMBRUVICA CAP 140MG
72imipram hcl tab 10mg
72imipram hcl tab 25mg
72imipram hcl tab 50mg
72
72
72
73
132
109
81
82
48
48
48
48
48
48
12
12
122
16
16
10
10
10
imipram pam cap 100mg
imipram pam cap 125mg
imipram pam cap 150mg
imipram pam cap 75mg
imiquimod cre 5%
NCRELEX INJ 40MG/4ML
indapamide tab 1.25mg
indapamide tab 2.5mg
indomethacin cap 25mg
indomethacin cap 50mg
indomethacin cap 75mg cr
indomethacin cap 75mg er
indomethacin cap 75mg sa
indomethacin cap 75mg sr
INFERGEN INJ 15MCG
INFERGEN INJ 9MCG
INFLUENZA FIRUS VACCINE
INLYTA TAB 1MG
INLYTA TAB 5MG
INTELENCE TAB 100MG
INTELENCE TAB 200MG
INTELENCE TAB 25MG
16INTRON A INJ 10MU
16INTRON A INJ 18MU
16INTRON A INJ 18MU
16INTRON A INJ 25MU
16INTRON A INJ 50MU
102introvale tab
88IOPIDINE SOL 1% OP
19ipratropium sol 0.02%inh
Drug Name Page # Drug Name Page #
19ipratropium spr 0.03%
19ipratropium spr 0.06%
42irbesar/hctz tab 150-12.5
42irbesar/hctz tab 300-12.5
42irbesartan tab 150mg
42irbesartan tab 300mg
42irbesartan tab 75mg
16IRESSA TAB 250MG
10ISENTRESS TAB 400MG
45isoditrate tab 40mg er
8isoniazid syp 50mg/5ml
8isoniazid tab 100mg
8isoniazid tab 300mg
45ISORDIL TAB 40MG
45isosorb din tab 10mg
45isosorb din tab 20mg
45isosorb din tab 30mg
45isosorb din tab 40mg er
45isosorb din tab 40mg sa
45isosorb din tab 5mg
45isosorb mono tab 10mg
45isosorb mono tab 120mg er
45isosorb mono tab 20mg
45isosorb mono tab 30mg er
45isosorb mono tab 60mg er
38isradipine cap 2.5mg
38isradipine cap 5mg
7itraconazole cap 100mg
16JAKAFI TAB 10MG
16JAKAFI TAB 15MG
16JAKAFI TAB 20MG
16JAKAFI TAB 25MG
16JAKAFI TAB 5MG
97JANUVIA TAB 100MG
97JANUVIA TAB 25MG
98JANUVIA TAB 50MG
102jencycla tab 0.35mg
107jinteli tab 1mg-5mcg
102jolessa tab
103jolivette tab 0.35mg
103junel 1.5/30 tab
103junel 1/20 tab
103junel fe tab 1.5/30
103junel fe tab 1/20
103junel fe 24 tab 1/20
80k citrate sol citr acd
10KALETRA SOL
10KALETRA TAB 100-25MG
10KALETRA TAB 200-50MG
119KALYDECO TAB 150MG
90kaopectate tab
103kariva tab 28 day
26KCENTRA KIT 1000UNIT
26KCENTRA KIT 500UNIT
82k-effervesce tab 25meq ef
103kelnor tab 1/35
129KENALOG AER SPRAY
4KETEK TAB 300MG
4KETEK TAB 400MG
124ketoconazole aer 2%
124ketoconazole cre 2%
124ketoconazole sha 2%
7ketoconazole tab 200mg
124ketodan aer 2%
48ketoprofen cap 200mg er
48ketoprofen cap 50mg
48ketoprofen cap 75mg
88ketorolac sol 0.4%
88ketorolac sol 0.5%
48ketorolac tab 10mg
84ketotif fum dro 0.025%op
103kimidess tab
82kionex sus 15gm/60
82klor-con 10 tab 10meq er
83klor-con 8 tab 8meq er
83klor-con m10 tab 10meq er
83KLOR-CON M15 TAB
83KLOR-CON M15 TAB 15MEQ ER
83klor-con m20 tab 20meq er
83klor-con spr cap 10meq
83klor-con spr cap 8meq
83klor-con/ef tab 25meq ef
83klor-con/ef tab 25meq fr
26koate-dvi inj 1000unit
26koate-dvi inj 250unit
26KOATE-DVI INJ 500UNIT
26KOGENATE FS INJ 1000/BS
26KOGENATE FS INJ 1000UNIT
26KOGENATE FS INJ 2000/BS
26KOGENATE FS INJ 2000UNIT
26KOGENATE FS INJ 250/BS
26KOGENATE FS INJ 250UNIT
26KOGENATE FS INJ 3000/BS
26KOGENATE FS INJ 3000UNIT
Drug Name Page # Drug Name Page #
26KOGENATE FS INJ 500/BS
26KOGENATE FS INJ 500UNIT
83k-prime tab 25meq ef
80KRISTALOSE PAK 10GM
80KRISTALOSE PAK 20GM
83k-sol sol 10%
83k-sol sol 20%
103kurvelo tab 0.15/30
83k-vescent tab 25meq ef
34labetalol tab 100mg
34labetalol tab 200mg
34labetalol tab 300mg
131laclotion lot 12%
131lactic acid lot 10%
80lactulose sol 10gm/15
80lactulose sol 20gm/30
58LAMICTAL CHW 25MG
58LAMICTAL CHW 5MG
58LAMICTAL KIT START 49
10lamivud/zido tab 150-300
10lamivudine sol 10mg/ml
10lamivudine tab 100mg
10lamivudine tab 150mg
10lamivudine tab 300mg
58lamotrigine chw 25mg
58lamotrigine chw 5mg
58lamotrigine tab 100mg
59lamotrigine tab 100mg er
59lamotrigine tab 150mg
59lamotrigine tab 200mg
59lamotrigine tab 200mg er
59lamotrigine tab 250mg er
59lamotrigine tab 25mg
59lamotrigine tab 25mg er
59lamotrigine tab 300mg er
59lamotrigine tab 50mg er
40lanoxin tab 0.125mg
40lanoxin tab 0.25mg
92lansoprazole cap 15mg dr
92lansoprazole cap 30mg dr
92LANSOPRAZOLE SUS 3MG/ML
99LANTUS INJ 100/ML
99LANTUS INJ SOLOSTAR
103larin tab 1.5/30
103larin tab 1/20
103larin 24 tab fe 1/20
103larin fe tab 1.5/30
103larin fe tab 1/20
84LASTACAFT SOL 0.25%
85latanoprost sol 0.005%
77LATUDA TAB 120MG
77LATUDA TAB 20MG
77LATUDA TAB 40MG
77LATUDA TAB 60MG
77LATUDA TAB 80MG
103layolis fe chw
130lc-4 lidocne cre 4%
103leena tab
116leflunomide tab 10mg
116leflunomide tab 20mg
103lessina tab
119LETAIRIS TAB 10MG
119LETAIRIS TAB 5MG
16letrozole tab 2.5mg
114leucovor ca tab 10mg
113leucovor ca tab 15mg
113leucovor ca tab 25mg
113leucovor ca tab 5mg
16LEUKERAN TAB 2MG
30LEUKINE INJ 250MCG
30LEUKINE INJ 500 MCG
23levalbuterol neb 0.31mg
23levalbuterol neb 0.63mg
23levalbuterol neb 1.25/0.5
23levalbuterol neb 1.25mg
34LEVATOL TAB 20MG
99LEVEMIR INJ
99LEVEMIR INJ FLEXPEN
99LEVEMIR INJ FLEXTOUC
59levetiraceta sol 100mg/ml
59levetiraceta sol 500/5ml
59levetiraceta tab 1000mg
59levetiraceta tab 250mg
59levetiraceta tab 500mg
59levetiraceta tab 500mg er
59levetiraceta tab 750mg
59levetiraceta tab 750mg er
59levetiracetm inj 500/5ml
85levobunolol sol 0.25% op
85levobunolol sol 0.5% op
1levocetirizi sol 2.5/5ml
1levocetirizi tab 5mg
103levo-eth est tab 90-20mcg
5levofloxacin inj 25mg/ml
Drug Name Page # Drug Name Page #
86levofloxacin sol 0.5%
5levofloxacin sol 25mg/ml
5levofloxacin tab 250mg
5levofloxacin tab 500mg
5levofloxacin tab 750mg
103levonest tab
103levonor/ethi tab 0.1-0.02
103levonor/ethi tab estradio
103levonorgestr tab 0.75mg
103levonorgestr tab 1.5mg
103levora-28 tab 0.15/30
50levorphanol tab 2mg
110levothyroxin inj 100mcg
110levothyroxin inj 200mcg
110levothyroxin inj 500mcg
110levothyroxin tab 100mcg
110levothyroxin tab 112mcg
110levothyroxin tab 125mcg
110levothyroxin tab 137mcg
110levothyroxin tab 150mcg
110levothyroxin tab 175mcg
110levothyroxin tab 200mcg
110levothyroxin tab 25mcg
110levothyroxin tab 300mcg
111levothyroxin tab 50mcg
111levothyroxin tab 75mcg
111levothyroxin tab 88mcg
111levothyroxine tab 0.075mg
111levoxyl tab 100mcg
111levoxyl tab 112mcg
111levoxyl tab 125mcg
111levoxyl tab 137mcg
111levoxyl tab 150mcg
111levoxyl tab 175mcg
111levoxyl tab 200mcg
111levoxyl tab 25mcg
111levoxyl tab 50mcg
111levoxyl tab 75mcg
111levoxyl tab 88mcg
10LEXIVA SUS 50MG/ML
10LEXIVA TAB 700MG
91LIALDA TAB 1.2GM
130lido/prilocn cre 2.5-2.5%
130lido/prilocn kit 2.5-2.5%
130lidocaine cre 3%
130lidocaine cre 4%
130lidocaine gel 2%
130lidocaine gel 2% jelly
130lidocaine oin 5%
89lidocaine sol 2% visc
130lidocaine sol 4%
130lidocream cre 4%
130lidopin cre 3%
126lindane lot 1%
126lindane sha 1%
2linezolid tab 600mg
93LINZESS CAP 145MCG
93LINZESS CAP 290MCG
111liothyronine tab 25mcg
111liothyronine tab 50mcg
111liothyronine tab 5mcg
43lisinop/hctz tab 10-12.5
43lisinop/hctz tab 20-12.5
43lisinop/hctz tab 20-25mg
43lisinopril tab 10mg
44lisinopril tab 2.5mg
44lisinopril tab 20mg
44lisinopril tab 30mg
44lisinopril tab 40mg
44lisinopril tab 5mg
63lithium carb cap 150mg
63lithium carb cap 300mg
63lithium carb cap 600mg
63lithium carb tab 300mg
63lithium carb tab 300mg er
63lithium carb tab 450mg er
63lithium sol 8meq/5ml
33LIVALO TAB 1MG
33LIVALO TAB 2MG
33LIVALO TAB 4MG
130livixil pak kit 2.5-2.5%
129locoid cre 0.1%
90lofene tab 2.5mg
129lokara lot 0.05%
103lomedia 24 tab fe
90lonox tab 2.5mg
90loperamide cap 2mg
107lopreeza tab 0.5-0.1
107lopreeza tab 1-0.5mg
69lorazepam tab 0.5mg
69lorazepam tab 1mg
69lorazepam tab 2mg
51lorcet tab 5-325mg
51lorcet hd tab 10-325mg
Drug Name Page # Drug Name Page #
51lorcet plus tab 7.5-325
51lortab tab 10-325mg
51lortab tab 5-325mg
51lortab tab 7.5-325
103loryna tab 3-0.02mg
21LORZONE TAB 750MG
42losartan pot tab 100mg
42losartan pot tab 25mg
42losartan pot tab 50mg
42losartan/hct tab 100-12.5
42losartan/hct tab 100-25
42losartan/hct tab 50-12.5
87LOTEMAX SUS 0.5%
33lovastatin tab 10mg
33lovastatin tab 20mg
33lovastatin tab 40mg
103low-ogestrel tab
77loxapine cap 10mg
77loxapine cap 25mg
77loxapine cap 50mg
77loxapine cap 5mg
130lp lite pak kit 2.5-2.5%
85LUMIGAN SOL 0.01%
103lutera tab
59LYRICA CAP 100MG
59LYRICA CAP 150MG
59LYRICA CAP 200MG
59LYRICA CAP 225MG
59LYRICA CAP 25MG
59LYRICA CAP 300MG
59LYRICA CAP 50MG
59LYRICA CAP 75MG
16LYSODREN TAB 500MG
103lyza tab 0.35mg
83magnesium cl inj 20%
126malathion lot 0.5%
73maprotiline tab 25mg
73maprotiline tab 50mg
73maprotiline tab 75mg
103marlissa tab 0.15/30
73MARPLAN TAB 10MG
16MATULANE CAP 50MG
37matzim la tab 180mg/24
37matzim la tab 240mg/24
37matzim la tab 300mg/24
37matzim la tab 360mg/24
37matzim la tab 420mg/24
23
88
91
91
48
48
48
109
109
109
109
48
9
109
16
16
16
16
16
109
16
16
48
48
48
69
69
107
107
107
107
108
107
124
51
MAXAIR AUTOH AER 200MCG MAXIDEX SUS 0.1% OP meclizine tab 12.5mg meclizine tab 25mg meclofen sod cap 100mg meclofen sod cap 50mg MEDI-SELTZER TAB medroxypr ac inj 150mg/ml medroxypr ac tab 10mg medroxypr ac tab 2.5mg medroxypr ac tab 5mg mefenam acid cap 250mg mefloquine tab 250mg MEGACE ES SUS
megestrol ac sus 400mg/10 megestrol ac sus 40mg/ml megestrol ac sus 800mg/20 megestrol ac tab 20mg megestrol ac tab 40mg megestrol sus 625mg/5m MEKINIST TAB 0.5MG MEKINIST TAB 2MG meloxicam sus 7.5/5ml meloxicam tab 15mg meloxicam tab 7.5mg memantine hc tab 10mg memantine tab hcl 5mg MENEST TAB 0.3MG MENEST TAB 0.625MG MENEST TAB 1.25MG MENEST TAB 2.5MG
MENOPUR INJ 75UNIT MENOSTAR DIS 14MCG MENTAX CRE 1%meperidine
inj 100mg/ml
51meperidine inj 10mg/ml
51meperidine inj 25mg/ml
51meperidine inj 50mg/ml
51meperidine sol 50mg/5ml
51meperidine tab 100mg
51meperidine tab 50mg
51meperitab tab 100mg
51meperitab tab 50mg
67meprobamate tab 200mg
67meprobamate tab 400mg
16mercaptopur tab 50mg
Drug Name Page # Drug Name Page #
91mesalamine ene 4gm
91mesalamine kit 4gm
21MESTINON SYP 60MG/5ML
56metadate tab 20mg er
23metaproteren syp 10mg/5ml
23metaproteren tab 10mg
23metaproteren tab 20mg
21metaxalone tab 400mg
21metaxalone tab 800mg
97metformin tab 1000mg
97metformin tab 500mg
97metformin tab 500mg er
97metformin tab 750mg er
97metformin tab 850mg
51methadone sol 10mg/5ml
51methadone sol 5mg/5ml
51methadone tab 10mg
51methadone tab 5mg
55methamphetam tab 5mg
85methazolamid tab 25mg
85methazolamid tab 50mg
14methenam hip tab 1gm
110methimazole tab 10mg
110methimazole tab 5mg
21methocarbam tab 500mg
21methocarbam tab 750mg
16methotrexate tab 2.5mg
19methscopolam tab 2.5mg
19methscopolam tab 5mg
81methyclothia tab 5mg
41methyldopa tab 250mg
41methyldopa tab 500mg
56methylphenid cap 10mg
56methylphenid cap 20mg
56methylphenid cap 20mg er
56methylphenid cap 30mg
56methylphenid cap 30mg er
56methylphenid cap 40mg
56methylphenid cap 40mg er
56methylphenid cap 50mg
56methylphenid cap 60mg
56methylphenid sol 10mg/5ml
56methylphenid sol 5mg/5ml
57methylphenid tab 10mg
57methylphenid tab 10mg er
57methylphenid tab 18mg er
57methylphenid tab 18mg er
57methylphenid tab 20mg
57methylphenid tab 20mg er
57methylphenid tab 20mg sr
57methylphenid tab 27mg er
57methylphenid tab 27mg er
57methylphenid tab 36mg er
57methylphenid tab 36mg er
57methylphenid tab 54mg er
57methylphenid tab 54mg er
57methylphenid tab 5mg
96methylpred pak 4mg
96methylpred tab 16mg
96methylpred tab 32mg
96methylpred tab 4mg
96methylpred tab 8mg
85metipranolol sol 0.3% oph
94metoclopram inj 10mg/2ml
94metoclopram inj 5mg/ml
94metoclopram sol 10/10ml
94metoclopram sol 5mg/5ml
94metoclopram tab 10mg
94metoclopram tab 5mg
82metolazone tab 10mg
82metolazone tab 2.5mg
82metolazone tab 5mg
34metoprl/hctz tab 100-25mg
34metoprl/hctz tab 100-50mg
34metoprl/hctz tab 50-25mg
34metoprol tar tab 100mg
34metoprol tar tab 25mg
34metoprol tar tab 50mg
34metoprolol tab 100mg er
35metoprolol tab 200mg er
35metoprolol tab 25mg er
35metoprolol tab 50mg er
9metronidazol cap 375mg
123metronidazol cre 0.75%
123metronidazol gel 0.75%vag
123metronidazol lot 0.75%
9metronidazol tab 250mg
9metronidazol tab 500mg
39mexiletine cap 150mg
39mexiletine cap 200mg
39mexiletine cap 250mg
103microgestin tab 1.5/30
104microgestin tab 1/20
104microgestin tab fe 1/20
Drug Name Page # Drug Name Page #
104microgestin tab fe1.5/30
69midazolam syp 2mg/ml
22midodrine tab 10mg
22midodrine tab 2.5mg
22midodrine tab 5mg
22MIGRANAL SPR 4MG/ML
107mimvey tab 1-0.5mg
107mimvey lo tab 0.5-0.1
6minocycline cap 100mg
6minocycline cap 50mg
6minocycline cap 75mg
6minocycline tab 100mg
132minocycline tab 135mg er
132minocycline tab 45mg er
6minocycline tab 50mg
6minocycline tab 75mg
132minocycline tab 90mg er
41minoxidil tab 10mg
41minoxidil tab 2.5mg
65MIRAPEX ER TAB 2.25MG
73mirtazapine tab 15mg
73mirtazapine tab 15mg odt
73mirtazapine tab 30mg
73mirtazapine tab 30mg odt
73mirtazapine tab 45mg
73mirtazapine tab 45mg odt
73mirtazapine tab 7.5mg
132MIRVASO GEL 0.33%
92misoprostol tab 100mcg
92misoprostol tab 200mcg
57modafinil tab 100mg
57modafinil tab 200mg
13moderiba tab 200mg
44moexipr/hctz tab 15-12.5
44moexipr/hctz tab 15-25mg
44moexipr/hctz tab 7.5-12.5
44moexipril tab 15mg
44moexipril tab 7.5mg
129mometasone cre 0.1%
129mometasone oin 0.1%
129mometasone sol 0.1%
26MONOCLATE-P INJ 250UNIT
27MONOCLATE-P INJ 500UNIT
104mono-linyah tab 0.25-35
104mononessa tab
27MONONINE INJ 500UNIT
118montelukast chw 4mg
118montelukast chw 5mg
118montelukast gra 4mg
118montelukast tab 10mg
14MONUROL PAK GRANULES
51morphine sul cap 100mg er
51morphine sul cap 120mg er
51morphine sul cap 20mg er
51morphine sul cap 30mg er
51morphine sul cap 30mg er
51morphine sul cap 45mg er
51morphine sul cap 50mg er
51morphine sul cap 60mg er
51morphine sul cap 60mg er
52morphine sul cap 75mg er
52morphine sul cap 80mg er
52morphine sul cap 90mg er
52morphine sul inj 0.5mg/ml
52morphine sul inj 10mg/ml
52morphine sul inj 150/30ml
52morphine sul inj 15mg/ml
52morphine sul inj 1mg/ml
52morphine sul inj 25mg/ml
52morphine sul inj 2mg/ml
52morphine sul inj 4mg/ml
52morphine sul inj 50mg/ml
52morphine sul inj 8mg/ml
52morphine sul sol 10/0.5ml
52morphine sul sol 100/5ml
52morphine sul sol 10mg/5ml
52morphine sul sol 20mg/5ml
52morphine sul sol 20mg/ml
52morphine sul sup 20mg
52morphine sul sup 5mg
52morphine sul tab 100mg cr
52morphine sul tab 100mg er
52morphine sul tab 15mg
52morphine sul tab 15mg cr
52morphine sul tab 15mg er
52morphine sul tab 200mg er
52morphine sul tab 30mg
52morphine sul tab 30mg cr
52morphine sul tab 30mg er
52morphine sul tab 60mg cr
52morphine sul tab 60mg er
86MOXEZA SOL 0.5%
6moxifloxacin tab 400mg
40MULTAQ TAB 400MG
Drug Name Page # Drug Name Page #
123
123
123
104
117
117
117
117
117
89
89
16
134
134
104
48
48
35
35
35
70
70
8948
mupirocin ca cre 2%
mupirocin cre 2%
mupirocin oin 2%
my way tab 1.5mg
mycophenolat cap 250mg
mycophenolat sus 200mg/ml
mycophenolat tab 500mg
mycophenolic tab 180mg dr
mycophenolic tab 360mg dr
mydral sol 0.5% op
mydral sol 1% op
MYLERAN TAB 2MG
MYRBETRIQ TAB 25MG
MYRBETRIQ TAB 50MG
myzilra tab
nabumetone tab 500mg
nabumetone tab 750mg
nadolol tab 20mg
nadolol tab 40mg
nadolol tab 80mg
naloxone inj 1mg/ml
naltrexone tab 50mg
naphazoline sol 0.1% op
naproxen sus 125/5ml
48naproxen tab 250mg
48naproxen tab 375mg
48naproxen tab 500mg
48naproxen dr tab 375mg
48naproxen dr tab 500mg
48naproxen ec tab 375mg
48naproxen ec tab 500mg
48naproxen sod tab 220mg
48naproxen sod tab 275mg
48naproxen sod tab 550mg
64naratriptan tab 1mg
64naratriptan tab 2.5mg
88NASONEX SPR 50MCG/AC
99nateglinide tab 120mg
99nateglinide tab 60mg
97NATESTO GEL 5.5MG
111nature-throi tab 130mg
111nature-throi tab 16.25mg
111nature-throi tab 195mg
111nature-throi tab 32.5mg
111nature-throi tab 65mg
9NEBUPENT INH 300MG
104necon tab 0.5/35
104necon tab 1/35
104necon tab 1/50-28
104necon tab 10/11-28
104necon tab 7/7/7
73nefazodone tab 100mg
73nefazodone tab 150mg
73nefazodone tab 200mg
73nefazodone tab 250mg
73nefazodone tab 50mg
88neo/poly/dex sus 0.1% op
88neo/poly/hc sol 1% otic
88neo/poly/hc sus 1% otic
89neofrin sol 10% op
89neofrin sol 2.5% op
2neomycin tab 500mg
123neuac gel 1.2-5%
30NEULASTA INJ 6MG/0.6M
30NEULASTA KIT 6MG/0.6M
30NEUPOGEN INJ 300/0.5
30NEUPOGEN INJ 300MCG
30NEUPOGEN INJ 480/0.8
30NEUPOGEN INJ 480MCG
65NEUPRO DIS 1MG/24HR
65NEUPRO DIS 2MG/24HR
65NEUPRO DIS 3MG/24HR
65NEUPRO DIS 4MG/24HR
65NEUPRO DIS 6MG/24HR
65NEUPRO DIS 8MG/24HR
88NEVANAC SUS 0.1%
10nevirapine sus 50mg/5ml
10nevirapine tab 200mg
10nevirapine tab 400mg er
16NEXAVAR TAB 200MG
104next choice tab 1.5mg
31niacin tab 500mg er
31niacin er tab 1000mg
31niacin er tab 500mg
31niacin er tab 750mg
39nicardipine cap 20mg
39nicardipine cap 30mg
20nicotine kit
20nicotine patch 14 mg/24hr
20nicotine patch 14 mg/24hr
20nicotine patch 21 mg/24hr
Drug Name Page # Drug Name Page #
20nicotine patch 21 mg/24hr
20nicotine patch 7 mg/24hr
20nicotine patch 7 mg/24hr
20nicotine polacrilex gum 2 mg
20nicotine polacrilex gum 2 mg
20nicotine polacrilex lozg 2 mg
20nicotine polacrilex lozg 2 mg
20nicotine polacrilex lozg 4 mg
20nicotine polacrilex lozg 4 mg
20NICOTROL INH
20NICOTROL NS SPR 10MG/ML
39nifediac cc tab 30mg er
39nifediac cc tab 60mg er
39nifedical xl tab 30mg
39nifedical xl tab 60mg
39nifedipine cap 10mg
39nifedipine cap 20mg
39nifedipine tab 30mg er
39nifedipine tab 60mg er
39nifedipine tab 90mg er
104nikki tab 3-0.02mg
16NILANDRON TAB 150MG
39nimodipine cap 30mg
39nisoldipine tab 17mg er
39nisoldipine tab 20mg
39nisoldipine tab 25.5mg
39nisoldipine tab 30mg
39nisoldipine tab 34mg er
39nisoldipine tab 40mg
39nisoldipine tab 8.5mg er
45NITRO-BID OIN 2%
45NITRO-DUR DIS 0.3MG/HR
14nitrofur mac cap 100mg
14nitrofur mac cap 50mg
14nitrofurantn cap 100mg
14nitrofurantn sus 25mg/5ml
14nitrofuranto cap 100mg
45nitroglycer aer 400mcg
45nitroglycer cap 2.5mg er
45nitroglycer cap 2.5mg sr
45nitroglycer cap 6.5mg er
45nitroglycer cap 6.5mg sr
45nitroglycer cap 9mg er
45NITRONAL SOL 1MG/ML
46NITROSTAT SUB 0.3MG
46NITROSTAT SUB 0.4MG
46NITROSTAT SUB 0.6MG
46nitro-time cap 2.5mg cr
46nitro-time cap 6.5mg cr
46nitro-time cap 9mg cr
91nizatidine cap 150mg
91nizatidine cap 300mg
91nizatidine sol 15mg/ml
119nohist-dm liq
104nora-be tab 0.35mg
104noreth/ethin chw fe
107noreth/ethin tab 0.5-2.5
104noreth/ethin tab 1/20
107noreth/ethin tab 1mg-5mcg
104noreth/ethin tab fe 1/20
109norethin ace tab 5mg
104norethindron tab 0.35mg
104norgest/ethi tab 0.25/35
104norgest/ethi tab estradio
104norlyroc tab 0.35mg
6NOROXIN TAB 400MG
40NORPACE CAP 100MG CR
104nortrel tab 0.5/35
104nortrel tab 1/35
104nortrel tab 7/7/7
73nortriptylin cap 10mg
73nortriptylin cap 25mg
73nortriptylin cap 50mg
73nortriptylin cap 75mg
73
10
10
10
99
99
99
99
99
99
99
99
27
27
27
27
nortriptylin sol 10mg/5ml
NORVIR CAP 100MG
NORVIR SOL 80MG/ML
NORVIR TAB 100MG
NOVOLIN INJ 70/30
NOVOLIN N INJ U-100
NOVOLIN R INJ U-100
NOVOLOG INJ 100/ML
NOVOLOG INJ FLEXPEN
NOVOLOG INJ PENFILL
NOVOLOG MIX INJ 70/30
NOVOLOG MIX INJ FLEXPEN
NOVOSEVEN 1,200 MCG VIAL
NOVOSEVEN 4,800 MCG VIAL
NOVOSEVEN INJ 2400MCG
NOVOSEVEN RT INJ 1MG
27NOVOSEVEN RT INJ 2MG
27NOVOSEVEN RT INJ 5MG
27NOVOSEVEN RT INJ 8MG
Drug Name Page # Drug Name Page #
7NOXAFIL SUS 40MG/ML
111np thyroid tab 30mg
111np thyroid tab 60mg
111np thyroid tab 90mg
53NUCYNTA ER TAB 100MG
53NUCYNTA ER TAB 200MG
53NUCYNTA TAB 100MG
53NUCYNTA TAB 75MG
70NUEDEXTA CAP 20-10MG
19nulev tab 0.125mg
109NUTROPIN INJ 10MG
109NUTROPIN AQ INJ 10MG/2ML
109NUTROPIN AQ INJ 20MG/2ML
109NUTROPIN AQ INJ NUSPIN 5
104NUVARING MIS
57NUVIGIL TAB 150MG
57NUVIGIL TAB 200MG
57NUVIGIL TAB 250MG
124nyamyc pow 100000
129nystat/triam cre
129nystat/triam oin
124nystatin cre 100000
124nystatin oin 100000
7nystatin pow
124nystatin pow 100000
7nystatin pow 10bu
7nystatin pow 150mu
7nystatin pow 1bu
7nystatin pow 2bu
7nystatin pow 500mu
7nystatin pow 50mu
7nystatin pow 5bu
7nystatin sus 100000
8nystatin tab 500000
124nystop pow 100000
104ocella tab 3-0.03mg
120OCTAGAM INJ 10GM
120OCTAGAM INJ 1GM
120OCTAGAM INJ 2.5GM
120OCTAGAM INJ 25GM
120OCTAGAM INJ 5GM
118OFEV CAP 100MG
118OFEV CAP 150MG
86ofloxacin dro 0.3% op
86ofloxacin dro 0.3%otic
6ofloxacin tab 200mg
6ofloxacin tab 300mg
6ofloxacin tab 400mg
104ogestrel tab
73olanza/fluox cap 12-25mg
73olanza/fluox cap 12-50mg
73olanza/fluox cap 6-25mg
73olanza/fluox cap 6-50mg
77olanzapine tab 10mg
77olanzapine tab 10mg odt
77olanzapine tab 15mg
77olanzapine tab 15mg odt
77olanzapine tab 2.5mg
78olanzapine tab 20mg
78olanzapine tab 20mg odt
78olanzapine tab 5mg
78olanzapine tab 5mg odt
78olanzapine tab 7.5mg
84Olopatadine SOL 0.1% OP
31omega-3-acid cap 1gm
92omeprazole cap 10mg
92omeprazole cap 20mg
92omeprazole cap 40mg
90ondansetron inj 4mg/2ml
90ondansetron sol 4mg/5ml
90ondansetron tab 24mg
90ondansetron tab 4mg
90ondansetron tab 4mg odt
90ondansetron tab 8mg
90ondansetron tab 8mg odt
62ONFI TAB 10MG
63ONFI TAB 20MG
63ONFI TAB 5MG
98ONGLYZA TAB 2.5MG
98ONGLYZA TAB 5MG
104opcicon tab 1.5mg
119OPSUMIT TAB 10MG
129oralone pst 0.1%
78ORAP TAB 1MG
78ORAP TAB 2MG
116ORENCIA INJ 125MG/ML
118ORFADIN CAP 10MG
118ORFADIN CAP 2MG
118ORFADIN CAP 5MG
48orph/asa/caf tab
22orphenadrine inj 30mg/ml
22orphenadrine tab 100mg cr
22orphenadrine tab 100mg er
104orsythia tab
Drug Name Page # Drug Name Page #
107
107
19
19
92
116
116
97
97
49
ortho-est tab 0.625 ortho-est tab 1.25 oscimin sub 0.125mg oscimin tab 0.125mg OSMOPREP TAB 1.5GM OTEZLA TAB 10/20/30 OTEZLA TAB 30MG
oxandrolone tab 10mg oxandrolone tab 2.5mg oxaprozin tab 600mg
69oxazepam cap 10mg
69oxazepam cap 15mg
69oxazepam cap 30mg
59oxcarbazepin sus 300mg/5m
59oxcarbazepin tab 150mg
59oxcarbazepin tab 300mg
59oxcarbazepin tab 600mg
124
124
131
133
133
133
133
133
53
53
53
53
53
53
53
53
53
53
53
53
53
53
53
53
53
53
53
OXISTAT CRE 1%
OXISTAT LOT 1%
OXSORALEN LOT 1%
oxybutynin syp 5mg/5ml
oxybutynin tab 10mg er
oxybutynin tab 15mg er
oxybutynin tab 5mg
oxybutynin tab 5mg er
oxycod/apap tab 10-325mg
oxycod/apap tab 2.5-325
oxycod/apap tab 5-325mg
oxycod/apap tab 7.5-325
oxycod/apap tab 7.5-500
oxycod/ibu tab 5-400mg
oxycodone cap 5mg
oxycodone sol 5mg/5ml
oxycodone tab 10mg
oxycodone tab 10mg er
oxycodone tab 15mg
oxycodone tab 20mg
oxycodone tab 20mg er
oxycodone tab 30mg
oxycodone tab 40mg er
oxycodone tab 5mg
oxycodone tab 80mg er
oxymorphone tab 10mg er
oxymorphone tab 15mg er
53oxymorphone tab 20mg er
53oxymorphone tab 30mg er
53oxymorphone tab 40mg er
53oxymorphone tab 5mg er
54oxymorphone tab 7.5mg er
54oxymorphone tab hcl 10mg
54oxymorphone tab hcl 5mg
40pacerone tab 200mg
40pacerone tab 400mg
78paliperidone tab er 1.5mg
78paliperidone tab er 3mg
78paliperidone tab er 6mg
78paliperidone tab er 9mg
93PANCREAZE CAP 10500UNT
93PANCREAZE CAP 16800UNT
93PANCREAZE CAP 21000UNT
93PANCREAZE CAP 4200UNIT
93pancrelipase cap 5000unit
92pantoprazole tab 20mg
92pantoprazole tab 40mg
89parcaine sol 0.5% op
136paricalcitol cap 1 mcg
136paricalcitol cap 2 mcg
136paricalcitol cap 4 mcg
87paroex sol 0.12%
8paromomycin cap 250mg
73paroxetine tab 10mg
73paroxetine tab 20mg
73paroxetine tab 30mg
73paroxetine tab 40mg
84PATADAY SOL 0.2%
4PCE TAB 333MG EC
4PCE TAB 500MG EC
124pedi-dri pow 100000
92peg 3350 sol electrol
92peg-3350 sol electrol
92peg-3350/kcl sol /sodium
63PEGANONE TAB 250MG
12PEGASYS 180 MCG/0.5 ML CONV.PK
12PEG-INTRON KIT 120 RP
12PEGINTRON KIT 120MCG
12PEG-INTRON KIT 120MCG
12PEG-INTRON KIT 150 RP
12PEGINTRON KIT 150MCG
12PEG-INTRON KIT 150MCG
12PEGINTRON KIT 50MCG
12PEG-INTRON KIT 50MCG
Drug Name Page # Drug Name Page #
12PEG-INTRON KIT 50MCG RP
12PEGINTRON KIT 80MCG
12PEG-INTRON KIT 80MCG
12PEG-INTRON KIT 80MCG RP
92pegylax pow
5penicilln vk sol 125/5ml
5penicilln vk sol 250/5ml
5penicilln vk tab 250mg
5penicilln vk tab 500mg
54penta/apap tab 25-650mg
91PENTASA CAP 250MG CR
91PENTASA CAP 500MG CR
54pentaz/nalox tab 50-0.5mg
31pentoxifylli tab 400mg cr
31pentoxifylli tab 400mg er
23PERFOROMIST NEB 20MCG
44perindopril tab 2mg
44perindopril tab 4mg
44perindopril tab 8mg
87periogard sol 0.12%
126permethrin cre 5%
78perphenazine tab 16mg
78perphenazine tab 2mg
78perphenazine tab 4mg
78perphenazine tab 8mg
126persa-gel gel 10%
126persa-gel xs gel 5%
93PERTZYE CAP
1phenadoz sup 25mg
130phenazo tab 200mg
130phenazo tab 95mg
130phenazopyrid tab 100mg
130phenazopyrid tab 200mg
130phenazopyrid tab 95mg
130phenazoyrid tab 95mg
74phenelzine tab 15mg
1phenergan sup 25mg
1phenergan sup 50mg
67phenobarb elx 20mg/5ml
67phenobarb sol 20mg/5ml
67phenobarb tab 100mg
67phenobarb tab 15mg
67phenobarb tab 16.2mg
68phenobarb tab 30mg
68phenobarb tab 32.4mg
68phenobarb tab 60mg
68phenobarb tab 64.8mg
68phenobarb tab 97.2mg
55phentermine tab 37.5mg
89phenylephrin sol 10% op
89phenylephrin sol 2.5% op
63PHENYTEK CAP 200MG
63PHENYTEK CAP 300MG
63phenytoin chw 50mg
63phenytoin ex cap 100mg
63phenytoin ex cap 200mg
63phenytoin ex cap 300mg
63phenytoin inj 50mg/ml
63phenytoin sus 125/5ml
104philith tab 0.4-35
83PHOSLYRA SOL
83phospha 250 tab neutral
85PHOSPHOLINE SOL 0.125%OP
133PICATO GEL 0.015%
133PICATO GEL 0.05%
85pilocarpine sol 1% op
85pilocarpine sol 2% op
85pilocarpine sol 4% op
21pilocarpine tab 5mg
21pilocarpine tab 7.5mg
104pimtrea tab
35pindolol tab 10mg
35pindolol tab 5mg
100pioglita/met tab 15-500mg
100pioglita/met tab 15-850mg
100pioglitazone tab 15mg
101pioglitazone tab 30mg
101pioglitazone tab 45mg
105pirmella tab 1/35
105pirmella tab 7/7/7
49piroxicam cap 10mg
49piroxicam cap 20mg
133podofilox sol 0.5%
92polyeth glyc pow 3350 nf
86polymyxin b/ sol trimethp
25polysaccharide iron complex cap 150 mg
25polysaccharide iron complex cap 200 mg
86polytrim sol op
16POMALYST CAP 1MG
16POMALYST CAP 2MG
16POMALYST CAP 3MG
17POMALYST CAP 4MG
105portia-28 tab
83pot bicarbon tab 25meq ef
Drug Name Page # Drug Name Page #
83pot chloride cap 10meq er
83pot chloride cap 8meq er
83pot chloride inj 10meq
83pot chloride inj 20meq
83pot chloride inj 2meq/ml
83pot chloride inj 40meq
83pot chloride sol 10%
83pot chloride sol 10% sf
83pot chloride sol 20%
83pot chloride sol 20% sf
83pot chloride tab 10meq cr
83pot chloride tab 10meq er
83pot chloride tab 20meq er
83pot chloride tab 25meq ef
83pot chloride tab 8meq cr
84pot chloride tab 8meq er
84pot chloride tab 8meq sa
84pot chloride tab 8meq sr
80pot citrate tab 1080mg
80pot citrate tab 1620mg
80pot citrate tab 540mg er
84pot cl micro tab 10meq cr
84pot cl micro tab 10meq er
84pot cl micro tab 20meq cr
84pot cl micro tab 20meq er
84pot/chloride tab 25meq ef
84potassium tab 25meq ef
60POTIGA TAB 200MG
60POTIGA TAB 300MG
60POTIGA TAB 400MG
60POTIGA TAB 50MG
126pr benzoyl liq 7% wash
28PRADAXA CAP 150MG
29PRADAXA CAP 75MG
65pramipexole tab 0.125mg
66pramipexole tab 0.25mg
66pramipexole tab 0.375mg
66pramipexole tab 0.5mg
66pramipexole tab 0.75mg
66pramipexole tab 1.5mg
66pramipexole tab 1mg
131prascion emu
33pravastatin tab 10mg
33pravastatin tab 20mg
33pravastatin tab 40mg
33pravastatin tab 80mg
31prazosin hcl cap 1mg
31prazosin hcl cap 2mg
31prazosin hcl cap 5mg
88PRED MILD SUS 0.12% OP
88pred sod pho sol 1% op
96pred sod pho sol 5mg/5ml
129prednicarbat cre 0.1%
96prednisolone sol 15mg/5ml
96prednisolone sol 15mg/5ml
96prednisolone sol 25mg/5ml
88prednisolone sus 1% op
96prednisolone syp 15mg/5ml
96PREDNISONE CON 5MG/ML
96prednisone pak 10mg
96prednisone pak 5mg
96prednisone sol 5mg/5ml
96prednisone tab 10mg
96prednisone tab 1mg
96prednisone tab 2.5mg
96prednisone tab 20mg
96prednisone tab 50mg
96prednisone tab 5mg
107PREFEST TAB
108pregnyl inj 10000unt
107PREMARIN TAB 0.3MG
108PREMARIN TAB 0.45MG
108PREMARIN TAB 0.625MG
108PREMARIN TAB 0.9MG
108PREMARIN TAB 1.25MG
108PREMARIN VAG CRE 0.625MG
108PREMPHASE TAB
108PREMPRO TAB .625-2.5
108PREMPRO TAB 0.3-1.5
108PREMPRO TAB 0.45-1.5
108PREMPRO TAB 0.625-5
134prenatal multivit-min w/fe-fa tab
134prenatal vit w/ ferrous fumarate-folic acid cap
135prenatal vit w/ ferrous fumarate-folic acid tab
135prenatal vit w/ ferrous gluconate-folic acid tab
92PREPOPIK PAK
31prevalite pow 4gm
31prevalite pow 4gm pk
105previfem tab
10PREZISTA TAB 150MG
10PREZISTA TAB 400MG
Drug Name Page # Drug Name Page #
10
11
11
9
62
62
74
120
121
121
23
23
84
84
78
78
78
30
30
30
30
30
30
129
129
129
129
129
27
109
109
109
101
115
30
30
30
30
1
1
119
1
1
PREZISTA TAB 600MG
PREZISTA TAB 75MG
PREZISTA TAB 800MG
primaquine tab 26.3mg
primidone tab 250mg
primidone tab 50mg
desvenlafaxin 100mg erPRIVIGEN INJ 10GRAMS
PRIVIGEN INJ 20GRAMS
PRIVIGEN INJ 5 GRAMS
PROAIR HFA AER
PROAIR RESPI AER
proben/colch tab 500-0.5
probenecid tab 500mg
prochlorper sup 25mg
prochlorper tab 10mg
prochlorper tab 5mg
PROCRIT INJ 10000/ML
PROCRIT INJ 2000/ML
PROCRIT INJ 20000/ML
PROCRIT INJ 3000/ML
PROCRIT INJ 4000/ML
PROCRIT INJ 40000/ML
proctocare cre -hc 2.5%
procto-pak cre 1%
proctosol hc cre 2.5%
proctozone cre -hc 2.5%
proctozone cre -hc 2.5%
PROFILNINE SD 500 UNITS VIAL
progesterone cap 100mg
progesterone cap 200mg
progesterone inj 50mg/ml
PROGLYCEM SUS 50MG/ML
PROLIA SOL 60MG/ML
PROMACTA TAB 12.5MG
PROMACTA TAB 25MG
PROMACTA TAB 50MG
PROMACTA TAB 75MG
prometh vc syp 6.25-5/5
prometh vc syp plain
prometh/cod syp 6.25-10
prometh/pe syp 6.25-5/5
promethazine sol 6.25/5ml
1promethazine sup 25mg
1promethazine sup 50mg
1promethazine syp 6.25/5ml
119promethazine syp dm
1promethazine tab 12.5mg
1promethazine tab 25mg
1promethazine tab 50mg
1promethegan sup 25mg
1promethegan sup 50mg
40propafenone cap 225mg er
40propafenone cap 325mg er
40propafenone cap 425mg sr
40propafenone tab 150mg
40propafenone tab 225mg
40propafenone tab 300mg
89proparacaine sol 0.5% op
35propranolol cap 120mg er
35propranolol cap 160mg er
35propranolol cap 60mg er
35propranolol cap 80mg er
35propranolol sol 20mg/5ml
35propranolol sol 40mg/5ml
35propranolol tab 10mg
35propranolol tab 20mg
35propranolol tab 40mg
35propranolol tab 60mg
35propranolol tab 80mg
110propylthiour tab 50mg
74protriptylin tab 10mg
74protriptylin tab 5mg
23PROVENTIL AER HFA
130PROZENA PAD 4%
96PULMICORT INH 180MCG
96PULMICORT INH 90MCG
119pulmosal neb 7%
119PULMOZYME SOL 1MG/ML
8pyrazinamide tab 500mg
21pyridostigm tab 60mg
21pyridostigmi tab 180mg
130qc azo tab 95mg
44qnapril/hctz tab 10-12.5
44qnapril/hctz tab 20-12.5
44qnapril/hctz tab 20-25mg
105quasense tab
78quetiapine tab 100mg
78quetiapine tab 200mg
78quetiapine tab 25mg
Drug Name Page # Drug Name Page #
78quetiapine tab 300mg
78quetiapine tab 400mg
78quetiapine tab 50mg
44quinapril tab 10mg
44quinapril tab 20mg
44quinapril tab 40mg
44quinapril tab 5mg
40quinidine gl tab 324mg cr
40quinidine gl tab 324mg er
40quinidine su tab 300mg
40quinidine su tab 300mg er
96QVAR AER 40MCG
96QVAR AER 80MCG
126ra renewal gel 10%
130ra urinary tab 95mg
130ra urinary tab pain max
92rabeprazole tab 20mg
106raloxifene hcl tab 60 mg
44ramipril cap 1.25mg
44ramipril cap 10mg
44ramipril cap 2.5mg
44ramipril cap 5mg
40RANEXA TAB 1000MG
40RANEXA TAB 500MG
91ranitidine syp 150/10ml
91ranitidine syp 15mg/ml
91ranitidine syp 75mg/5ml
92ranitidine tab 150mg
92ranitidine tab 300mg
22RAPAFLO CAP 8MG
117RAPAMUNE SOL 1MG/ML
114REBIF INJ 22/0.5
114REBIF INJ 44/0.5
114REBIF REBIDO INJ 22/0.5
114REBIF REBIDO INJ 44/0.5
114REBIF REBIDO INJ TITRATN
114REBIF TITRTN INJ PACK
105reclipsen tab
27RECOMBINATE INJ 220-400
27RECOMBINATE INJ 401-800
27RECOMBINATE INJ 801-1240
129rectacort-hc sup 25mg
133RECTIV OIN 0.4%
133REGRANEX GEL 0.01%
131relador pak kit 2.5-2.5%
131relador pak kit plus
13RELENZA AER DISKHALE
13RELENZA MIS DISKHALE
64RELPAX TAB 20MG
64RELPAX TAB 40MG
116REMICADE INJ 100MG
82RENAGEL TAB 400MG
82RENAGEL TAB 800MG
82RENVELA PAK 0.8GM
82RENVELA PAK 2.4GM
99repaglinide tab 0.5mg
99repaglinide tab 1mg
99repaglinide tab 2mg
66requip tab 1mg
11RESCRIPTOR TAB 100 MG
11RESCRIPTOR TAB 200MG
41reserpine tab 0.1mg
41reserpine tab 0.25mg
17REVLIMID CAP 10MG
17REVLIMID CAP 15MG
17REVLIMID CAP 2.5MG
17REVLIMID CAP 20MG
17REVLIMID CAP 25MG
17REVLIMID CAP 5MG
11REYATAZ CAP 100MG
11REYATAZ CAP 150MG
11REYATAZ CAP 200MG
11REYATAZ CAP 300MG
27RIASTAP SOL 1GM
13ribapak pak 1200/day
13ribapak pak 800/day
13ribasphere cap 200mg
13ribasphere tab 200mg
13ribasphere tab 400mg
13ribasphere tab 600mg
13ribatab pak 1000/day
13ribatab tab 1200/day
14ribatab tab 800/day
14ribavirin cap 200mg
14ribavirin tab 200mg
94RIDAURA CAP 3MG
8rifabutin cap 150mg
8RIFAMATE CAP
8rifampin cap 150mg
8rifampin cap 300mg
8rifampin inj 600 mg
70riluzole tab 50mg
9rimantadine tab 100mg
115risedronate tab 150mg
Drug Name Page # Drug Name Page #
78risperidone sol 1mg/ml
78risperidone tab 0.25 odt
78risperidone tab 0.25mg
78risperidone tab 0.5mg
78risperidone tab 0.5mg od
78risperidone tab 1 mg
78risperidone tab 1mg
79risperidone tab 1mg odt
79risperidone tab 2mg
79risperidone tab 2mg odt
79risperidone tab 3mg
79risperidone tab 3mg odt
79risperidone tab 4mg
79risperidone tab 4mg odt
17RITUXAN INJ 500MG
21rivastigmine cap 1.5mg
21rivastigmine cap 3mg
21rivastigmine cap 4.5mg
21rivastigmine cap 6mg
27RIXUBIS INJ 1000UNIT
27RIXUBIS INJ 2000UNIT
27RIXUBIS INJ 250 UNIT
27RIXUBIS INJ 3000UNIT
27RIXUBIS INJ 500UNIT
64rizatriptan tab 10mg
64rizatriptan tab 10mg odt
64rizatriptan tab 5mg
64rizatriptan tab 5mg odt
86romycin oin op
66ropinirole tab 0.25mg
66ropinirole tab 0.5mg
66ropinirole tab 12mg er
66ropinirole tab 1mg
66ropinirole tab 2mg
66ropinirole tab 2mg er
66ropinirole tab 3mg
66ropinirole tab 4mg
66ropinirole tab 4mg er
66ropinirole tab 5mg
66ropinirole tab 6mg er
66ropinirole tab 8mg er
123rosadan cre 0.75%
132rosanil emu cleanser
54roxicet tab 5-325mg
67ROZEREM TAB 8MG
60SABRIL POW 500MG
60SABRIL TAB 500MG
49salsalate tab 500mg
49salsalate tab 750mg
82SAMSCA TAB 15MG
82SAMSCA TAB 30MG
117SANDIMMUNE SOL 100MG/ML
133SANTYL OIN 250/GM
79SAPHRIS SUB 10MG
79SAPHRIS SUB 2.5MG
79SAPHRIS SUB 5MG
70SAVELLA MIS TITR PAK
70SAVELLA TAB 100MG
70SAVELLA TAB 25MG
70SAVELLA TAB 50MG
131sb urinary tab pain max
129scalacort lot 2%
126se bpo wash liq 7%
66selegiline cap 5mg
126selenium sul lot 2.5%
126selenium sul sha 2.25%
126selenium sul sha 2.5%
11SELZENTRY TAB 150MG
11SELZENTRY TAB 300MG
118SENSIPAR TAB 30MG
118SENSIPAR TAB 60MG
118SENSIPAR TAB 90MG
23SEREVENT DIS AER 50MCG
106serophene tab 50mg
79SEROQUEL XR TAB 150MG
79SEROQUEL XR TAB 200MG
79SEROQUEL XR TAB 300MG
79SEROQUEL XR TAB 400MG
79SEROQUEL XR TAB 50MG
74sertraline con 20mg/ml
74sertraline tab 100mg
74sertraline tab 25mg
74sertraline tab 50mg
105setlakin tab
82sevelamer tab 800mg
105sharobel tab 0.35mg
80SHUR-SEAL GEL 2%
109SIGNIFOR INJ 0.3MG/ML
109SIGNIFOR INJ 0.6MG/ML
109SIGNIFOR INJ 0.9MG/ML
46sildenafil tab 20mg
126silver sulfa cre 1%
85SIMBRINZA SUS 1-0.2%
116SIMPONI ARIA SOL 50MG/4ML
Drug Name Page # Drug Name Page #
116SIMPONI INJ 100MG/ML
116SIMPONI INJ 50/0.5ML
33simvastatin tab 10mg
33simvastatin tab 20mg
33simvastatin tab 40mg
33simvastatin tab 5mg
33simvastatin tab 80mg
117sirolimus tab 0.5mg
117sirolimus tab 1mg
117sirolimus tab 2mg
8SIRTURO TAB 100MG
126SKLICE LOT 0.5%
131sm urinary tab pain max
6smz/tmp ds tab 800-160
6smz-tmp ds tab 800-160
6smz-tmp sus 200-40/5
6smz-tmp tab 400-80mg
82sod poly sul sus 15gm/60
82sod poly sul sus 30/120ml
82sod poly sul sus 50/200ml
132sod sul/sulf emu 10-5%
86sod sulfacet sol 10% op
119sodium chlor neb 7%
115sodium fluoride chew 0.25 mg
115sodium fluoride chew 0.5 mg
115sodium fluoride chew 1 mg
115sodium fluoride chew 1.1 mg
115sodium fluoride chew 2.2 mg
115sodium fluoride lozg 1 mg
115sodium fluoride soln 0.125 mg/drop
115sodium fluoride soln 0.25 mg/drop
115sodium fluoride soln 0.5 mg/ml
115sodium fluoride tab 0.5 mg
115sodium fluoride tab 1 mg
105solia tab
109SOMATULINE INJ 90/0.3ML
109SOMAVERT INJ 10MG
109SOMAVERT INJ 15MG
109SOMAVERT INJ 20MG
110SOMAVERT INJ 25MG
110SOMAVERT INJ 30MG
35sorine tab 120mg
35sorine tab 160mg
35sorine tab 240mg
35sorine tab 80mg
35sotalol hcl tab 120mg
35sotalol hcl tab 160mg
35sotalol hcl tab 240mg
35sotalol hcl tab 80mg
12SOVALDI TAB 400MG
19SPIRIVA CAP HANDIHLR
19SPIRIVA SPR RESPIMAT
44spirono/hctz tab 25/25
45spironolact tab 100mg
45spironolact tab 25mg
45spironolact tab 50mg
7SPORANOX SOL 10MG/ML
105sprintec 28 tab 28 day
17SPRYCEL TAB 100MG
17SPRYCEL TAB 140MG
17SPRYCEL TAB 20MG
17SPRYCEL TAB 50MG
17SPRYCEL TAB 70MG
17SPRYCEL TAB 80MG
82sps sus 15gm/60
105sronyx tab
126ssd cre 1%
11stavudine cap 15mg
11stavudine cap 20mg
11stavudine cap 30mg
11stavudine cap 40mg
11stavudine sol 1mg/ml
60STAVZOR CAP 125MG
60STAVZOR CAP 250MG
60STAVZOR CAP 500MG
133STELARA INJ 45MG/0.5
17STIVARGA TAB 40MG
70STRATTERA CAP 100MG
70STRATTERA CAP 10MG
70STRATTERA CAP 18MG
70STRATTERA CAP 25MG
70STRATTERA CAP 40MG
70STRATTERA CAP 60MG
70STRATTERA CAP 80MG
11STRIBILD TAB
92sucralfate tab 1gm
88sulf/pred na sol op
86sulfacet sod sol 10% op
123sulfacetamid lot 10%
123sulfacetamid sus 10%
6sulfadiazine tab 500mg
6sulfasalazin tab 500mg
6sulfasalazin tab 500mg dr
6sulfatrim pd sus 200-40/5
Drug Name Page # Drug Name Page #
6sulfazine ec tab 500mg
6sulfazine tab 500mg
49sulindac tab 150mg
49sulindac tab 200mg
64sumatriptan inj 4mg/0.5
64sumatriptan inj 4mg/0.5
64sumatriptan inj 6mg/0.5
64sumatriptan spr 5mg/act
64sumatriptan tab 100mg
64sumatriptan tab 25mg
64
3
sumatriptan tab 50mg
SUPRAX SUS 500/5ML
3SUPRAX TAB 400MG
92SUPREP BOWEL SOL PREP
11SUSTIVA CAP 200MG
11SUSTIVA CAP 50MG
11SUSTIVA TAB 600MG
17SUTENT CAP 12.5MG
17SUTENT CAP 25MG
17SUTENT CAP 37.5MG
17SUTENT CAP 50MG
105syeda tab 3-0.03mg
17SYLATRON KIT 200MCG
17SYLATRON KIT 300MCG
17SYLATRON KIT 600MCG
17SYLATRON 296 MCG 4-PACK
17SYLATRON 444 MCG 4-PACK
17SYLATRON 888 MCG 4-PACK
19symax fastab tab 0.125mg
19symax-sl sub 0.125mg
96SYMBICORT AER 160-4.5
96SYMBICORT AER 80-4.5
97SYMLINPEN 60 INJ 1000MCG
13SYNAGIS INJ 50MG
108SYNAREL SOL 2MG/ML
111SYNTHROID TAB 100MCG
111SYNTHROID TAB 112MCG
111SYNTHROID TAB 125MCG
111SYNTHROID TAB 137MCG
111SYNTHROID TAB 150MCG
112SYNTHROID TAB 175MCG
112SYNTHROID TAB 200MCG
112SYNTHROID TAB 25MCG
112SYNTHROID TAB 300MCG
112SYNTHROID TAB 50MCG
112SYNTHROID TAB 75MCG
112SYNTHROID TAB 88MCG
94SYPRINE CAP 250MG
17TABLOID TAB 40MG
117tacrolimus cap 0.5mg
117tacrolimus cap 1mg
117tacrolimus cap 5mg
133tacrolimus oin 0.03%
133tacrolimus oin 0.1%
17TAFINLAR CAP 50MG
17TAFINLAR CAP 75MG
105take action tab 1.5mg
13TAMIFLU CAP 30MG
13TAMIFLU CAP 45MG
13TAMIFLU CAP 75MG
13TAMIFLU SUS 6MG/ML
17tamoxifen citrate tab 10 mg
17tamoxifen citrate tab 20 mg
22tamsulosin cap 0.4mg
17TARCEVA TAB 100MG
17TARCEVA TAB 150MG
17
105
18
18
133
133
133
133
37
TARCEVA TAB 25MG
tarina fe tab 1/20
TASIGNA CAP 150MG
TASIGNA CAP 200MG
TAZORAC CRE 0.05%
TAZORAC CRE 0.1%
TAZORAC GEL 0.05%
TAZORAC GEL 0.1%
taztia xt cap 180mg/24
37taztia xt cap 240mg/24
37taztia xt cap 300mg/24
37taztia xt cap 360mg/24
12TECHNIVIE TAB
45TEKTURNA TAB 150MG
45TEKTURNA TAB 300MG
42telmisartan tab 20mg
42telmisartan tab 40mg
42telmisartan tab 80mg
69temazepam cap 15mg
69temazepam cap 22.5mg
69temazepam cap 30mg
69temazepam cap 7.5mg
18temozolomide cap 100mg
18temozolomide cap 140mg
18temozolomide cap 180mg
Drug Name Page # Drug Name Page #
18temozolomide cap 20mg
18temozolomide cap 250mg
18temozolomide cap 5mg
31terazosin cap 10mg
31terazosin cap 1mg
31terazosin cap 2mg
31terazosin cap 5mg
7
23
23
124
124
124
97
97
97
89
70
70
113
89
6
7
89
89
114
114
114
114
terbinafine tab 250mg
terbutaline tab 2.5mg
terbutaline tab 5mg
terconazole cre 0.4%
terconazole cre 0.8%
terconazole sup 80mg
testosterone gel 1%(25mg)
testosterone gel 1%(50mg)
testosterone gel pump 1%
tetcaine sol 0.5% op
tetrabenazin tab 12.5mg
tetrabenazin tab 25mg
tetracaine inj 1%
tetracaine sol 0.5% op
tetracycline cap 250mg
tetracycline cap 500mg
tetravisc sol 0.5% op
tetravisc sol forte
THALOMID CAP 100MG
THALOMID CAP 150MG
THALOMID CAP 200MG
THALOMID CAP 50MG
134THEO-24 CAP 100MG CR
134THEO-24 CAP 200MG CR
134THEO-24 CAP 300MG CR
134THEO-24 CAP 400MG ER
134theochron tab 100mg cr
134theochron tab 200mg cr
134theochron tab 300mg cr
134theophylline elx 80/15ml
134theophylline tab 100mg cr
134theophylline tab 100mg er
134theophylline tab 200mg cr
134theophylline tab 200mg er
134theophylline tab 200mg sr
134theophylline tab 300mg cr
134theophylline tab 300mg er
134theophylline tab 300mg sr
134theophylline tab 400mg er
134theophylline tab 450mg er
134theophylline tab 600mg er
126thermazene cre 1%
79thioridazine tab 100mg
79thioridazine tab 10mg
79thioridazine tab 25mg
79thioridazine tab 50mg
79thiothixene cap 10mg
79thiothixene cap 1mg
79thiothixene cap 2mg
79thiothixene cap 5mg
112THYROLAR-1 TAB 60MG
112THYROLAR-1/2 TAB 30MG
112THYROLAR-1/4 TAB 15MG
112THYROLAR-2 TAB 120MG
112THYROLAR-3 TAB 180MG
60tiagabine tab 2mg
61tiagabine tab 4mg
29ticlopidine tab 250mg
40TIKOSYN CAP 125MCG
40TIKOSYN CAP 250MCG
40TIKOSYN CAP 500MCG
105tilia fe tab
85timolol gel sol 0.25% op
85timolol gel sol 0.5% op
85timolol mal sol 0.25% op
85timolol mal sol 0.5% op
35timolol mal tab 10mg
35timolol mal tab 20mg
35timolol mal tab 5mg
9tinidazole tab 250mg
9tinidazole tab 500mg
112TIROSINT CAP 100MCG
112TIROSINT CAP 112MCG
112TIROSINT CAP 125MCG
112TIROSINT CAP 137MCG
112TIROSINT CAP 13MCG
112TIROSINT CAP 150MCG
112TIROSINT CAP 25MCG
112TIROSINT CAP 50MCG
112TIROSINT CAP 75MCG
112TIROSINT CAP 88MCG
11TIVICAY TAB 50MG
21tizanidine tab 2mg
21tizanidine tab 4mg
88tobra/dexame sus 0.3-0.1%
88TOBRADEX OIN 0.3-0.1%
Drug Name Page # Drug Name Page #
2tobramycin neb 300/5ml
86tobramycin sol 0.3% op
86TOBREX OIN 0.3% OP
86tobrex sol 0.3% op
100tolazamide tab 250mg
100tolazamide tab 500mg
100tolbutamide tab 500mg
65tolcapone tab 100mg
49tolmetin sod cap 400mg
49tolmetin sod tab 200mg
49tolmetin sod tab 600mg
133tolterodine cap 2mg er
133tolterodine cap 4mg er
133tolterodine tab 1mg
133tolterodine tab 2mg
61topiragen tab 100mg
61topiragen tab 200mg
61topiragen tab 25mg
61topiragen tab 50mg
61topiramate cap 15mg
61topiramate cap 25mg
61topiramate tab 100mg
61topiramate tab 200mg
61topiramate tab 25mg
61topiramate tab 50mg
81torsemide tab 100mg
81torsemide tab 10mg
81torsemide tab 20mg
81torsemide tab 5mg
99TOUJEO SOLO INJ 300IU/ML
133TOVIAZ TAB 4MG
133TOVIAZ TAB 8MG
119TRACLEER TAB 125MG
119TRACLEER TAB 62.5MG
98TRADJENTA TAB 5MG
54tramadl/apap tab 37.5-325
54tramadol hcl tab 100mg er
54tramadol hcl tab 200mg er
54tramadol hcl tab 300mg er
54tramadol hcl tab 50mg
44trandolapril tab 1mg
44trandolapril tab 2mg
44trandolapril tab 4mg
27tranex acid tab 650mg
91TRANSDERM-SC DIS 1.5MG
91TRANSDERM-SC DIS 1MG
74tranylcyprom tab 10mg
85TRAVATAN Z DRO 0.004%
85travoprost dro 0.004%
74trazodone tab 100mg
74trazodone tab 150mg
74trazodone tab 300mg
74trazodone tab 50mg
18tretinoin cap 10mg
131tretinoin cre 0.025%
131tretinoin cre 0.05%
131tretinoin cre 0.1%
131tretinoin gel 0.01%
131tretinoin gel 0.025%
131tretinoin gel 0.05%
18TREXALL TAB 10MG
18TREXALL TAB 15MG
18TREXALL TAB 5MG
18TREXALL TAB 7.5MG
129triamcin/ora pst 0.1%
88triamcinolon aer 55mcg/ac
129triamcinolon aer spray
129triamcinolon cre 0.025%
129triamcinolon cre 0.1%
129triamcinolon cre 0.5%
129triamcinolon lot 0.025%
129triamcinolon lot 0.1%
129triamcinolon oin 0.025%
129triamcinolon oin 0.1%
129triamcinolon oin 0.5%
129triamcinolon pst 0.1%
81triamt/hctz cap 37.5-25
81triamt/hctz cap 50-25mg
81triamt/hctz tab 37.5-25
81triamt/hctz tab 75-50mg
69triazolam tab 0.125mg
69triazolam tab 0.25mg
129triderm cre 0.1%
105tri-estaryll tab
79trifluoperaz tab 10mg
79trifluoperaz tab 1mg
79trifluoperaz tab 2mg
79trifluoperaz tab 5mg
87trifluridine sol 1% op
65trihexyphen elx 0.4mg/ml
65trihexyphen tab 2mg
65trihexyphen tab 5mg
105tri-legest tab fe
105tri-linyah tab
Drug Name Page # Drug Name Page #
93
91
86
14
105
105
105
105
89
89
11
11
19
18
114
119
119
119
14
90
126
112
trilyte sol
trimethobenz cap 300mg trimethoprim sol polymyxn trimethoprim tab 100mg trinessa tab
tri-previfem tab
tri-sprintec tab
trivora-28 tab
tropicamide sol 0.5% op tropicamide sol 1% op
TRUVADA TAB
TRUVADA TAB 200-300 TUDORZA PRES AER 400/ACT TYKERB TAB 250MG TYSABRI
INJ 300/15ML TYVASO SOL
0.6MG/ML TYVASO REFIL SOL
0.6MG/ML TYVASO START SOL
0.6MG/ML TYZEKA TAB
600MG
TYZINE PED DRO 0.05%
ULESFIA LOT 5%
unith direct tab 100mcg
112unith direct tab 112mcg
112unith direct tab 125mcg
112unith direct tab 150mcg
112unith direct tab 175mcg
112unith direct tab 200mcg
112unith direct tab 25mcg
112unith direct tab 300mcg
112unith direct tab 50mcg
113unith direct tab 75mcg
113unith direct tab 88mcg
113unithroid tab 100mcg
113unithroid tab 112mcg
113unithroid tab 125mcg
113unithroid tab 137mcg
113unithroid tab 150mcg
113unithroid tab 175mcg
113unithroid tab 200mcg
113unithroid tab 25mcg
113unithroid tab 300mcg
113unithroid tab 50mcg
113unithroid tab 75mcg
113unithroid tab 88mcg
132urea cre 47%
131urinary pain tab 95mg
131urinary pain tab 97.5mg
93ursodiol cap 300mg
93ursodiol tab 250mg
93ursodiol tab 500mg
131uti relief tab 97.2mg
108
14
14
14
61
61
61
61
61
42
42
42
42
42
42
42
42
42
2
2
2
2
123
80
80
105
74
74
74
74
74
74
74
74
74
74
74
74
74
119
119
VAGIFEM TAB 10MCG
valacyclovir tab 1gm
valacyclovir tab 500mg
valganciclov tab 450mg
valproate inj 100mg/ml
valproate inj 500/5ml
valproic acd cap 250mg valproic
acd sol 250/5ml valproic acd
syp 250/5ml valsart/hctz tab
160-12.5 valsart/hctz tab
160-25mg valsart/hctz tab
320-12.5 valsart/hctz tab
320-25mg valsart/hctz tab
80-12.5 valsartan tab 160mg
valsartan tab 320mg
valsartan tab 40mg
valsartan tab 80mg vancomycin
cap 125mg vancomycin cap
250mg VANCOMYCN 25 SOL
25MG/ML VANCOMYCN 50 SOL
50MG/ML vandazole gel 0.75%
vcf vaginal aer contracp
vcf vaginal gel contrace velivet
pak
venlafaxine cap 150mg er
venlafaxine cap 37.5 er
venlafaxine cap 37.5mg
venlafaxine cap 75mg er
venlafaxine tab 100mg
venlafaxine tab 150mg er
venlafaxine tab 225mg er
venlafaxine tab 25mg
venlafaxine tab 37.5 er
venlafaxine tab 37.5mg
venlafaxine tab 50mg
venlafaxine tab 75mg
venlafaxine tab 75mg er
VENTAVIS SOL 10MCG/ML
VENTAVIS SOL 20MCG/ML
Drug Name Page # Drug Name Page #
23VENTOLIN HFA AER
88VERAMYST SPR 27.5MCG
37verapamil cap 100mg er
37verapamil cap 120mg er
37verapamil cap 120mg sr
37verapamil cap 180mg er
37verapamil cap 180mg sr
37verapamil cap 200mg er
37verapamil cap 240mg er
37verapamil cap 240mg sr
37verapamil cap 300mg er
38verapamil cap 360mg sr
38verapamil tab 120mg
38verapamil tab 120mg er
38verapamil tab 120mg sr
38verapamil tab 180mg er
38verapamil tab 180mg sa
38verapamil tab 180mg sr
38verapamil tab 240mg cr
38verapamil tab 240mg er
38verapamil tab 240mg sa
38verapamil tab 240mg sr
38verapamil tab 40mg
38verapamil tab 80mg
133VEREGEN OIN 15%
96VERIPRED 20 SOL 20MG/5ML
134VESICARE TAB 10MG
134VESICARE TAB 5MG
105vestura tab 3-0.02mg
88VEXOL SUS 1% OP
98VICTOZA INJ 18MG/3ML
12VICTRELIS CAP 200MG
11VIDEX SOL 2GM
11VIDEX SOL 4GM
12VIEKIRA PAK TAB
86VIGAMOX DRO 0.5%
75VIIBRYD TAB 10MG
75VIIBRYD TAB 20MG
75VIIBRYD TAB 40MG
61VIMPAT INJ 200MG/20
61VIMPAT SOL 10MG/ML
61VIMPAT TAB 100MG
62VIMPAT TAB 150MG
62VIMPAT TAB 200MG
62VIMPAT TAB 50MG
105viorele tab
11VIRACEPT TAB 250MG
11VIRACEPT TAB 625MG
11VIRAMUNE SUS 50MG/5ML
11VIRAMUNE XR TAB 100MG
11VIREAD POW 40MG/GM
11VIREAD TAB 150MG
11VIREAD TAB 200MG
12VIREAD TAB 250MG
12VIREAD TAB 300MG
84virt-phos tab 250 neut
80virtrate-k sol
80virtrate-k sol 1100-334
136vitamin d cap 50000unt
121VIVAGLOBIN SOL 160MG/ML
70VIVITROL INJ 380MG
133VOLTAREN GEL 1%
7voriconazole tab 200mg
7voriconazole tab 50mg
18VOTRIENT TAB 200MG
105vyfemla tab 0.4-35
33VYTORIN TAB 10-10MG
33VYTORIN TAB 10-20MG
33VYTORIN TAB 10-40MG
33VYTORIN TAB 10-80MG
55VYVANSE CAP 10MG
55VYVANSE CAP 20MG
55VYVANSE CAP 30MG
55VYVANSE CAP 40MG
55VYVANSE CAP 50MG
55VYVANSE CAP 60MG
55VYVANSE CAP 70MG
29warfarin tab 10mg
29warfarin tab 1mg
29warfarin tab 2.5mg
29warfarin tab 2mg
29warfarin tab 3mg
29warfarin tab 4mg
29warfarin tab 5mg
29warfarin tab 6mg
29warfarin tab 7.5mg
29warfarin sod tab 10mg
31WELCHOL PAK 3.75GM
31WELCHOL TAB 625MG
105wera tab 0.5/35
113westhroid tab 130mg
113westhroid tab 32.5mg
113westhroid tab 65mg
27WILATE INJ
Drug Name Page # Drug Name Page #
27WILATE 1,000-1,000 UNIT KIT
27WILATE 450-450 UNIT KIT
27WILATE 900-900 UNIT KIT
113WP THYROID TAB 130MG
105wymzya fe chw 0.4mg-35
18XALKORI CAP 200MG
18XALKORI CAP 250MG
29XARELTO STAR TAB 15/20MG
29XARELTO TAB 10MG
29XARELTO TAB 15MG
29XARELTO TAB 20MG
116XELJANZ TAB 5MG
93XENICAL CAP 120MG
115XGEVA INJ
2XIFAXAN TAB 200MG
2XIFAXAN TAB 550MG
119XOLAIR SOL 150MG
23XOPENEX HFA AER
18XTANDI CAP 40MG
105xulane dis 150-35
27XYNTHA INJ 1000UNIT
27XYNTHA INJ 2000UNIT
27XYNTHA INJ 250UNIT
27XYNTHA INJ 500UNIT
70XYREM SOL 500MG/ML
118zafirlukast tab 10mg
118zafirlukast tab 20mg
67zaleplon cap 10mg
67zaleplon cap 5mg
105zarah tab 3-0.03mg
124zazole cre 0.4%
124zazole cre 0.8%
124zazole sup 80mg
46zebutal cap
18ZELBORAF TAB 240MG
105zenchent tab
105zenchent fe chw 0.4mg-35
93ZENPEP CAP 10000UNT
93ZENPEP CAP 15000UNT
93ZENPEP CAP 20000UNT
93ZENPEP CAP 25000UNT
93ZENPEP CAP 3000UNIT
93ZENPEP CAP 40000UNT
93ZENPEP CAP 5000UNIT
32ZETIA TAB 10MG
88ZETONNA AER 37MCG
12ZIAGEN SOL 20MG/ML
12zidovudine cap 100mg
12zidovudine syp 50mg/5ml
12zidovudine tab 300mg
84zinc sulfate cap 220mg
86ZIOPTAN DRO 0.0015%
79ziprasidone cap 20mg
79ziprasidone cap 40mg
79ziprasidone cap 60mg
79ziprasidone cap 80mg
87ZIRGAN GEL 0.15%
18ZOLINZA CAP 100MG
64zolmitriptan tab 2.5mg
64zolmitriptan tab 5mg
67zolpidem tab 10mg
67zolpidem tab 5mg
67zolpidem er tab 12.5mg
67zolpidem er tab 6.25mg
109ZOMACTON INJ 10MG
62zonisamide cap 100mg
62zonisamide cap 25mg
62zonisamide cap 50mg
117ZORTRESS TAB 0.25MG
117ZORTRESS TAB 0.5MG
117ZORTRESS TAB 0.75MG
106zovia 1/35e tab
106zovia 1/50e tab
18ZYDELIG TAB 100MG
18ZYDELIG TAB 150MG
118ZYFLO CR TAB 600MG
18ZYTIGA TAB 250MG
2ZYVOX SUS 100MG/5M
2ZYVOX TAB 600MG
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