Drug Name Drug Requirements/ Drug Name Drug Requirements ... · 200mg 1 tramadol hcl er (biphasic)...

2016 State of New York eff 08/01/2016

1PA - Prior Authorization QL - Quantity Limits ST - Step Therapy B/D - Covered underMedicare B or D LA - Limited Access

Drug Name DrugTier

Requirements/Limits

ANALGESICSGOUTallopurinol tab 1ALOPRIM 3colchicine w/ probenecid 1COLCRYS 2probenecid 1ULORIC 2ZYLOPRIM 3MISCELLANEOUSARTHROTEC 50 3ARTHROTEC 75 3diclofenac w/ misoprostol 1NSAIDSANAPROX DS 3CELEBREX CAP 50MG 3CELEBREX CAP 100MG 3CELEBREX CAP 200MG 3CELEBREX CAP 400MG 3celecoxib CAPS 1DAYPRO 3diclofenac potassium 1diclofenac sodium TB24;TBEC

1

diflunisal 1EC-NAPROSYN 3etodolac 1etodolac er 1FELDENE 3FENOPROFEN CALCIUMCAPS 400mg

1

fenoprofen calcium TABS 1flurbiprofen TABS 1ibuprofen SUSP 1ibuprofen TABS 400mg,600mg, 800mg

1

ketoprofen CAPS; CP24 1mefenamic acid CAPS 1MELOXICAM SUSP 1meloxicam tabs 1MOBIC 3nabumetone TABS 1NALFON 3

Drug Name DrugTier

Requirements/Limits

NAPRELAN 3NAPROSYN TABS 3naproxen SUSP; TABS;TBEC

1

naproxen sodium TABS275mg, 550mg

1

naproxen sodium TB24375mg

3

NAPROXEN SODIUM TB24500mg

3

oxaprozin 1piroxicam CAPS 1PONSTEL 3sulindac TABS 1tolmetin sodium 1VIVLODEX 3OPIOID ANALGESICSacetaminophen w/ codeineSOLN

QL (5000 mL / 30 days)

1 QL

acetaminophen w/ codeineTABS

QL (400 tabs / 30 days)

1 QL

acetaminophen-caff-dihydrocod

QL (360 caps / 30 days)

1 QL

ASPIRIN-CAFFEINE-DIHYDROCODEINEBITARTRATE

1

BELBUCA 3butorphanol nasal spray 1butorphanol tartrate SOLN 1BUTRANS 5mcg/hr

QL (16 patches / 28days)

2 QL

BUTRANS 7.5mcg/hr,10mcg/hr

QL (8 patches / 28 days)

2 QL

BUTRANS 15mcg/hr,20mcg/hr

QL (4 patches / 28 days)

2 QL

capital and codeineQL (5000 mL / 30 days)

3 QL

nalbuphine hcl SOLN 1SYNALGOS-DC 3TRAMADOL HCL CP24 1tramadol hcl er TB24 100mg,200mg

1



Drug Name DrugTier

Requirements/Limits

TRAMADOL HCL ER TB24300mg

1

tramadol hcl er (biphasic)100mg

1


1


1

tramadol hcl tab 50 mg 1tramadol-acetaminophen

QL (240 tabs / 30 days)1 QL

trezixQL (360 caps / 30 days)

3 QL

tylenol with codeineQL (400 tabs / 30 days)

3 QL

ULTRACETQL (240 tabs / 30 days)

3 QL

ULTRAM 3ULTRAM ER 3ULTRAM ER TAB 100MG 3ULTRAM ER TAB 200MG 3OPIOID ANALGESICS, CIIABSTRAL

QL (120 tabs / 30 days)3 QL PA

ACTIQQL (120 lozenges / 30days)

3 QL PA

CODEINE SULFATE 1DILAUDID INJ 3 B/DDILAUDID TAB 3DILAUDID-5 ORAL LIQD 3DILAUDID-HP INJ 10MG/ML 3 B/DDILAUDID-HP INJ 250MG 3 B/DDOLOPHINE


DURAGESICQL (10 patches / 30days)

3 QL

DURAMORPH 1 B/DEMBEDA

QL (60 caps / 30 days)3 QL

endocetQL (360 tabs / 30 days)

1 QL

EXALGOQL (60 tabs / 30 days)

3 QL

Drug Name DrugTier

Requirements/Limits

fentanyl citrate LPOPQL (120 lozenges / 30days)

3 QL PA

fentanyl patch 12 mcg/hrQL (10 patches / 30days)

1 QL


1 QL


1 QL


1 QL


1 QL

FENTORAQL (120 tabs / 30 days)

3 QL PA

hycetQL (5400 mL / 30 days)

3 QL

hydrocodone-acetaminophen2.5-325mg


1 QL

hydrocodone-acetaminophen5-300mg


1 QL



1 QL



1 QL

hydrocodone-acetaminophen7.5-325 mg/15ml

QL (5400 mL / 30 days)

1 QL



1 QL



1 QL

hydrocodone-acetaminophentab 10-325mg


1 QL

hydrocodone-ibuprofen tab2.5-200mg

1

hydrocodone-ibuprofen tab 5-200mg

1



Drug Name DrugTier

Requirements/Limits

hydrocodone-ibuprofen tab7.5-200 mg

1

hydrocodone-ibuprofen tab10-200mg

1

hydromorphone hcl LIQD 1HYDROMORPHONE HCLSOLN 1mg/ml, 2mg/ml,4mg/ml

1 B/D

hydromorphone hcl SOLN500mg/50ml

1 B/D

hydromorphone hcl TABS 1hydromorphone tab 8mg er


hydromorphone tab 12mg erQL (60 tabs / 30 days)

1 QL

hydromorphone tab 16mg erQL (60 tabs / 30 days)

3 QL

HYDROMORPHONE TABS32MG


3 QL

HYSINGLA ER 20mg, 30mg,40mg, 60mg


2 QL

HYSINGLA ER 80mg,100mg, 120mg


3 QL

ibudone tab 5-200mg 1ibudone tab 10-200mg 1INFUMORPH 200 3 B/DINFUMORPH 500 3 B/DKADIAN


LAZANDAQL (30 bottles / 30 days)

3 QL PA

levorphanol tartrate TABS 1lorcet hd tab 10-325mg


lorcet plus tab 7.5-325QL (360 tabs / 30 days)

1 QL

lorcet tab 5-325mgQL (360 tabs / 30 days)

1 QL

lortab tab 5-325mgQL (360 tabs / 30 days)

1 QL

lortab tab 7.5-325QL (360 tabs / 30 days)

1 QL

lortab tab 10-325mgQL (360 tabs / 30 days)

1 QL

methadone hcl CONCQL (120 mL / 30 days)

1 QL

Drug Name DrugTier

Requirements/Limits

methadone hcl SOLNQL (600 mL / 30 days)

1 QL

methadone hcl TABSQL (240 tabs / 30 days)

1 QL

METHADONE INJ 10MG/ML 3METHADOSE CONC

QL (120 mL / 30 days)3 QL

MORPHINE SUL 20MG/MLORAL SOL

1

morphine sulfate CP2410mg, 20mg, 30mg, 50mg,60mg


1 QL

morphine sulfate CP2480mg, 100mg


3 QL

MORPHINE SULFATE SOLN1mg/ml, 10mg/ml, 15mg/ml

1 B/D

MORPHINE SULFATE SOLN2mg/ml, 4mg/ml, 8mg/ml

3 B/D

MORPHINE SULFATE SOLN10mg/5ml, 20mg/5ml

1

morphine sulfate SOLN.5mg/ml, 1mg/ml, 4mg/ml,8mg/ml

1 B/D

MORPHINE SULFATE TABS 1morphine sulfate beads


morphine sulfate ext-rel tab15mg, 30mg, 60mg, 100mg


1 QL

morphine sulfate ext-rel tab200mg


1 QL

MS CONTIN 15mg, 30mg,60mg, 100mg


3 QL

MS CONTIN 200mgQL (60 tabs / 30 days)

3 QL

norcoQL (360 tabs / 30 days)

3 QL

NUCYNTA 2NUCYNTA ER 50mg, 100mg


NUCYNTA ER 150mg,200mg, 250mg


2 QL

OPANA TABS 3



Drug Name DrugTier

Requirements/Limits

OPANA ER (CRUSHRESISTANT


2 QL

oxycodone hcl CAPS; CONC;TABS

1

OXYCODONE HCL SOLN 1oxycodone w/ acetaminophen2.5-325mg


1 QL

oxycodone w/ acetaminophen5-325mg


1 QL

oxycodone w/ acetaminophen7.5-325mg


1 QL

oxycodone w/ acetaminophen10-325mg


1 QL

oxycodone w/ acetaminophensoln 5-325 mg/5ml

QL (1800 mL / 30 days)

1 QL

oxycodone-aspirin 1oxycodone-ibuprofen 1OXYCONTIN


oxymorphone hcl TABS 1percocet 2.5/325


percocet 7.5/325QL (360 tabs / 30 days)

3 QL

percocet 10/325QL (360 tabs / 30 days)

3 QL

percocet tab 5-325mgQL (360 tabs / 30 days)

3 QL

reprexain tab 2.5-200mg 3reprexain tab 5-200mg 3reprexain tab 10-200mg 1roxicet soln

QL (1800 mL / 30 days)2 QL

roxicet tab 5-325mgQL (360 tabs / 30 days)

1 QL

ROXICODONE 3SUBSYS

QL (120 sprays / 30days)

3 QL PA

vicodinQL (400 tabs / 30 days)

1 QL

vicodin esQL (400 tabs / 30 days)

1 QL

Drug Name DrugTier

Requirements/Limits

vicodin hpQL (400 tabs / 30 days)

1 QL

VICOPROFEN 3XARTEMIS XR


xodol tab 5-300mgQL (400 tabs / 30 days)

3 QL

xodol tab 7.5-300QL (400 tabs / 30 days)

3 QL

xodol tab 10-300mgQL (400 tabs / 30 days)

3 QL

xylon tab 10-200mg 1zamicet

QL (5400 mL / 30 days)1 QL

ZOHYDRO ER (ABUSEDETERRENT) 10mg, 15mg,20mg


3 QL

ZOHYDRO ER (ABUSEDETERRENT) 30mg, 40mg,50mg


3 QL

ANESTHETICSLOCAL ANESTHETICSlidocaine hcl (local anesth.)4%

1

lidocaine hcl (local anesth.).5%, 1%

1 B/D

lidocaine inj 0.5% 1 B/Dlidocaine inj 1% 1 B/Dlidocaine inj 1.5% 1 B/Dlidocaine inj 2% 1 B/DXYLOCAINE .5%, 1%, 2% 3 B/DXYLOCAINE-MPF 4% 3XYLOCAINE-MPF .5%, 1%,1.5%, 2%

3 B/D

ANTI-INFECTIVESANTI-BACTERIALS - MISCELLANEOUSamikacin sulfate SOLN 1BETHKIS 3 B/Dgentamicin in saline 0.8 mg/ml 1gentamicin in saline 0.9mg/ml 3gentamicin in saline 1 mg/ml 1gentamicin in saline 1.2 mg/ml 1gentamicin in saline 1.4mg/ml 3gentamicin in saline 1.6 mg/ml 1



Drug Name DrugTier

Requirements/Limits

gentamicin in saline 2 mg/ml 1gentamicin sulfate SOLN 1KITABIS PAK 3 B/Dneomycin sulfate TABS 1paromomycin sulfate CAPS 1streptomycin sulfate SOLR 1sulfadiazine TABS 3TOBI NEB 3 B/DTOBI PODHALER 3 LA PAtobramycin NEBU 3 B/Dtobramycin sulfate SOLN;SOLR

1

ANTI-INFECTIVES - MISCELLANEOUSALBENZA 2ALINIA 2atovaquone SUSP 3AZACTAM 3AZACTAM/DEX INJ 1GM 3AZACTAM/DEX INJ 2GM 3aztreonam 1BACTRIM 3BACTRIM DS 3BILTRICIDE 2CAYSTON 2 LA PAcleocin SOLR 3CLEOCIN CAP 75MG 3CLEOCIN CAP 150MG 3CLEOCIN CAP 300MG 3CLEOCIN IN D5W 3CLEOCIN INJ 3CLEOCIN PHOSPHATE9gm/60ml, 300mg/2ml,600mg/4ml, 900mg/6ml

3

cleocin phosphate600mg/4ml, 900mg/6ml

3

clindamycin hcl CAPS 1clindamycin palmitatehydrochloride

1

clindamycin phosphate SOLN 1clindamycin phosphate in d5w 1colistimethate sodium SOLR 1COLY-MYCIN M 3CUBICIN 3DALVANCE 3

Drug Name DrugTier

Requirements/Limits

dapsone TABS 1DARAPRIM 3DORIBAX 3FLAGYL 3FURADANTIN

90 day limit per calendaryear if 65 years and older

3 PA

HIPREX 3imipenem-cilastatin 1INVANZ 3ivermectin TABS 1linezolid SOLN 3LINEZOLID SUSR; TABS 3LINEZOLID IN SODIUMCHLORIDE

3

MACROBID90 day limit per calendaryear if 65 years and older

3 PA

MACRODANTIN90 day limit per calendaryear if 65 years and older

3 PA

MEPRON 3meropenem 1MEROPENEM/SODIUMCHLORIDE

1

MERREM 3methenamine hippurate 1METRO IV 3metronidazole CAPS; TABS 1metronidazole inj 1NEBUPENT 3 B/Dnitrofurantoin SUSP


1 PA

nitrofurantoin macrocrystal25mg

PA applies if 65 years andolder after a 90 day supplyin a calendar year

3 PA

nitrofurantoin macrocrystal50mg, 100mg


3 PA

nitrofurantoin monohyd macro100mg


3 PA



Drug Name DrugTier

Requirements/Limits

nitrofurantoin monohyd macro100mg

PA applies if 65 years andolder after a 90 day supplyin a calendar year

3 PA

PENTAM 300 3polymyxin b sulfate SOLR 1PRIMAXIN 3PRIMSOL 3SIVEXTRO 3STROMECTOL 3sulfamethoxazole-trimethop 1sulfamethoxazole-trimethoprim inj

1

SYNERCID 3trimethoprim TABS 1TYGACIL 3VANCOCIN HCL 3vancomycin hcl CAPS 3vancomycin hcl inj 5gm 1vancomycin hcl inj 10gm 1vancomycin hcl inj 500mg 1vancomycin hcl inj 750mg 3vancomycin hcl inj 1000mg 1VANCOMYCIN IN NACL 3XIFAXAN TAB 200MG 3ZYVOX 3ANTIFUNGALSABELCET 3 B/DAMBISOME 3 B/Damphotericin b SOLR 1 B/DANCOBON 3CANCIDAS 3CRESEMBA 3DIFLUCAN 3ERAXIS 3fluconazole SUSR; TABS 1fluconazole in dextrose 1fluconazole in nacl 1flucytosine CAPS 3GRIS-PEG 3griseofulvin microsize 1griseofulvin ultramicrosize 1itraconazole CAPS 1 PA

Drug Name DrugTier

Requirements/Limits

ketoconazole TABS 1LAMISIL PACK 3 PALAMISIL TABS


MYCAMINE 3NOXAFIL 3nystatin TABS 1ONMEL 3 PASPORANOX 3 PASPORANOX PULSEPAK 3 PASPORANOX SOL 10MG/ML 3 PAterbinafine hcl TABS


VFEND IV 3VFEND SUS 40MG/ML 3VFEND TAB 3voriconazole SUSR; TABS 3voriconazole inj 200mg 1ANTIMALARIALSatovaquone-proguanil hcl tab62.5-25 mg

1

atovaquone-proguanil hcl tab250-100 mg

1

chloroquine phosphate TABS 1COARTEM 2MALARONE 3mefloquine hcl 1PRIMAQUINE PHOSPHATE 3QUALAQUIN 3quinine sulfate CAPS 1ANTIRETROVIRAL AGENTSabacavir sulfate 1APTIVUS 3CRIXIVAN 3didanosine 1EDURANT 3EMTRIVA 2EPIVIR SOL 10MG/ML 3EPIVIR TABS 3FUZEON 2INTELENCE 25mg 2INTELENCE 100mg, 200mg 3INVIRASE 3



Drug Name DrugTier

Requirements/Limits

ISENTRESS CHEW 25mg 2ISENTRESS CHEW 100mg 3ISENTRESS PACK 2ISENTRESS TABS 3lamivudine 1LEXIVA 3NEVIRAPINE SUSP 1nevirapine TABS; TB24 1NORVIR 2PREZISTA SUSP 3PREZISTA TABS 75mg,150mg

2

PREZISTA TABS 600mg,800mg

3

RESCRIPTOR 2RETROVIR CAPS 3RETROVIR IV INFUSION 3RETROVIR SYRP 3REYATAZ 3SELZENTRY 3stavudine 1SUSTIVA CAPS 2SUSTIVA TABS 3TIVICAY 50mg 3TYBOST 2VIDEX EC 3VIDEX PEDIATRIC 3VIRACEPT 3VIRAMUNE 3VIRAMUNE XR 100mg 2VIRAMUNE XR 400mg 3VIREAD 3VITEKTA 3ZERIT 3ZIAGEN SOLN 2ZIAGEN TABS 3zidovudine 1ANTIRETROVIRAL COMBINATIONAGENTSabacavir sulfate-lamivudine-zidovudine

3

ATRIPLA 3COMBIVIR 3

Drug Name DrugTier

Requirements/Limits

COMPLERA 3DESCOVY 3EPZICOM 3EVOTAZ 3GENVOYA 3KALETRA SOL 3KALETRA TAB 100-25MG 2KALETRA TAB 200-50MG 3lamivudine-zidovudine 3ODEFSEY 3PREZCOBIX 3STRIBILD 3TRIUMEQ 3TRIZIVIR 3TRUVADA 3TRUVADA TAB 100-150 3TRUVADA TAB 133-200 3TRUVADA TAB 167-250 3ANTITUBERCULAR AGENTSCAPASTAT SULFATE 3cycloserine CAPS 3ethambutol hcl TABS 1isoniazid SOLN; SYRP 1isoniazid tabs 1MYAMBUTOL 3MYCOBUTIN 3paser d/r 3PRIFTIN 3pyrazinamide TABS 1rifabutin 1rifadin CAPS 150mg 3RIFADIN CAPS 300mg 3RIFADIN SOLR 3rifamate 3rifampin CAPS; SOLR 1RIFATER 3SIRTURO 3 LATRECATOR 3ANTIVIRALSacyclovir CAPS; SUSP;TABS

1

acyclovir sodium SOLN 1 B/D



Drug Name DrugTier

Requirements/Limits

acyclovir sodium SOLR500mg

1 B/D

adefovir dipivoxil 3BARACLUDE SOLN 2BARACLUDE TABS 3cidofovir 3COPEGUS 3CYTOVENE 3 B/DDAKLINZA 3 PAentecavir 3EPIVIR HBV SOLN 2EPIVIR HBV TABS 3famciclovir TABS 1FAMVIR 3FLUMADINE 3ganciclovir inj 500mg 1 B/DHARVONI 3 PAHEPSERA 3lamivudine (hbv) 1moderiba pak MISC 3moderiba pak TABS 400mg 3MODERIBA PAK TABS600mg

3

moderiba tab 200mg 1PEG-INTRON REDIPEN 3 PAPEGASYS 3 PAPEGASYS PROCLICK 3 PAPEGINTRON 3 PAREBETOL 3RELENZA DISKHALER 2ribapak mis 600/day 3ribasphere CAPS 1ribasphere TABS 200mg,400mg

1

ribasphere TABS 600mg 3ribasphere ribapak 800 3ribasphere ribapak 1000 3ribasphere ribapak 1200 3ribavirin 200mg 1rimantadine hydrochloride 1SOVALDI 3 PATAMIFLU 2TYZEKA 3

Drug Name DrugTier

Requirements/Limits

valacyclovir hcl TABS 1VALCYTE 3valganciclovir hcl 3VALTREX 3ZOVIRAX CAPS; SUSP;TABS

3

CEPHALOSPORINSAVYCAZ 3CEDAX 3cefaclor 1cefaclor er tab 500mg 3cefadroxil 1CEFAZOLIN IN DEXTROSE2GM/100ML-4%

3

cefazolin inj 1cefazolin sodium 1gm, 20gm 1cefazolin/dextrose 3cefdinir 1CEFEPIME 1GM SOLN 3CEFEPIME 2GM SOLN 3CEFEPIME HCL ANDDEXTROSE

3

cefepime inj 1gm 1cefepime inj 2gm 1cefixime 1CEFOTAN 3cefotaxime sodium 1gm,2gm, 500mg

1

cefotetan disodium 1cefoxitin sodium 1CEFOXITIN SODIUM INDEXTROSE

3

cefpodoxime proxetil 1cefprozil 1ceftazidime 1CEFTAZIDIME/DEXTROSE 3CEFTIBUTEN 1CEFTIN 3ceftriaxone sodium SOLR1gm, 2gm, 10gm, 250mg,500mg

1

cefuroxime axetil 1cefuroxime sodium 1.5gm,7.5gm, 750mg

1

cephalexin 1



Drug Name DrugTier

Requirements/Limits

claforan 1gm, 2gm 3CLAFORAN 1gm, 2gm,10gm, 500mg

3

CLAFORAN/D5W 3FORTAZ 3MAXIPIME 3rocephin 3SUPRAX CAPS 2suprax CHEW 2suprax SUSR 100mg/5ml,200mg/5ml

2

SUPRAX SUSR 500mg/5ml 2tazicef SOLR 1tazicef vial 1TEFLARO 3ZERBAXA 3ZINACEF SOLR 3ERYTHROMYCINS/MACROLIDESAZITHROMYCIN PACK 1azithromycin SOLR; SUSR;TABS

1

BIAXIN 3clarithromycin SUSR; TABS;TB24

1

DIFICID 3e.e.s. 400 tab 400mg 1E.E.S. GRANULES 3ery-tab 1ERYPED 200 3ERYPED 400 3erythrocin lactobionate 3erythrocin stearate 1erythromycin base 1erythromycin cap 250mg ec 1erythromycin ethylsuccinate 1PCE 3ZITHROMAX 3ZITHROMAX TRI-PAK 3ZITHROMAX Z-PAK 3ZMAX 3FLUOROQUINOLONESAVELOX 3AVELOX ABC PACK 3

Drug Name DrugTier

Requirements/Limits

CIPRO SUSP 3CIPRO TABS 3CIPRO XR 3ciprofloxacin SOLN200mg/20ml

1

ciprofloxacin SUSR 1ciprofloxacin er 1ciprofloxacin hcl TABS 1ciprofloxacin in d5w 1ciprofloxacn inj 400mg/40ml 1LEVAQUIN 3levofloxacin 1levofloxacin in d5w 1MOXIFLOXACIN HCL SOLN 3moxifloxacin hcl TABS 1PENICILLINSamoxicillin 1amoxicillin & pot clavulanate 1ampicillin & sulbactam sodium 1ampicillin cap 250mg 1ampicillin cap 500 mg 1ampicillin inj 1ampicillin sodium 1ampicillin susp 1AUGMENTIN 3AUGMENTIN ES-600 3AUGMENTIN XR 3BACTOCILL INJ DEX 1GM 3BACTOCILL INJ DEX 2GM 3BICILLIN C-R 3BICILLIN L-A 3dicloxacillin sodium 1MOXATAG 3NAFCILLIN 3nafcillin sodium 1gm 1nafcillin sodium 2gm, 10gm 3NALLPEN ISO-OSMOTIC INDE

3

oxacillin sodium 1gm, 2gm 1oxacillin sodium 10gm 3PENICILLIN G POT INDEXTROSE

3



Drug Name DrugTier

Requirements/Limits

PENICILLIN G POTASSIUMIN

3

penicillin g procaine 3penicillin g sodium 1penicillin v potassium 1penicilln gk inj 5mu 1penicilln gk inj 20mu 1pfizerpen g inj 5mu 1pfizerpen-g inj 20mu 1piperacillin sodium-tazobactam sodium

1

UNASYN 3UNASYN BULK PACK 3ZOSYN 3TETRACYCLINESdemeclocycline hcl 1doxy 1doxycycline (monohydrate)CAPS 50mg, 75mg, 100mg

1

doxycycline (monohydrate)SUSR

1

doxycycline (monohydrate)TABS

1

doxycycline hyclate CAPS;SOLR; TABS

1

MINOCIN CAPS 3minocycline hcl CAPS; TABS;TB24

1

SOLODYN 3TETRACYCLINE HCL CAPS 1VIBRAMYCIN CAPS; SUSR 3VIBRAMYCIN SYRP 2ANTINEOPLASTIC AGENTSALKYLATING AGENTSALKERAN SOLR 3 B/DBENDEKA 3 B/DBICNU 3 B/DBUSULFEX 3 B/DCYCLOPHOSPHAMIDECAPS

2 B/D

cyclophosphamide SOLR1gm, 500mg

3 B/D

cyclophosphamide SOLR2gm

1 B/D

dacarbazine 1 B/D

Drug Name DrugTier

Requirements/Limits

EMCYT 2GLEOSTINE 3HEXALEN 3IFEX INJ 1GM 3 B/DIFEX INJ 3GM 3 B/Difosfamide inj 1 B/Difosfamide inj 1gm 1 B/DIFOSFAMIDE INJ 3GM 3 B/DLEUKERAN 2melphalan hcl 3 B/DMUSTARGEN 3 B/Dthiotepa SOLR 3 B/DTREANDA 3 B/DZANOSAR 3 B/DANTHRACYCLINESdaunorubicin hcl 1 B/DDOXIL 3 B/Ddoxorubicin hcl 50mg 1 B/Ddoxorubicin hcl liposomal inj(for iv infusion) 2 mg/ml

3 B/D

doxorubicin inj 50mg 1 B/DELLENCE 3 B/Depirubicin inj 50mg/25ml 1 B/Depirubicin inj 200mg 1 B/DIDAMYCIN PFS 3 B/Didarubicin hcl 3 B/DANTIBIOTICSbleomycin sulfate 1 B/DCOSMEGEN 3 B/Dmitomycin SOLR 1 B/DVALSTAR 3ANTIMETABOLITESadrucil 1 B/DALIMTA 3 B/DARRANON 3 B/Dazacitidine 3 B/Dcladribine 3 B/DCLOLAR 3 B/Dcytarabine inj 1 B/DDACOGEN 3 B/Ddecitabine 3 B/Dfludarabine phosphate 1 B/Dfluorouracil SOLN 1 B/D



Drug Name DrugTier

Requirements/Limits

FOLOTYN 3GEMCITABINE HCL SOLN 3 B/Dgemcitabine hcl SOLR 3 B/DGEMZAR 3 B/Dmercaptopurine TABS 1METHOTREXATE SODIUM50mg/2ml

1 B/D

methotrexate sodium50mg/2ml, 100mg/4ml,200mg/8ml, 250mg/10ml

1 B/D

methotrexate sodium inj 1 B/DNIPENT 3 B/DPURIXAN 3TABLOID 2VIDAZA 3 B/DANTIMITOTIC, TAXOIDSABRAXANE 3 B/DDOCETAXEL CONC20mg/ml, 80mg/4ml

3 B/D

docetaxel CONC 140mg/7ml 3 B/DDOCETAXEL SOLN20mg/2ml

1 B/D

DOCETAXEL SOLN80mg/8ml, 160mg/16ml,200mg/20ml

3 B/D

JEVTANA 3paclitaxel 1 B/DTAXOTERE 3 B/DANTIMITOTIC, VINCA ALKALOIDSvinblastine sulfate 1 B/Dvincasar 1 B/Dvincristine sulfate 1 B/Dvinorelbine tartrate 1 B/DBIOLOGIC RESPONSE MODIFIERSARZERRA 3 B/DAVASTIN 3 B/D LABELEODAQ 3CYRAMZA 3DARZALEX 3EMPLICITI 3 LAERBITUX 3 B/DERIVEDGE 3 LAFARYDAK 3 LAGAZYVA 3

Drug Name DrugTier

Requirements/Limits

HERCEPTIN 3 B/DIBRANCE 3 LAISTODAX 3 B/DKADCYLA 3 B/DKEYTRUDA 3LYNPARZA 3 LANINLARO 3OPDIVO 3PERJETA 3PORTRAZZA 3 LAPROLEUKIN 3 B/DRITUXAN 2 LATORISEL 3 B/DVECTIBIX 3 B/DVELCADE 3 B/DVENCLEXTA 3 LAVENCLEXTA STARTINGPACK

3 LA

YERVOY 3ZALTRAP 3ZOLINZA 3HORMONAL ANTINEOPLASTIC AGENTSanastrozole TABS 1ARIMIDEX 3AROMASIN 3bicalutamide 1CASODEX 3DEPO-PROVERA INJ 400/ML 3 B/DELIGARD INJ 7.5MG 3 B/DELIGARD INJ 22.5MG 3 B/DELIGARD INJ 30MG 3 B/DELIGARD INJ 45MG 3 B/Dexemestane 1FARESTON 3FASLODEX 3 B/DFEMARA 3FIRMAGON 3 B/Dflutamide 1letrozole TABS 1leuprolide acetate KIT 1 PALUPRON DEP INJ 11.25MG 3 PALUPRON DEP-PED INJ7.5MG

3 PA



Drug Name DrugTier

Requirements/Limits

LUPRON DEP-PED INJ11.25MG

3 PA

LUPRON DEP-PED INJ15MG

3 PA

LUPRON DEP-PED INJ30MG (3-MONTH)

3 PA

LUPRON DEPOT 3 PALUPRON DEPOT INJ 22.5MG(3-MONTH)

3 PA

LUPRON DEPOT INJ 30MG(3-MONTH)

3 PA

LYSODREN 2MEGACE ES 3MEGACE ORAL

PA if 65 years and older3 PA

megestrol acetate SUSP;TABS

PA if 65 years and older

3 PA

MEGESTROL SUS625MG/5ML

3

NILANDRON 3SOLTAMOX 3tamoxifen citrate TABS 1TRELSTAR MIXJECT 3 PAVANTAS 3 PAXTANDI 3 LAZOLADEX 3 PAZYTIGA 3 LAKINASE INHIBITORSAFINITOR 3AFINITOR DISPERZ 3ALECENSA 3 LABOSULIF 3CABOMETYX 3 LACAPRELSA 3 LACOMETRIQ 3 LACOTELLIC 3 LAGILOTRIF TAB 20MG 3 LAGILOTRIF TAB 30MG 3 LAGILOTRIF TAB 40MG 3 LAGLEEVEC 2ICLUSIG 3 LAimatinib mesylate 2IMBRUVICA CAP 140MG 3 LAINLYTA 3 LA

Drug Name DrugTier

Requirements/Limits

IRESSA 3 LAJAKAFI 3 LALENVIMA 8MG DAILY DOSE 3 LALENVIMA 10MG DAILYDOSE

3 LA

LENVIMA 14MG DAILYDOSE

3 LA


3 LA


3 LA


3 LA

MEKINIST 3 LANEXAVAR 3 LASPRYCEL 3STIVARGA 3 LASUTENT 3TAFINLAR 3 LATAGRISSO 3 LATARCEVA 3 LATASIGNA 3TYKERB 3 LAVOTRIENT 3 LAXALKORI 3 LAZELBORAF 3 LAZYDELIG 3 LAZYKADIA 3 LAMISCELLANEOUSbexarotene 3DROXIA 3ERWINAZE 3HALAVEN 3 B/DHYDREA 3hydroxyurea CAPS 1IXEMPRA KIT 3 B/DLONSURF 3MATULANE 3 LAmitoxantrone hcl 1 B/DODOMZO 3 LAONCASPAR 3POMALYST 3 LASYLATRON KIT 200MCG 3SYLATRON KIT 300MCG 3



Drug Name DrugTier

Requirements/Limits

SYLATRON KIT 600MCG 3SYLVANT 3SYNRIBO 3TARGRETIN CAPS 3tretinoin CAPS 2TRISENOX 3 B/DUVADEX 3 B/DPLATINUM-BASED AGENTScarboplatin 1 B/Dcisplatin 1 B/DELOXATIN 3 B/Doxaliplatin 3 B/DPROTECTIVE AGENTSamifostine crystalline 3 B/Ddexrazoxane 250mg 3 B/DELITEK 3 B/DFUSILEV 3 B/DKEPIVANCE 3 B/Dleucovorin calcium TABS 1leucovorin calcium inj 50mg 1 B/Dleucovorin calcium inj 100mg 1 B/Dleucovorin calcium inj 200mg 1 B/Dleucovorin calcium inj 350mg 1 B/Dleucovorin calcium inj 500mg 1 B/Dlevoleucovorin calcium 3 B/Dmesna 1 B/DMESNEX SOLN 3 B/DMESNEX TABS 3ZINECARD 3 B/DTOPOISOMERASE INHIBITORSCAMPTOSAR 3 B/DETOPOPHOS 3 B/Detoposide SOLN 500mg/25ml 1 B/DHYCAMTIN SOLR 3 B/Dirinotecan inj 40mg/2ml 1 B/Dirinotecan inj 100/5ml 1 B/Dirinotecan inj 500mg/25ml 1 B/Dtoposar 1gm/50ml 1 B/Dtopotecan hcl SOLR 3 B/DCARDIOVASCULARACE INHIBITOR COMBINATIONSACCURETIC 3

Drug Name DrugTier

Requirements/Limits

amlodipine besylate-benazepril hcl

1

benazepril &hydrochlorothiazide

1

captopril &hydrochlorothiazide

1

enalapril maleate &hydrochlorothiazide

1

fosinopril sodium &hydrochlorothiazide

1

lisinopril &hydrochlorothiazide

1

LOTREL 3moexipril-hydrochlorothiazide 1quinapril-hydrochlorothiazide 1TARKA 3trandolapril-verapamil hcl 1VASERETIC 3ZESTORETIC 3ACE INHIBITORSACCUPRIL 3ALTACE 3benazepril hcl TABS 1captopril TABS 1enalapril maleate TABS 1fosinopril sodium 1lisinopril TABS 1LOTENSIN 20mg, 40mg 3MAVIK 3moexipril hcl 1perindopril erbumine 1PRINIVIL 3quinapril hcl 1ramipril 1trandolapril 1VASOTEC 3ZESTRIL 3ALDOSTERONE RECEPTORANTAGONISTSALDACTONE 3eplerenone 1INSPRA 3spironolactone TABS 1ALPHA BLOCKERS



Drug Name DrugTier

Requirements/Limits

CARDURA 3doxazosin mesylate 1MINIPRESS 3prazosin hcl 1terazosin hcl 1ANGIOTENSIN II RECEPTORANTAGONIST COMBINATIONSamlodipine besylate-valsartantab 5-160 mg

1

amlodipine besylate-valsartantab 5-320 mg

1


1


1

amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg

1

amlodipine-valsartan-hydrochlorothiazide 5-160-25mg

1

amlodipine-valsartan-hydrochlorothiazide 10-160-12.5mg

1


1


1

ATACAND HCT 3AVALIDE 3AZOR 2BENICAR HCT 2candesartan cilexetil-hydrochlorothiazide

1

EDARBYCLOR 3ENTRESTO 3HYZAAR 3irbesartan-hydrochlorothiazide 1losartan-hydrochlorothiazide 1MICARDIS HCT 3telmisartan-amlodipine 1telmisartan-hydrochlorothiazide

1

TWYNSTA 3

Drug Name DrugTier

Requirements/Limits

valsartan-hydrochlorothiazide 1ANGIOTENSIN II RECEPTORANTAGONISTSATACAND 3AVAPRO 3BENICAR 2candesartan cilexetil 1COZAAR 3DIOVAN 3EDARBI 3eprosartan mesylate 1irbesartan 1losartan potassium 1MICARDIS 3telmisartan 1valsartan 1ANTIARRHYTHMICSamiodarone hcl 1amiodarone inj 50mg/ml 1BETAPACE 3BETAPACE AF 3disopyramide phosphate


dofetilide 1flecainide acetate 1mexiletine hcl 1MULTAQ 3NORPACE


NORPACE CRPA if 65 years and older

3 PA

pacerone 1propafenone hcl 1propafenone hcl 12hr 1quinidine gluconate TBCR 1quinidine sulfate TABS 1RYTHMOL 3RYTHMOL SR 3sorine 1sotalol hcl 1sotalol hcl (afib/afl) 1TIKOSYN 2



Drug Name DrugTier

Requirements/Limits

ANTILIPEMICS, HMG-CoA REDUCTASEINHIBITORSatorvastatin calcium TABS 1CRESTOR 2fluvastatin sodium 1fluvastatin sodium tab sr 24 hr80 mg

1

LESCOL 3LIVALO 3lovastatin 1PRAVACHOL 3pravastatin sodium 1rosuvastatin calcium 1simvastatin TABS 1ZOCOR 3ANTILIPEMICS, MISCELLANEOUSANTARA 3cholestyramine 1cholestyramine light 1choline fenofibrate 1COLESTID 3colestipol hcl 1FENOFIBRATE CAPS 1FENOFIBRATE TABS 40mg,120mg

1

fenofibrate TABS 48mg,54mg, 145mg, 160mg

1

fenofibrate micronized 1FENOFIBRIC ACID 1FENOGLIDE 3FIBRICOR 3gemfibrozil TABS 1JUXTAPID 3 LA PAKYNAMRO 3 PALIPOFEN 3lofibra 3LOPID 3LOVAZA CAP 1GM 3niacin er (antihyperlipidemic) 1niacor 1NIASPAN 3omega-3-acid ethyl esters 1PRALUENT 3 PA

Drug Name DrugTier

Requirements/Limits

prevalite 1questran 3questran light 3TRICOR 3TRILIPIX 3VASCEPA 3VYTORIN 2WELCHOL 2ZETIA TAB 10MG 2BETA-BLOCKER/DIURETICCOMBINATIONSatenolol & chlorthalidone 1bisoprolol &hydrochlorothiazide

1

CORZIDE 3DUTOPROL 3LOPRESSOR HCT 3metoprolol & hctz tab 50-25mg

1

metoprolol & hctz tab 100-25mg

1

metoprolol & hctz tab 100-50mg

1

nadolol & bendroflumethiazide 1propranolol &hydrochlorothiazide

1

TENORETIC 50 3TENORETIC 100 3ZIAC 3BETA-BLOCKERSacebutolol hcl CAPS 1atenolol TABS 1betaxolol hcl 1bisoprolol fumarate 1BYSTOLIC 2carvedilol 1COREG 3CORGARD 3INDERAL LA 3labetalol hcl SOLN; TABS 1LOPRESSOR 3metoprolol succinate 1metoprolol tartrate SOLN 1



Drug Name DrugTier

Requirements/Limits

metoprolol tartrate TABS25mg, 50mg, 100mg

1

nadolol TABS 1pindolol 1propranolol hcl er 1propranolol inj 1mg/ml 1propranolol sol 1propranolol tab 1SECTRAL 3SOTYLIZE 3TENORMIN 3timolol maleate TABS 1TOPROL XL 3TRANDATE 3ZEBETA 3CALCIUM CHANNEL BLOCKERSADALAT CC 3afeditab cr 1amlodipine besylate TABS 1CALAN 3CALAN SR 3CARDIZEM 60mg, 120mg 3CARDIZEM CD 3CARDIZEM LA 3cartia xt 1dilt-xr cap 1diltiazem cap 120mg/24hr 1diltiazem cap 240mg/24hr 1diltiazem cap er/12hr 1diltiazem hcl TABS 1diltiazem hcl coated beads 1diltiazem hcl er 1diltiazem hcl extended releasebeads

1

diltiazem inj 25mg/5ml 1diltiazem inj 50/10ml 1diltiazem inj 100mg 3diltiazem inj 125/25ml 1felodipine 1isradipine 1matzim la 1nicardipine hcl CAPS 1nifedical 1

Drug Name DrugTier

Requirements/Limits

nifedipine TB24 1nifedipine er 1nimodipine CAPS 3nisoldipine 1NORVASC 3NYMALIZE 3PROCARDIA XL 3SULAR 3taztia xt 1TIAZAC 3verapamil hcl CP24 100mg,120mg, 180mg, 200mg,240mg, 300mg

1

VERAPAMIL HCL CP24360mg

1

verapamil hcl SOLN 1verapamil hcl TABS 1verapamil hcl TBCR 1VERELAN 3VERELAN PM 3DIGITALIS GLYCOSIDESdigitek .25mg


digitek .125mg 1digox 125mcg 1digox 250mcg


digoxin TABS 125mcg 1digoxin TABS 250mcg


digoxin inj 1DIGOXIN SOL 50MCG/ML


LANOXIN 62.5mcg 3LANOXIN 187.5mcg


LANOXIN INJ 0.25MG/ML 3LANOXIN PEDIATRIC 3LANOXIN TAB 125mcg 3LANOXIN TAB 250mcg


DIRECT RENININHIBITORS/COMBINATIONSTEKTURNA 2TEKTURNA HCT 2



Drug Name DrugTier

Requirements/Limits

DIURETICSacetazolamide CP12; TABS 1acetazolamide sodium 1ALDACTAZIDE 3ALDACTAZIDE TAB 50/50 3amiloride &hydrochlorothiazide

1

amiloride hcl TABS 1bumetanide 1chlorothiazide tabs 1chlorthalidone 25mg, 50mg 1DEMADEX 3DEMADEX TAB 20MG 3DIAMOX 3DIURIL SUS 250/5ML 3DYAZIDE 3DYRENIUM 3EDECRIN 3furosemide SOLN; TABS 1furosemide inj 10mg/ml 1FUROSEMIDE INJ 10mg/ml 1furosemide oral soln 8 mg/ml 1hydrochlorothiazide CAPS;TABS

1

indapamide 1LASIX 3MAXZIDE 3MAXZIDE-25 3methazolamide TABS 1methyclothiazide 1metolazone 1MICROZIDE 3NEPTAZANE 3SODIUM DIURIL 3spironolactone &hydrochlorothiazide

1

torsemide inj 50mg/5ml 3torsemide tabs 1triamt/hctz cap 37.5-25 1triamt/hctz cap 50-25mg 1triamt/hctz tab 37.5-25 1triamt/hctz tab 75-50mg 1MISCELLANEOUS

Drug Name DrugTier

Requirements/Limits

BIDIL 2CATAPRES TAB 3CATAPRES-TTS DIS0.1/24HR

3

CATAPRES-TTS DIS0.2/24HR

3

CATAPRES-TTS DIS0.3/24HR

3

clonidine hcl PTWK; TABS 1clorpres 1CORLANOR 3DEMSER 3DIBENZYLINE 3hydralazine hcl SOLN; TABS 1KEVEYIS 3 PAmidodrine hcl 1minoxidil TABS 1phenoxybenzamine hclCAPS

3

RANEXA 2NITRATESDILATRATE SR 3ISORDIL TITRADOSE 5mg 3ISORDIL TITRADOSE 40mg 2isosorbide dinitrate 1isosorbide dinitrate er 1isosorbide mononitrate 1isosorbide mononitrate er 1minitran 1nitro-bid 3NITRO-DUR .1mg/hr,.2mg/hr, .4mg/hr, .6mg/hr

3

NITRO-DUR .3mg/hr, .8mg/hr 2nitroglycerin .4mg/spray 1NITROGLYCERIN LINGUAL 1nitroglycerin patches 1NITROLINGUAL SPRPUMPSPRA

3

NITROMIST 3NITROSTAT 2PULMONARY ARTERIAL HYPERTENSIONADCIRCA 3 PAADEMPAS 3 LA PAepoprostenol sodium 3 B/D LA



Drug Name DrugTier

Requirements/Limits

FLOLAN 3 B/D LALETAIRIS 3 LA PAOPSUMIT 3 LA PAORENITRAM TAB 0.25MG 3 LA PAORENITRAM TAB 0.125MG 3 LA PAORENITRAM TAB 1MG 3 LA PAORENITRAM TAB 2.5MG 3 LA PAREMODULIN 3 B/D LAREVATIO 3 PAsildenafil citrate (pulmonaryhypertension) SOLN

3 PA

sildenafil citrate (pulmonaryhypertension) TABS

1 PA

TRACLEER 3 LA PATYVASO 3 B/DUPTRAVI 3 LA PAVELETRI 3 B/D LAVENTAVIS 3 B/DCENTRAL NERVOUS SYSTEMANTIANXIETYalprazolam CONC


alprazolam TABS 1mgQL (120 tabs / 30 days)

1 QL

alprazolam TABS 2mgQL (150 tabs / 30 days)

1 QL

alprazolam TABS .5mgQL (240 tabs / 30 days)

1 QL

alprazolam TABS .25mgQL (480 tabs / 30 days)

1 QL

ATIVAN SOLN 3ATIVAN TABS


buspirone hcl TABS 1fluvoxamine maleate 1fluvoxamine maleate er 1lorazepam CONC


lorazepam SOLN 1lorazepam TABS


XANAX TAB 0.5MGQL (240 tabs / 30 days)

3 QL

XANAX TAB 0.25MGQL (480 tabs / 30 days)

3 QL

Drug Name DrugTier

Requirements/Limits

XANAX TAB 1MGQL (120 tabs / 30 days)

3 QL

XANAX TAB 2MGQL (150 tabs / 30 days)

3 QL

ANTICONVULSANTSAPTIOM 3BANZEL SUS 40MG/ML 3BANZEL TAB 200MG 3BANZEL TAB 400MG 3BRIVIACT INJ 3BRIVIACT SOLN 10MG/ML 3BRIVIACT TABS 3carbamazepine CHEW;CP12; SUSP; TABS; TB12

1

CARBATROL 3CELONTIN 3clonazepam TABS 1mg


clonazepam TABS 2mgQL (300 tabs / 30 days)

1 QL

clonazepam TABS .5mgQL (240 tabs / 30 days)

1 QL

clonazepam TBDP 1mgQL (120 tabs / 30 days)

1 QL

clonazepam TBDP 2mgQL (300 tabs / 30 days)

1 QL

clonazepam TBDP .5mgQL (240 tabs / 30 days)

1 QL


1 QL


1 QL

clorazepate dipotassium3.75mg, 7.5mg


1 QL

clorazepate dipotassium15mg


1 QL

DEPACON 3DEPAKENE 3DEPAKOTE 3DEPAKOTE ER 3DEPAKOTE SPRINKLES 3DIASTAT ACUDIAL 3DIASTAT PEDIATRIC 3diazepam CONC




Drug Name DrugTier

Requirements/Limits

diazepam SOLN 1mg/mlQL (1200 mL / 30 days)

1 QL

diazepam SOLN 5mg/ml 1diazepam TABS


DIAZEPAM GEL(ANTICONVULSANT)

1

dilantin 3DILANTIN-125 3divalproex sodium 1epitol 1ethosuximide CAPS; SOLN 1felbamate SUSP 3felbamate TABS 1FELBATOL 3FYCOMPA TABS 2gabapentin CAPS; SOLN;TABS

1

GABITRIL 3KEPPRA 3KEPPRA XR 3KLONOPIN 1mg


KLONOPIN 2mgQL (300 tabs / 30 days)

3 QL

KLONOPIN .5mgQL (240 tabs / 30 days)

3 QL

LAMICTAL TABS 3LAMICTAL CHEWABLEDISPERS

3

LAMICTAL ODT 3LAMICTAL STARTER 3LAMICTAL XR 3lamotrigine CHEW; KIT;TABS; TB24; TBDP

1

levetiracetam SOLN; TABS;TB24

1

LEVETIRACETAM IV 3levetiracetam oral soln 100mg/ml

1

LYRICA 2MYSOLINE 3NEURONTIN 3ONFI 3oxcarbazepine 1

Drug Name DrugTier

Requirements/Limits

OXTELLAR XR 2PEGANONE 3phenobarbital ELIX; TABS


PHENOBARBITAL SODIUMSOLN 65mg/ml


3 PA

phenobarbital sodium SOLN130mg/ml


3 PA

phenytek 3phenytoin CHEW; SUSP 1phenytoin inj 50mg/ml 1phenytoin sodium extended 1POTIGA 3primidone TABS 1QUDEXY XR 2roweepra 1SABRIL 3 LA PASPRITAM 3TEGRETOL 3TEGRETOL-XR 3tiagabine hcl 1TOPAMAX 3TOPAMAX SPRINKLE 3topiramate CPSP; TABS 1TOPIRAMATE CS24 1TRANXENE T 3.75mg,7.5mg


3 QL

TRANXENE T 15mgQL (180 tabs / 30 days)

3 QL

TRILEPTAL SUSP 3TRILEPTAL TABS 3TROKENDI XR 25mg, 50mg,100mg

2

TROKENDI XR 200mg 3VALIUM


valproate sodium SOLN;SYRP

1

valproic acid 1VIMPAT SOLN 2VIMPAT TABS 50mg 2VIMPAT TABS 100mg,150mg, 200mg

3



Drug Name DrugTier

Requirements/Limits

ZARONTIN CAPS 3zarontin SOLN 3ZONEGRAN 3zonisamide CAPS 1ANTIDEMENTIAARICEPT 5mg, 10mg 3donepezil odt 5mg 1donepezil odt 10mg 1donepezil tab hcl 23mg 1donepezil tabs 5mg 1donepezil tabs 10mg 1EXELON CAPS 3EXELON PATCHES 3galantamine hydrobromide 1memantine hcl

PA if < 30 yrs1 PA

NAMENDA SOL 10MG/5MLPA if < 30 yrs

2 PA

NAMENDA TABPA if < 30 yrs

3 PA

NAMENDA XRPA if < 30 yrs

3 PA

NAMENDA XR TITRATIONPACK

PA if < 30 yrs

3 PA

NAMZARIC 3RAZADYNE 3RAZADYNE ER 3rivastigmine tartrate 1rivastigmine td patch 24hr 4.6mg/24hr

1

rivastigmine td patch 24hr 9.5mg/24hr

1

rivastigmine td patch 24hr13.3 mg/24hr

1

ANTIDEPRESSANTSamitriptyline hcl TABS


amoxapine 1ANAFRANIL


BRINTELLIX 2bupropion hcl TABS; TB12;TB24

1

CELEXA 3citalopram hydrobromide 1

Drug Name DrugTier

Requirements/Limits

clomipramine hcl CAPSPA if 65 years and older

3 PA

CYMBALTA 3desipramine hcl TABS 1doxepin hcl CAPS; CONC


duloxetine hcl CPEP 20mg,30mg, 60mg

1

EFFEXOR XR 3EMSAM 3escitalopram oxalate 1FETZIMA 3FETZIMA TITRATION PACK 3fluoxetine hcl CAPS 1fluoxetine hcl CPDR 1fluoxetine hcl SOLN 1fluoxetine hcl TABS 10mg,20mg

1

FLUOXETINE HCL TABS60mg

2

FORFIVO XL 3imipramine hcl TABS


imipramine pamoatePA if 65 years and older

3 PA

LEXAPRO 3maprotiline hcl 1MARPLAN 3mirtazapine 1NARDIL 3nefazodone hcl 1NORPRAMIN 3nortriptyline hcl CAPS; SOLN 1PAMELOR 3PARNATE 3paroxetine er tab 1paroxetine hcl tabs 1PAXIL 3PAXIL CR 3PEXEVA 3phenelzine sulfate TABS 1PRISTIQ 3protriptyline hcl 1PROZAC 3



Drug Name DrugTier

Requirements/Limits

PROZAC WEEKLY 3REMERON 3REMERON SOLTAB 3sertraline hcl CONC; TABS 1SURMONTIL


TOFRANILPA if 65 years and older

3 PA

tranylcypromine sulfate 1trazodone hcl TABS 1trimipramine maleate CAPS


TRINTELLIX 2venlafaxine cap er 1venlafaxine hcl 1VENLAFAXINE HCL ER TAB(VERT)

3

venlafaxine tab 1VENLAFAXINE TAB 225MGER

1

venlafaxine tab er 1VIIBRYD 2VIIBRYD STARTER PACK 2WELLBUTRIN 3WELLBUTRIN SR 3WELLBUTRIN XL 3ZOLOFT 3ANTIPARKINSONIAN AGENTSamantadine hcl CAPS;SYRP; TABS

1

APOKYN 3 LA PAAZILECT 2BENZTROPINE MESYLATESOLN

1

benztropine mesylate TABSPA if 65 years and older

3 PA

bromocriptine mesylateCAPS; TABS

1

carbidopa TABS 3carbidopa-levodopa 1CARBIDOPA/LEVODOPA/ENTACAPONE

1

COGENTIN 3COMTAN 3DUOPA 3 B/D

Drug Name DrugTier

Requirements/Limits

ELDEPRYL 3ENTACAPONE 1LODOSYN 3MIRAPEX 3MIRAPEX ER 2.25mg, 3mg,3.75mg, 4.5mg

2

MIRAPEX ER .375mg,.75mg, 1.5mg

3

NEUPRO 2pramipexole dihydrochloride 1REQUIP 3ropinirole hydrochlorideTABS

1

RYTARY 3selegiline hcl CAPS; TABS 1SINEMET 3SINEMET CR 3STALEVO 3ZELAPAR 3ANTIPSYCHOTICSABILIFY DISCMELT TAB10MG

3

ABILIFY MAINTENA 3ABILIFY TABS 3aripiprazole odt 3aripiprazole oral solution 1mg/ml

3

aripiprazole tabs 3ARISTADA 3chlorpromaz inj 25mg/ml 3chlorpromazine hcl TABS 1chlorpromazine inj 3clozapine 1CLOZAPINE ODT 12.5mg,25mg, 100mg

1

CLOZAPINE ODT 150mg,200mg

3

CLOZARIL 3FANAPT 3FANAPT TITRATION PACK 3FAZACLO 3fluphenazine decanoateSOLN

1

fluphenazine hcl 1GEODON 3



Drug Name DrugTier

Requirements/Limits

GEODON INJ 3HALDOL 3HALDOL DECANOATE 50 3HALDOL DECANOATE 100 3haloperidol TABS 1haloperidol decanoate SOLN 1haloperidol lactate 1haloperidol lactate inj 5 mg/ml 1INVEGA 3INVEGA SUST INJ 39MG/0.25 ML

3

INVEGA SUST INJ 78 MG/0.5ML

3

INVEGA SUST INJ 117MG/0.75 ML

3

INVEGA SUST INJ156MG/ML

3

INVEGA SUST INJ 234MG/1.5 ML

3

INVEGA TRINZA 3LATUDA 2loxapine succinate 1molindone hcl 1NUPLAZID

QL (60 tabs / 30 days)3 QL LA PA

olanzapine 1olanzapine odt 1ORAP 3paliperidone 1perphenazine TABS 1pimozide 1quetiapine fumarate 1REXULTI 3RISPERDAL 3RISPERDAL INJ 12.5MG 2RISPERDAL INJ 25MG 2RISPERDAL INJ 37.5MG 3RISPERDAL INJ 50MG 3RISPERDAL M-TAB 3risperidone 1risperidone odt 1SAPHRIS 3SEROQUEL 3SEROQUEL XR 2

Drug Name DrugTier

Requirements/Limits

thioridazine hcl TABSPA if 65 years and older

3 PA

thiothixene 1trifluoperazine hcl 1VERSACLOZ 3VRAYLAR 3ziprasidone hcl 1ZYPREXA 3ZYPREXA RELPREVV 3ZYPREXA RELPREVV INJ210MG

3

ZYPREXA ZYDI TAB 10MG 3ZYPREXA ZYDIS 3ATTENTION DEFICIT HYPERACTIVITYDISORDERadderall tab 5mg 3adderall tab 7.5mg 3ADDERALL TAB 10MG 3adderall tab 12.5mg 3adderall tab 15mg 3ADDERALL TAB 20MG 3ADDERALL TAB 30MG 3ADDERALL XR CAP 5MG 3ADDERALL XR CAP 10MG 3ADDERALL XR CAP 15MG 3ADDERALL XR CAP 20MG 3ADDERALL XR CAP 25MG 3ADDERALL XR CAP 30MG 3amphetamine cap 10mg er 1amphetamine cap 15mg er 1amphetamine cap 20mg er 1amphetamine cap 25mg er 1amphetamine cap 30mg er 1amphetamine-dextroamphetamine cap sr24hr 5 mg

1

amphetamine-dextroamphetamine tab 5 mg

1

amphetamine-dextroamphetamine tab 7.5mg

1

amphetamine-dextroamphetamine tab 10mg

1



Drug Name DrugTier

Requirements/Limits

amphetamine-dextroamphetamine tab 12.5mg

1


1


1


1

APTENSIO XR 3CONCERTA 3DAYTRANA 2guanfacine hcl (adhd)


INTUNIVPA if 65 years and older

3 PA

METADATE CD 3metadate er tab 20mg 1METHYLIN 3METHYLIN CHEW TAB 3methylphenidate hcl CHEW 1methylphenidate hcl CP2420mg, 40mg

1

METHYLPHENIDATE HCLCP24 30mg

1

methylphenidate hcl CPCR 1methylphenidate hcl SOLN 1methylphenidate hcl TABS 1methylphenidate hcl TB24 1methylphenidate hcl TBCR 1methylphenidate hcl er TB24 1QUILLICHEW ER 3QUILLIVANT XR 3RITALIN 3RITALIN LA 3STRATTERA 2VYVANSE 2HYPNOTICSAMBIEN

QL (30 tabs / 30 days)90 day limit per calendaryear if 65 years and older

3 QL PA

HETLIOZ 3 LA PA

Drug Name DrugTier

Requirements/Limits

RESTORIL 7.5mgQL (30 caps / 30 days)


3 QL PA

RESTORIL 15mgQL (60 caps / 30 days)


3 QL PA

ROZEREMQL (30 tabs / 30 days)

3 QL

SILENOR 2temazepam 7.5mg

QL (30 caps / 30 days)90 day limit per calendaryear if 65 years and older

1 QL PA

temazepam 15mgQL (60 caps / 30 days)


1 QL PA

zolpidem tartrate TABSQL (30 tabs / 30 days)


3 QL PA

MIGRAINEalmotriptan malate 1AMERGE 3AXERT 3cafergot tab 1-100mg 3D.H.E. 45 3dihydroergotamine mesylate1mg/ml

1

DIHYDROERGOTAMINEMESYLATE 4mg/ml

3

ergomar 3FROVA TAB 2.5MG 3frovatriptan succinate 1IMITREX 3IMITREX STATDOSE REFILL 3IMITREX STATDOSESYSTEM

3

MAXALT 3MAXALT-MLT 3migergot 3MIGRANAL 3naratriptan hcl 1ONZETRA XSAIL 3RELPAX 2



Drug Name DrugTier

Requirements/Limits

rizatriptan benzoate 1SUMATRIPTAN INJ4MG/0.5ML

1

sumatriptan inj 6mg/0.5ml 1SUMATRIPTAN SUCCINATESOLN

1

sumatriptan succinate TABS 1SUMAVEL DOSEPRO 3ZEMBRACE SYMTOUCH 3zolmitriptan TABS 1zolmitriptan odt 1ZOMIG TABS 3ZOMIG ZMT 3MISCELLANEOUSBRISDELLE 2EQUETRO 3GRALISE 2GRALISE STARTER 2HORIZANT 3lithium carbonate CAPS;TABS; TBCR

1

LITHIUM SOLN 8MEQ/5ML 3LITHOBID 3MESTINON 3MESTINON SYRUP 2MESTINON TIMESPAN 2NUEDEXTA 2pyridostigmine bromideTABS; TBCR

1

RILUTEK 3riluzole 1SAVELLA 2SAVELLA TITRATION PACK 2tetrabenazine 3 PAXENAZINE 3 LA PAMULTIPLE SCLEROSIS AGENTSAMPYRA 3 LA PAAUBAGIO 3 LA PAAVONEX 3 PAAVONEX PEN 3 PACOPAXONE INJ 40MG/ML 3 PACOPAXONE KIT 20MG/ML 3 PAEXTAVIA 3 PA

Drug Name DrugTier

Requirements/Limits

GILENYA CAP 0.5MG 3 PAglatopa 3 PALEMTRADA 3 LA PAPLEGRIDY 3 PAPLEGRIDY STARTER PACK 3 PAREBIF 3 PAREBIF REBIDOSE 3 PAREBIF REBIDOSETITRATION

3 PA

REBIF TITRATION PACK 3 PATECFIDERA CAP 120MG 3 LA PATECFIDERA CAP 240MG 3 LA PATECFIDERA MIS STARTER 3 LA PATYSABRI 3 LA PAMUSCULOSKELETAL THERAPY AGENTSbaclofen TABS 1BOTOX INJ 100UNIT 3 PABOTOX INJ 200UNIT 3 PAcyclobenzaprine hcl TABS5mg, 10mg


3 PA

DANTRIUM 3dantrolene sodium CAPS 1DYSPORT 3 PAtizanidine 1XEOMIN 3 PAXEOMIN 200UNIT 3 PAZANAFLEX 3NARCOLEPSY/CATAPLEXYarmodafinil 50mg, 150mg,250mg

1 PA

ARMODAFINIL 200mg 1 PAmodafinil 100mg 1 PAmodafinil 200mg 3 PANUVIGIL 2 PAXYREM

QL (540 mL / 30 days)3 QL LA PA

PSYCHOTHERAPEUTIC-MISCacamprosate calcium 1antabuse 3buprenorphine hcl SUBL 1buprenorphine hcl-naloxonehcl sl

1

buproban 1



Drug Name DrugTier

Requirements/Limits

bupropion hcl (smokingdeterrent)

1

CHANTIX 2CHANTIX CONTINUINGMONTH

2

CHANTIX STARTER PACK 2disulfiram TABS 1naloxone hcl SOLN 1naltrexone hcl TABS 1NICOTROL INHALER 3NICOTROL NS 3SARAFEM 3VIVITROL 3 PAZUBSOLV SUB 1.4-0.36MG 3ZUBSOLV SUB 2.9-0.71MG 3ZUBSOLV SUB 5.7-1.4MG 3ZUBSOLV SUB 8.6-2.1MG 3ZUBSOLV SUB 11.4-2.9MG 3ZYBAN 3ENDOCRINE AND METABOLICANDROGENSANDRODERM 2 PAAVEED 3 PAAXIRON 2 PAdepo-testosterone 3 PAoxandrolone TABS 2.5mg 1 PAoxandrolone TABS 10mg 3 PASTRIANT 3 PAtestosterone cypionate SOLN 1 PAtestosterone enanthateSOLN

1 PA

ANTIDIABETICS, INJECTABLEALCOHOL SWABS 2BYDUREON 3BYETTA 3GAUZE PADS 2X2 2HUMULIN R U-500(CONCENTRATE)

3 B/D

HUMULIN R U-500 KWIKPEN 3INSULIN PEN NEEDLES 2INSULIN SAFETY NEEDLES 2INSULIN SYRINGES 2LANTUS 2

Drug Name DrugTier

Requirements/Limits

LANTUS SOLOSTAR 2LEVEMIR 2LEVEMIR FLEXTOUCH 2NOVOLIN 70/30 2NOVOLIN N 2NOVOLIN R 2NOVOLOG 2NOVOLOG FLEXPEN 2NOVOLOG MIX 70/30 2NOVOLOG MIX 70/30PREFILL

2

NOVOLOG PENFILL 2SYMLINPEN 60 2SYMLINPEN 120 3TANZEUM 3TOUJEO SOLOSTAR 2TRESIBA FLEXTOUCH 2TRULICITY 2VICTOZA 2ANTIDIABETICS, ORALacarbose 1ACTOPLUS MET TAB 15-500MG

3

ACTOPLUS MET TAB 15-850MG

3

ACTOPLUS MET XR 15-1000MG

3

ACTOPLUS MET XR 30-1000MG

3

ACTOS 3AMARYL 3DUETACT 3FARXIGA 2glimepiride 1glipizide TABS 1glipizide er 1GLIPIZIDE XL TB24 2.5MG 1GLIPIZIDE XL TB24 5MG 1glipizide-metformin 2.5-250mg

1

glipizide-metformin 2.5-500mg

1

glipizide-metformin 5-500mg 1GLUCOPHAGE 3



Drug Name DrugTier

Requirements/Limits

GLUCOPHAGE XR 3GLUCOTROL 3GLUCOTROL XL 3GLYSET 3GLYXAMBI 3INVOKAMET TAB 50-500MG 3INVOKAMET TAB 50-1000 3INVOKAMET TAB 150-500 3INVOKAMET TAB 150-1000 3INVOKANA TAB 100MG 3INVOKANA TAB 300MG 3JANUMET 2JANUMET XR TAB 50-500MG

2

JANUMET XR TAB 50-1000 2JANUMET XR TAB 100-1000 2JANUVIA 2JARDIANCE 2JENTADUETO 2KAZANO 3KOMBIGLYZE XR 2.5-1000MG

3

KOMBIGLYZE XR 5-500MG 3KOMBIGLYZE XR 5-1000MG 3metformin er 1metformin hcl TABS; TB24 1miglitol 1nateglinide 1NESINA 3ONGLYZA 3OSENI TAB 12.5-15MG 3OSENI TAB 12.5-30MG 3OSENI TAB 12.5-45MG 3OSENI TAB 25-15MG 3OSENI TAB 25-30MG 3OSENI TAB 25-45MG 3pioglitazone hcl 1pioglitazone hcl-glimepiride 1pioglitazone hcl-metformin hcl 1PRANDIMET 3PRANDIN 3PRECOSE 3repaglinide 1

Drug Name DrugTier

Requirements/Limits

repaglinide-metformin hcl 1RIOMET 3STARLIX 3SYNJARDY TAB 5-500MG 3SYNJARDY TAB 5-1000MG 3SYNJARDY TAB 12.5-500 3SYNJARDY TAB 12.5-1000 3TRADJENTA 2XIGDUO XR TAB 5-500MG 2XIGDUO XR TAB 5-1000MG 2XIGDUO XR TAB 10-500MG 2XIGDUO XR TAB 10-1000MG 2BISPHOSPHONATESACTONEL 3alendronate sodium 1BONIVA 3 B/DFOSAMAX 3ibandronate sodium 1 B/Dibandronate tab 150mg 1 B/Dpamidronate disodium SOLN6mg/ml

3 B/D

pamidronate disodium SOLN30mg/10ml, 90mg/10ml

1 B/D

RECLAST 3 B/DRISEDRONATE SODIUMTABS 5mg, 30mg

1

risedronate sodium TABS35mg, 150mg

1

risedronate sodium TBEC 1zoledronic inj 4mg/5ml 1 B/Dzoledronic inj 5/100ml 1 B/DZOMETA 3 B/DCALCIUM RECEPTOR AGONISTSSENSIPAR 2CHELATING AGENTSCHEMET 3DEPEN TITRATABS 3EXJADE 3 LA PAFERRIPROX 3 LA PAJADENU 3 PAKAYEXALATE 3kionex 1sodium polystyrene sulfonate 1



Drug Name DrugTier

Requirements/Limits

sps susp 15gm/60ml 1SYPRINE 3VELTASSA 3 LACONTRACEPTIVESaltavera 1amethia 91 day 1amethyst 28 day 1apri 28 day 1aranelle 28 1ashlyna 91 day 1aubra 28 day 1aviane 28 1balziva 28 day 1bekyree 28 day 1BEYAZ 2blisovi 21 fe 1.5/30 28 daypack

1

blisovi 21 fe 1/20 28 day pack 1blisovi 24 fe 1/20 28 day 1BREVICON-28 3briellyn 28 day 1camila 28 day 1CAMRESE LO TAB 1cryselle 28 1cyclafem 1/35 28 day 1cyclafem 7/7/7 28 day 1CYCLESSA 3cyred tab 1deblitane 28 day 1delyla 28 day 1DEPO-PROVERACONTRACEPTIVE

3

DEPO-SUBQ PROVERA 104 2DESOGEN 3desogestrel-ethinyl estradiol(biphasic)

1

drospirenone-ethinyl estradiol 1ELLA 3emoquette 1enpresse 28 day 1errin 28 day 1estarylla tab 0.25-35 1ESTROSTEP FE 3

Drug Name DrugTier

Requirements/Limits

falmina 28 day 1FEMCON FE 3GENERESS FE 3GIANVI TAB 3-0.02MG 1gildagia 1gildess 1.5/30 21 day 1gildess 24 fe 28 day 1heather 1introvale 91 day 1JOLESSA TAB 0.15-0.03 MG 1JOLIVETTE 1juleber 28 day 1junel 1.5/30 21 day 1junel 1/20 21 day 1junel fe 1.5/30 28 day 1junel fe 1/20 28 day 1junel fe 24 1/20 28 day 1kaitlib fe 28 day 1kariva 28 day 1kelnor 1/35 28 day 1kimidess 28 day 1larin 1.5/30 1larin 1/20 1larin fe 1.5/30 1larin fe 1/20 1LAYOLIS FE CHW 1LEENA TAB 1lessina 28 day 1levonest 28 day 1levonor/ethi tab 1levonorgestrel & eth estradiol 1levonorgestrel (emergencyoc)

1

levonorgestrel-ethinylestradiol (91-day)

1

levonorgestrel-ethinylestradiol (continuous)

1

levora 0.15/30 28 day 1LO LOESTRIN FE 2loestrin 1.5/30 21 day 3loestrin 1/20 21 day 3loestrin fe 1.5/30 28 day 3loestrin fe 1/20 28 day 3



Drug Name DrugTier

Requirements/Limits

lomedia 24 fe 1loryna 28 day 1LOSEASONIQUE 3low-ogestrel 1lutera 28 day 1lyza 1marlissa 28 day 1medroxyprogesterone acetate(contraceptive)

1

MICROGESTIN 1.5/30 1MICROGESTIN 1/20 1MICROGESTIN FE 1.5/30 1MICROGESTIN FE 1/20 1MINASTRIN 24 FE 2mircette 3MODICON 3mono-linyah tab 0.25-35 1MONONESSA 1myzilra 1necon 0.5/35 28 day 1necon 1/35 28 day 1NECON 7/7/7 1necon 10/11 28 day 3NECON TAB 1/50-28 1nikki 28 day 1NOR-QD 3NORA-BE TAB 1norethin acet & estrad-fe 1norethindrone & ethinylestradiol-fe

1

norethindrone (contraceptive) 1norgest/ethi tab 0.25/35 1norgestimate-ethinyl estradiol(triphasic)

1

NORINYL 1+35 3NORINYL 1+50 3norlyroc 28 day 1nortrel 0.5/35 28 day 1nortrel 1/35 21 day 1nortrel 1/35 28 day 1nortrel 7/7/7 28 day 1NUVARING 2OCELLA TAB 3-0.03MG 1

Drug Name DrugTier

Requirements/Limits

ogestrel 28 day 1orsythia 28 day 1ORTHO MICRONOR 3ORTHO TRI-CYCLEN LO 2ORTHO-CYCLEN 3ORTHO-NOVUM 1/35 3ORTHO-NOVUM 7/7/7 3ovcon 35 28 day 3philith 1pimtrea pack 1pirmella 1/35 28 day 1portia 28 day 1previfem 28 day 1QUARTETTE 3quasense 91 day 1reclipsen 28 day 1SEASONIQUE 3setlakin tab 1sharobel 28 day 1sprintec 28 day 1sronyx 28 day 1syeda 1tarina fe 1/20 28 day 1tri-legest 28 day 1tri-lo- estarylla 28 day 1tri-lo- tab marzia 1tri-lo-sprintec 28 day 1TRI-NORINYL 28 3tri-previfem 28 day 1tri-sprintec 28 day 1TRINESSA 1TRINESSA LO TAB 1trivora 28 day 1velivet 28 day 1vestura 1vienva 28 day 1viorele 1vyfemla 28 day 1wymzya fe 1xulane dis 150-35 1YASMIN 28 3YAZ 3



Drug Name DrugTier

Requirements/Limits

zarah 1zenchent fe 28 day 1zenchent tab 1zovia 1/35e 28 day 1zovia 1/50e 28 day 1ENDOMETRIOSISdanazol CAPS 1LUPANETA PACK 3 PASYNAREL 3ENZYME REPLACEMENTSADAGEN 3 LA PAALDURAZYME 3 LA PABUPHENYL POWD 3BUPHENYL TABS 3 LA PACARBAGLU 3 LA PACARNITOR 3 B/DCERDELGA 3 PACEREZYME 3 LA PACYSTADANE 3 LACYSTAGON 3 LA PAELAPRASE 3 LA PAELELYSO 3 PAFABRAZYME 3 LA PAKANUMA 3 LA PAKUVAN 3 LA PAlevocarnitine (metabolicmodifiers)

1 B/D

LUMIZYME 3 LA PAMYOZYME 3 LA PANAGLAZYME 3 LA PAORFADIN CAPS 3 LA PAPROCYSBI 3 LA PARAVICTI 3 PAsodium phenylbutyrate 3STRENSIQ 3 LA PAVIMIZIM 3 PAVPRIV 3 PAZAVESCA 3 LA PAESTROGENSALORA


CLIMARAPA if 65 years and older

3 PA

Drug Name DrugTier

Requirements/Limits

DELESTROGEN 3depo-estradiol 3estrace CREA 2estrace TABS


estradiol PTTW; PTWK;TABS


3 PA

estradiol valerate OIL 1ESTRING 3FEMRING 3fyavolv tab 1 mg-5 mcg


jinteliPA if 65 years and older

3 PA

MENOSTARPA if 65 years and older

3 PA

MINIVELLEPA if 65 years and older

3 PA

norethindrone acetate-ethinylestradiol


3 PA

PREMARIN CREAM 2PREMARIN INJ 3VAGIFEM 2VIVELLE-DOT


GLUCOCORTICOIDSa-hydrocort 1CORTEF 3cortisone acetate TABS 1DEPO-MEDROL INJ20MG/ML

3 B/D

DEPO-MEDROL INJ40MG/ML

3 B/D

DEPO-MEDROL INJ80MG/ML

3 B/D

dexamethasone CONC 3dexamethasone ELIX; SOLN;TABS

1

dexamethasone sodiumphosphate

1

dexpak 6 day 2dexpak 10 day 2dexpak taperpak 13 day 2fludrocortisone acetate TABS 1



Drug Name DrugTier

Requirements/Limits

hydrocortisone TABS 1MEDROL PAK 4MG 3MEDROL TAB 2MG 3 B/DMEDROL TAB 4MG 3 B/DMEDROL TAB 8MG 3 B/DMEDROL TAB 16MG 3 B/DMEDROL TAB 32MG 3 B/Dmethylpr ace inj 40mg/ml 1 B/Dmethylpr ace inj 80mg/ml 1 B/Dmethylpr ss inj 1gm 1 B/Dmethylpr ss inj 40mg 1 B/Dmethylpr ss inj 125mg 1 B/Dmethylpred pak 4mg 1methylpred tab 4mg 1 B/Dmethylpred tab 8mg 1 B/Dmethylpred tab 16mg 1 B/Dmethylpred tab 32mg 1 B/Dmillipred 3 B/Dmillipred dp 3ORAPRED ODT TAB 10MG 3 B/DORAPRED ODT TAB 15MG 3 B/DORAPRED ODT TAB 30MG 3 B/Dpediapred sol 6.7/5ml 3 B/Dpred sod pho sol 5mg/5ml 1 B/Dprednisolone sodiumphosphate

1 B/D

prednisolone sol 15mg/5ml 1 B/Dprednisolone sol 25mg/5ml 1 B/Dprednisolone syrup 15 mg/5ml 1 B/Dprednisone con 5mg/ml 3 B/Dprednisone pak 5mg 1prednisone pak 10mg 1prednisone sol 5mg/5ml 1 B/Dprednisone tab 1mg 1 B/Dprednisone tab 2.5mg 1 B/Dprednisone tab 5mg 1 B/Dprednisone tab 10mg 1 B/Dprednisone tab 20mg 1 B/Dprednisone tab 50mg 1 B/DRAYOS TAB 1MG 3 B/DRAYOS TAB 2MG 3 B/DRAYOS TAB 5MG 3 B/DSOLU-CORTEF 100MG 3

Drug Name DrugTier

Requirements/Limits

SOLU-CORTEF 250MG 3SOLU-CORTEF 500MG 3SOLU-CORTEF 1000MG 3SOLU-MEDROL INJ 1GM 3 B/DSOLU-MEDROL INJ 2GM 3 B/DSOLU-MEDROL INJ 40MG 3 B/DSOLU-MEDROL INJ 125MG 3 B/DSOLU-MEDROL INJ 500MG 3 B/Dveripred 3 B/DGLUCOSE ELEVATING AGENTSGLUCAGEN HYPOKIT 2GLUCAGON EMERGENCYKIT

2

KORLYM 3 LA PAPROGLYCEM SUS 50MG/ML 3HUMAN GROWTH HORMONESHUMATROPE 3 PAHUMATROPE COMBO PACK 3 PANORDITROPIN FLEXPRO 3 PASEROSTIM 3 LA PAZORBTIVE 3 PAMISCELLANEOUScabergoline 1calcitonin (salmon) nasalspray

1

CHORIONICGONADOTROPIN SOLR

1

EGRIFTA 1mg 3 LA PAEVISTA 3FORTICAL SPR 200/ACT 3H.P. ACTHAR 3 LA PAINCRELEX 3 LA PAmethylergonovine maleateTABS

1

MIACALCIN INJ 200U/ML 3 B/DMIACALCIN SPR 200/ACT 3MYALEPT 3 LA PANOVAREL INJ 10000UNT 1octreotide acetate 50mcg/ml,100mcg/ml

1 PA

octreotide acetate200mcg/ml, 500mcg/ml,1000mcg/ml

3 PA



Drug Name DrugTier

Requirements/Limits

PREGNYL W/DILUENTBENZYL

1

PROLIA 3raloxifene hcl 1SAMSCA 3 PASANDOSTATIN 3 PASANDOSTATIN LAR DEPOT 3 PASIGNIFOR 3 LA PASIGNIFOR LAR 3 LA PASOMATULINE DEPOT 3 PASOMAVERT 3 LA PAXGEVA 3 B/DPARATHYROID HORMONESFORTEO 3 PANATPARA 3 PAPHOSPHATE BINDER AGENTSAURYXIA 3calcium acetate (phosphatebinder)

1

eliphos 3FOSRENOL 3PHOSLO 3PHOSLYRA 2RENAGEL 3RENVELA PAK 2RENVELA TAB 800MG 2VELPHORO 3PROGESTINSaygestin 3CRINONE 2medroxyprogesterone acetate 1norethindrone acetate TABS 1progesterone micronizedCAPS

1

PROMETRIUM 3PROVERA 3THYROID AGENTSCYTOMEL 3levothyroxine sodium TABS 1LEVOXYL 1liothyronine sodium SOLN;TABS

1

methimazole TABS 1

Drug Name DrugTier

Requirements/Limits

propylthiouracil TABS 1SYNTHROID 3tapazole 3TIROSINT 3TRIOSTAT 3UNITHROID 1VASOPRESSINSDDAVP 3DESMOPRESSIN ACETATESOLN

1

desmopressin acetate TABS 1desmopressin acetate inj 1desmopressin acetate spray 1desmopressin acetate sprayrefrigerated

1

STIMATE 3GASTROINTESTINALANTIEMETICSAKYNZEO 3 B/DALOXI 3CESAMET 3 B/Dcompro supp 1dronabinol 2.5mg, 5mg 1 B/Ddronabinol 10mg 3 B/DEMEND CAP 40MG 3 B/DEMEND CAP 80MG 3 B/DEMEND CAP 125MG 3 B/DEMEND PAK 80 & 125 3 B/Dgranisetron hcl SOLN 1granisetron hcl TABS 1 B/DMARINOL 3 B/Dmeclizine hcl TABS 1metoclopramide hcl SOLN;TABS; TBDP

1

metoclopramide hcl inj 5mg/ml

1

metoclopramide odt 1ondansetron hcl TABS 1 B/Dondansetron hcl inj 1ondansetron hcl oral soln 1 B/Dondansetron odt 1 B/Dphenadoz




Drug Name DrugTier

Requirements/Limits

phenerganPA if 65 years and older

3 PA

phenergan injPA if 65 years and older

3 PA

prochlorperazine inj 5 mg/ml 1prochlorperazine maleateTABS

1

prochlorperazine supp 1promethazine hcl SOLN;SUPP; SYRP; TABS


3 PA

prometheganPA if 65 years and older

3 PA

REGLAN 3SANCUSO 3TRANSDERM-SCOP


VARUBI 2 B/DZOFRAN SOLN 4mg/5ml 3 B/DZOFRAN TABS 3 B/DZOFRAN ODT 3 B/DANTISPASMODICSATROPINE SULFATE SOLN.05mg/ml, .1mg/ml

1

BENTYL 3CANTIL 3CUVPOSA 3dicyclomine hcl 1glycopyrrolate SOLN; TABS 1methscopolamine bromideTABS

1

PAMINE 3PAMINE FORTE 3ROBINUL 3ROBINUL FORTE 3H2-RECEPTOR ANTAGONISTScimetidine TABS 1cimetidine sol 300/5ml 1famotidine SUSR 1famotidine TABS 20mg,40mg

1

famotidine inj 1nizatidine 1PEPCID SUSP 3pepcid tab 3

Drug Name DrugTier

Requirements/Limits

ranitidine hcl CAPS 1ranitidine hcl SOLN 1ranitidine hcl SYRP 1ranitidine hcl TABS 150mg,300mg

1

ZANTAC 3INFLAMMATORY BOWEL DISEASEAPRISO 2AZULFIDINE 3AZULFIDINE EN-TABS 3balsalazide disodium 1budesonide CPEP 3CANASA 3COLAZAL 3colocort 1CORTENEMA 3DIPENTUM 3ENTOCORT EC 3ENTYVIO 3 PAGIAZO 3HYDROCORTISONE(INTRARECTAL)

1

LIALDA 2mesalamine enema 1PENTASA 2ROWASA 3SF-ROWASA 3sulfasalazine dr 1sulfasalazine ir 1UCERIS 3UCERIS AER 2MG/ACT 3LAXATIVESCOLYTE-FLAVOR PACKS 3constulose 1enulose 1gaviltye-g 1gavilyte-c 1gavilyte-h 1gavilyte-n 1generlac 1GOLYTELY 3kristalose 3lactulose 1



Drug Name DrugTier

Requirements/Limits

lactulose (encephalopathy) 1MOVIPREP 2NULYTELY/FLAVOR PACKS 3OSMOPREP 3PEG 3350-KCL-SODBICARB-SOD CHLORIDE-SOD SULFATE

1

peg 3350-potassium chloride-sod bicarbonate-sod chloride

1

polyethylene glycol 3350PACK; POWD

1

PREPOPIK 3RELISTOR 3SUCLEAR 2SUPREP BOWEL PREP 2trilyte 1MISCELLANEOUSACTIGALL 3alosetron hcl 3AMITIZA 2amoxicillin-clarithromycin w/lansoprazole

1

CARAFATE SUSP 2CARAFATE TABS 3cromolyn sodium(mastocytosis)

3

CYTOTEC 3diphenoxylate w/ atropine 1GASTROCROM 3GATTEX 3 LA PALINZESS 2LOMOTIL 3loperamide hcl CAPS 1LOTRONEX 3misoprostol TABS 1MOVANTIK 2OMECLAMOX-PAK 3PREVPAC 3PYLERA 3SUCRAID 3 LAsucralfate TABS 1URSO 250 3URSO FORTE 3ursodiol CAPS; TABS 1

Drug Name DrugTier

Requirements/Limits

VIBERZI 3XIFAXAN TAB 550MG 3PANCREATIC ENZYMESCREON 2PANCREAZE 3PERTZYE 3ULTRESA 2VIOKACE 10 2VIOKACE 20 3ZENPEP 2PROTON PUMP INHIBITORSACIPHEX 3ACIPHEX SPR CAP 5MG 3ACIPHEX SPR CAP 10MG 3esomeprazole sodium inj 1lansoprazole CPDR 1NEXIUM I.V. 3omeprazole CPDR 1pantoprazole sodium 1PREVACID 3PRILOSEC 3PRILOSEC CAP 10MG 3PRILOSEC CAP 20MG 3PRILOSEC CAP 40MG 3PROTONIX INJ 3rabeprazole sodium 1GENITOURINARYBENIGN PROSTATIC HYPERPLASIAalfuzosin hcl 1AVODART 2CARDURA XL 3dutasteride 1dutasteride-tamsulosin hcl 1finasteride TABS 5mg 1FLOMAX 3PROSCAR 3RAPAFLO 2tamsulosin hcl 1UROXATRAL 3MISCELLANEOUSbethanechol chloride TABS 1ELMIRON 3



Drug Name DrugTier

Requirements/Limits

potassium citrate (alkalinizer)15meq

1

POTASSIUM CITRATE(ALKALINIZER) 540mg,1080mg

1

urecholine 3UROCIT-K 3URINARY ANTISPASMODICSDARIFENACINHYDROBROMIDE

1

DETROL 3DETROL LA 3DITROPAN XL 3ENABLEX 3GELNIQUE 2MYRBETRIQ 2oxybutynin chloride 1tolterodine tartrate er 1tolterodine tartrate tab 1 mg 1tolterodine tartrate tab 2 mg 1trospium chloride 1trospium chloride er 1VESICARE 2VAGINAL ANTI-INFECTIVESAVC 3CLEOCIN CREA 3CLEOCIN VAG SUPP 100MG 3clindamycin cre 2% vag 1CLINDESSE 3METROGEL-VAGINAL 3metronidazole vaginal 1miconazole 3 sup 200mg 1NUVESSA 3TERAZOL 3 3TERAZOL 7 3terconazole vaginal 1VANDAZOLE 1ZAZOLE 1HEMATOLOGICANTICOAGULANTSARIXTRA 3COUMADIN 3ELIQUIS TAB 2.5MG 2

Drug Name DrugTier

Requirements/Limits

ELIQUIS TAB 5MG 2enoxaparin sodium30mg/0.3ml, 40mg/0.4ml,60mg/0.6ml, 80mg/0.8ml,300mg/3ml

1

enoxaparin sodium100mg/ml, 120mg/0.8ml,150mg/ml

3

fondaparinux sodium2.5mg/0.5ml

1

fondaparinux sodium5mg/0.4ml, 7.5mg/0.6ml,10mg/0.8ml

3

FRAGMIN 2500unit/0.2ml,5000unit/0.2ml

2

FRAGMIN 7500unit/0.3ml,10000unit/ml,12500unit/0.5ml,15000unit/0.6ml,18000unt/0.72ml,95000unit/3.8ml

3

HEP SOD/NACL INJ 25000 1HEPARIN (PORCINE) INSODIUM CHLORIDE100U/ML

1

heparin sod inj 1000u/ml 1 B/DHEPARIN SOD INJ2000U/ML

3 B/D

HEPARIN SOD INJ2500U/ML

3 B/D

heparin sod inj 5000u/0.5ml 1 B/Dheparin sod inj 5000u/ml 1 B/Dheparin sod inj 10000u/ml 1 B/Dheparin sod inj 20000u/ml 1 B/DHEPARIN SODIUM/D5W 1HEPARIN SODIUM/NACL0.45%

3

jantoven 1LOVENOX 3PRADAXA 2SAVAYSA 3warfarin sodium 1XARELTO 2XARELTO STARTER PACK 2HEMATOPOIETIC GROWTH FACTORSARANESP ALBUMIN FREE 2 PAEPOGEN 3 PA



Drug Name DrugTier

Requirements/Limits

GRANIX 3 PALEUKINE 3 PAMIRCERA 3 PAMOZOBIL 3 PANEULASTA 3 PANEULASTA ONPRO KIT 3 PANEUMEGA 3 PANEUPOGEN 3 PANPLATE 3 PAPROCRIT 2 PAMISCELLANEOUSAGRYLIN 3anagrelide hcl 1BERINERT 3 PAcilostazol 1CINRYZE 3 LA PACYKLOKAPRON 3FIRAZYR 2 PAKALBITOR 3 PALYSTEDA 3pentoxifylline TBCR 1PLETAL 3PROMACTA 3 LA PARUCONEST 3 PASOLIRIS 3 PAtranexamic acid SOLN; TABS 1PLATELET AGGREGATION INHIBITORSAGGRENOX 3ASPIRIN-DIPYRIDAMOLE 1BRILINTA 2clopidogrel bisulfate 1DURLAZA 3EFFIENT 2ZONTIVITY 3IMMUNOLOGIC AGENTSDISEASE-MODIFYING ANTI-RHEUMATICDRUGS (DMARDS)ACTEMRA 3 PAARAVA 3CIMZIA 3 PAENBREL 3 PAENBREL SURECLICK 3 PA

Drug Name DrugTier

Requirements/Limits

HUMIRA 3 PAHUMIRA PEDIATRICCROHNS

3 PA

HUMIRA PEN 3 PAHUMIRA PEN-CROHNSSTARTER KIT

3 PA

HUMIRA PEN-PSORIASISSTARTER KIT

3 PA

hydroxychloroquine sulfate 1KINERET 3 PAleflunomide TABS 1methotrexate sodium tabs 1ORENCIA 3 PAOTEZLA 3 PAOTREXUP 3 PAPLAQUENIL 3RASUVO 3 PAREMICADE 3 PARHEUMATREX 2SIMPONI 3 PASIMPONI ARIA 3 PAtrexall 2 B/DXELJANZ 3 PAXELJANZ XR 3 PAIMMUNOGLOBULINSBIVIGAM 3 PACARIMUNE NANOFILTERED 3 PAFLEBOGAMMA 3 PAFLEBOGAMMA DIF 3 PAGAMASTAN S/D 2 B/DGAMMAGARD LIQUID 3 PAGAMMAGARD S/D 3 PAGAMMAGARD S/D IGA LESSTH

3 PA

GAMMAKED 3 PAGAMMAPLEX 2.5gm/50ml,5gm/100ml, 10gm/200ml

3 PA

GAMUNEX-C 3 PAHIZENTRA 3 PAHYQVIA 3 PAOCTAGAM 1gm/20ml,2gm/20ml, 2.5gm/50ml,5gm/100ml, 10gm/200ml,25gm/500ml

3 PA

PRIVIGEN 3 PA



Drug Name DrugTier

Requirements/Limits

IMMUNOMODULATORSACTIMMUNE 3 LA PAARCALYST 3 PAGRASTEK 2ILARIS 3 PAINTRON-A INJ 10MU 3 B/DINTRON-A INJ 18MU 3 B/DINTRON-A INJ 25MU 3 B/DINTRON-A INJ 50MU 3 B/DRAGWITEK 2REVLIMID 3 LATHALOMID 2IMMUNOSUPPRESSANTSASTAGRAF XL 3 B/DATGAM 3 B/Dazasan 2 B/Dazathioprine SOLR; TABS 1 B/DBENLYSTA 3 PACELLCEPT CAP 3 B/DCELLCEPT INTRAVENOUS 3 B/DCELLCEPT SUSP 3 B/DCELLCEPT TAB 3 B/Dcyclosporine CAPS; SOLN 1 B/Dcyclosporine modified (formicroemulsion)

1 B/D

ENVARSUS XR 3 B/Dgengraf 1 B/DIMURAN 3 B/Dmycophenolate mofetilCAPS; TABS

1 B/D

mycophenolate mofetil SUSR 3 B/Dmycophenolate sodium180mg

1 B/D

mycophenolate sodium360mg

3 B/D

MYFORTIC 3 B/DNEORAL 3 B/DNULOJIX 3 B/DPROGRAF 3 B/DRAPAMUNE 3 B/DSANDIMMUNE CAPS 3 B/DSANDIMMUNE INJ 3 B/DSANDIMMUNE SOLN 2 B/D

Drug Name DrugTier

Requirements/Limits

SIMULECT 3 B/DSIROLIMUS TABS 2mg 3 B/Dsirolimus TABS .5mg, 1mg 1 B/Dtacrolimus CAPS 5mg 3 B/Dtacrolimus CAPS .5mg, 1mg 1 B/DTHYMOGLOBULIN 3 B/DZORTRESS TAB 0.5MG 3 B/DZORTRESS TAB 0.25MG 3 B/DZORTRESS TAB 0.75MG 3 B/DVACCINESACTHIB 3ADACEL 3BCG VACCINE 3BEXSERO 3BOOSTRIX 3CERVARIX 3COMVAX 3DAPTACEL 3DIPHTHERIA/TETANUSTOXOID

3 B/D

ENGERIX-B SUSP 3 B/DGARDASIL 3GARDASIL 9 3HAVRIX 3HIBERIX 3IMOVAX RABIES (H.D.C.V.) 3INFANRIX 3IPOL INACTIVATED IPV 2IXIARO 3KINRIX 3M-M-R II 3MENACTRA 3MENOMUNE-A/C/Y/W-135 3MENVEO 3PEDIARIX 3PEDVAX HIB 3PENTACEL 3PROQUAD 3QUADRACEL 3RABAVERT 3RECOMBIVAX HB 3 B/DROTARIX 2ROTATEQ 3



Drug Name DrugTier

Requirements/Limits

SYNAGIS 3TENIVAC 3 B/DTETANUS/DIPHTHERIATOXOID

3 B/D

TRUMENBA 3TWINRIX INJ 3TYPHIM VI 3VAQTA 3VARIVAX 3YF-VAX 3ZOSTAVAX 3NUTRITIONAL/SUPPLEMENTSELECTROLYTESammonium chloride SOLN 3K-TAB 3KLOR-CON 8 1KLOR-CON 10 1klor-con m10 1klor-con m15 3klor-con m20 1klor-con pow 20meq 1klor-con spr cap 8meq 1klor-con spr cap 10meq 1MAGNESIUM SULFATESOLN 2gm/50ml, 4gm/100ml,4gm/50ml, 20gm/500ml,40gm/1000ml

3

magnesium sulfate SOLN50%

1

MAGNESIUM SULFATE IND5W

3

MAGNESIUM SULFATE INJ50%

1

MICRO-K 3POTASSIUM CHLORIDESOLN 10%, 20%

1

potassium chloride TBCR8meq

1

POTASSIUM CHLORIDETBCR 20meq

1

potassium chloride caps er 1potassium chloridemicroencapsulated crystals cr

1

POTASSIUM CHLORIDETAB CR 10 MEQ

1

Drug Name DrugTier

Requirements/Limits

SODIUM CHLORIDE SOLN2.5meq/ml

1

SODIUM FLUORIDE CHEW;TAB; 1.1 (0.5 F) MG/MLSOLN

1

TPN ELECTROLYTES 1 B/DIV NUTRITIONAMINOSYN 3 B/DAMINOSYN7%/ELECTROLYTES

3 B/D

AMINOSYN II 3 B/DAMINOSYN II8.5%/ELECTROL

1 B/D

AMINOSYN INJ 8.5/LYTE 1 B/DAMINOSYN M 3 B/DAMINOSYN-HBC 3 B/DAMINOSYN-PF 7% 3 B/DAMINOSYN-PF INJ 10% 3 B/DAMINOSYN-RF 3 B/DCLINIMIX 2.75%/DEXTROSE5%

3 B/D

CLINIMIX 4.25%/DEXTROSE5%

3 B/D


3 B/D


3 B/D


3 B/D

CLINIMIX 5%/DEXTROSE15%

3 B/D


3 B/D


3 B/D

CLINIMIX E2.75%/DEXTROSE 5%

3 B/D


3 B/D

CLINIMIX E 4.25%/D10 3 B/DCLINIMIX E4.25%/DEXTROSE 5%

3 B/D


3 B/D

CLINIMIX E 5%/DEXTROSE15%

3 B/D



Drug Name DrugTier

Requirements/Limits


3 B/D


3 B/D

clinisol 15 1 B/DFREAMINE HBC 6.9% 3 B/DFREAMINE III 3 B/DHEPATAMINE 1 B/DINTRALIPID INJ 20% 1 B/DINTRALIPID INJ 30% 3 B/DLIPOSYN II 3 B/DLIPOSYN III 3 B/DNEPHRAMINE 3 B/DNUTRILIPID INJ 20% 1 B/Dplenamine 1 B/Dpremasol 6% 1 B/Dpremasol 10% 3 B/DPROCALAMINE 3 B/DPROSOL 3 B/DTRAVASOL 3 B/DTROPHAMINE INJ 6% 3 B/DTROPHAMINE INJ 10% 3 B/DIV REPLACEMENT SOLUTIONSDEXTROSE SOLN 1DEXTROSE 2.5%/NACL0.45%

1

DEXTROSE 5% 1DEXTROSE 5%/ELECTROLYTE

3

DEXTROSE 5%/LACTATEDRING

1

DEXTROSE 5%/NACL 0.2% 1DEXTROSE 5%/NACL 0.3% 3DEXTROSE 5%/NACL 0.9% 1DEXTROSE 5%/NACL 0.33% 1DEXTROSE 5%/NACL 0.45% 1DEXTROSE 5%/NACL0.225%

1

DEXTROSE 5%/POTASSIUMCHL

1

DEXTROSE 10% FLEXCONTAIN

1

DEXTROSE 10% W/SODIUM CHLORIDE 0.2%

3

Drug Name DrugTier

Requirements/Limits

DEXTROSE 10%/NACL0.45%

1

ELECTROLYTE-R INDEXTROSE

3

IONOSOL-B/DEXTROSE 5% 3IONOSOL-MB/DEXTROSE5%

3

ISOLYTE P 3ISOLYTE S 3KCL0.15%/D5W/NACL0.2% 1KCL0.15%/D5W/NACL0.225%

3

KCL 0.3%/D5W/LR IV LAC RI 3KCL 0.3%/D5W/NACL 0.9% 3KCL 0.3%/D5W/NACL 0.45% 1KCL 0.15%/D5W/LR 3KCL 0.15%/D5W/NACL 0.9% 1KCL 0.075%/D5W/NACL0.45%

1

KCL IN NACL INJ .15-0.45 1KCL/D5W/NACL INJ0.22%/0.45%

1

KCL/D5W/NACL INJ .15/.33% 1KCL/D5W/NACL INJ .15/.45% 1KCL/NACL INJ 0.15%-0.9% 1LACTATED RINGERSVIAFLEX

1

NORMOSOL-M IN D5W 1NORMOSOL-R 3PLASMA-LYTE A 3PLASMA-LYTE-56/D5W 3PLASMA-LYTE-148 3pot chloride inj 2meq/ml 1POTASSIUM CHLORIDESOLN .4meq/ml,10meq/100ml, 10meq/50ml,20meq/100ml, 40meq/100ml

1

POTASSIUM CHLORIDE0.3%/D

1

potassium chloride in nacl 1POTASSIUM CHLORIDE INNACL

1

RINGER'S 1SODIUM CHLORIDE SOLN.9%, 3%, 5%

1



Drug Name DrugTier

Requirements/Limits

SODIUM CHLORIDE 0.45%VIA

1

VITAMINScalcitriol CAPS; SOLN 1 B/Ddoxercalciferol CAPS 1mcg,2.5mcg

3 B/D

doxercalciferol CAPS .5mcg 1 B/Ddoxercalciferol SOLN 1 B/DHECTOROL 3 B/Dparicalcitol CAPS 1 B/DPARICALCITOL SOLN 1 B/DPRENATAL VITAMIN/FOLICACID > 0.8 MG (GENERIC)

1

ROCALTROL 3 B/DZEMPLAR 3 B/DOPHTHALMICANTI-INFECTIVE/ANTI-INFLAMMATORYbacitracin-poly-neomycin-hc 1blephamide OINT 3BLEPHAMIDE SUSP 3MAXITROL 3neomycin-polymy-dexameth 1neomycin-polymyxin-hc(ophth)

1

PRED-G 3PRED-G S.O.P. 3sulfacetamide sod-prednisolone

1

TOBRADEX SUSP 3tobramycin-dexamethasone 1ZYLET 2ANTI-INFECTIVESAZASITE 3bacitracin (ophthalmic) 1bacitracin-polymyxin b (ophth) 1BESIVANCE 2BLEPH-10 3CILOXAN OIN 0.3% OP 3CILOXAN SOL 0.3% OP 3ciprofloxacin hcl (ophth) 1erythromycin (ophth) 1garamycin 3gatifloxacin (ophth) 1gentak 1

Drug Name DrugTier

Requirements/Limits

gentamicin sulfate (ophth) 1ilotycin 1levofloxacin (ophth) 1MOXEZA 2NATACYN 3neomycin-bacitracin zn-polymyxin

1

neomycin-polymyxin-gramicidin

1

neosporin solution 3OCUFLOX 3ofloxacin (ophth) 1polymyxin b-trimethoprim 1POLYTRIM 3sulfacet sod oin 10% op 1sulfacetamide sodium (ophth) 1tobramycin (ophth) 1TOBREX OINT 0.3% 3TOBREX SOL 0.3% OP 3trifluridine SOLN 1VIGAMOX 2VIROPTIC 3ZIRGAN 3ZYMAXID 3ANTI-INFLAMMATORIESACULAR 3ACULAR LS 3ALREX 2bromfenac sodium (ophth) 1BROMFENAC SODIUM(OPHTH)(ONCE-DAILY)

1

dexamethasone sodiumphosphate (ophth)

1

diclofenac sodium (ophth) 1DUREZOL 2FLAREX 3FLUOROMETHOLONE(OPHTH)

1

flurbiprofen sodium 1FML 3FML FORTE 3FML LIQUIFILM 3ILEVRO 3



Drug Name DrugTier

Requirements/Limits

ketorolac tromethamine(ophth)

1

LOTEMAX 2MAXIDEX 3OCUFEN 3OMNIPRED 3PRED FORTE 3PRED MILD 3PREDNISOLONE ACETATE(OPHTH)

1

prednisolone sodiumphosphate (ophth)

3

VEXOL 3ANTIALLERGICSALOCRIL 3ALOMIDE 3azelastine drop 0.05% 1BEPREVE 3cromolyn sodium (ophth) 1ELESTAT 3EMADINE 3epinastine hcl (ophth) 1LASTACAFT 3olopatadine hcl 1PATADAY 2PATANOL 2PAZEO 3ANTIGLAUCOMAALPHAGAN P 0.1% 2ALPHAGAN P 0.15% 3AZOPT 2BETAGAN 3betaxolol hcl (ophth) 1BETIMOL 2BETOPTIC-S 2brimonidine sol 0.2% 1BRIMONIDINE SOL 0.15% 1carteolol hcl (ophth) 1COMBIGAN 2COSOPT 3dorzolamide hcl 1dorzolamide hcl-timololmaleate

1

Drug Name DrugTier

Requirements/Limits

ISOPTO CARPINE 3ISTALOL 3latanoprost SOLN 1levobunolol hcl 1LUMIGAN 3metipranolol 1OPTIPRANOLOL 3PHOSPHOLINE IODIDE 3PILOCARPINE HCL SOLN 1SIMBRINZA SUS 1-0.2% 2timolol maleate (ophth) 1TIMOLOL MALEATE GEL 1TIMOPTIC 3TIMOPTIC OCUDOSE 3TIMOPTIC-XE 3TRAVATAN Z 2TRUSOPT 3XALATAN 3ZIOPTAN 3MISCELLANEOUSalcaine 3CYSTARAN 3 LA PAEYLEA 3LACRISERT 3LUCENTIS 3naphazoline 0.1% 1proparacaine hcl SOLN 1RESTASIS 2RESPIRATORYANTICHOLINERGIC/BETA AGONISTCOMBINATIONSANORO ELLIPT AER 62.5-25 2COMBIVENT RESPIMAT 2ipratropium-albuterol 1 B/DSTIOLTO RESPIMAT 3UTIBRON NEOHALER 3ANTICHOLINERGICSATROVENT 3ATROVENT HFA 3INCRUSE ELLIPTA 3ipratropium bromide (nasal) 1ipratropium sol inhal 1 B/D



Drug Name DrugTier

Requirements/Limits

SEEBRI NEOHALER 3SPIRIVA HANDIHALER 2SPIRIVA RESPIMAT 2TUDORZA PRESSAIR 3TUDORZA PRESSAIR(INSTITUTIONAL PACK)

3

ANTIHISTAMINE COMBINATIONSCLARINEX-D TAB 2.5-120 3SEMPREX-D 3ANTIHISTAMINESASTEPRO 3azelastine spr 0.1% 1azelastine spr 0.15% 1cetirizine syrup 1CLARINEX 3desloratadine 1diphenhydram inj 50mg/ml 1hydroxyzine hcl SOLN


levocetirizine soln 2.5mg/5ml 1levocetirizine tab 5 mg 1olopatadine hcl (nasal) 1PATANASE 3XYZAL 3BETA AGONISTSalbuterol sulfate NEBU 1 B/Dalbuterol sulfate SYRP; TABS 1albuterol sulfate er 1ARCAPTA NEOHALER 2BROVANA 3 B/DFORADIL AEROLIZER 2levalbuterol conc1.25mg/0.5ml

1 B/D

LEVALBUTEROL HCL NEBU1.25mg/3ml

1 B/D

levalbuterol hcl NEBU.31mg/3ml, .63mg/3ml

1 B/D

PERFOROMIST 2 B/DPROAIR HFA 2SEREVENT DISKUS 2STRIVERDI RESPIMAT 3terbutaline sulfate SOLN 3terbutaline sulfate TABS 1vospire 3

Drug Name DrugTier

Requirements/Limits

XOPENEX 3 B/DXOPENEX CONCENTRATE 3 B/DLEUKOTRIENE RECEPTORANTAGONISTSACCOLATE 3montelukast sodium CHEW;PACK; TABS

1

SINGULAIR 3zafirlukast 1ZYFLO CR 3MAST CELL STABILIZERScromolyn sodium NEBU 1 B/DMISCELLANEOUSacetylcysteine SOLN 10%,20%

1 B/D

ARALAST NP 3 LA PADALIRESP 2EPINEPHRINE SOAJ.3mg/0.3ml

1

epinephrine SOAJ.15mg/0.15ml

1

EPIPEN 2-PAK 2EPIPEN-JR 2-PAK 2ESBRIET 3 PAGLASSIA 3 LA PAKALYDECO 3 PANUCALA 3 LA PAOFEV 3 PAORKAMBI 3 PAPROLASTIN-C 3 LA PAPULMOZYME 3 B/Dtyzine .05% 3XOLAIR 3 LA PAZEMAIRA 3 LA PANASAL STEROIDSBECONASE AQ 3budesonide (nasal) 1flunisolide (nasal) 1fluticasone propionate (nasal) 1mometasone furoate (nasal) 1NASONEX 2OMNARIS 3QNASL 3



Drug Name DrugTier

Requirements/Limits

QNASL CHILDRENS 3RHINOCORT AQUA 3TRIAMCINOLONEACETONIDE (NASAL)

1

ZETONNA 3STEROID INHALANTSAEROSPAN 3ALVESCO 3ARNUITY ELLIPTA 3ASMANEX 2ASMANEX HFA 2budesonide (inhalation) 1 B/DFLOVENT DISKUS 2FLOVENT HFA 2PULMICORT FLEXHALER 2PULMICORT INH SUSP0.5MG/2 ML

3 B/D

PULMICORT INH SUSP0.25MG/2 ML

3 B/D

PULMICORT INH SUSP1MG/2ML

3 B/D

QVAR 2STEROID/BETA-AGONISTCOMBINATIONSADVAIR DISKUS 2ADVAIR HFA 2BREO ELLIPTA 3DULERA 2SYMBICORT 3XANTHINESaminophylline inj 1elixophyllin 3theo-24 3theophylline 1TOPICALDERMATOLOGY, ACNEABSORICA 3ACANYA 2ACZONE 3adapalene CREA; GEL 1amnesteem 1ATRALIN 2 PAAVITA 1 PA

Drug Name DrugTier

Requirements/Limits

AZELEX 3BENZACLIN 2BENZAMYCIN 3benzoyl peroxide-erythromycin

1

claravis 1CLEOCIN-T 3clindamax 1clindamycin phosphate(topical)

1

clindamycin phosphate-benzoyl peroxide

1

clindamycin phosphate-benzoyl peroxide (refrigerate)

1

DIFFERIN CREA; GEL 3DIFFERIN LOTN 2DUAC 3ery pad 2% 1erygel 3erythromycin (acne aid) 1EVOCLIN 3KLARON 3myorisan 1neuac gel 1.2-5% 1RETIN-A 3 PAsulfacetamide sodium (acne) 1tretinoin CREA 1 PATRETINOIN GEL .01% 1 PAtretinoin GEL .025%, .05% 1 PAtretinoin microsphere .1% 1 PATRETINOIN MICROSPHERE.04%

1 PA

zenatane 10mg, 20mg, 40mg 1ZENATANE 30mg 1DERMATOLOGY, ANTIBIOTICSALTABAX 3BACTROBAN CREA 3BACTROBAN OINT 2BACTROBAN NASAL 2CENTANY 3CORTISPORIN 3gentamicin sulfate (topical) 1mupirocin OINT 1mupirocin calcium (topical) 1



Drug Name DrugTier

Requirements/Limits

SILVADENE 3SILVER SULFADIAZINECREA

1

SSD 1SULFAMYLON 3DERMATOLOGY, ANTIFUNGALSciclopirox GEL 1ciclopirox cre 0.77% 1ciclopirox shampoo 1% 1ciclopirox sus 0.77% 1clotrimazole (topical) 1econazole nitrate CREA 1ERTACZO 3EXELDERM 3EXTINA 3ketoconazole (topical) 1ketodan aer 2% 1LOPROX SHAMPOO 3LUZU 2MENTAX 3NAFTIFINE HCL 1% 1naftifine hcl 2% 1NAFTIN 2nyamyc 1nystatin (topical) 1nystatin pow 100000 1nystop 1oxiconazole nitrate cream 1OXISTAT 3DERMATOLOGY, ANTIPRURITICanusol hc 3CORTIFOAM 2DOXEPIN HCL(ANTIPRURITIC)

1

procto-med 1procto-pak 1proctosol hc 2.5 % 1proctozone hc 1PRUDOXIN CRE 5% 1ZONALON 3DERMATOLOGY, ANTIPSORIATICSacitretin 3

Drug Name DrugTier

Requirements/Limits

calcipotriene CREA; OINT;SOLN

1

calcitrene oin 0.005% 1CALCITRIOL OINT 1COSENTYX 3 PACOSENTYX SENSOREADYPEN

3 PA

DOVONEX CRE 0.005% 3methoxsalen rapid 38-MOP 3OXSORALEN ULTRA 3SORIATANE 3SORILUX 2STELARA 3 PATAZORAC 2 PAVECTICAL 3DERMATOLOGY, ANTISEBORRHEICSketoconazole shampoo 1NIZORAL 3selenium sulfide LOTN 1DERMATOLOGY, CORTICOSTEROIDSaclovate 3ala-cort 1ala-scalp 3alclometasone dipropionate 1amcinonide CREA; LOTN 1amcinonide OINT 3betamethasone dipropionate(topical)

1

betamethasone dipropionateaugmented

1

betamethasone valerateCREA; FOAM; LOTN; OINT

1

calcipotriene/betamethasone 3CAPEX 2clobetasol e cream 0.05% 1clobetasol propionate CREA;FOAM; GEL; LIQD; LOTN;OINT; SOLN

1

clobetasol propionateemulsion

1

CLOBEX LIQD; LOTN 3clocortolone pivalate 1CLODERM PUMP 3CORDRAN TAPE 3



Drug Name DrugTier

Requirements/Limits

cormax 1CUTIVATE 3DERMA-SMOOTHE/FSBODY

3

DERMA-SMOOTHE/FSSCALP

3

DERMATOP 3DERMATOP CREAM 0.1% 3DESONATE 3DESONIDE CREA 1desonide LOTN; OINT 1DESOWEN CREA 3desowen LOTN 3desoximetasone CREA 1desoximetasone GEL 1DESOXIMETASONE OINT.05%

1

desoximetasone OINT .25% 1diflorasone diacetate 1DIPROLENE 3DIPROLENE AF 3ELOCON 3ENSTILAR 3fluocinolone acetonideCREA; OIL; OINT; SOLN

1

fluocinonide CREA .1% 3fluocinonide CREA .05% 1fluocinonide GEL 1fluocinonide OINT 1fluocinonide SOLN 1fluocinonide emulsified base 1flurandrenolide 1fluticasone propionate CREA;LOTN; OINT

1

halobetasol propionate 1HALOG 3hydrocortisone (topical) 1hydrocortisone butyrate 1hydrocortisone butyratehydrophilic lipo base

1

hydrocortisone valerate 1KENALOG 3LOCOID 3LOCOID LIPOCREAM 3

Drug Name DrugTier

Requirements/Limits

lokara 1mometasone furoate CREA;OINT; SOLN

1

OLUX 3PANDEL 3PREDNICARBATE CREA 1prednicarbate OINT 1psorcon 3SERNIVO 3SYNALAR 3TACLONEX 3TEMOVATE CREAM 3TEMOVATE E CREAM 3TEMOVATE GEL 3TEMOVATE OIN 3TEMOVATE SOLN 3texacort 2topicort CREA 3topicort GEL 3TOPICORT OINT .05% 3topicort OINT .25% 3TOPICORT SPRAY 0.25% 3triamcinolone acetonide(topical)

1

trianex 3triderm 1ULTRAVATE 3VANOS 3DERMATOLOGY, LOCAL ANESTHETICSEMLA 3 B/Dlidocaine OINT 1lidocaine PTCH 1 PAlidocaine hcl GEL 1lidocaine hcl SOLN 4% 1lidocaine-prilocaine 1 B/DLIDODERM 3 PASYNERA 3XYLOCAINE 4% 3DERMATOLOGY, MISCELLANEOUS SKINAND MUCOUS MEMBRANEacyclovir topical 1ALDARA 3



Drug Name DrugTier

Requirements/Limits

ammonium lactate CREA;LOTN

1

CONDYLOX GEL 2CONDYLOX SOLN 3DENAVIR 3diclofenac sodium (actinickeratoses)

3

diclofenac sodium (topical) 1diclofenac sodium (topical)1% gel

1

DOXYCYCLINE (ROSACEA) 1EFUDEX 3ELIDEL 2FINACEA AER 15% 2FINACEA GEL 15% 2fluorouracil (topical) CREA5%

1

FLUOROURACIL (TOPICAL)CREA .5%

3

fluorouracil (topical) SOLN 1imiquimod CREA 1LAC-HYDRIN 3METROCREAM 3METROGEL 3METROLOTION 3metronidazole (topical) 1ORACEA 3PANRETIN 3PENNSAID 3PICATO 3podofilox SOLN 1PROTOPIC 3RECTIV 3rosadan cre 0.75% 1SOLARAZE 3SOOLANTRA 2tacrolimus (topical) 1TARGRETIN GEL 3TOLAK 3VALCHLOR 3 LAVOLTAREN GEL 1% 2ZOVIRAX CREA; OINT 3DERMATOLOGY, SCABICIDES ANDPEDICULIDES

Drug Name DrugTier

Requirements/Limits

ELIMITE 3EURAX 3malathion 1ovide 3permethrin 1SKLICE 3DERMATOLOGY, WOUND CARE AGENTSacetic acid .25% 1neomycin/polymyxin b gu 1REGRANEX 3SANTYL 3SODIUM CHLORIDE 0.9% 1STERILE WATERIRRIGATION

1

MOUTH/THROAT/DENTAL AGENTScevimeline hcl 1chlorhexidine gluconate(mouth-throat)

1

clotrimazole TROC 1EVOXAC 3lidocaine hcl (mouth-throat) 1nystatin (mouth-throat) 1ORAVIG 3paroex sol 0.12% 1periogard soln 0.12% 1PILOCARPINE HCL (ORAL)5mg

1

pilocarpine hcl (oral) 7.5mg 1SALAGEN 3triamcinolone acetonide(mouth)

1

OTICacetasol hc 1acetic acid (otic) 1acetic acid sol/hc 1acetic acid-aluminum acetate 1CIPRO HC 3CIPRODEX 2COLY-MYCIN S 3CORTISPORIN-TC 3DERMOTIC 3fluocinolone acetonide (otic) 1neomycin-polymyxin-hc (otic) 1



Drug Name DrugTier

Requirements/Limits

ofloxacin (otic) 1


47

Index

88-MOP 43

Aa-hydrocort 29abacavir sulfate 6abacavir sulfate-lamivudine-

zidovudine 7ABELCET 6ABILIFY DISCMELT TAB

10MG 21ABILIFY MAINTENA 21ABILIFY TABS 21ABRAXANE 11ABSORICA 42ABSTRAL 2acamprosate calcium 24ACANYA 42acarbose 25ACCOLATE 41ACCUPRIL 13ACCURETIC 13acebutolol hcl 15acetaminophen w/ codeine 1acetaminophen-caff-

dihydrocod 1acetasol hc 45acetazolamide 17acetazolamide sodium 17acetic acid 45acetic acid (otic) 45acetic acid sol/hc 45acetic acid-aluminum

acetate 45acetylcysteine 41ACIPHEX 33ACIPHEX SPR CAP 10MG33ACIPHEX SPR CAP 5MG 33acitretin 43aclovate 43ACTEMRA 35ACTHIB 36ACTIGALL 33ACTIMMUNE 36ACTIQ 2ACTONEL 26ACTOPLUS MET TAB 15-

500MG 25ACTOPLUS MET TAB 15-

850MG 25ACTOPLUS MET XR 15-

1000MG 25ACTOPLUS MET XR 30-

1000MG 25ACTOS 25ACULAR 39ACULAR LS 39

acyclovir 7acyclovir sodium 7, 8acyclovir topical 44ACZONE 42ADACEL 36ADAGEN 29ADALAT CC 16adapalene 42ADCIRCA 17ADDERALL TAB 10MG 22adderall tab 12.5mg 22adderall tab 15mg 22ADDERALL TAB 20MG 22ADDERALL TAB 30MG 22adderall tab 5mg 22adderall tab 7.5mg 22ADDERALL XR CAP

10MG 22ADDERALL XR CAP




30MG 22ADDERALL XR CAP 5MG 22adefovir dipivoxil 8ADEMPAS 17adrucil 10ADVAIR DISKUS 42ADVAIR HFA 42AEROSPAN 42afeditab cr 16AFINITOR 12AFINITOR DISPERZ 12AGGRENOX 35AGRYLIN 35AKYNZEO 31ala-cort 43ala-scalp 43ALBENZA 5albuterol sulfate 41albuterol sulfate er 41alcaine 40alclometasone

dipropionate 43ALCOHOL SWABS 25ALDACTAZIDE 17ALDACTAZIDE TAB 50/50 17ALDACTONE 13ALDARA 44ALDURAZYME 29ALECENSA 12alendronate sodium 26alfuzosin hcl 33ALIMTA 10ALINIA 5ALKERAN 10allopurinol tab 1

almotriptan malate 23ALOCRIL 40ALOMIDE 40ALOPRIM 1ALORA 29alosetron hcl 33ALOXI 31ALPHAGAN P 0.1% 40ALPHAGAN P 0.15% 40alprazolam 18ALREX 39ALTABAX 42ALTACE 13altavera 27ALVESCO 42amantadine hcl 21AMARYL 25AMBIEN 23AMBISOME 6amcinonide 43AMERGE 23amethia 91 day 27amethyst 28 day 27amifostine crystalline 13amikacin sulfate 4amiloride &

hydrochlorothiazide 17amiloride hcl 17aminophylline inj 42AMINOSYN 37AMINOSYN

7%/ELECTROLYTES 37AMINOSYN II 37AMINOSYN II

8.5%/ELECTROL 37AMINOSYN INJ 8.5/LYTE 37AMINOSYN M 37AMINOSYN-HBC 37AMINOSYN-PF 7% 37AMINOSYN-PF INJ 10% 37AMINOSYN-RF 37amiodarone hcl 14amiodarone inj 50mg/ml 14AMITIZA 33amitriptyline hcl 20amlodipine besylate 16amlodipine besylate-

benazepril hcl 13amlodipine besylate-valsartan

tab 10-160 mg 14amlodipine besylate-valsartan



tab 5-320 mg 14amlodipine-valsartan-

hydrochlorothiazide 10-160-12.5mg 14

amlodipine-valsartan-hydrochlorothiazide 10-


48

160-25mg 14amlodipine-valsartan-

hydrochlorothiazide 10-320-25mg 14

amlodipine-valsartan-hydrochlorothiazide 5-160-12.5mg 14

amlodipine-valsartan-hydrochlorothiazide 5-160-25mg 14

ammonium chloride 37ammonium lactate 45amnesteem 42amoxapine 20amoxicillin 9amoxicillin & pot clavulanate 9amoxicillin-clarithromycin w/

lansoprazole 33amphetamine cap 10mg er 22amphetamine cap 15mg er 22amphetamine cap 20mg er 22amphetamine cap 25mg er 22amphetamine cap 30mg er 22amphetamine-

dextroamphetamine capsr 24hr 5 mg 22

amphetamine-dextroamphetamine tab10 mg 22

amphetamine-dextroamphetamine tab12.5 mg 23




amphetamine-dextroamphetamine tab 5mg 22

amphetamine-dextroamphetamine tab7.5 mg 22

amphotericin b 6ampicillin & sulbactam

sodium 9ampicillin cap 250mg 9ampicillin cap 500 mg 9ampicillin inj 9ampicillin sodium 9ampicillin susp 9AMPYRA 24ANAFRANIL 20anagrelide hcl 35ANAPROX DS 1anastrozole 11ANCOBON 6ANDRODERM 25

ANORO ELLIPT AER 62.5-25 40

antabuse 24ANTARA 15anusol hc 43APOKYN 21apri 28 day 27APRISO 32APTENSIO XR 23APTIOM 18APTIVUS 6ARALAST NP 41aranelle 28 27ARANESP ALBUMIN

FREE 34ARAVA 35ARCALYST 36ARCAPTA NEOHALER 41ARICEPT 20ARIMIDEX 11aripiprazole odt 21aripiprazole oral solution 1

mg/ml 21aripiprazole tabs 21ARISTADA 21ARIXTRA 34ARMODAFINIL 24armodafinil 24ARNUITY ELLIPTA 42AROMASIN 11ARRANON 10ARTHROTEC 50 1ARTHROTEC 75 1ARZERRA 11ashlyna 91 day 27ASMANEX 42ASMANEX HFA 42ASPIRIN-CAFFEINE-

DIHYDROCODEINEBITARTRATE 1

ASPIRIN-DIPYRIDAMOLE 35ASTAGRAF XL 36ASTEPRO 41ATACAND 14ATACAND HCT 14atenolol 15atenolol & chlorthalidone 15ATGAM 36ATIVAN 18atorvastatin calcium 15atovaquone 5atovaquone-proguanil hcl tab

250-100 mg 6atovaquone-proguanil hcl tab

62.5-25 mg 6ATRALIN 42ATRIPLA 7ATROPINE SULFATE 32ATROVENT 40ATROVENT HFA 40

AUBAGIO 24aubra 28 day 27AUGMENTIN 9AUGMENTIN ES-600 9AUGMENTIN XR 9AURYXIA 31AVALIDE 14AVAPRO 14AVASTIN 11AVC 34AVEED 25AVELOX 9AVELOX ABC PACK 9aviane 28 27AVITA 42AVODART 33AVONEX 24AVONEX PEN 24AVYCAZ 8AXERT 23AXIRON 25aygestin 31azacitidine 10AZACTAM 5AZACTAM/DEX INJ 1GM 5AZACTAM/DEX INJ 2GM 5azasan 36AZASITE 39azathioprine 36azelastine drop 0.05% 40azelastine spr 0.1% 41azelastine spr 0.15% 41AZELEX 42AZILECT 21AZITHROMYCIN 9azithromycin 9AZOPT 40AZOR 14aztreonam 5AZULFIDINE 32AZULFIDINE EN-TABS 32

Bbacitracin (ophthalmic) 39bacitracin-poly-neomycin-

hc 39bacitracin-polymyxin b

(ophth) 39baclofen 24BACTOCILL INJ DEX 1GM 9BACTOCILL INJ DEX 2GM 9BACTRIM 5BACTRIM DS 5BACTROBAN 42BACTROBAN NASAL 42balsalazide disodium 32balziva 28 day 27BANZEL SUS 40MG/ML 18BANZEL TAB 200MG 18BANZEL TAB 400MG 18


49

BARACLUDE 8BCG VACCINE 36BECONASE AQ 41bekyree 28 day 27BELBUCA 1BELEODAQ 11benazepril &

hydrochlorothiazide 13benazepril hcl 13BENDEKA 10BENICAR 14BENICAR HCT 14BENLYSTA 36BENTYL 32BENZACLIN 42BENZAMYCIN 42benzoyl peroxide-

erythromycin 42BENZTROPINE

MESYLATE 21benztropine mesylate 21BEPREVE 40BERINERT 35BESIVANCE 39BETAGAN 40betamethasone dipropionate

(topical) 43betamethasone dipropionate

augmented 43betamethasone valerate 43BETAPACE 14BETAPACE AF 14betaxolol hcl 15betaxolol hcl (ophth) 40bethanechol chloride 33BETHKIS 4BETIMOL 40BETOPTIC-S 40bexarotene 12BEXSERO 36BEYAZ 27BIAXIN 9bicalutamide 11BICILLIN C-R 9BICILLIN L-A 9BICNU 10BIDIL 17BILTRICIDE 5bisoprolol &

hydrochlorothiazide 15bisoprolol fumarate 15BIVIGAM 35bleomycin sulfate 10BLEPH-10 39BLEPHAMIDE 39blephamide 39blisovi 21 fe 1.5/30 28 day

pack 27blisovi 21 fe 1/20 28 day

pack 27

blisovi 24 fe 1/20 28 day 27BONIVA 26BOOSTRIX 36BOSULIF 12BOTOX INJ 100UNIT 24BOTOX INJ 200UNIT 24BREO ELLIPTA 42BREVICON-28 27briellyn 28 day 27BRILINTA 35BRIMONIDINE SOL 0.15%40brimonidine sol 0.2% 40BRINTELLIX 20BRISDELLE 24BRIVIACT INJ 18BRIVIACT SOLN

10MG/ML 18BRIVIACT TABS 18bromfenac sodium (ophth) 39BROMFENAC SODIUM

(OPHTH)(ONCE-DAILY) 39

bromocriptine mesylate 21BROVANA 41budesonide 32budesonide (inhalation) 42budesonide (nasal) 41bumetanide 17BUPHENYL 29buprenorphine hcl 24buprenorphine hcl-naloxone

hcl sl 24buproban 24bupropion hcl 20bupropion hcl (smoking

deterrent) 25buspirone hcl 18BUSULFEX 10butorphanol nasal spray 1butorphanol tartrate 1BUTRANS 1BYDUREON 25BYETTA 25BYSTOLIC 15

Ccabergoline 30CABOMETYX 12cafergot tab 1-100mg 23CALAN 16CALAN SR 16calcipotriene 43calcipotriene/betamethasone

43calcitonin (salmon) nasal

spray 30calcitrene oin 0.005% 43CALCITRIOL 43calcitriol 39calcium acetate (phosphate

binder) 31camila 28 day 27CAMPTOSAR 13CAMRESE LO TAB 27CANASA 32CANCIDAS 6candesartan cilexetil 14candesartan cilexetil-

hydrochlorothiazide 14CANTIL 32CAPASTAT SULFATE 7CAPEX 43capital

and codeine 1CAPRELSA 12captopril 13captopril &

hydrochlorothiazide 13CARAFATE 33CARBAGLU 29carbamazepine 18CARBATROL 18carbidopa 21carbidopa-levodopa 21CARBIDOPA/LEVODOPA/E

NTACAPONE 21carboplatin 13CARDIZEM 16CARDIZEM CD 16CARDIZEM LA 16CARDURA 14CARDURA XL 33CARIMUNE

NANOFILTERED 35CARNITOR 29carteolol hcl (ophth) 40cartia xt 16carvedilol 15CASODEX 11CATAPRES TAB 17CATAPRES-TTS DIS

0.1/24HR 17CATAPRES-TTS DIS

0.2/24HR 17CATAPRES-TTS DIS

0.3/24HR 17CAYSTON 5CEDAX 8cefaclor 8cefaclor er tab 500mg 8cefadroxil 8CEFAZOLIN IN DEXTROSE

2GM/100ML-4% 8cefazolin inj 8cefazolin sodium 8cefazolin/dextrose 8cefdinir 8CEFEPIME 1GM SOLN 8CEFEPIME 2GM SOLN 8CEFEPIME HCL AND

DEXTROSE 8


50

cefepime inj 1gm 8cefepime inj 2gm 8cefixime 8CEFOTAN 8cefotaxime sodium 8cefotetan disodium 8cefoxitin sodium 8CEFOXITIN SODIUM IN

DEXTROSE 8cefpodoxime proxetil 8cefprozil 8ceftazidime 8CEFTAZIDIME/DEXTROSE 8CEFTIBUTEN 8CEFTIN 8ceftriaxone sodium 8cefuroxime axetil 8cefuroxime sodium 8CELEBREX CAP 100MG 1CELEBREX CAP 200MG 1CELEBREX CAP 400MG 1CELEBREX CAP 50MG 1celecoxib 1CELEXA 20CELLCEPT CAP 36CELLCEPT

INTRAVENOUS 36CELLCEPT SUSP 36CELLCEPT TAB 36CELONTIN 18CENTANY 42cephalexin 8CERDELGA 29CEREZYME 29CERVARIX 36CESAMET 31cetirizine syrup 41cevimeline hcl 45CHANTIX 25CHANTIX CONTINUING

MONTH 25CHANTIX STARTER

PACK 25CHEMET 26chlorhexidine gluconate

(mouth-throat) 45chloroquine phosphate 6chlorothiazide tabs 17chlorpromaz inj 25mg/ml 21chlorpromazine hcl 21chlorpromazine inj 21chlorthalidone 17cholestyramine 15cholestyramine light 15choline fenofibrate 15CHORIONIC

GONADOTROPIN 30ciclopirox 43ciclopirox cre 0.77% 43ciclopirox shampoo 1% 43

ciclopirox sus 0.77% 43cidofovir 8cilostazol 35CILOXAN OIN 0.3% OP 39CILOXAN SOL 0.3% OP 39cimetidine 32cimetidine sol 300/5ml 32CIMZIA 35CINRYZE 35CIPRO HC 45CIPRO SUSP 9CIPRO TABS 9CIPRO XR 9CIPRODEX 45ciprofloxacin 9ciprofloxacin er 9ciprofloxacin hcl 9ciprofloxacin hcl (ophth) 39ciprofloxacin in d5w 9ciprofloxacn inj 400mg/40ml 9cisplatin 13citalopram hydrobromide 20cladribine 10CLAFORAN 9claforan 9CLAFORAN/D5W 9claravis 42CLARINEX 41CLARINEX-D TAB 2.5-120 41clarithromycin 9CLEOCIN 34cleocin 5CLEOCIN CAP 150MG 5CLEOCIN CAP 300MG 5CLEOCIN CAP 75MG 5CLEOCIN IN D5W 5CLEOCIN INJ 5CLEOCIN PHOSPHATE 5cleocin phosphate 5CLEOCIN VAG SUPP

100MG 34CLEOCIN-T 42CLIMARA 29clindamax 42clindamycin cre 2% vag 34clindamycin hcl 5clindamycin palmitate

hydrochloride 5clindamycin phosphate 5clindamycin phosphate

(topical) 42clindamycin phosphate in

d5w 5clindamycin phosphate-

benzoyl peroxide 42clindamycin phosphate-

benzoyl peroxide(refrigerate) 42

CLINDESSE 34CLINIMIX 2.75%/DEXTROSE

5% 37CLINIMIX 4.25%/DEXTROSE




5% 37CLINIMIX 5%/DEXTROSE



25% 37CLINIMIX E

2.75%/DEXTROSE10% 37

CLINIMIX E2.75%/DEXTROSE 5% 37

CLINIMIX E 4.25%/D10 37CLINIMIX E

4.25%/DEXTROSE25% 37

CLINIMIX E4.25%/DEXTROSE 5% 37

CLINIMIX E 5%/DEXTROSE15% 37



clinisol 15 38clobetasol e cream 0.05% 43clobetasol propionate 43clobetasol propionate

emulsion 43CLOBEX 43clocortolone pivalate 43CLODERM PUMP 43CLOLAR 10clomipramine hcl 20clonazepam 18clonidine hcl 17clopidogrel bisulfate 35clorazepate dipotassium 18clorpres 17clotrimazole 45clotrimazole (topical) 43clozapine 21CLOZAPINE ODT 21CLOZARIL 21COARTEM 6codeine

and capital 1CODEINE SULFATE 2COGENTIN 21COLAZAL 32colchicine w/ probenecid 1COLCRYS 1COLESTID 15


51

colestipol hcl 15colistimethate sodium 5colocort 32COLY-MYCIN M 5COLY-MYCIN S 45COLYTE-FLAVOR PACKS 32COMBIGAN 40COMBIVENT RESPIMAT 40COMBIVIR 7COMETRIQ 12COMPLERA 7compro supp 31COMTAN 21COMVAX 36CONCERTA 23CONDYLOX 45constulose 32COPAXONE INJ 40MG/ML24COPAXONE KIT 20MG/ML24COPEGUS 8CORDRAN 43COREG 15CORGARD 15CORLANOR 17cormax 44CORTEF 29CORTENEMA 32CORTIFOAM 43cortisone acetate 29CORTISPORIN 42CORTISPORIN-TC 45CORZIDE 15COSENTYX 43COSENTYX SENSOREADY

PEN 43COSMEGEN 10COSOPT 40COTELLIC 12COUMADIN 34COZAAR 14CREON 33CRESEMBA 6CRESTOR 15CRINONE 31CRIXIVAN 6cromolyn sodium 41cromolyn sodium

(mastocytosis) 33cromolyn sodium (ophth) 40cryselle 28 27CUBICIN 5CUTIVATE 44CUVPOSA 32cyclafem 1/35 28 day 27cyclafem 7/7/7 28 day 27CYCLESSA 27cyclobenzaprine hcl 24CYCLOPHOSPHAMIDE 10cyclophosphamide 10cycloserine 7

cyclosporine 36cyclosporine modified (for

microemulsion) 36CYKLOKAPRON 35CYMBALTA 20CYRAMZA 11cyred tab 27CYSTADANE 29CYSTAGON 29CYSTARAN 40cytarabine inj 10CYTOMEL 31CYTOTEC 33CYTOVENE 8

DD.H.E. 45 23dacarbazine 10DACOGEN 10DAKLINZA 8DALIRESP 41DALVANCE 5danazol 29DANTRIUM 24dantrolene sodium 24dapsone 5DAPTACEL 36DARAPRIM 5DARIFENACIN

HYDROBROMIDE 34DARZALEX 11daunorubicin hcl 10DAYPRO 1DAYTRANA 23DDAVP 31deblitane 28 day 27decitabine 10DELESTROGEN 29delyla 28 day 27DEMADEX 17DEMADEX TAB 20MG 17demeclocycline hcl 10DEMSER 17DENAVIR 45DEPACON 18DEPAKENE 18DEPAKOTE 18DEPAKOTE ER 18DEPAKOTE SPRINKLES 18DEPEN TITRATABS 26depo-estradiol 29DEPO-MEDROL INJ

20MG/ML 29DEPO-MEDROL INJ

40MG/ML 29DEPO-MEDROL INJ

80MG/ML 29DEPO-PROVERA

CONTRACEPTIVE 27DEPO-PROVERA INJ

400/ML 11DEPO-SUBQ PROVERA

104 27depo-testosterone 25DERMA-SMOOTHE/FS

BODY 44DERMA-SMOOTHE/FS

SCALP 44DERMATOP 44DERMATOP CREAM 0.1%44DERMOTIC 45DESCOVY 7desipramine hcl 20desloratadine 41DESMOPRESSIN

ACETATE 31desmopressin acetate 31desmopressin acetate inj 31desmopressin acetate

spray 31desmopressin acetate spray

refrigerated 31DESOGEN 27desogestrel-ethinyl estradiol

(biphasic) 27DESONATE 44DESONIDE 44desonide 44DESOWEN 44desowen 44DESOXIMETASONE 44desoximetasone 44DETROL 34DETROL LA 34dexamethasone 29dexamethasone sodium

phosphate 29dexamethasone sodium

phosphate (ophth) 39dexpak 10 day 29dexpak 6 day 29dexpak taperpak 13 day 29dexrazoxane 13DEXTROSE 38DEXTROSE 10% FLEX

CONTAIN 38DEXTROSE 10% W/

SODIUM CHLORIDE0.2% 38

DEXTROSE 10%/NACL0.45% 38

DEXTROSE 2.5%/NACL0.45% 38

DEXTROSE 5% 38DEXTROSE 5%

/ELECTROLYTE 38DEXTROSE 5%/LACTATED

RING 38DEXTROSE 5%/NACL

0.2% 38DEXTROSE 5%/NACL


52





0.9% 38DEXTROSE

5%/POTASSIUM CHL 38DIAMOX 17DIASTAT ACUDIAL 18DIASTAT PEDIATRIC 18diazepam 18, 19DIAZEPAM GEL

(ANTICONVULSANT) 19DIBENZYLINE 17diclofenac potassium 1diclofenac sodium 1diclofenac sodium (actinic

keratoses) 45diclofenac sodium (ophth) 39diclofenac sodium (topical) 45diclofenac sodium (topical)

1% gel 45diclofenac w/ misoprostol 1dicloxacillin sodium 9dicyclomine hcl 32didanosine 6DIFFERIN 42DIFICID 9diflorasone diacetate 44DIFLUCAN 6diflunisal 1digitek 16digox 16digoxin 16digoxin inj 16DIGOXIN SOL 50MCG/ML 16DIHYDROERGOTAMINE

MESYLATE 23dihydroergotamine

mesylate 23dilantin 19DILANTIN-125 19DILATRATE SR 17DILAUDID INJ 2DILAUDID TAB 2DILAUDID-5 ORAL LIQD 2DILAUDID-HP INJ

10MG/ML 2DILAUDID-HP INJ 250MG 2dilt-xr cap 16diltiazem cap 120mg/24hr 16diltiazem cap 240mg/24hr 16diltiazem cap er/12hr 16diltiazem hcl 16diltiazem hcl coated beads 16diltiazem hcl er 16diltiazem hcl extended

release beads 16diltiazem inj 100mg 16diltiazem inj 125/25ml 16diltiazem inj 25mg/5ml 16diltiazem inj 50/10ml 16DIOVAN 14DIPENTUM 32diphenhydram inj 50mg/ml 41diphenoxylate w/ atropine 33DIPHTHERIA/TETANUS

TOXOID 36DIPROLENE 44DIPROLENE AF 44disopyramide phosphate 14disulfiram 25DITROPAN XL 34DIURIL SUS 250/5ML 17divalproex sodium 19DOCETAXEL 11docetaxel 11dofetilide 14DOLOPHINE 2donepezil odt 10mg 20donepezil odt 5mg 20donepezil tab hcl 23mg 20donepezil tabs 10mg 20donepezil tabs 5mg 20DORIBAX 5dorzolamide hcl 40dorzolamide hcl-timolol

maleate 40DOVONEX CRE 0.005% 43doxazosin mesylate 14doxepin hcl 20DOXEPIN HCL

(ANTIPRURITIC) 43doxercalciferol 39DOXIL 10doxorubicin hcl 10doxorubicin hcl liposomal inj

(for iv infusion) 2 mg/ml 10doxorubicin inj 50mg 10doxy 10doxycycline (monohydrate) 10DOXYCYCLINE

(ROSACEA) 45doxycycline hyclate 10dronabinol 31drospirenone-ethinyl

estradiol 27DROXIA 12DUAC 42DUETACT 25DULERA 42duloxetine hcl 20DUOPA 21DURAGESIC 2DURAMORPH 2DUREZOL 39DURLAZA 35

dutasteride 33dutasteride-tamsulosin hcl 33DUTOPROL 15DYAZIDE 17DYRENIUM 17DYSPORT 24

Ee.e.s. 400 tab 400mg 9E.E.S. GRANULES 9EC-NAPROSYN 1econazole nitrate 43EDARBI 14EDARBYCLOR 14EDECRIN 17EDURANT 6EFFEXOR XR 20EFFIENT 35EFUDEX 45EGRIFTA 30ELAPRASE 29ELDEPRYL 21ELECTROLYTE-R IN

DEXTROSE 38ELELYSO 29ELESTAT 40ELIDEL 45ELIGARD INJ 22.5MG 11ELIGARD INJ 30MG 11ELIGARD INJ 45MG 11ELIGARD INJ 7.5MG 11ELIMITE 45eliphos 31ELIQUIS TAB 2.5MG 34ELIQUIS TAB 5MG 34ELITEK 13elixophyllin 42ELLA 27ELLENCE 10ELMIRON 33ELOCON 44ELOXATIN 13EMADINE 40EMBEDA 2EMCYT 10EMEND CAP 125MG 31EMEND CAP 40MG 31EMEND CAP 80MG 31EMEND PAK 80 & 125 31EMLA 44emoquette 27EMPLICITI 11EMSAM 20EMTRIVA 6ENABLEX 34enalapril maleate 13enalapril maleate &

hydrochlorothiazide 13ENBREL 35ENBREL SURECLICK 35


53

endocet 2ENGERIX-B 36enoxaparin sodium 34enpresse 28 day 27ENSTILAR 44ENTACAPONE 21entecavir 8ENTOCORT EC 32ENTRESTO 14ENTYVIO 32enulose 32ENVARSUS XR 36epinastine hcl (ophth) 40EPINEPHRINE 41epinephrine 41EPIPEN 2-PAK 41EPIPEN-JR 2-PAK 41epirubicin inj 200mg 10epirubicin inj 50mg/25ml 10epitol 19EPIVIR HBV 8EPIVIR SOL 10MG/ML 6EPIVIR TABS 6eplerenone 13EPOGEN 34epoprostenol sodium 17eprosartan mesylate 14EPZICOM 7EQUETRO 24ERAXIS 6ERBITUX 11ergomar 23ERIVEDGE 11errin 28 day 27ERTACZO 43ERWINAZE 12ery pad 2% 42ery-tab 9erygel 42ERYPED 200 9ERYPED 400 9erythrocin lactobionate 9erythrocin stearate 9erythromycin (acne aid) 42erythromycin (ophth) 39erythromycin base 9erythromycin cap 250mg ec 9erythromycin ethylsuccinate 9ESBRIET 41escitalopram oxalate 20esomeprazole sodium inj 33estarylla tab 0.25-35 27estrace 29estradiol 29estradiol valerate 29ESTRING 29ESTROSTEP FE 27ethambutol hcl 7ethosuximide 19etodolac 1

etodolac er 1ETOPOPHOS 13etoposide 13EURAX 45EVISTA 30EVOCLIN 42EVOTAZ 7EVOXAC 45EXALGO 2EXELDERM 43EXELON CAPS 20EXELON PATCHES 20exemestane 11EXJADE 26EXTAVIA 24EXTINA 43EYLEA 40

FFABRAZYME 29falmina 28 day 27famciclovir 8famotidine 32famotidine inj 32FAMVIR 8FANAPT 21FANAPT TITRATION

PACK 21FARESTON 11FARXIGA 25FARYDAK 11FASLODEX 11FAZACLO 21felbamate 19FELBATOL 19FELDENE 1felodipine 16FEMARA 11FEMCON FE 27FEMRING 29FENOFIBRATE 15fenofibrate 15fenofibrate micronized 15FENOFIBRIC ACID 15FENOGLIDE 15FENOPROFEN CALCIUM 1fenoprofen calcium 1fentanyl citrate 2fentanyl patch 100 mcg/hr 2fentanyl patch 12 mcg/hr 2fentanyl patch 25 mcg/hr 2fentanyl patch 50 mcg/hr 2fentanyl patch 75 mcg/hr 2FENTORA 2FERRIPROX 26FETZIMA 20FETZIMA TITRATION

PACK 20FIBRICOR 15FINACEA AER 15% 45

FINACEA GEL 15% 45finasteride 33FIRAZYR 35FIRMAGON 11FLAGYL 5FLAREX 39FLEBOGAMMA 35FLEBOGAMMA DIF 35flecainide acetate 14FLOLAN 18FLOMAX 33FLOVENT DISKUS 42FLOVENT HFA 42fluconazole 6fluconazole in dextrose 6fluconazole in nacl 6flucytosine 6fludarabine phosphate 10fludrocortisone acetate 29FLUMADINE 8flunisolide (nasal) 41fluocinolone acetonide 44fluocinolone acetonide

(otic) 45fluocinonide 44fluocinonide emulsified

base 44FLUOROMETHOLONE

(OPHTH) 39fluorouracil 10FLUOROURACIL

(TOPICAL) 45fluorouracil (topical) 45FLUOXETINE HCL 20fluoxetine hcl 20fluphenazine decanoate 21fluphenazine hcl 21flurandrenolide 44flurbiprofen 1flurbiprofen sodium 39flutamide 11fluticasone propionate 44fluticasone propionate

(nasal) 41fluvastatin sodium 15fluvastatin sodium tab sr 24

hr 80 mg 15fluvoxamine maleate 18fluvoxamine maleate er 18FML 39FML FORTE 39FML LIQUIFILM 39FOLOTYN 11fondaparinux sodium 34FORADIL AEROLIZER 41FORFIVO XL 20FORTAZ 9FORTEO 31FORTICAL SPR 200/ACT 30FOSAMAX 26


54

fosinopril sodium 13fosinopril sodium &

hydrochlorothiazide 13FOSRENOL 31FRAGMIN 34FREAMINE HBC 6.9% 38FREAMINE III 38FROVA TAB 2.5MG 23frovatriptan succinate 23FURADANTIN 5furosemide 17FUROSEMIDE INJ 17furosemide inj 17furosemide oral soln 8

mg/ml 17FUSILEV 13FUZEON 6fyavolv tab 1 mg-5 mcg 29FYCOMPA 19

Ggabapentin 19GABITRIL 19galantamine hydrobromide 20GAMASTAN S/D 35GAMMAGARD LIQUID 35GAMMAGARD S/D 35GAMMAGARD S/D IGA

LESS TH 35GAMMAKED 35GAMMAPLEX 35GAMUNEX-C 35ganciclovir inj 500mg 8garamycin 39GARDASIL 36GARDASIL 9 36GASTROCROM 33gatifloxacin (ophth) 39GATTEX 33GAUZE PADS 2X2 25gaviltye-g 32gavilyte-c 32gavilyte-h 32gavilyte-n 32GAZYVA 11GELNIQUE 34GEMCITABINE HCL 11gemcitabine hcl 11gemfibrozil 15GEMZAR 11GENERESS FE 27generlac 32gengraf 36gentak 39gentamicin in saline 0.8

mg/ml 4gentamicin in saline

0.9mg/ml 4gentamicin in saline 1 mg/ml4gentamicin in saline 1.2

mg/ml 4gentamicin in saline

1.4mg/ml 4gentamicin in saline 1.6

mg/ml 4gentamicin in saline 2 mg/ml5gentamicin sulfate 5gentamicin sulfate (ophth) 39gentamicin sulfate (topical) 42GENVOYA 7GEODON 21GEODON INJ 22GIANVI TAB 3-0.02MG 27GIAZO 32gildagia 27gildess 1.5/30 21 day 27gildess 24 fe 28 day 27GILENYA CAP 0.5MG 24GILOTRIF TAB 20MG 12GILOTRIF TAB 30MG 12GILOTRIF TAB 40MG 12GLASSIA 41glatopa 24GLEEVEC 12GLEOSTINE 10glimepiride 25glipizide 25glipizide er 25GLIPIZIDE XL TB24

2.5MG 25GLIPIZIDE XL TB24 5MG 25glipizide-metformin 2.5-250

mg 25glipizide-metformin 2.5-500

mg 25glipizide-metformin 5-

500mg 25GLUCAGEN HYPOKIT 30GLUCAGON EMERGENCY

KIT 30GLUCOPHAGE 25GLUCOPHAGE XR 26GLUCOTROL 26GLUCOTROL XL 26glycopyrrolate 32GLYSET 26GLYXAMBI 26GOLYTELY 32GRALISE 24GRALISE STARTER 24granisetron hcl 31GRANIX 35GRASTEK 36GRIS-PEG 6griseofulvin microsize 6griseofulvin ultramicrosize 6guanfacine hcl (adhd) 23

HH.P. ACTHAR 30

HALAVEN 12HALDOL 22HALDOL DECANOATE

100 22HALDOL DECANOATE 50 22halobetasol propionate 44HALOG 44haloperidol 22haloperidol decanoate 22haloperidol lactate 22haloperidol lactate inj 5

mg/ml 22HARVONI 8HAVRIX 36heather 27HECTOROL 39HEP SOD/NACL INJ

25000 34HEPARIN (PORCINE) IN

SODIUM CHLORIDE100U/ML 34

heparin sod inj 10000u/ml 34heparin sod inj 1000u/ml 34heparin sod inj 20000u/ml 34HEPARIN SOD INJ

2000U/ML 34HEPARIN SOD INJ

2500U/ML 34heparin sod inj

5000u/0.5ml 34heparin sod inj 5000u/ml 34HEPARIN SODIUM/D5W 34HEPARIN SODIUM/NACL

0.45% 34HEPATAMINE 38HEPSERA 8HERCEPTIN 11HETLIOZ 23HEXALEN 10HIBERIX 36HIPREX 5HIZENTRA 35HORIZANT 24HUMATROPE 30HUMATROPE COMBO

PACK 30HUMIRA 35HUMIRA PEDIATRIC

CROHNS 35HUMIRA PEN 35HUMIRA PEN-CROHNS

STARTER KIT 35HUMIRA PEN-PSORIASIS

STARTER KIT 35HUMULIN R U-500

(CONCENTRATE) 25HUMULIN R U-500

KWIKPEN 25HYCAMTIN 13hycet 2hydralazine hcl 17


55

HYDREA 12hydrochlorothiazide 17hydrocodone-acetaminophen

10-300mg 2hydrocodone-acetaminophen

2.5-325mg 2hydrocodone-acetaminophen




7.5-325 mg/15ml 2hydrocodone-acetaminophen


tab 10-325mg 2hydrocodone-ibuprofen tab

10-200mg 3hydrocodone-ibuprofen tab

2.5-200mg 2hydrocodone-ibuprofen tab 5-

200mg 2hydrocodone-ibuprofen tab

7.5-200 mg 3hydrocortisone 30HYDROCORTISONE

(INTRARECTAL) 32hydrocortisone (topical) 44hydrocortisone butyrate 44hydrocortisone butyrate

hydrophilic lipo base 44hydrocortisone valerate 44HYDROMORPHONE HCL 3hydromorphone hcl 3hydromorphone tab 12mg er3hydromorphone tab 16mg er3hydromorphone tab 8mg er 3HYDROMORPHONE TABS

32MG 3hydroxychloroquine sulfate 35hydroxyurea 12hydroxyzine hcl 41HYQVIA 35HYSINGLA ER 3HYZAAR 14

Iibandronate sodium 26ibandronate tab 150mg 26IBRANCE 11ibudone tab 10-200mg 3ibudone tab 5-200mg 3ibuprofen 1ICLUSIG 12IDAMYCIN PFS 10idarubicin hcl 10IFEX INJ 1GM 10IFEX INJ 3GM 10ifosfamide inj 10

ifosfamide inj 1gm 10IFOSFAMIDE INJ 3GM 10ILARIS 36ILEVRO 39ilotycin 39imatinib mesylate 12IMBRUVICA CAP 140MG 12imipenem-cilastatin 5imipramine hcl 20imipramine pamoate 20imiquimod 45IMITREX 23IMITREX STATDOSE

REFILL 23IMITREX STATDOSE

SYSTEM 23IMOVAX RABIES

(H.D.C.V.) 36IMURAN 36INCRELEX 30INCRUSE ELLIPTA 40indapamide 17INDERAL LA 15INFANRIX 36INFUMORPH 200 3INFUMORPH 500 3INLYTA 12INSPRA 13INSULIN PEN NEEDLES 25INSULIN SAFETY

NEEDLES 25INSULIN SYRINGES 25INTELENCE 6INTRALIPID INJ 20% 38INTRALIPID INJ 30% 38INTRON-A INJ 10MU 36INTRON-A INJ 18MU 36INTRON-A INJ 25MU 36INTRON-A INJ 50MU 36introvale 91 day 27INTUNIV 23INVANZ 5INVEGA 22INVEGA SUST INJ 117

MG/0.75 ML 22INVEGA SUST INJ

156MG/ML 22INVEGA SUST INJ 234

MG/1.5 ML 22INVEGA SUST INJ 39

MG/0.25 ML 22INVEGA SUST INJ 78

MG/0.5 ML 22INVEGA TRINZA 22INVIRASE 6INVOKAMET TAB 150-

1000 26INVOKAMET TAB 150-50026INVOKAMET TAB 50-100026INVOKAMET TAB 50-

500MG 26

INVOKANA TAB 100MG 26INVOKANA TAB 300MG 26IONOSOL-B/DEXTROSE

5% 38IONOSOL-MB/DEXTROSE

5% 38IPOL INACTIVATED IPV 36ipratropium bromide

(nasal) 40ipratropium sol inhal 40ipratropium-albuterol 40irbesartan 14irbesartan-

hydrochlorothiazide 14IRESSA 12irinotecan inj 100/5ml 13irinotecan inj 40mg/2ml 13irinotecan inj 500mg/25ml 13ISENTRESS 7ISOLYTE P 38ISOLYTE S 38isoniazid 7isoniazid tabs 7ISOPTO CARPINE 40ISORDIL TITRADOSE 17isosorbide dinitrate 17isosorbide dinitrate er 17isosorbide mononitrate 17isosorbide mononitrate er 17isradipine 16ISTALOL 40ISTODAX 11itraconazole 6ivermectin 5IXEMPRA KIT 12IXIARO 36

JJADENU 26JAKAFI 12jantoven 34JANUMET 26JANUMET XR TAB 100-

1000 26JANUMET XR TAB 50-

1000 26JANUMET XR TAB 50-

500MG 26JANUVIA 26JARDIANCE 26JENTADUETO 26JEVTANA 11jinteli 29JOLESSA TAB 0.15-0.03

MG 27JOLIVETTE 27juleber 28 day 27junel 1.5/30 21 day 27junel 1/20 21 day 27junel fe 1.5/30 28 day 27


56

junel fe 1/20 28 day 27junel fe 24 1/20 28 day 27JUXTAPID 15

KK-TAB 37KADCYLA 11KADIAN 3kaitlib fe 28 day 27KALBITOR 35KALETRA SOL 7KALETRA TAB 100-25MG 7KALETRA TAB 200-50MG 7KALYDECO 41KANUMA 29kariva 28 day 27KAYEXALATE 26KAZANO 26KCL 0.075%/D5W/NACL

0.45% 38KCL 0.15%/D5W/LR 38KCL 0.15%/D5W/NACL

0.9% 38KCL 0.3%/D5W/LR IV LAC

RI 38KCL 0.3%/D5W/NACL

0.45% 38KCL 0.3%/D5W/NACL

0.9% 38KCL IN NACL INJ .15-0.45 38KCL/D5W/NACL INJ

.15/.33% 38KCL/D5W/NACL INJ

.15/.45% 38KCL/D5W/NACL INJ

0.22%/0.45% 38KCL/NACL INJ 0.15%-

0.9% 38KCL0.15%/D5W/NACL0.2% 3

8KCL0.15%/D5W/NACL0.225

% 38kelnor 1/35 28 day 27KENALOG 44KEPIVANCE 13KEPPRA 19KEPPRA XR 19ketoconazole 6ketoconazole (topical) 43ketoconazole shampoo 43ketodan aer 2% 43ketoprofen 1ketorolac tromethamine

(ophth) 40KEVEYIS 17KEYTRUDA 11kimidess 28 day 27KINERET 35KINRIX 36kionex 26

KITABIS PAK 5KLARON 42KLONOPIN 19KLOR-CON 10 37KLOR-CON 8 37klor-con m10 37klor-con m15 37klor-con m20 37klor-con pow 20meq 37klor-con spr cap 10meq 37klor-con spr cap 8meq 37KOMBIGLYZE XR 2.5-

1000MG 26KOMBIGLYZE XR 5-

1000MG 26KOMBIGLYZE XR 5-

500MG 26KORLYM 30kristalose 32KUVAN 29KYNAMRO 15

Llabetalol hcl 15LAC-HYDRIN 45LACRISERT 40LACTATED RINGERS

VIAFLEX 38lactulose 32lactulose (encephalopathy) 33LAMICTAL 19LAMICTAL CHEWABLE

DISPERS 19LAMICTAL ODT 19LAMICTAL STARTER 19LAMICTAL XR 19LAMISIL 6lamivudine 7lamivudine (hbv) 8lamivudine-zidovudine 7lamotrigine 19LANOXIN 16LANOXIN INJ 0.25MG/ML 16LANOXIN PEDIATRIC 16LANOXIN TAB 16lansoprazole 33LANTUS 25LANTUS SOLOSTAR 25larin 1.5/30 27larin 1/20 27larin fe 1.5/30 27larin fe 1/20 27LASIX 17LASTACAFT 40latanoprost 40LATUDA 22LAYOLIS FE CHW 27LAZANDA 3LEENA TAB 27leflunomide 35

LEMTRADA 24LENVIMA 10MG DAILY

DOSE 12LENVIMA 14MG DAILY





DOSE 12LESCOL 15lessina 28 day 27LETAIRIS 18letrozole 11leucovorin calcium 13leucovorin calcium inj

100mg 13leucovorin calcium inj




50mg 13LEUKERAN 10LEUKINE 35leuprolide acetate 11levalbuterol conc

1.25mg/0.5ml 41LEVALBUTEROL HCL 41levalbuterol hcl 41LEVAQUIN 9LEVEMIR 25LEVEMIR FLEXTOUCH 25levetiracetam 19LEVETIRACETAM IV 19levetiracetam oral soln 100

mg/ml 19levobunolol hcl 40levocarnitine (metabolic

modifiers) 29levocetirizine soln

2.5mg/5ml 41levocetirizine tab 5 mg 41levofloxacin 9levofloxacin (ophth) 39levofloxacin in d5w 9levoleucovorin calcium 13levonest 28 day 27levonor/ethi tab 27levonorgestrel & eth

estradiol 27levonorgestrel (emergency

oc) 27levonorgestrel-ethinyl

estradiol (91-day) 27levonorgestrel-ethinyl


57

estradiol (continuous) 27levora 0.15/30 28 day 27levorphanol tartrate 3levothyroxine sodium 31LEVOXYL 31LEXAPRO 20LEXIVA 7LIALDA 32lidocaine 44lidocaine hcl 44lidocaine hcl (local anesth.) 4lidocaine hcl (mouth-throat)45lidocaine inj 0.5% 4lidocaine inj 1% 4lidocaine inj 1.5% 4lidocaine inj 2% 4lidocaine-prilocaine 44LIDODERM 44LINEZOLID 5linezolid 5LINEZOLID IN SODIUM

CHLORIDE 5LINZESS 33liothyronine sodium 31LIPOFEN 15LIPOSYN II 38LIPOSYN III 38lisinopril 13lisinopril &

hydrochlorothiazide 13lithium carbonate 24LITHIUM SOLN

8MEQ/5ML 24LITHOBID 24LIVALO 15LO LOESTRIN FE 27LOCOID 44LOCOID LIPOCREAM 44LODOSYN 21loestrin 1.5/30 21 day 27loestrin 1/20 21 day 27loestrin fe 1.5/30 28 day 27loestrin fe 1/20 28 day 27lofibra 15lokara 44lomedia 24 fe 28LOMOTIL 33LONSURF 12loperamide hcl 33LOPID 15LOPRESSOR 15LOPRESSOR HCT 15LOPROX SHAMPOO 43lorazepam 18lorcet hd tab 10-325mg 3lorcet plus tab 7.5-325 3lorcet tab 5-325mg 3lortab tab 10-325mg 3lortab tab 5-325mg 3lortab tab 7.5-325 3

loryna 28 day 28losartan potassium 14losartan-

hydrochlorothiazide 14LOSEASONIQUE 28LOTEMAX 40LOTENSIN 13LOTREL 13LOTRONEX 33lovastatin 15LOVAZA CAP 1GM 15LOVENOX 34low-ogestrel 28loxapine succinate 22LUCENTIS 40LUMIGAN 40LUMIZYME 29LUPANETA PACK 29LUPRON DEP INJ

11.25MG 11LUPRON DEP-PED INJ

11.25MG 12LUPRON DEP-PED INJ

15MG 12LUPRON DEP-PED INJ

30MG (3-MONTH) 12LUPRON DEP-PED INJ

7.5MG 11LUPRON DEPOT 12LUPRON DEPOT INJ

22.5MG (3-MONTH) 12LUPRON DEPOT INJ 30MG

(3-MONTH) 12lutera 28 day 28LUZU 43LYNPARZA 11LYRICA 19LYSODREN 12LYSTEDA 35lyza 28

MM-M-R II 36MACROBID 5MACRODANTIN 5MAGNESIUM SULFATE 37magnesium sulfate 37MAGNESIUM SULFATE IN

D5W 37MAGNESIUM SULFATE INJ

50% 37MALARONE 6malathion 45maprotiline hcl 20MARINOL 31marlissa 28 day 28MARPLAN 20MATULANE 12matzim la 16MAVIK 13

MAXALT 23MAXALT-MLT 23MAXIDEX 40MAXIPIME 9MAXITROL 39MAXZIDE 17MAXZIDE-25 17meclizine hcl 31MEDROL PAK 4MG 30MEDROL TAB 16MG 30MEDROL TAB 2MG 30MEDROL TAB 32MG 30MEDROL TAB 4MG 30MEDROL TAB 8MG 30medroxyprogesterone

acetate 31medroxyprogesterone

acetate (contraceptive) 28mefenamic acid 1mefloquine hcl 6MEGACE ES 12MEGACE ORAL 12megestrol acetate 12MEGESTROL SUS

625MG/5ML 12MEKINIST 12MELOXICAM 1meloxicam tabs 1melphalan hcl 10memantine hcl 20MENACTRA 36MENOMUNE-A/C/Y/W-13536MENOSTAR 29MENTAX 43MENVEO 36MEPRON 5mercaptopurine 11meropenem 5MEROPENEM/SODIUM

CHLORIDE 5MERREM 5mesalamine enema 32mesna 13MESNEX 13MESTINON 24MESTINON SYRUP 24MESTINON TIMESPAN 24METADATE CD 23metadate er tab 20mg 23metformin er 26metformin hcl 26methadone hcl 3METHADONE INJ

10MG/ML 3METHADOSE 3methazolamide 17methenamine hippurate 5methimazole 31METHOTREXATE

SODIUM 11


58

methotrexate sodium 11methotrexate sodium inj 11methotrexate sodium tabs 35methoxsalen rapid 43methscopolamine bromide 32methyclothiazide 17methylergonovine maleate 30METHYLIN 23METHYLIN CHEW TAB 23METHYLPHENIDATE HCL23methylphenidate hcl 23methylphenidate hcl er 23methylpr ace inj 40mg/ml 30methylpr ace inj 80mg/ml 30methylpr ss inj 125mg 30methylpr ss inj 1gm 30methylpr ss inj 40mg 30methylpred pak 4mg 30methylpred tab 16mg 30methylpred tab 32mg 30methylpred tab 4mg 30methylpred tab 8mg 30metipranolol 40metoclopramide hcl 31metoclopramide hcl inj 5

mg/ml 31metoclopramide odt 31metolazone 17metoprolol & hctz tab 100-

25mg 15metoprolol & hctz tab 100-

50mg 15metoprolol & hctz tab 50-

25mg 15metoprolol succinate 15metoprolol tartrate 15, 16METRO IV 5METROCREAM 45METROGEL 45METROGEL-VAGINAL 34METROLOTION 45metronidazole 5metronidazole (topical) 45metronidazole inj 5metronidazole vaginal 34mexiletine hcl 14MIACALCIN INJ 200U/ML 30MIACALCIN SPR 200/ACT 30MICARDIS 14MICARDIS HCT 14miconazole 3 sup 200mg 34MICRO-K 37MICROGESTIN 1.5/30 28MICROGESTIN 1/20 28MICROGESTIN FE 1.5/30 28MICROGESTIN FE 1/20 28MICROZIDE 17midodrine hcl 17migergot 23miglitol 26

MIGRANAL 23millipred 30millipred dp 30MINASTRIN 24 FE 28MINIPRESS 14minitran 17MINIVELLE 29MINOCIN 10minocycline hcl 10minoxidil 17MIRAPEX 21MIRAPEX ER 21MIRCERA 35mircette 28mirtazapine 20misoprostol 33mitomycin 10mitoxantrone hcl 12MOBIC 1modafinil 24MODERIBA PAK 8moderiba pak 8moderiba tab 200mg 8MODICON 28moexipril hcl 13moexipril-

hydrochlorothiazide 13molindone hcl 22mometasone furoate 44mometasone furoate

(nasal) 41mono-linyah tab 0.25-35 28MONONESSA 28montelukast sodium 41MORPHINE SUL 20MG/ML

ORAL SOL 3MORPHINE SULFATE 3morphine sulfate 3morphine sulfate beads 3morphine sulfate ext-rel tab 3MOVANTIK 33MOVIPREP 33MOXATAG 9MOXEZA 39MOXIFLOXACIN HCL 9moxifloxacin hcl 9MOZOBIL 35MS CONTIN 3MULTAQ 14mupirocin 42mupirocin calcium (topical) 42MUSTARGEN 10MYALEPT 30MYAMBUTOL 7MYCAMINE 6MYCOBUTIN 7mycophenolate mofetil 36mycophenolate sodium 36MYFORTIC 36myorisan 42

MYOZYME 29MYRBETRIQ 34MYSOLINE 19myzilra 28

Nnabumetone 1nadolol 16nadolol &

bendroflumethiazide 15NAFCILLIN 9nafcillin sodium 9NAFTIFINE HCL 43naftifine hcl 43NAFTIN 43NAGLAZYME 29nalbuphine hcl 1NALFON 1NALLPEN ISO-OSMOTIC IN

DE 9naloxone hcl 25naltrexone hcl 25NAMENDA SOL

10MG/5ML 20NAMENDA TAB 20NAMENDA XR 20NAMENDA XR TITRATION

PACK 20NAMZARIC 20naphazoline 0.1% 40NAPRELAN 1NAPROSYN TABS 1naproxen 1NAPROXEN SODIUM 1naproxen sodium 1naratriptan hcl 23NARDIL 20NASONEX 41NATACYN 39nateglinide 26NATPARA 31NEBUPENT 5necon 0.5/35 28 day 28necon 1/35 28 day 28necon 10/11 28 day 28NECON 7/7/7 28NECON TAB 1/50-28 28nefazodone hcl 20neomycin sulfate 5neomycin-bacitracin zn-

polymyxin 39neomycin-polymy-

dexameth 39neomycin-polymyxin-

gramicidin 39neomycin-polymyxin-hc

(ophth) 39neomycin-polymyxin-hc

(otic) 45neomycin/polymyxin b gu 45


59

NEORAL 36neosporin solution 39NEPHRAMINE 38NEPTAZANE 17NESINA 26neuac gel 1.2-5% 42NEULASTA 35NEULASTA ONPRO KIT 35NEUMEGA 35NEUPOGEN 35NEUPRO 21NEURONTIN 19NEVIRAPINE 7nevirapine 7NEXAVAR 12NEXIUM I.V. 33niacin er

(antihyperlipidemic) 15niacor 15NIASPAN 15nicardipine hcl 16NICOTROL INHALER 25NICOTROL NS 25nifedical 16nifedipine 16nifedipine er 16nikki 28 day 28NILANDRON 12nimodipine 16NINLARO 11NIPENT 11nisoldipine 16nitro-bid 17NITRO-DUR 17nitrofurantoin 5nitrofurantoin macrocrystal 5nitrofurantoin monohyd

macro 5, 6nitroglycerin 17NITROGLYCERIN

LINGUAL 17nitroglycerin patches 17NITROLINGUAL SPR

PUMPSPRA 17NITROMIST 17NITROSTAT 17nizatidine 32NIZORAL 43NOR-QD 28NORA-BE TAB 28norco 3NORDITROPIN FLEXPRO 30norethin acet & estrad-fe 28norethindrone & ethinyl

estradiol-fe 28norethindrone

(contraceptive) 28norethindrone acetate 31norethindrone acetate-ethinyl

estradiol 29

norgest/ethi tab 0.25/35 28norgestimate-ethinyl estradiol

(triphasic) 28NORINYL 1+35 28NORINYL 1+50 28norlyroc 28 day 28NORMOSOL-M IN D5W 38NORMOSOL-R 38NORPACE 14NORPACE CR 14NORPRAMIN 20nortrel 0.5/35 28 day 28nortrel 1/35 21 day 28nortrel 1/35 28 day 28nortrel 7/7/7 28 day 28nortriptyline hcl 20NORVASC 16NORVIR 7NOVAREL INJ 10000UNT 30NOVOLIN 70/30 25NOVOLIN N 25NOVOLIN R 25NOVOLOG 25NOVOLOG FLEXPEN 25NOVOLOG MIX 70/30 25NOVOLOG MIX 70/30

PREFILL 25NOVOLOG PENFILL 25NOXAFIL 6NPLATE 35NUCALA 41NUCYNTA 3NUCYNTA ER 3NUEDEXTA 24NULOJIX 36NULYTELY/FLAVOR

PACKS 33NUPLAZID 22NUTRILIPID INJ 20% 38NUVARING 28NUVESSA 34NUVIGIL 24nyamyc 43NYMALIZE 16nystatin 6nystatin (mouth-throat) 45nystatin (topical) 43nystatin pow 100000 43nystop 43

OOCELLA TAB 3-0.03MG 28OCTAGAM 35octreotide acetate 30OCUFEN 40OCUFLOX 39ODEFSEY 7ODOMZO 12OFEV 41ofloxacin (ophth) 39

ofloxacin (otic) 46ogestrel 28 day 28olanzapine 22olanzapine odt 22olopatadine hcl 40olopatadine hcl (nasal) 41OLUX 44OMECLAMOX-PAK 33omega-3-acid ethyl esters 15omeprazole 33OMNARIS 41OMNIPRED 40ONCASPAR 12ondansetron hcl 31ondansetron hcl inj 31ondansetron hcl oral soln 31ondansetron odt 31ONFI 19ONGLYZA 26ONMEL 6ONZETRA XSAIL 23OPANA 3OPANA ER (CRUSH

RESISTANT 4OPDIVO 11OPSUMIT 18OPTIPRANOLOL 40ORACEA 45ORAP 22ORAPRED ODT TAB

10MG 30ORAPRED ODT TAB

15MG 30ORAPRED ODT TAB

30MG 30ORAVIG 45ORENCIA 35ORENITRAM TAB

0.125MG 18ORENITRAM TAB 0.25MG18ORENITRAM TAB 1MG 18ORENITRAM TAB 2.5MG 18ORFADIN 29ORKAMBI 41orsythia 28 day 28ORTHO MICRONOR 28ORTHO TRI-CYCLEN LO 28ORTHO-CYCLEN 28ORTHO-NOVUM 1/35 28ORTHO-NOVUM 7/7/7 28OSENI TAB 12.5-15MG 26OSENI TAB 12.5-30MG 26OSENI TAB 12.5-45MG 26OSENI TAB 25-15MG 26OSENI TAB 25-30MG 26OSENI TAB 25-45MG 26OSMOPREP 33OTEZLA 35OTREXUP 35ovcon 35 28 day 28


60

ovide 45oxacillin sodium 9oxaliplatin 13oxandrolone 25oxaprozin 1oxcarbazepine 19oxiconazole nitrate cream 43OXISTAT 43OXSORALEN ULTRA 43OXTELLAR XR 19oxybutynin chloride 34OXYCODONE HCL 4oxycodone hcl 4oxycodone w/ acetaminophen

10-325mg 4oxycodone w/ acetaminophen

2.5-325mg 4oxycodone w/ acetaminophen

5-325mg 4oxycodone w/ acetaminophen

7.5-325mg 4oxycodone w/ acetaminophen

soln 5-325 mg/5ml 4oxycodone-aspirin 4oxycodone-ibuprofen 4OXYCONTIN 4oxymorphone hcl 4

Ppacerone 14paclitaxel 11paliperidone 22PAMELOR 20pamidronate disodium 26PAMINE 32PAMINE FORTE 32PANCREAZE 33PANDEL 44PANRETIN 45pantoprazole sodium 33PARICALCITOL 39paricalcitol 39PARNATE 20paroex sol 0.12% 45paromomycin sulfate 5paroxetine er tab 20paroxetine hcl tabs 20paser d/r 7PATADAY 40PATANASE 41PATANOL 40PAXIL 20PAXIL CR 20PAZEO 40PCE 9pediapred sol 6.7/5ml 30PEDIARIX 36PEDVAX HIB 36PEG 3350-KCL-SOD

BICARB-SOD

CHLORIDE-SODSULFATE 33

peg 3350-potassium chloride-sod bicarbonate-sodchloride 33

PEG-INTRON REDIPEN 8PEGANONE 19PEGASYS 8PEGASYS PROCLICK 8PEGINTRON 8PENICILLIN G POT IN

DEXTROSE 9PENICILLIN G POTASSIUM

IN 10penicillin g procaine 10penicillin g sodium 10penicillin v potassium 10penicilln gk inj 20mu 10penicilln gk inj 5mu 10PENNSAID 45PENTACEL 36PENTAM 300 6PENTASA 32pentoxifylline 35PEPCID SUSP 32pepcid tab 32percocet 10/325 4percocet 2.5/325 4percocet 7.5/325 4percocet tab 5-325mg 4PERFOROMIST 41perindopril erbumine 13periogard soln 0.12% 45PERJETA 11permethrin 45perphenazine 22PERTZYE 33PEXEVA 20pfizerpen g inj 5mu 10pfizerpen-g inj 20mu 10phenadoz 31phenelzine sulfate 20phenergan 32phenergan inj 32phenobarbital 19PHENOBARBITAL

SODIUM 19phenobarbital sodium 19phenoxybenzamine hcl 17phenytek 19phenytoin 19phenytoin inj 50mg/ml 19phenytoin sodium

extended 19philith 28PHOSLO 31PHOSLYRA 31PHOSPHOLINE IODIDE 40PICATO 45PILOCARPINE HCL 40

PILOCARPINE HCL(ORAL) 45

pilocarpine hcl (oral) 45pimozide 22pimtrea pack 28pindolol 16pioglitazone hcl 26pioglitazone hcl-glimepiride26pioglitazone hcl-metformin

hcl 26piperacillin sodium-

tazobactam sodium 10pirmella 1/35 28 day 28piroxicam 1PLAQUENIL 35PLASMA-LYTE A 38PLASMA-LYTE-148 38PLASMA-LYTE-56/D5W 38PLEGRIDY 24PLEGRIDY STARTER

PACK 24plenamine 38PLETAL 35podofilox 45polyethylene glycol 3350 33polymyxin b sulfate 6polymyxin b-trimethoprim 39POLYTRIM 39POMALYST 12PONSTEL 1portia 28 day 28PORTRAZZA 11pot chloride inj 2meq/ml 38POTASSIUM CHLORIDE 37,

38potassium chloride 37POTASSIUM CHLORIDE

0.3%/D 38potassium chloride caps er 37POTASSIUM CHLORIDE IN

NACL 38potassium chloride in nacl 38potassium chloride

microencapsulatedcrystals cr 37

POTASSIUM CHLORIDETAB CR 10 MEQ 37

POTASSIUM CITRATE(ALKALINIZER) 34

potassium citrate(alkalinizer) 34

POTIGA 19PRADAXA 34PRALUENT 15pramipexole

dihydrochloride 21PRANDIMET 26PRANDIN 26PRAVACHOL 15pravastatin sodium 15prazosin hcl 14


61

PRECOSE 26PRED FORTE 40PRED MILD 40pred sod pho sol 5mg/5ml 30PRED-G 39PRED-G S.O.P. 39PREDNICARBATE 44prednicarbate 44PREDNISOLONE ACETATE

(OPHTH) 40prednisolone sodium

phosphate 30prednisolone sodium

phosphate (ophth) 40prednisolone sol 15mg/5ml 30prednisolone sol 25mg/5ml 30prednisolone syrup 15

mg/5ml 30prednisone con 5mg/ml 30prednisone pak 10mg 30prednisone pak 5mg 30prednisone sol 5mg/5ml 30prednisone tab 10mg 30prednisone tab 1mg 30prednisone tab 2.5mg 30prednisone tab 20mg 30prednisone tab 50mg 30prednisone tab 5mg 30PREGNYL W/DILUENT

BENZYL 31PREMARIN CREAM 29PREMARIN INJ 29premasol 10% 38premasol 6% 38PRENATAL VITAMIN/FOLIC

ACID > 0.8 MG(GENERIC) 39

PREPOPIK 33PREVACID 33prevalite 15previfem 28 day 28PREVPAC 33PREZCOBIX 7PREZISTA 7PRIFTIN 7PRILOSEC 33PRILOSEC CAP 10MG 33PRILOSEC CAP 20MG 33PRILOSEC CAP 40MG 33PRIMAQUINE

PHOSPHATE 6PRIMAXIN 6primidone 19PRIMSOL 6PRINIVIL 13PRISTIQ 20PRIVIGEN 35PROAIR HFA 41probenecid 1PROCALAMINE 38

PROCARDIA XL 16prochlorperazine inj 5

mg/ml 32prochlorperazine maleate 32prochlorperazine supp 32PROCRIT 35procto-med 43procto-pak 43proctosol hc 2.5 % 43proctozone hc 43PROCYSBI 29progesterone micronized 31PROGLYCEM SUS

50MG/ML 30PROGRAF 36PROLASTIN-C 41PROLEUKIN 11PROLIA 31PROMACTA 35promethazine hcl 32promethegan 32PROMETRIUM 31propafenone hcl 14propafenone hcl 12hr 14proparacaine hcl 40propranolol &

hydrochlorothiazide 15propranolol hcl er 16propranolol inj 1mg/ml 16propranolol sol 16propranolol tab 16propylthiouracil 31PROQUAD 36PROSCAR 33PROSOL 38PROTONIX INJ 33PROTOPIC 45protriptyline hcl 20PROVERA 31PROZAC 20PROZAC WEEKLY 21PRUDOXIN CRE 5% 43psorcon 44PULMICORT FLEXHALER 42PULMICORT INH SUSP

0.25MG/2 ML 42PULMICORT INH SUSP

0.5MG/2 ML 42PULMICORT INH SUSP

1MG/2ML 42PULMOZYME 41PURIXAN 11PYLERA 33pyrazinamide 7pyridostigmine bromide 24

QQNASL 41QNASL CHILDRENS 42QUADRACEL 36

QUALAQUIN 6QUARTETTE 28quasense 91 day 28QUDEXY XR 19questran 15questran light 15quetiapine fumarate 22QUILLICHEW ER 23QUILLIVANT XR 23quinapril hcl 13quinapril-

hydrochlorothiazide 13quinidine gluconate 14quinidine sulfate 14quinine sulfate 6QVAR 42

RRABAVERT 36rabeprazole sodium 33RAGWITEK 36raloxifene hcl 31ramipril 13RANEXA 17ranitidine hcl 32RAPAFLO 33RAPAMUNE 36RASUVO 35RAVICTI 29RAYOS TAB 1MG 30RAYOS TAB 2MG 30RAYOS TAB 5MG 30RAZADYNE 20RAZADYNE ER 20REBETOL 8REBIF 24REBIF REBIDOSE 24REBIF REBIDOSE

TITRATION 24REBIF TITRATION PACK 24RECLAST 26reclipsen 28 day 28RECOMBIVAX HB 36RECTIV 45REGLAN 32REGRANEX 45RELENZA DISKHALER 8RELISTOR 33RELPAX 23REMERON 21REMERON SOLTAB 21REMICADE 35REMODULIN 18RENAGEL 31RENVELA PAK 31RENVELA TAB 800MG 31repaglinide 26repaglinide-metformin hcl 26reprexain tab 10-200mg 4reprexain tab 2.5-200mg 4


62

reprexain tab 5-200mg 4REQUIP 21RESCRIPTOR 7RESTASIS 40RESTORIL 23RETIN-A 42RETROVIR CAPS 7RETROVIR IV INFUSION 7RETROVIR SYRP 7REVATIO 18REVLIMID 36REXULTI 22REYATAZ 7RHEUMATREX 35RHINOCORT AQUA 42ribapak mis 600/day 8ribasphere 8ribasphere ribapak 1000 8ribasphere ribapak 1200 8ribasphere ribapak 800 8ribavirin 200mg 8rifabutin 7RIFADIN 7rifadin 7rifamate 7rifampin 7RIFATER 7RILUTEK 24riluzole 24rimantadine hydrochloride 8RINGER'S 38RIOMET 26RISEDRONATE SODIUM 26risedronate sodium 26RISPERDAL 22RISPERDAL INJ 12.5MG 22RISPERDAL INJ 25MG 22RISPERDAL INJ 37.5MG 22RISPERDAL INJ 50MG 22RISPERDAL M-TAB 22risperidone 22risperidone odt 22RITALIN 23RITALIN LA 23RITUXAN 11rivastigmine tartrate 20rivastigmine td patch 24hr

13.3 mg/24hr 20rivastigmine td patch 24hr 4.6

mg/24hr 20rivastigmine td patch 24hr 9.5

mg/24hr 20rizatriptan benzoate 24ROBINUL 32ROBINUL FORTE 32ROCALTROL 39rocephin 9ropinirole hydrochloride 21rosadan cre 0.75% 45rosuvastatin calcium 15

ROTARIX 36ROTATEQ 36ROWASA 32roweepra 19roxicet soln 4roxicet tab 5-325mg 4ROXICODONE 4ROZEREM 23RUCONEST 35RYTARY 21RYTHMOL 14RYTHMOL SR 14

SSABRIL 19SALAGEN 45SAMSCA 31SANCUSO 32SANDIMMUNE CAPS 36SANDIMMUNE INJ 36SANDIMMUNE SOLN 36SANDOSTATIN 31SANDOSTATIN LAR

DEPOT 31SANTYL 45SAPHRIS 22SARAFEM 25SAVAYSA 34SAVELLA 24SAVELLA TITRATION

PACK 24SEASONIQUE 28SECTRAL 16SEEBRI NEOHALER 41selegiline hcl 21selenium sulfide 43SELZENTRY 7SEMPREX-D 41SENSIPAR 26SEREVENT DISKUS 41SERNIVO 44SEROQUEL 22SEROQUEL XR 22SEROSTIM 30sertraline hcl 21setlakin tab 28SF-ROWASA 32sharobel 28 day 28SIGNIFOR 31SIGNIFOR LAR 31sildenafil citrate (pulmonary

hypertension) 18SILENOR 23SILVADENE 43SILVER SULFADIAZINE 43SIMBRINZA SUS 1-0.2% 40SIMPONI 35SIMPONI ARIA 35SIMULECT 36simvastatin 15

SINEMET 21SINEMET CR 21SINGULAIR 41SIROLIMUS 36sirolimus 36SIRTURO 7SIVEXTRO 6SKLICE 45SODIUM CHLORIDE 37, 38SODIUM CHLORIDE 0.45%

VIA 39SODIUM CHLORIDE 0.9% 45SODIUM DIURIL 17SODIUM FLUORIDE CHEW;

TAB; 1.1 (0.5 F) MG/MLSOLN 37

sodium phenylbutyrate 29sodium polystyrene

sulfonate 26SOLARAZE 45SOLIRIS 35SOLODYN 10SOLTAMOX 12SOLU-CORTEF 1000MG 30SOLU-CORTEF 100MG 30SOLU-CORTEF 250MG 30SOLU-CORTEF 500MG 30SOLU-MEDROL INJ

125MG 30SOLU-MEDROL INJ 1GM 30SOLU-MEDROL INJ 2GM 30SOLU-MEDROL INJ 40MG30SOLU-MEDROL INJ

500MG 30SOMATULINE DEPOT 31SOMAVERT 31SOOLANTRA 45SORIATANE 43SORILUX 43sorine 14sotalol hcl 14sotalol hcl (afib/afl) 14SOTYLIZE 16SOVALDI 8SPIRIVA HANDIHALER 41SPIRIVA RESPIMAT 41spironolactone 13spironolactone &

hydrochlorothiazide 17SPORANOX 6SPORANOX PULSEPAK 6SPORANOX SOL 10MG/ML6sprintec 28 day 28SPRITAM 19SPRYCEL 12sps susp 15gm/60ml 27sronyx 28 day 28SSD 43STALEVO 21STARLIX 26


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stavudine 7STELARA 43STERILE WATER

IRRIGATION 45STIMATE 31STIOLTO RESPIMAT 40STIVARGA 12STRATTERA 23STRENSIQ 29streptomycin sulfate 5STRIANT 25STRIBILD 7STRIVERDI RESPIMAT 41STROMECTOL 6SUBSYS 4SUCLEAR 33SUCRAID 33sucralfate 33SULAR 16sulfacet sod oin 10% op 39sulfacetamide sod-

prednisolone 39sulfacetamide sodium

(acne) 42sulfacetamide sodium

(ophth) 39sulfadiazine 5sulfamethoxazole-trimethop 6sulfamethoxazole-

trimethoprim inj 6SULFAMYLON 43sulfasalazine dr 32sulfasalazine ir 32sulindac 1SUMATRIPTAN INJ

4MG/0.5ML 24sumatriptan inj 6mg/0.5ml 24SUMATRIPTAN

SUCCINATE 24sumatriptan succinate 24SUMAVEL DOSEPRO 24SUPRAX 9suprax 9SUPREP BOWEL PREP 33SURMONTIL 21SUSTIVA 7SUTENT 12syeda 28SYLATRON KIT 200MCG 12SYLATRON KIT 300MCG 12SYLATRON KIT 600MCG 13SYLVANT 13SYMBICORT 42SYMLINPEN 120 25SYMLINPEN 60 25SYNAGIS 37SYNALAR 44SYNALGOS-DC 1SYNAREL 29SYNERA 44

SYNERCID 6SYNJARDY TAB 12.5-

1000 26SYNJARDY TAB 12.5-500 26SYNJARDY TAB 5-

1000MG 26SYNJARDY TAB 5-500MG 26SYNRIBO 13SYNTHROID 31SYPRINE 27

TTABLOID 11TACLONEX 44tacrolimus 36tacrolimus (topical) 45TAFINLAR 12TAGRISSO 12TAMIFLU 8tamoxifen citrate 12tamsulosin hcl 33TANZEUM 25tapazole 31TARCEVA 12TARGRETIN 13, 45tarina fe 1/20 28 day 28TARKA 13TASIGNA 12TAXOTERE 11tazicef 9tazicef vial 9TAZORAC 43taztia xt 16TECFIDERA CAP 120MG 24TECFIDERA CAP 240MG 24TECFIDERA MIS

STARTER 24TEFLARO 9TEGRETOL 19TEGRETOL-XR 19TEKTURNA 16TEKTURNA HCT 16telmisartan 14telmisartan-amlodipine 14telmisartan-

hydrochlorothiazide 14temazepam 23TEMOVATE CREAM 44TEMOVATE E CREAM 44TEMOVATE GEL 44TEMOVATE OIN 44TEMOVATE SOLN 44TENIVAC 37TENORETIC 100 15TENORETIC 50 15TENORMIN 16TERAZOL 3 34TERAZOL 7 34terazosin hcl 14terbinafine hcl 6

terbutaline sulfate 41terconazole vaginal 34testosterone cypionate 25testosterone enanthate 25TETANUS/DIPHTHERIA

TOXOID 37tetrabenazine 24TETRACYCLINE HCL 10texacort 44THALOMID 36theo-24 42theophylline 42thioridazine hcl 22thiotepa 10thiothixene 22THYMOGLOBULIN 36tiagabine hcl 19TIAZAC 16TIKOSYN 14timolol maleate 16timolol maleate (ophth) 40TIMOLOL MALEATE GEL 40TIMOPTIC 40TIMOPTIC OCUDOSE 40TIMOPTIC-XE 40TIROSINT 31TIVICAY 7tizanidine 24TOBI NEB 5TOBI PODHALER 5TOBRADEX 39tobramycin 5tobramycin (ophth) 39tobramycin sulfate 5tobramycin-

dexamethasone 39TOBREX OINT 0.3% 39TOBREX SOL 0.3% OP 39TOFRANIL 21TOLAK 45tolmetin sodium 1tolterodine tartrate er 34tolterodine tartrate tab 1

mg 34tolterodine tartrate tab 2

mg 34TOPAMAX 19TOPAMAX SPRINKLE 19TOPICORT 44topicort 44TOPICORT SPRAY 0.25% 44TOPIRAMATE 19topiramate 19toposar 13topotecan hcl 13TOPROL XL 16TORISEL 11torsemide inj 50mg/5ml 17torsemide tabs 17TOUJEO SOLOSTAR 25


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TPN ELECTROLYTES 37TRACLEER 18TRADJENTA 26TRAMADOL HCL 1TRAMADOL HCL ER 2tramadol hcl er 1tramadol hcl er (biphasic)

100mg 2tramadol hcl er (biphasic)

200mg 2tramadol hcl er (biphasic)

300mg 2tramadol hcl tab 50 mg 2tramadol-acetaminophen 2TRANDATE 16trandolapril 13trandolapril-verapamil hcl 13tranexamic acid 35TRANSDERM-SCOP 32TRANXENE T 19tranylcypromine sulfate 21TRAVASOL 38TRAVATAN Z 40trazodone hcl 21TREANDA 10TRECATOR 7TRELSTAR MIXJECT 12TRESIBA FLEXTOUCH 25TRETINOIN 42tretinoin 13, 42TRETINOIN

MICROSPHERE 42tretinoin microsphere 42trexall 35trezix 2tri-legest 28 day 28tri-lo- estarylla 28 day 28tri-lo- tab marzia 28tri-lo-sprintec 28 day 28TRI-NORINYL 28 28tri-previfem 28 day 28tri-sprintec 28 day 28triamcinolone acetonide

(mouth) 45TRIAMCINOLONE

ACETONIDE (NASAL) 42triamcinolone acetonide

(topical) 44triamt/hctz cap 37.5-25 17triamt/hctz cap 50-25mg 17triamt/hctz tab 37.5-25 17triamt/hctz tab 75-50mg 17trianex 44TRICOR 15triderm 44trifluoperazine hcl 22trifluridine 39TRILEPTAL SUSP 19TRILEPTAL TABS 19TRILIPIX 15

trilyte 33trimethoprim 6trimipramine maleate 21TRINESSA 28TRINESSA LO TAB 28TRINTELLIX 21TRIOSTAT 31TRISENOX 13TRIUMEQ 7trivora 28 day 28TRIZIVIR 7TROKENDI XR 19TROPHAMINE INJ 10% 38TROPHAMINE INJ 6% 38trospium chloride 34trospium chloride er 34TRULICITY 25TRUMENBA 37TRUSOPT 40TRUVADA 7TRUVADA TAB 100-150 7TRUVADA TAB 133-200 7TRUVADA TAB 167-250 7TUDORZA PRESSAIR 41TUDORZA PRESSAIR

(INSTITUTIONALPACK) 41

TWINRIX INJ 37TWYNSTA 14TYBOST 7TYGACIL 6TYKERB 12tylenol with codeine 2TYPHIM VI 37TYSABRI 24TYVASO 18TYZEKA 8tyzine 41

UUCERIS 32UCERIS AER 2MG/ACT 32ULORIC 1ULTRACET 2ULTRAM 2ULTRAM ER 2ULTRAM ER TAB 100MG 2ULTRAM ER TAB 200MG 2ULTRAVATE 44ULTRESA 33UNASYN 10UNASYN BULK PACK 10UNITHROID 31UPTRAVI 18urecholine 34UROCIT-K 34UROXATRAL 33URSO 250 33URSO FORTE 33ursodiol 33

UTIBRON NEOHALER 40UVADEX 13

VVAGIFEM 29valacyclovir hcl 8VALCHLOR 45VALCYTE 8valganciclovir hcl 8VALIUM 19valproate sodium 19valproic acid 19valsartan 14valsartan-

hydrochlorothiazide 14VALSTAR 10VALTREX 8VANCOCIN HCL 6vancomycin hcl 6vancomycin hcl inj 1000mg 6vancomycin hcl inj 10gm 6vancomycin hcl inj 500mg 6vancomycin hcl inj 5gm 6vancomycin hcl inj 750mg 6VANCOMYCIN IN NACL 6VANDAZOLE 34VANOS 44VANTAS 12VAQTA 37VARIVAX 37VARUBI 32VASCEPA 15VASERETIC 13VASOTEC 13VECTIBIX 11VECTICAL 43VELCADE 11VELETRI 18velivet 28 day 28VELPHORO 31VELTASSA 27VENCLEXTA 11VENCLEXTA STARTING

PACK 11venlafaxine cap er 21venlafaxine hcl 21VENLAFAXINE HCL ER TAB

(VERT) 21venlafaxine tab 21VENLAFAXINE TAB 225MG

ER 21venlafaxine tab er 21VENTAVIS 18VERAPAMIL HCL 16verapamil hcl 16VERELAN 16VERELAN PM 16veripred 30VERSACLOZ 22VESICARE 34


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vestura 28VEXOL 40VFEND IV 6VFEND SUS 40MG/ML 6VFEND TAB 6VIBERZI 33VIBRAMYCIN 10vicodin 4vicodin es 4vicodin hp 4VICOPROFEN 4VICTOZA 25VIDAZA 11VIDEX EC 7VIDEX PEDIATRIC 7vienva 28 day 28VIGAMOX 39VIIBRYD 21VIIBRYD STARTER PACK 21VIMIZIM 29VIMPAT 19vinblastine sulfate 11vincasar 11vincristine sulfate 11vinorelbine tartrate 11VIOKACE 10 33VIOKACE 20 33viorele 28VIRACEPT 7VIRAMUNE 7VIRAMUNE XR 7VIREAD 7VIROPTIC 39VITEKTA 7VIVELLE-DOT 29VIVITROL 25VIVLODEX 1VOLTAREN GEL 1% 45voriconazole 6voriconazole inj 200mg 6vospire 41VOTRIENT 12VPRIV 29VRAYLAR 22vyfemla 28 day 28VYTORIN 15VYVANSE 23

Wwarfarin sodium 34WELCHOL 15WELLBUTRIN 21WELLBUTRIN SR 21WELLBUTRIN XL 21wymzya fe 28

XXALATAN 40XALKORI 12

XANAX TAB 0.25MG 18XANAX TAB 0.5MG 18XANAX TAB 1MG 18XANAX TAB 2MG 18XARELTO 34XARELTO STARTER

PACK 34XARTEMIS XR 4XELJANZ 35XELJANZ XR 35XENAZINE 24XEOMIN 24XEOMIN 200UNIT 24XGEVA 31XIFAXAN TAB 200MG 6XIFAXAN TAB 550MG 33XIGDUO XR TAB 10-

1000MG 26XIGDUO XR TAB 10-



500MG 26xodol tab 10-300mg 4xodol tab 5-300mg 4xodol tab 7.5-300 4XOLAIR 41XOPENEX 41XOPENEX

CONCENTRATE 41XTANDI 12xulane dis 150-35 28XYLOCAINE 4, 44XYLOCAINE-MPF 4xylon tab 10-200mg 4XYREM 24XYZAL 41

YYASMIN 28 28YAZ 28YERVOY 11YF-VAX 37

Zzafirlukast 41ZALTRAP 11zamicet 4ZANAFLEX 24ZANOSAR 10ZANTAC 32zarah 29ZARONTIN 20zarontin 20ZAVESCA 29ZAZOLE 34ZEBETA 16ZELAPAR 21ZELBORAF 12

ZEMAIRA 41ZEMBRACE SYMTOUCH 24ZEMPLAR 39ZENATANE 42zenatane 42zenchent fe 28 day 29zenchent tab 29ZENPEP 33ZERBAXA 9ZERIT 7ZESTORETIC 13ZESTRIL 13ZETIA TAB 10MG 15ZETONNA 42ZIAC 15ZIAGEN 7zidovudine 7ZINACEF 9ZINECARD 13ZIOPTAN 40ziprasidone hcl 22ZIRGAN 39ZITHROMAX 9ZITHROMAX TRI-PAK 9ZITHROMAX Z-PAK 9ZMAX 9ZOCOR 15ZOFRAN 32ZOFRAN ODT 32ZOHYDRO ER (ABUSE

DETERRENT) 4ZOLADEX 12zoledronic inj 4mg/5ml 26zoledronic inj 5/100ml 26ZOLINZA 11zolmitriptan 24zolmitriptan odt 24ZOLOFT 21zolpidem tartrate 23ZOMETA 26ZOMIG 24ZOMIG ZMT 24ZONALON 43ZONEGRAN 20zonisamide 20ZONTIVITY 35ZORBTIVE 30ZORTRESS TAB 0.25MG 36ZORTRESS TAB 0.5MG 36ZORTRESS TAB 0.75MG 36ZOSTAVAX 37ZOSYN 10zovia 1/35e 28 day 29zovia 1/50e 28 day 29ZOVIRAX 8, 45ZUBSOLV SUB 1.4-

0.36MG 25ZUBSOLV SUB 11.4-

2.9MG 25ZUBSOLV SUB 2.9-


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0.71MG 25ZUBSOLV SUB 5.7-1.4MG 25ZUBSOLV SUB 8.6-2.1MG 25ZYBAN 25ZYDELIG 12ZYFLO CR 41ZYKADIA 12ZYLET 39ZYLOPRIM 1ZYMAXID 39ZYPREXA 22ZYPREXA RELPREVV 22ZYPREXA RELPREVV INJ

210MG 22ZYPREXA ZYDI TAB

10MG 22ZYPREXA ZYDIS 22ZYTIGA 12ZYVOX 6

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