(List of Covered Prescription and Over-the-Counter … alphabetical list of all of the drugs...

Other drug coverage: If you have Medicare, you need to get most of your prescription drugs through the Medicare Prescription Drug Program (Medicare Part D). You must be enrolled in a Medicare prescription drug plan to get these services. UCare does not pay for prescriptions that are covered under the Medicare Prescription Drug Program.

PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE

COVER IN THESE PLANS.

UCare Connect (SNBC)

MinnesotaCare

Prepaid Medical Assistance Program (PMAP)

Minnesota Senior Care Plus (MSC Plus)

PMAP MnCare MSC+ SNBC_110117_1 DHS Approved (11172017)

2018 Formulary(List of Covered Prescription and Over-the-Counter Drugs)

Civil Rights NoticeDiscrimination is against the law. UCare does not discriminate on the basis of any of the following:

• Race• Color• National Origin• Creed• Religion• Sexual Orientation• Public Assistance Status• Age• Disability (including physical or

mental impairment)

• Sex (including sex stereotypes and gender identity)

• Marital Status• Political Beliefs• Medical Condition• Health Status• Receipt of Health Care Services• Claims Experience• Medical History• Genetic Information

Auxiliary Aids and Services. UCare provides auxiliary aids and services, like qualified interpreters or information in accessible formats, free of charge and in a timely manner, to ensure an equal opportunity to participate in our health care programs. Contact UCare at 612‑676‑3200 (voice) or 1‑800‑203‑7225 (voice), 612‑676‑6810 (TTY), or 1‑800‑688‑2534 (TTY).

Language Assistance Services. UCare provides translated documents and spoken language interpreting, free of charge and in a timely manner, when language assistance services are necessary to ensure limited English speakers have meaningful access to our information and services. Contact UCare at 612‑676‑3200 (voice) or 1‑800‑203‑7225 (voice), 612‑676‑6810 (TTY), or 1‑800‑688‑2534 (TTY).

Civil Rights ComplaintsYou have the right to file a discrimination complaint if you believe you were treated in a discriminatory way by UCare. You may contact any of the following four agencies directly to file a discrimination complaint.

U.S. Department of Health and Human Services’ Office for Civil Rights (OCR)You have the right to file a complaint with the OCR, a federal agency, if you believe you have been discriminated against because of any of the following:

• Race• Color• National Origin• Age• Disability• Sex (including sex stereotypes and gender identity)

Contact the OCR directly to file a complaint:Director U.S. Department of Health and Human Services’ Office for Civil Rights 200 Independence Avenue SW Room 509F HHH Building Washington, DC 20201 800‑368‑1019 (Voice) 800‑537‑7697 (TDD) Complaint Portal – https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Minnesota Department of Human Rights (MDHR)

In Minnesota, you have the right to file a complaint with the MDHR if you believe you have been discriminated against because of any of the following:

• Race• Color• National Origin• Religion• Creed

• Sex• Sexual Orientation• Marital Status• Public Assistance Status• Disability

Contact the MDHR directly to file a complaint:Minnesota Department of Human Rights Freeman Building, 625 North Robert Street St. Paul, MN 55155 651‑539‑1100 (voice) 800‑657‑3704 (toll free) 711 or 800‑627‑3529 (MN Relay) 651‑296‑9042 (Fax) [email protected] (Email)

Minnesota Department of Human Services (DHS)You have the right to file a complaint with DHS if you believe you have been discriminated against in our health care programs because of any of the following:


mental impairment)



Complaints must be in writing and filed within 180 days of the date you discovered the alleged discrimination. The complaint must contain your name and address and describe the discrimination you are complaining about. After we get your complaint, we will review it and notify you in writing about whether we have authority to investigate. If we do, we will investigate the complaint.

DHS will notify you in writing of the investigation’s outcome. You have a right to appeal the outcome if you disagree with the decision. To appeal, you must send a written request to have DHS review the investigation outcome period. Be brief and state why you disagree with the decision. Include additional information you think is important.

If you file a complaint in this way, the people who work for the agency named in the complaint cannot retaliate against you. This means they cannot punish you in any way for filing a complaint. Filing a complaint in this way does not stop you from seeking out other legal or administration actions

Contact DHS directly to file a discrimination complaint:ATTN: Civil Rights Coordinator Minnesota Department of Human Services Equal Opportunity and Access Division P.O. Box 64997 St. Paul, MN 55164‑0997 651‑431‑3040 (voice) or use your preferred relay service

UCare Complaint NoticeYou have the right to file a complaint with UCare if you believe you have been discriminated against in our health care programs because of any of the following:


mental impairment)



Phone: 612‑676‑3200 or 1‑800‑203‑7225 toll free

TTY: 612‑676‑6810 or 1‑800‑688‑2534 toll free

Email: [email protected] Fax: 612‑884‑2021

Mailing address UCare Attn: Appeals and Grievances PO Box 52 Minneapolis, MN 55440‑0052

American Indians can continue or begin to use tribal and Indian Health Services (IHS) clinics. We will not require prior approval or impose any conditions for you to get services at these clinics. For elders age 65 years and older this includes Elderly Waiver (EW) services accessed through the tribe. If a doctor or other provider in a tribal or IHS clinic refers you to a provider in our network, we will not require you to see your primary care provider prior to the referral

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UCare Comprehensive Formulary i

What is the UCare Formulary?The UCare formulary is a list of prescription and over‑the‑counter (OTC) drugs that are covered by your health plan. The list is reviewed and updated by a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program.

The most recent version of the formulary can be found on the UCare website at www.ucare.org.

How do I use the Formulary?In the formulary, brand name drugs are capitalized (e.g. EPIPEN) and generic drugs are listed in lower‑case italics (e.g. maprotiline tablet). UCare covers both brand name drugs and generic drugs. A generic drug is approved by the Food and Drug Administration (FDA) as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs, but work just as well and are equally as safe as the branded product.

How to find prescription drugs in the formularyThere are two ways to find your prescription drugs in the formulary. You can search by medical condition associated with your drug or by alphabetical listing.

Search by Medical ConditionDrugs listed by medical condition begin on page 1. The drugs in this formulary are grouped into categories depending on the type of medical conditions they are used to treat. If you know what your drug is used for, look for the category in the list that begins on page 1. Then look under the category name for your drug.

Search by Alphabetical ListingIf you are not sure what category to look under, you can look for your drug in the Index. The Index gives an alphabetical list of all of the drugs included in the formulary. Both brand name and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information within the formulary.

Tier (Notes) for prescription drugsThe numbers in the Tier (Notes) column on the prescription drug formulary tell you the difference between brand name drug copays and generic drug copays. The number 1 shows that the drug is a generic drug and may have a generic drug copay. The number 2 shows that the drug is a brand name drug and may have a brand name drug copay. For more detailed information about copays, please review your Evidence of Coverage.

The abbreviations in the Tier (Notes) column on the formulary tell you if UCare has any special requirements or limits on coverage for that drug. Use the key below to help understand the meaning of each abbreviation.

• PA = Prior authorization – UCare requires you or your doctor to get prior authorization for certain drugs. This means that your provider will need to work with UCare to get coverage approval before you can fill your prescriptions. If you don’t get approval, UCare may not cover the drug.

• ST = Step therapy – Even though this drug is on the formulary, UCare requires that you try one or more alternative drugs on the formulary before this drug will be covered. Note: In many cases, if you are already on this drug prior to enrolling in UCare, UCare will pay for your drug and not require you to try other formulary drugs first.

• QL = Quantity limits – For certain drugs, UCare limits the amount of the drug that UCare will cover.

ii UCare Comprehensive Formulary

• SP = Specialty drugs – Fairview Specialty Pharmacy is the exclusive network provider of specialty drugs for UCare State Public Program (Medicaid) members. Specialty drugs are costly injectable or oral drugs that often require special handling or monitoring by a trained pharmacist.

Your specialty medication and any needed supplies will be shipped to your home, work, or doctor’s office. You can also contact Fairview Specialty Pharmacy and arrange to pick up your medication at one of their retail locations. A Fairview pharmacist is available 24 hours a day, seven days a week, to answer any questions related to your specialty medication.

If you use a specialty medication, please have your physician send your prescription to Fairview Specialty Pharmacy via e‑prescribing and select “FAIRVIEW MAIL ORDER/SPECIALTY PHARMACY” or fax it to 1‑866‑347‑4939. You can also have your current pharmacy transfer the prescription to Fairview Specialty Pharmacy. For any questions, please contact Fairview at 612-672-5260 or 1-800-595-7140 (toll free), 24 hours a day, seven days a week.

How to find OTC drugs in the formularyA list of covered OTC drugs is located in the back of the formulary. Covered OTC drugs are listed by medical condition.

What if my drug is not on the Formulary?If your drug is not included in this formulary, you should first contact UCare Customer Services to confirm that your drug is not covered. Call Customer Services at 612‑676‑3200 or 1‑800‑203‑7225 toll free or, for TTY users, 1‑800‑688‑2534, 8 a.m. ‑ 5 p.m., Monday ‑ Friday, or visit ucare.org. If you learn that UCare does not cover your drug, you can:

• Take a copy of this formulary to your doctor and ask him or her to prescribe a similar drug that is covered by UCare.

• Ask your doctor to request a formulary exception.*

*Note: Generally, UCare will only approve your doctor’s request for a formulary exception if the alternative drugs included on UCare’s formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

For more informationFor more detailed information about your UCare prescription or OTC drug coverage, please review your Evidence of Coverage and other plan materials.

If you have questions, please call the UCare Customer Services number on the back of your member ID card. TTY/TDD users should call 1‑800‑688‑2534 toll free. Or visit www.ucare.org.

UCare Minnesota Health Care Program Formulary

List of Covered Drugs

Drug Tier Notes

ANTIHISTAMINE DRUGS

carbinoxamine maleate oral liquid 4 mg/5 ml 1

carbinoxamine maleate oral tablet 4 mg 1

clemastine oral tablet 2.68 mg 1

cyproheptadine oral syrup 2 mg/5 ml 1

cyproheptadine oral tablet 4 mg 1

dimenhydrinate injection solution 50 mg/ml 1

diphenhydramine hcl injection solution 50 mg/ml

1

diphenhydramine hcl injection syringe 50 mg/ml

1

hydroxyzine hcl intramuscular solution 25 mg/ml, 50 mg/ml

1

hydroxyzine hcl oral solution 10 mg/5 ml 1

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg

1

hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg

1

promethazine injection solution 25 mg/ml, 50 mg/ml

1

promethazine oral syrup 6.25 mg/5 ml 1

promethazine oral tablet 12.5 mg, 25 mg, 50 mg

1

promethazine rectal suppository 12.5 mg, 25 mg

1

ANTI-INFECTIVE AGENTS

abacavir oral solution 20 mg/ml 1

abacavir oral tablet 300 mg 1

abacavir-lamivudine oral tablet 600-300 mg 1

abacavir-lamivudine-zidovudine oral tablet300-150-300 mg

1

acyclovir oral capsule 200 mg 1

acyclovir oral suspension 200 mg/5 ml 1

acyclovir oral tablet 400 mg, 800 mg 1

UCare Comprehensive Formulary

Effective February 1, 2018

1

Drug Tier Notes

acyclovir sodium intravenous recon soln1,000 mg, 500 mg

1

acyclovir sodium intravenous solution 50 mg/ml

1

adefovir oral tablet 10 mg 1 SP

ALBENZA ORAL TABLET 200 MG 2

ALINIA ORAL SUSPENSION FOR RECONSTITUTION 100 MG/5 ML

2

ALINIA ORAL TABLET 500 MG 2

amantadine hcl oral capsule 100 mg 1

amantadine hcl oral solution 50 mg/5 ml 1

amantadine hcl oral tablet 100 mg 1

amikacin injection solution 1,000 mg/4 ml, 500 mg/2 ml

1

amoxicillin oral capsule 250 mg, 500 mg 1

amoxicillin oral suspension for reconstitution125 mg/5 ml, 200 mg/5 ml, 250 mg/5 ml, 400 mg/5 ml

1

amoxicillin oral tablet 500 mg, 875 mg 1

amoxicillin oral tablet,chewable 125 mg, 250 mg

1

amoxicillin-pot clavulanate oral suspension for reconstitution 200-28.5 mg/5 ml, 250-62.5 mg/5 ml, 400-57 mg/5 ml, 600-42.9 mg/5 ml

1

amoxicillin-pot clavulanate oral tablet 250-125 mg, 500-125 mg, 875-125 mg

1

amoxicillin-pot clavulanate oral tablet extended release 12 hr 1,000-62.5 mg

1

amoxicillin-pot clavulanate oral tablet,chewable 200-28.5 mg, 400-57 mg

1

amphotericin b injection recon soln 50 mg 1

ampicillin oral capsule 250 mg, 500 mg 1

ampicillin sodium injection recon soln 1 gram, 10 gram, 125 mg, 2 gram, 250 mg, 500 mg

1

ampicillin sodium intravenous recon soln 1 gram, 2 gram

1

ampicillin-sulbactam injection recon soln 1.5 gram, 15 gram, 3 gram

1



2

Drug Tier Notes

ampicillin-sulbactam intravenous recon soln1.5 gram, 3 gram

1

APTIVUS ORAL CAPSULE 250 MG 2

APTIVUS ORAL SOLUTION 100 MG/ML 2

atazanavir oral capsule 150 mg, 200 mg, 300 mg

1

atovaquone oral suspension 750 mg/5 ml 1

atovaquone-proguanil oral tablet 250-100 mg, 62.5-25 mg

1

ATRIPLA ORAL TABLET 600-200-300 MG 2

azithromycin intravenous recon soln 500 mg 1

azithromycin oral packet 1 gram 1

azithromycin oral suspension for reconstitution 100 mg/5 ml, 200 mg/5 ml

1

azithromycin oral tablet 250 mg, 500 mg, 600 mg

1

BACIIM INTRAMUSCULAR RECON SOLN 50,000 UNIT

1

bacitracin intramuscular recon soln 50,000 unit

1

BARACLUDE ORAL SOLUTION 0.05 MG/ML

2 SP

BILTRICIDE ORAL TABLET 600 MG 2

CAYSTON INHALATION SOLUTION FOR NEBULIZATION 75 MG/ML

2 SP; QL

cefaclor oral capsule 250 mg, 500 mg 1

cefaclor oral tablet extended release 12 hr500 mg

1

cefadroxil oral capsule 500 mg 1

cefadroxil oral suspension for reconstitution250 mg/5 ml, 500 mg/5 ml

1

cefadroxil oral tablet 1 gram 1

cefazolin in dextrose (iso-os) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml

1

cefazolin injection recon soln 1 gram, 10 gram, 100 gram, 20 gram, 300 g, 500 mg

1

cefazolin intravenous recon soln 1 gram 1

cefdinir oral capsule 300 mg 1



3

Drug Tier Notes

cefdinir oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

1

cefditoren pivoxil oral tablet 200 mg 1

cefepime in dextrose,iso-osm intravenous piggyback 1 gram/50 ml, 2 gram/100 ml

1

cefepime injection recon soln 1 gram, 2 gram 1

cefotaxime injection recon soln 1 gram, 10 gram, 2 gram, 500 mg

1

cefotetan injection recon soln 1 gram, 2 gram 1

cefotetan intravenous recon soln 10 gram 1

cefoxitin in dextrose, iso-osm intravenous piggyback 1 gram/50 ml, 2 gram/50 ml

1

cefoxitin intravenous recon soln 1 gram, 10 gram, 2 gram

1

cefpodoxime oral suspension for reconstitution 100 mg/5 ml, 50 mg/5 ml

1

cefpodoxime oral tablet 100 mg, 200 mg 1

cefprozil oral suspension for reconstitution125 mg/5 ml, 250 mg/5 ml

1

cefprozil oral tablet 250 mg, 500 mg 1

ceftazidime injection recon soln 1 gram, 2 gram, 6 gram

1

ceftriaxone in dextrose,iso-os intravenous piggyback 1 gram/50 ml, 2 gram/50 ml

1

ceftriaxone injection recon soln 1 gram, 10 gram, 2 gram, 250 mg, 500 mg

1

ceftriaxone intravenous recon soln 1 gram, 2 gram

1

cefuroxime axetil oral tablet 250 mg, 500 mg 1

cefuroxime sodium injection recon soln 750 mg

1

cefuroxime sodium intravenous recon soln1.5 gram, 7.5 gram

1

cephalexin oral capsule 250 mg, 500 mg 1

cephalexin oral suspension for reconstitution125 mg/5 ml, 250 mg/5 ml

1

cephalexin oral tablet 250 mg, 500 mg 1

chloramphenicol sod succinate intravenous recon soln 1 gram

1



4

Drug Tier Notes

chloroquine phosphate oral tablet 250 mg, 500 mg

1

ciprofloxacin (mixture) oral tablet, er multiphase 24 hr 1,000 mg, 500 mg

1

ciprofloxacin hcl oral tablet 100 mg, 250 mg, 500 mg, 750 mg

1

ciprofloxacin in 5 % dextrose intravenous piggyback 200 mg/100 ml, 400 mg/200 ml

1

ciprofloxacin lactate intravenous solution 200 mg/20 ml, 400 mg/40 ml

1

ciprofloxacin oral suspension,microcapsule recon 250 mg/5 ml, 500 mg/5 ml

1

clarithromycin oral suspension for reconstitution 125 mg/5 ml, 250 mg/5 ml

1

clarithromycin oral tablet 250 mg, 500 mg 1

clarithromycin oral tablet extended release 24 hr 500 mg

1

clindamycin hcl oral capsule 150 mg, 300 mg 1

clindamycin palmitate hcl oral recon soln 75 mg/5 ml

1

CLINDAMYCIN PEDIATRIC ORAL RECON SOLN 75 MG/5 ML

1

clindamycin phosphate injection solution 150 mg/ml

1

clindamycin phosphate intravenous solution300 mg/2 ml, 600 mg/4 ml, 900 mg/6 ml

1

COARTEM ORAL TABLET 20-120 MG 2

colistin (colistimethate na) injection recon soln 150 mg

1

COMPLERA ORAL TABLET 200-25-300 MG 2

CRIXIVAN ORAL CAPSULE 200 MG, 400 MG

2

dapsone oral tablet 100 mg, 25 mg 2

daptomycin intravenous recon soln 500 mg 1

DARAPRIM ORAL TABLET 25 MG 2 PA

DESCOVY ORAL TABLET 200-25 MG 2

dicloxacillin oral capsule 250 mg, 500 mg 1



5

Drug Tier Notes

didanosine oral capsule,delayed release(dr/ec) 125 mg, 200 mg, 250 mg, 400 mg

1

doxycycline hyclate oral capsule 100 mg, 50 mg

1

doxycycline hyclate oral tablet 100 mg 1

doxycycline monohydrate oral capsule 100 mg, 150 mg, 50 mg

1

EDURANT ORAL TABLET 25 MG 2

efavirenz oral capsule 200 mg, 50 mg 1

EMTRIVA ORAL CAPSULE 200 MG 2

EMTRIVA ORAL SOLUTION 10 MG/ML 2

entecavir oral tablet 0.5 mg, 1 mg 1 SP

EPIVIR HBV ORAL SOLUTION 25 MG/5 ML (5 MG/ML)

2 SP

EPIVIR ORAL SOLUTION 10 MG/ML 2

ERYTHROCIN (AS STEARATE) ORAL TABLET 250 MG

1

erythromycin ethylsuccinate oral tablet 400 mg

1

erythromycin oral capsule,delayed release(dr/ec) 250 mg

1

erythromycin oral tablet 250 mg, 500 mg 1

ethambutol oral tablet 100 mg, 400 mg 1

EVOTAZ ORAL TABLET 300-150 MG 2

famciclovir oral tablet 125 mg, 250 mg, 500 mg

1 QL

fluconazole in dextrose(iso-o) intravenous piggyback 200 mg/100 ml, 400 mg/200 ml

1

fluconazole in nacl (iso-osm) intravenous piggyback 100 mg/50 ml, 200 mg/100 ml, 400 mg/200 ml

1

fluconazole oral suspension for reconstitution10 mg/ml, 40 mg/ml

1

fluconazole oral tablet 100 mg, 200 mg, 50 mg

1

fluconazole oral tablet 150 mg 1 QL

fosamprenavir oral tablet 700 mg 1

foscarnet intravenous solution 24 mg/ml 1



6

Drug Tier Notes

FUZEON SUBCUTANEOUS RECON SOLN 90 MG

2 SP

gentamicin in nacl (iso-osm) intravenous piggyback 100 mg/100 ml, 60 mg/50 ml, 70 mg/50 ml, 80 mg/100 ml, 80 mg/50 ml, 90 mg/100 ml

1

gentamicin injection solution 20 mg/2 ml, 40 mg/ml

1

gentamicin sulfate (ped) (pf) injection solution20 mg/2 ml

1

gentamicin sulfate (pf) intravenous solution100 mg/10 ml

1

GENVOYA ORAL TABLET 150-150-200-10 MG

2

griseofulvin microsize oral suspension 125 mg/5 ml

1

griseofulvin microsize oral tablet 500 mg 1

griseofulvin ultramicrosize oral tablet 125 mg, 250 mg

1

hydroxychloroquine oral tablet 200 mg 1

HYOPHEN ORAL TABLET 81.6-0.12-10.8 MG

1

INTELENCE ORAL TABLET 100 MG, 200 MG, 25 MG

2

INTRON A INJECTION RECON SOLN 10 MILLION UNIT (1 ML), 18 MILLION UNIT (1 ML), 50 MILLION UNIT (1 ML)

2 SP

INTRON A INJECTION SOLUTION 10 MILLION UNIT/ML, 6 MILLION UNIT/ML

2 SP

INVANZ INJECTION RECON SOLN 1 GRAM

2

INVANZ INTRAVENOUS RECON SOLN 1 GRAM

2

INVIRASE ORAL CAPSULE 200 MG 2

INVIRASE ORAL TABLET 500 MG 2

ISENTRESS HD ORAL TABLET 600 MG 2

ISENTRESS ORAL TABLET 400 MG 2

ISENTRESS ORAL TABLET,CHEWABLE 100 MG, 25 MG

2

isoniazid injection solution 100 mg/ml 1



7

Drug Tier Notes

isoniazid oral solution 50 mg/5 ml 1

isoniazid oral tablet 100 mg, 300 mg 1

itraconazole oral capsule 100 mg 1 QL

ivermectin oral tablet 3 mg 1

KALETRA ORAL TABLET 100-25 MG, 200-50 MG

2

ketoconazole oral tablet 200 mg 1

lamivudine oral solution 10 mg/ml 1

lamivudine oral tablet 100 mg, 150 mg, 300 mg

1

lamivudine-zidovudine oral tablet 150-300 mg

1

levofloxacin oral solution 250 mg/10 ml 1

levofloxacin oral tablet 250 mg, 500 mg, 750 mg

1

LEXIVA ORAL SUSPENSION 50 MG/ML 2

linezolid intravenous parenteral solution 600 mg/300 ml

1

linezolid oral suspension for reconstitution100 mg/5 ml

1

linezolid oral tablet 600 mg 1

linezolid-0.9% sodium chloride intravenous parenteral solution 600 mg/300 ml

1

lopinavir-ritonavir oral solution 400-100 mg/5 ml

1

LUGOLS ORAL SOLUTION 5 % 1

MAVYRET ORAL TABLET 100-40 MG 2 PA; SP

mefloquine oral tablet 250 mg 1

meropenem intravenous recon soln 1 gram, 500 mg

1

methenamine hippurate oral tablet 1 gram 1

methenamine mandelate oral tablet 0.5 g, 1 gram

1

metronidazole in nacl (iso-os) intravenous piggyback 500 mg/100 ml

1

metronidazole oral capsule 375 mg 1

metronidazole oral tablet 250 mg, 500 mg 1



8

Drug Tier Notes

minocycline oral capsule 100 mg, 50 mg, 75 mg

1

MYCAMINE INTRAVENOUS RECON SOLN 100 MG, 50 MG

2

nafcillin in dextrose iso-osm intravenous piggyback 1 gram/50 ml, 2 gram/100 ml

1

nafcillin injection recon soln 1 gram, 10 gram, 2 gram

1

nafcillin intravenous recon soln 1 gram, 2 gram

1

NEBUPENT INHALATION RECON SOLN 300 MG

2 SP

neomycin oral tablet 500 mg 1

nevirapine oral suspension 50 mg/5 ml 1

nevirapine oral tablet 200 mg 1

nitrofurantoin macrocrystal oral capsule 100 mg, 50 mg

1

nitrofurantoin monohyd/m-cryst oral capsule100 mg

1

nitrofurantoin oral suspension 25 mg/5 ml 1

NORVIR ORAL CAPSULE 100 MG 2

NORVIR ORAL SOLUTION 80 MG/ML 2

NORVIR ORAL TABLET 100 MG 2

nystatin oral powder 150 million unit, 500 million unit

1

nystatin oral suspension 100,000 unit/ml 1

nystatin oral tablet 500,000 unit 1

ODEFSEY ORAL TABLET 200-25-25 MG 2

ofloxacin oral tablet 300 mg, 400 mg 1

oseltamivir oral capsule 30 mg, 45 mg, 75 mg

1 QL

oseltamivir oral suspension for reconstitution6 mg/ml

1

oxacillin in dextrose(iso-osm) intravenous piggyback 1 gram/50 ml, 2 gram/50 ml

1

oxacillin injection recon soln 1 gram, 10 gram, 2 gram

1

oxacillin intravenous recon soln 1 gram, 2 gram

1



9

Drug Tier Notes

paromomycin oral capsule 250 mg 1

PEGASYS PROCLICK SUBCUTANEOUS PEN INJECTOR 135 MCG/0.5 ML, 180 MCG/0.5 ML

2 SP; QL; QL (2 per 30 days)

PEGASYS SUBCUTANEOUS SOLUTION 180 MCG/ML

2 SP; QL

PEGASYS SUBCUTANEOUS SYRINGE 180 MCG/0.5 ML

2 SP; QL

penicillin g potassium injection recon soln 20 million unit, 5 million unit

1

penicillin g procaine intramuscular syringe1.2 million unit/2 ml, 600,000 unit/ml

1

penicillin g sodium injection recon soln 5 million unit

1

penicillin v potassium oral recon soln 125 mg/5 ml, 250 mg/5 ml

1

penicillin v potassium oral tablet 250 mg, 500 mg

1

piperacillin-tazobactam intravenous recon soln 2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram

1

polymyxin b sulfate injection recon soln500,000 unit

1

PREZCOBIX ORAL TABLET 800-150 MG-MG

2

PREZISTA ORAL SUSPENSION 100 MG/ML

2

PREZISTA ORAL TABLET 150 MG, 600 MG, 75 MG, 800 MG

2

PRIFTIN ORAL TABLET 150 MG 2

PYLERA ORAL CAPSULE 140-125-125 MG 2

pyrazinamide oral tablet 500 mg 1

quinidine gluconate injection solution 80 mg/ml

1

quinidine gluconate oral tablet extended release 324 mg

1

quinidine sulfate oral tablet 200 mg, 300 mg 1

quinine sulfate oral capsule 324 mg 1

RELENZA DISKHALER INHALATION BLISTER WITH DEVICE 5 MG/ACTUATION

2 QL



10

Drug Tier Notes

RESCRIPTOR ORAL TABLET 200 MG 2

RESCRIPTOR ORAL TABLET, DISPERSIBLE 100 MG

2

RETROVIR INTRAVENOUS SOLUTION 10 MG/ML

2

ribavirin oral capsule 200 mg 1 SP

ribavirin oral tablet 200 mg 1 SP

rifabutin oral capsule 150 mg 1

rifampin intravenous recon soln 600 mg 1

rifampin oral capsule 150 mg, 300 mg 1

RIFATER ORAL TABLET 50-120-300 MG 2

rimantadine oral tablet 100 mg 1

SELZENTRY ORAL SOLUTION 20 MG/ML 2

SELZENTRY ORAL TABLET 150 MG, 300 MG

2

SIRTURO ORAL TABLET 100 MG 2

stavudine oral capsule 15 mg, 20 mg, 30 mg, 40 mg

1

stavudine oral recon soln 1 mg/ml 1

STRIBILD ORAL TABLET 150-150-200-300 MG

2

STRONG IODINE ORAL SOLUTION 5 % 1

sulfadiazine oral tablet 500 mg 1

sulfamethoxazole-trimethoprim intravenous solution 400-80 mg/5 ml

1

sulfamethoxazole-trimethoprim oral suspension 200-40 mg/5 ml

1

sulfamethoxazole-trimethoprim oral tablet400-80 mg, 800-160 mg

1

sulfasalazine oral tablet 500 mg 1

sulfasalazine oral tablet,delayed release (dr/ec) 500 mg

1

SUSTIVA ORAL TABLET 600 MG 2

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG

2 SP

SYNAGIS INTRAMUSCULAR SOLUTION 100 MG/ML, 50 MG/0.5 ML

2 SP



11

Drug Tier Notes

TAMIFLU ORAL SUSPENSION FOR RECONSTITUTION 6 MG/ML

2

tenofovir disoproxil fumarate oral tablet 300 mg

1

terbinafine hcl oral tablet 250 mg 1

tetracycline oral capsule 250 mg, 500 mg 1

TIVICAY ORAL TABLET 10 MG, 25 MG, 50 MG

2

tobramycin in 0.225 % nacl inhalation solution for nebulization 300 mg/5 ml

1 SP; QL; QL (280 per 30 days)

tobramycin in 0.9 % nacl intravenous piggyback 60 mg/50 ml

1

tobramycin sulfate injection recon soln 1.2 gram

1

tobramycin sulfate injection solution 10 mg/ml, 40 mg/ml

1

trimethoprim oral tablet 100 mg 1

TRIUMEQ ORAL TABLET 600-50-300 MG 2

TRUVADA ORAL TABLET 200-300 MG 2

UR N-C ORAL TABLET 81.6-10.8-40.8 MG 1

URIMAR-T ORAL TABLET 120-0.12-10.8 MG

1

UROGESIC-BLUE ORAL TABLET 81.6-40.8-0.12 MG

1

valacyclovir oral tablet 1 gram, 500 mg 1 QL

valganciclovir oral recon soln 50 mg/ml 1

valganciclovir oral tablet 450 mg 1

vancomycin in dextrose 5 % intravenous piggyback 1 gram/200 ml, 500 mg/100 ml

2

vancomycin intravenous recon soln 1,000 mg, 10 gram, 5 gram, 500 mg, 750 mg

1

vancomycin oral capsule 125 mg, 250 mg 1

VEMLIDY ORAL TABLET 25 MG 2 SP

VIDEX 2 GRAM PEDIATRIC ORAL RECON SOLN 10 MG/ML (FINAL)

2

VIRACEPT ORAL TABLET 250 MG, 625 MG 2

VIREAD ORAL POWDER 40 MG/SCOOP (40 MG/GRAM)

2 SP



12

Drug Tier Notes

VIREAD ORAL TABLET 150 MG, 200 MG, 250 MG

2 SP

voriconazole intravenous solution 200 mg 1

voriconazole oral suspension for reconstitution 200 mg/5 ml (40 mg/ml)

1 PA

voriconazole oral tablet 200 mg, 50 mg 1 PA

VOSEVI ORAL TABLET 400-100-100 MG 2 PA; SP

XIFAXAN ORAL TABLET 200 MG, 550 MG 2

zidovudine oral capsule 100 mg 1

zidovudine oral syrup 10 mg/ml 1

zidovudine oral tablet 300 mg 1

ANTINEOPLASTIC AGENTS

ADRUCIL INTRAVENOUS SOLUTION 2.5 GRAM/50 ML, 5 GRAM/100 ML, 500 MG/10 ML

1

AFINITOR DISPERZ ORAL TABLET FOR SUSPENSION 2 MG, 3 MG, 5 MG

2 PA; SP

AFINITOR ORAL TABLET 10 MG, 2.5 MG, 5 MG, 7.5 MG

2 PA; SP

ALECENSA ORAL CAPSULE 150 MG 2 PA; SP; QL (240 per 30 days)

ALUNBRIG ORAL TABLET 180 MG, 30 MG, 90 MG

2 PA; SP

ALUNBRIG ORAL TABLETS,DOSE PACK 90 MG (7)- 180 MG (23)

2 PA; SP

anastrozole oral tablet 1 mg 1

azacitidine injection recon soln 100 mg 1 SP

BAVENCIO INTRAVENOUS SOLUTION 20 MG/ML

2

BELEODAQ INTRAVENOUS RECON SOLN 500 MG

2

bexarotene oral capsule 75 mg 1

bicalutamide oral tablet 50 mg 1

bleomycin injection recon soln 15 unit, 30 unit

1

BLINCYTO INTRAVENOUS KIT 35 MCG 2

BOSULIF ORAL TABLET 100 MG, 400 MG, 500 MG

2 PA; SP



13

Drug Tier Notes

CABOMETYX ORAL TABLET 20 MG, 40 MG, 60 MG

2 PA; SP

capecitabine oral tablet 150 mg, 500 mg 1 SP

CAPRELSA ORAL TABLET 100 MG, 300 MG

2 PA; SP

carboplatin intravenous recon soln 150 mg 1

carboplatin intravenous solution 10 mg/ml 1

cisplatin intravenous solution 1 mg/ml 1

cladribine intravenous solution 10 mg/10 ml 1

COMETRIQ ORAL CAPSULE 100 MG/DAY(80 MG X1-20 MG X1), 140 MG/DAY(80 MG X1-20 MG X3), 60 MG/DAY (20 MG X 3/DAY)

2 PA; SP

COTELLIC ORAL TABLET 20 MG 2PA; SP; QL; QL (63 per 28 days)

cyclophosphamide intravenous recon soln 1 gram, 2 gram, 500 mg

1

CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG

2

CYRAMZA INTRAVENOUS SOLUTION 10 MG/ML

2 SP

cytarabine (pf) injection solution 100 mg/5 ml (20 mg/ml), 2 gram/20 ml (100 mg/ml), 20 mg/ml

1

cytarabine injection solution 20 mg/ml 1

dacarbazine intravenous recon soln 100 mg, 200 mg

1

daunorubicin intravenous recon soln 20 mg 1

daunorubicin intravenous solution 5 mg/ml 1

diclofenac sodium topical gel 3 % 1 PA

DOCETAXEL INTRAVENOUS SOLUTION 160 MG/16 ML (10 MG/ML), 160 MG/8 ML (20 MG/ML), 20 MG/2 ML (10 MG/ML), 20 MG/ML, 20 MG/ML (1 ML), 80 MG/4 ML (20 MG/ML), 80 MG/8 ML (10 MG/ML)

2

doxorubicin intravenous recon soln 10 mg, 50 mg

1

doxorubicin intravenous solution 10 mg/5 ml, 2 mg/ml, 20 mg/10 ml, 50 mg/25 ml

1



14

Drug Tier Notes

DROXIA ORAL CAPSULE 200 MG, 300 MG, 400 MG

2

EMCYT ORAL CAPSULE 140 MG 2

epirubicin intravenous recon soln 200 mg, 50 mg

1

epirubicin intravenous solution 50 mg/25 ml 1

ERIVEDGE ORAL CAPSULE 150 MG 2 PA; SP

etoposide intravenous solution 20 mg/ml 1

etoposide oral capsule 50 mg 1

exemestane oral tablet 25 mg 1

FARESTON ORAL TABLET 60 MG 2

FARYDAK ORAL CAPSULE 10 MG, 15 MG, 20 MG

2 PA; SP

FASLODEX INTRAMUSCULAR SYRINGE 250 MG/5 ML

2 SP

floxuridine injection recon soln 0.5 gram 1 SP

FLUOROPLEX TOPICAL CREAM 1 % 2

fluorouracil intravenous solution 1 gram/20 ml, 2.5 gram/50 ml, 5 gram/100 ml, 500 mg/10 ml

1

fluorouracil topical cream 5 % 1

fluorouracil topical solution 2 %, 5 % 1

flutamide oral capsule 125 mg 1

GILOTRIF ORAL TABLET 20 MG 2PA; SP; QL; QL (30 per 30 days)

GILOTRIF ORAL TABLET 30 MG, 40 MG 2 PA; SP; QL

HEXALEN ORAL CAPSULE 50 MG 2

hydroxyurea oral capsule 500 mg 1

IBRANCE ORAL CAPSULE 100 MG, 125 MG, 75 MG

2 PA; SP

ICLUSIG ORAL TABLET 15 MG 2 PA; SP; QL

ICLUSIG ORAL TABLET 45 MG 2PA; SP; QL; QL (30 per 30 days)

idarubicin intravenous solution 1 mg/ml 1

IDHIFA ORAL TABLET 100 MG, 50 MG 2 PA; SP

ifosfamide intravenous recon soln 1 gram, 3 gram

1



15

Drug Tier Notes

ifosfamide intravenous solution 1 gram/20 ml, 3 gram/60 ml

1

ifosfamide-mesna intravenous kit 1-1 gram 1

imatinib oral tablet 100 mg 1 PA; SP

imatinib oral tablet 400 mg 1 PA; SP; QL (60 per 30 days)

IMBRUVICA ORAL CAPSULE 140 MG 2 PA; SP

IMFINZI INTRAVENOUS SOLUTION 50 MG/ML

2 SP

INLYTA ORAL TABLET 1 MG, 5 MG 2 PA; SP


2 SP


2 SP

IRESSA ORAL TABLET 250 MG 2 PA; SP

irinotecan intravenous solution 100 mg/5 ml, 40 mg/2 ml

1

JAKAFI ORAL TABLET 10 MG, 15 MG, 20 MG, 25 MG, 5 MG

2 PA; SP

KADCYLA INTRAVENOUS RECON SOLN 100 MG, 160 MG

2 PA; SP

KEYTRUDA INTRAVENOUS SOLUTION 25 MG/ML

2

LENVIMA ORAL CAPSULE 10 MG/DAY (10 MG X 1/DAY), 14 MG/DAY(10 MG X 1-4 MG X 1), 18 MG/DAY (10 MG X 1-4 MG X2), 20 MG/DAY (10 MG X 2), 24 MG/DAY(10 MG X 2-4 MG X 1), 8 MG/DAY (4 MG X 2)

2 PA

letrozole oral tablet 2.5 mg 1

LEUKERAN ORAL TABLET 2 MG 2

leuprolide subcutaneous kit 1 mg/0.2 ml 1 SP

LONSURF ORAL TABLET 15-6.14 MG, 20-8.19 MG

2 PA; SP

LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG, 22.5 MG

2 PA; SP

LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG

2 PA; SP

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG

2 PA; SP



16

Drug Tier Notes

LUPRON DEPOT-PED INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG (PED)

2 PA; SP

LYNPARZA ORAL CAPSULE 50 MG 2 PA; SP

LYNPARZA ORAL TABLET 100 MG, 150 MG

2 PA; SP

MATULANE ORAL CAPSULE 50 MG 2 SP

megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml), 800 mg/20 ml (20 ml)

1 PA

megestrol oral tablet 20 mg, 40 mg 1 PA

MEKINIST ORAL TABLET 0.5 MG, 2 MG 2 PA; SP

melphalan hcl intravenous recon soln 50 mg 1

mercaptopurine oral tablet 50 mg 1

methotrexate sodium (pf) injection recon soln1 gram

1

methotrexate sodium (pf) injection solution25 mg/ml

1

methotrexate sodium injection solution 25 mg/ml

1

methotrexate sodium oral tablet 2.5 mg 1

mitomycin intravenous recon soln 20 mg, 40 mg, 5 mg

1

mitoxantrone intravenous concentrate 2 mg/ml

1 SP

MYLERAN ORAL TABLET 2 MG 2

NEXAVAR ORAL TABLET 200 MG 2 PA; SP

nilutamide oral tablet 150 mg 1

NINLARO ORAL CAPSULE 2.3 MG 2 PA; SP; QL; QL (6 per 28 days)

NINLARO ORAL CAPSULE 3 MG 2 PA; SP; QL; QL (4 per 28 days)

NINLARO ORAL CAPSULE 4 MG 2 PA; SP; QL; QL (3 per 28 days)

OPDIVO INTRAVENOUS SOLUTION 100 MG/10 ML, 40 MG/4 ML

2

oxaliplatin intravenous recon soln 100 mg, 50 mg

1

oxaliplatin intravenous solution 100 mg/20 ml, 50 mg/10 ml (5 mg/ml)

1

paclitaxel intravenous concentrate 6 mg/ml 1

PICATO TOPICAL GEL 0.015 %, 0.05 % 2



17

Drug Tier Notes

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG

2 SP

PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT

2 SP

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG

2 PA; SP

RITUXAN HYCELA SUBCUTANEOUS SOLUTION 1400 MG/11.7 ML (120 MG/ML), 1600 MG/13.4 ML (120 MG/ML)

2 PA

RUBRACA ORAL TABLET 200 MG, 250 MG, 300 MG

2 PA; SP

RYDAPT ORAL CAPSULE 25 MG 2 PA; SP

SPRYCEL ORAL TABLET 100 MG, 140 MG, 20 MG, 50 MG, 70 MG, 80 MG

2 PA; SP

STIVARGA ORAL TABLET 40 MG 2 PA; SP

SUTENT ORAL CAPSULE 12.5 MG, 25 MG, 37.5 MG, 50 MG

2 PA; SP

SYLATRON SUBCUTANEOUS KIT 200 MCG, 300 MCG, 600 MCG

2 SP

SYLVANT INTRAVENOUS RECON SOLN 100 MG, 400 MG

2 SP

TABLOID ORAL TABLET 40 MG 2

TAFINLAR ORAL CAPSULE 50 MG 2PA; SP; QL; QL (180 per 30 days)

TAFINLAR ORAL CAPSULE 75 MG 2 PA; SP; QL

TAGRISSO ORAL TABLET 40 MG 2PA; SP; QL; QL (60 per 30 days)

TAGRISSO ORAL TABLET 80 MG 2PA; SP; QL; QL (30 per 30 days)

tamoxifen oral tablet 10 mg, 20 mg 1

TARCEVA ORAL TABLET 100 MG, 150 MG, 25 MG

2 PA; SP

TARGRETIN TOPICAL GEL 1 % 2

TASIGNA ORAL CAPSULE 150 MG, 200 MG

2 PA; SP

TECENTRIQ INTRAVENOUS SOLUTION 1,200 MG/20 ML (60 MG/ML)

2 SP

TEMODAR INTRAVENOUS RECON SOLN 100 MG

2 SP



18

Drug Tier Notes

temozolomide oral capsule 100 mg, 140 mg, 180 mg, 20 mg, 250 mg, 5 mg

1 SP

TOPOSAR INTRAVENOUS SOLUTION 20 MG/ML

1

tretinoin (chemotherapy) oral capsule 10 mg 1

TYKERB ORAL TABLET 250 MG 2 PA; SP

UNITUXIN INTRAVENOUS SOLUTION 3.5 MG/ML

2

VALCHLOR TOPICAL GEL 0.016 % 2 SP

VECTIBIX INTRAVENOUS SOLUTION 100 MG/5 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML)

2 SP

VELCADE INJECTION RECON SOLN 3.5 MG

2 SP

VENCLEXTA ORAL TABLET 10 MG, 100 MG, 50 MG

2 PA; SP

VENCLEXTA STARTING PACK ORAL TABLETS,DOSE PACK 10 MG-50 MG- 100 MG

2 PA; SP

vinblastine intravenous solution 1 mg/ml 1

VINCASAR PFS INTRAVENOUS SOLUTION 2 MG/2 ML

1

vincristine intravenous solution 1 mg/ml, 2 mg/2 ml

1

vinorelbine intravenous solution 10 mg/ml, 50 mg/5 ml

1

VOTRIENT ORAL TABLET 200 MG 2 PA; SP

XALKORI ORAL CAPSULE 200 MG, 250 MG

2 PA; SP

XTANDI ORAL CAPSULE 40 MG 2 PA; SP

YONDELIS INTRAVENOUS RECON SOLN 1 MG

2 PA

ZEJULA ORAL CAPSULE 100 MG 2 PA; QL (90 per 30 days)

ZELBORAF ORAL TABLET 240 MG 2 PA; SP

ZOLINZA ORAL CAPSULE 100 MG 2 SP

ZYDELIG ORAL TABLET 100 MG, 150 MG 2 PA

ZYKADIA ORAL CAPSULE 150 MG 2 PA; SP

ZYTIGA ORAL TABLET 250 MG, 500 MG 2 PA; SP



19

Drug Tier Notes

ANTITOXINS,IMMUNE

GLOB,TOXOIDS,VACCINES

AFLURIA 2017-2018 (PF) INTRAMUSCULAR SYRINGE 45 MCG (15 MCG X 3)/0.5 ML

2

AFLURIA 2017-2018 INTRAMUSCULAR SUSPENSION 45 MCG (15 MCG X 3)/0.5 ML

2

AFLURIA QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE 60 MCG/0.5 ML

2

AFLURIA QUAD 2017-2018 INTRAMUSCULAR SUSPENSION 60 MCG/0.5 ML

2

BEXSERO INTRAMUSCULAR SYRINGE 50-50-50-25 MCG/0.5 ML

2

FLUAD 2017-2018 (65 YR UP)(PF) INTRAMUSCULAR SYRINGE 45 MCG (15 MCG X 3)/0.5 ML

2

FLUARIX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

2

FLUCELVAX QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

1

FLUCELVAX QUAD 2017-2018 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

1

FLULAVAL QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

2

FLULAVAL QUAD 2017-2018 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

2

FLUVIRIN 2017-2018 (PF) INTRAMUSCULAR SYRINGE 45 MCG (15 MCG X 3)/0.5 ML

2

FLUVIRIN 2017-2018 INTRAMUSCULAR SUSPENSION 45 MCG (15 MCG X 3)/0.5 ML

2

FLUZONE INTRADERM QUAD 2017-18 INTRADERMAL SYRINGE 36 MCG/0.1 ML

2



20

Drug Tier Notes

FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

2

FLUZONE QUAD 2017-2018 (PF) INTRAMUSCULAR SYRINGE 60 MCG (15 MCG X 4)/0.5 ML

2

FLUZONE QUAD 2017-2018 INTRAMUSCULAR SUSPENSION 60 MCG (15 MCG X 4)/0.5 ML

2

FLUZONE QUAD PEDI 2017-18 (PF) INTRAMUSCULAR SYRINGE 30 MCG (7.5 MCG X 4)/0.25 ML

2

GAMASTAN S/D INTRAMUSCULAR SOLUTION 15-18 % RANGE

2 SP

GAMMAGARD LIQUID INJECTION SOLUTION 10 %

2 SP

GAMMAGARD S-D (IGA < 1 MCG/ML) INTRAVENOUS RECON SOLN 10 GRAM, 5 GRAM

2 SP

GAMUNEX-C INJECTION SOLUTION 1 GRAM/10 ML (10 %), 10 GRAM/100 ML (10 %), 2.5 GRAM/25 ML (10 %), 20 GRAM/200 ML (10 %), 5 GRAM/50 ML (10 %)

2 SP

HIBERIX (PF) INTRAMUSCULAR RECON SOLN 10 MCG/0.5 ML

2

HIZENTRA SUBCUTANEOUS SOLUTION 1 GRAM/5 ML (20 %), 10 GRAM/50 ML (20 %), 2 GRAM/10 ML (20 %), 4 GRAM/20 ML (20 %)

2 SP

HYPERHEP B S/D INTRAMUSCULAR SOLUTION 220 UNIT/ML, 220 UNIT/ML (5 ML)

2 SP

HYPERHEP B S/D INTRAMUSCULAR SYRINGE 220 UNIT/ML

2 SP

HYPERHEP B S-D NEONATAL INTRAMUSCULAR SYRINGE 110 UNIT/0.5 ML

2 SP

HYPERRAB S/D (PF) INTRAMUSCULAR SOLUTION 150 UNIT/ML

2 SP

HYPERRHO S/D INTRAMUSCULAR SYRINGE 1,500 UNIT (300 MCG), 250 UNIT (50 MCG)

2 SP



21

Drug Tier Notes

MENACTRA (PF) INTRAMUSCULAR SOLUTION 4 MCG/0.5 ML

2

PNEUMOVAX 23 INJECTION SOLUTION 25 MCG/0.5 ML

2

PNEUMOVAX 23 INJECTION SYRINGE 25 MCG/0.5 ML

2

PREVNAR 13 (PF) INTRAMUSCULAR SYRINGE 0.5 ML

2

PRIVIGEN INTRAVENOUS SOLUTION 10 %

2 SP

QUADRACEL (PF) INTRAMUSCULAR SUSPENSION 15 LF-48 MCG- 5 LF UNIT/0.5ML

2

ROTATEQ VACCINE ORAL SOLUTION 2 ML

2

TRUMENBA INTRAMUSCULAR SYRINGE 120 MCG/0.5 ML

2

VAXCHORA VACCINE ORAL SUSPENSION FOR RECONSTITUTION 4X10EXP8 TO 2X 10EXP9 CF UNIT

2

WINRHO SDF INJECTION SOLUTION 1,500 UNIT/1.3 ML, 15,000 UNIT/13 ML, 2,500 UNIT/2.2 ML, 5,000 UNIT/4.4 ML

2 SP

ZOSTAVAX (PF) SUBCUTANEOUS SUSPENSION FOR RECONSTITUTION 19,400 UNIT/0.65 ML

2

AUTONOMIC DRUGS

acebutolol oral capsule 200 mg, 400 mg 1

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml

1

albuterol sulfate oral syrup 2 mg/5 ml 1

albuterol sulfate oral tablet 2 mg, 4 mg 1

albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg

1

ANORO ELLIPTA INHALATION BLISTER WITH DEVICE 62.5-25 MCG/ACTUATION

2

atenolol oral tablet 100 mg, 25 mg, 50 mg 1

atenolol-chlorthalidone oral tablet 100-25 mg, 50-25 mg

1



22

Drug Tier Notes

atropine injection solution 0.4 mg/ml, 1 mg/ml 1

atropine injection syringe 0.05 mg/ml, 0.1 mg/ml

1

baclofen oral tablet 10 mg, 20 mg 1

benztropine injection solution 2 mg/2 ml 1

benztropine oral tablet 0.5 mg, 1 mg, 2 mg 1

betaxolol oral tablet 10 mg, 20 mg 1

bethanechol chloride oral tablet 10 mg, 25 mg, 5 mg, 50 mg

1

bisoprolol fumarate oral tablet 10 mg, 5 mg 1

bisoprolol-hydrochlorothiazide oral tablet 10-6.25 mg, 2.5-6.25 mg, 5-6.25 mg

1

BOTOX INJECTION RECON SOLN 100 UNIT, 200 UNIT

2 PA; SP

brompheniramine-pseudoeph-dm oral syrup2-30-10 mg/5 ml

1

bupivacaine-epinephrine (pf) injection solution 0.25 %-1:200,000, 0.5 %-1:200,000

1

bupivacaine-epinephrine injection solution0.25 %-1:200,000, 0.5 %-1:200,000

1

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

1

cevimeline oral capsule 30 mg 1

CHANTIX ORAL TABLET 0.5 MG, 1 MG 2

CHANTIX STARTING MONTH BOX ORAL TABLETS,DOSE PACK 0.5 MG (11)- 1 MG (42)

2

chlorzoxazone oral tablet 250 mg, 500 mg 1

clonidine (pf) epidural solution 1,000 mcg/10 ml (100 mcg/ml)

1

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg

1

clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr

1 QL

COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION

2 QL

cyclobenzaprine oral tablet 10 mg, 5 mg 1

dantrolene oral capsule 100 mg, 25 mg, 50 mg

1



23

Drug Tier Notes

dicyclomine oral capsule 10 mg 1

dicyclomine oral solution 10 mg/5 ml 1

dicyclomine oral tablet 20 mg 1

dihydroergotamine injection solution 1 mg/ml 1

diphenoxylate-atropine oral liquid 2.5-0.025 mg/5 ml

1

diphenoxylate-atropine oral tablet 2.5-0.025 mg

1

dobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml)

1

dobutamine intravenous solution 250 mg/20 ml (12.5 mg/ml), 500 mg/40 ml (12.5 mg/ml)

1

donepezil oral tablet 10 mg, 5 mg 1

donepezil oral tablet,disintegrating 10 mg, 5 mg

1

dopamine in 5 % dextrose intravenous solution 200 mg/250 ml (800 mcg/ml), 400 mg/250 ml (1,600 mcg/ml), 400 mg/500 ml (800 mcg/ml), 800 mg/250 ml (3,200 mcg/ml), 800 mg/500 ml (1,600 mcg/ml)

1

dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 400 mg/10 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/10 ml (80 mg/ml), 800 mg/5 ml (160 mg/ml)

1

doxazosin oral tablet 1 mg, 2 mg, 8 mg 1 QL

doxazosin oral tablet 4 mg 1 QL; QL (30 per 30 days)

DULERA INHALATION HFA AEROSOL INHALER 100-5 MCG/ACTUATION, 200-5 MCG/ACTUATION

2 QL

DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT, 500 UNIT

2 PA; SP

ED-SPAZ ORAL TABLET,DISINTEGRATING 0.125 MG

1

ephedrine sulfate injection solution 50 mg/ml 1

epinephrine injection solution 1 mg/ml, 1 mg/ml (1 ml)

1

epinephrine injection syringe 0.1 mg/ml 1



24

Drug Tier Notes

EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML

2 QL; QL (2 per 30 days)

EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML


ergoloid oral tablet 1 mg 1

galantamine oral capsule,ext rel. pellets 24 hr16 mg, 24 mg, 8 mg

1

galantamine oral solution 4 mg/ml 1

galantamine oral tablet 12 mg, 4 mg, 8 mg 1

glycopyrrolate injection solution 0.2 mg/ml 1

glycopyrrolate oral tablet 1 mg, 2 mg 1

guanidine oral tablet 125 mg 1

hyoscyamine sulfate oral elixir 0.125 mg/5 ml 1

hyoscyamine sulfate oral tablet 0.125 mg 1

hyoscyamine sulfate oral tablet extended release 12 hr 0.375 mg

1

hyoscyamine sulfate oral tablet,disintegrating0.125 mg

1

hyoscyamine sulfate sublingual tablet 0.125 mg

1

ipratropium bromide inhalation solution 0.02 %

1

ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml

1

labetalol intravenous solution 5 mg/ml 1

labetalol intravenous syringe 20 mg/4 ml (5 mg/ml)

1

labetalol oral tablet 100 mg, 200 mg, 300 mg 1

lidocaine-epinephrine injection solution 0.5 %-1:200,000, 1 %-1:100,000, 2 %-1:100,000

1

metaproterenol oral syrup 10 mg/5 ml 1

metaproterenol oral tablet 10 mg, 20 mg 1

metaxalone oral tablet 800 mg 1

methocarbamol oral tablet 500 mg, 750 mg 1

methscopolamine oral tablet 2.5 mg, 5 mg 1

methyldopa oral tablet 250 mg, 500 mg 1

methyldopa-hydrochlorothiazide oral tablet250-15 mg, 250-25 mg

1



25

Drug Tier Notes

methyldopate intravenous solution 250 mg/5 ml

1

metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg

1

metoprolol ta-hydrochlorothiaz oral tablet100-25 mg, 100-50 mg, 50-25 mg

1

metoprolol tartrate intravenous solution 5 mg/5 ml

1

metoprolol tartrate intravenous syringe 5 mg/5 ml

1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

1

midodrine oral tablet 10 mg, 2.5 mg, 5 mg 1

nadolol oral tablet 20 mg, 40 mg, 80 mg 1

nadolol-bendroflumethiazide oral tablet 40-5 mg, 80-5 mg

1

NICOTROL INHALATION CARTRIDGE 10 MG

2

NICOTROL NS NASAL SPRAY,NON-AEROSOL 10 MG/ML

2

norepinephrine bitartrate intravenous solution1 mg/ml

1

orphenadrine citrate injection solution 30 mg/ml

1

orphenadrine citrate oral tablet extended release 100 mg

1

phenylephrine hcl injection solution 10 mg/ml 1

physostigmine salicylate injection solution 1 mg/ml

1

pilocarpine hcl oral tablet 5 mg, 7.5 mg 1

pindolol oral tablet 10 mg, 5 mg 1

prazosin oral capsule 1 mg, 2 mg, 5 mg 1

propantheline oral tablet 15 mg 1

propranolol intravenous solution 1 mg/ml 1

propranolol oral capsule,extended release 24 hr 120 mg, 160 mg, 60 mg, 80 mg

1

propranolol oral solution 20 mg/5 ml (4 mg/ml), 40 mg/5 ml (8 mg/ml)

1



26

Drug Tier Notes

propranolol oral tablet 10 mg, 20 mg, 40 mg, 60 mg, 80 mg

1

propranolol-hydrochlorothiazid oral tablet 40-25 mg, 80-25 mg

1

pyridostigmine bromide oral tablet 60 mg 1

REVONTO INTRAVENOUS RECON SOLN 20 MG

1

rivastigmine tartrate oral capsule 1.5 mg, 3 mg, 4.5 mg, 6 mg

1

rivastigmine transdermal patch 24 hour 13.3 mg/24 hour, 4.6 mg/24 hr, 9.5 mg/24 hr

1

SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG

1

SOTALOL AF ORAL TABLET 120 MG, 160 MG, 80 MG

1

sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg

1

SPIRIVA RESPIMAT INHALATION MIST 1.25 MCG/ACTUATION, 2.5 MCG/ACTUATION

2

SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG


STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION

2

SYMBICORT INHALATION HFA AEROSOL INHALER 160-4.5 MCG/ACTUATION, 80-4.5 MCG/ACTUATION

2 QL

tamsulosin oral capsule,extended release 24hr 0.4 mg

1

terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg

1 QL

terbutaline oral tablet 2.5 mg, 5 mg 1

terbutaline subcutaneous solution 1 mg/ml 1

timolol maleate oral tablet 10 mg, 20 mg, 5 mg

1

tizanidine oral capsule 2 mg, 4 mg, 6 mg 1

tizanidine oral tablet 2 mg, 4 mg 1

trihexyphenidyl oral elixir 0.4 mg/ml 1

trihexyphenidyl oral tablet 2 mg, 5 mg 1



27

Drug Tier Notes

VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION


XEOMIN INTRAMUSCULAR RECON SOLN 100 UNIT, 50 UNIT

2 PA; SP

BLOOD DERIVATIVES

albumin, human 25 % intravenous parenteral solution 25 %

1

ALBURX (HUMAN) 25 % INTRAVENOUS PARENTERAL SOLUTION 25 %

1

ALBUTEIN 25 % INTRAVENOUS PARENTERAL SOLUTION 25 %

1

ALBUTEIN 5 % INTRAVENOUS PARENTERAL SOLUTION 5 %

1

BLOOD FORMATION, COAGULATION,

THROMBOSIS

ADVATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 4,000 (+/-) UNIT, 500 (+/-) UNIT

2 SP

ADYNOVATE INTRAVENOUS SOLUTION 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT, 750 (+/-) UNIT

2

AFSTYLA INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT RANGE, 1,500 (+/-) UNIT RANGE, 2,000 (+/-) UNIT RANGE, 2,500 (+/-) UNIT RANGE, 250 (+/-) UNIT RANGE, 3,000 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE

2 SP

ALPHANATE INTRAVENOUS RECON SOLN 1,000 (400 VWF) UNIT/10 ML, 1,500 (600 VWF) UNIT/10 ML, 250 (100 VWF) UNIT/5 ML, 500 (200 VWF) UNIT/5 ML

2 SP

ALPROLIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 3,000 UNIT, 4,000 UNIT, 500 UNIT

2

aminocaproic acid intravenous solution 250 mg/ml

1

anagrelide oral capsule 0.5 mg, 1 mg 1



28

Drug Tier Notes

ARANESP (IN POLYSORBATE) INJECTION SOLUTION 100 MCG/ML, 150 MCG/0.75 ML, 200 MCG/ML, 25 MCG/ML, 300 MCG/ML, 40 MCG/ML, 60 MCG/ML

2 PA; SP

ARANESP (IN POLYSORBATE) INJECTION SYRINGE 100 MCG/0.5 ML, 150 MCG/0.3 ML, 200 MCG/0.4 ML, 25 MCG/0.42 ML, 300 MCG/0.6 ML, 40 MCG/0.4 ML, 500 MCG/ML, 60 MCG/0.3 ML

2 PA; SP

aspirin-dipyridamole oral capsule, er multiphase 12 hr 25-200 mg

1

BAL-CARE DHA ORAL COMBO PACK,TABLET AND CAP,DR 27-1-430 MG

1

BENEFIX INTRAVENOUS RECON SOLN 1,000 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT

2 SP

butalbital-aspirin-caffeine oral capsule 50-325-40 mg

1

butalbital-aspirin-caffeine oral tablet 50-325-40 mg

1

CATHFLO ACTIVASE INTRA-CATHETER RECON SOLN 2 MG

2

cilostazol oral tablet 100 mg, 50 mg 1

clopidogrel oral tablet 300 mg, 75 mg 1

COAGADEX INTRAVENOUS RECON SOLN 250 (+/-) UNIT RANGE, 500 (+/-) UNIT RANGE

2

CORIFACT INTRAVENOUS RECON SOLN 1,000-1,600 UNIT

2 SP

desmopressin injection solution 4 mcg/ml 1 PA

desmopressin nasal solution 0.1 mg/ml (refrigerate)

1

desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml)

1

desmopressin oral tablet 0.1 mg, 0.2 mg 1 PA

dipyridamole intravenous solution 5 mg/ml 1

dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1

ELITE-OB 400 ORAL CAPSULE 35-5-1.2-400 MG

1



29

Drug Tier Notes

ELOCTATE INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 4,000 UNIT, 5,000 UNIT, 500 UNIT, 6,000 UNIT, 750 UNIT

2 SP

enoxaparin subcutaneous solution 300 mg/3 ml

1 SP

enoxaparin subcutaneous syringe 100 mg/ml, 120 mg/0.8 ml, 150 mg/ml, 30 mg/0.3 ml, 40 mg/0.4 ml, 60 mg/0.6 ml, 80 mg/0.8 ml

1 SP

EPOGEN INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML

2 PA; SP

FEIBA NF INTRAVENOUS RECON SOLN 1,750-3,250 UNIT, 400-650 UNIT, 651-1,200 UNIT

2 SP

FOLIVANE-OB ORAL CAPSULE 85-1 MG 1

HELIXATE FS INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT

2 SP

HEP FLUSH-10 (PF) INTRAVENOUS SOLUTION 10 UNIT/ML

1

heparin (porcine) in 5 % dex intravenous parenteral solution 20,000 unit/500 ml (40 unit/ml), 25,000 unit/250 ml(100 unit/ml), 25,000 unit/500 ml (50 unit/ml)

1

heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml

1

heparin (porcine) injection cartridge 5,000 unit/ml (1 ml)

1

heparin (porcine) injection solution 1,000 unit/ml, 10,000 unit/ml, 20,000 unit/ml, 5,000 unit/ml

1

heparin flush(porcine)-0.9nacl intravenous kit100 unit/ml

1

heparin lock flush (porcine) intravenous syringe 100 unit/ml

1

HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE 10 UNIT/ML

1



30

Drug Tier Notes

HEPARIN LOCK INTRAVENOUS SOLUTION 100 UNIT/ML

1

HEPARIN LOCKFLUSH(PORCINE)(PF) INTRAVENOUS SYRINGE 10 UNIT/ML, 100 UNIT/ML

1

heparin(porcine) in 0.45% nacl intravenous parenteral solution 25,000 unit/250 ml, 25,000 unit/500 ml

1

heparin, porcine (pf) injection solution 1,000 unit/ml, 5,000 unit/0.5 ml

1

heparin, porcine (pf) injection syringe 5,000 unit/0.5 ml

1

heparin, porcine (pf) intravenous syringe 1 unit/ml, 100 unit/ml

1

IDELVION INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT

2 SP

INFED INJECTION SOLUTION 100 MG/2 ML (50 MG/ML)

1

IXINITY INTRAVENOUS RECON SOLN 1,000 UNIT, 1,500 UNIT, 2,000 UNIT, 250 UNIT, 3,000 UNIT, 500 UNIT

2 SP

JANTOVEN ORAL TABLET 1 MG, 10 MG, 2 MG, 2.5 MG, 3 MG, 4 MG, 5 MG, 6 MG, 7.5 MG

1

KOVALTRY INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT

2 SP

LEUKINE INJECTION RECON SOLN 250 MCG

2 SP

MOZOBIL SUBCUTANEOUS SOLUTION 24 MG/1.2 ML (20 MG/ML)

2 SP

MYNATAL ADVANCE ORAL TABLET 90-1-50 MG

1

MYNATAL ORAL CAPSULE 65 MG IRON- 1 MG

1

MYNATAL PLUS ORAL TABLET 65 MG IRON- 1 MG

1

MYNATAL-Z ORAL TABLET 65 MG IRON- 1 MG

1



31

Drug Tier Notes

NEULASTA SUBCUTANEOUS SYRINGE 6 MG/0.6ML

2 PA; SP; QL

NEULASTA SUBCUTANEOUS SYRINGE, W/ WEARABLE INJECTOR 6 MG/0.6 ML

2 PA; SP; QL

NEUPOGEN INJECTION SOLUTION 300 MCG/ML, 480 MCG/1.6 ML

2 PA; SP

NEUPOGEN INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML

2 PA; SP

NOVOEIGHT INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT

2

NUWIQ INTRAVENOUS RECON SOLN 1000 (+/-) UNIT, 2,000 (+/-) UNIT, 2,500 UNIT, 250 (+/-) UNIT, 3,000 UNIT, 4,000 UNIT, 500 (+/-) UNIT

2 SP

OBIZUR INTRAVENOUS RECON SOLN 500 (+/-) UNIT RANGE

2 PA

pentoxifylline oral tablet extended release400 mg

1

PNV OB+DHA ORAL COMBO PACK 27-1-50-250 MG

1

PNV-DHA + DOCUSATE ORAL CAPSULE 27-1.25-55-300 MG

1

PNV-DHA ORAL CAPSULE 27 MG IRON-1 MG -300 MG

1

PNV-OMEGA ORAL CAPSULE 28-1-300 MG

1

PNV-SELECT ORAL TABLET 27-1 MG 1

PR NATAL 400 EC ORAL COMBO PACK,TABLET AND CAP,DR 29-1-400 MG

1

PR NATAL 400 ORAL COMBO PACK 29-1-400 MG

1


1

PR NATAL 430 ORAL COMBO PACK 29 MG IRON-1 MG -430 MG

1

PRADAXA ORAL CAPSULE 110 MG, 150 MG, 75 MG

2

prasugrel oral tablet 10 mg, 5 mg 1



32

Drug Tier Notes

PRENAISSANCE ORAL CAPSULE 29-1.25-55-325 MG

1

PRENAISSANCE PLUS ORAL CAPSULE 28-1-50-250 MG

1

PRENATABS FA ORAL TABLET 29-1 MG 1

PRENATABS RX ORAL TABLET 29 MG IRON- 1 MG

1

PRENATAL LOW IRON ORAL TABLET 27 MG IRON- 1 MG

1

PRENATAL PLUS (CALCIUM CARB) ORAL TABLET 27 MG IRON- 1 MG

1

PRENATAL PLUS ORAL TABLET 29 MG IRON- 1 MG

1

PROCRIT INJECTION SOLUTION 10,000 UNIT/ML, 2,000 UNIT/ML, 20,000 UNIT/2 ML, 20,000 UNIT/ML, 3,000 UNIT/ML, 4,000 UNIT/ML, 40,000 UNIT/ML

2 PA; SP

PROMACTA ORAL TABLET 12.5 MG, 25 MG, 50 MG, 75 MG

2 PA; SP

RECOMBINATE INTRAVENOUS RECON SOLN 1,000 (+/-) UNIT, 1,500 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT

2 SP

SE-NATAL 19 (WITH DOCUSATE) ORAL TABLET 29 MG IRON- 1 MG-25 MG

1

SE-NATAL 19 ORAL TABLET,CHEWABLE 29 MG IRON- 1 MG

1

TARON-C DHA ORAL CAPSULE 35-1-200 MG

1

TARON-PREX PRENATAL-DHA ORAL CAPSULE 30 MG IRON-1.2 MG-55 MG-265 MG

1

ticlopidine oral tablet 250 mg 1

TL-SELECT ORAL CAPSULE 29-1.25-55-325 MG

1

TRETTEN INTRAVENOUS RECON SOLN 2,500 UNIT

2 SP

TRIADVANCE ORAL TABLET 90-1-50 MG 1

TRINATAL GT ORAL TABLET 90-1-50 MG 1



33

Drug Tier Notes

TRINATAL RX 1 ORAL TABLET 60 MG IRON-1 MG

1

TRINATE ORAL TABLET 28 MG IRON- 1 MG

1

TRIVEEN-DUO DHA ORAL COMBO PACK 29-1-400 MG

1

TRIVEEN-ONE ORAL CAPSULE 27 MG IRON-1 MG -250 MG

1

TRIVEEN-PRX RNF ORAL CAPSULE 26-1.2-55-300 MG

1

TRI-VIT WITH FLUORIDE AND IRON ORAL DROPS 0.25-10 MG/ML

1

ULTIMATECARE ONE NF ORAL CAPSULE 27-1-50-500 MG

1

ULTIMATECARE ONE ORAL CAPSULE 27-1-330 MG

1

VEMAVITE-PRX-2 ORAL CAPSULE 27-1.25-55-300 MG

1

VENA-BAL DHA ORAL COMBO PACK,TABLET AND CAP,DR 27-1-430 MG

1

VENOFER INTRAVENOUS SOLUTION 100 MG IRON/5 ML, 200 MG IRON/10 ML, 50 MG IRON/2.5 ML

2

VINACAL ORAL TABLET 27-1-50 MG 1

VINATE CARE ORAL TABLET,CHEWABLE 40 MG IRON- 1 MG

1

VINATE GT ORAL TABLET 90-1-50 MG 1

VINATE ONE ORAL TABLET 60 MG IRON-1 MG

1

VINATE ULTRA ORAL TABLET 90-1-50 MG 1

VIRT-PN DHA ORAL CAPSULE 27 MG IRON-1 MG -300 MG

1

VIRT-PN ORAL TABLET 27-1 MG 1

VIRT-PN PLUS ORAL CAPSULE 28-1-300 MG

1

VIRT-SELECT ORAL CAPSULE 29-1.25-55-325 MG

1

VITAFOL-OB ORAL TABLET 65-1 MG 1

VOL-NATE ORAL TABLET 28 MG IRON- 1 MG

1



34

Drug Tier Notes

VOL-TAB RX ORAL TABLET 29 MG IRON- 1 MG

1

VONVENDI INTRAVENOUS RECON SOLN 1,300 (+/-) UNIT RANGE, 650 (+/-) UNIT RANGE

2

warfarin oral tablet 1 mg, 10 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, 7.5 mg

1

XARELTO ORAL TABLET 10 MG, 15 MG, 20 MG

2

XARELTO ORAL TABLETS,DOSE PACK 15 MG (42)- 20 MG (9)

2

XYNTHA INTRAVENOUS SOLUTION 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 500 (+/-) UNIT

2 SP

XYNTHA SOLOFUSE INTRAVENOUS SYRINGE 1,000 (+/-) UNIT, 2,000 (+/-) UNIT, 250 (+/-) UNIT, 3,000 (+/-) UNIT, 500 (+/-) UNIT

2 SP

ZARXIO INJECTION SYRINGE 300 MCG/0.5 ML, 480 MCG/0.8 ML

2 PA; SP

ZATEAN-CH ORAL CAPSULE 27-1-50-250 MG

1

ZATEAN-PN DHA ORAL CAPSULE 27 MG IRON-1 MG -300 MG

1

ZATEAN-PN PLUS ORAL CAPSULE 28-1-300 MG

1

CARDIOVASCULAR DRUGS

acebutolol oral capsule 200 mg, 400 mg 1

acetazolamide oral capsule, extended release 500 mg

1

acetazolamide oral tablet 125 mg, 250 mg 1

acetazolamide sodium injection recon soln500 mg

1

adenosine (diagnostic) intravenous solution 3 mg/ml

1

adenosine intravenous solution 3 mg/ml 1

alprostadil injection solution 500 mcg/ml 1

amiloride-hydrochlorothiazide oral tablet 5-50 mg

1

amiodarone intravenous solution 50 mg/ml 1



35

Drug Tier Notes

amiodarone oral tablet 100 mg, 200 mg, 400 mg

1

amlodipine oral tablet 10 mg, 2.5 mg, 5 mg 1

amlodipine-benazepril oral capsule 10-20 mg, 10-40 mg, 2.5-10 mg, 5-10 mg, 5-20 mg, 5-40 mg

1


1

atenolol oral tablet 100 mg, 25 mg, 50 mg 1


1

atorvastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg

1 QL

benazepril oral tablet 10 mg, 20 mg, 40 mg, 5 mg

1

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

1

betaxolol oral tablet 10 mg, 20 mg 1

bisoprolol fumarate oral tablet 10 mg, 5 mg 1


1

bumetanide injection solution 0.25 mg/ml 1

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1

captopril oral tablet 100 mg, 12.5 mg, 25 mg, 50 mg

1

captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg

1

CARTIA XT ORAL CAPSULE,EXTENDED RELEASE 24HR 120 MG, 180 MG, 240 MG, 300 MG

1

carvedilol oral tablet 12.5 mg, 25 mg, 3.125 mg, 6.25 mg

1

chlorothiazide oral tablet 250 mg, 500 mg 1

chlorthalidone oral tablet 25 mg, 50 mg 1

cholestyramine (with sugar) oral powder 4 gram

1

cholestyramine (with sugar) oral powder in packet 4 gram

1



36

Drug Tier Notes

CHOLESTYRAMINE LIGHT ORAL POWDER 4 GRAM

1

CHOLESTYRAMINE LIGHT ORAL POWDER IN PACKET 4 GRAM

1

cilostazol oral tablet 100 mg, 50 mg 1


1

clonidine hcl oral tablet 0.1 mg, 0.2 mg, 0.3 mg

1

clonidine transdermal patch weekly 0.1 mg/24 hr, 0.2 mg/24 hr, 0.3 mg/24 hr

1 QL

colestipol oral granules 5 gram 1

colestipol oral packet 5 gram 1

colestipol oral tablet 1 gram 1

CORLANOR ORAL TABLET 5 MG, 7.5 MG 2 PA

DIGOX ORAL TABLET 125 MCG, 250 MCG 1

digoxin injection solution 250 mcg/ml 1

digoxin injection syringe 250 mcg/ml 1

digoxin oral solution 50 mcg/ml 1

digoxin oral tablet 125 mcg, 250 mcg 1

DILANTIN ORAL CAPSULE 30 MG 2

diltiazem hcl intravenous recon soln 100 mg 1

diltiazem hcl intravenous solution 5 mg/ml 1

diltiazem hcl oral capsule,ext.rel 24h degradable 120 mg, 180 mg, 240 mg

1

diltiazem hcl oral capsule,extended release 12 hr 120 mg, 60 mg, 90 mg

1

diltiazem hcl oral capsule,extended release 24 hr 120 mg, 180 mg, 240 mg, 300 mg, 360 mg, 420 mg

1

diltiazem hcl oral capsule,extended release 24hr 120 mg, 180 mg, 240 mg, 300 mg

1

diltiazem hcl oral tablet 120 mg, 30 mg, 60 mg, 90 mg

1

DILT-XR ORAL CAPSULE,EXT.REL 24H DEGRADABLE 120 MG, 180 MG, 240 MG

1

dipyridamole intravenous solution 5 mg/ml 1

dipyridamole oral tablet 25 mg, 50 mg, 75 mg 1



37

Drug Tier Notes

disopyramide phosphate oral capsule 100 mg, 150 mg

1

dobutamine in d5w intravenous parenteral solution 1,000 mg/250 ml (4,000 mcg/ml), 250 mg/250 ml (1 mg/ml), 500 mg/250 ml (2,000 mcg/ml)

1

dobutamine intravenous solution 250 mg/20 ml (12.5 mg/ml), 500 mg/40 ml (12.5 mg/ml)

1

dofetilide oral capsule 125 mcg, 250 mcg, 500 mcg

1

dopamine in 5 % dextrose intravenous solution 200 mg/250 ml (800 mcg/ml), 400 mg/250 ml (1,600 mcg/ml), 400 mg/500 ml (800 mcg/ml), 800 mg/250 ml (3,200 mcg/ml), 800 mg/500 ml (1,600 mcg/ml)

1

dopamine intravenous solution 200 mg/5 ml (40 mg/ml), 400 mg/10 ml (40 mg/ml), 400 mg/5 ml (80 mg/ml), 800 mg/10 ml (80 mg/ml), 800 mg/5 ml (160 mg/ml)

1

doxazosin oral tablet 1 mg, 2 mg, 8 mg 1 QL

doxazosin oral tablet 4 mg 1 QL; QL (30 per 30 days)

enalapril maleate oral tablet 10 mg, 2.5 mg, 20 mg, 5 mg

1

enalaprilat intravenous solution 1.25 mg/ml 1

enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg

1

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG

2

ENTRESTO ORAL TABLET 24-26 MG, 49-51 MG, 97-103 MG

2 PA

eplerenone oral tablet 25 mg, 50 mg 1

epoprostenol (glycine) intravenous recon soln 0.5 mg, 1.5 mg

1 SP

ezetimibe oral tablet 10 mg 1 QL

felodipine oral tablet extended release 24 hr10 mg, 2.5 mg, 5 mg

1

fenofibrate micronized oral capsule 130 mg, 134 mg, 200 mg, 43 mg, 67 mg

1

fenofibrate nanocrystallized oral tablet 145 mg, 48 mg

1



38

Drug Tier Notes

fenofibrate oral tablet 160 mg, 54 mg 1

fenofibric acid (choline) oral capsule,delayed release(dr/ec) 135 mg, 45 mg

1

FISH OIL ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG-180 MG- 60 MG-1,200 MG

2

flecainide oral tablet 100 mg, 150 mg, 50 mg 1

fosinopril oral tablet 10 mg, 20 mg, 40 mg 1

fosinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg

1

furosemide injection solution 10 mg/ml 1

furosemide injection syringe 10 mg/ml 1

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

1

furosemide oral tablet 20 mg, 40 mg, 80 mg 1

gemfibrozil oral tablet 600 mg 1

guanfacine oral tablet 1 mg, 2 mg 1

guanfacine oral tablet extended release 24 hr1 mg, 2 mg, 3 mg, 4 mg

1

hydralazine injection solution 20 mg/ml 1

hydralazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg

1

hydrochlorothiazide oral capsule 12.5 mg 1

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

1

indapamide oral tablet 1.25 mg, 2.5 mg 1

irbesartan oral tablet 150 mg, 300 mg, 75 mg 1

irbesartan-hydrochlorothiazide oral tablet150-12.5 mg, 300-12.5 mg

1

isosorbide dinitrate oral tablet 10 mg, 20 mg, 30 mg, 5 mg

1

isosorbide dinitrate oral tablet extended release 40 mg

1

isosorbide mononitrate oral tablet 10 mg, 20 mg

1

isosorbide mononitrate oral tablet extended release 24 hr 120 mg, 30 mg, 60 mg

1

isradipine oral capsule 2.5 mg, 5 mg 1



39

Drug Tier Notes

labetalol intravenous solution 5 mg/ml 1

labetalol intravenous syringe 20 mg/4 ml (5 mg/ml)

1

labetalol oral tablet 100 mg, 200 mg, 300 mg 1

LETAIRIS ORAL TABLET 10 MG, 5 MG 2 PA; SP

lidocaine (pf) intravenous solution 20 mg/ml (2 %)

1

lidocaine (pf) intravenous syringe 100 mg/5 ml (2 %), 50 mg/5 ml (1 %)

1

lidocaine in 5 % dextrose (pf) intravenous parenteral solution 8 mg/ml (0.8 %)

1

lisinopril oral tablet 10 mg, 2.5 mg, 20 mg, 30 mg, 40 mg, 5 mg

1

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

1

losartan oral tablet 100 mg, 25 mg, 50 mg 1

losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg

1

lovastatin oral tablet 10 mg, 20 mg 1 QL

lovastatin oral tablet 40 mg 1 QL; QL (30 per 30 days)

magnesium sulfate in water intravenous parenteral solution 20 gram/500 ml (4 %), 40 gram/1,000 ml (4 %)

1

magnesium sulfate in water intravenous piggyback 2 gram/50 ml (4 %), 4 gram/100 ml (4 %), 4 gram/50 ml (8 %)

1

magnesium sulfate injection solution 4 meq/ml (50 %)

1

magnesium sulfate injection syringe 4 meq/ml

1

mannitol 10 % intravenous parenteral solution 10 %

1


1

mannitol 25 % intravenous solution 25 % 1

mannitol 5 % intravenous parenteral solution5 %

1

methyldopa oral tablet 250 mg, 500 mg 1



40

Drug Tier Notes


1

methyldopate intravenous solution 250 mg/5 ml

1

metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1

metoprolol succinate oral tablet extended release 24 hr 100 mg, 200 mg, 25 mg, 50 mg

1


1

metoprolol tartrate intravenous solution 5 mg/5 ml

1

metoprolol tartrate intravenous syringe 5 mg/5 ml

1

metoprolol tartrate oral tablet 100 mg, 25 mg, 50 mg

1

mexiletine oral capsule 150 mg, 200 mg, 250 mg

1

milrinone in 5 % dextrose intravenous piggyback 20 mg/100 ml (200 mcg/ml), 40 mg/200 ml (200 mcg/ml)

1

milrinone intravenous solution 1 mg/ml 1

minoxidil oral tablet 10 mg, 2.5 mg 1

moexipril oral tablet 15 mg, 7.5 mg 1

moexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25 mg, 7.5-12.5 mg

1

nadolol oral tablet 20 mg, 40 mg, 80 mg 1


1

nicardipine intravenous solution 25 mg/10 ml 1

nicardipine oral capsule 20 mg, 30 mg 1

nifedipine oral capsule 10 mg, 20 mg 1

nifedipine oral tablet extended release 24hr30 mg, 60 mg, 90 mg

1

nifedipine oral tablet extended release 30 mg, 60 mg, 90 mg

1

nimodipine oral capsule 30 mg 1

NITRO-BID TRANSDERMAL OINTMENT 2 %

1



41

Drug Tier Notes

nitroglycerin in 5 % dextrose intravenous solution 100 mg/250 ml (400 mcg/ml), 200 mg/500 ml (400 mcg/ml), 50 mg/250 ml (200 mcg/ml)

1

nitroglycerin intravenous solution 50 mg/10 ml (5 mg/ml)

1

nitroglycerin sublingual tablet 0.3 mg, 0.4 mg, 0.6 mg

1

nitroglycerin transdermal patch 24 hour 0.1 mg/hr, 0.2 mg/hr, 0.4 mg/hr, 0.6 mg/hr

1

nitroglycerin translingual spray,non-aerosol400 mcg/spray

1

omega-3 acid ethyl esters oral capsule 1 gram

1 PA

papaverine injection solution 30 mg/ml 1

perindopril erbumine oral tablet 2 mg, 4 mg, 8 mg

1

phenytoin oral suspension 100 mg/4 ml, 125 mg/5 ml

1

phenytoin oral tablet,chewable 50 mg 1

phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg

1

phenytoin sodium intravenous solution 50 mg/ml

1

phenytoin sodium intravenous syringe 50 mg/ml

1

pindolol oral tablet 10 mg, 5 mg 1

PRALUENT PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML, 75 MG/ML

2 PA; SP

pravastatin oral tablet 10 mg, 20 mg, 40 mg, 80 mg

1 QL

prazosin oral capsule 1 mg, 2 mg, 5 mg 1

procainamide injection solution 100 mg/ml, 500 mg/ml

1

propafenone oral tablet 150 mg, 225 mg, 300 mg

1



1



42

Drug Tier Notes


1


1


1

quinapril oral tablet 10 mg, 20 mg, 40 mg, 5 mg

1

quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

1

quinidine gluconate injection solution 80 mg/ml

1

quinidine gluconate oral tablet extended release 324 mg

1

quinidine sulfate oral tablet 200 mg, 300 mg 1

ramipril oral capsule 1.25 mg, 10 mg, 2.5 mg, 5 mg

1

REPATHA PUSHTRONEX SUBCUTANEOUS WEARABLE INJECTOR 420 MG/3.5 ML

2 PA

REPATHA SURECLICK SUBCUTANEOUS PEN INJECTOR 140 MG/ML

2 PA; SP

REPATHA SYRINGE SUBCUTANEOUS SYRINGE 140 MG/ML

2 PA

rosuvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg

1 ST

sildenafil (antihypertensive) intravenous solution 10 mg/12.5 ml

1 PA; SP

sildenafil (antihypertensive) oral tablet 20 mg 1 PA; SP; QL

simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg, 80 mg

1 QL

SORINE ORAL TABLET 120 MG, 160 MG, 240 MG, 80 MG

1

SOTALOL AF ORAL TABLET 120 MG, 160 MG, 80 MG

1

sotalol oral tablet 120 mg, 160 mg, 240 mg, 80 mg

1

spironolactone oral tablet 100 mg, 25 mg, 50 mg

1



43

Drug Tier Notes

spironolacton-hydrochlorothiaz oral tablet 25-25 mg

1

terazosin oral capsule 1 mg, 10 mg, 2 mg, 5 mg

1 QL

THEOCHRON ORAL TABLET EXTENDED RELEASE 12 HR 100 MG, 200 MG, 300 MG

1

theophylline oral elixir 80 mg/15 ml 1

theophylline oral solution 80 mg/15 ml 1

theophylline oral tablet extended release 12 hr 100 mg, 200 mg, 300 mg, 450 mg

1

theophylline oral tablet extended release 24 hr 400 mg, 600 mg

1


1

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg

1

TRACLEER ORAL TABLET 125 MG, 62.5 MG

2 PA; SP

TRACLEER ORAL TABLET FOR SUSPENSION 32 MG

2 PA; SP

trandolapril oral tablet 1 mg, 2 mg, 4 mg 1

triamterene-hydrochlorothiazid oral capsule37.5-25 mg, 50-25 mg

1

triamterene-hydrochlorothiazid oral tablet37.5-25 mg, 75-50 mg

1

UPTRAVI ORAL TABLET 1,000 MCG, 1,200 MCG, 1,400 MCG, 1,600 MCG, 200 MCG, 400 MCG, 600 MCG, 800 MCG

2 PA

UPTRAVI ORAL TABLETS,DOSE PACK 200 MCG (140)- 800 MCG (60)

2 PA

valsartan oral tablet 160 mg, 320 mg, 40 mg, 80 mg

1

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

1

VELETRI INTRAVENOUS RECON SOLN 0.5 MG, 1.5 MG

1 SP

verapamil intravenous solution 2.5 mg/ml 1

verapamil intravenous syringe 2.5 mg/ml 1



44

Drug Tier Notes

verapamil oral capsule, 24 hr er pellet ct 100 mg, 200 mg, 300 mg

1

verapamil oral capsule,ext rel. pellets 24 hr120 mg, 180 mg, 240 mg, 360 mg

1

verapamil oral tablet 120 mg, 40 mg, 80 mg 1

verapamil oral tablet extended release 120 mg, 180 mg, 240 mg

1

WELCHOL ORAL POWDER IN PACKET 3.75 GRAM

2

WELCHOL ORAL TABLET 625 MG 2

CENTRAL NERVOUS SYSTEM AGENTS

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL RECON 300 MG, 400 MG

2

ABILIFY MAINTENA INTRAMUSCULAR SUSPENSION,EXTENDED REL SYRING 300 MG, 400 MG

2

acamprosate oral tablet,delayed release (dr/ec) 333 mg

1

acetaminophen-codeine oral solution 120 mg-12 mg /5 ml (5 ml), 120-12 mg/5 ml

1 QL (4500 per 30 days)

acetaminophen-codeine oral solution 300 mg-30 mg /12.5 ml


acetaminophen-codeine oral tablet 300-15 mg, 300-30 mg


acetaminophen-codeine oral tablet 300-60 mg


alprazolam oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg

1

amantadine hcl oral capsule 100 mg 1

amantadine hcl oral solution 50 mg/5 ml 1

amantadine hcl oral tablet 100 mg 1

amitriptyline oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

1

amitriptyline-chlordiazepoxide oral tablet12.5-5 mg, 25-10 mg

1

amoxapine oral tablet 100 mg, 150 mg, 25 mg, 50 mg

1

aripiprazole oral solution 1 mg/ml 1 ST



45

Drug Tier Notes

aripiprazole oral tablet 10 mg, 15 mg, 2 mg, 20 mg, 30 mg, 5 mg

1 ST; QL

aripiprazole oral tablet,disintegrating 10 mg, 15 mg

1 ST; QL

ASCOMP WITH CODEINE ORAL CAPSULE 30-50-325-40 MG



1

atomoxetine oral capsule 10 mg, 100 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg

1

AUSTEDO ORAL TABLET 12 MG, 6 MG, 9 MG

2 PA

BANZEL ORAL SUSPENSION 40 MG/ML 2 PA

BANZEL ORAL TABLET 200 MG, 400 MG 2 PA

belladonna alkaloids-opium rectal suppository 16.2-60 mg


BELLADONNA-OPIUM RECTAL SUPPOSITORY 16.2-30 MG


benztropine injection solution 2 mg/2 ml 1

benztropine oral tablet 0.5 mg, 1 mg, 2 mg 1

bromocriptine oral tablet 2.5 mg 1

buprenorphine hcl injection syringe 0.3 mg/ml 1

buprenorphine hcl sublingual tablet 2 mg 1 QL; QL (360 per 30 days)

buprenorphine hcl sublingual tablet 8 mg 1 QL; QL (90 per 30 days)

buprenorphine-naloxone sublingual tablet 2-0.5 mg


buprenorphine-naloxone sublingual tablet 8-2 mg


bupropion hcl (smoking deter) oral tablet extended release 12 hr 150 mg

1

bupropion hcl oral tablet 100 mg, 75 mg 1

bupropion hcl oral tablet extended release 12 hr 100 mg, 150 mg

1 QL

bupropion hcl oral tablet extended release 12 hr 200 mg





1 QL



46

Drug Tier Notes

buspirone oral tablet 10 mg, 15 mg, 30 mg, 5 mg, 7.5 mg

1

BUTALBITAL COMPOUND W/CODEINE ORAL CAPSULE 30-50-325-40 MG


butalbital-acetaminop-caf-cod oral capsule50-325-40-30 mg


butalbital-acetaminophen oral tablet 50-325 mg

1 QL (180 per 30 days)

butalbital-acetaminophen-caff oral capsule50-325-40 mg


butalbital-acetaminophen-caff oral tablet 50-325-40 mg


butalbital-aspirin-caffeine oral capsule 50-325-40 mg

1

cabergoline oral tablet 0.5 mg 1

caffeine citrate intravenous solution 60 mg/3 ml (20 mg/ml)

1

caffeine citrate oral solution 60 mg/3 ml (20 mg/ml)

1

carbamazepine oral capsule, er multiphase 12 hr 100 mg, 200 mg, 300 mg

1

carbamazepine oral suspension 100 mg/5 ml 1

carbamazepine oral tablet 200 mg 1

carbamazepine oral tablet extended release 12 hr 100 mg, 200 mg, 400 mg

1

carbamazepine oral tablet,chewable 100 mg 1

carbidopa-levodopa oral tablet 10-100 mg, 25-100 mg, 25-250 mg

1

carbidopa-levodopa oral tablet extended release 25-100 mg, 50-200 mg

1

carbidopa-levodopa oral tablet,disintegrating10-100 mg, 25-100 mg, 25-250 mg

1

carbidopa-levodopa-entacapone oral tablet12.5-50-200 mg, 18.75-75-200 mg, 25-100-200 mg, 31.25-125-200 mg, 37.5-150-200 mg, 50-200-200 mg

1

celecoxib oral capsule 100 mg, 200 mg, 400 mg, 50 mg

1 ST

CELONTIN ORAL CAPSULE 300 MG 2



47

Drug Tier Notes

chlordiazepoxide hcl oral capsule 10 mg, 25 mg, 5 mg

1

chlorpromazine injection solution 25 mg/ml 1

chlorpromazine oral tablet 10 mg, 100 mg, 200 mg, 25 mg, 50 mg

1

choline,magnesium salicylate oral liquid 500 mg/5 ml

1

citalopram oral solution 10 mg/5 ml 1

citalopram oral tablet 10 mg, 40 mg 1 QL

citalopram oral tablet 20 mg 1 QL; QL (30 per 30 days)

clomipramine oral capsule 25 mg, 50 mg, 75 mg

1

clonazepam oral tablet 0.5 mg, 1 mg, 2 mg 1

clonazepam oral tablet,disintegrating 0.125 mg, 0.25 mg, 0.5 mg, 1 mg, 2 mg

1


1

clorazepate dipotassium oral tablet 15 mg, 3.75 mg, 7.5 mg

1

clozapine oral tablet 100 mg, 200 mg, 25 mg, 50 mg

1

codeine sulfate oral tablet 15 mg, 30 mg, 60 mg


COMPRO RECTAL SUPPOSITORY 25 MG 1

desipramine oral tablet 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

1

dexmethylphenidate oral tablet 10 mg, 2.5 mg, 5 mg

1 QL

dextroamphetamine oral capsule, extended release 10 mg, 15 mg, 5 mg

1 QL

dextroamphetamine oral tablet 10 mg, 5 mg 1 QL

dextroamphetamine-amphetamine oral capsule,extended release 24hr 10 mg, 15 mg, 20 mg, 25 mg, 30 mg, 5 mg

1 QL

dextroamphetamine-amphetamine oral tablet10 mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg

1 QL

diazepam injection solution 5 mg/ml 1

diazepam injection syringe 5 mg/ml 1



48

Drug Tier Notes

DIAZEPAM INTENSOL ORAL CONCENTRATE 5 MG/ML

1

diazepam oral solution 5 mg/5 ml (1 mg/ml), 5 mg/5 ml (1 mg/ml, 5 ml)

1

diazepam oral tablet 10 mg, 2 mg, 5 mg 1

diclofenac potassium oral tablet 50 mg 1

diclofenac sodium oral tablet extended release 24 hr 100 mg

1

diclofenac sodium oral tablet,delayed release (dr/ec) 25 mg, 50 mg, 75 mg

1

diclofenac sodium topical gel 1 % 1

diflunisal oral tablet 500 mg 1

dihydroergotamine injection solution 1 mg/ml 1

DILANTIN ORAL CAPSULE 30 MG 2

DISKETS ORAL TABLET,SOLUBLE 40 MG 1 QL; QL (30 per 30 days)

divalproex oral capsule, delayed rel sprinkle125 mg

1

divalproex oral tablet extended release 24 hr250 mg, 500 mg

1

divalproex oral tablet,delayed release (dr/ec)125 mg, 250 mg, 500 mg

1

doxepin oral capsule 10 mg, 100 mg, 150 mg, 25 mg, 50 mg, 75 mg

1

doxepin oral concentrate 10 mg/ml 1

droperidol injection solution 2.5 mg/ml 1

duloxetine oral capsule,delayed release(dr/ec) 20 mg


duloxetine oral capsule,delayed release(dr/ec) 30 mg, 60 mg

1 QL

duloxetine oral capsule,delayed release(dr/ec) 40 mg

1

ENDOCET ORAL TABLET 10-325 MG, 5-325 MG, 7.5-325 MG


entacapone oral tablet 200 mg 1

EPITOL ORAL TABLET 200 MG 1

escitalopram oxalate oral solution 5 mg/5 ml 1

escitalopram oxalate oral tablet 10 mg, 5 mg 1 QL

escitalopram oxalate oral tablet 20 mg 1 QL; QL (30 per 30 days)



49

Drug Tier Notes

estazolam oral tablet 1 mg, 2 mg 1

eszopiclone oral tablet 1 mg, 2 mg, 3 mg 1 ST; QL

ethosuximide oral capsule 250 mg 1

ethosuximide oral solution 250 mg/5 ml 1

etodolac oral capsule 200 mg, 300 mg 1

etodolac oral tablet 400 mg, 500 mg 1

etodolac oral tablet extended release 24 hr400 mg, 500 mg, 600 mg

1

EVZIO INJECTION AUTO-INJECTOR 0.4 MG/0.4 ML

2

felbamate oral suspension 600 mg/5 ml 1

felbamate oral tablet 400 mg, 600 mg 1

FELBATOL ORAL SUSPENSION 600 MG/5 ML

2

fentanyl citrate buccal lozenge on a handle1,200 mcg

1 PA; QL; QL (39 per 30 days)

fentanyl citrate buccal lozenge on a handle1,600 mcg


fentanyl citrate buccal lozenge on a handle200 mcg








fentanyl transdermal patch 72 hour 100 mcg/hr, 12 mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr


flumazenil intravenous solution 0.1 mg/ml 1

fluoxetine oral capsule 10 mg 1 QL

fluoxetine oral capsule 20 mg 1

fluoxetine oral capsule 40 mg 1 QL; QL (60 per 30 days)

fluoxetine oral solution 20 mg/5 ml (4 mg/ml) 1

fluphenazine decanoate injection solution 25 mg/ml

1

fluphenazine hcl injection solution 2.5 mg/ml 1

fluphenazine hcl oral concentrate 5 mg/ml 1



50

Drug Tier Notes

fluphenazine hcl oral elixir 2.5 mg/5 ml 1

fluphenazine hcl oral tablet 1 mg, 10 mg, 2.5 mg, 5 mg

1

flurazepam oral capsule 15 mg, 30 mg 1

flurbiprofen oral tablet 100 mg, 50 mg 1

fluvoxamine oral tablet 100 mg 1 QL; QL (90 per 30 days)

fluvoxamine oral tablet 25 mg 1 QL

fluvoxamine oral tablet 50 mg 1 QL; QL (60 per 30 days)

fosphenytoin injection solution 100 mg pe/2 ml, 500 mg pe/10 ml

1

FYCOMPA ORAL TABLET 10 MG, 12 MG, 2 MG, 4 MG, 6 MG, 8 MG

2 PA

gabapentin oral capsule 100 mg, 300 mg, 400 mg

1

gabapentin oral solution 250 mg/5 ml, 250 mg/5 ml (5 ml), 300 mg/6 ml (6 ml)

1

gabapentin oral tablet 600 mg, 800 mg 1

GABITRIL ORAL TABLET 12 MG, 16 MG 2

guanfacine oral tablet 1 mg, 2 mg 1

haloperidol decanoate intramuscular solution100 mg/ml, 50 mg/ml

1

haloperidol lactate injection solution 5 mg/ml 1

haloperidol lactate oral concentrate 2 mg/ml 1

haloperidol oral tablet 0.5 mg, 1 mg, 10 mg, 2 mg, 20 mg, 5 mg

1

hydrocodone-acetaminophen oral solution7.5-325 mg/15 ml


hydrocodone-acetaminophen oral tablet 10-300 mg, 10-325 mg, 2.5-325 mg, 5-300 mg, 5-325 mg, 7.5-300 mg, 7.5-325 mg


hydrocodone-ibuprofen oral tablet 10-200 mg, 5-200 mg, 7.5-200 mg


hydromorphone oral liquid 1 mg/ml 1 QL; QL (1500 per 30 days)

hydromorphone oral tablet 2 mg, 4 mg, 8 mg 1 QL; QL (180 per 30 days)

hydromorphone rectal suppository 3 mg 1 QL; QL (120 per 30 days)

hydroxyzine hcl intramuscular solution 25 mg/ml

1

hydroxyzine hcl oral solution 10 mg/5 ml 1



51

Drug Tier Notes

hydroxyzine hcl oral tablet 10 mg, 25 mg, 50 mg

1

hydroxyzine pamoate oral capsule 100 mg, 25 mg, 50 mg

1

ibuprofen oral tablet 400 mg, 600 mg, 800 mg

1

imipramine hcl oral tablet 10 mg, 25 mg, 50 mg

1

imipramine pamoate oral capsule 100 mg, 125 mg, 150 mg, 75 mg

1

indomethacin oral capsule 25 mg, 50 mg 1

INVEGA SUSTENNA INTRAMUSCULAR SYRINGE 117 MG/0.75 ML, 156 MG/ML, 234 MG/1.5 ML, 39 MG/0.25 ML, 78 MG/0.5 ML

2

ketoprofen oral capsule 50 mg, 75 mg 1

ketoprofen oral capsule,ext rel. pellets 24 hr200 mg

1

ketorolac injection cartridge 15 mg/ml, 30 mg/ml

1

ketorolac injection solution 15 mg/ml, 30 mg/ml, 30 mg/ml (1 ml)

1

ketorolac intramuscular solution 60 mg/2 ml 1

ketorolac oral tablet 10 mg 1 QL

lamotrigine oral tablet 100 mg, 150 mg, 200 mg, 25 mg

1

lamotrigine oral tablet, chewable dispersible25 mg, 5 mg

1

LATUDA ORAL TABLET 120 MG, 20 MG, 40 MG, 60 MG, 80 MG

2 ST; QL

levetiracetam intravenous solution 500 mg/5 ml

1

levetiracetam oral solution 100 mg/ml, 500 mg/5 ml (5 ml)

1

levetiracetam oral tablet 1,000 mg, 250 mg, 500 mg, 750 mg

1

levetiracetam oral tablet extended release 24 hr 500 mg, 750 mg

1

levorphanol tartrate oral tablet 2 mg 1 QL; QL (120 per 30 days)



52

Drug Tier Notes

lithium carbonate oral capsule 150 mg, 300 mg, 600 mg

1

lithium carbonate oral tablet 300 mg 1

lithium carbonate oral tablet extended release 300 mg, 450 mg

1

lithium citrate oral solution 8 meq/5 ml 1

lorazepam injection solution 2 mg/ml, 4 mg/ml

1

lorazepam injection syringe 2 mg/ml, 4 mg/ml 1

LORAZEPAM INTENSOL ORAL CONCENTRATE 2 MG/ML

1

lorazepam oral concentrate 2 mg/ml 1

lorazepam oral tablet 0.5 mg, 1 mg, 2 mg 1

LORCET (HYDROCODONE) ORAL TABLET 5-325 MG


LORCET HD ORAL TABLET 10-325 MG 1 QL; QL (360 per 30 days)

loxapine succinate oral capsule 10 mg, 25 mg, 5 mg, 50 mg

1

LYRICA ORAL CAPSULE 100 MG, 150 MG, 200 MG, 225 MG, 25 MG, 300 MG, 50 MG, 75 MG

2 PA

magnesium chloride injection solution 200 mg/ml (20 %)

1


1


1


1


1

maprotiline oral tablet 25 mg, 50 mg, 75 mg 1

MARTEN-TAB ORAL TABLET 50-325 MG 1 QL (180 per 30 days)

meclofenamate oral capsule 100 mg, 50 mg 1

meloxicam oral suspension 7.5 mg/5 ml 1

meloxicam oral tablet 15 mg 1

meloxicam oral tablet 7.5 mg 1 QL



53

Drug Tier Notes

memantine oral solution 2 mg/ml 1

memantine oral tablet 10 mg, 5 mg 1

memantine oral tablets,dose pack 5-10 mg 1

meperidine oral solution 50 mg/5 ml 1 QL; QL (1200 per 30 days)

meperidine oral tablet 100 mg 1 QL; QL (120 per 30 days)

meperidine oral tablet 50 mg 1 QL; QL (240 per 30 days)

meprobamate oral tablet 200 mg, 400 mg 1

METADATE ER ORAL TABLET EXTENDED RELEASE 20 MG

1 QL

methadone oral concentrate 10 mg/ml 1 QL; QL (120 per 30 days)

methadone oral solution 10 mg/5 ml 1 QL; QL (600 per 30 days)

methadone oral solution 5 mg/5 ml 1 QL; QL (1200 per 30 days)

methadone oral tablet 10 mg 1 QL; QL (120 per 30 days)

methadone oral tablet 5 mg 1 QL; QL (240 per 30 days)

methadone oral tablet,soluble 40 mg 1 QL; QL (30 per 30 days)

METHADOSE ORAL CONCENTRATE 10 MG/ML


METHADOSE ORAL TABLET,SOLUBLE 40 MG


METHYLIN ORAL SOLUTION 10 MG/5 ML, 5 MG/5 ML

2 QL

methylphenidate hcl oral capsule, er biphasic 30-70 10 mg, 20 mg, 30 mg, 40 mg, 50 mg, 60 mg

1 QL

methylphenidate hcl oral capsule,er biphasic 50-50 20 mg, 30 mg, 40 mg

1 QL

methylphenidate hcl oral solution 10 mg/5 ml, 5 mg/5 ml

1 QL

methylphenidate hcl oral tablet 10 mg, 20 mg, 5 mg

1 QL

methylphenidate hcl oral tablet extended release 10 mg, 20 mg

1 QL

methylphenidate hcl oral tablet extended release 24hr 18 mg, 27 mg, 36 mg, 54 mg

1 QL

methylphenidate hcl oral tablet,chewable 10 mg, 2.5 mg, 5 mg

1 QL

midazolam oral syrup 2 mg/ml 1



54

Drug Tier Notes

mirtazapine oral tablet 15 mg, 30 mg, 45 mg, 7.5 mg

1

mirtazapine oral tablet,disintegrating 15 mg, 30 mg, 45 mg

1

modafinil oral tablet 100 mg, 200 mg 1 PA

morphine concentrate oral solution 100 mg/5 ml (20 mg/ml)


morphine oral solution 10 mg/5 ml, 20 mg/5 ml (4 mg/ml)


morphine oral tablet 15 mg, 30 mg 1 QL; QL (180 per 30 days)

morphine oral tablet extended release 100 mg


morphine oral tablet extended release 15 mg, 30 mg


morphine oral tablet extended release 200 mg


morphine oral tablet extended release 60 mg 1 QL; QL (100 per 30 days)

morphine rectal suppository 10 mg, 5 mg 1 QL; QL (360 per 30 days)

morphine rectal suppository 20 mg 1 QL; QL (180 per 30 days)

morphine rectal suppository 30 mg 1 QL; QL (120 per 30 days)

nabumetone oral tablet 500 mg, 750 mg 1

nalbuphine injection solution 10 mg/ml, 20 mg/ml

1

naloxone injection solution 0.4 mg/ml 1

naloxone injection syringe 0.4 mg/ml, 1 mg/ml

1

naltrexone oral tablet 50 mg 1

naproxen oral suspension 125 mg/5 ml 1

naproxen oral tablet 250 mg, 375 mg, 500 mg

1

naproxen oral tablet,delayed release (dr/ec)375 mg, 500 mg

1

naproxen sodium oral tablet 275 mg, 550 mg 1

NARCAN NASAL SPRAY,NON-AEROSOL 4 MG/ACTUATION

2

nefazodone oral tablet 100 mg, 150 mg, 200 mg, 250 mg, 50 mg

1

nortriptyline oral capsule 10 mg, 25 mg, 50 mg, 75 mg

1



55

Drug Tier Notes

nortriptyline oral solution 10 mg/5 ml 1

NUEDEXTA ORAL CAPSULE 20-10 MG 2 PA; QL; QL (60 per 30 days)

olanzapine intramuscular recon soln 10 mg 1

olanzapine oral tablet 10 mg 1 QL; QL (30 per 30 days)

olanzapine oral tablet 15 mg, 2.5 mg, 5 mg, 7.5 mg

1 QL

olanzapine oral tablet 20 mg 1

olanzapine oral tablet,disintegrating 10 mg, 15 mg, 20 mg, 5 mg

1 ST; QL

oxaprozin oral tablet 600 mg 1

oxazepam oral capsule 10 mg, 15 mg, 30 mg 1

oxcarbazepine oral suspension 300 mg/5 ml (60 mg/ml)

1

oxcarbazepine oral tablet 150 mg, 300 mg, 600 mg

1

oxycodone oral capsule 5 mg 1 QL; QL (360 per 30 days)

oxycodone oral concentrate 20 mg/ml 1 QL; QL (180 per 30 days)

oxycodone oral solution 5 mg/5 ml 1 QL; QL (360 per 30 days)

oxycodone oral tablet 10 mg, 15 mg, 20 mg 1 QL; QL (180 per 30 days)

oxycodone oral tablet 30 mg 1 QL; QL (134 per 30 days)

oxycodone oral tablet 5 mg 1 QL; QL (360 per 30 days)

OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG

2 ST; QL; QL (90 per 30 days)

OXYCODONE ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG


oxycodone-acetaminophen oral tablet 10-325 mg, 2.5-325 mg, 5-325 mg, 7.5-325 mg


oxycodone-aspirin oral tablet 4.8355-325 mg 1 QL; QL (270 per 30 days)

OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 10 MG, 15 MG, 20 MG, 30 MG, 40 MG, 60 MG


OXYCONTIN ORAL TABLET,ORAL ONLY,EXT.REL.12 HR 80 MG


paroxetine hcl oral tablet 10 mg, 40 mg 1 QL; QL (30 per 30 days)

paroxetine hcl oral tablet 20 mg 1 QL

paroxetine hcl oral tablet 30 mg 1 QL; QL (60 per 30 days)



56

Drug Tier Notes

paroxetine hcl oral tablet extended release 24 hr 12.5 mg


paroxetine hcl oral tablet extended release 24 hr 25 mg, 37.5 mg

1 QL

PEGANONE ORAL TABLET 250 MG 2

pentazocine-naloxone oral tablet 50-0.5 mg 1

perphenazine oral tablet 16 mg, 2 mg, 4 mg, 8 mg

1

perphenazine-amitriptyline oral tablet 2-10 mg, 2-25 mg, 4-10 mg, 4-25 mg, 4-50 mg

1

phenelzine oral tablet 15 mg 1

phenobarbital oral elixir 20 mg/5 ml (4 mg/ml) 1

phenobarbital oral tablet 100 mg, 15 mg, 16.2 mg, 30 mg, 32.4 mg, 60 mg, 64.8 mg, 97.2 mg

1

phenobarbital sodium injection solution 130 mg/ml, 65 mg/ml

1

phenytoin oral suspension 100 mg/4 ml, 125 mg/5 ml

1

phenytoin oral tablet,chewable 50 mg 1

phenytoin sodium extended oral capsule 100 mg, 200 mg, 300 mg

1

phenytoin sodium intravenous solution 50 mg/ml

1

phenytoin sodium intravenous syringe 50 mg/ml

1

piroxicam oral capsule 10 mg, 20 mg 1

pramipexole oral tablet 0.125 mg, 0.25 mg, 0.5 mg, 0.75 mg, 1 mg, 1.5 mg

1

primidone oral tablet 250 mg, 50 mg 1

prochlorperazine edisylate injection solution10 mg/2 ml (5 mg/ml)

1

prochlorperazine maleate oral tablet 10 mg, 5 mg

1

prochlorperazine rectal suppository 25 mg 1


1




57

Drug Tier Notes


1

promethazine rectal suppository 12.5 mg, 25 mg

1



1


1


1

protriptyline oral tablet 10 mg, 5 mg 1

quetiapine oral tablet 100 mg, 25 mg 1 QL; QL (90 per 30 days)

quetiapine oral tablet 200 mg, 400 mg, 50 mg 1 QL

quetiapine oral tablet 300 mg 1 QL; QL (60 per 30 days)

quetiapine oral tablet extended release 24 hr150 mg, 200 mg, 300 mg, 400 mg, 50 mg

1 ST; QL

riluzole oral tablet 50 mg 1

RISPERDAL CONSTA INTRAMUSCULAR SYRINGE 12.5 MG/2 ML, 25 MG/2 ML, 37.5 MG/2 ML, 50 MG/2 ML

2

risperidone oral solution 1 mg/ml 1

risperidone oral tablet 0.25 mg, 1 mg, 2 mg, 4 mg

1 QL

risperidone oral tablet 0.5 mg, 3 mg 1 QL; QL (60 per 30 days)

risperidone oral tablet,disintegrating 0.25 mg, 1 mg, 2 mg, 3 mg, 4 mg

1 ST; QL

risperidone oral tablet,disintegrating 0.5 mg 1 ST; QL; QL (60 per 30 days)

rizatriptan oral tablet 10 mg, 5 mg 1 QL

rizatriptan oral tablet,disintegrating 10 mg, 5 mg

1 QL

ropinirole oral tablet 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg, 5 mg

1

salsalate oral tablet 500 mg, 750 mg 1

SAVELLA ORAL TABLET 100 MG, 12.5 MG, 25 MG, 50 MG

2 PA; QL

SAVELLA ORAL TABLETS,DOSE PACK 12.5 MG (5)-25 MG(8)-50 MG(42)

2 PA; QL



58

Drug Tier Notes

SECONAL SODIUM ORAL CAPSULE 100 MG

1

selegiline hcl oral capsule 5 mg 1

selegiline hcl oral tablet 5 mg 1

sertraline oral concentrate 20 mg/ml 1

sertraline oral tablet 100 mg 1 QL; QL (60 per 30 days)

sertraline oral tablet 25 mg, 50 mg 1 QL

SUBOXONE SUBLINGUAL FILM 12-3 MG 2 QL; QL (60 per 30 days)

SUBOXONE SUBLINGUAL FILM 4-1 MG 2 QL; QL (240 per 30 days)

sulindac oral tablet 150 mg, 200 mg 1

sumatriptan nasal spray,non-aerosol 20 mg/actuation, 5 mg/actuation

1 QL

sumatriptan succinate oral tablet 100 mg, 25 mg, 50 mg

1 QL

sumatriptan succinate subcutaneous cartridge 4 mg/0.5 ml, 6 mg/0.5 ml

1 QL

sumatriptan succinate subcutaneous pen injector 4 mg/0.5 ml, 6 mg/0.5 ml

1 QL

sumatriptan succinate subcutaneous solution6 mg/0.5 ml

1 QL

temazepam oral capsule 15 mg, 22.5 mg, 30 mg, 7.5 mg

1

tetrabenazine oral tablet 12.5 mg, 25 mg 1 PA; SP

thioridazine oral tablet 10 mg, 100 mg, 25 mg, 50 mg

1

thiothixene oral capsule 1 mg, 10 mg, 2 mg, 5 mg

1

tiagabine oral tablet 2 mg, 4 mg 1


1

tolmetin oral capsule 400 mg 1

tolmetin oral tablet 200 mg, 600 mg 1

topiramate oral capsule, sprinkle 15 mg, 25 mg

1

topiramate oral tablet 100 mg, 200 mg, 25 mg, 50 mg

1

tramadol oral tablet 50 mg 1 QL; QL (240 per 30 days)



59

Drug Tier Notes

tramadol-acetaminophen oral tablet 37.5-325 mg


tranylcypromine oral tablet 10 mg 1

trazodone oral tablet 100 mg, 150 mg, 300 mg, 50 mg

1

triazolam oral tablet 0.125 mg, 0.25 mg 1

trifluoperazine oral tablet 1 mg, 10 mg, 2 mg, 5 mg

1

trihexyphenidyl oral elixir 0.4 mg/ml 1

trihexyphenidyl oral tablet 2 mg, 5 mg 1

valproate sodium intravenous solution 500 mg/5 ml (100 mg/ml)

1

valproic acid (as sodium salt) oral solution250 mg/5 ml, 250 mg/5 ml (5 ml), 500 mg/10 ml (10 ml)

1

valproic acid oral capsule 250 mg 1

venlafaxine oral capsule,extended release 24hr 150 mg, 37.5 mg, 75 mg

1 QL

venlafaxine oral tablet 100 mg, 25 mg, 37.5 mg, 75 mg

1 QL

venlafaxine oral tablet 50 mg 1 QL; QL (90 per 30 days)

venlafaxine oral tablet extended release 24hr150 mg, 75 mg

1 QL

venlafaxine oral tablet extended release 24hr225 mg, 37.5 mg


VIMPAT INTRAVENOUS SOLUTION 200 MG/20 ML

2

VIMPAT ORAL SOLUTION 10 MG/ML 2

VIMPAT ORAL TABLET 100 MG, 150 MG, 200 MG, 50 MG

2

VYVANSE ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG, 50 MG, 60 MG, 70 MG

2 QL

zaleplon oral capsule 10 mg 1 QL

zaleplon oral capsule 5 mg 1 QL; QL (30 per 30 days)

ziprasidone hcl oral capsule 20 mg, 40 mg, 60 mg, 80 mg

1 QL

zolmitriptan oral tablet 2.5 mg, 5 mg 1 QL

zolmitriptan oral tablet,disintegrating 2.5 mg, 5 mg

1 QL



60

Drug Tier Notes

zolpidem oral tablet 10 mg, 5 mg 1 QL

zolpidem oral tablet,ext release multiphase12.5 mg

1 QL

zolpidem oral tablet,ext release multiphase6.25 mg


zonisamide oral capsule 100 mg, 25 mg, 50 mg

1

ZYPREXA RELPREVV INTRAMUSCULAR SUSPENSION FOR RECONSTITUTION 210 MG, 300 MG, 405 MG

2

DEVICES

ACE AEROSOL CLOUD ENHANCER SPACER

2

BD PRE-FILLED NORMAL SALINE INJECTION SYRINGE

1

CLEO 90 INFUSION SET 24" INFUSION SET

2

COMFORT SHORT INFUSION SET 23" INFUSION SET

2

ECLIPSE SYRINGE SYRINGE 3 ML 21 GAUGE X 1"

2

HEP FLUSH-10 (PF) INTRAVENOUS SOLUTION 10 UNIT/ML

1

heparin (porcine) in nacl (pf) intravenous parenteral solution 1,000 unit/500 ml, 2,000 unit/1,000 ml

1

heparin flush(porcine)-0.9nacl intravenous kit100 unit/ml

1

heparin lock flush (porcine) intravenous syringe 100 unit/ml

1

HEPARIN LOCK FLUSH INTRAVENOUS SYRINGE 10 UNIT/ML

1

HEPARIN LOCK INTRAVENOUS SOLUTION 100 UNIT/ML

1

HEPARIN LOCKFLUSH(PORCINE)(PF) INTRAVENOUS SYRINGE 10 UNIT/ML, 100 UNIT/ML

1

heparin, porcine (pf) intravenous syringe 1 unit/ml, 100 unit/ml

1



61

Drug Tier Notes

MONOJECT MAGELLAN SYRINGE SYRINGE 3 ML 20 GAUGE X 1"

2

MONOJECT SYRINGE SYRINGE 1/2 ML 28 GAUGE

2

NORMAL SALINE FLUSH INJECTION SYRINGE

1

POLYFIN QR INFUSION SET 2

sodium chloride 0.9 % injection syringe 1

SYREX SODIUM CHLORIDE 0.9 % INJECTION SYRINGE

1

syringe with needle, safety syringe 1 ml 25 gauge x 5/8"

2

T:SLIM SUBCUTANEOUS CARTRIDGE 2

DIAGNOSTIC AGENTS

CANDIN INTRADERMAL ALLERGEN FDA STANDARD

1

cosyntropin injection recon soln 0.25 mg 1

cosyntropin intravenous solution 0.25 mg/ml 2

E-Z-CAT DRY ORAL POWDER IN PACKET 2 % (W/W)

2

E-Z-HD BARIUM ORAL SUSPENSION FOR RECONSTITUTION 98 %

2

E-Z-PAQUE ORAL SUSPENSION FOR RECONSTITUTION 96 % (W/W)

2

fluorescein-proparacaine ophthalmic (eye) drops 0.25-0.5 %

1

FLUROX OPHTHALMIC (EYE) DROPS 0.25-0.4 %

1

GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN 1 MG/ML

2

GLUCAGON HCL INJECTION RECON SOLN 1 MG

2

ISOVUE-300 INTRAVENOUS SOLUTION 61 %

2

ISOVUE-M 300 INTRATHECAL SOLUTION 61 %

2

LIQUID E-Z PAQUE ORAL SUSPENSION 60 % (W/V)

2



62

Drug Tier Notes


1


1



1

OMNIPAQUE 140 INTRAVENOUS SOLUTION 140 MG IODINE/ML

2


2


2

ONETOUCH ULTRA TEST STRIP 2

ONETOUCH VERIO STRIP 2

READI-CAT 2 ORAL SUSPENSION 2.1 % (W/V), 2.0 % (W/W)

2

SITZMARKS ORAL CAPSULE 24 MARKERS

2

TAGITOL V ORAL SUSPENSION 40 % (W/V)

2

thallous chloride tl-201 intravenous solution37 mbq/ml (1 mci/ml)

2

THYROGEN INTRAMUSCULAR RECON SOLN 1.1 MG

2 SP

VARIBAR THIN HONEY ORAL SUSPENSION 40 % (W/V) 29% (W/W)

2

VARIBAR THIN LIQUID ORAL POWDER 40 % (W/V)

2

VISIPAQUE INTRAVENOUS SOLUTION 270 MG IODINE/ML

2

VOLUMEN ORAL SUSPENSION 0.1 % 2

ELECTROLYTIC, CALORIC, AND WATER

BALANCE


1



1



63

Drug Tier Notes

acetic acid irrigation solution 0.25 % 1

amiloride-hydrochlorothiazide oral tablet 5-50 mg

1

ammonium chloride intravenous solution 5 meq/ml

2


1


1

BD PRE-FILLED NORMAL SALINE INJECTION SYRINGE

1

benazepril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg, 5-6.25 mg

1


1

bumetanide injection solution 0.25 mg/ml 1

bumetanide oral tablet 0.5 mg, 1 mg, 2 mg 1

calcium acetate oral capsule 667 mg 1

calcium acetate oral tablet 667 mg 1

calcium chloride intravenous solution 100 mg/ml (10 %)

1

calcium chloride intravenous syringe 100 mg/ml (10 %)

1

calcium gluconate intravenous solution 100 mg/ml (10%)

1

captopril-hydrochlorothiazide oral tablet 25-15 mg, 25-25 mg, 50-15 mg, 50-25 mg

1

CARBAGLU ORAL TABLET, DISPERSIBLE 200 MG

2 SP

chlorothiazide oral tablet 250 mg, 500 mg 1

chlorthalidone oral tablet 25 mg, 50 mg 1

chromium chloride intravenous solution 4 mcg/ml

1

CONSTULOSE ORAL SOLUTION 10 GRAM/15 ML

1

COPPER CHLORIDE INTRAVENOUS SOLUTION 0.4 MG/ML

1

CYTRA K CRYSTALS ORAL PACKET 3,300-1,002 MG

1



64

Drug Tier Notes

CYTRA-2 ORAL SOLUTION 500-334 MG/5 ML

1

CYTRA-3 ORAL SOLUTION 550-500-334 MG/5 ML

1

CYTRA-K ORAL SOLUTION 1,100-334 MG/5 ML

1

DELFLEX-LC/1.5% DEXTROSE INTRAPERITONEAL SOLUTION CA 2.5 MEQ/L- MG 0.5 MEQ/L

1


1


1

DELFLEX-SM WITH 1.5% DEXTROSE INTRAPERITONEAL SOLUTION CA 3.5 MEQ/L- MG 1.5 MEQ/L

2

dextrose 5 % in ringer's intravenous parenteral solution 5 %

1

dextrose 5 %-lactated ringers intravenous parenteral solution

1

DIANEAL LOW CALCIUM/1.5% DEX INTRAPERITONEAL SOLUTION CA 2.5 MEQ/L- MG 0.5 MEQ/L

2

DIANEAL PD-2 WITH 2.5 % DEX INTRAPERITONEAL SOLUTION CA 3.5 MEQ/L- MG 0.5 MEQ/L

2

DIANEAL PD-2 WITH 4.25 % DEX INTRAPERITONEAL SOLUTION CA 3.5 MEQ/L- MG 0.5 MEQ/L

2

DIANEAL PD-2/1.5% DEXTROSE INTRAPERITONEAL SOLUTION CA 3.5 MEQ/L- MG 0.5 MEQ/L

2

DIANEAL WITH 2.5 % DEXTROSE INTRAPERITONEAL SOLUTION CA 2.5 MEQ/L- MG 0.5 MEQ/L

2

DIANEAL WITH 4.25 % DEXTROSE INTRAPERITONEAL SOLUTION CA 2.5 MEQ/L- MG 0.5 MEQ/L

2

EFFER-K ORAL TABLET, EFFERVESCENT 25 MEQ

1



65

Drug Tier Notes

electrolyte-48 in d5w intravenous parenteral solution

1

ELIPHOS ORAL TABLET 667 MG 1

enalapril-hydrochlorothiazide oral tablet 10-25 mg, 5-12.5 mg

1

ENULOSE ORAL SOLUTION 10 GRAM/15 ML

1

fosinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg

1

FOSRENOL ORAL TABLET,CHEWABLE 1,000 MG, 500 MG, 750 MG

2

furosemide injection solution 10 mg/ml 1

furosemide injection syringe 10 mg/ml 1

furosemide oral solution 10 mg/ml, 40 mg/5 ml (8 mg/ml)

1

furosemide oral tablet 20 mg, 40 mg, 80 mg 1

GENERLAC ORAL SOLUTION 10 GRAM/15 ML

1

glycine urologic solution irrigation solution 1.5 %

1

hetastarch 6 % in 0.9 % nacl intravenous solution 6 %

1

hydrochlorothiazide oral capsule 12.5 mg 1

hydrochlorothiazide oral tablet 12.5 mg, 25 mg, 50 mg

1

indapamide oral tablet 1.25 mg, 2.5 mg 1

IONOSOL-B IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 %

2

IONOSOL-MB IN D5W INTRAVENOUS PARENTERAL SOLUTION 5 %

2

ISOLYTE S PH 7.4 INTRAVENOUS PARENTERAL SOLUTION

2

ISOLYTE-P IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 %

2

ISOLYTE-S INTRAVENOUS PARENTERAL SOLUTION

2

K-EFFERVESCENT ORAL TABLET, EFFERVESCENT 25 MEQ

1



66

Drug Tier Notes

KIONEX (WITH SORBITOL) ORAL SUSPENSION 15-19.3 GRAM/60 ML

1

KLOR-CON 10 ORAL TABLET EXTENDED RELEASE 10 MEQ

1

KLOR-CON 8 ORAL TABLET EXTENDED RELEASE 8 MEQ

1

KLOR-CON M10 ORAL TABLET,ER PARTICLES/CRYSTALS 10 MEQ

1


1


1

KLOR-CON ORAL PACKET 20 MEQ 1

KLOR-CON/EF ORAL TABLET, EFFERVESCENT 25 MEQ

1

lactated ringers intravenous parenteral solution

1

lactated ringers irrigation solution 1

lactulose oral solution 10 gram/15 ml, 10 gram/15 ml (15 ml), 20 gram/30 ml

1

lanthanum oral tablet,chewable 1,000 mg, 500 mg, 750 mg

1

lisinopril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

1

losartan-hydrochlorothiazide oral tablet 100-12.5 mg, 100-25 mg, 50-12.5 mg

1

manganese chloride intravenous solution 0.1 mg/ml

1


1


1



1


1

metolazone oral tablet 10 mg, 2.5 mg, 5 mg 1


1



67

Drug Tier Notes

moexipril-hydrochlorothiazide oral tablet 15-12.5 mg, 15-25 mg, 7.5-12.5 mg

1


1


1


1


1


1

NORMAL SALINE FLUSH INJECTION SYRINGE

1

NORMOSOL-M IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION

2

NORMOSOL-R IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 %

2

NORMOSOL-R INTRAVENOUS PARENTERAL SOLUTION

2

NORMOSOL-R PH 7.4 INTRAVENOUS PARENTERAL SOLUTION

2

NUTRILYTE INTRAVENOUS SOLUTION 25-40.6-5 MEQ/20 ML

1

PHOSPHA 250 NEUTRAL ORAL TABLET 250 MG

1

PHYSIOLYTE IRRIGATION SOLUTION 140-5-3-98 MEQ/L

2

PHYSIOSOL IRRIGATION IRRIGATION SOLUTION 140-5-3-98 MEQ/L

2

PLASMA-LYTE 148 INTRAVENOUS PARENTERAL SOLUTION

2

PLASMA-LYTE A INTRAVENOUS PARENTERAL SOLUTION

2

PLASMA-LYTE-56 IN 5 % DEXTROSE INTRAVENOUS PARENTERAL SOLUTION 5 %

2


1



68

Drug Tier Notes


1


1

potassium acetate intravenous solution 2 meq/ml

1

potassium bicarb and chloride oral tablet, effervescent 25 meq

1

potassium bicarb-citric acid oral tablet, effervescent 25 meq

1

potassium chlorid-d5-0.45%nacl intravenous parenteral solution 10 meq/l, 20 meq/l, 30 meq/l, 40 meq/l

1

potassium chloride in 0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

1

potassium chloride in 5 % dex intravenous parenteral solution 20 meq/l, 40 meq/l

1

potassium chloride in lr-d5 intravenous parenteral solution 20 meq/l, 40 meq/l

1

potassium chloride intravenous piggyback 10 meq/100 ml, 10 meq/50 ml, 20 meq/100 ml, 20 meq/50 ml, 30 meq/100 ml, 40 meq/100 ml

1

potassium chloride intravenous solution 2 meq/ml

1

potassium chloride oral capsule, extended release 10 meq, 8 meq

1

potassium chloride oral liquid 20 meq/15 ml, 40 meq/15 ml

1

potassium chloride oral tablet extended release 10 meq, 8 meq

1

potassium chloride oral tablet,er particles/crystals 10 meq, 20 meq

1

potassium chloride-0.45 % nacl intravenous parenteral solution 20 meq/l

1

potassium chloride-d5-0.2%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

1

potassium chloride-d5-0.3%nacl intravenous parenteral solution 20 meq/l

1

potassium chloride-d5-0.9%nacl intravenous parenteral solution 20 meq/l, 40 meq/l

1



69

Drug Tier Notes

potassium citrate oral tablet extended release 10 meq (1,080 mg), 5 meq (540 mg)

1

potassium citrate-citric acid oral solution1,100-334 mg/5 ml

1

potassium phosphate m-/d-basic intravenous solution 3 mmol/ml

1


1


1


1


1


1


1



1


1


1


1

probenecid oral tablet 500 mg 1

probenecid-colchicine oral tablet 500-0.5 mg 1


1

quinapril-hydrochlorothiazide oral tablet 10-12.5 mg, 20-12.5 mg, 20-25 mg

1

RAVICTI ORAL LIQUID 1.1 GRAM/ML 2 SP

RENAGEL ORAL TABLET 400 MG, 800 MG 2

RENVELA ORAL TABLET 800 MG 2

ringer's intravenous parenteral solution 1

ringer's irrigation solution 1

selenium intravenous solution 40 mcg/ml 1



70

Drug Tier Notes

sevelamer carbonate oral powder in packet0.8 gram, 2.4 gram

1

sodium acetate intravenous solution 2 meq/ml, 4 meq/ml

1

sodium bicarbonate intravenous solution 1 meq/ml (8.4 %), 4.2 %

1

sodium bicarbonate intravenous syringe 10 meq/10 ml (8.4 %), 4.2 % (0.5 meq/ml), 7.5 % (0.9 meq/ml), 8.4 % (1 meq/ml)

1

sodium chlor 0.9% bacteriostat injection solution 0.9 %

1

sodium chloride 0.45 % intravenous parenteral solution 0.45 %

1

sodium chloride 0.45 % intravenous piggyback 0.45 %

1

sodium chloride 0.9 % injection solution 1

sodium chloride 0.9 % injection syringe 1

sodium chloride 0.9 % intravenous parenteral solution

1

sodium chloride 0.9 % intravenous piggyback1

sodium chloride 3 % intravenous parenteral solution 3 %

1

sodium chloride 5 % intravenous parenteral solution 5 %

1

sodium chloride intravenous parenteral solution 2.5 meq/ml, 4 meq/ml

1

sodium chloride irrigation solution 0.9 % 1

sodium citrate-citric acid oral solution 500-334 mg/5 ml

1

sodium lactate intravenous solution 5 meq/ml 1

sodium phenylbutyrate oral powder 0.94 gram/gram

1

sodium phenylbutyrate oral tablet 500 mg 1

sodium phosphate intravenous solution 3 mmol/ml

1

SODIUM POLYSTYRENE (SORB FREE) ORAL SUSPENSION 15 GRAM/60 ML

1

sodium polystyrene sulfonate oral powder 1



71

Drug Tier Notes

sodium polystyrene sulfonate rectal enema30 gram/120 ml

1

spironolactone oral tablet 100 mg, 25 mg, 50 mg

1

spironolacton-hydrochlorothiaz oral tablet 25-25 mg

1

SPS (WITH SORBITOL) ORAL SUSPENSION 15-20 GRAM/60 ML

1

SPS (WITH SORBITOL) RECTAL ENEMA 30-40 GRAM/120 ML

1

SYREX SODIUM CHLORIDE 0.9 % INJECTION SYRINGE

1


1




1


1

torsemide oral tablet 10 mg, 100 mg, 20 mg, 5 mg

1


triamterene-hydrochlorothiazid oral capsule37.5-25 mg, 50-25 mg

1

triamterene-hydrochlorothiazid oral tablet37.5-25 mg, 75-50 mg

1

TRICITRATES ORAL SOLUTION 550-500-334 MG/5 ML

1


1


1


1


1


1



72

Drug Tier Notes


1


1

valsartan-hydrochlorothiazide oral tablet 160-12.5 mg, 160-25 mg, 320-12.5 mg, 320-25 mg, 80-12.5 mg

1

VELTASSA ORAL POWDER IN PACKET 16.8 GRAM, 25.2 GRAM, 8.4 GRAM

2 SP


1


1



1



1


1



1


1

water for irrigation, sterile irrigation solution 1


1


1

zinc chloride intravenous solution 1 mg/ml 1

zinc sulfate intravenous solution 5 mg/ml 1

ENZYMES

CATHFLO ACTIVASE INTRA-CATHETER RECON SOLN 2 MG

2

ELELYSO INTRAVENOUS RECON SOLN 200 UNIT

2 PA; SP



73

Drug Tier Notes

FABRAZYME INTRAVENOUS RECON SOLN 35 MG, 5 MG

2 PA; SP

LUMIZYME INTRAVENOUS RECON SOLN 50 MG

2 PA; SP

PULMOZYME INHALATION SOLUTION 1 MG/ML

2 SP

STRENSIQ SUBCUTANEOUS SOLUTION 100 MG/ML, 40 MG/ML

2 PA

SUCRAID ORAL SOLUTION 8,500 UNIT/ML 2 SP

VIMIZIM INTRAVENOUS SOLUTION 5 MG/5 ML (1 MG/ML)

2 SP

VPRIV INTRAVENOUS RECON SOLN 400 UNIT

2 PA; SP

EYE, EAR, NOSE AND THROAT (EENT)

PREPS.


1



1

acetic acid otic (ear) solution 2 % 1

apraclonidine ophthalmic (eye) drops 0.5 % 1

atropine ophthalmic (eye) drops 1 % 1

atropine ophthalmic (eye) ointment 1 % 1

azelastine nasal aerosol,spray 137 mcg (0.1 %)


azelastine nasal spray,non-aerosol 0.15 % (205.5 mcg)


azelastine ophthalmic (eye) drops 0.05 % 1

bacitracin ophthalmic (eye) ointment 500 unit/gram

1

bacitracin-polymyxin b ophthalmic (eye) ointment 500-10,000 unit/gram

1

BACTROBAN NASAL NASAL OINTMENT 2 %

2

BALANCED SALT INTRAOCULAR SOLUTION

1

betaxolol ophthalmic (eye) drops 0.5 % 1



74

Drug Tier Notes

BLEPHAMIDE OPHTHALMIC (EYE) DROPS,SUSPENSION 10-0.2 %

2

BLEPHAMIDE S.O.P. OPHTHALMIC (EYE) OINTMENT 10-0.2 %

2

brimonidine ophthalmic (eye) drops 0.15 %, 0.2 %

1

carteolol ophthalmic (eye) drops 1 % 1

chlorhexidine gluconate mucous membrane mouthwash 0.12 %

1

CIPRODEX OTIC (EAR) DROPS,SUSPENSION 0.3-0.1 %

2

ciprofloxacin hcl ophthalmic (eye) drops 0.3 %

1

cocaine topical solution 4 % 1

cromolyn ophthalmic (eye) drops 4 % 1

cyclopentolate ophthalmic (eye) drops 1 %, 2 %

1

CYSTARAN OPHTHALMIC (EYE) DROPS 0.44 %

2 SP

dexamethasone sodium phosphate ophthalmic (eye) drops 0.1 %

1

diclofenac sodium ophthalmic (eye) drops 0.1 %

1

dorzolamide ophthalmic (eye) drops 2 % 1

dorzolamide-timolol ophthalmic (eye) drops22.3-6.8 mg/ml

1

doxycycline hyclate oral tablet 20 mg 1

erythromycin ophthalmic (eye) ointment 5 mg/gram (0.5 %)

1

flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)


fluorescein-proparacaine ophthalmic (eye) drops 0.25-0.5 %

1

fluorometholone ophthalmic (eye) drops,suspension 0.1 %

1

flurbiprofen sodium ophthalmic (eye) drops0.03 %

1

FLUROX OPHTHALMIC (EYE) DROPS 0.25-0.4 %

1



75

Drug Tier Notes

GENTAK OPHTHALMIC (EYE) OINTMENT 0.3 % (3 MG/GRAM)

1

gentamicin ophthalmic (eye) drops 0.3 % 1

gentamicin ophthalmic (eye) ointment 0.3 % (3 mg/gram)

1

HOMATROPAIRE OPHTHALMIC (EYE) DROPS 5 %

1

hydrocortisone-acetic acid otic (ear) drops 1-2 %

1

ipratropium bromide nasal spray,non-aerosol0.03 %, 42 mcg (0.06 %)

1 QL

ketorolac ophthalmic (eye) drops 0.4 %, 0.5 %

1

latanoprost ophthalmic (eye) drops 0.005 % 1

levobunolol ophthalmic (eye) drops 0.5 % 1

lidocaine hcl mucous membrane jelly 2 % 1

lidocaine hcl mucous membrane jelly in applicator 2 %

1

lidocaine hcl mucous membrane solution 4 % (40 mg/ml)

1

LOTEMAX OPHTHALMIC (EYE) DROPS,SUSPENSION 0.5 %

2

LOTEMAX OPHTHALMIC (EYE) OINTMENT 0.5 %

2

metipranolol ophthalmic (eye) drops 0.3 % 1

moxifloxacin ophthalmic (eye) drops 0.5 % 1

NATACYN OPHTHALMIC (EYE) DROPS,SUSPENSION 5 %

2

neomycin-bacitracin-poly-hc ophthalmic (eye) ointment 3.5-400-10,000 mg-unit/g-1%

1

neomycin-bacitracin-polymyxin ophthalmic (eye) ointment 3.5-400-10,000 mg-unit-unit/g

1

neomycin-polymyxin b-dexameth ophthalmic (eye) drops,suspension 3.5mg/ml-10,000 unit/ml-0.1 %

1

neomycin-polymyxin b-dexameth ophthalmic (eye) ointment 3.5 mg/g-10,000 unit/g-0.1 %

1

neomycin-polymyxin-gramicidin ophthalmic (eye) drops 1.75 mg-10,000 unit-0.025mg/ml

1



76

Drug Tier Notes

neomycin-polymyxin-hc ophthalmic (eye) drops,suspension 3.5-10,000-10 mg-unit-mg/ml

1

neomycin-polymyxin-hc otic (ear) drops,suspension 3.5-10,000-1 mg/ml-unit/ml-%

1

neomycin-polymyxin-hc otic (ear) solution3.5-10,000-1 mg/ml-unit/ml-%

1

NEO-POLYCIN HC OPHTHALMIC (EYE) OINTMENT 3.5-400-10,000 MG-UNIT/G-1%

1

ofloxacin ophthalmic (eye) drops 0.3 % 1

ofloxacin otic (ear) drops 0.3 % 1

olopatadine ophthalmic (eye) drops 0.1 % 1

PERIOGARD MUCOUS MEMBRANE MOUTHWASH 0.12 %

1

phenylephrine hcl ophthalmic (eye) drops 10 %, 2.5 %

1

PHOSPHOLINE IODIDE OPHTHALMIC (EYE) DROPS 0.125 %

2

pilocarpine hcl ophthalmic (eye) drops 1 %, 2 %, 4 %

1

POLYCIN OPHTHALMIC (EYE) OINTMENT 500-10,000 UNIT/GRAM

1

polymyxin b sulf-trimethoprim ophthalmic (eye) drops 10,000 unit- 1 mg/ml

1

PRED MILD OPHTHALMIC (EYE) DROPS,SUSPENSION 0.12 %

2

prednisolone acetate ophthalmic (eye) drops,suspension 1 %

1

prednisolone sodium phosphate ophthalmic (eye) drops 1 %

1

proparacaine ophthalmic (eye) drops 0.5 % 1

RESTASIS OPHTHALMIC (EYE) DROPPERETTE 0.05 %

2 PA; QL

sulfacetamide sodium ophthalmic (eye) drops10 %

1

sulfacetamide sodium ophthalmic (eye) ointment 10 %

1

sulfacetamide-prednisolone ophthalmic (eye) drops 10 %-0.23 % (0.25 %)

1



77

Drug Tier Notes

TETCAINE OPHTHALMIC (EYE) DROPS 0.5 %

1

tetracaine hcl (pf) ophthalmic (eye) drops 0.5 %

1

tetracaine hcl ophthalmic (eye) drops 0.5 % 1

timolol maleate ophthalmic (eye) drops 0.25 %, 0.5 %

1

timolol maleate ophthalmic (eye) gel forming solution 0.25 %, 0.5 %

1

tobramycin ophthalmic (eye) drops 0.3 % 1

tobramycin-dexamethasone ophthalmic (eye) drops,suspension 0.3-0.1 %

1

tropicamide ophthalmic (eye) drops 0.5 %, 1 %

1

XIIDRA OPHTHALMIC (EYE) DROPPERETTE 5 %

2

ZIRGAN OPHTHALMIC (EYE) GEL 0.15 % 2

ZYLET OPHTHALMIC (EYE) DROPS,SUSPENSION 0.3-0.5 %

2

GASTROINTESTINAL DRUGS

alosetron oral tablet 0.5 mg, 1 mg 1

aprepitant oral capsule 125 mg, 40 mg, 80 mg

1 QL

aprepitant oral capsule,dose pack 125 mg (1)- 80 mg (2)

1 QL

ASACOL HD ORAL TABLET,DELAYED RELEASE (DR/EC) 800 MG

2

balsalazide oral capsule 750 mg 1

CANASA RECTAL SUPPOSITORY 1,000 MG

2

CARAFATE ORAL SUSPENSION 100 MG/ML

1

CESAMET ORAL CAPSULE 1 MG 2

cimetidine hcl oral solution 300 mg/5 ml 1

cimetidine oral tablet 300 mg, 400 mg, 800 mg

1

COMPRO RECTAL SUPPOSITORY 25 MG 1



78

Drug Tier Notes

CREON ORAL CAPSULE,DELAYED RELEASE(DR/EC) 12,000-38,000 -60,000 UNIT, 24,000-76,000 -120,000 UNIT, 3,000-9,500- 15,000 UNIT, 36,000-114,000- 180,000 UNIT, 6,000-19,000 -30,000 UNIT

2



1


1

dronabinol oral capsule 10 mg, 2.5 mg, 5 mg 1

famotidine (pf) intravenous solution 20 mg/2 ml

1

famotidine (pf)-nacl (iso-os) intravenous piggyback 20 mg/50 ml

1

famotidine intravenous solution 10 mg/ml 1

famotidine oral tablet 40 mg 1

GAVILYTE-C ORAL RECON SOLN 240-22.72-6.72 -5.84 GRAM

1

GAVILYTE-G ORAL RECON SOLN 236-22.74-6.74 -5.86 GRAM

1

GAVILYTE-N ORAL RECON SOLN 420 GRAM

1

granisetron (pf) intravenous solution 1 mg/ml (1 ml), 100 mcg/ml

1

granisetron hcl intravenous solution 1 mg/ml, 1 mg/ml (1 ml)

1

granisetron hcl oral tablet 1 mg 1 QL

HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML

2 PA; SP

HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML

2 PA; SP; QL

HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML

2 PA; SP; QL

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML

2 PA; SP; QL



79

Drug Tier Notes

HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML

2 PA; SP; QL

lansoprazole oral capsule,delayed release(dr/ec) 30 mg

1 QL

LINZESS ORAL CAPSULE 145 MCG, 290 MCG

2

mesalamine oral tablet,delayed release (dr/ec) 1.2 gram

1

mesalamine rectal enema 4 gram/60 ml 1

metoclopramide hcl injection solution 5 mg/ml

1

metoclopramide hcl injection syringe 5 mg/ml 1

metoclopramide hcl oral solution 5 mg/5 ml 1

metoclopramide hcl oral tablet 10 mg, 5 mg 1

misoprostol oral tablet 100 mcg, 200 mcg 1

nizatidine oral capsule 150 mg, 300 mg 1

nizatidine oral solution 150 mg/10 ml 1

OCALIVA ORAL TABLET 10 MG, 5 MG 2 PA; SP

omeprazole oral capsule,delayed release(dr/ec) 10 mg



1


1 QL

ondansetron hcl (pf) injection solution 4 mg/2 ml

1

ondansetron hcl (pf) injection syringe 4 mg/2 ml

1

ondansetron hcl intravenous solution 2 mg/ml 1

ondansetron hcl oral solution 4 mg/5 ml 1 QL; QL (150 per 30 days)

ondansetron hcl oral tablet 24 mg, 4 mg, 8 mg

1 QL

ondansetron oral tablet,disintegrating 4 mg, 8 mg

1 QL

pantoprazole oral tablet,delayed release (dr/ec) 20 mg

1 QL

pantoprazole oral tablet,delayed release (dr/ec) 40 mg

1



80

Drug Tier Notes

peg 3350-electrolytes oral recon soln 236-22.74-6.74 -5.86 gram, 240-22.72-6.72 -5.84 gram

1

peg-electrolyte soln oral recon soln 420 gram 1

PENTASA ORAL CAPSULE, EXTENDED RELEASE 250 MG, 500 MG

2


1


1


1


1

prochlorperazine edisylate injection solution10 mg/2 ml (5 mg/ml)

1

prochlorperazine maleate oral tablet 10 mg, 5 mg

1

prochlorperazine rectal suppository 25 mg 1

PYLERA ORAL CAPSULE 140-125-125 MG 2

ranitidine hcl oral syrup 15 mg/ml 1

ranitidine hcl oral tablet 150 mg, 300 mg, 75 mg

1


1

sucralfate oral suspension 100 mg/ml 1

sucralfate oral tablet 1 gram 1



1


1


1

trimethobenzamide oral capsule 300 mg 1


1

ursodiol oral capsule 300 mg 1



81

Drug Tier Notes

ursodiol oral tablet 250 mg, 500 mg 1


1

VIBERZI ORAL TABLET 100 MG, 75 MG 2




1

XERMELO ORAL TABLET 250 MG 2 PA


1

HEAVY METAL ANTAGONISTS

CHEMET ORAL CAPSULE 100 MG 2

CUPRIMINE ORAL CAPSULE 250 MG 2

deferoxamine injection recon soln 2 gram, 500 mg

1

EXJADE ORAL TABLET, DISPERSIBLE 125 MG, 250 MG, 500 MG

2 PA; SP

FERRIPROX ORAL TABLET 500 MG 2 PA; SP

HORMONES AND SYNTHETIC

SUBSTITUTES

acarbose oral tablet 100 mg, 25 mg, 50 mg 1

ALTAVERA (28) ORAL TABLET 0.15-0.03 MG

1 QL

ALYACEN 1/35 (28) ORAL TABLET 1-35 MG-MCG

1 QL

ALYACEN 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG

1 QL

AMETHIA LO ORAL TABLETS,DOSE PACK,3 MONTH 0.10 MG-20 MCG (84)/10 MCG (7)

1 QL

AMETHIA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7)

1 QL

AMETHYST ORAL TABLET 90-20 MCG 1 QL

anastrozole oral tablet 1 mg 1

ANDRODERM TRANSDERMAL PATCH 24 HOUR 2 MG/24 HOUR, 4 MG/24 HR

2 PA



82

Drug Tier Notes

ANDROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 20.25 MG/1.25 GRAM (1.62 %)

2 PA

ANDROGEL TRANSDERMAL GEL IN PACKET 1 % (25 MG/2.5GRAM), 1 % (50 MG/5 GRAM), 1.62 % (20.25 MG/1.25 GRAM), 1.62 % (40.5 MG/2.5 GRAM)

2 PA

APRI ORAL TABLET 0.15-0.03 MG 1 QL

ARANELLE (28) ORAL TABLET 0.5/1/0.5-35 MG-MCG

1 QL

ARMOUR THYROID ORAL TABLET 120 MG, 180 MG, 240 MG, 30 MG, 300 MG, 60 MG, 90 MG

2

AUBRA ORAL TABLET 0.1-20 MG-MCG 1 QL

AVIANE ORAL TABLET 0.1-20 MG-MCG 1 QL

AZURETTE (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5

1 QL

BALZIVA (28) ORAL TABLET 0.4-35 MG-MCG

1 QL

BASAGLAR KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

2

betamethasone acet,sod phos injection suspension 6 mg/ml

1

BLISOVI 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4)

1

BLISOVI FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7)

1

BLISOVI FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)

1

BRIELLYN ORAL TABLET 0.4-35 MG-MCG 1 QL

budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml

1

budesonide oral capsule,delayed,extend.release 3 mg

1

BYDUREON SUBCUTANEOUS PEN INJECTOR 2 MG/0.65 ML

2 PA

BYDUREON SUBCUTANEOUS SUSPENSION,EXTENDED REL RECON 2 MG

2 PA; QL



83

Drug Tier Notes

BYETTA SUBCUTANEOUS PEN INJECTOR 10 MCG/DOSE(250 MCG/ML) 2.4 ML

2 PA; QL

BYETTA SUBCUTANEOUS PEN INJECTOR 5 MCG/DOSE (250 MCG/ML) 1.2 ML

2 PA; QL; QL (2.4 per 30 days)

calcitonin (salmon) nasal spray,non-aerosol200 unit/actuation

1

CAMILA ORAL TABLET 0.35 MG 1

CAMRESE LO ORAL TABLETS,DOSE PACK,3 MONTH 0.10 MG-20 MCG (84)/10 MCG (7)

1 QL

CAMRESE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7)

1 QL

CAZIANT (28) ORAL TABLET 0.1/.125/.15-25 MG-MCG

1 QL

CHATEAL ORAL TABLET 0.15-0.03 MG 1 QL

chlorpropamide oral tablet 100 mg, 250 mg 1

cortisone oral tablet 25 mg 1

CRYSELLE (28) ORAL TABLET 0.3-30 MG-MCG

1 QL

CYCLAFEM 1/35 (28) ORAL TABLET 1-35 MG-MCG

1 QL

CYCLAFEM 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG

1 QL

cyred oral tablet 0.15-0.03 mg 1

danazol oral capsule 100 mg, 200 mg, 50 mg 1

DASETTA 1/35 (28) ORAL TABLET 1-35 MG-MCG

1 QL

DASETTA 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG

1 QL

DAYSEE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG (84)/10 MCG (7)

1 QL

DEPO-PROVERA INTRAMUSCULAR SUSPENSION 400 MG/ML

2

desmopressin injection solution 4 mcg/ml 1 PA

desmopressin nasal solution 0.1 mg/ml (refrigerate)

1

desmopressin nasal spray,non-aerosol 10 mcg/spray (0.1 ml)

1

desmopressin oral tablet 0.1 mg, 0.2 mg 1 PA



84

Drug Tier Notes

desogestrel-ethinyl estradiol oral tablet 0.15-0.03 mg

1 QL

DEXAMETHASONE INTENSOL ORAL DROPS 1 MG/ML

1

dexamethasone oral elixir 0.5 mg/5 ml 1

dexamethasone oral solution 0.5 mg/5 ml 1

dexamethasone oral tablet 0.5 mg, 0.75 mg, 1 mg, 1.5 mg, 2 mg, 4 mg, 6 mg

1

dexamethasone sodium phos (pf) injection solution 10 mg/ml

1

dexamethasone sodium phosphate injection solution 10 mg/ml, 4 mg/ml

1

drospirenone-ethinyl estradiol oral tablet 3-0.03 mg

1 QL


2 QL

ELINEST ORAL TABLET 0.3-30 MG-MCG 1 QL

ELLA ORAL TABLET 30 MG 2 QL

EMOQUETTE ORAL TABLET 0.15-0.03 MG 1 QL

ENPRESSE ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10)

1 QL

ENSKYCE ORAL TABLET 0.15-0.03 MG 1 QL

ERRIN ORAL TABLET 0.35 MG 1

ESTARYLLA ORAL TABLET 0.25-35 MG-MCG

1 QL

ESTRACE VAGINAL CREAM 0.01 % (0.1 MG/GRAM)

2

estradiol oral tablet 0.5 mg, 1 mg, 2 mg 1

estradiol transdermal patch semiweekly0.025 mg/24 hr, 0.0375 mg/24 hr, 0.075 mg/24 hr


estradiol transdermal patch semiweekly 0.05 mg/24 hr, 0.1 mg/24 hr


estradiol vaginal cream 0.01 % (0.1 mg/gram)

1

estradiol valerate intramuscular oil 20 mg/ml, 40 mg/ml

1



85

Drug Tier Notes

estradiol-norethindrone acet oral tablet 0.5-0.1 mg, 1-0.5 mg

1

ESTROGEL TRANSDERMAL GEL IN METERED-DOSE PUMP 1.25 GRAM/ACTUATION

2 QL

estropipate oral tablet 0.75 mg, 1.5 mg, 3 mg 1

EVAMIST TRANSDERMAL SPRAY,NON-AEROSOL 1.53 MG/SPRAY (1.7%)

2 QL

exemestane oral tablet 25 mg 1

FALMINA (28) ORAL TABLET 0.1-20 MG-MCG

1 QL

FARESTON ORAL TABLET 60 MG 2

FEMHRT LOW DOSE ORAL TABLET 0.5-2.5 MG-MCG

2 QL

FEMYNOR ORAL TABLET 0.25-35 MG-MCG

1

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION

2 QL

FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION

2 QL

FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION


fludrocortisone oral tablet 0.1 mg 1

FORTEO SUBCUTANEOUS PEN INJECTOR 20 MCG/DOSE - 600 MCG/2.4 ML

2 PA; SP; QL

GENOTROPIN MINIQUICK SUBCUTANEOUS SYRINGE 0.2 MG/0.25 ML, 0.4 MG/0.25 ML, 0.6 MG/0.25 ML, 0.8 MG/0.25 ML, 1 MG/0.25 ML, 1.2 MG/0.25 ML, 1.4 MG/0.25 ML, 1.6 MG/0.25 ML, 1.8 MG/0.25 ML, 2 MG/0.25 ML

2 PA; SP

GENOTROPIN SUBCUTANEOUS CARTRIDGE 12 MG/ML (36 UNIT/ML), 5 MG/ML (15 UNIT/ML)

2 PA; SP

GIANVI (28) ORAL TABLET 3-0.02 MG 1 QL

GILDAGIA ORAL TABLET 0.4-35 MG-MCG 1 QL

glimepiride oral tablet 1 mg 1 QL



86

Drug Tier Notes

glimepiride oral tablet 2 mg 1 QL; QL (150 per 30 days)

glimepiride oral tablet 4 mg 1 QL; QL (60 per 30 days)

glipizide oral tablet 10 mg 1 QL; QL (180 per 30 days)

glipizide oral tablet 5 mg 1 QL

glipizide oral tablet extended release 24hr 10 mg, 5 mg


glipizide oral tablet extended release 24hr2.5 mg


glipizide-metformin oral tablet 2.5-250 mg 1 QL; QL (300 per 30 days)

glipizide-metformin oral tablet 2.5-500 mg, 5-500 mg


GLUCAGEN DIAGNOSTIC KIT INJECTION RECON SOLN 1 MG/ML

2

GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG

2

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG

2

GLUCAGON HCL INJECTION RECON SOLN 1 MG

2

glyburide micronized oral tablet 1.5 mg, 3 mg 1 QL

glyburide micronized oral tablet 6 mg 1 QL; QL (60 per 30 days)

glyburide oral tablet 1.25 mg, 2.5 mg, 5 mg 1 QL

glyburide-metformin oral tablet 1.25-250 mg 1 QL; QL (300 per 30 days)

glyburide-metformin oral tablet 2.5-500 mg 1 QL; QL (180 per 30 days)

glyburide-metformin oral tablet 5-500 mg 1 QL

HEATHER ORAL TABLET 0.35 MG 1

HUMALOG SUBCUTANEOUS SOLUTION 100 UNIT/ML

2

HUMATROPE INJECTION CARTRIDGE 12 MG (36 UNIT), 24 MG (72 UNIT), 6 MG (18 UNIT)

2 PA; SP

HUMATROPE INJECTION RECON SOLN 5 (15 UNIT) MG

2 PA; SP

HUMULIN 70/30 KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)

2

HUMULIN 70/30 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30)

2



87

Drug Tier Notes

HUMULIN N KWIKPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

2

HUMULIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML

2

HUMULIN R U-100 INJECTION SOLUTION 100 UNIT/ML

2

HUMULIN R U-500 (CONCENTRATED) SUBCUTANEOUS SOLUTION 500 UNIT/ML

2

hydrocortisone oral tablet 10 mg, 20 mg, 5 mg

1

hydroxyprogesterone capr(bulk) powder 100 %

2

hydroxyprogesterone caproate intramuscular oil 250 mg/ml

2 PA

INTROVALE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG

1 QL

INVOKAMET ORAL TABLET 150-1,000 MG, 150-500 MG, 50-1,000 MG, 50-500 MG

2

INVOKANA ORAL TABLET 100 MG 2 QL

INVOKANA ORAL TABLET 300 MG 2 QL; QL (30 per 30 days)

JANUMET ORAL TABLET 50-1,000 MG 2 QL

JANUMET ORAL TABLET 50-500 MG 2 QL; QL (60 per 30 days)

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 100-1,000 MG, 50-1,000 MG

2 QL

JANUMET XR ORAL TABLET, ER MULTIPHASE 24 HR 50-500 MG


JANUVIA ORAL TABLET 100 MG, 25 MG, 50 MG

2 QL

JENCYCLA ORAL TABLET 0.35 MG 1

JINTELI ORAL TABLET 1-5 MG-MCG 1 QL

JOLESSA ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG

1 QL

JOLIVETTE ORAL TABLET 0.35 MG 1

JULEBER ORAL TABLET 0.15-0.03 MG 1

JUNEL 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG

1 QL

JUNEL 1/20 (21) ORAL TABLET 1-20 MG-MCG

1 QL



88

Drug Tier Notes

JUNEL FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7)

1 QL

JUNEL FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)

1 QL

JUNEL FE 24 ORAL TABLET 1 MG-20 MCG (24)/75 MG (4)

1

KAITLIB FE ORAL TABLET,CHEWABLE 0.8MG-25MCG(24) AND 75 MG (4)

1

KARIVA (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5

1 QL

KELNOR 1/35 (28) ORAL TABLET 1-35 MG-MCG

1 QL

KIMIDESS (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5

1

KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 2.5-1,000 MG, 5-500 MG

2 QL

KOMBIGLYZE XR ORAL TABLET, ER MULTIPHASE 24 HR 5-1,000 MG


KURVELO ORAL TABLET 0.15-0.03 MG 1 QL

l norgest/e.estradiol-e.estrad oral tablets,dose pack,3 month 0.10 mg-20 mcg (84)/10 mcg (7), 0.15 mg-30 mcg (84)/10 mcg (7)

1 QL

LANTUS SOLOSTAR SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (3 ML)

2

LANTUS SUBCUTANEOUS SOLUTION 100 UNIT/ML

2

larin 1.5/30 (21) oral tablet 1.5-30 mg-mcg 1

LARIN 1/20 (21) ORAL TABLET 1-20 MG-MCG

1

LARIN 24 FE ORAL TABLET 1 MG-20 MCG (24)/75 MG (4)

1

LARIN FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7)

1 QL

LARIN FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)

1 QL

LARISSIA ORAL TABLET 0.1-20 MG-MCG 1

LAYOLIS FE ORAL TABLET,CHEWABLE 0.8MG-25MCG(24) AND 75 MG (4)

1



89

Drug Tier Notes

LEENA 28 ORAL TABLET 0.5/1/0.5-35 MG-MCG

1 QL

LESSINA ORAL TABLET 0.1-20 MG-MCG 1 QL

letrozole oral tablet 2.5 mg 1

leuprolide subcutaneous kit 1 mg/0.2 ml 1 SP

LEVONEST (28) ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10)

1 QL

levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-mcg, 0.15-0.03 mg

1 QL

levonorgestrel-ethinyl estrad oral tablet 90-20 mcg

1

levonorgestrel-ethinyl estrad oral tablets,dose pack,3 month 0.15 mg-30 mcg

1 QL

levonorg-eth estrad triphasic oral tablet 50-30 (6)/75-40 (5)/125-30(10)

1

LEVORA-28 ORAL TABLET 0.15-0.03 MG 1 QL

levothyroxine intravenous recon soln 200 mcg, 500 mcg

1

levothyroxine oral tablet 100 mcg, 112 mcg, 125 mcg, 137 mcg, 150 mcg, 175 mcg, 200 mcg, 25 mcg, 300 mcg, 50 mcg, 75 mcg, 88 mcg

1

LEVOXYL ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 137 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 50 MCG, 75 MCG, 88 MCG

1

LILETTA INTRAUTERINE INTRAUTERINE DEVICE 19.5 MCG/24 HOUR (4 YEARS)

2

liothyronine intravenous solution 10 mcg/ml 1

liothyronine oral tablet 25 mcg, 5 mcg, 50 mcg

1

LORYNA (28) ORAL TABLET 3-0.02 MG 1 QL

LOW-OGESTREL (28) ORAL TABLET 0.3-30 MG-MCG

1 QL


LUPRON DEPOT (3 MONTH) INTRAMUSCULAR SYRINGE KIT 11.25 MG, 22.5 MG

2 PA; SP

LUPRON DEPOT (4 MONTH) INTRAMUSCULAR SYRINGE KIT 30 MG

2 PA; SP



90

Drug Tier Notes

LUPRON DEPOT INTRAMUSCULAR SYRINGE KIT 3.75 MG, 7.5 MG

2 PA; SP

LUPRON DEPOT-PED INTRAMUSCULAR KIT 11.25 MG, 15 MG, 7.5 MG (PED)

2 PA; SP

LUTERA (28) ORAL TABLET 0.1-20 MG-MCG

1 QL

LYZA ORAL TABLET 0.35 MG 1

MAKENA INTRAMUSCULAR OIL 250 MG/ML, 250 MG/ML (1 ML)

2 PA; SP

MARLISSA ORAL TABLET 0.15-0.03 MG 1 QL

medroxyprogesterone intramuscular suspension 150 mg/ml

1 QL

medroxyprogesterone intramuscular syringe150 mg/ml


medroxyprogesterone oral tablet 10 mg, 2.5 mg, 5 mg

1

megestrol oral suspension 400 mg/10 ml (10 ml), 400 mg/10 ml (40 mg/ml), 800 mg/20 ml (20 ml)

1 PA

megestrol oral tablet 20 mg, 40 mg 1 PA

metformin oral tablet 1,000 mg, 500 mg 1 QL

metformin oral tablet 850 mg 1 QL; QL (120 per 30 days)

metformin oral tablet extended release 24 hr500 mg, 750 mg

1 QL

metformin oral tablet extended release 24hr500 mg

1 QL

methimazole oral tablet 10 mg, 5 mg 1

METHITEST ORAL TABLET 10 MG 2

methylprednisolone acetate injection suspension 40 mg/ml, 80 mg/ml

1

methylprednisolone oral tablet 16 mg, 32 mg, 4 mg, 8 mg

1

methylprednisolone oral tablets,dose pack 4 mg

1

methylprednisolone sodium succ injection recon soln 125 mg, 40 mg

1

methylprednisolone sodium succ intravenous recon soln 1,000 mg

1



91

Drug Tier Notes

MICROGESTIN 1.5/30 (21) ORAL TABLET 1.5-30 MG-MCG

1 QL

MICROGESTIN 1/20 (21) ORAL TABLET 1-20 MG-MCG

1 QL

MICROGESTIN FE 1.5/30 (28) ORAL TABLET 1.5 MG-30 MCG (21)/75 MG (7)

1 QL

MICROGESTIN FE 1/20 (28) ORAL TABLET 1 MG-20 MCG (21)/75 MG (7)

1 QL

MIMVEY ORAL TABLET 1-0.5 MG 1

MONO-LINYAH ORAL TABLET 0.25-35 MG-MCG

1 QL

MONONESSA (28) ORAL TABLET 0.25-35 MG-MCG

1 QL

MYALEPT SUBCUTANEOUS RECON SOLN 5 MG/ML (FINAL CONC.)

2 PA

MYZILRA ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10)

1 QL

nateglinide oral tablet 120 mg, 60 mg 1

NATPARA SUBCUTANEOUS CARTRIDGE 100 MCG/DOSE, 25 MCG/DOSE, 50 MCG/DOSE, 75 MCG/DOSE

2 PA

NATURE-THROID ORAL TABLET 130 MG, 146.25 MG, 16.25 MG, 195 MG, 32.5 MG, 48.75 MG, 65 MG, 81.25 MG

1

NECON 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG

1 QL

NECON 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG

1 QL

NEXPLANON SUBDERMAL IMPLANT 68 MG

2 SP

nikki (28) oral tablet 3-0.02 mg 1

NORA-BE ORAL TABLET 0.35 MG 1

noreth-ethinyl estradiol-iron oral tablet,chewable 0.4mg-35mcg(21) and 75 mg (7), 0.8mg-25mcg(24) and 75 mg (4)

1

norethindrone (contraceptive) oral tablet 0.35 mg

1

norethindrone acetate oral tablet 5 mg 1

norethindrone ac-eth estradiol oral tablet 0.5-2.5 mg-mcg, 1-20 mg-mcg, 1-5 mg-mcg

1



92

Drug Tier Notes

norethindrone-e.estradiol-iron oral tablet 1 mg-20 mcg (21)/75 mg (7), 1 mg-20 mcg (24)/75 mg (4)

1

norgestimate-ethinyl estradiol oral tablet0.18/0.215/0.25 mg-25 mcg

1

norgestimate-ethinyl estradiol oral tablet0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg

1 QL

NORTREL 0.5/35 (28) ORAL TABLET 0.5-35 MG-MCG

1 QL

NORTREL 1/35 (21) ORAL TABLET 1-35 MG-MCG

1 QL

NORTREL 1/35 (28) ORAL TABLET 1-35 MG-MCG

1 QL

NORTREL 7/7/7 (28) ORAL TABLET 0.5/0.75/1 MG- 35 MCG

1 QL

NOVOLIN 70/30 SUBCUTANEOUS SUSPENSION 100 UNIT/ML (70-30)

2

NOVOLIN N SUBCUTANEOUS SUSPENSION 100 UNIT/ML

2

NOVOLIN R INJECTION SOLUTION 100 UNIT/ML

2

NOVOLOG FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML

2

NOVOLOG MIX 70-30 FLEXPEN SUBCUTANEOUS INSULIN PEN 100 UNIT/ML (70-30)

2

NOVOLOG MIX 70-30 SUBCUTANEOUS SOLUTION 100 UNIT/ML (70-30)

2

NOVOLOG PENFILL SUBCUTANEOUS CARTRIDGE 100 UNIT/ML

2

NOVOLOG SUBCUTANEOUS SOLUTION 100 UNIT/ML

2

NP THYROID ORAL TABLET 120 MG, 15 MG, 30 MG, 60 MG, 90 MG

1

NUTROPIN AQ NUSPIN SUBCUTANEOUS PEN INJECTOR 10 MG/2 ML (5 MG/ML), 20 MG/2 ML (10 MG/ML), 5 MG/2 ML (2.5 MG/ML)

2 PA; SP

NUVARING VAGINAL RING 0.12-0.015 MG/24 HR

2



93

Drug Tier Notes

OCELLA ORAL TABLET 3-0.03 MG 1 QL

octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

1 SP

octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml), 500 mcg/ml (1 ml)

1 SP

OGESTREL (28) ORAL TABLET 0.5-50 MG-MCG

1 QL

ONGLYZA ORAL TABLET 2.5 MG 2 QL

ONGLYZA ORAL TABLET 5 MG 2 QL; QL (30 per 30 days)

ORSYTHIA ORAL TABLET 0.1-20 MG-MCG 1 QL

oxandrolone oral tablet 10 mg, 2.5 mg 1 PA

PHILITH ORAL TABLET 0.4-35 MG-MCG 1 QL

PIMTREA (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5

1 QL

pioglitazone oral tablet 15 mg, 30 mg 1 QL

pioglitazone oral tablet 45 mg 1 QL; QL (30 per 30 days)

pioglitazone-metformin oral tablet 15-500 mg, 15-850 mg

1 QL

PIRMELLA ORAL TABLET 0.5/0.75/1 MG- 35 MCG, 1-35 MG-MCG

1 QL

PORTIA ORAL TABLET 0.15-0.03 MG 1 QL

prednisolone oral solution 15 mg/5 ml 1

prednisolone sodium phosphate oral solution15 mg/5 ml (3 mg/ml), 25 mg/5 ml (5 mg/ml), 5 mg base/5 ml (6.7 mg/5 ml)

1

PREDNISONE INTENSOL ORAL CONCENTRATE 5 MG/ML

1

prednisone oral solution 5 mg/5 ml 1

prednisone oral tablet 1 mg, 10 mg, 2.5 mg, 20 mg, 5 mg, 50 mg

1

prednisone oral tablets,dose pack 10 mg, 5 mg

1

PREMARIN INJECTION RECON SOLN 25 MG

2

PREMARIN VAGINAL CREAM 0.625 MG/GRAM

2



94

Drug Tier Notes

PREMPHASE ORAL TABLET 0.625 MG (14)/ 0.625MG-5MG(14)

2

PREMPRO ORAL TABLET 0.3-1.5 MG, 0.45-1.5 MG, 0.625-2.5 MG, 0.625-5 MG

2

PREVIFEM ORAL TABLET 0.25-35 MG-MCG

1 QL

progesterone intramuscular oil 50 mg/ml 1

progesterone micronized oral capsule 100 mg, 200 mg

1

PROGLYCEM ORAL SUSPENSION 50 MG/ML

2

propylthiouracil oral tablet 50 mg 1

QUASENSE ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG

1 QL

QVAR INHALATION AEROSOL 40 MCG/ACTUATION




raloxifene oral tablet 60 mg 1

RECLIPSEN (28) ORAL TABLET 0.15-0.03 MG

1 QL

repaglinide oral tablet 0.5 mg, 1 mg, 2 mg 1

repaglinide-metformin oral tablet 1-500 mg, 2-500 mg

1 QL

SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG

2 SP

SEROSTIM SUBCUTANEOUS RECON SOLN 4 MG, 5 MG, 6 MG

2 PA; SP

SETLAKIN ORAL TABLETS,DOSE PACK,3 MONTH 0.15 MG-30 MCG

1 QL

SIGNIFOR SUBCUTANEOUS SOLUTION 0.3 MG/ML (1 ML), 0.6 MG/ML (1 ML), 0.9 MG/ML (1 ML)

2 PA; SP

SOLU-CORTEF (PF) INJECTION RECON SOLN 1,000 MG/8 ML, 100 MG/2 ML, 250 MG/2 ML, 500 MG/4 ML

2

SOLU-CORTEF INJECTION RECON SOLN 100 MG

2

SOLU-MEDROL (PF) INJECTION RECON SOLN 125 MG/2 ML, 40 MG/ML

2



95

Drug Tier Notes

SOLU-MEDROL (PF) INTRAVENOUS RECON SOLN 1,000 MG/8 ML, 500 MG/4 ML

2

SOLU-MEDROL INTRAVENOUS RECON SOLN 1,000 MG

2

SOMATULINE DEPOT SUBCUTANEOUS SYRINGE 120 MG/0.5 ML, 60 MG/0.2 ML, 90 MG/0.3 ML

2 SP

SPRINTEC (28) ORAL TABLET 0.25-35 MG-MCG

1 QL

SRONYX ORAL TABLET 0.1-20 MG-MCG 1 QL


SYEDA ORAL TABLET 3-0.03 MG 1 QL


2 QL

SYMLINPEN 120 SUBCUTANEOUS PEN INJECTOR 2,700 MCG/2.7 ML

2 PA

SYMLINPEN 60 SUBCUTANEOUS PEN INJECTOR 1,500 MCG/1.5 ML

2 PA

SYNAREL NASAL SPRAY,NON-AEROSOL 2 MG/ML

2

tamoxifen oral tablet 10 mg, 20 mg 1

tarina fe 1/20 (28) oral tablet 1 mg-20 mcg (21)/75 mg (7)

1

testosterone cypionate intramuscular oil 100 mg/ml, 200 mg/ml

1

testosterone enanthate intramuscular oil 200 mg/ml

1

TESTOSTERONE TRANSDERMAL GEL 50 MG/5 GRAM (1 %)

2

testosterone transdermal gel in metered-dose pump 10 mg/0.5 gram /actuation, 12.5 mg/ 1.25 gram (1 %)

1 PA

testosterone transdermal gel in packet 1 % (25 mg/2.5gram), 1 % (50 mg/5 gram)

1 PA

THYROLAR-1 ORAL TABLET 12.5-50 MCG 2

THYROLAR-1/2 ORAL TABLET 6.25-25 MCG

2



96

Drug Tier Notes

THYROLAR-1/4 ORAL TABLET 3.1-12.5 MCG

2

THYROLAR-2 ORAL TABLET 25-100 MCG 2

THYROLAR-3 ORAL TABLET 37.5-150 MCG

2

TILIA FE ORAL TABLET 1-20(5)/1-30(7) /1MG-35MCG (9)

1

tolazamide oral tablet 250 mg 1 QL

tolazamide oral tablet 500 mg 1 QL; QL (60 per 30 days)

tolbutamide oral tablet 500 mg 1

TRI-ESTARYLLA ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)

1 QL

TRI-LEGEST FE ORAL TABLET 1-20(5)/1-30(7) /1MG-35MCG (9)

1 QL

TRI-LINYAH ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)

1 QL

tri-lo-estarylla oral tablet 0.18/0.215/0.25 mg-25 mcg

1

tri-lo-sprintec oral tablet 0.18/0.215/0.25 mg-25 mcg

1

TRINESSA (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)

1 QL

trinessa lo oral tablet 0.18/0.215/0.25 mg-25 mcg

1

TRI-PREVIFEM (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)

1 QL

TRI-SPRINTEC (28) ORAL TABLET 0.18/0.215/0.25 MG-35 MCG (28)

1 QL

TRIVORA (28) ORAL TABLET 50-30 (6)/75-40 (5)/125-30(10)

1 QL

UNITHROID ORAL TABLET 100 MCG, 112 MCG, 125 MCG, 150 MCG, 175 MCG, 200 MCG, 25 MCG, 300 MCG, 50 MCG, 75 MCG, 88 MCG

1

unithroid oral tablet 137 mcg 1

vasopressin injection solution 20 unit/ml 1

VELIVET TRIPHASIC REGIMEN (28) ORAL TABLET 0.1/.125/.15-25 MG-MCG

1 QL

VESTURA (28) ORAL TABLET 3-0.02 MG 1 QL



97

Drug Tier Notes

VICTOZA 2-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)

2 PA; QL

VICTOZA 3-PAK SUBCUTANEOUS PEN INJECTOR 0.6 MG/0.1 ML (18 MG/3 ML)


VIENVA ORAL TABLET 0.1-20 MG-MCG 1

VIORELE (28) ORAL TABLET 0.15-0.02 MGX21 /0.01 MG X 5

1 QL

WELCHOL ORAL POWDER IN PACKET 3.75 GRAM

2

WELCHOL ORAL TABLET 625 MG 2

WERA (28) ORAL TABLET 0.5-35 MG-MCG 1 QL

WESTHROID ORAL TABLET 130 MG, 32.5 MG, 65 MG

1

WYMZYA FE ORAL TABLET,CHEWABLE 0.4MG-35MCG(21) AND 75 MG (7)

1 QL

XULANE TRANSDERMAL PATCH WEEKLY 150-35 MCG/24 HR

1 QL

yuvafem vaginal tablet 10 mcg 1

ZARAH ORAL TABLET 3-0.03 MG 1 QL

ZENCHENT (28) ORAL TABLET 0.4-35 MG-MCG

1 QL

ZORBTIVE SUBCUTANEOUS RECON SOLN 8.8 MG

2 PA; SP

ZOVIA 1/35E (28) ORAL TABLET 1-35 MG-MCG

1 QL

ZOVIA 1/50E (28) ORAL TABLET 1-50 MG-MCG

1 QL

LOCAL ANESTHETICS (PARENTERAL)

bupivacaine (pf) injection solution 0.25 % (2.5 mg/ml), 0.5 % (5 mg/ml), 0.75 % (7.5 mg/ml)

1

bupivacaine injection solution 0.25 % (2.5 mg/ml), 0.5 % (5 mg/ml)

1

bupivacaine-dextrose-water(pf) injection solution 0.75 % (7.5 mg/ml)

1

bupivacaine-epinephrine (pf) injection solution 0.25 %-1:200,000, 0.5 %-1:200,000

1

bupivacaine-epinephrine injection solution0.25 %-1:200,000, 0.5 %-1:200,000

1



98

Drug Tier Notes

lidocaine (pf) in d7.5w intrathecal solution 50 mg/ml (5 %)

1

lidocaine (pf) injection solution 10 mg/ml (1 %), 15 mg/ml (1.5 %), 20 mg/ml (2 %), 40 mg/ml (4 %), 5 mg/ml (0.5 %)

1

lidocaine hcl injection solution 10 mg/ml (1 %), 20 mg/ml (2 %)

1

lidocaine-epinephrine injection solution 0.5 %-1:200,000, 1 %-1:100,000, 2 %-1:100,000

1

MISCELLANEOUS THERAPEUTIC

AGENTS

acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %)

1

ACTEMRA INTRAVENOUS SOLUTION 200 MG/10 ML (20 MG/ML), 400 MG/20 ML (20 MG/ML), 80 MG/4 ML (20 MG/ML)

2 PA; SP

ACTEMRA SUBCUTANEOUS SYRINGE 162 MG/0.9 ML

2 PA; SP

alendronate oral solution 70 mg/75 ml 1 QL

alendronate oral tablet 10 mg, 40 mg, 5 mg 1 QL

alendronate oral tablet 35 mg, 70 mg 1 QL; QL (4 per 30 days)

allopurinol oral tablet 100 mg, 300 mg 1

amifostine crystalline intravenous recon soln500 mg

1

AMPYRA ORAL TABLET EXTENDED RELEASE 12 HR 10 MG

2 PA; SP; QL

ATGAM INTRAVENOUS SOLUTION 50 MG/ML

2 SP

AUBAGIO ORAL TABLET 14 MG, 7 MG 2 PA; SP

AVONEX (WITH ALBUMIN) INTRAMUSCULAR KIT 30 MCG

2 PA; SP; QL

AVONEX INTRAMUSCULAR PEN INJECTOR KIT 30 MCG/0.5 ML

2 PA; SP; QL

AVONEX INTRAMUSCULAR SYRINGE KIT 30 MCG/0.5 ML

2 PA; SP; QL

azathioprine oral tablet 50 mg 1

BETASERON SUBCUTANEOUS KIT 0.3 MG

2 PA; SP; QL

BOTOX INJECTION RECON SOLN 100 UNIT, 200 UNIT

2 PA; SP



99

Drug Tier Notes

calcitonin (salmon) nasal spray,non-aerosol200 unit/actuation

1

CERDELGA ORAL CAPSULE 84 MG 2

CHEMET ORAL CAPSULE 100 MG 2

COLCRYS ORAL TABLET 0.6 MG 2 ST

CUPRIMINE ORAL CAPSULE 250 MG 2

cyclophosphamide intravenous recon soln 1 gram, 2 gram, 500 mg

1

CYCLOPHOSPHAMIDE ORAL CAPSULE 25 MG, 50 MG

2

cyclosporine intravenous solution 250 mg/5 ml

1

cyclosporine modified oral capsule 100 mg, 25 mg, 50 mg

1 SP

cyclosporine modified oral solution 100 mg/ml

1 SP

cyclosporine oral capsule 100 mg, 25 mg 1

CYSTAGON ORAL CAPSULE 150 MG, 50 MG

2 SP

deferoxamine injection recon soln 2 gram, 500 mg

1

DENTA 5000 PLUS DENTAL CREAM 1.1 % 1

DENTAGEL DENTAL GEL 1.1 % 1

dexrazoxane hcl intravenous recon soln 250 mg, 500 mg

1

disulfiram oral tablet 250 mg, 500 mg 1

dutasteride oral capsule 0.5 mg 1 ST

dutasteride-tamsulosin oral capsule, er multiphase 24 hr 0.5-0.4 mg

1 ST

DYSPORT INTRAMUSCULAR RECON SOLN 300 UNIT, 500 UNIT

2 PA; SP

ELIDEL TOPICAL CREAM 1 % 2 PA

ELMIRON ORAL CAPSULE 100 MG 2

ENBREL MINI SUBCUTANEOUS CARTRIDGE 50 MG/ML (0.98 ML)

2 PA; SP

ENBREL SUBCUTANEOUS RECON SOLN 25 MG (1 ML)

2 PA; SP; QL

ENBREL SUBCUTANEOUS SYRINGE 25 MG/0.5ML (0.51), 50 MG/ML (0.98 ML)

2 PA; SP; QL



100

Drug Tier Notes

ENBREL SURECLICK SUBCUTANEOUS PEN INJECTOR 50 MG/ML (0.98 ML)

2 PA; SP; QL

etidronate disodium oral tablet 200 mg, 400 mg

1

EVOTAZ ORAL TABLET 300-150 MG 2

EVZIO INJECTION AUTO-INJECTOR 0.4 MG/0.4 ML

2

EXTAVIA SUBCUTANEOUS KIT 0.3 MG 2 PA; SP; QL

finasteride oral tablet 5 mg 1

FIRAZYR SUBCUTANEOUS SYRINGE 30 MG/3 ML

2 PA; SP

flumazenil intravenous solution 0.1 mg/ml 1

FLUOR-A-DAY (WITH XYLITOL) ORAL TABLET,CHEWABLE 0.25 MG F (0.55 MG)-236.79MG, 1 MG F (2.2 MG)-236.79 MG

1

fluoride (sodium) oral drops 0.5 mg (1.1 mg sod.fluorid)/ml

1

fluoride (sodium) oral tablet,chewable 0.25 mg(0.55 mg sod. fluoride), 0.5 mg (1.1 mg sodium fluorid), 1 mg (2.2 mg sod. fluoride)

1

FLUORITAB ORAL TABLET,CHEWABLE 0.5 MG (1.1 MG SODIUM FLUORID), 1 MG (2.2 MG SOD. FLUORIDE)

1

fomepizole intravenous solution 1 gram/ml 1

FOSRENOL ORAL TABLET,CHEWABLE 1,000 MG, 500 MG, 750 MG

2

GILENYA ORAL CAPSULE 0.5 MG 2 PA; SP; QL

glatiramer subcutaneous syringe 20 mg/ml, 40 mg/ml

1 PA; SP

GLATOPA SUBCUTANEOUS SYRINGE 20 MG/ML

2 PA; SP; QL

GLUCAGEN HYPOKIT INJECTION RECON SOLN 1 MG

2

GLUCAGON EMERGENCY KIT (HUMAN) INJECTION KIT 1 MG

2

HUMIRA PEDIATRIC CROHN'S START SUBCUTANEOUS SYRINGE KIT 40 MG/0.8 ML

2 PA; SP



101

Drug Tier Notes

HUMIRA PEN CROHN'S-UC-HS START SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML

2 PA; SP; QL

HUMIRA PEN PSORIASIS-UVEITIS SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML

2 PA; SP; QL

HUMIRA PEN SUBCUTANEOUS PEN INJECTOR KIT 40 MG/0.8 ML

2 PA; SP; QL

HUMIRA SUBCUTANEOUS SYRINGE KIT 10 MG/0.2 ML, 20 MG/0.4 ML, 40 MG/0.8 ML

2 PA; SP; QL

hydroxychloroquine oral tablet 200 mg 1

ibandronate intravenous solution 3 mg/3 ml 2 SP

ibandronate intravenous syringe 3 mg/3 ml 1 SP

ibandronate oral tablet 150 mg 1 ST; QL

indomethacin oral capsule 25 mg, 50 mg 1


2 SP


2 SP

KIONEX (WITH SORBITOL) ORAL SUSPENSION 15-19.3 GRAM/60 ML

1

KRYSTEXXA INTRAVENOUS SOLUTION 8 MG/ML

2 PA; SP

lanthanum oral tablet,chewable 1,000 mg, 500 mg, 750 mg

1

leflunomide oral tablet 10 mg, 20 mg 1 QL

LEMTRADA INTRAVENOUS SOLUTION 12 MG/1.2 ML

2 PA

leucovorin calcium injection recon soln 100 mg, 200 mg, 350 mg, 50 mg, 500 mg

1 SP

leucovorin calcium oral tablet 10 mg, 15 mg, 25 mg, 5 mg

1 SP

levocarnitine (with sugar) oral solution 100 mg/ml

1

levocarnitine oral tablet 330 mg 1

levoleucovorin intravenous recon soln 175 mg

2 SP



102

Drug Tier Notes

LUDENT FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG(0.55 MG SOD. FLUORIDE), 0.5 MG (1.1 MG SODIUM FLUORID), 1 MG (2.2 MG SOD. FLUORIDE)

1



1


1


1


1

MEPHYTON ORAL TABLET 5 MG 2

mercaptopurine oral tablet 50 mg 1

mesna intravenous solution 100 mg/ml 1

MESNEX ORAL TABLET 400 MG 2 SP

methotrexate sodium (pf) injection recon soln1 gram

1

methotrexate sodium (pf) injection solution25 mg/ml

1

methotrexate sodium injection solution 25 mg/ml

1

methotrexate sodium oral tablet 2.5 mg 1

methylene blue (antidote) intravenous solution 1 % (10 mg/ml)

1

MITIGARE ORAL CAPSULE 0.6 MG 2

MULTI-VITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG, 0.5 MG, 1 MG

1

MULTIVITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG

1

MULTIVITAMINS WITH FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG, 1 MG

1

mycophenolate mofetil hcl intravenous recon soln 500 mg

1 SP

mycophenolate mofetil oral capsule 250 mg 1 SP



103

Drug Tier Notes

mycophenolate mofetil oral suspension for reconstitution 200 mg/ml

1 SP

mycophenolate mofetil oral tablet 500 mg 1 SP

mycophenolate sodium oral tablet,delayed release (dr/ec) 180 mg, 360 mg

1 SP

naloxone injection solution 0.4 mg/ml 1

naloxone injection syringe 0.4 mg/ml, 1 mg/ml

1

naltrexone oral tablet 50 mg 1

naproxen oral suspension 125 mg/5 ml 1

naproxen oral tablet 250 mg, 375 mg, 500 mg

1

naproxen oral tablet,delayed release (dr/ec)375 mg, 500 mg

1

naproxen sodium oral tablet 275 mg, 550 mg 1

OCREVUS INTRAVENOUS SOLUTION 30 MG/ML

2 PA

octreotide acetate injection solution 1,000 mcg/ml, 100 mcg/ml, 200 mcg/ml, 50 mcg/ml, 500 mcg/ml

1 SP

octreotide acetate injection syringe 100 mcg/ml (1 ml), 50 mcg/ml (1 ml), 500 mcg/ml (1 ml)

1 SP

ORENCIA CLICKJECT SUBCUTANEOUS AUTO-INJECTOR 125 MG/ML

2 PA; SP

ORENCIA SUBCUTANEOUS SYRINGE 125 MG/ML, 50 MG/0.4 ML, 87.5 MG/0.7 ML

2 PA; SP

ORFADIN ORAL CAPSULE 10 MG, 2 MG, 5 MG

2 SP

OTEZLA ORAL TABLET 30 MG 2 PA; SP; QL (60 per 30 days)

OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG (47)

2 PA; SP; QL (55 per 365 days)

OTEZLA STARTER ORAL TABLETS,DOSE PACK 10 MG (4)-20 MG (4)-30 MG(19)


pamidronate intravenous recon soln 30 mg, 90 mg

1

pamidronate intravenous solution 30 mg/10 ml (3 mg/ml), 60 mg/10 ml (6 mg/ml), 90 mg/10 ml (9 mg/ml)

1



104

Drug Tier Notes

physostigmine salicylate injection solution 1 mg/ml

1

PLEGRIDY SUBCUTANEOUS PEN INJECTOR 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML

2 PA; SP

PLEGRIDY SUBCUTANEOUS SYRINGE 125 MCG/0.5 ML, 63 MCG/0.5 ML- 94 MCG/0.5 ML

2 PA; SP

POMALYST ORAL CAPSULE 1 MG, 2 MG, 3 MG, 4 MG

2 SP

PREZCOBIX ORAL TABLET 800-150 MG-MG

2

probenecid oral tablet 500 mg 1

probenecid-colchicine oral tablet 500-0.5 mg 1

PROLEUKIN INTRAVENOUS RECON SOLN 22 MILLION UNIT

2 SP

PROLIA SUBCUTANEOUS SYRINGE 60 MG/ML

2 PA; SP

raloxifene oral tablet 60 mg 1

RAPAMUNE ORAL SOLUTION 1 MG/ML 2 SP

REBIF (WITH ALBUMIN) SUBCUTANEOUS SYRINGE 22 MCG/0.5 ML, 44 MCG/0.5 ML

2 PA; SP; QL

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 22 MCG/0.5 ML

2 PA; SP; QL; QL (8 per 30 days)

REBIF REBIDOSE SUBCUTANEOUS PEN INJECTOR 44 MCG/0.5 ML, 8.8MCG/0.2ML-22 MCG/0.5ML (6)

2 PA; SP; QL

REBIF TITRATION PACK SUBCUTANEOUS SYRINGE 8.8MCG/0.2ML-22 MCG/0.5ML (6)

2 PA; SP; QL

REMICADE INTRAVENOUS RECON SOLN 100 MG

2 SP

RENAGEL ORAL TABLET 400 MG, 800 MG 2

RENVELA ORAL TABLET 800 MG 2

REVLIMID ORAL CAPSULE 10 MG, 15 MG, 2.5 MG, 20 MG, 25 MG, 5 MG

2 PA; SP

SENSIPAR ORAL TABLET 30 MG, 60 MG, 90 MG

2 SP

SF 5000 PLUS DENTAL CREAM 1.1 % 1

SF DENTAL GEL 1.1 % 1



105

Drug Tier Notes

sirolimus oral tablet 0.5 mg, 1 mg, 2 mg 1

SODIUM POLYSTYRENE (SORB FREE) ORAL SUSPENSION 15 GRAM/60 ML

1

sodium polystyrene sulfonate oral powder 1

sodium polystyrene sulfonate rectal enema30 gram/120 ml

1

sodium thiosulfate intravenous solution 12.5 gram/50 ml (250 mg/ml)

1

SPS (WITH SORBITOL) ORAL SUSPENSION 15-20 GRAM/60 ML

1

SPS (WITH SORBITOL) RECTAL ENEMA 30-40 GRAM/120 ML

1




1

tacrolimus oral capsule 0.5 mg, 1 mg, 5 mg 1 SP

TECFIDERA ORAL CAPSULE,DELAYED RELEASE(DR/EC) 120 MG, 120 MG (14)- 240 MG (46), 240 MG

2 PA; SP

THALOMID ORAL CAPSULE 100 MG, 150 MG, 200 MG, 50 MG

2 PA; SP


1

TRI-VITAMIN WITH FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML, 0.5 MG FLUORIDE (1.1 MG)/ML

1

VISTOGARD ORAL GRANULES IN PACKET 10 GRAM

2

VITAMINS A,C,D AND FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML

1

XELJANZ ORAL TABLET 5 MG 2 PA; SP; QL (60 per 30 days)

XELJANZ XR ORAL TABLET EXTENDED RELEASE 24 HR 11 MG


XEOMIN INTRAMUSCULAR RECON SOLN 100 UNIT, 50 UNIT

2 PA; SP

XGEVA SUBCUTANEOUS SOLUTION 120 MG/1.7 ML (70 MG/ML)

2 SP

ZAVESCA ORAL CAPSULE 100 MG 2 SP



106

Drug Tier Notes

ZORTRESS ORAL TABLET 0.25 MG, 0.5 MG, 0.75 MG

2 SP

OXYTOCICS

oxytocin injection solution 10 unit/ml 1

RESPIRATORY TRACT AGENTS

acetylcysteine solution 100 mg/ml (10 %), 200 mg/ml (20 %)

1

albuterol sulfate inhalation solution for nebulization 0.63 mg/3 ml, 1.25 mg/3 ml, 2.5 mg /3 ml (0.083 %), 2.5 mg/0.5 ml, 5 mg/ml

1

albuterol sulfate oral syrup 2 mg/5 ml 1

albuterol sulfate oral tablet 2 mg, 4 mg 1

albuterol sulfate oral tablet extended release 12 hr 4 mg, 8 mg

1

aminophylline intravenous solution 250 mg/10 ml, 500 mg/20 ml

1

atropine injection solution 0.4 mg/ml, 1 mg/ml 1

atropine injection syringe 0.05 mg/ml, 0.1 mg/ml

1

ATROVENT HFA INHALATION HFA AEROSOL INHALER 17 MCG/ACTUATION

2 QL

brompheniramine-pseudoeph-dm oral syrup2-30-10 mg/5 ml

1

budesonide inhalation suspension for nebulization 0.25 mg/2 ml, 0.5 mg/2 ml, 1 mg/2 ml

1

carbinoxamine maleate oral liquid 4 mg/5 ml 1

carbinoxamine maleate oral tablet 4 mg 1

clemastine oral tablet 2.68 mg 1

codeine sulfate oral tablet 15 mg, 30 mg, 60 mg


COMBIVENT RESPIMAT INHALATION MIST 20-100 MCG/ACTUATION

2 QL

cromolyn ophthalmic (eye) drops 4 % 1

cromolyn oral concentrate 100 mg/5 ml 1

cyproheptadine oral syrup 2 mg/5 ml 1

cyproheptadine oral tablet 4 mg 1




107

Drug Tier Notes

diphenhydramine hcl injection solution 50 mg/ml

1

diphenhydramine hcl injection syringe 50 mg/ml

1


1


1


2 QL

ephedrine sulfate injection solution 50 mg/ml 1

epinephrine injection auto-injector 0.15 mg/0.3 ml, 0.3 mg/0.3 ml

1

epinephrine injection solution 1 mg/ml, 1 mg/ml (1 ml)

1

epinephrine injection syringe 0.1 mg/ml 1

EPIPEN 2-PAK INJECTION AUTO-INJECTOR 0.3 MG/0.3 ML


EPIPEN JR 2-PAK INJECTION AUTO-INJECTOR 0.15 MG/0.3 ML


epoprostenol (glycine) intravenous recon soln 0.5 mg, 1.5 mg

1 SP

ESBRIET ORAL CAPSULE 267 MG 2PA; SP; QL; QL (306 per 34 days)

ESBRIET ORAL TABLET 267 MG 2 PA; SP; QL (306 per 34 days)

ESBRIET ORAL TABLET 801 MG 2 PA; SP; QL (102 per 34 days)

FLOVENT DISKUS INHALATION BLISTER WITH DEVICE 100 MCG/ACTUATION, 250 MCG/ACTUATION, 50 MCG/ACTUATION

2 QL

FLOVENT HFA INHALATION HFA AEROSOL INHALER 110 MCG/ACTUATION, 220 MCG/ACTUATION

2 QL

FLOVENT HFA INHALATION HFA AEROSOL INHALER 44 MCG/ACTUATION


flunisolide nasal spray,non-aerosol 25 mcg (0.025 %)




108

Drug Tier Notes

fluticasone-salmeterol inhalation aerosol powdr breath activated 113-14 mcg/actuation, 232-14 mcg/actuation, 55-14 mcg/actuation

1

GASTROCROM ORAL CONCENTRATE 100 MG/5 ML

2

ipratropium bromide inhalation solution 0.02 %

1

ipratropium-albuterol inhalation solution for nebulization 0.5 mg-3 mg(2.5 mg base)/3 ml

1

KALYDECO ORAL TABLET 150 MG 2 PA; SP

LETAIRIS ORAL TABLET 10 MG, 5 MG 2 PA; SP


metaproterenol oral syrup 10 mg/5 ml 1

metaproterenol oral tablet 10 mg, 20 mg 1

montelukast oral granules in packet 4 mg 1

montelukast oral tablet 10 mg 1

montelukast oral tablet,chewable 4 mg, 5 mg 1

NUCALA SUBCUTANEOUS RECON SOLN 100 MG

2 PA

NUEDEXTA ORAL CAPSULE 20-10 MG 2 PA; QL; QL (60 per 30 days)

OFEV ORAL CAPSULE 100 MG, 150 MG 2 PA; SP; QL

ORKAMBI ORAL TABLET 100-125 MG, 200-125 MG

2 PA; SP

PROLASTIN-C INTRAVENOUS RECON SOLN 1,000 MG

2 SP

PROLASTIN-C INTRAVENOUS SOLUTION 1,000 MG (+/-)/20 ML

2


1



1

PULMOZYME INHALATION SOLUTION 1 MG/ML

2 SP







109

Drug Tier Notes

sildenafil (antihypertensive) intravenous solution 10 mg/12.5 ml

1 PA; SP

sildenafil (antihypertensive) oral tablet 20 mg 1 PA; SP; QL

SPIRIVA WITH HANDIHALER INHALATION CAPSULE, W/INHALATION DEVICE 18 MCG


STRIVERDI RESPIMAT INHALATION MIST 2.5 MCG/ACTUATION

2



2 QL

terbutaline oral tablet 2.5 mg, 5 mg 1

terbutaline subcutaneous solution 1 mg/ml 1


1




1

TRACLEER ORAL TABLET 125 MG, 62.5 MG

2 PA; SP

TUDORZA PRESSAIR INHALATION AEROSOL POWDR BREATH ACTIVATED 400 MCG/ACTUATION


VELETRI INTRAVENOUS RECON SOLN 0.5 MG, 1.5 MG

1 SP

VENTOLIN HFA INHALATION HFA AEROSOL INHALER 90 MCG/ACTUATION


XOLAIR SUBCUTANEOUS RECON SOLN 150 MG

2 PA; SP

zafirlukast oral tablet 10 mg, 20 mg 1 QL

SKIN AND MUCOUS MEMBRANE AGENTS

acitretin oral capsule 10 mg, 17.5 mg, 25 mg 1 SP

acyclovir topical ointment 5 % 1

adapalene topical cream 0.1 % 2 PA

adapalene topical gel 0.1 %, 0.3 % 2 PA

adapalene topical gel with pump 0.3 % 2 PA

alclometasone topical cream 0.05 % 1



110

Drug Tier Notes

alclometasone topical ointment 0.05 % 1

AZELEX TOPICAL CREAM 20 % 2

benzoyl peroxide topical cleanser 7 % 1

betamethasone dipropionate topical cream0.05 %

1

betamethasone dipropionate topical lotion0.05 %

1

betamethasone valerate topical cream 0.1 % 1

betamethasone valerate topical lotion 0.1 % 1

betamethasone valerate topical ointment 0.1 %

1

betamethasone, augmented topical cream0.05 %

1

betamethasone, augmented topical gel 0.05 %

1

betamethasone, augmented topical lotion0.05 %

1

betamethasone, augmented topical ointment0.05 %

1

BP 10-1 TOPICAL CLEANSER 10-1 % 1

BP-50% UREA TOPICAL EMULSION 50 % 1

calcipotriene topical cream 0.005 % 1

ciclopirox topical cream 0.77 % 1

ciclopirox topical solution 8 % 1

ciclopirox topical suspension 0.77 % 1

CLARAVIS ORAL CAPSULE 10 MG, 20 MG, 30 MG, 40 MG

1

CLEANSING WASH TOPICAL CLEANSER 10-4-10 %

1

CLINDACIN ETZ TOPICAL SWAB 1 % 1

CLINDACIN P TOPICAL SWAB 1 % 1

clindamycin phosphate topical foam 1 % 1

clindamycin phosphate topical gel 1 % 1

clindamycin phosphate topical lotion 1 % 1

clindamycin phosphate topical solution 1 % 1

clindamycin phosphate topical swab 1 % 1

clindamycin phosphate vaginal cream 2 % 1



111

Drug Tier Notes

clindamycin-tretinoin topical gel 1.2-0.025 % 1 PA

clobetasol scalp solution 0.05 % 1

clobetasol topical cream 0.05 % 1

clobetasol topical foam 0.05 % 1

clobetasol topical gel 0.05 % 1

clobetasol topical ointment 0.05 % 1

clobetasol-emollient topical cream 0.05 % 1

clobetasol-emollient topical foam 0.05 % 1

clotrimazole mucous membrane troche 10 mg

1

clotrimazole-betamethasone topical cream 1-0.05 %

1

CORMAX SCALP SOLUTION 0.05 % 1

COSENTYX (2 SYRINGES) SUBCUTANEOUS SYRINGE 150 MG/ML

2 PA; SP

COSENTYX PEN (2 PENS) SUBCUTANEOUS PEN INJECTOR 150 MG/ML

2 PA; SP

COSENTYX PEN SUBCUTANEOUS PEN INJECTOR 150 MG/ML

2 PA; SP

COSENTYX SUBCUTANEOUS SYRINGE 150 MG/ML

2 PA; SP

desonide topical cream 0.05 % 1

desonide topical lotion 0.05 % 1

desonide topical ointment 0.05 % 1

diclofenac sodium topical gel 1 % 1

diclofenac sodium topical gel 3 % 1 PA

diflorasone topical cream 0.05 % 1

diflorasone topical ointment 0.05 % 1

DOVONEX TOPICAL CREAM 0.005 % 2

DRITHOCREME HP TOPICAL CREAM 1 % 1

DRYSOL TOPICAL SOLUTION 20 % 2

DUPIXENT SUBCUTANEOUS SYRINGE 300 MG/2 ML

2 PA; SP

econazole topical cream 1 % 1

ELIDEL TOPICAL CREAM 1 % 2 PA

ERY PADS TOPICAL SWAB 2 % 1



112

Drug Tier Notes

erythromycin with ethanol topical gel 2 % 1

erythromycin with ethanol topical solution 2 %

1

erythromycin with ethanol topical swab 2 % 1

ethyl chloride topical aerosol,spray 100 % 1

EURAX TOPICAL CREAM 10 % 2

EURAX TOPICAL LOTION 10 % 2

FEM PH VAGINAL GEL 0.9-0.025 % 1

FINACEA TOPICAL GEL 15 % 2

fluocinolone topical cream 0.01 %, 0.025 % 1

fluocinolone topical ointment 0.025 % 1

fluocinolone topical solution 0.01 % 1

fluocinonide topical cream 0.05 %, 0.1 % 1

fluocinonide topical gel 0.05 % 1

fluocinonide topical ointment 0.05 % 1

fluocinonide topical solution 0.05 % 1

FLUOCINONIDE-E TOPICAL CREAM 0.05 %

1

FLUOROPLEX TOPICAL CREAM 1 % 2

fluorouracil topical cream 5 % 1

fluorouracil topical solution 2 %, 5 % 1

fluticasone topical cream 0.05 % 1

fluticasone topical ointment 0.005 % 1

FORMADON TOPICAL SOLUTION 10 % 1

FORMADON TOPICAL SOLUTION WITH APPLICATOR 10 %

1

gentamicin topical cream 0.1 % 1

gentamicin topical ointment 0.1 % 1

halobetasol propionate topical cream 0.05 % 1

halobetasol propionate topical ointment 0.05 %

1

hydrocortisone butyrate topical cream 0.1 % 1

hydrocortisone butyrate topical ointment 0.1 %

1

hydrocortisone butyrate topical solution 0.1 %

1

hydrocortisone rectal enema 100 mg/60 ml 1



113

Drug Tier Notes

hydrocortisone topical cream 2.5 % 1

hydrocortisone topical lotion 2.5 % 1

hydrocortisone topical ointment 2.5 % 1

hydrocortisone valerate topical cream 0.2 % 1

hydrocortisone valerate topical ointment 0.2 %

1

imiquimod topical cream in packet 5 % 1

KEPIVANCE INTRAVENOUS RECON SOLN 6.25 MG

2

ketoconazole topical cream 2 % 1

ketoconazole topical shampoo 2 % 1

lidocaine hcl laryngotracheal solution 4 % 1

lidocaine hcl topical cream 3 % 1

lidocaine hcl topical lotion 3 % 1

lidocaine hcl-hydrocortison ac rectal cream 3-0.5 %

1

lidocaine hcl-hydrocortison ac rectal kit 3-0.5 %, 3-1 % (7 gram)

1

lidocaine hcl-hydrocortison ac topical cream3-0.5 %

1

lidocaine topical ointment 5 % 1

lidocaine-hydrocortisone-aloe rectal gel 2.8-0.55 %

1

lidocaine-hydrocortisone-aloe rectal kit 2-2 %, 3-2.5 % (7 gram)

1

lidocaine-prilocaine topical cream 2.5-2.5 % 1

lidocaine-prilocaine topical kit 2.5-2.5 % 1

LTA PRE-ATTACHED LARYNGOTRACHEAL SOLUTION 4 %

1

malathion topical lotion 0.5 % 1

methoxsalen oral capsule,liqd-filled,rapid rel10 mg

1 SP

metronidazole topical cream 0.75 % 1

metronidazole topical gel 0.75 % 1

metronidazole topical lotion 0.75 % 1

metronidazole vaginal gel 0.75 % 1

MICONAZOLE-3 VAGINAL SUPPOSITORY 200 MG

1 QL



114

Drug Tier Notes

mometasone topical cream 0.1 % 1

mometasone topical ointment 0.1 % 1

mometasone topical solution 0.1 % 1

mupirocin calcium topical cream 2 % 1

mupirocin topical ointment 2 % 1

MYORISAN ORAL CAPSULE 10 MG, 20 MG, 40 MG

1

neomycin-polymyxin b gu irrigation solution40 mg-200,000 unit/ml

1

NYAMYC TOPICAL POWDER 100,000 UNIT/GRAM

1

nystatin topical cream 100,000 unit/gram 1

nystatin topical ointment 100,000 unit/gram 1

nystatin topical powder 100,000 unit/gram 1

nystatin-triamcinolone topical cream100,000-0.1 unit/g-%

1

nystatin-triamcinolone topical ointment100,000-0.1 unit/gram-%

1

NYSTOP TOPICAL POWDER 100,000 UNIT/GRAM

1

permethrin topical cream 5 % 1

phenazopyridine oral tablet 100 mg, 200 mg 1

PICATO TOPICAL GEL 0.015 %, 0.05 % 2

podofilox topical solution 0.5 % 1

prednicarbate topical cream 0.1 % 1

prednicarbate topical ointment 0.1 % 1

PROCTOFOAM HC RECTAL FOAM 1-1 % 2

PROCTO-PAK TOPICAL CREAM WITH PERINEAL APPLICATOR 1 %

1

PROCTOZONE-HC TOPICAL CREAM WITH PERINEAL APPLICATOR 2.5 %

1

RECTIV RECTAL OINTMENT 0.4 % (W/W) 2

ROSADAN TOPICAL CREAM 0.75 % 1

ROSADAN TOPICAL GEL 0.75 % 1

salicylic acid er-ceramides topical combo pack 6 %

1

salicylic acid er-ceramides topical kit,cleanser and cream er 6 %

1



115

Drug Tier Notes

salicylic acid topical cream 6 % 1

salicylic acid topical cream,extended release6 %

1

salicylic acid topical gel 6 % 1

salicylic acid topical lotion 6 % 1

salicylic acid topical lotion,extended release6 %

1

salicylic acid topical shampoo 6 % 1

SANTYL TOPICAL OINTMENT 250 UNIT/GRAM

2

SEB-PREV TOPICAL CLEANSER 10 % 1

selenium sulfide topical shampoo 2.25 % 1

silver nitrate topical ointment 10 % 1

silver nitrate topical solution 0.5 %, 10 %, 25 %, 50 %

1

silver sulfadiazine topical cream 1 % 1

spinosad topical suspension 0.9 % 1

SSD TOPICAL CREAM 1 % 1

SSS 10-5 TOPICAL CREAM 10-5 % (W/W) 1

STELARA SUBCUTANEOUS SOLUTION 45 MG/0.5 ML

2 PA; SP

STELARA SUBCUTANEOUS SYRINGE 45 MG/0.5 ML, 90 MG/ML

2 PA; SP

sulfacetamide sodium (acne) topical suspension 10 %

1

sulfacetamide sodium topical cleanser 10 % 1

sulfacetamide sodium-sulfur topical cleanser10-5 % (w/w)

1

sulfacetamide sodium-sulfur topical cream10-5 % (w/w)

1

sulfacetamide sodium-sulfur topical lotion 10-5 % (w/v), 10-5 % (w/w)

1

sulfacetamide sodium-sulfur topical pads, medicated 10-4 %

1

sulfacetamide sodium-sulfur topical suspension 10-5 %

1

sulfacetamide sod-sulfur-urea topical cleanser 10-5-10 %

1



116

Drug Tier Notes

sulfact na-sul-avobnz-otn-ocsa topical combo pack,cleanser and cream 9 %-4.5 % -spf 25

1

tacrolimus topical ointment 0.03 % 1 PA

tacrolimus topical ointment 0.1 % 1

TARGRETIN TOPICAL GEL 1 % 2

tazarotene topical cream 0.1 % 1 PA

TAZORAC TOPICAL CREAM 0.05 % 2 PA

TAZORAC TOPICAL GEL 0.05 %, 0.1 % 2 PA

terconazole vaginal cream 0.4 %, 0.8 % 1 QL

terconazole vaginal suppository 80 mg 1 QL

tretinoin topical cream 0.025 %, 0.05 %, 0.1 %

1 PA

tretinoin topical gel 0.01 %, 0.025 % 1 PA

triamcinolone acetonide topical cream 0.025 %, 0.1 %, 0.5 %

1

triamcinolone acetonide topical lotion 0.025 %, 0.1 %

1

triamcinolone acetonide topical ointment0.025 %, 0.1 %, 0.5 %

1

UREA NAIL STICK TOPICAL SOLUTION 50 %

1

urea topical cream 50 % 1

urea topical lotion 40 % 1

VALCHLOR TOPICAL GEL 0.016 % 2 SP

VANDAZOLE VAGINAL GEL 0.75 % 1

ZENATANE ORAL CAPSULE 10 MG, 20 MG, 40 MG

1

ZYCLARA TOPICAL CREAM IN METERED-DOSE PUMP 2.5 %, 3.75 %

2

ZYCLARA TOPICAL CREAM IN PACKET 3.75 %

2

SMOOTH MUSCLE RELAXANTS

aminophylline intravenous solution 250 mg/10 ml, 500 mg/20 ml

1

oxybutynin chloride oral syrup 5 mg/5 ml 1

oxybutynin chloride oral tablet 5 mg 1

oxybutynin chloride oral tablet extended release 24hr 10 mg, 15 mg

1



117

Drug Tier Notes

oxybutynin chloride oral tablet extended release 24hr 5 mg

1 QL


1




1

tolterodine oral capsule,extended release 24hr 2 mg, 4 mg

1

tolterodine oral tablet 1 mg, 2 mg 1

VITAMINS

ascorbic acid (vitamin c) injection solution500 mg/ml

1

B COMPLEX 100 INJECTION SOLUTION 100-2-100-2-2 MG/ML

1


1

calcitriol intravenous solution 1 mcg/ml 1

calcitriol oral capsule 0.25 mcg, 0.5 mcg 1

calcitriol oral solution 1 mcg/ml 1

COMPLETE NATAL DHA ORAL COMBO PACK 29-1-250 MG

1

COMPLETENATE ORAL TABLET,CHEWABLE 29 MG IRON- 1 MG

1

cyanocobalamin (vitamin b-12) injection solution 1,000 mcg/ml

1

ELITE OB WITH DHA ORAL CAPSULE 28-1.25-200 MG

1

ELITE-OB 400 ORAL CAPSULE 35-5-1.2-400 MG

1

ergocalciferol (vitamin d2) oral capsule50,000 unit

1

folic acid injection solution 5 mg/ml 1

FOLIVANE-OB ORAL CAPSULE 85-1 MG 1

HECTOROL INTRAVENOUS SOLUTION 2 MCG/ML (1 ML)

2

hydroxocobalamin intramuscular solution1,000 mcg/ml

1



118

Drug Tier Notes

M.V.I. ADULT INTRAVENOUS SOLUTION 3,300 UNIT- 150 MCG/10 ML

1

MEPHYTON ORAL TABLET 5 MG 2

MULTI-VITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG, 0.5 MG, 1 MG

1

MULTIVITAMIN WITH FLUORIDE ORAL TABLET,CHEWABLE 0.5 MG

1

MULTIVITAMINS WITH FLUORIDE ORAL TABLET,CHEWABLE 0.25 MG, 1 MG

1


1


1

MYNATAL ORAL TABLET 90-1-50 MG 1


1


1

MYNATE 90 PLUS ORAL TABLET EXTENDED RELEASE 90 MG IRON-1 MG

1

MYNEPHROCAPS ORAL CAPSULE 1 MG 1


1


1

PNV-DHA ORAL CAPSULE 27 MG IRON-1 MG -300 MG

1


1

PNV-SELECT ORAL TABLET 27-1 MG 1


1


1


1


1



119

Drug Tier Notes


1


1



1


1


1


1

PRENATAL-U ORAL CAPSULE 106.5-1 MG 1

pyridoxine (vitamin b6) injection solution 100 mg/ml

1

RENAL CAPS ORAL CAPSULE 1 MG 1

RENA-VITE RX ORAL TABLET 1-60-300 MG-MG-MCG

1

RENO CAPS ORAL CAPSULE 1 MG 1


1

SE-NATAL 19 ORAL TABLET,CHEWABLE 29 MG IRON- 1 MG

1

TARON-C DHA ORAL CAPSULE 35-1-200 MG

1


1


1


TRINATAL GT ORAL TABLET 90-1-50 MG 1


1


1


1



120

Drug Tier Notes


1


1


1

TRI-VITAMIN WITH FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML, 0.5 MG FLUORIDE (1.1 MG)/ML

1


1


1


1


1


VINATE CARE ORAL TABLET,CHEWABLE 40 MG IRON- 1 MG

1

VINATE GT ORAL TABLET 90-1-50 MG 1

VINATE II ORAL TABLET 29 MG IRON- 1 MG

1

VINATE M ORAL TABLET 27-1 MG 1


1

VINATE PN CARE ORAL TABLET 30-1-50 MG

1


VIRT-PN DHA ORAL CAPSULE 27 MG IRON-1 MG -300 MG

1

VIRT-PN ORAL TABLET 27-1 MG 1


1


1


VITAMIN D2 ORAL CAPSULE 50,000 UNIT 1



121

Drug Tier Notes

VITAMINS A,C,D AND FLUORIDE ORAL DROPS 0.25 MG FLUOR. (0.55 MG)/ML

1

VOL-CARE RX ORAL TABLET 1-60-300 MG-MG-MCG

1


1


1


1

ZATEAN-PN DHA ORAL CAPSULE 27 MG IRON-1 MG -300 MG

1


1



122

Index

abacavir................................... 1abacavir-lamivudine.................1abacavir-lamivudine-zidovudine............................... 1ABILIFY MAINTENA..............45acamprosate..........................45acarbose................................82ACE AEROSOL CLOUD ENHANCER.......................... 61acebutolol........................ 22, 35acetaminophen-codeine........ 45acetazolamide........... 35, 63, 74acetazolamide sodium...................................35, 63, 74acetic acid........................64, 74acetylcysteine................ 99, 107acitretin................................ 110ACTEMRA............................. 99acyclovir...........................1, 110acyclovir sodium...................... 2adapalene............................110adefovir....................................2adenosine.............................. 35adenosine (diagnostic).......... 35ADRUCIL...............................13ADVATE................................ 28ADYNOVATE........................ 28AFINITOR..............................13AFINITOR DISPERZ............. 13AFLURIA 2017-2018............. 20AFLURIA 2017-2018 (PF)..... 20AFLURIA QUAD 2017-2018..20AFLURIA QUAD 2017-2018 (PF)........................................20AFSTYLA...............................28ALBENZA................................ 2albumin, human 25 %............28ALBURX (HUMAN) 25 %...... 28ALBUTEIN 25 %....................28ALBUTEIN 5 %......................28albuterol sulfate............. 22, 107alclometasone............. 110, 111ALECENSA........................... 13alendronate............................99ALINIA..................................... 2allopurinol.............................. 99alosetron................................78

ALPHANATE......................... 28alprazolam............................. 45ALPROLIX............................. 28alprostadil .............................. 35ALTAVERA (28).................... 82ALUNBRIG............................ 13ALYACEN 1/35 (28).............. 82ALYACEN 7/7/7 (28)............. 82amantadine hcl.................. 2, 45AMETHIA...............................82AMETHIA LO.........................82AMETHYST........................... 82amifostine crystalline............. 99amikacin.................................. 2amiloride-hydrochlorothiazide......... 35, 64aminocaproic acid ..................28aminophylline ...............107, 117amiodarone......................35, 36amitriptyline ........................... 45amitriptyline-chlordiazepoxide ....................45amlodipine............................. 36amlodipine-benazepril........... 36ammonium chloride ............... 64amoxapine............................. 45amoxicillin................................ 2amoxicillin-pot clavulanate.......2amphotericin b ......................... 2ampicillin..................................2ampicillin sodium ..................... 2ampicillin-sulbactam............ 2, 3AMPYRA............................... 99anagrelide ..............................28anastrozole ...................... 13, 82ANDRODERM....................... 82ANDROGEL.......................... 83ANORO ELLIPTA.................. 22apraclonidine ......................... 74aprepitant ...............................78APRI...................................... 83APTIVUS................................. 3ARANELLE (28).................... 83ARANESP (IN POLYSORBATE)...................29aripiprazole ...................... 45, 46ARMOUR THYROID............. 83

ASACOL HD..........................78ASCOMP WITH CODEINE... 46ascorbic acid (vitamin c) ...... 118aspirin-dipyridamole.. 29, 36, 46atazanavir ................................ 3atenolol............................ 22, 36atenolol-chlorthalidone...................................22, 36, 64ATGAM..................................99atomoxetine........................... 46atorvastatin ............................ 36atovaquone..............................3atovaquone-proguanil..............3ATRIPLA..................................3atropine ....................23, 74, 107ATROVENT HFA.................107AUBAGIO.............................. 99AUBRA.................................. 83AUSTEDO............................. 46AVIANE................................. 83AVONEX................................99AVONEX (WITH ALBUMIN).. 99azacitidine ..............................13azathioprine........................... 99azelastine.............................. 74AZELEX...............................111azithromycin............................ 3AZURETTE (28).................... 83B COMPLEX 100.................118BACIIM.................................... 3bacitracin ........................... 3, 74bacitracin-polymyxin b........... 74baclofen................................. 23BACTROBAN NASAL........... 74BALANCED SALT................. 74BAL-CARE DHA...... 29, 64, 118balsalazide.............................78BALZIVA (28)........................ 83BANZEL.................................46BARACLUDE...........................3BASAGLAR KWIKPEN..........83BAVENCIO............................ 13BD PRE-FILLED NORMAL SALINE............................61, 64BELEODAQ...........................13belladonna alkaloids-opium... 46BELLADONNA-OPIUM......... 46



123

benazepril.............................. 36benazepril-hydrochlorothiazide......... 36, 64BENEFIX............................... 29benzoyl peroxide................. 111benztropine......................23, 46betamethasone acet,sod phos.......................................83betamethasone dipropionate.............................................111betamethasone valerate...... 111betamethasone, augmented 111BETASERON........................ 99betaxolol.................... 23, 36, 74bethanechol chloride............. 23bexarotene.............................13BEXSERO............................. 20bicalutamide.......................... 13BILTRICIDE.............................3bisoprolol fumarate.......... 23, 36bisoprolol-hydrochlorothiazide... 23, 36, 64bleomycin.............................. 13BLEPHAMIDE....................... 75BLEPHAMIDE S.O.P.............75BLINCYTO.............................13BLISOVI 24 FE...................... 83BLISOVI FE 1.5/30 (28).........83BLISOVI FE 1/20 (28)............83BOSULIF............................... 13BOTOX............................ 23, 99BP 10-1................................111BP-50% UREA.................... 111BRIELLYN............................. 83brimonidine............................ 75bromocriptine.........................46brompheniramine-pseudoeph-dm...............23, 107budesonide.................... 83, 107bumetanide......................36, 64bupivacaine........................... 98bupivacaine (pf)..................... 98bupivacaine-dextrose-water(pf)................................ 98bupivacaine-epinephrine. 23, 98bupivacaine-epinephrine (pf).........................................23, 98buprenorphine hcl..................46

buprenorphine-naloxone ........46bupropion hcl ......................... 46bupropion hcl (smoking deter) ..................................... 46buspirone...............................47BUTALBITAL COMPOUND W/CODEINE..........................47butalbital-acetaminop-caf-cod .........................................47butalbital-acetaminophen ...... 47butalbital-acetaminophen-caff .........................................47butalbital-aspirin-caffeine.29, 47BYDUREON.......................... 83BYETTA.................................84cabergoline ............................ 47CABOMETYX........................ 14caffeine citrate ....................... 47calcipotriene ........................ 111calcitonin (salmon).........84, 100calcitriol................................118calcium acetate ......................64calcium chloride .....................64calcium gluconate ..................64CAMILA................................. 84CAMRESE.............................84CAMRESE LO....................... 84CANASA................................78CANDIN.................................62capecitabine .......................... 14CAPRELSA........................... 14captopril ................................. 36captopril-hydrochlorothiazide.........................................36, 64CARAFATE........................... 78CARBAGLU...........................64carbamazepine...................... 47carbidopa-levodopa ............... 47carbidopa-levodopa-entacapone............................47carbinoxamine maleate ... 1, 107carboplatin............................. 14carteolol ................................. 75CARTIA XT............................36carvedilol ......................... 23, 36CATHFLO ACTIVASE..... 29, 73CAYSTON............................... 3CAZIANT (28)........................84

cefaclor.................................... 3cefadroxil ................................. 3cefazolin.................................. 3cefazolin in dextrose (iso-os)...3cefdinir ................................. 3, 4cefditoren pivoxil......................4cefepime.................................. 4cefepime in dextrose,iso-osm ..........................................4cefotaxime............................... 4cefotetan ..................................4cefoxitin ................................... 4cefoxitin in dextrose, iso-osm ..........................................4cefpodoxime ............................ 4cefprozil ................................... 4ceftazidime.............................. 4ceftriaxone............................... 4ceftriaxone in dextrose,iso-os.............................................4cefuroxime axetil......................4cefuroxime sodium.................. 4celecoxib ................................47CELONTIN............................ 47cephalexin............................... 4CERDELGA.........................100CESAMET............................. 78cevimeline ..............................23CHANTIX...............................23CHANTIX STARTING MONTH BOX.........................23CHATEAL.............................. 84CHEMET....................... 82, 100chloramphenicol sod succinate ................................. 4chlordiazepoxide hcl .............. 48chlorhexidine gluconate.........75chloroquine phosphate............ 5chlorothiazide .................. 36, 64chlorpromazine...................... 48chlorpropamide......................84chlorthalidone.................. 36, 64chlorzoxazone....................... 23cholestyramine (with sugar)...36CHOLESTYRAMINE LIGHT..37choline,magnesium salicylate................................48chromium chloride ................. 64



124

ciclopirox..............................111cilostazol..........................29, 37cimetidine.............................. 78cimetidine hcl.........................78CIPRODEX............................75ciprofloxacin.............................5ciprofloxacin (mixture)............. 5ciprofloxacin hcl................. 5, 75ciprofloxacin in 5 % dextrose...5ciprofloxacin lactate................. 5cisplatin..................................14citalopram.............................. 48cladribine............................... 14CLARAVIS...........................111clarithromycin.......................... 5CLEANSING WASH............ 111clemastine....................... 1, 107CLEO 90 INFUSION SET 24"......................................... 61CLINDACIN ETZ................. 111CLINDACIN P......................111clindamycin hcl........................ 5clindamycin palmitate hcl.........5CLINDAMYCIN PEDIATRIC....5clindamycin phosphate.... 5, 111clindamycin-tretinoin............112clobetasol............................ 112clobetasol-emollient.............112clomipramine......................... 48clonazepam........................... 48clonidine.......................... 23, 37clonidine (pf).............. 23, 37, 48clonidine hcl.....................23, 37clopidogrel............................. 29clorazepate dipotassium........48clotrimazole......................... 112clotrimazole-betamethasone112clozapine............................... 48COAGADEX.......................... 29COARTEM...............................5cocaine.................................. 75codeine sulfate.............. 48, 107COLCRYS........................... 100colestipol................................37colistin (colistimethate na)....... 5COMBIVENT RESPIMAT.......................................23, 107COMETRIQ........................... 14

COMFORT SHORT INFUSION SET 23"............... 61COMPLERA............................ 5COMPLETE NATAL DHA....118COMPLETENATE............... 118COMPRO........................ 48, 78CONSTULOSE......................64COPPER CHLORIDE............64CORIFACT............................ 29CORLANOR.......................... 37CORMAX.............................112cortisone ................................ 84COSENTYX.........................112COSENTYX (2 SYRINGES) 112COSENTYX PEN................ 112COSENTYX PEN (2 PENS) 112cosyntropin ............................ 62COTELLIC............................. 14CREON..................................79CRIXIVAN................................5cromolyn........................ 75, 107CRYSELLE (28).................... 84CUPRIMINE.................. 82, 100cyanocobalamin (vitamin b-12)....................................... 118CYCLAFEM 1/35 (28)............84CYCLAFEM 7/7/7 (28)...........84cyclobenzaprine.....................23cyclopentolate ........................75cyclophosphamide.........14, 100CYCLOPHOSPHAMIDE14, 100cyclosporine .........................100cyclosporine modified .......... 100cyproheptadine ................ 1, 107CYRAMZA............................. 14cyred......................................84CYSTAGON........................ 100CYSTARAN........................... 75cytarabine .............................. 14cytarabine (pf)........................14CYTRA K CRYSTALS........... 64CYTRA-2............................... 65CYTRA-3............................... 65CYTRA-K...............................65dacarbazine ........................... 14danazol .................................. 84dantrolene..............................23dapsone...................................5

daptomycin .............................. 5DARAPRIM..............................5DASETTA 1/35 (28)...............84DASETTA 7/7/7 (28)..............84daunorubicin.......................... 14DAYSEE................................ 84deferoxamine .................82, 100DELFLEX-LC/1.5% DEXTROSE...........................65DELFLEX-LC/2.5% DEXTROSE...........................65DELFLEX-LC/4.25% DEXTROSE...........................65DELFLEX-SM WITH 1.5% DEXTROSE...........................65DENTA 5000 PLUS............. 100DENTAGEL......................... 100DEPO-PROVERA..................84DESCOVY............................... 5desipramine........................... 48desmopressin .................. 29, 84desogestrel-ethinyl estradiol ..85desonide .............................. 112dexamethasone..................... 85DEXAMETHASONE INTENSOL.............................85dexamethasone sodium phos (pf)................................ 85dexamethasone sodium phosphate........................75, 85dexmethylphenidate .............. 48dexrazoxane hcl.................. 100dextroamphetamine...............48dextroamphetamine-amphetamine .........................48dextrose 5 % in ringer's......... 65dextrose 5 %-lactated ringers....................................65DIANEAL LOW CALCIUM/1.5% DEX.............65DIANEAL PD-2 WITH 2.5 % DEX....................................... 65DIANEAL PD-2 WITH 4.25 % DEX................................... 65DIANEAL PD-2/1.5% DEXTROSE...........................65DIANEAL WITH 2.5 % DEXTROSE...........................65



125

DIANEAL WITH 4.25 % DEXTROSE...........................65diazepam......................... 48, 49DIAZEPAM INTENSOL......... 49diclofenac potassium............. 49diclofenac sodium...........................14, 49, 75, 112dicloxacillin.............................. 5dicyclomine............................24didanosine............................... 6diflorasone........................... 112diflunisal.................................49DIGOX................................... 37digoxin................................... 37dihydroergotamine...........24, 49DILANTIN........................ 37, 49diltiazem hcl...........................37DILT-XR.................................37dimenhydrinate.......... 1, 79, 107diphenhydramine hcl....... 1, 108diphenoxylate-atropine.................................24, 79, 108dipyridamole.................... 29, 37DISKETS............................... 49disopyramide phosphate....... 38disulfiram............................. 100divalproex.............................. 49dobutamine......................24, 38dobutamine in d5w.......... 24, 38DOCETAXEL.........................14dofetilide................................ 38donepezil............................... 24dopamine.........................24, 38dopamine in 5 % dextrose.........................................24, 38dorzolamide........................... 75dorzolamide-timolol............... 75DOVONEX...........................112doxazosin........................ 24, 38doxepin.................................. 49doxorubicin............................ 14doxycycline hyclate............6, 75doxycycline monohydrate........ 6DRITHOCREME HP............112dronabinol..............................79droperidol...............................49drospirenone-ethinyl estradiol................................. 85

DROXIA.................................15DRYSOL..............................112DULERA.................. 24, 85, 108duloxetine .............................. 49DUPIXENT.......................... 112dutasteride ...........................100dutasteride-tamsulosin ........ 100DYSPORT..................... 24, 100ECLIPSE SYRINGE.............. 61econazole ............................ 112ED-SPAZ............................... 24EDURANT............................... 6efavirenz .................................. 6EFFER-K............................... 65electrolyte-48 in d5w..............66ELELYSO.............................. 73ELIDEL........................ 100, 112ELINEST................................85ELIPHOS............................... 66ELITE OB WITH DHA..........118ELITE-OB 400............... 29, 118ELLA......................................85ELMIRON............................ 100ELOCTATE............................30EMCYT.................................. 15EMOQUETTE........................85EMTRIVA.................................6enalapril maleate ................... 38enalaprilat .............................. 38enalapril-hydrochlorothiazide.........................................38, 66ENBREL.............................. 100ENBREL MINI......................100ENBREL SURECLICK.........101ENDOCET............................. 49enoxaparin .............................30ENPRESSE........................... 85ENSKYCE............................. 85entacapone............................49entecavir .................................. 6ENTRESTO........................... 38ENULOSE............................. 66ephedrine sulfate........... 24, 108epinephrine....................24, 108EPIPEN 2-PAK.............. 25, 108EPIPEN JR 2-PAK.........25, 108epirubicin ............................... 15EPITOL..................................49

EPIVIR.....................................6EPIVIR HBV............................ 6eplerenone .............................38EPOGEN............................... 30epoprostenol (glycine)... 38, 108ergocalciferol (vitamin d2)... 118ergoloid..................................25ERIVEDGE............................ 15ERRIN................................... 85ERY PADS.......................... 112ERYTHROCIN (AS STEARATE)............................ 6erythromycin ...................... 6, 75erythromycin ethylsuccinate.... 6erythromycin with ethanol....113ESBRIET............................. 108escitalopram oxalate..............49ESTARYLLA..........................85estazolam.............................. 50ESTRACE..............................85estradiol ................................. 85estradiol valerate ................... 85estradiol-norethindrone acet..86ESTROGEL........................... 86estropipate.............................86eszopiclone............................50ethambutol...............................6ethosuximide......................... 50ethyl chloride....................... 113etidronate disodium............. 101etodolac................................. 50etoposide............................... 15EURAX................................ 113EVAMIST...............................86EVOTAZ.......................... 6, 101EVZIO............................50, 101exemestane..................... 15, 86EXJADE.................................82EXTAVIA............................. 101E-Z-CAT DRY........................62ezetimibe ............................... 38E-Z-HD BARIUM................... 62E-Z-PAQUE........................... 62FABRAZYME.........................74FALMINA (28)........................86famciclovir................................6famotidine .............................. 79famotidine (pf)........................79



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famotidine (pf)-nacl (iso-os)..79FARESTON..................... 15, 86FARYDAK..............................15FASLODEX........................... 15FEIBA NF.............................. 30felbamate...............................50FELBATOL............................ 50felodipine............................... 38FEM PH............................... 113FEMHRT LOW DOSE........... 86FEMYNOR.............................86fenofibrate..............................39fenofibrate micronized........... 38fenofibrate nanocrystallized...38fenofibric acid (choline)..........39fentanyl.................................. 50fentanyl citrate....................... 50FERRIPROX..........................82FINACEA............................. 113finasteride............................ 101FIRAZYR............................. 101FISH OIL................................39flecainide............................... 39FLOVENT DISKUS........86, 108FLOVENT HFA..............86, 108floxuridine.............................. 15FLUAD 2017-2018 (65 YR UP)(PF)................................. 20FLUARIX QUAD 2017-2018 (PF)........................................20FLUCELVAX QUAD 2017-2018.......................................20FLUCELVAX QUAD 2017-2018 (PF)...............................20fluconazole.............................. 6fluconazole in dextrose(iso-o)............................................. 6fluconazole in nacl (iso-osm)... 6fludrocortisone....................... 86FLULAVAL QUAD 2017-2018.......................................20FLULAVAL QUAD 2017-2018 (PF)...............................20flumazenil...................... 50, 101flunisolide.......................75, 108fluocinolone......................... 113fluocinonide......................... 113FLUOCINONIDE-E..............113

FLUOR-A-DAY (WITH XYLITOL).............................101fluorescein-proparacaine . 62, 75fluoride (sodium)..................101FLUORITAB........................ 101fluorometholone.....................75FLUOROPLEX.............. 15, 113fluorouracil..................... 15, 113fluoxetine............................... 50fluphenazine decanoate ........ 50fluphenazine hcl...............50, 51flurazepam.............................51flurbiprofen .............................51flurbiprofen sodium ................ 75FLUROX.......................... 62, 75flutamide ................................ 15fluticasone........................... 113fluticasone-salmeterol..........109FLUVIRIN 2017-2018............ 20FLUVIRIN 2017-2018 (PF).... 20fluvoxamine........................... 51FLUZONE INTRADERM QUAD 2017-18...................... 20FLUZONE QUAD 2017-2018.......................................21FLUZONE QUAD 2017-2018 (PF)...............................21FLUZONE QUAD PEDI 2017-18 (PF)......................... 21folic acid...............................118FOLIVANE-OB.............. 30, 118fomepizole........................... 101FORMADON........................113FORTEO................................86fosamprenavir..........................6foscarnet ..................................6fosinopril................................ 39fosinopril-hydrochlorothiazide......... 39, 66fosphenytoin.......................... 51FOSRENOL...................66, 101furosemide.......................39, 66FUZEON..................................7FYCOMPA.............................51gabapentin .............................51GABITRIL.............................. 51galantamine ........................... 25GAMASTAN S/D................... 21

GAMMAGARD LIQUID..........21GAMMAGARD S-D (IGA < 1 MCG/ML)............................... 21GAMUNEX-C.........................21GASTROCROM.................. 109GAVILYTE-C......................... 79GAVILYTE-G......................... 79GAVILYTE-N......................... 79gemfibrozil ............................. 39GENERLAC...........................66GENOTROPIN...................... 86GENOTROPIN MINIQUICK.. 86GENTAK................................76gentamicin................. 7, 76, 113gentamicin in nacl (iso-osm)....7gentamicin sulfate (ped) (pf) ....7gentamicin sulfate (pf)............. 7GENVOYA...............................7GIANVI (28)........................... 86GILDAGIA..............................86GILENYA............................. 101GILOTRIF.............................. 15glatiramer.............................101GLATOPA............................101glimepiride ....................... 86, 87glipizide..................................87glipizide-metformin................ 87GLUCAGEN DIAGNOSTIC KIT................................... 62, 87GLUCAGEN HYPOKIT..87, 101GLUCAGON EMERGENCY KIT (HUMAN)................ 87, 101GLUCAGON HCL............62, 87glyburide................................ 87glyburide micronized ..............87glyburide-metformin...............87glycine urologic solution........ 66glycopyrrolate ........................ 25granisetron (pf)...................... 79granisetron hcl ....................... 79griseofulvin microsize.............. 7griseofulvin ultramicrosize....... 7guanfacine....................... 39, 51guanidine............................... 25halobetasol propionate........ 113haloperidol............................. 51haloperidol decanoate ........... 51haloperidol lactate................. 51



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HEATHER............................. 87HECTOROL.........................118HELIXATE FS........................30HEP FLUSH-10 (PF)....... 30, 61heparin (porcine)................... 30heparin (porcine) in 5 % dex..30heparin (porcine) in nacl (pf).........................................30, 61heparin flush(porcine)-0.9nacl............................. 30, 61HEPARIN LOCK..............31, 61HEPARIN LOCK FLUSH.30, 61heparin lock flush (porcine).........................................30, 61HEPARIN LOCKFLUSH(PORCINE)(PF)....................................... 31, 61heparin(porcine) in 0.45% nacl........................................ 31heparin, porcine (pf)........ 31, 61hetastarch 6 % in 0.9 % nacl. 66HEXALEN..............................15HIBERIX (PF)........................ 21HIZENTRA.............................21HOMATROPAIRE................. 76HUMALOG............................ 87HUMATROPE........................87HUMIRA........................ 80, 102HUMIRA PEDIATRIC CROHN'S START......... 79, 101HUMIRA PEN................ 79, 102HUMIRA PEN CROHN'S-UC-HS START.............. 79, 102HUMIRA PEN PSORIASIS-UVEITIS.........................79, 102HUMULIN 70/30.................... 87HUMULIN 70/30 KWIKPEN...87HUMULIN N...........................88HUMULIN N KWIKPEN......... 88HUMULIN R U-100................88HUMULIN R U-500 (CONCENTRATED).............. 88hydralazine............................ 39hydrochlorothiazide......... 39, 66hydrocodone-acetaminophen...................... 51hydrocodone-ibuprofen..........51hydrocortisone....... 88, 113, 114

hydrocortisone butyrate ....... 113hydrocortisone valerate ....... 114hydrocortisone-acetic acid.....76hydromorphone ..................... 51hydroxocobalamin ............... 118hydroxychloroquine......... 7, 102hydroxyprogesterone capr(bulk)...............................88hydroxyprogesterone caproate.................................88hydroxyurea ...........................15hydroxyzine hcl............1, 51, 52hydroxyzine pamoate ........ 1, 52HYOPHEN...............................7hyoscyamine sulfate .............. 25HYPERHEP B S/D................ 21HYPERHEP B S-D NEONATAL........................... 21HYPERRAB S/D (PF)............21HYPERRHO S/D................... 21ibandronate..........................102IBRANCE...............................15ibuprofen ................................52ICLUSIG................................ 15idarubicin ............................... 15IDELVION..............................31IDHIFA...................................15ifosfamide ........................ 15, 16ifosfamide-mesna.................. 16imatinib.................................. 16IMBRUVICA...........................16IMFINZI..................................16imipramine hcl....................... 52imipramine pamoate .............. 52imiquimod............................ 114indapamide ...................... 39, 66indomethacin ................. 52, 102INFED....................................31INLYTA.................................. 16INTELENCE............................ 7INTRON A................. 7, 16, 102INTROVALE.......................... 88INVANZ................................... 7INVEGA SUSTENNA............ 52INVIRASE................................7INVOKAMET......................... 88INVOKANA............................ 88IONOSOL-B IN D5W............. 66

IONOSOL-MB IN D5W.......... 66ipratropium bromide.25, 76, 109ipratropium-albuterol ......25, 109irbesartan...............................39irbesartan-hydrochlorothiazide............... 39IRESSA................................. 16irinotecan............................... 16ISENTRESS............................ 7ISENTRESS HD...................... 7ISOLYTE S PH 7.4................ 66ISOLYTE-P IN 5 % DEXTROSE...........................66ISOLYTE-S............................66isoniazid...............................7, 8isosorbide dinitrate................ 39isosorbide mononitrate .......... 39ISOVUE-300..........................62ISOVUE-M 300......................62isradipine ............................... 39itraconazole............................. 8ivermectin................................ 8IXINITY.................................. 31JAKAFI.................................. 16JANTOVEN........................... 31JANUMET..............................88JANUMET XR........................88JANUVIA............................... 88JENCYCLA............................88JINTELI..................................88JOLESSA.............................. 88JOLIVETTE........................... 88JULEBER.............................. 88JUNEL 1.5/30 (21).................88JUNEL 1/20 (21)....................88JUNEL FE 1.5/30 (28)........... 89JUNEL FE 1/20 (28).............. 89JUNEL FE 24.........................89KADCYLA..............................16KAITLIB FE............................89KALETRA................................ 8KALYDECO......................... 109KARIVA (28).......................... 89K-EFFERVESCENT.............. 66KELNOR 1/35 (28)................ 89KEPIVANCE........................ 114ketoconazole................... 8, 114ketoprofen..............................52



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ketorolac.......................... 52, 76KEYTRUDA........................... 16KIMIDESS (28)...................... 89KIONEX (WITH SORBITOL).......................................67, 102KLOR-CON............................67KLOR-CON 10.......................67KLOR-CON 8.........................67KLOR-CON M10....................67KLOR-CON M15....................67KLOR-CON M20....................67KLOR-CON/EF...................... 67KOMBIGLYZE XR................. 89KOVALTRY........................... 31KRYSTEXXA....................... 102KURVELO............................. 89l norgest/e.estradiol-e.estrad. 89labetalol........................... 25, 40lactated ringers...................... 67lactulose................................ 67lamivudine............................... 8lamivudine-zidovudine............. 8lamotrigine............................. 52lansoprazole.......................... 80lanthanum......................67, 102LANTUS................................ 89LANTUS SOLOSTAR............89larin 1.5/30 (21)..................... 89LARIN 1/20 (21).....................89LARIN 24 FE......................... 89LARIN FE 1.5/30 (28)............ 89LARIN FE 1/20 (28)............... 89LARISSIA.............................. 89latanoprost.............................76LATUDA................................ 52LAYOLIS FE.......................... 89LEENA 28..............................90leflunomide.......................... 102LEMTRADA......................... 102LENVIMA...............................16LESSINA............................... 90LETAIRIS.......................40, 109letrozole........................... 16, 90leucovorin calcium............... 102LEUKERAN........................... 16LEUKINE............................... 31leuprolide......................... 16, 90levetiracetam......................... 52

levobunolol ............................ 76levocarnitine ........................ 102levocarnitine (with sugar) .....102levofloxacin ..............................8levoleucovorin......................102LEVONEST (28).................... 90levonorgestrel-ethinyl estrad. 90levonorg-eth estrad triphasic. 90LEVORA-28...........................90levorphanol tartrate................52levothyroxine......................... 90LEVOXYL.............................. 90LEXIVA.................................... 8lidocaine.............................. 114lidocaine (pf) in d7.5w ...........99lidocaine (pf) .................... 40, 99lidocaine hcl .............76, 99, 114lidocaine hcl-hydrocortison ac.........................................114lidocaine in 5 % dextrose (pf)......................................... 40lidocaine-epinephrine ...... 25, 99lidocaine-hydrocortisone-aloe......................................114lidocaine-prilocaine ..............114LILETTA................................ 90linezolid ....................................8linezolid-0.9% sodium chloride.................................... 8LINZESS................................80liothyronine ............................ 90LIQUID E-Z PAQUE.............. 62lisinopril..................................40lisinopril-hydrochlorothiazide.........................................40, 67lithium carbonate ................... 53lithium citrate......................... 53LONSURF............................. 16lopinavir-ritonavir ..................... 8lorazepam ..............................53LORAZEPAM INTENSOL..... 53LORCET (HYDROCODONE)............... 53LORCET HD..........................53LORYNA (28)........................ 90losartan ..................................40

losartan-hydrochlorothiazide.........................................40, 67LOTEMAX............................. 76lovastatin ............................... 40LOW-OGESTREL (28).......... 90loxapine succinate................. 53LTA PRE-ATTACHED......... 114LUDENT FLUORIDE........... 103LUGOLS............ 8, 90, 103, 109LUMIZYME............................ 74LUPRON DEPOT............ 16, 91LUPRON DEPOT (3 MONTH).......................... 16, 90LUPRON DEPOT (4 MONTH).......................... 16, 90LUPRON DEPOT-PED....17, 91LUTERA (28)......................... 91LYNPARZA............................17LYRICA..................................53LYZA......................................91M.V.I. ADULT...................... 119magnesium chloride.............. 53magnesium sulfate.. 40, 53, 103magnesium sulfate in water.................................40, 53, 103MAKENA............................... 91malathion............................. 114manganese chloride .............. 67mannitol 10 %............40, 63, 67mannitol 20 %............40, 63, 67mannitol 25 %............40, 63, 67mannitol 5 %..............40, 63, 67maprotiline............................. 53MARLISSA............................ 91MARTEN-TAB....................... 53MATULANE........................... 17MAVYRET............................... 8meclofenamate...................... 53medroxyprogesterone............91mefloquine............................... 8megestrol.........................17, 91MEKINIST..............................17meloxicam ............................. 53melphalan hcl ........................ 17memantine.............................54MENACTRA (PF).................. 22meperidine.............................54MEPHYTON................ 103, 119



129

meprobamate........................ 54mercaptopurine..............17, 103meropenem............................. 8mesalamine........................... 80mesna..................................103MESNEX............................. 103METADATE ER..................... 54metaproterenol.............. 25, 109metaxalone............................ 25metformin...............................91methadone.............................54METHADOSE........................54methenamine hippurate...........8methenamine mandelate......... 8methimazole.......................... 91METHITEST.......................... 91methocarbamol......................25methotrexate sodium..... 17, 103methotrexate sodium (pf).......................................17, 103methoxsalen........................ 114methscopolamine.................. 25methyldopa...................... 25, 40methyldopa-hydrochlorothiazide... 25, 41, 67methyldopate................... 26, 41methylene blue (antidote).... 103METHYLIN............................ 54methylphenidate hcl...............54methylprednisolone............... 91methylprednisolone acetate...91methylprednisolone sodium succ....................................... 91metipranolol........................... 76metoclopramide hcl............... 80metolazone...................... 41, 67metoprolol succinate........26, 41metoprolol ta-hydrochlorothiaz........ 26, 41, 67metoprolol tartrate........... 26, 41metronidazole.................. 8, 114metronidazole in nacl (iso-os)............................................8mexiletine.............................. 41MICONAZOLE-3..................114MICROGESTIN 1.5/30 (21)...92MICROGESTIN 1/20 (21)......92

MICROGESTIN FE 1.5/30 (28)........................................ 92MICROGESTIN FE 1/20 (28)........................................ 92midazolam ............................. 54midodrine...............................26milrinone................................ 41milrinone in 5 % dextrose...... 41MIMVEY................................ 92minocycline ..............................9minoxidil .................................41mirtazapine ............................ 55misoprostol ............................ 80MITIGARE........................... 103mitomycin.............................. 17mitoxantrone..........................17modafinil................................ 55moexipril................................ 41moexipril-hydrochlorothiazide......... 41, 68mometasone........................115MONOJECT MAGELLAN SYRINGE.............................. 62MONOJECT SYRINGE......... 62MONO-LINYAH..................... 92MONONESSA (28)................92montelukast......................... 109morphine ................................55morphine concentrate............55moxifloxacin...........................76MOZOBIL.............................. 31MULTIVITAMIN WITH FLUORIDE.................. 103, 119MULTI-VITAMIN WITH FLUORIDE.................. 103, 119MULTIVITAMINS WITH FLUORIDE.................. 103, 119mupirocin ............................. 115mupirocin calcium................115MYALEPT..............................92MYCAMINE............................. 9mycophenolate mofetil .103, 104mycophenolate mofetil hcl... 103mycophenolate sodium ........104MYLERAN............................. 17MYNATAL................31, 68, 119

MYNATAL ADVANCE.................................31, 68, 119MYNATAL PLUS..... 31, 68, 119MYNATAL-Z............ 31, 68, 119MYNATE 90 PLUS.............. 119MYNEPHROCAPS.............. 119MYORISAN......................... 115MYZILRA............................... 92nabumetone ...........................55nadolol ............................. 26, 41nadolol-bendroflumethiazide...................................26, 41, 68nafcillin .....................................9nafcillin in dextrose iso-osm.... 9nalbuphine............................. 55naloxone ........................ 55, 104naltrexone ......................55, 104naproxen ........................55, 104naproxen sodium........... 55, 104NARCAN............................... 55NATACYN............................. 76nateglinide............................. 92NATPARA..............................92NATURE-THROID.................92NEBUPENT............................. 9NECON 0.5/35 (28)............... 92NECON 7/7/7 (28)................. 92nefazodone............................55neomycin ................................. 9neomycin-bacitracin-poly-hc..76neomycin-bacitracin-polymyxin...............................76neomycin-polymyxin b gu.... 115neomycin-polymyxin b-dexameth...............................76neomycin-polymyxin-gramicidin.............................. 76neomycin-polymyxin-hc......... 77NEO-POLYCIN HC................77NEULASTA............................32NEUPOGEN.......................... 32nevirapine ................................ 9NEXAVAR............................. 17NEXPLANON........................ 92nicardipine............................. 41NICOTROL............................ 26NICOTROL NS...................... 26nifedipine............................... 41



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nikki (28)................................ 92nilutamide.............................. 17nimodipine............................. 41NINLARO...............................17NITRO-BID............................ 41nitrofurantoin............................9nitrofurantoin macrocrystal...... 9nitrofurantoin monohyd/m-cryst......................................... 9nitroglycerin........................... 42nitroglycerin in 5 % dextrose. 42nizatidine............................... 80NORA-BE.............................. 92norepinephrine bitartrate....... 26noreth-ethinyl estradiol-iron... 92norethindrone (contraceptive).......................92norethindrone acetate............92norethindrone ac-eth estradiol................................. 92norethindrone-e.estradiol-iron.........................................93norgestimate-ethinyl estradiol................................. 93NORMAL SALINE FLUSH.........................................62, 68NORMOSOL-M IN 5 % DEXTROSE...........................68NORMOSOL-R......................68NORMOSOL-R IN 5 % DEXTROSE...........................68NORMOSOL-R PH 7.4..........68NORTREL 0.5/35 (28)........... 93NORTREL 1/35 (21).............. 93NORTREL 1/35 (28).............. 93NORTREL 7/7/7 (28)............. 93nortriptyline...................... 55, 56NORVIR...................................9NOVOEIGHT......................... 32NOVOLIN 70/30.................... 93NOVOLIN N...........................93NOVOLIN R...........................93NOVOLOG............................ 93NOVOLOG FLEXPEN........... 93NOVOLOG MIX 70-30...........93NOVOLOG MIX 70-30 FLEXPEN.............................. 93NOVOLOG PENFILL.............93

NP THYROID........................ 93NUCALA.............................. 109NUEDEXTA................... 56, 109NUTRILYTE...........................68NUTROPIN AQ NUSPIN....... 93NUVARING............................93NUWIQ.................................. 32NYAMYC............................. 115nystatin............................ 9, 115nystatin-triamcinolone..........115NYSTOP..............................115OBIZUR................................. 32OCALIVA............................... 80OCELLA................................ 94OCREVUS...........................104octreotide acetate .......... 94, 104ODEFSEY............................... 9OFEV...................................109ofloxacin............................ 9, 77OGESTREL (28)....................94olanzapine............................. 56olopatadine............................ 77omega-3 acid ethyl esters ..... 42omeprazole ............................80OMNIPAQUE 140..................63OMNIPAQUE 240..................63OMNIPAQUE 300..................63ondansetron ...........................80ondansetron hcl..................... 80ondansetron hcl (pf) ...............80ONETOUCH ULTRA TEST... 63ONETOUCH VERIO..............63ONGLYZA............................. 94OPDIVO.................................17ORENCIA............................ 104ORENCIA CLICKJECT........104ORFADIN............................ 104ORKAMBI............................ 109orphenadrine citrate ...............26ORSYTHIA............................ 94oseltamivir ............................... 9OTEZLA...............................104OTEZLA STARTER.............104oxacillin....................................9oxacillin in dextrose(iso-osm) .........................................9oxaliplatin...............................17oxandrolone ...........................94

oxaprozin............................... 56oxazepam .............................. 56oxcarbazepine ....................... 56oxybutynin chloride ......117, 118oxycodone............................. 56OXYCODONE....................... 56oxycodone-acetaminophen... 56oxycodone-aspirin ................. 56OXYCONTIN......................... 56oxytocin ............................... 107paclitaxel ................................17pamidronate .........................104pantoprazole..........................80papaverine.............................42paromomycin......................... 10paroxetine hcl.................. 56, 57peg 3350-electrolytes............ 81PEGANONE.......................... 57PEGASYS............................. 10PEGASYS PROCLICK.......... 10peg-electrolyte soln............... 81penicillin g potassium ............ 10penicillin g procaine............... 10penicillin g sodium ................. 10penicillin v potassium.............10PENTASA..............................81pentazocine-naloxone ........... 57pentoxifylline..........................32perindopril erbumine ..............42PERIOGARD......................... 77permethrin ........................... 115perphenazine .........................57perphenazine-amitriptyline.... 57phenazopyridine.................. 115phenelzine............................. 57phenobarbital .........................57phenobarbital sodium............ 57phenylephrine hcl............ 26, 77phenytoin......................... 42, 57phenytoin sodium............ 42, 57phenytoin sodium extended.........................................42, 57PHILITH.................................94PHOSPHA 250 NEUTRAL.... 68PHOSPHOLINE IODIDE....... 77PHYSIOLYTE........................ 68PHYSIOSOL IRRIGATION....68physostigmine salicylate 26, 105



131

PICATO......................... 17, 115pilocarpine hcl..................26, 77PIMTREA (28)....................... 94pindolol............................ 26, 42pioglitazone........................... 94pioglitazone-metformin.......... 94piperacillin-tazobactam..........10PIRMELLA.............................94piroxicam............................... 57PLASMA-LYTE 148...............68PLASMA-LYTE A.................. 68PLASMA-LYTE-56 IN 5 % DEXTROSE...........................68PLEGRIDY.......................... 105PNEUMOVAX 23...................22PNV OB+DHA... 32, 68, 81, 119PNV-DHA...................... 32, 119PNV-DHA + DOCUSATE...........................32, 69, 81, 119PNV-OMEGA...........32, 69, 119PNV-SELECT................ 32, 119podofilox.............................. 115POLYCIN...............................77POLYFIN QR INFUSION SET........................................62polymyxin b sulfate................ 10polymyxin b sulf-trimethoprim...........................77POMALYST................... 18, 105PORTIA................................. 94potassium acetate................. 69potassium bicarb and chloride.................................. 69potassium bicarb-citric acid... 69potassium chlorid-d5-0.45%nacl..............................69potassium chloride.................69potassium chloride in 0.9%nacl................................69potassium chloride in 5 % dex.........................................69potassium chloride in lr-d5.....69potassium chloride-0.45 % nacl........................................ 69potassium chloride-d5-0.2%nacl................................69potassium chloride-d5-0.3%nacl................................69

potassium chloride-d5-0.9%nacl ................................69potassium citrate ................... 70potassium citrate-citric acid ... 70potassium phosphate m-/d-basic ...................................... 70PR NATAL 400........ 32, 70, 119PR NATAL 400 EC..32, 70, 119PR NATAL 430........ 32, 70, 119PR NATAL 430 EC..32, 70, 119PRADAXA............................. 32PRALUENT PEN................... 42pramipexole........................... 57prasugrel ................................32pravastatin............................. 42prazosin ........................... 26, 42PRED MILD........................... 77prednicarbate .......................115prednisolone.......................... 94prednisolone acetate ............. 77prednisolone sodium phosphate........................77, 94prednisone .............................94PREDNISONE INTENSOL....94PREMARIN............................94PREMPHASE........................ 95PREMPRO............................ 95PRENAISSANCE...........................33, 70, 81, 120PRENAISSANCE PLUS...........................33, 70, 81, 120PRENATABS FA..... 33, 70, 120PRENATABS RX.....33, 70, 120PRENATAL LOW IRON.................................33, 70, 120PRENATAL PLUS... 33, 70, 120PRENATAL PLUS (CALCIUM CARB)... 33, 70, 120PRENATAL-U......................120PREVIFEM............................ 95PREVNAR 13 (PF)................ 22PREZCOBIX..................10, 105PREZISTA............................. 10PRIFTIN.................................10primidone...............................57PRIVIGEN............................. 22probenecid .....................70, 105probenecid-colchicine....70, 105

procainamide......................... 42prochlorperazine..............57, 81prochlorperazine edisylate.........................................57, 81prochlorperazine maleate 57, 81PROCRIT.............................. 33PROCTOFOAM HC.............115PROCTO-PAK.....................115PROCTOZONE-HC.............115progesterone......................... 95progesterone micronized ....... 95PROGLYCEM........................95PROLASTIN-C.................... 109PROLEUKIN..................18, 105PROLIA............................... 105PROMACTA.......................... 33promethazine .......1, 57, 58, 109propafenone.......................... 42propantheline .........................26proparacaine..........................77propranolol.....26, 27, 42, 43, 58propranolol-hydrochlorothiazid ..... 27, 43, 70propylthiouracil ...................... 95protriptyline ............................ 58PULMOZYME................74, 109PYLERA.......................... 10, 81pyrazinamide......................... 10pyridostigmine bromide......... 27pyridoxine (vitamin b6) ........ 120QUADRACEL (PF)................ 22QUASENSE...........................95quetiapine .............................. 58quinapril ................................. 43quinapril-hydrochlorothiazide.........................................43, 70quinidine gluconate..........10, 43quinidine sulfate...............10, 43quinine sulfate ....................... 10QVAR............................ 95, 109raloxifene....................... 95, 105ramipril...................................43ranitidine hcl .......................... 81RAPAMUNE........................ 105RAVICTI................................ 70READI-CAT 2........................ 63REBIF (WITH ALBUMIN).... 105REBIF REBIDOSE.............. 105



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REBIF TITRATION PACK... 105RECLIPSEN (28)...................95RECOMBINATE.................... 33RECTIV............................... 115RELENZA DISKHALER.........10REMICADE..........................105RENAGEL..................... 70, 105RENAL CAPS......................120RENA-VITE RX................... 120RENO CAPS....................... 120RENVELA......................70, 105repaglinide............................. 95repaglinide-metformin............95REPATHA PUSHTRONEX....43REPATHA SURECLICK........ 43REPATHA SYRINGE............ 43RESCRIPTOR....................... 11RESTASIS.............................77RETROVIR............................ 11REVLIMID......................18, 105REVONTO.............................27ribavirin.................................. 11rifabutin..................................11rifampin..................................11RIFATER............................... 11riluzole................................... 58rimantadine............................11ringer's...................................70RISPERDAL CONSTA.......... 58risperidone.............................58RITUXAN HYCELA............... 18rivastigmine........................... 27rivastigmine tartrate............... 27rizatriptan...............................58ropinirole................................58ROSADAN...........................115rosuvastatin........................... 43ROTATEQ VACCINE............ 22RUBRACA............................. 18RYDAPT................................ 18salicylic acid.........................116salicylic acid er-ceramides...115salsalate................................ 58SANTYL...............................116SAVELLA...............................58SEB-PREV.......................... 116SECONAL SODIUM.............. 59selegiline hcl.......................... 59

selenium................................ 70selenium sulfide ...................116SELZENTRY......................... 11SE-NATAL 19................ 33, 120SE-NATAL 19 (WITH DOCUSATE)........... 33, 81, 120SENSIPAR.................... 95, 105SEROSTIM............................95sertraline ................................59SETLAKIN............................. 95sevelamer carbonate ............. 71SF........................................ 105SF 5000 PLUS.....................105SIGNIFOR............................. 95sildenafil (antihypertensive).......................................43, 110silver nitrate......................... 116silver sulfadiazine................ 116simvastatin.............................43sirolimus .............................. 106SIRTURO.............................. 11SITZMARKS.......................... 63sodium acetate...................... 71sodium bicarbonate............... 71sodium chlor 0.9% bacteriostat ............................ 71sodium chloride ..................... 71sodium chloride 0.45 % ......... 71sodium chloride 0.9 % ..... 62, 71sodium chloride 3 % .............. 71sodium chloride 5 % .............. 71sodium citrate-citric acid ........ 71sodium lactate ....................... 71sodium phenylbutyrate.......... 71sodium phosphate................. 71SODIUM POLYSTYRENE (SORB FREE)............... 71, 106sodium polystyrene sulfonate .................. 71, 72, 106sodium thiosulfate ................106SOLU-CORTEF.....................95SOLU-CORTEF (PF).............95SOLU-MEDROL.................... 96SOLU-MEDROL (PF)...... 95, 96SOMATULINE DEPOT..........96SORINE...........................27, 43sotalol.............................. 27, 43SOTALOL AF.................. 27, 43

spinosad.............................. 116SPIRIVA RESPIMAT............. 27SPIRIVA WITH HANDIHALER............... 27, 110spironolactone ................. 43, 72spironolacton-hydrochlorothiaz.............. 44, 72SPRINTEC (28)..................... 96SPRYCEL..............................18SPS (WITH SORBITOL)72, 106SRONYX............................... 96SSD..................................... 116SSS 10-5............................. 116stavudine............................... 11STELARA............................ 116STIVARGA............................ 18STRENSIQ............................ 74STRIBILD.............................. 11STRIVERDI RESPIMAT 27, 110STRONG IODINE.........................11, 96, 106, 110SUBOXONE.......................... 59SUCRAID.............................. 74sucralfate............................... 81sulfacetamide sodium....77, 116sulfacetamide sodium (acne).............................................116sulfacetamide sodium-sulfur 116sulfacetamide sod-sulfur-urea..................................... 116sulfacetamide-prednisolone...77sulfact na-sul-avobnz-otn-ocsa..................................... 117sulfadiazine............................11sulfamethoxazole-trimethoprim...........................11sulfasalazine............11, 81, 106sulindac ................................. 59sumatriptan ............................59sumatriptan succinate............59SUSTIVA............................... 11SUTENT................................ 18SYEDA.................................. 96SYLATRON..................... 11, 18SYLVANT.............................. 18SYMBICORT........... 27, 96, 110SYMLINPEN 120...................96SYMLINPEN 60.....................96



133

SYNAGIS...............................11SYNAREL..............................96SYREX SODIUM CHLORIDE 0.9 %............62, 72syringe with needle, safety.... 62T:SLIM................................... 62TABLOID............................... 18tacrolimus.................... 106, 117TAFINLAR............................. 18TAGITOL V............................63TAGRISSO............................ 18TAMIFLU............................... 12tamoxifen......................... 18, 96tamsulosin............................. 27TARCEVA..............................18TARGRETIN..................18, 117tarina fe 1/20 (28).................. 96TARON-C DHA..............33, 120TARON-PREX PRENATAL-DHA......................... 33, 81, 120TASIGNA...............................18tazarotene............................117TAZORAC........................... 117TECENTRIQ..........................18TECFIDERA........................ 106temazepam............................59TEMODAR.............................18temozolomide........................ 19tenofovir disoproxil fumarate. 12terazosin.......................... 27, 44terbinafine hcl........................ 12terbutaline......................27, 110terconazole.......................... 117TESTOSTERONE................. 96testosterone...........................96testosterone cypionate.......... 96testosterone enanthate..........96TETCAINE.............................78tetrabenazine.........................59tetracaine hcl......................... 78tetracaine hcl (pf)...................78tetracycline............................ 12thallous chloride tl-201...........63THALOMID.......................... 106THEOCHRON. 44, 72, 110, 118theophylline..... 44, 72, 110, 118thioridazine............................ 59thiothixene............................. 59

THYROGEN.......................... 63THYROLAR-1........................96THYROLAR-1/2.....................96THYROLAR-1/4.....................97THYROLAR-2........................97THYROLAR-3........................97tiagabine ................................ 59ticlopidine...............................33TILIA FE................................ 97timolol maleate .... 27, 44, 59, 78TIVICAY.................................12tizanidine ............................... 27TL-SELECT....... 33, 72, 81, 120tobramycin............................. 78tobramycin in 0.225 % nacl... 12tobramycin in 0.9 % nacl ....... 12tobramycin sulfate ................. 12tobramycin-dexamethasone .. 78tolazamide............................. 97tolbutamide ............................ 97tolmetin.................................. 59tolterodine ............................118topiramate ..............................59TOPOSAR............................. 19torsemide.........................44, 72TRACLEER................... 44, 110tramadol.................................59tramadol-acetaminophen.......60trandolapril.............................44tranylcypromine ..................... 60trazodone ...............................60tretinoin ................................117tretinoin (chemotherapy) ........19TRETTEN.............................. 33TRIADVANCE......... 33, 72, 120triamcinolone acetonide.......117triamterene-hydrochlorothiazid ........... 44, 72triazolam................................ 60TRICITRATES....................... 72TRI-ESTARYLLA...................97trifluoperazine........................ 60trihexyphenidyl .................27, 60TRI-LEGEST FE....................97TRI-LINYAH...........................97tri-lo-estarylla......................... 97tri-lo-sprintec ..........................97trimethobenzamide ................ 81

trimethoprim...........................12TRINATAL GT............... 33, 120TRINATAL RX 1...... 34, 72, 120TRINATE................. 34, 72, 120TRINESSA (28)..................... 97trinessa lo.............................. 97TRI-PREVIFEM (28)..............97TRI-SPRINTEC (28).............. 97TRIUMEQ.............................. 12TRIVEEN-DUO DHA.................................34, 72, 120TRIVEEN-ONE........ 34, 72, 121TRIVEEN-PRX RNF...........................34, 72, 81, 121TRI-VIT WITH FLUORIDE AND IRON............. 34, 106, 121TRI-VITAMIN WITH FLUORIDE.................. 106, 121TRIVORA (28)....................... 97tropicamide ............................ 78TRUMENBA.......................... 22TRUVADA............................. 12TUDORZA PRESSAIR........ 110TYKERB................................ 19ULTIMATECARE ONE.................................34, 73, 121ULTIMATECARE ONE NF.................................34, 73, 121UNITHROID...........................97unithroid.................................97UNITUXIN..............................19UPTRAVI............................... 44UR N-C.................................. 12urea..................................... 117UREA NAIL STICK.............. 117URIMAR-T............................. 12UROGESIC-BLUE.................12ursodiol............................ 81, 82valacyclovir............................ 12VALCHLOR................... 19, 117valganciclovir......................... 12valproate sodium ................... 60valproic acid...........................60valproic acid (as sodium salt) ........................................60valsartan................................ 44valsartan-hydrochlorothiazide......... 44, 73



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vancomycin............................12vancomycin in dextrose 5 %..12VANDAZOLE.......................117VARIBAR THIN HONEY........63VARIBAR THIN LIQUID........ 63vasopressin........................... 97VAXCHORA VACCINE......... 22VECTIBIX.............................. 19VELCADE..............................19VELETRI........................44, 110VELIVET TRIPHASIC REGIMEN (28)...................... 97VELTASSA............................ 73VEMAVITE-PRX-2...........................34, 73, 82, 121VEMLIDY...............................12VENA-BAL DHA...... 34, 73, 121VENCLEXTA......................... 19VENCLEXTA STARTING PACK.....................................19venlafaxine............................ 60VENOFER............................. 34VENTOLIN HFA............ 28, 110verapamil......................... 44, 45VESTURA (28)...................... 97VIBERZI.................................82VICTOZA 2-PAK....................98VICTOZA 3-PAK....................98VIDEX 2 GRAM PEDIATRIC.12VIENVA................................. 98VIMIZIM................................. 74VIMPAT................................. 60VINACAL........... 34, 73, 82, 121VINATE CARE...............34, 121VINATE GT....................34, 121VINATE II.............................121VINATE M............................121VINATE ONE...........34, 73, 121VINATE PN CARE...............121VINATE ULTRA.34, 73, 82, 121vinblastine..............................19VINCASAR PFS.................... 19vincristine...............................19vinorelbine............................. 19VIORELE (28)........................98VIRACEPT.............................12VIREAD........................... 12, 13VIRT-PN........................ 34, 121

VIRT-PN DHA................34, 121VIRT-PN PLUS........34, 73, 121VIRT-SELECT... 34, 73, 82, 121VISIPAQUE........................... 63VISTOGARD....................... 106VITAFOL-OB........... 34, 73, 121VITAMIN D2........................ 121VITAMINS A,C,D AND FLUORIDE.................. 106, 122VOL-CARE RX.................... 122VOL-NATE...............34, 73, 122VOL-TAB RX........... 35, 73, 122VOLUMEN.............................63VONVENDI............................35voriconazole .......................... 13VOSEVI................................. 13VOTRIENT............................ 19VPRIV....................................74VYVANSE..............................60warfarin..................................35water for irrigation, sterile...... 73WELCHOL.......................45, 98WERA (28)............................ 98WESTHROID.........................98WINRHO SDF....................... 22WYMZYA FE......................... 98XALKORI............................... 19XARELTO..............................35XELJANZ.............................106XELJANZ XR.......................106XEOMIN........................ 28, 106XERMELO............................. 82XGEVA................................ 106XIFAXAN............................... 13XIIDRA...................................78XOLAIR............................... 110XTANDI................................. 19XULANE................................ 98XYNTHA................................ 35XYNTHA SOLOFUSE........... 35YONDELIS............................ 19yuvafem ................................. 98zafirlukast............................ 110zaleplon ................................. 60ZARAH.................................. 98ZARXIO................................. 35ZATEAN-CH...... 35, 73, 82, 122ZATEAN-PN DHA..........35, 122

ZATEAN-PN PLUS..35, 73, 122ZAVESCA............................106ZEJULA................................. 19ZELBORAF............................19ZENATANE......................... 117ZENCHENT (28)....................98zidovudine............................. 13zinc chloride...........................73zinc sulfate.............................73ziprasidone hcl .......................60ZIRGAN................................. 78ZOLINZA............................... 19zolmitriptan............................ 60zolpidem................................ 61zonisamide............................ 61ZORBTIVE.............................98ZORTRESS......................... 107ZOSTAVAX (PF)................... 22ZOVIA 1/35E (28).................. 98ZOVIA 1/50E (28).................. 98ZYCLARA............................ 117ZYDELIG............................... 19ZYKADIA............................... 19ZYLET................................... 78ZYPREXA RELPREVV..........61ZYTIGA..................................19



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UCare State Public Program OTC Drug Formulary 2018

UCARE STATE PUBLIC PROGRAM OTC DRUG FORMULARY

2018 The following list of over-the-counter (OTC) medications are covered by UCare for State Public Program members. The formulary only includes the generic version of products. Some brand products are listed in parentheses for reference purposes only. This list is subject to change. ANALGESICS AND ANTI-INFLAMMATORY DRUGS acetaminophen (TYLENOL) acetaminophen / pyrilamine / caffeine aspirin (BAYER) aspirin / acetaminophen/ caffeine (EXCEDRIN) aspirin / buffers (BUFFERIN) aspirin / sodium bicarb / citric acid (ALKA-SELTZER) ibuprofen (MOTRIN) naproxen (ALEVE) COUGH AND COLD MEDICATIONS ANTIHISTAMINES cetirizine (ZYRTEC) clemastine fumurate diphenhydramine (BENADRYL) loratadine (CLARITIN) DECONGESTANTS phenylephrine (SUDAFED PE) pseudoephedrine (SUDAFED) ANTIHISTAMINE / DECONGESTANT COMBINATIONS brompheniramine / pseudoephedrine brompheniramine / phenylephrine cetirizine / pseudoephedrine (ZYRTEC - D) chlorpheniramine / phenylephrine chlorpheniramine / phenylephrine / acetaminophen chlorpheniramine / phenylephrine / dextromethorphan / acetaminophen chlorpheniramine / pseudoephedrine chlorpheniramine / pseudoephedrine / acetaminophen chlorpheniramine / pseudoephedrine / dextrometorphah / acetaminophen diphenhyydramine / pseudoephedrine / acetaminophen diphenydramine / pseudoephedrine loratadine / pseudoephedrine (CLARITIN - D) phenylephrine / acetaminophen phenylephrine / guaifenesin


pseudoephedrine / ibuprofen psueodoephedrine / acetaminophen ANTITUSSIVES AND EXPECTORANT DRUGS dextromethorphan (ROBITUSSIN) dextromethorphan / phenylephrine dextromethorphan / phenylephrine / acetaminophen dextromethorphan / pseudoephedrine dextromethorphan / pseudoephedrine / acetaminophen guaifenesin (MUCINEX) guaifenesin / dextromethorphan (MUCINEX DM) guaifenesin / dextromethorphan / phenylephrine guaifenesin / dextromethorphan / pseudoephedrine guaifenesin / dextromethorphan / pseudoephedrine / acetaminophen guaifenesin / phenylephrine guaifenesin / pseudoephedrine DERMATOLOGICAL DRUGS ANTIACNE DRUGS benzoyl peroxide benzoyl peroxide / aloe vera KEROLYTIC DRUGS salicylic acid salicylic acid / acetic acid (COMPOUND W) PEDICULICIDES / SCABICIDES permethrin (NIX) piperonyl / pyrethrins (RID) TOPICAL ANESTHETICS pramoxine (PROCTO-FOAM) TOPICAL ANTIBACTERIAL DRUGS bacitracin bacitracin / polymyxin b (POLYSPORIN) chlorhexidine neomycin / bacitracin / polymixin (NEOSPORIN) neomycin / bacitracin / polymixin / pramoxine (NEOSPORIN PLUS) TOPICAL ANTIFUNGALS clotrimazole (LOTRIMIN) miconazole (MICATIN) terbinafine (LAMISIL) tolnaftate (TINACTIN) TOPICAL CORTICOSTEROIDS hydrocortisone / aloe vera hydrocortisone


OTHER TOPICAL DERMATOLOGICAL DRUGS ammonium lactate (AMLACTIN) calamine calamine / zinc oxide capsaicin (ZOSTRIX) chloroxylenol coal tar diphenhydramine diphenhydramine / calamine diphenhydramine / zinc dimethicone glyceryl / dimethicone / petrolatum (CETAPHIL) hydrogen peroxide methyl salicylate / menthol / camphor (BENGAY) mineral oil / petrolatum (AQUAPHOR, EUCERIN) petrolatum (VASELINE) povidone-iodine (BETADINE) pramoxine / calamine salonpas trolamine salicylate (MYOFLEX) urea (CARMOL) zinc oxide (DESITIN) DIABETIC SUPPLIES Insulin Needles Insulin Syringes Lancets Onetouch Ultra Test Strips Onetouch Ultra Meters Onetouch Verio Test Strips Onetouch Verio Meters Urine Ketone Test Kits EAR / NOSE / THROAT MEDICATIONS DRUGS AFFECTING THE EAR carbamide peroxide (DEBROX) DRUGS AFFECTING THE NOSE cromolyn (NASALCROM) oxymetazoline (AFRIN) phenylephrine (NEO-SYNEPHRINE) sodium chloride triamcinolone acetonide (NASACORT) DRUGS AFFECTING THE THROAT zinc


GASTROINTESTINAL DRUGS ANTACIDS aluminum hydroxide (ALTERNAGEL) calcium carbonate (TUMS) calcium carbonate / magnesium hydroxide (MYLANTA SUPREME) magnesium carbonate / aluminum hydroxide (GAVISCON) magnesium hydroxide / aluminum hydroxide / simethicone (MYLANTA) magnesium hydroxide / aluminum hydroxide (MAALOX) magnesium oxide (URO-MAG) sodium bicarbonate ANTIDIARRHEAL DRUGS bismuth subsalicylate (PEPTO-BISMOL) loperamide (IMMODIUM) ANTIULCER DRUGS famotidine (PEPCID) lansoprazole (PREVACID) ranitidine (ZANTAC) omeprazole (PRILOSEC) LAXATIVES AND CATHARTICS activated charcoal bisacodyl (DULCOLAX) calcium polycarbophil cellulose charcoal / sorbitol docusate calcium (SURFAK) docusate sodium (COLACE) glycerin magnesium citrate (CITROMA) magnesium hydroxide (PHILLIPS' MOM) methylcellulose (CITRUCEL) mineral oil polycarbophil polyethylene glycol 3350 (MIRALAX) psyllium (METAMUCIL) saline enema (FLEET ENEMA) senna / docusate sodium (PERI-COLACE) sennosides / calcium (EX-LAX) OTHER GI DRUGS hamamelis leaf / glycerin (TUCKS) lactase (LACTAID) phenylephrine phenylephrine / shark liver / petrolatum (PREPARATION H) simethicone (MYLICON)


sorbitol witch hazel MISCELLANEOUS (OTHER) Drugs dimenhydrinate (DRAMAMINE) levonorgestrel (PLAN B) meclizine phenazopyridine (AZO) OPHTHALMIC DRUGS OPHTHALMIC DRUGS carboxymethylcellulose drops dextran 70/he-cell drops (TEARS NATURALE-II) eyelid cleanser combinations glycerin / propylene glycol drops hydroxypropylmethylcellulose drops (GENTEAL) hypromellose drops (GENTEAL MILD) ketotifen drops (ZADITOR) lanolin/mineral oil / petrolatum ointment mineral oil / petrolatum ointment (LACRI-LUBE S.O.P.) naphazoline /pheniramine drops (NAPHCON-A) polyvinyl alcohol / povidone drops (REFRESH) polyvinyl alcohol drops (HYPOTEARS) propylene glycol (SYSTANE) propylene glycol / PEGs (SYSTANE ULTRA) sodium chloride sodium chloride / petrolatum / mineral oil (REFRESH PM) tetrahydrazoline drops (VISINE) SMOKING CESSATION PRODUCTS nicotine (NICODERM) nicotine gum nicotine polacrilex (COMMIT) VAGINAL ANTIFUNGAL VAGINAL ANTIFUNGALS clotrimazole (GYNE-LOTRIMIN) miconazole (MONISTAT) tioconazole (VAGISTAT) VITAMINS AND RELATED PRODUCTS MINERALS / ELECTROLYTES calcium carbonate calcium citrate calcium glubionate calcium gluconate calcium lactate calcium / magnesium calcium / magnesium / zinc


chromium electrolyte solution (pediatric) ferrous gluconate ferrous sulfate magensium chloride magnesium gluconate magnesium oxide potassium chloride potassium gluconate selenium sodium chloride zinc gluconate zinc sulfate MISCELLANEOUS NUTRIENTS beta-carotene biotin co-enzyme Q10 (COQ10) glucose glucosamine sulfate glucosamine / chondroitin omega-3 fatty acids protein replacement preparations VITAMINS cyanocobalmin (vitamin B12) folic acid niacin niacinamide pantothenic acid pyridoxine (vitamin B6) riboflavin (vitamin B2) thiamine (vitamin B1) vitamin A vitamin C vitamin D vitamin E VITAMIN COMBINATION PRODUCTS beta carotene / vitamin C / vitamin E / minerals calcium carbonate / vitamin D calcium carbonate / vitamin D / minerals folic acid / vitamin B complex / vitamin C multivitamins multivitamins / iron multivitamins / minerals


multivitamins / minerals / iron prenatal vitamin vitamin A / vitamin D vitamin A / vitamin C / vitamin D vitamin B complex vitamin B complex / folic acid vitamin B complex / minerals vitamin B complex / vitamin C vitamin B complex / vitamin C / vitamin E / zinc vitamin C / vitamin E

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(List of Covered Prescription and Over-the-Counter … alphabetical list of all of the drugs...

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