Printable Preferred Drug List | Select Health of South ... · mg/5 mL, 500 mg/5 mL cefadroxil oral...
Transcript of Printable Preferred Drug List | Select Health of South ... · mg/5 mL, 500 mg/5 mL cefadroxil oral...
Preferred Drug ListSelect Health PerformRx Pharmacy Services
Phone 1.866.610.2773 | Fax 1.866.610.2775Member ServicesPhone 1.888.276.2020Providers may request the addition or deletion of a medication
to this list. Requests must include the drug name, rationale for
inclusion on the list, role in therapy and medications that may
be replaced by the addition. Please direct such requests to:
Pharmacy and Therapeutics Committee at Select Health
PO Box 40849Charleston, SC 29423Members may request changes to the list by calling Member
Services.
For the most current Preferred Drug List (PDL), please use the
searchable PDL on our website, www.selecthealthofsc.com.
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
1
Drug Name Tier Requirements/Limits
Antihistamine Drugs
Ethanolamine Derivatives
dimenhydrinate oral
diphenhydramine HCl injection solution 50
mg/mL
diphenhydramine HCl injection syringe
diphenhydramine HCl oral capsule
diphenhydramine HCl oral liquid
diphenhydramine HCl oral syrup
diphenhydramine HCl oral tablet 25 mg
Sleep Aid (doxylamine)
First Gen. Antihist. Derivatives, Misc.
cyproheptadine
First Generation Antihistamines
chlorpheniramine maleate oral tablet
cyproheptadine
dimenhydrinate oral
diphenhydramine HCl injection solution 50
mg/mL
diphenhydramine HCl injection syringe
diphenhydramine HCl oral capsule
diphenhydramine HCl oral liquid
diphenhydramine HCl oral syrup
diphenhydramine HCl oral tablet 25 mg
Sleep Aid (doxylamine)
Phenothiazine Derivatives
promethazine oral
promethazine rectal
Promethazine VC
Promethazine VC-Codeine QL; AL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
2
Drug Name Tier Requirements/Limits
promethazine-DM
Piperazine Derivatives
hydroxyzine HCl oral solution 10 mg/5 mL
hydroxyzine HCl oral tablet
hydroxyzine pamoate
meclizine oral tablet 12.5 mg, 25 mg
meclizine oral tablet,chewable
Propylamine Derivatives
Carbaphen CH
Centergy
chlorpheniramine maleate oral tablet
Conex oral solution
Dimetapp Cold-Allergy (PE)
Ed Chlorped D
Lodrane D
LoHist - D
M-End DMX
NoHist-DM
Rynex PSE
Trexbrom
Second Generation Antihistamines
Allergy Relief (cetirizine) oral capsule ST
cetirizine oral solution 1 mg/mL
cetirizine oral tablet
cetirizine-pseudoephedrine ST
Children's Zyrtec Allergy oral tablet,disintegrating ST
fexofenadine oral suspension ST
fexofenadine oral tablet 180 mg ST
levocetirizine oral tablet
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
3
Drug Name Tier Requirements/Limits
loratadine oral capsule ST
loratadine oral solution ST
loratadine oral tablet
loratadine oral tablet,disintegrating ST
Anti-Infective Agents
1St Generation Cephalosporin Antibiotics
cefadroxil oral capsule
cefadroxil oral suspension for reconstitution 250
mg/5 mL, 500 mg/5 mL
cefadroxil oral tablet
cefazolin injection recon soln 1 gram, 10 gram,
500 mg
Specialty PA
cephalexin oral capsule 250 mg, 500 mg
cephalexin oral suspension for reconstitution
2Nd Generation Cephalosporin Antibiotics
cefotetan Specialty PA
cefotetan in dextrose, iso-osm Specialty PA
cefprozil
cefuroxime axetil oral tablet
cefuroxime sodium intravenous recon soln 7.5
gram
Specialty PA
3Rd Generation Cephalosporin Antibiotics
cefdinir QL
cefotaxime Specialty PA
ceftazidime Specialty PA
ceftriaxone in dextrose,iso-os Specialty PA
ceftriaxone injection recon soln 1 gram, 10 gram, 2
gram, 250 mg, 500 mg
Specialty PA
ceftriaxone intravenous Specialty PA
Claforan intravenous recon soln Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
4
Drug Name Tier Requirements/Limits
Suprax oral capsule QL
Suprax oral suspension for reconstitution 100 mg/5
mL, 200 mg/5 mL
TAZICEF intravenous Specialty PA
4Th Generation Cephalosporin Antibiotics
cefepime in dextrose 5 % Specialty PA
cefepime in dextrose,iso-osm Specialty PA
cefepime injection Specialty PA
Adamantane Antivirals
amantadine HCl oral capsule
amantadine HCl oral solution
rimantadine
Allylamine Antifungals
terbinafine HCl oral
Amebicides
metronidazole in NaCl (iso-os) Specialty PA
metronidazole oral tablet
Aminoglycoside Antibiotics
amikacin injection solution 1,000 mg/4 mL, 500
mg/2 mL
Specialty PA
gentamicin in NaCl (iso-osm) intravenous
piggyback 100 mg/100 mL, 100 mg/50 mL, 80
mg/100 mL, 80 mg/50 mL
Specialty PA
gentamicin injection Specialty PA
gentamicin sulfate (PF) intravenous solution 100
mg/10 mL, 60 mg/6 mL
Specialty PA
Tobi Podhaler Specialty PA
tobramycin in 0.225 % NaCl Specialty PA
tobramycin sulfate Specialty PA
Aminopenicillin Antibiotics
amoxicillin oral capsule
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
5
Drug Name Tier Requirements/Limits
amoxicillin oral suspension for reconstitution
amoxicillin oral tablet
amoxicillin oral tablet,chewable 125 mg, 250 mg
amoxicillin-pot clavulanate oral suspension for
reconstitution
amoxicillin-pot clavulanate oral tablet
amoxicillin-pot clavulanate oral tablet,chewable
ampicillin oral capsule
ampicillin sodium Specialty PA
ampicillin-sulbactam Specialty PA
Augmentin oral suspension for reconstitution 125-
31.25 mg/5 mL
Anthelmintics
Biltricide
Antifungals, Miscellaneous
griseofulvin microsize
griseofulvin ultramicrosize
SSKI
Antimalarials
atovaquone-proguanil
chloroquine phosphate
Daraprim Specialty PA
hydroxychloroquine
mefloquine
primaquine
quinidine gluconate oral
quinidine sulfate oral tablet
Antimycobacterials, Miscellaneous
dapsone oral
Antiprotozoals, Miscellaneous
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
6
Drug Name Tier Requirements/Limits
atovaquone PA
dapsone oral
metronidazole in NaCl (iso-os) Specialty PA
metronidazole oral tablet
Nebupent Specialty PA
Pentam Specialty PA
Antituberculosis Agents
amikacin injection solution 1,000 mg/4 mL, 500
mg/2 mL
Specialty PA
ciprofloxacin
ciprofloxacin (mixture)
ciprofloxacin HCl oral tablet 250 mg, 500 mg QL
ciprofloxacin HCl oral tablet 750 mg
ciprofloxacin in 5 % dextrose intravenous
piggyback 400 mg/200 mL
Specialty PA
clarithromycin QL
ethambutol
isoniazid oral
levofloxacin oral QL
moxifloxacin oral QL
Mycobutin
pyrazinamide
rifampin intravenous Specialty PA
rifampin oral
Antivirals, Miscellaneous
foscarnet Specialty PA
Azole Antifungals
fluconazole in dextrose(iso-o) intravenous
piggyback 400 mg/200 mL
Specialty PA
fluconazole in NaCl (iso-osm) intravenous
piggyback 200 mg/100 mL, 400 mg/200 mL
Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
7
Drug Name Tier Requirements/Limits
fluconazole oral suspension for reconstitution
fluconazole oral tablet 100 mg, 200 mg, 50 mg
fluconazole oral tablet 150 mg QL
itraconazole oral capsule PA
ketoconazole oral
Sporanox oral solution PA
Vfend IV Specialty PA
Carbapenem Antibiotics
Invanz Specialty PA
meropenem Specialty PA
Cephamycin Antibiotics
cefotetan Specialty PA
cefotetan in dextrose, iso-osm Specialty PA
Cyclic Lipopeptide Antibiotics
daptomycin intravenous recon soln 500 mg Specialty PA
Echinocandin Antifungals
caspofungin Specialty PA
Eraxis(Water Diluent) Specialty PA
Mycamine Specialty PA
Erythromycin Antibiotics
Ery-Tab
Erythrocin (as stearate) oral tablet 250 mg
erythromycin ethylsuccinate oral suspension for
reconstitution
erythromycin ethylsuccinate oral tablet
erythromycin oral capsule,delayed release(DR/EC)
erythromycin oral tablet
Extended-Spectrum Penicillins
piperacillin-tazobactam intravenous recon soln
2.25 gram, 3.375 gram, 4.5 gram, 40.5 gram
Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
8
Drug Name Tier Requirements/Limits
Zosyn in dextrose (iso-osm) Specialty PA
Glycopeptide Antibiotics
Firvanq
vancomycin in dextrose 5 % intravenous
piggyback 1 gram/200 mL, 750 mg/150 mL
Specialty PA
vancomycin intravenous recon soln 1,000 mg, 10
gram, 5 gram, 500 mg, 750 mg
Specialty PA
vancomycin oral capsule
Vibativ intravenous recon soln 750 mg Specialty PA
Glycylcycline Antibiotics
tigecycline Specialty PA
Hiv Entry And Fusion Inhibitors
Fuzeon subcutaneous recon soln PA
Selzentry oral tablet
Hiv Integrase Inhibitor Antiretrovirals
Genvoya
Isentress HD
Isentress oral tablet
Isentress oral tablet,chewable
Juluca
Stribild
Hiv Nonnucleoside Rev.Transcrip. Inhib.
Edurant
efavirenz
Intelence oral tablet 100 mg, 200 mg
nevirapine oral suspension
nevirapine oral tablet
nevirapine oral tablet extended release 24 hr 400
mg
Odefsey
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
9
Drug Name Tier Requirements/Limits
Rescriptor
Symfi
Symfi Lo
Viramune XR oral tablet extended release 24 hr
100 mg
Hiv Nucleoside, Nucleotide Rt Inhibitors
abacavir
abacavir-lamivudine
Cimduo
Descovy
didanosine
Emtriva
Epivir HBV
Genvoya
lamivudine oral solution
lamivudine oral tablet 150 mg, 300 mg
lamivudine-zidovudine
Odefsey
stavudine oral capsule
Stribild
Symfi
Symfi Lo
tenofovir disoproxil fumarate
Trizivir
Truvada
Videx 2 gram Pediatric
Viread oral tablet 150 mg, 200 mg, 250 mg
Zerit oral recon soln
zidovudine
Hiv Protease Inhibitor Antiretrovirals
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
10
Drug Name Tier Requirements/Limits
Aptivus
atazanavir
Crixivan oral capsule 200 mg, 400 mg
fosamprenavir
Invirase
Kaletra oral tablet
Lexiva oral suspension
lopinavir-ritonavir
Norvir oral capsule
Norvir oral solution
Prezcobix
Prezista oral suspension
Prezista oral tablet 150 mg, 600 mg, 75 mg, 800
mg
ritonavir
Viracept oral tablet
Interferon Antivirals
Alferon N Specialty PA
Intron A injection Specialty PA
Sylatron Specialty PA
Lincomycin Antibiotics
clindamycin HCl oral capsule 150 mg, 300 mg
clindamycin in 5 % dextrose Specialty PA
clindamycin palmitate HCl
clindamycin phosphate injection Specialty PA
clindamycin phosphate intravenous solution 900
mg/6 mL
Specialty PA
Lincocin Specialty PA
Macrolide Antibiotics
Ery-Tab
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
11
Drug Name Tier Requirements/Limits
Erythrocin (as stearate) oral tablet 250 mg
erythromycin ethylsuccinate oral suspension for
reconstitution
erythromycin ethylsuccinate oral tablet
erythromycin oral capsule,delayed release(DR/EC)
erythromycin oral tablet
Monobactam Antibiotics
Azactam in dextrose (iso-osm) Specialty PA
aztreonam Specialty PA
Cayston Specialty PA
Monoclonal Antibody Antivirals
Synagis PA
Natural Penicillin Antibiotics
Bicillin L-A
penicillin G potassium Specialty PA
penicillin V potassium
Neuraminidase Inhibitor Antivirals
oseltamivir QL
Relenza Diskhaler QL
Nucleoside And Nucleotide Antivirals
acyclovir oral capsule
acyclovir oral suspension 200 mg/5 mL
acyclovir oral tablet
adefovir Specialty PA
cidofovir Specialty PA
Cytovene Specialty PA
entecavir
Rebetol oral solution Specialty PA
valacyclovir QL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
12
Drug Name Tier Requirements/Limits
Other Macrolide Antibiotics
azithromycin oral QL
clarithromycin QL
Dificid PA
Zmax QL
Oxazolidinone Antibiotics
Zyvox intravenous Specialty PA
Penicillinase-Resistant Penicillins
dicloxacillin
nafcillin in dextrose iso-osm intravenous
piggyback 2 gram/100 mL
Specialty PA
nafcillin injection Specialty PA
oxacillin injection Specialty PA
Polyene Antifungals
Abelcet Specialty PA
AmBisome Specialty PA
nystatin oral powder 150 million unit, 500 million
unit
nystatin oral suspension
nystatin oral tablet
Polymyxin Antibiotics
colistin (colistimethate Na) Specialty PA
Quinolone Antibiotics
ciprofloxacin
ciprofloxacin (mixture)
ciprofloxacin HCl oral tablet 250 mg, 500 mg QL
ciprofloxacin HCl oral tablet 750 mg
ciprofloxacin in 5 % dextrose intravenous
piggyback 400 mg/200 mL
Specialty PA
levofloxacin oral QL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
13
Drug Name Tier Requirements/Limits
moxifloxacin oral QL
ofloxacin oral tablet 400 mg
Rifamycin Antibiotics
Mycobutin
rifampin intravenous Specialty PA
rifampin oral
Streptogramin Antibiotics
Synercid Specialty PA
Sulfonamide Antibiotics (Systemic)
sulfadiazine
sulfamethoxazole-trimethoprim intravenous Specialty PA
sulfamethoxazole-trimethoprim oral
sulfasalazine
Tetracycline Antibiotics
Doxy-100 Specialty PA
doxycycline hyclate oral capsule
doxycycline hyclate oral tablet 100 mg
doxycycline hyclate oral tablet,delayed release
(DR/EC) 75 mg
doxycycline monohydrate oral capsule 100 mg, 50
mg
doxycycline monohydrate oral tablet
minocycline oral capsule
minocycline oral tablet
tetracycline
Urinary Anti-Infectives
nitrofurantoin
nitrofurantoin macrocrystal oral capsule 100 mg,
50 mg
nitrofurantoin monohyd/m-cryst
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
14
Drug Name Tier Requirements/Limits
trimethoprim
Urin DS
Antineoplastic Agents
Antineoplastic Agents
Abraxane Specialty PA
Adcetris Specialty PA
Afinitor Specialty PA
Afinitor Disperz Specialty PA
Alferon N Specialty PA
Alimta Specialty PA
anastrozole
Arranon Specialty PA
Arzerra intravenous solution 100 mg/5 mL Specialty PA
Avastin Specialty PA
bexarotene Specialty PA
bicalutamide
BiCNU Specialty PA
bleomycin Specialty PA
Bosulif Specialty PA
busulfan Specialty PA
Camptosar intravenous solution 300 mg/15 mL Specialty PA
capecitabine Specialty PA
Caprelsa Specialty PA
carboplatin Specialty PA
cisplatin Specialty PA
cladribine Specialty PA
clofarabine Specialty PA
Cometriq Specialty PA
cyclophosphamide intravenous Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
15
Drug Name Tier Requirements/Limits
cytarabine Specialty PA
cytarabine (PF) injection solution Specialty PA
dacarbazine Specialty PA
Dacogen Specialty PA
dactinomycin Specialty PA
daunorubicin intravenous solution Specialty PA
Docefrez Specialty 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 (1 mL), 80 mg/4 mL (20
mg/mL), 80 mg/8 mL (10 mg/mL)
Specialty PA
Doxil Specialty PA
doxorubicin intravenous solution Specialty PA
Droxia
Eligard Specialty PA
Eligard (3 month) Specialty PA
Eligard (4 month) Specialty PA
Eligard (6 month) Specialty PA
Emcyt
epirubicin intravenous recon soln 50 mg Specialty PA
epirubicin intravenous solution Specialty PA
Erbitux Specialty PA
Erivedge Specialty PA
Erwinaze Specialty PA
Etopophos Specialty PA
etoposide Specialty PA
exemestane
Fareston Specialty PA
Faslodex Specialty PA
Firmagon kit w diluent syringe Specialty PA
Firmagon subcutaneous recon soln 120 mg Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
16
Drug Name Tier Requirements/Limits
floxuridine Specialty PA
fludarabine Specialty PA
fluorouracil intravenous Specialty PA
flutamide
Folotyn Specialty PA
gemcitabine intravenous recon soln Specialty PA
gemcitabine intravenous solution 1 gram/26.3 mL
(38 mg/mL), 2 gram/52.6 mL (38 mg/mL), 200
mg/5.26 mL (38 mg/mL)
Specialty PA
Gliadel Wafer Specialty PA
Halaven Specialty PA
Herceptin intravenous recon soln 440 mg Specialty PA
Hexalen
Hycamtin oral Specialty PA
hydroxyurea
Ibrance Specialty PA
Iclusig Specialty PA
idarubicin Specialty PA
ifosfamide Specialty PA
ifosfamide-mesna intravenous kit 1-1 gram Specialty PA
imatinib Specialty PA
Inlyta Specialty PA
Intron A injection Specialty PA
irinotecan Specialty PA
Ixempra Specialty PA
Jakafi Specialty PA
Jevtana Specialty PA
Kadcyla Specialty PA
Kyprolis intravenous recon soln 60 mg Specialty PA
letrozole QL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
17
Drug Name Tier Requirements/Limits
Leukeran
leuprolide subcutaneous kit Specialty PA
Lupron Depot Specialty PA
Lupron Depot (3 month) Specialty PA
Lupron Depot (4 month) Specialty PA
Lupron Depot (6 Month) Specialty PA
Lupron Depot-Ped Specialty PA
Lupron Depot-Ped (3 month) Specialty PA
Lysodren
Matulane
megestrol oral suspension 400 mg/10 mL (40
mg/mL)
megestrol oral suspension 625 mg/5 mL QL
megestrol oral tablet
melphalan
melphalan HCl Specialty PA
mercaptopurine
methotrexate sodium
methotrexate sodium (PF)
mitomycin intravenous Specialty PA
mitoxantrone Specialty PA
Mustargen Specialty PA
Myleran
Nexavar Specialty PA
nilutamide Specialty PA
Oncaspar Specialty PA
oxaliplatin Specialty PA
paclitaxel Specialty PA
Perjeta Specialty PA
Photofrin Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
18
Drug Name Tier Requirements/Limits
Pomalyst Specialty PA
Proleukin Specialty PA
Revlimid oral capsule 10 mg, 15 mg, 2.5 mg, 25
mg, 5 mg
Specialty PA
Rituxan Specialty PA
Rituxan Hycela Specialty PA
romidepsin Specialty PA
Sprycel Specialty PA
Stivarga Specialty PA
Supprelin LA Specialty PA
Sutent Specialty PA
Sylatron Specialty PA
Synribo Specialty PA
Tabloid
tamoxifen
Tarceva Specialty PA
Targretin topical Specialty PA
Tasigna Specialty PA
Temodar intravenous Specialty PA
temozolomide Specialty PA
teniposide Specialty PA
thiotepa Specialty PA
Tice BCG Specialty PA
topotecan Specialty PA
Torisel Specialty PA
Treanda intravenous recon soln Specialty PA
Trelstar Specialty PA
tretinoin (chemotherapy) Specialty PA
Tykerb Specialty PA
Valstar Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
19
Drug Name Tier Requirements/Limits
Vectibix Specialty PA
Velcade Specialty PA
Vidaza Specialty PA
vinblastine intravenous solution Specialty PA
vincristine Specialty PA
vinorelbine Specialty PA
Votrient Specialty PA
Xalkori Specialty PA
Xtandi Specialty PA
Yervoy Specialty PA
Zaltrap Specialty PA
Zanosar Specialty PA
Zelboraf Specialty PA
Zevalin (Y-90) Specialty PA
Zoladex Specialty PA
Zolinza Specialty PA
Zytiga oral tablet 250 mg Specialty PA
Antitoxins,Immune Glob,Toxoids,Vaccines
Antitoxins And Immune Globulins
Carimune NF Nanofiltered intravenous recon soln
12 gram, 6 gram
Specialty PA
CytoGam intravenous solution 50 mg/mL Specialty PA
Flebogamma DIF intravenous solution 5 % Specialty PA
GamaSTAN S/D Specialty PA
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
%)
Specialty PA
Hizentra subcutaneous solution 1 gram/5 mL (20
%), 2 gram/10 mL (20 %), 4 gram/20 mL (20 %)
Specialty PA
MICRhoGAM Ultra-Filtered PLUS Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
20
Drug Name Tier Requirements/Limits
Privigen Specialty PA
RhoGAM Ultra-Filtered PLUS Specialty PA
Rhophylac Specialty PA
WinRho SDF Specialty PA
Toxoids
Adacel(Tdap Adolesn/Adult)(PF)
Boostrix Tdap
Vaccines
Afluria 2017-2018 QL; AL
Afluria 2017-2018 (PF) QL; AL
Afluria Quad 2017-2018 QL; AL
Afluria Quad 2017-2018 (PF) QL; AL
Fluarix Quad 2017-2018 (PF) QL; AL
Flucelvax Quad 2017-2018 QL; AL
Flucelvax Quad 2017-2018 (PF) QL; AL
Flulaval Quad 2017-2018 (PF) QL; AL
Fluvirin 2017-2018 QL; AL
Fluvirin 2017-2018 (PF) QL; AL
Fluzone High-Dose 2017-18 (PF) QL; AL
Fluzone Intraderm Quad 2017-18 QL; AL
Fluzone Quad 2017-2018 QL; AL
Fluzone Quad 2017-2018 (PF) QL; AL
Fluzone Quad Pedi 2017-18 (PF) QL; AL
Tice BCG Specialty PA
Autonomic Drugs
Alpha- And Beta-Adrenergic Agonists
Bromfed DM
cetirizine-pseudoephedrine ST
Children's Silfedrine
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
21
Drug Name Tier Requirements/Limits
Conex oral solution
epinephrine injection auto-injector 0.15 mg/0.3
mL, 0.3 mg/0.3 mL
QL
epinephrine injection solution
epinephrine injection syringe 0.1 mg/mL
Lodrane D
LoHist - D
Lortuss EX oral syrup AL
M-End DMX
Nasal Decongestant (pseudoeph) oral tablet
pseudoephedrine HCl oral tablet 60 mg
pseudoephedrine-guaifenesin
Rynex PSE
Alpha-Adrenergic Agonists
Carbaphen CH
Centergy
clonidine
clonidine HCl oral tablet
Dimetapp Cold-Allergy (PE)
ED Bron GP
Ed Chlorped D
methyldopa
methyldopa-hydrochlorothiazide
midodrine
NoHist-DM
Promethazine VC
Promethazine VC-Codeine QL; AL
Trexbrom
Tussin CF (PE-DM-guaif)
Antimuscarinics/Antispasmodics
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
22
Drug Name Tier Requirements/Limits
Anoro Ellipta
Atrovent HFA
chlordiazepoxide-clidinium
Combivent Respimat
dicyclomine oral capsule
dicyclomine oral solution
dicyclomine oral tablet
diphenoxylate-atropine
glycopyrrolate oral tablet 1 mg, 2 mg
hydrocodone-homatropine oral syrup 5-1.5 mg/5
mL
AL
hydrocodone-homatropine oral tablet AL
hyoscyamine sulfate
ipratropium bromide inhalation
ipratropium-albuterol
methscopolamine
propantheline
Spiriva Respimat AL
Stiolto Respimat
Antiparkinsonian Agents
benztropine oral
trihexyphenidyl
Autonomic Drugs, Miscellaneous
Chantix QL
Chantix Starting Month Box QL
nicotine (polacrilex) buccal gum QL
nicotine (polacrilex) buccal lozenge QL
nicotine transdermal patch 24 hour 14 mg/24 hr,
21 mg/24 hr, 7 mg/24 hr
QL
Nicotrol QL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
23
Drug Name Tier Requirements/Limits
Nicotrol NS QL
Centrally Acting Skeletal Muscle Relaxnt
carisoprodol oral tablet 350 mg ST; QL
carisoprodol-ASA-codeine
carisoprodol-aspirin
chlorzoxazone oral tablet 500 mg
cyclobenzaprine oral tablet 10 mg, 5 mg
methocarbamol oral
tizanidine oral tablet
Gaba-Derivative Skeletal Muscle Relaxant
baclofen oral tablet 10 mg, 20 mg
Lioresal Specialty PA
Non-Sel. Beta-Adrenergic Blocking Agents
carvedilol
labetalol oral
nadolol
nadolol-bendroflumethiazide
pindolol
propranolol oral
propranolol-hydrochlorothiazid
sotalol oral
timolol maleate oral
Non-Sel.Alpha-1-Adrenergic Blocking Agts
doxazosin
prazosin
terazosin
Non-Sel.Alpha-Adrenergic Blocking Agents
dihydroergotamine injection
dihydroergotamine nasal QL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
24
Drug Name Tier Requirements/Limits
Ergomar
phenoxybenzamine
Parasympathomimetic (Cholinergic Agents)
bethanechol chloride
donepezil oral tablet 10 mg, 5 mg QL; AL
donepezil oral tablet 23 mg ST; QL
donepezil oral tablet,disintegrating QL; AL
Mestinon oral syrup
pyridostigmine bromide
rivastigmine tartrate AL
Selective Alpha-1-Adrenergic Block.Agent
alfuzosin
carvedilol
labetalol oral
tamsulosin
Selective Beta-2-Adrenergic Agonists
albuterol sulfate inhalation solution for
nebulization
albuterol sulfate oral syrup
albuterol sulfate oral tablet
albuterol sulfate oral tablet extended release 12 hr
8 mg
Anoro Ellipta
Breo Ellipta
Combivent Respimat
fluticasone-salmeterol
ipratropium-albuterol
levalbuterol tartrate ST
Serevent Diskus
Stiolto Respimat
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
25
Drug Name Tier Requirements/Limits
terbutaline oral
Ventolin HFA QL
Selective Beta-Adrenergic Blocking Agent
atenolol
atenolol-chlorthalidone
bisoprolol fumarate
bisoprolol-hydrochlorothiazide
metoprolol succinate
metoprolol ta-hydrochlorothiaz
metoprolol tartrate oral tablet 100 mg, 25 mg, 50
mg
Skeletal Muscle Relaxants, Miscellaneous
Botox Specialty PA
Dysport Specialty PA
Myobloc Specialty PA
orphenadrine citrate oral
Xeomin Specialty PA
Blood Formation, Coagulation, Thrombosis
Coumarin Derivatives
warfarin
Direct Factor Xa Inhibitors
Eliquis
Xarelto oral tablet 10 mg, 15 mg, 20 mg
Xarelto oral tablets,dose pack
Direct Thrombin Inhibitors
Pradaxa
Hematopoietic Agents
Aranesp (in polysorbate) Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
26
Drug Name Tier Requirements/Limits
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
Specialty PA
Fulphila Specialty PA
Granix subcutaneous syringe Specialty PA
Leukine injection recon soln Specialty PA
Mozobil Specialty PA
Neulasta Specialty PA
Neupogen Specialty PA
Nplate Specialty PA
Procrit Specialty PA
Promacta Specialty PA
RETACRIT 10,000 UNIT/ML VIAL L/F, P/F,
INNER, SDV
Specialty PA
RETACRIT 2,000 UNIT/ML VIAL L/F, P/F,
INNER, SDV
Specialty PA
RETACRIT 3,000 UNIT/ML VIAL L/F, P/F,
INNER, SDV
Specialty PA
RETACRIT 4,000 UNIT/ML VIAL L/F, P/F,
INNER, SDV
Specialty PA
RETACRIT 40,000 UNIT/ML VIAL L/F, P/F,
INNER, SDV
Specialty PA
Zarxio Specialty PA
Hemorrheologic Agents
pentoxifylline
Hemostatics
Amicar
DDAVP nasal solution PA
desmopressin nasal spray,non-aerosol PA
desmopressin oral PA
Heparins
enoxaparin subcutaneous solution
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
27
Drug Name Tier Requirements/Limits
enoxaparin subcutaneous syringe QL
heparin (porcine) in 5 % dex Specialty PA
heparin (porcine) in NaCl (PF) Specialty PA
heparin (porcine) injection solution 1,000 unit/mL,
5,000 unit/mL
heparin, porcine (PF) injection syringe
Iron Preparations
Atabex EC AL
Bio-35, Gluten Free
Cadeau DHA AL
Centrum Specialist Prenatal AL
Classic Prenatal AL
Daily Prenatal AL
Expecta Prenatal AL
FE C AL
FE C Plus AL
Feraheme Specialty PA
Ferocon
Ferrex 28
Ferrlecit Specialty PA
ferrous gluconate oral tablet 324 mg (37.5 mg
iron), 324 mg (38 mg iron)
ferrous sulfate oral drops
ferrous sulfate oral elixir
ferrous sulfate oral solution
ferrous sulfate oral tablet 325 mg (65 mg iron)
ferrous sulfate oral tablet,delayed release (DR/EC)
Infed
Injectafer
Iron Chews
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
28
Drug Name Tier Requirements/Limits
KPN oral tablet 9 mg iron- 267 mcg AL
Mini Prenatal AL
Multigen
Multigen Folic
Multigen Plus
Multi-Vit with Fluoride-Iron
Mynatal oral capsule AL
Mynatal Plus AL
Mynatal-Z AL
Obstetrix DHA AL
Obstetrix EC AL
O-Cal FA AL
O-Cal Prenatal AL
One A Day Women's Prenatal DHA AL
One-A-Day Womens Formula oral tablet 18 mg
iron-400 mcg-500 mg Ca
One-A-Day Women's Prenatal 1 AL
Perry Prenatal AL
PNV cmb#95-ferrous fumarate-FA AL
Poly-Vi-Flor with Iron
Prenatabs Rx AL
Prenatal + DHA oral combo pack 28 mg iron-800
mcg-200 mg
AL
Prenatal 19 AL
Prenatal Formula oral tablet 9 mg iron- 267 mcg AL
Prenatal Low Iron
Prenatal Multi-DHA (algal oil) AL
Prenatal Multi-DHA oral capsule 27 mg iron-800
mcg-228 mg
AL
Prenatal oral tablet 28 mg iron- 800 mcg AL
Prenatal Plus AL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
29
Drug Name Tier Requirements/Limits
Prenatal Plus (calcium carb) AL
Prenatal Plus DHA oral combo pack
Prenatal Vitamin Plus Low Iron AL
prenatal vit-iron fum-folic ac AL
prenatal vits96-iron fum-folic AL
ProRenal QD
Protect Iron
Right Step Prenatal Vitamins AL
Similac Prenatal AL
Slow Release Iron oral tablet extended release 143
mg (45 mg iron), 160 mg (50 mg iron)
TriAdvance AL
Trinatal GT AL
Trinatal Rx 1 AL
Trinate AL
Triveen-Duo DHA AL
Tri-Vit with Fluoride and Iron
Venofer
Vinate GT AL
Vinate M AL
Vinate One AL
Vinate Ultra AL
Vol-Nate AL
Vol-Tab Rx AL
Wee Care
Women's Daily Caplet
Women's Prenatal + DHA AL
Platelet-Aggregation Inhibitors
aspirin oral tablet
aspirin oral tablet,chewable
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
30
Drug Name Tier Requirements/Limits
aspirin oral tablet,delayed release (DR/EC) 325
mg, 81 mg
aspirin rectal
aspirin-dipyridamole
butalbital-aspirin-caffeine oral capsule
cilostazol
clopidogrel
dipyridamole oral
prasugrel
Thrombolytic Agents
Activase intravenous recon soln 50 mg Specialty PA
aspirin oral tablet
aspirin oral tablet,chewable
aspirin oral tablet,delayed release (DR/EC) 325
mg, 81 mg
aspirin rectal
butalbital-aspirin-caffeine oral capsule
Cathflo Activase Specialty PA
Cardiovascular Drugs
Alpha-Adrenergic Blocking Agents
carvedilol
doxazosin
labetalol oral
prazosin
terazosin
Alpha-Adrenergic Blocking Agt.(Hypoten)
doxazosin
labetalol oral
prazosin
terazosin
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
31
Drug Name Tier Requirements/Limits
Angiotensin Ii Receptor Antagon.(Hypotn)
amlodipine-valsartan ST
irbesartan ST
irbesartan-hydrochlorothiazide ST
losartan
losartan-hydrochlorothiazide
olmesartan ST
olmesartan-hydrochlorothiazide ST
telmisartan ST
valsartan oral tablet 160 mg, 40 mg, 80 mg ST
valsartan oral tablet 320 mg
valsartan-hydrochlorothiazide ST
Angiotensin Ii Receptor Antagonists
amlodipine-valsartan ST
Entresto
irbesartan ST
irbesartan-hydrochlorothiazide ST
losartan
losartan-hydrochlorothiazide
olmesartan ST
olmesartan-hydrochlorothiazide ST
telmisartan ST
valsartan ST
valsartan-hydrochlorothiazide ST
Angiotensin-Convert.Enzyme Inhib(Hypotn)
amlodipine-benazepril
benazepril
benazepril-hydrochlorothiazide
captopril
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
32
Drug Name Tier Requirements/Limits
captopril-hydrochlorothiazide
enalapril maleate
enalapril-hydrochlorothiazide
fosinopril
fosinopril-hydrochlorothiazide
lisinopril
lisinopril-hydrochlorothiazide
moexipril
moexipril-hydrochlorothiazide
perindopril erbumine
quinapril
quinapril-hydrochlorothiazide
ramipril
trandolapril
Angiotensin-Converting Enzyme Inhibitors
amlodipine-benazepril
benazepril
benazepril-hydrochlorothiazide
captopril
captopril-hydrochlorothiazide
enalapril maleate
enalapril-hydrochlorothiazide
fosinopril
fosinopril-hydrochlorothiazide
lisinopril
lisinopril-hydrochlorothiazide
moexipril
moexipril-hydrochlorothiazide
perindopril erbumine
quinapril
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
33
Drug Name Tier Requirements/Limits
quinapril-hydrochlorothiazide
ramipril
trandolapril
Antiarrhythmics, Miscellaneous
Digox
digoxin oral solution 50 mcg/mL
magnesium sulfate injection Specialty PA
Antilipemic Agents, Miscellaneous
Juxtapid Specialty PA
Kynamro Specialty PA
Niacin Flush Free oral capsule 750 mg
niacin oral capsule, extended release 250 mg, 500
mg
niacin oral tablet extended release 24 hr
Beta-Adrenergic Blocking Agents
atenolol
atenolol-chlorthalidone
bisoprolol fumarate
bisoprolol-hydrochlorothiazide
carvedilol
labetalol oral
metoprolol succinate
metoprolol ta-hydrochlorothiaz
metoprolol tartrate oral tablet 100 mg, 25 mg, 50
mg
nadolol
nadolol-bendroflumethiazide
pindolol
propranolol oral
propranolol-hydrochlorothiazid
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
34
Drug Name Tier Requirements/Limits
sotalol oral
timolol maleate oral
Beta-Adrenergic Blocking Agt.(Hypoten)
atenolol
atenolol-chlorthalidone
bisoprolol fumarate
bisoprolol-hydrochlorothiazide
labetalol oral
metoprolol succinate
metoprolol ta-hydrochlorothiaz
metoprolol tartrate oral tablet 100 mg, 25 mg, 50
mg
nadolol
nadolol-bendroflumethiazide
pindolol
propranolol oral
propranolol-hydrochlorothiazid
sotalol oral
timolol maleate oral
Bile Acid Sequestrants
cholestyramine (with sugar)
Cholestyramine Light oral powder in packet
colestipol
Prevalite oral powder
WelChol
Calcium-Channel Block.Agt,Misc(Hypoten)
diltiazem HCl oral capsule,ext.rel 24h degradable
diltiazem HCl oral capsule,extended release 12 hr
diltiazem HCl oral capsule,extended release 24 hr
diltiazem HCl oral capsule,extended release 24hr
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
35
Drug Name Tier Requirements/Limits
diltiazem HCl oral tablet
verapamil oral tablet
verapamil oral tablet extended release
Calcium-Channel Blocking Agents
amlodipine
amlodipine-benazepril
amlodipine-valsartan ST
diltiazem HCl oral capsule,ext.rel 24h degradable
diltiazem HCl oral capsule,extended release 12 hr
diltiazem HCl oral capsule,extended release 24 hr
diltiazem HCl oral capsule,extended release 24hr
diltiazem HCl oral tablet
felodipine
nifedipine oral capsule
nifedipine oral tablet extended release 24hr
nifedipine oral tablet extended release 30 mg, 90
mg
verapamil oral tablet
verapamil oral tablet extended release
Calcium-Channel Blocking Agents(Hypoten)
diltiazem HCl oral capsule,ext.rel 24h degradable
diltiazem HCl oral capsule,extended release 12 hr
diltiazem HCl oral capsule,extended release 24 hr
diltiazem HCl oral capsule,extended release 24hr
diltiazem HCl oral tablet
verapamil oral tablet
verapamil oral tablet extended release
Calcium-Channel Blocking Agents, Misc.
diltiazem HCl oral capsule,ext.rel 24h degradable
diltiazem HCl oral capsule,extended release 12 hr
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
36
Drug Name Tier Requirements/Limits
diltiazem HCl oral capsule,extended release 24 hr
diltiazem HCl oral capsule,extended release 24hr
diltiazem HCl oral tablet
verapamil oral tablet
verapamil oral tablet extended release
Carbonic Anhydrase Inhibitors(Hypoten)
acetazolamide
Cardiotonic Agents
Digox
digoxin oral solution 50 mcg/mL
Central Alpha-Agonists
clonidine
clonidine HCl oral tablet
guanfacine oral tablet
guanfacine oral tablet extended release 24 hr AL
methyldopa
methyldopa-hydrochlorothiazide
Class Ia Antiarrhythmics
disopyramide phosphate oral capsule
quinidine gluconate oral
quinidine sulfate oral tablet
Class Ib Antiarrhythmics
Dilantin
mexiletine
phenytoin oral suspension
phenytoin oral tablet,chewable
phenytoin sodium extended oral capsule 100 mg
Class Ic Antiarrhythmics
flecainide
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
37
Drug Name Tier Requirements/Limits
propafenone oral tablet
Class Ii Antiarrhythmics
atenolol
atenolol-chlorthalidone
bisoprolol fumarate
bisoprolol-hydrochlorothiazide
carvedilol
labetalol oral
metoprolol succinate
metoprolol ta-hydrochlorothiaz
metoprolol tartrate oral tablet 100 mg, 25 mg, 50
mg
nadolol
nadolol-bendroflumethiazide
pindolol
propranolol oral
propranolol-hydrochlorothiazid
sotalol oral
timolol maleate oral
Class Iii Antiarrhythmics
amiodarone oral tablet 200 mg, 400 mg
Pacerone oral tablet 100 mg
sotalol oral
Class Iv Antiarrhythmics
diltiazem HCl oral capsule,ext.rel 24h degradable
diltiazem HCl oral capsule,extended release 12 hr
diltiazem HCl oral capsule,extended release 24 hr
diltiazem HCl oral capsule,extended release 24hr
diltiazem HCl oral tablet
verapamil oral tablet
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
38
Drug Name Tier Requirements/Limits
verapamil oral tablet extended release
Dihydropyridines
amlodipine
amlodipine-benazepril
amlodipine-valsartan ST
felodipine
nifedipine oral capsule
nifedipine oral tablet extended release 24hr
nifedipine oral tablet extended release 30 mg, 90
mg
Dihydropyridines (Antihypertensive)
amlodipine
amlodipine-benazepril
amlodipine-valsartan ST
felodipine
nifedipine oral capsule
nifedipine oral tablet extended release 24hr
nifedipine oral tablet extended release 30 mg, 90
mg
Direct Vasodilators
BiDil
hydralazine oral
minoxidil oral
Diuretics, Miscellaneous (Hypotensive)
Theo-24
theophylline oral tablet extended release 12 hr
theophylline oral tablet extended release 24 hr
Fibric Acid Derivatives
fenofibrate micronized oral capsule 134 mg, 200
mg, 67 mg
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
39
Drug Name Tier Requirements/Limits
fenofibrate nanocrystallized oral tablet 145 mg, 48
mg
fenofibrate oral tablet 160 mg, 54 mg
gemfibrozil
Hmg-Coa Reductase Inhibitors
atorvastatin
lovastatin
pravastatin
rosuvastatin
simvastatin oral tablet 10 mg, 20 mg, 40 mg, 5 mg
Hypotensive Agents, Miscellaneous
amlodipine
amlodipine-benazepril
amlodipine-valsartan ST
carvedilol
doxazosin
felodipine
nifedipine oral capsule
nifedipine oral tablet extended release 24hr
nifedipine oral tablet extended release 30 mg, 90
mg
phenoxybenzamine
pindolol
propranolol oral
sotalol oral
terazosin
timolol maleate oral
Loop Diuretics (Hypotensive Agents)
bumetanide oral
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
40
Drug Name Tier Requirements/Limits
furosemide oral solution 10 mg/mL, 40 mg/5 mL
(8 mg/mL)
furosemide oral tablet
torsemide oral
Mineralocorticoid (Aldosterone) Antagnts
Aldactazide oral tablet 50-50 mg
spironolactone
spironolacton-hydrochlorothiaz
Mineralocorticoid(Aldoster.)Antag(Hypot)
Aldactazide oral tablet 50-50 mg
spironolactone
spironolacton-hydrochlorothiaz
Nitrates And Nitrites
BiDil
isosorbide dinitrate oral
isosorbide mononitrate
Nitro-Bid
Nitro-Dur transdermal patch 24 hour 0.3 mg/hr,
0.8 mg/hr
nitroglycerin oral
nitroglycerin transdermal patch 24 hour
Pcsk9 Inhibitors
Praluent Pen Specialty PA
Repatha Pushtronex Specialty PA
Repatha SureClick Specialty PA
Repatha Syringe Specialty PA
Phosphodiesterase Type 5 Inhibitors
Adcirca Specialty PA
cilostazol
Revatio intravenous Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
41
Drug Name Tier Requirements/Limits
Revatio oral suspension for reconstitution Specialty PA
sildenafil (antihypertensive) oral PA
Potassium-Sparing Diuretics (Hypoten)
Aldactazide oral tablet 50-50 mg
amiloride
amiloride-hydrochlorothiazide
spironolactone
spironolacton-hydrochlorothiaz
triamterene-hydrochlorothiazid oral capsule 37.5-
25 mg
triamterene-hydrochlorothiazid oral tablet
Renin-Angioten.-Aldost. Sys. Inhib, Misc
Entresto
Thiazide Diuretics(Hypotensive Agents)
Aldactazide oral tablet 50-50 mg
amiloride-hydrochlorothiazide
benazepril-hydrochlorothiazide
bisoprolol-hydrochlorothiazide
captopril-hydrochlorothiazide
chlorothiazide
Diuril
enalapril-hydrochlorothiazide
fosinopril-hydrochlorothiazide
hydrochlorothiazide
irbesartan-hydrochlorothiazide ST
lisinopril-hydrochlorothiazide
losartan-hydrochlorothiazide
methyclothiazide
methyldopa-hydrochlorothiazide
metoprolol ta-hydrochlorothiaz
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
42
Drug Name Tier Requirements/Limits
moexipril-hydrochlorothiazide
nadolol-bendroflumethiazide
olmesartan-hydrochlorothiazide ST
propranolol-hydrochlorothiazid
quinapril-hydrochlorothiazide
spironolacton-hydrochlorothiaz
triamterene-hydrochlorothiazid oral capsule 37.5-
25 mg
triamterene-hydrochlorothiazid oral tablet
valsartan-hydrochlorothiazide ST
Thiazide-Like Diuretics(Hypotensive Agt)
atenolol-chlorthalidone
chlorthalidone oral tablet 25 mg, 50 mg
indapamide
metolazone
Vasodilating Agents, Miscellaneous
amlodipine
amlodipine-benazepril
amlodipine-valsartan ST
aspirin-dipyridamole
diltiazem HCl oral capsule,ext.rel 24h degradable
diltiazem HCl oral capsule,extended release 12 hr
diltiazem HCl oral capsule,extended release 24 hr
diltiazem HCl oral capsule,extended release 24hr
diltiazem HCl oral tablet
dipyridamole oral
epoprostenol (glycine) Specialty PA
felodipine
Letairis Specialty PA
nifedipine oral capsule
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
43
Drug Name Tier Requirements/Limits
nifedipine oral tablet extended release 24hr
nifedipine oral tablet extended release 30 mg, 90
mg
Orenitram Specialty PA
Remodulin Specialty PA
Tracleer Specialty PA
Tyvaso Specialty PA
Tyvaso Refill Kit Specialty PA
Tyvaso Starter Kit Specialty PA
Veletri Specialty PA
Ventavis Specialty PA
verapamil oral tablet
verapamil oral tablet extended release
Cellular And Gene Therapy
Cellular And Gene Therapy
Provenge Specialty PA
Cellular Therapy
Provenge Specialty PA
Central Nervous System Agents
Adamantanes (Cns)
amantadine HCl oral capsule
amantadine HCl oral solution
Amphetamines
dextroamphetamine oral tablet PA; AL
dextroamphetamine-amphetamine oral
capsule,extended release 24hr
AL
dextroamphetamine-amphetamine oral tablet 10
mg, 12.5 mg, 15 mg, 20 mg, 30 mg, 5 mg, 7.5 mg
AL
Vyvanse AL
Analgesics And Antipyretics, Misc.
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
44
Drug Name Tier Requirements/Limits
acetaminophen oral elixir
acetaminophen oral liquid 160 mg/5 mL, 500 mg/5
mL
acetaminophen oral suspension 160 mg/5 mL
acetaminophen oral tablet
acetaminophen oral tablet,chewable
acetaminophen rectal
acetaminophen-codeine oral solution 120-12 mg/5
mL
AL
acetaminophen-codeine oral tablet AL
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
butalbital-acetaminophen oral tablet 50-325 mg
butalbital-acetaminophen-caff oral tablet 50-325-
40 mg
Feverall rectal suppository 325 mg, 80 mg
gabapentin oral capsule
gabapentin oral solution 250 mg/5 mL
gabapentin oral tablet 600 mg QL
gabapentin oral tablet 800 mg
hydrocodone-acetaminophen oral solution 7.5-325
mg/15 mL
hydrocodone-acetaminophen oral tablet 10-325
mg, 5-325 mg, 7.5-325 mg
isometh-dichloral-acetaminophn
Mapap (acetaminophen) oral capsule
Nortemp oral drops
oxycodone-acetaminophen oral tablet 10-325 mg,
5-325 mg, 7.5-325 mg
QL
Pain Relief oral tablet extended release
Prialt Specialty PA
tramadol-acetaminophen AL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
45
Drug Name Tier Requirements/Limits
Anticholinergic Agents (Cns)
benztropine oral
trihexyphenidyl
Anticonvulsants, Miscellaneous
Banzel ST; AL
carbamazepine oral suspension 100 mg/5 mL
carbamazepine oral tablet
carbamazepine oral tablet extended release 12 hr
carbamazepine oral tablet,chewable
divalproex
gabapentin oral capsule
gabapentin oral solution 250 mg/5 mL
gabapentin oral tablet 600 mg QL
gabapentin oral tablet 800 mg
lamotrigine oral tablet
lamotrigine oral tablet, chewable dispersible
lamotrigine oral tablets,dose pack
levetiracetam intravenous Specialty PA
levetiracetam oral solution 100 mg/mL
levetiracetam oral tablet
magnesium sulfate injection Specialty PA
oxcarbazepine oral tablet
Sabril oral tablet Specialty PA
topiramate oral capsule, sprinkle
topiramate oral tablet
valproic acid
valproic acid (as sodium salt) oral solution 250
mg/5 mL
vigabatrin Specialty PA
zonisamide
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
46
Drug Name Tier Requirements/Limits
Antidepressants, Miscellaneous
bupropion HCl (smoking deter) QL
bupropion HCl oral tablet
bupropion HCl oral tablet extended release 24 hr
150 mg, 300 mg
bupropion HCl oral tablet sustained-release 12 hr
mirtazapine
Antimanic Agents
divalproex
lithium carbonate
lithium citrate oral solution 8 mEq/5 mL
valproic acid
valproic acid (as sodium salt) oral solution 250
mg/5 mL
Antimigraine Agents, Miscellaneous
Aimovig Autoinjector Specialty PA
Aimovig Autoinjector (2 Pack) Specialty PA
aspirin oral tablet
aspirin oral tablet,chewable
aspirin oral tablet,delayed release (DR/EC) 325
mg, 81 mg
aspirin rectal
Butalbital Compound W/Codeine
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
butalbital-acetaminophen-caff oral tablet 50-325-
40 mg
butalbital-aspirin-caffeine oral capsule
dihydroergotamine injection
dihydroergotamine nasal QL
divalproex
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
47
Drug Name Tier Requirements/Limits
Ergomar
propranolol oral
timolol maleate oral
tramadol-acetaminophen AL
valproic acid
valproic acid (as sodium salt) oral solution 250
mg/5 mL
Antipsychotics, Miscellaneous
loxapine succinate AL
pimozide AL
Anxiolytics,Sedatives,And Hypnotics,Misc
buspirone
droperidol injection solution
eszopiclone ST
hydroxyzine HCl oral solution 10 mg/5 mL
hydroxyzine HCl oral tablet
hydroxyzine pamoate
promethazine oral
promethazine rectal
Sleep Aid (doxylamine)
zaleplon
zolpidem oral tablet
Atypical Antipsychotics
Abilify Maintena Specialty PA
aripiprazole oral solution AL
aripiprazole oral tablet QL; AL
Aristada Specialty PA
clozapine QL; AL
Geodon intramuscular PA
Invega Sustenna Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
48
Drug Name Tier Requirements/Limits
Invega Trinza Specialty PA
Latuda QL; AL
olanzapine intramuscular PA; AL
olanzapine oral QL; AL
olanzapine-fluoxetine QL; AL
paliperidone QL; AL
quetiapine QL; AL
Risperdal Consta Specialty PA
risperidone oral solution QL; AL
risperidone oral tablet QL; AL
risperidone oral tablet,disintegrating QL; AL
ziprasidone HCl QL; AL
Zyprexa Relprevv Specialty PA
Barbiturates (Anticonvulsants)
phenobarbital
primidone
Barbiturates (Anxiolytic, Sedative/Hyp)
Butalbital Compound W/Codeine
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
butalbital-acetaminophen oral tablet 50-325 mg
butalbital-acetaminophen-caff oral tablet 50-325-
40 mg
butalbital-aspirin-caffeine oral capsule
phenobarbital
Benzodiazepines (Anticonvulsants)
clonazepam
clorazepate dipotassium
Diazepam Intensol
diazepam oral solution 5 mg/5 mL (1 mg/mL)
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
49
Drug Name Tier Requirements/Limits
diazepam oral tablet
diazepam rectal QL
Lorazepam Intensol
lorazepam oral tablet
Benzodiazepines (Anxiolytic,Sedativ/Hyp)
alprazolam oral tablet
amitriptyline-chlordiazepoxide
chlordiazepoxide HCl
chlordiazepoxide-clidinium
clonazepam
clorazepate dipotassium
Diazepam Intensol
diazepam oral solution 5 mg/5 mL (1 mg/mL)
diazepam oral tablet
diazepam rectal QL
estazolam
Lorazepam Intensol
lorazepam oral tablet
midazolam oral syrup 2 mg/mL
oxazepam
temazepam oral capsule 15 mg, 30 mg
triazolam
Butyrophenones
haloperidol AL
haloperidol decanoate AL
haloperidol lactate injection AL
haloperidol lactate oral AL
Central Nervous System Agents, Misc.
atomoxetine AL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
50
Drug Name Tier Requirements/Limits
Austedo Specialty PA
guanfacine oral tablet
guanfacine oral tablet extended release 24 hr AL
Ingrezza Specialty PA
memantine oral tablet AL
memantine oral tablets,dose pack
Radicava Specialty PA
riluzole
Xenazine Specialty PA
Cyclooxygenase-2 (Cox-2) Inhibitors
celecoxib oral capsule 100 mg, 200 mg QL
celecoxib oral capsule 400 mg, 50 mg
Dopamine Precursors
carbidopa-levodopa oral tablet
carbidopa-levodopa oral tablet extended release
Ergot-Deriv. Dopamine Receptor Agonists
bromocriptine
cabergoline ST
Fibromyalgia Agents
duloxetine oral capsule,delayed release(DR/EC)
20 mg, 30 mg
duloxetine oral capsule,delayed release(DR/EC)
60 mg
QL
Savella
Hydantoins
Dilantin
phenytoin oral suspension
phenytoin oral tablet,chewable
phenytoin sodium extended oral capsule 100 mg
Monoamine Oxidase B Inhibitors
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
51
Drug Name Tier Requirements/Limits
selegiline HCl
Monoamine Oxidase Inhibitors
phenelzine
selegiline HCl
tranylcypromine
Nonergot-Deriv.Dopamine Receptor Agonist
APOKYN Specialty PA
pramipexole oral tablet
ropinirole oral tablet
Opiate Agonists
acetaminophen-codeine oral solution 120-12 mg/5
mL
AL
acetaminophen-codeine oral tablet AL
Butalbital Compound W/Codeine
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
carisoprodol-ASA-codeine
codeine sulfate oral tablet AL
codeine-guaifenesin QL; AL
fentanyl transdermal patch 72 hour 100 mcg/hr, 12
mcg/hr, 25 mcg/hr, 50 mcg/hr, 75 mcg/hr
QL
Guaifenesin AC AL
hydrocodone-acetaminophen oral solution 7.5-325
mg/15 mL
hydrocodone-acetaminophen oral tablet 10-325
mg, 5-325 mg, 7.5-325 mg
hydrocodone-homatropine oral syrup 5-1.5 mg/5
mL
AL
hydrocodone-homatropine oral tablet AL
hydromorphone oral liquid
hydromorphone oral tablet
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
52
Drug Name Tier Requirements/Limits
hydromorphone rectal
Lortuss EX oral syrup AL
meperidine oral
morphine concentrate oral solution
morphine oral solution
morphine oral tablet
morphine oral tablet extended release
oxycodone oral concentrate
oxycodone oral solution
oxycodone oral tablet 10 mg, 15 mg, 20 mg, 5 mg QL
oxycodone oral tablet 30 mg
oxycodone-acetaminophen oral tablet 10-325 mg,
5-325 mg, 7.5-325 mg
QL
Promethazine VC-Codeine QL; AL
promethazine-codeine QL; AL
tramadol oral tablet AL
tramadol-acetaminophen AL
Opiate Antagonists
Evzio PA
naltrexone
Narcan nasal spray,non-aerosol 4 mg/actuation QL
Vivitrol QL
Opiate Partial Agonists
buprenorphine HCl sublingual QL; AL
buprenorphine-naloxone sublingual tablet QL; AL
butorphanol tartrate nasal PA; QL
nalbuphine
Other Nonsteroidal Anti-Inflam. Agents
diclofenac potassium
diclofenac sodium oral
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
53
Drug Name Tier Requirements/Limits
diclofenac sodium topical gel 1 % ST
diflunisal
etodolac oral tablet
flurbiprofen oral tablet 50 mg
ibuprofen oral suspension
ibuprofen oral tablet
ibuprofen oral tablet,chewable
indomethacin oral capsule
Infant's Ibuprofen
ketoprofen oral capsule 50 mg, 75 mg
ketorolac oral
meclofenamate
meloxicam oral tablet
nabumetone
naproxen
naproxen sodium oral capsule
naproxen sodium oral tablet
piroxicam
sulindac
Phenothiazines
chlorpromazine AL
fluphenazine decanoate AL
fluphenazine HCl injection AL
fluphenazine HCl oral tablet AL
perphenazine AL
perphenazine-amitriptyline
prochlorperazine AL
prochlorperazine Edisylate injection solution 10
mg/2 mL (5 mg/mL)
AL
prochlorperazine maleate AL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
54
Drug Name Tier Requirements/Limits
thioridazine
trifluoperazine AL
Respiratory And Cns Stimulants
Butalbital Compound W/Codeine
butalbital-acetaminop-caf-cod oral capsule 50-
325-40-30 mg
butalbital-acetaminophen-caff oral tablet 50-325-
40 mg
butalbital-aspirin-caffeine oral capsule
caffeine citrate oral
dexmethylphenidate AL
methylphenidate HCl oral capsule, ER biphasic
30-70
AL
methylphenidate HCl oral solution 10 mg/5 mL AL
methylphenidate HCl oral tablet AL
methylphenidate HCl oral tablet extended release
20 mg
AL
methylphenidate HCl oral tablet extended release
24hr 18 mg, 27 mg, 36 mg, 54 mg
AL
Salicylates
aspirin oral tablet
aspirin oral tablet,chewable
aspirin oral tablet,delayed release (DR/EC) 325
mg, 81 mg
aspirin rectal
aspirin-dipyridamole
Butalbital Compound W/Codeine
butalbital-aspirin-caffeine oral capsule
carisoprodol-ASA-codeine
carisoprodol-aspirin
salsalate
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
55
Drug Name Tier Requirements/Limits
Sel.Serotonin,Norepi Reuptake Inhibitor
duloxetine oral capsule,delayed release(DR/EC)
20 mg, 30 mg
duloxetine oral capsule,delayed release(DR/EC)
60 mg
QL
Savella
venlafaxine oral capsule,extended release 24hr
venlafaxine oral tablet
Selective Serotonin Agonists
rizatriptan QL
sumatriptan QL
sumatriptan succinate oral QL
sumatriptan succinate subcutaneous cartridge QL
sumatriptan succinate subcutaneous pen injector QL
sumatriptan succinate subcutaneous solution QL
Selective-Serotonin Reuptake Inhibitors
citalopram oral tablet
escitalopram oxalate oral tablet
fluoxetine oral capsule
fluoxetine oral solution
fluoxetine oral tablet 10 mg, 20 mg
fluvoxamine oral tablet
olanzapine-fluoxetine QL; AL
paroxetine HCl oral tablet
sertraline oral concentrate
sertraline oral tablet QL
Serotonin Modulators
nefazodone
trazodone
Succinimides
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
56
Drug Name Tier Requirements/Limits
ethosuximide
Thioxanthenes
thiothixene AL
Tricyclics, Other Norepi-Ru Inhibitors
amitriptyline
amitriptyline-chlordiazepoxide
amoxapine
clomipramine
desipramine
doxepin oral
imipramine HCl
maprotiline
nortriptyline oral capsule
perphenazine-amitriptyline
Vesicular Monoamine Transport2 Inhibitor
Austedo Specialty PA
Ingrezza Specialty PA
Xenazine Specialty PA
Wakefulness-Promoting Agents
modafinil PA
Devices
Devices
Accu-Chek Aviva Control Soln
Accu-Chek Guide Glucose Meter
Accu-Chek Guide L1-L2 Ctrl Sol
Accu-Chek Multiclix Lancet
Accu-Chek SmartView Contrl Sol
Accu-Chek Soft Dev Lancets
Accu-Chek Softclix Lancet Dev
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
57
Drug Name Tier Requirements/Limits
Accu-Chek Softclix Lancets
Aerochamber MV
Euflexxa Specialty PA
Gelclair
Gel-One Specialty PA
Gelsyn-3 Specialty PA
GenVisc 850 Specialty PA
heparin (porcine) in NaCl (PF) Specialty PA
Hyalgan Specialty PA
Hyper-Sal inhalation solution for nebulization 7 % PA
Insulin Syringe syringe 0.5 mL 29 gauge x 1/2"
Lancets,Ultra Thin 26 gauge
Monovisc Specialty PA
ORTHOVISC Specialty PA
pen needle, diabetic needle 29 gauge x 1/2"
sodium chloride inhalation solution for
nebulization 0.9 %
QL
Soft Touch Lancets
Solesta Specialty PA
Supartz FX Specialty PA
Synvisc Specialty PA
Synvisc-One Specialty PA
Vortex Holding Chamber
Diagnostic Agents
Adrenocortical Insufficiency
Acthar H.P. PA
cosyntropin injection Specialty PA
Diabetes Mellitus
Accu-Chek Aviva Plus test strp QL
Accu-Chek Guide QL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
58
Drug Name Tier Requirements/Limits
Accu-Chek SmartView Test Strip QL
Thyroid Function
Thyrogen Specialty PA
Electrolytic, Caloric, And Water Balance
Alkalinizing Agents
Cytra-2
Oracit
potassium citrate oral tablet extended release 10
mEq (1,080 mg), 5 mEq (540 mg)
Ammonia Detoxicants
Carbaglu Specialty PA
Enulose
lactulose oral solution 10 gram/15 mL
Caloric Agents
Clinisol SF 15 % Specialty PA
D5 %-0.45 % sodium chloride Specialty PA
dextrose 70 % in water (D70W) Specialty PA
Intralipid intravenous emulsion 20 % Specialty PA
Liposyn III intravenous emulsion 10 %, 30 % Specialty PA
Prosol 20 % Specialty PA
Travasol 10 % Specialty PA
TrophAmine 10 % Specialty PA
Carbonic Anhydrase Inhibitors
acetazolamide
Diuretics, Miscellaneous
Theo-24
theophylline oral tablet extended release 12 hr
theophylline oral tablet extended release 24 hr
Irrigating Solutions
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
59
Drug Name Tier Requirements/Limits
sodium chloride irrigation
water for irrigation, sterile
Loop Diuretics
bumetanide oral
furosemide oral solution 10 mg/mL, 40 mg/5 mL
(8 mg/mL)
furosemide oral tablet
torsemide oral
Phosphate-Removing Agents
calcium acetate oral capsule
sevelamer carbonate oral tablet
Potassium-Removing Agents
Kionex (with sorbitol)
SPS (with sorbitol) rectal
Potassium-Sparing Diuretics
Aldactazide oral tablet 50-50 mg
amiloride
amiloride-hydrochlorothiazide
spironolactone
spironolacton-hydrochlorothiaz
triamterene-hydrochlorothiazid oral capsule 37.5-
25 mg
triamterene-hydrochlorothiazid oral tablet
Replacement Preparations
Atabex EC AL
Bio-35, Gluten Free
Ca-D3-mag-zinc-cop-mang-bor
CALCIUM 250-VIT D3 125 TABLET
Calcium 500 + D oral tablet 500 mg(1,250mg) -
400 unit
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
60
Drug Name Tier Requirements/Limits
CALCIUM 500 + VIT D CAPLET P/F, CAPLET
CALCIUM 500-VIT D3 200 TABLET P/F,NA/F
CALCIUM 500-VIT D3 600 TABLET
Calcium 600 + D(3) oral tablet 600 mg(1,500mg) -
200 unit
CALCIUM 600 + VIT D TABLET
CALCIUM 600 MG TABLET
CALCIUM 600-VIT D3 800 CAPLET S/F, P/F,
CAPLET
calcium carbonate-vitamin D3 oral tablet 1,000
mg(2,500 mg)-800 unit, 600 mg(1,500mg) -400
unit
calcium citrate-vitamin D3 oral tablet 315-250 mg-
unit
Citrus Calcium oral tablet 315-250 mg-unit
Daily Prenatal AL
Hyper-Sal inhalation solution for nebulization 7 % PA
Klor-Con
Klor-Con/EF
Mynatal oral capsule AL
Mynatal Plus AL
Mynatal-Z AL
O-Cal FA AL
O-Cal Prenatal AL
One A Day Women's Prenatal DHA AL
One-A-Day Womens Formula oral tablet 18 mg
iron-400 mcg-500 mg Ca
One-A-Day Women's Prenatal 1 AL
Oralyte
Oyster Shell Calcium-Vit D3 oral tablet 500
mg(1,250mg) -200 unit, 500 mg(1,250mg) -400
unit
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
61
Drug Name Tier Requirements/Limits
Perry Prenatal AL
potassium chloride oral capsule, extended release
10 mEq
potassium chloride oral liquid
potassium chloride oral tablet extended release 10
mEq, 8 mEq
potassium chloride oral tablet,ER particles/crystals
Prenatabs Rx AL
Prenatal Formula oral tablet 9 mg iron- 267 mcg AL
Prenatal Low Iron
Prenatal Plus AL
Prenatal Plus (calcium carb) AL
Prenatal Vitamin Plus Low Iron AL
prenatal vit-iron fum-folic ac AL
prenatal vits96-iron fum-folic AL
Prosteon
Right Step Prenatal Vitamins AL
selenium oral tablet,delayed release (DR/EC)
SM CALCIUM 500 MG TABLET
sodium chloride inhalation solution for
nebulization 0.9 %
QL
TheraCal D4000
TPN Electrolytes Specialty PA
TPN Electrolytes II Specialty PA
TriAdvance AL
Trinatal Rx 1 AL
Trinate AL
Triveen-Duo DHA AL
Upcal D
Vinate One AL
Vinate Ultra AL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
62
Drug Name Tier Requirements/Limits
VP-GGR-B6
Women's Daily Caplet
Thiazide Diuretics
Aldactazide oral tablet 50-50 mg
amiloride-hydrochlorothiazide
benazepril-hydrochlorothiazide
bisoprolol-hydrochlorothiazide
captopril-hydrochlorothiazide
chlorothiazide
Diuril
enalapril-hydrochlorothiazide
fosinopril-hydrochlorothiazide
hydrochlorothiazide
irbesartan-hydrochlorothiazide ST
lisinopril-hydrochlorothiazide
losartan-hydrochlorothiazide
methyclothiazide
methyldopa-hydrochlorothiazide
metoprolol ta-hydrochlorothiaz
moexipril-hydrochlorothiazide
nadolol-bendroflumethiazide
olmesartan-hydrochlorothiazide ST
propranolol-hydrochlorothiazid
quinapril-hydrochlorothiazide
spironolacton-hydrochlorothiaz
triamterene-hydrochlorothiazid oral capsule 37.5-
25 mg
triamterene-hydrochlorothiazid oral tablet
valsartan-hydrochlorothiazide ST
Thiazide-Like Diuretics
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
63
Drug Name Tier Requirements/Limits
atenolol-chlorthalidone
chlorthalidone oral tablet 25 mg, 50 mg
indapamide
metolazone
Uricosuric Agents
probenecid
probenecid-colchicine
Vasopressin Antagonists
Jynarque oral tablets, sequential 45 mg (AM)/ 15
mg (PM), 90 mg (AM)/ 30 mg (PM)
Specialty PA
Jynarque oral tablets, sequential 60 mg (AM)/ 30
mg (PM)
Specialty
Samsca Specialty PA
Enzymes
Enzymes
Activase intravenous recon soln 50 mg Specialty PA
Adagen Specialty PA
Aldurazyme Specialty PA
Cathflo Activase Specialty PA
Cerezyme intravenous recon soln 400 unit Specialty PA
Elaprase Specialty PA
Elelyso Specialty PA
Elitek Specialty PA
Fabrazyme Specialty PA
Naglazyme Specialty PA
Pulmozyme Specialty PA
Sucraid Specialty PA
Voraxaze Specialty PA
VPRIV Specialty PA
Xiaflex Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
64
Drug Name Tier Requirements/Limits
Eye, Ear, Nose And Throat (Eent) Preps.
Alpha-Adrenergic Agonists (Eent)
brimonidine
Antiallergic Agents
azelastine nasal
azelastine ophthalmic (eye) ST; QL
cromolyn nasal
cromolyn ophthalmic (eye)
ketotifen fumarate QL
olopatadine ophthalmic (eye) drops 0.1 % ST; QL
Antibacterials (Eent)
bacitracin-polymyxin B ophthalmic (eye)
Ciprodex
ciprofloxacin HCl ophthalmic (eye)
doxycycline hyclate oral tablet 20 mg
erythromycin ophthalmic (eye)
Gentak ophthalmic (eye) ointment
Moxeza
moxifloxacin ophthalmic (eye)
neomycin-bacitracin-poly-HC
neomycin-bacitracin-polymyxin
neomycin-polymyxin B-dexameth
neomycin-polymyxin-gramicidin
neomycin-polymyxin-HC
ofloxacin ophthalmic (eye)
ofloxacin otic (ear)
polymyxin B sulf-trimethoprim
sulfacetamide sodium ophthalmic (eye) drops
sulfacetamide-prednisolone
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
65
Drug Name Tier Requirements/Limits
tobramycin
tobramycin-dexamethasone
Tobrex ophthalmic (eye) ointment
Antivirals (Eent)
trifluridine
Beta-Adrenergic Blocking Agents (Eent)
carteolol
dorzolamide-timolol
levobunolol ophthalmic (eye) drops 0.5 %
metipranolol
timolol maleate ophthalmic (eye) drops
timolol maleate ophthalmic (eye) gel forming
solution
Carbonic Anhydrase Inhibitors (Eent)
acetazolamide
Azopt
dorzolamide
dorzolamide-timolol
Corticosteroids (Eent)
Ciprodex
dexamethasone sodium phosphate ophthalmic
(eye)
Flarex
fluorometholone
fluticasone nasal
FML Forte
FML S.O.P.
Maxidex
Nasal Allergy ST
neomycin-bacitracin-poly-HC
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
66
Drug Name Tier Requirements/Limits
neomycin-polymyxin B-dexameth
neomycin-polymyxin-HC ophthalmic (eye)
Ozurdex Specialty PA
Pred Mild
prednisolone acetate
prednisolone sodium phosphate ophthalmic (eye)
Retisert Specialty PA
tobramycin-dexamethasone
Eent Anti-Infectives, Miscellaneous
acetic acid otic (ear)
chlorhexidine gluconate mucous membrane
Ear Wax Treatment
Eent Anti-Inflammatory Agents, Misc.
Restasis ST
Restasis MultiDose ST
Xiidra ST
Eent Drugs, Miscellaneous
apraclonidine
Artificial Tears (petro/min)
Artificial Tears (polyvin alc)
Artificial Tears(glycerin-peg)
Ayr Sinus Rinse Refill
Baby Ayr Saline
Eylea Specialty PA
Hypotears
Iopidine ophthalmic (eye) dropperette
ipratropium bromide nasal
Lucentis intravitreal solution 0.3 mg/0.05 mL Specialty PA
Lucentis intravitreal syringe Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
67
Drug Name Tier Requirements/Limits
Macugen Specialty PA
Muro 128 ophthalmic (eye) drops 2 %
Saline Mist
sodium chloride ophthalmic (eye)
Visudyne Specialty PA
Eent Nonsteroidal Anti-Inflam. Agents
diclofenac sodium ophthalmic (eye)
flurbiprofen sodium
ketorolac ophthalmic (eye)
Local Anesthetics (Eent)
lidocaine HCl mucous membrane jelly in
applicator
lidocaine HCl mucous membrane solution 4 % (40
mg/mL)
Lidocaine Viscous
proparacaine
tetracaine HCl
tetracaine HCl (PF) ophthalmic (eye)
Tetravisc ophthalmic (eye) drops, viscous
Miotics
Phospholine Iodide
pilocarpine HCl ophthalmic (eye) drops 1 %, 2 %,
4 %
Mydriatics
atropine ophthalmic (eye)
cyclopentolate ophthalmic (eye) drops 1 %, 2 %
Homatropaire
tropicamide
Prostaglandin Analogs
latanoprost
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
68
Drug Name Tier Requirements/Limits
Vasoconstrictors
Neo-Synephrine (phenylephrine) nasal spray,non-
aerosol 0.25 %
phenylephrine HCl ophthalmic (eye)
Visine-A
Gastrointestinal Drugs
5-Ht3 Receptor Antagonists
Akynzeo (fosnetupitant) Specialty PA
Akynzeo (netupitant) PA
granisetron (PF) Specialty PA
granisetron HCl intravenous Specialty PA
granisetron HCl oral ST
ondansetron QL
ondansetron HCl (PF) injection solution Specialty PA
ondansetron HCl intravenous Specialty PA
ondansetron HCl oral solution QL
ondansetron HCl oral tablet 4 mg, 8 mg QL
palonosetron intravenous solution Specialty PA
Sustol Specialty PA
Antacids And Adsorbents
aluminum hydroxide gel oral suspension 320 mg/5
mL
Antacid Plus Anti-Gas oral suspension 400-400-40
mg/5 mL
Maalox Advanced oral tablet,chewable
magnesium oxide oral tablet 250 mg, 400 mg
(241.3 mg magnesium), 420 mg
Pink Bismuth oral suspension 262 mg/15 mL
sodium bicarbonate oral
Antidiarrhea Agents
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
69
Drug Name Tier Requirements/Limits
diphenoxylate-atropine
loperamide oral capsule
loperamide oral liquid 1 mg/5 mL
loperamide oral tablet
Pink Bismuth oral suspension 262 mg/15 mL
Antiemetics, Miscellaneous
Diclegis PA
Formula EM
Antiflatulents
Antacid Plus Anti-Gas oral suspension 400-400-40
mg/5 mL
Maalox Advanced oral tablet,chewable
Antihistamines (Gi Drugs)
Diclegis PA
dimenhydrinate oral
meclizine oral tablet 12.5 mg, 25 mg
meclizine oral tablet,chewable
prochlorperazine AL
prochlorperazine Edisylate injection solution 10
mg/2 mL (5 mg/mL)
AL
prochlorperazine maleate AL
trimethobenzamide oral
Anti-Inflammatory Agents (Gi Drugs)
balsalazide
Canasa
Delzicol oral capsule (with del rel tablets)
Dipentum
mesalamine oral tablet,delayed release (DR/EC)
1.2 gram
mesalamine rectal
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
70
Drug Name Tier Requirements/Limits
Pentasa
sulfasalazine
Cathartics And Laxatives
Amitiza
Atabex EC AL
docusate sodium oral capsule
docusate sodium oral syrup
Obstetrix EC AL
peg 3350-electrolytes
Perdiem Overnight Relief
polyethylene glycol 3350 oral powder
senna oral syrup 8.8 mg/5 mL
senna oral tablet
TriLyte With Flavor Packets
Vinate Ultra AL
Cholelitholytic Agents
ursodiol
Digestants
Creon
Zenpep oral capsule,delayed release(DR/EC)
10,000-32,000 -42,000 unit, 15,000-47,000 -
63,000 unit, 20,000-63,000- 84,000 unit, 25,000-
79,000- 105,000 unit, 3,000-10,000 -14,000-unit,
40,000-126,000- 168,000 unit, 5,000-17,000-
24,000 unit
Emetics
ipecac
Gi Drugs, Miscellaneous
Cimzia Specialty PA
Cimzia Powder for Reconst Specialty PA
Endari Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
71
Drug Name Tier Requirements/Limits
Entyvio Specialty PA
Gattex 30-Vial Specialty PA
Humira Specialty PA
Humira Pediatric Crohn's Start subcutaneous
syringe kit 80 mg/0.8 mL, 80 mg/0.8 mL-40
mg/0.4 mL
Specialty PA
Humira Pen Specialty PA
Humira Pen Crohn's-UC-HS Start subcutaneous
pen injector kit 80 mg/0.8 mL
Specialty PA
Humira Pen Psoriasis-Uveitis subcutaneous pen
injector kit 80 mg/0.8 mL-40 mg/0.4 mL
Specialty PA
Inflectra Specialty PA
Linzess oral capsule 145 mcg, 290 mcg AL
Ocaliva Specialty PA
Remicade Specialty PA
Renflexis Specialty PA
Simponi Specialty PA
Simponi ARIA Specialty PA
Histamine H2-Antagonists
cimetidine
cimetidine HCl oral
famotidine oral
nizatidine
ranitidine HCl injection solution 50 mg/2 mL (25
mg/mL)
Specialty PA
ranitidine HCl oral syrup
ranitidine HCl oral tablet
Neurokinin-1 Receptor Antagonists
Akynzeo (fosnetupitant) Specialty PA
Akynzeo (netupitant) PA
aprepitant oral capsule 80 mg
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
72
Drug Name Tier Requirements/Limits
aprepitant oral capsule,dose pack
Emend oral capsule 125 mg
Emend oral capsule 40 mg QL
Prokinetic Agents
metoclopramide HCl oral solution
metoclopramide HCl oral tablet
Prostaglandins
misoprostol
Protectants
sucralfate oral tablet
Proton-Pump Inhibitors
esomeprazole magnesium ST; QL
lansoprazole oral capsule,delayed release(DR/EC) ST; QL
Nexium 24HR oral tablet,delayed release (DR/EC) ST; QL
omeprazole oral capsule,delayed release(DR/EC) QL
omeprazole-sodium bicarbonate oral capsule 20-
1.1 mg-gram
ST; QL
pantoprazole oral QL
Prilosec oral susp,delayed release for recon QL; AL
Gold Compounds
Gold Compounds
Ridaura
Heavy Metal Antagonists
Heavy Metal Antagonists
Chemet
Cuprimine Specialty PA
deferoxamine Specialty PA
Depen Titratabs Specialty PA
Exjade Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
73
Drug Name Tier Requirements/Limits
Ferriprox oral tablet Specialty PA
Galzin Specialty PA
Jadenu Specialty PA
Jadenu Sprinkle Specialty PA
trientine Specialty PA
Hormones And Synthetic Substitutes
Adrenals
ArmonAir RespiClick
Arnuity Ellipta inhalation blister with device 100
mcg/actuation, 200 mcg/actuation
QL
Arnuity Ellipta inhalation blister with device 50
mcg/actuation
Asmanex HFA
Asmanex Twisthaler QL
Breo Ellipta
budesonide inhalation QL; AL
cortisone
Dexamethasone Intensol
dexamethasone oral elixir
dexamethasone oral solution
dexamethasone oral tablet
dexamethasone sodium phos (PF)
dexamethasone sodium phosphate injection
solution
Emflaza Specialty PA
Flovent Diskus QL
Flovent HFA QL
fludrocortisone
fluticasone-salmeterol
hydrocortisone oral
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
74
Drug Name Tier Requirements/Limits
Intrarosa
methylprednisolone
methylprednisolone sodium succ intravenous Specialty PA
prednisolone oral solution 15 mg/5 mL
prednisolone sodium phosphate oral solution 15
mg/5 mL (3 mg/mL), 5 mg base/5 mL (6.7 mg/5
mL)
prednisone
Prednisone Intensol
Qvar QL
Qvar RediHaler QL
Solu-Cortef (PF) injection recon soln 100 mg/2
mL
Androgens
danazol PA
estrogens-methyltestosterone
testosterone cypionate QL
testosterone enanthate QL
testosterone transdermal gel PA
testosterone transdermal gel in metered-dose pump
10 mg/0.5 gram /actuation, 12.5 mg/ 1.25 gram (1
%)
PA
testosterone transdermal gel in packet 1 % (25
mg/2.5gram), 1 % (50 mg/5 gram)
PA
testosterone transdermal solution in metered pump
w/app
PA
Antidiabetic Agents, Miscellaneous
WelChol
Antiestrogens
anastrozole
exemestane
letrozole QL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
75
Drug Name Tier Requirements/Limits
Antigonadtropins
Firmagon kit w diluent syringe Specialty PA
Firmagon subcutaneous recon soln 120 mg Specialty PA
Antiparathyroid Agents
calcitonin (salmon)
Antithyroid Agents
methimazole oral tablet 10 mg, 5 mg
propylthiouracil
SSKI
Biguanides
alogliptin-metformin ST
glipizide-metformin
glyburide-metformin
Janumet ST
Janumet XR ST
metformin oral tablet
metformin oral tablet extended release 24 hr
pioglitazone-metformin ST
Segluromet ST
Contraceptives
Aranelle (28)
Balziva (28)
desogestrel-ethinyl estradiol
Ella
ethynodiol diac-eth estradiol oral tablet 1-50 mg-
mcg
levonorgestrel-ethinyl estrad oral tablet 0.1-20 mg-
mcg, 0.15-0.03 mg
levonorgestrel-ethinyl estrad oral tablets,dose
pack,3 month
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
76
Drug Name Tier Requirements/Limits
levonorg-eth estrad triphasic
Low-Ogestrel (28)
Microgestin 1.5/30 (21)
Microgestin Fe 1.5/30 (28)
Microgestin FE 1/20 (28)
norethindrone (contraceptive)
norethindrone ac-eth estradiol oral tablet 1-20 mg-
mcg
norgestimate-ethinyl estradiol oral tablet
0.18/0.215/0.25 mg-35 mcg (28), 0.25-35 mg-mcg
Nortrel 0.5/35 (28)
Nortrel 1/35 (21)
Nortrel 1/35 (28)
Nortrel 7/7/7 (28)
NuvaRing
Velivet Triphasic Regimen (28)
Xulane
Zovia 1/35E (28)
Dipeptidyl Peptidase-4(Dpp-4) Inhibitors
alogliptin ST
alogliptin-metformin ST
alogliptin-pioglitazone ST
Janumet ST
Janumet XR ST
Januvia ST
Estrogen Agonist-Antagonists
Fareston Specialty PA
raloxifene
tamoxifen
Estrogens
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
77
Drug Name Tier Requirements/Limits
estradiol oral
estradiol transdermal
estradiol vaginal cream
estrogens-methyltestosterone
estropipate oral tablet 0.75 mg, 1.5 mg
Femhrt Low Dose
Jinteli
Menest oral tablet 0.3 mg, 0.625 mg, 1.25 mg
Premarin oral
Premarin vaginal
Premphase
Prempro
Yuvafem QL
Glycogenolytic Agents
Glucagon Emergency Kit (human) QL
Gonadotropins
Eligard Specialty PA
Eligard (3 month) Specialty PA
Eligard (4 month) Specialty PA
Eligard (6 month) Specialty PA
leuprolide subcutaneous kit Specialty PA
Lupron Depot Specialty PA
Lupron Depot (3 month) Specialty PA
Lupron Depot (4 month) Specialty PA
Lupron Depot (6 Month) Specialty PA
Lupron Depot-Ped Specialty PA
Lupron Depot-Ped (3 month) Specialty PA
Supprelin LA Specialty PA
Trelstar Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
78
Drug Name Tier Requirements/Limits
Zoladex Specialty PA
Gonadotropins And Antigonadotropins
Eligard Specialty PA
Eligard (3 month) Specialty PA
Eligard (4 month) Specialty PA
Eligard (6 month) Specialty PA
leuprolide subcutaneous kit Specialty PA
Lupron Depot Specialty PA
Lupron Depot (3 month) Specialty PA
Lupron Depot (4 month) Specialty PA
Lupron Depot (6 Month) Specialty PA
Lupron Depot-Ped Specialty PA
Lupron Depot-Ped (3 month) Specialty PA
Supprelin LA Specialty PA
Zoladex Specialty PA
Incretin Mimetics
Ozempic ST
Trulicity ST
Victoza 2-Pak ST
Victoza 3-Pak ST
Insulins
Admelog SoloStar U-100 Insulin QL
Admelog U-100 Insulin lispro QL
Basaglar KwikPen U-100 Insulin QL
Humalog Junior KwikPen U-100 QL
Humalog Mix 50-50 Insuln U-100 QL
Humalog Mix 50-50 KwikPen QL
Humalog Mix 75-25 KwikPen QL
Humalog Mix 75-25(U-100)Insuln QL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
79
Drug Name Tier Requirements/Limits
Humulin 70/30 U-100 Insulin QL
Humulin N NPH Insulin KwikPen QL
Humulin N NPH U-100 Insulin QL
Humulin R Regular U-100 Insuln QL
Novolin 70/30 U-100 Insulin QL
Novolin N NPH U-100 Insulin QL
Novolin R Regular U-100 Insuln QL
Novolog Mix 70-30 U-100 Insuln QL
Novolog Mix 70-30FlexPen U-100 QL
Intermediate-Acting Insulins
Humulin 70/30 U-100 Insulin QL
Humulin N NPH Insulin KwikPen QL
Humulin N NPH U-100 Insulin QL
Novolin 70/30 U-100 Insulin QL
Novolin N NPH U-100 Insulin QL
Long-Acting Insulins
Basaglar KwikPen U-100 Insulin QL
Parathyroid Agents
Forteo Specialty PA
Tymlos Specialty PA
Parathyroid And Antiparathyroid Agents
calcitonin (salmon)
Forteo Specialty PA
Tymlos Specialty PA
Pituitary
Acthar H.P. PA
DDAVP nasal solution PA
desmopressin nasal spray,non-aerosol PA
desmopressin oral PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
80
Drug Name Tier Requirements/Limits
Humatrope Specialty PA
Nutropin AQ Nuspin subcutaneous pen injector 5
mg/2 mL (2.5 mg/mL)
Specialty PA
Omnitrope Specialty PA
Saizen click.easy Specialty PA
Saizen subcutaneous recon soln 8.8 mg Specialty PA
Serostim subcutaneous recon soln 4 mg, 5 mg, 6
mg
Specialty PA
Progestins
Depo-Provera intramuscular suspension 400
mg/mL
Femhrt Low Dose
Jinteli
Makena Specialty PA
Makena (PF) Specialty PA
medroxyprogesterone
megestrol oral suspension 400 mg/10 mL (40
mg/mL)
megestrol oral suspension 625 mg/5 mL QL
megestrol oral tablet
norethindrone acetate
progesterone micronized
Rapid-Acting Insulins
Admelog SoloStar U-100 Insulin QL
Admelog U-100 Insulin lispro QL
Humalog Junior KwikPen U-100 QL
Humalog Mix 50-50 Insuln U-100 QL
Humalog Mix 50-50 KwikPen QL
Humalog Mix 75-25 KwikPen QL
Humalog Mix 75-25(U-100)Insuln QL
Novolog Mix 70-30 U-100 Insuln QL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
81
Drug Name Tier Requirements/Limits
Novolog Mix 70-30FlexPen U-100 QL
Short-Acting Insulins
Humulin 70/30 U-100 Insulin QL
Humulin R Regular U-100 Insuln QL
Novolin 70/30 U-100 Insulin QL
Novolin R Regular U-100 Insuln QL
Sodium-Gluc Cotransport 2 (Sglt2) Inhib
Segluromet ST
Steglatro ST
Somatostatin Agonists
octreotide acetate Specialty PA
Signifor Specialty PA
Somatuline Depot Specialty PA
Somatotropin Agonists
Increlex Specialty PA
Somatotropin Antagonists
Somavert subcutaneous recon soln 15 mg, 20 mg Specialty PA
Sulfonylureas
chlorpropamide
glimepiride
glipizide
glipizide-metformin
glyburide
glyburide micronized
glyburide-metformin
tolazamide
tolbutamide
Thiazolidinediones
alogliptin-pioglitazone ST
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
82
Drug Name Tier Requirements/Limits
pioglitazone ST
pioglitazone-metformin ST
Thyroid Agents
Armour Thyroid oral tablet 180 mg, 240 mg, 300
mg
levothyroxine oral
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
liothyronine oral
Nature-Throid oral tablet 130 mg, 16.25 mg, 195
mg, 32.5 mg, 65 mg
NP Thyroid oral tablet 15 mg, 30 mg, 60 mg, 90
mg
thyroid (pork) oral tablet 120 mg
Thyrolar-1
Thyrolar-1/2
Thyrolar-1/4
Thyrolar-2
Thyrolar-3
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
Miscellaneous Therapeutic Agents
5-Alpha-Reductase Inhibitors
dutasteride
finasteride oral tablet 5 mg
Alcohol Deterrents
disulfiram
naltrexone
Vivitrol QL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
83
Drug Name Tier Requirements/Limits
Antidotes
Chemet
deferoxamine Specialty PA
Evzio PA
Glucagon Emergency Kit (human) QL
Kionex (with sorbitol)
leucovorin calcium injection recon soln Specialty PA
leucovorin calcium oral
levoleucovorin calcium intravenous recon soln 50
mg
Specialty PA
magnesium sulfate injection Specialty PA
Narcan nasal spray,non-aerosol 4 mg/actuation QL
sevelamer carbonate oral tablet
SPS (with sorbitol) rectal
SSKI
Voraxaze Specialty PA
Antigout Agents
allopurinol
colchicine oral tablet ST; QL
indomethacin oral capsule
Krystexxa Specialty PA
naproxen
naproxen sodium oral capsule
naproxen sodium oral tablet
probenecid
probenecid-colchicine
Antisense Oligonucleotides
Kynamro Specialty PA
Spinraza (PF) Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
84
Drug Name Tier Requirements/Limits
Bone Resorption Inhibitors
alendronate oral tablet
calcitonin (salmon)
etidronate disodium
ibandronate intravenous syringe Specialty PA
pamidronate intravenous recon soln 30 mg Specialty PA
pamidronate intravenous solution Specialty PA
Prolia Specialty PA
raloxifene
Xgeva Specialty PA
zoledronic acid intravenous solution Specialty PA
zoledronic acid-mannitol-water intravenous
piggyback 5 mg/100 mL
Specialty PA
Zometa intravenous piggyback Specialty PA
Cariostatic Agents
fluoride (sodium) oral drops AL
fluoride (sodium) oral tablet,chewable AL
Gel-Kam AL
Multi-Vit with Fluoride-Iron
Multivitamin With Fluoride
Multi-Vitamin With Fluoride oral drops
Multivitamins With Fluoride oral tablet,chewable
0.25 mg, 1 mg
Poly-Vi-Flor
Poly-Vi-Flor with Iron
PreviDent 5000 Dry Mouth
PreviDent dental solution
SF AL
SF 5000 Plus AL
Tri-Vit with Fluoride and Iron
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
85
Drug Name Tier Requirements/Limits
Tri-Vitamin With Fluoride
Complement Inhibitors
Berinert intravenous kit Specialty PA
Cinryze PA
Firazyr Specialty PA
Haegarda Specialty PA
Kalbitor Specialty PA
Soliris Specialty PA
Disease-Modifying Antirheumatic Agents
Actemra Specialty PA
azathioprine
Cimzia Specialty PA
Cimzia Powder for Reconst Specialty PA
Cuprimine Specialty PA
cyclosporine intravenous Specialty PA
cyclosporine modified
cyclosporine oral capsule
Depen Titratabs Specialty PA
Enbrel Specialty PA
Enbrel Mini Specialty PA
Enbrel SureClick Specialty PA
Humira Specialty PA
Humira Pediatric Crohn's Start subcutaneous
syringe kit 80 mg/0.8 mL
Specialty PA
Humira Pen Specialty PA
Humira Pen Crohn's-UC-HS Start subcutaneous
pen injector kit 80 mg/0.8 mL
Specialty PA
Humira Pen Psoriasis-Uveitis subcutaneous pen
injector kit 80 mg/0.8 mL-40 mg/0.4 mL
Specialty PA
hydroxychloroquine
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
86
Drug Name Tier Requirements/Limits
Inflectra Specialty PA
Kevzara subcutaneous syringe Specialty PA
Kineret Specialty PA
leflunomide
methotrexate sodium
methotrexate sodium (PF)
Orencia Specialty PA
Orencia (with maltose) Specialty PA
Orencia ClickJect Specialty PA
Otezla Specialty PA
Otezla Starter Specialty PA
Remicade Specialty PA
Renflexis Specialty PA
Ridaura
Sandimmune intravenous Specialty PA
Simponi Specialty PA
Simponi ARIA Specialty PA
Stelara intravenous Specialty PA
Stelara subcutaneous syringe Specialty PA
sulfasalazine
Xeljanz oral tablet 5 mg Specialty PA
Xeljanz XR Specialty PA
Gonadotropin-Releasing Hormone Antagnts
Firmagon kit w diluent syringe Specialty PA
Firmagon subcutaneous recon soln 120 mg Specialty PA
Immunomodulatory Agents
Actemra Specialty PA
Actimmune Specialty PA
Aubagio Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
87
Drug Name Tier Requirements/Limits
Avonex (with albumin) Specialty PA
Avonex intramuscular pen injector kit Specialty PA
Avonex intramuscular syringe kit Specialty PA
azathioprine
Betaseron Specialty PA
Cimzia Specialty PA
Cimzia Powder for Reconst Specialty PA
Copaxone subcutaneous syringe Specialty PA
cyclosporine intravenous Specialty PA
cyclosporine modified
cyclosporine oral capsule
Enbrel Specialty PA
Enbrel Mini Specialty PA
Enbrel SureClick Specialty PA
Entyvio Specialty PA
Extavia Specialty PA
Gilenya oral capsule 0.5 mg Specialty PA
glatiramer Specialty PA
Glatopa subcutaneous syringe 20 mg/mL Specialty PA
Humira Specialty PA
Humira Pediatric Crohn's Start subcutaneous
syringe kit 80 mg/0.8 mL, 80 mg/0.8 mL-40
mg/0.4 mL
Specialty PA
Humira Pen Specialty PA
Humira Pen Crohn's-UC-HS Start subcutaneous
pen injector kit 80 mg/0.8 mL
Specialty PA
Humira Pen Psoriasis-Uveitis subcutaneous pen
injector kit 80 mg/0.8 mL-40 mg/0.4 mL
Specialty PA
hydroxychloroquine
Inflectra Specialty PA
Intron A injection Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
88
Drug Name Tier Requirements/Limits
Kevzara subcutaneous syringe Specialty PA
Kineret Specialty PA
leflunomide
Lemtrada Specialty PA
methotrexate sodium
methotrexate sodium (PF)
Ocrevus Specialty PA
Orencia Specialty PA
Orencia (with maltose) Specialty PA
Orencia ClickJect Specialty PA
Otezla Specialty PA
Otezla Starter Specialty PA
Plegridy Specialty PA
Pomalyst Specialty PA
Proleukin Specialty PA
Rebif (with albumin) Specialty PA
Rebif Rebidose Specialty PA
Rebif Titration Pack Specialty PA
Remicade Specialty PA
Renflexis Specialty PA
Revlimid oral capsule 10 mg, 15 mg, 2.5 mg, 25
mg, 5 mg
Specialty PA
Ridaura
Sandimmune intravenous Specialty PA
Simponi Specialty PA
Simponi ARIA Specialty PA
Stelara intravenous Specialty PA
Stelara subcutaneous syringe Specialty PA
sulfasalazine
Tecfidera Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
89
Drug Name Tier Requirements/Limits
Thalomid Specialty PA
Tysabri Specialty PA
Xeljanz oral tablet 5 mg Specialty PA
Xeljanz XR Specialty PA
Immunosuppressive Agents
Atgam Specialty PA
azathioprine
Benlysta intravenous Specialty PA
CellCept oral suspension for reconstitution
cyclophosphamide intravenous Specialty PA
cyclosporine intravenous Specialty PA
cyclosporine modified
cyclosporine oral capsule
Elidel PA
mercaptopurine
methotrexate sodium
methotrexate sodium (PF)
mycophenolate mofetil
mycophenolate mofetil HCl Specialty PA
mycophenolate sodium PA
Prograf intravenous Specialty PA
Rapamune oral solution PA
Sandimmune intravenous Specialty PA
Simulect Specialty PA
sirolimus PA
tacrolimus oral
Thymoglobulin Specialty PA
Zortress oral tablet 0.25 mg, 0.5 mg, 0.75 mg Specialty PA
Other Miscellaneous Therapeutic Agents
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
90
Drug Name Tier Requirements/Limits
acetylcysteine
Ampyra Specialty PA
Arcalyst Specialty PA
Botox Specialty PA
Cerdelga Specialty PA
Demser Specialty PA
Dysport Specialty PA
Endari Specialty PA
Ilaris (PF) subcutaneous solution Specialty PA
Kuvan oral tablet,soluble Specialty PA
levocarnitine (with sugar) Specialty PA
levocarnitine oral tablet
miglustat Specialty PA
Myobloc PA
octreotide acetate Specialty PA
Orfadin Specialty PA
Prezcobix
Remicade Specialty PA
Spinraza (PF) Specialty PA
Xeomin Specialty PA
Protective Agents
amifostine crystalline Specialty PA
dexrazoxane HCl Specialty PA
Elmiron QL
mesna Specialty PA
Oxytocics
Oxytocics
Methergine QL
Respiratory Tract Agents
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
91
Drug Name Tier Requirements/Limits
Alpha And Beta Adrenergic Agonist(Respr)
Bromfed DM
cetirizine-pseudoephedrine ST
Children's Silfedrine
Conex oral solution
epinephrine injection auto-injector 0.15 mg/0.3
mL, 0.3 mg/0.3 mL
QL
epinephrine injection solution
epinephrine injection syringe 0.1 mg/mL
Lodrane D
LoHist - D
Lortuss EX oral syrup AL
M-End DMX
Nasal Decongestant (pseudoeph) oral tablet
pseudoephedrine HCl oral tablet 60 mg
pseudoephedrine-guaifenesin
Rynex PSE
Anticholinergic Agents (Respir.Tract)
Anoro Ellipta
Atrovent HFA
Combivent Respimat
diphenoxylate-atropine
ipratropium bromide inhalation
ipratropium-albuterol
Spiriva Respimat AL
Antifibrotic Agents
Esbriet Specialty PA
Anti-Inflammatory Agents (Respiratory)
Nucala Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
92
Drug Name Tier Requirements/Limits
Antitussives
Adult Robitussin Peak Cold DM
benzonatate oral capsule 100 mg, 200 mg
Bromfed DM
Carbaphen CH
codeine sulfate oral tablet AL
codeine-guaifenesin QL; AL
Cough DM ER
Guaifenesin AC AL
hydrocodone-homatropine oral syrup 5-1.5 mg/5
mL
AL
hydrocodone-homatropine oral tablet AL
Lortuss EX oral syrup AL
M-End DMX
Mucinex DM oral tablet extended release 12 hr 30-
600 mg
NoHist-DM
Promethazine VC-Codeine QL; AL
promethazine-codeine QL; AL
promethazine-DM
Trexbrom
Tussin CF (PE-DM-guaif)
Cystic Fibrosis (Cftr) Correctors
Orkambi oral tablet Specialty PA
Symdeko Specialty PA
Cystic Fibrosis (Cftr) Potentiators
Kalydeco oral tablet Specialty PA
Orkambi oral tablet Specialty PA
Symdeko Specialty PA
Expectorants
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
93
Drug Name Tier Requirements/Limits
Adult Robitussin Peak Cold DM
codeine-guaifenesin QL; AL
ED Bron GP
Guaifenesin AC AL
guaifenesin oral liquid
guaifenesin oral tablet extended release 12hr 1,200
mg
Lortuss EX oral syrup AL
Mucinex DM oral tablet extended release 12 hr 30-
600 mg
pseudoephedrine-guaifenesin
SSKI
Tussin CF (PE-DM-guaif)
First Generation Antihist.(Respir Tract)
Bromfed DM
Carbaphen CH
Centergy
chlorpheniramine maleate oral tablet
Conex oral solution
cyproheptadine
Diclegis PA
dimenhydrinate oral
Dimetapp Cold-Allergy (PE)
diphenhydramine HCl injection solution 50
mg/mL
diphenhydramine HCl injection syringe
diphenhydramine HCl oral capsule
diphenhydramine HCl oral liquid
diphenhydramine HCl oral syrup
diphenhydramine HCl oral tablet 25 mg
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
94
Drug Name Tier Requirements/Limits
Ed Chlorped D
Lodrane D
LoHist - D
M-End DMX
NoHist-DM
promethazine oral
Promethazine VC
Promethazine VC-Codeine QL; AL
promethazine-codeine QL; AL
promethazine-DM
Rynex PSE
Sleep Aid (doxylamine)
Trexbrom
Interleukin Antagonists
Cinqair Specialty PA
Dupixent subcutaneous syringe 300 mg/2 mL Specialty PA
Fasenra Specialty PA
Leukotriene Modifiers
montelukast oral granules in packet QL; AL
montelukast oral tablet QL
montelukast oral tablet,chewable QL
Mast-Cell Stabilizers
cromolyn inhalation
cromolyn nasal
cromolyn ophthalmic (eye)
Mucolytic Agents
acetylcysteine
Pulmozyme Specialty PA
Nasal Preparations (Steroids)
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
95
Drug Name Tier Requirements/Limits
fluticasone nasal
Nasal Allergy ST
Orally Inhaled Preparations (Steroids)
ArmonAir RespiClick
Arnuity Ellipta inhalation blister with device 100
mcg/actuation, 200 mcg/actuation
QL
Arnuity Ellipta inhalation blister with device 50
mcg/actuation
Asmanex HFA
Asmanex Twisthaler QL
Breo Ellipta
budesonide inhalation QL; AL
Flovent Diskus QL
Flovent HFA QL
fluticasone-salmeterol
Qvar QL
Qvar RediHaler QL
Phosphodiesterase Type 4 Inhibitors
Daliresp ST
Respiratory Tract Agents, Miscellaneous
Aralast NP intravenous recon soln 500 mg PA
Glassia Specialty PA
Prolastin-C intravenous recon soln Specialty PA
Xolair subcutaneous recon soln PA
Second Generation Antihist(Respir Tract)
Allergy Relief (cetirizine) oral capsule ST
cetirizine oral solution 1 mg/mL
cetirizine oral tablet
cetirizine-pseudoephedrine ST
Children's Zyrtec Allergy oral tablet,disintegrating ST
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
96
Drug Name Tier Requirements/Limits
fexofenadine oral suspension ST
fexofenadine oral tablet 180 mg ST
levocetirizine oral tablet
loratadine oral capsule ST
loratadine oral solution ST
loratadine oral tablet
loratadine oral tablet,disintegrating ST
Select.Beta-2-Adrenergic Agonist(Respir)
albuterol sulfate inhalation solution for
nebulization
albuterol sulfate oral syrup
albuterol sulfate oral tablet
albuterol sulfate oral tablet extended release 12 hr
8 mg
Anoro Ellipta
Breo Ellipta
Combivent Respimat
fluticasone-salmeterol
ipratropium-albuterol
levalbuterol tartrate ST
Serevent Diskus
terbutaline oral
Ventolin HFA QL
Vasodilating Agents (Respiratory Tract)
Adcirca Specialty PA
epoprostenol (glycine) Specialty PA
Letairis Specialty PA
Orenitram Specialty PA
Remodulin Specialty PA
Revatio intravenous Specialty PA
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
97
Drug Name Tier Requirements/Limits
Revatio oral suspension for reconstitution Specialty PA
sildenafil (antihypertensive) oral PA
Tracleer Specialty PA
Tyvaso Specialty PA
Tyvaso Refill Kit Specialty PA
Tyvaso Starter Kit Specialty PA
Veletri Specialty PA
Ventavis Specialty PA
Xanthine Derivatives
Theo-24
theophylline oral tablet extended release 12 hr
theophylline oral tablet extended release 24 hr
Skin And Mucous Membrane Agents
Allylamines (Skin And Mucous Membrane)
terbinafine HCl topical
Antibacterials (Skin, Mucous Membrane)
bacitracin zinc topical ointment
Cleocin vaginal suppository
clindamycin phosphate topical gel
clindamycin phosphate topical lotion
clindamycin phosphate topical solution
clindamycin phosphate topical swab
clindamycin phosphate vaginal
Ery Pads
erythromycin with ethanol topical gel
erythromycin with ethanol topical solution
erythromycin-benzoyl peroxide
gentamicin topical
metronidazole topical cream
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
98
Drug Name Tier Requirements/Limits
metronidazole topical gel
metronidazole vaginal
mupirocin
Triple Antibiotic topical ointment
Anti-Inflammatory Agents (Skin, Mucous)
ApexiCon E
betamethasone dipropionate
betamethasone valerate topical cream
betamethasone valerate topical lotion
betamethasone valerate topical ointment
betamethasone, augmented
clobetasol scalp
clobetasol topical cream
clobetasol topical gel
clobetasol topical ointment
clobetasol-emollient topical cream
clotrimazole-betamethasone
Colocort
desonide
desoximetasone topical cream
desoximetasone topical gel
desoximetasone topical ointment 0.25 %
diflorasone
fluocinolone
fluocinolone and shower cap
fluocinonide topical cream 0.05 %
fluocinonide topical gel
fluocinonide topical ointment
fluocinonide topical solution
Fluocinonide-E
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
99
Drug Name Tier Requirements/Limits
fluticasone topical cream
fluticasone topical ointment
hydrocortisone acetate rectal suppository 25 mg
hydrocortisone butyrate topical cream
hydrocortisone butyrate topical ointment
hydrocortisone butyrate topical solution
hydrocortisone topical cream
hydrocortisone topical lotion
hydrocortisone topical ointment
hydrocortisone valerate
hydrocortisone-min oil-wht pet
hydrocortisone-pramoxine rectal cream 1-1 %
mometasone topical cream QL
mometasone topical ointment QL
mometasone topical solution
triamcinolone acetonide dental
triamcinolone acetonide topical cream
triamcinolone acetonide topical lotion
triamcinolone acetonide topical ointment 0.025 %,
0.1 %, 0.5 %
Antipruritics And Local Anesthetics
dibucaine
hydrocortisone-pramoxine rectal cream 1-1 %
lidocaine HCl topical cream 3 %
lidocaine topical cream 4 %
lidocaine-prilocaine topical cream QL
phenazopyridine oral tablet 100 mg, 200 mg
pramoxine
Antivirals (Skin And Mucous Membrane)
Abreva
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
100
Drug Name Tier Requirements/Limits
acyclovir topical PA
Zovirax topical cream PA
Astringents
aluminum chloride
Azoles (Skin And Mucous Membrane)
clotrimazole mucous membrane
clotrimazole topical
clotrimazole vaginal cream
clotrimazole-betamethasone
econazole
Fungi Cure
Gyne-Lotrimin
ketoconazole topical cream
ketoconazole topical shampoo
Lotrimin AF
Lotrimin AF Powder
Miconazole 7 vaginal cream
miconazole nitrate topical cream
miconazole nitrate vaginal suppository
Miconazole-3 vaginal suppository
terconazole
Basic Lotions And Liniments
ammonium lactate topical lotion
CeraVe topical lotion
Hydrocerin
Lac-Hydrin Five
Lubriderm Daily Moisture
Lubriderm Sensitive Skin
Basic Ointments And Protectants
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
101
Drug Name Tier Requirements/Limits
ammonium lactate topical cream
Aquaphor Healing
CeraVe topical cream
GRx Vitamin E topical cream
Minerin Creme
Benzylamines (Skin And Mucous Membrane)
Lotrimin Ultra
Cell Stimulants And Proliferants
Kepivance Specialty PA
tretinoin topical cream AL
tretinoin topical gel 0.01 %, 0.025 % AL
Corticosteroids (Skin, Mucous Membrane)
ApexiCon E
betamethasone dipropionate
betamethasone valerate topical cream
betamethasone valerate topical lotion
betamethasone valerate topical ointment
betamethasone, augmented
clobetasol scalp
clobetasol topical cream
clobetasol topical gel
clobetasol topical ointment
clobetasol-emollient topical cream
clotrimazole-betamethasone
Colocort
desonide
desoximetasone topical cream
desoximetasone topical gel
desoximetasone topical ointment 0.25 %
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
102
Drug Name Tier Requirements/Limits
diflorasone
fluocinolone
fluocinolone and shower cap
fluocinonide topical cream 0.05 %
fluocinonide topical gel
fluocinonide topical ointment
fluocinonide topical solution
Fluocinonide-E
fluticasone topical cream
fluticasone topical ointment
hydrocortisone acetate rectal suppository 25 mg
hydrocortisone butyrate topical cream
hydrocortisone butyrate topical ointment
hydrocortisone butyrate topical solution
hydrocortisone topical cream
hydrocortisone topical lotion
hydrocortisone topical ointment
hydrocortisone valerate
hydrocortisone-min oil-wht pet
hydrocortisone-pramoxine rectal cream 1-1 %
mometasone topical cream QL
mometasone topical ointment QL
mometasone topical solution
triamcinolone acetonide dental
triamcinolone acetonide topical cream
triamcinolone acetonide topical lotion
triamcinolone acetonide topical ointment 0.025 %,
0.1 %, 0.5 %
Hydroxypyridones (Skin, Mucous Membrane)
ciclopirox topical suspension
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
103
Drug Name Tier Requirements/Limits
Keratolytic Agents
benzoyl peroxide topical cleanser 10 %
benzoyl peroxide topical gel 10 %, 5 %
Neutrogena On The Spot
sulfacetamide sodium-sulfur topical cleanser 10-5
% (w/w)
sulfacetamide sodium-sulfur topical lotion 10-5 %
(w/v)
urea topical lotion 40 %
Keratoplastic Agents
Drithocreme HP
Local Anti-Infectives, Miscellaneous
chlorhexidine gluconate topical liquid 4 %
Neosporin Wound Cleanser Kids
silver sulfadiazine
sulfacetamide sodium (acne)
sulfacetamide sodium-sulfur topical cleanser 10-5
% (w/w)
sulfacetamide sodium-sulfur topical lotion 10-5 %
(w/v)
Nonsteroidal Anti-Inflammat.Agents(Skin)
diclofenac sodium topical gel 1 % ST
Pigmenting Agents
Oxsoralen Ultra Specialty PA
Polyenes (Skin And Mucous Membrane)
nystatin topical
nystatin-triamcinolone
Scabicides And Pediculicides
Complete Lice Treatment
Cutter Backwoods topical aerosol,spray QL; AL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
104
Drug Name Tier Requirements/Limits
Lice Killing
Off Deep Woods Dry QL; AL
Off Deep Woods topical aerosol,spray QL; AL
permethrin topical cream QL
Repel Sportsmen QL; AL
Repel Sportsmen Max topical aerosol,spray QL; AL
Sklice ST
SPINOSAD 0.9% TOPICAL SUSP ST
Skin And Mucous Membrane Agents, Misc.
Cosentyx Specialty PA
Cosentyx Pen Specialty PA
Cutter Backwoods topical aerosol,spray QL; AL
diclofenac sodium topical gel 1 % ST
Dupixent subcutaneous syringe 300 mg/2 mL Specialty PA
Elidel PA
Enbrel Specialty PA
Enbrel Mini Specialty PA
Enbrel SureClick Specialty PA
Humira Specialty PA
Humira Pediatric Crohn's Start subcutaneous
syringe kit 80 mg/0.8 mL
Specialty PA
Humira Pen Specialty PA
Humira Pen Crohn's-UC-HS Start subcutaneous
pen injector kit 80 mg/0.8 mL
Specialty PA
Humira Pen Psoriasis-Uveitis subcutaneous pen
injector kit 80 mg/0.8 mL-40 mg/0.4 mL
Specialty PA
imiquimod topical cream in packet QL
Inflectra Specialty PA
Insect Repellent (picaridin) QL; AL
Natrapel QL; AL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
105
Drug Name Tier Requirements/Limits
Off Deep Woods Dry QL; AL
Off Deep Woods topical aerosol,spray QL; AL
Otezla Specialty PA
Otezla Starter Specialty PA
podofilox
Remicade Specialty PA
Renflexis Specialty PA
Repel Sportsmen QL; AL
Repel Sportsmen Max topical aerosol,spray QL; AL
Santyl
Siliq Specialty PA
Stelara intravenous Specialty PA
Stelara subcutaneous syringe Specialty PA
tacrolimus topical PA
Taltz Autoinjector Specialty PA
Taltz Syringe Specialty PA
Targretin topical Specialty PA
Tremfya Specialty PA
Smooth Muscle Relaxants
Antimuscarinics
flavoxate
oxybutynin chloride
Oxytrol For Women
tolterodine
trospium oral tablet
Respiratory Smooth Muscle Relaxants
Theo-24
theophylline oral tablet extended release 12 hr
theophylline oral tablet extended release 24 hr
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
106
Drug Name Tier Requirements/Limits
Vitamins
Multivitamin Preparations
AquADEKs oral tablet,chewable
AquADEKs Pediatric
Atabex EC AL
Bio-35, Gluten Free
Cadeau DHA AL
Centrum Specialist Prenatal AL
Child Multivitamins
Classic Prenatal AL
Complete Natal DHA AL
Daily Prenatal AL
Expecta Prenatal AL
Flintstones Multi-Vit Gummies oral
tablet,chewable 200 mcg
KPN AL
Mini Prenatal AL
Multi-Vit with Fluoride-Iron
Multivitamin With Fluoride
Multi-Vitamin With Fluoride oral drops
Multivitamins With Fluoride oral tablet,chewable
0.25 mg, 1 mg
Mynatal AL
Mynatal Plus AL
Mynatal-Z AL
Mynate 90 Plus AL
Obstetrix DHA AL
Obstetrix EC AL
O-Cal FA AL
O-Cal Prenatal AL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
107
Drug Name Tier Requirements/Limits
One A Day Women's Prenatal DHA AL
One-A-Day Womens Formula oral tablet 18 mg
iron-400 mcg-500 mg Ca
One-A-Day Women's Prenatal 1 AL
Perry Prenatal AL
PNV cmb#95-ferrous fumarate-FA AL
Poly-Vi-Flor
Poly-Vi-Flor with Iron
Poly-Vitamins
Prenatabs Rx AL
Prenatal + DHA oral combo pack 28 mg iron-800
mcg-200 mg
AL
Prenatal 19 AL
Prenatal Formula oral tablet 9 mg iron- 267 mcg AL
Prenatal Gummy AL
Prenatal Low Iron
Prenatal Multi-DHA (algal oil) AL
Prenatal Multi-DHA oral capsule 27 mg iron-800
mcg-228 mg
AL
Prenatal oral tablet 28 mg iron- 800 mcg AL
Prenatal Plus AL
Prenatal Plus (calcium carb) AL
Prenatal Plus DHA oral combo pack
Prenatal Vitamin oral tablet AL
Prenatal Vitamin Plus Low Iron AL
prenatal vit-iron fum-folic ac AL
prenatal vits96-iron fum-folic AL
Prenatal-U AL
ProRenal QD
Protect Iron
Right Step Prenatal Vitamins AL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
108
Drug Name Tier Requirements/Limits
Similac Prenatal AL
TriAdvance AL
Trinatal GT AL
Trinatal Rx 1 AL
Trinate AL
Triveen-Duo DHA AL
Tri-Vit with Fluoride and Iron
Tri-Vitamin With Fluoride
Vinate GT AL
Vinate II AL
Vinate M AL
Vinate One AL
Vinate Ultra AL
Vol-Nate AL
Vol-Tab Rx AL
VP-GGR-B6
Women's Daily Caplet
Women's Prenatal + DHA AL
Vitamin A
Child Multivitamins
Tri-Vitamin With Fluoride
Vitamin B Complex
AquADEKs oral tablet,chewable
Atabex EC AL
Bio-35, Gluten Free
Cadeau DHA AL
Centrum Specialist Prenatal AL
Child Multivitamins
Classic Prenatal AL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
109
Drug Name Tier Requirements/Limits
cyanocobalamin (vitamin B-12) injection
Daily Prenatal AL
Diclegis PA
Expecta Prenatal AL
FE C Plus AL
Flintstones Multi-Vit Gummies oral
tablet,chewable 200 mcg
folic acid oral tablet 1 mg
KPN oral tablet 9 mg iron- 267 mcg AL
Mini Prenatal AL
Multigen Folic
Multigen Plus
Mynatal oral capsule AL
Mynatal Plus AL
Mynatal-Z AL
Nicomide
Obstetrix DHA AL
Obstetrix EC AL
O-Cal FA AL
O-Cal Prenatal AL
One A Day Women's Prenatal DHA AL
One-A-Day Womens Formula oral tablet 18 mg
iron-400 mcg-500 mg Ca
Perry Prenatal AL
PNV cmb#95-ferrous fumarate-FA AL
Prenatabs Rx AL
Prenatal + DHA oral combo pack 28 mg iron-800
mcg-200 mg
AL
Prenatal 19 AL
Prenatal Formula oral tablet 9 mg iron- 267 mcg AL
Prenatal Gummy AL
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
110
Drug Name Tier Requirements/Limits
Prenatal Low Iron
Prenatal Multi-DHA (algal oil) AL
Prenatal Multi-DHA oral capsule 27 mg iron-800
mcg-228 mg
AL
Prenatal oral tablet 28 mg iron- 800 mcg AL
Prenatal Plus AL
Prenatal Plus (calcium carb) AL
Prenatal Plus DHA oral combo pack
Prenatal Vitamin Plus Low Iron AL
prenatal vit-iron fum-folic ac AL
prenatal vits96-iron fum-folic AL
ProRenal QD
Protect Iron
pyridoxine (vitamin B6) oral tablet 25 mg
Rena-Vite
Rena-Vite Rx
Right Step Prenatal Vitamins AL
Similac Prenatal AL
TriAdvance AL
Trinatal GT AL
Trinatal Rx 1 AL
Trinate AL
Triveen-Duo DHA AL
Vinate GT AL
Vinate M AL
Vinate One AL
Vinate Ultra AL
Vol-Nate AL
Vol-Tab Rx AL
VP-GGR-B6
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
111
Drug Name Tier Requirements/Limits
Women's Daily Caplet
Women's Prenatal + DHA AL
Vitamin C
FE C AL
FE C Plus AL
Multigen Folic
Multigen Plus
Rena-Vite
Rena-Vite Rx
Tri-Vitamin With Fluoride
Vitamin D
Ca-D3-mag-zinc-cop-mang-bor
calcitriol intravenous solution 1 mcg/mL
calcitriol oral
CALCIUM 250-VIT D3 125 TABLET
Calcium 500 + D oral tablet 500 mg(1,250mg) -
400 unit
CALCIUM 500 + VIT D CAPLET P/F, CAPLET
CALCIUM 500-VIT D3 200 TABLET P/F,NA/F
Calcium 600 + D(3) oral tablet 600 mg(1,500mg) -
200 unit
CALCIUM 600 + VIT D TABLET
CALCIUM 600-VIT D3 800 CAPLET S/F, P/F,
CAPLET
calcium carbonate-vitamin D3 oral tablet 1,000
mg(2,500 mg)-800 unit, 600 mg(1,500mg) -400
unit
calcium citrate-vitamin D3 oral tablet 315-250 mg-
unit
Child Multivitamins
cholecalciferol (vitamin D3) oral capsule 1,000
unit
AL = Age Limit
GL = Gender Limit
PA = Prior Authorization
QL = Quantity Limit
ST = Step therapy
112
Drug Name Tier Requirements/Limits
cholecalciferol (vitamin D3) oral capsule 2,000
unit, 50,000 unit
cholecalciferol (vitamin D3) oral drops 400
unit/mL, 5,000 unit/mL
Citrus Calcium oral tablet 315-250 mg-unit
ergocalciferol (vitamin D2) oral capsule
ergocalciferol (vitamin D2) oral drops
HM VITAMIN D3 4,000 UNIT SFTGL
SOFTGEL
Kids Vitamin D3
One-A-Day Women's Prenatal 1 AL
Oyster Shell Calcium-Vit D3 oral tablet 500
mg(1,250mg) -200 unit, 500 mg(1,250mg) -400
unit
ProRenal QD
Tri-Vitamin With Fluoride
Upcal D
VITAMIN D 400 UNIT TABLET P/F,NA/F,S/F
VITAMIN D2 2,000 UNIT TABLET
VITAMIN D3 10,000 UNIT SOFTGEL
SOFTGEL
VITAMIN D3 2,000 UNIT SOFTGEL SOFTGEL
VITAMIN D3 5,000 UNIT CAPSULE S/F, P/F
Vitamin D3 oral capsule 1,000 unit, 400 unit
Vitamin D3 oral tablet 1,000 unit, 400 unit
Vitamin E
Child Multivitamins
Vitamin K Activity
AquADEKs Pediatric
phytonadione (vitamin K1) oral tablet 5 mg
113
Index
A abacavir .................................. 9
abacavir-lamivudine ............... 9
Abelcet ................................. 12
Abilify Maintena .................. 47
Abraxane .............................. 14
Abreva .................................. 99
Accu-Chek Aviva Control Soln
.......................................... 56
Accu-Chek Aviva Plus test strp
.......................................... 57
Accu-Chek Guide ................. 57
Accu-Chek Guide Glucose
Meter ................................ 56
Accu-Chek Guide L1-L2 Ctrl
Sol..................................... 56
Accu-Chek Multiclix Lancet 56
Accu-Chek SmartView Contrl
Sol..................................... 56
Accu-Chek SmartView Test
Strip .................................. 58
Accu-Chek Soft Dev Lancets
.......................................... 56
Accu-Chek Softclix Lancet
Dev ................................... 56
Accu-Chek Softclix Lancets. 57
acetaminophen ...................... 44
acetaminophen-codeine .. 44, 51
acetazolamide ........... 36, 58, 65
acetic acid ............................. 66
acetylcysteine ................. 90, 94
Actemra .......................... 85, 86
Acthar H.P. ..................... 57, 79
Actimmune ........................... 86
Activase .......................... 30, 63
acyclovir ....................... 11, 100
Adacel(Tdap
Adolesn/Adult)(PF) .......... 20
Adagen ................................. 63
Adcetris ................................ 14
Adcirca ........................... 40, 96
adefovir................................. 11
Admelog SoloStar U-100
Insulin ......................... 78, 80
Admelog U-100 Insulin lispro
.................................... 78, 80
Adult Robitussin Peak Cold
DM.............................. 92, 93
Aerochamber MV ................. 57
Afinitor ................................. 14
Afinitor Disperz .................... 14
Afluria 2017-2018 ................ 20
Afluria 2017-2018 (PF) ........ 20
Afluria Quad 2017-2018 ...... 20
Afluria Quad 2017-2018 (PF)
.......................................... 20
Aimovig Autoinjector........... 46
Aimovig Autoinjector (2 Pack)
.......................................... 46
Akynzeo (fosnetupitant) . 68, 71
Akynzeo (netupitant) ...... 68, 71
albuterol sulfate .............. 24, 96
Aldactazide ......... 40, 41, 59, 62
Aldurazyme .......................... 63
alendronate ........................... 84
Alferon N ........................ 10, 14
alfuzosin ............................... 24
Alimta ................................... 14
Allergy Relief (cetirizine) 2, 95
allopurinol ............................ 83
alogliptin ............................... 76
alogliptin-metformin ...... 75, 76
alogliptin-pioglitazone.... 76, 81
alprazolam ............................ 49
aluminum chloride .............. 100
aluminum hydroxide gel ....... 68
amantadine HCl ................ 4, 43
AmBisome ............................ 12
Amicar .................................. 26
amifostine crystalline ........... 90
amikacin ............................. 4, 6
amiloride ......................... 41, 59
amiloride-hydrochlorothiazide
.............................. 41, 59, 62
amiodarone ........................... 37
Amitiza ................................. 70
amitriptyline ......................... 56
amitriptyline-chlordiazepoxide
.................................... 49, 56
amlodipine .......... 35, 38, 39, 42
amlodipine-benazepril ... 31, 32,
35, 38, 39, 42
amlodipine-valsartan31, 35, 38,
39, 42
ammonium lactate ...... 100, 101
amoxapine ............................. 56
amoxicillin .......................... 4, 5
amoxicillin-pot clavulanate .... 5
ampicillin ................................ 5
ampicillin sodium ................... 5
ampicillin-sulbactam .............. 5
Ampyra ................................. 90
anastrozole ...................... 14, 74
Anoro Ellipta ...... 22, 24, 91, 96
Antacid Plus Anti-Gas .... 68, 69
ApexiCon E .................. 98, 101
APOKYN ............................. 51
apraclonidine ........................ 66
aprepitant ........................ 71, 72
Aptivus ................................. 10
AquADEKs ................. 106, 108
AquADEKs Pediatric . 106, 112
Aquaphor Healing .............. 101
Aralast NP ............................ 95
Aranelle (28) ......................... 75
Aranesp (in polysorbate) ...... 25
Arcalyst ................................. 90
aripiprazole ........................... 47
Aristada ................................. 47
ArmonAir RespiClick ..... 73, 95
Armour Thyroid .................... 82
Arnuity Ellipta ................ 73, 95
Arranon ................................. 14
Artificial Tears (petro/min) .. 66
Artificial Tears (polyvin alc) 66
Artificial Tears(glycerin-peg)
.......................................... 66
Arzerra .................................. 14
Asmanex HFA ................ 73, 95
Asmanex Twisthaler ....... 73, 95
aspirin ................. 29, 30, 46, 54
aspirin-dipyridamole . 30, 42, 54
Atabex EC 27, 59, 70, 106, 108
atazanavir .............................. 10
atenolol ............... 25, 33, 34, 37
atenolol-chlorthalidone .. 25, 33,
34, 37, 42, 63
Atgam ................................... 89
atomoxetine .......................... 49
114
atorvastatin ........................... 39
atovaquone ............................. 6
atovaquone-proguanil ............. 5
atropine ................................. 67
Atrovent HFA ................. 22, 91
Aubagio ................................ 86
Augmentin .............................. 5
Austedo........................... 50, 56
Avastin ................................. 14
Avonex ................................. 87
Avonex (with albumin) ........ 87
Ayr Sinus Rinse Refill.......... 66
Azactam in dextrose (iso-osm)
.......................................... 11
azathioprine .............. 85, 87, 89
azelastine .............................. 64
azithromycin ......................... 12
Azopt .................................... 65
aztreonam ............................. 11
B Baby Ayr Saline ................... 66
bacitracin zinc ...................... 97
bacitracin-polymyxin B ........ 64
baclofen ................................ 23
balsalazide ............................ 69
Balziva (28) .......................... 75
Banzel ................................... 45
Basaglar KwikPen U-100
Insulin ......................... 78, 79
benazepril ....................... 31, 32
benazepril-hydrochlorothiazide
........................ 31, 32, 41, 62
Benlysta ................................ 89
benzonatate ........................... 92
benzoyl peroxide ................ 103
benztropine ..................... 22, 45
Berinert ................................. 85
betamethasone dipropionate 98,
101
betamethasone valerate 98, 101
betamethasone, augmented.. 98,
101
Betaseron .............................. 87
bethanechol chloride ............ 24
bexarotene ............................ 14
bicalutamide ......................... 14
Bicillin L-A .......................... 11
BiCNU .................................. 14
BiDil ............................... 38, 40
Biltricide ................................. 5
Bio-35, Gluten Free ....... 27, 59,
106, 108
bisoprolol fumarate.. 25, 33, 34,
37
bisoprolol-hydrochlorothiazide
............ 25, 33, 34, 37, 41, 62
bleomycin ............................. 14
Boostrix Tdap ....................... 20
Bosulif .................................. 14
Botox .............................. 25, 90
Breo Ellipta......... 24, 73, 95, 96
brimonidine .......................... 64
Bromfed DM ...... 20, 91, 92, 93
bromocriptine ....................... 50
budesonide ...................... 73, 95
bumetanide ..................... 39, 59
buprenorphine HCl ............... 52
buprenorphine-naloxone ....... 52
bupropion HCl ...................... 46
bupropion HCl (smoking deter)
.......................................... 46
buspirone .............................. 47
busulfan ................................ 14
Butalbital Compound
W/Codeine ...... 46, 48, 51, 54
butalbital-acetaminop-caf-cod
.................. 44, 46, 48, 51, 54
butalbital-acetaminophen 44, 48
butalbital-acetaminophen-caff
........................ 44, 46, 48, 54
butalbital-aspirin-caffeine ... 30,
46, 48, 54
butorphanol tartrate .............. 52
C cabergoline ........................... 50
Ca-D3-mag-zinc-cop-mang-
bor ............................. 59, 111
Cadeau DHA ........ 27, 106, 108
caffeine citrate ...................... 54
calcitonin (salmon) ... 75, 79, 84
calcitriol .............................. 111
Calcium 500 ......................... 61
Calcium 500 + D .... 59, 60, 111
Calcium 500 + D (D3) .. 60, 111
Calcium 600 ......................... 60
Calcium 600 + D(3) ...... 60, 111
calcium acetate ..................... 59
calcium carbonate-vitamin D3
............................ 59, 60, 111
calcium citrate-vitamin D3 .. 60,
111
Camptosar ............................. 14
Canasa ................................... 69
capecitabine .......................... 14
Caprelsa ................................ 14
captopril .......................... 31, 32
captopril-hydrochlorothiazide
.............................. 32, 41, 62
Carbaglu ............................... 58
carbamazepine ...................... 45
Carbaphen CH ...... 2, 21, 92, 93
carbidopa-levodopa .............. 50
carboplatin ............................ 14
Carimune NF Nanofiltered ... 19
carisoprodol .......................... 23
carisoprodol-ASA-codeine .. 23,
51, 54
carisoprodol-aspirin ........ 23, 54
carteolol ................................ 65
carvedilol 23, 24, 30, 33, 37, 39
caspofungin ............................. 7
Cathflo Activase ............. 30, 63
Cayston ................................. 11
cefadroxil ................................ 3
cefazolin ................................. 3
cefdinir .................................... 3
cefepime ................................. 4
cefepime in dextrose 5 % ....... 4
cefepime in dextrose,iso-osm . 4
cefotaxime .............................. 3
cefotetan ............................. 3, 7
cefotetan in dextrose, iso-osm
........................................ 3, 7
cefprozil .................................. 3
ceftazidime ............................. 3
ceftriaxone .............................. 3
ceftriaxone in dextrose,iso-os . 3
cefuroxime axetil .................... 3
cefuroxime sodium ................. 3
celecoxib ............................... 50
CellCept ................................ 89
Centergy ..................... 2, 21, 93
Centrum Specialist Prenatal 27,
106, 108
cephalexin ............................... 3
CeraVe ........................ 100, 101
Cerdelga ................................ 90
Cerezyme .............................. 63
cetirizine ........................... 2, 95
115
cetirizine-pseudoephedrine.... 2,
20, 91, 95
Chantix ................................. 22
Chantix Starting Month Box 22
Chemet ........................... 72, 83
Child Multivitamins .. 106, 108,
111, 112
Children's Silfedrine ....... 20, 91
Children's Zyrtec Allergy . 2, 95
chlordiazepoxide HCl ........... 49
chlordiazepoxide-clidinium . 22,
49
chlorhexidine gluconate 66, 103
chloroquine phosphate............ 5
chlorothiazide ................. 41, 62
chlorpheniramine maleate . 1, 2,
93
chlorpromazine ..................... 53
chlorpropamide..................... 81
chlorthalidone ................. 42, 63
chlorzoxazone....................... 23
cholecalciferol (vitamin D3)
................................ 111, 112
cholestyramine (with sugar) . 34
Cholestyramine Light ........... 34
ciclopirox ............................ 102
cidofovir ............................... 11
cilostazol......................... 30, 40
Cimduo ................................... 9
cimetidine ............................. 71
cimetidine HCl ..................... 71
Cimzia ...................... 70, 85, 87
Cimzia Powder for Reconst. 70,
85, 87
Cinqair .................................. 94
Cinryze ................................. 85
Ciprodex ......................... 64, 65
ciprofloxacin..................... 6, 12
ciprofloxacin (mixture) .... 6, 12
ciprofloxacin HCl ....... 6, 12, 64
ciprofloxacin in 5 % dextrose 6,
12
cisplatin ................................ 14
citalopram ............................. 55
Citrus Calcium.............. 60, 112
cladribine .............................. 14
Claforan .................................. 3
clarithromycin .................. 6, 12
Classic Prenatal .... 27, 106, 108
Cleocin ................................. 97
clindamycin HCl................... 10
clindamycin in 5 % dextrose 10
clindamycin palmitate HCl ... 10
clindamycin phosphate ... 10, 97
Clinisol SF 15 %................... 58
clobetasol ...................... 98, 101
clobetasol-emollient ..... 98, 101
clofarabine ............................ 14
clomipramine ........................ 56
clonazepam ..................... 48, 49
clonidine ......................... 21, 36
clonidine HCl ................. 21, 36
clopidogrel ............................ 30
clorazepate dipotassium . 48, 49
clotrimazole ........................ 100
clotrimazole-betamethasone 98,
100, 101
clozapine ............................... 47
codeine sulfate ................ 51, 92
codeine-guaifenesin .. 51, 92, 93
colchicine.............................. 83
colestipol .............................. 34
colistin (colistimethate Na) .. 12
Colocort ........................ 98, 101
Combivent Respimat ..... 22, 24,
91, 96
Cometriq ............................... 14
Complete Lice Treatment ... 103
Complete Natal DHA ......... 106
Conex.................... 2, 21, 91, 93
Copaxone .............................. 87
cortisone ............................... 73
Cosentyx ............................. 104
Cosentyx Pen ...................... 104
cosyntropin ........................... 57
Cough DM ER ...................... 92
Creon .................................... 70
Crixivan ................................ 10
cromolyn ......................... 64, 94
Cuprimine ....................... 72, 85
Cutter Backwoods ...... 103, 104
cyanocobalamin (vitamin B-
12) ................................... 109
cyclobenzaprine .................... 23
cyclopentolate ....................... 67
cyclophosphamide .......... 14, 89
cyclosporine.............. 85, 87, 89
cyclosporine modified ... 85, 87,
89
cyproheptadine ................. 1, 93
cytarabine ............................. 15
cytarabine (PF) ..................... 15
CytoGam ............................... 19
Cytovene ............................... 11
Cytra-2 .................................. 58
D D5 %-0.45 % sodium chloride
.......................................... 58
dacarbazine ........................... 15
Dacogen ................................ 15
dactinomycin ........................ 15
Daily Prenatal . 27, 60, 106, 109
Daliresp ................................. 95
danazol .................................. 74
dapsone ............................... 5, 6
daptomycin ............................. 7
Daraprim ................................. 5
daunorubicin ......................... 15
DDAVP .......................... 26, 79
deferoxamine .................. 72, 83
Delzicol ................................. 69
Demser .................................. 90
Depen Titratabs .............. 72, 85
Depo-Provera ........................ 80
Descovy .................................. 9
desipramine ........................... 56
desmopressin .................. 26, 79
desogestrel-ethinyl estradiol . 75
desonide ........................ 98, 101
desoximetasone ............. 98, 101
dexamethasone ..................... 73
Dexamethasone Intensol ....... 73
dexamethasone sodium phos
(PF) ................................... 73
dexamethasone sodium
phosphate .................... 65, 73
dexmethylphenidate .............. 54
dexrazoxane HCl .................. 90
dextroamphetamine .............. 43
dextroamphetamine-
amphetamine ..................... 43
dextrose 70 % in water
(D70W) ............................. 58
diazepam ......................... 48, 49
Diazepam Intensol .......... 48, 49
dibucaine ............................... 99
Diclegis ................... 69, 93, 109
diclofenac potassium ............ 52
diclofenac sodium .... 52, 53, 67,
103, 104
116
dicloxacillin .......................... 12
dicyclomine .......................... 22
didanosine............................... 9
Dificid................................... 12
diflorasone .................... 98, 102
diflunisal ............................... 53
Digox .............................. 33, 36
digoxin ............................ 33, 36
dihydroergotamine ......... 23, 46
Dilantin ........................... 36, 50
diltiazem HCl 34, 35, 36, 37, 42
dimenhydrinate ........... 1, 69, 93
Dimetapp Cold-Allergy (PE) 2,
21, 93
Dipentum .............................. 69
diphenhydramine HCl ...... 1, 93
diphenoxylate-atropine .. 22, 69,
91
dipyridamole................... 30, 42
disopyramide phosphate ....... 36
disulfiram ............................. 82
Diuril .............................. 41, 62
divalproex ....................... 45, 46
Docefrez ............................... 15
docetaxel............................... 15
docusate sodium ................... 70
donepezil .............................. 24
dorzolamide .......................... 65
dorzolamide-timolol ............. 65
doxazosin .................. 23, 30, 39
doxepin ................................. 56
Doxil ..................................... 15
doxorubicin........................... 15
Doxy-100 .............................. 13
doxycycline hyclate ........ 13, 64
doxycycline monohydrate .... 13
Drithocreme HP.................. 103
droperidol ............................. 47
Droxia ................................... 15
duloxetine ....................... 50, 55
Dupixent ....................... 94, 104
dutasteride ............................ 82
Dysport ........................... 25, 90
E Ear Wax Treatment .............. 66
econazole ............................ 100
ED Bron GP ................... 21, 93
Ed Chlorped D ............ 2, 21, 94
Edurant ................................... 8
efavirenz ................................. 8
Elaprase ................................ 63
Elelyso .................................. 63
Elidel ............................ 89, 104
Eligard ...................... 15, 77, 78
Eligard (3 month) ..... 15, 77, 78
Eligard (4 month) ..... 15, 77, 78
Eligard (6 month) ..... 15, 77, 78
Eliquis ................................... 25
Elitek .................................... 63
Ella........................................ 75
Elmiron ................................. 90
Emcyt.................................... 15
Emend ................................... 72
Emflaza ................................. 73
Emtriva ................................... 9
enalapril maleate................... 32
enalapril-hydrochlorothiazide
.............................. 32, 41, 62
Enbrel ..................... 85, 87, 104
Enbrel Mini............. 85, 87, 104
Enbrel SureClick .... 85, 87, 104
Endari ............................. 70, 90
enoxaparin ...................... 26, 27
entecavir ............................... 11
Entresto ........................... 31, 41
Entyvio ........................... 71, 87
Enulose ................................. 58
epinephrine ..................... 21, 91
epirubicin .............................. 15
Epivir HBV............................. 9
Epogen .................................. 26
epoprostenol (glycine) .... 42, 96
Eraxis(Water Diluent) ............ 7
Erbitux .................................. 15
ergocalciferol (vitamin D2) 112
Ergomar .......................... 24, 47
Erivedge................................ 15
Erwinaze ............................... 15
Ery Pads ................................ 97
Ery-Tab ............................. 7, 10
Erythrocin (as stearate) ..... 7, 11
erythromycin .............. 7, 11, 64
erythromycin ethylsuccinate.. 7,
11
erythromycin with ethanol.... 97
erythromycin-benzoyl peroxide
.......................................... 97
Esbriet ................................... 91
escitalopram oxalate ............. 55
esomeprazole magnesium..... 72
estazolam .............................. 49
estradiol ................................ 77
estrogens-methyltestosterone
.................................... 74, 77
estropipate ............................. 77
eszopiclone ........................... 47
ethambutol .............................. 6
ethosuximide ......................... 56
ethynodiol diac-eth estradiol 75
etidronate disodium .............. 84
etodolac ................................. 53
Etopophos ............................. 15
etoposide ............................... 15
Euflexxa ................................ 57
Evzio ............................... 52, 83
exemestane ..................... 15, 74
Exjade ................................... 72
Expecta Prenatal ... 27, 106, 109
Extavia .................................. 87
Eylea ..................................... 66
F Fabrazyme ............................ 63
famotidine ............................. 71
Fareston .......................... 15, 76
Fasenra .................................. 94
Faslodex ................................ 15
FE C .............................. 27, 111
FE C Plus .............. 27, 109, 111
felodipine ............ 35, 38, 39, 42
Femhrt Low Dose ........... 77, 80
fenofibrate ............................. 39
fenofibrate micronized .......... 38
fenofibrate nanocrystallized . 39
fentanyl ................................. 51
Feraheme .............................. 27
Ferocon ................................. 27
Ferrex 28 ............................... 27
Ferriprox ............................... 73
Ferrlecit ................................. 27
ferrous gluconate .................. 27
ferrous sulfate ....................... 27
Feverall ................................. 44
fexofenadine ..................... 2, 96
finasteride ............................. 82
Firazyr ................................... 85
Firmagon ................... 15, 75, 86
Firmagon kit w diluent syringe
.............................. 15, 75, 86
Firvanq .................................... 8
Flarex .................................... 65
117
flavoxate ............................. 105
Flebogamma DIF.................. 19
flecainide .............................. 36
Flintstones Multi-Vit Gummies
................................ 106, 109
Flovent Diskus................ 73, 95
Flovent HFA ................... 73, 95
floxuridine ............................ 16
Fluarix Quad 2017-2018 (PF)
.......................................... 20
Flucelvax Quad 2017-2018 .. 20
Flucelvax Quad 2017-2018
(PF) ................................... 20
fluconazole ............................. 7
fluconazole in dextrose(iso-o) 6
fluconazole in NaCl (iso-osm) 6
fludarabine ............................ 16
fludrocortisone ..................... 73
Flulaval Quad 2017-2018 (PF)
.......................................... 20
fluocinolone .................. 98, 102
fluocinolone and shower cap
.................................. 98, 102
fluocinonide .................. 98, 102
Fluocinonide-E ............. 98, 102
fluoride (sodium) .................. 84
fluorometholone ................... 65
fluorouracil ........................... 16
fluoxetine .............................. 55
fluphenazine decanoate ........ 53
fluphenazine HCl.................. 53
flurbiprofen........................... 53
flurbiprofen sodium .............. 67
flutamide............................... 16
fluticasone ........ 65, 95, 99, 102
fluticasone-salmeterol ... 24, 73,
95, 96
Fluvirin 2017-2018 ............... 20
Fluvirin 2017-2018 (PF)....... 20
fluvoxamine .......................... 55
Fluzone High-Dose 2017-18
(PF) ................................... 20
Fluzone Intraderm Quad 2017-
18 ...................................... 20
Fluzone Quad 2017-2018 ..... 20
Fluzone Quad 2017-2018 (PF)
.......................................... 20
Fluzone Quad Pedi 2017-18
(PF) ................................... 20
FML Forte ............................ 65
FML S.O.P. .......................... 65
folic acid ............................. 109
Folotyn.................................. 16
Formula EM ......................... 69
Forteo.................................... 79
fosamprenavir ....................... 10
foscarnet ................................. 6
fosinopril .............................. 32
fosinopril-hydrochlorothiazide
.............................. 32, 41, 62
Fulphila ................................. 26
Fungi Cure .......................... 100
furosemide ...................... 40, 59
Fuzeon .................................... 8
G gabapentin ...................... 44, 45
Galzin ................................... 73
GamaSTAN S/D ................... 19
Gamunex-C .......................... 19
Gattex 30-Vial ...................... 71
Gelclair ................................. 57
Gel-Kam ............................... 84
Gel-One ................................ 57
Gelsyn-3 ............................... 57
gemcitabine .......................... 16
gemfibrozil ........................... 39
Gentak .................................. 64
gentamicin ........................ 4, 97
gentamicin in NaCl (iso-osm) 4
gentamicin sulfate (PF) .......... 4
GenVisc 850 ......................... 57
Genvoya.............................. 8, 9
Geodon ................................. 47
Gilenya ................................. 87
Glassia .................................. 95
glatiramer.............................. 87
Glatopa ................................. 87
Gliadel Wafer ....................... 16
glimepiride............................ 81
glipizide ................................ 81
glipizide-metformin ........ 75, 81
Glucagon Emergency Kit
(human) ...................... 77, 83
glyburide ............................... 81
glyburide micronized ............ 81
glyburide-metformin ...... 75, 81
glycopyrrolate ....................... 22
granisetron (PF) .................... 68
granisetron HCl .................... 68
Granix ................................... 26
griseofulvin microsize ............ 5
griseofulvin ultramicrosize ..... 5
GRx Vitamin E ................... 101
guaifenesin ............................ 93
Guaifenesin AC ........ 51, 92, 93
guanfacine ....................... 36, 50
Gyne-Lotrimin .................... 100
H Haegarda ............................... 85
Halaven ................................. 16
haloperidol ............................ 49
haloperidol decanoate ........... 49
haloperidol lactate ................ 49
heparin (porcine) .................. 27
heparin (porcine) in 5 % dex 27
heparin (porcine) in NaCl (PF)
.................................... 27, 57
heparin, porcine (PF) ............ 27
Herceptin .............................. 16
Hexalen ................................. 16
Hizentra ................................ 19
Homatropaire ........................ 67
Humalog Junior KwikPen U-
100 .............................. 78, 80
Humalog Mix 50-50 Insuln U-
100 .............................. 78, 80
Humalog Mix 50-50 KwikPen
.................................... 78, 80
Humalog Mix 75-25 KwikPen
.................................... 78, 80
Humalog Mix 75-25(U-
100)Insuln ................... 78, 80
Humatrope ............................ 80
Humira .............. 71, 85, 87, 104
Humira Pediatric Crohn's Start
...................... 71, 85, 87, 104
Humira Pen ....... 71, 85, 87, 104
Humira Pen Crohn's-UC-HS
Start ............... 71, 85, 87, 104
Humira Pen Psoriasis-Uveitis
...................... 71, 85, 87, 104
Humulin 70/30 U-100 Insulin
.................................... 79, 81
Humulin N NPH Insulin
KwikPen ........................... 79
Humulin N NPH U-100 Insulin
.......................................... 79
Humulin R Regular U-100
Insuln .......................... 79, 81
Hyalgan ................................. 57
118
Hycamtin .............................. 16
hydralazine ........................... 38
Hydrocerin .......................... 100
hydrochlorothiazide ........ 41, 62
hydrocodone-acetaminophen
.................................... 44, 51
hydrocodone-homatropine .. 22,
51, 92
hydrocortisone ........ 73, 99, 102
hydrocortisone acetate .. 99, 102
hydrocortisone butyrate 99, 102
hydrocortisone valerate 99, 102
hydrocortisone-min oil-wht pet
.................................. 99, 102
hydrocortisone-pramoxine .. 99,
102
hydromorphone .............. 51, 52
hydroxychloroquine ... 5, 85, 87
hydroxyurea .......................... 16
hydroxyzine HCl .............. 2, 47
hydroxyzine pamoate ....... 2, 47
hyoscyamine sulfate ............. 22
Hyper-Sal ....................... 57, 60
Hypotears ............................. 66
I ibandronate ........................... 84
Ibrance .................................. 16
ibuprofen .............................. 53
Iclusig ................................... 16
idarubicin .............................. 16
ifosfamide ............................. 16
ifosfamide-mesna ................. 16
Ilaris (PF).............................. 90
imatinib................................. 16
imipramine HCl .................... 56
imiquimod .......................... 104
Increlex ................................. 81
indapamide ..................... 42, 63
indomethacin .................. 53, 83
Infant's Ibuprofen ................. 53
Infed ..................................... 27
Inflectra ............ 71, 86, 87, 104
Ingrezza .......................... 50, 56
Injectafer............................... 27
Inlyta..................................... 16
Insect Repellent (picaridin) 104
Insulin Syringe ..................... 57
Intelence ................................. 8
Intralipid ............................... 58
Intrarosa ................................ 74
Intron A .................... 10, 16, 87
Invanz ..................................... 7
Invega Sustenna .................... 47
Invega Trinza ........................ 48
Invirase ................................. 10
Iopidine ................................. 66
ipecac .................................... 70
ipratropium bromide . 22, 66, 91
ipratropium-albuterol..... 22, 24,
91, 96
irbesartan .............................. 31
irbesartan-hydrochlorothiazide
.............................. 31, 41, 62
irinotecan .............................. 16
Iron Chews ........................... 27
Isentress .................................. 8
Isentress HD ........................... 8
isometh-dichloral-
acetaminophn.................... 44
isoniazid.................................. 6
isosorbide dinitrate ............... 40
isosorbide mononitrate ......... 40
itraconazole ............................ 7
Ixempra ................................. 16
J Jadenu ................................... 73
Jadenu Sprinkle .................... 73
Jakafi .................................... 16
Janumet ........................... 75, 76
Janumet XR .................... 75, 76
Januvia .................................. 76
Jevtana .................................. 16
Jinteli .............................. 77, 80
Juluca ...................................... 8
Juxtapid ................................ 33
Jynarque................................ 63
K Kadcyla ................................. 16
Kalbitor ................................. 85
Kaletra .................................. 10
Kalydeco ............................... 92
Kepivance ........................... 101
ketoconazole ................... 7, 100
ketoprofen ............................. 53
ketorolac ......................... 53, 67
ketotifen fumarate................. 64
Kevzara ........................... 86, 88
Kids Vitamin D3 ................ 112
Kineret ............................ 86, 88
Kionex (with sorbitol) .... 59, 83
Klor-Con ............................... 60
Klor-Con/EF ......................... 60
KPN ...................... 28, 106, 109
Krystexxa .............................. 83
Kuvan ................................... 90
Kynamro ......................... 33, 83
Kyprolis ................................ 16
L labetalol .. 23, 24, 30, 33, 34, 37
Lac-Hydrin Five ................. 100
lactulose ................................ 58
lamivudine .............................. 9
lamivudine-zidovudine ........... 9
lamotrigine ............................ 45
Lancets,Ultra Thin ................ 57
lansoprazole .......................... 72
latanoprost ............................ 67
Latuda ................................... 48
leflunomide ..................... 86, 88
Lemtrada ............................... 88
Letairis ............................ 42, 96
letrozole .......................... 16, 74
leucovorin calcium ............... 83
Leukeran ............................... 17
Leukine ................................. 26
leuprolide .................. 17, 77, 78
levalbuterol tartrate ......... 24, 96
levetiracetam ......................... 45
levobunolol ........................... 65
levocarnitine ......................... 90
levocarnitine (with sugar) ..... 90
levocetirizine .................... 2, 96
levofloxacin ...................... 6, 12
levoleucovorin calcium ........ 83
levonorgestrel-ethinyl estrad 75
levonorg-eth estrad triphasic 76
levothyroxine ........................ 82
Levoxyl ................................. 82
Lexiva ................................... 10
Lice Killing ......................... 104
lidocaine ............................... 99
lidocaine HCl .................. 67, 99
Lidocaine Viscous ................ 67
lidocaine-prilocaine .............. 99
Lincocin ................................ 10
Linzess .................................. 71
Lioresal ................................. 23
liothyronine ........................... 82
Liposyn III ............................ 58
lisinopril ................................ 32
119
lisinopril-hydrochlorothiazide
.............................. 32, 41, 62
lithium carbonate .................. 46
lithium citrate ....................... 46
Lodrane D ............. 2, 21, 91, 94
LoHist - D............. 2, 21, 91, 94
loperamide ............................ 69
lopinavir-ritonavir ................ 10
loratadine .......................... 3, 96
lorazepam ............................. 49
Lorazepam Intensol .............. 49
Lortuss EX.... 21, 52, 91, 92, 93
losartan ................................. 31
losartan-hydrochlorothiazide
.............................. 31, 41, 62
Lotrimin AF........................ 100
Lotrimin AF Powder .......... 100
Lotrimin Ultra .................... 101
lovastatin .............................. 39
Low-Ogestrel (28) ................ 76
loxapine succinate ................ 47
Lubriderm Daily Moisture . 100
Lubriderm Sensitive Skin ... 100
Lucentis ................................ 66
Lupron Depot ........... 17, 77, 78
Lupron Depot (3 month) 17, 77,
78
Lupron Depot (4 month) 17, 77,
78
Lupron Depot (6 Month) ..... 17,
77, 78
Lupron Depot-Ped .... 17, 77, 78
Lupron Depot-Ped (3 month)
.............................. 17, 77, 78
Lysodren ............................... 17
M Maalox Advanced .......... 68, 69
Macugen ............................... 67
magnesium oxide.................. 68
magnesium sulfate .... 33, 45, 83
Makena ................................. 80
Makena (PF) ......................... 80
Mapap (acetaminophen) ....... 44
maprotiline ........................... 56
Matulane ............................... 17
Maxidex ................................ 65
meclizine .......................... 2, 69
meclofenamate ..................... 53
medroxyprogesterone ........... 80
mefloquine .............................. 5
megestrol ........................ 17, 80
meloxicam ............................ 53
melphalan ............................. 17
melphalan HCl ...................... 17
memantine ............................ 50
M-End DMX .. 2, 21, 91, 92, 94
Menest .................................. 77
meperidine ............................ 52
mercaptopurine ............... 17, 89
meropenem ............................. 7
mesalamine ........................... 69
mesna .................................... 90
Mestinon ............................... 24
metformin ............................. 75
Methergine............................ 90
methimazole ......................... 75
methocarbamol ..................... 23
methotrexate sodium 17, 86, 88,
89
methotrexate sodium (PF) ... 17,
86, 88, 89
methscopolamine .................. 22
methyclothiazide ............ 41, 62
methyldopa ..................... 21, 36
methyldopa-
hydrochlorothiazide ... 21, 36,
41, 62
methylphenidate HCl ............ 54
methylprednisolone .............. 74
methylprednisolone sodium
succ ................................... 74
metipranolol.......................... 65
metoclopramide HCl ............ 72
metolazone...................... 42, 63
metoprolol succinate 25, 33, 34,
37
metoprolol ta-hydrochlorothiaz
............ 25, 33, 34, 37, 41, 62
metoprolol tartrate ... 25, 33, 34,
37
metronidazole ......... 4, 6, 97, 98
metronidazole in NaCl (iso-os)
........................................ 4, 6
mexiletine ............................. 36
Miconazole 7 ...................... 100
miconazole nitrate .............. 100
Miconazole-3 ...................... 100
MICRhoGAM Ultra-Filtered
PLUS ................................ 19
Microgestin 1.5/30 (21) ........ 76
Microgestin Fe 1.5/30 (28) ... 76
Microgestin FE 1/20 (28) ..... 76
midazolam ............................ 49
midodrine .............................. 21
miglustat ............................... 90
Minerin Creme .................... 101
Mini Prenatal ........ 28, 106, 109
minocycline .......................... 13
minoxidil ............................... 38
mirtazapine ........................... 46
misoprostol ........................... 72
mitomycin ............................. 17
mitoxantrone ......................... 17
modafinil ............................... 56
moexipril ............................... 32
moexipril-hydrochlorothiazide
.............................. 32, 42, 62
mometasone .................. 99, 102
Monovisc .............................. 57
montelukast ........................... 94
morphine ............................... 52
morphine concentrate ........... 52
Moxeza ................................. 64
moxifloxacin ............... 6, 13, 64
Mozobil ................................. 26
Mucinex DM .................. 92, 93
Multigen ............................... 28
Multigen Folic ...... 28, 109, 111
Multigen Plus ........ 28, 109, 111
Multi-Vit with Fluoride-Iron
............................ 28, 84, 106
Multivitamin With Fluoride 84,
106
Multi-Vitamin With Fluoride
.................................. 84, 106
Multivitamins With Fluoride
.................................. 84, 106
mupirocin .............................. 98
Muro 128 .............................. 67
Mustargen ............................. 17
Mycamine ............................... 7
Mycobutin ......................... 6, 13
mycophenolate mofetil ......... 89
mycophenolate mofetil HCl . 89
mycophenolate sodium ......... 89
Myleran ................................. 17
Mynatal ........... 28, 60, 106, 109
Mynatal Plus ... 28, 60, 106, 109
Mynatal-Z ....... 28, 60, 106, 109
Mynate 90 Plus ................... 106
120
Myobloc ......................... 25, 90
N nabumetone .......................... 53
nadolol ................ 23, 33, 34, 37
nadolol-bendroflumethiazide
............ 23, 33, 34, 37, 42, 62
nafcillin................................. 12
nafcillin in dextrose iso-osm 12
Naglazyme ............................ 63
nalbuphine ............................ 52
naltrexone ....................... 52, 82
naproxen ......................... 53, 83
naproxen sodium ............ 53, 83
Narcan ............................ 52, 83
Nasal Allergy.................. 65, 95
Nasal Decongestant
(pseudoeph) ................ 21, 91
Natrapel .............................. 104
Nature-Throid ....................... 82
Nebupent ................................ 6
nefazodone ........................... 55
neomycin-bacitracin-poly-HC
.................................... 64, 65
neomycin-bacitracin-
polymyxin......................... 64
neomycin-polymyxin B-
dexameth .................... 64, 66
neomycin-polymyxin-
gramicidin......................... 64
neomycin-polymyxin-HC ... 64,
66
Neosporin Wound Cleanser
Kids ................................ 103
Neo-Synephrine
(phenylephrine) ................ 68
Neulasta ................................ 26
Neupogen ............................. 26
Neutrogena On The Spot .... 103
nevirapine ............................... 8
Nexavar ................................ 17
Nexium 24HR ...................... 72
niacin .................................... 33
Niacin Flush Free ................. 33
Nicomide ............................ 109
nicotine ................................. 22
nicotine (polacrilex) ............. 22
Nicotrol................................. 22
Nicotrol NS .......................... 23
nifedipine ...... 35, 38, 39, 42, 43
nilutamide ............................. 17
Nitro-Bid .............................. 40
Nitro-Dur .............................. 40
nitrofurantoin ........................ 13
nitrofurantoin macrocrystal .. 13
nitrofurantoin monohyd/m-
cryst .................................. 13
nitroglycerin ......................... 40
nizatidine .............................. 71
NoHist-DM ........... 2, 21, 92, 94
norethindrone (contraceptive)
.......................................... 76
norethindrone acetate ........... 80
norethindrone ac-eth estradiol
.......................................... 76
norgestimate-ethinyl estradiol
.......................................... 76
Nortemp ................................ 44
Nortrel 0.5/35 (28) ................ 76
Nortrel 1/35 (21) ................... 76
Nortrel 1/35 (28) ................... 76
Nortrel 7/7/7 (28).................. 76
nortriptyline .......................... 56
Norvir ................................... 10
Novolin 70/30 U-100 Insulin
.................................... 79, 81
Novolin N NPH U-100 Insulin
.......................................... 79
Novolin R Regular U-100
Insuln .......................... 79, 81
Novolog Mix 70-30 U-100
Insuln .......................... 79, 80
Novolog Mix 70-30FlexPen U-
100 .............................. 79, 81
NP Thyroid ........................... 82
Nplate ................................... 26
Nucala ................................... 91
Nutropin AQ Nuspin ............ 80
NuvaRing.............................. 76
nystatin ......................... 12, 103
nystatin-triamcinolone ........ 103
O Obstetrix DHA ..... 28, 106, 109
Obstetrix EC ... 28, 70, 106, 109
O-Cal FA ........ 28, 60, 106, 109
O-Cal Prenatal 28, 60, 106, 109
Ocaliva.................................. 71
Ocrevus ................................. 88
octreotide acetate ............ 81, 90
Odefsey ............................... 8, 9
Off Deep Woods ......... 104, 105
Off Deep Woods Dry .. 104, 105
ofloxacin ......................... 13, 64
olanzapine ............................. 48
olanzapine-fluoxetine ..... 48, 55
olmesartan ............................. 31
olmesartan-
hydrochlorothiazide ... 31, 42,
62
olopatadine ........................... 64
omeprazole ........................... 72
omeprazole-sodium
bicarbonate ....................... 72
Omnitrope ............................. 80
Oncaspar ............................... 17
ondansetron ........................... 68
ondansetron HCl ................... 68
ondansetron HCl (PF) ........... 68
One A Day Women's Prenatal
DHA ........... 28, 60, 107, 109
One-A-Day Womens Formula
.................... 28, 60, 107, 109
One-A-Day Women's Prenatal
1 .................. 28, 60, 107, 112
Oracit .................................... 58
Oralyte .................................. 60
Orencia ........................... 86, 88
Orencia (with maltose) ... 86, 88
Orencia ClickJect ............ 86, 88
Orenitram ........................ 43, 96
Orfadin .................................. 90
Orkambi ................................ 92
orphenadrine citrate .............. 25
ORTHOVISC ....................... 57
oseltamivir ............................ 11
Otezla ...................... 86, 88, 105
Otezla Starter .......... 86, 88, 105
oxacillin ................................ 12
oxaliplatin ............................. 17
oxazepam .............................. 49
oxcarbazepine ....................... 45
Oxsoralen Ultra .................. 103
oxybutynin chloride ............ 105
oxycodone ............................. 52
oxycodone-acetaminophen .. 44,
52
Oxytrol For Women ........... 105
Oyster Shell Calcium-Vit D3
.................................. 60, 112
Ozempic ................................ 78
Ozurdex ................................ 66
121
P Pacerone ............................... 37
paclitaxel .............................. 17
Pain Relief ............................ 44
paliperidone .......................... 48
palonosetron ......................... 68
pamidronate .......................... 84
pantoprazole ......................... 72
paroxetine HCl ..................... 55
peg 3350-electrolytes ........... 70
pen needle, diabetic .............. 57
penicillin G potassium .......... 11
penicillin V potassium .......... 11
Pentam .................................... 6
Pentasa .................................. 70
pentoxifylline ....................... 26
Perdiem Overnight Relief..... 70
perindopril erbumine ............ 32
Perjeta ................................... 17
permethrin .......................... 104
perphenazine......................... 53
perphenazine-amitriptyline.. 53,
56
Perry Prenatal . 28, 61, 107, 109
phenazopyridine ................... 99
phenelzine............................. 51
phenobarbital ........................ 48
phenoxybenzamine ......... 24, 39
phenylephrine HCl ............... 68
phenytoin ........................ 36, 50
phenytoin sodium extended . 36,
50
Phospholine Iodide ............... 67
Photofrin ............................... 17
phytonadione (vitamin K1) 112
pilocarpine HCl .................... 67
pimozide ............................... 47
pindolol......... 23, 33, 34, 37, 39
Pink Bismuth .................. 68, 69
pioglitazone .......................... 82
pioglitazone-metformin .. 75, 82
piperacillin-tazobactam .......... 7
piroxicam .............................. 53
Plegridy ................................ 88
PNV cmb#95-ferrous
fumarate-FA ..... 28, 107, 109
podofilox ............................ 105
polyethylene glycol 3350 ..... 70
polymyxin B sulf-trimethoprim
.......................................... 64
Poly-Vi-Flor ................. 84, 107
Poly-Vi-Flor with Iron... 28, 84,
107
Poly-Vitamins ..................... 107
Pomalyst ......................... 18, 88
potassium chloride ................ 61
potassium citrate ................... 58
Pradaxa ................................. 25
Praluent Pen .......................... 40
pramipexole .......................... 51
pramoxine ............................. 99
prasugrel ............................... 30
pravastatin ............................ 39
prazosin .......................... 23, 30
Pred Mild .............................. 66
prednisolone ......................... 74
prednisolone acetate ............. 66
prednisolone sodium phosphate
.................................... 66, 74
prednisone ............................ 74
Prednisone Intensol .............. 74
Premarin ............................... 77
Premphase ............................ 77
Prempro ................................ 77
Prenatabs Rx ... 28, 61, 107, 109
Prenatal ................. 28, 107, 110
Prenatal + DHA .... 28, 107, 109
Prenatal 19 ............ 28, 107, 109
Prenatal Formula ... 28, 61, 107,
109
Prenatal Gummy ......... 107, 109
Prenatal Low Iron .. 28, 61, 107,
110
Prenatal Multi-DHA .... 28, 107,
110
Prenatal Multi-DHA (algal oil)
.......................... 28, 107, 110
Prenatal Plus ... 28, 61, 107, 110
Prenatal Plus (calcium carb) 29,
61, 107, 110
Prenatal Plus DHA 29, 107, 110
Prenatal Vitamin ................. 107
Prenatal Vitamin Plus Low
Iron ............. 29, 61, 107, 110
prenatal vit-iron fum-folic ac
.................... 29, 61, 107, 110
prenatal vits96-iron fum-folic
.................... 29, 61, 107, 110
Prenatal-U ........................... 107
Prevalite ................................ 34
PreviDent .............................. 84
PreviDent 5000 Dry Mouth .. 84
Prezcobix ........................ 10, 90
Prezista ................................. 10
Prialt ..................................... 44
Prilosec ................................. 72
primaquine .............................. 5
primidone .............................. 48
Privigen ................................. 20
probenecid ...................... 63, 83
probenecid-colchicine ..... 63, 83
prochlorperazine ............. 53, 69
prochlorperazine Edisylate .. 53,
69
prochlorperazine maleate 53, 69
Procrit ................................... 26
progesterone micronized ...... 80
Prograf .................................. 89
Prolastin-C ............................ 95
Proleukin ......................... 18, 88
Prolia ..................................... 84
Promacta ............................... 26
promethazine .............. 1, 47, 94
Promethazine VC ........ 1, 21, 94
Promethazine VC-Codeine .... 1,
21, 52, 92, 94
promethazine-codeine .... 52, 92,
94
promethazine-DM ....... 2, 92, 94
propafenone .......................... 37
propantheline ........................ 22
proparacaine ......................... 67
propranolol .. 23, 33, 34, 37, 39,
47
propranolol-hydrochlorothiazid
............ 23, 33, 34, 37, 42, 62
propylthiouracil .................... 75
ProRenal QD 29, 107, 110, 112
Prosol 20 % ........................... 58
Prosteon ................................ 61
Protect Iron ........... 29, 107, 110
Provenge ............................... 43
pseudoephedrine HCl ..... 21, 91
pseudoephedrine-guaifenesin
.............................. 21, 91, 93
Pulmozyme ..................... 63, 94
pyrazinamide .......................... 6
pyridostigmine bromide ........ 24
pyridoxine (vitamin B6) ..... 110
122
Q quetiapine ............................. 48
quinapril ............................... 32
quinapril-hydrochlorothiazide
........................ 32, 33, 42, 62
quinidine gluconate .......... 5, 36
quinidine sulfate ............... 5, 36
Qvar ................................ 74, 95
Qvar RediHaler .............. 74, 95
R Radicava ............................... 50
raloxifene ........................ 76, 84
ramipril ........................... 32, 33
ranitidine HCl ....................... 71
Rapamune ............................. 89
Rebetol ................................. 11
Rebif (with albumin) ............ 88
Rebif Rebidose ..................... 88
Rebif Titration Pack ............. 88
Relenza Diskhaler ................ 11
Remicade .... 71, 86, 88, 90, 105
Remodulin ...................... 43, 96
Rena-Vite ................... 110, 111
Rena-Vite Rx .............. 110, 111
Renflexis........... 71, 86, 88, 105
Repatha Pushtronex .............. 40
Repatha SureClick ................ 40
Repatha Syringe ................... 40
Repel Sportsmen ........ 104, 105
Repel Sportsmen Max 104, 105
Rescriptor ............................... 9
Restasis ................................. 66
Restasis MultiDose ............... 66
Retacrit ................................. 26
Retisert ................................. 66
Revatio ............... 40, 41, 96, 97
Revlimid ......................... 18, 88
RhoGAM Ultra-Filtered PLUS
.......................................... 20
Rhophylac............................. 20
Ridaura ..................... 72, 86, 88
rifampin ............................ 6, 13
Right Step Prenatal Vitamins
.................... 29, 61, 107, 110
riluzole .................................. 50
rimantadine ............................. 4
Risperdal Consta .................. 48
risperidone ............................ 48
ritonavir ................................ 10
Rituxan ................................. 18
Rituxan Hycela ..................... 18
rivastigmine tartrate .............. 24
rizatriptan.............................. 55
romidepsin ............................ 18
ropinirole .............................. 51
rosuvastatin ........................... 39
Rynex PSE ............ 2, 21, 91, 94
S Sabril .................................... 45
Saizen ................................... 80
Saizen click.easy .................. 80
Saline Mist ............................ 67
salsalate ................................ 54
Samsca .................................. 63
Sandimmune ............. 86, 88, 89
Santyl .................................. 105
Savella ............................ 50, 55
Segluromet...................... 75, 81
selegiline HCl ....................... 51
selenium................................ 61
Selzentry ................................. 8
senna ..................................... 70
Serevent Diskus .............. 24, 96
Serostim ................................ 80
sertraline ............................... 55
sevelamer carbonate ....... 59, 83
SF.......................................... 84
SF 5000 Plus ......................... 84
Signifor ................................. 81
sildenafil (antihypertensive) 41,
97
Siliq .................................... 105
silver sulfadiazine ............... 103
Similac Prenatal .... 29, 108, 110
Simponi .................... 71, 86, 88
Simponi ARIA .......... 71, 86, 88
Simulect ................................ 89
simvastatin ............................ 39
sirolimus ............................... 89
Sklice .................................. 104
Sleep Aid (doxylamine)... 1, 47,
94
Slow Release Iron ................. 29
sodium bicarbonate............... 68
sodium chloride .. 57, 59, 61, 67
Soft Touch Lancets ............... 57
Solesta .................................. 57
Soliris.................................... 85
Solu-Cortef (PF) ................... 74
Somatuline Depot ................. 81
Somavert ............................... 81
sotalol ................. 23, 34, 37, 39
spinosad .............................. 104
Spinraza (PF) .................. 83, 90
Spiriva Respimat ............ 22, 91
spironolactone ........... 40, 41, 59
spironolacton-hydrochlorothiaz
.................. 40, 41, 42, 59, 62
Sporanox ................................. 7
Sprycel .................................. 18
SPS (with sorbitol) ......... 59, 83
SSKI ..................... 5, 75, 83, 93
stavudine ................................. 9
Steglatro ................................ 81
Stelara ..................... 86, 88, 105
Stiolto Respimat ............. 22, 24
Stivarga ................................. 18
Stribild ................................ 8, 9
Sucraid .................................. 63
sucralfate ............................... 72
sulfacetamide sodium ........... 64
sulfacetamide sodium (acne)
........................................ 103
sulfacetamide sodium-sulfur
........................................ 103
sulfacetamide-prednisolone .. 64
sulfadiazine ........................... 13
sulfamethoxazole-trimethoprim
.......................................... 13
sulfasalazine ....... 13, 70, 86, 88
sulindac ................................. 53
sumatriptan ........................... 55
sumatriptan succinate ........... 55
Supartz FX ............................ 57
Supprelin LA ............ 18, 77, 78
Suprax ..................................... 4
Sustol .................................... 68
Sutent .................................... 18
Sylatron ........................... 10, 18
Symdeko ............................... 92
Symfi ...................................... 9
Symfi Lo ................................. 9
Synagis ................................. 11
Synercid ................................ 13
Synribo ................................. 18
Synvisc ................................. 57
Synvisc-One ......................... 57
T Tabloid .................................. 18
tacrolimus ..................... 89, 105
123
Taltz Autoinjector .............. 105
Taltz Syringe ...................... 105
tamoxifen ........................ 18, 76
tamsulosin............................. 24
Tarceva ................................. 18
Targretin ....................... 18, 105
Tasigna ................................. 18
TAZICEF ............................... 4
Tecfidera............................... 88
telmisartan ............................ 31
temazepam ............................ 49
Temodar ............................... 18
temozolomide ....................... 18
teniposide ............................. 18
tenofovir disoproxil fumarate . 9
terazosin ................... 23, 30, 39
terbinafine HCl ................. 4, 97
terbutaline ....................... 25, 96
terconazole ......................... 100
testosterone ........................... 74
testosterone cypionate .......... 74
testosterone enanthate .......... 74
tetracaine HCl ....................... 67
tetracaine HCl (PF)............... 67
tetracycline ........................... 13
Tetravisc ............................... 67
Thalomid .............................. 89
Theo-24 ............ 38, 58, 97, 105
theophylline ...... 38, 58, 97, 105
TheraCal D4000 ................... 61
thioridazine ........................... 54
thiotepa ................................. 18
thiothixene ............................ 56
Thymoglobulin ..................... 89
Thyrogen .............................. 58
thyroid (pork) ....................... 82
Thyrolar-1............................. 82
Thyrolar-1/2 ......................... 82
Thyrolar-1/4 ......................... 82
Thyrolar-2............................. 82
Thyrolar-3............................. 82
Tice BCG........................ 18, 20
tigecycline .............................. 8
timolol maleate .. 23, 34, 37, 39,
47, 65
tizanidine .............................. 23
Tobi Podhaler ......................... 4
tobramycin ............................ 65
tobramycin in 0.225 % NaCl .. 4
tobramycin sulfate .................. 4
tobramycin-dexamethasone . 65,
66
Tobrex .................................. 65
tolazamide ............................ 81
tolbutamide ........................... 81
tolterodine ........................... 105
topiramate ............................. 45
topotecan .............................. 18
Torisel ................................... 18
torsemide ........................ 40, 59
TPN Electrolytes .................. 61
TPN Electrolytes II ............... 61
Tracleer ........................... 43, 97
tramadol ................................ 52
tramadol-acetaminophen44, 47,
52
trandolapril ..................... 32, 33
tranylcypromine.................... 51
Travasol 10 % ....................... 58
trazodone .............................. 55
Treanda ................................. 18
Trelstar............................ 18, 77
Tremfya .............................. 105
tretinoin .............................. 101
tretinoin (chemotherapy) ...... 18
Trexbrom .............. 2, 21, 92, 94
TriAdvance ..... 29, 61, 108, 110
triamcinolone acetonide 99, 102
triamterene-hydrochlorothiazid
........................ 41, 42, 59, 62
triazolam ............................... 49
trientine ................................. 73
trifluoperazine ...................... 54
trifluridine ............................. 65
trihexyphenidyl ............... 22, 45
TriLyte With Flavor Packets 70
trimethobenzamide ............... 69
trimethoprim ......................... 14
Trinatal GT ........... 29, 108, 110
Trinatal Rx 1 ... 29, 61, 108, 110
Trinate ............ 29, 61, 108, 110
Triple Antibiotic ................... 98
Triveen-Duo DHA . 29, 61, 108,
110
Tri-Vit with Fluoride and Iron
............................ 29, 84, 108
Tri-Vitamin With Fluoride .. 85,
108, 111, 112
Trizivir .................................... 9
TrophAmine 10 % ................ 58
tropicamide ........................... 67
trospium .............................. 105
Trulicity ................................ 78
Truvada ................................... 9
Tussin CF (PE-DM-guaif) ... 21,
92, 93
Tykerb ................................... 18
Tymlos .................................. 79
Tysabri .................................. 89
Tyvaso ............................ 43, 97
Tyvaso Refill Kit ............ 43, 97
Tyvaso Starter Kit ........... 43, 97
U Unithroid ............................... 82
Upcal D ......................... 61, 112
urea ..................................... 103
Urin DS ................................. 14
ursodiol ................................. 70
V valacyclovir .......................... 11
valproic acid ............. 45, 46, 47
valproic acid (as sodium salt)
.............................. 45, 46, 47
valsartan ................................ 31
valsartan-hydrochlorothiazide
.............................. 31, 42, 62
Valstar ................................... 18
vancomycin ............................. 8
vancomycin in dextrose 5 % ... 8
Vectibix ................................ 19
Velcade ................................. 19
Veletri ............................. 43, 97
Velivet Triphasic Regimen
(28) ................................... 76
venlafaxine ........................... 55
Venofer ................................. 29
Ventavis .......................... 43, 97
Ventolin HFA ................. 25, 96
verapamil ...... 35, 36, 37, 38, 43
Vfend IV ................................. 7
Vibativ .................................... 8
Victoza 2-Pak ....................... 78
Victoza 3-Pak ....................... 78
Vidaza ................................... 19
Videx 2 gram Pediatric ........... 9
vigabatrin .............................. 45
Vinate GT ............. 29, 108, 110
Vinate II .............................. 108
Vinate M ............... 29, 108, 110
Vinate One ...... 29, 61, 108, 110
124
Vinate Ultra ..... 29, 61, 70, 108,
110
vinblastine ............................ 19
vincristine ............................. 19
vinorelbine ............................ 19
Viracept ................................ 10
Viramune XR ......................... 9
Viread ..................................... 9
Visine-A ............................... 68
Visudyne............................... 67
Vitamin D3 ......................... 112
Vivitrol ........................... 52, 82
Vol-Nate ............... 29, 108, 110
Vol-Tab Rx ........... 29, 108, 110
Voraxaze......................... 63, 83
Vortex Holding Chamber ..... 57
Votrient................................. 19
VP-GGR-B6 ......... 62, 108, 110
VPRIV .................................. 63
Vyvanse ................................ 43
W warfarin ................................ 25
water for irrigation, sterile .... 59
Wee Care .............................. 29
WelChol ......................... 34, 74
WinRho SDF ........................ 20
Women's Daily Caplet ... 29, 62,
108, 111
Women's Prenatal + DHA ... 29,
108, 111
X Xalkori .................................. 19
Xarelto .................................. 25
Xeljanz............................ 86, 89
Xeljanz XR ..................... 86, 89
Xenazine ......................... 50, 56
Xeomin ........................... 25, 90
Xgeva.................................... 84
Xiaflex .................................. 63
Xiidra .................................... 66
Xolair .................................... 95
Xtandi ................................... 19
Xulane .................................. 76
Y Yervoy .................................. 19
Yuvafem ............................... 77
Z zaleplon ................................ 47
Zaltrap .................................. 19
Zanosar ................................. 19
Zarxio ................................... 26
Zelboraf ................................ 19
Zenpep .................................. 70
Zerit ........................................ 9
Zevalin (Y-90) ...................... 19
zidovudine .............................. 9
ziprasidone HCl .................... 48
Zmax ..................................... 12
Zoladex ........................... 19, 78
zoledronic acid ...................... 84
zoledronic acid-mannitol-water
.......................................... 84
Zolinza .................................. 19
zolpidem ............................... 47
Zometa .................................. 84
zonisamide ............................ 45
Zortress ................................. 89
Zosyn in dextrose (iso-osm) ... 8
Zovia 1/35E (28) ................... 76
Zovirax ............................... 100
Zyprexa Relprevv ................. 48
Zytiga .................................... 19
Zyvox .................................... 12