2019 Drug Formulary - Kaiser Permanente...Tier 1 Preferred generic: Generic drugs are copies of...
Transcript of 2019 Drug Formulary - Kaiser Permanente...Tier 1 Preferred generic: Generic drugs are copies of...
HIOS ISSUER ID: 25768 and 80473
Effective December 2019
2019 Drug Formulary
For members with individual and family plans
or covered through small employer groups (1–50 employees)
Core
Access PPO
Drug Formulary INTRODUCTION
What is a formulary? A formulary is a list of generic, brand, and specialty drugs. It is used by practitioners to identify drugs that offer the best overall value, considering effectiveness, safety, and cost.
How is the drug formulary developed? The formulary is developed by the Kaiser Permanente Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is composed of physicians from various medical specialties, pharmacists, and a consumer member. The P&T Committee reviews and selects the most appropriate drugs in each class for the formulary based on safety, effectiveness, and cost. The P&T Committee meets quarterly to review new and existing drugs to ensure that the formulary remains responsive to the needs of members and providers.
How do I search the formulary? Drugs on the formulary are listed by therapeutic class. An alphabetical index is included at the end of this document to assist in locating specific drugs.
Drugs are listed by generic name if a generic is available. If there is no generic available, drugs are listed by the brand name. Drugs are organized by class and drug formulary tier. Drugs administered in a provider’s office or in a clinic (e.g., drugs given intravenously) may not be listed on the formulary. For coverage of these drugs, refer to your Benefit Booklet.
How do I use the formulary to understand my drug coverage? Drug coverage is based on an individual’s contracted benefit. Coverage for a specific drug is subject to each member’s medical coverage agreement. Please consult your Benefit Booklet or call Member Service if you have questions about your drug coverage.
Kaiser Permanente will only cover FDA-approved drugs used for non-experimental therapies. Most plans exclude experimental and investigational drugs, over-the-counter drugs, drugs used in the treatment of sexual dysfunction disorders, drugs for anticipated illnesses while traveling, or drugs used for cosmetic purposes. Please consult your Benefit Booklet for limitations and exclusions.
Medications not listed in this document are not on the formulary at the time of publication. The most current information is online at www.kp.org/wa/formulary. Non- formulary drugs are not covered unless approved by the health plan as a coverage exception. The prescriber must contact Kaiser Permanente to determine the medical necessity of the non-formulary medication. An alternative formulary medication will be recommended when clinically appropriate. If a coverage exception is not approved, the patient is responsible for the full price of thedrug.
Generic drugs are substituted when available and allowed by your prescriber. When a generic is available, the brand-name drug is generally considered non-formulary and subject to a higher cost share.
The drug formulary is updated periodically and is subject to change. If a drug will be removed from the formulary, members who filled the drug in the prior three months will be notified by letter of the upcoming change. A formulary change notice will also be posted on the member website at least 45 days prior to the effective date.
Drug Formulary Tiers
Tier Description
Tier P Preventative drugs and preferred contraceptives:
The Affordable Care Act (ACA) requires that preventative drugs recommended by the U.S. Preventative Services Task Force (USPSTF) are covered in full.
Tier 1 Preferred generic:
Generic drugs are copies of brand name drugs in safety, effectiveness, and quality. They contain the same exact quantities of the same active ingredients and are more affordable than the brand name drug.
Tier 2 Preferred brand:
Preferred brand drugs do not have a generic alternative, but were determined by the P&T Committee to have high value in their therapeutic class.
Tier 3 Non-preferred:
Non-preferred drugs were determined by the P&T Committee to have higher value alternatives in preferred tiers.
Tier 4 Specialty:
Specialty drugs are high-cost drugs prescribed by a physician for the treatment of complex conditions. Some specialty products are dispensed from a preferred specialty pharmacy vendor.
Tier C Oral chemotherapy:
Washington State law requires that cancer drugs be covered at a comparable level when received at a doctor’s office or picked up from the pharmacy. This tier was created to ensure comparable coverage of preferred anti-cancer drugs regardless where the drug was received.
Tier M Medical benefit:
These drugs are usually given at the provider’s office and are covered under the medical benefit.
What are the methods that Kaiser Permanente uses to ensure appropriate and safe use of formulary drugs?
Prior Authorization (PA) The P&T Committee determines that certain drugs should require prior authorization before they will be covered. These drugs most often have alternatives on the formulary, safety concerns, or a high potential for inappropriate use. To request coverage for prior authorization drugs, you or your prescriber must contact Kaiser Permanente. Drugs requiring prior authorization are indicated with a “PA” superscript next to the drug name.
Step Therapy (ST)
Step therapy requires you to try certain preferred drugs before receiving coverage for the drug you were prescribed. Step therapy is added by the P&T Committee. Step therapy automatically looks at your prescription history when you fill the drug you were prescribed. If you have tried the preferred drugs required by step therapy, the drug you were prescribed will automatically be covered. To request step therapy exceptions, you or your prescriber must contact Kaiser Permanente. Drugs requiring step therapy are indicated with a “ST” superscript next to the drug name.
Quantity Limit (QL)
A quantity limit defines how much of a particular drug you can get during a specific time period or the maximum days supply that you can get at once. The P&T Committee determines if a drug should have a quantity limit. To request exceptions to quantity limits, your prescriber must contact Kaiser Permanente. Drugs with quantity limits are indicated with “QL” superscript next to the drug name.
High Dose Pain Medicine Prescriber Review Members on high doses of certain pain medicines will need their prescriber to confirm safety standards are in place annually to continue coverage of therapy.
Drugs Limited to Select Pharmacies
Some drugs are required to be dispensed from a preferred specialty pharmacy vendor. Members with an out-of-network benefit may use other pharmacies; however, they may pay a higher cost share. Please consult your Benefit Booklet for limitations and exclusions. Drugs limited to select pharmacies are listed on the www.kp.org/wa/formulary webpage.
Covered Diabetic Supplies Some diabetic supplies may be covered at a Tier 1 cost share if they are filled as a prescription. These items are:
• Preferred blood glucose strips:
o One Touch Verio o One Touch Ultra o Prodigy – prior authorization required o Contour Next – prior authorization required o Freestyle – prior authorization required
• Disposable insulin syringes and needles
• Lancing devices and lancets
Preferred blood glucose meters are covered only when filled through mail order pharmacy.
Mail Order Pharmacy Service Mail order is convenient and efficiently utilizes Kaiser Permanente’s resources. This service works best for drugs that must be taken on regular basis, such as birth control pills and drugs for high blood pressure, high cholesterol, or other chronic conditions.
To begin using mail order, ask your prescriber to send your prescription directly to the Mail Order Pharmacy. To transfer an existing prescription from a retail pharmacy, contact the Mail Order Pharmacy.
Address: Kaiser Permanente Mail Order
Pharmacy PO Box 34383
Seattle, WA 98124-1383
Phone: 800-245-RXRX (1-800-245-7979)
Fax: 206-630-7950, or toll-free 1-800-350-1683
Preventative Medications and Preferred Contraceptives In accordance with the Affordable Care Act (ACA) requirements for preventive services, most plans cover preventative care medicines and contraceptives in full. If your plan offers ACA benefits, all prescribed FDA approved contraceptive methods from the Kaiser Permanente formulary list will be covered in full when obtained in-network. For plans with out-of-network (OON) benefits, contraceptives will be subject to the OON cost-share. The list of the preventative medications covered in full is available on the www.kp.org/wa/formulary webpage.
Please consult your Benefit Booklet under “Preventive Services” or call Member Service if you have questions about your coverage for these drugs.
If you request coverage for a non-preferred contraceptive, we will contact your provider to recommend a preferred generic or therapeutically equivalent product. If you and your provider determine that the preferred contraceptive(s) would be medically inappropriate, your provider must request a contraceptive waiver. If waiver is completed, the requested non- preferred contraceptive will be covered in full.
Excluded Prescription Products for Medications that have Over-The-Counter (OTC) Alternatives There are certain prescription products that have the same or similar products available over-the- counter (OTC) without a prescription. In certain cases, Kaiser Permanente will not cover the prescription product. The following prescription drug products are excluded from coverage: esomeprazole magnesium (Nexium), omeprazole/sodium bicarbonate (Zegerid), budesonide nasal spray (Rhinocort Aqua), and fluticasone propionate nasal spray (Flonase).
Medical Benefit Injectable Drugs Some drugs are given in a non-hospital setting such as home infusion, a medical office, a physician's office, or an infusion suite. These drugs are covered under the medical benefit but may require prior authorization or a non-hospital setting. The list of medical benefit injectable drugs is available on the www.kp.org/wa/formulary webpage.
How do I get additional information? Please contact Member Service at 1-888-630-4636 with any questions or concerns regarding the information contained in this document.
The most current drug formulary is available at www.kp.org/wa/formulary.
9
Table of Contents
Analgesics - Drugs for Pain and Inflammation ........................................................................ 11
Analgesics - Drugs for Pain .......................................................................................................... 12
Anesthetics ....................................................................................................................................... 15
Anti-Addiction / Substance Abuse Treatment Agents........................................................... 16
Antibacterials .................................................................................................................................... 16
Anticoagulants ................................................................................................................................. 21
Anticonvulsants - Drugs for Seizures ........................................................................................ 22
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia .............................. 23
Antidepressants ............................................................................................................................... 23
Antiemetics - Drugs for Nausea and Vomiting ........................................................................ 25
Antifungals ........................................................................................................................................ 25
Antigout Agents ............................................................................................................................... 27
Anti-inflammatory Agents ............................................................................................................. 27
Antimigraine Agents ....................................................................................................................... 27
Antimyasthenic Agents .................................................................................................................. 28
Antimycobacterials ......................................................................................................................... 28
Antineoplastics - Drugs for Cancer ............................................................................................ 28
Antiparasitics .................................................................................................................................... 32
Antiparkinson Agents ..................................................................................................................... 32
Antiplatelets ...................................................................................................................................... 33
Antipsychotics - Drugs for Mood Disorders ............................................................................ 33
Antivirals ............................................................................................................................................ 34
Anxiolytics - Drugs for Anxiety .................................................................................................... 36
Bipolar Agents - Drugs for Mood Disorders ............................................................................. 37
Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders......... 37
Cardiovascular Agents - Drugs for Heart and Circulation Conditions ............................. 38
Central Nervous System Agents - Drugs for Attention Deficit Disorder ......................... 44
Central Nervous System Agents - Drugs for Multiple Sclerosis......................................... 45
Central Nervous System Agents - Miscellaneous .................................................................. 45
Dental and Oral Agents - Drugs for Mouth and Throat Conditions ................................... 45
Dermatological Agents - Drugs for Skin Conditions ............................................................. 46
Diabetes - Antidiabetic Agents .................................................................................................... 52
Diabetes - Glucose Monitoring .................................................................................................... 53
Diabetes - Glycemic Agents ......................................................................................................... 54
Diabetes - Insulins ........................................................................................................................... 54
Electrolytes / Minerals / Metals / Vitamins ................................................................................ 55
10
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer ................................................. 57
Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions ............ 58
Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment .......... 60
Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions ................... 60
Genitourinary Agents - Drugs for Prostate Conditions ......................................................... 61
Hormonal Agents - Adrenal .......................................................................................................... 61
Hormonal Agents - Men's Health ................................................................................................. 63
Hormonal Agents - Osteoporosis ............................................................................................... 63
Hormonal Agents - Parathyroid ................................................................................................... 63
Hormonal Agents - Pituitary ......................................................................................................... 63
Hormonal Agents - Prostaglandins ............................................................................................ 64
Hormonal Agents - Sex Hormones and Birth Control ........................................................... 64
Hormonal Agents - Thyroid ........................................................................................................... 68
Immunological Agents - Drugs for Immune System Stimulation or Suppression ........ 69
Immunological Agents - Drugs for Vaccination ...................................................................... 71
Inflammatory Bowel Disease Agents ......................................................................................... 72
Metabolic Bone Disease Agents - Drugs for Osteoporosis ................................................. 73
Metabolic Bone Disease Agents - Other ................................................................................... 73
Miscellaneous Therapeutic Agents ............................................................................................ 73
Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation ........................ 75
Ophthalmic Agents - Drugs for Glaucoma ............................................................................... 76
Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions ......................................... 77
Otic Agents - Drugs for Ear Conditions ..................................................................................... 78
Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold ..................... 79
Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions .............................................................................................................................................................. 80
Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis ................................... 82
Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension ................ 82
Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm ........................................ 83
Sleep Disorder Agents ................................................................................................................... 83
Index of Drugs .................................................................................................................................. 86
Effective Date: 12/01/2019 11
Drug Name Drug Tier
Notes
Analgesics - Drugs for Pain and Inflammation
ARTHROTEC 3
aspirin adult P
aspirin adult low strength oral tablet delayed release
P
aspirin childrens P
aspirin ec low dose P
aspirin ec low strength P
aspirin low dose P
aspirin oral tablet P
aspirin oral tablet delayed release 325 mg
P
bayer aspirin P
bayer aspirin ec low dose P
CALDOLOR M
CAMBIA 3 PA
CELEBREX 3
celecoxib oral 1
choline-mag trisalicylate 1
DAYPRO 3
DICLOFENAC EPOLAMINE
3
diclofenac potassium 1
diclofenac sodium er 1
diclofenac sodium oral 1
diclofenac sodium transdermal gel 1 %
3
diclofenac sodium transdermal solution
3
diclofenac-misoprostol 3
DICLOFONO 3
diflunisal oral 1
DUEXIS 4 PA; QL
EC-NAPROSYN 3
ec-naproxen 3
etodolac 1
etodolac er 3
Drug Name Drug Tier
Notes
FELDENE 3
fenoprofen calcium oral 3
fenortho 3
FLECTOR 3
flurbiprofen oral 1
ibu 1
ibuprofen lysine M
ibuprofen oral suspension 3
ibuprofen oral tablet 400 mg, 600 mg, 800 mg
1
INDOCIN 3
indomethacin er 1
indomethacin oral 1
indomethacin sodium M
ketoprofen er 3
ketoprofen oral 3
ketorolac tromethamine injection
1
ketorolac tromethamine oral
3
KETOROLAC TROMETHAMINE SOLUTION 60 MG/2ML INTRAMUSCULAR
M
ketorolac tromethamine solution 60 mg/2ml intramuscular
M
LODINE 3
meclofenamate sodium oral
1
medique aspirin P
mefenamic acid oral 3
meloxicam oral 1
MOBIC 3
nabumetone oral 1
NALFON ORAL CAPSULE
3
NAPRELAN 3
NAPROSYN ORAL SUSPENSION
3
Effective Date: 12/01/2019 12
Drug Name Drug Tier
Notes
naproxen dr 3
naproxen oral 1
naproxen sodium er 3
naproxen sodium oral tablet 275 mg, 550 mg
1
oxaprozin 3
PENNSAID 3
piroxicam oral 1
qc aspirin low dose oral tablet delayed release
P
QMIIZ ODT 3
RELAFEN DS 3 PA
REXAPHENAC 3
salsalate oral 1
SPRIX 3
st joseph low dose oral tablet delayed release
P
sulindac oral 1
TIVORBEX 3
tolmetin sodium oral capsule
1
tolmetin sodium oral tablet 200 mg
1
tolmetin sodium oral tablet 600 mg
3
VIMOVO 4 PA; QL
VIVLODEX 3
VOLTAREN 3
ZIPSOR 3 PA
ZORVOLEX 3 PA
Analgesics - Drugs for Pain
ABSTRAL 4 PA; QL
acetaminophen-codeine 1 QL
acetaminophen-codeine #2
1 QL
acetaminophen-codeine #3
1 QL
acetaminophen-codeine #4
1 QL
ACTIQ 4 PA; QL
Drug Name Drug Tier
Notes
ALLZITAL 3
APADAZ 3 QL
apap-caff-dihydrocodeine 3 QL
ARYMO ER 3 ST; QL
ascomp-codeine 3 QL
BELBUCA 3 PA; QL
BENZHYDROCODONE-ACETAMINOPHEN
3 QL
BUPAP 3
BUPRENEX M
buprenorphine hcl injection
M
buprenorphine transdermal patch weekly 10 mcg/hr, 15 mcg/hr, 20 mcg/hr, 5 mcg/hr
3 PA; QL
BUPRENORPHINE TRANSDERMAL PATCH WEEKLY 7.5 MCG/HR
3 PA; QL
BUTALBITAL-ACETAMINOPHEN ORAL CAPSULE
3
butalbital-acetaminophen oral tablet
3
butalbital-apap-caff-cod 3 QL
butalbital-apap-caffeine oral capsule
3
butalbital-apap-caffeine oral tablet
1
butalbital-asa-caff-codeine
3 QL
butalbital-aspirin-caffeine 1
butorphanol tartrate injection
M
butorphanol tartrate nasal 3
BUTRANS 3 PA; QL
carisoprodol-aspirin-codeine
3 PA
clonidine hcl (analgesia) M
codeine sulfate 1 QL
CONZIP 3 ST; QL
Effective Date: 12/01/2019 13
Drug Name Drug Tier
Notes
DEMEROL INJECTION SOLUTION 100 MG/2ML, 100 MG/ML, 25 MG/0.5ML, 75 MG/1.5ML, 75 MG/ML
M
DILAUDID INJECTION M
DILAUDID ORAL 3 QL
DOLOPHINE 3 ST; QL
DURAGESIC-100 3 PA; QL
DURAGESIC-12 3 PA; QL
DURAGESIC-25 3 PA; QL
DURAGESIC-50 3 PA; QL
DURAGESIC-75 3 PA; QL
duramorph M
duraxin 3
DVORAH 3 QL
endocet 1 QL
esgic oral capsule 3
ESGIC ORAL TABLET 3
fentanyl citrate buccal lozenge on a handle
4 PA; QL
FENTANYL CITRATE BUCCAL TABLET
4 PA; QL
fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
1 PA; QL
fentanyl transdermal patch 72 hour 37.5 mcg/hr, 62.5 mcg/hr, 87.5 mcg/hr
3 PA; QL
FENTORA 4 PA; QL
FIORICET 3
FIORICET/CODEINE 3 QL
FIORINAL 3
FIORINAL/CODEINE #3 3 QL
hydrocodone-acetaminophen oral solution 10-325 mg/15ml
3 QL
Drug Name Drug Tier
Notes
hydrocodone-acetaminophen oral solution 2.5-108 mg/5ml, 5-217 mg/10ml, 7.5-325 mg/15ml
1 QL
hydrocodone-acetaminophen oral tablet 10-300 mg, 5-300 mg, 7.5-300 mg
3 QL
hydrocodone-acetaminophen oral tablet 10-325 mg, 5-325 mg, 7.5-325 mg
1 QL
hydrocodone-ibuprofen 3 QL
hydromorphone hcl er 3 ST; QL
hydromorphone hcl injection solution 2 mg/ml, 4 mg/ml
M
hydromorphone hcl oral 1 QL
hydromorphone hcl pf M
hydromorphone hcl rectal 1
HYDROMORPHONE HCL SOLUTION 1 MG/ML INJECTION
M
hydromorphone hcl solution 1 mg/ml injection
M
HYSINGLA ER 3 PA; QL
INFUMORPH 200 M
INFUMORPH 500 M
IONSYS 3
KADIAN 3 PA; QL
LAZANDA 4 PA; QL
levorphanol tartrate oral 1 PA; QL
lorcet 1 QL
lorcet hd 1 QL
lorcet plus 1 QL
LORTAB 3 QL
meperidine hcl injection M
meperidine hcl oral tablet 3 QL
methadone hcl injection M ST
methadone hcl intensol 1 ST; QL
methadone hcl oral 1 ST; QL
Effective Date: 12/01/2019 14
Drug Name Drug Tier
Notes
methadose oral concentrate 10 mg/ml
3 ST; QL
methadose oral tablet soluble
1 ST; QL
methadose sugar-free 3 ST; QL
mitigo M
MORPHABOND ER 3 PA; QL
morphine sulfate (concentrate) oral solution 100 mg/5ml, 20 mg/ml
1 QL
morphine sulfate (pf) M
morphine sulfate er beads 3 ST; QL
morphine sulfate er oral capsule extended release 24 hour 10 mg, 100 mg, 20 mg, 30 mg, 50 mg, 60 mg, 80 mg
3 PA; QL
morphine sulfate er oral capsule extended release 24 hour 40 mg
3 QL
morphine sulfate er oral tablet extended release
1 ST; QL
MORPHINE SULFATE INJECTION
M
morphine sulfate intramuscular
M
morphine sulfate intravenous solution 25 mg/ml, 50 mg/ml
M
morphine sulfate oral 1 QL
morphine sulfate rectal 1
MORPHINE SULFATE SOLUTION 1 MG/ML INTRAVENOUS
M
morphine sulfate solution 1 mg/ml intravenous
M
MS CONTIN 3 ST; QL
nalbuphine hcl injection M
NALOCET 3 QL
NORCO 3 QL
NUCYNTA 3 PA; QL
NUCYNTA ER 3 ST; QL
OPANA 3 QL
Drug Name Drug Tier
Notes
OXAYDO 3 QL
OXYCODONE HCL ER 2 ST; QL
oxycodone hcl oral capsule
3 QL
oxycodone hcl oral concentrate 100 mg/5ml
1 QL
oxycodone hcl oral solution
1 QL
oxycodone hcl oral tablet 1 QL
oxycodone-acetaminophen
1 QL
oxycodone-aspirin 1 QL
oxycodone-ibuprofen 3 QL
OXYCONTIN 2 ST; QL
oxymorphone hcl 3 QL
oxymorphone hcl er 3 ST; QL
pentazocine-naloxone hcl 3
PERCOCET 3 QL
PRIALT M
PRIMLEV 3 QL
PROBUPHINE IMPLANT KIT
M
ROXICODONE 3 QL
SUBSYS 4 PA; QL
tencon 3
tramadol hcl er (biphasic) 3 ST; QL
TRAMADOL HCL ER ORAL CAPSULE EXTENDED RELEASE 24 HOUR 100 MG, 200 MG, 300 MG
3 ST; QL
tramadol hcl er oral capsule extended release 24 hour 150 mg
3 ST; QL
tramadol hcl er oral tablet extended release 24 hour
3 ST; QL
tramadol hcl ir 1 QL
tramadol-acetaminophen 1 QL
TREZIX 3 QL
TYLENOL WITH CODEINE #3
3 QL
Effective Date: 12/01/2019 15
Drug Name Drug Tier
Notes
TYLENOL WITH CODEINE #4
3 QL
ULTRACET 3 QL
ULTRAM 3 QL
vicodin es 3 QL
vicodin hp 3 QL
XTAMPZA ER 4 ST; QL
zebutal 3
ZOHYDRO ER 3 PA; QL
Anesthetics
agoneaze 1
anodyne lpt 1
ASTERO 3
dermacinrx empricaine 1
dermacinrx prizopak 1
EHA 3
ethyl chloride 3
FLEXIN 3
GEBAUERS PAIN EASE 3
GEBAUERS SPRAY AND STRETCH
3
GEN7T 3
glydo external gel 2 % 1
LDO PLUS 3
LEVATIO 3
lido bdk 1
lidocaine external ointment
3
lidocaine external patch 1
lidocaine hcl (pf) injection solution 0.5 %, 1 %, 1.5 %, 2 %
3
lidocaine hcl external cream 3 %
3
LIDOCAINE HCL EXTERNAL CREAM 4.12 %
3
lidocaine hcl external lotion
3
Drug Name Drug Tier
Notes
lidocaine hcl external solution
3
lidocaine hcl injection solution
1
LIDOCAINE HCL INJECTION SOLUTION PREFILLED SYRINGE
3
lidocaine hcl urethral/mucosal external gel
1
lidocaine-epinephrine injection solution 1 %-1:100000
3
lidocaine-prilocaine 1
LIDODERM 3
lidopin external cream 3 %
3
lidopril 1
lidopril xr 1
lido-prilo caine pack 1
LIDORX 3
LIDO-SORB 3
LIDOTHOL EXTERNAL PATCH
3
LIDOTRAL 3
LIDOZION 3
livixil pak 1
MEDI-PATCH RX 3
premium lidocaine 3
prilolid 1
prilovix 1
prilovix plus 1
prilovix ultralite 1
priloxx lp 1
relador pak 1
relador pak plus 1
RENOVO 3
SOOTHEE 3
SYNERA 3
vexatrol 1
Effective Date: 12/01/2019 16
Drug Name Drug Tier
Notes
XYLOCAINE 3
XYLOCAINE/EPINEPHRINE INJECTION SOLUTION 1 %-1:100000
3
XYLOCAINE-MPF 3
zeruvia 3
ZTLIDO 3
Anti-Addiction / Substance Abuse Treatment Agents
acamprosate calcium 1
ANTABUSE 3
BUNAVAIL 3
buprenorphine hcl sublingual
1 QL
buprenorphine hcl-naloxone hcl sublingual film
3
buprenorphine hcl-naloxone hcl sublingual tablet sublingual
1
bupropion hcl er (smoking det)
P
CHANTIX P
CHANTIX CONTINUING MONTH PAK
P
CHANTIX STARTING MONTH PAK
P
disulfiram oral 1
EVZIO 3 PA
LUCEMYRA 4 PA; QL
naloxone hcl injection 1
naltrexone hcl oral 1
NARCAN 1
NICORETTE MOUTH/THROAT GUM 2 MG
P
nicotine polacrilex mouth/throat gum
P
nicotine polacrilex mouth/throat lozenge 2 mg
P
nicotine step 1 P
Drug Name Drug Tier
Notes
nicotine step 2 P
nicotine step 3 P
NICOTROL P
NICOTROL NS P
SUBLOCADE SUBCUTANEOUS SOLUTION PREFILLED SYRINGE 100 MG/0.5ML
M
SUBOXONE 3
VIVITROL 4 QL
ZUBSOLV 3
Antibacterials
ACTICLATE 3
AEMCOLO 3 PA
ALTABAX 3
amikacin sulfate injection M
amoxicillin 1
amoxicillin-potassium clavulanate er
3
amoxicillin-potassium clavulanate oral
1
ampicillin 1
ampicillin sodium injection solution reconstituted 1 gm, 125 mg, 250 mg, 500 mg
1
ampicillin sodium injection solution reconstituted 10 gm, 2 gm
M
ampicillin sodium intravenous
M
ampicillin-sulbactam sodium
M
ARIKAYCE 3
AUGMENTIN 3
AUGMENTIN ES-600 3
AVELOX M
avidoxy 1
AVYCAZ M
azithromycin intravenous M
Effective Date: 12/01/2019 17
Drug Name Drug Tier
Notes
azithromycin oral 1
BACTOCILL IN DEXTROSE INTRAVENOUS SOLUTION 1 GM/50ML, 2 GM/50ML
M
BACTRIM 3
BACTRIM DS 3
BAXDELA INTRAVENOUS
M
BAXDELA ORAL 4 PA; QL
BICILLIN C-R M
BICILLIN C-R 900/300 M
BICILLIN L-A 2
cefaclor 3
cefaclor er 3
cefadroxil 1
cefazolin sodium injection solution reconstituted 1 gm
1
cefazolin sodium injection solution reconstituted 10 gm, 100 gm, 300 gm, 500 mg
M
cefazolin sodium intravenous solution reconstituted
M
cefazolin sodium-dextrose M
cefdinir 1
cefditoren pivoxil 3
cefepime hcl injection solution reconstituted 1 gm
3
cefepime hcl injection solution reconstituted 2 gm
M
cefepime hcl intravenous M
cefepime-dextrose M
cefixime 1
cefotaxime sodium M
cefotetan disodium M
Drug Name Drug Tier
Notes
cefotetan disodium-dextrose
M
cefoxitin sodium M
cefoxitin sodium-dextrose M
cefpodoxime proxetil 3
cefprozil 1
ceftazidime and dextrose M
ceftazidime injection solution reconstituted 1 gm
1
ceftazidime injection solution reconstituted 2 gm, 6 gm
M
ceftriaxone sodium in dextrose
M
ceftriaxone sodium injection solution reconstituted 1 gm, 2 gm, 250 mg, 500 mg
1
ceftriaxone sodium injection solution reconstituted 100 gm
M
ceftriaxone sodium intravenous
M
ceftriaxone sodium-dextrose
M
cefuroxime axetil 1
cefuroxime sodium M
CENTANY 3
cephalexin oral capsule 250 mg, 500 mg
1
cephalexin oral capsule 750 mg
3
cephalexin oral suspension reconstituted
1
cephalexin oral tablet 3
chloramphenicol sod succinate
M
CIPRO ORAL SUSPENSION RECONSTITUTED 250 MG/5ML (5%)
2
Effective Date: 12/01/2019 18
Drug Name Drug Tier
Notes
CIPRO ORAL SUSPENSION RECONSTITUTED 500 MG/5ML (10%)
3
CIPRO ORAL TABLET 3
ciprofloxacin hcl oral 1
ciprofloxacin in d5w M
ciprofloxacin oral 1
clarithromycin er 3
clarithromycin oral 1
CLEOCIN 3
CLEOCIN PHOSPHATE INJECTION SOLUTION 300 MG/2ML
3
CLEOCIN PHOSPHATE INTRAVENOUS
M
clindamycin hcl oral 1
clindamycin palmitate hcl 1
clindamycin phosphate in d5w
M
CLINDAMYCIN PHOSPHATE IN NACL
M
clindamycin phosphate injection solution 300 mg/2ml
1
clindamycin phosphate injection solution 600 mg/4ml, 9 gm/60ml, 900 mg/6ml, 9000 mg/60ml
M
clindamycin phosphate vaginal
1
CLINDESSE 3
colistimethate sodium (cba)
1
COLY-MYCIN M 3
coremino 3 PA
DALVANCE M
daptomycin intravenous solution reconstituted 500 mg
M
demeclocycline hcl 3
dicloxacillin sodium 1
Drug Name Drug Tier
Notes
DIFICID 4 PA; QL
DORYX 3
DORYX MPC 3
doxy 100 M
doxycycline hyclate intravenous
M
doxycycline hyclate oral capsule
1
doxycycline hyclate oral tablet 100 mg, 150 mg, 50 mg, 75 mg
1
doxycycline hyclate oral tablet delayed release
3
doxycycline monohydrate oral capsule
1
doxycycline monohydrate oral suspension reconstituted
3
doxycycline monohydrate oral tablet
1
e.e.s. 400 3
E.E.S. GRANULES 3
ertapenem sodium M
ERYPED 200 3
ERYPED 400 3
ERY-TAB 3
erythrocin lactobionate solution reconstituted 500 mg intravenous
M
ERYTHROCIN LACTOBIONATE SOLUTION RECONSTITUTED 500 MG INTRAVENOUS
M
ERYTHROCIN STEARATE
3
erythromycin base 3
erythromycin ethylsuccinate oral
3
FIRST-VANCOMYCIN 3
FIRVANQ 2
FLAGYL 3
Effective Date: 12/01/2019 19
Drug Name Drug Tier
Notes
gentamicin in saline M
gentamicin sulfate external
1
gentamicin sulfate injection solution 10 mg/ml
M
gentamicin sulfate injection solution 40 mg/ml
1
HIPREX 3
imipenem-cilastatin M
INVANZ M PA
KEFLEX 3
LEVAQUIN ORAL TABLET 500 MG, 750 MG
3
levofloxacin in d5w M
levofloxacin intravenous M
levofloxacin oral 1
LINCOCIN 3
lincomycin hcl injection 3
linezolid in sodium chloride
M
linezolid intravenous M
linezolid oral 1 QL
MACROBID 3
MACRODANTIN 3
mafenide acetate external 3
MAXIPIME INJECTION SOLUTION RECONSTITUTED 1 GM
3
MAXIPIME INTRAVENOUS
M
meropenem M
MEROPENEM-SODIUM CHLORIDE INTRAVENOUS SOLUTION RECONSTITUTED 1 GM/50ML, 500-0.9 MG-%
M
methenamine hippurate 1
Drug Name Drug Tier
Notes
methenamine mandelate oral
3
metronidazole in nacl M
metronidazole oral capsule
3
metronidazole oral tablet 1
metronidazole vaginal 1
MINOCIN INTRAVENOUS
M
MINOCIN ORAL CAPSULE 50 MG
3
minocycline hcl er 3 PA
minocycline hcl oral capsule
1
minocycline hcl oral tablet 3
MINOLIRA 3 PA
mondoxyne nl 1
MONUROL 3
morgidox oral 1
moxifloxacin hcl in nacl M
MOXIFLOXACIN HCL INTRAVENOUS
M
moxifloxacin hcl oral 1
mupirocin calcium 1
mupirocin external 1
NAFCILLIN SODIUM IN DEXTROSE
M
nafcillin sodium injection solution reconstituted 1 gm, 2 gm
M
nafcillin sodium intravenous
M
neomycin sulfate oral 1
neomycin-polymyxin b gu 3
nitrofurantoin 1
nitrofurantoin macrocrystal oral
1
nitrofurantoin monohydrate macrocrystals
1
NUVESSA 3
Effective Date: 12/01/2019 20
Drug Name Drug Tier
Notes
NUZYRA ORAL 4 PA; QL
ofloxacin oral 3
okebo 1
ORBACTIV M
oxacillin sodium M
paromomycin sulfate oral 3
PENICILLIN G POT IN DEXTROSE
M
penicillin g potassium M
penicillin g procaine M
penicillin g sodium M
penicillin v potassium 1
pfizerpen injection solution reconstituted 5000000 unit
M
piperacillin sod-tazobactam so
M
polymyxin b sulfate injection
M
PRIMSOL 2
SEYSARA 4 PA; QL
SILVADENE 3
silver nitrate external 3
silver sulfadiazine external
1
SIVEXTRO INTRAVENOUS
M
SIVEXTRO ORAL 4 QL
SOLODYN 3 PA
SPECTRACEF 3
ssd 1
streptomycin sulfate intramuscular
3
sulfadiazine oral 3
sulfamethoxazole-trimethoprim intravenous
M
sulfamethoxazole-trimethoprim oral
1
SULFAMYLON 3
sulfatrim pediatric 1
Drug Name Drug Tier
Notes
SUPRAX ORAL CAPSULE
3
SUPRAX ORAL SUSPENSION RECONSTITUTED 100 MG/5ML, 200 MG/5ML
3
SUPRAX ORAL SUSPENSION RECONSTITUTED 500 MG/5ML
2
SUPRAX ORAL TABLET CHEWABLE
3
SYNERCID M
TARGADOX 3
tazicef injection solution reconstituted 1 gm
1
tazicef injection solution reconstituted 2 gm, 6 gm
M
TAZICEF SOLUTION RECONSTITUTED 1 GM INTRAVENOUS
M
tazicef solution reconstituted 1 gm intravenous
M
TAZICEF SOLUTION RECONSTITUTED 2 GM INTRAVENOUS
M
tazicef solution reconstituted 2 gm intravenous
M
TEFLARO M
tetracycline hcl oral 3
tinidazole oral 3
tobramycin sulfate injection
M
trimethoprim oral 1
VABOMERE M
VANCOCIN HCL 4 PA; QL
vancomycin hcl in dextrose intravenous solution 1-5 gm/200ml-%, 500-5 mg/100ml-%
M
Effective Date: 12/01/2019 21
Drug Name Drug Tier
Notes
vancomycin hcl in dextrose solution 750-5 mg/150ml-% intravenous
M
VANCOMYCIN HCL IN DEXTROSE SOLUTION 750-5 MG/150ML-% INTRAVENOUS
M
vancomycin hcl in nacl intravenous solution 1-0.9 gm/200ml-%, 500-0.9 mg/100ml-%
M
VANCOMYCIN HCL IN NACL SOLUTION 750-0.9 MG/150ML-% INTRAVENOUS
M
vancomycin hcl in nacl solution 750-0.9 mg/150ml-% intravenous
M
vancomycin hcl intravenous solution reconstituted 1 gm, 1.25 gm, 10 gm, 100 gm, 1000 mg, 250 mg, 5 gm, 500 mg, 750 mg
M
vancomycin hcl oral capsule
1 QL
vancomycin hcl oral solution reconstituted
1
vandazole 1
VIBATIV M
VIBRAMYCIN 3
XENLETA ORAL 3 PA
XEPI 3
XIFAXAN 4 PA; QL
XIMINO 3 PA
ZERBAXA M
ZITHROMAX ORAL 3
ZITHROMAX TRI-PAK 3
ZITHROMAX Z-PAK 3
ZOSYN INTRAVENOUS SOLUTION
M
ZYVOX INTRAVENOUS SOLUTION 200 MG/100ML
M
Drug Name Drug Tier
Notes
ZYVOX ORAL 4 PA; QL
Anticoagulants
ACTIVASE M
ARIXTRA 4 PA; QL
COUMADIN 3
DEFITELIO M
ELIQUIS 3 PA
ELIQUIS STARTER PACK
3 PA
enoxaparin sodium 1 QL
fondaparinux sodium 4 QL
FRAGMIN SUBCUTANEOUS SOLUTION 10000 UNIT/ML, 12500 UNIT/0.5ML, 15000 UNIT/0.6ML, 18000 UNT/0.72ML, 2500 UNIT/0.2ML, 5000 UNIT/0.2ML, 7500 UNIT/0.3ML
3
FRAGMIN SUBCUTANEOUS SOLUTION 95000 UNIT/3.8ML
3 PA
heparin (porcine) in nacl injection solution 100-0.45 unit/ml-%
M
heparin (porcine) in nacl intravenous solution 25000-0.45 ut/250ml-%
M
heparin sod (porcine) in d5w intravenous solution 100 unit/ml, 40-5 unit/ml-%
M
heparin sodium (porcine) injection solution 1000 unit/ml, 10000 unit/ml, 5000 unit/ml
1
heparin sodium (porcine) injection solution 20000 unit/ml
M
heparin sodium (porcine) pf
1
jantoven 1
Effective Date: 12/01/2019 22
Drug Name Drug Tier
Notes
LOVENOX 1 QL
PRADAXA 2
SAVAYSA 3 PA
THROMBATE III M
TNKASE M
warfarin sodium oral 1
XARELTO 2 PA
XARELTO STARTER PACK
2 PA
Anticonvulsants - Drugs for Seizures
APTIOM 4 PA; QL
BANZEL 4 PA; QL
BRIVIACT INTRAVENOUS
M
BRIVIACT ORAL 4 PA; QL
carbamazepine er 1
carbamazepine oral 1
CARBATROL 3
CELONTIN 2
clobazam 4 QL
DEPAKOTE 3
DEPAKOTE ER 3
DEPAKOTE SPRINKLES 3
DIACOMIT 4 PA; QL
DIASTAT ACUDIAL 3
DIASTAT PEDIATRIC 1
diazepam rectal 1
DILANTIN INFATABS 3
DILANTIN ORAL CAPSULE 100 MG
3
DILANTIN ORAL CAPSULE 30 MG
2
DILANTIN ORAL SUSPENSION
3
divalproex sodium er 1
divalproex sodium oral 1
EPIDIOLEX 4 PA; QL
epitol 1
Drug Name Drug Tier
Notes
EQUETRO 3
ethosuximide oral 1
felbamate 3 QL
FELBATOL 4 PA; QL
fosphenytoin sodium M
FYCOMPA 3 ST; QL
gabapentin oral 1
GABITRIL 3
KEPPRA ORAL 3
KEPPRA XR 3
LAMICTAL 3
LAMICTAL ODT ORAL TABLET DISPERSIBLE
3
LAMICTAL STARTER 3
LAMICTAL XR 3
lamotrigine er 3
lamotrigine oral tablet 1
lamotrigine oral tablet chewable
1
lamotrigine oral tablet dispersible
3
lamotrigine starter kit-blue 3
lamotrigine starter kit-green
3
lamotrigine starter kit-orange
3
levetiracetam er 1
levetiracetam in nacl M
levetiracetam intravenous M
levetiracetam oral 1
MYSOLINE 4 QL
NAYZILAM 4 PA; QL
NEMBUTAL 3
NEURONTIN 3
ONFI 4 PA; QL
oxcarbazepine 1
OXTELLAR XR 3
PEGANONE 3
Effective Date: 12/01/2019 23
Drug Name Drug Tier
Notes
pentobarbital sodium injection
3
phenobarbital oral 1
phenobarbital sodium injection solution 130 mg/ml
1
PHENYTEK 3
phenytoin infatabs 1
phenytoin oral 1
phenytoin sodium extended oral capsule 100 mg
1
phenytoin sodium extended oral capsule 200 mg, 300 mg
3
phenytoin sodium injection
1
primidone oral 1 QL
QUDEXY XR 3 PA
roweepra 1
roweepra xr 1
SABRIL 4 PA; QL
SPRITAM 3
subvenite 1
subvenite starter kit-blue 3
subvenite starter kit-green 3
subvenite starter kit-orange
3
SYMPAZAN 4
TEGRETOL 3
TEGRETOL-XR 3
tiagabine hcl 3
TOPAMAX 3
TOPAMAX SPRINKLE 3
topiramate er 3 PA
topiramate oral 1
TRILEPTAL 3
TROKENDI XR 3 PA
valproic acid oral 1
vigabatrin oral packet 4 PA; QL
Drug Name Drug Tier
Notes
vigabatrin oral tablet 4 QL
vigadrone 4 PA; QL
VIMPAT ORAL 3
ZARONTIN 3
ZONEGRAN 3
zonisamide oral 1
Antidementia Agents - Drugs for Alzheimer's Disease and Dementia
ARICEPT 3
donepezil hcl oral tablet 10 mg, 5 mg
1
donepezil hcl oral tablet 23 mg
3
donepezil hcl oral tablet dispersible
3
EXELON 3
galantamine hydrobromide
1
galantamine hydrobromide er
1
memantine hcl er 3 PA
memantine hcl oral solution
3
memantine hcl oral tablet 10 mg, 5 mg
1
memantine hcl oral tablet 28 x 5 mg & 21 x 10 mg
3
NAMENDA 3
NAMENDA TITRATION PAK
3
NAMENDA XR 3 PA
NAMENDA XR TITRATION PACK
3 PA
NAMZARIC 3
RAZADYNE 3
RAZADYNE ER 3
rivastigmine 3
rivastigmine tartrate 1
Antidepressants
amitriptyline hcl oral 1
Effective Date: 12/01/2019 24
Drug Name Drug Tier
Notes
amoxapine 1
ANAFRANIL 3
APLENZIN 3
BRISDELLE 3
bupropion hcl er (sr) 1
bupropion hcl er (xl) oral tablet extended release 24 hour 150 mg, 300 mg
1
BUPROPION HCL ER (XL) ORAL TABLET EXTENDED RELEASE 24 HOUR 450 MG
3 ST
bupropion hcl oral 1
CELEXA 3
chlordiazepoxide-amitriptyline
3
citalopram hydrobromide 1
clomipramine hcl oral 1
CYMBALTA 3
desipramine hcl oral 1
DESVENLAFAXINE ER 3 PA
desvenlafaxine succinate er
3 PA
doxepin hcl oral 1
DRIZALMA SPRINKLE 3
duloxetine hcl oral 1
EFFEXOR XR 3
EMSAM 4 PA; QL
escitalopram oxalate 1
FETZIMA 3 ST
FETZIMA TITRATION 3 PA
fluoxetine hcl (pmdd) 3
fluoxetine hcl oral capsule 1
fluoxetine hcl oral capsule delayed release
3
fluoxetine hcl oral solution 1
fluoxetine hcl oral tablet 1
fluvoxamine maleate 1
fluvoxamine maleate er 3
Drug Name Drug Tier
Notes
FORFIVO XL 3 ST
imipramine hcl oral 1
imipramine pamoate 3
KHEDEZLA 3 PA
LEXAPRO 3
maprotiline hcl 1
MARPLAN 3
mirtazapine oral 1
NARDIL 3
nefazodone hcl 3
NORPRAMIN 3
nortriptyline hcl oral 1
olanzapine-fluoxetine hcl 3
PAMELOR 3
PARNATE 3
paroxetine hcl 1
paroxetine hcl er 3
paroxetine mesylate 3
PAXIL CR 3
PAXIL ORAL SUSPENSION
2
PAXIL ORAL TABLET 3
perphenazine-amitriptyline
1
PEXEVA 3
phenelzine sulfate oral 1
PRISTIQ 3 PA
protriptyline hcl 1
PROZAC 3
REMERON 3
REMERON SOLTAB 3
SARAFEM 3
sertraline hcl oral 1
SYMBYAX 3
TOFRANIL 3
tranylcypromine sulfate 1
trazodone hcl oral 1
Effective Date: 12/01/2019 25
Drug Name Drug Tier
Notes
trimipramine maleate oral 3
TRINTELLIX 3 ST
venlafaxine hcl 1
venlafaxine hcl er oral capsule extended release 24 hour
1
venlafaxine hcl er oral tablet extended release 24 hour
3
VIIBRYD 3 ST
VIIBRYD STARTER PACK
3 ST
WELLBUTRIN SR 3
WELLBUTRIN XL 3
ZOLOFT 3
Antiemetics - Drugs for Nausea and Vomiting
AKYNZEO INTRAVENOUS
M
AKYNZEO ORAL 3
ALOXI M PA
ANZEMET 3
aprepitant oral capsule 125 mg, 80 & 125 mg, 80 mg
1
aprepitant oral capsule 40 mg
3
BONJESTA 3 PA
CINVANTI M
compro 1
DICLEGIS 3 PA
dimenhydrinate injection 1
doxylamine-pyridoxine 3 PA
dronabinol 1
droperidol injection M
EMEND INTRAVENOUS M
EMEND ORAL 3
EMEND TRI-PACK 3
fosaprepitant dimeglumine
M
Drug Name Drug Tier
Notes
granisetron hcl intravenous
M
granisetron hcl oral 3 PA
MARINOL 3
meclizine hcl oral tablet 3
metoclopramide hcl injection
1
metoclopramide hcl oral solution
1
metoclopramide hcl oral tablet
1
metoclopramide hcl oral tablet dispersible
3
ondansetron hcl injection 1
ondansetron hcl oral 1
ondansetron odt 1
palonosetron hcl intravenous solution 0.25 mg/5ml
M
perphenazine oral 1
prochlorperazine 1
prochlorperazine edisylate injection
1
prochlorperazine maleate oral
1
REGLAN 3
SANCUSO 3 PA
scopolamine 3
SUSTOL M
SYNDROS 3
TIGAN 3
TRANSDERM SCOP (1.5 MG)
3
TRANSDERM-SCOP (1.5 MG)
3
trimethobenzamide hcl oral
3
VARUBI 3 PA
ZOFRAN 3
ZUPLENZ 3
Antifungals
Effective Date: 12/01/2019 26
Drug Name Drug Tier
Notes
ABELCET M
AMBISOME M
ANCOBON 4 PA; QL
AVC VAGINAL 3
BIO-STATIN ORAL CAPSULE
3
bio-statin oral powder 3
caspofungin acetate M
ciclodan 1
ciclopirox external gel 1
ciclopirox external shampoo
3
ciclopirox external solution
1
ciclopirox olamine external
1
clotrimazole external 3
clotrimazole mouth/throat 1
CRESEMBA INTRAVENOUS
M
CRESEMBA ORAL 4 PA; QL
DIFLUCAN 3
econazole nitrate external 3
ECOZA 3
ERAXIS M
ERTACZO 3
EXELDERM 3
exoderm external lotion 3
EXTINA 3
fluconazole in sodium chloride
M
fluconazole oral 1
flucytosine oral 4 QL
griseofulvin microsize oral 1
griseofulvin ultramicrosize 1
GYNAZOLE-1 3
itraconazole oral 1 PA
JUBLIA 3 PA
KERYDIN 3 PA
Drug Name Drug Tier
Notes
ketoconazole external cream
1
ketoconazole external foam
3
ketoconazole external shampoo
1
ketoconazole oral 1
LOPROX EXTERNAL CREAM
3
LOPROX EXTERNAL KIT 0.77 % (SUSP)
3
LOPROX EXTERNAL SHAMPOO
3
LOPROX EXTERNAL SUSPENSION
3
LULICONAZOLE 3
LUZU 3
miconazole 3 vaginal suppository
3
MICONAZOLE-ZINC OXIDE-PETROLAT
3
MYCAMINE M
naftifine hcl 3
NAFTIN 3
NIZORAL 3
NOXAFIL INTRAVENOUS
M
NOXAFIL ORAL SUSPENSION
4 PA; QL
NOXAFIL ORAL TABLET DELAYED RELEASE
4 PA
nyamyc 1
nystatin external 1
nystatin mouth/throat 1
nystatin oral 1
nystatin-triamcinolone 1
nystop 1
ORAVIG 3
oxiconazole nitrate 3
OXISTAT 3
Effective Date: 12/01/2019 27
Drug Name Drug Tier
Notes
PENLAC 3
posaconazole 4 PA
SPORANOX 3 PA
SPORANOX PULSEPAK 3 PA
terbinafine hcl oral 1
terconazole 3
TOLSURA 3 PA
VFEND 4 PA
voriconazole intravenous M
voriconazole oral 1 PA
VUSION 3
XOLEGEL 3
Antigout Agents
allopurinol oral 1
allopurinol sodium M
COLCHICINE ORAL 2
colchicine-probenecid 1
COLCRYS 2
febuxostat oral tablet 40 mg
3 QL
febuxostat oral tablet 80 mg
3
KRYSTEXXA M PA
MITIGARE 3
probenecid 1
ULORIC ORAL TABLET 40 MG
3 PA; QL
ULORIC ORAL TABLET 80 MG
3 PA
ZYLOPRIM 3
Anti-inflammatory Agents
EMFLAZA 4 PA; QL
Antimigraine Agents
AIMOVIG 3 PA
AJOVY 3 PA
almotriptan malate 3 ST
AMERGE 3
CAFERGOT 3
Drug Name Drug Tier
Notes
D.H.E. 45 4 PA; QL
dihydroergotamine mesylate injection
1 QL
dihydroergotamine mesylate nasal
4
eletriptan hydrobromide 3 ST
EMGALITY 3 PA
EMGALITY (300 MG DOSE)
3 PA
ERGOMAR 2
ergotamine-caffeine 1
FROVA 3 ST
frovatriptan succinate 3 ST
IMITREX 3
IMITREX STATDOSE REFILL
3
IMITREX STATDOSE SYSTEM
3
MAXALT 3
MAXALT-MLT 3
MIGERGOT 2
MIGRANAL 4
naratriptan hcl 1
RELPAX 3 ST
rizatriptan benzoate 1
sumatriptan nasal 1
sumatriptan succinate oral
1
sumatriptan succinate refill
1
sumatriptan succinate subcutaneous
1
sumatriptan-naproxen sodium
3 ST
TOSYMRA 3
TREXIMET 3 ST
ZEMBRACE SYMTOUCH 3
zolmitriptan oral 1
ZOMIG 3
ZOMIG ZMT 3
Effective Date: 12/01/2019 28
Drug Name Drug Tier
Notes
Antimyasthenic Agents
BLOXIVERZ M
GUANIDINE HCL 3
MESTINON ORAL SYRUP 60 MG/5ML
3
MESTINON ORAL TABLET
3
MESTINON ORAL TABLET EXTENDED RELEASE
3
neostigmine methylsulfate intravenous solution 10 mg/10ml, 5 mg/10ml
M
pyridostigmine bromide er 1
pyridostigmine bromide oral
1
Antimycobacterials
CAPASTAT SULFATE M
cycloserine oral 3
dapsone oral 1
ethambutol hcl oral 1
isoniazid injection M
isoniazid oral 1
MYAMBUTOL 3
MYCOBUTIN 3
PASER 3
PRIFTIN 2
pyrazinamide oral 1
rifabutin 1
RIFADIN ORAL 3
RIFAMATE 3
rifampin intravenous M
rifampin oral 1
RIFATER 3
SIRTURO 4 PA; QL
TRECATOR 3
Antineoplastics - Drugs for Cancer
abiraterone acetate C QL
ABRAXANE M
Drug Name Drug Tier
Notes
ADCETRIS M PA
adriamycin M
adrucil M
AFINITOR C PA; QL
AFINITOR DISPERZ C PA; QL
ALECENSA C PA; QL
ALIMTA M
ALIQOPA M PA
ALKERAN ORAL C QL
ALUNBRIG C PA; QL
anastrozole oral C
ARIMIDEX C PA
AROMASIN C PA
ARRANON M
arsenic trioxide intravenous
M
ARZERRA M PA
AVASTIN M
azacitidine M
BALVERSA C PA; QL
BAVENCIO M PA
BELEODAQ M PA
BELRAPZO M PA
BENDAMUSTINE HCL M PA
BENDEKA M PA
BESPONSA M PA
bexarotene C PA; QL
bicalutamide C
BICNU M
bleomycin sulfate M
BLINCYTO M
BORTEZOMIB M
BOSULIF C PA; QL
BRAFTOVI C PA; QL
busulfan M
CABOMETYX C PA
CALQUENCE C PA; QL
CAMPATH M PA
Effective Date: 12/01/2019 29
Drug Name Drug Tier
Notes
CAMPTOSAR INTRAVENOUS SOLUTION 300 MG/15ML
M
capecitabine C QL
CAPRELSA C PA; QL
carboplatin M
carmustine M
CASODEX C PA
cisplatin intravenous solution
M
cladribine M
clofarabine M
COMETRIQ (100 MG DAILY DOSE)
C PA; QL
COMETRIQ (140 MG DAILY DOSE)
C PA; QL
COMETRIQ (60 MG DAILY DOSE)
C PA; QL
COPIKTRA C PA; QL
COTELLIC C PA; QL
cyclophosphamide injection
M
cyclophosphamide oral C
CYRAMZA M PA
cytarabine M
cytarabine (pf) M
dacarbazine M
dactinomycin M
DARZALEX M PA
daunorubicin hcl M
DAURISMO C PA; QL
decitabine M
docetaxel M
doxorubicin hcl M
doxorubicin hcl liposomal M
DROXIA C
ELITEK M
EMCYT C PA; QL
EMPLICITI M PA
Drug Name Drug Tier
Notes
epirubicin hcl M
ERBITUX M
ERIVEDGE C PA
ERLEADA C PA; QL
erlotinib hcl C PA; QL
ERWINAZE M
ETOPOPHOS M
etoposide intravenous M
etoposide oral C QL
EVOMELA M
exemestane C
FARESTON C PA
FARYDAK C PA; QL
FASLODEX M
FEMARA C PA
floxuridine injection M
fludarabine phosphate M
fluorouracil intravenous M
flutamide C
FOLOTYN M
fulvestrant M
GAZYVA M PA
gemcitabine hcl M
GILOTRIF C PA; QL
GLEEVEC C QL
GLEOSTINE C
GLIADEL WAFER M
HALAVEN M PA
HERCEPTIN M
HYCAMTIN ORAL C PA; QL
HYDREA 3 PA
hydroxyurea oral 1
IBRANCE C PA; QL
ICLUSIG C PA; QL
idarubicin hcl M
IDHIFA C PA; QL
Effective Date: 12/01/2019 30
Drug Name Drug Tier
Notes
IFEX INTRAVENOUS SOLUTION RECONSTITUTED 3 GM
M
ifosfamide M
imatinib mesylate C QL
IMBRUVICA C PA; QL
IMFINZI M PA
IMLYGIC M PA
INLYTA C PA; QL
INREBIC C PA; QL
IRESSA C PA; QL
irinotecan hcl M
ISTODAX (OVERFILL) M
IXEMPRA KIT M
JAKAFI C PA; QL
JEVTANA M PA
KADCYLA M PA
KEYTRUDA M PA
KHAPZORY M PA
KISQALI (200 MG DOSE) C PA
KISQALI (400 MG DOSE) C PA
KISQALI (600 MG DOSE) C PA
KISQALI FEMARA (400 MG DOSE)
C PA
KISQALI FEMARA (600 MG DOSE)
C PA
KISQALI FEMARA(200 MG DOSE)
C PA
KYPROLIS M PA
LARTRUVO M PA
LENVIMA (10 MG DAILY DOSE)
C PA; QL
LENVIMA (12 MG DAILY DOSE)
C PA; QL
LENVIMA (14 MG DAILY DOSE)
C PA; QL
LENVIMA (18 MG DAILY DOSE)
C PA; QL
LENVIMA (20 MG DAILY DOSE)
C PA; QL
Drug Name Drug Tier
Notes
LENVIMA (24 MG DAILY DOSE)
C PA; QL
LENVIMA (4 MG DAILY DOSE)
C PA; QL
LENVIMA (8 MG DAILY DOSE)
C PA; QL
letrozole oral C
leucovorin calcium injection solution reconstituted
M
leucovorin calcium oral C
LEUKERAN C
levoleucovorin calcium M
levoleucovorin calcium pf M
LONSURF C PA; QL
LORBRENA C PA; QL
LUTATHERA M PA
LYNPARZA C PA; QL
LYSODREN C PA
MARQIBO M
MATULANE C QL
MEKINIST C PA; QL
MEKTOVI C PA; QL
melphalan C QL
melphalan hcl M
mercaptopurine oral C
mesna 1
MESNEX ORAL C
mitomycin intravenous M
mitoxantrone hcl M
mutamycin M
MYLERAN C QL
MYLOTARG M PA
NERLYNX C PA; QL
NEXAVAR C PA; QL
NILANDRON C PA
nilutamide C PA
NINLARO C PA; QL
NIPENT M
Effective Date: 12/01/2019 31
Drug Name Drug Tier
Notes
NUBEQA C PA; QL
ODOMZO C PA; QL
ONCASPAR M
ONIVYDE M
OPDIVO M PA
oxaliplatin M
paclitaxel M
PANRETIN C PA; QL
PERJETA M PA
PHOTOFRIN M
PIQRAY (200 MG DAILY DOSE)
3 PA; QL
PIQRAY (250 MG DAILY DOSE)
3 PA; QL
PIQRAY (300 MG DAILY DOSE)
3 PA; QL
POMALYST C PA; QL
PORTRAZZA M PA
POTELIGEO M PA
PROLEUKIN M
PURIXAN C PA
QUADRAMET M
REVLIMID C PA; QL
RITUXAN M PA
RITUXAN HYCELA M PA
ROMIDEPSIN M
ROZLYTREK C PA; QL
RUBRACA C PA; QL
RYDAPT C PA; QL
SIKLOS 4 PA; QL
SOLTAMOX C PA
SPRYCEL C PA; QL
STIVARGA C PA; QL
SUTENT C PA; QL
SYLATRON C PA; QL
SYLVANT M PA
SYNRIBO M PA
TABLOID C
TAFINLAR C PA; QL
Drug Name Drug Tier
Notes
TAGRISSO C PA; QL
TALZENNA C PA; QL
tamoxifen citrate oral P
TARCEVA C PA; QL
TARGRETIN C PA; QL
TASIGNA C PA; QL
TAXOTERE M
TECENTRIQ INTRAVENOUS SOLUTION 1200 MG/20ML
M PA
TEMODAR INTRAVENOUS
M
TEMODAR ORAL C PA; QL
temozolomide C QL
teniposide M
TEPADINA M
THALOMID C PA; QL
thiotepa injection M
TIBSOVO C PA; QL
toposar M
topotecan hcl M
toremifene citrate C
TREANDA M PA
tretinoin oral C QL
TRISENOX M
TURALIO C PA; QL
TYKERB C PA; QL
UNITUXIN M
VALCHLOR 4 PA; QL
valrubicin M
VALSTAR M
VECTIBIX M PA
VENCLEXTA C PA; QL
VENCLEXTA STARTING PACK
C PA; QL
VERZENIO C PA; QL
vinblastine sulfate M
vincristine sulfate M
Effective Date: 12/01/2019 32
Drug Name Drug Tier
Notes
vinorelbine tartrate M
VITRAKVI C PA; QL
VIZIMPRO C PA; QL
VORAXAZE M
VOTRIENT C PA; QL
VYXEOS M PA
XALKORI C PA; QL
XELODA C PA; QL
XOFIGO M PA
XOSPATA C PA; QL
XPOVIO (100 MG ONCE WEEKLY)
C PA; QL
XPOVIO (60 MG ONCE WEEKLY)
C PA; QL
XPOVIO (80 MG ONCE WEEKLY)
C PA; QL
XPOVIO (80 MG TWICE WEEKLY)
C PA; QL
XTANDI C PA; QL
YERVOY M PA
YESCARTA M PA
YONDELIS M PA
YONSA C PA; QL
ZALTRAP M PA
ZANOSAR M
ZEJULA C PA; QL
ZELBORAF C PA; QL
ZOLINZA C PA; QL
ZYDELIG C PA; QL
ZYKADIA C PA; QL
ZYTIGA C PA; QL
Antiparasitics
albendazole oral 1
ALBENZA 3
ALINIA 2
atovaquone oral 4 QL
atovaquone-proguanil hcl 3 PA
BENZNIDAZOLE 3 PA; QL
BILTRICIDE 3
Drug Name Drug Tier
Notes
chloroquine phosphate oral
1
COARTEM 3
crotan 1
DARAPRIM 4 QL
ELIMITE 3
EMVERM 3
EURAX EXTERNAL CREAM
2
EURAX EXTERNAL LOTION
3
hydroxychloroquine sulfate oral
1
IMPAVIDO 4 PA; QL
ivermectin oral 3
KRINTAFEL 2
lindane 3
MALARONE 3 PA
malathion 3
mefloquine hcl 3 PA
MEPRON 4 PA; QL
NATROBA 3
NEBUPENT 3
OVIDE 3
PENTAM 3
pentamidine isethionate 3
permethrin external 1
PLAQUENIL 3
praziquantel oral 1
primaquine phosphate 1
QUALAQUIN 3
quinine sulfate oral 3
SKLICE 3
SOLOSEC 3 PA
spinosad 3
STROMECTOL 3
ULESFIA 2
Antiparkinson Agents
Effective Date: 12/01/2019 33
Drug Name Drug Tier
Notes
amantadine hcl oral 1
APOKYN 4 PA; QL
AZILECT 3 PA
benztropine mesylate 1
bromocriptine mesylate oral
1
carbidopa oral 1
carbidopa-levodopa er 1
carbidopa-levodopa oral tablet
1
carbidopa-levodopa oral tablet dispersible 10-100 mg, 25-100 mg
1
carbidopa-levodopa oral tablet dispersible 25-250 mg
3
carbidopa-levodopa-entacapone
1
COGENTIN 3
COMTAN 3
DUOPA 4 PA; QL
entacapone 1
GOCOVRI 4 PA; QL
INBRIJA 4 PA; QL
LODOSYN 3
MIRAPEX 3
MIRAPEX ER 3
NEUPRO 3
NOURIANZ 4 PA; QL
OSMOLEX ER 3 PA
PARLODEL 3
pramipexole dihydrochloride
1
pramipexole dihydrochloride er
3
rasagiline mesylate oral 1 PA
REQUIP XL 3
ropinirole hcl 1
ropinirole hcl er 3
RYTARY 3 PA
Drug Name Drug Tier
Notes
selegiline hcl oral 1
SINEMET 3
SINEMET CR 3
STALEVO 100 3
STALEVO 125 3
STALEVO 150 3
STALEVO 200 3
STALEVO 50 3
STALEVO 75 3
TASMAR 4 PA; QL
tolcapone 4 PA; QL
trihexyphenidyl hcl oral elixir
1
trihexyphenidyl hcl oral tablet
1
XADAGO 3 PA
ZELAPAR 4 PA; QL
Antiplatelets
AGGRASTAT M
AGGRENOX 3
aspirin-dipyridamole er 1
BRILINTA 2
CABLIVI 4 PA; QL
cilostazol 1
clopidogrel bisulfate oral 1
dipyridamole oral 1
DURLAZA 3
EFFIENT 3
PLAVIX 3
prasugrel hcl 1
ZONTIVITY 3
Antipsychotics - Drugs for Mood Disorders
ABILIFY 3
ABILIFY MAINTENA 4 QL
ABILIFY MYCITE 3
aripiprazole oral solution 1
aripiprazole oral tablet 1
Effective Date: 12/01/2019 34
Drug Name Drug Tier
Notes
aripiprazole oral tablet dispersible
3
ARISTADA 4 QL
ARISTADA INITIO 4 QL
chlorpromazine hcl injection
1
chlorpromazine hcl oral 1
clozapine oral tablet 1
clozapine oral tablet dispersible
3
CLOZARIL 3
FANAPT 3 ST
FANAPT TITRATION PACK
3 ST
FAZACLO 3
fluphenazine decanoate injection
1
fluphenazine hcl 1
GEODON 3
HALDOL 3
HALDOL DECANOATE 3
haloperidol decanoate intramuscular
1
haloperidol lactate 1
haloperidol oral 1
INVEGA 3 ST
INVEGA SUSTENNA 4
INVEGA TRINZA 4
LATUDA 4 PA; QL
loxapine succinate 1
molindone hcl 3
NUPLAZID 4 PA; QL
olanzapine 1
paliperidone er 3 ST
PERSERIS 4
pimozide 1
quetiapine fumarate 1
quetiapine fumarate er 1
REXULTI 3 PA
Drug Name Drug Tier
Notes
RISPERDAL 3
RISPERDAL CONSTA INTRAMUSCULAR SUSPENSION RECONSTITUTED 12.5 MG, 25 MG, 37.5 MG, 50 MG
2
risperidone oral solution 1
risperidone oral tablet 1
risperidone oral tablet dispersible
3
SAPHRIS 3 ST
SEROQUEL 3
SEROQUEL XR 3
thioridazine hcl oral 3
thiothixene 1
trifluoperazine hcl 1
VERSACLOZ 3
VRAYLAR 4 PA; QL
ziprasidone hcl 1
ZYPREXA 3
ZYPREXA RELPREVV 2
ZYPREXA ZYDIS 3
Antivirals
abacavir sulfate 1
abacavir sulfate-lamivudine
1 QL
abacavir-lamivudine-zidovudine
4 QL
acyclovir external 3
acyclovir oral 1
acyclovir sodium M
adefovir dipivoxil 1 QL
APTIVUS ORAL CAPSULE
4 QL
APTIVUS ORAL SOLUTION
4 PA; QL
atazanavir sulfate 1 QL
ATRIPLA 4 QL
Effective Date: 12/01/2019 35
Drug Name Drug Tier
Notes
BARACLUDE ORAL SOLUTION
4 QL
BARACLUDE ORAL TABLET
4 PA; QL
BIKTARVY 4 QL
cidofovir intravenous M
CIMDUO 4 QL
COMBIVIR 3
COMPLERA 4 PA; QL
CRIXIVAN 2
DELSTRIGO 4 PA; QL
DENAVIR 3
DESCOVY 4 QL
didanosine 1
DOVATO 4 PA; QL
EDURANT 2
efavirenz 1
EMTRIVA 2
entecavir 1 QL
EPCLUSA 4 PA; QL
EPIVIR 3
EPIVIR HBV ORAL SOLUTION
2
EPIVIR HBV ORAL TABLET
3
EPZICOM 4 PA; QL
EVOTAZ 4 PA; QL
famciclovir 3
FLUMADINE 3
fosamprenavir calcium 4 QL
FOSCAVIR M
FUZEON 4 PA; QL
GANCICLOVIR M
ganciclovir sodium intravenous solution reconstituted
M
GENVOYA 4 QL
HARVONI 4 PA; QL
HEPSERA 4 PA; QL
Drug Name Drug Tier
Notes
INTELENCE 2
INTRON A C QL
INVIRASE 2
ISENTRESS HD 2
ISENTRESS ORAL PACKET
3
ISENTRESS ORAL TABLET
2
ISENTRESS ORAL TABLET CHEWABLE
2
JULUCA 4 QL
KALETRA ORAL SOLUTION
3
KALETRA ORAL TABLET 2
lamivudine 1
lamivudine-zidovudine 1
LEDIPASVIR-SOFOSBUVIR
4 PA; QL
LEXIVA 4 QL
lopinavir-ritonavir 1
MAVYRET 4 PA; QL
nevirapine er 1
nevirapine oral suspension
3
nevirapine oral tablet 1
NORVIR ORAL PACKET 2
NORVIR ORAL SOLUTION
2
NORVIR ORAL TABLET 3
ODEFSEY 4 QL
oseltamivir phosphate oral
1
PEGASYS 4 QL
PEGASYS PROCLICK 4 QL
PEGINTRON 4 QL
PIFELTRO 4 PA; QL
PREVYMIS INTRAVENOUS
M
PREVYMIS ORAL 4 PA; QL
PREZCOBIX 2 QL
Effective Date: 12/01/2019 36
Drug Name Drug Tier
Notes
PREZISTA 2
RAPIVAB M
RELENZA DISKHALER 2
RESCRIPTOR 2
RETROVIR INTRAVENOUS
M
RETROVIR ORAL 3
REYATAZ ORAL CAPSULE
4 QL
REYATAZ ORAL PACKET
2
ribavirin inhalation 3
ribavirin oral 1 QL
rimantadine hcl 1
ritonavir 1
SELZENTRY 4 QL
SITAVIG 3
SOFOSBUVIR-VELPATASVIR
4 PA; QL
SOVALDI 4 PA; QL
stavudine 1
STRIBILD 4 PA; QL
SUSTIVA 3
SYMFI 1
SYMFI LO 1
SYMTUZA 4 QL
TAMIFLU 2
TEMIXYS 4 QL
tenofovir disoproxil fumarate
1
TIVICAY 2
TRIUMEQ 4 QL
TRIZIVIR 4 PA; QL
TRUVADA 4 QL
TYBOST 2 PA
valacyclovir hcl oral 1
VALCYTE 4 PA; QL
valganciclovir hcl oral solution reconstituted
4 PA; QL
Drug Name Drug Tier
Notes
valganciclovir hcl oral tablet
4 QL
VALTREX 3
VEMLIDY 4 PA; QL
VIDEX 2
VIDEX EC 3
VIEKIRA PAK 4 PA; QL
VIRACEPT 2
VIRAMUNE 3
VIRAMUNE XR 3
VIRAZOLE 3
VIREAD ORAL POWDER 2
VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG
2
VIREAD ORAL TABLET 300 MG
3
VOSEVI 4 PA; QL
XERESE 3
XOFLUZA 3
ZEPATIER 4 PA; QL
ZIAGEN 3
zidovudine 1
ZOVIRAX 3
Anxiolytics - Drugs for Anxiety
alprazolam er 1
ALPRAZOLAM INTENSOL
3
alprazolam oral tablet 1
alprazolam oral tablet dispersible
3
alprazolam xr 1
ATIVAN INJECTION SOLUTION 2 MG/ML
3
ATIVAN ORAL 3
buspirone hcl oral 1
chlordiazepoxide hcl 1
clonazepam oral 1
clorazepate dipotassium 1
Effective Date: 12/01/2019 37
Drug Name Drug Tier
Notes
diazepam injection 1
diazepam intensol 3
diazepam intramuscular 1
diazepam oral concentrate
3
diazepam oral solution 1
diazepam oral tablet 1
DORAL 3
estazolam 3
HALCION 3
hydroxyzine hcl intramuscular
M
hydroxyzine hcl oral 1
hydroxyzine pamoate oral 1
KLONOPIN 3
lorazepam injection solution 2 mg/ml
1
lorazepam intensol 1
lorazepam oral concentrate 2 mg/ml
1
lorazepam oral tablet 1
meprobamate 3
midazolam hcl injection solution 10 mg/2ml, 5 mg/ml
1
midazolam hcl oral 3
oxazepam 1
quazepam 3
TRANXENE-T 3
triazolam 1
VALIUM 3
VISTARIL 3
XANAX 3
XANAX XR 3
Bipolar Agents - Drugs for Mood Disorders
lithium 1
lithium carbonate er 1
lithium carbonate oral 1
Drug Name Drug Tier
Notes
LITHOBID 3
Blood Products / Modifiers / Volume Expanders - Drugs for Bleeding Disorders
ADVATE M PA
ADYNOVATE M PA
AFSTYLA M PA
AGRYLIN 3
ALPHANATE/VWF COMPLEX/HUMAN
M PA
ALPHANINE SD M PA
ALPROLIX M PA
AMICAR 3
aminocaproic acid intravenous
M
aminocaproic acid oral 3
anagrelide hcl 1
ARANESP (ALBUMIN FREE)
3 PA
BENEFIX M PA
CEPROTIN M
COAGADEX M PA
CORIFACT M PA
DOPTELET 4 PA; QL
ELOCTATE M PA
EPOGEN 2 PA
FIBRYGA M
FULPHILA 4 PA; QL
GRANIX SUBCUTANEOUS SOLUTION
4 QL
GRANIX SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
4 PA; QL
HEMLIBRA 4 PA; QL
hemofil m intravenous solution reconstituted 1000 unit, 250 unit, 500 unit
M PA
Effective Date: 12/01/2019 38
Drug Name Drug Tier
Notes
HEMOFIL M INTRAVENOUS SOLUTION RECONSTITUTED 1700 UNIT
M PA
HESPAN M
hetastarch-nacl M
HEXTEND M
HUMATE-P M PA
IDELVION INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 2000 UNIT, 250 UNIT, 500 UNIT
M PA
IXINITY M PA
KCENTRA M
KOATE M PA
KOATE-DVI INTRAVENOUS SOLUTION RECONSTITUTED 1000 UNIT, 500 UNIT
M PA
koate-dvi intravenous solution reconstituted 250 unit
M PA
KOGENATE FS M PA
KOVALTRY M PA
LEUKINE INTRAVENOUS SOLUTION RECONSTITUTED 250 MCG
M
LYSTEDA 3 QL
MIRCERA 3 PA
MONONINE M PA
MOZOBIL M PA
MULPLETA 4 PA; QL
NEULASTA 4 PA; QL
NEULASTA ONPRO 4 PA; QL
NEUPOGEN 4 QL
NIVESTYM 4 PA; QL
NOVOEIGHT M PA
Drug Name Drug Tier
Notes
NOVOSEVEN RT M PA
NPLATE M PA
NUWIQ M PA
OBIZUR M PA
PANHEMATIN M
PROCRIT 2 PA
PROFILNINE M PA
PROFILNINE SD M PA
PROMACTA 4 PA; QL
REBINYN M PA
RECOMBINATE M PA
RETACRIT 3 PA
RIASTAP M
RIXUBIS M PA
SOLIRIS M PA
TAVALISSE 4 PA; QL
tranexamic acid intravenous
M
tranexamic acid oral 1 QL
TRETTEN M PA
UDENYCA 4 PA; QL
ULTOMIRIS M
VONVENDI M PA
WILATE M PA
XYNTHA M PA
XYNTHA SOLOFUSE M PA
ZARXIO 4 QL
Cardiovascular Agents - Drugs for Heart and Circulation Conditions
ACCUPRIL 3
ACCURETIC 3
acebutolol hcl oral 1
acetazolamide oral tablet 125 mg
1
acetazolamide sodium 3
ADALAT CC 3
ALDACTAZIDE ORAL TABLET 25-25 MG
3
Effective Date: 12/01/2019 39
Drug Name Drug Tier
Notes
ALDACTAZIDE ORAL TABLET 50-50 MG
2
ALDACTONE 3
aliskiren fumarate 3 ST
alprostadil injection 1
ALTACE 3
ALTOPREV 3
amiloride hcl oral 1
amiloride-hydrochlorothiazide
1
amiodarone hcl oral tablet 100 mg, 400 mg
3
amiodarone hcl oral tablet 200 mg
1
amlodipine besylate oral 1
amlodipine besylate-benazepril hcl
1
amlodipine besylate-valsartan
3 ST
amlodipine-atorvastatin 3
amlodipine-olmesartan 1
amlodipine-valsartan-hctz 3
ANTARA 3
ATACAND 3
ATACAND HCT 3
atenolol oral 1
atenolol-chlorthalidone 1
atorvastatin calcium oral 1
AVALIDE 3
AVAPRO 3
AZOR 3
benazepril hcl oral 1
benazepril-hydrochlorothiazide
1
BENICAR 3
BENICAR HCT 3
BETAPACE 3
BETAPACE AF 3
betaxolol hcl oral 1
Drug Name Drug Tier
Notes
BIDIL 3
bisoprolol fumarate 1
bisoprolol-hydrochlorothiazide
1
bumetanide injection M
bumetanide oral 1
BUMEX 3
BYSTOLIC 3
CADUET 3
CALAN 3
CALAN SR 3
candesartan cilexetil 3
candesartan cilexetil-hctz 3
captopril oral 1
captopril-hydrochlorothiazide
1
CARDIZEM 3
CARDIZEM CD 3
CARDIZEM LA 3
CARDURA 3
CAROSPIR 3
cartia xt 1
carvedilol 1
carvedilol phosphate er 3
CATAPRES 3
CATAPRES-TTS-1 3
CATAPRES-TTS-2 3
CATAPRES-TTS-3 3
chlorothiazide 1
chlorthalidone 1
cholestyramine light packets
1
cholestyramine oral packets
1
choline fenofibrate 3
clonidine 1
clonidine hcl oral 1
colesevelam hcl 3
Effective Date: 12/01/2019 40
Drug Name Drug Tier
Notes
COLESTID 3
COLESTID FLAVORED 3
colestipol hcl 1
COREG 3
COREG CR 3
CORGARD 3
CORLANOR 3 PA
COZAAR 3
CRESTOR 3
DEMSER 3
DIBENZYLINE 4 PA; QL
digitek 1
digox 1
digoxin injection 1
digoxin oral 1
DILATRATE-SR 3
diltiazem hcl er beads 3
diltiazem hcl er coated beads oral capsule extended release 24 hour
1
diltiazem hcl er coated beads oral tablet extended release 24 hour
3
diltiazem hcl er oral capsule extended release 12 hour
1
diltiazem hcl oral 1
dilt-xr 1
DIOVAN 3
DIOVAN HCT 3
disopyramide phosphate 1
DIURIL 2
dofetilide 3 PA
doxazosin mesylate oral 1
DUTOPROL 3
DYAZIDE 3
DYRENIUM 2
EDARBI 3 ST
Drug Name Drug Tier
Notes
EDARBYCLOR 3 ST
EDECRIN 3 PA
enalapril maleate oral 1
enalapril-hydrochlorothiazide
1
ENTRESTO 2 PA
EPANED 3
epinephrine pf 1
eplerenone 1
eprosartan mesylate 3 ST
ethacrynate sodium M
ethacrynic acid 1 PA
ETHAMOLIN M
EXFORGE 3 ST
EXFORGE HCT 3
EZALLOR SPRINKLE 3
ezetimibe 1 PA
ezetimibe-simvastatin 1 PA
felodipine er 1
fenofibrate micronized 1
fenofibrate oral capsule 134 mg, 200 mg, 67 mg
1
fenofibrate oral capsule 150 mg, 50 mg
3
fenofibrate oral tablet 120 mg, 145 mg, 40 mg, 48 mg
3
fenofibrate oral tablet 160 mg, 54 mg
1
fenofibric acid oral capsule delayed release
3
fenofibric acid oral tablet 1
FENOGLIDE 3
FIBRICOR 3
flecainide acetate 1
FLOLIPID 3
fluvastatin sodium 3
fluvastatin sodium er 3
fosinopril sodium 1
Effective Date: 12/01/2019 41
Drug Name Drug Tier
Notes
fosinopril sodium-hctz 1
furosemide injection 1
furosemide oral 1
gemfibrozil oral 1
GONITRO 3
guanfacine hcl 1
HEMANGEOL C PA
hydralazine hcl oral 1
hydrochlorothiazide oral 1
HYZAAR 3
indapamide 1
INDERAL LA 3
INDERAL XL 3
INNOPRAN XL 3
INSPRA 3
irbesartan 1
irbesartan-hydrochlorothiazide
1
isoproterenol hcl injection 3
ISORDIL TITRADOSE ORAL TABLET 40 MG
2
ISORDIL TITRADOSE ORAL TABLET 5 MG
3
isosorbide dinitrate 1
isosorbide dinitrate er 3
isosorbide mononitrate 1
isosorbide mononitrate er 1
isradipine 1
ISUPREL 3
JUXTAPID 4 PA; QL
KAPSPARGO SPRINKLE 3
KATERZIA 3
labetalol hcl oral 1
LANOXIN 3
LANOXIN PEDIATRIC 3
LASIX 3
LESCOL XL 3
Drug Name Drug Tier
Notes
LIPITOR 3
LIPOFEN 3
lisinopril oral 1
lisinopril-hydrochlorothiazide
1
LIVALO 3
LOPID 3
LOPRESSOR 3
LOPRESSOR HCT 3
losartan potassium 1
losartan potassium-hctz 1
LOTENSIN HCT 3
LOTENSIN ORAL TABLET 20 MG, 40 MG
3
LOTREL 3
lovastatin 1
LOVAZA 3
matzim la 3
MAXZIDE 3
MAXZIDE-25 3
methyldopa 1
methyldopa-hydrochlorothiazide
3
metolazone 1
metoprolol succinate er 1
metoprolol tartrate oral 1
METOPROLOL-HCTZ ER 3
metoprolol-hydrochlorothiazide
1
mexiletine hcl oral 1
MICARDIS 3
MICARDIS HCT 3
midodrine hcl 1
milrinone lactate M
milrinone lactate in dextrose
M
MINIPRESS 3
minitran 1
Effective Date: 12/01/2019 42
Drug Name Drug Tier
Notes
minoxidil oral 1
moexipril hcl 1
MULTAQ 3
nadolol oral 1
niacin (antihyperlipidemic) 3
niacin er (antihyperlipidemic)
3
NIACOR 3
NIASPAN 3
nicardipine hcl oral 1
nifedipine er 1
nifedipine er osmotic release
1
nifedipine oral 1
nimodipine oral 1
nisoldipine er 3
NITRO-BID 2
NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.1 MG/HR, 0.2 MG/HR, 0.4 MG/HR, 0.6 MG/HR
3
NITRO-DUR TRANSDERMAL PATCH 24 HOUR 0.3 MG/HR, 0.8 MG/HR
2
nitroglycerin sublingual 1
nitroglycerin transdermal 1
nitroglycerin translingual 3
NITROLINGUAL 3
NITROMIST 3
NITROSTAT 3
nitro-time oral capsule extended release 9 mg
1
NORPACE 3
NORPACE CR 2
NORTHERA 4 PA; QL
NORVASC 3
NYMALIZE 4 PA; QL
Drug Name Drug Tier
Notes
olmesartan medoxomil oral
1
olmesartan medoxomil-hctz
1
olmesartan-amlodipine-hctz
3
omega-3-acid ethyl esters 3
pacerone oral tablet 100 mg, 400 mg
3
pacerone oral tablet 200 mg
1
papaverine hcl injection 1
pentoxifylline er 1
perindopril erbumine 1
phenoxybenzamine hcl oral
4 QL
phentolamine mesylate injection
1
pindolol 1
PRALUENT SUBCUTANEOUS SOLUTION AUTO-INJECTOR 75 MG/ML
4 PA; QL
PRALUENT SUBCUTANEOUS SOLUTION PEN-INJECTOR 150 MG/ML, 75 MG/ML
4 PA; QL
PRAVACHOL 3
pravastatin sodium 1
prazosin hcl oral 1
PRESTALIA 3
prevalite 1
PRINIVIL 3
procainamide hcl injection 1
PROCARDIA 3
PROCARDIA XL 3
propafenone hcl 1
propafenone hcl er 3
propranolol hcl er 1
propranolol hcl oral 1
Effective Date: 12/01/2019 43
Drug Name Drug Tier
Notes
propranolol-hctz 1
PROSTIN VR 3
QBRELIS 3
QUESTRAN 3
QUESTRAN LIGHT 3
quinapril hcl 1
quinapril-hydrochlorothiazide
1
quinidine gluconate er 1
quinidine sulfate 1
ramipril 1
RANEXA 3 PA
ranolazine er 3 PA
RECTIV 2
REPATHA 3 PA
REPATHA PUSHTRONEX SYSTEM
3 PA
REPATHA SURECLICK 3 PA
rosuvastatin calcium 1
RYTHMOL SR 3
simvastatin oral 1
sorine 1
sotalol hcl (af) 1
sotalol hcl oral 1
SOTYLIZE 3
spironolactone oral 1
spironolactone-hctz 1
SULAR 3
TARKA 3
taztia xt 3
TEKTURNA 3 ST
TEKTURNA HCT 3 ST
telmisartan 3
telmisartan-amlodipine 3
telmisartan-hctz 3
TENORETIC 100 3
TENORETIC 50 3
Drug Name Drug Tier
Notes
TENORMIN 3
TIAZAC 3
TIKOSYN 3 PA
timolol maleate oral 1
TOPROL XL 3
torsemide 1
trandolapril 1
trandolapril-verapamil hcl er
3
triamterene oral 1
triamterene-hctz 1
TRIBENZOR 3
TRICOR 3
TRILIPIX 3
TWYNSTA 3
valsartan 1
valsartan-hydrochlorothiazide
1
VASCEPA ORAL CAPSULE 0.5 GM
3 PA
VASCEPA ORAL CAPSULE 1 GM
3
VASERETIC 3
VASOTEC 3
VECAMYL 4 PA; QL
verapamil hcl er oral capsule extended release 24 hour 100 mg, 200 mg, 300 mg
3
verapamil hcl er oral capsule extended release 24 hour 120 mg, 180 mg, 240 mg, 360 mg
1
verapamil hcl er oral tablet extended release
1
verapamil hcl oral 1
VERELAN 3
VERELAN PM 3
VYNDAMAX 4 PA; QL
VYNDAQEL 4 PA; QL
Effective Date: 12/01/2019 44
Drug Name Drug Tier
Notes
VYTORIN 3 PA
WELCHOL 3
ZESTORETIC 3
ZESTRIL 3
ZETIA 3 PA
ZIAC 3
ZOCOR ORAL TABLET 10 MG, 20 MG, 40 MG, 80 MG
3
ZYPITAMAG 3
Central Nervous System Agents - Drugs for Attention Deficit Disorder
ADDERALL 3
ADDERALL XR 1 QL
ADHANSIA XR 3 ST; QL
ADZENYS ER 3 PA
ADZENYS XR-ODT 3 PA
amphetamine sulfate 3 PA
amphetamine-dextroamphetamine
1
amphetamine-dextroamphetamine er
1 QL
APTENSIO XR 3 ST; QL
atomoxetine hcl 1 ST
clonidine hcl er 3
CONCERTA 1 QL
COTEMPLA XR-ODT 3 PA; QL
DAYTRANA 3 ST; QL
DESOXYN 3
DEXEDRINE 3 QL
dexmethylphenidate hcl 1
dexmethylphenidate hcl er
3 ST; QL
dextroamphetamine sulfate er
1 QL
dextroamphetamine sulfate oral solution
3
dextroamphetamine sulfate oral tablet
1
DYANAVEL XR 3 ST
Drug Name Drug Tier
Notes
EVEKEO 3 PA
EVEKEO ODT 3 PA
FOCALIN 3
FOCALIN XR 3 ST; QL
guanfacine hcl er 1
INTUNIV 3
JORNAY PM 3 ST; QL
KAPVAY 3
metadate er 1 QL
methamphetamine hcl 3
METHYLIN 3
methylphenidate hcl er 1 QL
methylphenidate hcl er (cd)
1 QL
methylphenidate hcl er (la) oral capsule extended release 24 hour 10 mg
3 ST; QL
methylphenidate hcl er (la) oral capsule extended release 24 hour 20 mg, 30 mg, 40 mg, 60 mg
1 ST; QL
methylphenidate hcl oral solution
3
methylphenidate hcl oral tablet
1
methylphenidate hcl oral tablet chewable
3
MYDAYIS 3 PA; QL
PROCENTRA 3
QUILLICHEW ER 3 PA
QUILLIVANT XR 3 ST; QL
relexxii 1 QL
RITALIN 3
RITALIN LA 3 ST; QL
STRATTERA 3 ST
VYVANSE 3 PA; QL
zenzedi oral tablet 10 mg, 5 mg
1
ZENZEDI ORAL TABLET 15 MG, 2.5 MG, 20 MG, 30 MG, 7.5 MG
3
Effective Date: 12/01/2019 45
Drug Name Drug Tier
Notes
Central Nervous System Agents - Drugs for Multiple Sclerosis
AMPYRA 4 PA; QL
AUBAGIO 4 PA; QL
AVONEX PEN 4 PA; QL
AVONEX PREFILLED 4 PA; QL
BETASERON 4 PA; QL
COPAXONE 4 PA; QL
dalfampridine er 4 QL
EXTAVIA 4 QL
GILENYA 4 PA; QL
glatiramer acetate 4 QL
glatopa 4 QL
LEMTRADA M PA
MAVENCLAD (10 TABS) 4 PA; QL
MAVENCLAD (4 TABS) 4 PA; QL
MAVENCLAD (5 TABS) 4 PA; QL
MAVENCLAD (6 TABS) 4 PA; QL
MAVENCLAD (7 TABS) 4 PA; QL
MAVENCLAD (8 TABS) 4 PA; QL
MAVENCLAD (9 TABS) 4 PA; QL
MAYZENT 4 PA; QL
MAYZENT STARTER PACK
4 PA; QL
OCREVUS M PA
PLEGRIDY 4 PA; QL
PLEGRIDY STARTER PACK
4 PA; QL
REBIF 4 QL
REBIF REBIDOSE 4 QL
REBIF REBIDOSE TITRATION PACK
4 QL
REBIF TITRATION PACK 4 QL
TECFIDERA 4 PA; QL
TYSABRI M PA
Central Nervous System Agents - Miscellaneous
ADDYI 3 PA; QL
AUSTEDO 4 PA; QL
caffeine citrate oral 1
Drug Name Drug Tier
Notes
GRALISE 3
GRALISE STARTER 3
HORIZANT 3
INGREZZA 4 PA; QL
LYRICA 3 QL
LYRICA CR 3 PA
NUEDEXTA 3 PA
pregabalin oral 1 QL
RADICAVA M PA
RILUTEK 4 PA; QL
riluzole 1 QL
SAVELLA 3 ST
SAVELLA TITRATION PACK
3 ST
TEGSEDI 4 PA; QL
tetrabenazine 4 PA; QL
TIGLUTIK 4 QL
XENAZINE 4 PA; QL
Dental and Oral Agents - Drugs for Mouth and Throat Conditions
BOCASAL 3
cevimeline hcl 3
chlorhexidine gluconate mouth/throat
1
DEBACTEROL 3
EVOXAC 3
FIRST-MOUTHWASH BLM
3
KEPIVANCE M
lidocaine hcl mouth/throat 3
lidocaine viscous mouth/throat solution 2 %
1
MUCOSITISRX 3
NEUTRASAL 3
oralone 1
paroex 1
periogard 1
pilocarpine hcl oral tablet 5 mg
1
Effective Date: 12/01/2019 46
Drug Name Drug Tier
Notes
pilocarpine hcl oral tablet 7.5 mg
3
SALAGEN 3
SALIVAMAX 3
triamcinolone acetonide mouth/throat
1
XEROSTOMIA RELIEF SPRAY
3
Dermatological Agents - Drugs for Skin Conditions
ABSORICA 3
ACANYA 3
acitretin 1 QL
ACZONE 3
adapalene external cream 1
adapalene external gel 1
ADAPALENE EXTERNAL PAD
3
ADAPALENE EXTERNAL SOLUTION
3
adapalene-benzoyl peroxide
3
ADVANCED ALLERGY COLLECTION
3
AKLIEF 3 PA
ala-cort external cream 1 %
3
ala-cort external cream 2.5 %
1
alclometasone dipropionate
1
ALDARA 3
ALTRENO 3
amcinonide 3
AMELUZ 2 QL
amlactin external cream 12 %
3
ammonium lactate external
3
amnesteem 1
ANACAINE 3
Drug Name Drug Tier
Notes
arzol silver nit applicators 3
ATOPADERM 3
ATOPICLAIR 3
ATRALIN 3
AVAR 3
avar cleanser 1
AVAR LS 3
avar-e emollient 3
avar-e green 3
avita 1
azelaic acid external 1
AZELEX 2
balsam peru-castor oil 3
BENSAL HP 3
BENZACLIN 3
BENZACLIN WITH PUMP 3
BENZAMYCIN 3
benzepro foaming cloths 3
BENZIQ 3
BENZIQ LS 3
BENZOYL PEROX-HYDROCORTISONE
3
BENZOYL PEROXIDE EXTERNAL GEL 6.5 %, 8 %
3
BENZOYL PEROXIDE FORTE- HC
3
benzoyl peroxide-erythromycin
1
beser external lotion 3
betamethasone dipropionate aug
1
betamethasone dipropionate external
1
betamethasone valerate external
1
bp 10-1 3
bp cleansing wash 3
BPCO 3
Effective Date: 12/01/2019 47
Drug Name Drug Tier
Notes
bpo external gel 8 % 3
BRYHALI 3
calcipotriene 1
calcipotriene-betameth diprop
3
calcitrene 1
calcitriol external 1
CAPEX 2
CARAC 2
cem-urea 3
CERACADE 3
ceramax external cream 3
claravis 1
CLEOCIN-T 3
clindacin etz external swab
1
clindacin-p 1
CLINDAGEL 3
clindamycin phos-benzoyl perox external gel 1.2-2.5 %, 1.2-5 %, 2.5-1.2 %
3
clindamycin phosphate-benzoyl peroxide external gel 1-5 %
1
clindamycin phosphate external foam
3
clindamycin phosphate external lotion
1
clindamycin phosphate external solution
1
clindamycin phosphate external swab
1
CLINDAMYCIN PHOSPHATE GEL 1 % EXTERNAL
3
clindamycin phosphate gel 1 % external
1
clindamycin-tretinoin 3
clobetasol prop emollient base
3 ST
clobetasol propionate e 3 ST
Drug Name Drug Tier
Notes
clobetasol propionate emulsion
3
clobetasol propionate external cream
3 ST
clobetasol propionate external foam
3
clobetasol propionate external gel
1
clobetasol propionate external liquid
3
clobetasol propionate external lotion
1
clobetasol propionate external ointment
1
clobetasol propionate external shampoo
3
clobetasol propionate external solution
1
CLOBEX 3
CLOBEX SPRAY 3
clocortolone pivalate 3
clodan external shampoo 3
CLODERM 3
clotrimazole-betamethasone
1
CONDYLOX 2
CORDRAN EXTERNAL CREAM 0.05 %
3
CORDRAN EXTERNAL LOTION
3
CORDRAN EXTERNAL OINTMENT
3
CORDRAN EXTERNAL TAPE
2
CORTISPORIN EXTERNAL CREAM
3
CORTISPORIN EXTERNAL OINTMENT
2
CUTIVATE 3
dapsone external 3
DERMA-SMOOTHE/FS BODY
3
Effective Date: 12/01/2019 48
Drug Name Drug Tier
Notes
DERMA-SMOOTHE/FS SCALP
3
DERMULCERA 3
DESONATE 3
desonide external 1
DESOWEN 3
desoximetasone external cream
1
desoximetasone external gel
1
desoximetasone external liquid
3
desoximetasone external ointment
1
DEXERYL 3
diclofenac sodium transdermal gel 3 %
3
DIFFERIN EXTERNAL CREAM
1
DIFFERIN EXTERNAL GEL 0.3 %
3
DIFFERIN EXTERNAL LOTION
2
diflorasone diacetate 3
DIPROLENE 3
DIPROLENE AF 3
DOVONEX 3
doxepin hcl external 3
doxycycline 3
dritho-creme hp 1
DRYSOL 2
DUAC 3
DUPIXENT 4 PA; QL
EFUDEX C PA
ELETONE 3
ELETONE TWINPACK 3
ELIDEL 1
ELOCON 3
EMULSION SB 3
Drug Name Drug Tier
Notes
ENSTILAR 3
ENTTY SPRAY EMULSION
3
EPICERAM 3
EPIDUO 3
EPIDUO FORTE 3
EPIFOAM 3
ery 3
ERYGEL 3
erythromycin external 1
EUCRISA 3 PA; QL
EVOCLIN 3
FABIOR 3
FASENRA PEN 4 PA; QL
FINACEA EXTERNAL FOAM
2
FINACEA EXTERNAL GEL
3
fluocinolone acetonide body
1
fluocinolone acetonide external
1
fluocinolone acetonide scalp
1
fluocinonide emulsified base
1
fluocinonide external cream 0.05 %
1
fluocinonide external cream 0.1 %
3
fluocinonide external gel 1
fluocinonide external ointment
1
fluocinonide external solution
1
FLUOROPLEX 2
FLUOROURACIL EXTERNAL CREAM 0.5 %
2
fluorouracil external cream 5 %
C
Effective Date: 12/01/2019 49
Drug Name Drug Tier
Notes
fluorouracil external solution
C
flurandrenolide 3
fluticasone propionate external cream
1
fluticasone propionate external lotion
3
fluticasone propionate external ointment
3
grafco silver nit applicator 3
halcinonide 3
halobetasol propionate external cream
1
HALOBETASOL PROPIONATE EXTERNAL FOAM
3
halobetasol propionate external ointment
1
HALOG 3
HPR 3
HPR PLUS 3
hydrocortisone ace-pramoxine external
1
hydrocortisone butyr lipo base
3
hydrocortisone butyrate external cream
1
hydrocortisone butyrate external lotion
3
hydrocortisone butyrate external ointment
1
hydrocortisone butyrate external solution
1
hydrocortisone external cream 1 %
3
hydrocortisone external cream 2.5 %
1
hydrocortisone external lotion 2.5 %
1
hydrocortisone external ointment 1 %, 2.5 %
1
hydrocortisone valerate 1
Drug Name Drug Tier
Notes
HYLATOPIC PLUS EXTERNAL CREAM
3
HYLATOPIC PLUS EXTERNAL FOAM
3
imiquimod external 1
IMIQUIMOD PUMP 3
IMPOYZ 3 ST
isotretinoin oral 1
ivermectin external 3
KAMDOY 3
KENALOG EXTERNAL 3
KIVIK 3
KLARON 3
LAC-HYDRIN 3
lactic acid e 3
lactic acid external 3
LEVULAN KERASTICK 2 QL
LEXETTE 3
LIDOCAINE-HYDROCORTISONE ACE EXTERNAL
3
LIDOTREX 3
LOCOID 3
LOCOID LIPOCREAM 3
LOTRISONE 3
LOUTREX 3
LUXIQ 3
methoxsalen oral 4 QL
methoxsalen rapid 4 QL
METROCREAM 3
METROGEL 3
METROLOTION 3
metronidazole external cream
1
metronidazole external gel 0.75 %
1
metronidazole external gel 1 %
3
Effective Date: 12/01/2019 50
Drug Name Drug Tier
Notes
metronidazole external lotion
3
MICORT-HC 3
MIMYX 3
MIRVASO 3
mometasone furoate external
1
myorisan 1
NEOCERA 3
NEOSALUS CP 3
NEOSALUS EXTERNAL CREAM
3
NEOSALUS EXTERNAL FOAM
3
NEO-SYNALAR EXTERNAL CREAM
3
neuac external gel 3
NIVATOPIC PLUS 3
nolix 3
NORITATE 3
NOVACORT 3
NUCORT 3
OLUX 3
OLUX-E 3
ONEXTON 3
ORACEA 3 PA
OVACE PLUS EXTERNAL CREAM
3
OVACE PLUS EXTERNAL FOAM
3
OXSORALEN ULTRA 4 PA; QL
PANDEL 3
PENLEN 3
PHLAG SPRAY 3
PICATO C QL
pimecrolimus cream 1 % external
1
PIMECROLIMUS CREAM 1 % EXTERNAL
2
Drug Name Drug Tier
Notes
PLEXION CLEANSING CLOTH
3
podocon 3
podofilox external 1
PRAMOSONE EXTERNAL CREAM 1-1 %
2
PRAMOSONE EXTERNAL CREAM 1-2.5 %
3
PRAMOSONE EXTERNAL LOTION
2
pramox 3
prednicarbate 3
PRESERA 3
PROMISEB 3
PROTOPIC 3
PRUCLAIR 3
PRUDOXIN 3
PRUMYX 3
PSORCON 3
pyrogallic acid 3
QBREXZA 3 PA
REGENECARE 3
REGRANEX 4 PA; QL
RETIN-A 1
RETIN-A MICRO GEL 0.04 %, 0.1 %
1
RETIN-A MICRO PUMP EXTERNAL GEL 0.04 %, 0.1 %
1
RETIN-A MICRO PUMP EXTERNAL GEL 0.06 %, 0.08 %
3
RHOFADE 3
rosadan external cream 1
rosadan external gel 1
ROSADAN EXTERNAL KIT
3
salicylic acid external cream
3
Effective Date: 12/01/2019 51
Drug Name Drug Tier
Notes
salicylic acid external foam
3
salicylic acid external gel 3
salicylic acid external liquid
3
salicylic acid external lotion
3
salicylic acid external shampoo
3
salicylic acid external solution 26 %
3
salicylic acid wart remover
3
salimez 3
SALIMEZ FORTE 3
SANTYL 2
selenium sulfide external lotion
1
selenium sulfide external shampoo 2.25 %
3
SERNIVO 3
sodium hyaluronate external
3
sodium sulfacetamide 1
sodium sulfacetamide wash liquid 10 % external
3
SODIUM SULFACETAMIDE WASH LIQUID 10 % EXTERNAL
3
SOOLANTRA 3
SORIATANE 4 PA; QL
SORILUX 3
sss 10-5 3
sulfacetamide sodium (acne)
1
sulfacetamide sodium external
3
sulfacetamide sodium-sulfur external cream
3
sulfacetamide sodium-sulfur external emulsion
1
Drug Name Drug Tier
Notes
sulfacetamide sodium-sulfur external liquid
3
sulfacetamide sodium-sulfur external lotion 10-5 %
1
sulfacetamide sodium-sulfur external lotion 9.8-4.8 %
3
sulfacetamide sodium-sulfur external pad
3
sulfacetamide sodium-sulfur external suspension
3
sulfacetamide-sulfur in urea
1
sulfacleanse 8/4 3
sulfamez wash 3
SUVICORT 3
synalar external cream 1
synalar external ointment 1
SYNALAR EXTERNAL SOLUTION
3
SYNERDERM 3
TACLONEX 3
tacrolimus external 1
tazarotene external 1
TAZORAC EXTERNAL CREAM 0.05 %
2
TAZORAC EXTERNAL CREAM 0.1 %
1
TAZORAC EXTERNAL GEL
2
TEMOVATE EXTERNAL CREAM
3 ST
TEMOVATE EXTERNAL OINTMENT
3
TETRIX 3
TEXACORT 3
TOLAK C PA
TOPICORT 3
TOPICORT SPRAY 3
tovet external foam 3
Effective Date: 12/01/2019 52
Drug Name Drug Tier
Notes
tretinoin external cream 1
tretinoin external gel 0.01 %, 0.025 %
1
tretinoin external gel 0.05 %
3
tretinoin microsphere 1
tretinoin microsphere pump
1
triamcinolone acetonide external aerosol solution
3
triamcinolone acetonide external cream
1
triamcinolone acetonide external lotion
1
triamcinolone acetonide external ointment
1
TRIANEX 3
triderm 1
TRIDESILON 3
ULTRAVATE 3
umecta mousse 3
urea external cream 39 %, 41 %, 45 %, 47 %
3
urea external cream 40 % 1
UREA EXTERNAL FOAM 3 PA
urea external suspension 3
urea hydrating 3
urea nail 3
uredeb 3
uremez-40 1
URESOL 3
UTOPIC 3
VANOS 3
VANOXIDE-HC 3
VECTICAL 1
VELTIN 3
VENELEX 3
VERDESO 3
VEREGEN 3
Drug Name Drug Tier
Notes
XALIX 3
XERALUX 3
xurea 3
zaclir cleansing 3
zenatane 1
ZIANA 3
ZITHRANOL 3
ZONALON 3
ZYCLARA 3
ZYCLARA PUMP 3
Diabetes - Antidiabetic Agents
acarbose oral 1
ACTOPLUS MET 3
ACTOS 3
ADLYXIN 3 PA; QL
ADLYXIN STARTER PACK
3 PA; QL
ALOGLIPTIN BENZOATE 3 PA
ALOGLIPTIN-METFORMIN HCL
3 PA
ALOGLIPTIN-PIOGLITAZONE
3 PA
AMARYL 3
AVANDIA 3
BYDUREON 3 PA; QL
BYDUREON BCISE AUTOINJECTOR
3 PA; QL
BYETTA 10 MCG PEN 3 PA; QL
BYETTA 5 MCG PEN 3 PA; QL
CYCLOSET 3 ST
DUETACT 3
FARXIGA 3 PA; QL
FORTAMET ORAL TABLET EXTENDED RELEASE 24 HOUR 1000 MG
3 PA
FORTAMET ORAL TABLET EXTENDED RELEASE 24 HOUR 500 MG
3
Effective Date: 12/01/2019 53
Drug Name Drug Tier
Notes
glimepiride 1
glipizide er 1
glipizide ir 1
glipizide xl 1
glipizide-metformin hcl 3
GLUCOPHAGE 3
GLUCOPHAGE XR 3
GLUCOTROL 3
GLUCOTROL XL 3
GLUMETZA 3 PA
glyburide micronized 3
glyburide oral 1
glyburide-metformin 3
GLYNASE 3
GLYSET 3
GLYXAMBI 3 ST
INVOKAMET 3 PA; QL
INVOKAMET XR 3 PA; QL
INVOKANA 3 PA; QL
JANUMET 3 PA
JANUMET XR 3 PA
JANUVIA 3 PA
JARDIANCE 2 PA; QL
JENTADUETO 3 ST
JENTADUETO XR 3 ST
KAZANO 3 PA
KOMBIGLYZE XR 3 PA
metformin hcl er 1
metformin hcl er (mod) 3 PA
metformin hcl er (osm) oral tablet extended release 24 hour 1000 mg
3 PA
metformin hcl er (osm) oral tablet extended release 24 hour 500 mg
3
METFORMIN HCL ORAL SOLUTION
2
metformin hcl oral tablet 1
miglitol 3
Drug Name Drug Tier
Notes
nateglinide 3
NESINA 3 PA
ONGLYZA 3 PA
OSENI 3 PA
OZEMPIC 3 PA; QL
pioglitazone hcl 3
pioglitazone hcl-glimepiride
3
pioglitazone hcl-metformin hcl
3
PRECOSE 3
QTERN 3 PA; QL
repaglinide 3
repaglinide-metformin hcl 3
RIOMET 2
RYBELSUS 3 PA
SEGLUROMET 3 PA; QL
SOLIQUA 3 PA; QL
STARLIX 3
STEGLATRO 3 PA; QL
STEGLUJAN 3 PA; QL
SYMLINPEN 120 3
SYMLINPEN 60 3
SYNJARDY 3 PA; QL
SYNJARDY XR 3 PA; QL
tolbutamide 1
TRADJENTA 3 ST
TRULICITY 3 PA; QL
VICTOZA 3 PA; QL
XIGDUO XR 3 PA; QL
XULTOPHY 3 PA
Diabetes - Glucose Monitoring
ACCU-CHEK AVIVA IN VITRO
1
ACCU-CHEK COMPACT PLUS CONTROL
1
ACCU-CHEK FASTCLIX LANCET KIT
1
Effective Date: 12/01/2019 54
Drug Name Drug Tier
Notes
ACCU-CHEK GUIDE CONTROL
1
ACCU-CHEK MULTICLIX LANCET DEVICE KIT
1
ACCU-CHEK SMARTVIEW CONTROL
1
ACCU-CHEK SOFTCLIX LANCET DEVICE KIT
1
AUTOLET LANCING DEVICE
1
BAYER CONTOUR IN VITRO LIQUID HIGH , LOW , NORMAL
1
CARETOUCH LANCING/EJECTOR
1
CONTOUR NEXT CONTROL
1
CONTOUR NEXT TEST 1 PA; QL
DIATHRIVE GLUCOSE CONTROL SOLN
1
DIATHRIVE LANCING DEVICE
1
EASYMAX CONTROL 1
EMBRACE TALK GLUCOSE CONTROL
1
FORTISCARE CONTROL 1
FREESTYLE TEST 1 PA; QL
GENTEEL LANCING KIT (BLUE)
1
LANCETS 1
LANCETS KIT 1
MICROLET NEXT LANCING DEVICE
1
OMNIPOD DASH SYSTEM
3 PA
OMNIPOD STARTER 3 PA
ONETOUCH DELICA LANCING DEV
1
ONETOUCH DELICA PLUS LANCING
1
ONETOUCH ULTRA BLUE TEST STRIPS
1 QL
Drug Name Drug Tier
Notes
ONETOUCH VERIO IN VITRO SOLUTION HIGH
1
ONETOUCH VERIO TEST STRIPS
1 QL
SURESTEP PRO HIGH GLUCOSE
1
SURESTEP PRO LOW GLUCOSE
1
SURESTEP PRO NORMAL GLUCOSE
1
TRUE METRIX LEVEL 1 1
TRUE METRIX LEVEL 2 1
TRUE METRIX LEVEL 3 1
UNISTRIP CONTROL IN VITRO SOLUTION LOW
1
V-GO 20 3 PA
V-GO 30 3 PA
V-GO 40 3 PA
VIVAGUARD INO CONTROL SOLUTION
1
VIVAGUARD LANCING DEVICE
1
Diabetes - Glycemic Agents
BAQSIMI ONE PACK 3 PA
BAQSIMI TWO PACK 3 PA
GLUCAGEN HYPOKIT 2
GLUCAGON EMERGENCY
2
GVOKE PFS 4 PA; QL
PROGLYCEM 2
Diabetes - Insulins
ADMELOG 3 PA
ADMELOG SOLOSTAR 3 PA
AFREZZA 3 PA
APIDRA SOLOSTAR 3
APIDRA VIAL 3
BASAGLAR KWIKPEN 3 PA
BD AUTOSHIELD DUO PEN NEEDLES
1
BD ULTRA-FINE INSULIN SYRINGES
1
Effective Date: 12/01/2019 55
Drug Name Drug Tier
Notes
BD ULTRA-FINE PEN NEEDLES
1
FIASP 3 PA
FIASP FLEXTOUCH 3 PA
HUMALOG KWIKPEN 2
HUMALOG MIX 50/50 KWIKPEN
3
HUMALOG MIX 50/50 VIAL
3
HUMALOG MIX 75/25 KWIKPEN
3
HUMALOG MIX 75/25 VIAL
3
HUMALOG U-100 JUNIOR KWIKPEN
2
HUMALOG U-100 VIAL AND CARTRIDGE
2
HUMULIN 70/30 KWIKPEN
1
HUMULIN 70/30 VIAL 1
HUMULIN N KWIKPEN 1
HUMULIN N VIAL 1
HUMULIN R U-500 KWIKPEN
1
HUMULIN R U-500 VIAL (CONCENTRATED)
1
HUMULIN R VIAL 1
INSULIN LISPRO 2
INSULIN LISPRO SUBCUTANEOUS SOLUTION PEN-INJECTOR 100 UNIT/ML
2
INSULIN PEN NEEDLES 1
INSULIN SYRINGES 1
LANTUS SOLOSTAR 2
LANTUS U-100 VIAL 2
LEVEMIR U-100 FLEXTOUCH
2 PA
LEVEMIR U-100 VIAL 2 PA
MAXICOMFORT SYR 27G X 1/2"
1
Drug Name Drug Tier
Notes
NOVOFINE AUTOCOVER PEN NEEDLE
1
NOVOFINE PEN NEEDLE
1
NOVOFINE PLUS PEN NEEDLE
1
NOVOLIN 70/30 RELION 3 ST
NOVOLIN 70/30 VIAL 3 ST
NOVOLIN N RELION 3 ST
NOVOLIN N VIAL 3 ST
NOVOLIN R RELION 3 ST
NOVOLIN R VIAL 3 ST
NOVOLOG FLEXPEN 3
NOVOLOG MIX 70/30 FLEXPEN
3
NOVOLOG MIX 70/30 VIAL
3
NOVOLOG PENFILL 3
NOVOLOG U-100 VIAL 3
NOVOTWIST PEN NEEDLE
1
TOUJEO MAX SOLOSTAR
3 PA
TOUJEO SOLOSTAR 3 PA
TRESIBA 3 PA
TRESIBA FLEXTOUCH 3 PA
Electrolytes / Minerals / Metals / Vitamins
argyle sterile saline 1
argyle sterile water 3
CARBAGLU 4 PA; QL
CARNITOR INTRAVENOUS
M
CARNITOR ORAL 3
CARNITOR SF 3
CHEMET 3 PA
clovique 4 PA; QL
curity sterile saline 1
cyanocobalamin injection solution 1000 mcg/ml
1
Effective Date: 12/01/2019 56
Drug Name Drug Tier
Notes
cytra k crystals 1
d3 high potency oral capsule
P
d3 super strength P
d3 vitamin oral liquid 400 unit/ml
P
decara oral capsule 1.25 mg (50000 ut), 250 mcg (10000 ut)
P
DECARA ORAL CAPSULE 625 MCG (25000 UT)
P
deferasirox 4 QL
DRISDOL 3
EFFER-K ORAL TABLET EFFERVESCENT 10 MEQ, 20 MEQ
3
effer-k oral tablet effervescent 25 meq
3
ergocalciferol oral capsule 1
EXJADE 4 PA; QL
FERAHEME M PA
FERRIPROX ORAL SOLUTION
3 PA
FERRIPROX ORAL TABLET
4 PA; QL
ferrous sulfate oral solution
P
ferrous sulfate oral tablet 325 (65 fe) mg
P
ferrous sulfate oral tablet delayed release
P
FLUORABON P
fluoritab P
FLURA-DROPS P
folic acid injection P
folic acid oral tablet P
gnp folic acid P
INJECTAFER M PA
iodine strong oral 3
JADENU 4 PA; QL
Drug Name Drug Tier
Notes
JADENU SPRINKLE 4 PA; QL
JYNARQUE 4 PA; QL
kids first vitamin d3 gummies
P
kionex 1
klor-con 1
klor-con 10 1
klor-con m10 1
KLOR-CON M15 2
klor-con m20 1
klor-con sprinkle 1
klor-con/ef 3
K-PHOS 3
K-PHOS NO 2 3
k-prime 3
K-TAB ORAL TABLET EXTENDED RELEASE 10 MEQ
1
K-TAB ORAL TABLET EXTENDED RELEASE 20 MEQ, 8 MEQ
2
levocarnitine oral solution 1
levocarnitine oral tablet 1
LOKELMA 4 PA; QL
ludent P
MEPHYTON 1
MIFEPREX 3
mifepristone 3
multi prenatal P
na ferric gluc cplx in sucrose
M
nafrinse P
nafrinse drops P
ONE-A-DAY WOMENS PRENATAL 1
P
ORACIT 2
phospha 250 neutral 1
phosphorous 1
phospho-trin 250 neutral 1
Effective Date: 12/01/2019 57
Drug Name Drug Tier
Notes
physiolyte 3
physiosol irrigation 3
phytonadione injection 1
phytonadione oral 1
pot bicarb-pot chloride 3
potassium bicarbonate oral
3
potassium chloride crys er 1
potassium chloride er 1
potassium chloride oral 1
potassium citrate er 1
potassium citrate-citric acid
1
prenatal multi +dha oral capsule 27-0.8-228 mg, 27-0.8-250 mg
P
prenatal oral tablet 27-0.8 mg, 28-0.8 mg
P
ra iron oral tablet 325 (65 fe) mg
P
SAMSCA 4 PA; QL
sm vitamin d3 oral capsule 125 mcg (5000 ut)
P
sod citrate-citric acid 1
sodium chloride injection solution 0.9 %
1
sodium chloride irrigation 1
sodium fluoride oral P
sodium polystyrene sulfonate oral
1
sodium polystyrene sulfonate rectal
3
sps 1
sterile water for irrigation 3
SYPRINE 4 PA; QL
taron-crystals 1
tricitrates 1
trientine hcl 4 PA; QL
Drug Name Drug Tier
Notes
TRIFERIC HEMODIALYSIS PACKET
M
UROCIT-K 10 3
UROCIT-K 15 3
UROCIT-K 5 3
VELTASSA 3 PA
VENOFER M
virt-phos 250 neutral 1
vitamin d (cholecalciferol) oral capsule 10 mcg (400 unit)
P
vitamin d (cholecalciferol) oral tablet 25 mcg (1000 ut)
P
vitamin d (ergocalciferol) oral capsule 1.25 mg (50000 ut)
1
vitamin d3 oral capsule 125 mcg (5000 ut), 250 mcg (10000 ut), 50 mcg (2000 ut)
P
vitamin d3 oral tablet 10 mcg (400 unit), 125 mcg (5000 ut), 25 mcg (1000 ut), 50 mcg (2000 ut)
P
vitamin k1 injection 1
Gastrointestinal Agents - Drugs for Acid Reflux and Ulcer
ACIPHEX 3 ST
ACIPHEX SPRINKLE 3 PA
ASPIRIN-OMEPRAZOLE 3
CARAFATE ORAL SUSPENSION
2
CARAFATE ORAL TABLET
3
cimetidine hcl 1
cimetidine oral 1
CYTOTEC 3
DEXILANT 3 PA
esomeprazole magnesium oral capsule delayed release 20 mg
3
Effective Date: 12/01/2019 58
Drug Name Drug Tier
Notes
famotidine oral suspension reconstituted
1
famotidine oral tablet 20 mg, 40 mg
1
FIRST-LANSOPRAZOLE 3
FIRST-OMEPRAZOLE 3
lansoprazole oral capsule delayed release
1 ST
lansoprazole oral tablet dispersible 15 mg, 30 mg
3 PA
misoprostol oral 1
NEXIUM ORAL PACKET 3 PA
nizatidine 3
omeprazole oral capsule delayed release
1
OMEPRAZOLE+SYRSPEND SF ALKA
3
omeprazole-sodium bicarbonate oral packet
3 PA
pantoprazole sodium oral 1
PEPCID 3
PREVACID 3 ST
PREVACID SOLUTAB ORAL TABLET DISPERSIBLE 15 MG, 30 MG
3 PA
PRILOSEC 3
PROTONIX ORAL 3
RABEPRAZOLE SODIUM ORAL CAPSULE SPRINKLE
3 PA
rabeprazole sodium oral tablet delayed release
1 ST
ranitidine hcl oral capsule 3
ranitidine hcl oral syrup 1
ranitidine hcl oral tablet 150 mg, 300 mg
1
sucralfate oral tablet 1
YOSPRALA 3
ZEGERID ORAL PACKET
3 PA
Drug Name Drug Tier
Notes
Gastrointestinal Agents - Drugs for Bowel, Intestine and Stomach Conditions
ACTIGALL 3
alosetron hcl 4 PA; QL
AMITIZA 3 PA; QL
amoxicill-clarithro-lansopraz
3
belladonna alkaloids-opium
1
BENTYL 3
bisacodyl ec P
CHENODAL 4 PA; QL
chlordiazepoxide-clidinium
1
CHOLBAM 4 PA; QL
citroma P
clearlax P
CLENPIQ 3
COLYTE WITH FLAVOR PACKS
3
constulose 1
cromolyn sodium oral 3
CUVPOSA 3
dicyclomine hcl intramuscular
3
dicyclomine hcl oral 1
diphenoxylate-atropine 1
ed-spaz 3
ENTEREG 3
enulose 1
ex-lax ultra P
GASTROCROM 3
GATTEX 4 PA; QL
gavilax oral powder P
gavilyte-c P
gavilyte-h 3
gavilyte-n with flavor pack P
generlac 1
gentle laxative oral P
Effective Date: 12/01/2019 59
Drug Name Drug Tier
Notes
GLYCATE 3
glycolax P
glycopyrrolate injection solution
1
glycopyrrolate oral tablet 1 mg, 2 mg
1
GLYCOPYRROLATE ORAL TABLET 1.5 MG
3
GOLYTELY ORAL SOLUTION RECONSTITUTED 227.1 GM
2
GOLYTELY ORAL SOLUTION RECONSTITUTED 236 GM
3
hyoscyamine sulfate er 3
hyoscyamine sulfate injection
3
hyoscyamine sulfate oral 3
hyoscyamine sulfate sl 3
hyoscyamine sulfate sublingual
3
hyosyne 3
KRISTALOSE 3
lactulose encephalopathy 1
lactulose oral packet 3
lactulose oral solution 1
LEVSIN INJECTION 3
LIBRAX 3
LINZESS ORAL CAPSULE 145 MCG, 290 MCG
3 PA; QL
LINZESS ORAL CAPSULE 72 MCG
3 PA
LOMOTIL 3
loperamide hcl oral capsule
1
LOTRONEX 4 PA; QL
magnesium citrate oral solution
P
Drug Name Drug Tier
Notes
methscopolamine bromide oral
3
MOTEGRITY 3 PA
MOTOFEN 3
MOVANTIK 3 PA; QL
MOVIPREP 3
MYTESI 3
nulev 3
NULYTELY WITH FLAVOR PACKS
3
OMECLAMOX-PAK 3
opium 1
oscimin 3
oscimin sr 3
OSMOPREP 3
paregoric 3
peg 3350/electrolytes P
peg 3350-kcl-na bicarb-nacl
P
peg-3350/electrolytes P
peg-prep 3
PLENVU 3
PREPOPIK 3
propantheline bromide oral
1
PYLERA 2
RELISTOR ORAL 3 PA
RELISTOR SUBCUTANEOUS
2
SEROSTIM 4 PA; QL
SUPREP BOWEL PREP KIT
3
SYMAX DUOTAB 3
symax-sl 3
symax-sr 3
SYMPROIC 3 PA
trilyte P
TRULANCE 3 PA
URSO 250 3
Effective Date: 12/01/2019 60
Drug Name Drug Tier
Notes
URSO FORTE 3
ursodiol oral 1
VIBERZI 3 PA
XERMELO 4 PA; QL
ZELNORM 3 PA
ZORBTIVE 4 PA; QL
Genetic or Enzyme Disorder - Drugs for Replacement, Modification, Treatment
ALDURAZYME M PA
BUPHENYL 4 PA; QL
CERDELGA 4 PA; QL
CEREZYME M PA
CREON 2
CRYSVITA 4 PA; QL
CYSTADANE 3
CYSTAGON 2 PA
ELAPRASE M PA
ELELYSO M PA
EXONDYS 51 M PA
FABRAZYME M PA
GALAFOLD 4 PA; QL
KANUMA M PA
KUVAN 4 PA; QL
LUMIZYME M PA
MEPSEVII M PA
miglustat 4 PA; QL
MYALEPT 4 PA; QL
NAGLAZYME M PA
nitisinone 4 QL
NITYR 4 PA; QL
OCALIVA 4 PA; QL
ORFADIN 4 PA; QL
PALYNZIQ 4 PA; QL
PANCREAZE 3
PERTZYE 3
PROCYSBI 4 PA; QL
RAVICTI 4 PA; QL
sodium phenylbutyrate oral powder
4 PA; QL
Drug Name Drug Tier
Notes
sodium phenylbutyrate oral tablet
4 QL
STRENSIQ 4 PA; QL
SUCRAID 4 PA; QL
VIMIZIM M PA
VIOKACE 3
VPRIV M PA
ZAVESCA 4 PA; QL
ZENPEP 2
Genitourinary Agents - Drugs for Bladder, Genital and Kidney Conditions
acetic acid irrigation 1
aminoacetic acid M
AURYXIA 4 PA; QL
bethanechol chloride oral 1
calcium acetate (phos binder)
1
CIALIS 3 PA
CUPRIMINE 4 PA; QL
darifenacin hydrobromide er
3 ST
DEPEN TITRATABS 4 PA; QL
DETROL 3
DETROL LA 3
DITROPAN XL 3
D-PENAMINE 4 PA; QL
ELMIRON 2
ENABLEX 3 ST
FEM PH 3
flavoxate hcl 1
FOSRENOL ORAL PACKET
3
FOSRENOL ORAL TABLET CHEWABLE
4 PA; QL
GELNIQUE 3 ST
GELNIQUE PUMP 3 ST
glycine irrigation M
glycine urologic M
hyophen 3
Effective Date: 12/01/2019 61
Drug Name Drug Tier
Notes
INTRAROSA 3 PA
lanthanum carbonate 4 QL
LITHOSTAT 3
me/naphos/mb/hyo1 3
MYRBETRIQ 3 ST
oxybutynin chloride er 1
oxybutynin chloride oral 1
OXYTROL 3 ST
penicillamine oral 4 PA; QL
phenazo oral tablet 200 mg
1
phenazopyridine hcl oral tablet 100 mg, 200 mg
1
PHOSLYRA 3
phosphasal 3
RENACIDIN 3
RENAGEL 3
RENVELA 3
RIMSO-50 3
sevelamer carbonate 1
sevelamer hcl 1
solifenacin succinate 1
tadalafil oral 3 PA
THIOLA 4 PA; QL
THIOLA EC 4 PA
tolterodine tartrate 1
tolterodine tartrate er 1
TOVIAZ 3 ST
trospium chloride 1
trospium chloride er 1
URECHOLINE 3
urelle 3
uretron d/s 3
uribel 3
urimar-t 3
urin ds 3
uro-458 3
Drug Name Drug Tier
Notes
uro-mp 3
uryl 3
ustell 3
uticap 3
utira-c 3
utrona-c 3
VELPHORO 4 PA; QL
VESICARE 3
vilamit mb 3
vilevev mb 3
Genitourinary Agents - Drugs for Prostate Conditions
alfuzosin hcl er 1
AVODART 3
CARDURA XL 3
dutasteride oral 1
dutasteride-tamsulosin hcl 3
finasteride oral tablet 5 mg
1
FLOMAX 3
JALYN 3
PROSCAR 3
RAPAFLO 3
silodosin 3
tamsulosin hcl 1
terazosin hcl 1
UROXATRAL 3
Hormonal Agents - Adrenal
betamethasone sod phos & acet injection suspension 6 (3-3) mg/ml
3
CELESTONE SOLUSPAN
3
CORTEF 3
cortisone acetate oral 1
DECADRON 3
DEPO-MEDROL INJECTION SUSPENSION 20 MG/ML
2
Effective Date: 12/01/2019 62
Drug Name Drug Tier
Notes
DEPO-MEDROL INJECTION SUSPENSION 40 MG/ML, 80 MG/ML
3
DEXAMETHASONE (LA) 3
DEXAMETHASONE INTENSOL
2
dexamethasone oral elixir 1
dexamethasone oral solution
1
dexamethasone oral tablet
1
dexamethasone oral tablet therapy pack
3
dexamethasone sod phosphate pf injection solution
1
dexamethasone sodium phosphate injection
1
DEXPAK 10 DAY 3
DEXPAK 13 DAY 3
DEXPAK 6 DAY 3
DXEVO 11-DAY 3
fludrocortisone acetate oral
1
HIDEX 6-DAY 3
hydrocortisone oral 1
KENALOG INJECTION 3
MEDROL ORAL TABLET 16 MG, 32 MG, 4 MG, 8 MG
3
MEDROL ORAL TABLET 2 MG
2
MEDROL ORAL TABLET THERAPY PACK
3
methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml
1
methylprednisolone oral 1
Drug Name Drug Tier
Notes
methylprednisolone sodium succ injection solution reconstituted 1000 mg, 40 mg, 500 mg
M
methylprednisolone sodium succ injection solution reconstituted 125 mg
1
MILLIPRED 3
MILLIPRED DP 3
MILLIPRED DP 12-DAY 3
ORAPRED ODT 3
PEDIAPRED 3
prednisolone oral solution 1
prednisolone sodium phosphate oral solution 10 mg/5ml, 20 mg/5ml
3
prednisolone sodium phosphate oral solution 15 mg/5ml, 25 mg/5ml, 6.7 (5 base) mg/5ml
1
prednisolone sodium phosphate oral tablet dispersible
3
PREDNISONE INTENSOL
3
prednisone oral 1
RAYOS 3 PA
SOLU-CORTEF 2
SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 125 MG
3
SOLU-MEDROL INJECTION SOLUTION RECONSTITUTED 2 GM, 500 MG
M
TAPERDEX 12-DAY 3
TAPERDEX 6-DAY 3
TAPERDEX 7-DAY 3
triamcinolone acetonide suspension 40 mg/ml injection
3
Effective Date: 12/01/2019 63
Drug Name Drug Tier
Notes
TRIAMCINOLONE ACETONIDE SUSPENSION 40 MG/ML INJECTION
3
ZILRETTA M
Hormonal Agents - Men's Health
ANADROL-50 4 PA; QL
ANDRODERM 3 PA; QL
ANDROGEL 3 PA; QL
ANDROGEL PUMP 3 PA; QL
AVEED M PA
danazol oral 1
DEPO-TESTOSTERONE (brand testosterone cypionate intramuscular)
1 PA
FORTESTA 3 PA; QL
METHITEST 3 PA
methyltestosterone oral 3 PA
NATESTO 3 PA; QL
oxandrolone oral 3
STRIANT 3 PA; QL
TESTIM 3 PA; QL
TESTONE CIK 3
TESTOPEL M PA
TESTOSTERONE CYPIONATE INJECTION
1 PA
testosterone cypionate intramuscular
1 PA
testosterone enanthate intramuscular
1 PA
testosterone transdermal gel 10 mg/act (2%), 20.25 mg/1.25gm (1.62%), 20.25 mg/act (1.62%), 40.5 mg/2.5gm (1.62%)
3 PA; QL
testosterone transdermal gel 12.5 mg/act (1%), 25 mg/2.5gm (1%), 50 mg/5gm (1%)
1 PA; QL
testosterone transdermal solution
3 PA; QL
VOGELXO 3 PA; QL
Drug Name Drug Tier
Notes
VOGELXO PUMP 3 PA; QL
XYOSTED 3 PA
Hormonal Agents - Osteoporosis
EVISTA 3 PA
OSPHENA 3 PA
raloxifene hcl P PA
Hormonal Agents - Parathyroid
cinacalcet hcl 4 PA; QL
SENSIPAR 4 PA; QL
Hormonal Agents - Pituitary
ACTHAR 4 PA; QL
cabergoline 1
DDAVP 3
desmopressin ace spray refrig
1
desmopressin acetate injection
1
desmopressin acetate oral
1
desmopressin acetate spray
1
EGRIFTA 4 PA; QL
ELIGARD C PA
FIRMAGON M PA
GENOTROPIN 4 PA; QL
GENOTROPIN MINIQUICK
4 PA; QL
HUMATROPE 4 PA; QL
INCRELEX 4 PA; QL
leuprolide acetate injection
C
LUPRON DEPOT (1-MONTH)
C
LUPRON DEPOT (3-MONTH)
C
LUPRON DEPOT (4-MONTH) INTRAMUSCULAR KIT 30MG
C
Effective Date: 12/01/2019 64
Drug Name Drug Tier
Notes
LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG
C
LUPRON DEPOT-PED (1-MONTH)
2
LUPRON DEPOT-PED (3-MONTH)
2
NOCDURNA 3 PA
NOCTIVA 2
NORDITROPIN FLEXPRO
4 PA; QL
NUTROPIN AQ NUSPIN 10
4 PA; QL
NUTROPIN AQ NUSPIN 20
4 PA; QL
NUTROPIN AQ NUSPIN 5
4 PA; QL
octreotide acetate 1
OMNITROPE 4 PA; QL
ORILISSA 4 PA; QL
SAIZEN 4 PA; QL
SAIZENPREP 4 PA; QL
SANDOSTATIN 3
SANDOSTATIN LAR DEPOT
C QL
SIGNIFOR 4 PA; QL
SIGNIFOR LAR M PA
SOMATULINE DEPOT 4 PA; QL
SOMAVERT 4 PA; QL
STIMATE 2
SUPPRELIN LA M PA
SYNAREL 3 QL
TRELSTAR MIXJECT M PA
TRIPTODUR M PA
VANTAS M PA
ZOLADEX M PA
ZOMACTON 4 PA; QL
Hormonal Agents - Prostaglandins
carboprost tromethamine M
CERVIDIL 2
Drug Name Drug Tier
Notes
HEMABATE M
KORLYM 4 PA; QL
PREPIDIL 2
PROSTIN E2 2
Hormonal Agents - Sex Hormones and Birth Control
ACTIVELLA 3 PA
afirmelle P
ALORA 3
altavera P
alyacen 1/35 P
alyacen 7/7/7 P
amabelz 3 PA
amethia P
amethia lo P
amethyst P
ANGELIQ 3 PA
ANNOVERA P
apri P
aranelle P
ashlyna P
aubra P
aubra eq P
aurovela 1.5/30 P
aurovela 1/20 P
aurovela 24 fe P
aurovela fe 1.5/30 P
aurovela fe 1/20 P
aviane P
AYGESTIN 3
ayuna P
azurette P
BALCOLTRA P
balziva P
bekyree P
BEYAZ 3
BIJUVA 3 PA
Effective Date: 12/01/2019 65
Drug Name Drug Tier
Notes
blisovi 24 fe P
blisovi fe 1.5/30 P
blisovi fe 1/20 P
briellyn P
camila P
camrese P
camrese lo P
caziant P
chateal P
chateal eq P
CLIMARA 1
CLIMARA PRO 3 PA
COMBIPATCH 3 PA
covaryx 3
covaryx hs 3
CRINONE 3
cryselle-28 P
cyclafem 1/35 P
cyclafem 7/7/7 P
cyred P
cyred eq P
dasetta 1/35 P
dasetta 7/7/7 P
daysee P
deblitane P
DELESTROGEN 2
delyla P
DEPO-ESTRADIOL 2
DEPO-PROVERA 3
DEPO-SUBQ PROVERA 104
P
desogestrel-ethinyl estradiol
P
DIVIGEL 3
dotti 3
drospiren-eth estrad-levomefol
P
Drug Name Drug Tier
Notes
drospirenone-ethinyl estradiol
P
DUAVEE 3 PA
eemt 3
eemt hs 3
ELESTRIN 3
elinest P
ELLA P
emoquette P
ENDOMETRIN 3
enpresse-28 P
enskyce P
errin P
est estrogens-methyltest 3
est estrogens-methyltest ds
3
est estrogens-methyltest hs
3
estarylla P
ESTRACE 3
estradiol oral 1
estradiol transdermal patch twice weekly
3
estradiol transdermal patch weekly
1
estradiol vaginal 1
estradiol valerate intramuscular
1
estradiol-norethindrone acet
3 PA
ESTRING 2
ESTROGEL 3
ESTROSTEP FE 3
ethynodiol diac-eth estradiol
P
EVAMIST 3
falmina P
fayosim P
FEMHRT LOW DOSE 3 PA
Effective Date: 12/01/2019 66
Drug Name Drug Tier
Notes
FEMRING 2
femynor P
FIRST-PROGESTERONE VGS
3
fyavolv 3 PA
GENERESS FE 3
gianvi P
hailey 1.5/30 P
hailey 24 fe P
heather P
hydroxyprogesterone caproate intramuscular oil
1
hydroxyprogesterone caproate intramuscular solution
M PA
IMVEXXY MAINTENANCE PACK
3 PA
IMVEXXY STARTER PACK
3 PA
incassia P
introvale P
isibloom P
jasmiel P
jencycla P
jinteli 3 PA
jolessa P
juleber P
junel 1.5/30 P
junel 1/20 P
junel fe 1.5/30 P
junel fe 1/20 P
junel fe 24 P
kaitlib fe P
kalliga P
kariva P
kelnor 1/35 P
kelnor 1/50 P
kurvelo P
Drug Name Drug Tier
Notes
KYLEENA P
larin 1.5/30 P
larin 1/20 P
larin 24 fe P
larin fe 1.5/30 P
larin fe 1/20 P
larissia P
layolis fe P
leena P
lessina P
levonest P
levonorgest-eth est & eth est
P
levonorgest-eth estrad 91-day
P
levonorgestrel P
levonorgestrel-ethinyl estrad
P
levonorg-eth estrad triphasic oral tablet
P
levora 0.15/30 (28) P
LILETTA (52 MG) P
lillow P
LO LOESTRIN FE P
LOESTRIN 1.5/30 (21) 3
LOESTRIN 1/20 (21) 3
LOESTRIN FE 1.5/30 3
LOESTRIN FE 1/20 3
lopreeza 3 PA
loryna P
LOSEASONIQUE 3
low-ogestrel P
lo-zumandimine P
lutera P
lyza P
MAKENA INTRAMUSCULAR
3
Effective Date: 12/01/2019 67
Drug Name Drug Tier
Notes
MAKENA SUBCUTANEOUS
4 QL
marlissa P
medroxyprogesterone acetate intramuscular
P
medroxyprogesterone acetate oral
1
MEGACE ES 3
megestrol acetate oral suspension 40 mg/ml, 400 mg/10ml
1
megestrol acetate oral suspension 625 mg/5ml
3
megestrol acetate oral tablet
1
melodetta 24 fe P
MENEST 3
MENOSTAR 3
mibelas 24 fe P
microgestin 1.5/30 P
microgestin 1/20 P
microgestin fe 1.5/30 P
microgestin fe 1/20 P
mili P
mimvey 3 PA
MINASTRIN 24 FE 3
MINIVELLE 3
MIRCETTE 3
MIRENA (52 MG) P
mono-linyah P
NATAZIA P
necon 0.5/35 (28) P
NEXPLANON P
nikki P
nora-be P
norethin ace-eth estrad-fe P
norethindrone acetate oral
1
Drug Name Drug Tier
Notes
norethindrone acet-ethinyl est
P
norethindrone oral P
norethindrone-eth estradiol
3 PA
norethin-eth estradiol-fe P
norgestimate-eth estradiol P
norgestimate-ethinyl estradiol triphasic
P
norlyda P
norlyroc P
nortrel 0.5/35 (28) P
nortrel 1/35 (21) P
nortrel 1/35 (28) P
nortrel 7/7/7 P
NUVARING P
ocella P
ogestrel P
orsythia P
ORTHO MICRONOR 3
ORTHO TRI-CYCLEN LO 3
ORTHO-NOVUM 1/35 (28)
3
ORTHO-NOVUM 7/7/7 (28)
3
PARAGARD INTRAUTERINE COPPER
P
philith P
pimtrea P
pirmella 1/35 P
pirmella 7/7/7 P
PLAN B ONE-STEP 3
portia-28 P
PREFEST 3 PA
PREMARIN ORAL 3 ST
PREMARIN VAGINAL 2
PREMPHASE 3 PA
PREMPRO 3 PA
Effective Date: 12/01/2019 68
Drug Name Drug Tier
Notes
preventeza P
previfem P
progesterone intramuscular
1
progesterone micronized oral
1
PROMETRIUM 3
PROVERA 3
QUARTETTE 3
reclipsen P
rivelsa P
SAFYRAL P
SEASONIQUE 3
setlakin P
sharobel P
simliya P
simpesse P
SKYLA P
SLYND P
sprintec 28 P
sronyx P
syeda P
tarina 24 fe P
tarina fe 1/20 P
tarina fe 1/20 eq P
TAYTULLA P
tilia fe P
tri femynor P
tri-estarylla P
tri-legest fe P
tri-linyah P
tri-lo-estarylla P
tri-lo-marzia P
tri-lo-mili P
tri-lo-sprintec P
tri-mili P
tri-previfem P
Drug Name Drug Tier
Notes
tri-sprintec P
trivora (28) P
tri-vylibra P
tri-vylibra lo P
tulana P
tydemy P
VAGIFEM 3
velivet P
vienva P
viorele P
VIVELLE-DOT 3
vyfemla P
vylibra P
wera P
wymzya fe P
xulane P
YASMIN 28 3
YAZ 3
yuvafem 1
zarah P
zovia 1/35e (28) P
zumandimine P
Hormonal Agents - Thyroid
ARMOUR THYROID 3
CYTOMEL 3
euthyrox 3
levo-t 3
levothyroxine sodium oral 1
levothyroxine-liothyronine oral tablet 30 mg, 60 mg, 90 mg
3
levoxyl 3
liothyronine sodium oral 1
methimazole oral 1
Effective Date: 12/01/2019 69
Drug Name Drug Tier
Notes
NATURE-THROID ORAL TABLET 113.75 MG, 146.25 MG, 162.5 MG, 260 MG, 325 MG, 48.75 MG, 81.25 MG, 97.5 MG
3
nature-throid oral tablet 130 mg, 16.25 mg, 195 mg, 32.5 mg, 65 mg
3
np thyroid 3
PARSABIV M PA
propylthiouracil oral 1
SYNTHROID 3
TAPAZOLE 3
thyroid oral tablet 120 mg, 15 mg
3
TIROSINT 3
TIROSINT-SOL 3
unithroid 3
westhroid oral tablet 130 mg, 32.5 mg, 65 mg
3
WESTHROID ORAL TABLET 195 MG, 97.5 MG
3
WP THYROID 3
Immunological Agents - Drugs for Immune System Stimulation or Suppression
ACTEMRA ACTPEN 4 PA; QL
ACTEMRA INTRAVENOUS
M PA
ACTEMRA SUBCUTANEOUS
4 PA; QL
ACTIMMUNE 4 PA; QL
ALFERON N 3
ARAVA 3
ARCALYST 4 PA; QL
ASTAGRAF XL 3
ATGAM M
AZASAN 3
azathioprine oral 1
azathioprine sodium M
Drug Name Drug Tier
Notes
BENLYSTA INTRAVENOUS
M PA
BENLYSTA SUBCUTANEOUS
4 PA; QL
BERINERT 4 PA; QL
BIVIGAM M PA
CARIMUNE NF SOLUTION RECONSTITUTED 12 GM INTRAVENOUS
M PA
carimune nf solution reconstituted 12 gm intravenous
M PA
CARIMUNE NF SOLUTION RECONSTITUTED 6 GM INTRAVENOUS
M PA
carimune nf solution reconstituted 6 gm intravenous
M PA
CELLCEPT 3
CIMZIA 4 PA; QL
CIMZIA PREFILLED KIT 4 PA; QL
CIMZIA STARTER KIT 4 PA; QL
CINRYZE 4 PA; QL
COSENTYX (300 MG DOSE)
4 PA; QL
COSENTYX 150 MG/ML 4 PA; QL
COSENTYX SENSOREADY (300 MG)
4 PA; QL
COSENTYX SENSOREADY PEN
4 PA; QL
CUTAQUIG 4 PA; QL
CUVITRU 4 PA; QL
cyclosporine intravenous M
cyclosporine modified 1
cyclosporine oral 1
CYTOGAM M PA
ENBREL 4 PA; QL
ENBREL MINI 4 PA; QL
ENBREL SURECLICK 4 PA; QL
ENTYVIO M PA
Effective Date: 12/01/2019 70
Drug Name Drug Tier
Notes
ENVARSUS XR 3
FIRAZYR 4 PA; QL
FLEBOGAMMA DIF M PA
GAMASTAN M PA
gamastan s/d injectable intramuscular
M PA
GAMASTAN S/D INJECTABLE INTRAMUSCULAR
M PA
GAMIFANT INTRAVENOUS SOLUTION 10 MG/2ML
M
GAMIFANT INTRAVENOUS SOLUTION 50 MG/10ML
M PA
GAMMAGARD M PA
GAMMAGARD S/D LESS IGA
M PA
GAMMAKED M PA
GAMMAPLEX M PA
GAMUNEX-C M PA
gengraf 1
HAEGARDA 4 PA; QL
HEPAGAM B 3
HIZENTRA 4 PA; QL
HUMIRA 4 PA; QL
HUMIRA PEDIATRIC CROHNS START
4 PA; QL
HUMIRA PEN 4 PA; QL
HUMIRA CITRATE FREE 4 PA; QL
HUMIRA PEN-PS/UV/ADOL HS START
4 PA; QL
HYPERHEP B S/D 2
HYPERRAB 3
HYPERRAB S/D 3
HYPERRHO S/D M PA
HYPERTET S/D 3
HYQVIA 4 PA; QL
icatibant acetate 4 QL
ILARIS M PA
ILUMYA M PA
Drug Name Drug Tier
Notes
IMOGAM RABIES-HT 3
IMURAN 3
INFLECTRA M PA
KEDRAB 3
KEVZARA 4 PA; QL
KINERET 4 PA; QL
KYMRIAH M PA
leflunomide oral 1
methotrexate oral 1
methotrexate sodium 1
methotrexate sodium (pf) 1
MICRHOGAM ULTRA-FILTERED PLUS
M PA
mycophenolate mofetil 1
mycophenolate mofetil hcl M
mycophenolate sodium 1
MYFORTIC 3
nabi-hb 1
NEORAL 3
NULOJIX M PA
OCTAGAM INTRAVENOUS SOLUTION 1 GM/20ML, 10 GM/100ML, 10 GM/200ML, 2 GM/20ML, 2.5 GM/50ML, 20 GM/200ML, 25 GM/500ML, 5 GM/100ML, 5 GM/50ML
M PA
OLUMIANT 4 PA; QL
ORENCIA CLICKJECT 4 PA; QL
ORENCIA INTRAVENOUS
M PA
ORENCIA SUBCUTANEOUS
4 PA; QL
OTEZLA 4 PA; QL
Effective Date: 12/01/2019 71
Drug Name Drug Tier
Notes
OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 10 MG/0.4ML, 12.5 MG/0.4ML, 15 MG/0.4ML, 17.5 MG/0.4ML, 22.5 MG/0.4ML, 25 MG/0.4ML
3 PA
OTREXUP SUBCUTANEOUS SOLUTION AUTO-INJECTOR 20 MG/0.4ML
3
PRIVIGEN M PA
PROGRAF INTRAVENOUS
M
PROGRAF ORAL 3
PROVENGE M PA
RAPAMUNE 3
RASUVO 2
REMICADE M PA
RENFLEXIS M PA
RHOGAM ULTRA-FILTERED PLUS
M PA
RHOPHYLAC 3
RIDAURA 4 QL
RINVOQ 4 PA; QL
RUCONEST 4 PA; QL
SANDIMMUNE ORAL 3
SILIQ 4 PA; QL
SIMPONI 4 PA; QL
SIMPONI ARIA M PA
SIMULECT M
sirolimus oral 1
SKYRIZI (150 MG DOSE) 4 PA; QL
STELARA INTRAVENOUS
M PA
STELARA SUBCUTANEOUS
4 PA; QL
SYNAGIS M PA
tacrolimus oral 1
TALTZ 4 PA; QL
temsirolimus M
Drug Name Drug Tier
Notes
THYMOGLOBULIN M
TORISEL M
TREMFYA 4 PA; QL
TREXALL C PA
VARIZIG 3
WINRHO SDF M PA
XATMEP C PA; QL
XELJANZ 4 PA; QL
XELJANZ XR 4 PA; QL
XEMBIFY 4 PA; QL
ZINPLAVA M PA
ZORTRESS 4 PA; QL
Immunological Agents - Drugs for Vaccination
ACTHIB P
ADACEL P
AFLURIA QUADRIVALENT
P
BEXSERO P
BIOTHRAX 3
BOOSTRIX P
DAPTACEL P
DIPHTHERIA-TETANUS TOXOIDS DT
P
ENGERIX-B P
FLUAD P
FLUARIX QUADRIVALENT
P
FLUBLOK QUADRIVALENT
P
FLUCELVAX QUADRIVALENT
P
FLULAVAL QUADRIVALENT
P
FLUMIST QUADRIVALENT
P
FLUZONE HIGH-DOSE P
FLUZONE QUADRIVALENT
P
GARDASIL 9 P
Effective Date: 12/01/2019 72
Drug Name Drug Tier
Notes
HAVRIX P
HEPLISAV-B P
HIBERIX P
INFANRIX P
IPOL P
KINRIX P
MENACTRA P
MENVEO P
M-M-R II SUBCUTANEOUS INJECTABLE
P
PEDIARIX P
PEDVAX HIB P
PENTACEL P
pneumovax 23 injectable 25 mcg/0.5ml injection
P
PNEUMOVAX 23 INJECTABLE 25 MCG/0.5ML INJECTION
P
PREVNAR 13 P
PROQUAD P
QUADRACEL P
RECOMBIVAX HB P
ROTARIX P
ROTATEQ P
SHINGRIX P
TDVAX P
TENIVAC P
TRUMENBA P
TWINRIX P
VAQTA P
VARIVAX P
ZOSTAVAX P
Inflammatory Bowel Disease Agents
ANALPRAM-HC 3
anucort-hc 3
ANUSOL-HC RECTAL CREAM
3
Drug Name Drug Tier
Notes
anusol-hc rectal suppository
3
APRISO 3 ST
ASACOL HD 3 ST
AZULFIDINE 3
AZULFIDINE EN-TABS 3
balsalazide disodium 1
budesonide er 4 PA; QL
budesonide oral 3 PA
CANASA 3
COLAZAL 3
colocort 1
CORTENEMA 3
CORTIFOAM 2
DELZICOL 3 ST
DIPENTUM 4 PA; QL
ENTOCORT EC 4 PA
hemmorex-hc 3
hydrocortisone ace-pramoxine rectal cream 1-1 %
3
hydrocortisone acetate rectal
3
hydrocortisone rectal cream 1 %
3
hydrocortisone rectal cream 2.5 %
1
hydrocortisone rectal enema
1
LIALDA 1 ST
lidocaine-hydrocortisone ace rectal cream
3
lidocaine-hydrocortisone ace rectal gel
3
lidocaine-hydrocortisone ace rectal kit 3-0.5 %, 3-1 %
3
mesalamine oral capsule delayed release
3 ST
mesalamine oral tablet delayed release
1 ST
Effective Date: 12/01/2019 73
Drug Name Drug Tier
Notes
mesalamine rectal 1
mesalamine-cleanser 3
PENTASA 2 ST
PROCORT 3
PROCTOCORT RECTAL CREAM
3
PROCTOFOAM HC 2
procto-med hc 1
procto-pak 3
proctosol hc 1
proctozone-hc 1
ROWASA 3
SFROWASA 3
sulfasalazine oral 1
UCERIS ORAL 4 PA; QL
UCERIS RECTAL 3
Metabolic Bone Disease Agents - Drugs for Osteoporosis
ACTONEL 3 ST
alendronate sodium 1
ATELVIA 3 ST
BINOSTO 3
BONIVA ORAL 3
calcitonin (salmon) 3
doxercalciferol intravenous
M
FORTEO 4 PA; QL
FOSAMAX 3
FOSAMAX PLUS D 3
HECTOROL INTRAVENOUS SOLUTION 2 MCG/ML
M
ibandronate sodium intravenous
M PA
ibandronate sodium oral 1
MIACALCIN INJECTION 3
pamidronate disodium M
paricalcitol intravenous M
PROLIA M PA
Drug Name Drug Tier
Notes
RAYALDEE 3 PA
risedronate sodium oral tablet
1 ST
risedronate sodium oral tablet delayed release
3 ST
TYMLOS 4 PA
zoledronic acid intravenous concentrate
M PA
zoledronic acid intravenous solution
M
Metabolic Bone Disease Agents - Other
calcitriol intravenous M
calcitriol oral 1
doxercalciferol oral 3
etidronate disodium 1
NATPARA 4 PA; QL
paricalcitol oral 3
ROCALTROL 3
ZEMPLAR ORAL 3
Miscellaneous Therapeutic Agents
alcohol prep pads pad , 70 %
1
ALCOHOL PREP PADS PAD , 70 %
1
AMPHADASE M PA
ANDEXXA INTRAVENOUS SOLUTION RECONSTITUTED 100 MG
M PA
bacteriostatic water(benz alc)
3
BOTOX M PA
BREATHE EASE LARGE 2
BREATHE EASE MEDIUM
2
BREATHE EASE SMALL 2
BREATHERITE 2
CAYA P
Effective Date: 12/01/2019 74
Drug Name Drug Tier
Notes
deferoxamine mesylate injection solution reconstituted 2 gm
M
deferoxamine mesylate injection solution reconstituted 500 mg
1
DESFERAL 3
DIGIFAB M
diluent for treprostinil M
DYSPORT M PA
EASIVENT 2
ENDARI 4 PA; QL
ergoloid mesylates oral 3
EUFLEXXA M PA
FEMCAP P
FIRDAPSE 4 PA; QL
FLEXICHAMBER ADULT MASK/SMALL
2
FLEXICHAMBER CHILD MASK/LARGE
2
FLEXICHAMBER CHILD MASK/SMALL
2
GEL-ONE M PA
GELSYN-3 M PA
GENVISC 850 M PA
GLUCAGEN DIAGNOSTIC
2
GLUCAGON HCL (DIAGNOSTIC)
2
GRASTEK 3 PA
heparin lock flush intravenous solution 10 unit/ml, 100 unit/ml
M
heparin sodium lock flush M
HYALGAN M PA
HYLENEX M PA
INFED M
KALBITOR M PA
MASK VORTEX 2
methergine 1
Drug Name Drug Tier
Notes
methylergonovine maleate
1
MONOVISC M PA
MYOBLOC M PA
ODACTRA 3 PA
OMNIPOD 5 PACK 3 PA
OMNIPOD DASH 5 PACK
3 PA
OPTIONS CONCEPTROL
P
ORALAIR 3 PA
ORALAIR ADULT SAMPLE KIT
3 PA
ORALAIR ADULT STARTER PACK
3 PA
ORALAIR CHILDRENS SAMPLE KIT
3 PA
ORALAIR CHILDRENS STARTER PACK
3 PA
ORTHOVISC M PA
PANDA MASK LARGE 2
PANDA MASK MEDIUM 2
PANDA MASK SMALL 2
PEDIATRIC PANDA MASK
2
pocket spacer 2
PRO COMFORT SPACER ADULT
2
PRO COMFORT SPACER CHILD
2
PROCARE SPACER/ADULT MASK
2
PROCARE SPACER/CHILD MASK
2
RAGWITEK 3 PA
RUZURGI 4 PA; QL
SODIUM HYALURONATE INTRA-ARTICULAR
M PA
STERILE DILUENT FLOLAN PH 12
M
Effective Date: 12/01/2019 75
Drug Name Drug Tier
Notes
STERILE DILUENT FOR FLOLAN
M
sterile diluent/epoprostenol
M
sterile water for injection injection
1
SUPARTZ FX M PA
SYNVISC M PA
SYNVISC ONE M PA
TAKHZYRO 4 PA; QL
TRIVISC M PA
vcf vaginal contraceptive vaginal gel
P
VISCO-3 M PA
VISTOGARD 4 PA; QL
VITRASE M PA
WIDE-SEAL DIAPHRAGM 60
P
XEOMIN INTRAMUSCULAR SOLUTION RECONSTITUTED 200 UNIT
M PA
XIAFLEX M PA
Ophthalmic Agents - Drugs for Eye Allergy, Infection and Inflammation
ACULAR 3
ACULAR LS 3
ACUVAIL 3
ALOCRIL 3
ALOMIDE 2
ALREX 3
AZASITE 3
azelastine hcl ophthalmic 1
bacitracin ophthalmic 1
BEPREVE 3
BESIVANCE 3
BETADINE OPHTHALMIC PREP
3
BLEPH-10 3
Drug Name Drug Tier
Notes
bromfenac sodium (once-daily)
3
BROMSITE 3
CILOXAN OPHTHALMIC OINTMENT
2
CILOXAN OPHTHALMIC SOLUTION
3
ciprofloxacin hcl ophthalmic
1
cromolyn sodium ophthalmic
1
dexamethasone sodium phosphate ophthalmic
1
diclofenac sodium ophthalmic
1
DUREZOL 2
epinastine hcl 3
erythromycin ophthalmic 1
FLAREX 3
fluorometholone 1
flurbiprofen sodium 1
FML 2
FML FORTE 2
FML LIQUIFILM 3
gatifloxacin ophthalmic 1
gentak 1
gentamicin sulfate ophthalmic
1
ILEVRO 3
ILUVIEN M
INVELTYS 3
ketorolac tromethamine ophthalmic
1
KLARITY-A 3
KLARITY-B 3
KLARITY-L 3
levofloxacin ophthalmic 3
LOTEMAX 3
LOTEMAX SM 3
Effective Date: 12/01/2019 76
Drug Name Drug Tier
Notes
loteprednol etabonate 3
MAXIDEX 3
MOXEZA 2
moxifloxacin hcl ophthalmic
1
NATACYN 2
NEVANAC 3
OCUFLOX 3
ofloxacin ophthalmic 1
olopatadine hcl ophthalmic solution 0.1 %
1
olopatadine hcl ophthalmic solution 0.2 %
3
OZURDEX M
PATADAY 3
PATANOL 3
PAZEO 3
POVIDONE-IODINE OPHTHALMIC
3
PRED FORTE 3
PRED MILD 2
PREDNISOL ACE-MOXIFLOX-BROMFEN
3
prednisolone acetate ophthalmic
1
prednisolone acetate p-f 1
prednisolone sodium phosphate ophthalmic
3
PREDNISOLON-MOXIFLOX-NEPAFENAC
3
PROLENSA 3
RETISERT M
sulfacetamide sodium ophthalmic
1
tobramycin ophthalmic 1
TOBREX OPHTHALMIC OINTMENT
2
TOBREX OPHTHALMIC SOLUTION
3
TRIESENCE M
Drug Name Drug Tier
Notes
trifluridine 1
VIGAMOX 2
ZIRGAN 3
ZYMAXID 3
Ophthalmic Agents - Drugs for Glaucoma
acetazolamide er 1
acetazolamide oral tablet 250 mg
1
ALPHAGAN P 3
apraclonidine hcl 3
AZOPT 2
betaxolol hcl ophthalmic 1
BETIMOL 3
BETOPTIC-S 2
bimatoprost ophthalmic 1
brimonidine tartrate ophthalmic solution 0.15 %
3
brimonidine tartrate ophthalmic solution 0.2 %
1
BRIMONIDINE-DORZOLAMIDE
3
carteolol hcl 1
COMBIGAN 3
COSOPT 3
COSOPT PF OPHTHALMIC SOLUTION 22.3-6.8 MG/ML
3
dorzolamide hcl ophthalmic
1
dorzolamide hcl-timolol mal
1
dorzolamide hcl-timolol mal pf ophthalmic solution 22.3-6.8 mg/ml
3
IOPIDINE 3
ISOPTO CARPINE 3
ISTALOL 3
KEVEYIS 4 PA; QL
Effective Date: 12/01/2019 77
Drug Name Drug Tier
Notes
latanoprost ophthalmic 1
LATANOPROST-TIMOLOL MALEATE
3
levobunolol hcl 1
LUMIGAN 2
methazolamide oral 1
PHOSPHOLINE IODIDE 3
pilocarpine hcl ophthalmic 1
RHOPRESSA 3 PA
ROCKLATAN 3 PA
SIMBRINZA 3
timolol maleate ophthalmic gel forming solution
1
timolol maleate ophthalmic solution 0.25 %, 0.5 %
1
timolol maleate ophthalmic solution 0.5 % (daily)
3
TIMOLOL-BRIMON-DORZOL-LATANOPR
3
TIMOLOL-BRIMONIDINE-DORZOLAMID
3
TIMOLOL-DORZOLAMID-LATANOPROST
3
TIMOPTIC 3
TIMOPTIC OCUDOSE 3
TIMOPTIC-XE 3
TRAVATAN Z 2
TRUSOPT 3
VYZULTA 3 PA
XALATAN 3
XELPROS 3
ZIOPTAN 3
Ophthalmic Agents - Drugs for Miscellaneous Eye Conditions
ACUICYN EXTERNAL LIQUID , 0.01 %
3
Drug Name Drug Tier
Notes
ak-poly-bac 1
AKTEN 3
ALCAINE 3
altacaine 3
altafrin 1
ATROPINE SULFATE OPHTHALMIC EMULSION
1
atropine sulfate ophthalmic ointment
1
atropine sulfate ophthalmic solution
1
AVENOVA 3
bacitracin-polymyxin b ophthalmic
1
bacitra-neomycin-polymyxin-hc
1
BLEPHAMIDE 2
BLEPHAMIDE S.O.P. 2
CEQUA 3 PA
CYCLOGYL 3
CYCLOMYDRIL 3
cyclopentolate hcl ophthalmic
1
CYCLOSPORINE IN KLARITY
2 PA
CYSTARAN 4 PA; QL
EYLEA M PA
GATIFLOXACIN-DEXAMETHASONE
3
GELFILM OPHTHALMIC 3
homatropaire 1
homatropine hbr 1
HYPOCYN EXTERNAL LIQUID
3
JETREA M PA
LACRISERT 2
LASTACAFT 3
LUCENTIS M PA
LUXTURNA M PA
Effective Date: 12/01/2019 78
Drug Name Drug Tier
Notes
MACUGEN M
MAXITROL 3
neomycin-bacitracin zn-polymyx
3
neomycin-polymyxin-dexameth ophthalmic ointment
1
neomycin-polymyxin-dexameth ophthalmic suspension 3.5-10000-0.1
1
neomycin-polymyxin-gramicidin
1
neomycin-polymyxin-hc ophthalmic
3
neo-polycin 3
neo-polycin hc 1
OMIDRIA M
OXERVATE 4 PA; QL
phenylephrine hcl ophthalmic
1
polycin 1
polymyxin b-trimethoprim 1
POLYTRIM 3
PRED-G 2
PRED-G S.O.P. 2
PREDNISOLONE ACETATE-NEPAFENAC
3
PREDNISOLONE ACET-MOXIFLOXACIN
3
PREDNISOLONE-BROMFENAC
3
PREDNISOLONE-GATIFLOXACIN
3
PREDNISOLON-GATIFLOX-BROMFENAC
3
PREDNISOLON-MOXIFLOX-BROMFENAC
3
proparacaine hcl ophthalmic
3
RESTASIS 2 PA
Drug Name Drug Tier
Notes
RESTASIS MULTIDOSE OPHTHALMIC EMULSION 0.05 %
2 PA
sulfacetamide-prednisolone ophthalmic solution
1
tetcaine 3
tetracaine hcl ophthalmic 3
tetravisc 3
tetravisc forte 3
TOBRADEX OPHTHALMIC OINTMENT
2
TOBRADEX OPHTHALMIC SUSPENSION
3
TOBRADEX ST 3
tobramycin-dexamethasone
1
TROPICAMIDE-CYCLOPENTOLATE-PE
3
TROPICAMIDE-PHENYLEPHRINE
3 PA
TROPIC-PROPARACA-PE-KETOROLAC
3
VISUDYNE M
XIIDRA 2 PA
ZYLET 3
Otic Agents - Drugs for Ear Conditions
acetic acid otic 1
CETRAXAL 3
CIPRO HC 2
CIPRODEX 2
ciprofloxacin hcl otic 3
CIPROFLOXACIN-FLUOCINOLONE PF
3
COLY-MYCIN S 3
DERMOTIC 3
flac 3
FLOXIN OTIC 3
Effective Date: 12/01/2019 79
Drug Name Drug Tier
Notes
fluocinolone acetonide otic
3
hydrocortisone-acetic acid 3
neomycin-polymyxin-hc otic
1
ofloxacin otic 1
OTIPRIO M
OTOVEL 3
PRAMOTIC 3
Respiratory Tract / Pulmonary Agents - Drugs for Allergies, Cough, Cold
ADRENALIN NASAL 3
ASTEPRO 3
azelastine hcl nasal 1
BECONASE AQ 3 PA
benzonatate oral capsule 100 mg, 200 mg
1
benzonatate oral capsule 150 mg
3
bromfed dm 3
brompheniramine tannate 3
carbinoxamine maleate 1
cetirizine hcl oral solution 3
CINQAIR M PA
CLARINEX 3
CLARINEX-D 12 HOUR 3
clemastine fumarate oral tablet 2.68 mg
1
CUROSURF 3
cyproheptadine hcl oral 1
DERMACINRX AZENASE PAK
3
desloratadine 1
diphen oral elixir 3
diphenhydramine hcl injection
1
diphenhydramine hcl oral elixir
3
DYMISTA 3
FASENRA M PA
Drug Name Drug Tier
Notes
flunisolide nasal 1
hydrocodone polst-cpm polst er
3
hydrocodone-homatropine
1
hydromet 1
HYPERSAL INHALATION NEBULIZATION SOLUTION 3.5 %
3
INFASURF 3
ipratropium bromide nasal 1
KARBINAL ER 3
levocetirizine dihydrochloride oral
1
mometasone furoate nasal
3 PA
NASONEX 3 PA
nebusal inhalation nebulization solution 3 %
1
NEBUSAL INHALATION NEBULIZATION SOLUTION 6 %
3
NUCALA SUBCUTANEOUS SOLUTION AUTO-INJECTOR
4 PA; QL
NUCALA SUBCUTANEOUS SOLUTION PREFILLED SYRINGE
4 PA; QL
NUCALA SUBCUTANEOUS SOLUTION RECONSTITUTED
M PA
olopatadine hcl nasal 3
OMNARIS 3 PA
PATANASE 3
phenadoz 1
PHENERGAN 3
phenylephrine-guaifenesin oral liquid
3
promethazine hcl injection 3
Effective Date: 12/01/2019 80
Drug Name Drug Tier
Notes
promethazine hcl oral syrup
1
promethazine hcl oral tablet
1
promethazine hcl rectal 1
promethazine-codeine 3 PA
promethazine-dm 1
promethazine-phenyleph-codeine
3 PA
promethazine-phenylephrine
1
promethegan 1
PROPEL M PA
PROPEL MINI M PA
pseudoephedrine-bromphen-dm
3
pulmosal 1
QNASL 3 PA
QNASL CHILDRENS 3 PA
ryvent 1
SEMPREX-D 3
SINUVA M PA
sodium chloride inhalation nebulization solution 0.9 %, 3 %, 7 %
1
sodium chloride inhalation nebulization solution 10 %
3
SSKI 2
SURVANTA 2
TESSALON PERLES 3
TUSSICAPS 3
TUXARIN ER 3 PA; QL
TUZISTRA XR 3 PA
XHANCE 3 PA
XOLAIR SUBCUTANEOUS SOLUTION RECONSTITUTED
M PA
ZETONNA 3 PA
Drug Name Drug Tier
Notes
Respiratory Tract / Pulmonary Agents - Drugs for Asthma and Other Lung Conditions
ACCOLATE 3
acetylcysteine inhalation 1
ADVAIR DISKUS 1 ST
ADVAIR HFA 2 ST
ADYPHREN 3
ADYPHREN AMP 3
ADYPHREN AMP II 3
ADYPHREN II 3
AIRDUO RESPICLICK 113/14
3 PA
AIRDUO RESPICLICK 232/14
3 PA
AIRDUO RESPICLICK 55/14
3 PA
albuterol sulfate er 3
ALBUTEROL SULFATE HFA
3 QL
albuterol sulfate inhalation 1
albuterol sulfate oral 1
ALVESCO 2
aminophylline intravenous M
ANORO ELLIPTA 3 PA
ARALAST NP M PA
ARCAPTA NEOHALER 3
ARNUITY ELLIPTA 3 PA
ASMANEX (120 METERED DOSES)
2 ST
ASMANEX (14 METERED DOSES)
2 ST
ASMANEX (30 METERED DOSES)
2 ST
ASMANEX (60 METERED DOSES)
2 ST
ASMANEX (7 METERED DOSES)
2 ST
ASMANEX HFA 2 ST
ATROVENT HFA 2
Effective Date: 12/01/2019 81
Drug Name Drug Tier
Notes
AUVI-Q 3
BEVESPI AEROSPHERE 3 PA
BREO ELLIPTA 3 PA
BROVANA 3 PA
budesonide inhalation 1
COMBIVENT RESPIMAT 2
cromolyn sodium inhalation
1
DALIRESP 3
difil-g forte 3
DUAKLIR PRESSAIR 3 PA
DULERA 3 PA
ELIXOPHYLLIN 3
epinephrine injection solution 0.3 mg/0.3ml
1
epinephrine injection solution auto-injector
1
EPINEPHRINE PROFESSIONAL
3
EPINEPHRINESNAP-EMS
3
EPINEPHRINESNAP-V 3
EPIPEN 2-PAK 2
EPIPEN JR 2-PAK 2
EPISNAP 3
ESBRIET 4 PA; QL
FLOVENT DISKUS 2 PA
FLOVENT HFA INHALATION AEROSOL 110 MCG/ACT, 220 MCG/ACT
2 PA
FLOVENT HFA INHALATION AEROSOL 44 MCG/ACT
2
fluticasone-salmeterol inhalation aerosol powder breath activated 100-50 mcg/dose, 250-50 mcg/dose, 500-50 mcg/dose
1 ST
Drug Name Drug Tier
Notes
FLUTICASONE-SALMETEROL INHALATION AEROSOL POWDER BREATH ACTIVATED 113-14 MCG/ACT, 232-14 MCG/ACT, 55-14 MCG/ACT
3 PA
GLASSIA M PA
INCRUSE ELLIPTA 3 PA
ipratropium bromide inhalation
1
ipratropium-albuterol 1
levalbuterol hcl inhalation 3
LEVALBUTEROL HFA INHALATION AEROSOL 45 MCG/ACT
3 QL
LONHALA MAGNAIR REFILL KIT
3 PA
LONHALA MAGNAIR STARTER KIT
3 PA
metaproterenol sulfate oral
1
montelukast sodium oral 1
OFEV 4 PA; QL
PERFOROMIST 3
PROAIR DIGIHALER 3 QL
PROAIR HFA 3 QL
PROAIR RESPICLICK 3 QL
PROLASTIN-C M PA
PROVENTIL HFA 3 QL
PULMICORT FLEXHALER
3 PA
PULMICORT SUSPENSION
3
QVAR REDIHALER 3 PA
SEEBRI NEOHALER 3 PA
SEREVENT DISKUS 2 ST
SINGULAIR 3
SPIRIVA HANDIHALER 2
Effective Date: 12/01/2019 82
Drug Name Drug Tier
Notes
SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 1.25 MCG/ACT
2 ST
SPIRIVA RESPIMAT INHALATION AEROSOL SOLUTION 2.5 MCG/ACT
2
STIOLTO RESPIMAT 2
STRIVERDI RESPIMAT 2 PA
SYMBICORT 3 PA
SYMJEPI INJECTION SOLUTION PREFILLED SYRINGE 0.15 MG/0.3ML
3
terbutaline sulfate injection
3
terbutaline sulfate oral 1
THEO-24 3
theochron 1
theophylline 1
theophylline er 1
theophylline in d5w M
TRELEGY ELLIPTA 3 PA
TUDORZA PRESSAIR 3
UTIBRON NEOHALER 3 PA
VENTOLIN HFA 2 QL
XOPENEX 3
XOPENEX CONCENTRATE
3
XOPENEX HFA 3 QL
YUPELRI 3 PA
zafirlukast 3
ZEMAIRA M PA
zileuton er 4 PA; QL
ZYFLO 4 PA; QL
Respiratory Tract / Pulmonary Agents - Drugs for Cystic Fibrosis
BETHKIS 4 PA; QL
CAYSTON 4 PA; QL
Drug Name Drug Tier
Notes
KALYDECO 4 PA; QL
KITABIS PAK 4 PA; QL
ORKAMBI 4 PA; QL
PULMOZYME 4 QL
SYMDEKO 4 PA; QL
TOBI NEBULIZER 4 PA; QL
TOBI PODHALER 4 PA; QL
tobramycin nebulization solution 300 mg/5ml inhalation
4 PA; QL
TOBRAMYCIN NEBULIZATION SOLUTION 300 MG/5ML INHALATION
4 PA; QL
TRIKAFTA 4 PA; QL
Respiratory Tract / Pulmonary Agents - Drugs for Pulmonary Hypertension
ADCIRCA 4 PA; QL
ADEMPAS 4 PA; QL
alyq 4 PA; QL
ambrisentan 1 PA; QL
bosentan 1 PA; QL
epoprostenol sodium M PA
LETAIRIS 4 PA; QL
OPSUMIT 4 PA; QL
ORENITRAM ORAL TABLET EXTENDED RELEASE 0.125 MG
3 PA; QL
ORENITRAM ORAL TABLET EXTENDED RELEASE 0.25 MG, 1 MG, 2.5 MG, 5 MG
4 PA; QL
REVATIO ORAL SUSPENSION RECONSTITUTED
4 PA; QL
REVATIO ORAL TABLET 4 PA
sildenafil citrate intravenous
M
sildenafil citrate oral suspension reconstituted
4 QL
sildenafil citrate oral tablet 20 mg
4 PA
tadalafil (pah) 4 PA; QL
Effective Date: 12/01/2019 83
Drug Name Drug Tier
Notes
TRACLEER 4 PA; QL
TYVASO 4 PA; QL
TYVASO REFILL 4 PA; QL
TYVASO STARTER 4 PA; QL
UPTRAVI 4 PA; QL
VELETRI M PA
VENTAVIS 4 PA; QL
Skeletal Muscle Relaxants - Drugs for Muscle Pain and Spasm
AMRIX 3 PA; QL
baclofen intrathecal M
baclofen oral 1
carisoprodol oral 3 PA; QL
carisoprodol-aspirin 3 PA
chlorzoxazone oral tablet 375 mg, 500 mg, 750 mg
3 QL
cyclobenzaprine hcl er 3 PA; QL
cyclobenzaprine hcl oral tablet 10 mg, 5 mg
1 QL
cyclobenzaprine hcl oral tablet 7.5 mg
3 QL
DANTRIUM ORAL 3
dantrolene sodium oral 1
FEXMID 3 QL
FIRST-BACLOFEN 3
GABLOFEN M
LIORESAL INTRATHECAL INTRATHECAL SOLUTION 2000 MCG/ML, 40 MG/20ML, 500 MCG/ML
M
LIORESAL INTRATHECAL SOLUTION 0.05 MG/ML, 10 MG/20ML, 40 MG/20ML
M
LORZONE 3 QL
metaxalone 3 QL
methocarbamol injection 1
methocarbamol oral 1 QL
Drug Name Drug Tier
Notes
NORGESIC FORTE 3 QL
orphenadrine citrate er 1 QL
orphenadrine citrate injection
3
orphenadrine-aspirin-caffeine
3 QL
ORPHENGESIC FORTE 3 QL
OZOBAX 3
ROBAXIN 3
ROBAXIN-750 3 QL
SKELAXIN 3 QL
SOMA 3 PA; QL
tizanidine hcl oral capsule 3
tizanidine hcl oral tablet 1
ZANAFLEX 3
Sleep Disorder Agents
AMBIEN 3
AMBIEN CR 3
AMYTAL SODIUM 3
armodafinil 3 PA
BELSOMRA 3 PA
BUTISOL SODIUM 3
EDLUAR 3
eszopiclone 1
flurazepam hcl 1
HETLIOZ 4 PA; QL
INTERMEZZO 3
LUNESTA 3
modafinil 1
NUVIGIL 3 PA
PROVIGIL 3
ramelteon 3
RESTORIL 3
ROZEREM 3
SECONAL 2
SILENOR 3
SUNOSI 4 PA; QL
Effective Date: 12/01/2019 84
Drug Name Drug Tier
Notes
temazepam oral capsule 15 mg, 30 mg, 7.5 mg
1
temazepam oral capsule 22.5 mg
3
WAKIX 4 PA; QL
XYREM 4 PA; QL
zaleplon 1
zolpidem tartrate er 3
zolpidem tartrate oral 1
zolpidem tartrate sublingual
3
Effective Date: 12/01/2019 85
86
Index of Drugs
A abacavir sulfate ............... 34 abacavir sulfate-lamivudine
.................................... 34 abacavir-lamivudine-
zidovudine ................... 34 ABELCET ........................ 26 ABILIFY ........................... 33 ABILIFY MAINTENA ........ 33 ABILIFY MYCITE ............ 33 abiraterone acetate.......... 28 ABRAXANE ..................... 28 ABSORICA ...................... 46 ABSTRAL ........................ 12 acamprosate calcium ....... 16 ACANYA ......................... 46 acarbose ......................... 52 ACCOLATE ..................... 80 ACCU-CHEK AVIVA
DEVICE ....................... 53 ACCU-CHEK COMPACT
PLUS CONTROL ......... 53 ACCU-CHEK FASTCLIX
LANCET KIT ................ 53 ACCU-CHEK GUIDE
CONTROL ................... 54 ACCU-CHEK MULTICLIX
LANCET DEVICE KIT .. 54 ACCU-CHEK SMARTVIEW
CONTROL ................... 54 ACCU-CHEK SOFTCLIX
LANCET DEVICE KIT .. 54 ACCUPRIL ...................... 38 ACCURETIC ................... 38 acebutolol hcl .................. 38 acetaminophen-codeine .. 12 acetaminophen-codeine #2
.................................... 12 acetaminophen-codeine #3
.................................... 12 acetaminophen-codeine #4
.................................... 12 acetazolamide ........... 38, 76 acetazolamide er ............. 76 acetazolamide sodium ..... 38 acetic acid ................. 60, 78 acetylcysteine .................. 80 ACIPHEX ........................ 57 ACIPHEX SPRINKLE ...... 57 acitretin ............................ 46 ACTEMRA ....................... 69 ACTEMRA ACTPEN ....... 69 ACTHAR ......................... 63
ACTHIB ........................... 71 ACTICLATE .................... 16 ACTIGALL ....................... 58 ACTIMMUNE .................. 69 ACTIQ ............................. 12 ACTIVASE ...................... 21 ACTIVELLA ..................... 64 ACTONEL ....................... 73 ACTOPLUS MET ............ 52 ACTOS ............................ 52 ACUICYN ........................ 77 ACULAR ......................... 75 ACULAR LS .................... 75 ACUVAIL ......................... 75 acyclovir .......................... 34 acyclovir sodium .............. 34 ACZONE ......................... 46 ADACEL .......................... 71 ADALAT CC .................... 38 adapalene ....................... 46 ADAPALENE ................... 46 adapalene-benzoyl peroxide
.................................... 46 ADCETRIS ...................... 28 ADCIRCA ........................ 82 ADDERALL ..................... 44 ADDERALL XR ............... 44 ADDYI ............................. 45 adefovir dipivoxil .............. 34 ADEMPAS....................... 82 ADHANSIA XR ................ 44 ADLYXIN ......................... 52 ADLYXIN STARTER PACK
.................................... 52 ADMELOG ...................... 54 ADMELOG SOLOSTAR .. 54 ADRENALIN .................... 78 adriamycin ....................... 28 adrucil ............................. 28 ADVAIR DISKUS............. 80 ADVAIR HFA ................... 80 ADVANCED ALLERGY
COLLECTION ............. 46 ADVATE .......................... 37 ADYNOVATE .................. 37 ADYPHREN .................... 80 ADYPHREN AMP............ 80 ADYPHREN AMP II ......... 80 ADYPHREN II ................. 80 ADZENYS ER ................. 44 ADZENYS XR-ODT ......... 44 AEMCOLO ...................... 16 AFINITOR ....................... 28
AFINITOR DISPERZ ....... 28 afirmelle .......................... 64 AFLURIA QUADRIVALENT
.................................... 71 AFREZZA........................ 54 AFSTYLA ........................ 37 AGGRASTAT .................. 33 AGGRENOX ................... 33 agoneaze ........................ 15 AGRYLIN ........................ 37 AIMOVIG......................... 27 AIRDUO RESPICLICK
113/14 ......................... 80 AIRDUO RESPICLICK
232/14 ......................... 80 AIRDUO RESPICLICK
55/14 ........................... 80 AJOVY ............................ 27 AKLIEF ........................... 46 ak-poly-bac ..................... 77 AKTEN ............................ 77 AKYNZEO ....................... 25 ala-cort ............................ 46 albendazole ..................... 32 ALBENZA........................ 32 albuterol sulfate ............... 80 albuterol sulfate er ........... 80 ALBUTEROL SULFATE
HFA ............................. 80 ALCAINE......................... 77 alclometasone dipropionate
.................................... 46 alcohol prep pads ............ 73 ALCOHOL PREP PADS .. 73 ALDACTAZIDE ......... 38, 39 ALDACTONE .................. 39 ALDARA ......................... 46 ALDURAZYME ............... 60 ALECENSA ..................... 28 alendronate sodium ......... 73 ALFERON N ................... 69 alfuzosin hcl er ................ 61 ALIMTA ........................... 28 ALINIA ............................ 32 ALIQOPA ........................ 28 aliskiren fumarate ............ 39 ALKERAN ....................... 28 allopurinol........................ 27 allopurinol sodium ........... 27 ALLZITAL ........................ 12 almotriptan malate ........... 27 ALOCRIL......................... 75
87
ALOGLIPTIN BENZOATE .................................... 52
ALOGLIPTIN-METFORMIN HCL ............................. 52
ALOGLIPTIN-PIOGLITAZONE .......... 52
ALOMIDE ........................ 75 ALORA ............................ 64 alosetron hcl .................... 58 ALOXI.............................. 25 ALPHAGAN P ................. 76 ALPHANATE/VWF
COMPLEX/HUMAN ..... 37 ALPHANINE SD .............. 37 alprazolam ....................... 36 alprazolam er ................... 36 ALPRAZOLAM INTENSOL
.................................... 36 alprazolam xr ................... 36 ALPROLIX ....................... 37 alprostadil ........................ 39 ALREX ............................ 75 ALTABAX ........................ 16 altacaine .......................... 77 ALTACE .......................... 39 altafrin ............................. 77 altavera ........................... 64 ALTOPREV ..................... 39 ALTRENO ....................... 46 ALUNBRIG ...................... 28 ALVESCO ....................... 80 alyacen 1/35 .................... 64 alyacen 7/7/7 ................... 64 alyq ................................. 82 amabelz ........................... 64 amantadine hcl ................ 33 AMARYL ......................... 52 AMBIEN .......................... 83 AMBIEN CR .................... 83 AMBISOME ..................... 26 ambrisentan..................... 82 amcinonide ...................... 46 AMELUZ .......................... 46 AMERGE ......................... 27 amethia ........................... 64 amethia lo ........................ 64 amethyst .......................... 64 AMICAR .......................... 37 amikacin sulfate ............... 16 amiloride hcl .................... 39 amiloride-
hydrochlorothiazide ..... 39 aminoacetic acid .............. 60 aminocaproic acid ........... 37 aminophylline .................. 80
amiodarone hcl ................ 39 AMITIZA .......................... 58 amitriptyline hcl ............... 23 amlactin ........................... 46 amlodipine besylate ......... 39 amlodipine besylate-
benazepril hcl .............. 39 amlodipine besylate-
valsartan ...................... 39 amlodipine-atorvastatin ... 39 amlodipine-olmesartan .... 39 amlodipine-valsartan-hctz 39 ammonium lactate ........... 46 amnesteem ..................... 46 amoxapine....................... 24 amoxicill-clarithro-lansopraz
.................................... 58 amoxicillin ....................... 16 amoxicillin-potassium
clavulanate .................. 16 amoxicillin-potassium
clavulanate er .............. 16 AMPHADASE .................. 73 amphetamine sulfate ....... 44 amphetamine-
dextroamphetamine ..... 44 amphetamine-
dextroamphetamine er . 44 ampicillin ......................... 16 ampicillin sodium ............. 16 ampicillin-sulbactam sodium
.................................... 16 AMPYRA ......................... 45 AMRIX ............................. 82 AMYTAL SODIUM ........... 83 ANACAINE ...................... 46 ANADROL-50 .................. 63 ANAFRANIL .................... 24 anagrelide hcl .................. 37 ANALPRAM-HC .............. 72 anastrozole...................... 28 ANCOBON ...................... 26 ANDEXXA ....................... 73 ANDRODERM ................. 63 ANDROGEL .................... 63 ANDROGEL PUMP ......... 63 ANGELIQ ........................ 64 ANNOVERA .................... 64 anodyne lpt...................... 15 ANORO ELLIPTA ............ 80 ANTABUSE ..................... 16 ANTARA ......................... 39 anucort-hc ....................... 72 anusol-hc ........................ 72 ANUSOL-HC ................... 72
ANZEMET ....................... 25 APADAZ ......................... 12 apap-caff-dihydrocodeine 12 APIDRA SOLOSTAR ...... 54 APIDRA VIAL .................. 54 APLENZIN ...................... 24 APOKYN ......................... 33 apraclonidine hcl ............. 76 aprepitant ........................ 25 apri .................................. 64 APRISO .......................... 72 APTENSIO XR ................ 44 APTIOM .......................... 22 APTIVUS......................... 34 ARALAST NP .................. 80 aranelle ........................... 64 ARANESP (ALBUMIN
FREE) ......................... 37 ARAVA ............................ 69 ARCALYST ..................... 69 ARCAPTA NEOHALER ... 80 argyle sterile saline ......... 55 argyle sterile water .......... 55 ARICEPT ........................ 23 ARIKAYCE ...................... 16 ARIMIDEX ....................... 28 aripiprazole ............... 33, 34 ARISTADA ...................... 34 ARISTADA INITIO ........... 34 ARIXTRA ........................ 21 armodafinil ...................... 83 ARMOUR THYROID ....... 68 ARNUITY ELLIPTA ......... 80 AROMASIN ..................... 28 ARRANON ...................... 28 arsenic trioxide ................ 28 ARTHROTEC .................. 11 ARYMO ER ..................... 12 ARZERRA ....................... 28 arzol silver nit applicators 46 ASACOL HD ................... 72 ascomp-codeine .............. 12 ashlyna ........................... 64 ASMANEX (120 METERED
DOSES) ...................... 80 ASMANEX (14 METERED
DOSES) ...................... 80 ASMANEX (30 METERED
DOSES) ...................... 80 ASMANEX (60 METERED
DOSES) ...................... 80 ASMANEX (7 METERED
DOSES) ...................... 80 ASMANEX HFA .............. 80 aspirin ............................. 11
88
aspirin adult ..................... 11 aspirin adult low strength . 11 aspirin childrens .............. 11 aspirin ec low dose .......... 11 aspirin ec low strength ..... 11 aspirin low dose ............... 11 aspirin-dipyridamole er .... 33 ASPIRIN-OMEPRAZOLE 57 ASTAGRAF XL ................ 69 ASTEPRO ....................... 78 ASTERO ......................... 15 ATACAND ....................... 39 ATACAND HCT ............... 39 atazanavir sulfate ............ 34 ATELVIA ......................... 73 atenolol ............................ 39 atenolol-chlorthalidone .... 39 ATGAM ........................... 69 ATIVAN ........................... 36 atomoxetine hcl ............... 44 ATOPADERM .................. 46 ATOPICLAIR ................... 46 atorvastatin calcium ......... 39 atovaquone ..................... 32 atovaquone-proguanil hcl 32 ATRALIN ......................... 46 ATRIPLA ......................... 34 atropine sulfate ................ 77 ATROPINE SULFATE ..... 77 ATROVENT HFA ............. 80 AUBAGIO ........................ 45 aubra ............................... 64 aubra eq .......................... 64 AUGMENTIN ................... 16 AUGMENTIN ES-600 ...... 16 aurovela 1.5/30 ................ 64 aurovela 1/20................... 64 aurovela 24 fe .................. 64 aurovela fe 1.5/30 ............ 64 aurovela fe 1/20 ............... 64 AURYXIA ........................ 60 AUSTEDO ....................... 45 AUTOLET LANCING
DEVICE ....................... 54 AUVI-Q ............................ 80 AVALIDE ......................... 39 AVANDIA ........................ 52 AVAPRO ......................... 39 AVAR .............................. 46 avar cleanser ................... 46 AVAR LS ......................... 46 avar-e emollient ............... 46 avar-e green .................... 46 AVASTIN ......................... 28 AVC VAGINAL ................ 26
AVEED ............................ 63 AVELOX .......................... 16 AVENOVA ....................... 77 aviane ............................. 64 avidoxy ............................ 16 avita ................................ 46 AVODART ....................... 61 AVONEX PEN ................. 45 AVONEX PREFILLED ..... 45 AVYCAZ .......................... 16 AYGESTIN ...................... 64 ayuna .............................. 64 azacitidine ....................... 28 AZASAN .......................... 69 AZASITE ......................... 75 azathioprine ..................... 69 azathioprine sodium ........ 69 azelaic acid ..................... 46 azelastine hcl ............ 75, 78 AZELEX .......................... 46 AZILECT ......................... 33 azithromycin .............. 16, 17 AZOPT ............................ 76 AZOR .............................. 39 AZULFIDINE ................... 72 AZULFIDINE EN-TABS ... 72 azurette ........................... 64 B bacitracin ......................... 75 bacitracin-polymyxin b ..... 77 bacitra-neomycin-
polymyxin-hc ............... 77 baclofen .......................... 82 bacteriostatic water(benz
alc) .............................. 73 BACTOCILL IN DEXTROSE
.................................... 17 BACTRIM ........................ 17 BACTRIM DS .................. 17 BALCOLTRA ................... 64 balsalazide disodium ....... 72 balsam peru-castor oil ..... 46 BALVERSA ..................... 28 balziva ............................. 64 BANZEL .......................... 22 BAQSIMI ONE PACK ...... 54 BAQSIMI TWO PACK ..... 54 BARACLUDE .................. 35 BASAGLAR KWIKPEN.... 54 BAVENCIO...................... 28 BAXDELA ....................... 17 bayer aspirin .................... 11 bayer aspirin ec low dose 11 BAYER CONTOUR ......... 54
BD AUTOSHIELD DUO PEN NEEDLES ........... 54
BD ULTRA-FINE INSULIN SYRINGES.................. 54
BD ULTRA-FINE PEN NEEDLES ................... 55
BECONASE AQ .............. 78 bekyree ........................... 64 BELBUCA ....................... 12 BELEODAQ .................... 28 belladonna alkaloids-opium
.................................... 58 BELRAPZO ..................... 28 BELSOMRA .................... 83 benazepril hcl .................. 39 benazepril-
hydrochlorothiazide ..... 39 BENDAMUSTINE HCL .... 28 BENDEKA ....................... 28 BENEFIX......................... 37 BENICAR ........................ 39 BENICAR HCT ................ 39 BENLYSTA ..................... 69 BENSAL HP .................... 46 BENTYL .......................... 58 BENZACLIN .................... 46 BENZACLIN WITH PUMP
.................................... 46 BENZAMYCIN ................ 46 benzepro foaming cloths . 46 BENZHYDROCODONE-
ACETAMINOPHEN ..... 12 BENZIQ .......................... 46 BENZIQ LS ..................... 46 BENZNIDAZOLE ............. 32 benzonatate .................... 79 BENZOYL PEROX-
HYDROCORTISONE .. 46 BENZOYL PEROXIDE .... 46 BENZOYL PEROXIDE
FORTE- HC ................. 46 benzoyl peroxide-
erythromycin ................ 46 benztropine mesylate ...... 33 BEPREVE ....................... 75 BERINERT ...................... 69 beser ............................... 46 BESIVANCE ................... 75 BESPONSA .................... 28 BETADINE OPHTHALMIC
PREP .......................... 75 betamethasone
dipropionate ................ 46 betamethasone
dipropionate aug ......... 46
89
betamethasone sod phos & acet ............................. 61
betamethasone valerate .. 46 BETAPACE ..................... 39 BETAPACE AF ................ 39 BETASERON .................. 45 betaxolol hcl .............. 39, 76 bethanechol chloride ....... 60 BETHKIS ......................... 82 BETIMOL ........................ 76 BETOPTIC-S ................... 76 BEVESPI AEROSPHERE80 bexarotene ...................... 28 BEXSERO ....................... 71 BEYAZ ............................ 64 bicalutamide .................... 28 BICILLIN C-R .................. 17 BICILLIN C-R 900/300 ..... 17 BICILLIN L-A ................... 17 BICNU ............................. 28 BIDIL ............................... 39 BIJUVA ............................ 64 BIKTARVY ...................... 35 BILTRICIDE..................... 32 bimatoprost ..................... 76 BINOSTO ........................ 73 bio-statin .......................... 26 BIO-STATIN .................... 26 BIOTHRAX ...................... 71 bisacodyl ec..................... 58 bisoprolol fumarate .......... 39 bisoprolol-
hydrochlorothiazide ..... 39 BIVIGAM ......................... 69 bleomycin sulfate ............. 28 BLEPH-10 ....................... 75 BLEPHAMIDE ................. 77 BLEPHAMIDE S.O.P. ...... 77 BLINCYTO ...................... 28 blisovi 24 fe ..................... 64 blisovi fe 1.5/30 ............... 64 blisovi fe 1/20 .................. 64 BLOXIVERZ .................... 28 BOCASAL ....................... 45 BONIVA ........................... 73 BONJESTA ..................... 25 BOOSTRIX ...................... 71 BORTEZOMIB ................. 28 bosentan ......................... 82 BOSULIF ......................... 28 BOTOX ............................ 73 bp 10-1 ............................ 46 bp cleansing wash ........... 46 BPCO .............................. 46 bpo .................................. 47
BRAFTOVI ...................... 28 BREATHE EASE LARGE 73 BREATHE EASE MEDIUM
.................................... 73 BREATHE EASE SMALL 73 BREATHERITE ............... 73 BREO ELLIPTA ............... 80 briellyn ............................. 65 BRILINTA ........................ 33 brimonidine tartrate ......... 76 BRIMONIDINE-
DORZOLAMIDE .......... 76 BRISDELLE .................... 24 BRIVIACT ....................... 22 bromfed dm ..................... 79 bromfenac sodium (once-
daily) ........................... 75 bromocriptine mesylate ... 33 brompheniramine tannate 79 BROMSITE ..................... 75 BROVANA....................... 80 BRYHALI ......................... 47 budesonide................ 72, 80 budesonide er ................. 72 bumetanide ..................... 39 BUMEX ........................... 39 BUNAVAIL ...................... 16 BUPAP ............................ 12 BUPHENYL ..................... 60 BUPRENEX .................... 12 buprenorphine ................. 12 BUPRENORPHINE ......... 12 buprenorphine hcl...... 12, 16 buprenorphine hcl-naloxone
hcl ............................... 16 bupropion hcl ................... 24 bupropion hcl er (smoking
det) .............................. 16 bupropion hcl er (sr) ........ 24 bupropion hcl er (xl) ......... 24 BUPROPION HCL ER (XL)
.................................... 24 buspirone hcl ................... 36 busulfan .......................... 28 butalbital-acetaminophen 12 BUTALBITAL-
ACETAMINOPHEN ..... 12 butalbital-apap-caff-cod ... 12 butalbital-apap-caffeine ... 12 butalbital-asa-caff-codeine
.................................... 12 butalbital-aspirin-caffeine . 12 BUTISOL SODIUM .......... 83 butorphanol tartrate ......... 12 BUTRANS ....................... 12
BYDUREON .................... 52 BYDUREON BCISE
AUTOINJECTOR ........ 52 BYETTA 10 MCG PEN .... 52 BYETTA 5 MCG PEN...... 52 BYSTOLIC ...................... 39 C cabergoline ..................... 63 CABLIVI .......................... 33 CABOMETYX ................. 28 CADUET ......................... 39 CAFERGOT .................... 27 caffeine citrate ................. 45 CALAN ............................ 39 CALAN SR ...................... 39 calcipotriene .................... 47 calcipotriene-betameth
diprop .......................... 47 calcitonin (salmon) .......... 73 calcitrene......................... 47 calcitriol ..................... 47, 73 calcium acetate (phos
binder) ......................... 60 CALDOLOR .................... 11 CALQUENCE .................. 28 CAMBIA .......................... 11 camila ............................. 65 CAMPATH ...................... 28 CAMPTOSAR ................. 29 camrese .......................... 65 camrese lo ...................... 65 CANASA ......................... 72 candesartan cilexetil ........ 39 candesartan cilexetil-hctz 39 CAPASTAT SULFATE .... 28 capecitabine .................... 29 CAPEX ............................ 47 CAPRELSA ..................... 29 captopril .......................... 39 captopril-
hydrochlorothiazide ..... 39 CARAC ........................... 47 CARAFATE ..................... 57 CARBAGLU .................... 55 carbamazepine ............... 22 carbamazepine er ........... 22 CARBATROL .................. 22 carbidopa ........................ 33 carbidopa-levodopa ......... 33 carbidopa-levodopa er..... 33 carbidopa-levodopa-
entacapone ................. 33 carbinoxamine maleate ... 79 carboplatin ...................... 29 carboprost tromethamine 64
90
CARDIZEM ..................... 39 CARDIZEM CD ............... 39 CARDIZEM LA ................ 39 CARDURA ...................... 39 CARDURA XL ................. 61 CARETOUCH
LANCING/EJECTOR ... 54 carimune nf ..................... 69 CARIMUNE NF ............... 69 carisoprodol ..................... 82 carisoprodol-aspirin ......... 82 carisoprodol-aspirin-codeine
.................................... 12 carmustine ....................... 29 CARNITOR ..................... 55 CARNITOR SF ................ 55 CAROSPIR ..................... 39 carteolol hcl ..................... 76 cartia xt ............................ 39 carvedilol ......................... 39 carvedilol phosphate er ... 39 CASODEX ....................... 29 caspofungin acetate ........ 26 CATAPRES ..................... 39 CATAPRES-TTS-1 .......... 39 CATAPRES-TTS-2 .......... 39 CATAPRES-TTS-3 .......... 39 CAYA .............................. 73 CAYSTON ....................... 82 caziant ............................. 65 cefaclor ............................ 17 cefaclor er ....................... 17 cefadroxil ......................... 17 cefazolin sodium .............. 17 cefazolin sodium-dextrose
.................................... 17 cefdinir............................. 17 cefditoren pivoxil .............. 17 cefepime hcl .................... 17 cefepime-dextrose ........... 17 cefixime ........................... 17 cefotaxime sodium........... 17 cefotetan disodium .......... 17 cefotetan disodium-dextrose
.................................... 17 cefoxitin sodium ............... 17 cefoxitin sodium-dextrose 17 cefpodoxime proxetil ........ 17 cefprozil ........................... 17 ceftazidime ...................... 17 ceftazidime and dextrose . 17 ceftriaxone sodium .......... 17 ceftriaxone sodium in
dextrose....................... 17
ceftriaxone sodium-dextrose .................................... 17
cefuroxime axetil ............. 17 cefuroxime sodium .......... 17 CELEBREX ..................... 11 celecoxib ......................... 11 CELESTONE SOLUSPAN
.................................... 61 CELEXA .......................... 24 CELLCEPT...................... 69 CELONTIN ...................... 22 cem-urea ......................... 47 CENTANY ....................... 17 cephalexin ....................... 17 CEPROTIN...................... 37 CEQUA ........................... 77 CERACADE .................... 47 ceramax .......................... 47 CERDELGA .................... 60 CEREZYME .................... 60 CERVIDIL ....................... 64 cetirizine hcl .................... 79 CETRAXAL ..................... 78 cevimeline hcl .................. 45 CHANTIX ........................ 16 CHANTIX CONTINUING
MONTH PAK ............... 16 CHANTIX STARTING
MONTH PAK ............... 16 chateal ............................ 65 chateal eq ....................... 65 CHEMET ......................... 55 CHENODAL .................... 58 chloramphenicol sod
succinate ..................... 17 chlordiazepoxide hcl ........ 36 chlordiazepoxide-
amitriptyline ................. 24 chlordiazepoxide-clidinium
.................................... 58 chlorhexidine gluconate ... 45 chloroquine phosphate .... 32 chlorothiazide .................. 39 chlorpromazine hcl .......... 34 chlorthalidone .................. 39 chlorzoxazone ................. 82 CHOLBAM ...................... 58 cholestyramine ................ 39 cholestyramine light ......... 39 choline fenofibrate ........... 39 choline-mag trisalicylate .. 11 CIALIS ............................. 60 ciclodan ........................... 26 ciclopirox ......................... 26 ciclopirox olamine ............ 26
cidofovir .......................... 35 cilostazol ......................... 33 CILOXAN ........................ 75 CIMDUO ......................... 35 cimetidine ........................ 57 cimetidine hcl .................. 57 CIMZIA ............................ 69 CIMZIA PREFILLED KIT . 69 CIMZIA STARTER KIT .... 69 cinacalcet hcl .................. 63 CINQAIR ......................... 79 CINRYZE ........................ 69 CINVANTI ....................... 25 CIPRO ...................... 17, 18 CIPRO HC ...................... 78 CIPRODEX ..................... 78 ciprofloxacin .................... 18 ciprofloxacin hcl... 18, 75, 78 ciprofloxacin in d5w ......... 18 CIPROFLOXACIN-
FLUOCINOLONE PF .. 78 cisplatin ........................... 29 citalopram hydrobromide . 24 citroma ............................ 58 cladribine......................... 29 claravis ............................ 47 CLARINEX ...................... 79 CLARINEX-D 12 HOUR .. 79 clarithromycin .................. 18 clarithromycin er .............. 18 clearlax ........................... 58 clemastine fumarate ........ 79 CLENPIQ ........................ 58 CLEOCIN ........................ 18 CLEOCIN PHOSPHATE . 18 CLEOCIN-T ..................... 47 CLIMARA ........................ 65 CLIMARA PRO ............... 65 clindacin etz .................... 47 clindacin-p ....................... 47 CLINDAGEL .................... 47 clindamycin hcl ................ 18 clindamycin palmitate hcl 18 clindamycin phosphate ... 18,
47 CLINDAMYCIN
PHOSPHATE .............. 47 clindamycin phosphate in
d5w ............................. 18 CLINDAMYCIN
PHOSPHATE IN NACL 18 clindamycin phosphate-
benzoyl peroxide ......... 47 clindamycin-tretinoin ....... 47 CLINDESSE .................... 18
91
clobazam ......................... 22 clobetasol prop emollient
base ............................ 47 clobetasol propionate ...... 47 clobetasol propionate e ... 47 clobetasol propionate
emulsion ...................... 47 CLOBEX .......................... 47 CLOBEX SPRAY ............. 47 clocortolone pivalate ........ 47 clodan.............................. 47 CLODERM ...................... 47 clofarabine ....................... 29 clomipramine hcl ............. 24 clonazepam ..................... 36 clonidine .......................... 39 clonidine hcl .................... 39 clonidine hcl (analgesia) .. 12 clonidine hcl er ................ 44 clopidogrel bisulfate ......... 33 clorazepate dipotassium .. 36 clotrimazole ..................... 26 clotrimazole-betamethasone
.................................... 47 clovique ........................... 55 clozapine ......................... 34 CLOZARIL ....................... 34 COAGADEX .................... 37 COARTEM ...................... 32 codeine sulfate ................ 12 COGENTIN ..................... 33 COLAZAL ........................ 72 COLCHICINE .................. 27 colchicine-probenecid ...... 27 COLCRYS ....................... 27 colesevelam hcl ............... 39 COLESTID ...................... 39 COLESTID FLAVORED .. 40 colestipol hcl .................... 40 colistimethate sodium (cba)
.................................... 18 colocort ............................ 72 COLY-MYCIN M .............. 18 COLY-MYCIN S .............. 78 COLYTE WITH FLAVOR
PACKS ........................ 58 COMBIGAN ..................... 76 COMBIPATCH ................ 65 COMBIVENT RESPIMAT 80 COMBIVIR ...................... 35 COMETRIQ (100 MG
DAILY DOSE) .............. 29 COMETRIQ (140 MG
DAILY DOSE) .............. 29
COMETRIQ (60 MG DAILY DOSE) ......................... 29
COMPLERA .................... 35 compro ............................ 25 COMTAN ........................ 33 CONCERTA .................... 44 CONDYLOX .................... 47 constulose ....................... 58 CONTOUR NEXT
CONTROL ................... 54 CONTOUR NEXT TEST .. 54 CONZIP .......................... 12 COPAXONE .................... 45 COPIKTRA ...................... 29 CORDRAN ...................... 47 COREG ........................... 40 COREG CR ..................... 40 coremino ......................... 18 CORGARD ...................... 40 CORIFACT ...................... 37 CORLANOR .................... 40 CORTEF ......................... 61 CORTENEMA ................. 72 CORTIFOAM ................... 72 cortisone acetate ............. 61 CORTISPORIN ............... 47 COSENTYX (300 MG
DOSE) ......................... 69 COSENTYX 150 MG/ML . 69 COSENTYX
SENSOREADY (300 MG) .................................... 69
COSENTYX SENSOREADY PEN ... 69
COSOPT ......................... 76 COSOPT PF ................... 76 COTELLIC....................... 29 COTEMPLA XR-ODT ...... 44 COUMADIN ..................... 21 covaryx ............................ 65 covaryx hs ....................... 65 COZAAR ......................... 40 CREON ........................... 60 CRESEMBA .................... 26 CRESTOR....................... 40 CRINONE ....................... 65 CRIXIVAN ....................... 35 cromolyn sodium . 58, 75, 80 crotan .............................. 32 cryselle-28 ....................... 65 CRYSVITA ...................... 60 CUPRIMINE .................... 60 curity sterile saline ........... 55 CUROSURF .................... 79 CUTAQUIG ..................... 69
CUTIVATE ...................... 47 CUVITRU ........................ 69 CUVPOSA ...................... 58 cyanocobalamin .............. 55 cyclafem 1/35 .................. 65 cyclafem 7/7/7 ................. 65 cyclobenzaprine hcl ... 82, 83 cyclobenzaprine hcl er..... 82 CYCLOGYL .................... 77 CYCLOMYDRIL .............. 77 cyclopentolate hcl ............ 77 cyclophosphamide .......... 29 cycloserine ...................... 28 CYCLOSET ..................... 52 cyclosporine .................... 69 CYCLOSPORINE IN
KLARITY ..................... 77 cyclosporine modified ...... 69 CYMBALTA ..................... 24 cyproheptadine hcl .......... 79 CYRAMZA ...................... 29 cyred ............................... 65 cyred eq .......................... 65 CYSTADANE .................. 60 CYSTAGON .................... 60 CYSTARAN .................... 77 cytarabine ....................... 29 cytarabine (pf) ................. 29 CYTOGAM ...................... 69 CYTOMEL ....................... 68 CYTOTEC ....................... 57 cytra k crystals ................ 56 D D.H.E. 45 ........................ 27 d3 high potency ............... 56 d3 super strength ............ 56 d3 vitamin........................ 56 dacarbazine .................... 29 dactinomycin ................... 29 dalfampridine er .............. 45 DALIRESP ...................... 80 DALVANCE ..................... 18 danazol ........................... 63 DANTRIUM ..................... 83 dantrolene sodium ........... 83 dapsone .................... 28, 47 DAPTACEL ..................... 71 daptomycin ...................... 18 DARAPRIM ..................... 32 darifenacin hydrobromide er
.................................... 60 DARZALEX ..................... 29 dasetta 1/35 .................... 65 dasetta 7/7/7 ................... 65 daunorubicin hcl .............. 29
92
DAURISMO ..................... 29 DAYPRO ......................... 11 daysee............................. 65 DAYTRANA ..................... 44 DDAVP ............................ 63 DEBACTEROL ................ 45 deblitane .......................... 65 DECADRON .................... 61 decara ............................. 56 DECARA ......................... 56 decitabine ........................ 29 deferasirox ...................... 56 deferoxamine mesylate ... 73 DEFITELIO ...................... 21 DELESTROGEN ............. 65 DELSTRIGO.................... 35 delyla ............................... 65 DELZICOL ....................... 72 demeclocycline hcl .......... 18 DEMEROL ...................... 13 DEMSER ......................... 40 DENAVIR ........................ 35 DEPAKOTE ..................... 22 DEPAKOTE ER ............... 22 DEPAKOTE SPRINKLES 22 DEPEN TITRATABS ....... 60 DEPO-ESTRADIOL ......... 65 DEPO-MEDROL ........ 61, 62 DEPO-PROVERA ........... 65 DEPO-SUBQ PROVERA
104 .............................. 65 DEPO-TESTOSTERONE 63 DERMACINRX AZENASE
PAK ............................. 79 dermacinrx empricaine .... 15 dermacinrx prizopak ........ 15 DERMA-SMOOTHE/FS
BODY .......................... 47 DERMA-SMOOTHE/FS
SCALP ........................ 48 DERMOTIC ..................... 78 DERMULCERA ............... 48 DESCOVY ....................... 35 DESFERAL ..................... 73 desipramine hcl ............... 24 desloratadine ................... 79 desmopressin ace spray
refrig ............................ 63 desmopressin acetate ..... 63 desmopressin acetate spray
.................................... 63 desogestrel-ethinyl estradiol
.................................... 65 DESONATE..................... 48 desonide .......................... 48
DESOWEN...................... 48 desoximetasone .............. 48 DESOXYN....................... 44 DESVENLAFAXINE ER .. 24 desvenlafaxine succinate er
.................................... 24 DETROL ......................... 60 DETROL LA .................... 60 dexamethasone ............... 62 DEXAMETHASONE (LA) 62 DEXAMETHASONE
INTENSOL .................. 62 dexamethasone sod
phosphate pf................ 62 dexamethasone sodium
phosphate ............. 62, 75 DEXEDRINE ................... 44 DEXERYL ....................... 48 DEXILANT....................... 57 dexmethylphenidate hcl ... 44 dexmethylphenidate hcl er
.................................... 44 DEXPAK 10 DAY ............ 62 DEXPAK 13 DAY ............ 62 DEXPAK 6 DAY .............. 62 dextroamphetamine sulfate
.................................... 44 dextroamphetamine sulfate
er ................................. 44 DIACOMIT....................... 22 DIASTAT ACUDIAL ......... 22 DIASTAT PEDIATRIC ..... 22 DIATHRIVE GLUCOSE
CONTROL SOLN ........ 54 DIATHRIVE LANCING
DEVICE ....................... 54 diazepam .................. 22, 37 diazepam intensol ........... 37 DIBENZYLINE ................. 40 DICLEGIS ....................... 25 DICLOFENAC EPOLAMINE
.................................... 11 diclofenac potassium ....... 11 diclofenac sodium 11, 48, 75 diclofenac sodium er ....... 11 diclofenac-misoprostol ..... 11 DICLOFONO ................... 11 dicloxacillin sodium .......... 18 dicyclomine hcl ................ 58 didanosine ....................... 35 DIFFERIN ....................... 48 DIFICID ........................... 18 difil-g forte ....................... 80 diflorasone diacetate ....... 48 DIFLUCAN ...................... 26
diflunisal .......................... 11 DIGIFAB ......................... 73 digitek ............................. 40 digox ............................... 40 digoxin ............................ 40 dihydroergotamine mesylate
.................................... 27 DILANTIN........................ 22 DILANTIN INFATABS ..... 22 DILATRATE-SR .............. 40 DILAUDID ....................... 13 diltiazem hcl .................... 40 diltiazem hcl er ................ 40 diltiazem hcl er beads ..... 40 diltiazem hcl er coated
beads .......................... 40 dilt-xr ............................... 40 diluent for treprostinil ....... 73 dimenhydrinate ............... 25 DIOVAN .......................... 40 DIOVAN HCT .................. 40 DIPENTUM ..................... 72 diphen ............................. 79 diphenhydramine hcl ....... 79 diphenoxylate-atropine .... 58 DIPHTHERIA-TETANUS
TOXOIDS DT .............. 71 DIPROLENE ................... 48 DIPROLENE AF .............. 48 dipyridamole .................... 33 disopyramide phosphate . 40 disulfiram......................... 16 DITROPAN XL ................ 60 DIURIL ............................ 40 divalproex sodium ........... 22 divalproex sodium er ....... 22 DIVIGEL .......................... 65 docetaxel......................... 29 dofetilide ......................... 40 DOLOPHINE ................... 13 donepezil hcl ................... 23 DOPTELET ..................... 37 DORAL ........................... 37 DORYX ........................... 18 DORYX MPC .................. 18 dorzolamide hcl ............... 76 dorzolamide hcl-timolol mal
.................................... 76 dorzolamide hcl-timolol mal
pf ................................. 76 dotti ................................. 65 DOVATO ......................... 35 DOVONEX ...................... 48 doxazosin mesylate ......... 40 doxepin hcl ................ 24, 48
93
doxercalciferol ................. 73 doxorubicin hcl ................ 29 doxorubicin hcl liposomal. 29 doxy 100 .......................... 18 doxycycline ...................... 48 doxycycline hyclate.......... 18 doxycycline monohydrate 18 doxylamine-pyridoxine ..... 25 D-PENAMINE .................. 60 DRISDOL ........................ 56 dritho-creme hp ............... 48 DRIZALMA SPRINKLE .... 24 dronabinol ....................... 25 droperidol ........................ 25 drospiren-eth estrad-
levomefol ..................... 65 drospirenone-ethinyl
estradiol ....................... 65 DROXIA .......................... 29 DRYSOL ......................... 48 DUAC .............................. 48 DUAKLIR PRESSAIR ...... 80 DUAVEE ......................... 65 DUETACT ....................... 52 DUEXIS ........................... 11 DULERA .......................... 80 duloxetine hcl .................. 24 DUOPA ........................... 33 DUPIXENT ...................... 48 DURAGESIC-100 ............ 13 DURAGESIC-12 .............. 13 DURAGESIC-25 .............. 13 DURAGESIC-50 .............. 13 DURAGESIC-75 .............. 13 duramorph ....................... 13 duraxin ............................ 13 DUREZOL ....................... 75 DURLAZA ....................... 33 dutasteride ...................... 61 dutasteride-tamsulosin hcl
.................................... 61 DUTOPROL .................... 40 DVORAH ......................... 13 DXEVO 11-DAY .............. 62 DYANAVEL XR ............... 44 DYAZIDE ......................... 40 DYMISTA ........................ 79 DYRENIUM ..................... 40 DYSPORT ....................... 73 E e.e.s. 400 ........................ 18 E.E.S. GRANULES.......... 18 EASIVENT ...................... 73 EASYMAX CONTROL ..... 54 EC-NAPROSYN .............. 11
ec-naproxen .................... 11 econazole nitrate ............. 26 ECOZA ............................ 26 EDARBI ........................... 40 EDARBYCLOR ............... 40 EDECRIN ........................ 40 EDLUAR ......................... 83 ed-spaz ........................... 58 EDURANT ....................... 35 eemt ................................ 65 eemt hs ........................... 65 efavirenz ......................... 35 effer-k .............................. 56 EFFER-K ......................... 56 EFFEXOR XR ................. 24 EFFIENT ......................... 33 EFUDEX ......................... 48 EGRIFTA ........................ 63 EHA................................. 15 ELAPRASE ..................... 60 ELELYSO ........................ 60 ELESTRIN....................... 65 ELETONE ....................... 48 ELETONE TWINPACK .... 48 eletriptan hydrobromide ... 27 ELIDEL ............................ 48 ELIGARD ........................ 63 ELIMITE .......................... 32 elinest .............................. 65 ELIQUIS .......................... 21 ELIQUIS STARTER PACK
.................................... 21 ELITEK ............................ 29 ELIXOPHYLLIN ............... 80 ELLA ............................... 65 ELMIRON ........................ 60 ELOCON ......................... 48 ELOCTATE ..................... 37 EMBRACE TALK
GLUCOSE CONTROL 54 EMCYT ........................... 29 EMEND ........................... 25 EMEND TRI-PACK .......... 25 EMFLAZA ....................... 27 EMGALITY ...................... 27 EMGALITY (300 MG
DOSE) ......................... 27 emoquette ....................... 65 EMPLICITI....................... 29 EMSAM ........................... 24 EMTRIVA ........................ 35 EMULSION SB ................ 48 EMVERM ........................ 32 ENABLEX ....................... 60 enalapril maleate ............. 40
enalapril-hydrochlorothiazide ..... 40
ENBREL ......................... 69 ENBREL MINI ................. 69 ENBREL SURECLICK .... 69 ENDARI .......................... 73 endocet ........................... 13 ENDOMETRIN ................ 65 ENGERIX-B .................... 71 enoxaparin sodium .......... 21 enpresse-28 .................... 65 enskyce ........................... 65 ENSTILAR ...................... 48 entacapone ..................... 33 entecavir ......................... 35 ENTEREG ....................... 58 ENTOCORT EC .............. 72 ENTRESTO .................... 40 ENTTY SPRAY EMULSION
.................................... 48 ENTYVIO ........................ 69 enulose ........................... 58 ENVARSUS XR .............. 69 EPANED ......................... 40 EPCLUSA ....................... 35 EPICERAM ..................... 48 EPIDIOLEX ..................... 22 EPIDUO .......................... 48 EPIDUO FORTE ............. 48 EPIFOAM ........................ 48 epinastine hcl .................. 75 epinephrine ..................... 80 epinephrine pf ................. 40 EPINEPHRINE
PROFESSIONAL ........ 81 EPINEPHRINESNAP-EMS
.................................... 81 EPINEPHRINESNAP-V ... 81 EPIPEN 2-PAK ............... 81 EPIPEN JR 2-PAK .......... 81 epirubicin hcl ................... 29 EPISNAP ........................ 81 epitol ............................... 22 EPIVIR ............................ 35 EPIVIR HBV .................... 35 eplerenone ...................... 40 EPOGEN......................... 37 epoprostenol sodium ....... 82 eprosartan mesylate ........ 40 EPZICOM........................ 35 EQUETRO ...................... 22 ERAXIS ........................... 26 ERBITUX ........................ 29 ergocalciferol ................... 56 ergoloid mesylates .......... 73
94
ERGOMAR ...................... 27 ergotamine-caffeine ......... 27 ERIVEDGE ...................... 29 ERLEADA ....................... 29 erlotinib hcl ...................... 29 errin ................................. 65 ERTACZO ....................... 26 ertapenem sodium ........... 18 ERWINAZE ..................... 29 ery ................................... 48 ERYGEL .......................... 48 ERYPED 200 ................... 18 ERYPED 400 ................... 18 ERY-TAB ......................... 18 erythrocin lactobionate .... 18 ERYTHROCIN
LACTOBIONATE ......... 18 ERYTHROCIN STEARATE
.................................... 18 erythromycin .............. 48, 75 erythromycin base ........... 18 erythromycin ethylsuccinate
.................................... 18 ESBRIET ......................... 81 escitalopram oxalate ........ 24 esgic ................................ 13 ESGIC ............................. 13 esomeprazole magnesium
.................................... 57 est estrogens-methyltest . 65 est estrogens-methyltest ds
.................................... 65 est estrogens-methyltest hs
.................................... 65 estarylla ........................... 65 estazolam ........................ 37 ESTRACE ....................... 65 estradiol ........................... 65 estradiol valerate ............. 65 estradiol-norethindrone acet
.................................... 65 ESTRING ........................ 65 ESTROGEL ..................... 65 ESTROSTEP FE ............. 65 eszopiclone ..................... 83 ethacrynate sodium ......... 40 ethacrynic acid ................ 40 ethambutol hcl ................. 28 ETHAMOLIN ................... 40 ethosuximide ................... 22 ethyl chloride ................... 15 ethynodiol diac-eth estradiol
.................................... 65 etidronate disodium ......... 73 etodolac ........................... 11
etodolac er ...................... 11 ETOPOPHOS ................. 29 etoposide ........................ 29 EUCRISA ........................ 48 EUFLEXXA ..................... 73 EURAX ............................ 32 euthyrox .......................... 68 EVAMIST ........................ 65 EVEKEO ......................... 44 EVEKEO ODT ................. 44 EVISTA ........................... 63 EVOCLIN ........................ 48 EVOMELA ....................... 29 EVOTAZ .......................... 35 EVOXAC ......................... 45 EVZIO ............................. 16 EXELDERM .................... 26 EXELON ......................... 23 exemestane ..................... 29 EXFORGE....................... 40 EXFORGE HCT .............. 40 EXJADE .......................... 56 ex-lax ultra....................... 58 exoderm .......................... 26 EXONDYS 51 .................. 60 EXTAVIA ......................... 45 EXTINA ........................... 26 EYLEA ............................ 77 EZALLOR SPRINKLE ..... 40 ezetimibe ......................... 40 ezetimibe-simvastatin ...... 40 F FABIOR ........................... 48 FABRAZYME .................. 60 falmina ............................ 65 famciclovir ....................... 35 famotidine ....................... 58 FANAPT .......................... 34 FANAPT TITRATION PACK
.................................... 34 FARESTON ..................... 29 FARXIGA ........................ 52 FARYDAK ....................... 29 FASENRA ....................... 79 FASENRA PEN ............... 48 FASLODEX ..................... 29 fayosim ............................ 65 FAZACLO ....................... 34 febuxostat ....................... 27 felbamate ........................ 22 FELBATOL ...................... 22 FELDENE ....................... 11 felodipine er ..................... 40 FEM PH .......................... 60 FEMARA ......................... 29
FEMCAP ......................... 74 FEMHRT LOW DOSE ..... 65 FEMRING ....................... 65 femynor ........................... 65 fenofibrate ....................... 40 fenofibrate micronized ..... 40 fenofibric acid .................. 40 FENOGLIDE ................... 40 fenoprofen calcium .......... 11 fenortho ........................... 11 fentanyl ........................... 13 fentanyl citrate ................. 13 FENTANYL CITRATE ..... 13 FENTORA ....................... 13 FERAHEME .................... 56 FERRIPROX ................... 56 ferrous sulfate ................. 56 FETZIMA......................... 24 FETZIMA TITRATION ..... 24 FEXMID .......................... 83 FIASP ............................. 55 FIASP FLEXTOUCH ....... 55 FIBRICOR ....................... 40 FIBRYGA ........................ 37 FINACEA ........................ 48 finasteride ....................... 61 FIORICET ....................... 13 FIORICET/CODEINE ...... 13 FIORINAL ....................... 13 FIORINAL/CODEINE #3 . 13 FIRAZYR......................... 69 FIRDAPSE ...................... 74 FIRMAGON ..................... 63 FIRST-BACLOFEN ......... 83 FIRST-LANSOPRAZOLE 58 FIRST-MOUTHWASH BLM
.................................... 45 FIRST-OMEPRAZOLE .... 58 FIRST-PROGESTERONE
VGS ............................ 65 FIRST-VANCOMYCIN .... 18 FIRVANQ ........................ 18 flac .................................. 78 FLAGYL .......................... 18 FLAREX .......................... 75 flavoxate hcl .................... 60 FLEBOGAMMA DIF ........ 69 flecainide acetate ............ 40 FLECTOR ....................... 11 FLEXICHAMBER ADULT
MASK/SMALL ............. 74 FLEXICHAMBER CHILD
MASK/LARGE ............. 74 FLEXICHAMBER CHILD
MASK/SMALL ............. 74
95
FLEXIN ............................ 15 FLOLIPID ........................ 40 FLOMAX ......................... 61 FLOVENT DISKUS.......... 81 FLOVENT HFA ................ 81 FLOXIN OTIC .................. 78 floxuridine ........................ 29 FLUAD ............................ 71 FLUARIX QUADRIVALENT
.................................... 71 FLUBLOK QUADRIVALENT
.................................... 71 FLUCELVAX
QUADRIVALENT ......... 71 fluconazole ...................... 26 fluconazole in sodium
chloride ........................ 26 flucytosine ....................... 26 fludarabine phosphate ..... 29 fludrocortisone acetate .... 62 FLULAVAL
QUADRIVALENT ......... 71 FLUMADINE.................... 35 FLUMIST QUADRIVALENT
.................................... 71 flunisolide ........................ 79 fluocinolone acetonide .... 48,
78 fluocinolone acetonide body
.................................... 48 fluocinolone acetonide scalp
.................................... 48 fluocinonide ..................... 48 fluocinonide emulsified base
.................................... 48 FLUORABON .................. 56 fluoritab ........................... 56 fluorometholone ............... 75 FLUOROPLEX ................ 48 fluorouracil ........... 29, 48, 49 FLUOROURACIL ............ 48 fluoxetine hcl ................... 24 fluoxetine hcl (pmdd) ....... 24 fluphenazine decanoate .. 34 fluphenazine hcl .............. 34 FLURA-DROPS ............... 56 flurandrenolide ................. 49 flurazepam hcl ................. 83 flurbiprofen ...................... 11 flurbiprofen sodium .......... 75 flutamide .......................... 29 fluticasone propionate ..... 49 fluticasone-salmeterol ...... 81 FLUTICASONE-
SALMETEROL ............ 81
fluvastatin sodium............ 40 fluvastatin sodium er ....... 40 fluvoxamine maleate ....... 24 fluvoxamine maleate er ... 24 FLUZONE HIGH-DOSE .. 71 FLUZONE
QUADRIVALENT ........ 71 FML ................................. 75 FML FORTE .................... 75 FML LIQUIFILM .............. 75 FOCALIN ........................ 44 FOCALIN XR ................... 44 folic acid .......................... 56 FOLOTYN ....................... 29 fondaparinux sodium ....... 21 FORFIVO XL ................... 24 FORTAMET .................... 52 FORTEO ......................... 73 FORTESTA ..................... 63 FORTISCARE CONTROL
.................................... 54 FOSAMAX....................... 73 FOSAMAX PLUS D ......... 73 fosamprenavir calcium .... 35 fosaprepitant dimeglumine
.................................... 25 FOSCAVIR ...................... 35 fosinopril sodium ............. 40 fosinopril sodium-hctz ...... 40 fosphenytoin sodium ....... 22 FOSRENOL .................... 60 FRAGMIN ....................... 21 FREESTYLE TEST ......... 54 FROVA ............................ 27 frovatriptan succinate ...... 27 FULPHILA ....................... 37 fulvestrant ....................... 29 furosemide ...................... 41 FUZEON ......................... 35 fyavolv ............................. 66 FYCOMPA ...................... 22 G gabapentin ...................... 22 GABITRIL ........................ 22 GABLOFEN ..................... 83 GALAFOLD ..................... 60 galantamine hydrobromide
.................................... 23 galantamine hydrobromide
er ................................. 23 GAMASTAN .................... 69 gamastan s/d ................... 69 GAMASTAN S/D ............. 69 GAMIFANT...................... 70 GAMMAGARD ................ 70
GAMMAGARD S/D LESS IGA .............................. 70
GAMMAKED ................... 70 GAMMAPLEX ................. 70 GAMUNEX-C .................. 70 GANCICLOVIR ............... 35 ganciclovir sodium ........... 35 GARDASIL 9 ................... 71 GASTROCROM .............. 58 gatifloxacin ...................... 75 GATIFLOXACIN-
DEXAMETHASONE .... 77 GATTEX ......................... 58 gavilax ............................. 58 gavilyte-c ......................... 58 gavilyte-h......................... 58 gavilyte-n with flavor pack 58 GAZYVA ......................... 29 GEBAUERS PAIN EASE 15 GEBAUERS SPRAY AND
STRETCH ................... 15 GELFILM......................... 77 GELNIQUE ..................... 60 GELNIQUE PUMP .......... 60 GEL-ONE ........................ 74 GELSYN-3 ...................... 74 gemcitabine hcl ............... 29 gemfibrozil ....................... 41 GEN7T ............................ 15 GENERESS FE............... 66 generlac .......................... 58 gengraf ............................ 70 GENOTROPIN ................ 63 GENOTROPIN MINIQUICK
.................................... 63 gentak ............................. 75 gentamicin in saline ......... 19 gentamicin sulfate ..... 19, 75 GENTEEL LANCING KIT
(BLUE) ........................ 54 gentle laxative ................. 58 GENVISC 850 ................. 74 GENVOYA ...................... 35 GEODON ........................ 34 gianvi .............................. 66 GILENYA ........................ 45 GILOTRIF ....................... 29 GLASSIA......................... 81 glatiramer acetate ........... 45 glatopa ............................ 45 GLEEVEC ....................... 29 GLEOSTINE ................... 29 GLIADEL WAFER ........... 29 glimepiride ....................... 53 glipizide er ....................... 53
96
glipizide ir ........................ 53 glipizide xl ........................ 53 glipizide-metformin hcl ..... 53 GLUCAGEN DIAGNOSTIC
.................................... 74 GLUCAGEN HYPOKIT .... 54 GLUCAGON EMERGENCY
.................................... 54 GLUCAGON HCL
(DIAGNOSTIC) ............ 74 GLUCOPHAGE ............... 53 GLUCOPHAGE XR ......... 53 GLUCOTROL .................. 53 GLUCOTROL XL ............. 53 GLUMETZA ..................... 53 glyburide .......................... 53 glyburide micronized ........ 53 glyburide-metformin ......... 53 GLYCATE ....................... 59 glycine ............................. 60 glycine urologic ................ 60 glycolax ........................... 59 glycopyrrolate .................. 59 GLYCOPYRROLATE ...... 59 glydo ............................... 15 GLYNASE ....................... 53 GLYSET .......................... 53 GLYXAMBI ...................... 53 gnp folic acid ................... 56 GOCOVRI ....................... 33 GOLYTELY ..................... 59 GONITRO ....................... 41 grafco silver nit applicator 49 GRALISE ......................... 45 GRALISE STARTER ....... 45 granisetron hcl ................. 25 GRANIX .......................... 37 GRASTEK ....................... 74 griseofulvin microsize ...... 26 griseofulvin ultramicrosize26 guanfacine hcl ................. 41 guanfacine hcl er ............. 44 GUANIDINE HCL ............ 28 GVOKE PFS.................... 54 GYNAZOLE-1 .................. 26 H HAEGARDA .................... 70 hailey 1.5/30 .................... 66 hailey 24 fe ...................... 66 HALAVEN ....................... 29 halcinonide ...................... 49 HALCION ........................ 37 HALDOL .......................... 34 HALDOL DECANOATE ... 34 halobetasol propionate .... 49
HALOBETASOL PROPIONATE ............. 49
HALOG ........................... 49 haloperidol ...................... 34 haloperidol decanoate ..... 34 haloperidol lactate ........... 34 HARVONI ........................ 35 HAVRIX ........................... 71 heather ............................ 66 HECTOROL .................... 73 HEMABATE .................... 64 HEMANGEOL ................. 41 HEMLIBRA ...................... 37 hemmorex-hc .................. 72 hemofil m ........................ 37 HEMOFIL M .................... 38 HEPAGAM B ................... 70 heparin (porcine) in nacl .. 21 heparin lock flush ............ 74 heparin sod (porcine) in d5w
.................................... 21 heparin sodium (porcine) . 21 heparin sodium (porcine) pf
.................................... 21 heparin sodium lock flush 74 HEPLISAV-B ................... 71 HEPSERA ....................... 35 HERCEPTIN ................... 29 HESPAN ......................... 38 hetastarch-nacl ................ 38 HETLIOZ ......................... 83 HEXTEND ....................... 38 HIBERIX .......................... 71 HIDEX 6-DAY .................. 62 HIPREX ........................... 19 HIZENTRA ...................... 70 homatropaire ................... 77 homatropine hbr .............. 77 HORIZANT ...................... 45 HPR ................................ 49 HPR PLUS ...................... 49 HUMALOG KWIKPEN ..... 55 HUMALOG MIX 50/50
KWIKPEN .................... 55 HUMALOG MIX 50/50 VIAL
.................................... 55 HUMALOG MIX 75/25
KWIKPEN .................... 55 HUMALOG MIX 75/25 VIAL
.................................... 55 HUMALOG U-100 JUNIOR
KWIKPEN .................... 55 HUMALOG U-100 VIAL
AND CARTRIDGE ....... 55 HUMATE-P ..................... 38
HUMATROPE ................. 63 HUMIRA .......................... 70 HUMIRA PEDIATRIC
CROHNS START ........ 70 HUMIRA PEN ................. 70 HUMIRA PEN-CD/UC/HS
STARTER ................... 70 HUMIRA PEN-PS/UV/ADOL
HS START .................. 70 HUMULIN 70/30 KWIKPEN
.................................... 55 HUMULIN 70/30 VIAL ..... 55 HUMULIN N KWIKPEN ... 55 HUMULIN N VIAL ........... 55 HUMULIN R U-500
KWIKPEN ................... 55 HUMULIN R U-500 VIAL
(CONCENTRATED) .... 55 HUMULIN R VIAL ........... 55 HYALGAN ....................... 74 HYCAMTIN ..................... 29 hydralazine hcl ................ 41 HYDREA ......................... 29 hydrochlorothiazide ......... 41 hydrocodone polst-cpm
polst er ........................ 79 hydrocodone-
acetaminophen ............ 13 hydrocodone-homatropine
.................................... 79 hydrocodone-ibuprofen ... 13 hydrocortisone .... 49, 62, 72 hydrocortisone ace-
pramoxine ............. 49, 72 hydrocortisone acetate .... 72 hydrocortisone butyr lipo
base ............................ 49 hydrocortisone butyrate ... 49 hydrocortisone valerate ... 49 hydrocortisone-acetic acid
.................................... 78 hydromet ......................... 79 hydromorphone hcl ......... 13 HYDROMORPHONE HCL
.................................... 13 hydromorphone hcl er ..... 13 hydromorphone hcl pf ..... 13 hydroxychloroquine sulfate
.................................... 32 hydroxyprogesterone
caproate ...................... 66 hydroxyurea .................... 29 hydroxyzine hcl ............... 37 hydroxyzine pamoate ...... 37 HYLATOPIC PLUS ......... 49
97
HYLENEX ....................... 74 hyophen .......................... 60 hyoscyamine sulfate ........ 59 hyoscyamine sulfate er .... 59 hyoscyamine sulfate sl .... 59 hyosyne ........................... 59 HYPERHEP B S/D .......... 70 HYPERRAB..................... 70 HYPERRAB S/D .............. 70 HYPERRHO S/D ............. 70 HYPERSAL ..................... 79 HYPERTET S/D .............. 70 HYPOCYN ...................... 77 HYQVIA ........................... 70 HYSINGLA ER ................ 13 HYZAAR .......................... 41 I ibandronate sodium ......... 73 IBRANCE ........................ 29 ibu ................................... 11 ibuprofen ......................... 11 ibuprofen lysine ............... 11 icatibant acetate .............. 70 ICLUSIG .......................... 29 idarubicin hcl ................... 29 IDELVION ....................... 38 IDHIFA ............................ 29 IFEX ................................ 30 ifosfamide ........................ 30 ILARIS ............................. 70 ILEVRO ........................... 75 ILUMYA ........................... 70 ILUVIEN .......................... 75 imatinib mesylate ............. 30 IMBRUVICA .................... 30 IMFINZI ........................... 30 imipenem-cilastatin .......... 19 imipramine hcl ................. 24 imipramine pamoate ........ 24 imiquimod ........................ 49 IMIQUIMOD PUMP ......... 49 IMITREX .......................... 27 IMITREX STATDOSE
REFILL ........................ 27 IMITREX STATDOSE
SYSTEM ...................... 27 IMLYGIC ......................... 30 IMOGAM RABIES-HT ..... 70 IMPAVIDO ....................... 32 IMPOYZ .......................... 49 IMURAN .......................... 70 IMVEXXY MAINTENANCE
PACK .......................... 66 IMVEXXY STARTER PACK
.................................... 66
INBRIJA .......................... 33 incassia ........................... 66 INCRELEX ...................... 63 INCRUSE ELLIPTA ......... 81 indapamide...................... 41 INDERAL LA ................... 41 INDERAL XL ................... 41 INDOCIN ......................... 11 indomethacin ................... 11 indomethacin er ............... 11 indomethacin sodium ...... 11 INFANRIX ....................... 71 INFASURF ...................... 79 INFED ............................. 74 INFLECTRA .................... 70 INFUMORPH 200............ 13 INFUMORPH 500............ 13 INGREZZA ...................... 45 INJECTAFER .................. 56 INLYTA ........................... 30 INNOPRAN XL ................ 41 INREBIC ......................... 30 INSPRA ........................... 41 INSULIN LISPRO ............ 55 INSULIN PEN NEEDLES 55 INSULIN SYRINGES ....... 55 INTELENCE .................... 35 INTERMEZZO ................. 83 INTRAROSA ................... 61 INTRON A ....................... 35 introvale .......................... 66 INTUNIV .......................... 44 INVANZ ........................... 19 INVEGA .......................... 34 INVEGA SUSTENNA ...... 34 INVEGA TRINZA ............. 34 INVELTYS ....................... 75 INVIRASE ....................... 35 INVOKAMET ................... 53 INVOKAMET XR ............. 53 INVOKANA...................... 53 iodine strong .................... 56 IONSYS .......................... 13 IOPIDINE ........................ 76 IPOL ................................ 71 ipratropium bromide .. 79, 81 ipratropium-albuterol ....... 81 irbesartan ........................ 41 irbesartan-
hydrochlorothiazide ..... 41 IRESSA ........................... 30 irinotecan hcl ................... 30 ISENTRESS .................... 35 ISENTRESS HD .............. 35 isibloom ........................... 66
isoniazid .......................... 28 isoproterenol hcl .............. 41 ISOPTO CARPINE .......... 76 ISORDIL TITRADOSE .... 41 isosorbide dinitrate .......... 41 isosorbide dinitrate er ...... 41 isosorbide mononitrate .... 41 isosorbide mononitrate er 41 isotretinoin ....................... 49 isradipine......................... 41 ISTALOL ......................... 76 ISTODAX (OVERFILL) .... 30 ISUPREL......................... 41 itraconazole ..................... 26 ivermectin.................. 32, 49 IXEMPRA KIT ................. 30 IXINITY ........................... 38 J JADENU ......................... 56 JADENU SPRINKLE ....... 56 JAKAFI ............................ 30 JALYN ............................. 61 jantoven .......................... 21 JANUMET ....................... 53 JANUMET XR ................. 53 JANUVIA ......................... 53 JARDIANCE .................... 53 jasmiel ............................. 66 jencycla ........................... 66 JENTADUETO ................ 53 JENTADUETO XR .......... 53 JETREA .......................... 77 JEVTANA ........................ 30 jinteli ................................ 66 jolessa ............................. 66 JORNAY PM ................... 44 JUBLIA ............................ 26 juleber ............................. 66 JULUCA .......................... 35 junel 1.5/30 ..................... 66 junel 1/20 ........................ 66 junel fe 1.5/30 ................. 66 junel fe 1/20 .................... 66 junel fe 24 ....................... 66 JUXTAPID ....................... 41 JYNARQUE .................... 56 K KADCYLA ....................... 30 KADIAN .......................... 13 kaitlib fe ........................... 66 KALBITOR ...................... 74 KALETRA........................ 35 kalliga .............................. 66 KALYDECO .................... 82 KAMDOY ........................ 49
98
KANUMA ......................... 60 KAPSPARGO SPRINKLE41 KAPVAY .......................... 44 KARBINAL ER ................. 79 kariva .............................. 66 KATERZIA ....................... 41 KAZANO ......................... 53 KCENTRA ....................... 38 KEDRAB ......................... 70 KEFLEX .......................... 19 kelnor 1/35 ...................... 66 kelnor 1/50 ...................... 66 KENALOG ................. 49, 62 KEPIVANCE .................... 45 KEPPRA .......................... 22 KEPPRA XR .................... 22 KERYDIN ........................ 26 ketoconazole ................... 26 ketoprofen ....................... 11 ketoprofen er ................... 11 ketorolac tromethamine .. 11,
75 KETOROLAC
TROMETHAMINE ....... 11 KEVEYIS ......................... 76 KEVZARA ....................... 70 KEYTRUDA ..................... 30 KHAPZORY..................... 30 KHEDEZLA ..................... 24 kids first vitamin d3
gummies ...................... 56 KINERET ......................... 70 KINRIX ............................ 71 kionex .............................. 56 KISQALI (200 MG DOSE)30 KISQALI (400 MG DOSE)30 KISQALI (600 MG DOSE)30 KISQALI FEMARA (400 MG
DOSE) ......................... 30 KISQALI FEMARA (600 MG
DOSE) ......................... 30 KISQALI FEMARA(200 MG
DOSE) ......................... 30 KITABIS PAK .................. 82 KIVIK ............................... 49 KLARITY-A ...................... 75 KLARITY-B ...................... 75 KLARITY-L ...................... 75 KLARON ......................... 49 KLONOPIN ...................... 37 klor-con ........................... 56 klor-con 10 ...................... 56 klor-con m10.................... 56 KLOR-CON M15 ............. 56 klor-con m20.................... 56
klor-con sprinkle .............. 56 klor-con/ef ....................... 56 KOATE ............................ 38 koate-dvi ......................... 38 KOATE-DVI ..................... 38 KOGENATE FS ............... 38 KOMBIGLYZE XR ........... 53 KORLYM ......................... 64 KOVALTRY ..................... 38 K-PHOS .......................... 56 K-PHOS NO 2 ................. 56 k-prime ............................ 56 KRINTAFEL .................... 32 KRISTALOSE .................. 59 KRYSTEXXA ................... 27 K-TAB ............................. 56 kurvelo ............................ 66 KUVAN ............................ 60 KYLEENA ....................... 66 KYMRIAH ........................ 70 KYPROLIS ...................... 30 L labetalol hcl ..................... 41 LAC-HYDRIN .................. 49 LACRISERT .................... 77 lactic acid ........................ 49 lactic acid e ..................... 49 lactulose .......................... 59 lactulose encephalopathy 59 LAMICTAL....................... 22 LAMICTAL ODT .............. 22 LAMICTAL STARTER ..... 22 LAMICTAL XR ................. 22 lamivudine ....................... 35 lamivudine-zidovudine ..... 35 lamotrigine....................... 22 lamotrigine er .................. 22 lamotrigine starter kit-blue22 lamotrigine starter kit-green
.................................... 22 lamotrigine starter kit-
orange ......................... 22 LANCETS ....................... 54 LANOXIN ........................ 41 LANOXIN PEDIATRIC .... 41 lansoprazole .................... 58 lanthanum carbonate ....... 61 LANTUS SOLOSTAR ...... 55 LANTUS U-100 VIAL ....... 55 larin 1.5/30 ...................... 66 larin 1/20 ......................... 66 larin 24 fe ........................ 66 larin fe 1.5/30 .................. 66 larin fe 1/20 ..................... 66 larissia ............................. 66
LARTRUVO .................... 30 LASIX .............................. 41 LASTACAFT ................... 77 latanoprost ...................... 76 LATANOPROST-TIMOLOL
MALEATE ................... 76 LATUDA .......................... 34 layolis fe .......................... 66 LAZANDA ....................... 13 LDO PLUS ...................... 15 LEDIPASVIR-
SOFOSBUVIR ............. 35 leena ............................... 66 leflunomide ...................... 70 LEMTRADA .................... 45 LENVIMA (10 MG DAILY
DOSE) ......................... 30 LENVIMA (12 MG DAILY
DOSE) ......................... 30 LENVIMA (14 MG DAILY
DOSE) ......................... 30 LENVIMA (18 MG DAILY
DOSE) ......................... 30 LENVIMA (20 MG DAILY
DOSE) ......................... 30 LENVIMA (24 MG DAILY
DOSE) ......................... 30 LENVIMA (4 MG DAILY
DOSE) ......................... 30 LENVIMA (8 MG DAILY
DOSE) ......................... 30 LESCOL XL .................... 41 lessina ............................. 66 LETAIRIS ........................ 82 letrozole .......................... 30 leucovorin calcium ........... 30 LEUKERAN ..................... 30 LEUKINE......................... 38 leuprolide acetate ............ 63 levalbuterol hcl ................ 81 LEVALBUTEROL HFA .... 81 LEVAQUIN ...................... 19 LEVATIO ......................... 15 LEVEMIR U-100
FLEXTOUCH .............. 55 LEVEMIR U-100 VIAL ..... 55 levetiracetam ................... 22 levetiracetam er............... 22 levetiracetam in nacl ....... 22 levobunolol hcl ................ 76 levocarnitine .................... 56 levocetirizine
dihydrochloride ............ 79 levofloxacin ............... 19, 75 levofloxacin in d5w .......... 19
99
levoleucovorin calcium .... 30 levoleucovorin calcium pf. 30 levonest ........................... 66 levonorgest-eth est & eth
est ............................... 66 levonorgest-eth estrad 91-
day .............................. 66 levonorgestrel .................. 66 levonorgestrel-ethinyl estrad
.................................... 66 levonorg-eth estrad triphasic
.................................... 66 levora 0.15/30 (28) .......... 66 levorphanol tartrate.......... 13 levo-t ............................... 68 levothyroxine sodium ....... 68 levothyroxine-liothyronine 68 levoxyl ............................. 68 LEVSIN ........................... 59 LEVULAN KERASTICK ... 49 LEXAPRO ....................... 24 LEXETTE ........................ 49 LEXIVA ............................ 35 LIALDA ............................ 72 LIBRAX ........................... 59 lido bdk ............................ 15 lidocaine .......................... 15 lidocaine hcl .............. 15, 45 LIDOCAINE HCL ............. 15 lidocaine hcl (pf) .............. 15 lidocaine hcl
urethral/mucosal .......... 15 lidocaine viscous ............. 45 lidocaine-epinephrine ...... 15 lidocaine-hydrocortisone
ace .............................. 72 LIDOCAINE-
HYDROCORTISONE ACE ............................. 49
lidocaine-prilocaine .......... 15 LIDODERM ..................... 15 lidopin .............................. 15 lidopril .............................. 15 lidopril xr .......................... 15 lido-prilo caine pack ......... 15 LIDORX ........................... 15 LIDO-SORB..................... 15 LIDOTHOL ...................... 15 LIDOTRAL ....................... 15 LIDOTREX ...................... 49 LIDOZION ....................... 15 LILETTA (52 MG) ............ 66 lillow ................................ 66 LINCOCIN ....................... 19 lincomycin hcl .................. 19
lindane ............................ 32 linezolid ........................... 19 linezolid in sodium chloride
.................................... 19 LINZESS ......................... 59 LIORESAL....................... 83 LIORESAL INTRATHECAL
.................................... 83 liothyronine sodium ......... 68 LIPITOR .......................... 41 LIPOFEN ......................... 41 lisinopril ........................... 41 lisinopril-hydrochlorothiazide
.................................... 41 lithium .............................. 37 lithium carbonate ............. 37 lithium carbonate er ......... 37 LITHOBID ....................... 37 LITHOSTAT .................... 61 LIVALO ........................... 41 livixil pak .......................... 15 LO LOESTRIN FE ........... 66 LOCOID .......................... 49 LOCOID LIPOCREAM .... 49 LODINE ........................... 11 LODOSYN....................... 33 LOESTRIN 1.5/30 (21) .... 66 LOESTRIN 1/20 (21) ....... 66 LOESTRIN FE 1.5/30 ...... 66 LOESTRIN FE 1/20 ......... 66 LOKELMA ....................... 56 LOMOTIL ........................ 59 LONHALA MAGNAIR
REFILL KIT ................. 81 LONHALA MAGNAIR
STARTER KIT ............. 81 LONSURF ....................... 30 loperamide hcl ................. 59 LOPID ............................. 41 lopinavir-ritonavir ............. 35 lopreeza .......................... 66 LOPRESSOR .................. 41 LOPRESSOR HCT .......... 41 LOPROX ......................... 26 lorazepam ....................... 37 lorazepam intensol .......... 37 LORBRENA .................... 30 lorcet ............................... 13 lorcet hd .......................... 13 lorcet plus ........................ 13 LORTAB .......................... 13 loryna .............................. 66 LORZONE ....................... 83 losartan potassium .......... 41 losartan potassium-hctz... 41
LOSEASONIQUE ............ 66 LOTEMAX ....................... 75 LOTEMAX SM ................ 75 LOTENSIN ...................... 41 LOTENSIN HCT .............. 41 loteprednol etabonate ..... 75 LOTREL .......................... 41 LOTRISONE ................... 49 LOTRONEX .................... 59 LOUTREX ....................... 49 lovastatin ......................... 41 LOVAZA .......................... 41 LOVENOX ....................... 22 low-ogestrel ..................... 66 loxapine succinate ........... 34 lo-zumandimine ............... 66 LUCEMYRA .................... 16 LUCENTIS ...................... 77 ludent .............................. 56 LULICONAZOLE ............. 26 LUMIGAN........................ 76 LUMIZYME ..................... 60 LUNESTA ....................... 83 LUPRON DEPOT (1-
MONTH) ...................... 63 LUPRON DEPOT (3-
MONTH) ...................... 63 LUPRON DEPOT (4-
MONTH) INTRAMUSCULAR KIT 30MG .......................... 63
LUPRON DEPOT (6-MONTH) INTRAMUSCULAR KIT 45MG .......................... 63
LUPRON DEPOT-PED (1-MONTH) ...................... 64
LUPRON DEPOT-PED (3-MONTH) ...................... 64
LUTATHERA ................... 30 lutera ............................... 66 LUXIQ ............................. 49 LUXTURNA ..................... 77 LUZU .............................. 26 LYNPARZA ..................... 30 LYRICA ........................... 45 LYRICA CR ..................... 45 LYSODREN .................... 30 LYSTEDA........................ 38 lyza ................................. 66 M MACROBID ..................... 19 MACRODANTIN ............. 19 MACUGEN ...................... 77 mafenide acetate ............. 19
100
magnesium citrate ........... 59 MAKENA ......................... 66 MALARONE .................... 32 malathion ......................... 32 maprotiline hcl ................. 24 MARINOL ........................ 25 marlissa ........................... 66 MARPLAN ....................... 24 MARQIBO ....................... 30 MASK VORTEX .............. 74 MATULANE ..................... 30 matzim la ......................... 41 MAVENCLAD (10 TABS). 45 MAVENCLAD (4 TABS) .. 45 MAVENCLAD (5 TABS) .. 45 MAVENCLAD (6 TABS) .. 45 MAVENCLAD (7 TABS) .. 45 MAVENCLAD (8 TABS) .. 45 MAVENCLAD (9 TABS) .. 45 MAVYRET ....................... 35 MAXALT .......................... 27 MAXALT-MLT .................. 27 MAXICOMFORT SYR 27G
X 1/2 ............................ 55 MAXIDEX ........................ 75 MAXIPIME ....................... 19 MAXITROL ...................... 77 MAXZIDE ........................ 41 MAXZIDE-25 ................... 41 MAYZENT ....................... 45 MAYZENT STARTER
PACK .......................... 45 me/naphos/mb/hyo1 ........ 61 meclizine hcl .................... 25 meclofenamate sodium ... 11 MEDI-PATCH RX ............ 15 medique aspirin ............... 11 MEDROL ......................... 62 medroxyprogesterone
acetate .................. 66, 67 mefenamic acid ............... 11 mefloquine hcl ................. 32 MEGACE ES ................... 67 megestrol acetate ............ 67 MEKINIST ....................... 30 MEKTOVI ........................ 30 melodetta 24 fe ................ 67 meloxicam ....................... 11 melphalan ........................ 30 melphalan hcl .................. 30 memantine hcl ................. 23 memantine hcl er ............. 23 MENACTRA .................... 71 MENEST ......................... 67 MENOSTAR .................... 67
MENVEO ........................ 71 meperidine hcl ................. 13 MEPHYTON .................... 56 meprobamate .................. 37 MEPRON ........................ 32 MEPSEVII ....................... 60 mercaptopurine ............... 30 meropenem ..................... 19 MEROPENEM-SODIUM
CHLORIDE .................. 19 mesalamine ..................... 72 mesalamine-cleanser ...... 72 mesna ............................. 30 MESNEX ......................... 30 MESTINON ..................... 28 metadate er ..................... 44 metaproterenol sulfate ..... 81 metaxalone...................... 83 metformin hcl er .............. 53 metformin hcl er (mod) .... 53 metformin hcl er (osm) .... 53 metformin hcl ir ................ 53 METFORMIN HCL IR ...... 53 methadone hcl ................. 13 methadone hcl intensol ... 13 methadose ...................... 14 methadose sugar-free ..... 14 methamphetamine hcl ..... 44 methazolamide ................ 76 methenamine hippurate ... 19 methenamine mandelate . 19 methergine ...................... 74 methimazole .................... 68 METHITEST .................... 63 methocarbamol ............... 83 methotrexate ................... 70 methotrexate sodium ....... 70 methotrexate sodium (pf) . 70 methoxsalen .................... 49 methoxsalen rapid ........... 49 methscopolamine bromide
.................................... 59 methyldopa...................... 41 methyldopa-
hydrochlorothiazide ..... 41 methylergonovine maleate
.................................... 74 METHYLIN ...................... 44 methylphenidate hcl ........ 44 methylphenidate hcl er .... 44 methylphenidate hcl er (cd)
.................................... 44 methylphenidate hcl er (la)
.................................... 44 methylprednisolone ......... 62
methylprednisolone acetate .................................... 62
methylprednisolone sodium succ............................. 62
methyltestosterone .......... 63 metoclopramide hcl ......... 25 metolazone ..................... 41 metoprolol succinate er ... 41 metoprolol tartrate ........... 41 METOPROLOL-HCTZ ER
.................................... 41 metoprolol-
hydrochlorothiazide ..... 41 METROCREAM .............. 49 METROGEL .................... 49 METROLOTION .............. 49 metronidazole ..... 19, 49, 50 metronidazole in nacl ...... 19 mexiletine hcl .................. 41 MIACALCIN .................... 73 mibelas 24 fe ................... 67 MICARDIS ...................... 41 MICARDIS HCT .............. 41 miconazole 3 ................... 26 MICONAZOLE-ZINC
OXIDE-PETROLAT ..... 26 MICORT-HC ................... 50 MICRHOGAM ULTRA-
FILTERED PLUS......... 70 microgestin 1.5/30 ........... 67 microgestin 1/20 .............. 67 microgestin fe 1.5/30 ....... 67 microgestin fe 1/20 .......... 67 MICROLET NEXT
LANCING DEVICE ...... 54 midazolam hcl ................. 37 midodrine hcl ................... 41 MIFEPREX ...................... 56 mifepristone .................... 56 MIGERGOT .................... 27 miglitol ............................. 53 miglustat ......................... 60 MIGRANAL ..................... 27 mili .................................. 67 MILLIPRED ..................... 62 MILLIPRED DP ............... 62 MILLIPRED DP 12-DAY .. 62 milrinone lactate .............. 41 milrinone lactate in dextrose
.................................... 41 mimvey ........................... 67 MIMYX ............................ 50 MINASTRIN 24 FE .......... 67 MINIPRESS .................... 41 minitran ........................... 41
101
MINIVELLE ..................... 67 MINOCIN ......................... 19 minocycline hcl ................ 19 minocycline hcl er ............ 19 MINOLIRA ....................... 19 minoxidil .......................... 41 MIRAPEX ........................ 33 MIRAPEX ER .................. 33 MIRCERA ........................ 38 MIRCETTE ...................... 67 MIRENA (52 MG) ............ 67 mirtazapine ...................... 24 MIRVASO ........................ 50 misoprostol ...................... 58 MITIGARE ....................... 27 mitigo .............................. 14 mitomycin ........................ 30 mitoxantrone hcl .............. 30 M-M-R II .......................... 71 MOBIC ............................ 11 modafinil .......................... 83 moexipril hcl .................... 42 molindone hcl .................. 34 mometasone furoate .. 50, 79 mondoxyne nl .................. 19 mono-linyah ..................... 67 MONONINE..................... 38 MONOVISC ..................... 74 montelukast sodium ......... 81 MONUROL ...................... 19 morgidox ......................... 19 MORPHABOND ER ........ 14 morphine sulfate .............. 14 MORPHINE SULFATE .... 14 morphine sulfate
(concentrate) ............... 14 morphine sulfate (pf) ........ 14 morphine sulfate er .......... 14 morphine sulfate er beads
.................................... 14 MOTEGRITY ................... 59 MOTOFEN ...................... 59 MOVANTIK ..................... 59 MOVIPREP ..................... 59 MOXEZA ......................... 75 moxifloxacin hcl ......... 19, 75 MOXIFLOXACIN HCL ..... 19 moxifloxacin hcl in nacl .... 19 MOZOBIL ........................ 38 MS CONTIN .................... 14 MUCOSITISRX ............... 45 MULPLETA ..................... 38 MULTAQ ......................... 42 multi prenatal ................... 56 mupirocin ......................... 19
mupirocin calcium............ 19 mutamycin ....................... 30 MYALEPT ....................... 60 MYAMBUTOL ................. 28 MYCAMINE ..................... 26 MYCOBUTIN ................... 28 mycophenolate mofetil .... 70 mycophenolate mofetil hcl
.................................... 70 mycophenolate sodium ... 70 MYDAYIS ........................ 44 MYFORTIC ..................... 70 MYLERAN ....................... 30 MYLOTARG .................... 30 MYOBLOC ...................... 74 myorisan ......................... 50 MYRBETRIQ ................... 61 MYSOLINE...................... 22 MYTESI ........................... 59 N na ferric gluc cplx in sucrose
.................................... 56 nabi-hb ............................ 70 nabumetone .................... 11 nadolol ............................ 42 nafcillin sodium ................ 19 NAFCILLIN SODIUM IN
DEXTROSE................. 19 nafrinse ........................... 56 nafrinse drops ................. 56 naftifine hcl ...................... 26 NAFTIN ........................... 26 NAGLAZYME .................. 60 nalbuphine hcl ................. 14 NALFON ......................... 11 NALOCET ....................... 14 naloxone hcl .................... 16 naltrexone hcl .................. 16 NAMENDA ...................... 23 NAMENDA TITRATION
PAK ............................. 23 NAMENDA XR ................ 23 NAMENDA XR TITRATION
PACK .......................... 23 NAMZARIC ..................... 23 NAPRELAN ..................... 11 NAPROSYN .................... 11 naproxen ......................... 12 naproxen dr ..................... 12 naproxen sodium ............. 12 naproxen sodium er ......... 12 naratriptan hcl ................. 27 NARCAN ......................... 16 NARDIL ........................... 24 NASONEX....................... 79
NATACYN ....................... 75 NATAZIA ......................... 67 nateglinide ....................... 53 NATESTO ....................... 63 NATPARA ....................... 73 NATROBA ....................... 32 nature-throid .................... 68 NATURE-THROID .......... 68 NAYZILAM ...................... 22 NEBUPENT .................... 32 nebusal ........................... 79 NEBUSAL ....................... 79 necon 0.5/35 (28) ............ 67 nefazodone hcl ................ 24 NEMBUTAL .................... 22 NEOCERA ...................... 50 neomycin sulfate ............. 19 neomycin-bacitracin zn-
polymyx ....................... 77 neomycin-polymyxin b gu 19 neomycin-polymyxin-
dexameth .................... 77 neomycin-polymyxin-
gramicidin .................... 77 neomycin-polymyxin-hc .. 77,
78 neo-polycin ...................... 77 neo-polycin hc ................. 77 NEORAL ......................... 70 NEOSALUS .................... 50 NEOSALUS CP............... 50 neostigmine methylsulfate
.................................... 28 NEO-SYNALAR .............. 50 NERLYNX ....................... 30 NESINA .......................... 53 neuac .............................. 50 NEULASTA ..................... 38 NEULASTA ONPRO ....... 38 NEUPOGEN ................... 38 NEUPRO......................... 33 NEURONTIN ................... 22 NEUTRASAL .................. 45 NEVANAC ....................... 75 nevirapine ....................... 35 nevirapine er ................... 35 NEXAVAR ....................... 30 NEXIUM .......................... 58 NEXPLANON .................. 67 niacin (antihyperlipidemic)
.................................... 42 niacin er
(antihyperlipidemic) ..... 42 NIACOR .......................... 42 NIASPAN ........................ 42
102
nicardipine hcl ................. 42 NICORETTE.................... 16 nicotine polacrilex ............ 16 nicotine step 1 ................. 16 nicotine step 2 ................. 16 nicotine step 3 ................. 16 NICOTROL ...................... 16 NICOTROL NS ................ 16 nifedipine ......................... 42 nifedipine er ..................... 42 nifedipine er osmotic
release ........................ 42 nikki ................................. 67 NILANDRON ................... 30 nilutamide ........................ 30 nimodipine ....................... 42 NINLARO ........................ 30 NIPENT ........................... 30 nisoldipine er ................... 42 nitisinone ......................... 60 NITRO-BID ...................... 42 NITRO-DUR .................... 42 nitrofurantoin ................... 19 nitrofurantoin macrocrystal
.................................... 19 nitrofurantoin monohydrate
macrocrystals .............. 19 nitroglycerin ..................... 42 NITROLINGUAL .............. 42 NITROMIST..................... 42 NITROSTAT .................... 42 nitro-time ......................... 42 NITYR ............................. 60 NIVATOPIC PLUS ........... 50 NIVESTYM ...................... 38 nizatidine ......................... 58 NIZORAL ......................... 26 NOCDURNA.................... 64 NOCTIVA ........................ 64 nolix ................................. 50 nora-be ............................ 67 NORCO ........................... 14 NORDITROPIN FLEXPRO
.................................... 64 norethin ace-eth estrad-fe 67 norethindrone .................. 67 norethindrone acetate ...... 67 norethindrone acet-ethinyl
est ............................... 67 norethindrone-eth estradiol
.................................... 67 norethin-eth estradiol-fe ... 67 NORGESIC FORTE ........ 83 norgestimate-eth estradiol
.................................... 67
norgestimate-ethinyl estradiol triphasic ........ 67
NORITATE ...................... 50 norlyda ............................ 67 norlyroc ........................... 67 NORPACE ...................... 42 NORPACE CR ................ 42 NORPRAMIN .................. 24 NORTHERA .................... 42 nortrel 0.5/35 (28) ............ 67 nortrel 1/35 (21) ............... 67 nortrel 1/35 (28) ............... 67 nortrel 7/7/7 ..................... 67 nortriptyline hcl ................ 24 NORVASC ...................... 42 NORVIR .......................... 35 NOURIANZ ..................... 33 NOVACORT .................... 50 NOVOEIGHT ................... 38 NOVOFINE AUTOCOVER
PEN NEEDLE .............. 55 NOVOFINE PEN NEEDLE
.................................... 55 NOVOFINE PLUS PEN
NEEDLE ...................... 55 NOVOLIN 70/30 RELION 55 NOVOLIN 70/30 VIAL ..... 55 NOVOLIN N RELION ...... 55 NOVOLIN N VIAL ............ 55 NOVOLIN R RELION ...... 55 NOVOLIN R VIAL ............ 55 NOVOLOG FLEXPEN ..... 55 NOVOLOG MIX 70/30
FLEXPEN .................... 55 NOVOLOG MIX 70/30 VIAL
.................................... 55 NOVOLOG PENFILL ....... 55 NOVOLOG U-100 VIAL ... 55 NOVOSEVEN RT ............ 38 NOVOTWIST PEN
NEEDLE ...................... 55 NOXAFIL ......................... 26 np thyroid ........................ 68 NPLATE .......................... 38 NUBEQA ......................... 31 NUCALA ......................... 79 NUCORT ......................... 50 NUCYNTA ....................... 14 NUCYNTA ER ................. 14 NUEDEXTA ..................... 45 nulev ............................... 59 NULOJIX ......................... 70 NULYTELY WITH FLAVOR
PACKS ........................ 59 NUPLAZID ...................... 34
NUTROPIN AQ NUSPIN 10 .................................... 64
NUTROPIN AQ NUSPIN 20 .................................... 64
NUTROPIN AQ NUSPIN 5 .................................... 64
NUVARING ..................... 67 NUVESSA ....................... 19 NUVIGIL ......................... 83 NUWIQ ........................... 38 NUZYRA ......................... 20 nyamyc ........................... 26 NYMALIZE ...................... 42 nystatin ........................... 26 nystatin-triamcinolone ..... 26 nystop ............................. 26 O OBIZUR .......................... 38 OCALIVA ........................ 60 ocella .............................. 67 OCREVUS ...................... 45 OCTAGAM ...................... 70 octreotide acetate ............ 64 OCUFLOX ....................... 75 ODACTRA ...................... 74 ODEFSEY ....................... 35 ODOMZO ........................ 31 OFEV .............................. 81 ofloxacin .............. 20, 75, 78 ogestrel ........................... 67 okebo .............................. 20 olanzapine ....................... 34 olanzapine-fluoxetine hcl . 24 olmesartan medoxomil .... 42 olmesartan medoxomil-hctz
.................................... 42 olmesartan-amlodipine-hctz
.................................... 42 olopatadine hcl .......... 75, 79 OLUMIANT ..................... 70 OLUX .............................. 50 OLUX-E .......................... 50 OMECLAMOX-PAK ........ 59 omega-3-acid ethyl esters42 omeprazole ..................... 58 OMEPRAZOLE+SYRSPEN
D SF ALKA .................. 58 omeprazole-sodium
bicarbonate ................. 58 OMIDRIA......................... 77 OMNARIS ....................... 79 OMNIPOD 5 PACK ......... 74 OMNIPOD DASH 5 PACK
.................................... 74
103
OMNIPOD DASH SYSTEM .................................... 54
OMNIPOD STARTER ...... 54 OMNITROPE ................... 64 ONCASPAR .................... 31 ondansetron hcl ............... 25 ondansetron odt .............. 25 ONE TOUCH VERIO KIT
W/DEVICE ................... 54 ONE-A-DAY WOMENS
PRENATAL 1............... 56 ONETOUCH DELICA
LANCING DEV ............ 54 ONETOUCH DELICA PLUS
LANCING .................... 54 ONETOUCH ULTRA BLUE
TEST STRIPS ............. 54 ONEXTON ...................... 50 ONFI ............................... 22 ONGLYZA ....................... 53 ONIVYDE ........................ 31 OPANA ............................ 14 OPDIVO .......................... 31 opium .............................. 59 OPSUMIT ........................ 82 OPTIONS CONCEPTROL
.................................... 74 ORACEA ......................... 50 ORACIT ........................... 56 ORALAIR ........................ 74 ORALAIR ADULT SAMPLE
KIT ............................... 74 ORALAIR ADULT
STARTER PACK ......... 74 ORALAIR CHILDRENS
SAMPLE KIT ............... 74 ORALAIR CHILDRENS
STARTER PACK ......... 74 oralone ............................ 45 ORAPRED ODT .............. 62 ORAVIG .......................... 26 ORBACTIV ...................... 20 ORENCIA ........................ 70 ORENCIA CLICKJECT .... 70 ORENITRAM ................... 82 ORFADIN ........................ 60 ORILISSA ........................ 64 ORKAMBI ........................ 82 orphenadrine citrate ......... 83 orphenadrine citrate er .... 83 orphenadrine-aspirin-
caffeine ........................ 83 ORPHENGESIC FORTE . 83 orsythia ............................ 67 ORTHO MICRONOR ....... 67
ORTHO TRI-CYCLEN LO67 ORTHO-NOVUM 1/35 (28)
.................................... 67 ORTHO-NOVUM 7/7/7 (28)
.................................... 67 ORTHOVISC ................... 74 oscimin ............................ 59 oscimin sr ........................ 59 oseltamivir phosphate ..... 35 OSENI ............................. 53 OSMOLEX ER ................ 33 OSMOPREP ................... 59 OSPHENA....................... 63 OTEZLA .......................... 70 OTIPRIO ......................... 78 OTOVEL ......................... 78 OTREXUP ....................... 70 OVACE PLUS ................. 50 OVIDE ............................. 32 oxacillin sodium ............... 20 oxaliplatin ........................ 31 oxandrolone .................... 63 oxaprozin ........................ 12 OXAYDO ......................... 14 oxazepam ....................... 37 oxcarbazepine ................. 22 OXERVATE ..................... 78 oxiconazole nitrate .......... 26 OXISTAT ......................... 26 OXSORALEN ULTRA ..... 50 OXTELLAR XR ............... 22 oxybutynin chloride .......... 61 oxybutynin chloride er ..... 61 oxycodone hcl ................. 14 OXYCODONE HCL ER ... 14 oxycodone-acetaminophen
.................................... 14 oxycodone-aspirin ........... 14 oxycodone-ibuprofen ....... 14 OXYCONTIN ................... 14 oxymorphone hcl ............. 14 oxymorphone hcl er ......... 14 OXYTROL ....................... 61 OZEMPIC ........................ 53 OZOBAX ......................... 83 OZURDEX....................... 75 P pacerone ......................... 42 paclitaxel ......................... 31 paliperidone er ................ 34 palonosetron hcl .............. 25 PALYNZIQ ...................... 60 PAMELOR....................... 24 pamidronate disodium ..... 73 PANCREAZE .................. 60
PANDA MASK LARGE .... 74 PANDA MASK MEDIUM . 74 PANDA MASK SMALL .... 74 PANDEL ......................... 50 PANHEMATIN ................ 38 PANRETIN ...................... 31 pantoprazole sodium ....... 58 papaverine hcl ................. 42 PARAGARD
INTRAUTERINE COPPER ..................... 67
paregoric ......................... 59 paricalcitol ....................... 73 PARLODEL ..................... 33 PARNATE ....................... 24 paroex ............................. 45 paromomycin sulfate ....... 20 paroxetine hcl .................. 24 paroxetine hcl er.............. 24 paroxetine mesylate ........ 24 PARSABIV ...................... 68 PASER ............................ 28 PATADAY ....................... 75 PATANASE ..................... 79 PATANOL ....................... 75 PAXIL .............................. 24 PAXIL CR........................ 24 PAZEO ............................ 76 PEDIAPRED ................... 62 PEDIARIX ....................... 72 PEDIATRIC PANDA MASK
.................................... 74 PEDVAX HIB .................. 72 peg 3350/electrolytes ...... 59 peg 3350-kcl-na bicarb-nacl
.................................... 59 peg-3350/electrolytes ...... 59 PEGANONE .................... 22 PEGASYS ....................... 35 PEGASYS PROCLICK .... 35 PEGINTRON ................... 35 peg-prep ......................... 59 penicillamine ................... 61 PENICILLIN G POT IN
DEXTROSE ................ 20 penicillin g potassium ...... 20 penicillin g procaine ......... 20 penicillin g sodium ........... 20 penicillin v potassium ...... 20 PENLAC ......................... 27 PENLEN ......................... 50 PENNSAID ...................... 12 PENTACEL ..................... 72 PENTAM ......................... 32 pentamidine isethionate .. 32
104
PENTASA ....................... 72 pentazocine-naloxone hcl 14 pentobarbital sodium ....... 23 pentoxifylline er ............... 42 PEPCID ........................... 58 PERCOCET .................... 14 PERFOROMIST .............. 81 perindopril erbumine ........ 42 periogard ......................... 45 PERJETA ........................ 31 permethrin ....................... 32 perphenazine................... 25 perphenazine-amitriptyline
.................................... 24 PERSERIS ...................... 34 PERTZYE ........................ 60 PEXEVA .......................... 24 pfizerpen ......................... 20 phenadoz ........................ 79 phenazo .......................... 61 phenazopyridine hcl ......... 61 phenelzine sulfate ........... 24 PHENERGAN .................. 79 phenobarbital................... 23 phenobarbital sodium ...... 23 phenoxybenzamine hcl .... 42 phentolamine mesylate .... 42 phenylephrine hcl ............ 78 phenylephrine-guaifenesin
.................................... 79 PHENYTEK ..................... 23 phenytoin ......................... 23 phenytoin infatabs ........... 23 phenytoin sodium ............ 23 phenytoin sodium extended
.................................... 23 philith ............................... 67 PHLAG SPRAY ............... 50 PHOSLYRA ..................... 61 phospha 250 neutral ........ 56 phosphasal ...................... 61 PHOSPHOLINE IODIDE . 76 phosphorous.................... 56 phospho-trin 250 neutral .. 56 PHOTOFRIN ................... 31 physiolyte ........................ 57 physiosol irrigation ........... 57 phytonadione ................... 57 PICATO ........................... 50 PIFELTRO ....................... 35 pilocarpine hcl ..... 45, 46, 76 pimecrolimus ................... 50 PIMECROLIMUS ............. 50 pimozide .......................... 34 pimtrea ............................ 67
pindolol ............................ 42 pioglitazone hcl ............... 53 pioglitazone hcl-glimepiride
.................................... 53 pioglitazone hcl-metformin
hcl ............................... 53 piperacillin sod-tazobactam
so ................................ 20 PIQRAY (200 MG DAILY
DOSE) ......................... 31 PIQRAY (250 MG DAILY
DOSE) ......................... 31 PIQRAY (300 MG DAILY
DOSE) ......................... 31 pirmella 1/35 .................... 67 pirmella 7/7/7 ................... 67 piroxicam ......................... 12 PLAN B ONE-STEP ........ 67 PLAQUENIL .................... 32 PLAVIX ........................... 33 PLEGRIDY ...................... 45 PLEGRIDY STARTER
PACK .......................... 45 PLENVU .......................... 59 PLEXION CLEANSING
CLOTH ........................ 50 pneumovax 23 ................. 72 PNEUMOVAX 23 ............ 72 pocket spacer .................. 74 podocon .......................... 50 podofilox .......................... 50 polycin ............................. 78 polymyxin b sulfate .......... 20 polymyxin b-trimethoprim 78 POLYTRIM ...................... 78 POMALYST ..................... 31 portia-28 .......................... 67 PORTRAZZA .................. 31 posaconazole .................. 27 pot bicarb-pot chloride ..... 57 potassium bicarbonate .... 57 potassium chloride .......... 57 potassium chloride crys er
.................................... 57 potassium chloride er ...... 57 potassium citrate er ......... 57 potassium citrate-citric acid
.................................... 57 POTELIGEO ................... 31 POVIDONE-IODINE ........ 76 PRADAXA ....................... 22 PRALUENT ..................... 42 pramipexole dihydrochloride
.................................... 33
pramipexole dihydrochloride er ................................. 33
PRAMOSONE ................. 50 PRAMOTIC ..................... 78 pramox ............................ 50 prasugrel hcl ................... 33 PRAVACHOL .................. 42 pravastatin sodium .......... 42 praziquantel .................... 32 prazosin hcl ..................... 42 PRECOSE ...................... 53 PRED FORTE ................. 76 PRED MILD .................... 76 PRED-G .......................... 78 PRED-G S.O.P................ 78 prednicarbate .................. 50 PREDNISOL ACE-
MOXIFLOX-BROMFEN .................................... 76
prednisolone ................... 62 prednisolone acetate ....... 76 prednisolone acetate p-f .. 76 PREDNISOLONE
ACETATE-NEPAFENAC .................................... 78
PREDNISOLONE ACET-MOXIFLOXACIN ......... 78
prednisolone sodium phosphate ............. 62, 76
PREDNISOLONE-BROMFENAC ............. 78
PREDNISOLONE-GATIFLOXACIN .......... 78
PREDNISOLON-GATIFLOX-BROMFENAC ............. 78
PREDNISOLON-MOXIFLOX-BROMFENAC ............. 78
PREDNISOLON-MOXIFLOX-NEPAFENAC .............. 76
prednisone ...................... 62 PREDNISONE INTENSOL
.................................... 62 PREFEST ....................... 67 pregabalin ....................... 45 PREMARIN ..................... 67 premium lidocaine ........... 15 PREMPHASE ................. 67 PREMPRO ...................... 67 prenatal ........................... 57 prenatal multi +dha.......... 57 PREPIDIL........................ 64 PREPOPIK ...................... 59
105
PRESERA ....................... 50 PRESTALIA..................... 42 PREVACID ...................... 58 PREVACID SOLUTAB .... 58 prevalite ........................... 42 preventeza ...................... 67 previfem .......................... 67 PREVNAR 13 .................. 72 PREVYMIS ...................... 35 PREZCOBIX.................... 35 PREZISTA ....................... 36 PRIALT ............................ 14 PRIFTIN .......................... 28 prilolid .............................. 15 PRILOSEC ...................... 58 prilovix ............................. 15 prilovix plus ..................... 15 prilovix ultralite ................. 15 priloxx lp .......................... 15 primaquine phosphate ..... 32 primidone ........................ 23 PRIMLEV ........................ 14 PRIMSOL ........................ 20 PRINIVIL ......................... 42 PRISTIQ .......................... 24 PRIVIGEN ....................... 70 PRO COMFORT SPACER
ADULT ........................ 74 PRO COMFORT SPACER
CHILD ......................... 74 PROAIR DIGIHALER ...... 81 PROAIR HFA .................. 81 PROAIR RESPICLICK .... 81 probenecid ...................... 27 PROBUPHINE IMPLANT
KIT ............................... 14 procainamide hcl ............. 42 PROCARDIA ................... 42 PROCARDIA XL .............. 42 PROCARE
SPACER/ADULT MASK .................................... 74
PROCARE SPACER/CHILD MASK .......................... 74
PROCENTRA .................. 44 prochlorperazine .............. 25 prochlorperazine edisylate
.................................... 25 prochlorperazine maleate 25 PROCORT ...................... 72 PROCRIT ........................ 38 PROCTOCORT ............... 72 PROCTOFOAM HC ......... 72 procto-med hc ................. 72 procto-pak ....................... 72
proctosol hc ..................... 72 proctozone-hc ................. 72 PROCYSBI...................... 60 PROFILNINE ................... 38 PROFILNINE SD ............. 38 progesterone ................... 67 progesterone micronized . 67 PROGLYCEM ................. 54 PROGRAF ................ 70, 71 PROLASTIN-C ................ 81 PROLENSA ..................... 76 PROLEUKIN ................... 31 PROLIA ........................... 73 PROMACTA .................... 38 promethazine hcl ............. 79 promethazine-codeine ..... 79 promethazine-dm ............ 79 promethazine-phenyleph-
codeine ........................ 79 promethazine-
phenylephrine .............. 79 promethegan ................... 79 PROMETRIUM ................ 68 PROMISEB ..................... 50 propafenone hcl .............. 42 propafenone hcl er .......... 42 propantheline bromide ..... 59 proparacaine hcl .............. 78 PROPEL ......................... 79 PROPEL MINI ................. 79 propranolol hcl ................. 42 propranolol hcl er............. 42 propranolol-hctz .............. 42 propylthiouracil ................ 69 PROQUAD ...................... 72 PROSCAR ...................... 61 PROSTIN E2 ................... 64 PROSTIN VR .................. 42 PROTONIX ..................... 58 PROTOPIC ..................... 50 protriptyline hcl ................ 24 PROVENGE .................... 71 PROVENTIL HFA ............ 81 PROVERA....................... 68 PROVIGIL ....................... 83 PROZAC ......................... 24 PRUCLAIR ...................... 50 PRUDOXIN ..................... 50 PRUMYX ......................... 50 pseudoephedrine-
bromphen-dm .............. 79 PSORCON ...................... 50 PULMICORT FLEXHALER
.................................... 81
PULMICORT SUSPENSION ............. 81
pulmosal ......................... 79 PULMOZYME ................. 82 PURIXAN ........................ 31 PYLERA .......................... 59 pyrazinamide ................... 28 pyridostigmine bromide ... 28 pyridostigmine bromide er28 pyrogallic acid ................. 50 Q QBRELIS ........................ 43 QBREXZA ....................... 50 qc aspirin low dose .......... 12 QMIIZ ODT ..................... 12 QNASL ............................ 80 QNASL CHILDRENS ...... 80 QTERN ........................... 53 QUADRACEL .................. 72 QUADRAMET ................. 31 QUALAQUIN ................... 32 QUARTETTE .................. 68 quazepam ....................... 37 QUDEXY XR ................... 23 QUESTRAN .................... 43 QUESTRAN LIGHT ......... 43 quetiapine fumarate ........ 34 quetiapine fumarate er .... 34 QUILLICHEW ER ............ 44 QUILLIVANT XR ............. 44 quinapril hcl ..................... 43 quinapril-
hydrochlorothiazide ..... 43 quinidine gluconate er ..... 43 quinidine sulfate .............. 43 quinine sulfate ................. 32 QVAR REDIHALER ........ 81 R ra iron .............................. 57 rabeprazole sodium ......... 58 RABEPRAZOLE SODIUM
.................................... 58 RADICAVA ...................... 45 RAGWITEK ..................... 74 raloxifene hcl ................... 63 ramelteon ........................ 83 ramipril ............................ 43 RANEXA ......................... 43 ranitidine hcl .................... 58 ranolazine er ................... 43 RAPAFLO ....................... 61 RAPAMUNE .................... 71 RAPIVAB ........................ 36 rasagiline mesylate ......... 33 RASUVO ......................... 71
106
RAVICTI .......................... 60 RAYALDEE ..................... 73 RAYOS ............................ 62 RAZADYNE ..................... 23 RAZADYNE ER ............... 23 REBIF.............................. 45 REBIF REBIDOSE .......... 45 REBIF REBIDOSE
TITRATION PACK ....... 45 REBIF TITRATION PACK45 REBINYN ........................ 38 reclipsen .......................... 68 RECOMBINATE .............. 38 RECOMBIVAX HB........... 72 RECTIV ........................... 43 REGENECARE ............... 50 REGLAN ......................... 25 REGRANEX .................... 50 relador pak ...................... 15 relador pak plus ............... 15 RELAFEN DS .................. 12 RELENZA DISKHALER ... 36 relexxii ............................. 44 RELISTOR ...................... 59 RELPAX .......................... 27 REMERON ...................... 24 REMERON SOLTAB ....... 24 REMICADE ..................... 71 RENACIDIN..................... 61 RENAGEL ....................... 61 RENFLEXIS .................... 71 RENOVO ......................... 15 RENVELA ....................... 61 repaglinide ....................... 53 repaglinide-metformin hcl 53 REPATHA ....................... 43 REPATHA PUSHTRONEX
SYSTEM ...................... 43 REPATHA SURECLICK .. 43 REQUIP XL ..................... 33 RESCRIPTOR ................. 36 RESTASIS ...................... 78 RESTASIS MULTIDOSE . 78 RESTORIL ...................... 83 RETACRIT ...................... 38 RETIN-A .......................... 50 RETIN-A MICRO GEL 0.04
%, 0.1 % ...................... 50 RETIN-A MICRO PUMP .. 50 RETISERT ...................... 76 RETROVIR ...................... 36 REVATIO ........................ 82 REVLIMID ....................... 31 REXAPHENAC ................ 12 REXULTI ......................... 34
REYATAZ ....................... 36 RHOFADE....................... 50 RHOGAM ULTRA-
FILTERED PLUS ......... 71 RHOPHYLAC .................. 71 RHOPRESSA .................. 76 RIASTAP ......................... 38 ribavirin ........................... 36 RIDAURA ........................ 71 rifabutin ........................... 28 RIFADIN .......................... 28 RIFAMATE ...................... 28 rifampin ........................... 28 RIFATER ......................... 28 RILUTEK ......................... 45 riluzole ............................. 45 rimantadine hcl ................ 36 RIMSO-50 ....................... 61 RINVOQ .......................... 71 RIOMET .......................... 53 risedronate sodium .......... 73 RISPERDAL .................... 34 RISPERDAL CONSTA .... 34 risperidone ...................... 34 RITALIN .......................... 44 RITALIN LA ..................... 44 ritonavir ........................... 36 RITUXAN ........................ 31 RITUXAN HYCELA ......... 31 rivastigmine ..................... 23 rivastigmine tartrate ......... 23 rivelsa .............................. 68 RIXUBIS .......................... 38 rizatriptan benzoate ......... 27 ROBAXIN ........................ 83 ROBAXIN-750 ................. 83 ROCALTROL .................. 73 ROCKLATAN .................. 76 ROMIDEPSIN ................. 31 ropinirole hcl .................... 33 ropinirole hcl er ................ 33 rosadan ........................... 50 ROSADAN ...................... 50 rosuvastatin calcium ........ 43 ROTARIX ........................ 72 ROTATEQ ....................... 72 ROWASA ........................ 73 roweepra ......................... 23 roweepra xr ..................... 23 ROXICODONE ................ 14 ROZEREM ...................... 83 ROZLYTREK ................... 31 RUBRACA....................... 31 RUCONEST .................... 71 RUZURGI ........................ 74
RYBELSUS ..................... 53 RYDAPT ......................... 31 RYTARY ......................... 33 RYTHMOL SR ................ 43 ryvent .............................. 80 S SABRIL ........................... 23 SAFYRAL........................ 68 SAIZEN ........................... 64 SAIZENPREP ................. 64 SALAGEN ....................... 46 salicylic acid .............. 50, 51 salicylic acid wart remover
.................................... 51 salimez ............................ 51 SALIMEZ FORTE ............ 51 SALIVAMAX .................... 46 salsalate .......................... 12 SAMSCA ......................... 57 SANCUSO ...................... 25 SANDIMMUNE................ 71 SANDOSTATIN............... 64 SANDOSTATIN LAR
DEPOT ........................ 64 SANTYL .......................... 51 SAPHRIS ........................ 34 SARAFEM ....................... 24 SAVAYSA ....................... 22 SAVELLA ........................ 45 SAVELLA TITRATION
PACK .......................... 45 scopolamine .................... 25 SEASONIQUE ................ 68 SECONAL ....................... 83 SEEBRI NEOHALER ...... 81 SEGLUROMET ............... 53 selegiline hcl ................... 33 selenium sulfide .............. 51 SELZENTRY ................... 36 SEMPREX-D ................... 80 SENSIPAR ...................... 63 SEREVENT DISKUS ...... 81 SERNIVO ........................ 51 SEROQUEL .................... 34 SEROQUEL XR .............. 34 SEROSTIM ..................... 59 sertraline hcl .................... 24 setlakin ............................ 68 sevelamer carbonate ....... 61 sevelamer hcl .................. 61 SEYSARA ....................... 20 SFROWASA ................... 73 sharobel .......................... 68 SHINGRIX ....................... 72 SIGNIFOR ....................... 64
107
SIGNIFOR LAR ............... 64 SIKLOS ........................... 31 sildenafil citrate ................ 82 SILENOR ........................ 83 SILIQ ............................... 71 silodosin .......................... 61 SILVADENE .................... 20 silver nitrate ..................... 20 silver sulfadiazine ............ 20 SIMBRINZA ..................... 76 simliya ............................. 68 simpesse ......................... 68 SIMPONI ......................... 71 SIMPONI ARIA ................ 71 SIMULECT ...................... 71 simvastatin ...................... 43 SINEMET ........................ 33 SINEMET CR .................. 33 SINGULAIR ..................... 81 SINUVA ........................... 80 sirolimus .......................... 71 SIRTURO ........................ 28 SITAVIG .......................... 36 SIVEXTRO ...................... 20 SKELAXIN ....................... 83 SKLICE ........................... 32 SKYLA............................. 68 SKYRIZI (150 MG DOSE)71 SLYND ............................ 68 sm vitamin d3 .................. 57 sod citrate-citric acid ........ 57 sodium chloride ......... 57, 80 sodium fluoride ................ 57 sodium hyaluronate ......... 51 SODIUM HYALURONATE
.................................... 74 sodium phenylbutyrate .... 60 sodium polystyrene
sulfonate ...................... 57 sodium sulfacetamide ...... 51 sodium sulfacetamide wash
.................................... 51 SODIUM
SULFACETAMIDE WASH ......................... 51
SOFOSBUVIR-VELPATASVIR ............ 36
solifenacin succinate ....... 61 SOLIQUA ........................ 53 SOLIRIS .......................... 38 SOLODYN ....................... 20 SOLOSEC ....................... 32 SOLTAMOX .................... 31 SOLU-CORTEF ............... 62 SOLU-MEDROL .............. 62
SOMA ............................. 83 SOMATULINE DEPOT .... 64 SOMAVERT .................... 64 SOOLANTRA .................. 51 SOOTHEE....................... 15 SORIATANE ................... 51 SORILUX ........................ 51 sorine .............................. 43 sotalol hcl ........................ 43 sotalol hcl (af) .................. 43 SOTYLIZE ....................... 43 SOVALDI ........................ 36 SPECTRACEF ................ 20 spinosad .......................... 32 SPIRIVA HANDIHALER .. 81 SPIRIVA RESPIMAT ....... 81 spironolactone ................. 43 spironolactone-hctz ......... 43 SPORANOX .................... 27 SPORANOX PULSEPAK 27 sprintec 28....................... 68 SPRITAM ........................ 23 SPRIX ............................. 12 SPRYCEL ....................... 31 sps .................................. 57 sronyx ............................. 68 ssd .................................. 20 SSKI ................................ 80 sss 10-5 .......................... 51 st joseph low dose ........... 12 STALEVO 100 ................. 33 STALEVO 125 ................. 33 STALEVO 150 ................. 33 STALEVO 200 ................. 33 STALEVO 50 ................... 33 STALEVO 75 ................... 33 STARLIX ......................... 53 stavudine ......................... 36 STEGLATRO .................. 53 STEGLUJAN ................... 53 STELARA ........................ 71 STERILE DILUENT
FLOLAN PH 12 ........... 74 STERILE DILUENT FOR
FLOLAN ...................... 74 sterile diluent/epoprostenol
.................................... 74 sterile water for injection .. 74 sterile water for irrigation . 57 STIMATE ........................ 64 STIOLTO RESPIMAT ...... 81 STIVARGA ...................... 31 STRATTERA ................... 44 STRENSIQ ...................... 60 streptomycin sulfate ........ 20
STRIANT......................... 63 STRIBILD ........................ 36 STRIVERDI RESPIMAT .. 81 STROMECTOL ............... 32 SUBLOCADE .................. 16 SUBOXONE .................... 16 SUBSYS ......................... 14 subvenite......................... 23 subvenite starter kit-blue . 23 subvenite starter kit-green
.................................... 23 subvenite starter kit-orange
.................................... 23 SUCRAID ........................ 60 sucralfate ........................ 58 SULAR ............................ 43 sulfacetamide sodium 51, 76 sulfacetamide sodium
(acne) .......................... 51 sulfacetamide sodium-sulfur
.................................... 51 sulfacetamide-prednisolone
.................................... 78 sulfacetamide-sulfur in urea
.................................... 51 sulfacleanse 8/4 .............. 51 sulfadiazine ..................... 20 sulfamethoxazole-
trimethoprim ................ 20 sulfamez wash ................ 51 SULFAMYLON ................ 20 sulfasalazine ................... 73 sulfatrim pediatric ............ 20 sulindac ........................... 12 sumatriptan ..................... 27 sumatriptan succinate ..... 27 sumatriptan succinate refill
.................................... 27 sumatriptan-naproxen
sodium ........................ 27 SUNOSI .......................... 83 SUPARTZ FX .................. 74 SUPPRELIN LA .............. 64 SUPRAX ......................... 20 SUPREP BOWEL PREP
KIT .............................. 59 SURESTEP PRO HIGH
GLUCOSE................... 54 SURESTEP PRO LOW
GLUCOSE................... 54 SURESTEP PRO NORMAL
GLUCOSE................... 54 SURVANTA .................... 80 SUSTIVA......................... 36 SUSTOL ......................... 25
108
SUTENT .......................... 31 SUVICORT ...................... 51 syeda .............................. 68 SYLATRON ..................... 31 SYLVANT ........................ 31 SYMAX DUOTAB ............ 59 symax-sl .......................... 59 symax-sr .......................... 59 SYMBICORT ................... 81 SYMBYAX ....................... 24 SYMDEKO ...................... 82 SYMFI ............................. 36 SYMFI LO ....................... 36 SYMJEPI ......................... 81 SYMLINPEN 120 ............. 53 SYMLINPEN 60 ............... 53 SYMPAZAN..................... 23 SYMPROIC ..................... 59 SYMTUZA ....................... 36 SYNAGIS ........................ 71 synalar............................. 51 SYNALAR ....................... 51 SYNAREL ....................... 64 SYNDROS ...................... 25 SYNERA ......................... 15 SYNERCID ...................... 20 SYNERDERM ................. 51 SYNJARDY ..................... 53 SYNJARDY XR ............... 53 SYNRIBO ........................ 31 SYNTHROID ................... 69 SYNVISC ........................ 74 SYNVISC ONE ................ 74 SYPRINE ........................ 57 T TABLOID ......................... 31 TACLONEX ..................... 51 tacrolimus .................. 51, 71 tadalafil ............................ 61 tadalafil (pah) ................... 82 TAFINLAR ....................... 31 TAGRISSO ...................... 31 TAKHZYRO ..................... 74 TALTZ ............................. 71 TALZENNA ..................... 31 TAMIFLU ......................... 36 tamoxifen citrate .............. 31 tamsulosin hcl .................. 61 TAPAZOLE ..................... 69 TAPERDEX 12-DAY ........ 62 TAPERDEX 6-DAY.......... 62 TAPERDEX 7-DAY.......... 62 TARCEVA ....................... 31 TARGADOX .................... 20 TARGRETIN.................... 31
tarina 24 fe ...................... 68 tarina fe 1/20 ................... 68 tarina fe 1/20 eq .............. 68 TARKA ............................ 43 taron-crystals ................... 57 TASIGNA ........................ 31 TASMAR ......................... 33 TAVALISSE ..................... 38 TAXOTERE ..................... 31 TAYTULLA ...................... 68 tazarotene ....................... 51 tazicef .............................. 20 TAZICEF ......................... 20 TAZORAC ....................... 51 taztia xt ............................ 43 TDVAX ............................ 72 TECENTRIQ ................... 31 TECFIDERA .................... 45 TEFLARO ....................... 20 TEGRETOL ..................... 23 TEGRETOL-XR ............... 23 TEGSEDI ........................ 45 TEKTURNA ..................... 43 TEKTURNA HCT............. 43 telmisartan....................... 43 telmisartan-amlodipine .... 43 telmisartan-hctz ............... 43 temazepam ..................... 83 TEMIXYS ........................ 36 TEMODAR ...................... 31 TEMOVATE .................... 51 temozolomide .................. 31 temsirolimus .................... 71 tencon ............................. 14 teniposide ........................ 31 TENIVAC ........................ 72 tenofovir disoproxil fumarate
.................................... 36 TENORETIC 100............. 43 TENORETIC 50 .............. 43 TENORMIN ..................... 43 TEPADINA ...................... 31 terazosin hcl .................... 61 terbinafine hcl .................. 27 terbutaline sulfate ............ 81 terconazole...................... 27 TESSALON PERLES ...... 80 TESTIM ........................... 63 TESTONE CIK ................ 63 TESTOPEL ..................... 63 testosterone .................... 63 testosterone cypionate .... 63 TESTOSTERONE
CYPIONATE................ 63 testosterone enanthate .... 63
tetcaine ........................... 78 tetrabenazine .................. 45 tetracaine hcl ................... 78 tetracycline hcl ................ 20 tetravisc .......................... 78 tetravisc forte .................. 78 TETRIX ........................... 51 TEXACORT .................... 51 THALOMID ..................... 31 THEO-24 ......................... 81 theochron ........................ 81 theophylline ..................... 81 theophylline er ................. 81 theophylline in d5w .......... 82 THIOLA ........................... 61 THIOLA EC ..................... 61 thioridazine hcl ................ 34 thiotepa ........................... 31 thiothixene ....................... 34 THROMBATE III .............. 22 THYMOGLOBULIN ......... 71 thyroid ............................. 69 tiagabine hcl .................... 23 TIAZAC ........................... 43 TIBSOVO ........................ 31 TIGAN ............................. 25 TIGLUTIK ........................ 45 TIKOSYN ........................ 43 tilia fe .............................. 68 timolol maleate .... 43, 76, 77 TIMOLOL-BRIMON-
DORZOL-LATANOPR . 77 TIMOLOL-BRIMONIDINE-
DORZOLAMID ............ 77 TIMOLOL-DORZOLAMID-
LATANOPROST ......... 77 TIMOPTIC ....................... 77 TIMOPTIC OCUDOSE .... 77 TIMOPTIC-XE ................. 77 tinidazole ......................... 20 TIROSINT ....................... 69 TIROSINT-SOL ............... 69 TIVICAY .......................... 36 TIVORBEX ...................... 12 tizanidine hcl ................... 83 TNKASE ......................... 22 TOBI NEBULIZER ........... 82 TOBI PODHALER ........... 82 TOBRADEX .................... 78 TOBRADEX ST ............... 78 tobramycin ................ 76, 82 TOBRAMYCIN ................ 82 tobramycin sulfate ........... 20 tobramycin-dexamethasone
.................................... 78
109
TOBREX ......................... 76 TOFRANIL ...................... 24 TOLAK ............................ 51 tolbutamide ...................... 53 tolcapone ......................... 33 tolmetin sodium ............... 12 TOLSURA ....................... 27 tolterodine tartrate ........... 61 tolterodine tartrate er ....... 61 TOPAMAX ....................... 23 TOPAMAX SPRINKLE .... 23 TOPICORT ...................... 51 TOPICORT SPRAY ......... 51 topiramate ....................... 23 topiramate er ................... 23 toposar ............................ 31 topotecan hcl ................... 31 TOPROL XL .................... 43 toremifene citrate ............. 31 TORISEL ......................... 71 torsemide ........................ 43 TOSYMRA ...................... 27 TOUJEO MAX SOLOSTAR
.................................... 55 TOUJEO SOLOSTAR ..... 55 tovet ................................ 51 TOVIAZ ........................... 61 TRACLEER ..................... 82 TRADJENTA ................... 53 tramadol hcl er ................. 14 TRAMADOL HCL ER ...... 14 tramadol hcl er (biphasic) 14 tramadol hcl ir .................. 14 tramadol-acetaminophen . 14 trandolapril ...................... 43 trandolapril-verapamil hcl er
.................................... 43 tranexamic acid ............... 38 TRANSDERM SCOP (1.5
MG) ............................. 25 TRANSDERM-SCOP (1.5
MG) ............................. 25 TRANXENE-T ................. 37 tranylcypromine sulfate .... 24 TRAVATAN Z .................. 77 trazodone hcl ................... 24 TREANDA ....................... 31 TRECATOR..................... 28 TRELEGY ELLIPTA ........ 82 TRELSTAR MIXJECT ..... 64 TREMFYA ....................... 71 TRESIBA ......................... 55 TRESIBA FLEXTOUCH .. 55 tretinoin ..................... 31, 52 tretinoin microsphere ....... 52
tretinoin microsphere pump .................................... 52
TRETTEN ....................... 38 TREXALL ........................ 71 TREXIMET ...................... 27 TREZIX ........................... 14 tri femynor ....................... 68 triamcinolone acetonide.. 46,
52, 62 TRIAMCINOLONE
ACETONIDE ............... 63 triamterene ...................... 43 triamterene-hctz .............. 43 TRIANEX ........................ 52 triazolam ......................... 37 TRIBENZOR ................... 43 tricitrates ......................... 57 TRICOR .......................... 43 triderm ............................. 52 TRIDESILON ................... 52 trientine hcl ...................... 57 TRIESENCE .................... 76 tri-estarylla....................... 68 TRIFERIC ....................... 57 trifluoperazine hcl ............ 34 trifluridine ........................ 76 trihexyphenidyl hcl ........... 33 TRIKAFTA ....................... 82 tri-legest fe ...................... 68 TRILEPTAL ..................... 23 tri-linyah .......................... 68 TRILIPIX ......................... 43 tri-lo-estarylla ................... 68 tri-lo-marzia ..................... 68 tri-lo-mili .......................... 68 tri-lo-sprintec ................... 68 trilyte ............................... 59 trimethobenzamide hcl .... 25 trimethoprim .................... 20 tri-mili .............................. 68 trimipramine maleate ....... 25 TRINTELLIX .................... 25 tri-previfem ...................... 68 TRIPTODUR ................... 64 TRISENOX ...................... 31 tri-sprintec ....................... 68 TRIUMEQ ....................... 36 TRIVISC .......................... 74 trivora (28) ....................... 68 tri-vylibra ......................... 68 tri-vylibra lo ...................... 68 TRIZIVIR ......................... 36 TROKENDI XR ................ 23
TROPICAMIDE-CYCLOPENTOLATE-PE .................................... 78
TROPICAMIDE-PHENYLEPHRINE ...... 78
TROPIC-PROPARACA-PE-KETOROLAC .............. 78
trospium chloride ............. 61 trospium chloride er ......... 61 TRUE METRIX LEVEL 1 . 54 TRUE METRIX LEVEL 2 . 54 TRUE METRIX LEVEL 3 . 54 TRULANCE ..................... 59 TRULICITY ..................... 53 TRUMENBA .................... 72 TRUSOPT ....................... 77 TRUVADA ....................... 36 TUDORZA PRESSAIR .... 82 tulana .............................. 68 TURALIO ........................ 31 TUSSICAPS .................... 80 TUXARIN ER .................. 80 TUZISTRA XR ................ 80 TWINRIX ......................... 72 TWYNSTA ...................... 43 TYBOST ......................... 36 tydemy ............................ 68 TYKERB ......................... 31 TYLENOL WITH CODEINE
#3 ................................ 14 TYLENOL WITH CODEINE
#4 ................................ 15 TYMLOS ......................... 73 TYSABRI......................... 45 TYVASO ......................... 82 TYVASO REFILL ............ 82 TYVASO STARTER ........ 82 U UCERIS .......................... 73 UDENYCA ...................... 38 ULESFIA ......................... 32 ULORIC .......................... 27 ULTOMIRIS .................... 38 ULTRACET ..................... 15 ULTRAM ......................... 15 ULTRAVATE ................... 52 umecta mousse ............... 52 UNISTRIP CONTROL ..... 54 unithroid .......................... 69 UNITUXIN ....................... 31 UPTRAVI ........................ 82 urea ................................. 52 UREA .............................. 52 urea hydrating ................. 52 urea nail .......................... 52
110
URECHOLINE ................. 61 uredeb ............................. 52 urelle ............................... 61 uremez-40 ....................... 52 URESOL ......................... 52 uretron d/s ....................... 61 uribel ............................... 61 urimar-t ............................ 61 urin ds ............................. 61 uro-458 ............................ 61 UROCIT-K 10 .................. 57 UROCIT-K 15 .................. 57 UROCIT-K 5 .................... 57 uro-mp ............................. 61 UROXATRAL .................. 61 URSO 250 ....................... 59 URSO FORTE ................. 60 ursodiol ............................ 60 uryl .................................. 61 ustell ................................ 61 UTIBRON NEOHALER .... 82 uticap .............................. 61 utira-c .............................. 61 UTOPIC ........................... 52 utrona-c ........................... 61 V VABOMERE .................... 20 VAGIFEM ........................ 68 valacyclovir hcl ................ 36 VALCHLOR ..................... 31 VALCYTE ........................ 36 valganciclovir hcl ............. 36 VALIUM ........................... 37 valproic acid .................... 23 valrubicin ......................... 31 valsartan .......................... 43 valsartan-
hydrochlorothiazide ..... 43 VALSTAR ........................ 31 VALTREX ........................ 36 VANCOCIN HCL ............. 20 vancomycin hcl ................ 21 vancomycin hcl in dextrose
.............................. 20, 21 VANCOMYCIN HCL IN
DEXTROSE ................. 21 vancomycin hcl in nacl ..... 21 VANCOMYCIN HCL IN
NACL ........................... 21 vandazole ........................ 21 VANOS ............................ 52 VANOXIDE-HC ............... 52 VANTAS .......................... 64 VAQTA ............................ 72 VARIVAX ......................... 72
VARIZIG .......................... 71 VARUBI ........................... 25 VASCEPA ....................... 43 VASERETIC .................... 43 VASOTEC ....................... 43 vcf vaginal contraceptive . 74 VECAMYL ....................... 43 VECTIBIX ........................ 31 VECTICAL....................... 52 VELETRI ......................... 82 velivet .............................. 68 VELPHORO .................... 61 VELTASSA...................... 57 VELTIN ........................... 52 VEMLIDY ........................ 36 VENCLEXTA ................... 31 VENCLEXTA STARTING
PACK .......................... 31 VENELEX ....................... 52 venlafaxine hcl ................ 25 venlafaxine hcl er ............ 25 VENOFER ....................... 57 VENTAVIS ...................... 82 VENTOLIN HFA .............. 82 verapamil hcl ................... 43 verapamil hcl er ............... 43 VERDESO....................... 52 VEREGEN....................... 52 VERELAN ....................... 43 VERELAN PM ................. 43 VERSACLOZ .................. 34 VERZENIO ...................... 31 VESICARE ...................... 61 vexatrol ........................... 15 VFEND ............................ 27 V-GO 20 .......................... 54 V-GO 30 .......................... 54 V-GO 40 .......................... 54 VIBATIV .......................... 21 VIBERZI .......................... 60 VIBRAMYCIN .................. 21 vicodin es ........................ 15 vicodin hp ........................ 15 VICTOZA ........................ 53 VIDEX ............................. 36 VIDEX EC ....................... 36 VIEKIRA PAK .................. 36 vienva .............................. 68 vigabatrin ........................ 23 vigadrone ........................ 23 VIGAMOX ....................... 76 VIIBRYD .......................... 25 VIIBRYD STARTER PACK
.................................... 25 vilamit mb ........................ 61
vilevev mb ....................... 61 VIMIZIM .......................... 60 VIMOVO ......................... 12 VIMPAT .......................... 23 vinblastine sulfate ............ 31 vincristine sulfate ............. 31 vinorelbine tartrate .......... 32 VIOKACE ........................ 60 viorele ............................. 68 VIRACEPT ...................... 36 VIRAMUNE ..................... 36 VIRAMUNE XR ............... 36 VIRAZOLE ...................... 36 VIREAD .......................... 36 virt-phos 250 neutral ....... 57 VISCO-3 ......................... 74 VISTARIL ........................ 37 VISTOGARD ................... 74 VISUDYNE ...................... 78 vitamin d (cholecalciferol) 57 vitamin d (ergocalciferol) . 57 vitamin d3........................ 57 vitamin k1 ........................ 57 VITRAKVI........................ 32 VITRASE......................... 74 VIVAGUARD INO
CONTROL SOLUTION 54 VIVAGUARD LANCING
DEVICE ....................... 54 VIVELLE-DOT ................. 68 VIVITROL........................ 16 VIVLODEX ...................... 12 VIZIMPRO ....................... 32 VOGELXO ...................... 63 VOGELXO PUMP ........... 63 VOLTAREN ..................... 12 VONVENDI ..................... 38 VORAXAZE .................... 32 voriconazole .................... 27 VOSEVI .......................... 36 VOTRIENT ...................... 32 VPRIV ............................. 60 VRAYLAR ....................... 34 VUSION .......................... 27 vyfemla ........................... 68 vylibra ............................. 68 VYNDAMAX .................... 43 VYNDAQEL .................... 43 VYTORIN ........................ 43 VYVANSE ....................... 44 VYXEOS ......................... 32 VYZULTA ........................ 77 W WAKIX ............................ 83 warfarin sodium ............... 22
111
WELCHOL ...................... 43 WELLBUTRIN SR ........... 25 WELLBUTRIN XL ............ 25 wera ................................ 68 westhroid ......................... 69 WESTHROID .................. 69 WIDE-SEAL DIAPHRAGM
60 ................................ 75 WILATE ........................... 38 WINRHO SDF ................. 71 WP THYROID ................. 69 wymzya fe ....................... 68 X XADAGO ......................... 33 XALATAN ........................ 77 XALIX .............................. 52 XALKORI ......................... 32 XANAX ............................ 37 XANAX XR ...................... 37 XARELTO ....................... 22 XARELTO STARTER PACK
.................................... 22 XATMEP ......................... 71 XELJANZ ........................ 71 XELJANZ XR ................... 71 XELODA .......................... 32 XELPROS ....................... 77 XEMBIFY ........................ 71 XENAZINE ...................... 45 XENLETA ........................ 21 XEOMIN .......................... 75 XEPI ................................ 21 XERALUX ....................... 52 XERESE .......................... 36 XERMELO ....................... 60 XEROSTOMIA RELIEF
SPRAY ........................ 46 XHANCE ......................... 80 XIAFLEX ......................... 75 XIFAXAN ......................... 21 XIGDUO XR .................... 53 XIIDRA ............................ 78 XIMINO ........................... 21 XOFIGO .......................... 32 XOFLUZA ........................ 36 XOLAIR ........................... 80 XOLEGEL ....................... 27 XOPENEX ....................... 82 XOPENEX
CONCENTRATE ......... 82 XOPENEX HFA ............... 82 XOSPATA ....................... 32 XPOVIO (100 MG ONCE
WEEKLY) .................... 32
XPOVIO (60 MG ONCE WEEKLY) .................... 32
XPOVIO (80 MG ONCE WEEKLY) .................... 32
XPOVIO (80 MG TWICE WEEKLY) .................... 32
XTAMPZA ER ................. 15 XTANDI ........................... 32 xulane ............................. 68 XULTOPHY ..................... 53 xurea ............................... 52 XYLOCAINE .................... 16 XYLOCAINE/EPINEPHRIN
E .................................. 16 XYLOCAINE-MPF ........... 16 XYNTHA ......................... 38 XYNTHA SOLOFUSE ..... 38 XYOSTED ....................... 63 XYREM ........................... 83 Y YASMIN 28 ..................... 68 YAZ ................................. 68 YERVOY ......................... 32 YESCARTA ..................... 32 YONDELIS ...................... 32 YONSA ........................... 32 YOSPRALA ..................... 58 YUPELRI ......................... 82 yuvafem .......................... 68 Z zaclir cleansing ................ 52 zafirlukast ........................ 82 zaleplon ........................... 83 ZALTRAP ........................ 32 ZANAFLEX...................... 83 ZANOSAR ....................... 32 zarah ............................... 68 ZARONTIN ...................... 23 ZARXIO ........................... 38 ZAVESCA ....................... 60 zebutal ............................ 15 ZEGERID ........................ 58 ZEJULA ........................... 32 ZELAPAR ........................ 33 ZELBORAF ..................... 32 ZELNORM....................... 60 ZEMAIRA ........................ 82 ZEMBRACE SYMTOUCH
.................................... 27 ZEMPLAR ....................... 73 zenatane ......................... 52 ZENPEP .......................... 60 zenzedi ............................ 44 ZENZEDI ......................... 44 ZEPATIER....................... 36
ZERBAXA ....................... 21 zeruvia ............................ 16 ZESTORETIC ................. 44 ZESTRIL ......................... 44 ZETIA .............................. 44 ZETONNA ....................... 80 ZIAC ................................ 44 ZIAGEN .......................... 36 ZIANA ............................. 52 zidovudine ....................... 36 zileuton er ....................... 82 ZILRETTA ....................... 63 ZINPLAVA ....................... 71 ZIOPTAN ........................ 77 ziprasidone hcl ................ 34 ZIPSOR .......................... 12 ZIRGAN .......................... 76 ZITHRANOL .................... 52 ZITHROMAX ................... 21 ZITHROMAX TRI-PAK .... 21 ZITHROMAX Z-PAK ....... 21 ZOCOR ........................... 44 ZOFRAN ......................... 25 ZOHYDRO ER ................ 15 ZOLADEX ....................... 64 zoledronic acid ................ 73 ZOLINZA ......................... 32 zolmitriptan ...................... 27 ZOLOFT .......................... 25 zolpidem tartrate ............. 83 zolpidem tartrate er ......... 83 ZOMACTON ................... 64 ZOMIG ............................ 27 ZOMIG ZMT .................... 27 ZONALON ....................... 52 ZONEGRAN .................... 23 zonisamide ...................... 23 ZONTIVITY ..................... 33 ZORBTIVE ...................... 60 ZORTRESS .................... 71 ZORVOLEX .................... 12 ZOSTAVAX ..................... 72 ZOSYN ........................... 21 zovia 1/35e (28) .............. 68 ZOVIRAX ........................ 36 ZTLIDO ........................... 16 ZUBSOLV ....................... 16 zumandimine ................... 68 ZUPLENZ........................ 25 ZYCLARA ....................... 52 ZYCLARA PUMP ............ 52 ZYDELIG......................... 32 ZYFLO ............................ 82 ZYKADIA......................... 32 ZYLET ............................. 78
112
ZYLOPRIM ...................... 27 ZYMAXID ........................ 76 ZYPITAMAG.................... 44
ZYPREXA ....................... 34 ZYPREXA RELPREVV ... 34 ZYPREXA ZYDIS ............ 34
ZYTIGA ........................... 32 ZYVOX ............................ 21
Kaiser Permanente Nondiscrimination Notice and Language Access Services
KAISER PERMANENTE NONDISCRIMINATION NOTICE
Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (“Kaiser Permanente”) comply with applicable federal civil rights laws and do not discriminate, exclude people, or treat them differently on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity, or any other basis protected by applicable federal, state, or local law. We also:
Provide free aids and services to people with disabilities to help ensure effective communication, such as:
• Qualified sign language interpreters• Written information in other formats (large print, audio, and accessible electronic formats)• Assistive devices (magnifiers, Pocket Talkers, and other aids)
Provide free language services to people whose primary language is not English, such as:
• Qualified interpreters• Information written in other languages
If you need these services, contact Kaiser Permanente.
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity, you can file a grievance. Please call us if you need help submitting a grievance. The Civil Rights Coordinator will be notified of all grievances related to discrimination.
Kaiser Permanente Phone: 206-630-4636 Toll-free: 1-888-901-4636
TTY Washington Relay Service: 1-800-833-6388 or 711 TTY Idaho Relay Service: 1-800-377-3529 or 711
Electronically: kp.org/wa/feedback
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services 200 Independence Avenue SW., Room 509F HHH Building Washington, DC 20201 1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
For Medicare Advantage Plans Only: Kaiser Permanente is an HMO plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal.
© 2018 Kaiser Foundation Health Plan of Washington H5050_XB0001444_56_18 accepted2018-XB-7_ACA_Notice_Taglines
LANGUAGE ACCESS SERVICES
English: ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-888-901-4636 (TTY: 1-800-833-6388 or 711).
Español (Spanish): ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
中文 (Chinese):注意:如果您使用繁體中文,您可 以免費獲得語言援助服務。請致電 1-888-901-4636 (TTY: 1-800-833-6388 / 711)。
Tiếng Việt (Vietnamese): CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
한국어(Korean): 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-888-901-4636 (TTY: 1-800-833-6388 / 711) 번으로 전화해 주십시오.
Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-888-901-4636 (телетайп: 1-800-833-6388 / 711).
Filipino (Tagalog): PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
Українська (Ukrainian): УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-888-901-4636 (телетайп: 1-800-833-6388 / 711).
ភាសាខ្មែរ (Khmer)៖ របយ័ត៖ េ េបើសិនអកនិខ្យមរ, េ សជំនួខ្យផក េ យមិនគិតល គឺចនសំប់បំេ រអក។ ចូរទូ រស័ព 1-888-901-4636 (TTY: 1-800-833-6388 / 711)។日本語 (Japanese): 注意事項:日本語を話される場 合、無料の言語支援をご利用いただけます。1-888-901-4636 (TTY: 1-800-833-6388 / 711) まで、 お電話にてご連絡ください。
አማርኛ (Amharic) ፥ ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-888-901-4636 (መስማት ለተሳናቸው: 1-800-833-6388 / 711).
Oromiffa (Oromo): XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
ਪੰਜਾਬੀ (Punjabi) ਧਿਆਨ ਧਿਓ: ਜੇ ਤੁਸੀਂ ਪੰਜਾਬੀ ਬੋਲਿ ੇਹੋ, ਤਾਂ ਭਾਸਾ ਧ ਿੱ ਚ ਸਹਾਇਤਾ ਸੇ ਾ ਤੁਹਾਡੇ ਲਈ ਮੁਫਤ ਉਪਲਬਿ ਹੈ।1-888-901-4636 (TTY: 1-800-833-6388 / 711) ‘ਤੇ ਕਾਲ ਕਰੋ।
تتوافر اللغوية المساعدة خدمات فإن اللغة، اذكر تتحدث كنت إذا :ملحوظة في ومعلومات مساعدة على الحصول حق لديكم :(Arabic) العربية: (6388-833-800-1 / 711) .والبكم الصم هاتف رقم 4636-901-888-1 برقم اتصل .بالمجان لك
Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
ພາສາລາວ (Lao): ໂປດຊາບ: ຖ້າວ່າ ທ່ານເວ ້ າພາສາລາວ, ການບໍ ລິ ການຊ່ວຍເຫ ຼື ອດ້ານພາສາ, ໂດຍບໍ່ ເສັຽຄ່າ,ແມ່ນມີ ພ້ອມ ໃຫ້ທ່ານ. ໂທຣ 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
Srpsko-hrvatski (Serbo-Croatian): OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-888-901-4636 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 1-800-833-6388 / 711).
Français (French): ATTENTION: Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-888-901-4636 (ATS: 1-800-833-6388 / 711).
Română (Romanian): ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
Adamawa (Fulfulde): MAANDO: To a waawi Adamawa, e woodi ballooji-ma to ekkitaaki wolde caahu. Noddu 1-888-901-4636 (TTY: 1-800-833-6388 / 711).
می فراهم شما برای رايگان بصورت زبانی تسهيالت کنيد، می گفتگو فارسی زبان به اگر :توجه :(Farsi) فارسی.بگيريد تماس (TTY: 1-800-833-6388 / 711) 4636-901-888-1 با .باشد
XB0001444-56-18